The serum follicle-stimulating hormone-to-luteinizing hormone ratio at the start of stimulation with gonadotropins after pituitary down-regulation is inversely correlated with a mature oocyte yield and can predict "low responders"

Factors associated with the efficacy of mature oocyte production after dual-trigger controlled ovarian stimulation using a GnRH antagonist protocol

BACKGROUND

The number of mature oocytes retrieved plays a significant role in determining embryo development and pregnancy outcomes of in vitro fertilization (IVF). However, studies investigating factors predictive of the efficacy of mature oocyte production (EMOP) after dual-trigger controlled ovarian stimulation (COS) are rare. This study aims to identify key predictors of EMOP during dual-trigger COS with a gonadotropin-releasing hormone (GnRH) antagonist protocol for IVF.

METHODS

This retrospective cohort study included 359 first-time IVF patients undergoing dual-trigger COS with a GnRH antagonist protocol. EMOP was defined as the ratio of metaphase II (MII) oocyte count to antral follicle count (AFC). Based on EMOP results, patients were divided into two groups: group A (EMOP <70%; n = 232) and group B (EMOP ≥70%; n = 127).

RESULTS

Multivariate logistic regression analysis revealed that day-2 follicle-stimulating hormone (FSH), stimulation duration, and total oocyte count were the most significant predictors of EMOP ( p < 0.05; odds ratios: 1.637, 3.400, and 1.530, respectively). Receiver operating characteristic analysis demonstrated that total oocyte count <9.5 (area under the curve [AUC], 0.782; sensitivity, 76.2%; specificity, 69.2%; p < 0.001) and stimulation duration <9.5 days (AUC, 0.725; sensitivity, 63.5%; specificity, 66.7%; p < 0.001) significantly predicted EMOP <70%. Stimulation duration combined with total oocyte count exhibited the highest power in predicting EMOP <70% (AUC, 0.767; sensitivity, 92.3%; specificity, 42.4%).

CONCLUSION

Stimulation duration combined with total oocyte count was identified as the most important factor associated with the EMOP during dual-trigger COS in IVF using a GnRH antagonist protocol.

The serum follicle stimulating hormone-to-luteinizing hormone ratios can predict assisted reproductive technology outcomes in women undergoing gonadotropin releasing hormone antagonist protocol

BACKGROUND

The basal follicle stimulating hormone (FSH)/luteinizing hormone (LH) ratio is a useful predictor of ovarian response. In this study, we investigated whether the FSH/LH ratios during the entire controlled ovarian stimulation (COS) can be used as effective predictors of outcomes in women undergoing in vitro fertilization (IVF) treatment using the gonadotropin releasing hormone antagonist (GnRH-ant) protocol.

METHODS

A total of 1,681 women undergoing their first GnRH-ant protocol were enrolled in this retrospective cohort study. A Poisson regression model was used to analyze the association between the FSH/LH ratios during COS and embryological outcomes. Receiver operating characteristic analysis was performed to determine the optimal cutoff values for poor responders (≤ 5 oocytes) or poor reproductive potential (≤ 3 available embryos). A nomogram model was constructed to provide a tool for predicting the cycle outcomes of individual IVF treatments.

RESULTS

The FSH/LH ratios (at the basal day, stimulation day 6 (SD6) and trigger day) were significantly correlated with the embryological outcomes. The basal FSH/LH ratio was the most reliable predictor of poor responders with a cutoff value of 1.875 (area under the curve (AUC) = 72.3%, P < 0.05), or of poor reproductive potential with a cutoff value of 2.515 (AUC = 66.3%, P < 0.05). The SD6 FSH/LH ratio predicted poor reproductive potential with a cutoff value of 4.14 (AUC = 63.8%, P < 0.05). The trigger day FSH/LH ratio predicted poor responders with a cutoff value of 9.665 (AUC = 63.1%, P < 0.05). The basal FSH/LH ratio, combined with the SD6 and trigger day FSH/LH ratios, slightly increased these AUC values and improved the prediction sensitivity. The nomogram provides a reliable model with which to assess the risk of poor response or poor reproductive potential directly based on the combined indicators.

CONCLUSIONS

FSH/LH ratios are useful predictors of poor ovarian response or reproductive potential throughout the entire COS with the GnRH antagonist protocol. Our findings also provide insights into the potential for LH supplementation and regimen adjustment during COS to achieve improved outcomes.

The comparison of evaluative effectiveness between antral follicle count/age ratio and ovarian response prediction index for the ovarian reserve and response functions in infertile women

Aim of the present study was to explore the evaluative effectiveness of age, ovarian volume (OV), antral follicle count (AFC), serum follicle-stimulating hormone (FSH), anti-Müllerian hormone (AMH), AFC/Age ratio, AMH/Age ratio, FSH/luteinizing hormone (LH) ratio, and ovarian response prediction index (ORPI) to determine which could more advantageously assess ovarian reserve and response.This research enrolled 319 consecutive infertile women who had undergone in vitro fertilization-ET/intracytoplasmic sperm injection (IVF-ET/ICSI) treatments. Abovementioned variables were measured and calculated. Receiver operating characteristic (ROC) curve analysis was used to analyze the predictive accuracy of variables and to calculate cut-off values and corresponding sensitivity and specificity.Our study revealed that the significant variables for evaluating a decline in ovarian reserve include age, OV, FSH, AFC/Age ratio, AMH/Age ratio, and ORPI. Moreover, the area under the curve (AUC) of AFC/Age ratio was higher than other 5 variables (AUC = 1.000), and the cut-off value of AFC/Age ratio was 0.111 (sensitivity 100.00%, specificity 100.00%). The significant variables forecasting excessive ovarian response were age, AFC, AMH, FSH, AFC/Age ratio, AMH/Age ratio, FSH/LH ratio, and ORPI, and the significant variables forecasting poor ovarian response were AMH, LH, OV, AFC/Age ratio, AMH/Age ratio, and FSH/LH ratio. When ORPI was used to predict excessive response, the cut-off value of ORPI was 0.880 (sensitivity 84.72%, specificity 67.32%) and ORPI presented better effectiveness. When used to predict poor response, the evaluative effectiveness of 6 variables was almost similar, although the AUC of AFC/Age ratio presented the largest value.Regarding the infertile women, AFC/Age ratio performed better than did the other variables in evaluating ovarian reserve, and it offered excellent effectiveness in predicting poor ovarian response, however, ORPI presented better effectiveness in predicting excessive ovarian response.

Highly Purified Human Menopausal Gonadotropin (Menopur®): A Profile of Its Use in Infertility

Menopur^® is a highly purified, urine-derived, human menopausal gonadotropin containing both follicle stimulating hormone (FSH) and luteinizing hormone (LH) activity. It is an effective option for controlled ovarian stimulation (COS) in assisted reproductive technology protocols and for ovulation induction (OI) in anovulatory infertility, and is associated with a different endocrine profile from that of recombinant (r) FSH in these settings (in terms of serum levels of FSH, androgens and/or estradiol). When used for COS in women undergoing in vitro fertilization (IVF)/intracytoplasmic sperm injection (ICSI), Menopur^® was as good as rFSH in terms of pregnancy rates (despite being associated with a lower oocyte yield) and was found to improve some aspects of embryo quality in the IVF (but not ICSI) setting; using Menopur^® in combination with highly purified urinary FSH resulted in similar reproductive outcomes as Menopur^® alone. Data for Menopur^® in OI are limited, but suggest ovulation rates may be as good as those with rFSH + rLH (in type 1 anovulation) and rFSH (in type 2 anovulation). Moreover, compared with rFSH, Menopur^® appeared to be associated with a less pronounced follicular response and a lower risk of ovarian overstimulation.

The significance of anthropometric and endocrine parameters in ovulation induction with clomiphene citrate in women with polycystic ovary syndrome

Objectives:

To investigate factors associated with the response to ovarian stimulation in patients with polycystic ovary syndrome.

Methods:

The records of patients with polycystic ovary syndrome and infertility who underwent ovulation induction with clomiphene citrate were reviwed between January 2011 and December 2014 in Etlik Zübeyde Hanim Women’s Health Training and Research Hospital Ankara, Turkey. The anthropometric and endocrine factors of patients who were resistant to treatment at a dose of 150 mg/day (n=84) were compared with those who responded with growth of at least one graaffian follicle at a dose of 50 mg/day (n=342).

Results:

Of the parameters examined, body mass index, luteinizing hormone level, and luteinizing hormone/follicle stimulating hormone ratio were significantly higher in the clomiphene citrate-resistant group compared with the responsive group.

Conclusion:

Reproductive treatment in patients with polycystic ovary syndrome show different outcomes. Significantly higher body mass index, luteinizing hormone level, and luteinizing hormone/follicle stimulating hormone ratio observed in clomiphene citrate resistant group can be a possible explanation for this impedance.

Impact of high basal FSH/LH ratio in women with normal FSH levels on in vitro fertilization outcomes

Basal luteinizing hormone (LH) levels have also been suggested to impact on ovarian responsiveness as well as basal follicular stimulating hormone (FSH) levels. The aim of this study was to compare the in vitro fertilization (IVF) outcomes according to cycle day 3 FSH/LH ratio and to assess the proper stimulation protocol between gonadotropin-releasing hormone (GnRH) agonist and GnRH antagonist protocols. The retrospective cohort study recruited a total of 1211 women having the laboratory values of FSH (<10 IU/L) and LH within 3 months before IVF. Patients were treated with GnRH agonist long or GnRH antagonist protocols and stimulated with recombinant FSH (rFSH). The number of total retrieved oocytes and mature oocytes, implantation rate, clinical pregnancy rate and ongoing pregnancy rate were analyzed between groups: Group I: FSH/LH < 2 and Group II: FSH/LH ≥ 2. The Group II had the small number of retrieved oocytes and mature oocytes compared to the Group I (p = 0.000). Clinical and ongoing pregnancy rate were lower in Group II (p = 0.006, 0.006, respectively). In comparison of each protocol within groups, Group II showed significantly low pregnancy rate when GnRH antagonist was administered. In women with normal FSH level, high day 3 FSH/LH ratio can present subclinically low ovarian reserve and be predictive of lower pregnancy outcomes in fresh IVF cycles, and the choice of GnRH agonist can be related to favorable IVF outcomes.

Elevated day 3 FSH/LH ratio: a marker to predict IVF outcome in young and older women

PURPOSE

To evaluate the value of elevated day 3 FSH/LH ratio in predicting IVF results in young and older women.

METHODS

One hundred seventy-four women with normal day 3 FSH levels undergoing IVF treatment were studied. Patients were divided into two groups according to basal FSH/LH ratio: Group 1(FSH/LH ≥3, n = 43) and Group 2 (FSH/LH <3, n = 131). The effects of FSH/LH ratio on IVF outcomes were compared. Also, the impact of elevated FSH/LH levels on younger (<35 years; n = 113) and older (≥35 years; n = 61) women was evaluated.

RESULTS

Group 1 had significantly lower mean day 3 LH levels (p = 0.001), lower number of oocytes retrieved (p = 0.004) and lower clinical pregnancy rate (p = 0.04). Older women with elevated FSH/LH ratio (n = 23) had significantly lower transferred good grade embryo counts (p = 0.04) and lower pregnancy rate (p = 0.03) versus older women with lower FSH/LH ratio. But in younger women treatment outcomes were similar in both subgroups.

CONCLUSION

Elevated day 3 FSH/LH ratio is useful in predicting IVF outcome in older women, but does not seem to be an accurate predictor in younger women.

Controlled clinical trial assessing the effect of laparoscopic uterine arterial occlusion on ovarian reserve

STUDY OBJECTIVE

To assess the effect on ovarian reserve function after laparoscopic uterine artery occlusion (LUAO) compared with laparoscopic surgery supracervical hysterectomy (LSH) and laparoscopic myomectomy (LM).

DESIGN

Prospective cohort study (Canadian Task Force classification II-1).

SETTING

Hospital with experience in gynecologic minimal access surgery.

PATIENTS

Ninety patients with uterine myomas operated on from August through December 2007.

INTERVENTION

Ninety patients were divided into 3 groups of 30 patients each: the study group underwent LUAO and myomectomy (LUAO-M), control group 1 underwent LSH, and control group 2 underwent LM only.

MEASUREMENTS AND MAIN RESULTS

Blood samples were collected before surgery and at 1, 3, and 6 months postoperatively. Concentrations of follicle-stimulating hormone (FSH), leuteinizing hormone (LH), and estradiol (EZ) were determined using an immunoassay, and serum inhibin B (INHB) concentration was evaluated using an enzyme-linked immunosorbent assay. No significant differences in preoperative hormone concentrations between the 3 groups were found (p>.05). In the LSH group, FSH, LH, and E2 concentrations were significantly increased, whereas the INHB concentration was significantly decreased at 1 month postoperatively (p<.05); after 3 months, only the INHB concentration was significantly decreased (p<.05). However, in the LOUA-M and LM groups, there were no significant differences between preoperative and postoperative hormone concentrations (p>.05). Serum concentrations of FSH, LH, and INHB in the LSH group were significantly different from those in the study group at 1 and 3 months postoperatively (p<.05); however, the differences in postoperative hormone concentrations between the study group and the LM group were not significant (p>.05).

CONCLUSION

At short-term follow-up, no significant effect on ovarian reserve in patients with myoma who underwent LUAO was found.

Predicting fertility

Various predictors of fertility have been described, suggesting that none are ideal. The literature on tests of ovarian reserve is largely limited to women undergoing in vitro fertilization, and is reliant on the use of surrogate markers, such as cycle cancellation and number of oocytes retrieved, as reference standards. Currently available prediction models are far from ideal; most are applicable only to subfertile women seeking assisted reproduction, and lack external validation. Systematic reviews and meta-analyses of predictors of fertility are limited by their heterogeneity in terms of the population sampled, predictors tested and reference standards used. There is an urgent need for consensus in the design of these studies, definition of abnormal tests, and, above all, a need to use robust outcomes such as live birth as the reference standard. There are no reliable predictors of fertility that can guide women as to how long childbearing can be deferred.

Granulosa cell aromatase activity in women undergoing IVF: a comparison of good and poor responders

OBJECTIVE

We wished to investigate the aromatase activity (AA) of granulosa cells (GCs) in women undergoing ovarian follicular stimulation for in vitro fertilization (IVF).

METHODS

Granulosa cells were harvested from follicular fluid aspirated at the time of oocyte retrieval in women undergoing IVF. Data related to the follicular stimulation and IVF were collected by chart review. We conducted a retrospective analysis of the relation between the response to stimulation and the AA of GCs obtained from IVF patients. We assessed the response to stimulation by calculation of the area under the curve (AUC) of the monitored serum estradiol levels, and divided patients into "poor responders" and "good responders."

RESULTS

There was no difference in AA between women with a poor response to stimulation and women with a good response. Implantation rates and pregnancy rates were significantly lower in poor responders (5.3% and 9.1% respectively) than in good responders (19.7% and 54.8% respectively), even though embryo quality was similar in each group.

CONCLUSIONS

Women who have a poor response to ovarian follicular stimulation preceding IVF have lower pregnancy rates than women with a good response. The lower pregnancy rates do not appear to be a consequence of an abnormal follicular environment, because AA and the ratio of serum estradiol AUC to oocytes retrieved was similar in both groups of women.

The impact of luteinizing hormone in assisted reproduction: a review

PURPOSE OF REVIEW

Although the key role of luteinizing hormone in ovarian function, the promotion of follicular growth and maturation, is widely acknowledged, its usefulness as a predictor of ovarian status, and as a supplement during fertility treatment, remains controversial.

RECENT FINDINGS

Luteinizing hormone alone is not an effective predictor of ovarian function. In combination with follicle-stimulating hormone, as the so-called follicle-stimulating hormone: luteinizing hormone ratio, it serves as a useful marker of ovarian status. Although published data on luteinizing hormone supplementation during ovarian hyperstimulation are somewhat limited, recent well-designed studies suggest a beneficial effect of: (1) luteinizing hormone supplementation for women with inadequate responses to follicle-stimulating hormone-only stimulation; (2) in primarily young patients with low baseline luteinizing hormone levels and, consequently, insufficient remaining endogenous luteinizing hormone concentration during pituitary suppression; and (3) in older women with higher baseline luteinizing hormone levels and age-appropriate ovarian function, who require higher luteinizing hormone thresholds, even during pituitary suppression.

SUMMARY

Luteinizing hormone levels, as a component of the follicle-stimulating hormone: luteinizing hormone ratio, contribute to the assessment of ovarian function, whereas the supplementation of luteinizing hormone on an individualized basis, in carefully selected patients, improves outcomes of ovarian stimulation with gonadotropins.

Simple tools for assessment of ovarian reserve (OR): individual ovarian dimensions are reliable predictors of OR

OBJECTIVE

To determine the association between individual ovarian dimensions, advancing age, and declining ovarian reserve (OR) in an infertile population.

DESIGN

An ongoing prospective observational study.

SETTING

Academic infertility practice.

PATIENT(S)

Sixty-nine premenopausal women presenting for the evaluation and management of infertility.

INTERVENTION(S)

Transvaginal ultrasound assessment of the ovarian dimensions (length, width, and overall diameter in cm) and evaluation of the OR status by measuring serum levels of FSH and E(2) in the early follicular phase of the menstrual cycle.

MAIN OUTCOME MEASURE(S)

Relationship of the individual ovarian dimensions to age (years) and OR (reflected by historical maximal FSH levels).

RESULT(S)

A statistically significant decrease in three ovarian size parameters accompanied advancing age (ovarian width, r = -0.30; ovarian length, r = -0.24; and the mean overall ovarian diameter, r = -0.30). Levels of FSH demonstrated a significant and linear correlation with age (r = 0.39). Increasing levels of FSH (and hence declining OR) were associated with statistically significant declines in the mean ovarian width (r = -0.39), length (r = -0.38), and overall mean ovarian diameter (r = -.42), Patients with a known diagnosis of diminished OR demonstrated significantly reduced ovarian dimensions compared with patients with other infertility etiologies. Multivariate linear regression analysis confirmed individual ovarian measurements (width, length, and overall diameter) as independent predictors of OR (FSH levels) after adjusting for parameters that are known to influence ovarian size, i.e., age, smoking status, body mass index, and anovulation history. Ovarian width emerged as the strongest predictor of OR (largest beta coefficient and hence the strongest association with OR status), compared with ovarian length and the mean ovarian diameter.

CONCLUSION(S)

Single ovarian dimensions are reliable predictors of advancing age and declining OR status in premenopausal infertile women. The magnitude of this association is most robust for the ovarian width.

Differential effects of oral conjugated equine estrogen and transdermal estrogen on atherosclerotic vascular disease risk markers and endothelial function in healthy postmenopausal women

BACKGROUND

Recent studies have revealed that HRT may increase the risk for atherosclerotic vascular disease (ASVD).

METHODS

We investigated the effects of HRT via different administration routes on the markers for ASVD and endothelial function in healthy postmenopausal women. The oral HRT group (n=18) received conjugated equine estrogen 0.625 mg/day; the transdermal HRT group (n=18) received 17beta-estradiol (E2) gel 0.6 mg/day for 6 months. The control group (n=30) had no treatment for 6 months.

RESULTS

The C-reactive protein (CRP) rose from 0.129+/-0.116 to 0.752+/-0.794 mg/dl (P<0.01) in the oral HRT group but remained unchanged in the transdermal HRT and control groups. The flow-mediated vasodilation (FMD) in the brachial artery was increased significantly by HRT from 6.0% before oral HRT to 14.7% after oral HRT (P<0.001) and from 5.9% before transdermal HRT to 13.9% after transdermal HRT (P=0.001).

CONCLUSIONS

These data suggest that oral estrogen induces ASVD risk by increasing acute inflammation; however, transdermal estrogen avoids this untoward effect. Additionally, transdermal estrogen exerts a positive effect on endothelial function similar to that of oral estrogen. Therefore, the transdermal route might be favourable in terms of ASVD risks.

Is there a need for recombinant human luteinizing hormone (lutropin alfa) supplementation in ovarian stimulation for assisted reproduction?

Luteinizing hormone is now available as the recombinant product, lutropin alfa for the treatment of female infertility. It is necessary in the natural process of follicular growth and maturation. It is not yet clear which patients really benefit from the addition of this medication to conventional gonadotropin stimulation procedures in infertility treatment. Certainly, it has a proven benefit in patients suffering from hypogonadotropic hypogonadism (WHO I). Others may be older patients, patients with a profound gonadotropin suppression stimulated in long gonadotropin-releasing hormone agonist protocols, or patients with poor ovarian response to conventional stimulation strategies. The available data are reviewed herein.

The forgotten variable: impact of luteinizing hormone on the prediction of ovarian reserve

The impact of basal LH levels in the prediction of ovarian function in women initiating fertility treatment remains controversial. The present study demonstrates high-normal basal LH levels as a good, and low-normal basal LH levels as a negative prognostic sign for oocyte yield in regular-cycling women with borderline basal FSH levels (10.1-15 mU/mL).