GnRH agonist for final oocyte maturation trigger in GnRH antagonist IVF/ICSI treatment cycles

1. Mohamed AFM Youssef
Gonadotropin-releasing hormone agonist versus HCG for oocyte triggering in antagonist assisted reproductive technology : Updated Cochrane Systematic review & meta-analysis
Luebeck
University

2. Background
Long GnRH agonist + FSH/ HMG
Period
GnRH antagonists
5000- 10000 IU
HCG
GnRH agonists Oocyte retrieval
GnRH antagonist IVF/ICSI cycle
34-36 hrs

3. Background
Oocyte triggering with HCG may lead to:
• Low oocyte & embryo quality
• Less endometrial receptivity
• OHSS
Oocyte triggering with GnRH agonists may lead to :
• Better oocyte and embryo quality as a result of the
induced physiologic LH &FSH surges
• More endometrial receptivity and implantation due to
associated lower luteal phase steroid levels
• OHSS

4. What is the review question?
• To evaluate the effectiveness and safety of
GnRH agonists in comparison to HCG for
triggering final oocyte maturation in IVF and ICSI
for women undergoing controlled ovarian
hyperstimulation in a GnRH-antagonist protocol.

5. Methodology

6. Inclusion Criteria
• Types of studies
• Only Published and unpublished randomised controlled
trials (RCTs)
• Types of participants
• Infertile couples undergoing IVF/ICSI for therapeutic
reasons or for oocyte donation
• Types of interventions
• GnRH agonists vs. HCG for final oocyte maturation
triggering in GnRH-antagonist cycles followed by
embryo transfer (ET) with or without luteal phase
support, in both autologous and donor cycles

7. Outcomes
• Primary outcomes
• Live birth rate (LBR) per woman randomised
• Ovarian hyperstimulation syndrome (OHSS) incidence
• Secondary outcomes
• Ongoing pregnancy rate (OPR)
• Clinical pregnancy rate (CPR)
• Early miscarriage rate per woman randomised
• Multiple pregnancy rate per woman randomised

8. Literature search

9. Studies flow diagram

10. Results

11. Live birth rate (LBR) per women randomized

12. Ongoing pregnancy rate per women randomized

13. Miscarriage rate per women randomized

14. Incidence of OHSS per women randomized

15. Summary of findings (1/2)
GnRH agonist trigger compared to HCG:
1.Fresh autologous cycles:
• Low live birth rate, ongoing pregnancy rate & high
miscarriage rate
2.Donor-recipient cycles:
• No differences in ongoing pregnancy rate or early
miscarriage rate
3.Both cycles:
• Low OHSS incidence

16. Interpretation of autologous cycles

17. Different regimens have been tried :
1.LPS with LH activity
• Repeated injections of GnRH agonist
• rec LH
• HCG supplementation
2.LPS without LH activity
• High dose of Progesterone
• Combined progesterone & estradiol
Modified Luteal phase support (LPS) strategies

18. Modified LPS in terms of LBR

19. Modified LPS in terms of OPR

20. Modified LPS in terms of OHSS incidence

21. Who will get benefit from GnRH agonist trigger

22. Summary of findings (2/2)
Modified Luteal phase support
• LPS with LH activity: overcome the lower
OPR & increases risk of OHSS
• LPS without LH activity: not overcome the
lower OPR and keep the low OHSS risk

23. Take home message
Final oocyte maturation triggering with GnRH agonists
instead of HCG in fresh autologous GnRH antagonist-
IVF/ICSI treatment cycles prevents OHSS to the
detriment of live birth rate. In donor-recipient cycles the
use of GnRH agonist instead of HCG resulted in a lower
incidence of OHSS, with no evidence of a difference in
live birth rate

24. No miracle cure