1 / 20

Shahar Kol , Maccabi Health Care Services Rambam Health Care Campus

Individualized treatment from theory to practice: the private case of adding LH during GnRH antagonist-based stimulation protocol. Shahar Kol , Maccabi Health Care Services Rambam Health Care Campus Technion , Israel Institute of Technology. Faculty Disclosure. Off-Label Product Use.

wilda
Download Presentation

Shahar Kol , Maccabi Health Care Services Rambam Health Care Campus

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. Individualized treatment from theory to practice: the private case of adding LH during GnRH antagonist-based stimulation protocol. ShaharKol, Maccabi Health Care Services Rambam Health Care Campus Technion, Israel Institute of Technology

  2. Faculty Disclosure Off-Label Product Use

  3. Background • LH is vital during the follicular phase. • GnRH analogs are used to prevent premature LH rise, and untimely ovulation. • GnRH analogs attenuate endogenous LH secretion.

  4. LH level [U/L] 100 80 60 40 20 0 Days Is exogenous LH needed? (1) Lisi et al. 2002 Marrs et al. 2004 • GnRH agonist-based stimulation: • Global LH supplementation is of no benefit. • Advantage in LH-suppressed patients.

  5. LH level [U/L] 100 80 60 40 20 0 Days Is exogenous LH needed? (2) Konig et al. 2013 • GnRH antagonist-based stimulation: • Global LH supplementation is of no benefit

  6. Is exogenous LH needed? (3) Huirneet al. 2005 • GnRH antagonist-based stimulation: • Drop in LH concentration during antagonist treatment is associated with low pregnancy rate, with no relevance to the actual concentrations.

  7. What matters? Actual level or change?

  8. Ganirelix dose finding study Bad reproductive outcome with 1mg and 2 mg doses

  9. Response to GnRH antagonist: “Bell shape” “hypo-responders” “hyper-responders”

  10. OPTIMALH: Antagonist – Luveris study Who needs exogenous LH during ovarian stimulation after administration of a GnRH antagonist?

  11. Objectives • What is the proportion of patients that sharply decrease their LH levels following the first GnRH antagonist 0.25 mg administration? • Do these patients benefit from added LH?

  12. Definition of GnRH antagonist hyper-responder: 0.25 mg 0.5 mg 1.0, 2.0 mg <50% pre-antagonist LH level recovery 24 hours later.

  13. Study protocol • Ovarian stimulation from day 2 - 3 of cycle. • First Cetrotide dose 4 – 5 days later, following baseline blood test. • 24 hours later: another blood test to determine LH recovery. • If recovery is <50% = hyper-responder, add Luveris 150 IU daily until trigger day. • Rest is routine IVF treatment. • Cost: 1 additional blood test.

  14. Results • 12 patients out of 46 were defined as “hyper-responders” with a mean LH recovery of 34%. • 34 patients – “normal responders” with a mean LH recovery of 75%.

  15. Results (1)

  16. Results (2)

  17. Results (3)

  18. Discussion (1) • It is widely accepted that to secure the best clinical results of assisted reproductive technology, an individualized approach is required. • Implication to the LH question: Give to the patient that needs it! • Follicular phase LH physiology: LH levels are more or less constant, allowing for a sufficient supply of androgens, and for a continuous rise in E2levels. • We hypothesized that a sharp drop in LH causes a sudden decrease in precursor availability. • The result is insufficient E2production by the growing follicles.

  19. Discussion (2) • In 'long' agonist-based, pituitary down-regulation ovarian stimulation, LH levels are low, but with minimal fluctuations. • in antagonist-based cycles, a sudden antagonist-mediated LH drop leads to depleted E2biosynthesis. • the LH-starved system quickly recovers with exogenous LH, resulting in accelerated E2production.

  20. Conclusions • About 25% of patients treated with the antagonist protocol hyper-respond, and may benefit from LH supplementation. • High basal LH is associated with hyper response. • This simple approach can shift “individualized treatment” from slogan to practice.

More Related