Confino E, Zhang X, Kazer R R
Department of OB/GYN, Northwestern University Medical School, Chicago, IL, USA.
Int J Gynaecol Obstet. 2004 Apr;85(1):36-9. doi: 10.1016/S0020-7292(03)00344-8.
GnRH agonist administered early in the menstrual cycle (flare) causes an endogenous discharge of FSH and LH. Flare has been used in conjunction with gonadotropin ovarian stimulation for IVF 'poor responders'. There is an ongoing controversy regarding whether flare protocols improve pregnancy rates in 'poor responders'. The current study was designed to compare a GnRHa flare protocol with long suppression GnRHa IVF in 'poor responders'.
Seventy-three newly diagnosed poor responders who failed long GnRHa suppression IVF attempts were compared retrospectively with 128 age-matched IVF patients previously known poor ovarian responders treated with a long GnRHa suppression protocol. 'Poor responders' consisted of patients with peak E(2) less than 1000 pg/ml and/or less than five mature follicles with diameter >15 mm on the day of hCG administration. Student's t-test was used to analyze the data and the chi-squared test was used to compare fertilization and pregnancy rates.
The flare protocol produced higher peak E(2) levels (1647+/-747 vs. 720+/-258 mIU/ml, P<0.05) and a larger number of mature follicles (5.8+/-2.2 vs. 4.0+/-1.0 P<0.05) in the study vs. the control group. A 30% pregnancy rate was achieved during this second IVF attempt using GnRHa flare protocol in the study group vs. 37 in the control group (P>0.05, NS).
A comparison between the flare protocol group and the age-matched control group of poor ovarian responders subject to down regulation protocol, revealed higher peak E(2) levels and more mature follicles, respectively. However, both groups yielded comparable pregnancy rates. The use of high dose gonadotropin treatment in our study groups seems to be the only explanation for their subsequent successful outcome. We concluded that GnRH agonist flare protocol does not result in better IVF outcome compared with long GnRH agonist suppression protocol in IVF poor responders.
在月经周期早期给予促性腺激素释放激素（GnRH）激动剂（激发方案）会引起促卵泡生成素（FSH）和促黄体生成素（LH）的内源性释放。激发方案已与促性腺激素卵巢刺激联合用于体外受精（IVF）的“低反应者”。关于激发方案是否能提高“低反应者”的妊娠率，目前仍存在争议。本研究旨在比较GnRHa激发方案与长效抑制GnRHa方案在IVF“低反应者”中的效果。
回顾性比较73例新诊断的低反应者，这些患者在长效GnRHa抑制的IVF尝试中失败，与128例年龄匹配的IVF患者，这些患者先前已知为卵巢低反应者，接受长效GnRHa抑制方案治疗。“低反应者”包括在注射人绒毛膜促性腺激素（hCG）当天，雌二醇（E₂）峰值低于1000 pg/ml和/或直径>15 mm的成熟卵泡少于5个的患者。采用学生t检验分析数据，卡方检验比较受精率和妊娠率。
与对照组相比，研究组采用激发方案产生了更高的E₂峰值水平（1647±747 vs. 720±258 mIU/ml，P<0.05）和更多的成熟卵泡（5.8±2.2 vs. 4.0±1.0，P<0.05）。研究组在第二次IVF尝试中使用GnRHa激发方案的妊娠率为30%，而对照组为37%（P>0.05，无统计学差异）。
对接受降调节方案的卵巢低反应者的激发方案组与年龄匹配的对照组进行比较，分别显示出更高的E₂峰值水平和更多的成熟卵泡。然而，两组的妊娠率相当。在我们的研究组中使用高剂量促性腺激素治疗似乎是其后续成功结局的唯一解释。我们得出结论，在IVF低反应者中，与长效GnRH激动剂抑制方案相比，GnRH激动剂激发方案不会导致更好的IVF结局。
