Downloaded 14 times
Uploaded byabayomi ajayi
Final Oocyte Maturation: HCG VS GNRH Agonist by Dr. Abayomi Ajayi
This document discusses methods for final oocyte maturation in IVF treatment. It notes that human chorionic gonadotropin (HCG) has traditionally been used but gonadotropin-releasing hormone (GnRH) agonists can also be used to reduce the risk of ovarian hyperstimulation syndrome (OHSS). While GnRH agonists prevent OHSS, they are associated with lower pregnancy rates. However, combining a GnRH agonist trigger with low-dose HCG or vitrification of all embryos may optimize pregnancy rates while still preventing OHSS. The optimal luteal phase support when using a GnRH agonist trigger remains an area of ongoing research.
More Related Content
Similar to Final Oocyte Maturation: HCG VS GNRH Agonist by Dr. Abayomi Ajayi
Final Oocyte Maturation: HCG VS GNRH Agonist by Dr. Abayomi Ajayi
- 1. FINAL OOCYTE MATURATION: HCG VSGNRH AGONIST By Dr. Abayomi Ajayi by Dr. Abayomi Ajayiby Dr. Abayomi Ajayi
- 2. Significant advancement sinceLouise Brown was born 40 years ago. Unstimulated cycle.
- 3. The introduction ofCOS using gonadotropins for multiple follicular development, arguably the single most effective measure ever taken for improving ART outcome 1,2.
- 4. Porter et al1984 reported the introduction of GnRH agonist for pituitary suppression to prevent spontaneous LH surge, reducing cycle cancellation rate from about 35% 2.
- 5. The GnRH agonistlong protocol was the gold standard of IVF since the 80’s 4. The attendant risk of OHSS and the not too convincing experience with short, ultra short, flare, microflare and stop protocols in poor responders pointed to the need for alternative methods of pituitary suppression.
- 6. Itskovitz Eldor 5reported the 1st established using the antagonist protocol in 1998. Though greeted with initial suspicion, the introduction of GnRH antagonist for pituitary suppression in COS has become so widespread in usage due to better knowledge and experience 6,7.
- 7. Initial concerns centredaround: when to initiate it’s administration 7,8,11,12 single or multiple dosage 9 , whether to supplement the follicular phase with LH 9, whether or not to increase the gonadotropin dosage at antagonist initiation 10, as well as use of OCP pre treatment 13
- 8. Traditionally, final oocytematuration was done with HCG since it shares the same α subunit and 81% of the amino acid residues with the β in Of LH. Bind to the same receptors13
- 9. With the useof GnRH antagonist, it became possible to use GnRH agonist for final oocyte maturation 11,14
- 10. The use ofGnRH agonist to replace HCG is probably the only proven method to reduce/prevent severe OHSS in high-risk patients. As there is less release of EGF 2,15
- 11. Prevention of OHSSwith use of GnRH agonist is however associated with reduction in on-going pregnancy/ live birth rate and increased miscarriage rates in fresh autologous cycles. 16,17,18,19
- 12. The reason forthe poor pregnancy rate was initially a source of controversy 1.Egg quality 2.Endometrial receptivity Cochrane study 2011: 11 randomized control trials 1055 women (Yousef M.A et al 2016) 8 studies – fresh autologous 3 studies - donor recipient cycles ↓ live birth rates in fresh autologous cycles No difference in live birth rates in donor recipient cycles
- 13. Experience with donorshave shown no significant difference in number of retrieved oocytes, meta phase 11 oocytes, fertilization rates and more importantly no difference in pregnancy and implantation rates in the two groups of randomized recipients 22. There was a significant difference in luteal phase length in the donors (4.16 Vs 13.6 days) and in the rates of OHSS: None in the agonist group33
- 14. These point tothe current thinking that there is a luteal phase deficiency in cycles where GnRH agonist is used as trigger 18,23. The LH surge induced by GnRH agonist has been found not to be identical to that which occurs in the natural cycle
- 25. Prediction of therisk of OHSS was then used to classify patients into a)Low risk b)Moderate risk c)High risk Aljawoan et al 25 reported that patients having with an antagonist protocol triggered with more than 18 follicles or an estradiol concentration > 5000pg|ml have a sensitivity of 83% with a specificity of 84% for developing OHSS
- 26. Based on thelow and high risk, the idea of personalized luteal support was introduced: bid to optimize pregnancy rates and still prevent OHSS i.Low risk : < 14 ii.Moderate risk : 15-25 iii.High risk : >25
- 27. i. Use oflow dose HCG : 1500IU a) OPU day b) 5 days after OPU (2) Dual trigger; 1000/1500IU HCG + GnRHa (Mahajan N. et al 2016, griffin 2017) ii. Modified intensive luteal support : injectables + virginal tablets/pessaries iii. Cycle segmentation : freeze
- 29. Our aim asART practitioners is to maximize the chance of the birth of healthy baby/babies with minimum risk to the mother OHSS is an iatrogenic and potentially fatal disorder that can complicate ART due to multifollicular development that follows COH The introduction of GnRHa for trigger is the most effective way of reducing OHSS
- 30. The problem isthe lower on-going pregnancy/live birth rates associated with the use of GnRHa trigger. Recent experience show similar ongoing pregnancy rate when GnRHa trigger is combined with low dose HCG compared to the conventional dose of HCG (5,000-10,000) with much reduction in OHSS rate. Advancement in embryo cryopreservation especially Vitrification has made it possible to “freeze” all thereby separate IVF from ET. The ET can then be done in a natural or hormone replacement cycle.
- 31. Initial reports pointto better pregnancy rates and reduced OHSS as this circumvents the defficient luteal phase usually associated with GnRHa trigger. This might just be the gateway to the much awaited OHSS- free clinic. The search for the most optimal LPS for use in GnRHa trigger is however on-going
- 32. It is nowpossible to routinely use GnRHa to replace HCG for triggering ovulation in donor cycles In regular ART, it can be used in case of OHSS threat But since the optimal LPS in such a scenario is still controversial, combination with cryopreservation(preferably Vitrification) gives excellent results