Recombinant follicular stimulating hormone plus recombinant luteinizing hormone versus human menopausal gonadotropins- does the source of LH bioactivity affect ovarian stimulation outcome?

OBJECTIVE

Luteinizing hormone (LH) and human chorionic gonadotropin (hCG) activate distinct intracellular signaling cascades. However, due to their similar structure and common receptor, they are used interchangeably during ovarian stimulation (OS). This study aims to assess if the source of LH used during OS affects IVF outcome.

PATIENTS AND METHODS

This was a cross sectional study of patients who underwent two consecutive IVF cycles, one included recombinant follicular stimulating hormone (FSH) plus recombinant LH [rFSH+rLH, (Pergoveris)] and the other included urinary hCG [highly purified hMG (HP-hMG), (Menopur)]. The OS protocol, except of the LH preparation, was identical in the two IVF cycles.

RESULTS

The rate of mature oocytes was not different between the treatment cycles (0.9 in the rFSH+rLH vs 0.8 in the HP-hMG, p = 0.07). Nonetheless, the mean number of mature oocytes retrieved in the rFSH+rLH treatment cycles was higher compared to the HP-hMG treatment cycles (10 ± 5.8 vs 8.3 ± 4.6, respectively, P = 0.01). Likewise, the mean number of fertilized oocytes was higher in the rFSH+rLH cycles compared with the HP-hMG cycles (8.5 ± 5.9 vs 6.4 ± 3.6, respectively, p = 0.05). There was no difference between the treatment cycles regarding the number of top-quality embryos, the ratio of top-quality embryos per number of oocytes retrieved or fertilized oocytes or the pregnancy rate.

CONCLUSION

The differences in treatment outcome, derived by different LH preparations reflect the distinct physiological role of these molecules. Our findings may assist in tailoring a specific gonadotropin regimen when assembling an OS protocol.

Recombinant human luteinizing hormone co-treatment in ovarian stimulation for assisted reproductive technology in women of advanced reproductive age: a systematic review and meta-analysis of randomized controlled trials

INTRODUCTION

Several studies suggest that luteinizing hormone (LH) could improve IVF outcome in women of advanced reproductive age by optimizing androgen production. In this review, we assessed the role of recombinant-human LH (r-hLH) and recombinant human follicle stimulating hormone (r-hFSH) co-treatment in ovarian stimulation for assisted reproductive technology in women of advanced reproductive age candidates for assisted reproduction.

MATERIAL AND METHODS

Using a preregistered protocol we systematically searched Medline/PubMed, Scopus and the ISI Web of Science databases to identify randomized controlled trials in which r-hFSH monotherapy protocols were compared with r-hFSH/r-hLH co-treatment in women ≥35 years undergoing fresh IVF cycles. We calculated the pooled odds ratio (OR) for dichotomous data and the weight mean difference (WMD) for continuous data with an associated 95% confidence interval (CI). The meta-analyses were conducted using the random-effect model. P values < 0.05 were considered statistically significant. Subgroup analyses of all primary and secondary outcomes were performed only in women aged 35-40 years.

RESULTS

Twelve studies were identified. In women aged between 35 and 40 years, r-hFSH/r-hLH co-treatment was associated with higher clinical pregnancy rates (OR 1.45, CI 95% 1.05-2.00, I² = 0%, P = 0.03) and implantation rates (OR 1.49, CI 95% 1.10-2.01, I² = 13%, P = 0.01) versus r-hFSH monotherapy. Fewer oocytes were retrieved in r-hFSH/r-hLH-treated patients than in r-hFSH-treated patients both in women aged ≥35 years (WMD -0.82 CI 95% -1.40 to - 0.24, I² = 88%, P = 0.005) and in those aged between 35 and 40 years (WMD -1.03, CI - 1.89 to - 0.17, I² = 0%, P = 0.02). The number of metaphase II oocytes, miscarriage rates and live birth rates did not differ between the two groups of women overall or in subgroup analysis.

CONCLUSION

Although more oocytes were retrieved in patients who underwent r-hFSH monotherapy, this meta-analysis suggests that r-hFSH/r-hLH co-treatment improves clinical pregnancy and implantation rates in women between 35 and 40 years of age undergoing ovarian stimulation for assisted reproduction technology. However, more RCTs using narrower age ranges in advanced age women are warranted to corroborate these findings.

The Role of Hormone Stimulation in Men With Nonobstructive Azoospermia Undergoing Surgical Sperm Retrieval

Nonobstructive azoospermia, (NOA) is the most common cause of azoospermia. NOA is characterized by hypergonadotropic hypogonadism, testicular failure, and impaired spermatogenesis. The recent development of surgical sperm retrieval techniques such as microsurgical testicular sperm extraction (mTESE) has, for the first time, allowed some men with NOA to father biological children. It is common practice for endocrine stimulation therapies such as gonadotropins, selective estrogen receptor modulators (SERMs), and aromatase inhibitors to be used prior to mTESE to increase intratesticular testosterone synthesis with the aim of improving sperm retrieval rates; however, there is currently a paucity of data underpinning their safety and efficacy. We present 2 cases of men with NOA undergoing endocrine stimulation therapy and mTESE. We also discuss the current evidence and controversies associated with the use of hormonal stimulation therapy in couples affected by this severe form of male infertility.

Comparison of the combination of recombinant follicle-stimulating hormone and recombinant luteinizing hormone protocol versus human menopausal gonadotropin protocol in controlled ovarian stimulation: A systematic review and meta-analysis

OBJECTIVE

To systematically review the efficacy of a combination of recombinant follicle-stimulating hormone (rFSH) and recombinant luteinizing hormone (rLH) protocol versus human menopausal gonadotropin (hMG) protocol in controlled ovarian stimulation (COS).

METHODS

PubMed, EMbase, The Cochrane Central Register of Controlled Trials, China National Knowledge Infrastructure, and WanFang Data were searched to collect studies published prior to January 2019 on the efficacy of rFSH combined with rLH versus hMG alone in COS. Two reviewers independently screened the literature, conducted the data extraction, and assessed the risk of bias for all selected studies. Then, Review Manager 5.3 software was used for the meta-analysis.

RESULTS

There were 2767 patients from 9 studies. The results showed that among patients aged >30 years for IUI, the combination of rFSH and rLH was superior to hMG alone in clinical pregnancy rate per patient (relative risk [RR] = 1.47, 95% confidence interval [CI] 1.02 to 2.12) and endometrial thickness (mean difference [MD] = 0.34, 95% CI 0.04 to 0.64). In patients over 30 years old who received IVF, the results tended to favor the combination of rFSH and rLH in clinical pregnancy rate per patient (RR = 4.48, 95% CI 1.15 to 17.46) and live birth rate per started cycle (RR = 1.69, 95% CI 1.96 to 2.71). In patients less than 30 years old who received IVF, the combination of rFSH and rLH was superior to hMG in the number of retrieved oocytes (MD = 3.70, 95% CI 3.27 to 4.13) and inferior to hMG in number of high-quality embryos (MD = -0.60, 95% CI -0.91 to -0.29).

CONCLUSION

The combination of rFSH and rLH may have better efficacy than hMG alone in COS. However, considering the limited sample size of the included studies, the current evidence is not definitive.

The hypothalamic-pituitary-gonadal axis and thyroid hormone regulation interact to influence seasonal breeding in green anole lizards (Anolis carolinensis)

Reproductive physiology and behavior is mainly regulated by the hypothalamus-pituitary-gonad (HPG) axis, although abnormal thyroid hormone (TH) levels alter HPG axis activity. Seasonally breeding animals, such as green anole lizards (Anolis carolinensis), undergo drastic hormonal and behavioral changes between breeding and non-breeding seasons, with increased sex steroid hormones, larger gonads and increased reproductive behaviors during the breeding compared to non-breeding seasons. Relatively less is known regarding the regulation of gonadal TH in seasonal reproduction. We examined whether the gonadal expression of enzymes involved in TH activation are altered in concert with seasonal reproduction. Type 2 deiodinase (Dio2) mRNA, the TH activating enzyme, was upregulated in breeding compared to non-breeding testes, while type 3 deiodinase (Dio3) mRNA, the TH deactivating enzyme, was upregulated in breeding ovaries. To study the association between the HPG axis and local activation of TH, we manipulated the HPG axis during the non-breeding season by subcutaneously injecting luteinizing hormone (LH) and follicle stimulating hormone (FSH) in male lizards. We found that acute LH and FSH injections induced many aspects of breeding, with increased testes size and testosterone levels. Surprisingly, Dio3 was upregulated in the testes after LH and FSH injections, while Dio2 mRNA levels were unchanged. These results suggest that there might be different roles for local TH activation in developing and maintaining fully mature and functional gonads. Our findings continue to support the role for TH in regulating reproduction.

Androgen production in response to LH is impaired in theca cells from nonovulatory dominant follicles in early-postpartum dairy cows

Most dairy cows develop a dominant follicle within two weeks postpartum, but 60% of these follicles fail to ovulate. In a previous study, we determined that cows destined to ovulate have higher LH pulse frequency and circulating estradiol. The latter characteristic provided a method for distinguishing ovulatory from nonovulatory follicles during development and we found that nonovulatory follicles have lower estradiol and androstenedione in their follicular fluid. We hypothesized that lower LH pulse frequency impairs androgen production by theca cells of nonovulatory cows, reducing their ability to make estradiol. In the present study, we applied our method for predicting follicle fate to collect dominant follicles from predicted ovulatory (n = 7) and nonovulatory (n = 3) follicles. Theca and granulosa cells were separated and cultured in the absence or presence of LH, FSH, and/or testosterone for three days, with daily collection of culture medium for steroid RIAs. Estradiol and progesterone production by granulosa cells were not different between ovulatory and nonovulatory follicles. By contrast, overall androstenedione production by theca cells from ovulatory follicles was significantly higher compared with nonovulatory follicles on all three days of culture and, as culture progressed, theca from nonovulatory follicles had increasingly poorer responses to LH. In the same cultures, the progesterone production by theca cells was similar in ovulatory and nonovulatory groups. In support of our hypothesis, the results show that estradiol production by granulosa cells from nonovulatory follicles is robust when androgen substrate is present, but that thecal androgen production in response to LH is impaired. This suggests that the initial defect in steroidogenesis in dominant follicles that fail to ovulate postpartum is lower production of androgen by theca cells.

Hypothalamic Reproductive Endocrine Pulse Generator Activity Independent of Neurokinin B and Dynorphin Signaling

CONTEXT

Kisspeptin-neurokinin B (NKB)-dynorphin neurons are critical regulators of the hypothalamic-pituitary-gonadal axis. NKB and dynorphin are hypothesized to influence the frequency of GnRH pulses, whereas kisspeptin is hypothesized to be a generator of the GnRH pulse. How these neuropeptides interact remains unclear.

OBJECTIVE

To probe the role of NKB in GnRH pulse generation and to determine the interactions between NKB, kisspeptin, and dynorphin in humans and mice with a complete absence of NKB.

DESIGN

Case/control.

SETTING

Academic medical center.

PARTICIPANTS

Members of a consanguineous family bearing biallelic loss-of-function mutations in the gene encoding NKB and NKB-deficient mice.

INTERVENTIONS

Frequent blood sampling to characterize neuroendocrine profile and administration of kisspeptin, GnRH, and naloxone, a nonspecific opioid receptor antagonist used to block dynorphin.

MAIN OUTCOME MEASURES

LH pulse characteristics.

RESULTS

Humans lacking NKB demonstrate slow LH pulse frequency, which can be increased by opioid antagonism. Mice lacking NKB also demonstrate impaired LH secretion, which can be augmented with an identical pharmacologic manipulation. Both mice and humans with NKB deficiency respond to exogenous kisspeptin.

CONCLUSION

The preservation of LH pulses in the absence of NKB and dynorphin signaling suggests that both peptides are dispensable for GnRH pulse generation and kisspeptin responsiveness. However, NKB and dynorphin appear to have opposing roles in the modulation of GnRH pulse frequency.

Do poor-responder patients undergoing IVF benefit from splitting and increasing the daily gonadotropin dose?

We aim to retrospectively evaluate the role of increasing the gonadotropin daily dose from 450 IU/day to 300 IU twice a day on IVF-ET outcome in poor responder patients. All consecutive women admitted to our IVF unit and underwent COH consisting of daily gonadotropin dose of 450 IU, followed by an IVF cycle using 300 IU twice a day, were included. Ovarian stimulation characteristics, number of oocytes retrieved, number of embryo transferred and pregnancy rate was assessed. Twenty-three patients undergoing both cycles were evaluated. While there was no between-group difference in the duration of COH, number of 2PN embryos, fertilization rate and number of embryos transferred, patients receiving daily gonadotropin 300 IU twice a day achieved a significantly higher peak estradiol levels (3350.39 ± 2364.26 vs. 2223.74 ± 1299.91; p < .03, respectively), and yielded significantly higher number of follicles >15 mm in diameter on day of hCG administration (3.2 ± 2.4 vs 1.8 ± 1; p < .03, respectively) and higher number of oocytes retrieved (3.48 ± 2.54 vs 1.87 ± 1.1; p < .02, respectively) with an acceptable live birth rate (5%). To conclude, in poor responders undergoing COH a daily gonadotropin dose of 450 IU, increasing the dose to 300 IU twice daily may result in higher oocyte yield, with the possible improvement in IVF outcome.

A cohort study of both human menopausal gonadotropin (HMG) and recombinant luteinizing hormone addition at early follicular stage in in vitro fertilization outcome: A STROBE-compliant study

At present, the precise role of human menopausal gonadotropin (HMG) and recombinant luteinizing hormone (rLH) supplementation at an early time of follicular phase on in vitro fertilization (IVF)/intra cytoplasmatic sperm injection (ICSI) outcomes remains uncertain.Here infertile women of normal ovarian function undergoing their first cycle of IVF/ICSI were studied and were randomly allocated into 3 groups. Group 1, ovarian stimulation with 150IU recombinant follicle-stimulating hormone (FSH) alone. Group 2, patients received 75IU rFSH and 75IU HMG. Group 3 patients were given 150IU rFSH and 75IU rLH.There were no significant differences in the clinical characteristics, ovarian response, the biochemical, clinical and ongoing pregnancy rates among the 3 groups. No significant differences were found in biochemical, clinical and ongoing pregnancy rates between the patients whose LH levels were lower than 0.75 mIU/ml and those above this threshold in group 1. Furthermore, there were also no significant differences in biochemical, clinical and ongoing pregnancy rates among the 3 group patients whose LH level lower than 0.75 mIU/ml.The results showed that either the addition of HMG or rLH supplementation at an early time of follicular phase produce no significant benefit on IVF outcome in patients with normal ovarian function.

Management of ovulation induction and intrauterine insemination in infertile patients with hypogonadotropic hypogonadism

AIM

To investigate the effectiveness of ovulation induction and intrauterine insemination (OI + IUI) in female patients with hypogonadotropic hypogonadism (HH), and to compare the outcomes of different stimulation protocols and cycle characteristics.

MATERIAL AND METHODS

The outcomes of OI + IUI treatments in patients with HH diagnosed between 2010 and 2018 were retrospectively evaluated. Cycles using recombinant (rec) luteinizing hormone (LH) or human menopausal gonadotropin (hMG) as LH sources were compared with each other. The cycle characteristics and pregnancy rates of the first cycles were compared with those of the second cycles in patients who underwent 2 or more cycles.

RESULTS

Of 104 patients diagnosed with World Health Organization type 1 anovulation, 99 were treated with hMG or rec LH + rec follicle-stimulating hormone (FSH) in a total of 220 cycles. The mean age of the study patients was 27.8 ± 4.6 years (range, 19-39 years). Rec FSH + rec LH was given in 37 cycles, and hMG was used in 183 cycles. The hormone values were as follows: FSH, 1.4 ± 1.6 mIU/mL; LH, 0.7 ± 1.2 mIU/mL; oestradiol, 13 (15.8 ± 12.0) pg/mL; and anti-Müllerian hormone, 2.1 (2.6 ± 1.2) ng/mL. A dominant follicle was observed in 85.7% of the first cycles and in 86.2% of the second cycles. The treatment lasted 17.2 ± 5.0 and 15.5 ± 3.8 days until the human chorionic gonadotropin (hCG) administration day in the first and second cycles, respectively, and the difference was statistically significant (p < 0.05). The cycle cancellation rate was 8.1% (n = 3) in cycles done using rec gonadotropins and 29% (n = 53) in patients stimulated with hMG, and the difference was statistically significant (p < 0.05). The pregnancy rates were 12.7% and 28.3% per cycle and per patient, respectively. The pregnancy rate in hCG-triggered patients (successful stimulation) was 17.1% per cycle in all patients.

CONCLUSION

OI with gonadotropins and IUI is a safe, efficient, and relatively cost-effective treatment option in patients with HH, yielding reasonable pregnancy rates per cycle and per patient. The use of rec FSH + rec LH facilitates cycle management but does not positively contribute to pregnancy rates and is more expensive than some other feasible options.

Recombinant luteinizing hormone supplementation in assisted reproductive technology: a systematic review

OBJECTIVE

To assess the role of recombinant human LH (r-hLH) supplementation in ovarian stimulation for ART in specific subgroups of patients.

DESIGN

Systematic review.

SETTING

Centers for reproductive care.

PATIENT(S)

Six populations were investigated: 1) women with a hyporesponse to recombinant human FSH (r-hFSH) monotherapy; 2) women at an advanced reproductive age; 3) women cotreated with the use of a GnRH antagonist; 4) women with profoundly suppressed LH levels after the administration of GnRH agonists; 5) normoresponder women to prevent ovarian hyperstimulation syndrome; and 6) women with a "poor response" to ovarian stimulation, including those who met the European Society for Human Reproduction and Embryology Bologna criteria.

INTERVENTION(S)

Systematic review.

MAIN OUTCOME MEASURE(S)

Implantation rate, number of oocytes retrieved, live birth rate, ongoing pregnancy rate, fertilization rate, and number of metaphase II oocytes.

RESULT(S)

Recombinant hLH supplementation appears to be beneficial in two subgroups of patients: 1) women with adequate prestimulation ovarian reserve parameters and an unexpected hyporesponse to r-hFSH monotherapy; and 2) women 36-39 years of age. Indeed, there is no evidence that r-hLH is beneficial in young (<35 y) normoresponders cotreated with the use of a GnRH antagonist. The use of r-hLH supplementation in women with suppressed endogenous LH levels caused by GnRH analogues and in poor responders remains controversial, whereas the use of r-hLH supplementation to prevent the development of ovarian hyperstimulation syndrome warrants further investigation.

CONCLUSION(S)

Recombinant hLH can be proposed for hyporesponders and women 36-39 years of age.

Novel Concepts for Inducing Final Oocyte Maturation in In Vitro Fertilization Treatment

Infertility affects one in six of the population and increasingly couples require treatment with assisted reproductive techniques. In vitro fertilization (IVF) treatment is most commonly conducted using exogenous FSH to induce follicular growth and human chorionic gonadotropin (hCG) to induce final oocyte maturation. However, hCG may cause the potentially life-threatening iatrogenic complication "ovarian hyperstimulation syndrome" (OHSS), which can cause considerable morbidity and, rarely, even mortality in otherwise healthy women. The use of GnRH agonists (GnRHas) has been pioneered during the last two decades to provide a safer option to induce final oocyte maturation. More recently, the neuropeptide kisspeptin, a hypothalamic regulator of GnRH release, has been investigated as a novel inductor of oocyte maturation. The hormonal stimulus used to induce oocyte maturation has a major impact on the success (retrieval of oocytes and chance of implantation) and safety (risk of OHSS) of IVF treatment. This review aims to appraise experimental and clinical data of hormonal approaches used to induce final oocyte maturation by hCG, GnRHa, both GnRHa and hCG administered in combination, recombinant LH, or kisspeptin. We also examine evidence for the timing of administration of the inductor of final oocyte maturation in relationship to parameters of follicular growth and the subsequent interval to oocyte retrieval. In summary, we review data on the efficacy and safety of the major hormonal approaches used to induce final oocyte maturation in clinical practice, as well as some novel approaches that may offer fresh alternatives in future.

The impact of luteinizing hormone supplementation in gonadotropin-releasing hormone antagonist cycles: a retrospective cohort study

The impact of exogenous luteinizing hormone (LH) supplementation to patients undergoing controlled ovarian stimulation with gonadotropin-releasing hormone (GnRH) antagonists on cycle outcomes is controversial. Here, we present a retrospective cohort study including cycles from December 2015 to December 2016. Totally 320 cycles were divided into two groups according to with or without exogenous LH supplementation. No significant differences regarding the number of retrieved oocytes, the number of good-quality embryos, and clinical pregnancy rate between the two groups were found. The logistic regression analysis revealed that LH supplementation was not independently associated with clinical pregnancy rate (OR = 0.577, 95% CI: 0.272-1.222, p = .58) or a biochemical pregnancy rate (OR = 0.922, 95% CI: 0.444-1.916, p = .83). When patients were divided into subgroups based on age, more retrieved oocytes (5.60 vs. 3.97, p = .04) and good-quality embryos (3.07 vs. 1.93, p = .01) were achieved in cycles with exogenous LH supplementation for 40 years and over group. We conclude that for aged women (40 years old and over), LH supplementation has a positive impact on the number of retrieved oocytes and good-quality embryos in GnRH antagonist cycles.

Recombinant luteinizing hormone supplementation to recombinant follicle stimulating hormone therapy in gonadotropin releasing hormone analogue cycles: what is the evidence?

OBJECTIVE

To look into current evidence exploring the added value of rLH supplementation to rFSH in GnRH analogues cycles, to identify groups of women that still have no evidence for adjuvant rLH therapy and to discuss ways that may advance research on this topic.

METHODS

Eight systematic reviews and meta-analyses exploring the benefit for pregnancy achievement of rLH supplementation, excluding other LH activity preparations, to GnRH analogues cycles in the ART setting were thoroughly evaluated.

RESULTS

Evidence exists to show that rLH supplementation seems to have added value for pregnancy achievement in women with poor ovarian response and in women ≥35 years of age employing the GnRH agonist protocol, while the evidence is still debatable when the GnRH antagonist is administered. In the general infertile population, rLH supplementation does not have added value in the GnRH-antagonist cycles while the evidence is still controversial when the GnRH agonist is employed. Whether rLH supplementation may have a benefit in some young, normo-gonadotropic women, who may develop LH deficiency following GnRH analogues, is still to be shown. The main task remains how to identify subgroups of women that may benefit from rLH supplementation.

CONCLUSION

An accurate definition of the LH threshold in GnRH analogue treated cycles may contribute to the discussion of which subgroups of women may benefit from adjuvant rLH therapy.

Effects of propylene glycol or elevated luteinizing hormone during follicle development on ovulation, fertilization, and early embryo development

Seventeen nonlactating Holstein cows were superovulated in a Latin-square designed experiment to determine the effects of increased propylene glycol (PROP) and luteinizing hormone (LH) during antral follicle development on ovarian function, fertilization, and early embryo quality. PROP was orally drenched every 4 h for 7 days to induce hyperinsulinemia and associated metabolic changes. LH concentrations were altered by increasing LH (3-fold) during last 2 days of superovulation. Treatment groups were as follows: (1) control-oral drenching with water plus low-LH preparation; (2) high LH(HLH)-water plus HLH preparation; (3) PROP-drenching with PROP plus low LH; (4) PROP/HLH-PROP plus HLH. PROP increased glucose (P < 0.05) and insulin (P < 0.02) concentrations at all time points analyzed. Neither PROP nor LH affected numbers of follicles > 9 mm at time of gonadotropin-releasing hormone-induced LH surge, although percentage of these follicles that ovulated was decreased by both PROP (P = 0.002) and LH (P = 0.048). In addition, PROP tended (P = 0.056) to decrease total number of ovulations. PROP reduced (P = 0.028) fertilization rate, while LH tended (P = 0.092) to increase fertilization rate. There was no effect of either PROP or LH on any measure of embryo quality including percentage of embryos that were degenerate, quality 1, or quality 1 and 2 of total structures collected or fertilized structures. These results indicate that acute elevation in insulin during the preovulatory follicular wave can decrease percentage of large follicles that ovulate, particularly when combined with increased LH, and reduce fertilization of ovulated oocytes.

The effect of rLH supplementation to the GnRH-antagonist protocol on endocrine dynamics in the advanced reproductive age

PURPOSE

To explore serum endocrine dynamics, specifically LH levels, following rLH supplementation to rFSH following GnRH-antagonist treatment in the advance reproductive age.

METHODS

Women were prospectively and similarly treated employing rFSH and the flexible GnRH-antagonist protocol, while rLH was supplemented only to the study group. Serum FSH, LH, E_2, and P were evaluated throughout the follicular phase. Three strategies were a priori planned to examine endocrine dynamics among women enrolled.

RESULTS

While serum LH drop were similar before GnRH-antagonist stimulation, it dropped more times in the control group compared to the study group. Among women receiving rFSH only, serum LH levels dropped ≤2, ≤1 and ≤0.5 mIU/mL in 71.4, 46.4, and 28.6% of cases, while this occurred only in 38.7% (P = 0.01), 6.5% (P = 0.0004) and 3.2% (P = 0.007) of women receiving combined rFSH and rLH treatment, respectively. The same trend was found when serum LH dropped in at least two occasions following the GnRH-antagonist administration. Conversely, serum LH diagrams throughout the follicular phase did not differ between the two groups. Furthermore, individual area under the curve values of LH, E_2, and P was similar between the two groups following GnRH-antagonist initiation.

CONCLUSIONS

Different strategies to explore LH dynamics following the GnRH-antagonist administration have resulted in diverse results, implying the need for a consensus definition of LH threshold for adequate folliculogenesis and steroidogenesis. Such action would pave the way for understanding which groups of patients may benefit from rLH supplementation.

Recombinant luteinizing hormone (rLH) and recombinant follicle stimulating hormone (rFSH) for ovarian stimulation in IVF/ICSI cycles

BACKGROUND

One of the various ovarian stimulation regimens used for in-vitro fertilisation (IVF) or intracytoplasmic sperm injection (ICSI) cycles is the use of recombinant follicle-stimulating hormone (rFSH) in combination with a gonadotrophin-releasing hormone (GnRH) analogue. GnRH analogues prevent premature luteinizing hormone (LH) surges. Since they deprive the growing follicles of LH, the question arises as to whether supplementation with recombinant LH (rLH) would increase live birth rates. This is an updated Cochrane Review; the original version was published in 2007.

OBJECTIVES

To compare the effectiveness and safety of recombinant luteinizing hormone (rLH) combined with recombinant follicle-stimulating hormone (rFSH) for ovarian stimulation compared to rFSH alone in women undergoing in-vitro fertilisation/intracytoplasmic sperm injection (IVF/ICSI).

SEARCH METHODS

For this update we searched the following databases in June 2016: the Gynaecology and Fertility Group Specialised Register, CENTRAL, MEDLINE, Embase, CINAHL, PsycINFO and ongoing trials registers, and checked the references of retrieved articles.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) comparing rLH combined with rFSH versus rFSH alone in IVF/ISCI cycles.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected studies, assessed risk of bias, and extracted data. We combined data to calculate odds ratios (ORs) and 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 GRADE methods. Our primary outcomes were live birth rate and incidence of ovarian hyperstimulation syndrome (OHSS). Secondary outcomes included ongoing pregnancy rate, miscarriage rate and cancellation rates (for poor response or imminent OHSS).

MAIN RESULTS

We included 36 RCTs (8125 women). The quality of the evidence ranged from very low to moderate. The main limitations were risk of bias (associated with poor reporting of methods) and imprecision.Live birth rates: There was insufficient evidence to determine whether there was a difference between rLH combined with rFSH versus rFSH alone in live birth rates (OR 1.32, 95% CI 0.85 to 2.06; n = 499; studies = 4; I² = 63%, very low-quality evidence). The evidence suggests that if the live birth rate following treatment with rFSH alone is 17% it will be between 15% and 30% using rLH combined with rFSH.OHSS: There may be little or no difference between rLH combined with rFSH versus rFSH alone in OHSS rates (OR 0.38, 95% CI 0.14 to 1.01; n = 2178; studies = 6; I² = 10%, low-quality evidence). The evidence suggests that if the rate of OHSS following treatment with rFSH alone is 1%, it will be between 0% and 1% using rLH combined with rFSH.Ongoing pregnancy rate: The use of rLH combined with rFSH probably improves ongoing pregnancy rates, compared to rFSH alone (OR 1.20, 95% CI 1.01 to 1.42; participants = 3129; studies = 19; I² = 2%, moderate-quality evidence). The evidence suggests that if the ongoing pregnancy rate following treatment with rFSH alone is 21%, it will be between 21% and 27% using rLH combined with rFSH.Miscarriage rate: The use of rLH combined with rFSH probably makes little or no difference to miscarriage rates, compared to rFSH alone (OR 0.93, 95% CI 0.63 to 1.36; n = 1711; studies = 13; I² = 0%, moderate-quality evidence). The evidence suggests that if the miscarriage rate following treatment with rFSH alone is 7%, the miscarriage rate following treatment with rLH combined with rFSH will be between 4% and 9%.Cancellation rates: There may be little or no difference between rLH combined with rFSH versus rFSH alone in rates of cancellation due to low response (OR 0.77, 95% CI 0.54 to 1.10; n = 2251; studies = 11; I² = 16%, low quality evidence). The evidence suggests that if the risk of cancellation due to low response following treatment with rFSH alone is 7%, it will be between 4% and 7% using rLH combined with rFSH.We are uncertain whether use of rLH combined with rFSH improves rates of cancellation due to imminent OHSS compared to rFSH alone. Use of a fixed effect model suggested a benefit in the combination group (OR 0.60, 95% CI 0.40 to 0.89; n = 2976; studies = 8; I² = 60%, very low quality evidence) but use of a random effects model did not support the conclusion that there was a difference between the groups (OR 0.82, 95% CI 0.34 to 1.97).

AUTHORS' CONCLUSIONS

We found no clear evidence of a difference between rLH combined with rFSH and rFSH alone in rates of live birth or OHSS. The evidence for these comparisons was of very low-quality for live birth and low quality for OHSS. We found moderate quality evidence that the use of rLH combined with rFSH may lead to more ongoing pregnancies than rFSH alone. There was also moderate-quality evidence suggesting little or no difference between the groups in rates of miscarriage. There was no clear evidence of a difference between the groups in rates of cancellation due to low response or imminent OHSS, but the evidence for these outcomes was of low or very low quality.We conclude that the evidence is insufficient to encourage or discourage stimulation regimens that include rLH combined with rFSH in IVF/ICSI cycles.

A comparison between r-LH and urinary supplements containing LH activity in patients undergoing the microdose GnRH agonist flare protocol for in-vitro fertilization: a pilot study

BACKGROUND

The aim of this study was to compare pregnancy rates and stimulation parameters in patients with diminished ovarian reserve, who were treated with recombinant human luteinizing hormone (r-LH) or menopausal gonadotropins (hMG), as part of a microdose flare protocol.

METHODS

A retrospective cohort study was performed. Comparisons between the group that was stimulated with r-LH plus follicle stimulating hormone (FSH) to those treated with hMG and FSH, were performed. Measurements included: medication doses, number of oocyte collected, number of embryos obtained, pregnancy and clinical pregnancy rates.

RESULTS

Patients in the r-LH group (N.=40) had significant higher clinical pregnancy rates (33% vs. 14%; P=0.04) and used lower dose of LH (1938 IU vs. 2807 IU; P=0.02) compared to patients that were stimulated with hMG (N.=39).

CONCLUSIONS

r-LH may offer advantages for the treatment of diminished ovarian reserve when performing a microdose flare protocol when compared to hMG. Both larger and prospective studies should be carried out to confirm these findings.

The effect of LH supplementation to the GnRH antagonist protocol in advanced reproductive ageing women: a prospective randomized controlled study

OBJECTIVE

Although the fundamental significance of both LH and FSH for adequate ovarian folliculogenesis and steroidogenesis has been extensively discussed, the clinical implication of recombinant (r) LH to rFSH for ovarian stimulation employing the GnRH antagonist protocol remains to be elucidated. The aim of this prospective randomized controlled study was to explore whether rLH supplementation to rFSH following GnRH antagonist has an added value to the late follicular ovarian steroidogenesis in the advanced reproductive aged women.

DESIGN AND SUBJECTS

Sixty-three consecutive infertile women above 35 years of age and/or with a previous low ovarian response admitted for IVF/ICSI treatment were prospectively randomized. Women in the study and control groups were similarly treated employing the rFSH 300 IU/day and the flexible GnRH antagonist 0·25 mg/day protocol. On the day of antagonist initiation, rLH 150 IU/day was added only to the study group and continued till the hCG day.

RESULTS

Serum E2 level on hCG day did not significantly differ between the study and control groups, corresponding to 1268 ± 1006 and 1113 ± 669 pg/mL, respectively (P = 0·9). In the study group, the duration of GnRH antagonist administration was significantly lower than the control group corresponding to 5·0 ± 1·5 to 4·0 ± 1·5 days, respectively (P < 0·05). The total dosage of rFSH administration did not differ between the two groups.

CONCLUSIONS

rLH supplementation to rFSH following GnRH antagonist administration employing the flexible protocol does not seem to significantly augment serum E2 level on the day of hCG administration in the advanced reproductive ageing women. This suggests that endogenous serum LH levels following GnRH antagonist initiation are sufficient for adequate late follicular ovarian steroidogenesis in this setting.

Long-acting FSH versus daily FSH for women undergoing assisted reproduction

BACKGROUND

Assisted reproduction techniques (ART), such as in vitro fertilisation (IVF) and intracytoplasmic sperm injection (ICSI), can help subfertile couples to create a family. It is necessary to induce multiple follicles, which is achieved by follicle stimulating hormone (FSH) injections. Current treatment regimens prescribe daily injections of FSH (urinary FSH either with or without luteinizing hormone (LH) injections or recombinant FSH (rFSH)).Recombinant DNA technologies have produced a new recombinant molecule which is a long-acting FSH, named corifollitropin alfa (Elonva) or FSH-CTP. A single dose of long-acting FSH is able to keep the circulating FSH level above the threshold necessary to support multi-follicular growth for an entire week. The optimal dose of long-acting FSH is still being determined. A single injection of long-acting FSH can replace seven daily FSH injections during the first week of controlled ovarian stimulation (COS) and can make assisted reproduction more patient friendly.

OBJECTIVES

To compare the effectiveness of long-acting FSH versus daily FSH in terms of pregnancy and safety outcomes in women undergoing IVF or ICSI treatment cycles.

SEARCH METHODS

We searched the following electronic databases, trial registers and websites from inception to June 2015: the Cochrane Central Register of Controlled Trials (CENTRAL), the Cochrane Menstrual Disorders and Subfertility Group (MDSG) Specialized Register, MEDLINE, EMBASE, PsycINFO, CINAHL, electronic trial registers for ongoing and registered trials, citation indexes, conference abstracts in the ISI Web of Knowledge, LILACS, Clinical Study Results (for clinical trial results of marketed pharmaceuticals), PubMed and OpenSIGLE. We also carried out handsearches.

SELECTION CRITERIA

We included all randomised controlled trials (RCTs) comparing long-acting FSH versus daily FSH in women who were part of a couple with subfertility and undertaking IVF or ICSI treatment cycles with a GnRH antagonist or agonist protocol.

DATA COLLECTION AND ANALYSIS

Two review authors independently performed study selection, data extraction and assessment of risk of bias. We contacted trial authors in cases of missing data. We calculated risk ratios for each outcome, and our primary outcomes were live birth rate and ovarian hyperstimulation syndrome (OHSS) rate. Our secondary outcomes were ongoing pregnancy rate, clinical pregnancy rate, multiple pregnancy rate, miscarriage rate, any other adverse event (including ectopic pregnancy, congenital malformations, drug side effects and infection) and patient satisfaction with the treatment. Trials reported all outcomes, except patient satisfaction with the treatment.

MAIN RESULTS

We included six RCTs with a total of 3753 participants and we graded the quality of the included studies as moderate. All studies included women with an indication for COS as part of an IVF/ICSI cycle with age ranging from 18 to 41 years. A comparison of long-acting FSH versus daily FSH did not show evidence of difference in effect on overall live birth rate (Risk ratio (RR) 0.95, 95% confidence interval (CI) 0.84 to 1.07; 2363 participants, eight studies; I² statistic = 44%) or OHSS (RR 1.00, 95% CI 0.74 to 1.37; 3753 participants, nine studies; I² statistic = 0%). We compared subgroups by dose of long-acting FSH. There was evidence of reduced live birth rate in women who received lower doses (60 to 120 μg) of long-acting FSH compared to daily FSH (RR 0.70, 95% CI 0.52 to 0.93; 645 participants, three studies; I² statistic = 0%). There was no evidence a difference between the groups in live births in the medium dose (150 to 180 μg) subgroup (RR 1.03, 95% CI 0.90 to 1.18; 1685 participants, four studies; I² statistic = 6%). There was no evidence of a difference between the groups in the clinical pregnancy rate (any dose), ongoing pregnancy rate (any dose), multiple pregnancy rate (any dose), miscarriage rate (low or medium dose), ectopic pregnancy rate (any dose), congenital malformation rate, congenital malformation rate; major or minor (low or medium dose).

AUTHORS' CONCLUSIONS

The use of a medium dose (150 to 180 μg) of long-acting FSH is a safe treatment option and equally effective compared to daily FSH in women with unexplained subfertility. There was evidence of reduced live birth rate in women receiving a low dose (60 to 120 μg) of long-acting FSH compared to daily FSH. Further research is needed to determine whether long-acting FSH is safe and effective for use in hyper- or poor responders and in women with all causes of subfertility.

Recombinant luteinizing hormone supplementation in women undergoing in vitro fertilization/ intracytoplasmic sperm injection with gonadotropin releasing hormone antagonist protocol: a systematic review and meta-analysis

The objective of this meta-analysis is to assess the impact of LH supplementation in women undergoing in vitro fertilization/ intracytoplasmic sperm injection (IVF/ICSI) with gonadotropin releasing hormone (GnRH) antagonist protocol. No significant difference in outcomes between LH supplementation and r-FSH alone in women undergoing IVF/ICSI with GnRH antagonist protocol is currently present, and further studies are necessary for more solid conclusions on pregnancy likelihood to be drawn.

Recombinant LH administration in subsequent cycle after "unexpected" poor response to recombinant FSH monotherapy

Abstract Poor ovarian response (POR) is most frequently linked to the condition known as diminished ovarian reserve, but it can also occur in the absence of pathological ovarian reserve tests ("unexpected" POR). Because possible explanations include theca cells function deficiency, our aim was to evaluate the effect of r-LH administration in "unexpected" poor responders. A retrospective, single-centre, cohort study was conducted on 65 patients with AMH >0.5 ng/ml and/or AFC >5 with POR in their first cycle. Patients underwent a second IVF cycle with same protocol (long- or antagonist) and same starting dose of r-FSH used in the first cycle, plus daily addiction of 150 IU of r-LH from day 1. Compared to the first cycle, r-LH addition in the second cycle determined an increase in number of oocytes retrieved (p < 0.001), number of metaphase II oocytes (p < 0.05), E2 levels at hCG triggering (p < 0.001) and number of embryos transferred (p = 0.002). A 15% clinical pregnancy rate was also observed in the second cycle. Our results suggest that patients with non-pathological ovarian reserve tests and previous "unexpected" POR seem to benefit from r-LH addition in subsequent cycles without the need to increase the r-FSH starting dose, possibly due to an underlying occult theca cells deficiency.

[The influence of exogenous LH/hCG activity on serum progesterone levels on the day of hCG administration in in vitro fertilization]

OBJECTIVES

Clarifying whether the addition of recombinant LH (rLH) to recombinant FSH (rFSH) leads to progesterone (P4) levels on dhCG comparable to those obtained with stimulation with FSH and hCG (HP-hMG) MATERIALS AND METHODS: Pituitary-desensitized patients, matched for age and follicle reserve, received rFSH+LH (n=729) or HP-hMG (n=729). In the rFSH+rLH group, rLH (75 UI/day) was started at day 6. To control for the influence of ovarian response on P4, we divided serum P4 levels by the number of growing follicles (13-22 mm; "per follicle" P4 levels) and performed a multivariate analysis.

RESULTS

Serum P4 levels on dHCG were lower in the HP-hMG (median: 0.63 ng/mL, max-min: 0.10-2.97) than in the rFSH+rLH group (0.91 ng/mL; 0.10-4.65, P<0.0001), as well as "per-follicle" P4 levels (0.055 ng/mL/growing follicle, 0.006-0.284 vs 0.077 ng/mL/growing follicle, 0.003-0.336; P<0.0001).

CONCLUSIONS

HP-hMG led to lower P4 levels on day hCG than rFSH+rLH irrespective of the intensity of the ovarian response and the adjunction of rLH (75 IU/day from day 6 onward).

Recombinant human luteinizing hormone to trigger ovulation: randomized, controlled, dose-finding pilot study in ovulation induction

OBJECTIVE

To evaluate recombinant human luteinizing hormone (r-hLH) versus urine-derived human chorionic gonadotropin (u-hCG) to trigger ovulation in women (aged 20-40 years) with WHO Group II anovulatory infertility undergoing ovulation induction (OI) with recombinant human follicle-stimulating hormone (r-hFSH) (150 IU/day starting dose).

STUDY DESIGN

For this Phase II, open-label, dose-finding pilot study, patients were randomized to doses of 825, 2,750, 5,500, 11,000, or 22,000 IU r-hLH or u-hCG (5,000 IU). Primary endpoints were ovulation and ratio of ruptured follicles/follicle > or = 15 mm (day of r-hLH/ u-hCG administration). Secondary endpoints included monofollicular ovulation and clinical pregnancy rates.

RESULTS

All 67 randomized patients completed treatment. All patients in the r-hLH 2,750 (13/13), 5,500 (12/ 12), 11,000 IU (13/13), and u-hCG 5,000 IU (12/ 12) groups ovulated; 3/5 patients in the r-hLH 825 IU and 2/12 in the r-hLH 22,000 IU group failed to ovulate (p = 0.105 between evaluable groups). The mean ratio of ruptured follicles/ follicle > or = 15 mm was 1.1 (p = 0.675 between groups). The monofollicular ovulation rate was 15/60 (25%). Two cases of ovarian hyperstimulation syndrome were reported.

CONCLUSION

This open-label, pilot study (conducted in 1999-2001) suggests that the minimal effective dose of r-hLH to trigger ovulation in women with WHO Group II anovulatory infertility undergoing OI with r-hFSH (150 IU starting dose) was 2,750 IU.

Does the addition of recombinant luteinizing hormone to progesterone for luteal supplementation improve IVF outcomes in high-responder patients? A preliminary randomized controlled study

OBJECTIVE

To determine the impact of recombinant luteinizing hormone (rLH) combined with vaginal progesterone (P)for luteal supplementation on in vitro fertilization (IVF) pregnancy outcomes in high-responder patients undergoing long gonadotropin-releasing hormone (GnRH) agonist cycles.

STUDY DESIGN

A total of 47 patients undergoing IVF cycles with the serum estradiol levels of > or = 2,500 pg/mL on the day of human chorionic gonadotropin administration were included in this prospective randomized study. Patients were divided into 2 treatment groups: the control group (n = 23) used luteal vaginal P, and the study group (n = 24) received a combination of vaginal P and 75 IU rLH, 4 doses every 3 days, starting on the day of embryo transfer. The main outcome measure was the clinical pregnancy rate (PR).

RESULTS

The study group had 11 pregnancies (45.8%), while the control group had 6 (26.1%). There was no significant difference between the groups in clinical PRs (p = 0.15). No differences were found with respect to the implantation rate, miscarriage rate, and multiple PR.

CONCLUSION

Our data show that luteal supplementation with rLH combined to vaginal P was not found to improve pregnancy outcomes in high responder patients undergoing long GnRH agonist IVF treatments.

[Ovarian stimulation with gonadotropins: comparison between recombinant FSH plus menotropins versus recombinant FSH + LH]

BACKGROUND

Nowadays various assisted reproduction ovarian stimulation schemes are used for different clinical outcomes is interesting to compare.

OBJECTIVE

Compare two ovarian stimulation protocols: recombinant FSH + LH versus recombinant FSH + Menotropins.

MATERIAL AND METHODS

Observational, retrospective study, 38 cycles were analyzed, made from 2010 until 2013, assigned to two groups (n = 19 each), group 1 received FSHr + LHr, group 2 received FSHr + menotropins. Study variables were: days of ovarian stimulation, total gonadotropin dose, retrieved oocytes, fertilization rate, pregnancy rate and number of vitrified embryos.

RESULTS

Fewer stimulation days (8.5 +/- 1.5 vs 9 +/- 1.1) were found in group 1 (recombinant gonadotropins). Group 2 (FSHr + Menotropins), had a greater total dose of gonadotropins (1930.2 +/- 346.2 vs 2000 +/- 418.8) and more retrieved oocytes (8.15 +/- 3.9 vs 8.57 +/- 4). Group 1 patients had higher pregnancy and fertilization rates (56.2 vs 36.8%, and 75.4 vs 69.3%) respectively, no statistical significance was found.

CONCLUSION

This study found higher pregnancy and fertilization rates in patients treated with recombinant gonadotropins (FSH + LH) for ovarian stimulation.

Effect of addition of FSH, LH and proteasome inhibitor MG132 to in vitro maturation medium on the developmental competence of yak (Bos grunniens) oocytes

BACKGROUND

The competence for embryonic development after IVF is low in the yak, therefore, we investigated the effects of supplementation of FSH, LH and the proteasome inhibitor MG132 in IVM media on yak oocyte competence for development after IVF.

METHODS

In Experiment 1, yak cumulus-oocyte complexes (COCs) were in vitro matured (IVM) in TCM-199 with 20% fetal calf serum (FCS), 1 microg/mL estradiol-17beta, and different combinations of LH (50 or 100 IU/mL) and FSH (0, 1, 5, 10 microg/mL) at 38.6 degrees C, 5% CO2 in air for 24 h. Matured oocytes were exposed to frozen-thawed, heparin-capacitated yak sperm. Presumptive zygotes were cultured in SOF medium containing 6 mg/ml BSA, 0.5 mg/mL myoinositol, 3% (v/v) essential amino acids, 1% nonessential amino acids and 100 μg/mL L-glutamine (48 h, 38.5 degrees C, 5% CO2, 5% O2, and 90% N2). In Experiment 2, cumulus cells were collected at the end of IVM to determine FSHR and LHR mRNA expression by real-time PCR. In Experiment 3 and 4, COCs were cultured in the presence or absence of the proteasomal inhibitor MG132 from either 0-6 h or 18-24 h after initiation of maturation.

RESULTS

The optimum concentration of FSH and LH in IVM media was 5 microg/mL FSH and 50 IU/mL LH which resulted in the greatest cleavage (79.1%) and blastocyst rates (16.1%). Both FSHR and LHR mRNA were detected in yak cumulus cells after IVM. Treatment with MG132 early in maturation reduced (P<0.05) cleavage and blastocyst rates. Conversely, treatment with MG132 late in maturation improved (P<0.05) blastocyst rate. Optimal results with MG132 were achieved at a concentration of 10 microM.

CONCLUSIONS

An optimum concentration of FSH and LH in IVM medium, and treatment with MG132 late in maturation can improve yak oocytes competence for development after IVF.

Recombinant human follicle-stimulating hormone (r-hFSH) plus recombinant luteinizing hormone versus r-hFSH alone for ovarian stimulation during assisted reproductive technology: systematic review and meta-analysis

BACKGROUND

The potential benefit of adding recombinant human luteinizing hormone (r-hLH) to recombinant human follicle-stimulating hormone (r-hFSH) during ovarian stimulation is a subject of debate, although there is evidence that it may benefit certain subpopulations, e.g. poor responders.

METHODS

A systematic review and a meta-analysis were performed. Three databases (MEDLINE, Embase and CENTRAL) were searched (from 1990 to 2011). Prospective, parallel-, comparative-group randomized controlled trials (RCTs) in women aged 18-45 years undergoing in vitro fertilization, intracytoplasmic sperm injection or both, treated with gonadotrophin-releasing hormone analogues and r-hFSH plus r-hLH or r-hFSH alone were included. The co-primary endpoints were number of oocytes retrieved and clinical pregnancy rate. Analyses were conducted for the overall population and for prospectively identified patient subgroups, including patients with poor ovarian response (POR).

RESULTS

In total, 40 RCTs (6443 patients) were included in the analysis. Data on the number of oocytes retrieved were reported in 41 studies and imputed in two studies. Therefore, data were available from 43 studies (r-hFSH plus r-hLH, n=3113; r-hFSH, n=3228) in the intention-to-treat (ITT) population (all randomly allocated patients, including imputed data). Overall, no significant difference in the number of oocytes retrieved was found between the r-hFSH plus r-hLH and r-hFSH groups (weighted mean difference -0.03; 95% confidence interval [CI] -0.41 to 0.34). However, in poor responders, significantly more oocytes were retrieved with r-hFSH plus r-hLH versus r-hFSH alone (n=1077; weighted mean difference +0.75 oocytes; 95% CI 0.14-1.36). Significantly higher clinical pregnancy rates were observed with r-hFSH plus r-hLH versus r-hFSH alone in the overall population analysed in this review (risk ratio [RR] 1.09; 95% CI 1.01-1.18) and in poor responders (n=1179; RR 1.30; 95% CI 1.01-1.67; ITT population); the observed difference was more pronounced in poor responders.

CONCLUSIONS

These data suggest that there is a relative increase in the clinical pregnancy rates of 9% in the overall population and 30% in poor responders. In conclusion, this meta-analysis suggests that the addition of r-hLH to r-hFSH may be beneficial for women with POR.

Endocrine profile following stimulation with recombinant follicle stimulating hormone and luteinizing hormone versus highly purified human menopausal gonadotropin

BACKGROUND

Luteinizing hormone (LH) activity in human menopausal gonadotropin (hMG) preparations is derived from human chorionic gonadotropin (hCG) rather than LH. Therefore, we aimed to determine whether there are similarities in the endocrine and follicular profiles of serum and follicular fluid from controlled ovarian stimulation with the recombinant gonadotropins follicle-stimulating hormone plus luteinizing hormone (rFSH + rLH) or highly purified human menopausal gonadotropin (HP-hMG).

METHODS

We performed a prospective observational study with 50 oocyte donors that received either a combination of recombinant gonadotropins (rFSH + rLH) or a mixture of urinary gonadotropins (HP-hMG) plus purified urinary FSH (uFSH). Results were analyzed using Student's t-test to compare continuous variables and the chi-squared test to compare proportions. P-values < 0.05 were considered statistically significant.

RESULTS

Although more oocytes were retrieved after treatment with recombinant than urinary gonadotropins (16.5 vs. 11.8; P = 0.049), a higher proportion of metaphase II ova (71.2% vs. 80.6%; P = 0.003) were obtained using urinary gonadotropins. On day 6 and on the day of triggering, serum steroid hormone levels were slightly but not significantly elevated in the recombinant group compared with the urinary group. In follicular fluid, no statistical differences were observed for intra-follicular levels of steroid hormones between the two protocols; ongoing pregnancy rates were similar (46.1% vs. 46.1%).

CONCLUSIONS

Our data suggest that endocrinological and follicular profiles do not differ between rFSH + rLH and HP-hMG stimulation.

[Effect of administration of recombinant LH on the 5th day versus the 8th day in ovarian stimulation cycles]

BACKGROUND

Ovarian stimulation is a key component in assisted reproduction techniques. Supraphysiologic levels secondary to hormonal stimulation with high doses of exogenous hormones affect endometrial receptivity, the function of the corpus luteum, ovulation and embryo quality. The use of stimulation protocols called "minimal stimulation" may have a beneficial effect in achieving pregnancy.

OBJECTIVES

To evaluate the clinical efficacy (pregnancy rate) of rLH treatment on Day 5 (minimum group "A") vs. Day 8 (minimum group "B") of the ovarian stimulation cycle.

MATERIAL AND METHODS

Cohort, retrospective, pilot study. Two groups of 22 patients each who received minimal stimulation "A" or "B" (control group) in the period from April to August 2010.

RESULTS

No statistically significant difference in the following variables: age, FSH, estradiol and basal follicles. The median of mature follicles at the shooting day, the minimum group "A" was 3 vs. 2 for low B, the number of oocytes at metaphase II: Minimum group "A" 37/65 (57%) vs. 24/38 (63 %) at minimal group "B". Patients with grade 1+ quality embryos were 7 in minimal group "A" vs. 6 in the minimal group "B". In the minimal group "A", the pregnancy rate per started cycle was 27.3% and 37.5% for transfer, in the minimal group "B", the pregnancy rate per started cycle was 22.7% and per patient transfer which underwent 25%.

CONCLUSIONS

Receiving the minimal stimulation protocol "A" has a 15% higher risk of becoming pregnant, compared with minimal group "B" based on pregnancy rate per transfer, for the sample size, the p value was 0.32.

Adding luteinizing hormone to follicle stimulating hormone from day 3-5 improves pregnancy outcome in normal but not poor responders using gonadotropin releasing hormone antagonists

PURPOSE

To determine if the addition of luteinizing hormone (LH) to follicle stimulating hormone (FSH) stimulation for controlled ovarian hyperstimulation (COH) protocols using gonadotropin releasing hormone (GnRH) antagonists improves pregnancy rates following in vitro fertilization-embryo transfer (IVF-ET).

MATERIALS AND METHODS

All IVF-ET cycles using a GnRH antagonist were evaluated according to whether FSH was used exclusively or if LH was added. The cycles were further stratified according to age (< or = 39 and 40-42 years) and according to good responders (> or = five oocytes retrieved) or poor responders (< or = four oocytes).

RESULTS

Combining all data, a significantly higher clinical and live delivered pregnancy rates were found in those adding LH (34.7% and 32.3%) vs those taking all FSH (33.4% and 25.8%). The only subgroup not showing this effect was the women aged 40-42 years with diminished oocyte reserve.

CONCLUSIONS

LH should be added not only to COH protocols using GnRH agonists but also those using GnRH antagonists.

Efficacy of different gonadotropin combinations to support ovulation induction in WHO type I anovulation infertility: clinical evidences of human recombinant FSH/human recombinant LH in a 2:1 ratio and highly purified human menopausal gonadotropin stimulation protocols

BACKGROUND

The World Helath Organization (WHO) Group I anovulation, or hypogonadotropic hypogonadism (HH), is characterized by reduced hypothalamic/pituitary activity which results in abnormally low serum FSH and LH levels and negligible estrogen activity.

AIM

To compare the efficacy of human recombinant FSH (r-hFSH) plus human recombinant LH (r-hLH) in a 2:1 ratio with highly purified human menopausal gonadotropin (hMG-HP) urinary extract, containing LH-like activity, in women with HH.

SUBJECTS AND METHODS

This two-arm randomized open-label study included 35 HH women (aged 25-36 yr) attending our Center. Eighteen patients received 150 IU hMG-HP (150 IU FSH + 150 IU LH-like activity) and seventeen received 150IU r-hFSH/75IU rhLH daily for a maximum of 16 days. Ovulation was induced by a single administration of hCG on the day after the last hMG-HP or r-hFSH/r-hLH.

RESULTS

The primary efficacy endpoint was ovulation induction as measured by follicle ≥17 mm, pre-ovulatory estradiol (E 2 ) ≥400 pmol/l and mid-luteal phase progesterone (P 4 ) ≥25 nmol/l. Secondary efficacy endpoints included E 2 levels/follicle at mid-cycle, number of follicles at mid-cycle and pregnancy rate (PR). Following a total of 70 cycles, 70% of r-hFSH/r-hLH treated patients met the primary endpoint vs 88% in hMG-HP group (p=0.11). However, PR in r-hFSH/r-hLH group was 55.6% compared to 23.3% in hMG-HP group (p=0.01).

CONCLUSIONS

The primary endpoint achievement did not correlate with PR. This study has shown the superiority of LH compared to hCG in supporting FSH-induced follicular development in HH women.

Dynamic testosterone responses to near-physiological LH pulses are determined by the time pattern of prior intravenous LH infusion

The long-lived glycoprotein hormone, human chorionic gonadotropin (hCG), downregulates testosterone (T) biosynthesis in vitro and in vivo in animals and humans. The degree to which short-lived pulses of pituitary luteinizing hormone (LH) do so, particularly at physiological concentrations, is not known. We test the hypothesis that continuous LH infusion compared with bolus injections of LH every 1 h or every 2 h overnight downregulates T secretory responses to a subsequent fixed template of three consecutive intravenous pulses of a physiological amount of recombinant human (rh) LH (triple stimulus). Nineteen healthy men ages 18-49 yr each underwent four separate randomly ordered overnight gonadotropin-releasing hormone-receptor antagonist treatments with superimposed intravenous infusions of saline or rhLH (1-h pulses, 2-h pulses, or continuously). Each 12-h infusion protocol was followed by the triple rhLH-pulse stimulus the next morning. During the triple stimulus, basal (nonpulsatile) as well as total (basal plus pulsatile) T secretion was higher after overnight 2- and 1-h rhLH pulses than after continuous rhLH or saline delivery. Approximate entropy, a probabilistic measure of feedforward-induced irregularity of T concentration time series, was higher after 1-h rhLH pulses than after continuous rhLH. Analytical estimation of pulsatile rhLH-T dose-response measures revealed higher T secretory sensitivity and greater rhLH potency (lower EC₅₀) after exposure to 1-h than 2-h rhLH pulses. Collectively, these data indicate that in vivo dynamics of LH-stimulated T secretion under standardized conditions in men depend on the prior time mode of LH delivery in the bloodstream.

Long-acting FSH versus daily FSH for women undergoing assisted reproduction

BACKGROUND

Assisted reproduction techniques (ART) such as in vitro fertilisation (IVF) and intracytoplasmic sperm injection (ICSI) can help subfertile couples to create a family. It is necessary to induce multiple follicles; this is achieved by follicle stimulating hormone (FSH) injections. Current treatment regimens prescribe daily injections of FSH (urinary FSH with or without luteinizing hormone (LH) injections or recombinant FSH (rFSH)).Recombinant DNA technologies have produced a new recombinant molecule which is a long-acting FSH, named corifollitropin alfa (Elonva) or FSH-CTP. A single dose of long-acting FSH is able to keep the circulating FSH level above the threshold necessary to support multi-follicular growth for an entire week. The optimal dose of long-acting FSH is still being determined. A single injection of long-acting FSH can replace seven daily FSH injections during the first week of controlled ovarian stimulation (COS) and can make assisted reproduction more patient friendly.

OBJECTIVES

To compare the effectiveness of long-acting FSH versus daily FSH in terms of pregnancy and safety outcomes in women undergoing IVF or ICSI treatment cycles.

SEARCH METHODS

We searched the following electronic databases, trial registers and websites: the Cochrane Central Register of Controlled Trials (CENTRAL), the Menstrual Disorders and Subfertility Group (MDSG) Specialised Register, MEDLINE, EMBASE, PsycINFO, CINAHL, electronic trial registers for ongoing and registered trials, citation indexes, conference abstracts in the ISI Web of Knowledge, LILACS, Clinical Study Results (for clinical trial results of marketed pharmaceuticals), PubMed and OpenSIGLE (10 October 2011). We also carried out handsearches.

SELECTION CRITERIA

All randomised controlled trials (RCTs) comparing long-acting FSH versus daily FSH in women who were part of a couple with subfertility and undertaking IVF or ICSI treatment cycles with a GnRH antagonist or agonist protocol were included.

DATA COLLECTION AND ANALYSIS

Data extraction and assessment of risk of bias was independently done by two review authors. Original trial authors were contacted in the case of missing data. We calculated Peto odds ratios for each outcome; our primary outcomes were live birth rate and ovarian hyperstimulation syndrome (OHSS) rate.

MAIN RESULTS

We included four RCTs with a total of 2335 participants. A comparison of long-acting FSH versus daily FSH did not show evidence of difference in effect on overall live birth rate (Peto OR 0.92; 95% CI 0.76 to 1.10, 4 RCTs, 2335 women) or OHSS (Peto OR 1.12; 95% CI 0.79 to 1.60, 4 RCTs, 2335 women). We compared subgroups by dose of long-acting FSH. There was evidence of reduced live birth rate in women who received lower doses (60 to 120 μg) of long-acting FSH compared to daily FSH (Peto OR 0.60; 95% CI 0.40 to 0.91, 3 RCTs, 645 women). There was no evidence of effect on live births in the medium dose subgroup (Peto OR 1.03; 95% CI 0.84 to 1.27) and no evidence of effect on clinical pregnancy rate, ongoing pregnancy rate, multiple pregnancy rate, miscarriage rate or ectopic pregnancy rate.

AUTHORS' CONCLUSIONS

The use of a medium dose of long-acting FSH is a safe treatment option and equally effective compared to daily FSH. Further research is needed to determine if long-acting FSH is safe and effective for use in hyper- or poor responders and in women with all causes of subfertility.

Recombinant human LH supplementation versus supplementation with urinary hCG-based LH activity during controlled ovarian stimulation in the long GnRH-agonist protocol: a matched case-control study

An observational, matched, case-control study was carried out to compare the efficacy of recombinant human luteinizing hormone (r-hLH) supplementation with that of urinary human menopausal gonadotrophin (u-hMG)-based LH activity during controlled ovarian stimulation (COS) for assisted reproductive technology (ART) using a long gonadotrophin-releasing hormone (GnRH)-agonist protocol. A total of 4719 women, 1573 per group, matched by age, body mass index, indication and number of previous ART cycles, were treated with either recombinant human follicle-stimulating hormone (r-hFSH) and r-hLH in a fixed 2:1 ratio or u-hMG, either alone or in combination with r-hFSH, after down-regulation in a long GnRH-agonist protocol. Compared with the two u-hMG groups (u-hMG alone or in combination with r-hFSH, respectively), r-hFSH consumption was significantly lower (p < 0.001; p < 0.001), and pregnancy rates per cycle (p = 0.006; p = 0.022) and per embryo transfer (p = 0.025; p = 0.008), and implantation rate per embryo transferred (p < 0.001; p < 0.001) were significantly higher in the group treated with the fixed combination of r-hFSH and r-hLH. In COS protocols with r-hFSH, supplementation with r-hLH appears to be more effective than supplementation with u-hMG using the long GnRH-agonist protocol for ART.

Older men exhibit reduced efficacy of and heightened potency downregulation by intravenous pulses of recombinant human LH: a study in 92 healthy men

Direct sampling of the human spermatic veins has disclosed concomitant LH and testosterone (T) pulses, suggesting pulsatile LH concentration-dependent stimulation of T secretion. However, studies to date have examined this hypothesis using only pharmacological stimulation with hCG. The present study tests the hypothesis that age is marked by decreased T secretory responses to repeated near-physiological iv pulses of recombinant human LH administered in a Clinical Translational Science Center. Participants included 92 healthy men aged 18-75 yr with BMI 18-34 kg/m(2). The contribution of endogenous LH pulses was minimized by combined injection of a selective GnRH receptor antagonist sc and successive pulses of biosynthetic LH iv. A new analytical dose response model was applied to estimate the properties of exogenous LH's drive of T secretion. Regression of LH-T dose response potency estimates on age showed that the efficacy of pulses of biosynthetic LH progressively decreased with age (P = 0.014, r = 0.26). Testis sensitivity to exogenous LH pulses also declined with age (P = 0.011, r = 0.27). Moreover, estimated Leydig cell downregulation by LH pulses rose significantly with age (P = 0.039, r = 0.22). These outcomes were selective, since the recovery potency of infused LH was not affected by age but was reduced by increasing BMI (P = 0.011, r = 0.27). Assuming stable bioactivity of infused recombinant human LH, these novel data indicate that factors associated with age and BMI attenuate LH efficacy and testis sensitivity and augment Leydig cell downregulation in healthy men.

Characterization of serum-free buffalo granulosa cell culture and analysis of genes involved in terminal differentiation from FSH- to LH-responsive phenotype

In the present study, buffalo granulosa cells were cultured under serum-free conditions and characterized to study the changes in gene expression associated with the transition of granulosa cells from estrogen- to progesterone-secreting phenotype. The cells were cultured in vitro under completely serum-free conditions for 8 d. Gene expression and hormone analysis showed that on day 4 granulosa cells exhibit FSH responsiveness with preovulatory phenotype having highest CYP19 gene expression and 17β-estradiol production, whereas a significant increase in transcript abundance of STAR, CYP11, and HSD3B genes accompanied with an increase in progesterone production was observed on day 8. Cells treated with LH on day 4 followed by gene expression analysis at 1, 2, 4, 6, 18, and 24 h showed significant increase in transcripts of LH-responsive genes. In conclusion, culture condition used in the present study showed that granulosa cells were FSH responsive and attained attributes of granulosa cells of dominant follicles at day 4 with highest CYP19 and LHR gene expression beyond which they acquired the ability to luteinize and thus were more LH responsive. In addition, after LH treatment, analysis of early LH-responsive genes (EGR2, RUNX1, and NR4A1) on day 4 showed that granulosa cells at this stage in culture exhibits phenotype similar to that of preovulatory follicles before LH surge in vivo and corresponds to the in vivo transition of well-orchestrated gene expression profile after LH surge. The characterized culture conditions represent a suitable in vitro model for analysis of genes involved in terminal differentiation of granulosa cells from FSH- to LH-responsive phenotype during folliculogenesis in buffalo.

Does supplementation with recombinant luteinizing hormone prevent ovarian hyperstimulation syndrome in down regulated patients undergoing recombinant follicle stimulating hormone multiple follicular stimulation for IVF/ET and reduces cancellation rate for high risk of hyperstimulation?

Aim of this study was to assess the efficacy of recombinant luteinizing hormone (rLH) supplementation in late follicular phase in multiple follicular stimulation with recombinant follicle stimulating hormone (rFSH) in Triptoreline down-regulated patients undergoing IVF, on preventing clinical OHSS and cycles cancellation for OHSS risk. Nine hundred ninety-nine patients aged ≤ 40 with basal FSH ≤ 12 mUI/Ml were down-regulated before starting rFSH stimulation for oocytes recovery. Patients were allocated in two groups: (A) (501 patients) treated with 150 IU of rFSH eventually adjusting rFSH dosage day 7 of stimulation until recombinant human chorionic gonadotropin (rhCG) administration, (B) (498 patients) treated with 150 IU of rFSH and 75 IU of rLH since day 7 of stimulation until rhCG administration and adjusting rFSH at the same day. E2 the day of rhCG was higher in group B (p < 0.0001); number of cycles cancelled in group A (42/8.3%) for risk of ovarian hyperstimulation syndrome (OHSS) was higher than group B (12/2.4%) (p < 0.000001). We observed an increase in pregnancies in group B compared with group A (16.8% vs 11.9%) (p < 0.05) and we observed also a larger number of clinical OHSS in group A than in group B (p < 0.05).

[The impact of exogenous luteinizing hormone on IVF/ICSI cycles parameters]

OBJECTIVE

To evaluate the effect of exogenous luteinizing hormone on IVF/ICSI success.

DESIGN

Retrospective clinical study.

SETTING

2nd Department of Gynaecology and Obstetrics, Medical Faculty and L. Pasteur University Hospital Kosice, Slovak Republic.

METHODS

Individual parameters and clinical pregnancy rate of 232 IVF/ICSI cycles were compared in dependence on stimulation protocol (pure rFSH vs. rFSH and 75 IU rLH from S7).

RESULTS

There was no statistically significant difference in IVF/ICSI success between individual groups and subgroups, but we demonstrated the increase in clinical pregnancy rate per ET in agonist cycles group with exogenous LH activity totally above 11% (27.6% vs. 38.6%), in patients under 35 years above 12% (30.4% vs. 42.6%) and in patients over 35 years above 14% (16.7% vs. 30.8%). In antagonist cycles group there was demonstrated the increase in clinical pregnancy rate only in women over 35 years - above 14% (13.3% vs. 30.8%).

CONCLUSIONS

Despite of negative statistical analyses, from the clinical point of view we can strongly recommend the LH addition during COH, especially in agonist cycles and in older women.

A 2:1 formulation of follitropin alfa and lutropin alfa in routine clinical practice: a large, multicentre, observational study

BACKGROUND

A 2:1 (150 IU:75 IU) follitropin alfa:lutropin alfa formulation has been developed. A 3-year post-marketing surveillance study is ongoing in Germany to explore the use of this formulation in routine clinical practice.

MATERIALS AND METHODS

An 11-month interim analysis of data from assisted reproductive technology (ART) cycles only is described.

RESULTS

Data were available from 857 patients undergoing 919 cycles of ART at 19 centres. Most patients (58.7%) were aged ≥ 35 years, and many (41.3%) were undergoing their first ART cycle. Main reasons cited by physicians for prescribing this formulation were poor response in a previous treatment cycle (n = 303) and low basal luteinizing hormone (LH) level (n = 107). Mean (standard deviation) duration of ovarian stimulation was 10.8 (2.6) days. In 90.7% of cycles, the 2:1 formulation was administered throughout the stimulation period. Most frequent LH daily dose was 75 IU. Embryo transfer was conducted in 741 cycles; clinical pregnancy rate per transfer was 27.5%. Three cases of ovarian hyperstimulation syndrome developed in three patients (3/741 [0.4%] cycles); one required hospitalization. No other major safety events were reported.

CONCLUSION

This interim analysis shows that use of the 2:1 formulation for ovarian stimulation during routine ART procedures is effective in achieving clinical pregnancies and is associated with a positive safety profile.

Luteinizing hormone add-back: is it needed in controlled ovarian stimulation, and if so, when?

OBJECTIVE

To present an evidence-based rationale for or against the use of supplemental luteinizing hormone (LH) versus follicle-stimulating hormone (FSH) alone in various controlled ovarian stimulation (COS) protocols and specific patient populations. Any evidence for or against an association between endogenous LH levels and the likelihood of pregnancy in in vitro fertilization (IVF) procedures will also be presented.

STUDY DESIGN

Literature review and critical analysis of evidence drawn from systematic reviews and metaanalyses published in the last 3 years and from data subsequently reported (through mid-2009) by well-controlled randomized trials. Evidence from observational and retrospective studies will be discussed if no higher-level evidence is available on a particular topic.

RESULTS

Low endogenous LH levels associated with long gonadotropin-releasing hormone (GnRH) agonist protocols do not appear to decrease the probability of a successful IVF outcome. Supplemental LH does not appear to be routinely indicated for patients undergoing COS in long GnRH agonist protocols, though the evidence seems to favor some form of LH add-back in certain well-defined subgroups treated with these protocols.

CONCLUSION

Current evidence suggests that exogenous LH does not confer any significant benefit in women undergoing treatment with GnRH antagonist regimens, but more data are needed to confirm this finding.

A novel method of luteal supplementation with recombinant luteinizing hormone when a gonadotropin-releasing hormone agonist is used instead of human chorionic gonadotropin for ovulation triggering: a randomized prospective proof of concept study

This pilot study investigates the role of luteal supplementation with recombinant LH in an attempt to reverse the poor reproductive outcome previously noticed after GnRH-agonist triggering of final oocyte maturation for IVF. Similar implantation rates were achieved with the novel recombinant LH luteal supplementation scheme compared with the standard luteal P protocol (25.0% vs. 26.7%, respectively). No cases of ovarian hyperstimulation syndrome (OHSS) were noticed in either group.

[Use of recombinant human luteinizing hormone for ovulation stimulation in in vitro fertilization-embryo transfer]

OBJECTIVE

To evaluate application of recombinant human luteinizing hormone (r-hLH) used in ovarian stimulation of assisted reproductive technique and impact on outcome of pregnancy.

METHODS

From Apr. to Jul. 2009, 123 patients with low LH level (< 1 U/L) at day 3 of menstruation and down-regulation of pituitary function undergoing in vitro fertilization-embryo transfer (IVF-ET) in Reproductive Medical Center, Provincial Hospital Affiliated to Shandong University were enrolled in this study, whom were classified into 66 cases treated by r-hLH in r-hLH group and 57 cases without r-hLH treatment in non-r-hLH group. In the mean time, 145 patients with normal level of serum LH (1 - 2 U/L) not given by r-hLH treatment and undergoing IVF-ET were matched as control group. Total amount of gonadotropin, estradiol levels and LH levels on the administration of human chorionic gonadotropin (hCG), number of oocytes retrieved, number of 2PN zygotes, rate of high quality embryos, the rates of implantation and clinical pregnancy were compared among these three groups.

RESULTS

The level of serum LH on the day of hCG administration were (1.59 ± 0.77) U/L in r-hLH group, (0.54 ± 0.25) U/L in non-r-hLH group and (2.39 ± 1.01) U/L in control group, which reached statistical difference between every two groups (P < 0.05). The rates of high quality embryo were 59.36% in r-hLH group, 57.79% in non-r-hLH group, which were significantly lower than 65.94% in control group, respectively (P < 0.05). The rates of 2PN were 67.62% in r-hLH group and 68.32% in control group, which were significantly higher than 62.84% in non-r-hLH group, respectively (P < 0.05). The rates of implantation of 29.77% in r-hLH group were significantly higher than 18.26% in non-r-hLH group (P < 0.05). The total amount of gonadotropin, estradiol level on the day of hCG administration, the number of oocytes retrieved, and clinical pregnancy rate were not significantly different among those three groups (P > 0.05).

CONCLUSION

The administration of recombinant human luteinizing hormone in patients who are profoundly suppressed after down-regulation with long protocol can get more quality embryos, the higher rates of 2PN and implantation.

Effects of female sex hormones on caffeine-induced epileptiform activity in rats

Research on female sex hormones has demonstrated that estrogen aggravates epileptogenesis. Theoretically, this means that the frequency of epileptic attacks should be decreased in epileptic women during menopause. However, although epilepsy attacks are reported to decrease in some women during menopause, they may not change in others. Increases in attack frequency have even been reported during menopause in some epileptic women. This study has investigated the effects of estrogen, progesterone, luteinizing hormone (LH) and follicle stimulating hormone (FSH) on caffeine-induced epileptiform activity in rats. Estrogen was found to increase epileptiform activity in a dose-dependent manner via its own receptors. In contrast, progesterone had no effect on epileptiform activity. FSH and LH suppressed epileptiform activity at low doses; however, at high doses they enhanced it. In conclusion, we suggest that the occurrence or aggravation of epilepsy, despite estrogen deficiency in the menopausal or post-menopausal period, is related to excessive accumulation of FSH and LH.

Discontinuation of rLH two days before hCG may increase the number of oocytes retrieved in IVF

BACKGROUND

Administration of recombinant luteinizing hormone (rLH) in controlled ovarian hyperstimulation may benefit a subpopulation of patients. However, late follicular phase administration of high doses of rLH may also reduce the size of the follicular cohort and promote monofollicular development.

METHODS

To determine if rLH in late follicular development had a negative impact on follicular growth and oocyte yield, IVF patients in our practice who received rFSH and rLH for the entire stimulation were retrospectively compared with those that had the rLH discontinued at least two days prior to hCG trigger.

RESULTS

The two groups had similar baseline characteristics before stimulation with respect to age, FSH level and antral follicle count. However, the group which had the rLH discontinued at least two days prior to their hCG shot, had a significantly higher number of oocytes retrieved, including a higher number of MII oocytes and number of 2PN embryos.

CONCLUSIONS

When using rLH for controlled ovarian hyperstimulation, administering it from the start of stimulation and stopping it in the late follicular phase, at least two days prior to hCG trigger, may increase oocyte and embryo yield.

Age-dependent role of steroids in the regulation of growth of the hen follicular wall

BACKGROUND

The ovaries are the primary targets of senescence effects in mammalian and avian species. In the present study, relationships between reproductive aging, sex steroids and the growth pattern of the pre-ovulatory follicle wall were investigated using young hens with long clutch (YLC), old hens with long clutch (OLC), old hens with short clutch (OSC), and old hens with interrupted long clutch (OILC).

METHODS

Experiment 1: Hens were sacrificed 1.5 and 14.5 h after ovulation. Experiment 2: YLC and OILC hens were sacrificed 3.5 h after treatments with LH and/or aminoglutethimide (AG), an inhibitor of steroid synthesis. Volumes of pre-ovulatory follicles (F1-F5) and plasma concentrations of ovarian steroids were determined. Experiment 3: Granulosa and theca cells from F3 follicles of OSC and/or YLC hens were exposed in vitro to estradiol-17beta (E2), testosterone (T) and LH and the proliferative activity of the cells was examined using CellTiter 96 Aqueous One Solution Assay.

RESULTS

In YLC and OLC groups, the total volume of F1-F5 follicles rose between 1.5 and 14.5 h after ovulation (P < 0.01), negatively correlating with the plasma level of E2 (P < 0.01). There was no growth of pre-ovulatory follicles in the middle of the ovulatory cycle in the OSC group, with a positive correlation being present between E2 and the follicular volume (P < 0.05). In young hens, AG caused a rise in the total follicular volume. This rise was associated with a fall in E2 (r = -0.54, P < 0.05). E2 enhanced proliferation of granulosa cells from YLC and OSC groups. The proliferative activity of granulosa and theca cells of YLC hens depended on the interaction between T and LH (P < 0.01).

CONCLUSIONS

These data indicate for the first time that the growth pattern of pre-ovulatory follicles during the ovulatory cycle changes in the course of reproductive aging. E2 seems to play a dual role in this adjustment; it stimulates the growth of the follicular wall in reproductive aged hens, whereas it may inhibit this process in young birds. T and LH are apparently involved in the growth regulation during the pre-ovulatory surge in young hens.

LH supplementation in down-regulated women undergoing assisted reproduction with baseline low serum LH levels

AIM

The aim of our study is to evaluate the effect of recombinant-human LH supplementation on ovarian response and pregnancy outcome, during ovarian stimulation, in down-regulated women with baseline low serum LH levels undergoing assisted reproductive technology.

STUDY DESIGN

A prospective randomized study performed with 80 women, with serum LH levels 50.5 IU/l on cycle Day 6 of stimulation. Group-A (40): 14-days after down-regulation with leuprorelin, ovarian stimulation was initiated only with r-FSH 225 IU. Group-B (40): at the same time stimulation was initiated with rFSH 225 IU associated with rLH 75 UI on cycle Day 6 of stimulation.

RESULTS

Serum-E2 levels on the hCG-day administration were significantly reduced in the Group-A. FF-VEGF levels were higher in Group-A. We did not find significant differences in the number of retrieved oocytes. The quality of oocytes proved to be higher and more significant from a statistical point of view in Group-B. The number of embryos obtained and transferred, the pregnancy rate lower in Group-A.

CONCLUSIONS

In our study, it was shown that LH supplementation seems to have a beneficial effect on the maturity and fertilizability of oocyte. Lower FF VEGF levels, found in Group B, could be an indication of a lower apoptosis rate in human cumulus cells after administration of LH. We can affirm that LH-supplementation is beneficial in patients who show asignificant serum LH suppression during the receptorial down-regulation

Outcomes after early or midfollicular phase LH supplementation in previous inadequate responders

Second cycle outcomes of 75 patients who had previous inadequate ovarian response with recombinant FSH (rFSH)-only ovarian stimulation during gonadotrophin-releasing hormone analogue (GnRHa) down-regulated cycles were evaluated retrospectively. In these second cycles, both rFSH and human menopausal gonadotrophin (HMG) in GnRHa long down-regulation were given to all patients, HMG initiated either on day 1 (group A, n=37) or day 5-6 of the ovarian stimulation (group B, n=38). Total HMG dose was higher (1198+/-514 IU versus 726+/-469 IU; P<0.001), cumulative rFSH consumption was lower (1823+/-804 IU versus 2863+/-1393 IU; P=0.001) and duration of stimulation was shorter (8.94+/-1.15 days versus 10.37+/-1.80 days; P<0.001) in group A than in group B. No significant differences were found regarding fertilization, implantation or pregnancy rates and embryo quality between the groups. Further analysis by supplementary HMG dose (75 IU versus 150 IU) revealed that total gonadotrophin and HMG consumption was lower in 75 IU-supplemented subgroups. Notably, pregnancy rate was higher in patients where 75 IU HMG was supplemented on day 5-6 of ovarian stimulation, which deserves further evaluation.

Effects of recombinant human LH and hCG on serum and urine LH and androgens in men

CONTEXT

The administration of gonadotrophins is prohibited in sport but the effect in men of recently available recombinant hCG and LH on serum and urine concentrations of gonadotrophins and androgens has not been systematically evaluated in the antidoping context.

OBJECTIVE

To determine the time-course of recombinant LH (rhLH) and hCG (rhCG) on blood and urine hormone profiles in men to develop effective tests to detect rhLH and rhCG doping.

DESIGN

Two randomized controlled studies with a 2 x 2 factorial design.

SETTING

Academic research centre.

PARTICIPANTS

Healthy male volunteers aged 18-45 years.

INTERVENTIONS

In the rhLH study, men were randomized into (i) either of two single doses of rhLH (75 IU or 225 IU), and (ii) suppression of endogenous LH and testosterone by nandrolone or no suppression. In the rhCG study, men were randomized into (i) either of two single doses of rhCG (250 or 750 microg), and (ii) suppression of endogenous LH and testosterone by nandrolone decanoate (ND) or no suppression. ND suppression comprised a single dose of 200 mg ND 3 days prior to, and in the rhCG study an additional dose 1 day after gonadotrophin injection.

MAIN OUTCOME MEASURES

Serum and urine hCG, LH, T, T : LH ratio, urine epitestosterone (E) and urine T : E ratio.

RESULTS

Neither rhLH dose produced a significant increase in serum or urine LH or T or in the T : E or T : LH ratios regardless of ND-induced suppression of endogenous LH and T. Nor did an even higher dose (750 IU) in three healthy men with unsuppressed gonadal axis. These findings were confirmed with two different commercial LH immunoassays together with adjustment for any influence of urine sediment and dilution. Both rhCG doses produced a steep, dose-proportional increase in serum and urine hCG with increases in serum and urine T and suppression of serum and urine LH, regardless of hCG dose. Serum but not urine T was lowered by ND suppression. The T : LH ratio showed a progressive increase unrelated to rhCG dose or ND suppression, whereas both rhCG and ND suppression minimally increased T : E ratio.

CONCLUSIONS

Both rhCG doses produce a striking increase in serum hCG and T with suppression of serum LH but, at single doses up to 750 IU, rhLH has no influence on serum or urine LH or T. Effective rhLH doping, which relies on a sustained increases in endogenous T, would require much higher and more frequent daily rhLH doses. Use of LH immunoassays optimized for serum to detect rhLH doping by urine LH measurement requires more standardization and validation and, at present, is unreliable. The T : LH ratio is, however, a useful screening test for hCG doping although its utility requires further evaluation.