Factors involved in the induction of fertile ovulation with human gonadotrophins

The Use of Estrone-3-Glucuronide and Pregnanediol-3-Glucuronide Excretion Rates to Navigate the Continuum of Ovarian Activity

The patterns of a woman's normal ovarian activity can take many forms from childhood to menopause. These patterns lie on a continuum ranging from no ovarian activity to a fully fertile ovulatory cycle, but among the other defined patterns are cycles with anovulatory ovarian activity, including luteinized unruptured follicles (LUFs), and ovulatory cycles with deficient or short luteal phases. For any woman, these patterns can occur in any order, and one can merge into the next, without an intervening bleed, or be missed entirely. Consequently, it is not yet possible to predict the pattern of a future cycle, but it is possible to use our knowledge of the continuum to interpret the current cycle, which has clear implications for the management of personal fertility. An individual's position in the continuum can be monitored directly in real time by daily monitoring of ovarian hormone excretion rates, without either calendar-type calculations or reference to population means and standard deviations. The excretion of urinary estrone glucuronide (E1G) gives a direct measure of follicular growth, and the post-ovulatory rise in urinary pregnanediol glucuronide (PdG) following an E1G peak provides good evidence of ovulation. Specific values of the PdG excretion rate can be used to determine whether a cycle is anovulatory with or without a LUF, or is ovulatory and infertile or ovulatory and fertile. These specific values are important signposts for navigating the continuum. For a woman to take advantage of the knowledge of the continuum, the data must be reliable, and their interpretation has to be based on the underlying science and provided in an appropriate form. We discuss the various factors involved in acquiring and providing such information to enable each woman to navigate her own reproductive life.

WITHDRAWN: Recombinant FSH versus urinary gonadotrophins or recombinant FSH for ovulation induction in subfertility associated with polycystic ovary syndrome

This review has been replaced by a review entitled 'Gonadotrophins for ovulation induction in women with polycystic ovarian syndrome'.

The editorial group responsible for this previously published document have withdrawn it from publication.

WITHDRAWN: Gonadotrophin therapy for ovulation induction in subfertility associated with polycystic ovary syndrome

This review has been replaced by a review entitled 'Gonadotrophins for ovulation induction in women with polycystic ovarian syndrome'.

The editorial group responsible for this previously published document have withdrawn it from publication.

Ovulation induction in the management of anovulatory polycystic ovary syndrome

The aim of this brief review is to describe the management of anovulatory infertility in the polycystic ovary syndrome (PCOS). This has traditionally involved the use of clomiphene citrate (CC), and then gonadotropin therapy or laparoscopic ovarian surgery, in those who are clomiphene resistant (The Thessaloniki ESHRE/ASRM-Sponsored PCOS Consensus Workshop Group, 2008). Recently developed therapeutic approaches include aromatase inhibitors and the potential use of in vitro maturation (IVM) of oocytes collected from unstimulated (or minimally stimulated) polycystic ovaries. Unfortunately the early promise of the insulin sensitizing drugs has not been translated into significant improvement in outcomes and therefore are not prescribed unless the patient has an impairment of glucose tolerance (The Thessaloniki ESHRE/ASRM-Sponsored PCOS Consensus Workshop Group, 2008). There has been an unfortunate shift away from Mono-follicular ovulation induction remains the first line approach for the management of anovulatory PCOS, and in vitro fertilization treatment (IVF) should be reserved for those who fail to respond or who have additional infertility factors (The Thessaloniki ESHRE/ASRM-Sponsored PCOS Consensus Workshop Group, 2008). Superovulation for IVF presents significant risks for women with polycystic ovaries, namely the potentially life-threatening complication of ovarian hyperstimulation syndrome (OHSS). Carefully conducted and monitored ovulation induction can achieve good cumulative conception rates and furthermore, multiple pregnancy rates can be minimized with strict adherence to criteria that limit the number of follicles that are permitted to ovulate.

Types of ovarian activity in women and their significance: the continuum (a reinterpretation of early findings)

BACKGROUND

There are many types of ovarian activity that occur in women. This review provides information on the relationship between the hormone values and the degree of biological response to the hormones including the frequency and degree of uterine bleeding. The continuous process is termed the ‘Continuum’ and is thus similar to other processes in the body.

METHODS

This review draws on information already published from monitoring ovarian activity by urinary oestrogen and pregnanediol measurements using timed 24-h specimens of urine. Much of the rationalization was derived from 5 to 6 year studies of girls progressing from childhood to adulthood, women progressing through menopause, and the return of fertility post-partum. During these times, all the reported types of ovarian activity were encountered.

RESULTS

All cycle types can be understood in terms of steps in the normal maturation of fertility at the beginning of reproductive life, its return post-partum and its demise at menopause. Each step merges into the next and therefore the sequence is termed the ‘Continuum’. Unpredictable movement from fertile to infertile types and back can occur at any time during reproductive life. Stress is a major causative factor. Hormonal definitions for each step, the relevance of the various cycle types in determining fertility and in the initiation of uterine bleeding and the roles of the pituitary hormones in causing them, are presented.

CONCLUSIONS

The findings explain the erratic fertility of women and why ovulation is not always associated with fertility. They provide an understanding of the various types of ovarian activity and their relation to pituitary function, fertility and uterine bleeding.

Follicle-stimulating hormone levels and medication compliance during in vitro fertilization

OBJECTIVE

To report the use of serum FSH levels during gonadotropin therapy for IVF to ensure medication compliance.

DESIGN

Case report.

SETTING

University-based reproductive endocrinology clinic.

PATIENT(S)

Two women with normal ovarian reserve undergoing IVF cycles with unexpected clinical responses.

INTERVENTION(S)

FSH laboratory values.

MAIN OUTCOME MEASURE(S)

Ovarian follicular development.

RESULT(S)

Adequate follicular response leading to oocyte retrieval.

CONCLUSION(S)

Determination of serum FSH levels may help detect noncompliance with recommended gonadotropin regimens during IVF.

Ovulation induction: a mini review

Ovulation induction is the method for treating anovulatory infertility. For patients with hypogonadotrophic hypogonadism, the treatment involves administration of both FSH and LH, while HCG is injected for follicle rupture. Pulsatile GnRH has the same effectiveness as gonadotrophins and the advantage of the low multiple pregnancy rate. In polycystic ovary syndrome (PCOS), the first treatment choice is clomiphene citrate. With this drug, in properly selected patients, the cumulative pregnancy rate approaches that of normal women. Low-dose protocols of FSH are the second line of treatment, effective in inducing monofollicular development. Laparoscopic ovarian drilling can be an alternative but not as a first choice treatment in clomiphene-resistant patients. Other treatments, such as pulsatile GnRH and GnRH agonists, are hardly used today in PCOS. However, in obese women with PCOS, weight loss and exercise should be recommended as the first line of therapy. Newer agents including aromatase inhibitors and insulin sensitizers, although promising, need further evaluation.

Time to revolutionize the triggering of ovulation

Methods used for ovarian stimulation constantly change with advances in gonadotrophin therapy. In this Commentary, an appeal is made for more attention to the use of LH for the induction of ovulation. Its typical characteristics during the LH surge are finely balanced to induce normal ovulation and luteinization. It does not induce ovarian hyperstimulation, for example. The recent commercial availability of recombinant LH (LHr) offers a chance of escaping from the use of urinary human chorionic gonadotrophin (HCG) and its varied forms such as those with a shorter half-life. It should also avoid the weakly effective bursts of FSH and LH and weak luteal phases released associated with the use of gonadotrophin-releasing hormone agonists. Currently, large dosages of LHr are needed to match the endocrine events typical of inducing ovulation by the endogenous LH surge. In the interests of patients' safety and improved forms of luteal phase endocrinology, research should be devoted to improving the properties of rLH to make it induce surges similar to endogenous discharges. This would replace the current use of HCG to induce ovulation, with its attendant risks of ovarian hyperstimulation and luteal phase anomalies.

Assessment and management of anovulatory infertility in polycystic ovary syndrome

PCOS is the most common cause of anovulatory infertility. Anovulation in PCOS is exacerbated by weight gain and improved by calorie restriction in overweight subjects. Fertility can usually be restored by appropriate choice of induction of ovulation, but careful monitoring is required, even when using clomiphene alone.

Ovulation induction for polycystic ovary syndrome

Polycystic ovary syndrome (PCOS) is the commonest cause of anovulatory infertility. Various factors influence ovarian function, and fertility is adversely affected by an individual being overweight or having high serum concentrations of LH. Strategies to induce ovulation include weight loss, oral anti-oestrogens (principally clomiphene citrate), parenteral gonadotrophin therapy and laparoscopic ovarian surgery. There have been no adequately powered randomized studies to determine which of these therapies provides the best overall chance of an ongoing pregnancy. Women with PCOS are at risk of ovarian hyperstimulation syndrome (OHSS) and so ovulation induction has to be monitored carefully with serial ultrasound scans. The recognition of an association between hyperinsulinaemia and PCOS has resulted in the use of insulin sensitizing agents, such as metformin, which appear to ameliorate the biochemical profile and improve reproductive function.

Recombinant FSH versus urinary gonadotrophins or recombinant FSH for ovulation induction in subfertility associated with polycystic ovary syndrome

BACKGROUND

Over the last four decades, various urinary FSH (uFSH) products of different purity have been developed. In 1988 recombinant FSH (rFSH ) was prepared by transfecting Chinese hamster ovary cell lines with both FSH subunit genes. Both rFSH and uFSH are known to be effective in inducing ovulation in women with clomiphene-resistant polycystic ovary syndrome. Ovulation induction with FSH bears the risk of multiple follicle development, multiple pregnancies and ovarian hyperstimulation syndrome. The dose regimen used can affect the incidence of these complications.

OBJECTIVES

To compare in women with clomiphene-resistant polycystic ovary syndrome (PCOS) the safety and effectiveness in terms of ovulation, pregnancy, miscarriage, multiple pregnancy rate and ovarian hyperstimulation syndrome (OHSS) of 1) rFSH with uFSH and 2) different dose regimens of rFSH.

SEARCH STRATEGY

The search strategy of the Menstrual Disorders and Subfertility review group was used to identify all relevant trials. Please see Review Group details.

SELECTION CRITERIA

All relevant published RCT's were selected. Randomised controlled trials were eligible for inclusion if treatment consisted of recombinant FSH versus urinary FSH or recombinant FSH in different dose regimens, to induce ovulation in subfertile women with PCOS.

DATA COLLECTION AND ANALYSIS

A computerised MEDLINE and EMBASE search was used to identify randomised and non randomised controlled trials. The reference lists of all studies found were checked for relevant articles. Handsearching of bibliographies of relevant publications and reviews and abstracts of scientific meetings was performed. Serono Benelux BV and NV Organon, the manufacturers of follitropin alpha (Gonal F(R)) and follitropin beta (Puregon(R)) respectively, were asked for unpublished data and ongoing studies. Relevant data were extracted independently by two reviewers (NB, MW). Validity was assessed in terms of method of randomisation, completeness of follow-up, presence or absence of cross-over and co-intervention. All trials were screened and analysed according to predetermined quality criteria.

DATA SYNTHESIS

2X2 tables were generated for all the relevant outcomes. Odds ratios were generated using the Peto modified Mantel-Haenszel technique.

MAIN RESULTS

Four randomised trials comparing rFSH versus uFSH were identified. No significant differences were demonstrated for the relevant outcomes. The odds ratio for ovulation rate was 1.19 (95% CI 0.78,1.80), for pregnancy rate 0.95 (95% CI 0.64,1.41), for miscarriage rate 1.26 (95% CI 0.59,2.70), for multiple pregnancy rate 0.44 (95% CI 0.16,1.21) and for OHSS 1.55 (95% CI 0.50,4.84). Similarly, in the only randomised trial that compared chronic low dose versus conventional regimen with rFSH no significant differences were found.

REVIEWER'S CONCLUSIONS

At this moment there are not sufficient data to determine which of rFSH or uFSH is preferable for ovulation induction in women with PCOS.

Recombinant human follicle-stimulating hormone for ovulation induction in polycystic ovary syndrome: a prospective, randomized trial of two starting doses in a chronic low-dose step-up protocol

PURPOSE

The aim was to compare the follicular response to 37.5 and 50 IU of recombinant follicle-stimulating hormone (FSH) as starting doses for ovulation induction in patients with polycystic ovary syndrome (PCOS).

METHODS

Prospective, randomized, crossover study including 15 women with clomiphene citrate-resistant chronic anovulatory infertility. Patients were treated with subcutaneous recombinant FSH at starting doses of 37.5 IU and 50 IU, respectively, according to a low-dose step-up protocol. Each woman received both treatments, in a randomized order, with an interval of > or = 1 month between treatments.

RESULTS

All treatment cycles were ovulatory after an appropriate follicular response and hormone levels were similar with both treatments, although the total quantity of FSH required and the mean daily dose required to induce identical follicular development were significantly lower with a starting dose of 37.5 IU FSH. The mean duration of treatment to achieve ovulation was approximately 13 days with both treatments but treatment periods > or = 20 days were required in some patients.

CONCLUSIONS

In women with PCOS, a starting dose of 37.5 IU recombinant FSH may be adequate to induce follicular growth. However, the use of low starting doses may result in some cases in increased treatment periods and need for monitoring.

Gonadotrophin therapy for ovulation induction in subfertility associated with polycystic ovary syndrome

BACKGROUND

Approximately 15% of patients with PCOS remain anovulatory despite treatment with oral anti-oestrogen medications such as clomiphene citrate. In addition, about half of women with PCOS ovulating on anti-oestrogen treatment fail to conceive. Gonadotrophin stimulation is the next step in treatment for women who are "clomiphene resistant", however, results of gonadotrophin stimulation in women with PCOS are less successful. In PCOS associated with hypersecretion of LH, purified urinary follicle-stimulating hormone (u-FSH) preparations have theoretical advantages over the use of human menopausal gonadotrophin (hMG) preparations (containing both FSH and LH), but whether this claimed advantage extends into clinical practice remains uncertain. In addition, the use of gonadotrophin-releasing hormone analogues (GnRH-a) to produce pituitary desensitisation prior to ovulation induction in PCOS has been claimed to increase the success rates of treatment as well as reduce complications such as OHSS and multiple pregnancy. Gonadotrophin preparations have also been administered via different routes (intramuscular or subcutaneous), or using different stimulation regimens and protocols (step-up or standard) in an attempt to improve efficacy.

OBJECTIVES

To determine the effectiveness of urinary-derived gonadotrophins as ovulation induction agents in patients with PCOS trying to conceive. In particular, to assess the effectiveness of (1) different gonadotrophin preparations, (2) the addition of a gonadotrophin-releasing hormone agonist (GnRH-a) to gonadotrophin stimulation and (3) different modalities of gonadotrophin administration.

SEARCH STRATEGY

The search strategy to identify RCTs consisted of (1) the Group's Specialised Register of Controlled Trials using the search strategy developed for the Menstrual Disorders and Subfertility Group as a whole (see the Review Group details for more information), (2) additional specific electronic Medline searches and (3) bibliographies of identified studies and narrative reviews.

SELECTION CRITERIA

RCTs in which urinary-derived gonadotrophins were used for ovulation induction in patients with primary or secondary subfertility attributable to PCOS.

DATA COLLECTION AND ANALYSIS

Twenty three RCTs were identified, 9 of which were excluded from analysis. The data were extracted independently by 2 authors. The following criteria were assessed: (1) the methodological characteristics of the trials, (2) the baseline characteristics of the studied groups and (3) the outcomes of interest: pregnancy rate (per cycle), ovulation rate (per cycle), miscarriage rate (per pregnancy), multiple pregnancy rate (per pregnancy), overstimulation rate (per cycle) and ovarian hyperstimulation syndrome (OHSS) rate (per cycle). Where suitable, meta-analysis was performed using Peto's OR with 95% CI with the fixed effect Mantel-Haentszel equation.

MAIN RESULTS

(1) A reduction in the incidence of OHSS with FSH compared to hMG in stimulation cycles without the concomitant use of a GnRH-a (OR 0.20; 95% CI 0.08-0.46) and (2) a higher overstimulation rate when a GnRH-a is added to gonadotrophins (OR 3.15; 95% CI 1.48-6.70).

REVIEWER'S CONCLUSIONS

Although 14 RCTs were included in this review, few dealt with the same comparisons, all were small to moderate size and their methodological quality was generally poor. Any conclusions, therefore, remain tentative as they are based on a limited amount of data and will require further RCTs to substantiate them. In none of the comparisons was there a significant improvement in pregnancy rate but this may be due to the lack of power (i.e. insufficient patients randomised to demonstrate a significant difference between treatments). There was a trend towards better pregnancy rates with the addition of a GnRH-a to gonadotrophin stimulation and these interventions warrant further study. Despite theoretical advantages, urinary-derived FSH preparations did not improve pregnancy rates when compared to traditional and cheaper hMG preparations; their only demonstrable benefit was a reduced risk of OHSS in cycles when administered without the concomitant use of a GnRH-a. No conclusions can be drawn on miscarriage and multiple pregnancy rates due to insufficient reporting of these outcomes in the trials.

Endocrine methods of ovulation induction

The rationale of ovulation induction is to achieve the development of a single follicle and ultimately a singleton healthy baby. Problems faced by women with anovulatory polycystic ovary syndrome are the sensitivity of the ovary to stimulation and health issues such as obesity. This chapter will discuss medical management including strategies to lose weight, address hyperinsulinaemia with insulin-sensitizing agents, such as metformin, and outline methods of ovulation induction from the usual first-line therapy of clomiphene citrate and the subsequent use of gonadotrophin therapy in clomiphene-resistant patients. Appropriately directed surgical ovulation induction with laparoscopic ovarian diathermy appears to be as efficacious as gonadotrophin therapy but will not be discussed in the context of this chapter.

Surgical ovulation induction: the role of ovarian diathermy in polycystic ovary syndrome

Notwithstanding the shortcomings of the available data, this review of the available literature strongly suggests some real benefits of laparoscopic treatment for carefully selected patients who fail clomiphene citrate therapy. While we very cautiously endorse a place for this procedure in the armamentarium of the clinician, we would like to state emphatically that this procedure has not been shown to be free of risks to the fertility status of women. The notion that this procedure is not associated with adhesion formation is false, and the reports of ovarian atrophy, while rare, are also of serious concern. These issues, as well as the cost and risk associated with any operative procedure, underscore the importance of performing this operation only when all other available options have been exhausted. It is, in our opinion, a great disservice to the patient to perform laparoscopic equivalents of ovarian wedge resection after only a cursory infertility evaluation and a brief attempt at clomiphene citrate ovulation induction. Until it can be conclusively shown that laparoscopic ovulation induction does no harm to fertility potential or to long-term health, these procedures should be used when all available non-invasive options have been explored.

Surgically induced ovulation in the polycystic ovary syndrome: wedge resection revisited in the age of laparoscopy

OBJECTIVE

To provide an up-to-date comprehensive review of published data on laparoscopic methods of ovulation induction in the polycystic ovary syndrome (PCOS). Areas to be considered include the historical background of these procedures, their outcomes as reported in the literature, and their potential adverse effects. Through the careful review of these issues, some recommendations for clinical use and further study are offered.

DESIGN

Relevant studies were identified through a the search of a computerized bibliographic database of holdings in the National Library of Medicine as well as the manual scanning and cross-referencing of relevant medical journals.

RESULTS

Twenty-nine relevant studies were identified in the English language literature. These studies consist almost exclusively of uncontrolled case series. Pregnancies after laparoscopic ovulation induction procedures have been reported in an average of 55% of treated subjects (range 20% to 65%). Potential advantages of laparoscopic ovulation induction over gonadotropin therapy may include possible cost savings, serial repetitive ovulatory events resulting from a single treatment, no increased risk of ovarian hyperstimulation or multiple gestation, and the prospect for a higher live birth rate owing to a seemingly lower incidence of miscarriage. Reported adverse effects include a high rate of intra-abdominal adhesion formation and a single case of iatrogenic premature menopause due to postoperative ovarian atrophy.

CONCLUSIONS

The available circumstantial evidence suggests that laparoscopic procedures designed to induce ovulation may be of value in the PCOS subject who, despite an exhaustive trial of clomiphene citrate therapy, remains anovulatory and is unable or unwilling to undergo gonadotropin therapy. However, because of the risks of postoperative ovarian adhesions, carefully constructed controlled trials must be performed before these procedures can be viewed as efficacious and safe.

Folliculogenesis--the stimulated way

The initial techniques of stimulating follicular development in the anovulatory woman involved the use of human pituitary gonadotrophin (hPG) and thus replaced the function of the pituitary gland. Despite extreme care with administration of hPG and extensive monitoring to assess the ovarian response, ovarian hyperstimulation and multiple pregnancy were common. Less expensive and easier methods of treatment soon followed with oral clomiphene citrate (early 1960s), oral bromocriptine (early 1970s) and pulsatile gonadotrophin-releasing hormone (late 1970s) being used. Currently all of these methods, alone or in combination, are employed and successful ovulation induction (except in women with elevated FSH levels) can now virtually be guaranteed. Controlled ovarian hyperstimulation, just the outcome one was attempting to avoid in the treatment of anovulatory women, has become the treatment of choice for women having in vitro fertilization (IVF) or gamete intrafallopian transfer (GIFT). The extra oocytes produced by this treatment results in more embryos being available for transfer and/or freezing and improves the overall pregnancy rate. The concurrent use of gonadotrophin-releasing hormone agonists (GnRH-a) has resulted in more mature oocytes being developed, less cancelled cycles for a spontaneous midcycle LH surge, and allowed even more embryos to be produced thereby increasing the pregnancy rate further to the current expected 20% per cycle commenced. As techniques are further modified, adverse effects of elevated LH levels on pregnancy and take home baby rates should be able to be overcome, and oocyte freezing and long-term storage should become a possibility.(ABSTRACT TRUNCATED AT 250 WORDS)

The relationship between follicle-stimulating hormone dose and level and its relevance for ovulation induction with adjuvant gonadotropin-releasing hormone-agonist treatment

OBJECTIVE

To investigate the effect of a GnRH agonist (GnRH-a) on the FSH threshold level and the relationship between the FSH dose and the FSH level of patients suffering from polycystic ovarian syndrome (PCOS).

DESIGN

The stimulation with low-dose FSH in PCOS (group 1) was compared with the subsequently performed stimulation with low-dose FSH combined with GnRH-a in another group of patients suffering from the same syndrome (group 2).

SETTING

Specialist Reproductive Endocrine Unit.

PATIENTS

Suffering from clomiphene citrate-resistant PCOS.

MAIN OUTCOME MEASURES

The FSH threshold level for ongoing follicular growth and the relationship between dose and level of FSH.

RESULTS

In 15 patients in group 1 and in 13 patients in group 2, respectively, 39 and 32 stimulation cycles were performed. Below and above threshold values of FSH of group 1 and 2 did not differ significantly. For the equation stable level of FSH (Y mIU/mL) = A X infusion rate of FSH (X IU/24 h) + basal level of FSH (B mIU/mL), the median A of group 1 was 0.027 and A of group 2 was 0.055 (significant difference).

CONCLUSIONS

In PCOS, a change of the FSH threshold level for ongoing follicular growth induced by the GnRH-a could neither be proven nor ruled out. The use of a GnRH-a resulted in larger FSH level increases per IU/24 h of FSH administered and might therefore interfere with the effect of low-dose FSH treatment.

Complications of ovulation induction

Induction of ovulation has its own risks. Since this treatment is elective the physician should be convinced that it is really indicated for the specific patient. Multiple pregnancies still occur in 4 to 15% in in vivo treatment and in 15 to 20% in assisted reproduction. Abortions occur in 20% of the pregnancies achieved. These numbers demonstrate the complexity of induction of ovulation. In recent years the average age of the treated patient has increased, but it is too early to see whether this influences the frequency of complications. The physician should be aware of the possible complications and should remain in contact with the patients at risk after completion of the treatment. The patient should be well informed about the possible complications before starting treatment. At the end of the treatment she should be able to recognize any clinical warning signs of OHSS and inform her physician, in order to be treated appropriately. Further studies of the pathogenesis of OHSS in the future will hopefully lead to more specific treatments or even prevention of this phenomenon. The increasing experience in selective fetal reduction seems to be a practical solution to high rank multifetal gestation, preventing extreme prematurity and its sequelae.

Comparison of hCG versus GnRH analog for releasing oocytes following ultra low-dose gonadotropin stimulation

Previous data have suggested there is a higher incidence of luteinized unruptured follicle (LUF) syndrome (defined as failure to release any oocyte as determined by sonography) in gonadotropin-treated patients following human chorionic gonadotropin (hCG) versus the gonadotropin releasing hormone agonist (GnRH-a) leuprolide acetate. The present study was designed to determine if an ultra low-dose gonadotropin regimen, designed not to raise the serum estradiol level much above normal for non-stimulated cycles, might result in a decrease in LUF following hCG treatment, and even reduce the rate to that seen following leuprolide acetate. The hypothesis tested was that the higher estradiol levels might suppress the pre-ovulatory follicle stimulating hormone (FSH) surge which, in turn, would inhibit plasmin production, thus preventing detachment of the oocyte from the follicle. The data did show a reduced rate of LUF incidence with either hCG or leuprolide acetate in ultra low-dose human menopausal gonadotropin-(hMG-) treated patients compared to data from previous studies with conventional hMG/hCG therapy. Pregnancy rates were also similar following hCG or leuprolide acetate for release in low-dose hMG-treated patients. Preliminary data show that leuprolide acetate is superior to hCG for causing oocyte release when stimulation is with low-dose purified FSH, and possibly also that low-dose hMG is superior to low-dose purified FSH for producing superior pregnancy rates.

Efficacy of low dose purified FSH in ovulation induction following pituitary desensitization in polycystic ovarian syndrome

OBJECTIVES

We evaluated the efficacy of ovulation induction using purified FSH in either low dose or conventional dosage in patients with polycystic ovarian syndrome. We assessed whether gonadotrophin measurement by radioimmunoassay or immunoradiometric assay is a better indicator of whether pituitary desensitization with a GnRH agonist (Zoladex) has occurred.

DESIGN

Two different protocols were used. Pituitary desensitization was carried out with a GnRH agonist (Zoladex, ICI Pharmaceuticals UK). The patients were then randomized into one of two treatment groups. Conventional dose protocol: Patients commenced with a daily FSH (Metrodin, Serono Laboratories Ltd, UK) dose of 75 units for at least 7 days. The FSH dose was then increased, if necessary, based on ultrasound scans and plasma oestradiol (E2) levels in 75-unit increments. Low dose protocol: The same protocol was used except that the starting dose of FSH was 37.5 units daily with increments of 37.5 units.

RESULTS

Low dose protocol (six patients, six cycles). There was a high incidence of multiple follicular development (10.3 +/- 5.6 (+/- SD) follicles, 5.0 +/- 3.8 follicles > 14 mm in diameter). Three cycles resulted in ovulation, one was anovulatory and two patients underwent gamete intrafallopian transfer due to multiple follicular development. Conventional dose protocol (seven patients, eight cycles). Again there was multiple follicular development (10.1 +/- 8.6 follicles, 2.0 +/- 2.3 > 14 mm). Three cycles were ovulatory, one anovulatory, three abandoned due to multiple follicular development and one underwent gamete intrafallopian transfer with the development of severe hyperstimulation necessitating steroid therapy. There was no difference between the two protocols in the number of days of FSH administration (low dose protocol 26 +/- 6.5, conventional dose protocol 23 +/- 8.1 days), the total number of units of FSH given per patient was 2844 +/- 1816 vs 2635 +/- 1726. The peak E2 level (pmol/l) during FSH treatment was 3193 +/- 662 vs 2389 +/- 3099 and the rate of increase in the FSH dose in ampoules of Metrodin per day was 0.058 +/- 0.03 vs 0.057 +/- 0.03. All patients were 'downregulated' (E2 < 70 pmol/l) prior to ovulation induction. However, gonadotrophin levels (IU/l) were 4.3 +/- 1.5 (LH) and 2.8 +/- 1.2 (FSH) by radioimmunoassay and LH was unchanged throughout FSH treatment whereas LH measured by immunoradiometric assay was < 1.0 IU/l prior to ovulation induction and remained so throughout. The mean LH radioimmunoassay to immunoradiometric assay ratio was 6.2 +/- 2.1.

CONCLUSIONS

We conclude that regardless of the starting dose the use of pure FSH in patients with polycystic ovarian syndrome whose LH has been completely down regulated may be associated with multiple follicular development and a poor outcome. LH measured by radioimmunoassay is not a good indicator of whether pituitary densensitization has occurred but LH measured by immunoradiometric assay appears to be. These results strongly suggest that a basic minimum amount of LH is necessary for normal ovulatory development.

Early miscarriage and fetal malformations after induction of ovulation (by clomiphene citrate and/or human menotropins), in vitro fertilization, and gamete intrafallopian transfer

From the reviewed data, it appears that CC, hMG-hCG, or the association of these drugs with IVF-ET and GIFT programs do not carry an increased risk for congenital malformations as a whole, nor is there any specific malformation that has an increased incidence or is related in any way with the use of these drugs. Table 7 represents the specific malformation rate per 1,000 births in the general population and in newborns delivered after treatment with CC, hMG-hCG, or IVF-ET and GIFT. The malformation rate in the treated groups does not differ from that of the general population. However, as shown by McIntosh et al., the incidence of congenital malformations often rises with a longer follow-up. Most of the reports about babies born after ovulation induction are based on the initial examination done shortly after birth. Thus, studies including examination of these infants up to at least 12 months of age will be undoubtedly of value. Also, data concerning the reproductive capability of women born after ovulation induction is lacking. With regard to the abortion rate in pregnancies achieved after such treatments and procedures, it can be concluded that it does not appear to be higher than that of the general population, particularly when early pregnancy loss, advanced maternal age, the infertility status, and the increased incidence of multiple pregnancies occurring in these patients are taken into consideration.

Common problems in induction of ovulation

There are many groups of women with anovulatory infertility who respond abnormally to conventional treatment. It is important to diagnose the underlying disorder correctly before commencing treatment. In this chapter we have discussed the various treatment modalities available and how they may be adapted to fit the particular clinical needs. In women who are profoundly hypo-oestrogenic, the 'priming' of the ovary using prolonged low-dose gonadotrophins offers a possible solution if both subcutaneous and intravenous pulsatile GnRH therapy has failed. It may also reduce the incidence of multiple pregnancies in these women. Growth hormone seems to augment the response to gonadotrophin in these women and may prove a useful adjunct to therapy once further experience of its use has been reported. Women with PCO have been a difficult group to treat because of their tendency to hyperstimulate. The low-dose gonadotrophin regimen outlined in this chapter overcomes the majority of these problems without reducing the rate of conception. This group continue to have an increased incidence of miscarriage. The introduction of combined therapy of hMG with a GnRH analogue may improve this situation, but the data from randomized controlled studies are still awaited. Ovarian failure remains an untreatable cause of infertility. A few women may become pregnant spontaneously, but these are the exception rather than the rule. Hormone replacement therapy should be offered to all these women because of the long-term problems of osteoporosis and cardiovascular disease. Products containing a low dose of oestrogen (e.g. Premarin 0.625 mg) will not interfere with ovulation if there should be a spontaneous resumption of ovarian activity.

Factors affecting fetal loss in induction of ovulation with gonadotropins: increased abortion rates related to hormonal profiles in conceptual cycles

Thirty-six first-trimester abortions (9.7%), 16 second-trimester abortions (4.3%), 11 ectopic pregnancies (2.9%), and 10 stillbirths (2.7%) occurred in 373 conceptual cycles after gonadotropin induction of ovulation. Fetal wastage was higher in spontaneous pregnancies that occurred before therapy (54.3%, p less than 0.0001) and lower with subsequent spontaneous pregnancies (10.1%, p less than 0.05). Significant risk factors for overall fetal loss during induced ovulation were a continuous rise of estrogen excretion until ovulation (p less than 0.01) and previous abortion (p less than 0.05). For first-trimester abortion, the risk factor was continuous estrogen rise (p less than 0.01); for second-trimester abortion, the risk factors were a low luteal pregnanediol-to-estrogen excretion ratio (p less than 0.002), increased age at conception (p less than 0.02), and high baseline estrogen excretion (p less than 0.05). Multiple pregnancy was not significant. The continuous rising estrogen pattern may serve as a marker of abnormal oocyte maturation. We propose that future studies on infertility treatment should report on pregnancy outcome.

Administration of pure follicle-stimulating hormone during gonadotropin-releasing hormone agonist therapy in patients with clomiphene-resistant polycystic ovarian disease: hormonal evaluations and clinical perspectives

Nine women with chronic anovulation caused by polycystic ovarian disease, which was unresponsive to clomiphene citrate therapy, were given a gonadotropin-releasing hormone agonist (buserelin) to induce pituitary desensitization. After 4 weeks induction of ovulation was attempted with a step-up administration of urinary follicle-stimulating hormone. Buserelin treatment was discontinued only in the presence of a positive pregnancy test result. Different responses were observed between the first and subsequent cycles. Whereas estradiol production and follicular growth were closely correlated in the first attempt, we recorded a dissociation between these two parameters of ovarian response during subsequent stimulations. Four clinical pregnancies occurred in these nine patients, and there was one abortion. This therapeutic approach can be successfully used to induce ovulation; however, prolonging pituitary suppression between treatment cycles changes the type of ovarian response and is not followed by better results.

The importance of human chorionic gonadotropin support of the corpus luteum during human gonadotropin therapy in women with anovulatory infertility

One hundred ten women with anovulatory infertility (World Health Organization [WHO] group I n = 50, WHO group II n = 60) were given 341 treatment courses with human menopausal gonadotropin (hMG) and human chorionic gonadotropin (hCG). Additional hCG was given as single or repeated injections during the luteal phase in 205 ovulatory cycles. In WHO group I, the incidence of luteal phase defects was lower and the pregnancy rate higher in cycles with extra hCG administration during the luteal phase than in cycles with no extra hCG. In WHO group II, there was no such difference after supplemental hCG. The abortion rate was the same after cycles with or without extra hCG administration. It is suggested that during ovulation induction with hMG/hCG in anovulatory women with no evidence of endogenous estrogen activity, the luteal phase should be supplemented with additional hCG.

Treatment-independent pregnancies after cessation of gonadotropin ovulation induction in women with oligomenorrhea and anovulatory menses

Life-table analysis was performed for the cumulative spontaneous pregnancy rate (CSPR) of 56 patients with oligomenorrhea and anovulatory cycles who had been treated with gonadotropin for ovulation induction between 1963 and 1985. Twenty-seven had at least one spontaneous pregnancy, giving rise to a CSPR of 66.4% (95% confidence limit [CL] 42.4% to 90.4%) at 115 months for the first spontaneous pregnancy, which is significantly lower than the cumulative induced pregnancy rate (CIPR) of 88.6% at 23 months for the first course of gonadotropin therapy (P less than 0.0001). This fertility potential was not affected by the baseline estrogen and follicle-stimulating hormone levels, diagnosis, result of gonadotropin therapy, and age and menstrual pattern during exposure to spontaneous pregnancy by Cox regression analysis. More multiple births occurred in the induced pregnancies than in the spontaneous pregnancies (P = 0.005).

The effect of the dose of human chorionic gonadotropin and the type of gonadotropin stimulation on oocyte recovery rates in an in vitro fertilization program

The effect of the dose of human chorionic gonadotropin (hCG) on oocyte retrieval in an in vitro fertilization (IVF) program was studied. Following ovulation induction using clomiphene citrate and either pure follicle-stimulating hormone (FSH) or human menopausal gonadotropin (hMG), hCG was administered at a dose of 2000 IU (n = 88), 5000 IU (n = 110), and 10,000 IU (n = 104). There was a significantly lower successful oocyte recovery in patients who received 2000 IU of hCG (77.3%) compared with patients who received either 5000 IU of hCG (95.5%) or 10,000 IU of hCG (98.1%; P less than 0.001). There was no significant difference between 5000 or 10,000 IU of hCG. In patients who received 2000 IU of hCG, successful oocyte recovery was significantly lower when pure FSH was used (60%) compared with those who received hMG (84.1%; P less than 0.03). Patients have different thresholds for follicular response to hCG and the recommended minimum dose of hCG should be at least 5000 IU.

Ovulation of a single dominant follicle during treatment with low-dose pulsatile follicle stimulating hormone in women with polycystic ovary syndrome

Ten women with clomiphene-resistant chronic anovulation associated with polycystic ovary syndrome were treated with purified urinary FSH (urofollitrophin). The gonadotrophin was given s.c. by pulsatile infusion pump starting at a low dose (1 ampoule or 75 U/d) and increasing by 37.5 U/d at weekly stages in an attempt to induce ovulation of a single follicle. Seventy percent of the 33 cycles were ovulatory and in 18 of these (78%) a single dominant follicle developed and ovulated. Each of the 10 women ovulated when the optimum dose was reached and five of these women became pregnant. The maximum dose of FSH in uni-ovulatory cycles was 150 U/d or less. Endogenous LH concentrations which were raised at the onset of treatment were suppressed in the late follicular phase. The rate of follicular growth and gonadal steroid concentrations were consistent with those observed in spontaneous ovulatory cycles. This study demonstrates that by using low-dose gonadotrophin therapy it is possible to find the 'threshold' dose of FSH to promote maturation of a single dominant follicle. The high rate of ovulation and pregnancy suggest that this approach is of practical importance in treatment of infertile patients with polycystic ovaries.

Ultrasonographic and clinical correlates of menotropin versus sequential clomiphene citrate: menotropin therapy for induction of ovulation

Forty-six women remaining infertile with clomiphene citrate (CC) with or without human chorionic gonadotropin (hCG) were treated by either human menopausal gonadotropin (hMG, 44 cycles) or CC + hMG (33 cycles) and monitored by serum estradiol (E2) and ultrasonography. Ovarian hyperstimulation syndrome (OHS) and pregnancy outcome were compared in both regimens. In the presence of dominant follicles (greater than or equal to 18 mm) alone or with a single secondary follicle (14 to 16 mm) at hCG administration, OHS did not develop. A significant increase in OHS was noted when three or more secondary follicles were observed. Overall pregnancy rates were similar in both regimens but significantly higher when hCG was injected before rather than after the E2 peak. The results suggest secondary follicles rather than dominant follicles are a valuable sign of possible OHS development; and CC + hMG should be considered in CC-failure patients.

Analysis of the outcome of in vitro fertilization in relation to the timing of human chorionic gonadotropin administration by the duration of estradiol rise in stimulated cycles

A retrospective analysis was carried out to assess the outcome of ovarian stimulation on in vitro fertilization when human chorionic gonadotropin (hCG) was administered after 5, 6, or 7 days of continuously rising plasma estradiol (E2). There was no significant difference in the number and size of large follicles in each group although the number of small follicles (less than 15 mm in diameter) decreased significantly after 7 days of E2 rise. After hCG injection in the 7-day group, the E2 level fell below the previous day's value in 40% of patients, whereas a similar fall was observed in only 16% of patients in the 5- and 6-day groups. In those cycles where a luteinizing hormone surge occurred, most surges were detected during the seventh day of E2 rise. The pregnancy rate was 31% when hCG was given after 6 days of rising E2, 21% after 5 days, and 14% after 7 days. In patients achieving pregnancy in the 6-day group, 53% of embryos were derived from leading follicles. In the 7-day group, only 15% of embryos associated with pregnancies were derived from leading follicles. These results strongly suggest that in stimulated cycles, hCG should be administered after 6 days of continuously rising E2. It is therefore postulated that 6 days of rising E2 represents a mean optimal period for follicular growth and oocyte maturation in stimulated cycles.

The luteal phase after hyperstimulation for in vitro fertilization

Of 500 cycles in which in vitro fertilization (IVF) was undertaken, laparoscopy was performed 372 times, 272 embryo transfers were carried out, and 55 pregnancies resulted, 30 of which resulted in delivery. Of those patients who underwent laparoscopy, 156 received clomiphene citrate alone, 203 clomiphene citrate and hMG, and 13 hMG alone. All patients were found to have a luteal-phase length of 10 days or greater (measured from the time of ovulation). The midluteal urinary total estrogen (UTE) value and pregnanediol excretion (Pd2) far exceeded the levels seen in normal cycles. There were no significant differences between conceptual and nonconceptual cycles and the high levels encountered would be expected after deliberate hyperstimulation. Fifty-five patients (in whom 11 pregnancies resulted) were monitored every other day throughout the luteal phase after embryo transfer. Both conceptual and nonceptual cycles showed a peak in pregnanediol glucuronide level around luteal day 6, which then fell. The level rose again if the corpus luteum was "rescued" by the implanting embryo. While the difference was not statistically significant, the estradiol levels appeared to decrease earlier in the nonconceptual cycles than in the continuing pregnancy cycles. It is important to note that the pattern of steroid production in the follicular phase was similar in both conceptual and nonconceptual cycles. While these data are not conclusive, they suggest that some nonconceptual cycles may have suffered early corpus luteal regression. Whether luteal-phase support is indicated in patients treated with clomiphene or clomiphene/hMG therapy cannot be determined from this study. However, it is thought that a controlled study of luteal-phase support in patients so stimulated is warranted. It appears that patients treated with hMG alone tend to undergo a compressed cycle and should be given luteal-phase support since other studies have reported shortened luteal phases following such hMG therapy.

Growth rate of follicular estrogen secretion in relation to the outcome of in vitro fertilization and embryo replacement

Estradiol growth rate (EGR) during active follicular development was calculated for 89 stimulated in vitro fertilization cycles by exponential curve fit (r = 0.83). Cycles could be divided into four groups with very low, low, moderate, and high EGR values. Cases without oocyte fertilization and/or embryo replacement did not occur in the moderate EGR range, which also corresponded to a significantly better ratio of replaceable embryos versus oocytes recovered. This group was also endowed with a pregnancy rate amounting to 28.5% per laparoscopy and per replacement, i.e., about three times higher than in the three other groups. Very low or high EGR entailed significantly higher percentages of missed oocyte recovery and/or fertilization failure. The frequency of occurrence of a spontaneous luteinizing hormone peak was negatively correlated with EGR. The data indicate that a better outcome of in vitro fertilization may be expected when the estrogen rise starts early in the cycle and adopts a moderate growth rate (0.3 to 0.4).

Induction of ovulation with gonadotrophins--a ten year review

We describe the outcome of induction of ovulation with gonadotrophins (HMG/HCG) in 46 patients treated over 138 cycles. Ovulation was induced in 88 per cent of cycles and there were 43 conceptions in 33 patients with a cumulative conception rate of 96 per cent. The incidence of multiple pregnancy was 36 per cent of those reaching a gestation of 13 weeks or more and accounted for all the second and third trimester foetal losses. Overall, 61 per cent of the patients have taken home at least one healthy child. Mild symptomatic ovarian hyperstimulation complicated 9.4 per cent of courses and was more frequent among patients with normal pretreatment oestrogen levels. We found continuous biochemical monitoring of follicular growth to be a poor predictor of multiple pregnancy or hyperstimulation. We discuss our local experience with reference to published reports from other centres and in relation to recent advances in management and consider the future role of this therapy.

Factors influencing the success of in vitro fertilization for alleviating human infertility

The program for in vitro fertilization at Bourn Hall began in October 1980. Various types of infertility have been treated during this time using the natural menstrual cycle or stimulation of follicular growth with antiestrogens and gonadotrophins. Follicular growth and maturation are assayed by urinary estrogens and LH, monitored regularly during the later follicular stage. Many patients had an endogenous LH surge; others needed an injection of HCG to induce ovulation. All oocytes were recovered by laparoscopy. Wide variations occurred in the time interval between the start of the LH surge and oocyte recovery and between oocyte recovery and insemination. Embryos taken between the one- and the eight-cell stage were replaced into their mother, no standard procedure being adopted for all patients. The results of all treatments including patient's responses during the follicular and luteal phases, oocyte recovery, fertilization, cleavage, replacement, implantation, abortion, and birth and the effect of factors such as replacing two or more embryos, maternal age, and previous obstetric history are described in detail. The incidence of implantation after embryo replacement improved from 16.5% initially to 30% currently. More than 118 babies have been born, and many pregnancies are continuing.

Current status of in-vitro fertilisation and implantation of human embryos

Between October, 1980, and April, 1983, embryos fertilised in vitro were replaced in the uteri of 1200 women. The "clinical" pregnancy rate rose from 16.5% from October, 1980, until September, 1982, to almost 30% in 1983. The proportion of pregnancies ending in abortion varied from 25-35%. Factors favourably modifying implantation rate were maternal age of under 40 years, priming with clomiphene alone, and the replacing of more than one embryo in the uterus. The replacing of two or more embryos, increasing maternal age, a poor obstetric history, and high levels of follicular oestrogens raised the chances of abortion.

Ovulation induction with subcutaneous pulsatile gonadotropin-releasing hormone: singleton pregnancies in patients with previous multiple pregnancies after gonadotropin therapy

Three patients with hypothalamic amenorrhea who had previously had multiple pregnancies following gonadotropin therapy were treated with subcutaneous pulsatile gonadotropin-releasing hormone (GnRH), administered by a portable pump. After treatment with lower doses in some cases, pulses of 5 to 10 micrograms were given at 90-minute intervals, resulting in ovulation on six occasions. Ovarian steroid profiles closely resembled those of normal ovulatory cycles, and spontaneous ovulation of a single ovarian follicle was consistently demonstrated by ultrasound. Singleton pregnancy was confirmed in each patient. The results imply normal operation of the ovarian-pituitary feedback loop and suggest that subcutaneous pulsatile GnRH therapy is a safe and effective means of ovulation induction in clomiphene-resistant cases of hypothalamic amenorrhea and may possibly become the preferred method of treatment.