A controlled study of gonadotropin-releasing hormone agonist (buserelin acetate) for folliculogenesis in routine in vitro fertilization patients

Relationship between serum human chorionic gonadotrophin levels and body mass index in women undergoing in vitro fertilisation cycles

OBJECTIVE

To ascertain if serum concentrations following injection of human chorionic gonadotropin (hCG) influenced the outcome of in vitro fertilisation (IVF) treatment and correlated to body mass index (BMI).

STUDY DESIGN

A prospective study conducted with the participation of 149 women undergoing IVF and/or intracytoplasmic sperm injection (ICSI) treatment at the regional IVF Unit in Liverpool, UK. The BMI of each individual was calculated and serum hCG concentrations were measured at 12 and 36 h following a subcutaneously (SC) injection of 5000 IU hCG. The main outcome measures were fertilisation rate and biochemical pregnancy rate.

RESULTS

No correlation was found between serum hCG levels at 12 and 36 h with the number of oocytes retrieved or the number of oocytes fertilised. Furthermore, there was no correlation between BMI and hCG levels at 12 and 36 h following administration (Pearson's correlation coefficient: -0.23, -0.24, respectively).

CONCLUSION

Our results suggest that the serum concentrations of hCG do not influence IVF outcome and that the serum levels of hCG achieved following administration do not correlate with the individual's BMI. Serum hCG concentration also does not correlate with number of oocytes collected or fertilisation rate.

Effects of Gonadotrophin-Releasing Hormone Agonists on Apoptosis of Granulosa Cells

Granulosa cells are known to contribute to maturation of oocytes, and most of the growth factors exert their action via granulosa cells. It has been established that granulosa cell death during follicular atresia and luteolysis results from apoptosis. However, the precise mechanistic pathways of granulosa cell apoptosis have not yet been defined. In this study, we determined the proportions of apoptosis in granulosa cells treated with two kinds of gonadotrophin-releasing hormone agonists (GnRHa): buserelin and leuprorelin depot. The incidences of DNA fragmentation of human granulosa cells treated with buserelin and leuprorelin were 54.33% and 39.02%, respectively. The proportions of apoptotic bodies were 6.04% and 4.29%, respectively. There was a significant difference in the proportions of DNA fragmentation between the two kinds of GnRHa-treated granulosa cells. The apoptosis pathway and associated protein expression in granulosa cells treated with GnRHa were also determined. The Bax molecule, a pro-apoptosis protein, was expressed in granulosa cells undergoing apoptosis. In contrast, Bcl-2, an anti-apoptosis protein, could not be detected in the same group of granulosa cells. The distribution of cytochrome c determined via immunostaining showed a diffuse pattern, which most likely indicated that cytochrome c was translocated from mitochondria into the cytoplasm. Western blotting showed the expressions of caspase-9 and caspase-3 in patients' granulosa cells. The GnRHa effects on granulosa cells indicated a higher incidence of DNA fragmentation and apoptotic bodies in the buserelin-treated than in the leuprorelin depot-treated group. The granulosa cells go through the mitochondria-dependent apoptosis pathway; the indicated pro-apoptosis protein Bax was expressed and induced cytochrome c release from mitochondria, which then activated caspase-9 and caspase-3 until cell death occurred.

GnRH agonist action on granulosa cells at varying follicular stages

In the present review, we attempt to summarize our recent research related to comparative effects of gonadotropin-releasing hormone (GnRH) agonist on the proliferation, apoptosis and differentiated function of cultured porcine granulosa cells from varying follicular stages. The inhibitory effect of GnRH agonist on Proliferating cell nuclear antigen positive rate of cultured cells was prominent in granulosa cells from small and medium but not from large follicles. By contrast, the inhibitory effect of GnRH agonist on 17beta-estradiol and progesterone secretion by cultured cells was prominent in granulosa cells from large but not from small and medium follicles. The stimulatory effect of GnRH agonist on apoptosis positive rate of cultured cells was, however, uniform regardless of the stages of follicular growth. These results demonstrate that GnRH agonist exerts diverse actions on granulosa cells over the course of follicular growth. One downregulates granulosa cell proliferation in immature follicles as well as steroidogenesis in mature follicles, and the other upregulates apoptosis of granulosa cells regardless of the stages of follicular growth.

Oral versus injectable ovulation induction agents for unexplained subfertility

BACKGROUND

Oral (anti-oestrogens) and injectable (gonadotrophins) ovulation induction agents have been used to increase the number of eggs produced by a woman per cycle in treatment for unexplained subfertility. It is unclear whether there are significant advantages of one type of treatment over the other in this context or in terms of fertility.

OBJECTIVES

To assess the efficacy of oral versus injectable ovulation induction agents for unexplained subfertility.

SEARCH STRATEGY

The search strategy of the Menstrual Disorders and Subfertility Group was used for the identification of relevant randomised controlled trials.

SELECTION CRITERIA

All trials where oral ovulation induction agents were compared with injectable ovulation induction agents in treatment groups generated by randomisation, from couples with unexplained subfertility, were considered for inclusion in the review.

DATA COLLECTION AND ANALYSIS

Five randomised controlled trials, including a total of 231 identified couples with unexplained subfertility, were found and included in this review. All trials were assessed for quality criteria. The studied outcomes were pregnancy, live birth, miscarriage, multiple birth, occurrence of ovarian hyperstimulation syndrome and cycle cancellation.

MAIN RESULTS

Where trials with important co-interventions were excluded, there was no significant difference in the odds of beneficial outcomes for oral versus injectable ovulation induction agents - live birth per couple (OR 0.06, 95%CI 0.00-1.15), pregnancy per woman (OR 0.33, 95%CI 0.09-1.20); nor of detrimental outcomes for injectable versus oral agents - miscarriage (OR 0.11, 95%CI 0.00-2.84); there were no reported cases of multiple births, cases of ovarian hyperstimulation or discontinued cycles consequent upon overstimulation. Where trials with the co-intervention of a human chorionic gonadotrophin trigger injection (given only in the injectable ovulation induction agent treatment arm) were not excluded there was no significant difference in the odds of live birth per couple (OR 0.40, 95%CI 0.15-1.08). However oral ovulation induction agents had significantly reduced odds of pregnancy per woman compared to injectable ovulation induction agents (OR 0.41, 95%CI 0.17-0.80). For detrimental outcomes, there were no significant differences in the odds of miscarriage (OR 0.61, 95%CI 0.09-4.01) and multiple birth (OR 1.08, 95%CI 0.16-7.03) for injectable versus oral agents. No data were available concerning the occurrence of ovarian hyperstimulation syndrome nor cycle cancellation.

REVIEWER'S CONCLUSIONS

There is insufficient evidence to suggest that oral agents are inferior or superior to injectable agents in the treatment of unexplained subfertility. Information on harms is sketchy, and remains compatible with large differences in either direction. Much larger trials than have previously been undertaken are required to provide information on relative harms as well as benefits.

A prospective randomized comparison of routine buserelin acetate and a decreasing dosage of nafarelin acetate with a low-dose gonadotropin-releasing hormone agonist protocol for in vitro fertilization and intracytoplasmic sperm injection

OBJECTIVE

To compare the efficacy of a draw-back nafarelin acetate protocol with routine buserelin acetate administration for in vitro fertilization (IVF) and intracytoplasmic sperm injection (ICSI).

DESIGN

Prospective clinical study.

SETTING

Mie University School of Medicine, Tsu, Mie, Japan.

PATIENT(S)

One hundred sixty-nine women treated with IVF and 183 women treated with ICSI.

INTERVENTION(S)

Nafarelin acetate and buserelin acetate in ovarian hyperstimulation in IVF and ICSI were administered.

MAIN OUTCOME MEASURE(S)

The concentrations of estradiol (E(2)), FSH, LH, gonadotropin dosages; the number of oocytes retrieved, oocytes fertilized, and embryos; and pregnancy rates.

RESULT(S)

A prospective study was conducted with 44 cycles for 34 couples with nafarelin acetate (group 1) and 47 cycles for 40 couples with buserelin acetate (group 2) with a long IVF protocol; 68 cycles for 46 couples with nafarelin acetate (group 3) and 56 cycles for 39 couples with buserelin acetate (group 4) with a short IVF protocol; 39 cycles for 32 couples with nafarelin acetate (group 5) and 50 cycles for 30 couples with buserelin acetate (group 6) with a long ICSI protocol; and 87 cycles for 60 couples with nafarelin acetate (group 7) and 81 cycles for 61 couples with buserelin acetate (group 8) with a short ICSI protocol. Patients were randomized to receive either full-dose nafarelin acetate (200 microg b.i.d.) treatment for 7 days followed by half-dose nafarelin acetate (200 microg daily) or buserelin acetate (300 microg t.i.d.). There were no statistically significant differences in baseline concentrations of E(2) and FSH, concentrations of E(2), P4, FSH, LH on hCG administration, gonadotropin dosage, the number of oocytes retrieved and embryos transferred, or pregnancy rates between groups 1 and 2, groups 3 and 4, groups 5 and 6, and groups 7 and 8.

CONCLUSION(S)

Full-dose nafarelin acetate treatment for 7 days followed by half-dose nafarelin acetate ("draw-back" protocol) is an effective new protocol for IVF and ICSI.

Serum and follicular fluid hormone levels during in vitro fertilization after short- or long-course treatment with a gonadotropin-releasing hormone agonist

OBJECTIVE

To examine the impact of flare (short) vs. down-regulation (long) GnRH agonist (GnRH-a) on serum and follicular fluid (FF) LH and androgen concentrations in women undergoing IVF treatment cycles.

DESIGN

Prospective observational study.

SETTING

IVF clinic.

PATIENT(S)

One hundred sixteen ovulatory subjects undergoing IVF.

INTERVENTION(S)

Fifty-eight ovulatory patients undergoing a down-regulation regimen matched with 58 undergoing the flare regimen as part of an IVF cycle.

MAIN OUTCOME MEASURE(S)

Serum concentrations of LH, FSH, Progesterone (P4), Androstenedione (A), T, and E(2) on the day of hCG administration were compared between the two groups. In addition, the FF P4, 17OHP4, A, T, and E(2) levels were compared in the two groups.

RESULT(S)

Serum LH was significantly higher with the flare regimen (15.2 +/- 1.14 IU/L, P<.05) when compared with results with the down-regulation protocol (9.5 +/- 0.77 IU/L). In addition, FF A was significantly higher in the flare protocol (57.3 +/- 13.3 ng/mL, P<.05) compared with in the down-regulation protocol (27 +/- 2.44 ng/mL). Serum and FF P4, 17OH P4, T, and E(2) were not statistically significantly different between the two groups.

CONCLUSION(S)

Serum LH and FF A are significantly higher in the flare regimen in comparison with the down-regulation regimen. Circulating LH appears to play a role in determining FF A concentration.

Gonadotropin stimulation following GnRH-a priming for poor responders in in vitro fertilization-embryo transfer programs

The effect of gonadotropin-releasing hormone agonist (GnRH-a) administration before gonadotropin superovulation on the stimulation characteristics of poor responder patients was assessed in an in vitro fertilization (IVF) program. Thirty consecutive patients who had exhibited low ovarian response (fewer than four retrieved oocytes) in at least two previous IVF cycles (control cycles, n = 60), were eligible for the study. GnRH-a (nafarelin) was administered daily for 7-10 days from the mid-luteal phase of the previous cycle until the first day of menstruation. Menotropin treatment was commenced on cycle day 3 (with no additional GnRH-a) (study cycles, n = 39). A significantly higher number of oocytes was retrieved (p < 0.0002) and a higher number of embryos transferred (p < 0.003) in the study cycles than in the control cycles. No cases of premature luteinizing hormone surge were recorded. Pregnancy rates per embryo transfer and per cycle were 10.4% and 7.7% for the study cycles and 2.8% and 1.6% for the control cycles, respectively. GnRH-a, administered prior to gonadotropin treatment, should be an additional option of ovulation induction protocol for poor responders in IVF programs.

Gonadotropin-releasing hormone agonist use in assisted reproduction cycles: the influence of long and short regimens on pregnancy rates

OBJECTIVE

To compare the efficacy of GnRH agonists used in either the flare (short) or down-regulation (long) regimen as part of IVF or GIFT treatment cycles.

DESIGN

Observational study.

SETTING

Three IVF clinics.

PATIENT(S)

One thousand two hundred forty-four couples accepted for IVF or GIFT treatment at participating clinics.

INTERVENTION(S)

In vitro fertilization or GIFT protocols standard to each clinic were recorded.

MAIN OUTCOME MEASURE(S)

Treatment cycle characteristics and outcomes, including E2 level, number of oocytes retrieved, and clinical pregnancy rate.

RESULT(S)

At site 1, there were 146 clinical pregnancies in 980 flare cycles, for a pregnancy rate of 14.9%, compared with 148 clinical pregnancies in 650 down-regulation cycles, for a pregnancy rate of 22.8%. This difference persisted after adjustment for age, primary infertility diagnosis, GIFT or IVF therapy, and year of treatment, and appeared to be mediated largely by the number of oocytes retrieved (mean, 9.8 for downregulation and 8.7 for flare in the first cycle). Despite having fewer oocytes retrieved, women who received flare regimens had higher E2 levels before hCG administration.

CONCLUSION(S)

Women who received GnRH agonists in a flare regimen had 11% fewer oocytes retrieved and a 35% reduction in the clinical pregnancy rate compared with those who received them in a down-regulation regimen; this difference was not explained by patient selection factors.

Administration of human chorionic gonadotropin for in vitro fertilization-embryo transfer based on the serum luteinizing hormone (LH) concentration: the importance of synchronization with endogenous LH rises

OBJECTIVE

To examine whether synchronized administration of hCG at the onset of the endogenous LH rise promotes successful IVF.

DESIGN

A prospective randomized study.

SETTING

In vitro fertilization program at a university hospital.

PATIENTS

A total of 208 IVF cycles in 148 patients.

INTERVENTIONS

Serum LH concentrations were measured daily and hMG was administered daily. Independent of follicle size and E2 concentration, hCG was administered as soon as the LH concentration exceeded the J level, defined as the minimum value + (the day 3 value-the minimum value) x 1/3(J group). Alternatively, hCG was administered when the serum LH concentration turned to increase but was still less than the J level, or 1 day after the serum LH concentration exceeded the J level (non-J group).

RESULTS

The rates of total and ongoing pregnancy per cycle were significantly higher in the J group (35.6% and 26.0%, respectively, n = 104) than in the non-J group (21.2% and 12.5%, respectively, n = 104). Pregnancies in the J group were achieved over a wide range of dominant follicle diameters (13 to 25 mm), E2 levels (198 to 1,700 pg/mL; conversion factor to SI units, 3.671), and E2 level per follicle > or = 12 mm (24 to 225 pg/mL per follicle) recorded on the day of hCG administration.

CONCLUSION

Synchronized administration of hCG in accordance with endogenous LH rises produces a high rate of pregnancy in IVF.

In vitro fertilization for women with pure tubal occlusion: the impact of short gonadotropin-releasing hormone agonist treatment

OBJECTIVE

To evaluate the impact of a short GnRH agonist (GnRH-a) protocol on follicular and luteal characteristics and treatment outcome in women undergoing IVF for isolated pure tubal occlusion.

DESIGN

A prospective randomized study.

PATIENTS

Eighty patients with pure tubal occlusion undergoing IVF for the first time.

INTERVENTIONS

Patients in group 1 (control group) were administered hMG from day 3 of the menstrual cycle. Patients in group 2 were administered 900 micrograms/d buserelin acetate intranasally from day 1 of the menstrual cycle, followed by hMG administration from day 3. Buserelin acetate was discontinued on the day of hCG administration.

MAIN OUTCOME MEASURES

Information collected included E2 levels and follicular growth throughout cycle, amount of hMG required for stimulation, number of oocytes retrieved, fertilization, pregnancy, and cancellation rates.

RESULTS

The short GnRH-a protocol resulted in significantly higher E2 levels and required less hMG for stimulation. However, the number of follicles aspirated, number of oocytes retrieved, fertilization rate, number of embryos transferred, pregnancy rate, and cancellation rate in both groups were comparable.

CONCLUSIONS

The findings suggest that administration of a short protocol of GnRH-a to patients with pure tubal occlusion has no obvious superiority in comparison with hMG alone, except for the lower amount of hMG required for ovarian stimulation.

Selection of ovarian stimulation protocol is related to IVF treatment outcome in women 35 years of age and older

PURPOSE

The aim of this study was to assess if the woman's age influenced IVF treatment outcome when a long GnRHa-hMG or a CC-hMG ovarian stimulation protocol was used. Two hundred women were included in the study, 100 women under the age of 35 and 100 women 35 years of age and older (mean 31.8 years and 36.7 years respectively). In the younger group as well as in the older group 50 women were stimulated according to a GnRHa-hMG protocol and 50 women received a CC-hMG regimen.

RESULTS

Significant differences between stimulation protocols were found in the older group for the mean numbers of oocytes recovered (4.7 vs 3.0), preembryos obtained (3.2 vs 2.0) and replaced (2.3 vs 1.7), as well as pregnancy (30% vs 10%) and delivery (24% vs 4%) rates per replacement.

CONCLUSION

It is concluded that women over 35 years of age seem to have a more favorable outcome of IVF treatment when using a long GnRHa-hMG protocol compared with CC-hMG, while this difference was not as obvious and lacking statistical significance under the age of 35.

The routine use of gonadotropin-releasing hormone agonists prior to in vitro fertilization and gamete intrafallopian transfer: a meta-analysis of randomized controlled trials

OBJECTIVE

To assess the efficacy of gonadotropin-releasing hormone agonists (GnRH-a) used in ovulation induction for in vitro fertilization and embryo transfer (IVF-ET) and gamete intrafallopian transfer (GIFT).

DESIGN

Meta-analysis of 10 trials comparing treatment cycle outcomes after GnRH-a (n = 914) with other ovulation induction protocols (n = 722) and 7 trials comparing outcomes after short flare-up (n = 368) with longer suppression (n = 476) GnRH-a protocols.

MAIN OUTCOME MEASURES

The outcome of primary interest was clinical pregnancy rate (PR) per treatment cycle commenced. Data describing the amount of gonadotropin used, cycle cancellation rate, clinical pregnancy per ET, and multiple pregnancy and abortion rates were also analyzed.

RESULTS

Clinical PR per cycle commenced was significantly improved after GnRH-a use for IVF (common odds ratio [OR] 1.80, 95% confidence interval [CI] 1.33 to 2.44) and GIFT (common OR 2.37, 95% CI 1.24 to 4.51). Clinical PR per embryo transfer was also significantly improved with GnRH-a use (common OR 1.40, 95% CI 1.01 to 1.95). Cycle cancellation was decreased (common OR 0.33, 95% CI 0.25 to 0.44), whereas spontaneous abortion rate was similar with and without GnRH-a use. Cycle cancellation and PRs after short flare-up and longer suppression protocols were similar between groups.

CONCLUSIONS

This meta-analysis supports the routine use of GnRH-a for IVF and GIFT. Further research is needed, however, to assess the potential for increased rates of multiple pregnancy and ovarian hyperstimulation syndrome, which may be associated with this treatment.