Endocrine profile in serum and follicular fluid differs after ovarian stimulation with HP-hMG or recombinant FSH in IVF patients

Exposing cultured mouse ovarian follicles under increased gonadotropin tonus to aromatizable androgens influences the steroid balance and reduces oocyte meiotic capacity

Acquisition of oocyte developmental competence relies on the well-controlled events accompanying antral follicular development. Elevated basal androgen levels, as in PCOS, potentially affect oocyte quality. Current experiments in an in vitro follicle bioassay studied dose-effects of androstenedione and testosterone on FSH and hCG stimulated antral follicle growth and meiotic maturation. The addition of either androgens altered follicle's endogenous production of androstenedione, testosterone, estradiol, and progesterone and affected the oocyte's capacity to resume meiosis. Exposure to 200 nM androstenedione induced an increased production of testosterone and estradiol. Exposure to a concentration of ≥200 nM testosterone induced elevated levels of estradiol and progesterone. Significant dose-dependent negative effects on polar body extrusion were seen at concentrations of ≥200 nM of either androgen. In addition, chromosome displacement on the metaphase plate was observed in oocytes obtained from androstenedione-treated follicles. Follicles exposed to a combination of 25 mIU/ml FSH and 3 mIU/ml hCG and elevated aromatizable androgens altered the steroid production profile, affected the follicular development and impaired oocyte meiotic competence.

A prospective randomized noninferiority study comparing recombinant FSH and highly purified menotropin in intrauterine insemination cycles in couples with unexplained infertility and/or mild-moderate male factor

OBJECTIVE

To demonstrate the noninferiority of highly purified menotropin (HP-hMG) compared with recombinant FSH (rFSH) regarding clinical pregnancy rate (PR) in intrauterine insemination (IUI) cycles.

DESIGN

Prospective randomized noninferiority trial.

SETTING

Unit of physiopathology of human reproduction, university hospital.

PATIENT(S)

Five hundred twenty-three patients with unexplained infertility or mild male infertility undergoing controlled ovarian hyperstimulation for IUI.

INTERVENTION(S)

Patients were randomized for treatment with rFSH (262 patients) or HP-hMG (261 patients). Insemination was performed 34-36 hours after hCG injection.

MAIN OUTCOME MEASURE(S)

The primary outcome was clinical pregnancy rate (PR). The secondary outcome was the number of interrupted cycles for high risk of ovarian hyperstimulation syndrome (OHSS) and multiple pregnancy.

RESULT(S)

The clinical PR was 19.7% (95% confidence interval [CI] 15.3%-25.1%) in the HP-hMG group and 21.4% (95% CI 16.9%-26.8%) in the rFSH group [absolute difference -1.7% (95% CI -8.6%-5.2%)]; therefore, the noninferiority was demonstrated. The number of interrupted cycles for OHSS risk and multiple pregnancy was significantLy higher in the rFSH group, 8.4% (95% CI 5.6%-12.4%) than in the HP-hMG group 1.2% (95% CI 0.4%-3.3%) [absolute difference -7.27% (95% CI -11.3 to -3.7)].

CONCLUSION(S)

HP-hMG is not inferior compared with rFSH regarding clinical PR.

Recombinant human follicle-stimulating hormone produces more oocytes with a lower total dose per cycle in assisted reproductive technologies compared with highly purified human menopausal gonadotrophin: a meta-analysis

BACKGROUND

Human menopausal gonadotrophins and recombinant human follicle stimulating hormone are the two main gonadotrophin products utilized for controlled ovarian stimulation in assisted reproductive technologies. In this meta-analysis, the number of oocytes was designated as the most relevant endpoint directly resulting from ovarian stimulation, and therefore where the drug effect may be estimated with the best sensitivity.

METHODS

All published randomized controlled trials on ovarian stimulation comparing the two gonadotrophin products were evaluated. Internal validity was determined using Chalmers' validated scale. If trials did not meet the established quality criteria, a sensitivity analysis assessed the stability of the results. The comparison of continuous variables was conducted following the weighted mean difference and the standardized mean difference (Cohen's effect size) with the random model. Given the known relationship of baseline conditions on treatment endpoints, results were adjusted for age, body mass index and type of infertility.

RESULTS

Sixteen studies involving 4040 patients were included. Treatment with human menopausal gonadotrophins resulted in fewer oocytes (-1.54; 95% CI: -2.53 to -0.56; P < 0.0001) compared to recombinant human follicle-stimulating hormone. When adjusting for baseline conditions, the mean difference estimate was -2.10 (95% CI: -2.83 to -1.36; P < 0.001). A higher total dose of human menopausal gonadotrophin was necessary (mean difference, 235.46 IU [95% CI: 16.62 to 454.30; P = 0.03]; standardized mean difference, 0.33 [95% CI: 0.08 to 0.58; P = 0.01]). The pregnancy absolute risk difference (RD [hMG-r-hFSH]) for fresh transfers was 3% (P = 0.051), and the relative risk 1.10 (P = 0.06). When adjusted for baseline conditions, the relative risk was 1.04 (P = 0.49) and absolute difference was 0.01 (P = 0.34), respectively.

CONCLUSIONS

Because baseline conditions are predictive of outcome, meta-analytic results are more sensitive when these variables are considered. Using an endpoint closely associated with the stimulation period, sufficient sensitivity is achieved to compare gonadotrophin treatments. As the largest meta-analysis published to date on this subject, treatment with human menopausal gonadotrophins is characterized by fewer oocytes and a higher total dose. When considering only fresh transfers, pregnancy rates were similar.

HP-HMG versus rFSH in treatments combining fresh and frozen IVF cycles: success rates and economic evaluation

The economic implications of the choice of gonadotrophin influence decision making but their cost-effectiveness in frozen-embryo transfer cycles has not been adequately studied. An economic evaluation was performed comparing highly purified human menopausal gonadotrophin (HP-HMG) and recombinant FSH (rFSH) using individual patient data (n=986) from two large randomized controlled trials using a long agonist IVF protocol. The simulation model incorporated live birth data and published UK costs of IVF-related medical resources. After treatment for up-to-three cycles (one fresh and up to two subsequent fresh or frozen cycles conditional on availability of cryopreserved embryos), the cumulative live birth rate was 53.7% (95% CI 49.3-58.1%) for HP-HMG and 44.6% (40.2-49.0%) for rFSH (OR 1.44, 95% CI 1.12-1.85; P<0.005). The mean costs per IVF treatment for HP-HMG and rFSH were pound5393 ( pound5341-5449) and pound6269 ( pound6210-6324), respectively (number needed to treat to fund one additional treatment was seven; P<0.001). With maternal and neonatal costs applied, the median cost per IVF baby delivered with HP-HMG was pound11,157 ( pound11,089-11,129) and pound14,227 ( pound14,183-14,222) with rFSH (P<0.001). The cost saving using HP-HMG remained after varying model parameters in a probabilistic sensitivity analysis.

Liquid chromatography-tandem mass spectrometry applications in endocrinology

Liquid chromatography-tandem mass spectrometry (LC-MS/MS) has been recognized as a primary methodology for the accurate analysis of endogenous steroid hormones in biological samples. This review focuses on the use of LC-MS/MS in clinical laboratories to assist with the diagnosis of diverse groups of endocrine and metabolic diseases. Described analytical methods use on-line and off-line sample preparation and analytical derivatization to enhance analytical sensitivity, specificity, and clinical utility. Advantages of LC-MS/MS as an analytical technique include high specificity, possibility to simultaneously measure multiple analytes, and the ability to assess the specificity of the analysis in every sample. All described analytical methods were extensively validated, utilized in routine diagnostic practice, and were applied in a number of clinical and epidemiological studies, including a study of the steroidogenesis in ovarian follicles.

Cumulus cell gene expression is associated with oocyte developmental quality and influenced by patient and treatment characteristics

BACKGROUND

Gene expression of cumulus cells (CC) could predict oocyte developmental quality. Knowledge of the genes involved in determining oocyte quality is scanty. The aim was to correlate clinical and biological characteristics during ovarian stimulation with the expression of 10 selected genes in CC.

METHODS

Sixty-three ICSI patients were stimulated with GnRH-agonist plus highly purified hMG (n = 35) or recombinant FSH (n = 28). Thirteen variables were analyzed: Age, BMI, duration of stimulation, serum concentrations of progesterone, 17beta-estradiol, FSH and LH on day of hCG, Ovarian Response, Oocyte Maturity, 2 pronuclei and three embryo morphology related variables: > or =7 cells, Low Fragmentation, Good Quality Embryos score. Expression of HAS2, VCAN, SDC4, ALCAM, GREM1, PTGS1, PTGS2, DUSP16, SPROUTY4 and RPS6KA2 was analyzed in pooled CC using quantitative PCR, and the relationship to the 13 variables was evaluated by multivariable analysis.

RESULTS

All 10 genes are expressed at oocyte retrieval, with PTGS1, SPROUTY4, DUSP16 and RPS6KA2 described in human ovary for the first time. The three variables that correlated most often with differential expression were Age, BMI and serum FSH level. Significant correlation was found with Oocyte Maturity (VCAN, P < 0.005), Low Fragmentation (RPS6KA2, P < 0.05), Embryos with > or =7 cells (ALCAM and GREM1, P < 0.05). The expression of the other genes was also correlated to oocyte developmental quality but to a less extent. SDC4, VCAN, GREM1, SPROUTY4 and RPS6KA2 showed gonadotrophin preparation-dependent expression and/or interactions (all P < 0.05).

CONCLUSION

The expression of ovulation related genes in CC is associated with patient and treatment characteristics, oocyte developmental potential and differs with the type of gonadotrophin used.

Pre-stimulation parameters predicting live birth after IVF in the long GnRH agonist protocol

This retrospective study aimed to identify novel pre-stimulation parameters associated with live birth in IVF and to develop a model for prediction of the chances of live birth at an early phase of the treatment cycle. Data were collected from a randomized trial in couples with unexplained infertility, tubal factor, mild male factor or other reason for infertility. All women (n=731) had undergone an IVF cycle (no intracytoplasmic sperm injection) after stimulation with human menopausal gonadotrophin or follicle-stimulating hormone following the long gonadotrophin-releasing hormone agonist protocol. The univariate tests identified several novel parameters that were significantly (P<0.05) associated with live birth (duration of agonist use, endometrial thickness, pre-stimulation progesterone, androstenedione and total testosterone concentrations, pre-stimulation free androgen index and primary infertility diagnosis), in addition to the well-known predictors female age and duration of infertility. Using multivariable logistic regression analysis, the best predictive model (area under the curve=0.65) was obtained using the parameters age, duration of infertility, infertility diagnosis, endometrial thickness and pre-stimulation total testosterone and sex hormone-binding globulin concentrations. The results indicate that younger age and marked suppression of ovarian steroids prior to starting stimulation may increase the likelihood of live birth in the long protocol.

LH supplementation in down-regulated women undergoing assisted reproduction with baseline low serum LH levels

AIM

The aim of our study is to evaluate the effect of recombinant-human LH supplementation on ovarian response and pregnancy outcome, during ovarian stimulation, in down-regulated women with baseline low serum LH levels undergoing assisted reproductive technology.

STUDY DESIGN

A prospective randomized study performed with 80 women, with serum LH levels 50.5 IU/l on cycle Day 6 of stimulation. Group-A (40): 14-days after down-regulation with leuprorelin, ovarian stimulation was initiated only with r-FSH 225 IU. Group-B (40): at the same time stimulation was initiated with rFSH 225 IU associated with rLH 75 UI on cycle Day 6 of stimulation.

RESULTS

Serum-E2 levels on the hCG-day administration were significantly reduced in the Group-A. FF-VEGF levels were higher in Group-A. We did not find significant differences in the number of retrieved oocytes. The quality of oocytes proved to be higher and more significant from a statistical point of view in Group-B. The number of embryos obtained and transferred, the pregnancy rate lower in Group-A.

CONCLUSIONS

In our study, it was shown that LH supplementation seems to have a beneficial effect on the maturity and fertilizability of oocyte. Lower FF VEGF levels, found in Group B, could be an indication of a lower apoptosis rate in human cumulus cells after administration of LH. We can affirm that LH-supplementation is beneficial in patients who show asignificant serum LH suppression during the receptorial down-regulation

Identifying real differences in live birth rates between HMG and rFSH in IVF

Fertility treatment strives for the delivery of a healthy live birth. Human menopausal gonadotrophin (HMG) and recombinant FSH (rFSH) are the two types of gonadotrophin currently used for ovarian stimulation in assisted reproduction treatments. Although both HMG and rFSH have been shown to be effective, a number of studies have examined whether a potential difference in clinical benefit or outcome exists between treatments. Unlike rFSH preparations, HMG contains both FSH and LH activity (in the form of LH and human chorionic gonadotrophin, which are short- and long-acting, respectively). The beneficial effect of exogenous LH activity has been investigated in the Menotrophin versus Recombinant FSH in-vitro Fertilisation Trial (MERiT), which revealed differences in embryo quality and endometrial receptivity between rFSH and highly purified HMG. Current evidence suggests that HMG provides significantly higher live birth rates than rFSH in women undergoing ovarian stimulation for in-vitro fertilization/intracytoplasmic sperm injection cycles using long gonadotrophin-releasing hormone agonist protocol. Further studies will continue to provide data with which to expand these findings and optimize the chances of achieving a live birth following assisted reproduction treatment.

Efficacy of recombinant versus human derived follicle stimulating hormone on the oocyte and embryo quality in IVF-ICSI cycles: Randomised, controlled, multi-centre trial

The aim of this trial, comparing human follicle stimulating hormone (hFSH) and recombinant FSH (rFSH) was to evaluate the efficacy on oocyte and embryo quality in in vitro fertilisation/intracytoplasmic sperm injection cycles. Four-hundred and one women were randomised in two groups to receive or hFSH or rFSH in stimulation protocols. The primary end point of this study was the oocyte/embryo quality. No significant difference in oocyte/embryo quality was observed between the two groups. The number of oocytes retrieved was significantly higher in the hFSH group (6 +/- 2.8 in hFSH group vs. 5 +/- 2.6 in rFSH group; P = 0.003). A less amounts of gonadotropins consumed (2106 +/- 719 IU in hFSH group vs. 3536 +/- 1099 IU in rFSH group; P < 0.0001) and shorter duration of stimulation (human chorionic gonadotropin day of administration: Day 12.3 +/- 1.0 in hFSH and Day 13.3 +/- 1.2 in rFSH group, respectively; P < 0.0001) was registered in hFSH group. Fertilisation, cleavage and implantation rates, pregnancy and abortion rates were similar in both groups. However, lower clinical abortion rate (not significant) in hFSH group might be noteworthy. In our study, we demonstrated that hFSH and rFSH products are equivalent in terms of clinical efficacy.

Intrafollicular antimüllerian hormone levels predict follicle responsiveness to follicle-stimulating hormone (FSH) in normoandrogenic ovulatory women undergoing gonadotropin releasing-hormone analog/recombinant human FSH therapy for in vitro fertilization and embryo transfer

OBJECTIVE

To investigate the relationship between antimüllerian hormone (AMH) and steroidogenesis in follicles of normoandrogenic ovulatory women undergoing follicle-stimulating hormone (FSH) therapy for in vitro fertilization/embryo transfer (IVF-ET).

DESIGN

Prospective cohort.

SETTING

Institutional/private practice.

PATIENT(S)

26 normoandrogenic ovulatory women. All women received gonadotropin-releasing hormone (GnRH) analog and ovarian stimulation for IVF-ET.

INTERVENTION(S)

Follicle fluid was aspirated at oocyte retrieval from the first follicle of each ovary.

MAIN OUTCOME MEASURE(S)

Follicle fluid was assayed for AMH, estradiol (E(2)), progesterone, androstenedione, testosterone, dihydrotestosterone, insulin, and FSH.

RESULT(S)

Intrafollicular AMH levels positively and negatively correlated with E(2) and FSH concentrations in follicles, respectively, causing a positive relationship between follicle fluid AMH levels and E(2)/FSH ratios as a measure of follicle sensitivity to FSH. A positive relationship also existed in follicles between AMH levels and E(2)/androgen ratios as a marker of aromatase activity.

CONCLUSION(S)

The AMH levels in follicles of IVF patients positively correlate with follicle sensitivity to FSH.

Follicular fluid steroid hormone levels are associated with fertilization outcome after intracytoplasmic sperm injection

OBJECTIVE

To investigate the association between hormone levels from individual follicles and fertilization outcome among patients undergoing intracytoplasmic sperm injection (ICSI). Differences in concentrations of selected sex steroids and pituitary hormones in individual follicular aspirates between oocytes that fertilize successfully, those that fail to fertilize, and those that degenerate with ICSI were examined.

DESIGN

Prospective cohort study.

SETTING

Academic medical center.

PATIENT(S)

Women undergoing ovarian stimulation and ICSI.

INTERVENTION(S)

Follicular fluid was sampled by transvaginal ultrasound-guided aspiration of the hyperstimulated ovary. Each follicle was individually aspirated and collected. Intracytoplasmic sperm injection and subsequent embryo culture were performed using standard laboratory technique. Follicular fluid gonadotropin and steroid hormone levels were measured by immunoassay.

MAIN OUTCOME MEASURE(S)

Oocyte fertilization outcome with ICSI.

RESULT(S)

Oocytes that fertilized normally came from follicles with higher estradiol (adjusted odds ratio [AOR]=1.28) and testosterone (AOR=1.35) concentrations compared with those that degenerated with ICSI. Oocytes that fertilized normally also came from follicles with higher estradiol (AOR=1.14) and progesterone (AOR=1.09) concentrations compared with those that failed to fertilize.

CONCLUSION(S)

The hormonal profile of the follicular fluid yielding a degenerative egg or an egg that fails to fertilize is different from that resulting in normal fertilization. Higher follicular fluid estradiol may be a marker for oocytes that will fertilize normally with ICSI.

A differential cytokine expression profile is induced by highly purified human menopausal gonadotropin and recombinant follicle-stimulating hormone in a pre- and postovulatory mouse follicle culture model

OBJECTIVE

To compare the differential effects of highly purified (HP) hMG or recombinant FSH (rFSH) on cytokine expression before and after ovulation in an in vitro mouse ovarian follicle model.

DESIGN

A prospective laboratory in vitro study.

SETTING

A university-based reproductive biology laboratory. MATERIAL(S): Mechanically isolated mouse preantral follicles from 14-day-old prepubertal mouse ovaries (F1 hybrids: C57BL/6JxCBA/ca).

INTERVENTION(S)

Randomly distributed mouse early preantral follicles were exposed to two hyperstimulation conditions with either HP-hMG or rFSH. An ovulatory stimulus was given using hCG/epidermal growth factor. Conditioned media from the two culture conditions were collected on the days before and after in vitro ovulation. Conditioned media were compared for their relative cytokine profile content as measured by a cytokine antibody array analysis.

MAIN OUTCOME MEASURE(S)

Relative concentrations of 62 cytokines in conditioned media before and after ovulation.

RESULT(S)

Statistically significant increase in the production of a number of cytokines was found after HP-hMG stimulation compared with rFSH: 14 and 24 pre- and post-rhCG, respectively. Cytokines with the largest significant difference (more than 5 times) before and after ovulation included thymus-expressed cytokine (TECK), sTNFRI, and SDF-1alpha. The cytokines that are most strongly related to oocyte and embryo quality and implantation and that have been related to oocyte yield and maturation were significantly higher with HP-hMG.

CONCLUSION(S)

The significant differences in follicular cytokine production induced by HP-HMG and rFSH before and after in vitro ovulation might explain the difference in treatment outcome.

Applications of estradiol and testosterone assays in the management of the infertile female patient

A collaborative effort to improve steroid hormone measurements in patient care was convened by the Centers for Disease Control in March 2008 to discuss the need for enhanced performance and standardization of clinical estradiol and testosterone assays. This article discusses the current status of estradiol and testosterone assays in the treatment of infertile women to include the assessment of ovarian reserve, ovulation induction and follicle tracking, ovarian hyperstimulation syndrome, and the role of testosterone in fertility management.

Highly purified HMG versus recombinant FSH for ovarian stimulation in IVF cycles

The objective of this study was to compare the live birth rates resulting from ovarian stimulation with highly purified human menopausal gonadotrophin (HP-HMG), which combines FSH and human chorionic gonadotrophin-driven LH activities, or recombinant FSH (rFSH) alone in women undergoing IVF cycles. An integrated analysis was performed of the raw data from two randomized controlled trials that were highly comparable in terms of eligibility criteria and post-randomization treatment regimens with either HP-HMG or rFSH for ovarian stimulation in IVF, following a long down-regulation protocol. All randomized subjects who received at least one dose of gonadotrophin in an IVF cycle (HP-HMG, n = 491; rFSH, n = 495) were included in the analysis. Subjects who underwent intracytoplasmic sperm injection cycles were excluded. The superiority of one gonadotrophin preparation over the other was tested using the likelihood ratio test in a logistic regression analysis. The live birth rate per cycle initiated was 26.5% (130/491) with HP-HMG and 20.8% (103/495) with rFSH (P = 0.041). The odds ratio in favour of HP-HMG was 1.36 (95% confidence interval: 1.01-1.83). Thus, the findings of this integrated analysis demonstrate that ovarian stimulation with HP-HMG, following a long down-regulation protocol, in IVF cycles results in significantly more live births than stimulation with rFSH alone.

Morphological selection of gametes

Methods of selecting gametes before the intracytoplasmic sperm injection (ICSI) technique are of paramount importance, especially where for religious, ethical or legal reasons the production of supernumerary embryos has to be avoided. In these circumstances, in fact, the research has to be focused on the identification of early markers of embryo quality at the oocyte and sperm stage before fertilisation. Oocyte quality can be influenced by several factors such as controlled ovarian hyperstimulation protocols, pharmaceutical preparations and perifollicular vascularisation. Several intracytoplasmic and extracytoplasmic abnormalities have been described, but whether these abnormalities might be predictive of oocyte competence is controversial and the selection methods proposed are still poorly effective. Recently, we have observed that oocyte morphological abnormalities might be indicators of oocyte competence. An abnormal first polar body (but not fragmented), a large perivitelline space, increased cytoplasmic granularity, and the presence of a centrally located granular area seem to have a negative effect on the oocyte potential to fertilise, cleave, and/or develop into a viable embryo. Sperm morphology can be more accurately observed at high magnification using an inverted microscope equipped with Normarski optics (1000x magnification under mineral oil) and a digital system in order to reach a final magnification of approximately 6300x. Single sperm nuclear abnormalities based on strict selection criteria seems to have a clear negative association with ICSI outcome. The possibility of observing the spermatozoa in real time at higher magnification might also be a good opportunity to study the relationship between particular sperm defects and ICSI outcome. In addition to morphology, it has been suggested that spermatozoa selection might be performed on the basis of its biochemical ability to bind to solid hyaluronic acid. However, it must be underlined that prospective randomised studies are necessary to confirm the preliminary results regarding the efficacy of the described criteria proposed, to morphologically select gametes prior to in vitro insemination.

Highly purified hMG versus recombinant FSH in ovarian hyperstimulation with GnRH antagonists--a randomized study

BACKGROUND

Highly purified hMG (hp-hMG) has recently shown better cycle outcome than the recombinant FSH (rFSH) when compared in GnRH agonist long protocol cycles. However, they have not yet been compared in GnRH antagonist cycles.

METHODS

A RCT comparing the ongoing pregnancy rate (primary end-point) in 280 patients undergoing IVF/ICSI after stimulation with hp-hMG or rFSH controlled with a GnRH antagonist.

RESULTS

No significant differences were observed between hp-hMG and rFSH in terms of the ongoing pregnancy rate per started cycle (35.0 versus 32.1%, respectively; P = 0.61); relative risk: 1.09 (95% confidence interval: 0.78-1.51; risk difference: 2.9%). No differences were observed for implantation, clinical pregnancy and pregnancy loss rates. More oocytes were obtained from patients receiving rFSH then hMG (14.4 +/- 8.1 versus 11.3 +/- 6.0, respectively; P = 0.001). Estradiol was higher at the end of stimulation in the hp-hMG group (P = 0.02), whereas progesterone was higher in patients stimulated with rFSH (P < 0.001).

CONCLUSIONS

A similar outcome was observed for hp-hMG and rFSH when used for stimulation in GnRH antagonist cycles. However, some differences were found in ovarian response in terms of oocyte yield and hormonal profile. Clinical Trials.gov

TRIAL REGISTRATION NUMBER

NCT00669786.

Effectiveness of highly purified human menopausal gonadotropin vs. recombinant follicle-stimulating hormone in first-cycle in vitro fertilization–intracytoplasmic sperm injection patients

OBJECTIVE

To compare the effectiveness of highly purified hMG with recombinant FSH (rFSH) in IVF-intracytoplasmic sperm injection patients who were treated with a GnRH agonist.

DESIGN

An open-label, prospective, randomized comparison of fixed gonadotropin regimens.

SETTING

Eighteen Dutch IVF centers.

PATIENT(S)

Six hundred twenty-nine patients who were selected for IVF-intracytoplasmic sperm injection.

INTERVENTION(S)

Patients were randomized to receive either highly purified hMG or rFSH in a fixed dosage of 150 IU/d after GnRH-agonist suppression (long protocol).

MAIN OUTCOME MEASURE(S)

Ongoing pregnancy rate per started cycle. Difference between the two treatment groups was tested by using odds ratios, including the 95% confidence limits (intention-to-treat sample), and by using the Fisher's exact test (per-protocol sample).

RESULT(S)

The ongoing pregnancy rates per started cycle were 26.3% and 25.2% for highly purified hMG and rFSH, respectively (no statistically significant difference). Treatment with highly purified hMG resulted in statistically significantly fewer oocytes (n = 7.8) than did treatment with rFSH (n = 10.6). There were no differences with respect to fertilization rates and implantation rates. Cycles with highly purified hMG were statistically significantly less often canceled as a result of ovarian hyperresponse (2.0% vs. 6.0% for highly purified hMG and rFSH, respectively).

CONCLUSION(S)

Compared with rFSH, highly purified hMG did not result in superiority in ongoing pregnancy rates in first-cycle IVF-intracytoplasmic sperm injection patients who were treated with a fixed dosage of 150 IU of gonadotropin per day. Compared with rFSH, treatment with highly purified hMG resulted in retrieval of fewer oocytes, a lower incidence of hyperresponse, and comparable pregnancy rates.

Differential actions of FSH and LH during folliculogenesis

In the gonadotrophin-dependent stage of follicular development, FSH- and LH-signalling pathways play an obligatory role in follicle differentiation, selection and survival. Under the effect of LH the theca-interstitial cell layer acts as an androgen producer. Thus, androgen diffusing into the mural granulosa cell layer represents the substrate for FSH-induced aromatase for follicular oestradiol synthesis. This is the landmark 'two cell-two gonadotrophin' concept in the physiology of ovarian function in mammals. The increase in plasma FSH during luteo-follicular transition is the basis for follicle selection. The rise of FSH to the threshold concentration represents a critical condition for the growth of the most sensitive follicle in a given time frame of the last 14 days of the dominant follicle odyssey. The gonadotrophin-induced follicular oestradiol secretion inhibits pituitary secretion of FSH, which in turn causes the concentration of FSH in the developing cohort follicles to drop below threshold concentrations and the arrest of the development of the less FSH-sensitive follicle (FSH threshold and window concept). In the gonadotrophin-dependent phase of follicular development, LH also seems to acts within a critical window of the hormone concentration framed between the minimal threshold and a ceiling for the normal functions of the follicle unit.