Vanessa N. Weitzman, M.D., Lawrence Engmann, M.D., Andrea DiLuigi, M.D., Donald Maier, M.D., John Nulsen, M.D., and Claudio Benadiva, M.D.

Transcription

1 Comparison of luteal estradiol patch and gonadotropin-releasing hormone antagonist suppression protocol before gonadotropin stimulation versus microdose gonadotropin-releasing hormone agonist protocol for patients with a history of poor in vitro fertilization outcomes Vanessa N. Weitzman, M.D., Lawrence Engmann, M.D., Andrea DiLuigi, M.D., Donald Maier, M.D., John Nulsen, M.D., and Claudio Benadiva, M.D. Center for Advanced Reproductive Services, University of Connecticut School of Medicine, Department of Obstetrics and Gynecology, Farmington, Connecticut Objective: To compare IVF outcomes in poor-responder patients undergoing stimulation after luteal phase E 2 patch/gnrh antagonist (LPG) protocol versus microdose GnRH agonist protocol. Design: Retrospective analysis. Setting: University-based IVF center. Patient(s): Forty-five women undergoing ovarian stimulation for IVF using the LPG protocol were compared with 76 women stimulated with the microdose GnRH agonist protocol from May 2005 to April Main Outcome Measure(s): Cancellation rate, number of oocytes retrieved, and clinical pregnancy rates. Result(s): The mean number of oocytes ( vs ) and mature oocytes ( vs ) retrieved were similar, as were the fertilization rates (70.0% 24.2% vs. 69.9% 21.5%) and the number of embryos transferred ( vs ). The cancellation rate was not significantly different between the groups (13/45, 28.9% vs. 23/76, 30.3%). Likewise, there were no significant differences among the implantation rate (15.0% vs. 12.5%), clinical pregnancy rate (43.3% vs. 45.1%), and ongoing pregnancy rate per transfer (33.3% vs. 26.0%) between both groups. Conclusion(s): This study demonstrates that the use of an E 2 patch and a GnRH antagonist during the preceding luteal phase in patients with a history of failed cycles can provide similar IVF outcomes when compared with the microdose GnRH agonist protocol. (Fertil Steril Ò 2009;92: Ó2009 by American Society for Reproductive Medicine.) Key Words: Ovarian stimulation, IVF, poor responders, GnRH antagonists Poor-responder patients present a challenge in assisted reproduction due to their inadequate response to controlled ovarian hyperstimulation (COH), high cancellation rates, and high incidence of implantation failure. Although this group of patients has been poorly defined in the literature, they represent a significant portion of patients seeking assisted reproductive technologies. Poor ovarian response can be attributed to many different factors, including chronological age, diminished ovarian reserve, severe endometriosis, smoking, and prior ovarian surgery, with a reported incidence in the literature ranging from 5% to 18% (1 3). Multiple strategies have been attempted with the hope of overcoming these obstacles Received January 4, 2008; revised and accepted April 11, 2008; published online August 4, Presented atthe62ndannual Meeting ofthe American SocietyforReproductive Medicine, which was held in New Orleans, on October 21 25, V.N.W. has nothing to disclose. L.E. has nothing to disclose. A.D. has nothing to disclose. D.M. has nothing to disclose. J.M. has nothing to disclose. C.B. has nothing to disclose. Reprint requests: Claudio Benadiva, M.D., Center for Advanced Reproductive Services, Dowling South Building, 263 Farmington Avenue, Farmington, Connecticut (FAX: ; benadiva@up.uchc.edu). to assisted reproduction. One protocol commonly used for patients with anticipated poor response is the microdose agonist (GnRH-a) protocol, which takes advantage of the initial rise in endogenous gonadotropins that follows the agonist administration in the early follicular phase and subsequently prevents a premature LH surge. With oral contraceptive pretreatment to prevent corpus luteum rescue and subsequent stimulation from the initial flare effect, the microdose agonist protocol in poor responders has proven to have fewer cycle cancellations, improved cycle parameters, and increased pregnancy rates compared with traditional luteal phase GnRH-a protocols (3 6). More recently, a novel approach has been proposed, using transdermal E 2 and a GnRH antagonist in the luteal phase before starting gonadotropin stimulation in a GnRH antagonist cycle. The goal of this protocol is to synchronize follicular growth during stimulation to improve cycle parameters and ultimately increase pregnancy rates (7, 8). The purpose of this study was to compare the outcomes of patients with anticipated poor ovarian response who had undergone stimulation with either a luteal phase GnRH antagonist and E 2 patch protocol (LPG group) or the microdose agonist flare protocol (microdose group) over a 1-year period. 226 Fertility and Sterility â Vol. 92, No. 1, July /09/$36.00 Copyright ª2009 American Society for Reproductive Medicine, Published by Elsevier Inc. doi: /j.fertnstert

2 MATERIALS AND METHODS This study included 121 women with anticipated poor ovarian response who underwent COH for IVF at the Center for Advanced Reproductive Services at the University of Connecticut. Charts were reviewed for all patients completing either LPG or microdose agonist cycles at our center from May 2005 to April The study was approved by the Institutional Review Board at the University of Connecticut. At our center, anticipated poor responders are defined when one or more of the following criteria are present: [1] age R40 years, [2] previous poor response to stimulation with gonadotropins (four or fewer follicles or eggs in a prior IVF cycle), [3] elevated day 3 FSH level of R10 miu/ml, or [4] previously canceled cycle(s) due to inadequate ovarian response. Forty-five women underwent IVF using the LPG protocol (LPG group). These patients began applying a transdermal E 2 patch (0.1 mg) every other day on the 10th day after their LH surge that was detected with a home urinary ovulation predictor kit. On the 11th day, patients began daily administration of ganirelix acetate (Ganirelix; Organon Pharmaceuticals, West Orange, NJ) 0.25 mg SC for 3 days. Once menses began, the patches were removed and stimulation was initiated with IU recombinant FSH (rec-fsh; Follistim, Organon Pharmaceuticals; or Gonal-F, Serono Pharmaceuticals, Rockland, MA) with or without the addition of IU hmg (Repronex or Menopur, Ferring Pharmaceuticals, Tarrytown, NY) at the discretion of the physician. The gonadotropin regimen was maintained daily and adjusted individually according to serum E 2 concentrations and ovarian response as noted by ultrasound. Ganirelix acetate 0.25 mg SC was then added once the leading follicle reached R14 mm in diameter or the E 2 level was R400 pg/ml and continued daily until and including the day of hcg administration (Fig. 1). Results were compared with 76 women who underwent ovarian stimulation for IVF using the microdose agonist protocol (microdose group). These women received 21 days of oral contraceptive pills (OCPs; Desogen; Organon Pharmaceuticals, Inc.) beginning on the third day of their menstrual cycle before the treatment cycle. On the third day after completing OCPs, baseline evaluation was performed and patients began administration of leuprolide acetate 40 mg SC twice per day. Serum E 2, FSH, and LH were evaluated on the fifth day after menses, and gonadotropins were initiated. Individual adjustments in dose were made in the same fashion as mentioned above. In both groups, 3,300 10,000 IU of hcg were administered SC when at least two follicles reached R17 mm in diameter, followed 35 hours later by ultrasound-guided transvaginal oocyte retrieval. The IVF and intracytoplasmic sperm injection (ICSI) procedures were performed as described elsewhere (9). Embryos were transferred on the third day after FIGURE 1 LPG and Microdose Flare protocols. Fertility and Sterility â 227

3 TABLE 1 Patient characteristics. Treatment protocol LPG group Microdose group P No. of cycles Age, years NS Day 3 FSH level, miu/ml NS No. of previous cycles <.05 Body mass index NS Etiology of infertility (%): Fibroids 6 (13.3) 6 (7.9) NS Endometriosis 5 (11.1) 16 (21.1) NS Unexplained 13 (28.8) 24 (31.5) NS Male factor 9 (20.0) 9 (11.8) NS Tubal factor 11 (24.4) 15 (19.7) NS Other 1 (2.2) 6 (7.9) NS Note: Values are means SD. NS ¼ not significant. retrieval, with the number of embryos depending on embryo quality and patient s age. All patients received 50 mg P in oil IM daily for luteal support, which was initiated the day after oocyte retrieval. This was continued until a negative serum pregnancy test (b-hcg) was obtained. If the serum pregnancy test was positive (b-hcg >5 IU/L), P was continued at least until a transvaginal ultrasound confirmed fetal heart activity. Clinical pregnancy was defined as a normal gestational sac measured with a transvaginal ultrasound after 5 weeks and an ongoing pregnancy was defined as a clearly visible fetal pole with a normal fetal heart rate observed after 8 weeks. Primary outcome measures were cancellation rate, number of oocytes retrieved, and clinical pregnancy rates. Secondary outcomes included total dose of gonadotropins, days of stimulation, peak E 2 levels on the day of hcg administration, number of mature oocytes, implantation rates, and ongoing pregnancy rates. The c 2 -test, Fisher s exact test, and paired t-tests were used as deemed appropriate. P<.05 was considered statistically significant. Data are presented as the mean SD. The SPSS 15.0 for Windows software package was used to perform all statistical analyses (SPSS, Chicago). RESULTS Demographic parameters were similar between both groups, including age and baseline FSH levels (Table 1). Of note, the mean number of previous cycles was significantly higher in the LPG group versus the microdose group. In the LPG group, the total number of days of stimulation and the total dose of gonadotropins were significantly greater than in the microdose group (Table 2). In contrast, peak E 2 on the day of hcg administration was significantly lower in the LPG group. The cancellation rate was similar in both groups; all cancelled cycles were due to poor follicular response (fewer than four mature follicles), except for one cycle in the LPG group, which was cancelled because of a >50% drop in E 2 levels. Likewise, the mean number of oocytes retrieved, mean number of mature oocytes, fertilization rate, and the number of embryos transferred were similar between both groups. In each group, there were two patients who did not undergo ET owing to lack of fertilization or poor embryo development. In addition, no significant differences were noted in the implantation rate (12/80, 15.0% vs. 18/144, 12.5%), clinical pregnancy rate (13/30, 43.3% vs. 23/51, 45.1%), or ongoing pregnancy rate per transfer (9/30, 30.0% vs. 13/50, 26.0%). A subset of 19 patients underwent ovarian stimulation with both the LPG and the microdose protocols (19/121), serving as their own controls. Six of those patients underwent the LPG protocol first, while 13 patients cycled first using the microdose protocol. In this subgroup of patients, no significant differences were observed in cycle parameters, cancellation rate, number of days of stimulation, amount of gonadotropins used, peak E 2,or mean number of mature oocytes retrieved or in IVF outcomes, fertilization rates, mean number of embryos transferred, implantation rate, clinical pregnancy rate, or spontaneous abortion rate. DISCUSSION The definition of patients with poor response to ovarian stimulation remains controversial and varies in the literature. The heterogeneity in patient populations and inclusion criteria has only increased the difficulty in comparing outcomes between the various treatment approaches that have been advocated by different investigators. One of the frequently used approaches for the treatment of poor responders is the use of a microdose agonist flare protocol (3 5). This protocol takes advantage of the initial rise in endogenous gonadotropins that follows GnRH-a administration in the early follicular phase and maintains efficacy in premature LH surge prevention. Pretreatment with OCPs prevents corpus luteum formation and subsequent stimulation from 228 Weitzman et al. LPG versus microdose agonist protocol Vol. 92, No. 1, July 2009

4 TABLE 2 IVF outcomes according to treatment group. Treatment protocol LPG group Microdose group P No. of cycles No. of days of stimulation <.05 Gonadotropins used, IU <.05 Peak E 2, pg/ml <.05 Mean oocytes retrieved NS Mean mature oocytes retrieved NS Mean embryos transferred NS Rate of ICSI (%) 30/33 (90.1) 44/53 (83.0) NS Cancellation rate (%) 13/45 (28.9) 23/76 (30.3) NS Fertilization rate (%) NS Implantation rate (%) 12/80 (15.0) 18/144 (12.5) NS Clinical pregnancy rate (%) 13/30 (43.3) 23/51 (45.1) NS Ongoing pregnancies per ET (%) 9/30 (30.0) 13/50 (26.0) NS Spontaneous abortion rate (%) 4/30 (13.3) 10/50 (20.0) NS Note: Values are means SD. NS ¼ not significant. exogenous GnRH-a. Scott and Navot initially showed improved ovarian response to gonadotropins by the use of microdoses of GnRH-a (20 mg of leuprolide acetate twice daily) during ovulation induction (5). In a prospective study, Schoolcraft et al. found that the use of microdose GnRH-a (40 mgof leuprolide acetate twice daily) in conjunction with growth hormone in poor-responder patients resulted in improved IVF outcomes (3). Surrey et al. assessed the effects of the microdose agonist protocol (40 mg of leuprolide acetate twice daily) without the addition of growth hormone in poor responders and also showed improved clinical outcomes (4). The microdose agonist protocol, therefore, has been proven to improve cycle parameters, decrease cancellation rates, and increase both clinical and ongoing pregnancy rates in poor responders. In recent years, GnRH antagonist protocols have gradually gained favor because of decreased cost and increased convenience for the patient. Although original reports suggested lower pregnancy rates compared with GnRH-a protocols, more recent evidence, including multiple meta-analyses, has demonstrated that pregnancy and implantation rates are at least equivalent to those obtained with GnRH-a (1, 2, 10 13). More recently, Mahutte et al. (1) published a review of the role of GnRH antagonists in the treatment of poor-responder patients that indicates that GnRH antagonists may offer several advantages, including a shorter duration of stimulation, a decrease in the total amount of gonadotropins, lower cost, and a shorter interval between successive treatment cycles. The absence of pituitary down-regulation also allows the initiation of gonadotropins in cycles in which the baseline antral follicle count and FSH levels are more favorable, as poor responders tend to have intercycle variability in their baseline FSH levels (1). In a prospective, randomized trial, we found that the GnRH antagonist ganirelix appeared as effective as the microdose agonist protocol for treatment of poor-responder patients (2). More recently, a better understanding of follicular development and ovarian physiology has resulted in the development of new strategies for ovarian stimulation that may benefit poor-responder patients. During the late luteal phase, about 5 days before menses, FSH levels increase progressively to preserve antral follicles from atresia and ensure growth. There is good evidence that larger follicles are more sensitive to these gradient levels of FSH and therefore begin to respond and develop during the late luteal phase (8, 14 17). This may lead to a discrepancy in size by the early follicular phase of the subsequent cycle. This discrepancy is detrimental in COH, for which coordination of the early antral follicles is necessary to achieve a more synchronized maturation of the follicular cohort. Coordination of the early antral follicles has been accomplished by two separate methods, luteal E 2 and premenstrual administration of a GnRH antagonist. Fanchin et al. (8, 14) described the use of luteal E 2 to decrease the premature gradual exposure of follicles to FSH in the late luteal phase. By using the late luteal E 2, there was a significant reduction of mean follicular size at baseline and improvement in overall follicular size homogeneity. More recently, the same investigators described the use of GnRH antagonist in the late luteal phase to also decrease the exposure of early antral follicles to gradient levels of FSH and noted an attenuation of follicular size discrepancies on day 2 of the cycle pretreated with GnRH antagonist (15). A novel stimulation protocol for poor responders was recently reported by Dragisic et al. (7), using a luteal E 2 patch combined with GnRH antagonist in the luteal phase before starting gonadotropin stimulation in a subsequent GnRH antagonist cycle. In a retrospective review, they found this new protocol to be a viable option in the treatment of poor responders, yielding superior results when compared with the same patients prior IVF cycles, including a lower Fertility and Sterility â 229

5 cancellation rate, a higher mean number of oocytes retrieved and fertilized oocytes, and a significantly higher number of embryos transferred (7). Although very promising, a major limitation in that study design is the comparison of the results to the patient s previous cycle. The aim of our study was to evaluate the efficacy of this new LPG protocol for treatment of poor-responder patients and to compare the IVF outcomes with a similar group of patients treated with the microdose agonist protocol. Our results showed no significant differences in the mean number of oocytes, mature oocytes, fertilization rates, implantation rates, or clinical pregnancy rates. One limitation of this study, as with most published trials of stimulation protocols for poor responders, is its retrospective nature, which accounts for the lack of uniformity in the stimulation protocol as well as the varied dosages of both gonadotropins and hcg. Nevertheless, this study is the first to compare the use of a microdose agonist protocol with the LPG protocol for poor responders. Although most demographic parameters were similar in both groups of patients, women who underwent stimulation with the LPG protocol had a significantly greater number of previously failed cycles, some of which (11/45) included stimulation with the microdose protocol. It is conceivable that the patient population may have been skewed to include more women with a worse prognosis in the LPG group, further underscoring the potential value of this protocol for poor-prognosis patients. An interesting observation is the subgroup of patients who underwent both the LPG and the microdose agonist protocols. Separate analysis of those 19 women showed no significant differences in cancellation rate, number of oocytes retrieved, or fertilization, implantation, or pregnancy rates between both protocols. One possible explanation for why there is little difference in outcomes between these two protocols may be that pretreatment with OCPs in the cycle directly before the treatment cycle in the microdose agonist protocol essentially acts in much the same way as the E 2 patch and the GnRH antagonist. By pretreating the cycle with OCPs, these patients FSH levels are also lower at the beginning of the next cycle; potentially synchronizing the early antral follicles and allowing for an increase in the number of oocytes available at the time of retrieval. However, one significant difference between the two protocols was the number of days of gonadotropins, which was greater in the LPG protocol. This is due to the inherent nature of the LPG protocol as there is increased pituitary suppression due to the elevated E 2 levels as well as exposure to the GnRH antagonist in the late luteal phase, which delays FSH elevation. Randomized, controlled trials are necessary to demonstrate whether or not this increase in duration of exposure to rec- FSH during stimulation may ultimately allow an increase in the number or the quality of oocytes available for retrieval. In conclusion, our findings suggest that the use of the LPG protocol is at least as effective as the microdose agonist protocol for poor responders. This novel stimulation protocol using luteal phase E 2 patch and a GnRH antagonist appears to be an effective and promising option for the treatment of this challenging group of patients. As poor responders typically may fail several cycle attempts, having alternative choices to offer may allow improvement in outcomes for many of these women. REFERENCES 1. Mahutte MG, Arici A. Role of gonadotropin-releasing hormone antagonists in poor responders. Fertil Steril 2007;87: Schmidt DW, Bremner T, Orris JJ, Maier DB, Benadiva CA, Nulsen JC. 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Fertil Steril 2004;81: Hohmann FP, Macklon NS, Fauser BCJM. A randomized comparison of two ovarian stimulation protocols with GnRH antagonist cotreatment for in vitro fertilization commencing recombinant follicle-stimulating hormone on cycle day 2 or 5 with the standard long GnRH agonist protocol. J Clin Endocrinol Metab 2003;88: McNatty KP, Hillier SG, van den Boogaard AM, Trimbos-Kemper TC, Reichert LE Jr, van Hall EV. Follicular development during the luteal phase of the human menstrual cycle. J Clin Endocrinol Metab 1983;56: Weitzman et al. LPG versus microdose agonist protocol Vol. 92, No. 1, July 2009