GnRH-a and Pregnancy Rate in In Vitro Fertilization (IVF) Cycles.

• Sponsor: University of Ioannina (Other)
• Overall Status: Completed
• CT.gov ID: NCT01269125
• Collaborator: University of Patras (Other), Tottori University Hospital (Other)
• Enrollment: 180
• Location: 1
• Arms: 3
• Duration (Months): 76
• Patients Per Site Per Month: 2.4

Study Details

Study Description

Brief Summary

The investigators attempted to establish a rationale for the Gonadotropin Releasing Hormone-agonist (GnRH-a) administration, post-laparoscopically, in women with mild endometriosis (until stage II, according to AFS) who underwent IVF-ET procedure. Since GnRH-a reduces cytokine's concentration in serum (Iwabe et al., 1998; Iwabe et al., 2003) and peritoneal fluid of women with endometriosis (Taketani et al., 1992) the investigators hypothesized that GnRH-a can reduces also cytokine's concentration in the follicular fluid and this action may improve the oocyte quality and the fertility of these women.

Condition or Disease	Intervention/Treatment	Phase
Endometriosis; Infertility	Drug: Leuprolide; Procedure: IVF	N/A

Detailed Description

This prospective, randomized study with control group was carried out at the Department of Obstetrics and Gynecology, Ioannina University School of Medicine (Ioannina, Greece). The study population consisted of 120 infertile women (more than a year of sexual attempts), aged 29-38 years, with laparoscopically documented endometriosis referred to the In Vitro Fertilization (IVF) Unit of the Department for infertility treatment during a 7-years period (May 2004 to September 2010). In addition, in the current study, we used 60 women with tubal infertility, documented by laparoscopy, without prior history of ovarian surgery, hydrosalpinx, and/or endometriosis as control group. This group was used to see if endometriosis affect the women's fertility. The participant's enrolment was made by three following authors A.K., K.Z., and M.P. During laparoscopy, the endoscopist documented the extension of the disease, the distribution of endometriotic lesions into the peritoneal cavity, and the presence/absence of active endometriotic lesions (red vascularized areas). All visible active endometriotic lesions were cauterized with bipolar diathermy. Women with sonographic evidence of ovarian endometrioma > 2 cm in mean diameter, with early follicular phase serum Follicular Stimulating Hormone (FSH) levels > 12 mIU/ml were excluded from the study. Cases of male factor infertility defined as a concentration of motile sperm less than 10 x 106 /ml and sperm with normal morphology less than 4% (Kruger, strict criteria) were also excluded from the study.

All women who decided to undergo an IVF-Embryo Transfer (ET) attempt were randomized into two groups according to administration or not of GnRH-a treatment, post-laparoscopy. The randomization is performed by accessing a central internet-based randomization program. The random allocation sequence and the assignment of the participants to interventions were made by the first author of the study (A.K.). The first group (Group A) was consisted of 60 women who received a depot preparation of a GnRH-a, 3.75 mg s.c, (leuprolide, Daronda depot, 3.75, Abbott, Hellas) every 28 days for three injections. The investigators preferred to pre-treat study patients with a long-acting GnRH-a for a period of 3 months because it has already reported that pregnancy rates after IVF-ET are similar in patients with endometriosis who are pre-treated with a GnRH-a for 10 to 90 days or greater than 90 days (Caruso 1997; Surrey et al., 2002). In this group, laparoscopies were performed 4 to 6 months prior of any cycle initiation for infertility. The second group (Group B) was consisted of 60 infertile women with endometriosis who did not receive the long-acting GnRH-a. All women were comparable regarding mean age, BMI, and duration of infertility.

All women of control and of group B, underwent controlled ovarian hyperstimulation (COH) after down-regulation with a GnRH-a (leuprolide, 20 IU/day, Daronda, 2.8, Abbott, Hellas) in a long protocol with a mid-luteal start. Administration of recombinant follicle stimulating hormone (rFSH, Gonal-F, Serono, Geneva, Switzeland) was started after at least 14 days of leuprolide therapy and when serum estradiol (E2) had been less than 100 pmol/l and when the thickness of the endometrium was less than 5mm. Down-regulation in women of group A was initiated 30 to 45 days after the third GnRH-a injection. A starting dose of 150 IU of follicle stimulating hormone (rFSH, Gonal-F, Serono, Geneva, Switzerland) was adjusted individually from day 6 of the cycle according to estradiol (E2) values and ultrasonographic follicular measurements. An ovulatory dose of human chorionic gonadotropin (HGG) (Pregnyl, Organon, Oss, The Netherlands) 5,000-10,000 IU was administered I.M. when mean diameter of an average of two to four follicles was larger than 16mm and the plasma estradiol concentration was higher than 1500 pmol/l.

All women were provided to luteal-phase support with natural micronized progesterone (Ultrogestan, Faran, Athens, Greece), 600 mgr daily vaginally in three divided dosages, starting the day after embryos transfer.

Follicular fluid sampling, oocyte collection and IVF Follicular fluid (FF) samples were collected during oocyte retrieval. From each patient, follicular fluid was sampled from the first one to three mature follicles, having a diameter of 18-20mm. Tumor Necrosis Factor(TNF)-a, Interleukine (IL)-1β, IL-6, IL-8 and IL-1-ra were measured in the FF of all women (secondary outcome measures). To prevent any cytokine alterations, only blood-free samples were used. IVF was performed in all cases. The fertilization rates were estimated for every woman 24 hours after oocyte retrieval (primary outcome measure).

Embryo grading and transfer The embryo quality and the clinical pregnancy rate were also primary outcome measures. Embryo development was evaluated 2 days after oocyte pick-up. The number of blastomeres and the proportion of embryo volume occupied by fragments were used for the evaluation. Embryos with < 10%, < 10-20%, < 20-30% and >30% fragments were estimated as grade 1,2,3 and 4, respectively. Three embryos with the highest blastomere number and the best morphology were transferred in each cycle. The remaining high-grade embryos were cryopreserved the same day.

Pregnancy was diagnosed by quantitative β-hCG, two weeks after embryos transfer. Clinical pregnancy was confirmed by observing fetal cardiac activity on transvaginal ultrasound four weeks after a positive pregnancy test. The clinical pregnancy rate and the quality of embryos were estimated in all women. The pregnancy rate was defined as the presence of sonographically visualized cardiac activity per cycle initiated.

Study Design

• Study Type: Interventional
• Actual Enrollment: 180 participants
• Allocation: Randomized
• Intervention Model: Parallel Assignment
• Masking: None (Open Label)
• Primary Purpose: Treatment
• Official Title: Ultralong Administration of GnRH-a Before in Vitro Fertilization Improves Fertilization Rate But Not Pregnancy Rate in Women With Endometriosis. A Prospective, Randomized, Controlled Trial.
• Study Start Date: May 1, 2004
• Actual Primary Completion Date: Aug 1, 2010
• Actual Study Completion Date: Sep 1, 2010

Arms and Interventions

Arm	Intervention/Treatment
Active Comparator: Endometriosis, leuprolide, IVF Women with stage II endometriosis received GnRH-a (leuprolide) prior to an IVF attempt.	Drug: Leuprolide; single injection of 3.75 leuprolide every 28 days, 3 dosages; Other Names: Daronda depot 3.75, Abbott, Hellas ; Procedure: IVF; Assisted Reproduction Technique.
Active Comparator: Endometriosis, IVF Women with mild endometriosis who underwent an IVF attempt without prior administration of GnRH-a.	Drug: Leuprolide; single injection of 3.75 leuprolide every 28 days, 3 dosages; Other Names: Daronda depot 3.75, Abbott, Hellas ; Procedure: IVF; Assisted Reproduction Technique.
Active Comparator: Tubal infertility, IVF Women with tubal infertility underwent an IVF attempt.	Procedure: IVF; Assisted Reproduction Technique.

Outcome Measures

Primary Outcome Measures

1. Clinical Pregnancy Rate [June 2004-August 2010]

   Clinical pregnancy was confirmed by observing fetal cardiac activity on transvaginal ultrasound four weeks after a positive pregnancy test.

2. Embryo Quality (the Percentage of Grade 1 Embryos Per Participant). [June 2004-August 2010]

   Embryo development was evaluated 2 days after oocyte pick-up. The number of blastomeres and the proportion of embryo volume occupied by fragments were used for the evaluation. Embryos with < 10%, < 10-20%, < 20-30% and >30% fragments were estimated as grade 1,2,3 and 4, respectively.

3. Fertilization Rate (Percentage of Fertilized Oocytes). [June 2004-August 2010]

   The fertilization rate was estimated for every woman 24 hours after oocyte retrieval

4. Clinical Pregnancy Rate [4 weeks after a positive pregnancy test]

   Clinical pregnancy rate was confirmed by observing fetal cardiac activity on transvaginal ultrasound four weeks after a positive pregnancy test.

Secondary Outcome Measures

1. Follicular Fluid's TNF-a Concentration. [June 2004-August 2010]

   TNF-a was measured in the FF of all women (secondary outcome measures). To prevent any cytokine alterations, only blood-free samples were used.

Eligibility Criteria

Criteria

• Ages Eligible for Study: 29 Years to 38 Years
• Sexes Eligible for Study: Female
• Accepts Healthy Volunteers: No

Inclusion Criteria:

• Infertility

• Mild endometriosis (until stage II)

Exclusion Criteria:

• ovarian endometrioma > 2 cm

• FSH > 12 mIU/ml

• Mail factor infertility

Contacts and Locations

Locations

	Site	City	State	Country	Postal Code
1	Dept. of Obstetrics & Gynecology, University Hospital	Ioannina	Epirus	Greece	45111

Sponsors and Collaborators

• University of Ioannina
• University of Patras
• Tottori University Hospital

Investigators

• Principal Investigator: Apostolos Kaponis, MD, Ioannina University School of Medicine

Study Documents (Full-Text)

None provided.

More Information

Publications

• Fedele L, Parazzini F, Radici E, Bocciolone L, Bianchi S, Bianchi C, Candiani GB. Buserelin acetate versus expectant management in the treatment of infertility associated with minimal or mild endometriosis: a randomized clinical trial. Am J Obstet Gynecol. 1992 May;166(5):1345-50.
• Rickes D, Nickel I, Kropf S, Kleinstein J. Increased pregnancy rates after ultralong postoperative therapy with gonadotropin-releasing hormone analogs in patients with endometriosis. Fertil Steril. 2002 Oct;78(4):757-62.
• Sallam HN, Garcia-Velasco JA, Dias S, Arici A. Long-term pituitary down-regulation before in vitro fertilization (IVF) for women with endometriosis. Cochrane Database Syst Rev. 2006 Jan 25;(1):CD004635. Review.
• Vercellini P, Crosignani PG, Fadini R, Radici E, Belloni C, Sismondi P. A gonadotrophin-releasing hormone agonist compared with expectant management after conservative surgery for symptomatic endometriosis. Br J Obstet Gynaecol. 1999 Jul;106(7):672-7.

• Responsible Party: Apostolos Kaponis, Lecturer of Ob/Gyn, University of Patras
• ClinicalTrials.gov Identifier: NCT01269125
• Other Study ID Numbers: 2003/89 PGNI
• First Posted: Jan 4, 2011
• Last Update Posted: Jul 30, 2013
• Last Verified: Jul 1, 2013

• Keywords provided by Apostolos Kaponis, Lecturer of Ob/Gyn, University of Patras: cytokines; endometriosis; fertilization rate; follicular fluid; pregnancy rate
• Additional relevant MeSH terms: Infertility; Endometriosis; Leuprolide

Study Results

Participant Flow

Recruitment Details	This prospective, randomized study with control group was carried out at the Department of Obstetrics and Gynecology, Ioannina University School of Medicine (Ioannina, Greece)during a 7-years period (May 2004 to September 2010).
Pre-assignment Detail	Assessed for eligibility (n= 570) Excluded (n= 390) Not meeting inclusion criteria (n= 102) Declined to participate; underwent expectant management or IUI (n= 253) Other reasons; lost to follow up (n=35)

Arm/Group Title	Endometriosis, GnRH-a Treatment, IVF	Endometriosis, IVF	Tubal Infertility, IVF
Arm/Group Description	Women with mild endometriosis who received GnRH-a treatment prior to an IVF attempt.	Women with mild endometriosis who underwent an IVF attempt without prior administration of GnRH-a.	Women with tubal infertility underwent an IVF attempt.
Period Title: Overall Study
STARTED	60	60	60
COMPLETED	53	55	60
NOT COMPLETED	7	5	0

Baseline Characteristics

Arm/Group Title	Endometriosis, GnRH-a Treatment, IVF	Endometriosis, IVF	Tubal Infertility, IVF	Total
Arm/Group Description	Women with mild endometriosis who received GnRH-a treatment prior to an IVF attempt.	Women with mild endometriosis who underwent an IVF attempt without prior administration of GnRH-a.	Women with tubal infertility underwent an IVF attempt.	Total of all reporting groups
Overall Participants	60	60	60	180
Age (Count of Participants)
<=18 years	0 0%	0 0%	0 0%	0 0%
Between 18 and 65 years	60 100%	60 100%	60 100%	180 100%
>=65 years	0 0%	0 0%	0 0%	0 0%
Age (years) [Mean (Standard Deviation) ]
Mean (Standard Deviation) [years]	33.8 (3.2)	31.8 (2.1)	35.4 (1.9)	33.6 (2.4)
Sex: Female, Male (Count of Participants)
Female	60 100%	60 100%	60 100%	180 100%
Male	0 0%	0 0%	0 0%	0 0%
Region of Enrollment (participants) [Number]
Greece	60 100%	60 100%	60 100%	180 100%

Outcome Measures

1. Primary Outcome

Title	Clinical Pregnancy Rate
Description	Clinical pregnancy was confirmed by observing fetal cardiac activity on transvaginal ultrasound four weeks after a positive pregnancy test.
Time Frame	June 2004-August 2010

Outcome Measure Data

Analysis Population Description

The study period was seven years. Practical issues such as, no more funds for measuring cytokines, my transportation to different University stopped this study before reaching adequate power. The flow of the participants in our Department was low.

Arm/Group Title	Endometriosis, GnRH-a Treatment, IVF	Endometriosis, IVF	Tubal Infertility, IVF
Arm/Group Description	Women with mild endometriosis who received GnRH-a treatment prior to an IVF attempt.	Women with mild endometriosis who underwent an IVF attempt without prior administration of GnRH-a.	Women with tubal infertility underwent an IVF attempt.
Measure Participants	53	55	60
Mean (95% Confidence Interval) [percentage]	28.3	25.4	33.3

Statistical Analysis 1

Statistical Analysis Overview	Comparison Group Selection	Endometriosis, GnRH-a Treatment, IVF, Endometriosis, IVF
	Comments
	Type of Statistical Test	Superiority or Other
	Comments
Statistical Test of Hypothesis	p-Value	0.80
	Comments
	Method	Chi-squared
	Comments
Method of Estimation	Estimation Parameter	Odds Ratio (OR)
	Estimated Value	0.28
	Confidence Interval	(2-Sided) 95%; -0.2 to 0.3
	Parameter Dispersion	Type: Standard Error of the Mean; Value: 0
	Estimation Comments

2. Primary Outcome

Title	Embryo Quality (the Percentage of Grade 1 Embryos Per Participant).
Description	Embryo development was evaluated 2 days after oocyte pick-up. The number of blastomeres and the proportion of embryo volume occupied by fragments were used for the evaluation. Embryos with < 10%, < 10-20%, < 20-30% and >30% fragments were estimated as grade 1,2,3 and 4, respectively.
Time Frame	June 2004-August 2010

Outcome Measure Data

Analysis Population Description

[Not Specified]

Arm/Group Title	Endometriosis, GnRH-a Treatment, IVF	Endometriosis, IVF	Tubal Infertility, IVF
Arm/Group Description	Women with mild endometriosis who received GnRH-a treatment prior to an IVF attempt.	Women with mild endometriosis who underwent an IVF attempt without prior administration of GnRH-a.	Women with tubal infertility underwent an IVF attempt.
Measure Participants	53	55	60
Mean (95% Confidence Interval) [Percentage of grade 1 embryos]	25.5	22.6	27.0

3. Primary Outcome

Title	Fertilization Rate (Percentage of Fertilized Oocytes).
Description	The fertilization rate was estimated for every woman 24 hours after oocyte retrieval
Time Frame	June 2004-August 2010

Outcome Measure Data

Analysis Population Description

[Not Specified]

Arm/Group Title	Endometriosis, GnRH-a Treatment, IVF	Endometriosis, IVF	Tubal Infertility, IVF
Arm/Group Description	Women with mild endometriosis who received GnRH-a treatment prior to an IVF attempt.	Women with mild endometriosis who underwent an IVF attempt without prior administration of GnRH-a.	Women with tubal infertility underwent an IVF attempt.
Measure Participants	53	55	60
Mean (95% Confidence Interval) [percentage]	73.7	62.7	75.7

4. Secondary Outcome

Title	Follicular Fluid's TNF-a Concentration.
Description	TNF-a was measured in the FF of all women (secondary outcome measures). To prevent any cytokine alterations, only blood-free samples were used.
Time Frame	June 2004-August 2010

Outcome Measure Data

Analysis Population Description

[Not Specified]

Arm/Group Title	Endometriosis, GnRH-a Treatment, IVF	Endometriosis, IVF	Tubal Infertility, IVF
Arm/Group Description	Women with mild endometriosis who received GnRH-a treatment prior to an IVF attempt.	Women with mild endometriosis who underwent an IVF attempt without prior administration of GnRH-a.	Women with tubal infertility underwent an IVF attempt.
Measure Participants	53	55	60
TNF-a	21.4 (6.7)	38.6 (7.6)	22.5 (5.4)
IL-1β	3.1 (1.1)	9.3 (4)	2.9 (0.8)
IL-6	16.7 (5.2)	32.1 (6.5)	14.7 (4.4)
IL-8	238.1 (66.4)	347.8 (59.6)	241 (46.7)
IL-1-ra	166.6 (42.6)	183 (46)	151.7 (39.6)

5. Primary Outcome

Title	Clinical Pregnancy Rate
Description	Clinical pregnancy rate was confirmed by observing fetal cardiac activity on transvaginal ultrasound four weeks after a positive pregnancy test.
Time Frame	4 weeks after a positive pregnancy test

Outcome Measure Data

Analysis Population Description

In order to handle the problem of small sample size bootstrap techniques are used. Ader et al recommend bootstrap procedures(a) distribution is complicated or unknown, (b) a small sample is available. Finally, the bootstrap distribution has been used in order to calculate all the confidence intervals.

Arm/Group Title	Endometriosis, GnRH-a Treatment, IVF	Endometriosis, IVF	Tubal Infertility, IVF
Arm/Group Description	Women with mild endometriosis who received GnRH-a treatment prior to an IVF attempt.	Women with mild endometriosis who underwent an IVF attempt without prior administration of GnRH-a.	Women with tubal infertility underwent an IVF attempt.
Measure Participants	53	55	60
Mean (95% Confidence Interval) [Percentage]	28.3	25.4	33.3

Statistical Analysis 1

Statistical Analysis Overview	Comparison Group Selection	Endometriosis, GnRH-a Treatment, IVF, Endometriosis, IVF
	Comments
	Type of Statistical Test	Superiority or Other
	Comments
Statistical Test of Hypothesis	p-Value	0.80
	Comments
	Method	Chi-squared
	Comments
Method of Estimation	Estimation Parameter	Odds Ratio (OR)
	Estimated Value	0.05
	Confidence Interval	() 95%; -0.2 to 0.3
	Parameter Dispersion	Type: Standard Error of the Mean; Value: 0
	Estimation Comments

Statistical Analysis 2

Statistical Analysis Overview	Comparison Group Selection	Endometriosis, GnRH-a Treatment, IVF, Tubal Infertility, IVF
	Comments	In order to handle the problem of small sample size combined with the inability to identify the theoretical statistical distribution of data, bootstrap techniques are used (10). Ader and co-workers recommend the bootstrap procedure when (a) the theoretical distribution is complicated or unknown, and/or (b) power calculations have to be performed and a small sample is available (11). Finally, the bootstrap distribution has been used in order to calculate all the confidence intervals.
	Type of Statistical Test	Superiority or Other
	Comments
Statistical Test of Hypothesis	p-Value	0.48
	Comments
	Method	Chi-squared
	Comments
Method of Estimation	Estimation Parameter	Odds Ratio (OR)
	Estimated Value	-0.1
	Confidence Interval	() 95%; -0.4 to 0.2
	Parameter Dispersion	Type: Standard Error of the Mean; Value: 0
	Estimation Comments

Statistical Analysis 3

Statistical Analysis Overview	Comparison Group Selection	Endometriosis, IVF, Tubal Infertility, IVF
	Comments	In order to handle the problem of small sample size combined with the inability to identify the theoretical statistical distribution of data, bootstrap techniques are used (10). Ader and co-workers recommend the bootstrap procedure when (a) the theoretical distribution is complicated or unknown, and/or (b) power calculations have to be performed and a small sample is available (11). Finally, the bootstrap distribution has been used in order to calculate all the confidence intervals.
	Type of Statistical Test	Superiority or Other
	Comments
Statistical Test of Hypothesis	p-Value	0.22
	Comments
	Method	Chi-squared
	Comments
Method of Estimation	Estimation Parameter	Odds Ratio (OR)
	Estimated Value	-0.15
	Confidence Interval	() 95%; -0.4 to 0.1
	Parameter Dispersion	Type: Standard Error of the Mean; Value: 0
	Estimation Comments

Adverse Events

Time Frame	A 7-year period (2004-2010).
Arm/Group Title	Endometriosis, GnRH-a Treatment, IVF		Endometriosis, IVF		Tubal Infertility, IVF
Arm/Group Description	Women with mild endometriosis who received GnRH-a treatment prior to an IVF attempt.		Women with mild endometriosis who underwent an IVF attempt without prior administration of GnRH-a.		Women with tubal infertility underwent an IVF attempt.
All Cause Mortality
	Endometriosis, GnRH-a Treatment, IVF		Endometriosis, IVF		Tubal Infertility, IVF
	Affected / at Risk (%)	# Events	Affected / at Risk (%)	# Events	Affected / at Risk (%)	# Events
Total	/ (NaN)		/ (NaN)		/ (NaN)
Serious Adverse Events
	Endometriosis, GnRH-a Treatment, IVF		Endometriosis, IVF		Tubal Infertility, IVF
	Affected / at Risk (%)	# Events	Affected / at Risk (%)	# Events	Affected / at Risk (%)	# Events
Total	2/60 (3.3%)		4/60 (6.7%)		0/60 (0%)
Reproductive system and breast disorders
Ovarian hyperstimulation syndrome	2/60 (3.3%)	2	4/60 (6.7%)	4	0/60 (0%)	0
Other (Not Including Serious) Adverse Events
	Endometriosis, GnRH-a Treatment, IVF		Endometriosis, IVF		Tubal Infertility, IVF
	Affected / at Risk (%)	# Events	Affected / at Risk (%)	# Events	Affected / at Risk (%)	# Events
Total	1/56 (1.8%)		1/60 (1.7%)		0/60 (0%)
Reproductive system and breast disorders
Premature luteinization	1/56 (1.8%)	1	1/60 (1.7%)	1	0/60 (0%)	0

Limitations/Caveats

[Not Specified]

More Information

Certain Agreements

All Principal Investigators ARE employed by the organization sponsoring the study.

There is NOT an agreement between Principal Investigators and the Sponsor (or its agents) that restricts the PI's rights to discuss or publish trial results after the trial is completed.