Improvement of delivery and live birth rates after ICSI in women aged >40 years by ovarian co-stimulation with growth hormone

Therapeutic management in women with a diminished ovarian reserve: a systematic review and meta-analysis of randomized controlled trials

IMPORTANCE

The clinical management of women with diminished ovarian reserve (DOR) is a challenge in the field of medically assisted reproduction. Several therapeutic strategies have been proposed, but with mixed results, mainly because the definition of DOR used was inconsistent among trials.

OBJECTIVE

To investigate adjuvant treatments and protocols involving only women with DOR according to POSEIDON (Patient-Oriented Strategies Encompassing IndividualizeD Oocyte Number) criteria.

DATA SOURCES

We conducted a systematic search using the MEDLINE (PubMed), EMBASE, and ISI Web of Knowledge databases to identify relevant studies published up to June 2024.The review protocol was registered at http://www.crd.york.ac.uk/PROSPERO/ (registration number: CRD42022346117).

STUDY SELECTION AND SYNTHESIS

After duplication removal, the titles and abstracts of 4,806 articles were scrutinized, and 124 full-text articles were assessed for eligibility. In total, 38 randomized controlled trials were included in the qualitative/quantitative analysis. The following interventions were evaluated: dehydroepiandrosterone (n = 1,336); testosterone (n = 418); high- vs. low-dose gonadotropin (n = 957); delayed-start protocol with gonadotropin hormone-releasing hormone antagonist (n = 398); letrozole (n = 612); clomiphene citrate (1,113); growth hormone (311); luteal phase stimulation (n = 57); dual triggering (n = 139); dual stimulation (168); luteinizing hormone (979); oestradiol pretreatment (n = 552); and corifollitropin alfa (n = 561).

MAIN OUTCOMES

The primary outcome was live birth rate or ongoing pregnancy if data on live birth were unavailable. Secondary outcomes were number of oocytes retrieved, number of metaphase II oocytes, clinical pregnancy rate and miscarriage rate.

RESULTS

Testosterone supplementation is associated with higher live birth rates compared with nonsupplemented women among all interventions evaluated (odds ratio: 2.19, 95% confidence interval [CI]: 1.11-4.32, four studies, 368 patients). Testosterone (weighted mean difference [WMD] 0.88, 95% CI: 0.03-1.72; 4 studies, n = 368 patients), dehydroepiandrosterone (WMD 0.60, 95% CI: 0.07-1.13; 4 studies, n = 418 patients), and delayed started protocol (WMD 1.32, 95% CI: 0.74 to 1.89; 3 studies, n = 398 patients) significantly improved the total number of eggs collected. Lower number of oocytes retrieved is achieved in women undergoing low dose gonadotropin regimen vs high dose (WMD: -1.57, 95% CI: -2.12 to -1.17; 2 studies, n = 905 patients), The other interventions did not produce significant improvements.

CONCLUSION AND RELEVANCE

Specific interventions such as testosterone seem to correlate with a better live birth rate in women with DOR; these findings should be further explored in randomized trials.

Growth hormone improves the pregnancy outcomes in poor ovarian responders undergoing in vitro fertilization: an umbrella review

Poor ovarian response (POR) significantly impacts the success of assisted reproductive technology (ART), and growth hormone (GH) has been proposed as an adjuvant treatment to improve outcomes in POR patients undergoing in vitro fertilization (IVF). A systematic review and meta-analysis were conducted to evaluate the effectiveness of GH in enhancing pregnancy outcomes, registering a protocol on PROSPERO and searching multiple databases up to September 2023. Twelve systematic reviews/meta-analysis and 20 randomized controlled trials (RCTs) involving 1984 patients were included. Quality assessment was performed using AMSTAR 2, GRADE, and RoB tools. The meta-analysis revealed that GH significantly increased live birth rates [OR=1.80, 95% CI (1.22, 2.64)] and clinical pregnancy rates [OR=1.92, 95% CI (1.51, 2.43)] compared to the control group. Subgroup analysis indicated that administering 5-10 IU/d of GH combined with a long protocol during the middle and late follicular stages maximized these benefits. Despite these promising findings, most outcome indicators exhibited low-quality evidence, highlighting the need for improved research standards to ensure solid evidence supports treatment strategies for POR, thereby promoting reliable application of GH in IVF treatments.

In vitro maturation of oocytes: what is already known?†

Assisted reproductive technologies (ARTs) involve the laboratory manipulation of gametes and embryos to help couples with fertility problems become pregnant. One of these procedures, controlled ovarian stimulation, uses pharmacological agents to induce ovarian and follicular maturation in vivo. Despite the effectiveness in achieving pregnancy and live births, some patients may have complications due to over-response to gonadotropins and develop ovarian hyperstimulation syndrome. In vitro maturation (IVM) of oocytes has emerged as a technique to reduce the risk of ovarian hyperstimulation syndrome, particularly in women with polycystic ovary syndrome, and for fertility preservation in women undergoing oncological treatment. Although there are some limitations, primarily due to oocyte quality, recent advances have improved pregnancy success rates and neonatal and infant outcomes. Different terms have been coined to describe variations of IVM, and the technique has evolved with the introduction of hormones to optimize results. In this review, we provide a comprehensive overview of IVM relating hormonal priming, culture system and media, and clinical indications for IVM with its reproductive outcomes during ARTs.

The effects of growth hormone supplementation in poor ovarian responders undergoing In vitro fertilization or Intracytoplasmic sperm injection: A systematic review and meta-analysis of randomized controlled trials

To evaluate the effect of growth hormone (GH) supplementation on outcomes of in vitro fertilization (IVF) or Intracytoplasmic sperm injection (ICSI) for women with poor ovarian response. Relevant randomized controlled trials (RCTs) were obtained through search in several databases including PubMed, Scopus, Clinicaltrials.gov, Google Scholar, and Cochrane Library. Outcome measures included live birth rate, clinical pregnancy rate, cycle cancelation rate, number of retrieved oocytes, number of transferred embryos, total dose of gonadotropin, duration of gonadotropin treatment, and peak estradiol level. Additionally, a meta-regression analysis was carried out to determine any potential linear relationships between these outcomes and IVF success. After analyzing 18 RCTs comprising of 1870 patients, the study found that GH supplementation improved the number of retrieved oocytes [standardized mean difference (SMD), 0.65; 95% confidence interval (CI), 0.29-1.00] and transferred embryos group (SMD, 0.80, 95% CI, 0.39, 1.21) as well as peak E2 level (SMD, 1.20; 95% CI, 0.59, 1.81). While reduced the total dose and duration of gonadotropin treatment (SMD, -0.82, 95% CI, -1.25, -0.39, and SMD, -0.63, 95% CI, -1.04, -0.22, respectively). The meta-regression analysis found no linear relationship between clinical pregnancy, live birth rate, or cycle cancelation rate and the outcomes measured (p>0.1). Based on the available evidence, GH supplementation appears to improve the outcomes of IVF or ICSI in women with poor response. However, there is a need for further RCTs with larger sample sizes to determine the cost-effectiveness of adding GH to conventional protocols of IVF/ICSI for treating infertility in women with poor ovarian response.

Effect of growth hormone administration on ameliorating pregnancy outcome in women with advanced maternal age and exploration of its optimized utilization

Background

Age-related fertility decay is a great challenge for clinicians. Growth hormone (GH) supplementation has been studied as an adjuvant since late 1980s. However, it has not come to a consensus on the GH administration due to the ambiguous efficacy among studies with different enrolled population and dosage regime.

Methods

A self-controlled retrospective study was conducted on women with advanced maternal age who underwent at least a previous cycle without GH (GH-) and a subsequent cycle with GH co-treatment (GH+). The ovarian stimulation parameters and outcomes were compared between the two cycles and logistical analysis was applied to further explore the association between GH administration protocol as well as other clinical parameters and cumulative live birth in GH+cycle.

Results

A total of 150 women aged 35-43 were included. The number of oocytes retrieved, MII oocytes, 2PNs, transferrable embryos and good-quality embryos in GH+ significantly increased (p < 0.001). The proportion of cycles with no transferrable embryos was significantly reduced in GH+ cycle compared with previous GH- cycle (3 vs. 32; p < 0.001). GH co-treatment cycles showed significantly higher clinical pregnancy rates (43.75% vs. 6.06%; 38.35% vs. 12.04%, p < 0.001), live birth rates (29.17% vs. 0; 27.07% vs. 0, p < 0.001) in both fresh and frozen-thawed embryo transfer cycle. Cumulative live birth rate of the GH+ cycle reached 33.33%. Use of GH prior to Gn stimulation and lasting until the hCG day seemed to achieve a higher successful live birth rate (OR 2.312, 95%CI 1.074-5.163, p=0.032).

Conclusion

GH supplementation could ameliorate pregnancy outcome in women with advanced maternal age. Dosage regimen of long-term pretreatment prior to Gn stimulation (4 IU every other day) and 4 IU per day until hCG day may of greater efficacy compared with concurrent administration with Gn. Additionally, it's worthy of exploring whether an individualized dosage regimen based on the IGF or IGFBP level of patient would be more reasonable and effective. More well-designed prospective trials with large sample size and fundamental experiments on the mechanism are required to testify findings above.

The Advantage of Growth Hormone Alone as an Adjuvant Therapy in Advanced Age and BMI ≥ 24 kg/m2 with In Vitro Fertilization Failure Due to Poor Embryo Quality

This study aimed to assess the effects of GH adjuvant therapy on the cumulative live birth rate in patients with poor embryo quality and to determine the characteristics of patients who are more responsive to GH. A retrospective cohort study was carried out in patients who have suffered from previous IVF failure due to poor embryonic development and underwent IVF with or without a 6-week pretreatment with GH in the subsequent cycle from January 2018 to December 2020. Clinical parameters including the cumulative live birth rate between the (-) GH and (+) GH groups were compared. Multivariate analysis was performed to ascertain associations between clinical parameters and cumulative live birth rate. Upon analysis of the clinical data from 236 IVF cycles, 84 patients received GH and 152 did not receive GH. In frozen embryo transfer cycles, compared with the (-) GH group, the implantation rate and live birth rate were significantly higher in the (+) GH group (p < 0.05). After adjusting for possible confounding factors, GH improved cumulative live birth per oocyte retrieval cycle by 1.96 folds (p = 0.032). Furthermore, when patients were subdivided based on age and BMI, a significant increase in the cumulative live birth rate was found in the (+) GH group of patients between 35 and 42 years old and BMI ≥ 24 kg/m², respectively (p < 0.05). GH may increase the live birth rate in women who experienced IVF failure because of poor embryonic development, particularly in obese patients and women with advanced age.

Growth hormone supplementation ameliorates blastocyst euploidy rates and improves pregnancy outcomes in women undergoing preimplantation genetic testing for aneuploidy cycles

BACKGROUND

Growth hormone (GH) supplementation has been shown to improve oocyte quality and live birth, but few studies have examined whether GH can reduce embryonic aneuploidy. Chromosomal abnormalities in preimplantation embryos have been regarded as the principal cause of implantation failure and miscarriage, and an increased percentage of aneuploid embryos has been observed in patient cohorts with unexplained recurrent pregnancy loss (RPL), recurrent implantation failure (RIF), and advanced maternal age.

METHODS

This prospective cohort study was conducted on women whose previous PGT-A cycle ended up with no transferrable blastocysts, or the aneuploidy rate was above 50% and no live birth was acquired. The participants were divided into GH co-treatment and comparison groups according to whether GH was administered in the subsequent PGT-A cycle. In addition, within the GH co-treatment group, the previous failed cycle constituted the self-control group.

RESULTS

208 women were recruited in the study (GH co-treatment group: 96 women, comparison group: 112 women). Compared to the self-control and comparison groups, the rate of euploid blastocysts was significantly higher in the GH co-treatment group (GH vs self-control: 32.00% vs 9.14%, odds ratio [OR]: 4.765, 95% confidence interval [CI]: 2.420-9.385, P < 0.01; GH vs comparison: 32.00% vs. 21.05%, OR: 1.930, 95% CI: 1.106-3.366, P = 0.021), and their frozen embryo transfers resulted in more pregnancies and live births. In the subgroup analysis, for the <35 and 35-40 years groups, the euploidy rate in the GH co-treatment group was significantly higher than those in the self-control and comparison groups, but in the >40 years group, there was no difference in euploidy rate.

CONCLUSION

Our study presents preliminary evidence that GH supplementation may ameliorate blastocyst aneuploidy and improve pregnancy outcomes in women who have previously experienced pregnancy failures along with high aneuploidy rates, particularly in those younger than 40 years. Therefore, the use of GH in such women should be considered. However, considering the limited sample size and mixed indications for PGT-A, further scientific research on the underlying mechanism as well as clinical trials with larger sample sizes are needed to confirm the effects and optimal protocols.

The Clinical Application of Growth Hormone and Its Biological and Molecular Mechanisms in Assisted Reproduction

Growth hormone (GH) has been used as a co-gonadotrophin in assisted reproduction, particularly in poor ovarian responders. The application of GH has been alleged to activate primordial follicles and improve oocyte quality, embryo quality, and steroidogenesis. However, the effects of GH on the live birth rate among women is controversial. Additionally, although the basic biological mechanisms that lead to the above clinical differences have been investigated, they are not yet well understood. The actions of GH are mediated by GH receptors (GHRs) or insulin-like growth factors (IGFs). GH regulates the vital signal transduction pathways that are involved in primordial follicular activation, steroidogenesis, and oocyte maturation. However, the therapeutic windows and duration of GH administration during assisted reproductive technology require further investigation. The review aimed to clarify the role of GH in human fertility from a molecular and biological point of view to provide evidence for proper GH administration.

Molecular Clues to Understanding Causes of Human-Assisted Reproduction Treatment Failures and Possible Treatment Options

More than forty years after the first birth following in vitro fertilization (IVF), the success rates of IVF and of IVF-derived assisted reproduction techniques (ART) still remain relatively low. Interindividual differences between infertile couples and the nature of the problems underlying their infertility appear to be underestimated nowadays. Consequently, the molecular basis of each couple's reproductive function and of its disturbances is needed to offer an individualized diagnostic and therapeutic approaches to each couple, instead of applying a standard or minimally adapted protocols to everybody. Interindividual differences include sperm and oocyte function and health status, early (preimplantation) embryonic development, the optimal window of uterine receptivity for the implanting embryo, the function of the corpus luteum as the main source of progesterone production during the first days of pregnancy, the timing of the subsequent luteoplacental shift in progesterone production, and aberrant reactions of the uterine immune cells to the implanting and recently implanted embryos. In this article, the molecular basis that underlies each of these abnormalities is reviewed and discussed, with the aim to design specific treatment options to be used for each of them.

Administration of growth hormone improves endometrial function in women undergoing in vitro fertilization: a systematic review and meta-analysis

BACKGROUND

The positive effects of growth hormone (GH) on IVF are often attributed to improvements in oocyte and embryo quality. While emerging evidence emphasizes GH-induced improvements in the endometrium, these results are controversial.

OBJECTIVE AND RATIONALE

This meta-analysis aimed to evaluate whether GH administration improved endometrial function and reproductive outcomes during IVF cycles and to thus guide clinical practice.

SEARCH METHODS

A literature search in the Cochrane Central Register of Controlled Trials, PubMed and Embase was performed through to 30 November 2021, without language restrictions. Randomized controlled trials (RCTs) evaluating the effects of GH on IVF outcomes were included. Risk of bias and quality of evidence (QoE) were assessed according to the Cochrane Collaboration's tool and the Grading of Recommendations Assessment, Development and Evaluation system. Odds ratios (ORs) and mean differences (MDs) with 95% confidence intervals (CIs) were assessed by random-effects models.

OUTCOMES

A total of 25 trials with 2424 women were included. Seventeen RCTs with poor responders (n = 1723) showed that GH administration significantly increased endometrial thickness (EMT) (MD = 0.38, 95% CI: 0.18-0.59; moderate QoE), which contributed to an improved live birth rate (OR = 1.67, 95% CI: 1.13-2.49; very low QoE) and clinical pregnancy rate (CPR) (OR = 1.97, 95% CI: 1.43-2.72; low QoE). Subgroup analyses showed a dose- and time-dependent relationship between GH cotreatment and IVF outcomes; the optimal recommendation for improving CPR was consistent with that for EMT, rather than for oocytes and embryos. Hence, GH might improve fertility via effects on the endometrium. Administration of GH daily from the follicular phase of previous cycle until the hCG trigger with < 5 IU/day led to a thicker endometrium and a greater chance of becoming pregnant, while 5-10 IU/day or administration from the luteal phase of the previous cycle until the hCG trigger resulted in higher oocyte and embryo quality. Poor responders might benefit from cotreatment with the GnRH agonist long protocol more than other stimulation protocols. Pooled data from four trials (n = 354) on women with a thin endometrium indicated that improved endometrial function might be critical for improving reproductive outcomes during GH treatment, as no improvements in embryo quality were found. GH administration not only increased EMT (MD = 1.48, 95% CI: 1.21-1.75; moderate QoE) but also promoted endometrial morphology (OR = 2.67, 95% CI: 1.36-5.23; low QoE) and perfusion (OR = 5.84, 95% CI: 1.30-26.17; low QoE), thereby improving the CPR (OR = 2.71, 95% CI: 1.69-4.34; P < 0.0001; low QoE). There was insufficient evidence to reach a conclusion regarding the effects of GH in normal responders (n = 80). Due to obvious improvements in the CPR, women with a thin endometrium might be the most appropriate population to benefit from GH administration.

WIDER IMPLICATIONS

Improving endometrial function might be another vital mechanism by which GH improves IVF outcomes. Optimal treatment should be offered to the target population according to their personal conditions and needs. The QoE was moderate to very low, due to limited sample sizes and methodological problems; thus, the results should be interpreted with caution. More rigorous RCTs with large sample sizes are needed to confirm the effects and determine optimal GH protocols.

Growth hormone improved oxidative stress in follicle fluid by influencing Nrf2/Keap1 expression in women of advanced age undergoing IVF

OBJECTIVES

To investigate whether growth hormone (GH) can improve oxidative stress (OS) by affecting) /nuclear factor erythroid 2-related factor 2 (Nrf2)/Kelch-like ECH-associated protein 1 (Keap1) in women of advanced age undergoing in vitro fertilization (IVF).

METHODS

This retrospective study enrolled 141 patients, including 65 aged C patients (patients not treated with GH) and 76 aged GH patients (patients treated with GH). The outcomes included IVF-ET results, OS markers in follicle fluid (FF) and Nrf2 and Keap1 mRNA and protein expressions in granulosa cells (GCs).

RESULTS

The results showed that GH improved the available blastocyst (p=.047) and implantation rate (p=.043) in women of advanced age undergoing IVF. The malondialdehyde (MDA) content of FF was significantly higher in the aged-C group than in the aged-GH group (p=.013). The antioxidant enzyme activities of superoxide dismutase (SOD), glutathione peroxidase (GSH-px) and catalase (CAT) were significantly lower in the aged-C group than in the aged-GH group (p= .000, p= .049, p= .012 respectively). Nrf2 mRNA and protein expression was significantly higher and Keap1 mRNA and protein expression was lower in the aged-GH group than in the aged-C group (p= .000, p= .000 respectively).

CONCLUSIONS

The study showed that GH improved embryo quality and implantation rate and alleviated OS in FF, which may be related to Nrf2/Keap1.

The role of growth hormone in assisted reproduction

In contemporary ART, the use of "add-ons" during ovarian stimulation has increased, especially in poor responders. Growth Hormone (GH) is an adjunctive therapy that has been studied extensively in the translational and clinical setting, with an ongoing scientific debate over its effectiveness and optimal use. In this review, we aim to provide an overview of the physiologic basis for the use of GH in ART, and to summarize the latest evidence regarding its clinical use, primarily as an adjunct to ovarian stimulation, but also in the IVF lab and with regards to its effects on the endometrium.

Towards Personalized Antioxidant Use in Female Infertility: Need for More Molecular and Clinical Studies

Treatment with antioxidants is increasingly used to slow down aging processes in different organs of the human body, including those implicated in female fertility. There is a plethora of different natural, synthetic or semi-synthetic medicines available on the market; most of them can be purchased without medical prescription. Even though the use of antioxidants, even under conditions of auto-medication, was shown to improve many functions related to female infertility related to oxidative stress, the lack of medical control and supervision can lead to an overmedication resulting in an opposite extreme, reductive stress, which can be counterproductive with regard to reproductive function and produce various adverse health effects in general. This paper reviews the current knowledge relative to the effects of different antioxidants on female reproductive function. The persisting gaps in this knowledge are also highlighted, and the need for medical supervision and personalization of antioxidant prescription is underscored.

Growth hormone for in vitro fertilisation (IVF)

BACKGROUND

In an effort to improve outcomes of in vitro fertilisation (IVF) cycles, the use of growth hormone (GH) has been considered as adjuvant treatment in ovarian stimulation. Improving the outcomes of IVF is especially important for women with infertility who are considered 'poor responders'. We have compared the outcomes of IVF with adjuvant GH versus no adjuvant treatment in routine use, and specifically in poor responders.

OBJECTIVES

To assess the effectiveness and safety of growth hormone as an adjunct to IVF compared to standard IVF for women with infertility SEARCH METHODS: We searched the following databases (to November 2020): Cochrane Gynaecology and Fertility (CGF) Group specialised register, CENTRAL, MEDLINE, Embase, CINAHL, Epistemonikos database and trial registers together with reference checking and contact with study authors and experts in the field to identify additional trials.

SELECTION CRITERIA

We included all randomised controlled trials (RCTs) of adjuvant GH treatment in IVF compared with no adjuvant treatment for women with infertility. We excluded trials where additional adjuvant treatments were used with GH. We also excluded trials comparing different IVF protocols.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures recommended by Cochrane. Two review authors independently performed assessment of trial risk of bias and extraction of relevant data. The primary review outcome was live birth rate. The secondary outcomes were clinical pregnancy rate, oocytes retrieved, embryo transfer, units of gonadotropin used and adverse events, i.e. ectopic pregnancy, multiple pregnancy, ovarian hyperstimulation syndrome (OHSS), congenital anomalies, oedema.

MAIN RESULTS

We included 16 RCTs (1352 women). Two RCTs (80 women) studied GH in routine use, and 14 RCTs (1272 women) studied GH in poor responders. The evidence was low to very low certainty, the main limitations being risk of bias, imprecision and heterogeneity. Adjuvant growth hormone compared to no adjuvant: routine use for in vitro fertilisation (IVF) The evidence is very uncertain about the effect of GH on live birth rate per woman randomised for routine use in IVF (odds ratio (OR) 1.32, 95% confidence interval (CI) 0.40 to 4.43; I2 = 0%; 2 trials, 80 participants; very low-certainty evidence). If the chance of live birth without adjuvant GH is assumed to be 15%, the chance of live birth with GH would be between 6% and 43%. There was insufficient evidence to reach a conclusion regarding clinical pregnancy rates per woman randomised, number of women with at least one oocyte retrieved per woman randomised and embryo transfer achieved per woman randomised; reported data were unsuitable for analysis. The evidence is very uncertain about the effect of GH on mean number of oocytes retrieved in normal responders (mean difference (MD) -0.02, 95% CI -0.79 to 0.74; I2 = 0%; 2 trials, 80 participants; very low-certainty evidence). The evidence is very uncertain about the effect of GH on mean units of gonadotropin used in normal responders (MD 13.57, 95% CI -112.88 to 140.01; I2 = 0%; 2 trials, 80 participants; very low-certainty evidence). We are uncertain of the effect of GH on adverse events in normal responders. Adjuvant growth hormone compared to no adjuvant: use in poor responders for in vitro fertilisation (IVF) The evidence is very uncertain about the effect of GH on live birth rate per woman randomised for poor responders (OR 1.77, 95% CI 1.17 to 2.70; I2 = 0%; 8 trials, 737 participants; very low-certainty evidence). If the chance of live birth without adjuvant GH is assumed to be 11%, the chance of live birth with GH would be between 13% and 25%. Adjuvant GH results in a slight increase in pregnancy rates in poor responders (OR 1.85, 95% CI 1.35 to 2.53; I2 = 15%; 11 trials, 1033 participants; low-certainty evidence). The results suggest, if the pregnancy rate without adjuvant GH is assumed to be 15%, with GH the pregnancy rate in poor responders would be between 19% and 31%. The evidence suggests that GH results in little to no difference in number of women with at least one oocyte retrieved (OR 5.67, 95% CI 1.54 to 20.83; I2 = 0%; 2 trials, 148 participants; low-certainty evidence). If the chance of retrieving at least one oocyte in poor responders was 81%, with GH the chance is between 87% and 99%. There is a slight increase in mean number of oocytes retrieved with the use of GH for poor responders (MD 1.40, 95% CI 1.16 to 1.64; I2 = 87%; 12 trials, 1153 participants; low-certainty evidence). The evidence is very uncertain about the effect of GH on embryo transfer achieved (OR 2.32, 95% CI 1.08 to 4.96; I2 = 25%; 4 trials, 214 participants; very low-certainty evidence). If the chance of achieving embryo transfer is assumed to be 77%, the chance with GH will be 78% to 94%. Use of GH results in reduction of mean units of gonadotropins used for stimulation in poor responders (MD -1088.19, 95% CI -1203.20 to -973.18; I2 = 91%; 8 trials, 685 participants; low-certainty evidence). High heterogeneity in the analyses for mean number of oocytes retrieved and units of GH used suggests quite different effects according to differences including in trial protocols (populations, GH dose and schedule), so these results should be interpreted with caution. We are uncertain of the effect of GH on adverse events in poor responders as six of the 14 included trials failed to report this outcome.

AUTHORS' CONCLUSIONS

The use of adjuvant GH in IVF treatment protocols has uncertain effect on live birth rates and mean number of oocytes retrieved in normal responders. However, it slightly increases the number of oocytes retrieved and pregnancy rates in poor responders, while there is an uncertain effect on live birth rates in this group. The results however, need to be interpreted with caution, as the included trials were small and few in number, with significant bias and imprecision. Also, the dose and regimen of GH used in trials was variable. Therefore, further research is necessary to fully define the role of GH as adjuvant therapy in IVF.

A 10-Year Perspective on the Utility of Three Adjuvants Often Used in IVF: Growth Hormone, Melatonin and DHEA

Since 2010, numerous studies reported from PIVET, a pioneer IVF facility established over 40 years ago, have explored the use of three adjuvants designed to improve laboratory and clinical outcomes in cases where a poor prognosis has been demonstrated. The adjuvants reported commenced with recombinant growth hormone (rGH), followed by dehydroepiandrosterone (DHEA) after developing a unique troche to avoid the first-pass effect and, subsequently, melatonin. The studies show that rGH is beneficial in the situation where women have poor-quality embryos in the setting of additional poor prognosis factors, such as advanced female age, a very low ovarian reserve, an insulin growth factor profile in the lowest quartile or recurrent implantation failure. The studies also imply that the adjuvants may actually reduce live birth productivity rates if used on women without poor prognosis factors; hence, further studies, which can now be better designed, should be undertaken to explore the notion of underlying adult growth hormone deficiency in some cases as well as the suggestion that DHEA can provide equivalent benefits in some poor prognosis settings. Melatonin showed no suggestive benefits in any of the studies and can be excluded from consideration in this context. Future studies should compare rGH and DHEA with a focus on those women who have poor embryo quality with additional poor prognosis factors. Such trials should be extended to 12 weeks to cover the entire period of oocyte activation.

Human growth hormone use in poor ovarian response - caution and opportunities

Human growth hormone has found favour as a co-gonadotrophin in assisted reproduction particularly in the circumstances of a poor response to stimulation. Its use has been based on animal studies suggesting insulin-like growth factor-1 enhances granulosa and cumulus cell function and possibly oocyte quality. While there is limited ovarian cellular information in women, the use of human growth hormone is alleged to improve egg numbers, embryo quality, clinical pregnancies and live birth in women with a poor ovarian response. A number of cohort studies have claimed these benefits compared with prior nil treatment, but there are a limited number of quality randomised controlled studies. The few good randomised trials indicate an enhanced ovarian response in terms of oestradiol secretion and oocyte maturity with controversial improvement in ongoing pregnancy and live birth. Given the cost of the medication, the lack of convincing data on enhanced clinical outcomes and the theoretical possibility of side effects, we propose it is still too early to determine human growth hormone’s true cost-benefit for widespread use. However, a number of emerging randomised trials may tilt the equation to a positive outlook in the future. Meanwhile, the hormone should only be used after full informed consent from the patient as to its effectiveness and efficacy.

Growth hormone ameliorates the age-associated depletion of ovarian reserve and decline of oocyte quality via inhibiting the activation of Fos and Jun signaling

Oocyte quality typically begins to decline with aging, which contributes to subfertility and infertility. However, there is still no effective treatment to restore the ovarian reserve and improve aged-oocyte quality. According to the present study, growth hormone (GH) secretion changes with maternal age in female mice. After intraperitoneal injection with GH (1 mg/kg body weight) every two days for two months, the 10-month-old mice showed a better ovarian reserve and oocyte quality than control mice. GH treatment decreased the occurrence rate of aneuploidy caused by spindle/chromosome defects. Additionally, the single oocyte transcriptome analysis indicated that GH decreased the expression of apoptosis-related genes in oocytes. It was also observed that GH treatment reduced the expression of γH2AX and apoptosis of aged oocytes via decreasing the activation of Fos and Jun. Collectively, our results indicate that GH treatment is an effective way to reverse the age-associated depletion of ovarian reserve and the decline of oocyte quality by decreasing apoptosis.

Ovarian Aging: Molecular Mechanisms and Medical Management

This is a short review of the basic molecular mechanisms of ovarian aging, written with a particular focus on the use of this data to improve the diagnostic and therapeutic protocols both for women affected by physiological (age-related) ovarian decay and for those suffering premature ovarian insufficiency. Ovarian aging has a genetic basis that conditions the ovarian activity via a plethora of cell-signaling pathways that control the functions of different types of cells in the ovary. There are various factors that can influence these pathways so as to reduce their efficiency. Oxidative stress, often related to mitochondrial dysfunction, leading to the apoptosis of ovarian cells, can be at the origin of vicious circles in which the primary cause feeds back other abnormalities, resulting in an overall decline in the ovarian activity and in the quantity and quality of oocytes. The correct diagnosis of the molecular mechanisms involved in ovarian aging can serve to design treatment strategies that can slow down ovarian decay and increase the quantity and quality of oocytes that can be obtained for an in vitro fertilization attempt. The available treatment options include the use of antioxidants, melatonin, growth hormones, and mitochondrial therapies. All of these treatments have to be considered in the context of each couple's history and current clinical condition, and a customized (patient-tailored) treatment protocol is to be elaborated.

The effect of growth hormone adjuvant therapy on assisted reproductive technologies outcomes in patients with diminished ovarian reserve or poor ovarian response

Low response of patients with diminished ovarian reserve to exogenous gonadotropins in controlled ovarian stimulation (COS) protocols is one of the important problems of reproductive endocrinology. Various treatment protocols have been developed in patients with diminished ovarian reserve (DOR) or poor ovarian response (POR). Recently, the addition of growth hormone (GH) to treatment protocols has been brought to the agenda in these patients. In this study, we aimed to investigate the effect of GH adjuvant treatment on intracytoplasmic sperm injection (ICSI) cycle results in patients with DOR or POR. This retrospective cohort study was carried out with patients who diagnosed as DOR or POR and underwent ICSI. The patients were divided into the groups according to whether GH was used. In this study, ongoing pregnancy rates and live birth rates were observed to be significantly higher in the group receiving GH compared to the control group. In addition, there was a significant increase in embryo quality in the group receiving GH. As a result, the addition of GH to COS protocols in DOR and POR patients may increase the ongoing pregnancy rate, live birth rate, embryo quality.

Growth hormone alleviates oxidative stress and improves the IVF outcomes of poor ovarian responders: a randomized controlled trial

BACKGROUND

Oxidative stress (OS), defined as an imbalance between excessive reactive oxygen species (ROS) and/or reactive nitrogen species (RNS) production and antioxidant insufficiency, has been suggested to be involved in the pathogenesis of poor ovarian response (POR). Growth hormone (GH) can reduce OS in some cell types. This study investigated whether GH can improve OS and the in vitro fertilization and embryo transfer (IVF-ET) outcomes of poor ovarian responders.

METHODS

This study enrolled 105 patients with POR and 58 patients without POR (controls) who were diagnosed according to the Bologna criteria and underwent conventional IVF-ET. Poor ovarian responders were randomly assigned to two groups: the POR-GH group, which received pretreatment with GH 4 IU/d on day 2 of the previous menstrual cycle before IVF until the trigger day, and the POR-C group, which received no pretreatment. OS markers in follicular fluid (FF), ROS levels in granulosa cells (GCs), and the IVF outcomes of the groups were compared.

RESULTS

Endometrial thickness on trigger day, the number of cleaved embryos, the number of higher-quality embryos, and the rates of embryo formation, higher-quality embryo formation, implantation and clinical pregnancy were significantly increased in the POR-GH group compared with the POR-C group (P < 0.05). Moreover, compared to those in the non-POR group, FF malondialdehyde (MDA), total oxidant status (TOS), oxidative stress index (OSI) and ROS levels in GCs were significantly higher, whereas superoxide dismutase (SOD) and the total antioxidant capacity (TAC) were significantly lower in the POR-C group (P < 0.05). Furthermore, compared with those in the POR-C group, the FF TAC was significantly increased in the POR-GH group, and TOS, OSI and intracellular ROS levels were significantly reduced (P < 0.05).

CONCLUSIONS

Pretreatment with GH alleviates OS and improves oocyte quality and IVF outcomes of poor ovarian responders.

TRIAL REGISTRATION

Chinese Clinical Trial Registry. ChiCTR1900021269 . Registered 8 February 2019, http://www.chictr.org.cn/edit.aspx?pid=35837&htm=4 .

The effect of growth hormone supplementation in poor ovarian responders undergoing IVF or ICSI: a meta-analysis of randomized controlled trials

PURPOSE

The aim of this meta-analysis was to evaluate the effect of growth hormone (GH) supplementation in poor responders undergoing in vitro fertilization (IVF) or intracytoplasmic sperm injection (ICSI).

METHODS

PubMed, MEDLINE and Cochrane Library databases were searched for the identification of relevant randomized controlled trials. Outcome measures were live birth rate, clinical pregnancy rate, miscarriage rate, cycle cancelation rate, number of retrieved oocytes and total dose of gonadotropin.

RESULTS

Fifteen randomized controlled trails (RCTs) involving 1448 patients were eligible for the analysis. GH supplementation improved live birth rate (RR, 1.74; 95% CI, 1.19-2.54), clinical pregnancy rate (RR, 1.65; 95% CI, 1.31-2.08) and retrieved oocytes number (SMD, 0.72; 95% CI, 0.28-1.16), while reducing cancelled cycles rate (RR, 0.62; 95% CI, 0.44-0.85) and dose of Gonadotropin (SMD,-1.05 95% CI, - 1.62 - -0.49) for poor ovarian response patients. Besides, there was no significant difference in the miscarriage rate between GH group and control group.

CONCLUSIONS

Based on the limited available evidence, growth hormone supplementation seems to improve IVF/ICSI outcomes for poor ovarian responders. Further randomized controlled trials with large sample sizes are required to clarify the effect of GH adjuvant therapy in the treatment of women with poor ovarian response.

Hormonal Effects in Reproductive Technology with Focus on Diminished Ovarian Reserve

Modern use of reproductive technologies has revolutionized the treatment of infertile couples. Strategies to improve ovarian function in cases of diminished ovarian reserve are perhaps the least understood area in this field and will be the chief focus of this chapter.

Evaluation of growth hormone co-treatment in in vitro fertilization in patients responding better to the GnRH antagonist short protocol

Objective

The present study aims at evaluating the results obtained after in vitro fertilization in bad responders, using controlled ovarian hyperstimulation together with the use of gonadotrophin releasing hormone (GnRH) antagonist (cetrorelix acetate) in a short protocol.

Methods

This is an analytical, longitudinal, retrospective and controlled study involving patients who underwent in vitro fertilization (IVF) procedures in the assisted reproduction program of the Reproferty clinic, in the municipality of São José dos Campos/SP, from January 2012 to December 2016. We collected the data obtained from the medical records of patients considered to have undergone controlled ovarian hyperstimulation using GnRH antagonist (cetrorelix acetate) and Growth Hormone (GH) in a short cycle protocol. The patients considered controls were those submitted to the same hyperstimulation process, without using GH.

Results

There were significant differences in the following analyzed parameters: gonadotrophin regimen dose, stimulation duration, and estradiol levels on the day of HCG administration, number of follicles, number of retrieved oocytes, number of mature oocytes and number of good-quality embryos. On the other hand, the GH administration was not significant in the number of cycles that achieved transfer, the number of embryos transferred and the number of frozen cycles. In the case group, there was no increase in the number of cycles that reached pregnancy rate βhCG+; however, the clinical pregnancy rates and live birth rates were significant.

Conclusion

The present investigation demonstrated that GH administration as a supplement in poor responders improves the majority of the parameters to achieve a full term pregnancy in these patients.

What Is the Best Regimen for Ovarian Stimulation of Poor Responders in ART/IVF?

The infertile patients with aging ovaries-also sometimes referred to as impending premature ovarian insufficiency (POI), impending premature ovarian failure (POF), or poor ovarian responders (POR), constitute a significant and increasing bulk of the patients appealing to IVF/ART. Different causes have been cited in the literature, among the identified etiologies, including chromosomal and genetic etiology, metabolic, enzymatic, iatrogenic, toxic, autoimmune, and infectious causes. Although the most successful and ultimate treatment of POI/POF/POR patients is egg donation (ED), many, if not most, of these infertile women are reluctant to consent to ED upon the initial diagnostic interview, requesting alternative solutions despite the low odds for success. Despite anecdotal case reports, no unequivocal treatment proved to be successful for these patients in prospective randomized controlled trials. Nevertheless, the addition of growth hormone (GH) to ovarian stimulation in POR with GH deficiency may improve the results of controlled ovarian hyperstimulation (COH) and the IVF success. In patients with autoimmune etiology for POR/POI, the combination of glucocorticosteroids, pituitary-ovarian suppression, and COH may be successful in achieving the desired conception.

The Effect of GH Administration on Oocyte and Zygote Quality in Young Women With Repeated Implantation Failure After IVF

Growth hormone (GH) has been shown to improve implantation and live birth rates in women of >40 years of age treated by in vitro fertilization (IVF). This effect was initially attributed to a GH effect on oocyte quality, but later studies showed that GH can also improve uterine receptivity for embryo implantation. As to younger women with previous failures of embryo implantation after IVF, data reported in the literature are ambiguous. This retrospective study focused on this latter category of women, comparing the numbers and morphological appearance of oocytes recovered from women with two previous IVF failures, aged between 30 and 39 years and treated with GH, with a comparable group of women without GH treatment. These results were complemented with the analysis of morphological markers of zygote and embryo quality and IVF clinical outcomes in both groups. The oocytes, zygotes and embryos from women treated with GH showed better morphological scores, and their uterine transfer resulted in more implantations, pregnancies and live births, as compared with the untreated group. It is concluded that the improvement of IVF outcomes in women with previous repeated IVF failures by exogenous GH administration is, at least partly, related to an increase in oocyte developmental potential. The statistically evident improvement of oocyte and embryo quality is the main finding of this study. Its weakness is its retrospective nature.

Clinical Outcomes of Frozen-Thawed Embryos Generated From Growth Hormone Stimulation in Expected Poor Responders

OBJECTIVE

This study aimed to elucidate whether growth hormone (GH) adjuvant therapy significantly improves clinical outcomes for expected poor responders in frozen-thawed cycles.

METHODS

Expected poor responders undergoing controlled ovarian stimulation with or without GH adjuvant therapy, and subsequently underwent the first frozen-thawed transfer from January 2017 to March 2020 were retrospectively reviewed. Maternal age was matched at a 1:1 ratio between the GH and control groups. All statistical analyses were performed with the Statistical Package for the Social Sciences software.

RESULTS

A total of 376 frozen-thawed cycles comprised the GH and control groups at a ratio of 1:1. The number of oocytes (7.13 ± 3.93 vs. 5.89 ± 3.33; p = 0.001), two pronuclei zygotes (4.66 ± 2.76 vs. 3.99 ± 2.31; p = 0.011), and day 3 available embryos (3.86 ± 2.62 vs. 3.26 ± 2.04; p = 0.014) obtained in the GH group was significantly higher than the control group in corresponding fresh cycles. The clinical pregnancy (30.3 vs. 31.0%; p = 0.883), implantation (25.3 vs. 26.2%; p = 0.829), early abortion (16.1 vs. 15.8%; p = 0.967), and live birth rates (20.6 vs. 20.8%; p=0.980) were comparable between the two groups in frozen-thawed cycles. Improvement in the clinical pregnancy (46.8 vs. 32.1%; p = 0.075), early miscarriage (10.3 vs. 20.0%; p = 0.449), and live birth rates (35.7 vs. 18.9%; p = 0.031) was found in the subgroup of poor ovarian responders (PORs) with good quality blastocyst transfer (≥4BB) following GH co-treatment.

CONCLUSIONS

GH administration would increase oocyte quantity and quality, in turn, improve live birth rate in PORs.

Growth hormone supplementation may improve the pregnancy rate and endometrial receptivity among women aged more than 40 years undergoing in vitro fertilization

Background

Growth hormone (GH) supplements have been shown to improve pregnancy and live-birth rates, suggesting that GH has a beneficial effect on oocyte quality. However, the effects of GH on implantation and receptivity remain unknown. This study evaluated the efficacy of GH in women aged more than 40 years participating in assisted reproductive technology (ART) programs.

Methods

Cycles of in vitro fertilization/intracytoplasmic sperm injection-embryo transfer (IVF/ICSI-ET) in women aged more than 40 years (range, 40–43 years) between January 2009 and March 2014 at a university-based reproductive center were reviewed. Women were divided into two groups, those with and without GH co-stimulation. ART outcomes were evaluated.

Results

Supplement of GH significantly lowered cycle cancellation rate by increasing the per cycle rates of harvesting at least one oocyte and transferring at least one embryo (80.2% vs. 69.4%). GH increased the per cycle clinical pregnancy (15.9% vs. 6.8%) and favorable ultrasonic endometrial pattern (60.9% vs. 39.3%) rates. GH also increased the per transfer clinical pregnancy (19.9% vs. 9.9%) and implantation (11.2% vs. 5.2%) rates and the rate of a favorable ultrasonic endometrial pattern (65.1% vs. 45.0%).

Conclusion

GH supplementation reduces the cycle cancellation rate in women aged more than 40 years, and increases the favorable ultrasonic endometrial pattern, pregnancy, and implantation rates by its beneficial actions on embryo quality and endometrial receptivity.

Live birth outcomes of vitrified embryos generated under growth hormone stimulation are improved for women categorized as poor-prognosis

OBJECTIVE

To determine the clinical pregnancy (CP) and live birth (LB) rates arising from frozen embryo transfers (FETs) that had been generated under the influence of in vitro fertilization (IVF) adjuvants given to women categorized as poor-prognosis.

METHODS

A registered, single-center, retrospective study. A total of 1,119 patients with first FETs cycle include 310 patients with poor prognosis (109 treated with growth hormone [GH], (+)GH group vs. 201 treated with dehydroepiandrosterone, (-)GH group) and 809 patients with good prognosis (as control, (-)Adj (Good) group).

RESULTS

The poor-prognosis women were significantly older, with a lower ovarian reserve than the (-)Adj (Good) group, and demonstrated lower chances of CP (p<0.005) and LB (p<0.005). After adjusting for confounders, the chances of both CP and LB in the (+)GH group were not significantly different from those in the (-)Adj (Good) group, indicating that the poor-prognosis patients given GH had similar outcomes to those with a good prognosis. Furthermore, the likelihood of LB was significantly higher for poor-prognosis women given GH than for those who did not receive GH (p<0.028). This was further confirmed in age-matched analyses.

CONCLUSION

The embryos cryopreserved from fresh IVF cycles in which adjuvant GH had been administered to women classified as poor-prognosis showed a significant 2.7-fold higher LB rate in subsequent FET cycles than a matched poor-prognosis group. The women with a poor prognosis who were treated with GH had LB outcomes equivalent to those with a good prognosis. We therefore postulate that GH improves some aspect of oocyte quality that confers improved competency for implantation.

Growth hormone co-treatment on controlled ovarian stimulation in normal ovarian response women can improve embryo quality

To investigate the clinical efficacy of growth hormone (GH) in normal response patients with poor embryo quality in previous in vitro fertilization cycles. A total of 1562 infertile women were enrolled in this matched case-control study: 781 women were treated with GH (study group), whereas 781 matched patients were treated without GH (control group). GH was administered by a daily subcutaneous injection of 2 or 4 IU started from either D2 of the previous cycle (6 weeks GH pretreatment) or the initial day of controlled ovarian stimulation (2 weeks GH pretreatment) until hCG trigger. The study group was further divided into four subgroups: 2 IU-6 weeks GH pretreatment, 4 IU-6 weeks GH pretreatment, 2 IU-2 weeks GH pretreatment, and 2 IU-4 weeks GH pretreatment. Patients receiving GH showed significantly lower Gn dosage. The total number of oocytes retrieved, embryos formed, endometrial thickness on hCG day were significantly higher with GH. 2PN rate and high-quality embryo rate were lower in the GH group. However, GH increased clinical pregnancy rate with significant difference. 4 IU-6 weeks GH pretreatment showed lowest duration of Gn and highest clinical pregnancy rate compared with other three groups. Number of transferred embryos was confounding factor both in univariate and multivariate analysis. Our study showed that co-treatment with GH in patients with normal ovarian response could increase pregnancy rate.

Growth hormone during in vitro fertilization in older women modulates the density of receptors in granulosa cells, with improved pregnancy outcomes

OBJECTIVE

To study the effect of aging and granulosa cell growth hormone receptor (GHR) expression, and the effect of growth hormone (GH) co-treatment during IVF on receptor expression.

DESIGN

Laboratory study.

SETTING

University.

PATIENT(S)

A total of 445 follicles were collected from 62 women undergoing standard infertility treatment.

INTERVENTION(S)

Preovulatory ovarian follicle biopsies of granulosa cells and follicular fluid.

MAIN OUTCOME MEASURE(S)

Older women with a poor ovarian reserve were co-treated with GH to determine the effect of the adjuvant during IVF on the granulosal expression density of FSH receptor (FSHR), LH receptor (LHR), bone morphogenetic hormone receptor (BMPR1B), and GHR. Ovarian reserve, granulosa cell receptor density, oocyte quality, and pregnancy and live birth rates were determined.

RESULT(S)

Growth hormone co-treatment increased the receptor density for granulosal FSHR, BMPR1B, LHR, and GHR compared with the non-GH-treated patients of the same age and ovarian reserve. Growth hormone co-treatment increased GHR density, which may increase GHR activity. The GH co-treatment was associated with a significant increase in pregnancy rate.

CONCLUSION(S)

Growth hormone co-treatment restored the preovulatory down-regulation of FSHR, BMPR1B, and LHR density of the largest follicles, which may improve the maturation process of luteinization in older patients with reduced ovarian reserve. The fertility of the GH-treated patients improved.

Human growth hormone for poor responders: a randomized placebo-controlled trial provides no evidence for improved live birth rate

RESEARCH QUESTION

Does the addition of human growth hormone (HGH) to an IVF cycle improve the live birth rate in previously documented poor responders to FSH?

DESIGN

Double-blind, placebo-controlled, randomized clinical trial comparing HGH to placebo in maximal stimulation in an IVF cycle. The study was stopped after 4 years. Women receiving ovarian stimulation in one IVF cycle, having failed to produce more than 5 eggs in a previous cycle with more than 250 IU/day of FSH were included. Basal FSH was ≤15 IU/l, body mass index <33 kg/m², age <41 years. HGH or placebo were added from the start of the cycle in a double-blinded manner. The primary outcome was live birth rate.

MAIN RESULTS

The live birth rates following an IVF cycle were 9/62 (14.5%) for growth hormone and 7/51 (13.7%) for the placebo group (risk difference 0.8%, 95% confidence interval [CI] -12.1 to 13.7%; odds ratio [OR] 1.07, 95% CI 0.37-3.10). There was a greater odds of oocyte retrieval with growth hormone (OR 5.67, 95% CI 1.54-20.80) but no better chance of embryo transfer (OR 1.42, 95% CI 0.50-4.00). Birth weights were comparable.

CONCLUSIONS

Planned participant numbers were not reached. It was not possible to demonstrate an increase in live birth rate from the addition of growth hormone in women with a previous poor ovarian response to IVF.

Growth Hormone and Endometrial Receptivity

Administration of growth hormone (GH) during ovarian stimulation has shown beneficial effects on in vitro fertilization (IVF) outcomes. It is generally believed that this improvement is due to the stimulating effect of GH on oocyte quality. However, studies are emerging that show possible positive effect of GH administration on endometrial receptivity, thus suggesting an additional potential benefit at the level of the uterus, especially among women with recurrent implantation failure, thin endometrium, and older normal responders. This review summarizes recent data on GH co-treatment effects on endometrium and endometrial receptivity among infertile women undergoing IVF, and proposes possible mechanisms of GH actions in the endometrium.

Application of Growth Hormone in in vitro Fertilization

Growth hormone (GH) is a peptide hormone secreted mainly by the anterior part of the pituitary gland and plays a critical role in cell growth, development, and metabolism throughout the body. GH can not only directly influence human oocytes and cumulus cells but also indirectly improve oocyte quality through activating synthesis of insulin-like growth factor-I or promoting follicle-stimulating hormone-induced ovarian steroidogenesis. Since GH can regulate female and male infertility, it has been applied in the management of infertility for many years, especially in patients with poor ovarian response or poor prognosis. During ovarian stimulation, GH administration might improve the success rate of in vitro fertilization (IVF) probably through the beneficial effects of GH on oocyte quality as indicated by a higher number of mature oocytes and embryos arriving at the transfer stage and a higher fertility rate in GH-treated patients. However, there is still great controversy in the application of GH in IVF. While some researchers showed that pregnancy, implantation and live birth rates could be increased by ovarian pretreatment with GH, others did not support GH as an effective adjuvant for infertility treatment because the live birth rate was not increased. This study reviewed and summarized recent advancements and benefits in clinical application of GH, trying to reach a just unbiased conclusion regarding the effect of GH therapy in IVF.

Growth Hormone Promotes in vitro Maturation of Human Oocytes

Increasing the success rate of in vitro maturation (IVM) for human oocytes has a major clinical significance. Previous studies have shown that growth hormone (GH) added into IVM medium could promote IVM of oocytes from non-human beings. However, few studies on systematic IVM for human oocytes with GH have been reported. Human germinal vesicle (GV) oocytes collected for IVM were cultured with different concentrations of GH to optimize the concentration. Metaphase II (MII) stage oocytes obtained from IVM were fertilized by intracytoplasmic sperm injection (ICSI). Maturation rate, fertilization rate, and blastocyst rate were assessed after IVM with or without GH. Furthermore, gene expression profiles were compared in oocytes between the two groups using single-cell RNA-seq. The optimal concentration of GH for IVM was 200 ng/ml, and the maturation rate of this group reached 70% which was double that of the control group (35%, P = 0.004). The fertilization rate (73.1 vs. 60.3%) and blastocyst rate (25.0 vs. 15.5%) both had an increasing trend in the GH group compared to controls. Single-cell RNA-Seq and real-time PCR data showed that GH could significantly enhance the expression of genes associated with meiotic progression and embryo development, such as AURKA (aurora kinase A, P = 0.007), PDIA6 (protein disulfide isomerase family A member 6, P = 0.007), LINGO2 (leucine rich repeat and Ig domain containing 2, P = 0.007), and CENPJ (centromere protein J, P = 0.039). Taken together, GH could promote maturation of human oocytes, probably through accelerating meiotic progression, balancing redox homeostasis of cellular environment, and promoting oocyte developmental competence.

The Evolving Concept of Poor-Prognosis for Women Undertaking IVF and the Notion of Growth Hormone as an Adjuvant; A Single-Center Viewpoint

IVF is currently regarded as a successful new technology with the number of IVF children currently well over 8 million worldwide. This has been achieved by an explosive plethora of facilities. However, from its earliest history, IVF has been beset by poor-prognosis on a treatment cycle basis, an aspect which has been a constant feature for the majority of treatments to this stage. The 2019 Australian and New Zealand Assisted Reproduction Database (ANZARD) report shows that IVF clinics have live birth productivity rates (from combined initiated fresh and frozen cycles) ranging from 9.3 to 33.2%. Over the past 40 years there have been a number of innovations which have steadily moved the success rates forward, but progress is held back by an intransigent group of women who can be classified as being poor-prognosis from one or more adverse factors, namely advanced age (>40 years), poor ovarian response (POR) to ovarian stimulation, inability to generate high quality blastocyst-stage embryos, recurrent implantation failure, or recurrent early pregnancy losses. A number of strategies are variously applied including the use of recombinant growth hormone (GH) adjuvant therapy. Our retrospective studies at PIVET over the past decade show a 6.2-fold chance of live birth for fresh cycle embryo transfers following GH injections of 1-1.5 IU daily given for 3-6 weeks in the lead-up to the trigger for ovum pick-up. We have also recently reported the live birth rates from frozen embryo transfers utilizing those blastocyst embryos generated under GH influence and showed the live birth rate was 2.7-fold higher in a carefully matched poor-prognosis group. This experience has been compared to the total 42 GH studies reported since the year 2000, the majority matching those of PIVET with significant increases in both oocyte and embryo utilization rates but only ~50% are followed by elevated live birth rates. We argue that this discrepancy relates to failure in addressing other causes of poor-prognosis along with the wastage of transferring more than a single embryo in the fresh cycle, when ANZARD data indicates a significantly higher chance of live birth from frozen embryo transfers.

The Effect of Growth Hormone on the Clinical Outcomes of Poor Ovarian Reserve Patients Undergoing in vitro Fertilization/Intracytoplasmic Sperm Injection Treatment: A Retrospective Study Based on POSEIDON Criteria

The aim of this retrospective analysis is to explore whether growth hormone (GH) pretreatment is beneficial for patients with poor ovarian reserve undertaking in vitro fertilization/intracytoplasmic sperm injection (IVF/ICSI) treatment. Poor ovarian reserve patients with anti-Mullerian hormone (AMH) <1.2 ng/mL were recruited and divided into the GH adjuvant group (GH+ group) and the counterpart without GH pretreatment (GH- group). One-to-one case-control matching was performed to adjust essential confounding factors between the GH+ group and GH- group. A total of 676 cycles were included in the present study with 338 cycles in each group. Conventional ovarian stimulation protocols were applied for ART treatment. Patients were further divided into POSEIDON group 3 (PG3, age <35 years) and POSEIDON group 4 (PG4, age ≥35 years), based on POSEIDON criteria. The demographic data, cycle characteristics, and clinical outcomes between the GH+ group and GH- group, as well as in the further stratified analysis of PG3 and PG4 were compared. GH adjuvant showed a beneficial effect on the ovarian response and live birth rate in poor ovarian reserve patients. Further stratification revealed that in PG4, there was a significantly increased number of good-quality embryos in the GH+ group compared to the GH- group (1.58 ± 1.71 vs. 1.25 ± 1.55, P = 0.032), accompanied by a reduced miscarriage rate and a greatly improved live birth rate (29.89 vs. 17.65%, P = 0.028). GH adjuvant failed to promote the live birth rate in PG3. In conclusion, GH pretreatment is advantageous by elevating ovarian response and correlated with an improved live birth rate and reduced miscarriage rate in POSEIDON poor ovarian reserve patients older than 35.

Customised Oocyte Donation Enhancement and New Findings Regarding the Role of Growth Hormone

In vitro fertilisation (IVF) with donated oocytes is the most effective assisted reproduction treatment currently available; however, repeated implantation failure (RIF) can occur with this treatment. The protocol of patient preparation for IVF with donated oocytes is relatively simple and works well in most cases; however, it can fail in a minority of women, which is what occurs in RIF patients. While the probability of RIF occuring is 20–35%, it is reasonable to take adequate measures in all patients in order to avoid procedural failure. The risk of oocyte donation failure can be minimised by applying a customised oocyte donation enhancement (CODE) protocol, in which pitfalls of the standard protocol are detected and corrected in the pretreatment phase, during the patient’s uterus preparation for embryo transfer, and after the transfer. Growth hormone, recently reported to improve pregnancy outcomes in women with RIF after oocyte donation, is a possible component of the CODE protocol, but it cannot be considered a unique solution to RIF. This article reviews possible causes of RIF and places growth hormone treatment in the context of other important measures to be followed in the CODE protocol.

The addition of growth hormone adjuvant therapy to the long down regulation protocol in poor responders undergoing in vitro fertilization: Randomized control trial

OBJECTIVE

to detect the impact of growth hormone (GH) co-treatment to the long down regulation protocol, on the outcomes of IVF/ICSI cycles in poor responders.

STUDY DESIGN

this parallel open label randomized control trial was conducted in a university hospital. It included 240 females satisfying the bologna criteria for poor responders. The enrolled females were randomized into 2 groups: A (long/GH) receiving GH adjuvant therapy to the long protocol and group B (control) receiving the long protocol alone. The main outcome measure was the live birth rate (fresh, frozen and cumulative).

RESULTS

GH supplementation improved the number of collected oocytes (5.4 ± 1.7 vs. 4.3 ± 2.1), MII oocytes (4.1 ± 2.1 vs. 2.1 ± 1.4), fertilized oocytes (4.0 ± 2.2 vs. 2.0 ± 1.2), transferred embryos (2.4 ± 0.9 vs. 1.6 ± 1.1) and cryopreserved (0.5 ± 0.7 vs. 0.2 ± 0.5). There was no significant difference in the live birth rate whether fresh (17.5% vs. 14.1%) or cumulative (18.3% vs. 14.7%).

CONCLUSIONS

Further studies are needed to know the true impact of adding GH to the induction protocols in poor responders, as there was no difference in the live birth rates between the study groups, indicating a lack of trend toward benefit from GH supplementation in poor responders.

CLINICAL TRIAL REGISTRATION

NCT02338206.

Effects of growth hormone plus gonadotropins on controlled ovarian stimulation in infertile women of advanced age, poor responders, and previous in vitro fertilization failure patients

OBJECTIVE

To investigate the effects of growth hormone (GH) cotreatment in ovarian stimulation in infertile women of advanced age, poor responders, and patients with one or more previous IVF treatment failures.

MATERIALS AND METHODS

We conducted a retrospective observational study of 436 patients undergoing GH cotreatment in ovarian stimulation. The first arm included 134 infertile women of advanced age. The second arm included 236 patients with one or more IVF previous treatment failures, and the third arm included 66 younger poor responders. Main outcome measures were the number of oocytes and embryos, quality of embryos, and implantation and pregnancy rates.

RESULTS

In infertile women of advanced age, GH plus ovarian stimulation yielded no statistical differences in the numbers of oocytes and embryos, quality of embryo, and rates of implantation and pregnancy. In the second arm, the mature oocyte number (8.2 vs. 6.8), implantation rate (16.1% vs. 0%), and pregnancy rate (33.9% vs. 0%) in the GH cotreatment group differed significantly from those in the control group; the rate of good-quality embryos in the GH cotreatment group improved from 35.5% ± 31.1%-41.4% ± 30.6% in this arm. Similar results were observed in the third arm; in this arm, the clinical pregnancy rate was 30.3% in the GH cotreatment group and 6.1% in the control group.

CONCLUSION

No significant differences were observed in infertile women of advanced age, which may be due to the low GH dose. The GH adjuvant therapy for patients with one or more previous IVF treatment failures and for poor responders significantly improved the oocyte and embryo numbers as well as implantation and pregnancy rates.

Growth hormone in IVF cycles: any hope?

PURPOSE OF REVIEW

Growth hormone (GH) has been used as an adjunct in ovulation induction and IVF for 25 years, particularly as an adjunct to ovarian stimulation for women who had a previous poor response to stimulation in an IVF cycle. It does not have US Food and Drug Administration approval for this use. Unfortunately, due to the problems inherent with recruiting women who have undergone unsuccessful IVF treatment cycles and their inevitable low live birth rate per initiated cycle, many studies performed to date have been underpowered.

RECENT FINDINGS

Previous meta-analyses of studies performed in populations of women with a poor response to ovarian stimulation, demonstrated an increase in the live birth rate for the use of GH. With the recent publication of three studies and the presentation of the Australian LIGHT study, we undertook an updated meta-analysis.

SUMMARY

Meta-analysis demonstrated a benefit for the use of the adjunct GH, with a reduction in the duration of ovarian stimulation required for oocyte retrieval, the collection of a greater number of oocytes than placebo, and an improvement in many of the early clinical parameters; however, there was no evidence of an increased chance of a live birth for the use of GH.

DHEA Supplementation Confers No Additional Benefit to that of Growth Hormone on Pregnancy and Live Birth Rates in IVF Patients Categorized as Poor Prognosis

BACKGROUND

In vitro fertilization (IVF) patients receive various adjuvant therapies to enhance success rates, but the true benefit is actively debated. Growth hormone (GH) and dehydroepiandrosterone (DHEA) supplementation were assessed in women undergoing fresh IVF transfer cycles and categorized as poor prognosis from five criteria.

METHODS

Data were retrospectively analyzed from 626 women undergoing 626 IVF cycles, where they received no adjuvant, GH alone, or GH-DHEA in combination. A small group received DHEA alone. The utilization of adjuvants was decided between the attending clinician and the patient depending on various factors including cost.

RESULTS

Despite patients being significantly older with lower ovarian reserve, live birth rates were significantly greater with GH alone (18.6%) and with GH-DHEA (13.0%) in comparison to those with no adjuvant (p < 0.003). No significant difference was observed between the GH groups (p = 0.181). Overall, patient age, quality of the transferred embryo, and GH treatment were the only significant independent predictors of live birth chance. Following adjustment for patient age, antral follicle count, and quality of transferred embryo, GH alone and GH-DHEA led to a 7.1-fold and 5.6-fold increase in live birth chance, respectively (p < 0.000).

CONCLUSION

These data indicated that GH adjuvant may support more live births, particularly in younger women, and importantly, the positive effects of GH treatment were still observed even if DHEA was also used in combination. However, supplementation with DHEA did not indicate any potentiating benefit or modify the effects of GH treatment. Due to the retrospective design, and the risk of a selection bias, caution is advised in the interpretation of the data.

Increased proportion of mature oocytes with sustained-release growth hormone treatment in poor responders: a prospective randomized controlled study

PURPOSE

Supplementation of growth hormone (GH) during controlled ovarian stimulation (COS) has been suggested to improve ovarian response. Despite potential benefits in poor responders, multiple injections of GH during COS are inconvenient. We conducted a randomized controlled study to evaluate the efficacy and safety of sustained-release human GH in poor responders undergoing in vitro fertilization (IVF).

METHODS

This was a single-center, randomized, open-label, parallel study. Infertile women who satisfied the Bologna criteria for poor responders were randomized into GH treatment and control groups. The treatment group received a sustained-release GH (Eutropin Plus^® 20 mg) three times before and during COS (mid-luteal, late luteal, and menstrual cycle day 2). The baseline characteristics and IVF outcomes were compared between the two groups.

RESULTS

A total of 127 patients were included in the analysis. The mean age was 39.6 years and mean anti-Müllerian hormone level was 0.6 ng/ml. There was no significant difference in the baseline characteristics between GH treatment and control groups. The number of follicles on the human chorionic gonadotropin triggering day (3.1 ± 2.3 vs. 2.4 ± 1.6, P = 0.043) and the proportion of metaphase II oocytes (67.5 vs. 52.3%, P = 0.030) were higher in the GH group than in controls. The percentage of clinical and ongoing pregnancy and miscarriage was not different between the two groups.

CONCLUSION

Supplementation of sustained-release GH before and during COS improved ovarian response, with an increase in mature oocytes in poor responders. Further studies are needed to ensure this benefit in general infertility patients.

Effect of Growth Hormone on Uterine Receptivity in Women With Repeated Implantation Failure in an Oocyte Donation Program: A Randomized Controlled Trial

Background and Objective:

Administration of growth hormone (GH) during ovarian stimulation has been shown to improve success rates of in vitro fertilization. GH beneficial effect on oocyte quality is shown in several studies, but GH effect on uterine receptivity is not clear. To assess it, we studied whether GH administration can improve the chance of pregnancy and birth in women who experienced repeated implantation failure (RIF) using donated oocyte programs.

Design and Study Population:

A total of 105 infertile women were enrolled in the randomized controlled trial: 70 women were with a history of RIF with donated oocytes, and 35 infertile women underwent the first oocyte donation attempt. Women receiving donated oocytes were treated with progressively increasing doses of oral estradiol, followed by intravaginal progesterone after previous pituitary desensitization with gonadotropin-releasing hormone agonist. Thirty-five RIF patients were treated with GH (GH patients), whereas the rest of the 35 RIF patients (non-GH patients) and 35 first-attempt patients (positive control group) were not.

Results:

RIF patients receiving GH showed significantly thicker endometrium and higher pregnancy and live birth rates as compared with RIF patients of non-GH study group, although these rates remained somewhat lower as compared with the non-RIF patients of the positive control group. No abnormality was detected in any of the babies born.

Conclusion:

Our data of improved implantation, pregnancy, and live birth rates among infertile RIF patients treated with GH indicate that GH improves uterine receptivity.

Insights from clinical experience in treating IVF poor responders

'Poor responders' is a term used to describe a subpopulation of IVF patients who do not respond well to ovarian stimulation with gonadotrophins. While there is no standard definition of a poor responder, these patients tend to be of advanced maternal age (≥40 years), have a history of poor ovarian response with conventional stimulation protocols, and/or have low ovarian reserve. Despite the heterogeneity of this patient group, there are characteristics and needs common to many poor responders that can be addressed through a holistic approach. Stimulation during the earlier stages of follicle maturation may help synchronize follicle development for improved response to later gonadotrophin stimulation, and supplementation with dehydroepiandrosterone or human growth hormone may promote early follicle development in poor responders. IVF protocols should be specifically tailored to poor responders to complement the patient's natural cycle. Because poor responders tend to have high levels of stress and anxiety, patients should receive psychological counselling and support, both prior to and during IVF cycles, to ensure optimal outcomes and improve patients' experience. It is important to set realistic expectations with poor responders and their partners to help patients make informed decisions and better manage their distress and anxiety.

Single-centre retrospective analysis of growth hormone supplementation in IVF patients classified as poor-prognosis

BACKGROUND

Patients undergoing in vitro fertilisation (IVF) receive various adjuvant therapies in order to enhance success rates, but the true benefit is actively debated. Growth hormone (GH) supplementation was assessed in poor-prognosis women undergoing fresh IVF transfer cycles.

METHODS

Data were retrospectively analysed from 400 IVF cycles, where 161 women received GH and 239 did not.

RESULTS

Clinical pregnancy, live birth rates and corresponding ORs and CIs were significantly greater with GH, despite patients being significantly older with lower ovarian reserve. Patient's age, quality of transferred embryo and GH were the only significant independent predictors of clinical pregnancy (OR: 0.90, 5.00 and 2.49, p<0.002, respectively) and live birth chance (OR: 0.91, 3.90 and 4.75, p<0.014, respectively). GH increased clinical pregnancy chance by 3.42-fold (95% CI 1.82 to 6.44, p<0.0005) and live birth chance by 6.16-fold (95% CI 2.83 to 13.39, p<0.0005) after adjustment for maternal age, antral follicle count and transferred embryo quality.

CONCLUSION

These data provided further evidence to indicate that GH may support more live births, particularly in younger women. It also appears that embryos generated under GH have a better implantation potential, but whether the biological mechanism is embryo-mediated or endometrium-mediated is unclear.