Individual luteolysis post GnRH-agonist-trigger in GnRH-antagonist protocols

Abstract

Over the past few years, the use of Gonadotropin-releasing-hormone (GnRH)-agonist for final oocyte maturation in GnRH-antagonist-protocols in stimulated IVF/ICSI cycles has gained worldwide acceptance, as this approach reduces significantly the risk for development of ovarian hyperstimulation syndrome (OHSS). Final oocyte maturation with GnRH-agonist leads to sever luteolysis, which cannot be counterbalanced using standard luteal phase support with purely progesterone (P4) application and therefore administration of hCG or high doses of P4 is considered to be essential to prevent/counteract luteolysis. However, lately publications indicate, that luteolysis is not always complete after GnRH-agonist for trigger. This case-series evaluates the degree of luteolysis in high-responder-patients, who received GnRH-agonist for final oocyte maturation. Assessment of estradiol (E2)- and P4-levels 48 h after oocyte-pick-up (OPU) procedure demonstrate clearly, that luteolysis after GnRH-agonist trigger is individual-specific, even in high-responder patients with the same number of oocytes. Hence, individualization of luteal phase support with the focus on avoiding unnecessary administration of hCG, bearing the risk for development of OHSS, a new concept of luteal coasting needs to be developed, based on severity of luteolysis following luteal coasting.

Severe Ovarian Hyperstimulation Syndrome in a Woman With Breast Cancer Under Letrozole Triggered With GnRH Agonist: A Case Report and Review of the Literature

“…Regarding the LPS, it is important to introduce the concept of “luteal costing,” which could be adapted to patients with cancer ( 29 , 30 ). The idea of individualizing the LPS by monitoring serum progesterone levels could be used in these patients to identify the best timing for the administration of GnRH-a depot to prevent the onset of OHSS.…”

Individual luteolysis pattern after GnRH-agonist trigger for final oocyte maturation

“…However, recently published case reports [15,19] and our data demonstrate clearly that luteolysis after GnRH-agonist-trigger is individual-specific and will not follow the same pattern.…”

“…Previously, it was demonstrated, that GnRH-agonist trigger for final oocyte maturation would lead to severe luteolysis [ 5 ] and additional the reproductive outcome of the first studies, using GnRH-agonist for final oocyte maturation with a “standard” luteal phase support were poor [ 14 ] as a result of severe luteolysis. However, recently published case reports [ 15 , 19 ] and our data demonstrate clearly that luteolysis after GnRH-agonist-trigger is individual-specific and will not follow the same pattern.…”

“…However, lately several case reports demonstrate that luteolysis after GnRH-agonist trigger is not complete and varies, indicating distinct differences among patients [15–19]. …”

“…The first studies using GnRH-agonist for final oocyte maturation reported a very poor reproductive outcome due to the severe luteolysis and it was assumed that the extend of the induced luteolysis cannot be counterbalanced by using standard luteal phase support with “only” progesterone administration [ 14 ]. However, lately several case reports demonstrate that luteolysis after GnRH-agonist trigger is not complete and varies, indicating distinct differences among patients [ 15 – 19 ].…”