RESUMO
BACKGROUND: A number of studies have looked at dual triggers with hCG and GnRH agonist (GnRHa) in varying doses, but the question remains: what is the optimal dose of hCG to minimize ovarian hyperstimulation syndrome (OHSS) and still offer adequate pregnancy rates? The purpose of this study was to compare pregnancy and OHSS rates following dual trigger for oocyte maturation with GnRHa and a low-dose hCG versus hCG alone. A secondary objective was the assess pregnancy outcomes in subsequent frozen cycles for the same population. METHODS: A total of 963 women < 41 years old, with a BMI 18-40 kg/m2 and an AMH > 2 ng/mL who underwent fresh autologous in vitro fertilization (IVF) with GnRH antagonist protocol at a University-based fertility center were included in this retrospective cohort study. Those who received a low dose dual trigger with hCG (1000u) and GnRHa (2 mg) were compared to those who received hCG alone (10,000u hCG/250-500 µg Ovidrel). Differences in implantation rates, pregnancy, live birth, and OHSS were investigated. RESULTS: The dual trigger group was younger (mean 33.6 vs 34.1 years), had a higher AMH (6.3 vs 4.9 ng/mL,) more oocytes retrieved (18.1 vs 14.9) and a higher fertilized oocyte rate (80% vs 77%) compared with the hCG only group. Yet, the dual trigger group had a lower probability of clinical pregnancy (gestational sac, 43.4% vs 52.8%) and live birth (33.4% vs 45.8%), all of which were statistically significant. There were 3 cases of OHSS, all in the hCG-only trigger group. In subsequent frozen cycles, pregnancy rates were comparable between the two groups. CONCLUSIONS: The dual trigger group had a better prognosis based on age and AMH levels and had better stimulation outcomes, but significantly worse pregnancy outcomes, suggesting the low dose hCG (1000u) in the dual trigger may not have provided adequate luteal support, compared to an hCG-only trigger (10,000u hCG/250-500 µg Ovidrel). Interestingly, the pregnancy rates were comparable in subsequent frozen cycles, further supporting the hypothesis that the issue lies in inadequate luteal phase support, rather than embryo quality. Based on these findings, our program has changed the protocol to 1500u of hCG in a dual trigger.
RESUMO
PURPOSE: The purpose of this study was to compare baseline characteristics and ovarian stimulation outcomes between patients presenting for medically indicated vs. elective fertility preservation consultation and to determine the impact of the 2013 ASRM guidelines on oocyte cryopreservation on the patient population presenting for fertility preservation consultation. METHODS: Retrospective cohort study conducted at an academic center. Study population included 332 patients presenting for medically indicated fertility preservation consultation and 210 patients presenting for elective consultation. RESULTS: Patients presenting for elective fertility preservation consultation were more likely to be of advanced age, non-Caucasian, highly educated, single, nulligravid, and meet criteria for diminished ovarian reserve (DOR). Additionally, patients presenting electively were more likely to have fertility insurance benefits. A higher percentage of patients with insurance benefits for oocyte cryopreservation proceeded to stimulation. There were no differences in stimulation parameters or number of retrieved oocytes between the groups when adjusted for age. Following release of the ASRM guidelines on oocyte cryopreservation, there was no difference in the percentage of patients in the medical group who proceeded with stimulation; however, a higher percentage of patients presenting electively underwent ovarian stimulation. CONCLUSION: Although the populations presenting for medical compared with elective fertility preservation differ at baseline, ovarian stimulation parameters and outcomes are similar when adjusted for age. Insurance benefits for fertility preservation are not comprehensive and impact the decision to proceed with stimulation in all patients. The publication of the ASRM guidelines on oocyte cryopreservation increased utilization of this technology among patients presenting electively; however, they remained at an advanced age and with decreased ovarian reserve parameters.
