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Naseem H, Lokman M, Fitzgerald C. Management of congenital hypogonadotropic hypogonadism in females. HUM FERTIL 2023; 26:622-631. [PMID: 34753367 DOI: 10.1080/14647273.2021.1998929] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2020] [Accepted: 08/02/2021] [Indexed: 10/19/2022]
Abstract
This review explores the challenges in the diagnosis of hypogonadotropic hypogonadism, the transition of care from paediatric to adult care and the considerable health implications of this condition. The role gynaecologists and general practitioners have in managing hormone replacement therapy and reproductive potential is also highlighted. The fertility treatment options, which include ovulation induction with gonadotrophins and in-vitro fertilisation, are discussed in detail along with highlighting the fact that anovulation and markers of low ovarian reserve prior to priming treatment may not be reflective of poor reproductive potential. The holistic management of women with hypogonadotropic hypogonadism is still not standardised and evidence for subfertility management is scarce. This review aims to highlight this concern and provide guidance by evaluating current evidence.
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Affiliation(s)
- Hafiza Naseem
- Reproductive Medicine Department, Saint Mary's Hospital, Manchester University NHS Foundation Trust, Manchester, United Kingdom
| | - Mariam Lokman
- Reproductive Medicine Department, Saint Mary's Hospital, Manchester University NHS Foundation Trust, Manchester, United Kingdom
| | - Cheryl Fitzgerald
- Reproductive Medicine Department, Saint Mary's Hospital, Manchester University NHS Foundation Trust, Manchester, United Kingdom
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Kim D, Lee S, Cho YH, Kang MJ, Ku CR, Chi H, Ahn J, Lee K, Han J, Chi S, Song MY, Cha SH, Lee EJ. Long-acting recombinant human follicle-stimulating hormone (SAFA-FSH) enhances spermatogenesis. Front Endocrinol (Lausanne) 2023; 14:1132172. [PMID: 36909328 PMCID: PMC9996080 DOI: 10.3389/fendo.2023.1132172] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/26/2022] [Accepted: 02/13/2023] [Indexed: 02/25/2023] Open
Abstract
INTRODUCTION Administration of follicle-stimulating hormone (FSH) has been recommended to stimulate spermatogenesis in infertile men with hypogonadotropic hypogonadism, whose sperm counts do not respond to human chorionic gonadotropin alone. However, FSH has a short serum half-life requiring frequent administration to maintain its therapeutic efficacy. To improve its pharmacokinetic properties, we developed a unique albumin-binder technology, termed "anti-serum albumin Fab-associated" (SAFA) technology. We tested the feasibility of applying SAFA technology to create long-acting FSH as a therapeutic candidate for patients with hypogonadotropic hypogonadism. METHODS SAFA-FSH was produced using a Chinese hamster ovary expression system. To confirm the biological function, the production of cyclic AMP and phosphorylation of ERK and CREB were measured in TM4-FSHR cells. The effect of gonadotropin-releasing hormone agonists on spermatogenesis in a hypogonadal rat model was investigated. RESULTS In in vitro experiments, SAFA-FSH treatment increased the production of cyclic AMP and increased the phosphorylation of ERK and CREB in a dose-dependent manner. In animal experiments, sperm production was not restored by human chorionic gonadotropin treatment alone, but was restored after additional recombinant FSH treatment thrice per week or once every 5 days. Sperm production was restored even after additional SAFA-FSH treatment at intervals of once every 5 or 10 days. DISCUSSION Long-acting FSH with bioactivity was successfully created using SAFA technology. These data support further development of SAFA-FSH in a clinical setting, potentially representing an important advancement in the treatment of patients with hypogonadotropic hypogonadism.
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Affiliation(s)
- Daham Kim
- Department of Internal Medicine, Institute of Endocrine Research, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Soohyun Lee
- Department of Internal Medicine, Institute of Endocrine Research, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Yoon Hee Cho
- Department of Internal Medicine, Institute of Endocrine Research, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Min Jeong Kang
- Department of Internal Medicine, Institute of Endocrine Research, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Cheol Ryong Ku
- Department of Internal Medicine, Institute of Endocrine Research, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Hyunjin Chi
- AprilBio Co., Ltd., Rm 602, Biomedical Science Building, Kangwon National University, Chuncheon, Republic of Korea
| | - Jungsuk Ahn
- AprilBio Co., Ltd., Rm 602, Biomedical Science Building, Kangwon National University, Chuncheon, Republic of Korea
| | - Kyungsun Lee
- AprilBio Co., Ltd., Rm 602, Biomedical Science Building, Kangwon National University, Chuncheon, Republic of Korea
| | - Jaekyu Han
- AprilBio Co., Ltd., Rm 602, Biomedical Science Building, Kangwon National University, Chuncheon, Republic of Korea
| | - Susan Chi
- AprilBio Co., Ltd., Rm 602, Biomedical Science Building, Kangwon National University, Chuncheon, Republic of Korea
| | - Moo Young Song
- AprilBio Co., Ltd., Rm 602, Biomedical Science Building, Kangwon National University, Chuncheon, Republic of Korea
| | - Sang-Hoon Cha
- AprilBio Co., Ltd., Rm 602, Biomedical Science Building, Kangwon National University, Chuncheon, Republic of Korea
| | - Eun Jig Lee
- Department of Internal Medicine, Institute of Endocrine Research, Yonsei University College of Medicine, Seoul, Republic of Korea
- *Correspondence: Eun Jig Lee,
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Bøtkjær JA, Kristensen SG, Olesen HØ, Larsson P, Mannaerts B, Andersen CY. Dose-dependent stimulation of human follicular steroidogenesis by a novel rhCG during ovarian stimulation with fixed rFSH dosing. Front Endocrinol (Lausanne) 2022; 13:1004596. [PMID: 36339420 PMCID: PMC9632659 DOI: 10.3389/fendo.2022.1004596] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2022] [Accepted: 10/04/2022] [Indexed: 11/13/2022] Open
Abstract
Background Choriogonadotropin (CG) beta (FE 999302), a novel recombinant human (h)CG produced by a human cell line, has a longer half-life and higher potency than CG alfa produced by a Chinese hamster ovary cell line. hCG augments steroid production, but the extent of which CG beta treatment during ovarian stimulation (OS) increases steroidogenesis is unknown. Objective To explore how increasing doses of CG beta during OS augment follicular steroidogenesis and change gene expression in cumulus cells. Study design This study is part of a randomized, double-blind, placebo-controlled trial to investigate the efficacy and safety of CG beta plus recombinant follicle-stimulating hormone (rFSH) in women undergoing OS during a long gonadotrophin-releasing hormone agonist protocol. The study primary endpoint was intrafollicular steroid concentrations after CG beta administration. Secondary outcomes were gene expression of FSHR , LHR, CYP19a1, and androgen receptor (AR). Participants/methods 619 women with anti-Müllerian hormone levels 5-35 pmol/L were randomized to receive placebo or 1, 2, 4, 8, or 12 µg/day CG beta from Day 1 of OS plus rFSH. Follicular fluid (FF) (n=558), granulosa (n=498) and cumulus cells (n=368) were collected at oocyte retrieval. Steroid FF hormones were measured using enzyme-linked immunosorbent assays, gene expression was analyzed in cumulus cells by quantitative reverse transcriptase polymerase chain reaction (qRT-PCR) and single nucleotide polymorphism (SNP) analysis was performed in granulosa cells. Results 17-OH-progesterone, androstenedione, testosterone, and estradiol concentrations significantly increased in a CG-beta dose-dependent manner during OS (p<0.0001), reaching up to 10 times higher values in the highest dose group versus placebo. There was no difference between CG beta dose groups and placebo for progesterone. Expression levels of CYP19a1 increased significantly in the highest dose group of CG beta (p=0.0325) but levels of FSHR , LHR and AR were not affected by CG beta administration. There were no differences between the FSHR (307) or LHR(312) SNP genotypes for dose-dependent effects of CG beta in relation to number of oocytes, intrafollicular steroid hormone levels, or gene expression levels. Conclusions These results reflect the importance of the combined effect of FSH and hCG/LH during OS on granulosa cell activity, follicle health and potentially oocyte quality. Trial Registration number 2017-003810-13 (EudraCT Number). Trial Registration date 21 May 2018. Date of first patient’s enrolment 13 June 2018. Presented at the 38th Annual Meeting of the European Society of Human Reproduction and Embryology, P-567, 2022.
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Affiliation(s)
- Jane Alrø Bøtkjær
- Laboratory of Reproductive Biology, University Hospital of Copenhagen, Rigshospitalet, Copenhagen, Denmark
| | - Stine Gry Kristensen
- Laboratory of Reproductive Biology, University Hospital of Copenhagen, Rigshospitalet, Copenhagen, Denmark
| | - Hanna Ørnes Olesen
- Laboratory of Reproductive Biology, University Hospital of Copenhagen, Rigshospitalet, Copenhagen, Denmark
| | - Per Larsson
- Global Biometrics, Ferring Pharmaceuticals A/S, Copenhagen, Denmark
| | - Bernadette Mannaerts
- Reproductive Medicine & Maternal Health, Ferring Pharmaceuticals A/S, Copenhagen, Denmark
| | - Claus Yding Andersen
- Laboratory of Reproductive Biology, University Hospital of Copenhagen, Rigshospitalet, Copenhagen, Denmark
- Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
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Vyrides AA, El Mahdi E, Giannakou K. Ovulation induction techniques in women with polycystic ovary syndrome. Front Med (Lausanne) 2022; 9:982230. [PMID: 36035398 PMCID: PMC9411864 DOI: 10.3389/fmed.2022.982230] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2022] [Accepted: 07/25/2022] [Indexed: 11/13/2022] Open
Abstract
Anovulation is very common and has several different clinical manifestations, including amenorrhea, oligomenorrhea and abnormal uterine bleeding. Various mechanisms can cause anovulation. The clinical consequences and commonest chronic anovulatory disorder, polycystic ovary syndrome (PCOS), has a prevalence that ranges between 6 to 10% of the global population. While multiple causes can eventually result in PCOS, various methods have been described in the literature for its management, often without ascertaining the underlying cause. Ovulation Induction (OI) is a group of techniques that is used in women with PCOS who are looking to conceive and are unbale to do so with natural means. This narrative review presents a summary of the current evidence and available techniques for OI in women with PCOS, highlighting their performance and applicability.
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Affiliation(s)
- Andreas A. Vyrides
- Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, United Kingdom
| | - Essam El Mahdi
- Department of Obstetrics and Gynecology, Newham University Hospital NHS Trust, London, United Kingdom
| | - Konstantinos Giannakou
- Department of Health Sciences, School of Sciences, European University Cyprus, Nicosia, Cyprus
- *Correspondence: Konstantinos Giannakou
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Meng F, Yao H, Li J, Zhuo Y, Yu G, Bu G, Cao X, Du X, Liang Q, Zeng X, Han X. Effects of active immunization against a 13-amino acid receptor-binding epitope of FSHβ on fertility regulation in female mice. Reprod Biol 2022; 22:100669. [PMID: 35772190 DOI: 10.1016/j.repbio.2022.100669] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2021] [Revised: 06/19/2022] [Accepted: 06/21/2022] [Indexed: 10/17/2022]
Abstract
Follicle-stimulating hormone (FSH) is crucial for ovarian folliculogenesis and thus essential for female fertility. Here, we developed a novel FSH vaccine based on the tandem of a 13-amino acid receptor-binding epitope of FSHβ (FSHβ13AA-T) and used a mouse model to test its efficacy in female fertility regulation. Compared to placebo-immunized controls, FSHβ13AA-T vaccination: induced a marked (P < 0.05) antibody generation; reduced (P < 0.05) serum concentrations of FSH, inhibin B and 17β-estradiol; disrupted (P < 0.05) normal estrous cyclicity; delayed (P = 0.08) establishment of pregnancy; blocked (P < 0.05) folliculogenesis; and reduced (P < 0.05) litter size. Mechanistically, FSH vaccination reduced (P < 0.05) ovarian estrogen production by decreasing Lhcgr, Cyp19a1 and HSD3β1 expression, and suppressed ovarian follicular development by decreasing ovarian Fshr, Inhα, Foxo3a, Bmp15 and Cdh1 expression. Overall, vaccination of female mice with FSHβ13AA-T substantially disrupted FSH-dependent ovarian steroidogenesis and folliculogenesis, and caused subfertility. Therefore, vaccines based on FSHβ13AA-T have potential as anti-fertility/contraceptive agents in females.
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Affiliation(s)
- Fengyan Meng
- Isotope Research Lab, Biological Engineering and Application Biology Department, Sichuan Agricultural University, Ya'an 625014, China
| | - Huan Yao
- Isotope Research Lab, Biological Engineering and Application Biology Department, Sichuan Agricultural University, Ya'an 625014, China
| | - Jiaxin Li
- Isotope Research Lab, Biological Engineering and Application Biology Department, Sichuan Agricultural University, Ya'an 625014, China
| | - Yong Zhuo
- Key Laboratory for Animal Disease-Resistant Nutrition of the Ministry of Education of China, Animal Nutrition Institute, Sichuan Agricultural University, Chengdu 611130, China
| | - Guozhi Yu
- Isotope Research Lab, Biological Engineering and Application Biology Department, Sichuan Agricultural University, Ya'an 625014, China
| | - Guixian Bu
- Isotope Research Lab, Biological Engineering and Application Biology Department, Sichuan Agricultural University, Ya'an 625014, China
| | - Xiaohan Cao
- Isotope Research Lab, Biological Engineering and Application Biology Department, Sichuan Agricultural University, Ya'an 625014, China
| | - XiaoGang Du
- Isotope Research Lab, Biological Engineering and Application Biology Department, Sichuan Agricultural University, Ya'an 625014, China
| | - Qiuxia Liang
- Isotope Research Lab, Biological Engineering and Application Biology Department, Sichuan Agricultural University, Ya'an 625014, China
| | - Xianyin Zeng
- Isotope Research Lab, Biological Engineering and Application Biology Department, Sichuan Agricultural University, Ya'an 625014, China
| | - Xingfa Han
- Isotope Research Lab, Biological Engineering and Application Biology Department, Sichuan Agricultural University, Ya'an 625014, China.
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Shiraiwa A, Takahashi T, Okoshi C, Wada M, Ota K, Suganuma R, Jimbo M, Soeda S, Watanabe T, Yoshida-Komiya H, Fujimori K. Successful pregnancy and delivery after a vitrified-warmed embryo transfer in a woman with Kallmann syndrome: A case report and literature review. Fukushima J Med Sci 2022; 68:49-55. [PMID: 35314524 PMCID: PMC9071358 DOI: 10.5387/fms.2021-09] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Kallmann syndrome, a congenital disorder of idiopathic hypogonadotropic hypogonadism associated with anosmia, results in infertility because of anovulation. Assisted reproductive technology (ART) is considered when optimal ovulation induction therapy is difficult or when several cycles of ovulation induction therapy do not result in pregnancy. However, evidence is lacking regarding the optimal ART treatment for Kallmann syndrome. We report the case of a 33-year-old woman who successfully achieved pregnancy and delivery after ART treatment. At 29 years old, she was diagnosed with Kallmann syndrome due to hypothalamic amenorrhea and anosmia. At 33 years old, she revisited the hospital, desiring a child after one year of infertility. Due to anovulation, she was treated with gonadotropin therapy, but controlling follicular development was difficult, and thus ART treatment was initiated. The controlled ovarian stimulation (COS) protocol for ART treatment employed gonadotropins, recombinant follicular stimulating hormone/human menopausal gonadotropin plus human chorionic gonadotropin, to promote follicular growth. Four oocytes were retrieved, and two cleaved embryos were vitrified and cryopreserved. After vitrified-warmed embryo transfer of a morula stage embryo in a hormone replacement cycle, pregnancy was achieved but resulted in a miscarriage. A second oocyte retrieval was performed under the same COS; four oocytes were retrieved, and two cleaved embryos were vitrified and cryopreserved. Further, a pregnancy was achieved through the vitrified warmed embryo transfer. At 40 weeks and 6 days of gestation, a baby boy weighing 3,344 g with an Apgar score of 7/8 was delivered vaginally. The mother’s postpartum course and neonate were free from adverse events. For women with Kallmann syndrome, ART treatment and selective embryo cryopreservation may be a reasonable and safe option.
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Affiliation(s)
- Aya Shiraiwa
- Department of Obstetrics and Gynecology, Fukushima Medical University School of Medicine
| | - Toshifumi Takahashi
- Fukushima Medical Center for Children and Women, Fukushima Medical University
| | - Chihiro Okoshi
- Department of Obstetrics and Gynecology, Fukushima Medical University School of Medicine
| | - Marina Wada
- Department of Obstetrics and Gynecology, Fukushima Medical University School of Medicine
| | - Kuniaki Ota
- Fukushima Medical Center for Children and Women, Fukushima Medical University
| | - Ryota Suganuma
- Department of Obstetrics and Gynecology, Fukushima Medical University School of Medicine
| | - Masatoshi Jimbo
- Fukushima Medical Center for Children and Women, Fukushima Medical University
| | - Shu Soeda
- Department of Obstetrics and Gynecology, Fukushima Medical University School of Medicine
| | - Takafumi Watanabe
- Department of Obstetrics and Gynecology, Fukushima Medical University School of Medicine
| | - Hiromi Yoshida-Komiya
- Department of Obstetrics and Gynecology, Fukushima Medical University School of Medicine
| | - Keiya Fujimori
- Department of Obstetrics and Gynecology, Fukushima Medical University School of Medicine
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Abdelaal AE, Behery MA, Abdelkawi AF. Reproductive outcomes in women with hypogonadotrophic hypogonadism, a case series study. MIDDLE EAST FERTILITY SOCIETY JOURNAL 2021. [DOI: 10.1186/s43043-021-00055-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
Hypogonadotropic hypogonadism (HH) is a rare condition in which there is gonadal hypofunction due to absence of gonadotropin drive. In this condition, there are very low serum levels of gonadotropins. Pituitary gland may itself have some disease or disorder, or there may be loss of gonadotropin-releasing hormone (GnRH) pulses from the hypothalamus. The pharmacological interventions in HH women formed the basis for superovulation strategies for assisted reproduction techniques (ART) with a special reference to the role of LH and its impact on oocyte and embryo quality.
Results
The medians ±inter quartile ranges for number of oocytes retrieved, number of MII oocytes, and number of embryos transferred were 5±7, 4±3, and 3±1 respectively. The pregnancy rate was 31.5% for this group of patients. The live birth rate and miscarriage rate were 21% and 11.5% respectively.
Conclusion
The reproductive outcomes of patients of hypogonadotrophic hypogonadism are reasonable after ICSI and clinical trials are recommended to corroborate this concern.
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Gordon CM, Ackerman KE, Berga SL, Kaplan JR, Mastorakos G, Misra M, Murad MH, Santoro NF, Warren MP. Functional Hypothalamic Amenorrhea: An Endocrine Society Clinical Practice Guideline. J Clin Endocrinol Metab 2017; 102:1413-1439. [PMID: 28368518 DOI: 10.1210/jc.2017-00131] [Citation(s) in RCA: 224] [Impact Index Per Article: 32.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2017] [Accepted: 02/23/2017] [Indexed: 02/04/2023]
Abstract
COSPONSORING ASSOCIATIONS The American Society for Reproductive Medicine, the European Society of Endocrinology, and the Pediatric Endocrine Society. This guideline was funded by the Endocrine Society. OBJECTIVE To formulate clinical practice guidelines for the diagnosis and treatment of functional hypothalamic amenorrhea (FHA). PARTICIPANTS The participants include an Endocrine Society-appointed task force of eight experts, a methodologist, and a medical writer. EVIDENCE This evidence-based guideline was developed using the Grading of Recommendations, Assessment, Development, and Evaluation approach to describe the strength of recommendations and the quality of evidence. The task force commissioned two systematic reviews and used the best available evidence from other published systematic reviews and individual studies. CONSENSUS PROCESS One group meeting, several conference calls, and e-mail communications enabled consensus. Endocrine Society committees and members and cosponsoring organizations reviewed and commented on preliminary drafts of this guideline. CONCLUSIONS FHA is a form of chronic anovulation, not due to identifiable organic causes, but often associated with stress, weight loss, excessive exercise, or a combination thereof. Investigations should include assessment of systemic and endocrinologic etiologies, as FHA is a diagnosis of exclusion. A multidisciplinary treatment approach is necessary, including medical, dietary, and mental health support. Medical complications include, among others, bone loss and infertility, and appropriate therapies are under debate and investigation.
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Affiliation(s)
| | - Kathryn E Ackerman
- Boston Children's Hospital, Boston, Massachusetts 02115
- Massachusetts General Hospital, Boston, Massachusetts 02114
| | - Sarah L Berga
- Wake Forest School of Medicine, Winston-Salem, North Carolina 27157
| | - Jay R Kaplan
- Wake Forest School of Medicine, Winston-Salem, North Carolina 27157
| | - George Mastorakos
- Areteio Hospital, Medical School, National and Capodistrian University of Athens, Athens, Greece 10674
| | | | - M Hassan Murad
- Division of Preventive Medicine, Mayo Clinic, Rochester, Minnesota 55905
| | | | - Michelle P Warren
- Center for Menopause, Hormonal Disorders, and Women's Health, Columbia University Medical Center, New York, New York 10021
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Bry-Gauillard H, Larrat-Ledoux F, Levaillant JM, Massin N, Maione L, Beau I, Binart N, Chanson P, Brailly-Tabard S, Hall JE, Young J. Anti-Müllerian Hormone and Ovarian Morphology in Women With Isolated Hypogonadotropic Hypogonadism/Kallmann Syndrome: Effects of Recombinant Human FSH. J Clin Endocrinol Metab 2017; 102:1102-1111. [PMID: 28324034 DOI: 10.1210/jc.2016-3799] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2016] [Accepted: 01/24/2017] [Indexed: 02/13/2023]
Abstract
CONTEXT Isolated hypogonadotropic hypogonadism (IHH), characterized by gonadotropin deficiency and absent puberty, is very rare in women. IHH prevents pubertal ovarian stimulation, but anti-Müllerian hormone (AMH) and antral follicle count (AFC) have not been studied. OBJECTIVES (1) To compare, in IHH vs controls, AMH, ovarian volume (OV), and AFC. (2) To compare, in IHH, ovarian responses to recombinant human follicle-stimulating hormone (rhFSH) and rhFSH plus recombinant human luteinizing hormone (rhLH). SUBJECTS Sixty-eight IHH women; 51 matched healthy women. METHODS Serum LH, FSH, sex steroids, inhibin B (InhB), AMH, and OV and AFC (sonography) were compared. Ovarian response during rhFSH administration was assessed in 12 IHH women with low AMH levels and low AFC and compared with hormonal changes observed in six additional IHH women receiving rhFSH plus rhLH. RESULTS InhB was lower in IHH than in controls. AMH levels were also significantly lower in the patients, but two-thirds had normal values. Mean OV and total, larger, and smaller AFCs were lower in IHH than in controls. Ovarian stimulation by rhFSH led to a significant increase in serum estradiol and InhB levels and in the number of larger antral follicles. AMH and smaller AFC increased early during rhFSH stimulation but then declined despite continued stimulation. rhFSH plus rhLH stimulation led to a significantly higher increase in estradiol levels but to similar changes in circulating InhB and AMH than with rhFSH alone. CONCLUSIONS IHH women have both low AMH levels and low AFC. However, their decrease can be reversed by follicle-stimulating hormone. Serum AMH and AFC should not serve as prognostic markers of fertility in this population.
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Affiliation(s)
- Hélène Bry-Gauillard
- Assistance Publique-Hôpitaux de Paris
- Department of Reproductive Endocrinology
- Medical Procreation Unit, Gynecology-Obstetrics Department, University of Paris XII, Créteil Hospital, 94000 Créteil, France
| | | | - Jean-Marc Levaillant
- Assistance Publique-Hôpitaux de Paris
- Department of Gynecology-Obstetrics, and
- University of Paris-Sud, Paris-Sud Medical School, 94276 Le Kremlin-Bicêtre, France
- Medical Procreation Unit, Gynecology-Obstetrics Department, University of Paris XII, Créteil Hospital, 94000 Créteil, France
| | - Nathalie Massin
- Medical Procreation Unit, Gynecology-Obstetrics Department, University of Paris XII, Créteil Hospital, 94000 Créteil, France
| | - Luigi Maione
- Assistance Publique-Hôpitaux de Paris
- Department of Reproductive Endocrinology
- Department of Hormonology and Molecular Genetics, Bicêtre Hospital, 94275 Le Kremlin-Bicêtre, France
- University of Paris-Sud, Paris-Sud Medical School, 94276 Le Kremlin-Bicêtre, France
| | - Isabelle Beau
- Department of Reproductive Endocrinology
- University of Paris-Sud, Paris-Sud Medical School, 94276 Le Kremlin-Bicêtre, France
- INSERM Unité 1185, 94276 Le Kremlin-Bicêtre, France
| | - Nadine Binart
- University of Paris-Sud, Paris-Sud Medical School, 94276 Le Kremlin-Bicêtre, France
- INSERM Unité 1185, 94276 Le Kremlin-Bicêtre, France
| | - Philippe Chanson
- Assistance Publique-Hôpitaux de Paris
- Department of Reproductive Endocrinology
- University of Paris-Sud, Paris-Sud Medical School, 94276 Le Kremlin-Bicêtre, France
- INSERM Unité 1185, 94276 Le Kremlin-Bicêtre, France
| | - Sylvie Brailly-Tabard
- Assistance Publique-Hôpitaux de Paris
- Department of Hormonology and Molecular Genetics, Bicêtre Hospital, 94275 Le Kremlin-Bicêtre, France
- University of Paris-Sud, Paris-Sud Medical School, 94276 Le Kremlin-Bicêtre, France
- INSERM Unité 1185, 94276 Le Kremlin-Bicêtre, France
| | - Janet E Hall
- Reproductive Endocrine Unit, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts 02114
- Clinical Research Branch, National Institute of Environmental Health Sciences, Research Triangle Park, North Carolina 27709
| | - Jacques Young
- Assistance Publique-Hôpitaux de Paris
- Department of Reproductive Endocrinology
- University of Paris-Sud, Paris-Sud Medical School, 94276 Le Kremlin-Bicêtre, France
- INSERM Unité 1185, 94276 Le Kremlin-Bicêtre, France
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Pharmacokinetics and Pharmacodynamics of Follicle-Stimulating Hormone in Healthy Women Receiving Single and Multiple Doses of Highly Purified Human Menotrophin and Urofollitrophin. Clin Drug Investig 2017; 36:1031-1044. [PMID: 27638053 PMCID: PMC5107195 DOI: 10.1007/s40261-016-0451-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
BACKGROUND AND OBJECTIVE Highly purified human menotrophin and urofollitrophin preparations obtained from human urine via a novel patented purification method have been tested over a timeframe of 14 years in the studies presented in this article. The objective of the studies was to investigate the pharmacokinetics and the pharmacodynamics of follicle-stimulating hormone (FSH) after single subcutaneous and intramuscular doses and multiple subcutaneous doses of the tested preparations in healthy fertile pituitary-suppressed women. DESIGNS We performed five open, randomised, crossover, single-dose bioequivalence and/or bioavailability studies and one open, multiple-dose, pharmacokinetics and pharmacodynamics study. STUDY SUBJECTS AND TREATMENTS The six studies included 121 healthy fertile women taking their usual combined oral contraceptives for 3 months before the study: Study 1: 300 international units (IU) of highly purified menotrophin as single subcutaneous and intramuscular doses. Study 2: 300 IU of highly purified menotrophin (test formulation vs. comparator) as single subcutaneous doses. Study 3: 300 IU of highly purified urofollitrophin (hp-FSH) (test formulation vs. comparator) as single subcutaneous doses. Study 4: 300 IU (2 × 150 IU vs. 4 × 75 IU) of hp-FSH as single subcutaneous doses. Study 5: 225 and 445 IU of hp-FSH as single subcutaneous doses. Study 6: daily 225 IU of hp-FSH as subcutaneous doses for 5 consecutive days. MAIN OUTCOME MEASURES The main outcome measures were the FSH pharmacokinetic parameters, estradiol concentrations, and the number and size of the follicles. RESULTS FSH after single subcutaneous and intramuscular injections of menotrophin or urofollitrophin attained a systemic peak (maximum) concentration (C max) that was on average consistent throughout the first four studies and ranged from 4.98 to 7.50 IU/L. The area under the plasma concentration-time curve (AUC) from administration to the last observed concentration time t (AUCt) ranged from 409.71 to 486.16 IU/L·h and the elimination half-life (t ½) ranged from 39.02 to 53.63 h. After multiple doses of urofollitrophin (225 IU) for 5 days, FSH attained a mean C max of 14.93 ± 2.92 IU/L and had an AUC during the time interval τ between two consecutive doses at steady state (AUCτ) of 322.59 ± 57.92 IU/L·h, which was similar to the mean AUCt after a single subcutaneous dose of 225 IU of urofollitrophin in study 5 (306.82 ± 68.37 IU/L·h). CONCLUSIONS In our studies, the intramuscular and subcutaneous routes of menotrophin were equivalent; both menotrophin and urofollitrophin were bioequivalent to their marketed reference; FSH kinetic parameters following injection of urofollitrophin were dose proportional and independent from the administered concentration; and multiple doses of FSH increased estradiol levels and enhanced growth of follicles with a good dose-response correlation. Local tolerability was excellent throughout the six studies.
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Rinaldi L, Selman H. Profile of follitropin alpha/lutropin alpha combination for the stimulation of follicular development in women with severe luteinizing hormone and follicle-stimulating hormone deficiency. Int J Womens Health 2016; 8:169-79. [PMID: 27307766 PMCID: PMC4888763 DOI: 10.2147/ijwh.s88904] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
A severe gonadotropin deficiency together with chronic estradiol deficiency leading to amenorrhea characterizes patients suffering from hypogonadotropic hypogonadism. Administration of both follicle-stimulating hormone (FSH) and luteinizing hormone (LH) to these patients has been shown to be essential in achieving successful stimulation of follicular development, ovulation, and rescue of fertility. In recent years, the availability of both recombinant FSH (rFSH) and recombinant LH (rLH) has provided a new therapeutic option for the stimulation of follicular growth in hypopituitary–hypogonadotropic women (World Health Organization Group I). In this article, we review the data reported in the literature to highlight the role and the efficacy of using recombinant gonadotropins, rFSH and rLH, in the treatment of women with severe LH/FSH deficiency. Although the studies on this issue are limited and the experiences available in the literature are few due to the small number of such patients, it is clearly evident that the recombinant gonadotropins rFSH and rLH are efficient in treating patients affected by hypogonadotropic hypogonadism. The results observed in the studies reported in this review suggest that recombinant gonadotropins are able to induce proper follicular growth, oocyte maturation, and eventually pregnancy in this group of women. Moreover, the clinical use of recombinant gonadotropins in this type of patients has given more insight into some endocrinological aspects of ovarian function that have not yet been fully understood.
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Boehm U, Bouloux PM, Dattani MT, de Roux N, Dodé C, Dunkel L, Dwyer AA, Giacobini P, Hardelin JP, Juul A, Maghnie M, Pitteloud N, Prevot V, Raivio T, Tena-Sempere M, Quinton R, Young J. Expert consensus document: European Consensus Statement on congenital hypogonadotropic hypogonadism--pathogenesis, diagnosis and treatment. Nat Rev Endocrinol 2015; 11:547-64. [PMID: 26194704 DOI: 10.1038/nrendo.2015.112] [Citation(s) in RCA: 491] [Impact Index Per Article: 54.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
Congenital hypogonadotropic hypogonadism (CHH) is a rare disorder caused by the deficient production, secretion or action of gonadotropin-releasing hormone (GnRH), which is the master hormone regulating the reproductive axis. CHH is clinically and genetically heterogeneous, with >25 different causal genes identified to date. Clinically, the disorder is characterized by an absence of puberty and infertility. The association of CHH with a defective sense of smell (anosmia or hyposmia), which is found in ∼50% of patients with CHH is termed Kallmann syndrome and results from incomplete embryonic migration of GnRH-synthesizing neurons. CHH can be challenging to diagnose, particularly when attempting to differentiate it from constitutional delay of puberty. A timely diagnosis and treatment to induce puberty can be beneficial for sexual, bone and metabolic health, and might help minimize some of the psychological effects of CHH. In most cases, fertility can be induced using specialized treatment regimens and several predictors of outcome have been identified. Patients typically require lifelong treatment, yet ∼10-20% of patients exhibit a spontaneous recovery of reproductive function. This Consensus Statement summarizes approaches for the diagnosis and treatment of CHH and discusses important unanswered questions in the field.
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Affiliation(s)
- Ulrich Boehm
- University of Saarland School of Medicine, Germany
| | | | | | | | | | | | - Andrew A Dwyer
- Endocrinology, Diabetes and Metabolism Sevice of the Centre Hospitalier Universitaire Vaudois (CHUV), du Bugnon 46, Lausanne 1011, Switzerland
| | | | | | | | | | - Nelly Pitteloud
- Endocrinology, Diabetes and Metabolism Sevice of the Centre Hospitalier Universitaire Vaudois (CHUV), du Bugnon 46, Lausanne 1011, Switzerland
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Revelli A, Pettinau G, Basso G, Carosso A, Ferrero A, Dallan C, Canosa S, Gennarelli G, Guidetti D, Filippini C, Benedetto C. Controlled Ovarian Stimulation with recombinant-FSH plus recombinant-LH vs. human Menopausal Gonadotropin based on the number of retrieved oocytes: results from a routine clinical practice in a real-life population. Reprod Biol Endocrinol 2015; 13:77. [PMID: 26209525 PMCID: PMC4514947 DOI: 10.1186/s12958-015-0080-6] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
BACKGROUND The association of recombinant FSH (rFSH) plus recombinant LH (rLH) is currently used for Controlled Ovarian Stimulation (COS) in human IVF, but its efficacy has, to date, not yet been compared to that of human Menopausal Gonadotropin (hMG), the FSH + LH activity-containing urinary drug. METHODS Eight hundred forty-eight (848) IVF patients classified as expected "poor" or "normal" responders according to antral follicle count (AFC) and basal (day 3) FSH were treated with rFSH + rLH (2:1 ratio, n = 398, Group A) or hMG (n = 450, Group B). Data were collected under real-life practice circumstances and the pregnancy rate with fresh embryos was calculated by stratifying patients according to the number of retrieved oocytes (1-2, 3-4, 5-6, 7-8, >8). RESULTS Overall, the pregnancy rate in both groups progressively improved according to the number of oocytes retrieved. When comparing patients within the same subgroup of oocyte yield, Group A and B showed a comparable outcome up to the reported highest yield (>8). When more than 8 oocytes were available, Group A had a significantly better pregnancy rate outcome. Patients' characteristics did not significantly differ between the two groups and the better outcome in the best responding patients in Group A was confirmed by a multivariable logistic regression analysis, that showed that both the use of rFSH + rLH and the total number of retrieved oocytes increased the probability of pregnancy with odd ratio (OR) of 1.628 and 1.083, respectively. CONCLUSIONS When comparing patients with the same number of retrieved oocytes under real-life circumstances, the association of rFSH + rLH results in a significantly higher pregnancy rate than hMG when more than 8 oocytes are retrieved. The reason(s) for this are unknown, but a more favorable effect on oocyte quality and/or endometrial receptivity could be involved.
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Affiliation(s)
- Alberto Revelli
- Gynecology and Obstetrics, Physiopathology of Reproduction and IVF Unit, Department of Surgical Sciences, University of Torino, S. Anna Hospital, Torino, Italy.
- LIVET Infertility and IVF Clinic, Torino, Italy.
| | - Grazia Pettinau
- Gynecology and Obstetrics, Physiopathology of Reproduction and IVF Unit, Department of Surgical Sciences, University of Torino, S. Anna Hospital, Torino, Italy.
| | - Gemma Basso
- Gynecology and Obstetrics, Physiopathology of Reproduction and IVF Unit, Department of Surgical Sciences, University of Torino, S. Anna Hospital, Torino, Italy.
| | - Andrea Carosso
- Gynecology and Obstetrics, Physiopathology of Reproduction and IVF Unit, Department of Surgical Sciences, University of Torino, S. Anna Hospital, Torino, Italy.
| | - Alessandro Ferrero
- Gynecology and Obstetrics, Physiopathology of Reproduction and IVF Unit, Department of Surgical Sciences, University of Torino, S. Anna Hospital, Torino, Italy.
| | - Cecilia Dallan
- Gynecology and Obstetrics, Physiopathology of Reproduction and IVF Unit, Department of Surgical Sciences, University of Torino, S. Anna Hospital, Torino, Italy.
| | - Stefano Canosa
- Gynecology and Obstetrics, Physiopathology of Reproduction and IVF Unit, Department of Surgical Sciences, University of Torino, S. Anna Hospital, Torino, Italy.
| | - Gianluca Gennarelli
- Gynecology and Obstetrics, Physiopathology of Reproduction and IVF Unit, Department of Surgical Sciences, University of Torino, S. Anna Hospital, Torino, Italy.
- LIVET Infertility and IVF Clinic, Torino, Italy.
| | | | - Claudia Filippini
- Statistics, Department of Surgical Sciences, University of Torino, MolinetteHospital, Torino, Italy.
| | - Chiara Benedetto
- Gynecology and Obstetrics, Physiopathology of Reproduction and IVF Unit, Department of Surgical Sciences, University of Torino, S. Anna Hospital, Torino, Italy.
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Yilmaz S, Ozgu-Erdinc AS, Yumusak O, Kahyaoglu S, Seckin B, Yilmaz N. The reproductive outcome of women with hypogonadotropic hypogonadism undergoingin vitrofertilization. Syst Biol Reprod Med 2015; 61:228-32. [DOI: 10.3109/19396368.2015.1037936] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Abstract
Although hormonal regulation of ovarian follicle development has been extensively investigated, most studies concentrate on the development of early antral follicles to the preovulatory stage, leading to the successful use of exogenous FSH for infertility treatment. Accumulating data indicate that preantral follicles are under stringent regulation by FSH and local intraovarian factors, thus providing the possibility to develop new therapeutic approaches. Granulosa cell-derived C-type natriuretic factor not only suppresses the final maturation of oocytes to undergo germinal vesicle breakdown before ovulation but also promotes preantral and antral follicle growth. In addition, several oocyte- and granulosa cell-derived factors stimulate preantral follicle growth by acting through wingless, receptor tyrosine kinase, receptor serine kinase, and other signaling pathways. In contrast, the ovarian Hippo signaling pathway constrains follicle growth and disruption of Hippo signaling promotes the secretion of downstream CCN growth factors capable of promoting follicle growth. Although the exact hormonal factors involved in primordial follicle activation has yet to be elucidated, the protein kinase B (AKT) and mammalian target of rapamycin signaling pathways are important for the activation of dormant primordial follicles. Hippo signaling disruption after ovarian fragmentation, combined with treating ovarian fragments with phosphatase and tensin homolog (PTEN) inhibitors and phosphoinositide-3-kinase stimulators to augment AKT signaling, promote the growth of preantral follicles in patients with primary ovarian insufficiency, leading to a new infertility intervention for such patients. Elucidation of intraovarian mechanisms underlying early folliculogenesis may allow the development of novel therapeutic strategies for patients diagnosed with primary ovarian insufficiency, polycystic ovary syndrome, and poor ovarian response to FSH stimulation, as well as for infertile women of advanced reproductive age.
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Affiliation(s)
- Aaron J W Hsueh
- Program of Reproductive and Stem Cell Biology (A.J.W.H., Y.C.), Department of Obstetrics and Gynecology, Stanford University School of Medicine, Stanford, CA 94305-5317; Department of Obstetrics and Gynecology (K.K.), St. Mariana University School of Medicine, Kawasaki, Kanagawa 216-8511, Japan; Department of Reproductive Medicine & Gynecology (B.C.J.M.F.), University Medical Center Utrecht, 3584 CX Utrecht, The Netherlands
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McNeilly AS, Duncan WC. Rodent models of polycystic ovary syndrome. Mol Cell Endocrinol 2013; 373:2-7. [PMID: 23098676 DOI: 10.1016/j.mce.2012.10.007] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2011] [Revised: 09/27/2012] [Accepted: 10/05/2012] [Indexed: 02/06/2023]
Abstract
Rodents are clearly valuable models for assessing disruption of fertility. The effects of different steroid treatments at different stages of reproductive life through from fetal to adult have been assessed for effects on fertility, ovarian morphology, hypothalamic-pituitary function or metabolic consequences. The results show that steroid treatments do disrupt fertility in many cases, but the underlying mechanisms are complicated by the effects of the different treatments at multiple sites. As models for PCOS at the ovarian level however, there are a number of problems particularly related to the fact that rodents are multi-ovular species. Apart from an absence of ovulation and corpora lutea, many of the different steroid regimes result in an increase in large atretic, or cystic follicles that do not parallel PCOS in women. Indeed a number of treatments are given at times when they will cause disruption of the positive feedback effects of estradiol, thus blocking ovulation in adult life. The resulting ovarian morphology thus appears to be like that of PCOS but is in fact not a clear mimic. This review of the various studies highlights parallels and problems with the use of rodents to study the mechanisms underlying the development of PCOS in women.
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Affiliation(s)
- Alan S McNeilly
- MRC Centre for Reproductive Health, Queen's Medical Research Institute, University of Edinburgh, 47 Little France Crescent, Edinburgh EH16 4TJ, United Kingdom.
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Xu J, Xu M, Bernuci MP, Fisher TE, Shea LD, Woodruff TK, Zelinski MB, Stouffer RL. Primate follicular development and oocyte maturation in vitro. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2013; 761:43-67. [PMID: 24097381 DOI: 10.1007/978-1-4614-8214-7_5] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
The factors and processes involved in primate follicular development are complex and not fully understood. An encapsulated three-dimensional (3D) follicle culture system could be a valuable in vitro model to study the dynamics and regulation of folliculogenesis in intact individual follicles in primates. Besides the research relevance, in vitro follicle maturation (IFM) is emerging as a promising approach to offer options for fertility preservation in female patients with cancer. This review summarizes the current published data on in vitro follicular development from the preantral to small antral stage in nonhuman primates, including follicle survival and growth, endocrine (ovarian steroid hormone) and paracrine/autocrine (local factor) function, as well as oocyte maturation and fertilization. Future directions include major challenges and strategies to further improve follicular growth and differentiation with oocytes competent for in vitro fertilization and subsequent embryonic development, as well as opportunities to investigate primate folliculogenesis by utilizing this 3D culture system. The information may be valuable in identifying optimal conditions for human follicle culture, with the ultimate goal of translating the experimental results and products to patients, thereby facilitating diagnostic and therapeutic approaches for female fertility.
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Affiliation(s)
- Jing Xu
- Division of Reproductive and Developmental Sciences, Oregon National Primate Research Center, Oregon Health & Science University, 505 NW 185th Avenue, Beaverton, OR, 97006, USA,
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Awwad JT, Farra C, Mitri F, Abdallah MA, Jaoudeh MA, Ghazeeri G. Split daily recombinant human LH dose in hypogonadotrophic hypogonadism: a nonrandomized controlled pilot study. Reprod Biomed Online 2012. [PMID: 23177418 DOI: 10.1016/j.rbmo.2012.09.016] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
This prospective controlled nonrandomized pilot study was conducted to investigate whether split daily doses of recombinant human LH (rHLH) is more efficacious than the single daily dose in supporting follicular development and ovulation in primary hypogonadotrophic hypogonadism (HH). Twenty-seven women with HH received a 150 IU fixed daily subcutaneous dose of recombinant human FSH, supplemented by 75 IU daily dose of rHLH given either as a single dose (n=9; single-dose group) or four equally divided doses (n=18; split-dose group). Ovulation was defined by three efficacy end points: at least one follicle ⩾17mm in diameter, pre-ovulatory serum oestradiol ⩾400pmol/l and a midluteal progesterone ⩾25nmol/l. Although lacking statistical significance, the proportion of women in the rHLH split-dose group who fulfilled all three end points was higher than the single-dose group (72.2% versus 55.6%). Women in the split-dose group achieved higher serum oestradiol concentrations per follicle, endometrial thickness measurements and numbers of follicles than in the single-dose group (not statistically significant). The odds ratio for ovulation rate was 2.08 (not statistically significant). There were no serious untoward side effects. Administering rHLH in split daily doses could provide superior results compared with the traditional single daily dose. We conducted this clinical study to investigate whether a split daily dose protocol of recombinant human LH (rHLH) is more efficacious than the single daily dose in supporting follicular development and ovulation in primary hypogonadotrophic hypogonadism (HH). HH is an uncommon entity that can lead to very low or undetectable serum gonadotrophin concentrations. It manifests in anovulation, amenorrhoea and subsequent infertility. Twenty-seven women with HH received a 150 IU fixed daily subcutaneous dose of recombinant human FSH, supplemented by a 75 IU daily dose of rHLH given either as a single dose (n=9; single-dose group) or four equally divided doses (n=18; split-dose group). Ovulation was defined by these three efficacy end points: at least one follicle ⩾17mm in mean diameter, pre-ovulatory serum oestradiol concentration ⩾400pmol/l and a midluteal progesterone concentration ⩾25nmol/l. The proportion of women in the rHLH split-dose group who fulfilled all three end points was higher than the single-dose group (72.2% versus 55.6%). Women in the split-dose group achieved higher serum oestradiol concentrations per follicle, endometrial thickness measurements and numbers of follicles than in the single-dose group, without statistical significance. Women who received the split-dose regimen were more likely to have ovulation than the other group. We had no serious problematic side effects. Our results suggest that administering rHLH in split daily doses could provide superior results compared to the traditional single daily dose.
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Affiliation(s)
- Johnny T Awwad
- Department of Obstetrics and Gynecology, American University of Beirut Medical Center, Beirut, Lebanon
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Hill MJ, Levy G, Levens ED. Does exogenous LH in ovarian stimulation improve assisted reproduction success? An appraisal of the literature. Reprod Biomed Online 2011; 24:261-71. [PMID: 22285265 DOI: 10.1016/j.rbmo.2011.12.005] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2011] [Revised: 11/11/2011] [Accepted: 12/14/2011] [Indexed: 10/14/2022]
Abstract
A review of the scientific literature on the use of exogenous LH in assisted reproductive technology was performed by searching the MEDLINE, PubMed and Cochrane online databases. Scientific evidence was reviewed comparing recombinant FSH-only protocols to protocols supplemented with exogenous LH activity: human menopausal gonadotrophin (HMG), recombinant LH and mid-follicular human chorionic gonadotrophin (HCG). Studies were further compared based on pituitary suppression with gonadotrophin- releasing hormone (GnRH) antagonist and agonist protocols. Primary focus was given to randomized controlled trials and meta-analyses. Data from hypogonadotrophic hypogonadal patients demonstrated the importance of LH activity for success of assisted reproduction treatment. However, the majority of normogonadotrophic patients had adequate endogenous LH to successfully drive ovarian steroidogenesis and oocyte maturation. Exogenous LH supplementation was consistently associated with higher peak oestradiol concentrations. The use of HMG in long GnRH agonist cycles was associated with a 3–4% increase in live birth rate. There was insufficient evidence to make definitive conclusions on the need for exogenous LH activity in GnRH antagonist cycles or the benefit of recombinant LH and HCG protocols. Poor responders and patients 35 years of age and older may benefit from exogenous LH.
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Affiliation(s)
- Micah J Hill
- Program in Reproductive and Adult Endocrinology, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, MD 20892, USA
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Propst AM, Hill MJ, Bates GW, Palumbo M, Van Horne AK, Retzloff MG. Low-dose human chorionic gonadotropin may improve in vitro fertilization cycle outcomes in patients with low luteinizing hormone levels after gonadotropin-releasing hormone antagonist administration. Fertil Steril 2011; 96:898-904. [PMID: 21839437 DOI: 10.1016/j.fertnstert.2011.06.069] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2011] [Revised: 06/27/2011] [Accepted: 06/30/2011] [Indexed: 11/19/2022]
Abstract
OBJECTIVE To evaluate the effect of low levels of endogenous luteinizing hormone (LH) and low-dose human chorionic gonadotropin (hCG) supplementation on in vitro fertilization (IVF) cycle outcomes in a gonadotropin-releasing hormone (GnRH) antagonist protocol. DESIGN Retrospective study. SETTING Military medical center. PATIENT(S) General in vitro fertilization/embryo transfer (IVF-ET) population. INTERVENTION(S) Addition of low-dose urinary hCG to IVF stimulations using a recombinant follicle-stimulating hormone (FSH) and GnRH antagonist protocol. MAIN OUTCOME MEASURE(S) Implantation and live-birth rates. RESULT(S) As part of a larger cohort of 239 patients, 42 patients with LH levels ≤ 0.5 mIU/mL were evaluated. In the larger cohort, there were no differences in implantation and pregnancy rates between the recombinant FSH only (n = 113) and the recombinant FSH with low-dose hCG supplementation (n = 126) groups. In the FSH-only group, patients with LH levels ≤ 0.5 mIU/mL had decreased implantation rates (19% vs. 42%) and live-birth rates (25% vs. 54%) as compared with patients with LH levels >0.5 mIU/mL. Low LH patients in the recombinant FSH with low-dose urinary hCG group had statistically significantly higher implantation rates (54% vs. 19%) and live-birth rates (64% vs. 25%) as compared with patients with similar low LH levels in the recombinant FSH-only group. CONCLUSION(S) Endogenous LH levels ≤ 0.5 mIU/mL after GnRH antagonist treatment are associated with statistically significantly lower implantation and pregnancy rates in recombinant FSH-only cycles. The addition of low-dose urinary hCG results in improved implantation and live-birth rates in patients with low LH levels.
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Affiliation(s)
- Anthony M Propst
- Program in Reproductive and Adult Endocrinology, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, Maryland, USA.
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Westergaard LW, Bossuyt PMM, Van der Veen F, van Wely M. WITHDRAWN: Human menopausal gonadotropin versus recombinant follicle stimulation hormone for ovarian stimulation in assisted reproductive cycles. Cochrane Database Syst Rev 2011; 2011:CD003973. [PMID: 21328264 PMCID: PMC10680421 DOI: 10.1002/14651858.cd003973.pub2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
BACKGROUND hMG and recombinant FSH, have both been used successfully for controlled ovarian hyperstimulation in in vitro fertilization and embryo transfer (IVF-ET). OBJECTIVES To compare the effectiveness of hMG with rFSH in ovarian stimulation protocols in IVF or ICSI treatment cycles. SEARCH STRATEGY We searched the Cochrane Menstrual Disorders and Subfertility Group trials register (searched 3rd Jan 2002), PubMed, MEDLINE, Web of Science (all searched 1985 to May 15 2002), and reference lists of articles. We also contacted manufacturers and researchers in the field. SELECTION CRITERIA Randomised trials comparing hMG with rFSH for ovarian stimulation in IVF or ICSI treatment for treatment of infertility in normogonadotrophic women. DATA COLLECTION AND ANALYSIS The main outcome measure was ongoing pregnancy/live birth per woman.Secondary outcomes included total gonadotrophin dose used, cancellation, number of oocytes retrieved, implantation, clinical pregnancy per woman, multiple pregnancy, spontaneous abortion and ovarian hyperstimulation syndrome. Peto odds ratios (OR) for hMG relative to rFSH were calculated after testing for homogeneity of treatment effect across all trials. Analyses were performed separately for the three different GnRHa protocols used: (1) without GnRHa down-regulation, (2) with GnRHa down-regulation using a short protocol and (3) with GnRHa down-regulation using a long protocol. MAIN RESULTS Eight trials that met the inclusion criteria could be identified. One trial did not use down-regulation, one trial used a short protocol and six trials used a long down-regulation protocol. In the one trial with non-down-regulated women and in the one trial that used a short down-regulation protocol there was no evidence of a difference between hMG and rFSH in any clinical outcome. Data of four truly randomised trials in women down-regulated using a long protocol could be pooled. There was no evidence of a difference between hMG and rFSH in ongoing pregnancy/live birth per woman (OR 1.27; 95% CI 0.98 to 1.64). Furthermore there was no clear difference on any of the secondary outcomes, although the clinical pregnancy rate per woman was of borderline significance in favour of hMG (summary OR 1.28; 95% CI 1.00 to 1.64). The other secondary outcomes were comparable for both gonadotrophins. AUTHORS' CONCLUSIONS For all three GnRHa protocols analysed there is insufficient evidence of a difference between hMG and rFSH on ongoing pregnancy or live birth. More large randomised trials are needed to estimate the difference between hMG and rFSH more precisely. Such trials should preferably (1) use a consistent long GnRHa protocol and (2) use a fixed dose of gonadotrophin such to prevent potentially subjective decisions of the clinician in dosing and (3) take live birth as primary endpoint. At this moment in time however, in prescribing gonadotrophins for ovarian hyperstimulation in IVF one should use the least expensive medication.
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Affiliation(s)
- Lars W Westergaard
- Odense University HospitalDepartment of Obstetrics and GynecologyOdense CDenmarkDK5000
| | - Patrick MM Bossuyt
- Academic Medical Center, University of AmsterdamDepartment of Clinical Epidemiology and BiostatisticsRoom J2‐209, PO Box 22700AmsterdamNetherlands1105 DD
| | - Fulco Van der Veen
- Academic Medical CenterCenter for Reproductive Medicine ‐ H4‐205, Department of Obstetrics & GynaecologyUniversity of AmsterdamMeibergdreef 9AmsterdamNetherlands1105 AZ
| | - Madelon van Wely
- University of Amsterdam, Academic Medical CentreCentre for Reproductive Medicine, Department of Obstetrics and GynaecologyCenter Meibergdreef 9AmsterdamNetherlands1105 AZ
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Xu J, Bernuci MP, Lawson MS, Yeoman RR, Fisher TE, Zelinski MB, Stouffer RL. Survival, growth, and maturation of secondary follicles from prepubertal, young, and older adult rhesus monkeys during encapsulated three-dimensional culture: effects of gonadotropins and insulin. Reproduction 2010; 140:685-97. [PMID: 20729335 DOI: 10.1530/rep-10-0284] [Citation(s) in RCA: 100] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
A three-dimensional culture system supports the development of primate preantral follicles to the antral stage with appreciable steroid production. This study assessed i) whether in vitro developmental competence of follicles is age dependent, ii) the role of gonadotropins and insulin in supporting folliculogenesis, and iii) anti-Müllerian hormone (AMH) and vascular endothelial growth factor (VEGF) production by growing follicles. Ovaries were obtained from prepubertal, young, and older adult rhesus macaques. Secondary follicles were encapsulated into alginate beads and cultured individually for 40 days in media containing 0.05 or 5 μg/ml insulin, with or without recombinant human (rh) FSH (500 mIU/ml). No follicles survived in the culture without rhFSH. In the presence of rhFSH, survival was lower for follicles from older animals, whereas growth, i.e. follicle diameter, was less by day 40 for follicles from prepubertal animals. The surviving follicles were categorized as no-grow (NG; ≤ 250 μm), slow-grow (SG; 250-500 μm), and fast-grow (FG; ≥ 500 μm) according to their diameters. SG follicles cultured with 5 μg/ml insulin produced more ovarian steroids than those cultured with 0.05 μg/ml insulin by week 5. SG and FG follicles produced more AMH and VEGF than the NG, and levels peaked at weeks 2 and 5 respectively. After 100 ng/ml rh chorionic gonadotropin treatment for 34 h, more healthy oocytes were retrieved from young adults whose follicles were cultured with 5 μg/ml insulin. This culture system offers an opportunity to characterize the endocrine and paracrine function of primate follicles that influence follicle growth and oocyte maturation.
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Affiliation(s)
- Jing Xu
- Division of Reproductive Sciences, Oregon National Primate Research Center, Oregon Health & Science University, 505 Northwest 185th Avenue, Beaverton, Oregon 97006, USA
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Foresta C, Selice R, Ferlin A, Garolla A. Recombinant FSH in the treatment of oligozoospermia. Expert Opin Biol Ther 2010; 9:659-66. [PMID: 19379121 DOI: 10.1517/14712590902932673] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND FSH plays a crucial role in human reproduction. Treatment with gonadotrophins has been shown to be effective in males affected by hypogonadotrophic hypogonadism. The success of this treatment has brought about the utilization of the same therapy in infertile oligozoospermic subjects, aimed at obtaining increased sperm count. This physiological role in spermatogenesis has induced various attempts to treat idiopathic oligozoospermic men with FSH, often inducing the restoration of normal spermatogenesis and spontaneous pregnancy. OBJECTIVE To evaluate clinical efficacy of recombinant FSH in male infertility. METHODS Evaluation of pharmacokinetic, pharmacodynamic properties, efficacy and safety of this hormone preparation, on the basis of the data published in literature. CONCLUSIONS Recombinant FSH is effective, safe and well tolerated. Treatment with this hormone may represent a valid tool for infertile men. However it should be performed on selected patients utilizing some predictive parameters able to identify a priori responder subjects with high probability.
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Affiliation(s)
- Carlo Foresta
- Department of Histology, Section of Clinical Pathology & Centre for Male Gamete Cryopreservation, University of Padova, Padova, Italy.
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Krause BT, Ohlinger R, Haase A. Lutropin alpha, recombinant human luteinizing hormone, for the stimulation of follicular development in profoundly LH-deficient hypogonadotropic hypogonadal women: a review. Biologics 2009; 3:337-47. [PMID: 19707419 PMCID: PMC2726078 DOI: 10.2147/btt.2009.3306] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Hypogonadotropic hypogonadism is defined as a medical condition with low or undetectable gonadotropin secretion, associated with a complete arrest of follicular growth and very low estradiol. The main cause can be traced back to an irregular or absent hypothalamic GnRH secretion, whereas only a minority suffers from a pituitary disorder. The choice of treatment to reverse this situation is a pulsatile GnRH application or a direct ovarian stimulation using gonadotropin injections. The goal is to achieve a proper ovarian function in these cases for a short time to allow ovulation and chance of pregnancy. Since the pulsatile GnRH treatment lost its former importance, several gonadotropins are in use to stimulate follicular growth, such as urine-derived human menopausal gonadotropin, highly purified follicle stimulating hormone (FSH) or recombinant FSH, all with different success. The introduction of recombinant luteinizing hormone (LH) and FSH provided an opportunity to investigate the distinct influences of LH and FSH alone and in combination on follicular growth in monofollicular ovulation induction cycles, and additionally on oocyte maturation, fertilization competence of the oocyte and embryo quality in downregulated IVF patients. Whereas FSH was known to be indispensable for normal follicular growth, the role of LH remained questionable. Downregulated IVF patients with this short-term gonadotropin depletion displayed no advance in stimulation success with the use of recombinant LH. Patients with hypogonadotropic hypogonadism undergoing monofollicular stimulation for ovulation induction showed clearly a specific role and need for both hormones in normal follicular growth. Therefore, a combined stimulation with FSH and LH seems to be the best treatment choice. In the first half of the stimulation cycle the FSH dosage should exceed that of LH by 2:1, with an inverse ratio for the second half.
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Affiliation(s)
- Bernd Th Krause
- Center for Endocrinology and Reproductive Medicine, MVZ Uhlandstr, Berlin, Germany.
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Hirshfeld-Cytron J, Barnes RB, Ehrmann DA, Caruso A, Mortensen MM, Rosenfield RL. Characterization of functionally typical and atypical types of polycystic ovary syndrome. J Clin Endocrinol Metab 2009; 94:1587-94. [PMID: 19240152 PMCID: PMC2684483 DOI: 10.1210/jc.2008-2248] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
CONTEXT The typical polycystic ovary syndrome (PCOS) phenotype includes 17-hydroxyprogesterone (17OHP) hyperresponsiveness to GnRH agonist (GnRHag) testing. Functionally atypical PCOS lacks this feature. OBJECTIVE The hypothesis was tested that the typical PCOS ovarian dysfunction results from intrinsically increased sensitivity to LH/human chorionic gonadotropin (hCG) due to a flaw in FSH action. PARTICIPANTS/DESIGN/INTERVENTIONS/MAIN OUTCOME MEASURES: After phenotyping a cohort of 60 women, steroid and inhibin-B responses to gonadotropins were evaluated in representative typical (n = 7) and atypical (n = 5) PCOS and healthy controls (n = 8). Submaximal hCG testing before and after an FSH test dose was performed in random order before and after prolonged ovarian suppression by depot GnRHag. SETTING The study was performed at a Clinical Research Center. RESULTS Of our PCOS cohort, 68% were the typical type. Typical PCOS had 17OHP hyperresponsiveness and, unlike controls, significant androgen and estradiol responses to hCG. FSH increased inhibin-B and did not inhibit free testosterone or enhance estradiol responsiveness to hCG, all unlike controls. After ovarian suppression, 17OHP, androstenedione, and inhibin-B responsiveness to gonadotropin testing persisted. Atypical PCOS had significantly higher body mass index but lower ovarian volume and plasma free testosterone than typical PCOS. Steroid responses to hCG were insignificant and similar to controls. FSH suppressed free testosterone but stimulated inhibin-B. The estradiol level after combined hCG-FSH was subnormal. Free testosterone was less GnRHag suppressible than in typical PCOS. CONCLUSIONS Typical PCOS is characterized by intrinsic ovarian hypersensitivity to hCG to which excessive paracrine FSH signaling via inhibin-B may contribute. Atypical PCOS is due to a unique type of ovarian dysfunction that is relatively gonadotropin hyposensitive.
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Affiliation(s)
- Jennifer Hirshfeld-Cytron
- Department of Obstetrics and Gynecology, Feinberg School of Medicine, Northwestern University, Chicago, IL 60611, USA
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Comparison of embryological and clinical outcome in GnRH antagonist vs. GnRH agonist protocols for in vitro fertilization in PCOS non-obese patients. A prospective randomized study. J Assist Reprod Genet 2008; 25:365-74. [PMID: 18802744 DOI: 10.1007/s10815-008-9249-7] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2008] [Accepted: 08/27/2008] [Indexed: 10/21/2022] Open
Abstract
PURPOSE Embryological and clinical efficacy of gonadotropin-releasing hormone (GnRH) antagonist and agonist stimulation protocols in non-obese women with polycystic ovarian syndrome (PCOS) were compared. METHODS A prospective randomized study. SETTING Medical University Hospital. PATIENTS 70 infertile PCOS patients; 33 in GnRH antagonist and 37 in GnRH agonist group. RESULTS Similar mature metaphase II oocyte rate (76% vs. 76%) was observed in both protocols. Optimal pronuclear morphology zygotes dominated in both groups (64% vs. 66%). Transferred embryo quality did not differ in both protocols. No significant differences between both protocols were found in delivery rate (p = 0.481), pregnancy rate (p = 0.810), multiple pregnancy rate (p = 0.501), miscarriage rate (p = 0.154), fertilization rate (p = 0.388) and implantation rate (p = 1.000). Duration of stimulation and total follicle-stimulating hormone (FSH) dose were significantly lower in GnRH antagonist protocol (p = 0.0005). CONCLUSIONS GnRH antagonist and agonist protocols in non-obese PCOS patients yield similar embryological and clinical outcomes. Shorter duration of treatment and lower FSH requirement in GnRH antagonist group may be financially beneficial and therefore attractive for patients.
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Shoham Z, Smith H, Yeko T, O'Brien F, Hemsey G, O'Dea L. Recombinant LH (lutropin alfa) for the treatment of hypogonadotrophic women with profound LH deficiency: a randomized, double-blind, placebo-controlled, proof-of-efficacy study. Clin Endocrinol (Oxf) 2008; 69:471-8. [PMID: 18485121 DOI: 10.1111/j.1365-2265.2008.03299.x] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To confirm the safety and efficacy of 75 IU lutropin alfa with concomitant follitropin alfa in inducing follicular development in women with profound gonadotrophin deficiency. DESIGN Double-blind, randomized, placebo-controlled trial conducted in 25 medical centres in four countries. PATIENTS Thirty-nine patients with LH < 1.2 IU/l and FSH < 5.0 IU/l were treated with concomitant 75 IU lutropin alfa and 150 IU follitropin alfa or concomitant placebo and 150 IU follitropin alfa. MEASUREMENTS Primary efficacy end-point (intent-to-treat): follicular development defined by (i) at least one follicle >or= 17 mm; (ii) serum E(2) level >or= 400 pmol/l on day of hCG administration (DhCG); and (iii) mid-luteal phase progesterone level >or= 25 nmol/l. RESULTS In the analysis of evaluable patients, 66.7% (16 of 24) of patients given lutropin alfa achieved follicular development compared with 20.0% (2 of 10) of patients receiving placebo (P = 0.023). In the intent-to-treat analysis, follicular development was achieved in 65.4% (17 of 26) of patients receiving lutropin alfa and 15.4% (2 of 13) of patients receiving placebo (P = 0.006). The statistical difference between treatment groups was preserved when over-response leading to cycle cancellation was analysed as a failed response (P = 0.034). Lutropin alfa was well tolerated. CONCLUSION Subcutaneous co-administration of 75 IU lutropin alfa with follitropin alfa is safe and effective in inducing follicular development in women with profound gonadotrophin deficiency.
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Affiliation(s)
- Z Shoham
- Department of Obstetrics and Gynecology, Kaplan Medical Center, Rehovot, Israel
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Grossman MP, Nakajima ST, Fallat ME, Siow Y. Müllerian-inhibiting substance inhibits cytochrome P450 aromatase activity in human granulosa lutein cell culture. Fertil Steril 2008; 89:1364-70. [PMID: 17517397 DOI: 10.1016/j.fertnstert.2007.03.066] [Citation(s) in RCA: 123] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2006] [Revised: 03/15/2007] [Accepted: 03/19/2007] [Indexed: 11/29/2022]
Abstract
OBJECTIVE To investigate the effects of Müllerian-inhibiting substance (MIS) on cytochrome P450 aromatase (CYP19) gene expression in cultured human granulosa lutein cells (GLC). DESIGN In vitro primary cell culture study. SETTING Academic research laboratory and hospital-based fertility center. PATIENT(S) Eight normo-ovulatory patients undergoing IVF procedures due to male factor or tubal infertility. INTERVENTION(S) Serum and follicular fluid (FF) collected and stored at -80 degrees C until assayed. Granulosa lutein cells were harvested from follicular aspirates obtained during oocyte retrieval and cultured for 7 days with media in the presence or absence of MIS (10 ng/mL) or FSH 0.2 IU/mL. MAIN OUTCOME MEASURE(S) Serum and FF levels of E2 and MIS, and E2 production by GLC in culture. Levels of CYP19 mRNA in cultured GLC were determined by quantitative polymerase chain reaction (PCR) and CYP19 protein by Western blot. Statistical comparison used ANOVA and post hoc Tukey tests. RESULT(S) Follicle-stimulating hormone significantly increased E2 production in cultured GLC compared with control. The increase in E2 production is associated with higher levels of CYP19 mRNA and protein in GLC. The presence of MIS significantly inhibited FSH-induced E2 production, with concomitant reduction in CYP19mRNA and protein levels. CONCLUSION(S) Müllerian-inhibiting substance inhibits FSH augmentation of CYP19 enzyme activity and CYP19 gene expression in GLC. These findings may help to explain the association of high MIS levels and low FF E2 levels reported in women with polycystic ovary syndrome (PCOS).
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Affiliation(s)
- Michael P Grossman
- Department of Obstetrics and Gynecology, University of Louisville, Louisville, Kentucky 40292, USA
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Abstract
This review summarizes a series of lectures given at a recent Continuing Medical Education meeting in Hamburg, Germany (May 2007), aiming to understand the role of luteinizing hormone (LH) in follicular development during the natural menstrual cycle and controlled ovarian stimulation. Clinical situations and target groups of patients who might benefit from LH supplementation during their ovarian stimulation were discussed and defined. The lectures updated knowledge on the physiology of LH during the normal menstrual cycle and the role of LH in ovarian stimulation. The concept of the 'LH window' was presented, and the use of LH supplementation in different groups of patients undergoing controlled ovarian stimulation was discussed, including those with advanced age, hypogonadotrophic hypogonadism, pituitary down-regulation and poor response. In addition, the different ways of using LH or human chorionic gonadotrophin supplementation in ovulation induction protocols were described.
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30
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Kaufmann R, Dunn R, Vaughn T, Hughes G, O'Brien F, Hemsey G, Thomson B, O'Dea LSL. Recombinant human luteinizing hormone, lutropin alfa, for the induction of follicular development and pregnancy in profoundly gonadotrophin-deficient women. Clin Endocrinol (Oxf) 2007; 67:563-9. [PMID: 17692110 DOI: 10.1111/j.1365-2265.2007.02925.x] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To provide evidence of efficacy and safety for use of lutropin alfa in inducing follicular development and pregnancy in hypogonadotrophic hypogonadal women with profound gonadotrophin deficiency. DESIGN An open-label, noncomparative extension of a randomized, double-blind, placebo-controlled study PATIENTS A total of 31 hypogonadotrophic hypogonadal women with profound gonadotrophin deficiency in 23 medical centres in four countries were studied. INTERVENTIONS Lutropin alfa 75 IU and follitropin alfa (75-225 IU), individually based on each patient's response as is consistent with usual medical practice. MEASUREMENTS Follicular development as defined by (i) at least one follicle >or= 17 mm; (ii) preovulatory serum oestradiol level >or= 109 pg/ml on the day of hCG administration; and (iii) midluteal phase P(4) level >or= 7.9 ng/ml. Pregnancy and over-response leading to cycle cancellation were considered treatment successes. Pregnancy rates were assessed. RESULTS In a total of 54 cycles, 27 of 31 (87.1%) profoundly gonadotrophin-deficient patients achieved follicular development within three cycles. Twenty of 27 patients (74.1%) who achieved follicular development and received hCG became pregnant; 16 (59.3%) continued to clinical pregnancy. One patient was hospitalized for severe ovarian hyperstimulation syndrome. Lutropin alfa was well tolerated. CONCLUSIONS Coadministration of lutropin alfa 75 IU and follitropin alfa is safe and effective in inducing follicular development and pregnancy in hypogonadotrophic hypogonadal women with profound gonadotrophin deficiency in a setting consistent with established medical practice.
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Affiliation(s)
- Robert Kaufmann
- South-eastern Fertility Centre, PA, Mt. Pleasant, South Carolina, USA
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31
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Bitonti AJ, Dumont JA. Pulmonary administration of therapeutic proteins using an immunoglobulin transport pathway. Adv Drug Deliv Rev 2006; 58:1106-18. [PMID: 16997417 DOI: 10.1016/j.addr.2006.07.015] [Citation(s) in RCA: 53] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2005] [Accepted: 07/25/2006] [Indexed: 10/24/2022]
Abstract
We have applied a "physiologic" approach to the pulmonary delivery of therapeutic proteins, utilizing an immunoglobulin (antibody) transport pathway recently shown to be present predominantly in the conducting airways of the human respiratory tract. Therapeutic proteins are fused to the Fc-domain of an IgG1, allowing them to bind with high affinity to the antibody transport receptor, FcRn. Liquid aerosols are administered into the lung using normal breathing maneuvers and efficient delivery of several different Fc-fusion proteins has been achieved with retention of biological activity and an increase in circulating half-life. A new paradigm for the pulmonary delivery of therapeutic proteins and a fundamental advance in the construction of Fc-fusion proteins for this purpose will be described.
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Affiliation(s)
- Alan J Bitonti
- Syntonix Pharmaceuticals, 9 Fourth Avenue, Waltham, MA 02451, USA.
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Dumont JA, Low SC, Peters RT, Bitonti AJ. Monomeric Fc fusions: impact on pharmacokinetic and biological activity of protein therapeutics. BioDrugs 2006; 20:151-60. [PMID: 16724863 DOI: 10.2165/00063030-200620030-00002] [Citation(s) in RCA: 106] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Abstract
The delivery of therapeutic proteins by noninvasive routes of administration has been a challenging goal, hence current modes of delivery generally require injections. However, we have recently shown that a naturally occurring receptor, the neonatal Fc receptor (FcRn) can be utilized to carry aerosolized therapeutic proteins conjugated to a portion of its respective ligand (Fc domain of immunoglobulin G) across epithelial cells of the lung to effectively deliver biologically active molecules to the bloodstream. First-generation dimeric Fc fusion molecules were successfully transported by the pulmonary route and biologic activity was demonstrated in both non-human primates and human volunteers. Continuing efforts to improve transport efficiency have led to the development of an alternate configuration of Fc fusion proteins with improved characteristics. These second generation Fc fusion molecules are monomeric with respect to the therapeutic protein and dimeric with respect to the Fc region, and have been termed Fc fusion 'monomers'. Several different Fc fusion monomers have demonstrated improved transport efficiency, achieving high bioavailabilities for pulmonary delivery in non-human primates. While the traditional dimeric Fc fusion molecule generally increases the half-life compared with the unconjugated effector molecule, the monomer configuration has been shown to result in an even greater extension of the circulating half-life, which improves pharmacokinetic parameters for protein therapeutics, whether administered by pulmonary delivery or injection. Finally, many of the Fc monomer fusions have enhanced biologic activity compared with the dimeric configuration. Because of these many advantages, the monomer configuration promises to be an enabling advance to achieve clinically relevant, noninvasive delivery with potentially less frequent administration regimens for a broad range of protein therapeutics. In addition, molecules that are comprised of heterodimeric subunits or multi-subunit complexes can also be constructed as Fc fusions that result in a molecule with enhanced pharmacokinetics and greater bioactivity. Several examples of novel Fc fusion proteins, both monomer and heterodimer are described herein.
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Finas D, Hornung D, Diedrich K, Schultze-Mosgau A. Cetrorelix in the treatment of female infertility and endometriosis. Expert Opin Pharmacother 2006; 7:2155-68. [PMID: 17020439 DOI: 10.1517/14656566.7.15.2155] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
The use of cetrorelix within ovarian-stimulation protocols demonstrates several advantages compared with gonadotropin-releasing hormone (GnRH) agonist-containing protocols, which include, for example, significantly less time for analogue treatment and a reduction in the amount of gonadotropins needed. Furthermore, fewer side effects can be expected. There is no difference regarding endometrium quality and hormone profiles, and the results of assisted reproduction cycles are comparable. Cetrorelix also seems to be useful in the treatment of endometriosis which, in most cases, is an estrogen-dependent disease. Furthermore, fewer side effects occur with this agent (e.g., postmenopausal symptoms) and no estradiol add-back is needed. In the future, new nonpeptic GnRH antagonists are expected to be available for oral administration. Although they are still under investigation, these agents have the potential to improve patients' comfort and compliance.
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Affiliation(s)
- Dominique Finas
- Department of Andrology and the Out-Patient Clinic, Department of Obstetrics and Gynaecology, University Clinic of Schleswig-Holstein, Campus Luebeck, Ratzeburger Allee 160, 23538 Luebeck, Germany.
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La Marca A, Volpe A. Anti-Müllerian hormone (AMH) in female reproduction: is measurement of circulating AMH a useful tool? Clin Endocrinol (Oxf) 2006; 64:603-10. [PMID: 16712660 DOI: 10.1111/j.1365-2265.2006.02533.x] [Citation(s) in RCA: 191] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Anti-Müllerian hormone (AMH) is a dimeric glycoprotein, a member of the transforming growth factor (TGF) superfamily. It is produced exclusively in the gonads and is involved in the regulation of follicular growth and development. In the ovary AMH is produced by the granulosa cells of early developing follicles and seems to be able to inhibit the initiation of primordial follicle growth and FSH-induced follicle growth. As AMH is largely expressed throughout folliculogenesis, from the primary follicular stage towards the antral stage, serum levels of AMH may represent both the quantity and quality of the ovarian follicle pool. Compared to other ovarian tests, AMH seems to be the best marker reflecting the decline of reproductive age. AMH measurement could be useful in the prediction of the menopausal transition. It could also be used to predict poor ovarian response and possibly the prognosis of in vitro fertilization (IVF) cycles. AMH has been shown to be a good surrogate marker for polycystic ovary syndrome (PCOS). Finally, its use as a marker for granulosa cell tumours has been proposed. A clearer understanding of its role in ovarian physiology may help clinicians to find a role for AMH measurement in the field of reproductive medicine.
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Affiliation(s)
- A La Marca
- Mother-Infant Department, Institute of Obstetrics and Gynaecology, University of Modena and Reggio Emilia, Modena, Italy.
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35
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Kolibianakis EM, Papanikolaou EG, Fatemi HM, Devroey P. Estrogen and folliculogenesis: is one necessary for the other? Curr Opin Obstet Gynecol 2005; 17:249-53. [PMID: 15870558 DOI: 10.1097/01.gco.0000169101.83342.96] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW During folliculogenesis the primordial follicle undergoes several steps of maturation in order to develop into a preovulatory follicle. The exact role of estrogen during this process has not yet been fully assessed. RECENT FINDINGS Estrogen appears to regulate cyclic gonadotropin release via its action on estrogen receptor alpha in the hypothalamus/hypophysis axis and to enhance folliculogenesis through its actions via estrogen receptor beta in the ovary. In addition, a role of estrogen during the very early stages of folliculogenesis is possible. However, it is likely that oocyte quality and developmental potential are not estrogen dependent. This might explain the lack of association between estrogen and in-vitro fertilization outcome in humans. SUMMARY The advent of knockout mice models has enhanced our understanding of the role of estrogen during folliculogenesis. Existing data suggest that estrogen might be involved in the very early steps of this process, but its role in sustaining ovulation is mainly central.
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Bosch E, Escudero E, Crespo J, Simón C, Remohí J, Pellicer A. Serum luteinizing hormone in patients undergoing ovarian stimulation with gonadotropin-releasing hormone antagonists and recombinant follicle-stimulating hormone and its relationship with cycle outcome. Fertil Steril 2005; 84:1529-32. [PMID: 16275263 DOI: 10.1016/j.fertnstert.2005.05.040] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2004] [Revised: 05/02/2005] [Accepted: 05/02/2005] [Indexed: 11/20/2022]
Abstract
The serum LH was determined on days 3, 6, and 8 of stimulation and on the day of hCG in 110 normogonadotropic patients undergoing controlled ovarian hyperstimulation (COH) for IVF induced with GnRH antagonists and recombinant FSH, creating three groups of patients according to Tukey's hinges (percentiles 25 and 75) for each determination. No differences were observed between the number of oocytes recovered or the fertilization, implantation, and pregnancy rates (PR) of the groups, although patients with high serum LH levels during stimulation showed significantly higher serum E2 levels on the day of hCG.
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Affiliation(s)
- Ernesto Bosch
- Instituto Valenciano de Infertilidad, Valencia, Spain
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37
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Caglar GS, Asimakopoulos B, Nikolettos N, Diedrich K, Al-Hasani S. Recombinant LH in ovarian stimulation. Reprod Biomed Online 2005; 10:774-85. [PMID: 15970010 DOI: 10.1016/s1472-6483(10)61123-6] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
The advent of recombinant gonadotrophins brought significant changes in fertility therapy. Treatment options with recombinant gonadotrophins add more to knowledge on folliculogenesis and ovarian steroidogenesis. Over a decade, recombinant LH (rLH) has been used for clinical trials, and the amount of peripheral LH that is necessary for optimal follicular growth, oocyte maturation, subsequent embryo development and assisted reproduction outcome during ovulation induction can now be better evaluated. This review evaluates the effect of rLH supplementation on ovarian stimulation and assisted reproduction outcome. The studies conducted with rLH supplementation in ovarian stimulation in different groups of patients and in cases of controlled ovarian stimulation are clearly discussed in this review.
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Affiliation(s)
- Gamze Sinem Caglar
- Department of Obstetrics and Gynecology, Medical University, Lubeck, Germany
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38
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Liu SY, Han JL, Peng XD, Dong X, Xu J, Yan JM. Effect of midfollicular luteinizing hormone levels on ovarian response and pregnancy outcome in patients undergoing in vitro fertilization in a short-term protocol. Fertil Steril 2005; 83:1043-6. [PMID: 15820825 DOI: 10.1016/j.fertnstert.2004.12.015] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2004] [Revised: 12/08/2004] [Accepted: 12/08/2004] [Indexed: 11/19/2022]
Abstract
In a retrospective study, levels of LH in the midfollicular phase had a significant impact on ovarian response and pregnancy outcome. High LH levels were associated with reduced implantation and clinical pregnancy rates.
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Affiliation(s)
- Su-ying Liu
- Shanghai Jiai Genetics and IVF Institute, Obstetrics and Gynecology Hospital, Fudan University, 588 Fangxie Road, 200 011 Shanghai, People's Republic of China.
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Low SC, Nunes SL, Bitonti AJ, Dumont JA. Oral and pulmonary delivery of FSH–Fc fusion proteins via neonatal Fc receptor-mediated transcytosis. Hum Reprod 2005; 20:1805-13. [PMID: 15817590 DOI: 10.1093/humrep/deh896] [Citation(s) in RCA: 86] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND The alpha and beta subunits of FSH were fused to the Fc domain of IgG1 either in a single chain or a heterodimer format. These molecules were absorbed through the epithelium in lung and intestine by neonatal Fc receptor (FcRn)-mediated transcytosis. METHODS AND RESULTS Single chain and heterodimer FSH-Fc were made recombinantly in Chinese hamster ovary cells. Treatment of rats with a single s.c. dose of single chain or heterodimer FSH-Fc resulted in greater stimulation of ovarian weight (20.8+/-3.9 and 26.9+/-6.1 mg respectively) compared to those receiving vehicle (12.1+/-1.0 mg) or an equimolar dose of recombinant human FSH (14.3+/-1.7 mg). Both FSH-Fc fusion proteins were absorbed after oral dosing of newborn rats with long terminal half-lives of approximately 60 h, and pulmonary delivery in four cynomolgus monkeys produced maximum serum concentrations between 69 and 131 ng/ml with long terminal half-lives between 55 and 210 h. Serum inhibin levels increased after pulmonary dosing with single chain FSH-Fc (1.3- and 1.4-fold) and heterodimer FSH-Fc (5.9- and 7.1-fold) and remained elevated for >12 days after treatment with heterodimer FSH-Fc. CONCLUSIONS We have shown that FSH-Fc fusion proteins have increased stability in blood and improved bioactivity in vivo, and that heterodimer FSH-Fc is more active in rats and monkeys than single chain FSH-Fc. These data suggest that Fc fusion proteins offer the potential for oral and pulmonary delivery of FSH.
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Affiliation(s)
- S C Low
- Syntonix Pharmaceuticals, Inc., 9 Fourth Avenue, Waltham, MA 02451, USA.
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Shoham Z. Treatment of female infertility with recombinant human luteinising hormone: is there a benefit over other available drugs? Expert Opin Pharmacother 2005; 4:1985-94. [PMID: 14596652 DOI: 10.1517/14656566.4.11.1985] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
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.
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Affiliation(s)
- Zeev Shoham
- Reproductive Medicine and Infertility Unit, Department of Obstetrics and Gynecology, Kaplan Medical Center, Rehovot 76100, Israel.
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Lisi F, Rinaldi L, Fishel S, Caserta D, Lisi R, Campbell A. Evaluation of two doses of recombinant luteinizing hormone supplementation in an unselected group of women undergoing follicular stimulation for in vitro fertilization. Fertil Steril 2005; 83:309-15. [PMID: 15705367 DOI: 10.1016/j.fertnstert.2004.07.969] [Citation(s) in RCA: 44] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2004] [Revised: 07/20/2004] [Accepted: 07/20/2004] [Indexed: 10/25/2022]
Abstract
OBJECTIVE To evaluate the efficacy of two doses of recombinant (r)LH, 75 IU (recommended) or 37.5 IU, for follicular stimulation and outcomes in a randomized cohort of IVF patients. DESIGN Randomized, prospective analysis. SETTING Private hospital incorporating an established IVF center. PATIENT(S) Women undergoing IVF who had a body mass index >18 or <35 and no abnormal karyotype, anovulation, oligomenorrhea, or any known endocrinopathy/illness. INTERVENTION(S) Pituitary desensitization was achieved with triptorelin (0.1 mg SC), and gonadotropin stimulation was performed with either rFSH alone (group A) or in combination with rLH in one of two doses: 37.5 IU (group B) or 75 IU (group C), daily. MAIN OUTCOME MEASURE(S) A range of endocrinologic, embryologic, clinical, and outcome parameters were evaluated. RESULT(S) With rLH supplementation there was a significant increase in the incidence of implantation (9% for rFSH only [group A] vs. 11% and 16% with 37.5 IU rLH and 75.0 IU rLH [groups B and C], respectively) and clinical pregnancy (19% vs. 23% and 31%) (P<.01 and P<.04, respectively), whereas there was no difference in the multiple pregnancy rates. There was a significant (P<.001) increase in the total units of rFSH used in proportion to the amount of rLH supplementation (2,645 U vs. 3,475 U and 3,681 U) and in the level of peripheral E(2) on the day of hCG administration (1,049 pg/mL vs. 1,640 pg/mL and 1,226 pg/mL) (P<.001). There was no significant between difference in mean age, numbers of oocytes recovered, basal and downregulation hormone levels, or the incidence of fertilization in the absence or presence of rLH supplementation, but a higher incidence of grade 1 to 2 embryos was observed when rLH was supplemented. CONCLUSION(S) After pituitary desensitization, there was an increase in the incidence of implantation, clinical pregnancy, and delivery rates in patients stimulated with rFSH supplemented with rLH.
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Affiliation(s)
- Franco Lisi
- BIOGENESI, Casa di Cura Villa Europa all'EUR, Rome, Italy
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Angelopoulos N, Goula A, Tolis G. The role of luteinizing hormone activity in controlled ovarian stimulation. J Endocrinol Invest 2005; 28:79-88. [PMID: 15816376 DOI: 10.1007/bf03345534] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
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.
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Affiliation(s)
- N Angelopoulos
- Endocrine Department, "Hippokrateion" Hospital of Athens, Athens, Greece.
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La Marca A, Malmusi S, Giulini S, Tamaro LF, Orvieto R, Levratti P, Volpe A. Anti-Müllerian hormone plasma levels in spontaneous menstrual cycle and during treatment with FSH to induce ovulation. Hum Reprod 2004; 19:2738-41. [PMID: 15459174 DOI: 10.1093/humrep/deh508] [Citation(s) in RCA: 146] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Anti-Müllerian hormone (AMH) is member of the transforming growth factor-beta superfamily of growth factors. AMH is detected in serum from women of reproductive age and its levels vary slightly with the menstrual cycle, reaching the peak value in the late follicular phase. The present study was undertaken to assess the effect of controlled ovarian stimulation on AMH secretion by the ovary in healthy women in order to obtain more insight into the relationship between this peptide and gonadal steroids. METHODS Twenty-four normally cycling women attending the infertility clinic volunteered for this study and AMH was measured in blood samples obtained during both spontaneous and FSH-treated cycles. RESULTS AMH plasma levels did not change significantly from day 2 to day 6 in spontaneous cycles. On the contrary, AMH levels decreased progressively from day 2 to day 6 in FSH-treated cycles. A significant positive correlation was found between the decrease in AMH and the increase in estradiol plasma levels in FSH-treated cycles and between basal AMH and the peak estradiol (E2) during exogenous FSH administration. CONCLUSIONS The present study demonstrated that AMH plasma levels did not change during the follicular phase of the menstrual cycle and that exogenous FSH administration is followed by a significant reduction in AMH levels which is probably secondary to the gonadotrophin effect on the process of follicular development.
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Affiliation(s)
- Antonio La Marca
- Department of Obstetrics Gynaecology and Paediatric Sciences, Institute of Obstetrics and Gynaecology, University of Modena and Reggio Emilia, Policlinico of Modena, Largo del Pozzo, 41100 Modena, Italy.
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El-Shawarby SA, Turner CF, Reddy N, Margara RA, Trew GH, Lavery SA. Pregnancy following monofollicular ovulation induction with recombinant FSH, recombinant LH and timed coitus in an amenorrheic woman with long-standing hypogonadotrophic hypogonadism. BJOG 2004; 111:1481-4. [PMID: 15663144 DOI: 10.1111/j.1471-0528.2004.00275.x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- Salem A El-Shawarby
- The Assisted Conception Unit, Department of Reproductive Medicine and Science, Hammersmith Hospital, Imperial College School of Medicine, London, UK
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Merviel P, Antoine JM, Mathieu E, Millot F, Mandelbaum J, Uzan S. Luteinizing hormone concentrations after gonadotropin-releasing hormone antagonist administration do not influence pregnancy rates in in vitro fertilization–embryo transfer. Fertil Steril 2004; 82:119-25. [PMID: 15236999 DOI: 10.1016/j.fertnstert.2003.11.040] [Citation(s) in RCA: 51] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2003] [Revised: 11/10/2003] [Accepted: 11/10/2003] [Indexed: 11/27/2022]
Abstract
OBJECTIVE To determine the impact of circulating LH concentrations during controlled ovarian hyperstimulation on the outcome of IVF. DESIGN Retrospective study. SETTING University hospital. PATIENT(S) Two-hundred seventy women who had a short stimulation protocol with GnRH antagonist and ovarian stimulation with recombinant FSH (rFSH). INTERVENTION(S) GnRH antagonist and rFSH were administered SC; blood samples were collected on the day of GnRH antagonist administration, 1 day after, and on the day of hCG administration. MAIN OUTCOME MEASURE(S) A threshold of 0.5 IU/L on the day of hCG was chosen to discriminate between women with LH concentrations <or=0.5 IU/L (group A, n = 119) or >0.5 IU/L (group B, n = 151). RESULT(S) The two groups were comparable with regard to the clinical parameters. In group A, significantly lower LH concentrations were observed on day 9 of the cycle and on the day of hCG administration. The numbers of oocytes retrieved, embryos obtained, and embryos cryopreserved were significantly higher in group A compared with group B. The proportion of clinical pregnancies was similar in the two groups (21.1% vs. 22.7 % per ET). CONCLUSION(S) In GnRH antagonist and rFSH protocols, suppressed serum LH concentrations do not have any influence on the final stages of follicular maturation, pregnancy rates, or outcomes.
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Affiliation(s)
- Philippe Merviel
- Department of Gynecology, Obstetrics and Reproductive Medicine, Hôpital Tenon, Paris, France.
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Scholtes MCW, Schnittert B, van Hoogstraten D, Verhoeven HC, Zrener A, Warne DW. A comparison of 3-day and daily follicle-stimulating hormone injections on stimulation days 1-6 in women undergoing controlled ovarian hyperstimulation. Fertil Steril 2004; 81:996-1001. [PMID: 15066454 DOI: 10.1016/j.fertnstert.2003.09.043] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2003] [Revised: 09/08/2003] [Accepted: 09/08/2003] [Indexed: 11/29/2022]
Abstract
OBJECTIVE To evaluate the efficacy of ovarian hyperstimulation by intermittent doses of 450 IU of recombinant human (h)FSH compared with daily 150-IU doses of recombinant hFSH. DESIGN A pilot, open, randomized, parallel-group study. SETTING Center for Reproductive Medicine, Düsseldorf, Germany. PATIENT(S) Infertile women with indication for IVF/intracytoplasmic sperm injection after at least 1 year of unprotected intercourse. INTERVENTION(S) Recombinant hFSH was administered daily or intermittently (3-day intervals) from days 1 to 6 of stimulation and thereafter by daily injection. MAIN OUTCOME MEASURE(S) Number of preovulatory follicles, retrieved oocytes, two-pronuclei (2PN) zygotes, implantation, and pregnancy rates. RESULT(S) The number of oocytes in the daily-dose group was significantly greater. There were no significant differences in mean values for number of follicles > or =11 mm (except for day 7) and > or =14 mm, 2PN zygotes, and number of transferred embryos. Implantation and pregnancy rates per cycle were in favor of the intermittent 450-IU dose regimen; implantation rates were 17.0% and 9.8% in the 3-day-dose and daily-dose groups, respectively, and biochemical and clinical pregnancy rates were 33.3% and 15.7% and 25.5% and 13.7%, respectively. CONCLUSION(S) Intermittent administration of recombinant hFSH significantly reduces the total number of recombinant hFSH injections, compared with a conventional FSH regimen, without detrimental effects on implantation rate or pregnancy rate.
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van Wely M, Westergaard LG, Bossuyt PMM, van der Veen F. Effectiveness of human menopausal gonadotropin versus recombinant follicle-stimulating hormone for controlled ovarian hyperstimulation in assisted reproductive cycles: a meta-analysis. Fertil Steril 2003; 80:1086-93. [PMID: 14607553 DOI: 10.1016/s0015-0282(03)02187-3] [Citation(s) in RCA: 75] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To compare the effectiveness of hMG and recombinant FSH after down-regulation for ovulation stimulation in assisted reproductive cycles. DESIGN Meta-analysis. SETTING Infertility centers providing assisted reproductive techniques. PATIENT(S) Two thousand thirty women undergoing IVF or ICSI. INTERVENTIONS Ovarian hyperstimulation with hMG or recombinant FSH after down-regulation. MAIN OUTCOME MEASURE(S) Clinical pregnancy rate, ongoing pregnancy/live birth rate, gonadotropin dose used, oocytes retrieved, implantation rate, miscarriage rate, and multiple pregnancy rate. RESULT(S) Six randomized controlled trials were included. In all trials, the group of women treated with hMG had higher pregnancy rates. Pooling the five trials that used a long GnRH agonist protocol resulted in a higher clinical pregnancy rate for hMG compared with recombinant FSH (relative risk, 1.22 [95% CI, 1.03 to 1.44]). However, there was no evidence of a difference in rates of ongoing pregnancy or live birth per woman between hMG recipients and recombinant FSH recipients (relative risk, 1.20 [95% CI, 0.99 to 1.45]). No differences were found in gonadotropin dose used, oocytes retrieved, miscarriage rate, or multiple pregnancy rate. CONCLUSION(S) Use of hMG resulted in higher clinical pregnancy rates than did use of recombinant FSH in IVF/ICSI cycles after GnRH agonist down-regulation in a long protocol.
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48
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Kolibianakis EM, Albano C, Camus M, Tournaye H, Van Steirteghem AC, Devroey P. Initiation of gonadotropin-releasing hormone antagonist on day 1 as compared to day 6 of stimulation: effect on hormonal levels and follicular development in in vitro fertilization cycles. J Clin Endocrinol Metab 2003; 88:5632-7. [PMID: 14671145 DOI: 10.1210/jc.2003-030805] [Citation(s) in RCA: 45] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/12/2023]
Abstract
The objective of the present study was to assess the effect of altering the timing of GnRH antagonist initiation on the hormonal environment and follicular development in in vitro fertilization cycles. Sixty women undergoing in vitro fertilization participated in a prospective randomized controlled trial. Patients were stimulated with a fixed dose of 200 IU recombinant FSH, starting on d 2 of the cycle, and with GnRH-antagonist, starting either on d 1 (n = 30) or on d 6 of stimulation (n = 30). A significantly lower exposure to LH (P < 0.001) and estradiol (P < 0.001) during the follicular phase was observed in the d-1 group, compared with the d-6 group of antagonist administration. No differences in follicular development were seen between the two groups on either d 6 of stimulation or on the day of human chorionic gonadotropin administration. Similar fertilization rates, implantation rates, and ongoing pregnancy rates per transfer were, in addition, present between the two groups compared. In conclusion, administration of GnRH antagonist on d 1 (compared with d 6) of stimulation is associated with a lower exposure to LH and estradiol, which does not seem to affect follicular development.
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Filicori M, Cognigni GE, Pocognoli P, Ciampaglia W, Bernardi S. Current concepts and novel applications of LH activity in ovarian stimulation. Trends Endocrinol Metab 2003; 14:267-73. [PMID: 12890591 DOI: 10.1016/s1043-2760(03)00085-7] [Citation(s) in RCA: 36] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Luteinizing hormone (LH) is a crucial physiological regulator of the human menstrual cycle. LH activity is also contained in many medications used to treat anovulation and to stimulate multiple folliculogenesis for assisted reproduction techniques. However, LH activity had previously been regarded as just a contaminant of follicle-stimulating hormone (FSH)-containing products and deemed potentially detrimental for reproductive function. Novel experimental and clinical evidence now suggests that the administration of pharmacological amounts of LH activity, instead of being harmful, is therapeutically advantageous, particularly in the support and modulation of ovarian folliculogenesis. The aim of this article is to provide an overview of the effects of LH activity administration in ovarian stimulation and to outline novel unconventional gonadotropin regimens that might improve the efficacy, safety and convenience of ovulation induction.
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Affiliation(s)
- Marco Filicori
- Reproductive Endocrinology Center, University of Bologna, Via Massarenti 13, 40138 Bologna, Italy.
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Affiliation(s)
- Howard D McClamrock
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of Maryland School of Medicine, Baltimore 21201, USA.
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