Abstract
Ovarian stimulation in a gonadotropin-releasing hormone (GnRH) antagonist protocol with the use of GnRH agonist for final oocyte maturation is the state-of-the-art treatment in patients with an expected or known high response to avoid or at least reduce significantly the risk for development of ovarian hyperstimulation syndrome (OHSS). Due to a shortened LH surge after administration of GnRH agonist in most patients, the luteal phase will be characterized by luteolysis and luteal phase insufficiency. Maintaining a sufficient luteal phase is crucial for achievement of a pregnancy; however, the optimal approach is still under debate. Administration of human chorionic gonadotropin (hCG) within 72 h rescues the corpora lutea function; however, the so far often used 1,500 IU still bear the risk for development of OHSS. The recently introduced concept of “luteal coasting” individualizes the luteal phase support by monitoring the progesterone concentrations and administering a rescue dosage of hCG when progesterone concentrations drop significantly. This retrospective proof-of-concept study explored the correlation between hCG dosages ranging from 375 up to 1,500 IU and the progesterone levels in the early and mid-luteal phases as well as the likelihood of pregnancy, both early and ongoing. The chance of pregnancy is highest with progesterone level ≥13 ng/ml at 48 h postoocyte retrieval. Among the small sample size of 52 women studied, it appears that appropriate progesterone levels can be achieved with hCG dosages as low as 375 IU. This may well optimize the chance of pregnancy while reducing the risk of OHSS associated with higher doses of hCG supplementation in the luteal phase.
Highlights
Over the past few decades, increasing knowledge of ovarian physiology and the possibility to evaluate accurately the ovarian reserve has led progressively to individualization and tailoring of ovarian stimulation for in vitro fertilization (IVF)—treatment.Final oocyte maturation is the crucial step in ovarian stimulation cycles for IVF to retrieve mature oocytes for further processing in the IVF laboratory
It was assumed that all patients will develop severe luteolysis within a matter of 5 days after gonadotropin-releasing hormone (GnRH) agonist trigger [3]; recently, it was clearly demonstrated that luteolysis after GnRH agonist trigger is patient specific [4]
Information from 52 patients being treated between September 2015 and May 2017 for primary/secondary infertility and indication for ovarian stimulation for IVF/ICSI in IVI Middle East Fertility Clinic, Abu Dhabi, United Arab Emirates, and who received GnRH agonist for final oocyte maturation due to the risk for development of ovarian hyperstimulation syndrome (OHSS), as the ultrasound findings showed the existence of ≥13 follicles of a diameter ≥11 mm, as described by Papanikolaou et al [13] was gathered for this retrospective study
Summary
Over the past few decades, increasing knowledge of ovarian physiology and the possibility to evaluate accurately the ovarian reserve has led progressively to individualization and tailoring of ovarian stimulation for in vitro fertilization (IVF)—treatment.Final oocyte maturation is the crucial step in ovarian stimulation cycles for IVF to retrieve mature oocytes for further processing in the IVF laboratory. Luteal Coasting and Individualization of hCG (GnRH) antagonist cycles, human chorionic gonadotropin (hCG) and GnRH agonist can be administered for final oocyte maturation. In patients with an expected or known high response, stimulation in a GnRH antagonist protocol with the use of GnRH agonist for final oocyte maturation is the stateof-the-art treatment to avoid or at least reduce significantly the risk for the development of ovarian hyperstimulation syndrome (OHSS) [1]. The GnRH agonist dislocates the GnRH antagonist in the pituitary from the GnRH receptors. This results in a surge of LH and FSH, inducing final oocyte maturation and ovulation [2]. There are so far no established predictive parameters to estimate the severity of the luteolysis
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