hCG vs. GnRH-agonist for final maturation of the oocyte

Ovarian Club

Paris 9.11.2019

Robert FischerFertility Center Hamburg

Robert.fischer@amedes-group.com

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PP Vorlage.potx

I receive honoraria for lectures from the MERCK Company

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Physiology

Number of Oocytes

Quality of Oocytes

OHSS

Luteal Phase

Pregnancy rate

Empty Follicles

Dyn, dynorphin;ER, estrogen receptor; ME, median eminence;POA, preoptic area;PR, progesterone receptor. Skorupskaite K, at al. Hum Reprod Update. 2014;20:485-500.

Neuroendocrine control of final follicular maturation

POA/

infundibular

nucleus

Sex steroids

Gonads

GnRH

LH/FSH

ME

Pituitary

KiSS1

KiSS1

KiSS1

KiSS1

+

+

+

+

DynNKB

+− ER

PR

GnRH neurone

Kisspeptin

neurone

POA Infundibular nucleus

KND

neurone

ER PR

(sex steroid receptor)

NKB3R

(neurokinin B receptor)

Kiss1r/KiSS1R

(kisspeptin receptor)

KOR

(koppa opioid receptor)

+

−

hCG

• FSH, follicle-stimulating hormone; GnRH, gonadotropin-releasing hormone; hCG, human chorionic

• gonadotropin; IVF, in vitro fertilization; KND, kisspeptin/neurokinin B/dynorphin; LH, luteinizing hormone.

• Fritz MA, Speroff, L. Clinical gynecologic endocrinology and infertility. 8th ed. Philadelphia: Lipincott Williams & Wilkins; 2011.

• Kasum M, et al. Gynecol Endocrinol. 2017;33:583-7.

Final oocyte maturationSerum hormone levels from a natural cycle

LH surge

• Resumption of oocyte meiosis

• Follicular rupture and oocyte expulsion

• Luteinization

2 4 6 8 10 12 14 16 18 4 6 8 10 12 14

Time (days)

Ovulation

20

Time (weeks)

Implantation

FSH

LH

Progesterone

hCG

KND neurons

Neurokinin B

Neurokinin B

Kisspeptin

+

Dynorphin A

GnRHneurons

GnRH

pulse

GnRH

pulse

Neurokinin B

Role of FSH surge • Promotes formation of LH receptors

• Nuclear maturation

• Cumulus expansion

• Stimulates plasminogen activator leading to dissociation of the oocyte from the follicular wall

• Keeps the gap junctions open between the oocyte and cumulus cells

Eppig JJ. Nature 1979;281:483–484Strickland and Beers. J Biol Chem 1976;251:5694–5702Yding Andersen C. Reprod Biomed Online 2002;5:232–239Yding Andersen C, et al. Mol Hum Reprod 1999;5:726–731Zelinski-Wooten MB, et al. Human Reprod 1995;10:1658–1666

7

Adding 450 IU FSH to hCG resulted in:

More oocytes

More normal fertilizations

Lamb et al F&S, 2011

Normal responders

• hCG trigger standard dosage: 6,500 IU rhCG

• Dual trigger: 0.2 mg triptorelin and 6,500 IU rhCG

• Lin MH, et al. Fertil Steril. 2013;100:1296-302.

Dual trigger with GnRH agonist and hCG improves LBR for normal responders

VariableControl

(hCG)

hCG +

triptorelin

p

value

Implantation rate, % 18.43 29.68 < 0.001

Clinical pregnancy rate per ET, % 40.11 50.79 0.047

Abortion rate, % 18.67 16.49 NS

LBR per ET, % 30.49 41.36 0.042

Blastocyst progression rate, % 55.6 52.9 NS

OHSS rate, % 0.005 0 NS

Outcomes of IVF/ICSI cycles

VariableControl

(hCG)

hCG +

triptorelin

p

value

Total dose of gonadotropins, IU 4,062 3,851 NS

Duration of stimulation, days 10.3 9.6 NS

E2 on trigger day, pg/mL 2,139 2,083 NS

Progesterone on trigger day, ng/mL 1.84 2.09 NS

Duration of GnRH-antagonist treatment, d 3.5 3.4 NS

Endometrial thickness on trigger day, mm 9.8 10.1 NS

Oocytes retrieved, n 10.10 12.36 < 0.01

MII oocytes retrieved, n 8.03 10.53 < 0.01

Embryos obtained, n 5.3 5.8 NS

Top quality embryos obtained, n 2.9 2.9 NS

Embryos transferred, n 2.84 2.79 NS

Embryos cryopreserved, n 1.60 1.97 < 0.01

Characteristics of ovarian stimulation

• *p < 0.05.• Haas J, et al. Fertil Steril. 2016;106:653-59.

hCG versus double trigger for final oocyte maturation in granulosa cells

hCG hCG + GnRH

agonist

0

0.5

1.0

1.5

2.0

FS

HR

/-a

ctin

mR

NA

hCG hCG + GnRH

agonist

0

0.5

1.0

1.5

LH

R/

-act

in

mR

NA

hCG hCG + GnRH

agonist

Am

ph

ireg

ulin

/-a

ctin

mR

NA

0

1

2

3*

hCG hCG + GnRH

agonist

0

1

2

3

4

5

Ep

ireg

ulin

/-a

ctin

mR

NA

*

FSHR LHR

Amphiregulin Epiregulin

• hCG induces luteinization of the granulosa cells, final oocyte maturation, and resumption of meiosis

• Final follicular maturation is usually triggered by one bolus of hCG (5,000–10,000 units)

– This is administered as close as possible to the time of ovulation (i.e. 36 hours before oocyte recovery)

• Orvieto R. J Ovarian Res. 2015;8:60.

hCG is a surrogate of the naturally occurring LH surge

Does the routine trigger meet our needs?

hCG AS TRIGGER

11

The default, “gold standard”, trigger agent

Works fine for most patients

Usually followed by vaginal progesterone for luteal support

Is this the best we can have?

10,000 IU hCG

Natural mid-cycle LH surge

GnRHa trigger-induced LH

surge

12

What are the problems with hCG as trigger?

Deviations from physiology:

No FSH surge

Long half life

Early luteal over-stimulation

13

LH

cAMP (protein kinase A)

EGF-like (AR, β-cellulin, epiregulin)

Ras

ERK 1/2

FSH action Ovulation

Oocyte

maturation

COC

expansion

Follicle

rupture

Luteinization

PGE2/EP2

LH hCG

AR, amphiregulin;cAMP, cyclic AMP;COC, cumulus cell-oocyte complex; EBP, enhancer binding protein;EGF, epidermal growth factor; EP, epiregulin;PgE2, prostaglandin E2. Fan HY, et al. Science. 2009;324:938-41.

LH versus hCG signalling

C/EBPβ and

other factors

• Choi J and Smitz J. Mol Cell Endocrinol. 2014;383:203-13.

LH and hCG action on the same receptor: differences in intracellular signaling

16

Induction of Ovulation with GnRH

16

GnRH agonist for triggering of final oocyte maturationand ovulation

• Of interest in the late eighties/early nineties

( Hoff et al., 1983; Gonen et al., 1990; Itskovitz et al.,1988;1991)

• Not applicable in cycles down-regulated with GnRHa

• Renewed interest with the introduction of GnRH antagonist protocols

1st Interest Group Meeting on GnRHa triggering of

final oocyte maturation, Copenhagen, December 2009

Fertil &Steril

June 2014

ET, embryo transfer; w, week(s). Fauser BC, et al. J Clin Endocrinol Metab. 2002;87:709-15.

LH, FSH, estradiol, and progesterone levels following triggering of final oocyte maturation

0

400

800

1,200

1,600

2,000

E2 (pg/mL)

hCG

Triptorelin

Leuprorelin

0 4 8 12 24 OPU ET ET + 1w ET + 2w

Time (hours)

0

20

40

60

0 4 8 12 24 OPU ET ET + 1w ET + 2w

P (ng/mL)

Time (hours)

0

5

10

15

20

25

FSH (IU/L)

0 4 8 12 24 OPU ET ET + 1w ET + 2w

Time (hours)

120

80

40

0

200

300

100

hCG (IU/L)LH (IU/L)

LH hCG

LH triptorelin

LH leuprorelin

hCG

0 4 8 12 24 OPU ET ET + 1w ET + 2w

Time (hours)

hCG

Triptorelin

Leuprorelin

hCG

Triptorelin

Leuprorelin

Benefits of GnRH-a vs. hCG triggering

More MII oocytes Humaidan etal. Hum Rep. 2005

Higher fertilisation rate Oktay et al. RBM online 2010

Higher nuclear maturity Maman et al.Fertil Steril 2012

Higher LHR expression in Cumulus cells Borgbo et al.Fertil Steril 2013

-Different clusters according to ovarian reserve and type of triggering-VEGF lower after GnRH triggering

• 1. Fauser BC, et al. J Clin Endocrinol Metab. 2002;87:709-15.• 2. Kolibianakis EM, et al. Hum Reprod. 2005;20:2887-92. 3. Humaidan P, et al. Hum Reprod.

2005;20:1213-20. 4. Acevedo B, et al. Fertil Steril. 2006;86:1682-7. 5. Erb TM, et al. Fertil Steril. 2010;93:374-8.

GnRH agonist vs hCG

Studies Oocytes, n MII, nMII/

oocytes, n

Top quality

embryo, n

Fauser et al, 20021 = = =

Kolibianakis et al, 20052 = = =

Humaidan et al, 20053 = >

Acevedo et al, 20064 = = = =

Erb et al, 20105 > > >When effects are observed across studies, they are always in the same direction – consistently improved

366 Patients in 539 IVF cycles triggered with GnRHa or hCG

Oocyte number as a predictor forovarian hyperstimulation syndromeand live birth: an analysis of 256,381in vitro fertilization cycles

Ryan G. Steward, M.D.,a Lan Lan, Ph.D.,b Anish A. Shah, M.D., M.H.S.,a Jason S. Yeh, M.D.,a

Thomas M. Price, M.D.,a James M. Goldfarb, M.D.,c and Suheil J. Muasher, M.D.aFigure 2

Percentages of ovarian

hyperstimulation syndrome (OHSS)

and live birth (LB)

per retrieved oocyte numbers

per IVF cycle among

SART members

from 2008 to 2010.

1

ORIGINAL ARTICLES: ASSISTED REPRODUCTIOn Fertility and Sterility

April 2014 : Vol.101;4;967-973

OHSS risk: GnRH agonist vs hCG trigger

Youssef et al., Cochrane Database Syst Rev 2014

GnRH-a Trigger and OHSS

Humaidan et al., Hum Reprod Update. 2011.

GnRH-a Trigger and Total Freeze• Griesinger et al., 2007, , 20 HIGH Risk Patients

(≥ 20 Follicles ≥ 11mm)

- Cumulativ ongoing pregrnancy rate 37 %

• Griesinger et al., 2011, 51 High Risk Patients

(≥ 20 Follicles ≥ 11mm)

- Cumulativ Pregnancy Rate 37 %

Garcia-Velasco F&S. 2012

Herrero et al.,F&S 2011

92 OHSS – Risk Patients(>20Foll. E2>4000pg/ml)

- 50% Pregnancy Rate und 32% Implantation Rate

GnRH antagonist cycle and GnRH agonist trigger to almost eliminate the risk of OHSS

Gold Standard in Egg Donation• Acevedo et al., F&S 2006

• Shapiro et al.,F&S 2007

• Bodri et al., F&S 2009

• Galindo et al.,Gyn.Endokrin. 2009

• Hernández et al., F&S 2009

• Melo et al., RBM online 2009

• Sismanoglu et al., ARG 2009

• Erb et al. F&S 2010

The Luteal Phase

Luteal phase progesterone in natural vs hCG triggered cycle

Adapted from Jones-1996 by Fauser and Devroey-2003

Serum concentrations of LH (hCG), FSH, E2, and P ( during triggering of final stages of oocyte maturation with two GnRH agonist or hCG

Fauser B C et al. JCEM 2002;87:709-715©2002 by Endocrine Society

Filicori et al., 1984

Correlation between LH and P4 during mid-luteal phase

Filicori et al.,

J. Clin. Invest, 1984

Mid-luteal LH levels

• 6.0 IU/l in natural cycle (Tavaniotou and Devroey 2003)

• 1.5 IU/l – GnRHa trigger (Humaidan et al., 2005)

• 0.2 IU/l – HCG trigger (Humaidan et al., 2005)

Physiology in COS• Supraphysiological steroid level (estradiol and progesterone)

in early-mid luteal phase exert a negative feed-back on the hypothalamic-pituitary axis reducing LH secretion in early luteal phase.

(Tavaniotou and Devroey, 2006; Tavaniotou et al., 2001)

▪ GnRHa triggering leads to significantly reduced total amounts of gonadotropins (LH and FSH) released by the pituitary due to profile and duration of surge.(Gonen et al., 1990; Itskovitz et al., 1991)

hCG trigger: price to pay

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

Abnormal P production (peak P not with implantation)

Out-of-phase endometrium given high early luteal P

39

OPU

hCG

Day 8

Day 6.5

hCG

hCG

The luteal phase reality after hCG trigger

LH activity deficiency period

Progesterone support needed appx. 8 days

OPU

LH

Day 8

Damewood et al., 1989; Bonduelle et al., 1988; Gonen et al., 1990; Itskovitz et al., 1991

28-32 hours

GnRHa

LH activity deficiency period

hCG

Early luteal phase after GnRHa trigger

GnRH agonist fortriggering of ovulation

and Fresh E.T.First trials low clinical pregnancy rate – high early pregnancy loss(Humaidan et al., 2005; Kolibianakis et al., 2005 Griesinger et al., Fertil Steril 2007; Hum. Rep. Update 2006)

Low live birth rate after GnRHa versus hCG triggering(Griesinger et al., Fertil Steril 2007)

Low reproductive outcome attributed to a luteal phase insufficiency despite supplementation with progesterone and estradiol

Different Strategies for Lut.Phase Support(after GnRH-a Triggering)

• E2+Progesterone :(i.m.) high dose until 10 weeks pregnancy

(Engmann et al. 2008)

• HCG :Multi Low-Dose 450 I.U. (Krause et al. 2006)

Single- Dose 1500 I.U. /Double Dose (Humaidan et al.2010;2013)

Dual –Triggering (GnRHa+1000 I.U. hCG,if E2<4000pg/ml)

(Shapiro et al.,2011; Engmann et al., 2012 )

Daily Micro-Dose (125 I.U.) hCG (C.Y.Andersen et al. 2015))

Luteal Phase Coasting (Kol et al.2016;Fatemi et al.2017&2018)

• Rec LH: Multiple Dose 300 I.U. (Papanikolaou et al. 2011)

• GnRH –Agonist :Multiple Dose daily (Pirard et al. 2006,2015)

(Bar Hava et al. 2016)

A new concept of Luteal support

0

50

100

150

200

250

300

0 24 48 72 96 120 144 168 192 216 240 264 288

hC

G (

IU/L

)

Time (hours)

125 IU hCG daily

1.500 IU hCG on OPU and OPU+5

10.000 IU hCG on ovulation triggerGnRHa trigger induced mid-cycle surge of LH

OPU OPU+2 OPU+4 OPU+6 OPU+7

hCG during the luteal phase with different dosing

FISCHER´S CONCEPT

Ongoing Pregnancy:GnRH agonist vs hCG trigger

Youssef et al., Cochrane Database Syst Rev 2014

GnRH agonist vs hCG trigger„From the clinical point of view,

the luteal support used is the

variable which affects the

pregnancy rate and not the

use of GnRHa trigger for final

oocyte maturation.Therefore ,

a meaningful comparison

between GnRHa and

HCG trigger

must be confined to

outcome measures

that are not affected by

the luteal support used.“

Results June2011-Dec.2012matched group for hCG trigger and

GnRHa trigger (Cycles1-3 No PBGS for RIF or AMA)) hGG trigger (n=680) GnRH-a trigger (n=664)

CPR /ET age <34 132/245 (53,9%) * 106/168 (63,1%)* I.R. 40.1% 45.2%CPR /ET age 35-39 63/143 (43,4%) * 79/145 (54,5%)*I.R. 29.7% 36.8%CPR /ET age >=40 3/26 (11,5%) * 12/41 (29,3 %)*I.R. 16.8% 22.1% OHSS EARLY ONSET 3% * 0

*) Significant(Fischer,Unpublished Data)

•• Beck-Fruchter R, et al. Hum Reprod.

2012;27:1357-67.

Incidence of EFS

The incidence of EFS is 0.045–3.4%; genuine EFS prevalence is 0–1.1% Author (year) No. of OPU cycles

No. of EFS cycles(genuine)

EFS prevalence (%) (genuine%)

No. of patients with EFS Recurrent EFS

Ben-Shlomo et al. (1991) 1,321 26 (NM) 2 (NM) 26 1/21

Harrison, Fawzy (1996) 1,418 1 (NM) 0.07 (NM) 1Ndukwe et al. (1996) 716 6 (0) 0.8 (0) 6Fiszbain et al. (1997) 376 9 (0) 2.4 (0) 9

Awonuga et al. (1998) 2,059 11 (3) 0.92 (0.58) 11 0/5Driscoll et al. (1998) 4,236 43 (NM) 1.01 (NM) 42

Quintans et al. (1998) 1,118 5 (0) 0.44 5Zreik et al. (2000) 3,004 57 (NM) 1.89 37 55/200

Aktas et al. (2005) 3,060 25 (14) 0.81 (0.45) 25 0/12Coskun et al. (2010) 5,238 NM (58) NM (1.1) 26 4/13

Reichman et al. (2010) 15,729 7 (0) 0.045 (0) 7

Griesinger et al. (2006) 51 1 (NM) 2 (NM) 1

Mesen et al. (2011) 12,359 11 (2) 0.089 (0.016) 11Baum et al. (2011) 8,292 163 (NM) 2 (NM) 136 16/101Castillo et al. (2012) 3,467 118 3.4 118

• Low hCG bioavailability resulting from variation in the absorption or clearance of hCG

• Variation in the threshold for follicular response to hCG

• Variation in the time needed from hCG exposure to maturation of oocyte–cumulus complexes

• Intrinsic defects in the biological activity of hCG preparation

• High BMI-Bad absorbtion.

• Incorrect injection

Beck-Fruchter R, et al. Hum Reprod. 2012;27:1357-67.

Causes of failure to retrieve oocytes

Other suggested aetiologies

• Ovarian aging

• Dysfunctional folliculogenesis due to

increased apoptosis

• Defective granulosa cell function

• Faulty oocyte development and maturation

• Strong attachment of cumulus cell

complexes to the follicular wall

• Dysfunctional ovulation induction

Inan MS, et al. Reprod Biomed Online. 2006;13:481-91.Yariz KO, et al. Fertil Steril. 2011;96:e125-30.

A genetic cause?

Empty follicle syndrome (EFS) GnRH-a versus hCG Trigger

Retrospektive Analyse of> 3000 Zyklen from 2009/2010

• 2034 Egg Donation Cycles and GnRHa Trigger

• 1433 IVF Cycles and hCG Trigger

• EFS Incidence: 3.5 % (GnRHa) versus 3.1 % (hCG) (NS)

Castillo, J C, Garcia-Velsaco J, Humaidan P, 2012

(2012)

Double trigger

• GnRH agonist: 40 hours prior to OPU

• hCG: 34 hours prior to OPU

This trigger combines the advantages of both

• Prolongation of the time between ovulation triggering and OPU

• GnRH agonist trigger with the consequent simultaneous induction of an FSH surge

Beck-Fruchter R, et al. Hum Reprod. 2012;27:1357-67.

OPU

−40h −36h −34h

ET

High responders

Normal

responders

Abnormal oocyte

maturation

Poor responders

hCG 5,000–10,000 IU

GnRH agonist

hCG 1,500 IU

h, hours. Orvieto Journal of Ovarian Research (2015) 8:60

Triggering final follicular maturation

HCG for triggering of ovulation

HCG has been used as a surrogate for LH for decades

effectively inducing:

• Final oocyte maturation

• Ovulation

• Luteinization of theca/granulosa cells

• Corpus luteum formation

due to structural and biological similarities with LH

HCG for triggering of ovulation - drawbacks

• Due to the longer half-life of hCG it is detectable up to 6 days following a single injection of 5000 IU

• Supraphysiological steroid levels (estradiol and progesterone), leading to disrupted luteal phase

• No FSH surge

• The sustained luteotropic effect may facilitate OHSS

GnRH-a trigger:Do we get what we need?

61

Combined LH+FSH surge – yes

More Oocytes harvested-yes

Avoid negative impact of hCG on oocyte quality-yes

Avoid early luteal over stimulation - yes

Assure smooth luteal P rise to peak - yes

Assure peak P coincides with implantation window – yes

Avoid negative impact of hCG on endometrium receptivity-yes

Avoid OHSS-yes

Decrease patient burden - yes

How to use GnRHa triggerNo difference between different GnRHa types and

administration forms (Parneix et al., 1996)

Most commonly used GnRHa triggering doses:

• Buserelin 0.5mg s.c.

• Buserelin 0.2mg i.n.

• Triptorelin 0.2mg s.c.

• Leuprolide 1mg s.c.

Timing of bolus:

• Same as for hCG triggering (34-36 hours)

Which Patients can not be treated with GnRH-agonist Triggering

for Ovulation Induction?

Patients with-Hypogonadotrophic/ Hypogonadism(WHO I )

All Patients with -GnRH – Agonist (Long –Protocol)

• -

HAMBURG

Thank you for your time