Triptorelin acetate administration in early pregnancy: case reports and review of the literature

Comparison of pregnancy rates in antagonist cycles after luteal support with GnRH-agonist versus progesterone: prospective randomized study

PURPOSE

To compare pregnancy rates in GnRH-antagonist cycles triggered with hCG after luteal phase support with intranasal GnRH-agonist as sole luteal phase support versus standard vaginal progesterone preparation.

METHODS

Prospective randomized controlled study of patients who underwent antagonist-based IVF cycles triggered with hCG at university-affiliated tertiary medical center between 2020 and 2022. Patients meeting the inclusion criteria were randomly assigned to either intranasal GnRH-agonist or vaginal progesterone for luteal phase support. Pregnancy rates were the main outcome compared between the two study groups.

RESULTS

A total of 150 patients underwent 164 cycles, 127 cycles of which were included in the study cohort. Of them, 64 (50.4%) and 63 (49.6%) cycles were treated with GnRH-agonist or progesterone, respectively, as sole luteal phase support. A significantly higher pregnancy rate was demonstrated in the GnRH-agonist group compared with the progesterone group. After adjustment of several potential confounders such as age, body mass index, past obstetric history, number of IVF cycles, oocyte retrieved and embryos transferred, GnRH-agonist was still associated with a higher pregnancy rate (odds ratio 3.4, 95% confidence interval 1.4-8.3). Ovarian hyperstimulation syndrome rates were similar between the groups.

CONCLUSIONS

This prospective study suggests that nasal GnRH-agonist for luteal phase support is associated with higher pregnancy rates compared with standard progesterone support in an antagonist-based protocol triggered with hCG, while maintaining a similar safety profile.

TRIAL REGISTRATION

Clinicaltrials.gov NCT05484193. Date of registration: August 02 2022. The trial was retrospectively registered.

Update on Pregnancy Following Breast Cancer Diagnosis and Treatment

ABSTRACT

Survivorship has become a crucial component in breast cancer care. For women who have not completed their family planning, conceiving at the end of anticancer treatments should not be discouraged but might be challenging. Oncofertility counseling should be offered at the time of diagnosis to all patients, in order to inform them about the potential treatment-induced gonadotoxicity as well as the available strategies for fertility preservation, thus allowing to increase the chances of a future pregnancy. This article reports an updated overview on the current state of the art on pregnancy in women with prior breast cancer diagnosis and treatment, with a main focus on the issues faced by patients with history of hormone receptor-positive disease and BRCA carriers.

GnRH agonist as luteal phase support in assisted reproduction technique cycles: results of a pilot study

BACKGROUND

The aim of the study was to investigate whether intranasal (IN) administration of a GnRH agonist could provide luteal support in IVF/ICSI patients.

METHODS

Controlled ovarian hyperstimulation (COH) was performed using hMG/FSH and a GnRH antagonist. Patients were then randomly allocated to either 10,000 IU hCG, followed by vaginal administration of micronized progesterone (3x 200 mg/day) (group A), or 200 microg IN buserelin followed by either 100 microg every 2 days (group B), or 100 microg every day (group C), or 100 microg twice a day (group D), or 100 microg three times a day (group E). Luteal support was continued for 15 days.

RESULTS

Twenty-three patients were randomized. Groups B and C were discontinued prematurely in view of the short luteal phase. The luteal phase was significantly shorter in groups B, C and D, whereas group E was comparable with group A, 13.5 and 13.0 days, respectively. In the mid-luteal phase, median progesterone levels were significantly lower in groups B, C and D, whereas group E was comparable with group A, 68.9 and 98.0 ng/ml, respectively. Estradiol (E2) was significantly reduced in groups B and D but sustained in group E. In the hCG group, LH levels were undetectable (<0.1 IU/l), whereas LH was detectable and significantly higher in groups C, D and E. Two pregnancies were obtained in the hCG group (two of five), one ectopic and one ongoing. Three pregnancies were obtained in group E, one miscarriage and two ongoing twin pregnancies (three of five).

CONCLUSION

IN administration of buserelin may be effective in triggering follicular maturation and providing luteal phase support in patients undergoing assisted reproduction techniques (ART).

Increased prevalence of gestational diabetes mellitus in in vitro fertilization pregnancies inadvertently conceived during treatment with long-acting triptorelin acetate

Thirty-five pregnancies were inadvertently conceived during the midluteal application of the long-acting gonadotropin-releasing hormone agonist triptorelin acetate before ovarian stimulation for in vitro fertilization. Most of the conceptions occurred before the first or second IVF trial, and were associated with a significantly increased tendency to develop gestational diabetes. No increase in pregnancy wastage or appearance of congenital malformations occurred.

GnRH agonist as novel luteal support: results of a randomized, parallel group, feasibility study using intranasal administration of buserelin*

BACKGROUND

The study objective was to investigate whether repeated intranasal administration of a GnRH agonist could provide convenient and safe luteal support.

METHODS

Twenty-four patients with unexplained infertility were enrolled. All patients were treated with an aromatase inhibitor. When ovulation trigger criteria were met, patients were randomly allocated to either 5000 IU hCG (group A), or 200 microg intranasal buserelin followed by 100 microg every 3 days (group B), 100 microg every 2 days (group C), or 100 microg every day (group D), up to day 14 of the luteal phase. All patients underwent intrauterine insemination.

RESULTS

Follicular development was similar in all groups with 1.1 +/- 0.3 follicles > or = 16 mm, 229.4 +/- 95.2 pg/ml estradiol (E2) and 0.8 +/- 0.5 ng/ml progesterone (mean+/-SD). The luteal phase duration (median; 95% confidence interval) was 15 (14.1, 15.0), 14 (12.5, 15.5), 15 (11.8, 18.2) and 15 (14.4, 15.6) days in groups A, B, C and D respectively. From luteal phase day 7 onwards, progesterone levels tended to be higher in group D compared with A. On day 14 of the luteal phase, progesterone levels were 3.0 (0.8, 5.2), 1.7 (-0.5, 3.9), 3.9 (-0.7, 8.5) and 7.7 (3.4, 11.9) ng/ml in groups A, B, C and D respectively (P = 0.045). No pregnancy was recorded in group A, but there was one biochemical pregnancy in group B, one biochemical and one singleton clinical pregnancy in group C, and two singleton clinical pregnancies in group D.

CONCLUSION

Intranasal administration of buserelin could be effective to provide luteal support. This treatment was associated with a good pregnancy rate (5/18, 28%).

A benefit-risk assessment of medical treatment for uterine leiomyomas

The growth of a uterine leiomyoma growth stops and regresses after the menopause suggesting that leiomyoma growth is dependent on ovarian steroids. Therefore, estrogen has received much attention as the major factor responsible for the development of uterine leiomyomas, but progesterone also plays an important role in development of this disease. Cytogenetic analyses of resected samples has revealed that about 40 to 50% of leiomyomas show karyotypically detectable chromosomal abnormalities. Gonadotrophin releasing hormone (GnRH) agonists exert their action through the suppression of endogenous gonadotrophins and gonadal steroid secretion. Significant reductions of uterine/leiomyoma volume under GnRH agonist therapy has been reported in several studies. However, the leiomyoma generally returns to its pretreatment volume within a few months after discontinuation of the GnRH agonist. To minimise the adverse effects of hypoestrogenism during GnRH agonist treatment, add back therapy can be used (estrogen-progestin, progestin alone and recently tibolone). Antiprogestins have a potential clinical utility in uterine leiomyomas. Mifepristone is a synthetic steroid with both antiprogesterone and antiglucocorticoid activities, that may have an inhibitory effect on growth of leiomyoma. Danazol is an isoxazole of 17beta-ethinyl testosterone, a synthetic steroid, which has a suppressive effect on sex hormone binding globulin concentrations, resulting in efficacy in the short-term treatment of uterine leiomyomas. Gestrinone is a tri-enic steroid with antiestrogen and antiprogesterone properties and has been shown to reduce uterine volume and stop bleeding. Growth factors play a relevant role on the pathophysiology of uterine leiomyoma and probably the inhibition of the action of growth factors on the myometrium will be the basis for future therapy. A number of agents are under investigation for treating uterine leiomyoma. Agents developed from increasing genetic knowledge of this condition could represent, in the next few years, new trends in the medical treatment of uterine leiomyomas.

Should we still advise infertile couples to use (barrier) contraception before IVF down-regulation?

OBJECTIVE

To determine the outcome of spontaneous conceptions in women who received GnRH agonists during mid-luteal phase down-regulation before IVF treatment.

DESIGN

Retrospective analysis of case records and study of the literature.

SETTING

Two university-affiliated reproductive medicine units.

PATIENT(S)

Seventy-three women who conceived spontaneously after starting down-regulation with a GnRH agonist before controlled ovarian hyperstimulation.

INTERVENTION(S)

None.

MAIN OUTCOME MEASURE(S)

Course and clinical outcome of pregnancies.

RESULT(S)

Seventy-four pregnancies occurred in 73 women who received a GnRH agonist. Of these patients, 6 (8%) had a biochemical pregnancy, 6 (8%) had an ectopic pregnancy, 21 (28%) miscarried, and 41 pregnancies resulted in successfully delivered babies; there were 2 cases of congenital abnormalities.

CONCLUSION(S)

These cases, together with other published data, suggest that pregnancy outcome is not adversely affected by exposure to GnRH agonist during luteal-phase down-regulation. A central register of pregnant women who received a GnRH agonist is needed.