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Middle East Fertility Society Journal
Middle East Fertility Society
ISSN: 1110-5690
Vol. 12, Num. 3, 2007, pp. 166-167
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Untitled Document
Middle East Fertility Society Journal, Vol. 12, No. 3, 2007, pp. 166-167
DEBATE
Luteal phase support in assisted reproduction
Code Number: mf07031
Comment by: Heshan Al Insany, M.D.
Luteal phase supplementation or support is a common practice in IVF treatment.
It significantly improves the embryo implantation rate, pregnancy and delivery
rates as ovarian superstimulation during IVF is commonly associated with luteal
phase deficiency. The aspiration of the granulosa cells that surround the oocyte
and the use of gonadotropin releasing hormone agonists (GnRHa) during assisted
reproduction technology (ART) treatment can interfere with the production,
during the luteal phase, of progesterone, which is necessary for successful
implantation of the embryo (1).
The second mechanism of luteal phase deficiency is caused by gonadotropin
releasing hormone agonist (GnRH-a) used in the ovarian stimulation regimen
to prevent premature LH surge. This results in persistent block of the LH output
for at least ten days after discontinuing GnRH-a, which can result in impairment
of progesterone secretion by the corpus luteum (2). This increases estrogen/
progesterone ratio, which is associated with an inhibitory effect on embryo
implantation.
In an attempt to enhance the probability of pregnancy, different doses, durations
and types of treatments for LPS have been evaluated. There is, however, no
agreement regarding the optimal supplementation scheme (3). Some authors suggested
IM progesterone-in-oil as the best method of luteal phase support (4). Others
suggested vaginal progesterone (5) while some claimed that both hCG and intra-vaginal
progesterone are equally effective (6).
GnRH agonist was recently suggested as a novel luteal phase support. The mechanism
of the presumed beneficial effect of luteal-phase GnRH agonist administration
is not clear and may be due to the drug action at multiple levels. It was hypothesized
that GnRH agonist may support the corpus luteum by stimulating the secretion
of LH by pituitary gonadotrophin cells or by acting directly on the endometrium
through the locally expressed GnRH receptors (7). Tesarik et al. (2004) evaluated
138 women who were assigned to receive a single injection of 0.1 triptorelin
6 days after ICSI treatment or to receive placebo. In their series, they reported
a significantly higher implantation and pregnancy rates in the GnRH agonist
treated group compared with the placebo (8). Moreover, Pirard et al. (2005)
investigating whether the intranasal administration of 100 µg of buserelin
to 23 patients who underwent IVF treatment, found that E2 and P concentrations
were sustained and the implantation and pregnancy rates were significantly
improved with increased doses and frequency of GnRH-a administration. These
findings may suggest a direct effect of GnRH agonist on the embryo (7). In
a prospective randomized study, Tesarik et al. evaluated the effect of GnRH
agonist (0.1 mg triptorelin) administration in the luteal phase on outcomes
in both GnRH agonist (n = 300) and GnRH antagonist (n = 300) ovarian stimulation
protocols (9). They were randomly assigned to receive a single injection of
GnRH agonist (study group) or placebo (control group) 6 days after ICSI. The
PR were enhanced for both protocols, in long GnRH agonist protocol the clinical
implantation rate were 29.8 versus 18.2% respectively (P < 0.05). Ongoing
PR were 46.8 versus 38.0% respectively (P = NS). In patients treated with the
GnRH antagonist protocol, clinical implantation rates were 27.1 versus 17.4%
respectively (P < 0.05) and ongoing PR were 44.8 versus 31.9% respectively
(P < 0.05).
Luteal-phase GnRH agonist administration additionally increased the luteal-phase
serum hCG, E2 and progesterone concentrations in both ovarian stimulation regimens.
It was postulated that the beneficial effect may have resulted from a combination
of effects on the embryo and on the corpus luteum (9).
Despite these encouraging results, this way of supplementation was not widely
adopted as great concern exists about possible adverse effects on oocytes and,
more importantly, on embryos (10). However, the incidence of miscarriage and
the long term follow-up of children born after inadvertent administration of
GnRH-a in early pregnancy do not appear to be altered (11, 12). In order to
establish a potential positive role of GnRH agonist administration in the luteal
phase of stimulated IVF cycles, further large prospective trials are needed.
REFERENCES
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