Comment on “Progesterone elevation does not compromise pregnancy rates in high responders: a pooled analysis of in vitro fertilization patients treated with recombinant follicle-stimulating hormone/releasing hormone antagonist in six trials”

24 10 2013

To the Editor:

I read with great interest and attention the original article published recently by Griesinger et al. (1) entitled “Progesterone elevation does not compromise pregnancy rates in high responders: a pooled analysis of in vitro fertilization patients treated with recombinant follicle-stimulating hormone/releasing hormone antagonist in six trials.” In this article, Griesinger et al. conclude that a progesterone (P) elevation > 1.5 ng/mL on the day of hCG administration is associated with a lower ongoing pregnancy rate (OPR) in the general population, but not in patients with a high ovarian response, defined as an oocyte yield > 18 oocytes.

These authors performed excellent statistical work, pooling data from six multicenter randomized controlled trials relatively similar in their design, and presented the results as if all came from one single study. However, the study deserves several comments that question the unequivocal conclusion that is presented even in the title of the manuscript. Read the rest of this entry »

Elimination of OHSS

14 03 2012

To the Editor:

I read with interest the recently published discussion on the etiology and prevention of OHSS (1-2). While the reviews comprehensively covered their aims, there are some issues that should be highlighted.

Agonist and antagonist coast

Coasting, or the complete discontinuation of exogenous gonadotropin while continuing GnRH analogues administration, is a preventive measure that is completely related on serum E2 levels at gonadotropin discontinuation and on the drop in E2 levels on day of hCG administration (1). However, while “it is well established that high E2 levels are associated with a high incidence of OHSS” (1), OHSS may occur in patients who conceived spontaneously, and in those with low or high serum E2 levels on the day of hCG administration (details in ref. 3). These versatile observations actually suggest that the previously accepted risk factors to develop OHSS, especially high serum E2 levels, are unreliable for the prediction of severe OHSS (3).

Therefore, we were not surprised at the finding of the recently published Cochrane review (4), which reported no difference in the incidence of moderate or severe OHSS after coasting. Read the rest of this entry »

Ovarian hyperstimulation syndrome or massive intraperitoneal hemorrhage?

21 06 2011

To the Editor:

I read with interest a recent paper by Griesinger et al. (1) describing, for the first time in the English literature, a case of severe ovarian hyperstimulation syndrome (OHSS) post-GnRH agonist trigger of ovulation. However, the clinical details of the case cast serious shadow on the correct diagnosis.

The hallmark of severe OHSS is elevated hematocrit (>45%, or >30% increment over baseline values) secondary to hemoconcentration (2). However, the described patient experienced severe intraperitoneal hemorrhage leading to decreasing hematocrit (41% on day of trigger, 37% on day of oocyte retrieval). Blood transfusion was given (no details on amount) due to “drastic decrease of hemoglobin levels to 4.9 mmol/L,” with hematocrit “15,000, oliguria, elevated creatinine, liver dysfunction, anasarca) were not given. Read the rest of this entry »

To add GnRH antagonists to controlled ovarian stimulation in management of subfertile couples with IUI may not have additional effect in terms of clinical pregnancy rates

16 05 2011

I read with interest the article published in your journal by Bakas (1).
The authors said that in the GnRH antagonist group, when the leading follicle had reached a mean diameter of ≥ 16 mm, 0.25 mg ganirelix was started. Why did authors choose a mean diameter of 18 mm to start of antagonist? It can be argued that when GnRH antagonists were first administered, premature elevation in LH had already occurred. In actuality we could not measure serum progesterone and LH serially. Therefore, the intervention may have been too late. In Lamback’s study, when GnRH anatgonist started at a dominant follicle, premature luteinization was detected in 3.4% of the cycles (2). Furthermore, it has been reported that almost 50% of the cycles that showed a premature LH elevation had dominant follicles that were 16.5 mm or smaller (3). Read the rest of this entry »

Discussion on letrozole-Gn-antagonist group needing an early start of antagonist

4 05 2011

To the Editor:

I read with great interest the article by Elassar et al. (1) in which they addressed the risk of a premature luteinizing hormone (LH) surge (LH ≥ 10 mIU/mL occurring before the detection of the leading follicle ≥ 18 mm in diameter) in letrozole-gonadotropin (Gn)-antagonist group and suggested that “an early start and possibly a higher dose of the antagonist should be considered when using letrozole.” This is a good concept. But they did not explore the cause. They mentioned “ovaries with diminished ovarian reserve are more prone to a premature LH surge.” However, it is not the cause leading to the high rate of premature LH surge associated with letrozole supplementation. Read the rest of this entry »

Prevention of ovarian hyperstimulation syndrome

7 04 2011

To the Editor:

I read the recent publication on ovarian hyperstimulation syndrome (OHSS) with great interest (1). The dopamine agonist bromocriptine and gonadotropin-releasing hormone agonist for the prevention of OHSS were mentioned (1,2). Indeed, there are many recent studies on how to prevent OHSS. Apart from using an agonist, there are also other concerns for management. The classification of the risk before the procedure (3) and the individualized adjustment of drug dosage (4) seem to be the two additional means for prevention of OHSS.

Viroj Wiwanitkit, M.D.
Wiwanitkit House
Bangkok, Thailand
Read the rest of this entry »

Progesterone administration route in GnRH antagonist cycles

9 04 2010

To the Editor:

We read interest the paper of Kahraman et al. comparing the effectiveness of vaginal and intramuscular progesteron as luteal phase support among women undergoing IVF with intracytoplasmic sperm injection (ICSI) with gonadotropin-releasing hormone (GnRH) antagonist (1). Read the rest of this entry »