Follicle stimulating hormone (FSH) dynamics of low dose step-up ovulation induction with FSH in patients with polycystic ovary syndrome

The Relationship Between Serum Delta FSH Level and Ovarian Response in IVF/ICSI Cycles

Background

When ovarian response to FSH stimulation for IVF/ICSI is unsatisfactory, the FSH dose is often adjusted in the treatment cycles, thereby assuming that hormone status and follicular development were insufficient for optimal stimulation.

Objectives

To evaluate whether serum delta FSH levels between D6 of gonadotrophin use and basal serum FSH or between D6 of gonadotrophin use and D1 of gonadotrophin use predict ovarian response in IVF/ICSI cycles.

Method

The participants of this retrospective study were chosen from the Reproductive Medicine, The First Affiliated Hospital of Zhengzhou University between August 2015 and December 2017 (n = 3,109), and during the COS, each participant was given a fixed dose of rFSH in the first 6 days. Delta FSH1: The difference of serum FSH between D6 of gonadotrophin use and basal serum FSH. Delta FSH2: The difference of serum FSH between D6 of gonadotrophin use and D1 of gonadotrophin use. Logistic regression was used to analyze the association between delta FSH1 level and delta FSH2 level and ovarian response. Besides, we also use the tertile statistics to divide the groups.

Results

Part I: Delta FSH1 levels (mean: 1.41 ± 3.46) in normal responders were higher than delta FSH1 levels (mean: 1.07 ± 23.89) in hyper responders (P = 0.0248). The tertile of delta FSH1 is dif ≤ 0, 0 < dif ≤ 2.25 and dif > 2.25. Compared with the hyper responder, the delta FSH1 (0 < dif ≤ 2.25 and dif > 2.25) in the normal responder has a higher ratio and is statistically significant. Part II: Delta FSH2 levels (mean: 4.90 ± 2.84) in normal responders were similar with delta FSH2 levels (mean: 4.74 ± 2.09) in hyper responders (P = 0.103). The tertile of delta FSH1 is dif ≤ 3.91, 3.91 < dif ≤ 5.69 and dif > 5.69. Compared with the hyper responders, the delta FSH2 (3.91 < dif ≤ 5.69 and dif > 5.69) in the normal responders has a higher ratio and is statistically significant.

Conclusions

There is a weak relationship between ovarian response and serum delta FSH levels.

Immature oocyte incidence: Contributing factors and effects on mature sibling oocytes in intracytoplasmic sperm injection cycles

Objective

The aim of this study was to investigate which factors contribute to the incidence of immature oocytes (germinal vesicle -GV- and metaphase I -MI-) and how they impact the intracytoplasmic sperm injection (ICSI) outcomes of sibling mature oocytes.

Methods

Data from 3,920 cycles performed from June/2010 to August/2016 in a private university-affiliated IVF center were evaluated for the influence of controlled ovarian stimulation protocol (COS) on immature oocytes incidence and its effects on ICSI outcomes.

Results

MI (p=0.004) and GV (p=0.029) number were negatively correlated with gonadotropin dose. Patients stimulated by rFSH had increased GV/oocyte rate in both GnRH agonists (p<0.001) and antagonist (p=0.042) protocols, in comparison to rFSH associated with rLH protocol. MI and GV/oocyte rates were negatively correlated to fertilization (p<0.001), high-quality embryo on da p<0.001; GV/oocyte p=0.033) and pregnancy (MI/oocyte p=0.002; GV/oocyte p=0.013) rates. Cycles above a 10.5% MI/oocyte cut-off were correlated to higher response to ovarian stimulation, poor embryo development and almost two times lower pregnancy rate. Immature oocyte incidence is affected by COS and impacts on ICSI outcomes.

Conclusion

Our evidence suggests that oocytes derived from a cohort with high incidence of maturation fail may have detrimental clinical outcomes.

Individualization of FSH Doses in Assisted Reproduction: Facts and Fiction

The art of ovarian stimulation for IVF/ICSI treatment using exogenous FSH should be balanced against the relative contribution of other steps of the ART process such as the IVF-lab-phase and the Embryo-Transfer. The aim of ovarian stimulation is to obtain a certain number of oocytes, that will enable the best probability of achieving a live birth. It has been suggested that more oocytes will create a better prospect for pregnancy, but studies on the question whether the retrieval of a few oocytes less or more will make the difference are not clearly supportive for this mantra. Personalization strategies have been the subject of many studies over the past 20 years. Creating the optimal response in a patient in terms of live birth prognosis as well as OHSS risks may be based on information from the Ovarian Reserve testing using the Antral Follicle Count or Anti-Mullerian Hormone, the patient's bodyweight, the ovarian response in a previous cycle, and the dosage level of FSH. Taken together, steering the ovarian response into a supposed optimal range may appear difficult as the interrelation for each of these factors with the egg number is weak. Using OR testing for choosing FSH dosage, compared to a standard normal dosage of 150 IU, has been studied in several trials. Dosage individualization, in general, does not appear to improve the prospects for live birth, but the reduction in OHSS risk may be substantial. This implies that the use of high dosages of FSH in predicted LOW responders lacks any cost-benefit for the patient and may be abandoned, while in predicted HIGH responders, reduction of the usual dosage level of 150 IU may create better safety, provided that in case of an unexpected LOW response cancelation of the cycle is refrained from. In view of recent developments in using GnRH agonist triggering of final oocyte maturation, the trend could be that with the Antagonist co-medication system and a standard dosage of 150 IU of FSH, prior ovarian reserve testing may become futile, as safety can be managed well in actual HIGH responders by replacing the high dose hCG trigger.

Identification and analysis of differentially expressed long non-coding RNAs between multiparous and uniparous goat (Capra hircus) ovaries

Long non-coding RNAs (lncRNAs) play important roles in almost all biological processes. However, there is little information on the effects of lncRNAs on ovulation and lambing rates. In the present study, we used high-throughput RNA sequencing to identify differentially expressed lncRNAs between the ovaries of multiparous (Mul) and uniparous (Uni) Anhui White goats. Among the 107,255,422 clean reads, 183,754 lncRNAs were significantly differentially expressed between the Uni and Mul. Among them, 455 lncRNAs were co-expressed between the two samples, whereas, 157,523 lncRNAs were uniquely expressed in the Uni, and 25,776 uniquely lncRNAs were expressed in the Mul. Through Cis role analysis, 24 lncRNAs were predicted to overlap with cis-regulatory elements, which involved in Progesterone-mediated oocyte maturation, Steroid biosynthesis, Oocyte meiosis, and gonadotropin-releasing hormone (GnRH) signaling pathway. These 4 pathways were related to ovulation, and the KEGG pathway analysis on target genes of the differentially expressed lncRNAs confirmed this results. In addition, 10 lncRNAs harbored precursors of 40 miRNAs, such as TCONS_00320849 related to a mature miRNA sequence, miR-365a, which was reported to be related to proliferation, were annotated in the precursor analysis of miRNAs. The present expand the understanding of lncRNA biology and contribute to the annotation of the goat genome. The study will provide a resource for lncRNA studies of ovulation and lambing.

Pharmacokinetics and Pharmacodynamics of Follicle-Stimulating Hormone in Healthy Women Receiving Single and Multiple Doses of Highly Purified Human Menotrophin and Urofollitrophin

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 (AUC_t) 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 (AUC_τ) of 322.59 ± 57.92 IU/L·h, which was similar to the mean AUC_t 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.

Identification and characterization of microRNAs in the ovaries of multiple and uniparous goats (Capra hircus) during follicular phase

Background

Superior kidding rate is an important economic trait in production of meat goat, and ovulation rate is the precondition of kidding rate. MicroRNAs (miRNAs) play critical roles in almost all ovarian biological processes, including folliculogenesis, follicle development, follicle atresia, luteal development and regression. To find out the different ovarian activity and follicle recruitment with miRNA-mediated posttranscriptional regulation, the small RNAs expressed pattern in the ovarian tissues of multiple and uniparous Anhui White goats during follicular phase was analyzed using Solexa sequencing data.

Results

1008 miRNAs co-expressed, 309 and 433 miRNAs specifically expressed in the ovaries of multiple and uniparous goats during follicular phase were identified. The 10 most highly expressed miRNAs in the multiple library were also the highest expressed in the uniparous library, and there were no significantly different between each other. The highest specific expressed miRNA in the multiple library was miR-29c, and the one in the uniparous library was miR-6406. 35 novel miRNAs were predicted in total. GO annotation and KEGG Pathway analyses were implemented on target genes of all miRNA in two libraries. RT-PCR was applied to detect the expression level of 5 randomly selected miRNAs in multiple and uniparous hircine ovaries, and the results were consistent with the Solexa sequencing data.

Conclusions

In the present study, the different expression of miRNAs in the ovaries of multiple and uniparous goats during follicular phase were characterized and investigated using deep sequencing technology. The result will help to further understand the role of miRNAs in kidding rate regulation and also may help to identify miRNAs which could be potentially used to increase hircine ovulation rate and kidding rate in the future.

Electronic supplementary material

The online version of this article (doi:10.1186/1471-2164-15-339) contains supplementary material, which is available to authorized users.

Role of anti-Müllerian hormone and bone morphogenetic proteins in the regulation of FSH sensitivity

The ovary is under control of the hypothalamus and pituitary through the glycoprotein hormones LH and FSH. These hormones undergo a cyclic variation which results in the selection of the species-specific number of follicles that will ovulate during the cycle. Where LH is the main ovulatory hormone and regulator of corpus luteum function, FSH plays an essential role in the cyclic recruitment of the follicles. Within the microenvironment of the ovary, growth factors affect this dominant control of FSH by regulating the FSH sensitivity of individual follicles. In this review we discuss the role of anti-Müllerian hormone (AMH) and bone morphogenetic proteins (BMPs) in this process.

Follicular stimulating hormone enhances Notch 1 expression in SK-OV-3 ovarian cancer cells

OBJECTIVE

Notch is known as a transmembranous receptor family with four homologous forms - Notch 1, Notch 2, Notch 3, and Notch 4 and related to cell fate regulation and angiogenesis. The purpose is to investigate the effect of follicular stimulating hormone (FSH) on the Notch 1 expression and proliferation in ovarian cancer cells.

METHODS

Human ovarian cancer cell line, SK-OV-3 and FSH were used. XTT cell proliferation and cell migration assay were carried out with FSH 100 mIU/mL and Notch 1 siRNA. Western blots and reverse transcriptase-polymerase chain reactions (RT-PCR) were carried out to determine the expression level of the Notch 1 protein and mRNA with FSH treatment in 0, 1, 5, 10, 100, 200, 300 mIU/mL concentrations. Immunofluorescent (IF) stains were performed in SK-OV-3 cell cultures with FSH 100 mIU/mL. Student-t tests were used in statistical analyses.

RESULTS

The SK-OV-3 have Notch 1 receptors in their natural status. FSH stimulated SK-OV-3 cells in XTT cell proliferation and cell migration assays and notch 1 siRNA inhibited. The expression level of Notch 1 protein and mRNA were increased in a dose dependent pattern according to FSH concentrations compared to untreated cells. IF stains also showed brighter Notch1 expressions in the FSH treated cells compared to the control cells.

CONCLUSION

FSH enhances proliferation & migration and Notch 1 signaling in SK-OV-3 cells. The Notch signaling probably supports one of the cell proliferating mechanisms of FSH in ovarian cancer cells.

Embryo implantation rates in natural and stimulated assisted reproduction treatment cycles in poor responders

Controlled ovarian stimulation with exogenous gonadotrophins and gonadotrophin-releasing hormone (GnRH) analogues enables the collection of multiple oocytes and subsequent development of multiple embryos. However, interfering with the natural hormonal milieu may decrease the probability of successful embryo implantation due to effects on oocytes and/or endometrium. In order to provide a fair comparison of embryo implantation rates between natural cycles and stimulated cycles, bias caused by the presence of multiple embryos available for transfer in stimulated cycles should be avoided. This retrospective study analysed embryo implantation rates in cycles in which only a single embryo was available for transfer in 304 women who had poorly responded to ovarian stimulation in the previous cycle. Embryo implantation rates with different stimulation protocols were as follows: natural cycle, 20% (6/30); gonadotrophin only, 5.6% (3/54); long GnRH protocol, 3.8% (2/52); co-flare protocol, 1.9% (1/52); microdose flare-up, 15.4% (4/26); GnRH antagonists, 14.4% (13/90). Although the difference was not statistically significant there was a trend towards higher implantation rates with natural cycles in this group of women. Natural cycle IVF may be a reasonable and patient-friendly treatment choice yielding an acceptable outcome for women who are known or anticipated poor responders to ovarian stimulation.

Predicting the FSH threshold dose in women with WHO Group II anovulatory infertility failing to ovulate or conceive on clomiphene citrate

BACKGROUND

The objective of this investigation was to establish independent predictors of follicle-stimulating hormone (FSH) threshold dose in anovulatory women undergoing ovulation induction with FSH preparations.

METHODS

One hundred and fifty-one patients with WHO Group II anovulatory infertility failing to ovulate or conceive on clomiphene citrate underwent ovarian stimulation with FSH-only preparations following a low-dose step-up protocol. The individual FSH threshold dose was defined as the FSH dose when meeting the human chorionic gonadotrophin criteria (one follicle ≥17 mm, or 2–3 follicles ≥15 mm). The influence of demographics, physical characteristics, obstetric and infertility and menstrual cycle history, ovarian ultrasonography, endocrine parameters and type of gonadotrophin preparation on the FSH threshold dose was assessed through multiple regression analysis.

RESULTS

In the univariate analysis, age, body mass index (BMI), failure to ovulate with clomiphene citrate, menstrual cycle history (amenorrhea, oligomenorrhea or anovulatory cycles of 21–35 days), mean ovarian volume, LH/FSH ratio, testosterone and free androgen index were significant (P < 0.05) predictors of FSH threshold dose. In the multivariate analysis, menstrual cycle history, mean ovarian volume and BMI remained significant (P < 0.001).

CONCLUSIONS

The individual FSH threshold dose for ovulation induction in anovulatory women can be predicted based on three variables easily determined in clinical practice: menstrual cycle history, mean ovarian volume and BMI. A FSH dosage nomogram was constructed based on these parameters.

Hopes and facts about mild ovarian stimulation

Over the last two decades, easier and less expensive stimulation treatments have been largely replaced by more complex and more demanding protocols. Since the mid-nineties, long-term gonadotrophin-releasing hormone agonist stimulation protocols have been widely used. Such lengthy expensive regimens are not free from short- and long-term risks and complications. Mild stimulation protocols reduce the mean number of days of stimulation, the total amount of gonadotrophins used and the mean number of oocytes retrieved. The proportion of high quality and euploid embryos seems to be higher compared with conventional stimulation protocols and the pregnancy rate per embryo transfer is comparable. Moreover, the reduced costs, the better tolerability for patients and the less time needed to complete an IVF cycle make mild approaches clinically and cost-effective over a given period of time. However, further prospective randomized studies are needed to compare cumulative pregnancy rates between the two protocols. Natural cycle IVF, with minimal stimulation, has been recently proposed as an alternative to conventional stimulation protocols in normo- and poor responder patients. Although acceptable results have been reported, further large prospective randomized studies are needed to better evaluate the efficacy of these minimal regimens compared with conventional stimulation approaches.

Improved monofollicular ovulation in anovulatory or oligo-ovulatory women after a low-dose step-up protocol with weekly increments of 25 international units of follicle-stimulating hormone

OBJECTIVE

To compare the effectiveness and efficiency of two low-dose step-up protocols for ovulation induction in women with anovulatory infertility (World Health Organization group II).

DESIGN

Open-label, prospective, randomized, group-comparative, multicenter study.

SETTING

Eighteen infertility centers in Europe and Canada.

PATIENT(S)

One hundred fifty-eight anovulatory or oligo-ovulatory infertile women.

INTERVENTION(S)

Patients were randomly assigned to one of two protocols for one cycle of follitropin beta (rFSH) using a pen device. The starting dosage was 50 IU/day for 7 days. In the absence of follicles > or =12 mm, the daily dosage was increased by either 25 or 50 IU per week.

MAIN OUTCOME MEASURE(S)

The percentage of all subjects treated who ovulated after one treatment cycle (efficacy) and the total rFSH dose to reach ovulation (efficiency).

RESULT(S)

The 25-IU group had a higher incidence of monofollicular growth (41.3% of 80 vs. 21.8% of 78 women) and ovulation (81.3% vs. 60.3%), a lower cumulative rFSH dose (887 IU vs. 984 IU), and fewer cancellations due to hyperresponse (>3 follicles > or =15 mm; 5.0% vs. 20.5%). Both protocols were well tolerated.

CONCLUSION(S)

Weekly increments of 25 IU in the daily dose were more effective and efficient than 50-IU increments.

Ovarian feedback, mechanism of action and possible clinical implications

The secretion of gonadotrophins from the pituitary in women is under ovarian control via negative and positive feedback mechanisms. Steroidal and non-steroidal substances mediate the ovarian effects on the hypothalamic-pituitary system. During the follicular phase of the cycle, estradiol (E(2)) plays a key role, while circulating progesterone (at low concentrations) and inhibin B contribute to the control of LH and FSH secretion respectively. During the luteal phase, both E(2) and progesterone regulate secretion of the two gonadotrophins, while inhibin A plays a role in FSH secretion. The intercycle rise of FSH is related to changes in the levels of the steroidal and non-steroidal substances during the luteal-follicular transition. In terms of the positive feedback mechanism, E(2) is the main component sensitizing the pituitary to GnRH. Activity of a non-steroidal ovarian substance, named gonadotrophin surge-attenuating factor (GnSAF), has been detected after ovarian stimulation. It is hypothesized that GnSAF, by antagonizing the sensitizing effect of E(2) on the pituitary, regulates the amplitude of the endogenous LH surge at midcycle. Disturbances in the feedback mechanisms can occur in various abnormal conditions or after treatment with pharmaceutical compounds that interfere with the production or the action of endogenous hormones.

Gonadotrophin treatment in patients with polycystic ovary syndrome

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

Estimation of the follicle-stimulating hormone (FSH) threshold for initiating the final stages of follicular development in women with elevated FSH levels in the early follicular phase

OBJECTIVE

To test the hypothesis that the follicle-stimulating hormone (FSH) threshold in patients with elevated FSH levels in the early follicular phase (EFP) is higher than in controls.

DESIGN

Pilot study.

SETTING

Academic hospital.

PATIENT(S)

Six patients with elevated EFP FSH (>10 IU/L) and 13 controls.

INTERVENTION(S)

Treatment with a GnRH agonist in the midluteal phase before IV administration of recombinant FSH was started in an ultra-low-dose step-up protocol. The FSH threshold was determined by the mean of FSH levels of the above threshold value and the below threshold value.

MAIN OUTCOME MEASURE(S)

Follicle-stimulating hormone threshold, FSH screening value, E(2), number of follicles.

RESULT(S)

The FSH threshold in the elevated EFP FSH group was 6.75 IU/L and was significantly higher than the FSH threshold of the controls (4.65 IU/L). The FSH screening value on day 3 was 12.0 IU/L in the patient group and 5.0 IU/L in the controls. Estradiol was significantly lower on the day that the largest follicle was 18 mm in the elevated EFP FSH group compared with controls (277 vs. 491 pmol/L, respectively). On the day of hCG administration, the number of smaller (10-13 mm) follicles was equal but the number of larger (>14 mm) follicles was higher in the control group compared with the elevated FSH group. In the control group, the basal FSH levels correlated highly with the FSH threshold levels (r = 0.8), but in the patients with elevated EFP FSH this correlation was absent.

CONCLUSION(S)

In normal women, basal FSH day 3 values represent the ovarian threshold for FSH. In women with elevated day 3 FSH, the FSH threshold is higher but not as high as basal FSH values. We postulate that the FSH threshold in patients with elevated EFP FSH is higher because of intraovarian factors. Basal FSH overshoots the threshold, probably because of the limited feedback by the ovary.

Follicle-stimulating hormone and advanced follicle development in the human

The great majority of human oocytes is destined to undergo atresia. Only follicles able to respond to stimulation by follicle-stimulating hormone (FSH) will enter the final stage of development and ovulate. While the role of FSH in early follicle development is unclear, late follicular development is FSH-dependent. FSH levels increase during the luteo-follicular transition and give rise to continued growth of a cohort of follicles. In the normo-ovulatory cycle, one follicle achieves a diameter of >8 mm and produces high concentrations of estradiol. In response to negative feedback from rising estradiol and inhibin levels, FSH levels fall in the late follicle phase. The dominant follicle has increased sensitivity to the falling FSH levels and continues growing. Follicles that initiate the latter stages of development after FSH levels begin to fall undergo atresia. The duration of this FSH window during which FSH levels are above the threshold required to stimulate ongoing development determines the number of follicles that can develop to the pre-ovulatory stage. Recognition of this concept has resulted in new approaches in ovulation induction treatment and ovarian hyperstimulation therapy for in vitro fertilization (IVF).

New concepts in superovulation strategies for assisted conception treatments

Controlled ovarian stimulation for in-vitro fertilization treatment using preparations that contain follicle-stimulating hormone has been routinely performed since the 1980s. The early preparations were urinary human menopausal gonadotrophins, containing follicle-stimulating hormone and luteinizing hormone. In the early 1990s, highly purified follicle-stimulating hormone preparations were introduced because of a desire to provide drugs for subcutaneous administration with a lower risk of allergic reactions. Intensive research resulted in the discovery of recombinant follicle-stimulating hormone, which is more potent that the highly purified follicle-stimulating hormone, resulting in significantly higher clinical pregnancy rates. The two recombinant follicle-stimulating hormone preparations available appear to be equally effective and provide comparable results. Gonadotrophin-releasing hormone antagonists, which have recently been introduced, appear to be effective in preventing a premature rise in luteinizing hormone during ovarian stimulation for in-vitro fertilization, as well as improved response to lower doses of gonadotrophins. It is envisaged that the availability of recombinant gonadotrophins and gonadotrophin-releasing hormone antagonists will ultimately lead to shorter, cheaper and safer treatments, using reduced dosages.

Ovulation induction with low dose alternate day recombinant follicle stimulating hormone (Puregon)

We investigated whether a recombinant follicle stimulating hormone (FSH) (Puregon) can be administered less frequently and at lower doses during ovulation induction than is current practice. Patients (20-35 years, body mass index <30 kg/m(2)) with infertility and chronic anovulation secondary to polycystic ovarian syndrome and resistant to previous clomiphene treatment received (Puregon); 100 IU, n = 17 patients, or 50 IU, n = 10 patients) on alternate days. After 2 weeks and in the absence of follicular recruitment, doses were increased stepwise at weekly intervals (50 IU/alternate days). Twenty-two cycles out of 27 were ovulatory. There were six pregnancies, five from Puregon (100 IU) and one from Puregon (50 IU); four pregnancies proceeded to term. The duration of stimulation (mean, range) with Puregon (100 IU) was 16.4, 7-29 and Puregon (50 IU) 19.1, 8-38 days. The gonadotrophin doses administered (mean; range) were 689, 200-1800 IU (Puregon 50 IU) and 939, 400-2300 IU (Puregon 100 IU). We conclude that low dose alternate day Puregon treatment is suitable for this difficult patient group.

Limited ovarian stimulation results in the recovery of mature oocytes in polycystic ovarian disease patients: a preliminary report

This pilot study including five patients, examined the feasibility of obtaining oocytes from partially stimulated ovarian follicles in patients with polycystic ovarian disease (PCOD). We evaluated oocyte maturity, and fertilization potentials. The diagnosis of PCOD was based on ultrasound findings and endocrine criteria. The long protocol of pituitary ovarian axis down-regulation was used and follicles were stimulated with daily injections of human menopausal gonadotropin (HMG), until the mean diameter of the leading follicle reached 12 mm. A full dose of HCG (10000 I.U.) was administered and oocytes were collected 36 h later. The mean number of oocytes collected per patient was 12.6+/-4.9, the mean number of MII oocytes was 8.8+/-4.4, with fertilization rate of 70.5% following intracytoplasmic sperm injection (ICSI). To our knowledge this is the first report in the literature documenting the recovery of mature oocytes following limited stimulation of the ovaries. The potentials of this novel approach open a new dimension in the management of patients with PCOD.

Retrieval, maturation, and fertilization of immature oocytes obtained from unstimulated patients with polycystic ovary syndrome

PURPOSE

Our purpose was to determine whether immature oocytes could be retrieved under local anesthesia, whether these oocytes would mature and fertilize in vitro, and whether adequate endometrium development could be obtained after hormonal supplementation.

METHODS

Ovum pick-up was performed under local anesthesia. Immature oocytes were cultured and inseminated. To prepare the endometrium, estradiolvalerate was administered in combination with micronized progesterone.

RESULTS

Immature oocytes were obtained in all cases. Fifty-six percent (n = 30) of the oocytes developed into metaphase II (MII) after 48 hr of culture, and another 20% reached the MII stage by 72 hr. Normal fertilization was observed in only 10% of oocytes inseminated. No embryonic development occurred, and therefore embryo transfer was not performed in any of the patients. Endometrial microbiopsy was performed in all subjects and endometrial development was considered sufficient in eight patients.

CONCLUSIONS

We collected immature oocytes from patients with polycystic ovary syndrome without general anesthesia. In vitro maturation of these oocytes seemed adequate but fertilization rates were poor. Sufficient endometrial quality was obtained after hormonal substitution.

Cohort size rather than follicle-stimulating hormone threshold level determines ovarian sensitivity in polycystic ovary syndrome

The aim of the presented study was to compare FSH threshold levels and ovarian response to stimulation with one of two standard increments of exogenous FSH above the threshold in patients with polycystic ovary syndrome (PCOS) (n = 12) and eumenorrheic women (n = 11). The individual FSH threshold was determined by treatment according to a low-dose, step-up protocol with urinary FSH (Metrodin; Ares Serono, Geneva, Switzerland). In a subsequent treatment cycle, six PCOS patients and six eumenorrheic women were randomly assigned to double-blind treatment with the threshold dose plus 1/2 ampoule; the other six PCOS patients and five eumenorrheic women were treated with 1 ampoule above the threshold dose. Determination of threshold levels showed no significant differences in median and range between PCOS patients and eumenorrheic women. The number of follicles on the day of human chorionic gonadotropin administration showed no significant correlation with the increase in FSH level above the threshold level. Irrespective of the dose given, the number of follicles in the PCOS group was significantly higher than in eumenorrheic women. The higher sensitivity for gonadotropin stimulation in patients with PCOS compared with women with regular menstrual cycles therefore appears not to be dependent on differences in FSH threshold level, but rather on the larger size of the FSH sensitive cohort of small antral follicles.

The importance of endogenous feedback for monofollicular growth in low-dose step-up ovulation induction with follicle-stimulating hormone in polycystic ovary syndrome: a randomized study

OBJECTIVE

To evaluate the role of endogenous feedback in monofollicular growth during low-dose gonadotrophin therapy in polycystic ovary syndrome (PCOS) by measuring FSH levels in a group of patients cotreated with a GnRH agonist (GnRH-a) (group B) compared with patients not cotreated with an agonist (group A).

DESIGN

Prospective randomized study.

SETTING

University tertiary care Reproductive Endocrinology Unit.

PATIENTS

Women with clomiphene citrate-resistant PCOS.

MAIN OUTCOME MEASURES

Follicle-stimulating hormone, E2, and inhibin levels, follicular growth.

RESULTS

In group A, FSH levels decreased significantly from 7.3 mIU/mL (conversion factor to SI unit, 1.00) at day -5 to 5.9 mIU/mL at day 0 (day that hCG was administered) despite a constant dose, whereas they remained at a level of 7.4 mIU/mL in group B. The rate of monofollicular growth was significantly higher in group A (80%) than in group B (22%). No significant differences in E2 levels or inhibin levels were found between the groups.

CONCLUSIONS

The absence of a decrease of FSH during GnRH-a treatment in association with a lower rate of monofollicular growth suggests that endogenous feedback during low-dose step-up ovulation induction in PCOS plays an important role. The absence of this feedback mechanism in the presence of normal inhibin levels suggests that negative feedback control by inhibin during follicular stimulation is minimal.