Rescue of corpus luteum function with peri-ovulatory HCG supplementation in IVF/ICSI GnRH antagonist cycles in which ovulation was triggered with a GnRH agonist: a pilot study

Investigation of luteal HCG supplementation in GnRH-agonist-triggered fresh embryo transfer cycles: a randomized controlled trial

RESEARCH QUESTION

Does splitting the human chorionic gonadotrophin (HCG) support in IVF cycles triggered by a gonadotrophin-releasing hormone agonist result in a better progesterone profile?

DESIGN

Randomized controlled three-arm study, performed at the Fertility Clinic, Odense University Hospital, Denmark. Patients with 12-25 follicles ≥12 mm were randomized into three groups: Group 1 - ovulation triggered with 6500 IU HCG; Group 2 - ovulation triggered with 0.5 mg GnRH agonist, followed by 1500 IU HCG on the day of oocyte retrieval (OCR); and Group 3 - ovulation triggered with 0.5 mg GnRH agonist, followed by 1000 IU HCG on the day of OCR and 500 IU HCG on OCR + 5. All groups received 180 mg vaginal progesterone. Progesterone concentrations were analysed in eight blood samples from each patient.

RESULTS

Sixty-nine patients completed the study. Baseline and laboratory data were comparable. Progesterone concentration peaked on OCR + 4 in Groups 1 and 2, and peaked on OCR + 6 in Group 3. On OCR + 6, the progesterone concentration in Group 2 was significantly lower compared with Groups 1 and 3 (P = 0.003 and P < 0.001, respectively). On OCR + 8, the progesterone concentration in Group 3 was significantly higher compared with the other groups (both P<0.001). Progesterone concentrations were significantly higher in Group 3 from OCR + 6 until OCR + 14 compared with the other groups (all P ≤ 0.003). Four patients developed ovarian hyperstimulation syndrome in Group 3.

CONCLUSION

Sequential HCG support after a GnRH agonist trigger provides a better progesterone concentration in the luteal phase.

Transcriptome profiling reveals superovulation with the gonadotropin-releasing hormone agonist trigger impaired embryo implantation in mice

Introduction

Superovulation is a critical step in assisted reproductive technology, but the use of human chorionic gonadotropin (hCG) as a trigger for superovulation can result in ovarian hyperstimulation. Thus, the use of Gonadotropin-releasing hormone agonist (GnRHa) trigger has been increasingly adopted, although it has been associated with a higher rate of pregnancy failure compared to natural cycles. This study aimed to investigate the effect of GnRHa trigger on embryo implantation in a mouse model.

Methods

Mice in the superovulation (PG) group were administered 7.5 IU of PMSG, followed by the injection of 3.5 μg of GnRHa (Leuprorelin) 48 h later, while mice in the control group (CTR) mated naturally. We compared the number of oocytes, blastocysts, and corpus luteum between the two groups and the implantation sites after the transfer of natural blastocysts. Ovaries, uterus, and serum 2 and 4 days after mating were collected for qRT-PCR, transcriptome sequencing, and hormone assays.

Results

The PG group had more oocytes, blastocysts, and corpus luteum after superovulation than the CTR group. However, the mRNA expression of leukemia inhibitory factor (Lif) and the number of implantation sites were reduced in the PG group. The ELISA assay revealed that superovulation increased ovarian estrogen secretion. The transcriptome analysis showed that superphysiological estrogen led to a response of the uterus to a high estrogen signal, resulting in abnormal endometrium and extracellular matrix remodeling and up-regulation of ion transport and inflammation-related genes.

Conclusion

Our findings suggest that a combination of PMSG and GnRHa trigger impaired embryo implantation in mice, as the excessive uterine response to superphysiological estrogen levels can lead to the change of gene expression related to endometrial remodeling, abnormal expression of uterine ion transport genes and excessive immune-related genes.

The HERA (Hyper-response Risk Assessment) Delphi consensus for the management of hyper-responders in in vitro fertilization

PURPOSE

To provide agreed-upon guidelines on the management of a hyper-responsive patient undergoing ovarian stimulation (OS) METHODS: A literature search was performed regarding the management of hyper-response to OS for assisted reproductive technology. A scientific committee consisting of 4 experts discussed, amended, and selected the final statements. A priori, it was decided that consensus would be reached when ≥66% of the participants agreed, and ≤3 rounds would be used to obtain this consensus. A total of 28/31 experts responded (selected for global coverage), anonymous to each other.

RESULTS

A total of 26/28 statements reached consensus. The most relevant are summarized here. The target number of oocytes to be collected in a stimulation cycle for IVF in an anticipated hyper-responder is 15-19 (89.3% consensus). For a potential hyper-responder, it is preferable to achieve a hyper-response and freeze all than aim for a fresh transfer (71.4% consensus). GnRH agonists should be avoided for pituitary suppression in anticipated hyper-responders performing IVF (96.4% consensus). The preferred starting dose in the first IVF stimulation cycle of an anticipated hyper-responder of average weight is 150 IU/day (82.1% consensus). ICoasting in order to decrease the risk of OHSS should not be used (89.7% consensus). Metformin should be added before/during ovarian stimulation to anticipated hyper-responders only if the patient has PCOS and is insulin resistant (82.1% consensus). In the case of a hyper-response, a dopaminergic agent should be used only if hCG will be used as a trigger (including dual/double trigger) with or without a fresh transfer (67.9% consensus). After using a GnRH agonist trigger due to a perceived risk of OHSS, luteal phase rescue with hCG and an attempt of a fresh transfer is discouraged regardless of the number of oocytes collected (72.4% consensus). The choice of the FET protocol is not influenced by the fact that the patient is a hyper-responder (82.8% consensus). In the cases of freeze all due to OHSS risk, a FET cycle can be performed in the immediate first menstrual cycle (92.9% consensus).

CONCLUSION

These guidelines for the management of hyper-response can be useful for tailoring patient care and for harmonizing future research.

Post-trigger luteinizing hormone concentration to positively predict oocyte yield in the antagonist protocol and its association with genetic variants of LHCGR

BACKGROUND

The concentration of human chorionic gonadotropin (hCG)/ luteinizing hormone (LH) after triggering is generally accepted as a predictor of the normal ovarian response to the trigger, but few studies have explored the distribution model of concentration and its impact on oocyte yield. Genetic variations in LHCGR, known as a receptor for hCG and LH, also play a role in oocyte maturation and retrieval. The objective of the study was to investigate the impact of concentrations of hCG/LH after triggering on oocyte yield and its association with genetic variants of LHCGR.

METHODS

A retrospective cohort study including 372 antagonist IVF cycles, in which 205 received the recombinant hCG trigger and 167 received the gonadotropin-releasing hormone agonist (GnRH-a) trigger, was conducted. The post-trigger concentrations of hCG/LH and the LHCGR N312S (rs2293275) genotype were evaluated in patients to analyse the impact of these factors on oocyte yield.

RESULTS

The oocyte retrieval rate (ORR) increased significantly among the low-, medium- and high-hCG-concentration groups (0.91 ± 0.25, 0.99 ± 0.23 and 1.08 ± 0.19, P < 0.001) and among the low-, medium- and high-LH-concentration groups (0.80 ± 0.29, 0.95 ± 0.21 and 1.07 ± 0.19, P < 0.001). The Pearson correlation coefficient between the post-trigger hCG concentration and ORR was 0.242 (P < 0.001), and that between the LH concentration and ORR was 0.454 (P < 0.001). After adjustment for confounding factors, high post-trigger LH concentrations remained associated with the significantly higher ORRs (adjusted R2 = 0.541, P < 0.001). Patients with the AG genotype of LHCGR N312S were more likely to have low post-trigger LH concentrations (46.10 IU/L versus 60.91 IU/L, P < 0.001) and a significantly lower ORR (0.85 versus 0.96, P = 0.042) than patients with the GG genotype after the GnRH-a trigger.

CONCLUSIONS

The post-trigger LH concentration can positively predict oocyte yield in antagonist IVF cycles, and patients with the AG genotype of LHCGR rs2293275 could have a suboptimal oocyte yield using the GnRH-a trigger.

The effect of gonadotrophin-releasing hormone agonist versus human chorionic gonadotrophin trigger on pregnancy and neonatal outcomes in Letrozole-HMG IUI cycles

BACKGROUND

GnRHa and hCG are both used for oocyte maturation and ovulation triggering. However, GnRHa have a shorter half-life than hCG, which leads to luteal phase deficiency. Letrozole (LE) has been found to improve the luteal function. Thus, the choice of triggering strategy can be different in intrauterine insemination (IUI) cycles using LE and human menopausal gonadotropin (HMG). The aim of this study was to compare the pregnancy and neonatal outcomes of patients triggered with GnRHa versus hCG versus dual trigger in LE-IUI cycles.

METHODS

This retrospective cohort study included 6,075 LE-HMG IUI cycles between January 2010 and May 2021 at a tertiary-care academic medical center in China. All cycles were divided into three groups according to different trigger strategies as hCG trigger group, GnRHa trigger group and dual trigger group. The primary outcome was clinical pregnancy rate. Logistic regression analysis was performed to explore other risk factors for clinical pregnancy rate.

RESULTS

No significant difference was observed in clinical pregnancy rate between hCG, GnRHa and dual trigger cycles in LE-HMG IUI cycles (P = 0.964). The miscarriage rate was significantly lower in the GnRHa trigger group, and higher in the dual trigger group, compared with the hCG group (P = 0.045). Logistic analysis confirmed that triggering strategy was associated with miscarriage (aOR:0.427, 95%CI: 0.183-0.996, P = 0.049; aOR:0.298, 95%CI: 0.128-0.693, P = 0.005). No significant differences were observed regarding neonatal outcomes between the three groups.

CONCLUSIONS

Our findings suggested that both GnRHa and dual trigger can be used to trigger ovulation in LE-HMG IUI cycles, but dual trigger must be used with caution.

Dydrogesterone supplementation in addition to routine micronized progesterone administration for luteal support in cycles triggered with lone GnRH agonist results in an acceptable pregnancy rate and avoids the need to freeze embryos

BACKGROUND

Ovarian hyperstimulation syndrome (OHSS) is reduced when using antagonist cycle with gonadotrophin releasing hormone (GnRH) agonist trigger before ovum pick up. This trigger induces short luteinizing hormone (LH) and follicle stimulating hormone (FSH) peaks, resulting in an inadequate luteal phase and a reduced implantation rate. We assessed whether the luteal phase can be rescued by supplementing with oral dydrogesterone (duphaston) in antagonist cycles after a lone GnRH agonist trigger.

METHODS

A retrospective cohort study. The study group (N.=123) included women who underwent IVF. Patients received a GnRH-antagonist with a lone GnRH-agonist trigger due to imminent OHSS. The control group (N.=374) included patients who underwent a standard antagonist protocol with a dual trigger of a GnRH-agonist and human chorionic gonadotrophin (hCG). All the patients were treated with micronized progesterone (utrogestan) for luteal phase support. Study patients were given duphaston in addition.

RESULTS

The fertilization rate was comparable between the two groups. The mean number of embryos transferred, the clinical pregnancy rate and the take-home baby rate were comparable between groups (1.5±0.6 vs. 1.5±0.5 and 46.3% vs. 41.2%, and 66.7% vs. 87.7%, respectively). No OHSS event was reported in either group.

CONCLUSIONS

This study was the first to evaluate outcomes of duphaston supplementation for luteal support in an antagonist cycle with lone GnRH agonist trigger. The functionality of the luteal phase of those cycles could be restored by adding duphaston. This approach was found to be safe and prevented the need to postpone embryo transfer in case of pending OHSS.

Current pharmacotherapy and future directions for neuroendocrine causes of female infertility

INTRODUCTION

Infertility is recognized as a major global health issue, often associated with significant psychological distress for affected couples. Causes of female infertility include endocrine conditions leading to oligo/anovulation, in addition to structural causes such as tubal, uterine, or peritoneal disorders. Pharmacological treatments, targeting pathways in the hypothalamic-pituitary-ovarian axis, can improve rates of ovulation, conception, pregnancy, and birth. Some existing therapeutic options are hindered by limited efficacy or by a non-physiological mechanism, which can risk excessive stimulation and treatment-related adverse effects. Therefore, there is a continued need for novel therapies to improve care for patients suffering with infertility.

AREAS COVERED

In this review, the authors focus on endocrine causes of oligo/anovulation in women and on advances in assisted reproductive technology. Current pharmacological treatments and putative future therapeutic avenues in development to aid fertility in women are outlined.

EXPERT OPINION

A deeper understanding of the reproductive neuroendocrine network governing hypothalamic gonadotropin-releasing hormone release can offer novel therapeutic targets for the treatment of female subfertility, leading to improved clinical outcomes, less invasive routes of administration, and decreased treatment-related side-effects. The ultimate aim of development in female subfertility is to offer therapeutic interventions that are effective, reproducible, associated with minimal risks, and have an acceptable route of administration.

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.

The effect of the ratio of serum progesterone level to oocyte count on the day of IVF-ICSI injection on pregnancy outcomes in HCG cycles

BACKGROUND

There has been several discussion and debates regarding the possible setremental influence of elevated serum progesterone (SP) on the day of human chorionic gonadotropin (hCG) administration. Our study aims to assess progestron to oocyte rates for assessing CPR and live birth rate (LBR) in IVF cycles and review previous articles.

METHODS

In this prospective cohort study, women under ovulation induction through IVF-ICSI using the GnRH-antagonist protocol were studied. Five specific indicators were considered to assess pregnancy outcome. The statistical analysis was done using SPSS software.

RESULTS

In the present research, 78 patients underwent IVF. The cut-off points for each of the three parameters were 1.2 (with a sensitivity of 65.4% and a specificity of 54%), 6.5 (with a sensitivity of 73.1% and a specificity of 56%), and 0.16 (with a sensitivity of 65.4% and a specificity of 60%, respectively). Only the number of oocytes (area below the curve of 0.64) was able to predict clinical pregnancy. The cut-off point for this parameter was 6.5 (with a sensitivity of 74.1% and a specificity of 66%). On the other hand, none of the parameters were able to predict live birth.

CONCLUSIONS

The findings of this study should assist in the clinical management of patients with high SP on the day of HCG administration. We recommend, that the ratio of SP to oocyte is a useful parameter for refining the criteria of patients who have had embryo freezing of all embryos (by selective freezing) and subsequent transfer of frozen embryos.

Agonist triggering in oocyte donation programs-Mini review

Oocyte donation programs involve young and healthy women undergoing heavy ovarian stimulation protocols in order to yield good-quality oocytes for their respective recipient couples. These stimulation cycles were for many years beset by a serious and potentially lethal complication known as ovarian hyperstimulation syndrome (OHSS). The use of the short antagonist protocol not only is patient-friendly but also has halved the need for hospitalization due to OHSS sequelae. Moreover, the replacement of beta-human chorionic gonadotropin (b-hCG) with gonadotropin-releasing hormone agonist (GnRH-a) triggering has reduced OHSS occurrence significantly, almost eliminating its moderate to severe presentations. Despite differences in the dosage and type of GnRH-a used across different studies, a comparable number of mature oocytes retrieved, fertilization, blastulation, and pregnancy rates in egg recipients are seen when compared to hCG-triggered cycles. Nowadays, GnRH-a tend to be the triggering agents of choice in oocyte donation cycles, as they are effective and safe and reduce OHSS incidence. However, as GnRH-a triggering does not eliminate OHSS altogether, caution should be practiced in order to avoid unnecessary lengthy and heavy ovarian stimulation that could potentially compromise both the donor's wellbeing and the treatment's efficacy.

Individualized luteal phase support after fresh embryo transfer: unanswered questions, a review

Background

Luteal phase support (LPS) is an important part of assisted reproductive technology (ART), and adequate LPS is crucial for embryo implantation. At present, a great number of studies have put emphasis on an individualized approach to controlled ovarian stimulation (COS) and endometrium preparation of frozen- thawed embryo transfer (FET); However, not much attention has been devoted to the luteal phase and almost all ART cycles used similar LPS protocol bases on experience.

Main body

This review aims to concisely summarize individualized LPS protocols in fresh embryo transfer cycles with hCG trigger or GnRH-a trigger. The PubMed and Google Scholar databases were searched using the keywords: (luteal phase support or LPS) AND (assisted reproductive technology or ART or in vitro fertilization or IVF). We performed comprehensive literature searches in the English language describing the luteal phase support after ART, since 1978 and ending in May 2019. Recent studies have shown that many modified LPS programs were used in ART cycle. In the cycle using hCG for final oocyte maturation, the progesterone with or without low dose of hCG may be adequate to maintain pregnancy. In the cycle using GnRH-a for trigger, individualized low dose of hCG administration with or without progesterone was suggested. The optimal timing to start the LPS would be between 24 and 72 h after oocyte retrieval and should last at least until the pregnancy test is positive. Addition of E₂ and the routes of progesterone administration bring no beneficial effect on the outcomes after ART.

Conclusions

Individualized LPS should be applied, according to the treatment protocol, the patients’ specific characteristics, and desires.

Luteal phase support (LPS) is an important part of assisted reproductive technology (ART). In the cycle using hCG for final oocyte maturation, the progesterone with or without low dose of hCG may be adequate to maintain pregnancy. In the cycle using GnRH-a for trigger, individualized low dose of hCG administration with or without progesterone was suggested. The optimal timing to start the LPS would be between 24 and 72 h after oocyte retrieval and should last at least until the pregnancy test is positive. Addition of E₂ and the routes of progesterone administration bring no beneficial effect on the outcomes after ART. Individualized LPS should be applied, according to the treatment protocol, the patients’ specific characteristics, and desires.

Reproductive Outcome After GnRH Agonist Triggering With Co-Administration of 1500 IU hCG on the Day of Oocyte Retrieval in High Responders: A Long-Term Retrospective Cohort Study

While triggering oocyte maturation with GnRH agonist (GnRHa) seems to be safe and effective in terms of the risk of developing OHSS and the number of metaphase II oocytes, it nevertheless results in luteal phase deficiency. To date, strategies have been developed in order to rescue defective luteal phase of GnRHa triggered cycles. Our study aimed to assess the reproductive outcome of GnRHa triggered cycles combined with modified luteal support (1500 IU hCG at the day of oocyte retrieval) in women with high ovarian response and to compare the outcome with hCG triggered cycles in GnRH antagonist IVF-ICSI procedures. A retrospective cohort database review of the results of GnRH antagonist IVF-ICSI cycles was conducted at a tertiary-care IVF center in Ljubljana, Slovenia. A total of 6126 cycles, performed from January 1, 2014, to December 31, 2020, were included in the final analysis. Final oocyte maturation was performed with either 5000, 6500, or 10,000 IU hCG (women with normal ovarian response) or 0.6 mg GnRHa (buserelin), supplemented with 1500 IU hCG on the day of oocyte retrieval (in women with high ovarian response). In cases of excessive ovarian response and/or high risk of OHSS luteal support was not introduced and all good quality blastocysts were frozen. According to significant differences in patients' age and the number of oocytes in the two groups, matching by age and number of oocytes was performed. No significant differences were observed regarding pregnancy rate per embryo transfer, rate of early pregnancy loss, and livebirth rate per pregnancy between the GnRHa and hCG trigger groups, respectively. A significant difference in the number of developed embryos and blastocysts, as well as the number of frozen blastocysts, was seen in favor of the GnRHa trigger. However, the birth weight in the GnRHa trigger group was significantly lower.

CONCLUSION

The results of our study support the use of GnRHa for final oocyte maturation in GnRH antagonist IVF cycles in women with high ovarian response. Luteal phase rescue was performed by co-administration of 1500 IU hCG on the day of oocyte retrieval and estradiol and progesterone supplementation. In our experience, such an approach results in a comparable reproductive outcome with hCG trigger group.

The exogenous progesterone-free luteal phase: two pilot randomized controlled trials in IVF patients

RESEARCH QUESTION

Is the reproductive outcome similar after gonadotrophin-releasing hormone agonist (GnRHa) trigger followed by luteal human chorionic gonadotrophin (HCG) boluses compared with HCG trigger and a standard luteal phase support (LPS)?

DESIGN

Two open-label pilot randomized controlled trials (RCT) with 250 patients from 2014 to 2019, with a primary outcome of ongoing pregnancy per embryo transfer. Patients with ≤13 follicles on the trigger day were randomized (RCT 1) to: Group A (n = 65): GnRHa trigger followed by a bolus of 1500 IU HCG s.c. on the oocyte retrieval day (ORD) and 1000 IU HCG s.c. 4 days later, and no vaginal LPS; or Group B (n = 65): 6500 IU HCG trigger, followed by a standard vaginal progesterone LPS. Patients with 14-25 follicles on the trigger day were randomized (RCT 2) to Group C (n = 60): GnRHa trigger followed by 1000 IU HCG s.c. on ORD and 500 IU HCG s.c. 4 days later, and no vaginal LPS; or Group D (n = 60): 6500 IU HCG trigger and a standard vaginal LPS.

RESULTS

In RCT 1, the ongoing pregnancy rate was 44% (22/50) in the GnRHa group versus 46% (25/54) in the HCG trigger group (RR 0.95, 95% CI 0.62-1.45). No ovarian hyperstimulation syndrome (OHSS) was seen in Groups A or B. In RCT 2, the ongoing pregnancy rate was 51% (25/49) in the GnRHa group versus 60% (31/52) in the HCG trigger group (RR 0.86, 95% CI 0.60-1.22). The OHSS rates were 3.3% and 6.7%, respectively.

CONCLUSIONS

Although a larger-scale study is needed before standard clinical implementation, the present study supports that the exogenous progesterone-free LPS is efficacious, simple and patient-friendly.

Suboptimal response to GnRH agonist trigger: causes and practical management

PURPOSE OF REVIEW

GnRH agonist products are used extensively worldwide to trigger ovulation and final oocyte maturation in in vitro fertilization cycles. The purpose of this article is to outline possible causes for a suboptimal response to the GnRH agonist trigger.

RECENT FINDINGS

Risk factors for such a suboptimal response include prolonged hormonal contraceptive use, previous GnRHa-induced pituitary downregulation, a hypogonadotropic/hypogonadal condition, patient error, environmental conditions that may damage the GnRHa product used, GnRH and luteinizing hormone (LH) receptors polymorphisms, low baseline LH and low endogenous serum LH levels on trigger day as well as low BMI. The induction of an adequate LH surge can be ascertained by an LH urine test 12 h post trigger.

SUMMARY

In most cases, GnRHa trigger elicits effective LH+follicle stimulating hormone surges, resulting in mature, fertilizable oocytes. Clinical awareness to conditions that may predispose to a suboptimal response to the GnRHa trigger may prevent failed oocyte retrial.

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.

GnRHa for trigger and luteal phase support in natural cycle frozen embryo transfer - A proof of concept study

We aimed to explore whether ovulation induced by a GnRH analogue (GnRHa), followed by daily GnRHa luteal support provides an efficient platform for natural cycle frozen embryo transfer (NC-FET). In this cohort study, included were normo-ovulatory women who underwent NC-FET cycles, under the age of 40, with an antral follicle count > eight. Ovulation was triggered with triptorelin (0.2 mg Decapeptyl; Ferring), and luteal support was initiated two days later, using a Nafarelin inhaler (Synarel, Pfizer), 200 μg twice daily. Main outcome measures were luteal estradiol and progesterone levels (three to five days following ovulation), implantation rate, ongoing pregnancy rate, early pregnancy loss rate, and live birth rate. Fifty-one patients treated between 2017 and 2018 were included. Mid luteal progesterone levels among study patients, were non-significantly different between patients who achieved pregnancy and those who did not, but differed significantly on day 14 following ovulation (86.0 ± 31.3 vs. 9.8 ± 9.5 nmol/L, respectively, p < 0.001). Twenty-three patients achieved a clinical pregnancy (45.1 %); interestingly, there were no chemical pregnancies. Three pregnancies ended in an early abortion at 6-7 weeks gestation, and 20 pregnancies continued as ongoing pregnancies (39.2 %). One patient had a late abortion at 16 weeks gestation, and 14 had a live birth. In conclusion, in this proof of concept study, inducing ovulation with a bolus of GnRHa in NC-FET, followed by repeated daily GnRHa administration, resulted in satisfactory luteal phase steroid levels and high ongoing pregnancy and live birth rates.

Gonadotropin-releasing hormone agonist for ovulation trigger - OHSS prevention and use of modified luteal phase support for fresh embryo transfer

The introduction of gonadotrophin-releasing hormone agonist (GnRHa) trigger greatly impacted modern IVF treatment. Patients at low risk of ovarian hyperstimulation syndrome (OHSS) development, undergoing fresh embryo transfer and GnRHa trigger can be offered a virtually OHSS-free treatment with non-inferior reproductive outcomes by using a modified luteal phase support in terms of small boluses of human chorionic gonadotrophin (hCG), daily recombinant luteinizing hormone LH (rLH) or GnRHa. In the OHSS risk patient, GnRHa trigger can safely be performed, followed by a 'freeze-all' policy with a minimal risk of OHSS development and high live birth rates in the subsequent frozen embryo transfer cycle. Importantly, GnRHa trigger opened the 'black box' of the luteal phase, promoting research in the most optimal steroid levels during the luteal phase. GnRHa trigger allows high-dose gonadotropin stimulation to achieve the optimal number of oocytes and embryos needed to ensure the highest chance of live birth. This review thoroughly discusses how the GnRHa trigger concept adds safety and efficacy to modern IVF in terms of OHSS prevention. Furthermore, the optimal luteal phase management after GnRHa trigger in fresh embryo transfer cycles is discussed.

ESHRE guideline: ovarian stimulation for IVF/ICSI†

STUDY QUESTION

What is the recommended management of ovarian stimulation, based on the best available evidence in the literature?

SUMMARY ANSWER

The guideline development group formulated 84 recommendations answering 18 key questions on ovarian stimulation.

WHAT IS KNOWN ALREADY

Ovarian stimulation for IVF/ICSI has been discussed briefly in the National Institute for Health and Care Excellence guideline on fertility problems, and the Royal Australian and New Zealand College of Obstetricians and Gynaecologist has published a statement on ovarian stimulation in assisted reproduction. There are, to our knowledge, no evidence-based guidelines dedicated to the process of ovarian stimulation.

STUDY DESIGN SIZE DURATION

The guideline was developed according to the structured methodology for development of ESHRE guidelines. After formulation of key questions by a group of experts, literature searches and assessments were performed. Papers published up to 8 November 2018 and written in English were included. The critical outcomes for this guideline were efficacy in terms of cumulative live birth rate per started cycle or live birth rate per started cycle, as well as safety in terms of the rate of occurrence of moderate and/or severe ovarian hyperstimulation syndrome (OHSS).

PARTICIPANTS/MATERIALS SETTING METHODS

Based on the collected evidence, recommendations were formulated and discussed until consensus was reached within the guideline group. A stakeholder review was organized after finalization of the draft. The final version was approved by the guideline group and the ESHRE Executive Committee.

MAIN RESULTS AND THE ROLE OF CHANCE

The guideline provides 84 recommendations: 7 recommendations on pre-stimulation management, 40 recommendations on LH suppression and gonadotrophin stimulation, 11 recommendations on monitoring during ovarian stimulation, 18 recommendations on triggering of final oocyte maturation and luteal support and 8 recommendations on the prevention of OHSS. These include 61 evidence-based recommendations-of which only 21 were formulated as strong recommendations-and 19 good practice points and 4 research-only recommendations. The guideline includes a strong recommendation for the use of either antral follicle count or anti-Müllerian hormone (instead of other ovarian reserve tests) to predict high and poor response to ovarian stimulation. The guideline also includes a strong recommendation for the use of the GnRH antagonist protocol over the GnRH agonist protocols in the general IVF/ICSI population, based on the comparable efficacy and higher safety. For predicted poor responders, GnRH antagonists and GnRH agonists are equally recommended. With regards to hormone pre-treatment and other adjuvant treatments (metformin, growth hormone (GH), testosterone, dehydroepiandrosterone, aspirin and sildenafil), the guideline group concluded that none are recommended for increasing efficacy or safety.

LIMITATIONS REASON FOR CAUTION

Several newer interventions are not well studied yet. For most of these interventions, a recommendation against the intervention or a research-only recommendation was formulated based on insufficient evidence. Future studies may require these recommendations to be revised.

WIDER IMPLICATIONS OF THE FINDINGS

The guideline provides clinicians with clear advice on best practice in ovarian stimulation, based on the best evidence available. In addition, a list of research recommendations is provided to promote further studies in ovarian stimulation.

STUDY FUNDING/COMPETING INTERESTS

The guideline was developed and funded by ESHRE, covering expenses associated with the guideline meetings, with the literature searches and with the dissemination of the guideline. The guideline group members did not receive payment. F.B. reports research grant from Ferring and consulting fees from Merck, Ferring, Gedeon Richter and speaker's fees from Merck. N.P. reports research grants from Ferring, MSD, Roche Diagnositics, Theramex and Besins Healthcare; consulting fees from MSD, Ferring and IBSA; and speaker's fees from Ferring, MSD, Merck Serono, IBSA, Theramex, Besins Healthcare, Gedeon Richter and Roche Diagnostics. A.L.M reports research grants from Ferring, MSD, IBSA, Merck Serono, Gedeon Richter and TEVA and consulting fees from Roche, Beckman-Coulter. G.G. reports consulting fees from MSD, Ferring, Merck Serono, IBSA, Finox, Theramex, Gedeon-Richter, Glycotope, Abbott, Vitrolife, Biosilu, ReprodWissen, Obseva and PregLem and speaker's fees from MSD, Ferring, Merck Serono, IBSA, Finox, TEVA, Gedeon Richter, Glycotope, Abbott, Vitrolife and Biosilu. E.B. reports research grants from Gedeon Richter; consulting and speaker's fees from MSD, Ferring, Abbot, Gedeon Richter, Merck Serono, Roche Diagnostics and IBSA; and ownership interest from IVI-RMS Valencia. P.H. reports research grants from Gedeon Richter, Merck, IBSA and Ferring and speaker's fees from MSD, IBSA, Merck and Gedeon Richter. J.U. reports speaker's fees from IBSA and Ferring. N.M. reports research grants from MSD, Merck and IBSA; consulting fees from MSD, Merck, IBSA and Ferring and speaker's fees from MSD, Merck, IBSA, Gedeon Richter and Theramex. M.G. reports speaker's fees from Merck Serono, Ferring, Gedeon Richter and MSD. S.K.S. reports speaker's fees from Merck, MSD, Ferring and Pharmasure. E.K. reports speaker's fees from Merck Serono, Angellini Pharma and MSD. M.K. reports speaker's fees from Ferring. T.T. reports speaker's fees from Merck, MSD and MLD. The other authors report no conflicts of interest.

DISCLAIMER

This guideline represents the views of ESHRE, which were achieved after careful consideration of the scientific evidence available at the time of preparation. In the absence of scientific evidence on certain aspects, a consensus between the relevant ESHRE stakeholders has been obtained. Adherence to these clinical practice guidelines does not guarantee a successful or specific outcome, nor does it establish a standard of care. Clinical practice guidelines do not replace the need for application of clinical judgment to each individual presentation, nor variations based on locality and facility type. ESHRE makes no warranty, express or implied, regarding the clinical practice guidelines and specifically excludes any warranties of merchantability and fitness for a particular use or purpose. (Full disclaimer available at www.eshre.eu/guidelines.) †ESHRE Pages content is not externally peer reviewed. The manuscript has been approved by the Executive Committee of ESHRE.

Independent serum markers of corpora lutea function after gonadotropin-releasing hormone agonist trigger and adjuvant low dose human chorionic gonadotropin in in vitro fertilization

OBJECTIVE

To characterize corpora lutea (CL) function after gonadotropin-releasing hormone agonist (GnRHa) trigger with the use of adjuvant human chorionic gonadotropin (hCG).

DESIGN

Secondary analysis of serum from prospective randomized clinical trial.

SETTING

University-based fertility center.

PATIENT(S)

Women under 40 years of age at risk of ovarian hyperstimulation syndrome (OHSS) with serum E₂ level <4,000 pg/mL.

INTERVENTIONS(S)

All subjects underwent ovarian stimulation with the use of a GnRH antagonist protocol. Within a larger study, subjects were randomized to receive 1,000 IU hCG at the time of GnRHa trigger and placebo at the time of vaginal oocyte retrieval (VOR) or placebo at the time of GnRHa trigger and 1,500 IU hCG at the time of VOR.

MAIN OUTCOME MEASURE(S)

Luteal phase and early pregnancy curves of serum prorenin and 17α-hydroxyprogesterone (17OH-P).

RESULT(S)

Thirty subjects enrolled in this secondary analysis. Serum 17OH-P peaked in the early luteal phase, 5 days after GnRHa trigger, with a nadir in the mid-luteal phase 9 days after trigger. Serum prorenin peaked in the luteal phase 2 days after GnRHa trigger, independently from adjuvant hCG timing, and reached a nadir at 9 days after trigger. CL function appears higher when adjuvant hCG is given at VOR compared with adjuvant hCG given at the time of trigger.

CONCLUSION(S)

CL function, as interpreted by proxy measures of serum prorenin and 17OH-P with pregnancy, continues despite GnRHa trigger. Both options for adjuvant hCG timing are sufficient for CL rescue and successful pregnancy, so the potential for OHSS risk with increased CL activity after hCG at VOR should be considered.

CLINICAL TRIAL REGISTRATION NUMBER

NCT01815138.

Impact of estradiol and progesterone levels during the late follicular stage on the outcome of GnRH antagonist protocols

The study aimed to assess the impacts and the targets of progesterone (P4) and estradiol (E2) levels on IVF outcomes in GnRH antagonist protocols. The study was retrospective and concerned patients for their first fresh embryo transfers, after stimulation by a recombinant FSH (rFSH)-GnRH antagonist protocol, between September 2012 and July 2017 in the Toulouse University Hospital. Multivariable analysis, taking into account female age and the ovarian stimulation index, showed that E2 levels had no impact on IVF outcomes, while high P4 levels (>1.10 ng/mL) were associated to low pregnancy rate. The P4 concentrations were significantly negatively correlated to the percentage of top embryos and to the implantation rate. Therefore, the deleterious effect of high levels P4 could to act mainly by impairing embryo quality, which questions the place of the freeze-all strategy in these cases.

Luteal phase support with GnRH agonist does not eliminate the risk for ovarian hyperstimulation syndrome

This study aims to report a case of early, severe ovarian hyperstimulation syndrome (OHSS) following GnRH agonist trigger for final oocyte maturation despite luteal support with a GnRH agonist. Contrary to the claim that luteal support using a GnRH agonist eliminates the risk for OHSS in high-risk patients, this report alerts practitioners to the risk of severe OHSS development despite GnRH agonist luteal support in patients receiving GnRH antagonist protocol with GnRH agonist triggering and cautions the practitioners to consider other measures of OHSS prevention.

Low dose human chorionic gonadotropin administration at the time of gonadotropin releasing-hormone agonist trigger versus 35 h later in women at high risk of developing ovarian hyperstimulation syndrome - a prospective randomized double-blind clinical trial

BACKGROUND

Ovarian hyperstimulation syndrome remains a serious complication during in vitro fertilization cycles if high dose human chorionic gonadotropin (hCG) is used to trigger ovulation in high responder patients. Though much of this risk is mitigated with trigger using gonadotropin releasing-hormone (GnRH) agonist alone, it may result in lower birth rates. GnRH-agonist trigger and adjuvant low dose hCG has been proposed to improve birth rates, but timing of this hCG support to corpus luteum function has never been fully described. In this randomized, prospective trial, we explore differences in live birth rates and incidence of ovarian hyperstimulation syndrome (OHSS) in high-responder patients undergoing in vitro fertilization (IVF) receiving low dose hCG at the time of GnRH-agonist (dual trigger) or hCG adjuvant at the time of oocyte retrieval. Does the timing of hCG support make a difference?

RESULTS

Thirty-four subjects high-responder patients were randomized to receive low-dose hCG at the time of GnRH-agonist trigger (Group 1) and 37 received low-dose hCG at the time of oocyte retrieval (Group 2). There were no differences in the baseline characteristics and outcome of ovarian stimulation between the two groups. There were no differences in the live birth rates between Group 1 and Group 2 by intention-to-treat (14/34, 41.2% versus 21/37, 56.8%, p = 0.19) or per-protocol (14/26, 53.8% versus 19/31, 61.3%, p = 0.57) analyses. There was a slightly higher incidence of OHSS in Group 2 compared to Group 1 although the difference was not statistically significant (3/31, 9.7% versus 1/26, 3.8%). All the cases of OHSS in Group 2 were moderate while the one case of OHSS in Group 1 was mild.

CONCLUSIONS

For high responder patients receiving GnRH-agonist trigger, low dose hCG supplementation allowed high pregnancy rates after fresh embryo transfer, regardless of whether it was given at the time of trigger or at oocyte retrieval. Dual trigger may be preferable to reduce the risk of OHSS.

Association between progesterone to number of mature oocytes index and live birth in GnRH antagonist protocols

RESEARCH QUESTION

What is the association between blood progesterone level alone, progesterone to mature oocytes index (PMOI) and IVF outcomes?

DESIGN

Clinical data from 960 couples undergoing their first fresh embryo transfer after an intracytoplasmic sperm injection attempt carried out between September 2012 and July 2017 were analysed. All patients underwent ovarian stimulation combining recombinant FSH and gonadotrophin releasing hormone antagonist. Progesterone was measured on the day on which ovulation was triggered. The PMOI was divided into four groups based on 25th, 50th and 75th percentiles, and live birth and implantation rates were compared between the groups.

RESULTS

A negative association was found between PMOI levels, live birth and implantation rates. When adjusting for age, ovarian stimulation index (OSI) and number of embryos transferred, the PMOI remained negatively correlated to live birth rate (LBR) (OR = 0.147 [0.031 to 0.701]; P = 0.0161), whereas total blood progesterone was no longer evident. Moreover, the LBR (18.5% versus 28.4%; P < 0.01) and implantation rate (12.4% versus 21.0%; P < 0.01) were significantly decreased only when PMOI was 0.167 ng/ml or greater, irrespective of progesterone concentration (< or ≥1.08 ng/ml). The opposite was not true, however. Similar PMOIs were recorded in the same patient from one attempt to the next, and were partially linked to basal FSH, anti-Müllerian hormone, antral follicle count and OSI.

CONCLUSIONS

PMOI seems to be more predictive than total progesterone level of IVF outcome and reflects the ability of embryos to develop as it is linked to the implantation rate.

Low LH Level on the Day of GnRH Agonist Trigger Is Associated With Reduced Ongoing Pregnancy and Live Birth Rates and Increased Early Miscarriage Rates Following IVF/ICSI Treatment and Fresh Embryo Transfer

Objective: To examine the correlation between serum luteinizing hormone (LH) levels on the day of GnRH agonist (GnRH-a) trigger and reproductive outcomes following in vitro fertilization/intracytoplasmic sperm injection (IVF/ICSI) treatment and fresh embryo transfer, and to identify a pre-trigger serum LH threshold which would be compatible with the most optimal cycle outcome. Design: This study is based on data from a previously published randomized controlled trial conducted from 2014 to 2016. Patients: A total of 322 participants were enrolled. Setting: Private IVF center. Intervention(s): GnRH-antagonist-based IVF cycles triggered with GnRH-a. For the purpose of the study, patients were stratified according to preovulatory LH quartiles (Q1-Q4). Main Outcome Measure(s): Ongoing pregnancy rates (OP), live birth rates (LB) and early pregnancy loss (EPL) rates. Results: The results of the present study showed increasing OP as well as LB rates and decreasing EPL rates with increasing pre-trigger serum LH levels (P for trend < 0.06, 0.07, and 0.02), respectively. The absolute difference between the highest LH(Q4) and the lowest LH (Q1) group was 13.4%, 12.1%, and 12% in OP, LB, and EPL rates, respectively. In multivariate regression analysis, a pre-trigger serum LH level of 1.60 mIU/ml was identified as a threshold below which reproductive outcomes decreased. The ROC curve values were statistically significant for OP, LB, and EPL; the AUC (95% CI) = [0.57 (0.50-0.63) P < 0.04; 0.57 (0.50-0.63) P < 0.05, and 0.60 (0.51-0.70) P < 0.04], respectively. A significant positive correlation was found on the day of GnRH-a trigger between serum LH, the number of follicles, serum P4, and serum E2, p < 0.03; P < 0.03; and P < 0.001, respectively. Conclusion: Low serum LH levels on the day of GnRH-a trigger is associated with reduced ongoing pregnancy and live birth rates and increased early miscarriage rates. Our findings suggest a lower threshold of serum LH values on the day of GnRH-a trigger necessary to optimize reproductive outcomes in fresh embryo transfer cycles. Clinical Trial Registration: www.ClinicalTrials.gov, Number: 02053779.

Gonadotropin-releasing hormone agonist triggering with concomitant administration of low doses of human chorionic gonadotropin or a freeze-all strategy in high responders

Objectives:

To compare the live birth rates and moderate/severe ovarian hyperstimulation syndrome (OHSS) rates of 2 different approaches using gonadotropin-releasing hormone (GnRH) agonist triggering in high responder women.

Methods:

A retrospective cohort study was performed to evaluate intracytoplasmic sperm injection (ICSI) and embryo transfer (ET) outcomes in high responder women who underwent ovulation induction with a GnRH antagonist protocol between April 2011 and March 2015. In group 1 (n=74), GnRH agonist was used for ovulation triggering with the concomitant use of 1500 IU of urinary human chorionic gonadotropin (hCG) immediately after oocyte retrieval followed by fresh ET and standard luteal support. In group 2 (n=48), GnRH agonist was used for triggering after freezing all embryos and subsequent frozen/thawed embryo transfer (FET); this approach is considered the “freeze-all” approach.

Results:

Baseline characteristics were similar between the groups. The clinical pregnancy rates for group 1 was 45.9% and group 2 was 43.8% (p=0.812, chi-squared test) and live birth rates for group 1 was 40.5% and for group 2 41.7% (p=0.902, chi-squared test) were comparable between groups. In group 1, late-onset OHSS was observed (one severe case and one moderate case) in 2 patients (2.7%). In group 2, none of the patients experienced moderate/severe OHSS.

Conclusion:

The live birth rate with GnRH agonist triggering and concomitant use of 1500 IU of hCG immediately after oocyte retrieval was similar to that obtained with the freeze-all approach and FET in a subsequent cycle. The administration of a low dose of hCG in GnRH agonist trigger cycles caused moderate/severe OHSS in 2.7% of the patients.

PCOS and pregnancy: a review of available therapies to improve the outcome of pregnancy in women with polycystic ovary syndrome

INTRODUCTION

Polycystic ovary syndrome (PCOS) is a common cause of female infertility affecting multiple aspects of a women's health.

AREAS COVERED

The aim of this review is to summarize the existing evidence on the treatment of PCOS patients and to examine the actual available therapies to overcome the problem of infertility and improve the outcome of pregnancy. We analyse different treatment strategies such as lifestyle modification, bariatric surgery, insulin sensitizing agents, inositol, clomiphene citrate (CC), aromatase inhibitors, gonadotrophins, laparoscopic ovarian drilling, and assisted reproductive techniques (ART).

EXPERT COMMENTARY

Lifestyle modification is the best initial management for obese PCOS patients seeking pregnancy and insulin sensitizing agents seem to have an important role in treating insulin resistance. Up to now, CC maintains a central role in the induction of ovulation and it has been confirmed as the first-line treatment; the use of gonadotrophins is considered the second-line in CC resistant patients; laparoscopic ovarian drilling is an alternative to gonadotrophins in patients who need laparoscopy for another reason. However, in anovulatory patients, ART represents the only possible alternative to obtain pregnancy. Larger and well-designed studies are needed to clarify the best way to improve the outcome of pregnancy in PCOS women.

Comparison of dual trigger with combination GnRH agonist and hCG versus hCG alone trigger of oocyte maturation for normal ovarian responders

OBJECTIVE

To investigate whether dual triggering of oocyte maturation with a gonadotropin-releasing hormone (GnRH) agonist and standard dose of human chorionic gonadotropin (hCG) can improve clinical outcomes for normal ovarian responders in GnRH antagonist cycles.

METHODS

The present retrospective cohort study included women aged up to 40 years with normal ovarian response who underwent in vitro fertilization and/or intracytoplasmic sperm injection under the GnRH antagonist protocol at Nanfang Hospital, China, between January 1 and December 31, 2015. Patients were grouped by whether oocyte maturation was triggered with GnRH agonist plus 5000-10 000 IU of hCG (dual trigger) or hCG alone. The primary outcome was live delivery rate.

RESULTS

There were 325 women included; 224 in the dual trigger group and 101 in the hCG alone group. The live delivery rate did not differ significantly between the groups (P=0.083). The mean number of retrieved oocytes was similar in the two groups (P=0.719), but the mean number of two-pronuclear embryos (P=0.004), the mean number of embryos available (P=0.001), and the mean number of high-quality embryos (P=0.011) was higher in the dual trigger group.

CONCLUSIONS

Dual trigger of oocyte maturation was not associated with any change in the live delivery rate but was associated with improvements in the quantity and quality of embryos; it could optimize pregnancy outcomes for normal ovarian responders.

Mid-Luteal 17-OH Progesterone Levels in 614 Women Undergoing IVF-Treatment and Fresh Embryo Transfer-Daytime Variation and Impact on Live Birth Rates

Introduction: Corpus luteum (CL) produces progesterone (P₄) and 17-OH progesterone (17-OH P₄) during the luteal phase. Contrary to P₄, 17-OH P₄ is not supplied as part of the luteal phase support following IVF-treatment. Therefore, measuring endogenous serum 17-OH P₄ levels may more accurately reflect the CL function compared to monitoring serum P₄ concentrations. Objective: To explore the correlation between mid-luteal serum 17-OH P₄ levels and live birth rates and to explore the possible daytime variations in mid-luteal serum 17-OH P_4. Design: Prospective cohort study. Patients: 614 women undergoing IVF-treatment and fresh embryo transfer. Intervention: All patients had serum 17-OH P₄ measured 7 days after oocyte pick-up (OPU+7). Furthermore, on OPU+7, seven patients underwent repeated blood sampling during daytime to clarify the endogenous daytime secretory pattern of 17-OH P₄. Outcome measure: Live birth rate. Secondary outcome measure: Daytime variation in serum 17-OH P₄ levels. Results: The highest chance of a live birth was seen with mid-luteal 17-OH P₄ between 6.0 and 14.0 nmol/l. The chance of a live birth was reduced below (RD -10%, p = 0.07), but also above the optimal range for 17-OH P₄ (RD -12%, p = 0.04). Patients with diminished CL-function (17-OH P₄ < 6 nmol/l) displayed clinically stable 17-OH P₄ values, whereas patients with 17-OH P₄ levels >6 nmol/l showed random 17-OH P₄ fluctuations during daytime. Conclusion: The association between 17-OH P₄ and reproductive outcomes is non-linear, and the negative effect of excessive CL-secretion seems to be just as strong as the negative effect of a reduced CL-function during the peri-implantation period.

Impact of Mid-Luteal Phase GnRH Agonist Administration on Reproductive Outcomes in GnRH Agonist-Triggered Cycles: A Randomized Controlled Trial

OBJECTIVE

To explore whether the addition of a mid-luteal bolus of GnRH agonist (GnRHa) improves the implantation rate (IR) in in vitro fertilization (IVF) cycles.

DESIGN

A randomized controlled trial.

SETTING

Private IVF center.

PATIENTS

328 IVF/intracytoplasmic sperm injection patients were triggered with GnRHa and received 1,500 IU HCG on the day of oocyte pick-up (OPU) in addition to a standard luteal phase support (LPS).

INTERVENTIONS

In addition, the study group received a bolus of GnRHa 6 days after OPU, whereas the control group did not.

MAIN OUTCOME MEASURE

Implantation rate.

SECONDARY OUTCOME MEASURES

Ongoing pregnancy (OP) and live birth (LB) rates.

RESULTS

Although serum concentrations of FSH, LH, E2, and P on day OPU + 7 were significantly higher in the study group compared to the control group, the IR was not statistically different between the treatment group (27%) and the control group (23%) [odds ratio (OR) 1.2 (95% CI 0.9-1.7), P < 0.27]. Similarly, the OP rate was 37% in the treatment group and 31% in the control group [OR 1.3 (95% CI 0.8-2.0), P < 0.23]. The LB rate was 36% in the treatment group and 31% in the control group [OR: 1.3 (95% CI 0.8-2.0), P < 0.27].

CONCLUSION

Although a trend toward a higher IR and pregnancy rate was observed in the treatment group, this difference was not statistically significant. However, the absolute risk difference of 5% found for LB is clinically relevant, warranting further investigation.

NCT

02053779.

Impact of Mid-Luteal Phase GnRH Agonist Administration on Reproductive Outcomes in GnRH Agonist-Triggered Cycles: A Randomized Controlled Trial

OBJECTIVE

To explore whether the addition of a mid-luteal bolus of GnRH agonist (GnRHa) improves the implantation rate (IR) in in vitro fertilization (IVF) cycles.

DESIGN

A randomized controlled trial.

SETTING

Private IVF center.

PATIENTS

328 IVF/intracytoplasmic sperm injection patients were triggered with GnRHa and received 1,500 IU HCG on the day of oocyte pick-up (OPU) in addition to a standard luteal phase support (LPS).

INTERVENTIONS

In addition, the study group received a bolus of GnRHa 6 days after OPU, whereas the control group did not.

MAIN OUTCOME MEASURE

Implantation rate.

SECONDARY OUTCOME MEASURES

Ongoing pregnancy (OP) and live birth (LB) rates.

RESULTS

Although serum concentrations of FSH, LH, E2, and P on day OPU + 7 were significantly higher in the study group compared to the control group, the IR was not statistically different between the treatment group (27%) and the control group (23%) [odds ratio (OR) 1.2 (95% CI 0.9-1.7), P < 0.27]. Similarly, the OP rate was 37% in the treatment group and 31% in the control group [OR 1.3 (95% CI 0.8-2.0), P < 0.23]. The LB rate was 36% in the treatment group and 31% in the control group [OR: 1.3 (95% CI 0.8-2.0), P < 0.27].

CONCLUSION

Although a trend toward a higher IR and pregnancy rate was observed in the treatment group, this difference was not statistically significant. However, the absolute risk difference of 5% found for LB is clinically relevant, warranting further investigation.

NCT

02053779.

GnRH Agonist Trigger and LH Activity Luteal Phase Support versus hCG Trigger and Conventional Luteal Phase Support in Fresh Embryo Transfer IVF/ICSI Cycles-A Systematic PRISMA Review and Meta-analysis

INTRODUCTION

The use of GnRH agonist (GnRHa) for final oocyte maturation trigger in oocyte donation and elective frozen embryo transfer cycles is well established due to lower ovarian hyperstimulation syndrome (OHSS) rates as compared to hCG trigger. A recent Cochrane meta-analysis concluded that GnRHa trigger was associated with reduced live birth rates (LBRs) in fresh autologous IVF cycles compared to hCG trigger. However, the evidence is not unequivocal, and recent trials have found encouraging reproductive outcomes among couples undergoing GnRHa trigger and individualized luteal LH activity support. Thus, the aim was to compare GnRHa trigger followed by luteal LH activity support with hCG trigger in IVF patients undergoing fresh embryo transfer.

MATERIAL AND METHODS

We conducted a systematic review and meta-analysis of randomized trials published until December 14, 2016. The population was infertile patients submitted to IVF/ICSI cycles with GnRH antagonist cotreatment who underwent fresh embryo transfer. The intervention was GnRHa trigger followed by LH activity luteal phase support (LPS). The comparator was hCG trigger followed by a standard LPS. The critical outcome measures were LBR and OHSS rate. The secondary outcome measures were number of oocytes retrieved, clinical and ongoing pregnancy rates, and miscarriage rates.

RESULTS

A total of five studies met the selection criteria comprising a total of 859 patients. The LBR was not significantly different between the GnRHa and hCG trigger groups (OR 0.84, 95% CI 0.62, 1.14). OHSS was reported in a total of 4/413 cases in the GnRHa group compared to 7/413 in the hCG group (OR 0.48, 95% CI 0.15, 1.60). We observed a slight, but non-significant increase in miscarriage rate in the GnRHa triggered group compared to the hCG group (OR 1.85; 95% CI 0.97, 3.54).

CONCLUSION

GnRHa trigger with LH activity LPS resulted in comparable LBRs compared to hCG trigger. The most recent trials reported LBRs close to unity indicating that individualization of the LH activity LPS improved the luteal phase deficiency reported in the first GnRHa trigger studies. However, LPS optimization is needed to further limit OHSS in the subgroup of normoresponder patients (<14 follicles ≥ 11 mm).

PROSPERO REGISTRATION NUMBER

CRD42016051091.

Combined ovulation triggering with GnRH agonist and hCG in IVF patients

The aim of the review is to analyse the combination of a gonadotrophin releasing hormone (GnRH) agonist with a human chorionic gonadotrophin (hCG) trigger, for final oocyte maturation in in vitro fertilisation (IVF) cycles. The concept being a ''dual trigger'' combines a single dose of the GnRH agonist with a reduced or standard dosage of hCG at the time of triggering. The use of a GnRH agonist with a reduced dose of hCG in high responders demonstrated luteal phase support with improved pregnancy rates, similar to those after conventional hCG and a low risk of ovarian hyperstimulation syndrome (OHSS). The administration of a GnRH agonist and a standard hCG in normal responders, demonstrated significantly improved live-birth rates and a higher number of embryos of excellent quality, or cryopreserved embryos. The concept of the ''double trigger" represents a combination of a GnRH agonist and a standard hCG, when used 40 and 34 h prior to ovum pick-up, respectively. The use of the ''double trigger" has been successfully offered in the treatment of empty follicle syndrome and in patients with a history of immature oocytes retrieved or with low/poor oocytes yield. Further prospective studies are required to confirm the aforementioned observations prior to clinical implementation.

Micro-dose hCG as luteal phase support without exogenous progesterone administration: mathematical modelling of the hCG concentration in circulation and initial clinical experience

For the last two decades, exogenous progesterone administration has been used as luteal phase support (LPS) in connection with controlled ovarian stimulation combined with use of the human chorionic gonadotropin (hCG) trigger for the final maturation of follicles. The introduction of the GnRHa trigger to induce ovulation showed that exogenous progesterone administration without hCG supplementation was insufficient to obtain satisfactory pregnancy rates. This has prompted development of alternative strategies for LPS. Augmenting the local endogenous production of progesterone by the multiple corpora lutea has been one focus with emphasis on one hand to avoid development of ovarian hyper-stimulation syndrome and, on the other hand, to provide adequate levels of progesterone to sustain implantation. The present study evaluates the use of micro-dose hCG for LPS support and examines the potential advances and disadvantages. Based on the pharmacokinetic characteristics of hCG, the mathematical modelling of the concentration profiles of hCG during the luteal phase has been evaluated in connection with several different approaches for hCG administration as LPS. It is suggested that the currently employed LPS provided in connection with the GnRHa trigger (i.e. 1.500 IU) is too strong, and that daily micro-dose hCG administration is likely to provide an optimised LPS with the current available drugs. Initial clinical results with the micro-dose hCG approach are presented.

GnRH agonist with low-dose hCG (dual trigger) is associated with higher risk of severe ovarian hyperstimulation syndrome compared to GnRH agonist alone

PURPOSE

The purpose of this study was to compare rates of ovarian hyperstimulation syndrome (OHSS) after using gonadotropin-releasing hormone agonists (GnRHa) alone and GnRHa in combination with low-dose human chorionic gonadotropin (hCG, dual trigger) for final oocyte maturation in women undergoing controlled ovarian hyperstimulation (COH).

METHODS

A retrospective cohort study was conducted at an academic center. Study population included 108 women who received GnRHa trigger and 66 women who received dual trigger (GnRHa + low-dose [1000 IU] hCG trigger). The main outcome measure was OHSS. Secondary outcomes included total oocyte yield and oocyte maturity.

RESULTS

The incidence of early OHSS was significantly higher after dual trigger than GnRHa trigger (8.6 vs 0 %). Moreover, four of the six patients that developed OHSS developed severe OHSS. Logistic modeling revealed that the combination of age, BMI, baseline AFC, and E2 >4000 pg/mL was predictive of OHSS with an area under the receiver operating characteristic curve of 0.84 and was superior to each factor alone. Adjusted analyses revealed that dual trigger was associated with a higher number of total oocytes (adjusted OR 1.27; 95 % confidence interval, 1.18, 1.38) and percentage of mature oocytes (AOR 1.10; 95 % confidence interval, 1.03, 1.17) obtained compared to GnRHa trigger alone.

CONCLUSIONS

Dual trigger for final oocyte maturation using GnRHa and low-dose hCG is associated with a significantly increased risk of severe OHSS compared to GnRH alone. However, dual trigger may be associated with a modest increase in oocyte yield, both in terms of number and maturity.

Is It Possible to Prevent Ovarian Hyperstimulation Syndrome by Gonadotropin-Releasing Hormone Agonist Triggering and Modified Luteal Support in Patients With Polycystic Ovarian Morphology?

BACKGROUND

Gonadotropin-releasing hormone (GnRH) agonist triggering plus 1,500 IU human chorionic gonadotropin (hCG) supplementation protocol was previously claimed effective in reducing the ovarian hyperstimulation syndrome (OHSS) incidence in high responders.

METHODS

This retrospective study included women with polycystic ovarian (PCO) morphology who were at high risk of OHSS and were given the GnRH agonist trigger plus hCG luteal support protocol in a single center.

RESULTS

The mean peak estradiol level was 5,336 ± 2,341 (1,187 - 19,746) pg/mL. The mean number of follicles > 12 mm on the day of trigger was 22 ± 7 (9 - 51). A total of 88 cycles were undertaken. Sixty-three (71.5%) women underwent fresh embryo transfer. Fresh embryo transfer was canceled in 21 (23.8%) and embryo transfer was canceled in four (4.5%) women. The overall clinical pregnancy rate was 46.4% per started cycle. A total of 12 (13.6%) patients developed OHSS. "Freeze-all" policy did not attenuate OHSS in four patients, and three of these patients developed OHSS despite 1,500 IU hCG was not administered.

CONCLUSION

We conclude that OHSS may still occur with the use of a GnRH agonist trigger combined with low-dose hCG supplementation protocol in women with polycystic ovary syndrome (PCOS) or PCO morphology. Furthermore, we also conclude that "freeze-all" policy also will not completely eliminate OHSS development in high-risk women.

Early Short Stimulation Modified Natural Cycle IVF With GnRH Agonist Trigger and In Vitro Maturation in a Woman with Polycystic Ovary Syndrome: A Case Report

BACKGROUND

Gonadotropin-releasing hormone agonist (GnRHa) triggering of final oocyte maturation has been used successfully in GnRH antagonist IVF cycles. It has not been used to date in cycles in which immature oocytes are matured in vitro.

CASE

We report here for the first time that GnRHa triggering in a variation on the modified natural IVF cycle can be used as a strategy in the treatment of infertility secondary to polycystic ovary syndrome. In this approach, follicles were stimulated with gonadotropins for three to five days when they were small, and triggering of ovulation occurred when the largest follicles were 10 to 12 mm in diameter. This was followed by retrieval of many immature oocytes that were matured in vitro and subsequently developed to form blastocysts that resulted in a live birth.

CONCLUSION

This is the first human evidence that GnRHa triggering of ovulation can be used successfully when the aim is in vitro maturation of oocytes.

Segmented ART - The new era in ART?

Currently up to 4% of infants born in developing countries are conceived through assisted reproductive technology (ART). Even though most of these conceptions occur and progress without complications, ART procedures and processes may increase iatrogenesis through complications in - and after conception. We herein review and discuss the clinically and scientific implications and evidence of iatrogenesis, and show how the evolution in ART technologies and procedures has led to the current presumption that frozen embryo transfer might be a more optimal strategy than fresh embryo transfer, in terms of not only reproduction, but also of maternal and fetal outcomes. There is increasing scientific evidence to support the notion that controlled ovarian stimulation could induce significant changes to the endocrine profile of a reproductive cycle, especially to the reproductively important early luteal phase. These changes may not only have a negative effect on implantation and early placentation, but also on the mother, the fetus, and the infant. The overt consequences of controlled ovarian stimulation include ovarian hyperstimulation syndrome, reduced embryo implantation, increased ectopic pregnancy, and altered placentation and fetal growth. The cumulative scientific evidence from this review suggests that GnRHa trigger in segmented ART might constitute the future routine treatment regimen for IVF patients, providing a safe, effective, and patient friendly treatment.

Regimen of ovarian stimulation affects oocyte and therefore embryo quality

Without any doubt the regimen used to mature multiple capable oocytes for IVF impacts IVF outcomes. Studies have indicated that the inclusion of LH activity, adjuvant agents such as growth hormone (GH), and regimens providing for simultaneous action of both LH and FSH during final oocyte maturation may have beneficial effects on IVF outcomes. Because of the difficulty in improving IVF outcomes in poor responders, the studies on GH are of particular interest. As pointed out in this review, the apparent beneficial effects of GH on oocyte competence may also apply to older women or to normal responders with reduced embryo quality. A much more difficult question is whether and how much ovarian stimulation impacts on oocyte competence. Paradoxically it seems that there are not demonstrated differences between the stimulated and the natural unstimulated cycle, whereas studies in laboratory animals and IVF patients have shown deleterious effects of higher compared with lower doses of gonadotropins. Recent studies suggest that the use of high doses of gonadotropins as an independent factor correlates negatively with the probability of live birth, whereas a high ovarian response per se is associated with better cumulative pregnancy rates, owing to the availability of more euploid and good-quality embryos. Although adjunctive use of androgens has not been discussed here, it is briefly covered in the first review of this series.

Ovarian hyperstimulation syndrome in the 21st century: the role of gonadotropin-releasing hormone agonist trigger and kisspeptin

PURPOSE OF REVIEW

Ovarian hyperstimulation syndrome (OHSS) complicates a considerable part of stimulated in-vitro fertilization (IVF) cycles and is a potential iatrogenic cause of death in otherwise healthy women undergoing fertility treatment. The triggering factor of OHSS is the widespread use of human chorionic gonadotropin (hCG) to induce final oocyte maturation. The aim of this review is to summarize different approaches available, using alternative triggering protocols such as gonadotropin-releasing hormone agonist (GnRHa) or kisspeptin for final oocyte maturation.

RECENT FINDINGS

According to the latest European Society of Human Reproduction and Embryology report, the incidence of OHSS ranges from 0.18 to 1.40% in European countries. However, OHSS is still subject to substantial underreporting. New triggering protocols using GnRHa have shown to be similar to the gold standard hCG-trigger with regard to the reproductive outcome, but with a significant decrease in - and almost elimination of - OHSS. Lately, promising results have been reported for the use of kisspeptin to induce final oocyte maturation. Although until now no study has been performed in an OHSS risk population, theoretically, the risk of OHSS development might be even further reduced after kisspeptin trigger.

SUMMARY

GnRHa trigger is currently the best tool we have to prevent OHSS and at the same time maintain good reproductive outcomes. Future research will explore the safety and efficacy of kisspeptin trigger.

GnRH agonist trigger for the induction of oocyte maturation in GnRH antagonist IVF cycles: a SWOT analysis

Gonadotrophin releasing hormone agonist (GnRHa) trigger is effective in the induction of oocyte maturation and prevention of ovarian hyperstimulation syndrome during IVF treatment. This trigger concept, however, results in early corpora lutea demise and consequently luteal phase dysfunction and impaired endometrial receptivity. The aim of this strenghths, weaknesses, opportunities and threats analysis was to summarize the progress made over the past 15 years to optimize ongoing pregnancy rates after GnRHa trigger. The advantages and potential drawbacks of this type of triggering are reviewed. The current approach to the management of GnRHa trigger in autologous cycles is based on the peak serum oestradiol level or follicle number and aims at a fresh embryo transfer or a segmentation approach with elective cryopreservation policy. We recommend intensive luteal support with transdermal oestradiol and intramuscular progesterone alone if peak serum oestradiol is 4000 or more pg/ml after GnRHa trigger or dual trigger with GnRHa and HCG 1000 IU if peak serum oestradiol is less than 4000 pg/mL. On the contrary, we recommend HCG 1500 IU 35 h after GnRHa trigger if there are less than 25 follicles, or freeze all oocytes or embryos if there are over 25 follicles.