Dual Trigger With 250 Mcg Recombinant Human Chorionic Gonadotropin And 1 Mg Leuprolide Acetate Compared With 250 Mcg Recombinant Human Chorionic Gonadotropin Alone For Final Oocyte Maturation And Effects On Clinical Outcome

Human chorionic gonadotropin (hCG) is the traditional agent used to trigger oocyte maturation.Similarity between the beta subunits of LH and hCG molecules enable the latter to stimulate LH receptors on granulosa cells. However, hCG has a longer half-life than LH and provides extended stimulation to multiple corpora lutea following ER. This is associated with an increased risk of ovarian hyperstimulation syndrome (OHSS), a major risk of ovarian stimulation. A single bolus of a gonadotropin releasing hormone agonist (GnRH-a) also induces an endogenous LH surge. The short duration of the GnRH-a induced LH surge leads to luteolysis and significantly decreases risk of OHSS. However, luteolysis is associated with decreased pregnancy and increased miscarriage rates following fresh embryo transfer in GnRH-a triggered cycles. The addition of a small dose of hCG for luteal phase support restores clinical outcome to some extent, at the cost of a small risk of OHSS, precluding the use of hCG at all in women under high risk of OHSS.This retrospective study compared outcomes of the standard 6,000 IU hCG trigger with a dual trigger comprised of 6,000 IU hCG and 0.1 mg leuprolide acetate for oocyte maturation in intracytoplasmic sperm injection (ICSI) cycle.Material and Method : All women undergoing egg retrieval were given dual trigger including 0.1 mg leuprolide acetate and 6000 IU recombinant hCG for oocyte maturation between January and September 2018. These women comprised the Dual Trigger group. Women who received 6000 IU rhCG as the ovuation trigger between September 2017 and January 2018 (the three month period immediately before dual trigger) and September 2018 and January 2019 (the three month period immediately after the dual trigger) comprised the hCG trigger group. Women deemed to be at risk of ovarian hyperstimulation syndrome was not given any hCG at all and excluded. Gonadotropins were started on the 2nd or 3rd day of the menstrual cycle after ruling out ovarian or endometrial pathology Ovarian response to gonadotropin was evaluated by ultrasound the 5th or 6th day of stimulation and every one to three days afterwards, based on clinical judgement. Daily 25 mcg GnRH antagonist injections were started when the leading follicle diameter was 14 mm or serum estradiol level exceeded 200 ng/ml. Final oocyte maturation was triggered when two follicles were > 17 mm. Transvaginal oocyte collection was done 36 hours after the trigger Fertilization was by ICSI, all embryos were cultured to the blastocyst stage, regardless of oocyte number.Result:Total number of patients in each group was 50. There were no statistically significant difference between two groups in the median number of oocytes (8 in dual trigger and 7 in hCG only group), Metaphase two oocytes (6 in dual trigger and 5.5 in hCG only group) and the median number of blastocyst was 1 in both groups. Women only underwent embryo transfer if they had at least one blastocyst. Fresh embryo transfer was done for 30 out of 50 patients in dual trigger and 25 out of 50 patients in hCG only group. Similar number of embyros were transferred in both groups, the vast majority was single blastocyst transfers. Clinical pregnancy rate per patient was 28% and 22% in dual trigger and control groups, respectively. Pregnancy rate per transfer was: 53.3% in dual trigger and 53.8% in hCG only group, respectively.Ongoing pregnancy rate was 22% for patients in dual trigger and 20% in hCG only group. Differences were short of statistical significance. Miscarriage rate was 8% in both groups. There were no case of severe OHSS in any of two groups.Conclusion: In a non selected group of women representing general ART patient population, the addition of a GnRH agonist to the standard dose of hCG, as dual trigger for oocyte maturation stimulation in normal responders and poor responder patients failed to improve outcomes of ICSI. Most studies published to date are retrospective and publication bias favoring positive findings. Proper randomized trilas are still needed

کلیدواژه ها:

Dual Trigger ، Infertility ، GnRG agonist ، hCG ، IVF outcome ، oocyte maturation