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Mao R, Hou X, Feng X, Wang R, Fei X, Zhao J, Chen H, Cheng J. Recombinant human luteinizing hormone increases endometrial thickness in women undergoing assisted fertility treatments: a systematic review and meta-analysis. Front Pharmacol 2024; 15:1434625. [PMID: 39135787 PMCID: PMC11317380 DOI: 10.3389/fphar.2024.1434625] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2024] [Accepted: 07/11/2024] [Indexed: 08/15/2024] Open
Abstract
Introduction The optimal dosage of recombinant human luteinizing hormone (r-hLH) and its impact on endometrial thickness (EMT) when administered alongside recombinant human follicle-stimulating hormone (r-hFSH) during controlled ovarian stimulation (COS) for in vitro fertilization/intracytoplasmic sperm injection and embryo transfer are uncertain, which formed the aims of this systematic review and meta-analysis. Method A search was performed in PubMed, Cochrane Library, Web of Science, EMBASE, CNKI, and Wanfang from its inception to 10 July 2023. Twenty-seven Randomized controlled trials comparing r-hFSH/r-hLH co-treatment with r-hFSH alone during in vitro fertilization/intracytoplasmic sperm injection and embryo transfer (IVF/ICSI-ET) were included. Pooled odds ratios (OR) for dichotomous data and mean differences (MD) for continuous data, with their respective 95% confidence intervals (CI), were generated. Meta-analysis employed fixed-effect or random-effect models based on heterogeneity, using Q-test and I2-index calculations. The main outcomes included EMT on trigger day, clinical pregnancy rate (CPR) and live birth rate (LBR). Results r-hFSH/r-hLH significantly increased EMT on trigger day (MD = 0.27; 95% CI, 0.11-0.42; I2 = 13%), but reduced oocyte number (MD = -0.60; 95% CI, -1.07 to -0.14; I2 = 72%) and high-quality embryos (MD = -0.76; 95% CI, -1.41 to -0.10; I2 = 94%) than r-hFSH alone, more pronounced with the gonadotrophin-releasing hormone agonist long protocol. A subgroup analysis showed r-hLH at 75 IU/day increased CPR (OR = 1.23; 95% CI, 1.02-1.49; I2 = 16%) and EMT on trigger day (MD = 0.40; 95% CI, 0.19-0.61; I2 = 0%). Participants ≥35 years of age exhibited decreased retrieved oocytes (MD = -1.26; 95% CI, -1.78 to -0.74; I2 = 29%), but an increase in EMT on trigger day (MD = 0.26; 95% CI, 0.11-0.42; I2 = 29%). Conclusion r-hFSH/r-hLH during COS significantly improved EMT compared to r-hFSH alone. An r-hLH dose of 75 IU/day may be considered for optimal pregnancy outcomes, which still require further clinical studies to support this dosing regime. Systematic Review Registration [www.crd.york.ac.uk/PROSPERO], identifier [CRD42023454584].
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Affiliation(s)
- Routong Mao
- Reproductive Center, Department of Obstetrics and Gynecology, The Second Affiliated Hospital and Yuying Children’s Hospital of Wenzhou Medical University, Wenzhou, China
| | - Xiaohong Hou
- Reproductive Center, Department of Obstetrics and Gynecology, The Second Affiliated Hospital and Yuying Children’s Hospital of Wenzhou Medical University, Wenzhou, China
| | - Xiao Feng
- Reproductive Center, Department of Obstetrics and Gynecology, The Second Affiliated Hospital and Yuying Children’s Hospital of Wenzhou Medical University, Wenzhou, China
| | - Ruina Wang
- Reproductive Center, Department of Obstetrics and Gynecology, The Second Affiliated Hospital and Yuying Children’s Hospital of Wenzhou Medical University, Wenzhou, China
| | - Xiaofan Fei
- Reproductive Center, Department of Obstetrics and Gynecology, The Second Affiliated Hospital and Yuying Children’s Hospital of Wenzhou Medical University, Wenzhou, China
| | - Junzhao Zhao
- Reproductive Center, Department of Obstetrics and Gynecology, The Second Affiliated Hospital and Yuying Children’s Hospital of Wenzhou Medical University, Wenzhou, China
| | - Hui Chen
- School of Life Sciences, Faculty of Science, University of Technology Sydney, Sydney, NSW, Australia
| | - Jing Cheng
- Reproductive Center, Department of Obstetrics and Gynecology, The Second Affiliated Hospital and Yuying Children’s Hospital of Wenzhou Medical University, Wenzhou, China
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Castillo J, Quaas AM, Kol S. LH supplementation in IVF: human nature, politics, and elephants in the room. J Assist Reprod Genet 2024; 41:609-612. [PMID: 38246921 PMCID: PMC10957814 DOI: 10.1007/s10815-024-03033-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2023] [Accepted: 01/12/2024] [Indexed: 01/23/2024] Open
Abstract
Luteinizing hormone (LH) is present throughout the natural follicular phase. However, the debate is still not settled on whether LH is needed during ovarian stimulation in IVF. This commentary looks at the evolution of this debate, mentioning three elephants in the room that were ignored by the Pharma industry, professional organizations, and clinicians alike: 1. The different endocrinology between the long agonist and the antagonist protocols. 2. The fixed dose of the two most widely commercially available antagonist preparations, namely cetrorelix and ganirelix. 3. The fact that most research in this area uses population-based criteria, ignoring endocrine parameters. Individual genetics of the LH receptor gene may also serve to individualize LH needs during stimulation; however, the jury is still out regarding this approach. CONCLUSIONS: Individual endocrine and genetics parameters may shed meaningful light on the question of LH supplemental during ovarian stimulation.
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Affiliation(s)
- Juan Castillo
- Department of Reproductive Medicine, Instituto Bernabeu, Alicante, Spain
| | | | - Shahar Kol
- IVF unit, Elisha Hospital, 12 Yair Katz Street, Haifa, Israel.
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Li Q, Zhou X, Ye B, Tang M, Zhu Y. Ovarian response determines the luteinizing hormone suppression threshold for patients following the gonadotrophin releasing hormone antagonist protocol: A retrospective cohort study. Heliyon 2024; 10:e23933. [PMID: 38187350 PMCID: PMC10767281 DOI: 10.1016/j.heliyon.2023.e23933] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2023] [Revised: 12/15/2023] [Accepted: 12/15/2023] [Indexed: 01/09/2024] Open
Abstract
Background Ovarian reactivity to gonadotrophin stimulation varies, and individual adjustments to the timing and dose of gonadotrophin-releasing hormone (GnRH) antagonist administration are necessary to prevent excessive increases and decreases in luteinizing hormone (LH) levels in patients with different ovarian response following the GnRH antagonist (GnRH-A) protocol. The present study aims to investigate optimal LH suppression thresholds for patients with normal ovarian response (NOR), high ovarian response (HOR), and poor ovarian response (POR) following the GnRH-A protocol respectively. Methods A total of 865 in vitro fertilization (IVF) cycles using a flexible or fixed GnRH-A protocol were included. Patients were categorized into the HOR, NOR, or POR group according to their anti-Müllerian hormone (AMH) levels. Then, patients in each group were stratified into one of four subgroups according to the quartile (Q1-Q4) of the basal LH level to LH on triggering day ratio (bLH/hLH). The primary outcomes were the clinical pregnancy and live birth rates, and the secondary outcomes were the number of oocytes retrieved, MII oocytes, two pronucleus (2PN) embryos, and good-quality embryos. Results There were 526 patients with NOR, 180 with HOR, and 159 with POR. Basal LH level, LH on triggering day and bLH/hLH were identified as independent predictors of clinical pregnancy rate and live birth rate by logistics regression analysis. Compared to those with NOR, patients with POR had the lowest embryo implantation rate (22.6% vs. 32.8%, P < 0.05), clinical pregnancy rate (32.3% vs. 47.3%, P < 0.05) and live birth rate (22.6 vs. 37.8%, P < 0.05) of fresh embryo transfer (ET). The embryo implantation, clinical pregnancy and live birth rates of frozen embryo transfer (FET) were not significantly different among the three groups. In the subgroup analysis, patients with HOR had the highest embryo implantation rate (51.6%, P < 0.05), clinical pregnancy rate (68.4%, P < 0.05) and live birth rate (52.6%, P < 0.05) of ET in Q3, with a bLH/hLH ratio of 2.40-3.69. In the NOR group, the embryo implantation rate (41.9%, P < 0.05), clinical pregnancy rate (61.5%, P < 0.05) and live birth rate (50.8%, P < 0.05) of ET and live birth rate (53.1%, P < 0.05) of FET were highest in Q2, with a bLH/hLH ratio of 1.29-2.05. Patients with POR had the highest clinical pregnancy rate (57.1%, P < 0.05) and live birth rate (42.9%, P < 0.05) of ET in Q2, with a bLH/hLH ratio of 0.86-1.35. Conclusions In the present study, the bLH/hLH ratio represented the LH suppression threshold. The subgroup analysis of HOR, NOR and POR showed that, the LH suppression threshold varies according to ovarian response. We recommend LH suppression thresholds of 2.40-3.69 for HOR, 1.29-2.05 for NOR, and 0.86-1.35 for POR to obtain the highest clinical pregnancy rate and live birth rate. This study provides comprehensive and precise references for clinicians to monitor LH levels individually during controlled ovarian stimulation (COS) according to the patient's ovarian response following the GnRH-A protocol.
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Affiliation(s)
- Qingfang Li
- Department of Reproductive Endocrinology, Women’s Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang, 310006, China
| | - Xiaoqian Zhou
- Department of Reproductive Endocrinology, Women’s Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang, 310006, China
| | - Bingru Ye
- Department of Reproductive Endocrinology, Women’s Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang, 310006, China
| | - Minyue Tang
- Department of Reproductive Endocrinology, Women’s Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang, 310006, China
| | - Yimin Zhu
- Department of Reproductive Endocrinology, Women’s Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang, 310006, China
- Key Laboratory of Reproductive Genetics (Ministry of Education) and Women’s Reproductive Health Laboratory of Zhejiang Province, Women’s Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang, 310006, China
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Huang C, Shen X, Mei J, Sun Y, Sun H, Xing J. Effect of recombinant LH supplementation timing on clinical pregnancy outcome in long-acting GnRHa downregulated cycles. BMC Pregnancy Childbirth 2022; 22:632. [PMID: 35945551 PMCID: PMC9364622 DOI: 10.1186/s12884-022-04963-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2022] [Accepted: 08/03/2022] [Indexed: 11/17/2022] Open
Abstract
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.
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Affiliation(s)
- Chenyang Huang
- Center for Reproductive Medicine and Obstetrics and Gynecology, Nanjing Drum Tower Hospital, Nanjing University Medical School, Nanjing, 210008, China.,Center for Molecular Reproductive Medicine, Nanjing University, Nanjing, 210008, China
| | - Xiaoyue Shen
- Center for Reproductive Medicine and Obstetrics and Gynecology, Nanjing Drum Tower Hospital, Nanjing University Medical School, Nanjing, 210008, China.,Center for Molecular Reproductive Medicine, Nanjing University, Nanjing, 210008, China
| | - Jie Mei
- Center for Reproductive Medicine and Obstetrics and Gynecology, Nanjing Drum Tower Hospital, Nanjing University Medical School, Nanjing, 210008, China.,Center for Molecular Reproductive Medicine, Nanjing University, Nanjing, 210008, China
| | - Yanxin Sun
- Center for Reproductive Medicine and Obstetrics and Gynecology, Nanjing Drum Tower Hospital, Nanjing University Medical School, Nanjing, 210008, China.,Center for Molecular Reproductive Medicine, Nanjing University, Nanjing, 210008, China
| | - Haixiang Sun
- Center for Reproductive Medicine and Obstetrics and Gynecology, Nanjing Drum Tower Hospital, Nanjing University Medical School, Nanjing, 210008, China. .,Center for Molecular Reproductive Medicine, Nanjing University, Nanjing, 210008, China. .,Drum Tower Clinic Medical College, Nanjing Medical University, Nanjing, 210008, China.
| | - Jun Xing
- Center for Reproductive Medicine and Obstetrics and Gynecology, Nanjing Drum Tower Hospital, Nanjing University Medical School, Nanjing, 210008, China. .,Center for Molecular Reproductive Medicine, Nanjing University, Nanjing, 210008, China.
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Jirge PR, Patil MM, Gutgutia R, Shah J, Govindarajan M, Roy VS, Kaul-Mahajan N, Sharara FI. Ovarian Stimulation in Assisted Reproductive Technology Cycles for Varied Patient Profiles: An Indian Perspective. J Hum Reprod Sci 2022; 15:112-125. [PMID: 35928474 PMCID: PMC9345274 DOI: 10.4103/jhrs.jhrs_59_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2022] [Revised: 06/21/2022] [Accepted: 06/23/2022] [Indexed: 11/10/2022] Open
Abstract
Controlled ovarian stimulation has been an integral part of in vitro fertilisation (IVF) treatment cycles. Availability of different gonadotropins for ovarian stimulation and gonadotropin releasing hormone (GnRH) analogues for prevention of premature rise of leutinising hormone during follicular phase offer an opportunity to utilise them for a successful outcome in women with different subsets of ovarian response. Further, use of GnRH agonist as an alternative for human chorionic gonadotropin improves safety of ovarian stimulation in hyper-responders. Mild ovarian stimulation protocols have emerged as an alternative to conventional protocols in the recent years. Individualisation plays an important role in improving safety of IVF in hyper-responders while efforts continue to improve efficacy in poor responders. Some of the follicular and peri-ovulatory phase interventions may be associated with negative impact on the luteal phase and segmentalisation of the treatment with frozen embryo transfer may be an effective strategy in such a clinical scenario. This narrative review looks at the available evidence on various aspects of ovarian stimulation strategies and their consequences. In addition, it provides a concise summary of the evidence that has emerged from India on various aspects of ovarian stimulation.
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Affiliation(s)
- Padma Rekha Jirge
- Shreyas Hospital and Sushrut Assisted Conception Clinic, Kohlhapur, India
| | | | | | - Jatin Shah
- Mumbai Fertility Clinic & IVF Centre, Mumbai, India
| | | | | | | | - Faddy I Sharara
- Virginia Center for Reproductive Medicine, Reston; Department of O&G, George Washington University, Washington, DC, USA
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Di Segni N, Busnelli A, Secchi M, Cirillo F, Levi-Setti PE. Luteinizing hormone supplementation in women with hypogonadotropic hypogonadism seeking fertility care: Insights from a narrative review. Front Endocrinol (Lausanne) 2022; 13:907249. [PMID: 35979440 PMCID: PMC9377693 DOI: 10.3389/fendo.2022.907249] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2022] [Accepted: 07/08/2022] [Indexed: 11/20/2022] Open
Abstract
The management of infertile women affected by hypogonadotropic hypogonadism (HH) or conditions mimicking it is particularly challenging. In the present narrative review, we aimed to synthesize the available evidence on the benefit (if any) of exogenous luteinizing hormone (LH) supplementation in this group of patients. Available data support LH supplementation in women with organic or functional HH. On the contrary, the benefit of exogenous LH on reproductive outcomes both in advanced maternal age patients and in cases of depletion of FSH and LH levels induced by GnRH analogues has not been demonstrated. unfortunately, the inhomogeneous study populations as well as the methodological heterogeneity between studies focused on women affected by conditions mimicking HH do not allow reliable conclusions to be drawn.
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Affiliation(s)
- Noemi Di Segni
- Division of Gynecology and Reproductive Medicine, Department of Gynecology, Fertility Center, IRCCS Humanitas Research Hospital, Milan, Italy
- Department of Biomedical Sciences, Humanitas University, Milan, Italy
| | - Andrea Busnelli
- Division of Gynecology and Reproductive Medicine, Department of Gynecology, Fertility Center, IRCCS Humanitas Research Hospital, Milan, Italy
- Department of Biomedical Sciences, Humanitas University, Milan, Italy
| | - Matteo Secchi
- Department of Biomedical Sciences, Humanitas University, Milan, Italy
| | - Federico Cirillo
- Division of Gynecology and Reproductive Medicine, Department of Gynecology, Fertility Center, IRCCS Humanitas Research Hospital, Milan, Italy
- Department of Biomedical Sciences, Humanitas University, Milan, Italy
| | - Paolo Emanuele Levi-Setti
- Division of Gynecology and Reproductive Medicine, Department of Gynecology, Fertility Center, IRCCS Humanitas Research Hospital, Milan, Italy
- Department of Biomedical Sciences, Humanitas University, Milan, Italy
- *Correspondence: Paolo Emanuele Levi-Setti,
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Recombinant luteinizing hormone supplementation in assisted reproductive technology: a review of literature. MIDDLE EAST FERTILITY SOCIETY JOURNAL 2021. [DOI: 10.1186/s43043-021-00083-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
Luteinizing hormone (LH) has the main role in ovarian function in both natural and artificial cycles. A normal LH concentration during controlled ovarian hyperstimulation is positively correlated to the number and quality of retrieved oocytes and resulting embryos.
Main body of the abstract
In this study, we reviewed whether rLH administration, adjunct to the ovarian stimulation regimen, could improve clinical outcomes. The literature review showed that rLH supplementation improves assisted reproductive technology (ART) outcomes among women with hypogonadotropic hypogonadism, and hyporesponsive women to follicle-stimulating hormone monotherapy. Besides, rLH supplementation has advantages for poor responder women 36–39 years of age. Even though the data suggested no priority regarding the LH source for improving ART outcome, women with different LH polymorphisms who did not respond similarly to ovarian stimulation may benefit from adjuvant rLH therapy.
Conclusion
rLH usage for improving ART outcome should be scrutinized via well-designed studies considering the subgroups of infertile women who benefit the most from rLH adjuvant therapy, the type of ovarian stimulation protocol to which rLH would be added, and also the exact dosage, as well as the proper timing (during or prior to a cycle).
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Chen LH, Chin TH, Huang SY, Yu HT, Chang CL, Huang HY, Wang HS, Soong YK, Wu HM. Supplementation with human menopausal gonadotropin in the gonadotropin-releasing hormone antagonist cycles of women with high AMH: Pregnancy outcomes and serial hormone levels. Taiwan J Obstet Gynecol 2021; 60:739-744. [PMID: 34247817 DOI: 10.1016/j.tjog.2021.05.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/04/2020] [Indexed: 10/20/2022] Open
Abstract
OBJECTIVE To evaluate the value of using both HMG and recombinant FSH (r-FSH) in the GnRH antagonist protocol for women with high AMH. MATERIALS AND METHODS This retrospective, single-center cohort study was conducted from January 2013 to December 2018. Of 277 GnRH antagonist IVF/ICSI cycles in women with anti-Mullerian hormone (AMH) ≥5 μg/L, 170 cycles receiving the combination of r-FSH and HMG (77 with HMG added at the beginning of the GnRH antagonist cycle and 93 with HMG added after GnRH antagonist administration) and 107 cycles receiving r-FSH alone were analyzed. The dynamic hormone profiles and embryonic and clinical outcomes of the patients were evaluated. RESULTS We observed significantly lower serum LH levels in the r-FSH + HMG groups during ovarian stimulation. The serum estradiol and progesterone levels were lower in the r-FSH + HMG groups on the trigger day. Nevertheless, there were no significant differences with respect to the number of oocytes retrieved, maturation, fertilization, blastocyst formation rate or ovarian hyperstimulation syndrome (OHSS). The implantation and live birth rates were increased in the r-FSH + HMG groups compared with the r-FSH alone group, with no statistical significance. CONCLUSIONS HMG for LH supplementation in the GnRH antagonist protocol for patients with high AMH is not significantly superior to r-FSH alone in terms of ovarian response and pregnancy outcome. Nevertheless, HMG supplementation might be appropriate for women with an initially inadequate response to r-FSH or intracycle LH deficiency.
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Affiliation(s)
- Liang-Hsuan Chen
- Department of Obstetrics and Gynecology, Chang Gung Memorial Hospital Linkou Medical Center, No. 5, Fusing St., Gueishan Township, Taoyuan County 333, Taiwan
| | - Tzu-Hsuan Chin
- Department of Obstetrics and Gynecology, Chang Gung Memorial Hospital Linkou Medical Center, No. 5, Fusing St., Gueishan Township, Taoyuan County 333, Taiwan
| | - Shang-Yu Huang
- Department of Obstetrics and Gynecology, Chang Gung Memorial Hospital Linkou Medical Center, No. 5, Fusing St., Gueishan Township, Taoyuan County 333, Taiwan
| | - Hsing-Tse Yu
- Department of Obstetrics and Gynecology, Chang Gung Memorial Hospital Linkou Medical Center, No. 5, Fusing St., Gueishan Township, Taoyuan County 333, Taiwan
| | - Chia-Lin Chang
- Department of Obstetrics and Gynecology, Chang Gung Memorial Hospital Linkou Medical Center, No. 5, Fusing St., Gueishan Township, Taoyuan County 333, Taiwan
| | - Hong-Yuan Huang
- Department of Obstetrics and Gynecology, Chang Gung Memorial Hospital Linkou Medical Center, No. 5, Fusing St., Gueishan Township, Taoyuan County 333, Taiwan
| | - Hsin-Shih Wang
- Department of Obstetrics and Gynecology, Chang Gung Memorial Hospital Linkou Medical Center, No. 5, Fusing St., Gueishan Township, Taoyuan County 333, Taiwan
| | - Yung-Kuei Soong
- Department of Obstetrics and Gynecology, Chang Gung Memorial Hospital Linkou Medical Center, No. 5, Fusing St., Gueishan Township, Taoyuan County 333, Taiwan
| | - Hsien-Ming Wu
- Department of Obstetrics and Gynecology, Chang Gung Memorial Hospital Linkou Medical Center, No. 5, Fusing St., Gueishan Township, Taoyuan County 333, Taiwan.
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Conforti A, Esteves SC, Humaidan P, Longobardi S, D'Hooghe T, Orvieto R, Vaiarelli A, Cimadomo D, Rienzi L, Ubaldi FM, Zullo F, Alviggi C. Recombinant human luteinizing hormone co-treatment in ovarian stimulation for assisted reproductive technology in women of advanced reproductive age: a systematic review and meta-analysis of randomized controlled trials. Reprod Biol Endocrinol 2021; 19:91. [PMID: 34154604 PMCID: PMC8215738 DOI: 10.1186/s12958-021-00759-4] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2020] [Accepted: 05/10/2021] [Indexed: 01/08/2023] Open
Abstract
INTRODUCTION Several studies suggest that luteinizing hormone (LH) could improve IVF outcome in women of advanced reproductive age by optimizing androgen production. In this review, we assessed the role of recombinant-human LH (r-hLH) and recombinant human follicle stimulating hormone (r-hFSH) co-treatment in ovarian stimulation for assisted reproductive technology in women of advanced reproductive age candidates for assisted reproduction. MATERIAL AND METHODS Using a preregistered protocol we systematically searched Medline/PubMed, Scopus and the ISI Web of Science databases to identify randomized controlled trials in which r-hFSH monotherapy protocols were compared with r-hFSH/r-hLH co-treatment in women ≥35 years undergoing fresh IVF cycles. We calculated the pooled odds ratio (OR) for dichotomous data and the weight mean difference (WMD) for continuous data with an associated 95% confidence interval (CI). The meta-analyses were conducted using the random-effect model. P values < 0.05 were considered statistically significant. Subgroup analyses of all primary and secondary outcomes were performed only in women aged 35-40 years. RESULTS Twelve studies were identified. In women aged between 35 and 40 years, r-hFSH/r-hLH co-treatment was associated with higher clinical pregnancy rates (OR 1.45, CI 95% 1.05-2.00, I2 = 0%, P = 0.03) and implantation rates (OR 1.49, CI 95% 1.10-2.01, I2 = 13%, P = 0.01) versus r-hFSH monotherapy. Fewer oocytes were retrieved in r-hFSH/r-hLH-treated patients than in r-hFSH-treated patients both in women aged ≥35 years (WMD -0.82 CI 95% -1.40 to - 0.24, I2 = 88%, P = 0.005) and in those aged between 35 and 40 years (WMD -1.03, CI - 1.89 to - 0.17, I2 = 0%, P = 0.02). The number of metaphase II oocytes, miscarriage rates and live birth rates did not differ between the two groups of women overall or in subgroup analysis. CONCLUSION Although more oocytes were retrieved in patients who underwent r-hFSH monotherapy, this meta-analysis suggests that r-hFSH/r-hLH co-treatment improves clinical pregnancy and implantation rates in women between 35 and 40 years of age undergoing ovarian stimulation for assisted reproduction technology. However, more RCTs using narrower age ranges in advanced age women are warranted to corroborate these findings.
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Affiliation(s)
- Alessandro Conforti
- University of Naples Federico II, Department of Neuroscience, Reproductive Science and Odontostomatology, University of Naples Federico II, Naples, Italy.
| | - Sandro C Esteves
- ANDROFERT, Andrology and Human Reproduction Clinic, Campinas, Brazil
- Department of Surgery, University of Campinas, Campinas, Brazil
- Faculty of Health, Aarhus University, Aarhus, Denmark
| | - Peter Humaidan
- Faculty of Health, Aarhus University, Aarhus, Denmark
- Fertility Clinic, Skive Regional Hospital, Skive, Denmark
| | | | - Thomas D'Hooghe
- Department of Development and Regeneration, Biomedical Sciences Group, KU Leuven (University of Leuven), Merck, Leuven, Belgium
- KGaA, Darmstadt, Germany
| | - Raoul Orvieto
- Department of Obstetrics and Gynecology, Chaim Sheba Medical Center, Ramat Gan, Israel
- The Tarnesby-Tarnowski Chair for Family Planning and Fertility Regulation, Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Alberto Vaiarelli
- Clinica Valle Giulia, G.EN.E.R.A. Centers for Reproductive Medicine, Rome, Italy
| | - Danilo Cimadomo
- Clinica Valle Giulia, G.EN.E.R.A. Centers for Reproductive Medicine, Rome, Italy
| | - Laura Rienzi
- Clinica Valle Giulia, G.EN.E.R.A. Centers for Reproductive Medicine, Rome, Italy
| | - Filippo Maria Ubaldi
- Clinica Valle Giulia, G.EN.E.R.A. Centers for Reproductive Medicine, Rome, Italy
| | - Fulvio Zullo
- University of Naples Federico II, Department of Neuroscience, Reproductive Science and Odontostomatology, University of Naples Federico II, Naples, Italy
| | - Carlo Alviggi
- University of Naples Federico II, Department of Neuroscience, Reproductive Science and Odontostomatology, University of Naples Federico II, Naples, Italy
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Zhang Y, Zhang C, Shu J, Guo J, Chang HM, Leung PCK, Sheng JZ, Huang H. Adjuvant treatment strategies in ovarian stimulation for poor responders undergoing IVF: a systematic review and network meta-analysis. Hum Reprod Update 2020; 26:247-263. [PMID: 32045470 DOI: 10.1093/humupd/dmz046] [Citation(s) in RCA: 100] [Impact Index Per Article: 25.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2019] [Revised: 11/10/2019] [Accepted: 11/19/2019] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND Despite great advances in assisted reproductive technology, poor ovarian response (POR) is still considered as one of the most challenging tasks in reproductive medicine. OBJECTIVE AND RATIONALE The aim of this systemic review is to evaluate the role of different adjuvant treatment strategies on the probability of pregnancy achievement in poor responders undergoing IVF. Randomized controlled trials (RCTs) comparing 10 adjuvant treatments [testosterone, dehydroepiandrosterone (DHEA), letrozole, recombinant LH, recombinant hCG, oestradiol, clomiphene citrate, progesterone, growth hormone (GH) and coenzyme Q10 (CoQ10)] were included. SEARCH METHODS Relevant studies published in the English language were comprehensively selected using PubMed, Embase and the Cochrane Central Register of Controlled Trials (CENTRAL) until 11 July 2018. We included studies that investigated various adjuvant agents, including androgen and androgen-modulating agents, oestrogen, progesterone, clomiphene citrate, GH and CoQ10, during IVF treatment and reported subsequent pregnancy outcomes. The administration of GnRH analogs and gonadotrophins without adjuvant treatment was set as the control. We measured study quality based on the methodology and categories listed in the Cochrane Collaboration Handbook. This review protocol was registered with PROSPERO (CRD42018086217). OUTCOMES Of the 1124 studies initially identified, 46 trials reporting on 6312 women were included in this systematic review, while 19 trials defining POR using the Bologna criteria reporting 2677 women were included in the network meta-analysis. Compared with controls, DHEA and CoQ10 treatments resulted in a significantly higher chance of clinical pregnancy [odds ratio (OR) 2.46, 95% CI 1.16 to 5.23; 2.22, 1.08-4.58, respectively]. With regard to the number of retrieved oocytes, HCG, oestradiol and GH treatments had the highest number of oocytes retrieved [weighted mean difference (WMD) 2.08, 0.72 to 3.44; 2.02, 0.23 to 3.81; 1.72, 0.98 to 2.46, compared with controls, respectively]. With regard to the number of embryos transferred, testosterone and GH treatment led to the highest number of embryos transferred (WMD 0.72, 0.11 to 1.33; 0.67, 0.43 to 0.92; compared with controls, respectively). Moreover, GH resulted in the highest oestradiol level on the HCG day (WMD 797.63, 466.45 to 1128.81, compared with controls). Clomiphene citrate, letrozole and GH groups used the lowest dosages of gonadotrophins for ovarian stimulation (WMD 1760.00, -2890.55 to -629.45; -1110.17, -1753.37 to -466.96; -875.91, -1433.29 to -282.52; compared with controls, respectively). CoQ10 led to the lowest global cancelation rate (OR 0.33, 0.15 to 0.74, compared with controls). WIDER IMPLICATIONS For patients with POR, controlled ovarian stimulation protocols using adjuvant treatment with DHEA, CoQ10 and GH showed better clinical outcomes in terms of achieving pregnancy, and a lower dosage of gonadotrophin required for ovulation induction. Furthermore, high-level RCT studies using uniform standards for POR need to be incorporated into future meta-analyses.
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Affiliation(s)
- Yu Zhang
- International Peace Maternity and Child Health Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai 200030, China.,Department of Reproductive Endocrinology, Zhejiang Provincial People's Hospital, Hangzhou Medical College, Hangzhou 310014, China.,Shanghai Key Laboratory of Embryo Original Diseases, Shanghai 200030, China.,Department of Obstetrics and Gynaecology, BC Children's Hospital Research Institute, University of British Columbia, Vancouver, British Columbia V5Z 4H4, Canada
| | - Chao Zhang
- Center for Evidence-Based Medicine and Clinical Research, Taihe Hospital, Hubei University of Medicine, Shiyan 442000, China
| | - Jing Shu
- Department of Reproductive Endocrinology, Zhejiang Provincial People's Hospital, Hangzhou Medical College, Hangzhou 310014, China
| | - Jing Guo
- Department of Reproductive Endocrinology, Zhejiang Provincial People's Hospital, Hangzhou Medical College, Hangzhou 310014, China
| | - Hsun-Ming Chang
- Department of Obstetrics and Gynaecology, BC Children's Hospital Research Institute, University of British Columbia, Vancouver, British Columbia V5Z 4H4, Canada
| | - Peter C K Leung
- Department of Obstetrics and Gynaecology, BC Children's Hospital Research Institute, University of British Columbia, Vancouver, British Columbia V5Z 4H4, Canada
| | - Jian-Zhong Sheng
- Department of Pathology and Pathophysiology, School of Medicine, Zhejiang University, Hangzhou 310058, China
| | - Hefeng Huang
- International Peace Maternity and Child Health Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai 200030, China.,Shanghai Key Laboratory of Embryo Original Diseases, Shanghai 200030, China
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The Conundrum of Poor Ovarian Response: From Diagnosis to Treatment. Diagnostics (Basel) 2020; 10:diagnostics10090687. [PMID: 32932955 PMCID: PMC7555981 DOI: 10.3390/diagnostics10090687] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2020] [Revised: 08/27/2020] [Accepted: 09/09/2020] [Indexed: 12/11/2022] Open
Abstract
Despite recent striking advances in assisted reproductive technology (ART), poor ovarian response (POR) diagnosis and treatment is still considered challenging. Poor responders constitute a heterogeneous cohort with the common denominator of under-responding to controlled ovarian stimulation. Inevitably, respective success rates are significantly compromised. As POR pathophysiology entails the elusive factor of compromised ovarian function, both diagnosis and management fuel an ongoing heated debate depicted in the literature. From the criteria employed for diagnosis to the plethora of strategies and adjuvant therapies proposed, the conundrum of POR still puzzles the practitioner. What is more, novel treatment approaches from stem cell therapy and platelet-rich plasma intra-ovarian infusion to mitochondrial replacement therapy have emerged, albeit not claiming clinical routine status yet. The complex and time sensitive nature of this subgroup of infertile patients indicates the demand for a consensus on a horizontally accepted definition, diagnosis and subsequent effective treating strategy. This critical review analyzes the standing criteria employed in order to diagnose and aptly categorize POR patients, while it proceeds to critically evaluate current and novel strategies regarding their management. Discrepancies in diagnosis and respective implications are discussed, while the existing diversity in management options highlights the need for individualized management.
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Hosein Rashidi B, Kabodmehri R, Shariat M, Shahrokh Tehraninejad E, Abdollahi A, Bagheri M, Hagholahi F. Luteinizing hormone changes in gonadotropin-releasing hormone antagonist protocol in in vitro fertilization cycles: A cross-sectional study. Int J Reprod Biomed 2019; 17. [PMID: 31435601 PMCID: PMC6661140 DOI: 10.18502/ijrm.v17i3.4520] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2018] [Revised: 10/29/2018] [Accepted: 12/12/2018] [Indexed: 11/24/2022] Open
Abstract
Background Because of the unexpected and often dramatic inhibition of luteinizing hormone (LH) secretion related with the usage of gonadotropin-releasing hormone (GnRH)-antagonist, there has been a probable need for exogenous LH supplementation. There is a basic and clinical evidences that show late development of follicle needs an LH but there is a threshold for LH requirements during folliculogenesis. Objective The purpose of this study was to evaluate the changes in serum LH and the identification of patients who benefit from the addition of LH. Materials and Methods Seventy volunteers for antagonist protocol in IVF cycle were enrolled in this prospective cross-sectional study. The study was carried out in Reproductive Health Research Center, University of Medical Sciences between July 2016 and February 2016. Serum LH level was estimated 24 h before and after the first (GnRH) antagonist injection. The primary outcome was the serum level of LH and its change in the three groups and the secondary outcome was Egg and Embryo quality. Results LH changes above or below 50% had no effect on the number of follicle, the number of oocyte, Germinal vesicle oocyte, metaphase 1 oocyte, metaphase 2 oocyte, endometrial thickness, and chemical and clinical pregnancy. Conclusion We evaluated the changes of serum LH in the patients who were entered in the antagonist protocol. Our study showed no significant difference in LH levels 24 h before and after the injection of the antagonist between the three groups, and LH changes did not affect the outcome of pregnancy.
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Affiliation(s)
- Batool Hosein Rashidi
- Health Reproductive Research Center, Imam Khomeini Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Roya Kabodmehri
- Health Reproductive Research Center, Imam Khomeini Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Mamak Shariat
- Health Reproductive Research Center, Imam Khomeini Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Ensieh Shahrokh Tehraninejad
- Health Reproductive Research Center, Imam Khomeini Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Alireza Abdollahi
- Health Reproductive Research Center, Imam Khomeini Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Maryam Bagheri
- Health Reproductive Research Center, Imam Khomeini Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Fedieh Hagholahi
- Health Reproductive Research Center, Imam Khomeini Hospital, Tehran University of Medical Sciences, Tehran, Iran
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Alviggi C, Conforti A, Esteves SC, Andersen CY, Bosch E, Bühler K, Ferraretti AP, De Placido G, Mollo A, Fischer R, Humaidan P. Recombinant luteinizing hormone supplementation in assisted reproductive technology: a systematic review. Fertil Steril 2018; 109:644-664. [PMID: 29653717 DOI: 10.1016/j.fertnstert.2018.01.003] [Citation(s) in RCA: 71] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2017] [Revised: 12/08/2017] [Accepted: 01/04/2018] [Indexed: 11/19/2022]
Abstract
OBJECTIVE To assess the role of recombinant human LH (r-hLH) supplementation in ovarian stimulation for ART in specific subgroups of patients. DESIGN Systematic review. SETTING Centers for reproductive care. PATIENT(S) Six populations were investigated: 1) women with a hyporesponse to recombinant human FSH (r-hFSH) monotherapy; 2) women at an advanced reproductive age; 3) women cotreated with the use of a GnRH antagonist; 4) women with profoundly suppressed LH levels after the administration of GnRH agonists; 5) normoresponder women to prevent ovarian hyperstimulation syndrome; and 6) women with a "poor response" to ovarian stimulation, including those who met the European Society for Human Reproduction and Embryology Bologna criteria. INTERVENTION(S) Systematic review. MAIN OUTCOME MEASURE(S) Implantation rate, number of oocytes retrieved, live birth rate, ongoing pregnancy rate, fertilization rate, and number of metaphase II oocytes. RESULT(S) Recombinant hLH supplementation appears to be beneficial in two subgroups of patients: 1) women with adequate prestimulation ovarian reserve parameters and an unexpected hyporesponse to r-hFSH monotherapy; and 2) women 36-39 years of age. Indeed, there is no evidence that r-hLH is beneficial in young (<35 y) normoresponders cotreated with the use of a GnRH antagonist. The use of r-hLH supplementation in women with suppressed endogenous LH levels caused by GnRH analogues and in poor responders remains controversial, whereas the use of r-hLH supplementation to prevent the development of ovarian hyperstimulation syndrome warrants further investigation. CONCLUSION(S) Recombinant hLH can be proposed for hyporesponders and women 36-39 years of age.
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Affiliation(s)
- Carlo Alviggi
- Department of Neuroscience, Reproductive Science and Odontostomatology, University of Naples Federico II, Naples, Italy.
| | - Alessandro Conforti
- Department of Neuroscience, Reproductive Science and Odontostomatology, University of Naples Federico II, Naples, Italy
| | - Sandro C Esteves
- Androfert, Andrology and Human Reproduction Clinic, São Paulo, Brazil
| | - Claus Yding Andersen
- Laboratory of Reproductive Biology, University Hospital of Copenhagen, Faculty of Health and Medical Sciences, Copenhagen, Denmark
| | - Ernesto Bosch
- Instituto Valenciano de Infertilidad, Valencia, Spain
| | - Klaus Bühler
- Center for Gynecology, Endocrinology, and Reproductive Medicine, Ulm and Stuttgart, Germany
| | | | - Giuseppe De Placido
- Department of Neuroscience, Reproductive Science and Odontostomatology, University of Naples Federico II, Naples, Italy
| | - Antonio Mollo
- Department of Neuroscience, Reproductive Science and Odontostomatology, University of Naples Federico II, Naples, Italy
| | | | - Peter Humaidan
- Fertility Clinic, Skive Regional Hospital, Skive, Denmark, and Faculty of Health, Aarhus University, Aarhus, Denmark
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Younis JS, Laufer N. Recombinant luteinizing hormone supplementation to recombinant follicle stimulating hormone therapy in gonadotropin releasing hormone analogue cycles: what is the evidence? Curr Med Res Opin 2018; 34:881-886. [PMID: 29292650 DOI: 10.1080/03007995.2017.1417827] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
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.
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Affiliation(s)
- Johnny S Younis
- a Reproductive Medicine, Department of Obstetrics and Gynecology , Poriya Medical Center , Tiberias , Israel
- b Faculty of Medicine in Galilee , Bar Ilan University , Tiberias , Israel
| | - Neri Laufer
- c Reproductive Medicine, Department of Obstetrics and Gynecology , Hadassah-Hebrew University Medical Center , Ein-Kerem , Jerusalem , Israel
- d Hadassah Medical School , Hebrew University , Jerusalem , Israel
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Younis JS, Izhaki I, Ben-Ami M. The effect of rLH supplementation to the GnRH-antagonist protocol on endocrine dynamics in the advanced reproductive age. J Endocrinol Invest 2017; 40:831-839. [PMID: 28290093 DOI: 10.1007/s40618-017-0618-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2016] [Accepted: 01/16/2017] [Indexed: 12/01/2022]
Abstract
PURPOSE To explore serum endocrine dynamics, specifically LH levels, following rLH supplementation to rFSH following GnRH-antagonist treatment in the advance reproductive age. METHODS Women were prospectively and similarly treated employing rFSH and the flexible GnRH-antagonist protocol, while rLH was supplemented only to the study group. Serum FSH, LH, E2, and P were evaluated throughout the follicular phase. Three strategies were a priori planned to examine endocrine dynamics among women enrolled. RESULTS While serum LH drop were similar before GnRH-antagonist stimulation, it dropped more times in the control group compared to the study group. Among women receiving rFSH only, serum LH levels dropped ≤2, ≤1 and ≤0.5 mIU/mL in 71.4, 46.4, and 28.6% of cases, while this occurred only in 38.7% (P = 0.01), 6.5% (P = 0.0004) and 3.2% (P = 0.007) of women receiving combined rFSH and rLH treatment, respectively. The same trend was found when serum LH dropped in at least two occasions following the GnRH-antagonist administration. Conversely, serum LH diagrams throughout the follicular phase did not differ between the two groups. Furthermore, individual area under the curve values of LH, E2, and P was similar between the two groups following GnRH-antagonist initiation. CONCLUSIONS Different strategies to explore LH dynamics following the GnRH-antagonist administration have resulted in diverse results, implying the need for a consensus definition of LH threshold for adequate folliculogenesis and steroidogenesis. Such action would pave the way for understanding which groups of patients may benefit from rLH supplementation.
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Affiliation(s)
- J S Younis
- Reproductive Medicine Unit, Department of Obstetrics and Gynecology, Poriya Medical Center, 15208, Tiberias, Israel.
- Faculty of Medicine in Galilee, Bar-Ilan University, Ramat Gan, Israel.
| | - I Izhaki
- Department of Evolutionary and Environmental Biology, University of Haifa, Haifa, Israel
| | - M Ben-Ami
- Reproductive Medicine Unit, Department of Obstetrics and Gynecology, Poriya Medical Center, 15208, Tiberias, Israel
- Faculty of Medicine in Galilee, Bar-Ilan University, Ramat Gan, Israel
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