Letter to the editor |
Reply: ‘GnRH agonist trigger: looking for the coin under the lamp post?’
1 Unit for Human Reproduction, Aristotle University, Thessaloniki, Greece, 2Centre of Reproductive Medicine, Dutch-speaking Brussels Free University, Brussels, Belgium and 3Department of Gynecology and Obstetrics, Division of Gynaecological Endocrinology and Reproductive Medicine, University Clinic of Schleswig-Holstein, Campus Luebeck, Luebeck, Germany
4 To whom correspondence should be addressed. E-mail: stratis.kolibianakis{at}otenet.gr
Sir,
We would like to thank Dr Kol for his interest in the study by Kolibianakis et al. (2005)
, published in Human Reproduction. It is clear that Dr Kol does not express any criticism regarding the way the study was designed and performed, the way the data were analysed or regarding the conclusions drawn.
Dr Kol suggests that the GnRH agonist trigger totally prevents ovarian hyperstimulation syndrome (OHSS); however, it has been suggested that this is not always true (van der Meer et al., 1993). Moreover, he questions the rationale of performing a randomized controlled trial (RCT) comparing agonist versus HCG for triggering final oocyte maturation in normal responders, although he acknowledges that this is the only population in which such a comparison can be performed for ethical reasons. In addition, although Dr Kol appears to criticize the standard knowledge approach of testing hypotheses by RCTs, he does not suggest a more efficient way of approaching the truth.
Dr Kol appears to be concerned that the recently published studies (Humaidan et al., 2005; Kolibianakis et al., 2005) comparing GnRH agonists versus HCG for triggering final oocyte maturation could undermine efforts to curb OHSS occurrence. We, in contrast, are in favour of any properly conducted study that leads to valid conclusions regarding the hypothesis tested and thus is enhancing our knowledge in IVF. It was important to know if an intervention (administration of GnRH agonist for triggering final oocyte maturation), proposed with the aim to prevent a serious complication of IVF treatment (OHSS), was not affecting adversely at the same time the goal of IVF treatment (achievement of pregnancy). The study by Kolibianakis et al. (2005) has shown that the replacement of HCG by GnRH agonist is not feasible in IVF, as it results in a significantly decreased probability of ongoing pregnancy.
Dr Kol appears to make a distinction between the leading centres in Western Europe in which, as he mentions, ‘OHSS is extremely rare, apparently’, and the rest of the world (in which, OHSS occurrence is apparently higher). We do not have comparative data to agree or disagree with this statement. However, OHSS occurrence is related to the way patients are stimulated, in terms of FSH dose used but also in terms of the task of ovarian stimulation set. Perhaps, instead of jumping from plane in the mid-air using an agonist parachute (thus concentrating on the prevention of a complication that we induce during IVF treatment), it is more appropriate to make OHSS as rare as it can be. This might be achieved not only in the leading Western Europe centres but also in the rest of the world by adopting less-aggressive, strict criteria for HCG administration (Kolibianakis et al., 2005), especially in the era that single-embryo transfer becomes a necessity.
References
Humaidan P, Bredkjaer HE, Bungum L, Bungum M, Grondahl ML, Westergaard L and Andersen CY (2005) GnRH agonist (buserelin) or hCG for ovulation induction in GnRH antagonist IVF/ICSI cycles: a prospective randomized study. Hum Reprod 20,1213–1220.
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 20,2887–2892.
van der Meer S, Gerris J, Joostens M and Tas B (1993) Triggering of ovulation using a gonadotrophin-releasing hormone agonist does not prevent ovarian hyperstimulation syndrome. Hum Reprod 8,1628–1631.
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