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Liang Y, Hou X, Chen H, Yang R, Wang R, Mao R, Zhao J, Chen H, Cheng J. Assisted Reproductive Technology Outcomes in Women with Normal Ovarian Response Receiving Recombinant Luteinizing Hormone/Human Menopausal Gonadotropin: An Observational Study. Int J Womens Health 2024; 16:1103-1111. [PMID: 38895039 PMCID: PMC11185249 DOI: 10.2147/ijwh.s454410] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2023] [Accepted: 05/30/2024] [Indexed: 06/21/2024] Open
Abstract
Objective Additive human menopausal gonadotropin (HMG)/recombinant luteinizing hormone (r-LH) to follicle-stimulating hormone (FSH) can improve pregnancy outcomes in patients with poor ovarian response during assisted reproductive procedures. However, their effects on patients with normal ovarian response during such procedures are unclear, which formed the aim of this study. Methods This retrospective study enrolled 456 infertile women who underwent in vitro fertilization or intracytoplasmic sperm injection treatment. Group 1 received FSH; Group 2 received FSH+HMG/r-LH; Group 3 received FSH+HMG+r-LH. Results The age and Body Mass Index were significantly greater in Group III. The endometrial thickness was greater in Groups II and III, suggesting better endometrial receptivity. Better pregnancy and birth outcomes were seen in Group 3. In sub-cohorts of women older than 32 years old or with overweight/obesity, pregnancy and birth outcomes were also much better in Group 3, albeit without statistical significance. Conclusion The addition of both HMG and r-LH to FSH may improve the chance of infertile women with normal ovarian responses to have more success in having live birth babies, specifically in those over 32 years of age or with overweight/obese patients who typically face challenges in conceiving and sustaining a pregnancy.
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Affiliation(s)
- Yingxiu Liang
- Reproductive Center, Department of Obstetrics and Gynecology, The Second Affiliated Hospital and Yuying Children’s Hospital of Wenzhou Medical University, Wenzhou, Zhejiang Province, 325088, People’s Republic of China
| | - Xiaohong Hou
- Reproductive Center, Department of Obstetrics and Gynecology, The Second Affiliated Hospital and Yuying Children’s Hospital of Wenzhou Medical University, Wenzhou, Zhejiang Province, 325088, People’s Republic of China
| | - Haoying Chen
- Reproductive Center, Department of Obstetrics and Gynecology, The Second Affiliated Hospital and Yuying Children’s Hospital of Wenzhou Medical University, Wenzhou, Zhejiang Province, 325088, People’s Republic of China
| | - Ruqing Yang
- Reproductive Center, Department of Obstetrics and Gynecology, The Second Affiliated Hospital and Yuying Children’s Hospital of Wenzhou Medical University, Wenzhou, Zhejiang Province, 325088, People’s Republic of China
| | - Ruina Wang
- Reproductive Center, Department of Obstetrics and Gynecology, The Second Affiliated Hospital and Yuying Children’s Hospital of Wenzhou Medical University, Wenzhou, Zhejiang Province, 325088, People’s Republic of China
| | - Ruotong Mao
- Reproductive Center, Department of Obstetrics and Gynecology, The Second Affiliated Hospital and Yuying Children’s Hospital of Wenzhou Medical University, Wenzhou, Zhejiang Province, 325088, People’s Republic of China
| | - Junzhao Zhao
- Reproductive Center, Department of Obstetrics and Gynecology, The Second Affiliated Hospital and Yuying Children’s Hospital of Wenzhou Medical University, Wenzhou, Zhejiang Province, 325088, People’s Republic of China
| | - Hui Chen
- School of Life Sciences, Faculty of Science, University of Technology Sydney, Ultimo, New South Wales, 2007, Australia
| | - Jing Cheng
- Reproductive Center, Department of Obstetrics and Gynecology, The Second Affiliated Hospital and Yuying Children’s Hospital of Wenzhou Medical University, Wenzhou, Zhejiang Province, 325088, People’s Republic of China
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Strezsak V, Allignol A, Bühler K, Fischer R, Hubbard J, Longobardi S, Lispi M, Schertz J, Verpillat P. Dosing Characteristics of Recombinant Human Luteinizing Hormone or Human Menopausal Gonadotrophin-Derived LH Activity in Patients Undergoing Ovarian Stimulation: A German Fertility Database Study. Gynecol Obstet Invest 2023; 88:214-225. [PMID: 37369184 PMCID: PMC10614274 DOI: 10.1159/000530360] [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: 07/11/2022] [Accepted: 03/07/2023] [Indexed: 06/29/2023]
Abstract
OBJECTIVES The aim of the study was to evaluate dosing of recombinant human luteinizing hormone (r-hLH) or human menopausal gonadotrophin (hMG)-derived medications with LH activity in ovarian stimulation (OS) cycles for in vitro fertilization (IVF)/intracytoplasmic sperm injection (ICSI). DESIGN A non-interventional study was performed to analyse data from the German RecDate database (January 2007-December 2011). PARTICIPANTS/MATERIALS, SETTING, METHODS Starting/total r-hLH/hMG dose, OS duration/cycle number, r-hLH/hMG initiation day (first day of administration), and population/cycle characteristics were assessed in women (≥18 years) undergoing OS for IVF/ICSI using r-hLH or hMG-derived medications (excluding corifollitropin alfa, clomiphene citrate, letrozole, mini/micro-dose human chorionic gonadotrophin, and urofollitropin alone). Data were summarized descriptively. RESULTS 67,858 identified cycles utilized medications containing r-hLH (10,749), hMG (56,432), or both (677). Mean (standard deviation) OS duration with r-hLH and hMG was 10.1 (4.43) and 9.8 (6.16) days, respectively. Median (25th-75th percentile) r-hLH starting dose (75.0 [75.0-150.0] IU) was consistent across patients regardless of age, infertility diagnosis, or gonadotrophin-releasing hormone (GnRH) protocol. Median (25th-75th percentile) hMG-derived LH activity starting dose was 225.0 (150.0-300.0) IU, regardless of GnRH protocol, but was lower in women aged <35 years and those with ovulation disorders/polycystic ovary syndrome. Median (25th-75th percentile) total dose for r-hLH (750.0 [337.5-1,125.0] IU) and hMG-derived LH activity (1,575.0 [750.0-2,625.0] IU) varied according to patients' age, infertility diagnosis, cycle number, and r-hLH/hMG initiation day. GnRH antagonist use resulted in a numerically higher median total hMG-derived LH activity dose than GnRH agonist use. LIMITATIONS The data used in this study were taken from electronic medical records relating to a specific timeframe (2007-2011) and therefore may not accurately reflect current clinical practice; however, it is likely that the differences between the two compounds would be maintained. Additionally, secondary data sources may suffer from uniformity and quality issues. CONCLUSIONS The standard of care for OS cycles is described with respect to IVF/ICSI treatment including an LH component in Germany during the specified timeframe.
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Affiliation(s)
- Valerie Strezsak
- Global Clinical Development, Research and Development, EMD Serono Research and Development Institute, Inc., an affiliate of Merck KGaA, Billerica, MA, USA
| | - Arthur Allignol
- Global Epidemiology, Research and Development, Merck Healthcare KGaA, Darmstadt, Germany
| | - Klaus Bühler
- Department of Gynaecology and Reproductive Medicine, University Hospital Jena, Friedrich-Schiller-University Jena, Jena, Germany
- Scientific-Clinical Centre for Endometriosis of the University Hospitals of Saarland, Saarbrücken, Germany
| | | | - Julie Hubbard
- Global Clinical Development, Research and Development, EMD Serono Research & Development Institute, Inc., an affiliate of Merck KGaA, Billerica, MA, USA
| | - Salvatore Longobardi
- Global Clinical Development, Research and Development, Merck Healthcare KGaA, Darmstadt, Germany
| | - Monica Lispi
- Global Medical Affairs Fertility, Research and Development, Merck Healthcare KGaA, Darmstadt, Germany
- Unit of Endocrinology, PhD School of Clinical and Experimental Medicine, University of Modena and Reggio Emilia, Modena, Italy
| | - Joan Schertz
- Global Clinical Development, Research and Development, EMD Serono Research & Development Institute, Inc., an affiliate of Merck KGaA, Billerica, MA, USA
| | - Patrice Verpillat
- Global Epidemiology, Research and Development, Merck Healthcare KGaA, Darmstadt, Germany
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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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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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Chen MJ, Yi YC, Guu HF, Chen YF, Kung HF, Chang JC, Chuan ST, Chen LY. A retrospective, matched case-control study of recombinant LH versus hMG supplementation on FSH during controlled ovarian hyperstimulation in the GnRH-antagonist protocol. Front Endocrinol (Lausanne) 2022; 13:931756. [PMID: 36046790 PMCID: PMC9420867 DOI: 10.3389/fendo.2022.931756] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2022] [Accepted: 07/25/2022] [Indexed: 12/27/2022] Open
Abstract
BACKGROUND The role of luteinizing hormone (LH) in controlled ovarian hyperstimulation (COH) requires more evidence for its efficacy. Several studies compared recombinant human LH (r-hLH) or human menopausal gonadotropin (hMG) in combination with recombinant human follicle-stimulating hormone (r-hFSH) but lack the results with GnRH-antagonist protocol and in Asians. METHODS This is a retrospective, single-center study inspecting women receiving GnRH antagonist protocol and r-hFSH+hMG or r-hFSH+r-hLH regimen for over five days for COH in the in vitro fertilization (IVF)/intracytoplasmic sperm injection (ICSI) cycle in Taiwan from 2013 to 2018. The outcomes of IVF/ICSI cycles were analyzed after propensity score matching between the two groups. A subgroup analysis was conducted in cycles in which women underwent their first embryo transfer (ET), including fresh ET and frozen ET (FET). RESULTS With a total of 503 cycles, the results revealed that the r-hFSH+r-hLH group performed better in terms of numbers of oocytes retrieved (r-hFSH+hMG vs. r-hFSH+r-hLH, 11.7 vs. 13.7, p=0.014), mature oocytes (8.7 vs. 10.9, p=0.001), and fertilized oocytes (8.3 vs. 9.8, p=0.022), while other outcomes were comparable. The analysis of first ET cycles also showed similar trends. Although the implantation rate (39% vs. 43%, p=0.37), pregnancy rate (52% vs. 53%, p=0.90), and live birth rate (39% vs. 45%, p=0.19) were not significantly different, the miscarriage rate was higher in the r-hFSH+hMG group than the r-hFSH+r-hLH group (26% vs. 15%, p<0.05) in first ET cycles. The cumulative pregnancy rate was significantly higher in the r-hFSH+r-hLH group (53% vs. 64%, p=0.02). No significant difference in rates of ovarian hyperstimulation syndrome (OHSS) was observed. CONCLUSION The results support the hypothesis that the treatment of r-hLH+r-hFSH improves COH clinical outcomes in the IVF/ICSI cycle.
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Affiliation(s)
- Ming-Jer Chen
- Department of Obstetrics and Gynecology and Women’s Health, Taichung Veterans General Hospital, Taichung, Taiwan
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
- *Correspondence: Ming-Jer Chen,
| | - Yu-Chiao Yi
- Department of Obstetrics and Gynecology and Women’s Health, Taichung Veterans General Hospital, Taichung, Taiwan
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Hwa-Fen Guu
- Department of Obstetrics and Gynecology and Women’s Health, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Ya-Fang Chen
- Department of Obstetrics and Gynecology and Women’s Health, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Hsiao-Fan Kung
- Department of Obstetrics and Gynecology and Women’s Health, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Jui-Chun Chang
- Department of Obstetrics and Gynecology and Women’s Health, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Shih-Ting Chuan
- Department of Obstetrics and Gynecology and Women’s Health, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Li-Yu Chen
- Department of Obstetrics and Gynecology and Women’s Health, Taichung Veterans General Hospital, Taichung, Taiwan
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Kaminsky AV, Chaika OO. HORMONAL STATUS OF PATIENTS WITH A PREDICTED WEAK RESPONSE OF THE OVARIES TO GONADOTROPIN STIMULATION. WIADOMOSCI LEKARSKIE (WARSAW, POLAND : 1960) 2022; 75:2374-2378. [PMID: 36472263 DOI: 10.36740/wlek202210110] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/17/2023]
Abstract
OBJECTIVE The aim: To assess the hormonal status of patients with weak ovarian response to stimulation with various gonadotropins. PATIENTS AND METHODS Materials and methods: The hormonal examination recommended before infertility treatment with the use of assisted reproductive techniques consisted of determining basal serum concentrations of FSH, LH, estradiol (E2), AMH, thyroid hormone, prolactin on day 3 to 5 of the spontaneous menstrual cycle. The study was carried out by radioimmune and enzyme immunoassay methods. The concentration of serum STH and growth factors, such as IGF-I and IGFBP-3, was measured on day 2 to 3 of the spontaneous menstrual cycle and on the day of transvaginal puncture of follicles (TPV). RESULTS Results: During hormonal examination, signs of restricted ovarian reserve associated with a basal FSH increase to 10-15 IU were detected in 61 patients (43.6%). Signs of ovarian reserve reduction associated with a decrease in AMH to values less than 1 ng/ml were found in 110 women (78.5%). The STH concentration in and serum on the day of TPO in the main group was significantly higher than that in the comparison group, while the IGF BP-3 concentration in the main group was significantly lower than that in the comparison group. CONCLUSION Conclusions: In patients in the main group, stimulation of superovulation with urinary gonadotropins leads to an increase in serum STH concentration, a decrease in IGFBP-activity on the day of TPO compared to day 2 to 3 of menstrual cycle, while in patients in the second group, the concentration of these indicators remains unchanged.
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Affiliation(s)
| | - Oksana O Chaika
- SHUPYK NATIONAL HEALTHCARE UNIVERSITY OF UKRAINE, KYIV, UKRAINE
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Bühler KF, Fischer R, Verpillat P, Allignol A, Guedes S, Boutmy E, Bilger W, Richter E, D'Hooghe T. Comparative effectiveness of recombinant human follicle-stimulating hormone alfa (r-hFSH-alfa) versus highly purified urinary human menopausal gonadotropin (hMG HP) in assisted reproductive technology (ART) treatments: a non-interventional study in Germany. Reprod Biol Endocrinol 2021; 19:90. [PMID: 34134695 PMCID: PMC8207759 DOI: 10.1186/s12958-021-00768-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2021] [Accepted: 05/25/2021] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND This study compared the effectiveness of recombinant human follicle-stimulating hormone alfa (r-hFSH-alfa; GONAL-f®) with urinary highly purified human menopausal gonadotropin (hMG HP; Menogon HP®), during assisted reproductive technology (ART) treatments in Germany. METHODS Data were collected from 71 German fertility centres between 01 January 2007 and 31 December 2012, for women undergoing a first stimulation cycle of ART treatment with r-hFSH-alfa or hMG HP. Primary outcomes were live birth, ongoing pregnancy and clinical pregnancy, based on cumulative data (fresh and frozen-thawed embryo transfers), analysed per patient (pP), per complete cycle (pCC) and per first complete cycle (pFC). Secondary outcomes were pregnancy loss (analysed per clinical pregnancy), cancelled cycles (analysed pCC), total drug usage per oocyte retrieved and time-to-live birth (TTLB; per calendar week and per cycle). RESULTS Twenty-eight thousand six hundred forty-one women initiated a first treatment cycle (r-hFSH-alfa: 17,725 [61.9%]; hMG HP: 10,916 [38.1%]). After adjustment for confounding variables, treatment with r-hFSH-alfa versus hMG HP was associated with a significantly higher probability of live birth (hazard ratio [HR]-pP [95% confidence interval (CI)]: 1.10 [1.04, 1.16]; HR-pCC [95% CI]: 1.13 [1.08, 1.19]; relative risk [RR]-pFC [95% CI]: 1.09 [1.05, 1.15], ongoing pregnancy (HR-pP [95% CI]: 1.10 [1.04, 1.16]; HR-pCC [95% CI]: 1.13 [1.08, 1.19]; RR-pFC [95% CI]: 1.10 [1.05, 1.15]) and clinical pregnancy (HR-pP [95% CI]: 1.10 [1.05, 1.14]; HR-pCC [95% CI]: 1.14 [1.10, 1.19]; RR-pFC [95% CI]: 1.10 [1.06, 1.14]). Women treated with r-hFSH-alfa versus hMG HP had no statistically significant difference in pregnancy loss (HR [95% CI]: 1.07 [0.98, 1.17], were less likely to have a cycle cancellation (HR [95% CI]: 0.91 [0.84, 0.99]) and had no statistically significant difference in TTLB when measured in weeks (HR [95% CI]: 1.02 [0.97, 1.07]; p = 0.548); however, r-hFSH-alfa was associated with a significantly shorter TTLB when measured in cycles versus hMG HP (HR [95% CI]: 1.07 [1.02, 1.13]; p = 0.003). There was an average of 47% less drug used per oocyte retrieved with r-hFSH-alfa versus hMG HP. CONCLUSIONS This large (> 28,000 women), real-world study demonstrated significantly higher rates of cumulative live birth, cumulative ongoing pregnancy and cumulative clinical pregnancy with r-hFSH-alfa versus hMG HP.
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Affiliation(s)
- Klaus F Bühler
- Department of Gynaecology, Jena-University Hospital-Friedrich Schiller University, 07737, Jena, Germany
- Scientific-Clinical Centre for Endometriosis of the University Hospitals of Saarland, 66121, Saarbrücken, Germany
| | - Robert Fischer
- Gynecological Endocrinology and Reproductive Medicine, Fertility Centre Hamburg, 20095, Hamburg, Germany
| | - Patrice Verpillat
- Global Epidemiology, Research and Development, Merck KGaA, Frankfurter Strasse 250, 64293, Darmstadt, Germany
| | - Arthur Allignol
- Global Epidemiology, Research and Development, Merck KGaA, Frankfurter Strasse 250, 64293, Darmstadt, Germany
| | - Sandra Guedes
- Global Epidemiology, Research and Development, Merck KGaA, Frankfurter Strasse 250, 64293, Darmstadt, Germany
| | - Emmanuelle Boutmy
- Global Epidemiology, Research and Development, Merck KGaA, Frankfurter Strasse 250, 64293, Darmstadt, Germany
| | - Wilma Bilger
- Medical Affairs Fertility, Endocrinology and General Medicine, Merck Serono GmbH, an affiliate of Merck KGaA, Darmstadt, Germany, Alsfelder Str. 17, 64289, Darmstadt, Germany
| | - Emilia Richter
- Global Medical Affairs Fertility, Research and Development, Merck KGaA, Frankfurter Strasse 250, 64293, Darmstadt, Germany
| | - Thomas D'Hooghe
- Global Medical Affairs Fertility, Research and Development, Merck KGaA, Frankfurter Strasse 250, 64293, Darmstadt, Germany.
- Department of Development and Regeneration, Laboratory of Endometrium, Endometriosis & Reproductive Medicine, KU Leuven (University of Leuven), Oude Markt 13, 3000, Leuven, Belgium.
- Department of Obstetrics, Gynecology, and Reproductive Sciences, Yale University Medical School, 333 Cedar St, New Haven, CT, 06510, USA.
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Orvieto R, Venetis CA, Fatemi HM, D’Hooghe T, Fischer R, Koloda Y, Horton M, Grynberg M, Longobardi S, Esteves SC, Sunkara SK, Li Y, Alviggi C. Optimising Follicular Development, Pituitary Suppression, Triggering and Luteal Phase Support During Assisted Reproductive Technology: A Delphi Consensus. Front Endocrinol (Lausanne) 2021; 12:675670. [PMID: 34040586 PMCID: PMC8142593 DOI: 10.3389/fendo.2021.675670] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2021] [Accepted: 04/08/2021] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND A Delphi consensus was conducted to evaluate global expert opinions on key aspects of assisted reproductive technology (ART) treatment. METHODS Ten experts plus the Scientific Coordinator discussed and amended statements plus supporting references proposed by the Scientific Coordinator. The statements were distributed via an online survey to 35 experts, who voted on their level of agreement or disagreement with each statement. Consensus was reached if the proportion of participants agreeing or disagreeing with a statement was >66%. RESULTS Eighteen statements were developed. All statements reached consensus and the most relevant are summarised here. (1) Follicular development and stimulation with gonadotropins (n = 9 statements): Recombinant human follicle stimulating hormone (r-hFSH) alone is sufficient for follicular development in normogonadotropic patients aged <35 years. Oocyte number and live birth rate are strongly correlated; there is a positive linear correlation with cumulative live birth rate. Different r-hFSH preparations have identical polypeptide chains but different glycosylation patterns, affecting the biospecific activity of r-hFSH. r-hFSH plus recombinant human LH (r-hFSH:r-hLH) demonstrates improved pregnancy rates and cost efficacy versus human menopausal gonadotropin (hMG) in patients with severe FSH and LH deficiency. (2) Pituitary suppression (n = 2 statements): Gonadotropin releasing hormone (GnRH) antagonists are associated with lower rates of any grade ovarian hyperstimulation syndrome (OHSS) and cycle cancellation versus GnRH agonists. (3) Final oocyte maturation triggering (n=4 statements): Human chorionic gonadotropin (hCG) represents the gold standard in fresh cycles. The efficacy of hCG triggering for frozen transfers in modified natural cycles is controversial compared with LH peak monitoring. Current evidence supports significantly higher pregnancy rates with hCG + GnRH agonist versus hCG alone, but further evidence is needed. GnRH agonist trigger, in GnRH antagonist protocol, is recommended for final oocyte maturation in women at risk of OHSS. (4) Luteal-phase support (n = 3 statements): Vaginal progesterone therapy represents the gold standard for luteal-phase support. CONCLUSIONS This Delphi consensus provides a real-world clinical perspective on the specific approaches during the key steps of ART treatment from a diverse group of international experts. Additional guidance from clinicians on ART strategies could complement guidelines and policies, and may help to further improve treatment outcomes.
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Affiliation(s)
- Raoul Orvieto
- Infertility and IVF Unit, Department of Obstetrics and Gynecology, Chaim Sheba Medical Center (Tel Hashomer), Ramat Gan, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- The Tarnesby-Tarnowski Chair for Family Planning and Fertility Regulation, Sackler Faculty of Medicine, Tel-Aviv University, Tel Aviv, Israel
- *Correspondence: Raoul Orvieto,
| | - Christos A. Venetis
- Centre for Big Data Research in Health & School of Women’s and Children’s Health, UNSW Medicine, University of New South Wales, Sydney, NSW, Australia
- IVF Australia, Sydney, NSW, Australia
| | - Human M. Fatemi
- Assisted Reproductive Technology (ART), Fertility Clinics, Abu Dhabi, United Arab Emirates
| | - Thomas D’Hooghe
- Global Medical Affairs, Research and Development, Merck Healthcare KGaA, Darmstadt, Germany
- Research Group Reproductive Medicine, Department of Development and Regeneration, Organ Systems, Group Biomedical Sciences, KU Leuven (University of Leuven), Leuven, Belgium
- Department of Obstetrics, Gynecology, and Reproductive Sciences, Yale School of Medicine, New Haven, CT, United States
| | | | - Yulia Koloda
- Center of Reproduction “Life Line”, Moscow, Russia
- Department of Obstetrics and Gynecology, Russian Medical Academy of Continuous Professional Education, Moscow, Russia
| | - Marcos Horton
- Pregna Medicina Reproductiva, Buenos Aires, Argentina
| | - Michael Grynberg
- Service de Médecine de la Reproduction et Préservation de la Fertilité, Hôpital Antoine Béclère, Clamart, France
| | - Salvatore Longobardi
- Global Clinical Development, Merck Serono, Italy, an Affiliate of Merck KGaA, Darmstadt, Germany
| | - Sandro C. Esteves
- ANDROFERT, Andrology and Human Reproduction Clinic, Center for Male Reproduction, Campinas, Brazil
- Faculty of Health, Aarhus University, Aarhus, Denmark
| | - Sesh K. Sunkara
- Faculty of Life Sciences and Medicine, King’s College London, London, United Kingdom
| | - Yuan Li
- Medical Center for Human Reproduction, Beijing Chao-yang Hospital, Capital Medical University, Beijing, China
| | - Carlo Alviggi
- Department of Neuroscience, Reproductive Science and Odontostomatology, University of Naples Federico II, Naples, Italy
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Kan O, Simsir C, Atabekoglu CS, Sonmezer M. The impact of adding hp-hMG in r-FSH started GnRH antagonist cycles on ART outcome. Gynecol Endocrinol 2019; 35:869-872. [PMID: 30973022 DOI: 10.1080/09513590.2019.1600667] [Citation(s) in RCA: 4] [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: 12/24/2022] Open
Abstract
While luteinizing hormone (LH) activity is believed to play a role in follicle maturation, human chorionic gonadotropin (hCG) might play an important role in implantation process. We aimed to investigate whether addition of human menopausal gonadotropin (hMG) in recombinant-follicle-stimulating hormone (r-FSH) started GnRH antagonist controlled ovarian hyperstimulation (COH) cycles might enhance implantation rate and improve in vitro fertilization (IVF) success. A total of 246 patients undergoing GnRH antagonist IVF cycles were analyzed. One hundred and twenty-three cycles (%50) were treated with only r-FSH and 123 cycles were treated with r-FSH plus hp-hMG combination. Total gonadotropin doses, total number of oocytes retrieved, metaphase 2 (MII) oocytes, top quality embryos, fertilization and implantation rates, clinical pregnancy rates (CPRs) and ovarian hyperstimulation syndrome (OHSS) rates were compared between the groups. Both groups were comparable in terms of demographic details and baseline characteristics. Peak estradiol and progesterone levels in hCG trigger day, number of retrieved oocytes and top quality embryo counts, fertilization rates were similar between the groups. In r-FSH + hp-hMG group, significantly higher implantation rates (35.3% vs 24.3%, p=.017), CPRs (51.2% vs 35.8%, p=.015) and lower OHSS rates (1.6% vs 7.4%, p = .03) were observed respectively compared to r-FSH only treated patients. In conclusion, addition of hp-hMG on the day of antagonist initiation might increase CPRs. A better endometrial receptivity associated with higher implantation rates might be achieved due to hCG component in hp-hMG.
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Affiliation(s)
- Ozgur Kan
- Department of Obstetrics and Gynecology, Faculty of Medicine, Hitit University, Corum, Turkey
| | - Coskun Simsir
- Department of Obstetrics and Gynecology, Liv Hospital, Ankara, Turkey
| | - Cem Somer Atabekoglu
- Department of Obstetrics and Gynecology, Faculty of Medicine, Ankara University, Ankara, Turkey
| | - Murat Sonmezer
- Department of Obstetrics and Gynecology, Faculty of Medicine, Ankara University, Ankara, Turkey
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Orvieto R. HMG versus recombinant FSH plus recombinant LH in ovarian stimulation for IVF: does the source of LH preparation matter? Reprod Biomed Online 2019; 39:1001-1006. [PMID: 31672439 DOI: 10.1016/j.rbmo.2019.08.010] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2019] [Revised: 08/22/2019] [Accepted: 08/30/2019] [Indexed: 12/21/2022]
Abstract
Studies on the role of LH supplementation in patients undergoing assisted reproductive technique use different sources of LH bioactivity-containing preparations, daily doses and modes of administration. This review aims to critically present the available evidence comparing the effect of the two commercially available LH preparations (human menopausal gonadotrophin [HMG] and recombinant FSH + recombinant LH) with different sources of intrinsic LH bioactivity (HCG versus LH, respectively) on ovarian stimulation characteristics and IVF cycle outcomes. A literature review was conducted for all relevant articles reporting on IVF and intracytoplasmic sperm injection treatment outcome after ovarian stimulation using HMG or recombinant FSH plus recombinant LH. The available studies are mostly observational, using different daily doses and modes of administration. No statistically significant differences were observed in ovarian stimulation variables and clinical pregnancy and live birth rates when HMG was compared with recombinant FSH + recombinant LH. Moreover, combined analysis of all the available prospective and retrospective studies produced no firm conclusions in favour of either source of LH bioactivity. Further large randomized controlled studies are needed to investigate the effect of the LH source on IVF outcome and to identify patients who are most likely to benefit from the addition of LH bioactivity supplementation.
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Affiliation(s)
- Raoul Orvieto
- Department of Obstetrics and Gynecology, Chaim Sheba Medical Center, Tel-Hashomer, Ramat Gan, Israel; Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel; The Tarnesby-Tarnowski Chair for Family Planning and Fertility Regulation, Sackler Faculty of Medicine, Tel-Aviv University, Israel.
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11
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Tayyar AT, Kahraman S. Comparison between cycles of the same patients when using recombinant luteinizing hormone + recombinant follicle stimulating hormone (rFSH), human menopausal gonadotropin + rFSH and rFSH only. Arch Med Sci 2019; 15:673-679. [PMID: 31110533 PMCID: PMC6524176 DOI: 10.5114/aoms.2017.72408] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2017] [Accepted: 12/11/2017] [Indexed: 11/17/2022] Open
Abstract
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.
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Affiliation(s)
- Ahter Tanay Tayyar
- Department of Obstetrics and Gynecology, Health Sciences University Zeynep Kamil Maternity and Children’s Research Hospital, Istanbul, Turkey
| | - Semra Kahraman
- Department of Assisted Reproductive Technologies and Reproductive Genetics, Istanbul Memorial Hospital, Istanbul, Turkey
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12
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Panić-Janković T, Mitulović G. Human chorionic gonadotrophin pharmaceutical formulations of urinary origin display high levels of contaminant proteins-A label-free quantitation proteomics study. Electrophoresis 2019; 40:1622-1629. [PMID: 30883802 PMCID: PMC6593423 DOI: 10.1002/elps.201900087] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2019] [Revised: 03/14/2019] [Accepted: 03/15/2019] [Indexed: 12/17/2022]
Abstract
To determine whether there is a measurable protein background in different formulations of urinary and recombinant human chorionic gonadotropin (hCG). Primary outcome measures: identification of contaminant proteins in urinary‐derived formulations of hCG; secondary outcome measures: quantitative values of contaminant proteins in different batches of urinary –derived hCG formulations. It was found that urinary‐derived batches have high presence of contaminant proteins beside the active substance. The relative amount of contaminant proteins and hCG differs strongly between different batches.
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Affiliation(s)
- Tanja Panić-Janković
- Clinical Department of Laboratory Medicine, Medical University of Vienna, Vienna, Austria
| | - Goran Mitulović
- Clinical Department of Laboratory Medicine, Medical University of Vienna, Vienna, Austria.,Proteomic Core Facility, Medical University of Vienna, Vienna, Austria
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Bühler KF. Commentary: Management Strategies for POSEIDON Groups 3 and 4. Front Endocrinol (Lausanne) 2019; 10:920. [PMID: 32038485 PMCID: PMC6992565 DOI: 10.3389/fendo.2019.00920] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2019] [Accepted: 12/17/2019] [Indexed: 12/03/2022] Open
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Shahrokh Tehraninejad E, Farshbaf Taghinejad M, Hossein Rashidi B, Haghollahi F. Controlled ovarian stimulation with r-FSH plus r-LH vs. HMG plus r-FSH in patients candidate for IVF/ICSI cycles: An RCT. Int J Reprod Biomed 2017. [DOI: 10.29252/ijrm.15.7.435] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022] Open
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Outcomes and Recommendations of an Indian Expert Panel for Improved Practice in Controlled Ovarian Stimulation for Assisted Reproductive Technology. Int J Reprod Med 2017; 2017:9451235. [PMID: 28246628 PMCID: PMC5299198 DOI: 10.1155/2017/9451235] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2016] [Revised: 12/08/2016] [Accepted: 12/21/2016] [Indexed: 11/17/2022] Open
Abstract
Purpose. To improve success of in vitro fertilization (IVF), assisted reproductive technology (ART) experts addressed four questions. What is optimum oocytes number leading to highest live birth rate (LBR)? Are cohort size and embryo quality correlated? Does gonadotropin type affect oocyte yield? Should “freeze-all” policy be adopted in cycles with progesterone >1.5 ng/mL on day of human chorionic gonadotropin (hCG) administration? Methods. Electronic database search included ten studies on which panel gave opinions for improving current practice in controlled ovarian stimulation for ART. Results. Strong association existed between retrieved oocytes number (RON) and LBRs. RON impacted likelihood of ovarian hyperstimulation syndrome (OHSS). Embryo euploidy decreased with age, not with cohort size. Progesterone > 1.5 ng/dL did not impair cycle outcomes in patients with high cohorts and showed disparate results on day of hCG administration. Conclusions. Ovarian stimulation should be designed to retrieve 10–15 oocytes/treatment. Accurate dosage, gonadotropin type, should be selected as per prediction markers of ovarian response. Gonadotropin-releasing hormone (GnRH) antagonist based protocols are advised to avoid OHSS. Cumulative pregnancy rate was most relevant pregnancy endpoint in ART. Cycles with serum progesterone ≥1.5 ng/dL on day of hCG administration should not adopt “freeze-all” policy. Further research is needed due to lack of data availability on progesterone threshold or index.
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Revelli A, Pettinau G, Basso G, Carosso A, Ferrero A, Dallan C, Canosa S, Gennarelli G, Guidetti D, Filippini C, Benedetto C. Controlled Ovarian Stimulation with recombinant-FSH plus recombinant-LH vs. human Menopausal Gonadotropin based on the number of retrieved oocytes: results from a routine clinical practice in a real-life population. Reprod Biol Endocrinol 2015; 13:77. [PMID: 26209525 PMCID: PMC4514947 DOI: 10.1186/s12958-015-0080-6] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
BACKGROUND The association of recombinant FSH (rFSH) plus recombinant LH (rLH) is currently used for Controlled Ovarian Stimulation (COS) in human IVF, but its efficacy has, to date, not yet been compared to that of human Menopausal Gonadotropin (hMG), the FSH + LH activity-containing urinary drug. METHODS Eight hundred forty-eight (848) IVF patients classified as expected "poor" or "normal" responders according to antral follicle count (AFC) and basal (day 3) FSH were treated with rFSH + rLH (2:1 ratio, n = 398, Group A) or hMG (n = 450, Group B). Data were collected under real-life practice circumstances and the pregnancy rate with fresh embryos was calculated by stratifying patients according to the number of retrieved oocytes (1-2, 3-4, 5-6, 7-8, >8). RESULTS Overall, the pregnancy rate in both groups progressively improved according to the number of oocytes retrieved. When comparing patients within the same subgroup of oocyte yield, Group A and B showed a comparable outcome up to the reported highest yield (>8). When more than 8 oocytes were available, Group A had a significantly better pregnancy rate outcome. Patients' characteristics did not significantly differ between the two groups and the better outcome in the best responding patients in Group A was confirmed by a multivariable logistic regression analysis, that showed that both the use of rFSH + rLH and the total number of retrieved oocytes increased the probability of pregnancy with odd ratio (OR) of 1.628 and 1.083, respectively. CONCLUSIONS When comparing patients with the same number of retrieved oocytes under real-life circumstances, the association of rFSH + rLH results in a significantly higher pregnancy rate than hMG when more than 8 oocytes are retrieved. The reason(s) for this are unknown, but a more favorable effect on oocyte quality and/or endometrial receptivity could be involved.
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Affiliation(s)
- Alberto Revelli
- Gynecology and Obstetrics, Physiopathology of Reproduction and IVF Unit, Department of Surgical Sciences, University of Torino, S. Anna Hospital, Torino, Italy.
- LIVET Infertility and IVF Clinic, Torino, Italy.
| | - Grazia Pettinau
- Gynecology and Obstetrics, Physiopathology of Reproduction and IVF Unit, Department of Surgical Sciences, University of Torino, S. Anna Hospital, Torino, Italy.
| | - Gemma Basso
- Gynecology and Obstetrics, Physiopathology of Reproduction and IVF Unit, Department of Surgical Sciences, University of Torino, S. Anna Hospital, Torino, Italy.
| | - Andrea Carosso
- Gynecology and Obstetrics, Physiopathology of Reproduction and IVF Unit, Department of Surgical Sciences, University of Torino, S. Anna Hospital, Torino, Italy.
| | - Alessandro Ferrero
- Gynecology and Obstetrics, Physiopathology of Reproduction and IVF Unit, Department of Surgical Sciences, University of Torino, S. Anna Hospital, Torino, Italy.
| | - Cecilia Dallan
- Gynecology and Obstetrics, Physiopathology of Reproduction and IVF Unit, Department of Surgical Sciences, University of Torino, S. Anna Hospital, Torino, Italy.
| | - Stefano Canosa
- Gynecology and Obstetrics, Physiopathology of Reproduction and IVF Unit, Department of Surgical Sciences, University of Torino, S. Anna Hospital, Torino, Italy.
| | - Gianluca Gennarelli
- Gynecology and Obstetrics, Physiopathology of Reproduction and IVF Unit, Department of Surgical Sciences, University of Torino, S. Anna Hospital, Torino, Italy.
- LIVET Infertility and IVF Clinic, Torino, Italy.
| | | | - Claudia Filippini
- Statistics, Department of Surgical Sciences, University of Torino, MolinetteHospital, Torino, Italy.
| | - Chiara Benedetto
- Gynecology and Obstetrics, Physiopathology of Reproduction and IVF Unit, Department of Surgical Sciences, University of Torino, S. Anna Hospital, Torino, Italy.
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Humaidan P, Schertz J, Fischer R. Efficacy and Safety of Pergoveris in Assisted Reproductive Technology--ESPART: rationale and design of a randomised controlled trial in poor ovarian responders undergoing IVF/ICSI treatment. BMJ Open 2015; 5:e008297. [PMID: 26141305 PMCID: PMC4499676 DOI: 10.1136/bmjopen-2015-008297] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2015] [Revised: 05/29/2015] [Accepted: 06/16/2015] [Indexed: 01/02/2023] Open
Abstract
INTRODUCTION The results of a recent meta-analysis showed that adding recombinant human luteinising hormone (r-hLH) to recombinant human follicle-stimulating hormone (r-hFSH) for ovarian stimulation was beneficial in poor responders, resulting in a 30% relative increase in the clinical pregnancy rate compared with r-hFSH monotherapy. However, a limitation of the meta-analysis was that the included studies used heterogeneous definitions of poor ovarian response (POR). Furthermore, the use of r-hLH supplementation during ovarian stimulation is a topic of ongoing debate, and well-designed, adequately powered, multicentre, randomised controlled trials in this setting are warranted. Therefore, the objective of the ESPART trial is to explore the possible superiority of a fixed-dose combination of r-hFSH plus r-hLH over r-hFSH monotherapy in patients with POR, as per a definition aligned with the European Society of Human Reproduction and Embryology (ESHRE) Bologna criteria. METHODS AND ANALYSIS Phase III, randomised, single-blind, parallel-group trial in women undergoing in vitro fertilisation and/or intracytoplasmic sperm injection. Approximately 946 women aged 18-<41 years from 18 countries will be randomised (1:1) to receive a fixed-dose combination of r-hFSH plus r-hLH in a 2:1 ratio (Pergoveris) or r-hFSH monotherapy (GONAL-f). The primary end point is the total number of retrieved oocytes per participant. Secondary end points include: ongoing pregnancy rate, live birth rate, implantation rate, biochemical pregnancy rate and clinical pregnancy rate. Safety end points include: incidence and severity of ovarian hyperstimulation syndrome, and of adverse events and serious adverse events. ETHICS AND DISSEMINATION The study will be performed in accordance with ethical principles that have their origin in the Declaration of Helsinki, with the International Conference on Harmonisation-Good Clinical Practice guidelines and all applicable regulatory requirements. All participants will provide written informed consent prior to entry. The results of this study will be publically disseminated. TRIAL REGISTRATION NUMBERS ClinicalTrials.gov identifier: NCT02047227; EudraCT Number: 2013-003817-16; Clinical Trial Protocol Number: EMR200061-005 V.3.0, 15 April 2014.
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Affiliation(s)
- P Humaidan
- The Fertility Clinic, Skive Regional Hospital, Skive, Denmark Faculty of Health, Aarhus University, Aarhus, Denmark
| | - J Schertz
- Fertility Global Clinical Development Unit, EMD Serono Research & Development Institute, Inc, Billerica, Massachusetts, USA
| | - R Fischer
- Fertility Center Hamburg, Hamburg, Germany
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18
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Ezcurra D, Humaidan P. A review of luteinising hormone and human chorionic gonadotropin when used in assisted reproductive technology. Reprod Biol Endocrinol 2014; 12:95. [PMID: 25280580 PMCID: PMC4287577 DOI: 10.1186/1477-7827-12-95] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2014] [Accepted: 09/20/2014] [Indexed: 12/02/2022] Open
Abstract
Gonadotropins extracted from the urine of post-menopausal women have traditionally been used to stimulate folliculogenesis in the treatment of infertility and in assisted reproductive technology (ART). Products, such as human menopausal gonadotropin (hMG), consist not only of a mixture of the hormones, follicle-stimulating hormone (FSH), luteinising hormone (LH) and human chorionic gonadotropin (hCG), but also other biologically active contaminants, such as growth factors, binding proteins and prion proteins. The actual amount of molecular LH in hMG preparations varies considerably due to the purification process, thus hCG, mimicking LH action, is added to standardise the product. However, unlike LH, hCG plays a different role during the natural human menstrual cycle. It is secreted by the embryo and placenta, and its main role is to support implantation and pregnancy. More recently, recombinant gonadotropins (r-hFSH and r-hLH) have become available for ART therapies. Recombinant LH contains only LH molecules. In the field of reproduction there has been controversy in recent years over whether r-hLH or hCG should be used for ART. This review examines the existing evidence for molecular and functional differences between LH and hCG and assesses the clinical implications of hCG-supplemented urinary therapy compared with recombinant therapies used for ART.
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Affiliation(s)
- Diego Ezcurra
- EMD/Merck Serono, One Technology Place, Rockland, MA 02370 USA
| | - Peter Humaidan
- Skive Regional Hospital and Faculty of Health, Aarhus University and Odense University, Resenvej 25, Skive, 7800 Denmark
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Papaleo E, Alviggi C, Colombo GL, Pisanelli C, Ripellino C, Longobardi S, Canonico PL. Cost-effectiveness analysis on the use of rFSH + rLH for the treatment of anovulation in hypogonadotropic hypogonadal women. Ther Clin Risk Manag 2014; 10:479-84. [PMID: 25028553 PMCID: PMC4077876 DOI: 10.2147/tcrm.s62351] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
Background Hypogonadotropic hypogonadal women are characterized by ovarian functionality deficiency, caused by low concentrations of follicle-stimulating hormone (FSH) and luteinizing hormone (LH). To recover reproduction functionality, recommended therapies for ovarian induction involve injections of FSH and LH medications. Objective Since important differences exist between recombinant and urinary gonadotropin therapies in terms of efficacy and cost, the objective of this study was to develop a cost-effectiveness model to compare recombinant FSH (rFSH) + recombinant LH (rLH) and highly purified human menopausal gonadotropin (HP-HMG). Methods A Markov model was developed, considering three cycles of therapy; probability of pregnancy and miscarriage were considered, and the efficacy was evaluated in terms of pregnancy occurrence. The perspective of the model was that of the Italian Health Service, so only direct cost (drugs, specialist visits, patient examinations, and hospitalizations) were included. Results rFSH + rLH is associated with a higher total cost (€3,453.50) and higher efficacy (0.87) compared with HP-HMG (€2,719.70 and 0.50). rFSH + rLH generated an incremental cost effectiveness ratio equal to €2,007.30 compared to HP-HMG; the average cost per pregnancy is estimated to be €3,990.00 for recombinant strategy and €5,439.80 for urinary strategy. Results of probabilistic sensitivity analysis were consistent with the abovementioned findings. Conclusion Despite the higher acquisition cost in comparison to HP-HMG, rFSH + rLH resulted in a higher pregnancy rate, which makes it the recommended choice when considering cost-effectiveness of LH in supporting FSH-induced follicular gonadotropins in hypogonadotropic hypogonadal women.
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Affiliation(s)
- Enrico Papaleo
- Centro Scienze della Natalità, Gynecological-Obstetrics Department, San Raffaele Hospital, Vita-Salute San Raffaele, Milan, Italy
| | - Carlo Alviggi
- Department of Neuroscience, Reproductive Sciences and Odontostomatology, University "Federico II" of Naples, Naples, Italy
| | - Giorgio Lorenzo Colombo
- Department of Drug Sciences, University of Pavia, Pavia, Italy ; SAVE Studi Analisi Valutazioni Economiche, Milan, Italy
| | - Claudio Pisanelli
- ACO San Filippo Neri, Rome, Italy ; Società Italiana Di Farmacia Ospedaliera, Milan, Italy
| | | | | | - Pier Luigi Canonico
- Department of Pharmaceutical Sciences, University of Piemonte Orientale, Novara, Italy
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Bühler K, Naether OGJ, Bilger W. A large, multicentre, observational, post-marketing surveillance study of the 2:1 formulation of follitropin alfa and lutropin alfa in routine clinical practice for assisted reproductive technology. Reprod Biol Endocrinol 2014; 12:6. [PMID: 24423045 PMCID: PMC3902060 DOI: 10.1186/1477-7827-12-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2013] [Accepted: 12/29/2013] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Follicle-stimulating hormone (FSH) and luteinizing hormone (LH) both have a role to play in follicular development during the natural menstrual cycle. LH supplementation during controlled ovarian stimulation (COS) for assisted reproductive technology (ART) is used for patients with hypogonadotropic hypogonadism. However, the use of exogenous LH in COS in normogonadotropic women undergoing ART is the subject of debate. The aim of this study was to investigate characteristics of infertile women who received the 2:1 formulation of follitropin alfa and lutropin alfa (indicated for stimulation of follicular development in women with severe LH and FSH deficiency) in German clinical practice. METHODS A 3-year, multicentre, open-label, observational/non-interventional, post-marketing surveillance study of women (21-45 years) undergoing ART. Primary endpoint: reason for prescribing the 2:1 formulation of follitropin alfa and lutropin alfa. Secondary variables included: COS duration/dose; oocytes retrieved; fertilization; clinical pregnancy; ovarian hyperstimulation syndrome (OHSS). RESULTS In total, 2220 cycles were assessed; at least one reason for prescribing the 2:1 formulation was given in 1834/2220 (82.6%) cycles. Most common reasons were: poor ovarian response (POR) (39.4%), low baseline LH (17.8%), and age (13.8%). COS: mean dose of the 2:1 formulation on first day, 183.1/91.5 IU; mean duration, 10.8 days. In 2173/2220 (97.9%) cycles, human chorionic gonadotrophin was administered. Oocyte pick-up (OPU) was attempted in 2108/2220 (95.0%) cycles; mean (standard deviation) 8.0 (5.4) oocytes retrieved/OPU cycle. Fertilization (≥1 oocyte fertilized) rates: in vitro fertilization (IVF), 391/439 (89.1%) cycles; intracytoplasmic sperm injection (ICSI)/IVF + ICSI, 1524/1613 (94.5%) cycles. Clinical pregnancy rate: all cycles, 25.9%; embryo transfer cycles, 31.3%. OHSS: hospitalization for OHSS, 8 (0.36%) cycles, Grade 2, 60 (2.7%), and Grade 3, 1 (0.05%). CONCLUSIONS In German routine clinical practice, the most common reasons for using the 2:1 formulation of follitropin alfa and lutropin alfa for women undergoing ART were POR, low baseline LH, and age. Severe OHSS incidence was low and similar to that reported previously.
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MESH Headings
- Adult
- Chemistry, Pharmaceutical
- Databases, Factual/trends
- Drug Therapy, Combination
- Female
- Follicle Stimulating Hormone, Human/administration & dosage
- Follicle Stimulating Hormone, Human/chemistry
- Glycoprotein Hormones, alpha Subunit/administration & dosage
- Glycoprotein Hormones, alpha Subunit/chemistry
- Humans
- Infertility, Female/drug therapy
- Infertility, Female/epidemiology
- Middle Aged
- Pregnancy
- Pregnancy Rate/trends
- Product Surveillance, Postmarketing/methods
- Product Surveillance, Postmarketing/trends
- Prospective Studies
- Recombinant Proteins/administration & dosage
- Recombinant Proteins/chemistry
- Reproductive Techniques, Assisted/trends
- Young Adult
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Affiliation(s)
- Klaus Bühler
- Centre for Gynaecology, Endocrinology and Reproductive Medicine, Ulm and Stuttgart D-70174, Germany
| | - Olaf GJ Naether
- MVZ Fertility Center Hamburg, Speersort 4, 20095, Hamburg, Germany
| | - Wilma Bilger
- Fertility, Endocrinology & General Medicine, Merck Serono GmbH, Alsfelder Str. 17, D-64289, Darmstadt, Germany
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21
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Leão RDBF, Esteves SC. Gonadotropin therapy in assisted reproduction: an evolutionary perspective from biologics to biotech. Clinics (Sao Paulo) 2014; 69:279-93. [PMID: 24714837 PMCID: PMC3971356 DOI: 10.6061/clinics/2014(04)10] [Citation(s) in RCA: 58] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2013] [Revised: 08/30/2013] [Accepted: 08/30/2013] [Indexed: 11/18/2022] Open
Abstract
Gonadotropin therapy plays an integral role in ovarian stimulation for infertility treatments. Efforts have been made over the last century to improve gonadotropin preparations. Undoubtedly, current gonadotropins have better quality and safety profiles as well as clinical efficacy than earlier ones. A major achievement has been introducing recombinant technology in the manufacturing processes for follicle-stimulating hormone, luteinizing hormone, and human chorionic gonadotropin. Recombinant gonadotropins are purer than urine-derived gonadotropins, and incorporating vial filling by mass virtually eliminated batch-to-batch variations and enabled accurate dosing. Recombinant and fill-by-mass technologies have been the driving forces for launching of prefilled pen devices for more patient-friendly ovarian stimulation. The most recent developments include the fixed combination of follitropin alfa + lutropin alfa, long-acting FSH gonadotropin, and a new family of prefilled pen injector devices for administration of recombinant gonadotropins. The next step would be the production of orally bioactive molecules with selective follicle-stimulating hormone and luteinizing hormone activity.
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Affiliation(s)
- Rogério de Barros F Leão
- Referral Center for Male Reproduction, Andrology & Human Reproduction Clinic (ANDROFERT), Campinas, SP, Brazil
| | - Sandro C Esteves
- Referral Center for Male Reproduction, Andrology & Human Reproduction Clinic (ANDROFERT), Campinas, SP, Brazil
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22
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Dahan MH, Agdi M, Shehata F, Son W, Tan SL. A comparison of outcomes from in vitro fertilization cycles stimulated with either recombinant luteinizing hormone (LH) or human chorionic gonadotropin acting as an LH analogue delivered as human menopausal gonadotropins, in subjects with good or poor ovarian reserve: a retrospective analysis. Eur J Obstet Gynecol Reprod Biol 2013; 172:70-3. [PMID: 24314801 DOI: 10.1016/j.ejogrb.2013.10.027] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2012] [Revised: 10/10/2013] [Accepted: 10/27/2013] [Indexed: 11/30/2022]
Abstract
OBJECTIVES To compare rates of pregnancy and IVF parameters in subjects who were stimulated with FSH plus recombinant human luteinizing hormone or menopausal gonadotropins. To determine whether responses to type of LH differ in poor or good responders. STUDY DESIGN Retrospective analysis at a university-based fertility center. Subjects were women with good and poor ovarian reserve, who underwent in vitro fertilization during a 2 year period, as part of a long agonist (N=122), or microdose flair (N=79) protocol. Measurements included FSH and LH dose, number of oocytes collected, number of embryos obtained, and pregnancy and clinical pregnancy rates. RESULTS Patients treated with r-hLH (n=105) had higher numbers of eggs retrieved and of embryos while using less FSH than their hMG-treated (n=96) counterparts. Pregnancy and clinical pregnancy rates were significantly higher with r-hLH than with hMG protocols (p=0.008 and 0.009, respectively). If patients had a baseline serum FSH level ≥10IU/L, clinical pregnancy rates were higher when r-hLH was used. When the antral follicle count was below 6 no significant differences in stimulation parameters or outcomes were detected between the groups. CONCLUSION r-hLH may be beneficial when compared to hMG and used for in-vitro fertilization, except in subjects with baseline follicle counts less than 6. Further data should be obtained.
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Affiliation(s)
- Michael H Dahan
- McGill Reproductive Center, McGill University, Royal Victoria Hospital, 687 Pine Ave west, Montreal, QC H3A 1A1, Canada.
| | - Mohammed Agdi
- McGill Reproductive Center, McGill University, Royal Victoria Hospital, 687 Pine Ave west, Montreal, QC H3A 1A1, Canada
| | - Fady Shehata
- McGill Reproductive Center, McGill University, Royal Victoria Hospital, 687 Pine Ave west, Montreal, QC H3A 1A1, Canada
| | - Weonyoung Son
- McGill Reproductive Center, McGill University, Royal Victoria Hospital, 687 Pine Ave west, Montreal, QC H3A 1A1, Canada
| | - Seang Lin Tan
- McGill Reproductive Center, McGill University, Royal Victoria Hospital, 687 Pine Ave west, Montreal, QC H3A 1A1, Canada
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23
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Fábregues F, Creus M, Casals G, Carmona F, Balasch J. Outcome from consecutive ICSI cycles in patients treated with recombinant human LH and those supplemented with urinary hCG-based LH activity during controlled ovarian stimulation in the long GnRH-agonist protocol. Gynecol Endocrinol 2013; 29:430-5. [PMID: 23350573 DOI: 10.3109/09513590.2012.754873] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Clinical results were compared in a well-established, assisted reproduction program during the cross-over from highly purified (HP)-human menopausal gonadotropin (hMG) to rhFSH/rhLH. We included the last 33 patients treated with HP-hMG and the first 33 patients receiving rhFSH/rhLH for ovarian stimulation in their first intracytoplasmic sperm injection cycle. Patient baseline characteristics were almost identical in the two groups. Ovarian stimulation characteristics (days of stimulation, total amount of FSH administered using a modest initial loading dose of 150 IU/d, patients with oocyte retrieval) were similar for the two groups. However, the number of total and leading follicles and E2 serum levels on the human chorionic gonadotropin injection day were significantly higher in the rhFSH/rhLH group. The oocyte yield was significantly higher in the rhFSH/rhLH group as well as the number of metaphase II oocytes, difference almost reaching the statistical significance. The number of oocytes fertilized was also higher in patients receiving rhFSH/rhLH treatment. Implantation and clinical pregnancy rates were similar in both the study groups. It is concluded that in women undergoing controlled ovarian hyperstimulation under pituitary suppression for ART, the recombinant combined product containing FSH and LH in a fixed 2:1 ratio is more effective than HP-hMG in terms of follicle development, oocyte yield and quality, and fertilization rates.
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Affiliation(s)
- Francisco Fábregues
- Faculty of Medicine, Institut Clínic of Gynecology, Obstetrics and Neonatology, Hospital Clínic - Institut d´Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), University of Barcelona, Barcelona, Spain
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24
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Carone D, Caropreso C, Vitti A, Chiappetta R. Efficacy of different gonadotropin combinations to support ovulation induction in WHO type I anovulation infertility: clinical evidences of human recombinant FSH/human recombinant LH in a 2:1 ratio and highly purified human menopausal gonadotropin stimulation protocols. J Endocrinol Invest 2012; 35:996-1002. [PMID: 23095369 DOI: 10.3275/8657] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND The World Helath Organization (WHO) Group I anovulation, or hypogonadotropic hypogonadism (HH), is characterized by reduced hypothalamic/pituitary activity which results in abnormally low serum FSH and LH levels and negligible estrogen activity. AIM To compare the efficacy of human recombinant FSH (r-hFSH) plus human recombinant LH (r-hLH) in a 2:1 ratio with highly purified human menopausal gonadotropin (hMG-HP) urinary extract, containing LH-like activity, in women with HH. SUBJECTS AND METHODS This two-arm randomized open-label study included 35 HH women (aged 25-36 yr) attending our Center. Eighteen patients received 150 IU hMG-HP (150 IU FSH + 150 IU LH-like activity) and seventeen received 150IU r-hFSH/75IU rhLH daily for a maximum of 16 days. Ovulation was induced by a single administration of hCG on the day after the last hMG-HP or r-hFSH/r-hLH. RESULTS The primary efficacy endpoint was ovulation induction as measured by follicle ≥17 mm, pre-ovulatory estradiol (E 2 ) ≥400 pmol/l and mid-luteal phase progesterone (P 4 ) ≥25 nmol/l. Secondary efficacy endpoints included E 2 levels/follicle at mid-cycle, number of follicles at mid-cycle and pregnancy rate (PR). Following a total of 70 cycles, 70% of r-hFSH/r-hLH treated patients met the primary endpoint vs 88% in hMG-HP group (p=0.11). However, PR in r-hFSH/r-hLH group was 55.6% compared to 23.3% in hMG-HP group (p=0.01). CONCLUSIONS The primary endpoint achievement did not correlate with PR. This study has shown the superiority of LH compared to hCG in supporting FSH-induced follicular development in HH women.
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Affiliation(s)
- D Carone
- Center of Reproduction and Andrology (CREA), Taranto, Italy.
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25
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Oliveira JBA, Baruffi RLR, Petersen CG, Mauri AL, Nascimento AM, Vagnini L, Ricci J, Cavagna M, Franco JG. A new ovarian response prediction index (ORPI): implications for individualised controlled ovarian stimulation. Reprod Biol Endocrinol 2012; 10:94. [PMID: 23171004 PMCID: PMC3566907 DOI: 10.1186/1477-7827-10-94] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2012] [Accepted: 11/14/2012] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The objective was to present a new ovarian response prediction index (ORPI), which was based on anti-Müllerian hormone (AMH) levels, antral follicle count (AFC) and age, and to verify whether it could be a reliable predictor of the ovarian stimulation response. METHODS A total of 101 patients enrolled in the ICSI programme were included. The ORPI values were calculated by multiplying the AMH level (ng/ml) by the number of antral follicles (2-9 mm), and the result was divided by the age (years) of the patient (ORPI=(AMH x AFC)/Patient age). RESULTS The regression analysis demonstrated significant (P<0.0001) positive correlations between the ORPI and the total number of oocytes and of MII oocytes collected. The logistic regression revealed that the ORPI values were significantly associated with the likelihood of pregnancy (odds ratio (OR): 1.86; P=0.006) and collecting greater than or equal to 4 oocytes (OR: 49.25; P<0.0001), greater than or equal to 4 MII oocytes (OR: 6.26; P<0.0001) and greater than or equal to 15 oocytes (OR: 6.10; P<0.0001). Regarding the probability of collecting greater than or equal to 4 oocytes according to the ORPI value, the ROC curve showed an area under the curve (AUC) of 0.91 and an efficacy of 88% at a cut-off of 0.2. In relation to the probability of collecting greater than or equal to 4 MII oocytes according to the ORPI value, the ROC curve had an AUC of 0.84 and an efficacy of 81% at a cut-off of 0.3. The ROC curve for the probability of collecting greater than or equal to 15 oocytes resulted in an AUC of 0.89 and an efficacy of 82% at a cut-off of 0.9. Finally, regarding the probability of pregnancy occurrence according to the ORPI value, the ROC curve showed an AUC of 0.74 and an efficacy of 62% at a cut-off of 0.3. CONCLUSIONS The ORPI exhibited an excellent ability to predict a low ovarian response and a good ability to predict a collection of greater than or equal to 4 MII oocytes, an excessive ovarian response and the occurrence of pregnancy in infertile women. The ORPI might be used to improve the cost-benefit ratio of ovarian stimulation regimens by guiding the selection of medications and by modulating the doses and regimens according to the actual needs of the patients.
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Affiliation(s)
- Joao Batista A Oliveira
- Centre for Human Reproduction Prof. Franco Junior, Preto, Ribeirao, Brazil
- Paulista Centre for Diagnosis, Research and Training, Preto, Ribeirao, Brazil
- Department of Gynaecology and Obstetrics, Botucatu Medical School, São Paulo State University, Botucatu, UNESP, Brazil
| | - Ricardo LR Baruffi
- Centre for Human Reproduction Prof. Franco Junior, Preto, Ribeirao, Brazil
- Paulista Centre for Diagnosis, Research and Training, Preto, Ribeirao, Brazil
| | - Claudia G Petersen
- Centre for Human Reproduction Prof. Franco Junior, Preto, Ribeirao, Brazil
- Paulista Centre for Diagnosis, Research and Training, Preto, Ribeirao, Brazil
- Department of Gynaecology and Obstetrics, Botucatu Medical School, São Paulo State University, Botucatu, UNESP, Brazil
| | - Ana L Mauri
- Centre for Human Reproduction Prof. Franco Junior, Preto, Ribeirao, Brazil
- Paulista Centre for Diagnosis, Research and Training, Preto, Ribeirao, Brazil
| | | | - Laura Vagnini
- Paulista Centre for Diagnosis, Research and Training, Preto, Ribeirao, Brazil
| | - Juliana Ricci
- Centre for Human Reproduction Prof. Franco Junior, Preto, Ribeirao, Brazil
| | - Mario Cavagna
- Centre for Human Reproduction Prof. Franco Junior, Preto, Ribeirao, Brazil
- Paulista Centre for Diagnosis, Research and Training, Preto, Ribeirao, Brazil
- Women’s Health Reference Centre, Perola Byington Hospital, Paulo, Sao, Brazil
| | - Jose G Franco
- Centre for Human Reproduction Prof. Franco Junior, Preto, Ribeirao, Brazil
- Paulista Centre for Diagnosis, Research and Training, Preto, Ribeirao, Brazil
- Department of Gynaecology and Obstetrics, Botucatu Medical School, São Paulo State University, Botucatu, UNESP, Brazil
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