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Agonist (Lupron) Flare And Late Antagonist (Antagon/Cetrotide/Cetrorelix) Protocols In “Poor Responders”
by Geoffrey Sher, M.D.
Immediately following agonist (e.g. Lupron) administration, LH is expunged from the pituitary gland. The high LH triggers excessive production and release of ovarian stromal androgens (mainly testosterone). While some testosterone is essential for normal estradiol production by the follicles and to egg development, too much testosterone (especially in women over 40 and in “poor responders") overloads and exhausts the granulosa cells in the follicle that produce estradiol, compromising both follicle and egg and embryo quality wit reduced potential for pregnancy.
The main objective in stimulation is to optimize egg quality by protecting against this effect which is most prominent in "poor responders. It is also the reason why administering too much LH-containing drugs (e.g. Repronex) to such patients may be deleterious and why using antagonists (e.g. Cetrotide, Antagon, Orgalutron, Ganirelix), where such administration begins late in the follicular phase (cycle 6-8 of the stimulation with gonadotropins), by failing to protect the early (and often most vulnerable) developing follicles from over exposure to higher than normal LH levels often a feature in women with reduced ovarian reserve, is in my opinion also suboptimal.