Physician-To-Physician Consult

Dear colleagues

During the last month 3 different doctors from different centers came across a frustrating situation. Patients for FP underwent antagonist cycle with an excellent response- progressive follicle growth, high adequate E2 levels, timed triggering, timed egg collection. HOWEVER, NO EGGS ONE CASE, INAPROPRIATE 2 AND 3 EGGS IN THE OTHERS.
As these patients had only one chance these are devastating results.
Options that were raised to explain included :

1. Bad medication- 3 different centers, however in all cases LH levels were not available post triggering.
2. Administration of the Antagonist in the evening only few hours prior to GnRH. Does someone have experience with this?
3. Too high E2 levels that might interfere with LH secretion.
4. Time between triggering and egg collection – in all cases the time was no less than 36h.

I will be happy to receive your comments.
Thank you and Happy Holidays and Happy New Year

Dror Meirow, Israel

View Answers

Answer by Hong Qingqing

As we all know: In natural cycle, the transition from suppression to stimulation of LH release occurs as estradiol rises during the midfollicular phase. There are two critical features in this mechanism: (1) the concentration of estradiol and (2) the length of time during which the estradiol elevation is sustained. In women, the estradiol concentration necessary to achieve a positive feedback is more than 200 pg/mL, and this concentration must be sustained for approximately 50 hours.This level of estrogen essentially never occurs until the dominant follicle has reached a diameter of 15 mm. The estrogen stimulus must be sustained beyond the initiation of the LH surge until after the surge actually begins. Otherwise, the LH surge is abbreviated or fails to occur at all.

According to our experence, we had a serum hormone test on trigger day morning, then performed another test 8-10 hours after GnRH(we injected GnRH on 11PM, hormone test on next day morning 7-9AM) . We compared estradiol and LH level,(1) if the estrogen concentration increased but LH less than 20 miu/ml, we arranged the patient had blood test again on oocyte retrieval day morning, if estrogen concentration decreased and P increased, oocyte pick up would be performed . Time between triggering and egg collection was about 36-38h. (2) If the P level didn't change but E increased, we would administed hCG trigger. (3) There is a postive correlation on LH level between trigger day morning and 8-10 hours after GnRH, if LH level on trigger day lower than 1miu/ ml,it is suggested that was less than 40miu/ml on the time 8-10 hours after trigger. (4) The response to GnRH is various in women, we should measure LH level routinely on the next morning of trigger day, determined the appropriate time for oocyte pick up according the LH, E, P level. Oocyte retrieval should be done when E level is decreasing.

Hong Qingqing, MD, China
Department of Assisted Reproduction, Shanghai Ninth People's Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, People's Republic of China

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