Rescue in vitro fertilization using a GnRH antagonist in hyper-responders from gonadotropin intrauterine insemination (IUI) cycles

Abstract

Objective To evaluate the outcomes in the conversion of high-response gonadotropin intrauterine insemination (IUI) cycles to "rescue" in vitro fertilization (IVF) using a Gonadotropin-Releasing Hormone (GnRH) antagonist, with regards to implantation rates, pregnancy rates, cost, and ovarian hyperstimulation syndrome (OHSS) as compared to matched, hyper-responder, IVF controls. Methods This prospective cohort study was conducted between January 2007 and December 2009 at our institution. In order to decrease high-order multiple pregnancy, minimize the incidence of OHSS, and avoid cycle cancellation, highresponse stimulated-IUI patients opted to convert to "rescue" IVF using the GnRH antagonist cetrorelix acetate. We then compared their clinical outcomes with matched patients from high-response IVF cycles of the standard long mid-luteal GnRH agonist protocol (14 or more collected oocytes). Only cases of conventional IVF without intra-cytoplasmic sperm injection (ICSI) were included in the control group.Results Out of 184 patients undergoing stimulated-IUI cycles with gonadotropins, 87 patients developed a hyperresponse, and 20 opted to convert to "rescue" IVF. These patients were compared with 157 matched, hyper responder IVF controls from our registry. The implantation rate was 25.6 % in the "rescue" IVF group and 20.7 % in the control IVF group (p<0.0047). The ongoing clinical pregnancy rate per embryo transfer was 45.0 % and 33.6 % in the "rescue" IVF and the control IVF groups, respectively (p<0.0001). The mean duration of stimulation was comparable between cohorts (10.0 vs.10.4 days, p=0.6324). The mean dose of gonadotropin used per cycle was higher in the control group, 2664 international units (IU) of follicle stimulation hormone (FSH) compared to 1450 IU of FSH in the "rescue" IVF group (p<0.0001). The incidence of severe OHSS is also higher in the control group, 5.1 % versus no cases in the "rescue" IVF group (p<0.0001). Conclusion Our study demonstrates that conversion of high-response gonadotropin-IUI cycles to "rescue" IVF using a GnRH antagonist is a cost-effective strategy that produces better results than regular IVF with relatively minimal morbidity, and shorter duration to achieve pregnancy. Implantation and ongoing clinical pregnancy rates tend to be higher than those from hyper-responder regular IVF patients. Capsule Conversion of high-response gonadotropin-IUI cycles to "rescue" IVF using a GnRH antagonist is a cost-effective strategy that produces better results than regular IVF.

Prevention of multiple pregnancies in gonadotropin-insemination cycles

“…Several studies of rescue IVF have all reported favourable outcomes when high response gonadotropin cycles were converted to IVF [27]. In a prospective cohort study published by our group, we showed that conversion of high-response gonadotropin-IUI cycles to 'rescue IVF' is a cost-effective strategy with relatively minimal morbidity, which provides better clinical outcomes than conventional IVF [26].…”

“…Several studies of rescue IVF have all reported favourable outcomes when high response gonadotropin cycles were converted to IVF [27]. In a prospective cohort study published by our group, we showed that conversion of high-response gonadotropin-IUI cycles to ‘rescue IVF’ is a cost-effective strategy with relatively minimal morbidity, which provides better clinical outcomes than conventional IVF [26]. In addition, implantation and pregnancy rates were higher than those from hyper-responder IVF patients (≥ 14 collected oocytes) who have been started on mid-luteal long GnRH agonist protocols [26].…”

“…In a prospective cohort study published by our group, we showed that conversion of high-response gonadotropin-IUI cycles to ‘rescue IVF’ is a cost-effective strategy with relatively minimal morbidity, which provides better clinical outcomes than conventional IVF [26]. In addition, implantation and pregnancy rates were higher than those from hyper-responder IVF patients (≥ 14 collected oocytes) who have been started on mid-luteal long GnRH agonist protocols [26]. Despite being used in many IVF centers around the globe, this technique needs to be better evaluated in a well designed prospective randomized study.…”

“…In addition, implantation and pregnancy rates were higher than those from hyper-responder IVF patients ( 14 collected oocytes) who have been started on mid-luteal long GnRH agonist protocols [26]. Despite being used in many IVF centers around the globe, this technique needs to be better evaluated in a well designed prospective randomized study.…”

“…A viable option to bypass these aforementioned problems would be to convert the cycle of ovarian stimulation in question to an IVF cycle (Tables 1 and 2), despite the financial burden to the patients. This interesting approach has been termed as 'rescue IVF' [26]. With the advent of GnRH antagonists (Cetrorelix or Ganirelix), the latter can be readily accomplished by provision of the antagonist in order to prevent a premature LH surge, performing transvaginal egg retrieval, and proceeding with embryo culture and transfer.…”