Effect of Different Ovulation Induction Regimens on Pregnancy Outcome of Patients with Endometriosis and Infertility Treated with In Vitro Fertilization and Transplantation

for clinical research, this paper compared the pregnancy outcomes of IVF treatment in patients with endometriosis and infertility by three ovulation induction regimens: modified long protocol, ultra-long protocol and antagonist protocol.

General information: From December 2016 to December 2019, 324 patients with endometriosis and infertility were selected as subjects. The age was (32.46±3.32) y, the duration of infertility was (4.24±3.07) y and the body mass index (BMI) was (22.20±3.35). Inclusion criteria-In line with the EMT diagnostic criteria of the Chinese Medical Association of Obstetrics and Gynecology; patients and their families are informed and voluntarily sign the research consent; whether the woman’s uterus can bear pregnancy; Age 22-45 y; those who have fertility needs and have not been pregnant for at least one year without contraceptive measures. Exclusion criteria-Either male or female suffered from serious mental illness; either male or female suffered from acute infection of urogenital system and sexually transmitted diseases; poor compliance, unable to receive IVF treatment and timely review; hydrosalpinx with impact on IVF pregnancy outcome, ≥4 cm uterine leiomyoma, severe adenomyosis; spouse with infertility; parallel participants in other clinical studies. In this study, patients were divided into three groups according to different ovulation induction protocols, including super long protocol group, modified long protocol group and antagonist protocol group. This study met the requirements of medical ethics and was www.ijpsonline.com Special Issue 3, 2021 Indian Journal of Pharmaceutical Sciences 141 compared among the three groups: total gonadotropin (Gn) dosage, Gn days, luteinizing hormone (LH) level (U/L), progesterone (P) level (mg/L) and follicle stimulating hormone (FSH) level (U/L). The number of retrieved oocytes, mature oocytes, normal cleavage and high-quality embryos were compared among the three groups. Pregnancy diagnosis-blood was drawn 14 d after transplantation, and 30 d after transplantation, B-ultrasound was used to determine whether clinical pregnancy, intrauterine and extrauterine conditions, germ and heart tube pulsation were detected, and clinical pregnancy rate, live birth rate and abortion rate were calculated. Statistical analysis: All data were analyzed by SPSS 22.0 software. Continuous variables pass the normality test to express. The count variables were expressed by the number of cases and percentage, and the comparison between groups was performed by chi square test; the test level was bilateral α=0.05. p<0.05 was considered statistically significant.

AND DISCUSSION The average age, infertility years, BMI and embryo transfer number of the three groups were not statistically significant (p>0.05), indicating that the three groups were comparable, as shown in Table 1. According to the statistics of IVF of three groups, we found that the total number of GN days and the total number of GN in the super long protocol group were lower than those in the modified long protocol group and the antagonist group (p0.05). For p level before oocyte retrieval, the modified long protocol group was the lowest, followed by the super long protocol group, and the antagonist group was the highest (p<0.05), as shown in Table 2. The number of retrieved oocytes, mature oocytes and normal cleavage in the modified long protocol group were significantly higher than those in the super long protocol group (p<0.05). The number of retrieved oocytes, mature oocytes, normal cleavage and excellent embryos in the modified long protocol group were higher than those in the antagonist protocol group (p<0.05); the number of retrieved oocytes, mature oocytes and normal cleavage in the super long protocol injected intramuscularly that night. After 36-38 h, the oocytes were removed by vaginal ultrasound. According to hormone level, embryo condition, endometrium condition and patient’s will, ovum freezing or transplantation is decided. Vitrification was used for freezing. The ovums were treated with cryoprotectant and stored in liquid nitrogen. The ovums waiting for transplantation were placed in a 5 % CO 2 incubator at 37°. IVF: IVF was performed according to the technical specification for human assisted reproduction[8]. On the day of in vitro fertilization, the semen of the man was fully liquefied, and the semen was treated by density gradient centrifugation. After 5 h of oocytes retrieval, sperm was added into the micro drop of the fertilization dish, and the final concentration of sperm was 250 000 pieces of PR grade sperm/ovums, which were cultured overnight in a 5 % CO2 incubator at 37°. The fertilization was observed 16-20 h after insemination, and the embryo quality was scored according to the consensus of Istanbul experts in 2001. The evaluation criteria of high-quality embryos were as follows: normal fertilization on the first day, division into 3-5 cells on the second day, more than 7 embryo cells on the third day, and the fragmentation rate was less than 20 %. The blastomeres were homogeneous, without vacuoles and multi-nucleation. Fresh embryos were taken from all the above programs, and all available embryos were preserved by vitrification. According to the patient’s menstrual cycle, the endometrial preparation scheme was selected: the natural cycle was selected for those with regular menstruation and normal ovulation; the hormone replacement cycle was selected for those with irregular menstruation or ovulation disorder. Embryo transfer was performed according to the routine freezing and resuscitation in our center. 14 d after transplantation, blood samples were taken to check the level of human chorionic gonadotropin (hCG). Ultrasound examination was performed 4-5 w after transplantation. If the gestational sac and heart tube pulsation were found in the uterine cavity, it was confirmed as clinical pregnancy. Observation index: The general conditions of the three groups were compared: age, infertility years, BMI, and embryo transfer number. Ovulation induction indexes were www.ijpsonline.com Special Issue 3, 2021Indian Journal of Pharmaceutical Sciences142 will not only bring physical and mental damage to women, affect family harmony and happiness, but also increase the econom ic burden of patients. The pathological and physiological process of endometriosis is complex and changeable, which may be the result of the synergistic effect of pelvic microenvironment and anatomical structure changes, oxidative stress injury, immune inflammatory response, genetic factors and endocrine dysfunction. The method to improve the pregnancy outcome of EMT with infertility has been a hot and difficult point in clinical research. IVF has become an important treatment method to improve the pregnancy outcome of EMT patients. One of the key factors for successful pregnancy is the quality of oocytes obtained by ovulation induction, in which pituitary down regulation is the key process to ensure the quality of oocytes [11] . In this study, a retrospective analysis was used to compare the embryo and pregnancy status of 324 patients with endometriosis and infertility. Our group were higher than those in the antagonist protocol group (p<0.05), as shown in Table 3. Statistics of pregnancy outcomes of the three groups showed that the pregnancy rate and live birth rate of the super long protocol group were significantly higher than those of the modified long protocol group and the antagonist protocol group (p<0.05), and the abortion rate was significantly lower than that of the other two groups (p<0.05). The pregnancy rate and live birth rate of the modified long protocol group were higher than those of the antagonist protocol group, and the abortion rate was lower (p<0.05), as shown in Table 4. Endometriosis is a common clinical gynecological disease in young and middle-aged women. It means that the active endometrial tissue (glands and stroma) is implanted outside the uterus and invades other normal tissues. Its main symptoms and consequences are abdominal pain and infertility. EMT combined with infertility has gradually become an important cause of infertility in women of childbearing age. This disease Groups Average age Years of infertility BMI Number of embryo transfer Modified long protocol 34.63±2.86 4.24±3.07 22.43±3.12 1.84±0.52 Ultra-long protocol 33.41±3.09 4.17±3.14 22.06±3.32 1.79±0.43 Antagonist regimen 32.48±3.30 4.25±3.1 7 22.45±3.52 1.86±0.58 TABLE 1: COMPARISON OF BASIC DATA OF THREE GROUPS OF PATIENTS (x̄ ±S) Groups Total Gn days Total Gn LH level before oocyte retrieval (U/L) P level before oocyte retrieval (mg/L) FSH level before oocyte retrieval (U/L) Modified long protocol 9.98±3.12 $ 2384.40±961.33 4.52±1.32 0.52±0.15 #$ 9.83±4.40 Ultra-long protocol 7.13±2.08 *# 2060.83±733.89 4.31±2.67 0.73±0.18* # 10.24±4.12 Antagonist regimen 9.55±2.22 $ 2349.40±949.26 4.09±2.11 0.84±0.27 $ * 9.31±3.45 TABLE 2: COMPARISON OF IVF OUTCOMES AMONG THE THREE GROUPS (X̄ ±S) Note： * means p<0.05 vs. Modified long protocol; # means p<0.05 vs. Antagonist regimem; $ means p<0.05 vs. Ultra long protocol Groups N Number of oocytes Number of mature oocytes Normal oocytes division number Number of excellent embryos Modified long protocol 105 11.55±8.25 #$ 10.26±7.29 #$ 6.42±5.43 #$ 3.23±3.19 # Antagonist regimen 62 7.21±5.35$* 6.07±4.83$* 3.92±3.01$* 2.19±2.09* Ultra-long protocol 157 9.04±5.80 *# 8.31±5.67 *# 5.11±4.08 *# 2.62±2.63 TABLE 3: COMPARISON OF OOCYTE RETRIEVAL AND EMBRYO RETRIEVAL AMONG THREE GROUPS (X̄ ±S) Note: *means p<0.05 vs. Modified long protocol; # means p<0.05 vs. Antagonist regimem; $ means p<0.05 vs. Ultra long protocol Groups N Gestation Live birth Abortion Modified long protocol 105 76 (72.4 %) #$ 56 (53.3 %) #$ 20 (19.0 %) #$ Antagonist regimen 62 42 (67.7 %)* $ 25 (40.3 %)* $ 17 (27.4 %)* $ Ultra long protocol 157 116 (73.9 %) # * 103 (65.6 %) # * 13 (8.3 %) # * TABLE 4: COMPARISON OF PREGNANCY OUTCOMES AMONG THE THREE GROUPS [N (%)] Note: *means p<0.05 vs. Modified long protocol; # means p<0.05 vs. Antagonist regimem; $ means p<0.05 vs. Ultra long protocol www.ijpsonline.com Special Issue 3, 2021 Indian Journal of Pharmaceutical Sciences 143 total number of GN days and the total amount of GN in the super long protocol group were lower than those in the modified long protocol group and the antagonist group, which had the advantage of clinical significance. It was a worthy ovulation induction program for patients with endometriosis and infertility.

This work was supported by the General Hospital of NorthernTheater Command. Conflicts of interest: The authors report no conflicts of interest.

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Danhof NA, Van Wely M, Koks CA, Gianotten J, De Bruin JP, survey results showed that the pregnancy rate and live birth rate of patients treated with ultra-long protocol were higher than those treated with modified long protocol and antagonist protocol, and the abortion rate was significantly lower than those treated with modified long protocol and antagonist protocol, indicating that the ultra-long protocol can significantly improve the pregnancy outcome of patients with endometriosis complicated with infertility The transplantation rate and clinical pregnancy rate of fresh cycle were analyzed. The results of this study also showed that the total number of days of GN and the total amount of GN in the super long protocol group were lower than those in the modified long protocol group and the antagonist group, indicating that the super long protocol was convenient for medication and less injection times, which directly affected the clinical compliance and patient acceptance. The reason may be the decrease of estrogen level in the process of promoting ovulation, which improves endometrial receptivity and avoids ovarian hyper stimulation[12]. The number of retrieved oocytes, mature oocytes and normal cleavage in the modified long protocol group was significantly higher than that in the super long protocol group and the antagonist protocol group. The number of retrieved oocytes, mature oocytes and normal cleavage in the super long protocol group was higher than that in the antagonist protocol group. This study found that the pregnancy rate and live birth rate of modified long protocol were high, and the abortion rate was low [13]. GnRH-a is a drug that can compete with endogenous GnRH to act on the pituitary gland, which can make the pituitary GnRH-a receptor in a desensitized state, thus inhibiting the ovarian secretion of related hormones[14]. In this study, GnRH-a was used in both modified long protocol and super long protocol to achieve the effect of pituitary down regulation. However, the antagonist scheme also has its clinical advantages. The GN releasing hormone used in this scheme has a wide range of application, avoids the transient increase effect of GnRH-a, does not need the down-regulation process, has short treatment cycle, and is flexible and convenient to use[15]. In conclusion, modified long protocol has clinical advantages in improving the number of IVF oocytes and laboratory embryos, but the pregnancy rate and live birth rate of super long protocol are higher than those of modified long protocol and antagonist protocol, and the abortion rate is significantly lower than that of modified long protocol and antagonist protocol. In addition, the www.ijpsonline.com Special Issue 3, 2021Indian Journal of Pharmaceutical Sciences 144 embryo quality in Thai native heifers. 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Comparison of three superovulation protocols with or without GnRH treatment at the time of artificial insemination on ovarian response and This article was originally published in a special issue, “Evolutionary Strategies in Biomedical Research and Pharmaceutical Sciences” Indian J Pharm Sci 2021:83(3) Spl issue;139-144 This is an open access article distributed under the terms of the Creative Commons Attribution-NonCommercial-ShareAlike 3.0 License, which allows others to remix, tweak, and build upon the work non-commercially, as long as the author is credited and the new creations are licensed under the identical terms