Pituitary down-regulation using leuprolide for the intensive ovulation management of poor prognosis patients having in vitro fertilization (IVF)-related treatments

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Abstract
A review of 118 treatment cycles in 115 women under prolonged GnRH analogue (GnRHa; leuprolide) treatment is presented. Patients were selected for treatment primarily on the grounds of poor previous response to stimulation (n=40). advanced age (>35 years; n=29), previous premature luteinizing hormone (LH) surge (n=30), polycystic ovarian disease (PCO; n=12), and elevaved androgens without evidence of PCO (n=5). An overall pregnancy rate of 28.8% per treatment cycle was attained, compared with a pregnancy rate of 6.2% (6/97, of which none went to term) in the previous completed treatment cycle for the same patients. Ovarian response, as measured by oocytes recovered and maximum estradiol levels observed, was significantly improved in all groups and this was associated with a prolonged follicular phase, significantly more human menopausal gonadotropin (hMG) stimulation and a relatively high incidence of ovarian hyperstimulation, particularly in pregnant patients Of specific techniques in the GnRHa cycle, GIFT produced a pregnancy rate per treatment of 50% (10/20); IVF-ET, 22% (8/36); PROST, 28% (13/46); and TEST 19% (3/16). No cyles were abandoned, compared with a cancellation rate of 24% in previous cycles without GnRHa. Patients with PCO performed paricularly well on GnRHa management, with a pregnancy rate per treatment of 58% (7/12). Pregnancy rates per treatment for the other groups were as follows: elevated age, 27% (9/33), high androgen, 40% (2/5); premature LH surges, 32% (9/28); and poor responders, 17.5% (7/40). A comparison using patients undertaking IVF-ET cycles in 1987 and 1988 shows that the use of GnRHa treatment in the poorprognosis groups lifts their performance into line with that seen in the “good”-prognosis groups. We conclude that pituitary down-regulation with GnRHa (long regimen) offers significant advantages for ovarian management in most groups of infertility patients and it is now being evaluated for routine use in the majority of cases in our practice.