Comparison of efficacy of high-dose pure follicle-stimulating hormone versus human menopausal gonadotropins for in vitro fertilization

Impact of 'LH activity' supplementation on serum progesterone levels during controlled ovarian stimulation: a systematic review

BACKGROUND

The influence of LH on serum progesterone rise during gonadotrophin stimulation is a matter of debate. The purpose of this analysis was to assess the impact of supplementation with 'LH activity' products on serum progesterone changes before hCG administration in GnRH analog-treated women.

METHODS

A computerized literature search was performed to identify studies comparing FSH treatment alone to those that provided supplementation with 'LH activity' using hMG, recombinant (r)LH (rLH) or hCG in GnRH analog protocols. Data regarding stimulation regimens were extracted from those that reported serum progesterone levels at the time of hCG in order to assess the specific role of LH activity products.

RESULTS

Serum progesterone determination at the time of hCG administration was performed in 34 out of 108 studies comparing the effects of FSH alone or in combination with LH activity products. In a vast majority, no significant difference in serum progesterone could be found between stimulation regimens. However, in four studies where LH activity (three hMG and one rLH) was administered from the beginning of ovarian stimulation, serum P-values were significantly decreased. In contrast, in two studies where LH activity (hCG) was provided during the late follicular phase, serum P-values were significantly increased. Analysis of confounding factors showed that the intensity of ovarian stimulation is the most important determining factor to explain serum progesterone elevation at the time of hCG administration,

CONCLUSIONS

This systematic review shows that providing LH activity supplementation in combination with FSH during ovarian stimulation does not have a consistent effect on serum progesterone concentrations at the time of hCG administration. However, these data also suggest that, in accordance with physiological concept, the timing of LH activity administration could influence the impact on serum progesterone changes.

Evaluation of mixed protocols with bravelle® (human-derived FSH) and repronex® (hMG) to assess clinical efficacy (EMBRACE) in women undergoing in vitro fertilization

OBJECTIVE

To compare the efficacy and safety of three different ratios of human-derived follicle-stimulating hormone/human menopausal gonadotropin (human-derived FSH:hMG, Bravelle and Repronex) mixed together in the same syringe and administered subcutaneously once daily, to in vitro fertilization (IVF) patients <34 years or 34 to 40 years of age.

DESIGN

Two randomized, prospective, age stratified, IVF studies.

SETTING

Twenty-one academic and private clinics with experience in IVF/embryo transfer (ET).

PATIENT(S)

Infertile premenopausal women undergoing IVF-ET.

INTERVENTION(S)

Pituitary suppression with leuprolide acetate, randomization to one of three treatment groups, followed by gonadotropin stimulation (GS) for up to 15 days. The human-derived FSH:hMG ratios were the following: Group 1, a 1:1 ratio throughout; Group 2, a 3:0 ratio that was changed to 1:1 after GS day 5; Group 3, a 2:1 ratio that was increased to 3:1, 4:1, or 5:1 after GS day 5, as needed.

MAIN OUTCOME MEASURE(S)

Mean number of oocytes retrieved; peak estradiol levels; dose and duration of stimulation; implantation rates; adverse events; injection site pain; and pregnancy and live birth rates.

RESULT(S)

Overall, women <34 years had higher E(2) levels, more oocytes retrieved, and improved implantation and live birth rates compared with women 34 to 40 years old. Nonetheless, each ratio of human-derived FSH:hMG produced comparable implantation rates, and continuing pregnancy and take-home baby rates.

CONCLUSION(S)

All three ratios of human-derived FSH:hMG in both age groups produced comparable pregnancy and live birth rates with similar safety results.

Subcutaneously administered Repronex in oligoovulatory female patients undergoing ovulation induction is as effective and well tolerated as intramuscular human menopausal gonadotropin treatment

OBJECTIVE

To determine the efficacy and safety of Repronex SC as compared with Repronex IM and Pergonal IM in patients undergoing ovulation induction.

DESIGN

Randomized, open-label, multicenter, parallel group study.

SETTING

Ten academic and private fertility clinics with expertise in ovualtion induction.

PATIENT(S)

Premenopausal anovulatory and oligoovulatory females (n = 115) undergoing ovulation induction.

INTERVENTION(S)

Down-regulation with leuprolide acetate followed by up to 12 days of treatment with gonadotropins and hCG administration and luteal phase progesterone support.

MAIN OUTCOME MEASURE(S)

Percentage of patients ovulating; percentage of cycles with follicular development meeting criteria for hCG administration; number of follicles recruited per cycle meeting hCG criteria; peak serum E(2) levels; rates of chemical, clinical and ongoing pregnancies; adverse events; injection-site pain scores.

RESULT(S)

There was no statistically significant difference in the percentage of women who ovulated among the treatment groups. However, Repronex SC was significantly more effective than Pergonal IM in producing follicular development in patients who met hCG criteria. There were no significant differences in clinical, ongoing, or continuing pregnancy rates or in multiple pregnancies among the treatment groups. No differences were found in the safety assessments, proportions or seriousness of adverse events or treatment discontinuations. Also, there were no differences between the three treatment groups in patient-recorded scores of injection-site pain or injection-site reactions.

CONCLUSION(S)

Repronex SC is as efficacious and well tolerated as Repronex IM or Pergonal IM in ovulation induction. Self-administration of Repronex SC provides a convenient treatment alternative to daily IM injections.

A randomized prospective assessor-blind evaluation of luteinizing hormone dosage and in vitro fertilization outcome

OBJECTIVE

To determine the effect of exogenous LH dosage on IVF outcome.

DESIGN

Single-blinded (assessor-blinded) study with random assignment of treatment groups.

SETTING

Human Assisted Reproduction Unit, Rotunda Hospital, Dublin, Ireland.

PATIENT(S)

Infertile normogonadotropic women undergoing their first cycle of IVF were studied.

INTERVENTION(S)

Patients were randomized to gonadotropin drugs with varying doses of LH per ampule: recombinant FSH containing no LH (group 0, n = 39), urinary FSH containing <1 IU of LH per ampule (group 1, n = 30), hMG containing 25 IU of LH per ampule (group 25, n = 30), and hMG containing 75 IU of LH per ampule (group 75, n = 29). The FSH dose was kept constant at 75 IU per ampule. A long-protocol GnRH-analog regimen was used.

MAIN OUTCOME MEASURE(S)

Dose and duration of gonadotropin stimulation, follicle and oocyte numbers, implantation rate, and pregnancy rate.

RESULT(S)

The median duration of ovarian stimulation; median number of gonadotropin ampules used; serum E2 levels; and numbers of follicles, oocytes, and embryos were similar among the four groups. Median LH levels on the day of hCG administration, however, differed significantly. Live birth rates per cycle differed markedly, but statistical significance was not achieved (23%, 7%, 20%, and 31% for groups 0, 1, 25, and 75, respectively). A significant trend in implantation rates was noted with increasing LH dosage of the urinary preparations (19%, 10%, 18%, and 28% for groups 0, 1, 25, and 75, respectively).

CONCLUSION(S)

In the present study, although the residual endogenous LH after down-regulation was adequate for ovarian response and E2 synthesis, the addition of exogenous LH improved implantation. An FSH/LH ratio of 75/75 IU per ampule appeared to be the optimum dose.

Follicle-stimulating hormone or human menopausal gonadotropin for ovarian stimulation in in vitro fertilization cycles: a meta-analysis

OBJECTIVE

To reanalyze the results of using FSH alone and hMG during IVF treatment, taking into account the different protocols of administration of superactive GnRH agonist analogs.

DESIGN

Meta-analysis.

SETTING

The London Women's Clinic.

PATIENT(S)

Women undergoing IVF treatment.

INTERVENTION(S)

A meta-analysis of published randomized controlled trials from 1985 to 1999 of the use of FSH versus hMG for ovarian stimulation during IVF treatment. The common Peto odds ratio was calculated with use of a fixed effect model. The overall log odds ratio was estimated after demonstrating the consistency or homogeneity of the study results.

MAIN OUTCOME MEASURE(S)

Clinical pregnancy rate per cycle of IVF.

RESULT(S)

The results suggested that in the "long and short GnRH agonists protocol" of IVF, FSH, and hMG were equally effective in achieving ovarian stimulation, and there were no differences in the clinical pregnancy rates per cycle of IVF. However, in protocols where no pituitary desensitization was used, FSH alone was more efficacious.

CONCLUSION(S)

The optimum choice of gonadotropin preparation for ovarian stimulation during IVF treatment is influenced by the regimen of pituitary desensitization used. The optimum gonadotropin to be used when GnRH antagonists are used has yet to be determined.

The role of luteinizing hormone in folliculogenesis and ovulation induction

OBJECTIVE

To review the physiologic, pathophysiologic, and clinical roles of LH in follicle and oocyte development and maturation and to assess the effects of LH content in exogenous gonadotropin preparations used for ovulation induction.

DESIGN

Critical review of the scientific literature devoted to folliculogenesis. Evaluation of comparison studies that used different gonadotropin preparations for ovulation induction.

CONCLUSION(S)

Folliculogenesis and oocyte maturation are complex processes that require the action of both LH and FSH. Luteinizing hormone is essential to provide the androgen substrate for estrogen synthesis, which in turn contributes to oocyte maturation and may play a relevant role in optimizing fertilization and embryo quality. Although the excessive LH secretion that is present in some disorders is detrimental to reproductive function, this is not applicable to ovulation induction with hMG because this menotropin does not increase daily plasma LH levels. The results of ovulation induction with hMG or FSH-only regimens did not differ in studies conducted in patients with polycystic ovary syndrome and in most studies conducted in ovulatory women undergoing assisted reproductive techniques; conversely, hMG was clearly superior to purified FSH for the treatment of hypogonadotropic hypogonadism. Miscarriage rates were not affected by the use of hMG. Thus, low but detectable LH concentrations positively influence the outcome of ovulation induction in patients with ovulatory disorders and women undergoing assisted reproductive techniques.