Trigger Timing in Controlled Ovarian Stimulation for Female Infertility

Overseen By Forest Garner, MS

Age: 18 - 65

Sex: Female

Trial Phase: Academic

Sponsor: Fertility Center of Las Vegas

Disqualifiers: Oocyte banking, Undue risk, others

No Placebo Group All trial participants will receive the active study treatment (no placebo)

Approved in 3 Jurisdictions This treatment is already approved in other countries

Compensation: Varies

Number of Visits: Unknown

Duration: Varies based on follicle development

What You Need to Know Before You Apply

What is the purpose of this trial?

This trial explores the optimal timing for a medication used to mature eggs in women undergoing IVF, with all embryos frozen for future use. Researchers aim to determine whether administering this medication, known as an ovulatory trigger, earlier or later in the process affects outcomes. Women with at least eight follicles on an ultrasound who plan an IVF cycle with embryo freezing might be suitable candidates. Participants must also read and understand English to provide informed consent.

As an unphased trial, this study allows participants to contribute to research that could optimize IVF treatments for future patients.

Do I need to stop my current medications for this trial?

The trial information does not specify whether you need to stop taking your current medications. It's best to discuss this with the trial team or your doctor.

What prior data suggests that ovulatory trigger timing is safe for controlled ovarian stimulation?

Research has shown that both early and delayed timings for triggering ovulation are generally safe in controlled ovarian stimulation (COS). For early timing, studies have found that using human chorionic gonadotropin (hCG) leads to consistent pregnancy rates, with an 18.1% clinical pregnancy rate observed in a review of COS cycles. This indicates that patients tolerate the treatment well.

For delayed timing, research suggests that waiting an extra day or two before using the hCG trigger might increase the number of eggs collected, potentially leading to better outcomes. This suggests the delayed method is also safe and might offer additional benefits.

Overall, both timing options have been studied and appear safe, with some evidence suggesting they may differ in effectiveness. ^{1 2 3 4 5}

Why are researchers excited about this trial?

Researchers are excited about the potential of using ovulatory trigger timing as a method to enhance controlled ovarian stimulation for female infertility. Unlike traditional methods that follow a standard trigger schedule, this approach investigates the effects of varying the timing of the trigger, with "Early Trigger" and "Delayed Trigger" options being explored. This could lead to more personalized and optimized treatment plans, potentially improving outcomes by aligning the trigger with each individual's unique physiological responses. By gaining insights into how different timings affect success rates, this trial could pave the way for more tailored infertility treatments, offering new hope to those struggling to conceive.

What evidence suggests that this trial's treatments could be effective for female infertility?

This trial will compare the effects of early versus delayed ovulation trigger timing in controlled ovarian stimulation for female infertility. Research has shown that triggering ovulation early with hCG (a hormone that initiates ovulation) can improve pregnancy chances in some fertility treatments. Studies have found that administering hCG early enhances egg maturity and embryo quality, which are crucial for a successful pregnancy.

Conversely, waiting 1-2 days longer to trigger ovulation might result in collecting more eggs, but this doesn't always lead to more embryos. Some studies suggest that delaying the trigger can increase the number of mature eggs, particularly in certain IVF treatments. Both early and delayed methods have demonstrated a clinical pregnancy rate of about 18.1% in the cycles studied, indicating their potential effectiveness in aiding conception. Participants in this trial will be assigned to either the early trigger or delayed trigger group to evaluate these outcomes. ^{1 2 6 7 8}

Are You a Good Fit for This Trial?

This trial is for adult women aged 18-35 with normal ovarian response, who are undergoing IVF and plan to freeze all embryos reaching the blastocyst stage. They must understand English to consent and can have had previous IVF cycles but only one cycle under this study.

Inclusion Criteria

I have had IVF before, but I haven't collected eggs more than once in this study.

Ability to read and understand English sufficiently to obtain informed consent

My tests show I have a normal or better chance of producing eggs.

Exclusion Criteria

Any cycle type that would preclude immediate culture to blastocyst stage (e.g. oocyte banking)

Any condition that, in the opinion of the physician or principal investigator, would place the patient at undue risk under this protocol or would otherwise make the protocol inappropriate for that subject

Timeline for a Trial Participant

Screening

Participants are screened for eligibility to participate in the trial

2-4 weeks

Treatment

Participants undergo controlled ovarian stimulation with early or delayed trigger timing for final oocyte maturation

Varies based on follicle development

Follow-up

Participants are monitored for the formation of good-quality blastocysts within 7 days of oocyte retrieval

1 week

What Are the Treatments Tested in This Trial?

Interventions

• Ovulatory trigger timing

Trial Overview

The study tests two different timings for administering 'trigger' drugs that help mature eggs in controlled ovarian stimulation during IVF. All participants will have their embryos frozen at the blastocyst stage for future use.

How Is the Trial Designed?

Group I: Early Trigger Experimental Treatment 1 Intervention

Group II: Delayed trigger Experimental Treatment 1 Intervention

Ovulatory trigger timing is already approved in European Union, United States, Canada for the following indications:

Approved in European Union as hCG trigger for:

• Assisted reproductive technology (ART)
• Infertility treatment

Approved in United States as hCG trigger for:

• Infertility treatment
• Ovulation induction
• Assisted reproductive technology (ART)

Approved in Canada as hCG trigger for:

• Infertility treatment
• Assisted reproductive technology (ART)

Who Is Running the Clinical Trial?

Fertility Center of Las Vegas

Lead Sponsor

Trials

6

Recruited

550+

Published Research Related to This Trial

In a study of 203 IVF cycles using a low-dose GnRH analogue, elevated LH levels were found in 13% of women at the time of hCG administration, but this did not negatively impact pregnancy success rates.

The presence of elevated LH did not correlate with key reproductive outcomes such as the number of follicles, oocytes, or embryos, indicating that it does not adversely affect the efficacy of the IVF protocol.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

Elevated luteinizing hormone on the day of human chorionic gonadotropin administration does not reduce cycle fecundity in a low-dose flare-up in vitro fertilization protocol. Lincoln, SR., Long, CA., Whitworth, NS., et al.[2019]

In a study of 377 IVF patients, cycles with a spontaneous LH surge showed fewer preovulatory oocytes retrieved compared to controls, indicating that timing of oocyte retrieval is crucial for success.

Retrieving oocytes more than 35 hours after hCG administration resulted in a higher number of preovulatory oocytes, while monitoring serum estradiol levels can help optimize retrieval timing and potentially reduce cancellations in IVF cycles.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

Timing of oocyte retrieval in cycles with a spontaneous luteinizing hormone surge in a large in vitro fertilization program. Droesch, K., Muasher, SJ., Kreiner, D., et al.[2019]

In a review of 365 controlled ovarian hyperstimulation (COH) cycles, the overall clinical pregnancy rate was 18.1%, with r-hCG administration before intrauterine insemination (IUI) leading to a significantly higher pregnancy rate (18.2%) compared to spontaneous LH surge (5.8%).

When r-hCG was given alongside a serum LH surge, the clinical pregnancy rate increased even further to 30.8%, especially in patients treated with r-FSH, highlighting the importance of timing and medication in improving fertility outcomes.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

Controlled Ovarian Hyperstimulation with Intrauterine Insemination Is More Successful After r-hCG Administration Than Spontaneous LH Surge. Taerk, E., Hughes, E., Greenberg, C., et al.[2020]

The traditional use of hCG (human chorionic gonadotropin) as a trigger for oocyte maturation in infertility treatments may not effectively support the hormonal environment needed for optimal luteal phase function, leading to abnormal hormonal patterns compared to natural cycles.

The study suggests that the hCG trigger may induce oocyte maturation less efficiently than the natural surge of luteinizing hormone and follicle-stimulating hormone, potentially impacting implantation success and pregnancy rates, indicating a need for more individualized and physiological approaches in treatment.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

Shortcomings of an unphysiological triggering of oocyte maturation using human chorionic gonadotropin. Andersen, CY., Kelsey, T., Mamsen, LS., et al.[2021]

In a study of 73 women under 40 with low oocyte maturation rates, the dual trigger method (using both GnRH agonist and hCG) significantly improved oocyte maturation rates (84.0% vs. 55.5%) compared to the traditional hCG trigger.

The dual trigger also led to higher cumulative pregnancy rates (69.4% vs. 40.0%) and live birth rates (66.7% vs. 36.0%), suggesting it may be a more effective option for enhancing reproductive outcomes in this population.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

Dual trigger for final oocyte maturation in expected normal responders with a high immature oocyte rate: a randomized controlled trial. Yan, MH., Sun, ZG., Song, JY.[2023]

In a study of 39 patients at risk of ovarian hyper-stimulation syndrome (OHSS) undergoing IVF/ICSI, follicular reduction resulted in a lower median number of punctured follicles compared to coasting, but both methods showed similar rates of OHSS development (10.5% for follicular reduction vs. 30% for coasting).

Pregnancy and cancellation rates were also comparable between the two groups, indicating that neither method significantly improved outcomes in terms of pregnancy success or cycle cancellations.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

Follicular aspiration versus coasting for ovarian hyper-stimulation syndrome prevention. Bushaqer, NJ., Dayoub, NM., AlHattali, KK., et al.[2018]

Triggering ovulation with a short-acting GnRH agonist using the patient's own pituitary LH can achieve satisfactory ovulation and pregnancy rates, comparable to traditional hCG methods, based on current literature.

This method significantly reduces the risk of ovarian hyperstimulation syndrome (OHSS) and potentially lowers the chances of multiple pregnancies, making it a safer alternative for patients undergoing fertility treatments.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

[Therapeutic induction of ovulation: towards the replacement of hCG with LH]. Emperaire, JC.[2006]

This study will evaluate the effectiveness of a dual trigger approach (using both GnRH agonist and hCG) for final oocyte maturation in 90 individuals undergoing controlled ovarian hyperstimulation, aiming to improve the quantity and quality of mature oocytes and pregnancy outcomes.

The primary outcome measured will be the rate of metaphase-II (MII) oocytes, with secondary outcomes including fertilization rates and clinical pregnancy rates, providing a comprehensive assessment of the dual trigger's impact on IVF success.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

GnRH Agonist and hCG (Dual Trigger) Versus hCG Trigger for Final Oocyte Maturation in Expected Normal Responders With a High Immature Oocyte Rate: Study Protocol for a Randomized, Superiority, Parallel Group, Controlled Trial. Yan, MH., Cao, JX., Hou, JW., et al.[2022]

The combination of GnRH antagonist co-treatment with a GnRH-agonist trigger, along with the addition of a low-dose HCG bolus, has been shown to improve reproductive outcomes in patients at risk for severe ovarian hyperstimulation syndrome (OHSS), although it may not completely eliminate the risk of OHSS.

Using GnRH-agonist triggers alongside standard hCG doses can enhance oocyte and embryo quality, suggesting that this dual or double trigger approach may optimize fertility treatments.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

Triggering final follicular maturation--hCG, GnRH-agonist or both, when and to whom? Orvieto, R.[2018]

In a study of 33 poor responder patients undergoing IVF, the 'double trigger' method (using both GnRH agonist and hCG) resulted in a significantly higher number of top quality embryos compared to other triggering methods, indicating improved efficacy in follicular maturation.

While the double trigger showed promising results, the overall pregnancy rates were acceptable but not significantly different among the groups, suggesting that further research with larger sample sizes is needed to confirm these findings before changing standard IVF practices.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

Does double trigger (GnRH-agonist + hCG) improve outcome in poor responders undergoing IVF-ET cycle? A pilot study. Haas, J., Zilberberg, E., Nahum, R., et al.[2019]

The study aims to evaluate the safety and efficacy of using low dose hCG alongside GnRH agonist for oocyte maturation in 82 women undergoing IVF, focusing on preventing ovarian hyperstimulation syndrome (OHSS) and improving pregnancy rates.

By comparing two groups—one receiving low dose hCG at the trigger and placebo at retrieval, and the other receiving placebo at trigger and higher hCG at retrieval—the study will assess live birth rates and OHSS incidence, providing insights into optimal IVF protocols.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

The dual trigger study: Rationale and study design of a prospective double-blind randomized clinical trial comparing pregnancy rates after co-administration of low dose hCG at the time of GnRH agonist trigger or 35 h later for the prevention of OHSS. Griffin, D., Benadiva, C., Budinetz, T., et al.[2020]

In a study of 140 IVF patients with premature LH surge, earlier oocyte retrieval (OPU) did not significantly reduce the risk of cycle cancellation compared to standard timing, with cancellation rates of 74.3% for earlier OPU versus 65.9% for standard timing.

Despite a higher clinical pregnancy rate (44.4%) in the earlier OPU group compared to standard timing (27.3%), this group also experienced a significantly higher miscarriage rate (22% vs. 0%), indicating potential risks associated with earlier retrieval.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

The effectiveness of earlier oocyte retrieval in the case of a premature luteinizing hormone surge on hCG day in in vitro fertilization-embryo transfer cycles. Choi, MH., Cha, SH., Park, CW., et al.[2021]

Citations

1.

pmc.ncbi.nlm.nih.gov

pmc.ncbi.nlm.nih.gov/articles/PMC10372826/

A delayed ovulation of progestin-primed ovarian ...

PPOS suppresses the LH level before trigger and decreases the synthesis of progesterone after trigger, thus delaying the ovulation by downregulating the LHCGR- ...

2.

mefj.springeropen.com

mefj.springeropen.com/articles/10.1186/s43043-024-00166-w

The dilemma of the trigger timing in IVF: a review

In conclusion, delaying the hCG trigger (1–2 days) in agonist ICSI cycles would result in better oocyte yield which in turn may have a positive ...

3.

ovarianresearch.biomedcentral.com

ovarianresearch.biomedcentral.com/articles/10.1186/s13048-024-01379-3

Meta-analysis of trigger timing in normal responders ...

Delaying trigger time in GnRH antagonist protocol increased the number of oocytes retrieved but not the number of embryos.

4.

withpower.com

withpower.com/trial/phase-infertility-female-7-2022-0a875

Trigger Timing in Controlled Ovarian Stimulation for ...

In a review of 365 controlled ovarian hyperstimulation (COH) cycles, the overall clinical pregnancy rate was 18.1%, with r-hCG administration before ...

5.

pmc.ncbi.nlm.nih.gov

pmc.ncbi.nlm.nih.gov/articles/PMC9178246/

Optimal Timing of Ovulation Triggering to Achieve Highest ...

LH surge was calculated to start in 25% of cases at an E2 level of 637 pmol/l, in 50% of cases at 911 pmol/l and in 75% of cases at an E2 level ...

6.

pmc.ncbi.nlm.nih.gov

pmc.ncbi.nlm.nih.gov/articles/PMC12273475/

Spontaneous ovulation, hormonal profiles, and the impact of ...

This retrospective cohort study included 196 first-time NPP-FET cycles with single euploid blastocyst transfers between January 2023 and October 2024.

7.

pmc.ncbi.nlm.nih.gov

pmc.ncbi.nlm.nih.gov/articles/PMC7714888/

Is there a critical LH level for hCG trigger after the detection ...

Our study suggests that hCG can be administered at any time between the start of LH rise (≥ 15 IU/L) and LH peak level (≥ 40 IU/L) without a detrimental effect ...

8.

clinicaltrials.gov

clinicaltrials.gov/study/NCT01614067

NCT01614067 | Delayed Start to Ovarian Stimulation

For example, recently our group found that a modification of ovulation trigger toward a more physiologic process improves oocyte quality and pregnancy outcomes.