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

Le syndrome des ovaires polykystiques (SOPK)

Polycystic ovaries syndrome (PCOS) is one of the most common female hormonal disorders. Its multiple components--reproductive, metabolic, neoplasic and cardiovascular--have a major impact on the public health. Androgen excess and resistance to insulin, probably from genetic origin, are responsible for most of the clinical symptomatology. Resistance to insulin seems to be accompanied by a greater risk of glucose intolerance, type 2 diabetes, lipidic anomalies and can involve the development of cardiovascular diseases. In addition, sleep apnea syndrome is more progressively described in PCOS. Infertility, menses disorders and hirsutism often push these patients to consult their physician. A better understanding of the physiopathological mechanisms led to the emergence of new therapeutic options increasing the sensitivity to insulin. Besides the pregnancy wishes, cares aim to attenuate the marks of the hyper-androgenism (hormonal treatment and cosmetic) and to correct cardiovascular, respiratory and gynaecological risk factors. In case of infertility by anovulation, cares must be performed by trained experts to minimize the risk of ovarian hyper-stimulation syndrome and multiple pregnancies. A gradation from loose weight to clomiphene citrate ovulation induction, ovarian drilling, low dose gonadotropin, in vitro fertilisation, or in vitro maturation of oocytes should bring back good reproduction potential.

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.

Pregnancy complications in PCOS

Complications of pregnancy associated with maternal PCOS include increased prevalence of early pregnancy loss (EPL), gestational diabetes (GDM), pregnancy-induced hypertensive disorders (PET/PIH), and the birth of small-for-gestational-age (SGA) babies. Increased risk of EPL has been attributed to obesity, hyperinsulinaemia, elevated luteinizing hormone concentrations, and endometrial dysfunction. Avoiding obesity before pregnancy and treatment with metformin are therapeutic options, also for the increased prevalence of GDM. Administration of metformin throughout pregnancy is a contentious issue. Screening pregnant women with PCOS for GDM and PET/PIH-especially if they are obese-is recommended, although data for a firm association between PCOS and PET/PIH is weak. Impaired insulin-mediated growth and fetal programming are possible explanations for a higher prevalence of SGA infants in mothers with PCOS. Only prospective studies employing a large cohort of women with well-defined PCOS compared with a control group matched for BMI and parity can solve the remaining questions.

Ovulation induction: a mini review

Ovulation induction is the method for treating anovulatory infertility. For patients with hypogonadotrophic hypogonadism, the treatment involves administration of both FSH and LH, while HCG is injected for follicle rupture. Pulsatile GnRH has the same effectiveness as gonadotrophins and the advantage of the low multiple pregnancy rate. In polycystic ovary syndrome (PCOS), the first treatment choice is clomiphene citrate. With this drug, in properly selected patients, the cumulative pregnancy rate approaches that of normal women. Low-dose protocols of FSH are the second line of treatment, effective in inducing monofollicular development. Laparoscopic ovarian drilling can be an alternative but not as a first choice treatment in clomiphene-resistant patients. Other treatments, such as pulsatile GnRH and GnRH agonists, are hardly used today in PCOS. However, in obese women with PCOS, weight loss and exercise should be recommended as the first line of therapy. Newer agents including aromatase inhibitors and insulin sensitizers, although promising, need further evaluation.

The role of luteinizing hormone activity in controlled ovarian stimulation

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

Gonadotrophin treatment in patients with polycystic ovary syndrome

Gonadotrophin treatment in clomiphene citrate resistant polycystic ovarian syndrome (PCOS) patients, using either low-dose step-up or low-dose step-down protocols, is highly effective to achieve singleton live births. Concomitant use of gonadotrophin releasing hormone analogues (GnRHa), which will block the endogenous feedback for monofollicular development during the low-dose step-up protocol, should not be employed. It is more difficult to induce ovulation in patients with more 'severe' PCOS, characterized by obesity and insulin resistance. There is need for optimization of starting doses for both the low-dose step-up and step-down protocols. Such optimization will prevent hyperstimulation due to a starting dose far above the FSH threshold, as well as minimize the time-consuming low-dose increments by starting with a higher dose in women with augmented FSH threshold. External validation of reported models for prediction of FSH response is warranted for tailoring and optimizing treatment for everyday clinical practice. Although preliminary, the partial cessation of follicular development, along with regression leading to atresia, lends support to the LH ceiling theory, emphasizing the delicate balance and need for both FSH and LH in normal follicular development. Future well-designed randomized controlled trials will reveal whether IVF with or without in-vitro maturation of the oocytes will improve safety and efficacy compared with classical ovulation induction strategies.

Management of infertility and prevention of ovarian hyperstimulation in women with polycystic ovary syndrome

Anovulatory infertility is a prevalent presenting feature of polycystic ovary syndrome (PCOS). Restoration of ovulation might be achieved by ovarian stimulation or by reducing insulin and LH concentrations. Clomiphene citrate is the first-line ovulation-inducing agent, usually followed by direct stimulation with follicle stimulating hormone (FSH), if unsuccessful. The prevalent complications of ovarian hyperstimulation syndrome and multiple pregnancies can largely be avoided by administering FSH in a low dose and individualized regimen. Hyperinsulinaemia can be corrected by weight loss or insulin-sensitizing agents, such as metformin, which alone or in combination with other agents are capable of restoring ovulation. Advice about weight loss is critical in modern management of PCOS and infertility. Laparoscopic ovarian drilling produces similar results to FSH stimulation, and in vitro fertilization/embryo transfer (IVF/ET)-if all else fails-produces excellent results. The possible use of aromatase inhibitors, novel insulin sensitizers and in vitro maturation of oocytes is still being evaluated. The plethora of treatment options available today ensures that the great majority of women who are subfertile due to PCOS can be treated successfully.

The management of infertility associated with polycystic ovary syndrome

Polycystic ovary syndrome [PCOS] is the commonest cause of anovulatory infertility. Treatment modes available are numerous mainly relying on ovarian stimulation with FSH, a reduction in insulin concentrations and a decrease in LH levels as the basis of the therapeutic principles. Clomiphene citrate is still the first line treatment and if unsuccessful is usually followed by direct FSH stimulation. This should be given in a low dose protocol, essential to avoid the otherwise prevalent complications of ovarian hyperstimulation syndrome and multiple pregnancies. The addition of a GnRH agonists, while very useful during IVF/ET, adds little to ovulation induction success whereas the position of GnRH antagonists is not yet clear. Hyperinsulinemia is the commonest contributor to the state of anovulation and its reduction, by weight loss or insulin sensitizing agents such as metformin, will alone often restore ovulation or will improve results when used in combination with other agents. Laparoscopic ovarian drilling is proving equally as successful as FSH for the induction of ovulation, particularly in thin patients with high LH concentrations. Aromatase inhibitors are presently being examined and may replace clomiphene in the future. When all else has failed, IVF/ET produces excellent results. In conclusion, there are very few women suffering from anovulatory infertility associated with PCOS who cannot be successfully treated today.

Comparison of the effectiveness of recombinant and urinary FSH preparations in the achievement of follicular selection in chronic anovulation

In order to compare the effectiveness of urinary and recombinant FSH (rFSH) preparations in achieving the threshold of follicular growth, stimulated cycles from patients with chronic anovulation, treated with a constant dose of FSH until the emergence of a selected follicle, were retrospectively analysed. Sixty-four cycles were performed using a similar starting dose of either urinary FSH (group 1) or rFSH (group 2), which was kept constant up to the time of follicular selection, assessed on ultrasound (follicular diameter >10 mm). The results of this study showed that, while the number of selected follicles was similar, the mean daily FSH dose required to achieve the threshold of follicular selection was significantly lower in group 2 (70.4 +/- 3.4 IU/day) than in group 1 (86.5 +/- 4 IU/day; P < 0.005). Furthermore, at the time of human chorionic gonadotrophin (HCG) administration, the total FSH dose was significantly lower in group 2 than in group 1, but plasma oestradiol values were equivalent. These data suggest that the higher effectiveness of rFSH preparations over urinary ones may be explained by a lower threshold dose required to achieve follicular selection.

Correction of hyperinsulinemia in oligoovulatory women with clomiphene-resistant polycystic ovary syndrome: a review of therapeutic rationale and reproductive outcomes

Polycystic ovary syndrome (PCOS) describes a convergence of chronic multisystem endocrine derangements, including irregular menses, hirsutism, obesity, hyperlipidemia, androgenization, large and cystic-appearing ovaries, insulin resistance and subfertility. Few PCOS patients exhibit all of these features, and often only one sign or symptom is evident. The sequelae of PCOS reach beyond reproductive health, as women affected with PCOS have increased relative risks for myocardial infarction, hypertension, ischemic heart disease, thromboembolic disease and diabetes. Although the adverse health consequences associated with PCOS are substantial, unfortunately most women are not aware of these risks. Indeed, in infertility practice such concerns are secondary as most patients are referred for treatment specifically to achieve a pregnancy. Impairments in insulin metabolism appear central to the physiologic cascade of PCOS, yet clomiphene therapy fails to remedy this defect. Several investigators have described satisfactory reproductive outcomes for PCOS patients treated with oral insulin-lowering agents. In this report, we outline a diagnostic and therapeutic approach for women with PCOS refractory to clomiphene with attention to the underlying insulin imbalance associated with impaired fertility.

Urinary follicle-stimulating hormone for normogonadotropic clomiphene-resistant anovulatory infertility: prospective, randomized comparison between low dose step-up and step-down dose regimens

A low dose step-up and step-down regimen for induction of ovulation using urinary FSH was compared in a prospective randomized fashion in 37 normogonadotropic clomiphene-resistant oligo- or amenorrheic infertile women. The objectives was to assess potential differences in duration of treatment, ovarian stimulation (serum FSH levels), and response [serum estradiol (E2) levels and number and size of follicles]. Monitoring (blood sampling and transvaginal sonography) took place on the day of initiation of treatment, the first day of ovarian response as assessed by ultrasound (i.e. the first day a follicle > or = 10 mm could be recognized), the day of hCG administration to induce ovulation, and 3 days thereafter. The median duration of treatment in the low dose step-up group was 18 (range, 7-41) days compared to 9 (range, 4-16) days in the step-down group (P = 0.003), and the total numbers of ampules administered were 20 (range, 7-69) and 14 (range, 7-33), respectively (P = NS). Serum FSH levels from the first day of sonographic ovarian response until the administration of hCG were constant (median increase, 2%/day) in patients receiving the low dose step-up protocol, but showed a decrease (median, 5%/day) in step-down cycles (P < 0.001). Monofollicular growth, defined as not more than one follicle 16 mm or larger on the day of hCG administration, was observed in 56% of low dose step-up and 88% of step-down cycles (P = 0.04). The percentage of patients with normal range periovulatory E2 serum levels (500-1500 pmol/L) was 33% in the low dose step-up group vs. 71% in the step-down group (P = 0.03). We conclude that a step-down protocol for gonadotropin induction of ovulation exhibits a more physiological, late follicular phase FSH serum profile than a low dose step-up protocol. This results in a shorter duration of treatment, a greater number of monofollicular cycles, and more cycles with periovulatory E2 levels within the normal range in the step-down protocol.