Optimizing use of assisted reproduction

Infertile couples who have failed to achieve pregnancy now have new options that have become available in the last two decades. The costs are generally large and frequently not covered by insurance. Risks include multiple pregnancy and hyperstimulation syndrome. Evidence concerning results of several treatment options is presented. The large difference in success between age groups is displayed. Results to be expected from donor eggs to overcome the low success in older age groups (>38 years) are presented.

Efficacy and pregnancy outcome of two methods of semen preparation for intrauterine insemination: a prospective randomized study

OBJECTIVE

To examine pregnancy outcome with two methods of semen preparation for intrauterine insemination (IUI).

DESIGN

Prospective and randomized study.

SETTINGS

Academic tertiary center.

PATIENT(S)

Three hundred eleven couples undergoing 676 consecutive cycles of assisted conception using IUI.

INTERVENTION(S)

Semen samples collected for IUI were randomized to wash only or density gradient centrifugation (DGC) processing.

MAIN OUTCOME MEASURE(S)

Various prepreparation and postpreparation semen parameters were used for IUI. The influence of the method of semen processing, and impact of various semen parameters and female factors on pregnancy were examined by receiver operating characteristics (ROC) curves, logistic regression, and life table analysis.

RESULT(S)

Of the 676 cycles, 88 resulted in conception leading to an overall clinical pregnancy rate of 13.0% per cycle and 28.3% per patient with a miscarriage rate of 34.0%. Eighty-eight percent of pregnancies occurred in the first three cycles of IUI and 95.5% within the first four cycles. The pregnancy rate for wash only was 11.6% (37 of 319) and the rate for DGC was 14.3% (51 of 356). However, in samples with <22 million motile sperm in the inseminate, pregnancy rates were 4% for wash and 18% for DGC. The woman's age for both methods and the percentage of sperm in the original semen with a velocity of > or =80 micro m/s for the wash method influenced pregnancy outcome.

CONCLUSION(S)

Although samples with an acceptable number of motile sperm can be processed efficiently by wash only, poor quality semen samples should be processed using DGC.

Biochemical and functional characterization of the human zona pellucida

A successful interaction between spermatozoa and the zona pellucida is critical for fertilization. This biological step reflects multiple sperm functions, including the acquisition and completion of capacitation, recognition and binding to specific zona pellucida receptors, and induction of the physiological acrosome reaction. The recognition of carbohydrate sequences by complimentary receptors has been demonstrated in gamete interaction in different animal species. It has been proposed that, in the human, sperm binding to the zona pellucida requires a 'selectin-like' interaction. The hemizona assay (a unique internally controlled bioassay that evaluates tight binding of human spermatozoa to the homologous zona pellucida) and advanced methods of carbohydrate analysis have been used to test this hypothesis. Compelling evidence exists to demonstrate that oligosaccharide recognition is also required for specific, tight human gamete binding. The induction of the acrosome reaction using the physiological inducers, i.e. the zona pellucida and progesterone, was also examined. It has also been demonstrated that there is a priming effect of the steroid on the acrosome reaction inducing capacity of the zona pellucida. These studies may allow for a better understanding of human gamete interaction in physiological and pathological situations.

Relationship between zona pellucida-induced acrosome reaction, sperm morphology, sperm-zona pellucida binding, and in vitro fertilization

OBJECTIVE

To evaluate the possible relationships between sperm morphology, acrosome responsiveness to solubilized human zona pellucida, and sperm-zona binding potential among [1] consecutive andrology referrals and [2] randomly selected in vitro fertilization (IVF) cases.

DESIGN

Prospective analytical study.

SETTING

Academic training hospital.Randomly selected couples consulting for infertility.

INTERVENTION(S)

Acrosome reaction response to solubilized human zona pellucida was recorded.

MAIN OUTCOME MEASURE(S)

We determined the difference in the percentage of sperm that acrosome reacted after exposure to solubilized zona pellucida and spontaneous acrosome reaction. The results were expressed as percentage zona induced acrosome reaction (ZIAR).

RESULT(S)

Data were analyzed using correlation coefficients (r) and receiver operator characteristics (ROC curve analyses). The ROC curve analyses indicated ZIAR to be a sensitive indicator for fertilization failure during IVF therapy, with sensitivity and specificity of 81% and 75%, respectively. For andrology referrals, a positive and statistically significant correlation existed between ZIAR data and sperm morphology (r = 0.65) and sperm-zona binding (r = 0.57).

CONCLUSION(S)

ZIAR results provide further information regarding dysfunctional sperm and can be used as an additional diagnostic test. Our results predicted fertilization failure during IVF treatment.

Pathophysiology of oligoasthenoteratozoo-spermia: are we improving in the diagnosis?

Male infertility is one of the most common identifiable causes of human reproductive failure. Although considerable progress has been made toward understanding sperm physiology and the biology of gamete interaction, still more work is needed to achieve objectivity and standardization of some of the andrological diagnostic methods used in the clinical setting. More information is needed to definitively establish which tests are more accurate predictors of sperm performance and how they correlate with pregnancy potential following in-vivo and in-vitro interventions. Infertile men can be successfully treated with defined urological and medical therapies or with assisted reproductive technologies. Among the latter, intracytoplasmic sperm injection (ICSI) has become a validated means to overcome multiple sperm deficiencies. However, male infertility remains idiopathic in a large proportion of cases. As a consequence, it is expected that simplified and more cost-efficient therapeutic modalities will be developed as additional basic (cellular-molecular) and pathophysiological/clinical knowledge is gained.

Should patients with polycystic ovary syndrome be treated with metformin? Benefits of insulin sensitizing drugs in polycystic ovary syndrome--beyond ovulation induction

The debate on metformin use in polycystic ovary syndrome (PCOS) has mainly focused on its treatment for infertility in ovulation induction and menstrual cyclicity. Here we will summarize the data supporting the effect of metformin on improving hyperandrogenaemia and hyperinsulinaemia in PCOS patients. We propose that metformin benefits PCOS patients undergoing gonadotrophin therapy and IVF as well as ovulation induction. We also advocate the use of insulin sensitizing drugs to reduce miscarriage rates, and risks associated with coronary artery disease, gestational diabetes and obesity.

Sperm DNA quality predicts intrauterine insemination outcome: a prospective cohort study

BACKGROUND

We aimed to investigate whether sperm DNA quality may predict intrauterine insemination (IUI) outcome.

METHODS

The study was designed in a prospective cohort fashion, at a tertiary centre for reproductive medicine. A total of 119 patients underwent 154 cycles of IUI. Parameters related to demography, cycle management and semen sample used for IUI were evaluated. Conventional semen parameters, morphology (strict criteria), sperm DNA fragmentation and stability [evaluated by terminal deoxynucleotidyl transferase-mediated dUDP nick-end labelling (TUNEL) and acridine orange staining under both acid and acid + heat denaturing conditions respectively] were measured. The main outcome measure was clinical pregnancy, defined as ultrasonographic visualization of intrauterine gestational sac(s).

RESULTS

Logistic regression analyses were done on six sets of data, including all cycles combined, cycles with washed samples, first cycle of each couple, first cycle of each couple with washed samples, cycles stimulated with gonadotrophins and finally gonadotrophin-stimulated cycles with washed samples. The number of pre-ovulatory follicles on day of hCG, the age of the woman and the percentage of sperm with acid- + heat-resistant DNA were the parameters that predicted IUI outcome in most of these data subsets. For the gonadotrophin-stimulated cycles, age of the man appeared as a predictor as opposed to that of the woman; and for the cycles within this subgroup, where the semen sample was washed, sperm DNA fragmentation and age of the man were the only two parameters to predict IUI outcome. No samples with >12% of sperm having DNA fragmentation resulted in pregnancy.

CONCLUSIONS

The number of follicles, age of the woman/man and sperm DNA quality may predict IUI outcome.

Minimal ovarian hyperstimulation for in vitro fertilization using sequential clomiphene citrate and gonadotropin with or without the addition of a gonadotropin-releasing hormone antagonist

OBJECTIVE

To compare the results of a minimal-stimulation protocol with those of a standard protocol used for IVF.

DESIGN

Retrospective, controlled study.

SETTING

University center.

PATIENT(S)

Fifty-five patients undergoing IVF using a minimal-stimulation protocol with or without adjuvant therapy with a GnRH antagonist. A control group consisted of age- and diagnosis-matched patients undergoing a standard long GnRH agonist (GnRH-a)-gonadotropin stimulation during the same time period.

INTERVENTION(S)

Clomiphene citrate and gonadotropins, with or without the GnRH antagonist ganirelix.

MAIN OUTCOME MEASURE(S)

Oocytes recovered and pregnancy rates.

RESULT(S)

The number of oocytes retrieved was significantly lower for the minimal-stimulation regimen compared with the case of the long GnRH-a protocol (4.8 +/- 2.6 vs. 16.2 +/- 7.5, respectively). The clinical pregnancy rate per transfer, however, was not significantly different between the two regimens (37% vs. 41%, minimal stimulation vs. long GnRH-a protocol, respectively). The addition of ganirelix resulted in at least the same pregnancy outcome as compared with the case of cycles without the antagonist.

CONCLUSION(S)

Minimal stimulation using clomiphene citrate followed by gonadotropin for IVF results in pregnancy rates equal to the standard long GnRH-a-gonadotropin protocol. The addition of ganirelix resulted in at least similar results with the advantage of eliminating the occurrence of a premature endogenous LH surge.

Caspase activity and apoptotic markers in ejaculated human sperm

The objectives of this study were to determine if human ejaculated sperm exhibit active caspases and if caspase-dependent apoptosis markers are identifiable. Sperm from fertile donors and infertile patients were examined after gradient separation into leukocyte-free fractions of high and low motility. Sperm were evaluated for motion parameters, morphology, caspase activation, and apoptosis markers including phosphatidylserine (PS) translocation (annexin V binding) and DNA fragmentation (TUNEL). Active caspase-3 was detected by immunofluorescent microscopy in a small proportion of sperm in situ, in fractions of high and low motility sperm of patients and donors, but low motility fractions had significantly higher numbers of positive sperm. Immunoblot analysis detected inactive procaspase-3 (32 kDa) in all fractions of low sperm motility from patients and donors, while active caspase-3 (17 kDa) was only detected by immunoblotting in a limited number of low motility fractions from patients and in even fewer fractions from donors. Caspase enzymatic activity, as measured using the fluorogenic substrate DEVD-afc, was higher in patients than in donors in both low and high motility fractions. Annexin V staining and DNA fragmentation were detected in a proportion of sperm, with a higher frequency in the low motility fractions. A significant positive correlation between in-situ active caspase-3 in the sperm midpiece and DNA fragmentation was observed in the low motility fractions of patients, suggesting that caspase-dependent apoptotic mechanisms could originate in the cytoplasmic droplet or within mitochondria and function in the nucleus. These data suggest that in some ejaculated sperm populations, caspases are present and may function to increase PS translocation and DNA fragmentation.

Should ICSI be the treatment of choice for all cases of in-vitro conception? No, not in light of the scientific data

There is an ongoing debate among reproductive endocrinologists and embryologists about the indications for ICSI in the management of the infertile couple. Analysis of published results indicates that there are no data to suggest that ICSI should be performed in all cases of in-vitro conception. If the results of the basic semen analysis and sperm function tests demonstrate an impairment of sperm fertilizing capacity, couples should be directed to ICSI. In cases of previous fertilization failure, ICSI usually results in an improved outcome. This suggests the presence of 'occult' male or female gamete defects that can be bypassed by ICSI. We stress that efforts should be geared toward the identification of the aetiology and pathophysiology of sperm and oocyte lesions/dysfunctions responsible for fertilization impairment and their potential contributions to defective embryogenesis. A better definition of the indications for ICSI is needed, together with the development of directed, simpler, less expensive and safer alternatives.

In vivo effect of leukemia inhibitory factor (LIF) and an anti-LIF polyclonal antibody on murine embryo and fetal development following exposure at the time of transcervical blastocyst transfer

Leukemia inhibitory factor (LIF) enhances in vitro murine preimplantation development in a time- and dose-dependent fashion. Knockout experiments have demonstrated that endometrial LIF is essential for in vivo murine implantation. We assessed the impact of LIF and an anti-LIF polyclonal antibody (pab) on in vivo development and developed a novel and successful nonsurgical method of embryo transfer for this species, a transcervical blastocyst transfer technique. The objectives of this study were to evaluate the effects of LIF and the anti-LIF pab on 1) implantation, resorption, pregnancy, and viability rates and 2) the overall structural and skeletal development. Two-cell embryos were recovered from superovulated mated donors, cultured to the expanded blastocyst stage, and transferred transcervically into pseudopregnant recipients. Exposure to 5000 U/ml LIF resulted in significant increases in implantation, pregnancy, and viability rates compared with controls. A similar dose of pab produced overall inhibitory effects with a significant decrease in implantation rate. Paradoxically, lower pab doses resulted in significantly increased viability rates. Exposure to LIF had no effect on fetoplacental development. However, pab treatments had variable but significant negative effects on placental length, ossification of the exoccipital bone, and vertebral space width compared with controls. Exposure of murine blastocysts to LIF at the time of transcervical transfer resulted in pronounced positive effects on implantation and pregnancy rates without affecting fetal development. A similar pab dose dramatically reduced implantation and pregnancy rates; at high and low doses, pab produced deleterious effects on placental and skeletal development.

Zona pellucida-induced acrosome reaction in human sperm: dependency on activation of pertussis toxin-sensitive G(i) protein and extracellular calcium, and priming effect of progesterone and follicular fluid

In these studies, we aimed to characterize the effects of the physiological, homologous agonists of the acrosome reaction, i.e. the zona pellucida (ZP) and progesterone/follicular fluid, on human sperm. The specific aims of our studies were: (i) to examine the dependency of the solubilized ZP-induced acrosome reaction on G(i) protein activation and presence of extracellular calcium; and (ii) to determine whether progesterone/follicular fluid exert a priming or synergist effect on the solubilized ZP-induced acrosome reaction. Highly motile sperm from fertile donors were exposed to the agonists in a microassay and the acrosomal status of live sperm was determined by indirect immunofluorescence using PSA-FITC/Hoechst double-staining. Pretreatment with pertussis-toxin (100 ng/ml) and EGTA (2.5 mmol/l) significantly inhibited the ZP-induced acrosome reaction without affecting the spontaneous rate of exocytosis. Progesterone (1.25 microg/ml) and human follicular fluid (10%) exerted a priming, time-dependent effect on the ZP-induced acrosome reaction. These studies demonstrated that: (i) acrosomal exocytosis of capacitated human sperm triggered by the homologous ZP is dependent on the activation of G(i) proteins (pertussis toxin-sensitive) and the presence of extracellular calcium; and (ii) progesterone and follicular fluid exert a priming effect on the ZP-induced acrosome reaction.

Zona pellucida induced acrosome reaction, sperm morphology, and sperm-zona binding assessments among subfertile men

PURPOSE

The study aimed to evaluate the relationship between the zona pellucida induced acrosome reaction (ZIAR) and (i) percentage normal spermatozoa as well as (ii) sperm-zona pellucida binding potential among men referred for a routine semen analysis.

METHODS

Semen samples of 164 consecutive men referred to the andrology laboratory for routine semen analysis were studied. Semen samples were analyzed using the new WHO standards (strict criteria). ZIAR was recorded with a lectin conjugated Pisum sativum agglutinin microassay, while sperm-zona binding was evaluated with a standard hemizona assay (HZA).

RESULTS

Andrology patients were divided according to the percentage normal spermatozoa in the ejaculate, namely <4% normal forms (n = 71), 5-14%, normal forms (n = 73), and >14% normal forms (n = 20). ZIAR data of the <4%, 5-14%, and >14% groups was (9.6 +/- 0.6)%, (13.9 +/- 0.5)%, and (15.0 +/- 1.1)%, respectively. The ZIAR data of fertile control men was (26.6 +/- 1.4)% which differed significantly from the three andrology referrals groups. Likewise significant differences were recorded during the hemizona assay namely, 38.0% (<4% normal forms), 54.5% (5-1% normal forms), and 62.6% (>14% normal forms). Among the group with >14% normal forms, five cases had impaired ZIAR outcome (<15%). Three of these men had normal morphology and HZAs.

CONCLUSIONS

ZIAR testing should become part of the second level of male fertility investigations, i.e., sperm functional testing, since 15% of andrology referrals revealed an impaired acrosome reaction response to solubilized zona pellucida.

Intrauterine insemination: a systematic review on determinants of success

Intrauterine insemination (IUI) is a frequently indicated therapeutic modality in infertility. Here, a systematic review of the literature was performed to examine the current status of clinical and laboratory methodologies used in IUI and the impact of female and male factors on pregnancy success. Emphasis was centred in questioning the following: (i) the value of IUI against timed intercourse; (ii) IUI application with or without controlled ovarian hyperstimulation; (iii) timing and frequency of IUI; and (iv) impact of various parameters (male/female) on the prediction of pregnancy outcome. The odds of multiple pregnancy occurrence and its risk factors, as well as the cost-effectiveness of IUI treatment compared with more complex assisted reproductive technologies are discussed. A computerized literature search was performed including Medline and the Cochrane library, as well as a crossover search from retrieved papers. It is concluded that although IUI is a successful contemporary treatment for appropriately selected cases of female and/or male infertility, further research is needed through well-designed studies to improve the methodologies currently utilized. Importantly, the clinical management of the infertile couple should be performed in an expedited manner taking into consideration the age of the woman, the presence of multifactorial infertility and cost-effectiveness of the available treatment alternatives.

Effect of different incubation conditions on phosphatidylserine externalization and motion parameters of purified fractions of highly motile human spermatozoa

The objective of this study was to assess the temporal effects of sperm incubation at body temperature with various amounts of human serum albumin (HSA) on motion parameters and phosphatidylserine externalization, an expression of membrane integrity. Purified sperm populations were prepared by discontinuous gradient separation, incubated at 37 degrees C in 3 different culture conditions (human tubal fluid [HTF] alone, HTF plus 0.3% HSA, and HTF plus 3% HSA) and evaluated at 0, 1, 3, 6, and 24 hours. Annexin V binding was used to monitor membrane translocation of phosphatidylserine and a computer-assisted semen analyzer was used to evaluate motion parameters. All incubation conditions led to a time-dependent, significant decline in sperm motion parameters and an increase in exposure of phosphatidylserine (annexin V+, live cells) to the outer leaflet of the plasma membrane in both patients and donors. Patients had a higher degree of motility loss and externalization of phosphatidylserine than donors. The decline in the percentage of normal cells (annexin V-, live) was greater in HTF alone up to 6 hours, and the decline in the percentages of motile and rapid sperm were greater in HTF alone throughout 24 hours when compared with HSA supplementation. We conclude that prolonged incubation of purified populations of highly motile human spermatozoa at body temperature was associated with significant motility loss and membrane changes as revealed by phosphatidylserine translocation. A higher concentration of HSA resulted in a relative protective effect against such impairments, particularly during the first 6 hours of incubation. Under the experimental conditions tested, significant differences were observed between infertile men and fertile controls.

Functional studies of subcutaneous ovarian transplants in non-human primates: steroidogenesis, endometrial development, ovulation, menstrual patterns and gamete morphology

BACKGROUND

The study objective was to determine if ovarian function would be restored following fresh and cryopreserved extrapelvic autologous ovarian transplantation and if vascular endothelial growth factor (VEGF) administration would augment the success rate.

METHODS

Sixteen regularly cycling female cynomolgus monkeys underwent bilateral oophorectomy and were randomly assigned to one of three treatment groups: (i) sham transplant group (n = 5) underwent transplantation of pieces of adipose tissue; (ii) fresh autologous ovarian transplantation without VEGF administration (n = 6) and (iii) fresh autologous ovarian transplantation with 1 microg of VEGF (n = 5) administered at the transplantation site daily for 14 days after transplantation. The ovarian tissue from the sham transplanted group was cryopreserved. This material was later thawed and transplanted in four out of five of the sham operated group.

RESULTS

Five out of six (83%) of the primates in our transplantation group without VEGF had functioning ovarian transplants while two of five (40%) primates in our transplantation group with VEGF administration had functioning ovarian transplants. The cryopreserved group had two of four primates (50%) with functioning transplants. Ovarian stimulation yielded multiple follicles and one metaphase II oocyte from the fresh and one metaphase II oocyte from the cryopreserved group.

CONCLUSIONS

The success of ovarian transplantation in these non-human primates with menstrual cycles bodes well for the development of ovarian transplantation protocols for women at risk of ovarian failure.

Delaying the initiation of progesterone supplementation results in decreased pregnancy rates after in vitro fertilization: a randomized, prospective study

OBJECTIVE

To compare IVF outcome between two protocols for luteal phase supplementation, one beginning on day 3 after oocyte retrieval and the other beginning on day 6 after retrieval.

DESIGN

Prospective, randomized study.

SETTING

University-based assisted reproductive technology center.

PATIENT(S)

One hundred twenty-six consecutive patients undergoing IVF between January and July 2000.

INTERVENTION(S)

Patients were randomized to begin luteal phase support using vaginal progesterone beginning either on day 3 after oocyte retrieval or on day 6 after oocyte retrieval.

MAIN OUTCOME MEASURE(S)

Clinical pregnancy rates and implantation rates.

RESULT(S)

All patients randomized underwent transfer. There were no differences in age, oocytes retrieved, or embryos transferred between the two groups. Those patients receiving luteal phase support with progesterone beginning on day 6 after retrieval had a significantly lower clinical pregnancy rate per transfer compared with those beginning support on day 3 after retrieval (44.8% vs. 61.0%, respectively). This difference in pregnancy rates was greater in those patients undergoing a luteal gonadotropin releasing hormone (GnRH) agonist down-regulation protocol (47.5% vs. 71.4%, day 6 vs. day 3, respectively). Beginning support on day 6 also significantly decreased implantation rates in the GnRH agonist group (21.0% vs. 34.0%, day 6 vs. day 3, respectively).

CONCLUSION(S)

Pregnancy rates are significantly decreased by initiating luteal-phase progesterone supplementation on day 6 after oocyte retrieval during in vitro fertilization cycles.

Cryopreservation of fractionated, highly motile human spermatozoa: effect on membrane phosphatidylserine externalization and lipid peroxidation

INTRODUCTION

This study investigated lipid peroxidation (LPO) and membrane integrity following cryopreservation-thawing.

METHODS

Infertile men (study group) and donors (control group) were examined. Purified populations of highly motile spermatozoa were cryopreserved using TEST-yolk buffer and glycerol (TYB-G) followed by quick thaw. LPO was measured by a spectrophotometric assay, with and without a ferrous ion promoter. Annexin V binding was used to assess membrane translocation of phosphatidylserine (PS).

RESULTS

Pre-freeze LPO was significantly higher in the study than in the control group (P = 0.03). In both groups, LPO measurements after thawing were significantly higher than the pre-freeze samples not exposed to TYB-G (P = 0.002 and P = 0.001 respectively). However, when the pre-freeze samples with TYB-G were compared with the post-thaw samples (all exposed to TYB-G), these differences were not significant. There was a significant increase in PS externalization following cryopreservation in both groups (P = 0.02 and P = 0.003 respectively). In donors, pre-freeze LPO concentrations had a significant positive correlation with thawed spermatozoa depicting PS externalization (r = 0.77, P = 0.04).

CONCLUSION

Although patients had higher basal LPO than donors, LPO did not differ between fresh and cryopreserved-thawed fractionated motile spermatozoa. Freezing-thawing was associated with translocation of PS to the external membrane leaflet.

Characterization of telomerase activity in the human oocyte and preimplantation embryo

Telomerase, a ribonucleoprotein, has been described as an essential component of highly proliferative cells as it stabilizes the telomeres and avoids cellular senescence. The objective of this study was to modify the polymerase chain reaction-based telomeric repeat amplification protocol to detect telomerase activity in the single cell and to characterize the activity expressed in the human oocyte through to the blastocyst stage embryo. A comparative evaluation of telomerase activity and developmental stage was conducted using discarded or donated human oocytes and embryos. Telomerase activity was detected in all developmental stages evaluated from immature oocytes through to blastocyst stage embryos. Immature oocytes and blastocysts had similar levels of telomerase activity; however, both groups had significantly (P < 0.05) higher activity than zygote through to pre-morula stage embryos. Seventy-five thawed zygotes were cultured to day 3, biopsied by removing 1-2 cells, and the biopsied embryos were cultured to blastocyst stage. There was no difference (P < 0.05) in telomerase activity between cells biopsied from embryos that reached the blastocyst stage and cells from those that arrested in growth. This study has shown that human oocytes through to blastocyst stage embryos express telomerase activity, but that the level of telomerase activity in biopsied blastomeres, of the day 3 cleavage stage embryo, is not predictive of embryonic growth potential.

High FSH:LH ratio and low LH levels in basal cycle day 3: impact on follicular development and IVF outcome

PURPOSE

To examine the impact of low basal cycle day 3 serum LH levels or a high FSH:LH ratio on IVF results.

METHODS

A homogeneous group of patients was analyzed as identified by normal basal cycle of follicle stimulating hormone (FSH), Luteinizing hormone (LH), and estradiol (E2) levels. High responders (high LH:FSH ratio) and low responders (high FSH or E2 levels, and women > or = 42 years of age) were excluded from analysis. Only cycles stimulated with a combination of a GnRHa (luteal suppression) and pure FSH were studied.

RESULTS

Patients with low basal LH levels (< 3 mIU/mL) did not differ significantly from controls in terms of response to controlled ovarian hyperstimulation but there was a clear trend toward poorer implantation and clinical pregnancy rates. On the other hand, patients with a high FSH:LH ratio (> 3) had significantly fewer mature oocytes aspirated, and lower implantation and clinical pregnancy rates than patients with gonadotropin ratio < or = 3. These negative effects were evident in the presence of normal basal FSH levels and after adequate matching of female's age and number of embryos transferred.

CONCLUSIONS

These studies highlight a negative impact of a basal cycle high FSH:LH ratio (and possibly low LH levels) on follicular development and oocyte quality in these patients subjected to pituitary down-regulation followed by pure FSH administration. A high FSH:LH ratio may be therefore used as an early biomarker of poor ovarian response.