Is Ganirelix acetate appropriate with low responder in vitro fertilization (IVF) patients?

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Objective: Previous strategies for improving outcome with the low responder population include, increasing daily ampules of gonadotropins, decreasing dosage of gonadotropin-releasing hormone (GnRH) agonist. In the study we have assessed pregnancy outcome of the low responder patient using ganirelix acetate (Antagon; Organon, Inc., West Orange, NJ). Design: Retrospective analysis of year 2000 data. Materials/Methods: Gonadotropin stimulation was started on day 2 or 3 of cycle, with a daily administration of gonadotropins (∼6 ampules/day). Ganirelix acetate was routinely started on day 6 of stimulation or when lead follicles reached 12 mm. HCG was administered when 2 lead follicles measuring at least 18 mm were noted. The following criteria was used to classify a low responder: ≥40 years of age, or peak estradiol (E2) at hCG injection of <1000 pg/ml, or mildly diminished ovarian reserve, or ≤4 dominant follicles at time of hCG injection. Embryology and embryo transfer procedures were followed per clinic routine. Results: 39 cycles qualified for the study. Patient’s mean age was 39 ± 4.7 years. Etiology of infertility at time of cycle initiation was as follows: 17—diminished ovarian reserve, 7—ovarian dysfunction, 4—endometriosis (various stages), 4—tubal disease, 4—other, and 3—unexplained infertility. Mean number of ampules per cycle was 59 ± 13.5. The average peak E2 at hCG was 1383 ± 855.5 pg/ml. The average day for hCG administration was 10 ± 1.3 days. The mean number of mature oocyctes retrieved was 6 ± 5.6. Five cycles were cancelled before retrieval due to poor response to stimulation and 4 had no embryos to transfer. The number of patients who had assisted zona hatching (AZH) was 23/30 (76.6%). A total of 81 embryos transferred. 8 sacs were identified by trans vaginal ultrasound (9.9% implantation rate). The mean number of embryos transferred was 2.7± per transfer. There were 6 clinical pregnancies out of 30 patients who had embryo transfer (pregnancy rate 20%). Of the pregnancies, four were singleton, and two were twin. One of the twin pregnancies ended with a spontaneous abortion. A dilatation and curettage was performed and trisomy 20 was documented on pathology. The ongoing pregnancy rate was 16.7%. Only one patient had embryos cryopreserved. The frozen embryos transfer of two embryos did not result into a pregnancy. Conclusions: The results indicate a pregnancy rate consistent with other currently used low responder protocols at our clinic (stop Lupron, no Lupron, and micro-dose Lupron). A prospective and randomized study comparing these protocol seems indicated.