1. RECOMBINANT LH, RECOMBINANT HCG AND GNRH AGONIST TO TRIGGER OVULATION IN ANTAGONIST CYCLES: A CRITICAL EVALUATION SHAHAR KOL AUGUST 2014

2. THE NATURAL CYCLE LH surge goes together with FSH surge.

3. HOW TO IMITATE NATURE? Use recombinant LH

4. RECOMBINANT LH FOR FINAL OOCYTE MATURATION European Recombinant LH Study Group. J Clin Endocrinol Metab 2001;86:2607–2618

5. ●15,000 + 10,000 IU gave 20% live birth rate but with a 12% OHSS rate Treatment arm5000 IU15,000 IU30,000 IU15,000 + 10,000 IU p (linearity) Parameters examined rhLH (n=39) u-hCG (n=34) rhLH (n=39) u-hCG (n=41) rhLH (n=26) u-hCG (n=22) rhLH (n=25) u-hCG (n=24) No. of follicles >10 mm 14.03 ± 5.3216.44 ± 6.95 15.17 ± 8.3415.46 ± 6.7514.23 ± 5.6114.00 ± 4.90 aa 0.3007 No. of oocytes retrieved 10.23 ± 4.7011.74 ± 6.27 11.84 ± 7.5311.78 ± 6.7512.62 ± 6.2210.82 ± 5.70 aa 0.1702 Oocytes in metaphase II 85.5%77.8% 90.8%88.6%57.6%84.5% aa 0.183 No. of oocytes inseminated 9.82 ± 4.7411.26 ± 5.73 11.63 ± 7.5211.57 ± 6.5712.38 ± 6.2510.55 ± 5.74 aa 0.1687 No. of embryos 5.42 ± 3.337.00 ± 4.68 6.65 ± 5.026.36 ± 4.687.67 ± 4.346.33 ± 5.19 aa 0.0983 No. of embryos transferred 2.39 ± 0.602.48 ± 0.85 2.58 ± 0.62.52 ± 0.622.78 ± 0.82.67 ± 0.73 aa 0.4310 Implantation rate 6.0 ± 0.16%15.0 ± 0.31% 6.0 ± 0.19%9.0 ± 0.24% 11.0 ± 0.26% 3.0 ± 0.09% 19.0 ± 0.33% 17.0 ± 0.33% 0.1373 Pregnancy (total) 15.4% (n=6)26.5% (n=9) 10.3% (n=4) 24.4% (n=10) 23.1% (n=6)13.6% (n=3)32.0% (n=8)37.5% (n=9)0.2689 Clinical pregnancy 10.3% (n=4)23.5% (n=8) 7.7% (n=3)14.6% (n=6)15.4% (n=4)13.6% (n=3)28.0% (n=7)25.0% (n=6)0.1479 Live birth 5.1% (n=2)17.6% (n=6)7.7% (n=3)12.2% (n=5)15.4% (n=4)4.5% (n=1)20.0% (n=5)16.7% (n=4)0.0606 Cryopreserved embryos 4.42 ± 2.656.81 ± 3.677.93 ± 4.184.90 ± 3.246.27 ± 2.964.80 ± 3.195.75 ± 2.49 9.89 ± 3.220.2645 Cryopreserved embryos transferred 3.42 ±1.835.67 ± 2.653.50 ± 1.843.27 ± 1.49 3.00 ± 1.412.17 ± 0.982.50 ± 0.714.75 ± 2.43 0.9092 Pregnancy from cryopreserved embryos (total) 16.7% (n=2/12) 0.0% (n=0/9) 50.0% (n=5/10) 27.3% (n=3/11) 62.5% (n=5/8) 33.3% (n=2/6) 0.0% (n=0/2) 0.0% (n=0/8) b Clinical pregnancy from cryopreserved embryos 8.3% (n=1/12) 0.0% (n=0/9) 40.0% (n=4/10) 27.3% (n=3/11) 50.0% (n=4/8) 16.7% (n=1/6) 0.0% (n=0/2) 0.0% (n=0/8) b Live birth from cryopreserved embryos 8.3% (n=1/12) 0.0% (n=0/9) 30.0% (n=3/10) 18.2% (n=2/11) 12.5% (n=1/8) 0.0% (n=0/6) 0.0% (n=0/2) 0.0% (n=0/8) b

6. High P during implantation window: after hCG or 2 LH boluses 3 days apart

7. CONCLUSIONS The results show that a single dose of rhLH is effective in inducing final follicular maturation and early luteinization in vitro fertilization and embryo transfer patients and is comparable with 5,000 IU u-hCG. A single dose of rhLH results in a highly significant reduction in OHSS compared with hCG.

8. “TRIAL 21447” a double-blind large (437 patients) multicenter randomized study (Trial 21447), compared the implantation and pregnancy rates following triggering ovulation by r-hLH versus HCG. pregnancy rates and clinical pregnancy rates were significantly lower in the r-hLH group than in the u-HCG group (P = 0.018 and P = 0.023 respectively). In order for r-hLH to be as efficacious as u-HCG, the dose would have to be increased to a point where the cost/benefit ratio may become adverse. The study was not published and the manufacturer of r-hLH decided not to register or manufacture the high dose of r-hLH used for triggering ovulation. Aboulghar & Al-Inany RBMOnline, 2005

9. HCG AS TRIGGER The default trigger agent Recombinant human hCG or urinary hCG Question of dose

10. Recombinant hCG is better in: More mature oocytes (9.4 vs. 7.1) Higher luteal progesterone Better injection tolerance

11. “There is no evidence of a difference in the clinical outcomes of life birth/ongoing pregnancy, pregnancy, miscarriage and OHSS between urinary and recombinant gonadotrophins for induction of final follicular maturation”. Same conclusions in a Cochrane review 2011.

12. WHAT ARE THE PROBLEMS WITH HCG AS TRIGGER? No FSH surge Long half life

13. POTENTIAL BENEFIT OF FSH SURGE Promotes LH receptor formation in luteinizing granulosa cells Promotes nuclear maturation (i.e. resumption of meiosis) Promotes cumulus expansion Eppig JJ. Nature 1979;281:483–484 Strickland and Beers. J Biol Chem 1976;251:5694–5702 Yding Andersen C. Reprod Biomed Online 2002;5:232–239 Yding Andersen C, et al. Mol Hum Reprod 1999;5:726–731 Zelinski-Wooten MB, et al. Human Reprod 1995;10:1658–1666

14. Conclusions: Adding a bolus of FSH 450 IU at the time of hCG improves oocyte recovery and fertilization rate. Lamb at al, F&S 2011

15. hCG long half life

16. HCG AND LUTEAL PHASE DEFECT Supraphysiologic stimulation of CL in early luteal phase Supraphysioloigc levels of E2 and P Negative feedback at the pituitary level Low endogenous LH secretion Luteal phase defect Need of luteal phase supplementation

17. GNRH AGONIST TRIGGER This possibility was first introduced in 1988: “Induction of LH surge and oocyte maturation by GnRH analogue (Buserelin) in women undergoing ovarian stimulation for IVF.” Itskovitz et al, Gynecological Endocrinology 1988, 2:Suppl1, 165.

18. THE PHYSIOLOGY OF AGONIST TRIGGER 1.Humaidan P, et al. Reprod Biomed Online 2011 2. Gonen Y, et al. J Clin Endocrinol Metab 1990 LH surge 1 FSH surge 2

19. CAN AGONIST TRIGGER WORK IN ANTAGONIST-BASED OVARIAN STIMULATION? Can the agonist displace the antagonist from the receptor? Can a short LH surge promote final oocyte maturation? antagonist

20. Endocrine Profiles after Triggering of Final Oocyte Maturation with GnRH Agonist after Cotreatment with the GnRH Antagonist Ganirelix during Ovarian Hyperstimulation for in Vitro Fertilization The study was designed to examine whether, after daily late follicular phase treatment with 0.25 mg ganirelix, administration of a single dose of GnRH agonist is at least as effective as hCG in inducing final oocyte maturation in patients undergoing ovarian hyperstimulation for IVF Fauser et al, 2002

21. CLINICAL OUTCOME (MEAN±SD) Triptorelin (n=17) Leuprorelin (n=15) hCG (n=15) Number of oocytes/subject9.8 ± 5.48.7 ± 4.58.3 ± 3.3 Proportion of metaphase II oocyte72 ± 18%85 ± 17%86 ± 17% Fertilization61 ± 30%62 ± 23%56 ± 18% No. of embryos obtained per subject, grades 1 and 2 pooled2.7 ± 34%3.2 ± 2.63.3 ± 2.0 Implantation rate15 ± 34%18 ± 37%7 ± 14% Ongoing pregnancy rate18%20%13% Fauser et al, 2002

22. What is the advantage of agonist trigger? Agonist trigger causes quick and irreversible luteolysis. This leaves the clinician with the options to specifically control the luteal phase.

23. CLINICAL USE OF AGONIST TRIGGER Egg donors Prevention of OHSS Patient comfort Special cases

24. No OHSS! Bodri et al, Fertil Steril. 2010

25. Melo et al RBMonline 2009

26. "We did find differences in the duration of the luteal phase: The period to menstrual onset in the non-hCG group was significantly shorter (10.2 days vs. 5.2 days; P<.001). Also, 42% of those who received hCG reported subjective complaints (mostly abdominal discomfort), whereas this percentage was 0% in those who received GnRH agonist to trigger ovulation. No OHSS was observed in either cohort." Cerrillo et al, 2009, IVI Madrid …and when OHSS is not the main issue?

27. AGONIST TRIGGER IN THE CONTEXT OF OHSS PREVENTION The dream of OHSS-free IVF treatment is real!

28. ANTAGONIST ERA Use of a single bolus of GnRH agonist triptorelin to trigger ovulation after GnRH antagonist ganirelix treatment in women undergoing ovarian stimulation for assisted reproduction, with special reference to the prevention of ovarian hyperstimulation syndrome: preliminary report: Short communication. Itskovitz-Eldor et al, 2000

29. Youssef MA, et al. Human Reprod Update 2010;16:459–466 GnRH agonist versus hCG for oocyte triggering in GnRH antagonist ART cycles Total events 0 (GnRH) 21 (hCG)

30. OHSS % (n)n Ovulation trigger Oocyte source Trial typeReference 0 (0/13) 31(4/13) 15 13 GnRHa hCG ownRCT, high risk Babayof et al 2006 0 (0/33) 31 (10/32) 33 32 GnRHa hCG ownRCT, high risk Engamnn et al 2008 0 (0/30) 17 (5/30) 30 GnRHa hCG donorsRCT Acevedo et al 2006 0 (0/1046) 1.3 (13/1031) 1046 1031 GnRHa hCG donorsRetrospective Bodri et al 2009 0 (0/40)40 GnRHa own Observational, High risk Griesinger et al 2010 0 (0/152) 2 (3/150) 152 150 GnRHa hCG ownRCT Humaidan et al 2009 0 (0/23) 4 (1/23) 23 GnRHa hCG own Retrospective, case- controlled, high risk Engmann et al 2006 0 (0/42)42 GnRHa hCG - cancelled own Retrospective case- control, high risk Manzanares et al 2009 0 (0/254) 6 (10/175) 254 175 GnRHa hCG donorsRetrospective Hernandez et al 2009 0 (0/82) 7 (5/69) 82 69 GnRHa hCG own Retrospective, high risk Orvieto et al 2006 0 (0/32) 1 (1/42) 32 42 GnRHa hCG donors Retrospective, high risk: agonist arm only Shapiro et al 2007 0 (0/44) 7 (3/44) 44 GnRHa hCG donorsRCT Sismanoglu et al 2009 8 (1/12)12 GnRH, luteal rescue with hCG 1500IU own Observational, high risk Humaidan et al 2009 0 (0/106) 8 (9/106) 106 GnRHa hCG donorsRCT Galindo et al 2009 0 (0/50) 16(8/50) 50 GnRHa hCG donorsRCT Melo at al 2009 0 (0/45) 15 (33) 45 GnRHa hCG ownRCT, high risk Shahrokh et al 2010 16 publications Agonist: 2,005 patients, not a single case of OHSS! hCG: 92 cases in 1,810 patients, 5.1%

31. A safe and OHSS-free clinical environment

33. PREGNANCY RATE POST AGONIST TRIGGER We showed that agonist trigger causes quick and irreversible luteolysis. Therefore, the right luteal support is crucial. The evolution of post agonist luteal support.

34. The concept of “tailored” luteal phase support: Extreme response (>25 follicles >11 mm): freeze all High response (15-25 follicles): a bolus of 1,500 IU hCG on retrieval day Normal response: an alternative to hCG trigger Humaidan and plyzos F&S 2014

35. THE ADVANTAGE FOR THE ‘NORMAL RESPONDER’ Kol S, et al. Human Reprod 2011;26:2874–2877 FSH/hMG Antagonist Agonist trigger 36 hours OPU 1500 IU hCG 4 days 1500 IU hCG ET

36. Stimulation characteristics and embryology data Stimulation (days)9.3 ± 2.0 GnRH antagonist (days)3.8 ± 0.9 FSH (units)2443 ± 925 E 2 day of trigger (pmol/L)3764 ± 1227 P day of trigger (nmol/L)2.4 ± 1.65 LH day of trigger (IU/L)1.9 ± 1.3 Oocytes retrieved6.7 ± 2.5 Embryos obtained3.6 ± 1.7 Embryos transferred2.9 ± 0.9 Embryos frozen0.8 ± 1.5 Beta hCG (IU/L)152 ± 86 E 2 (day of pregnancy test, pmol/L)6607 ± 3789 P (day of pregnancy test, nmol/L)182 ± 50 Values are mean ± SD Reproductive outcomes Positive hCG/cycle, n (%)11/15 (73) Clinical ongoing pregnancy, n (%)7/15 (47) Early pregnancy loss, n (%)4/11 (36) Kol S, et al. Human Reprod 2011;26:2874–2877

37. Lin et al, 2013 Dual trigger improves: Implantation rate Clinical pregnancy rate Live birth rate

38. SPECIAL CASES Empty follicles Recurrent IVF failure

39. Beck-Fruchter at al 2012 IS FSH SURGE REDUNDANT IN ALL WOMEN???

40. SURVEY RESULTS: Triggering of ovulation with GnRH-a in ART: Worldwide feedback on an emerging new option with great potential Take home message “The results of this survey indicate that GnRH trigger is widely used worldwide and therefore has become part of the standard of care today. Hence, doctors are entitled to prescribe it just as patients may ask that this option is considered in their case.”

41. “Agonist triggering is viewed as one of the major advances in ovarian stimulation, with the potential to eliminate OHSS…”

42. OutIn “long agonist” protocolsAntagonist-based protocols hCG triggerAgonist trigger Progesterone-based luteal supportLH activity-based luteal support ~1% severe OHSSTotal OHSS elimination Painful P injections or leaky, messy vaginal P. Patient friendly luteal phase Revolution in the making Thank you