OBJECTIVE:The objective of this study is to evaluate if gonadotropin-releasing hormone agonist (GnRHa) trigger is a better alternative to human chorionic gonadotropin (hCG) in polycystic ovary syndrome (PCOS) of Indian origin undergoing in vitro fertilization (IVF) cycles with GnRH antagonist for the prevention of ovarian hyperstimulation syndrome (OHSS).DESIGN:Prospective randomized control trial.SETTING:Tertiary care center.MATERIALS AND METHODS:A total of 227 patients diagnosed with PCOS, undergoing IVF in an antagonist protocol were recruited and randomly assigned into two groups: Group A (study group): GnRHa trigger 0.2 mg (n = 92) and Group B (control group): 250 μg of recombinant hCG as trigger (n = 101) 35 h before oocyte retrieval. We chose segmentation strategy, freezing all embryos in both the groups.STATISTICAL ANALYSIS:Continuous variables were expressed as mean ± standard deviation independent sample t-test and Kolmogorov-Smirnov test were used for continuous variables which were normally distributed and Mann-Whitney U-test for data not normally distributed.MAIN OUTCOME MEASURES:Primary outcome: OHSS (mild, moderate, and severe) rates. Secondary outcomes: Maturity rate of the oocytes, fertilization rate, availability of top quality embryos on day 3 (Grade 1 and Grade 2).RESULTSThe incidence of moderate to severe OHSS in the hCG group was 37.6% and 0% in the GnRHa group with P < 0.001. The GnRHa group had significantly more mature oocytes retrieved (19.1 ± 11.7 vs. 14.1 ± 4.3), more fertilized oocytes (15.6 ± 5.6 vs. 11.7 ± 3.6), and a higher number of top quality cleavage embryos on day 3 (12.9 ± 4.7 vs. 7.5 ± 4.3) than the hCG group.CONCLUSIONS:The most effective strategy which significantly eliminates the occurrence of OHSS in PCOS following ovarian stimulation in antagonist IVF cycles is the use of GnRHa trigger yielding more mature oocytes and good quality embryos when compared with hCG trigger.

Objective: The use of Gonadotrophin releasing hormone agonist (GnRHa), with freeze-all strategy followed by frozen embryo transfer (FET) has been found to eliminate the risk of ovarian hyperstimulation syndrome (OHSS) in women with polycystic ovarian syndrome (PCOS) undergoing IVF cycles. However, physicians still hesitate to routinely use GnRHa as a trigger, replacing human chorionic gonadotrophin (hCG), for concerns of compromised cycle outcome. We aimed to evaluate outcomes following the transfer of embryos in FET cycles obtained from GnRHa trigger in comparison with hCG trigger in PCOS patients of Asian origin. Methods: Prospective observational cohort study. 210 PCOS patients undergoing IVF in an antagonist protocol who were randomized in the previous study (to evaluate if GnRHa trigger is a better alternative than hCG in PCOS patients to prevent OHSS; Group A: GnRHa trigger (n=92)] and Group B: hCG trigger (n=101)], were followed up in FET cycles to assess the outcomes. Results: The odds of cumulative live birth rate per stimulation cycle favors GnRHa trigger against the hCG trigger [OR=2.15; (CI 1.2-3.83); p=0.008]. A significantly higher number of mature oocytes (19.1±11.7 versus 14.1±4.3; p<0.001) and blastocysts (4.2±1.63 versus 3.26±1.22; p<0.001) were available in the GnRHa group as compared to the hCG group. Conclusion: The cumulative live birth rate was better following transfer of frozen-thawed embryos generated from GnRHa-triggered cycles compared to hCG trigger. Hence, in PCOS undergoing IVF, as a good practice point, hCG trigger should be replaced by a GnRHa trigger with vitrification of all embryos followed by FET.