RESEARCH PROPOSAL FOR MASTER OF MEDICINE

(OBSTETRICS AND GYNAECOLOGY)

DEPARTMENT OF OBSTETRICS & GYNAECOLOGY

UNIVERSITI KEBANGSAAN MALAYSIA

Intra-uterine Injection of Human Chorionic Gonadotrophin (hCG) Before Embryo Transfer in In-
Vitro Fertilization/ Intra-cytoplasmic Sperm Injection and IVF Outcome

Dr Norfazilawaty Binti Abdul Latif

MD UKM

SUPERVISOR : PROF DR MOHD. HASHIM BIN OMAR

INTRODUCTION

LITERATURE REVIEWS

RATIONALE OF THE STUDY

Intra-uterine injection of hCG before embryo transfer in IVF/ICSI may increase T cells (Treg) and
improved the implantation and pregnancy rates.

OBJECTIVE

General Objective

To study the effect of intrauterine injection of HCG before embryo transfer on the implantation and
pregnancy rates after IVF/ICSI.

Specific Objectives

1. To compare clinical pregnancy rate between interventional group (who received intra-uterine
hCG injection before embryo transfer) and control group (who didn’t received intra-uterine hCG
injection before embryo transfer).
2. To compare miscarriage rate in between 2 group.

RESEARCH HYPOTHESIS

Intra-uterine injection of hCG in luteal phase before embryo transfer of IVF/ICSI cycle improves
implantation and pregnancy rate.

NULL HYPOTHESIS

No difference in term of implantation and pregnancy rate following intra-uterine injection of hCG during
IVF/ICSI embryo transfer.

METHODOLOGY
Study Design

Prospective interventional case control study

Setting

Medical Assisted Conception Unit, Department of Obstetrics & Gynecology, National University of
Malaysia Medical Center (UKMSC), Kuala Lumpur, Malaysia.

Duration of Study

1st September 2015 until 29th February 2016

Sample Size

One recent study by Santibañez A. et al in 2014 investigated the value of intrauterine injection of hCG
before embryo transfer in improving implantation and pregnancy rates in IVF cycles.

 The implantation rate was significantly higher in the hCG group compared to the control group
(52.4% vs 35.7%).
 The clinical pregnancy rate was also significantly higher in the hCG group compared to the
control group (50.4 vs 33.0%).

Using confidence interval of 95% and power of 80%, the sample size is calculated using the formula
below (Fleiss JL. 1988):

m=n1=size of sample from population 1 n2=size of sample from population 2

P1=proportion of exposure in population 1 P2=proportion of exposure in population 2

α= "Significance” = 0.05 β=chance of not detecting a difference = 0.2

(1/P)-β = Power = 0.8 r/Q = (n2/n1)/(1-P) = ratio of cases to controls

= (P1+rP2)/(r+1)

n1 = m n2 = rm

From table A.2 in Fleiss;

If 1- α is 0.95 then cα/2 is 1.960

If 1- β is 0.80 then c1-beta is -0.842

We are planning a study of independent cases and controls with 1 control(s) per case.

Sample size calculation based on outcome, namely implantation rate and clinical pregnancy rate.

Implantation rate:

Prior data indicate that the implantation rate among controls is 0.357. If the true implantation rate for
experimental subjects is 0.524, we will need to study 138 case subjects and 138 control subjects to be
able to reject the null hypothesis that the implantation rates for case and control subjects are equal with
probability (power) 0.8. The Type I error probability associated with this test of this null hypothesis is
0.05. We will use an uncorrected chi-squared statistic to evaluate this null hypothesis.

Clinical pregnancy rate:

Prior data indicate that the pregnancy rate among controls is 0.33. If the true pregnancy rate for
experimental subjects is 0.504, we will need to study 125 case subjects and 125 control subjects to be
able to reject the null hypothesis that the pregnancy rates for case and control subjects are equal with
probability (power) 0.8. The Type I error probability associated with this test of this null hypothesis is
0.05. We will use an uncorrected chi-squared statistic to evaluate this null hypothesis.

Study Population

Infertile woman undergoing first IVF/ICSI cycle.

Inclusion criteria
 1. Female age less than 40 years old
2. Male factor infertility
3. Normal female hormonal profile and uterine activity.
4. Day 2 or 3 embryo transfer

Exclusion criteria

1. Previous IVF/ICSI failure

2. Azoospermia
3. Male partner requiring Percutaneous Sperm Aspiration (PESA) or Testicular Sperm Extraction
(TESE) to extract the sperm during IVF/ICSI.
4. Body mass index more than 35 kg/m2
5. Poor responders (defined as day 3 serum FSH level > 12 IU/L or < than 4 follicles on hCG day.
6. Those with fibroid distorting pelvic cavity or with uterine abnormality.
7. Presence of ongoing pelvic infection or hydrosalphinx.

Study Procedure

Patients who undergo their first cycle of IVF/ICSI embryo transfer will be selected and recruited for the
study. Patient who fulfilled the inclusion and exclusion criteria and consented for intrauterine injection
of HCG will be put in the interventional group. Intrauterine injection of 200 hCG iu will be done during
dummy embryo transfer, 10-15 minutes before actual embryo transfer, which performed on day 2 or
day 3.

For the control group, several criteria will be standardized in the control group; age, class of body mass
index according World Health Organization and day of embryo transfer.

Patient in both groups will undergo the same control ovarian hyperstimulation protocol i.e GnRH
antagonist protocol. FSH will be given on Day 2 of menses and follicular monitoring will be done on day
8, 10 and 12. GnRH antagonist i.e orgalutron or cetriotide 0.25 mg will be commenced once the follicle
size has reached 12 mm. HCG 10000 iu will be give once 3 or more follicles has reached the size of 17
mm. Oocyte retrieval will be performed 36 hours following the HCG trigger. The number of embryos and
the mode of their transfer were determined by their availability as well as by age and clinical history. 2
weeks following embryo transfer, serum beta hCG will be taken and if positive, 4 weeks later, a clinic
appointment will be given and ultrasound will be performed to confirm gestational sac.

Outcome of the study

Primary Outcome

The primary outcome is implantation rate and clinical pregnancy rate.

Implantation is the number of embryonal sac confirmed by sonography. Implantation rate is the ratio
between number of embryonal sacs diagnosed by sonography and the total numbers of embryos
transferred into the uterus.

Clinical pregnancy is confirmed by the presence of an intrauterine gestational sac by transvaginal

ultrasound, with fetal heartbeats. Clinical pregnancy rate is expressed as the ratio between the numbers
of patient in whom clinical pregnancy was diagnosed and the total numbers of patient underwent
embryo transfer.

Secondary Outcome

Secondary outcomes include multiple pregnancy rate, extra-uterine pregnancy, and miscarriage rate.
Miscarriage rate is defined as all women in whom pregnancy did not continue after a positive pregnancy
test in serum and before 24 hours gestation.

Flow chart of study procedure

Statistical Analysis

Data collection and analysis were performed with SPSS version 20.0

The chi-square test will be used for categorical variables and an independent sample t-test will be used
for continuous variables that are normally distributed. P value < 0.05 is considered significant.

GANTT CHART

BUDGET
REFERRENCES

DATA COLLECTION SHEET

RECORD NO: _________

TITLE: Intra-uterine Injection of Human Chorionic Gonadotrophin (hCG) Before Embryo Transfer
in In-Vitro Fertilization/ Intra-cytoplasmic Sperm Injection and IVF Outcome

PATIENT BIODATA:

Name:

MRN:

Age:

Race: Malay/ Chinese/ Indian/ Others: ___________________

Occupation

Duration of subfertility (years):________________________

Causes of infertility:

Male:

Female:

Unexplained:

Assisted reproductive method: