Shyr-Yeu Lin

Dual trigger with combination of gonadotropin-releasing hormone agonist and human chorionic gonadotropin significantly improves the live-birth rate for normal responders in GnRH-antagonist cycles

OBJECTIVE To investigate whether dual triggering of final oocyte maturation with a combination of gonadotropin-releasing hormone (GnRH) agonist and human chorionic gonadotropin (hCG) can improve the live-birth rate for normal responders in GnRH-antagonist in vitro fertilization/intracytoplasmic sperm injection (IVF-ICSI) cycles. DESIGN Retrospective cohort study. SETTING Infertility unit of a university-affiliated medical center. PATIENT(S) Normal responders to controlled ovarian hyperstimulation who were undergoing IVF-ICSI with a GnRH antagonist protocol. INTERVENTION(S) Standard dosage of hCG trigger (6,500 IU of recombinant hCG) versus dual trigger (0.2 mg of triptorelin and 6,500 IU of recombinant hCG). MAIN OUTCOME MEASURE(S) Live-birth, clinical pregnancy, and implantation rates per cycle. RESULT(S) A total of 376 patients with 378 completed cycles with embryo transfer were enrolled (hCG trigger/control group: n = 187; dual trigger/study group: n = 191). The dual trigger group demonstrated statistically significantly higher implantation (29.6% vs. 18.4%), clinical pregnancy (50.7% vs. 40.1%), and live-birth (41.3% vs. 30.4%) rates as compared with the hCG trigger group. There was no statistically significant difference in terms of patient demographics, cycle parameters, or embryo quality. CONCLUSION(S) Dual trigger of final oocyte maturation with a GnRH-agonist and a standard dosage of hCG in normal responders statistically significantly improves implantation, clinical pregnancy, and live-birth rates in GnRH-antagonist IVF cycles.

Ultra-short metformin pretreatment for clomiphene citrate-resistant polycystic ovary syndrome

Objective: To evaluate the effect of ultra‐short (12 days) metformin pretreatment in clomiphene‐citrate (CC) resistant polycystic ovary syndrome (PCOS). Method: Eighty women with CC‐resistant PCOS were randomly allocated to metformin pretreatment or usual treatment. Forty women received 1500 mg metformin daily for 12 days, followed by clomiphene 150 mg daily for 5 days along with metformin. Forty women (control group) received the same dose of clomiphene but no metformin pretreatment. Results: In the metformin group, 17 (42.5%) women ovulated, and 6 (15%) conceived. In the control group, 5 (12.5%) women ovulated but none conceived. Compared with the control group, the metformin group had significantly higher ovulation (P = 0.03) and pregnancy rates (P = 0.026). Conclusion: Twelve days of metformin pretreatment improves ovulation and pregnancy rates in women with CC‐resistant PCOS.

The predictability of serum anti-Müllerian level in IVF/ICSI outcomes for patients of advanced reproductive age

BackgroundThe role of serum anti-Müllerian hormone (AMH) as predictor of in-vitro fertilization outcomes has been much debated. The aim of the present study is to investigate the practicability of combining serum AMH level with biological age as a simple screening method for counseling IVF candidates of advanced reproductive age with potential poor outcomes prior to treatment initiation.MethodsA total of 1,538 reference patients and 116 infertile patients aged greater than or equal to 40 years enrolled in IVF/ICSI cycles were recruited in this retrospective analysis. A reference chart of the age-related distribution of serum AMH level for Asian population was first created. IVF/ICSI patients aged greater than or equal to 40 years were then divided into three groups according to the low, middle and high tertiles the serum AMH tertiles derived from the reference population of matching age. The cycle outcomes were analyzed and compared among each individual group.ResultsFor reference subjects aged greater than or equal to 40 years, the serum AMH of the low, middle and high tertiles were equal or lesser than 0.48, 0.49-1.22 and equal or greater than 1.23 ng/mL respectively. IVF/ICSI patients aged greater than or equal to 40 years with AMH levels in the low tertile had the highest cycle cancellation rate (47.6%) with zero clinical pregnancy. The nadir AMH level that has achieved live birth was 0.56 ng/mL, which was equivalent to the 36.4th percentile of AMH level from the age-matched reference group. The optimum cut-off levels of AMH for the prediction of nonpregnancy and cycle cancellation were 1.05 and 0.68 ng/mL, respectively.ConclusionsTwo criteria: (1) age greater than or equal to 40 years and (2) serum AMH level in the lowest tertile (equal or lesser than 33.3rd percentile) of the matching age group, may be used as markers of futility for counseling IVF/ICSI candidates.

Reproducibility of the revised American Fertility Society classification of endometriosis using laparoscopy or laparotomy

Objective: To assess the discrepancy between laparoscopic and laparotomic scoring methods using the revised American Fertility Society (AFS) classification of endometriosis. Method: In this prospective study, 84 patients with endometriosis were scored twice (laparoscopically and laparotomically) by the same subspecialty‐certified reproductive endocrinologist. The magnitude of inter‐method variability was reported quantitatively by the S.D. of the differences in scores between the pairs. The differences in the mean endometriosis scores between the two methods were assessed by the paired Students t‐test. P<0.05 was considered as statistically significant. Discrepancy between the two methods in the staging of endometriosis patients was presented by kappa measure of agreement. Result: There was considerable variability in the scores between the two scoring methods by the same observer. Among individual components of the scoring system, the greatest variability occurred in the ovarian endometriosis and cul‐de‐sac obliteration subscores, with the least variability observed for peritoneum endometriosis. The inter‐method variation in score was sufficient to alter the endometriosis staging in 34.5% of patients, including a difference of two stages in 3.6% of patients. The kappa coefficient was 0.49, indicating fair‐to‐good agreement between the two scoring methods. Conclusion: Inter‐method variability between laparoscopic and laparotomic scoring methods was high for ovarian endometriosis subscore using the revised AFS classification of endometriosis. Agreement in endometriosis staging between the two methods was fair to good.

Treatment of infertile women with unilateral tubal occlusion by intrauterine insemination and ovarian stimulation

OBJECTIVE The aim of this study was to evaluate the value of intrauterine insemination (IUI) combined with ovarian stimulation in women with unilateral tubal occlusion detected on hysterosalpingography (HSG). MATERIALS AND METHODS A total of 703 patients undergoing IUI and controlled ovarian hyperstimulation were enrolled in this study. The study group consisted of 133 patients treated for unilateral tubal occlusion diagnosed by HSG during 2005-2011. The control group consisted of 570 patients with unexplained infertility treated during the same period. In all cases of the retrospective study, menstrual cycles were regular, basal serum follicle-stimulating hormone levels and sperm parameters were normal. RESULTS There were no significant differences in pregnancy rate per cycle between the study (17.3%) and control groups (18.9%). The pregnancy rate was higher in patients with proximal tubal occlusion (21.7%) compared with mid-distal tubal occlusion (12.5%) or unexplained infertility (18.9%), but the difference was not statistically significant. CONCLUSIONS Infertile patients with only unilateral proximal tubal occlusion detected on HSG can be treated initially by IUI combined with ovarian stimulation. The cycle outcomes in patients with proximal tubal occlusion are similar to patients with unexplained infertility. However, the stimulated IUI might not be a good choice for patients with unilateral mid-distal tubal occlusion because of a lower success rate, although further evidence is needed.

A New Simple Intracorporeal Knot-Tying Technique in Operative Laparoscopy: A Loop-Forming and Alternate-Handed Method

ABSTRACT This article is a concise description of a new approach to intracorporeal knot-tying in operative laparoscopy. The new technique provides another choice for surgeons and surgical students when a classic intracorporeal knot is not easy to perform. There are four key points in the practice of this new method: (1) always start on the long end, (2) form the loop by spinning the grasping forceps, (3) at the cross of the loop, the distal part must be medial to the proximal part, and (4) the method is alternate handed. The details and advantages are presented. (J GYNECOL SURG 13;93, 1997)