The effects of low-dose human chorionic gonadotropin combined with human menopausal gonadotropin protocol on women with hypogonadotropic hypogonadism undergoing ovarian stimulation for in vitro fertilization

Management of congenital hypogonadotropic hypogonadism in females

This review explores the challenges in the diagnosis of hypogonadotropic hypogonadism, the transition of care from paediatric to adult care and the considerable health implications of this condition. The role gynaecologists and general practitioners have in managing hormone replacement therapy and reproductive potential is also highlighted. The fertility treatment options, which include ovulation induction with gonadotrophins and in-vitro fertilisation, are discussed in detail along with highlighting the fact that anovulation and markers of low ovarian reserve prior to priming treatment may not be reflective of poor reproductive potential. The holistic management of women with hypogonadotropic hypogonadism is still not standardised and evidence for subfertility management is scarce. This review aims to highlight this concern and provide guidance by evaluating current evidence.

Reproductive endocrine characteristics and in vitro fertilization treatment of female patients with partial 17α-hydroxylase deficiency: Two pedigree investigations and a literature review

BACKGROUND

17α-hydroxylase/17, 20-lyase deficiency (17-OHD) is caused by the mutations of the CYP17A1 gene. The classical phenotype of 17-OHD includes hypertension, hypokalemia, and abnormal sexual development, with partial 17-OHD typically less severe than the complete deficiency. Infertility is always one of the main clinical manifestations of partial 17-OHD. However, to date, the pregnancy potentials of partial 17-OHD female patients have rarely been investigated, and few live-birth cases have been reported among them. Moreover, the reproductive endocrine characteristics of partial 17-OHD female patients have not been completely clarified and the treatment skills of in vitro fertilization and embryo transfer (IVF-ET) have not been well summarized yet.

METHODS

Two Chinese infertile female patients clinically diagnosed as partial 17-OHD were enrolled and their pedigree investigations were performed. Hormones were determined to depict the endocrine conditions of partial 17-OHD female patients. The adrenocorticotropic hormone (ACTH) stimulation test was performed to evaluate the functions of the adrenal cortex. Genotype analysis was conducted by next-generation sequencing (NGS) and Sanger sequencing was used to verify the results. IVF-ET was performed for the treatment of their infertility. Specifically, the progestin-primed ovarian stimulation (PPOS) protocol was chosen for the controlled ovarian hyperstimulation (COH) cycles, and the hormone replacement treatment (HRT) protocol was adopted for the endometrial preparation in frozen-thawed embryo transfer (FET) cycles.

RESULTS

Hormone assays revealed a reduced estradiol (E2) and testosterone (T) level, and an elevated progesterone (P4) level. The classic ACTH stimulating test evidenced a suboptimal response of cortisol to ACTH. Genotype analysis demonstrated that the proband1 carried two variants: c.1459_1467del (p.Asp487_Phe489del)^het and c.995T>C (p.lle332Thr)^het. The proband2 was found to be a homozygote with the mutation of c.1358T>A (p.Phe453Ser)^hom. The two female patients both succeeded in pregnancy and delivery of healthy babies through IVF-ET, with the usage of PPOS, HRT, and low-dose glucocorticoids.

CONCLUSIONS

Partial 17-OHD female patients manifested menstrual cycle disorders and infertility clinically; displayed high P4 and low E2 and T; showed sparse pubic hair in physical examinations; and revealed multiple ovarian cysts in ultrasonic visualization. Moreover, the pregnancy potentials of infertile partial 17-OHD women seemed to increase with the adoption of IVF-ET. Considering the sustained elevated P4 level, PPOS is a feasible protocol for them in COH.

Reproductive outcomes in women with hypogonadotrophic hypogonadism, a case series study

Background

Hypogonadotropic hypogonadism (HH) is a rare condition in which there is gonadal hypofunction due to absence of gonadotropin drive. In this condition, there are very low serum levels of gonadotropins. Pituitary gland may itself have some disease or disorder, or there may be loss of gonadotropin-releasing hormone (GnRH) pulses from the hypothalamus. The pharmacological interventions in HH women formed the basis for superovulation strategies for assisted reproduction techniques (ART) with a special reference to the role of LH and its impact on oocyte and embryo quality.

Results

The medians ±inter quartile ranges for number of oocytes retrieved, number of MII oocytes, and number of embryos transferred were 5±7, 4±3, and 3±1 respectively. The pregnancy rate was 31.5% for this group of patients. The live birth rate and miscarriage rate were 21% and 11.5% respectively.

Conclusion

The reproductive outcomes of patients of hypogonadotrophic hypogonadism are reasonable after ICSI and clinical trials are recommended to corroborate this concern.

Successful outcome of a pregnancy derived from premature ovulation in a gonadotropin-releasing hormone antagonist protocol: A case report

In the gonadotropin-releasing hormone (GnRH) antagonist protocol, it is necessary to reinforce contraceptive guidance assuming that luteinizing hormone surge is not detected by measurement of serum level and ovulation is not suppressed by GnRH antagonist.

Early Follicular Phase Human Chorionic Gonadotropin Addition May Improve the Outcomes of In Vitro Fertilization/Intracytoplasmic Sperm Injection in Patients With "Unpredictable" Poor Response to Gonadotropin-Releasing Hormone Antagonist Protocol

PURPOSE

To compare the effects of early and mid-late follicular phase administration of 150 IU of human chorionic gonadotropin (hCG) on gonadotropin-releasing hormone (GnRH) antagonist protocol in "unpredictable" poor ovarian response (POR) women undergoing in vitro fertilization/intracytoplasmic sperm injection (IVF/ICSI) treatment.

METHODS

A retrospective single-center cohort study was conducted on 67 patients with "unpredictable" POR in their first IVF/ICSI cycle receiving GnRH antagonist protocol. Patients were treated with a second IVF/ICSI cycle using the same GnRH antagonist protocol with the same starting dose of recombinant follicle-stimulating hormone (rFSH) as the first cycle; a daily dose of 150 IU of hCG was administrated on either stimulation day 1 (Group A, n = 35) or day 6 (Group B, n = 32). The number of oocytes retrieved, number of usable embryos, serum level of estradiol (E₂) on day of hCG trigger, and clinical pregnant outcomes were studied.

RESULTS

The addition of 150 IU of hCG on either the first day or sixth day of stimulation increases the serum level of E₂, luteinizing hormone (LH), and hCG on the day of hCG trigger. Only the use of 150 IU of hCG on the first stimulation day improved the number of oocytes retrieved, mature of oocytes, and usable embryos, but not the addition of hCG on stimulation day 6. Implantation rate, clinical pregnancy rate, and ongoing pregnancy rate showed an increasing trend in patients receiving 150 IU of hCG in the early phase compared with mid-late phase, even thought there was no statistically significant difference.

CONCLUSIONS

Our study demonstrated that adding 150 IU of hCG in subsequent GnRH antagonist cycle in "unpredictable" poor responders is associated with the improvement of response to stimulation. Furthermore, early follicular phase addition of 150 IU of hCG significantly increased the number of oocytes retrieved and usable embryos than did the mid-late addition of the same dose.

Late Effects of Parasellar Lesion Treatment: Hypogonadism and Infertility

Central hypogonadism, also defined as hypogonadotropic hypogonadism, is a recognized complication of hypothalamic-pituitary-gonadal axis damage following treatment of sellar and parasellar masses. In addition to radiotherapy and surgery, CTLA4-blocking antibodies and alkylating agents such as temozolomide can also lead to hypogonadism, through different mechanisms. Central hypogonadism in boys and girls may lead to pubertal delay or arrest, impairing full development of the genitalia and secondary sexual characteristics. Alternatively, cranial irradiation or ectopic hormone production may instead cause early puberty, affecting hypothalamic control of the gonadostat. Given the reproductive risks, discussion of fertility preservation options and referral to reproductive specialists before treatment is essential. Steroid hormone replacement can interfere with other replacement therapies and may require specific dose adjustments. Adequate gonadotropin stimulation therapy may enable patients to restore gametogenesis and conceive spontaneously. When assisted reproductive technology is needed, protocols must be tailored to account for possible long-term gonadotropin insufficiency prior to stimulation. The aim of this review was to provide an overview of the risk factors for hypogonadism and infertility in patients treated for parasellar lesions and to give a summary of the current recommendations for management and follow-up of these dysfunctions in such patients. We have also briefly summarized evidence on the physiological role of pituitary hormones during pregnancy, focusing on the management of pituitary deficiencies.

Impact of hypogonadotropic hypogonadism on ovarian reserve and response

OBJECTIVE

To evaluate the hormonal profile, antral follicle count (AFC) and ovarian response of patients with hypogonadotropic hypogonadism (HH).

DESIGN

Observational retrospective cohort including infertile women with HH undergoing assisted reproductive treatment (ART).

SETTING

University-affiliated infertility center.

PATIENT(S)

Thirty-three women with HH who underwent ART between January 2007 and September 2018. The control group comprised 66 age-matched counterparts with tubal or male factor infertility. The patients with an abnormal karyotype, and those presenting primary or secondary amenorrhea due to other causes, were cautiously excluded.

INTERVENTION(S)

None.

MAIN OUTCOME MEASURE(S)

The primary outcome was serum levels of anti-Müllerian hormone (AMH) and AFC. We also investigated whether HH impacts ovarian response and reproductive outcomes.

RESULT(S)

Although AFC was similar between groups, HH patients showed significantly higher AMH levels (4.6 ± 2.7 ng/mL vs. 3.0 ± 1.9, p = 0.010) and lower basal FSH and LH. While the HH group needed longer stimulation [13 days (11-26) vs. 10 (7-14), p < 0.001] and higher gonadotropin doses [2700 IU (825-6300) vs. 2100 (425-5000), p = 0.038 ], no significant differences were detected in either the number or maturity of retrieved oocytes, or in the fertilization rate, number of embryos transferred, implantation rate, clinical pregnancy rate and live birth rate per cycle.

CONCLUSION(S)

HH patients present higher AMH levels, but similar AFC. Despite requiring longer stimulation and higher gonadotropin doses, ovarian response and reproductive outcomes seem unaffected.