Dual trigger as good as GnRHa alone trigger for mature oocyte retrieval

Dual triggering with gonadotropin-releasing hormone agonist (GnRHa) and human chorionic gonadotropin (hCG) was not superior to GnRHa alone in terms of mature oocyte retrieval for elective fertility preservation, according to a study presented at ESHRE 2024.

The researchers analysed 104 women (aged <35 years) undergoing controlled ovarian stimulation, using recombinant follicle-stimulating hormone at a dose ranging from 225–300 IU/day, for elective fertility preservation. Baseline antral follicle count was 10, and the serum anti-Müllerian hormone level was 1.3 ng/mL. For triggering, the participants were randomized to receive GnRHa (triptorelin 0.2 mg) and hCG 250 mcg (dual trigger group; n=51) or GnRHa alone (n=53). Oocyte retrieval was performed 36 hours after the trigger.

Ovarian stimulation is a vital part of in vitro fertilization (IVF) treatment and is currently used worldwide. Ovarian stimulation in IVF maximizes success, patient compliance, and cost-effectiveness while minimizing adverse outcomes. [Best Pract Res Clin Obstet Gynaecol 2023;89:102341]

In terms of ovarian stimulation outcomes, the number of mature oocytes was similar between the dual trigger and GnRHa-alone trigger groups (6.86 vs 7.87), as was the overall number of retrieved oocytes (8.71 vs 9.51). [ESHRE 2024, abstract O-074]

Real-world evidence has shown that the number of oocytes retrieved following ovarian stimulation is a strong prognostic indicator of IVF success. [Best Pract Res Clin Obstet Gynaecol 2023;89:102341]

As for the hormonal profile, on the day following the trigger, neither the dual trigger group nor the GnRHa-alone group showed any significant differences in oestradiol (2,064.60 vs 2,494.41 pg/mL), progesterone (7.78 vs 8.94 ng/mL), luteinizing hormone (56.28 vs 63.41 IU/L), and follicle-stimulating hormone (31.14 vs 31.53 IU/L) levels.

Of note, no cases of ovarian hyperstimulation syndrome or empty follicle syndrome were observed in either treatment group.

However, the researchers acknowledged that one limitation of the study was that the sample size was calculated to detect differences in the number of mature oocytes. Accordingly, results for secondary outcomes, such as the number of oocytes retrieved and hormonal profile, should be interpreted with caution.

“This is the first randomized controlled trial comparing dual trigger vs GnRHa [only] in good prognosis patients,” said Dr Valeria Donno from Dexeus University Hospital in Barcelona, Spain. “Adding hCG to GnRHa for triggering final oocyte maturation does not confer any additional benefits in elective fertility preservation in terms of mature oocytes compared with GnRHa alone.”

“[Therefore,] we should not worry about a suboptimal response after a GnRHa trigger in [this patient population],” she noted.

Moreover, since we are considering elective fertility preservation, the study did not explore embryo development and pregnancy outcomes, and perhaps that could be a good starting point for further studies, Donno mentioned.