To add or not to add LH: comments on a recent commentary

Recombinant luteinizing hormone supplementation in assisted reproductive technology: a review of literature

Background

Luteinizing hormone (LH) has the main role in ovarian function in both natural and artificial cycles. A normal LH concentration during controlled ovarian hyperstimulation is positively correlated to the number and quality of retrieved oocytes and resulting embryos.

Main body of the abstract

In this study, we reviewed whether rLH administration, adjunct to the ovarian stimulation regimen, could improve clinical outcomes. The literature review showed that rLH supplementation improves assisted reproductive technology (ART) outcomes among women with hypogonadotropic hypogonadism, and hyporesponsive women to follicle-stimulating hormone monotherapy. Besides, rLH supplementation has advantages for poor responder women 36–39 years of age. Even though the data suggested no priority regarding the LH source for improving ART outcome, women with different LH polymorphisms who did not respond similarly to ovarian stimulation may benefit from adjuvant rLH therapy.

Conclusion

rLH usage for improving ART outcome should be scrutinized via well-designed studies considering the subgroups of infertile women who benefit the most from rLH adjuvant therapy, the type of ovarian stimulation protocol to which rLH would be added, and also the exact dosage, as well as the proper timing (during or prior to a cycle).

Clinical effects of a natural extract of urinary human menopausal gonadotrophin in normogonadotropic infertile patients

Purified human menopausal gonadotropin (HMG) is a natural product extracted from the urine of postmenopausal women that contains pituitary follicle-stimulating hormone (FSH), luteinizing hormone (LH), and a small amount of human chorionic gonadotropin (HCG). Here we retrospectively conducted a clinical pharmaceutical study on a cohort of normogonadotropic infertile patients addressed to long GnRH-agonist protocol with serum LH concentration ranging from 0.5 IU/L to 1.5 IU/L during the midfollicle phase, aiming at evaluating the effects of purified HMG supplementation during ovarian stimulation. There was no significant difference in either the basic clinical features of the patients or the pregnancy rate (71.4% versus 66.3%, P > 0.05) or other related indicators of pregnancy outcome. However, there was a higher level of serum oestradiol (E2) on the day of human chorionic gonadotropin (HCG) (1999.10 ± 860.50 IU/L versus 2883.29 ± 1427.382 IU/L, P = 0.000) but lower fertilization rate (89.1% versus 69.6%, P < 0.000) in patients getting HMG supplementation and a higher risk of developing ovarian hyperstimulation syndrome (OHSS). We suppose that exogenous LH supplementation is not needed when serum LH concentration of the midfollicle phase is around 0.5-1.5 IU/L during the long GnRH-agonist protocol. Adding exogenous HMG may decrease the fertilization rate and increase the risk of developing OHSS.

Recombinant human follicle-stimulating hormone produces more oocytes with a lower total dose per cycle in assisted reproductive technologies compared with highly purified human menopausal gonadotrophin: a meta-analysis

BACKGROUND

Human menopausal gonadotrophins and recombinant human follicle stimulating hormone are the two main gonadotrophin products utilized for controlled ovarian stimulation in assisted reproductive technologies. In this meta-analysis, the number of oocytes was designated as the most relevant endpoint directly resulting from ovarian stimulation, and therefore where the drug effect may be estimated with the best sensitivity.

METHODS

All published randomized controlled trials on ovarian stimulation comparing the two gonadotrophin products were evaluated. Internal validity was determined using Chalmers' validated scale. If trials did not meet the established quality criteria, a sensitivity analysis assessed the stability of the results. The comparison of continuous variables was conducted following the weighted mean difference and the standardized mean difference (Cohen's effect size) with the random model. Given the known relationship of baseline conditions on treatment endpoints, results were adjusted for age, body mass index and type of infertility.

RESULTS

Sixteen studies involving 4040 patients were included. Treatment with human menopausal gonadotrophins resulted in fewer oocytes (-1.54; 95% CI: -2.53 to -0.56; P < 0.0001) compared to recombinant human follicle-stimulating hormone. When adjusting for baseline conditions, the mean difference estimate was -2.10 (95% CI: -2.83 to -1.36; P < 0.001). A higher total dose of human menopausal gonadotrophin was necessary (mean difference, 235.46 IU [95% CI: 16.62 to 454.30; P = 0.03]; standardized mean difference, 0.33 [95% CI: 0.08 to 0.58; P = 0.01]). The pregnancy absolute risk difference (RD [hMG-r-hFSH]) for fresh transfers was 3% (P = 0.051), and the relative risk 1.10 (P = 0.06). When adjusted for baseline conditions, the relative risk was 1.04 (P = 0.49) and absolute difference was 0.01 (P = 0.34), respectively.

CONCLUSIONS

Because baseline conditions are predictive of outcome, meta-analytic results are more sensitive when these variables are considered. Using an endpoint closely associated with the stimulation period, sufficient sensitivity is achieved to compare gonadotrophin treatments. As the largest meta-analysis published to date on this subject, treatment with human menopausal gonadotrophins is characterized by fewer oocytes and a higher total dose. When considering only fresh transfers, pregnancy rates were similar.

Outcomes after early or midfollicular phase LH supplementation in previous inadequate responders

Second cycle outcomes of 75 patients who had previous inadequate ovarian response with recombinant FSH (rFSH)-only ovarian stimulation during gonadotrophin-releasing hormone analogue (GnRHa) down-regulated cycles were evaluated retrospectively. In these second cycles, both rFSH and human menopausal gonadotrophin (HMG) in GnRHa long down-regulation were given to all patients, HMG initiated either on day 1 (group A, n=37) or day 5-6 of the ovarian stimulation (group B, n=38). Total HMG dose was higher (1198+/-514 IU versus 726+/-469 IU; P<0.001), cumulative rFSH consumption was lower (1823+/-804 IU versus 2863+/-1393 IU; P=0.001) and duration of stimulation was shorter (8.94+/-1.15 days versus 10.37+/-1.80 days; P<0.001) in group A than in group B. No significant differences were found regarding fertilization, implantation or pregnancy rates and embryo quality between the groups. Further analysis by supplementary HMG dose (75 IU versus 150 IU) revealed that total gonadotrophin and HMG consumption was lower in 75 IU-supplemented subgroups. Notably, pregnancy rate was higher in patients where 75 IU HMG was supplemented on day 5-6 of ovarian stimulation, which deserves further evaluation.

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

BACKGROUND

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

METHODS

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

RESULT(S)

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

CONCLUSION

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

The ratio of late-follicular to mid-follicular phase LH concentrations efficiently predicts ART outcomes in women undergoing ART treatment with GnRH-agonist long protocol and stimulation with recombinant FSH

PURPOSE

To establish an index to predict ART outcomes and to identify infertile patients who need LH supplementation during ovarian stimulation.

METHODS

Serum LH concentrations were measured during the mid- and late-follicular phase in 86 normogonadotropic infertile patients who underwent ART treatment using GnRH-agonist long protocol with recombinant-FSH. The relationships between serum LH concentrations at both time points and ART outcomes were retrospectively analyzed, and the relationships between the ratio of late-follicular to mid-follicular LH concentrations and ART outcomes were also evaluated.

RESULTS

There were no significant correlations between the mid- or late-follicular LH concentrations and ART outcomes. The ratio of late-follicular to mid-follicular LH concentrations <1.0 was considered the relatively LH decreased group (RD group) and ratio >or= 1.0 was considered the relatively LH increased group (RI group). The number of usable embryos in RD group was similar to that in RI group, but the pregnancy and implantation rates in the RD group (9.7% and 5.8%) were significantly lower than those in the RI group (31.1% and 17.2%; p < 0.05).

CONCLUSIONS

Relatively decreased LH concentrations during ovarian stimulation using GnRH-agonist long protocol with rec-FSH had a negative effect on ART outcomes. Therefore, the ratio of mid- to late-follicular phase LH concentrations is suggested to be an efficient index to identify patients who might benefit from LH supplementation.

Bioequivalence of recombinant human FSH and recombinant human LH in a fixed 2:1 combination: two phase I, randomised, crossover studies

OBJECTIVES

To assess bioequivalence of recombinant human follicle stimulating hormone (r-hFSH, follitropin alfa) and recombinant human luteinising hormone (r-hLH, lutropin alfa) in a fixed 2:1 combination (Pergoveris) compared with injection of each of the hormones separately.

RESEARCH DESIGN AND METHODS

Two, two-way crossover, phase I studies in healthy female volunteers after gonadotrophin-releasing hormone agonist down-regulation. Volunteers were randomised to the order in which they received subcutaneous injections. In the r-hFSH study, volunteers received one injection of r-hFSH (300 IU) and one of r-hFSH (300 IU)/r-hLH (150 IU) > or = 7 days apart; in the r-hLH study they received r-hLH (450 IU) and r-hFSH (900 IU)/r-hLH (450 IU) > 21 days apart.

MAIN OUTCOME MEASURES

The serum concentration-time profiles of FSH in the r-hFSH study and LH in the r-hLH study from zero to the last measurable concentration (AUC(0-last)) and the peak FSH/LH serum concentrations (C(max)) were assessed by non-compartmental analysis. The pre-defined range for bioequivalence was 0.8-1.25 for 90% confidence intervals (CI) of the ratio (fixed combination/single gonadotrophin) of the mean for each pharmacokinetic parameter.

RESULTS

Bioequivalence criteria were met for the r-hFSH study (n = 34) for C(max) (ratio of means 1.0024, 90% confidence interval (CI) 0.9611-1.0454) and AUC(0-last) (ratio of means 1.0167, 90% CI 0.9933-1.0407), and for the r-hLH study (n = 63) for C(max) (ratio of means 0.9687, 90% CI 0.9194-1.0207) and AUC(0-last) (ratio of means 0.9753, 90% CI 0.8990-1.0581). In the r-hFSH study, 20 adverse events (AEs) were reported after injection of r-hFSH and 20 after r-hLH/r-hFSH. In the r-hLH study, 179 AEs were reported after injection of r-hLH and 193 after the fixed-dose combination. Across both studies, headache was the most commonly reported AE. No serious AEs occurred.

CONCLUSIONS

These studies demonstrated bioequivalence between r-hFSH and r-hLH administered alone or in fixed 2:1 combination. The 2:1 combination of follitropin alfa and lutropin alfa allows administration of both recombinant gonadotrophins in a single injection.

Predictors of ovarian response: progress towards individualized treatment in ovulation induction and ovarian stimulation

Ovarian stimulation is applied in the clinic to restore mono-ovulatory cycles in anovulatory women (ovulation induction) or to induce the development of multiple dominant follicles for assisted reproduction. Ovarian response is the endocrine and follicular reaction of the ovaries to stimulation. Achieving an appropriate ovarian response to anti-estrogens or exogenous gonadotrophins is central to ovulation induction and ovarian stimulation protocols. However, achieving an adequate response, without cycle cancellation or adverse events related to under- or over-stimulation, is complicated by high intra- and inter-individual variability. To predict each patient's ovarian response to medication for ovarian stimulation and to individualize the starting dose of exogenous gonadotrophin or the need for exogenous luteinizing hormone, various clinical, endocrine, ovarian ultrasonographic and genetic characteristics have been explored. Some of these features have been incorporated into prediction models. In this review, the methodology behind predictive factors and prediction models and their potential clinical applicability across ovulation induction and ovarian stimulation are explored.

LH in the follicular phase: neither too high nor too low

The role of LH in the natural menstrual cycle is not disputed. However, there are a variety of opinions regarding the potential role of exogenous LH in ovulation induction and whether it is actually needed. Recent years have seen renewed interest in this issue for several reasons. First, ovulation-inducing drugs are increasingly being administered to normally ovulating women. Second, recombinant human FSH products completely devoid of LH activity are now available. Third, gonadotrophin-releasing hormone (GnRH) analogues (agonists and antagonists) prevent the untimely LH surge but also suppress endogenous LH activity during the follicular phase. This review analyses whether or not all patients need LH for follicular growth stimulation and new opportunities for improved treatment as a result of the availability of recombinant human LH both in patients with ovulatory disorders (World Health Organization (WHO) groups I and II anovulatory patients) and those undergoing multiple follicular development for assisted reproduction.

To add or not to add LH: comments on recent commentaries

Human reproductive evolution, involving a complex interaction of the hypothalamic-pituitary-ovarian axis, the release of pulsatile and threshold concentrations of gonadotrophins and positive and negative feedback systems, has ensured the release of a single viable egg and functioning corpora lutea in the natural menstrual cycle. The use of follicular stimulation regimens to obtain multiple eggs has resulted in a compromise - in terms of the risk of ovarian hyperstimulation, cost, multiple pregnancies, wastage of or the need for cryopreservation of surplus embryos. Even some women with apparently normal menstrual cycles might become 'poor responders' when administered with follicular stimulants, and we still do not know if the incidence of oocyte aneuploidy is artificially raised after stimulation. After the advent of recombinant FSH and LH, the precise roles of these hormones individually needs to be elucidated to understand the physiological requirements for successful ovarian stimulation in each woman undergoing IVF, to maximize her chance and minimise attendant risks. One of the key debates is the role of LH, which in the natural cycle is significant, but may be redundant during ovarian stimulation for IVF. Current outcome indicators are crude when attempting to understand the physiology, and more basic research and randomized, focused clinical trials are needed.