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Submitted November 28, 2001; accepted February 20, 2002
Purpose: To compare two GnRHa flare protocols among poor responders undergoing IVF-ET and to evaluate if a Day 6 estradiol level can predict outcome.
Methods: Retrospective analyses of GnRHa flare IVF cycles among poor responders. Group A ("miniflare," N D 36) 40 1g GnRHa s.c. b.i.d. from Day 3; GroupB("standard flare," N D 24) 1 mg GnRHa on Days 2-3; 0.5 mg GnRHa from Day 4. ROC analysis was performed to find a Day 6 estradiol value that is predictive of cycle outcome.
Results: With the standard flare, patients required less gonadotropins and tended to have fewer cancellations and higher pregnancy rates. A Day 6 estradiol level [middot]75 pg/mL was predictive of cycle cancellation, but not of pregnancy outcome.
Conclusions: Standard GnRHa flare offers some advantages over the miniflare. Day 6 estradiol [middot]75 pg/mL is predictive of cycle cancellation. When the estradiol level is low on Day 6 (no flare), early cancellation should be considered.
KEY WORDS: Cycle cancellation; GnRHa flare; IVF-ET; poor responder; pregnancy.
INTRODUCTION
Women with diminished ovarian reserve undergoing assisted reproduction typically respond poorly to standard ovarian hyperstimulation regimens. Poor responders frequently require higher doses of gonadotropins, are more likely to get cancelled, have fewer oocytes and embryos during IVF, and have lower pregnancy rates. To optimize ovarian stimulation, several alternative stimulation protocols have been suggested. The use of lower dose gonadotropin-releasing hormone agonist (GnRHa), a "GnRHa stop" protocol, and the use of GnRHa flare have all been suggested to be associated with better outcome (1,2). GnRHa is used to suppress the pituitary, thereby preventing an endogenous luteinizing hormone (LH) surge. It also allows better cycle scheduling, and the use of suppression could lead to better synchronization of the cohort of follicles.
When GnRHa is started in the beginning of a cycle, it has an initial stimulatory effect and then provides adequate suppression of the endogenous LH surge. The presence of this "flare effect" should be evident by increased serum estradiol levels after a few days. GnRHa can be given in several ways, and studies report the use of different doses (3-7). The aims of our study are to compare outcomes with two different GnRHa flare protocols and to assess if Day 6...