Outcomes of premature LH rise in patients undergoing IVF during a GnRH antagonist cycle

Abstract

OBJECTIVE: Women undergoing ovulation induction have superphysiologic E2 levels that may induce a surge of LH prior to retrieval. To avoid this GnRH antagonist are used. In spite of this, there are some patients who will have a transient LH elevation prior to retrieval. The objective of this study was to compare the outcomes of those patients with a premature LH surge to those who did not surge. DESIGN: Retrospective cohort study. MATERIALS AND METHODS: Charts were reviewed for all patients who underwent a fresh IVF cycle using Ganirelix Acetate (Organon, Inc., West Orange, NJ) in either standard GnRH-antagonist protocol or the luteal phase ganirelix protocol between January 2006 and December 2007. 109 patients in their first cycle were identified with a premature LH surge (LH≥ 10IU/L and >50% rise from baseline). These patients were then compared to 562 patients, in their first cycle, that did not have a premature LH rise. Patients were stratified by age and number of oocytes retrieved. Stimulation was initiated on day 2 with recombinant follicle stimulating hormone (rec-FSH) ± human menopausal gonadotropins (HMG). Daily dosing of Ganirelix 0.25mg was then added once the lead follicle reached ≥14mm in diameter or E2 ≥ 350 pg/ml and was continued until the day of human chorionic gonadotropin (hCG) administration. hCG was administered when two follicles reached ≥17 mm in diameter. Main outcomes measured were cancellation rate, number of oocytes retrieved and clinical pregnancy rates. Cancellations were due to poor response or no embryo available for transfer. RESULTS: Table 1.Table 1OutcomesCycle TypeLH SurgeControlP valueN=109562Age37.7±4.535.6±4.50.001Day 3 FSH7.3±3.97.0±3.2NSCancellation rate (%)42/109 (38.5)34/562 (6.0)0.001Total Gonadotropin dose∗ (IU)4682±23463375±17850.001Peak E2∗ (pg/mL)1376±9981664±7390.001Mean No. Oocytes retrieved10.7±8.413.0±7.20.001Mean embryos transferred2.2±1.32.4±1.1NSClinical pregnancy rate per embryo transfer (%)28/67 (41.8)269/529 (50.9)NS∗ For non-cancelled cycles. Values are means±SD. NS=not significant. Open table in a new tab ∗ For non-cancelled cycles. Values are means±SD. NS=not significant. CONCLUSIONS: A premature LH surge does not appear to impair clinical pregnancy rates per embryo transfer. Therefore, cycles with a premature LH elevation should not be canceled solely on the basis of that elevation. However, it is associated with a decreased response to gonadotropins, decreased oocyte yield as well as an increased cancellation rate.