Use of Triggers on in vitro Fertilization and Evaluation of Risk Factors for Sub-Optimal Maturation Rate / Uso de gatilhos na fertilização in vitro e avaliação dos fatores de risco para taxa de maturação subótima

Abstract Objective To compare the oocyte maturation rate in the treatment of in vitro fertilization (IVF) in terms of the use of human chorionic gonadotropin (hCG), agonist gonadotropin-releasing hormone (GnRH) and dual trigger and to evaluate the associated risk factors for sub-optimal maturation rates. Methods A retrospective cohort study with 856 women who underwent IVF. They performed oocyte retrieval and were classified into 3 groups (1 - hCG, 2 - GnRHagonist, 3 - dual trigger). The primary outcome was maturation rate per trigger, and the secondary outcomes were the pregnancy rate per oocyte retrieval and the correlations between low maturation rate as well as the clinical and treatment characteristics of women. Results The maturation rate was 77% in group 1; 76% in group 2, and 83% in group 3 (p=0.003). Group 2 showed women with better ovarian reserve, greater number of oocytes collected, and more mature oocytes and embryos compared with the other groups (p<0.001). The cumulative clinical pregnancy rate was no different between the groups (p=0.755). Low ovarian reserve and low doses of follicle-stimulating hormone (FSH) administered during the stimulus were associated with a higher chance of null maturation rate. Conclusion The oocyte maturation rates and IVF results were similar in all groups. Low ovarian reserve is associated with the worst treatment results.

Resumo Objetivo Comparar a taxa de maturação oocitária no tratamento de fertilização in vitro (FIV) emrelação so o uso de gonadotrofina coriônica humana (hCG), agonista de hormônio liberador de gonadotrofina (GnRH), e gatilho duplo e avaliar os fatores de risco associados a taxas de maturação subótimas. Métodos Estudo de coorte retrospectivo com 856 mulheres submetidas à FIV. Elas foram classificadas em 3 grupos (1 - hCG, 2 - GnRH agonista, 3 - gatilho duplo). O desfecho primário foi a taxa de maturação por gatilho, e os desfechos secundários foram a taxa de gravidez por recuperação de oócitos e as correlações entre a baixa taxa de maturação bem como as características clínicas e do tratamento das mulheres. Resultados A taxa de maturação foi de 77% no grupo 1; 76% no grupo 2, e 83% no grupo 3 (p=0,003). O grupo 2 apresentou mulheres com melhor reserva ovariana, maior número de oócitos coletados, oócitosmaduros, e embriões, emcomparação aos demais grupos (p<0,001). A taxa cumulativa de gravidez clínica não foi diferente entre os grupos (p=0,755). Baixa reserva ovariana e baixas doses de hormônio folículoestimulante (FSH) administradas durante o estímulo foram associadas a uma maior chance de taxa de maturação nula. Conclusão As taxas de maturação oocitárias e os resultados de FIV foram semelhantes em todos os grupos. A baixa reserva ovariana está associada aos piores resultados do tratamento.

Técnica de doble disparo (doubble trigger) en pacientes normorrespondedoras con bajo porcentaje de ovocitos maduros / Doubble Trigger in patients with a normal response with a low percentage of mature oocytes

Resumen OBJETIVO: Evaluar el efecto del doble disparo en pacientes con un ciclo previo con menos de 65% de ovocitos maduros respecto de los ovocitos capturados, en una población con respuesta normal a la inducción de la ovulación con hCG recombinante o urinaria. MATERIALES Y MÉTODOS: Estudio de cohorte, prospectivo, efectuado en pacientes con diagnóstico de infertilidad, en tratamiento con fertilización in vitro, evaluadas en el Centro Mexicano de Fertilidad (Hospital Ángeles Lomas) entre 2017 y 2019. El tratamiento se llevó a cabo en la misma paciente, en cuyo ciclo previo convencional con esquema de antagonista e inducción de la ovulación con hCG tuvo respuesta ovárica subóptima y captura ovocitaria con menos de 65% en fase M2 (Grupo 1). Posteriormente se les indicó un segundo ciclo con el mismo esquema de gonadotropinas e inducción de la ovulación con doble disparo: acetato de triptorelina 1 mg + 5000 UI de hCG urinaria 40 y 34 horas previas a la captura (Grupo 2). Se evaluaron el porcentaje y la cantidad de ovocitos capturados en fase M2. RESULTADOS: Se registraron 34 pacientes en quienes se llevaron a cabo 68 ciclos. La cantidad de ovocitos capturados fue mayor en el grupo 2 (agonista de GnRH + hCG urinaria; p = 0.03). El doble disparo aumentó el porcentaje de ovocitos maduros (65.4 ± 21.3 vs 74.6 ± 20.2; p = 0.07). CONCLUSIONES: La técnica de doble disparo es valiosa para el tratamiento de pacientes con captura de ovocitos deficiente, aun con desarrollo folicular normal y concentraciones de estradiol adecuadas y óptimas de hCG el día de la captura. Se requieren estudios prospectivos de gran tamaño para dilucidar la recomendación mencionada de la técnica de "doble disparo".

Abstract OBJECTIVE: To evaluate the effect of double trigger in patients with a previous cycle with less than 65% of mature oocytes compared to the captured oocytes, in a normorresponding population with induction of ovulation with recombinant or urinary hCG. MATERIALS AND METHODS: A prospective cohort study, conducted in patients diagnosed with infertility, treated with in vitro fertilization, evaluated at the Mexican Fertility Center (Hospital Angeles Lomas) between 2017 and 2019. The treatment was carried out in the same patient, in whose previous conventional cycle with antagonist scheme and induction of ovulation with hCG had suboptimal ovarian response and oocyte capture with less than 65% in M2 phase (Group 1). Subsequently, a second cycle was performed with the same scheme of gonadotropins and induction of ovulation with double shot: 1 mg triptorelin acetate + 5000 IU of urinary hCG 40 and 34 hours prior to capture (Group 2 or double trigger). Percentage and quantity of oocytes captured in M2 phase were evaluated. RESULTS: 34 patients were registered, in whom 68 cycles were performed. The number of oocytes captured was greater in group 2 (agonist of GnRH + urinary hCG; p = 0.03). The double shot increased the percentage of mature oocytes 65.4 ± 21.3 vs 74.6 ± 20.2 (p = 0.07). CONCLUSIONS: The double trigger technique is valuable for the treatment of patients with poor oocyte capture, even with normal follicular development and adequate and optimal hCG estradiol concentrations on the day of capture. Large prospective studies are required to elucidate the aforementioned recommendation of the "double shot" technique.