CNY updated IVF strategy /Use of Antagonist with Lupron trigger

CNY updated IVF strategy /Use of Antagonist with Lupron trigger

By Edward Ditkoff MD

The use of the agonist (Lupron) has become commonplace during IVF stimulation since the 80’s.   The antagonists (Ganirelix [FDA approved 1999] and Cetrotide [FDA approved 2000]) have since become increasingly popular during IVF stimulations too.  Antagonists are as effective as agonists, but require less time and are easier to use.  The agonist is generally given 2 to 3 weeks until LH and FSH hormones become suppressed prior to initiating the IVF stimulation, and occasionally causes ovarian cysts due to its initial flare effect from the increased production of LH and FSH.   The antagonist directly inhibits LH and FSH production, has no flare effect, shortens the IVF process, therefore requiring less medication and injections.  Although both Lupron (agonist) and Cetrotide/Ganirelix (antagonists) are helpful during IVF by preventing the LH surge and premature release of eggs prior to retrieval, use of the antagonist shortens the cycle and is easier to use.
 
hCG has become commonplace since the early 80’s in the treatment for triggering egg maturation prior to egg retrieval.   During the early 90’s, it was determined Lupron may also trigger egg maturation while minimizing or eliminating the side effects of hyperstimulation (OHSS).   The use of Lupron to trigger egg maturation over the past 4-5 years has gained popularity when given in a single higher dose  (4mg) with aggressive supplementation of estrogen and progesterone following the egg retrieval.   Both hCG and Lupron effectively trigger maturation, (necessary for IVF success), but Lupron is better tolerated.
 
Although both hcg and Lupron trigger egg maturation prior to egg retrieval, Lupron can only be effective if the antagonist is used earlier during the IVF stimulation.  Lupron will not trigger egg maturation if used earlier since it would prevent the artificially timed production of a LH surge, which is required for the eggs to mature.  Hence, Lupron can effectively trigger maturation only if the antagonist is used earlier during the IVF stimulation.
 
The antagonist offers other benefits compared to the agonist during IVF stimulation too.  Besides enabling Lupron (agonist) to effectively trigger egg maturation, the antagonist is beneficial for low and high responding patients.   The agonist may decrease one’s response in low responders when used prior to IVF stimulation.  If used initially as a flare to increase one’s response, a premature rise in LH and/or progesterone may occur and release eggs prematurely.    Antagonists are also beneficial in high responding patients by lowering the risk for OHSS by suppressing LH more so then the agonist.
 
In summary, as IVF treatments continue to improve, so do our protocols.  Antagonist use during the IVF stimulation is becoming increasingly more popular while use of the agonist (Lupron trigger) is gaining popularity for maturing eggs and minimizing side effects from the stimulation.   The end result is improved tolerance and better outcomes for our patients undergoing IVF.