Citation Information :
Yadav S, Panchal S, Nagori C, Nadagouda S, Thakker M. Comparative Study of Dual Trigger vs hCG Trigger in Intrauterine Insemination Cycles. Donald School J Ultrasound Obstet Gynecol 2022; 16 (4):266-271.
Aim: The aim of this study was to assess if follicle-stimulating hormone (FSH) surge induced by gonadotropin-releasing hormone agonist (GnRHa), when given in addition to human chorionic gonadotropin (hCG) for triggering ovulation in intrauterine insemination (IUI) cycles, was beneficial and resulted in higher pregnancy rates. Background: Gonadotropin-releasing hormone agonist (GnRHa), when given as an ovulation trigger, causes a surge of both FSH and luteinizing hormone (LH) due to its “flare” effect mimicking the midcycle surge of gonadotropins in a natural cycle. The role of midcycle FSH surge in humans is not completely understood. But when GnRHa alone is used as an ovulation trigger, it causes luteolysis and luteal phase defect due to its shorter duration of action. In IUI cycles, GnRHa can be combined with hCG, which is responsible for only LH surge, and compared with cycles in which hCG alone is used as a trigger to analyze the impact of midcycle FSH on clinical pregnancy rates. Materials and methods: A total of 60 IUI cycles were analyzed that were divided into two groups. Group I received hCG alone and group II received hCG + GnRHa for ovulation trigger. In both groups stimulation protocol used was letrozole, which started from day 2 of the cycle for 5 days, and recombinant FSH (rFSH) from day 7. Follicular monitoring was done using two-dimensional (2D) ultrasound and color Doppler. Once follicles and endometrium attained functional maturity, an ovulation trigger was given. In group I, recombinant hCG and in group II, triptorelin acetate (0.2 mg) along with recombinant hCG was given. In both groups, IUI was done 34–36 hours after the trigger; luteal support was given with 800 mg micronized vaginal progesterone per day. Clinical pregnancy rates were compared in both groups. Results: There was a difference in pregnancy rates between the hCG group (26.7%) and GnRHa + hCG group (40%). Conclusion: It was concluded that though there was a difference in pregnancy rates in both groups, the difference was not statistically significant due to the small patient cohort (p = 0.273).
Nakano R, Mizuno T, Kotsuji F, et al. ”Triggering” of ovulation after infusion of synthetic luteinizing hormone releasing factor (LRF). Acta Obstet Gynecol Scand 1973;52(3):269–272. DOI: 10.3109/00016347309158325
Yding Andersen C. Effect of FSH and its different isoforms on maturation of oocytes from pre-ovulatory follicles. Reprod Biomed Online 2002;5(3):232–239. DOI: 10.1016/s1472-6483(10)61826-3
Zelinski-Wooten MB, Hutchison JS, Hess DL, et al. Follicle stimulating hormone alone supports follicle growth and oocyte development in gonadotropin-releasing hormone antagonist-treated monkeys. Hum Reprod 1995;10(7):1658–1666. DOI: 10.1093/oxfordjournals.humrep.a136151
Eppig JJ. FSH stimulates hyaluronic acid synthesis by oocyte-cumulus cell complexes from mouse preovulatory follicles. Nature 1979;281(5731):483–484. DOI: 10.1038/281483a0
Richards JS, Jahnsen T, Hedin L, et al. Ovarian follicular development: from physiology to molecular biology. Recent Prog Horm Res 1987;43:231–276. DOI: 10.1016/b978-0-12-571143-2.50012-5
Shapiro BS, Daneshmand ST, Garner FC, et al. Gonadotropin-releasing hormone agonist combined with a reduced dose of human chorionic gonadotropin for final oocyte maturation in fresh autologous cycles of in vitro fertilization. Fertil Steril 2008;90(1):231–233. DOI: 10.1016/j.fertnstert.2007.06.030
Griffin D, Benadiva C, Kummer N, et al. Dual trigger of oocyte maturation with gonadotropin-releasing hormone agonist and low-dose human chorionic gonadotropin to optimize live birth rates in high responders. Fertil Steril 2012;97(6):1316–1320. DOI: 10.1016/j.fertnstert.2012.03.015
Castillo JC, Moreno J, Dolz M, et al. Successful pregnancy following dual triggering concept (rhCG + GnRH agonist) in a patient showing repetitive inmature oocytes and empty follicle syndrome: case report. J Med Cases 2013;5:221–226. DOI: 10.4021//JMC.V4I4.1055
Lanzone A, Fulghesu AM, Apa R, et al. LH surge induction by GnRH agonist at the time of ovulation. Gynaecol Endocrinol 2009;3(3):213–220. DOI: 10.3109/09513598909152302
Fauser BC, de Jong D, Olivennes F, et al. 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 2002; 87(2):709–715. DOI: 10.1210/jcem.87.2.8197
Panchal S, Nagori C. Ultrasound-based decision making on stimulation protocol for superovulated intrauterine insemination cycles. IJIFM 2016;7(1):7–13. DOI: 10.5005/jp-journals-10016-1119
Moor RM, Osborn JC, Cran DG, et al. Selective effect of gonadotropins on cell coupling, nuclear maturation and protein synthesis in mammalian oocytes. J Embryol Exp Morphol 1981;61:347–365. PMID: 6790654.
Yding Andersen C, Westergaard LG, Figenschau Y, et al. Endocrine composition of follicular fluid comparing human chorionic gonadotropin to a gonadotropin-releasing hormone agonist for ovulation induction. Hum Reprod 1993;8(6):840–843. DOI: 10.1093/oxfordjournals.humrep.a138151
Andersen CY, Humaidan P, Ejdrup HB, et al. Hormonal characteristics of follicular fluid from women receiving either GnRH agonist or hCG for ovulation induction. Hum Reprod 2006;21(8):2126–2130. DOI: 10.1093/humrep/del119
Hoff JD, Quigley ME, Yen SS. Hormonal dynamics at midcycle: a reevaluation. J Clin Endocrinol Metab 1983;57(4):792–796. DOI: 10.1210/jcem-57-4-792
Humaidan P, Bredkjaer HE, Bungum L, et al. GnRH agonist (buserelin) or hCG for ovulation induction in GnRH antagonist IVF/ICSI cycles: a prospective randomized study. Hum Reprod 2005;20(5):1213–1220. DOI: 10.1093/humrep/deh765
Itskovitz J, Boldes R, Levron J, et al. Induction of preovulatory luteinizing hormone surge and prevention of ovarian hyperstimulation syndrome by gonadotropin-releasing hormone agonist. Fertil Steril 1991;56(2):213–220. DOI: 10.1016/S0015-0282(16)54474-4
Hill MJ, Whitecomg BW, Lewis TD, et al. Progesterone luteal support after ovulation induction and intrauterine insemination: a systematic review and meta-analysis. Fertil Steril 2013;100(5):1373–1380. DOI: 10.1016/j.fertnstert.2013.06.034
Blake EJ, Norris PM, Dorfman SF, et al. Single and multidose pharmacokinetic study of a vaginal micronized progesterone insert (Endometrin) compared with vaginal gel in healthy reproductive-aged female subjects. Fertil Steril 2010;94(4):1296–1301. DOI: 10.1016/j.fertnstert.2009.06.014