O-292 Comparison of effect of two different trigger regimens; single (hCG) versus dual (hCG + Leuprolide) on outcome of fresh IVF cycles: A randomized controlled trial

Study question

Does adding gonadotropin-releasing hormone agonist (GnRHa) to hCG trigger increases the number of high-grade embryos in GnRH antagonist protocol in fresh non-donor IVF?

Summary answer

Final oocyte maturation triggered by dual trigger increases the number of MII oocytes thus transferring good-quality embryos and cryopreserving surplus embryos compared to hCG trigger.

What is known already

hCG has been conventionally used as a ‘faux’ LH surge to bring about final oocyte maturation due to structural similarity between the two. GnRH agonist, on the other hand, induces a more physiological gonadotropin surge for follicular maturation, but is associated with luteal phase deficiency. Recent studies have shown that combining GnRHa with hCG trigger improves oocyte maturation and embryo quality with the added benefit of a luteal phase support, thereby improving IVF outcomes in terms of both embryological and reproductive outcomes.

Study design, size, duration

A single-center, open labelled, randomized controlled trial including 100 normal responder patients between 21-38 years undergoing IVF using GnRH antagonist protocol between January 2020 to August 2021. The study excluded patients with the presence of other variables of adverse outcomes like diminished ovarian reserve (AFC < 5 or AMH < 1.2 ng/ml), endocrine disorders, thin endometrium (<6mm), previous history of uterine surgeries, and high responders.

Participants/materials, setting, methods

100 patients undergoing fresh IVF cycle using GnRH antagonist protocol were randomized after informed consent to receive either dual trigger (Leuprolide acetate 1 mg + rhCG 250 mcg, n = 50) or single hCG trigger (rhCG 250 mcg, n = 50). Oocyte retrieval was done 35-37 hours after trigger followed by IVF/ICSI, as indicated. Oocyte and embryo grading was done using Istanbul consensus. Analysis was done by ITT. Outcomes were analyzed using Independent t-test and Chi-square test.

Main results and the role of chance

The baseline characteristics were comparable in both arms. the number of MII oocytes retrieved (7.82 versus 5.92, p = 0.003) and the number of day-3 grade-1 embryos (4.24 versus 1.8, p < 0.001) were higher in the dual trigger group, whereas fertilization rates between the two groups (91.82% versus 88.51%, p=NS) were comparable. Consequently, the number of embryos cryopreserved (2.68 versus 0.94, p < 0.001) were significantly higher in the dual trigger group. However, the implantation rate between the two groups (21% versus 19.6%, p = 0.770) was comparable. The serum LH levels 12 hours post trigger were measured in both the arms and as expected, high serum LH values were documented in the dual trigger group (46.23 mIU/ml vs 0.93 mIU/ml, p < 0.0001).

Limitations, reasons for caution

Due to the impact of the Covid-19 pandemic causing an intermittent pause in IVF services at our center, a smaller sample size of 100 patients could be enrolled in the study, and reproductive outcomes in terms of live births and cumulative live births could not be assessed

Wider implications of the findings

This study, though small, has contributed to some evidence of redesigning the dual trigger in all antagonist cycles, with the exception of high responders and PCOS patients. The addition of GnRHa to hCG trigger has led to the possibility of cryopreserving surplus embryos thereby increasing the cumulative live births.

Trial registration number

CTRI/2020/08/027030

THU0531 A PROSPECTIVE STUDY EVALUATING THE ROLE OF 68GA-RGD2 PET/CT ANGIOGENESIS IMAGING IN ASSESSING DISEASE ACTIVITY AND TREATMENT RESPONSE IN RHEUMATOID ARTHRITIS AND ITS COMPARISON WITH DAS28

Background:

PET/CT imaging of synovial angiogenesis using68Ga-RGD (cyclic tripeptide agent targeting αvβ3integrin) to study disease activity in rheumatoid arthritis (RA) has been demonstrated earlier in a few patients. However, post treatment changes in disease activity on68Ga-RGD2PET/CT imaging have not been adequately assessed.

Objectives:

To compare the performance of68Ga-RGD2PET/CT with disease activity score (DAS) 28 in assessing disease activity and treatment response in RA.

Methods:

Thirty patients (24F, 6M) aged 43±12 years with clinically diagnosed RA were prospectively studied. After calculation of DAS28 by a rheumatologist, all 30 patients underwent68Ga-RGD2PET/CT scan. Of these, 27 patients underwent a second68Ga-RGD2PET/CT scan and clinical assessment after at least 3 months of treatment. Total body and regional images of the upper limbs were acquired and interpreted by two nuclear medicine physicians blinded to the clinical findings. Joints showing focally increased tracer uptake compared to the background were considered positive and joints showing uptake equal to or less than background were considered negative. Data of 30 patients were used for inter-observer and inter-modality agreement calculations. Changes in PET parameters and DAS28 were compared in 27 patients to assess treatment response.

Results:

Out of 1560 joints examined in the initial scan, 394 were positive on PET/CT compared to 348 on clinical evaluation. Inter-observer agreement between nuclear medicine physicians was excellent (Cohen’s kappa 0.92, p<0.05) and inter-modality agreement between PET and clinical examination was moderate (Cohen’s kappa 0.55, p<0.05). The DAS28 and SUVmax values (highest and average) of 27 patients showed significant reduction on follow-up compared to the initial evaluation. There was significant correlation between percentage change in DAS28 and percentage change in scan parameters like PET positive joint counts (0.689, p<0.001), average SUVmax (0.712, p<0.001) and highest SUVmax values (0.558, p=0.003) of scan-positive joints in 27 patients. Additional advantages of68Ga-RGD2PET/CT included objective assessment, whole body evaluation of all small and large joints, and greater reproducibility.

Conclusion:

68Ga-RGD2PET/CT is a promising tool for objective assessment of disease activity and treatment response in patients with RA.

Table 1.

Clinical and PET parameters of the patients

ParameterInitial data (n=27)Mean (SD)/Median (IQR)Follow-up data (n=27)Mean (SD)/Median (IQR)TJC(28)10 (5-13)3 (2-4)SJC(28)6 (3-7)1 (0-2)ESR25 (20-41)24 (18-35)PtGA6.0 (5.0-6.0)3.0 (2.0-4.0)DAS28(3)5.14 (0.85)3.74 (0.88)DAS28(4)5.60 (0.90)3.80 (0.96)PET positive Joints12 (7-8)4 (2-9)aSUVmax2.08 (1.68-2.52)1.79 (1.00-2.06)hSUVmax3.45 (2.71-4.70)3.34 (1.95-4.25)

TJC/SJC: tender/swollen joint counts; ESR: erythrocyte sedimentation rate; PtGA: patients global assessment scale; DAS: disease activity score; aSUVmax/hSUVmax: average/highest SUVmax (maximum standardized uptake value); SD: standard deviation; IQR: interquartile range

Figure 1.

68Ga-RGD2PET scan of a 26-year female RA patient on treatment.A.Initial scan shows increased tracer uptake in multiple joints of upper and lower limbs and tendon sheaths of hands and ankle region (arrows); DAS28 was 4.56 (moderate disease activity) and ESR 12 mm/1sthour.B. Follow-up scan after 4 months shows resolution of tracer activity in the previously involved joints with only a mild focus persisting in the left knee joint; DAS28 was 1.73 (clinical remission according to ARA) and ESR 08 mm/1sthour.

Acknowledgments:

This study was supported by Indian Council of Medical Research, New Delhi [grant no.3/2/June-2017/PG-Thesis-HRD (23)]

Disclosure of Interests:

None declared