Equivalency of human menopausal gonadotropin and follicle-stimulating hormone stimulation after gonadotropin-releasing hormone agonist suppression

Recombinant LH (lutropin alfa) for the treatment of hypogonadotrophic women with profound LH deficiency: a randomized, double-blind, placebo-controlled, proof-of-efficacy study

OBJECTIVE

To confirm the safety and efficacy of 75 IU lutropin alfa with concomitant follitropin alfa in inducing follicular development in women with profound gonadotrophin deficiency.

DESIGN

Double-blind, randomized, placebo-controlled trial conducted in 25 medical centres in four countries.

PATIENTS

Thirty-nine patients with LH < 1.2 IU/l and FSH < 5.0 IU/l were treated with concomitant 75 IU lutropin alfa and 150 IU follitropin alfa or concomitant placebo and 150 IU follitropin alfa.

MEASUREMENTS

Primary efficacy end-point (intent-to-treat): follicular development defined by (i) at least one follicle >or= 17 mm; (ii) serum E(2) level >or= 400 pmol/l on day of hCG administration (DhCG); and (iii) mid-luteal phase progesterone level >or= 25 nmol/l.

RESULTS

In the analysis of evaluable patients, 66.7% (16 of 24) of patients given lutropin alfa achieved follicular development compared with 20.0% (2 of 10) of patients receiving placebo (P = 0.023). In the intent-to-treat analysis, follicular development was achieved in 65.4% (17 of 26) of patients receiving lutropin alfa and 15.4% (2 of 13) of patients receiving placebo (P = 0.006). The statistical difference between treatment groups was preserved when over-response leading to cycle cancellation was analysed as a failed response (P = 0.034). Lutropin alfa was well tolerated.

CONCLUSION

Subcutaneous co-administration of 75 IU lutropin alfa with follitropin alfa is safe and effective in inducing follicular development in women with profound gonadotrophin deficiency.

Evidence of improving quality of reporting of randomized controlled trials in subfertility

BACKGROUND

The quality of randomized controlled trials (RCTs) in subfertility and their suitability for inclusion in meta-analyses have been assessed in the past and found to be insufficient. Our aim was to assess whether this quality has improved over time, particularly since the publication of the Consolidated Standards of Reporting Trials (CONSORT) statement, and to assess what proportion of trials could be included in the meta-analyses of pregnancy outcomes such as those included in Cochrane Reviews.

METHODS

A selection of subfertility trials published in 1990, 1996 and 2002 was collected from the Cochrane Menstrual Disorder and Subfertility Group (MDSG) database. Only trials published in English as full journal articles, claiming to be randomized and reporting on pregnancy outcomes, were included.

RESULTS

One hundred and sixty-four trials met our inclusion criteria. Twenty-four (15%) were found not to be randomized, despite claims, and only 10 trials (6%) provided adequate details on the methods of randomization and allocation concealment. Of these, only three had sufficient details extractable to allow for an intention-to-treat analysis of the outcome 'live birth'.

CONCLUSIONS

Although an improvement in some subfertility-specific issues was observed, the quality of reporting of RCTs still needs to improve to make them suitable for inclusion in meta-analyses such as those in the Cochrane Library.

Controlled ovarian hyperstimulation protocols for in vitro fertilization: two decades of experience after the birth of Elizabeth Carr

OBJECTIVE

To critically discuss the current protocols for the management of controlled ovarian hyperstimulation in assisted reproduction technology.

DESIGN

Review of the literature and presentation of our experience.

MAIN OUTCOME MEASURE(S)

Ovarian response (peak serum estrogen levels, number of oocytes retrieved, quality of oocytes and embryos) and pregnancy outcome (clinical, delivery, and multiple pregnancy rates).

RESULT(S)

Controversies still exist regarding selection of gonadotropin preparation, choice of adjuvant therapy with GnRH analogues, and use of oral contraceptive pills. Patients identified as intermediate responders have an excellent outcome with adjuvant therapy with either a GnRH agonist (long protocol) or a GnRH antagonist, but tailoring of gonadotropin dose must be performed to achieve optimized results. High responders perform favorably with gentler gonadotropin stimulation that minimizes the occurrence of ovarian hyperstimulation syndrome. On the other hand, results in low responders remain suboptimal both in terms of ovarian response and oocyte/embryo quality in spite of a variety of stimulation regimens used.

CONCLUSION(S)

Ovarian stimulation is a critical step in in vitro fertilization therapy. A variety of controlled ovarian hyperstimulation regimens are available and efficacious, but individualization of management is essential and depends on assessment of the ovarian reserve. Identification of the etiologies of poor ovarian response constitutes a formidable challenge facing reproductive endocrinologists.

Management of poor responders in IVF

Correct controlled ovarian stimulation is of paramount importance in assisted reproductive technologies. Therefore, analysis of the ovarian reserve of the patient is mandatory to tailor the best ovarian stimulation regimen. When the ovarian reserve is reduced, the induction of a multifollicular growth remains a challenge. Several factors could be associated with reduced ovarian response. However, reduced ovarian reserve either in older patients or in young patients represents the most frequent aetiological factor. Whatever is the aetiology, one of the main problems is how to predict a reduced ovarian response, and although several tests have been suggested, no very accurate predictive test is available. A variety of different stimulation protocols have been suggested but the lack of any large-scale, prospective, randomized, controlled trials of the different management strategies and the lack of a uniform definition of the population may result in comparisons of heterogeneous groups of patients, making it difficult to draw any definitive conclusions. Natural cycle IVF may represent an easy and cheap approach in the management of this group of patients. Although no controlled large prospective randomized studies are available to compare the natural IVF procedure with ovarian stimulation IVF in poor responder patients, the efficacy of natural cycle IVF is hampered by high cancellation rates mainly due to untimely LH surge. The use of gonadotrophin-releasing hormone antagonists in the late follicular phase, which reduces the premature LH rise rate, and the improvements in laboratory conditions and fertilization techniques, increase the embryo transfer rates, making this procedure more cost-effective.

Follicular phase serum levels of luteinizing hormone do not influence delivery rates in in vitro fertilization cycles down-regulated with a gonadotropin-releasing hormone agonist and stimulated with recombinant follicle-stimulating hormone

OBJECTIVE

To assess the value of serum LH measurements in early and late follicular phase as predictors of ovarian response and IVF outcome in patients treated with recombinant FSH with GnRH agonist (GnRH-a) pituitary down-regulation.

DESIGN

Retrospective cohort analysis.

SETTING

Institutional.

PATIENT(S)

Women undergoing 157 consecutive IVF cycles suppressed with leuprolide acetate (LA) started in the midluteal phase and stimulated with recombinant FSH. Only women <40 years of age and with a basal cycle day 3 serum FSH </=9 IU/L were included.

INTERVENTION(S)

Serum LH levels were measured on cycle days 3 (D3) and 10 (D10).

MAIN OUTCOME MEASURE(S)

Delivery rates. Other secondary outcome measures included fertilization rate, clinical pregnancy rate, and parameters of ovarian response (peak E(2), number of metaphase II oocytes, and number of ampules of recombinant FSH).

RESULTS

No significant differences were found with respect to ovarian response, fertilization rate, and outcome of pregnancy, when three threshold values of D3 and D10 serum LH (1, 1.5, and 2 mIU/mL) were analyzed. In addition, no significant differences were found between conception (n = 87) and no conception (n = 71) groups with respect to D3 or D10 LH. Receiver operator characteristic (ROC) analysis showed that neither the serum LH concentration on D3 nor on D10 was able to discriminate between conception and nonconception cycles (area under the curve [AUC](ROC)= 0.54, AUC(ROC)= 0.56), or between delivered pregnancies and first trimester pregnancy loss (AUC(ROC)= 0.53, AUC(ROC) = 0.61).

CONCLUSIONS

The suppressed levels of early and late follicular serum LH in women <40 years of age with normal ovarian function desensitized with a GnRH-a and treated with recombinant FSH are not predictive of ovarian response, pregnancy, or delivery. These data do not support the use of exogenous LH supplementation in this clinical scenario.

Alternative Approaches in the Management of Poor Response in Controlled Ovarian Hyperstimulation (COH)

Improving pregnancy rates in patients with many failed attempts remains a challenge during IVF-ET or ICSI-ET programs. The availability of good-quality oocytes is a prerequisite for good results in such programs. The use of a personalized protocol for controlled ovarian hyperstimulation (COH) that gives the best possible results for the specific patient is a main factor for the success in IVF or ICSI. The response of many patients to the ovarian stimulation used is very poor, giving fewer oocytes than expected, resulting in much lower, if any, pregnancy rates. The definition of a poor responder is not clear and differs among researchers. A variety of strategies have been used to improve response in these patients, regardless of the definition used. These include various ovulation induction protocols that we believe might assist these patients achieve a pregnancy. The difficulty is greater due to the fact that poor responders are not a homogeneous group and each patient may have a different cause. More studies with large numbers of patients are needed in order to find those protocols that could provide these couples with an acceptable pregnancy rate.

Induction of follicular growth and ovulation with urinary and recombinant gonadotrophins

Gonadotrophins have been used since the 1930s. By the 1990s, a pure biological extract of FSH was obtained. The increase in the demand for new assisted reproduction techniques led to the creation of recombinant FSH, 99% pure and highly consistent between batches, with no LH activity, and a high specific activity. In gonadotrophin protocols, follicular growth can be monitored with regular ultrasounds and/or hormonal testing, mainly oestradiol in the follicular phase. In assisted reproduction the adoption of ovulation induction strategies with GnRH analogues, control the endogenous secretion of LH, avoiding cancellations due to an early LH surge, and premature ovulation. Depending on the moment when pituitary suppression starts, there are short, ultra-short and long protocols The use of long protocols not only increases pregnancies and live births, it also allows an easier programming and simplifies IVF treatments. Ovarian stimulation entails some risks such as ovarian hyperstimulation syndrome and multiple pregnancies that can be avoided in many cases with an accurate prediction and an active prevention.

[Revisiting the role of LH in follicular development]

During the last decade, two pivotal events widened the gap between the hormonal dynamics of ovarian stimulation and that of the menstrual cycle. First, the profound and routine suppression of endogenous gonadotropins by GnRH analogues used in ovarian stimulation pressed us to recreate the hormonal environment necessary for adequate follicular maturation and steroidogenesis. Second, drugs with reduced or null LH activity became available, based on the hypothesis that FSH action was sufficient to follicular development and maturation irrespective of residual endogenous gonadotropin levels. Today, there is a renewed interest in the possible role of LH on follicular development, in an effort to mimic the hormonal events of the menstrual cycle to optimize ovarian stimulation outcome.

Subcutaneously administered Repronex in oligoovulatory female patients undergoing ovulation induction is as effective and well tolerated as intramuscular human menopausal gonadotropin treatment

OBJECTIVE

To determine the efficacy and safety of Repronex SC as compared with Repronex IM and Pergonal IM in patients undergoing ovulation induction.

DESIGN

Randomized, open-label, multicenter, parallel group study.

SETTING

Ten academic and private fertility clinics with expertise in ovualtion induction.

PATIENT(S)

Premenopausal anovulatory and oligoovulatory females (n = 115) undergoing ovulation induction.

INTERVENTION(S)

Down-regulation with leuprolide acetate followed by up to 12 days of treatment with gonadotropins and hCG administration and luteal phase progesterone support.

MAIN OUTCOME MEASURE(S)

Percentage of patients ovulating; percentage of cycles with follicular development meeting criteria for hCG administration; number of follicles recruited per cycle meeting hCG criteria; peak serum E(2) levels; rates of chemical, clinical and ongoing pregnancies; adverse events; injection-site pain scores.

RESULT(S)

There was no statistically significant difference in the percentage of women who ovulated among the treatment groups. However, Repronex SC was significantly more effective than Pergonal IM in producing follicular development in patients who met hCG criteria. There were no significant differences in clinical, ongoing, or continuing pregnancy rates or in multiple pregnancies among the treatment groups. No differences were found in the safety assessments, proportions or seriousness of adverse events or treatment discontinuations. Also, there were no differences between the three treatment groups in patient-recorded scores of injection-site pain or injection-site reactions.

CONCLUSION(S)

Repronex SC is as efficacious and well tolerated as Repronex IM or Pergonal IM in ovulation induction. Self-administration of Repronex SC provides a convenient treatment alternative to daily IM injections.

The role of gonadotropins in follicular development and their use in ovulation induction protocols for assisted reproduction

During the 1960s, hypogonadotropic patients with polycystic ovary syndrome and those with clomiphene citrate resistance were the first to achieve pregnancy after urinary human menopausal gonadotropin (hMG) administration plus preovulatory human chorionic gonadotropin injection, with cumulative pregnancy rates ranging from 40% to 80% after six to 12 treatment cycles. Ever since, dramatically more progress has been achieved regarding methods and medication in assisted conception techniques, involving both a rapidly increased number of subfertile couples, as well as many practitioners in obstetrics and gynecology. The purpose of this review was to highlight the most crucial historical steps of this remarkable process, by emphasizing the role of gonadotropins in ovulation induction protocols according to the various clinical categories of subfertile patients. In the late 1970s, urinary hMG was the most widely used gonadotropin for ovarian stimulation during in vitro fertilization-embryo transfer for assisted reproduction. The often concurrent problems of premature luteinizing hormone (LH) surges and premature luteinizations, and thus cancellations of the cycles, were efficiently overcome by 'reversible medical hypophysectomy', performed by gonadotropin releasing hormone (GnRH) analogs, introduced in 1982. According to its initiation and duration, GnRH analog use was divided into three protocols: the long, most widely used, protocol, which was the best for suppression of endogenous, high tonic LH levels, especially in polycystic ovary syndrome and normogonadotropic patients; and the short and ultra-short protocols, which were mainly used in poor responders to ovarian stimulation treatment, older or hypergonadotropic patients with ovarian failure, because of the well-known 'flare-up phenomenon'. Recently, GnRH antagonists, which directly do not permit GnRH action by binding to the GnRH gonadotropic cell receptors, have been used, but no final results from large, multicenter clinical trials that are still being undertaken have yet been achieved. Various sub-products of urinary hMG have been produced since the 1980s, with the intention of eliminating most or all of the LH, such as a form with a 3:1 proportion ratio between follicle stimulating hormone (FSH) and LH, as well as a form resulting in the removal of almost all of the LH, the 'pure' urinary FSH. Finally, in the mid-1990s, recombinant pure FSH was produced in vitro from hamster ovarian cell cultures. The theoretical basis for the broad use of pure urinary FSH and recombinant FSH is that the very low endogenous LH levels after pituitary desensitization are sufficient for proper theca steroidogenesis; still, data in the literature and clinical experience may be controversial upon that issue. From the clinical point of view, clinicians nowadays tend to stimulate polycystic ovary syndrome patients with recombinant FSH plus the application of GnRH analogs in a long protocol. However, in poor responders, patients in whom ovulation is resistant to clomiphene citrate, those older than 40 years or hypergonadotropic patients with ovarian failure, urinary hMG, because endogenous LH levels are obviously not sufficient for proper steroidogenesis in the theca cells of the follicles of these patients, is necessary in add to the administration of GnRH analogs in a short or ultra-short protocol. Regarding normogonadotropic women (the majority of patients), most authors agree with the long-protocol application of GnRH analogs. In these patients, it is not certain whether recombinant FSH alone is sufficient for the best possible induction or whether exogenous LH administration in the form of urinary hMG still remains necessary.

Evaluating strategies for improving ovarian response of the poor responder undergoing assisted reproductive techniques

OBJECTIVE

To assess the efficacy of various controlled ovarian hyperstimulation (COH) regimens in the prior poor-responder patient preparing for assisted reproductive techniques.

DESIGN

English-language literature review.

PATIENT(S)

Candidates for assisted reproductive techniques who had been defined as having a prior suboptimal response to standard COH regimens.

INTERVENTION(S)

A variety of regimes are reviewed, including increased gonadotropin doses, change of gonadotropins, adjunctive growth hormone (GH), luteal phase (long) GnRH agonist (GnRH-a) initiation, early follicular phase (flare) GnRH-a initiation, low-dose luteal phase (ultrashort) GnRH-a initiation, progestin pretreatment, and microdose flare GnRH-a initiation.

MAIN OUTCOME MEASURE(S)

Maximal serum E(2) levels, follicular development, dose, and duration of gonadotropin therapy, cycle cancellation rates, oocytes retrieved, embryos transferred, and clinical and ongoing pregnancy rates.

RESULT(S)

A lack of uniformity in definition of the poor responder and of prospective randomized trials make data interpretation somewhat difficult. Of the varied strategies proposed, those that seem to be more uniformly beneficial are microdose GnRH-a flare and late luteal phase initiation of a short course of low-dose GnRH-a discontinued before COH.

CONCLUSION(S)

No single regimen will benefit all poor responders. General acceptance of uniform definitions and performance of large-scale prospective randomized trials are critical. Development of a reliable precycle screen will allow effective differentiation among normal responders, poor responders, and those who will not conceive with their own oocytes.

Role of LH and FSH in ovarian function

Human gonadotrophin preparations have been used in the treatment of infertility for almost four decades. The earliest preparations were derived from urine from postmenopausal women and contained approximately equal amounts of follicle stimulating hormone (FSH) and luteinizing hormone (LH) activities. However, with the recognition that FSH is the principal regulator of follicular growth and maturation, these have been largely superseded by highly purified urinary FSH preparations and, more recently, recombinant human FSH (r-hFSH). Because of its complexity, r-hFSH is expressed in mammalian cells grown in culture and, from a manufacturing stand point, offers superior purity and batch-to-batch consistency, compared with urinary preparations. A number of clinical trials have compared the efficacy of r-hFSH and urinary FSH in women undergoing assisted reproductive technologies (ART). In general, these have shown that fewer FSH ampoules are required to achieve ovarian stimulation with r-hFSH, while the number of oocytes retrieved and embryos produced are higher than with urinary FSH. Additionally, the results of a recent meta-analysis have also shown that the clinical pregnancy rate per cycle started is significantly higher with r-hFSH, compared with urinary FSH. Furthermore, in poor responder patients, higher implantation rates were seen in patients treated with r-hFSH than in those treated with urinary FSH, suggesting that embryo viability is increased following use of the recombinant preparations. The finding that FSH preparations produce effective ovarian stimulation compared to human menopausal gonadotrophins in women undergoing ART raises the question of whether LH is required for ovarian stimulation. This has been investigated in a number of recent studies. For example, results have suggested that implantation rates may actually be lower in women who received exogenous LH. Such studies suggest, therefore, that in normogonadotrophic women, the addition of LH to an r-hFSH regimen does not add any further clinical benefit and may actually be detrimental. Hence, it appears that LH administration is necessary only in women with hypogonadotrophic hypogonadism. In conclusion, r-hFSH is a consistently pure and high quality gonadotrophin preparation and contributes to increasing the successful outcome of an ART cycle. Together with careful auditing of routine clinical practice, and the application of evidence-based medicine to facilitate clinical decision making, this means that a total quality management approach can be applied to optimize the outcome of assisted reproduction.

A randomized prospective cross-over study of highly purified follicle-stimulating hormone and human menopausal gonadotrophin for ovarian hyperstimulation in women aged 37-41 years

PURPOSE

In the present study, we investigated the benefits of highly purified FSH (H.P. FSH) in comparison with human menopausal gonadotrophin (hMG) in IVF patients aged 37-41 years.

METHODS

Twenty patients experienced within a period of four months both preparations in subsequent cycles through a prospective randomized cross-over design. A standard hormonal treatment consisting of a flare-up protocol using gonadotrophin-releasing hormone agonist (GnRHa) in combination with the same starting dose of H.P. FSH or hMG was used in all cycles.

RESULTS

Cycles stimulated with H.P. FSH resulted in a significantly higher mean number (10.3 +/- 3) of ovocytes retrieved with a significantly shorter (13 +/- 2.3 days) duration of stimulation compared to cycles treated with hMG [mean number of oocytes 7.3 +/- 5 (P < 0.01) and mean duration of stimulation 14.7 +/- 3.9 days (P < 0.02)]. No detrimental effect of basal or exogenous LH on oocyte quality was observed in our study.

CONCLUSIONS

In our experience, H.P. FSH preparations seemed to be more effective than hMG preparations for ovarian stimulation in this group of women aged 37-41 years.

Follicle-stimulating hormone or human menopausal gonadotropin for ovarian stimulation in in vitro fertilization cycles: a meta-analysis

OBJECTIVE

To reanalyze the results of using FSH alone and hMG during IVF treatment, taking into account the different protocols of administration of superactive GnRH agonist analogs.

DESIGN

Meta-analysis.

SETTING

The London Women's Clinic.

PATIENT(S)

Women undergoing IVF treatment.

INTERVENTION(S)

A meta-analysis of published randomized controlled trials from 1985 to 1999 of the use of FSH versus hMG for ovarian stimulation during IVF treatment. The common Peto odds ratio was calculated with use of a fixed effect model. The overall log odds ratio was estimated after demonstrating the consistency or homogeneity of the study results.

MAIN OUTCOME MEASURE(S)

Clinical pregnancy rate per cycle of IVF.

RESULT(S)

The results suggested that in the "long and short GnRH agonists protocol" of IVF, FSH, and hMG were equally effective in achieving ovarian stimulation, and there were no differences in the clinical pregnancy rates per cycle of IVF. However, in protocols where no pituitary desensitization was used, FSH alone was more efficacious.

CONCLUSION(S)

The optimum choice of gonadotropin preparation for ovarian stimulation during IVF treatment is influenced by the regimen of pituitary desensitization used. The optimum gonadotropin to be used when GnRH antagonists are used has yet to be determined.

Follicle-stimulating hormone and human menopausal gonadotropin for ovarian stimulation in assisted reproduction cycles

OBJECTIVES

To conduct a systematic overview of available data comparing FSH and hMG in IVF treatment cycles.

SEARCH STRATEGY

This review has drawn on the search strategy developed for the Subfertility Group as a whole. Relevant trials were identified in the Group's Specialised Register of Controlled Trials. See Review Group details for more information.

DATA COLLECTION AND ANALYSIS

A systematic review and meta-analysis of randomized trials of FSH versus hMG use in ovarian stimulation protocols, with or without GnRH agonists, in IVF treatment cycles. Common odds ratios (OR) were calculated after demonstrating homogeneity of treatment effect across all trials.

MAIN RESULTS

MAIN OUTCOME MEASURES

Clinical pregnancy rates per cycle started, per cycle reaching oocyte retrieval, and per cycle reaching embryo transfer (ET).

RESULTS

Eight trials met the inclusion criteria. The overall OR in favour of FSH for cycle start, oocyte retrieval, and ET were 1.70 (95% CI, 1.11-2.60), 1.68 (95% CI, 1.10-2.56), and 1.69 (95% CI, 1.10-2.59), respectively.

REVIEWER'S CONCLUSIONS

This meta-analysis demonstrates that in IVF cycles the use of FSH is associated with a significantly higher clinical pregnancy rate than hMG.

A prospective, randomized comparison of ovulation induction using highly purified follicle-stimulating hormone alone and with recombinant human luteinizing hormone in in-vitro fertilization

The commercial availability of highly purified, s.c. administered urinary follicle stimulating hormone (FSH) preparations for ovarian stimulation marked the beginning of a new era in the treatment of infertility. As these new formulations contain essentially no luteinizing hormone (LH), supplemental LH may be needed for optimal folliculogenesis. It was the aim of this pilot study to compare fertilization rates, embryo morphology, implantation rates and pregnancy outcomes prospectively in two age-matched patient groups: women who received highly purified FSH (FSH-HP) (n = 17), and women who received FSH-HP plus recombinant human LH (rhLH, n = 14) throughout ovarian stimulation. All patients received mid-luteal pituitary down-regulation with s.c. gonadotrophin-releasing hormone agonist (GnRHa) (leuprolide). Mean implantation rates were 26.9 and 11.9% in the FSH-HP only and FSH-HP + rhLH groups respectively. The mean clinical pregnancy/initiated cycle rate was 64.7 and 35.7% for the FSH-HP only and FSH-HP + rhLH patients respectively. FSH-HP patients and FSH-HP + rhLH patients achieved clinical pregnancy/transfer rates of 68.8 and 45.5% respectively. One patient in the FSH-HP + rhLH group had a spontaneous abortion; no pregnancy losses occurred in the FSH-HP only group. There were more cancellations for poor ovarian response among FSH-HP + rhLH patients (n = 3) than among FSH-HP patients (n = 1). The trend toward better pregnancy outcomes among patients who received FSH-HP without supplemental rhLH did not reach statistical significance. It is postulated that appropriate endogenous LH concentrations exist despite luteal GnRHa pituitary suppression, thereby obviating the need for supplemental LH administration.

The role of luteinizing hormone in folliculogenesis and ovulation induction

OBJECTIVE

To review the physiologic, pathophysiologic, and clinical roles of LH in follicle and oocyte development and maturation and to assess the effects of LH content in exogenous gonadotropin preparations used for ovulation induction.

DESIGN

Critical review of the scientific literature devoted to folliculogenesis. Evaluation of comparison studies that used different gonadotropin preparations for ovulation induction.

CONCLUSION(S)

Folliculogenesis and oocyte maturation are complex processes that require the action of both LH and FSH. Luteinizing hormone is essential to provide the androgen substrate for estrogen synthesis, which in turn contributes to oocyte maturation and may play a relevant role in optimizing fertilization and embryo quality. Although the excessive LH secretion that is present in some disorders is detrimental to reproductive function, this is not applicable to ovulation induction with hMG because this menotropin does not increase daily plasma LH levels. The results of ovulation induction with hMG or FSH-only regimens did not differ in studies conducted in patients with polycystic ovary syndrome and in most studies conducted in ovulatory women undergoing assisted reproductive techniques; conversely, hMG was clearly superior to purified FSH for the treatment of hypogonadotropic hypogonadism. Miscarriage rates were not affected by the use of hMG. Thus, low but detectable LH concentrations positively influence the outcome of ovulation induction in patients with ovulatory disorders and women undergoing assisted reproductive techniques.

Efficacy assessment of highly purified follicle-stimulating hormone alone or in combination with human menopausal gonadotropin during pituitary suppression in patients undergoing GIFT for unexplained infertility

The purpose of this study was to compare the efficacy of highly purified follicle-stimulating hormone (FSH-HP) alone versus the combination of FSH-HP + human menopausal gonadotropin (hMG) treatment during pituitary suppression with gonadotropin-releasing hormone (GnRH) analog on the clinical outcome and endocrine parameters in 120 randomized women undergoing gamete intra-Fallopian transfer (GIFT) for unexplained infertility. Our data did not show any significant difference between the two groups as regards dose of administered gonadotropins, duration of treatment, estradiol 17 beta 17 beta increase curves, number of follicles > 16 mm, number of recruited and transferred oocytes, and endometrial thickness. The percentages of clinical pregnancies (33.3% with FSH-HP and 31.6% with FSH-HP + hMG), of miscarriages and twin gestations were also similar in the two groups. It is concluded that, during GnRH analog suppression, FSH-HP treatment alone is effective in inducing normal follicular steroidogenesis and adequate oocyte maturation, but no detrimental effect of luteinizing hormone (LH) activity of hMG on the outcome of the outcome of ovarian stimulation was found.

Characteristics of consecutive in vitro fertilization cycles among patients treated with follicle-stimulating hormone (FSH) and human menopausal gonadotropin versus FSH alone

OBJECTIVE

To compare the endocrine responses of patients who first received hMG plus FSH, then were treated in a subsequent cycle with FSH alone.

DESIGN

Retrospective study.

SETTING

An academic research environment.

PATIENT(S)

Ninety-six women with pituitary down-regulation who underwent two sequential IVF treatments, the first with combined hMG and FSH and the second with FSH alone.

MAIN OUTCOME MEASURE(S)

Duration of stimulation, serum estradiol level on the day of hCG administration, amount of gonadotropin used, number of oocytes retrieved, number of oocytes fertilized, and selected preembryo morphologic features.

RESULT(S)

No difference in the mean duration of stimulation was observed between the treatment cycles among patients who received hMG and FSH (11.9 days) followed by FSH alone (11.7 days). The mean number of oocytes retrieved, the mean number of oocytes fertilized, the percentage of preembryo fragmentation, and the preembryo cell number at transfer did not differ significantly between the stimulation protocols. The cumulative amount of gonadotropin used during stimulation was slightly greater in the cycles stimulated with FSH alone, but this difference was not significant (29.4 ampules of hMG plus FSH versus 31.8 ampules of FSH alone). Serum estradiol levels measured on the day of hCG administration during stimulation with hMG and FSH (1,382 pg/mL) were higher than those measured during stimulation with FSH alone (1,149 pg/mL).

CONCLUSION(S)

Follicular response and preembryo quality were not significantly different when patients were treated first with hMG and FSH and then with FSH alone in a subsequent cycle. Similarities in ovarian response and preembryo characteristics, as well as differences in estradiol patterns seen in each stimulation setting, should be anticipated when patients receive these protocols.

Cessation of gonadotropin-releasing hormone agonist therapy combined with high-dose gonadotropin stimulation yields favorable pregnancy results in low responders

OBJECTIVE

To evaluate the pregnancy results of an ovarian hyperstimulation protocol for IVF-ET that combines GnRH agonist down-regulation, cessation of GnRH agonist therapy with the onset of menstruation, and high-dose gonadotropin administration in low responders.

DESIGN

Prospective analysis.

SETTING

Academic IVF program.

PATIENT(S)

One hundred eighty-two low responders undergoing 224 IVF-ET cycles.

INTERVENTION(S)

Down-regulation was obtained with the administration of leuprolide acetate beginning in the midluteal phase and ending with the onset of menses. Daily administration of 6 ampules of FSH alone or in combination with hMG was initiated on cycle day 3.

MAIN OUTCOME MEASURE(S)

Stimulation characteristics and pregnancy rates (PRs) were compared between fresh cycles in which pure FSH alone was used and 35 cycles in which a combination of FSH and hMG was administered.

RESULT(S)

The clinical PR per transfer, the ongoing PR per transfer, and the implantation rate were 32%, 24%, and 9%, respectively. No differences were noted between cycles in which pure FSH alone was used in comparison with cycles in which a combination of FSH and hMG was administered.

CONCLUSION(S)

Short-term ovarian suppression begun in the luteal phase and discontinued with the onset of menses followed by high-dose stimulation with gonadotropins yields favorable pregnancy results in low responders.

Implications of using follicle-stimulating hormone preparations depleted of luteinizing hormone to achieve follicular growth in in vitro fertilization

We aimed to compare the outcome of in vitro fertilization (IVF) treatment using follicle-stimulating hormone (FSH) containing gonadotropins with human menopausal gonadotropin (hMG) containing gonadotropins for ovarian stimulation. A retrospective analysis of 82 patients undergoing IVF in a private fertility clinic was performed over a specific period of time. Eighteen women received hMG, 20 received Normegon and 44 received FSH. In addition, 17 of these patients received hMG in one cycle and FSH in the other. The main outcome measures studied were duration of treatment, dose of gonadotropins required to achieve optimum follicular growth, number and size of follicles, endometrial thickness, serum estradiol concentrations, number of oocytes retrieved, pregnancy rates and the incidence of ovarian hyperstimulation syndrome (OHSS). At the time of administration of human chorionic gonadotropin (hCG), the mean (+/- SD) serum estradiol concentrations in patients treated with preparations containing FSH and luteinizing hormone (LH) in a ratio of 1:1 was 10,044.3 +/- 5378.8 pmol/l compared with 6819.5 +/- 2597.9 pmol/l in patients treated with preparations with FSH and LH in a ratio of 3:1 and 7369 +/- 4300 pmol/l in patients treated with FSH. The differences between the first and the second two groups were significant (p < 0.05). Endometrial thickness in the three groups of patients were 11 +/- 1.7 mm, 11 +/- 1.5 mm and 9.7 +/- 1.5 mm, respectively (p < 0.001). Comparing cycles of treatment with hMG and FSH in the same patient, we found significantly higher estradiol levels, thicker endometrium, more developing follicles and a shorter duration of treatment in the hMG-treated cycles compared with those in FSH-treated cycles. However, there were no differences between the incidence of OHSS or the pregnancy rates between the three treatment groups. With the advent of recombinant human FSH and the shortage of LH-containing preparations, it is important to note that serum estradiol concentrations on the day of administration of hCG underrepresent the degree of follicular maturation. In the context of the use of a 'long' protocol of gonadotropin-releasing hormone (GnRH) analog therapy and LH-depleted gonadotropin preparations, serum estradiol is no longer a reliable marker of follicle development.

Significance of an abnormal response during pituitary desensitization in an in vitro fertilization and embryo transfer program

PURPOSE

Our purpose was to evaluate the IVF-ET outcome in patients who did not achieve timely pituitary-ovarian suppression following "long"-protocol GnRH agonist (GnRH-a) administration.

METHODS

A retrospective analysis was done on 96 IVF treatment cycles characterized by a delayed response (DR) to long-protocol GnRH-a treatment. The study included those patients who either achieved ovarian suppression (E2 < or = 110 pM) despite an elevated LH level (group DR-A) or had pituitary desensitization (LH < or = 1.5 IU/L) without ovarian suppression (group DR-B) on day 12 of GnRH-a treatment but needed an extended course of GnRH-a treatment to achieve complete suppression. These patients had gonadotropin stimulation either from day 12, despite an elevated level of LH (subgroup DR-A1; n = 13) or elevated E2 levels (subgroup DR-B1; n = 9), or after achieving a complete hypogonadotropic-hypopgonadal state following an extended course of GnRH-a treatment [subgroups DR-A2 (n = 46) and DR-B2 (n = 28)]. The outcome was compared with that of 88 cycles of normal responders (group NR) who had pituitary-ovarian suppression by day 12 day GnRH-a administration.

RESULTS

Ovarian response and pregnancy rates in subgroups DR-A1 and DR-A2 were statistically not different and comparable to those in the NR group. In subgroups DR-B1 and DR-B2, E2 response and rates of oocyte retrieval and pregnancy were significantly lower than those in the other groups, but fertilization and cleavage rates were similar. The requirement of gonadotropin for ovarian stimulation was comparatively higher in subgroup DR-A2 and both DR-B subgroups.

CONCLUSIONS

There was no treatment cancellation in group NR and both DR-A subgroups, but 22% of the cycles in DR-B1 and 14% of the cycles in DR-B2 were canceled due to poor ovarian response. It therefore appears that during long-protocol pituitary desensitization, the post-GnRH-a level of serum E2, rather than LH, better predicts IVF-ET outcome.

Use of follicle-stimulating hormone alone (urofollitropin) to stimulate the ovaries for assisted conception after pituitary desensitization

OBJECTIVE

Analyse outcome of FSH therapy alone after pituitary desensitization for assisted conception to compare with published results of conventional hMG.

DESIGN

Descriptive study of complete series of patients undergoing IVF-ET or GIFT treatment using the chosen drug protocol without exception.

SETTING

University private IVF-ET clinic within a comprehensive fertility service.

PATIENTS

All couples (n = 773), including 10% > or = 40 years old, treated by IVF-ET or GIFT (1,097 cycles started and 1,012 attempted egg recoveries) for mainly tubal pelvic infective damage (36% of cycles), endometriosis (16%), sperm disorders (14%) and prolonged unexplained infertility (34%) during 3 calendar years, 1990 to 1992.

INTERVENTIONS

Ovarian stimulation using FSH alone (urofollitropin, Metrodin; Serono Laboratories Limited, Welwyn Garden City, United Kingdom) after pituitary desensitization using buserelin acetate nasal spray (Suprefact; Hoechst, Hounslow, United Kingdom) from the previous midluteal phase, monitored by ultrasonography and serum E2 measurements, followed by standard IVF-ET or GIFT treatment methods limited to the transfer of no more than three embryos or eggs.

OUTCOME MEASURES

Rates per cycle started of cancellation of egg recovery, failure of egg recovery, clinical pregnancy (ultrasound detection of sac), livebirths, and cumulative pregnancy rates (PR) and birth rates.

RESULTS

In women < 40 years old and men with favorable sperm (77% of couples and 84% of cycles) the cycle cancellation rate of egg recovery was 7%; attempted egg recovery was successful in every case. For IVF-ET the clinical PR per started cycle and the livebirth rate were 27% and 23%, respectively, and for GIFT 39% and 33%, respectively. The four-cycle cumulative PR by either treatment was 77% and livebirth rate 68%. In women > 40 years old, the cycle PR and birth rate were 14% and 8%, respectively. In cases of sperm disorder the rates in women < 40 years old were 17% and 14%, respectively, and > 40 years old were 18% and 0, respectively.

CONCLUSIONS

By comparison with the best worldwide results of assisted conception employing pituitary desensitization, the findings demonstrate that FSH alone to stimulate the ovaries is fully effective and highly successful, and supplementation with LH is not needed.

Infertility treatment: from cookery to science. The epidemiology of randomised controlled trials

OBJECTIVES

To review the epidemiology of published randomised controlled trials in infertility treatment over the last 25 years, with special emphasis on the number and quality of trials.

DESIGN

Computer literature review by MEDLINE backed up by a manual search of 41 journals. Each trial was classified according to the methodology described and quality criteria. The results were recorded in a computer database. Odds ratios (OR) and confidence intervals (CI) were calculated where the data were sufficient.

SUBJECTS

Couples suffering from primary or secondary infertility. The trials studied 33,761 patients overall.

SETTING

Institute of Epidemiology and Health Services Research, Leeds.

RESULTS

Five hundred and one randomised trials in male and female infertility treatment were identified between 1966 and 1990. Pregnancy was an outcome in 291 (58%) and these were the subject of detailed analysis. Two hundred and twenty-four (77%) and 67 (23%) 'pregnancy trials' were concerned, respectively, with female and male infertility. Four per cent of the trials were preceded by a sample size calculation, and the average sample size was 96 patients (range 5-933); 700 patients per group would be required to demonstrate plausible success rates for most treatments. The method of randomisation was unstated or pseudo-randomised in 206 (71%) of trials where pregnancy was an outcome. Only 29 (5.8%) of studies were multicentre. The method of confirmation of pregnancy was omitted for 70% of papers. Cross-over design was used in 103 (21%) of cases. Meta-analysis is possible for selected topics such as the use of anti-oestrogens in idiopathic oligospermia and unexplained female infertility. Eight cases of double reporting were identified.

CONCLUSIONS

Trials using randomised methodology were relatively few in comparison with other branches of medicine, although their use is important in the evaluation of treatment for infertility as treatment-independent pregnancy is common. It was encouraging to note that an exponential increase in the use of this methodology occurred during the last three years, especially in association with assisted conception techniques, and meta-analysis has become possible for selected topics. However, many trials suffer from an unrealistically small sample size, inappropriate use of cross-over design or pseudo-randomisation. The trend towards properly controlled studies should be encouraged but these studies should be of improved quality and organised on a multicentre or even international basis.

The differential effects of FSH and LH on the human ovary

The basic foundation for normal puberty and adult reproductive function is established during fetal life with the adequate development of the hypothalamus, pituitary and gonads. Further maturation and differentiation of the hypothalamic-pituitary-gonadal axis continues throughout childhood, puberty, adult life and senescence. Pituitary FSH and LH play a central role in the cascade of events in the hypothalamic-pituitary-gonadal axis by mediating between the brain and hypothalamus on one hand and the end-organ, the ovary, on the other. Absent or low pituitary secretion of FSH and LH, as occurs in hypothalamic/pituitary hypogonadism, leads in women to anovulation, amenorrhoea and absent ovarian follicular development. The ability of gonadotrophins to modulate ovarian function depends on their rate of synthesis by the pituitary gonadotrophs, on their circulating concentrations (which vary throughout life and throughout the menstrual cycle), on the relative abundance of the multiple forms of gonadotrophins that have varying biological activity, on the presence of their receptors on the different cell types of the ovary, on the intracellular adenylate cyclase enzyme that causes the production of cAMP, and on the extra- and intragonadal factors that are able to modulate the effects of gonadotrophins in the ovary. Recent clinical and basic research with recombinant gonadotrophins, molecular biological studies on the localization, function and regulation of the long sought after gonadotrophin receptors, as well as research on the interaction between gonadotrophins and local intragonadal factors have widened our knowledge about the function and role of FSH and LH in the ovary and have provided new insights into previously unanswered questions of ovarian physiology and pathophysiology and will provide the basis for the design of new treatment strategies to overcome ovulatory gonadotrophin-dependent dysfunction in the future.

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

OBJECTIVES

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

DESIGN

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

RESULTS

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

CONCLUSIONS

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

Progesterone levels on the day of human chorionic gonadotropin administration in cycles with gonadotropin-releasing hormone agonist suppression are not predictive of pregnancy outcome

In in vitro fertilization (IVF) cycles using gonadotropin-releasing hormone agonist (GnRH-a) suppression, we investigated whether an elevated progesterone (P) level on the day of human chorionic gonadotropin (hCG) administration indicates premature luteinization and is associated with a lower pregnancy rate. We retrospectively studied 101 patients treated with the GnRH-a leuprolide acetate, begun in the luteal phase of the prior menstrual cycle and continued until the day of hCG administration. On the day of hCG, 72 patients had P less than 0.9 ng/mL and 29 had less than or equal to 0.9 ng/mL. Patients in the high P group had a significantly greater estradiol level on the day of hCG. No significant difference in clinical pregnancy rates or ongoing pregnancy rates occurred between the low P and high P groups. We conclude that in IVF cycles pretreated with GnRH-a, P levels on the day of hCG are not predictive of conceiving in that cycle.