Absence of luteal phase defect and spontaneous pregnancy in IVF patients despite GnRH-agonist trigger and “freeze all policy” without luteal phase support: a report of four cases

Abstract

Human chorionic gonadotropin (hCG) is commonly used for final oocyte maturation in "in vitro fertilization" (IVF)-treatment cycles, however, the main important risk is development of severe ovarian hyperstimulation syndrome (OHSS). OHSS can almost be avoided by using gonadotrophin-releasing-hormone agonist for final oocyte maturation in an antagonist protocol. However, primarily this approach lead to a very poor reproductive outcome, despite the use of a standard luteal phase support. The reason seems to be severe luteolysis. Obviously, luteolysis post-gonadotropin-releasing-hormone-agonist (post-GnRH-a) trigger is individual specific, and not all patients will develop a complete luteolysis, as expected previously. Luteolysis can been reverted by the administration of hCG. Unprotected intercourse around the time of ovulation induction and oocyte retrieval can lead to a spontaneous conception in IVF treatment and, endogenous hCG, produced by the trophoblast, will rescue the corpora lutea. Therefore, one should not rely on complete luteolysis after GnRH-a triggering and, especially patients for egg donation and pre-implantation-genetic diagnosis for single gene disorder, have to be counselled to avoid unprotected intercourse.

Severe early ovarian hyperstimulation syndrome after spontaneous pregnancy and despite GnRH-agonist trigger during controlled ovarian stimulation in an oocyte donor cycle: a case report

“…12,[25][26][27] Such as Gurbuz have recently exhibited in a report of 4 cases, luteolysis post GnRH agonist trigger might be individual dependant and not all of these patients will develop complete luteolysis. 2 After GnRH agonist has been administered, some patient's corpora luteum have the capability of recovering its function even after 7 days from LH deprivation. Moreover, after fertilisation hCG is produced by the embryo previous to its implantation.…”

“…Ovarian hyperstimulation syndrome (OHSS) is the most serious and potentially lethal complication of In Vitro Fertilization (IVF) cycles. 1,2 OHSS is characterized by the shift of protein-rich fluid from the intravascular space to the third space that follows ovarian enlargement due to follicular stimulation. The pathogenesis involves an increased number of granulosa cells, due to multifollicular growth, and the resultant increased vascular endothelial growth factor (VEGF) production during the luteinization of these cells.…”

“…11 It is well recognized that GnRH-agonist trigger in antagonist protocols results in prevention of clinically significant ovarian hyperstimulation syndrome (OHSS) by inducing quick and irreversible luteolysis hence preventing the secretion of vasoactive substances. [1][2][3][4] conversely, this results in decreased implantation and pregnancy rates due to its deleterious effects on the endometrium. While hCG trigger continues its action for up to 5 days, GnRH agonists provide a two phases gonadotrophins surge that persists up to 24-36h.…”

Ovarian hyperstimulation syndrome following GnRH agonist trigger—think ectopic

“…Of emphasize, Gurbuz et al [13] recently described four cases of failed complete luteolysis post-GnRHa trigger, which was sufficient to allow embryo implantation and development, where one of these patients developed OHSS, obviously, a consequence of the endogenous hCG secretion. This case emphasize that unprotected intercourse should be advised against, following GnRHa trigger in order to eliminate the occurrence of OHSS.…”

GNRH Agoni̇st İle Teti̇kleme Sonrasi Tüm Embri̇yolarin Dondurulduğu Olguda Spontan Kli̇ni̇k Gebeli̇k / Spontaneous Clinical Pregnancy Following GNRH Agonist Triggering and Freeze All Policy

“…Sonuç olarak, tek başına GnRH agonistlerinin kullanımı sonrası şiddetli luteolizin geliştiği ve luteal fazın yetersiz olacağı düşünülmektedir. Ancak bu görüşün aksine, GnRH agonist ile final oosit matürasyonu sağlanarak sonrasında tüm embriyoların dondurulduğu toplam 5 hastada luteal faz desteği verilmemesine karşın spontan gebelik oluştuğu henüz bildirilmiştir (13,14). Benzer şekilde bizim vakamızda da GnRH agonisti ile tetikleme ve tüm embriyoların dondurulması stratejisine karşın, luteal faz desteği sağlanmadan spontan klinik gebelik izlendi.…”