Gonadotropin-releasing hormone agonist improves the efficiency of controlled ovarian hyperstimulation/intrauterine insemination

Comparison of urinary and recombinant human chorionic gonadotropin during ovulation induction in intrauterine insemination cycles: a prospective randomized clinical trial

OBJECTIVES

To compare the in vivo effectiveness of recombinant (r) hCG with urinary (u) hCG during controlled ovarian hyperstimulation and intrauterine insemination (COH-IUI) cycles.

DESIGN

Prospective controlled clinical study.

SETTING

Private IVF center.

PATIENT(S)

Two hundred eighty-four subjects undergoing COH-IUI cycles.

INTERVENTIONS(S)

Women were randomized into receiving r-hCG or u-hCG for final maturation and induction of ovulation.

MAIN OUTCOME MEASURE(S)

Clinical pregnancy rate and outcome of pregnancy.

RESULT(S)

Background characteristics were similar in the two groups studied except for a slight difference in the mean duration of infertility (3.0 vs. 2.3). There was no significant difference in the number of follicles > or =16 mm, mean peak E(2), or mean 1-week P levels between the two groups. The clinical pregnancy rate was 27.1% in the recombinant group compared with 28.5% in the urinary group. The outcome of pregnancy was similar in both groups.

CONCLUSION(S)

Recombinant hCG was found to be as effective as u-hCG in achieving pregnancy during COH-IUI cycles. This is in agreement with earlier studies on the effectiveness of r-hCG in IVF cycles.

GnRH antagonist-induced inhibition of the premature LH surge increases pregnancy rates in IUI-stimulated cycles. A prospective randomized trial

BACKGROUND

Our prospective randomized controlled trial was designed to assess whether the use of GnRH antagonists can improve the success rate of controlled ovarian stimulation (COS)/intrauterine insemination (IUI) treatments, via inhibition of the premature LH rise.

METHODS

A total of 104 patients were randomly divided, using a randomization list, into two groups: in group A (n = 52), recombinant FSH (rFSH) was given with GnRH antagonist Cetrorelix, and in group B (n = 52), the patients received rFSH alone in a manner similar to that of group A. The primary outcome measure was clinical pregnancy rate per couple.

RESULTS

The pregnancy rate per patient was 53.8% in group A and 30.8% in group B (P = 0.017). The rate of premature LH surge was 7% in group A and 35% in group B (P < 0.0001). A premature luteinization was observed in two cycles of 144 in group A (1.4%) and in 16 cycles of 154 in group B (10.4%) (P = 0.001). The mean values of LH and progesterone were significantly lower in patients receiving GnRH antagonist than in those who did not (3.3 +/- 3.3 mIU/ml in group A versus 9.9 +/- 7.9 mIU/ml in group B, P < 0.0001, for LH; 1.3 +/- 1.1 ng/ml versus 2.1 +/- 1.9 ng/ml for group A and B, respectively, P < 0.0001, for progesterone).

CONCLUSION

The use of GnRH antagonist in COS/IUI cycles improves pregnancy rate, preventing the premature LH rise and luteinization.

Impact of leuprolide acetate on luteal phase function in women undergoing controlled ovarian hyperstimulation and intrauterine insemination

OBJECTIVE

To determine if the combination of leuprolide acetate (LA) and human menopausal gonadotropin (hMG) results in luteal phase dysfunction.

DESIGN

A prospective, randomized clinical trial.

SETTING

A tertiary care university fertility center.

PATIENT(S)

One hundred thirty-five couples with various etiologies of infertility.

INTERVENTION(S)

Patients were prospectively randomized to receive either hMG and intrauterine insemination (IUI) or luteal phase down-regulation with LA, hMG, and IUI.

MAIN OUTCOME MEASURE(S)

Serum luteal phase progesterone (P) and luteal phase estradiol (E2) were obtained 9 days after hCG administration. Twenty-four-hour urinary P and luteinizing hormone (LH) were analyzed 9 days after human chorionic gonadotropin (hCG). Endometrial biopsies were performed 11 days after hCG and evaluated for luteal phase defects (LPD) using Noyes' criteria.

RESULT(S)

No significant differences in the incidence of LPD (11.9% vs. 13.9%), cycle fecundity (16.6% vs. 16.3%), or luteal phase hormone profiles were observed between the groups receiving and not receiving LA. A significant difference in E2 levels (on the day of hCG administration) between cycles with a luteal phase defect (967 pg/mL +/- 106) and without a luteal phase defect (1,422 pg/mL +/- 83) was observed (P<.05).

CONCLUSION(S)

Pituitary down-regulation with LA combined with hMG did not result in luteal phase dysfunction. The E2 levels on the day of hCG administration in both groups were lower in women with documented luteal phase defects.

The value of gonadotrophin releasing hormone analogue in an intrauterine insemination (IUI) programme

Gonadotrophin releasing hormone analogue (GnRHa) is widely used in in-vitro fertilisation programmes and has no doubt led to a significant improvement in the pregnancy rate as well as cycle planning. However, its use in intrauterine insemination (IUI) programmes remains controversial. This is a retrospective review of patients who received IUI treatment at our assisted conception unit, during a 12-month period from August 1997 to July 1998. Fifty-two patients underwent a total of 85 cycles. Six cycles were abandoned, five due to excessive response and one for continuous bleeding. They all received Nafarelin nasal spray from day 2 until ovulatory HCG was administered. Metrodin injection was given from day 3. There were 18 clinical pregnancies. Seventy-nine cycles were completed giving a pregnancy rate of 22.8% per completed cycle. There were five (27.8%) multiple pregnancies. The use of GnRHa in our programme enabled us to achieve a good cycle control as well as flexibility in the timing of insemination such that weekend work was avoided. We conclude that the use of GnRHa facilitates the efficiency of an IUI programme.

Prediction of over-response to ovarian stimulation in an intrauterine insemination programme

Prediction of poor-response is of equal importance to prediction of over-response in intrauterine insemination programmes. The gonadotrophin-releasing hormone agonist (GnRHa) stimulation test (GAST) was assessed as a predictor of over-response to ovarian stimulation in 81 patients. Blood samples were taken on cycle day 2 (before and 24 h after starting the GnRHa). Day 2 and 3 samples were assayed for oestradiol, follicle stimulating hormone (FSH) and luteinizing hormone (LH). Linear and logistic regression analyses were used to assess age, day 2 FSH, day 2 FSH/LH, oestradiol ratio (oestradiol on day 3/oestradiol on day 2) and FSH ratio (FSH on day 3/FSH on day 2) as predictors of the number of follicles (total and > or = 14 mm), oestradiol on HCG day, and clinical pregnancy rate as appropriate. Several parameters were also compared between the patients who produced < or = 3 (> or = 14 mm) follicles (group A) and those who produced >3 (> or = 14 mm) follicles (group B). The mean +/- SEM age of the patients in the study was 32 +/- 0.4 years. The mean total dose of recombinant FSH was 800 +/- 20 IU and the mean duration of stimulation was 7.6 +/- 0.2 days. Nine (11%) and 12 (15%) patients were cancelled for poor and over-response respectively. The oestradiol ratio was significantly positively correlated with oestradiol on HCG day (P < 0.001), and with the number of mature follicles (> or = 14 mm) (P = 0.01). Age, day 2 FSH and FSH ratio were not significantly correlated with oestradiol on HCG day, total follicles and follicles > or = 14 mm. None of the above-mentioned variables was correlated with clinical pregnancy rate. Group A had significantly lower oestradiol ratio (P = 0.007), longer duration of stimulation (P = 0.002), higher total FSH dose (P = 0.001), and lower oestradiol on HCG day (P = 0.001). GAST is therefore useful in predicting the high responders to gonadotrophin stimulation.

Early resort to ovarian stimulation improves the cost-effectiveness of a donor insemination programme

Women undergoing donor insemination (DI) are usually regularly ovulating, therefore the role of ovulation induction in this modality of treatment has been controversial. Some recent studies reported higher pregnancy rates in stimulated cycles in comparison with natural cycles. We employed a sequential step-up protocol in which treatment was started in a natural cycle, continued with a clomiphene citrate-stimulated cycle, and finished with an ovulation induction cycle. The patients were allowed three attempts at each step before moving to the next if conception did not occur. The aim of this protocol was to enhance the cost-effectiveness of the DI programme by increasing the cycle fecundability. A total of 101 patients underwent 216 cycles of DI, including 44 patients in 80 natural cycles, 38 patients in 89 CC-stimulated cycles, and 19 patients in 47 ovulation induction cycles. The clinical pregnancy rate per started cycle (CPR/C) and per patient during this period was 14% and 30% respectively. The pregnancy rates per started cycle and per patient in the natural, CC-stimulated and ovulation induction cycles were: 13 and 32%, 10 and 18%, and 21 and 53% respectively. There was no significant difference in the CPR/C in the three groups; however, the CPR per patient in the induced ovulation cycles was significantly higher than in the CC-stimulated cycles (P = 0.005). Only one patient during this period had a multiple pregnancy in the ovulation induction group, giving an overall multiple pregnancy of 3%. By using this treatment strategy, we achieved a high clinical pregnancy rate, a low multiple pregnancy rate and a low cost of treatment per pregnancy.

The management of unexplained infertility

Unexplained infertility is a diagnosis made by exclusion after all of the standard investigations have revealed no abnormality (1). The range of the prevalence is from 6 to 60 percent (23), depending on the diagnostic criteria. This article reviews the literature in the management of unexplained infertility; published data suggest no benefit of danazol or bromocriptine. The empirical use of clomiphene citrate suggests that ovarian stimulation using clomiphene citrate can double the spontaneous pregnancy rate (52, 58, 59). Induction of ovulation with human menopausal gonadotrophin (hMG) yields an overall pregnancy rate between 2 and 26 percent per cycle (68, 74). These results seem to be lower than those reported for in vitro fertilization (IVF) or gamete intrafallopian transfer (GIFT) procedures in similar patients (25-30 percent (92, 95)). Based on the literature, a rational treatment plan for treating infertility in couples with unexplained infertility includes up to four cycles of clomiphene citrate with or without intrauterine insemination (IUI). Superovulation with hMG and IUI or stimulated intrauterine insemination (SIUI) is the next step for three-cycle treatments and if unsuccessful, one of the variants of assisted reproductive techniques (ART) should be considered.

TARGET AUDIENCE

Obstetricians & Gynecologists, Family Physicians.

LEARNING OBJECTIVES

After completion of this article, the reader will understand the appropriate tests and work up for unexplained infertility, the various treatment options for the unexplained infertility couple including which drugs are effective and not effective, and to be able to outline an appropriate treatment plan for such patients.

Intrauterine insemination as first line treatment of unexplained and male factor infertility

OBJECTIVE

The purpose of this study was to evaluate the efficacy of intrauterine inseminations (IUI) as first line treatment of unexplained or male factor infertility.

STUDY DESIGN

Retrospective analysis of 414 consecutive IUI treatment cycles in 124 couples with unexplained or male factor infertility.

RESULTS

In 414 cycles 25 pregnancies were achieved (6% pregnancy rate per cycle and 20% per couple respectively). 24 healthy babies were born (20 singletons and 2 twins) as a result of our treatment. There was no significant difference in ejaculate parameters of patients who achieved a pregnancy compared with patients who failed to do so. Lowest values at which pregnancies were achieved were 0.8 mill sperm/ml and 11% progressive motility after sperm processing and 8% normal morphology before semen preparation.

CONCLUSION

There is still a place for IUI as first line treatment for couples with unexplained or male factor infertility. Even in patients with moderate impairment of semen quality pregnancy rates up to 20% per couple can be achieved.

Long gonadotrophin releasing hormone agonist/human menopausal gonadotrophin protocol for ovarian stimulation in intrauterine insemination treatment

OBJECTIVE

This prospective study was undertaken to examine the usefulness of a long gonadotrophin releasing hormone agonist (GnRH-a)/human menopausal gonadotrophin (hMG) protocol in intrauterine insemination (IUI) treatment. The results were compared to those of clomiphene citrate (CC)/hMG/IUI.

STUDY DESIGN

Seventy-five patients were recruited to a GnRH-a/hMG group (group 1) while 88 patients underwent CC/hMG stimulation and served as controls (group 2). The study subjects were stimulated with a long GnRH-a/hMG regimen. IUI was performed 36 h after the administration of human chorionic gonadotrophin.

RESULTS

The number of preovulatory follicles, the thickness of endometrium and sperm parameters were similar in both groups. The hMG requirements were significantly higher in group 1 than in group 2 (21.2 +/- 5.1 vs. 8.1 +/- 3.1 ampoules). The pregnancy rate was 20% in group 1 and 12.5% in group 2, the difference being not significant.

CONCLUSION

The pregnancy rates were not significantly different between the GnRH-a/hMG/ IUI and CC/hMG/IUI groups. In addition, GnRH-a/hMG stimulation is notably more expensive than CC/hMG, and for these reasons, GnRH-a/hMG stimulation is not cost-effective in routine IUI therapy.

Selective use of leuprolide acetate in women undergoing superovulation with intrauterine insemination results in significant improvement in pregnancy outcome

OBJECTIVE

To examine the incidence of premature luteinization in individuals undergoing hMG with IUI therapy, the association between premature luteinization, cycle fecundity, and pregnancy outcome, and to determine if the selective use of leuprolide acetate (LA) in women demonstrating premature luteinization improves pregnancy outcome in subsequent hMG with IUI cycles.

DESIGN AND SETTING

Retrospective analysis of superovulation cycles from January 1990 until December 1991 at the University of Connecticut Health Center.

PATIENTS

All women with ovulatory function undergoing hMG superovulation with IUI.

INTERVENTIONS

All patients were tested for evidence of premature luteinization. Those demonstrating premature luteinization were started on LA in the luteal phase in their subsequent hMG with IUI cycle.

MAIN OUTCOME MEASURES

Peak serum E2, the number of mature preovulatory follicles, the number of ampules of hMG, days of hMG therapy, cycle fecundity, and spontaneous abortion rate.

RESULTS

Thirty-three percent of all hMG with IUI patients showed evidence of premature luteinization, with premature luteinization occurring in 22.2% of conception cycles and 37.4% of nonconception cycles. For those women who demonstrated premature luteinization in their conception cycle, 90.0% of the pregnancies ended with either spontaneous abortion or were biochemical in nature compared with 44.3% in the cycles without evidence of premature luteinization. Cycle fecundity was 11.1% in patients demonstrating premature luteinization compared with 26.3% for patients without premature luteinization. All women demonstrating premature luteinization and not conceiving were placed on LA in the luteal phase and had a subsequent cycle fecundity of 18.9% with the percent pregnancy wastage being significantly less (33.3% versus 90.0%) when LA was used.

CONCLUSIONS

Premature luteinization is a common occurrence during hMG therapy and is associated with decreased cycle fecundity and an increased incidence of spontaneous abortion and biochemical pregnancies. The selective use of LA in those individuals demonstrating premature luteinization results in a significant increase in the percent of women conceiving a viable pregnancy.

Therapeutic intrauterine insemination improves with gonadotropin ovarian stimulation

Therapeutic intrauterine insemination (IUI) is frequently used as a first line of treatment of infertility. The reported results vary, depending on the indication and the use of ovulation simulation protocols. In the present study, we review the experience at the Jones Institute for Reproductive Medicine in Virginia from January 1989 to January 1991. The patients were preferentially treated with ovulation induction with gonadotropins. With the addition of gonadotropin stimulation, the total and term pregnancy rates per cycle were 14% and 11%, respectively, including all etiologic factors. These rates were improved over the 3% and 2.6% rates reported in our previous study in which ovarian stimulation was not generally used. In male factor patients, the term pregnancy rate was 9%, higher than the 4% term pregnancy rate reported in our previous study. In the present series, morphology was the only severely impaired parameter. The term pregnancy rate was 11% for patients with ovulatory dysfunction, 10% for those with cervical factor, and 10.5% for those with unexplained infertility.

Poor in vitro fertilization outcome with semen yielding low sperm density "swim-ups" is not because of altered sperm motion parameters

OBJECTIVE

To examine fertilization, cleavage, and pregnancy rates (PRs) with semen samples yielding numbers of total motile sperm per swim-up ranging from < 1 to > 20 x 10(6) and to correlate the findings with changes, if any, in the sperm motion parameters.

DESIGN

Fertilization, cleavage, and pregnancy outcomes in 439 in vitro fertilization (IVF) cycles were correlated with the total number of motile sperm per swim-up and the sperm motion parameters as determined with an automated semen analyzer.

SETTING

A university-based tertiary referral hospital center.

PATIENTS

Patients undergoing IVF or intrauterine insemination treatments for multiple etiologies.

RESULTS

Higher numbers of motile sperm per swim-up, most notably above the value of 3 x 10(6) motile sperm, were associated with improved fertilization rates and viable PRs. Sperm velocity, linearity, amplitude of lateral head displacement, and flagellar beat per cross frequency for sperm from swim-ups with poor or good pregnancy outcome, however, showed no significant differences.

CONCLUSIONS

As a group, semen samples that yield < or = 3 x 10(6) motile sperm per swim-up are associated with poor fertilization rates, cleavage rates, and PRs. This relationship can not be attributed to differences in sperm motion parameters.

Randomized trial of three luteinizing hormone-releasing hormone analogues used for ovarian stimulation in an in vitro fertilization program

OBJECTIVE

To determine if biochemical differences in luteinizing hormone-releasing hormone analogues (LH-RH-a) have a clinical influence, we studied three of these molecules: buserelin acetate (group B), triptorelin (group T), and leuprorelin (group L).

DESIGN

Clinical trial.

SETTING

In Vitro Fertilization (IVF) Center.

PATIENTS

Two hundred forty-six patients, undergoing their first IVF attempt, were randomly allocated to one group. The analogues were used in a long protocol for ovarian stimulation in an IVF program.

RESULTS

After 15 days of LH-RH-a therapy, the follicle-stimulating hormone level was lower in group B (2.9 +/- 1, 4.3 +/- 1.7, 4.8 +/- 2.1 UI/L for B, T, and L groups, respectively; P less than 0.001), although no difference was found in LH and estradiol (E2) levels. After follicular growth stimulation by human menopausal gonadotropins (hMG), E2 level was significantly lower in B group (1,799 +/- 1,101, 2,440 +/- 1,298, 2,137 +/- 1,044 pg/mL for B, T, and L groups, respectively; P less than 0.01), as well as the E2 level per hMG ampule (67 +/- 51, 97 +/- 61, 82 +/- 49 for B, T, and L groups respectively; P less than 0.01). The pregnancy per stimulated cycle rate was not significantly different among the groups.

CONCLUSIONS

These results suggest that LH-RH-a could act not only on the pituitary but also on the ovaries. Moreover, these data suggest that buserelin acetate could be preferentially used for high responders and triptorelin for poor responders.