Luteal Phase Support With GnRH Agonist Alone After GnRH Agonist Triggering and Fresh Embryo Transfer Compared to the Reference Protocol (hCG Triggering and Progesterone Luteal Support): a Randomised Controlled Trial
Overview
- Phase
- Phase 3
- Intervention
- Ovulation induction with hCG + Luteal phase support with vaginal progesterone
- Conditions
- In Vitro Fertilization
- Sponsor
- Assistance Publique - Hôpitaux de Paris
- Enrollment
- 652
- Locations
- 1
- Primary Endpoint
- Live birth, defined as the presence of a live birth after 22 weeks' gestation. Twin pregnancies will be counted as a single birth.
- Status
- Recruiting
- Last Updated
- 8 months ago
Overview
Brief Summary
The development of stimulation protocols for in vitro fertilisation (IVF) has led to a paradox. It has now been established that obtaining a large number of oocytes is a key to success, but that it is also a risk factor for embryo transfer failure after puncture (disruption of endometrial receptivity due to luteal insufficiency) and a risk factor for complications such as ovarian hyperstimulation syndrome (OHSS).
Detailed Description
It is currently established that obtaining a large number of oocytes is a key of success in IVF/ICSI cycles. However, it is also a risk factor for ovarian hyperstimulation syndrome (OHSS) and a risk factor of implantation failure after fresh embryo transfer because of the alteration of endometrial receptivity. A freeze all strategy can be proposed to avoid these risks but vitrification of embryos, although more efficient than slow freezing in terms of embryo survival, is not without risk. Furthermore, proper endometrial and embryo timing for frozen-thawed embryo transfer is still debated. Recent preliminary works suggest another possible way to combine an optimal ovarian response with the recovery of a large number of oocytes, good chances of implantation and a reduced risk of OHSS. To achieve this goal, ovulation triggering and luteal phase support need to be modified together. The human chorionic gonadotropin (hCG) (mimicking the Luteinising Hormone (LH)peak to trigger ovulation) that induces OHSS is replaced by an a GnRH agonist (GnRHa) triggering allowing an endogenous peak of Follicle Stimulating Hormone (FSH) and LH. Then, the usual support of the luteal phase by exogenous vaginal progesterone, whose absorption seems to be suboptimal for about 30% of patients, is replaced by endogenous progesterone production by the corpora lutea, supported by the maintenance of LH activity through the continuation of agonist of gonadotropin releasing hormone (AgoGnRH) in the luteal phase. Pilot studies show that a 10% to 15% increase in ongoing pregnancy rates can be expected with this type of protocol. The objective of our study is to demonstrate an increase in ongoing pregnancy rate per cycle with this new strategy combining GnRHa triggering and GnRHa luteal phase support compared to the reference protocol (hCG triggering and exogenous progesterone luteal phase support).
Investigators
Eligibility Criteria
Inclusion Criteria
- •Patients requiring conventional IVF or IVF with sperm injection (ICSI) from the partner or donor under the conditions of management defined by French law.
- •Patients aged 18 to 39 included
- •First or second attempt at IVF or ICSI for pregnancy
- •BMI \< 35 kg/m2
- •Anti-Mullerian hormone (AMH) \> 1 ng/ml (= 7 pmol/L) and/or antral follicle count ≥ 8 within the year prior to inclusion
- •AMH \< 5 ng/ml and/or antral follicle count \<40 within the year prior to inclusion
- •Treatment with recombinant FSH
- •Antagonist protocol (with pre-treatment or not)
- •Initial dose of recombinant FSH between 75 and 450 IU
- •Signed informed consent
Exclusion Criteria
- •Patient diagnosed with HIV infection
- •ICSI with sperm from testicular biopsy
- •Pre-implantation diagnosis
- •Hypogonadotropic hypogonadism (amenorrhea or spaniomenorrhea with basal LH \<1.2 IU/L)
- •History of severe ovarian hyperstimulation syndrome (OHSS)
- •Unoperated hydrosalpinx
- •Intracavitary polyps or myomas deforming the cavity
- •Known hypersensitivity to the investigational drugs and/or their excipients (human chorionic gonadotropin, progesterone, nafarelin acetate, GnRH, GnRH analogues, mannitol, sodium chloride, water for injection, glacial acetic acid, Sodium hydroxide and/or hydrochloric acid, sorbitol, purified water, benzalkonium chloride, sunflower oil, soybean lecithin, gelatin, glycerol, titanium dioxide (E171), methionine, poloxamer 18, phosphoric acid).
- •Gynaecological bleeding or genital haemorrhage
- •History of epilepsy and/or intracranial tumors potentially causing epilepsy
Arms & Interventions
Ovulation triggering with hCG + Luteal phase support with vaginal progesterone
hCG 250µg subcutaneously between 36h and 38h before oocyte retrieval + Progesterone 600mg/d (200mg tid) vaginally from the evening of the oocyte retrieval until the first pregnancy test
Intervention: Ovulation induction with hCG + Luteal phase support with vaginal progesterone
Ovulation triggering with Triptorelin + Luteal phase support with Nafarelin
Triptorelin 0.2 mg subcutaneously between 36h and 38h before oocyte retrieval as a single dose Nafarelin 400µg /day (200µg in the morning 200µg in the evening) nasally from the evening of the oocyte retrieval until the first pregnancy test
Intervention: Ovulation triggering by Triptorelin + Luteal phase support by Nafarelin
Outcomes
Primary Outcomes
Live birth, defined as the presence of a live birth after 22 weeks' gestation. Twin pregnancies will be counted as a single birth.
Time Frame: 22 weeks' gestation
To demonstrate an increase in the rate of live births after 22 weeks' amenorrhoea (SA) per cycle with induction and support by GnRH agonist compared with the reference protocol combining induction by hCG and luteal support by exogenous vaginal progesterone
Secondary Outcomes
- Number of patients with medical termination of pregnancy(between 12 weeks of gestation and 22 weeks of gestation)
- Pregnancy defined as an hCG level > 10 IU/ml 14 days after oocyte retrieval.(14 days after oocyte retrieval.)
- Estradiol levels during follow-up, presence of pregnancy and presence of miscarriage.(19 months)
- Embryo implantation defined as the presence of a gestational sac on the first ultrasound (5-8 WG)(5-8 weeks' gestation)
- Clinical pregnancy, defined as an intrauterine gestational sac with embryo showing cardiac activity on ultrasound at 5-10 WG(5-10 weeks' gestation)
- Number of patients with pre-eclampsia and its onset,(between 12 weeks of gestation and 22 weeks of gestation)
- Number of patients with gravidic hypertension and its onset,(between 12 weeks of gestation and 22 weeks of gestation)
- Number of patients with gestational diabetes and its onset(between 12 weeks of gestation and 22 weeks of gestation)
- Number of patients with late miscarriage (between 12 and 22 WG)(between 12 weeks of gestation and 22 weeks of gestation)
- Ovarian hyperstimulation syndrome, defined as the presence of moderate to severe syndrome, early and late. Early defined as the period before D10 post retrieval and late defined as pregnancy related OHSS, after D10 post oocyte retrieval(before Day 10 post retrieval and after Day 10 post oocyte retrieval)
- hCG levels during follow-up, presence of pregnancy and presence of miscarriage.(19 months)
- number of mature oocytes(oocyte puncture visit)
- Miscarriage prior to 12 WG, defined as the termination of a pregnancy prior to 12 WG.(12 weeks' gestation)
- Ongoing pregnancy, defined as the presence of an intra-uterine sac with an embryo with cardiac activity visible on ultrasound between 11 weeks of gestations(WG) and 13 WG+6 days (first trimester ultrasound).(first trimester ultrasound (11 weeks of gestation and 13weeks of gestation +6days))
- Number of patients with term and mode of delivery(between 12 weeks of gestation and 22 weeks of gestation)
- Number of patients with fetal death in utero(between 12 weeks of gestation and 22 weeks of gestation)
- Progesterone levels on day of oocyte pick up and at Day 7 post oocyte pick up.(Day 7 post oocyte pick up)
- Estradiol levels on day of oocyte pick up and at Day 7 post oocyte pick up.(Day 7 post oocyte pick up)
- LH levels on day of oocyte pick up and at Day 7 post oocyte pick up.(Day 7 post oocyte pick up)
- hCG levels on day of oocyte pick up and at Day 7 post oocyte pick up.(Day 7 post oocyte pick up)
- All adverse events up to delivery(19 months)
- number of oocytes fertilised,(5th day post oocyte puncture visit)
- number of blastocysts transferred,(5th day post oocyte puncture visit)
- number of blastocysts frozen.(5th day post oocyte puncture visit)
- Progesterone levels during follow-up, presence of pregnancy and presence of miscarriage.(19 months)
- LH levels during follow-up, presence of pregnancy and presence of miscarriage.(19 months)
- Number of oocytes collected,(oocyte puncture visit)
- number of embryos on the second day of development,(5th day post oocyte puncture visit)
- number of blastocysts obtained,(5th day post oocyte puncture visit)