Risk factors for a suboptimal response to gonadotropin-releasing hormone agonist trigger during in vitro fertilization cycles

Abstract

Long-term hormonal contraception use is an independent risk factor for suboptimal response to GnRH-agonist trigger. Patients with very low endogenous serum LH levels on the day of LH trigger are at increased risk for a suboptimal GnRH-agonist trigger response. Understanding the at-risk phenotype and using trigger day LH as a marker for increased risk of suboptimal GnRH-agonist trigger response can be helpful for individualizing treatment and selecting a safe and efficacious trigger medication for patients undergoing IVF.

Sliding scale HCG trigger yields equivalent pregnancy outcomes and reduces ovarian hyperstimulation syndrome: Analysis of 10,427 IVF-ICSI cycles

“…Evidence indicates that lower doses of hCG are as effective to the standard 10,000 IU with regards to achieving equivalent oocyte maturity, however no threshold of hCG has been established [15,19–21]. One study reported that patients receiving 2,000 IU hCG had a significantly lower number of MII oocytes retrieved compared to patients receiving 5,000 or 10,000 IU.…”

“…Despite the paradigm shift to use antagonist-based protocols with subsequent GnRHa trigger some literature suggests reduced clinical pregnancy, delivery rates and increased miscarriage rates. In addition, patients with significant hypothalamic suppression, either secondary to prolonged oral contraceptive use or due to endogenous low serum LH levels, may have a sub optimal response to GnRH agonist trigger and therefore data regarding hCG trigger alone remains pertinent [13] [14] [15]. Limited data exists, however, on the lowest threshold dose of hCG required to bring about oocyte maturity with high reproducibility, or whether pregnancy rates are affected by lower serum absorption of hCG.…”

Profound Pituitary Suppression Following Oral Contraceptive Pretreatment in Gonadotropin-releasing Hormone Antagonist Cycles Does Not Impact Outcome: A Retrospective Cohort Study

“…GnRH antagonist protocols that utilize a GnRH agonist, either alone or in combination with a low dose of hCG (dual trigger) to induce ovulation, have been shown to minimize the risk of OHSS [31]. A recent retrospective study of GnRH antagonist cycles identified long-term OCP use (i.e., OCP use upon the patient's initial clinical visit), a practice often utilized with egg donors, as a risk factor for suboptimal response to a GnRH agonist or dual trigger (defined as serum LH <15 mIU/mL on the morning after trigger) [32]. These findings suggest that a GnRH agonist or dual trigger may not be appropriate for use in patients with profound pituitary suppression.…”

Prevention and management of ovarian hyperstimulation syndrome

“…It should also be noted that patients who exhibit signs of significant suppression of the hypothalamic-pituitary axis, as determined by low serum LH (<0.5 mIU/mL) on the day of trigger, have a 25% chance of a suboptimal response to use of a GnRH agonist for final oocyte maturation [25]. To overcome this inadequate response, dual triggering with hCG (1000IU) and GnRH agonist trigger have been used, but this negates the principal advantage of removing exogenous hCG, the principal driver of OHSS [26].…”