- Email: [email protected]
Agonist “flare-up” versus antagonist in the management of poor responders undergoing in vitro fertilization treatment
Agonist “flare-up” versus antagonist in the management of poor responders undergoing in vitro fertilization treatment Kamel A. Mohamed, M.R.C.O.G.,a W. A. R. Davies, F.R.C.O.G.,a Julian Allsopp, M.Med.Sci.,a and Hany Lashen, M.D.b a
CARE at the Three Shires Hospital, Northampton, and b Section of Reproductive and Developmental Medicine, University of Sheffield, Sheffield, United Kingdom
Objective: To compare the agonist flare-up and antagonist protocols in the management of poor responders to the standard long down-regulation protocol. Design: Retrospective comparative study. Setting: Assisted conception center. Patient(s): One hundred thirty-four patients undergoing IVF/ intracytoplasmic sperm injection (ICSI) treatment, who responded poorly to the standard long down-regulation protocol in their first treatment cycle. In the second cycle, 77 received short flare-up agonist and 57 received antagonist protocol. We analyzed the outcome of the second cycle. Intervention(s): Peak serum E2 was assayed on the day of hCG administration. Main Outcome Measure(s): Cycle cancellation rate due to poor ovarian response. Result(s): There was no cycle cancellation in the flare-up protocol and 7% cancellation rate in the antagonist protocol due to lack of response. A significantly higher number of patients had embryo transfer in the flare-up protocol. There was no difference in pregnancy rate (PR) between the two groups. Conclusion(s): Both the flare-up and the antagonist protocols significantly improved the ovarian response of known poor responders. However, a significantly higher cycle cancellation rate and less patients having embryo transfer in the antagonist group tips the balance in favor of the flare-up protocol. (Fertil Steril威 2005;83:331–5. ©2005 by American Society for Reproductive Medicine.) Key Words: Agonist, antagonist, flare-up, IVF, poor responders
The treatment of poor responders has challenged many in the field of assisted reproduction. A variety of ovarian stimulation protocols have been tried with some degree of success indicating different reasons for poor response. Many clinicians simply increase the gonadotropin daily dose despite the lack of supporting evidence (1, 2). The short down-regulation protocol (flare-up) has been reported to successfully improve ovarian response in poor responders (3–5), albeit, the pregnancy rates (PR) remained invariably lower than those achieved by the normal responders (4). Schoolcraft et al. (6) suggested that patients with declining ovarian reserve who had previously failed to stimulate with standard protocols might benefit from a combination of precycle estrogen (E) and P treatment followed by a microdose GnRH flare-up protocol along with FSH and GH. The GnRH antagonists were also used successfully to improve the outcome in poor responders (7–9). The successful use of GnRH antagonists in normal responders (10 –12) encouraged Akman et al. (13) to compare the short “flare-up” and the antagonist protocols in the manReceived October 31, 2003; revised and accepted July 21, 2004. Reprint requests: Kamel Mohamed, M.R.C.O.G., CARE at the Three Shires Hospital, Northampton, NN1 5DR, United Kingdom (FAX: 4401604-603275; E-mail: [email protected]).
0015-0282/05/$30.00 doi:10.1016/j.fertnstert.2004.07.963
agement of poor responders in a small prospective study. Despite an apparent higher PR in the antagonist group, statistical significance could not be reached due to the small sample size. Poor responders represent on average 10% of the patients in most assisted conception clinics, which creates a logistic problem for carrying out a prospective study with sufficient power. Furthermore, poor responders are not a homogeneous group of patients but a mixture of inherently low responders with normal ovarian reserve and those with diminished ovarian reserve. This fact is the main source of discrepancy in the reported success rates of different protocols and a major obstacle to carrying out a multicenter study. For these reasons, retrospective large studies may help provide extra supporting evidence. In this large retrospective study we compared the ovarian response of a group of known poor responders to either short agonist flare-up or GnRH antagonist protocol. MATERIALS AND METHODS Between April 2001 and November 2002, 134 IVF/intracytoplasmic sperm injection (ICSI) cycles were started in women who had a background of cancellation because they developed less than three mature follicles in a previous IVF cycle under the standard long down-regulation protocol. The
Fertility and Sterility姞 Vol. 83, No. 2, February 2005 Copyright ©2005 American Society for Reproductive Medicine, Published by Elsevier Inc.
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long midluteal phase down-regulation protocol is the standard protocol used for the first cycle of all patients with normal early follicular phase FSH (⬍13 IU/L).
The gonadotropins used in both groups were hMG, menopur (Ferring Pharmaceuticals, Langly, UK).
If a patient produces less than three follicles measuring ⱖ17 mm despite adequate stimulation (in terms of dose and duration) they were considered poor responders. The cycle was then cancelled and either a short agonist flare-up or antagonist protocol was used for the subsequent cycle. The choice of the protocol was based on individual preference of the clinician carrying out the treatment regardless of the patient’s failed cycle parameters. A normal early follicular phase FSH was confirmed in all patients before proceeding to the next cycle. The average gap between the poor response cycle and the following cycle was 2–3 months. None of the patients received any hormonal pretreatment.
Hormonal Assay All patients had their FSH and LH rechecked on days 2–5 of the cycle preceding the treatment cycle.
In the standard long protocol the patients started the down-regulation from midluteal phase (day 21) with 500 g buserelin (Suprefact; Hoechst, Denham, Uxbridge, UK) SC injections daily. Once successful down-regulation is confirmed (E2 ⬍200 pmol/L, LH ⬍5 IU/L and endometrial thickness ⬍5 mm) ovarian stimulation was started at a dose of 150 or 225 IU/d of gonadotropin depending on the patient’s age (⬍30 years receive 150 IU and ⱖ30 years receive 225 IU). A step-up protocol was adopted and the gonadotropin dose was increased by 75 IU/d if less than three follicles measuring 12 mm or more were found on stimulation day 7. For the purpose of this study, the patients were divided into two groups according to the stimulation protocol they received in their second cycle.
Serum peak E2 was assayed in every patient on the day of hCG administration. Hormonal assays were carried out using IMx assay (Abbott Laboratories, Diagnostic Division, Abbott Park, IL). The IMx assay is based on the microparticle enzyme immunoassay technology. The precision test (reproducibility) of IMx FSH showed coefficient of variation (CV) of 8% at 5 mIU/mL, 8.9% at 24.9 mIU/mL, and 12% at 70.3 mIU/mL. The same test of IMx LH showed CV of 8.7% at 5.37 mIU/mL, 6.4% at 43.2 mIU/mL, and 6.2% at 82.5 mIU/mL. The precision test of IMx E2 assay showed CV of 19.1% at 67 pg/mL, 9.2% at 140 pg/mL, 5.7% at 524 pg/mL, and 6.1% at 1,166 pg/mL. Oocyte Retrieval The hCG (10,000 IU, Profasi; Serono, Feltham, UK) was administered SC when at least three follicles measuring ⱖ18 mm were seen on ultrasound scan. Transvaginal ultrasound scanguided oocyte retrievals were performed 36 hours after hCG administration under Sedoanalgesia (a combination of intravenously administered sedative and analgesic). Midazolam (Hypnovel; Roche, Welwyn Garden City, UK) and pethidine were the sedative and analgesic used.
Group 1 included the patients who underwent the GnRH agonist short flare-up down-regulation protocol. In this protocol, buserelin (Suprefact, Hoechst), 500 g/d SC injections were started from day 1 of the menstrual cycle. The gonadotropin administration started on day 3 of the same cycle with a dose of 225–375 IU/d based on the highest gonadotropin dose the patient reached in the previous poor response cycle.
Embryo Transfer Up to three embryos at 4- to 8-cell stage were replaced per patient under ultrasound scan guidance. Progesterone vaginal pessaries (Cyclogest, Shire Andover, UK), 400 mg twice daily, were used for luteal phase support until the patient had her pregnancy test 2 weeks after embryo transfer (ET). If the pregnancy test was positive, the patient was advised to continue using the pessaries up to and including week 12 of gestation.
The patients were then monitored for ovarian response using ultrasound scan starting on cycle day 9 (stimulation day 7) then daily or on alternate days depending on their response. The gonadotropin dose was increased by 75 IU/d if less than three follicles measuring 12 mm or more were seen on day 9. Both the buserelin and gonadotropin stimulation were continued until the day of hCG administration.
The Study’s Outcome Measures The main outcome measure in this study was the cycle cancellation rate due to poor ovarian response.
Group 2 included the patients who underwent the GnRH antagonist protocol. In this protocol, the gonadotropin dose selection and the monitoring process were the same as for group 1. The GnRH antagonist was administered on cycle day 8 (stimulation day 6 as stipulated by the manufacturer) with a daily dose of 0.25 mg SC cetrorelix (Cetrotide; Asta Medica, Cambridge, UK) and continued until the day of hCG administration. 332
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Other outcome measures were daily gonadotropin dose, duration of gonadotropin stimulation, peak E2, number of oocytes collected, fertilization rate, and clinical PR per cycle and per ET (clinical pregnancy was diagnosed by the visualization of fetal cardiac activity on ultrasound scan). Statistical Analysis The statistical analysis was carried out using SPSS software package (Chicago, IL). The 2, Fisher’s exact, and t tests
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TABLE 1 Outcome of short flare-up vs. antagonist protocol.
Age Early follicular phase FSH Early follicular phase LH Gonadotropin/day Days of stimulation Endometrial thickness Peak E2 level No. of follicles No. of oocytes Fertilization rate (FR) No. of embryos transferred No. of patients reaching ET Implantation rate Failed oocyte retrieval Failed fertilization Failed cleavage Cancellation (poor response) Clinic pregnancy rate/cycle Clinic pregnancy rate/ET a
Group 1 (flare-up) 77 cycles
Group 2 (antagonist) 57 cycles
P value
38 ⫾ 4 9.3 ⫾ 3.3 IU/L 5.3 ⫾ 2.8 IU/L 303 ⫾ 63 IU 11 ⫾ 2 days 10.3 ⫾ 2 mm 5,910 ⫾ 3,162 pmol/L 6⫾3 5.2 ⫾ 2.6 65.4% 2.1 ⫾ 0.8 73/77 (94.8%) 21/165 (12.8%) 0 3/77 (3.9%) 1/74 (1.4%) None 19/77 (24.7%) 19/73 (26%)
38 ⫾ 4 8.6 ⫾ 3.2 4.5 ⫾ 1.9 318 ⫾ 68 IU 9.8 ⫾ 1.6 days 10.2 ⫾ 2 mm 3,923 ⫾ 2,040 pmol/L 6⫾3 5.4 ⫾ 3.6 57.4% 1.9 ⫾ 1.1 47/57 (82.5%) 14/109 (12.8%) 2/53 (3.8%) 4/51 (7.8%) 0 4 (7%) 10/57 (17.5%) 10/47(21.3%)
NS NS NS NS .01a NS .001a NS NS NS NS .02a NS NS NS NS .03a NS NS
Significant.
Mohamed. Flare-up vs. antagonist in poor responders. Fertil Steril 2005.
were used where appropriate. A P value ⬍.05 was considered significant. The data are presented as mean ⫾ SD.
of stimulation (P⫽.01), and higher peak E2 (P⫽.001). Otherwise, the two groups were statistically similar with regard to all other compared parameters (Table 1).
RESULTS A total of 134 patients, who were recognized as poor responders based on their previous ovarian response, were included in the study. There were 77 patients (77 cycles) included in group 1 (short flare-up protocol) and 57 patients (57 cycles) included in group 2 (antagonist protocol). Both groups were similar with regard to age and basal (cycle day 2) FSH and LH levels (Table 1).
The details of the four cancelled cycles are summarized in Table 2.
The causes of infertility were male infertility factor (23 cases in each group), endometriosis (13 in group 1 and 6 in group 2), tubal factor (11 in each group), anovulation (3 in group 1 and 2 in group 2), unexplained (17 in group 1 and 10 in group 2), and multifactorial (10 in group 1 and 5 in group 2). There was no significant difference in the distribution of causes of infertility between both groups. A total of 43 and 26 patients underwent IVF treatment in groups 1 and 2, respectively, whereas 34 and 31 patients underwent ICSI treatment in groups 1 and 2, respectively. A comparison of both groups is summarized in Table 1. The patients in group 1 (short flare-up agonist protocol) had significantly lower cycle cancellation rate (P⫽.03), were more likely to reach ET stage (P⫽.02), had longer duration Fertility and Sterility姞
DISCUSSION Poor response to ovarian stimulation can be broadly defined as unsatisfactory ovarian response despite adequate ovarian stimulation. Although we may all agree on this definition, the quantification of the word unsatisfactory has been the center of controversy. Many clinicians consider the production of less than three mature follicles as poor response, whereas others take into account the maximum E2 levels, the minimal cumulative dose, or days of gonadotropin stimulation required in a prior cycle when defining poor responders (14). The quality of ovarian response should be considered in conjunction with the stimulation protocol used. Profound pituitary down-regulation is more likely to reduce ovarian response (15). Hence, the tendency to use the short downregulation protocol (flare-up), with regular dose or microdose of GnRH agonist, in patients who are likely to have a poor response (3– 6). The initial agonistic flare-up that occurs with the short protocol may also aid follicular recruit333
TABLE 2 Details of the four cancelled cycles.
Age Cause of infertility FSHa Daily dose Days of stimulation Follicles E2 (pmol/L) a
1
2
3
4
34 Male factor 7 300 10 1 1,125
40 Male factor 7 375 9 0 1,050
35 Endometriosis 11 375 10 1 950
43 Male factor 12.7 375 9 0 933
Early follicular phase.
Mohamed. Flare-up vs. antagonist in poor responders. Fertil Steril 2005.
ment, which may theoretically reduce the gonadotropin requirements. The use of GnRH antagonists in the stimulation protocol of poor responders would benefit from the endogenously produced gonadotropins as well as prevent premature LH surge. Therefore, it theoretically lends itself perfectly to the treatment of poor responders (7–9). In a small prospective study, Akman et al. (13) reported no difference in the clinical PRs between patients undergoing short flare-up or antagonist protocols. However, based on the outcome of their study, a sample size of 1,789 is required to verify their findings with 80% power. Recruiting such numbers of poor responders is not realistic. However, their findings along with other small prospective and large retrospective studies may provide us with a general trend in the outcome of the treatment protocols in question. Although our study is retrospective, it comprises a relatively large sample size. Furthermore, the allocation of patients to one protocol or the other was not influenced by the parameters of the previous failed cycle and was merely dependent on the clinician’s preference. This reduces, but by no means eliminates, the systematic bias given the retrospective nature of the study. The similarity in age and early follicular phase FSH and LH levels between the two groups supports this point. Our results showed that both protocols gave better ovarian response compared to the previous poor ovarian response under the standard long down-regulation protocol. The background of cancellation due to poor ovarian response in both groups dropped from 100% under the long down-regulation protocol to 0% and 7% in short flare-up and antagonist protocols, respectively. This along with the similarity in the number of follicles and oocytes retrieved are in agreement with the results published by Akman et al. (13). In contrast to the findings reported by Akman et al. (13) we reported a significantly higher cycle cancellation rate due 334
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to poor ovarian response in the antagonist group (P⬍.03). The exact reason for this is not known; however, it may be due to the initial flare-up of endogenous gonadotropin that enhanced follicular recruitment in group 1 (short flare-up group). Because six patients did not reach the ET stage in group 2 (antagonist group) due to poor ovarian response or failure to retrieve oocytes, one can conclude that the short flare-up protocol had an advantage over the antagonist one. Despite the improvement achieved in these patients’ response in the second cycle of treatment, four patients failed to respond and were canceled. Relying on early follicular FSH to screen for genuine poor response due to diminished ovarian reserve has been argued by some investigators to be inadequate and other tests were suggested such as clomiphene citrate (CC) challenge test, GnRH agonist stimulation test, antral follicle count, and basal inhibin B level (14, 16, 17). However, the predictive values and the practicality of usage limited the daily application of these tests. Furthermore, it remains very difficult to preclude patients from undergoing IVF treatment based on the result of these tests alone knowing their limited specificity and sensitivity (16). Most of these screening tests predict poor ovarian response to standard stimulation protocols but do not address the value of alternative regimens that we address in this study (14). In this study, however, we found that the duration of ovarian stimulation was significantly longer in the agonist group flare-up. Although this did not have an overall impact on the total gonadotropin dose used, we believe that it might be the reason for a significantly higher peak E2 in this group. This difference, however, is in agreement with previous findings (13) and is not unique to poor responders (18). Although measuring the serum P would be an advantage when comparing the PR and implantation rate between the
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two groups, we did not determine that it affected our study, as the main outcome measure was cycle cancellation rate due to poor response. The low implantation rate in both groups of the study is hardly surprising knowing that implantation is the limiting factor to the success of IVF treatment. Furthermore, oocytes obtained from poor responders with diminished ovarian reserve may be of lower quality, which may affect the overall implantation rate for the study groups. Given the design and objectives of this study further assessment of the implantation rate is not possible. In conclusion, although our study did not show a significant difference in the PRs in the two protocols, the study indicates that patients receiving the short flare-up protocol are more likely to proceed to the ET stage. We, therefore, believe that given a large enough number of patients this finding would impact on the overall PR in favor of the short flare-up protocol. REFERENCES 1. Land J, Yarmolinskaya M, Dumoulin J, Evers J. Higher dose menopausal gonadotrophin stimulation in poor responders does not improve in vitro fertilization outcome. Fertil Steril 1996;65:961–5. 2. Lashen H, Ledger W, Bernal A, Evan B, Barlow D. Super ovulation with high gonadotrophin dose for invitro fertilization, is it effective? J Assisted Reprod Genet 1998;15:438 – 43. 3. Padilla S, Dugan K, Maruschak V, Shalika S, Smith R. Use of the flare up protocol with high dose human follicle stimulating hormone and human menopausal gonadotrophin for IVF in poor responders. Fertil Steril 1996;65:796 –9. 4. Karande V, Morris R, Rinehart J, Miller C, Rao R, Gleicher N. Limited success using the flare protocol in poor responders in cycles with low basal follicle stimulating hormone levels during in vitro fertilization. Fertil Steril 1997;67:900 –3. 5. Surrey E, Bower J, Hill D, Ramsey J, Surrey M. Clinical and endocrine effects of a microdose GnRH agonist flare regimen administered to poor responders who are undergoing in vitro fertilization. Fertil Steril 1998;69:419 –24. 6. Schoolcraft W, Schlenker T, Gee M, Stevens J, Wagley L. Improved controlled ovarian hyperstimulation in poor responders in vitro fertili-
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zation patients with a microdose follicle stimulating hormone flare, growth hormone protocol. Fertil Steril 1997;67:93–7. Craft I, Gorgy A, Hill J, Menon D, Podsiadly B. Will GnRH antagonists provide new hope for patients considered difficult responders to GnRH agonist protocols? Hum Reprod 1999;14:2959 – 62. Akman M, Erden H, Tosun S, Bayazit N, Akosy E, Bahceci M. Addition of GnRH antagonist in cycles of poor responders undergoing IVF. Hum Reprod 2000;15:2145–7. Nikolettos N, Al-Hassani S, Felberbaum R, Damirel L, Kupker W, Montzka P, et al. Gonadotrophin-releasing hormone antagonist protocol: a novel method of ovarian stimulation in poor responders. Eur J Obstet Gyn Reprod Biol 2001;97:202–7. Felberbaum R, Albano C, Ludwig M, Riethmuller-Winzen H, Grigat M, Devroey P, et al. Ovarian stimulation for assisted reproduction with HMG and concomitant midcycle administration of the GnRH antagonist cetrorelix according to the multiple dose protocol: a prospective uncontrolled phase III study. Hum Reprod 2000;15:1015–20. The European and Middle East Orgalutran Study Group. Comparable clinical outcome using the GnRH antagonist ganirelix or a long protocol of the GnRH agonist triptorelin for the prevention of premature LH surges in women undergoing ovarian stimulation. Hum Reprod 2001; 16:644 –51. Olivennes F, Mannaerts B, Struijs M, Bonduelle M, Devroey P. Perinatal outcome of pregnancy after GnRH antagonist (ganirelix) treatment during ovarian stimulation for conventional IVF or ICSI: a preliminary report. Hum Reprod 2001;16:1588 –91. Akman M, Erden H, Tosun S, Bayazit N, Akosy E, Behceci M. Comparison of agonistic flare up protocol and antagonistic multiple dose protocol in ovarian stimulation of poor responders: results of a prospective randomized trial. Hum Reprod 2001;16:868 –70. Surrey E, Schoolcraft W. Evaluating strategies for improving ovarian response of the poor responder undergoing assisted reproduction techniques. Fertil Steril 2000;73:667–76. Fleming R, Lloyd F, Herbert M, Fenwick J, Griffith T, Murdoch A. Effect of profound suppression of luteinising hormone during ovarian stimulation on follicular activity, oocyte and embryo function in cycles stimulated with purified follicle stimulating hormone. Hum Reprod 1998;13:1788 –92. Scott R, Hofmann G. Prognostic assessment of ovarian reserve. Fertil Steril 1995;63:1–11. Bancsi L, Broekmans F, Eijkemans M, de Jong F, Habbema J, te Velde E. Predictors of poor ovarian response in in vitro fertilization: a prospective study comparing basal markers of ovarian reserve. Fertil Steril 2002;77:328 –36. Garecia-Velasco J, Isaza V, Vidal C, Landazabal A, Remohi J, Simon C, et al. Human ovarian steroid secretion in vivo: effects of GnRH agonist versus antagonist (cetrorelix). Hum Reprod 2001;16:2533–9.
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CARE at the Three Shires Hospital, Northampton, and b Section of Reproductive and Developmental Medicine, University of Sheffield, Sheffield, United Kingdom
Objective: To compare the agonist flare-up and antagonist protocols in the management of poor responders to the standard long down-regulation protocol. Design: Retrospective comparative study. Setting: Assisted conception center. Patient(s): One hundred thirty-four patients undergoing IVF/ intracytoplasmic sperm injection (ICSI) treatment, who responded poorly to the standard long down-regulation protocol in their first treatment cycle. In the second cycle, 77 received short flare-up agonist and 57 received antagonist protocol. We analyzed the outcome of the second cycle. Intervention(s): Peak serum E2 was assayed on the day of hCG administration. Main Outcome Measure(s): Cycle cancellation rate due to poor ovarian response. Result(s): There was no cycle cancellation in the flare-up protocol and 7% cancellation rate in the antagonist protocol due to lack of response. A significantly higher number of patients had embryo transfer in the flare-up protocol. There was no difference in pregnancy rate (PR) between the two groups. Conclusion(s): Both the flare-up and the antagonist protocols significantly improved the ovarian response of known poor responders. However, a significantly higher cycle cancellation rate and less patients having embryo transfer in the antagonist group tips the balance in favor of the flare-up protocol. (Fertil Steril威 2005;83:331–5. ©2005 by American Society for Reproductive Medicine.) Key Words: Agonist, antagonist, flare-up, IVF, poor responders
The treatment of poor responders has challenged many in the field of assisted reproduction. A variety of ovarian stimulation protocols have been tried with some degree of success indicating different reasons for poor response. Many clinicians simply increase the gonadotropin daily dose despite the lack of supporting evidence (1, 2). The short down-regulation protocol (flare-up) has been reported to successfully improve ovarian response in poor responders (3–5), albeit, the pregnancy rates (PR) remained invariably lower than those achieved by the normal responders (4). Schoolcraft et al. (6) suggested that patients with declining ovarian reserve who had previously failed to stimulate with standard protocols might benefit from a combination of precycle estrogen (E) and P treatment followed by a microdose GnRH flare-up protocol along with FSH and GH. The GnRH antagonists were also used successfully to improve the outcome in poor responders (7–9). The successful use of GnRH antagonists in normal responders (10 –12) encouraged Akman et al. (13) to compare the short “flare-up” and the antagonist protocols in the manReceived October 31, 2003; revised and accepted July 21, 2004. Reprint requests: Kamel Mohamed, M.R.C.O.G., CARE at the Three Shires Hospital, Northampton, NN1 5DR, United Kingdom (FAX: 4401604-603275; E-mail: [email protected]).
0015-0282/05/$30.00 doi:10.1016/j.fertnstert.2004.07.963
agement of poor responders in a small prospective study. Despite an apparent higher PR in the antagonist group, statistical significance could not be reached due to the small sample size. Poor responders represent on average 10% of the patients in most assisted conception clinics, which creates a logistic problem for carrying out a prospective study with sufficient power. Furthermore, poor responders are not a homogeneous group of patients but a mixture of inherently low responders with normal ovarian reserve and those with diminished ovarian reserve. This fact is the main source of discrepancy in the reported success rates of different protocols and a major obstacle to carrying out a multicenter study. For these reasons, retrospective large studies may help provide extra supporting evidence. In this large retrospective study we compared the ovarian response of a group of known poor responders to either short agonist flare-up or GnRH antagonist protocol. MATERIALS AND METHODS Between April 2001 and November 2002, 134 IVF/intracytoplasmic sperm injection (ICSI) cycles were started in women who had a background of cancellation because they developed less than three mature follicles in a previous IVF cycle under the standard long down-regulation protocol. The
Fertility and Sterility姞 Vol. 83, No. 2, February 2005 Copyright ©2005 American Society for Reproductive Medicine, Published by Elsevier Inc.
331
long midluteal phase down-regulation protocol is the standard protocol used for the first cycle of all patients with normal early follicular phase FSH (⬍13 IU/L).
The gonadotropins used in both groups were hMG, menopur (Ferring Pharmaceuticals, Langly, UK).
If a patient produces less than three follicles measuring ⱖ17 mm despite adequate stimulation (in terms of dose and duration) they were considered poor responders. The cycle was then cancelled and either a short agonist flare-up or antagonist protocol was used for the subsequent cycle. The choice of the protocol was based on individual preference of the clinician carrying out the treatment regardless of the patient’s failed cycle parameters. A normal early follicular phase FSH was confirmed in all patients before proceeding to the next cycle. The average gap between the poor response cycle and the following cycle was 2–3 months. None of the patients received any hormonal pretreatment.
Hormonal Assay All patients had their FSH and LH rechecked on days 2–5 of the cycle preceding the treatment cycle.
In the standard long protocol the patients started the down-regulation from midluteal phase (day 21) with 500 g buserelin (Suprefact; Hoechst, Denham, Uxbridge, UK) SC injections daily. Once successful down-regulation is confirmed (E2 ⬍200 pmol/L, LH ⬍5 IU/L and endometrial thickness ⬍5 mm) ovarian stimulation was started at a dose of 150 or 225 IU/d of gonadotropin depending on the patient’s age (⬍30 years receive 150 IU and ⱖ30 years receive 225 IU). A step-up protocol was adopted and the gonadotropin dose was increased by 75 IU/d if less than three follicles measuring 12 mm or more were found on stimulation day 7. For the purpose of this study, the patients were divided into two groups according to the stimulation protocol they received in their second cycle.
Serum peak E2 was assayed in every patient on the day of hCG administration. Hormonal assays were carried out using IMx assay (Abbott Laboratories, Diagnostic Division, Abbott Park, IL). The IMx assay is based on the microparticle enzyme immunoassay technology. The precision test (reproducibility) of IMx FSH showed coefficient of variation (CV) of 8% at 5 mIU/mL, 8.9% at 24.9 mIU/mL, and 12% at 70.3 mIU/mL. The same test of IMx LH showed CV of 8.7% at 5.37 mIU/mL, 6.4% at 43.2 mIU/mL, and 6.2% at 82.5 mIU/mL. The precision test of IMx E2 assay showed CV of 19.1% at 67 pg/mL, 9.2% at 140 pg/mL, 5.7% at 524 pg/mL, and 6.1% at 1,166 pg/mL. Oocyte Retrieval The hCG (10,000 IU, Profasi; Serono, Feltham, UK) was administered SC when at least three follicles measuring ⱖ18 mm were seen on ultrasound scan. Transvaginal ultrasound scanguided oocyte retrievals were performed 36 hours after hCG administration under Sedoanalgesia (a combination of intravenously administered sedative and analgesic). Midazolam (Hypnovel; Roche, Welwyn Garden City, UK) and pethidine were the sedative and analgesic used.
Group 1 included the patients who underwent the GnRH agonist short flare-up down-regulation protocol. In this protocol, buserelin (Suprefact, Hoechst), 500 g/d SC injections were started from day 1 of the menstrual cycle. The gonadotropin administration started on day 3 of the same cycle with a dose of 225–375 IU/d based on the highest gonadotropin dose the patient reached in the previous poor response cycle.
Embryo Transfer Up to three embryos at 4- to 8-cell stage were replaced per patient under ultrasound scan guidance. Progesterone vaginal pessaries (Cyclogest, Shire Andover, UK), 400 mg twice daily, were used for luteal phase support until the patient had her pregnancy test 2 weeks after embryo transfer (ET). If the pregnancy test was positive, the patient was advised to continue using the pessaries up to and including week 12 of gestation.
The patients were then monitored for ovarian response using ultrasound scan starting on cycle day 9 (stimulation day 7) then daily or on alternate days depending on their response. The gonadotropin dose was increased by 75 IU/d if less than three follicles measuring 12 mm or more were seen on day 9. Both the buserelin and gonadotropin stimulation were continued until the day of hCG administration.
The Study’s Outcome Measures The main outcome measure in this study was the cycle cancellation rate due to poor ovarian response.
Group 2 included the patients who underwent the GnRH antagonist protocol. In this protocol, the gonadotropin dose selection and the monitoring process were the same as for group 1. The GnRH antagonist was administered on cycle day 8 (stimulation day 6 as stipulated by the manufacturer) with a daily dose of 0.25 mg SC cetrorelix (Cetrotide; Asta Medica, Cambridge, UK) and continued until the day of hCG administration. 332
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Other outcome measures were daily gonadotropin dose, duration of gonadotropin stimulation, peak E2, number of oocytes collected, fertilization rate, and clinical PR per cycle and per ET (clinical pregnancy was diagnosed by the visualization of fetal cardiac activity on ultrasound scan). Statistical Analysis The statistical analysis was carried out using SPSS software package (Chicago, IL). The 2, Fisher’s exact, and t tests
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TABLE 1 Outcome of short flare-up vs. antagonist protocol.
Age Early follicular phase FSH Early follicular phase LH Gonadotropin/day Days of stimulation Endometrial thickness Peak E2 level No. of follicles No. of oocytes Fertilization rate (FR) No. of embryos transferred No. of patients reaching ET Implantation rate Failed oocyte retrieval Failed fertilization Failed cleavage Cancellation (poor response) Clinic pregnancy rate/cycle Clinic pregnancy rate/ET a
Group 1 (flare-up) 77 cycles
Group 2 (antagonist) 57 cycles
P value
38 ⫾ 4 9.3 ⫾ 3.3 IU/L 5.3 ⫾ 2.8 IU/L 303 ⫾ 63 IU 11 ⫾ 2 days 10.3 ⫾ 2 mm 5,910 ⫾ 3,162 pmol/L 6⫾3 5.2 ⫾ 2.6 65.4% 2.1 ⫾ 0.8 73/77 (94.8%) 21/165 (12.8%) 0 3/77 (3.9%) 1/74 (1.4%) None 19/77 (24.7%) 19/73 (26%)
38 ⫾ 4 8.6 ⫾ 3.2 4.5 ⫾ 1.9 318 ⫾ 68 IU 9.8 ⫾ 1.6 days 10.2 ⫾ 2 mm 3,923 ⫾ 2,040 pmol/L 6⫾3 5.4 ⫾ 3.6 57.4% 1.9 ⫾ 1.1 47/57 (82.5%) 14/109 (12.8%) 2/53 (3.8%) 4/51 (7.8%) 0 4 (7%) 10/57 (17.5%) 10/47(21.3%)
NS NS NS NS .01a NS .001a NS NS NS NS .02a NS NS NS NS .03a NS NS
Significant.
Mohamed. Flare-up vs. antagonist in poor responders. Fertil Steril 2005.
were used where appropriate. A P value ⬍.05 was considered significant. The data are presented as mean ⫾ SD.
of stimulation (P⫽.01), and higher peak E2 (P⫽.001). Otherwise, the two groups were statistically similar with regard to all other compared parameters (Table 1).
RESULTS A total of 134 patients, who were recognized as poor responders based on their previous ovarian response, were included in the study. There were 77 patients (77 cycles) included in group 1 (short flare-up protocol) and 57 patients (57 cycles) included in group 2 (antagonist protocol). Both groups were similar with regard to age and basal (cycle day 2) FSH and LH levels (Table 1).
The details of the four cancelled cycles are summarized in Table 2.
The causes of infertility were male infertility factor (23 cases in each group), endometriosis (13 in group 1 and 6 in group 2), tubal factor (11 in each group), anovulation (3 in group 1 and 2 in group 2), unexplained (17 in group 1 and 10 in group 2), and multifactorial (10 in group 1 and 5 in group 2). There was no significant difference in the distribution of causes of infertility between both groups. A total of 43 and 26 patients underwent IVF treatment in groups 1 and 2, respectively, whereas 34 and 31 patients underwent ICSI treatment in groups 1 and 2, respectively. A comparison of both groups is summarized in Table 1. The patients in group 1 (short flare-up agonist protocol) had significantly lower cycle cancellation rate (P⫽.03), were more likely to reach ET stage (P⫽.02), had longer duration Fertility and Sterility姞
DISCUSSION Poor response to ovarian stimulation can be broadly defined as unsatisfactory ovarian response despite adequate ovarian stimulation. Although we may all agree on this definition, the quantification of the word unsatisfactory has been the center of controversy. Many clinicians consider the production of less than three mature follicles as poor response, whereas others take into account the maximum E2 levels, the minimal cumulative dose, or days of gonadotropin stimulation required in a prior cycle when defining poor responders (14). The quality of ovarian response should be considered in conjunction with the stimulation protocol used. Profound pituitary down-regulation is more likely to reduce ovarian response (15). Hence, the tendency to use the short downregulation protocol (flare-up), with regular dose or microdose of GnRH agonist, in patients who are likely to have a poor response (3– 6). The initial agonistic flare-up that occurs with the short protocol may also aid follicular recruit333
TABLE 2 Details of the four cancelled cycles.
Age Cause of infertility FSHa Daily dose Days of stimulation Follicles E2 (pmol/L) a
1
2
3
4
34 Male factor 7 300 10 1 1,125
40 Male factor 7 375 9 0 1,050
35 Endometriosis 11 375 10 1 950
43 Male factor 12.7 375 9 0 933
Early follicular phase.
Mohamed. Flare-up vs. antagonist in poor responders. Fertil Steril 2005.
ment, which may theoretically reduce the gonadotropin requirements. The use of GnRH antagonists in the stimulation protocol of poor responders would benefit from the endogenously produced gonadotropins as well as prevent premature LH surge. Therefore, it theoretically lends itself perfectly to the treatment of poor responders (7–9). In a small prospective study, Akman et al. (13) reported no difference in the clinical PRs between patients undergoing short flare-up or antagonist protocols. However, based on the outcome of their study, a sample size of 1,789 is required to verify their findings with 80% power. Recruiting such numbers of poor responders is not realistic. However, their findings along with other small prospective and large retrospective studies may provide us with a general trend in the outcome of the treatment protocols in question. Although our study is retrospective, it comprises a relatively large sample size. Furthermore, the allocation of patients to one protocol or the other was not influenced by the parameters of the previous failed cycle and was merely dependent on the clinician’s preference. This reduces, but by no means eliminates, the systematic bias given the retrospective nature of the study. The similarity in age and early follicular phase FSH and LH levels between the two groups supports this point. Our results showed that both protocols gave better ovarian response compared to the previous poor ovarian response under the standard long down-regulation protocol. The background of cancellation due to poor ovarian response in both groups dropped from 100% under the long down-regulation protocol to 0% and 7% in short flare-up and antagonist protocols, respectively. This along with the similarity in the number of follicles and oocytes retrieved are in agreement with the results published by Akman et al. (13). In contrast to the findings reported by Akman et al. (13) we reported a significantly higher cycle cancellation rate due 334
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to poor ovarian response in the antagonist group (P⬍.03). The exact reason for this is not known; however, it may be due to the initial flare-up of endogenous gonadotropin that enhanced follicular recruitment in group 1 (short flare-up group). Because six patients did not reach the ET stage in group 2 (antagonist group) due to poor ovarian response or failure to retrieve oocytes, one can conclude that the short flare-up protocol had an advantage over the antagonist one. Despite the improvement achieved in these patients’ response in the second cycle of treatment, four patients failed to respond and were canceled. Relying on early follicular FSH to screen for genuine poor response due to diminished ovarian reserve has been argued by some investigators to be inadequate and other tests were suggested such as clomiphene citrate (CC) challenge test, GnRH agonist stimulation test, antral follicle count, and basal inhibin B level (14, 16, 17). However, the predictive values and the practicality of usage limited the daily application of these tests. Furthermore, it remains very difficult to preclude patients from undergoing IVF treatment based on the result of these tests alone knowing their limited specificity and sensitivity (16). Most of these screening tests predict poor ovarian response to standard stimulation protocols but do not address the value of alternative regimens that we address in this study (14). In this study, however, we found that the duration of ovarian stimulation was significantly longer in the agonist group flare-up. Although this did not have an overall impact on the total gonadotropin dose used, we believe that it might be the reason for a significantly higher peak E2 in this group. This difference, however, is in agreement with previous findings (13) and is not unique to poor responders (18). Although measuring the serum P would be an advantage when comparing the PR and implantation rate between the
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Vol. 83, No. 2, February 2005
two groups, we did not determine that it affected our study, as the main outcome measure was cycle cancellation rate due to poor response. The low implantation rate in both groups of the study is hardly surprising knowing that implantation is the limiting factor to the success of IVF treatment. Furthermore, oocytes obtained from poor responders with diminished ovarian reserve may be of lower quality, which may affect the overall implantation rate for the study groups. Given the design and objectives of this study further assessment of the implantation rate is not possible. In conclusion, although our study did not show a significant difference in the PRs in the two protocols, the study indicates that patients receiving the short flare-up protocol are more likely to proceed to the ET stage. We, therefore, believe that given a large enough number of patients this finding would impact on the overall PR in favor of the short flare-up protocol. REFERENCES 1. Land J, Yarmolinskaya M, Dumoulin J, Evers J. Higher dose menopausal gonadotrophin stimulation in poor responders does not improve in vitro fertilization outcome. Fertil Steril 1996;65:961–5. 2. Lashen H, Ledger W, Bernal A, Evan B, Barlow D. Super ovulation with high gonadotrophin dose for invitro fertilization, is it effective? J Assisted Reprod Genet 1998;15:438 – 43. 3. Padilla S, Dugan K, Maruschak V, Shalika S, Smith R. Use of the flare up protocol with high dose human follicle stimulating hormone and human menopausal gonadotrophin for IVF in poor responders. Fertil Steril 1996;65:796 –9. 4. Karande V, Morris R, Rinehart J, Miller C, Rao R, Gleicher N. Limited success using the flare protocol in poor responders in cycles with low basal follicle stimulating hormone levels during in vitro fertilization. Fertil Steril 1997;67:900 –3. 5. Surrey E, Bower J, Hill D, Ramsey J, Surrey M. Clinical and endocrine effects of a microdose GnRH agonist flare regimen administered to poor responders who are undergoing in vitro fertilization. Fertil Steril 1998;69:419 –24. 6. Schoolcraft W, Schlenker T, Gee M, Stevens J, Wagley L. Improved controlled ovarian hyperstimulation in poor responders in vitro fertili-
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