Sandro Esteves, MD, PhD!
Director, ANDROFERT!
Campinas, BRAZIL!
!
GnRH Agonist vs. Antagonist
in ICSI and Its Impact on
Cy...
Lecture Outline
1. Why LH suppression is desirable in COS!
2. How GnRH analogues work !
3. What we achieve by using GnRH
a...
http://www.androfert.com.br/review
GnRH Agonist vs. Antagonists in ICSI and
its Impact on Cycle Outcome
ANDROFERT
androfer...
Why LH surge suppression
is desirable in COS
ANDROFERT
androfert.com.br
ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL...
Ovulation leading to cycle cancellation
Low number oocytes retrieved/atresia
Reduced fertilization and embryo quality
Poor...
LH surge is mediated by
estradiol and GnRH 
ANDROFERT
androfert.com.br
ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL ...
LH Suppression in COS
•  Administration of GnRH analogues!
–  Synthetic versions of native GnRH!
–  Options are GnRH agoni...
How GnRH analogues work
ANDROFERT
androfert.com.br
ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPR...
ANDROFERT
androfert.com.br
ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION
S ESTEVES, 9
20...
GnRH Antagonist
pyro (Glu) – His – Trp – Ser – Tyr – Gly – Leu – Arg – Pro – Gly – NH2
ANDROFERT
androfert.com.br
ANDROLOG...
0
1
2
3
4
5
6
-6 0 6 12 18 24 30 36 42 48
Hours
LH(IU/L)
Antagonist
Antagonist • Half-­‐life	
  ~20h	
  (Cetrorelix)	
  
•...
GnRH Agonist vs. Antagonist in COS
Antagonist
Protocol
Gonadotropin administration
Can exclude early
pregnancy
Can be inte...
GnRH Antagonists in COS
Effects on Cycle Parameters!
§  Impact of estradiol level decline upon
antagonist administration
...
Impact of E2 Decline Following
Antagonist Administration
Olivennes, et al. Fertil Steril 1998;70:S14
Days post Cetrorelix ...
Is LH Needed in Antagonist Protocol?
Estradiol levels
hCG day!
WMD: 571!
(95% CI: 259; 882) !
-! WMD: 514 !
(95% CI: 368; ...
61%	
  
25%	
  
19%	
  
68%	
  
33%	
  
27%	
  
%2PN	
   Ongoing	
  PR	
  	
   ImplantaLon	
  
rFSH	
   rFSH	
  +	
  rLH	
...
Cetrorelix 0.25mg! Flexible*; N=68! Fixed; N=72 !
P
value!
Duration of COS! 9.7 ± 1.9! 9.9 ± 2.7! NS!
Total gonadotropin d...
GnRH Antagonist and
Endometrium Receptivity
!
Prapas N et al, RBM Online. 2009; 18:276.!
Recipients	
  (n=49)	
  
Endometr...
Metaphase II oocytes! 6.1 ± 4.9! 9.2 ± 7.1! .009!
% Fertilization rate! 66.7 ± 23.4! 70.1 ± 20.9! .44!
% Ongoing
Pregnancy...
6 RCT; 1,343 patients
Duration of stimulation (days)! WMD: +1.33 (+0.61; +2.05)!
Total gonadotropin dose (UI)! WMD: +360 (...
•  No negative impact of transitory E2 decline!
•  No need LH supplementation, but for aged women!
•  No negative impact e...
Practical Tips in GnRH
Antagonist Cycle
Management


•  Avoid gonadotropin step-down in the first 24h after
antagonist !
• ...
What we achieve by using
GnRH Antagonist vs.
Agonist in COS
ANDROFERT
androfert.com.br
ANDROLOGY AND HUMAN REPRODUCTION CL...
Similar live birth rates
Cochrane 2011 (N=7,511)
Al-Inany et al. Cochrane Database Syst Rev. 2011; 5:CD001750.
OR: 0.86
(9...
GnRH antagonists have a better
safety profile vs GnRH Agonists
Al-Inany1 Kolibianakis2
Duration of
ovarian
stimulation
−1.5...
Pundir et al, 2012!
9 RCT; N=966!
Xiao et al, 2013!
7 RCT; N=755!
Clinical PR!
RR: 1.01 !
(95% CI 0.88; 1.15)!
OR: 1.08 !
...
Pundir et al, 2012!
9 RCT; N=966!
Xiao et al, 2013!
7 RCT; N=755!
Duration of COS! -0.74 (95% CI -1.12; -0.36)! -!
Gonadot...
GnRH-agonist vs hCG: 11 RCT – 1,055 women
Fresh
autologous
cycles (8 RCT)
Live birth
 Pregnancy
Moderate/
severe OHSS
OR 0...
Humaidan et al. Fertil Steril 2012;
Engmann & Benadiva Fertil Steril 2012
Modified LPS
hCG bolus OPU day (1,500 UI) or 3x ...
GnRH Antagonist in COS 


OHSS Protection Levels








1st Level: Antagonist rather than agonists
2nd Level: In patients...
Poor responder: No difference CPR 
Pu,	
  et	
  al.	
  Hum	
  Reprod.	
  2011.	
  
Pu D et al. Hum Reprod. 2011
ANDROFERT
a...
Poor responder: No difference in
No. oocytes
Pu,	
  et	
  al.	
  Hum	
  Reprod.	
  2011.	
  
Pu D et al. Hum Reprod. 2011
A...
1999	
  
2011	
  
15%	
  
65%	
  
REDLARA Registry; ART World Report (ICMART)
Cycles with Antagonists in
South America
AND...
GnRH Agonist vs. Antagonists in ICSI
and its Impact on Cycle Outcome
Take-home messages!
GnRH analogues allow ovarian stim...
GnRH agonist versus antagonist and impact on cycle outcome
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GnRH agonist versus antagonist and impact on cycle outcome

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GnRH agonist versus antagonist and impact on cycle outcome

  1. 1. Sandro Esteves, MD, PhD! Director, ANDROFERT! Campinas, BRAZIL! ! GnRH Agonist vs. Antagonist in ICSI and Its Impact on Cycle Outcome
  2. 2. Lecture Outline 1. Why LH suppression is desirable in COS! 2. How GnRH analogues work ! 3. What we achieve by using GnRH antagonists vs. agonists in COS! GnRH Agonist vs. Antagonists in ICSI and its Impact on Cycle Outcome ANDROFERT androfert.com.br ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION S ESTEVES, 2 2014 APRIL ANDROFERT
  3. 3. http://www.androfert.com.br/review GnRH Agonist vs. Antagonists in ICSI and its Impact on Cycle Outcome ANDROFERT androfert.com.br ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION S ESTEVES, 3 2014 APRIL ANDROFERT
  4. 4. Why LH surge suppression is desirable in COS ANDROFERT androfert.com.br ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION S ESTEVES, 4 2014 APRIL ANDROFERT
  5. 5. Ovulation leading to cycle cancellation Low number oocytes retrieved/atresia Reduced fertilization and embryo quality Poor prognosis for pregnancy Psychological burden & financial loss Premature Luteinization in IVF ANDROFERT androfert.com.br ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION S ESTEVES, 5 2014 APRIL ANDROFERT
  6. 6. LH surge is mediated by estradiol and GnRH ANDROFERT androfert.com.br ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION S ESTEVES, 6 2014 APRIL ANDROFERT
  7. 7. LH Suppression in COS •  Administration of GnRH analogues! –  Synthetic versions of native GnRH! –  Options are GnRH agonist and antagonist ! •  GnRH Agonist! –  1984! –  Buserelin, nafarelin, triptorelin, leuprolide! •  GnRH Antagonist! –  1999! –  Cetrorelix, ganirelix! ANDROFERT androfert.com.br ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION S ESTEVES, 7 2014 APRIL ANDROFERT
  8. 8. How GnRH analogues work ANDROFERT androfert.com.br ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION S ESTEVES, 8 2014 APRIL ANDROFERT
  9. 9. ANDROFERT androfert.com.br ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION S ESTEVES, 9 2014 APRIL ANDROFERT GnRH Agonist pyro (Glu) – His – Trp – Ser – Tyr – Gly – Leu – Arg – Pro – Gly – NH2
  10. 10. GnRH Antagonist pyro (Glu) – His – Trp – Ser – Tyr – Gly – Leu – Arg – Pro – Gly – NH2 ANDROFERT androfert.com.br ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION S ESTEVES, 10 2014 APRIL ANDROFERT
  11. 11. 0 1 2 3 4 5 6 -6 0 6 12 18 24 30 36 42 48 Hours LH(IU/L) Antagonist Antagonist • Half-­‐life  ~20h  (Cetrorelix)   •   Suppress  LH  by  80%  of  baseline  levels       ANDROFERT androfert.com.br ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION S ESTEVES, 11 2014 APRIL ANDROFERT
  12. 12. GnRH Agonist vs. Antagonist in COS Antagonist Protocol Gonadotropin administration Can exclude early pregnancy Can be integrated in spontaneous/OI cycles No flare effect with possible cyst formation Long GnRH Agonist Protocol Gonadotropin administration Pre-treatment cycle Treatment cycle Flare up effect Pituitary suppression No hormonal withdrawal Allow GnRH-a trigger Longer treatment ANDROFERT androfert.com.br ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION S ESTEVES, 12 2014 APRIL ANDROFERT
  13. 13. GnRH Antagonists in COS Effects on Cycle Parameters! §  Impact of estradiol level decline upon antagonist administration §  Need of LH supplementation §  Impact on endometrium §  Fixed vs. flexible protocol §  Day of hCG administration §  OCP pre-treatment ANDROFERT androfert.com.br ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION S ESTEVES, 13 2014 APRIL ANDROFERT
  14. 14. Impact of E2 Decline Following Antagonist Administration Olivennes, et al. Fertil Steril 1998;70:S14 Days post Cetrorelix 3 mg 0 400 800 1200 1600 Day 0 Day 1 Day 2 Day 3 Day 4 Day 5 Day 6 0 5 10 15 20 FollicleSize(mm) Estradiol(pg/ml) Lead Follicle E2 Although some patients experience a decline or plateau in E2 following antagonist administration, there is no evidence of negative impact on treatment outcome. ANDROFERT androfert.com.br ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION S ESTEVES, 14 2014 APRIL ANDROFERT
  15. 15. Is LH Needed in Antagonist Protocol? Estradiol levels hCG day! WMD: 571! (95% CI: 259; 882) ! -! WMD: 514 ! (95% CI: 368; 660)! No. retrieved oocytes! WMD: 0.50! (95% CI: -0.68; 1.68) ! -! WMD: 0.41 ! (95% CI -0.44; 1.3) ! No. mature oocytes! -! -! WMD: 0.88 ! (95% CI: 0.21; 1.54 ) ! Clinical PR! OR: 0.79 ! (95% CI: 0.26; 2.43)! -! OR: 0.89 ! (95% CI: 0.57; 1.39! Live birth! OR 0.86! (0.04; 1.85)! r-hFSH+rLH vs. r-hFSH alone in antagonist cycles ANDROFERT androfert.com.br ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION S ESTEVES, 15 2014 APRIL ANDROFERT Mochtar et al, 2007! 3 RCT (N=216)! Kolibianakis et al, 2007! 2 RCT (N=176)! Baruffi et al, 2007! 5 RCT (N= 434)!
  16. 16. 61%   25%   19%   68%   33%   27%   %2PN   Ongoing  PR     ImplantaLon   rFSH   rFSH  +  rLH   292 NG women aged 36-39 Fixed (D6) antagonist COH protocol P=0.02 OR=1.49 95% CI 0.93-2.38 OR=1.56 95% CI 1.04-2.33 Bosch et al. Fertil Steril. 2011; 95:1031-6 Is LH needed in Antagonist Protocol? ANDROFERT androfert.com.br ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION S ESTEVES, 16 2014 APRIL ANDROFERT
  17. 17. Cetrorelix 0.25mg! Flexible*; N=68! Fixed; N=72 ! P value! Duration of COS! 9.7 ± 1.9! 9.9 ± 2.7! NS! Total gonadotropin dose! 2,225 ± 1,128! 2,190 ± 833! NS! No. oocytes retrieved! 12 ± 6.6! 10.3 ± 4.7! NS! No. metaphase II oocytes! 11.7 ± 6.5! 9.8 ± 5.2! NS! % Fertilization rate! 54.9 ± 22.8! 56.3 ± 21.4! NS! % Pregnancy rate! 24.7%! 23.3%! NS! No. antagonist injections! 3.4 ± 1.1! 5.3 ± 1.8! <.05! Kolibianakis EM, et al. Fertil Steril. 2011; 95:558-62 Flexible:  LH  >10  IU/L,  and/or  mean  follicle  >12  mm,  and/or  serum  E2  >150   pg/mL;  Fixed:  Day  6   Flexible vs. Fixed Antagonist ANDROFERT androfert.com.br ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION S ESTEVES, 17 2014 APRIL ANDROFERT
  18. 18. GnRH Antagonist and Endometrium Receptivity ! Prapas N et al, RBM Online. 2009; 18:276.! Recipients  (n=49)   Endometrial  priming  with   estradiol  +  antagonist   0.25mg  daily     Recipients  (n=49)   Endometrial  priming   with  estradiol  only   Pregnancy     55.1%   59.1%   ImplantaLon     26.1%   24.4   ANDROFERT androfert.com.br ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION S ESTEVES, 18 2014 APRIL ANDROFERT Oocyte  donors   (n=49)  
  19. 19. Metaphase II oocytes! 6.1 ± 4.9! 9.2 ± 7.1! .009! % Fertilization rate! 66.7 ± 23.4! 70.1 ± 20.9! .44! % Ongoing Pregnancy rate! 34.6% ! 40.7%! .55! Kyrou D et al. Fertil Steril. 2011; 96(5):1112-5. Antagonist Protocol and Day hCG Administration RCT involving 120 NG women <39 yo. ANDROFERT androfert.com.br ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION S ESTEVES, 19 2014 APRIL ANDROFERT hCG administration! ≥3 follicles of ≥16mm! One day later ! P value!
  20. 20. 6 RCT; 1,343 patients Duration of stimulation (days)! WMD: +1.33 (+0.61; +2.05)! Total gonadotropin dose (UI)! WMD: +360 (+158; +563)! Oocytes retrieved (n)! WMD: +0.63 (-0.08; +1.25)! Ongoing Pregnancy (%)! RR: 0.80 (0.66; 0.97)! OR: 0.74 (0.58; 0.96)! Griesinger et al. Fertil Steril 2010 ! Antagonist Protocol and OCP ANDROFERT androfert.com.br ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION S ESTEVES, 20 2014 APRIL ANDROFERT
  21. 21. •  No negative impact of transitory E2 decline! •  No need LH supplementation, but for aged women! •  No negative impact endometrium ! •  Flexible similar to fixed, but less vials! •  hCG day+1 not detrimental! •  OCP seems to impact outcome! Conclusions! Effects of GnRH Antagonists on cycle parameters ANDROFERT androfert.com.br ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION S ESTEVES, 21 2014 APRIL ANDROFERT
  22. 22. Practical Tips in GnRH Antagonist Cycle Management
 •  Avoid gonadotropin step-down in the first 24h after antagonist ! •  Make pill-free interval flexible if OCP for scheduling purposes! •  Start antagonist no later than stimulation day 8 or follicle size 14 mm in flexible protocol! •  Start antagonist if >6 follicles 11-13 mm diameter regardless of stimulation day! •  Use last antagonist injection on hCG day (17mm mean diameter or any sign of endometrium luteinization)! ANDROFERT androfert.com.br ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION S ESTEVES, 22 2014 APRIL ANDROFERT
  23. 23. What we achieve by using GnRH Antagonist vs. Agonist in COS ANDROFERT androfert.com.br ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION S ESTEVES, 23 2014 APRIL ANDROFERT
  24. 24. Similar live birth rates Cochrane 2011 (N=7,511) Al-Inany et al. Cochrane Database Syst Rev. 2011; 5:CD001750. OR: 0.86 (95% CI 0.69-1.08)
  25. 25. GnRH antagonists have a better safety profile vs GnRH Agonists Al-Inany1 Kolibianakis2 Duration of ovarian stimulation −1.54 days (95% CI −2.42, −0.66; P=0.0006) −1.13 days (95% CI −1.83, −0.44) Risk of severe OHSS OR 0.61 (95% CI –0.42, 0.89; P=0.01) RR 0.46* (95% CI 0.26, 0.82; P=0.01) Interventions to prevent OHSS OR 0.44 (95% CI 0.21, 0.93; P=0.03) *For every 59 women treated with a GnRH agonist vs GnRH antagonist, 1 additional case of severe OHSS will occur; RR = risk ratio. 1. Al-Inany et al. Cochrane Database Syst Rev. 2006;3:CD001750. 2. Kolibianakis et al. Hum Reprod Update. 2006;12:651. ANDROFERT androfert.com.br ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION S ESTEVES, 25 2014 APRIL ANDROFERT
  26. 26. Pundir et al, 2012! 9 RCT; N=966! Xiao et al, 2013! 7 RCT; N=755! Clinical PR! RR: 1.01 ! (95% CI 0.88; 1.15)! OR: 1.08 ! (95% CI 0.80-1.45)! Miscarriage rate! RR: 0.79 ! (95% CI 0.49; 1.28)! OR: 0.91! (95% CI: 0.54-1.53)! Pundir  J  et  al.  RBM  Online  2012;  24:  6-­‐22.;  Xiao  et  al,  Gynecol  Endocrinol.  2013;  ;29(3):187-­‐91  .   PCOS: No difference in ongoing pregnancy rate ANDROFERT androfert.com.br ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION S ESTEVES, 26 2014 APRIL ANDROFERT
  27. 27. Pundir et al, 2012! 9 RCT; N=966! Xiao et al, 2013! 7 RCT; N=755! Duration of COS! -0.74 (95% CI -1.12; -0.36)! -! Gonadotropin dose! MD: -0.28 ! (95% CI -0.43; -0.13)! MD = -2.05 ! (95% CI -4.14; 0.05)! Oocytes retrieved! WMD: 0.01! (95% CI -0.24; 0.26)! MD = -0.38 ! (95% CI -2.32; 1.56)! Risk of OHSS! 20% vs 32% ! OR = 0.36 ! (95% CI 0.25; 0.52)! Moderate and Severe! RR: 0.59 ! (95% CI 0.45-0.76)! -! PCOS: Antagonists have better safety profile ANDROFERT androfert.com.br ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION S ESTEVES, 27 2014 APRIL ANDROFERT 40% reduction in moderate/severe OHSS by using antagonists compared to agonists
  28. 28. GnRH-agonist vs hCG: 11 RCT – 1,055 women Fresh autologous cycles (8 RCT) Live birth Pregnancy Moderate/ severe OHSS OR 0.44 (0.29 - 0.68) OR 0.45 (0.31 - 0.65) OR 0.10, (0.01 to 0.82) Youssef et al. Cochrane Database Syst Rev. 2011 ANDROFERT androfert.com.br ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION S ESTEVES, 28 2014 APRIL ANDROFERT
  29. 29. Humaidan et al. Fertil Steril 2012; Engmann & Benadiva Fertil Steril 2012 Modified LPS hCG bolus OPU day (1,500 UI) or 3x 500 UI boluses; recLH; progesterone + estradiol; combined Risk difference for pregnancy (hCG vs. GnRHa) 18% (Before) vs 6% (After) Modified LPS LH Trigger with GnRH-agonist Freeze all Vitrification vs. Slow-freezing Meta-analysis of 5 RCT OPR = 35% x 27%; OR: 1.82; 95% CI: 1.04-3.20 IR = 29% x 24%; OR: 1.49, 95% CI: 1.03-2.15 AbdelFahez et al . RBM Online 2010 ANDROFERT androfert.com.br ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION S ESTEVES, 29 2014 APRIL ANDROFERT
  30. 30. GnRH Antagonist in COS 
 OHSS Protection Levels
 
 
 
 1st Level: Antagonist rather than agonists 2nd Level: In patients on antagonist protocol at risk of OHSS, replace hCG with GnRH-a for oocyte maturation triggering 3rd Level: In patients with early OHSS onset, use GnRH- antagonist luteal phase. Devroey et al. Hum Reprod 2011; 10: 2593-97. ANDROFERT androfert.com.br ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION S ESTEVES, 30 2014 APRIL ANDROFERT
  31. 31. Poor responder: No difference CPR Pu,  et  al.  Hum  Reprod.  2011.   Pu D et al. Hum Reprod. 2011 ANDROFERT androfert.com.br ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION S ESTEVES, 31 2014 APRIL ANDROFERT OR = 1.23 (95% CI 0.92; 1.66)
  32. 32. Poor responder: No difference in No. oocytes Pu,  et  al.  Hum  Reprod.  2011.   Pu D et al. Hum Reprod. 2011 ANDROFERT androfert.com.br ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION S ESTEVES, 32 2014 APRIL ANDROFERT OR = -0.17 (95% CI -0.69; 0.34)
  33. 33. 1999   2011   15%   65%   REDLARA Registry; ART World Report (ICMART) Cycles with Antagonists in South America ANDROFERT androfert.com.br ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION S ESTEVES, 33 2014 APRIL ANDROFERT
  34. 34. GnRH Agonist vs. Antagonists in ICSI and its Impact on Cycle Outcome Take-home messages! GnRH analogues allow ovarian stimulation to be controlled! Safety, duration of treatment pro antagonist! No difference in number of oocytes and live birth rate between antagonist and agonist! Protocol of first choice for PCOS patients !and high responders ! ANDROFERT androfert.com.br ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION S ESTEVES, 34 2014 APRIL ANDROFERT
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