New Hope for Hyperstim...Curing the OHSS Woes (Part 1: Lupron Trigger).
Posted Sep 12 2012 9:22am
I have been writing this blog for a couple of years now. Year in and year out the most popular post has been my discussion of OHSS (see the OHSS Woes ). Hundreds of comments have been posted with some pretty scary stories of OHSS. Well, there will always be some risk of OHSS in patients who take fertility drugs but some recent advances may markedly reduce the risk. So here are some details about some new ways to manage OHSS that you may want to discuss with your RE.... #1. Lupron trigger All egg collections must be timed so that the egg within the follicle is ready to ovulate but the procedure is scheduled before that occurs. Traditional timing of egg collection is 34-36 hours after an HCG injection. HCG is very similar to the LH hormone produced by the pituitary (master gland in the brain) and fools the follicle into thinking (if follicles could think) that it is time for the egg to pack its bags and get ready to pop out. The problem is that HCG hangs around for over a week whereas the LH that the brain releases is gone within hours. It is this prolonged HCG exposure that drives the OHSS bus. Similarly this explains why pregnancy makes OHSS so much worse...the developing placenta makes HCG constantly increasing the production from the ovary of the proteins that lead to OHSS symptoms.
So we need HCG in order to do the egg collection and actually get eggs out of the follicles but we really want the HCG to go away quicker to prevent OHSS. Some of us use 5000 IU of HCG to try and avoid OHSS, but the truth of the matter is that all my severe OHSS patients have gotten 5000 IU instead of 10,000 IU so clearly this is not all that effective...
However, some fertility clinics (including ours) are now using Lupron to trigger patients for egg collection. Lupron will cause the patient's pituitary glad to release the LH that is in storage and that LH is usually sufficient to get the eggs ready to be retrieved. The LH then drops precipitously and the risk of OHSS is very close to zero! Wow! What a great option....BUT...
Unfortunately, there is always a "but."
First of all, you can't use Lupron trigger in patients who have been on Lupron for their stim...no MDL flare patient, no Luteal Lupron protocol patients.
Secondly, the estrogen levels with Lupron trigger fall FAST. I mean really fast. This rapid drop in estrogen levels is good for OHSS prevention. It is not so good for implantation. DrD attended the Santa Barbara IVF meeting this summer and came back enthusiastic about Lupron trigger but he noted that although the rate of OHSS is nearly zero, the present recommendation is to freeze all the embryos and save them for an FET cycle because most REs believe that the implantation rate in a Lupron trigger fresh cycle is much lower than expected.
Thirdly, in patients with insurance coverage for IVF this may be problematic as the insurance could count this as 2 separate IVF attempts (one fresh and one FET...even though no fresh ET was ever planned)....Ugh. Nothing is ever simple.
So how do we like Lupron trigger? Well, I have had some very nice success rates with FET cycles with Lupron trigger but our experience seemed consistent with that of other clinics when it came to fresh ET with Lupron trigger. Some patients with really difficult stims (PCOS, AMH level off the wall, history of canceled cycles with estrogen levels >10,000 pg/mL) have made it through egg collection without an issue and their estrogen levels fall really fast and they have very little symptoms of OHSS. I believe this represents the future of IVF stimulations but there remain some unanswered questions....
Next post: New Hope for Hyperstim...Curing the OHSS Woes (Part 2: GnRH-antagonist Rescue).