Gonadotropin-releasing hormone agonist-induced ovarian hyperstimulation: low-dose side effects in women and monkeys

A preliminary study on reduced dose (33 or 25 microg) gonadotropin-releasing hormone agonist long protocol for multifollicular ovarian stimulation in patients with high basal serum follicle-stimulating hormone levels undergoing in vitro fertilization-embryo transfer

The aim of the present study was to evaluate the clinical efficacy of half-dose (50 mug) and further reduced dose (33 or 25 mug) gonadotropin-releasing hormone agonist (GnRH-a; triptorelin) long protocols for multifollicular ovarian stimulation (MFOS) for patients with high basal serum follicle-stimulating hormone (FSH) level undergoing in vitro fertilization and embryo transfer (IVF-ET). One hundred and two IVF-ET cycles performed in 84 infertile patients with high basal serum FSH (>10.0 mIU/ml) were included in this retrospective study. Study subjects were assigned to two groups: continuous half-dose GnRH-a long protocol (group A, n = 63) vs. further reduced dose GnRH-a long protocol (group B, n = 39) from half-dose at the start of GnRH-a to one-third or one-quarter dose after pituitary downregulation. Exogenous FSH or human menopausal gonadotropin was administered for MFOS in step-down mode, four or fewer embryos were transferred, and the outcomes of MFOS were compared between the two groups. Serum estradiol (E(2)) level on the day of human chorionic gonadotropin administration was significantly higher in group B (mean +/- standard deviation (SD): 1318.3 +/- 1120.4 vs. 2054.9 +/- 1773.5 pg/ml, p = 0.015). The number of transferable and good-quality embryos was also significantly higher in group B (mean +/- SD: 2.9 +/- 1.7 vs. 3.7 +/- 2.0, p = 0.027; 1.8 +/- 1.4 vs. 2.7 +/- 2.0, p = 0.020). No statistically significant difference in the outcomes was observed with respect to the dose of gonadotropins administered, the number of oocytes retrieved or the clinical pregnancy rate. In conclusion, GnRH-a long protocol with a reduced dose, tapered from the starting half-dose to a third or a quarter of the normal dose after pituitary suppression, may be beneficial for MFOS in IVF-ET patients with a high basal serum FSH level. A further prospective randomized controlled study on a larger scale is needed to confirm these findings.

Early and late hormonal responses to the microdose gonadotropin-releasing hormone agonist in normal menstruating women

OBJECTIVE

To assess the effect of a microdose gonadotropin-releasing hormone (GnRH) agonist on the LH, FSH, and E2 secretion in normal menstruating women.

DESIGN

Prospective study.

SETTING

Tertiary teaching hospital.

PATIENT(S)

Five normal menstruating women.

INTERVENTION(S)

Five microg of triptorelin was injected daily in 5 women for 7 days beginning from the cycle day 3. In the next cycle, the same amount of triptorelin was injected into the same women daily for 3 days.

MAIN OUTCOME MEASURE(S)

Serial serum FSH, LH, and E2 levels.

RESULT(S)

The FSH levels peaked (27.53 +/- 6.34 IU/L) after 5 hours, and the LH levels peaked (34.35 +/- 7.81 IU/L) by 4 hours. The increased gonadotropin levels persisted even after the second and third day of the GnRH-agonist injections, although the peak levels were not as high as observed with the first injection (19.56 IU/L in the second day, 9.15 IU/L in the third day for FSH; 32.18 IU/L in the second day, 13.59 IU/L in the third day for LH). The down-regulation of gonadotropins was established in 4 days. When the GnRH-agonist was administered for 7 days, the E2 level began to increase 6 days after the last injection. When the GnRH-agonist was administered for 3 days, the E2 level began to increase 3 days after the last injection.

CONCLUSION(S)

Pituitary down-regulation could be achieved even with a microdose of GnRH agonist. The increased level of gonadotropins persisted for 3 days at this dose. The duration of the down-regulation was influenced by the duration of GnRH-agonist administration.

Clinical outcome of using ganirelix acetate versus a 4-day follicular phase leuprolide acetate protocol in unselected women undergoing in vitro fertilization

OBJECTIVE

To compare the clinical outcome of controlled ovarian hyperstimulation (COH) in unselected patients undergoing IVF using multidose ganirelix acetate versus 4 days of administration of leuprolide acetate.

DESIGN

Retrospective cohort study.

SETTING

A fertility and IVF center.

PATIENT(S)

Two hundred forty-seven women who underwent COH-IVF between April 1, 1999, and January 30, 2001.

INTERVENTION(S)

Pituitary suppression according to a 4-day follicular phase leuprolide acetate protocol (236 women) or a multidose ganirelix acetate regimen (133 women).

MAIN OUTCOME MEASURE(S)

Amount of gonadotropin used, days of stimulation, cancellation rate, number of oocytes retrieved, implantation rate, and clinical pregnancy rate.

RESULT(S)

Compared with leuprolide acetate recipients, ganirelix recipients required significantly less gonadotropin and the mean day of hCG administration was 4 days earlier. Among women younger than 35 years of age, the implantation rate (15% vs. 6%) and the clinical pregnancy rate per initiated and transferred cycle (27% vs. 12% and 32% vs. 15%, respectively) were significantly higher in the ganirelix group than the leuprolide acetate group.

CONCLUSION(S)

Compared with a 4-day leuprolide acetate protocol, COH-IVF using a multidose ganirelix acetate protocol reduces treatment duration and amount of gonadotropin used. In younger women, the latter protocol is associated with significantly better pregnancy and implantation rates.

Comparison of agonistic flare-up-protocol and antagonistic multiple dose protocol in ovarian stimulation of poor responders: results of a prospective randomized trial

The management of poor responders in IVF has always been a big problem. The ideal approach has yet to be formulated. In this study we aim to compare two alternative stimulation protocols. A total of 48 poor responder patients described from previous cycles were included and grouped into two: group I consisted of 24 patients in 24 cycles in which leuprolide acetate (40 microg s.c. per day) was initiated on cycle day 2 followed by exogenous gonadotrophins on cycle day 3; group II consisted of 24 patients in 24 cycles in which ovarian stimulation included gonadotrophin-releasing hormone (GnRH) antagonist (cetrorelix, 0.25 mg daily during late follicular phase) administration. While only the oestradiol concentrations on the day of HCG were lower in group II compared with group I, the clinical pregnancy and implantation rates among groups did not show any significance. The impact of these two regimens in ovarian stimulation of poor responders seem to be same and to establish these results further randomized studies with larger sample sizes are required.

Effectiveness of low dose of gonadotropin releasing hormone agonist on hormonal flare-up

PURPOSE

The hormonal response (flare-up) following administration of a standard dose (100 micrograms) or a low dose (25 micrograms) of gonadotropin releasing hormone agonist (GnRH-a) (Triptorelin) was compared in patients prior to an in vitro fertilization (IVF) cycle and during the early follicular phase of a short-term IVF protocol.

METHODS

The gonadotroph (FSH, LH) and steroid [estradiol (E2) and progesterone (P)] flare-up was studied on two consecutive cycles in 30 normo-ovulatory women. Patients were randomized to receive either 25 or 100 micrograms of triptorelin for three days at the beginning of the first cycle. Then doses were switched according to a crossing over design in the second cycle.

RESULTS

No significant difference in the magnitude of FSH and E2 release could be observed following administration of the two doses of agonist whereas maximal plasma LH level was significantly reduced after injection of 25 micrograms of triptorelin.

CONCLUSIONS

As compared to a standard dose, using a low dose of GnRH-a induces an hormonal flare-up which seems adequate for an optimal follicular recruitment.

Microdose follicular phase gonadotropin-releasing hormone agonist (GnRH-a) compared with luteal phase GnRH-a for ovarian stimulation at in vitro fertilization

OBJECTIVE

To compare an ovarian stimulation protocol using microdose follicular phase GnRH agonist (GnRH-a) and oral contraceptive (OC) pills to a luteal phase GnRH-a protocol.

DESIGN

Retrospective analysis.

SETTING

University affiliated IVF program.

PATIENT(S)

One hundred seventy patients who underwent IVF and ET in 1996.

INTERVENTION(S)

Patients were assigned to either a midluteal start of leuprolide acetate (LA) 1 mg/d, reduced to 0.5 mg/d after addition of gonadotropins (LUT), or OC pills until cycle day 0 followed by 20 microg of LA every 12 hours on cycle day 3 with addition of gonadotropins on cycle day 5 (MICRO).

MAIN OUTCOME MEASURE(S)

Number of FSH ampules, days of stimulation, peak E2, and number of oocytes retrieved.

RESULT(S)

There were no statistically significant differences in the main outcome measures between the two groups using an age-matched ANOVA. Clinical pregnancy rate per cycle start was not statistically different (LUT = 54%, and MICRO = 37%). The cancellation rate was significantly higher in the MICRO group (22.5% vs. 8.2%).

CONCLUSION(S)

Given the higher cancellation rate in the microdose group, a randomized clinical trial is required to determine the possible benefit of a lower dose of GnRH-a in patients with normal ovarian function.

Intranasal nafarelin versus buserelin (short protocol) for controlled ovarian hyperstimulation before in vitro fertilization: a prospective clinical trial

The aim of this study was to compare the effect of nafarelin acetate with that of buserelin acetate nasal spray, when administered in a 'short' protocol, as an adjunct to human menopausal gonadotropin (hMG) for controlled ovarian hyperstimulation before in vitro fertilization (IVF). Twenty-two IVF subjects were randomly recruited. Each underwent two consecutive treatment cycles; one with buserelin (900 micrograms/day) and another with nafarelin (400 micrograms/day). The treatment protocol included transnasal gonadotropin-releasing hormone (GnRH) analog from the second cycle day and hMG from the fourth day of the cycle. The buserelin and nafarelin cycles did not differ significantly in the following parameters: baseline hormone profile, duration of GnRH analog treatment, mean hMG dose required, peak estradiol levels, number of preovulatory follicles, number of aspirated oocytes, fertilization rate and number of transferred or frozen embryos. No side-effects or cancellations of treatment were recorded. The average dose required was lower for nafarelin and, because this analog was given only twice a day, it was more convenient to administer. These findings suggest that nafarelin is as effective as buserelin (when administered in a "short' protocol) in achieving controlled ovarian hyperstimulation. It even offers advantages over buserelin with respect to the total dose required (which probably reflects its relatively high potency) and the subjects' compliance.

Evaluation of the impact of concurrent gonadotropin-releasing hormone (GnRH) antagonist administration on GnRH agonist-induced gonadotrope desensitization

OBJECTIVE

To evaluate the impact of chronic GnRH antagonist therapy on the extent of GnRH agonist-induced gonadotrope desensitization.

DESIGN

Prospective and controlled.

SETTING

Primate Research Center.

PARTICIPANTS

Six reproductive age cycling female baboons (Papio cyanocephalus anubis).

INTERVENTIONS

The animals were divided into two groups. Group A received a total of 19 pulses of 0.83 microgram/kg leuprolide acetate (LA) on a 12-hour dosing schedule. Group B received Nal-Lys (3 mg/kg then 1 mg/kg every other day) for 1 week and then added an identical 19 pulses of LA while continuing Nal-Lys therapy.

MAIN OUTCOME MEASURES

Characterization of the gonadotropin response was done by collecting serum samples at -15, 0, 15, 30, 60, 90, 120, 240, and 480 minutes relative to the injection of the LA.

RESULTS

After equivalent baseline responses, the baboons pretreated with Na-Lys had an increased LH and FSH response to the administration of the LA. After a total of 19 pulses of the LA, the Nal-Lys-treated animals had an increased FSH response in comparison to the untreated controls. This indicates that the extent of gonadotrope desensitization was reduced in the presence of the GnRH antagonist.

CONCLUSIONS

The presence of GnRH antagonist reduces the extent of gonadotrope desensitization in response to the administration of repetitive pulses of GnRH agonist.

Minidose gonadotropin-releasing hormone agonist is the treatment of choice in poor responders with high follicle-stimulating hormone levels

OBJECTIVE

To investigate the effectiveness of minidose GnRH agonist (GnRH-a) + hMG in poor responders with elevated basal level FSH.

DESIGN

Retrospective analysis of IVF cycles.

SETTING

IVF Unit, Golda Medical Center, Petah Tikva, Israel.

PATIENTS

One hundred six patients who were defined as poor responders on two previous IVF attempts. Three treatment protocols of midluteal Decapeptyl (D-Trp6) were compared: [1] a single-dose of 3.75 mg; [2] 0.5 mg daily until menstruation, followed by 0.1 mg daily; and [3] 0.1 mg daily until menstruation, followed by 0.05 mg daily.

MAIN OUTCOME MEASURES

Comparisons were made among the three protocols regarding basal FSH levels, number of oocytes retrieved and fertilized, number of days of stimulation, follicular phase, P levels, and pregnancy and miscarriage rates.

RESULTS

Treatment with minidose GnRH-a resulted in higher E2 levels and lower P levels on the day of hCG and lower cancellation rates. Furthermore, a higher number of oocytes recovered and fertilized and embryos transferred were recorded. The trend indicated improved pregnancy and implantation rates with a lower miscarriage rate.

CONCLUSION

Minidose GnRH-a is a better choice than regular GnRH-a strategies in poor-responder patients undergoing IVF treatment.

Enhancement of ovarian responsiveness with microdoses of gonadotropin-releasing hormone agonist during ovulation induction for in vitro fertilization

OBJECTIVE

To determine if women who previously had demonstrated poor ovarian responsiveness during ovulation induction for IVF would obtain an improved follicular response by the administration of microdoses of GnRH agonist (GnRH-a).

DESIGN

Prospective evaluation using the same patients' previous assisted reproductive technology cycles as historic controls.

SETTING

Large military tertiary care center.

PATIENTS

Thirty four patients who were low responders (peak E2 < 500 pg/mL [conversion factor to SI unit, 3.67]) during ovulation induction with luteal phase GnRH-a suppression followed by exogenous gonadotropins.

INTERVENTIONS

Follicular phase administration of 20 micrograms leuprolide acetate every 12 hours beginning on cycle day 3 and supplemented with exogenous gonadotropins beginning on cycle day 5.

MAIN OUTCOME MEASURES

Paired analysis of initial E2 response, peak E2 level attained, number of follicles > or = 16 mm, duration of stimulation, ampules of gonadotropins required, late follicular LH levels, number of mature oocytes retrieved, and fertilization rates.

RESULTS

Ovarian responsiveness was enhanced during the microdose GnRH-a stimulation cycle when compared with the previous stimulation cycle. Specifically, the patients had a more rapid rise in E2 levels, much higher peak E2 levels, the development of more mature follicles, and the recovery of larger numbers of mature oocytes at the time of retrieval. None of the patients had premature LH surges as evidenced by a significant rise in LH levels or a significant decline in E2 levels. There were no differences in the fertilization rates.

CONCLUSION

Microdose GnRH-a administration beginning in the early follicular phase may result in an augmented ovarian response when compared with traditional GnRH-a-exogenous gonadotropin stimulations. Additionally, it may decrease gonadotropin requirements while effectively preventing premature LH surges.

Interval required for gonadotropin-releasing hormone-agonist-induced down regulation of the pituitary in cynomolgus monkeys and duration of the refractory state

OBJECTIVES

To determine the minimal interval of gonadotropin-releasing hormone agonist (GnRH-a) administration required to induce pituitary refractoriness to the positive feedback effects of estradiol (E2) and to determine the duration of the induced refractory state in a nonhuman primate model.

SETTING

Research laboratories of The Jones Institute for Reproductive Medicine.

SUBJECTS

Cynomolgus monkeys with documented regular menstrual cycles.

INTERVENTIONS

Part 1. Groups of four monkeys treated with leuprolide acetate (LA) for increasing intervals (0, 2, 4, 6, and 8 days), then challenged with E2 benzoate to induce a gonadotropin surge. Part 2. Groups of four monkeys treated with LA for the minimal time required to induce pituitary refractoriness (6 days), then challenged with E2 benzoate 2, 4, or 7 days after cessation of LA treatment.

MAIN OUTCOME MEASURE(S)

Pituitary luteinizing hormone and follicle-stimulating hormone and E2 levels were monitored.

RESULTS

A minimum of 5 days of treatment is required for LA to induce pituitary refractoriness to the positive feedback effects of E2 benzoate. Once the down regulated condition is achieved, the refractory state lasts for at least 4 but not more than 6 days.

CONCLUSION

The minimal treatment interval required for a GnRH-a to induce pituitary refractoriness to the positive feedback effects of estrogen and the duration of the induced refractory state are determined to be 5 days for these primates.