title: Risk factors for a suboptimal response to gonadotropin-releasing hormone agonist trigger during in vitro fertilization cycles.
abstract: OBJECTIVE
  To identify risk factors for a suboptimal response to gonadotropin-releasing hormone (GnRH) agonist trigger in in vitro fertilization (IVF) cycles.
  
  
  METHODS
  Retrospective cohort study.
  
  
  METHODS
  Academic medical center.
  
  
  METHODS
  All 424 patients undergoing fresh IVF cycles (n = 500) between August 2007 and June 2013 in whom a GnRH agonist was used as all or part of the ovulation trigger.
  
  
  METHODS
  GnRH-antagonist-based IVF cycles triggered with leuprolide acetate alone or in combination with low-dose human chorionic gonadotropin.
  
  
  METHODS
  Suboptimal response to GnRH-agonist trigger, as defined by a serum luteinizing hormone (LH) level <15 mIU/mL on the morning after trigger.
  
  
  RESULTS
  The rate of suboptimal response to the GnRH-agonist trigger was 5.2%. Patients with a suboptimal hormone response had lower follicle-stimulating hormone (<0.1 vs. 3.48) and LH (<0.1 vs. 2.51) levels on day 2 of the cycle start, lower LH (0.109 vs. 0.596) on the day of trigger, and required longer stimulation and more gonadotropins than those with an adequate response. Suboptimal responders were also more likely to have irregular menses and be on long-term oral contraception. Patients with an undetectable LH on the day of trigger had a 25% chance of a suboptimal LH surge. In our study cohort, limiting the use of the GnRH-agonist trigger alone to patients with a trigger day LH ≥0.5 would have reduced the rate of suboptimal response from 5.2% to 0.2%.
  
  
  CONCLUSIONS
  Long-term hormonal contraception use is an independent risk factor for suboptimal response to GnRH-agonist trigger. Patients with very low endogenous serum LH levels on the day of LH trigger are at increased risk for a suboptimal GnRH-agonist trigger response. Understanding the at-risk phenotype and using trigger day LH as a marker for increased risk of suboptimal GnRH-agonist trigger response can be helpful for individualizing treatment and selecting a safe and efficacious trigger medication for patients undergoing IVF.
authors.affiliation: Ronald O. Perelman and Claudia Cohen Center for Reproductive Medicine, Weill Cornell Medical Center, New York, New York.
authors.forename: Laura
authors.initials: L
authors.lastname: Meyer
authors.affiliation: Ronald O. Perelman and Claudia Cohen Center for Reproductive Medicine, Weill Cornell Medical Center, New York, New York.
authors.forename: Lauren A
authors.initials: LA
authors.lastname: Murphy
authors.affiliation: School of Medicine, George Washington University, Washington, D.C.
authors.forename: Arielle
authors.initials: A
authors.lastname: Gumer
authors.affiliation: Ronald O. Perelman and Claudia Cohen Center for Reproductive Medicine, Weill Cornell Medical Center, New York, New York.
authors.forename: David E
authors.initials: DE
authors.lastname: Reichman
authors.affiliation: Ronald O. Perelman and Claudia Cohen Center for Reproductive Medicine, Weill Cornell Medical Center, New York, New York.
authors.forename: Zev
authors.initials: Z
authors.lastname: Rosenwaks
authors.affiliation: Ronald O. Perelman and Claudia Cohen Center for Reproductive Medicine, Weill Cornell Medical Center, New York, New York. Electronic address: icholst@med.cornell.edu.
authors.forename: Ina N
authors.initials: IN
authors.lastname: Cholst
mesh_terms: D000328:Adult; D015415:Biomarkers / Q000097:blood; D006063:Chorionic Gonadotropin / Q000627:therapeutic use; D003278:Contraceptives, Oral, Hormonal / Q000009:adverse effects; D004359:Drug Therapy, Combination; D005260:Female; D005298:Fertility / Q000187:drug effects*; D005300:Fertility Agents, Female / Q000627:therapeutic use*; D005307:Fertilization in Vitro; D007987:Gonadotropin-Releasing Hormone / Q000819:agonists*; D006801:Humans; D007246:Infertility / Q000097:blood / Q000175:diagnosis / Q000503:physiopathology / Q000628:therapy*; D016729:Leuprolide / Q000627:therapeutic use*; D007986:Luteinizing Hormone / Q000097:blood; D008599:Menstruation Disturbances / Q000150:complications / Q000503:physiopathology; D011247:Pregnancy; D012189:Retrospective Studies; D012307:Risk Factors; D017211:Treatment Failure
chemical_list: D015415:Biomarkers; D006063:Chorionic Gonadotropin; D003278:Contraceptives, Oral, Hormonal; D005300:Fertility Agents, Female; D007987:Gonadotropin-Releasing Hormone; D007986:Luteinizing Hormone; D016729:Leuprolide
keywords: Complications; GnRH agonist; OHSS; donor egg; empty follicle syndrome; fertility preservation; ovulation trigger; prevention of OHSS; suboptimal response