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Double-edged sword of gonadotropin-releasing hormone (GnRH): A novel role of GnRH in the multiple beneficial functions of endometrial stem cells. Cell Death Dis 2018; 9:828. [PMID: 30069003 PMCID: PMC6070560 DOI: 10.1038/s41419-018-0892-3] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2018] [Revised: 06/30/2018] [Accepted: 07/05/2018] [Indexed: 12/18/2022]
Abstract
Gonadotropin-releasing hormone (GnRH) stimulates the synthesis and release of gonadotropins, which induce estrogen production and subsequent ovulation. Therefore, long-term GnRH exposure to regulate ovarian hyperstimulation is recognized as the gold standard for most in vitro fertilization (IVF) strategies. However, one of the most disappointing aspects of current IVF technology is relatively low rate (between 35 and 50%) of positive pregnancy outcomes, and the major reason for this high cancellation rate has not yet been revealed. Previous studies have demonstrated that resident stem cell deficiency limits the cyclic regenerative capacity of the endometrium and subsequently increases pregnancy failure rates. Therefore, we hypothesized that long-term GnRH exposure directly damages endometrial stem cells and consequently negatively affects pregnancy outcomes in GnRH-based IVF. In addition to their well-known roles in regulating the hypothalamus-pituitary-gonadal axis, GnRH and its receptors also localize in the extra-hypothalamic endometrium, suggesting a possible non-canonical role in endometrial stem cells. Consistent with our hypothesis, we show for the first time that GnRH suppresses the multiple beneficial functions of endometrial stem cells via the PI3K/Akt signaling pathway in vitro and in vivo. To the best of our knowledge, this is the first study to focus on the direct effects of GnRH on the regenerative potential of stem cells, and the findings will facilitate the development of more promising IVF strategies.
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Ferreira ACA, Cadenas J, Sá NAR, Correia HHV, Guerreiro DD, Lobo CH, Alves BG, Maside C, Gastal EL, Rodrigues APR, Figueiredo JR. In vitro culture of isolated preantral and antral follicles of goats using human recombinant FSH: Concentration-dependent and stage-specific effect. Anim Reprod Sci 2018; 196:120-129. [PMID: 30049427 DOI: 10.1016/j.anireprosci.2018.07.004] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2018] [Revised: 06/28/2018] [Accepted: 07/16/2018] [Indexed: 01/05/2023]
Abstract
The present study aimed to investigate a concentration-response curve of human recombinant FSH (hrFSH) for in vitro culture of isolated preantral and early antral follicles of goats. Isolated follicles were cultured for 18 days using the following treatments: basic culture medium (control); or control medium supplemented with 10, 50, and 100 mIU/mL of hrFSH. At the end of the culture, cumulus-oocyte complexes were recovered and subjected to in vitro maturation. The following endpoints were evaluated: follicle morphology, growth rate and antrum formation, oocyte viability and meiotic stage, and estradiol production, as well as relative expression of FSH receptor (FSHR), and steroidogenic enzyme (3β-HSD, CYP17, and CYP19A1) genes. In antral follicles, the FSH addition at 50 mIU/mL increased follicular diameter and growth rate, percentage of fully developed oocytes, and oocyte diameter (P < 0.05), and tended to increase the percentage of MII oocytes when compared to the control (P = 0.07). With preantral follicles, FSH addition at 100 mIU/mL increased relative abundance of mRNA for CYP19A1 when compared to the control (P < 0.05). At the same FSH concentrations of 100 and 50 mIU/mL, there was a greater relatively abundance of mRNA for 3β-HSD and CYP17 in preantral than in antral follicles (P < 0.05). For preantral and antral follicle comparisons when the same treatments were imposed, there were greater concentrations of estradiol for antral follicles (P < 0.05). In conclusion, hrFSH enhanced in a concentration-dependent manner the in vitro development of caprine antral follicles; however, there was no positive effect in the culture of preantral follicles.
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Affiliation(s)
- Anna Clara A Ferreira
- Laboratory of Manipulation of Oocytes and Preantral Follicles, Faculty of Veterinary, State University of Ceará, Fortaleza, CE, Brazil
| | - Jesús Cadenas
- Laboratory of Manipulation of Oocytes and Preantral Follicles, Faculty of Veterinary, State University of Ceará, Fortaleza, CE, Brazil
| | - Naiza A R Sá
- Laboratory of Manipulation of Oocytes and Preantral Follicles, Faculty of Veterinary, State University of Ceará, Fortaleza, CE, Brazil
| | - Hudson H V Correia
- Laboratory of Manipulation of Oocytes and Preantral Follicles, Faculty of Veterinary, State University of Ceará, Fortaleza, CE, Brazil
| | - Denise D Guerreiro
- Laboratory of Manipulation of Oocytes and Preantral Follicles, Faculty of Veterinary, State University of Ceará, Fortaleza, CE, Brazil
| | - Carlos H Lobo
- Laboratory of Animal Physiology, Department of Animal Science, Federal University of Ceará, Fortaleza, CE, Brazil
| | - Benner G Alves
- Institute of Biomedical Sciences, Federal University of Uberlândia, Uberlândia, MG, Brazil
| | - Carolina Maside
- Department of Animal Medicine and Surgery, Faculty of Veterinary Medicine, University of Murcia, Murcia, Spain
| | - Eduardo L Gastal
- Department of Animal Science, Food and Nutrition, Southern Illinois University, Carbondale, IL, United States
| | - Ana Paula R Rodrigues
- Laboratory of Manipulation of Oocytes and Preantral Follicles, Faculty of Veterinary, State University of Ceará, Fortaleza, CE, Brazil
| | - José Ricardo Figueiredo
- Laboratory of Manipulation of Oocytes and Preantral Follicles, Faculty of Veterinary, State University of Ceará, Fortaleza, CE, Brazil.
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Fragoulakis V, Pescott CP, Smeenk JMJ, van Santbrink EJP, Oosterhuis GJE, Broekmans FJM, Maniadakis N. Economic Evaluation of Three Frequently Used Gonadotrophins in Assisted Reproduction Techniques in the Management of Infertility in the Netherlands. APPLIED HEALTH ECONOMICS AND HEALTH POLICY 2016; 14:719-727. [PMID: 27581117 DOI: 10.1007/s40258-016-0259-9] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
BACKGROUND AND OBJECTIVE Subfertility represents a multidimensional problem associated with significant distress and impaired social well-being. In the Netherlands, an estimated 50,000 couples visit their general practitioner and 30,000 couples seek medical specialist care for subfertility. We conducted an economic evaluation comparing recombinant human follicle-stimulating hormone (follitropin alfa, r-hFSH, Gonal-F®) with two classes of urinary gonadotrophins-highly purified human menopausal gonadotrophin (hp-HMG, Menopur®) and urinary follicle-stimulating hormone (uFSH, Fostimon®)-for ovarian stimulation in women undergoing in vitro fertilization (IVF) treatment in the Netherlands. METHODS A pharmacoeconomic model was developed, simulating each step in the IVF protocol from the start of therapy until either a live birth, a new IVF treatment cycle or cessation of IVF, following a long down-regulation protocol. A decision tree combined with a Markov model details progress through each health state, including ovum pickup, fresh embryo transfer, up to two subsequent cryo-preserved embryo transfers, and (ongoing) pregnancy or miscarriage. A health insurer perspective was chosen, and the time horizon was set at a maximum of three consecutive treatment cycles, in accordance with Dutch reimbursement policy. Transition probabilities and costing data were derived from a real-world observational outcomes database (from Germany) and official tariff lists (from the Netherlands). Adverse events were considered equal among the comparators and were therefore excluded from the economic analysis. A Monte Carlo simulation of 5000 iterations was undertaken for each strategy to explore uncertainty and to construct uncertainty intervals (UIs). All cost data were valued in 2013 Euros. The model's structure, parameters and assumptions were assessed and confirmed by an external clinician with experience in health economics modelling, to inform on the appropriateness of the outcomes and the applicability of the model in the chosen setting. RESULTS The mean total treatment costs were estimated as €5664 for follitropin alfa (95 % UI €5167-6151), €5990 for hp-HMG (95 % UI €5498-6488) and €5760 for uFSH (95 % UI €5256-6246). The probability of a live birth was estimated at 36.1 % (95 % UI 27.4-44.3 %), 33.9 % (95 % UI 26.2-41.5 %) and 34.1 % (95 % UI 25.9-41.8 %) for follitropin alfa, hp-HMG and uFSH, respectively. The costs per live birth estimates were €15,674 for follitropin alfa, €17,636 for hp-HMG and €16,878 for uFSH. Probabilistic sensitivity analysis indicated a probability of 72.5 % that follitropin alfa is cost effective at a willingness to pay of €20,000 per live birth. The probabilistic results remained constant under several analyses. CONCLUSION The present analysis shows that follitropin alfa may represent a cost-effective option in comparison with uFSH and hp-HMG for IVF treatment in the Netherlands healthcare system.
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Affiliation(s)
- Vassilis Fragoulakis
- Department of Health Services Organization and Management, National School of Public Health, 196 Alexandras Avenue, Athens, 11521, Greece.
| | - Chris P Pescott
- Department of Global Evidence and Value Development, Merck KgaA, Frankfurter Straße 250, F135/101, 64293, Darmstadt, Germany
| | - Jesper M J Smeenk
- Department of Gynaecology, St Elisabeth Ziekenhuis, Hilvarenbeekseweg 60, 5022 GC, Tilburg, The Netherlands
| | - Evert J P van Santbrink
- Department of Reproductive Medicine, Reinier de Graaf Groep, Diaconessenhuis Voorburg, Fonteynenburghlaan 5, 2275 CX, Voorburg, The Netherlands
| | - G Jur E Oosterhuis
- Department of Gynaecology, St Antonius Ziekenhuis, Koekoekslaan 1, 3435 CM, Nieuwegein, The Netherlands
| | - Frank J M Broekmans
- Department of Reproductive Medicine and Surgery, Universitair Medisch Centrum Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
| | - Nikos Maniadakis
- Department of Health Services Organization and Management, National School of Public Health, 196 Alexandras Avenue, Athens, 11521, Greece
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Shavit T, Shalom-Paz E, Samara N, Aslih N, Michaeli M, Ellenbogen A. Comparison between stimulation with highly purified hMG or recombinant FSH in patients undergoing IVF with GnRH antagonist protocol. Gynecol Endocrinol 2016; 32:629-633. [PMID: 26939574 DOI: 10.3109/09513590.2016.1153058] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
PURPOSE Highly purified Human Menopausal Gonadotropins (hp-hMG) and recombinant FSH (rFSH) are widely used in assisted reproductive technology (ART). The aim of this study was to compare ART results of the two preparations in GnRH antagonist cycles. METHODS In this retrospective cohort study, IVF antagonist cycles performed from 2011 through 2013 were reviewed. There were 508 antagonist cycles: 320 stimulated with rFSH and 188 with hp-hMG. For every hp-hMG, two rFSH were matched for patient's age and infertility diagnosis. Subgroup analysis of patients younger and older than 35 was done as well. RESULTS Both treatments were resulted in comparable pregnancy and live birth rates. However, cumulative pregnancy rates were higher for the rFSH group. In the matching analysis, the rFSH group had more mature oocytes and more embryos while using lower doses of gonadotropins. Pregnancy, cumulative pregnancy rates, and live birth rates were comparable. In the subgroup analysis, young patients in the rFSH group had better cycle outcomes compared with those in the hp-hMG group. CONCLUSION In antagonist protocol, different gonadotropin products are equally effective. The choice of one or the other should depend on the availability, convenience of use, and cost.
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Affiliation(s)
- Tal Shavit
- a IVF Unit, Department of Obstetrics & Gynecology, Hillel Yaffe Medical Center, Rappaport School of Medicine, Technion, Israel Institute of Technology , Haifa , Hadera , IL , Israel
| | - Einat Shalom-Paz
- a IVF Unit, Department of Obstetrics & Gynecology, Hillel Yaffe Medical Center, Rappaport School of Medicine, Technion, Israel Institute of Technology , Haifa , Hadera , IL , Israel
| | - Nivin Samara
- a IVF Unit, Department of Obstetrics & Gynecology, Hillel Yaffe Medical Center, Rappaport School of Medicine, Technion, Israel Institute of Technology , Haifa , Hadera , IL , Israel
| | - Nardin Aslih
- a IVF Unit, Department of Obstetrics & Gynecology, Hillel Yaffe Medical Center, Rappaport School of Medicine, Technion, Israel Institute of Technology , Haifa , Hadera , IL , Israel
| | - Madiea Michaeli
- a IVF Unit, Department of Obstetrics & Gynecology, Hillel Yaffe Medical Center, Rappaport School of Medicine, Technion, Israel Institute of Technology , Haifa , Hadera , IL , Israel
| | - Adrian Ellenbogen
- a IVF Unit, Department of Obstetrics & Gynecology, Hillel Yaffe Medical Center, Rappaport School of Medicine, Technion, Israel Institute of Technology , Haifa , Hadera , IL , Israel
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Nardo L, Bosch E, Lambalk C, Gelbaya T. Controlled ovarian hyperstimulation regimens: a review of the available evidence for clinical practice. Produced on behalf of the BFS Policy and Practice Committee. HUM FERTIL 2013; 16:144-50. [DOI: 10.3109/14647273.2013.795385] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Dose of recombinant FSH and oestradiol concentration on day of HCG affect embryo development kinetics. Reprod Biomed Online 2012; 25:382-9. [DOI: 10.1016/j.rbmo.2012.06.016] [Citation(s) in RCA: 54] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2011] [Revised: 06/13/2012] [Accepted: 06/14/2012] [Indexed: 11/21/2022]
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Tejera A, Herrero J, de los Santos M, Garrido N, Ramsing N, Meseguer M. Oxygen consumption is a quality marker for human oocyte competence conditioned by ovarian stimulation regimens. Fertil Steril 2011; 96:618-623.e2. [DOI: 10.1016/j.fertnstert.2011.06.059] [Citation(s) in RCA: 54] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2011] [Revised: 06/22/2011] [Accepted: 06/22/2011] [Indexed: 11/26/2022]
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Westergaard LW, Bossuyt PMM, Van der Veen F, van Wely M. WITHDRAWN: Human menopausal gonadotropin versus recombinant follicle stimulation hormone for ovarian stimulation in assisted reproductive cycles. Cochrane Database Syst Rev 2011; 2011:CD003973. [PMID: 21328264 PMCID: PMC10680421 DOI: 10.1002/14651858.cd003973.pub2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
BACKGROUND hMG and recombinant FSH, have both been used successfully for controlled ovarian hyperstimulation in in vitro fertilization and embryo transfer (IVF-ET). OBJECTIVES To compare the effectiveness of hMG with rFSH in ovarian stimulation protocols in IVF or ICSI treatment cycles. SEARCH STRATEGY We searched the Cochrane Menstrual Disorders and Subfertility Group trials register (searched 3rd Jan 2002), PubMed, MEDLINE, Web of Science (all searched 1985 to May 15 2002), and reference lists of articles. We also contacted manufacturers and researchers in the field. SELECTION CRITERIA Randomised trials comparing hMG with rFSH for ovarian stimulation in IVF or ICSI treatment for treatment of infertility in normogonadotrophic women. DATA COLLECTION AND ANALYSIS The main outcome measure was ongoing pregnancy/live birth per woman.Secondary outcomes included total gonadotrophin dose used, cancellation, number of oocytes retrieved, implantation, clinical pregnancy per woman, multiple pregnancy, spontaneous abortion and ovarian hyperstimulation syndrome. Peto odds ratios (OR) for hMG relative to rFSH were calculated after testing for homogeneity of treatment effect across all trials. Analyses were performed separately for the three different GnRHa protocols used: (1) without GnRHa down-regulation, (2) with GnRHa down-regulation using a short protocol and (3) with GnRHa down-regulation using a long protocol. MAIN RESULTS Eight trials that met the inclusion criteria could be identified. One trial did not use down-regulation, one trial used a short protocol and six trials used a long down-regulation protocol. In the one trial with non-down-regulated women and in the one trial that used a short down-regulation protocol there was no evidence of a difference between hMG and rFSH in any clinical outcome. Data of four truly randomised trials in women down-regulated using a long protocol could be pooled. There was no evidence of a difference between hMG and rFSH in ongoing pregnancy/live birth per woman (OR 1.27; 95% CI 0.98 to 1.64). Furthermore there was no clear difference on any of the secondary outcomes, although the clinical pregnancy rate per woman was of borderline significance in favour of hMG (summary OR 1.28; 95% CI 1.00 to 1.64). The other secondary outcomes were comparable for both gonadotrophins. AUTHORS' CONCLUSIONS For all three GnRHa protocols analysed there is insufficient evidence of a difference between hMG and rFSH on ongoing pregnancy or live birth. More large randomised trials are needed to estimate the difference between hMG and rFSH more precisely. Such trials should preferably (1) use a consistent long GnRHa protocol and (2) use a fixed dose of gonadotrophin such to prevent potentially subjective decisions of the clinician in dosing and (3) take live birth as primary endpoint. At this moment in time however, in prescribing gonadotrophins for ovarian hyperstimulation in IVF one should use the least expensive medication.
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Affiliation(s)
- Lars W Westergaard
- Odense University HospitalDepartment of Obstetrics and GynecologyOdense CDenmarkDK5000
| | - Patrick MM Bossuyt
- Academic Medical Center, University of AmsterdamDepartment of Clinical Epidemiology and BiostatisticsRoom J2‐209, PO Box 22700AmsterdamNetherlands1105 DD
| | - Fulco Van der Veen
- Academic Medical CenterCenter for Reproductive Medicine ‐ H4‐205, Department of Obstetrics & GynaecologyUniversity of AmsterdamMeibergdreef 9AmsterdamNetherlands1105 AZ
| | - Madelon van Wely
- University of Amsterdam, Academic Medical CentreCentre for Reproductive Medicine, Department of Obstetrics and GynaecologyCenter Meibergdreef 9AmsterdamNetherlands1105 AZ
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van Wely M, Kwan I, Burt AL, Thomas J, Vail A, Van der Veen F, Al‐Inany HG. Recombinant versus urinary gonadotrophin for ovarian stimulation in assisted reproductive technology cycles. Cochrane Database Syst Rev 2011; 2011:CD005354. [PMID: 21328276 PMCID: PMC7388278 DOI: 10.1002/14651858.cd005354.pub2] [Citation(s) in RCA: 79] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND Several systematic reviews compared recombinant gonadotrophin with urinary gonadotrophins (HMG, purified FSH, highly purified FSH) for ovarian hyperstimulation in IVF and ICSI cycles and these reported conflicting results. Each of these reviews used different inclusion and exclusion criteria for trials. Our aim in producing this review is to bring together all randomised studies in this field under common inclusion criteria with consistent and valid statistical methods. OBJECTIVES To compare the effectiveness of recombinant gonadotrophin (rFSH) with the three main types of urinary gonadotrophins (i.e. HMG, FSH-P and FSH-HP) for ovarian stimulation in women undergoing IVF or ICSI treatment cycles. SEARCH STRATEGY An extended search was done according to Cochrane guidelines including the Menstrual Disorders & Subfertility Group's Specialised Register of controlled trials, The Cochrane Central Register of Controlled Trials, MEDLINE (1966 to May 2010), EMBASE (1980 to May 2010), CINAHL (1982 to May 2010), National Research Register, and Current Controlled Trials. SELECTION CRITERIA All randomised controlled trials reporting data comparing clinical outcomes for women undergoing IVF/ICSI cycles and using recombinant FSH in comparison with HMG or highly purified HMG, purified urinary FSH (FSH-P), and highly purified urinary FSH (FSH-HP) for ovarian hyperstimulation in IVF or ICSI cycles were included. DATA COLLECTION AND ANALYSIS Primary outcome measure was live birth rate and OHSS per randomised woman.Binary outcomes were analysed using odds ratios and also reported in absolute terms. Grouped analyses were carried out for all outcomes to explore whether relative effects differed due to key features of the trials. MAIN RESULTS We included 42 trials with a total of 9606 couples. Comparing rFSH to any of the other gonadotrophins irrespective of the down-regulation protocol used, did not result in any evidence of a statistically significant difference in live birth rate (28 trials, 7339 couples, odds ratio 0.97, 95% CI 0.87 to 1.08). This suggests that for a group with a 25% live birth rate using urinary gonadotrophins the rate would be between 22.5% and 26.5% using rFSH. There was also no evidence of a difference in the OHSS rate (32 trials, 7740 couples, OR 1.18, 95% CI 0.86 to 1.61). This means that for a group with 2% risk of OHSS using urinary gonadotrophins, the risk would be between 1.7% and 3.2% using rFSH. AUTHORS' CONCLUSIONS Clinical choice of gonadotrophin should depend on availability, convenience and costs. Further research on these comparisons is unlikely to identify substantive differences in effectiveness or safety.
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Affiliation(s)
- Madelon van Wely
- Academic Medical Centre, University of AmsterdamCentre for Reproductive Medicine, Department of Obstetrics and GynaecologyCenter Meibergdreef 9AmsterdamNetherlands1105 AZ
| | - Irene Kwan
- Institute of Education, University of LondonEvidence for Policy and Practice Information and Coordinating Centre (EPPI‐Centre), Social Science Research Unit (SSRU)10 Woburn SquareLondonUKWC1H 0NR
| | - Anna L Burt
- The Royal College of Obstetricians & GynaecologistsNational Collaborating Centre for Women`s and Children`s Health27 Sussex Place, Regent´s ParkLondonUKNW1 4RG
| | - Jane Thomas
- Auckland UniversityCochrane MSDG FMHSGrafton CampusAucklandNew Zealand
| | - Andy Vail
- University of ManchesterHealth Methodology Research GroupR & D Support Unit, Salford Royal HospitalStott LaneSalfordUKM6 8HD
| | - Fulco Van der Veen
- Academic Medical Center, University of AmsterdamCenter for Reproductive Medicine, Department of Obstetrics & GynaecologyUniversity of AmsterdamMeibergdreef 9AmsterdamNetherlands1105 AZ
| | - Hesham G Al‐Inany
- Faculty of Medicine, Cairo UniversityObstetrics & Gynaecology8 Moustapha Hassanin StManialCairoEgypt
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The effect of low dose human chorionic gonadotropin on follicular response and oocyte maturation in PCOS patients undergoing IVF cycles: a randomized clinical trial of efficacy and safety. Arch Gynecol Obstet 2011; 284:1431-8. [DOI: 10.1007/s00404-010-1827-0] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2010] [Accepted: 12/21/2010] [Indexed: 11/26/2022]
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Genazzani AR, Monteleone P, Papini F, Artini PG. Pharmacotherapy of ovarian hyperstimulation syndrome. Expert Opin Pharmacother 2010; 11:2527-34. [DOI: 10.1517/14656566.2010.499359] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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12
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Melo M, Bellver J, Garrido N, Meseguer M, Pellicer A, Remohí J. A prospective, randomized, controlled trial comparing three different gonadotropin regimens in oocyte donors: ovarian response, in vitro fertilization outcome, and analysis of cost minimization. Fertil Steril 2010; 94:958-64. [PMID: 19931075 DOI: 10.1016/j.fertnstert.2009.05.005] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2009] [Revised: 04/25/2009] [Accepted: 05/04/2009] [Indexed: 11/29/2022]
Affiliation(s)
- Marco Melo
- Instituto Valenciano de Infertilidad, Universidad de Valencia, Department of Obsterics and Gynaecology, University Hospital Dr. Peset, Valencia, Spain.
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Krause BT, Ohlinger R, Haase A. Lutropin alpha, recombinant human luteinizing hormone, for the stimulation of follicular development in profoundly LH-deficient hypogonadotropic hypogonadal women: a review. Biologics 2009; 3:337-47. [PMID: 19707419 PMCID: PMC2726078 DOI: 10.2147/btt.2009.3306] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
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.
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Affiliation(s)
- Bernd Th Krause
- Center for Endocrinology and Reproductive Medicine, MVZ Uhlandstr, Berlin, Germany.
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Nyachieo A, Spiessens C, Mwenda JM, Debrock S, D’Hooghe TM. Improving ovarian stimulation protocols for IVF in baboons: Lessons from humans and rhesus monkeys. Anim Reprod Sci 2009; 110:187-206. [DOI: 10.1016/j.anireprosci.2008.08.023] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2008] [Revised: 08/18/2008] [Accepted: 08/21/2008] [Indexed: 10/21/2022]
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Abstract
The ability to prevent an endogenous LH surge revolutionised the efficacy of assisted reproductive techniques (ART) such that GnRH agonists were rapidly adopted in the 1980s. Prior to this, premature luteinisation occurred in up to 25% of superovulated cycles leading to cycle cancellation and severely compromised outcomes. Analogues have been applied in a variety of drug protocols (long, short flare) but there has been little research to moderate the degree of pituitary suppression. There has also been ongoing and unresolved debate about the role of LH in supporting follicular development. By 2001, the first GnRH antagonists were registered for use in ART. Their ability to cause immediate suppression of gonadotrophin (particularly LH) secretion means that they can be given after exogenous stimulation has begun and thereby dramatically shorten the total duration of a treatment cycle. After initial enthusiasm and then scepticism that pregnancy rates may not be as high as the established agonist regimens, these preparations are now being increasingly adopted with at least comparable outcomes in large trials. They are certainly favoured by patients for their reduced side-effect profile and particularly for the shortening of the total cycle length. This shift in practice is occurring alongside gathering momentum in favour of milder stimulation protocols and a new perception of what constitutes successful treatment. The focus is moving away from surrogate outcomes such as oocyte numbers and conception rates towards long-term outcomes for women and their offspring, namely the achievement of a live singleton birth per treatment started.
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Affiliation(s)
- Catherine Hayden
- Reproductive Medicine Unit, The Leeds Teaching Hospitals NHS Trust, Clarendon Wing, Belmont Grove, Leeds LS29NS, UK.
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Ubaldi F, Rienzi L. Morphological selection of gametes. Placenta 2008; 29 Suppl B:115-20. [PMID: 18762336 DOI: 10.1016/j.placenta.2008.08.009] [Citation(s) in RCA: 46] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2008] [Revised: 07/17/2008] [Accepted: 08/05/2008] [Indexed: 11/18/2022]
Abstract
Methods of selecting gametes before the intracytoplasmic sperm injection (ICSI) technique are of paramount importance, especially where for religious, ethical or legal reasons the production of supernumerary embryos has to be avoided. In these circumstances, in fact, the research has to be focused on the identification of early markers of embryo quality at the oocyte and sperm stage before fertilisation. Oocyte quality can be influenced by several factors such as controlled ovarian hyperstimulation protocols, pharmaceutical preparations and perifollicular vascularisation. Several intracytoplasmic and extracytoplasmic abnormalities have been described, but whether these abnormalities might be predictive of oocyte competence is controversial and the selection methods proposed are still poorly effective. Recently, we have observed that oocyte morphological abnormalities might be indicators of oocyte competence. An abnormal first polar body (but not fragmented), a large perivitelline space, increased cytoplasmic granularity, and the presence of a centrally located granular area seem to have a negative effect on the oocyte potential to fertilise, cleave, and/or develop into a viable embryo. Sperm morphology can be more accurately observed at high magnification using an inverted microscope equipped with Normarski optics (1000x magnification under mineral oil) and a digital system in order to reach a final magnification of approximately 6300x. Single sperm nuclear abnormalities based on strict selection criteria seems to have a clear negative association with ICSI outcome. The possibility of observing the spermatozoa in real time at higher magnification might also be a good opportunity to study the relationship between particular sperm defects and ICSI outcome. In addition to morphology, it has been suggested that spermatozoa selection might be performed on the basis of its biochemical ability to bind to solid hyaluronic acid. However, it must be underlined that prospective randomised studies are necessary to confirm the preliminary results regarding the efficacy of the described criteria proposed, to morphologically select gametes prior to in vitro insemination.
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Affiliation(s)
- F Ubaldi
- G.EN.E.R.A. Centre for Reproductive Medicine, Valle Giulia Clinic, Via G. De Notaris 2, 00197 Rome, Italy.
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Abstract
Endocrine therapy for male infertility is broadly categorized as specific or nonspecific therapy. Although uncommon, primary endocrine diagnoses in infertile men are amenable to targeted therapy. The efficacy of empiric endocrine therapy for idiopathic male infertility, however, has not been demonstrated conclusively by clinical trials. With better understanding of the underlying pathophysiology of idiopathic male infertility, careful evaluation of endocrine therapy in well-selected treatment groups and well-designed randomized, controlled trials is warranted. Although empiric endocrine therapy for idiopathic male infertility has been largely replaced by assisted reproductive techniques, both treatment modalities could play a role, perhaps as combination therapy.
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Affiliation(s)
- Howard H Kim
- Department of Urology, Weill Medical College of Cornell University and Cornell Institute for Reproductive Medicine, 525 East 68th Street, New York, NY 10065, USA
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18
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Barrenetxea G, Agirregoikoa JA, Jiménez MR, de Larruzea AL, Ganzabal T, Carbonero K. 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. Fertil Steril 2007; 89:546-53. [PMID: 17531989 DOI: 10.1016/j.fertnstert.2007.03.088] [Citation(s) in RCA: 59] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2006] [Revised: 03/27/2007] [Accepted: 03/27/2007] [Indexed: 11/30/2022]
Abstract
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.
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Affiliation(s)
- Gorka Barrenetxea
- Center for Reproductive Medicine and Infertility Quirón Bilbao, Bilbao, Spain.
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19
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Gomes MKO, Vieira CS, Moura MD, Manetta LA, Leite SP, Reis RM, Ferriani RA. Controlled ovarian stimulation with exclusive FSH followed by stimulation with hCG alone, FSH alone or hMG. Eur J Obstet Gynecol Reprod Biol 2007; 130:99-106. [PMID: 16835006 DOI: 10.1016/j.ejogrb.2006.05.025] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2005] [Revised: 04/16/2006] [Accepted: 05/17/2006] [Indexed: 11/21/2022]
Abstract
OBJECTIVE To assess if low-dose hCG is similar to hMG and to rFSH in the late follicular phase. STUDY DESIGN In a prospective randomized controlled trial, 51 patients undergoing controlled ovarian stimulation received ovarian priming with rFSH and then received hCG (200 IU/day) (hCG group, n=17), hMG (225 IU/day) (hMG group, n=17) or rFSH (200 IU/day) (FSH group, n=17) in the late stage of follicular development. Parameters of follicular response and serum estradiol, progesterone and testosterone levels were assessed. RESULTS Pre-ovulatory ovarian follicle occurrence and length of treatment were similar among the three treatment groups. Serum progesterone level on the day of pre-ovulatory hCG was significantly higher in the hCG group than in the hMG or rFSH group. Clinical pregnancy rates were similar for all groups. The total cost of treatment was significantly lower for the hCG group than for the groups supplemented with hMG or rFSH. CONCLUSIONS LH in the form of low-dose hCG during the late follicular phase induced the same follicular pattern as hMG and rFSH after ovulation induction. The procedure using hCG produced pregnancy rates similar to those obtained using hMG and rFSH, even though the patients showed higher serum progesterone levels on the hCG day.
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Affiliation(s)
- Mariana K O Gomes
- Department of Gynaecology and Obstetrics of the University of São Paulo Ribeirão Preto School of Medicine, Ribeirão Preto, Brazil
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20
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Martin-Johnston M, Beltsos AN, Grotjan HE, Uhler ML. Adding human menopausal gonadotrophin to antagonist protocols – is there a benefit? Reprod Biomed Online 2007; 15:161-8. [PMID: 17697491 DOI: 10.1016/s1472-6483(10)60704-3] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
The objective of this retrospective analysis was to compare the clinical outcomes of recombinant FSH (r-FSH) with combination r-FSH plus human menopausal gonadotrophin (HMG) protocols in a large private practice using a single IVF laboratory, from 2001 to 2003. Patients underwent ovarian stimulation by standard gonadotrophin-releasing hormone (GnRH) antagonist protocol using r-FSH or combination r-FSH plus HMG. When two or more follicles had attained a minimum mean diameter of 20 mm, follicular triggering was achieved with either recombinant HCG (r-HCG; Ovidrel, 250 microg s.c.) or urinary HCG (u-HCG; 10,000 IU i.m.). The main outcome measures were number of oocytes retrieved and clinical pregnancy rate. There was a lower percentage of cancelled cycles and an increased number of oocytes retrieved, mature oocytes, oocytes that fertilized, embryo that cleaved and a tendency towards higher clinical pregnancy rates in patients treated with r-FSH alone compared with those treated with r-FSH plus HMG. Patients treated with r-FSH plus HMG had lower miscarriage rates and the live birth rate was similar in both treatment groups. In conclusion, irrespective of age, using a treatment regimen consisting of a combination of HMG plus r-FSH was not beneficial compared with r-FSH alone in patients using a GnRH antagonist protocol.
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21
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Muasher SJ, Abdallah RT, Hubayter ZR. Optimal stimulation protocols for in vitro fertilization. Fertil Steril 2006; 86:267-73. [PMID: 16753157 DOI: 10.1016/j.fertnstert.2005.09.067] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2004] [Revised: 09/29/2005] [Accepted: 09/29/2005] [Indexed: 11/16/2022]
Abstract
OBJECTIVE To update clinicians on different gonadotropin regimens for ovarian stimulation for IVF including the use of urinary and recombinant gonadotropins, the value of added LH to FSH in the stimulation regimen, the use of GnRH agonists and antagonists, and the role of minimal stimulation protocols. DESIGN Literature review and critical analysis of major articles during the last five years on ovarian stimulation for IVF. CONCLUSION(S) Urinary and recombinant gonadotropins, for ovarian stimulation for IVF, are probably equally safe and effective. The higher cost for recombinant products limits their worldwide use in IVF. Conflicting data exist regarding the benefit of adding LH to FSH in the stimulation regimens. The use of different GnRH-agonists, of varying potency, may account for different levels of LH suppression. Adding LH should be considered in severe situations of LH suppression such as with the use of potent GnRH-agonists or when GnRH-antagonists are introduced during the course of stimulation. GnRH-antagonists provide advantages to patients in terms of fewer injections, shorter stimulation days, and avoidance of adverse effects of agonists. The incidence of ovarian hyperstimulation syndrome is probably less with antagonists compared to agonists, with the option to use an agonist as a surrogate LH surge. Fixed and early start of the antagonist is probably more effective than an individualized and late start. The earlier reported lower pregnancy rates with antagonists compared to agonists is not fully understood and needs to be continually monitored. Minimal stimulation protocols using a combination of clomiphene citrate and gonadotropins are attractive and should be considered in some patients owing to lower costs and acceptable success rates. The optimal stimulation protocol for IVF should be an individualized regimen based on the patient's ovarian physiology and prior IVF experience, if any.
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Affiliation(s)
- Suheil J Muasher
- Muasher Center for Fertility and IVF, Fairfax, Virginia 22031, USA.
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22
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Macklon NS, Stouffer RL, Giudice LC, Fauser BCJM. The science behind 25 years of ovarian stimulation for in vitro fertilization. Endocr Rev 2006; 27:170-207. [PMID: 16434510 DOI: 10.1210/er.2005-0015] [Citation(s) in RCA: 338] [Impact Index Per Article: 18.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
To allow selection of embryos for transfer after in vitro fertilization, ovarian stimulation is usually carried out with exogenous gonadotropins. To compensate for changes induced by stimulation, GnRH analog cotreatment, oral contraceptive pretreatment, late follicular phase human chorionic gonadotropin, and luteal phase progesterone supplementation are usually added. These approaches render ovarian stimulation complex and costly. The stimulation of multiple follicular development disrupts the physiology of follicular development, with consequences for the oocyte, embryo, and endometrium. In recent years, recombinant gonadotropin preparations have become available, and novel stimulation protocols with less detrimental effects have been developed. In this article, the scientific background to current approaches to ovarian stimulation for in vitro fertilization is reviewed. After a brief discussion of the relevant aspect of ovarian physiology, the development, application, and consequences of ovarian stimulation strategies are reviewed in detail.
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Affiliation(s)
- Nick S Macklon
- Department of Reproductive Medicine and Gynecology, University Medical Center Utrecht, P.O. Box 85500, 3508 GA Utrecht, The Netherlands.
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23
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Chung K, Krey L, Katz J, Noyes N. Evaluating the role of exogenous luteinizing hormone in poor responders undergoing in vitro fertilization with gonadotropin-releasing hormone antagonists. Fertil Steril 2005; 84:313-8. [PMID: 16084870 DOI: 10.1016/j.fertnstert.2005.02.028] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2004] [Revised: 02/15/2005] [Accepted: 02/15/2005] [Indexed: 11/21/2022]
Abstract
OBJECTIVE To evaluate the importance of exogenous LH in poor responders undergoing IVF with GnRH antagonists. DESIGN Retrospective cohort study. SETTING University-based IVF center. PATIENT(S) All patients with a history of poor response to ovarian stimulation undergoing IVF with GnRH antagonists between September 2000 and August 2001. INTERVENTION(S) None. MAIN OUTCOME MEASURE(S) Clinical pregnancy rates. RESULT(S) Two hundred forty GnRH-antagonist cycles were initiated in poor responders. One hundred fifty-three progressed to oocyte retrieval. Seventy-five patients received recombinant FSH (Rec) for ovarian stimulation, and 66 received hMG in combination with Rec. In patients aged <40 years, there were no significant differences in amount and duration of treatment, number of oocytes retrieved, and number of embryos between treatment groups. In patients aged > or =40 years, significantly fewer oocytes were retrieved in groups who received exogenous LH in their stimulation, resulting in significantly fewer fertilized embryos. Implantation and clinical pregnancy rates did not differ by treatment group. CONCLUSION(S) In poor responders undergoing IVF with GnRH antagonists, outcomes are comparable whether stimulation is achieved in the presence or absence of supplemental LH. Exogenous LH does not appear to be necessary to achieve pregnancy in these challenging patients and may be detrimental to older patients with a history of poor response.
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Affiliation(s)
- Karine Chung
- New York University Program for Infertility, Reproductive Surgery, and In Vitro Fertilization, New York, New York, USA.
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24
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Arslan M, Bocca S, Mirkin S, Barroso G, Stadtmauer L, Oehninger S. Controlled ovarian hyperstimulation protocols for in vitro fertilization: two decades of experience after the birth of Elizabeth Carr. Fertil Steril 2005; 84:555-69. [PMID: 16169382 DOI: 10.1016/j.fertnstert.2005.02.053] [Citation(s) in RCA: 71] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2004] [Revised: 02/02/2005] [Accepted: 02/02/2005] [Indexed: 10/25/2022]
Abstract
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.
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Affiliation(s)
- Murat Arslan
- Department of Obstetrics and Gynecology, The Jones Institute for Reproductive Medicine, Eastern Virginia Medical School, Norfolk, Virginia, USA
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25
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Rashidi BH, Sarvi F, Tehrani ES, Zayeri F, Movahedin M, Khanafshar N. The effect of HMG and recombinant human FSH on oocyte quality: a randomized single-blind clinical trial. Eur J Obstet Gynecol Reprod Biol 2005; 120:190-4. [PMID: 15925050 DOI: 10.1016/j.ejogrb.2004.11.007] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2004] [Revised: 08/11/2004] [Accepted: 11/11/2004] [Indexed: 11/22/2022]
Abstract
OBJECTIVE To compare the effect of HMG and rhFSH on oocyte quality in ICSI cycle. SETTING Vali-e-Asr university teaching hospital. METHOD Prospective single-blind randomized clinical trial. SUBJECTS Sixty women undergoing ovarian stimulation for ICSI were randomized to receive a standard protocol of either HMG or rhFSH in down-regulation cycles. INTERVENTIONS Prior to microinjection, each oocyte was assessed regarding the nuclear maturity, morphology of zona plucida, cytoplasmic appearance and polar body morphology. Fertilization rate was followed. MAIN OUTCOME The percentage of metaphase II oocytes in HMG and rhFSH groups. STATISTICAL ANALYSIS Statistical analyses were carried out by the Mann-Whitney, Fisher's exact, chi2 tests and Student's t-test. RESULTS No significant differences were found between two groups in regard to the demographic data, the ovarian response and pregnancy/implantation rates (P>0.05). The percentage of metaphase II oocytes in HMG and rhFSH groups were 81.3% versus 80.6%, respectively. CONCLUSIONS There were no significant differences between parameters such as, oocyte quality and percentage of metaphase II oocytes between these two groups.
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Affiliation(s)
- Batool Hossein Rashidi
- Vali-e-Asr Reproductive Health Research Center, Tehran University of Medical Sciences, Imam Khomeini Hospital Complex, Keshavarz Blvd., Tehran 14194, Iran
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26
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Mitwally MFM, Casper RF, Diamond MP. The role of aromatase inhibitors in ameliorating deleterious effects of ovarian stimulation on outcome of infertility treatment. Reprod Biol Endocrinol 2005; 3:54. [PMID: 16202169 PMCID: PMC1266397 DOI: 10.1186/1477-7827-3-54] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2005] [Accepted: 10/04/2005] [Indexed: 12/24/2022] Open
Abstract
Clinical utilization of ovulation stimulation to facilitate the ability of a couple to conceive has not only provided a valuable therapeutic approach, but has also yielded extensive information on the physiology of ovarian follicular recruitment, endometrial receptivity and early embryo competency. One of the consequences of the use of fertility enhancing agents for ovarian stimulation has been the creation of a hyperestrogenic state, which may influence each of these parameters. Use of aromatase inhibitors reduces hyperestrogenism inevitably attained during ovarian stimulation. In addition, the adjunct use of aromatase inhibitors during ovarian stimulation reduces amount of gonadotropins required for optimum stimulation. The unique approach of reducing hyperestrogenism, as well as lowering amount of gonadotropins without affecting the number of mature ovarian follicles is an exciting strategy that could result in improvement in the treatment outcome by ameliorating the deleterious effects of the ovarian stimulation on follicular development, endometrial receptivity, as well as oocyte and embryo quality.
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Affiliation(s)
- Mohamed FM Mitwally
- Division of Reproductive Endocrinology & Infertility, Department of Obstetrics & Gynecology, Wayne State University, Detroit, Michigan, USA
| | - Robert F Casper
- Reproductive Sciences Division, Department of Obstetrics & Gynecology, University of Toronto, Toronto, Ontario, Canada
| | - Michael P Diamond
- Division of Reproductive Endocrinology & Infertility, Department of Obstetrics & Gynecology, Wayne State University, Detroit, Michigan, USA
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27
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Caglar GS, Asimakopoulos B, Nikolettos N, Diedrich K, Al-Hasani S. Recombinant LH in ovarian stimulation. Reprod Biomed Online 2005; 10:774-85. [PMID: 15970010 DOI: 10.1016/s1472-6483(10)61123-6] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
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.
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Affiliation(s)
- Gamze Sinem Caglar
- Department of Obstetrics and Gynecology, Medical University, Lubeck, Germany
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28
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Abdalla H, Thum MY. Repeated testing of basal FSH levels has no predictive value for IVF outcome in women with elevated basal FSH. Hum Reprod 2005; 21:171-4. [PMID: 16155077 DOI: 10.1093/humrep/dei288] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND It is a common practice to repeatedly test the level of basal FSH early in the cycle and to start IVF treatment only when the FSH level is below a certain threshold value. This is based on the idea that these women will respond better to ovarian stimulation when the basal FSH level is lower at the start of the cycle. The aim of this study is to assess the value of this practice. METHODS Between January 1995 and January 2003, 39 women were identified. These women underwent two IVF treatment cycles within a 12 month period. The basal FSH level prior to each of these cycles was known to have changed. The treatment cycles were divided into cycles with a high basal FSH (> or =10 IU/l) and cycles with a low basal FSH (<10 IU/l). RESULTS The 39 women underwent a total of 78 treatment cycles (in the first cycle 20 had elevated level of FSH and 19 had low FSH and vice versa in the second cycle). Therefore, there were 39 cycles with high FSH and 39 cycles with low FSH. There was obviously no live birth in the first treatment cycle, hence the reason for the patient undergoing another treatment cycle within 12 months of the first one. In the high FSH group, six became pregnant [pregnancy rate (PR) = 15.4%] and five delivered [live birth rate (LBR) = 12.8%]. In the low FSH group, three became pregnant (PR = 7.7%) and two delivered (LBR = 5.1%). The difference in PR and LBR, however, was not significant. Neither were there significant differences between the two groups with regard to the number of oocytes collected, oocytes fertilized, embryos transferred or miscarriage rate. CONCLUSION The results of this study reveal that women who are poor responders or with reduced ovarian reserve have a poor outcome and repeatedly testing them will add no value. Cycling women with a history of elevated FSH should be offered treatment without further delay. Delaying treatment for these women could be counterproductive, as they may have to wait for many months, during which time they are getting older and closer to their menopause.
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Affiliation(s)
- H Abdalla
- Lister Fertility Clinic, Lister Hospital, Chelsea Bridge Road, London SW1W 8RH, UK.
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29
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Kolibianakis EM, Collins J, Tarlatzis B, Papanikolaou E, Devroey P. Are endogenous LH levels during ovarian stimulation for IVF using GnRH analogues associated with the probability of ongoing pregnancy? A systematic review. Hum Reprod Update 2005; 12:3-12. [PMID: 16123054 DOI: 10.1093/humupd/dmi030] [Citation(s) in RCA: 50] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
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.
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Affiliation(s)
- E M Kolibianakis
- Department of Obstetrics and Gynaecology, Unit for Human Reproduction, Aristotle University of Thessaloniki, Thessaloniki, Greece.
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30
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Liu SY, Han JL, Peng XD, Dong X, Xu J, Yan JM. Effect of midfollicular luteinizing hormone levels on ovarian response and pregnancy outcome in patients undergoing in vitro fertilization in a short-term protocol. Fertil Steril 2005; 83:1043-6. [PMID: 15820825 DOI: 10.1016/j.fertnstert.2004.12.015] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2004] [Revised: 12/08/2004] [Accepted: 12/08/2004] [Indexed: 11/19/2022]
Abstract
In a retrospective study, levels of LH in the midfollicular phase had a significant impact on ovarian response and pregnancy outcome. High LH levels were associated with reduced implantation and clinical pregnancy rates.
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Affiliation(s)
- Su-ying Liu
- Shanghai Jiai Genetics and IVF Institute, Obstetrics and Gynecology Hospital, Fudan University, 588 Fangxie Road, 200 011 Shanghai, People's Republic of China.
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Al-Inany H, Aboulghar MA, Mansour RT, Serour GI. Ovulation induction in the new millennium: recombinant follicle-stimulating hormone versus human menopausal gonadotropin. Gynecol Endocrinol 2005; 20:161-9. [PMID: 16019356 DOI: 10.1080/09513590400027232] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
Abstract
The renewed interest in luteinizing hormone (LH), together with limited and decreasing health resources, make essential the comparison of high-cost, recombinant follicle-stimulating hormone (rFSH) preparations (devoid of LH) and human menopausal gonadotropin (hMG) in terms of clinical efficacy. All published, randomized controlled trials (RCTs) comparing rFSH versus hMG under different protocols of stimulation were examined. Eight true RCTs were included in this meta-analysis, recruiting 2031 participants. Data for ongoing pregnancy/live birth rate, clinical pregnancy rate, miscarriage rate, multiple pregnancy rate and ovarian hyperstimulation syndrome (OHSS) were extracted, and odds ratios (ORs) and 95% confidence intervals (CIs) were calculated with the use of a fixed-effects model. Data for the meta-analysis were combined using RevMan software (using the Mantel-Haenszel method). Pooling the results of these RCTs showed no significant difference between rFSH and hMG regarding the different outcomes: ongoing pregnancy/live birth rate, OR 1.18 (95% CI 0.93-1.50); clinical pregnancy rate, OR 1.2 (95% CI 0.99-1.47), miscarriage rate, OR 1.2 (95% CI 0.70-2.16); multiple pregnancy rate, OR 1.35 (95% CI 0.96-1.90); incidence of moderate/severe OHSS, OR 1.79 (95% CI 0.74-4.33). However, there was significant reduction in the amount of gonadotropins in favor of hMG over rFSH. There was no significant heterogeneity of treatment effect across the trials. In conclusion, there is no clinically significant difference between hMG and rFSH in in vitro fertilization/intracytoplasmic sperm injection cycles. Decision-makers should establish their choice of one drug over the other based on the most up-to-date evidence available.
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Gerli S, Casini ML, Unfer V, Costabile L, Bini V, Di Renzo GC. Recombinant versus urinary follicle-stimulating hormone in intrauterine insemination cycles: A prospective, randomized analysis of cost effectiveness. Fertil Steril 2004; 82:573-8. [PMID: 15374698 DOI: 10.1016/j.fertnstert.2004.04.026] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2003] [Revised: 04/06/2004] [Accepted: 04/06/2004] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To compare the clinical results and the cost effectiveness of urinary FSH and recombinant FSH in ovarian stimulation for IUI cycles. DESIGN Prospective, randomized trial. SETTING University Hospital, Perugia, and A.G.UN.CO. Obstetrics and Gynaecology Centre, Rome, Italy. PATIENT(S) IUI cycles were performed in 67 infertile patients. INTERVENTION(S) Protocols of ovarian stimulation with urinary FSH or recombinant FSH were randomly assigned, for a total of 138 cycles performed (67 and 71, respectively). MAIN OUTCOME MEASURE(S) Number of mature follicles, days of stimulation, number of ampules, and IU used per cycle, biochemical/clinical pregnancy rates and cost-effectiveness ratio. RESULT(S) Follicular development, length of stimulation, pregnancy and delivery rates were not statistically different. Although in the urinary FSH group a significantly higher number of IU of gonadotropins were used (815.5 +/- 284.9 vs. 596.0 +/- 253.8), the cost per cycle remained significantly lower (220.73 +/- 94.72 vs. 318.50 +/- 125.21). The cost-effectiveness ratio was 1,848.61 euro in the urinary FSH group and 2,512.61 euro in the recombinant FSH group. CONCLUSION(S) Urinary FSH and recombinant FSH are both effective in ovarian stimulation in IUI cycles. The urinary preparation is more cost effective due to the difference of its cost per IU.
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Affiliation(s)
- Sandro Gerli
- Centre of Reproductive and Perinatal Medicine, Department of Gynecological, Obstetrical and Pediatric Sciences, University of Perugia, Policlinico Monteluce, Perugia 06122, Italy.
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Stouffer RL, Zelinski-Wooten MB. Overriding follicle selection in controlled ovarian stimulation protocols: quality vs quantity. Reprod Biol Endocrinol 2004; 2:32. [PMID: 15200679 PMCID: PMC442134 DOI: 10.1186/1477-7827-2-32] [Citation(s) in RCA: 48] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2004] [Accepted: 06/16/2004] [Indexed: 11/25/2022] Open
Abstract
Selection of the species-specific number of follicles that will develop and ovulate during the ovarian cycle can be overridden by increasing the levels of pituitary gonadotropin hormones, FSH and LH. During controlled ovarian stimulation (COS) in nonhuman primates for assisted reproductive technology (ART) protocols, the method of choice (but not the only method) has been the administration of exogenous gonadotropins, either of nonprimate or primate origin. Due to species-specificity of the primate LH (but not FSH) receptor, COS with nonprimate (e.g., PMSG) hormones can be attributed to their FSH activity. Elevated levels of FSH alone will produce large antral follicles containing oocytes capable of fertilization in vitro (IVF). However, there is evidence that LH, probably in lesser amounts, increases the rate of follicular development, reduces heterogeneity of the antral follicle pool, and improves the viability and rate of pre-implantation development of IVF-produced embryos. Since an endogenous LH surge typically does not occur during COS cycles (especially when a GnRH antagonist is added), a large dose of an LH-like hormone (i.e., hCG) may be given to reinitiate meiosis and produce fertilizable oocytes. Alternate approaches using exogenous LH (or FSH), or GnRH agonist to induce an endogenous LH surge, have received lesser attention. Current protocols will routinely yield dozens of large follicles with fertilizable eggs. However, limitations include non/poor-responding animals, heterogeneity of follicles (and presumably oocytes) and subsequent short luteal phases (limiting embryo transfer in COS cycles). However, the most serious limitation to further improvements and expanded use of COS protocols for ART is the lack of availability of nonhuman primate gonadotropins. Human, and even more so, nonprimate gonadotropins are antigenic in monkeys, which limits the number of COS cycles to as few as 1 (PMSG) or 3 (recombinant hCG) protocols in macaques. Production and access to sufficient supplies of nonhuman primate FSH, LH and CG would overcome this major hurdle.
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Affiliation(s)
- Richard L Stouffer
- Division of Reproductive Sciences, Oregon National Primate Research Center, Oregon Health & Science University, Beaverton, Oregon, USA
| | - Mary B Zelinski-Wooten
- Division of Reproductive Sciences, Oregon National Primate Research Center, Oregon Health & Science University, Beaverton, Oregon, USA
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Gerli S, Casini ML, Unfer V, Costabile L, Mignosa M, Di Renzo GC. Ovulation induction with urinary FSH or recombinant FSH in polycystic ovary syndrome patients: a prospective randomized analysis of cost-effectiveness. Reprod Biomed Online 2004; 9:494-9. [PMID: 15588465 DOI: 10.1016/s1472-6483(10)61632-x] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
The aim of this prospective, randomized trial was to compare the clinical results and the cost-effectiveness of urinary FSH (uFSH) and recombinant FSH (rFSH) in ovarian stimulation for intrauterine insemination (IUI) cycles in polycystic ovary syndrome (PCOS) patients. One-hundred and seventy PCOS infertile patients undergoing IUI were enrolled, and protocols of ovarian stimulation with uFSH or rFSH were randomly assigned. The total number of cycles performed was 379 (182 and 197, respectively). The main outcome measures were the number of mature follicles, the days of stimulation, the number of ampoules and IU used per cycle, the biochemical/clinical pregnancy rates, the number of multiple pregnancies and the cost-effectiveness. No statistically significant differences were found in the follicular development, length of stimulation, pregnancy rates, delivery rates and multiple pregnancies between the two groups. In the uFSH group, the cost per cycle remained significantly lower (218.51 +/- 88.69 versus 312.22 +/- 118.12; P < 0.0001), even though a significantly higher number of IU of gonadotrophins were used (809.3 +/- 271.9 versus 589.1 +/- 244.7; P < 0.0001). The cost-effectiveness (i. e. within a group, the total cost of all cycles divided by no. of clinical pregnancies) was 1729.08 in the uFSH group and 3075.37 in the rFSH group. In conclusion, uFSH and rFSH demonstrated the same effectiveness in ovarian stimulation in IUI cycles in PCOS patients. The urinary preparation is more cost-effective due to the difference of its cost per IU.
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Affiliation(s)
- Sandro Gerli
- Centre of Reproductive and Perinatal Medicine, Department of Gynecological, Obstetrical and Pediatric Sciences, University of Perugia, Italy.
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van Wely M, Westergaard LG, Bossuyt PMM, van der Veen F. Effectiveness of human menopausal gonadotropin versus recombinant follicle-stimulating hormone for controlled ovarian hyperstimulation in assisted reproductive cycles: a meta-analysis. Fertil Steril 2003; 80:1086-93. [PMID: 14607553 DOI: 10.1016/s0015-0282(03)02187-3] [Citation(s) in RCA: 75] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To compare the effectiveness of hMG and recombinant FSH after down-regulation for ovulation stimulation in assisted reproductive cycles. DESIGN Meta-analysis. SETTING Infertility centers providing assisted reproductive techniques. PATIENT(S) Two thousand thirty women undergoing IVF or ICSI. INTERVENTIONS Ovarian hyperstimulation with hMG or recombinant FSH after down-regulation. MAIN OUTCOME MEASURE(S) Clinical pregnancy rate, ongoing pregnancy/live birth rate, gonadotropin dose used, oocytes retrieved, implantation rate, miscarriage rate, and multiple pregnancy rate. RESULT(S) Six randomized controlled trials were included. In all trials, the group of women treated with hMG had higher pregnancy rates. Pooling the five trials that used a long GnRH agonist protocol resulted in a higher clinical pregnancy rate for hMG compared with recombinant FSH (relative risk, 1.22 [95% CI, 1.03 to 1.44]). However, there was no evidence of a difference in rates of ongoing pregnancy or live birth per woman between hMG recipients and recombinant FSH recipients (relative risk, 1.20 [95% CI, 0.99 to 1.45]). No differences were found in gonadotropin dose used, oocytes retrieved, miscarriage rate, or multiple pregnancy rate. CONCLUSION(S) Use of hMG resulted in higher clinical pregnancy rates than did use of recombinant FSH in IVF/ICSI cycles after GnRH agonist down-regulation in a long protocol.
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Filicori M, Cognigni GE, Pocognoli P, Ciampaglia W. Choice of ovarian stimulation regimens in assisted reproduction: finding the thread in the gonadotropin maze. Fertil Steril 2003; 80:1114-6. [PMID: 14607558 DOI: 10.1016/s0015-0282(03)02192-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Affiliation(s)
- Marco Filicori
- Reproductive Endocrinology Center, University of Bologna, Bologna, Italy.
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Affiliation(s)
- John Collins
- Department of Obstetrics and Gynecology, McMaster University, Hamilton, Ontario, Canada.
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Filicori M, Cognigni GE, Pocognoli P, Ciampaglia W, Bernardi S. Current concepts and novel applications of LH activity in ovarian stimulation. Trends Endocrinol Metab 2003; 14:267-73. [PMID: 12890591 DOI: 10.1016/s1043-2760(03)00085-7] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Luteinizing hormone (LH) is a crucial physiological regulator of the human menstrual cycle. LH activity is also contained in many medications used to treat anovulation and to stimulate multiple folliculogenesis for assisted reproduction techniques. However, LH activity had previously been regarded as just a contaminant of follicle-stimulating hormone (FSH)-containing products and deemed potentially detrimental for reproductive function. Novel experimental and clinical evidence now suggests that the administration of pharmacological amounts of LH activity, instead of being harmful, is therapeutically advantageous, particularly in the support and modulation of ovarian folliculogenesis. The aim of this article is to provide an overview of the effects of LH activity administration in ovarian stimulation and to outline novel unconventional gonadotropin regimens that might improve the efficacy, safety and convenience of ovulation induction.
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Affiliation(s)
- Marco Filicori
- Reproductive Endocrinology Center, University of Bologna, Via Massarenti 13, 40138 Bologna, Italy.
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40
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Russell I, Russell D. Evidence-based fertility treatment: what do we mean? HUM FERTIL 2003; 6 Suppl 1:S35-41. [PMID: 12869778 DOI: 10.1080/1464770312331369253] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
This article explores the meaning of 'evidence-based fertility treatment' and reviews the relevance of evidence-based health care to the proposed National Service Framework (NSF) for Infertility Services. It summarizes the principles of systematic literature reviewing and proposes an agenda for those developing the NSF. This agenda is illustrated by data from a preliminary review by the authors. The main strength of the proposed NSF lies in the National Evidence-Based Clinical Guidelines but the main weakness lies in the lack of rigorous positive evidence underpinning these guidelines. The NSF team will have to appraise, enhance, extend and synthesize these reviews. The lack of an NSF would threaten the future effectiveness and cost-effectiveness of infertility services in the UK.
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Affiliation(s)
- Ian Russell
- Institute of Medical and Social Care Research, University of Wales Bangor, Bangor, Gwynedd LL57 2UW, UK
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Abstract
Ovarian stimulation during assisted human reproduction is currently a standard procedure in assisted reproductive techniques (ART). Its objective is to stimulate the growth of several follicles by injections of FSH-containing compounds, most recently recombinant FSH (rFSH). An injection of human chorionic gonadotrophin (HCG), or a luteinizing hormone-releasing hormone agonist to discharge pituitary LH is then given to invoke follicle and oocyte maturation. Various other medications are also used in addition to specific drugs such as human menopausal gonadotrophin, rFSH, HCG and rLH. Non-specific drugs include clomiphene citrate, other anti-oestrogens, bromoergocryptine, and gonadotrophin-releasing hormone (GnRH) agonists and antagonists. Numerous protocols have been utilized with these agents, the most common being clomiphene citrate and various regimens of gonadotrophins, including step-up, step-down and continuous. The regimens are used with or without GnRH agonists, and with or without GnRH antagonists. In this brief review, the advantages and disadvantages of each protocol are presented.
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Ludwig M, Westergaard LG, Diedrich K, Andersen CY. Developments in drugs for ovarian stimulation. Best Pract Res Clin Obstet Gynaecol 2003; 17:231-47. [PMID: 12758097 DOI: 10.1016/s1521-6934(02)00168-2] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Drugs for ovarian stimulation have been improved during the last decades. Initially gonadotrophins were extracted from human pituitary glands and urine; nowadays they are produced from transformed cell-lines. All three gonadotrophins--follicle stimulating hormone (FSH), luteinizing hormone (LH) and human chorionic gonadotrophin (hCG)--are now marketed as recombinant (r-) products. The near-100% pure FSH preparations might, in some situations, cause abnormally low LH levels and it is likely that the addition of LH may be beneficial in these situations. It is possible that r-LH will become available in sufficient dosages to replace hCG for ovulation induction and this may reduce the incidence of ovarian hyperstimulation syndrome due to its shorter half-life. In parallel to the development of gonadotrophin preparations, protocols for ovarian stimulation are now more comfortable for the patients, especially with the introduction of gonadotrophin receptor hormone (GnRH)-agonists in the early 1980s and, more recently, the introduction of GnRH-antagonists.
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Affiliation(s)
- M Ludwig
- Department of Gynaecology and Obstetrics, Division of Reproductive Medicine and Gynaecologic Endocrinology, University Clinic, Ratzeburger Allee 160, 23538 Lübeck, Germany.
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Van Wely M, Westergaard LG, Bossuyt PMM, Van der Veen F. Human menopausal gonadotropin versus recombinant follicle stimulation hormone for ovarian stimulation in assisted reproductive cycles. Cochrane Database Syst Rev 2003:CD003973. [PMID: 12535497 DOI: 10.1002/14651858.cd003973] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND hMG and recombinant FSH, have both been used successfully for controlled ovarian hyperstimulation in in vitro fertilization and embryo transfer (IVF-ET). OBJECTIVES To compare the effectiveness of hMG with rFSH in ovarian stimulation protocols in IVF or ICSI treatment cycles. SEARCH STRATEGY We searched the Cochrane Menstrual Disorders and Subfertility Group trials register (searched 3rd Jan 2002), PubMed, MEDLINE, Web of Science (all searched 1985 to May 15 2002), and reference lists of articles. We also contacted manufacturers and researchers in the field. SELECTION CRITERIA Randomised trials comparing hMG with rFSH for ovarian stimulation in IVF or ICSI treatment for treatment of infertility in normogonadotrophic women. DATA COLLECTION AND ANALYSIS The main outcome measure was ongoing pregnancy/live birth per woman. Secondary outcomes included total gonadotrophin dose used, cancellation, number of oocytes retrieved, implantation, clinical pregnancy per woman, multiple pregnancy, spontaneous abortion and ovarian hyperstimulation syndrome. Peto odds ratios (OR) for hMG relative to rFSH were calculated after testing for homogeneity of treatment effect across all trials. Analyses were performed separately for the three different GnRHa protocols used: (1) without GnRHa down-regulation, (2) with GnRHa down-regulation using a short protocol and (3) with GnRHa down-regulation using a long protocol. MAIN RESULTS Eight trials that met the inclusion criteria could be identified. One trial did not use down-regulation, one trial used a short protocol and six trials used a long down-regulation protocol. In the one trial with non-down-regulated women and in the one trial that used a short down-regulation protocol there was no evidence of a difference between hMG and rFSH in any clinical outcome. Data of four truly randomised trials in women down-regulated using a long protocol could be pooled. There was no evidence of a difference between hMG and rFSH in ongoing pregnancy/live birth per woman (OR 1.27; 95% CI 0.98 to 1.64). Furthermore there was no clear difference on any of the secondary outcomes, although the clinical pregnancy rate per woman was of borderline significance in favour of hMG (summary OR 1.28; 95% CI 1.00 to 1.64). The other secondary outcomes were comparable for both gonadotrophins. REVIEWER'S CONCLUSIONS For all three GnRHa protocols analysed there is insufficient evidence of a difference between hMG and rFSH on ongoing pregnancy or live birth. More large randomised trials are needed to estimate the difference between hMG and rFSH more precisely. Such trials should preferably (1) use a consistent long GnRHa protocol and (2) use a fixed dose of gonadotrophin such to prevent potentially subjective decisions of the clinician in dosing and (3) take live birth as primary endpoint. At this moment in time however, in prescribing gonadotrophins for ovarian hyperstimulation in IVF one should use the least expensive medication.
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Affiliation(s)
- M Van Wely
- Center for Reproductive Medicine, Dept. of Obstetrics & Gynaecology, Academic Medical Center, Meibergdreef 9, Amsterdam, Netherlands, 1105 AZ.
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Selman HA, De Santo M, Sterzik K, Coccia E, El-Danasouri I. Effect of highly purified urinary follicle-stimulating hormone on oocyte and embryo quality. Fertil Steril 2002; 78:1061-7. [PMID: 12413994 DOI: 10.1016/s0015-0282(02)04202-4] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVE To determine the effects of ovarian stimulation with highly purified urofollitropin on oocyte and embryo quality. DESIGN Parallel randomized open-label clinical study. SETTING Assisted reproduction centers. PATIENT(S) Two hundred sixty-seven infertile couples undergoing IVF/ICSI. INTERVENTION(S) All participants underwent standard down-regulation with GnRH analogue. One hundred thirty-three participants received highly purified urinary FSH and 134 controls received recombinant FSH. MAIN OUTCOME MEASURE(S) Primary end points were number of morphologically mature oocytes retrieved, embryo quality, and pregnancy and implantation rates. Secondary end points were: total number of days of FSH stimulation, total dose of gonadotropin administered, fertilization rate per number of retrieved oocytes, embryo cleavage rate, live birth and miscarriage rates, endometrial thickness and estradiol level on the day of hCG administration, cancellation rate, and incidence of moderate or severe ovarian hyperstimulation syndrome. RESULT(S) Pregnancy and implantation rates were nonsignificantly higher in the urinary FSH group than the recombinant FSH group (46.5% vs. 36.8% and 22.1% vs. 15.8%, respectively). The grade 1 embryo score was significantly higher in the urinary FSH group than the recombinant FSH (42.1% vs. 33.5%), and the live birth rate was nonsignificantly higher in the former group. CONCLUSION(S) Highly purified urinary FSH is as effective, efficient, and safe for clinical use as recombinant FSH.
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Affiliation(s)
- Helmy A Selman
- Istituto Europeo Medicina della Riproduzione Abruzzese, Spatocco Hospital, Chieti, Italy.
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Fanchin R. [Revisiting the role of LH in follicular development]. GYNECOLOGIE, OBSTETRIQUE & FERTILITE 2002; 30:753-64. [PMID: 12478981 DOI: 10.1016/s1297-9589(02)00438-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
During the last decade, two pivotal events widened the gap between the hormonal dynamics of ovarian stimulation and that of the menstrual cycle. First, the profound and routine suppression of endogenous gonadotropins by GnRH analogues used in ovarian stimulation pressed us to recreate the hormonal environment necessary for adequate follicular maturation and steroidogenesis. Second, drugs with reduced or null LH activity became available, based on the hypothesis that FSH action was sufficient to follicular development and maturation irrespective of residual endogenous gonadotropin levels. Today, there is a renewed interest in the possible role of LH on follicular development, in an effort to mimic the hormonal events of the menstrual cycle to optimize ovarian stimulation outcome.
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Affiliation(s)
- R Fanchin
- Service de gynécologie-obstétrique et médecine de la reproduction, hôpital Antoine Béclère, 157, rue de la Porte-de-Trivaux, 92141 Clamart, France.
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Efficacy and safety of highly purified menotropin versus recombinant follicle-stimulating hormone in in vitro fertilization/intracytoplasmic sperm injection cycles: a randomized, comparative trial. Fertil Steril 2002; 78:520-8. [PMID: 12215327 DOI: 10.1016/s0015-0282(02)03250-8] [Citation(s) in RCA: 97] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
OBJECTIVE To demonstrate that highly purified human menopausal gonadotropin (HP-hMG) is as efficient and safe as recombinant FSH in females undergoing in vitro fertilization/intracytoplasmic sperm injection (IVF/ICSI) treatment cycles. DESIGN Multinational, open label, randomized, parallel group, comparative phase III trial. SETTING In 22 centers across six countries; Belgium (1 center), Germany (6 centers), Israel (6 centers), The Netherlands (2 centers), Switzerland (1 center) and the United Kingdom (6 centers). PATIENT(S) A total of 781 women were enrolled between May 1999 and November 2000. INTERVENTION(S) In the all-patients-treated population, 373 patients received HP-hMG and 354 received recombinant FSH. A long protocol GnRH agonist regimen was used. MAIN OUTCOME MEASURE(S) The primary end point was ongoing pregnancy rate following one IVF/ICSI treatment cycle. Safety was assessed as a secondary end point. RESULT(S) Ongoing pregnancy rates 10 weeks after ovum pickup in the per-protocol population were 25% (n = 85/344) in the HP-hMG group and 22% (n = 71/317) in the recombinant FSH group. The incidence of ovarian hyperstimulation syndrome, miscarriage, adverse events, and injection site reactions (tolerability) were similar in both treatment groups. CONCLUSION(S) We found HP-hMG to be as effective as recombinant FSH in terms of ongoing clinical pregnancy. Both treatments have a similar safety/tolerability profile.
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Dyer SJ. The conflict between effective and affordable health care--a perspective from the developing world. Hum Reprod 2002; 17:1680-3. [PMID: 12093823 DOI: 10.1093/humrep/17.7.1680] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
The recent introduction of recombinant FSH into the clinical management of patients suffering from infertility appears to be associated with several treatment benefits when compared with urinary human menopausal gonadotrophin. However, from the perspective of the developing world the associated increase in cost is a cause for concern--particularly if the "cheaper" urinary gonadotrophins are no longer marketed. The need for infertility care in Africa is significant, but health resources are very limited. The commonest cause of infertility in Africa is tubal disease, so that assisted reproductive techniques, and therefore exogenous gonadotrophins, are central to effective management. The conflict between affordable and effective health care is addressed.
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Affiliation(s)
- S J Dyer
- Andrology Laboratory MB118 First Floor, Maternity Centre, Observatory 7925, South Africa.
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Sykes D, Out HJ, Palmer SJ, van Loon J. The cost-effectiveness of IVF in the UK: a comparison of three gonadotrophin treatments. Hum Reprod 2001; 16:2557-62. [PMID: 11726574 DOI: 10.1093/humrep/16.12.2557] [Citation(s) in RCA: 42] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND The objective of this study was to evaluate the cost-effectiveness of women undergoing IVF treatment with recombinant FSH (rFSH) in comparison with highly purified urinary FSH (uFSH-HP) and human menopausal gonadotrophins (HMG). METHODS A decision-analytic model was used to estimate cost-effectiveness ratios for 'the average cost per ongoing pregnancy' and 'incremental cost per additional pregnancy' for women entering into IVF treatment for a maximum of three cycles. The model was constructed based on a previously published large prospective randomized clinical trial comparing rFSH and uFSH-HP. Where necessary, these data were augmented with a combination of expert opinion, evidence from the literature and observational data relating to the management and cost of IVF treatment in the UK. The cost of rFSH, uFSH-HP and HMG were obtained from National Health Service list prices in the UK. RESULTS The model predicted a cumulative pregnancy rate after three cycles of 57.1% for rFSH and 44.4% for both uFSH-HP and HMG. The cost of IVF treatment was 5135 pounds sterling for rFSH, 4806 pounds sterling for uFSH-HP and 4202 pounds sterling for HMG. When assessed in association with outcomes, the average cost per ongoing pregnancy was more favourable with rFSH (8992 pounds sterling) than with either uFSH-HP (10 834 pounds sterling) or HMG (9472 pounds sterling). The incremental cost per additional pregnancy was 2583 pounds sterling using rFSH instead of uFSH-HP and 7321 pounds sterling using rFSH instead of HMG. These results were robust to changes in the baseline assumptions of the model. CONCLUSION rFSH is a cost-effective treatment strategy in ovulation induction prior to IVF.
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Affiliation(s)
- D Sykes
- Organon Laboratories, Cambridge Science Park, Milton Road, Cambridge CB4 0FL, UK
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49
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Blumenfeld Z. Recombinant FSH vs. urinary FSH--retrospective study of matched pairs for type of treatment (IVF or ICSI). Fertil Steril 2001; 76:1289-90. [PMID: 11730777 DOI: 10.1016/s0015-0282(01)02919-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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50
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Check JH. HMG is possibly superior to recombinant FSH for IVF. Hum Reprod 2001; 16:2473. [PMID: 11679540 DOI: 10.1093/humrep/16.11.2473] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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