Human chorionic gonadotropin administration does not increase plasma androgen levels in patients undergoing controlled ovarian hyperstimulation

Influence of multiple injections of human chorionic gonadotropin (hCG) on urine and serum endogenous steroids concentrations

Since it is established that human chorionic gonadotropin (hCG) affects testosterone production and release in the human body, the use of this hormone as a performance enhancing drug has been prohibited by the World Anti-Doping Agency. Nowadays, the only validated biomarker of a hCG doping is its direct quantification in urine. However, this specific parameter is subjected to large inter-individual variability and its determination is directly dependent on the reliability of hCG immunoassays used. In order to counteract these weaknesses, new biomarkers need to be evidenced. To address this issue, a pilot clinical study was performed on 10 volunteers submitted to 3 subsequent hCG injections. Blood and urine samples were collected during two weeks in order to follow the physiological effects on related compounds such as the steroid profile or hormones involved in the hypothalamo-pituitary axis. The hCG pharmacokinetic observed in all subjects was, as expected, prone to important inter-individual variations. Using ROC plots, level of testosterone and testosterone on luteinizing hormone ratio in both blood and urine were found to be the most relevant biomarker of a hCG abuse, regardless of inter-individual variations. In conclusion, this study showed the crucial importance of reliable quantification methods to assess low differences in hormonal patterns. In regard to these results and to anti-doping requirements and constraints, blood together with urine matrix should be included in the anti-doping testing program. Together with a longitudinal follow-up approach it could constitute a new strategy to detect a hCG abuse, applicable to further forms of steroid or other forbidden drug manipulation.

Role of androgens in the treatment of patients with low ovarian response

The objective of the current report was to provide a summary of knowledge concerning the treatment of women with poor ovarian response with androgens and androgen modulating agents. This involved a review of the literature. The literature search was performed using PubMed. Information concerning the role of androgens and androgen modulating agents in treating women with poor ovarian response is limited. The search of the literature yielded five studies and one case report concerning the treatment of poor responders with androgens. The variations in patient selection, type of androgens employed and the different duration of exposure preclude drawing any definite conclusions. Aromatase inhibitors block the conversion of androgens to oestrogens, thereby promoting an androgen-rich intrafollicular environment. The evidence presented in this review suggests a potential beneficial role for the use of aromatase inhibitors in treating women who have previously experienced failure of standard IVF protocols. The optimal dose and duration of this treatment is yet to be determined. Although the results of studies concerning LH supplementation in poor responders are conflicting, the latest Cochrane review on the use of recombinant LH for ovarian stimulation supports its use in poor responders, based on pooled pregnancy estimates.

The use of metformin for women with PCOS undergoing IVF treatment

BACKGROUND

Metformin appears to improve reproductive function in some women with polycystic ovary syndrome (PCOS). We wished to explore the effect of metformin in women with PCOS undergoing IVF.

METHODS

A randomized, placebo-controlled, double-blind study was carried out between 2001 and 2004. Patients with PCOS undergoing IVF/ICSI treatment using a long GnRH agonist protocol were randomized to receive metformin (MET), 850 mg, or placebo (PLA) tablets twice daily from the start of the down-regulation process until the day of oocyte collection. The primary outcome was to be an improvement in the overall fertilization rate.

RESULTS

One-hundred and one IVF/ICSI cycles were randomized to receive metformin (52) or to receive placebo (49). There was no difference in the total dose of rFSH required per cycle (median dose: MET = 1200 U, PLA = 1300 U; P = 0.937). The median number of oocytes retrieved per cycle (MET = 17.2, PLA = 16.2; P = 0.459) and the overall fertilization rates (MET = 52.9%, PLA = 54.9%; P = 0.641) did not differ. However, both the clinical pregnancy rates beyond 12 weeks gestation per cycle (MET = 38.5%, PLA = 16.3%; P = 0.023) and per embryo transfer (MET = 44.4%, PLA = 19.1%; P = 0.022) were significantly higher in those treated with metformin. Furthermore, a significant decrease in the incidence of severe ovarian hyperstimulation syndrome (OHSS) was observed (MET = 3.8%, PLA = 20.4%; P = 0.023), and this was still significant after adjustment for BMI, total rFSH dose and age (OR = 0.15; 95% CI: 0.03, 0.76; P = 0.022).

CONCLUSION

Short-term co-treatment with metformin for patients with PCOS undergoing IVF/ICSI cycles does not improve the response to stimulation but significantly improves the pregnancy outcome and reduces the risk of OHSS.

Serum androgen levels in patients undergoing controlled ovarian hyperstimulation for in vitro fertilization cycles

AIM

To investigate androgen behavior during controlled ovarian hyperstimulation (COH) for in vitro fertilization (IVF).

DESIGN

A prospective, observational study.

SETTING

An IVF unit of an academic medical center.

PATIENTS AND METHODS

Blood was drawn three times during the COH cycle from 17 consecutive patients undergoing the long gonadotropin-releasing hormone-analog protocol: the day on which adequate suppression was obtained (Day-S); the day of or prior to administration of human chorionic gonadotropin (Day-hCG); and (3) the day of ovum pick-up (Day-OPU).

RESULTS

There was a significant increase in serum sex steroid levels during gonadotropin treatment. After hCG administration, there was a significant increase in levels of serum 17-hydroxyprogesterone (17-OHP) and ovarian androgens (total and free testosterone and androstenedione), with no significant change in adrenal androgen (dehydroepiandrosterone sulfate). Significant correlations were observed between plasma estradiol (E(2)) and androgen levels during COH and until hCG administration, but not after hCG administration. The E(2)/testosterone ratio increased significantly during COH and until hCG administration, and then decreased significantly. The number of oocytes retrieved correlated significantly with serum 17-OHP, E(2) and E(2)/testosterone ratio. The number of gonadotropin ampoules used correlated inversely only with serum E(2) levels.

CONCLUSION

In patients undergoing COH for IVF, androgen levels increase in response to gonadotropin, and then again after hCG administration. Although the E(2)/testosterone ratio correlates with the number of oocytes retrieved, androgen levels do not.

Ovarian androgens but not estrogens correlate with the degree of systemic inflammation observed during controlled ovarian hyperstimulation

AIM

To investigate the behavior and association of serum androgen and serum C-reactive protein (CRP) in patients undergoing controlled ovarian hyperstimulation (COH) for in vitro fertilization (IVF).

DESIGN

Prospective, observational study.Setting. An IVF unit of an academic medical center.

PATIENTS AND METHODS

Blood was drawn three times during the COH cycle from 15 patients undergoing the long gonadotropin-releasing hormone-analog protocol: the day on which adequate suppression was obtained (Day-S); the day of or prior to administration of human chorionic gonadotropin (Day-hCG); and the day of ovum pick-up (Day-OPU). Levels of sex steroids and serum CRP were compared among the three time points.

RESULTS

There was a significant increase in serum ovarian androgen levels during gonadotropin treatment. After hCG administration, there was a significant increase in the levels of both serum CRP and ovarian androgens (testosterone, androstenedione), with no significant change in adrenal androgen (dehydroepiandrosterone). Significant correlations were observed between CRP and ovarian androgen levels but not with dehydroepiandrosterone sulfate or estradiol levels.

CONCLUSION

In patients undergoing COH for IVF, ovarian androgen levels increase in correlation with the degree of inflammation, as reflected by CRP levels. Further studies are necessary to elucidate whether androgens play a role in or are predictive of the systemic inflammatory response in COH.

Per-follicle measurements indicate that anti-müllerian hormone secretion is modulated by the extent of follicular development and luteinization and may reflect qualitatively the ovarian follicular status

OBJECTIVE

To investigate the possible influence of follicular maturation and luteinization on anti-müllerian hormone (AMH) secretion and the relationship between per-follicle AMH levels, ovarian follicular status, and responsiveness to controlled ovarian hyperstimulation (COH).

DESIGN

Prospective study.

SETTING

University hospital in France.

PATIENT(S)

Thirty seven in vitro fertilization/embryo transfer candidates undergoing COH.

INTERVENTION(S)

On the day of oocyte retrieval, serum samples and follicular fluids from two small (8-12 mm in diameter) and two large (16-20 mm in diameter) follicles were collected for AMH, E2, and progesterone (P4) measurements.

MAIN OUTCOME MEASURE(S)

Per-follicle AMH levels.

RESULT(S)

Small follicles secreted AMH levels that were approximately three times as high as large follicles. Follicular fluid AMH and P4 levels were negatively correlated to each other both in small and large follicles. Per-follicle AMH levels in both follicular classes were positively correlated with antral follicle count on cycle day 3 before COH and with growing follicle (> or =12 mm) count and oocytes retrieved, but negatively correlated with FSH requirement.

CONCLUSION(S)

Both final follicular maturation and luteinization interfere with granulosa cell AMH production. The relationship between intrafollicular AMH content, the surrounding follicular status, and ovarian response to COH indicates that peripheral AMH levels reflect not only follicle count but also per-follicle AMH production.

Dynamics of serum anti-Müllerian hormone levels during the luteal phase of controlled ovarian hyperstimulation

BACKGROUND

To investigate the dynamics of serum anti-Müllerian hormone (AMH) levels during the luteal phase of controlled ovarian hyperstimulation (COH) and its possible association with follicle development.

METHODS

We prospectively studied 34 women undergoing COH with GnRH agonist and FSH. On the day of hCG (dhCG), serum AMH, estradiol (E2), progesterone and hCG levels were measured, and ovarian follicles were sorted into three size classes: <12, 12-15 and 16-22 mm. Hormonal measurements were repeated 4 days (hCG + 4) and 7 days (hCG + 7) after hCG.

RESULTS

From dhCG to hCG + 4, we observed a decline in serum AMH levels (-64 +/- 3%; P < 0.0001), which paralleled that of E2 levels. From hCG + 4 to hCG + 7, an increase in AMH levels occurred (82 +/- 28%; P < 0.02), whose magnitude was correlated with the number of < 12 mm follicles (r = 0.68; P < 0.0001) but not with other follicle size classes nor with the remaining hormone levels.

CONCLUSIONS

After hCG, AMH levels initially decline, presumably as an effect of follicle luteinization, then increase during the mid-luteal phase. Although the mechanisms implicated in the mid-luteal AMH increase are unclear, its positive association with small follicle count, but not with luteal progesterone and E2 levels, supports the hypothesis that AMH levels might reflect luteal follicle development.

Assessing uterine receptivity in 2001: ultrasonographic glances at the new millennium

The understanding and control of embryo implantation represents the major challenge for assisted reproductive technologies. Along with developments in basic research and efforts to optimize embryo quality, the improvement of noninvasive and reliable methods to assess uterine receptivity constitutes an important step toward meeting such a challenge. Today, ultrasound-based approaches to evaluate endometrial echogenicity and uterine perfusion and contractility are available for practical use. Increasing evidence indicates that echogenic patterns of the endometrium reflect histologic processes that are involved in the establishment of receptivity. This constitutes a possible explanation for the reported association between premature hyperechogenic patterns of the endometrium and poor implantation rates. Nevertheless, additional studies aiming at correlating further morpho-biochemical events in the endometrium with its echogenicity patterns are needed. Further, developments in vascular assessment by Doppler, Doppler-related, and vascular detection technologies will also be instrumental in monitoring and improving vascular changes that lead to uterine receptivity. Finally, data supporting the hypothesis that uterine contractility, as visualized by ultrasound, influences in vitro fertilization-embryo transfer (IVF-ET) pregnancy rates encourage further investigation on both the regulation and control of uterine contractions. This article discusses some of the advantages and limitations of ultrasonographic assessments of uterine receptivity in the perspective of the new millennium.

Effects of vaginal progesterone administration on uterine contractility at the time of embryo transfer

OBJECTIVE

To investigate whether uterine contractility at the time of embryo transfer (ET) can be reduced by early onset of luteal support with progesterone administered vaginally.

DESIGN

Prospective analysis.

SETTING

Assisted reproduction unit.

PATIENT(S)

Eighty-four women undergoing 84 GnRH-a and FSH/hCG cycles for IVF-ET were studied.

INTERVENTION(S)

Vaginal progesterone was randomly started on the day of oocyte retrieval (group A, n = 43) or on the evening of ET (group B, n = 41). On the day of hCG administration and just before ET, 2-minute sagittal uterine scans were obtained by ultrasound and digitized with an image analysis system for assessing uterine contraction frequency.

MAIN OUTCOME MEASURE(S)

Uterine contraction frequency.

RESULT(S)

Whereas uterine contraction frequency was similar in both groups on the day of hCG (4.6 +/- 0.3 and 4.5 +/- 0.3 contractions per minute, respectively), only women in group A showed decreased uterine contraction frequency on the day of ET (2.8 +/- 0.2 vs. 4.2 +/- 0.3 contractions per minute).

CONCLUSION(S)

Vaginal progesterone administration starting on the day of oocyte retrieval induced a decrease in uterine contraction frequency on the day of ET as compared with preovulatory values. Uterine relaxation before ET is likely to improve IVF-ET outcome by avoiding the displacement of embryos from the uterine cavity.