Outcomes after early or midfollicular phase LH supplementation in previous inadequate responders

The impact of adding hp-hMG in r-FSH started GnRH antagonist cycles on ART outcome

While luteinizing hormone (LH) activity is believed to play a role in follicle maturation, human chorionic gonadotropin (hCG) might play an important role in implantation process. We aimed to investigate whether addition of human menopausal gonadotropin (hMG) in recombinant-follicle-stimulating hormone (r-FSH) started GnRH antagonist controlled ovarian hyperstimulation (COH) cycles might enhance implantation rate and improve in vitro fertilization (IVF) success. A total of 246 patients undergoing GnRH antagonist IVF cycles were analyzed. One hundred and twenty-three cycles (%50) were treated with only r-FSH and 123 cycles were treated with r-FSH plus hp-hMG combination. Total gonadotropin doses, total number of oocytes retrieved, metaphase 2 (MII) oocytes, top quality embryos, fertilization and implantation rates, clinical pregnancy rates (CPRs) and ovarian hyperstimulation syndrome (OHSS) rates were compared between the groups. Both groups were comparable in terms of demographic details and baseline characteristics. Peak estradiol and progesterone levels in hCG trigger day, number of retrieved oocytes and top quality embryo counts, fertilization rates were similar between the groups. In r-FSH + hp-hMG group, significantly higher implantation rates (35.3% vs 24.3%, p=.017), CPRs (51.2% vs 35.8%, p=.015) and lower OHSS rates (1.6% vs 7.4%, p = .03) were observed respectively compared to r-FSH only treated patients. In conclusion, addition of hp-hMG on the day of antagonist initiation might increase CPRs. A better endometrial receptivity associated with higher implantation rates might be achieved due to hCG component in hp-hMG.

The evaluation of recombinant LH supplementation in patients with suboptimal response to recombinant FSH undergoing IVF treatment with GnRH agonist down-regulation

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.

Analysis of androgen receptor and anti-Müllerian hormone pathways in human granulosa cells under luteinizing hormone treatment

BACKGROUND

The objective of this study was to determine the gene expression profiles of the androgen/androgen receptor (AR) and anti-Müllerian hormone (AMH)/ Sry-related high-mobility group box 9 (SOX9) pathways in granulosa-luteal cells from patients undergoing standard in vitro fertilization (IVF) with or without recombinant luteinizing hormone (rLH) therapy.

METHODS

Levels of reproductive hormones in the pre-ovulatory follicular fluid and the expression levels of LHR (luteinizing hormone receptor), AR, SOX9, AMH, AR-associated protein 54(ARA54)and ARA70 were determined in granulosa-luteal cells by real-time reverse-transcription PCR. The effects of androgen and rLH treatments on AR and AMH expression levels were also tested in vitro using HO23 cells.

RESULTS

We collected 35 an 70 granulosa cell samples from patients cycled with and without rLH supplementation, respectively. The clinical outcomes were similar in patients who received rLH therapy and those who did not, though the pre-ovulatory follicular fluid levels of androstenedione, testosterone, and estradiol were significantly higher and progesterone was lower in the rLH supplementation group. Moreover, granulosa-luteal cell mRNA levels of LHR, AR, AMH, and SOX9 were significantly higher in the rLH supplementation group relative to the group that did not receive rLH supplementation. In addition, we observed significant correlations between LHR and AR mRNA expression and among AR, AMH, and SOX9 mRNA expression in granulosa-luteal cells from patients undergoing standard IVF treatment.

CONCLUSIONS

Increased expression of LHR, AR, AMH, and SOX9 is characteristic of granulosa-luteal cells from IVF/ intracytoplasmic sperm injection (ICSI) patients receiving rLH supplementation.

Outcome of in vitro fertilization in patients with proven poor ovarian responsiveness after early vs. mid-follicular LH exposure: a prospective, randomized, controlled study

OBJECTIVE

To compare early vs. mid-follicular exposure to LH in patients with poor ovarian responsiveness undergoing in vitro fertilization (IVF).

DESIGN

Prospective, randomized, controlled trial.

SETTING

University Hospital, University-affiliated private Clinic.

PATIENTS

Five hundred-thirty women with poor ovarian responsiveness during the first IVF cycle, undergoing their second IVF attempt.

INTERVENTIONS

In a GnRH-analogue long protocol, ovarian stimulation with recombinant FSH (300 IU/day) plus randomly assigned addition of recombinant LH (150 IU/day) from day 1 (early LH exposure; n = 264) or from day 7 (late LH exposure; n = 266).

MAIN OUTCOME MEASURE(S)

Primary outcome was the number of oocytes retrieved. Secondary outcomes were: cancellation rate, total gonadotropin dose, duration of ovarian stimulation, number of embryos available for transfer, pregnancy rate per started cycle, per OPU and per embryo transfer, implantation rate, delivered/ongoing pregnancy rate.

RESULTS

Apart from the totally administered LH dose, that was significantly higher in the group receiving it from day 1, all parameters related to IVF outcome were non significantly different in the two groups.

CONCLUSIONS

Adding LH to FSH from day 1 or from day 7 of ovarian stimulation in a GnRH-agonist long protocol exerts comparable effects on IVF outcome in poor responders.

Does 75 IU difference improve the cycle performance in poor responders? Comparison of daily 375 versus 450 IU gonadotrophin doses

OBJECTIVE

To compare the efficacy on the cycle performance of 375 versus 450 IU/day gonadotrophin on the microdose flare-up protocol in poor responders.

STUDY DESIGN

A total of 91 poor responder patients who were treated with the microdose flare-up protocol were enrolled in this study. Group 1 (n = 40) was stimulated with 375 IU/day gonadotrophin. Group 2 (n = 51) was stimulated with 450 IU/day gonadotrophin. Main outcome measurements were accepted as the results of controlled ovarian hyperstimulation, implantation, clinical pregnancy, and live birth rates.

RESULTS

Baseline characteristics are similar between the two groups. Higher number of oocyte cumulus complexes and lower total gonadotrophin requirement were noted in Group 1 compared with Group 2. Number of metaphase II oocytes and implantation rates were similar between the groups. A trend toward higher clinical pregnancy and live birth rate was observed in Group 1 but these results did not reach statistical significance.

CONCLUSIONS

Total gonadotrophin costs are lower using the 375 IU/day gonadotrophin compared to the 450 IU/day in poor responders. Additional 75 IU/day does not give any improvement neither embryology nor pregnancy outcomes.

Defining ovarian reserve to better understand ovarian aging

Though a widely utilized term and clinical concept, ovarian reserve (OR) has been only inadequately defined. Based on Medline and PubMed searches we here define OR in its various components, review genetic control of OR, with special emphasis on the FMR1 gene, and discuss whether diminished OR (DOR) is treatable. What is generally referred to as OR reflects only a small portion of total OR (TOR), a pool of growing (recruited) follicles (GFs) at different stages of maturation. Functional OR (FOR) depends on size of the follicle pool at menarche and the follicle recruitment rate. Both vary between individuals and, at least partially, are under genetic control. The FMR1 gene plays a role in defining FOR at all ages. Infertility treatments have in the past almost exclusively only centered on the last two weeks of folliculogenesis, the gonadotropin-sensitive phase. Expansions of treatments into earlier stages of maturation will offer opportunity to significantly improve ovarian stimulation protocols, especially in women with DOR. Dehydroepiandrosterone (DHEA) may represent a first such intervention. Data generated in DHEA-supplemented women, indeed, suggest a new ovarian aging concept, based on aging of ovarian environments and not, as currently is believed, aging oocytes.