A Comparison of Outcomes from In Vitro Fertilization Cycles Stimulated with Follicle Stimulating Hormone Plus either Recombinant Luteinizing Hormone or Human Menopausal Gonadotropins in Subjects Treated with Long Gonadotropin Releasing Hormone Agonist Protocols

Luteinizing hormone supplementation in women with hypogonadotropic hypogonadism seeking fertility care: Insights from a narrative review

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.

Pregnancy confirmed after controlled ovarian stimulation for infertility: A case report

RATIONAL

Induction of ovarian stimulation by use of the gonadotropin-releasing hormone agonist (GnRHa) long protocol in the luteal phase is a common practice and results in stable pregnancy and live births; it is often used in patients with normal ovarian function. Some patients with normal ovulation may be pregnant before ovulation induction, which can be easily confirmed by asking the patient about cessation of menstruation. However, some pregnancy complications may cause vaginal bleeding along with normal menstrual blood loss; in such a situation, hormone levels can often mirror that seen in pituitary down-regulation and the value of β-HCG may be less than 5 mIU/mL. Under these conditions, the physician might start the cycle of ovarian stimulation. During ovarian stimulation, the increase in β-HCG can cause premature luteinization and follicle maturation disorder, and poor embryo quality, which can easily be overlooked. In this study, we report a case of pregnancy at the end of controlled ovarian stimulation induced by GnRHa long protocol in the luteal phase, followed by follicle maturation disorder and poor embryo quality. This case provided a reference and served as a cautionary note that could perhaps obviate occurrence of similar cases.

PATIENT CONCERNS

A 30-year-old woman with a diagnosis of unexplained infertility was scheduled for in vitro fertilization embryo culture (IVF) at our clinic. Pregnancy was confirmed at the end of controlled ovarian stimulation, which was followed by follicular maturation disorder and poor embryo quality.

DIAGNOSIS

The patient with a diagnosis of unexplained infertility was scheduled for IVF at our clinic.

INTERVENTIONS

Oocyte retrieval was still arranged for her after confirmation of pregnancy. As per the β-HCG level and the trans-vaginal ultrasound examination findings, we considered 2 possibilities: an adverse intrauterine pregnancy or extra-uterine pregnancy. Therefore, we decided to terminate the pregnancy; hence, 50 mg/d of mifepristone was given for 2 days, combined with 200 μg misoprostol.

OUTCOMES

Elevated β-HCG level had an adverse effect on maturation and fertilization of oocytes, and even embryo quality.

CONCLUSION

Once pregnancy is confirmed, ovulation induction should be terminated as soon as possible.

Interplay Between mTOR and Hippo Signaling in the Ovary: Clinical Choice Guidance Between Different Gonadotropin Preparations for Better IVF

One of the most widely used types of assisted reproduction technology is the in vitro fertilization (IVF), in which women undergo controlled ovarian stimulation through the administration of the appropriate hormones to produce as many mature follicles, as possible. The most common hormone combination is the co-administration of gonadotropin-releasing hormone (GnRH) analogues with recombinant or urinary-derived follicle-stimulating hormone (FSH). In the last few years, scientists have begun to explore the effect that different gonadotropin preparations have on granulosa cells' maturation and apoptosis, aiming to identify new predictive markers of oocyte quality and successful fertilization. Two major pathways that control the ovarian development, as well as the oocyte-granulosa cell communication and the follicular growth, are the PI3K/Akt/mTOR and the Hippo signaling. The purpose of this article is to briefly review the current knowledge about the effects that the different gonadotropins, used for ovulation induction, may exert in the biology of granulosa cells, focusing on the importance of these two pathways, which are crucial for follicular maturation. We believe that a better understanding of the influence that the various ovarian stimulation protocols have on these critical molecular cascades will be invaluable in choosing the best approach for a given patient, thereby avoiding cancelled cycles, reducing frustration and potential treatment-related complications, and increasing the pregnancy rate. Moreover, individualizing the treatment plan will help clinicians to better coordinate assisted reproductive technology (ART) programs, discuss the specific options with the couples undergoing IVF, and alleviate stress, thus making the IVF experience easier.

Comparison between cycles of the same patients when using recombinant luteinizing hormone + recombinant follicle stimulating hormone (rFSH), human menopausal gonadotropin + rFSH and rFSH only

INTRODUCTION

Recombinant follicle stimulating hormone (rFSH), recombinant luteinizing hormone (rLH), and urinary human menopausal gonadotropin (uHMG) are widely used for controlled ovarian stimulation (COS). This study compares the effects of rFSH only, rLH + rFSH, and HMG + rFSH administration on in vitro fertilization (IVF) outcomes for patients in three different yearly follow-up cycles.

MATERIAL AND METHODS

This retrospective, single-center cohort study was conducted from January 2001 to June 2016 at Istanbul Memorial Hospital, Artificial Reproductive Technology Center. From a total of 27,024 IVF cycles in women aged 18 to 45 years (17,536 rFSH only; 2147 rLH + rFSH; 7341 HMG + rFSH), the results of 2,147 cycles receiving a treatment of rLH + rFSH over the 3-year evaluation and 2,081 total cycles in which rLH + rFSH was used at least once were evaluated, and different gonadotropin combinations were compared.

RESULTS

The age and body mass index of the patients in the uHMG + rFSH group were found to be significantly higher than those of the patients in the rLH + rFSH and rFSH only groups (p < 0.001). The total gonadotropin (GND) dosage of the patients in the rLH + rFSH group was found to be significantly lower than that of the HMG + rFSH group (p = 0.001). No statistically significant differences were found between the clinical and ongoing pregnancy rates, while the highest clinical and ongoing pregnancy rate was observed in the rLH + rFSH group at age 35-39 years.

CONCLUSIONS

Recombinant luteinizing hormone administration may increase the number of clinical pregnancies for patients aged 35-39 years.

[Effects of luteinizing hormone supplementation on outcomes of in vitro fertilization and embryo transfer in patients undergoing GnRH-agonist long protocol]

OBJECTIVE

To compare the clinical outcomes of in vitro fertilization and embryo transfer (IVF-ET) among patients in different conditions receiving luteinizing hormone supplementation in GnRH-agonist long protocol.

METHODS

Between June, 2010 and December, 2015, 671 IVF-ET cycles with GnRH-agonist long protocol were performed at our center. These cycles were divided into group A with FSH only and group B with FSH and recombinant luteinizing hormone (r-LH) supplementation, and each group was divided into 4 subgroups according to age (<35 or ≥35) and the LH level on the initial day (<1.0 U/L or ≥1.0 U/L). The effects of LH supplementation on the clinical pregnancy rate and implantation rate were compared among different subgroups.

RESULTS

No statistical significances were found between groups A and B in age, body mass index (BMI), basal FSH, basal LH, basal E2, Gn dosage, Gn day, LH on HCG day, E2 on HCG day, P on HCG day, number of oocytes, fertilization rate, available embryo rate or good quality embryo rate per oocyte, but the endometrium thickness on HCG day differed significantly between the two groups. In women below 35 years of age with a LH level on HCG day over 1.0 U/L, r-LH supplementation resulted in a clinical pregnancy rate of 60%, significantly lower than the rate of 79.55% in women without r-LH supplementation (P<0.05). In women over 35 years with a LH level below 1.0 U/L, r-LH supplementation resulted in an implantation rate of 44.74%, as compared with 24.74% in women without r-LH supplementation (P<0.05).

CONCLUSION

In the long protocol, LH supplementation does not improve the oocyte number, fertilization rate, or good quality embryo per oocyte, and does not bring benefits to women below 35 years with a low LH level (<1.0 U/L) or those over 35 years with normal LH level (≥1.0 U/L) after GnRH-agonist administration. But for women over 35 years with low LH levels, r-LH supplementation may improve the clinical pregnancy rate and implantation rate of IVF-ET cycles.