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

Optimal timing of GnRH antagonist initiation in IVF-ET: a retrospective cohort study on advanced maternal age women

Background

Several studies have compared the effects of fixed and flexible gonadotropin releasing hormone antagonist (GnRH-ant) protocols during in vitro fertilization and embryo transfer (IVF-ET). However, which GnRH-ant initiation strategy is better remains controversial. Moreover, no studies have assessed the optimal timing of GnRH-ant initiation in women of advanced maternal age (AMA).

Methods

In this retrospective cohort study, a total of 472 infertile women aged ≥ 35 years old undergoing their first IVF cycle from August 2015 to September 2021 at a tertiary academic medical center were recruited, of whom 136 followed fixed GnRH-ant protocol and 336 followed flexible GnRH-ant protocol. The primary outcomes measured were the cumulative live birth rate (CLBR) per IVF cycle and the time to live birth (TTLB) from the date of oocyte retrieval. Cox proportional models were used to calculate the hazard ratio (HR) and 95% confidence interval (CI) of CLBR regarding GnRH-ant timing.

Results

No significant difference in CLBR was found between the fixed and flexible GnRH-ant groups (27.9% vs 20.5%, p=0.105). The TTLB was also comparable between groups (10.56 vs 10.30 months, p=0.782). The Kaplan-Meier analysis for CLBR also showed comparable results between groups (P=0.351, HR=0.83; 95%CI: 0.56-1.23). After establishing a multiple Cox proportional hazard model, the fixed GnRH-ant group still had comparable CLBR with the flexible GnRH-ant group (HR=0.85; 95%CI: 0.53-1.38; P=0.518). Subgroup and sensitivity analyses also demonstrated similar results.

Conclusion

GnRH-ant protocols can be tailored to the needs of AMA women, and timing of GnRH-ant initiation can be adjusted flexibly.

LH level on ovulation trigger day has a different impact on the outcomes of agonist and antagonist regimens during in vitro fertilization

BACKGROUND

To assess the impact of the luteinizing hormone level on ovulation trigger day (LHOTD) on in vitro fertilization (IVF) outcomes in gonadotropin-releasing hormone (GnRH) agonist and antagonist regimens during fresh embryo transfer cycles.

METHODS

A stepwise, progressive multivariate regression model was introduced to assess the effect of the LHOTD on clinical pregnancy and live birth rates. Mantel‒Haenszel stratification analysis was used to examine the association between the LHOTD and clinical outcomes with the antagonist regimen.

RESULTS

The LHOTD had different distributions in the agonist and antagonist regimens. The cycles were assigned into three LHOTD tertile groups. In the agonist regimen, compared with the 1^st tertile (T1), in the 2^nd (T2) and 3^rd (T3) tertiles, the adjusted odds ratios (ORs) (95% confidence intervals [CIs], P value) were 1.187 (1.047-1.345, 0.007) and 1.420 (1.252-1.610, < 0.001) for clinical pregnancy, respectively, and 1.149 (1.009-1.309, 0.036) and 1.476 (1.296-1.681, < 0.001) for live birth. In the antagonist regimen, there was no significant difference in clinical pregnancy and live birth rates among the tertiles. However, in the stratified group of patients aged less than 35 years, the ORs (95% CIs, P value) of T2 and T3 were 1.316 (1.051-1.648, 0.017) and 1.354 (1.077-1.703, 0.009) for clinical pregnancy, respectively, and 1.275 (1.008-1.611, 0.043) and1.269 (0.999-1.611, 0.051) for live birth. Moreover, there was a discrepancy in the results among the subdivided LHOTD T1 groups adopting the antagonist regimen. Compared with that of the < 1.06 mIU/mL subgroup, the ORs (95% CIs, P value) of the > 1.5 mIU/mL subgroup were 1.693 (1.194-2.400, 0.003) for clinical pregnancy and 1.532 (1.057-2.220, 0.024) for live birth after eliminating potential confounders.

CONCLUSIONS

The LHOTD was profoundly suppressed in the agonist regimen, and its level was positively correlated with clinical pregnancy and live birth rates. In contrast, in the flexible antagonist regimen, the LHOTD was significantly higher than that in the agonist regimen and did not correlate with the outcome, except for women in the nonadvanced age group and those with an excessively suppressed LHOTD. Further investigation is required to determine the rationale for these findings.

Preventing Growth Stagnation and Premature LH Surge Are the Keys to Obtaining a Viable Embryo in Monofollicular IVF Cycles: A Retrospective Cohort Study

How LH levels influenced the outcomes of monofollicular IVF cycles using different stimulation protocols was controversial. In this single-center, retrospective study, we analyzed 815 monofollicular IVF cycles between 2016−2022 using natural cycle (NC), medroxyprogesterone acetate (MPA) or clomiphene citrate (CC) in addition to human menopausal gonadotropin (hMG), with or without GnRH antagonist. A viable embryo was obtained in 35.7% of all cycles. Growth stagnation and premature LH surge are two markedly negative factors for obtaining viable embryos (odds ratios of 0.12 [0.08−0.65], p < 0.0001 and 0.33 [0.26,0.42], p < 0.0001, respectively). NC/hMG cycles are prone to premature LH surge (40.4%), yielding a significantly lower opportunity of obtaining embryos (24.7%, p = 0.029). The administration of GnRH antagonist on the background of MPA resulted in a significant decrease in LH levels (from 2.26 IU/L to −0.89 IU/L relative to baseline, p = 0.000214), leading to a higher risk of growth stagnation (18.6%, p = 0.007). We hypothesized that the abrupt decline of LH might increase the risk of apoptosis in granulosa cells. We proposed a “marginal effect” framework to emphasize that the change of LH was the key to its bioactivity, rather than the traditional “window” concept with fixed cutoff values of a threshold and a ceiling.

Correlation analysis of serum reproductive hormones and metabolites during multiple ovulation in sheep

BACKGROUND

The establishment of non-invasive diagnostic method for multiple ovulation prediction is helpful to improve the efficiency of multiple ovulation. The blood hormones and metabolites would be suitable indexes for this subject.

METHODS

In this study, 86 estrus ewes (65 of induced estrus (IE) and 21 of spontaneous estrus (SE)) were selected and the blood samples were collected at the day before follicle-stimulating hormone (FSH) injection (1^st) and before artificial insemination (2^nd). The serum reproductive hormones ofFSH, luteinizing hormone (LH), 17β-Estradiol (E2), progesterone (P4) and anti-Mullerian hormone (AMH) were measured through enzyme linked immunosorbent assay (ELISA) and the untargeted metabolomics analysis was processed through LC-MS/MS. The embryos were collected after 6.5 days of artificial insemination.

RESULTS

In total, 975 and 406 embryos were collected in IE and SE group, respectively. The analysis of reproductive hormones showed that concentrations of FSH, E2 and AMH were positive correlated with the embryo yield while concentrations of LH and P4 were negative correlated in both group at 1^st detection. At 2^nd detection, the trends of reproductive hormones were similar with 1^st except P4, which was positive correlated with embryo yield. The metabolomics analysis showed that 1158 metabolites (721 in positive iron mode and 437 in negative iron mode) were detected and 617 were annotated. In 1^st comparation of high and low embryonic yield populations, 56 and 53 differential metabolites were identified in IE and SE group, respectively. The phosphatidyl choline (PC) (19:0/20:5) and PC (18:2/18:3) were shared in two groups. In 2^nd comparation, 48 and 49 differential metabolites were identified in IE and SE group, respectively. The PC (18:1/18:2) and pentadecanoic acid were shared. Most differential metabolites were significantly enriched in amino acid, fatty acid metabolism, digestive system secretion and ovarian steroidogenesis pathways.

CONCLUSIONS

This study showed that FSH, P4, AMH, the PC relevant metabolites and some anomic acids could be potential biomarkers for embryonic yield prediction in ovine multiple ovulation. The results would help to explain the relation between blood material and ovarian function and provide a theoretical basis for the multiple ovulation prediction.

The anti-androgenic effect of quercetin on hyperandrogenism and ovarian dysfunction induced in a dehydroepiandrosterone rat model of polycystic ovary syndrome

Polycystic ovary syndrome (PCOS) is a multi-factorial endocrine disorder associated with hyperandrogenism. Dehydroepiandrosterone (DHEA) administration to prepubertal rats stimulates androgen biosynthesis and generation of the PCOS model. The present study aimed to evaluate the anti-androgenic effects of quercetin (Q) in comparison with metformin (MET) on hyperandrogenism and ovarian dysfunction in a DHEA-induced PCOS rat model. After induction of PCOS, female rats were allocated into six groups with 7 rats in each group: normal control; PCOS (DHEA), MET (25 mg/kg, oral administration), Q (25 mg/kg, oral administration), DHEA + MET (25 mg/kg, oral administration), and DHEA + Q (25 mg/kg, oral administration) for 28 days. MET and Q individually reduced body weight, serum free testosterone (T) and luteinizing hormone (LH), and LH/follicle-stimulating hormone (FSH) ratio in the PCOS rats. Both treatments elevated estradiol (E2) level, ovarian aromatase protein content, and E2/free T ratio in the PCOS rats. Additionally, MET and Q increased preantral, antral, and preovulatory follicles and corpora lutea counts, while both treatments decreased atretic follicle count and eliminated the formation of cysts in the PCOS rats. MET and Q reduced ovarian Bax and elevated Bcl-2 protein abundance in the PCOS rats. Our study revealed that Q is as effective as MET in reducing hyperandrogenism via decreasing free T level and improving hypothalamic-pituitary-ovarian axis function. The results suggest that MET and Q may enhance E2 concentration, ovarian aromatase protein content, folliculogenesis, and decrease atresia via attenuation of hyperandrogenism in PCOS rats.

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).

Expression of genes that regulate follicle development and maturation during ovarian stimulation in poor responders

RESEARCH QUESTION

Sex hormone-binding globulin (SHBG), androgen receptor (AR), LH beta polypeptide (LHB), progesterone receptor membrane component 1 (PGRMC1) and progesterone receptor membrane component 2 (PGRMC2) regulate follicle development and maturation. Their mRNA expression was assessed in peripheral blood mononuclear cells (PBMC) of normal and poor responders, during ovarian stimulation.

DESIGN

Fifty-two normal responders and 15 poor responders according to the Bologna criteria were enrolled for IVF and intracytoplasmic sperm injection and stimulated with 200 IU of follitrophin alpha and gonadotrophin-releasing hormone antagonist. HCG was administered for final oocyte maturation. On days 1, 6 and 10 of stimulation, blood samples were obtained, serum hormone levels were measured, RNA was extracted from PBMC and real-time polymerase chain reaction was carried out to identify the mRNA levels. Relative mRNA expression of each gene was calculated by the comparative 2^-DDCt method.

RESULTS

Differences between mRNA levels of each gene on the same time point between the two groups were not significant. PGRMC1 and PGRMC2 mRNA levels were downregulated, adjusted for ovarian response and age. Positive correlations between PGRMC1 and AR (standardized beta = 0.890, P < 0.001) from day 1 to 6 and PGRMC1 and LHB (standardized beta = 0.806, P < 0.001) from day 1 to 10 were found in poor responders. PGRMC1 and PGRMC2 were positively correlated on days 6 and 10 in normal responders.

CONCLUSIONS

PGRMC1 and PGRMC2 mRNA are significantly decreased during ovarian stimulation, with some potential differences between normal and poor responders.

Variants in the Kisspeptin-GnRH Pathway Modulate the Hormonal Profile and Reproductive Outcomes

Kisspeptin has been identified as a key regulatory protein in the release of gonadotropin-releasing hormone (GnRH), which subsequently increases gonadotropin secretion during puberty to establish reproductive function and regulate the hypothalamic-pituitary-gonadal axis. The effects of variants in the KISS1, KISS1R, and GNRHR genes and their possible association with assisted reproduction outcomes remain to be elucidated. In this study, we used next-generation sequencing to investigate the associations of the genetic diversity at the candidate loci for KISS1, KISS1R, and GNRHR with the hormonal profiles and reproductive outcomes in 86 women who underwent in vitro fertilization treatments. Variants in the KISS1 and KISS1R genes were associated with luteinizing hormone (rs35431622:T>C), anti-Mullerian hormone (rs71745629delT), follicle-stimulating hormone (rs73507529:C>A), and estradiol (rs73507527:G>A, rs350130:A>G, and rs73507529:C>A) levels, as well as with reproductive outcomes such as the number of oocytes retrieved (s35431622:T>C), metaphasis II oocytes (rs35431622:T>C), and embryos (rs1132506:G>C). Additionally, variants in the GNRHR UTR3' (rs1038426:C>A, rs12508464:A>C, rs13150734:C>A, rs17635850:A>G, rs35683646:G>A, rs35610027:C>G, rs35845954:T>C, rs17635749:C>T, and rs7666201:C>T) were associated with low prolactin levels. A conjoint analysis of clinical, hormonal, and genetic variables using a generalized linear model identified two variants of the KISS1 gene (rs71745629delT and rs1132506:G>C) that were significantly associated with hormonal variations and reproductive outcomes. The findings suggest that variants in KISS1, KISS1R, and GNRHR genes can modulate hormone levels and reproductive outcomes.

LH Levels May Be Used as an Indicator for the Time of Antagonist Administration in GnRH Antagonist Protocols-A Proof-Of-Concept Study

Objective: To investigate whether circulating LH levels could be used as an indicator for the timing of antagonist addition in GnRH antagonist protocol. Design: Retrospective cohort study. Setting: University-based hospital. Patients: A total of 567 women stimulated with recombinant FSH monotherapy in a GnRH antagonist protocol were studied. Among them, 256 patients showed relatively low LH levels [highest LH level (LHmax) < 4 IU/L] during the entire ovarian stimulation process; 88 (Group A) and 168 patients (Group B) were stimulated without and with antagonist co-treatment, respectively. The remaining 311 patients had LHmax≥4 IU/L and were stimulated with a modified flexible antagonist protocol based on LH levels (Group C). Intervention(s): Patients in Group B and C received antagonist during ovarian stimulation, whereas patients in Group A did not. Main outcome measure: Clinical pregnancy rate and ongoing pregnancy rate. Results: The clinical and ongoing pregnancy rates were significantly higher in group A than group B (69.3 vs. 54.7%, P = 0.03 and 62.5 vs. 48.2%, P = 0.04, respectively), but the primary outcome measures did not differ between groups B and C. There were no significant differences in terms of patient demographics, LH levels, total dosage of gonadotrophin, duration of stimulation, follicular output rate between groups A and B, and between groups B and C. Also, there were no significant differences in laboratory and clinical outcomes in pairwise group comparisons. No canceled cycles due to premature ovulation was reported among the treated patients. Conclusion: LH levels may be used as an indicator for the time of antagonist addition. Patients with sustained low LH levels (LHmax<4 IU/L) during controlled ovarian stimulation (COS) might not require antagonist administration. Although further well-designed randomized controlled trials (RCTs) are needed to confirm our results, a novel treatment regimen based on LH measurements during COS might provide clinicians new insights about when to start antagonist administration in the GnRH antagonist protocol.

Cryosurvival of rabbit embryos obtained after superovulation with corifollitropin alfa with or without LH

The efficiency of an embryo bank depends on provision of optimal conditions for recovery, cryopreservation and transfer to a breed or strain. In this sense, increasing the number of embryos available using superovulation should improve the cryobank efficiency. However, vagueness of response to conventional protocols to control or increase ovarian response and the quality of oocytes and embryos and their cryotolerance remain a challenge. The aim of our study was to evaluate the effect of corifollitropin alpha (CTP) and a recombinant human FSH (rhFSH), alone or supplemented with rhLH, on embryo cryosurvival by in vitro development and OCT4 and NANOG mRNA abundance at blastocyst stage and offspring rate. In vitro development of vitrified embryos was not significantly affected by superstimulation with or without rhLH supplementation, resulting in similar development rates to those of the control groups (fresh and vitrified embryos from non-superstimulated donor does). Blastocysts developed from vitrified embryos showed higher levels of OCT4 transcript abundance than fresh control, while NANOG transcript abundance was only higher in the blastocysts developed from vitrified embryos after superstimulation treatment in comparison with control groups. The implantation and offspring rates at birth were negatively affected by supplementation with rhLH. Both rhFSH or CTP vitrified embryo groups showed an implantation rate similar to those of the control groups, but an offspring rate lower than control. In conclusion, embryos produced using corifollitropin alpha did not compromise the cryosurvival of vitrified embryos in the rabbit. In addition, this study points out the negative effect of rhLH supplementation in terms of offspring rate on embryo vitrification.

Efficacy of Follicle-Stimulating Hormone (FSH) Alone, FSH + Luteinizing Hormone, Human Menopausal Gonadotropin or FSH + Human Chorionic Gonadotropin on Assisted Reproductive Technology Outcomes in the "Personalized" Medicine Era: A Meta-analysis

SETTING

Luteinizing hormone (LH) and human chorionic gonadotropin (hCG) act on the same receptor, activating different signal transduction pathways. The role of LH or hCG addition to follicle-stimulating hormone (FSH) as well as menopausal gonadotropins (human menopausal gonadotropin; hMG) in controlled ovarian stimulation (COS) is debated.

OBJECTIVE

To compare FSH + LH, or FSH + hCG or hMG vs. FSH alone on COS outcomes.

DESIGN

A meta-analysis according to PRISMA statement and Cochrane Collaboration was performed, including prospective, controlled clinical trials published until July 2016, enrolling women treated with FSH alone or combined with other gonadotropins. Trials enrolling women with polycystic ovarian syndrome were excluded (PROSPERO registration no. CRD42016048404).

RESULTS

Considering 70 studies, the administration of FSH alone resulted in higher number of oocytes retrieved than FSH + LH or hMG. The MII oocytes number did not change when FSH alone was compared to FSH + LH, FSH + hCG, or hMG. Embryo number and implantation rate were higher when hMG was used instead of FSH alone. Pregnancy rate was significantly higher in FSH + LH-treated group vs. others. Only 12 studies reported live birth rate, not providing protocol-dependent differences. Patients' stratification by GnRH agonist/antagonist identified patient subgroups benefiting from specific drug combinations.

CONCLUSION

In COS, FSH alone results in higher oocyte number. HMG improves the collection of mature oocytes, embryos, and increases implantation rate. On the other hand, LH addition leads to higher pregnancy rate. This study supports the concept of a different clinical action of gonadotropins in COS, reflecting previous in vitro data.

Effect of luteinizing hormone on rabbit ovarian superstimulation and embryo developmental potential

Assisted reproduction technologies require ovarian stimulation to increase the number of oocytes and embryos. Currently, superstimulation is achieved by gonadotropin treatment, but the embryo yield and quality are highly variable. Commonly, commercial preparations derived from pituitary and urinary origin are used to superovulate. Hence, ovarian superstimulation protocols have usually included both FSH and LH. The appearance of recombinant gonadotropins manufactured by genetic engineering techniques has ensured high quality and batch-to-batch consistency. Moreover, this enables us to assess the importance of LH in the ovarian stimulation. The main aim of this study was to evaluate the effect of recombinant human LH supplementation (10%) on embryonic development produced by rabbit does superovulated with low or high concentration (18.75 or 37.50 IU) of recombinant human FSH (rhFSH). Females treated with rhFSH increased the ovulation rate, and it was significantly higher when the high FSH dose was supplemented with LH. The superstimulation treatment used did not significantly affect in vitro development rate until the expanded blastocyst stage. The results of this study seem to suggest that, in terms of superovulatory response, when rabbit does are treated with 37.5-IU rhFSH, the use of LH supplementation allows an increase in the number of follicles recruited and the quality of embryos, in terms of ability to develop in vitro until blastocyst, and the expression profile of OCT4, NANOG, and SOX2 genes is not affected.

Recombinant LH administration in subsequent cycle after "unexpected" poor response to recombinant FSH monotherapy

Abstract Poor ovarian response (POR) is most frequently linked to the condition known as diminished ovarian reserve, but it can also occur in the absence of pathological ovarian reserve tests ("unexpected" POR). Because possible explanations include theca cells function deficiency, our aim was to evaluate the effect of r-LH administration in "unexpected" poor responders. A retrospective, single-centre, cohort study was conducted on 65 patients with AMH >0.5 ng/ml and/or AFC >5 with POR in their first cycle. Patients underwent a second IVF cycle with same protocol (long- or antagonist) and same starting dose of r-FSH used in the first cycle, plus daily addiction of 150 IU of r-LH from day 1. Compared to the first cycle, r-LH addition in the second cycle determined an increase in number of oocytes retrieved (p < 0.001), number of metaphase II oocytes (p < 0.05), E2 levels at hCG triggering (p < 0.001) and number of embryos transferred (p = 0.002). A 15% clinical pregnancy rate was also observed in the second cycle. Our results suggest that patients with non-pathological ovarian reserve tests and previous "unexpected" POR seem to benefit from r-LH addition in subsequent cycles without the need to increase the r-FSH starting dose, possibly due to an underlying occult theca cells deficiency.

Dysregulation of ovarian follicular development in female rat: LH decreases FSH sensitivity during preantral-early antral transition

Several clinical studies have shown a correlation of hypersecretion of LH and polycystic ovary syndrome (PCOS), infertility, and miscarriage in women, suggesting that chronically elevated LH impairs fertility. Growth arrest of small antral follicles in PCOS is also assumed to be associated with an abnormal endocrine environment involving increased LH stimulation, a hyperandrogenic milieu, and subsequent dysregulated FSH action in the ovarian follicles. In this study, we examined whether and how LH modulates follicular development and steroid production during preantral-early antral follicle transition by using a rat preantral follicle culture system. LH augments testosterone and estradiol production in preantral follicles via up-regulating mRNA abundance of CYP17A1 and CYP19A1. LH promotes rat preantral follicle growth, and the follicular size reaches that of early antral follicles in vitro, a response attenuated by the specific androgen receptor antagonist and a targeted disruption of androgen receptor gene. Sustained follicle stimulation by LH, but not by androgen, decreases FSH receptor mRNA levels and FSH receptor signaling and inhibits FSH-induced follicular growth. The data suggest that LH promotes preantral-early antral transition via the increased synthesis and growth-promoting action of androgen. However, chronic LH stimulation impairs FSH-dependent antral follicle growth by suppressing granulosa cell FSHR expression via the modulation of intraovarian regulators, including LH-induced thecal factors.

Outcome from consecutive ICSI cycles in patients treated with recombinant human LH and those supplemented with urinary hCG-based LH activity during controlled ovarian stimulation in the long GnRH-agonist protocol

Clinical results were compared in a well-established, assisted reproduction program during the cross-over from highly purified (HP)-human menopausal gonadotropin (hMG) to rhFSH/rhLH. We included the last 33 patients treated with HP-hMG and the first 33 patients receiving rhFSH/rhLH for ovarian stimulation in their first intracytoplasmic sperm injection cycle. Patient baseline characteristics were almost identical in the two groups. Ovarian stimulation characteristics (days of stimulation, total amount of FSH administered using a modest initial loading dose of 150 IU/d, patients with oocyte retrieval) were similar for the two groups. However, the number of total and leading follicles and E2 serum levels on the human chorionic gonadotropin injection day were significantly higher in the rhFSH/rhLH group. The oocyte yield was significantly higher in the rhFSH/rhLH group as well as the number of metaphase II oocytes, difference almost reaching the statistical significance. The number of oocytes fertilized was also higher in patients receiving rhFSH/rhLH treatment. Implantation and clinical pregnancy rates were similar in both the study groups. It is concluded that in women undergoing controlled ovarian hyperstimulation under pituitary suppression for ART, the recombinant combined product containing FSH and LH in a fixed 2:1 ratio is more effective than HP-hMG in terms of follicle development, oocyte yield and quality, and fertilization rates.

Morphogenesis of polycystic ovaries as assessed by pituitary-ovarian androgenic function

Despite polycystic ovaries (PCO) being a common morphology in women with polycystic ovary syndrome and regular menstruation, the regulatory principles in the morphogenesis of antral follicles have not yet been elucidated. In recognition of the complementary interaction between androgen-induced expression of the FSH receptor and FSH-augmented expression of the androgen receptor in granulose cells of antral follicles, a possible correlation of antral follicle count (AFC) and pituitary-ovarian androgenic function was investigated in 180 infertile women over days 3-5 of the menstrual cycle. Six discrete types of PCO with decreasing pituitary-ovarian androgenic function were identified: Type I (classical Stein-Leventhal syndrome), Type II (hyperandrogenemism), Type III (singular hyper-LH), Type IV (cryptic hyperandrogenism), Type V (relative LH dominancy) and Type VI (relative FSH dominancy), in parallel to a diminishing number of AFC from Type I to Type VI. Because during the early follicular phase of the cycle until the selection of the dominant follicle, antral follicles are composed of newly emerged healthy follicles plus atretic antral follicles that remain non-ovulated from previous cycles, it is proposed that the six types of PCO may represent the folliculogenetic spectra along which PCO morphogenesis proceeds.

Oocyte-granulosa-theca cell interactions during preantral follicular development

The preantral-early antral follicle transition is the penultimate stage of follicular development in terms of gonadotropin dependence and follicle destiny (growth versus atresia). Follicular growth during this period is tightly regulated by oocyte-granulosa-theca cell interactions. Formation of the theca cell layer is a key event that occurs during this transitional stage. Granulosal factor(s) stimulates the recruitment of theca cells from cortical stromal cells, while oocyte-derived growth differentiation factor-9 (GDF-9) is involved in the differentiation of theca cells during this early stage of follicular development. The preantral to early antral transition is most susceptible to follicular atresia. GDF-9 promotes follicular survival and growth during transition from preantral stage to early antral stage by suppressing granulosa cell apoptosis and follicular atresia. GDF-9 also enhances preantral follicle growth by up-regulating theca cell androgen production. Thecal factor(s) promotes granulosa cell proliferation and suppress granulosa cell apoptosis. Understanding the intraovarian mechanisms in the regulation of follicular growth and atresia during this stage may be of clinical significance in the selection of the best quality germ cells for assisted reproduction. In addition, since certain ovarian dysfunctions, such as polycystic ovarian syndrome and gonadotropin poor-responsiveness, are consequences of dysregulated follicle growth at this transitional stage, understanding the molecular and cellular mechanisms in the control of follicular development during the preantral-early antral transition may provide important insight into the pathophysiology and rational treatment of these conditions.

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.

Differential actions of FSH and LH during folliculogenesis

In the gonadotrophin-dependent stage of follicular development, FSH- and LH-signalling pathways play an obligatory role in follicle differentiation, selection and survival. Under the effect of LH the theca-interstitial cell layer acts as an androgen producer. Thus, androgen diffusing into the mural granulosa cell layer represents the substrate for FSH-induced aromatase for follicular oestradiol synthesis. This is the landmark 'two cell-two gonadotrophin' concept in the physiology of ovarian function in mammals. The increase in plasma FSH during luteo-follicular transition is the basis for follicle selection. The rise of FSH to the threshold concentration represents a critical condition for the growth of the most sensitive follicle in a given time frame of the last 14 days of the dominant follicle odyssey. The gonadotrophin-induced follicular oestradiol secretion inhibits pituitary secretion of FSH, which in turn causes the concentration of FSH in the developing cohort follicles to drop below threshold concentrations and the arrest of the development of the less FSH-sensitive follicle (FSH threshold and window concept). In the gonadotrophin-dependent phase of follicular development, LH also seems to acts within a critical window of the hormone concentration framed between the minimal threshold and a ceiling for the normal functions of the follicle unit.

Low-dose HCG is useful in preventing OHSS in high-risk women without adversely affecting the outcome of IVF cycles

Severe ovarian hyperstimulation syndrome (OHSS) is a rare but potentially fatal condition associated with conventional IVF treatment. It is found predominantly in women with polycystic ovaries who have an exaggerated response to exogenous FSH, leading to a large number of follicles and an overproduction of vascular endothelial growth factor with resultant excessive increases in vascular permeability. There is evidence to suggest that OHSS is also linked to the use of human chorionic gonadotrophin (HCG) to induce ovulation. Therefore, while HCG is essential for corpus luteum function, high amounts of HCG can lead to OHSS in high responders. In a pilot study, infertile patients at high risk of developing OHSS were given half the current minimum dose of HCG (i.e. 2500 IU). No woman developed moderate or severe OHSS; 13 women (61.9%) conceived and there were three twin pregnancies. In women at high risk of OHSS, a low dose of HCG appears to prevent the development of OHSS without compromising success rates.

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

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

Recombinant LH supplementation to recombinant FSH during induced ovarian stimulation in the GnRH-antagonist protocol: a meta-analysis

This study aims to compare the efficacy of recombinant LH (rLH) supplementation for ovarian stimulation in gonadotrophin-releasing hormone-antagonist protocol for IVF/intracytoplasmic sperm injection cycles. Search strategies included online surveys of databases. The fixed effects model was used for odds ratio (OR) and effect size (weighted mean difference, WMD). Five trials fulfilled the inclusion criteria. When the meta-analysis was carried out, advantages were observed for the LH supplementation protocol with respect to higher serum oestradiol concentrations on the day of human chorionic gonadotrophin administration P < 0.0001; WMD: 514, 95% CI 368, 660) and higher number of mature oocytes (P = 0.0098; WMD: 0.88, 95% CI 0.21, 1.54). However, these differences were not observed in the total amount of recombinant FSH (rFSH) administered, days of stimulation, number of oocyets retrieved, the clinical pregnancy rate per oocyte retrieval, the implantation rate and miscarriage rate. This result demonstrates that the association of rLH with rFSH may prevent any decrease in oestradiol after antagonist administration and that a significantly higher number of mature oocytes was available for laboratory work. Nevertheless, it failed to show any statistically significant difference in clinically significant end-points in IVF (implantation and pregnancy rates). Additional randomized controlled trials are needed to confirm these results further.

Recombinant luteinizing hormone supplementation to recombinant follicle-stimulation hormone during induced ovarian stimulation in the GnRH-agonist protocol: a meta-analysis

PURPOSE

to compare the efficacy of recombinant LH supplementation for controlled ovarian stimulation in recombinant FSH and GnRH-agonist protocol.

METHODS

Search strategies included on-line surveys of databases. The fixed effects model was used for odds ratio and effect size (weighted mean difference). Four trials fulfilled the inclusion criteria.

RESULTS

a fewer days of stimulation (p<0.0001), a fewer total amount of r-FSH administered (p<0.0001) and a higher serum estradiol levels on the day of hCG administration (p<0.0001) were observed for the r-LH supplementation protocol. However, differences were not observed in number of oocyte retrieved, number of mature oocytes, clinical pregnancy per oocyte retrieval, implantation and miscarriage rates.

CONCLUSIONS

more randomized controlled trials are necessary before evidence-based recommendations regarding exogenous LH supplementation in ovarian stimulation protocols with FSH and GnRH-agonist for assisted reproduction treatment can be provided.