Folliculogenesis in hypophysectomized rats after treatment with recombinant human follicle-stimulating hormone

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

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

OUP accepted manuscript

STUDY QUESTION

SUMMARY ANSWER

WHAT IS KNOWN ALREADY

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PARTICIPANTS/MATERIALS, SETTING, METHODS

MAIN RESULTS AND THE ROLE OF CHANCE

LIMITATIONS, REASONS FOR CAUTION

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DATE OF FIRST PATIENT’S ENROLMENT

Ovarian Folliculogenesis and Uterine Endometrial Receptivity after Intermittent Vaginal Injection of Recombinant Human Follicle-Stimulating Hormone in Infertile Women Receiving In Vitro Fertilization and in Immature Female Rats

The uterine first-pass effect occurs when drugs are delivered vaginally. However, the effect of vaginally administered recombinant human follicle-stimulating hormone (rhFSH) on ovarian folliculogenesis and endometrial receptivity is not well established. We aimed to compare the efficacy of rhFSH administered vaginally and abdominally in clinical in vitro fertilization (IVF) treatment, pharmacokinetic study, and animal study. In IVF treatment, the number of oocytes retrieved, endometrial thickness and uterine artery blood perfusion were not different between women who received the rhFSH either vaginally or abdominally. For serum pharmacokinetic parameters, significantly lower Tmax, clearance, and higher AUC and T_1/2_elimination of rhFSH were observed in women who received rhFSH vaginally, but urine parameters were not different. Immature female rats that received daily abdominal or vaginal injections (1 IU twice daily for 4 days) or intermittent vaginal injections (4 IU every other day for two doses) of rhFSH had more total follicles than the control group. In addition, the serum progesterone and progesterone receptors in the local endometrium were significantly higher in the groups treated with intermittent abdominal or vaginal injection of rhFSH, compared with those who recieved daily injection. In summary, vaginal administration of rhFSH may provide an alternative treatment regimen in women receiving IVF.

LAPS-FSH: a new and effective long-acting follicle-stimulating hormone analogue for the treatment of infertility

Although several long-acting follicle-stimulating hormone (FSH) therapies have been developed to enhance the ovarian response, a disadvantage of FSH therapy is its relatively short half-life, which requires women to receive one to two injections per day for almost 2 weeks. In the present study, we developed a novel FSH analogue by conjugating recombinant human FSH (rhFSH) and the constant region of the human immunoglobulin G4 fragment via non-peptidyl linkers. The efficacy of the FSH analogue was evaluated in vitro by cAMP level assessments, pharmacokinetic studies and a determination of ovarian weight and by comparing these findings with the results from other FSH analogues. In addition, the total number of antral and Graafian follicles was determined after 7 days of treatment with control, 6µgkg(-1) follitropin β, 6, 12 or 42µgkg(-1) corifollitropin α or 3, 6 or 12µgkg(-1) long acting protein/peptide discovery-follicle-stimulating hormone (LAPS-FSH). As a result, the animals treated with 12µgkg(-1) LAPS-FSH produced additional and larger healthy follicles. These data demonstrate that LAPS-FSH promotes growth and inhibits atresia of the ovarian follicle compared with other available drugs, suggesting that our new drug enhances the efficacy and duration of treatment. It is expected that our new FSH analogue will result in a higher chance of pregnancy in patients who are unresponsive to other drugs.

Genetic approaches to the improvement of fertility traits in the pig

One of the major determinants for litter size in pigs is prenatal mortality. It occurs most frequently during the first few weeks of gestation and can be attributed to abnormalities in developmental processes during embryogenesis including trophoblastic elongation and blastocyst implantation. Improvement of litter size has been attempted by means of phenotypic selection. However, another promising approach in pursuit of this aim has been the use of genotypic information. Reproductive traits in general are well-suited for application of marker-assisted selection (MAS). The possibility of exerting selection criteria at the molecular level shortens the generation interval as the selection decision can take place early in the life of an animal. Moreover, in consideration of the sex-limited nature of reproductive traits, genotypic information allows for selection in the gender in which the trait cannot be directly observed. Accordingly, there has been considerable interest in mapping and identifying genes involved in the regulation of reproductive traits and in elucidating their expression patterns. This review offers a comprehensive, if not exhaustive, account of the efforts being made and the approaches currently used in this field. One approach has been to choose candidate genes a priori because of the physiological importance of the proteins they encode and their role in the reproduction of other mammals. The usefulness of candidate genes is then examined by association studies between genetic polymorphisms identified in the respective candidate genes and the phenotypic reproductive traits. The other approach discussed uses pre-existing or designed families for linkage analyses in order to map the location of quantitative trait loci (QTL) for the reproductive trait of interest. The results reported were not consistent among different studies but the QTL regions detected may be useful for identification of positional candidate genes in further molecular genetic studies. However, a better understanding of porcine reproduction requires that these functional genomic approaches are merged and integrated with detailed analyses of the proteome to establish linkages between predisposition and physiology.

The role of aromatase inhibitors in ameliorating deleterious effects of ovarian stimulation on outcome of infertility treatment

Clinical utilization of ovulation stimulation to facilitate the ability of a couple to conceive has not only provided a valuable therapeutic approach, but has also yielded extensive information on the physiology of ovarian follicular recruitment, endometrial receptivity and early embryo competency. One of the consequences of the use of fertility enhancing agents for ovarian stimulation has been the creation of a hyperestrogenic state, which may influence each of these parameters. Use of aromatase inhibitors reduces hyperestrogenism inevitably attained during ovarian stimulation. In addition, the adjunct use of aromatase inhibitors during ovarian stimulation reduces amount of gonadotropins required for optimum stimulation. The unique approach of reducing hyperestrogenism, as well as lowering amount of gonadotropins without affecting the number of mature ovarian follicles is an exciting strategy that could result in improvement in the treatment outcome by ameliorating the deleterious effects of the ovarian stimulation on follicular development, endometrial receptivity, as well as oocyte and embryo quality.

Glycosylation of an N-terminal extension prolongs the half-life and increases the in vivo activity of follicle stimulating hormone

FSH is a key component in assisted reproductive technologies. Because of rapid clearance of the hormone, patients have to be treated with daily injections. To address this problem, a long-acting FSH mutein was created by introduction of additional N-linked glycosylation into the molecule. New glycosylation sites were introduced by two different approaches: structure-aided, site-directed introduction of sites within the FSH molecule and addition of N-terminal extensions. A mutein with the extension sequence ANITVNITV at the N terminus of the alpha-chain (FSH1208) was efficiently glycosylated at both new sites. This resulted in a molecule with increased size and charge, factors known to reduce renal clearance of proteins. FSH1208 was found to have a 3- to 4-fold increased serum half-life, compared with wild-type recombinant FSH. Furthermore, in spite of a lower in vitro activity, FSH1208 had a markedly increased in vivo potency, as shown by increased ability to augment the ovarian weight and stimulate the serum estradiol levels in rats. These characteristics make FSH1208 a possible candidate for improved infertility treatment.

Aromatase inhibitors for the treatment of infertility

Ovarian stimulation during infertility treatment is used either alone or in conjunction with intrauterine insemination and assisted reproductive technologies. At the present time, the two main medications used for ovarian stimulation include an oral antioestrogen, clomiphene citrate and injectable gonadotrophins. In spite of the high ovulation rate, the use of clomiphene citrate is associated with adverse side effects and low pregnancy rates. In clomiphene citrate failures, gonadotrophin injections are generally the next treatment option but, especially in polycystic ovarian syndrome, are associated with increased risk of severe ovarian hyperstimulation syndrome and high multiple pregnancies. Therefore, an effective oral treatment that could be used without risk of ovarian hyperstimulation syndrome and with minimal monitoring is preferred. It was hypothesised that aromatase inhibitors can be administered early in the follicular phase to induce ovulation by releasing the hypothalamus and/or pituitary from oestrogen negative feedback. The success of aromatase inhibitors in induction and augmentation of ovulation has been reported. In addition, increased intraovarian androgen levels may synergise with central effects of decreased oestrogen to enhance ovarian response to gonadotrophin stimulation. This increased sensitivity to follicle-stimulating hormone may be especially useful in poor responders. The potential future applications for aromatase inhibitors in infertility management are also discussed.

Are estrogens of import to primate/human ovarian folliculogenesis?

The notion that estrogens play a meaningful role in ovarian folliculogenesis stems from a large body of in vitro and in vivo experiments carried out in certain rodent models, (e.g., rats) wherein the stimulatory role of estrogen on granulosa cell growth and differentiation is undisputed. However, evidence derived from these polyovulatory species may not be readily generalizable to the monoovulatory subhuman primates, let alone the human. Only recently, significant observations on the ovarian role(s) of estrogen have been reported for the primate/human. It is thus the objective of this communication to review the evidence for and against a role for estrogens in primate/human ovarian follicular development with an emphasis toward the application of the concepts so developed to contemporary reproductive physiology and to the practice of reproductive medicine. The role(s) of estrogens will be examined not only by analyzing the physiological evidence to the effect that these hormones control ovarian function and follicular growth, but also by summarizing the molecular evidence for the existence and distribution of the cognate receptors.

Recombinant porcine follicle stimulating hormone produced in baculovirus-insect cells induces rat ovulation in vivo and gene expression of tissue plasminogen activator in vitro

Superovulatory responses in cattle are known to be highly variable. In the present study, a recombinant porcine follicle stimulating hormone (rpFSH) produced in baculovirus-insect cells was utilised to evaluate the role of this recombinant FSH in control of the ovulatory process. Immature hypophysectomised rats were implanted with oestrogen pellet (10 mg diethylstilbestrol) and then primed with pregnant mare serum gonadotropin (PMSG, 17.5 IU, sc). Fifty-two hours later, 100 microg rpFSH or saline was injected (sc) to induce ovulation. All rats that received rpFSH ovulated with about eight ova rat(-1), whereas none of the control animals did. Ovulation induced by rpFSH was associated with an increase in the ovarian activity and message levels of tissue-type plasminogen activator (tPA), a protease important in the preovulatory degradation of the follicle wall. Furthermore, addition of rpFSH to the cultured rat granulosa cells resulted in a significant increase in tPA enzyme activity. These results demonstrate that rpFSH produced in baculovirus-insect cells has biological potency in ovulation as well as gene expression of tPA, providing a large advantage of this massive expression system in the reproduction of domestic animals.

Baculovirus-insect cell production of bioactive porcine FSH

The in vitro and in vivo bioactivity of recombinant porcine FSH (rpFSH) produced from insect cells through use of a baculovirus expression system were studied and compared with those of natural FSH preparations. Determination of in vitro bioactivity, using the rat Sertoli cell aromatase bioassay, indicated that rpFSH is as active as purified pituitary FSH. Determination of in vivo bioactivity, using the mouse uterine weight bioassay, indicated that rpFSH is as active as purified pituitary FSH. Using the mouse Leydig cell testosterone bioassay, it was demonstrated that the intrinsic LH bioactivity of rpFSH is negligible. The increases in ovarian and uterine weight, and the stimulation in follicular growth in immature hypophysectomized rats induced by rpFSH supplemented with hCG were comparable to those induced by natural FSH preparations. Furthermore, rpFSH alone in hypophysectomized mice stimulated preantral follicular growth to preovulatory stages, and the subsequent injection of hCG caused ovulation. These results demonstrate that in vitro and in vivo biological characteristics of rpFSH produced from baculovirus-insect cells are indistinguishable from those of FSH isolated from natural sources.

Mammalian oocyte growth and development in vitro

This paper is a review of the current status of technology for mammalian oocyte growth and development in vitro. It compares and contrasts the characteristics of the various culture systems that have been devised for the culture of either isolated preantral follicles or the oocyte-granulosa cell complexes form preantral follicles. The advantages and disadvantages of these various systems are discussed. Endpoints for the evaluation of oocyte development in vitro, including oocyte maturation and embryogenesis, are described. Considerations for the improvement of the culture systems are also presented. These include discussions of the possible effects of apoptosis and inappropriate differentiation of oocyte-associated granulosa cells on oocyte development. Finally, the potential applications of the technology for oocyte growth and development in vitro are discussed. For example, studies of oocyte development in vitro could help to identify specific molecules produced during oocyte development that are essential for normal early embryogenesis and perhaps recognize defects leading to infertility or abnormalities in embryonic development. Moreover, the culture systems may provide the methods necessary to enlarge the populations of valuable agricultural, pharmaceutical product-producing, and endangered animals, and to rescue the oocytes of women about to undergo clinical procedures that place oocytes at risk.