Coasting (withholding gonadotrophins) for preventing ovarian hyperstimulation syndrome

Arianna D'Angelo; Nazar N Amso; Rudaina Hassan

doi:10.1002/14651858.CD002811.pub4

Coasting疗法（抑制促性腺激素）预防卵巢过度刺激综合征

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Referencias

References to studies included in this review

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estudios excluidos
otras referencias
otras versiones publicadas

Aboulghar M, Mansour R, Amin Y, Al‐Inany H, Aboulghar M, Serour G. A prospective randomized study comparing coasting with GnRH antagonist administration in patients at risk for severe OHSS. Reproductive Biomedicine Online 2007;15(3):271‐9.

Aflatoonian A, Mahani I, Tabibnejad N, Aflatoonian B, Aflatoonian R. Comparison of coasting with aspiration half of follicles before hCG injection for prevention of OHSS in ART cycles. Human Reproduction 2006;21(Suppl 1):i37.

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Dalal R, Mishra A. Comparison of coasting with cabergoline administration for prevention of early severe OHSS in ART cycles. BJOG Eposter2014:78.

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Egbase PE, Al Sharhan M, Grudzinskas JG. Early unilateral follicular aspiration compared with coasting for the prevention of severe ovarian hyperstimulation syndrome: a prospective randomized study. Human Reproduction 1999;14(6):1421‐5.

Egbase P, Al Sharhan M, Masangcay M, Egbase E. Follicle stimulating hormone (FSH) administer with trigger dose human chorionic gonadotropin (hCG) completely prevents ovarian hyperstimulation syndrome (OHSS). Randomised controlled trial. Fertility and Sterility 2011;96(3):S20.

Kamthane V, Goswami S, Ghosh S, Chattopadhay R, Chakravarty B. Does coasting prevent OHSS without compromising pregnancy outcome?. Human Reproduction 2004;19 Suppl(6):i121.

Google Scholar

Lukaszuk K, Liss J, Jakiel G. 'Internal Coasting' for prevention of ovarian hyperstimulation syndrome (OHSS) in IVF/ICSI. Ginekol Pol 2011;82:812‐6.

Sohrabvand F, Ansaripour MD, Bagheri M, Shariat M, Jafarabadi M. Cabergoline versus coasting in the prevention of ovarian hyperstimulation syndrome and assisted reproductive outcome in high risk patients. International Journal of Fertility and Sterility 2009;3(1):35‐40.

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References to studies excluded from this review

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estudios incluidos
otras referencias
otras versiones publicadas

Aboulghar MA, Mansour RT, Serour GI, Sattar M, Ranzy AM, Amin Y. Successful prevention of ovarian hyperstimulation syndrome by reduction of human menopausal gonadotrophin dose following by delayed HCG injection. Human Reproduction 1998;13:243‐4.

Al‐Shawaf T, Zosmer A, Hussain S, Tozer A, Panay N, Wilson C, et al. Prevention of severe ovarian hyperstimulation syndrome in IVF with or without ICSI and embryo transfer: a modified 'coasting' strategy based on ultrasound identification of high‐risk patients. Human Reproduction 2001;1(16):24‐30.

Benadiva CA, Davis O, Kligman I, Moomjy M, Hung‐Ching L, Rosenwaks Z. Withholding gonadotropin administration is an effective alternative for the prevention of ovarian hyperstimulation syndrome. Fertility and Sterility 1997;67(4):724‐7.

Dhont M, Van der Straeten F, De Sutter P. Prevention of severe ovarian hyperstimulation by coasting. Fertility and Sterility 1998;70(9):847‐50.

Esinler I, Bozdag G. Preventing ovarian hyperstimulation syndrome: cabergoline versus coasting. Archives of Gynecology and Obstetrics 2013;288:1159‐63.

Fluker MR, Hooper WM, Yuzpe A. Withholding gonadotropins ('coasting') to minimize the risk of ovarian hyperstimulation during superovulation and in vitro fertilization‐embryo transfer cycles. Fertility and Sterility 1999;71(2):294‐301.

Herrero L, Pareja S, Losada C, Cobo AC, Pellicer A, Garcia‐Velasco. Avoiding the use of human chorionic gonadotrophin combined with oocyte vitrification and GnRH agonist versus coasting: a new strategy to avoid ovarian hyperstimulation syndrome.. Fertility and Sterility 2011;95(3):1137‐40.

Lee C, Tummon I, Martin J, Nisker J, Power S, Tekpetey F. Does withholding gonadotropin administration prevent severe ovarian hyperstimulation syndrome?. Human Reproduction 1998;13(5):1157‐8.

Sher G, Zouves C, Feinman M, Maassarani G. 'Prolonged coasting': an effective method for preventing severe ovarian hyperstimulation syndrome in patients undergoing in vitro fertilization. Human Reproduction 1995;10(12):3107‐9.

Tortoriello DV, McGovern P, Colon JM, Skurnick JH, Lipetz K, Santoro N. 'Coasting' does not adversely affect cycle outcome in a subset of highly responsive in vitro fertilization patients. Fertility and Sterility 1998;69(3):454‐60.

Tortoriello DV. Exogenous gonadotropin withdrawal for the prevention of severe ovarian hyperstimulation syndrome: a critical review. Assisted Reproduction 1999;9(1):17‐22.

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Ulug U, Bahceci M, Erden HF, Shalev E, Ben‐Shlomo I. The significance of coasting duration during ovarian stimulation for conception in assisted fertilization cycles. Human Reproduction 2002;17(2):310‐3.

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Additional references

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Agrawal R, Tan SL, Wild S, Sladkevicius P, Engnrann L, Payne N, et al. Serum vascular endothelium growth factor concentrations in in vitro fertilization cycles predict the risk of ovarian hyperstimulation syndrome. Fertility and Sterility 1999;71:287‐93.

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Golan A, Ron‐El R, Herman A, Soffer Y, Wainraub Z, Caspi E. Ovarian hyperstimulation syndrome: an update review. Obstetrical and Gynaecological Survey 1989;44:430‐40.

Goldsman MP, Pedram A, Dominiguez CE, Ciuffardi I, Levin E, Asch RH. Increased capillary permeability induced by human follicular fluid: a hypothesis for an ovarian origin of the hyperstimulation syndrome. Fertility and Sterility 1995;63:268‐72.

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Navot D, Bergh PA, Laufer N. Ovarian hyperstimulation syndrome in novel reproductive technologies: prevention and treatment. Fertility and Sterility 1992;58:249‐61.

Rabau E, Serr DM, David A, Mashiach S, Lunenfield B. Human menopausal gonadotrophins for anovulation and sterility. American Journal of Obstetrics and Gynaecology 1967;98:92‐8.

Rizk B, Aboulghar MA. Classification, pathophysiology and management of ovarian hyperstimulation syndrome. In: Brinsden P editor(s). A Textbook of In Vitro Fertilization and Assisted Reproduction. 2nd Edition. London: Parthenon Publishing, 1999:131‐55.

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Schenker JG, Weinstein D. Ovarian hyperstimulation syndrome: a current survey. Fertility and Sterility 1978;30:255‐68.

Sher G, Salem R, Feinman M, Dodge S, Zouves C, Knutzen V. Eliminating the risk of life‐endangering complications following overstimulation with menotropin fertility agents: a report on women undergoing in vitro fertilization and embryo transfer. Obstetrics and Gynaecology 1993;81(6):1009‐11.

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Tsirigotis M, Craft I. Ovarian hyperstimulation syndrome (OHSS): how much do we really know about it?. European Journal of Obstetrics and Gynecology 1994;55(3):151‐5.

References to other published versions of this review

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estudios incluidos
estudios excluidos
otras referencias

D'Angelo A, Amso N. "Coasting" (withholding gonadotropins) for the treatment of Ovarian Hyperstimulation Syndrome. Cochrane Database of Systematic Reviews 2000, Issue 4. [DOI: 10.1002/14651858.CD002811]

Google Scholar

D'Angelo A, Amso N. "Coasting" (withholding gonadotrophins) for preventing ovarian hyperstimulation syndrome. Cochrane Database of Systematic Reviews 2002, Issue 3. [DOI: 10.1002/14651858.CD002811]

Google Scholar

D'Angelo A, Brown J, Amso NN. Coasting (withholding gonadotrophins) for preventing ovarian hyperstimulation syndrome. Cochrane Database of Systematic Reviews 2011, Issue 1. [DOI: 10.1002/14651858.CD002811]

D'Angelo A, Brown J, Amso NN. Coasting (withholding gonadotrophins) for preventing ovarian hyperstimulation syndrome. Cochrane Database of Systematic Reviews 2011, Issue 6. [DOI: 10.1002/14651858.CD002811]

Characteristics of studies

Characteristics of included studies [ordered by study ID]

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estudios excluidos

Aboulgar 2007

Methods	Randomised controlled trial, single centre.
Participants	Eygpt. IVF centre. Of 1536 women undergoing IVF/ICSI, 190 were eligible and randomised. Inclusion: undergoing first IVF trial, at actual risk of developing severe OHSS with large number of follicles (≥ 20) on both ovaries, with 90% of the follicles being small (< 14 mm in mean diameter), and estradiol concentration ≥ 3000 pg/ml. Age in the coasting group was 30 ± 4.9 years, and in the antagonist group was 29.6 ± 4.6 years
Interventions	Ovarian stimulation using long GnRH agonist down‐regulation protocol. Coasting group (N = 96) hMG injections stopped and GnRH agonist continued. HmCG given when E2 ≤ 3000 pg/ml. Oocyte retrieval performed 36 hours after HCG administration. GnRHa group (N = 94) treated with subcutaneous GnRH antagonist (ganirelix acetate 250 µg) daily until day of HCG administration. GnRH agonist was discontinued with the start of antagonist and hMG injections continued daily until E2 ≤ 3000 pg/ml, then 10,000 IU of hCG given. Oocyte retrieval performed 36 hours after HCG administration. Embryo transfer on day 2 or day 3 with two to three embryos transferred.
Outcomes	The primary outcomes were number of high quality embryos. Secondary outcomes were days of intervention, number of oocytes, pregnancy rate, multiple pregnancy, number of cryopreserved embryos and incidence of severe OHSS
Notes	Sample size calculation estimated N = 182
*Risk of bias*
Bias	Authors' judgement	Support for judgement
Random sequence generation (selection bias)	Unclear risk	'randomised' ‐ no other details
Allocation concealment (selection bias)	Low risk	'dark, sealed envelopes .... created by a third party not involved in the allocation process.' 'sequentially numbered'
Blinding (performance bias and detection bias) All outcomes	High risk	'The patient was informed about the allocated arm'
Incomplete outcome data (attrition bias) All outcomes	Low risk	All those randomised were analyzed, no loss to follow‐up reported
Selective reporting (reporting bias)	Unclear risk	Did not report live birth

Aflatoonian 2006

Methods	Randomised controlled trial
Participants	Iran and UK study 52 women undergoing IVF treatment cycles at high risk for developing OHSS (> 20 follicles in both ovaries, serum estradiol = E2 > 3000 pg/ml).
Interventions	Induction of ovulation with long protocol beginning with pituitary desensitisation with subcutaneous buserelin and followed by hMG 3 amp from day 2. On day 9 randomised to: Coasting group (N = 27) IVF/ICSI defined as presence of > 10 follicles per ovary with a leading follicle > 17 mm and E2 > 3000 pg/ml (maximum 3 days). Then 10000 units hCG administered and oocyte retrieval 34 to 36 hours later. Aspiration follicle group (N = 26) had > 15 follicles 15 to 16mm in each ovary and E2 > 3000 pg/ml. Unilateral aspiration follicular aspiration performed before hCG administration. Oocyte retrieval performed 34 to 36 hours later in the other ovary. Embryo transfer was done 2 days later in both groups.
Outcomes	Number of follicles, number of oocytes, pregnancy rate, OHSS.
Notes
*Risk of bias*
Bias	Authors' judgement	Support for judgement
Random sequence generation (selection bias)	Unclear risk	'randomized controlled trial'
Allocation concealment (selection bias)	Unclear risk	No details
Blinding (performance bias and detection bias) All outcomes	High risk	No blinding
Incomplete outcome data (attrition bias) All outcomes	Unclear risk	No details
Selective reporting (reporting bias)	Unclear risk	Outcomes not mentioned in methods ‐ this was a conference abstract. Did not report live birth.

Dalal 2014

Methods	Randomised control trial
Participants	India study 60 women undergoing IVF considered at risk of OHSS (> 20 follicles of more than 11 mm, serum E2 > 3000 pg/ml on day 9 of stimulation, or both).
Interventions	Coasting group (30 patients), exogenous gonadotropins were withheld to allow E2 to decrease while GnRH‐a was maintained. Then 10,000 units hCG was administrated and oocyte retrieval was performed 36 hours later Cabergoline group (30 patients) were administered with 0.5 mg cabergoline tablet on day of hCG injection, continued for 8 days.
Outcomes	Number of mature oocytes, number of embryos, clinical pregnancy rate, OHSS
Notes	Source of funding not stated and no correspondence details for author. Obtained missing data from another review
*Risk of bias*
Bias	Authors' judgement	Support for judgement
Random sequence generation (selection bias)	Low risk	Computer generated randomization
Allocation concealment (selection bias)	High risk	No allocation concealment
Blinding (performance bias and detection bias) All outcomes	High risk	No blinding
Incomplete outcome data (attrition bias) All outcomes	Low risk	All participants analyzed
Selective reporting (reporting bias)	Unclear risk	Outcomes not mentioned in methods. Did not report live birth

Egbase 1999

Methods	Randomised controlled trial; parallel prospective design; single centre; power calculation included; randomization based on serially numbered sealed envelopes.
Participants	Kuwait study 37 women recruited: 30 infertile women (consented and randomised) < 39 years, considered at risk of OHSS (15 coasting/15 EUFA); E2 (major risk factor for OHSS) was > 6000 pg/ml; Mean (± SD) age (coasting) 33.5 ± 2.8, (EUFA) 34.6 ± 3.2; Duration of infertility: not stated; Causes of infertility: unexplained (2 versus 2); anovulation (2 versus 2); tubal factor (1 versus 3); tubal + anovulation (2 versus 2); male factor (5 versus 4); male factor + anovulation (5 versus 4); BMI > 30 (13 versus 10) and > 40 (6 versus 5).
Interventions	Treatment group: coasting (hMG injections were withheld until E2 < 3000 pg/ml and GnRh‐a continued until day of hCG; duration 3 to 7 days). Control group: early unilateral follicular flushing (left ovarian follicular aspiration 10 to 12 hours after hCG administration).
Outcomes	Method of diagnosing different grades of OHSS: Schenker and Weinstein (1978) and Navot criteria (1992). Moderate and severe OHSS Clinical pregnancy rate/woman Number of oocytes retrieved Fertilization rate Number of embryos transferred
Notes	Source of funding: not stated. Authors contacted on two occasions ‐ extra data obtained
*Risk of bias*
Bias	Authors' judgement	Support for judgement
Random sequence generation (selection bias)	Low risk	Computer generated random numbers
Allocation concealment (selection bias)	Low risk	"serially numbered sealed envelopes"
Blinding (performance bias and detection bias) All outcomes	High risk	No blinding
Incomplete outcome data (attrition bias) All outcomes	Low risk	All patients analyzed
Selective reporting (reporting bias)	Unclear risk	Outcomes not mentioned in methods. Did not report live birth

Egbase 2011

Methods	Randomised controlled trial, single centre, randomization based on serially numbered sealed envelopes.
Participants	Kuwait study, 102 women recruited undergoing IVF cycles at risk of OHS with serum E2 ≥ 3500 pg/ml, > 15 follicles in each ovary and two leading follicles of ≥18mm in size.
Interventions	Coasting group (N = 51): long protocol starting dose 225 iu hMG, hMG was withheld until E2 levels fell < 1500 pg/ml, when trigger dose HCG was administered. FSH co‐trigger group (N = 51): Long protocol, pure FSH was administered with the trigger dose of hCG, regardless of the E2 levels ≥ 3500 pg/ml. Three cleaved D3 or two D5 blastocyst embryos transferred.
Outcomes	Golan 2009 classification of OHSS used Moderate or severe OHSS Clinical pregnancy rate (48.6% versus 51.8%) Number of oocytes retrieved (8.6 ± 2.9 versus 26.4 ± 3.5) Multiple pregnancy rate, live birth rate, miscarriage rate (reported as no significant difference)
Notes	Source of funding not stated, author contacted twice, responded once with partial data.
*Risk of bias*
Bias	Authors' judgement	Support for judgement
Random sequence generation (selection bias)	Low risk	Computer generated random numbers
Allocation concealment (selection bias)	Low risk	"serially numbered sealed envelopes"
Blinding (performance bias and detection bias) All outcomes	High risk	No blinding
Incomplete outcome data (attrition bias) All outcomes	Low risk	All participants analyzed
Selective reporting (reporting bias)	Unclear risk	Outcomes not mentioned in methods. Did not report data suitable for analysis on live birth

Kamthane 2007

Methods	Randomised study
Participants	68 patients at risk of developing OHSS, aged 25 to 38 years undergoing controlled ovarian hyperstimulation in IVF/ICSI. Inclusion: intermediate follicles (11 to 14mm) > 10, E2 > 700 pg/ml on day 7 or day 8 of controlled ovarian hyperstimulation, or both
Interventions	Group A (N = 16) early coasting from day 8 onwards on basis of high E2 (> 700 pg/ml). Group B (N = 18) late coasting when one of the follicles reached 15 mm; E2 < 700 pg/ml on day 8 but number of intermediate follicles were more than 10. Group C (N = 34) no coasting, E2 level of 3000 pg/ml to < 4000 pg/ml hCG day. These women had neither E2 > 700 pg/ml, nor intermediate follicles > 10mm.
Outcomes	OHSS severity, terminal E2 mean number of oocytes retrieved, endometrial thickness, clinical pregnancy, miscarriage, live birth.
Notes	Women with E2 > 4000 pg/ml on hCG day had transvaginal ovum retrieval, and following fertilisation, the embryos were frozen and not transferred in that cycle. These women received prophylactic IV albumin and were excluded from the study.
*Risk of bias*
Bias	Authors' judgement	Support for judgement
Random sequence generation (selection bias)	Low risk	'randomised'
Allocation concealment (selection bias)	Unclear risk	No details
Blinding (performance bias and detection bias) All outcomes	Unclear risk	No details
Incomplete outcome data (attrition bias) All outcomes	Unclear risk	Women who were excluded due to high E2 levels were not detailed
Selective reporting (reporting bias)	Low risk	All a priori outcomes reported

Lukaszuk 2011

Methods	Randomised controlled trial, single centre, randomization based on generated table of random numbers
Participants	139 women recruited, who had unsuccessfully undergone standard long protocol ICSI procedure complicated by moderate or severe OHSS. For the next cycle, women randomised to standard long protocol or 'internal' coasting.
Interventions	Coasting group (N = 68): long protocol, received 2 days 225 iu hMG, then 2 days without hMG and 150 hMG for remainder of the stimulation period. Control group (N = 71): received standard dose hMG as in the first cycle. All patient underwent ICSI (routine practice in the centre) and maximum two embryos transferred on D3 for women < 36 and three embryos for older women.
Outcomes	Rizk and Aboulgar OHSS classification used Moderate or severe OHSS Clinical pregnancy rate Number of oocytes retrieved Multiple pregnancy rate
Notes	Source of funding not stated; author contacted twice ‐ no response.
*Risk of bias*
Bias	Authors' judgement	Support for judgement
Random sequence generation (selection bias)	Low risk	'randomised'.
Allocation concealment (selection bias)	Low risk	only known to administrative staff
Blinding (performance bias and detection bias) All outcomes	High risk	No blinding
Incomplete outcome data (attrition bias) All outcomes	Low risk	All participants analyzed
Selective reporting (reporting bias)	Low risk	Includes expected outcomes

Sohrabvand 2009

Methods	Randomised controlled trial
Participants	60 participants undergoing IVF at risk of developing OHSS (20 follicles in both ovaries, majority < 15 mm in diameter and serum E2 level 3000 pg/ml)
Interventions	All participants underwent long protocol with a starting dose of 75 to150 iu r‐FSH, and dose adjusted on individual response. In Cabergoline Group A (30 patients), when the number of follicles exceeded 20, with at least two leading follicles 18 mm, 10,000 hCG was administered and 0.5 mg oral cabergoline was started immediately for seven days after hCG administration In Coasting Group B (30 patients), when the number of follicles was 20 or more and mean leading follicle was 16 mm, gonadotrophin was ceased until E2 levels dropped below 3000 pg/ml. All participants underwent ICSI procedure and 2 to 3 embryos transferred, depending on patient's age and quality of embryos.
Outcomes	Number of oocytes, clinical pregnancy rate, OHSS
Notes	Source of funding not stated. Attempts made to contact authors but there was no response
*Risk of bias*
Bias	Authors' judgement	Support for judgement
Random sequence generation (selection bias)	Low risk	block randomization
Allocation concealment (selection bias)	Unclear risk	not stated
Blinding (performance bias and detection bias) All outcomes	High risk	No blinding
Incomplete outcome data (attrition bias) All outcomes	Low risk	All participants data analyzed
Selective reporting (reporting bias)	Low risk	Main outcome measure reported

OHSS: ovarian hyperstimulation syndrome

EUFA: early unilateral follicular aspiration

E2: estradiol

BMI: body mass index

hMG: human menopausal gonadotrophin

GnRh‐a: gonadotrophin‐releasing hormone analogue

hCG: human chorionic gonadotrophin

FSH: Follicle stimulating hormone

Characteristics of excluded studies [ordered by study ID]

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estudios incluidos

Study	Reason for exclusion
Aboulghar 1998	Prospective randomised trial with historical control
Al‐Shawaf 2001	Prospective observational study
Benadiva 1997	Retrospective observational study
Dhont 1998	Retrospective case‐control study
Esinler 2013	Retrospective cohort study
Fluker 1999	Retrospective observational study
Herrero 2011	Retrospective observational study
Lee 1998	Prospective observational study
Sher 1995	Prospective observational study
Tortoriello 1998	Retrospective observational study
Tortoriello 1999	Retrospective observational study
Ulug 2002	Retrospective observational study
VanderStraeten 1998	Retrospective case‐control study
Waldenstrom 1999	Prospective observational study

Data and analyses

Open in table viewer

Comparison 1. Coasting versus no coasting

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 OHSS Show forest plot	2	207	Odds Ratio (M‐H, Fixed, 95% CI)	0.11 [0.05, 0.24]
Open in figure viewer Analysis 1.1 Comparison 1 Coasting versus no coasting, Outcome 1 OHSS.
2 Live birth Show forest plot	1	68	Odds Ratio (M‐H, Fixed, 95% CI)	0.48 [0.14, 1.62]
Open in figure viewer Analysis 1.2 Comparison 1 Coasting versus no coasting, Outcome 2 Live birth.
3 Clinical pregnancy Show forest plot	2	207	Odds Ratio (M‐H, Fixed, 95% CI)	0.82 [0.46, 1.44]
Open in figure viewer Analysis 1.3 Comparison 1 Coasting versus no coasting, Outcome 3 Clinical pregnancy.
4 Multiple pregnancy Show forest plot	1	139	Odds Ratio (M‐H, Fixed, 95% CI)	0.31 [0.12, 0.81]
Open in figure viewer Analysis 1.4 Comparison 1 Coasting versus no coasting, Outcome 4 Multiple pregnancy.
5 Miscarriage Show forest plot	2	207	Odds Ratio (M‐H, Fixed, 95% CI)	0.85 [0.25, 2.86]
Open in figure viewer Analysis 1.5 Comparison 1 Coasting versus no coasting, Outcome 5 Miscarriage.
6 Number of oocytes retrieved Show forest plot	2	207	Mean Difference (IV, Fixed, 95% CI)	‐3.86 [‐4.38, ‐3.33]
Open in figure viewer Analysis 1.6 Comparison 1 Coasting versus no coasting, Outcome 6 Number of oocytes retrieved.

Open in table viewer

Comparison 2. Coasting versus early unilateral follicular aspiration (EUFA)

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 OHSS Show forest plot	2	83	Odds Ratio (M‐H, Fixed, 95% CI)	0.98 [0.34, 2.85]
Open in figure viewer Analysis 2.1 Comparison 2 Coasting versus early unilateral follicular aspiration (EUFA), Outcome 1 OHSS.
2 Clinical Pregnancy Show forest plot	2	83	Odds Ratio (M‐H, Fixed, 95% CI)	0.67 [0.25, 1.79]
Open in figure viewer Analysis 2.2 Comparison 2 Coasting versus early unilateral follicular aspiration (EUFA), Outcome 2 Clinical Pregnancy.
3 Number of oocytes retrieved Show forest plot	2	83	Mean Difference (IV, Fixed, 95% CI)	‐4.42 [‐6.08, ‐2.75]
Open in figure viewer Analysis 2.3 Comparison 2 Coasting versus early unilateral follicular aspiration (EUFA), Outcome 3 Number of oocytes retrieved.

Open in table viewer

Comparison 3. Coasting versus gonadotrophin‐releasing hormone antagonist (antagonist)

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 OHSS Show forest plot	1	190	Odds Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
Open in figure viewer Analysis 3.1 Comparison 3 Coasting versus gonadotrophin‐releasing hormone antagonist (antagonist), Outcome 1 OHSS.
2 Clinical Pregnancy Show forest plot	1	190	Odds Ratio (M‐H, Fixed, 95% CI)	0.74 [0.42, 1.31]
Open in figure viewer Analysis 3.2 Comparison 3 Coasting versus gonadotrophin‐releasing hormone antagonist (antagonist), Outcome 2 Clinical Pregnancy.
3 Multiple pregnancy Show forest plot	1	190	Odds Ratio (M‐H, Fixed, 95% CI)	0.84 [0.39, 1.80]
Open in figure viewer Analysis 3.3 Comparison 3 Coasting versus gonadotrophin‐releasing hormone antagonist (antagonist), Outcome 3 Multiple pregnancy.
4 Number of oocytes retrieved Show forest plot	1	190	Mean Difference (IV, Fixed, 95% CI)	‐2.44 [‐4.30, ‐0.58]
Open in figure viewer Analysis 3.4 Comparison 3 Coasting versus gonadotrophin‐releasing hormone antagonist (antagonist), Outcome 4 Number of oocytes retrieved.

Open in table viewer

Comparison 4. Coasting versus FSH co‐trigger with hCG administration

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 OHSS Show forest plot	1	102	Odds Ratio (M‐H, Fixed, 95% CI)	43.74 [2.54, 754.58]
Open in figure viewer Analysis 4.1 Comparison 4 Coasting versus FSH co‐trigger with hCG administration, Outcome 1 OHSS.
2 Clinical pregnancy Show forest plot	1	102	Odds Ratio (M‐H, Fixed, 95% CI)	0.92 [0.43, 2.01]
Open in figure viewer Analysis 4.2 Comparison 4 Coasting versus FSH co‐trigger with hCG administration, Outcome 2 Clinical pregnancy.
3 Number of oocytes retrieved Show forest plot	1	102	Mean Difference (IV, Fixed, 95% CI)	‐17.80 [‐19.05, ‐16.55]
Open in figure viewer Analysis 4.3 Comparison 4 Coasting versus FSH co‐trigger with hCG administration, Outcome 3 Number of oocytes retrieved.

Open in table viewer

Comparison 5. Coasting versus cabergoline

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 OHSS Show forest plot	2	120	Odds Ratio (M‐H, Fixed, 95% CI)	1.98 [0.69, 5.68]
Open in figure viewer Analysis 5.1 Comparison 5 Coasting versus cabergoline, Outcome 1 OHSS.
2 Clinical pregnancy rate Show forest plot	2	120	Odds Ratio (M‐H, Fixed, 95% CI)	0.38 [0.16, 0.88]
Open in figure viewer Analysis 5.2 Comparison 5 Coasting versus cabergoline, Outcome 2 Clinical pregnancy rate.
3 Number of oocytes retrieved Show forest plot	1	60	Mean Difference (IV, Fixed, 95% CI)	‐4.30 [‐7.88, ‐0.72]
Open in figure viewer Analysis 5.3 Comparison 5 Coasting versus cabergoline, Outcome 3 Number of oocytes retrieved.

Figure 1

Study flow diagram: July 2016 search for 2017 review update

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Figure 2

Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.

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Figure 3

Risk of bias summary: review authors' judgements about each risk of bias item for each included study.

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Figure 4

Forest plot of comparison: 3 Coasting versus no coasting, outcome: 3.1 OHSS.

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Figure 5

Forest plot of comparison: 1 Coasting versus EUFA, outcome: 1.1 OHSS.

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Figure 6

Forest plot of comparison: 5 Coasting versus cabergoline, outcome: 5.1 OHSS.

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Analysis 1.1

Comparison 1 Coasting versus no coasting, Outcome 1 OHSS.

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Analysis 1.2

Comparison 1 Coasting versus no coasting, Outcome 2 Live birth.

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Analysis 1.3

Comparison 1 Coasting versus no coasting, Outcome 3 Clinical pregnancy.

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Analysis 1.4

Comparison 1 Coasting versus no coasting, Outcome 4 Multiple pregnancy.

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Analysis 1.5

Comparison 1 Coasting versus no coasting, Outcome 5 Miscarriage.

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Analysis 1.6

Comparison 1 Coasting versus no coasting, Outcome 6 Number of oocytes retrieved.

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Analysis 2.1

Comparison 2 Coasting versus early unilateral follicular aspiration (EUFA), Outcome 1 OHSS.

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Analysis 2.2

Comparison 2 Coasting versus early unilateral follicular aspiration (EUFA), Outcome 2 Clinical Pregnancy.

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Analysis 2.3

Comparison 2 Coasting versus early unilateral follicular aspiration (EUFA), Outcome 3 Number of oocytes retrieved.

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Analysis 3.1

Comparison 3 Coasting versus gonadotrophin‐releasing hormone antagonist (antagonist), Outcome 1 OHSS.

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Analysis 3.2

Comparison 3 Coasting versus gonadotrophin‐releasing hormone antagonist (antagonist), Outcome 2 Clinical Pregnancy.

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Analysis 3.3

Comparison 3 Coasting versus gonadotrophin‐releasing hormone antagonist (antagonist), Outcome 3 Multiple pregnancy.

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Analysis 3.4

Comparison 3 Coasting versus gonadotrophin‐releasing hormone antagonist (antagonist), Outcome 4 Number of oocytes retrieved.

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Analysis 4.1

Comparison 4 Coasting versus FSH co‐trigger with hCG administration, Outcome 1 OHSS.

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Analysis 4.2

Comparison 4 Coasting versus FSH co‐trigger with hCG administration, Outcome 2 Clinical pregnancy.

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Analysis 4.3

Comparison 4 Coasting versus FSH co‐trigger with hCG administration, Outcome 3 Number of oocytes retrieved.

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Analysis 5.1

Comparison 5 Coasting versus cabergoline, Outcome 1 OHSS.

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Analysis 5.2

Comparison 5 Coasting versus cabergoline, Outcome 2 Clinical pregnancy rate.

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Analysis 5.3

Comparison 5 Coasting versus cabergoline, Outcome 3 Number of oocytes retrieved.

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Summary of findings for the main comparison. Coasting versus no coasting for prevention of ovarian hyperstimulation syndrome

Coasting versus no coasting for prevention of ovarian hyperstimulation syndrome (OHSS)
Population: Women undergoing assisted reproduction Setting: Assisted reproduction clinics Intervention: Coasting Comparison: No coasting
Outcomes	*Anticipated absolute effects^ (95% CI)**		Relative effect (95% CI)	№ of participants (studies)	Quality of the evidence (GRADE)	Comments
Outcomes	Risk with no coasting	Risk with coasting	Relative effect (95% CI)	№ of participants (studies)	Quality of the evidence (GRADE)	Comments
OHSS	457 per 1000	85 per 1000 (40 to 168)	OR 0.11 (0.05 to 0.24)	207 (2 RCTs)	⊕⊕⊝⊝ LOW^1,2
Live birth	265 per 1000	147 per 1000 (48 to 368)	OR 0.48 (0.14 to 1.62)	68 (1 RCT)	⊕⊝⊝⊝ VERY LOW^1,3
Clinical pregnancy	390 per 1000	344 per 1000 (228 to 480)	OR 0.82 (0.46 to 1.44)	207 (2 RCTs)	⊕⊕⊝⊝ LOW^1,2
Multiple pregnancy	268 per 1000	102 per 1000 (42 to 228)	OR 0.31 (0.12 to 0.81)	139 (1 RCT)	⊕⊝⊝⊝ LOW^1,2
Miscarriage	57 per 1,000	49 per 1,000 (15 to 148)	OR 0.85 (0.25 to 2.86)	207 (2 studies)	⊕⊕⊝⊝ VERY LOW^1,3
*The risk in the intervention group (and its 95% confidence interval) is based on the mean risk in the comparison group and the relative effect of the intervention (and its 95% CI). CI: Confidence interval; OR: Odds ratio;
GRADE Working Group grades of evidence High quality: We are very confident that the true effect lies close to that of the estimate of the effect Moderate quality: We are moderately confident in the effect estimate: The true effect is likely to be close to the estimate of the effect, but there is a possibility that it is substantially different Low quality: Our confidence in the effect estimate is limited: The true effect may be substantially different from the estimate of the effect Very low quality: We have very little confidence in the effect estimate: The true effect is likely to be substantially different from the estimate of effect
¹ Downgraded one level for serious risk of bias: one study did not clearly describe the methods used, studies not blinded ² Downgraded one level for serious imprecision: few events, wide confidence intervals, or both ³ Downgraded two levels for very serious imprecision: very few events, very wide confidence intervals, or both

Summary of findings for the main comparison. Coasting versus no coasting for prevention of ovarian hyperstimulation syndrome

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Summary of findings 2. Coasting versus early unilateral follicular aspiration for preventing ovarian hyperstimulation syndrome

Coasting versus early unilateral follicular aspiration for preventing ovarian hyperstimulation syndrome (OHSS)
Population: Women undergoing assisted reproduction Setting: Assisted reproduction clinics Intervention: Coasting Comparison: Early unilateral follicular aspiration (EUFA)
Outcomes	*Anticipated absolute effects^ (95% CI)**		Relative effect (95% CI)	№ of participants (studies)	Quality of the evidence (GRADE)	Comments
	Risk with early unilateral follicular aspiration (EUFA)	Risk with coasting
OHSS	244 per 1000	240 per 1000 (99 to 479)	OR 0.98 (0.34 to 2.85)	83 (2 RCTs)	⊕⊝⊝⊝ VERY LOW^1,2
Live birth	No data available
Clinical Pregnancy	317 per 1000	237 per 1000 (104 to 454)	OR 0.67 (0.25 to 1.79)	83 (2 RCTs)	⊕⊝⊝⊝ VERY LOW^1,2
Multiple pregnancy	No data available
Miscarriage	No data available
*The risk in the intervention group (and its 95% confidence interval) is based on the mean risk in the comparison group and the relative effect of the intervention (and its 95% CI). CI: Confidence interval; OR: Odds ratio
GRADE Working Group grades of evidence High quality: We are very confident that the true effect lies close to that of the estimate of the effect Moderate quality: We are moderately confident in the effect estimate: The true effect is likely to be close to the estimate of the effect, but there is a possibility that it is substantially different Low quality: Our confidence in the effect estimate is limited: The true effect may be substantially different from the estimate of the effect Very low quality: We have very little confidence in the effect estimate: The true effect is likely to be substantially different from the estimate of effect
¹ Downgraded one level for serious risk of bias: one study did not clearly describe methods, lack of blinding ² Downgraded two levels for very serious imprecision: very few events and very wide confidence intervals

Summary of findings 2. Coasting versus early unilateral follicular aspiration for preventing ovarian hyperstimulation syndrome

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Summary of findings 3. Coasting versus gonadotrophin‐releasing hormone antagonist for preventing ovarian hyperstimulation syndrome

Coasting versus gonadotrophin‐releasing hormone antagonist for preventing ovarian hyperstimulation syndrome (OHSS)
Population: Women undergoing assisted reproduction Setting: Assisted reproduction clinics Intervention: Coasting Comparison: Gonadotrophin‐releasing hormone antagonist
Outcomes	*Anticipated absolute effects^ (95% CI)**		Relative effect (95% CI)	№ of participants (studies)	Quality of the evidence (GRADE)	Comments
	Risk with gonadotrophin‐releasing hormone antagonist	Risk with coasting
OHSS	Not estimable	Not estimable	not estimable	190 (1 RCT)	⊕⊕⊝⊝ VERY LOW^1,2
Live birth	No data available
Clinical Pregnancy	553 per 1000	478 per 1000 (342 to 619)	OR 0.74 (0.42 to 1.31)	190 (1 RCT)	⊕⊕⊝⊝ LOW^1,3
Multiple pregnancy	181 per 1000	156 per 1000 (79 to 284)	OR 0.84 (0.39 to 1.80)	98 (1 RCT)	⊕⊕⊝⊝ VERY LOW^1,2
Miscarriage	No data available
*The risk in the intervention group (and its 95% confidence interval) is based on the mean risk in the comparison group and the relative effect of the intervention (and its 95% CI). CI: Confidence interval; RR: Risk ratio; OR: Odds ratio
GRADE Working Group grades of evidence High quality: We are very confident that the true effect lies close to that of the estimate of the effect Moderate quality: We are moderately confident in the effect estimate: The true effect is likely to be close to the estimate of the effect, but there is a possibility that it is substantially different Low quality: Our confidence in the effect estimate is limited: The true effect may be substantially different from the estimate of the effect Very low quality: We have very little confidence in the effect estimate: The true effect is likely to be substantially different from the estimate of effect
¹ Downgraded one level due to serious risk of bias: method of sequence generation not reported, lack of blinding ² Downgraded two levels due to very serious imprecision: no OHSS occurred in either group. Few events for multiple pregnancy. ³ Downgraded one level due to serious imprecision. Wide confidence intervals, few events

Summary of findings 3. Coasting versus gonadotrophin‐releasing hormone antagonist for preventing ovarian hyperstimulation syndrome

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Summary of findings 4. Coasting versus follicle stimulating hormone administration at time of hCG for preventing ovarian hyperstimulation syndrome

Coasting versus follicle stimulating hormone (FSH) administration at time of hCG trigger in preventing ovarian hyperstimulation syndrome (OHSS)
Population: Women undergoing assisted reproduction Setting: Assisted reproduction clinics Intervention: Coasting Comparison: FSH co‐trigger with hCG administration
Outcomes	*Anticipated absolute effects^ (95% CI)**		Relative effect (95% CI)	№ of participants (studies)	Quality of the evidence (GRADE)	Comments
	Risk with FSH co‐trigger with hCG administration	Risk with Coasting
OHSS	Not estimable	Not estimable	OR 43.74 (2.54 to 754.58)	102 (1 RCT)	⊕⊝⊝⊝ VERY LOW^1,2
Live birth	No data available
Clinical Pregnancy	510 per 1000	489 per 1000 (309 to 676)	OR 0.92 (0.43 to 2.01)	102 (1 RCT)	⊕⊕⊝⊝^1,3 LOW
Multiple pregnancy	No data available
Miscarriage	No data available
*The risk in the intervention group (and its 95% confidence interval) is based on the mean risk in the comparison group and the relative effect of the intervention (and its 95% CI). CI: Confidence interval; OR: Odds ratio; hCG: human chorionic gonadotrophin
GRADE Working Group grades of evidence High quality: We are very confident that the true effect lies close to that of the estimate of the effect Moderate quality: We are moderately confident in the effect estimate: The true effect is likely to be close to the estimate of the effect, but there is a possibility that it is substantially different Low quality: Our confidence in the effect estimate is limited: The true effect may be substantially different from the estimate of the effect Very low quality: We have very little confidence in the effect estimate: The true effect is likely to be substantially different from the estimate of effect
1 Downgraded one level due to serious risk of bias: method of sequence generation not reported, lack of blinding ² Downgraded two levels due to very serious imprecision: only 15 events, all in one arm. ³ Downgraded one level due to serious imprecision: very wide confidence intervals

Summary of findings 4. Coasting versus follicle stimulating hormone administration at time of hCG for preventing ovarian hyperstimulation syndrome

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Summary of findings 5. Coasting compared to cabergoline for preventing ovarian hyperstimulation syndrome

Coasting compared to cabergoline for preventing ovarian hyperstimulation syndrome (OHSS)
Population: Women undergoing assisted reproduction Setting: Assisted reproduction clinics Intervention: Coasting Comparison: Cabergoline
Outcomes	*Anticipated absolute effects^ (95% CI)**		Relative effect (95% CI)	№ of participants (studies)	Quality of the evidence (GRADE)	Comments
	Risk with cabergoline	Risk with Coasting
OHSS	100 per 1000	180 per 1000 (71 to 387)	OR 1.98 (0.69 to 5.68)	120 (2 RCTs)	⊕⊝⊝⊝^1,2 VERY LOW
Live birth	Not reported
Clinical pregnancy rate	367 per 1000	180 per 1000 (85 to 338)	OR 0.38 (0.16 to 0.88)	120 (2 RCTs)	⊕⊕⊝⊝¹ VERY LOW
Multiple pregnancy	Not reported
Miscarriage	Not reported
*The risk in the intervention group (and its 95% confidence interval) is based on the mean risk in the comparison group and the relative effect of the intervention (and its 95% CI). CI: Confidence interval; RR: Risk ratio; OR: Odds ratio
GRADE Working Group grades of evidence High quality: We are very confident that the true effect lies close to that of the estimate of the effect Moderate quality: We are moderately confident in the effect estimate: The true effect is likely to be close to the estimate of the effect, but there is a possibility that it is substantially different Low quality: Our confidence in the effect estimate is limited: The true effect may be substantially different from the estimate of the effect Very low quality: We have very little confidence in the effect estimate: The true effect is likely to be substantially different from the estimate of effect
1 Downgraded two levels due to very serious risk of bias: one study did not clearly define method, method of sequence generation not reported, lack of blinding ² Downgraded one level due to serious imprecision: very few events and/or wide confidence interval.

Summary of findings 5. Coasting compared to cabergoline for preventing ovarian hyperstimulation syndrome

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Table 1. Golan classification of ovarian hyperstimulation syndrome

Classification	Size of ovaries	Grade	Symptoms
Mild	5 to 10 cm	grade 1	abdominal tension and discomfort
		grade 2	grade 1 signs plus nausea, vomiting, diarrhoea, or a combination
Moderate	> 10 cm	grade 3	grade 2 signs plus ultrasound evidence of ascites
Severe	> 12 cm	grade 4	grade 3 signs plus clinical evidence of ascites, pleural effusion and dyspnoea, or a combination
		grade 5	grade 4 signs plus haemoconcentration increased blood viscosity, hypovolaemia, decreased renal perfusion, oliguria
Golan 1989

Table 1. Golan classification of ovarian hyperstimulation syndrome

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Table 2. Navot classification of severe ovarian hyperstimulation syndrome

Severe	Critical
Variably enlarged ovary	Variably enlarged ovary
Massive ascites ± hydrothorax	Tense ascites ± hydrothorax
Hct > 45% (> 30% increment over baseline value)	Hct > 55%
WBC > 15,000	WBC > 35,000
Oliguria
Creatinine 1.0 to 1.5	Creatinine > 1.6
Creatinine clearance > 50 ml/min	Creatinine clearance < 50ml/min
Liver dysfunction	Renal failure
Anasarca	Thromboembolic phenomena
	Adult respiratory distress syndrome (ARDS)
Navot 1992 Hct: haematocrit WBC: white blood cells

Table 2. Navot classification of severe ovarian hyperstimulation syndrome

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Table 3. Aboulghar and Rizk classification of ovarian hyperstimulation syndrome (1999)

Moderate	Severe Grade A	Severe Grade B	Severe Grade C
Discomfort, pain, nausea, distension, ultrasonic evidence of ascites and enlarged ovaries, normal haematological and biological profile	Dyspnoea, oliguria, nausea, vomiting, diarrhoea, abdominal pain, clinical evidence of ascites, marked distension of abdomen or hydro‐thorax, US showing large ovaries and marked ascites, normal biochemical profile	Grade A plus massive tension ascites, markedly enlarged ovaries, severe dyspnoea and marked oliguria, increased haematocrit, elevated serum creatinine and liver dysfunction	Complications such as respiratory distress syndrome, renal shut‐down, or venous thrombosis
Rizk 1999

Table 3. Aboulghar and Rizk classification of ovarian hyperstimulation syndrome (1999)

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Table 4. Different coasting regimens

Authors	E2 at coasting	E2 at hCG	Number and follicle size	Coasting time
Sher 1995	> 3000 pg/mL or > 11,000 pmol/L*	< 3000 pg/mL or < 11,000 pmol/L*	> 29 follicles at least 30% > 15 mm	3 to 11 days (mean 6.1)
Benadiva 1997	≥ 3000 pg/ml or ≥ 11,000 pmol/l*	< 3000 pg/ml or < 11,000 pmol/l*	at least 3 follicles of 15.6 ± 1.4 mm	1.9 ± 0.9 days
Tortoriello 1998	> 3000 pg/ml or > 11,000 pmol/l*	< 3000 pg/mL or < 11,000 pmol/L*	5 follicles at least 16 mm, two of which are at least 19 mm	1 to 5 days
Dhont 1998	> 2500 pg/ml or > 9000 pmol/l*	< 2500 pg/ml or < 9000 pmol/l*	≥ 20 follicles > 15 mm	1 to 6 days (mean 1.94)
Lee 1998	> 2700 pg/ml or > 10,000 pmol/l*	no values given	many immature follicles < 3 at 18 mm	3 days
VanderStraeten 1998	> 2500 pg/ml or > 9000 pmol/l*	< 2500 pg/ml or < 9000 pmol/l*	≥ 20 follicles > 14 mm	1 to 6 days (mean 1.94)
Egbase 1999	> 6000 pg/ml or > 22,000 pmol/l*	< 3000 pg/ml or 11,000 pmol/l*	> 15 follicles, each of > 18 mm in each ovary	4.9 ± 1.6 days
Waldenstrom 1999	> 2700 pg/ml or > 10,000 pmol/l*	< 2700 pg/ml or < 10,000 pmol/l*	> 25 follicles, at least 3 follicles > 17 mm	3 to 6 days (mean 4.3)
Fluker 1999	> 3000 pg/ml or > 11,000 pmol/l*	25% decline < 2250 pg/ml or 8250 pmol/l*	> 3 follicles of > 18 mm	3 to 5 days (mean 3.4 ± 0.1)
Al‐Shawaf 2001	> 3600 pg/ml or > 13,000 pmol/l*	< 2700 pg/ml or < 10,000 pmol/l*	at least 25% of the follicles > 15 mm	2 to 9 days (mean 3.4 ± 1.6)
Aboulghar 1998	> 3000 pg/ml or > 11,000 pmol/l*	< 5500 pg/ml or < 20,000 pmol/l*	> 20 follicles at least 15 mm	2.8 days
Ulug 2002	> 4000 pg/ml or > 14,684 pmol/l*	< 4000 pg/ml or < 14,684 pmol/l*	> 20 follicles, at least 30% of them >15 mm	2.9 ± 0.33 days

* conversion factor to SI unit, 3.671

Table 4. Different coasting regimens

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Comparison 1. Coasting versus no coasting

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 OHSS Show forest plot	2	207	Odds Ratio (M‐H, Fixed, 95% CI)	0.11 [0.05, 0.24]

2 Live birth Show forest plot	1	68	Odds Ratio (M‐H, Fixed, 95% CI)	0.48 [0.14, 1.62]

3 Clinical pregnancy Show forest plot	2	207	Odds Ratio (M‐H, Fixed, 95% CI)	0.82 [0.46, 1.44]

4 Multiple pregnancy Show forest plot	1	139	Odds Ratio (M‐H, Fixed, 95% CI)	0.31 [0.12, 0.81]

5 Miscarriage Show forest plot	2	207	Odds Ratio (M‐H, Fixed, 95% CI)	0.85 [0.25, 2.86]

6 Number of oocytes retrieved Show forest plot	2	207	Mean Difference (IV, Fixed, 95% CI)	‐3.86 [‐4.38, ‐3.33]

Comparison 1. Coasting versus no coasting

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Comparison 2. Coasting versus early unilateral follicular aspiration (EUFA)

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 OHSS Show forest plot	2	83	Odds Ratio (M‐H, Fixed, 95% CI)	0.98 [0.34, 2.85]

2 Clinical Pregnancy Show forest plot	2	83	Odds Ratio (M‐H, Fixed, 95% CI)	0.67 [0.25, 1.79]

3 Number of oocytes retrieved Show forest plot	2	83	Mean Difference (IV, Fixed, 95% CI)	‐4.42 [‐6.08, ‐2.75]

Comparison 2. Coasting versus early unilateral follicular aspiration (EUFA)

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Comparison 3. Coasting versus gonadotrophin‐releasing hormone antagonist (antagonist)

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 OHSS Show forest plot	1	190	Odds Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]

2 Clinical Pregnancy Show forest plot	1	190	Odds Ratio (M‐H, Fixed, 95% CI)	0.74 [0.42, 1.31]

3 Multiple pregnancy Show forest plot	1	190	Odds Ratio (M‐H, Fixed, 95% CI)	0.84 [0.39, 1.80]

4 Number of oocytes retrieved Show forest plot	1	190	Mean Difference (IV, Fixed, 95% CI)	‐2.44 [‐4.30, ‐0.58]

Comparison 3. Coasting versus gonadotrophin‐releasing hormone antagonist (antagonist)

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Comparison 4. Coasting versus FSH co‐trigger with hCG administration

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 OHSS Show forest plot	1	102	Odds Ratio (M‐H, Fixed, 95% CI)	43.74 [2.54, 754.58]

2 Clinical pregnancy Show forest plot	1	102	Odds Ratio (M‐H, Fixed, 95% CI)	0.92 [0.43, 2.01]

3 Number of oocytes retrieved Show forest plot	1	102	Mean Difference (IV, Fixed, 95% CI)	‐17.80 [‐19.05, ‐16.55]

Comparison 4. Coasting versus FSH co‐trigger with hCG administration

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Comparison 5. Coasting versus cabergoline

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 OHSS Show forest plot	2	120	Odds Ratio (M‐H, Fixed, 95% CI)	1.98 [0.69, 5.68]

2 Clinical pregnancy rate Show forest plot	2	120	Odds Ratio (M‐H, Fixed, 95% CI)	0.38 [0.16, 0.88]

3 Number of oocytes retrieved Show forest plot	1	60	Mean Difference (IV, Fixed, 95% CI)	‐4.30 [‐7.88, ‐0.72]

Comparison 5. Coasting versus cabergoline

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Referencias

References to studies included in this review

Aboulgar 2007 {published data only}

Aflatoonian 2006 {published data only}

Dalal 2014 {published and unpublished data}

Egbase 1999 {published data only}

Egbase 2011 {published data only}

Kamthane 2007 {published data only}

Lukaszuk 2011 {published data only}

Sohrabvand 2009 {published data only}

References to studies excluded from this review

Aboulghar 1998 {published data only}

Al‐Shawaf 2001 {published data only}

Benadiva 1997 {published data only}

Dhont 1998 {published data only}

Esinler 2013 {published data only}

Fluker 1999 {published data only}

Herrero 2011 {published data only}

Lee 1998 {published data only}

Sher 1995 {published data only}

Tortoriello 1998 {published data only}

Tortoriello 1999 {published data only}

Ulug 2002 {published data only}

VanderStraeten 1998 {published data only}

Waldenstrom 1999 {published data only}

Additional references

Agrawal 1999

ASRM 2016

Calhaz‐Jorge 2016

Golan 1989

Goldsman 1995

GRADEpro GDT 2014 [Computer program]

Higgins 2011

Kawwass 2015

Navot 1992

Rabau 1967

Rizk 1999

Schenker 1978

Sher 1993

Tsirigotis 1994

References to other published versions of this review

D'Angelo 2000

D'Angelo 2002

D'Angelo 2011

D'Angelo 2011b

Characteristics of studies

Characteristics of included studies [ordered by study ID]

Characteristics of excluded studies [ordered by study ID]

Data and analyses

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