Puregon

For the GnRH-ant protocol, COH was started with 72.5–300 IU gonadotropin (Puregon, Organon, Netherlands) on day 2–3 of the menstrual cycle. The initial dose of gonadotropin was administered on the basis of the woman’s age, AFC, BMI, and ovarian response to stimulation. A daily dose of 0.25–0.75 mg GnRH antagonist (Cetrotide, Pierre Fabre, Aquitaine Pharm International) was initiated on the sixth day of rFSH stimulation or when the lead follicle reached a mean diameter of 12–14 mm, and the gonadotropin was continued until the day of the trigger administration (5000 IU u-HCG, Livzon Pharmaceuticals or 250 μg r-hCG, Merck Serono in combination with 2000 IU u-HCG). The Oocytes were then retrieved 35–37 h after the trigger (Li F. et al., 2020 (link); Figure 4).

Pituitary blockage was performed with the administration of a GnRH antagonist
and the ovarian stimulation was started on the 3^rd day of the
menstrual cycle with the administration of recombinant FSH (FSHr:
Gonal-F^®, Serono, Brazil; Puregon^®,
Organon, Brazil), 150 to 300 IU per day, for 6 days. Follicular development
was monitored daily by transvaginal ultrasound (USTV) from the
7^th day of stimulation and the dose of FSHr was adjusted
according to follicular growth and maintained until the day of the trigger.
Trigger for final follicular maturation was done when at least 3 follicles
reached a size larger than 17 mm, with 0.2 mg triptorelin (Gonapeptildaily
0,1mg/ml Ferring GmbH Wittland 11 - D-24109 - Kiel, Germany) or 0.2 mg
leuprorelin (Lupron kit 5mg/ml, Famar L’Aigle Saint-Remy-Sur-Avre -
France).

During the period of study, the majority of the stimulation protocol used was the long protocol (860, 80%). Other stimulation protocols including the antagonist protocol were not included because there were too few cases for proper statistical analysis. Detailed information on the controlled ovarian hyperstimulation protocols is described in a previous literature [4 (link)]. In brief, pituitary down-regulation was achieved by the long luteal GnRH agonist (GnRH-a) down-regulation protocol. Buserelin nasal spray (Suprecur; Hoechst, Hørsholm, Germany) 1000 μg daily was given for at least 14 days from the mid-luteal phase of the preceding cycle. Complete pituitary desensitization was confirmed by low serum luteinizing hormone (LH) (< 10 IU/L) and estradiol (E2) (< 200 pmol/L) concentrations. Patients also had an ultrasound examination to exclude functional ovarian cysts and verify that endometrial thickness was < 5 mm. Once adequate down-regulation had been achieved, ovarian stimulation was started using hMG (Pergonal; Serono, Aubonne/Switzerland) or recombinant follicle-stimulating hormone (FSH) (Gonad-F; Serono; or Puregon; Organon, Skovlunde, Holland). The dose of gonadotropin was determined according to the age of the female partner and the previous responses to treatment if any.

All women in this study were stimulated with the short gonadotrophin-releasing hormone (GnRH) antagonist protocol. Ovarian hyperstimulation was initiated using recombinant gonadotrophin, follitrophin beta (PuregonⓇ, Organon Malaysia Sdn Bhd) and was dictated according to patients' responses to stimulation, which was evaluated by serial vaginal ultrasound examinations (Acuson 50, Siemen Healthineers, Erlangen, Germany). When the majority of the follicles reached 13-14 mm in diameter, GnRH antagonist, ganirelix (OrgalutronⓇ, Vetter Pharma-Pertigung GmbH & Co. KG) was added at a dose of 250 μg daily. Once at least 3 leading follicles reached a size of 18 mm, 10,000 IU intramuscular human chorionic gonadotrophin (hCG; PregnylⓇ, Merck Sharp & Dohme, Malaysia) was administered. During this time, the number of mature follicles, endometrial thickness, and level of serum progesterone were determined. Oocyte retrieval was then performed 34-36 hr after the hCG administration. Using the total oocyte scoring system, the oocytes were scored as -1 (poor quality), 0 (almost normal), and +1 (normal) oocytes (17). The semen was prepared using the density gradient method (18), and the most motile and normal sperm was selected for the ICSI procedure.