The relationship between follicle-stimulating hormone dose and level and its relevance for ovulation induction with adjuvant gonadotropin-releasing hormone-agonist treatment

Comparison of embryological and clinical outcome in GnRH antagonist vs. GnRH agonist protocols for in vitro fertilization in PCOS non-obese patients. A prospective randomized study

PURPOSE

Embryological and clinical efficacy of gonadotropin-releasing hormone (GnRH) antagonist and agonist stimulation protocols in non-obese women with polycystic ovarian syndrome (PCOS) were compared.

METHODS

A prospective randomized study.

SETTING

Medical University Hospital.

PATIENTS

70 infertile PCOS patients; 33 in GnRH antagonist and 37 in GnRH agonist group.

RESULTS

Similar mature metaphase II oocyte rate (76% vs. 76%) was observed in both protocols. Optimal pronuclear morphology zygotes dominated in both groups (64% vs. 66%). Transferred embryo quality did not differ in both protocols. No significant differences between both protocols were found in delivery rate (p = 0.481), pregnancy rate (p = 0.810), multiple pregnancy rate (p = 0.501), miscarriage rate (p = 0.154), fertilization rate (p = 0.388) and implantation rate (p = 1.000). Duration of stimulation and total follicle-stimulating hormone (FSH) dose were significantly lower in GnRH antagonist protocol (p = 0.0005).

CONCLUSIONS

GnRH antagonist and agonist protocols in non-obese PCOS patients yield similar embryological and clinical outcomes. Shorter duration of treatment and lower FSH requirement in GnRH antagonist group may be financially beneficial and therefore attractive for patients.

Effect of midfollicular luteinizing hormone levels on ovarian response and pregnancy outcome in patients undergoing in vitro fertilization in a short-term protocol

In a retrospective study, levels of LH in the midfollicular phase had a significant impact on ovarian response and pregnancy outcome. High LH levels were associated with reduced implantation and clinical pregnancy rates.

Does the addition of recombinant LH in WHO group II anovulatory women over-responding to FSH treatment reduce the number of developing follicles? A dose-finding study

BACKGROUND

In anovulatory women undergoing ovulation induction, addition of recombinant human LH (rLH) to FSH treatment may promote the dominance of a leading follicle when administered in the late follicular phase. The objective of this study was to find the optimal dose of rLH that can maintain the growth of a dominant follicle, whilst causing atresia of secondary follicles.

METHODS

Women with infertility due to anovulation and over-responding to FSH treatment were randomized to receive, in addition to 37.5 IU recombinant human FSH (rFSH), either placebo or different doses of rLH (6.8, 13.6, 30 or 60 microg) daily for a maximum of 7 days. The primary efficacy endpoint was the proportion of patients who had exactly one follicle > or = 16 mm on hCG day.

RESULTS

Among 153 enrolled patients, the five treatment groups were similar in terms of baseline characteristics. The proportion of patients with exactly one follicle > or = 16 mm ranged from 13.3% in the placebo group to 32.1% in the 30 microg rLH group (P = 0.048). The pregnancy rate ranged from 10.3% in the 60 microg group to 28.6% in the 30 microg rLH group. Adverse events were similar between groups.

CONCLUSIONS

In patients over-responding to FSH during ovulation induction, doses of up to 30 microg rLH/day appear to increase the proportion of patients developing a single dominant follicle (> or = 16 mm). Our data support the 'LH ceiling' concept whereby addition of rLH is able to control development of the follicular cohort.

The importance of endogenous feedback for monofollicular growth in low-dose step-up ovulation induction with follicle-stimulating hormone in polycystic ovary syndrome: a randomized study

OBJECTIVE

To evaluate the role of endogenous feedback in monofollicular growth during low-dose gonadotrophin therapy in polycystic ovary syndrome (PCOS) by measuring FSH levels in a group of patients cotreated with a GnRH agonist (GnRH-a) (group B) compared with patients not cotreated with an agonist (group A).

DESIGN

Prospective randomized study.

SETTING

University tertiary care Reproductive Endocrinology Unit.

PATIENTS

Women with clomiphene citrate-resistant PCOS.

MAIN OUTCOME MEASURES

Follicle-stimulating hormone, E2, and inhibin levels, follicular growth.

RESULTS

In group A, FSH levels decreased significantly from 7.3 mIU/mL (conversion factor to SI unit, 1.00) at day -5 to 5.9 mIU/mL at day 0 (day that hCG was administered) despite a constant dose, whereas they remained at a level of 7.4 mIU/mL in group B. The rate of monofollicular growth was significantly higher in group A (80%) than in group B (22%). No significant differences in E2 levels or inhibin levels were found between the groups.

CONCLUSIONS

The absence of a decrease of FSH during GnRH-a treatment in association with a lower rate of monofollicular growth suggests that endogenous feedback during low-dose step-up ovulation induction in PCOS plays an important role. The absence of this feedback mechanism in the presence of normal inhibin levels suggests that negative feedback control by inhibin during follicular stimulation is minimal.

Polycystic ovary syndrome: induction of ovulation

In summarizing the treatment of infertility associated with PCOS, basically the induction of ovulation may be achieved by boosting FSH stimulation of the ovaries, either indirectly with clomiphene or native pulsatile GnRH, or directly with gonadotrophin preparations. There seem to be two main determinants of the success of this treatment in achieving a live birth: the degree of hyperinsulinaemia and the concentration of circulating LH. Either of these, when in excess, not only makes induction of ovulation and conception relatively difficult but is also associated with a high rate of early miscarriage. Their correction, particularly in obstinate cases, should be a major consideration in the attempt to achieve optimal results. With such a range of reasonably successful treatments for the induction of ovulation in PCOS, the emphasis in the selection of therapy should now be placed on minimizing the prevalence of undesired side-effects while retaining acceptable efficiency.

The regulation of follicle growth: some clinical implications in reproductive endocrinology

OBJECTIVE

To review the literature concerning the regulation of follicle growth, to describe a model for unifollicular ovulation based upon the information gleaned, and to discuss some clinical implications in reproductive endocrinology underscored by this expanding knowledge.

DESIGN

Studies relating to follicular growth in lower animals and primates were reviewed. From the most pertinent articles the individual agents playing a significant role in the regulation of follicle growth were identified along with their mechanisms of action. A model for unifollicular development was proposed based upon the results of the review of these studies. Refinements in the management of some clinical problems in reproductive endocrinology were discussed based upon this model.

RESULTS

From a review of these studies it appears that in the human and primate menstrual cycle one follicle is selected because it has adequate FSH receptors when plasma FSH levels are high. This follicle becomes dominant despite falling FSH levels because of increased sensitivity of the follicle to FSH brought about by intraovarian growth regulators.

CONCLUSIONS

Improved care of patients requiring ovulation induction for differing indications should be possible with this more comprehensive knowledge of natural follicle growth.

Pharmacokinetics of follicle-stimulating hormone: clinical significance

OBJECTIVE

To review studies that examine the pharmacokinetics and pharmacodynamics of endogenous, as well as several exogenous FSH preparations.

DESIGN

Related studies were identified through a computerized bibliographic search.

PATIENTS

Initial pharmacodynamic studies were done in animal models and in women and men with either hypogonadotropic hypogonadism or suppressed hypothalamic-pituitary-gonadal axis. More recent studies evaluated FSH pharmacokinetics during ovulation induction treatment in women with normal ovulatory cycles or polycystic ovarian syndrome.

RESULTS

Various types of FSH exist according to their sialic acid content. High estrogen levels induce the secretion of less sialylated molecules with higher receptor affinity and an increased clearance rate. It appears that there is a threshold FSH level that should be reached to achieve an ovarian response. A very narrow range exists between the threshold and ceiling level for monofollicular growth. This threshold level is surpassed intentionally during IVF treatment cycles to induce multiple follicular recruitment. The threshold level can change under situations such as polycystic ovaries, perimenopause, oral contraceptives, and GnRH analogue treatment.

CONCLUSIONS

To avoid the risk of ovarian hyperstimulation syndrome and multiple pregnancies, careful adjustments of serum FSH levels should be made by fine dosage modifications. By monitoring FSH levels and using less sialylated preparations, the efficacy of the treatment probably will improve.