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The freeze-all strategy versus agonist triggering with low-dose hCG for luteal phase support in IVF/ICSI for high responders: a randomized controlled trial.
Hum Reprod. 2020 12 01; 35(12):2808-2818.HR

Abstract

STUDY QUESTION

Does the freeze-all strategy in high-responders increase pregnancy rates and improve safety outcomes when compared with GnRH agonist triggering followed by low-dose hCG intensified luteal support with a fresh embryo transfer?

SUMMARY ANSWER

Pregnancy rates after either fresh embryo transfer with intensified luteal phase support using low-dose hCG or the freeze-all strategy did not vary significantly; however, moderate-to-severe ovarian hyperstimulation syndrome (OHSS) occurred more frequently in the women who attempted a fresh embryo transfer.

WHAT IS KNOWN ALREADY

Two strategies following GnRH agonist triggering (the freeze-all approach and a fresh embryo transfer attempt using a low-dose of hCG for intensified luteal phase support) are safer alternatives when compared with conventional hCG triggering with similar pregnancy outcomes. However, these two strategies have never been compared head-to-head in an unrestricted predicted hyper-responder population.

STUDY DESIGN, SIZE, DURATION

This study included women with an excessive response to ovarian stimulation (≥18 follicles measuring ≥11 mm) undergoing IVF/ICSI in a GnRH antagonist suppressed cycle between 2014 and 2017. Our primary outcome was clinical pregnancy at 7 weeks after the first embryo transfer. Secondary outcomes included live birth and the development of moderate-to-severe OHSS.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Following GnRH agonist triggering, women were randomized either to cryopreserve all good-quality embryos followed by a frozen embryo transfer in an subsequent artificial cycle or to perform a fresh embryo transfer with intensified luteal phase support (1500 IU hCG on the day of oocyte retrieval, plus oral estradiol 2 mg two times a day, plus 200 mg of micronized vaginal progesterone three times a day).

MAIN RESULTS AND THE ROLE OF CHANCE

A total of 212 patients (106 in each arm) were recruited in the study, with three patients (one in the fresh embryo transfer group and two in the freeze-all group) later withdrawing their consent to participate in the study. One patient in the freeze-all group became pregnant naturally (clinical pregnancy diagnosed 38 days after randomization) prior to the first frozen embryo transfer. The study arms did not vary significantly in terms of the number of oocytes retrieved and embryos produced/transferred. The intention to treat clinical pregnancy and live birth rates (with the latter excluding four cases lost to follow-up: one in the fresh transfer and three in the freeze-all arms, respectively) after the first embryo transfer did not vary significantly among the fresh embryo transfer and freeze-all study arms: 51/105 (48.6%) versus 57/104 (54.8%) and 41/104 (39.4%) versus 42/101 (41.6%), respectively (relative risk for clinical pregnancy 1.13, 95% CI 0.87-1.47; P = 0.41). However, moderate-to-severe OHSS occurred solely in the group that received low-dose hCG (9/105, 8.6%, 95% CI 3.2% to 13.9% vs 0/104, 95% CI 0 to 3.7, P < 0.01).

LIMITATIONS, REASONS FOR CAUTION

The sample size calculation was based on a 19% absolute difference in terms of clinical pregnancy rates, therefore smaller differences, as observed in the trial, cannot be reliably excluded as non-significant.

WIDER IMPLICATIONS OF THE FINDINGS

This study offers the first comparative analysis of two common strategies applied to women performing IVF/ICSI with a high risk to develop OHSS. While pregnancy rates did not vary significantly, a fresh embryo transfer with intensified luteal phase support may still not avoid the risk of moderate-to-severe OHSS and serious consideration should be made before recommending it as a routine first-line treatment. Future trials may allow us to confirm these findings.

STUDY FUNDING/COMPETING INTEREST(S)

The authors have no conflicts of interest to disclose. No external funding was obtained for this study.

TRIAL REGISTRATION NUMBER

ClinicalTrials.gov identifier NCT02148393.

TRIAL REGISTRATION DATE

28 May 2014.

DATE OF FIRST PATIENT’S ENROLMENT

30 May 2014.

Authors+Show Affiliations

IVIRMA Lisboa, Avenida Infante Dom Henrique 333 H 1-9, Lisbon, Portugal. Department of Obstetrics and Gynecology, Faculty of Medicine, University of Lisbon, Lisboa, Portugal. Center for Reproductive Medicine, Universitair Ziekenhuis Brussel, Brussels, Belgium.Center for Reproductive Medicine, Universitair Ziekenhuis Brussel, Brussels, Belgium.Center for Reproductive Medicine, Universitair Ziekenhuis Brussel, Brussels, Belgium.Center for Reproductive Medicine, Universitair Ziekenhuis Brussel, Brussels, Belgium.Department of Obstetrics, Gynecology and Reproductive Medicine, Dexeus University Hospital, Barcelona, Spain. Department of Surgical and Clinical Science, Faculty of Medicine and Pharmacy, Vrije Universiteit Brussel, Brussels, Belgium. Department of Clinical Medicine, Faculty of Health, Aarhus University, Aarhus, Denmark.Center for Reproductive Medicine, Universitair Ziekenhuis Brussel, Brussels, Belgium.Center for Reproductive Medicine, Universitair Ziekenhuis Brussel, Brussels, Belgium. Department of Surgical and Clinical Science, Faculty of Medicine and Pharmacy, Vrije Universiteit Brussel, Brussels, Belgium.Center for Reproductive Medicine, Universitair Ziekenhuis Brussel, Brussels, Belgium.Center for Reproductive Medicine, Universitair Ziekenhuis Brussel, Brussels, Belgium.Center for Reproductive Medicine, Universitair Ziekenhuis Brussel, Brussels, Belgium. Department of Obstetrics and Gynaecology, School of Medicine, University of Zagreb, Zagreb, Croatia.

Pub Type(s)

Journal Article
Randomized Controlled Trial

Language

eng

PubMed ID

32964939

Citation

Santos-Ribeiro, Samuel, et al. "The Freeze-all Strategy Versus Agonist Triggering With Low-dose hCG for Luteal Phase Support in IVF/ICSI for High Responders: a Randomized Controlled Trial." Human Reproduction (Oxford, England), vol. 35, no. 12, 2020, pp. 2808-2818.
Santos-Ribeiro S, Mackens S, Popovic-Todorovic B, et al. The freeze-all strategy versus agonist triggering with low-dose hCG for luteal phase support in IVF/ICSI for high responders: a randomized controlled trial. Hum Reprod. 2020;35(12):2808-2818.
Santos-Ribeiro, S., Mackens, S., Popovic-Todorovic, B., Racca, A., Polyzos, N. P., Van Landuyt, L., Drakopoulos, P., de Vos, M., Tournaye, H., & Blockeel, C. (2020). The freeze-all strategy versus agonist triggering with low-dose hCG for luteal phase support in IVF/ICSI for high responders: a randomized controlled trial. Human Reproduction (Oxford, England), 35(12), 2808-2818. https://doi.org/10.1093/humrep/deaa226
Santos-Ribeiro S, et al. The Freeze-all Strategy Versus Agonist Triggering With Low-dose hCG for Luteal Phase Support in IVF/ICSI for High Responders: a Randomized Controlled Trial. Hum Reprod. 2020 12 1;35(12):2808-2818. PubMed PMID: 32964939.
* Article titles in AMA citation format should be in sentence-case
TY - JOUR T1 - The freeze-all strategy versus agonist triggering with low-dose hCG for luteal phase support in IVF/ICSI for high responders: a randomized controlled trial. AU - Santos-Ribeiro,Samuel, AU - Mackens,Shari, AU - Popovic-Todorovic,Biljana, AU - Racca,Annalisa, AU - Polyzos,Nikolaos P, AU - Van Landuyt,Lisbet, AU - Drakopoulos,Panagiotis, AU - de Vos,Michel, AU - Tournaye,Herman, AU - Blockeel,Christophe, PY - 2020/01/16/received PY - 2020/07/19/revised PY - 2020/9/24/pubmed PY - 2021/5/5/medline PY - 2020/9/23/entrez KW - ARTs KW - embryo transfer KW - freeze-all strategy KW - luteal phase support KW - ovarian hyperstimulation syndrome KW - ovarian stimulation KW - polycystic ovary syndrome SP - 2808 EP - 2818 JF - Human reproduction (Oxford, England) JO - Hum Reprod VL - 35 IS - 12 N2 - STUDY QUESTION: Does the freeze-all strategy in high-responders increase pregnancy rates and improve safety outcomes when compared with GnRH agonist triggering followed by low-dose hCG intensified luteal support with a fresh embryo transfer? SUMMARY ANSWER: Pregnancy rates after either fresh embryo transfer with intensified luteal phase support using low-dose hCG or the freeze-all strategy did not vary significantly; however, moderate-to-severe ovarian hyperstimulation syndrome (OHSS) occurred more frequently in the women who attempted a fresh embryo transfer. WHAT IS KNOWN ALREADY: Two strategies following GnRH agonist triggering (the freeze-all approach and a fresh embryo transfer attempt using a low-dose of hCG for intensified luteal phase support) are safer alternatives when compared with conventional hCG triggering with similar pregnancy outcomes. However, these two strategies have never been compared head-to-head in an unrestricted predicted hyper-responder population. STUDY DESIGN, SIZE, DURATION: This study included women with an excessive response to ovarian stimulation (≥18 follicles measuring ≥11 mm) undergoing IVF/ICSI in a GnRH antagonist suppressed cycle between 2014 and 2017. Our primary outcome was clinical pregnancy at 7 weeks after the first embryo transfer. Secondary outcomes included live birth and the development of moderate-to-severe OHSS. PARTICIPANTS/MATERIALS, SETTING, METHODS: Following GnRH agonist triggering, women were randomized either to cryopreserve all good-quality embryos followed by a frozen embryo transfer in an subsequent artificial cycle or to perform a fresh embryo transfer with intensified luteal phase support (1500 IU hCG on the day of oocyte retrieval, plus oral estradiol 2 mg two times a day, plus 200 mg of micronized vaginal progesterone three times a day). MAIN RESULTS AND THE ROLE OF CHANCE: A total of 212 patients (106 in each arm) were recruited in the study, with three patients (one in the fresh embryo transfer group and two in the freeze-all group) later withdrawing their consent to participate in the study. One patient in the freeze-all group became pregnant naturally (clinical pregnancy diagnosed 38 days after randomization) prior to the first frozen embryo transfer. The study arms did not vary significantly in terms of the number of oocytes retrieved and embryos produced/transferred. The intention to treat clinical pregnancy and live birth rates (with the latter excluding four cases lost to follow-up: one in the fresh transfer and three in the freeze-all arms, respectively) after the first embryo transfer did not vary significantly among the fresh embryo transfer and freeze-all study arms: 51/105 (48.6%) versus 57/104 (54.8%) and 41/104 (39.4%) versus 42/101 (41.6%), respectively (relative risk for clinical pregnancy 1.13, 95% CI 0.87-1.47; P = 0.41). However, moderate-to-severe OHSS occurred solely in the group that received low-dose hCG (9/105, 8.6%, 95% CI 3.2% to 13.9% vs 0/104, 95% CI 0 to 3.7, P < 0.01). LIMITATIONS, REASONS FOR CAUTION: The sample size calculation was based on a 19% absolute difference in terms of clinical pregnancy rates, therefore smaller differences, as observed in the trial, cannot be reliably excluded as non-significant. WIDER IMPLICATIONS OF THE FINDINGS: This study offers the first comparative analysis of two common strategies applied to women performing IVF/ICSI with a high risk to develop OHSS. While pregnancy rates did not vary significantly, a fresh embryo transfer with intensified luteal phase support may still not avoid the risk of moderate-to-severe OHSS and serious consideration should be made before recommending it as a routine first-line treatment. Future trials may allow us to confirm these findings. STUDY FUNDING/COMPETING INTEREST(S): The authors have no conflicts of interest to disclose. No external funding was obtained for this study. TRIAL REGISTRATION NUMBER: ClinicalTrials.gov identifier NCT02148393. TRIAL REGISTRATION DATE: 28 May 2014. DATE OF FIRST PATIENT’S ENROLMENT: 30 May 2014. SN - 1460-2350 UR - https://www.unboundmedicine.com/medline/citation/32964939/The_freeze_all_strategy_versus_agonist_triggering_with_low_dose_hCG_for_luteal_phase_support_in_IVF/ICSI_for_high_responders:_a_randomized_controlled_trial_ DB - PRIME DP - Unbound Medicine ER -