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Meta-Analysis
. 2017 May 25;5(5):CD006109.
doi: 10.1002/14651858.CD006109.pub3.

Oral contraceptive pill, progestogen or oestrogen pretreatment for ovarian stimulation protocols for women undergoing assisted reproductive techniques

Affiliations
Meta-Analysis

Oral contraceptive pill, progestogen or oestrogen pretreatment for ovarian stimulation protocols for women undergoing assisted reproductive techniques

Cindy Farquhar et al. Cochrane Database Syst Rev. .

Abstract

Background: Among subfertile women undergoing assisted reproductive technology (ART), hormone pills given before ovarian stimulation may improve outcomes.

Objectives: To determine whether pretreatment with the combined oral contraceptive pill (COCP) or with a progestogen or oestrogen alone in ovarian stimulation protocols affects outcomes in subfertile couples undergoing ART.

Search methods: We searched the following databases from inception to January 2017: Cochrane Gynaecology and Fertility Group Specialised Register, The Cochrane Central Register Studies Online, MEDLINE, Embase, CINAHL and PsycINFO. We also searched the reference lists of relevant articles and registers of ongoing trials.

Selection criteria: Randomised controlled trials (RCTs) of hormonal pretreatment in women undergoing ART.

Data collection and analysis: We used standard methodological procedures recommended by Cochrane. The primary review outcomes were live birth or ongoing pregnancy and pregnancy loss.

Main results: We included 29 RCTs (4701 women) of pretreatment with COCPs, progestogens or oestrogens versus no pretreatment or alternative pretreatments, in gonadotrophin-releasing hormone (GnRH) agonist or antagonist cycles. Overall, evidence quality ranged from very low to moderate. The main limitations were risk of bias and imprecision. Most studies did not describe their methods in adequate detail. Combined oral contraceptive pill versus no pretreatmentWith antagonist cycles in both groups the rate of live birth or ongoing pregnancy was lower in the pretreatment group (OR 0.74, 95% CI 0.58 to 0.95; 6 RCTs; 1335 women; I2 = 0%; moderate quality evidence). There was insufficient evidence to determine whether the groups differed in rates of pregnancy loss (OR 1.36, 95% CI 0.82 to 2.26; 5 RCTs; 868 women; I2 = 0%; moderate quality evidence), multiple pregnancy (OR 2.21, 95% CI 0.53 to 9.26; 2 RCTs; 125 women; I2 = 0%; low quality evidence), ovarian hyperstimulation syndrome (OHSS; OR 0.98, 95% CI 0.28 to 3.40; 2 RCTs; 642 women; I2 = 0%, low quality evidence), or ovarian cyst formation (OR 0.47, 95% CI 0.08 to 2.75; 1 RCT; 64 women; very low quality evidence).In COCP plus antagonist cycles versus no pretreatment in agonist cycles, there was insufficient evidence to determine whether the groups differed in rates of live birth or ongoing pregnancy (OR 0.89, 95% CI 0.64 to 1.25; 4 RCTs; 724 women; I2 = 0%; moderate quality evidence), multiple pregnancy (OR 1.36, 95% CI 0.85 to 2.19; 4 RCTs; 546 women; I2 = 0%; moderate quality evidence), or OHSS (OR 0.63, 95% CI 0.20 to 1.96; 2 RCTs; 290 women, I2 = 0%), but there were fewer pregnancy losses in the pretreatment group (OR 0.40, 95% CI 0.22 to 0.72; 5 RCTs; 780 women; I2 = 0%; moderate quality evidence). There were no data suitable for analysis on ovarian cyst formation.One small study comparing COCP versus no pretreatment in agonist cycles showed no clear difference between the groups for any of the reported outcomes. Progestogen versus no pretreatmentAll studies used the same protocol (antagonist, agonist or gonadotrophins) in both groups. There was insufficient evidence to determine any differences in rates of live birth or ongoing pregnancy (agonist: OR 1.35, 95% CI 0.69 to 2.65; 2 RCTs; 222 women; I2 = 24%; low quality evidence; antagonist: OR 0.67, 95% CI 0.18 to 2.54; 1 RCT; 47 women; low quality evidence; gonadotrophins: OR 0.63, 95% CI 0.09 to 4.23; 1 RCT; 42 women; very low quality evidence), pregnancy loss (agonist: OR 2.26, 95% CI 0.67 to 7.55; 2 RCTs; 222 women; I2 = 0%; low quality evidence; antagonist: OR 0.36, 95% CI 0.06 to 2.09; 1 RCT; 47 women; low quality evidence; gonadotrophins: OR 1.00, 95% CI 0.06 to 17.12; 1 RCT; 42 women; very low quality evidence) or multiple pregnancy (agonist: no data available; antagonist: OR 1.05, 95% CI 0.06 to 17.76; 1 RCT; 47 women; low quality evidence; gonadotrophins: no data available). Three studies, all using agonist cycles, reported ovarian cyst formation: rates were lower in the pretreatment group (OR 0.16, 95% CI 0.08 to 0.32; 374 women; I2 = 1%; moderate quality evidence). There were no data on OHSS. Oestrogen versus no pretreatmentIn antagonist or agonist cycles, there was insufficient evidence to determine whether the groups differed in rates of live birth or ongoing pregnancy (antagonist versus antagonist: OR 0.79, 95% CI 0.53 to 1.17; 2 RCTs; 502 women; I2 = 0%; low quality evidence; antagonist versus agonist: OR 0.88, 95% CI 0.51 to 1.50; 2 RCTs; 242 women; I2 = 0%; very low quality evidence), pregnancy loss (antagonist versus antagonist: OR 0.16, 95% CI 0.02 to 1.47; 1 RCT; 49 women; very low quality evidence; antagonist versus agonist: OR 1.59, 95% CI 0.62 to 4.06; 1 RCT; 220 women; very low quality evidence), multiple pregnancy (antagonist versus antagonist: no data available; antagonist versus agonist: OR 2.24, 95% CI 0.09 to 53.59; 1 RCT; 22 women; very low quality evidence) or OHSS (antagonist versus antagonist: no data available; antagonist versus agonist: OR 1.54, 95% CI 0.25 to 9.42; 1 RCT; 220 women). Ovarian cyst formation was not reported. Head-to-head comparisonsCOCP was compared with progestogen (1 RCT, 44 women), and with oestrogen (2 RCTs, 146 women), and progestogen was compared with oestrogen (1 RCT, 48 women), with an antagonist cycle in both groups. COCP in an agonist cycle was compared with oestrogen in an antagonist cycle (1 RCT, 25 women). Data were scant but there was no clear evidence that any of the groups differed in rates of live birth or ongoing pregnancy, pregnancy loss or other adverse events.

Authors' conclusions: Among women undergoing ovarian stimulation in antagonist protocols, COCP pretreatment was associated with a lower rate of live birth or ongoing pregnancy than no pretreatment. There was insufficient evidence to determine whether rates of live birth or ongoing pregnancy were influenced by pretreatment with progestogens or oestrogens, or by COCP pretreatment using other stimulation protocols. Findings on adverse events were inconclusive, except that progesterone pretreatment may reduce the risk of ovarian cysts in agonist cycles, and COCP in antagonist cycles may reduce the risk of pregnancy loss compared with no pretreatment in agonist cycles.

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Conflict of interest statement

LR was the first author of a randomized trial about oral contraceptive pretreatment (Rombauts 2006). This study was sponsored by Organon/Schering Plough. He was not involved in selection of that study or in extraction and interpretation of data from it. He is a minority shareholder in an IVF unit that has received research grants from MSD, Merck‐Serono and Ferring. He has received educational grants from MSD, Merck‐Serono and Ferring and provided consultancy services and board membership to Ferring Australia.

ROA, AL, CF and JK have no interests to declare.

Figures

1
1
Methodological quality graph: review authors' judgements about each methodological quality item presented as percentages across all included studies.
2
2
Methodological quality summary: review authors' judgements about each methodological quality item for each included study.
3
3
Study PRISMA flow chart
4
4
Forest plot of comparison: 1 Combined oral contraceptive pill (OCP) versus no pretreatment (Rx), outcome: 1.1 Live birth or ongoing pregnancy.
5
5
Forest plot of comparison: 1 Combined oral contraceptive pill (COCP) versus no pretreatment (Rx), outcome: 1.2 Pregnancy loss.
6
6
Forest plot of comparison: 3 Oestrogen versus no pretreatment (Rx), outcome: 3.1 Live birth or ongoing pregnancy.
7
7
Forest plot of comparison: 3 Oestrogen versus no pretreatment (Rx), outcome: 3.2 Pregnancy loss.

Update of

References

References to studies included in this review

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Huirne 2006a {published data only}
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Huirne 2006c {published data only}
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Hwang 2004 {published data only}
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Kim 2011 {published data only}
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Kolibianakis 2006 {published data only}
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Lukaszuk 2015 {published data only}
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Obruca 2002 {published data only}
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Porrati 2010 {published data only}
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Rombauts 2006 {published data only}
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Ye 2009 {published data only}
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References to studies excluded from this review

Aghahosseini 2011 {published data only}
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Chung 2006 {published data only}
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Copperman 2003 {published data only}
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Couzinet 1995 {published data only}
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Damario 1997 {published data only}
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Davar 2014 {published data only}
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Davy 2004 {published data only}
    1. Davy C, Guibert J, Blanchet V, Nataf E, Olivennes F. The 'wash out' period do not create asynchrony of the follicle cohort when contraceptive pill is used to program GnRH antagonist IVF cycles. Human Reproduction. 2004; Vol. 19 Suppl 1:i5‐6.
    1. Olivennes F Sr, Davy C, Guibert J, Nataf E, Blanchet V. Asynchrony of the follicle cohort is not induced by the “wash out” period when contraceptive pill is used to program GnRH antagonist IVF cycles. Fertility and Sterility 2004; Vol. Suppl 2, 82:S234.
De Ziegler 1999 {published data only}
    1. Ziegler D, Brioschi PA, Benchaa C, Campana A, Ditesheim PJ, Fanchin R, et al. Programming ovulation in the menstrual cycle by a simple innovative approach: back to the future of assisted reproduction. Fertility and Sterility 1999;72(1):77‐82. - PubMed
Dickey 2001 {published data only}
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Ditkoff 1997 {published data only}
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Fanchin 2001 {published data only}
    1. Fanchin R, Schonauer L, Cunha Filho J, Kadoch I, Cohen Bacrie P, Frydman R. Luteal E2 administration reduces size and improves homogeneity of selectable follicles on cycle‐day 3: bases for novel controlled ovarian hyperstimulation (COH) concepts. Fertility and Sterility 2001; Vol. Suppl 1, 76, issue 3:S90.
Fanchin 2003b {published data only}
    1. Fanchin R, Cunha Filho J, Schonauer L, Kadoch I, Cohen Bacri P, Frydman R. Co‐ordination of early antral follicles by luteal estradiol administration: basis for novel controlled ovarian hyperstimulation. Human Reproduction. 2002; Vol. 17 Abstract Book 1:88‐9.
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    1. Ghanem M, Bediary MH, Helal AS, et al. Is adding estradiole (E2) to progesterone (P) luteal support in high responder long GnRH agonist ICSI cycles detrimental to outcome? Randomised controlled trial (RCT). Fertility & Sterility 2015;104 Suppl(3):e224.
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    1. Gonzalez P, Maloul S, Ciuffardi I, Frederick JL, Balmaceda JP, Asch RH. The use of progestins for programming assisted reproductive cycles and gonadotropin‐releasing hormone agonist flare‐up protocols in older patients. Fertility and Sterility 1995;63(2):249‐51. - PubMed
Greco 2016 {published data only}
    1. Greco E, Litwicka K, Arrivi C, Varricchio MT, Caragia A, Greco A, et al. The endometrial preparation for frozen‐thawed euploidblastocyst transfer: a prospective randomized trial comparing clinical results from natural modified cycle and exogenous hormone stimulation with GnRH agonist. Journal of Assisted Reproduction and Genetics 2016;33:873‐84. [DOI: 10.1007/s10815-016-0736-y] - DOI - PMC - PubMed
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    1. Hugues JN, Attalah M, Hervé F, Martin‐Pont B, Kottler ML, Santarelli J. Effects of short‐term GnRH agonist ‐ human menopausal gonadotropin stimulation in patients pre‐treated with progestogen. Human Reproduction 1992;7(8):1079‐84. - PubMed
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    1. Karande VC, Latash WDZ, Birkenkamp T, Cavanaugh J, Melone K, Hazlett D. Preliminary report of a prospective randomized controlled trial comparing the use of NuvaRing® to Desogen® in in vitro fertilization cycles with ganirelix acetate. Fertility and Sterility 2004; Vol. Suppl 2, 82:S31‐2.
Keltz 2007 {published data only}
    1. Keltz MD, Gera PS, Skorupski J, Stein DE. Comparison of FSH flare with and without pretreatment with oral contraceptive pills in poor responders undergoing in vitro fertilization. Fertility and Sterility 2007;88(2):350‐3. [DOI: 10.1016/j.fertnstert.2006.11.123] - DOI - PubMed
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    1. Kovacs P, Barg PE, Witt BR. Hypothalamic‐pituitary suppression with oral contraceptive pills does not improve outcome in poor responder patients undergoing in vitro fertilization‐embryo transfer cycles. Journal of Assisted Reproduction and Genetics 2001;18(7):391‐4. - PMC - PubMed
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Leondires 1999 {published data only}
    1. Leondires MP, Escalpes M, Segars JH, Scott RT, Miller BT. Microdose follicular phase gonadotropin‐releasing hormone agonist (GnRH‐a) compared with luteal phase GnRH‐a for ovarian stimulation at in vitro fertilization. Fertility and Sterility 1999;72(6):1018‐23. - PubMed
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    1. Lewin A, Fatum M, Shufaro Y, Simon A, Reubinoff B, Laufer N, et al. Artificial endometrial preparation for frozen‐thawed embryo transfer using oral oestradiol and a new low‐dose vaginal progesterone preparation: Endometrin tablets. Human Reproduction 2001; Vol. Suppl 1, 16:152.
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    1. Lindheim SR, Barad DH, Witt B, Ditkoff E, Sauer MV. Short‐term gonadotropin suppression with oral contraceptives benefits poor responders prior to controlled ovarian hyperstimulation. Journal of Assisted Reproduction and Genetics 1996;13(9):745‐7. - PubMed
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Loutradis 2003 {published data only}
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Mashiach 1989 {published data only}
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Meldrum 2002 {published data only}
    1. Meldrum D, Scott R, Levy MJ, Alper M, Noyes N. A pilot study to assess oral contraceptive (OC) pretreatment in women undergoing controlled ovarian hyperstimulation (COH) in ganirelix acetate cycles. Fertility and Sterility 2002; Vol. Suppl 1, 78, issue 3:S176.
Meldrum 2008 {published data only}
    1. Meldrum DR, Cassidenti DL, Rosen GF, Yee B, Wisot AL. Oral contraceptive pretreatment and half dose of ganirelix does not excessively suppress LH and may be an excellent choice for scheduling IUI cycles. Journal of Assisted Reproduction and Genetics 2008;25:417‐20. [DOI: 10.1007/s10815-008-9244-z] - DOI - PMC - PubMed
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    1. Min JK, Claman P. Oral contraceptive (OC) pre‐treatment does not influence oocyte yield in poor responders undergoing gonadotropin releasing hormone (GnRH) antagonist cycles for in vitro fertilization (IVF). Fertility and Sterility 2005; Vol. Suppl 1, 84:S45‐6.
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    1. Mirkin S, Stadtmauer LA, Gibbons WE, Oehninger S. Clinical and endocrine impact of pretreatment with oral contraceptive pills in poor responders undergoing IVF with a combination of microdose flare leuprolide acetate and high dose gonadotropins. Fertility and Sterility 2003; Vol. Suppl 3, 80:S190‐1.
Mulangi 1997 {published data only}
    1. Mulangi AS, Nelson‐White TM, Racowsky C, Gelety TJ. Follicular phase endocrine response to oral contraceptives (OCs) followed by gonadotropin releasing hormone agonist (GnRHa) for down‐regulation prior to controlled ovarian hyperstimulation (COH) for the purpose of IVF. Fertility and Sterility 1997; Vol. Suppl 1, 68:S6.
Neal 1993 {published data only}
    1. Neal GS, Sultan KM, Liu HC, Davis OK, Rosenwaks Z. A dual approach to ovarian suppression using oral contraceptive pills and leuprolide acetate in high responder patients undergoing IVF. Fertility and Sterility 1993;60(5):S111.
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Pinkas 2008 {published data only}
    1. Pinkas H, Sapir O, Avrech OM, Ben‐Haroush A, Ashkenzi J, Fisch B, et al. The effect of oral contraceptive pill for cycle scheduling prior to GnRH‐antagonist protocol on IVF cycle parameters and pregnancy outcome. Journal of Assisted Reproduction and Genetics 2008;25:29‐33. [DOI: 10.1007/s10815-007-9189-7] - DOI - PMC - PubMed
Ramsewak 2005 {published data only}
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Talebian 2007 {published data only}
    1. Talebian S, Krey LC, Reh A, Granguly N, Liu M, Noyes N. Oral contraceptive (OC) pre‐treatment in GnRH antagonist (ANT) cycles is a reasonable option to control the timing of IVF cycles. Fertility and Sterility 2007; Vol. Suppl 1, 88:S291.
Tarlatzis 1993 {published data only}
    1. Tarlatzis BC, Pazaitou K, Bili H, Bontis J, Papadimas J, Lagos S, et al. Growth hormone, oestradiol, progesterone and testosterone concentrations in follicular fluid after ovarian stimulation with various regimes for assisted reproduction. Human Reproduction 1993;8(10):1612‐6. - PubMed
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Yoshida 2005 {published data only}
    1. Yoshida A, Kakinuma M, Matsuba T, Seida K, Suzuki H, Tanaka M. Effectiveness of using estradiol‐GnRH antagonist protocol with unsuccessful oral contraceptive pill‐GnRH antagonist protocol cases (full term pregnancies had not resulted) in in‐vitro fertilization (IVF) cycles. Fertility and Sterility 2005; Vol. Suppl 1, 84:S45.
Youssef 2017 {published data only}
    1. Youssef M, Wely M, Al‐Inany H, Madani T, Jahangiri N, Khodabakhshi S, et al. A mild ovarian stimulation in women with poor ovarian reserve undergoing IVF: a multicenter randomized non‐inferiority trial. Human Reproduction 2017;32(1):112‐8. - PubMed
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Zhao 2008 {published data only}
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