Keywords: blastocyst cryopreservation, GnRH antagonist, long protocol, luteolysis, OHSS

Transcription

1 RBMOnline - Vol 18 No Reproductive BioMedicine Online; on web 5 November 28 Article Management of severe OHSS using GnRH antagonist and blastocyst cryopreservation in PCOS patients treated with long protocol Trifon G Lainas studied medicine at the University of Athens, Greece. He obtained his MD degree in 1973 and his PhD in 1995 also from the University of Athens. He served as Senior Registrar at Elena Venizelou Maternity Hospital from July 1979 to May He is Clinical Director at Eugonia ART Unit in Athens, Greece. His research interests are various, including optimization of ovarian stimulation protocols, ovarian hyperstimulation syndrome, reproductive endocrinology and reproductive endoscopic surgery. Dr Trifon G Lainas TG Lainas 1, IA Sfontouris 1, IZ Zorzovilis 1, GK Petsas 1, GT Lainas 1, GS Iliadis 1, EM Kolibianakis 2,3 1 Eugonia Iatriki Erevna IVF Unit, 7 Ventiri str., 11528, Athens, Greece; 2 Unit for Human Reproduction, Aristotle University of Thessaloniki, Thessaloniki, Greece 3 Correspondence: stratis.kolibianakis@irg.gr Abstract Despite the fact that many methods have been proposed for the management of severe ovarian hyperstimulation syndrome (OHSS), its prevention is mainly achieved by withholding human chorionic gonadotrophin (HCG) administration and cycle cancellation. Currently no curative therapy is available. Three women diagnosed with polycystic ovarian syndrome underwent ovarian stimulation for IVF using a long gonadotrophin-releasing hormone (GnRH) agonist protocol. Six days after oocyte retrieval, severe early OHSS was diagnosed by analysis of haematocrit, white blood cell (WBC) count, serum urea, and ultrasonographic assessment of ovarian size and ascitic fluid. On the same day, antagonist administration was administrated and continued daily for 1 week, while resulting blastocysts were cryopreserved. Progression of severe early OHSS was inhibited in all three patients. A marked decrease of haematocrit, WBC, ascitic fluid, oestradiol, progesterone and ovarian volume was observed, during 1 week of follow-up suggesting a luteolytic effect of GnRH antagonist. None of the patients required hospitalization. In conclusion, GnRH antagonist administration combined with blastocyst cryopreservation 6 days post retrieval might represent a new approach for the effective management of patients with established severe OHSS. The flexibility of the approach allows the elongation of the monitoring period up to 8 days following HCG administration. Keywords: blastocyst cryopreservation, GnRH antagonist, long protocol, luteolysis, OHSS Introduction Despite the fact that many methods have been proposed for the management of severe ovarian hyperstimulation syndrome (OHSS), its prevention is mainly achieved by withholding human chorionic gonadotrophin (HCG) administration and cycle cancellation. Currently, no curative therapy is available (Pride et al., 1986; Abramov et al., 1999). Several approaches have been proposed for reducing the incidence of the syndrome, including coasting (Sher et al., 1995), glucocorticoid administration (Lainas et al., 22), intravenous administration of albumin (Asch et al., 1993; Shoham et al., 1994), use of recombinant LH (The European Recombinant LH Study Group, 21), recombinant HCG (Driscoll et al., 2) and gonadotrophin-releasing hormone (GnRH) agonist for triggering final oocyte maturation (Itskovitz et al., 1991; Engmann et al., 26; Griesinger et al., 26, 27; Orvieto et al., 26) prolonged use of GnRH agonist (Rizk and Smitz, 1992), or early follicular aspiration of the ovary (Tomazevic and Meden-Vrtovec, 1996). However, none of them has been proven consistently efficient in the prevention of severe OHSS in high-risk patients (Aboulghar and Mansour, 23). While cryopreservation of all embryos can prevent pregnancy-associated late OHSS, it seems to reduce but not completely eliminate early OHSS, which is associated with the administration of HCG (Wada et al., 1992a; Queenan et al., 1997; D Angelo and Amso, 22; Aboulghar and Mansour, 23). Continuation of Published by Reproductive Healthcare Ltd, Duck End Farm, Dry Drayton, Cambridge CB23 8DB, UK

2 16 GnRH agonist administration after HCG combined with embryo cryopreservation has yielded conflicting results regarding OHSS prevention (Wada et al., 1992b; Endo et al., 22). In addition, administration of GnRH antagonist in patients with high risk for OHSS, pretreated with long GnRH agonist protocol, resulted in a rapid reduction of oestradiol concentrations and was related with reduction of OHSS incidence (Gustofson et al., 26). A recent prospective study (Aboulghar et al., 27) showed that antagonist administration, as a method for OHSS prevention, is equally safe with coasting in high-risk patients, while the use of GnRH antagonists for the prevention of LH surge has been associated with a decreased probability of OHSS as compared with GnRH agonists (Al-Inany et al., 27; Kolibianakis et al., 27). A novel strategy for the flexible management of severe OHSS was recently reported (Lainas et al., 27). Under this approach, following a GnRH antagonist stimulation regimen, antagonist is reinitiated 3 days post oocyte retrieval and administered daily for a week, while all embryos are cryopreserved. This study reports that management of severe early OHSS is also feasible by administrating GnRH antagonist 6 days after oocyte retrieval, combined with blastocyst cryopreservation in three patients treated with a long GnRH agonist protocol. Materials and methods Between January 26 and October 27 in Eugonia Iatriki Erevna IVF and Infertility Unit in Athens, Greece, three patients diagnosed with polycystic ovarian syndrome (PCOS; presence of oligo-ovaluation/anovulation and of polycystic ovaries) underwent ovarian stimulation for IVF, using a long GnRH agonist protocol. The patients received oral contraceptive pill (OCP) starting on day 2 of spontaneous menses of the cycle prior to the treatment cycle, after blood test confirmed the presence of a baseline hormone profile. The OCP contained.3 mg ethinyl oestradiol and.75 mg gestodene (Minulet, Wyeth, Greece) and were taken daily for 21 days. The patients started daily administration of.1 mg/ day triptorelin (Arvecap, Ipsen, France) 3 days before discontinuation of the pill. All patients had blood loss after discontinuation of the OCP. When desensitization was achieved as demonstrated by plasma oestradiol concentrations of 8 pg/ml and progesterone <1.6 ng/ml, the absence of ovarian follicles and the absence of a thick endometrium by transvaginal ultrasound examination (Barash et al., 1998), daily s.c. injection of 125 IU follitropin (Puregon, Organon, The Netherlands) was commenced. The dose of GnRH agonist was decreased on that day to.5 mg/day and continued until and including the day of HCG administration. The dose of recombinant FSH was adjusted during ovarian stimulation, depending on the ovarian response as assessed by oestradiol concentrations and ultrasound. When at least three follicles were 17 mm, 5 IU HCG (Pregnyl, Organon) were administrated intramuscularly, as previously described (Abdalla et al., 1987; Kolibianakis et al., 27). Transvaginal ultrasound-guided oocyte retrieval was performed 36 h later. In all patients, more than 2 cumulus oocyte complexes were expected to be retrieved during oocyte retrieval, based on the ultrasound information during monitoring of ovarian stimulation. The standard practice in the centre in such high-risk cases for developing OHSS is to withhold HCG administration and cancel the cycle. Although this was proposed to the patients reported here, they requested that the treatment cycle continued at least to oocyte retrieval. An informed consent was obtained from each patient after all risks associated with OHSS development were fully explained by the treating physician. The intervention was approved by the study centre s institutional review board. Severe early OHSS was diagnosed 6 days after oocyte retrieval, defined as the presence of large ovaries (>1 mm), marked ascites, haematocrit >45%, and white blood cell (WBC) count >15,/mm 3 (Navot et al., 1992; Rizk and Aboulghar, 1999). On the same day, blastocyst cryopreservation was performed in all patients, to prevent further progression of the severe form of the syndrome and development of pregnancy-associated late, potentially life-threatening OHSS. Concomitantly,.25 mg of the GnRH antagonist ganirelix (Orgalutran, Organon) was administered and was continued daily with subcutaneous injections for 6 days. During that period, 2 IU enoxaparin sodium (Clexane, Aventis Pharma SA, France) were also administered, starting concomitantly with GnRH antagonist. The follow-up included estimation of haematocrit, WBC, serum urea, creatinine and ultrasound assessment of ovarian size and ascitic fluid on days 3, 6, 8, 1, 12 and 14 post retrieval. Oestradiol and progesterone concentrations were monitored during the same period. Results Baseline characteristics and embryological data of the three patients are shown in Table 1. Antagonist initiation 6 days after oocyte retrieval, in combination with cryopreservation of all embryos, resulted in the inhibition of progression of severe early OHSS, in improvement of patients symptoms, ultrasound and laboratory findings (Figure 1). In patients 1, 2 and 3 respectively, the highest values of haematocrit (46.2, 46.9 and 45.1%), WBC count (224/ mm 3, 249 /mm 3 and 372 /mm 3 ), serum urea 63 mg/dl, 65 mg/dl and 52 mg/dl), oestradiol (5912 pg/ml, 417 pg/ml and 3385 pg/ml) and progesterone (251 ng/ml, 243 ng/ml, and 185 ng/ml), as well as the highest ovarian volume, were observed on day 6 post retrieval. These values progressively decreased following GnRH antagonist administration, and returned to normal concentrations by the end of the monitoring period, 14 days after oocyte retrieval (Figure 1). Similarly, all patients demonstrated increased ascites on the day of antagonist initiation, which declined to non-detectable concentrations at the end of the monitoring period. None of the patients required hospitalization. Discussion This is the first report of severe early OHSS management using administration of GnRH antagonist 6 days after oocyte retrieval

3 Table 1. Baseline characteristics, ovarian stimulation and embryological data. Patient 1 Patient 2 Patient 3 Age BMI (kg/m 2 ) FSH (IU/l) LH (IU/l) Oestradiol (pg/ml) Progesterone (ng/ml) Years of infertility Total dose of FSH (IU) Duration of stimulation (days) Number of COC retrieved Method of fertilization IVF ICSI IVF Number of fertilized oocytes (2PN) Number of blastocysts frozen BMI = body mass index; COC = cumulus oocyte complexes; ICSI = intracytoplasmic sperm injection; PN = pronuclei. Oestradiol (pg/ml) Ovarian volume (cm 3 ) R Urea (mg/dl) White blood cells/mm 3 Patient a Patient b 3 7 a Patient c 25 b c 6 d e f g 1 h Progesterone (ng/ml) Ovarian volume (cm 3 ) L Haematocrit % Creatinine (mg/dl) Figure 1. Concentrations of (a) oestradiol, (b) progesterone, (c) right and (d) left ovarian volume, (e) urea, (f) haematocrit, (g) white blood cells and (h) creatinine during the monitoring period of the three patients studied. Start and stop arrows indicate the day of initiation and termination of gonadotrophinreleasing hormone antagonist administration. Human chorionic gonadotrophin was administered on day 2 and oocyte retrieval was performed on day. 17

4 18 combined with cryopreservation of all blastocysts in PCOS patients treated for IVF using a long GnRH agonist protocol. This flexible approach inhibited the progression of established severe early OHSS, and improved patients symptoms, ultrasound and laboratory findings, avoiding hospitalization in all patients studied. During the follow-up period, marked decreases in haematocrit, WBC count, urea and ascites as well as in ovarian size, oestradiol and progesterone were observed. The reinitiation of GnRH antagonist and elective embryo cryopreservation 3 days post retrieval has been recently described as a promising new method for the management of severe early OHSS in PCOS patients treated for IVF using a GnRH antagonist protocol (Lainas et al., 27). That approach achieved the regression of severe early OHSS to a moderate form and prevented hospitalization in all patients studied, offering at the same time flexibility in the management and monitoring of the patients. Freezing of embryos on day 1, 2 or 3 may be preferable for patients who have poor embryo cleavage. The present study takes the investigation one step further. Here, a GnRH agonist protocol was used for ovarian stimulation, and the monitoring period was extended until day 6 post retrieval. This offers further flexibility regarding the decision to proceed or not to embryo transfer in patients at high risk for OHSS. Symptoms of early OHSS have been reported to appear 1 5 days following oocyte retrieval (Dahl Lyons et al., 1994). Patient monitoring for 6 days after oocyte retrieval allows the clinician to assess whether the patient does or does not develop a severe form of early OHSS. If severe early OHSS develops, GnRH antagonist can be administered in combination with blastocyst cryopreservation. Although cryopreservation of blastocysts on day 6 has been found to be suboptimal compared with day 5, recent studies have shown no differences in survival and implantation rates between days 5 and 6 blastocysts (Veeck et al., 24; Liebermann and Tucker, 26). This intervention appears to assist in the regression of the syndrome, avoiding the need for hospitalization. On the other hand, if in a high-risk patient severe early OHSS does not develop until day 6 of stimulation, embryo transfer may still be performed. With this flexible approach, it is possible to avoid an unnecessary cancellation of embryo transfer and elective embryo cryopreservation, which have been proven to reduce but not completely eliminate the incidence early OHSS (Queenan et al., 1997; D Angelo and Amso, 22), without compromising patient s safety. It can be argued that OHSS resolution, observed within the time frame of the follow-up performed in the current study, might be attributed to the natural course of the severe form of OHSS and not to administration of GnRH antagonist. Although such a possibility cannot be excluded, it has to be noted that, all three patients were diagnosed with severe OHSS that has a tendency to develop to a critical form of the syndrome (Navot et al., 1992), requiring prolonged hospitalization, frequently accompanied by multiple ascites punctures. Moreover, fatalities due to severe OHSS have been reported in the literature (Semba et al., 2; Fineschi et al., 26). However, none of the patients reported here required hospitalization, indicating a beneficial role of GnRH antagonist administration in the regression of the severe form of the syndrome. The main action of GnRH antagonist is to suppress endogenous LH secretion, which during the luteal phase might stimulate the existing numerous corpora lutea. However, concentrations of LH during the luteal phase, following ovarian stimulation with GnRH analogues and gonadotrophins, are always very low and thus this does not appear to be the mechanism through which antagonist administration might be involved in the regression of severe early OHSS. It is more likely that GnRH antagonist has a direct luteolytic effect on the ovary, which is supported by a marked decline in oestradiol, progesterone and ovarian volume. Expression of GnRH receptors exist in the human ovary (Minaretzis et al., 1995; Choi et al., 26) and GnRH antagonists have been shown to inhibit the expression of locally produced ovarian angiogenic factors (Taylor et al., 24; Asimakopoulos et al., 26). Several prostaglandins, cytokines and growth factors have been suggested to increase capillary permeability and fluid shift to the third space leading to the development of OHSS, including vascular endothelial growth factor, the ovarian rennin angiotensin system, interleukins 1, 2, 6 and 8, histamine, prolactin, prostaglandins PGE 2 and PGI 2, endothelin and selectins (Rizk et al., 1997; Delvigne and Rozenberg, 22). Thus it might be postulated that luteolysis following GnRH antagonist administration is mediated by minimising production of vasoactive cytokines from numerous corpora lutea of hyperstimulated ovaries. Further research, with recruitment of more patients, is necessary to evaluate the efficiency of the approach proposed here in the management of severe OHSS. On the basis of the initial experience reported here, this appears worthwhile. If the effectiveness of the approach proposed here is established, then GnRH antagonist administration may be the treatment of established severe OHSS, when all methods of OHSS prevention have failed or have not been performed, changing the currently accepted notion/dogma that withholding HCG and cycle cancellation are the only preventive measures for OHSS. However, it has to be acknowledged that it is difficult to subject the management of OHSS to the rigorous testing of randomized controlled trials, mainly for ethical reasons. Acknowledgements The authors would like to thank C Barnes for her contribution in the embryology laboratory, G Stavropoulou for the coordination of IVF programmes, R Karousou for data input and assistance in the preparation of the manuscript, and E Vourvoulia for performing the laboratory assays. 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6 from women at risk of the ovarian hyperstimulation syndrome. Human Reproduction 7, Wada I, Matson PL, Horne G et al. 1992b Is continuation of a gonadotrophin-releasing hormone agonist (GnRHa) necessary for women at risk of developing the ovarian hyperstimulation syndrome? Human Reproduction 7, Declaration: The authors report no financial or commercial conflicts of interest. Received 8 February 28; refereed 1 March 28; accepted 18 July 28. 2