Dual trigger with combination of gonadotropin-releasing hormone agonist and human chorionic gonadotropin significantly improves the live-birth rate for normal responders in GnRH-antagonist cycles

Comparison between hCG and GnRH Agonist for Ovulation Trigger in GnRH Antagonist In-Vitro Fertilization Cycles in a Tertiary Hospital in Malaysia: An observational study

OBJECTIVE

hCG is commonly used as an ovulation trigger in IVF. Its usage is associated with OHSS. GnRH agonist is an alternative to hCG and is associated with reduced incidence of OHSS. This study compared the cycle outcomes of GnRH agonists with hCG as an ovulation trigger in IVF cycles.

METHODS

The medical notes of 209 IVF cycles receiving GnRH agonist and hCG as ovulation trigger over 18 months were reviewed in this retrospective study. The number and quality of mature oocytes, the number and quality of embryos, pregnancy rates, and outcomes were compared using Independent T-test or One-way ANOVA for normal distribution. The Mann-Whitney test or Kruskal-Wallis test was used for not normally distributed. p<0.05 was considered statistically significant.

RESULTS

The cycle outcomes of 107 GnRH agonist-trigger and 102 hCG-trigger were compared. The MII oocytes retrieved and 2PN count was significantly higher in the GnRH agonist trigger group (p<0.001). Clinical pregnancy rate and ongoing pregnancy were higher in the GnRH agonist trigger group but were not statistically significant. The GnRH agonist trigger group was associated with low OHSS than the hCG trigger group (n=2(1.9%) and n=12(11.8%) respectively, p=0.004).

CONCLUSION

GnRH agonist trigger is an option as a final maturation trigger in high-responder women undergoing IVF or ICSI cycles.

Effect of GnRH agonist trigger with or without low-dose hCG on reproductive outcomes for PCOS women with freeze-all strategy: a propensity score matching study

PURPOSE

This study aimed to compare the effect of gonadotropin-releasing hormone agonist (GnRHa) trigger alone versus dual trigger comprising GnRHa and low-dose human chorionic gonadotropin (hCG) on reproductive outcomes in patients with polycystic ovary syndrome (PCOS) who received the freeze-all strategy.

METHODS

A total of 615 cycles were included in this retrospective cohort study. Propensity score matching (PSM) was performed to control potential confounding factors between GnRHa-trigger group (0.2 mg GnRHa) and dual-trigger group (0.2 mg GnRHa plus 1000/2000 IU hCG) in a 1:1 ratio. Multivariate logistic regression was applied to estimate the association between trigger methods and reproductive outcomes.

RESULTS

After PSM, patients with dual trigger (n = 176) had more oocytes retrieved, mature oocytes, and 2PN embryos compared to that with GnRHa trigger alone. However, the oocytes maturation rate, normal fertilization rate, and frozen embryos between the two groups were not statistically different. The incidence of ovarian hyperstimulation syndrome (OHSS) (14.8% vs. 2.8%, P < 0.001) and moderate/severe OHSS (11.4% vs. 1.7%, P < 0.001) were significantly higher in dual-trigger group than in GnRHa-alone group. Logistic regression analysis showed the adjusted odds ratio of dual trigger was 5.971 (95% confidence interval 2.201-16.198, P < 0.001) for OHSS. The pregnancy and single neonatal outcomes were comparable between the two groups (P > 0.05).

CONCLUSION

For PCOS women with freeze-all strategy, GnRHa trigger alone decreased the risk of OHSS without damaging oocyte maturation and achieved satisfactory pregnancy outcomes.

Cycle outcomes of dual trigger (GnRH agonist+hCG) versus human chorionic gonadotropin trigger alone in POSEDION group 3-4 poor-responders and normo-responders: A prospective randomized study

INTRODUCTION

Recently, dual trigger was proposed in an attempt to improve in vitro fertilization (IVF) cycle outcomes in poor and normo-responder patients (PR and NR, respectively). The study's aim was to compare cycle outcomes of dual trigger versus human chorionic gonadotropin (hCG) trigger in NRs and POSEIDON group 3/4 (PG 3/4) PRs.

MATERIAL AND METHODS

A prospective randomized controlled trial included PG 3/4 PRs and NRs undergoing IVF using a gonadotropin-releasing hormone (GnRH) antagonist protocol. PRs and NRs were divided into two subgroups: (1) study groups in both arms received dual trigger and (2) control groups received only HCG.

RESULTS

Two-hundred twenty-five women participated in the study. The mean patient age was significantly higher in the dual trigger group versus the HCG trigger group in PG 3/4 PRs. The number of retrieved oocytes and MII oocytes and the number of patients with good quality embryos were comparable between groups and live birth rates (LBR) per embryo transfer (ET) were significantly higher in the HCG group versus the dual trigger group in PG3/4 PRs (39.2% versus 19.2%; p = 0.026). NR dual trigger and HCG trigger groups were comparable in terms of patient age and LBR per ET did not significantly differ between these groups. The number of patients with good quality embryos was significantly higher in the dual trigger group versus the HCG group in NRs CONCLUSION: Dual trigger does not seem to add additional benefits in terms of live birth rates in PG3/4 PRs and NRs. Nonetheless, considering the age difference and lack of homogenity in the number and day of embryos transferred in PG 3/4 PRs, major conclusion that can be drawn from the study is that dual trigger is not systematically useful even in poor responders since the number of mature oocytes is comparable between groups. Larger scale studies are required for additional potential implications.

Triggering of ovulation for GnRH-antagonist cycles in normal and low ovarian responders undergoing IVF/ICSI: A systematic review and meta-analysis of randomized trials

OBJECTIVE

To conduct a systematic review andmeta-analysis of all randomized controlled trials (RCTs) that investigated whether dual triggering [a combination of gonadotropin-releasing hormone (GnRH) agonist and human chorionic gonadotropin (hCG)] of final oocyte maturation can improve the number of oocytes retrieved and clinical pregnancy rate in low or normal responders undergoing in-vitro fertilization/intracytoplasmic sperm injection (IVF/ICSI) cycles using a GnRH-antagonist protocol.

STUDY DESIGN

Studies up to October 2022 were identified from PubMed, Scopus, Cochrane Library and Web of Science. The risk of bias of included studies was assessed. Dichotomous outcomes were reported as relative risks (RR), and continuous outcomes were reported as weighted mean differences (WMD) with 95% confidence intervals (CI). The primary outcomes were number of oocytes retrieved, number of mature [metaphase II (MII)] oocytes, clinical pregnancy rate and ongoing pregnancy rate; other IVF outcomes were considered as secondary outcomes.

RESULTS

Seven studies were identified, and 898 patients were eligible for inclusion in this meta-analysis. The results showed that the number of oocytes retrieved [WMD = 1.38 (95% CI 0.47-2.28), I2 = 66%, p = 0.003, low evidence], number of MII oocytes [WMD = 0.7 (95% CI 0.35-1.05), I2 = 42%, p < 0.0001, moderate evidence], number of embryos [WMD = 0.68 (95% CI 0.07-1.3), I2 = 67%, p = 0.03, low evidence] and number of good-quality embryos [WMD = 1.14 (95% CI 0.35-1.93), I2 = 0%, p = 0.005, moderate evidence] in the dual trigger group were significantly higher than in the hCG trigger group. The results of the ovarian response subgroup analysis showed significant differences in all of these outcomes in normal responders, and no differences in any of the outcomes in low responders, except for the number of MII oocytes. In low responders, clinical pregnancy rates may be improved in the dual trigger group [RR = 2.2 (95% CI 1.05-4.61), I2 = 28%, p = 0.04, low evidence].

CONCLUSION

Dual triggering by GnRH agonist and hCG improved oocyte maturity and embryo grading for normal responders in GnRH-antagonist cycles. Dual triggering for final oocyte maturation may improve clinical pregnancy rates in low responders.

Beyond the Umbrella: A Systematic Review of the Interventions for the Prevention of and Reduction in the Incidence and Severity of Ovarian Hyperstimulation Syndrome in Patients Who Undergo In Vitro Fertilization Treatments

Ovarian hyperstimulation syndrome (OHSS) is the main severe complication of ovarian stimulation for in vitro fertilization (IVF) cycles. The aim of the current study was to identify the interventions for the prevention of and reduction in the incidence and severity of OHSS in patients who undergo IVF not included in systematic reviews with meta-analyses of randomized controlled trials (RCTs) and assess and grade their efficacy and evidence base. The best available evidence for each specific intervention was identified, analyzed in terms of safety/efficacy ratio and risk of bias, and graded using the Oxford Centre for Evidence-Based Medicine (CEBM) hierarchy of evidence. A total of 15 interventions to prevent OHSS were included in the final analysis. In the IVF population not at a high risk for OHSS, follitropin delta for ovarian stimulation may reduce the incidence of early OHSS and/or preventive interventions for early OHSS. In high-risk patients, inositol pretreatment, ovulation triggering with low doses of urinary hCG, and the luteal phase administration of a GnRH antagonist may reduce OHSS risk. In conclusion, even if not supported by systematic reviews with homogeneity of the RCTs, several treatments/strategies to reduce the incidence and severity of OHSS have been shown to be promising.

In Vitro Fertilization Outcomes With a Dual Trigger in Normoresponders in Antagonist Cycles

Objectives To evaluate whether the dual trigger of ovulation with a gonadotropin-releasing hormone (GnRH) agonist and the standard dose of recombinant human chorionic gonadotropin (hCG) (dual trigger) is better than hCG alone in in vitro fertilization (IVF) cycles of patients who responded well to ovarian stimulation. Methods Between January 2013 and December 2021, 5593 antagonist cycles of patients were reviewed. This study included women who had an antral follicle count of 5 or more and exhibited a normoresponse to ovarian stimulation using the GnRH antagonist protocol, as determined by the follicular output rate (FORT). The primary outcome indicators consisted of the quantities of retrieved oocytes and mature oocytes. The secondary outcome markers included live birth rates, clinical pregnancy rates, and continued pregnancy rates. Results A total of 1244 normoresponder women who met the inclusion criteria were identified from the scanned files and subsequently enrolled in the GnRH antagonist protocol. A total of 383 cycles were observed in the group that was given the standard hCG trigger while 861 cycles were observed in the group that was given the dual trigger. The number of mature oocytes and top-quality embryos was significantly higher in the dual trigger group. The maturation rate in the hCG group was 74.8% while it was 76.9% in the dual trigger group (p=0.018). The dual trigger group exhibited an ongoing pregnancy rate of 37.6%, whereas the hCG group had a rate of 30.1% (p = 0.02). The dual trigger group exhibited a slightly higher live birth rate (34.3% vs 29.2%, p = 0.11), although this difference did not reach statistical significance. Conclusion Dual trigger of ovulation was superior to hCG alone in terms of the number of mature oocytes yielded, top quality of embryos, maturation rates, and ongoing pregnancy in IVF cycles of normoresponders having ovarian stimulation on the GnRH antagonist protocol.

The role of amphiregulin in ovarian function and disease

Amphiregulin (AREG) is an epidermal growth factor (EGF)-like growth factor that binds exclusively to the EGF receptor (EGFR). Treatment with luteinizing hormone (LH) and/or human chorionic gonadotropin dramatically induces the expression of AREG in the granulosa cells of the preovulatory follicle. In addition, AREG is the most abundant EGFR ligand in human follicular fluid. Therefore, AREG is considered a predominant propagator that mediates LH surge-regulated ovarian functions in an autocrine and/or paracrine manner. In addition to the well-characterized stimulatory effect of LH on AREG expression, recent studies discovered that several local factors and epigenetic modifications participate in the regulation of ovarian AREG expression. Moreover, aberrant expression of AREG has recently been reported to contribute to the pathogenesis of several ovarian diseases, such as ovarian hyperstimulation syndrome, polycystic ovary syndrome, and epithelial ovarian cancer. Furthermore, increasing evidence has elucidated new applications of AREG in assisted reproductive technology. Collectively, these studies highlight the importance of AREG in female reproductive health and disease. Understanding the normal and pathological roles of AREG and elucidating the molecular and cellular mechanisms of AREG regulation of ovarian functions will inform innovative approaches for fertility regulation and the prevention and treatment of ovarian diseases. Therefore, this review summarizes the functional roles of AREG in ovarian function and disease.

Comparison of dual-trigger and human chorionic gonadotropin-only trigger among polycystic ovary syndrome couples who underwent controlled ovarian stimulation and intrauterine insemination: A retrospective cohort study

The dual-trigger regime, consisting of gonadotrophin releasing hormone agonist and human chorionic gonadotropin (HCG), has been shown to offer advantage over the HCG-only trigger regime. However, little is known about the influence of dual-trigger or HCG-only trigger regime on the reproductive outcome of polycystic ovary syndrome (PCOS) couples undergoing controlled ovarian stimulation (COS) and intrauterine insemination (IUI). A total of 404 cycles of COS and IUI treatments from couples with PCOS were enrolled, and divided, according to the regime of trigger, into dual-trigger group (n = 109, 0.1-0.2 mg gonadotrophin releasing hormone agonist plus 6000 IU HCG) and HCG-only group (n = 295, 10,000 IU HCG or 250 μg recombinant HCG). Baseline characteristics of the 2 groups were comparable (all P > .05). In dual-trigger group, live birth rate, clinical pregnancy rate and β -HCG positive rate were all higher as compared to the HCG-only group (20.18% vs 18.98%, 25.69% vs 23.39% and 28.44% vs 25.08% respectively), despite the differences failed to achieve statistical significances (all P > .05). Moreover, early miscarriage rate and multiple pregnancy rate of the dual-trigger group were lower than those of the HCG-only group (17.86% vs 18.84% and 3.57% vs 7.25% respectively), although no statistical significances were found (all P > .05). Additionally, logistic regression analysis revealed that age contributed significantly to the live birth of couples with PCOS ( P = .043, OR = 0.900). Dual-trigger regime for oocyte maturation seems to associate with beneficial improvements in reproductive outcomes of PCOS couples undergoing COS and IUI. Instead of HCG-only trigger, dual-trigger regime might be an alternative option in COS and IUI cycles for couples with PCOS.

Comparison of an HCG-only trigger versus dual trigger for final oocyte maturation in a progestin-primed ovarian stimulation protocol

RESEARCH QUESTION

Is there any difference in clinical outcomes between a human chorionic gonadotrophin (HCG)-only trigger and a dual trigger combining gonadotrophin-releasing hormone agonist (GnRHa) and HCG in a progestin-primed ovarian stimulation (PPOS) protocol?

DESIGN

This retrospective cohort study included women younger than 40 years old with a normal ovarian reserve who underwent IVF/intracytoplasmic sperm injection treatment with a PPOS protocol. Participants were allocated to two groups according to the triggering medicines. The clinical outcomes were compared, with cumulative live birth rate (CLBR) being the primary outcome.

RESULTS

In total, 1066 women were included, 565 in the HCG-only group and 501 in the dual trigger group. Demographic parameters were comparable between the groups. Fewer oocytes were retrieved in the HCG-only trigger group (dual trigger 12.56 ± 7.12 versus HCG-only trigger 11.62 ± 6.02, P = 0.020). No significant difference was observed in the numbers of two-pronuclear embryos (7.12 ± 4.90 versus 6.76 ± 4.45, P = 0.208) and high-quality embryos (4.01 ± 3.70 versus 3.96 ± 3.32, P = 0.815). The CLBR after one complete cycle was also similar (40.72% versus 43.72%, P = 0.354). Multivariate logistic analysis confirmed that the trigger method had no association with CLBR (odds ratio [OR] 0.763, 95% confidence interval [CI] 0.578-1.005, P = 0.055) in the PPOS-treated patients.

CONCLUSIONS

Compared with the HCG-only trigger group, comparable embryological and clinical outcomes were achieved, although more oocytes were retrieved in the dual trigger group. This suggests that there may be no extra benefit from dual triggering, and that it should not be recommended for routine use in the general population undergoing PPOS protocols.

Reproductive outcomes of dual trigger with combination GnRH agonist and hCG versus trigger with hCG alone in women undergoing IVF/ICSI cycles: a retrospective cohort study with propensity score matching

Background

Despite a large number of studies on the selection of trigger drugs, it remains unclear whether the dual trigger with human chorionic gonadotropin (hCG) and gonadotropin-releasing hormone (GnRH) agonist, compared to the trigger with hCG alone, can improve the reproductive outcome of patients undergoing assisted reproductive technology. Therefore, this study aimed to compare the laboratory and clinical outcomes of dual trigger versus single trigger.

Methods

In this retrospective cohort study, we evaluated 520 in vitro fertilization/intracytoplasmic sperm injection (IVF/ICSI) cycles between July 2014 and September 2020 at the Reproductive and Genetic Center of Integrative Medicine, The Affiliated Hospital of Shandong University of Traditional Chinese Medicine. All patients underwent IVF/ICSI treatment with fresh embryo transfer using the GnRH antagonist protocol. We used propensity score matching to control for confounding variables and binary logistic regression analysis to determine the correlations between trigger methods and pregnancy outcomes. After propensity score matching, 57 cycles from each group were evaluated and compared for laboratory or clinical outcomes in this retrospective cohort study.

Results

There was no significant difference in the number of oocytes retrieved, embryos available, top-quality embryos, or the rate of normal fertilization between the dual-trigger and single-trigger protocols, respectively. The incidence of ovarian hyperstimulation syndrome, implantation rate, biochemical pregnancy rate, clinical pregnancy rate, ectopic pregnancy rate, early miscarriage rate, and live birth rate were also similar between the two groups, while the miscarriage rate (37.0% vs. 12.5%, p = 0.045) was higher in the dual-trigger than the single-trigger group. Subsequent binary logistic regression analysis showed that age was a remarkably significant independent predictor of both clinical pregnancy rate (odds ratio = 0.90, 95% confidence interval: 0.84–0.97, p = 0.006) and live birth rate (odds ratio = 0.89, 95% confidence interval: 0.82–0.97, p = 0.005).

Conclusions

Therefore, dual-trigger for final oocyte maturation might increase miscarriage rate, but in terms of the laboratory and other pregnancy outcomes such as clinical pregnancy rate, early miscarriage rate or live birth rate, there was no evidence to show that dual trigger was superior to an hCG-trigger alone for patients undergoing GnRH-antagonist cycles with fresh embryo transfer.

Trial registration

Retrospectively registered.

Dual trigger with gonadotropin releasing hormone agonist and human chorionic gonadotropin improves live birth rates in POSEIDON group 3 and 4 expected poor responders

OBJECTIVE

Aim of this study was to evaluate the effects of dual triggering with gonadotropin releasing hormone agonist and human chorionic gonadotropin (hCG) on outcomes of fresh embryo transfers following gonadotropin antagonist cycles in POSEIDON group 3 and group 4 low prognosis women and to compare the outcomes with hCG-only triggering.

METHODS

This study was conducted by retrospective analysis of patients with expected poor ovarian response (POSEIDON group 3 and 4) that underwent fresh embryo transfers following in-vitro fertilization/intracytoplasmic sperm injection cycles with either dual triggering or hCG-only triggering between January 2010 and April 2020. A total of 1068 women that underwent dual triggering and 1931 that underwent hCG-only triggering were included in the study.

RESULTS

Number of retrieved oocytes, M2 oocytes, oocyte maturation rate, fertilization rate, obtained 2PN embryos, implantation rate, clinical pregnancy rate and live birth delivery rates were found significantly higher in dual-triggering group in comparison to hCG-only group (p < 0.001, p < 0.001, p < 0.001, p < 0.001, p < 0.001, p < 0.001, p = 0.02, p < 0.001 respectively).

CONCLUSION

Dual trigger with concomitant injections of GnRH agonist and hCG in GnRH antagonist cycles appears to improve IVF outcomes, increase quality of embryos, reduce miscarriage rates and consequently increase live birth delivery rates in POSEIDON groups 3/4 poor responders.

Whole ovary laparoscopic incisions improve hormonal response and fertility in extremely poor ovarian response patients

STUDY OBJECTIVE

Recent findings have shown mechanical fragmentation of ovarian cortex and ovarian drilling could promote follicle growth in patients with premature ovarian insufficiency (POI) and polycystic ovarian syndrome, respectively. A common element shared by these treatments is the mechanical disturbance of ovarian extracellular matrix (ECM) tissues. We thus hypothesized a simplified whole ovary laparoscopic incision (WOLI) procedure may provide the intrinsic stimuli needed to activate resting follicles in extremely poor ovarian response (EPOR) patients who had negligible chance of becoming pregnant with their own oocytes via modern IVF practice.

DESIGN

Retrospective pilot study SETTING: The study was conducted in a research medical center in Taiwan.

PATIENTS

Women who had multiple canceled ovarian stimulation cycles due to the lack of follicle growth were recruited. A total of 6 EPOR patients received the WOLI procedure, which covers the whole surface of ovaries, in 2015-2017.

INTERVENTIONS

After receiving an outpatient WOLI procedure, ovarian response and follicle growth were monitored for 90 days with or without gonadotropin stimulation. Embryo quality and clinical outcomes were analyzed.

MEASUREMENTS AND MAIN RESULTS

Following the WOLI treatment, 5 out of 6 patients had significant increases in serum estradiol level and improved follicle growth (p = 0.000537). Multiple oocytes were retrieved from each of these patients, and it led to thawed embryo transfer cycles in four patients (p = 0.010). On average, the duration from the WOLI procedure to the first ovum pickup was 24 days (11-58 days). Following embryo transfer, two patients became pregnant and delivered healthy babies. Two other patients received embryo transfer, and one led to a chemical pregnancy. One patient had cryopreserved embryos with pending transfer.

CONCLUSION

The standardizable WOLI procedure restored hormonal responses in a majority of EPOR patients. Further validation of this novel and yet simple laparoscopic procedure, which requires only one laparoscopic surgery, may provide a practical option to reactivate the aging ovarian environment in EPOR and POI patients.

Dual Trigger with hCG Plus GnRHa for Final Oocyte Maturation in PGT-A Cycles Results in Similar Euploidy Rates when Compared to hCG-Only Trigger

Factors that may have an effect on euploidy rate of blastocysts have been investigated thoroughly in the literature. We aimed to assess whether dual trigger alters the ploidy chance of a blastocyst in preimplantation genetic screening for aneuploidy (PGT-A) cycles. This retrospective cohort study was conducted in a total of 385 PGT-A cycles at a single tertiary center for various indications. Final oocyte maturation was triggered using human chorionic gonadotropin (hCG) or the combination of hCG and gonadotropin-releasing hormone agonists (GnRHa) (dual trigger). Participants were divided based on triggering method and all demographic and clinical characteristics of the patients were compared. Final oocyte maturation was triggered in 143 cycles with hCG (37.1%), and in 242 cycles with dual trigger (62.9%). The duration of stimulation was shorter in the dual trigger arm compared to the hCG trigger group (10.0 ± 1.6 vs. 9.4 ± 1.4 days, p ≤ .001). Euploidy rates per blastocyst tested were 23.4% and 26.1% respectively for hCG and dual trigger groups without significance. Similar rates of euploidy were noted, even after age stratification. There was no significant difference between the groups regarding positive pregnancy result and ongoing pregnancy rates (p = .779 vs. p = .188). Although dual triggering, compared to hCG triggering, does not provide an additional superiority on blastocyst euploidy rate, further studies in women with different infertility etiology are needed to specifically evaluate the impact of triggering method on ploidy rates.

Effect of dual trigger on reproductive outcome in low responders: a systematic PRISMA review and meta-analysis

OBJECTIVE

Poor ovarian responders (PORs) pose a great challenge for fertility clinics worldwide. The aim of this study was to examine whether 'dual trigger' consisting of human chorionic gonadotropin (hCG) plus gonadotropin-releasing hormone agonist (GnRHa) is beneficial or not regarding implantation rate, pregnancy rate, and live birth rate for POR.

METHODS

This systematic review was conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) statement. Risk of bias was evaluated by the Newcastle-Ottawa scale or version 2 (NOS) of the Cochrane risk-of-bias tool for randomized trials (ROB2) independently by two authors. Furthermore, RevMan version 5.4 was used to analyze the extracted data and to create an inverse-weighted summary-odds ratio (OR).

RESULTS

A total of 1390 studies were screened. Seven studies containing a total of 2474 POR were included. The pooled meta-analysis revealed a 1.62-fold increase in clinical pregnancy rate (OR = 1.62 [1.00, 2.62], p = .05) and a 2.65-fold increase in live birth rate (OR = 2.65 [1.66, 4.24], p < .0001) in the dual trigger group compared to hCG trigger. The pooled analysis showed no significant difference between the two groups regarding implantation rate (OR = 1.14 [0.93, 1.39], p = .21).

CONCLUSIONS

The meta-analysis of this study indicates that dual trigger as finale oocyte maturation is advantageous compared to hCG trigger among POR. However, large-scale, high-quality, randomized controlled trials (RCT) are required to confirm this conclusion and fully address the magnitude of this effect.

Dual trigger with gonadotropin-releasing hormone agonist and recombinant human chorionic gonadotropin improves the outcome of intrauterine insemination

Objective

The objective of this study was to evaluate the effectiveness of dual trigger, which is a combination of gonadotropin-releasing agonist (GnRH-a) and recombinant human chorionic gonadotropin (hCG) in the final oocyte maturation, in the outcome of intrauterine insemination (IUI).

Methods

This retrospective observational study was conducted from January 2016 to October 2018 and involved 639 IUI cycles at the Halim Fertility Center, Indonesia. Controlled ovarian stimulation was performed during IUI cycles. The ovulation triggers were divided into two groups: group I received a combination of GnRH-a and recombinant hCG as a dual trigger, and group II received only recombinant hCG as a single trigger. The baseline characteristics, cycle parameters, and IUI outcomes of both groups were compared.

Results

Our study included a total of 639 IUI cycles, 334 were in the dual trigger group and 305 in the single trigger group. The clinical pregnancy rates were significantly higher in the dual trigger group than in the single trigger group (P<0.001). Based on the multivariate analysis, the dual trigger increased the clinical pregnancy rate by 2.524 times than that by the single trigger.

Conclusion

Our data showed that the dual trigger combination of GnRH-a and recombinant hCG significantly improves the outcome of intrauterine insemination.

Clinical efficacy of dual trigger with human chorionic gonadotropin and a gonadotropin‐releasing hormone agonist for women undergoing fertility preservation

Purpose

To determine the optimal maturation method to increase the yield of mature oocytes, especially for cancer patients with fewer chances of fertility preservation (FP) before gonadotoxic therapy.

Methods

A total of 373 cycles in 293 patients undergoing controlled ovarian stimulation (COS) for FP using a gonadotropin‐releasing hormone (GnRH) antagonist protocol were enrolled. The control group (n = 225) received 250 µg of recombinant human chorionic gonadotropin (rhCG) while the study group (n = 148) received 250 µg of rhCG and 0.2 mg of triptorelin for triggering. Subgroup analyses were performed for stimulation cycles with diminished ovarian reserve (DOR; anti‐Müllerian hormone (AMH) levels <1.1 ng/ml, n = 86), with endometrioma (n = 104), or with breast cancer and endometrial cancer using 5 mg of letrozole during the COS cycles (n = 84).

Results

There was no significant difference in the baseline characteristics or the number of total and mature oocytes between the two groups. Subgroup analyses for women with endometrioma or DOR showed similar results. However, the dual trigger group had a significantly higher number of mature oocytes than the rhCG trigger group in breast and endometrial cancer patients using letrozole during the COS cycles (6.9 ± 6.0 vs. 4.6 ± 3.6, p = 0.034). The maturation rate was higher in the dual trigger group, although the difference was not statistically significant (59.3 ± 26.7 vs. 50.0 ± 28.0, p = 0.124).

Conclusions

Dual triggering can be an efficient maturation method to maximize the yield of mature oocytes in breast or endometrial cancer patients using letrozole‐combined GnRH antagonist protocol for FP.

Prediction, assessment, and management of suboptimal GnRH agonist trigger: a systematic review

PURPOSE

This systematic review aimed to identify baseline patient demographic and controlled ovarian stimulation characteristics associated with a suboptimal response to GnRHa triggering, and available options for prevention and management of suboptimal response.

METHODS

PubMed, Google Scholar, Medline, and the Cochrane Library were searched for keywords related to GnRHa triggering, and peer-reviewed articles from January 2000 to September 2021 included.

RESULTS

Thirty-seven studies were included in the review. A suboptimal response to GnRHa triggering was more likely following long-term or recent oral contraceptive use and with a low or high body mass index. Low basal serum follicle-stimulating hormone (FSH), luteinizing hormone (LH), and estradiol serum levels were correlated with suboptimal oocyte yield, as was a low serum LH level on the day of triggering. A prolonged stimulation period and increased gonadotropin requirements were correlated with suboptimal response to triggering. Post-trigger LH < 15 IU/L best correlated with an increased risk for empty follicle syndrome and a lower oocyte retrieval rate. Retriggering with hCG may be considered in patients with suboptimal response according to post-trigger LH, as in cases of failed aspiration.

CONCLUSION

Pre-treatment assessment of patient characteristics, with pre- and post-triggering assessment of clinical and endocrine cycle characteristics, may identify cases at risk for suboptimal response to GnRHa triggering and optimize its utilization.

Association between different dual trigger dosages and IVF results in patients with POSEIDON Group IV

Objective

Dual trigger is used to induce final oocyte maturation during the process of controlled ovarian hyperstimulation, yet yielding controversial results. Also, there are yet no data regarding the effect of the dosage of the dual trigger on clinical outcomes. Based on the Patient-Oriented Strategies Encompassing IndividualizeD Oocyte Number (POSEIDON) criteria, this study aimed to determine the clinical difference of a single bolus versus two boluses of gonadotropin-releasing hormone agonist (GnRHa) in POSEIDON group IV patients using dual trigger.

Methods

We screened a total of 1,256 patients who underwent in vitro fertilization (IVF) cycles who met the POSEIDON group IV criteria. Six hundred and twenty-nine patients received one bolus of GnRHa, and 627 patients were given two boluses. All patients received the same dose of recombinant human chorionic gonadotropin during the dual trigger cycle.

Results

Metaphase II oocyte retrieval rate, fertilization rate and clinical pregnancy rate did not differ between the two groups. However, a lower percentage of at least one top-quality embryo transfer (34.3% vs. 26.0%, P=0.001) in the two bolus-GnRHa group was noted.

Conclusion

A double bolus of GnRHa did not show superior clinical results compared to a single bolus of GnRHa in the dual trigger IVF cycle. Therefore, GnRHa doses for use should be decided based on individual clinical situations considering cost-effectiveness and patient compliance, but further investigation will be needed.

GnRH Agonist and hCG (Dual Trigger) Versus hCG Trigger for Final Oocyte Maturation in Expected Normal Responders With a High Immature Oocyte Rate: Study Protocol for a Randomized, Superiority, Parallel Group, Controlled Trial

INTRODUCTION

The choice of trigger drug for the controlled ovarian hyperstimulation (COH) protocol correlates with the outcome of in vitro fertilization/intracytoplasmic sperm injection embryo transfer (IVF/ICSI-ET). The co-administration of gonadotropin releasing hormone agonist (GnRH-a) and human chorionic gonadotropin (hCG), i.e., dual trigger, for final oocyte maturation, has received much attention in recent years. This trial was designed to determine whether a dual trigger approach by lengthening the time between trigger and ovum pick-up (OPU) improves the quantity and quality of mature oocytes/top-quality embryos and pregnancy outcomes in expected normal responders with a high immature oocyte rate.

METHODS AND ANALYSIS

We propose a study at the Affiliated Hospital of Shandong University of Chinese Medicine. A total of 90 individuals undergoing COH use a fixed GnRH antagonist protocol. They will be assigned randomly into two groups according to the trigger method and timing: recombinant hCG (6500 IU) will be injected only 36 hours before OPU for final oocyte maturation (hCG-only trigger); co-administration of GnRH-a and hCG for final oocyte maturation, 40 and 34 hours prior to OPU, respectively (Dual trigger). The primary outcome is metaphase-II (MII) oocytes rate. Secondary outcomes are number of oocytes retrieved, fertilization rate, top-quality embryos rate, blastula formation rate, embryo implantation rate, clinical pregnancy rate, miscarriage rate, live birth rate, cumulative pregnancy/live birth rates, and ovarian hyperstimulation syndrome (OHSS) rate.

ETHICS AND DISSEMINATION

The reproductive ethics committee of the Affiliated Hospital of Shandong University of Traditional Chinese Medicine certified this study (Identifier: SDUTCM/2021.7.26) as ethical. All individuals will sign written informed consent. All data and biological samples will be protected according to law. The results of this study will be disseminated in a peer-reviewed scientific journal.

CLINICAL TRIAL REGISTRATION

[chictr.gov.cn], identifier [ChiCTR2100049292].

Aneuploidy rates and morphokinetic parameters of embryos cultured in distinct culture media: a sibling oocyte study

STUDY QUESTION

Do embryos from sibling oocytes assigned to distinct single-step media culture systems demonstrate differences in early embryo development, morphokinectics or aneuploidy rates?

SUMMARY ANSWER

Embryo quality, morphokinetic parameters and aneuploidy rates from trophectoderm biopsy were similar between sibling embryos cultured in distinct media systems from the time of gamete isolation.

WHAT IS KNOWN ALREADY

Studies on the effect of commercially available embryo culture media systems have demonstrated inconsistent impact on human embryonic development, morphokinetics, aneuploidy rates and clinical outcomes. In addition, these studies have been primarily randomized at the level of the embryo or the patient to culture media.

STUDY DESIGN, SIZE, DURATION

Prospective sibling oocyte cohort derived from 200 subjects undergoing IVF at a tertiary academic medical center between February 2018 and November 2019.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Sibling oocytes were allocated to Global® or SAGE® media system based upon laterality of ovary from which they were retrieved. All embryos were cultured in a time-lapse incubator. Blastocysts underwent trophectoderm biopsy for preimplantation genetic testing for aneuploidy using next-generation sequencing.

MAIN RESULTS AND THE ROLE OF CHANCE

One hundred twenty-seven subjects (n = 127) had paired blastocysts for biopsy in each culture media system. There was no difference in top quality blastocyst formation (47.1 ± 31.0 vs 48.1 ± 27.2%; P = 0.87) nor aneuploidy rate (62.3 ± 34.0 vs 56.1 ± 34.4%; P = 0.07) for sibling embryos cultured in Global versus SAGE media system. Embryo morphokinetic parameters including time to each cell division from two cells (t2) to eight cells (t8), time to morula stage (tM), time to blastocele formation (tSB), time to fully formed blastocyst (tB) and time to expansion of the blastocyst (tEB) were similar between paired blastocysts from each culture media system.

LIMITATIONS, REASONS FOR CAUTION

Pregnancy outcomes and offspring health data were not available for analysis.

WIDER IMPLICATIONS OF THE FINDINGS

Commercially available culture media may not have a differential impact on embryo development and blastocyst aneuploidy rate when patient and stimulation-related factors are held constant.

STUDY FUNDING/COMPETING INTEREST(S)

There was no external funding for this study. C.H. is owner of a consultancy company, IVF Professionals, Chief Scientific Officer at Apricity, Executive Director at TMRW and co-owner and shareholder of Aria Fertility. She has received speaker fees, consulting fees and travel support from Cooper Surgical and Vitrolife. J.B. is an employee and shareholder of vitrolife.

TRIAL REGISTRATION NUMBER

N/A.

Dual trigger with the combination of gonadotropin-releasing hormone agonist and standard dose of human chorionic gonadotropin improves in vitro fertilisation outcomes in poor ovarian responders

The study aimed to evaluate the impact of the dual trigger with the combination of GnRH agonist and standard dose of recombinant hCG on IVF outcomes in poor ovarian responders with GnRH antagonist protocol. 1283 cycles of 1010 poor responder patients according to Bologna criteria were retrospectively analysed in terms of final oocyte maturation: dual trigger group (250 μg hCG + 0.2 mg triptorelin) or standard group (250 μg hCG). Primary outcome measures were the number of retrieved and mature oocytes. The secondary outcome measures were clinical pregnancy rates and live birth rates.The number of retrieved oocytes, mature oocytes, and the top-quality embryos transferred were significantly higher in the dual trigger group (p < .001). Fertilisation rates (73.6% vs 69.6%, p = .009), implantation rates (18.7% vs 14.6, p = .039), clinical pregnancy rate per embryo transfer (27.5% vs. 19.9%, p = .010) and live birth rate per embryo transfer (21.6% vs. 14.9%, p = .011) were also significantly higher in the dual trigger group as compared to the hCG trigger group. The usage of dual trigger with a GnRH agonist and a standard dosage of hCG could improve clinical pregnancy rates and live birth rates in poor ovarian responders undergoing GnRH antagonist IVF/ICSI cycles.IMPACT STATEMENTWhat is already known on this subject? Dual trigger with standard dose of hCG has been the subject of trials in normal responders to optimise IVF outcomes. The results of these studies showed significant improvements in implantation and pregnancy rates with an increase in the number of mature oocytes retrieved. As a result, dual trigger has become a popular ovulation trigger option in GnRH antagonist cycles.What do the results of this study add? There is limited data about the use of dual trigger in poor ovarian responders (PORs). According to our study, increasing the number of retrieved oocytes, mature oocytes, the number of fertilised oocytes, the number of transferred embryos and top quality embryos transferred by using dual trigger in patients with PORs have a positive impact on pregnancy outcomes.What are the implications of these findings for clinical practice and/or further research? These findings implies potential advantages of dual trigger usage for improving IVF outcomes in PORs. With large sample sized prospective randomised trials, dual trigger with combination of GnRHa and a standard dose of hCG might replace the traditional ovulation trigger with hCG in PORs.

Dual trigger protocol is an effective in vitro fertilization strategy in both normal and high responders without compromising pregnancy outcomes in fresh cycles

Objective

To study the birth rates of normal vs. high responders after dual trigger of final oocyte maturation with gonadotropin-releasing hormone (GnRH) agonist and human chorionic gonadotropin in fresh in vitro fertilization (IVF) cycles in which ovarian stimulation was achieved by a flexible GnRH antagonist protocol.

Design

Retrospective cohort study.

Setting

University hospital.

Patient(s)

In women <35 years of age, 290 fresh IVF cycles using the dual trigger protocol with day 5 embryo transfers from January 2013 to July 2018 were included. Cycles excluded were those with preimplantation genetic testing, gestational carriers, donor oocytes, and fertility preservation.

Intervention(s)

IVF with dual trigger.

Main Outcome Measure(s)

Clinical pregnancy rate, live birth rate.

Result(s)

Comparing normal responders, defined as <30 oocytes retrieved, and high responders, defined as ≥30 oocytes retrieved, the clinical pregnancy rates (67.0% vs. 69.3%, respectively) and live birth rates (60.5% vs. 60.0%, respectively) were not significantly different. No cases of ovarian hyperstimulation syndrome were reported in either group.

Conclusion(s)

Ovarian stimulation by a flexible GnRH antagonist protocol followed by dual trigger yields comparable outcomes between normal and high responders in fresh IVF cycles.

Outcomes comparison of IVF/ICSI among different trigger methods for final oocyte maturation: A systematic review and meta-analysis

During the in vitro fertilization treatment, human chorionic gonadotrophin (hCG) is routinely used as a substitute for the natural endogenous LH surge during the final stage of oocyte maturation. However, it does not provide the FSH surge observed in the mid-cycle of the natural cycle. To date, whether the FSH surge can improve oocyte quality and pregnancy outcomes remains unknown. Randomized controlled trials comparing the following four trigger methods to conventional hCG were examined: GnRH agonist (GnRHa), kisspeptin, GnRHa plus hCG (dual trigger), and FSH plus hCG (FSH co-trigger). The results showed that the use of dual triggers was associated with a significantly higher number of retrieved cumulus-oocyte complexes (COCs) (weighted mean difference [WMD] 1.625, 95% CI 0.684-2.565), retrieved mature oocytes (WMD 0.986, 95% CI 0.426-1.545) and fertilized (2PN) oocytes (WMD 0.792, 95% CI 0.083-1.501), compared with the use of hCG. However, there was no significant difference between the two groups in terms of pregnancy rate. The FSH co-trigger resulted in significantly higher rates of 2PN oocytes retrieved than the hCG trigger (WMD 0.077, 95% CI 0.028-0.126). Notably, the risk of OHSS did not differ among the three treatment groups compared to that of the hCG group. This review protocol was registered with PROSPERO (CRD 42020194201).

GnRH agonist and hCG (dual trigger) versus hCG trigger for follicular maturation: a systematic review and meta-analysis of randomized trials

BACKGROUND

Traditionally, final follicular maturation is triggered by a single bolus of human chorionic gonadotropin (hCG). This acts as a surrogate to the naturally occurring luteinizing hormone (LH) surge to induce luteinization of the granulosa cells, resumption of meiosis and final oocyte maturation. More recently, a bolus of gonadotropin-releasing hormone (GnRH) agonist in combination with hCG (dual trigger) has been suggested as an alternative regimen to achieve final follicular maturation.

METHODS

This study was a systematic review and meta-analysis of randomized trials evaluating the effect of dual trigger versus hCG trigger for follicular maturation on pregnancy outcomes in women undergoing in vitro fertilization (IVF). The primary outcome was the live birth rate (LBR) per started cycle.

RESULTS

A total of 1048 participants were included in the analysis, with 519 in the dual trigger group and 529 in the hCG trigger group. Dual trigger treatment was associated with a significantly higher LBR per started cycle compared with the hCG trigger treatment (risk ratio (RR) = 1.37 [1.07, 1.76], I² = 0%, moderate evidence). There was a trend towards an increase in both ongoing pregnancy rate (RR = 1.34 [0.96, 1.89], I² = 0%, low evidence) and implantation rate (RR = 1.31 [0.90, 1.91], I² = 76%, low evidence) with dual trigger treatment compared with hCG trigger treatment. Dual trigger treatment was associated with a significant increase in clinical pregnancy rate (RR = 1.29 [1.10, 1.52], I² = 13%, low evidence), number of oocytes collected (mean difference (MD) = 1.52 [0.59, 2.46), I² = 53%, low evidence), number of mature oocytes collected (MD = 1.01 [0.43, 1.58], I² = 18%, low evidence), number of fertilized oocytes (MD = 0.73 [0.16, 1.30], I² = 7%, low evidence) and significantly more usable embryos (MD = 0.90 [0.42, 1.38], I² = 0%, low evidence).

CONCLUSION

Dual trigger treatment with GnRH agonist and HCG is associated with an increased live birth rate compared with conventional hCG trigger.

TRIAL REGISTRATION

CRD42020204452 .

Low dose hCG supplementation in a Gn-RH-agonist trigger protocol is associated with worse pregnancy outcomes: a retrospective cohort study

Background

A number of studies have looked at dual triggers with hCG and GnRH agonist (GnRHa) in varying doses, but the question remains: what is the optimal dose of hCG to minimize ovarian hyperstimulation syndrome (OHSS) and still offer adequate pregnancy rates? The purpose of this study was to compare pregnancy and OHSS rates following dual trigger for oocyte maturation with GnRHa and a low-dose hCG versus hCG alone. A secondary objective was the assess pregnancy outcomes in subsequent frozen cycles for the same population.

Methods

A total of 963 women < 41 years old, with a BMI 18–40 kg/m² and an AMH > 2 ng/mL who underwent fresh autologous in vitro fertilization (IVF) with GnRH antagonist protocol at a University-based fertility center were included in this retrospective cohort study. Those who received a low dose dual trigger with hCG (1000u) and GnRHa (2 mg) were compared to those who received hCG alone (10,000u hCG/250-500 μg Ovidrel). Differences in implantation rates, pregnancy, live birth, and OHSS were investigated.

Results

The dual trigger group was younger (mean 33.6 vs 34.1 years), had a higher AMH (6.3 vs 4.9 ng/mL,) more oocytes retrieved (18.1 vs 14.9) and a higher fertilized oocyte rate (80% vs 77%) compared with the hCG only group. Yet, the dual trigger group had a lower probability of clinical pregnancy (gestational sac, 43.4% vs 52.8%) and live birth (33.4% vs 45.8%), all of which were statistically significant. There were 3 cases of OHSS, all in the hCG-only trigger group. In subsequent frozen cycles, pregnancy rates were comparable between the two groups.

Conclusions

The dual trigger group had a better prognosis based on age and AMH levels and had better stimulation outcomes, but significantly worse pregnancy outcomes, suggesting the low dose hCG (1000u) in the dual trigger may not have provided adequate luteal support, compared to an hCG-only trigger (10,000u hCG/250-500 μg Ovidrel). Interestingly, the pregnancy rates were comparable in subsequent frozen cycles, further supporting the hypothesis that the issue lies in inadequate luteal phase support, rather than embryo quality. Based on these findings, our program has changed the protocol to 1500u of hCG in a dual trigger.

Effect of a "Dual Trigger" Using a GnRH Agonist and hCG on the Cumulative Live-Birth Rate for Normal Responders in GnRH-Antagonist Cycles

“Dual triggering” for final oocyte maturation using a combination of a gonadotropin-releasing hormone agonist (GnRHa) and human chorionic gonadotropin (hCG) can improve clinical outcomes in high responders during in vitro fertilization–intracytoplasmic sperm injection (IVF–ICSI) GnRH-antagonist cycles. However, whether this dual trigger is also beneficial to normal responders is not known. We retrospectively analyzed the data generated from 469 normal responders from 1 January to 31 December 2017. The final oocyte maturation was undertaken with a dual trigger with a GnRHa combined with hCG (n = 270) or hCG alone (n = 199). Patients were followed up for 3 years. The cumulative live-birth rate was calculated as the first live birth achieved after all cycles having an embryo transfer (cycles using fresh embryos and frozen–thawed embryos) among both groups. Women in the dual-trigger group achieved a slightly higher number of oocytes retrieved (11.24 vs. 10.24), higher number of two-pronuclear (2PN) embryos (8.37 vs. 7.67) and a higher number of embryos available (4.45 vs. 4.03). However, the cumulative live-birth rate and the all-inclusive success rate for assisted reproductive technology was similar between the two groups (54.07 vs. 59.30%). We showed that a dual trigger was not superior to a hCG-alone trigger for normal responders in GnRH-antagonist cycles in terms of the cumulative live-birth rate.

Superovulation with gonadotropin-releasing hormone agonist or chorionic gonadotropin for ovulation trigger differentially affects leukocyte populations in the peri-implantation mouse uterus

OBJECTIVE

To investigate the effect of superovulation with human chorionic gonadotropin (hCG) or gonadotropin-releasing hormone agonist (GnRHa) trigger on leukocyte density and expression of leukocyte-specific genes in the peri-implantation period in the mouse uterus.

DESIGN

Laboratory research.

SETTING

University laboratory facility.

INTERVENTIONS

Female mice were mated to fertile male mice in one of three protocols: (1) natural mating or mating following injection with pregnant mare serum gonadotropin followed by trigger with (2) GnRHa or (3) hCG. Female mice were killed prior to implantation, 3 days after ovulation (E3.5), and the ovaries and uterine tissue were collected. Total RNA was isolated and assayed using quantitative reverse transcription polymerase chain reaction, and the uterine tissue was stained for histologic analysis of immune cell markers.

MAIN OUTCOME MEASURES

Endometrial leukocyte (CD45) and vessel density (CD31) by immunohistochemical staining; expression of leukocyte markers CD11b, CD335, and CD22, by quantitative reverse transcription polymerase chain reaction in the whole uterine tissue.

RESULTS

Superovulation decreased (compared with controls) the endometrial leukocyte density, based on the number of cells staining for CD45, and endometrial vessel density, based on the number of cells staining for CD31. Leukocyte density was additionally decreased in the GnRHa trigger group compared with that in the hCG trigger group. Superovulation with hCG and GnRHa triggers decreased the uterine expression of the B-cell marker CD22 compared with controls. The expression of the natural killer cell marker CD11b was decreased by the hCG trigger but not by the GnRHa. Abundance of mRNA encoding the CD335 natural killer cell marker was not affected by superovulation or trigger agent.

CONCLUSIONS

In mice, superovulation with the GnRHa trigger compared with that with the hCG trigger differentially alters key immunologic factors in the uterine peri-implantation. These altered immunologic factors have roles in angiogenesis that may assist in elucidating the effects of assisted reproductive technologies on implantation efficiency and fetal growth and development.

GnRH agonist in association with hCG versus hCG alone for final oocyte maturation triggering in GnRH antagonist cycles

Objective:

To analyze gonadotropin-releasing hormone (GnRH) agonist in association with human chorionic gonadotropin (hCG) (dual triggering) versus hCG alone (conventional triggering) for final oocyte maturation triggering in GnRH antagonist cycles in an unselected population of Brazilian women.

Methods:

This prospective case-control study involved 114 patients referred to autologous in vitro fertilization treatment between February 2018 and August 2019, recruited regardless of age, infertility factor or number of cycles. The patients were randomly allocated into two groups according to oocyte maturation triggering approach: group A (n = 48) - hCG only; and group B (n = 66) - hCG plus GnRH agonist. The main outcomes measured were the number of total and metaphase II (MII) oocytes retrieved.

Results:

The groups were homogenous in terms of age. There were no moderate or severe ovarian hyperstimulation syndrome events. There were no statistical differences concerning total or MII oocytes retrieved between the groups (p > 0.05). The MII/total oocyte rate was 70.9% in group A, and 74.5% in group B (p = 0.679). There was no oocyte retrieved in 2/48 patients (4.16%) in group A, 1/66 (1.5%) in group B. There were no MII oocytes in 4/48 patients (8.3%) in group A, and 2/66 (3%) in group B. Age was directly correlated to the number of total and MII oocytes retrieved (p < 0.05).

Conclusions:

Dual triggering was equivalent to conventional hCH triggering in terms of the number of total and MII oocytes retrieved in the general population. Further studies are necessary to ascertain dual triggering indication in selected groups of women.

The depot GnRH agonist protocol improves the live birth rate per fresh embryo transfer cycle, but not the cumulative live birth rate in normal responders: a randomized controlled trial and molecular mechanism study

STUDY QUESTION

Do cumulative live birth rates (CLBRs) after one complete ART cycle differ between the three commonly used controlled ovarian stimulation (COS) protocols (GnRH antagonist, depot GnRHa (GnRH agonist) and long GnRHa) in normal responders undergoing IVF/ICSI?

SUMMARY ANSWER

There were similar CLBRs between the GnRH antagonist, depot GnRHa and long GnRHa protocols.

WHAT IS KNOWN ALREADY

There is no consensus on which COS protocol is the most optimal in women with normal ovarian response. The CLBR provides the final success rate after one complete ART cycle, including the fresh and all subsequent frozen-thawed embryo transfer (ET) cycles. We suggest that the CLBR measure would allow for better comparisons between the different treatment protocols.

STUDY DESIGN, SIZE, DURATION

A prospective controlled, randomized, open label trial was performed between May 2016 and May 2017. A total of 819 patients were allocated to the GnRH antagonist, depot GnRHa or long GnRHa protocol in a 1:1:1 ratio. The minimum follow-up time from the first IVF cycle was 2 years. To further investigate the potential effect of COS with the GnRH antagonist, depot GnRHa or long GnRHa protocol on endometrial receptivity, the expression of homeobox A10 (HOXA10), myeloid ecotropic viral integration site 1 (MEIS1) and leukemia inhibitory factor (LIF) endometrial receptivity markers was evaluated in endometrial tissue from patients treated with the different COS protocols.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Infertile women with normal ovarian response (n = 819) undergoing IVF/ICSI treatment were randomized to the GnRH antagonist, depot GnRHa or long GnRHa protocol. Both IVF and ICSI cycles were included, and the sperm samples used were either fresh or frozen partner ejaculates or frozen donor ejaculates. The primary outcome was the live birth rate (LBR) per fresh ET cycle, and the CLBR after one complete ART cycle, until the birth of a first child (after 28 weeks) or until all frozen embryos were used, whichever occurred first. Pipelle endometrial biopsies from 34 female patients were obtained on Days 7-8 after oocyte retrieval or spontaneous ovulation in natural cycles, respectively, and HOXA10, MEIS1 and LIF mRNA and protein expression levels in the human endometrium was determined by quantitative real-time PCR and western blot, respectively.

MAIN RESULTS AND THE ROLE OF CHANCE

There were no significant differences in CLBRs between the GnRH antagonist, depot GnRHa or long GnRHa protocol (71.4 versus 75.5 versus 72.2%, respectively). However, there was a significantly higher LBR per fresh ET cycle in the depot GnRHa protocol than in the long GnRHa and GnRH antagonist protocols (62.6 versus 52.1% versus 45.6%, P < 0.05). Furthermore, HOXA10, MEIS1 and LIF mRNA and protein expression in endometrium all showed significantly higher in the depot GnRHa protocol than in the long GnRHa and GnRH antagonist protocols (P < 0.05).

LIMITATIONS, REASONS FOR CAUTION

A limitation of our study was that both our clinicians and patients were not blinded to the randomization for the randomized controlled trial (RCT). An inclusion criterion for the current retrospective cohort study was based on the 'actual ovarian response' during COS treatment, while the included population for the RCT was 'expected normal responders' based on maternal age and ovarian reserve test. In addition, the analysis was restricted to patients under 40 years of age undergoing their first IVF cycle. Furthermore, the endometrial tissue was collected from patients who cancelled the fresh ET, which may include some patients at risk for ovarian hyperstimulation syndrome, however only patients with 4-19 oocytes retrieved were included in the molecular study.

WIDER IMPLICATIONS OF THE FINDINGS

The depot GnRH agonist protocol improves the live birth rate per fresh ET cycle, but not the cumulative live birth rate in normal responders. A possible explanation for the improved LBR after fresh ET in the depot GnRHa protocol could be molecular signalling at the level of endometrial receptivity.

STUDY FUNDING/COMPETING INTEREST(S)

This project was funded by Grant 81571439 from the National Natural Sciences Foundation of China and Grant 2016YFC1000206-5 from the National Key Research & Development Program of China. The authors declare no conflict of interest.

TRIAL REGISTRATION NUMBER

The RCT trial was registered at the Chinese Clinical Trial Registry, Study Number: ChiCTR-INR-16008220.

TRIAL REGISTRATION DATE

5 April 2016.

DATE OF FIRST PATIENT’S ENROLLMENT

12 May 2016.

GnRH agonist and hCG (dual trigger) versus hCG trigger for final follicular maturation: a double-blinded, randomized controlled study

STUDY QUESTION

Does co-administration of GnRH agonist and Human chorionic gonadotropin (hCG; dual trigger) in IVF cycles improve the number of mature oocytes and pregnancy outcome compared to hCG alone?

SUMMARY ANSWER

Using the dual trigger for final follicular maturation increases the number of oocytes, mature oocytes and number of blastocysts (total and top-quality) compared to triggering with hCG alone.

WHAT IS KNOWN ALREADY

hCG is used at the end of controlled ovarian hyperstimulation as a surrogate LH surge to induce final oocyte maturation. Recently, based on retrospective studies, the co-administration of GnRH agonist and hCG for final oocyte maturation (dual trigger) has been suggested to improve IVF outcome and pregnancy rates.

STUDY DESIGN, SIZE, DURATION

A single center, randomized controlled, double-blinded clinical trial between May 2016 and June 2018 analyzed by intention to treat (ITT).

PARTICIPANTS/MATERIALS, SETTINGS, METHODS

One hundred and fifty-five normal responder patients were randomized either to receive hCG or dual trigger for final oocyte maturation. Data on patients age, BMI, AMH, number of oocytes retrieved, number of metaphase 2 (MII) oocytes, zygotes and blastocysts, clinical pregnancy rate and live birth rate were assessed and compared between the dual trigger group and the hCG group. We performed a planned interim analysis after the recruitment of 50% of the patients. Based on the totality of outcomes at the interim analysis we decided to discontinue further recruitment.

MAIN RESULTS AND THE ROLE OF CHANCE

One hundred and fifty-five patients were included in the study. The age (36 years versus 35.3 years P = NS), BMI (24 kg/m2 versus 23.7 kg/m2) and the AMH (20.1 pmol/l versus 22.4 pmol/l) were comparable between the two groups. Based on ITT analysis, the number of eggs retrieved (11.1 versus 13.4, P = 0.002), the MII oocytes (8.6 versus 10.3, P = 0.009), total number of blastocysts (2.9 versus 3.9, P = 0.01) and top-quality blastocysts transferred (44.7% versus 64.9%; P = 0.003) were significantly higher in the dual trigger group compared to the hCG group. The clinical pregnancy rate (24.3% versus 46.1%, OR 2.65 (1.43-1.93), P = 0.009) and the live birth rate per transfer (22% versus 36.2%, OR= 1.98 (1.05-3.75), P = 0.03) were significantly higher in the dual trigger group compared to the hCG group.

LIMITATIONS, REASONS FOR CAUTION

None.

WIDER IMPLICATIONS OF THE FINDINGS

The enhanced response observed with the dual trigger might lead to better IVF outcomes were it used more widely.

STUDY FUNDING/COMPETING INTEREST(S)

The study was funded by TRIO Fertility. There are no conflicts of interest to declare.

TRIAL REGISTRATION NUMBER

ClinicalTrials.gov identifier: NCT02703584.

DATE OF TRIAL REGISTRATION

March 2016.

DATE OF FIRST PATIENT'S ENROLLMENT

May 2016.

Do basal Luteinizing Hormone and Luteinizing Hormone/Follicle-Stimulating Hormone Ratio Have Significance in Prognosticating the Outcome of In vitro Fertilization Cycles in Polycystic Ovary Syndrome?

Context:

Tonic hypersecretion of luteinizing hormone (LH) appears to impact both fertility and pregnancy outcomes in women with polycystic ovary syndrome (PCOS).

Aim:

Whether high basal day 2/3 serum LH levels and day 2/3 LH/follicle-stimulating hormone (FSH) ratio affect in vitro fertilization (IVF) cycle outcomes in PCOS patients undergoing controlled ovarian hyperstimulation using gonadotropin-releasing hormone (GnRH) antagonists.

Settings and Design:

A retrospective cohort study was conducted in Assisted Reproductive Technique Center, Department of Obstetrics and Gynaecology, at a tertiary care institute, on PCOS patients undergoing IVF/intracytoplasmic sperm injection (ICSI) using GnRH antagonist protocol with human chorionic gonadotropin trigger between January 2014 to December 2019.

Methods and Material:

Data related to patient's age, body mass index, day 2/3 serum FSH, serum LH, day 2/3 LH/FSH ratio, and infertility treatment-related variables were collected from the patient record files. IVF cycle characteristics, number of oocytes retrieved, number of embryos transferred were also recorded. The clinical pregnancy rate per embryo transfer was calculated.

Statistical Analysis:

Statistical software SPSS IBM version 24.0 was used to analyze the data. Descriptive statistics such as mean, standard deviation , and range values were calculated. To compare the difference between the groups, the paired t-test was applied for continuous variables and the Chi-square test for categorical variables. A value of P < 0.05 was considered statistically significant.

Results:

High basal day 2/3 LH level and day 2/3 LH/FSH ratio have no statistically significant effect on embryos formed, embryo transferred, and clinical pregnancy rate. However, fertilization rates were significantly less in these groups.

Conclusion:

The elevated basal day 2/3 LH and LH/FSH ratio do not impair the outcome of GnRH antagonist protocol treated IVF/ICSI cycles in PCOS women.

Severe ovarian hyperstimulation syndrome associated with long-acting GnRH agonist in oncofertility patients

PURPOSE

To report three cases of severe ovarian hyperstimulation syndrome (OHSS) among oncofertility patients receiving a long-acting GnRH agonist for ovarian suppression after controlled ovarian hyperstimulation (COH) with a GnRH antagonist protocol METHODS: Chart abstraction was completed for three patients at a single academic medical center. Patients included were undergoing fertility preservation prior to gonadotoxic chemotherapy. All patients underwent COH with GnRH antagonist protocol and embryo cryopreservation immediately followed by ovarian suppression with long-acting GnRH agonist. Main outcome measure was development of OHSS.

RESULTS

Despite using GnRH agonist trigger and freezing all embryos, patients developed ascites, intermittent hyponatremia and hemoconcentration consistent with severe early-onset OHSS after receiving long-acting GnRH agonist immediately following oocyte retrieval for ovarian preservation.

CONCLUSIONS

Risk of severe OHSS may be increased when a long-acting GnRH agonist is used for ovarian suppression immediately following oocyte retrieval. A delay in initiating long-acting GnRH agonist after oocyte retrieval in patients at high risk for developing OHSS should be considered.

Genuine Empty Follicle Syndrome: Role of Double Trigger and Delayed Oocyte Retrieval (DTDO)

BACKGROUND

Empty follicle syndrome (EFS) is a condition of undetermined etiology where no oocytes are retrieved in an ART cycle despite adequate response to ovarian stimulation and diligent follicular aspiration. Because of the rarity of this condition, no much published strategies are available to tackle this.

AIM

The aim of this study was to evaluate whether sequential administration of gonadotropin-releasing hormone agonist (GnRHa) and human chorionic gonadotropin (hCG) as a trigger at 40 h and 36 h, respectively, before oocyte retrieval (OCR) could correct genuine empty follicle syndrome (GEFS).

STUDY SETTING AND DESIGN

This retrospective observational cohort study was conducted in a tertiary fertility center over a period of 6 years from January 2014 to December 2019. Patients with a history of GEFS were administered GnRHa and recombinant hCG subcutaneously at 40 h and 36 h, respectively, before OCR, i.e., double trigger and delayed oocyte retrieval (DTDO) (n = 13). The primary outcome measures studied were number of mature oocytes retrieved, oocyte maturation index (OMI), number of fertilized oocytes, and number of embryos available for embryo transfer. The secondary outcome measures were clinical pregnancy rate (CPR), miscarriage rate (MR) and live birth rate (LBR) per first frozen embryo transfer (FET) cycle, incidence of inadvertent premature ovulation, and ovarian hyperstimulation syndrome.

STATISTICAL ANALYSIS

Comparison between the groups was analysed by Fisher's exact test and paired t-test.

RESULTS

Patients in the DTDO group showed a significant improvement (P < 0.01) in the number of mature oocytes retrieved, OMI, number of fertilized oocytes, and number of embryos available for embryo transfer. In the first FET cycle, CPR (44.44%), LBR (44.44%), and MR (11.11%) were observed in the DTDO group.

CONCLUSION

Our findings implicate that double trigger and delayed OCR (DTDO) is a safe and efficacious treatment strategy for GEFS.

Dual Trigger for Final Follicular Maturation Improves Cumulative Live-Birth Rate in Ovarian Stimulation for Freeze-All In Vitro Fertilization/Intracytoplasmic Sperm Injection Cycles

STUDY QUESTION

Does dual trigger in freeze-all in vitro fertilization (IVF)/intracytoplasmic sperm injection (ICSI) cycles improve the cumulative live-birth outcome compared with human chorionic gonadotropin (hCG) trigger?

SUMMARY ANSWER

Dual trigger for final follicular maturation improves the cumulative pregnancy and live-birth rates compared with hCG trigger in freeze-all IVF/ICSI cycles.

WHAT IS KNOWN ALREADY

Dual trigger could increase the numbers of oocytes and mature oocytes and improve pregnancy rates.

STUDY DESIGN SIZE DURATION

This retrospective cohort analysis included data from 4438 freeze-all IVF/ICSI cycles between January 2012 and December 2017.

PARTICIPANTS/MATERIALS SETTING METHODS

Women aged 20-49 years who underwent ovarian stimulation and oocyte retrieval for autologous IVF/ICSI with a freeze-all policy in our centre were enrolled. Data on number of oocytes retrieved, number of mature oocytes, clinical pregnancy rate, live-birth rate, cumulative pregnancy rate, and cumulative live-birth rate (CLBR) were assessed and compared between patients who underwent a dual trigger and hCG trigger. Multivariate logistic regression was performed to identify and adjust for factors known to independently affect the CLBR.

MAIN RESULTS AND THE ROLE OF CHANCE

A total of 4438 IVF/ICSI cycles were analyzed, including 1445 cycles with single hCG trigger and 2993 cycles with dual trigger. The cumulative biochemical pregnancy rate (60.8% vs. 68.1%, P<0.001; odds ratio (OR): 0.727; 95% confidence interval (CI): 0.638-0.828), cumulative clinical pregnancy rate (52.9% vs. 58.5%, P<0.001; OR: 0.796; 95%CI: 0.701-0.903), and CLBR (44.3% vs. 50.5%, P<0.001; OR: 0.781; 95%CI: 0.688-10.886) were all significantly lower in the hCG-trigger group compared with the dual-trigger group. The clinical pregnancy rate (48.2% vs. 58.2%, P=0.002; OR: 0.829; 95%CI: 0.737-0.934) and embryo implantation rate (34.4% vs. 38.9%, P<0.001; OR: 0.823; 95%CI: 0.750-0.903) in each transfer cycle were also significantly lower in the hCG-trigger group compared with the dual-trigger group. After controlling for all potential confounding variables, the trigger method was identified as an independent factor affecting the CLBR. The OR and 95%CI for hCG trigger were 0.780 and 0.641-0.949 (P=0.013).

LIMITATIONS REASONS FOR CAUTION

The data used to analyse the effect of dual trigger on cumulative pregnancy and live-birth outcomes were retrospective, and the results may thus have been subject to inherent biases. Further prospective randomized controlled trials are required to verify the beneficial effects of dual trigger.

WIDER IMPLICATIONS OF THE FINDINGS

Dual trigger had a positive effect on CLBRs, suggesting that it could be used as a routine trigger method in freeze-all cycles.

STUDY FUNDING/COMPETING INTERESTS

This study was supported by grants from National Key Research and Development Program of China (2018YFC1004800), the Natural Science Program of Zhejiang (LY19H040009), the National Natural Science Foundation of China (No. 81601236). No authors have competing interests to declare.

Angiogenic cytokine and interleukin 8 levels in early luteal phase after triggering ovulation with gonadotropin-releasing hormone agonist in high-responder patients

PROBLEM

Interleukin 8 (IL-8), vascular endothelial growth factor A (VEGFA), its receptors 1 (VEGFR1) and 2 (VEGFR2) are associated with ovarian hyperstimulation syndrome (OHSS) pathophysiological mechanisms. The aim of this study was to evaluate the concentrations of these cytokines depending on the way of ovulation triggering.

METHOD OF STUDY

A total of 51 high-responder patients underwent IVF program and received gonadotropin-releasing hormone agonists (GnRHa) trigger + 1500 IU human chorionic gonadotropin (hCG) support on the oocyte pick-up (OPU) day (group I), dual trigger (GnRHa + 1500 IU hCG; group II), or hCG trigger 10,000 IU (group III) for the final oocyte maturation. The concentrations of cytokines were evaluated in serum by the enzyme-linked immunosorbent assay kit.

RESULT(S)

VEGFR2 levels were significantly lower in groups I and II than in group III in serum on the OPU (I vs. III, p = .0456; II vs. III, p = .0122) and OPU + 5 day (I vs. III, p = .0004; II vs. III, p = .0082). VEGFA levels were lower in group I than in group III (p = .0298) on the OPU day, however, were similar in all groups on the OPU + 5 day.

CONCLUSION(S)

A small dose of hCG elicits similar concentrations of VEGFA to a full dose of hCG; however, GnRHa triggering reduces the concentrations of VEGFR2, which could lead to the OHSS prevention.

Effect of a dual trigger on oocyte maturation in young women with decreased ovarian reserve for the purpose of elective oocyte cryopreservation

Objective

The aim of this study was to determine whether co-administration of a gonadotropin-releasing hormone (GnRH) agonist and human chorionic gonadotropin (hCG) for final oocyte maturation improved mature oocyte cryopreservation outcomes in young women with decreased ovarian reserve (DOR) compared with hCG alone.

Methods

Between January 2016 and August 2019, controlled ovarian stimulation (COS) cycles in women (aged ≤35 years, anti-Müllerian hormone [AMH] <1.2 ng/mL) who underwent elective oocyte cryopreservation for fertility preservation were retrospectively analyzed.

Results

A total of 76 COS cycles were triggered with a GnRH agonist and hCG (the dual group) or hCG alone (the hCG group). The mean age and serum AMH levels were comparable between the two groups. The duration of stimulation, total dose of follicle-stimulating hormone used, and total number of oocytes retrieved were similar. However, the number of mature oocytes retrieved and the oocyte maturation rate were significantly higher in the dual group than in the hCG group (p=0.010 and p<0.001). After controlling for confounders, the dual-trigger method remained a significant factor related to the number of mature oocytes retrieved (p=0.016).

Conclusion

We showed improved mature oocyte collection and maturation rate with the dual triggering of oocyte maturation in young women with DOR. A dual trigger appears to be more beneficial than hCG alone in terms of mature oocyte cryopreservation for young women with DOR.

Does thyroid autoimmunity affect the reproductive outcome in women with thyroid autoimmunity undergoing assisted reproductive technology?

PROBLEM

Our study aims to investigate whether the anti-thyroperoxidase antibody (TPO-Ab) and TSH level in euthyroid women have any association with reproductive outcomes after the ART cycle.

METHODS OF STUDY

A total of 1107 patients who were enrolled in the study were divided into four groups based on serum TSH level and TPO-Ab status: group A, 0.3 ≤ TSH < 2.5 mIU/L and TPO-Ab^- ; group B, 0.3 ≤ TSH < 2.5 mIU/L and TPO-Ab⁺ ; group C, 2.5 ≤ TSH < 4.2 mIU/L, and TPO-Ab^- ; and group D, 2.5 ≤ TSH < 4.2 mIU/L, TPO-Ab⁺ . The differences in ART cycles and pregnancy outcomes were analyzed between study groups.

RESULTS

The fertilization rate in group D (73%) was significantly lower than that in groups A (83% P < .001), B (84% P = .001), and C (82% P = .002). The biochemical pregnancy rates of groups B (7%) and D (12%) were significantly higher than those of group A (2%) (P = .028 and P = .017, respectively). TPO-Ab was related to a higher biochemical pregnancy rate (P = .002, OR = 5.311, 95% CI 1.859-15.169) and TSH over 2.5 mIU/L was related to higher ICSI rate (P = .001, OR = 1.759, 95% CI 1.250-2.476) by logistic regression analysis. The receiver operating characteristic (ROC) also verified the results.

CONCLUSION

The impacts of TSH ≥ 2.5 mIU/L on the intracytoplasmic sperm injection (ICSI) rate, TSH ≥ 2.5 mIU/L and TPO-Ab⁺ on the fertilization rate, and TPO-Ab⁺ on the biochemical pregnancy rate, rather than the effect on abortion, clinical pregnancy, and live birth, were emphasized.

Comparative study between single versus dual trigger for poor responders in GnRH-antagonist ICSI cycles: A randomized controlled study

OBJECTIVE

To investigate whether dual triggering of final oocyte maturation with a combination of gonadotropin-releasing hormone (GnRH) agonist and human chorionic gonadotropin (hCG) can improve the number of retrieved oocytes and clinical pregnancy rate in poor responders undergoing in vitro fertilization/intracytoplasmic sperm injection (IVF-ICSI) cycles using a GnRH-antagonist protocol.

METHODS

A randomized controlled trial included poor ovarian responders indicated for ICSI using a GnRH-antagonist protocol. They were divided equally into two groups: group I received 10 000 units of hCG plus 0.2 mg of triptorelin while group II received 10 000 units of hCG only for triggering of ovulation. The primary outcome parameter was the number of oocytes retrieved. Secondary outcomes included metaphase II oocytes number, cancellation rate, number of obtained embryos, chemical and clinical pregnancy rates.

RESULTS

One hundred and sixty women were included in the study, with 80 women in each treatment group. Dual triggering was associated with higher number of retrieved oocytes (5.3 ± 1.9 vs 4.5 ± 2.4, P=0.014), metaphase II oocytes (3.8 ± 1.4 vs 3.1 ± 1.7, P=0.004), total and grade 1 embryos (2.7 ± 1.1 and 2.3 ± 1.0 vs 1.9 ± 1.2 and 1.1 ± 0.2, P=0.001 and 0.021 respectively), and transferred embryos (2.2 ± 0.9 vs 1.6 ± 0.9, P=0.043, and lower cancellation rate (7.5% vs 20%, P=0.037) compared with single triggering. There were significantly higher chemical (25% vs 11.3%, P=0.039) and clinical (22.5% vs 8.8%, P=0.028) pregnancy rates in women with dual triggering compared with those with single triggering.

CONCLUSION

Dual triggering is associated with better IVF outcome in poor responders compared with single trigger. Clinical trial registration NCT04008966.

Dual-trigger improves the outcomes of in vitro fertilization cycles in older patients with diminished ovarian reserve: A retrospective cohort study

Background

Dual-trigger for final oocyte maturation has been applied on the women with poor ovarian response or diminished ovarian reserve. However, the results were controversial. The Patient-Oriented Strategies Encompassing IndividualizeD Oocyte Number (POSEIDON) stratification is a set of newly established criteria for low prognosis patients. The aim of this study was to examine the effectiveness of dual-trigger for final oocyte maturation on the in vitro fertilization (IVF) outcomes of patients who fulfill the POSEIDON group 4 criteria.

Methods

This retrospective cohort study investigated 384 cycles fulfilling the POSEIDON group 4 criteria. The patients underwent IVF treatment using the gonadotropin-releasing hormone (GnRH) antagonist protocol. The study group contained 194 cycles that received dual-trigger (human chorionic gonadotropin [hCG] plus GnRH-agonist) for final oocyte maturation. The control group included 114 cycles where final oocyte maturation was performed with only hCG. Baseline characteristics and cycle parameters, as well as IVF outcomes of both groups were compared.

Results

Baseline characteristics were similar between the dual trigger group and the control group. In terms of IVF outcomes, the dual trigger group demonstrated significantly higher number of retrieved oocytes, metaphase II oocytes, fertilized oocytes, day-3 embryos, and top-quality day-3 embryos. A statistically significant improvement in clinical pregnancy rate and live birth rate was also observed in the dual trigger group.

Conclusions

Our data suggests that dual trigger for final oocyte maturation might improve clinical pregnancy rates and live birth rates of IVF cycles in patients fulfilling the POSEIDON group 4 criteria.

Gonadotropin-releasing hormone agonist ovulation trigger-beyond OHSS prevention

In this review the advantages of the gonadotropin-releasing hormone agonist (GnRHa) trigger are discussed beyond those immediately associated with ovarian hyperstimulation syndrome (OHSS) prevention. The GnRHa trigger concept has sparked the development of novel protocols, enriching the assisted reproductive technology (ART) armamentarium for the benefit of present and future patients. Thus, GnRHa trigger already has a pivotal role, not only for the standard in vitro fertilisation (IVF) patient, but also for patient groups like oocyte donors, cancer patients, patients with poor ovarian reserve, and patients with immature oocyte syndrome and empty follicle syndrome. Herein, we discuss the importance of the GnRHa-elicited midcycle FSH surge and the potential improvement in oocyte yield and embryo competence.

Dual trigger using recombinant HCG and gonadotropin-releasing hormone agonist improve oocyte maturity and embryo grading for normal responders in GnRH antagonist cycles: Randomized controlled trial

OBJECTIVES

To evaluate the effectiveness of dual trigger using gonadotropin-releasing hormone (GnRH) agonist and recombinant human chorionic gonadotropin (rHCG) versus rHCG alone for normal responders in GnRH antagonist intracytoplasmic sperm injection (ICSI) cycles.

PATIENTS AND METHODS

The current study was a registered open-labeled randomized controlled trial (clinical trial.gov: NCT02916173) conducted in the ART Unit of a tertiary University hospital between October 2016 and October 2018. The study participants were randomized to either group I (HCG group) or group II (dual trigger group). The primary outcome was the number of mature (MII) oocytes in both groups.

RESULTS

Both groups were similar regarding the baseline demographic and clinical characteristics. Women in the dual trigger group had a statistically significant higher number of retrieved oocytes (p = 0.001), MII oocytes (p = 0.01) and the number of grade one embryos (p = 0.04). Both groups were similar regarding the fertilization, implantation, clinical pregnancy and live birth rates in a fresh cycle. Dual trigger group was significantly higher in the clinical pregnancy rate and live birth rate after frozen embryo transfer (p = 0.04, 0.03, respectively).

CONCLUSION

Dual trigger by GnRH agonist and rHCG improve the oocyte maturity and embryo grading for normal responders in GnRH antagonist ICSI cycles.

GnRH agonist versus HCG triggering in different IVF/ICSI cycles of same patients: a retrospective study

The aim of this study was to assess Gonadotropin Releasing Hormone agonist (GnRHa) trigger results of fresh in vitro fertilisation (IVF), Intracytoplasmic Sperm Injection (ICSI) cycles in high-responder patients. Thirty-six high-responder patients, undergoing GnRH antagonist protocol combined with GnRHa trigger for final oocyte maturation, were included. All cycles were autologous fresh transfer cycles. Fifteen of 36 patients had previous IVF/ICSI cycles triggered with human chorionic gonadotropin (hCG) and both cycles of these patients were compared. The mean fertilisation rate, blastocyst development and clinical pregnancy rates were 67%, 44.4% and 44.4%, respectively. The hCG and GnRHa trigger cycles of the same patients were compared as two groups (n: 15). 2PN oocyte counts were significantly higher in agonist trigger cycles (p .048). There were no differences in terms of M2 oocyte count and fertilisation rate. The blastocyst formation and clinical pregnancy rates for hCG and GnRHa trigger cycles were 33.3-66.7% and 13.3-46.7%, respectively. These results were found to be 2-fold and 3.5-fold higher, but not statistically significant. GnRHa trigger in combination with LPS is a good option for final oocyte maturation due to its good pregnancy outcomes and virtually eliminating OHSS risks.IMPACT STATEMENTWhat is already known on this subject? Gonadotrophin releasing hormone agonist (GnRHa) trigger is effective in the induction of oocyte maturation and prevention of Ovarian Hyperstimulation Syndrome (OHSS) on IVF cycles using antagonist protocol.What do the results of this study add? The main strength of this study is the comparison of different triggers in different cycles of the same patients. GnRHa trigger in combination with Luteal Phase Support (LPS) is a good option for final oocyte maturation due to its good pregnancy outcomes and virtually eliminating OHSS risks.What are the implications of these findings for clinical practice and/or further research? We suppose that GnRHa trigger combined with modified LPS is clinically more successful than Human Chorionic Gonadotropin (hCG) in regard to OHSS prevention and reproductive outcomes on fresh IVF/ICSI cycles. More extensive studies are needed to draw firm conclusions.

Screening Human Embryos for Polygenic Traits Has Limited Utility

The increasing proportion of variance in human complex traits explained by polygenic scores, along with progress in preimplantation genetic diagnosis, suggests the possibility of screening embryos for traits such as height or cognitive ability. However, the expected outcomes of embryo screening are unclear, which undermines discussion of associated ethical concerns. Here, we use theory, simulations, and real data to evaluate the potential gain of embryo screening, defined as the difference in trait value between the top-scoring embryo and the average embryo. The gain increases very slowly with the number of embryos but more rapidly with the variance explained by the score. Given current technology, the average gain due to screening would be ≈2.5 cm for height and ≈2.5 IQ points for cognitive ability. These mean values are accompanied by wide prediction intervals, and indeed, in large nuclear families, the majority of children top-scoring for height are not the tallest.

[Dual trigger with gonadotropin-releasing hormone agonist and hCG to improve oocyte maturation rate]

OBJECTIVE

This study investigates dual trigger with GnRHa and hCG as a potential treatment in patients with a history of ≥25 % immature oocytes retrieved in IVF/ICSI cycles.

METHODS

This is a retrospective case-control study performed between October 2008 and December 2017. Forty-seven patients who experienced high oocyte immaturity rate (≥25 %) during their first IVF/ICSI cycle (analyzed as control group) and received a dual trigger for their subsequent cycle, were involved. During dual trigger cycles, patients received antagonist protocol and ovulation triggering using triptorelin 0.2mg and hCG. Primary endpoint was maturation rate (MR). Secondary endpoints were fertilization, D2 top quality embryo (TQE) rates, clinical pregnancy rate per fresh embryo transfer and cumulative clinical pregnancy rate per couple.

RESULTS

A significant increase in MR was achieved in case of dual trigger (71.0 %) when compared to control group (47.8 %; P<0.0001). Moreover, cumulative clinical pregnancy rate yielded 46.8 % in dual trigger group, which was statistically higher than 27.6 % obtained in control group (P=0.05). However, fertilization, D2 TQE rates and clinical pregnancy rates/transfer were statistically similar when compared between the two groups.

CONCLUSION

Dual trigger seems efficient for managing patients with high oocyte immaturity rate.

Does double trigger (GnRH-agonist + hCG) improve outcome in poor responders undergoing IVF-ET cycle? A pilot study

Many strategies are offered for the treatment of poor responders. However, no compelling advantage for one stimulation protocol over another has been hitherto established. In this study, we aimed to evaluate the role of different modes and timings of final follicular maturation trigger, on in vitro fertilization (IVF) cycle outcome of poor responder patients. In the present randomized controlled study, poor responder patients, according to the Bologna criteria, undergoing controlled ovarian hyperstimulation (COH) using the gonadotropin-releasing hormone (GnRH) antagonist protocol were randomly assigned to three different final follicular maturation trigger modes and timings: hCG 36 h before oocyte pick-up (OPU) (hCG trigger); GnRH agonist (GnRHag) 36 h before (OPU) and hCG on day of OPU (GnRHag trigger); and GnRHag and hCG, 40 and 34 h prior to OPU, respectively (double trigger). Pregnancy rate, number of oocytes, and top quality embryos (TQEs). Thirty-three poor responder patients were recruited and randomized to the different study groups. While there were no in-between groups' differences in patients' demographics and stimulation variables, patients in the double trigger group had a significantly higher number of TQE (1.1 ± 0.9 vs. 0.3 ± 0.8 and 0.5 + 0.7; p<.02) as compared to the hCG trigger and the GnRH-ag trigger groups, respectively, with an acceptable pregnancy rate. Double trigger offers an additional benefit to poor responder patients. Larger studies are required to support this new concept prior to its implementation to IVF practice.