J Assist Reprod Genet (2011) 28:901910

DOI 10.1007/s10815-011-9613-x

ASSISTED REPRODUCTION TECHNOLOGIES

The time interval between hCG priming and oocyte retrieval

in ART program: a meta-analysis
Wei Wang & Xue-Hong Zhang & Wei-Hua Wang &
Ya-Li Liu & Li-Hui Zhao & Shi-Long Xue & Ke-Hu Yang

Received: 8 April 2011 / Accepted: 11 July 2011 / Published online: 27 July 2011
# Springer Science+Business Media, LLC 2011

Abstract groups with regard to fertilization rate (RR, 0.99; 95% CI,
Objective To evaluate the relationship between different 0.941.04), implantation rate (RR, 0.91; 95% CI, 0.402.04),
hCG priming-to-oocyte retrieval intervals and assisted and pregnancy rate (RR, 0.79; 95% CI, 0.581.08).
reproductive technology (ART) outcome. Conclusion The percentage of mature (MII) oocytes can be
Methods We systematically searched PubMed, EMBASE, increased by prolonging the interval between hCG priming
the Cochrane Library, Science Citation Index, Chinese and oocyte retrieval. The prolonged interval could not
biomedicine (CBM) literature database, and Chinese Journal increase the fertilization rate, implantation rate, and
Full-text Database for randomized controlled trials (RCTs) pregnancy rate. Although there was evidence to confirm
published up to November 2010. Data was extracted from the results, they still need to be confirmed by large-sample,
the studies by two independent reviewers. Statistical analysis multicenter, randomized controlled trials. The time interval
was performed with Cochrane Collaborations Review dependent mechanisms responsible for ART performance
Manager (RevMan) 5.0.2. From extracted data, Risk Ratio need to be elucidated.
(RR) with 95% confidence interval (CI) was calculated.
Results 5 RCTs totaling 895 participants were included. Keywords Human chorionic gonadotropin . Oocyte
Oocyte maturation rate was higher in the long interval group retrieval . Time interval . Infertility . Assisted reproductive
compared with short interval group (RR, 0.67; 95% CI, 0.62 technology . Meta-analysis
0.73). There were no significant difference between the two
Abbreviations
ART Assisted reproductive technology
Capsule In ART treatment cycles, the chances to achieve a pregnancy ATP Adenosine triphosphate
are critically dependent on the retrieval of a suitable number of high CC Clomiphene citrate
quality oocytes and embryos. Angiotensin II, vascular endothelial COH Controlled ovarian hyperstimulation
growth factor (VEGF), interleukin I (IL-1), IL-6, IL-8, angiopoietin,
insulin-like growth factor (IGF), basic fibroblast growth factor ET Embryo transfer
(bFGF), and endothelin levels appear able to identify women FSH Follicle-stimulating hormone
candidate for an ART treatment from whom a suitable number of high GnRH-a Gonadotropic hormone releasing hormone analogue
quality oocytes may be retrieved. hCG Human chorionic gonadotropin
W. Wang : X.-H. Zhang (*) : W.-H. Wang (*) : L.-H. Zhao : hMG Human menopausal gonadotropin
S.-L. Xue ICSI Intracytoplasmic sperm injection
The Reproductive Medicine Center,
IGF Insulin-like growth factor
the First Hospital of Lanzhou University,
Lanzhou, China IL Interleukin
e-mail: [email protected] IM Intramuscular injection
e-mail: [email protected] IUI Intrauterine insemination
Y.-L. Liu : K.-H. Yang
IVF In vitro fertilization
The Evidence-Based Medicine Center of Lanzhou University, IVM In vitro maturation
Lanzhou, China LH Luteinizing hormone
902 J Assist Reprod Genet (2011) 28:901910

LI Long interval mean time of 32 h [7]. Nader et al. [8] studied the
MII Metaphase II pharmacokinetics of hCG and its relation to ovulation and
NA Not available concluded that ovulation may occur earlier than 36 h in
RCT Randomized controlled trial some women, they advised aiming for a <35 h interval if
RevMan Review Manager ovulation is to be avoided. In most in vitro fertilization
RR Risk ratio (IVF) programs, the commonly practiced interval was 32 to
SI Short interval 36 h that was derived from the studies on patients who used
TUS Transvaginal ultrasound Clomiphene Citrate (CC) and/or human menopausal go-
VEGF Vascular endothelial growth factor nadotropin (hMG) for ovulation induction [911]. However,
2PN Two-pronuclear several studies [2, 1214] had shown that ideal ART
95% CI 95% confidence interval performance can be obtained when oocyte retrieval was
done more than 36 h (up to 39 h) after hCG priming.
Successful fertilization in vitro of oocytes retrieved 60 h
after hCG injection was reported in 1998 [15]. The
Introduction prolonged luteinization-to-oocyte retrieval increased the
production of oocytes with fully expanded cumulus, which
During controlled ovarian hyperstimulation (COH), the may reflect oocyte maturation, then researchers presumed
natural endogenous Luteinizing Hormone (LH) surge often that the subsequent proportion of oocytes proceeding to
does not appear, or has appeared with improper timing and fertilization and cleavage also increased, implying that a
magnitude. Therefore, exogenous gonadotropin is needed longer interval may improve gamete quality by allowing
to replace the endogenous LH surge. The most commonly more optimal in vivo maturation. Significantly more high
used exogenous LH is human chorionic gonadotropin quality cleaving embryos had been reported to be obtained
(hCG), which simulates the physiologic effects of LH, and when the interval was 38 h rather than 36 h [12].
is used to trigger the final follicular maturation before oocyte Meanwhile, there were studies [16, 17] indicated that there
retrieval in ART program [1]. The interval between hCG was no significant difference on the outcome of IVF
priming and oocyte retrieval is very important, because a treatment cycles among the interval prolonged. Therefore,
series of crucial processes, such as the start of luteinization, we carry out a meta-analysis to determine whether a
expansion of cumulus cells, and the resumption of oocyte prolonged hCG-to-oocyte retrieval interval is beneficial to
meiosis are accomplished in the interval [2]. Many factors, ART outcome.
such as the final products of renin angiotensin system,
angiotensin II, vascular endothelial growth factor (VEGF),
interleukin I (IL-1), IL-6, IL-8, angiopoietin, insulin-like Methods
growth factor (IGF), basic fibroblast growth factor, and
endothelin are also involved in follicular development, Inclusion criteria
oocyte maturation, fertilization, and embryo development.
All of these substances have an effect in a time-dependent We included randomized and quasi-randomized controlled
manner after hCG priming [35]. For example, VEGF can trials that provided original analyses on the relationship
increase follicular vascularization and thus optimize dis- between different hCG priming-to-oocyte retrieval intervals
solved oxygen content in follicle and consequently increase and ART outcome. Infertility patients presented with
follicular maturation and oocyte quality. The follicular fluid indications, such as primary infertility, tubal factor, male
VEGF level was significantly higher in the hCG +38 h factor, or unexplained indication, underwent their ART
oocyte retrieval group compared with the hCG +34 h oocyte treatment cycles and reported the outcome. We included
retrieval group (2276.0790.1 versus 1946.6954.5 pg/ml, participants from the general population were in good
P<0.001) [5]. On the day of hCG administration, serum IL-6 general health, besides infertility, without other diseases.
concentration was 8.406.68 pg/ml, and 7.100.68 pg/ml The COH protocols were performed by combined therapy
on the day of oocyte retrieval [6]. So the optimal time of gonadotropic hormone releasing hormone analogue
interval between hCG priming and oocyte retrieval has been (GnRH-a) and hMG or follicle-stimulating hormone (FSH).
encountered controversy, whether prolonged interval (>36 h) We excluded studies in which the hCG was added to the
has any influence on the ART outcome, such as oocyte culture medium rather than injection for patients. Studies in
maturation rate, fertilization rate, implantation rate, and which the outcome data were not clearly defined were
pregnancy rate. excluded. Reviews letters, commentaries, case reports, and
Physiologic studies suggest that ovulation occurs any- editorials were also excluded if they did not contain original
time from 24 to 56 h after the onset of LH surge, with a data. If multiple published reports from the same study
J Assist Reprod Genet (2011) 28:901910 903

were available, only the one with the most detailed Ya-Li Liu) according to the criteria stated in The Cochrane
information for original data and outcome was included. Collaboration Handbook [18]. For each study, the risk of
bias assessed and tabulated for each of the following items:
Literature search sequence generation, allocation concealment, blinding
(participants, personnel, outcome assessors, and data
We systematically searched PubMed, EMBASE, Cochrane analysts), incomplete outcome data, selective outcome
Library, Science Citation Index, Chinese biomedicine reporting, and other sources of bias. Judgement of Yes
(CBM) literature database, and Chinese Journal Full-text indicates low risk of bias, No indicates high risk of bias,
Database (from their inception to November 2010) for and Unclear indicates unclear or unknown risk of bias.
randomized controlled trials (RCTs), using the text and key Disagreements were resolved by discussion with a third
words in combination both as MeSH (Medical Subject reviewer (Ke-Hu Yang).
Headings) terms and text words. The search strategy used
the following main search terms: human chorionic Data extraction
gonadotropin in combination with interval. We hand-
searched reference lists of every retrieved study and Two reviewers, Wei Wang and Ya-Li Liu extracted data
reviewed relevant studies for additional publications. We independently from full text papers. Differences were
searched the National Institute of Health, National Research resolved by discussion with a third reviewer (Ke-Hu Yang).
Register, Current Controlled Trials, and Trials Central for For each study, we extracted the following information: first
unpublished studies and those in progress. We also used author, year of publication, location of study, sample size,
search engine such as Google to search for related patients characteristics, such as mean age, duration of
references on the Internet. The search was restricted to human infertility, causes of infertility, usage and dose of hCG, and
studies and without language restriction. Two reviewers (Wei different methods of ART.
Wang and Ya-Li Liu) independently assessed the titles and
abstracts of all identified studies to confirm fulfillment of Statistical analysis
inclusion criteria; disagreements were resolved in consultation
with a third reviewer (Ke-Hu Yang). Data was analyzed by using the Cochrane Review Manager
(RevMan) 5.0.2 to mix the extracted data for summary
Types of intervention effect estimates and generate forest plots. Results for
dichotomous variables would be expressed as Risk Ratio
Types of intervention were short time interval (<36 h) (RR) with 95% confidence interval (CI). We used fixed-effect
between hCG priming and oocyte retrieval versus long time model for calculations of summary estimates and their 95%
interval (>36 h) between hCG priming and oocyte retrieval CIs unless there was significant heterogeneity, in which result
in the ART treatment cycles. was confirmed by using the random-effect model. For the
summary of each total or subtotal, we provided the 2-test
Types of outcome measures statistic for heterogeneity across studies with its degree of
freedom and P value, the statistic I2 that measured the extent
The outcome measures of ART program were: oocyte of inconsistency in results, and the Z statistic with P value
maturation rate, defined as percentage of mature (MII) for overall effect. Generally, values of I2 above 50% are
oocytes, metaphase II oocytes were defined by the deemed to suggest large heterogeneity, values of 2550% are
presence of first polar body and round ooplasm. deemed to show modest heterogeneity, and values below 25%
Fertilization rate, defined as the mean number of two- are deemed to represent low heterogeneity. However, these
pronuclear (2PN) zygotes divided by MII-aspirated estimates can have large uncertainty, especially in the presence
oocytes. Implantation rate, defined as percentage of of few trials, and should be interpreted with caution [19].
transferred embryos of all embryos available for transfer.
Pregnancy rate was calculated by considering clinical
pregnancy, determined by the visualization of a viable Results
gestational sac within the uterine cavity by ultrasound 3
4 weeks after embryo transfer. Literature search results

Quality assessment Detailed search procedures were summarized in the flow

diagram (Fig. 1) illustrating the mechanisms of exclusion
The methodological quality of included studies was for certain studies in accordance with the Preferred
assessed independently by two reviewers (Wei Wang and Reporting Items for Systematic Reviews and Meta-
904 J Assist Reprod Genet (2011) 28:901910

Fig. 1 Flow diagram of search

strategy Potentially relevant studies
identified and screened for retrieval
(n=326)
Studies excluded on the basis of title
and/or abstract due to studies were not
relevant (n=308)
Studies retrieved for more detailed
evaluation (n=18)
Studies excluded, with reasons (n=3)
Cohort study (n=2)
Case-control study (n=1)
Potentially appropriate studies to
be included in the meta-analysis
(n=15) Studies excluded, with reasons (n=10)
Studies with different experiment
designs (n=5)
Studies were missing test group or
control group (n=3)
Study without outcome data (n=1)
Studies with usable information Duplicate publication (n=1)
included in final meta-analysis
(n=5)

Analyses: The PRISMA Statement [20]. The search The methodological quality of included studies
strategy retrieved 326 potentially eligible studies and
subsequently excluded 321 studies with the following One trial [28] described odd or even IVF identity numbers
reasons: 308 were not relevant to the contents we of patients were used for the allocation of patients, this
interested; two were cohort studies and 1 used case- trial was known as quasi-randomized trial. Of the five
control design; five were with different experiment designs included studies, only 1 trial [13] mentioned blinding:
[2125], the time interval referred to hCG-to-intrauterine the gynecologist who performed the oocyte aspiration
insemination (IUI) or hMG-to-hCG rather than hCG-to- was blinded to the time interval, and only 1 trial [17] had
oocyte retrieval; three were missing test group or control adequate allocation concealment described: randomiza-
group [12, 26, 27]; one was missing available outcome data tion was performed by drawing of sealed envelopes by a
[10]; one was duplicate publication [17]. Finally, 5 RCTs nurse who was not an active participant in the study.
[13, 16, 17, 28, 29] totaling 895 participants were included There was no losing of follow-up, the outcome data was
in this meta-analysis. complete, and without selective reporting bias. The

Table 1 Methodological quality

assessment of included studies Study Sequence Allocation Blinding Incomplete Selective Other bias
generation concealment outcome data reporting bias

Raziel A (2006) [28] IVF identity Unclear Unclear Yes Yes Unclear
number
Nargund G (2001) [16] Unclear Unclear Unclear Yes Yes Unclear
Bjercke S (2000) [17] Unclear Yes Unclear Yes Yes Unclear
Mansour RT (1994) [13] Unclear Unclear Yes Yes Yes Unclear
Jamieson ME (1991) [29] Unclear Unclear Unclear Yes Yes Unclear
IVF in vitro fertilization
J Assist Reprod Genet (2011) 28:901910 905

Table 2 COH protocols of ART treatment cycles first polar body and round ooplasm. Figure 2 showed the
Study Controlled Ovarian Hyperstimulation Risk Ratio with 95% CI of oocyte maturation rate
(COH) associated with interval between hCG priming and oocyte
retrieval in randomized studies, a total of 1624 oocytes
Raziel A (2006) [28] Triptorelin or Nafarelin + hMG were retrieved in two eligible studies [13, 28], there were
or recombinant preparations
1,020 oocytes reached MII. The oocyte maturation rate was
Nargund G (2001) [16] GnRH-a Buserelin acetate + hMG
significantly higher when oocyte retrieval >36 h after hCG
Bjercke S (2000) [17] GnRH-a Suprefact + FSH
injection compared with oocyte retrieval <36 h after hCG
Mansour RT (1994) [13] GnRH-a Buserelin acetate + hMG
injection (RR, 0.67; 95% CI, 0.620.73; I2 =33%).
Jamieson ME (1991) [29] GnRH-a Buserelin acetate + hMG Fertilization rate, defined as the mean number of 2PN
zygotes divided by MII-aspirated oocytes. Figure 3 showed
the Risk Ratio with 95% CI of fertilization rate associated
methodological quality of included studies was summa- with interval between hCG priming and oocyte retrieval in
rized in Table 1. randomized studies, a total of 3455 MII oocytes were
retrieved in four eligible studies [13, 17, 28, 29], there were
The characteristics of included studies 2285 MII oocytes fertilized into 2PN zygotes. The
fertilization rate did not differ significantly between short
The retrieved five trials were done in Israel, England, interval group and long interval group (RR, 0.99; 95% CI,
Norway, Egypt, and Scotland respectively from 1991 to 0.941.04; I2 =47%).
2006. One trial described the ethical approval that was Implantation rate, defined as percentage of transferred
obtained from the local research ethics committee [16]. embryos of all embryos available for transfer. Figure 4
Three trials applied IVF treatment cycles and two trials showed the Risk Ratio with 95% CI of implantation rate
applied intracytoplasmic sperm injection (ICSI) treat- associated with interval between hCG priming and oocyte
ment cycles. Two trials reported the ART outcome retrieval in randomized studies, a total of 488 embryos
oocyte maturation rate, four trials reported the fertiliza- available for transfer in two eligible studies [17, 28], there
tion rate, two trials reported the implantation rate, and were 62 embryos transferred on the ET (embryo transfer)
four trials reported the pregnancy rate. The COH day. Since the implantation rate was heterogeneous (I2 =58%)
protocols of the five studies were performed by among the included studies, random-effect model was used
combined therapy of GnRH-a and hMG or FSH to confirm the result (Fig. 5). There was no statistically
(Table 2). The characteristics of included studies were significant difference between short interval group and long
summarized in Table 3. interval group (RR, 0.91; 95% CI, 0.402.04; I2 =58%).
There were no differences in the pooled results of the
Meta-analysis results two studies between fixed effect model and random effect
model, although the weighted proportion for each study
The meta-analysis results of outcome measures were shown was changed. So the tendency of implantation rate was not
in Table 4. changed.
Oocyte maturation rate, defined as percentage of mature Pregnancy rate was calculated by considering only
(MII) oocytes, MII oocytes were defined by the presence of clinical pregnancy, determined by the visualization of a

Table 3 Characteristics of included studies

Study Location Sample size Mean age Mean duration of Causes of infertility Usage and ART
of study (SI/LI) (years) infertility (years) dose of hCG

Raziel A (2006) [28] Israel 72 (36/36) 31.34.9 53.6 Primary infertility 5000 IU, IM ICSI
Nargund G (2001) [16] England 533 (258/275) 33.4 NA Tubal damage, male factor, 10000 IU, NA IVF
and unexplained infertility
Bjercke S (2000) [17] Norway 170 (83/87) SI: 35 NA Tubal factor 10000 IU, IVF
LI: 33 subcutaneously
Mansour RT (1994) [13] Egypt 60 (30/30) SI: 32.63.1, NA Male factor 10000 IU, IM ICSI
LI: 31.22.3
Jamieson ME (1991) [29] Scotland 60 (30/30) NA NA Tubal factor or unexplained 5000 IU, NA IVF
infertility

SI short interval (<36 h); LI long interval (>36 h); IM intramuscular injection; IVF in vitro fertilization; ICSI intracytoplasmic sperm injection; NA
not available
906 J Assist Reprod Genet (2011) 28:901910

Table 4 Meta-analysis results

of ART outcome measures Outcome measures No. of Heterogeneity Statistical Effect size 95% CI P value
trials (I2, %) model

Oocyte maturation rate 2 33 Fixed RR 0.67(0.620.73) <0.00001

Fertilization rate 4 47 Fixed RR 0.99(0.941.04) 0.64
Implantation rate 2 58 Random RR 0.91(0.402.04) 0.81
Pregnancy rate 4 18 Fixed RR 0.79(0.581.08) 0.13

viable gestational sac within the uterine cavity by ultra- between hCG priming and oocyte retrieval. Most infertility
sound 34 weeks after embryo transfer. Figure 6 showed patients were willing to cooperate with doctors with better
the Risk Ratio with 95% CI of pregnancy rate associated compliance, there was no losing of follow-up unless
with interval between hCG priming and oocyte retrieval in suffered spontaneous ovulation to cancel the treatment
randomized studies, a total of 835 patients were included in cycle, thus the outcome data was relatively complete.
four eligible studies [16, 17, 28, 29], and 137 patients Further research should pay attention to the impact of
become pregnant after embryo transfer. The pregnancy geographic differences. We still need more high-quality,
rate did not differ significantly between the two groups multicenter, randomized controlled trials from other
(RR, 0.79; 95% CI, 0.581.08; I2 =18%). countries and regions.
There were two kinds of hCG dose used in the five
studies, two studies used 5000 IU and three studies used
Discussion 10000 IU. The hCG dose was determined according to the
patients responding to COH, levels of estradiol. An hCG
The number of included studies is relatively small. The dose of 5000 IU can give similar results compared to a dose
small number of participants and included studies, as well of 10000 IU in terms of oocyte maturation rate, fertilization
as the low quality of most studies, might not allow for a rate, and pregnancy rate, regardless of the route of
reliable conclusion. Adequate randomization can prevent administration. So the differences between hCG dose does
selection bias in allocating interventions to participants. not affect the ART outcome [30, 31]. The causes of
However, proper randomization is not always possible in infertility showed in the five studies were primary infertility,
the clinical context of infertility, as patients choices have to tubal factor, male factor, or unexplained infertility. These
be taken into account such as work and travel arrange- causes above are the very indications for IVF or ICSI,
ments. Future study should describe how to generate the and their differences dose not interfere with the outcome
randomized allocation sequence. For example, opaque, of ART. Only one study described the duration of
sealed envelopes mentioned herein were used to conceal infertility, further study should describe the information
allocation. Blinding participants to the time interval might of patients in detail with similar demographics to
reduce the impact of subjective psychological factors. compare the baseline conditions roundly.
Blinding the doctors who perform oocyte retrieval, outcome The timing of oocyte maturation in vivo after an
assessors, and data analysts to the time interval could injection of hCG was first estimated by Jagiello [32]. Of
ensure that the compared groups receive similar attention, the five retrieved studies, the comparison was based on the
treatment and assessment. Without effective blinding might short interval versus long interval: 35.30.7 versus 38.6
result in performance bias and measurement bias. In this 1.2 h, 33 versus 41 h, 34 versus 38 h, 35 versus 37 h, and
meta-analysis, the follow-up time just was the interval 34 versus 39 h. The short interval varied from 33 to 36 h,

Short Interval Long Interval Risk Ratio Risk Ratio

Study or Subgroup Events Total Events Total Weight M-H, Fixed, 95% CI M-H, Fixed, 95% CI

Mansour RT 1994 129 260 209 263 34.7% 0.62 [0.54, 0.72]
Raziel A 2006 248 497 434 604 65.3% 0.69 [0.63, 0.77]

Total (95% CI) 757 867 100.0% 0.67 [0.62, 0.73]

Total events 377 643
Heterogeneity: Chi = 1.50, df = 1 (P = 0.22); I = 33%
0.5 0.7 1 1.5 2
Test for overall effect: Z = 9.63 (P < 0.00001)
Favours Long Interval Favours Short Interval

Fig. 2 Oocyte maturation rate of short interval versus long interval in ART program
J Assist Reprod Genet (2011) 28:901910 907

Short Interval Long Interval Risk Ratio Risk Ratio

Study or Subgroup Events Total Events Total Weight M-H, Fixed, 95% CI M-H, Fixed, 95% CI

Bjercke S 2000 554 867 598 963 50.4% 1.03 [0.96, 1.10]
Jamieson ME 1991 232 302 255 303 22.6% 0.91 [0.84, 0.99]
Mansour RT 1994 76 129 120 209 8.1% 1.03 [0.85, 1.24]
Raziel A 2006 159 248 291 434 18.8% 0.96 [0.85, 1.07]

Total (95% CI) 1546 1909 100.0% 0.99 [0.94, 1.04]

Total events 1021 1264
Heterogeneity: Chi = 5.66, df = 3 (P = 0.13); I = 47%
0.5 0.7 1 1.5 2
Test for overall effect: Z = 0.46 (P = 0.64)
Favours Long Interval Favours Short Interval

Fig. 3 Fertilization rate of short interval versus long interval in ART program

while the long interval varied from 36 to 41 h. Van is possible to control the follicular development more
Steirteghem et al. reported that of the oocytes retrieved readily and reduce the variations in response to hCG.
3336 h after hCG priming, 85% were in the MII stage The hCG was administered when a sufficient number
[33]. Steptoe and Edwards reported that the preovulatory of follicles had developed, typically more than three
oocytes were in the predicted stage about 35 to 36 h after follicles 17 mm in mean diameter, and the transvaginal
hCG injection [34]. In stimulated cycles with CC or hMG, ultrasound (TUS) guided approach was used for oocyte
ovulation can occur between 32 h and 36 h [35]. Mansour retrieval.
et al. [13] concluded that oocyte maturity was attained 36 h One of our concerns was the possibility of spontaneous
after hCG injection, and therefore oocyte recovery should ovulation before the scheduled time for oocyte retrieval as a
not be performed before 36 h. Fertilization rate and result of prolonged exposure to hCG. Andersen et al. [36]
cleavage rate were significantly higher in oocytes retrieved found a mean time interval of 38.3 h from hCG injection to
>36 h after luteinizing stimulus than in those <36 h after first follicular rupture. Nargund et al. concluded that no
luteinizing stimulus. So we defined the 36 h as the women ovulated up to 41 h from hCG administration.
demarcation to determine short interval group and long Fleming et al. reported that no ovulation occurs within a
interval group. delay of less than 39.5 h [14]. Gudmundsson et al. [2]
Natural ovulation after LH surge may occur between described 39 h as the critical time to avoid spontaneous
30 h and 36 h, whereas ovulation after hCG injection ovulation. Of the five included studies, a patient from 38 h
may occur between 36 h and 40 h in superovulation group [17] encountered spontaneous ovulation. We should
cycles without the use of GnRH-a [10]. Nevertheless, in control the interval properly to avoid cancelling the
the five included studies, the COH protocols were treatment cycles as a result of spontaneous ovulation.
performed by combined therapy of GnRH-a and hMG or Since the hours after luteinizing stimulus is a period of
FSH. The use of COH protocols is intended to produce intense nuclear and cytoplasmic activity in human oocytes,
large cohorts of follicles and oocytes by creating continuous so the interval between hCG priming and oocyte retrieval
pituitary suppression and eliminate endogenous gonado- probably determines the degree of cellular and cytogenetic
tropin fluctuations. It is well known that with GnRH-a maturation. A prolonged interval would have an increased
COH there is an implicit LH suppression and a longer in intrafollicular influence, yield oocytes in which all processes
vivo maturation time than is possible without the use of are completed, allow more in vivo maturation, and therefore
GnRH-a. By producing a hypogonadotropic condition it more likely to develop into 2PN zygotes and high quality

Short Interval Long Interval Risk Ratio Risk Ratio

Study or Subgroup Events Total Events Total Weight M-H, Fixed, 95% CI M-H, Fixed, 95% CI

Bjercke S 2000 24 157 20 166 62.9% 1.27 [0.73, 2.20]

Raziel A 2006 6 79 12 86 37.1% 0.54 [0.21, 1.38]

Total (95% CI) 236 252 100.0% 1.00 [0.63, 1.59]

Total events 30 32
Heterogeneity: Chi = 2.35, df = 1 (P = 0.12); I = 58%
0.02 0.1 1 10 50
Test for overall effect: Z = 0.00 (P = 1.00)
Favours Long Interval Favours Short Interval

Fig. 4 Implantation rate of short interval versus long interval in ART program (Fixed-effect model)
908 J Assist Reprod Genet (2011) 28:901910

Short Interval Long Interval Risk Ratio Risk Ratio

Study or Subgroup Events Total Events Total Weight M-H, Random, 95% CI M-H, Random, 95% CI

Bjercke S 2000 24 157 20 166 60.2% 1.27 [0.73, 2.20]

Raziel A 2006 6 79 12 86 39.8% 0.54 [0.21, 1.38]

Total (95% CI) 236 252 100.0% 0.91 [0.40, 2.04]

Total events 30 32
Heterogeneity: Tau = 0.21; Chi = 2.35, df = 1 (P = 0.12); I = 58%
0.02 0.1 1 10 50
Test for overall effect: Z = 0.24 (P = 0.81)
Favours Long Interval Favours Short Interval

Fig. 5 Implantation rate of short interval versus long interval in ART program (Random-effect model)

normal cleaving embryos. The incidence of fully expanded increased [40]. When implanted 3 embryos, the pregnancy
cumulus cells is increased in the patients with longer interval rate has not increased any more, the risk of multiple
(>36 h), and this apparent benefit is reflected in higher pregnancy is increased. In women under 35 years of age,
fertilization rate and cleavage rate. Immature oocytes are transferring double high-quality embryos can help maximize
firmly attached to the follicular wall and not easy to aspirate; clinical pregnancy rate while minimizing multiple pregnancy
when oocytes reach maturity, this attachment becomes loose rate. Moreover, elective single embryo transfer with an
and oocytes are easily retrieved [37]. The procedure becomes acceptable pregnancy rate might be considered if a top
easier and faster, flushing of oocytes with its potential quality embryo is available. The pregnancy rate of once-
disadvantages is avoided. In addition, extension of the in transfer was 40%, and the cumulative pregnancy rate was
vivo maturation might reduce the incidence of polyspermy. 60%, equal to even higher than the cumulative pregnancy
Oocyte meiotic maturation is an important factor for rate of double-embryo transfer [4143]. The quality of
achieving fertilization and developing high quality embryos. embryos (cleavage speed and morphologic distribution):
Delaying oocyte retrieval to a longer interval is helpful to embryos that absence of multinucleated blastomeres, four
improve oocyte maturity, while there is no significant or five blastomeres on day 2, seven or more cells on day 3,
improvement in fertilization rate, implantation rate, and and 20% anucleated fragments are considered as top
pregnancy rate. Son WY et al. obtained the similar results in quality embryos [44]. The majority of embryos selected for
their programmed in vitro maturation (IVM) cycles [38]. transfer were at the 4-cell stage on day 2 at 42 h post-
Apart from the time required for hCG to become available insemination. It is clear that 4-cell embryos on day 2 are
after administration analyzed herein, ART outcome is also more likely to be good grade embryos on day 3 and that 3-
associated with other factors as follows. The age of patient: cell and greater than 4-cell embryos have poor developmen-
the oocytes quality would become poorer with increased age tal potential. Considering cell number at a set time (4244 h
of women. The number of mitochondria in the cytoplasm is post-hCG), even (two and four cells) rather than uneven (3, 5
reduced, incidence of DNA mutation is increased, adenosine and greater) cell numbers were significant in positive
triphosphate (ATP) is reduced, active oxygen is increased, pregnancy events. The transition from 2-cell to 4-cell
and aneuploidy is increased, thus the developmental poten- requires that the embryo proceeds through a 3-cell phase
tial of oocytes and embryos are decreased [39]. The number first and then rapidly cleaves again to form a 4-cell
of transferred embryos: although more embryos transfer tetrahedron embryo [4547]. If an embryo is cleaving too
could increase pregnancy rate, multiple pregnancy is also fast, relevant to all other embryos, it is most likely abnormal

Short Interval Long Interval Risk Ratio Risk Ratio

Study or Subgroup Events Total Events Total Weight M-H, Fixed, 95% CI M-H, Fixed, 95% CI

Bjercke S 2000 20 83 17 87 21.8% 1.23 [0.70, 2.19]

Jamieson ME 1991 6 30 8 30 10.5% 0.75 [0.30, 1.90]
Nargund G 2001 27 258 41 275 52.0% 0.70 [0.45, 1.11]
Raziel A 2006 6 36 12 36 15.7% 0.50 [0.21, 1.19]

Total (95% CI) 407 428 100.0% 0.79 [0.58, 1.08]

Total events 59 78
Heterogeneity: Chi = 3.67, df = 3 (P = 0.30); I = 18%
0.2 0.5 1 2 5
Test for overall effect: Z = 1.50 (P = 0.13)
Favours Long Interval Favours Short Interval

Fig. 6 Pregnancy rate of short interval versus long interval in ART program
J Assist Reprod Genet (2011) 28:901910 909

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Bin Ma, Lei Jiang, Wen-Qin Jia, Kang Yi, and Lun Li (Evidence-
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Conflicts of interest statement The authors declared no conflicts of
two hCG-to-oocyte aspiration intervals on the outcome of in vitro
interest related to this study.
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