Recombinant follicle-stimulating hormone versus human menopausal gonadotropin in the late follicular phase during ovarian hyperstimulation for in vitro fertilization

Live birth after fresh embryo transfer vs elective embryo cryopreservation/frozen embryo transfer in women with polycystic ovary syndrome undergoing IVF (FreFro-PCOS): study protocol for a multicenter, prospective, randomized controlled clinical trial

Background

Polycystic ovary syndrome (PCOS) patients are at increased risk of pregnancy complications, which may impair pregnancy outcome. Transfer of fresh embryos after superovulation may lead to abnormal implantation and placentation and further increase risk for pregnancy loss and complications. Some preliminary data suggest that elective embryo cryopreservation followed by frozen–thawed embryo transfer into a hormonally primed endometrium could result in a higher clinical pregnancy rate than that achieved by fresh embryo transfer.

Methods/Design

This study is a multicenter, prospective, randomized controlled clinical trial (1:1 treatment ratio of fresh vs. elective frozen embryo transfers).. A total of 1,180 infertile PCOS patients undergoing the first cycle of in vitro fertilization (IVF) or intracytoplasmic sperm injection will be enrolled and randomized into two parallel groups. Participants in group A will undergo fresh embryo transfer on day 3 after oocyte retrieval, and participants in group B will undergo elective embryo cryopreservation after oocyte retrieval and frozen–thawed embryo transfer in programmed cycles. The primary outcome is the live birth rate. Our study is powered at 80 to detect an absolute difference of 10 at the significance level of 0.01 based on a two-sided test.

Discussion

We hypothesize that elective embryo cryopreservation and frozen–thawed embryo transfer will reduce the incidence of pregnancy complications and increase the live birth rate in PCOS patients who need IVF to achieve pregnancy.

Trial registration

ClinicalTrials.gov Identifier: NCT01841528

The impact of luteinizing hormone in assisted reproduction: a review

PURPOSE OF REVIEW

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

RECENT FINDINGS

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

SUMMARY

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

Clinical effects of ovulation induction with recombinant follicle-stimulating hormone supplemented with recombinant luteinizing hormone or low-dose recombinant human chorionic gonadotropin in the midfollicular phase in microdose cycles in poor responders

OBJECTIVE

To assess the clinical effects of recombinant luteinizing hormone (LH) or low-dose recombinant human chorionic gonadotropin (hCG) supplementation administered in the midfollicular phase in microdose gonadotropin-releasing hormone analogue (GnRH-a) flare-up cycles.

DESIGN

Prospective randomized study.

SETTING

Private infertility clinic.

PATIENT(S)

A total of 170 women enrolled, with 145 women eligible for randomization.

INTERVENTION(S)

After randomization, 51 patients (group A) received only 600 IU of recombinant follicle-stimulating hormone (FSH) as the control group, 46 patients (group B) received 600 IU of recombinant FSH plus daily supplementation with 75 IU of recombinant luteinizing hormone, and 48 patients (group C) received 600 IU of recombinant FSH plus daily supplementation with 75 IU of recombinant hCG.

MAIN OUTCOME MEASURE(S)

Peak estradiol (E(2)) levels, days of stimulation with recombinant FSH, total recombinant FSH dosage, metaphase II oocytes retrieved, pregnancy rate (positive hCG levels), clinical pregnancy rate (positive fetal cardiac activity), and cancellation rates of stimulation and embryo transfer.

RESULT(S)

The pregnancy rates were 35.1%, 27.6% and 31.2% for groups A, B, and C, respectively. Clinical pregnancy rates were 27.1%, 27.5, and 21.8% for groups A, B, and C, respectively. There were no statistically significant differences in the age, peak serum E(2) concentration, total recombinant FSH dosage, days of stimulation with recombinant FSH, total number of metaphase II oocytes retrieved, number of embryos transferred, pregnancy rates, clinical pregnancy rates, or cancellation rates of stimulation and embryo transfer among the three groups.

CONCLUSION(S)

Additional exogenous LH activity in the form of either recombinant luteinizing hormone or low-dose recombinant hCG is unnecessary in microdose cycles to increase pregnancy rates.

The science behind 25 years of ovarian stimulation for in vitro fertilization

To allow selection of embryos for transfer after in vitro fertilization, ovarian stimulation is usually carried out with exogenous gonadotropins. To compensate for changes induced by stimulation, GnRH analog cotreatment, oral contraceptive pretreatment, late follicular phase human chorionic gonadotropin, and luteal phase progesterone supplementation are usually added. These approaches render ovarian stimulation complex and costly. The stimulation of multiple follicular development disrupts the physiology of follicular development, with consequences for the oocyte, embryo, and endometrium. In recent years, recombinant gonadotropin preparations have become available, and novel stimulation protocols with less detrimental effects have been developed. In this article, the scientific background to current approaches to ovarian stimulation for in vitro fertilization is reviewed. After a brief discussion of the relevant aspect of ovarian physiology, the development, application, and consequences of ovarian stimulation strategies are reviewed in detail.

Evaluating the role of exogenous luteinizing hormone in poor responders undergoing in vitro fertilization with gonadotropin-releasing hormone antagonists

OBJECTIVE

To evaluate the importance of exogenous LH in poor responders undergoing IVF with GnRH antagonists.

DESIGN

Retrospective cohort study.

SETTING

University-based IVF center.

PATIENT(S)

All patients with a history of poor response to ovarian stimulation undergoing IVF with GnRH antagonists between September 2000 and August 2001.

INTERVENTION(S)

None.

MAIN OUTCOME MEASURE(S)

Clinical pregnancy rates.

RESULT(S)

Two hundred forty GnRH-antagonist cycles were initiated in poor responders. One hundred fifty-three progressed to oocyte retrieval. Seventy-five patients received recombinant FSH (Rec) for ovarian stimulation, and 66 received hMG in combination with Rec. In patients aged <40 years, there were no significant differences in amount and duration of treatment, number of oocytes retrieved, and number of embryos between treatment groups. In patients aged > or =40 years, significantly fewer oocytes were retrieved in groups who received exogenous LH in their stimulation, resulting in significantly fewer fertilized embryos. Implantation and clinical pregnancy rates did not differ by treatment group.

CONCLUSION(S)

In poor responders undergoing IVF with GnRH antagonists, outcomes are comparable whether stimulation is achieved in the presence or absence of supplemental LH. Exogenous LH does not appear to be necessary to achieve pregnancy in these challenging patients and may be detrimental to older patients with a history of poor response.

Ovulation induction in the new millennium: recombinant follicle-stimulating hormone versus human menopausal gonadotropin

The renewed interest in luteinizing hormone (LH), together with limited and decreasing health resources, make essential the comparison of high-cost, recombinant follicle-stimulating hormone (rFSH) preparations (devoid of LH) and human menopausal gonadotropin (hMG) in terms of clinical efficacy. All published, randomized controlled trials (RCTs) comparing rFSH versus hMG under different protocols of stimulation were examined. Eight true RCTs were included in this meta-analysis, recruiting 2031 participants. Data for ongoing pregnancy/live birth rate, clinical pregnancy rate, miscarriage rate, multiple pregnancy rate and ovarian hyperstimulation syndrome (OHSS) were extracted, and odds ratios (ORs) and 95% confidence intervals (CIs) were calculated with the use of a fixed-effects model. Data for the meta-analysis were combined using RevMan software (using the Mantel-Haenszel method). Pooling the results of these RCTs showed no significant difference between rFSH and hMG regarding the different outcomes: ongoing pregnancy/live birth rate, OR 1.18 (95% CI 0.93-1.50); clinical pregnancy rate, OR 1.2 (95% CI 0.99-1.47), miscarriage rate, OR 1.2 (95% CI 0.70-2.16); multiple pregnancy rate, OR 1.35 (95% CI 0.96-1.90); incidence of moderate/severe OHSS, OR 1.79 (95% CI 0.74-4.33). However, there was significant reduction in the amount of gonadotropins in favor of hMG over rFSH. There was no significant heterogeneity of treatment effect across the trials. In conclusion, there is no clinically significant difference between hMG and rFSH in in vitro fertilization/intracytoplasmic sperm injection cycles. Decision-makers should establish their choice of one drug over the other based on the most up-to-date evidence available.

Exogenous luteinizing hormone in controlled ovarian hyperstimulation for assisted reproduction techniques

OBJECTIVE

To investigate the role of exogenous LH in controlled ovarian hyperstimulation for assisted reproductive technologies.

DESIGN

Prospective randomized study.

SETTING

SISMER fertility unit.

PATIENT(S)

Women showing a hyporesponsiveness to FSH under GnRH agonist down-regulation were randomized into three groups: group A (n = 54) received an increased dosage of FSH; group B (n = 54) was administered recombinant LH in addition to the increased dose of FSH; group C (n = 22) was given additional FSH and LH using hMG as a combined drug. Fifty-four age-matched women with no need to increase the FSH dose were included as a control group (D).

INTERVENTION(S)

None.

MAIN OUTCOME MEASURE(S)

Implantation and live birth rate per started cycles.

RESULT(S)

In group B, the pregnancy and implantation rates were statistically higher when compared with groups A and C and did not differ from the control group for normal response. The live birth rate was similar in groups B and D but was half as high in groups A and C.

CONCLUSION(S)

Hyporesponsiveness to FSH could be related to iatrogenic LH deficiency that, in turn, could affect oocyte competence. Addition of a small amount of recombinant LH is able to rescue oocyte competence to produce viable embryos.

LH improves early follicular recruitment in women over 38 years old

Although the capacity of recombinant FSH alone to induce folliculogenesis is undisputed, many believe that follicular recruitment in women over 38 years old could be improved by supplementing rFSH with human menopausal gonadotrophin (HMG). The present study sought to determine whether recombinant LH could reproduce the effect of HMG in women over 38 years during ovulation induction. Fifty-eight patients received rFSH (225 IU/day) supplemented with one ampoule of HMG (75 IU of FSH/75 IU of LH/HCG per day) for 5 days. Another 36 patients received rFSH (300 IU/day) supplemented with one ampoule of rLH (75 IU/day), also for 5 days. Both groups of patients received similar amounts of rFSH (1500 IU), LH/HCG (375 IU) and rLH (375 IU) and recruited a similar number of follicles as counted on day 6 (4.07 +/- 3.1 in the HMG group versus 3.7 +/- 3.2 in the LH group respectively) or on the day that human chorionic gonadotrophin (HCG) was indicated (6.5 +/- 2.7 versus 5.8 +/- 2.5 respectively). Ovarian stimulation was shorter, but not significantly so, in the group of patients receiving rFSH + HMG (10.5 +/- 1.7 days) than in the group of patients treated with rFSH +/- rLH (12 +/- 1.8 days). Significantly more MII oocytes were seen in the group treated with rFSH + rLH than in the group treated with rFSH + HMG (93.1 versus 75.3%, P < 0.05). With respect to pregnancy rates, 14/54 (26%) patients receiving rFSH + HMG and 16/34 (47%) patients receiving rFSH + rLH had a positive serum HCG. No significant difference in the number of miscarriages was observed between the two groups. In conclusion, the present results seem to indicate that rLH could be the HMG component that aids early follicular recruitment.

Pregnancy after administration of high dose recombinant human LH alone to support final stages of follicular maturation in a woman with long-standing hypogonadotrophic hypogonadism

Traditionally, the roles of LH in folliculogenesis have been considered to be limited to stimulating theca cells androgen production, triggering ovulation and supporting the corpus luteum. However, in the late stages of follicle development, granulosa cells become receptive to LH stimulation and LH becomes capable of exerting its actions on both theca cells and granulosa cells. Thus, it has been postulated that once an appropriate (i.e. LH-responsive) stage of follicular development has been achieved in response to treatment with FSH, there are theoretical grounds for reducing or completely withdrawing FSH and maintaining tonic stimulation of the dominant follicle with exogenous LH. This hypothesis was tested in a woman with long-standing hypogonadotrophic hypogonadism, which is the best and only true model to investigate correctly any LH hypothesis. Ovulation induction treatment was carried out with daily s.c. injections of 150 IU recombinant human FSH (rhFSH) (increased to 225 IU daily on stimulation day 15) and 375 IU recombinant human LH (rhLH). When a 14-mm follicle was identified on stimulation day 26, rhFSH was discontinued and from treatment days 26 to 29 the patient was given only rhLH at the above-mentioned dose of 375 IU/day. On treatment day 30, the single dominant follicle measured 22 mm in diameter and oestradiol serum concentration was 148 pg/ml. Thus, an injection of 10,000 IU i.m. human chorionic gonadotrophin was given and sexual intercourse was advised. The patient conceived and a viable singleton intrauterine pregnancy was obtained.