Ovulation induction with urinary follicle stimulating hormone versus human menopausal gonadotropin for clomiphene-resistant polycystic ovary syndrome

Sequential clomiphene citrate/hMG versus hMG for ovulation induction in clomiphene citrate-resistant women

OBJECTIVE

This study was designed to compare sequential clomiphene citrate/hMG regimen to hMG regimen for ovulation induction in clomiphene citrate-resistant women.

STUDY DESIGN

A comparative prospective study.

PATIENTS AND METHODS

Ninety infertile women were randomized to receive either sequential CC/hMG regimen (45 women) or low-dose step-up protocol of hMG (45 women). All participants had received at least six consecutive cycles of clomiphene citrate for ovulation induction within the last year before inclusion in this study, but they did not conceive. The CC/hMG regimen group received clomiphene citrate 100 mg/day for 5 days, followed by hMG 75 IU for 4 days. The hMG group received low-dose step-up protocol for 10-14 days. To detect the number and size of the follicles, TVS was done on cycle day 8 and repeated daily or every other day according to follicular development. When one to three follicles reached a diameter ≥18 mm, hCG injection was scheduled. Before hCG injection, the E2 level and endometrial thickness were evaluated. β-hCG levels were measured on cycle day 22.

RESULTS

There was no significant difference between the two studied groups regarding the demographic data, sperm parameters, and day 3 FSH, LH and estradiol. Also, there was no significant difference between the two studied groups regarding endometrial thickness, number of mature follicles, peak of E2 before hCG injection and number of cases that developed ovarian cyst or OHSS. The dose of gonadotropins used was significantly low in the CC/hMG group compared to the hMG group (295.2 ± 75.5 vs. 625.3 ± 65.0, respectively), and the pregnancy rate was significantly high in the CC/hMG group compared to the hMG group [12 (26.7 %) vs. 3 (6.7 %), respectively, p < 0.05].

CONCLUSION

The sequential CC/hMG regimen is as effective as hMG regimen for ovulation induction, produces satisfactory pregnancy results and reduces the treatment cost.

The role of luteinizing hormone activity in controlled ovarian stimulation

The role of LH in the natural menstrual cycle is undisputed. The active participation of LH in both steroidogenesis and ovulation is well established, but its potential effect on oocyte maturation in the issue of assisted reproduction protocols remains a topic of debate. Although several studies have added to our understanding of the specific actions of androgens in human follicular development, some discrepancies persist regarding their role in oocyte atresia. Clinical situations, where LH is either decreased or absent (e.g. in women with hypogonadotrophic hypogonadism or LH-receptor gene mutations), provide important data supporting the necessity for a minimal amount of LH to evoke ovulation. Recent use of GnRH antagonists, which results in profound suppression of LH concentration, in combination with the pharmacological production of recombinant gonadotrophins, has attracted the attention of investigators. Identification of sub-fertilized women, in whom LH administration could be beneficial and should be indicated, is arousing ever more interest. Based on the available data in the literature, the aims of this review are to assess the role of both endogenous and exogenous LH activity in stimulated cycles, and to evaluate the effects of recombinant human LH supplementation on the ovarian hormonal milieu and on the main outcomes of controlled stimulated cycles.

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.

A prospective, open, randomized clinical study to assess the efficacy and safety of two gonadotropin preparations administered in WHO Group II anovulatory subfertile women

OBJECTIVE

To assess the efficacy and safety of 2 gonadotropin preparations in inducing ovulation in clomiphene-resistant WHO Group II anovulatory subfertile women.

METHODS

Twenty-patients were randomized to receive either Metrodin intramuscularly or Metrodin HP subcutaneously and underwent 45 treatment cycles. A maximum of 3 cycles were offered unless conception or severe adverse reaction occurred. The presence of redness, swelling, bruising and pain of the injection sites was noted and compared.

RESULTS

Seven patients became pregnant (3 in the Metrodin group and 4 in the Metrodin HP group) and the pregnancy rates per patient and per cycle were 7/20 (35%) and 7/45 (15.6%), respectively. No local reactions were found in the majority of cycles. There was no significant difference in pregnancy rates and the number of cycles complicated by bruise, pain, itching, redness or swelling between these 2 groups.

CONCLUSIONS

This clinical study shows that in WHO Group II anovulatory patients Metrodin HP administered subcutaneously by self-injection is as safe and effective as Metrodin administered intramuscularly in inducing ovulation.