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Alviggi C, Humaidan P, Fischer R, Conforti A, Dahan MH, Marca AL, Orvieto R, Polyzos NP, Roque M, Sunkara SK, Ubaldi FM, Vuong L, Yarali H, D'Hooghe T, Longobardi S, Esteves SC. Patients with low prognosis in ART: a Delphi consensus to identify potential clinical implications and measure the impact of POSEIDON criteria. Reprod Biol Endocrinol 2024; 22:122. [PMID: 39385174 PMCID: PMC11465546 DOI: 10.1186/s12958-024-01291-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2024] [Accepted: 09/28/2024] [Indexed: 10/11/2024] Open
Abstract
BACKGROUND Currently, there is no consensus on the optimal management of women with low prognosis in ART. In this Delphi consensus, a panel of international experts provided real-world clinical perspectives on a series of literature-supported consensus statements regarding the overall relevance of the POSEIDON criteria for women with low prognosis in ART. METHODS Using a Delphi-consensus framework, twelve experts plus two Scientific Coordinators discussed and amended statements and supporting references proposed by the Scientific Coordinators (Round 1). Statements were distributed via an online survey to an extended panel of 53 experts, of whom 36 who voted anonymously on their level of agreement or disagreement with each statement using a six-point Likert-type scale (1 = Absolutely agree; 2 = More than agree; 3 = Agree; 4 = Disagree; 5 = More than disagree; 6 = Absolutely disagree) (Round 2). Consensus was reached if > 66% of participants agreed or disagreed. RESULTS The extended panel voted on seventeen statements and subcategorized them according to relevance. All but one statement reached consensus during the first round; the remaining statement reached consensus after rewording. Statements were categorized according to impact, low-prognosis validation, outcomes and patient management. The POSEIDON criteria are timely and clinically sound. The preferred success measure is cumulative live birth and key management strategies include the use of recombinant FSH preparations, supplementation with r-hLH, dose increases and oocyte/embryo accumulation through vitrification. Tools such as the ART Calculator and Follicle-to-Oocyte Index may be considered. Validation data from large, prospective studies in each POSEIDON group are now needed to corroborate existing retrospective data. CONCLUSIONS This Delphi consensus provides an overview of expert opinion on the clinical implications of the POSEIDON criteria for women with low prognosis to ovarian stimulation.
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Affiliation(s)
- Carlo Alviggi
- Department of Public Health, University of Naples Federico II, Via Sergio Pansini, Naples, 80131, Italy
| | - Peter Humaidan
- The Fertility Clinic, Faculty of Health, Skive Regional Hospital, Aarhus University, Aarhus C, Denmark
| | | | - Alessandro Conforti
- Department of Neuroscience, Reproductive Science and Odontomastology, University of Naples Federico II, Via Sergio Pansini, Naples, 80131, Italy
| | - Michael H Dahan
- Department of Obstetrics and Gynecology, McGill University, 888 De Maisonneuve Est., Montreal, QC, H2L 4S8, Canada
| | - Antonio La Marca
- Department of Medical and Surgical Sciences for Mother, Child and Adult, University of Modena and Reggio Emilia, Modena, Italy
| | - Raoul Orvieto
- Department of Obstetrics and Gynecology, Chaim Sheba Medical Center, Tel-Hashomer, Ramat Gan, 52621, Israel
- The Tarnesby-Tarnowski Chair for Family Planning and Fertility Regulation, Faculty of Medical and Health Science, Tel-Aviv University, Tel Aviv-Yafo, 6997801, Israel
| | - Nikolaos P Polyzos
- Dexeus Fertility, Dexeus University Hospital, Barcelona, 08028, Spain
- Faculty of Medicine and Health Sciences, University of Ghent, Gent, 9000, Belgium
| | - Matheus Roque
- Department of Reproductive Medicine, Mater Prime, São Paulo, Brazil
| | | | | | - Lan Vuong
- Department of Obstetrics and Gynaecology, University of Medicine and Pharmacy at Ho Chi Minh City, Ho Chi Minh City, Vietnam
| | - Hakan Yarali
- Anatolia IVF and Women Health Centre, Ankara, Turkey
| | - Thomas D'Hooghe
- Merck Healthcare KGaA, Darmstadt, Germany
- Department of Development and Regeneration, Laboratory of Endometrium, Endometriosis & Reproductive Medicine, KU Leuven, Leuven, Belgium
- Department of Obstetrics, Gynecology, and Reproductive Sciences, Yale University Medical School, New Haven, USA
| | - Salvatore Longobardi
- Global Clinical Development, Merck Serono S.p.A (an affiliate of Merck KGaA, Darmstadt 64293, Germany), Rome, 00176, Italy
| | - Sandro C Esteves
- ANDROFERT, Andrology and Human Reproduction Clinic, Campinas, São Paulo, Brazil.
- Faculty of Health, Aarhus University, Aarhus, Denmark.
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Mao R, Hou X, Feng X, Wang R, Fei X, Zhao J, Chen H, Cheng J. Recombinant human luteinizing hormone increases endometrial thickness in women undergoing assisted fertility treatments: a systematic review and meta-analysis. Front Pharmacol 2024; 15:1434625. [PMID: 39135787 PMCID: PMC11317380 DOI: 10.3389/fphar.2024.1434625] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2024] [Accepted: 07/11/2024] [Indexed: 08/15/2024] Open
Abstract
Introduction The optimal dosage of recombinant human luteinizing hormone (r-hLH) and its impact on endometrial thickness (EMT) when administered alongside recombinant human follicle-stimulating hormone (r-hFSH) during controlled ovarian stimulation (COS) for in vitro fertilization/intracytoplasmic sperm injection and embryo transfer are uncertain, which formed the aims of this systematic review and meta-analysis. Method A search was performed in PubMed, Cochrane Library, Web of Science, EMBASE, CNKI, and Wanfang from its inception to 10 July 2023. Twenty-seven Randomized controlled trials comparing r-hFSH/r-hLH co-treatment with r-hFSH alone during in vitro fertilization/intracytoplasmic sperm injection and embryo transfer (IVF/ICSI-ET) were included. Pooled odds ratios (OR) for dichotomous data and mean differences (MD) for continuous data, with their respective 95% confidence intervals (CI), were generated. Meta-analysis employed fixed-effect or random-effect models based on heterogeneity, using Q-test and I2-index calculations. The main outcomes included EMT on trigger day, clinical pregnancy rate (CPR) and live birth rate (LBR). Results r-hFSH/r-hLH significantly increased EMT on trigger day (MD = 0.27; 95% CI, 0.11-0.42; I2 = 13%), but reduced oocyte number (MD = -0.60; 95% CI, -1.07 to -0.14; I2 = 72%) and high-quality embryos (MD = -0.76; 95% CI, -1.41 to -0.10; I2 = 94%) than r-hFSH alone, more pronounced with the gonadotrophin-releasing hormone agonist long protocol. A subgroup analysis showed r-hLH at 75 IU/day increased CPR (OR = 1.23; 95% CI, 1.02-1.49; I2 = 16%) and EMT on trigger day (MD = 0.40; 95% CI, 0.19-0.61; I2 = 0%). Participants ≥35 years of age exhibited decreased retrieved oocytes (MD = -1.26; 95% CI, -1.78 to -0.74; I2 = 29%), but an increase in EMT on trigger day (MD = 0.26; 95% CI, 0.11-0.42; I2 = 29%). Conclusion r-hFSH/r-hLH during COS significantly improved EMT compared to r-hFSH alone. An r-hLH dose of 75 IU/day may be considered for optimal pregnancy outcomes, which still require further clinical studies to support this dosing regime. Systematic Review Registration [www.crd.york.ac.uk/PROSPERO], identifier [CRD42023454584].
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Affiliation(s)
- Routong Mao
- Reproductive Center, Department of Obstetrics and Gynecology, The Second Affiliated Hospital and Yuying Children’s Hospital of Wenzhou Medical University, Wenzhou, China
| | - Xiaohong Hou
- Reproductive Center, Department of Obstetrics and Gynecology, The Second Affiliated Hospital and Yuying Children’s Hospital of Wenzhou Medical University, Wenzhou, China
| | - Xiao Feng
- Reproductive Center, Department of Obstetrics and Gynecology, The Second Affiliated Hospital and Yuying Children’s Hospital of Wenzhou Medical University, Wenzhou, China
| | - Ruina Wang
- Reproductive Center, Department of Obstetrics and Gynecology, The Second Affiliated Hospital and Yuying Children’s Hospital of Wenzhou Medical University, Wenzhou, China
| | - Xiaofan Fei
- Reproductive Center, Department of Obstetrics and Gynecology, The Second Affiliated Hospital and Yuying Children’s Hospital of Wenzhou Medical University, Wenzhou, China
| | - Junzhao Zhao
- Reproductive Center, Department of Obstetrics and Gynecology, The Second Affiliated Hospital and Yuying Children’s Hospital of Wenzhou Medical University, Wenzhou, China
| | - Hui Chen
- School of Life Sciences, Faculty of Science, University of Technology Sydney, Sydney, NSW, Australia
| | - Jing Cheng
- Reproductive Center, Department of Obstetrics and Gynecology, The Second Affiliated Hospital and Yuying Children’s Hospital of Wenzhou Medical University, Wenzhou, China
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Salehpour S, Aleyasin A, Moini A, Mousavifar N, Mohammadhossein N, Abdollahi Fard S, Marzie S, Mohammadzadeh M, Fischer R. Luteinizing hormone supplementation in controlled ovarian stimulation: the Iran Delphi consensus. FRONTIERS IN REPRODUCTIVE HEALTH 2024; 6:1397446. [PMID: 38784124 PMCID: PMC11111922 DOI: 10.3389/frph.2024.1397446] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2024] [Accepted: 04/01/2024] [Indexed: 05/25/2024] Open
Abstract
Introduction Numerous consensus documents worldwide address luteinizing hormone (LH) supplementation in controlled ovarian stimulation, yet to the best of our knowledge, only one consensus paper has been published in the Arab region. This study presents a Delphi consensus by seven Iranian infertility experts, offering real-world clinical perspectives. The aim was to develop evidence-based opinions on LH's role alongside FSH in various aspects of assisted reproductive technology (ART), including LH levels, monitoring, r-hLH use, and suggested activity. Methods Employing the Delphi consensus approach, the Iran consensus unfolded in three steps. In Step 1, eight out of 10 statements gained approval, while two unclear statements were removed. In Step 2, the 20-member extended panel voted on the remaining eight statements. Results Only one (statement 3) lacked consensus (55% agreement), prompting a modification. The revised statement (noted as statement 3') obtained an 83% agreement. Discussion The clinical perspectives included in this consensus complement clinical guidelines and policies that help further improve treatment outcomes, especially for patients with FSH and LH deficiencies.
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Affiliation(s)
- Saghar Salehpour
- Obstetrics and Gynecology Department, Shahid Beheshti University of Medical Science, Tehran, Iran
| | - Ashraf Aleyasin
- Obstetrics and Gynecology Department, Tehran Medical Science University, Tehran, Iran
| | - Ashraf Moini
- Department of Gynecology and Obstetrics, Arash Women's Hospital, Tehran University of Medical Sciences, Tehran, Iran
- Department of Endocrinology and Female Infertility, Reproductive Biomedicine Research Center, Royan Institute for Reproductive Biomedicine, ACECR, Tehran, Iran
- Breast Disease Research Center (BDRC), Tehran University of Medical Sciences, Tehran, Iran
| | - Nezhat Mousavifar
- Armaghan Infertility Center, Mashhad Medical Science University, Mashhad, Iran
| | - Nasresfahani Mohammadhossein
- Animal Biotechnology Department, Reproductive Biomedicine Research Center, Royan Institute for Biotechnology, ACECR, Isfahan, Iran
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Castillo J, Quaas AM, Kol S. LH supplementation in IVF: human nature, politics, and elephants in the room. J Assist Reprod Genet 2024; 41:609-612. [PMID: 38246921 PMCID: PMC10957814 DOI: 10.1007/s10815-024-03033-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2023] [Accepted: 01/12/2024] [Indexed: 01/23/2024] Open
Abstract
Luteinizing hormone (LH) is present throughout the natural follicular phase. However, the debate is still not settled on whether LH is needed during ovarian stimulation in IVF. This commentary looks at the evolution of this debate, mentioning three elephants in the room that were ignored by the Pharma industry, professional organizations, and clinicians alike: 1. The different endocrinology between the long agonist and the antagonist protocols. 2. The fixed dose of the two most widely commercially available antagonist preparations, namely cetrorelix and ganirelix. 3. The fact that most research in this area uses population-based criteria, ignoring endocrine parameters. Individual genetics of the LH receptor gene may also serve to individualize LH needs during stimulation; however, the jury is still out regarding this approach. CONCLUSIONS: Individual endocrine and genetics parameters may shed meaningful light on the question of LH supplemental during ovarian stimulation.
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Affiliation(s)
- Juan Castillo
- Department of Reproductive Medicine, Instituto Bernabeu, Alicante, Spain
| | | | - Shahar Kol
- IVF unit, Elisha Hospital, 12 Yair Katz Street, Haifa, Israel.
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Huang C, Shen X, Mei J, Sun Y, Sun H, Xing J. Effect of recombinant LH supplementation timing on clinical pregnancy outcome in long-acting GnRHa downregulated cycles. BMC Pregnancy Childbirth 2022; 22:632. [PMID: 35945551 PMCID: PMC9364622 DOI: 10.1186/s12884-022-04963-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2022] [Accepted: 08/03/2022] [Indexed: 11/17/2022] Open
Abstract
Background Timely and moderate luteinizing hormone (LH) supplementation plays positive roles in in vitro fertilization/intracytoplasmic sperm injection and embryo transfer (IVF/ICSI-ET) cycles with long-acting gonadotropin-releasing hormone agonist (GnRHa) pituitary downregulation. However, the appropriate timing of LH supplementation remains unclear. Methods We carried out a retrospective cohort study of 2226 cycles at our reproductive medicine centre from 2018 to 2020. We mainly conducted smooth curve fitting to analyse the relationship between the dominant follicle diameter when recombinant LH (rLH) was added and the clinical pregnancy outcomes (clinical pregnancy rate or early miscarriage rate). In addition, total cycles were divided into groups according to different LH levels after GnRHa and dominant follicle diameters for further analysis. Results Smooth curve fitting showed that with the increase in the dominant follicle diameter when rLH was added, the clinical pregnancy rate gradually increased, and the early miscarriage rate gradually decreased. Conclusions In long-acting GnRHa downregulated IVF/ICSI-ET cycles, the appropriate timing of rLH supplementation has a beneficial impact on the clinical pregnancy outcome. Delaying rLH addition is conducive to the clinical pregnancy rate and reduces the risk of early miscarriage. Supplementary Information The online version contains supplementary material available at 10.1186/s12884-022-04963-x.
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Affiliation(s)
- Chenyang Huang
- Center for Reproductive Medicine and Obstetrics and Gynecology, Nanjing Drum Tower Hospital, Nanjing University Medical School, Nanjing, 210008, China.,Center for Molecular Reproductive Medicine, Nanjing University, Nanjing, 210008, China
| | - Xiaoyue Shen
- Center for Reproductive Medicine and Obstetrics and Gynecology, Nanjing Drum Tower Hospital, Nanjing University Medical School, Nanjing, 210008, China.,Center for Molecular Reproductive Medicine, Nanjing University, Nanjing, 210008, China
| | - Jie Mei
- Center for Reproductive Medicine and Obstetrics and Gynecology, Nanjing Drum Tower Hospital, Nanjing University Medical School, Nanjing, 210008, China.,Center for Molecular Reproductive Medicine, Nanjing University, Nanjing, 210008, China
| | - Yanxin Sun
- Center for Reproductive Medicine and Obstetrics and Gynecology, Nanjing Drum Tower Hospital, Nanjing University Medical School, Nanjing, 210008, China.,Center for Molecular Reproductive Medicine, Nanjing University, Nanjing, 210008, China
| | - Haixiang Sun
- Center for Reproductive Medicine and Obstetrics and Gynecology, Nanjing Drum Tower Hospital, Nanjing University Medical School, Nanjing, 210008, China. .,Center for Molecular Reproductive Medicine, Nanjing University, Nanjing, 210008, China. .,Drum Tower Clinic Medical College, Nanjing Medical University, Nanjing, 210008, China.
| | - Jun Xing
- Center for Reproductive Medicine and Obstetrics and Gynecology, Nanjing Drum Tower Hospital, Nanjing University Medical School, Nanjing, 210008, China. .,Center for Molecular Reproductive Medicine, Nanjing University, Nanjing, 210008, China.
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Di Segni N, Busnelli A, Secchi M, Cirillo F, Levi-Setti PE. Luteinizing hormone supplementation in women with hypogonadotropic hypogonadism seeking fertility care: Insights from a narrative review. Front Endocrinol (Lausanne) 2022; 13:907249. [PMID: 35979440 PMCID: PMC9377693 DOI: 10.3389/fendo.2022.907249] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2022] [Accepted: 07/08/2022] [Indexed: 11/20/2022] Open
Abstract
The management of infertile women affected by hypogonadotropic hypogonadism (HH) or conditions mimicking it is particularly challenging. In the present narrative review, we aimed to synthesize the available evidence on the benefit (if any) of exogenous luteinizing hormone (LH) supplementation in this group of patients. Available data support LH supplementation in women with organic or functional HH. On the contrary, the benefit of exogenous LH on reproductive outcomes both in advanced maternal age patients and in cases of depletion of FSH and LH levels induced by GnRH analogues has not been demonstrated. unfortunately, the inhomogeneous study populations as well as the methodological heterogeneity between studies focused on women affected by conditions mimicking HH do not allow reliable conclusions to be drawn.
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Affiliation(s)
- Noemi Di Segni
- Division of Gynecology and Reproductive Medicine, Department of Gynecology, Fertility Center, IRCCS Humanitas Research Hospital, Milan, Italy
- Department of Biomedical Sciences, Humanitas University, Milan, Italy
| | - Andrea Busnelli
- Division of Gynecology and Reproductive Medicine, Department of Gynecology, Fertility Center, IRCCS Humanitas Research Hospital, Milan, Italy
- Department of Biomedical Sciences, Humanitas University, Milan, Italy
| | - Matteo Secchi
- Department of Biomedical Sciences, Humanitas University, Milan, Italy
| | - Federico Cirillo
- Division of Gynecology and Reproductive Medicine, Department of Gynecology, Fertility Center, IRCCS Humanitas Research Hospital, Milan, Italy
- Department of Biomedical Sciences, Humanitas University, Milan, Italy
| | - Paolo Emanuele Levi-Setti
- Division of Gynecology and Reproductive Medicine, Department of Gynecology, Fertility Center, IRCCS Humanitas Research Hospital, Milan, Italy
- Department of Biomedical Sciences, Humanitas University, Milan, Italy
- *Correspondence: Paolo Emanuele Levi-Setti,
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Setti AS, Braga DPDAF, Iaconelli A, Borges E. Improving Implantation Rate in 2nd ICSI Cycle through Ovarian Stimulation with FSH and LH in GNRH Antagonist Regimen. REVISTA BRASILEIRA DE GINECOLOGIA E OBSTETRÍCIA 2021; 43:749-758. [PMID: 34784631 PMCID: PMC10183840 DOI: 10.1055/s-0041-1736306] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022] Open
Abstract
OBJECTIVE To investigate whether patients with a previous recombinant follicle stimulating hormone (rFSH)-stimulated cycle would have improved outcomes with rFSH + recombinant luteinizing hormone (rLH) stimulation in the following cycle. METHODS For the present retrospective case-control study, 228 cycles performed in 114 patients undergoing intracytoplasmic sperm injection (ICSI) between 2015 and 2018 in an in vitro fertilization (IVF) center were evaluated. Controlled ovarian stimulation (COS) was achieved with rFSH (Gonal-f, Serono, Geneva, Switzerland) in the first ICSI cycle (rFSH group), and with rFSH and rLH (Pergoveris, Merck Serono S.p.A, Bari, Italy) in the second cycle (rFSH + rLH group). The ICSI outcomes were compared among the groups. RESULTS Higher estradiol levels, oocyte yield, day-3 high-quality embryos rate and implantation rate, and a lower miscarriage rate were observed in the rFSH + rLH group compared with the rFSH group. In patients < 35 years old, the implantation rate was higher in the rFSH + rLH group compared with the rFSH group. In patients ≥ 35 years old, higher estradiol levels, oocyte yield, day-3 high-quality embryos rate, and implantation rate were observed in the rFSH + rLH group. In patients with ≤ 4 retrieved oocytes, oocyte yield, mature oocytes rate, normal cleavage speed, implantation rate, and miscarriage rate were improved in the rFSH + rLH group. In patients with ≥ 5 retrieved oocytes, higher estradiol levels, oocyte yield, and implantation rate were observed in the rFSH + rLH group. CONCLUSION Ovarian stimulation with luteinizing hormone (LH) supplementation results in higher implantation rates, independent of maternal age and response to COS when compared with previous cycles stimulated with rFSH only. Improvements were also observed for ICSI outcomes and miscarriage after stratification by age and retrieved oocytes.
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Conforti A, Esteves SC, Humaidan P, Longobardi S, D'Hooghe T, Orvieto R, Vaiarelli A, Cimadomo D, Rienzi L, Ubaldi FM, Zullo F, Alviggi C. Recombinant human luteinizing hormone co-treatment in ovarian stimulation for assisted reproductive technology in women of advanced reproductive age: a systematic review and meta-analysis of randomized controlled trials. Reprod Biol Endocrinol 2021; 19:91. [PMID: 34154604 PMCID: PMC8215738 DOI: 10.1186/s12958-021-00759-4] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2020] [Accepted: 05/10/2021] [Indexed: 01/08/2023] Open
Abstract
INTRODUCTION Several studies suggest that luteinizing hormone (LH) could improve IVF outcome in women of advanced reproductive age by optimizing androgen production. In this review, we assessed the role of recombinant-human LH (r-hLH) and recombinant human follicle stimulating hormone (r-hFSH) co-treatment in ovarian stimulation for assisted reproductive technology in women of advanced reproductive age candidates for assisted reproduction. MATERIAL AND METHODS Using a preregistered protocol we systematically searched Medline/PubMed, Scopus and the ISI Web of Science databases to identify randomized controlled trials in which r-hFSH monotherapy protocols were compared with r-hFSH/r-hLH co-treatment in women ≥35 years undergoing fresh IVF cycles. We calculated the pooled odds ratio (OR) for dichotomous data and the weight mean difference (WMD) for continuous data with an associated 95% confidence interval (CI). The meta-analyses were conducted using the random-effect model. P values < 0.05 were considered statistically significant. Subgroup analyses of all primary and secondary outcomes were performed only in women aged 35-40 years. RESULTS Twelve studies were identified. In women aged between 35 and 40 years, r-hFSH/r-hLH co-treatment was associated with higher clinical pregnancy rates (OR 1.45, CI 95% 1.05-2.00, I2 = 0%, P = 0.03) and implantation rates (OR 1.49, CI 95% 1.10-2.01, I2 = 13%, P = 0.01) versus r-hFSH monotherapy. Fewer oocytes were retrieved in r-hFSH/r-hLH-treated patients than in r-hFSH-treated patients both in women aged ≥35 years (WMD -0.82 CI 95% -1.40 to - 0.24, I2 = 88%, P = 0.005) and in those aged between 35 and 40 years (WMD -1.03, CI - 1.89 to - 0.17, I2 = 0%, P = 0.02). The number of metaphase II oocytes, miscarriage rates and live birth rates did not differ between the two groups of women overall or in subgroup analysis. CONCLUSION Although more oocytes were retrieved in patients who underwent r-hFSH monotherapy, this meta-analysis suggests that r-hFSH/r-hLH co-treatment improves clinical pregnancy and implantation rates in women between 35 and 40 years of age undergoing ovarian stimulation for assisted reproduction technology. However, more RCTs using narrower age ranges in advanced age women are warranted to corroborate these findings.
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Affiliation(s)
- Alessandro Conforti
- University of Naples Federico II, Department of Neuroscience, Reproductive Science and Odontostomatology, University of Naples Federico II, Naples, Italy.
| | - Sandro C Esteves
- ANDROFERT, Andrology and Human Reproduction Clinic, Campinas, Brazil
- Department of Surgery, University of Campinas, Campinas, Brazil
- Faculty of Health, Aarhus University, Aarhus, Denmark
| | - Peter Humaidan
- Faculty of Health, Aarhus University, Aarhus, Denmark
- Fertility Clinic, Skive Regional Hospital, Skive, Denmark
| | | | - Thomas D'Hooghe
- Department of Development and Regeneration, Biomedical Sciences Group, KU Leuven (University of Leuven), Merck, Leuven, Belgium
- KGaA, Darmstadt, Germany
| | - Raoul Orvieto
- Department of Obstetrics and Gynecology, Chaim Sheba Medical Center, Ramat Gan, Israel
- The Tarnesby-Tarnowski Chair for Family Planning and Fertility Regulation, Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Alberto Vaiarelli
- Clinica Valle Giulia, G.EN.E.R.A. Centers for Reproductive Medicine, Rome, Italy
| | - Danilo Cimadomo
- Clinica Valle Giulia, G.EN.E.R.A. Centers for Reproductive Medicine, Rome, Italy
| | - Laura Rienzi
- Clinica Valle Giulia, G.EN.E.R.A. Centers for Reproductive Medicine, Rome, Italy
| | - Filippo Maria Ubaldi
- Clinica Valle Giulia, G.EN.E.R.A. Centers for Reproductive Medicine, Rome, Italy
| | - Fulvio Zullo
- University of Naples Federico II, Department of Neuroscience, Reproductive Science and Odontostomatology, University of Naples Federico II, Naples, Italy
| | - Carlo Alviggi
- University of Naples Federico II, Department of Neuroscience, Reproductive Science and Odontostomatology, University of Naples Federico II, Naples, Italy
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Bosch E, Alviggi C, Lispi M, Conforti A, Hanyaloglu AC, Chuderland D, Simoni M, Raine-Fenning N, Crépieux P, Kol S, Rochira V, D'Hooghe T, Humaidan P. Reduced FSH and LH action: implications for medically assisted reproduction. Hum Reprod 2021; 36:1469-1480. [PMID: 33792685 PMCID: PMC8129594 DOI: 10.1093/humrep/deab065] [Citation(s) in RCA: 46] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2020] [Revised: 12/18/2020] [Indexed: 12/11/2022] Open
Abstract
Luteinizing hormone (LH) and follicle-stimulating hormone (FSH) play complementary roles in follicle development and ovulation via a complex interaction in the hypothalamus, anterior pituitary gland, reproductive organs, and oocytes. Impairment of the production or action of gonadotropins causes relative or absolute LH and FSH deficiency that compromises gametogenesis and gonadal steroid production, thereby reducing fertility. In women, LH and FSH deficiency is a spectrum of conditions with different functional or organic causes that are characterized by low or normal gonadotropin levels and low oestradiol levels. While the causes and effects of reduced LH and FSH production are very well known, the notion of reduced action has received less attention by researchers. Recent evidence shows that molecular characteristics, signalling as well as ageing, and some polymorphisms negatively affect gonadotropin action. These findings have important clinical implications, in particular for medically assisted reproduction in which diminished action determined by the afore-mentioned factors, combined with reduced endogenous gonadotropin production caused by GnRH analogue protocols, may lead to resistance to gonadotropins and, thus, to an unexpected hypo-response to ovarian stimulation. Indeed, the importance of LH and FSH action has been highlighted by the International Committee for Monitoring Assisted Reproduction Technologies (ICMART) in their definition of hypogonadotropic hypogonadism as gonadal failure associated with reduced gametogenesis and gonadal steroid production due to reduced gonadotropin production or action. The aim of this review is to provide an overview of determinants of reduced FSH and LH action that are associated with a reduced response to ovarian stimulation.
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Affiliation(s)
| | - C Alviggi
- Department of Neuroscience, Reproductive Science and Odontostomatology, University Federico II, Naples, Italy
| | - M Lispi
- Global Medical Affairs Fertility, Merck KGaA, Darmstadt, Germany.,International PhD School in Clinical and Experimental Medicine (CEM), University of Modena and Reggio Emilia, Modena, Italy
| | - A Conforti
- Department of Neuroscience, Reproductive Science and Odontostomatology, University Federico II, Naples, Italy
| | - A C Hanyaloglu
- Institute of Reproductive and Developmental Biology, Department of Metabolism, Digestion and Reproduction, Imperial College London, London, UK
| | - D Chuderland
- Global Medical Affairs Fertility, Merck KGaA, Darmstadt, Germany
| | - M Simoni
- Unit of Endocrinology, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Modena, Italy
| | - N Raine-Fenning
- Department of Child Health, Obstetrics and Gynaecology, School of Medicine, University of Nottingham, Nottingham, UK
| | - P Crépieux
- Physiologie de la Reproduction et des Comportements, UMR INRA 085, CNRS 7247, Université de Tours, Nouzilly, France
| | - S Kol
- IVF Unit, Elisha Hospital, Haifa, Israel
| | - V Rochira
- Institute of Reproductive and Developmental Biology, Department of Metabolism, Digestion and Reproduction, Imperial College London, London, UK.,Unit of Endocrinology, Azienda Ospedaliero-Universitaria of Modena, Ospedale Civile di Baggiovara, Modena, Italy
| | - T D'Hooghe
- Global Medical Affairs Fertility, Merck KGaA, Darmstadt, Germany.,Department of Development & Regeneration, University of Leuven (KU Leuven), Leuven, Belgium.,Department of Obstetrics and Gynecology, Yale University, New Haven, CT, USA
| | - P Humaidan
- Fertility Clinic, Skive Regional Hospital, and the Department of Clinical Medicine, Faculty of Health, Aarhus University, Aarhus, Denmark
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10
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Liu S, Liu M, Li L, Li H, Qu D, Ren H, Su H, Zhang Y, Li Y. Patients With Deep Ovarian Suppression Following GnRH Agonist Long Protocol May Benefit From a Modified GnRH Antagonist Protocol: A Retrospective Cohort Study. Front Endocrinol (Lausanne) 2021; 12:618580. [PMID: 34326810 PMCID: PMC8314175 DOI: 10.3389/fendo.2021.618580] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2020] [Accepted: 06/29/2021] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVE To verify if patients with deep ovarian suppression following gonadotropin releasing hormone (GnRH) agonist long protocol may benefit from a modified GnRH antagonist protocol based on luteinizing hormone (LH) levels. DESIGN Retrospective cohort study. SETTING University-based hospital. PATIENTS 110 patients exhibited ultra-low LH levels during ovarian stimulation using GnRH agonist long protocol. INTERVENTIONS As all the embryos in the first cycle were exhausted without being pregnant, these patients proposed to undergo a second cycle of ovarian stimulation. 74 of them were treated with a modified GnRH antagonist protocol based on LH levels. Other 36 patients were still stimulated following GnRH agonist long protocol. MAIN OUTCOME MEASURE The primary outcome was live birth rate (LBR). The second outcomes were biochemical pregnancy rate, clinical pregnancy rate (CPR), ongoing pregnancy rate (OPR) and cancellation rate. RESULTS Reproductive outcomes were much better in the modified GnRH antagonist protocol. The OPR and LBR were much higher in the GnRH antagonist protocol group than in the GnRH agonist long protocol group [odds ratio (OR) 3.82, 95% confidence interval (CI) 1.47, 10.61, P=0.018; OR 4.33, 95% CI 1.38, 13.60, P=0.008; respectively]. Meanwhile, the cancellation rate was much lower in the GnRH antagonist protocol group (OR 0.13, 95% CI 0.02, 0.72; P=0.014). Mean LH level during stimulation did not have a predictive value on live birth. However, it was independently associated with the occurrence of ongoing pregnancy (OR 2.70, 95% CI 1.25, 5.85; P=0.01). The results of sensitivity analyses were consistent with the data mentioned above. The patients got completely different and excellent clinical outcomes in their second cycles stimulated with the modified GnRH antagonist protocol. CONCLUSION Patients with deep ovarian suppression following GnRH agonist long protocol may benefit from a modified GnRH antagonist protocol based on LH levels.
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11
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Alviggi C, Conforti A, Esteves SC, Andersen CY, Bosch E, Bühler K, Ferraretti AP, De Placido G, Mollo A, Fischer R, Humaidan P. Recombinant luteinizing hormone supplementation in assisted reproductive technology: a systematic review. Fertil Steril 2018; 109:644-664. [PMID: 29653717 DOI: 10.1016/j.fertnstert.2018.01.003] [Citation(s) in RCA: 71] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2017] [Revised: 12/08/2017] [Accepted: 01/04/2018] [Indexed: 11/19/2022]
Abstract
OBJECTIVE To assess the role of recombinant human LH (r-hLH) supplementation in ovarian stimulation for ART in specific subgroups of patients. DESIGN Systematic review. SETTING Centers for reproductive care. PATIENT(S) Six populations were investigated: 1) women with a hyporesponse to recombinant human FSH (r-hFSH) monotherapy; 2) women at an advanced reproductive age; 3) women cotreated with the use of a GnRH antagonist; 4) women with profoundly suppressed LH levels after the administration of GnRH agonists; 5) normoresponder women to prevent ovarian hyperstimulation syndrome; and 6) women with a "poor response" to ovarian stimulation, including those who met the European Society for Human Reproduction and Embryology Bologna criteria. INTERVENTION(S) Systematic review. MAIN OUTCOME MEASURE(S) Implantation rate, number of oocytes retrieved, live birth rate, ongoing pregnancy rate, fertilization rate, and number of metaphase II oocytes. RESULT(S) Recombinant hLH supplementation appears to be beneficial in two subgroups of patients: 1) women with adequate prestimulation ovarian reserve parameters and an unexpected hyporesponse to r-hFSH monotherapy; and 2) women 36-39 years of age. Indeed, there is no evidence that r-hLH is beneficial in young (<35 y) normoresponders cotreated with the use of a GnRH antagonist. The use of r-hLH supplementation in women with suppressed endogenous LH levels caused by GnRH analogues and in poor responders remains controversial, whereas the use of r-hLH supplementation to prevent the development of ovarian hyperstimulation syndrome warrants further investigation. CONCLUSION(S) Recombinant hLH can be proposed for hyporesponders and women 36-39 years of age.
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Affiliation(s)
- Carlo Alviggi
- Department of Neuroscience, Reproductive Science and Odontostomatology, University of Naples Federico II, Naples, Italy.
| | - Alessandro Conforti
- Department of Neuroscience, Reproductive Science and Odontostomatology, University of Naples Federico II, Naples, Italy
| | - Sandro C Esteves
- Androfert, Andrology and Human Reproduction Clinic, São Paulo, Brazil
| | - Claus Yding Andersen
- Laboratory of Reproductive Biology, University Hospital of Copenhagen, Faculty of Health and Medical Sciences, Copenhagen, Denmark
| | - Ernesto Bosch
- Instituto Valenciano de Infertilidad, Valencia, Spain
| | - Klaus Bühler
- Center for Gynecology, Endocrinology, and Reproductive Medicine, Ulm and Stuttgart, Germany
| | | | - Giuseppe De Placido
- Department of Neuroscience, Reproductive Science and Odontostomatology, University of Naples Federico II, Naples, Italy
| | - Antonio Mollo
- Department of Neuroscience, Reproductive Science and Odontostomatology, University of Naples Federico II, Naples, Italy
| | | | - Peter Humaidan
- Fertility Clinic, Skive Regional Hospital, Skive, Denmark, and Faculty of Health, Aarhus University, Aarhus, Denmark
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12
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Humaidan P, Chin W, Rogoff D, D'Hooghe T, Longobardi S, Hubbard J, Schertz J. Efficacy and safety of follitropin alfa/lutropin alfa in ART: a randomized controlled trial in poor ovarian responders. Hum Reprod 2018; 32:544-555. [PMID: 28137754 PMCID: PMC5850777 DOI: 10.1093/humrep/dew360] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2016] [Accepted: 01/10/2017] [Indexed: 01/15/2023] Open
Abstract
STUDY QUESTION How does the efficacy and safety of a fixed-ratio combination of recombinant human FSH plus recombinant human LH (follitropin alfa plus lutropin alfa; r-hFSH/r-hLH) compare with that of r-hFSH monotherapy for controlled ovarian stimulation (COS) in patients with poor ovarian response (POR)? SUMMARY ANSWER The primary and secondary efficacy endpoints were comparable between treatment groups and the safety profile of both treatment regimens was favourable. WHAT IS KNOWN ALREADY Although meta-analyses of clinical trials have suggested some beneficial effect on reproductive outcomes with r-hLH supplementation in patients with POR, the definitions of POR were heterogeneous and limit the comparability across studies. STUDY DESIGN, SIZE, DURATION Phase III, single-blind, active-comparator, randomized, parallel-group clinical trial. Patients were followed for a single ART cycle. A total of 939 women were randomized (1:1) to receive either r-hFSH/r-hLH or r-hFSH. Randomization, stratified by study site and participant age, was conducted via an interactive voice response system. PARTICIPANTS/MATERIALS, SETTING, METHODS Women classified as having POR, based on criteria incorporating the ESHRE Bologna criteria, were down-regulated with a long GnRH agonist protocol and following successful down-regulation were randomized (1:1) to COS with r-hFSH/r-hLH or r-hFSH alone. The primary efficacy endpoint was the number of oocytes retrieved following COS. Safety endpoints included the incidence of adverse events, including ovarian hyperstimulation syndrome (OHSS). Post hoc analyses investigated safety outcomes and correlations between live birth and baseline characteristics (age and number of oocytes retrieved in previous ART treatment cycles or serum anti-Müllerian hormone (AMH)). The significance of the treatment effect was tested by generalized linear models (Poisson regression for counts and logistic regression for binary endpoints) adjusting for age and country. MAIN RESULTS AND THE ROLE OF CHANCE Of 949 subjects achieving down-regulation, 939 were randomized to r-hFSH/r-hLH (n = 477) or r-hFSH (n = 462) and received treatment. Efficacy assessment: In the intention-to-treat (ITT) population, the mean (SD) number of oocytes retrieved (primary endpoint) was 3.3 (2.71) in the r-hFSH/r-hLH group compared with 3.6 (2.82) in the r-hFSH group (between-group difference not statistically significant). The observed difference between treatment groups (r-hFSH/r-hLH and r-hFSH, respectively) for efficacy outcomes decreased over the course of pregnancy (biochemical pregnancy rate: 17.3% versus 23.9%; clinical pregnancy rate: 14.1% versus 16.8%; ongoing pregnancy rate: 11.0% versus 12.4%; and live birth rate: 10.6% versus 11.7%). An interaction (identified post hoc) between baseline characteristics related to POR and treatment effect was noted for live birth, with r-hFSH/r-hLH associated with a higher live birth rate for patients with moderate or severe POR, whereas r-hFSH was associated with a higher live birth rate for those with mild POR. A post hoc logistic regression analysis indicated that the incidence of total pregnancy outcome failure was lower in the r-hFSH/r-hLH group (6.7%) compared with the r-hFSH group (12.4%) with an odds ratio of 0.52 (95% CI 0.33, 0.82; P = 0.005). Safety assessment: The overall proportion of patients with treatment-emergent adverse events (TEAEs) occurring during or after r-hFSH/r-hLH or r-hFSH use (stimulation or post-stimulation phase) was 19.9% and 26.8%, respectively. There was no consistent pattern of TEAEs associated with either treatment. LIMITATIONS, REASONS FOR CAUTION Despite using inclusion criteria for POR incorporating the ESHRE Bologna criteria, further investigation is needed to determine the impact of the heterogeneity of POR in the Bologna patient population. The observed correlation between baseline clinical characteristics related to POR and live birth rate, as well as the observed differences between groups regarding total pregnancy outcome failure were from post hoc analyses, and the study was not powered for these endpoints. In addition, the attrition rate for pregnancy outcomes in this trial may not reflect general medical practice. Furthermore, as the patient population was predominantly White these results might not be applicable to other ethnicities. WIDER IMPLICATIONS OF THE FINDINGS In the population of women with POR investigated in this study, although the number of oocytes retrieved was similar following stimulation with either a fixed-ratio combination of r-hFSH/r-hLH or r-hFSH monotherapy, post hoc analyses showed that there was a lower rate of total pregnancy outcome failure in patients receiving r-hFSH/r-hLH, in addition to a higher live birth rate in patients with moderate and severe POR. These findings are clinically relevant and require additional investigation. The benefit:risk balance of treatment with either r-hFSH/r-hLH or r-hFSH remains positive. STUDY FUNDING/COMPETING INTEREST(S) This study was funded by Merck KGaA, Darmstadt, Germany. P.H. has received honoraria for lectures and unrestricted research grants from Ferring, Merck KGaA and MSD. D.R. is a former employee of EMD Serono, a business of Merck KGaA, Darmstadt, Germany. J.S., J.H. and W.C. are employees of EMD Serono Research and Development Institute, a business of Merck KGaA, Darmstadt, Germany. T.D.’H. and S.L. are employees of Merck KGaA, Darmstadt, Germany. TRIAL REGISTRATION NUMBER ClinicalTrials.gov identifier: NCT02047227; EudraCT Number: 2013-003817-16. TRIAL REGISTRATION DATE ClinicalTrials.gov: 24 January 2014; EudraCT: 19 December 2013. DATE OF FIRST PATIENT'S ENROLMENT 30 January 2014.
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Affiliation(s)
- P Humaidan
- The Fertility Clinic, Skive Regional Hospital, Skive, Denmark.,Faculty of Health, Aarhus University, Aarhus, Denmark
| | - W Chin
- Global Biostatistics and Epidemiology, EMD Serono, Billerica, MA, USA, a business of Merck KGaA, Darmstadt, Germany
| | - D Rogoff
- Global Clinical Development, EMD Serono Research and Development Institute, Billerica, MA, USA, a business of Merck KGaA, Darmstadt, Germany
| | - T D'Hooghe
- Global Medical Affairs Fertility, Merck KGaA, Darmstadt, Germany
| | - S Longobardi
- Global Medical Affairs Fertility, Merck KGaA, Darmstadt, Germany
| | - J Hubbard
- Global Clinical Development, EMD Serono Research and Development Institute, Billerica, MA, USA, a business of Merck KGaA, Darmstadt, Germany
| | - J Schertz
- Global Clinical Development, EMD Serono Research and Development Institute, Billerica, MA, USA, a business of Merck KGaA, Darmstadt, Germany
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13
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Hackbart KS, Bender RW, Carvalho PD, Vieira LM, Dresch AR, Guenther JN, Gencoglu H, Nascimento AB, Shaver RD, Wiltbank MC. Effects of propylene glycol or elevated luteinizing hormone during follicle development on ovulation, fertilization, and early embryo development. Biol Reprod 2017; 97:550-563. [PMID: 28575154 PMCID: PMC6248555 DOI: 10.1093/biolre/iox050] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2017] [Accepted: 05/27/2017] [Indexed: 12/31/2022] Open
Abstract
Seventeen nonlactating Holstein cows were superovulated in a Latin-square designed experiment to determine the effects of increased propylene glycol (PROP) and luteinizing hormone (LH) during antral follicle development on ovarian function, fertilization, and early embryo quality. PROP was orally drenched every 4 h for 7 days to induce hyperinsulinemia and associated metabolic changes. LH concentrations were altered by increasing LH (3-fold) during last 2 days of superovulation. Treatment groups were as follows: (1) control-oral drenching with water plus low-LH preparation; (2) high LH(HLH)-water plus HLH preparation; (3) PROP-drenching with PROP plus low LH; (4) PROP/HLH-PROP plus HLH. PROP increased glucose (P < 0.05) and insulin (P < 0.02) concentrations at all time points analyzed. Neither PROP nor LH affected numbers of follicles > 9 mm at time of gonadotropin-releasing hormone-induced LH surge, although percentage of these follicles that ovulated was decreased by both PROP (P = 0.002) and LH (P = 0.048). In addition, PROP tended (P = 0.056) to decrease total number of ovulations. PROP reduced (P = 0.028) fertilization rate, while LH tended (P = 0.092) to increase fertilization rate. There was no effect of either PROP or LH on any measure of embryo quality including percentage of embryos that were degenerate, quality 1, or quality 1 and 2 of total structures collected or fertilized structures. These results indicate that acute elevation in insulin during the preovulatory follicular wave can decrease percentage of large follicles that ovulate, particularly when combined with increased LH, and reduce fertilization of ovulated oocytes.
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Affiliation(s)
- Katherine S Hackbart
- Department of Dairy Science, University of Wisconsin–Madison, Madison, WI,
USA
- Endocrinology & Reproductive Physiology Program, University of
Wisconsin–Madison, Madison, WI, USA
| | - Robb W Bender
- Department of Dairy Science, University of Wisconsin–Madison, Madison, WI,
USA
| | - Paulo D Carvalho
- Department of Dairy Science, University of Wisconsin–Madison, Madison, WI,
USA
| | - Lais M Vieira
- Department of Dairy Science, University of Wisconsin–Madison, Madison, WI,
USA
- University of Sao Paulo-VRA, Sao Paulo, Brazil
| | - Ana R Dresch
- Department of Dairy Science, University of Wisconsin–Madison, Madison, WI,
USA
| | - Jerry N Guenther
- Department of Dairy Science, University of Wisconsin–Madison, Madison, WI,
USA
| | - Hidir Gencoglu
- Department of Dairy Science, University of Wisconsin–Madison, Madison, WI,
USA
| | - Anibal B Nascimento
- Department of Dairy Science, University of Wisconsin–Madison, Madison, WI,
USA
| | - Randy D Shaver
- Department of Dairy Science, University of Wisconsin–Madison, Madison, WI,
USA
| | - Milo C Wiltbank
- Department of Dairy Science, University of Wisconsin–Madison, Madison, WI,
USA
- Endocrinology & Reproductive Physiology Program, University of
Wisconsin–Madison, Madison, WI, USA
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14
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Mochtar MH, Danhof NA, Ayeleke RO, Van der Veen F, van Wely M. Recombinant luteinizing hormone (rLH) and recombinant follicle stimulating hormone (rFSH) for ovarian stimulation in IVF/ICSI cycles. Cochrane Database Syst Rev 2017; 5:CD005070. [PMID: 28537052 PMCID: PMC6481753 DOI: 10.1002/14651858.cd005070.pub3] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
BACKGROUND One of the various ovarian stimulation regimens used for in-vitro fertilisation (IVF) or intracytoplasmic sperm injection (ICSI) cycles is the use of recombinant follicle-stimulating hormone (rFSH) in combination with a gonadotrophin-releasing hormone (GnRH) analogue. GnRH analogues prevent premature luteinizing hormone (LH) surges. Since they deprive the growing follicles of LH, the question arises as to whether supplementation with recombinant LH (rLH) would increase live birth rates. This is an updated Cochrane Review; the original version was published in 2007. OBJECTIVES To compare the effectiveness and safety of recombinant luteinizing hormone (rLH) combined with recombinant follicle-stimulating hormone (rFSH) for ovarian stimulation compared to rFSH alone in women undergoing in-vitro fertilisation/intracytoplasmic sperm injection (IVF/ICSI). SEARCH METHODS For this update we searched the following databases in June 2016: the Gynaecology and Fertility Group Specialised Register, CENTRAL, MEDLINE, Embase, CINAHL, PsycINFO and ongoing trials registers, and checked the references of retrieved articles. SELECTION CRITERIA We included randomised controlled trials (RCTs) comparing rLH combined with rFSH versus rFSH alone in IVF/ISCI cycles. DATA COLLECTION AND ANALYSIS Two review authors independently selected studies, assessed risk of bias, and extracted data. We combined data to calculate odds ratios (ORs) and 95% confidence intervals (CIs). We assessed statistical heterogeneity using the I2 statistic. We assessed the overall quality of the evidence for the main comparisons using GRADE methods. Our primary outcomes were live birth rate and incidence of ovarian hyperstimulation syndrome (OHSS). Secondary outcomes included ongoing pregnancy rate, miscarriage rate and cancellation rates (for poor response or imminent OHSS). MAIN RESULTS We included 36 RCTs (8125 women). The quality of the evidence ranged from very low to moderate. The main limitations were risk of bias (associated with poor reporting of methods) and imprecision.Live birth rates: There was insufficient evidence to determine whether there was a difference between rLH combined with rFSH versus rFSH alone in live birth rates (OR 1.32, 95% CI 0.85 to 2.06; n = 499; studies = 4; I2 = 63%, very low-quality evidence). The evidence suggests that if the live birth rate following treatment with rFSH alone is 17% it will be between 15% and 30% using rLH combined with rFSH.OHSS: There may be little or no difference between rLH combined with rFSH versus rFSH alone in OHSS rates (OR 0.38, 95% CI 0.14 to 1.01; n = 2178; studies = 6; I2 = 10%, low-quality evidence). The evidence suggests that if the rate of OHSS following treatment with rFSH alone is 1%, it will be between 0% and 1% using rLH combined with rFSH.Ongoing pregnancy rate: The use of rLH combined with rFSH probably improves ongoing pregnancy rates, compared to rFSH alone (OR 1.20, 95% CI 1.01 to 1.42; participants = 3129; studies = 19; I2 = 2%, moderate-quality evidence). The evidence suggests that if the ongoing pregnancy rate following treatment with rFSH alone is 21%, it will be between 21% and 27% using rLH combined with rFSH.Miscarriage rate: The use of rLH combined with rFSH probably makes little or no difference to miscarriage rates, compared to rFSH alone (OR 0.93, 95% CI 0.63 to 1.36; n = 1711; studies = 13; I2 = 0%, moderate-quality evidence). The evidence suggests that if the miscarriage rate following treatment with rFSH alone is 7%, the miscarriage rate following treatment with rLH combined with rFSH will be between 4% and 9%.Cancellation rates: There may be little or no difference between rLH combined with rFSH versus rFSH alone in rates of cancellation due to low response (OR 0.77, 95% CI 0.54 to 1.10; n = 2251; studies = 11; I2 = 16%, low quality evidence). The evidence suggests that if the risk of cancellation due to low response following treatment with rFSH alone is 7%, it will be between 4% and 7% using rLH combined with rFSH.We are uncertain whether use of rLH combined with rFSH improves rates of cancellation due to imminent OHSS compared to rFSH alone. Use of a fixed effect model suggested a benefit in the combination group (OR 0.60, 95% CI 0.40 to 0.89; n = 2976; studies = 8; I2 = 60%, very low quality evidence) but use of a random effects model did not support the conclusion that there was a difference between the groups (OR 0.82, 95% CI 0.34 to 1.97). AUTHORS' CONCLUSIONS We found no clear evidence of a difference between rLH combined with rFSH and rFSH alone in rates of live birth or OHSS. The evidence for these comparisons was of very low-quality for live birth and low quality for OHSS. We found moderate quality evidence that the use of rLH combined with rFSH may lead to more ongoing pregnancies than rFSH alone. There was also moderate-quality evidence suggesting little or no difference between the groups in rates of miscarriage. There was no clear evidence of a difference between the groups in rates of cancellation due to low response or imminent OHSS, but the evidence for these outcomes was of low or very low quality.We conclude that the evidence is insufficient to encourage or discourage stimulation regimens that include rLH combined with rFSH in IVF/ICSI cycles.
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Affiliation(s)
- Monique H Mochtar
- Academic Medical Center, University of AmsterdamCenter for Reproductive MedicineMeibergdreef 9AmsterdamNetherlands1105 AZ
| | - Nora A Danhof
- Academic Medical Center, University of AmsterdamCenter for Reproductive MedicineMeibergdreef 9AmsterdamNetherlands1105 AZ
| | - Reuben Olugbenga Ayeleke
- University of AucklandDepartment of Obstetrics and GynaecologyPrivate Bag 92019AucklandNew Zealand
| | - Fulco Van der Veen
- Academic Medical Center, University of AmsterdamCenter for Reproductive MedicineMeibergdreef 9AmsterdamNetherlands1105 AZ
| | - Madelon van Wely
- Academic Medical Center, University of AmsterdamCenter for Reproductive MedicineMeibergdreef 9AmsterdamNetherlands1105 AZ
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15
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Mak SMJ, Wong WY, Chung HS, Chung PW, Kong GWS, Li TC, Cheung LP. Effect of mid-follicular phase recombinant LH versus urinary HCG supplementation in poor ovarian responders undergoing IVF - a prospective double-blinded randomized study. Reprod Biomed Online 2016; 34:258-266. [PMID: 28063801 DOI: 10.1016/j.rbmo.2016.11.014] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2016] [Revised: 11/20/2016] [Accepted: 11/29/2016] [Indexed: 10/20/2022]
Abstract
Luteinizing hormone (LH) is crucial for the development of follicular growth and oocyte maturation, especially in the management of poor ovarian responders (PORs). This study presents the results of a prospective double-blinded randomized study to compare the effect of mid-follicular phase recombinant LH (rLH) supplementation with urinary human chorionic gonadotrophin (uHCG) supplementation when using a fixed gonadotrophin-releasing hormone (GnRH) antagonist protocol in IVF cycles. A total of 49 women with poor ovarian response (POR) according to the Bologna criteria were recruited. This study showed no statistically significant difference in cycle cancellation rates, numbers of oocytes retrieved per cycle initiated, fertilization rates, the numbers of embryos obtained per cycle initiated, implantation, clinical pregnancy and live birth rates, although the live birth rate per cycle initiated in the uHCG group (29.2%) was 3.6 times that of the rLH group (8.0%). Further studies are required to verify if uHCG supplementation produces better clinical outcomes compared with rLH in women with POR.
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Affiliation(s)
- Sze Man Jennifer Mak
- Assisted Reproduction Technology Unit, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong
| | - Wai Yee Wong
- Assisted Reproduction Technology Unit, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong
| | - Hoi Sze Chung
- Assisted Reproduction Technology Unit, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong
| | - Pui Wah Chung
- Assisted Reproduction Technology Unit, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong
| | - Grace Wing Shan Kong
- Assisted Reproduction Technology Unit, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong.
| | - Tin Chiu Li
- Assisted Reproduction Technology Unit, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong
| | - Lai Ping Cheung
- Assisted Reproduction Technology Unit, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong
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16
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Agirregoitia E, Totorikaguena L, Expósito A, Mendoza R, Matorras R, Agirregoitia N. Dynamic of expression and localization of cannabinoid-degrading enzymes FAAH and MGLL in relation to CB1 during meiotic maturation of human oocytes. Cell Tissue Res 2016; 365:393-401. [PMID: 26948343 DOI: 10.1007/s00441-016-2381-2] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2015] [Accepted: 02/19/2016] [Indexed: 12/11/2022]
Abstract
The endogenous cannabinoid system has been characterized in some female reproductive organs but little is known about the expression and localization pattern of cannabinoid-degrading enzymes in relation to the CB1 cannabinoid receptor in human oocytes. In this study, we focus on the investigation of the presence and differential distribution of fatty acid amide hydrolase (FAAH) and monoglyceride lipase (MGLL) in relation to CB1 during the maturation of human oocytes. We used a total of 290 human oocytes not suitable for in vitro fertilization/intracytoplasmic sperm injection (ICSI): germinal-vesicle (GV) and metaphase-I (MI) stages and metaphase-II (MII) oocytes that had not developed into an embryo after ICSI. Cannabinoid-degrading enzymes and the cannabinoid CB1 receptor were present in human oocytes. Specifically, FAAH was detected in the periphery of the oocyte from the GV to MI stage and co-localized with CB1. Later, by the MII stage, FAAH was spread within the oocyte, whereas MGLL immunostaining was homogeneous across the oocyte at all stages of maturation and only overlapped with CB1 at the GV stage. This coordinated redistribution of cannabinoid system proteins suggests a role for this system in the maturation of the female gamete.
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Affiliation(s)
- Ekaitz Agirregoitia
- Department of Physiology, Faculty of Medicine and Dentistry, University of the Basque Country, Barrio Sarriena s/n, Leioa, 48940, Bizkaia, Spain.
| | - Lide Totorikaguena
- Department of Physiology, Faculty of Medicine and Dentistry, University of the Basque Country, Barrio Sarriena s/n, Leioa, 48940, Bizkaia, Spain
| | - Antonia Expósito
- Human Reproduction Unit, Cruces University Hospital, University of the Basque Country, Plaza de Cruces s/n, Barakaldo, 48903, Bizkaia, Spain
| | - Rosario Mendoza
- Human Reproduction Unit, Cruces University Hospital, University of the Basque Country, Plaza de Cruces s/n, Barakaldo, 48903, Bizkaia, Spain
| | - Roberto Matorras
- Human Reproduction Unit, Cruces University Hospital, University of the Basque Country, Plaza de Cruces s/n, Barakaldo, 48903, Bizkaia, Spain
| | - Naiara Agirregoitia
- Department of Physiology, Faculty of Medicine and Dentistry, University of the Basque Country, Barrio Sarriena s/n, Leioa, 48940, Bizkaia, Spain
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17
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Behre HM, Howles CM, Longobardi S. Randomized trial comparing luteinizing hormone supplementation timing strategies in older women undergoing ovarian stimulation. Reprod Biomed Online 2015. [PMID: 26194884 DOI: 10.1016/j.rbmo.2015.06.002] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
In this open-label study, women aged 36-40 years undergoing ovarian stimulation were randomized to recombinant human FSH (rhFSH) plus recombinant human luteinizing hormone (rhLH) from stimulation day 1 (group A; n = 103), or rhFSH alone (days 1-5) followed by rhFSH plus rhLH from day 6 (group B; n = 99). The primary objective was equivalence in number of oocytes retrieved per patient. The mean (±SD) number of oocytes retrieved was 9.7 (±6.9) in group A and 10.9 (±6.5) in group B; the estimated difference between groups (-1.28 oocytes [95% confidence interval: -3.15 to 0.59]) did not reach the predefined limit of equivalence (±3 oocytes). The study's primary objective was therefore not met. In both groups, a mean (±SD) of 1.9 (±0.6) embryos were transferred per patient. Implantation rates were 24.7% in group A and 13.3% in group B. Clinical pregnancy rates per started cycle and per embryo transfer were 31.6% and 34.4% in Group A, 17.2% and 18.9% in Group B. Ovarian hyperstimulation syndrome was reported in four (group A) and five (group B) patients. The potential benefit of initiating LH supplementation earlier during ovarian stimulation in older women is of interest, warranting further exploration.
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Affiliation(s)
- Hermann M Behre
- Centre for Reproductive Medicine and Andrology, University Halle, Germany.
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Liu X, Hao C, Wang J. Efficacy of Highly Purified Urinary FSH versus Recombinant FSH in Chinese Women over 37 Years Undergoing Assisted Reproductive Techniques. INTERNATIONAL JOURNAL OF FERTILITY & STERILITY 2015; 8:385-92. [PMID: 25780520 PMCID: PMC4355925 DOI: 10.22074/ijfs.2015.4178] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Subscribe] [Scholar Register] [Received: 06/22/2013] [Accepted: 11/25/2013] [Indexed: 11/04/2022]
Abstract
BACKGROUND Urine derived follicle-stimulating hormone (uFSH) contains a higher proportion of acidic isoforms, whereas recombinant FSH (rFSH) contains a higher proportion of less-acidic isoforms. Less-acidic isoforms have a faster clearance, and thus a shorter half-life than the acidic FSH isoforms. The slow clearance of the acidic isoforms has a longer half-life and higher biological activity. This study was designed to determine whether uFSH or rFSH is more effective in older Chinese women undergoing assisted reproductive techniques (ART). MATERIALS AND METHODS This is a prospective, randomized, controlled cohort study. A total of 508 Chinese women over 37 years were randomized into two following study groups for their in vitro fertilization (IVF) or intracytoplasmic sperm injection (ICSI) cycles: i. group A (n=254) were treated with rFSH, and ii. group B (n=254) were treated with uFSH. Both groups were suppressed with a gonadotropin-releasing hormone (GnRH) analogue using a long down-regulation protocol. The main outcomes for comparison were days of stimulation, estradiol (E2) on the day of human chorionic gonadotropin (hCG) administration, number of oocytes collected, amount of FSH used, quantity of FSH/oocyte, endometrial thickness at hCG day, M П oocyte rate, 2PN zygote rate, grade І embryo rate, number of embryos cryopreserved, pregnancy rate, implantation rate, abortion rate and the rate of no transferable embryos. RESULTS Twenty two cycles including 16 cycles with poor ovarian response and six cycles with ovarian hyperstimulation syndrome were cancelled. There were 243 cycles left in each group. The patients treated with uFSH had a significantly higher 2PN zygote rate (87.4 vs. 76.6%, p<0.001), grade І embryo rate (49.8 vs. 40.8%, p<0.001) and endometrial thickness on day of hCG (11.8 mm vs. 11.2 mm, respectively, p=0.006) and a lower rate of no transferable embryos (1.2 vs. 5.3%, p=0.019) than women treated with rFSH. The other measures evaluated showed no statistically significant differences between groups (p>0.05). CONCLUSION This study showed that uFSH produced a significantly higher proportion of grade І embryos than rFSH in older Chinese women and there was a significantly lower chance of no transferable embryos in uFSH cycles. The clinical efficacy of the two gonadotropins was equivalent.
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Affiliation(s)
- Xuemei Liu
- Reproductive Medicine Center, Yantai Yuhuangding Hospital, Affiliated Hospital of Qingdao University, Yantai, Shandong, China
| | - Cuifang Hao
- Reproductive Medicine Center, Yantai Yuhuangding Hospital, Affiliated Hospital of Qingdao University, Yantai, Shandong, China
| | - Jinfang Wang
- Reproductive Medicine Center, Yantai Yuhuangding Hospital, Affiliated Hospital of Qingdao University, Yantai, Shandong, China
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Vuong TNL, Phung HT, Ho MT. Recombinant follicle-stimulating hormone and recombinant luteinizing hormone versus recombinant follicle-stimulating hormone alone during GnRH antagonist ovarian stimulation in patients aged >=35 years: a randomized controlled trial. Hum Reprod 2015; 30:1188-95. [DOI: 10.1093/humrep/dev038] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2014] [Accepted: 02/09/2015] [Indexed: 11/14/2022] Open
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Yazıcı Yılmaz F, Görkemli H, Çolakoğlu MC, Aktan M, Gezginç K. The evaluation of recombinant LH supplementation in patients with suboptimal response to recombinant FSH undergoing IVF treatment with GnRH agonist down-regulation. Gynecol Endocrinol 2015; 31:141-4. [PMID: 25237892 DOI: 10.3109/09513590.2014.965675] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
We aimed to evaluate the clinical efficacy of r-LH supplementation to r-FSH in patients with suboptimal response to ovarian stimulation undergoing assisted reproduction with GnRH-a downregulation and stimulation with r-FSH. One-hundred thirty-seven patients were included in the study; among them 52 showed normal ovarian response to stimulation and composed the control group (Group 1), and 85 showed suboptimal response to stimulation and were divided into two groups. For Group 2 (n = 50), 75 IU/L r-LH was added to the treatment, for Group 3 (n = 35) r-FSH dose was increased by 75 IU/L. IVF results were compared between the groups. Implantation rates were 34.8% in control group, and 36.1% and 15% in LH supplementation group and increased-dose r-FSH group, respectively. Implantation rates were statistically significantly higher in Groups 1 and 2 compared to Group 3 (p < 0.02). Pregnancy rate was noticed in 64.7% of Group 1, 57.8% of Group 2 and at 32.4% of Group 3. Pregnancy rate was significantly higher in Group 2 than Group 3 (p < 0.05). r-LH supplementation is an option for improving IVF outcome in patients with suboptimal ovarian response to ovulation induction with r-FSH during GnRH agonist down-regulation. Particularly, r-LH is recommended as it may have a beneficial action on implantation in selected group.
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Affiliation(s)
- Fatma Yazıcı Yılmaz
- Department of Obstetrics and Gynecology, Minister of Health Sisli Etfal Training&Research Hospital , Istanbul , Turkey and
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Xiong Y, Bu Z, Dai W, Zhang M, Bao X, Sun Y. Recombinant luteinizing hormone supplementation in women undergoing in vitro fertilization/ intracytoplasmic sperm injection with gonadotropin releasing hormone antagonist protocol: a systematic review and meta-analysis. Reprod Biol Endocrinol 2014; 12:109. [PMID: 25420965 PMCID: PMC4255634 DOI: 10.1186/1477-7827-12-109] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2014] [Accepted: 10/02/2014] [Indexed: 12/02/2022] Open
Abstract
The objective of this meta-analysis is to assess the impact of LH supplementation in women undergoing in vitro fertilization/ intracytoplasmic sperm injection (IVF/ICSI) with gonadotropin releasing hormone (GnRH) antagonist protocol. No significant difference in outcomes between LH supplementation and r-FSH alone in women undergoing IVF/ICSI with GnRH antagonist protocol is currently present, and further studies are necessary for more solid conclusions on pregnancy likelihood to be drawn.
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Affiliation(s)
- Yujing Xiong
- Reproductive Medical Centre, the First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan Province China
| | - Zhiqin Bu
- Reproductive Medical Centre, the First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan Province China
| | - Wei Dai
- Reproductive Medical Centre, the First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan Province China
| | - Meixiang Zhang
- Reproductive Medical Centre, the First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan Province China
| | - Xiao Bao
- Reproductive Medical Centre, the First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan Province China
| | - Yingpu Sun
- Reproductive Medical Centre, the First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan Province China
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Matorras R, Aparicio V, Corcostegui B, Prieto B, Mendoza R, Ramón O, Gomez-Picado O, Exposito A. Failure of intrauterine insemination as rescue treatment in low responders with adequate HCG timing with no oocytes retrieved. Reprod Biomed Online 2014; 29:634-9. [PMID: 25263264 DOI: 10.1016/j.rbmo.2014.07.020] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2014] [Revised: 07/15/2014] [Accepted: 07/15/2014] [Indexed: 10/24/2022]
Abstract
In this retrospective study, the efficiency of carrying out rescue intrauterine insemination (IUI) in low-responder patients undergoing IVF when no oocytes were retrieved after follicular aspiration and when HCG timing was adequate was analysed. A historical control group was used. Over 13 years, women undergoing IVF with failure to obtain oocytes at follicular aspiration underwent rescue IUI if the following criteria were met: adequate HCG timing; one normal tube; motile sperm count after preparation over 3 million/ml; and ultrasound visualization of one to six follicles over 13 mm. The rescue IUI was carried out 1 h after follicular aspiration. Results were compared with those of a standard IUI population (5394 cycles) in the same period. Confidence intervals were calculated using Poisson 97.5% confidence upper tail limits when no event was observed in the study sample. No pregnancies were achieved among the 54 cases who underwent rescue IUI (confidence interval: 0 to 6.8%). This pregnancy rate was lower than that observed in the general IUI population (17.5%) (relative risk, 19.2). After adjusting for age and endometriosis, the relative risk was 11.7. The rescue IUI is an inefficient procedure. Its efficacy is unlikely to exceed 7% pregnancy rate per IUI.
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Affiliation(s)
- Roberto Matorras
- Human Reproduction Unit, Cruces University Hospital, University of the Basque Country, Plaza de Cruces s/n Baracaldo (Vizcaya), 48903 Vizcaya, Spain
| | - Victoria Aparicio
- Human Reproduction Unit, Cruces University Hospital, University of the Basque Country, Plaza de Cruces s/n Baracaldo (Vizcaya), 48903 Vizcaya, Spain
| | - Beatriz Corcostegui
- Human Reproduction Unit, Cruces University Hospital, University of the Basque Country, Plaza de Cruces s/n Baracaldo (Vizcaya), 48903 Vizcaya, Spain
| | - Begoña Prieto
- Human Reproduction Unit, Cruces University Hospital, University of the Basque Country, Plaza de Cruces s/n Baracaldo (Vizcaya), 48903 Vizcaya, Spain
| | - Rosario Mendoza
- Human Reproduction Unit, Cruces University Hospital, University of the Basque Country, Plaza de Cruces s/n Baracaldo (Vizcaya), 48903 Vizcaya, Spain
| | - Olga Ramón
- Human Reproduction Unit, Cruces University Hospital, University of the Basque Country, Plaza de Cruces s/n Baracaldo (Vizcaya), 48903 Vizcaya, Spain
| | - Oihane Gomez-Picado
- Human Reproduction Unit, Cruces University Hospital, University of the Basque Country, Plaza de Cruces s/n Baracaldo (Vizcaya), 48903 Vizcaya, Spain
| | - Antonia Exposito
- Human Reproduction Unit, Cruces University Hospital, University of the Basque Country, Plaza de Cruces s/n Baracaldo (Vizcaya), 48903 Vizcaya, Spain.
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Lehert P, Kolibianakis EM, Venetis CA, Schertz J, Saunders H, Arriagada P, Copt S, Tarlatzis B. Recombinant human follicle-stimulating hormone (r-hFSH) plus recombinant luteinizing hormone versus r-hFSH alone for ovarian stimulation during assisted reproductive technology: systematic review and meta-analysis. Reprod Biol Endocrinol 2014; 12:17. [PMID: 24555766 PMCID: PMC4015269 DOI: 10.1186/1477-7827-12-17] [Citation(s) in RCA: 85] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2013] [Accepted: 02/12/2014] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The potential benefit of adding recombinant human luteinizing hormone (r-hLH) to recombinant human follicle-stimulating hormone (r-hFSH) during ovarian stimulation is a subject of debate, although there is evidence that it may benefit certain subpopulations, e.g. poor responders. METHODS A systematic review and a meta-analysis were performed. Three databases (MEDLINE, Embase and CENTRAL) were searched (from 1990 to 2011). Prospective, parallel-, comparative-group randomized controlled trials (RCTs) in women aged 18-45 years undergoing in vitro fertilization, intracytoplasmic sperm injection or both, treated with gonadotrophin-releasing hormone analogues and r-hFSH plus r-hLH or r-hFSH alone were included. The co-primary endpoints were number of oocytes retrieved and clinical pregnancy rate. Analyses were conducted for the overall population and for prospectively identified patient subgroups, including patients with poor ovarian response (POR). RESULTS In total, 40 RCTs (6443 patients) were included in the analysis. Data on the number of oocytes retrieved were reported in 41 studies and imputed in two studies. Therefore, data were available from 43 studies (r-hFSH plus r-hLH, n=3113; r-hFSH, n=3228) in the intention-to-treat (ITT) population (all randomly allocated patients, including imputed data). Overall, no significant difference in the number of oocytes retrieved was found between the r-hFSH plus r-hLH and r-hFSH groups (weighted mean difference -0.03; 95% confidence interval [CI] -0.41 to 0.34). However, in poor responders, significantly more oocytes were retrieved with r-hFSH plus r-hLH versus r-hFSH alone (n=1077; weighted mean difference +0.75 oocytes; 95% CI 0.14-1.36). Significantly higher clinical pregnancy rates were observed with r-hFSH plus r-hLH versus r-hFSH alone in the overall population analysed in this review (risk ratio [RR] 1.09; 95% CI 1.01-1.18) and in poor responders (n=1179; RR 1.30; 95% CI 1.01-1.67; ITT population); the observed difference was more pronounced in poor responders. CONCLUSIONS These data suggest that there is a relative increase in the clinical pregnancy rates of 9% in the overall population and 30% in poor responders. In conclusion, this meta-analysis suggests that the addition of r-hLH to r-hFSH may be beneficial for women with POR.
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Affiliation(s)
- Philippe Lehert
- Faculty of Economics, Université Catholique de Louvain (UCL Mons), 7000 Mons, Belgium
- Faculty of Medicine, the University of Melbourne, Melbourne 3010, Victoria, Australia
| | - Efstratios M Kolibianakis
- Unit for Human Reproduction, 1st Department of Obstetrics and Gynaecology, Medical School, Aristotle University of Thessaloniki 54124 Thessaloniki, Greece
| | - Christos A Venetis
- Unit for Human Reproduction, 1st Department of Obstetrics and Gynaecology, Medical School, Aristotle University of Thessaloniki 54124 Thessaloniki, Greece
| | - Joan Schertz
- Fertility Global Clinical Development Unit, EMD Serono, Inc, Rockland, MA 02370, USA (an affiliate of Merck KGaA, Darmstadt, Germany
| | - Helen Saunders
- Formerly Merck Serono S.A, Geneva, Switzerland (an affiliate of Merck KGaA, Darmstadt, Germany
- Preglem SA, Chemin du Pré-Fleuri 3, 1228 Plan-les-Ouates, Geneva, Switzerland
| | - Pablo Arriagada
- Formerly Merck Serono S.A, Geneva, Switzerland (an affiliate of Merck KGaA, Darmstadt, Germany
- Preglem SA, Chemin du Pré-Fleuri 3, 1228 Plan-les-Ouates, Geneva, Switzerland
| | - Samuel Copt
- Formerly Merck Serono S.A, Geneva, Switzerland (an affiliate of Merck KGaA, Darmstadt, Germany
- Biosensors, rue de Lausanne 31, 1100 Morges, Switzerland
| | - Basil Tarlatzis
- Unit for Human Reproduction, 1st Department of Obstetrics and Gynaecology, Medical School, Aristotle University of Thessaloniki 54124 Thessaloniki, Greece
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Matorras R, Andrés M, Mendoza R, Prieto B, Pijoan JI, Expósito A. Prevention of ovarian hyperstimulation syndrome in GnRH agonist IVF cycles in moderate risk patients: randomized study comparing hydroxyethyl starch versus cabergoline and hydroxyethyl starch. Eur J Obstet Gynecol Reprod Biol 2013; 170:439-43. [DOI: 10.1016/j.ejogrb.2013.07.010] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2013] [Revised: 05/17/2013] [Accepted: 07/04/2013] [Indexed: 11/25/2022]
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Matorras R, Rabanal A, Prieto B, Diez S, Brouard I, Mendoza R, Exposito A. Hysteroscopic hydrosalpinx occlusion with Essure device in IVF patients when salpingectomy or laparoscopy is contraindicated. Eur J Obstet Gynecol Reprod Biol 2013; 169:54-9. [DOI: 10.1016/j.ejogrb.2013.02.008] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2012] [Revised: 01/10/2013] [Accepted: 02/04/2013] [Indexed: 10/27/2022]
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26
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Gatta V, Tatone C, Ciriminna R, Vento M, Franchi S, d'Aurora M, Sperduti S, Cela V, Borzì P, Palermo R, Stuppia L, Artini PG. Gene expression profiles of cumulus cells obtained from women treated with recombinant human luteinizing hormone + recombinant human follicle-stimulating hormone or highly purified human menopausal gonadotropin versus recombinant human follicle-stimulating hormone alone. Fertil Steril 2013; 99:2000-8.e1. [PMID: 23472943 DOI: 10.1016/j.fertnstert.2013.01.150] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2012] [Revised: 01/28/2013] [Accepted: 01/28/2013] [Indexed: 10/27/2022]
Abstract
OBJECTIVE To evaluate cumulus cell (CC) expression profile modulation after different stimulation protocols. DESIGN CCs transcriptome variations were evaluated by microarray in patients undergoing different treatments for ovarian stimulation, namely, r-hLH + r-hFSH and hp-hMG, compared with a control group treated with r-hFSH. SETTING Healthy patients undergoing assisted reproduction protocols. PATIENT(S) Sixteen healthy women with regular cycles and tubal disease or unexplained infertility. INTERVENTION(S) Four patients received hp-hMG, four received r-hFSH + r-hLH, and eight received r-hFSH daily. Aspiration of the oocytes was performed 36 hours after hCG administration. Only samples derived from cumulus-oocyte complexes containing mature oocytes showing polar body were processed. MAIN OUTCOME MEASURE(S) Comparison of genes differentially expressed in both treatment groups with the use of a hierarchic clustering analysis. RESULT(S) Data clustering analysis allowed detection of four clusters containing genes differentially expressed in both treatment groups compared with control. Functional analysis of the affected transcripts revealed genes involved in oocyte development and maturation. CONCLUSION(S) r-hLH and hCG, though acting on the same receptor, produce a differential activation of intracellular pathways. It can be hypothesized that this effect depends on their different structures and specific binding affinity for the receptor.
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Affiliation(s)
- Valentina Gatta
- Department of Psychology, Humanities, and Territory Sciences, G. d'Annunzio University, Chieti, Italy.
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Follicular fluid hormonal profile and cumulus cell gene expression in controlled ovarian hyperstimulation with recombinant FSH: effects of recombinant LH administration. J Assist Reprod Genet 2012. [PMID: 23188412 DOI: 10.1007/s10815-012-9893-9] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
PURPOSE Down-regulation with gonadodropin-releasing agonist (GnRH-a) protocol during IVF stimulation leads to a severe endogenous LH suppression, which may affect the follicular development. The aim of the study was to evaluate the effects of recombinant LH (r-LH) administration, during late follicular development stages, in recombinant FSH (r-FSH) stimulated cycles on follicular fluid (FF) parameters and on cumulus cell quality. METHODS Twenty patients undergoing IVF were stimulated in a long GnRH agonist protocol with r-FSH alone or with r-LH supplementation when the leading follicle reached diameter of 14 mm. FF was collected at the time of oocyte retrieval from 32 follicles ≥ 18 mm. Serum FSH, LH, estradiol (E(2)), and progesterone (P(4)) were evaluated on the day of hCG administration. Intra-follicular E(2), P(4), AMH and TGF-β were assayed. Total RNA from 18 individual cumuli was isolated for gene expression analyses. RESULTS R-LH increased FF P(4) levels. FF TGF-β levels and PTGS2 and HAS2 expression in cumulus cells (CCs) positively correlated with increased P(4) levels observed in FFs, while a negative correlation was found between P(4) and AMH levels. CONCLUSIONS FF positive correlation between P(4) and TGF-β levels and CC expression of PTGS2 and HAS2 suggest an association with a better follicle quality. In addition, our data suggest that late follicular phase r-LH supplementation leads to a more advanced stage of follicular maturation.
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Matorras R, Meabe A, Mendoza R, Prieto B, Ramón O, Mugica J, Aspichueta F, Exposito A. Human chorionic gonadotropin (hCG) plasma levels at oocyte retrieval and IVF outcomes. J Assist Reprod Genet 2012; 29:1067-71. [PMID: 22815004 DOI: 10.1007/s10815-012-9826-7] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2012] [Accepted: 06/26/2012] [Indexed: 10/28/2022] Open
Abstract
PURPOSE The aim of our study was to ascertain the influence of hCG levels at oocyte pick-up on IVF outcomes, and their relationship with clinical parameters. METHODS A prospective study was performed including 473 women undergoing IVF, aged under 40 years. Blood samples to analyze hCG levels were obtained at the time of follicular aspiration, 36 h after the administration of 250 μg of recombinant hCG. RESULTS Neither the numbers of oocytes obtained or fertilized, nor the pregnancy rate, were correlated with hCG levels. Moreover, hCG values were very similar in women who did and did not become pregnant (123.3 ± 48.7 and 117.5 ± 44.7 mUI/mL). Cases in which no oocytes were recovered after follicular aspiration had similar hCG levels to those in which more than 1 oocyte was obtained. On the other hand, hCG levels were negatively related to body mass index, weight, and age. CONCLUSIONS These data indicate that after the administration of 250 μg of recombinant hCG, hCG levels are not responsible for failure to recover oocytes. Specifically, there was no correlation between plasma hCG levels and the number of oocytes obtained or other markers of IVF outcome. There was, however, an inverse relationship with BMI, body weight and age.
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Affiliation(s)
- R Matorras
- Assisted Reproduction Unit, Department of Obstetrics and Gynecology, Cruces University Hospital, C/Plaza de Cruces S/N. 48903 Baracaldo, Vizcaya, Spain.
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Expression and localization of opioid receptors during the maturation of human oocytes. Reprod Biomed Online 2012; 24:550-7. [DOI: 10.1016/j.rbmo.2012.02.007] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2011] [Revised: 02/10/2012] [Accepted: 02/15/2012] [Indexed: 11/23/2022]
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Howles CM, Ezcurra D, Homburg R. Ovarian stimulation protocols in assisted reproductive technology: an update. Expert Rev Endocrinol Metab 2012; 7:319-330. [PMID: 30780844 DOI: 10.1586/eem.12.18] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
Controlled ovarian stimulation (COS) with gonadotropins to produce multiple follicular development and high-quality oocytes is the cornerstone of assisted reproductive technology. Today, recombinant human follicle-stimulating hormone (r-hFSH) is widely used for COS. A long-acting r-hFSH and a combination of r-hFSH and recombinant human luteinizing hormone have recently become available. Formulations of purified urinary FSH with or without luteinizing hormone activity (provided by human chorionic gonadotropin) are also available. COS protocols can now be individualized to optimize efficacy and safety - defined as singleton pregnancies with a low incidence of ovarian hyperstimulation syndrome. This is facilitated by an estimation of ovarian response using the antral follicle count and/or serum anti-Müllerian hormone levels; anti-Müllerian hormone is viewed as the most reliable single marker. However, an efficient management strategy for poor responders to COS is still required. Developments in biomarkers and other techniques for accurate identification of viable oocytes and embryos and optimal uterine receptivity are expected.
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Affiliation(s)
- Colin M Howles
- a Merck Serono S.A. - Geneva , Geneva, Switzerland
- c Merck Serono S.A. - Geneva , Geneva, Switzerland.
| | | | - Roy Homburg
- b Barzilai Medical Centre, Ashkelon, Israel and Homerton University Hospital, Hackney, London, UK
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Improved pregnancy rates with luteinizing hormone supplementation in patients undergoing ovarian stimulation for IVF. J Assist Reprod Genet 2012; 29:579-83. [PMID: 22466744 DOI: 10.1007/s10815-012-9740-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2011] [Accepted: 02/27/2012] [Indexed: 10/28/2022] Open
Abstract
INTRODUCTION Luteinizing hormone (LH) is believed to play a role in follicle maturation during the natural cycle. However, the need for co-treatment with recombinant LH (rLH) for controlled ovarian stimulation is controversial. PURPOSE The primary objective of our study was to determine if pregnancy rates are improved when rLH is used in addition to rFSH for ovarian stimulation. Secondary outcomes were fertilization rate, implantation rate and live birth rate. METHODS A retrospective cohort study was performed of 1565 IVF or ICSI cycles. Outcomes were compared between ovarian stimulation cycles from 2007 when rLH and rFSH was used (n = 765) to 2006 when rFSH only was used (n-800). RESULTS Improved outcomes were found for rLH + rFSH versus rFSH alone for; pregnancy rate (61% and 54% respectively, p = 0.006), live birth rate (49% and 42% respectively, P = 0.01), fertilization rate (74% versus 72% respectively, p = 0.04 and implantation rate (41% versus 37% respectively, p = 0.03). CONCLUSIONS Our large retrospective cohort study showed an improved pregnancy rate and live birth rate with rLH supplementation. This was associated with an improved fertilization and implantation rate and therefore may reflect an improvement in oocyte quality and/or uterine receptivity.
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Hill MJ, Levens ED, Levy G, Ryan ME, Csokmay JM, DeCherney AH, Whitcomb BW. The use of recombinant luteinizing hormone in patients undergoing assisted reproductive techniques with advanced reproductive age: a systematic review and meta-analysis. Fertil Steril 2012; 97:1108-14.e1. [PMID: 22365075 DOI: 10.1016/j.fertnstert.2012.01.130] [Citation(s) in RCA: 77] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2011] [Revised: 01/30/2012] [Accepted: 01/31/2012] [Indexed: 10/28/2022]
Abstract
OBJECTIVE To evaluate the effect of recombinant LH in assisted reproduction technology (ART) cycles in patients of advanced reproductive age. DESIGN A systematic review and meta-analysis. SETTING Published randomized controlled clinical trials comparing recombinant LH plus recombinant FSH versus recombinant FSH only in patients of advanced reproductive age. PATIENT(S) Patients 35 years and older undergoing assisted reproduction. INTERVENTION(S) Recombinant LH plus recombinant FSH controlled ovarian hyperstimulation (COH) versus recombinant FSH stimulation only in assisted reproduction cycles. MAIN OUTCOME MEASURE(S) Implantation and clinical pregnancy. RESULT(S) Seven trials were identified that met inclusion criteria and comprised 902 assisted reproduction technology cycles. No differences in serum E(2) on the day of hCG administration were reported in any trials. Two trials reported lower oocyte yield and one trial reported lower metaphase II oocyte yield in the recombinant LH-supplemented group. One trial reported higher fertilization rates in the recombinant LH-supplemented group. In a fixed effect model, implantation was higher in the recombinant LH-supplemented group (odds ratio 1.36, 95% confidence interval 1.05-1.78). Similarly, clinical pregnancy was increased in the recombinant LH-supplemented group (odds ratio 1.37, 95% confidence interval 1.03-1.83). CONCLUSION(S) The addition of recombinant LH to ART cycles may improve implantation and clinical pregnancy in patients of advanced reproductive age.
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Affiliation(s)
- Micah J Hill
- Program in Reproductive and Adult Endocrinology, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, Maryland 20892, USA
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Hill MJ, Levy G, Levens ED. Does exogenous LH in ovarian stimulation improve assisted reproduction success? An appraisal of the literature. Reprod Biomed Online 2011; 24:261-71. [PMID: 22285265 DOI: 10.1016/j.rbmo.2011.12.005] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2011] [Revised: 11/11/2011] [Accepted: 12/14/2011] [Indexed: 10/14/2022]
Abstract
A review of the scientific literature on the use of exogenous LH in assisted reproductive technology was performed by searching the MEDLINE, PubMed and Cochrane online databases. Scientific evidence was reviewed comparing recombinant FSH-only protocols to protocols supplemented with exogenous LH activity: human menopausal gonadotrophin (HMG), recombinant LH and mid-follicular human chorionic gonadotrophin (HCG). Studies were further compared based on pituitary suppression with gonadotrophin- releasing hormone (GnRH) antagonist and agonist protocols. Primary focus was given to randomized controlled trials and meta-analyses. Data from hypogonadotrophic hypogonadal patients demonstrated the importance of LH activity for success of assisted reproduction treatment. However, the majority of normogonadotrophic patients had adequate endogenous LH to successfully drive ovarian steroidogenesis and oocyte maturation. Exogenous LH supplementation was consistently associated with higher peak oestradiol concentrations. The use of HMG in long GnRH agonist cycles was associated with a 3–4% increase in live birth rate. There was insufficient evidence to make definitive conclusions on the need for exogenous LH activity in GnRH antagonist cycles or the benefit of recombinant LH and HCG protocols. Poor responders and patients 35 years of age and older may benefit from exogenous LH.
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Affiliation(s)
- Micah J Hill
- Program in Reproductive and Adult Endocrinology, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, MD 20892, USA
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Musters AM, van Wely M, Mastenbroek S, Kaaijk EM, Repping S, van der Veen F, Mochtar MH. The effect of recombinant LH on embryo quality: a randomized controlled trial in women with poor ovarian reserve. Hum Reprod 2011; 27:244-50. [PMID: 22095792 DOI: 10.1093/humrep/der371] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Poor ovarian response is a common clinical problem, affecting up to 26% of IVF cycles. For these women, addition of recombinant luteinizing hormone (rLH) to ovarian hyperstimulation with recombinant FSH has a beneficial effect on ongoing pregnancy rates, but its effect on the yield of top-quality embryos is unknown. METHODS We conducted a randomized controlled trial in women expected to respond poorly under ovarian hyperstimulation during their first IVF cycle [all women aged 35-41 and women with FSH > 12 IU/ml and antral follicle count (AFC) ≤ 5]. Women were randomly allocated to rFSH and rLH (2:1 ratio) or rFSH alone (control group) after down-regulation with a GnRH agonist. The primary outcome was the proportion of top-quality embryos per woman on the day of transfer. Secondary outcomes were the number of stimulation days, the number of follicles ≥17 mm, the number of oocytes, the fertilization rate, the number of embryos, the number of women with ≥1 top-quality embryo, the biochemical, clinical and ongoing pregnancy rates and the miscarriage rate. RESULTS There were 116 women allocated to the rLH group and 128 allocated to the control group. The proportion of top-quality embryos per woman was 17% in the rLH group and 11% in the control group [mean difference 0.06; 95% confidence interval (CI) -0.01-0.14]. In the rLH and control groups respectively, 47 (41%) and 41 (32%) women had at least one top-quality embryo on the day of transfer (relative risk: 1.3, 95% CI 0.91-1.77). The ongoing pregnancy rate was 13 versus 12% (relative risk: 1.1; 95% CI 0.57-2.16) for the rLH group compared with the control group. CONCLUSIONS This study found no significant difference in embryo quality after the addition of rLH to rFSH for ovarian stimulation in women with poor ovarian reserve. CLINICAL TRIALS IDENTIFIER NTR1457.
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Affiliation(s)
- A M Musters
- Centre for Reproductive Medicine, Department of Obstetrics and Gynaecology (H4-205), Academic Medical Centre, University of Amsterdam, PO Box 22700, Amsterdam 1100 DE, The Netherlands.
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Fábregues F, Iraola A, Casals G, Creus M, Carmona F, Balasch J. Evaluation of two doses of recombinant human luteinizing hormone supplementation in down-regulated women of advanced reproductive age undergoing follicular stimulation for IVF: a randomized clinical study. Eur J Obstet Gynecol Reprod Biol 2011; 158:56-61. [DOI: 10.1016/j.ejogrb.2011.04.003] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2010] [Revised: 01/12/2011] [Accepted: 04/04/2011] [Indexed: 10/18/2022]
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Propst AM, Hill MJ, Bates GW, Palumbo M, Van Horne AK, Retzloff MG. Low-dose human chorionic gonadotropin may improve in vitro fertilization cycle outcomes in patients with low luteinizing hormone levels after gonadotropin-releasing hormone antagonist administration. Fertil Steril 2011; 96:898-904. [PMID: 21839437 DOI: 10.1016/j.fertnstert.2011.06.069] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2011] [Revised: 06/27/2011] [Accepted: 06/30/2011] [Indexed: 11/19/2022]
Abstract
OBJECTIVE To evaluate the effect of low levels of endogenous luteinizing hormone (LH) and low-dose human chorionic gonadotropin (hCG) supplementation on in vitro fertilization (IVF) cycle outcomes in a gonadotropin-releasing hormone (GnRH) antagonist protocol. DESIGN Retrospective study. SETTING Military medical center. PATIENT(S) General in vitro fertilization/embryo transfer (IVF-ET) population. INTERVENTION(S) Addition of low-dose urinary hCG to IVF stimulations using a recombinant follicle-stimulating hormone (FSH) and GnRH antagonist protocol. MAIN OUTCOME MEASURE(S) Implantation and live-birth rates. RESULT(S) As part of a larger cohort of 239 patients, 42 patients with LH levels ≤ 0.5 mIU/mL were evaluated. In the larger cohort, there were no differences in implantation and pregnancy rates between the recombinant FSH only (n = 113) and the recombinant FSH with low-dose hCG supplementation (n = 126) groups. In the FSH-only group, patients with LH levels ≤ 0.5 mIU/mL had decreased implantation rates (19% vs. 42%) and live-birth rates (25% vs. 54%) as compared with patients with LH levels >0.5 mIU/mL. Low LH patients in the recombinant FSH with low-dose urinary hCG group had statistically significantly higher implantation rates (54% vs. 19%) and live-birth rates (64% vs. 25%) as compared with patients with similar low LH levels in the recombinant FSH-only group. CONCLUSION(S) Endogenous LH levels ≤ 0.5 mIU/mL after GnRH antagonist treatment are associated with statistically significantly lower implantation and pregnancy rates in recombinant FSH-only cycles. The addition of low-dose urinary hCG results in improved implantation and live-birth rates in patients with low LH levels.
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Affiliation(s)
- Anthony M Propst
- Program in Reproductive and Adult Endocrinology, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, Maryland, USA.
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Nardo LG, Fleming R, Howles CM, Bosch E, Hamamah S, Ubaldi FM, Hugues JN, Balen AH, Nelson SM. Conventional ovarian stimulation no longer exists: welcome to the age of individualized ovarian stimulation. Reprod Biomed Online 2011; 23:141-8. [DOI: 10.1016/j.rbmo.2011.05.008] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2010] [Revised: 04/29/2011] [Accepted: 05/03/2011] [Indexed: 01/20/2023]
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Peralta L, Agirregoitia E, Mendoza R, Expósito A, Casis L, Matorras R, Agirregoitia N. Expression and localization of cannabinoid receptors in human immature oocytes and unfertilized metaphase-II oocytes. Reprod Biomed Online 2011; 23:372-9. [PMID: 21778114 DOI: 10.1016/j.rbmo.2011.05.011] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2010] [Revised: 03/11/2011] [Accepted: 05/18/2011] [Indexed: 12/19/2022]
Abstract
Endocannabinoid anandamide and cannabinoid receptors have been described in some organs of the female reproductive system, but little is known about the expression of these receptors in human oocytes. The aim of the study was to describe the expression of cannabinoid receptors in human oocytes and to investigate their differential distribution at various stages of meiotic resumption in human oocytes. A total of 750 human oocytes from 214 patients were analysed by Western blot, immunocytochemistry and PCR. For this study, oocytes that were not suitable for intracytoplasmic sperm injection (ICSI) (germinal-vesicle and metaphase-I stages), as well as metaphase-II oocytes that had not developed into an embryo after ICSI were used. Western blot analysis revealed the presence of CB1 and CB2 receptor proteins in human oocytes. CB1 and CB2 receptor immunostaining patterns changed during the various stages of meiotic resumption. Localization of CB1 receptor was peripheral at germinal-vesicle stage, homogeneous over the entire oocyte at metaphase I and peripheral at mature metaphase II. CB2 receptor localization was peripheral at germinal-vesicle and metaphase-I stages but homogeneous over the entire cell at metaphase II. This finding suggests a possible role for endocannabinoids, acting via receptors, in the maturation of female gametes and fertilization. The number of couples with sterility problems attending fertility programmes is rising but treatment is not always successful. Important problems associated with failure to conceive remain unresolved because many physiological aspects of human reproduction are still unknown. Endocannabinoids are endogenous chemical compounds that mimic the action of the main psychoactive component of marijuana, delta-9-tetrahydrocannabinol. An endogenous cannabinoid named anandamide has been found in human follicular fluid. Thus, in order to develop knowledge in this field, in the present study we have described the presence of the cannabinoid receptors CB1 and CB2 (the proteins required to mediate the action of the cannabinoids) in the early stages of meiotic resumption of oocytes (the stages before ovulation) and we could postulate that the endocannabinoids could act in the regulation of maturation of oocytes. Our study, together with other studies, indicates that the endocannabinoid system may play a role in human reproduction.
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Affiliation(s)
- L Peralta
- Department of Physiology, Faculty of Medicine and Dentistry, University of the Basque Country, Bilbao, Bizkaia, Spain
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Wong PC, Qiao J, Ho C, Ramaraju GA, Wiweko B, Takehara Y, Nadkarni PV, Cheng LC, Chen HF, Suwajanakorn S, Vuong TNL. Current opinion on use of luteinizing hormone supplementation in assisted reproduction therapy: an Asian perspective. Reprod Biomed Online 2011; 23:81-90. [PMID: 21550853 DOI: 10.1016/j.rbmo.2011.03.023] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2010] [Revised: 03/29/2011] [Accepted: 03/29/2011] [Indexed: 11/16/2022]
Abstract
LH and FSH have complementary functions in ensuring optimal oocyte maturation and ovulation. In women undergoing assisted reproduction technology protocols with gonadotrophin-releasing hormone analogues, LH and FSH concentrations are reduced. While FSH use in assisted reproduction technology is well established, there is no published consensus on the need for exogenous LH in Asian patients. Having reviewed the concept of the LH therapeutic window and differences between recombinant human LH (r-HLH) and human menopausal gonadotrophin, a consensus was reached on which patient subgroups may benefit from LH supplementation. Adjuvant r-HLH gives clinicians precise control over the dose of LH bioactivity administered to target the therapeutic window. The use of r-HLH is recommended in women with poor response in a previous cycle or suboptimal follicular progression in a current cycle by day 6-8 of stimulation. r-HLH should also be considered in women at risk of suboptimal response, specifically age > 35 years. Other risk markers that suggest the need for LH supplementation, which include baseline/day-6 serum LH and anti-Müllerian hormone concentrations, antral follicle count and LH polymorphisms require further research and verification. For measurement of LH response adequacy, the monitoring of follicular progression, oestradiol concentrations and endometrial thickness is recommended.
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Affiliation(s)
- Peng Cheang Wong
- Department of Obstetrics and Gynaecology, National University Hospital, Singapore.
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Matorras R, Osuna C, Exposito A, Crisol L, Pijoan JI. Recombinant FSH versus highly purified FSH in intrauterine insemination: systematic review and metaanalysis. Fertil Steril 2011; 95:1937-42, 1942.e1-3. [PMID: 21429486 DOI: 10.1016/j.fertnstert.2011.02.030] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2010] [Revised: 01/27/2011] [Accepted: 02/13/2011] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To compare the pregnancy rates (PRs) in intrauterine insemination (IUI) using recombinant FSH (rec-FSH) or highly purified urinary FSH (HP-FSH). DESIGN Systematic review and metaanalysis. SETTING University hospital. PATIENT(S) None. INTERVENTION(S) Electronic and manual searches. MAIN OUTCOME MEASURE(S) PR, per first cycle PR and per woman PR. RESULT(S) Six randomized trials (713 women, 1,581 cycles) were identified. In three the same doses of rec-FSH and HP-FSH were used ("equal dose" group), whereas in the other three the ratio HP-FSH:rec-FSH dose was 1.5. The global metaanalysis showed no differences in PRs. The PR per cycle was similar across the 1.5 ratio group (14.51% vs. 14.93%; relative risk [RR], 0.970; 95% confidence interval [CI], 0.687-1.369). However, the metaanalysis of the equal dose group, showed differences in the PR in favor of rec-FSH (16.36% vs. 12.31%; RR, 1.394; 95% CI, 1.004-1.936). Per woman PR analysis showed similar results (41.44% vs. 31.55%; RR, 1.273; 95% CI, 0.987-1.643). Per first cycle PR analysis showed a similar trend, although the difference did not reach significance (RR, 1.434; 95% CI, 0.934-2.203). CONCLUSION(S) Rec-FSH was associated with higher per cycle PR than HP-FSH, when used at the same dose, whereas the PR were similar when the dose of rec-FSH was 50% lower.
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Affiliation(s)
- Roberto Matorras
- Human Reproduction Unit, Department of Obstetrics and Gynecology, Hospital de Cruces, Pais Vasco University, Baracaldo, Vizcaya, Spain.
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