Requirements for human chorionic gonadotropin and recombinant human luteinizing hormone for follicular development and maturation

A Narrative Review Discussing the Efficiency of Personalized Dosing Algorithm of Follitropin Delta for Ovarian Stimulation and the Reproductive and Clinical Outcomes

Background: Follitropin delta is the third recombinant human follicle-stimulating hormone (r-hFSH) expressed in a host cell line of human fetal retinal origin that currently emphasizes that the actual tendency of administration is a personalized dosing algorithm based on the anti-Müllerian hormone (AMH) and body mass index (BMI) for ovarian stimulation. Methods: In this context, we aimed, in the present manuscript, to gather all available data published between 2018-2022 regarding the co-administration and administration of follitropin delta and the clinical outcomes reported following an in vitro fertilization (IVF). Results: Follitropin delta is non-inferior in contrast to its previously launched agents for ovarian stimulation, enhancing a similar-to-superior response reflected by both the reproductive and pregnancy outcomes in parallel with a low risk of ovarian hyperstimulation syndrome (OHSS), being well tolerated. The body weight and AMH level are factors that may influence the outcome in a patient. Despite controversy and results that refute these arguments on several occasions, follitropin delta exceeds the benefits of conventional dosing with either follitropin alfa or follitropin beta. Thus, all post hoc, derived analyses and subsets of patients that participated in subsequent studies support this statement. Conclusions: Despite the relatively limited spectrum of data in the current literature, most authors brought potent proof, supporting the subsequent use of this drug depending on the patient's profile and overcoming ethnic-related limitations. Although others contradict these observations, this topic and drug possess substantial potential, which is why additional studies are mandatory to fill the existing gaps in our knowledge and expand these experiences at a larger scale supported by the obtained reproductive and clinical outcomes that clearly indicate an overcoming of all limitations.

OUP accepted manuscript

STUDY QUESTION

SUMMARY ANSWER

WHAT IS KNOWN ALREADY

STUDY DESIGN, SIZE, DURATION

PARTICIPANTS/MATERIALS, SETTING, METHODS

MAIN RESULTS AND THE ROLE OF CHANCE

LIMITATIONS, REASONS FOR CAUTION

WIDER IMPLICATIONS OF THE FINDINGS

STUDY FUNDING/COMPETING INTEREST(S)

TRIAL REGISTRATION NUMBER

TRIAL REGISTRATION DATE

DATE OF FIRST PATIENT’S ENROLMENT

GnRH triggering may improve euploidy and live birth rate in hyper-responders: a retrospective cohort study

PURPOSE

Despite the increasing use of GnRHa to trigger final oocyte maturation in segmented IVF cycles, the effects of trigger modality on chromosomal competence and embryo quality remain controversial. Hence, the purpose of this study was to compare euploidy rates and pregnancy outcomes among hyper-responding women using hCG versus GnRHa trigger.

METHODS

This retrospective study included 333 hyper-responders, defined as >15 oocytes retrieved, who underwent preimplantation genetic testing (PGT-A) in segmented IVF cycles using either GnRHa or urinary hCG trigger. Live birth rate (LBR) was the primary outcome of interest. Implantation rate (IR), clinical pregnancy rate (CPR), and euploidy rate were secondary outcomes.

RESULTS

GnRH triggering was associated with improved IR (70.5 vs. 53.2%, p = 0.0475), LBR (51.3 vs. 33.8%, p = 0.0170) compared to hCG. A greater number of oocytes were retrieved (21.9 vs 18.4%, p < 0.001) and euploid embryos produced (2.8 vs. 2.1, p = 0.0109) after GnRHa triggering, while higher euploidy rates were only observed among women <35-years-old (62.0 vs. 51.7%, p = 0.0307) using GnRHa trigger. Higher OHSS rates were observed after hCG triggering (10.6 vs. 2.1%, p = 0.0009).

CONCLUSION

Hyper-responders who received GnRHa trigger experienced improved pregnancy outcomes and lower rates of OHSS compared to hCG triggering. The higher number of oocytes retrieved and euploid embryos produced may reflect an improved developmental competence using GnRHa triggering due to physiologic induction of both LH and FSH surge or other undefined mechanisms that improve embryo development. However, higher overall euploid rates were only observed among women <35-years-old using the GnRHa trigger. Further prospective studies are required to validate this observation and evaluate the specific influence of different ovulation triggers on gamete developmental competence among hyper-responder women.

Administration of Gonadotropins for Superovulation in Mice

For experiments that require large numbers of preimplantation mouse embryos, such as microinjection of zygotes, gonadotropins are administered to females before mating to increase the number of oocytes that are ovulated (i.e., to induce superovulation). Pregnant mare serum gonadotropin (PMSG) is used to mimic the oocyte maturation effect of the endogenous follicle-stimulating hormone (FSH), and human chorionic gonadotropin (hCG) is used to mimic the ovulation induction effect of luteinizing hormone (LH).

Does supplementation with recombinant luteinizing hormone prevent ovarian hyperstimulation syndrome in down regulated patients undergoing recombinant follicle stimulating hormone multiple follicular stimulation for IVF/ET and reduces cancellation rate for high risk of hyperstimulation?

Aim of this study was to assess the efficacy of recombinant luteinizing hormone (rLH) supplementation in late follicular phase in multiple follicular stimulation with recombinant follicle stimulating hormone (rFSH) in Triptoreline down-regulated patients undergoing IVF, on preventing clinical OHSS and cycles cancellation for OHSS risk. Nine hundred ninety-nine patients aged ≤ 40 with basal FSH ≤ 12 mUI/Ml were down-regulated before starting rFSH stimulation for oocytes recovery. Patients were allocated in two groups: (A) (501 patients) treated with 150 IU of rFSH eventually adjusting rFSH dosage day 7 of stimulation until recombinant human chorionic gonadotropin (rhCG) administration, (B) (498 patients) treated with 150 IU of rFSH and 75 IU of rLH since day 7 of stimulation until rhCG administration and adjusting rFSH at the same day. E2 the day of rhCG was higher in group B (p < 0.0001); number of cycles cancelled in group A (42/8.3%) for risk of ovarian hyperstimulation syndrome (OHSS) was higher than group B (12/2.4%) (p < 0.000001). We observed an increase in pregnancies in group B compared with group A (16.8% vs 11.9%) (p < 0.05) and we observed also a larger number of clinical OHSS in group A than in group B (p < 0.05).

Effects of long-acting recombinant human follicle-stimulating hormone analogs containing N-linked glycosylation on murine folliculogenesis

OBJECTIVE

To evaluate the efficacy of two novel long-acting rhFSH analogs, rhFSH-N2 and rhFSH-N4, in stimulating murine folliculogenesis.

DESIGN

Experimental study.

SETTING

Academic research environment.

ANIMAL(S)

Immature female mice.

INTERVENTION(S)

Recombinant hFSH-N2 and -N4 were administered via single IP injection to 3-week-old female mice (n = 10) who were killed 48 hours later for dissection and histologic examination of reproductive organs and serum inhibin A. Results were compared with other groups of mice who received either single or q 12 hour injections for 48 hours of commercial rhFSH, or a single injection of pregnant mare serum gonadotropin (PMSG). A subgroup of the mice receiving rhFSH-N4 was supplemented with daily injections of small doses of hCG to simulate LH add-back.

MAIN OUTCOME MEASURE(S)

Serum inhibin A levels, ovarian and uterine weights, and ovarian antral follicle counts.

RESULTS(S)

Recombinant human FSH-N2 and -N4 administration induced a statistically significant increase in ovarian weights, uterine weights, and inhibin A levels compared with single and twice-daily injection of rhFSH. PMSG induced the greatest increases in all three measured parameters. There was no statistical difference between rhFSH-N2 and rhFSH-N4 for any parameter analyzed. A single injection of rhFSH-N2 or -N4 induced a greater number of antral follicles than did either single or q 12 hour injections of rhFSH. The addition of small doses of hCG to rhFSH-N4 increased inhibin A levels and antral follicle number to reach statistical equivalence to PMSG treatment.

CONCLUSION(S)

Addition of a synthetic polypeptide containing two or four N-linked glycosylation sites to rhFSH increases in vivo bioactivity of the hormone compared to commercial rhFSH. After a single injection, both rhFSH-N2 and rhFSH-N4 effectively induced a greater follicular response in the mouse than did rhFSH.

Use of recombinant FSH and recombinant LH in multiple follicular stimulation for IVF: a preliminary study

Twelve patients (17 cycles) who needed >3000 IU of recombinant FSH (rFSH) on previous follicular stimulation attempts for IVF using rFSH (group A) underwent further attempts (a total of 12 cycles) using rFSH supplemented with rLH from day 7 of stimulation (group B). There was no significant difference in the total quantitative administration of rFSH (mean: 4759 versus 4800 IU rFSH), days of stimulation (14.0 versus 12.6), number of M2 oocytes per patient (3.76 versus 4.17) or embryo morphology between group A and group B respectively. However, there was a significant increase in the incidence of fertilization (60.9 versus 86.0%; P = 0.006) and clinical (ongoing) pregnancies (1 versus 6; P = 0.022). The higher incidence of fertilization increased the mean number of embryos transferred per patient, although in this small group the data was not significant (1.75 versus 2.71). This preliminary clinical trial suggests that in poor responders superimposing rLH upon a down-regulated cycle stimulated with rFSH improves relevant outcome data; and this preliminary trial has encouraged the need for a larger and more detailed study.

The clinical therapeutic window for luteinizing hormone in controlled ovarian stimulation

OBJECTIVE

To discuss the clinical therapeutic window for LH during the follicular phase.

DESIGN

Review of selected papers that were retrieved through a Medline search and a review of clinical trials, the results of which are in the process of publication.

PATIENT(S)

Women undergoing infertility treatment.

INTERVENTION(S)

Recombinant human LH (r-hLH) was administered SC as a supplement to FSH during controlled ovarian hyperstimulation.

MAIN OUTCOME MEASURE(S)

Follicular development, E2 production, and endometrial thickness.

RESULT(S)

Optimal follicular maturation is the result of both FSH and LH stimulation. In patients with hypogonadotropic hypogonadism, 75 IU of r-hLH and 150 IU of FSH per day resulted in more follicles and provided sufficient E2 for optimal endometrial proliferation. Additional r-hLH (>250 IU/day), in patients with either hypogonadotropic hypogonadism or polycystic ovary disease, may precipitate a series of deleterious physiological actions leading to atresia of developing follicles. Adding r-hLH to FSH in women treated with GnRH agonist showed no benefits in terms of number of mature oocytes, fertilization, and cleavage. However, those who experience profound pituitary desensitization may benefit from adding LH to the stimulation protocol. No obvious clinical criteria have been established to define this group of patients.

CONCLUSION(S)

A "threshold" and "ceiling" level for LH (therapeutic window) is proposed, below which E2 production is not adequate and above which LH may be detrimental to follicular development.

Effect of gonadotrophin dose on oocyte retrieval in superovulated BALB/c mice

Mice are commonly used animal models in reproductive and developmental research. In order to get satisfying results from such experiments, large numbers of ova must be available and this can be achieved by using various ovulation induction protocols. To obtain an optimal response from these stimulation protocols, parameters such as breeding-housing conditions of the animal strains, the best age for superovulation, and type and dose of gonadotrophins must be optimized. The aim of this study was to investigate the impact of exogenous stimulation with increasing amounts of gonadotrophins on the number and quality of oocytes/pre-embryos recovered from outbred BALB/c mice. A dose-response analysis was performed by stimulating prepubescent (21- to 25-day-old) and sexually mature (6 to 8 weeks old) female mice with hMG, which contains equal amounts of follicle-stimulating hormone (FSH) and luteinizing hormone (LH). The stimulation dose contained 5, 10, 15, 20, 25 or 30 IU of FSH/LH. The effect of increasing stimulation was assessed by monitoring the number and maturity of ova recovered from the tubes. The data were analyzed by using a one-way Anova test and student t-test. Increasing stimulation doses in the prepubescent females resulted in an increased number of ova. A maximum of 55 ova per mouse was reached when stimulating with 20 IU of FSH/LH; higher stimulation doses showed no further increase in oocyte recovery. In the prepubescent group, a maximal number of recovered mature ova was reached with 15 IU of FSH/LH. In the sexually mature female group, 20 IU of FSH/LH gave the best quantitative and qualitative results. Positive effects of copulation on the number and maturity of oocytes in all induction doses were more evident in the prepubescent females and these parameters were significantly more improved (P < 0.05) in this group when compared to the pubertal females. Our findings led to the conclusion that ovulation induction of prepubescent outbred BALB/c mice with 15 IU FSH/LH and sexually mature ones with 20 IU FSH/LH give the best results in terms of oocyte number and maturity.