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Dual trigger for final oocyte maturation improves the oocyte retrieval rate of suboptimal responders to gonadotropin-releasing hormone agonist
ORIGINAL ARTICLE: ASSISTED REPRODUCTION
Dual trigger for final oocyte maturation improves the oocyte retrieval rate of suboptimal responders to gonadotropin-releasing hormone agonist
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 Q3 Xuefeng Lu, Ph.D., Qingqing Hong, M.D., LiHua Sun, M.D., Qiuju Chen, Ph.D., Yonglun Fu, M.D., AiAi, M.D., 20 Q1 Qifeng Lyu, Ph.D., and Yanping Kuang, M.D., Ph.D. 21 Department of Assisted Reproduction, Shanghai Ninth People's Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, People's Republic of China 22 23 24 25 Objective: To identify the risk factors for suboptimal response to GnRH agonist (GnRH-a) trigger and evaluate the effect of hCG on the outcome of patients with suboptimal response to GnRH-a. 26 Design: A retrospective data analysis. 27 Setting: A tertiary-care academic medical center. 28 Patient(s): A total of 8,092 women undergoing 8,970 IVF/intracytoplasmic sperm injection (ICSI) treatment cycles. 29 Intervention(s): All women underwent hMG þ medroxyprogesterone acetate (MPA)/P treatment cycles during IVF/ICSI, which were 30 triggered using a GnRH-a alone or in combination with hCG (1,000, 2,000, or 5,000 IU). Viable embryos were cryopreserved for later 31 transfer. 32 Main Outcome Measure(s): The rates of oocyte retrieval, mature oocytes, fertilization, and the number of oocytes retrieved, mature oocytes, and embryos frozen. 33 Result(s): In total, 2.71% (243/8,970) of patients exhibited a suboptimal response to GnRH-a. The suboptimal responders (LH %15 34 mIU/mL) had a significantly lower oocyte retrieval rate (48.16% vs. 68.26%), fewer mature oocytes (4.10 vs. 8.29), and fewer frozen 35 embryos (2.32 vs. 3.54) than the appropriate responders. Basal LH levels served as the single most valuable marker for 36 differentiating suboptimal responders with the areas under the receiver operating curve of 0.805. Administering dual trigger 37 (GnRH-a and hCG 1,000, 2,000, 5,000 IU) significantly increased oocyte retrieval rates (60.04% vs. 48.16%; 68.13% vs. 48.16%; and 38 65.76% vs. 48.16%, respectively) in patients with a suboptimal response. Conclusion(s): Basal LH level was useful predictor of the suboptimal response to GnRH-a trigger. Administrating dual trigger including 39 1,000 IU hCG for final oocyte maturation could improve the oocytes retrieval rate of GnRH-a suboptimal responder. (Fertil SterilÒ 40 2016;-:-–-. Ó2016 by American Society for Reproductive Medicine.) 41 Key Words: Infertility, IVF, dual trigger, GnRH-a, hCG 42 43 Discuss: You can discuss this article with its authors and with other ASRM members at 44 45 46 47 48 49 Received May 10, 2016; revised June 28, 2016; accepted July 11, 2016. uring the ovulatory cycle, the 50 X.L. has nothing to disclose. Q.H. has nothing to disclose. L.S. has nothing to disclose. Q.C. has nothing LH surge induced by E2 from 51 to disclose. Y.F. has nothing to disclose. A.A. has nothing to disclose. Q.L. has nothing to disclose. Y.K. has nothing to disclose. the preovulatory follicles trig52 Supported by grants from National Natural Science Foundation of China (81571397, 81270749, gers a series of reactions, including a 53 81302295). loss of gap junctions between oocyte Reprint requests: Yanping Kuang, M.D., Ph.D., Department of Assisted Reproduction, Shanghai Ninth 54 People's Hospital, Shanghai Jiaotong University School of Medicine, 639 Zhizaoju Road, and cumulus cells, cumulus expansion, 55 Shanghai 200001, People's Republic of China (E-mail: [email protected]). germinal vesicle breakdown, resump56 Fertility and Sterility® Vol. -, No. -, - 2016 0015-0282/$36.00 tion of meiosis, and luteinization of 57 Copyright ©2016 Published by Elsevier Inc. on behalf of the American Society for Reproductive the granulosa cells (GCs) (1). During 58 Medicine controlled ovarian stimulation (COS), http://dx.doi.org/10.1016/j.fertnstert.2016.07.1068 59
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hCG, which is similar to LH in its physiological activities, is the most widely used surrogate for inducing the luteinization of the GCs, final oocyte maturation, and resumption of meiosis, close to the time of oocyte retrieval (i.e., 34–36 hours before oocyte retrieval) (2). However, administering high doses of hCG after ovarian stimulation is associated with an increased risk of ovarian hyperstimulation syndrome (OHSS) in patients with a large number of follicles (3). Gonadotropin-releasing hormone agonist (GnRH-a) can also induce sustained release of LH and ‘‘flare-up effect,’’ triggering oocyte maturation and ovulation. Triggering with GnRH-a to induce oocyte maturation has been shown to be the most effective method to reduce the risk of OHSS (3). Some studies (4, 5) have shown that severe OHSS can be almost completely prevented by replacing hCG with GnRH-a to trigger ovulation. However, studies (6, 7) have also reported significantly lower implantation rates, clinical pregnancy rates (PRs), live birth rates and ongoing pregnancy rates in patients who were triggered with GnRH-a than in those triggered with conventional hCG. Although the reasons for these observations are unclear, studies (8–10) have indicated that a small subset of patients who did not respond to GnRH-a with an adequate LH surge (%15 mIU/mL) were more likely to have dramatically lower oocyte retrieval rates and poorer cycle outcome. In addition, Meyer et al. (9) also found that suboptimal responses to GnRH-a were not a random events and that having a lesser LH level on the day of trigger is a risk factor for a suboptimal response. Adding of a bolus of low dose hCG had been demonstrated to rescue the luteal phase and improve reproductive outcomes (11). Concomitant administration of GnRH-a and low dose hCG (1,500 IU) to induce final oocyte maturation appears to be effective and safe in high responders in terms of their ability to achieve ongoing pregnancies, yet reducing the risk of OHSS (12). Using a dual trigger for oocyte maturation that includes GnRH-a and low dose hCG (1,000 IU) in high responders with a peak E2 <4,000 pg/mL improved the probability of conception and live birth without increasing the risk of significant OHSS (13). Recently, we reported that medroxyprogesterone acetate (MPA) and oral P (Utrogestan) were effective alternatives for preventing premature LH surges in women undergoing COS for IVF (14, 15). The combination of MPA and P has the advantage of being orally administered, easily accessible, and it allows LH levels to be controlled. Compared with a short protocol, the MPA and P (Utrogestan) cotreatment resulted in comparable counts of oocytes, fertilized eggs, and cleavage embryos, but the duration of gonadotropin administration and hMG doses were higher in MPA and P (Utrogestan) cotreatment group. To avoid the negative impact on endometrial receptivity, the ‘‘freeze-all’’ strategy was performed for all hMGþMPA and P treatment IVF- intracytoplasmic sperm injection (ICSI) cycles. However, using a MAP and P-primed ovarian stimulation protocol, the pituitary LH levels were suppressed after MAP and P administration. The mean LH level on the trigger day was 1.8 mIU/mL, and a low incidence of premature LH surge was observed (14, 15). Hypothalamic suppression may have affected responses to
the GnRH-a trigger. In the present study, we determined the incidence of patients who do not respond to an adequate LH surge and identified specific characteristics associated with these nonresponders. In addition, we analyzed the benefit of using one bolus of low dose hCG concomitant with GnRH-a (a dual trigger), 34–36 hours before oocyte retrieval.
MATERIALS AND METHODS Study Population and Design This is a retrospective analysis of a cohort of IVF-ICSI cycles (n ¼ 8,970) in 8,092 patients in the Department of Assisted Reproduction of the Ninth People's Hospital of Shanghai Jiaotong University School of Medicine from November 2013 to January 2016 (Supplemental Fig. 1). To reflect the broad range of patients who are typically encountered in clinical practice, no inclusion or exclusion criteria regarding baseline characteristics were applied. Patients underwent COS using hMG (150–225 IU/d; Anhui Fengyuan Pharmaceutical Co.) and MPA (4, 8, or 10 mg/d) and/or Utrogestan (100 mg twice a day) from menstrual cycle 3 (14, 15). The initiating dose of 150 IU/d was used for patients with high antral follicle counts >20 or slightly elevated basal FSH (>7 IU/L), whereas 225 IU/d was used for all other patients. The choice of either MPA or Utrogestan was based on physician preference. In total, there were 1,320 IVF-ICSI cycles treated with hMG þ Utrogestan protocol, and 7,650 IVFICSI cycles treated with hMGþMPA protocol. The final stage of oocyte maturation was triggered using triptorelin (0.1– 0.2 mg; Decapeptyl, Ferring Pharmaceuticals) or cotriggered using SC injections of a combination of triptorelin (0.1– 0.2 mg) and hCG (1,000, 2,000, or 5,000 IU) (Lizhu Pharmaceutical Trading Co.). The choice of either GnRH-a trigger or dual trigger was based on physician preference. Transvaginal ultrasound-guided oocyte retrieval was conducted 34– 36 hours after the trigger. All follicles with diameters of >10 mm were aspirated. Fertilization of the aspirated oocytes was performed in vitro, using either conventional insemination or ICSI, depending on semen parameters. Embryos were examined for the number and regularity of blastomeres and the degree of embryonic fragmentation on the third day, according to the criteria described by Cummins et al. (16). The freeze-all strategy was performed for all IVF-/ICSI cycles. All good-quality embryos (including grade 1 and grade 2 8-cell embryos) were frozen by vitrification on the third day after oocyte retrieval. Only embryos that were not of top quality were placed in extended culture until they reached the blastocyst stage. During this stage, only good-morphology blastocysts were frozen on day 5 or day 6. The vitrification procedure for freezing cleavage-stage embryos and blastocysts was performed as previously described (14). This study was approved by the Ethics Committee (Institutional Review Board) of the Ninth People's Hospital of Shanghai.
Hormone Analysis Serum FSH, LH, E2, and P levels were measured on menstrual cycle 3, the trigger day, and the day after trigger (10 hours VOL. - NO. - / - 2016
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after the injection of GnRH-a/hCG or GnRH-a). Hormone levels were measured using chemiluminescence (Abbott Biologicals B.V.). The lower limits of sensitivity were as follows: FSH, 0.06 mIU/mL; LH, 0.09 mIU/mL; E2, 10 pg/mL; and P, 0.1 ng/mL. The upper limit for E2 measurement was set at 5,000 pg/mL. The E2 levels were recorded as 5,000 pg/mL if they were higher than the upper limit on the trigger day or the day after trigger.
Statistical Analysis The oocyte retrieval rate was defined as the ratio of the total number of oocytes retrieved to the number of follicles aspirated (diameter, R10 mm) on the day of oocyte retrieval. The rate of mature oocyte was defined as the ratio of metaphase II oocytes to the number of collected oocytes. Data are presented as the mean SD. Comparisons among groups were analyzed by analysis of variance (ANOVA) followed by an appropriated post hoc test. For nonparametric data, the means SD were calculated. The c2, t, and Fisher's exact tests were used to investigate the differences. P< .05 was considered statistically significant. The receiver operating curve analyses were used to assess and compare the predictive accuracy of basal FSH and LH, and FSH and LH levels on the day of trigger. The optimal cutoff value for basal LH was determined using the value that maximizes (sensitivity þ specificity 1). The receiver operating curve and all other data were analyzed using the Statistical Package for the Social Sciences for Windows (ver. 22, SPSS Inc.).
RESULTS In previous studies (8–10), patients who had an insufficient pituitary response (LH, %15 mIU/mL) were more likely to have a lower oocyte retrieval rate, have empty follicle syndrome, have fewer mature oocytes retrieved, and experience poor outcomes. In the present study, 2.71% (243/8,970) of the included patients exhibited a suboptimal response to GnRH-a, as defined by a serum LH %15 mIU/mL, approximately 10 hours after GnRH-a trigger (Table 1 and Supplemental Fig. 1). There were no statistically significant differences in the mean age (33.38 6.36 years vs. 32.48 5.10 years; P>.05), day 3 E2 level (34.50 15.85 pg/mL vs. 38.78 19.53 pg/mL; P>.05), day 3 serum P level (0.52 1.14 ng/mL vs. 0.32 0.41 ng/mL; P>.05), number of antral follicles (8.82 8.76 vs.8.17 7.69; P>.05), or triptorelin dose (0.11 0.02 mg vs. 0.11 0.03 mg; P>.05) between suboptimal and appropriate responders (serum LH, >15 mIU/mL 10 hours after GnRH-a trigger), respectively (Table 1). In addition, no difference was observed in the proportion of IVF indications, including tubal factor, male infertility factor, endometriosis, polycystic ovary syndrome (PCOS), combination of factor, and unknown factor (Table 1). However, the suboptimal responders had a significantly higher body mass index (BMI; 24.86 3.92 vs. 21.83 5.09; P< .001), lower basal FSH levels (5.68 2.37 mIU/ mL vs. 6.35 2.97 mIU/mL; P< .001), and lower basal LH levels (2.13 1.12 mIU/mL vs. 3.85 2.16 mIU/mL; P< .001) than the appropriate responders (Table 1). The stimulation and hormonal characteristics are presented in Table 1.
TABLE 1 Characteristics of the patients with suboptimal or appropriate response to the GnRH-a trigger. Characteristic Age of women (y) BMI of women Basal FSH (mIU/mL) Basal LH (mIU/mL) Basal E2 (pg/mL) Basal P (ng/mL) Antral follicles Duration of stimulation (d) Total hMG dose (IU) Triptorelin dose (mg) Hormones on day of trigger FSH (mIU/mL) LH (mIU/mL) E2 (pg/mL) P (ng/mL) No. of follicles aspirated Infertility causes, n (%) Tubal factor Male factor Endometriosis Combination of factors Unknown factor Infertility causes including PCOS Infertility causes including hypothalamic amenorrhea
LH £15 mIU/mL (n [ 243)
LH >15 mIU/mL (n [ 8,727)
P value
32.91 4.79 24.21 3.72 5.45 2.34 2.08 1.64 41.64 38.99 0.38 1.54 7.02 7.16 12.55 3.65 2,157.68 855.33 0.11 0.02
32.95 5.15 21.78 5.44 6.87 4.28 3.83 2.34 39.30 88.54 0.35 0.74 7.84 7.20 10.78 2.59 1,796.28 586.67 0.11 0.03
NS < .001 < .001 < .001 NS NS NS < .001 < .001 NS
13.68 4.01 1.93 4.65 1,873.66 1,441.11 1.02 1.82 11.64 9.65
15.19 4.49 2.26 2.25 2,503.48 1,672.44 1.33 4.96 14.36 10.94
< .001 .035 < .001 NS < .001
121 (49.79) 20 (8.23) 5 (2.06) 92 (37.86) 5 (2.06) 25 (10.29) 0 (0.00)
4,054 (46.45) 1,028 (11.78) 205 (2.35) 3,064 (35.11) 376 (4.31) 626 (7.17) 0 (0.00)
NS NS NS NS NS NS NS
Note: The data are presented as the means SD and percentage. BMI ¼ body mass index; GnRH-a ¼ GnRH agonist; NS ¼ no significant difference; PCOS ¼ polycystic ovary syndrome. Lu. Dual trigger improves oocyte retrieval. Fertil Steril 2016.
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ORIGINAL ARTICLE: ASSISTED REPRODUCTION Suboptimal responders to the GnRH-a trigger responded to stimulation with fewer follicles aspirated (11.64 9.65 vs. 14.36 10.94; P< .001) and lower peak E2 levels (1,873.66 1,441.11 pg/mL vs. 2,503.48 1,672.44 pg/mL; P< .001) than appropriate responders and required more total hMG (2,157.68 855.33 IU vs.1,796.28 586.67 IU; P< .001) and a longer duration time of stimulation (12.55 3.65 days vs. 10.78 2.56 days; P< .001). In addition, the suboptimal responders had significantly lower FSH levels (13.68 4.01 mIU/mL vs. 15.19 4.49 mIU/mL; P< .001) and LH level (1.93 4.65 mIU/mL vs. 2.26 2.25 mIU/mL; P< .001) on the day of the GnRH-a trigger. In previous reports (9), the LH level on the day of trigger was found to be the single most valuable marker for helping clinicians assess a patient's risk of showing a suboptimal response to a GnRH-a trigger. In our study, we found that suboptimal responders had significantly lower basal levels of FSH and LH, and significantly lower FSH and LH levels on the day of trigger. To analyze the accuracy of using basal and day-oftrigger FSH and LH levels for predicting which patients will be suboptimal responders to GnRH-a trigger, receiver operating curve analysis was performed. The results revealed that a patient's basal LH level was the single most valuable marker for identifying suboptimal responders with an AUC (the areas under the receiver operating curve) of 0.805. Basal FSH level and trigger day FSH and LH levels had AUC values of 0.665, 0.591, and 0.652, respectively (Fig. 1). Therefore, a lower basal LH level (LH, <2.27 mIU/mL) is a useful predictor of a suboptimal response to GnRH-a trigger. In addition, we further analyzed the risk of a suboptimal response by basal and trigger day LH levels. As shown in Supplemental Figure 2, as basal and trigger day decreased, the risk of a suboptimal response to GnRH-a trigger increased. A basal LH level of <4.0, 3.0, 2.5, 2.0, 1.5, 1.0, or 0.5 mIU/mL was associated with a suboptimal GnRH-a trigger response rates of 3.51%, 4.98%, 6.68%, 10.21%, 18.37%, 29.27% and 45.45%, respectively. However,
FIGURE 1
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Receiver operating curve analyses of basal FSH levels, basal LH levels, trigger day FSH levels, and trigger day LH levels. The cutoff value was 2.27 mIU/mL for basal LH levels. Lu. Dual trigger improves oocyte retrieval. Fertil Steril 2016.
a trigger day LH level of >2.0, 1.5, 1.0, 0.75, 0.5, 0.3, or 0.1 mIU/mL was associated with a suboptimal GnRH-a trigger response rate of 3.30%, 3.76%, 4.56%, 5.32%, 6.32%, 7.88%, and 10.71%, respectively. These results demonstrate that in patients undergoing hMGþMPA and P treatment protocol, the basal LH level is the most valuable marker for differentiating suboptimal responders to a GnRH-a trigger. To analyze the outcomes associated with a suboptimal response to the GnRH-a, we further analyzed all patients who received a GnRH-a trigger alone (Supplemental Fig. 1). In all, 2.10% (31/1,484) of the patients who received a GnRH-a trigger alone exhibited a suboptimal response to the GnRH-a (Table 2). The suboptimal responders who received a GnRH-a trigger alone had baseline characteristics, hormone profiles, and stimulation characteristics that were similar to the overall population of suboptimal responders who received a GnRH-a trigger alone or a dual trigger (Table 2). There were no significant difference in the number of follicles aspirated and the rates of mature oocyte and fertilization between the suboptimal responders and appropriate responders (Table 2). However, the suboptimal responders who received GnRH-a had a significantly lower oocyte retrieval rate (48.16% 29.27% vs. 68.26% 22.61%; P< .001), fewer mature oocytes retrieved (4.10 5.85 vs. 8.29 6.94; P< .001), and fewer embryos frozen (2.32 2.76 vs. 3.54 3.11; P¼ .031, P< .05) than the appropriate responders (Table 2). In addition, oocyte retrieval rates were not significantly different between patients who underwent hMGþMPA treatment cycles and those who underwent hMGþP treatment cycles (Supplemental Fig. 3), indicating that the difference in the oocyte retrieval rate was not due to a difference in the progestin used. Empty follicle syndrome (EFS) has been defined as a condition in which no oocytes are retrieved from mature follicle after ovulation induction in IVF-ICSI cycles (17, 18). A previous study (8) showed that all cases (7/508) of EFS occurred in patients with suboptimal response (LH, <15 mIU/mL) to GnRH-a trigger. In our study, there were 3.22% (1/31) cycles with suboptimal response to GnRH-a trigger and 0.55% (8/1,453) cycles with appropriate response to GnRH-a trigger had no oocytes obtained. No significant difference was in the EFS rates between the suboptimal responders and appropriate responders (Table 2). The one patient with suboptimal response to GnRH-a trigger and four patients with appropriate response to GnRH-a trigger, who had no oocytes obtained, were older than 40 years. We also noted all cases without oocytes obtained in our study have only one to two dominant follicles despite profound ovarian hyperstimulation. The most effective time and dose at which to add hCG to improve the reproductive outcomes of suboptimal responders are still unknown. In our study, we evaluated the effect of using a dual trigger (GnRH-a and hCG 1,000, 2,000, or 5,000 IU), 34–36 hours before oocyte retrieval in patients with a suboptimal response to a GnRH-a trigger (Table 3 and Supplemental Fig. 1). Baseline characteristics were similar across the GnRH-a-alone group, dual trigger (GnRH-aþhCG 1,000 IU) group, dual trigger (GnRH-aþhCG 2,000 IU) group, and dual trigger (GnRH-aþhCG 5,000 IU) group (Table 3). The VOL. - NO. - / - 2016
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TABLE 2 Characteristics of the IVF/ICSI cycles triggered with GnRH-a alone and associated outcomes. Characteristic Age of women (y) BMI of women Basal FSH (mIU/mL) Basal LH (mIU/mL) Basal E2 (pg/mL) Basal P (ng/mL) Antral follicles Duration of stimulation (d) Total hMG dose (IU) Hormones on day of trigger FSH (mIU/mL) LH (mIU/mL) E2 (pg/mL) P (ng/mL) No. of follicles aspirated No. of oocytes retrieved Oocytes retrieval rate (%) Empty follicle syndrome (%) Mature oocytes The rate of mature oocytes (%) Fertilization rate (%) Embryos frozen Infertility causes, n (%) Tubal factor Male factor Endometriosis Combination of factors Unknown factor Infertility causes including PCOS Infertility causes including hypothalamic amenorrhea
LLH £15 mIU/mL (n [ 31)
LH >15 mIU/mL (n [ 1,453)
P value
33.38 6.36 24.86 3.21 5.68 2.37 2.13 1.12 34.50 15.85 0.52 1.14 8.82 8.76 12.10 2.21 1,935.48 516.15
32.48 5.10 21.83 5.24 6.35 2.97 3.85 2.16 38.78 19.53 0.32 0.41 8.17 7.69 10.96 2.29 1,708.31 595.97
NS < .001 NS < .001 NS NS NS .007 .033
12.10 4.03 2.94 2.63 1,906.41 1,656.87 5.71 10.35 12.77 14.95 4.83 6.33 48.16 29.27 1 (3.22) 4.10 5.85 85.84 26.59 76.85 33.30 2.32 2.76
14.42 4.86 3.11 2.24 2,753.23 1,616.34 4.27 17.33 14.85 12.40 9.70 7.76 68.26 22.61 8 (0.55) 8.29 6.94 86.63 19.38 75.26 47.78 3.54 3.11
.008 NS .005 NS NS < .001 < .001 NS .001 NS NS .031
15 (48.39) 4 (12.9) 0 (0.00) 12 (38.71) 0 (0.00) 5 (16.13) 0 (0.00)
684 (47.08) 156 (10.74) 23 (1.58) 551 (37.92) 39 (2.76) 154 (10.60) 0 (0.00)
NS NS NS NS NS NS NS
Note: The data are presented as the means SD and percentage. BMI ¼ body mass index; GnRH-a ¼ GnRH agonist; ICSI ¼ intracytoplasmic sperm injection; NS ¼ no significant difference; PCOS ¼ polycystic ovary syndrome. Lu. Dual trigger improves oocyte retrieval. Fertil Steril 2016.
oocyte retrieval rate was significantly higher in the dual trigger group than in the GnRH-a-alone group (GnRHaþhCG 1,000 IU: 60.04% 25.24% vs. 48.16% 29.27%; GnRHaþhCG 2,000 IU: 68.13% 19.65% vs. 48.16% 29.27%; and GnRH-aþhCG 5,000 IU: 65.76% 23.60% vs. 48.16% 29.27%; P< .05 for all) (Table 3). However, there were no significant differences in oocyte retrieval rates between the dual trigger groups. We noted that the dual trigger GnRHaþhCG 1,000 IU group and the dual trigger GnRH-aþhCG 2,000 IU group showed a greater number of retrieved oocytes (6.60 5.81 vs. 4.83 6.32 and 7.00 3.22 vs. 4.83 6.32, respectively), more mature oocytes (5.96 5.22 vs. 4.10 5.85 and 6.00 3.08 vs. 4.10 5.85, respectively), and more embryos frozen (2.79 2.66 vs. 2.32 2.76 and 2.32 2.76 vs. 2.32 2.76, respectively) than the GnRH-a trigger alone group. However, these differences did not reach significance (Table 3), which might have been because the small number of included patients limited the statistical power of the analyses. The use of hCG is associated with a risk of OHSS. In our study, two cases with moderate-to-severe OHSS were observed in the dual trigger GnRH-aþhCG 5,000 IU group. There were no cases of OHSS in the dual trigger GnRHaþhCG 1,000 IU group or the dual trigger GnRH-aþhCG 2,000 IU group.
DISCUSSION Using GnRH-a to induce oocyte maturation has been shown to be the most effective method for reducing the risk of OHSS. However, in some patients with low gonadotropin reserves or in those who have experienced pituitary downregulation, the pituitary is unable to induce an adequate endogenous LH surge. Our recent study (14) showed that MPA administration shows potential as an effective oral alternative for preventing a premature LH surge in patients undergoing IVF cycles. In addition P (Utrogestan), as well as MPA, prevents a premature LH surge when applied in patients with COS (15). In hMGþMPA-Utrogestan treatment protocol, the pituitary is down-regulated by MPA or Utrogestan, resulting in low LH levels on the day of trigger. Our study showed that using a dual trigger consisting of GnRH-a and a low dose of hCG provided beneficial effect to oocyte maturation in patients using this regimen. However, the appropriate trigger strategies that should be used in patients being treated with hMGþMPA-P protocol remain unknown. In the present study, we analyzed 8,970 IVF-ICSI cycles and found that only 2.71% (243/8,970) of the included patients exhibited a suboptimal response to the GnRH-a. A suboptimal response to the GnRH-a was associated with a significantly decreased oocyte retrieval rate, fewer mature occytes retrieved, and
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ORIGINAL ARTICLE: ASSISTED REPRODUCTION 591 TABLE 3 592 593 Baseline characteristics, ovarian stimulation characteristics, and outcomes in suboptimal responders who were triggered with GnRH-a combined 594 with different doses of hCG. 595 hCG 596 Characteristic 0 (n [ 31) 1,000 (n [ 139) 2,000 (n [ 21) 5,000 (n [ 38) P value 597 598 Age of women (y) 33.38 6.36 32.67 4.45 32.91 3.96 33.91 3.96 NS BMI of women 24.86 3.92 23.79 3.85 23.68 3.13 23.99 2.93 NS 599 Basal FSH (mIU/mL) 5.68 2.37 5.45 2.50 5.39 1.08 6.13 1.96 NS 600 Basal LH (mIU/mL) 2.13 1.12 2.03 1.69 2.33 1.58 1.99 1.10 NS 601 34.50 15.85 39.25 40.54 43.86 22.25 56.23 41.54 NS Basal E2 (pg/mL) 602 Basal P (ng/mL) 0.52 1.14 0.56 2.60 0.24 0.10 0.26 0.11 NS Antral follicles 8.82 8.76 7.023 7.30 6.91 4.62 6.59 3.99 NS 603 Duration of stimulation (d) 12.10 2.21 12.14 2.97 12.21 4.89 12.08 2.70 NS 604 Total hMG dose (IU) 1,935.48 516.15 2,070.32 641.41 2,185.71 948.47 2,007.24 477.99 NS 605 Hormones on day of trigger 606 14.01 4.07a 15.79 4.33a 14.69 4.45 < .05 FSH (mIU/mL) 12.10 4.03a LH (mIU/mL) 2.94 2.63 1.83 5.6 1.85 1.99 1.41 0.85 NS 607 1,906.41 1,656.87 1,994.82 1,520.68 1,991.81 1,190.88 1,526.42 1,000.93 NS E2 (pg/mL) 608 b b 12.02 9.72 10.29 3.96 7.82 4.60 < .05 No. of follicles aspirated 12.76 14.95 609 60.04 25.24c 68.13 19.65c 65.76 23.60c < .05 Oocytes retrieved rate 48.16 29.27c No. of oocytes retrieved 4.83 6.32 6.60 5.81 7.00 3.22 4.74 3.01 NS 610 No. of mature oocytes 4.10 5.85 5.96 5.22 6.00 3.08 3.84 2.75 NS 611 The rate of mature oocyte 85.84 26.59 92.10 26.83 87.16 18.42 82.15 24.68 NS 612 Fertilization rate 76.85 23.30 78.67 24.65 78.18 23.08 68.78 32.15 NS 613 Embryos frozen 2.32 2.76 2.79 2.66 2.74 1.91 2.58 2.51 NS Infertility causes, n (%) 614 Tubal factor 15 (48.39) 68 (48.92) 9 (42.86) 16 (42.11) NS 615 Male factor 4 (12.9) 12 (8.63) 2 (9.52) 2 (5.26) NS 616 Endometriosis 0 (0.00) 2 (1.43) 1 (4.76) 3 (7.89) NS Combination of factors 12 (38.71) 52 (37.4) 9 (42.86) 17 (44.74) NS 617 Unknown factor 0 (0.00) 5 (3.60) 0 (0.00) 0 (0.00) NS 618 Infertility causes including 5 (16.13) 17 (12.23) 2 (9.52) 1 (2.63) NS 619 PCOS 620 Infertility causes including 0 (0.00) 0 (0.00) 0 (0.00) 0 (0.00) NS hypothalamic 621 amenorrhea 622 Note: The data are presented as means SD and percentage. GnRH-a ¼ GnRH agonist; NS ¼ no significant difference; PCOS ¼ polycystic ovary syndrome. a 623 The group triggered with GnRH-a versus the group triggered with the dual trigger GnRH-aþhCG (1,000 IU) or the dual trigger GnRH-aþhCG (2,000 IU). b The group triggered with GnRH-a versus the group triggered with dual trigger GnRH-aþhCG (5,000 IU). 624 c The group triggered with GnRH-a versus the dual trigger groups. 625 Lu. Dual trigger improves oocyte retrieval. Fertil Steril 2016. 626 627 628 fewer embryos frozen, but neither with the rate of mature no significant differences in the number of antral follicles 629 oocyte nor the fertilization rate. These results were consistent between the appropriate and suboptimal responder groups. 630 with previous reports that found suboptimal response to the In addition, the basal FSH level and the LH level were lower 631 GnRH-a (LH, %15 mIU/mL) is associated with a dramatically in the suboptimal responder group than that in the appro632 lower oocyte yield but not with the oocyte maturity rate and priate responder group. All of these data were consistent 633 fertilization rate (10). with what was found in the GnRH-antagonist-based IVF cy634 The EFS is uncommon but a frustrating complication of cles, and the lower LH responses had been presumed to be due 635 IVF-ICSI cycles, leading to cycle cancellation. In our study, to down-regulation of the hypothalamic-pituitary axis (9). 636 there were 3.22% (1/31) cycles with appropriate response In our study, we also showed that addition of a bolus of 637 GnRH-a trigger and 0.55% (8/1,453) cycles with appropriate hCG significantly increased the oocyte retrieval rate, but 638 Q2 response to GnRH-a trigger had no oocytes obtained. No signot the oocyte maturity and fertilization rate. However, there 639 nificant differences between the suboptimal responders and were no significant difference in the oocyte retrieval rate 640 appropriate responders were in EFS rates. In the eight IVFamong the dual trigger group (GnRH-aþhCG 1,000 IU), the 641 ICSI cycles with appropriate response to GnRH-a trigger, the dual trigger group (GnRH-aþhCG 2,000 IU), and the dual 642 occurrence of EFS could be linked to ovulation before follicle trigger group (GnRH-aþhCG 5,000 IU). Our results also 643 puncture, advanced age, and poor ovarian response. Consisshowed that there were no cases of OHSS in the dual trigger 644 tent with our result, in addition to false trigger, the advanced group (GnRHaþhCG 1,000 IU). These results indicated that 645 age and poor ovarian response have been suggested to be the low dose of hCG (1,000 IU) could safely and effectively 646 risk factors for the EFS (18, 19). improved the oocytes retrieval rate. 647 In the present report, we noted that the suboptimal A strategy for predicting patients at risk for suboptimal 648 responders required more hMG and a longer duration of stimresponse to GnRH-a would be helpful for patients to receive 649 ulation compared with the appropriate responders. There were a safe and effective trigger in IVF-ICSI cycles. Here, we VOL. - NO. - / - 2016
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identified the characteristics associated with suboptimal responders whose serum LH was %15 mIU/mL approximately 10 hours after GnRH-a trigger. The suboptimal responders had higher BMIs and lower basal FSH and LH levels, in addition to lower trigger day FSH and LH levels. The basal serum LH was found to be the most important predictor for helping clinicians assess the risk of a suboptimal response to GnRH-a trigger, as defined by a serum LH %15 mIU/mL approximately 10 hours after GnRH-a trigger. This finding also differs from that described in a previous report (9) that identified the LH level on the day of trigger as the single most valuable predictive marker. This difference may be because the variably suppressed LH level by the MPA and/or P on the day of trigger in hMGþMPA or P treatment protocols. In conclusion, we identified a small subset of patients who showed a suboptimal response to GnRH-a trigger yet undergoing an hMGþMPA or P treatment protocol. The basal serum LH level (LH, <2.27 mIU/mL) was the best predictor of a response to a GnRH-a trigger. Using a dual trigger that included a low dose of hCG (1,000 IU) as an adjuvant to GnRH-a to induce final oocyte maturation significantly improved the oocytes retrieval rate of suboptimal responders, without increasing the risk of clinically significant OHSS. However, this is a retrospective study with its inherent limitations and bias. The observed benefit of using a higher dose of hCG for improving reproductive outcomes in suboptimal responders needs to be further tested in randomized controlled trials.
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Orvieto R. Triggering final follicular maturation—hCG, GnRH-agonist or both, when and to whom? J Ovarian Res 2015;8:60. Ludwig M, Doody KJ, Doody KM. Use of recombinant human chorionic gonadotropin in ovulation induction. Fertil Steril 2003;79:1051–9. Orvieto R. Can we eliminate severe ovarian hyperstimulation syndrome? Hum Reprod 2005;20:320–2. Kol S. Luteolysis induced by a gonadotropin-releasing hormone agonist is the key to prevention of ovarian hyperstimulation syndrome. Fertil Steril 2004;81:1–5. Devroey P, Polyzos NP, Blockeel C. An OHSS-Free Clinic by segmentation of IVF treatment. Hum Reprod 2011;26:2593–7. Kolibianakis EM, Schultze-Mosgau A, Schroer A, van Steirteghem A, Devroey P, Diedrich K, et al. A lower ongoing pregnancy rate can be
expected when GnRH agonist is used for triggering final oocyte maturation instead of HCG in patients undergoing IVF with GnRH antagonists. Hum Reprod 2005;20:2887–92. 7. Humaidan P, Bredkjaer HE, Bungum L, Bungum M, Grondahl ML, Westergaard L, et al. GnRH agonist (buserelin) or hCG for ovulation induction in GnRH antagonist IVF/ICSI cycles: a prospective randomized study. Hum Reprod 2005;20:1213–20. 8. Kummer NE, Feinn RS, Griffin DW, Nulsen JC, Benadiva CA, Engmann LL. Predicting successful induction of oocyte maturation after gonadotropinreleasing hormone agonist (GnRHa) trigger. Hum Reprod 2013;28:152–9. 9. Meyer L, Murphy LA, Gumer A, Reichman DE, Rosenwaks Z, Cholst IN. Risk factors for a suboptimal response to gonadotropin-releasing hormone agonist trigger during in vitro fertilization cycles. Fertil Steril 2015;104: 637–42. 10. Chen SL, Ye DS, Chen X, Yang XH, Zheng HY, Tang Y, et al. Circulating luteinizing hormone level after triggering oocyte maturation with GnRH agonist may predict oocyte yield in flexible GnRH antagonist protocol. Hum Reprod 2012;27:1351–6. 11. Shapiro BS, Daneshmand ST, Garner FC, Aguirre M, Hudson C. Comparison of ‘‘triggers’’ using leuprolide acetate alone or in combination with low-dose human chorionic gonadotropin. Fertil Steril 2011;95:2715–7. 12. Shapiro BS, Daneshmand ST, Garner FC, Aguirre M, Thomas S. Gonadotropin-releasing hormone agonist combined with a reduced dose of human chorionic gonadotropin for final oocyte maturation in fresh autologous cycles of in vitro fertilization. Fertil Steril 2008;90:231–3. 13. Griffin D, Benadiva C, Kummer N, Budinetz T, Nulsen J, Engmann L. Dual trigger of oocyte maturation with gonadotropin-releasing hormone agonist and low-dose human chorionic gonadotropin to optimize live birth rates in high responders. Fertil Steril 2012;97:1316–20. 14. Kuang Y, Chen Q, Fu Y, Wang Y, Hong Q, Lyu Q, et al. Medroxyprogesterone acetate is an effective oral alternative for preventing premature luteinizing hormone surges in women undergoing controlled ovarian hyperstimulation for in vitro fertilization. Fertil Steril 2015;104:62–70.e63. 15. Zhu X, Zhang X, Fu Y. Utrogestan as an effective oral alternative for preventing premature luteinizing hormone surges in women undergoing controlled ovarian hyperstimulation for in vitro fertilization. Medicine 2015;94:e909. 16. Cummins JM, Breen TM, Harrison KL, Shaw JM, Wilson LM, Hennessey JF. A formula for scoring human embryo growth rates in in vitro fertilization: its value in predicting pregnancy and in comparison with visual estimates of embryo quality. J In Vitro Fert Embryo Transf 1986;3:284–95. 17. Kim JH, Jee BC. Empty follicle syndrome. Clin Exp Reprod Med 2012;39: 132–7. 18. Aktas M, Beckers NG, van Inzen WG, Verhoeff A, de Jong D. Oocytes in the empty follicle: a controversial syndrome. Fertil Steril 2005;84:1643–8. 19. Baum M, Machtinger R, Yerushalmi GM, Maman E, Seidman DS, Dor J, et al. Recurrence of empty follicle syndrome with stimulated IVF cycles. Gynecol Endocrinol 2012;28:293–5.
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Dual trigger for final oocyte maturation improves the oocyte retrieval rate of suboptimal responders to gonadotropin-releasing hormone agonist
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 Q3 Xuefeng Lu, Ph.D., Qingqing Hong, M.D., LiHua Sun, M.D., Qiuju Chen, Ph.D., Yonglun Fu, M.D., AiAi, M.D., 20 Q1 Qifeng Lyu, Ph.D., and Yanping Kuang, M.D., Ph.D. 21 Department of Assisted Reproduction, Shanghai Ninth People's Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, People's Republic of China 22 23 24 25 Objective: To identify the risk factors for suboptimal response to GnRH agonist (GnRH-a) trigger and evaluate the effect of hCG on the outcome of patients with suboptimal response to GnRH-a. 26 Design: A retrospective data analysis. 27 Setting: A tertiary-care academic medical center. 28 Patient(s): A total of 8,092 women undergoing 8,970 IVF/intracytoplasmic sperm injection (ICSI) treatment cycles. 29 Intervention(s): All women underwent hMG þ medroxyprogesterone acetate (MPA)/P treatment cycles during IVF/ICSI, which were 30 triggered using a GnRH-a alone or in combination with hCG (1,000, 2,000, or 5,000 IU). Viable embryos were cryopreserved for later 31 transfer. 32 Main Outcome Measure(s): The rates of oocyte retrieval, mature oocytes, fertilization, and the number of oocytes retrieved, mature oocytes, and embryos frozen. 33 Result(s): In total, 2.71% (243/8,970) of patients exhibited a suboptimal response to GnRH-a. The suboptimal responders (LH %15 34 mIU/mL) had a significantly lower oocyte retrieval rate (48.16% vs. 68.26%), fewer mature oocytes (4.10 vs. 8.29), and fewer frozen 35 embryos (2.32 vs. 3.54) than the appropriate responders. Basal LH levels served as the single most valuable marker for 36 differentiating suboptimal responders with the areas under the receiver operating curve of 0.805. Administering dual trigger 37 (GnRH-a and hCG 1,000, 2,000, 5,000 IU) significantly increased oocyte retrieval rates (60.04% vs. 48.16%; 68.13% vs. 48.16%; and 38 65.76% vs. 48.16%, respectively) in patients with a suboptimal response. Conclusion(s): Basal LH level was useful predictor of the suboptimal response to GnRH-a trigger. Administrating dual trigger including 39 1,000 IU hCG for final oocyte maturation could improve the oocytes retrieval rate of GnRH-a suboptimal responder. (Fertil SterilÒ 40 2016;-:-–-. Ó2016 by American Society for Reproductive Medicine.) 41 Key Words: Infertility, IVF, dual trigger, GnRH-a, hCG 42 43 Discuss: You can discuss this article with its authors and with other ASRM members at 44 45 46 47 48 49 Received May 10, 2016; revised June 28, 2016; accepted July 11, 2016. uring the ovulatory cycle, the 50 X.L. has nothing to disclose. Q.H. has nothing to disclose. L.S. has nothing to disclose. Q.C. has nothing LH surge induced by E2 from 51 to disclose. Y.F. has nothing to disclose. A.A. has nothing to disclose. Q.L. has nothing to disclose. Y.K. has nothing to disclose. the preovulatory follicles trig52 Supported by grants from National Natural Science Foundation of China (81571397, 81270749, gers a series of reactions, including a 53 81302295). loss of gap junctions between oocyte Reprint requests: Yanping Kuang, M.D., Ph.D., Department of Assisted Reproduction, Shanghai Ninth 54 People's Hospital, Shanghai Jiaotong University School of Medicine, 639 Zhizaoju Road, and cumulus cells, cumulus expansion, 55 Shanghai 200001, People's Republic of China (E-mail: [email protected]). germinal vesicle breakdown, resump56 Fertility and Sterility® Vol. -, No. -, - 2016 0015-0282/$36.00 tion of meiosis, and luteinization of 57 Copyright ©2016 Published by Elsevier Inc. on behalf of the American Society for Reproductive the granulosa cells (GCs) (1). During 58 Medicine controlled ovarian stimulation (COS), http://dx.doi.org/10.1016/j.fertnstert.2016.07.1068 59
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hCG, which is similar to LH in its physiological activities, is the most widely used surrogate for inducing the luteinization of the GCs, final oocyte maturation, and resumption of meiosis, close to the time of oocyte retrieval (i.e., 34–36 hours before oocyte retrieval) (2). However, administering high doses of hCG after ovarian stimulation is associated with an increased risk of ovarian hyperstimulation syndrome (OHSS) in patients with a large number of follicles (3). Gonadotropin-releasing hormone agonist (GnRH-a) can also induce sustained release of LH and ‘‘flare-up effect,’’ triggering oocyte maturation and ovulation. Triggering with GnRH-a to induce oocyte maturation has been shown to be the most effective method to reduce the risk of OHSS (3). Some studies (4, 5) have shown that severe OHSS can be almost completely prevented by replacing hCG with GnRH-a to trigger ovulation. However, studies (6, 7) have also reported significantly lower implantation rates, clinical pregnancy rates (PRs), live birth rates and ongoing pregnancy rates in patients who were triggered with GnRH-a than in those triggered with conventional hCG. Although the reasons for these observations are unclear, studies (8–10) have indicated that a small subset of patients who did not respond to GnRH-a with an adequate LH surge (%15 mIU/mL) were more likely to have dramatically lower oocyte retrieval rates and poorer cycle outcome. In addition, Meyer et al. (9) also found that suboptimal responses to GnRH-a were not a random events and that having a lesser LH level on the day of trigger is a risk factor for a suboptimal response. Adding of a bolus of low dose hCG had been demonstrated to rescue the luteal phase and improve reproductive outcomes (11). Concomitant administration of GnRH-a and low dose hCG (1,500 IU) to induce final oocyte maturation appears to be effective and safe in high responders in terms of their ability to achieve ongoing pregnancies, yet reducing the risk of OHSS (12). Using a dual trigger for oocyte maturation that includes GnRH-a and low dose hCG (1,000 IU) in high responders with a peak E2 <4,000 pg/mL improved the probability of conception and live birth without increasing the risk of significant OHSS (13). Recently, we reported that medroxyprogesterone acetate (MPA) and oral P (Utrogestan) were effective alternatives for preventing premature LH surges in women undergoing COS for IVF (14, 15). The combination of MPA and P has the advantage of being orally administered, easily accessible, and it allows LH levels to be controlled. Compared with a short protocol, the MPA and P (Utrogestan) cotreatment resulted in comparable counts of oocytes, fertilized eggs, and cleavage embryos, but the duration of gonadotropin administration and hMG doses were higher in MPA and P (Utrogestan) cotreatment group. To avoid the negative impact on endometrial receptivity, the ‘‘freeze-all’’ strategy was performed for all hMGþMPA and P treatment IVF- intracytoplasmic sperm injection (ICSI) cycles. However, using a MAP and P-primed ovarian stimulation protocol, the pituitary LH levels were suppressed after MAP and P administration. The mean LH level on the trigger day was 1.8 mIU/mL, and a low incidence of premature LH surge was observed (14, 15). Hypothalamic suppression may have affected responses to
the GnRH-a trigger. In the present study, we determined the incidence of patients who do not respond to an adequate LH surge and identified specific characteristics associated with these nonresponders. In addition, we analyzed the benefit of using one bolus of low dose hCG concomitant with GnRH-a (a dual trigger), 34–36 hours before oocyte retrieval.
MATERIALS AND METHODS Study Population and Design This is a retrospective analysis of a cohort of IVF-ICSI cycles (n ¼ 8,970) in 8,092 patients in the Department of Assisted Reproduction of the Ninth People's Hospital of Shanghai Jiaotong University School of Medicine from November 2013 to January 2016 (Supplemental Fig. 1). To reflect the broad range of patients who are typically encountered in clinical practice, no inclusion or exclusion criteria regarding baseline characteristics were applied. Patients underwent COS using hMG (150–225 IU/d; Anhui Fengyuan Pharmaceutical Co.) and MPA (4, 8, or 10 mg/d) and/or Utrogestan (100 mg twice a day) from menstrual cycle 3 (14, 15). The initiating dose of 150 IU/d was used for patients with high antral follicle counts >20 or slightly elevated basal FSH (>7 IU/L), whereas 225 IU/d was used for all other patients. The choice of either MPA or Utrogestan was based on physician preference. In total, there were 1,320 IVF-ICSI cycles treated with hMG þ Utrogestan protocol, and 7,650 IVFICSI cycles treated with hMGþMPA protocol. The final stage of oocyte maturation was triggered using triptorelin (0.1– 0.2 mg; Decapeptyl, Ferring Pharmaceuticals) or cotriggered using SC injections of a combination of triptorelin (0.1– 0.2 mg) and hCG (1,000, 2,000, or 5,000 IU) (Lizhu Pharmaceutical Trading Co.). The choice of either GnRH-a trigger or dual trigger was based on physician preference. Transvaginal ultrasound-guided oocyte retrieval was conducted 34– 36 hours after the trigger. All follicles with diameters of >10 mm were aspirated. Fertilization of the aspirated oocytes was performed in vitro, using either conventional insemination or ICSI, depending on semen parameters. Embryos were examined for the number and regularity of blastomeres and the degree of embryonic fragmentation on the third day, according to the criteria described by Cummins et al. (16). The freeze-all strategy was performed for all IVF-/ICSI cycles. All good-quality embryos (including grade 1 and grade 2 8-cell embryos) were frozen by vitrification on the third day after oocyte retrieval. Only embryos that were not of top quality were placed in extended culture until they reached the blastocyst stage. During this stage, only good-morphology blastocysts were frozen on day 5 or day 6. The vitrification procedure for freezing cleavage-stage embryos and blastocysts was performed as previously described (14). This study was approved by the Ethics Committee (Institutional Review Board) of the Ninth People's Hospital of Shanghai.
Hormone Analysis Serum FSH, LH, E2, and P levels were measured on menstrual cycle 3, the trigger day, and the day after trigger (10 hours VOL. - NO. - / - 2016
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after the injection of GnRH-a/hCG or GnRH-a). Hormone levels were measured using chemiluminescence (Abbott Biologicals B.V.). The lower limits of sensitivity were as follows: FSH, 0.06 mIU/mL; LH, 0.09 mIU/mL; E2, 10 pg/mL; and P, 0.1 ng/mL. The upper limit for E2 measurement was set at 5,000 pg/mL. The E2 levels were recorded as 5,000 pg/mL if they were higher than the upper limit on the trigger day or the day after trigger.
Statistical Analysis The oocyte retrieval rate was defined as the ratio of the total number of oocytes retrieved to the number of follicles aspirated (diameter, R10 mm) on the day of oocyte retrieval. The rate of mature oocyte was defined as the ratio of metaphase II oocytes to the number of collected oocytes. Data are presented as the mean SD. Comparisons among groups were analyzed by analysis of variance (ANOVA) followed by an appropriated post hoc test. For nonparametric data, the means SD were calculated. The c2, t, and Fisher's exact tests were used to investigate the differences. P< .05 was considered statistically significant. The receiver operating curve analyses were used to assess and compare the predictive accuracy of basal FSH and LH, and FSH and LH levels on the day of trigger. The optimal cutoff value for basal LH was determined using the value that maximizes (sensitivity þ specificity 1). The receiver operating curve and all other data were analyzed using the Statistical Package for the Social Sciences for Windows (ver. 22, SPSS Inc.).
RESULTS In previous studies (8–10), patients who had an insufficient pituitary response (LH, %15 mIU/mL) were more likely to have a lower oocyte retrieval rate, have empty follicle syndrome, have fewer mature oocytes retrieved, and experience poor outcomes. In the present study, 2.71% (243/8,970) of the included patients exhibited a suboptimal response to GnRH-a, as defined by a serum LH %15 mIU/mL, approximately 10 hours after GnRH-a trigger (Table 1 and Supplemental Fig. 1). There were no statistically significant differences in the mean age (33.38 6.36 years vs. 32.48 5.10 years; P>.05), day 3 E2 level (34.50 15.85 pg/mL vs. 38.78 19.53 pg/mL; P>.05), day 3 serum P level (0.52 1.14 ng/mL vs. 0.32 0.41 ng/mL; P>.05), number of antral follicles (8.82 8.76 vs.8.17 7.69; P>.05), or triptorelin dose (0.11 0.02 mg vs. 0.11 0.03 mg; P>.05) between suboptimal and appropriate responders (serum LH, >15 mIU/mL 10 hours after GnRH-a trigger), respectively (Table 1). In addition, no difference was observed in the proportion of IVF indications, including tubal factor, male infertility factor, endometriosis, polycystic ovary syndrome (PCOS), combination of factor, and unknown factor (Table 1). However, the suboptimal responders had a significantly higher body mass index (BMI; 24.86 3.92 vs. 21.83 5.09; P< .001), lower basal FSH levels (5.68 2.37 mIU/ mL vs. 6.35 2.97 mIU/mL; P< .001), and lower basal LH levels (2.13 1.12 mIU/mL vs. 3.85 2.16 mIU/mL; P< .001) than the appropriate responders (Table 1). The stimulation and hormonal characteristics are presented in Table 1.
TABLE 1 Characteristics of the patients with suboptimal or appropriate response to the GnRH-a trigger. Characteristic Age of women (y) BMI of women Basal FSH (mIU/mL) Basal LH (mIU/mL) Basal E2 (pg/mL) Basal P (ng/mL) Antral follicles Duration of stimulation (d) Total hMG dose (IU) Triptorelin dose (mg) Hormones on day of trigger FSH (mIU/mL) LH (mIU/mL) E2 (pg/mL) P (ng/mL) No. of follicles aspirated Infertility causes, n (%) Tubal factor Male factor Endometriosis Combination of factors Unknown factor Infertility causes including PCOS Infertility causes including hypothalamic amenorrhea
LH £15 mIU/mL (n [ 243)
LH >15 mIU/mL (n [ 8,727)
P value
32.91 4.79 24.21 3.72 5.45 2.34 2.08 1.64 41.64 38.99 0.38 1.54 7.02 7.16 12.55 3.65 2,157.68 855.33 0.11 0.02
32.95 5.15 21.78 5.44 6.87 4.28 3.83 2.34 39.30 88.54 0.35 0.74 7.84 7.20 10.78 2.59 1,796.28 586.67 0.11 0.03
NS < .001 < .001 < .001 NS NS NS < .001 < .001 NS
13.68 4.01 1.93 4.65 1,873.66 1,441.11 1.02 1.82 11.64 9.65
15.19 4.49 2.26 2.25 2,503.48 1,672.44 1.33 4.96 14.36 10.94
< .001 .035 < .001 NS < .001
121 (49.79) 20 (8.23) 5 (2.06) 92 (37.86) 5 (2.06) 25 (10.29) 0 (0.00)
4,054 (46.45) 1,028 (11.78) 205 (2.35) 3,064 (35.11) 376 (4.31) 626 (7.17) 0 (0.00)
NS NS NS NS NS NS NS
Note: The data are presented as the means SD and percentage. BMI ¼ body mass index; GnRH-a ¼ GnRH agonist; NS ¼ no significant difference; PCOS ¼ polycystic ovary syndrome. Lu. Dual trigger improves oocyte retrieval. Fertil Steril 2016.
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ORIGINAL ARTICLE: ASSISTED REPRODUCTION Suboptimal responders to the GnRH-a trigger responded to stimulation with fewer follicles aspirated (11.64 9.65 vs. 14.36 10.94; P< .001) and lower peak E2 levels (1,873.66 1,441.11 pg/mL vs. 2,503.48 1,672.44 pg/mL; P< .001) than appropriate responders and required more total hMG (2,157.68 855.33 IU vs.1,796.28 586.67 IU; P< .001) and a longer duration time of stimulation (12.55 3.65 days vs. 10.78 2.56 days; P< .001). In addition, the suboptimal responders had significantly lower FSH levels (13.68 4.01 mIU/mL vs. 15.19 4.49 mIU/mL; P< .001) and LH level (1.93 4.65 mIU/mL vs. 2.26 2.25 mIU/mL; P< .001) on the day of the GnRH-a trigger. In previous reports (9), the LH level on the day of trigger was found to be the single most valuable marker for helping clinicians assess a patient's risk of showing a suboptimal response to a GnRH-a trigger. In our study, we found that suboptimal responders had significantly lower basal levels of FSH and LH, and significantly lower FSH and LH levels on the day of trigger. To analyze the accuracy of using basal and day-oftrigger FSH and LH levels for predicting which patients will be suboptimal responders to GnRH-a trigger, receiver operating curve analysis was performed. The results revealed that a patient's basal LH level was the single most valuable marker for identifying suboptimal responders with an AUC (the areas under the receiver operating curve) of 0.805. Basal FSH level and trigger day FSH and LH levels had AUC values of 0.665, 0.591, and 0.652, respectively (Fig. 1). Therefore, a lower basal LH level (LH, <2.27 mIU/mL) is a useful predictor of a suboptimal response to GnRH-a trigger. In addition, we further analyzed the risk of a suboptimal response by basal and trigger day LH levels. As shown in Supplemental Figure 2, as basal and trigger day decreased, the risk of a suboptimal response to GnRH-a trigger increased. A basal LH level of <4.0, 3.0, 2.5, 2.0, 1.5, 1.0, or 0.5 mIU/mL was associated with a suboptimal GnRH-a trigger response rates of 3.51%, 4.98%, 6.68%, 10.21%, 18.37%, 29.27% and 45.45%, respectively. However,
FIGURE 1
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Receiver operating curve analyses of basal FSH levels, basal LH levels, trigger day FSH levels, and trigger day LH levels. The cutoff value was 2.27 mIU/mL for basal LH levels. Lu. Dual trigger improves oocyte retrieval. Fertil Steril 2016.
a trigger day LH level of >2.0, 1.5, 1.0, 0.75, 0.5, 0.3, or 0.1 mIU/mL was associated with a suboptimal GnRH-a trigger response rate of 3.30%, 3.76%, 4.56%, 5.32%, 6.32%, 7.88%, and 10.71%, respectively. These results demonstrate that in patients undergoing hMGþMPA and P treatment protocol, the basal LH level is the most valuable marker for differentiating suboptimal responders to a GnRH-a trigger. To analyze the outcomes associated with a suboptimal response to the GnRH-a, we further analyzed all patients who received a GnRH-a trigger alone (Supplemental Fig. 1). In all, 2.10% (31/1,484) of the patients who received a GnRH-a trigger alone exhibited a suboptimal response to the GnRH-a (Table 2). The suboptimal responders who received a GnRH-a trigger alone had baseline characteristics, hormone profiles, and stimulation characteristics that were similar to the overall population of suboptimal responders who received a GnRH-a trigger alone or a dual trigger (Table 2). There were no significant difference in the number of follicles aspirated and the rates of mature oocyte and fertilization between the suboptimal responders and appropriate responders (Table 2). However, the suboptimal responders who received GnRH-a had a significantly lower oocyte retrieval rate (48.16% 29.27% vs. 68.26% 22.61%; P< .001), fewer mature oocytes retrieved (4.10 5.85 vs. 8.29 6.94; P< .001), and fewer embryos frozen (2.32 2.76 vs. 3.54 3.11; P¼ .031, P< .05) than the appropriate responders (Table 2). In addition, oocyte retrieval rates were not significantly different between patients who underwent hMGþMPA treatment cycles and those who underwent hMGþP treatment cycles (Supplemental Fig. 3), indicating that the difference in the oocyte retrieval rate was not due to a difference in the progestin used. Empty follicle syndrome (EFS) has been defined as a condition in which no oocytes are retrieved from mature follicle after ovulation induction in IVF-ICSI cycles (17, 18). A previous study (8) showed that all cases (7/508) of EFS occurred in patients with suboptimal response (LH, <15 mIU/mL) to GnRH-a trigger. In our study, there were 3.22% (1/31) cycles with suboptimal response to GnRH-a trigger and 0.55% (8/1,453) cycles with appropriate response to GnRH-a trigger had no oocytes obtained. No significant difference was in the EFS rates between the suboptimal responders and appropriate responders (Table 2). The one patient with suboptimal response to GnRH-a trigger and four patients with appropriate response to GnRH-a trigger, who had no oocytes obtained, were older than 40 years. We also noted all cases without oocytes obtained in our study have only one to two dominant follicles despite profound ovarian hyperstimulation. The most effective time and dose at which to add hCG to improve the reproductive outcomes of suboptimal responders are still unknown. In our study, we evaluated the effect of using a dual trigger (GnRH-a and hCG 1,000, 2,000, or 5,000 IU), 34–36 hours before oocyte retrieval in patients with a suboptimal response to a GnRH-a trigger (Table 3 and Supplemental Fig. 1). Baseline characteristics were similar across the GnRH-a-alone group, dual trigger (GnRH-aþhCG 1,000 IU) group, dual trigger (GnRH-aþhCG 2,000 IU) group, and dual trigger (GnRH-aþhCG 5,000 IU) group (Table 3). The VOL. - NO. - / - 2016
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TABLE 2 Characteristics of the IVF/ICSI cycles triggered with GnRH-a alone and associated outcomes. Characteristic Age of women (y) BMI of women Basal FSH (mIU/mL) Basal LH (mIU/mL) Basal E2 (pg/mL) Basal P (ng/mL) Antral follicles Duration of stimulation (d) Total hMG dose (IU) Hormones on day of trigger FSH (mIU/mL) LH (mIU/mL) E2 (pg/mL) P (ng/mL) No. of follicles aspirated No. of oocytes retrieved Oocytes retrieval rate (%) Empty follicle syndrome (%) Mature oocytes The rate of mature oocytes (%) Fertilization rate (%) Embryos frozen Infertility causes, n (%) Tubal factor Male factor Endometriosis Combination of factors Unknown factor Infertility causes including PCOS Infertility causes including hypothalamic amenorrhea
LLH £15 mIU/mL (n [ 31)
LH >15 mIU/mL (n [ 1,453)
P value
33.38 6.36 24.86 3.21 5.68 2.37 2.13 1.12 34.50 15.85 0.52 1.14 8.82 8.76 12.10 2.21 1,935.48 516.15
32.48 5.10 21.83 5.24 6.35 2.97 3.85 2.16 38.78 19.53 0.32 0.41 8.17 7.69 10.96 2.29 1,708.31 595.97
NS < .001 NS < .001 NS NS NS .007 .033
12.10 4.03 2.94 2.63 1,906.41 1,656.87 5.71 10.35 12.77 14.95 4.83 6.33 48.16 29.27 1 (3.22) 4.10 5.85 85.84 26.59 76.85 33.30 2.32 2.76
14.42 4.86 3.11 2.24 2,753.23 1,616.34 4.27 17.33 14.85 12.40 9.70 7.76 68.26 22.61 8 (0.55) 8.29 6.94 86.63 19.38 75.26 47.78 3.54 3.11
.008 NS .005 NS NS < .001 < .001 NS .001 NS NS .031
15 (48.39) 4 (12.9) 0 (0.00) 12 (38.71) 0 (0.00) 5 (16.13) 0 (0.00)
684 (47.08) 156 (10.74) 23 (1.58) 551 (37.92) 39 (2.76) 154 (10.60) 0 (0.00)
NS NS NS NS NS NS NS
Note: The data are presented as the means SD and percentage. BMI ¼ body mass index; GnRH-a ¼ GnRH agonist; ICSI ¼ intracytoplasmic sperm injection; NS ¼ no significant difference; PCOS ¼ polycystic ovary syndrome. Lu. Dual trigger improves oocyte retrieval. Fertil Steril 2016.
oocyte retrieval rate was significantly higher in the dual trigger group than in the GnRH-a-alone group (GnRHaþhCG 1,000 IU: 60.04% 25.24% vs. 48.16% 29.27%; GnRHaþhCG 2,000 IU: 68.13% 19.65% vs. 48.16% 29.27%; and GnRH-aþhCG 5,000 IU: 65.76% 23.60% vs. 48.16% 29.27%; P< .05 for all) (Table 3). However, there were no significant differences in oocyte retrieval rates between the dual trigger groups. We noted that the dual trigger GnRHaþhCG 1,000 IU group and the dual trigger GnRH-aþhCG 2,000 IU group showed a greater number of retrieved oocytes (6.60 5.81 vs. 4.83 6.32 and 7.00 3.22 vs. 4.83 6.32, respectively), more mature oocytes (5.96 5.22 vs. 4.10 5.85 and 6.00 3.08 vs. 4.10 5.85, respectively), and more embryos frozen (2.79 2.66 vs. 2.32 2.76 and 2.32 2.76 vs. 2.32 2.76, respectively) than the GnRH-a trigger alone group. However, these differences did not reach significance (Table 3), which might have been because the small number of included patients limited the statistical power of the analyses. The use of hCG is associated with a risk of OHSS. In our study, two cases with moderate-to-severe OHSS were observed in the dual trigger GnRH-aþhCG 5,000 IU group. There were no cases of OHSS in the dual trigger GnRHaþhCG 1,000 IU group or the dual trigger GnRH-aþhCG 2,000 IU group.
DISCUSSION Using GnRH-a to induce oocyte maturation has been shown to be the most effective method for reducing the risk of OHSS. However, in some patients with low gonadotropin reserves or in those who have experienced pituitary downregulation, the pituitary is unable to induce an adequate endogenous LH surge. Our recent study (14) showed that MPA administration shows potential as an effective oral alternative for preventing a premature LH surge in patients undergoing IVF cycles. In addition P (Utrogestan), as well as MPA, prevents a premature LH surge when applied in patients with COS (15). In hMGþMPA-Utrogestan treatment protocol, the pituitary is down-regulated by MPA or Utrogestan, resulting in low LH levels on the day of trigger. Our study showed that using a dual trigger consisting of GnRH-a and a low dose of hCG provided beneficial effect to oocyte maturation in patients using this regimen. However, the appropriate trigger strategies that should be used in patients being treated with hMGþMPA-P protocol remain unknown. In the present study, we analyzed 8,970 IVF-ICSI cycles and found that only 2.71% (243/8,970) of the included patients exhibited a suboptimal response to the GnRH-a. A suboptimal response to the GnRH-a was associated with a significantly decreased oocyte retrieval rate, fewer mature occytes retrieved, and
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ORIGINAL ARTICLE: ASSISTED REPRODUCTION 591 TABLE 3 592 593 Baseline characteristics, ovarian stimulation characteristics, and outcomes in suboptimal responders who were triggered with GnRH-a combined 594 with different doses of hCG. 595 hCG 596 Characteristic 0 (n [ 31) 1,000 (n [ 139) 2,000 (n [ 21) 5,000 (n [ 38) P value 597 598 Age of women (y) 33.38 6.36 32.67 4.45 32.91 3.96 33.91 3.96 NS BMI of women 24.86 3.92 23.79 3.85 23.68 3.13 23.99 2.93 NS 599 Basal FSH (mIU/mL) 5.68 2.37 5.45 2.50 5.39 1.08 6.13 1.96 NS 600 Basal LH (mIU/mL) 2.13 1.12 2.03 1.69 2.33 1.58 1.99 1.10 NS 601 34.50 15.85 39.25 40.54 43.86 22.25 56.23 41.54 NS Basal E2 (pg/mL) 602 Basal P (ng/mL) 0.52 1.14 0.56 2.60 0.24 0.10 0.26 0.11 NS Antral follicles 8.82 8.76 7.023 7.30 6.91 4.62 6.59 3.99 NS 603 Duration of stimulation (d) 12.10 2.21 12.14 2.97 12.21 4.89 12.08 2.70 NS 604 Total hMG dose (IU) 1,935.48 516.15 2,070.32 641.41 2,185.71 948.47 2,007.24 477.99 NS 605 Hormones on day of trigger 606 14.01 4.07a 15.79 4.33a 14.69 4.45 < .05 FSH (mIU/mL) 12.10 4.03a LH (mIU/mL) 2.94 2.63 1.83 5.6 1.85 1.99 1.41 0.85 NS 607 1,906.41 1,656.87 1,994.82 1,520.68 1,991.81 1,190.88 1,526.42 1,000.93 NS E2 (pg/mL) 608 b b 12.02 9.72 10.29 3.96 7.82 4.60 < .05 No. of follicles aspirated 12.76 14.95 609 60.04 25.24c 68.13 19.65c 65.76 23.60c < .05 Oocytes retrieved rate 48.16 29.27c No. of oocytes retrieved 4.83 6.32 6.60 5.81 7.00 3.22 4.74 3.01 NS 610 No. of mature oocytes 4.10 5.85 5.96 5.22 6.00 3.08 3.84 2.75 NS 611 The rate of mature oocyte 85.84 26.59 92.10 26.83 87.16 18.42 82.15 24.68 NS 612 Fertilization rate 76.85 23.30 78.67 24.65 78.18 23.08 68.78 32.15 NS 613 Embryos frozen 2.32 2.76 2.79 2.66 2.74 1.91 2.58 2.51 NS Infertility causes, n (%) 614 Tubal factor 15 (48.39) 68 (48.92) 9 (42.86) 16 (42.11) NS 615 Male factor 4 (12.9) 12 (8.63) 2 (9.52) 2 (5.26) NS 616 Endometriosis 0 (0.00) 2 (1.43) 1 (4.76) 3 (7.89) NS Combination of factors 12 (38.71) 52 (37.4) 9 (42.86) 17 (44.74) NS 617 Unknown factor 0 (0.00) 5 (3.60) 0 (0.00) 0 (0.00) NS 618 Infertility causes including 5 (16.13) 17 (12.23) 2 (9.52) 1 (2.63) NS 619 PCOS 620 Infertility causes including 0 (0.00) 0 (0.00) 0 (0.00) 0 (0.00) NS hypothalamic 621 amenorrhea 622 Note: The data are presented as means SD and percentage. GnRH-a ¼ GnRH agonist; NS ¼ no significant difference; PCOS ¼ polycystic ovary syndrome. a 623 The group triggered with GnRH-a versus the group triggered with the dual trigger GnRH-aþhCG (1,000 IU) or the dual trigger GnRH-aþhCG (2,000 IU). b The group triggered with GnRH-a versus the group triggered with dual trigger GnRH-aþhCG (5,000 IU). 624 c The group triggered with GnRH-a versus the dual trigger groups. 625 Lu. Dual trigger improves oocyte retrieval. Fertil Steril 2016. 626 627 628 fewer embryos frozen, but neither with the rate of mature no significant differences in the number of antral follicles 629 oocyte nor the fertilization rate. These results were consistent between the appropriate and suboptimal responder groups. 630 with previous reports that found suboptimal response to the In addition, the basal FSH level and the LH level were lower 631 GnRH-a (LH, %15 mIU/mL) is associated with a dramatically in the suboptimal responder group than that in the appro632 lower oocyte yield but not with the oocyte maturity rate and priate responder group. All of these data were consistent 633 fertilization rate (10). with what was found in the GnRH-antagonist-based IVF cy634 The EFS is uncommon but a frustrating complication of cles, and the lower LH responses had been presumed to be due 635 IVF-ICSI cycles, leading to cycle cancellation. In our study, to down-regulation of the hypothalamic-pituitary axis (9). 636 there were 3.22% (1/31) cycles with appropriate response In our study, we also showed that addition of a bolus of 637 GnRH-a trigger and 0.55% (8/1,453) cycles with appropriate hCG significantly increased the oocyte retrieval rate, but 638 Q2 response to GnRH-a trigger had no oocytes obtained. No signot the oocyte maturity and fertilization rate. However, there 639 nificant differences between the suboptimal responders and were no significant difference in the oocyte retrieval rate 640 appropriate responders were in EFS rates. In the eight IVFamong the dual trigger group (GnRH-aþhCG 1,000 IU), the 641 ICSI cycles with appropriate response to GnRH-a trigger, the dual trigger group (GnRH-aþhCG 2,000 IU), and the dual 642 occurrence of EFS could be linked to ovulation before follicle trigger group (GnRH-aþhCG 5,000 IU). Our results also 643 puncture, advanced age, and poor ovarian response. Consisshowed that there were no cases of OHSS in the dual trigger 644 tent with our result, in addition to false trigger, the advanced group (GnRHaþhCG 1,000 IU). These results indicated that 645 age and poor ovarian response have been suggested to be the low dose of hCG (1,000 IU) could safely and effectively 646 risk factors for the EFS (18, 19). improved the oocytes retrieval rate. 647 In the present report, we noted that the suboptimal A strategy for predicting patients at risk for suboptimal 648 responders required more hMG and a longer duration of stimresponse to GnRH-a would be helpful for patients to receive 649 ulation compared with the appropriate responders. There were a safe and effective trigger in IVF-ICSI cycles. Here, we VOL. - NO. - / - 2016
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identified the characteristics associated with suboptimal responders whose serum LH was %15 mIU/mL approximately 10 hours after GnRH-a trigger. The suboptimal responders had higher BMIs and lower basal FSH and LH levels, in addition to lower trigger day FSH and LH levels. The basal serum LH was found to be the most important predictor for helping clinicians assess the risk of a suboptimal response to GnRH-a trigger, as defined by a serum LH %15 mIU/mL approximately 10 hours after GnRH-a trigger. This finding also differs from that described in a previous report (9) that identified the LH level on the day of trigger as the single most valuable predictive marker. This difference may be because the variably suppressed LH level by the MPA and/or P on the day of trigger in hMGþMPA or P treatment protocols. In conclusion, we identified a small subset of patients who showed a suboptimal response to GnRH-a trigger yet undergoing an hMGþMPA or P treatment protocol. The basal serum LH level (LH, <2.27 mIU/mL) was the best predictor of a response to a GnRH-a trigger. Using a dual trigger that included a low dose of hCG (1,000 IU) as an adjuvant to GnRH-a to induce final oocyte maturation significantly improved the oocytes retrieval rate of suboptimal responders, without increasing the risk of clinically significant OHSS. However, this is a retrospective study with its inherent limitations and bias. The observed benefit of using a higher dose of hCG for improving reproductive outcomes in suboptimal responders needs to be further tested in randomized controlled trials.
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