The effectiveness of GnRH antagonist in poor ovarian responders undergoing in vitro fertilization a systematic review and meta analysis

Capsule:
In poor responders undergoing in vitro fertilization, the clinical efficacy of a gonadotropin-releasing hormone (GnRH) antagonist was similar to that of a GnRH agonist.

Authors:
Jinsong Xiao , M.D., Shuang Chang, B.S., Shuangyun Chen, M.D.

Volume 100, Issue 6, Pages 1594-1601.e9, December 2013

Abstract:

Objective:
To evaluate the effectiveness of gonadotropin-releasing hormone (GnRH) antagonist in poor ovarian responders undergoing in vitro fertilization (IVF).

Design:
Systematic review and meta-analysis.

Setting:
Affiliated hospital with a medical university.

Patient(s):
None.

Intervention(s):
Electronic search.

Main Outcome Measure(s):
Clinical pregnancy rate, number of oocytes retrieved, cycle cancellation rate.

Result(s):
A total of 12 published studies (1,332 cases) were included. Both the stimulation period (mean difference [MD], −0.43; 95% confidence interval [CI], −0.68 to −0.17) and the gonadotropin dosage (MD, −5.41; 95% CI, −7.51 to −3.31) were statistically significantly lower in the GnRH antagonist protocol than in the long GnRH agonist protocol. Both the endometrial thickness (MD −0.45; 95% CI, −0.76 to −0.13) and estrogen (E2) level on the day of hCG administration (MD, −1,299.15; 95% CI, −1,716.34 to −881.95) were statistically significantly lower in the GnRH antagonist protocol than the GnRH agonist protocol. Fewer oocytes were retrieved for the GnRH antagonist protocol than the long GnRH agonist protocol (MD, −0.34; 95% CI, −0.54 to −0.13) or the short GnRH agonist protocol (MD, −0.54; 95% CI, −0.9, 8 to −0.10). The cycle cancellation and clinical pregnancy rates were not statistically significantly different between the two groups.

Conclusion(s):
Compared with GnRH agonist protocols, the GnRH antagonist protocol is associated with fewer oocytes retrieved, lower E2 levels, and thinner endometrium whereas the clinical pregnancy and cycle cancellation rates are similar.

  • Amanda N. Kallen

    This is a impressively large, well-designed meta-analysis that attempts to clarify the role of antagonist protocols in IVF. I do agree with the authors that there is heterogeneity in the definitions of “poor responders” and that multicenter RCTs are needed to more clearly answer this question. One other thought regarding the differences between the two groups: while the endometrium was thinner in the antagonist groups, the difference didn’t seem to be in a clinically significant range (i.e. the thinnest mean ET in the antagonist group was still 9.6). I wonder if the authors could clarify this point? Thanks again for your work.

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