Letter to the editor |
‘GnRH agonist trigger: looking for the coin under the lamp post?’
IVF Unit, Department of Obstetrics and Gynaecology, Rambam Medical Center, POB 9602, Haifa 31096, Israel
E-mail: skol{at}rambam.health.gov.il
Sir,
The main advantage of GnRH agonist trigger is its ability to totally prevent ovarian hyperstimulation syndrome (OHSS). Ethical considerations cast a serious doubt on our ability to conduct a randomized controlled trial (RCT) to assess agonist versus HCG trigger in the context of OHSS prevention. Similar considerations prevent us from conducting an RCT on the benefit of a parachute when jumping from an airplane in mid-air (Smith and Pell, 2004
). Since evidence-based medicine and RCTs are the current gods of medical research, it leaves no alternative but to compare the two triggers in normal responder. Why look for an alternative to HCG in the normal responder is not clear; however, an RCT can be easily performed under these circumstances. Consequently, Kolibianakis et al. (2005) chose to repeat previous work (Fauser et al., 2002) to conclude that agonist trigger results in lower pregnancy rate compared to HCG.
Unfortunately, these publications may undermine efforts to curb OHSS occurrence, as practitioners are left with the impression that agonist trigger should be abandoned altogether. OHSS is still there. A reliable method for its prevention is urgently needed, if not for the leading centres in Western Europe (in which OHSS is extremely rare, apparently), then for the rest of the world. Is the true occurrence of OHSS higher than reported (Delvigne, 2005)? Agonist trigger prevents OHSS by inducing irreversible luteolysis (Kol, 2004). The scientific community must find a way to bring this gift to OHSS high-risk patients. Agonist trigger can save patients lives.
References
Delvigne A (2005) Request for information on unreported cases of severe ovarian hyperstimulation syndrome (OHSS). Hum Reprod 20,2033.
Fauser BC, de Jong D, Olivennes F, Wramsby H, Tay C, Itskovitz-Eldor J and van Hooren HG (2002) Endocrine profiles after triggering of final oocyte maturation with GnRH agonist after cotreatment with the GnRH antagonist ganirelix during ovarian hyperstimulation for in vitro fertilization. J Clin Endocrinol Metab 87,709–715.
Kol S (2004) Luteolysis induced by a gonadotropin-releasing hormone agonist is the key to prevention of ovarian hyperstimulation syndrome. Fertil Steril 81,1–5.[Web of Science][Medline]
Kolibianakis EM, Schultze-Mosgau A, Schroer A, van Steirteghem A, Devroey P, Diedrich K and Griesinger G (2005) A lower ongoing pregnancy rate can be expected when GnRH agonist is used for triggering final oocyte maturation instead of HCG in patients undergoing IVF with GnRH antagonists. Hum Reprod June 24 [Epub ahead of print].
Smith GC and Pell JP (2004) Parachute use to prevent death and major trauma related to gravitational challenge: systematic review of [randomized] controlled trials. J Int Assoc Physicians AIDS Care (Chic Ill) 3,108–109.
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