Withholding Gonadotropins Until Human Chorionic Gonadotropin Administration

Rony Abdallah; Isaac Kligman; Owen Davis; Zev Rosenwaks

doi:10.1055/s-0030-1265675

Seminars in Reproductive Medicine, Table of Contents

Semin Reprod Med 2010; 28(6): 486-492
DOI: 10.1055/s-0030-1265675

Withholding Gonadotropins Until Human Chorionic Gonadotropin Administration

Rony Abdallah¹ , Isaac Kligman¹ , Owen Davis¹ , Zev Rosenwaks¹

¹The Ronald O. Perelman and Claudia Cohen Center for Reproductive Medicine, Weill Cornell Medical College, New York

Abstract

ABSTRACT

Withholding gonadotropins in women who exhibit high estradiol responses before follicles reach full maturation is called “coasting.” Coasting, or suspending gonadotropin administration, can be an effective strategy for decreasing the risk of ovarian hyperstimulation syndrome (OHSS) while reducing cancelation rates. In in vitro fertilization cycles, mechanistically it is believed that withholding gonadotropins starves smaller follicles, induces apoptosis, and decreases the potential for these follicles to elaborate vascular endothelial growth factor, a known mediator of OHSS. It is generally accepted that coasting should be initiated when the estradiol (E₂) level is >3000 pg/mL in the setting of immature follicles. The human chorionic gonadotropin (hCG) trigger should be administered when the E₂ level subsequently drops to a “safe” level. Cycle cancellation should be considered if, after 3 to 4 days of coasting, the E₂ level remains excessively elevated. Oocyte retrieval may also be cancelled if the E₂ level on the day after hCG trigger drops precipitously. In gonadotropin-releasing hormone agonist (GnRHa)-based protocols, one can consider withholding GnRHa administration if the E₂ level continues to increase after a few days of coasting. Current data seem to show that the coasting period is short and/or is less likely to be required in GnRH-antagonist protocols as compared with GnRHa-based protocols. Large randomized control trials are still needed to establish the relative efficacy of coasting versus embryo cryopreservation in the context of OHSS prevention.

KEYWORDS

In vitro fertilization - OHSS - coasting - VEGF - GnRH agonist - GnRH antagonist

Full Text

References

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Zev RosenwaksM.D.

The Ronald O. Perelman and Claudia Cohen Center for Reproductive Medicine, Weill Cornell Medical College

1305 York Avenue, New York, NY 10021

Email: rta9002@med.cornell.edu