HCG trigger versus GnRH agonist trigger in PCOS patients undergoing IVF cycles: frozen embryo transfer outcomes

Abstract

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.

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“…A recent meta analysis concluded that there was a statistically significant higher clinical pregnancy rate after the transfer of embryos obtained from the GnRHa group in comparison to that from the HCG group in frozen-thawed cycles, that might be linked to a higher number of oocytes retrieved, greater maturity, better fertilization, greater number of high quality embryos and a higher number of blastocysts gained in the GnRHa group in comparison to the HCG group. 13 Moreover, in the present study, there was no statistically significant difference between HCG triggering group and GnRH agonist triggering group as regard the quality of embryos nor the number of transferred embryos.…”

“…So, in IVF cycles for PCOS women, a trigger by HCG should be substituted by a trigger by GnRHa with vitrification of all embryos followed by frozen embryo transfer. 6 In the current study, there was no statistically significant difference between GnRH agonist and HCG triggering regarding the quality of oocytes.…”

“…So, reduces the OHSS risk, but with a possibility of compromised cycle outcomes and decreased pregnancy rates. 6 Review articles revealed that fertility outcome in triggering by GnRH agonist is alike that after hCG trigger. So, it is suggested that GnRH-a trigger is an appropriate method for ladies at risk of OHSS and also oocyte donors.…”

Optimization of assisted reproductive technology outcomes in patients with polycystic ovarian syndrome: updates and unanswered questions

“…Embryos were graded using the Istanbul consensus [35] and grade 1 was a top-quality cleavage stage embryo in this study. This group also demonstrated that among the same cohort of 210 patients, pregnancy rates following frozen ETs after use of an agonist trigger are comparable or improved compared to those with the use of hCG [36 ▪ ]. There were 170 subsequent FET cycles in the GnRHa group and 195 FET cycles in the hCG trigger group.…”

Live Birth Outcomes for PCOS Patients Under the Follicular-Phase Long-Acting GnRH Agonist Protocol or Antagonist Protocol – A Retrospective Chinese Cohort

“…27 As the risk of OHSS is due to the effect of hCG, 28 using GnRH agonist protocols to trigger ovulation and reducing hCG usage can reduce OHSS in the GnRH antagonist protocol. 29,30 For our center, there were only a few mild OHSS cases in the two groups. Those patients with a high potential risk of OHSS occurrence on embryo transfer day will not have fresh cycle implementation.…”