GnRH-agonist triggering for ovulation induction and freeze-all policy (segmented cycles) is now widely used to avoid the risk of OHSS in high responders and in egg donation program.
Due to the profile of the LH surge an intensive luteal support is needed for fresh embryo transfer.
The FSH surge which accompanies the LH surge after GnRH-agonist triggering, is more physiologic and is responsible for several benefits like more favorable gene expression profile of the cumulus and granulose cells, more mature oocytes, better fertilization rates and higher implantation rates.
We successfully changed in 2011 the treatment conception in the Fertility Center Hamburg and integrated the ovulation induction with GnRH-agonist for all ART patients including a very individualized luteal support and fresh embryo transfer.

Individualized to age, AMH levels and AFC ,a controlled ovarian stimulation with rFSH+rLH(2:1) in a flexible antagonist regime was used and ovalution was triggered with Triptorelin 0,2 mg s.c. when 2-3 follicles were at least 17mm or more. Egg retrieval was performed 35 hours later.
For luteal support HCG 1500 I.U. (i.m.) was injected after egg retrieval (recovery room). The HCG dose was reduced to 1000-1200 I.U. if more than 18 follicle of
12 mm or more were present and no HCG was injected and all fertilized oocytes were frozen if the number of follicle greater than 12mm exceeded 30. (The cycle was then segmented)
Conventional luteal.support started 48 hours after egg retrieval with
17ß E2 (micronised,natural) 4mg (2x2mg) vaginally and micronized Progesterone 600mg( 3x200mg) vaginally increased to 800 mg(300-200-300) after embryo transfer (or Progesterone vaginal gel 8% daily in the morning )
Most embryo transfers were performed on day 3 (due to German legislation)
An individualised second HCG bolus was injected 5 days after egg retrieval but only if the number of follicles(=>12mm) at egg retrieval was less than 14!
( 750-1500 i.u.if less than 10 follicles.>12mm and 450-500 i.u if 10-14 follicles >12mm ).
In case of a pregnancy the conventional luteal support was continued until
10-12 weeks.
The attached figures are showing the results of the last four years of using this conception in our clinic. After a pilot period of 11/2 years by myself the whole clinic started using the same protocol from January 2013 onwards .We treated 1760 Patient in 3161 cycles and did not experience any early OHSS case in this time and the few (20=0,6%) very mild and very moderate late onset OHSS cases were due to the learning curve of the individualized luteal phase HCG policy and were not experienced after that any more.
In a mean age group of the patient population of 36.1years a pos pregnancy was achieved in 47,8% and with only 19,2% early pregnancy loss the ongoing pregnancy and delivery rate per embryo transfer was 36,3% with an excellent implantation rate of 36,3% for all patients and up to 58,5% in the young patient group of less than 35 years old.
We believe that routine GnRH-agonist triggering for ovulation induction and fresh embryo transfer with individualized luteal phase support will benefit all ART patients.

Fertility Center Hamburg
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