GnRH agonist trigger for the induction of oocyte maturation in GnRH antagonist IVF cycles: a SWOT analysis

Abstract

Gonadotrophin releasing hormone agonist (GnRHa) trigger is effective in the induction of oocyte maturation and prevention of ovarian hyperstimulation syndrome during IVF treatment. This trigger concept, however, results in early corpora lutea demise and consequently luteal phase dysfunction and impaired endometrial receptivity. The aim of this strenghths, weaknesses, opportunities and threats analysis was to summarize the progress made over the past 15 years to optimize ongoing pregnancy rates after GnRHa trigger. The advantages and potential drawbacks of this type of triggering are reviewed. The current approach to the management of GnRHa trigger in autologous cycles is based on the peak serum oestradiol level or follicle number and aims at a fresh embryo transfer or a segmentation approach with elective cryopreservation policy. We recommend intensive luteal support with transdermal oestradiol and intramuscular progesterone alone if peak serum oestradiol is 4000 or more pg/ml after GnRHa trigger or dual trigger with GnRHa and HCG 1000 IU if peak serum oestradiol is less than 4000 pg/mL. On the contrary, we recommend HCG 1500 IU 35 h after GnRHa trigger if there are less than 25 follicles, or freeze all oocytes or embryos if there are over 25 follicles.

Gonadotropin Releasing Hormone Agonist Final Oocyte Maturation and Human Chorionic Gonadotropin as Exclusive Luteal Support in Normal Responders

“…FSH has a role in the process of oocyte maturation; it induces LH receptor formation on the luteinized granulose cells and promotes oocyte maturation and cumulus expansion [11]. As opposed to hCG, a single dose of GnRHa induces an endogenous LH and FSH surge [8]. In addition, there are GnRH receptors on ovarian granulose cells, which have been shown to play a role in regulating ovulation [11,12].…”

“…It is assumed that the combined effect of the high estradiol levels due to the ovarian stimulation and the GnRHa bolus dramatically reduces the endogenous LH concentration during the luteal phase [5]. The subsequent pituitary desensitization and withdrawal of LH support account for the defective corpus luteum function [8]. Thus, a modification of the luteal supplementation is essential.…”

“…Efforts were made to improve the reproductive outcome by manipulating the luteal phase. Researchers have suggested intensive luteal phase progesterone and estradiol support alone or in combination with hCG support [8]. An additional strategy is the "freeze-all" policy [8].…”

“…The use of GnRHa to induce final oocyte maturation in normal responders is still not widely accepted and the optimal luteal phase support in this protocol has not been determined [6,8]. More studies are needed to define its proper role in order to achieve an optimal reproductive outcome with a minimal risk of OHSS.…”

Pharmacokinetic, pharmacodynamic, and clinical aspects of ovulation induction agents: A review of the literature

“…Youssef et al (39) recommended the use of GnRH agonists as an oocyte maturation trigger for women who are spared for fresh transfers, who are oocyte donors, and who demand to freeze autologous oocytes for fertility preservation. Recently, Engmann et al (40) reviewed the advantages and potential drawbacks of GnRH agonist triggering by performing a strengths, weaknesses, opportunities and threats (SWOT) analysis. Based on this analysis modality, the authors recommended intensive luteal support with transdermal oestradiol and intramuscular progesterone alone if peak serum oestradiol is 4000 or more pg/mL after GnRHa triggering or dual triggering with GnRH agonist and hCG 1000 IU if peak serum oestradiol is less than 4000 pg/mL.…”