Gonadotropin Releasing Hormone Agonist (GnRHa) Versus Estrogen and Progesterone for Luteal Support in High Responders
NCT ID: NCT04797338
Last Updated: 2021-04-01
Study Results
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Basic Information
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UNKNOWN
PHASE4
100 participants
INTERVENTIONAL
2017-12-29
2021-09-30
Brief Summary
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Detailed Description
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The mechanism by which GnRH agonist improve implantation rates is unknown. Several hypotheses were suggested including promoting corpus luteum maintenance by secretion of LH from pituitary gonadotropin cells, a direct effect on the endometrium and the embryo through GnRH receptors and regulatory effect on hCG secretion by the placenta at the preimplantation phase. In 2004, Tesarik et al, conducted a prospective randomized trial including 276 oocyte recipients. Oocytes from each individual donor were divided to two recipients, one of whom received a single dose of a GnRH agonist (0.1 mg triptorelin) 3 days after embryo transfer and the other received placebo at the same time. Of note, the endometrium was prepared by oral estradiol valerate treatment following by vaginal progesterone (Utrogestan) as widely accepted. The results demonstrated significantly higher implantation and live birth rate in the group treated with GnRH agonist compared to the control group with significantly higher twin pregnancy rates while no difference in miscarriage and abortion rates was observed between the two study groups. The authors concluded that GnRH agonist administration at the time of implantation has a positive effect on embryo developmental potential. It's important to note that this study evaluated the effect of a single dose of GnRH agonist in addition to a conventional luteal support in a population of oocyte recipients that are not at risk for OHSS and tend to have higher implantation and pregnancy rates also without GnRH agonist supplementation. A study by Pirard et al. was the first to evaluate the administration of GnRH agonist alone for luteal support compared to compared to the standard treatment with vaginal progesterone. The study group included 35 patients who were treated with antagonist protocol. Intranasal GnRH agonist (Buserilin) was given for final oocyte maturation and luteal support was achieved by administration of intranasal GnRH agonist for up to 16 days after the oocytes retrieval. The control group included 18 women treated with a long GnRH protocol for pituitary suppression. Final oocytes maturation was achieved by administration of 10000 units of hCG and vaginal progesterone was used for luteal support. Implantation and pregnancy rates were higher among the study group compared to the control group however, no statistical significance was achieved. Progesterone levels on day 5 were significantly lower while LH levels were significantly higher during all the luteal phase in the study group compared to the control group. The authors concluded that intranasal administration of Buserelin is as effective as standard progesterone treatment for providing luteal phase support in IVF/ICSI antagonist protocols. To our knowledge, the only study, so far that evaluated the efficacy of GnRH agonist treatment for luteal support in high responder patients with increased risk for OHSS was conducted by Bar-Hava et al. It included 46 women at risk for OHSS that were treated with GnRH antagonist protocol for pituitary suppression. The final oocyte maturation was achieved by GnRH agonist (Triptorelin) and a daily intranasal GnRH agonist (Nafarelin 200 micrograms twice daily) was administered for luteal support for two weeks following the oocytes retrieval. 52% clinical pregnancy rates were obtained while no cases od OHSS or other substantial adverse effects were observed.
The main disadvantage of the study is the lack of a comparison to a control group. To the best of our knowledge, no study so far compared administration of GnRH agonist at the same protocol described by Bar-Hava et al. to intensive estrogen and progesterone treatment for luteal support among women treated with GnRH antagonist protocol and GnRH agonist triggering for final oocytes maturation. A randomized controlled trial in an infertility population at increased risk for OHSS, will enable us to evaluate the efficacy of GnRH agonist treatment compared to standard treatment for luteal support and to determine the best treatment approach in the high responder population undergoing a fresh embryo transfer new approach undergoing a fresh embryo transfer following GnRHa triggering.
The aim of the current study isto compare the efficacy of GnRH agonist versus estrogen and progesterone supplementation for luteal support in high responders undergoing fresh embryo transfer following GnRHa triggering.
Conditions
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Study Design
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RANDOMIZED
PARALLEL
At the day of triggering for final oocyte maturation, patients will sign an informed consent and will be allocated to one of the study arms according to the instructions in the envelop attached to the consent form.
TREATMENT
NONE
Study Groups
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GnRHa treatment based luteal support
Patients will initiate intranasal treatment with Nafarelin inhaler: 200 micrograms twice daily (a total of 400 micrograms/d; Synarel, Pfizer) on the evening after oocyte retrieval which will be continued up to the bHCG blood test, 12 days post embryo transfer. In cases with positive serum hCG results, the treatment will be stopped.
Synarel, 0.2 Mg/Inh Nasal Spray
Intranasal treatment with Nafarelin inhaler: 200 micrograms twice daily (a total of 400 micrograms/d; Synarel, Pfizer) on the evening after oocyte retrieval, which will be continued up to the bHCG blood test, 12 days post embryo transfer. In cases with positive serum bHCG results, the treatment will be stopped.
Estrogen and progesterone supplementation
Patients will start treatment with a combination of oral estrogen (Estrofem or Progynova 4 mg twice daily), vaginal progesterone (vaginal Utrogestan 200mg or Endometrin 100 mg three times daily) and intramuscular injection of progesterone retard 250 mg once every five days. The treatment will start at the day of the oocyte retrieval up to the bHCG blood test, 12 days post embryo transfer. In cases with positive serum hCG results, the treatment will be continued up to 9+0 weeks of pregnancy.
Estrofem
A combination of oral estrogen (Estrofem or Progynova 4 mg twice daily), vaginal progesterone (vaginal Utrogestan 200mg or Endometrin 100 mg three times daily) and intramuscular injection of Hydroxyprogesterone Caproate 250 mg once every five days. The treatment will start at the day of the oocyte retrieval up to the bHCG blood test, 12 days post embryo transfer. In cases with positive serum bHCG results, the treatment will be continued up to 9+0 weeks of pregnancy.
Utrogestan
A combination of oral estrogen (Estrofem or Progynova 4 mg twice daily), vaginal progesterone (vaginal Utrogestan 200mg or Endometrin 100 mg three times daily) and intramuscular injection of Hydroxyprogesterone Caproate 250 mg once every five days. The treatment will start at the day of the oocyte retrieval up to the bHCG blood test, 12 days post embryo transfer. In cases with positive serum bHCG results, the treatment will be continued up to 9+0 weeks of pregnancy.
Hydroxyprogesterone Caproate
A combination of oral estrogen (Estrofem or Progynova 4 mg twice daily), vaginal progesterone (vaginal Utrogestan 200mg or Endometrin 100 mg three times daily) and intramuscular injection of Hydroxyprogesterone Caproate 250 mg once every five days. The treatment will start at the day of the oocyte retrieval up to the bHCG blood test, 12 days post embryo transfer. In cases with positive serum bHCG results, the treatment will be continued up to 9+0 weeks of pregnancy.
Interventions
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Synarel, 0.2 Mg/Inh Nasal Spray
Intranasal treatment with Nafarelin inhaler: 200 micrograms twice daily (a total of 400 micrograms/d; Synarel, Pfizer) on the evening after oocyte retrieval, which will be continued up to the bHCG blood test, 12 days post embryo transfer. In cases with positive serum bHCG results, the treatment will be stopped.
Estrofem
A combination of oral estrogen (Estrofem or Progynova 4 mg twice daily), vaginal progesterone (vaginal Utrogestan 200mg or Endometrin 100 mg three times daily) and intramuscular injection of Hydroxyprogesterone Caproate 250 mg once every five days. The treatment will start at the day of the oocyte retrieval up to the bHCG blood test, 12 days post embryo transfer. In cases with positive serum bHCG results, the treatment will be continued up to 9+0 weeks of pregnancy.
Utrogestan
A combination of oral estrogen (Estrofem or Progynova 4 mg twice daily), vaginal progesterone (vaginal Utrogestan 200mg or Endometrin 100 mg three times daily) and intramuscular injection of Hydroxyprogesterone Caproate 250 mg once every five days. The treatment will start at the day of the oocyte retrieval up to the bHCG blood test, 12 days post embryo transfer. In cases with positive serum bHCG results, the treatment will be continued up to 9+0 weeks of pregnancy.
Hydroxyprogesterone Caproate
A combination of oral estrogen (Estrofem or Progynova 4 mg twice daily), vaginal progesterone (vaginal Utrogestan 200mg or Endometrin 100 mg three times daily) and intramuscular injection of Hydroxyprogesterone Caproate 250 mg once every five days. The treatment will start at the day of the oocyte retrieval up to the bHCG blood test, 12 days post embryo transfer. In cases with positive serum bHCG results, the treatment will be continued up to 9+0 weeks of pregnancy.
Other Intervention Names
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Eligibility Criteria
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Inclusion Criteria
* Increased risk for OHSS (PCOS, previous history of OHSS, high antral follicle count (AFC) etc.).
Exclusion Criteria
* Oocyte donation, fertility preservation or Freeze all (freezing all the embryos) cycles.
* Moderate to severe endometriosis
* An evidence of hydrosalpinx
18 Years
45 Years
FEMALE
No
Sponsors
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Assaf-Harofeh Medical Center
OTHER_GOV
Responsible Party
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Assaf Harofeh MC
principal investigator
Principal Investigators
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Michal Youngster, MD
Role: PRINCIPAL_INVESTIGATOR
Assaf-Harofeh Medical Center
Locations
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Shamir Medical center
Be’er Ya‘aqov, , Israel
Countries
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Central Contacts
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Facility Contacts
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References
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Gomez R, Soares SR, Busso C, Garcia-Velasco JA, Simon C, Pellicer A. Physiology and pathology of ovarian hyperstimulation syndrome. Semin Reprod Med. 2010 Nov;28(6):448-57. doi: 10.1055/s-0030-1265670. Epub 2010 Nov 16.
Damewood MD, Shen W, Zacur HA, Schlaff WD, Rock JA, Wallach EE. Disappearance of exogenously administered human chorionic gonadotropin. Fertil Steril. 1989 Sep;52(3):398-400. doi: 10.1016/s0015-0282(16)60906-8.
Leth-Moller K, Hammer Jagd S, Humaidan P. The Luteal Phase after GnRHa Trigger-Understanding An Enigma. Int J Fertil Steril. 2014 Oct;8(3):227-34. Epub 2014 Nov 1.
Youssef MA, Van der Veen F, Al-Inany HG, Mochtar MH, Griesinger G, Nagi Mohesen M, Aboulfoutouh I, van Wely M. Gonadotropin-releasing hormone agonist versus HCG for oocyte triggering in antagonist-assisted reproductive technology. Cochrane Database Syst Rev. 2014 Oct 31;2014(10):CD008046. doi: 10.1002/14651858.CD008046.pub4.
Atkinson P, Koch J, Ledger WL. GnRH agonist trigger and a freeze-all strategy to prevent ovarian hyperstimulation syndrome: a retrospective study of OHSS risk and pregnancy rates. Aust N Z J Obstet Gynaecol. 2014 Dec;54(6):581-5. doi: 10.1111/ajo.12277.
van der Linden M, Buckingham K, Farquhar C, Kremer JA, Metwally M. Luteal phase support for assisted reproduction cycles. Cochrane Database Syst Rev. 2015 Jul 7;2015(7):CD009154. doi: 10.1002/14651858.CD009154.pub3.
Golan A, Ron-el R, Herman A, Weinraub Z, Soffer Y, Caspi E. Fetal outcome following inadvertant administration of long-acting DTRP6 GnRH microcapsules during pregnancy: a case report. Hum Reprod. 1990 Jan;5(1):123-4. doi: 10.1093/oxfordjournals.humrep.a137031.
Isherwood PJ, Ibrahim ZH, Matson PL, Morroll DR, Burslem RW, Lieberman BA. Endocrine changes in women conceiving during treatment with an LHRH agonist. Hum Reprod. 1990 May;5(4):409-12. doi: 10.1093/oxfordjournals.humrep.a137112.
Jackson AE, Curtis P, Amso N, Shaw RW. Exposure to LHRH agonists in early pregnancy following the commencement of mid-luteal buserelin for IVF stimulation. Hum Reprod. 1992 Oct;7(9):1222-4. doi: 10.1093/oxfordjournals.humrep.a137830.
Elefant E, Biour B, Blumberg-Tick J, Roux C, Thomas F. Administration of a gonadotropin-releasing hormone agonist during pregnancy: follow-up of 28 pregnancies exposed to triptoreline. Fertil Steril. 1995 May;63(5):1111-3. doi: 10.1016/s0015-0282(16)57557-8.
Balasch J, Martinez F, Jove I, Cabre L, Coroleu B, Barri PN, Vanrell JA. Inadvertent gonadotrophin-releasing hormone agonist (GnRHa) administration in the luteal phase may improve fecundity in in-vitro fertilization patients. Hum Reprod. 1993 Jul;8(7):1148-51. doi: 10.1093/oxfordjournals.humrep.a138210.
Wilshire GB, Emmi AM, Gagliardi CC, Weiss G. Gonadotropin-releasing hormone agonist administration in early human pregnancy is associated with normal outcomes. Fertil Steril. 1993 Dec;60(6):980-3. doi: 10.1016/s0015-0282(16)56396-1.
Weissman A, Shoham Z. Favourable pregnancy outcome after administration of a long-acting gonadotrophin-releasing hormone agonist in the mid-luteal phase. Hum Reprod. 1993 Mar;8(3):496-7. doi: 10.1093/oxfordjournals.humrep.a138079.
Young DC, Snabes MC, Poindexter AN 3rd. GnRH agonist exposure during the first trimester of pregnancy. Obstet Gynecol. 1993 Apr;81(4):587-9.
Gartner B, Moreno C, Marinaro A, Remohi J, Simon C, Pellicer A. Accidental exposure to daily long-acting gonadotrophin-releasing hormone analogue administration and pregnancy in an in-vitro fertilization cycle. Hum Reprod. 1997 Nov;12(11):2557-9. doi: 10.1093/humrep/12.11.2557.
Tesarik J, Hazout A, Mendoza C. Enhancement of embryo developmental potential by a single administration of GnRH agonist at the time of implantation. Hum Reprod. 2004 May;19(5):1176-80. doi: 10.1093/humrep/deh235. Epub 2004 Apr 7.
Tesarik J, Hazout A, Mendoza-Tesarik R, Mendoza N, Mendoza C. Beneficial effect of luteal-phase GnRH agonist administration on embryo implantation after ICSI in both GnRH agonist- and antagonist-treated ovarian stimulation cycles. Hum Reprod. 2006 Oct;21(10):2572-9. doi: 10.1093/humrep/del173. Epub 2006 Aug 22.
Pirard C, Loumaye E, Laurent P, Wyns C. Contribution to More Patient-Friendly ART Treatment: Efficacy of Continuous Low-Dose GnRH Agonist as the Only Luteal Support-Results of a Prospective, Randomized, Comparative Study. Int J Endocrinol. 2015;2015:727569. doi: 10.1155/2015/727569. Epub 2015 Apr 5.
Bar-Hava I, Mizrachi Y, Karfunkel-Doron D, Omer Y, Sheena L, Carmon N, Ben-David G. Intranasal gonadotropin-releasing hormone agonist (GnRHa) for luteal-phase support following GnRHa triggering, a novel approach to avoid ovarian hyperstimulation syndrome in high responders. Fertil Steril. 2016 Aug;106(2):330-3. doi: 10.1016/j.fertnstert.2016.04.004. Epub 2016 Apr 22.
Other Identifiers
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0245-17-ASF
Identifier Type: -
Identifier Source: org_study_id
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