A pharmacokinetic and endocrine comparison of recombinant follicle-stimulating hormone and human menopausal gonadotrophin in polycystic ovary syndrome

DuoStim - a reproducible strategy to obtain more oocytes and competent embryos in a short time-frame aimed at fertility preservation and IVF purposes. A systematic review

Recent evidence suggests that follicular development occurs in a wave-like model during the ovarian cycle, where up to three cohorts of follicles are recruited to complete folliculogenesis. This understanding overtakes the previous dogma stating that follicles grow only during the follicular phase of the menstrual cycle. Therefore, in in vitro fertilization (IVF), novel protocols regarding ovarian stimulation have been theorized based on the use of gonadotrophins to prompt the growth of antral follicles at any stage of the menstrual cycle. These unconventional protocols for ovarian stimulation aim at a more efficient management of poor-prognosis patients, otherwise exposed to conflicting outcomes after conventional approaches. DuoStim appears among these unconventional stimulation protocols as one of the most promising. It combines two consecutive stimulations in the follicular and luteal phases of the same ovarian cycle, aimed at increasing the number of oocytes retrieved and embryos produced in the short time-frame. This protocol has been suggested for the treatment of all conditions requiring a maximal and urgent exploitation of the ovarian reserve, such as oncological patients and poor responders at an advanced maternal age. At present, data from independent studies have outlined the consistency and reproducibility of this approach, which might also reduce the drop-out between consecutive failed IVF cycles in poor-prognosis patients. However, the protocol must be standardized, and more robust studies and cost-benefit analyses are needed to highlight the true clinical pros and cons deriving from DuoStim implementation in IVF.

Apoptotic effect of cordycepin combined with cisplatin and/or paclitaxel on MA-10 mouse Leydig tumor cells

Background

Chemotherapy is not limited to a single treatment, and the evidence demonstrates that different drug combinations can have positive results in patients. In this study, we sought to determine whether cordycepin combined with cisplatin and/or paclitaxel would have an additive effective on inducing apoptosis in mouse Leydig tumor cells, and the mechanisms were also briefly examined.

Methods

The additive effects of cordycepin combined with cisplatin and/or paclitaxel on apoptosis in MA-10 cells were investigated by monitoring changes in morphological characteristics and examining cell viability, flow cytometry assays, and Western blot analyses.

Results

Combination of cordycepin plus cisplatin and/or paclitaxel for 12 and 24 hours induced apoptotic features in MA-10 cells. The MTT assay showed that the combination treatment reduced the viability of MA-10 cells in a dose-dependent manner, with additive effects. Cell cycle analysis showed that combination treatment significantly increased subG1 phase cell numbers in MA-10 cells, indicating apoptosis. Moreover, cordycepin plus cisplatin and/or paclitaxel significantly induced cleavage of caspase-8, caspase-9, caspase-3, and poly ADP-ribose polymerase, and phosphorylation of c-Jun NH2-terminal kinase, extracellular signal-regulated kinase, p38, and p53 proteins in MA-10 cells.

Conclusion

Cordycepin plus cisplatin and/or paclitaxel can have an additive effect on apoptosis in MA-10 cells, with activation of caspase, mitogen-activated protein kinase, and p53 signal pathways.

Live-birth rates after HP-hMG stimulation in the long GnRH agonist protocol: association with mid-follicular hCG and progesterone concentrations, but not with LH concentrations

The aim of this retrospective study was to investigate the impact of endogenous and exogenous luteinizing hormone (LH) activity on treatment outcome, when taking into consideration potential confounding variables. Data were derived from IVF patients (n = 358) stimulated with highly purified menotrophin (HP-hMG) in a long gonadotrophin-releasing hormone (GnRH) agonist protocol. Simple retrospective logistic regression analysis showed that the mid-follicular exogenous concentrations of human chorionic gonadotrophin (hCG) (p = 0.027), provided by the HP-hMG preparation, and female age (p = 0.009) were significantly associated with live-birth rate, while the mid-follicular progesterone concentration (p = 0.075), the estradiol concentration on last stimulation day (p = 0.075) and number of embryos transferred (p = 0.071) were borderline significant. Endogenous LH was not associated with live-birth rate; neither at start of stimulation (p = 0.123), nor in the mid-follicular phase (p = 0.933) or on the last day of stimulation (p = 0.589). In the multiple regression analysis of life birth, mid-follicular hCG (p = 0.016) was identified as a positive predictor, and age (p = 0.004) and mid-follicular progesterone (p = 0.029) as negative predictors. In conclusion, mid-follicular concentrations of exogenous hCG and progesterone, but not endogenous LH, are associated with live-birth rate in IVF patients treated with HP-hMG in a long GnRH agonist cycle.

Exogenous hCG activity, but not endogenous LH activity, is positively associated with live birth rates in anovulatory infertility

Objective

To evaluate, retrospectively, the roles of endogenous and exogenous luteinising hormone (LH) activity on live birth rate in ovulation induction cycles.

Methods

Associations between LH activity at baseline, end of stimulation and live birth rate were analysed in relation to patient characteristics, baseline and end of stimulation variables in WHO group II anovulatory women (n=155) stimulated with recombinant follicle-stimulating hormone (rFSH) or highly purified human menopausal gonadotrophin (HP-hMG). HP-hMG provides FSH and exogenous LH activity mainly in the form of human chorionic gonadotrophin (hCG).

Results

Serum LH concentrations at baseline or end of stimulation were not predictive of live birth rate in the rFSH group (n=79) or HP-hMG group (n=76). Serum hCG concentration at end of stimulation was a significant positive predictor in HP-hMG-treated women. Other variables were not independently predictive of live birth in either of the groups, except for a negative association between serum FSH concentrations at the start of stimulation and live birth in the rFSH-treated group.

Conclusions

Endogenous LH concentrations are not predictive of live birth in anovulatory WHO group II patients undergoing ovulation induction with rFSH or HP-hMG. On the other hand, exogenous hCG activity during HP-hMG stimulation is positively associated with treatment outcome.

LH in the follicular phase: neither too high nor too low

The role of LH in the natural menstrual cycle is not disputed. However, there are a variety of opinions regarding the potential role of exogenous LH in ovulation induction and whether it is actually needed. Recent years have seen renewed interest in this issue for several reasons. First, ovulation-inducing drugs are increasingly being administered to normally ovulating women. Second, recombinant human FSH products completely devoid of LH activity are now available. Third, gonadotrophin-releasing hormone (GnRH) analogues (agonists and antagonists) prevent the untimely LH surge but also suppress endogenous LH activity during the follicular phase. This review analyses whether or not all patients need LH for follicular growth stimulation and new opportunities for improved treatment as a result of the availability of recombinant human LH both in patients with ovulatory disorders (World Health Organization (WHO) groups I and II anovulatory patients) and those undergoing multiple follicular development for assisted reproduction.

Treatment of female infertility with recombinant human luteinising hormone: is there a benefit over other available drugs?

This manuscript reviews the role of recombinant human luteinising hormone (rhLH) as a therapeutic drug in ovarian stimulation for assisted reproductive technology (ART) and ovulation induction. For this purpose, the role of LH during the follicular phase and during the ovulatory surge, along with the role of human chorionic gonadotropin (hCG) as a surrogate LH, is reviewed and compared to the results available with the new rhLH formulation. The use of rhLH was found to be safe and highly effective given during the follicular phase and to mimic an endogenous LH surge. The availability of both LH and follicle stimulating hormone (FSH) as separate recombinant preparations enables physicians to adjust the doses of each gonadotropin to the individual patient according to the 'therapeutic window' concept for each drug to maximise the success of ovarian stimulation.

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.

Oocyte quality in patients with severe ovarian hyperstimulation syndrome: a self-controlled clinical study

OBJECTIVE

To investigate the oocyte quality in patients with severe ovarian hyperstimulation syndrome (OHSS).

DESIGN

Self-controlled clinical study.

SETTING

University teaching hospital.

PATIENT(S)

Twenty-two patients from our assisted reproductive technology (ART) program who developed severe OHSS during their first controlled ovarian hyperstimulation for IVF or intracytoplasmic sperm injection (ICSI) (OHSS cycles) during a period of 10 years and had a second ART attempt performed in our center in which OHSS did not develop (control cycles).

INTERVENTION(S)

IVF and ICSI.

MAIN OUTCOME MEASURE(S)

Oocyte yield and quality, fertilization rate, embryo yield and quality, implantation rate, and pregnancy rate.

RESULT(S)

The total number of oocytes retrieved and the mean number of metaphase II oocytes were significantly higher in patients with OHSS than in control cycles. Fertilization rates were similar in both groups of ART cycles, and thus the number of viable embryos were significantly higher in OHSS cycles. Implantation and pregnancy rates were similar in OHSS and control cycles. Oocyte and embryo yield and quality were similar in early and late OHSS. Oocyte yield and quality, embryological outcome, and implantation and pregnancy rates were similar in patients with and without polycystic ovarian syndrome (PCOS) both in cycles developing OHSS and control cycles.

CONCLUSION(S)

Oocyte quality is not compromised in severe OHSS cycles irrespective of whether patients had or did not have PCOS.