[Ovarian stimulation: is exogenous LH necessary in all patients?]

The follicular-phase depot GnRH agonist protocol results in a higher live birth rate without discernible differences in luteal function and child health versus the daily mid-luteal GnRH agonist protocol: a single-centre, retrospective, propensity score matched cohort study

BACKGROUND

The gonadotropin-releasing hormone agonist (GnRH-a) has been used in in vitro fertilization/intracytoplasmic sperm injection (IVF/ICSI) cycles for a long time. This paper evaluates the efficacy and safety of two commonly used protocols (follicular-phase depot GnRH-a protocol and daily mid-luteal long GnRH-a protocol) in normal responders undergoing IVF/ICSI using propensity score matching (PSM) analysis.

METHODS

A total of 6,816 infertile women treated within the period from January 2016 to September 2020 were stratified into cohorts. A total of 2,851 patients received the long-acting group (depot GnRH-a protocol), and 1,193 used the short-acting group (long GnRH-a protocol) after the data-selection process. PSM was utilized for sampling by up to 1:1 nearest neighbour matching to adjust the numerical difference and balance the confounders between groups. The primary outcome was the live birth rate (LBR). Multivariable logistic analysis was used to evaluate the difference between these two protocols in relation to the LBR.

RESULT(S)

In this study, 1:1 propensity score matching was performed to create a perfect match of 964 patients in each group. After matching, the blastocyst formation rates, oestradiol (E₂) value on Day hCG + 9, progesterone (P) value on Day hCG + 9, implantation rates, clinical pregnancy rates, and LBR were more favourable in the depot GnRH-a protocol than in the long GnRH-a protocol (P < 0.05). However, the moderate or severe OHSS rates were higher in the depot group than in the long group (P < 0.001). There were no significant differences in endometrial thickness, luteal support medication, early pregnancy loss rates, mid- and late-term pregnancy loss rates, or foetal malformation rates between the two protocols.

CONCLUSION(S)

Compared with the daily short-acting GnRH agonist protocol, the follicular-phase depot GnRH-a protocol might improve LBRs in normogonadotropic women without discernible differences in luteal function and child health.

To add or not to add LH: comments on recent commentaries

Human reproductive evolution, involving a complex interaction of the hypothalamic-pituitary-ovarian axis, the release of pulsatile and threshold concentrations of gonadotrophins and positive and negative feedback systems, has ensured the release of a single viable egg and functioning corpora lutea in the natural menstrual cycle. The use of follicular stimulation regimens to obtain multiple eggs has resulted in a compromise - in terms of the risk of ovarian hyperstimulation, cost, multiple pregnancies, wastage of or the need for cryopreservation of surplus embryos. Even some women with apparently normal menstrual cycles might become 'poor responders' when administered with follicular stimulants, and we still do not know if the incidence of oocyte aneuploidy is artificially raised after stimulation. After the advent of recombinant FSH and LH, the precise roles of these hormones individually needs to be elucidated to understand the physiological requirements for successful ovarian stimulation in each woman undergoing IVF, to maximize her chance and minimise attendant risks. One of the key debates is the role of LH, which in the natural cycle is significant, but may be redundant during ovarian stimulation for IVF. Current outcome indicators are crude when attempting to understand the physiology, and more basic research and randomized, focused clinical trials are needed.

GnRH antagonist versus long GnRH agonist protocol in poor responders undergoing IVF: a randomized controlled trial

BACKGROUND

This is the first published report of a prospective, randomized, controlled trial comparing a fixed, multi-dose GnRH antagonist protocol with a long GnRH agonist protocol in poor responders undergoing IVF.

METHODS

Sixty-six poor responders were randomized into two groups: the study group received 0.25 mg of cetrorelix daily starting on day 6 of stimulation; the control group received 600 microg of buserelin acetate daily starting in the mid-luteal phase of the preceding cycle. Both groups were given a fixed dose of recombinant FSH (300 IU daily) for stimulation.

RESULTS

There were no significant differences in the cycle cancellation rates, duration of stimulation, consumption of gonadotrophins, and mean numbers of mature follicles, oocytes and embryos obtained. The implantation rates were similar, but the number of embryos transferred was significantly higher for the antagonist group (2.32 +/- 0.58 versus 1.50 +/- 0.83; P = 0.01). The pregnancy rates were also higher in the antagonist group, but the difference was not statistically significant.

CONCLUSION

A fixed multi-dose GnRH antagonist protocol is feasible for patients who are poor responders on a long agonist protocol; however, our study failed to demonstrate an overall improvement in ovarian responsiveness. Clinical outcomes may be improved by developing more flexible antagonist regimens, an approach that requires further evaluation.