Final maturation induction

<h2 id="usage-with-ovulation">Usage with ovulation</h2>
Induction of final maturation also initiates the mechanisms that eventually result in <a href="/facts/Ovulation/0K3MLdAv">ovulation</a>, and thereby makes the oocytes destined to undergo ovulation unless artificial <a href="/facts/Oocyte_retrieval/3j2bWJNC">oocyte retrieval</a> is performed first. Therefore, induction of final maturation is also called triggering oocyte release from the ovary, and the administration of <a href="/facts/Pharmaceutical_drug/h9mhwWP2">pharmaceutical drugs</a> to induce final maturation is colloquially called giving a "trigger shot", even if the plan is to perform artificial oocyte retrieval before ovulation.<a class="footnote-ref" id="fnref:2" href="#fn:2">2</a>
Administration of a drug to trigger oocyte release without oocyte retrieval results in a predictable time of ovulation, with the interval from drug administration to ovulation depending on the type of drug. This avails for <a href="/facts/Sexual_intercourse/okjwpVnB">sexual intercourse</a> or <a href="/facts/Intrauterine_insemination/ccbKoyu4">intrauterine insemination</a> (IUI) to conveniently be scheduled at ovulation, the most likely time to achieve pregnancy.<a class="footnote-ref" id="fnref:3" href="#fn:3">3</a>
In <a href="/facts/Ovulation_induction/PKB21JVx">ovulation induction</a>, using <a href="/facts/Clomifene/DHUn89Vt">clomifene</a> for intended conception by sexual intercourse, however, triggering oocyte release has been shown to decrease pregnancy chances compared to frequent monitoring with <a href="/facts/LH_surge/a6znte2S">LH surge</a> tests.<a class="footnote-ref" id="fnref:4" href="#fn:4">4</a> Therefore, in such cases, triggering oocyte release is best reserved for women who require IUI and in whom LH monitoring proves difficult or unreliable.<a class="footnote-ref" id="fnref:5" href="#fn:5">5</a> It may also be used when LH monitoring hasn't shown an LH surge by cycle day 18 (where cycle day 1 is the first day of the preceding menstruation) and there is an <a href="/facts/Ovarian_follicle/7eKGUwb6">ovarian follicle</a> of over 20 mm in size.<a class="footnote-ref" id="fnref:6" href="#fn:6">6</a>

<h2 id="usage-with-artificial-oocyte-retrieval">Usage with artificial oocyte retrieval</h2>
In <a href="/facts/In_vitro_fertilization/kQNMtaBu">in vitro fertilization</a> (IVF), induction of final maturation avails for <a href="/facts/Egg_retrieval/3j2bWJNC">egg retrieval</a> when the eggs are fully mature.
In IVF, final maturation induction is preceded by <a href="/facts/Controlled_ovarian_hyperstimulation/AVCwAznG">controlled ovarian hyperstimulation</a>. It is suggested that there should be a size of <a href="/facts/Ovarian_follicle/7eKGUwb6">ovarian follicles</a> of at least 15 mm, and serum estradiol level of 0.49 nmol/L before commencing final maturation induction. There are better prospects at a follicle size of 18 mm and serum estradiol level of 0.91 nmol/L.<a class="footnote-ref" id="fnref:7" href="#fn:7">7</a>

<h2 id="medications">Medications</h2>
Medications used for final maturation and/or release of oocytes include:

<ul><li><a href="/facts/Human_chorionic_gonadotropin/AKeIq9nd">Human chorionic gonadotropin</a> (HCG or hCG) in a low dose, which may be injected after completed ovarian stimulation. Final maturation with hCG is also termed hCG priming.<a class="footnote-ref" id="fnref:8" href="#fn:8">8</a> Ovulation will occur between 38 and 40 hours after a single HCG injection.<a class="footnote-ref" id="fnref:9" href="#fn:9">9</a> It is also used in <a href="/facts/In_vitro_fertilization/kQNMtaBu">in vitro fertilization</a>, where it makes the follicles perform their final maturation. A <a href="/facts/Transvaginal_oocyte_retrieval/3j2bWJNC">transvaginal oocyte retrieval</a> is then performed at a time usually between 34 and 36 hours after hCG injection, that is, shortly before when the follicles would rupture. A retrieval at 36 hours after final maturation induction appears to result in optimal embryo quality and pregnancy outcomes.<a class="footnote-ref" id="fnref:10" href="#fn:10">10</a> HCG injection confers a risk of <a href="/facts/Ovarian_hyperstimulation_syndrome/n0V2VfDu">ovarian hyperstimulation syndrome</a>.</li>
<li><a href="/facts/Recombinant_DNA/dT3PL7M6">Recombinant</a> <a href="/facts/Luteinizing_hormone/a6znte2S">luteinizing hormone</a> (rLH), recombinant HCG (rHCG) and <a href="/facts/Urine/oNUYVtvX">urine</a>-derived hCG (uHCG) are equally effective in achieving final follicular maturation in IVF with regards to pregnancy rates and risk of ovarian hyperstimulation syndrome.<a class="footnote-ref" id="fnref:11" href="#fn:11">11</a> Therefore, urine-derived hCG (uHCG) is regarded as the best choice for final oocyte maturation triggering in IVF due to availability and cost.<a class="footnote-ref" id="fnref:12" href="#fn:12">12</a></li>
<li><a href="/facts/GnRH_agonist/g8awqhvS">GnRH agonist</a>, which necessitates using a <a href="/facts/GnRH_antagonist/6aEgJlqo">GnRH antagonist</a> protocol for <a href="/facts/Controlled_ovarian_hyperstimulation/AVCwAznG">suppression of ovulation during ovarian hyperstimulation</a>, because using GnRH agonist for that purpose as well inactivates the axis for which it is intended to work for final maturation induction.</li></ul>
<h3>HCG versus GnRH agonist</h3>
Final maturation induction using GnRH agonist results in a substantial decrease in the risk of <a href="/facts/Ovarian_hyperstimulation_syndrome/n0V2VfDu">ovarian hyperstimulation syndrome</a> (OHSS). A <a href="/facts/Cochrane_review/UlmdJ1H8">Cochrane review</a> estimated that using GnRH agonist instead of hCG in IVF decreases the risk of mild, moderate or severe OHSS with an <a href="/facts/Odds_ratio/7WcmubfN">odds ratio</a> of approximately 0.15. The review estimated that, for a woman with a 5% risk of mild, moderate or severe OHSS with the use of HCG, the risk of OHSS with the use of a GnRH agonist would be between 0 and 2%.<a class="footnote-ref" id="fnref:13" href="#fn:13">13</a>
However, using GnRH agonist has a lower <a href="/facts/Live_birth_rate/hEDdgYMo">live birth rate</a> than when using hCG in <a href="/facts/Autotransplantation/Hv2U9gaG">autologous</a> oocyte transfers (rather than ones using <a href="/facts/Oocyte_donation/jv7npewL">oocyte donation</a>). A Cochrane review of autologous oocyte transfers estimated that GnRH agonist, compared to hCG, gives an <a href="/facts/Odds_ratio/7WcmubfN">odds ratio</a> of pregnancy of approximately 0.47. It estimated that, for a woman with a 31% chance of achieving live birth with the use of hCG, the chance of a live birth with the use of an GnRH agonist would be between 12% and 24%.<a class="footnote-ref" id="fnref:14" href="#fn:14">14</a> Likewise, using GnRH agonist instead of hCG was associated with a lower ongoing pregnancy rate (pregnancy beyond 12 weeks) than was seen with HCG (odds ratio 0.70) and a higher rate of early (less than 12 weeks) <a href="/facts/Miscarriage/sFq0vdnU">miscarriage</a> (odds ratio 1.74). However, a higher pregnancy rate when using hCG is only found in those receiving <a href="/facts/Luteal_support/aca9wSmj">luteal support</a> without <a href="/facts/Luteinizing_hormone/a6znte2S">luteinizing hormone</a> activity (such as <a href="/facts/Progesterone/WEj2TGRm">progesterone</a> or <a href="/facts/Progestin/8xMJYV3A">progestin</a>).<a class="footnote-ref" id="fnref:15" href="#fn:15">15</a>
Final maturation induction using a GnRH agonist is recommended in women with cancer undergoing <a href="/facts/Fertility_preservation/NrjReGYw">fertility preservation</a>, because ovarian hyperstimulation syndrome is associated with an increased risk of arterial thrombotic events such as <a href="/facts/Stroke/DwpjdzY0">stroke</a>, <a href="/facts/Myocardial_infarction/xoGw0qcG">myocardial infarction</a> and peripheral <a href="/facts/Arterial_embolism/7jkbLLRm">arterial embolism</a>, and this risk can add to an already increased risk caused by the cancer.<a class="footnote-ref" id="fnref:16" href="#fn:16">16</a>
Using hCG versus GnRH agonist has no effect on the risk of <a href="/facts/Multiple_pregnancy/bVVVhRvs">multiple pregnancy</a>.<a class="footnote-ref" id="fnref:17" href="#fn:17">17</a> Also, no difference has been found between the regimens regarding <a href="/facts/Live_birth_rate/hEDdgYMo">live birth rate</a> or ongoing <a href="/facts/Pregnancy_rate/hEDdgYMo">pregnancy rate</a> when the controlled ovarian hyperstimulation was followed by <a href="/facts/Oocyte_donation/jv7npewL">oocyte donation</a>.<a class="footnote-ref" id="fnref:18" href="#fn:18">18</a>

<h2 id="references">References</h2>

<ol>
<li id="fn:1">Youssef, Mohamed AFM; Van der Veen, Fulco; Al-Inany, Hesham G; Mochtar, Monique H; Griesinger, Georg; Nagi Mohesen, Mohamed; Aboulfoutouh, Ismail; van Wely, Madelon; Youssef, Mohamed AFM (2014). "Gonadotropin-releasing hormone agonist versus HCG for oocyte triggering in antagonist-assisted reproductive technology". Cochrane Database of Systematic Reviews. 2014 (10): CD008046. doi:10.1002/14651858.CD008046.pub4. PMC 10767297. PMID 25358904. <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10767297" target="_blank">https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10767297</a> <a href="#fnref:1" class="footnote-back-ref">↩</a></li>
<li id="fn:2">"About.com". Archived from the original on 2012-11-18. Retrieved 2014-05-10. <a href="https://web.archive.org/web/20121118205858/http://infertility.about.com/od/infertilitytreatments/ss/ivf_treatment_5.htm" target="_blank">https://web.archive.org/web/20121118205858/http://infertility.about.com/od/infertilitytreatments/ss/ivf_treatment_5.htm</a> <a href="#fnref:2" class="footnote-back-ref">↩</a></li>
<li id="fn:3">IVF.com > Ovulation Induction Archived 2012-02-26 at the Wayback Machine Retrieved on Mars 7, 2010 <a href="http://www.ivf.com/ovind.html" target="_blank">http://www.ivf.com/ovind.html</a> <a href="#fnref:3" class="footnote-back-ref">↩</a></li>
<li id="fn:4">Practice Committee of the American Society for Reproductive Medicine (August 2013). "Use of clomiphene citrate in infertile women: a committee opinion". Fertil. Steril. 100 (2): 341–8. doi:10.1016/j.fertnstert.2013.05.033. PMID 23809505. <a href="https://doi.org/10.1016%2Fj.fertnstert.2013.05.033" target="_blank">https://doi.org/10.1016%2Fj.fertnstert.2013.05.033</a> <a href="#fnref:4" class="footnote-back-ref">↩</a></li>
<li id="fn:5">Practice Committee of the American Society for Reproductive Medicine (August 2013). "Use of clomiphene citrate in infertile women: a committee opinion". Fertil. Steril. 100 (2): 341–8. doi:10.1016/j.fertnstert.2013.05.033. PMID 23809505. <a href="https://doi.org/10.1016%2Fj.fertnstert.2013.05.033" target="_blank">https://doi.org/10.1016%2Fj.fertnstert.2013.05.033</a> <a href="#fnref:5" class="footnote-back-ref">↩</a></li>
<li id="fn:6">Clomiphene Citrate, Clomid Archived 2014-05-10 at archive.today. By Robert B. McWilliams. The Center for Reproduction and Women's Health Care, Houston, Texas. Retrieved May 2014 <a href="http://www.houstonfertilityspecialist.com/clomid.html" target="_blank">http://www.houstonfertilityspecialist.com/clomid.html</a> <a href="#fnref:6" class="footnote-back-ref">↩</a></li>
<li id="fn:7">Follicular monitoring from Radiopaedia. By Dr Praveen Jha et al. <a href="http://radiopaedia.org/articles/follicular-monitoring" target="_blank">http://radiopaedia.org/articles/follicular-monitoring</a> <a href="#fnref:7" class="footnote-back-ref">↩</a></li>
<li id="fn:8">Ghasemian F, Faraji R, Asgharnia M, Zahiri Z, Bahadori MH (2013). "The impact of different time intervals between hCG priming and oocyte retrieval on ART outcomes". Iran J Reprod Med. 11 (7): 559–64. PMC 3941349. PMID 24639791.{{cite journal}}: CS1 maint: multiple names: authors list (link)
 <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3941349" target="_blank">https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3941349</a> <a href="#fnref:8" class="footnote-back-ref">↩</a></li>
<li id="fn:9">HCG Injection After Ovulation Induction With Clomiphene Citrate at Medscape. By Peter Kovacs. Posted: 04/23/2004 <a href="http://www.medscape.com/viewarticle/473515" target="_blank">http://www.medscape.com/viewarticle/473515</a> <a href="#fnref:9" class="footnote-back-ref">↩</a></li>
<li id="fn:10">Son WY, Chung JT, Chian RC, Herrero B, Demirtas E, Elizur S; et al. (2008). "A 38 h interval between hCG priming and oocyte retrieval increases in vivo and in vitro oocyte maturation rate in programmed IVM cycles". Hum Reprod. 23 (9): 2010–6. doi:10.1093/humrep/den210. PMC 2517153. PMID 18556681.{{cite journal}}: CS1 maint: multiple names: authors list (link)
 <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2517153" target="_blank">https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2517153</a> <a href="#fnref:10" class="footnote-back-ref">↩</a></li>
<li id="fn:11">Farquhar, Cindy; Marjoribanks, Jane (17 August 2018). "Assisted reproductive technology: an overview of Cochrane Reviews". The Cochrane Database of Systematic Reviews. 2018 (8): CD010537. doi:10.1002/14651858.CD010537.pub5. ISSN 1469-493X. PMC 6953328. PMID 30117155. <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6953328" target="_blank">https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6953328</a> <a href="#fnref:11" class="footnote-back-ref">↩</a></li>
<li id="fn:12">Farquhar, Cindy; Marjoribanks, Jane (17 August 2018). "Assisted reproductive technology: an overview of Cochrane Reviews". The Cochrane Database of Systematic Reviews. 2018 (8): CD010537. doi:10.1002/14651858.CD010537.pub5. ISSN 1469-493X. PMC 6953328. PMID 30117155. <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6953328" target="_blank">https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6953328</a> <a href="#fnref:12" class="footnote-back-ref">↩</a></li>
<li id="fn:13">Youssef, Mohamed AFM; Van der Veen, Fulco; Al-Inany, Hesham G; Mochtar, Monique H; Griesinger, Georg; Nagi Mohesen, Mohamed; Aboulfoutouh, Ismail; van Wely, Madelon; Youssef, Mohamed AFM (2014). "Gonadotropin-releasing hormone agonist versus HCG for oocyte triggering in antagonist-assisted reproductive technology". Cochrane Database of Systematic Reviews. 2014 (10): CD008046. doi:10.1002/14651858.CD008046.pub4. PMC 10767297. PMID 25358904. <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10767297" target="_blank">https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10767297</a> <a href="#fnref:13" class="footnote-back-ref">↩</a></li>
<li id="fn:14">Youssef, Mohamed AFM; Van der Veen, Fulco; Al-Inany, Hesham G; Mochtar, Monique H; Griesinger, Georg; Nagi Mohesen, Mohamed; Aboulfoutouh, Ismail; van Wely, Madelon; Youssef, Mohamed AFM (2014). "Gonadotropin-releasing hormone agonist versus HCG for oocyte triggering in antagonist-assisted reproductive technology". Cochrane Database of Systematic Reviews. 2014 (10): CD008046. doi:10.1002/14651858.CD008046.pub4. PMC 10767297. PMID 25358904. <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10767297" target="_blank">https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10767297</a> <a href="#fnref:14" class="footnote-back-ref">↩</a></li>
<li id="fn:15">Youssef, Mohamed AFM; Van der Veen, Fulco; Al-Inany, Hesham G; Mochtar, Monique H; Griesinger, Georg; Nagi Mohesen, Mohamed; Aboulfoutouh, Ismail; van Wely, Madelon; Youssef, Mohamed AFM (2014). "Gonadotropin-releasing hormone agonist versus HCG for oocyte triggering in antagonist-assisted reproductive technology". Cochrane Database of Systematic Reviews. 2014 (10): CD008046. doi:10.1002/14651858.CD008046.pub4. PMC 10767297. PMID 25358904. <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10767297" target="_blank">https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10767297</a> <a href="#fnref:15" class="footnote-back-ref">↩</a></li>
<li id="fn:16">Somigliana, E.; Peccatori, F. A.; Filippi, F.; Martinelli, F.; Raspagliesi, F.; Martinelli, I. (2014). "Risk of thrombosis in women with malignancies undergoing ovarian stimulation for fertility preservation". Human Reproduction Update. 20 (6): 944–951. doi:10.1093/humupd/dmu035. ISSN 1355-4786. PMID 25013217. <a href="https://doi.org/10.1093%2Fhumupd%2Fdmu035" target="_blank">https://doi.org/10.1093%2Fhumupd%2Fdmu035</a> <a href="#fnref:16" class="footnote-back-ref">↩</a></li>
<li id="fn:17">Youssef, Mohamed AFM; Van der Veen, Fulco; Al-Inany, Hesham G; Mochtar, Monique H; Griesinger, Georg; Nagi Mohesen, Mohamed; Aboulfoutouh, Ismail; van Wely, Madelon; Youssef, Mohamed AFM (2014). "Gonadotropin-releasing hormone agonist versus HCG for oocyte triggering in antagonist-assisted reproductive technology". Cochrane Database of Systematic Reviews. 2014 (10): CD008046. doi:10.1002/14651858.CD008046.pub4. PMC 10767297. PMID 25358904. <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10767297" target="_blank">https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10767297</a> <a href="#fnref:17" class="footnote-back-ref">↩</a></li>
<li id="fn:18">Youssef, Mohamed AFM; Van der Veen, Fulco; Al-Inany, Hesham G; Mochtar, Monique H; Griesinger, Georg; Nagi Mohesen, Mohamed; Aboulfoutouh, Ismail; van Wely, Madelon; Youssef, Mohamed AFM (2014). "Gonadotropin-releasing hormone agonist versus HCG for oocyte triggering in antagonist-assisted reproductive technology". Cochrane Database of Systematic Reviews. 2014 (10): CD008046. doi:10.1002/14651858.CD008046.pub4. PMC 10767297. PMID 25358904. <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10767297" target="_blank">https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10767297</a> <a href="#fnref:18" class="footnote-back-ref">↩</a></li>
</ol>

Final maturation induction open-in-new

Final maturation induction