FERTILITY AND STERILITY VOL. 74, NO. 5, NOVEMBER 2000 Copyright 2000 American Society for Reproductive Medicine Published by Elsevier Science Inc. Printed on acid-free paper in U.S.A. Effects of functional ovarian cysts detected on the 7th day of gonadotropin-releasing hormone analog administration on the outcome of IVF treatment Marinko M. Biljan, M.R.C.O.G., Louise Lapensée, M.D., Neal G. Mahutte, M.D., François Bissonnette, M.D., Robert Hemmings, M.D., and Seang Lin Tan, F.R.C.O.G. McGill Reproductive Center, Department of Obstetrics and Gynecology, Royal Victoria Hospital, McGill University, Montreal, Québec, Canada Objective: To investigate the impact of functional ovarian cysts on the time required to achieve pituitary suppression, follicular development, embryo quality, and pregnancy rates during IVF treatment. Design: Prospective observational study. Intervention(s): Daily treatment with buserelin (sc 500 g) was initiated on day 2 of menstruation. Ultrasound and hormonal tests were performed on days 1, 7, 11, 14, and weekly thereafter until pituitary suppression was achieved. Result(s): 48 patients underwent 51 cycles of IVF treatment. A functional cyst was detected in three cycles (5.8%) with baseline ultrasound scan and in 27 cycles (52.9%) on day 7 of buserelin administration. Patients who developed a cyst required a significantly longer time to achieve pituitary suppression (21 vs. 7 days), had a significantly lower FSH level at the time of initiation of gonadotropins, required more ampules of gonadotropin (45 vs. 41 ampules), developed less follicles (13 vs. 17.5), and had lower embryo quality. However, there were no differences in the implantation (23.5% vs. 17.2%) and pregnancy rates (37.2% vs. 29.2%) between two groups. Conclusion(s): Functional cysts prolong the period to achieving pituitary suppression, increase gonadotropin requirements, and decrease follicular recruitment and embryo quality. They have, however, no negative effect on pregnancy rates. (Fertil Steril 2000;74:941 5. 2000 by American Society for Reproductive Medicine.) Key Words: Ovarian cysts, long protocol, pituitary suppression, GnRH-a, implantation Received November 29, 2000; accepted May 19, 2000. Presented at the Conjoint Annual Meeting of American Society for Reproductive Medicine and Canadian Fertility and Andrology Society, Toronto, Ontario, Canada, September 25 30, 1999. Reprint requests: Marinko M. Biljan M.R.C.O.G., McGill Reproductive Center, Department of Obstetrics and Gynecology, Royal Victoria Hospital, Women s Pavilion, 687 Pine Avenue West, Montreal H3A 1A1, Quebec, Canada (FAX: 514-843-1678; E-mail: mbiljan @rvhob2.lan.mcgill.ca). 0015-0282/00/$20.00 PII S0015-0282(00)01555-7 The formation of functional ovarian cysts has been recognized as one of the side effects of gonadotropin-releasing hormone analog (GnRH-a) treatment (1). The pathophysiology of cyst formation was elucidated some time ago (2), but its effects on cycle success remain controversial. Although some studies suggest very poor outcome of cycles where functional cysts were detected, including high cancellation and low pregnancy rates (3 6), others have failed to report a difference in any outcome measures when comparing the patients who did develop functional ovarian cysts with those who did not (1, 7 10). Pretreatment with oral contraceptives (11, 12) or progesterone (13, 14) can to a large extent decrease cyst formation, but it cannot completely abolish it. It is, therefore, of considerable scientific interest to clarify the exact role that the presence of cysts plays on cycle outcome. If high cancellation or low pregnancy rates follow cyst formation, it would be of some benefit to abandon a treatment cycle prior to the start of costly ovulation induction with gonadotropins (5). Studies conducted thus far have failed to investigate prospectively the hormonal changes caused by cyst formation, and their potential effect on IVF treatment cycle outcome. In this study, our objective was to assess the differences in the dynamics of hormonal changes and subsequent treatment outcome in patients who developed a cyst and those who did not. MATERIALS AND METHODS The study recruited 48 patients on whom a long protocol of pituitary suppression was be- 941
ing performed, commencing in the early follicular phase, as a part of IVF-ET. Patients were treated with a standard long protocol of daily subcutaneous buserelin (500 g; Suprefact, Hoechst Marion Roussel, Laval, Quebec, Canada) doses initiated on the second day of the menstrual cycle (15). A transvaginal ultrasound scan was performed and a blood sample taken on the first day of the menstrual bleed. Thereafter, blood tests and ultrasound scans were repeated on days 7, 11, and 14 of the buserelin administration. Functional ovarian cysts were defined as any intraovarian sonolucent structure with a mean diameter 15 mm with a serum E 2 concentration greater than 40 pg/ml. Regardless of their functional status, patients were excluded from the study if they had an ovarian cyst measuring more than 15 mm in diameter, as detected on an ultrasound scan performed in the cycle prior to the commencement of IVF treatment. Pituitary suppression was defined as a serum E 2 concentration greater than 40 pg/ml. If pituitary suppression was not achieved following 14 days of buserelin administration, then the dose of buserelin was increased to 500 g twice a day (16), and an intramuscular injection of progesterone (100 mg) was administered (17). If pituitary suppression still was not achieved after 3 weeks of buserelin administration, the ovarian cyst was aspirated under ultrasound guidance. Ovarian stimulation was started at least 3 days following cyst aspiration provided that the serum E 2 levels had decreased to below 40 pg/ml. The serum from all blood samples was separated and stored at 20 C for subsequent batch assay. Serum LH and FSH concentrations were measured with commercially available chemiluminometric (sandwich) immunoassays (ACS- LH, Chiron Diagnostics, Medfield, MA; and ACS-FSH, Chiron Diagnostics). The detection level for both LH and FSH assays was 0.3 miu/ml with intra-assay precision of 4.7% at 5.3 miu/ml for LH, and 2.8% at 4.3 miu/ml for FSH. To analyze serum concentrations of E 2, a competitive chemiluminescent immunoassay was used (ACS-estradiol-6, Chiron Diagnostics). This assay had a detection level of 10 pg/ml, and gave an intra-assay precision of 4.2% at 234 pg/ml. Following satisfactory pituitary suppression, ovarian stimulation was achieved with hmg (75 IU FSH and 75 IU LH, Humegon; Organon, Scarborough, Ontario, Canada) or with pure follicle-stimulating hormone (75 IU FSH, Fertinorm; Serono, Oakville, Ontario, Canada). The choice between the two types of gonadotropins was left to the patient s individual preference. The initial dose of gonadotropins used was determined according to the patient s age and the serum FSH level on day 3 of the cycle, and was subsequently adjusted according to the follicular response as determined by serial ultrasound scans. hcg (Profasi; Serono, Oakville, Ontario, Canada) was administered when there were at least three follicles with a mean diameter (measured in three planes) of at least 18 mm. Transvaginal oocyte recovery was performed 36 hours following hcg administration and the embryo transfer was performed 2 days after oocyte retrieval. Prior to transfer, all embryos were graded and given a rating according to blastomere quality as follows: Grade I, equal sized symmetrical blastomeres with 10% fragmentation were given a rating of 4; Grade II, uneven blastomeres with 10% fragmentation were rated as 3; Grade III, 10% to 50% fragmentation were rated as 2; and Grade IV, 50% fragmentation were given a rating of 1. An embryo score per individual embryo was calculated by multiplying the rating of the embryo by the number of blastomeres. The scores of all embryos transferred per patient were summed to give the cumulative embryo score (CES) (18). All embryos were assessed by one embryologist. The luteal phase was supplemented with 200 mg of micronized progesterone (Prometrium; Schering, Point-Claire, Quebec, Canada) which was self-administered by the patients, vaginally, twice daily, starting from the day of oocyte collection. A serum pregnancy test was performed 14 days following the embryo transfer. This protocol was approved by the Royal Victoria Hospital Ethics Committee and each patient gave written, informed consent before participating in the study. Statistics At least 22 patients were required in each group for the study to have 80% power to detect a reduction, from 65% to 20%, in the proportion of patients who achieved pituitary suppression following 7 days of GnRH-a administration ( 0.05). The normality of data distribution was tested using the Shapiro-Wilks test. As the results were found not to be normally distributed, the data were analyzed using a Mann- Whitney test, 2 and Fisher-Irwin test. A 95% confidence interval was calculated for all performed tests. A P value.05 was considered statistically significant. RESULTS The study included 48 patients on whom were performed 51 cycles of IVF-ET. Three patients had a functional ovarian cyst detected during the ultrasound scan on the first day. In two of these patients, the cysts enlarged and the serum E 2 level increased following 7 days of buserelin administration. In one patient, the cyst decreased in diameter from 14 to 12 mm and the serum E 2 level declined from 64 pg/ml to 21 pg/ml. Additionally, 25 patients who had no functional cysts detected on baseline ultrasound scan developed one or multiple functional ovarian cysts during the first 7 days of buserelin administration. The median size of functional cysts detected on day 7 of buserelin administration was 23 mm (range 15 38). There were no significant differences in age (P.1, median difference 2.3 years, 95% confidence interval 942 Biljan et al. Functional ovarian cysts and IVF outcome Vol. 74, No. 5, November 2000
FIGURE 1 The difference in (A) FSH, (B) LH, and (C)E 2 levels ( 85% confidence interval) among patients who did not develop an ovarian cyst (E) and those who did ( ). Biljan. Functional ovarian cysts and IVF outcome. Fertil Steril 2000. 0.1 to 5.2), cause of infertility (P.36), or incidence of polycystic ovaries (P.96) found between patients who formed cysts with those who did not. Similarly, there were no significant differences between the two groups with regard to serum E 2 levels (MD 1.5 pg/ml, 95% CI 18.1 to 15.0), FSH levels (MD 0.6 miu/ml, 95% CI 1.8 to 3.0) and LH levels (MD 1.0 miu/ml, 95% CI 0.6 to 2.8) on day 1 of the menstrual cycle. Additionally, there was no difference in the proportion of patients who used pure FSH instead of hmg for ovulation induction (20 vs. 28.6%, P.88, odds ratio 1.4, 95% CI 0.3 to 7.3). The FSH levels were observed to be significantly more suppressed in patients who developed a cyst (Fig. 1A). The LH levels were initially marginally higher in cyst formers (MD 0.1 miu/ml, 95% CI 1.6 to 1.7); however, by the time of commencement of gonadotropin treatment, the levels decreased below those recorded in patients who did not develop a cyst (MD 0.8 miu/ml, 95% CI 1.9 to 0.3 (see Fig. 1B). Functional ovarian cysts served as an estrogen reservoir, which resulted in significantly higher serum levels of E 2 during the first 14 days of buserelin administration (see Fig. 1C). In spite of a prolonged exposure to buserelin and progesterone administration, in three patients pituitary suppression was not achieved, so ovarian cyst aspiration was performed. As a result of their sustained elevated E 2 levels, patients who developed an ovarian cyst required a significantly longer period of buserelin treatment prior to initiation of the treatment with gonadotropins (MD 7 days, 95% CI 0 to 14) (Table 1). In patients who developed an ovarian cyst, follicular recruitment and development were suppressed. This resulted in a significant increase in gonadotropin requirements (MD 4 ampules, 95% CI 0 to 13), a decrease in follicular development (MD 4 follicles, 95% CI 0 to 8), and fertilization rate (OR 1.8, 95% CI 1.3 to 2.6). Interest- FERTILITY & STERILITY 943
TABLE 1 Comparison between patients who did and did not develop a functional ovarian cyst. Developed Ovarian Cyst (n 27) Did Not Develop Ovarian Cyst (n 24) P Value Age 37.0 a (30.5 42.2) b 34.2 (23.7 42.3) NS Days on buserelin required to achieve pituitary suppression 21 (11 35) 7 (7 28).006 FSH level at the time of gonadotropin treatment (miu/ml) 1.8 (0.4 7.7) 4.4 (1.3 9.3).02 LH level at the time of gonadotropin treatment (miu/ml) 1.3 (0.4 4.7) 2.5 (0.8 6.7) NS Days on gonadotropins 12 (9 16) 11 (9 4) NS Total quantity of gonadotropins used (amp) 45 (36 113) 41 (24 84).05 E 2 (pg/ml) on the day of hcg administration 1774 (308 4970) 1738 (485 7514) NS Number of follicles 13 (3 20) 17.5 (3 32).04 Number of oocytes collected 10 (3 19) 10.5 (3 32) NS Fertilization rate (%) 51 (0 89) 64 (13 100).0037 Number of embryos 5 (0 15) 8 (2 20).02 Cumulative embryo score 28 (6 66) 36 (28 56).05 Number of embryos replaced 3 (0 3) 3 (0 3) NS Implantation rate (%) 23 (0 67) 17 (0 100) NS Clinical pregnancy rate per cycle started (%) 37.4 29.2 NS NS nonsignificant. a median. b range. Biljan. Functional ovarian cysts and IVF outcome. Fertil Steril 2000. ingly, in spite of a lower number of available embryos (MD 2.5 embryos, 95% CI 0 to 5) and lower cumulative embryo scores (MD 8, 95% CI 0 to 14), patients who developed cysts maintained marginally higher implantation (OR 1.8, 95% CI 0.7 to 4.7) and pregnancy rates (OR 1.4, 95% CI 0.4 to 5.5) (see Table 1). DISCUSSION The implications of functional ovarian cysts on cycle outcome are still controversial. Some authors have reported high cancellation and low pregnancy rates (3 6) in patients who developed ovarian cysts, but others have failed to demonstrate a detrimental effect of cyst formation on cycle outcome (1, 7 10). Our data offer new insights and possible explanations for the controversy in the literature. In cyst formers, we confirmed a significant increase in E 2 levels, probably caused by a passive diffusion from the cyst into the circulation. As E 2 levels were used as a criterion of pituitary suppression, cyst formers were exposed to significantly longer periods of GnRH-a administration prior to the initiation of gonadotropin therapy. The most interesting finding, however, is the deep suppression of endogenous FSH secretion observed in cyst formers, which was more profound with prolonged exposure to GnRH-a. The FSH suppression was probably caused by a continuous diffusion of E 2 from the ovarian cyst, by the same mechanism of suppression previously observed when ethinyl E 2 was given orally to women in the early follicular phase (19). This profound suppression of endogenous FSH levels may be an explanation for the significant increase in gonadotropin requirements, lower follicular recruitment, and lower fertilization rate, which ultimately lead to a poorer choice of embryos available for transfer. In the literature two different approaches have been advocated in the management of functional ovarian cysts. In one group of studies, ovarian cysts were aspirated early and treatment with gonadotropins was started several days later following a rapid decline in E 2 levels (20, 21). In this group of studies, cyst formers developed a similar number of follicles to patients who did not develop ovarian cysts. In the other group of studies (2, 5, 10), treatment with GnRH-a was continued for a lengthy period of time allowing a more gradual decrease in E 2 levels. In those studies, similar to ours, a decrease in follicular recruitment was observed. In one study (21) some patients had early ovarian cyst aspiration while others continued with GnRH-a until satisfactory levels of E 2 were achieved. Patients who followed this conservative course of treatment required significantly more ampules of gonadotropins to achieve satisfactory ovarian stimulation, had lower peak serum E 2 levels, and had significantly fewer oocytes retrieved. In the only prospective study by Rizk and colleagues (22), no significant difference in either follicular recruitment or embryo development was observed between patients who had a cyst aspirated and those who did not. In that study, however, cyst aspiration was performed at least 21 days following the start of GnRH-a administration. At that point, endogenous FSH suppression was probably profoundly depressed in both groups, which might account for an absence of a significant improvement of folliculogenesis following 944 Biljan et al. Functional ovarian cysts and IVF outcome Vol. 74, No. 5, November 2000
cyst aspiration. Interestingly, in studies where cysts were aspirated early, in spite of an improved follicular recruitment and embryo quality, a significant decrease in pregnancy rate was observed (6, 20). This may be due to the negative effect of a rapid decline in E 2 levels following cyst aspiration on the endometrium (23). In summary, patients who develop ovarian cysts require a prolonged period of time to achieve pituitary suppression. This causes difficulties in cycle programming and increases the patients anxiety. For these reasons, prevention of cyst formation with either an oral contraceptive (11, 12) or progesterone (13, 14) should be attempted. However, our data demonstrate that the occurrence of an ovarian cyst in general should not be an indication for cycle cancellation, as it does not decrease either implantation or pregnancy rates. The comparable pregnancy rate is, perhaps, the result of the balance between a negative effect on follicular recruitment and a positive effect on endometrial receptivity. It should not be overlooked, however, that cyst formers have impaired follicular recruitment, leading to a decreased number of good quality embryos available for transfer. Early aspiration of ovarian cysts probably improves follicular recruitment but not necessarily pregnancy rates. References 1. Feldberg D, Ashkenazi J, Dicker D, Yeshaya A, Goldman GA, Goldman JA. Ovarian cyst formation: a complication of gonadotropinreleasing hormone agonist therapy. Fertil Steril 1989;51:42 5. 2. Ron-El R, Herman A, Golan A, Raziel A, Soffer Y, Caspi E. Follicle cyst formation following long-acting gonadotropin-releasing hormone analog administration. Fertil Steril 1989;52:1063 6. 3. Thatcher SS, Jones E, DeCherney AH. Ovarian cysts decrease the success of controlled ovarian stimulation and in vitro fertilization. Fertil Steril 1989;52:812 6. 4. Segal S, Shifren JL, Isaacson KB, Leykin L, Chang Y, Pal L, et al. Effect of a baseline ovarian cyst on the outcome of in vitro fertilizationembryo transfer. Fertil Steril 1999;71:274 7. 5. Keltz MD, Jones EE, Duleba AJ, Polcz T, Kennedy K, Olive DL. Baseline cyst formation after luteal phase gonadotropin-releasing hormone agonist administration is linked to poor in vitro fertilization outcome. Fertil Steril 1995;64:568 72. 6. Ben-Rafael Z, Bider D, Menashe Y, Maymon R, Zolti M, Mashiach S. Follicular and luteal cysts after treatment with gonadotropin-releasing hormone analog for in vitro fertilization. Fertil Steril 1990;53:1091 4. 7. Karande VC, Scott RT, Jones GS, Muasher SJ. Non-functional ovarian cysts do not affect ipsilateral or contralateral ovarian performance during in-vitro fertilization. Hum Reprod 1990;5:431 3. 8. Hornstein MD, Barbieri RL, Ravnikar VA, McShane PM. The effects of baseline ovarian cysts on the clinical response to controlled ovarian hyperstimulation in an in vitro fertilization program. Fertil Steril 1989; 52:437 40. 9. Herman A, Ron-El R, Golan A, Nahum H, Soffer Y, Caspi E. Follicle cysts after menstrual versus midluteal administration of gonadotropinreleasing hormone analog in in vitro fertilization. Fertil Steril 1990;53: 854 8. 10. Sampaio M, Serra V, Miro F, Calatayud C, Castellvi RM, Pellicer A. Development of ovarian cysts during gonadotrophin-releasing hormone agonists (GnRHa) administration. Hum Reprod 1991;6:194 7. 11. Biljan MM, Mahutte NG, Dean N, Hemmings R, Bissonnette F, Tan SL. Pretreatment with an oral contraceptive is effective in reducing the incidence of functional ovarian cyst formation during pituitary suppression by gonadotropin-releasing hormone analogues. J Assist Reprod Gen 1998;15:599 604. 12. Biljan MM, Mahutte NG, Dean N, Hemmings R, Bissonnette F, Tan SL. Effects of pre-treatment with an oral contraceptive pill on the time required to achieve pituitary suppression by GnRh analogues and subsequent implantation and pregnancy rates. Fertil Steril 1998;70: 1063 9. 13. Aston K, Arthur I, Masson GM, Jenkins JM. Progestogen therapy and prevention of functional ovarian cysts during pituitary desensitisation with GnRH agonists. Br J Obstet Gynaecol 1995;102:835 7. 14. Engmann L, Maconochie N, Bekir J, Tan SL. A prospective randomized study to assess the effect of progestogen therapy during pituitary desensitization with GnRH agonist in the prevention of functional cyst formation. Am J Obstet Gynecol 1999;181:576 82. 15. Tan SL, Maconochie N, Doyle P, Campbell S, Balen A, Bekir J, et al. Cumulative conception and live-birth rates after in vitro fertilization with and without the use of long, short, and ultrashort regimens of the gonadotropin-releasing hormone agonist buserelin. Am J Obstet Gynecol 1994;171:513 20. 16. Meldrum DR, Gutlay AL, Wisot A, Huynh D, Hamilton F, Kempton W. Timing of initiation and dose schedule of leuprolide influence the time course of ovarian suppression. Fertil Steril 1988;50:400 2. 17. Shaker AG, Pittrof R, Zaidi J, Bekir J, Kyei-Mensah A, Tan SL. Administration of progestogens to hasten pituitary desensitization after the use of gonadotropin-releasing hormone agonist in in vitro fertilization a prospective randomized study. Fertil Steril 1995;64:791 5. 18. Steer CV, Mills CL, Tan SL, Campbell S, Edwards RG. The cumulative embryo score: a predictive embryo scoring technique to select the optimal number of embryos to transfer in an in-vitro fertilization and embryo transfer programme. Hum Reprod 1992;7:117 9. 19. Tsai CC, Yen SSC. The effect of ethinyl estradiol administration during early follicular phase of the cycle on the gonadotropin levels and ovarian function. J Clin Endocrinol Metab 1971;33:917 23. 20. Tarlatzis BC, Bili H, Bontis J, Lagos S, Vatev I, Mantalenakis S. Follicle cyst formation after administration of different gonadotrophinreleasing hormone analogues for assisted reproduction. Hum Reprod 1994;9:1983 6. 21. Parinaud J, Cohen K, Oustry P, Perineau M, Monrozies X, Reme JM. Influence of ovarian cysts on the results of in vitro fertilization. Fertil Steril 1992;58:1174 7. 22. Rizk B, Tan SL, Kingsland C, Steer C, Mason BA, Campbell S. Ovarian cyst aspiration and the outcome of in vitro fertilization. Fertil Steril 1990;54:661 4. 23. Weissman A, Barash A, Manor M, Ben-Arie A, Granot I, Shoham Z. Acute changes in endometrial thickness after aspiration of functional ovarian cysts. Fertil Steril 1998;69:1142 4. FERTILITY & STERILITY 945