Treatment of low responders

A comparison of gonadotropin-releasing hormone (GnRH) antagonist and GnRH agonist flare protocols for poor responders undergoing in vitro fertilization

OBJECTIVE

To compare stimulation profiles, pregnancy, and live birth rates in poor responders during in vitro fertilization (IVF) cycles using either a gonadotropin-releasing hormone (GnRH) antagonist (cetrorelix) or a GnRH agonist flare protocol (leuprolide).

DESIGN

Retrospective chart review.

SETTING

A university-affiliated IVF program.

PATIENT(S)

Women designated as poor responders based on a prior stimulation cycle or baseline follicle-stimulating hormone (FSH) level of >10 mIU/mL, who needed at least 375 IU of starting daily gonadotropins in the study cycle.

INTERVENTION(S)

Administration of GnRH agonist flare or GnRH antagonist protocol.

MAIN OUTCOME MEASURE(S)

Clinical pregnancy rate, live birth rate.

RESULT(S)

For 68 GnRH antagonist and 45 GnRH agonist flare cycles, the groups were similar with respect to age (38.8 versus 38.6 years) and basal FSH concentration (8.33 versus 8.65 mIU/mL). No statistically significant differences between the protocol types were noted in peak estradiol levels, amount of gonadotropins used, number of oocytes obtained, or embryos transferred. The pregnancy rates (40% versus 45.2%) and live birth rates (27.7% versus 31.7%) in the GnRH antagonist and flare groups, respectively, were similar.

CONCLUSION(S)

We achieved excellent and comparable pregnancy and live birth rates in poor responders of advanced reproductive age with the use of either GnRH antagonist or flare protocol.

Expression and comparison of gap junction protein connexin 37 in granulosa cells aspirates from follicles of poor responder and nonpoor responder patients

OBJECTIVE

To localize gap junction protein connexin 37 (Cx37) in granulosa cells obtained from aspiration of follicles, and to compare differences between poor responder and nonpoor responder patients in assisted reproductive technology.

DESIGN

Prospective clinical study.

SETTING

IVF unit of a university hospital.

PATIENT(S)

Seventy patients with various causes of infertility, undergoing an IVF treatment.

INTERVENTION(S)

Controlled ovarian hyperstimulation, serum hormone level measurements, ultrasonography scanning of ovarian follicles, oocyte retrieval after hCG administration and embryo transfer.

MAIN OUTCOME MEASURE(S)

Outcome of the IVF treatment and expression rate of Cx37 in granulosa cells.

RESULT(S)

Connexin 37 was expressed in the granulosa cells of all the patients. Connexin 37 rate in granulosa cells in the poor responder group was 81.32 +/- 35.86% (distribution: 2.95%-99.9%), while it was 88.98 +/- 23.73% (distribution: 6.30%-100.00%) in the nonpoor responder group. Connexin 37 rates between the two groups were not significantly different.

CONCLUSION(S)

Connexin 37 is expressed in the granulosa layer of follicles in the human ovary, and expression of Cx37 in granulosa cells was not different between poor responder and nonpoor responder patients.

Poor responders in IVF: cancellation of a first cycle is not predictive of a subsequent failure

Management of women with a poor response to controlled ovarian hyperstimulation during IVF remains a frustrating challenge. The present study included 96 cycles from an equal number of women with a poor ovarian response and successful oocyte retrieval. Poor response was defined by the presence of at least one of the following characteristics: three or fewer oocytes on retrieval, serum estradiol level less than 500 pg/mL on the day of hCG administration, and serum FSH levels less than 20 IU/L. The same patients had a previous cycle cancelled because of a poor ovarian response whereas in the second cycle they preferred to continue the treatment despite the poor prognosis. We obtained 241 oocytes in the 96 IVF cycles. The fertilization rate was 60.2%. Three oocytes per cycle were retrieved in 56 cycles (58.3%), two oocytes per cycle in 33 cycles (34.4%), and one oocyte per cycle in 7 cycles (7.3%). In 19 cycles (19.8%) no fertilization was achieved. An embryo transfer was finally performed in 74 out of 96 cycles. Pregnancy rate was 12.5% per cycle and 16.2% per transfer. Among the 12 pregnancies achieved, 7 were in the 3-oocyte cycles and 5 in the 2-oocyte cycles. No pregnancies were achieved in the 1-oocyte cycles. Our data demonstrate that continuation of therapy in poor responders undergoing IVF can be an option despite the low pregnancy rates. The prognosis of these patients is not affected by a poor response in the first cycle and for some of them the outcome can be favorable.

Cumulative exposure to high estradiol levels during the follicular phase of IVF cycles negatively affects implantation

PURPOSE

To investigate the effect of the cumulative exposure to estradiol (E(2)) during the follicular phase on IVF outcome.

METHODS

Patients were stimulated with recombinant FSH after GnRH agonist suppression and had a day 3-embryo transfer. Estrogen exposure was determined as the area under the curve (AUC) for serum E(2) levels measured from the first day of stimulation through the day after hCG administration.

RESULTS

E(2) AUC thresholds for 10th and 90th percentiles were 4704 pg/ml and 16338 pg/ml, respectively. The pregnancy and implantation rates were highest in the 10th-90th percentile group, and were statistically higher in this group than in the >90th percentile group (54.6% vs. 33.3% and 24.8% and 12.9%, respectively, for pregnancy and implantation rates, P < 0.05). Recovered mature oocytes, fertilization, and number and mean score of transferred embryos were similar.

CONCLUSIONS

High cumulative E(2) exposure during the follicular phase of IVF cycles has detrimental effects on implantation.

Controlled ovarian hyperstimulation protocols for in vitro fertilization: two decades of experience after the birth of Elizabeth Carr

OBJECTIVE

To critically discuss the current protocols for the management of controlled ovarian hyperstimulation in assisted reproduction technology.

DESIGN

Review of the literature and presentation of our experience.

MAIN OUTCOME MEASURE(S)

Ovarian response (peak serum estrogen levels, number of oocytes retrieved, quality of oocytes and embryos) and pregnancy outcome (clinical, delivery, and multiple pregnancy rates).

RESULT(S)

Controversies still exist regarding selection of gonadotropin preparation, choice of adjuvant therapy with GnRH analogues, and use of oral contraceptive pills. Patients identified as intermediate responders have an excellent outcome with adjuvant therapy with either a GnRH agonist (long protocol) or a GnRH antagonist, but tailoring of gonadotropin dose must be performed to achieve optimized results. High responders perform favorably with gentler gonadotropin stimulation that minimizes the occurrence of ovarian hyperstimulation syndrome. On the other hand, results in low responders remain suboptimal both in terms of ovarian response and oocyte/embryo quality in spite of a variety of stimulation regimens used.

CONCLUSION(S)

Ovarian stimulation is a critical step in in vitro fertilization therapy. A variety of controlled ovarian hyperstimulation regimens are available and efficacious, but individualization of management is essential and depends on assessment of the ovarian reserve. Identification of the etiologies of poor ovarian response constitutes a formidable challenge facing reproductive endocrinologists.

Gonadotropin-releasing hormone (GnRH)-antagonist versus GnRH-agonist in ovarian stimulation of poor responders undergoing IVF

PURPOSE

The objective of this study was to compare the efficacy of GnRH-antagonists to GnRH-agonists in ovarian stimulation of poor responders undergoing IVF.

METHODS

Retrospective analysis of our data revealed that 56 patients underwent treatment with a GnRH-agonist according to the flare-up protocol. Patients failing to achieve an ongoing pregnancy (n = 53) were subsequently treated in the next cycle with a GnRH-antagonist according to the multiple-dose protocol. Main outcome measures included the clinical pregnancy and implantation rates.

RESULTS

While ovulation induction characteristics and results did not differ between the two protocols, the number of embryos transferred was significantly higher (P = 0.046) in the GnRH-antagonist than in the GnRH-agonist stimulation protocol (2.5 +/- 1.6 vs. 2.0 +/- 1.4, respectively). The clinical pregnancy and implantation rates per transfer in the GnRH-antagonist group appeared higher than in the GnRH-agonist, but did not differ statistically (26.1 and 10.7 compared with 12.2 and 5.9%, respectively). However, the ongoing pregnancy rate per transfer was statistically significantly higher (P = 0.03) in the GnRH-antagonist than in the GnRH-agonist group (23.9 vs. 7.3%, respectively).

CONCLUSION

Applying GnRH-antagonists to ovarian stimulation protocols may offer new hope for IVF poor responder patients. However, further controlled randomized prospective studies with larger sample sizes are required to establish these results.

Treatment-associated serum FSH levels in very poor responders to ovarian stimulation

PURPOSE

To compare treatment-associated follicle-stimulating hormone (FSH) response in patients undergoing controlled ovarian hyperstimulation with either microdose flare (MDF) leuprolide acetate or clomiphene citrate and human menopausal gonadotropin (CC/hMG).

METHODS

Thirteen patients who were deemed poor responders underwent stimulation with one of two poor responder stimulation protocols (MDF group: n = 8; CC/hMG group: n = 5). Serum FSH, estrone (E1), estrone sulfate (E1S), and estradiol (E2) levels were measured at baseline, day 5 of medication, and on day of hCG administration. Ovarian and uterine responses were evaluated by ultrasound.

RESULTS

Treatment-associated FSH levels were consistently higher in the group that took CC/hMG. However, serum E1, E1S, and E2 values were similar in both groups as were the number of oocytes retrieved and the endometrial echo complex. There were no differences between the two groups with regards to the quality of the oocytes obtained, fertilization rate, or the quality of the embryos.

CONCLUSION

Clomiphene citrate, when administered in conjunction with exogenous hMG, is a more potent stimulator of FSH production than MDF leuprolide acetate among poor responders to ovarian stimulation. However, the number of oocytes is not increased.

Contemporary Pharmacological Manipulation in Assisted Reproduction

Follicle-stimulating hormone (FSH) treatment to induce follicular development in anovulating women and multiple follicular development for assisted conception has been incorporated in almost all reproductive treatment cycles in the form of either urinary, purified urinary or recombinant preparations. Besides improved tolerance and theoretically lower chances of infection by prions, the latter may be more effective in terms of clinical pregnancy rates, FSH requirement and cost effectiveness. The low-dose, step-up protocol to induce monofollicular development, which is applied worldwide, has to compete with the equally effective but health economically beneficial step-down protocol. The long protocol using recombinant FSH 150 IU/day is advocated when using gonadotropin-releasing hormone (GnRH) agonists in in vitro fertilisation (IVF) or intracytoplasmatic sperm injection treatment. However, the current paradigmatic hyperstimulation came under scrutiny after the introduction of the GnRH antagonists, which allow milder and more convenient approaches with acceptable cancellation and pregnancy rates but lower requirements for FSH. Risk of ovarian hyperstimulation syndrome (OHSS) can be further eliminated if recombinant luteinising hormone (rLH) or GnRH agonists are used to trigger oocyte maturation and ovulation; the latter require pituitary responsiveness and are therefore excluded in agonist protocols. FSH and LH are both required for appropriate folliculo- and steroidogenesis. In hypogonadotropic women, the addition of LH (human menopausal gonadotropin, human chorionic gonadotropin or rLH) is therefore obligate to achieve appropriate follicular growth and pregnancy. The role of LH in ovulation induction is still a matter of debate, although in GnRH agonistic protocols there seems to be a 'therapeutic window'; levels that are too high or too low have detrimental effects on IVF outcome. To broaden the pharmaceutical armoury, recent efforts have been directed towards the development of novel GnRH antagonists and FSH preparations with optimal pharmacokinetic, pharmacodynamic and safety profiles. Alternative strategies with fewer adverse effects and higher benefit/cost ratios are under development. However, before the GnRH agonist is abandoned for the antagonist as standard therapy, the cause of the observed possible lower pregnancy rates with the latter need to be clarified. In addition, prospective studies investigating possible direct effects of GnRH analogues, optimal dose-finding studies and treatment regimens under different conditions, with or without pharmacological coadministration and for different indications, should be performed to optimise the efficacy and tailor treatment strategies to individual needs.

Antagonists in poor-responder patients

To review treatment options for poor-responding patients who are undergoing infertility treatment. Review article and case studies.A comprehensive determination of potential ovarian response for the poor-responding patient is important in the individualization of treatment options for these patients. Treatment options include both the microdose flare leuprolide acetate and GnRH antagonist stimulation protocols. For GnRH antagonist stimulation protocols, individualization of treatment includes use of oral contraceptive pretreatment and alterations in duration of gonadotropin stimulation and start day of antagonist administration. For poor-responding patients, the benefits of using GnRH antagonists for the suppression of premature LH surges plus the determination that stimulation protocols that include GnRH antagonists are at least as good as the microdose flare and provide better cycle outcomes than the long luteal leuprolide acetate down-regulation protocols have the potential to bring changes to the existing protocols for ovarian stimulation.

Prospective evaluation of two stimulation protocols for low responders who were undergoing in vitro fertilization-embryo transfer

OBJECTIVE

To compare two stimulation protocols designed for low responders undergoing IVF.

DESIGN

Randomized, prospective study.

SETTING

University hospital IVF unit.

PATIENT(S)

Sixty low responders who were recruited on the basis of results in previous cycles.

INTERVENTION(S)

Modified flare protocol in which a high dose of GnRH agonist was administered for the first 4 days, followed by a standard agonist dose, or a modified long protocol in which a standard agonist dose was used until pituitary down-regulation, after which the agonist dose was halved during stimulation.

MAIN OUTCOME MEASURE(S)

Number of oocytes retrieved.

RESULT(S)

Twenty-nine cycles were performed with the modified flare protocol and 31 were performed with the modified long protocol. Significantly more oocytes were obtained with the modified long protocol than the modified flare protocol (4.42 +/- 2.6 vs. 3.07 +/- 2.15). The number and quality of embryos available for transfer was similar in both groups. One clinical pregnancy (3.4%) was achieved with the modified flare protocol, and 7 pregnancies (22.5%) were achieved using the modified long protocol.

CONCLUSION(S)

These preliminary results substantiate the poor prognosis and outcome for low responders undergoing IVF. A modified long "mini-dose" protocol appears to be superior to a modified mega-dose flare protocol in terms of oocyte yield and cycle outcome.

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.

Evaluation and treatment of low responders in assisted reproductive technology: a challenge to meet

PURPOSE

To investigate the various methods of evaluation and treatment of patients with a low response to controlled ovarian hyperstimulation in assisted reproductive technologies (ART).

METHODS

Review and analysis of relevant studies published in the last decade, identified through the literature and Medline searches.

RESULTS

While a universally accepted definition for low responders is still lacking, these patients are reported to represent about 10% of the ART population. Several ovarian reserve screening techniques have been proposed; however, currently the best-characterized and most sensitive screening tools available are the basal day 3 serum follicle-stimulating hormone level and the clomiphene citrate challenge test. When abnormal, these tests allow physicians to counsel patients that their prognosis for conception is poor. Although the presence of a normal result does indicate better long-term chances for conception, on age-related decline in fecundity remains and patient age should still be considered when counseling patients with normal screening results. Several stimulation protocols have been applied in the low-response group with varying success. Recent studies show that the use of a minidose gonadotropin-releasing hormone-agonist protocol may result in significantly decreased cycle cancellations as well as increased clinical and ongoing pregnancies, and thus is proposed as a first-line therapy. Studies evaluating supplementary forms of treatment to the ovulation induction regimen show improved outcome when pretreating with oral contraceptives, whereas there seems to be no benefit from cotreatment with growth hormone or glucocorticoids. Blastocyst culture and transfer and assisted hatching in low responders are still under evaluation, whereas natural cycle in vitro fertilization may be used in cases of repeated failures as a last option before resorting to oocyte donation or adoption. Future possible forms of treatment like in vitro maturation of immature human oocytes, cytoplasm, and nuclear transfer currently are experimental in nature and their efficacy has still to be proven.

CONCLUSIONS

The evaluation and treatment of low responders in ART remains a challenge. Understanding of the underlying etiology and pathophysiology of this disorder may help the clinician to approach it successfully.

Female poor responders

Female poor responders are represented by normovulatory women showing a 'gonadal failure' in term of inadequate number of recruited follicles under conventional controlled ovarian hyperstimulation (COH) for assisted reproductive technologies (ART). ARTs offers today a high chance of pregnancy to infertile couples when a normal ovarian response provides a large choice of embryos for transfer. On the contrary, failure of the ovary to produce enough oocyte for treatment, reduces significantly the likelihood of conceiving in ART, not only in the treatment cycle, but also predicting a poor prognosis in subsequent cycles. Up to date, poor response remains one of the most frequent problems in the field of assisted reproduction. First described in 1981, poor response has been investigated by several authors, but many aspects are still controversial. In this paper definition, pathophysiology and management of poor response are revised and discussed.

A randomized prospective cross-over study of highly purified follicle-stimulating hormone and human menopausal gonadotrophin for ovarian hyperstimulation in women aged 37-41 years

PURPOSE

In the present study, we investigated the benefits of highly purified FSH (H.P. FSH) in comparison with human menopausal gonadotrophin (hMG) in IVF patients aged 37-41 years.

METHODS

Twenty patients experienced within a period of four months both preparations in subsequent cycles through a prospective randomized cross-over design. A standard hormonal treatment consisting of a flare-up protocol using gonadotrophin-releasing hormone agonist (GnRHa) in combination with the same starting dose of H.P. FSH or hMG was used in all cycles.

RESULTS

Cycles stimulated with H.P. FSH resulted in a significantly higher mean number (10.3 +/- 3) of ovocytes retrieved with a significantly shorter (13 +/- 2.3 days) duration of stimulation compared to cycles treated with hMG [mean number of oocytes 7.3 +/- 5 (P < 0.01) and mean duration of stimulation 14.7 +/- 3.9 days (P < 0.02)]. No detrimental effect of basal or exogenous LH on oocyte quality was observed in our study.

CONCLUSIONS

In our experience, H.P. FSH preparations seemed to be more effective than hMG preparations for ovarian stimulation in this group of women aged 37-41 years.

Recombinant follicle stimulating hormone stimulation in poor responders with normal basal concentrations of follicle stimulating hormone and oestradiol: improved reproductive outcome

A total of 30 young infertile patients who exhibited a poor response in two previous consecutive cycles, despite having normal basal follicle stimulating hormone (FSH) and oestradiol concentrations, were invited to participate in a prospective randomized study comparing the clinical efficacy of recombinant (rFSH) and urinary (uFSH) follicle stimulating hormone. An evaluation of the total dose used (3800 IU versus 4600 IU, P < 0.05) and duration of treatment (10.2 days versus 13.2 days, P < 0.05) showed a significantly shorter treatment period as well as a significantly lower total dose of FSH required to induce ovulation successfully in the group of patients treated with rFSH. Significantly more oocytes (7.2 versus 5. 6, P < 0.05) as well as mature oocytes (5.9 versus 3.2, P < 0.01) were retrieved after rFSH treatment. In addition, significantly more good quality embryos were obtained (3.4 versus 1.8, P < 0.05) in the group of patients treated with rFSH and, as a result, higher pregnancy (33 versus 7%, P < 0.01) and implantation (16 versus 3%, P < 0.01) rates were achieved in these patients. It is concluded that rFSH is more effective than uFSH in inducing multifollicular development and achieving pregnancy in young low responders.

Young low responders protected from untoward effects of reduced ovarian response

OBJECTIVE(S)

To correlate fertilization and clinical pregnancy rates (PRs) in low responders with their E2 levels (<500, 500-800, >800-1,000 pg/mL), age (20-30, 31-40, >40 years), number of follicles, and number of oocytes retrieved.

DESIGN

A retrospective study.

SETTING

The IVF unit of an academic hospital.

PATIENT(S)

One hundred forty-three women who failed to attain E2 levels of 1,000 pg/mL on the day of hCG administration.

INTERVENTION(S)

Controlled ovarian hyperstimulation, blood E2 and progesterone measurements, ultrasonographic scanning of ovarian follicles, oocyte retrieval after hCG administration, and ET.

MAIN OUTCOME MEASURE

Clinical PR.

RESULT(S)

Although E2 levels, fertilization rates, age, and number of oocytes did not differ significantly between the three age groups, the PR achieved in the youngest group was approximately three times as high (19.3%) as that achieved in the two older groups.

CONCLUSION

Young low responders represent a unique subset in that their age protects them from the deleterious effects of poor ovarian response.

Follicle-stimulating hormone levels on cycle day 3 to predict ovarian response in women undergoing controlled ovarian hyperstimulation for in vitro fertilization using a flare-up protocol

OBJECTIVE

To determine whether cycle day 3 serum FSH levels predict poor ovarian response and cycle cancellation in women undergoing controlled ovarian hyperstimulation (COH) for IVF.

DESIGN

Prospective case series.

SETTING

University hospital IVF program.

PATIENT(S)

The study includes outcomes of 637 initial cycles of IVF.

INTERVENTION(S)

Controlled ovarian hyperstimulation was undertaken with a short, flare-up GnRH agonist and hMG protocol. The relation of cycle day 3 FSH levels with various cycle characteristics and outcomes was determined.

MAIN OUTCOME MEASURE(S)

The accuracy of cycle day 3 FSH levels in predicting poor ovarian response and cycle cancellation was evaluated. Receiver operating characteristic curves were constructed to determine the optimum cutoff value for the cycle day 3 serum FSH level that best predicted poor ovarian response and cycle cancellation.

RESULT(S)

A cycle day 3 serum FSH level > or = 13 mIU/mL (conversion factor to SI unit, 1.00) was associated with a high likelihood of poor ovarian response and cycle cancellation. The sensitivity, specificity, and positive likelihood ratio of an FSH level of 13 mIU/mL in predicting cycle cancellation were 52%, 91%, and 6.04, respectively.

CONCLUSION(S)

Cycle day 3 FSH screening appears to be a fairly accurate predictor of poor ovarian response and cycle cancellation in women undergoing COH using a short, flare-up GnRH agonist and hMG protocol.

Use of the flare-up protocol with high dose human follicle stimulating hormone and human menopausal gonadotropins for in vitro fertilization in poor responders

OBJECTIVE

To analyze the effect of high dose human FSH in combination with hMG with a flare-up leuprolide acetate (LA) protocol in patients undergoing IVF at risk for a poor response.

DESIGN

Prospective.

SETTING

Free-standing ambulatory IVF center.

PATIENTS

Two hundred eighty-four patients underwent a LA screening test for IVF. Patients with a lack of flare response were considered at risk for a poor response and underwent ovarian stimulation with the flare-up LA protocol in combination with high dose human FSH and hMG.

RESULTS

The poor responder group was compared with the good responders on the flare-up LA protocol and to patients undergoing ovulation induction with a luteal phase LA protocol. There were 53 poor responder flare-up LA cycles, 177 good responder flare-up LA cycles, and 54 luteal phase LA cycles. The cancellation rate was higher in poor flare-up LA responders (11.3 percent) compared with good flare-up LA responders (1.1 percent) and luteal phase LA cycles (1.8 percent). Peak E2 levels, number of oocytes, and number of embryos were significantly higher in the good flare-up LA responders. Fertilization rate was similar in all groups. Ongoing pregnancy rate per retrieval was 28 percent in good responders, 29 percent in poor responders, and 33 percent in luteal phase LA patients. Only one patient (0.4 percent) was hospitalized for severe ovarian hyperstimulation.

CONCLUSION

The flare-up protocol with high-dose human FSH and hMG is a very good alternative for patients who are at high risk for a poor response. Although peak E2 and number of oocytes were significantly lower in this group, the patients who responded had the same fertilization and pregnancy rate as the good responders. Cancellation rate remains high in poor responders.

Double-blind placebo controlled study: human biosynthetic growth hormone for assisted reproductive technology

OBJECTIVE

To study whether the effect of cotreatment with human biosynthetic GH improves the outcome of poor IVF responders.

DESIGN

A double-blind placebo-controlled study using a GnRH agonist (GnRH-a) and gonadotropin in a "boost" flare-up protocol for ovarian stimulation together with either placebo, 4, or 12 IU of human GH followed by oocyte retrieval and IVF-ET.

PATIENTS

Twenty-two patients with previously demonstrated poor responses in at least two assisted reproductive technology cycles were recruited.

INTERVENTIONS

Pretreatment and post-treatment blood samples and daily morning blood samples during ovarian stimulation were collected after an overnight fast. Human GH or placebo and GnRH-a were administered SC; gonadotropin was administered IM. Oocytes were collected by ultrasound-guided transvaginal aspiration of follicles. Embryos were cultured in vitro and transferred transcervically.

MAIN OUTCOME MEASURES

Serum E2, FSH, GH, insulin-like growth factor-I (IGF-1), IGF binding protein 1 (IGFBP-1), and IGFBP-3 concentrations. Number of FSH ampules, follicles, oocytes, embryos, and pregnancies.

RESULTS

No improvement in cycle outcome was demonstrated with daily adjuvant human GH administration with either 4 or 12 IU. Serum IGF-I levels were highest in the 12 IU human GH group and lowest in the placebo group. Serum IGFBP-3 levels increased 2 days after IGF-I levels in the 12 IU human GH group only. Serum IGFBP-1 levels were unchanged in all groups.

CONCLUSION

Poor IVF responders do not benefit from cotreatment with human GH during their ovarian stimulation.