Ganirelix acetate causes a rapid reduction in estradiol levels without adversely affecting oocyte maturation in women pretreated with leuprolide acetate who are at risk of ovarian hyperstimulation syndrome*

Discovery of a Lead Brain-Penetrating Gonadotropin-Releasing Hormone Receptor Antagonist with Saturable Binding in Brain

We report the synthesis, radiosynthesis and biological characterisation of two gonadotropin-releasing hormone receptor (GnRH-R) antagonists with nanomolar binding affinity. A small library of GnRH-R antagonists was synthesised in 20-67 % overall yield with the aim of identifying a high-affinity antagonist capable of crossing the blood-brain barrier. Binding affinity to rat GnRH-R was determined by autoradiography in competitive-binding studies against [125 I]buserelin, and inhibition constants were calculated by using the Cheng-Prusoff equation. The radioligands were obtained in 46-79 % radiochemical yield and >95 % purity and with a molar activity of 19-38 MBq/nmol by direct nucleophilic radiofluorination. Positron emission tomography imaging in rat under baseline conditions in comparison to pretreatment with a receptor-saturating dose of GnRH antagonist revealed saturable uptake (0.1 %ID/mL) into the brain.

What is the impact of short- and long-term supplementation of either cabergoline or clarithromycin on resolving rat ovarian hyperstimulation syndrome (OHSS) model?

This study aimed to evaluate the effects of coasting, cabergoline and clarithromycin in a rat ovarian hyperstimulation syndrome (OHSS) model. The 42 female Wistar rats were divided into seven groups: control, OHSS (was given 10 IU of pregnant mare serum gonadotropin for 4 consecutive days from day 22 and 30 IU hCG on the fifth day to induce OHSS ), coasting (hCG was applied on the 27th day after gonadotropin injections and the rats were decapitated on the 28th day), Cabergoline (100 mg/kg/d) and clarithromycin (100 mg/kg/d) were given (on the 26th day) with a short-term supplementation (on the 26th day) and long-term supplementation (from the 22nd to the 26th day) groups. The rats were decapitated on the 27th day. Cabergoline and clarithromycin significantly lowered VEGF-2 levels. Clarithromycin significantly reduced IL-1b and TNF-a and significantly increased IL-10 levels. Clarithromycin may be an effective drug for the treatment of OHSS. Impact statement What is already known on this subject? Ovarian hyper-stimulation syndrome (OHSS) is a self-limited disease, in which vascular endothelial growth factor (VEGF) plays the most important role and has a large clinical spectrum related with increased capillary permeability and fluid retention. Some treatment methods that block VEGF over-expression are used in treatment of OHSS. Clarithromycin is known to suppress the production of some pro-inflammatory molecules such as VEGF, IL-8, IL-1, IL-6 and TNF-a. In our study, we compared the efficacy of coasting, short- and long-term supplementation of clarithromycin and cabergoline on correcting OHSS parameters in an experimental study. What do the results of this study add? As a result of our study, we found that OHSS parameters improved better in early prophylactic treatment regimens. We have shown that clarithromycin may be a more effective treatment agent than coasting and cabergoline. What are the implications of these findings for clinical practice and/or further research? Although our study is important in that it is the first pilot study to show that clarithromycin is effective in the treatment of OHSS, there is a need for larger clinical trials.

Laparoscopic ovarian drilling versus GnRH antagonist combined with cabergoline as a prophylaxis against the re-development of ovarian hyperstimulation syndrome

OBJECTIVE

The aim of this work was to investigate the value of laparoscopic ovarian drilling (LOD) compared with GnRH antagonist flexible protocol combined with cabergoline (Cb), as a prophylaxis against the re-development of ovarian hyperstimulation syndrome (OHSS) in women with clomiphene citrate-resistant polycystic ovary disease (CCR-PCOD) who had severe OHSS before in a previous ICSI cycle.

STUDY DESIGN

It is a prospective controlled study, where 250 CCR-PCOD women (n = 250) with a history of severe OHSS before, had been recruited for the study. LOD had been performed for 120 (n = 120) of the recruited women before ovarian induction, and considered as group A. GnRH antagonist (Cetrotide 0.25 mg) was added when a leading follicle reaches 14-16 mm combined with oral Cb in a dose 0.5 mg a day before hCG, and for 8 d for another 130 (n = 130) women, and considered as group B. Pregnancy was diagnosed with BhCG level ≥25 IU/L, ± 14 d after embryo transfer, followed with transvaginal ultrasound scanning (TVS) 2 weeks later to confirm intra-uterine pregnancy (IUP). Women were followed up weekly for 3 months for the possible development of any signs and symptoms of OHSS.

RESULTS

None of the participants in group A developed severe OHSS, and only six women (5%) developed mild to moderate OHSS. The incidence of severe OHSS was significantly higher (n = 3, 15%) in group B compared with group A (p < .001). Another (n = 17, 13.3%) women in group B developed mild to moderate OHSS. The probability of developing severe OHSS was also significantly higher in group B as well (p = .031). Pregnancy rate (PR) was significantly higher in group A more than group B (67% versus 39%, respectively), and all were single intrauterine pregnancies (IUP) and all developed after fresh embryo transfer (ET), compared with frozen embryo transfer (FET) which was performed in 42 cases in group B after postponing ET due to significantly severe OHSS developed.

CONCLUSION

LOD could be considered a good prophylactic measure against OHSS, in addition to improving the total outcome of IVF cycles in women with CCR-PCOS.

Small molecule piperazinyl-benzimidazole antagonists of the gonadotropin-releasing hormone (GnRH) receptor

In this communication, we report the synthesis and characterization of a library of small molecule antagonists of the human gonadotropin releasing hormone receptor based upon the 2-(4-tert-butylphenyl)-4-piperazinyl-benzimidazole scaffold via Cu-catalysed azide alkyne cycloaddition. Our main purpose was to find a more soluble compound based on the WAY207024 lead with nanomolar potency to inhibit the GnRH receptor. A late stage diversification by the use of click chemistry was, furthermore developed to allow for expansion of the library in future optimisations. All compounds were tested in a functional assay to determine the individual potency of inhibiting stimulation of the receptor by the endogenous agonist GnRH. In conclusion, we found that compound 8a showed improved solubility compared to WAY207024 and nanomolar affinity to GnRH receptor.

GnRH antagonist administered twice the day before hCG trigger combined with a step-down protocol may prevent OHSS in IVF/ICSI antagonist cycles at risk for OHSS without affecting the reproductive outcomes: a prospective randomized control trial

PURPOSE

The purpose this study is to investigate whether a double antagonist dose (0.25 mg/12 h) administered the day before hCG trigger is effective in preventing ovarian hyperstimulation syndrome (OHSS) in GnRH antagonist IVF/intracytoplasmic sperm injection (ICSI) cycles at risk for OHSS.

METHODS

This is a prospective randomized control study, conducted from November 2012 to January 2016. A total of 194 patients undergoing a IVF/ICSI GnRH antagonist cycle that were at risk of OHSS and chose to proceed with embryo transfer and avoid cycle cancellation or embryo cryopreservation were allocated into two groups. The inclusion criteria consisted of a rapid rise of oestradiol ≥ 3500 pg/ml combined with ≥ 18 follicles > 11 mm in diameter without any mature follicle > 16 mm, in any day of stimulation. Overall, 97 patients (intervention group A) received a double dose of GnRH antagonist (0.25 mg/12 h) the day before hCG while 97 patients (control group B) did not. Recombinant FSH administration was tapered to 100 IU/24 h the day of the allocation in both groups.

RESULTS

Incidence of early-onset moderate/severe OHSS was significantly lower in intervention group A compared to control group B (0 vs 12.37%, P < 0.001). Clinical pregnancy rate per cycle (50.52 vs 42.27%, P = 0.249) was not significantly different between the two groups. Oestradiol (3263.471 ± 1271.53 vs 5233 ± 1425.17, P < 0.001), progesterone (0.93 ± 0.12 vs 1.29 ± 0.14, P < 0.001) and luteinizing hormone (1.42 ± 0.31 vs 1.91 ± 0.33, P < 0.001) were significantly lower in group A the day of the hCG triggering.

CONCLUSION

The administration of a rescue double GnRH antagonist dose the day before hCG trigger may represent a safe alternative preventive strategy for early OHSS without affecting the reproductive outcomes.

TRIAL REGISTRATION NUMBER

ISRCTN02750360.

Is Coasting Valuable in All Patients with Any Cause of Infertility?

OBJECTIVES

This study aimed to assess the influence of coasting duration on the number and quality of oocytes and fertilization rate in male factor infertile women and those with polycystic ovary syndrome (PCOS).

METHODS

In this prospective observational follow-up study, 114 patients undergoing coasting (53 women with male factor infertility and 61 women with PCOS) were evaluated at the Royan Institute Research Center, Iran, between 2010 and 2012.

RESULTS

The results were analyzed according to the coasting periods of 1-4 days. In normal females, the number of oocytes retrieved was significantly reduced after the second day (p = 0.004). In addition, a statistically significant drop was observed in the number of metaphase II oocytes and fertilization rate after the third day (p = 0.006 and p = 0.006, respectively). No significant differences were observed in the number and quality of oocytes retrieved and fertilization rate with regard to coasting days in PCOS patients.

CONCLUSION

Coasting with duration of more than three days should be performed with caution in normal females who are at risk of developing ovarian hyperstimulation syndrome.

GnRH antagonist rescue protocol combined with cabergoline versus cabergoline alone in the prevention of ovarian hyperstimulation syndrome: a randomized controlled trial

Background

The aim of this study was to compare the efficacy of antagonist rescue protocol (replacing GnRH agonist with GnRH antagonist and reducing the dose of gonadotropins) combined with cabergoline versus cabergoline alone in the prevention of ovarian hyperstimulation syndrome (OHSS) in patients pretreated with GnRH agonist long protocol who were at high risk for OHSS.

Methods

Two hundred and thirty six patients were randomized in a 1:1 ratio to the cabergoline group or the antagonist rescue combined with cabergoline group. Both groups received oral cabergoline (0.5 mg/day) for eight days beginning on the day of HCG administration. In the antagonist rescue combined with cabergoline group, when the leading follicle reached 16 mm, GnRH agonist (triptorelin) was replaced with GnRH antagonist (cetrorelix acetate) and the dose of HP-uFSH was reduced to 75 IU/day. HCG (5,000 IU/I.M) was administered when the serum estradiol level dropped below 3500 pg/ml. The study was open label and the outcome assessors (laboratory staff and the doctor who performed oocyte retrieval) were blind to treatment allocation.

Results

The incidence of moderate/severe OHSS was significantly lower in the antagonist rescue combined with cabergoline group [5.08 % Vs 13.56 %, P value =0.025, OR = 0.342, 95 % CI, 0.129–0.906]. Four cycles were cancelled in the cabergoline group. There were no significant differences between the groups with respect to the number of retrieved oocytes, metaphase II oocytes, high quality embryos and fertilization rate. Moreover, the implantation and pregnancy rates were comparable between both groups.

Conclusion

GnRH antagonist rescue protocol combined with cabergoline is more effective than cabergoline alone in the prevention of OHSS.

Trial registration

Clinical trial.gov (NCT02461875).

Serum Oestradiol Pattern during Coasting is Different in Antagonist Cycles Compared with Long Agonist Cycles in In Vitro Fertilisation

BACKGROUND

GnRH agonists and antagonists have different mechanism of action, and therefore serum estradiol levels might differ during coasting in IVF.

AIMS

To compare the change in serum oestradiol levels after withholding the gonadotropins for coasting between long agonist and antagonist cycles.

STUDY DESIGN

Retrospective study.

METHODS

Antagonist and long agonist cycles, in which coasting was performed, were analysed in this retrospective analysis. Antagonist cycles (n=50) were compared with long agonist cycles (n=52) with respect to daily serum oestradiol levels following withholding of gonadotropins.

RESULTS

The pattern of change in serum oestradiol was different between groups; it increased on the first day by 11.2% and decreased thereafter on the second and third days in the agonist group. However, it began to decrease from the first day in the antagonist group. Therefore, peak serum oestradiol levels were significantly higher in the agonist group than in the antagonist group (mean±standard deviation; 5798±1748 vs 5104±1351 pg/mL). The duration of coasting was shorter in the antagonist group compared with that in the agonist group (mean±standard deviation; 2.60±1.40 vs 1.96±0.88 days).

CONCLUSION

Serum oestradiol pattern during coasting is different in antagonist cycles compared with long agonist cycles in in vitro fertilisation.

Antagonist rescue of agonist IVF cycle at risk of OHSS: a case series

We describe a series of in vitro fertilisation (IVF) long protocol cycles presenting a risk of ovarian hyperstimulation syndrome (OHSS) which were rescued with an antagonist at a university-based tertiary-care fertility centre. Nineteen IVF patients presenting a risk of OHSS during treatment with long protocol, between 2009 and November 2012 were included in the present study. After discussion of available options, the agonist was stopped and a daily gonadotropin-releasing hormone (GnRH) antagonist injection was initiated ("rescue protocol") and maintained until ovulation trigger. Fourteen patients were triggered with human chorionic gonadotropin (hCG) and five with GnRH agonist bolus, yielding competent oocytes. Seventeen embryo transfers were performed in the fresh cycles. One patient developed moderate OHSS. There were eight clinical pregnancies after the fresh IVF cycle (42% per patient), and six further pregnancies after frozen-thawed cycles, resulting in a 73% cumulative clinical pregnancy rate within one year. We conclude that the "rescue protocol with antagonist" of the long IVF cycle with a high risk of OHSS allows us to carry on with the cycle, without compromising its success or the patient safety, thus broadening the possibility of applying the long protocol.

Optimal usage of the GnRH antagonists: a review of the literature

Gonadotropin-releasing hormone (GnRH) antagonists, which became commercially available from 1999, have been used for the prevention of premature luteinizing hormone (LH) surges in controlled ovarian stimulation for in vitro fertilization or intracytoplasmic sperm injection. This review focuses on the recent literature on the use of GnRH antagonists and provides guidelines for optimal use in light of increasing evidence showing that GnRH antagonists are safe and effective, allowing flexibility of treatment in a wide range of patient populations. This includes patients undergoing first-line controlled ovarian stimulation, poor responders, and women diagnosed with polycystic ovary syndrome. The GnRH antagonist offers a viable alternative to the long agonists, providing a shorter duration of treatment with fewer injections and with no adverse effects on assisted reproductive technology outcome. This results in a significantly lower amount of gonadotropins required, which is likely to lead to improved patient compliance.

GnRH antagonist rescue in high responders at risk for OHSS results in excellent assisted reproduction outcomes

Gonadotrophin-releasing hormone (GnRH) antagonist rescue is performed by replacing a GnRH agonist with a GnRH antagonist in patients with rapidly rising serum oestradiol who are at risk of ovarian hyperstimulation syndrome (OHSS) during stimulation. It results in a rapid reduction in serum oestradiol, allowing for the avoidance of cycle cancellation and the continuation of exogenous gonadotrophin administration. A total of 387 patients who underwent GnRH antagonist rescue for ovarian hyperresponse were compared with 271 patients who did not receive GnRH antagonist rescue and had oestradiol concentrations >4000 pg/ml on the day of human chorionic gonadotrophin (HCG) administration. GnRH antagonist rescue decreased the mean oestradiol concentration by 35% on the first day of use. There was no difference in oocyte maturity (82% versus 83%) or fertilization rate (69% versus 67%) between the antagonist rescue and comparison groups, respectively. The percentage of high-grade embryos on day 3 and the blastocyst development rate were also similar between groups. The live-birth rate was 41.9% in the antagonist rescue group and 36.9% in the comparison group. GnRH antagonist rescue enabled cycle completion with high live-birth rates in patients at risk for OHSS. GnRH antagonist was associated with high oocyte quality, blastocyst development and pregnancy. Gonadotrophin-releasing hormone (GnRH) antagonist rescue is a protocol to reduce the risk of ovarian hyperstimulation syndrome (OHSS) in assisted reproduction treatment. Patients who have a hyperresponse to medication during their treatment cycle have their GnRH agonist discontinued and a GnRH antagonist started in its place. This causes a rapid reduction in oestrogen concentrations and allows for the continuation of stimulation medication. We evaluated the effectiveness of this protocol by comparing patients who had GnRH antagonist rescue against high-responding patients who did not receive GnRH antagonist rescue. GnRH antagonist rescue resulted in a 35% reduction in oestrogen concentration and only a 1.5% cycle cancellation rate. There were no differences in oocyte maturity or fertilization between the two groups. There were no differences in the quality of day-3 and day-5 embryos between the two groups. The live birth rate was 41.9% in the antagonist rescue group and 36.9% in the comparison group. GnRH antagonist rescue reduced serum oestradiol concentrations and enabled cycle completion with high live-birth rates in patients at risk for OHSS. GnRH antagonist was associated with high oocyte quality, blastocyst development and pregnancy.

Gonadotropin releasing hormone antagonists suppress aromatase and anti-Müllerian hormone expression in human granulosa cells

OBJECTIVE

To investigate the effects of a gonadotropin-releasing hormone antagonist (GnRH-ANT) on the expression of anti-Müllerian Hormone (AMH) and aromatase (via the exon CYP19IIa promoter), in cultured human granulosa cells (hGCs) and the human granulosa cell line (HGL5).

DESIGN

Primary cell cultures of hGCs and culture of HGL5 cells.

SETTING

Academic center.

PATIENT(S)

Women undergoing IVF because of male factor, tubal infertility, or donor eggs.

INTERVENTION(S)

hGCs and HGL5 cells were treated with a GnRH-ANT (1 nM and 1 μM) alone or in combination with cAMP (1 mM). Media was collected and stored at -80°C until assayed.

MAIN OUTCOME MEASURE(S)

mRNA levels of CYP19 IIa, AMH, steroidogenic factor 1 (SF-1) and liver receptor homologue-1 (LRH-1) were determined by quantitative polymerase chain reaction. ELISA was used to determined estradiol (E(2)) levels in the culture media. Pooled results from triplicate experiments were analyzed using one-way analysis of variance with Student-Newman-Keuls multiple-comparison methods.

RESULT(S)

The GnRH-ANT decreased the expressions of CYP19 IIa, AMH, SF-1, and LRH-1. cAMP induced aromatase and AMH expression. Cotreatment with cAMP and GnRH-ANT caused a dose-dependent suppression of AMH and CYP19 IIa mRNA. A GnRH agonist (GnRH-A) increased the mRNA expressions of CYP 19 IIa and AMH. The GnRH-ANT decreased E(2) production in cultured hGCs.

CONCLUSION(S)

GnRH-ANTs, in addition to their central suppressive effects on the pituitary, may have a direct effect on ovarian granulosa cells with inhibition of aromatase and AMH expression. Furthermore, the inhibitory effect could be mediated via suppression of SF-1 and LRH-1, and may play a role in estrogen-mediated ovarian folliculogenesis.

Short coasting of 1 or 2 days by withholding both gonadotropins and gonadotropin-releasing hormone agonist prevents ovarian hyperstimulation syndrome without compromising the outcome

OBJECTIVE

To evaluate the effect of short coasting, by withdrawing both gonadotropins and gonadotropin-releasing hormone (GnRH) agonist, on the prevention of severe ovarian hyperstimulation syndrome (OHSS) without compromising pregnancy outcome.

DESIGN

Retrospective study.

SETTING

Large urban medical center.

PATIENT(S)

Forty-four women who had been coasted during controlled ovarian hyperstimulation (COH) for in vitro fertilization (IVF).

INTERVENTION(S)

When >or=20 follicles >15 mm with serum estradiol (E(2)) level of 4000 pg/mL were detected, both gonadotropins and GnRH agonist were withheld for 1 to 2 days.

MAIN OUTCOME MEASURE(S)

Changes of serum E(2) levels, number of oocytes retrieved, pregnancy rate.

RESULT(S)

The mean serum E(2) level fell from 7915 pg/mL at the onset of coasting to 3908 pg/mL on the day of human chorionic gonadotropin (hCG) administration. The mean number of oocytes retrieved and fertilization rate were 17.2% and 75.0%, respectively. Eighteen patients became pregnant (43.9%), and the implantation rate was 12.7%. Twenty-eight patients were coasted for 1 day, and 13 were coasted for 2 days. The mean decrease rate of serum E(2) level was 45.3% in 1-day coasting and 26.4% (first day) and 75.3% (second day) in 2-day coasting. The pregnancy outcome was similar between both groups. After coasting, three mild and two severe cases of OHSS occurred.

CONCLUSION(S)

Coasting for 1 or 2 days can be used successfully to prevent OHSS without compromising IVF cycle outcome.

Serum cetrorelix concentrations do not affect clinical pregnancy outcome in assisted reproduction

OBJECTIVE

To analyze the potential association between serum cetrorelix levels and clinical pregnancy outcome in patients who had undergone assisted reproduction cycles with a GnRH antagonist cetrorelix acetate 3-mg injection.

DESIGN

Retrospective case-control study.

SETTING

University-affiliated private-assisted reproduction center.

PATIENT(S)

130 IVF and intracytoplasmic sperm injection first cycles, treated with the same cetrorelix acetate protocol, in two matched groups according to whether the cycle resulted in clinical pregnancy (n = 56) or not (n = 74).

INTERVENTION(S)

Cetrorelix acetate administration at 3 mg in a sandwich protocol.

MAIN OUTCOME MEASURE(S)

Serum cetrorelix concentrations on the day of hCG administration with regard to clinical pregnancy outcome, pre- versus post-hCG percent change in serum E(2) levels and implantation rates.

RESULT(S)

The cetrorelix serum concentrations were in the range of 0.29 to 5.12 ng/mL. The comparisons between groups with and without clinical pregnancy revealed comparable serum cetrorelix levels. There was no significant correlation between the serum cetrorelix concentrations and percent change in pre- versus post-hCG serum E(2) levels. Serum cetrorelix levels were comparable among patients with various implantation rates.

CONCLUSION(S)

Although a wide range of serum cetrorelix levels could be detected during a GnRH antagonist cycle, these levels were comparable in patients with and without clinical pregnancies.

A prospective randomized study comparing coasting with GnRH antagonist administration in patients at risk for severe OHSS

This work evaluated possible advantages of gonadotrophin-releasing hormone (GnRH) antagonist administration as an alternative to coasting in prevention of severe ovarian hyperstimulation syndrome (OHSS) in women undergoing IVF/ intracytoplasmic sperm injection. A prospective randomized study comparing coasting (group A) (n = 96) and GnRH antagonist administration (group B) (n = 94) in patients at risk of OHSS was performed. The primary outcome measure was high quality embryos. The secondary outcome measures were days of intervention, number of oocytes, pregnancy rate, number of cryopreserved embryos and incidence of severe OHSS. There were significantly more high quality embryos (2.87 +/- 1.2 versus 2.21 +/- 1.1; P < 0.0001), and more oocytes (16.5 +/- 7.6 versus 14.06 +/- 5.2; P = 0.02), in group B as compared with group A. There were more days of coasting as compared with days of antagonist administration (2.82 +/- 0.97 versus 1.74 +/- 0.91; P < 0.0001). In conclusion, GnRH antagonist was superior to coasting in producing significantly more high quality embryos and more oocytes as well as reducing the time until HCG administration. There was no significant difference in pregnancy rate between the two groups. No OHSS developed in either group.