Use of gonadotrophin-releasing hormone agonists in controlled ovarian hyperstimulation for in vitro fertilization.

The aim of ovarian hyperstimulation for in vitro fertilization (IVF) is the recruitment of multiple fertilizable healthy oocytes. Transfer of multiple embryos yields a better success rate than single-embryo transfers. Moreover, cryopreservation of excess pre-embryos allows patients an added opportunity to achieve a pregnancy without undergoing a repeat stimulated cycle. In the last 4 years, gonadotrophin-releasing hormone (Gn-RH) agonists have been used widely as adjuncts to gonadotrophins for ovarian hyperstimulation. Advantages of Gn-RH agonist use include prevention of a premature luteinising hormone (LH) surge, suppression of endogenous basal LH levels and recruitment of a larger cohort of follicles. Gn-RH agonists can be used in a long (suppression) or a short (stimulatory, flare-up) protocol. In our clinic, the use of Gn-RH agonist suppression (starting in the mid-luteal phase) prior to ovarian hyperstimulation was demonstrated to be extremely beneficial in intermediate and high responder patients but not in low responders (defined endocrinologically as patients with a basal follicle-stimulating hormone [FSH]: LH ratio of 1:1 and a basal LH:FSH ratio of greater than or equal to 1.5, respectively). We have not been able to demonstrate any beneficial effects from the use of Gn-RH agonist suppression in low responder patients (defined endocrinologically as patients with a basal FSH greater than or equal to 15 mIU/ml). In such low responder patients, the use of a 'flare-up' Gn-RH agonist protocol (Gn-RH agonist starting on day 2 of the cycle, followed by gonadotrophins on day 4 of the cycle), taking advantage of the initial agonistic stimulatory effect of Gn-RH agonists on endogenous FSH and LH secretion, has provided significant improvements in stimulation characteristics and better pregnancy results. It should be emphasised that comparisons of results cannot be attempted due to the selective use of each protocol in different patient populations.