Endocrine changes induced by GnRH immunisation and subsequent early re-stimulation of testicular function with a GnRH agonist in stallions

CONTEXT

Resumption of testicular function after gonadotrophin-releasing hormone (GnRH) immunisation varies among individual animals and some stallions regain fertility only after a prolonged time.

AIMS

This study evaluated endocrine effects of GnRH immunisation and early subsequent re-stimulation with a GnRH agonist. We hypothesised that GnRH agonist treatment advances resumption of normal endocrine function in GnRH-vaccinated stallions.

METHODS

Shetland stallions were assigned to an experimental and a control group (n =6 each). Experimental stallions were GnRH-immunised twice, 4weeks apart. Each experimental stallion was hemicastrated together with an age-matched control animal when testosterone concentration decreased below 0.3ng/mL. Three weeks later, daily treatment with the GnRH agonist buserelin was initiated (4μg/day for 4weeks followed by 8μg/day). The remaining testicle was removed when testosterone concentration exceeded 0.5ng/mL in vaccinated stallions. Blood was collected for LH, FSH, oestradiol and anti-müllerian hormone (AMH) analyses, and testicular and epididymal tissue were conserved for real-time qPCR and histology.

KEY RESULTS

GnRH vaccination reduced blood concentrations of LH and FSH, with a structural deterioration of testicular tissue and disruption of spermatogenesis. Daily buserelin treatment for approximately 60days partially restored gonadotropin secretion and induced a recovery of the functional organisation of the testicular tissue with effective spermatogenesis.

CONCLUSIONS

Endocrine testicular function can be restored in GnRH-vaccinated stallions by daily low-dose buserelin treatment. The buserelin treatment protocol may potentially be improved regarding the dose, interval and duration.

IMPLICATIONS

Daily buserelin treatment can be recommended for treatment of GnRH-vaccinated stallions with prolonged inhibition of testicular function.

Gonadotrophin-releasing hormone agonist protocols for pituitary suppression in assisted reproduction

BACKGROUND

Gonadotrophin-releasing hormone agonists (GnRHa) are commonly used in assisted reproduction technology (ART) cycles to prevent a luteinising hormone surge during controlled ovarian hyperstimulation (COH) prior to planned oocyte retrieval, thus optimising the chances of live birth.

OBJECTIVES

To evaluate the effectiveness of the different GnRHa protocols as adjuncts to COH in women undergoing ART cycles.

SEARCH METHODS

We searched the following databases from inception to April 2015: the Cochrane Menstrual Disorders and Subfertility Group Specialised Register, the Cochrane Central Register of Controlled Trials (CENTRAL) in the Cochrane Library (2015, Issue 3), MEDLINE, EMBASE, CINAHL, PsycINFO, and registries of ongoing trials. Reference lists of relevant articles were also searched.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) comparing any two protocols of GnRHa used in in vitro fertilisation (IVF) or intracytoplasmic sperm injection (ICSI) cycles in subfertile women.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected studies, assessed trial eligibility and risk of bias, and extracted the data. The primary outcome measure was number of live births or ongoing pregnancies per woman/couple randomised. Secondary outcome measures were number of clinical pregnancies, number of oocytes retrieved, dose of gonadotrophins used, adverse effects (pregnancy losses, ovarian hyperstimulation, cycle cancellation, and premature luteinising hormone (LH) surges), and cost and acceptability of the regimens. We combined data to calculate odds ratios (OR) for dichotomous variables and mean differences (MD) for continuous variables, with 95% confidence intervals (CIs). We assessed statistical heterogeneity using the I² statistic. We assessed the overall quality of the evidence for the main comparisons using 'Grading of Recommendations Assessment, Development and Evaluation' (GRADE) methods.

MAIN RESULTS

We included 37 RCTs (3872 women), one ongoing trial, and one trial awaiting classification. These trials made nine different comparisons between protocols. Twenty of the RCTs compared long protocols and short protocols. Only 19/37 RCTs reported live birth or ongoing pregnancy.There was no conclusive evidence of a difference between a long protocol and a short protocol in live birth and ongoing pregnancy rates (OR 1.30, 95% CI 0.94 to 1.81; 12 RCTs, n = 976 women, I² = 15%, low quality evidence). Our findings suggest that in a population in which 14% of women achieve live birth or ongoing pregnancy using a short protocol, between 13% and 23% will achieve live birth or ongoing pregnancy using a long protocol. There was evidence of an increase in clinical pregnancy rates (OR 1.50, 95% CI 1.18 to 1.92; 20 RCTs, n = 1643 women, I² = 27%, moderate quality evidence) associated with the use of a long protocol.There was no evidence of a difference between the groups in terms of live birth and ongoing pregnancy rates when the following GnRHa protocols were compared: long versus ultrashort protocol (OR 1.78, 95% CI 0.72 to 4.36; one RCT, n = 150 women, low quality evidence), long luteal versus long follicular phase protocol (OR 1.89, 95% CI 0.87 to 4.10; one RCT, n = 223 women, low quality evidence), when GnRHa was stopped versus when it was continued (OR 0.75, 95% CI 0.42 to 1.33; three RCTs, n = 290 women, I² = 0%, low quality evidence), when the dose of GnRHa was reduced versus when the same dose was continued (OR 1.02, 95% CI 0.68 to 1.52; four RCTs, n = 407 women, I² = 0%, low quality evidence), when GnRHa was discontinued versus continued after human chorionic gonadotrophin (HCG) administration in the long protocol (OR 0.89, 95% CI 0.49 to 1.64; one RCT, n = 181 women, low quality evidence), and when administration of GnRHa lasted for two versus three weeks before stimulation (OR 1.14, 95% CI 0.49 to 2.68; one RCT, n = 85 women, low quality evidence). Our primary outcomes were not reported for any other comparisons.Regarding adverse events, there were insufficient data to enable us to reach any conclusions except about the cycle cancellation rate. There was no conclusive evidence of a difference in cycle cancellation rate (OR 0.95, 95% CI 0.59 to 1.55; 11 RCTs, n = 1026 women, I² = 42%, low quality evidence) when a long protocol was compared with a short protocol. This suggests that in a population in which 9% of women would have their cycles cancelled using a short protocol, between 5.5% and 14% will have cancelled cycles when using a long protocol.The quality of the evidence ranged from moderate to low. The main limitations in the evidence were failure to report live birth or ongoing pregnancy, poor reporting of methods in the primary studies, and imprecise findings due to lack of data. Only 10 of the 37 included studies were conducted within the last 10 years.

AUTHORS' CONCLUSIONS

When long GnRHa protocols and short GnRHa protocols were compared, we found no conclusive evidence of a difference in live birth and ongoing pregnancy rates, but there was moderate quality evidence of higher clinical pregnancy rates in the long protocol group. None of the other analyses showed any evidence of a difference in birth or pregnancy outcomes between the protocols compared. There was insufficient evidence to make any conclusions regarding adverse effects.

Assessment of effective absorbed dose of (111)In-DTPA-Buserelin in human on the basis of biodistribution rat data

In this study, the effective absorbed dose to human organs was estimated, following intra vascular administration of (111)In-DTPA-Buserelin using biodistribution data from rats. Rats were sacrificed at exact time intervals of 0.25, 0.5, 1, 2, 4 and 24 h post injections. The Medical Internal Radiation Dose formulation was applied to extrapolate from rats to humans and to project the absorbed radiation dose for various human organs. From rat data, it was estimated that a 185-MBq injection of (111)In-DTPA-Buserelin into the human might result in an estimated absorbed dose of 24.27 mGy to the total body and the highest effective absorbed dose was in kidneys, 28.39 mSv. The promising results of this study emphasises the importance of absorbed doses in humans estimated from data on rats.

[Treatment of bitches with ovarian cysts using human chorionic gonadotropin-releasing hormone analogue. A case series of 30 bitches]

OBJECTIVE

Ovarian cysts have great clinical relevance in bitches. Currently, ovariohysterectomy is regarded as the gold standard, but there is a paucity of information on the aetiology and hormonal treatment in this species. Standardised protocols for non-surgical treatment are, however, virtually non-existent. Reports on the success of hormonal therapy are rare and generally restricted to individual case reports. The objective of the present study was to determine the success rate of human chorionic gonadotropin (hCG) or the gonadotropin-releasing hormone analogue buserelin in a larger cohort of bitches.

MATERIAL AND METHODS

A total of 30 bitches with ovarian cysts were treated with a maximum of three attempts per individual, utilising different protocols of the hCG and/or buserelin treatment.

RESULTS

Hormonal therapy was successful in 63% of the treated cases. There was no significant difference between the success rates of the hCG- and buserelin-based protocols. The first treatment attempted had a success rate of 40%, with 33% and 67% for the second and third treatments, respectively. The success of conservative therapy failed in the first treatment attempt in two cases, after the second in seven cases, and after the third attempt in one bitch. In these 10 cases, an ovariohysterectomy was performed.

CONCLUSION AND CLINICAL RELEVANCE

The hormonal therapy of ovarian cysts in bitches provides an acceptable alternative to the current gold standard of ovariohysterectomy, especially to avoid negative side-effects of spaying. However, conservative therapy requires a pre-interventional health check to exclude uteropathies and oestrogen-induced changes in the haemogram or blood chemistry. Compared to the surgical treatment, there is the chance of recrudescence.

Outcomes from ovarian hyperstimulation following the sole administration of gonadotrophin-releasing hormone agonist in the context of in vitro fertilization: report of two cases and review of the literature

OBJECTIVE

To report the outcomes from two cases of ovarian stimulation following the sole administration of gonadotrophin-releasing hormone agonist (GnRHa) in the context of in vitro fertilization (IVF).

DESIGN

A case study was conducted.

SETTING

National Referral Unit of Reproductive Medicine.

PATIENTS

Two infertile women undergoing IVF participated in the study.

INTERVENTIONS

Controlled ovarian hyperstimulation using a long protocol. GnRHa (Buserelin) was started in the luteal phase, in a dose of 600 µg/day, for 12 days.

MAIN OUTCOME MEASURES

Number of retrieved oocytes, fertilization rate, number of embryos transferred, implantation rate, ongoing pregnancy, and live birth.

RESULTS

Both women underwent egg retrieval and transfer of good quality embryos. One of them conceived and recently gave birth to a healthy full-term baby.

CONCLUSIONS

The ovarian hyperstimulation after the sole administration of GnRHa is a rare condition. Oocyte retrieval may be a reasonable treatment under these circumstances instead of cycle cancellation. As far as it is known, this is the third case reported of a live birth following the sole administration of GnRHa in the context of IVF.

Endogenous estrogens lower plasma PCSK9 and LDL cholesterol but not Lp(a) or bile acid synthesis in women

OBJECTIVE

Cholesterol and lipoprotein metabolism display pronounced gender differences. Premenopausal women have lower LDL and higher HDL cholesterol, whereas men display higher synthetic rates of bile acids and cholesterol. The effects of the administration of exogenous hormones to humans and animals indicate that these gender differences can often be explained by estrogens. We evaluated how increased levels of endogenous estrogens modulate cholesterol and lipoprotein metabolism in women.

METHODS AND RESULTS

We studied healthy women during initiation of in vitro fertilization using blood samples obtained when endogenous estrogens were low and high. Cholesterol in VLDL and LDL, but not in HDL, was reduced 20% when estrogens were high. Apolipoprotein B levels decreased 13%. Apolipoprotein A-I and triglyceride levels increased 8% and 37%, respectively, whereas lipoprotein(a) levels were unchanged. Circulating PCSK9, a suppressor of LDL receptors, was reduced 14% when estrogens were high. Serum markers of bile acid and cholesterol synthesis were unaltered. Growth hormone levels increased 3-fold when estrogens were high, whereas insulin-like growth factor-1 and fibroblast growth factor-21 concentrations were unaltered.

CONCLUSION

In women, Apolipoprotein B-containing particles and circulating PCSK9 are reduced when endogenous estrogens are high, indicating that endogenous estrogens induce hepatic LDL receptors partly through a posttranscriptional mechanism. However, estrogens do not stimulate bile acid or cholesterol synthesis.

Gonadotrophin-releasing hormone agonist protocols for pituitary suppression in assisted reproduction

BACKGROUND

Gonadotrophin-releasing hormone agonists (GnRHa) are used in assisted reproduction technology (ART) cycles to prevent a luteinizing hormone surge. Various protocols have been described in the literature, such as long protocols (continuous and stop or reduce dose, long luteal, or long follicular protocol); short protocols and ultrashort protocols.

OBJECTIVES

To determine the most effective GnRHa protocol as an adjuvant to gonadotrophins in ART cycles.

SEARCH STRATEGY

We searched the Cochrane Menstrual Disorders and Subfertility Group Specialised Register, Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library), MEDLINE, EMBASE, CINHAHL and PsycINFO. Reference lists of relevant articles were also searched. All the searches were updated to August 2010.

SELECTION CRITERIA

Only randomised controlled trials comparing any two protocols of GnRHa in in vitro fertilization (IVF) or intra-cytoplasmic sperm injection (ICSI) cycles were included.

DATA COLLECTION AND ANALYSIS

The primary outcome measure was live births per women. Secondary outcome measures were pregnancy rate, ongoing pregnancy rate, number of oocytes retrieved and amount of gonadotrophins used. Data were independently extracted in 2 x 2 tables by two authors. Odds ratios (OR) with 95% confidence intervals (CI) were calculated after verifying the presence of homogeneity of treatment effect across all trials. For continuous variables mean differences (MD) were calculated.

MAIN RESULTS

Of 29 included studies, 17 compared long with short protocols; two compared long with ultrashort protocols; four compared a follicular versus luteal start of GnRHa; three compared continuation versus stopping the GnRHa at the start of stimulation; three compared continuation of the same dose versus reduced dose of GnRHa and one compared a short versus short stop protocol.There was no evidence of a difference in the live birth rate but this outcome was only reported by three studies.There was evidence of a significant increase in clinical pregnancy rate (OR 1.50, 95% CI 1.16 to 1.93) in a long protocol when compared to a short protocol. That is there is a 50% increase in chance of achieving pregnancy if a long protocol is used as compared to a short protocol, although this difference could range from 16% to 93% increased chance of pregnancy. This difference did not persist when the meta-analysis was done only on the studies with adequate randomisation (OR 1.38, 95% CI 0.93 to 2.05).There was evidence of an increased number of oocytes (MD 1.61, 95% CI 0.18 to 3.04) obtained when a long protocol was used as compared to a short protocol. That is there is a 60% increase in the number of oocytes retrieved when a long protocol is used as compared to a short protocol, although this difference could range from 18% to 304% more oocytes.There was evidence of an increase (MD 12.90, 95% CI 3.29 to 22.51) in the requirement for gonadotrophins in long as compared to short protocols. That is approximately 12.9 more ampoules of gonadotrophins were consumed when a long protocol was used as compared to a short protocol. This difference could range from 3.29 to 22.51 more gonadotrophin ampoules.There was no evidence of a difference in any of the outcome measures for luteal versus follicular start of GnRHa and stopping versus continuation of GnRHa at the start of stimulation.

AUTHORS' CONCLUSIONS

The pregnancy rate was found to be higher when GnRHa was used in a long protocol as compared to a short or ultrashort protocol. There was no evidence of a difference in live birth rate, but this outcome was only reported by three studies. There was no evidence of a difference in the outcomes amongst various long protocols; nor that stopping or reducing GnRHa at the start of stimulation was associated with a reduced pregnancy rate. For all comparison, except a long versus short protocol, there was a lack of power.

Pre-mating injection of an analogue of gonadotrophin-releasing hormone (GnRH) and pregnancy rates to first insemination

Two hundred and ninety two dairy cows received a subcutaneous injection of a 2.5 ml solution containing 10 microg GnRH-analogue (Receptal, Hoechst A.G.) 0-6 hours before insemination, while 284 cows acting as controls were injected with 2.5 ml of sterile pyrogen-free water at the same time. The two groups, the treated and the control, were formed by matching (pairing) each oestrous cow with another on the basis of interval from calving to first mating, condition score, and age on the day of first mating after calving. The cows were in 3 factory supply dairy herds, which were visited daily during the first 3 weeks of the mating season. All the cows presented for mating each day were inseminated by the same technician using 0.5 ml of ambient-temperature semen containing 2 million spermatozoa per insemination. The semen used on any particular day originated from one ejaculate of one bull (same batch number). The cows were manually examined for pregnancy 2 to 3 months after their first insemination. A similar response was seen in all three herds irrespective of the interval from calving to mating. First mating pregnancy rates were 9.3% higher in the Receptal-treated cows than in the control group (P = 0.025). It is suggested that Receptal may have a beneficial effect on the pregnancy rate of cows that have recently ovulated as well as on those having delayed ovulation.

Cost-effectiveness analysis of LHRH agonists in the treatment of metastatic prostate cancer in Italy

OBJECTIVES

Luteinizing hormone-releasing hormone (LHRH) agonists represent one of the main cost factors in the management of patients with metastatic prostate cancer. We compared the cost-effectiveness of the five different 3-month formulations of LHRH agonists currently available for advanced prostate cancer in Italy, because these differ both in their capacity to suppress testosterone and in their acquisition costs.

METHODS

A probabilistic, patient-level simulation model was developed to compare the cost-effectiveness, from the perspective of the Italian National Health Service (INHS), of leuprorelin 11.25 mg and 22.5 mg, triptorelin 11.25 mg, buserelin 9.9 mg, and goserelin 10.8 mg. The model incorporated testosterone-dependent progression-free and cancer-specific survival functions, LHRH agonist effectiveness data, and national costs and tariffs. Cox's proportional hazard models were used to compute total and progression-free survival functions based on clinical data from 129 patients with metastatic prostate cancer treated in an Italian center. Bayesian random effects models were employed to summarize evidence from published literature on testosterone suppression obtained with the available LHRH agonists.

RESULTS

Estimated total survival was ≈5 years, with a maximum difference between treatment options of ≈2 months. There was a mean difference of almost €2,500 in lifetime total costs between the least costly option (leuprorelin 22.5 mg) and the most expensive (goserelin). In the incremental cost-effectiveness analysis, leuprorelin 22.5 mg dominated all alternatives except buserelin, which had an incremental cost-effectiveness ratio versus leuprorelin 22.5 mg of ≈€12,000 per life-month gained.

CONCLUSIONS

Based on modelling with meta-analysis of comparative survival data, leuprorelin 22.5 mg was the most cost-effective treatment of the available depot formulation LHRH agonists.

Expression of type I GNRH receptor and in vivo and in vitro GNRH-I effects in corpora lutea of pseudopregnant rabbits

The expression of type I GNRH receptor (GNRHR-I) and the direct role of GNRH-I on corpora lutea (CL) function were studied in the pseudopregnant rabbit model. Immunohistochemistry evidenced GNRHR-I and GNRH-I in luteal cells at early (day 4 pseudopregnancy)-, mid (day 9)-, and late (day 13)-luteal stages. Real-time RT-PCR and western blotting revealed GNRHR-I mRNA and protein at the three luteal stages. Buserelin in vivo treatment at days 9 and 13 decreased plasma progesterone levels for 48 and 24  h respectively. In in vitro cultured CL, buserelin reduced progesterone secretion, increased prostaglandin F(2α) (PGF(2α)) secretion and cyclo-oxygenase-2 (COX-2) and nitric oxide synthase (NOS) activities at days 9 and 13, and decreased PGE₂ at day 13. Co-incubation with antagonists for GNRH-I (antide), inositol 1,4,5-trisphosphate (IP₃, 2-amino-ethoxydiphenylborate), and diacylglycerol (DAG, 1-hexadecyl-2-acetyl glycerol) or inhibitors for phospholipase C (PLC, compound 48/80), and protein kinase C (PKC, staurosporine) counteracted the buserelin effects. Buserelin co-incubated with COX inhibitor (acetylsalicylic acid) increased progesterone and decreased PGF(2α) and NOS activity at days 9 and 13, whereas co-incubation with NOS inhibitor (N-nitro-l-arginine methyl ester) increased progesterone at the same luteal stages. These results suggest that GNRHR-I is constitutively expressed in rabbit CL independently of luteal stage, whereas GNRH-I down-regulates directly CL progesterone production via PGF(2α) at mid- and late-luteal stages of pseudopregnancy, utilizing its cognate type I receptor with a post-receptorial mechanism that involves PLC, IP₃, DAG, PKC, COX-2, and NOS.

Gonadotrophin-releasing hormones agonist therapy increases peritoneal fibrinolytic activity and prevents adhesion formation after myomectomy

The aim of this study was to evaluate uterine adhesions after myomectomy and peritoneal fibrinolytic capacity in women treated with gonadotrophin-releasing hormone agonist (GnRHa) before surgery. A prospective observational study comprised 15 infertile women who underwent myomectomy. Before surgery, 10 were treated with buserelin acetate (900 microg/day) for 10-12 weeks followed by additional postoperative treatment with GnRHa for 4 weeks (GnRHa group) and five received no treatment (control group). Peritoneal fluid specimens were taken at the beginning of myomectomy and the adhesions were estimated by second-look surgery (caesarean section or laparoscopy). Levels of plasminogen activator (PA) and PA inhibitor (PAI) were determined by enzyme-immunosorbent assays. Pre- and postoperative GnRHa therapy significantly reduced adhesion formation compared with control groups (adhesion scores; 0.2 +/- 0.4 vs. 2 +/- 1, P<0.0001). GnRHa group showed a significant decrease in PAI level (P<0.0001) but no significant change in PA level, suggesting increased fibrinolytic capacity in peritoneal fluid from GnRHa-treated patients. These data suggest that GnRHa therapy is successful in preventing adhesion formation after myomectomy. GnRHa-induced shift to more fibrinolytic activity, mainly because of a decreased level of PAI, may play a critical role in the mechanism of the GnRHa's action on postoperative adhesion development.

Successful long-term management of adenomyosis associated with deep thrombosis by low-dose gonadotropin-releasing hormone agonist therapy

We report the case of a patient with adenomyosis complicated by deep vein thrombosis in whom low-dose gonadotropin-releasing hormone agonist (GnRHa) therapy was useful as a uterus-conserving therapeutic option. The patient was a 34-year-old nulliparous woman who presented with edema and pain in the left lower leg. The patient had been treated with four cycles of GnRHa therapy for adenomyosis and repeatedly experienced chronic pelvic pain, dysmenorrhea and anemia due to hypermenorrhea. Leg venography confirmed deep vein thrombosis, and thrombolytic therapy was performed to eliminate symptoms. Because the patient strongly wanted to conserve the uterus, low-dose GnRHa therapy was initiated. The patient is currently taking 450 microg/day buserelin acetate nasally (regular dose: 900 microg/day), and estradiol levels have been maintained at 24-50 pg/ml. Anemia, leg numbness and chronic pelvic pain have dissipated, and the patient has not experienced estrogen deficiency symptoms for more than two years.

Prevention of suckling improves postpartum reproductive responses to hormone treatments in Pelibuey ewes

To determine the effects of suckling on postpartum (pp) reproductive efficiency in Pelibuey ewes, two experiments were performed. In Experiment 1, 112 ewes were randomly assigned to one of two groups at parturition: Without restriction of suckling (WRS) 24 h day(-1) for 60 days (n=56), and Weaned Ewes (WE), weaned at 40 days pp (n=56). On Day 30 pp, all ewes were given Prostaglandin (PGF2alpha) and one of four treatments (n=14): T1, intravaginal progestagen (FGA; 40 mg) for 12 days from day 30 pp+equine chorionic gonadotropin (eCG; 300 UI) until 2 days before removing FGA; T2, FGA was applied for 12 days; T3, a second application of PGF2alpha was given on day 40 pp+eCG on the same day; T4, a second injection of PGF2alpha was applied on day 40 pp only. In all the analyzed characteristics, the best results were obtained in WE. Within the WE group, the best treatment (P<0.05) was T1 with 85.7% of the ewes in oestrus, 71.4% pregnant and a prolificacy of 1.9. Within the WRS group the best results were observed in T1. In both groups, the lowest results (P<0.05) were obtained in T4. In Experiment 2, 75 ewes were randomly assigned to one of three groups (n=25) immediately after parturition: Group 1, Without restriction of suckling (WRS, as in Experiment 1); Group 2, with restriction of suckling (RS; suckling for 30 min day(-1)); Group 3, Early Weaning (EW: at 7 days pp). All ewes were given PGF2alpha at 30 days pp and the same hormonal treatment, FGA for 12 days+PGF2alpha and eCG 2 days before removing FGA. No differences were observed (P>0.05) between RS and EW for the presentation of oestrus (96% vs. 92%), pregnancy (72% vs. 76%) or prolificacy (1.9 vs. 1.9), although group WRS did not perform (P<0.05) as well as groups RS and EW for any measure of performance. In conclusion, the combination of hormonal treatment (FGA plus eCG) with weaning at 7 or 40 days pp, or restricted suckling, improves postpartum reproductive efficiency in Pelibuey ewes, demonstrating the inhibitory role of suckling on postpartum reproduction in this breed.

Does high serum progesterone level on the day of human chorionic gonadotropin administration affect pregnancy rate after intracytoplasmic sperm injection and embryo transfer?

OBJECTIVE

The present study was conducted to evaluate the effect of serum progesterone (P) levels on the day of human chorionic gonadotropin (hCG) administration on embryo quality and pregnancy rate in intracytoplasmic sperm injection (ICSI) cycles.

DESIGN AND SETTING

This was a retrospective analysis conducted in the in vitro fertilization (IVF) unit of a tertiary hospital.

PATIENTS

Two hundred and one patients who underwent a total of 280 IVF treatment cycles allocated to ICSI during routine IVF/embryo transfer treatment. Results. In cycles with elevated serum P, higher estradiol levels were noted (1915 pg/ml vs. 1256 pg/ml; p<0.05), more oocytes were retrieved and manipulated, and more embryos were available for transfer. Embryo grading was comparable between the two groups. The average age was lower in the group with elevated P; but the pregnancy rate was significantly lower (16.4% vs. 27.6%, p = 0.03).

CONCLUSIONS

Our data demonstrate no deleterious effect of elevated P on embryo quality. However, high serum P adversely affects implantation and pregnancy rates.

Ovulation induced by mucosa vaginal absorption of buserelin and triptorelin in rabbit

The aim of this study was to evaluate the supplementation of semen extender with two synthetic GnRH analogues (buserelin and triptorelin) to induce ovulation in rabbit does submitted to artificial insemination. In a first experiment, 255 receptive multiparous does were inseminated with 0.5 mL of Tris-citrate-glucose extender supplemented or not with two GnRH synthetic analogues. Experimental groups were: NC (not supplemented extender), PC (not supplemented extender and does treated with 1 microg of buserelin i.m.), B2 (2 microg per female buserelin supplemented extender), B5 (5 microg per female buserelin supplemented extender), T2 (2 microg per female triptorelin supplemented extender) and T5 (5 microg per female triptorelin supplemented extender). Thirteen does of NC females ovulated, reaching an ovulation rate similar to the other groups. Ovulation rate was similar in all groups (11.4-12.5). The efficiency of ovulation induction was very low (32.5%) in NC group and showed the higher results in PC females (97.8%). Only B5 females reached similar ovulation induction response than PC group. In a second experiment, 702 receptive does were inseminated to compare fertility and prolificacy parameters from the conventional insemination technique (control group, females treated with 1 microg per female of buserelin intramuscularly) versus a supplementation with buserelin or triptorelin (5 microg per female) in semen extender (B5 and T5 groups, respectively). Fertility and prolificacy parameters were similar among the groups (77.8% fertility rate, 73.9% kindling rate, 9.4 live born and 9.9 total born). This study demonstrate the possibility of ovulation induction in rabbits by adding two GnRH synthetic analogues in the seminal doses and open up new prospects for changing rabbit insemination procedures.

Comparison of oocyte quality and intracytoplasmic sperm injection outcome in women with isolated polycystic ovaries or polycystic ovarian syndrome

OBJECTIVE

To compare the oocyte quality and intracytoplasmic sperm injection performance in women with isolated polycystic ovaries or polycystic ovarian syndrome.

DESIGN

Retrospective study.

SETTING

Fertility unit.

POPULATION

Three study groups were identified: women with PCO-only morphology (50 cycles), PCOS (51 cycles) and age matched control group (104 cycles) with isolated male factor infertility necessitating ICSI.

METHOD

Controlled ovarian hyperstimulation and ICSI.

MAIN OUTCOME MEASURES

Response to gonadotropin stimulation, oocyte and embryo quality, clinical pregnancy rate and pregnancy outcome.

RESULTS

Despite a significantly lower total gonadotropin dose, a significantly higher serum E2 level was attained in both the PCOS and the PCO-only groups compared to the control group. Although significantly more oocytes were retrieved in the PCOS and PCO-only groups, the number of 2-pronuclear embryos was similar to controls. No significant differences were noted in the maturity of the oocytes, oocyte dysmorphism, embryo quality, implantation and pregnancy rates among the three groups. However the clinical miscarriage rate was significantly lower in women with PCO-only morphology group (15.4 versus 31%, P < 0.05) than in the PCOS group.

CONCLUSION

Women with PCO-only appearance have shown to have similar characteristics to women with PCOS in terms of ovarian response to hMG stimulation, oocyte and embryo quality and pregnancy rates. However miscarriage rates were significantly lower in the PCO-only group than the PCOS group. Our findings suggest that factors unrelated to oocyte and embryo morphology present in PCOS patients may be instrumental in adverse reproductive outcomes in these women.

Clinical outcome with half-dose depot triptorelin is the same as reduced-dose daily buserelin in a long protocol of controlled ovarian stimulation for ICSI/embryo transfer: a randomized double-blind clinical trial (NCT00461916)

BACKGROUND

Traditional doses of depot GnRH agonist may be excessive for ovarian stimulation. We compared half-dose depot triptorelin (Group I) with reduced-dose daily buserelin (Group II) in a long protocol ICSI/embryo transfer through a double-blind randomized clinical trial.

METHODS

Controlled ovarian stimulation (COS) was started by a pretreatment with oral contraceptives for 21 days. Then, 182 patients were randomized into two groups of 91. Group I received 1.87 mg triptorelin depot i.m. followed by daily s.c. injections of saline. Group II (reduced-dose protocol) received a bolus injection of i.m. saline followed by daily s.c. injections of 0.5 mg buserelin, which was then reduced to 0.25 mg at the start of human menopausal gonadotrophin stimulation. When transvaginal ultrasound showed at least two follicles of 16-20 mm diameter, HCG was given and ICSI was performed 40-42 h later.

RESULTS

No significant differences were seen in the mean (SD) number of follicles at HCG administration, as our primary outcome [10.3 (4.4) in Group I versus 11.1 (4.2) in Group II, P = 0.180, mean difference = 0.86, 95% confidence interval 0.39-2.11]. The other early results of COS, clinical and ongoing pregnancy rates, or early pregnancy loss were also not significantly different between the groups. Group I endured longer stimulation period [11.2 (1.8) days versus 10.6 (1.9), P = 0.030].

CONCLUSIONS

Clinical outcomes were not significantly different between Group I and Group II.

Corpus luteum function and embryonic mortality in buffaloes treated with a GnRH agonist, hCG and progesterone

The effect of treatment with a GnRH agonist, hCG or progesterone (P(4)) on corpus luteum function and embryonic mortality was investigated in buffaloes inseminated during mid-winter. Italian Mediterranean buffaloes (n=309) were synchronized using the Ovsynch with timed-AI program and mated by AI at 16 h (Day 0) and 40 h after the second injection of GnRH. On Day 5, buffaloes were randomly assigned to four groups: Control (no treatment, n=69), GnRH agonist (buserelin acetate, 12.6 microg, n=73), hCG (1500 IU, n=75) and P(4) (PRID without E(2) for 10 days, n=77). Progesterone (pg/ml) was determined in milk whey on Days 5, 10, 15 and 20 and pregnancy diagnosis was undertaken on Day 26 by ultrasound and Day 40 by rectal palpation. Treatment with buserelin and hCG increased (p<0.05) P(4) on Day 15 compared with controls (456+/-27, 451+/-24 and 346+/-28 pg/ml, respectively). Buffaloes treated with a PRID had intermediate P(4) concentrations (380+/-23 pg/ml). Embryonic mortality between Days 26 and 40 (22.9%) and pregnancies at Day 40 (48.9%) did not differ between treatments. A higher (p<0.01) P(4) concentration was found on Day 20 in pregnant animals compared with non-pregnant and embryonic mortality buffaloes, which did not differ. In summary, buserelin and hCG increased P(4) concentrations on Day 15 but this was not associated with a reduced incidence of embryonic mortality in buffaloes during mid-winter.

Allopregnanolone decrease with symptom improvement during placebo and gonadotropin-releasing hormone agonist treatment in women with severe premenstrual syndrome

BACKGROUND

Neurosteroids such as allopregnanolone and pregnanolone are suggested to be of importance for the pathophysiology of premenstrual dysphoric disorder. The aim of this study was to investigate whether the luteal-phase serum concentrations of these neurosteroids are associated with improvement of premenstrual symptoms in 12 women with severe premenstrual syndrome after treatment with low-dose gonadotropin-releasing hormone agonist and placebo.

METHODS

Daily ratings for mood and physical symptoms were made prior to treatment and throughout the study. Serum progesterone, allopregnanolone and pregnanolone were assessed in the luteal phase (cycle day -9 to cycle day -1). Based on their symptom ratings, subjects were grouped as either buserelin responders (n = 6) or placebo responders (n = 6).

RESULTS

Buserelin responders displayed decreased levels of allopregnanolone (p < 0.05) and progesterone (p < 0.05) in parallel with improvement of symptoms. During the placebo treatment, the placebo responders had lower serum allopregnanolone concentrations than buserelin responders (p < 0.05). This was associated with improvement in symptoms compared with pre-treatment ratings.

CONCLUSION

Treatment response, whether induced by buserelin or placebo, appears to be associated with a decrease in allopregnanolone concentration.

A novel in situ forming drug delivery system for controlled parenteral drug delivery

The objective of this study was to investigate the in vitro drug (diltiazem hydrochloride and buserelin acetate) release from different in situ forming biodegradable drug delivery systems, namely polymer solutions (in situ implants) and in situ microparticle (ISM) systems. The drug release from ISM systems [poly(d,l-lactide) (PLA) or poly(d,l-lactide-co-glycolide) (PLGA)-solution dispersed into an external oil phase] was investigated as a function of the type of solvent and polymer, polymer concentration and internal polymer phase:external oil phase ratio and was compared to the drug release from in situ implant systems and microparticles prepared by conventional methods (solvent evaporation or film grinding). Upon contact with the release medium, the internal polymer phase of the ISM system solidified and formed microparticles. The initial drug release from ISM systems decreased with increasing polymer concentration and decreasing polymer phase:external oil phase ratio. The type of biocompatible solvent also affected the drug release. It decreased in the rank order DMSO>NMP>2-pyrrolidone. In contrast to the release of the low molecular weight diltiazem hydrochloride, the peptide release (buserelin acetate) was strongly dependent on the polymer degradation/erosion. One advantage of the ISM system when compared to in situ implant systems was the significantly reduced burst effect because of the presence of an external oil phase. ISM systems resulted in drug release profiles comparable to the drug release of microparticles prepared by the solvent evaporation method. Therefore, the ISM systems are an attractive alternative to existing complicated microencapsulation methods.

Buserelin acetate microparticle dispersion effects drug release and plasma E(1) levels

We investigated the effect of different dispersion methods on release behavior and efficacy onset following microparticle administration of buserelin acetate (BA) sustained-release injection. In this in vitro release study, the initial dispersion of BA increased with increased stirring speed (p<0.01). Stability of BA was studied over 7 days after BA release. The initial BA release rate was higher (p<0.01) after a 1-min vibration dispersion method (VDM) using a test tube mixer (2000 rpm) compared with the standard dispersion method (SDM) by hand. Without shaking, powder aggregation was observed, and BA release was lower than in either the SDM or VDM methods. In this study using 4-week-old Sprague-Dawley female rats, the initial plasma estrone (E(1)) concentrations were lower (p<0.05) in the VDM method than in the SDM method. Observations by optical microscope and scanning microscope showed no change in microparticle shape or distribution of size induced by SDM, VDM or the ultrasonication dispersion method. These results suggest that different dispersion methods do not change the shape and distribution of microparticle size, but clearly change the BA release rate and the transition in plasma E(1) concentrations that can affect drug efficacy.

Reversible reproductive control in harbour seals (Phoca vitulina) with a gonadotropin-releasing hormone agonist

Reproductive control in captive pinnipeds is an important management subject for many facilities. To date reproductive control in harbour seals (Phoca vitulina) has been achieved using anti-androgens, progestagen preparations, castration, and physical separation of the sexes. The harbour seal group at the seal station in Friedrichskoog, Germany consists of three mature females (all >10 years), one older mature male (13 years of age in 2000) and one male who reached maturity during the study (3 years of age in 2000). In 2000 the older mature male received for the first time a 3-month depot injection of a gonadotropin-releasing hormone agonist (buserelin acetetate, 9.9 mg) by subcutaneous injection. This male was subsequently given the gonadotropin-releasing hormone agonist in 2001, 2004 and 2005. The younger male reached maturity during the investigation and received burserelin for the first time in 2004 and again in 2005. No pups were born in 2001, 2002, 2005 or 2006. No reproductive control was performed in 2002 and 2003, resulting in three newborns in 2003 and 2004. Serum levels of testosterone were measured by a routine liquid chromatography coupled with mass spectometry. Pre-burserelin testosterone levels varied between 0.02 and 2.18 ng/ml. Post-burserelin levels were under the detection limit except for the first year of the investigation. No behavioural changes such as changes in social ranking and no clinical side effects were observed. This study shows that the gonadotropin-releasing hormone agonist, burserelin acetate, can be used for reversible reproductive control in harbour seals without observed side effects or detrimental behavioural changes.

Effect of suckling on basal and GnRH-induced LH release in post-partum dairy buffaloes

Suckling, a common practice in smallholder dairy-farming systems in the developing world, delays the onset of post-partum ovarian activity in dairy buffalo. The present study was designed to assess the effect of suckling on pituitary function in lactating buffaloes 25-35 days post-partum. Six suckled and nine non-suckled buffaloes were challenged intravenously with a bolus injection of GnRH (20microg buserelin acetate; Receptal). Heparinized venous blood samples were collected at 15min intervals for 2h before and up to 4h after GnRH for luteinizing hormone (LH) estimation. Pretreatment basal LH concentrations were similar in the suckled (0.6+/-0.2ng/ml) and the non-suckled (0.5+/-0.1ng/ml) buffaloes. All but one suckled buffaloes released a LH surge, starting 15-60min post-GnRH treatment, which lasted for 180-225min. While one suckled buffalo did not respond to GnRH, the LH response in the remaining suckled buffaloes was significantly less than in the non-suckled buffaloes in terms of peak LH concentrations (14.3+/-2.7ng/ml versus 26.2+/-4.3ng/ml) and area under the LH curve (1575.6+/-197.4mm(2) versus 2108.9+/-323.9mm(2)). The LH response was least in suckled buffaloes challenged with GnRH while in the luteal phase of an oestrus cycle and with plasma progesterone concentration >1ng/ml. In conclusion, suckling suppressed pituitary responsiveness to exogenous GnRH challenge in post-partum buffaloes.

Duration of Testosterone Suppression after a 9.45mg Implant of the GnRH-Analogue Buserelin in Patients with Localised Carcinoma of the Prostate

OBJECTIVES

(1) To determine the duration of androgen deprivation after a single buserelin implant 9.45 mg in the neoadjuvant setting in combination with curative radiation therapy of carcinoma of the prostate, and (2) to evaluate the time to recovery of gonadal function, and the incidence and duration of hypogonadal symptoms.

METHODS

We prospectively evaluated 21 men with carcinoma of the prostate who received one implant of 9.45 mg buserelin subcutaneously. Release of buserelin, changes in serum testosterone concentration, hot flushing and sexual function over a 12-month study period were recorded.

RESULTS

Testosterone was suppressed below the castration limit (0.58 ng/ml=2 nmol/l) for 224 days (range, 139-309). The mean time to first return of testosterone above the castration limit was 246 days (range, 168-344); 50% of pre-treatment value was reached after 285 days (range, 218-370). The prevalence of hot flushing was 19 of 21 patients (90%) at 12 weeks. At the end of the study period, serum testosterone had reached 80% (range, 33%-166%) of pre-treatment concentration, sexual interest was present in 52%, erection was possible in 60%, and hot flushing remained in 24%.

CONCLUSION

A single injection of 3-month buserelin implant 9.45 mg suppresses serum testosterone below the castration limit for at least 6 months. Testosterone secretion recovers by 8-12 months. Hypogonadal symptoms decreased with the restoration of serum testosterone secretion. These data are clinically relevant regarding the dose schedule for buserelin and the patient information provided.

Comparison of outcome of clomiphene citrate/human menopausal gonadotropin/cetrorelix protocol and buserelin long protocol--a randomized study

This study evaluates the efficacy of a stimulation protocol with clomiphene citrate (CC)/human menopausal gonadotropin (hMG)/cetrorelix and its effects on oocyte quality and endometrium. One hundred and twenty couples with male-factor infertility who were about to undergo their first intracytoplasmic sperm injection cycles were randomized into two groups. Sixty women were stimulated with the CC/hMG/cetrorelix protocol (cetrorelix group) and 60 received the buserelin long protocol (buserelin group). Fewer oocytes were recovered in the cetrorelix group than in the buserelin group (mean +/- standard deviation (SD): 11.1 +/- 4.0 vs. 17.3 +/- 5.8, p < 0.001); however, the percentages of metaphase II, metaphase I and germinal vesicle oocytes were similar between the two groups. Serum estradiol level was significantly lower in the cetrorelix than in the buserelin group (mean +/- SD: 2600.58 +/- 1189.11 vs. 3293.46 +/- 1221.49 pg/ml, p = 0.006), but the endometrial thickness was similar. The implantation rates (19.2% vs. 17.7%) and the pregnancy rates (41.7% vs. 40.0%) were similar between groups. The ampoules (mean +/- SD: 18.9 +/- 3.0 vs. 38.9 +/- 12.2, p < 0.001) and injections (mean +/- SD: 6.8 +/- 1.1 vs. 15.7 +/- 3.1, p < 0.001) of gonadotropin used were significantly lower in the cetrorelix group than in the buserelin group. No patients in either group developed a premature luteinizing hormone surge. The present study found no statistically significant difference between the two treatment modalities with regard to pregnancy rates.

GnRH agonist as luteal phase support in assisted reproduction technique cycles: results of a pilot study

BACKGROUND

The aim of the study was to investigate whether intranasal (IN) administration of a GnRH agonist could provide luteal support in IVF/ICSI patients.

METHODS

Controlled ovarian hyperstimulation (COH) was performed using hMG/FSH and a GnRH antagonist. Patients were then randomly allocated to either 10,000 IU hCG, followed by vaginal administration of micronized progesterone (3x 200 mg/day) (group A), or 200 microg IN buserelin followed by either 100 microg every 2 days (group B), or 100 microg every day (group C), or 100 microg twice a day (group D), or 100 microg three times a day (group E). Luteal support was continued for 15 days.

RESULTS

Twenty-three patients were randomized. Groups B and C were discontinued prematurely in view of the short luteal phase. The luteal phase was significantly shorter in groups B, C and D, whereas group E was comparable with group A, 13.5 and 13.0 days, respectively. In the mid-luteal phase, median progesterone levels were significantly lower in groups B, C and D, whereas group E was comparable with group A, 68.9 and 98.0 ng/ml, respectively. Estradiol (E2) was significantly reduced in groups B and D but sustained in group E. In the hCG group, LH levels were undetectable (<0.1 IU/l), whereas LH was detectable and significantly higher in groups C, D and E. Two pregnancies were obtained in the hCG group (two of five), one ectopic and one ongoing. Three pregnancies were obtained in group E, one miscarriage and two ongoing twin pregnancies (three of five).

CONCLUSION

IN administration of buserelin may be effective in triggering follicular maturation and providing luteal phase support in patients undergoing assisted reproduction techniques (ART).

Effect of gonadotropin-releasing hormone agonist and antagonist on steroidogenesis of low responders undergoing in vitro fertilization

The aim of the study was to investigate the cause of the lower estradiol (E(2)) concentration in women treated with gonadotropin-releasing hormone (GnRH) antagonist compared with those treated with agonist protocol in in vitro fertilization (IVF). Thirty patients who were known low responders were prospectively randomized into two equal groups for IVF treatment. Group 1 used GnRH agonist (flare-up) protocol and group 2 used antagonist protocol. The results showed that serum luteinizing hormone (LH) levels were significantly higher in the agonist group during the folliculogenesis stage. Despite this higher LH, serum E(2) levels were significantly higher in the agonist group on cycle day 2 only, not on day 5 or day 9. The significantly higher E(2) level in the agonist group reappeared on the day of administration of human chorionic gonadotropin (hCG). The rate of folliculogenesis in the antagonist group was faster than in the agonist group; therefore their E(2) production should have been higher on hCG day. Furthermore, the rate of decline in E(2) after hCG administration was significantly higher in the antagonist group. These findings, along with the fact that both groups received exogenous LH (human menopausal gonadotropin) that should optimize steroidogenesis and make the difference in E(2) insignificant, enable us to conclude that GnRH antagonists have a suppressive effect on the production of E(2).

Evaluation of the buserelin stimulation test in diagnosing gonadotropin deficiency in males with delayed puberty

OBJECTIVE

To assess the efficacy of the gonadotropin-releasing hormone (GnRH) agonist buserelin in a stimulated gonadotropin test for the investigation of delayed puberty in males.

STUDY DESIGN

Prepubertal males (n = 31; age range, 10.3 to 17.2 years) were studied; buserelin (100 microg) was administered subcutaneously, with blood sampling at 0 and 4 hours for serum luteinizing hormone (LH) and follicle-stimulating hormone (FSH). At follow-up (mean, 4.2 years), 8/31 (26%) failed to progress into puberty, constituting hypogonadotropic hypogonadism (HH), but 23/31 (74%) had testicular enlargement (> or =8 mL) consistent with a normal hypothalamic-pituitary-gonadal (HPG) axis.

RESULTS

Stimulated serum LH response to buserelin was lower in males with HH (mean +/- standard error under the mean for HH, 1.4 +/- 0.5 U/L, compared with a normal HPG axis of 17.4 +/- 2.0 U/L; P < .0001). Stimulated serum FSH response was nondiscriminatory (HH, 7.7 +/- 2.2 U/L; normal HPG axis, 11.5 +/- 1.6 U/L; P = .27). All males with HH had a stimulated serum LH level <5 U/L, whereas only 1/23 with a normal HPG axis had a stimulated serum LH below this level. Using this value as the criterion for diagnosing HH, the buserelin stimulation test yielded a sensitivity of 100%, specificity of 96%, and positive predictive value of 89%.

CONCLUSIONS

The buserelin stimulation test is a highly specific and sensitive GnRH agonist test for the investigation of males with delayed puberty.

Effect of enhancement of uterine involution and earlier initiation of post-partum cyclicity on the reproductive performance of buffalo

The aim of the present work was to study the effect of either gonadotrophin-releasing hormone (GnRH)–prostaglandin PGF2α–GnRH (G–P–G) or equine chorionic gonadotrophin (eCG)–PGF2α–GnRH (eCG–P–G) regimes with or without intramuscular injection of ergometrine maleate (Methergin) within 24 h post partum on the uterine involution, initiation of post partum cyclicity and subsequent reproductive performance of buffalo. A total of 60 parturient Egyptian buffalos (2–4 lactations) were used to conduct this study. The involved animals were allotted into two main groups (A and B), each with 30 animals, on the basis of whether buffalo cows received an i.m. injection of 3 mg of Methergin within the first 24 h post partum (A, Meth. T) or not (B, Meth. NT). Each main group was subdivided into three subgroups: A1, A2 and A3 in case of A and B1, B2 and B3 in case of B. The G–P–G regime was applied on both A1 (Meth. T) and B1 (Meth. NT) buffalos, where each individual received two i.m. injections of 0.020 mg GnRH analogue (buserelin) at Days 18 and 33 post partum with i.m. injection of 25 mg PGF2α (Dinoprost) in between at Day 25. The eCG–P–G regime was applied on both A2 (Meth. T) and B2 (Meth. NT) buffalos, where each individual received i.m. injection of 1000 IU eCG, 25 mg of PGF2α (Dinoprost) and 0.020 mg of GnRH analogue (buserelin) at Days 8, 18 and 25 post partum, respectively. The A3 subgroup (Meth. T, alone) was control for A1 and A2 subgroups and the B3 subgroup was the non-treated control for all subgroups. There was a significant (P < 0.01) decrease in the days required for complete uterine involution in subgroups A1, B1 and A3, indicating the enhancement of uterine involution. The post partum cyclicity was initiated earlier in all of the treatment regimes applied in the present study, as was indicated by significant (P < 0.01) decrease in the days to first ovulation in these subgroups compared with the non-treated control subgroup. The reproductive performance of treated buffalos improved as was shown by the significant (P < 0.01) decrease in days to first service, days open and calving interval. It is concluded that enhancement of uterine involution and/or earlier initiation of post-partum cyclicity improve the reproductive performance of buffalos.

Optimizing assisted reproduction: impact of low-dose gonadotropin-releasing hormone agonist on in vitro fertilization outcome

A novel method of assessing factors that could benefit in vitro fertilization outcome is illustrated by comparison of a low (250 microg) with a standard (500 microg) dose of gonadotropin-releasing hormone agonist, revealing a small decrease in cancellation rates.

The use of recombinant human LH (lutropin alfa) in the late stimulation phase of assisted reproduction cycles: a double-blind, randomized, prospective study

BACKGROUND

The effect of recombinant human LH (r-hLH; lutropin alfa) in women undergoing controlled ovarian stimulation with recombinant human FSH (r-hFSH) prior to IVF was investigated.

METHODS

After down-regulation with the GnRH agonist, buserelin, 114 normo-ovulatory women (aged 18-37 years) received r-hFSH alone until the lead follicle reached a diameter of 14 mm. Patients were then randomized in a double-blind fashion to receive r-hFSH in addition to r-hLH, 75 IU s.c., or placebo daily for a maximum of 10 days prior to oocyte retrieval and IVF. The primary end-point was the number of metaphase II oocytes.

RESULTS

There were no significant differences between treatment groups for the primary end-point. Serum estradiol concentrations on the day of HCG administration were significantly higher in the group receiving r-hLH plus r-hFSH than in the group receiving r-hFSH alone (P = 0.0001), but there were no significant differences between the groups in dose and duration of r-hFSH treatment required, oocyte maturation, fertilization rate, pregnancy rate and live birth rate.

CONCLUSION

In this patient population, the addition of r-hLH during the late follicular phase of a long GnRH agonist and r-hFSH stimulation cycle provides no further benefit in terms of oocyte maturation or other end-points.

The pituitary and testicular responses to GnRH challenge between 4 and 14 months of age in thoroughbred colts born in spring and autumn

Gonadotropin releasing-hormone analogue (buserelin) challenges were carried out every 8 weeks from 4 to 14 months of age on thoroughbred colts born in the spring (n = 6) or autumn (n = 5) to define the onset of puberty. In all colts, luteinizing hormone (LH) secretion followed a seasonal pattern, with high baseline and maximal concentrations in the spring and summer and low concentrations in the winter. Testosterone concentrations were undetectable before spring and, thus, autumn-born colts were younger than spring-born colts when a testosterone response to buserelin was first observed. Mean weights of the autumn-born colts were 300 kg (282-327 kg) at the time of the first detectable testosterone response in the following spring (October). Spring-born colts had reached this weight in the winter (May and June, before day length had increased) but did not exhibit a significant testosterone response until the spring at a mean weight of 352 kg (327-403 kg). It is proposed that colts must achieve a threshold body weight concurrently with stimulatory photoperiod for onset of puberty to occur.

Follicle stimulating hormone as a predictor of ovarian response in women undergoing controlled ovarian hyperstimulation for IVF

OBJECTIVE

To evaluate the effect of basal follicle stimulating hormone (FHS) level on ovarian response in women undergoing controlled ovarian hyperstimulation for in vitro fertilization.

METHODS

A descriptive and analytic study of 212 cycles of IVF chosen from about 2200 files of women treated at Royan Institute, Tehran, Iran, from 1991 to 1999. Treatment was started with intranasal or subcutaneous buserlin (0.5 cm3), on day 21 (long protocol). On day 2 of the next cycle, stimulation with human menopausal gonadotropin (hMG) was initiated. When the number and size of follicles were suitable, human chorionic gonadotropin (hCG) was given intramuscularly for ovulation induction, followed by oocyte retrieval 36 to 40 h later. Embryos were transferred about 48 to 72 h after oocyte retrieval. The women were assigned to 2 groups on the basis of day 3 serum FSH levels (>or=15 IU/mL, group 1 and <15 IU/mL, group 2).

RESULTS

There were statistically significant differences between the 2 groups in number of follicles, number of oocytes retrieved and embryos transferred (lower in group 1), and level of serum luteinizing hormone and number of canceled cycles (higher in group 1). There were no statistical differences in number of ampoules of hMG used or age of patients.

CONCLUSION

Day-3 serum FSH level was a predictor of ovarian response and IVF outcome in this study.

The experiences of men receiving androgen deprivation treatment for prostate cancer: a qualitative study

OBJECTIVE

This exploratory study was intended to investigate men's ways of integrating and understanding experiences with Androgen Deprivation Therapy (ADT), including how hormone treatment affected their sense of identity.

PATIENTS AND METHODS

Twelve men, averaging 61 years of age and treated with ADT, participated in a single interview about their experiences with prostate cancer and hormone treatment. In keeping with a qualitative approach, questions were initially open-ended, with patients encouraged to describe experiences in their own words.

RESULTS

Seven prominent themes appeared in the interviews: 1) starting on hormones, 2) matching expectations with reality, 3) tracking changes, 4) dealing with changes in sexuality, 5) navigating relationships, 6) putting things in context, and 7) interpreting gender-relevant changes.

CONCLUSION

The effects of ADT on men with prostate cancer were varied and often substantial in their impact. Additionally, men often receive insufficient information to prepare them to deal with side effects. While the physiological situation of the men in our study could be described as "liminal" (i.e., straddled between two categories of gender), interview data showed that they refuse their liminality, claiming to be neither less masculine nor more feminine because of treatment. While men are grateful to receive potentially life-extending treatment, the challenge for the health care system is to provide them with the information and clinical support that will make their remaining years the best that they can be.

Achievement of pregnancy three times in the same patient during luteal GnRH agonist administration

Gonadotrophin-releasing hormone agonist (GnRHa) administration from the mid-luteal phase onwards is considered the gold standard of ovarian stimulation for IVF treatment. It might, however, coincide with an implanting spontaneous pregnancy. Concerns have therefore been raised with regard to the evolution of the resulting pregnancies and long-term outcome of the children born. The current case report describes the achievement of three pregnancies in the same patient during luteal administration of GnRHa. One pregnancy ended in spontaneous abortion and the other two resulted in the delivery of two female infants. The children have so far been followed for 3.5 and 7 years. The physical examination of both children was unremarkable. However, the older child has recently been diagnosed with attention deficit hyperactivity disorder and dyslexia.

Incidence of spontaneous ovulation and development of the corpus luteum in non-mated dromedary camels (Camelus dromedarius)

The occurrence of spontaneous ovulation in dromedaries was examined in two separate studies including 20 non-lactating, barren and 12 lactating dromedaries, respectively. Lactating camels were milked twice a day with an automatic bucket milking machine. Ovarian activity was monitored by repeated ultrasonography. Blood samples for progesterone were collected daily or two to three times a week. To compare CL development after spontaneous and induced ovulations, ovulation was induced by a GnRH analogue in eight lactating dromedaries. Spontaneous ovulation was observed in one non-lactating camel (1 of 20 camels, 5%; 1 of 70 follicular waves, 1.4%), whereas, spontaneous ovulation was detected more frequently in lactating dromedaries (5 of 12 camels, 41.7%; 13 of 91 follicular waves, 14.3%). In one lactating camel, spontaneous ovulation occurred repeatedly for nine times. There was a significant effect of type of ovulation (spontaneous versus induced, P < 0.05) and day (P < 0.001) on serum progesterone concentration. Mean serum progesterone levels and total progesterone production (AUC) were higher after induced ovulation. Luteal diameter and serum progesterone concentration were positively correlated (r = 0.71, P < 0.001), but there was a significant difference between morphological and functional development of the CL. In dromedaries, morphological development starts earlier, morphological regression starts later and last longer than functional development and regression of the CL. Compared to induced ovulation, functional development of the CL after spontaneous ovulation might be altered but the morphological development is not affected.

A randomised study of GnRH antagonist (cetrorelix) versus agonist (busereline) for controlled ovarian stimulation: effect on safety and efficacy

OBJECTIVE

To assess safety and efficacy of cetrorelix utilisation in controlled ovarian stimulation (COS).

STUDY DESIGN

Phase III, randomized, single center study of 131 patients undergoing COS and IVF with or without ICSI, in a University affiliated Hospital. Sixty-six patients were allocated to the protocol with antagonist and 65 to the agonist protocol arm. The Student's t-test, the Mann-Whitney test and the chi-square test were applied as required, using SPSS for Windows with a two-sided 5% significance level.

RESULTS

The mean (+/-S.D.) duration of stimulation was 9.5+/-1.7 days in the antagonist group and 10.6+/-2.1 days in the agonist group (P=0.02). The mean (+/-S.D.) duration of suppression was 4.6+/-1.3 days in the antagonist group and 27.3+/-5.2 days in the agonist group (P<0.0001). No significant differences were noted in other outcome measures: amount of rFSH required, estradiol level on hCG day, number of follicles>or=15 mm and endometrial thickness on oocyte retrieval day, number of oocytes retrieved, fertilization rate and number of OHS cases. Clinical pregnancy rates per-attempt and per-transfer were 15.1% and 17.0% in the antagonist group and 16.9% and 20.0% in the agonist group (P=0.79 and 0.71, respectively).

CONCLUSIONS

GnRH antagonists are an effective, safe and well tolerated alternative to agonists for COS.

GnRH agonist as novel luteal support: results of a randomized, parallel group, feasibility study using intranasal administration of buserelin*

BACKGROUND

The study objective was to investigate whether repeated intranasal administration of a GnRH agonist could provide convenient and safe luteal support.

METHODS

Twenty-four patients with unexplained infertility were enrolled. All patients were treated with an aromatase inhibitor. When ovulation trigger criteria were met, patients were randomly allocated to either 5000 IU hCG (group A), or 200 microg intranasal buserelin followed by 100 microg every 3 days (group B), 100 microg every 2 days (group C), or 100 microg every day (group D), up to day 14 of the luteal phase. All patients underwent intrauterine insemination.

RESULTS

Follicular development was similar in all groups with 1.1 +/- 0.3 follicles > or = 16 mm, 229.4 +/- 95.2 pg/ml estradiol (E2) and 0.8 +/- 0.5 ng/ml progesterone (mean+/-SD). The luteal phase duration (median; 95% confidence interval) was 15 (14.1, 15.0), 14 (12.5, 15.5), 15 (11.8, 18.2) and 15 (14.4, 15.6) days in groups A, B, C and D respectively. From luteal phase day 7 onwards, progesterone levels tended to be higher in group D compared with A. On day 14 of the luteal phase, progesterone levels were 3.0 (0.8, 5.2), 1.7 (-0.5, 3.9), 3.9 (-0.7, 8.5) and 7.7 (3.4, 11.9) ng/ml in groups A, B, C and D respectively (P = 0.045). No pregnancy was recorded in group A, but there was one biochemical pregnancy in group B, one biochemical and one singleton clinical pregnancy in group C, and two singleton clinical pregnancies in group D.

CONCLUSION

Intranasal administration of buserelin could be effective to provide luteal support. This treatment was associated with a good pregnancy rate (5/18, 28%).

Comparison between “short” and “long” protocols in an ICSI programme

In the present retrospective study we compare the efficacy of gonadotropin-releasing hormone (GnRH) agonist in a long protocol and a GnRH agonist in a short protocol administration for controlled ovarian hyperstimulation (COH) in an ICSI program. A total of 424 consecutive patients with a history of male factor were included in the present study. Three hundred and three patients were included in the long protocol and 121 in the short protocol. Patients treated with the short protocol were stimulated in a shorter time and achieved lower estradiol levels. A significantly higher percentage of oocytes transferred were found in the long protocol. The clinical pregnancy rate per embryo transfer was 39.3% in the long protocol and 19.2% in the short protocol (p=0.001).

Efficacy of the Ovsynch protocol for synchronization of ovulation and fixed-time artificial insemination in Murrah buffaloes (Bubalus bubalis)

Two experiments were conducted to assess the timing and synchrony of ovulation, plasma LH concentrations, and pregnancy rate in Murrah buffaloes (Bubalus bubalis) treated with the Ovsynch (GnRH-PGF(2 alpha)-GnRH) protocol. In Experiment 1, 10 non-lactating cycling buffaloes received 10 microg of a GnRH analogue i.m. (buserelin acetate) without regard to the stage of the estrous cycle (day of treatment, day 0), followed by 25mg of PGF(2 alpha) i.m. (dinoprost thromethamine) 7 days later. A second-treatment of the same GnRH analogue (10 microg, i.m.) was given 48 h after PGF(2 alpha). Ovulation was confirmed by transrectal palpation (at 2-h intervals) from the second-GnRH treatment to detection of ovulation or up to 96 h after the second-GnRH treatment. Plasma LH concentrations were determined in blood samples collected at 15-min intervals for 6h, starting at the second-GnRH treatment, and thereafter at 2-h intervals until 2h after detection of ovulation. Ovulation occurred in 9/10 buffalo (90%) 23.3+/-1.3h (mean+/-S.E.M.; range 20--32 h) after the second-GnRH treatment. Peak LH concentrations 13.5+/-3.5 ng/mL (range 3.9--40.0 ng/mL) occurred 2.1+/-0.1h (range 1.2-3.0 h) after the second-GnRH treatment. In Experiment 2, 15 lactating, cycling buffaloes were subjected to the Ovsynch protocol, with fixed-time AI 12 and 24h after the second-GnRH treatment and 75 lactating buffaloes were inseminated, approximately 12h after detection of spontaneous estrus. Pregnancy rates were 33.3% for TAI and were 30.7% for buffaloes inseminated following spontaneous estrus (P=0.84). In conclusion, the Ovsynch protocol effectively synchronized ovulation in Murrah buffaloes and resulted in conception rates (to two fixed-time inseminations) that were comparable to those achieved with a single AI after detection of spontaneous estrus.

GnRH antagonist versus long GnRH agonist protocol in poor responders undergoing IVF: a randomized controlled trial

BACKGROUND

This is the first published report of a prospective, randomized, controlled trial comparing a fixed, multi-dose GnRH antagonist protocol with a long GnRH agonist protocol in poor responders undergoing IVF.

METHODS

Sixty-six poor responders were randomized into two groups: the study group received 0.25 mg of cetrorelix daily starting on day 6 of stimulation; the control group received 600 microg of buserelin acetate daily starting in the mid-luteal phase of the preceding cycle. Both groups were given a fixed dose of recombinant FSH (300 IU daily) for stimulation.

RESULTS

There were no significant differences in the cycle cancellation rates, duration of stimulation, consumption of gonadotrophins, and mean numbers of mature follicles, oocytes and embryos obtained. The implantation rates were similar, but the number of embryos transferred was significantly higher for the antagonist group (2.32 +/- 0.58 versus 1.50 +/- 0.83; P = 0.01). The pregnancy rates were also higher in the antagonist group, but the difference was not statistically significant.

CONCLUSION

A fixed multi-dose GnRH antagonist protocol is feasible for patients who are poor responders on a long agonist protocol; however, our study failed to demonstrate an overall improvement in ovarian responsiveness. Clinical outcomes may be improved by developing more flexible antagonist regimens, an approach that requires further evaluation.

Agonist “flare-up” versus antagonist in the management of poor responders undergoing in vitro fertilization treatment

OBJECTIVE

To compare the agonist flare-up and antagonist protocols in the management of poor responders to the standard long down-regulation protocol.

DESIGN

Retrospective comparative study.

SETTING

Assisted conception center.

PATIENT(S)

One hundred thirty-four patients undergoing IVF/ intracytoplasmic sperm injection (ICSI) treatment, who responded poorly to the standard long down-regulation protocol in their first treatment cycle. In the second cycle, 77 received short flare-up agonist and 57 received antagonist protocol. We analyzed the outcome of the second cycle.

INTERVENTION(S)

Peak serum E(2) was assayed on the day of hCG administration.

MAIN OUTCOME MEASURE(S)

Cycle cancellation rate due to poor ovarian response.

RESULT(S)

There was no cycle cancellation in the flare-up protocol and 7% cancellation rate in the antagonist protocol due to lack of response. A significantly higher number of patients had embryo transfer in the flare-up protocol. There was no difference in pregnancy rate (PR) between the two groups.

CONCLUSION(S)

Both the flare-up and the antagonist protocols significantly improved the ovarian response of known poor responders. However, a significantly higher cycle cancellation rate and less patients having embryo transfer in the antagonist group tips the balance in favor of the flare-up protocol.

[New method of endocrine therapy for male infertility]

We undertook a prospective trial to compare the efficacy and adverse effects of a gonadotropin releasing-hormone analogue (GnRHa) and clomiphene citrate therapy for idiopathic normogonadotropic oligoasthenozoospermia (INOA). Fifty-nine newly-diagnosed INOA patients were randomly allocated to treatment with GnRHa or clomiphene citrate. Efficacy was assessed by measuring changes in semen parameters prior to and after 3 months of treatment. Thirty-six INOA patients underwent GnRHa therapy with 15 microg of diluted buserelin acetate given once a day intranasally, and 23 INOA patients were treated with 50 mg of clomiphene citrate daily by oral administration. The mean sperm density in the GnRHa group increased from 13.7 x 10(6)/ml to 22.1 x 10(6)/ml (p < 0.01), while the mean sperm density did not change significantly in the group treated with clomiphene. Similarly, the mean sperm motility increased from 35.9% to 43.9% in the GnRHa group (p < 0.05), but did not significantly change in the clomiphene group. No adverse effects were observed in either group. This GnRHa treatment protocol can be administered on an outpatient basis and is hoped to be of benefit to INOA patients.