Assessment of the role of serum luteinizing hormone and estradiol response to follicle-stimulating hormone on in vitro fertilization treatment outcome

More is not always better-lower estradiol to mature oocyte ratio improved IVF outcomes

AIM

To find a cut-off ratio of estradiol/metaphase II oocyte (E2/M2) ratio and to evaluate the correlation with patients' characteristics, embryo morphokinetics using EmbryoScope™ and IVF cycle outcomes.

MATERIAL AND METHODS

For this retrospective cohort study, records of all fresh cycles that were cultured and scored by EmbryoScope™ were evaluated. The peak E2/M2 ratio was calculated on the day of human chorionic gonadotropin (hCG) administration and correlated to embryo morphokinetic quality and cycle outcomes. A receiver operating characteristics analysis was calculated for the E2/M2 ratio and clinical pregnancy rates.

RESULTS

A total of 2461 oocytes were collected from 319 patients. Receiver operating characteristics analysis revealed a cutoff of 204 as a discriminative point to predict clinical pregnancy with a sensitivity of 69.5% and specificity of 62.1% (P < 0.001). E2/M2 > 204 group were older, had higher E2 concentration, fewer M2 oocytes despite elevated gonadotrophin doses. E2/M2 ratio ≤ 204 was correlated with higher fertilization rate, better embryo quality, higher pregnancy and live birth rates, and more frozen embryos.

CONCLUSION

E2/M2 ratio < 204 yielded the best probability to achieve good quality embryos with good morphokinetic scores and better pregnancy outcomes and may be used to predict IVF cycle outcomes. Advanced maternal age and low ovarian response received higher concentrations of gonadotrophins, which resulted in higher E2/M2 ratio. Milder stimulation to those patients may improve their cycle outcomes.

The effects of luteinising hormone gene polymorphism on the outcomes of in vitro fertilisation and embryo transfer

Trp8Arg polymorphism of the LH beta gene has decreased bioactivity in vivo and previous studies showed conflicting data on the effect of LH beta gene polymorphism on the IVF outcome. In this study, 591 IVF patients were recruited. Patients with the variant allele(s) were the carrier group. In GnRH antagonist cycles, the clinical pregnancy rate was significantly lower in the carrier group (18.9%) than in the noncarrier group (37.1%). In long GnRH agonist cycles, the clinical pregnancy rate was comparable between both groups. To clarify the effect of COH protocols, IVF outcomes in the GnRH antagonist and long GnRH agonist protocol groups in carriers were analysed. Among carriers, the clinical pregnancy rate was significantly lower in the GnRH antagonist protocol group (18.9%) than in the long GnRH agonist protocol group (45.2%). Single nucleotide polymorphism analysis may contribute to the individualisation of COH protocols for each patient in the future.Impact StatementWhat is already known on this subject? Trp8Arg polymorphism of the LH beta gene is known to have decreased bioactivity in vivo. Previous studies have demonstrated hypo-sensitivity in the patients with the variant LH beta protein, while other study showed similar carrier frequency between the poor and the normal response group.What the results of this study add? The variant LH beta gene was associated with a lower clinical pregnancy rate in GnRH antagonist cycles but not in long GnRH agonist cycles.What the implications are of these findings for clinical practice and/or further research? Single nucleotide polymorphism analysis may contribute to the individualisation of COH protocols for each patient in the future.

Can Ratios Between Prognostic Factors Predict the Clinical Pregnancy Rate in an IVF/ICSI Program with a GnRH Agonist-FSH/hMG Protocol? An Assessment of 2421 Embryo Transfers, and a Review of the Literature

None of the models developed in in vitro fertilization/intracytoplasmic sperm injection (IVF/ICSI) is sufficiently good predictors of pregnancy. The aim of this study was to determine whether ratios between prognostic factors could predict the clinical pregnancy rate in IVF/ICSI. We analyzed IVF/ICSI cycles (based on long GnRH agonist-FSH protocols) at two ART centers (the second to validate externally the data). The ratios studied were (i) the total FSH dose divided by the serum estradiol level on the hCG trigger day, (ii) the total FSH dose divided by the number of mature oocytes, (iii) the serum estradiol level on the trigger day divided by the number of mature oocytes, (iv) the serum estradiol level on the trigger day divided by the endometrial thickness on the trigger day, (v) the serum estradiol level on the trigger day divided by the number of mature oocytes and then by the number of grade 1 or 2 embryos obtained, and (vi) the serum estradiol level on the trigger day divided by the endometrial thickness on the trigger day and then by the number of grade 1 or 2 embryos obtained. The analysis covered 2421 IVF/ICSI cycles with an embryo transfer, leading to 753 clinical pregnancies (31.1% per transfer). Four ratios were significantly predictive in both centers; their discriminant power remained moderate (area under the receiver operating characteristic curve between 0.574 and 0.610). In contrast, the models' calibration was excellent (coefficients: 0.943-0.978; p < 0.001). Our ratios were no better than existing models in IVF/ICSI programs. In fact, a strongly discriminant predictive model will be probably never be obtained, given the many factors that influence the occurrence of a pregnancy.

Inhibin A-A Promising Predictive Parameter for Determination of Final Oocyte Maturation in Ovarian Stimulation for IVF/ICSI

The number of mature oocytes is a key factor in the success of Assisted Reproductive Techniques (ART). Exogenous gonadotropins are administered during ovarian stimulation in order to maximize the number of oocytes available for fertilization. During stimulation, monitoring is mandatory to evaluate individual response, to avoid treatment complications and assist in the determination of the optimal day for final oocyte maturation and oocyte retrieval. Routine monitoring during stimulation includes transvaginal ultrasound examinations and measurement of serum estradiol (E2). Due to multifollicular growth of follicles of varying size, serum E2 levels are commonly supraphysiological and often variable, rendering E2-measurement during ovarian stimulation unreliable as a determinant of oocyte maturity. In contrast to serum E2, serum Inhibin A levels increase once a minimum follicle size of 12-15 mm is achieved. Due to this fact, serum Inhibin A levels could present in combination with ultrasound monitoring a more reliable parameter to determine the optimal follicle size for final oocyte maturation, as only follicles with a size of 12 mm and beyond will contribute to the serum Inhibin A level. This prospective observational, cross-sectional study demonstrates, that on the day of final oocyte maturation serum Inhibin A is strongly correlated to the number of follicles ≥15 mm (0.72) and to the number of retrieved and mature oocytes (ρ 0.82/0.77, respectively), whereas serum E2 is moderately correlated to the parameters mentioned above (ρ 0.64/0.69/0.69, respectively). With an area under the curve (AUC) of 0.91 for Inhibin A, compared to an AUC of 0.84 for E2, Inhibin A can be regarded as a better predictor for the optimal timing of trigger medication with a threshold number of ≥10 mature oocytes. It can be concluded from this data that serum Inhibin A in combination with transvaginal ultrasound monitoring may be a more powerful tool in the decision making process on trigger timing as compared to E2.

GnRH antagonist versus follicular-phase single-dose GnRH agonist protocol in patients of normal ovarian responses during controlled ovarian stimulation

OBJECTIVE

This study aims to explore the differences of the ovarian stimulation (OS) characteristics, laboratory, and clinical outcomes between follicular-phase single-dose gonadotropin-releasing hormone (GnRH) agonist protocol and GnRH antagonist protocol during controlled ovarian hyperstimulation (COH).

METHODS

About 1883 consecutive IVF/ICSI fresh cycles of normal ovarian responders were retrospectively analyzed, with 1229 in the single-dose GnRH agonist protocol group and 654 in the GnRH antagonist protocol group at Reproductive Medical Center of Tongji Hospital from 1 January 2014 to 31 December 2017.

RESULTS

The follicular-phase single-dose GnRH agonist group showed significantly more oocytes obtained, higher implantation rate and pregnancy rate, as well as lower luteinizing hormone (LH) level and estradiol (E2)/oocyte ratio on the day of human chorionic gonadotropin (hCG) administration. However, differences were not significant in meiosis II (MII) oocyte rate, two pronuclear zygote (2PN) embryo rate, viable embryo rate or high-quality embryo rate, compared with the GnRH antagonist group. Further comparison of clinical outcomes in the first frozen-thawed cycles did not show significant difference in either implantation or clinical pregnancy rate between the two protocol groups.

CONCLUSIONS

Follicular-phase single-dose GnRH agonist protocol may achieve better clinical outcomes in normal ovarian responders, which could be explained more by positive effect on endometrial receptivity rather than embryo quality.

Luteal oestradiol for patients with serum oestradiol levels lower than expected per oocyte

Although the efficiency of progesterone in providing luteal phase support has been established, the role of oestradiol supplementation during the luteal phase remains controversial. We evaluated pregnancy outcomes of patients who had a ratio of serum E2 levels on the hCG day to the number of oocytes retrieved (oestradiol/oocyte ratio - EOR) levels of <100 pg/ml by supporting them with additional oestradiol during the luteal phase. In total, 150 patients with an EOR < 100 pg/ml of oestradiol undergoing antagonist intracytoplasmic sperm injection (ICSI) cycles were randomly assigned into two groups to receive either oral oestradiol (4 mg/d) plus vaginal progesterone (90 mg, 2 × 1/day) (group 1) or vaginal progesterone (90 mg, 2 × 1/d) alone (group 2). Implantation rate following transfer of a single embryo did not differ between the two groups (group 1 = 33.3%; group 2 = 34.9%; p = 0.85). Similarly, both groups gave comparable clinical pregnancy rates per embryo transfer with 31.7% in group 1 compared with 28.6% in group 2 (p = 0.69). In conclusion the study suggests that the addition of 4 mg oral E2 to progesterone does not increase the probability of pregnancy.

Soluble LH-HCG receptor and oestradiol as predictors of pregnancy and live birth in IVF

RESEARCH QUESTION

Circulating soluble LH-HCG receptor (sLHCGR) is a first-trimester marker for screening pregnancy pathologies and predicts premature or multiple births before fertility treatment. Oestradiol per oocyte at ovulation induction predicts IVF treatment outcomes. We asked whether sLHCGR levels are stable during fertility treatment and whether, alone or with oestradiol, they could improve prediction of fertility treatment outcomes.

DESIGN

Serum sLHCGR, anti-Müllerian hormone [AMH] and oestradiol were measured in patients undergoing IVF. Antral follicle count before ovarian stimulation and oocyte yield were used to establish sLHCGR- oocyte ratio (SOR), sLHCGR- antral follicle ratio (SAR), oestradiol at trigger per oocyte (oestradiol-oocyte ratio [EOR]) and oestradiol at trigger per antral follicle (oestradiol-antral follicle ratio [EAR]).

RESULTS

The relatively stable sLHCGR was negatively related to AMH when oocyte yield was high. The sLHCGR levels were proportional (r = 0.49) to oestradiol at early cycle (day-3). Pregnancy and live birth were highest at low sLHCGR (≤1.0 pmol/ml) and SOR (≤ 0.1 pmol/ml/oocyte). A total of 86-89% of live births in IVF treatment were within the cut-off parameters of SAR and SOR (0.5 pmol/ml) and EAR and EOR (380 pg/ml). For failed pregnancy, age, SOR and EOR together had positive and negative predictive values of 0.841 and 0.703, respectively.

CONCLUSIONS

sLHCGR levels are negatively related to AMH when oocyte yield is high. High early cycle sLHCGR is associated with elevated day-3 oestradiol. Low sLHCGR and SOR are indicators of increased clinical pregnancy and live birth rates. Patient age and SOR, combined with EOR, might improve prediction of IVF treatment outcomes.

Relationship between a low ratio of serum estradiol to follicle number and fertility treatment outcomes: A retrospective cohort study of 516 cases

The aim of this retrospective study was to examine how a low estradiol/follicle (E2/fol) may be related to in vitro fertilization/intracytoplasmic sperm injection (IVF/ICSI)-embryo transfer outcomes in polycystic ovary syndrome (PCOS) and non-PCOS patients, respectively. Between 2013 and 2017, 516 IVF/ICSI cycles (146 cycles in PCOS patients and 370 cycles in non-PCOS patients) with a long gonadotrophin releasing hormone receptor agonist protocol-including 338 involved fresh transfer cycles (89 cycles in PCOS patients and 249 cycles in non-PCOS patients)-were conducted. Outcomes were compared between 5 groups of PCOS patients defined by E2/fol (pg/mL) as follows: A, <140; B, 140 to 210; C, 210 to 280; D, 280 to 350; and E, >350. Non-PCOS patients' outcomes are grouped as well. Whether in PCOS or non-PCOS patients, those in the lowest E2/fol group (<140 pg/mL) tended to be younger, and with a greater body mass index (BMI) and antral follicle count (AFC), than the patients in the other groups. Relative to the other groups, Group A showed a lower number and rate of oocytes, higher single pronucleus (1PN) and triple pronucleus (3PN) formation rate, early and advanced abortion rates, but these did not differ significantly from those of the other groups, it perhaps due to the limited sample size. Group A have a higher incidence of moderate or severe ovarian hyperstimulation syndrome than the other groups in non-PCOS patients (P > .05). Whether in PCOS or non-PCOS patients, greater BMI, greater AFC, and younger age may favor the phenomenon of low E2/fol. In turn, low E2/fol may reduce the oocyte retrieval rate and increase the risk of 1PN and 3PN formation and abortion.

The serum estradiol/oocyte ratio in patients with breast cancer undergoing ovarian stimulation with letrozole and gonadotropins

Objective

To investigate the patterns of estradiol-oocyte ratio (EOR) and estradiol-mature oocyte ratio (EMOR) in patients with breast cancer undergoing controlled ovarian stimulation (COS) using letrozole and gonadotropins for fertility preservation.

Methods

This retrospective study included 32 breast cancer patients underwent COS for fertility preservation and no patients had previously undergone gonadotoxic treatments. Basal characteristics and in vitro fertilization (IVF) outcomes were compared according to the age of women (age <35 vs. age ≥35) and the starting phase of ovarian stimulation (early follicular phase vs. late follicular phase vs. luteal phase).

Results

Patients who were administered with a letrozole-combined regimen, the peak serum estradiol (E2) was maintained at a low level (386.3±346.9 pg/mL). EOR was 52.4±78.8 pg/mL, and EMOR was 71.0±41.2 pg/mL. When the 2 groups were compared according to the age of women (age <35 vs. age ≥35), EOR was 34.5 (22.2–46.5) pg/mL and 40.7 (19.3–65.3) pg/mL, respectively; EMOR was 79.8 (40.8–90.6) pg/mL and 68.8 (44.5–85.9) pg/mL, respectively. There was no significant difference in the IVF outcomes. When the 2 groups were compared according to the starting phase of ovarian stimulation, there were no significant differences in IVF outcomes, EOR and EMOR among the groups.

Conclusion

Measuring the peak E2 concentration in breast cancer patients undergoing IVF for fertility preservation with a co-treatment of letrozole allows for the prediction of the numbers of oocytes and mature oocytes.

Should we continue to measure endometrial thickness in modern-day medicine? The effect on live birth rates and birth weight

The evaluation of endometrial thickness (EMT) is still part of standard cycle monitoring during IVF, despite the lack of robust evidence of any value of this measurement to predict little revalidation in contemporary medical practice; other tools, however, such as endocrine profile monitoring, have become increasingly popular. The aim of this study was to reassess whether EMT affects the outcome of a fresh embryo transfer in modern-day medicine, using a retrospective, single-centre cohort of 3350 IVF cycles (2827 women) carried out between 2010 and 2014. In the multivariate regression analysis, EMT was non-linearly associated with live birth, with live birth rates being the lowest with an EMT less than 7.0 mm (21.6%; P < 0.001) and then between 7.0 mm and 9.0 mm (30.2%; P = 0.008). An EMT less than 7.0 mm was also associated with a decrease in neonatal birthweight z-scores (-0.40; 95% CI -0.69 to -0.12). In conclusion, these results reaffirm the use of EMT as a potential prognostic tool for live birth rates and neonatal birthweight in contemporary IVF, namely when considered together with other ovarian stimulation monitoring methods, such as the late-follicular endocrine profile.

Optimization of oestradiol assays to improve utility in an in vitro fertilization setting

Background The measurement of oestradiol is an integral component for the management of ovarian stimulation for in vitro fertilization. Automated immunoassays offer fast assay times and high throughput, with less sensitivity and specificity. The aim of this study is to optimize the oestradiol assay in patients undergoing ovarian stimulation for in vitro fertilization via comparison of oestradiol values obtained using two immunoassays compared with mass spectrometry. Methods Patients undergoing ovarian stimulation were prospectively recruited. Serum samples were analysed with ADVIA Centaur® CP Immunoassay, Abbott Architect i1000® immunoassay and AB Sciex 5500 liquid chromatography-tandem mass spectrometry (LC-MS/MS) systems. Per cent bias was determined for each system to report the average tendency of the values to be larger or smaller than the LC-MS/MS value. Linear regression of total follicular volume and oestradiol was computed. Results The ADVIA Centaur® CP assay had a positive bias of 20% compared with LC-MS/MS, while the Architect i1000® had a non-significant, negative bias of 0.3%. With regression fit, a clear, positive relationship was seen between follicular volume and oestradiol. The Architect i1000® assay had a greater correlation (R²= 0.46) compared with Centaur® CP (R²= 0.36), when oestradiol values were >1000 pg/mL (3670 pmol/L). Conclusions The Abbott Architect i1000® oestradiol assay exhibits greater agreement with LC-MS/MS and exhibited better correlation to follicular volume when oestradiol values are >1000 pg/mL (3670 pmol/L), prompting a change in the clinic's oestradiol platform. Attention to assay quality assurance via LC-MS/MS can improve the oestradiol accuracy and permit more informed clinical decisions for improved patient outcomes.

Serum estradiol:oocyte ratio as a predictor of reproductive outcome: an analysis of data from >9000 IVF cycles in the Republic of Ireland

PURPOSE

The purpose of this study was to evaluate the serum estradiol (E2) per oocyte ratio (EOR) as a function of selected embryology events and reproductive outcomes with IVF.

METHODS

This retrospective analysis included all IVF cycles where oocyte collection and fresh transfer occurred between January 2001 and November 2012 at a single institution. Patients were divided by three age groups (<35, 35-39, and ≥40 years) and further stratified into nine groups based on EOR (measured in pmol/L/oocyte). Terminal serum E2 (pmol/mL) was recorded on day of hCG trigger administration, and fertilization rate, cleavage rate, number of good quality embryos, and reproductive outcomes were recorded for each IVF cycle.

RESULTS

During the study interval, 9109 oocyte retrievals were performed for 5499 IVF patients (mean = 1.7 cycles/patient). A total of 63.4 % of transfers were performed on day 3 (n = 4926), while 36.6 % were carried out on day 5 (n = 2843). Clinical pregnancy rates were highest in patients with EOR of 250-750 and declined as this ratio increased, independent of patient age. While the odds ratio (OR) for clinical pregnancy where EOR = 250-750 vs. EOR > 1500 was 3.4 (p < 0.001; 95 % CI 2.67-4.34), no statistically significant correlation was seen in fertilization, cleavage rates or number of good quality embryos as a function of EOR.

CONCLUSIONS

Predicting reproductive outcomes with IVF has great utility both for patients and providers. The former have the opportunity to build realistic expectations, and the latter are better able to counsel according to measured clinical parameters. A better understanding of follicular dynamics and ovarian response to gonadotropin stimulation could optimize IVF treatments going forward.

Luteinizing hormone and human chorionic gonadotropin: a review of their varied clinical applications in assisted reproductive technology

Luteinizing hormone (LH) and human chorionic gonadotropin (hCG) are often viewed as interchangeable from a functional standpoint because they are highly homologous members of the same glycoprotein hormone family that share a common α-subunit and receptor. However, technological advances yielding highly purified and recombinant gonadotropin preparations have revealed that LH and hCG fulfill different roles, both endogenously and when administered exogenously. These differences are becoming more apparent as the individual hormones are incorporated into the treatment of infertility - a therapeutic area that is continually advancing with the introduction of new agents and emerging clinical trial data. This review examines the unique attributes of LH and hCG that drive their distinctive applications in the treatment of female infertility.

Adding serum estradiol measurements to ultrasound monitoring does not change the yield of mature oocytes in IVF/ICSI

In a non-randomized, comparative prospective study (416 patients) we compared the outcome of IVF/ICSI in two parallel control groups: one in which patients were followed up using combined monitoring (ultrasound plus serum estradiol monitoring, the UHM group) and one in which only ultrasound monitoring was used (the UM group). This study has taken the number of mature oocytes at the moment of egg retrieval as its primary end variable. After adjustment for age, gravidity, antagonist protocol, AMH and infertility diagnosis, the average difference in number of mature oocytes between the UHM group and the UM group was -0.4 (95% CI: -1.7 to 1.0), which met our definition of clinical equivalence (95% CI for the adjusted mean difference between -2 and 2). Larger studies are still needed to evaluate the differences in the live birth rates per cycle and to further confirm that blood sampling definitively has no added value in monitoring ovarian stimulation for IVF/ICSI.

Gonadotropin therapy in assisted reproduction: an evolutionary perspective from biologics to biotech

Gonadotropin therapy plays an integral role in ovarian stimulation for infertility treatments. Efforts have been made over the last century to improve gonadotropin preparations. Undoubtedly, current gonadotropins have better quality and safety profiles as well as clinical efficacy than earlier ones. A major achievement has been introducing recombinant technology in the manufacturing processes for follicle-stimulating hormone, luteinizing hormone, and human chorionic gonadotropin. Recombinant gonadotropins are purer than urine-derived gonadotropins, and incorporating vial filling by mass virtually eliminated batch-to-batch variations and enabled accurate dosing. Recombinant and fill-by-mass technologies have been the driving forces for launching of prefilled pen devices for more patient-friendly ovarian stimulation. The most recent developments include the fixed combination of follitropin alfa + lutropin alfa, long-acting FSH gonadotropin, and a new family of prefilled pen injector devices for administration of recombinant gonadotropins. The next step would be the production of orally bioactive molecules with selective follicle-stimulating hormone and luteinizing hormone activity.

A decrease in serum estradiol levels after human chorionic gonadotrophin administration predicts significantly lower clinical pregnancy and live birth rates in in vitro fertilization cycles

BACKGROUND

Although close observation of serum estradiol (E2) levels remains a mainstay of assessing clinical response to controlled ovarian stimulation, the prognostic value of any change in E2 levels after administration of hCG remains unclear. The objective of this study is to evaluate the relationship between serum E2 response after hCG administration and the clinical pregnancy and live birth rates in fresh IVF cycles.

METHODS

We conducted a retrospective cohort study of women aged 21-45 years undergoing their first IVF cycle from 1999 to 2008 at a single practice. We compared the post-hCG serum E2 level with values on the day of hCG trigger. IVF cycles were stratified by post-hCG E2 response and appropriate parametric and non-parametric statistics were performed. Clinical intrauterine pregnancy and live births were the primary outcomes of interest. Multivariable logistic regression models were created to identify predictive factors associated with outcomes while adjusting for potential confounders.

RESULTS

Among the 1712 IVF cycles, 1065 exhibited a >10% increase (Group A), 525 had a plateau (± 10%, Group B) and 122 showed a >10% decrease (Group C) in post-hCG E2 levels. While the E2 levels on the day of hCG were similar across groups, Group C had more patients with diminished ovarian reserve, required higher gonadotrophin doses and had the lowest implantation rates. After adjusting for age, total gonadotrophin dose, infertility diagnosis, number of oocytes and number of transferred embryos, the associations between post-hCG E2 decline (Group C) and clinical pregnancy [adjusted odds ratio (aOR): 0.53; 95% confidence interval (CI): 0.33-0.84, P= 0.007] and live birth (aOR: 0.40; 95% CI: 0.22-0.71, P= 0.002) were significant. We also found significant associations between E2 plateau (Group B) and clinical pregnancy (aOR: 0.73; 95% CI: 0.57-0.94, P= 0.013) and live birth (aOR: 0.74; 95% CI: 0.56-0.97, P= 0.032) when adjusting for the same factors.

CONCLUSIONS

In our study, >10% decrease in E2 levels after hCG administration was associated with 40-50% reduction in clinical pregnancy and live birth rates. Similarly, post-hCG E2 plateau (± 10%) lowered the clinical pregnancy and live birth rates by >25%. Our study suggests that the change in the post-hCG E2 level is another parameter that can be used by clinicians to counsel patients regarding their likelihood of success with assisted reproductive technologies prior to oocyte retrieval.

Monitoring stimulated cycles during in vitro fertilization treatment with ultrasound only--preliminary results

OBJECTIVE

To evaluate if monitoring patients by ultrasound (US) only during in vitro fertilization (IVF) treatment is safe.

DESIGN

Randomized prospective study.

INTERVENTION

Patients undergoing their first IVF treatment were randomized into two groups. The ultrasound only group (study group) was monitored by US for follicle size and endometrial thickness without blood tests. In this group, only one blood test was taken before human chorionic gonadotropin (hCG) injection, to ensure a safe level of estradiol (E(2)) regarding ovarian hyperstimulation syndrome (OHSS) risk. The control group was monitored by ultrasound plus serum estradiol and progesterone concentration at each visit.

MAIN OUTCOME MEASURE

Clinical pregnancy rate.

RESULTS

No differences were found between the groups in the parameters of IVF treatment, induction days, number of ampoules, E(2) level of hCG, as well as embryo quality. The clinical pregnancy rate was not statistically different between the groups, 57.5% vs. 40.0%, respectively (p = 0.25). No OHSS cases were found among the study or control groups.

CONCLUSION

Ultrasound as a single monitoring tool for IVF cycles is reliable, safe, patient friendly, and reduces treatment expenses. In an era of cost effectiveness awareness, this regimen should be considered for routine management in IVF programs.

Recombinant human LH supplementation versus supplementation with urinary hCG-based LH activity during controlled ovarian stimulation in the long GnRH-agonist protocol: a matched case-control study

An observational, matched, case-control study was carried out to compare the efficacy of recombinant human luteinizing hormone (r-hLH) supplementation with that of urinary human menopausal gonadotrophin (u-hMG)-based LH activity during controlled ovarian stimulation (COS) for assisted reproductive technology (ART) using a long gonadotrophin-releasing hormone (GnRH)-agonist protocol. A total of 4719 women, 1573 per group, matched by age, body mass index, indication and number of previous ART cycles, were treated with either recombinant human follicle-stimulating hormone (r-hFSH) and r-hLH in a fixed 2:1 ratio or u-hMG, either alone or in combination with r-hFSH, after down-regulation in a long GnRH-agonist protocol. Compared with the two u-hMG groups (u-hMG alone or in combination with r-hFSH, respectively), r-hFSH consumption was significantly lower (p < 0.001; p < 0.001), and pregnancy rates per cycle (p = 0.006; p = 0.022) and per embryo transfer (p = 0.025; p = 0.008), and implantation rate per embryo transferred (p < 0.001; p < 0.001) were significantly higher in the group treated with the fixed combination of r-hFSH and r-hLH. In COS protocols with r-hFSH, supplementation with r-hLH appears to be more effective than supplementation with u-hMG using the long GnRH-agonist protocol for ART.

Relationship between the oestradiol/oocyte ratio and the outcome of assisted reproductive technology cycles with gonadotropin releasing hormone agonist

The aim of this study was to evaluate the relationship of oestradiol level on the day of hCG (peak E2)/oocyte ratio and the outcome of ART cycles. Of the patients who underwent IVF-ET, 600 normal and high responders to the first cycle of COH with gonadotropin releasing hormone (GnRH)-agonist were included in the study. Patients were designated into three groups based on peak E2/oocyte ratio (Group A: <100 pg/ml per oocyte, Group B: 100-200 pg/ml per oocyte, Group C: >200 pg/ml per oocyte). A comparison among groups was made regarding ovarian stimulation characteristics, fertilisation, implantation and pregnancy rates. After the division based on E2/oocyte ratio, in Group C, the number of oocytes retrieved, 2PN and M2 oocyte were statistically lower than both of the other two groups (p = 0.001, 0.001, 0.001, 0.045). HCG day E2 level was significantly different in all groups (p = 0.001), and fertilisation rate was meaningfully highest in Group C and lowest in Group A (p = 0.001). No difference existed among the three groups with respect to the number of embryos transferred and implantation rates. However, clinical pregnancy rate was significantly lower in Group A than others (p = 0.04). In ART cycles suppressed by GnRH-agonist, IVF outcomes are lower in patients with an E2/oocyte proportion of <100 pg/ml per oocyte.

Can serum oestradiol be a predictor of quality of oocytes and embryos, maturation of oocytes and pregnancy rate in ICSI cycles?

Our aim was to assess the influence of ratios of oestradiol (E2) to either number of follicles ≥ 14 mm on the day of human chorionic gonadotropin administration (E2/fol) or the number of oocytes retrieved (E2/o) during oocyte pick up and total serum E2 levels on the day of embryo transfer (ETE2) on the outcome of ICSI cycles. The assessed outcomes were number of oocytes retrieved (NRO), number of mature oocytes (NMO), number of fertilised oocytes (NFO), number of transferred embryos (NTE), qualities of oocytes (OQS), qualities of embryos (EQS) and pregnancy rates (PR). Two hundred and twenty-seven ICSI-ET cycles admitted to our IVF clinic during a 2-year period with normal ovarian reserve receiving long luteal GnRH agonist protocol were included. The E2/fol levels correlated positively with NRO (r = 0.202, p = 0.002), NMO (r = 0.199, p = 0.003) and NFO (r = 0.159, p = 0.018). However, we observed negative correlations between E2/o and NMO (r = -0.329, p <0.001), NFO (r = -0.219, p = 0.001), EQ5 (r = -0.203, p = 0.040). Oocyte quality scores were not affected from either E2/fol or E2/o levels. Implantation, clinical and ongoing PRs were comparable between groups categorised due to E2/fol, E2/o and ETE2. It seems that high E2/fol ratio may have beneficial effects on NRO, NMO and NFO while E2/o may adversely affect these parameters. Neither of the E2 levels is associated with pregnancy rates in women with normal ovarian reserve.

Urinary bisphenol A concentrations and ovarian response among women undergoing IVF

Bisphenol A (BPA) is a synthetic chemical used in the manufacture of materials present in many common consumer products. In experimental animals, BPA caused oocyte aneuploidy and reduced production of oestradiol. In a prospective cohort study, we investigated the association between urinary BPA concentrations and ovarian response among women undergoing in vitro fertilization (IVF) at the Massachusetts General Hospital (MGH) Fertility Center. The geometric mean of two specific-gravity (SG) adjusted urinary BPA concentrations collected during each IVF cycle was used as the cycle-specific BPA exposure level. BPA concentrations were measured using online solid phase extraction coupled to isotope dilution-high-performance liquid chromatography-tandem mass spectrometry. Peak serum oestradiol was measured using the Elecsys Estradiol II immunoassay kit. Multivariable mixed effect models and Poisson regression models adjusting for correlation between multiple IVF cycles in the same woman were used to evaluate the association between urinary BPA concentrations and ovarian response, adjusting for age, BMI and day 3 follicle stimulating hormone (FSH) levels, a clinical measure of ovarian reserve. Urinary BPA concentrations were measured in 84 women (mean age 35.6 years) undergoing 112 IVF cycles; 23 women (27%) contributed more than one IVF cycle. BPA concentrations ranged from <0.4 to 25.5 microg/L (geometric mean 2.52 +/- SD 3.2); 15% of urine samples had concentrations <0.4 microg/L. Peak serum oestradiol levels correlated with the total number of oocytes retrieved per cycle (r = 0.65, p < 0.001). For each log unit increase in SG-BPA, there was an average decrease of 12% (95% CI: 4, 23%; p = 0.007) in the number of oocytes retrieved and an average decrease of 213 pg/ml (95% CI: -407, -20; p = 0.03) in peak oestradiol. BPA was detected in the urine of the majority of women undergoing IVF, and was inversely associated with number of oocytes retrieved and peak oestradiol levels.

"hCG priming" effect in controlled ovarian stimulation through a long protocol

BACKGROUND

Recently, it has been demonstrated that, in patients down-regulated by GnRH analogues (GnRHa), a short-term pre-treatment with recombinant LH (rLH), prior to recombinant FSH (rFSH) administration, increases the number of small antral follicle prior to FSH stimulation and the yield of normally fertilized embryos. However, no data exist in the literature regarding the potential beneficial effect of "hCG priming" in controlled ovarian hyperstimulation (COH) through a long GnRH-a protocol, which binds the same receptor (LH/hCGR), though it is a much more potent compared to LH. The primary aims of this study were to assess the effect of short-term pre-rFSH administration of hCG in women entering an ICSI treatment cycle on follicular development, quality of oocytes and early embryo development. The secondary endpoints were to record the effects on endometrial quality and pregnancy rate.

METHODS

Patients with a history of at least one previous unsuccessful ICSI cycle were randomly assigned into two groups to receive treatment with either a long protocol with rFSH (control group) or a long protocol with rFSH and pre-treatment with hCG (hCG group). In particular, in the latter group, a fixed 7 days course of 200 IU/day hCG was administered as soon as pituitary desensitization was confirmed.

RESULTS

The mean number of oocytes retrieved was not significantly different between the two treatment groups, although the percentage of mature oocytes tended to be higher but not significantly different in hCG-treated patients. The percentage of patients with more than one grade 3 embryos was higher in the pre-treatment group, which also showed a higher pregnancy rate.

CONCLUSION

All the above clinical observations, in conjunction with previous data, suggest a point towards a beneficial "hCG priming" effect in controlled ovarian hyperstimulation through a long GnRH-a down-regulation protocol, particularly in patients with previous ART failures.

Lutropin alpha, recombinant human luteinizing hormone, for the stimulation of follicular development in profoundly LH-deficient hypogonadotropic hypogonadal women: a review

Hypogonadotropic hypogonadism is defined as a medical condition with low or undetectable gonadotropin secretion, associated with a complete arrest of follicular growth and very low estradiol. The main cause can be traced back to an irregular or absent hypothalamic GnRH secretion, whereas only a minority suffers from a pituitary disorder. The choice of treatment to reverse this situation is a pulsatile GnRH application or a direct ovarian stimulation using gonadotropin injections. The goal is to achieve a proper ovarian function in these cases for a short time to allow ovulation and chance of pregnancy. Since the pulsatile GnRH treatment lost its former importance, several gonadotropins are in use to stimulate follicular growth, such as urine-derived human menopausal gonadotropin, highly purified follicle stimulating hormone (FSH) or recombinant FSH, all with different success. The introduction of recombinant luteinizing hormone (LH) and FSH provided an opportunity to investigate the distinct influences of LH and FSH alone and in combination on follicular growth in monofollicular ovulation induction cycles, and additionally on oocyte maturation, fertilization competence of the oocyte and embryo quality in downregulated IVF patients. Whereas FSH was known to be indispensable for normal follicular growth, the role of LH remained questionable. Downregulated IVF patients with this short-term gonadotropin depletion displayed no advance in stimulation success with the use of recombinant LH. Patients with hypogonadotropic hypogonadism undergoing monofollicular stimulation for ovulation induction showed clearly a specific role and need for both hormones in normal follicular growth. Therefore, a combined stimulation with FSH and LH seems to be the best treatment choice. In the first half of the stimulation cycle the FSH dosage should exceed that of LH by 2:1, with an inverse ratio for the second half.

Effects of recombinant LH supplementation to recombinant FSH during induced ovarian stimulation in the GnRH-agonist protocol: a matched case-control study

BACKGROUND

Some studies have suggested that the suppression of endogenous LH secretion does not seem to affect the majority of patients who are undergoing assisted reproduction and stimulation with recombinant FSH (r-FSH). Other studies have indicated that a group of normogonadotrophic women down-regulated and stimulated with pure FSH preparations may experience low LH concentrations that compromise the IVF parameters. The present study aimed to compare the efficacy of recombinant LH (r-LH) supplementation for controlled ovarian stimulation in r-FSH and GnRH-agonist (GnRH-a) protocol in ICSI cycles.

METHODS

A total of 244 patients without ovulatory dysfunction, aged <40 years and at the first ICSI cycle were divided into two groups matched by age according to an ovarian stimulation scheme: Group I (n = 122): Down-regulation with GnRH-a + r-FSH and Group II (n = 122): Down-regulation with GnRH-a + r-FSH and r-LH (beginning simultaneously).

RESULT(S)

The number of oocytes collected, the number of oocytes in metaphase II and fertilization rate were significantly lower in the Group I than in Group II (P = 0.036, P = 0.0014 and P = 0.017, respectively). In addition, the mean number of embryos produced per cycle and the mean number of frozen embryos per cycle were statistically lower (P = 0.0092 and P = 0.0008, respectively) in Group I than in Group II. Finally the cumulative implantation rate (fresh+thaw ed embryos) was significantly lower (P = 0.04) in Group I than in Group II. The other clinical and laboratory results analyzed did not show difference between groups.

CONCLUSION

These data support r-LH supplementation in ovarian stimulation protocols with r-FSH and GnRH-a for assisted reproduction treatment.

Recombinant LH (lutropin alfa) for the treatment of hypogonadotrophic women with profound LH deficiency: a randomized, double-blind, placebo-controlled, proof-of-efficacy study

OBJECTIVE

To confirm the safety and efficacy of 75 IU lutropin alfa with concomitant follitropin alfa in inducing follicular development in women with profound gonadotrophin deficiency.

DESIGN

Double-blind, randomized, placebo-controlled trial conducted in 25 medical centres in four countries.

PATIENTS

Thirty-nine patients with LH < 1.2 IU/l and FSH < 5.0 IU/l were treated with concomitant 75 IU lutropin alfa and 150 IU follitropin alfa or concomitant placebo and 150 IU follitropin alfa.

MEASUREMENTS

Primary efficacy end-point (intent-to-treat): follicular development defined by (i) at least one follicle >or= 17 mm; (ii) serum E(2) level >or= 400 pmol/l on day of hCG administration (DhCG); and (iii) mid-luteal phase progesterone level >or= 25 nmol/l.

RESULTS

In the analysis of evaluable patients, 66.7% (16 of 24) of patients given lutropin alfa achieved follicular development compared with 20.0% (2 of 10) of patients receiving placebo (P = 0.023). In the intent-to-treat analysis, follicular development was achieved in 65.4% (17 of 26) of patients receiving lutropin alfa and 15.4% (2 of 13) of patients receiving placebo (P = 0.006). The statistical difference between treatment groups was preserved when over-response leading to cycle cancellation was analysed as a failed response (P = 0.034). Lutropin alfa was well tolerated.

CONCLUSION

Subcutaneous co-administration of 75 IU lutropin alfa with follitropin alfa is safe and effective in inducing follicular development in women with profound gonadotrophin deficiency.

The particular problems of ambulatory controlled ovarian stimulation

The impact of infertility treatments on the frequency of multiple pregnancies in France was investigated using data on total multiple deliveries and multiple deliveries from assisted reproduction and intrauterine insemination (IUI) between 1994 and 2004, and by making assumptions about the expected rate of natural multiple deliveries. During this period, 72.0% of multiple deliveries were the result of infertility treatments. The rate of triplet delivery after assisted reproduction decreased by 50% between 2000 and 2004, despite a large increase in deliveries resulting from assisted reproduction. In 2004, assisted reproduction techniques accounted for 23.6% of all triplets delivered and for 34.9% of those delivered after infertility treatments. The corresponding figures for IUI were 12.2% and 18.0% respectively, with a doubling since 1996; for ovulation induction without IUI the corresponding figures were 27.7% and 37.9% respectively. The figures for ovulation induction are slightly higher than for assisted reproduction treatment, probably due to the high number of quadruplets and higher order deliveries in this group. However, no conclusion can be drawn on the relative contribution of increased risk for a given ovarian stimulation cycle on one hand and of a simple increase in the number of treated cycles on the other, since no surveillance data to distinguish between them exists in France. There is a real need for more investigation on ovulation induction in France.

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.

Efficacy of a combined protocol of urinary and recombinant follicle-stimulating hormone used for ovarian stimulation of patients undergoing ICSI cycle

PURPOSE

To evaluate the efficacy of using both urinary and recombinant FSH in a combined protocol for ovarian stimulation in an IVF treatment program.

METHOD

A total of 119 infertile couples undergoing ICSI treatment were randomized prospectively in this study. After a standard down-regulation with GnRH analogue, the patients were randomized in 2 groups 58 received combined urinary and recombinant FSH, starting with uFSH and then rFSH, and 61 controls received only recombinant FSH.

RESULT(S)

Pregnancy and implantation rates were significantly higher in the combined uFSH/rFSH group than the control (rFSH) group (43.9% vs 22.1% and 27.5% vs 13.2% respectively). Metaphase II oocyte and grade 1 embryos were significantly higher in favour of combined uFSH/rFSH group than the recombinant FSH group.

CONCLUSION(S)

This study shows that using a combination of both urinary and recombinant FSH for ovarian stimulation improves oocyte maturity and embryo cleavage, and increases pregnancy and implantation rates.

Does measuring early basal serum follicular luteinising [correction of lutinising] hormone assist in predicting in vitro fertilization (IVF)/intracytoplasmic sperm injection (ICSI) outcome?

BACKGROUND

The aim was to examine the correlation of early follicular serum lutinising hormone (LH) and the clinical outcome of assisted reproduction technique (ART).

METHODS

An observational study included 1333 consecutive women undergoing in vitro fertilization (IVF) and intracytoplasmic sperm injection (ICSI). 964 women were having their first cycle of ART. Data were entered prospectively. All women had serum LH measured in the 6 months before the index cycle studied. No repeat cycles were included. The main outcomes measured were clinical pregnancy (CP) and live birth (LB) correlation to serum LH. Forward multivariate stepwise regression analysis was applied, and other statistical tests were used as appropriate.

RESULTS

There was non significant correlation between basal serum LH and CP and LB in the polycystic ovary syndrome group (R2 = 0.02, F = 1.7 and P = 0.76) (R2 = 0.01, F = 2.6 and P = 0.77) respectively after adjusting for age, BMI, day of oocyte retrieval, starting dose, total dose of stimulation, type of gonadotrophin used, number of oocytes retrieved, fertilization rate and number of embryos transferred. Other aetiological causes group there was similarly non significant correlation between basal serum LH and CP (R2 = 0.05, F = 13.1 and P = 0.66), nor for LB (R2 = 0.007, F = 4.5 and P = 0.9).

CONCLUSION

Early follicular serum LH measurements in the 6 months before IVF/ICSI treatment cycle did not correlate with the clinical pregnancy or the live birth rate.

Ovarian response and pregnancy outcome in poor-responder women: a randomized controlled trial on the effect of luteinizing hormone supplementation on in vitro fertilization cycles

OBJECTIVE

To prospectively assess the effect of using a combination of recombinant follicle-stimulating hormone (rFSH) and recombinant luteinizing hormone (rLH) on ovarian stimulation parameters and treatment outcome among poor-responder patients.

DESIGN

Prospective randomized trial.

SETTING

University-associated private medical center.

PATIENT(S)

Eighty-four patients who had a basal FSH level of >or=10 mIU/mL, who were >or=40 years of age, and who were undergoing their first IVF cycle participated in this controlled trial.

INTERVENTION(S)

Patients were randomly allocated into two study groups: group A, in which ovarian stimulation included GnRH analogue and rFSH and rLH, and group B, in which patients received GnRH analogue and rFSH without further LH addition.

MAIN OUTCOME MEASURE(S)

Primary outcome measures included the ongoing pregnancy rate per retrieval and implantation rate per embryo transferred. The number of days of gonadotropin treatment, E(2) level on rHCG administration day, number of developed follicles, number of retrieved oocytes, number of normally fertilized zygotes (at the two-pronuclear [2PN] stage), cumulative embryo score, and number of transferred embryos were also evaluated.

RESULT(S)

The overall pregnancy rate was 22.61% (19 pregnancies among 84 couples). The pregnancy wastage rate was 30.00% in group A and 22.22% in group B. There were no differences in either primary or secondary end points.

CONCLUSION(S)

The results of this prospective and randomized trial show that the addition of rLH at a given time of follicular development produces no further benefit in the patient population of our study. A reduced ovarian response cannot be overcome by changes in the stimulation protocol.

[Management of an ovarian stimulation in case of a Kallmann-De Morsier syndrome. The role of LH]

We report a case of ovarian stimulation in a woman with a Kallmann-De Morsier syndrome, which resulted in a triple pregnancy and childbirth by caesarean section at 36 weeks of amenorrhea of three girls weighing from 1,950 to 2,300 g. Starting from a literature review of Kallmann-De Morsier syndrome, we discuss the role of LH during the follicular phase and the monitoring of ovarian stimulation.

Single-dose depot leuprolide is as efficient as daily short-acting leuprolide in ICSI cycles

BACKGROUND

In this prospective randomized study, we aimed to compare the efficacy of a single depot (1.88 mg) reduced dose with a daily low dose (0.5 mg/day) of leuprolide for pituitary suppression as part of controlled ovarian hyperstimulation (COH) in an ICSI program.

METHODS

The study population consisted of 103 patients randomized into two groups. Group 1 (n = 52) consisted of patients who had daily low-dose leuprolide injections. Group 2 (n = 51) consisted of patients who had the 1.88 mg single-dose leuprolide injection.

RESULTS

The age of the patients, the number of metaphase II oocytes, the number and quality of embryos transferred were similar between the two groups. Although the length of gonadotrophin stimulation was significantly longer in group 2 (P < 0.01), the amount of gonadotrophins used was similar (P = 0.34). Leuprolide levels were significantly lower in group 2 within the first 8 h after injection (P < 0.05), but no difference was observed thereafter. Although LH levels on the day of hCG (P = 0.06) administration and estradiol levels on day 3 (P < 0.01) were lower in group 2, LH levels and progesterone levels 1 week after embryo transfer did not show any statistically significant difference. Clinical pregnancy rates per embryo transfer, implantation rates and first trimester abortion rates were also similar for both groups.

CONCLUSIONS

A single reduced depot dose (1.88 mg) of leuprolide was found to be as effective as classical long multi-dose protocol for pituitary desensitization in COH for ICSI cycles.

High Serum Estradiol Levels are not Detrimental to In Vitro Fertilization Outcome

OBJECTIVE

To evaluate the impact of high estradiol (E2) levels and a high number of retrieved oocytes on the outcome of in vitro fertilization (IVF) cycles.

MATERIALS AND METHODS

We retrospectively reviewed 274 IVF cycles. These patients were divided into five groups according to their peak E2 levels on the human chorionic gonadotropin day: < or = 2,000 pg/mL (130 cycles); 2,001-3,000 pg/mL (53 cycles); 3,001-4,000 pg/mL (46 cycles); 4,001-5,000 pg/mL (29 cycles); > 5,000 pg/mL (16 cycles). Fertilization, pregnancy, and implantation rates were analyzed between these groups. We also compared the outcome of IVF for high responders (> 15 retrieved oocytes) and normal responders (< or = 15 retrieved oocytes).

RESULTS

The oocyte fertilization and embryo cleavage rates were not significantly different among these five groups. Although decrease in pregnancy and implantation rates was observed when E2 levels were > 5,000 pg/mL compared with those having lower E2 levels, there were no statistically significant differences between these five groups. In addition, similar IVF outcome was detected for those cycles with > 15 oocytes and < or = 15 oocytes obtained.

CONCLUSION

High serum E2 levels and high oocyte yield are not detrimental to IVF outcome. More studies are needed to characterize the threshold E2 levels above which implantation rates are reduced.

The influence of estradiol/follicle and estradiol/oocyte ratios on the outcome of controlled ovarian stimulation for in vitro fertilization

OBJECTIVE

The aim of the study was to evaluate the influence of the ratios of estradiol (E2) to either the number of follicles >14 mm on the day of human chorionic gonadotropin administration (E2/follicle) or the number of oocytes retrieved (E2/oocytes) during controlled ovarian hyperstimulation (COH) with gonadotropin-releasing hormone (GnRH)-agonist (agonist group) and GnRH-antagonist (antagonist group), on the outcome of in vitro fertilization (IVF) cycles.

PATIENTS AND METHODS

All consecutive women aged <35 years admitted to our IVF unit during a 6-year period with normal to high response to COH were retrospectively studied. Ovarian stimulation characteristics, number of oocytes retrieved, number of embryos transferred and pregnancy rate were assessed.

RESULTS

Six hundred and ninety consecutive IVF cycles were evaluated, 301 in the agonist group and 389 in the antagonist group. The ratios of E2/follicle and E2/oocyte were significantly higher in the agonist group (p < 0.001 for both). Moreover, while pregnancy rates within E2/oocyte ratio of 100-200 pg/ml were comparable between the agonist and antagonist groups, when E2/oocyte ratios were <100 pg/ml or >200 pg/ml, pregnancy rates were significantly higher in the agonist group. Furthermore, no difference in pregnancy rates was observed within the agonist group between different E2/oocytes ratios, while within the antagonist group, higher pregnancy rates were observed when comparing those with E2/oocyte ratio of 100-200 pg/ml with those with E2/oocyte ratio <100 pg/ml or >200 pg/ml.

CONCLUSION

While E2/oocyte ratio cannot predict the success of GnRH-agonist protocol, patients undergoing GnRH-antagonist protocol should reach E2/oocyte ratio within the 100-200 pg/ml range in order to achieve the best IVF outcome.

Effect of a sharp serum oestradiol fall before HCG administration during ovarian stimulation in donors

The current study evaluated how a sudden fall in serum oestradiol during ovarian stimulation in donors affects recipient outcome. After the assessment of pregnancy rate in cases of oestradiol falls of <10 or > or =10% (57.0 versus 45.6%), <20 or > or = 20% (55.2 versus 44.9%), <25 or > or =25% (57.2 versus 41.2%), and < 30 or > or =30% (57.1 versus 32.0%; P < 0.05), a significantly lower pregnancy rate was observed when the fall was > or =30%. Therefore, the study group (n = 25) included recipients who received oocytes from donors with a fall of > or =30%, and the control group included patients (n = 197) in which the fall in oestradiol was <30% and all cases with no fall in oestradiol concentrations. Pregnancy rates in both groups were 32.0 versus 57.1%; P < 0.05. The number of morphologically normal oocytes was similar (14.2 versus 18.1%) and good quality embryos was lower (8.0 versus 21.0%; P < 0.05) for study group. This seems related to a lower capability of the embryos to implant (15.2 versus 37.4%; P < 0.001). These data indicate that a fall of > or =30% in serum oestradiol concentration during ovarian stimulation in donors negatively affects pregnancy rates and embryo quality in recipients. In these cases, cycle cancellation should be considered.

Estradiol production during controlled ovarian hyperstimulation correlates with treatment outcome in women undergoing in vitro fertilization–embryo transfer

OBJECTIVE

To study the value of E(2) production during controlled ovarian hyperstimulation (COH) in predicting IVF-ET outcome.

DESIGN

Historical cohort.

SETTING

Academic infertility center.

PATIENT(S)

A cohort of 270 patients who completed 324 consecutive IVF-ET treatment cycles.

INTERVENTION(S)

None.

MAIN OUTCOME MEASURE(S)

Area under the curve for E(2) levels (AUC-E(2)) from the first day of COH until the day of hCG administration was calculated and cycles grouped into low, average, and high AUC-E(2) groups. Clinical pregnancy rates per cycle were compared among the three groups, and correlations with AUC-E(2) values were calculated for all patients and after sub-grouping according to age, COH protocol and infertility diagnosis.

RESULT(S)

Cycles with low and high AUC-E(2) values had significantly lower pregnancy rates particularly in patients 35 years or older. There was a positive correlation between AUC-E(2) and pregnancy rates up to a certain AUC-E(2) level above which a negative correlation was found. The turning point between positive and negative correlations occurred at a significantly lower AUC-E(2) level in patients 35 years or older.

CONCLUSIONS

Estradiol production during COH correlates with IVF-ET outcome. Women >35 years of age seem more vulnerable to high E(2) levels.

Pharmacogenetics in ovarian stimulation - current concepts and future options

Tailoring ovarian stimulation to the individual patient can be challenging because the ovarian response varies substantially between patients. Pharmacogenetics has emerged as a new area of research to improve the balance between desired and undesired actions of drugs, based upon the genetic predisposition of the individual patient. Clinical studies have demonstrated that the p.N680S polymorphism of the FSH-receptor gene determines the ovarian response to FSH stimulation in patients undergoing IVF. In homozygous Ser(680)/Ser(680) type women, the FSH receptor appears to be more resistant to FSH action even in normal menstrual cycles. Therefore, genotyping of patients scheduled for ovarian stimulation could be an attractive tool to individualize FSH dosing according to genetic differences in ovarian sensitivity. More clinical studies are warranted to investigate the usefulness of genotyping for the p.N680S polymorphism as a routine diagnostic test before ovarian stimulation.

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.

Differences in serum LH and FSH levels using depot or daily GnRH agonists in controlled ovarian stimulation: influence on ovarian response and outcome of ART

PURPOSE

To study effects of endogenous LH levels on ovarian response and outcome in ART cycles a controlled study was performed with two patient groups differing in the intensity of pituitary downregulation.

METHODS

Group I (n = 27) received 3.75 mg of the GnRH agonist triptorelin acetate depot, group II (n = 54) was given 0.1 mg triptorelin acetate daily, followed by ovarian stimulation with recombinant FSH.

RESULTS

After downregulation serum LH and FSH levels were significantly lower in group I. Patients of group I needed significantly higher FSH doses to achieve comparable levels of serum estradiol and preovulatory follicles. The number of retrieved oocytes and transferable embryos was lower in group I.

CONCLUSION

Patients with profound endogenous LH suppression by depot GnRH agonists show higher FSH stimulation dose requirements and lower oocyte number and fertilization rate, indicating a need for minimal LH activity in folliculogenesis and oocyte development.

Estrogen and folliculogenesis: is one necessary for the other?

PURPOSE OF REVIEW

During folliculogenesis the primordial follicle undergoes several steps of maturation in order to develop into a preovulatory follicle. The exact role of estrogen during this process has not yet been fully assessed.

RECENT FINDINGS

Estrogen appears to regulate cyclic gonadotropin release via its action on estrogen receptor alpha in the hypothalamus/hypophysis axis and to enhance folliculogenesis through its actions via estrogen receptor beta in the ovary. In addition, a role of estrogen during the very early stages of folliculogenesis is possible. However, it is likely that oocyte quality and developmental potential are not estrogen dependent. This might explain the lack of association between estrogen and in-vitro fertilization outcome in humans.

SUMMARY

The advent of knockout mice models has enhanced our understanding of the role of estrogen during folliculogenesis. Existing data suggest that estrogen might be involved in the very early steps of this process, but its role in sustaining ovulation is mainly central.

Serum luteinizing hormone in patients undergoing ovarian stimulation with gonadotropin-releasing hormone antagonists and recombinant follicle-stimulating hormone and its relationship with cycle outcome

The serum LH was determined on days 3, 6, and 8 of stimulation and on the day of hCG in 110 normogonadotropic patients undergoing controlled ovarian hyperstimulation (COH) for IVF induced with GnRH antagonists and recombinant FSH, creating three groups of patients according to Tukey's hinges (percentiles 25 and 75) for each determination. No differences were observed between the number of oocytes recovered or the fertilization, implantation, and pregnancy rates (PR) of the groups, although patients with high serum LH levels during stimulation showed significantly higher serum E2 levels on the day of hCG.

Recombinant LH in ovarian stimulation

The advent of recombinant gonadotrophins brought significant changes in fertility therapy. Treatment options with recombinant gonadotrophins add more to knowledge on folliculogenesis and ovarian steroidogenesis. Over a decade, recombinant LH (rLH) has been used for clinical trials, and the amount of peripheral LH that is necessary for optimal follicular growth, oocyte maturation, subsequent embryo development and assisted reproduction outcome during ovulation induction can now be better evaluated. This review evaluates the effect of rLH supplementation on ovarian stimulation and assisted reproduction outcome. The studies conducted with rLH supplementation in ovarian stimulation in different groups of patients and in cases of controlled ovarian stimulation are clearly discussed in this review.

The use of recombinant human LH (lutropin alfa) in the late stimulation phase of assisted reproduction cycles: a double-blind, randomized, prospective study

BACKGROUND

The effect of recombinant human LH (r-hLH; lutropin alfa) in women undergoing controlled ovarian stimulation with recombinant human FSH (r-hFSH) prior to IVF was investigated.

METHODS

After down-regulation with the GnRH agonist, buserelin, 114 normo-ovulatory women (aged 18-37 years) received r-hFSH alone until the lead follicle reached a diameter of 14 mm. Patients were then randomized in a double-blind fashion to receive r-hFSH in addition to r-hLH, 75 IU s.c., or placebo daily for a maximum of 10 days prior to oocyte retrieval and IVF. The primary end-point was the number of metaphase II oocytes.

RESULTS

There were no significant differences between treatment groups for the primary end-point. Serum estradiol concentrations on the day of HCG administration were significantly higher in the group receiving r-hLH plus r-hFSH than in the group receiving r-hFSH alone (P = 0.0001), but there were no significant differences between the groups in dose and duration of r-hFSH treatment required, oocyte maturation, fertilization rate, pregnancy rate and live birth rate.

CONCLUSION

In this patient population, the addition of r-hLH during the late follicular phase of a long GnRH agonist and r-hFSH stimulation cycle provides no further benefit in terms of oocyte maturation or other end-points.

Are endogenous LH levels during ovarian stimulation for IVF using GnRH analogues associated with the probability of ongoing pregnancy? A systematic review

The aim of this systematic review was to evaluate, among women with normal ovulation or World Health Organization (WHO) II oligoanovulation who undergo ovarian stimulation for IVF using GnRH analogues, whether endogenous LH levels predict the likelihood of ongoing pregnancy beyond 12 weeks. A literature search identified six studies that answered the research question, among which two were prospective studies (one in GnRH agonist and one in GnRH antagonist cycles). None of the retrospective studies suggest that low endogenous LH levels are associated with a significantly decreased probability of ongoing pregnancy beyond 12 weeks in such patients. In the two prospective studies high endogenous LH levels during down-regulation were associated with a decreased probability of ongoing pregnancy beyond 12 weeks. Until further prospective studies modify the existing evidence summarized here, an adverse effect of low endogenous LH levels on the probability of ongoing pregnancy beyond 12 weeks is not a sensible rationale for LH supplementation during ovarian stimulation for IVF using GnRH analogues.

The serum follicle-stimulating hormone-to-luteinizing hormone ratio at the start of stimulation with gonadotropins after pituitary down-regulation is inversely correlated with a mature oocyte yield and can predict "low responders"

OBJECTIVE

The aim of this study was to investigate the relationship of serum FSH and LH levels at the commencement of stimulation to ovarian follicular development in women undergoing pituitary down-regulation and controlled ovarian hyperstimulation with gonadotropins in IVF or intracytoplasmic sperm injection (ICSI) cycles.

DESIGN

Retrospective analysis.

SETTING

An IVF program in a tertiary medical center.

PATIENT(S)

A total of 245 women proven to be pituitary down-regulated by their serum E(2) levels.

INTERVENTION(S)

Patients treated with a GnRH agonist and FSH and hMG underwent assisted reproductive technique (ART).

MAIN OUTCOME MEASURE(S)

Mature oocyte yield, pregnancy rate (PR), and live birth rate.

RESULT(S)

The serum FSH levels and the FSH-to-LH ratio at the commencement of gonadotropin stimulation were inversely correlated to the number of mature oocytes (r = -0.193 and r = -0.224, respectively). When assessed with receiver-operating characteristic (ROC) analysis, there was statistically significant ability for the FSH/LH ratio to differentiate between the "poor response" cycles (with mature oocyte yield < or =4) and the normal response cycles. Using the cutoff value derived from ROC analysis, cycles with the FSH-to-LH ratio > or =3 produced less mature oocytes (8.25 vs. 11.74), lower peak E(2) levels (1,975.3 pg/mL vs. 3,324.8 pg/mL), and higher percentage of poor ovarian response cycles (32.5% vs. 14.3%).

CONCLUSION(S)

The serum FSH-to-LH ratio at the start of gonadotropin stimulation after pituitary down-regulation provided a practical method for early prediction of mature oocyte yield.

IVF/ICSI outcome and serum LH concentration on day 1 of ovarian stimulation with recombinant FSH under pituitary suppression

BACKGROUND

Down-regulation with GnRH agonist has been suggested to result in a profound suppression of LH bioactivity, reduced estradiol synthesis, and thus impaired IVF and pregnancy outcome. The aims of this study were: (i) to assess the usefulness of serum LH measurement on stimulation day 1 as a predictor of ovarian response, conception and pregnancy outcome in patients treated with long-term down-regulation with GnRH agonist and recombinant FSH, and (ii) to define the best threshold LH value, if any, to discriminate between women with different outcomes of IVF.

METHODS

Records of 2625 cycles in 1652 infertile women undergoing IVF (n = 1856) and/or ICSI (n = 769) treatment were reviewed.

RESULTS

The range of LH concentrations on stimulation day 1 overlapped among non-conception cycles, conception cycles, ongoing pregnancies and early pregnancy losses. Receiver operating characteristic (ROC) analysis showed that serum LH concentrations on stimulation day 1 were unable to discriminate between conception and non-conception cycles (AUC(ROC) = 0.51; 95% CI: 0.49-0.54) or ongoing pregnancies versus early pregnancy loss groups (AUC(ROC) = 0.52; 95% CI: 0.47-0.57). Stratification for various low serum levels of LH did not reveal significant differences with respect to conception or pregnancy outcome among different LH levels on stimulation day 1.

CONCLUSIONS

Serum LH concentration on stimulation day 1 cannot predict ovarian response, conception and pregnancy outcome in women receiving long-term down-regulation during assisted reproduction treatment.

Treatment of female infertility with recombinant human luteinising hormone: is there a benefit over other available drugs?

This manuscript reviews the role of recombinant human luteinising hormone (rhLH) as a therapeutic drug in ovarian stimulation for assisted reproductive technology (ART) and ovulation induction. For this purpose, the role of LH during the follicular phase and during the ovulatory surge, along with the role of human chorionic gonadotropin (hCG) as a surrogate LH, is reviewed and compared to the results available with the new rhLH formulation. The use of rhLH was found to be safe and highly effective given during the follicular phase and to mimic an endogenous LH surge. The availability of both LH and follicle stimulating hormone (FSH) as separate recombinant preparations enables physicians to adjust the doses of each gonadotropin to the individual patient according to the 'therapeutic window' concept for each drug to maximise the success of ovarian stimulation.

Effect of halving the daily dose of triptorelin at the start of ovarian stimulation on hormone serum levels and the outcome of in vitro fertilization

Halving the standard daily dose of triptorelin at the start of ovarian stimulation in down-regulated women stimulated with recombinant FSH is enough for pituitary suppression and was associated with higher LH serum concentrations in the follicular phase. However, this did not translate into higher serum concentrations of androstenedione and E2 and had no significant effect on ovarian response and the outcome of IVF/intracytoplasmic sperm injection.