GnRHa flare and IVF pregnancy rates

What should be the maximum FSH dose in IVF/ICSI in poor responders?

Various protocols of ovarian stimulation have been proposed for optimising IVF/ICSI results in women presenting with a poor response to controlled ovarian stimulation; however, achieving a good response to stimulation for this category of patients still remains a challenge. The most extensively employed strategy to improve follicular response in these so-called 'poor responders' involves the use of high doses of gonadotrophins. A small number of randomised controlled trials and retrospective studies have evaluated the effectiveness of the high-dose FSH regimes over a 300 IU threshold. The results of these studies have shown these approaches to be of little or no clinical benefit, although both the costs of treatment and side-effects were higher. There are other studies that have examined 450 IU FSH regimens or even more. This paper presents an overview in all these clinical trials, trying to evaluate the safest and most effective upper limit of FSH that may be used for controlled ovarian hyperstimulation.

What is the optimum maximal gonadotropin dosage used in microdose flare-up cycles in poor responders?

OBJECTIVE

To find out the optimum maximal dosage of recombinant follicle stimulating hormone (rFSH) in microdose gonadotropin-releasing hormone analog (GnRH-a) flare cycles in poor responders.

DESIGN

Prospective randomized study.

SETTING

Private infertility clinic.

PATIENT(S)

A total of 119 women were taken into the study.

INTERVENTION(S)

The study group underwent a microdose protocol with a GnRH-agonist followed by rFSH administration. On the third day of GnRH-a administration, 119 patients were randomized in three groups to receive daily fixed doses of 300 IU of rFSH (group A, n = 38), or 450 IU of rFSH (group B, n = 39), or 600 IU of rFSH (group C, n = 42).

MAIN OUTCOME MEASURE(S)

Peak E(2) levels, days of stimulation with rFSH, total rFSH dosage, total number of oocytes retrieved, M2 oocytes retrieved, total number of embryos, number of embryos transferred, number of Grade-1 embryos transferred, clinical pregnancy rate (positive fetal cardiac activity), and cancellation rates of stimulation and embryo transfer.

RESULT(S)

Clinical pregnancy rates were 13.1%, 15.3%, and 16.1% for group A, group B, and group C, respectively. There were no significant differences in the age, peak serum E(2) concentration, days of stimulation with rFSH, total number of M2 oocytes retrieved, number of embryos transferred, clinical pregnancy rates, and cancellation rates of stimulation and embryo transfer between the three groups except for total rFSH dosage.

CONCLUSION(S)

There is no need to use doses above 300 IU of rFSH to increase the pregnancy rate in microdose cycles. In addition, because the duration of stimulation does not differ between the groups, the usage of 300 IU rFSH in microdose cycles results in less total amount of rFSH consumed in a cycle compared with higher dosages, and this would obviously cost less money to the patients.

A comparison of gonadotropin-releasing hormone (GnRH) antagonist and GnRH agonist flare protocols for poor responders undergoing in vitro fertilization

OBJECTIVE

To compare stimulation profiles, pregnancy, and live birth rates in poor responders during in vitro fertilization (IVF) cycles using either a gonadotropin-releasing hormone (GnRH) antagonist (cetrorelix) or a GnRH agonist flare protocol (leuprolide).

DESIGN

Retrospective chart review.

SETTING

A university-affiliated IVF program.

PATIENT(S)

Women designated as poor responders based on a prior stimulation cycle or baseline follicle-stimulating hormone (FSH) level of >10 mIU/mL, who needed at least 375 IU of starting daily gonadotropins in the study cycle.

INTERVENTION(S)

Administration of GnRH agonist flare or GnRH antagonist protocol.

MAIN OUTCOME MEASURE(S)

Clinical pregnancy rate, live birth rate.

RESULT(S)

For 68 GnRH antagonist and 45 GnRH agonist flare cycles, the groups were similar with respect to age (38.8 versus 38.6 years) and basal FSH concentration (8.33 versus 8.65 mIU/mL). No statistically significant differences between the protocol types were noted in peak estradiol levels, amount of gonadotropins used, number of oocytes obtained, or embryos transferred. The pregnancy rates (40% versus 45.2%) and live birth rates (27.7% versus 31.7%) in the GnRH antagonist and flare groups, respectively, were similar.

CONCLUSION(S)

We achieved excellent and comparable pregnancy and live birth rates in poor responders of advanced reproductive age with the use of either GnRH antagonist or flare protocol.

Early follicular progesterone concentrations and in vitro fertilization pregnancy outcomes

In IVF cycles using a GnRH agonist down-regulation short protocol, when the concentration of P on day 4 of stimulation was >3 ng/mL, patients experienced a significantly reduced implantation rate (14.1%), pregnancy rate (24.6%), and ongoing pregnancy rate (20.0%), with an elevated early miscarriage rate (18.8%).