Respectfully, I do agree with you, but this is something you need to discuss with your treating RE

“Triggering” Egg Maturation in IVF: Comparing urine-derived hCG, Recombinant DNA-hCG and GnRH-agonist:

 Geoffrey Sher MD

Ideal egg development sets the scene for optimal egg maturation that occurs 36-42h prior to ovulation or egg retrieval. Without prior optimal egg development (ovogenesis), egg maturation will often be dysfunctional and many/most eggs will be rendered “incompetent” and unable upon fertilization to propagate viable embryos. In IVF, optimal ovogenesis requires the selection and implementation of an individualized approach to COS. Thereupon, at the ideal time, maturational “reproductive division” of the egg’s chromosomes (i.e., meiosis) is “triggered” through the administration of hCG or by inducing an LH surge through the administration of a GnRHa (e.g., Lupron, Buserelin, Superfact, Decapeptyl. The dosage, type and timing of this “trigger shot” can profoundly affect the efficiency of meiosis as well as the potential to yield “competent (euploid) mature (M2) eggs, and as such it often represents a rate limiting step in the IVF process.

 Until quite recently, the standard method used to “trigger” egg maturation was through the administration of 10,000 units of hCGu. Subsequently, a hCG-DNA recombinant (hCGr) available commercially as Ovitrelle or Ovitrel) was introduced and marketed in 250 mcg doses.  But clinical experience soon strongly suggested that 250 mcg of Ovidrel was most likely not equivalent in biological potency, to the standard dosage of hCGu, 10,000 unit and as such might not be sufficient to fully promote meiosis, especially in cases where the woman had numerous follicles.  For this reason, we hold that when hCGr is selected as the “trigger shot” the dosage should be doubled to 500 mcg at which dosage it will probably have an equivalent effect on promoting meiosis as would  10,000 units of hCGu. Failure to “trigger” with 10,000U hCGu or 500mcg hCGr, might increase the likelihood of disorderly meiosis, “incompetent (aneuploid) eggs” and introduce the risk of follicles not yielding eggs at egg retrieval (“empty follicles”).

 Some clinicians, when faced with a risk of OHSS developing will deliberately elect to reduce the “trigger” dosage of hCG in the hope that the risk of critical OHSS developing will thereby be lowered. However, this approach might not be optimal because a low dose of hCG (e.g., 5000 units, hCGu or 250mcg hCGr) is often inadequate to optimize the efficiency of meiosis particularly when it comes to cases such as this where there are many follicles. It has been suggested that the preferential use of a GnRHa “trigger” in women at risk of developing OHSS could potentially reduce the risk of the condition becoming critical and thereby placing the woman at risk of developing life-endangering complications. It is against this background that many RE’s prefer to “trigger” meiosis by way of administering a GnRHa rather than through the use of hCG.  The GnRHa promptly causes the woman’s pituitary gland to expunge a large amount of LH over a short period of time and it is this induced “LH surge” that triggers meiosis. While this approach definitely reduces the risk of severe OHSS-related complications developing, it often comes at the expense of egg quality.  For this reason, we prefer to use a full dosage of 10,000U hCGu (or 500mcg hCGr) for the “trigger” after adequate duration of  “prolonged coasting” and so reduce the risk of critical OHSS.

 Another “acceptable” approach is to reduce the dosage of hCG administered as a “trigger” and to combine this with a GnRH a and so reduce the risk of OHSS developing.

The timing of the “trigger shot “to initiate meiosis should coincide with the majority of ovarian follicles being >15 mm in mean diameter with several follicles having reached 18-22 mm.  Follicles of larger than 22 mm will usually harbor overdeveloped eggs which in turn will usually fail to produce good quality eggs. Conversely, follicles less than 15 mm will usually harbor underdeveloped eggs that are more likely to be aneuploid and incompetent following the “trigger”. 

Geoff Sher

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ADDITIONAL INFORMATION:

I am attaching online links to two E-books which I recently  co-authored with  my partner at SFS-NY  (Drew Tortoriello MD)……. for your reading pleasure:

1.From In Vitro Fertilization to Family: A Journey with Sher Fertility Solutions (SFS) “

http://sherfertilitysolutions.com/sher-fertility-solutions-ebook.pdf

1. “Recurrent Pregnancy Loss and Unexplained IVF Failure: The Immunologic Link

https://drive.google.com/file/d/1iYKz-EkAjMqwMa1ZcufIloRdxnAfDH8L/view