Serum luteinizing hormone during ovulation induction with human menopausal gonadotropin for in vitro fertilization in normally menstruating women

Assessment of ovarian follicular dynamics and folliculogenesis associated endocrine profiles following gonadotropin stimulation in the bonnet monkey

We evaluated ovarian follicular dynamics in bonnet monkeys by employing trans-abdominal ultrasonography. Following the administration of human follicle stimulating hormone (hFSH) and/or human menopausal gonadotropin (hMG), multiple follicular development was assessed and their numbers, size and growth profiles were monitored. The ultrasonograms showed that the follicular antrum appeared distinctly anechoic with well-defined hyperechoic borders. Depending on the type, quantity (12.5-25IU), and duration (6-9days) of hormones administered, the number of developing follicles was 2-12 per ovary with their lowest diameter being 2mm. With continued hormone administration, their numbers and diameters increased; which were more pronounced in animals administered with hFSH than with hMG, with follicles of 6-8mm. Interestingly, human chorionic gonadotropin (hCG) injection (2000-3000IU), when follicles acquiring >6-8mm sizes, induced the maximum expansion of antral follicles with sizes reaching up to 14mm. On days 3-5 post-hCG, the ultrasonograms showed loosely demarcated multiple hypoechoic structures and well-demarcated hyperechoic structures with anechoic/hypoechoic cores corresponding to unruptured luteinized follicles and corpora lutea, respectively. On day 4 post-hCG, there was a substantial reduction in the number of antral follicles. In stimulated animals, follicular growth, ovulation, and formation of luteal structures were accompanied by corresponding physiological changes in the serum estradiol and progesterone profiles. These findings, for the first time, showed that ultrasonographic imaging approach is useful for precise monitoring of temporal changes in follicular developmental dynamics and to time the hCG induced ovulation in the bonnet monkey.

Gonadotropin surge-inhibiting/attenuating factors: a review of current evidence, potential applications, and future directions for research

Animal studies in the 1980s suggested the existence of an ovarian hormone, termed gonadotropin surge-inhibiting/attenuating factor (GnSIF/AF), that modulates pituitary secretion of luteinizing hormone (LH). Given the importance of identifying regulatory factors of the hypothalamic-pituitary-ovarian axis and the accumulating data suggesting its existence, we conducted a comprehensive literature search using PubMed, Web of Science, Scopus, and Embase to identify articles related to GnSIF/AF. The search generated 161 publications, of which 97 were included in this study. Several attempts have been made to identify and characterize this hormone and several candidates have been identified, but the protein sequences of these putative GnSIF/AF factors differ widely from one study to another. In addition, while the RF-amide RFRP-3 is known foremost as a neuropeptide, some research supports an ovarian origin for this non-steroidal hormone, thereby suggesting a role for RFRP-3 either as a co-modulator of GnSIF/AF or as a gonadotropin-inhibiting factor in the hypothalamus (GnIH). Discovery of the KNDy neurons that modulate GnRH secretion, on the other hand, further encourages the search for substance(s) that modulate their activity and that indirectly affect LH secretion and the hypothalamic-pituitary-ovarian axis. While it has remained an elusive hormone, GnSIF/AF holds many potential applications for contraception, in vitro fertilization, and/or cancer as well as for understanding polycystic ovary syndrome, metabolic diseases, and/or pubertal development. In this review, we rigorously examine the available evidence regarding the existence of GnSIF/AF, previous attempts at its identification, limitations to its discovery, future directions of research, and potential clinical applications.

Involvement of rat gonadotrope progesterone receptor in the ovary-mediated inhibitory action of FSH on LH synthesis

Rat ovaries stimulated with human follicle-stimulating hormone (hFSH) overexpress a factor that attenuates the LH surge in the rat: the putative gonadotropin surge-attenuating factor (GnSAF). A reduced gondadotrope progesterone receptor (PR) phosphorylation/activation is likely to be the main causative factor involved in GnSAF bioactivity on LH release. Besides, GnSAF reduces LH synthesis as well as LH secretion, and it is not known whether PR is involved in the inhibitory action of GnSAF on LH synthesis. Thus, the purpose of the present work was to evaluate the involvement of PR in the inhibitory effects of GnSAF on LH synthesis in cycling rats. To this end we used a specific radioimmunoassay and reverse transcription-polymerase chain reaction (RT-PCR) to study the effect on LH pituitary content and LHβ mRNA expression of PR occupancy with P (3 mg/0.2 ml oil in diestrus) on the inhibitory effects of hFSH (0, 0.1, 1, and 10 IU) in metestrus (day 2) and diestrus (day 3) on LH synthesis on proestrus in intact and on day 4 in day 2 ovariectomized (OVX) rats injected with 5 and 10 μg of estradiol benzoate (EB) on days 2 and 3, respectively. Results showed that (1) hFSH decreased pituitary LH content in intact, but not in OVX rats injected with EB, without affecting LHβ mRNA levels, and (2) PR occupancy with P annulled the inhibitory action of hFSH on pituitary LH content. These results indicate that PR is involved in ovarian GnSAF effect on LH content probably at a post-transcriptional level.

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

OBJECTIVE

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

DESIGN

Review of the literature and presentation of our experience.

MAIN OUTCOME MEASURE(S)

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

RESULT(S)

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

CONCLUSION(S)

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

The early days of IVF outside the UK

In this article the history of IVF in geographical regions outside the UK are traced by pioneers of that time. Following the birth of Louise Brown in 1978, live births after IVF occurred in Australia in 1980, in the USA in 1981 and in Sweden and France in 1982. Following the first IVF birth in Australia, the Government of Victoria established a review of IVF research and practice which led to the proclamation of the Infertility (Medical Procedures) Act 1984, the first legislation to regulate IVF and its associated human embryo research. Despite such restriction, IVF doctors and scientists from Victoria, especially those under the leadership of Carl Wood, Alan Trounson and Ian Johnston continued to initiate new treatments for infertility and new methods for delivering this treatment. In the USA IVF research began on animals as early as the 1930s, when Pincus and Enzmann at Harvard were involved in attempts at IVF in the rabbit. In the 1940s, John Rock attempted human IVF with 138 human oocytes without success. In 1965, Bob Edwards was with Georgeanna and Howard Jones at Johns Hopkins where attempts were made to fertilize oocytes in vitro. Clinical IVF began in earnest in the USA in 1980 with the first birth in 1981 achieved by the use of HMG--a first successful use with IVF. In France, two groups Frydman and Testart (Clamart) and Cohen, Mandelbaum and Plachot (Sevres) focused their research in particular directions. In 1981, the Clamart group developed a plasma assay for the initial rise in LH. The Sevres group developed a transport technique. Plachot produced a long series of cytogenetic analyses of oocytes and human embryos. Mandelbaum described the microstructures of the human oocyte. The start of IVF in France benefited from the help of animal researchers from the Institut National de la Recherche Agronomique. The first babies were born in Clamart in February 1982 and in Sèvres in June 1982. Important contributions to the development of IVF from the Nordic countries include techniques for ovarian stimulation, sonographic techniques for monitoring and vaginal oocyte retrieval and also unique possibilities for monitoring IVF safety. These developments, in combination with relatively permissive laws for the practice of reproductive medicine and relatively generous reimbursement policies, as well as a general public confidence in IVF, have led to an exceptionally high availability of IVF, within international comparison.

IVF: past and future

The introduction of IVF into the New World had its roots in Robert Edwards' six-week fellowship at Johns Hopkins in 1965, when he and I made a systematic attempt to fertilize human oocytes in vitro. While fertilization was not claimed in the publication of the work done in 1965, a retrospective examination of published photos indicate that human fertilization was obtained at that time. Edwards and Steptoe achieved a term birth with IVF in 1978, and this stimulated the establishment of an IVF clinic in Norfolk, Virginia. Using ovarian stimulation in 1981, the first delivery in the New World took place. This led to a series of studies on the influence of ovarian stimulation on the normal menstrual cycle and resulted in the finding that with ovarian stimulation there are three response patterns: high, normal and low. It was shown that an LH surge does not occur in ovarian stimulation. This latter observation led to the discovery of the LH surge inhibiting factor. The Norfolk programme became involved in the societal impact of IVF through an invitation to the Vatican, the Ethical Committee of the American Fertility Society (later the American Society for Reproductive Medicine), a lawsuit for libel against the local newspaper, and other activities.

The luteinizing hormone surge--the final stage in ovulation induction: modern aspects of ovulation triggering

OBJECTIVE

To compile updated information regarding gonadotropin secretion, specifically the physiology of the midcycle LH surge, in natural cycles and under various ovulation induction protocols.

DATA IDENTIFICATION AND SELECTION

Studies that deal with the clinical aspects of LH surge manipulation or substitution were identified through literature and Medline searches.

RESULTS

Three major regulatory factors have been identified as participants in the induction of the midcycle gonadotropin surge. These are hypothalamic GnRH secretion, ovarian and adrenal steroids, and less well-characterized ovarian peptide hormones. Gonadotropin-releasing hormone pulsatility is regulated by a complex mechanism that integrates multiple neurotransmitters and sex steroids. Estradiol plays a central role in the pituitary secretion of LH, which also is influenced by P concentrations. Gonadotropin surge attenuating factor also has been implicated in the regulation of timing and amplitude of the LH surge. Human chorionic gonadotropin is used extensively as a LH surrogate, but its use is associated with a number of disadvantages. Induction of an endogenous LH surge through use of the flare effect of GnRH analogues has been examined more recently and has been found to have several advantages. Recombinant human LH is in the final stages of clinical testing.

CONCLUSION

Although much is known about the physiology of the midcycle LH surge and its variations under different clinical conditions, new approaches to the induction or substitution of the LH surge currently are being examined and learned. The introduction of recombinant gonadotropins into clinical practice is likely to influence ovulation induction and IVF practice to a significant degree in the near future.

Development and influence of an endogenous serum luteinizing hormone surge after ovulation induction in stimulated cycles

The aim of this study was to investigate whether the endogenous serum luteinizing hormone (LH) discharge in stimulated cycles--either simultaneously with or shortly after exogenous human chorionic gonadotropin (hCG) administration--is influenced by serum steroid hormones and follicle stimulating hormone (FSH). We also tested whether the LH discharge affects intrafollicular hormone metabolism and oocyte fertilization. In a group of 46 women with tubal pathology who were undergoing in vitro fertilization (IVF), follicular fluids were collected during oocyte retrieval. In addition blood samples were drawn daily, starting at cycle day 7 until the day of oocyte retrieval. LH, FSH, estradiol, progesterone, testosterone and prolactin were determined in all samples of serum and follicular fluid. Oocyte maturation was classified according to the morphology of the oocyte corona-cumulus complex. Of the 46 women studied, 15 showed no LH surge (group A) and 31 developed an endogenous LH surge (group B). Serum samples showed no significant differences between the two groups in follicular phase estradiol, progesterone, testosterone and prolactin. Only levels of serum FSH showed a significant difference between groups A and B (p < 0.0005). In follicular fluid samples LH (p < 0.05) and FSH levels (p < 0.005) were significantly different. Fertilization rate and cleavage rate, however, did not differ significantly. The late endogenous LH surge occurring simultaneously with or shortly after hCG application for ovulation induction did not affect intrafollicular steroid metabolism, oocyte maturation, fertilization rate or cleavage rate.

Elevated serum inhibin levels and suppressed luteinizing hormone surge in young patients stimulated with gonadotropins

The physiological role of inhibin and its relation to other sex hormones (estradiol, progesterone, follicle stimulating hormone (FSH) and luteinizing hormone (LH)) has been investigated during gonadotropin-stimulated cycles of 38 in vitro fertilization-embryo transfer/gamete intrafallopian transfer (IVF-ET/GIFT) patients. Human menopausal gonadotropin (hMG) was given from day 3 of the cycle until 1 day before ovulation induction with human chorionic gonadotropin (hCG). Blood samples were taken twice daily and hormone measurements performed by radioimmunoassay or enzyme immunoassay. Patients were divided into two groups: Group A comprised patients < 35 years of age (n = 20) and Group B included patients > or = 35 years of age (n = 18). The pregnancy rate was significantly higher in Group A. During the follicular phase, serum inhibin level rose gradually in both groups but the values were higher in Group A (significantly between days -2 and 0). During the early luteal phase serum inhibin concentrations were similar in both groups. Estradiol pattern did not differ in the two groups. Estradiol pattern did not differ in the two groups. Whilst serum estradiol level did not increase significantly after day 0, serum inhibin concentration reached its peak value 1 day later, on day +1. Serum progesterone was higher in Group A between days +1 and +4 (significantly on days +1, +3 and +4). Serum FSH increased slowly in both groups and did not correlate with serum inhibin concentration. Basal LH concentrations were similar between days -6 and -2 in both groups. Around the time of ovulation induction (day -1, 0 and +1) serum LH was lower in Group A (significantly on day 0).(ABSTRACT TRUNCATED AT 250 WORDS)

The effects of spontaneous luteinizing hormone surges on superovulatory cycles

OBJECTIVE

To determine the effect of a spontaneous luteinizing hormone (LH) surge on the cycle fecundity during superovulation induction.

DESIGN

Superovulatory cycles of patients with various diagnoses are retrospectively compared.

SETTING

Reproductive Endocrinology Outpatient Clinic.

PATIENTS

A total of 1,185 superovulatory cycles from July 1, 1982 until November 1, 1991 are compared.

MAIN OUTCOME MEASURE

The probability of achieving a pregnancy per treatment cycle.

RESULTS

Patients with unexplained infertility and hyperprolactinemia were more likely to have a spontaneous LH surge during superovulation than patients with either endometriosis or polycystic ovarian disease. However, the cycle fecundity rate did not differ whether or not an LH surge occurred, regardless of the diagnosis.

CONCLUSIONS

Spontaneous onset of an LH surge during superovulation induction does not influence the chances for pregnancy.

Pregnancy rates after timed intercourse or intrauterine insemination after human menopausal gonadotropin stimulation of normal ovulatory cycles: a controlled study

Forty-eight patients with male (n = 16) or idiopathic (n = 32) infertility were stimulated with human menopausal gonadotropin. Intrauterine insemination (IUI) or natural intercourse were performed after either human chorionic gonadotropin (hCG)-induced or spontaneous, urinary luteinizing hormone (LH) surge-monitored ovulation. A total of 148 cycles were analyzed. In 40 cycles treated with hCG-induced ovulation and IUI, 3 (7.5%) patients conceived, whereas 37 women accomplished natural intercourse after hCG-induced ovulation and 2 (5.5%) became pregnant. When inseminated after a spontaneous LH surge, 3 (8.8%) of 34 patients achieved a pregnancy; no conception occurred in 37 spontaneously ovulatory cycles combined with timed intercourse. Pregnancy rates did not substantially differ between the treatment modalities or between mono-ovulatory and polyovulatory cycles. The cycle characteristics between spontaneous ovulatory and hCG-induced cycles significantly did differ.

Induction of ovulation for assisted reproduction programmes

The decision to use enhancement of the natural ovarian/menstrual cycle to attempt collection of several oocytes during IVF and GIFT cycles has dramatically increased the pregnancy rates. Furthermore, the recovery of multiple fertilizable oocytes allows for cryopreservation of extra or surplus pre-embryos (or embryos), with the consequent reduction in the risk of multiple pregnancies and the improvement of the cumulative pregnancy rate following IVF and GIFT cycles. Here, we have reviewed the underlying physiological mechanisms in the natural ovarian-menstrual cycle. Subsequently, we have analysed the more frequently utilized ovarian stimulatory regimens with special emphasis on the use of gonadotrophins. Several conclusions may be drawn from the experience to date with these methods of ovarian stimulation. Primarily, lower doses of medication, when used appropriately, may result in a more favourable outcome. Most significant, it seems to be beneficial to tailor the dosages and timing of drug administration to the patient's individual response to medication. Because ovarian stimulation therapy is difficult to manage, a major challenge in reproductive endocrinology has been to develop stimulation protocols that would 'ideally' synchronize the development of a cohort of follicles. The development of GnRH analogues (agonists and antagonists) and the experience (both in women and macaques) gained so far when these drugs are used in combination with gonadotrophins, have helped both in the understanding of the underlying physiology and in the improvement of clinical results.

Human menopausal gonadotropin induces ovulation in sheep, but embryo recovery after prostaglandin F2α synchronization is compromised by premature luteal regression

Using pregnant mares' serum gonadotropin (PMSG) and follicle stimulating hormone (FSH-P) as conventional gonadotropins, human menopausal gonadotropin (hMG) was tested for its comparative ability to induce multiple ovulations in sheep. Estrous cycles were synchronized using either prostaglandin F2alpha (PGF2alpha) or progestogen (MAP)-impregnated pessaries. During the mid-luteal phase, control ewes received serial saline injections, whereas test females (which also served as embryo donors) received either a single PMSG injection (1200 IU) or serial injections of FSH-P (total, 21 mg) or hMG (total, 1350 IU) over 3.5 d. These sheep were naturally mated and artificially inseminated (AI) in utero. Number of CL and transferable-quality embryos 5 d after AI was greater (P<0.05) in FSH-P-and hMG-treated donors than in PMSG-treated ewes. The lower number of transferable-quality embryos produced by PMSG-treated donors was attributed to a reduced (P<0.05) fertilization rate compared with that of the other treatment groups. There were no differences (P>0.05) in daily circulating estradiol-17beta and progesterone concentrations among the gonadotropin treatment groups. Gonadotropin-treated ewes demonstrated estrus approximately 24 h earlier than control ewes and, therefore, exhibited an accelerated estradiol-17beta surge and rise in circulating progesterone. Progesterone production in gonadotropin-treated ewes was also more variable than in the controls; this was due, in part, to premature luteal regression which occurred in 4 of 10 PMSG-, 3 of 10 FSH-P- and 6 of 10 hMG-treated ewes also given PGF2alpha. Ewes with prematurely regressing CL experienced transient luteal tissue development within 4 d of ovulation and produced no embryos. Overall results 1) demonstrate that serial administration of hMG induces multiple ovulations in sheep comparable to FSH-P, and 2) suggest that PGF2alpha treatment during ovulation induction adversely affects newly formed luteal tissue compromising subsequent embryo recovery.

Basic and clinical aspects of GnRH-agonists in reproduction

Within recent years GnRH agonists have gained increasing importance in the treatment of reproductive failure. Their use as a pretreatment for in vitro fertilization increases the pregnancy rate at least under certain conditions. In cases of endometriosis and uterus myomatosus, GnRH agonists achieve high remission rates and may avoid or at least postpone the need for surgical intervention. The physiological basis and current clinical strategies are discussed.

Patterns of serum-luteinizing hormone surges in stimulated cycles in relation to injections of human chorionic gonadotropin

Endogenous-luteinizing hormone (LH) surges may complicate the management of in vitro fertilization cycles. To investigate the effects of LH surges after hormonal stimulation 53 IVF cycles were analyzed by assessing LH levels three times daily until egg collection. In 43% the LH rise started before the planned exogenous trigger for ovulation was given, in 11% the rise occurred simultaneously with and in 45% after the injection of human chorionic gonadotropin. Three main patterns of serum LH surges were identified: (A) low-LH tonus with straight increase to maximum; (B) low tonus with elevation before straight increase; (C) high tonus with large variations but no prominant peak. These patterns were not related to the follicular estradiol increase, luteal steroid concentrations or resulting pregnancy rates.

Effectiveness of short pituitary suppression with gonadotropin-releasing hormone agonist leuprolide during induction of ovulation for in vitro fertilization

A short suppression regimen with daily 0.5 mg leuprolide commencing the first day of in vitro fertilization (IVF) cycles was evaluated in 10 women who previously underwent similar IVF cycle without suppression. Induction of ovulation, oocyte retrieval, incubation, and embryo transfer were similar in all the cycles. Assessment included the amount of human menopausal gonadotropin (hMG) used, length of stimulation, serum estradiol and luteinizing hormone (LH) levels, number of oocytes retrieved and their quality, cleavage rate, and number of embryos. The results showed that when leuprolide was used, no endogenous LH surge was detected, and there was a significant increase in hMG injected, from 19.0 +/- 5.8 to 34.4 +/- 17 ampoules, and in estradiol levels, from 1276 +/- 470 to 2618 +/- 1084 pg/ml (mean +/- SD). In addition, there was an increase in the total oocytes retrieved from 54 to 94, their cleavage rate from 59 to 86%, and the number of embryos from 24 to 70 in the suppressed cycle. No deleterious effects were observed and there were two pregnancies in this group.

Predictive value of hormonal profiles before stimulation for in vitro fertilization

Ovarian responses to stimulation for in vitro fertilization by clomiphene citrate menotropins have been correlated to the hormonal profiles determined during spontaneous cycles. The authors found 80% of high plasmatic luteinizing hormone (LH) and/or androgens levels associated with an inappropriated response: premature LH surge, multifollicular ovarian response, or dissociated cystic response, versus only 11% with appropriated responses. High plasmatic follicle-stimulating hormone existed in 71% of the no response group. Detryptoréline, a luteinizing hormone-releasing hormone agonist associated with menotropins, in a "short procedure" maintained the adequate responses and suppressed premature LH surges. The no response group was moderately improved, as were multifollicular and dissociated cystic response groups. Hormonal profiles could be useful predictive factors of the ovarian response for adaptation on the first procedure of stimulation.

Effects of progesterone on luteinizing hormone release and estradiol/progesterone ratio in the luteal phase of women superovulated for in vitro fertilization and embryo transfer

The present study extends the information on the effects of progesterone (P) on the luteinizing hormone (LH) release, and estradiol (E2)/P ratio in the luteal phase in women superovulated for in vitro fertilization and embryo transfer (IVF-ET). Two groups of 34 patients were induced for ovulation with clomiphene citrate and human menopausal gonadotropins. One group was given 25 mg P (Gesterol, Steris Laboratory Inc., Phoenix, AZ) at the time of, or 4 to 6 hours before human chorionic gonadotropin (hCG) administration and another group served as control (no Gesterol). Of the 34 patients in the Gesterol group, 10 had Gesterol 4 to 6 hours before the administration of hCG, 13 at the time of hCG, and 11 after the spontaneous LH surge. Administration of Gesterol 4 to 6 hours before hCG significantly increased the LH values (19.0 +/- 10.3) compared with those who had Gesterol at the time of hCG (6.8 +/- 2.8, P = 0.0006). A single dose of Gesterol (25 mg P) significantly reduced the E2/P ratio during the luteal phase (P = 0.0005). However, the outcome of IVF-ET was the same in the Gesterol and no-Gesterol groups. It is concluded that a significant increase in P triggers an LH surge and a single dose of Gesterol decreases E2/P ratio in the luteal phase of women after ovarian stimulation. The biochemical mechanisms are unclear.

Blockage of the positive feedback effect of oestradiol during prolonged administration of clomiphene citrate to normal women

The effect of clomiphene citrate on the occurrence and timing of the endogenous LH surge in superovulated cycles is unclear. To study further this event, five normally ovulating women were treated with clomiphene citrate 100 mg per day in two different cycles, that is, for 5 days in one cycle (days 2 to 6, CC-5) and for 15 days in another cycle (days 2 to 16, CC-15). During the CC-5 cycle, the normal pattern of LH levels seen in spontaneous cycles was observed with an endogenous LH surge in all women followed by ovulation and normal luteal function. In contrast, during the CC-15 cycle, a continuous and progressive increase of basal LH levels was seen with no surge, resulting in follicular luteinization but no ovulation. The results suggest that in normal women treated with clomiphene the occurrence of an endogenous LH surge is dependent on a significant decrease in the circulatory concentration of clomiphene at mid-cycle.

Spontaneous luteinizing hormone (LH) surges are associated with more rapidly increasing estradiol (E2) and follicle stimulating hormone (FSH) in in vitro fertilization and embryo transfer

In a retrospective analysis of 64 patients stimulated with human menopausal gonadotropin (hMG) and/or pure follicle stimulating hormone (FSH); 35 cycles with spontaneous luteinizing hormone (LH) surges were compared with 29 control cycles with respect to serum FSH and estradiol (E2) levels drawn on the day prior to and the day of human chorionic gonadotropin (hCG), approximately 16 hr after gonadotropin stimulation. FSH decreased significantly (P less than 0.05) in control cycles where two or more preovulatory oocytes (preovs) were obtained, in contrast to cycles with a spontaneous LH surge, where FSH increased irrespective of the number of preovs. The E2 increase in the LH surge cycles was significantly higher (P less than 0.05) than in the control cycles. However, the increase in E2 did not correlate with the change in FSH levels or with the number of preovs.

The effect of cycle length on the outcome of in vitro fertilization

In order to study the effect of cycle length on the pregnancy rate in an in vitro fertilization and embryo transfer (IVF-ET) program, 173 consecutive patients were divided into short menstrual cycle (mode 26 days or less) and normal cycle (mode 27 days or more) groups. Patients were randomly allocated to one of two treatments, commencing ovarian stimulation with human menopausal gonadotropin (hMG) on either day 2 or day 4 of their cycle. The number of oocytes retrieved and embryos transferred did not differ significantly. The amount of hMG used and day of human chorionic gonadotrophin administration both differed significantly (P less than 0.01) between regimens but was independent of cycle length. Both the clinical pregnancy rate (30.2% versus 9.4%, P less than 0.05) and the number of cleaved embryos giving rise to gestation sacs (16% versus 3.4%, P less than 0.02) was significantly higher in patients with a normal cycle length. Mode cycle length has a significant bearing on the outcome of IVF-ET cycles.

Timing of oocyte retrieval in cycles with a spontaneous luteinizing hormone surge in a large in vitro fertilization program

Forty-four cycles with a spontaneous luteinizing hormone (LH) surge among 377 in vitro fertilization (IVF) patients were studied for outcome with different timing of oocyte retrieval. Mean number of preovulatory oocytes per retrieval and per transfer was significantly less in these cycles than in controls. Mean number of preovulatory oocytes per retrieval and per transfer was significantly higher when the human chorionic gonadotropin (hCG)-retrieval interval was greater than 35 hours, compared with less than 24 hours. In cycles with an hCG-retrieval interval of less than 24 hours, percentage of preovulatory oocytes was higher when serum estradiol (E2) decreased by greater than 15% on the morning after hCG administration compared with a plateau or an increase in serum E2. Timing oocyte retrieval after spontaneous LH surge should consider the hCG-retrieval interval and changes in E2 levels after hCG administration; this may avoid cancellation for many patients.

Spontaneous luteinizing hormone surge and cleavage of in vitro fertilized embryos

The importance of monitoring luteinizing hormone (LH) secretion during gonadotropin stimulation remains controversial. In the present study, the authors evaluated the occurrence of spontaneous LH surges in 170 cycles stimulated by clomiphene citrate and human menopausal gonadotropin, and correlated the success rate of embryo cleavage to the time interval between the occurrence of the LH surge peak value and the time of human chorionic gonadotropin (hCG) administration. LH was quantitated from urine by an avidin-biotin enzyme immunoassay. The results indicated that a spontaneous LH surge occurred in 18% of the cycles. The number of oocytes recovered was not affected by the occurrence of a spontaneous LH surge. In 12% of all cases, the spontaneous LH surge occurred less than 12 hours before the administration of hCG, and in these cases embryo cleavage was not reduced. In 6% of all cases, the spontaneous LH surge occurred over 12 hours before hCG administration, and in these cases embryo cleavage was reduced significantly.

Superovulation with exogenous gonadotropins does not inhibit the luteinizing hormone surge

The administration of human chorionic gonadotropin to women undergoing superovulation with exogenous gonadotropins was delayed in order to document the occurrence of a surge of luteinizing hormone (LH). An LH surge was seen to occur in 10 of 10 women receiving clomiphene citrate (CC) and pulsatile human menopausal gonadotropin (hMG); in 10 of 12 women treated with pulsatile hMG alone; and in 12 of 14 women treated with single daily injections of hMG without CC. The height of the surge was attenuated in all cycles and the timing of its onset was significantly earlier among women receiving single daily injections of hMG. Possible mechanisms for these findings are discussed.

The influence of exogenous human chorionic gonadotropin cycles with spontaneous luteinizing hormone surges on the outcome of in vitro fertilization

Thirty consecutive patients who displayed endogenous luteinizing hormone (LH) surges and reached oocyte recovery for the purpose of in vitro fertilization were reviewed (LH surge group). Another 37 patients receiving human chorionic gonadotropin (hCG) in the absence of an LH surge served as a control group (no surge-hCG group). All patients underwent ovulation induction using clomiphene citrate (CC) plus human menopausal gonadotropin (hMG). The numbers of oocytes recovered and embryos transferred were significantly lower in the LH surge group compared with the no surge-hCG group (P less than 0.05). Nevertheless, the pregnancy rate per oocyte recovery between the two groups appeared similar (20 versus 16%). Among the 30 patients with a LH surge, 9 received hCG after a LH surge was verified, whereas the others did not. Addition of hCG to the LH surge increased the numbers of oocytes recovered, embryos transferred, and the pregnancy rate (3 out of 9 versus 3 out of 21); however, this difference is not statistically significant. Furthermore, the addition of exogenous hCG to a spontaneous LH surge appears to be necessary to maximize the number of oocytes recovered, embryos transferred, and pregnancies obtained.

The outcome of continued treatment of luteinizing hormone-surged cycles in in vitro fertilization with the use of human menopausal gonadotropin

Over a 2-year period 75 patients were treated for 109 cycles with human menopausal gonadotropin for in vitro fertilization. The occurrence of endogenous luteinizing hormone (LH) surges was monitored by daily blood sampling. Forty-six cycles (42%) showed an endogenous LH surge. Instead of canceling the treatment cycle as other programs do, we proceeded to oocyte collection when the surge was detected. Human chorionic gonadotropin was administered routinely to the "surge" patients as soon as the LH surge was determined. The oocyte collection was carried out around 24 hours after the "surge" blood had been drawn, although the beginning of the endogenous LH surge was unable to be pinpointed. Significantly more immature oocytes, lower fertilization rate, and lower cleavage rate were seen in the "surge" patients than in the "nonsurge" patients. In five "surge" cycles laparoscopy for oocyte collection was canceled, but none was canceled because of premature ovulation detected by the immediately preoperative ultrasonography. In four "surge" cycles no potentially fertilizable egg was recovered. This was not significantly different from that of the "nonsurge" group. The pregnancy rate of the "surge" group (4/41 or 9.8% per laparoscopy and 4/34 of 11.8% per embryo transfer) was not statistically different from that of the "nonsurge" group (7/61 or 11.5% per laparoscopy and 7/56 or 12.5% per embryo transfer). This study presents the possibility of proceeding to oocyte collection, fertilization, embryo transfer, and pregnancy in patients with endogenous LH surge in in vitro fertilization procedures with the use of human menopausal gonadotropin treatment.

Endogenous luteinizing hormone release using human menopausal gonadotropins for in vitro fertilization

This study demonstrates that luteinizing hormone (LH) release may occur despite sustained elevations of estradiol E2 in women receiving human menopausal gonadotropin. Mean levels of E2 did not correlate with the LH surge, however, the follicle number and a rapid rise in E2 did. Therefore, it appears that the protective influence of inhibitory proteins secreted by multiple follicles can be overridden, allowing spontaneous LH release.

Clinical aspects with regard to the occurrence of an endogenous luteinizing hormone surge in gonadotropin-induced normal menstrual cycles

A decline in serum E2 the day before laparoscopy indicated that ovulation had occurred in 16 cycles stimulated with exogenous gonadotropins for the purpose of in vitro fertilization (IVF). In contrast to 18 control cycles with rising E2 values after human chorionic gonadotropin (hCG) administration and without evidence of ovulation, the onset of the endogenous luteinizing hormone (LH) surge had been initiated. From this study, it is believed that the onset of an endogenous LH surge can be identified by the terminal preovulatory E2 pattern. Further, the incidence of an endogenous LH surge in gonadotropin-induced menstrual cycles and the present clinical approach of the Norfolk IVF program to this phenomenon are discussed.

The effect of pulsatile follicle stimulating hormone on the endogenous luteinizing hormone surge in women

The effect of pulsatile administration of 'pure' FSH on the endogenous LH surge was investigated in 10 infertile but otherwise normal women. In each woman the LH surge in the spontaneous cycle preceding the treatment cycle was characterized in blood samples taken every 6 h. FSH was injected s.c. via a pump (28 IU every 3 h) starting on cycle day 2. Only five of the FSH-treated women displayed an endogenous LH surge, and this was markedly attenuated in four of them. The LH surge occurred significantly earlier in the FSH-treated than in the corresponding spontaneous cycle (cycle day 10.2 +/- 0.5 vs 13.6 +/- 0.8 mean- +/- SEM, P less than 0.05), although it tended to occur later in the FSH-treated cycles with a higher total follicular fluid volume of follicles 12-15 mm in diameter. This volume was even greater in the FSH-treated cycles without an endogenous LH surge. Serum progesterone levels increased significantly in all five FSH-treated cycles after the onset of the LH surge and ovulation was confirmed by ultrasound in four of them. These results suggest that the LH surge during superovulation induction with pulsatile FSH in normally cycling women is a variable event. We postulate that unknown inhibitory substances secreted be small growing follicles antagonize the positive feedback effect of E2 on LH secretion.

Differences in ovarian stimulation in human menopausal gonadotropin treated woman may be related to follicle-stimulating hormone accumulation

Two groups of normal ovulatory women who displayed either a marked (high responders; HR) or a more subtle (low responders; LR) ovarian response to a fixed dose of human menopausal gonadotropins (hMG) were evaluated for differences in blood levels of hormones. Serum follicle-stimulating hormone (FSH) levels doubled during the first 3 days of treatment (to approximately 20 mIU/ml) in all patients; thereafter, the levels plateaued in LR but continued to rise steadily (to 35 mIU/ml) in HR. In the latter group, rise in estradiol (E2) and FSH was accompanied by an increase of luteinizing hormone (LH; two to five times) progesterone (P; four to eight times) testosterone (T; three to four times) and prolactin (PRL; 2 times) toward the end of the follicular phase. Positive correlation was found between FSH and E2 in HR and LR. Positive correlation was found, however, between LH, T, and P and between E2, P, and PRL only in HR. The extent of FSH accumulation in the circulation may be a principal factor in determining an individual's response to hMG therapy. Temporal changes of blood hormones indicated that the continuous rise in FSH levels in HR was associated with early luteinization of the follicles. Increased secretion of P in the follicular phase of these women (HR) probably synergized with the elevated E2 levels to elicit LH release. Similar changes in blood hormones were not found in LR.

Relationships between the characteristics of endogenous luteinizing hormone surge and the degree of ovarian hyperstimulation during superovulation induction in women

Ovarian hyperstimulation was induced in 17 normally cycling women undergoing in-vitro fertilization (IVF) and embryo transfer with clomiphene (9 cycles), clomiphene followed by pulsatile hMG (12 cycles) or clomiphene followed by pulsatile FSH (11 cycles). Hyperstimulation was greater with the combined treatments than with clomiphene alone. In all 32 cycles an endogenous LH surge occurred. The peak values and the duration of the LH surge showed significant negative correlations with the plasma oestradiol levels, the number of the follicles and the total follicular fluid volume aspirated at laparoscopy. We suggest that during superovulation induction for IVF, the endogenous LH surge is attenuated by factors which are related to the degree of ovarian hyperstimulation.

Patterns of estradiol response in patients with endogenous gonadotropin surges during follicular recruitment in an in vitro fertilization and embryo transfer program

This report is an analysis of 16 cycles in 15 patients stimulated with human menopausal gonadotropin and clomiphene citrate for the purpose of follicular recruitment in an in vitro fertilization program, all of which resulted in endogenous luteinizing hormone (LH) surges. A study of the pattern of estradiol (E2) response to stimulation revealed two groups of cycles, designated "leap" pattern (9 cycles) and "plateau" pattern (7 cycles), the rate of rise of E2 increasing or decreasing, respectively, as the time of the LH surge was approached. There were no significant differences between these groups of cycles in the peak E2 level attained or the number of follicles greater than or equal to 12 mm on the day of peak E2. In the plateau, but not in the leap pattern cycles, a significant correlation (r = 0.958) was found between the number of follicles greater than or equal to 12 mm and the peak E2. We tentatively conclude that "plateau" pattern cycles reflect relatively synchronous follicular recruitment; the greater the number of follicles recruited, the higher the E2 level attained, increased amounts of inhibin-like substances being available to restrain the LH surge; "leap" pattern cycles reflect asynchronous follicular recruitment.

Induction of ovulation with pulsatile subcutaneous administration of human menopausal gonadotropin in anovulatory infertile women

Pulsatile administration of human menopausal gonadotropin (hMG) via the subcutaneous route was evaluated in 15 patients with various ovulatory disorders. Administration of hMG was started at a dose of 4.6875 IU (75 IU/day) or 9.375 IU (150 IU/day) per pulse every 90 minutes. Ovulation was observed in 26 (92.9%) of 28 treatment cycles, and two singleton pregnancies were confirmed. Ovarian hyperstimulation was observed in 1 to 26 ovulatory cycles; however, no other side effects were observed during treatment. A regimen of 75 IU/day resulted in a significant increase (P less than 0.0001) of the total dose and prolongation of the treatment period for induction of ovulation, as compared with that of 150 IU/day. Shortened luteal phases occurred in ovulatory cycles induced by pulsatile subcutaneous treatment. Human chorionic gonadotropin administration given every other day until the midluteal phase significantly prolonged the duration of the luteal phase (P less than 0.05). This treatment in patients with the polycystic ovary syndrome was followed by a normalization of luteinizing hormone/follicle-stimulating hormone ratio and resulted in a successful induction of ovulation in 8 to 10 cycles. The present data demonstrated that pulsatile subcutaneous administration of hMG was effective in inducing follicular maturation and ovulation in patients with various types of anovulatory infertility.

In vitro fertilization management and results in stimulated cycles with spontaneous luteinizing hormone discharge

During a period of 14 months, in an in vitro fertilization program, 97 ultrasonically guided follicular punctures were performed in women with premature spontaneous luteinizing hormone (LH) discharge (group I) and 217 in women with a normal LH value who received human chorionic gonadotropin injection as a surrogate LH surge (group II). All cycles were stimulated by clomiphene citrate plus human menopausal gonadotropin. In group I, oocytes were not recovered in 35% of punctures, compared with only 21.2% in group II (P less than 0.02). In cycles in which the serum 17 beta-estradiol (E2) levels was less than 1200 pg/ml and the number of follicles greater than or equal to 14 mm diameter monitored was less than three, 69% of punctures in group I and 36.7% of punctures in group II failed to yield oocytes. We suggest that patients stimulated in this way who have a spontaneous LH discharge with an E2 value of less than 1200 pg/ml and less than three follicles 14 mm in diameter present should not proceed to follicular puncture.

Endogenous luteinizing hormone surge in women during induction of multiple follicular development with pulsatile follicle stimulating hormone

In this study nine consecutive normally cycling women undergoing in-vitro fertilization (IVF) were superovulated with clomiphene citrate followed by pulsatile 'pure' FSH injected s.c. via a pump (28 IU every 3 h). All women displayed an endogenous LH surge, which was markedly attenuated in most of the cases (peak value 44.5 +/- 5.9 U/l, duration 29.2 +/- 1.2 h, mean +/- SEM) as compared to spontaneous cycles. An increase in serum progesterone levels before the onset of the LH surge was seen in only one woman at a time when the LH values were low. During the LH surge serum progesterone levels increased significantly in all patients (12.7 +/- 1.90 nmol/l vs 4.74 +/- 1.57 nmol/l at the onset of the surge, mean +/- SEM, P less than 0.05) indicating follicular luteinization. Very high oestradiol levels in serum were found at the onset of the LH surge (7504 +/- 898 pmol/l, mean +/- SEM). Preovulatory oocytes were recovered from all women through a laparoscope 34-36 h after the beginning of the LH surge and embryos were replaced to them after IVF. One ongoing clinical pregnancy occurred. In contrast to results in monkeys, these results demonstrate for the first time that normally cycling women superovulated with clomiphene pulsatile 'pure' FSH will display an endogenous LH surge. Although the surge is attenuated implantation can occur.

Characteristics of patients with and without gonadotropin surges during follicular recruitment in an in vitro fertilization/embryo transfer program

Fifteen ovulatory patients undergoing ovarian stimulation with clomiphene citrate-human menopausal gonadotropin-human chorionic gonadotropin (hCG) for in vitro fertilization were studied. All 15 attained peak estradiol (E2) levels of greater than 600 pg/ml. Eight patients had an endogenous luteinizing hormone (LH) surge before the administration of hCG. The characteristics of these "surge" patients were compared with those of the remaining seven "nonsurge" patients. There was no significant difference in the peak morning E2 achieved before hCG or the endogenous LH surge, nor in the peak absolute increase in E2 over a 24-hour period in these two groups. The surge group had significantly higher E2 levels per follicle greater than or equal to 15 mm, measured by ultrasound on the morning of the day of administration of hCG or the LH surge (P less than or equal to 0.005). In addition, nonsurge patients had a greater number of follicles greater than or equal to 15 mm, compared with surge patients (P less than or equal to 0.05). It is hypothesized that greater quantities of nonsteroidal hormones, such as inhibin, produced by a greater number of preovulatory follicles in nonsurge patients, may block the pituitary response to hypothalamic gonadotropin-releasing hormone in the face of high and rising E2 levels.

Urinary oestrogen levels and follicle ultrasound measurements in clomiphene induced cycles with an endogenous luteinizing hormone surge

Total oestrogen in urine and the ultrasonic size of the follicles were measured in relation to the onset of the endogenous luteinizing hormone (LH) surge (day 0) in 18 cycles induced with clomiphene citrate in an in-vitro fertilization programme. Oestrogen values in urine (microgram/24 h) increased progressively during the late follicular phase up to the day of the onset of the surge. The mean maximum follicle diameter (22.3, SD 4.7 mm) estimated by ultrasound was measured on day 0. At the onset of the LH surge, the values of urinary total oestrogen showed a better relation with the total volume of the first three follicles in order estimated by ultrasound (r = 0.71) than with the mean ultrasonic diameter of the leading follicle (r = 0.56). A wide range of individual values for both urinary oestrogen and follicle size was found. In another group of 32 women treated with clomiphene for recovery of oocytes used for research purposes, a good correlation was found between the mean ultrasonic follicle diameter 16 h before the laparoscopy and the follicle diameter calculated from the fluid volume at aspiration (r = 0.80). These results suggest that the decision when to give human chorionic gonadotrophin (hCG) in an in-vitro fertilization programme remains arbitrary in many individual cases. Apart from the oestrogen levels, the calculation of the size of all follicles, instead of only the leading one, may give further help in timing the hCG.