Pharmacokinetics of follicle-stimulating hormone: clinical significance

Optimizing FSH Concentration Modulation in the Short-Acting GnRH-a Long Protocol for IVF/ICSI: A Retrospective Study

INTRODUCTION

Exogenous gonadotropin (Gn) is given to regulate follicle-stimulating hormone (FSH) levels to achieve optimal ovarian response in in vitro fertilization/intracytoplasmic sperm injection (IVF/ICSI). The objective of this study was to analyze the optimal degree of change in FSH blood concentration with ovarian responsiveness in a short-acting gonadotropin-releasing hormone agonist (GnRH-a) long protocol for IVF/ICSI.

METHODS

This retrospective study was conducted at Changzhou Maternity and Child Health Hospital's Reproductive Center from May 2017 to May 2023. A total of 794 ovarian stimulation cycles for IVF/ICSI using the short-acting GnRH-a long protocol was included. Ovarian responsiveness was assessed based on the number of follicles > 14 mm on human chorionic gonadotropin (HCG) trigger day, refine-follicular output rate (Refine-FORT) and good quality embryos. Delta 1 referred to the change in FSH level between days 6-8 of gonadotropin usage and baseline FSH, while Delta 2 referred to the change in FSH level between HCG trigger day and days 6-8 of gonadotropin usage. Simple and multiple linear regression analysis were performed to adjust for confounding factors.

RESULTS

The number of follicles > 14 mm on HCG trigger day was found to be the most suitable indicator for evaluating ovarian responsiveness compared to the number of follicles > 16 mm and the number of retrieved oocytes. When Delta 1 ranged from 1.94 to 3.37, the number of follicles > 14 mm on HCG trigger day was the highest. When Delta 1 ranged from 3.37 to 5.90, the Refine-FORT was the highest. However, when Delta 1 exceeded 5.90, the number of follicles > 14 mm on HCG trigger day, Refine-FORT and good quality embryo all significantly decreased. On the other hand, when Delta 2 was ≤ - 1.58, the number of follicles > 14 mm on HCG trigger day and the Refine-FORT were both the highest.

CONCLUSION

This study identifies optimal Delta 1 and Delta 2 ranges for effective ovarian responsiveness in a short-acting GnRH-a long protocol for IVF/ICSI and introduces the novel measure of the number of follicles > 14 mm on HCG trigger day. The optimal range for Delta 1 was 1.94 to 3.37, and Delta 2 should be < - 1.58 for achieving a higher number and quality of oocytes.

The serum follicle stimulating hormone-to-luteinizing hormone ratios can predict assisted reproductive technology outcomes in women undergoing gonadotropin releasing hormone antagonist protocol

BACKGROUND

The basal follicle stimulating hormone (FSH)/luteinizing hormone (LH) ratio is a useful predictor of ovarian response. In this study, we investigated whether the FSH/LH ratios during the entire controlled ovarian stimulation (COS) can be used as effective predictors of outcomes in women undergoing in vitro fertilization (IVF) treatment using the gonadotropin releasing hormone antagonist (GnRH-ant) protocol.

METHODS

A total of 1,681 women undergoing their first GnRH-ant protocol were enrolled in this retrospective cohort study. A Poisson regression model was used to analyze the association between the FSH/LH ratios during COS and embryological outcomes. Receiver operating characteristic analysis was performed to determine the optimal cutoff values for poor responders (≤ 5 oocytes) or poor reproductive potential (≤ 3 available embryos). A nomogram model was constructed to provide a tool for predicting the cycle outcomes of individual IVF treatments.

RESULTS

The FSH/LH ratios (at the basal day, stimulation day 6 (SD6) and trigger day) were significantly correlated with the embryological outcomes. The basal FSH/LH ratio was the most reliable predictor of poor responders with a cutoff value of 1.875 (area under the curve (AUC) = 72.3%, P < 0.05), or of poor reproductive potential with a cutoff value of 2.515 (AUC = 66.3%, P < 0.05). The SD6 FSH/LH ratio predicted poor reproductive potential with a cutoff value of 4.14 (AUC = 63.8%, P < 0.05). The trigger day FSH/LH ratio predicted poor responders with a cutoff value of 9.665 (AUC = 63.1%, P < 0.05). The basal FSH/LH ratio, combined with the SD6 and trigger day FSH/LH ratios, slightly increased these AUC values and improved the prediction sensitivity. The nomogram provides a reliable model with which to assess the risk of poor response or poor reproductive potential directly based on the combined indicators.

CONCLUSIONS

FSH/LH ratios are useful predictors of poor ovarian response or reproductive potential throughout the entire COS with the GnRH antagonist protocol. Our findings also provide insights into the potential for LH supplementation and regimen adjustment during COS to achieve improved outcomes.

Extended Injection Intervals of Gonadotropins by Intradermal Administration in IVF Treatment

CONTEXT

Gonadotropins can be administered every 5 days under intradermal injection in in vitro fertilization (IVF) treatment.

OBJECTIVE

To explore the effectiveness of intradermal injection of recombinant human FSH (rhFSH) for women undergoing IVF.

METHODS

Women who received their first IVF treatment enrolled in this prospective intervention in 2018. All women received a bolus of 900 IU rhFSH intradermally at day 2 of the treatment cycle followed by additional dosage of rhFSH at day 7 and/or day 10. The main outcome measures included the total dose of rhFSH and number of injections required, sequential serum FSH level detected, and number of mature oocytes retrieved.

RESULTS

Seventy women completed the study. On average, 2.31 ± 0.73 injections and 1662 ± 397 IU of rhFSH were administered. While the baseline FSH level was 5.6 ± 2.2 IU/L, the serum concentrations of FSH after rhFSH administration were 35.3 ± 7.0 on the first day (24 hours) and 10.7 ± 3.7 IU/L on the fifth day (120 hours). A total of 10.5 ± 6.6 mature oocytes were retrieved, resulting in 7.3 ± 5.1 pronuclear embryos; 1.8 ± 0.6 embryos were transferred to the uterus. Our findings resulted in 72% fertilization, 91% cleavage, 31% implantation, and 36% live birth rates. Although fewer larger follicles were found, noninferiority results were noted in the mature oocytes retrieved, good embryos available, and clinical pregnancy rate compared with those received conventional daily subcutaneous rhFSH administration.

CONCLUSION

Intradermal administration of rhFSH, with a smaller dose of rhFSH and fewer injections, may achieve the goal of a cost-effective and more patient-friendly regimen.

Ovarian Folliculogenesis and Uterine Endometrial Receptivity after Intermittent Vaginal Injection of Recombinant Human Follicle-Stimulating Hormone in Infertile Women Receiving In Vitro Fertilization and in Immature Female Rats

The uterine first-pass effect occurs when drugs are delivered vaginally. However, the effect of vaginally administered recombinant human follicle-stimulating hormone (rhFSH) on ovarian folliculogenesis and endometrial receptivity is not well established. We aimed to compare the efficacy of rhFSH administered vaginally and abdominally in clinical in vitro fertilization (IVF) treatment, pharmacokinetic study, and animal study. In IVF treatment, the number of oocytes retrieved, endometrial thickness and uterine artery blood perfusion were not different between women who received the rhFSH either vaginally or abdominally. For serum pharmacokinetic parameters, significantly lower Tmax, clearance, and higher AUC and T_1/2_elimination of rhFSH were observed in women who received rhFSH vaginally, but urine parameters were not different. Immature female rats that received daily abdominal or vaginal injections (1 IU twice daily for 4 days) or intermittent vaginal injections (4 IU every other day for two doses) of rhFSH had more total follicles than the control group. In addition, the serum progesterone and progesterone receptors in the local endometrium were significantly higher in the groups treated with intermittent abdominal or vaginal injection of rhFSH, compared with those who recieved daily injection. In summary, vaginal administration of rhFSH may provide an alternative treatment regimen in women receiving IVF.

A Novel Nomogram for Individualized Gonadotropin Starting Dose in GnRH Antagonist Protocol

Controlled ovarian stimulation (COS) is one of the most vital parts of in vitro fertilization-embryo transfer (IVF-ET). At present, no matter what kinds of COS protocols are used, clinicians have to face the challenge of selection of gonadotropin starting dose. Although several nomograms have been developed to calculate the appropriate gonadotropin starting dose in gonadotropin releasing hormone (GnRH) agonist protocol, no nomogram was suitable for GnRH antagonist protocol. This study aimed to develop a predictive nomogram for individualized gonadotropin starting dose in GnRH antagonist protocol. Single-center prospective cohort study was conducted, with 198 women aged 20-45 years underwent IVF/intracytoplasmic sperm injection (ICSI)-ET cycles. Blood samples were collected on the second day of the menstrual cycle. All women received ovarian stimulation using GnRH antagonist protocol. Univariate and multivariate analysis were performed to identify predictive factors of ovarian sensitivity (OS). A nomogram for gonadotropin starting dose was developed based on the multivariate regression model. Validation was performed using concordance statistics and bootstrap resampling. A multivariate regression model based on serum anti-Müllerian hormone (AMH) level, antral follicle count (AFC), and body mass index (BMI) was developed and accounted for 59% of the variability of OS. An easy-to-use predictive nomogram for gonadotropin starting dose was established with excellent accuracy. The concordance index (C-index) of the nomogram was 0.833 (95% CI, 0.829-0.837). Internal validation using bootstrap resampling further showed the good performance of the nomogram. In conclusion, gonadotropin starting dose in antagonist protocol can be predicted precisely by a novel nomogram.

Alcohol and fertility: how much is too much?

Alcohol use is prevalent in the United States. Given that a substantial portion of the drinking population is of reproductive age, it is not uncommon for couples who are attempting conception, or for women who are already pregnant, to be regularly consuming alcohol. Alcohol use is associated with multiple reproductive risks, including having a child with a Fetal Alcohol Spectrum Disorder, increased risk of fetal loss, and decreased chance of live birth. This review serves to examine the risks of alcohol in the context of reproductive health.

Alcohol, cigarette smoking, and ovarian reserve in reproductive-age African-American women

BACKGROUND

Although alcohol consumption and cigarette smoking are common behaviors in reproductive-age women, little is known about the impact of consumption patterns on ovarian reserve. Even less is known about the effects of smoking and alcohol use in reproductive-age African-American women.

OBJECTIVE

The objective of the study was to examine the impact of the patterns of alcohol intake and cigarette smoking on anti-Müllerian hormone levels as a marker of ovarian reserve in African-American women.

STUDY DESIGN

This was a cross-sectional analysis from the baseline clinical visit and data collection of the Study of Environment, Lifestyle, and Fibroids performed by the National Institute of Environmental Health Sciences. A total of 1654 volunteers, aged 23-34 years, recruited from the Detroit, Michigan community completed questionnaires on alcohol intake and cigarette smoking and provided serum for anti-Müllerian hormone measurement. Multivariable linear and logistic regressions were used as appropriate to estimate the effect of a range of exposure patterns on anti-Müllerian hormone levels while adjusting for potential confounders including age, body mass index, and hormonal contraception.

RESULTS

Most participants were alcohol drinkers (74%). Of those, the majority (74%) engaged in binge drinking at least once in the last year. Women who reported binge drinking twice weekly or more had 26% lower anti-Müllerian hormone levels compared with current drinkers who never binged (95% confidence interval, -44, -2, P < .04). Other alcohol consumption patterns (both past and current) were unrelated to anti-Müllerian hormone. The minority of participants currently (19%) or formerly (7%) smoked, and only 4% of current smokers used a pack a day or more. Neither smoking status nor second-hand smoke exposure in utero, childhood, or adulthood was associated with anti-Müllerian hormone levels.

CONCLUSION

Results suggest that current, frequent binge drinking may have an adverse impact on ovarian reserve. Other drinking and smoking exposures were not associated with anti-Müllerian hormone in this cohort of healthy, young, African-American women. A longitudinal study of how these common lifestyle behaviors have an impact on the variability in age-adjusted anti-Müllerian hormone levels is merited.

Effect of alcohol consumption on in vitro fertilization

OBJECTIVE

To estimate whether alcohol use at the initiation of an in vitro fertilization (IVF) cycle is associated with IVF outcomes.

METHODS

In this prospective cohort study, men and women completed a self-administered questionnaire before their first IVF cycle. Participants reported alcohol type, amount, and frequency consumed. Discrete survival analysis was applied to calculate the odds ratio (OR) and 95% confidence interval (CI) for live birth-the primary outcome. Secondary outcomes were cycle characteristics and points of failure in the IVF process (cycle cancellation, failed fertilization, implantation failure, and spontaneous abortion). We conducted multicycle analyses with final models adjusted for potential confounders that included cycle number, cigarette use, body mass index, and age.

RESULTS

A total of 2,545 couples contributed 4,729 cycles. Forty-one percent of women and 58% of men drank one to six drinks per week. Women drinking at least four drinks per week had 16% less odds of a live birth rate compared with those who drank fewer than four drinks per week (OR 0.84, CI 0.71-0.99). For couples in which both partners drank at least four drinks per week, the odds of live birth were 21% lower compared with couples in which both drank fewer than four drinks per week (OR 0.79; CI 0.66-0.96).

CONCLUSION

Consumption of as few as four alcoholic drinks per week is associated with a decrease in IVF live birth rate.

LEVEL OF EVIDENCE

II.

Ghrelin suppresses secretion of luteinizing hormone (LH) and follicle-stimulating hormone (FSH) in women

CONTEXT

Ghrelin has been shown to suppress secretion of LH and, less regularly, of FSH in male and female animals and human males. However, no such evidence exists for human females.

OBJECTIVE

The aim was to study the effect of ghrelin on secretion of LH and FSH in women. DESIGN/PARTICIPANTS/INTERVENTION: Nocturnal (2000-0700 h) secretion profiles of LH and FSH were determined in six healthy women (age, 25.5±2.9 yr) twice, receiving 50 μg ghrelin or placebo at 2200, 2300, 2400, and 0100 h in this single-blind, randomized, crossover study.

RESULTS

LH secretion after ghrelin injection as assessed by the area under the curve (4.01±1.37 mIU/min·ml) was significantly (P=0.031) lower than after placebo injection (5.46±1.33 mIU/min·ml). Also, FSH secretion after ghrelin injection (5.54±0.64 mIU/min·ml) was significantly (P=0.038) lower than after placebo injection (5.87±0.56 mIU/min·ml). LH pulses occurred significantly (P=0.007) less frequently after ghrelin injection (2.3±0.5) than after placebo injection (3.8±0.9). Accordingly, the interval between first and second LH pulse after treatment was significantly (P=0.002) longer after ghrelin injection (300±86 min) than after placebo injection (187±60 min). One of the six women exhibited clear FSH pulses, which overall paralleled LH pulses; two FSH and LH pulses occurred after ghrelin injection, but three occurred after placebo in this woman.

CONCLUSIONS

This is the first report that ghrelin suppresses the secretion of LH and FSH in women. These findings resemble those in male and female animals and in men.

Human chorionic gonadotrophin stimulation test as a predictor of ovarian response and pregnancy in IVF cycles stimulated with GnRH agonist gonadotrophin treatment: a pilot study

BACKGROUND

Recent evidence supports a specific and broad role of androgen produced by theca cells in reproductive physiology. This pilot study evaluated the usefulness of hCG theca stimulation test in predicting ovarian response and pregnancy.

METHODS

Prospective cohort study including 80 infertile women treated with IVF/ICSI. On Day 3 of the menstrual cycle preceding, the first IVF/ICSI cycle a blood sample was drawn to evaluate baseline FSH, estradiol (E(2)), 17-hydroxy-progesterone, androstenedione and testosterone levels. All women then received 250 µg recombinant hCG s.c. and underwent a second blood sampling 24 h after hCG injection to measurement steroid serum levels.

RESULTS

Percentage increment of E(2) but not its precursors was significantly higher in normo-responders and pregnancy cycles than in poor responders and non-pregnancy cycles (P = 0.03 and P = 0.02, respectively) diagnostic accuracy being 67 and 75%, respectively. The percentage increase in E(2) thus still fails in as many as 33 and 25% of patients in predicting ovarian response and pregnancy, respectively. In addition, E(2) concentrations are poorly reproducible and a wide range of variation in all serum steroids investigated-including E(2)-after hCG injection was observed.

CONCLUSIONS

The predictive power of the hCG test is based on E(2) but not androgen response to hCG injection. This test cannot be recommended in routine clinical practice because it is too laborious for screening purposes, shows great variability in the response obtained and its overall accuracy is not better than that reported for other available markers of ovarian reserve. The use of the currently available markers, antral follicle count and anti-Müllerian hormone, is therefore recommended.

Day-5 inhibin B serum concentrations and antral follicle count as predictors of ovarian response and live birth in assisted reproduction cycles stimulated with gonadotropin after pituitary suppression

OBJECTIVE

To investigate the usefulness of day-5 inhibin B and antral follicle count (AFC) in predicting ovarian response and live birth in the first cycle of assisted reproduction.

DESIGN

Prospective cohort study.

SETTING

University hospital.

PATIENT(S)

Ninety-eight infertile women treated with in vitro fertilization-intracytoplasmic sperm injection (IVF-ICSI) comprising 72 normal responders and 26 poor responders.

INTERVENTION(S)

Ovarian stimulation with gonadotropin-releasing hormone agonist-gonadotropin treatment.

MAIN OUTCOME MEASURE(S)

Basal ultrasonographic (AFC, total ovarian volume) and basal (follicle-stimulating hormone, estradiol, and inhibin B) and stimulation day-5 (estradiol, inhibin B) hormone parameters.

RESULT(S)

The AFC had the best predictive value among the basal variables for outcome of ovarian stimulation. Among the dynamic hormone measurements, day-5 inhibin serum measurement emerged as the best predictive variable of poor response in IVF-ICSI cycles, but it was not statistically significantly better than basal AFC. The association of day-5 inhibin B with live-birth rate was statistically significant and stronger than the effect of any other variable investigated.

CONCLUSION(S)

Basal AFC and day-5 inhibin B have similar predictive properties for ovarian response in assisted reproduction cycles stimulated with gonadotropin after pituitary suppression, but day-5 inhibin B is a superior predictor of live birth.

A successful conception by a shift from human menopausal gonadotropin therapy to therapy with recombinant human follicular-stimulating hormone for the treatment of male hypogonadotropic hypogonadism

Stimulatory therapy with gonadotropins effectively induces spermatogenesis and increases the chances of successful reproduction. However, the optimal treatment modality and schedule, and required duration of treatment have not been determined. A 27-year-old man presented with erectile and ejaculatory disorder. Endocrinological examinations revealed isolated luteinizing hormone-releasing hormone (LHRH) deficiency of the hypothalamus, resulting in hypogonadotropic hypogonadism. No causative abnormality was detected in imaging studies. Having a diagnosis of adult-onset hypogonadotropic hypogonadism, the patient received pulsatile subcutaneous human chorionic gonadotropin (hCG) and human menopausal gonadotropin (hMG). Hypogonadism did not improve with hCG/hMG combination therapy. He was successfully treated with the replacement therapy from hMG into recombinant human follicular-stimulating hormone (rhFSH) for induction of spermatogenesis, along with pregnancy in the female partner.

Review of the evidence base of strategies to prevent ovarian hyperstimulation syndrome

The English-language literature was reviewed to examine the evidence base for strategies that have been used to prevent ovarian hyperstimulation syndrome (OHSS). Prediction of OHSS by pretreatment patient characteristics and ovarian response parameters is unreliable, with a significant number of OHSS cases occurring in patients not thought to be high risk, while the majority of 'high-risk' cycles do not result in OHSS. Alternatives to ovarian stimulation should always be considered, depending on the clinical situation. Monofollicular ovulation induction with a cautious step-up regime carries a lower risk of overstimulation than step-down regimes. In in vitro fertilization (IVF) cycles, a low starting dose of follicle-stimulating hormone (FSH) and the use of 5000 iu human chorionic gonadotrophin (hCG) for final follicular maturation may benefit patients at high risk of OHSS. The role of GnRH antagonists is unclear. In women with polycystic ovaries, who are undergoing ovarian stimulation for IVF, metformin co-treatment may reduce the risk of OHSS. Coasting of cycles with over-response is associated with a reduced risk of OHSS, although precise criteria for initiating and ending coasting are not definable at present. Elective cryopreservation of all embryos prevents late OHSS, but its value has been poorly researched. The literature does not support a role for intravenous albumin, administered around the time of oocyte retrieval, in preventing OHSS. Evidence is insufficient regarding a possible role for hexa-ethyl starch. hCG should not be used for luteal support, as it is associated with a higher risk of OHSS, and equivalent pregnancy rates are obtained with the use of progesterone.

Pharmacokinetics of gonadotropin therapy

Ovulation is the result of an integrated action of the hypothalamus, pituitary and ovaries. During the process, gonadal steroids, peptides and growth factors are produced and influence the synthesis and release of gonadotropin-releasing hormone (GnRH), follicle stimulating hormone (FSH) and luteinizing hormone (LH). These latter compounds play a crucial role in folliculogenesis and are frequently used in the management of infertility.

Strategies to reduce multiple pregnancies due to ovulation stimulation

OBJECTIVE

To review factors associated with high-order multiple births (HOMB) due to ovulation induction (OI) and the efficacy of strategies to reduce their occurrence.

DESIGN

Retrospective analysis of published studies of OI with intrauterine insemination (IUI) where patient and cycle characteristics were fully documented.

RESULT(S)

High-order multiple pregnancies (HOMP) were positively related to use of high doses of gonadotropin, number of 7-10 mm preovulatory follicles, and E(2), and inversely related to age and number of treatment cycles. Strategies successful in reducing HOMP include: use of clomiphene (CC) before gonadotropins, minimal gonadotropin doses, cancellation for more than three follicles >10-15 mm, and aspiration of excess follicles. Depending on the strategy used, 5%-20% of cycles may be canceled but HOMP rates can be less than 2% and pregnancy rates can average 10%-20% per cycle. Pregnancy rates per patient need not be reduced if low doses are continued for 4-6 cycles.

CONCLUSION(S)

High-order multiple pregnancies due to OI can be reduced to 2% or less by less aggressive stimulation without reducing overall chances of pregnancy for most patients.

Follicle-stimulating hormone levels and medication compliance during in vitro fertilization

OBJECTIVE

To report the use of serum FSH levels during gonadotropin therapy for IVF to ensure medication compliance.

DESIGN

Case report.

SETTING

University-based reproductive endocrinology clinic.

PATIENT(S)

Two women with normal ovarian reserve undergoing IVF cycles with unexpected clinical responses.

INTERVENTION(S)

FSH laboratory values.

MAIN OUTCOME MEASURE(S)

Ovarian follicular development.

RESULT(S)

Adequate follicular response leading to oocyte retrieval.

CONCLUSION(S)

Determination of serum FSH levels may help detect noncompliance with recommended gonadotropin regimens during IVF.

Effects of breed on kinetics of ovine FSH and ovarian response in superovulated sheep

Embryo production is a useful tool for ex situ conservation of endangered species and breeds, despite a high variability in the ovarian response to superovulatory treatments. The current study evaluated the incidence and mechanisms of genetic factors in such variability, by determining the pharmacokinetics and pharmacodynamics of a standard treatment with ovine FSH (oFSH) in two endangered Spanish sheep breeds (Rubia del Molar, R, and Negra de Colmenar, N) in comparison to Manchega ewes (M, control group). In the first experiment, pharmacokinetics of an i.m. single dose of 1.32 mg of oFSH was evaluated in seven animals of each breed. Plasma FSH concentrations reached their maximum at 4h post-administration in all the ewes, but several of the kinetic parameters (plasma FSH concentration at 4h post-administration, maximum plasma FSH concentration, C(max), and both the area under the plasma concentration-time curve extrapolated to the infinite, AUC(inf), and to the last moment of sampling, AUC(last)) were higher in the N group. In the second trial, 10 animals of each breed were superovulated using eight decreasing doses of oFSH (3 x 1.32 mg, 2 x 1.10 mg, and 3 x 0.88 mg). The R group, when compared to N and M, showed both a higher number of corpora lutea (13.7+/-0.6 versus 10.0+/-0.4 in N and 9.8+/-0.6 in M, P<0.05 for both) and embryos (7.9+/-0.8 versus 4.3+/-0.4 in N, P<0.05, and 6.7+/-0.5 in M, n.s.). Evaluation of pharmacokinetic and dynamic parameters showed that, although there was a trend for a higher hormone availability in R sheep, mean FSH plasma concentrations were similar between breeds (0.54+/-0.08 ng/ml for R, 0.45+/-0.05 ng/ml for N and 0.35+/-0.05 ng/ml for M). However, differences were found in the number of preovulatory follicles growing in response to the FSH treatment between R (24.4+/-2.2), M (18.9+/-1.5, n.s.) and N sheep (14.1+/-1.4; P<0.01). Thus, differences in embryo yields between breeds would be related to differences in the pattern of follicular growth in response to FSH treatment.

Pretreatment with transdermal testosterone may improve ovarian response to gonadotrophins in poor-responder IVF patients with normal basal concentrations of FSH

BACKGROUND

Treatment of poor-responder patients to controlled ovarian stimulation for assisted reproduction, who have normal basal FSH concentrations, is one of the most difficult challenges in reproductive medicine. This study investigated the usefulness of testosterone pretreatment in such patients.

METHODS

Prospective, therapeutic, self-controlled clinical trial including 25 consecutive infertile patients who had a background of the first and second IVF treatment cycle cancellations due to poor follicular response, in spite of vigorous gonadotrophin ovarian stimulation and having normal basal FSH levels. In the third IVF attempt, all patients received transdermal testosterone treatment (20 microg/kg per day) during the 5 days preceding gonadotrophin treatment.

RESULTS

Twenty patients (80%) showed an increase of over fivefold in the number of recruited follicles, produced 5.8+/-0.4 (mean+/-SEM) oocytes, received two or three embryos and achieved a clinical pregnancy rate of 30% per oocyte retrieval. There were 20% cancelled cycles.

CONCLUSION

Pretreatment with transdermal testosterone may be a useful approach for women known to be low responders on the basis of a poor response to controlled ovarian stimulation but having normal basal FSH concentrations.

Previous cycle cancellation due to poor follicular development as a predictor of ovarian response in cycles stimulated with gonadotrophin-releasing hormone agonist-gonadotrophin treatment

BACKGROUND

There is scanty information analysing the predictive value of a poor response, in terms of cancellation of the IVF cycle because of poor follicular development, as a predictor of ovarian response in a subsequent treatment cycle. This study, where logistic regression analysis was used, was undertaken to investigate the relative power of the woman's age, basal FSH, and previous cycle cancellation both as single and combined predictors of ovarian response in an IVF program where pituitary desensitization is routinely used.

METHODS

One hundred and twenty-nine consecutive patients having their first cycle of IVF/ICSI treatment cancelled because of poor follicular response and undergoing a second attempt within 6 months after the failed treatment cycle were initially selected (group 1). Group 2 comprised 129 patients undergoing the first cycle of IVF/ICSI treatment and who were randomly selected from our assisted reproductive treatment program matching by BMI and indication for IVF/ICSI to those in group 1.

RESULTS

Cancellation rate was significantly higher but ovarian response significantly lower in group 1 as compared with group 2. As indicated by the AUC(ROC) determined with ROC analysis, such a poor outcome in patients having a previous IVF/ICSI cycle cancelled due to poor response was observed whatever the level of basal FSH. In a logistic regression analysis and according to the odds ratio values, the predictive capacity of a previous poor response was 9 and 7.6 times higher than the predictive capacity of age and basal FSH, respectively. Any two or all three variables studied did not improve the predictive value of previous cycle cancellation alone.

CONCLUSIONS

The history of an IVF/ICSI cancelled cycle due to poor follicular response in a standard stimulation protocol is a better predictor of cancellation in subsequent treatment cycles than age or FSH. The poor ovarian response associated with previous cycle cancellation occurs whatever the level of basal FSH.

FSH: what is the highest dose for ovarian stimulation that makes sense on an evidence-based level?

The widely applied practice of a gonadotrophin dose increase in case of low response is not on an evidence-based level and not efficacious. All known comparative studies failed to show a difference in favour of the high-dose group regarding their pregnancy rate per embryo transfer. However if more oocytes and more embryos are available for cryopreservation, the real benefit in terms of cumulative pregnancy outcome might be with the high-dose regimen. This publication will show - as a review of the literature - that the frequent clinical practice of increasing the FSH dose does not lead to a higher pregnancy rate, which is in line with recommendation for milder stimulation regimes in IVF. Thus, the collective evidence to date would suggest that 150 IU/day to 250 IU/day of FSH or human menopausal gonadotrophin (HMG) is an appropriate starting dose for most women undergoing ovarian hyperstimulation for IVF as part of a gonadotrophin-releasing hormone (GnRH) antagonist or a long GnRH agonist protocol.

The effects of ovulation induction during infertility treatment on gingival inflammation

BACKGROUND

Ovulation induction is the most common method of infertility treatment in which the ovaries are stimulated to produce multiple follicles. The aim of this study was to assess the effects of three drug protocols of ovulation induction: clomiphene citrate (CC) alone, CC combined with follicle stimulating hormone (FSH), and CC combined with human menopausal gonadotropin (HMG) on the gingival tissues of women who were undergoing infertility treatment.

METHODS

Study population was composed of 18 women using CC for three menstrual cycles or less and 16 women using CC for more than three cycles; 21 women using CC-FSH; and 24 women using CC-HMG who had at least four cycles of CC alone the previous year. All subjects were clinically examined for plaque levels (plaque index), gingival inflammation (gingival index), bleeding on probing, and gingival crevicular fluid volume. The results were compared with a control group of 20 women matched for age, educational and professional level, and oral habits and who had never used ovulation drugs.

RESULTS

Despite similar plaque levels (P>0.05), women using CC for more than three cycles and combined protocols of CC-FSH and CC-HMG had higher levels of gingival inflammation (P<0.01, P<0.001 and P<0.001, respectively), bleeding (P<0.001), and GCF volume (P<0.001) when compared to the control group and to the users of CC for three cycles or less.

CONCLUSIONS

The results of this study have shown that ovulation induction, which is the most common method in the management of infertility, exacerbates gingival inflammation, bleeding, and GCF volume and that the duration of the usage of these drugs is strongly associated with the severity of gingival inflammation.

Value of the serum estradiol level for preventing ovarian hyperstimulation syndrome: a retrospective case control study

OBJECTIVE

To assess the value of different serum E(2) cut-off levels for predicting women at risk for ovarian hyperstimulation syndrome (OHSS).

DESIGN

Retrospective case-control study of a cohort of women undergoing assisted reproduction treatment (ART) over 12 months.

SETTING

Tertiary university hospital.

PATIENT(S)

The study group included women with OHSS who fulfilled the endocrine inclusion criteria (n = 40). The control group was a random sample (n = 40) from the cohort of women undergoing ART.

INTERVENTION(S)

None.

MAIN OUTCOME MEASURE(S)

To evaluate the sensitivity and specificity of different serum E(2) cut-off levels on day 11 of ovarian stimulation in preventing the establishment of OHSS.

RESULT(S)

Three hundred ninety-nine cycles (IVF and intracytoplasmic sperm injection) were undertaken between June 2000 and May 2001. The study group (n = 40) was compared with the control group (n = 40) undergoing ART during the same period of time. On day 8 of ovarian stimulation, the mean (SD) E(2) level in the study group was 8,517(5.3) pmol/L (2,320 pg/mL), and in the control group it was 2,540 (2.6) pmol/L (691 pg/mL). On day 11 of stimulation the mean (SD) E(2) level was 15,662 (4.2) pmol/L (4,266 pg/mL) and 5,804 (4.5) pmol/L (1,581 pg/mL), respectively. Twenty-four (60%) women who developed OHSS had E(2)levels >6,000 pmol/L (1,634 pg/mL) on day 8 and above 11,000 pmol/L (2,996 pg/mL) on day 11. Sixteen (40%) had E(2) levels <6,000 pmol/L (1,634 pg/mL) on day 8, but all had levels above 11,000 pmol/l (2,996 pg/mL) on day 11.

CONCLUSION(S)

A serum E(2) level of 12,315 pmol/L (3,354 pg/mL) on day 11 of ovarian stimulation gives a sensitivity and specificity of 85% for the detection of women at risk for OHSS.

Biochemical and functional aspects of gonadotrophin-releasing hormone and gonadotrophins

Reproductive function in mammals is governed by the hypothalamic-pituitary-gonadal axis, which conforms a functional unit. Sexual maturation and the subsequent development of reproductive competence depend on the precise and coordinated function of this axis. The components of the reproductive axis communicate each other through endocrine signals. The hypothalamus synthesizes gonadotrophin-releasing hormone or GnRH, which in turn stimulates synthesis and secretion of the pituitary gonadotrophins, follicle-stimulating hormone (FSH) and luteinizing hormone (LH). The ovarian follicles and the interstitial and Sertoli cells of the testis are the targets for these pituitary signals. Under gonadotrophic stimulation, the gonads produce and secrete several steroid and non-steroid (polypeptide) factors, which in turn regulate in different ways the function of the hypothalamic-pituitary axis. An episodic and pulsatile mode of secretion of hormonal signals characterize (as in other endocrine systems) the function of the reproductive axis, particularly that of the hypothalamic-pituitary unit. The target cell response, and consequently the harmonic function of the corresponding gland, will depend on the adequate dynamics of this pulsatile secretion. The function of each component of the reproductive axis is strongly influenced by locally-produced signals acting either in a paracrine or autocrine manner; these particular signals represent fine-tuning regulation systems that eventually amplify or restrain the magnitude of response to a particular endocrine signal, providing additional mechanisms for tissue homeostasis and a better functional plasticity of the target gland. The design and rational use of novel therapeutic strategies for an optimal exogenously-controlled reproductive function largely depend on the detailed knowledge of the hypothalamic-pituitary-gonadal axis function and the structure and mechanism of action of those factors and signals involved in its regulation.

Ovulation induction--optimizing results and minimizing risks

The aim of ovulation induction therapy should be, wherever possible, to correct the underlying disturbance and achieve safe, repeated unifollicular ovulation to achieve the live birth of singleton babies. This article outlines the main causes of anovulatory infertility but deals mostly with the management of anovulatory polycystic ovary syndrome (PCOS), which is the most common problem to confront specialists in reproductive medicine. PCOS is associated with insulin resistance, particularly in those who are overweight. Thus, strategies to achieve weight loss and improve insulin sensitivity, including the use of drugs such as metformin, enhance reproductive function. Therapies to induce ovulation involve first the use of the anti-oestrogen clomiphene citrate. For those who fail to ovulate in response to clomiphene citrate, the principal options include parenteral gonadotrophin therapy or laparoscopic ovarian diathermy.

Ovulation induction for polycystic ovary syndrome

Polycystic ovary syndrome (PCOS) is the commonest cause of anovulatory infertility. Various factors influence ovarian function, and fertility is adversely affected by an individual being overweight or having high serum concentrations of LH. Strategies to induce ovulation include weight loss, oral anti-oestrogens (principally clomiphene citrate), parenteral gonadotrophin therapy and laparoscopic ovarian surgery. There have been no adequately powered randomized studies to determine which of these therapies provides the best overall chance of an ongoing pregnancy. Women with PCOS are at risk of ovarian hyperstimulation syndrome (OHSS) and so ovulation induction has to be monitored carefully with serial ultrasound scans. The recognition of an association between hyperinsulinaemia and PCOS has resulted in the use of insulin sensitizing agents, such as metformin, which appear to ameliorate the biochemical profile and improve reproductive function.

Ovarian hyperstimulation syndrome and its effect on renal function in a renal transplant patient undergoing IVF treatment: case report

Ovarian hyperstimulation syndrome (OHSS) in a renal transplant patient undergoing assisted conception treatment is reported. A couple with infertility secondary to tubal blockage and pelvic endometriosis received IVF treatment. Ovarian enlargement secondary to OHSS resulted in obstruction in the transplanted kidney and deterioration of renal function. No other systemic manifestations of OHSS were evident. Conservative management was successful and a twin live birth was later achieved by replacement of two frozen-thawed embryos.

Definition and measurement of follicle stimulating hormone

FSH has a key role in the development and function of the reproductive system and is widely used both diagnostically and therapeutically in developmental and reproductive medicine. The accurate measurement of FSH levels, in patients for diagnosis and monitoring and in therapeutic preparations for clinical use, is essential for safe and successful treatment. Historically, FSH was defined on the basis of classical in vivo endocrine activity, and early therapeutic preparations were calibrated using in vivo bioassays. There was early recognition that reference preparations were required for calibration if the results from different laboratories were to be comparable. In response to the perceived need, the World Health Organization established the first standard for such preparations in 1959. Subsequent developments in biotechnology have led to recognition that there is no single molecule that can be uniquely defined as FSH, and that FSH can induce a range of biological activities. Several highly purified standards for FSH are now available, but discontinuity and heterogeneity of estimates of FSH activity in terms of these standards made using in vitro assays and binding assays have been noted. It is thus essential that any measurement of FSH include specification both of the standard with which the measured FSH is compared and the assay method used for that comparison.

Follicular development and hormonal levels following highly purified or recombinant follicle-stimulating hormone administration in ovulatory women undergoing ovarian stimulation after pituitary suppression for in vitro fertilization: implications for implantation potential

PURPOSE

The main goal in the present study was to compare follicular development and estradiol levels after ovarian stimulation in pituitary suppressed normally ovulating women undergoing IVF, using highly purified urinary follicle stimulating hormone (FSH) (u-FSH-HP) and recombinant FSH (rec-FSH). A secondary variable in our study was embryo implantation potential, which is closely related to appropriate follicular development and oocyte competence.

METHODS

For the main purpose of this study, 30 IVF patients (group 1) were treated during IVF consecutive cycles, using the same stimulation protocol, with u-FSH-HP in the first treatment study cycle and rec-FSH in the second one. As a control group (group 2) for implantation rates obtained in cycles treated with rec-FSH, 30 additional IVF patients were included who underwent a second IVF attempt again with u-FSH-HP.

RESULTS

The total dose of FSH used and ovarian response obtained in terms of estradiol plasma levels and the total number of growing follicles on the day of human chronic gonadotropin (HCG) injection were similar in both treatment cycles in group 1 but better follicular dynamics and oocyte maturity were obtained with rec-FSH. The implantation rate was significantly higher in rec-FSH treated cycles in patients in group 1 than in control women (group 2).

CONCLUSIONS

rec-FSH is more efficacious than u-FSH-HP when used in the same patient in inducing multiple follicular development in down-regulated cycles as indicated by ovarian performance and oocyte maturity. In addition, rec-FSH yields significantly higher implantation rates than u-FSH-HP when used in patients undergoing their second IVF attempt.

Endocrine methods of ovulation induction

The rationale of ovulation induction is to achieve the development of a single follicle and ultimately a singleton healthy baby. Problems faced by women with anovulatory polycystic ovary syndrome are the sensitivity of the ovary to stimulation and health issues such as obesity. This chapter will discuss medical management including strategies to lose weight, address hyperinsulinaemia with insulin-sensitizing agents, such as metformin, and outline methods of ovulation induction from the usual first-line therapy of clomiphene citrate and the subsequent use of gonadotrophin therapy in clomiphene-resistant patients. Appropriately directed surgical ovulation induction with laparoscopic ovarian diathermy appears to be as efficacious as gonadotrophin therapy but will not be discussed in the context of this chapter.

A comparative study of fixed-dose, step-down, and low-dose step-up regimens of human menopausal gonadotropin for patients with polycystic ovary syndrome

OBJECTIVE

To compare the efficacy and safety of the fixed-dose, the step-down, and the low-dose step-up regimens of hMG for women with polycystic ovary syndrome (PCOS).

DESIGN

Prospective randomized study.

SETTING

Gunma University School of Medicine, Maebashi, Japan.

PATIENT(S)

Thirty-seven women with PCOS.

INTERVENTION(S)

The fixed-dose, the step-down. and the low-dose step-up regimens were administered.

MAIN OUTCOME MEASURE(S)

The number of growing follicles and serum hormone levels.

RESULT(S)

Serum FSH levels on the day of hCG administration were significantly higher in the fixed-dose regimen group than in the step-down and the low-dose step-up regimen groups, and the number of growing follicles (> or =11 mm) in the low-dose step-up regimen group was significantly smaller than in the fixed-dose regimen group. On the 7th day after hCG administration, the maximal diameter of the ovaries in the low-dose step-up regimen group was significantly smaller than in the fixed-dose and the step-down regimen groups, and the risk of excessive ovarian enlargement (> or =70 mm) was significantly lower in the low-dose step-up regimen group than in the fixed-dose regimen group.

CONCLUSION

The low-dose step-up regimen of hMG for patients with PCOS may be the safest protocol among the three stimulation regimens for reducing multiple follicular development.

Engineering human glycoprotein hormone superactive analogues

We report the generation of superactive analogues of human glycoprotein hormones, with potential applications in thyroid and reproductive disorders. Current biological and structural data were used to rationalize mutagenesis. The 11-20 region in the alpha-subunit with a cluster of lysine residues forms a previously unrecognized domain critical for receptor binding and signal transduction, as well as an important motif in the evolution of glycoprotein hormone activities. The gradual elimination of basic residues in the alpha-subunit coincided with the evolutionary divergence of the hominids from the Old World monkeys. By selective reconstitution of certain critical residues present in homologous nonhuman hormones we have developed human thyroid stimulating hormone and chorionic gonadotropin analogues with substantial increases in receptor binding affinity and bioactivity, thus providing a paradigm for the design of novel therapeutic protein analogues.