Ovarian stimulation for assisted reproduction with HMG and concomitant midcycle administration of the GnRH antagonist cetrorelix according to the multiple dose protocol: a prospective uncontrolled phase III study

Ovarian Stimulation with FSH Alone versus FSH plus a GnRH Antagonist for Elective Freezing in an Oocyte Donor/Recipient Programme: A Protocol for a Pilot Multicenter Observational Study

Preliminary data have shown that it is possible to attempt in vitro fertilization (IVF) treatment in fresh cycles without the use of a gonadotropin-releasing hormone (GnRH) antagonist or any other medication to prevent the luteinizing hormone (LH) surge during ovarian stimulation. To date, there is no information on this topic in the context of a prospective controlled trial. However, as prevention of the LH surge is an established procedure in fresh cycles, the question is whether such a study can be performed in frozen cycles. We aim to perform a pilot study in order to compare the efficacy of a protocol using FSH alone with that of a protocol using follicle-stimulating hormone (FSH) plus a GnRH antagonist for controlled ovarian hyperstimulation (COH) in cycles of elective freezing in the context of a donor/recipient program. This is a seven-center, two-arm prospective pilot cohort study conducted at the respective Assisted Reproductive Units in Greece. The hypothesis to be tested is that an ovarian stimulation protocol that includes FSH alone without any LH surge prevention regimens is not inferior to a protocol including FSH plus a GnRH antagonist in terms of the clinical outcome in a donor/recipient model. The results of the present study are expected to show whether the addition of the GnRH antagonist is necessary in terms of the frequency of LH secretory peaks and progesterone elevations >1 ng/mL during the administration of the GnRH antagonist according to the adopted frequency of blood sampling in all Units.

Effect of recombinant LH supplementation timing on clinical pregnancy outcome in long-acting GnRHa downregulated cycles

Background

Timely and moderate luteinizing hormone (LH) supplementation plays positive roles in in vitro fertilization/intracytoplasmic sperm injection and embryo transfer (IVF/ICSI-ET) cycles with long-acting gonadotropin-releasing hormone agonist (GnRHa) pituitary downregulation. However, the appropriate timing of LH supplementation remains unclear.

Methods

We carried out a retrospective cohort study of 2226 cycles at our reproductive medicine centre from 2018 to 2020. We mainly conducted smooth curve fitting to analyse the relationship between the dominant follicle diameter when recombinant LH (rLH) was added and the clinical pregnancy outcomes (clinical pregnancy rate or early miscarriage rate). In addition, total cycles were divided into groups according to different LH levels after GnRHa and dominant follicle diameters for further analysis.

Results

Smooth curve fitting showed that with the increase in the dominant follicle diameter when rLH was added, the clinical pregnancy rate gradually increased, and the early  miscarriage rate gradually decreased.

Conclusions

In long-acting GnRHa downregulated IVF/ICSI-ET cycles, the appropriate timing of rLH supplementation has a beneficial impact on the clinical pregnancy outcome. Delaying rLH addition is conducive to the clinical pregnancy rate and reduces the risk of early miscarriage.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12884-022-04963-x.

Quantitative evaluation of intercellular local deformation of human oocytes during Piezo-assisted intracytoplasmic sperm injection using video-based motion analysis

OBJECTIVE

To evaluate the relationship between the quantitative properties of local deformation of the ooplasm during Piezo-assisted intracytoplasmic sperm injection (Piezo-ICSI) and oocyte developmental fate after Piezo-ICSI.

DESIGN

Video-based motion analysis and case-control study.

SETTING

Private fertility center.

PATIENT(S)

A total of 99 couples assigned to the standard Piezo-ICSI program.

INTERVENTION(S)

Video recordings of the sperm injection process during Piezo-ICSI.

MAIN OUTCOME MEASURE(S)

Quantitative deformation properties consisting of the orientation of deformation perpendicular (Perp) or parallel (Para) to the oolemma and the mechanical response of the ooplasm (elongation, contraction, and total): Perp_-elongation, Perp_-contraction, Perp_-total, Para_-elongation, Perp_-contraction, and Para_-total.

RESULT(S)

The deformation parameters were compared among different angular ranges of 30°-60°, 60°-90°, 90°-120°, and 120°-150° (defined as 0° at the 3 o'clock puncture site). The Perp_-total value at 30°-60° was significantly greater than that at the other angles (130.2 vs. 57.7-85.5, respectively) primarily due to substantially greater Perp_-elongation values. The Para_-total value at 30°-60° was significantly greater than that at the other angles (20.1 vs. 6.7-10.3, respectively) primarily due to substantially smaller Para_-contraction values. The deformation parameters of the ooplasm adjacent to the first polar body were also compared among different developmental fates (fertilization failure, cleavage arrest, and blastocyst development). The Perp_-total value of oocytes derived from blastocyst formation was significantly smaller than those derived from other developmental fates (58.1 vs. 70.0-87.3, respectively).

CONCLUSION(S)

The Piezo-ICSI process induced deformation with various mechanical behaviors in different regions within a single oocyte. Furthermore, the exposure of the ooplasm adjacent to the first polar body to excessive deformation was found to be a possible trigger for adverse fertilization and embryo development after Piezo-ICSI.

Recombinant luteinizing hormone supplementation to recombinant follicle stimulating hormone therapy in gonadotropin releasing hormone analogue cycles: what is the evidence?

OBJECTIVE

To look into current evidence exploring the added value of rLH supplementation to rFSH in GnRH analogues cycles, to identify groups of women that still have no evidence for adjuvant rLH therapy and to discuss ways that may advance research on this topic.

METHODS

Eight systematic reviews and meta-analyses exploring the benefit for pregnancy achievement of rLH supplementation, excluding other LH activity preparations, to GnRH analogues cycles in the ART setting were thoroughly evaluated.

RESULTS

Evidence exists to show that rLH supplementation seems to have added value for pregnancy achievement in women with poor ovarian response and in women ≥35 years of age employing the GnRH agonist protocol, while the evidence is still debatable when the GnRH antagonist is administered. In the general infertile population, rLH supplementation does not have added value in the GnRH-antagonist cycles while the evidence is still controversial when the GnRH agonist is employed. Whether rLH supplementation may have a benefit in some young, normo-gonadotropic women, who may develop LH deficiency following GnRH analogues, is still to be shown. The main task remains how to identify subgroups of women that may benefit from rLH supplementation.

CONCLUSION

An accurate definition of the LH threshold in GnRH analogue treated cycles may contribute to the discussion of which subgroups of women may benefit from adjuvant rLH therapy.

The value of delaying hCG administration to enable maturation of medium-sized follicles in patients undergoing superovulation for IVF/ICSI

PURPOSE

The purpose of the study is to determine whether continued stimulation of mature follicles to allow "catch up" growth of medium-sized follicles in assisted reproductive technology compromises the clinical pregnancy (CPR) and live birth (LBR) rates in IVF/ICSI cycles.

METHODS

This retrospective cohort study reviewed 200 first IVF ± ICSI cycles out of a total of 340 cycles with complete data. Women underwent stimulation protocols with gonadotropins (Gn) and GnRH antagonist. Treatment cycles were divided into two groups (Gp): hCG administration delayed despite the presence of two mature follicles, defined as ≥ 18 mm [Gp1, n = 79] and hCG administration given when there were two mature follicles [Gp2, n = 121].

RESULTS

The patients in Gp1 were significantly younger than those in Gp2 [32.9 (4.5) vs. 34.3 (4.8), p = 0.04] and needed a median of one more day of superovulation before ovulation was triggered with hCG. The extra days was associated with the use of 450 [75-2025] more Gn, such that at the time the hCG was administered, patient's in group 1 had developed significantly greater number of follicles ≥ 18 mm [mean (SD), 4.9 (1.8) vs. 3.4 (1.7), p < 0.0001]. The clinical pregnancy (48.1 vs. 38.0%, [OR (95% CI)] [1.6 (1.0-2.5), p = 0.09]) and live birth (43.0 vs. 35.5%, [1.4 (0.9-2.3), p = 0.21]) rates per cycle started were not significantly different between the two groups. Forward stepwise logistic regression showed that only maternal age (p = 0.04) influenced clinical pregnancy rates (OR = 0.88, CI 0.78-0.99) and only the number of days for superovulation influenced live birth rates (OR = 0.65, CI 0.486-0.869).

CONCLUSION

This study demonstrated that delaying hCG administration to allow further growth of the medium-sized follicles added further days of superovulation and cost without improvement in CPR and LBR.

GnRH antagonist-based protocols for in vitro fertilization

In this chapter we elaborate on the intricacies of employing GnRH antagonists for prevention of the endogenous luteinizing hormone surge during IVF. Several practical aspects of implementing a GnRH antagonist-based stimulation protocol are described; selection of the correct dose, choosing when to start the antagonist, programming of cycle starts, selection of the appropriate gonadotropins, and triggering of final oocyte maturation are elucidated.

Outcome of cryopreserved pronuclear oocytes obtained after ovarian stimulation with either HMG or recFSH and the GnRH-antagonist cetrorelix

The present retrospective study evaluated the outcome of frozen-thaw cycles with oocytes obtained either during a multiple dose protocol of cetrorelix, or after the use of a gonadotrophin-releasing hormone (GnRH) agonist. A total of 101 subfertile couples were included. These couples had a total of 222 transfers of frozen-thawed pronuclear oocytes after IVF/intracytoplasmic sperm injection (ICSI) treatment. According to the stimulation protocol during various cycles, four groups were established: cetrorelix/recombinant FSH (recFSH) (69 cycles), cetrorelix/human menopausal gonadotrophin (HMG) (10 cycles), GnRH-agonist/recFSH (71 cycles) and GnRH-agonist/HMG (72 cycles). The transfer cycles were mildly stimulated with transdermal oestradiol. No statistically significant difference was seen among the four groups regarding post-thaw survival rate, cumulative embryo score, implantation rate and pregnancies. Frozen-thawed pronuclear oocytes obtained with the use of cetrorelix give satisfactory implantation and pregnancy rates, similar to those obtained with a GnRH-agonist. These results do not depend on the gonadotrophins (HMG or recFSH) used in the collecting cycle.

Safety aspects of gonadotrophin-releasing hormone antagonists in ovarian stimulation procedures: ovarian hyperstimulation syndrome and health of children born

The safety of ovarian stimulation procedures or the procedure of assisted reproduction in general can be estimated by various parameters. Two of the most important are the health of children born after the procedure and the incidence of ovarian hyperstimulation syndrome (OHSS). The latter is important because it is the most severe, potentially life-threatening complication of any stimulation procedure. The use of gonadotrophin-releasing hormone (GnRH) antagonists in ovarian stimulation protocols has had no impact on the health of children born. This was proven in 227 children born after the use of cetrorelix and in 73 children born after the use of ganirelix. To analyse the incidence of OHSS and the impact of GnRH antagonists on clinical pregnancy rates compared with the long protocol, a meta-analysis was done. This showed a reduction of OHSS with the use of cetrorelix. Furthermore, when compared with the long protocol, clinical and ongoing pregnancy rates were not significantly reduced with the use of cetrorelix. Taken together, the use of GnRH antagonists are safe with regard to children's health. The incidence of OHSS does not increase with ganirelix, and a reduction can be expected with cetrorelix.

The role of GnRH antagonists in assisted reproduction

The different schemes of application of gonadotrophin-releasing hormone (GnRH) antagonists in ovarian stimulation protocols for assisted reproduction are reviewed. Starting from the initial schemes of single and/or multiple doses, the efficacy of GnRH antagonists in 'soft' protocols of ovarian stimulation has been evaluated in natural cycles, and the possibility of inducing the final oocyte maturation under antagonists either with native luteinizing hormone-releasing hormone or with GnRH agonists. The largest clinical studies carried out with cetrorelix or with ganirelix and published to date were analysed. Apart from the benefits of reducing the duration of the treatment, gonadotrophin requirements and ovarian hyperstimulation syndrome incidence, there is still a serious debate on the potential deleterious effect of GnRH antagonists on implantation and pregnancy rates. More specific aspects such as cycle programming, application of GnRH antagonists in protocols for poor responders etc., were also reviewed in this survey.

GnRH antagonists: do they open new pathways to safer treatment in assisted reproductive techniques?

GnRH antagonists (GnRHnt) induce a rapid decrease in LH and FSH, preventing and interrupting LH surges. Their properties do not require a desensitization period and allow their use in the late follicular phase. GnRHnt could replace GnRH agonists (GnRHa) in ovarian stimulation without their side-effects and their long period of desensitivity. Both protocols using GnRHnt were associated with a smaller amount of gonadotrophin, a shorter stimulation period and a lower incidence of ovarian hyperstimulation syndrome (OHSS) with statistically comparable pregnancy rates. There is room for improvement of both protocols concerning the programming, the antagonist dose and the timing of antagonist administration. Luteal support should be maintained until the results of further studies. The perinatal outcome appears to be similar to that of other stimulation regimens. Triggering of ovulation can be facilitated by GnRHa for patients at risk of OHSS. Provided that pregnancy rates equivalent to those obtained with GnRHa are confirmed in larger series, GnRHnt will clearly represent a safer alternative to GnRHa protocols in IVF.

GnRH antagonist, cetrorelix, for pituitary suppression in modern, patient-friendly assisted reproductive technology

BACKGROUND

Gonadotropin-releasing hormone (GnRH) analogues are used routinely to prevent a premature luteinizing hormone (LH) surge in women undergoing assisted reproductive technology (ART) treatments. In contrast to GnRH agonists, antagonists produce rapid and reversible suppression of LH with no initial flare effect.

OBJECTIVE

To review the role of cetrorelix, the first GnRH antagonist approved for the prevention of premature LH surges during controlled ovarian stimulation in modern ART.

METHOD

A review of published literature on cetrorelix.

RESULTS

Both multiple- and single-dose cetrorelix protocols were shown to be at least as effective as long GnRH agonist regimens for pituitary suppression in Phase II/III clinical trials. Furthermore, cetrorelix co-treatment resulted in similar live birth rates but a shorter duration of gonadotropin stimulation, a lower total gonadotropin dose requirement and lower incidence of ovarian hyperstimulation syndrome compared with long agonist regimens. A single-dose cetrorelix protocol further decreased the number of injections required. Preliminary studies have also produced promising data on the use of cetrorelix in modified ART protocols, such as frozen embryo transfer and donor oocyte recipient cycles.

CONCLUSION

Cetrorelix offers a potential therapeutic alternative to GnRH agonists during controlled ovarian stimulation and has become an integral part of modern, patient-friendly reproductive medicine.

Drug delivery for in vitro fertilization: rationale, current strategies and challenges

In vitro fertilization has experienced phenomenal progress in the last thirty years and awaits the additional refinement and enhancement of medication delivery systems. Opportunity exists for the novel delivery of gonadotropins, progesterone and other adjuvants. This review highlights the rationale for various medications, present delivery methods and introduces the status of novel ideas and possibilities.

Effect of a lower-dose cetrorelix acetate protocol on in-vitro fertilization outcome

OBJECTIVE

To determine whether a low initial dosage of cetrorelix acetate could prevent a premature luteinizing hormone (LH) surge in women undergoing controlled ovarian stimulation.

METHOD

Treatment with a recombinant follicle stimulating hormone was started on Day 3 of the menstrual cycle, and 0.125 mg of cetrorelix was injected daily from Day 5 of the ovarian stimulation until the diameter of the dominant follicle reached at least 16 mm. The dosage was then doubled and maintained at 0.250 mg/day until the day before the injection of human chorionic gonadotropin.

RESULT

There was a significant decrease in serum LH concentration 1 day after doubling the cetrorelix dosage, and the LH concentration remained low during the follicular phase. Clinical pregnancy occurred in 18 women (42.8%), with 2 intrauterine fetal deaths before the 12th week.

CONCLUSION

Increasing the cetrorelix dosage from 0.125 to 0.250 mg/day when the follicular size is appropriate can prevent a premature LH surge.

The levels of steroid hormones and cytokines in individual follicles are not associated with the fertilization outcome after intracytoplasmic sperm injection

OBJECTIVE

To investigate the association between the levels of two steroid hormones and eight cytokines in fluids from individual follicles and the fertilization outcome of the oocytes derived from the same follicles.

DESIGN

Prospective study.

SETTING

University hospital.

PATIENT(S)

Forty-three women participating in intracytoplasmic sperm injection (ICSI)/ET cycles.

INTERVENTION(S)

The ovarian stimulation followed the multidose GnRH antagonist protocol. ICSI was performed in mature oocytes. The concentrations of estradiol, progesterone, tumor necrosis factor-alpha, interleukin (IL) -1beta, IL-6, vascular endothelial growth factor, leptin, basic fibroblast growth factor, epidermal growth factor, and insulin-like growth factor-I were measured by immunoassay methods in the follicles from which the mature oocytes were derived.

MAIN OUTCOME MEASURE(S)

The concentrations of the above hormones and cytokines in individual follicles and the fertilization outcome of the oocytes derived from the same follicles.

RESULT(S)

The intrafollicular concentrations of the above factors were not significantly associated with the fertilization outcome. These factors were not correlated with embryo quality, with the exception of leptin, which was weakly associated with embryo score (R = 0.276).

CONCLUSION(S)

The intrafollicular concentrations of the above factors cannot predict the fertilization outcome after ICSI.

Subtle progesterone rise in the single-dose gonadotropin-releasing hormone antagonist (cetrorelix) stimulation protocol in patients undergoing in vitro fertilization or intracytoplasmic sperm injection cycles

A subtle rise in serum progesterone during the late follicular phase in patients undergoing in vitro fertilization (IVF) or intracytoplasmic sperm injection (ICSI) cycles is a frequent event that can decrease implantation and pregnancy rates in controlled ovarian hyperstimulation (COH) protocols that use a gonadotropin-releasing hormone (GnRH) antagonist. The aim of the present study was to evaluate the prevalence and effect of the subtle progesterone rise during COH with single-dose GnRH antagonist in combination with clomiphene citrate (CC) and human menopausal gonadotropins (hMG) in IVF or ICSI cycles. Ninety-five women undergoing COH with CC, hMG and a single 2.5 mg dose of the GnRH antagonist, cetrorelix, were enrolled in the study. Patients were grouped according to serum progesterone level on the day of human chorionic gonadotropin (hCG) administration (P < 1.2 ng/ml or P >/= 1.2 ng/ml). The incidence of a subtle progesterone rise was 54.7% (52/95). The group with P >/= 1.2 ng/ml had significantly higher serum levels of luteinizing hormone (p = 0.002) and estradiol (p < 0.001) on the day of hCG injection than the group with P < 1.2 ng/ml, and more oocytes were retrieved (p = 0.001). However, there was no significant difference in fertilization, clinical pregnancy or implantation rate between the two groups. In conclusion, a subtle progesterone rise during the late follicular phase is common but not associated with pregnancy outcome.

Comparison of preovulatory follicular concentrations of epidermal growth factor, insulin-like growth factor-I, and inhibins A and B in women undergoing assisted conception treatment with gonadotropin-releasing hormone (GnRH) agonists and GnRH antagonists

Follicular fluid contents of 69 age-matched women undergoing ovarian stimulation with a GnRH agonist and a GnRH antagonist were collected during oocyte retrieval. The groups did not differ in baseline characteristics and in terms of assisted conception treatment outcome. Similarly, follicular fluid levels of epidermal growth factor, insulin-like growth factor, and inhibins A and B were found not to be different. Our results suggest that follicular development in regard to ovarian growth factor dynamics is not different in women undergoing ovarian stimulation with GnRH antagonists than in women using GnRH agonists.

Cetrorelix in the treatment of female infertility and endometriosis

The use of cetrorelix within ovarian-stimulation protocols demonstrates several advantages compared with gonadotropin-releasing hormone (GnRH) agonist-containing protocols, which include, for example, significantly less time for analogue treatment and a reduction in the amount of gonadotropins needed. Furthermore, fewer side effects can be expected. There is no difference regarding endometrium quality and hormone profiles, and the results of assisted reproduction cycles are comparable. Cetrorelix also seems to be useful in the treatment of endometriosis which, in most cases, is an estrogen-dependent disease. Furthermore, fewer side effects occur with this agent (e.g., postmenopausal symptoms) and no estradiol add-back is needed. In the future, new nonpeptic GnRH antagonists are expected to be available for oral administration. Although they are still under investigation, these agents have the potential to improve patients' comfort and compliance.

Cytokine and hormonal profile in blood serum and follicular fluids during ovarian stimulation with the multidose antagonist or the long agonist protocol

BACKGROUND

The aim of our study was to explore cytokine and hormonal profiles in blood and follicular fluids from normal women stimulated with either the multidose antagonist or the long agonist protocol.

METHODS

Fifty-six patients were stimulated with the multidose antagonist protocol and 12 with the long agonist protocol. Interleukin (IL)-1beta, IL-6, tumour necrosis factor-alpha (TNFalpha), leptin, vascular endothelial growth factor (VEGF), basic fibroblast growth factor (bFGF), estradiol (E(2)), progesterone and testosterone levels were measured in serum and follicular fluids by immunoassays.

RESULTS

The two treatment groups had similar cytokine concentrations in serum. The intrafollicular concentrations of IL-1beta, IL-6, VEGF and leptin were also similar in the two groups. The concentrations of bFGF in follicular fluids from the antagonist group (169.5 +/- 113.2 ng/ml) were lower than those from the agonist group (249.7 +/- 119.8 ng/ml). bFGF concentrations were correlated with the amount of administered gonadotrophins (R = 0.364, P < 0.01) which was significantly lower in the antagonist group (antagonist group: 2037.7 +/- 725.8 IU; agonist group: 2836.4 +/- 1163.5 IU).

CONCLUSIONS

Normal women stimulated with either the multidose antagonist or the long agonist protocol generally have similar cytokine profiles in serum and follicular fluids. The intrafollicular levels of bFGF tend to be lower in antagonist cycles because of the lower amount of administered gonadotrophins.

Antimüllerian hormone and pituitary gland activity after prolonged down-regulation with goserelin acetate

The size of the pool of growing follicles was normal after prolonged down-regulation, as indicated by normal AMH levels 4 and 8 weeks after goserelin administration. However, there was a profound down-regulation of LH levels; therefore we suggest administration of exogenous LH to proceed to IVF or alternatively stimulation of endogenous LH secretion with daily administration of GnRH agonist. These need to be assessed prospectively.

Gonadotropin-releasing hormone antagonists do not influence the secretion of steroid hormones but affect the secretion of vascular endothelial growth factor from human granulosa luteinized cell cultures

OBJECTIVE

To evaluate the secretion of E(2), P, and vascular endothelial growth factor (VEGF) in human granulosa luteinized cell cultures with the presence of a gonadotropin-releasing hormone (GnRH) agonist or antagonist.

DESIGN

In vitro cell culture study.

SETTING

Research laboratory of a university hospital.

PATIENTS

Granulosa luteinized cells were obtained from 24 patients undergoing ovarian stimulation for IVF treatment.

INTERVENTIONS

Granulosa cells were cultured for 48 hours with 1 nM of cetrorelix or leuprorelide. For a further 48 hours, granulosa cells were cultured with or without the combination of cetrorelix plus leuprorelide.

MAIN OUTCOMES

At the end of each culturing period, the concentrations of E(2), P, and VEGF were measured in culture supernatants by immunoassays.

RESULTS

Estradiol and P concentrations were similar between the culture supernatants from controls and treatment groups. The VEGF concentrations in supernatants from cultures with cetrorelix (2,315.1 +/- 1,565.5 pg/mL) were moderately, but significantly, lower than in controls (2,604.3 +/- 1,907.1 pg/mL) or cultures with leuprorelide (2,558.8 +/- 1,403.1 pg/mL).

CONCLUSIONS

The GnRH analogues do not affect steroidogenesis in human granulosa luteinized cell cultures. The GnRH antagonists moderately affect the secretion of VEGF from human granulosa luteinized cells.

Safety of drugs used in assisted reproduction techniques

Infertility may affect one in six couples; however, the development of the assisted reproduction technique (ART) created the opportunity for a large proportion of the infertile population to bear children. Pharmacological agents are routinely used in ART, and new ones are introduced regularly, with the aim of retrieving multiple oocytes to increase the prospect of pregnancy. The combinations of drugs that are used have specific adverse effects, but it is mostly the combined action of more than one agent that causes the greatest concern. The matter is complicated by the suspicion that some techniques in ART, for example intracytoplasmic sperm injection for severe male infertility problems (including azoospermia), may also contribute to the increase in adverse effects, especially congenital malformation. Gonadotropin releasing hormone (GnRH) agonists are widely used in controlled ovarian hyperstimulation. It may give rise to a short period of estradiol withdrawal symptoms and it may also lead to luteal phase deficiency. Similarly GnRHa antagonists, which have been recently introduced to control ovarian hyperstimulation, can lead to luteal phase deficiency and may cause some local injection site reactions. The more pure form of gonadotropin leads to less local injection site reactions and their main adverse effects are associated with the consequences of multiple ovulations. It has been proposed that gonadotropins may be a factor in the increasing risk of ovarian cancer and possibly breast cancer, but this has not been substantiated. Prion infection is another potential hazard, although no cases have been reported. Ovarian hyperstimulation syndrome is a well recognised complication of controlled ovarian hyperstimulation in ART. It is usually a result of recruitment of a large number of ovarian follicles. Efforts to minimise the incidence of this syndrome and its severity are now well developed. Congenital malformations are another possible adverse effect of fertility drugs, but it is more probable that the increase in congenital abnormality that is reported in ART is because of the population studied, i.e. patients already at high risk of congenital malformation, rather than the fertility drugs used or the technique employed. High order multiple pregnancy and its sequela is a well established complication of controlled ovarian hyperstimulation. This could be a result of multiple ovulations or more than one embryo replacement. Reducing the number of embryos transferred can reduce this more serious adverse effect for expectant mothers and for children conceived from ART.

Is a lower dose of cetrorelix acetate effective for prevention of LH surge during controlled ovarian hyperstimulation?

PURPOSE

This study was performed to evaluate whether a lower dose (0.2 mg) of cetrorelix would prevent premature LH surge in patients undergoing controlled ovarian hyperstimulation.

METHODS

Controlled ovarian hyperstimulation was carried out in 45 patients, starting on menstrual cycle day 3 with recombinant FSH (r-FSH), and a cetrorelix of 0.2 mg was administered from day 5 evening of ovarian stimulation until the day before hCG injection.

RESULTS

There was a statistically significant decrease in serum LH level one day after the first cetrorelix injection and on the day of hCG administration. Serum LH concentrations were maintained constantly low during the follicular phase with no premature LH surge occurring in any of the patients. Clinical pregnancy was achieved for 18 women (40%), with one of these experiencing intrauterine fetal death before 12 week' gestation.

CONCLUSION

This study demonstrates that a daily dose of cetrorelix 0.2 mg is able to prevent premature LH surge.

Ovarian feedback, mechanism of action and possible clinical implications

The secretion of gonadotrophins from the pituitary in women is under ovarian control via negative and positive feedback mechanisms. Steroidal and non-steroidal substances mediate the ovarian effects on the hypothalamic-pituitary system. During the follicular phase of the cycle, estradiol (E(2)) plays a key role, while circulating progesterone (at low concentrations) and inhibin B contribute to the control of LH and FSH secretion respectively. During the luteal phase, both E(2) and progesterone regulate secretion of the two gonadotrophins, while inhibin A plays a role in FSH secretion. The intercycle rise of FSH is related to changes in the levels of the steroidal and non-steroidal substances during the luteal-follicular transition. In terms of the positive feedback mechanism, E(2) is the main component sensitizing the pituitary to GnRH. Activity of a non-steroidal ovarian substance, named gonadotrophin surge-attenuating factor (GnSAF), has been detected after ovarian stimulation. It is hypothesized that GnSAF, by antagonizing the sensitizing effect of E(2) on the pituitary, regulates the amplitude of the endogenous LH surge at midcycle. Disturbances in the feedback mechanisms can occur in various abnormal conditions or after treatment with pharmaceutical compounds that interfere with the production or the action of endogenous hormones.

Effect of gonadotropin-releasing hormone agonist and antagonist on steroidogenesis of low responders undergoing in vitro fertilization

The aim of the study was to investigate the cause of the lower estradiol (E(2)) concentration in women treated with gonadotropin-releasing hormone (GnRH) antagonist compared with those treated with agonist protocol in in vitro fertilization (IVF). Thirty patients who were known low responders were prospectively randomized into two equal groups for IVF treatment. Group 1 used GnRH agonist (flare-up) protocol and group 2 used antagonist protocol. The results showed that serum luteinizing hormone (LH) levels were significantly higher in the agonist group during the folliculogenesis stage. Despite this higher LH, serum E(2) levels were significantly higher in the agonist group on cycle day 2 only, not on day 5 or day 9. The significantly higher E(2) level in the agonist group reappeared on the day of administration of human chorionic gonadotropin (hCG). The rate of folliculogenesis in the antagonist group was faster than in the agonist group; therefore their E(2) production should have been higher on hCG day. Furthermore, the rate of decline in E(2) after hCG administration was significantly higher in the antagonist group. These findings, along with the fact that both groups received exogenous LH (human menopausal gonadotropin) that should optimize steroidogenesis and make the difference in E(2) insignificant, enable us to conclude that GnRH antagonists have a suppressive effect on the production of E(2).

Recombinant gonadotrophins associated with GnRH antagonist (cetrorelix) in ovarian stimulation for ICSI: comparison of r-FSH alone and in combination with r-LH

OBJECTIVE

The objective was to verify the outcome of intracytoplasmic sperm injection (ICSI) with ovulation induction performed with GnRH antagonists, comparing the use of recombinant follicle-stimulating hormone (r-FSH) alone and in combination with recombinant luteinizing hormone (r-LH) in a prospective and randomized trial.

STUDY DESIGN

Forty male-factor infertile normo-ovulatory patients undergoing ovarian stimulation for ICSI took part in the study. After initiating ovarian stimulation with only r-FSH, all patients were treated with GnRH antagonist (cetrorelix). When beginning cetrorelix administration, the patients were randomized into two groups: in group I, 20 patients continued to receive r-FSH alone and in group II, 20 patients received combined r-FSH and r-LH. The number of metaphase II oocytes, estradiol concentration at the time of hCG administration, fertilization rate, grade 1 embryo rate, pregnancy rate per cycle, and implantation rate were measured. Results are expressed as mean+/-S.D.

RESULTS

In group I, the women's age was 32.3+/-2.30 years, and FSH concentration was 7.8+/-1.7 IU/ml. In group II, the women's age was 32.2+/-2.46 years and FSH concentration was 7.5+/-1.7 IU/ml. The number of oocytes retrieved was 9.6+/-2.9 and the number of metaphase II oocytes was 6.7+/-2.2 in group I. In group II the number of retrieved oocytes were 9.9+/-2.6 and the number of metaphase II oocytes 6.9+/-2.1 (p>0.05). Estradiol concentration at the time of hCG was 4.6+/-1.8 nm/l in group I and 6.7+/-2.0 nm/l in group II (p<0.01). Fertilization rate was 73.0% in group I versus 78.2% in group II. In group I, we obtained 53.9% of grade 1 embryos versus 54.4% in group II (p>0.05). Pregnancy and implantation rates in group I were 30.0 and 16.7%, respectively and in group II 35.0 and 20.4%, respectively (p>0.05).

CONCLUSIONS

The use of recombinant LH in addition to recombinant FSH may prevent a decrease in estradiol after GnRH antagonist administration, but does not influence positively the outcome of oocyte number, maturation, embryo quality, fertilization rate, pregnancy rate per cycle, and implantation rate.

Estrogen and folliculogenesis: is one necessary for the other?

PURPOSE OF REVIEW

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

RECENT FINDINGS

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

SUMMARY

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

Alternate day and daily administration of GnRH antagonist may prevent premature luteinization to a similar extent during FSH treatment

BACKGROUND

This randomized controlled trial was designed to evaluate whether a GnRH antagonist given every other day could prevent premature luteinization in women undergoing IVF/ICSI treatment.

METHODS

A total of 73 women receiving ovulation stimulation IVF cycles with recombinant FSH were allocated randomly on cycle day 7 to GnRH antagonist ganirelix in multiple doses (0.25 mg each), either daily (n = 37 women, group 1) or every other day (n = 36 women, group 2) until the day of HCG administration.

RESULTS

Serum FSH, LH, estradiol and progesterone values showed similar trends in the two groups. During FSH stimulation, 13 (35%) of the women in group 1 had premature LH rises (> or = 10 IU/l) of which eight (22%) were after the start of antagonist administration. In group 2 there were 14 (39%) LH rises during FSH stimulation of which 10 (28%) were after the start of antagonist administration. Luteinization (serum progesterone >2 ng/ml) occurred in only one woman in each group overall (3%). A significantly smaller total dose of the antagonist was used in group 2 than in group 1 (P < 0.001). The study did not have power to evaluate differences in total dose of FSH, number of oocytes recovered and clinical pregnancy rate, all of which appeared similar in the two groups.

CONCLUSIONS

Whether alternate day is as effective as daily administration of ganirelix in preventing premature luteinization should be addressed in a non-inferiority trial powered to evaluate live birth rate.

Clinical efficacy of the gonadotropin-releasing hormone antagonist, ganirelix, in Korean women undergoing controlled ovarian hyperstimulation for in vitro fertilization and embryo transfer with recombinant follicle-stimulating hormone

AIM

To assess the clinical efficacy and safety of the gonadotropin-releasing hormone (GnRH) antagonist, ganirelix (Orgalutran), treatment in women undergoing controlled ovarian hyperstimulation (COH) for in vitro fertilization and embryo transfer (IVF-ET) in Korean women.

METHODS

This was a non-comparative, open-label, single-center trial carried out on 31 infertile Korean women. A daily dose of 0.25 mg of the GnRH antagonist, ganirelix, was given, beginning on the sixth day of recombinant follicle-stimulating hormone (FSH) treatment. If the ovarian response was low, ganirelix treatment was delayed until the leading follicle reached a mean diameter of 14 mm. The ganirelix treatment was continued until the day of human chorionic gonadotropin (hCG) injection. Descriptive statistics were recorded for all parameters.

RESULTS

The median duration of ganirelix treatment was 4 days (range: 2-6 days) and the median total recombinant FSH dose was 1350 IU (900-2350 IU). During ganirelix treatment, the incidence of luteinizing hormone (LH) rises (LH = 10 IU/L) was 3.2% (one of 31 cases). On the day ovulation was triggered by hCG, the mean number of follicles >/=11 mm in diameter was 12.4 +/- 4.5, and the median of serum estradiol concentration was 4289.9 (1893.7-8268.5) pmol/L. The mean number of oocytes per retrieval was 10.9 +/- 6.1. The fertilization rate was 61.5%, and the mean number of replaced embryos was 2.8 +/- 0.6. The mean implantation rate was 10.0%, and the clinical pregnancy rate per transfer was 23.3% (seven of 30 cases) and the ongoing pregnancy rate per transfer was 20.0% (six of 30 cases).

CONCLUSION

The results of the present study support ganirelix as a safe, short, convenient and effective treatment for patients undergoing COH for IVF in Korean women.

Agonist “flare-up” versus antagonist in the management of poor responders undergoing in vitro fertilization treatment

OBJECTIVE

To compare the agonist flare-up and antagonist protocols in the management of poor responders to the standard long down-regulation protocol.

DESIGN

Retrospective comparative study.

SETTING

Assisted conception center.

PATIENT(S)

One hundred thirty-four patients undergoing IVF/ intracytoplasmic sperm injection (ICSI) treatment, who responded poorly to the standard long down-regulation protocol in their first treatment cycle. In the second cycle, 77 received short flare-up agonist and 57 received antagonist protocol. We analyzed the outcome of the second cycle.

INTERVENTION(S)

Peak serum E(2) was assayed on the day of hCG administration.

MAIN OUTCOME MEASURE(S)

Cycle cancellation rate due to poor ovarian response.

RESULT(S)

There was no cycle cancellation in the flare-up protocol and 7% cancellation rate in the antagonist protocol due to lack of response. A significantly higher number of patients had embryo transfer in the flare-up protocol. There was no difference in pregnancy rate (PR) between the two groups.

CONCLUSION(S)

Both the flare-up and the antagonist protocols significantly improved the ovarian response of known poor responders. However, a significantly higher cycle cancellation rate and less patients having embryo transfer in the antagonist group tips the balance in favor of the flare-up protocol.

Use of antagonists in ovarian stimulation protocols

Gonadotrophin-releasing hormone (GnRH) antagonists have been introduced in IVF to prevent premature LH surge. They bind competitively to pituitary receptors and prevent endogenous GnRH from exerting any stimulus on pituitary cells, avoiding the initial 'flare-up' effect and decreasing gonadotrophin secretion within a few hours. Pituitary reserve and gonadotrophin synthesis are not affected; therefore, the recovery of pituitary function is rapid. Two different regimes have been described. The multiple-dose protocol involves the administration of 0.25 mg cetrorelix (or ganirelix) daily from day 6-7 of stimulation, or when the leading follicle is 14-15 mm, until human chorionic gonadotrophin (HCG) administration. The single-dose protocol involves the single administration of 3 mg cetrorelix on day 7-8 of stimulation. Both antagonists with either regimen seem to be equally effective in the prevention of the LH surge. Compared with a long luteal agonist protocol, the treatment is shorter and requires a smaller amount of gonadotrophins. Pregnancy rate seems to be lower, but a decrease in the incidence of severe ovarian hyperstimulation syndrome (OHSS) is reported by several studies. A promising aspect of antagonists may be the possibility of making treatment less aggressive. Finally, in antagonist cycles, ovulation triggering is possible by GnRH agonists, avoiding the deleterious effect of HCG and thus preventing OHSS.

Extrapituitary effects of GnRH antagonists in assisted reproduction: a review

GnRH antagonists are used to prevent premature LH surges in assisted reproduction. The pregnancy rates obtained in several studies have been similar to those obtained in the long protocol with gonadotrophin-releasing hormone (GnRH) agonists. However, lower oestrogen serum concentrations have been observed and fewer oocytes retrieved using GnRH antagonists. Thus, potential effects at extrapituitary GnRH receptors in the ovary and the endometrium have been claimed. The article reviews the currently available data from the literature as well as current investigations with respect to effects of cetrorelix on the ovary and the endometrium. No evidence was found to support the hypothesis of extrapituitary effects of GnRH antagonists such as cetrorelix at doses used in assisted reproduction.

Luteinizing hormone supplementation increases pregnancy rates in gonadotropin-releasing hormone antagonist donor cycles

OBJECTIVE

To determine whether LH supplementation improved pregnancy and implantation rates in GnRH antagonist donor cycles.

DESIGN

Donors were randomly assigned to a protocol using GnRH antagonist (GnRH-a) alone or GnRH-a + recombinant LH. Analysis of variance, Student's t-test and Fisher's exact test were used where appropriate.

SETTING

Private clinical setting.

PATIENT(S)

Young voluntary donors with antagonist (n = 20) and antagonist + LH (n = 22). Fifty-five patients received oocytes.

INTERVENTION(S)

Donors received the GnRH-a (Cetrorelix, 0.25 mg/day) alone or in combination with recombinant LH (75 IU/day). Ovulation induction was carried out with recombinant FSH in a step-down protocol. The endometrial tissue of recipient patients was prepared with oral E(2) and P.

MAIN OUTCOME MEASURE(S)

Pregnancy and implantation rates in a donor program.

RESULT(S)

A significant increase in MII oocyte (80% vs. 71%), fertilization rates (83% vs. 71%), G1 embryos (17% vs. 3%), and implantation rates (35% vs. 15%), were found in recipients whose embryos originated from donors receiving GnRH-a + recombinant LH as compared to donors receiving GnRH-a alone. Estradiol levels, pregnancy/transfer and clinical pregnancies were lower (not significant) in donors treated with the GnRH-a alone vs. those receiving the recombinant LH-supplemented GnRH-a.

CONCLUSION(S)

The LH supplementation improved the possibilities of gestation for recipients whose embryos originated from GnRH-a-treated donors.

Prolongation of the follicular phase in in vitro fertilization results in a lower ongoing pregnancy rate in cycles stimulated with recombinant follicle-stimulating hormone and gonadotropin-releasing hormone antagonists

OBJECTIVE

To assess the effect of altering the timing of hCG administration on ongoing pregnancy rates in patients stimulated with recombinant FSH (rec-FSH) and GnRH antagonists for IVF.

DESIGN

Prospective, randomized, controlled trial.

SETTING

Tertiary referral center.

PATIENT(S)

Four hundred thirteen patients undergoing IVF.

INTERVENTION(S)

Rec-FSH stimulation starting on day 2 of the cycle combined with daily GnRH antagonist starting on day 6 of stimulation. Patients were randomized to receive 10000 IU of hCG either as soon as at least three follicles were >or=17 mm on ultrasound (early-hCG group, 208 patients) or 2 days later after this criterion was met (late-hCG group, 205 patients).

MAIN OUTCOME MEASURE(S)

Ongoing pregnancy rate.

RESULT(S)

Fertilization rates and number and quality of embryos transferred did not differ between the two groups. However, a significantly lower ongoing pregnancy rate was present in the late-hCG as compared with the early-hCG group (25.0% vs. 35.6%, respectively).

CONCLUSION(S)

Prolongation of the follicular phase in patients stimulated with rec-FSH and GnRH antagonists for IVF does not affect oocyte or embryo quality but is associated with a significantly lower ongoing pregnancy rate.

FSH and LH together in ovarian stimulation

The authors review the physiology of the ovulatory cycle and the role of the gonadotrophins in ovulation induction in patients with anovulatory disorders and in multifollicular development for assisted reproductive technologies. The use of gonadotrophins with luteinizing hormone (LH) activity and the use of recombinant LH associated with follicle stimulating hormone (FSH) are discussed. The authors point out that administration of gonadotrophins with LH activity is essential in hypogonadotropic hypogonadal anovulation, and data available in the medical literature allow the conclusion that recombinant LH may be added to all ovarian stimulation protocols because it is difficult to determine which patients will benefit from LH administration and there is no evidence that LH affects adversely the outcome of ovarian stimulation. The use of recombinant LH in addition to recombinant FSH may be particularly useful when a GnRH antagonist is associated with the ovarian stimulation regimen, by preventing the fall in estradiol and diminishing FSH requirements.

Triptorelin versus cetrorelix in intracytoplasmic sperm injection cycles in women with a single ovary

OBJECTIVE

To compare the response to ovarian stimulation with either the long protocol of a GnRH-agonist or the multiple protocol of a GnRH-antagonist, in women with a single ovary who underwent intracytoplasmic sperm injection (ICSI) cycles.

STUDY DESIGN

Retrospective study including 75 ICSI cycles from 26 women. Sixty-three cycles were stimulated with triptorelin/hMG or rFSH, whereas 12 cycles were stimulated with cetrorelix/hMG or rFSH.

RESULTS

There was not found any statistical significant difference between the two groups regarding the days of stimulation, the number of gonadotropins' ampoules, the peak estradiol levels, the number of aspirated follicles and the number of retrieved oocytes. The fertilization rate, the number of transferred embryos as well as the cumulative embryo score were also similar in both groups.

CONCLUSION

The multiple stimulation protocol of cetrorelix is equally effective with the long protocol of triptorelin in the ovarian stimulation of women with a single ovary.

Gonadotropin-Releasing Hormone Antagonists for Assisted Reproductive Techniques

Gonadotropin-releasing hormone (GnRH) antagonists have been tested extensively in ovarian stimulation protocols for assisted reproductive techniques (ART). GnRH antagonists immediately and rapidly inhibit gonadotropin release by the anterior pituitary gland by competitive blockage of the GnRH receptor, preventing and interrupting luteinising hormone surges in controlled ovarian hyperstimulation for infertility treatment. A review of the available literature on GnRH antagonists for ART is presented, focusing on the pharmacological and clinical properties of the two compounds available on the market, cetrorelix and ganirelix. Both cetrorelix and ganirelix are well tolerated and effective drugs for controlled ovarian hyperstimulation and are of comparable value for infertility treatment. Cetrorelix is available as a 0.25mg preparation for daily injections and as a 3mg intermediate depot preparation. Ganirelix is available as a 0.25mg preparation for daily injections.Currently, two treatment protocols are used in clinical practice: the GnRH antagonist multiple-dose protocol and the GnRH antagonist single-dose protocol. Both protocols are effective and well tolerated. Cetrorelix and ganirelix have not yet been directly compared in a clinical trial; nor have the single-dose and the multiple-dose approaches been compared in a randomised, controlled trial. Data to compare these compounds in clinical terms can be extrapolated only from results of phase II dose-finding studies and phase III studies comparing GnRH agonist cycles with GnRH antagonists in single- and multiple-dose protocols. Therefore, all conclusions on clinical differences between cetrorelix and ganirelix should remain tentative, as they are based on a limited amount of available data.Randomised, controlled trials comparing cetrorelix and ganirelix are warranted to further evaluate benefits and drawbacks of individual GnRH antagonists. Furthermore, more data are needed to determine the efficacy and safety of cetrorelix and ganirelix in established treatment protocols in patients other than those included in clinical trials investigating new drugs, such as "poor responders", patients with polycystic ovaries, patients with a history of allergy or overweight patients.

Comparative efficacy and safety of cetrorelix with or without mid-cycle recombinant LH and leuprolide acetate for inhibition of premature LH surges in assisted reproduction

An open label, randomized, multi-centre study was performed to compare cetrorelix and leuprolide acetate for prevention of premature LH surge and to assess whether patients treated with cetrorelix benefit from addition of recombinant human (r-h)LH. Normo-ovulatory women (n = 74) undergoing ovarian stimulation prior to intracytoplasmic sperm injection were treated with leuprolide acetate (n = 25) before ovarian stimulation with recombinant human FSH (r-hFSH) or with cetrorelix 3 mg on stimulation day 7 (with (n = 25) or without (n = 24) r-hLH 150 IU on days 7-10). The main outcome measures were the number of metaphase II (MII) oocytes retrieved; secondary efficacy end-points; adverse events (AE) and other safety measures. There were no significant differences between groups for MII oocytes retrieved, duration of stimulation, total r-hFSH dose and pregnancy rates. The group treated with cetrorelix alone had a significantly lower concentration of oestradiol per follicle compared with the other groups. The majority of AE were mild to moderate in severity. Cetrorelix and leuprolide acetate appear to have comparable efficacy and safety, although cetrorelix has the advantage of typically requiring only one injection.

No influence of body weight on pregnancy rate in patients treated with cetrorelix according to the single- and multiple-dose protocols

The question of whether adjustment to body weight is necessary in in-vitro fertilization (IVF) cycles using GnRH antagonists is currently under discussion. Therefore, a data analysis of five prospective studies using either the single- or the multiple-dose antagonist protocol with cetrorelix (Cetrotide) was performed. The influence of stimulation procedure, gonadotrophins and body weight on pregnancy rate was evaluated in a linear logit model. The effect of the stimulation procedure and body weight on the cumulus-oocyte complex (COC) and follicle number was explored in an ANOVA model. Cetrorelix plasma concentrations were tested for any correlation with body weight. Baseline and outcome parameters in different body weight groups (<50 kg, 50-59 kg, 60-69 kg, 70-79 kg, > or =80 kg) were assessed for human menopausal gonadotrophin and recombinant human FSH stimulation separately. Cetrorelix plasma concentrations were correlated with body weight, but no influence of the type of stimulation or body weight on pregnancy rate was found. Body weight did not influence cetrorelix plasma concentrations. In contrast, body weight significantly influenced the number of retrieved COC as well as the number of follicles on the day of human chorionic gonadotrophin administration. Body weight does not influence the outcome of treatment in cetrorelix cycles.