This document provides an overview of a lecture on LH suppression in controlled ovarian hyperstimulation (COH) using GnRH antagonists. The key points covered include: 1) The importance of LH suppression in COH to prevent premature luteinization and improve outcomes. 2) How GnRH antagonists can be used for LH suppression compared to agonists. Clinical trials show antagonists reduce OHSS risk and duration of stimulation compared to agonists without impacting live birth rates. 3) Flexible or fixed antagonist protocols, use of oral contraceptives, and timing of hCG administration do not significantly impact outcomes. LH supplementation is generally not needed.

1. Insight’12 – Lite, Coimbatore, India – May 2012

2. Lecture Overview
 Importance of LH suppression in COH
 LH suppresion using GnRH-antagonists
 Clinical Results
 Take-Home Messages
Esteves, 2

3. www.slideshare.net/sandroesteves

4. Ovarian Stimulation
Protocols
Central
Paradigm
Minimize
Maximize beneficial
complications and
effects of treatment
risks
High-quality Cycle cancellation,
oocyte yield OHSS,
multiple pregnancy
Esteves, 4 Fauser et al., 2008

5. Theca externa cells
Theca interna cells
Granulosa
cells Follicular
antrum
Zona pellucida
Oocyte
Cumulus
Oophorus
cells
Capillary network Basement membrane
Esteves, 5 Zeleznik et al 1974; Adashi 1996, Hillier 1994.

6. Rationale of LH suppression in COH
 Premature luteinization in IVF
— Cycle cancellation
— Low number of oocytes retrieved/atresia
— Reduced fertilization rate and embryo quality
— Poor prognosis for pregnancy
— Psychological burden & Financial loss
Reduced risk of Allows ovarian
LH suppression premature LH surge and stimulation to be
untimely ovulation controlled
1Loumaye, et al. Human Reprod 1990;5:357
2Balasch J. In: Female Infertility Therapy:Current Practice (Shoham, Howles, Jacobs, eds). Martin Dunitz
Esteves, 6 1998:189

7. Physiologic Actions of GnRH
 Stimulates synthesis and release of LH and FSH
pyro (Glu) – His – Trp – Ser – Tyr – Gly – Leu – Arg – Pro – Gly – NH2
Short Term Long Term
U
U
U GnRH
LH
FSH
U U
Esteves, 7

8. LH Surge Prevention: GnRH Antagonists
GnRH receptor activation Receptor affinity Biologic activity
pyro (Glu) – His – Trp – Ser – Tyr – Gly – Leu – Arg – Pro – Gly – NH2
Esteves, 8

9. The difference in LH suppression
Agonist Follicular
2-4
Luteal
30 weeks
LH, FSH
E2 , P4
20
10 Synchronized follicles
0 Start Administration
6
5
Antagonist • Half-life ~20h (Cetrorelix)
4
• Suppress LH by 80% of
LH (IU/L)
Antagonist
baseline levels
3
2
1
0
-6 0 6 12 18 24 30 36 42 48
Esteves, 9 Hours

10. Comparison of Long GnRH Agonist
and GnRH Antagonist Protocols
Prevent
Can be OHSS by
integrated in GnRH-a
No flare spontaneous/OI
GnRH antagonist Antagonist
effect with No hormonal cycles
protocol administration
possible cyst withdrawal
formation Gonadotropin administration
Less gona-
Can exclude dotropins
early
pregnancy
Flare up Pituitary
effect suppression
Gonadotropin administration
Long GnRH
agonist Longer Agonist administration
protocol treatment
Pre-treatment cycle Treatment cycle

11. Why has introduction of antagonists
in clinical practice has been slow?
 Experience with Agonists
— Why change if it is working
 Clinicians´ concerns
— E2 decrease
— Not been able to program
aspirations on weekdays
— LH surge (more monitoring)
— Difficult to use
Esteves, 11

12. GnRH Antagonists in COH
Clinical Results and
Effects on Cycle Parameters
Level Type of evidence
1a Obtained from meta-analysis of randomised trials
1b Obtained from at least one randomised trial
2a Obtained from one well-designed controlled study without
randomisation
2b Obtained from at least one other type of well-designed quasi-
experimental study
3 Obtained from well-designed non-experimental studies, such as
comparative and correlation studies, and case reports
4 Obtained from expert committee reports or opinions or clinical
experience of respected authorities
Esteves, 12 Modified from Sackett et al. Oxford Centre for Evidence-based Medicine Levels of Evidence (2009)

13. GnRH Antagonist in COH
1a
GnRH Antagonists vs Agonists
Probability of Live birth
Al-Inany et al (2011)1 Kolibianakis et al (2006)2
N studies 45 22
Included IUI cycles Yes No
N patients 7,511 3,176
Primary outcome Ongoing PR or LBR LBR
Odds ratio 0.86 0.86
(95% CI 0.69-1.08) (95% CI 0.72 to 1.02)
*Live birth rate included ongoing pregnancies (Al-Inany) or calculated rates (Kolibianakis).
1. Al-Inany et al. Cochrane Database Syst Rev. 2011; 5:CD001750.
Esteves, 13 2. Kolibianakis et al. Hum Reprod Update. 2006;12:651.

14. GnRH Antagonist in COH
1a
GnRH Antagonists vs Agonists
Al-Inany et al1 Kolibianakis et al2
Duration of ovarian -1.13 days -1.54 days
stimulation (-1.83; -0.44) (-2.42; -0.66; p=.0006)
Oocytes retrieved -- -1.19 (-1.82; -0.56)
Risk of severe 0.43* OR=0.61
OHSS (95% CI 0.33 to 0.57) (0.42; 0.89; p=.01)
*For every 59 women treated with a GnRH agonist vs GnRH
antagonist, one additional case of severe OHSS will occur.
1. Al-Inany et al. Cochrane Database Syst Rev. 2011; 5:CD001750.
Esteves, 14 2. Kolibianakis et al. Hum Reprod Update. 2006;12:651.

15. GnRH Antagonist in COH
OHSS – 3 levels of Protection
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 trigger.
3rd Level: In patients with early OHSS onset,
use of GnRH-ant luteal phase.
Esteves, 15

16. GnRH Antagonist in COH
Poor Responders 1a Pu D, Wu J, Liu J.. Hum Reprod. 2011; 26: 2742
Antagonist vs Duration of Oocytes Cycle CPR
Agonist stimulation retrieved cancellation
14 RCT; 1127 -1.9 days -0.17 1.01 1.23
patients (-3.6; -0.12) (-2.42; -0.66) (0.71; 1.42) (0.92, 1.66)
PCOS 1b Lainas et al. Hum Reprod. 2010; 25:683
Antagonist vs Duration of Oocytes Grades II + III CPR (%)
Agonist stimulation; retrieved; N OHSS (%)
days
RCT; 220 10 vs 12 28 vs 27 65 vs 44 50.9 vs 47.3
patients (P<.001) (P=.22) (P=0.006) (P=.68)
Esteves, 16

17. What is the Best
Antagonist Protocol?
 Fixed or Flexible daily
 OCP pretreatment
 Day of hCG administration
 LH supplementation
Esteves, 17

18. GnRH Antagonist in COH
1b
Flexible or Fixed
Cetrorelix 0.25mg P
Flexible*; N=68 Fixed; N=72
value
Duration of COH 9.7 ± 1.9 9.9 ± 2.7 .72
Age* 2,225 ± 1,128 2,190 ± 833 .84
Oocytes retrieved* 12 ± 6.6 10.3 ± 4.7 NS
Metaphase II
11.7 ± 6.5 9.8 ± 5.2 .07
oocytes*
Fertilization rate 54.9 ± 22.8 56.3 ± 21.4 .77
Pregnancy rate 24.7% 23.3% NS
*Flexible: LH >10 IU/L, and/or mean follicle >12 mm, and/or serum
E2 >150 pg/mL; Fixed: Day 6; No LH surge reported
Kolibianakis EM, et al. Fertil Steril. 2011; 95:558-62
Esteves, 18

19. GnRH Antagonist in COH
1a
Pretreatment with OCP
4 RCT; 847 patients
Duration of stimulation (days) +1.41 (+1.13; +1.68)
Gonadotropin consumption (UI) +542 (+127; +956)
Oocytes retrieved (n) 1.63 (-0.34; 3.61)
Ongoing Pregnancy (%) 0.74 (0.53; 1.03)
Griesinger et al. Fertil Steril 2008; 90: 1055-63.
Esteves, 19

20. GnRH Antagonist in COH
1b
Day of hCG administration
hCG administration ≥3 follicles of One day P
≥16mm later value
120 NG women 39 y-o undergoing antagonist COH protocol
Mean ± Metaphase II
6.1 ± 4.9 9.2 ± 7.1 .009
oocytes
Mean ± Fertilization
66.7 ± 23.4 70.1 ± 20.9 .44
rate
Ongoing Pregnancy
34.6% 40.7% .55
rate
Kyrou D et al. Fertil Steril. 2011; 96(5):1112-5.
Esteves, 20

21. Is LH needed in a GnRH antagonist
Protocol?
1b
Sauer et al (2004) - multicenter study using 3mg flexible
protocol (+OCP): no benefit of LH supplementation
(150 IU r-hLH day 6 FSH) on MII oocytes or pregnancy
rate vs no supplementation or GnRH agonist protocol
Cédrin-Durnerin et al (2004) - multicenter study using
3mg flexible protocol (+OCP): no benefit of LH
supplementation (75 IU r-hLH day antag) on oocytes or
delivery rates
Sauer et al, Reprod Biomed Online 2004;9:487–93;
Esteves, 21 Cédrin-Durnerin et al, Hum Reprod 2004;19:1979–84.

22. Is LH needed for older women in
GnRH antagonist Protocol?
292 NG women aged 36-39 1b
Fixed (D6) antagonist COH protocol
rFSH rFSH + rLH
P=0.02 68%
61%
OR=1.49 OR=1.56
95% CI 0.93-2.38 95% CI 1.04-2.33
33%
25% 27%
19%
%2PN Ongoing PR Implantation
Esteves, 22
Bosch et al. Fertil Steril. 2011; 95:1031-6.

23. GnRH Antagonists in COH
Summary
Clinical Outcomes Evidence
No difference in probability of live birth (overall and 1a
subgroups) compared to agonists
Significantly lower OHSS and duration of 1a
stimulation
No difference in Flexible or Fixed Antagonist 1b
Protocols
OCP programming or delaying hCG (+1 day) not 1a
detrimental
No need of LH supplementation overall; subgroup 1b
analysis suggest that aged women may benefit
Esteves, 23

24. Currently, >50% COH cycles use
ANTAGONISTS
Cycles with GnRH
Antagonists
60%
15%
1999
2009
Esteves, 24
REDLARA Registry; ART World Report (ICMART)

25. Practical Tips in GnRH
Antagonist Cycle
Management
 Avoid step-down rFSH/hMG in the first 48 hours after
antagonist
 Use OCP for scheduling purposes
— Make pill-free interval flexible
 Flexible GnRH antagonist no later than day 8 of
stimulation or follicle size 14 mm;
 If >6 follicles 11-13 mm diameter start GnRH
antagonist
 Use last antagonist injection on hCG day
Esteves, 25

26. Take-home Messages
 Agonists yield higher number of oocytes
 Antagonists are safer than agonists
— Decreased moderate and severe OHSS rates
 Antagonists more patient-friendly
— Shorter duration of COH
 Probability of live birth in COS is independent of
the analog used for pituitary suppression
Esteves, 26