LH and LH-like activity: The Advantage of Differentiation

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1 LH and LH-like activity: The Advantage of Differentiation Sochi Russian Association of Human Reproduction ISO 9001:2008 ISO Robert Fischer Fertility Center Hamburg

2 Outline LH mode of action Who will need LH What are the sources of LH LH and HCG are different Progesterone elevation in late follicular phase Fischer s Concept Conclusions

3 Many variables impact success rates in ART Patient characteristics Age,weight,smoking,life Type of infertility Psychological stre styless Laboratory Conditions Pharmaceutical grade culture media Control air/water quality Incubator conditions Sperm quality and art of preparation Embryo transfer procedure Quality Management System in clinical practice Type of stimulation regimen Type of gonadotrophin preparation

4 Natural menstrual cycle Speroff et al. 5th Edition

Advantages of utilizing recombinant technology Control of source material Purity and Specific Activity Consistency of active product Efficacy and Efficiency Safety The robust manufacturing process

5 Advantages of utilizing recombinant technology Control of source material Purity and Specific Activity Consistency of active product Efficacy and Efficiency Safety The robust manufacturing process ensures that r-hfsh is the gold standard in Reproductive Medicine offering consistency and purity Follitropin Alfa Filled-by-Mass ( FbM) offers more precise dosing, enabling better control of ovarian response

6 Role of LH in menstrual cycle Follicular phase Midcycle Luteal phase Promotes androgen secretion theca. Synergic action with FSH in producing estrogens Support dominance once FSH levels decrease Resumption of oocyte meiosis Maturation of COC Follicular rupture Granullosa luteinization Maintenance of corpus luteum and P4 secretion Endometrial receptivity and implantation Recruit a new pool of follicles (FSH)

Two cell two gonadotropin hypothesis Ken Ryan 1979 LH

to preovulatory follicle Expression of Receptors : FSH:

LH Receptors on both theca and granulosa Zeleznik et al

2mm 10mm FSH-LH independent FSH dependent LH dependent LH

7 Two cell two gonadotropin hypothesis Ken Ryan 1979 LH receptor is needed for the progression from antral follicle to preovulatory follicle Expression of Receptors : FSH: granulosa cells LH : theca cells Adashi 1996 Expression of LH Receptors on both theca and granulosa Zeleznik et al 1974 Primordial and primary Preantral Antral Preovulatory 2mm 10mm FSH-LH independent FSH dependent LH dependent LH is able to exert its action on both : granulosa and theca cells Hillier 1994

8 Jeppepesen et al.j Clin Endocrinol Metab Aug. 97(8)

9 LH-Receptor Gene Expression in Cumulus Cells Jeppepesen et al.j Clin Endocrinol Metab Aug. 97(8) E1524-E1531

10 LH LH-R Leading follicle FSH Theca interna 4 -A E 2 Paracrine network (EGF, IGF-1, Inhibin) GRANULOSA Aromatase activity Production and release of 4 -androgens LH levels IU/L LH levels (IU/L) Day

11 LH levels (IU/L) LH levels IU/L LH serum level (IU/L) LH LH-R Leading follicle Adaptation mechanisms FSH to abnormal LH exogenous (supra-physiological) FSH activity Theca interna Paracrine network (EGF, IGF-1, GRANULOSA Inhibin) Production and release of 4 -androgens 20,0 15,0 10,0 5,0 0,0 4 -A E 2 Enhancement of paracrine network (Inhibin and GFs) Aromatase activity Theca cells (all follicles) Granulosa cells Increase in sensitivity to LH activity: optimal androgen production with <1% LH receptors occupied (spare receptor hypothesis) GnRH-a Long protocol GnRH antagonist Spontaneous Compensation in the reduction of LH Stimulation Day day

compromised P4 synthesis aromatase cellular prolif Balasch and Fabreques 2002 Diminished steroid production 75IU

13 LH therapeutic window in follicular development Adapted from Hiller SG,1994 Over-exposure to LH LH ceiling 1,2-10 IU/ml LH threshold Under-exposure to LH High LH Follicular atresia Premature luteinizaion Oocyte development compromised P4 synthesis aromatase cellular prolif Balasch and Fabreques 2002 Diminished steroid production 75IU rlh is sufficient for promoting optimal follicular development The European Recombinant Human LH Study Group, JCEM 1998; 83:1507

14 To LH or not to LH?

15 Do patients need LH supplementation during COS? Who might benefit from LH treatment? LH supplementation is mandatory in the hypogonadotrophic hypogonadal patient (FSH and LH < 1.2 IU/l) For most women «FSH-only» stimulation is sufficient as their endogenous LH level, even after down-regulation, will support follicular development and steroidogenic activity. BUT There are Patients with LH deficiency during COS

16 LH supplementation in ART No benefit in unselected population (Kobilianakis et al. 2007) Benefit in profound LH suppression in GnRH agonist long protocol Potential benefit in initial poor response Potential benefit and better outcome in patients > 35 years old Controverted results Confusing evidences Lack of consensus Studies use different doses, starting day, duration, type of LH activity, LH assay Mochtar et al, 2007 Cochrane Database Syst Rev.18: 2

given LH supplementation in antagonist cycles in which their intra-cycle

17 Conclusion: This study, though relatively small, demonstrated significantly higher number of eggs and higher live birth rates in women given LH supplementation in antagonist cycles in which their intra-cycle LH levels were very low. Monitoring indicates this occurs in over half of antagonist cycles.

LH(n=310) FSH = FSH + LH(n=192) FSH = FSH + LH(n=426) FSH + LH > FSH (n=88) FSH + LH > FSH (n=38) FSH + LH = FSH(n=100) Fábregues et al, 2006 Matorras et al, 2009

18 Is there a benefit in advanced age? Increased IR in women > 35 years of age < 35 years old 35 years old GnRH agonist Long vs Marrs et al, 2004 Humaidan et al, 2004 NyboeAndersen et al, 2008 FSH = FSH + LH(n=310) FSH = FSH + LH(n=192) FSH = FSH + LH(n=426) FSH + LH > FSH (n=88) FSH + LH > FSH (n=38) FSH + LH = FSH(n=100) Fábregues et al, 2006 Matorras et al, 2009 FSH + LH = FSH(n=120) FSH + LH > FSH(n=131) Sauer et al, 2004 FSH = FSH + LH (n=49) Griesinger et al, 2005 FSH = FSH + LH(n=126) Short protocol Levi-Setti et al, 2006 FSH = FSH + LH(n=40) GnRH antag. Bosch et al, 2011 König et al, 2014 FSH =FSH + LH (n=333) FSH+LH > FSH (n=292) FSH+LH=FSH (n=253)

19 LH supplementation for women >35 years is beneficial Hill et al Fertil Steril 2012

20 Why is LH Supplementation benefitial in advanced age(>35)? Ovarian ageing : It is a question of androgens and the anti-apoptotic effect of LH She looks like 45 Feels like 35 But is 55

21 Ovarian Aging Androgens secretion Piltonen 2003 Functional LH receptors Vihko 1996 LH immunorreactivity Mitchell 1995, Marama 1984 Ovarian paracrine activity Hurwitz & Santoro 2004

22 Role of LH Increase in pre-antral and antral follicles recruitability (Vendola et al., 1998; 1999; Spinder et al., 1989) LH supplementation increases FSH receptor responsiveness (Weil et al., 1999) LH supplementation up-regulates growth factors Act synergistically with IGF1 LH supplementation reduces the apoptosis of cumulus and granulosa cells LH supplementation enhances the expression of antiapoptotic proteins Rimon et al., 2004; Ruvolo et al., 2007 Tilly JL et al., 1992; Peluso JJ et al., 2001,Grondahl et al., 2008; Ben Ami et al., 2009

23 Growth Factors and LH LH act synergistically with IGF1 Follicle growth (Vendola et al., 1999) FGF2 - one of the most prominent factors for angiogenesis, located in theca and granulosa cell Growth factors: amphiregulin (AR) and epiregulin (Ep) present in granulosa cells They are all Upregulated by LH (Rimon E et al., 2004; Robinson RS et al., 2007)

24 When to start LH? Day 1. or 6.?

25 Which improvement could be expected in poor responders? Ovarian effect better follicular recruitment higher number of oocytes - higher quality embryos? Implantation improved implantation rate

26 Live birth rate (%) ORIGINAL ARTICLE Infertility Association between the number of eggs and live birth in IVF treatment: an analysis of treatment cycles Sesh Kamal Sunkara1, Vivian Rittenberg1, Nick Raine-Fenning2, Siladitya Bhattacharya3, Javier Zamora4, and ArriCoomarasamy5,* 40 The number of eggs to maximize the LBR is ~15. LBR declined beyond 20 eggs Egg number Hum Reprod 2011;26: ( )

27 LH: androgen modulating agent LH is an androgen modulating agent causing raised intra ovarian androgen levels Androgens augment FSH receptors in the granulosa cells Androgens enhance FSH responsiveness of immature follicles and promote follicle selection and maturation Assumption: LH improves stimulation outcome in poor responders (Nielsen et al., Mol Hum Reprod 2011) (Weil et al., J Clin Endocrinol Metab 1999)

28 Lehert et al 2014 Meta-analysis of r- LH improving oocyte yield Poor responders treated with rlh produced a statistically significant increase of 0.75 oocytes/pt produced a relative increase of 30% in Clinical PR (sinificant) This difference is not seen in normal responders and all patients Sunkara et al., Hum Reprod. 2011

29 hcg supplementation for poor responders Berkkanoglu et al., Fertil Steril poor responders randomised to rhcg vs control No significant difference in clinical pregnancy (RD -5%; 95% CI: -20% to +10%)

LH Supplementation Follicular growth stagnation Hypo-responder 12-14 % of patients have a suboptimal response

31 LH Supplementation Follicular growth stagnation Hypo-responder % of patients have a suboptimal response to FSH only (Barrenatexea et al., 2000; de Placido et al., 2004; Ferraretti et al., 2004; Ruvolo et al., 2007)

32 Patients showing hypo-responsiveness to FSH A. increasig r-hfsh B. r-hlh & r-hfsh C. hmg & r-hfsh D. control N (patients) age (mean) E 2 d hcg (pg/ml) 1020 * N oocytes 8.2 * 11.1 * PR / ET 24.4%* 54.0% * 11.0% 41.0% implantation rate 14.1% 36.8% 7.4% 35.4% LBR / in. cycle 22% 40,7% 18% 37% LH level d * p< 0.05 Ferraretti et al 2004 Fertil Steril 82,

33 LH Supplementation Follicular growth stagnation Why is there a Suboptimal response to FSH only? FSH and LH work in synergy So probably there is a - Reduced bioactivity of endogenous LH - Polymorphism

Structure Function V-LHb Two amino acid changes in b-chain Additional sulphation in b-chain Increased in vitro bioactivity Decreased circulatory half-life Increased promoter activity Net effect?

34 Structure Function V-LHb Two amino acid changes in b-chain Additional sulphation in b-chain Increased in vitro bioactivity Decreased circulatory half-life Increased promoter activity Net effect? Associated with reduced bioactivity of LH Association with ovulatory disorders and infertility K. Pettersson and I. Huhtaniemi, 1998 Jiang et al., 1999; Ropelato et al., 1999) 3Y 3 Trp8Arg Ile15Thr additional sulphated sugar at asn-13

35 Worldwide occurrence of variant LH Percent V/V + V/WT Western India (Kota) Mexico (Mayan) Spain (Vasco) United States (Hispanic) Japan Jordan Thailand Italy Sweden (Göteborg) China The Netherlands United States (black) United Kingdom South Africa (black) Sweden (Stockholm) Poland Estonia Greenland Iceland Faroe Islands Finland Finland (Lapp) Australia/Aboriginals %

36 What are the potential sources of LH? For Real LH molecules Recombinant human LH (r-hlh) 75 IU,99% pure (r-hfsh+r-hlh) 150:75 IU, 99% pure For LH Activity (LH and/or hcg molecules) Human Chorionic Gonadotropin Recombinant 250 mcg = 6750 IU of hcg, 99% pure Urinary 10,000 IU - >50% impuritites Human Menop. Gonadotropin 75 IU FSH: 75 IU of LH activity, 95% hcg derived and >30% impurities

37 hphmg is spiked with u-hcg for LH activity Publications 1. van de Weijer et al. RBM Online 2003;7: ; 2. Wolfenson C. et al., RBM Online2005:4: Giudice et al. J Clin Res 2001;4: Basset et al.. RBM Online 2009 The presence of hcg in hmg is due to the artificial addition to compensate for the lost LH

hcg - α 92 aa - β 145 aa 8 Glycosylation

Molecule and Dose rlh 150 IU rhcg 250mcg

28 ± 3 Terminal Half-life (hrs) SC route

38 hcg - α 92 aa - β 145 aa 8 Glycosylation sites - 37 kda Trophoblastic embryonic cells LH - α 92 aa - β 121 aa 3 Glycosylation sites 28kDa Anterior Pituitary Gland hcg LH Molecule and Dose rlh 150 IU rhcg 250mcg Initial or Distribution Half-life (hrs) 1.0 ± ± 0.8 Terminal Half-life (hrs) IV route 11 ± 8 28 ± 3 Terminal Half-life (hrs) SC route Cotonnec, et al. FS 1998;69: Trinchard, et al. RBMonline 2002;4:

They attach to the same receptor (LHCG-R) Sharing the

the β subunit, LH and hcg bind to the same receptor:

, 1979) Constitutively expressed on theca cells

39 They attach to the same receptor (LHCG-R) Sharing the same α subunit and 81% of the aminoacid residues of the β subunit, LH and hcg bind to the same receptor: LH/hCG receptor (Kessler et al., 1979) Constitutively expressed on theca cells Expressed on granulosa cells at a follicle size of 8-12 mm Research Institute, Inc

They have functional differences at LHCG-R level: The LHCGR is able to differentiate the activity of LH and hcg LH induces more potent and faster ERK and AKT activation camp pathway: hcg

40 They have functional differences at LHCG-R level: The LHCGR is able to differentiate the activity of LH and hcg LH induces more potent and faster ERK and AKT activation camp pathway: hcg Biopotency 5x higher LH Action 6 x faster LH reduced action ins 12h Progesterone production is equivalent by both L. Casarini et al., ESHRE Stockholm 2011 P312, Universita degli Studi di Modena

41 Sereum HCG(IU/L) Serum hcg levels increase during hmg stimulation (16 IU/hCG=116 IU/L LH) hcg stronger affinity to receptor than LH and 3x time longer half life time: down regulation LH-R on granulosa & cumulus cells 10 1 HMG/ GnRHa intranasal HMG/ GnRHa sc 0.1 FSH/GnRHa intranasal FSH/ GnRHa sc 1 8 Stimulation day UO P Westergaard et al, 2001

42 Does it play a role whether HMG (hcg) or rlh? Gene Expression in Granulosa cells 30 IVF/ICSI patients randomized to rlh or HMG treatment At aspiration granulosa cells collected for gene expression analysis Results: 85 genes statistically significantly different in expression Expression levels of LH/hCG receptor gene and genes involved in biosynthesis of cholesterol and steroids were expressed at a lower level in HMG-treated granulosa cells Conclusion: Grønlund ML et al., Fert Ster 2008 Preparation used for COS significantly influences the developmental competence of the oocyte and the function of the corpus luteum

43 Gatta et al.,f&s 2013

Gene Expression- Are LH and hcg equvivalent?

ALDH8A1) Meiosis and follicular maturation (TRA : RXRB, TTR, ALDH8A1; IL11; AKT3)

AKT3) Ovarian stereodogenesis (TRA : RXRB, TTR, ALDH8A1) Embryo development &

44 Gene Expression- Are LH and hcg equvivalent? LH hcg LH hcg LHR and FSHR expression (Trafficking of retinoic acid : RXRB, TTR, ALDH8A1) Meiosis and follicular maturation (TRA : RXRB, TTR, ALDH8A1; IL11; AKT3) Follicular development (IL11; AKT3) Cellular growth (RXRB, TTR, ALDH8A1; IL11; AKT3) Ovarian stereodogenesis (TRA : RXRB, TTR, ALDH8A1) Embryo development & survival (AKT3) Inibition of aromatase (PPARS) Apoptosis enhancement (DNAsi) Società Italiana di Embriologia Riproduzione e Ricerca, 2011

6 80 patients randomized to rfsh/rlh vs rfsh/rhcg in a 1:1 ratio:

45 Number of oocytes and embryos Preliminary data from a study - LH versus hcg 11.1 ± ± patients randomized to rfsh/rlh vs rfsh/rhcg in a 1:1 ratio: oocytes and embryos 8.5 ± 3.8 * 7.3 ± 3.7 * 4.2 ± ± ± 1.7 ** *P<0.01 **** P= 0.09 * * * ** Humaidan (2011)

46 LH versus hcg activity Significant differences exist between LH and hcg at the: Molecular and functional level This will influence clinical outcomes

oocytes/embryos 2/3 of the patients in rfsh+rlh group have frozen

47 rh-fsh + rh-lh (2:1) vs ufsh + hcg (hmg) ( HP-hMG )in ART Fabregues 2013 (n=33 per group) Conclusions: rfsh+rlh(2:1) produced more oocytes/embryos 2/3 of the patients in rfsh+rlh group have frozen embryos to transfer if fresh transfer failed 1/3 of the patients in hmg have frozen embryos

48 matched case-controlled study women included per group matched by: age, BMI, indication, previous ART cycles ( German multicenter observational study & FCH) 3 groups: r-[fsh-lh] (2:1) u-hmg u-hmg & r-fsh Bühler, Fischer 2011, GynecolEndocrinol

Bühler & Fischer (Gynecol Endocrinol 2011) Mean number of 75 IU ampoules Mean duration of treatment (days) 60 40 20

49 Bühler & Fischer (Gynecol Endocrinol 2011) Mean number of 75 IU ampoules Mean duration of treatment (days) ,35 36,38 r-hfsh + r-hlh hmg 46,31 r-hfsh + hmg 11, , ,8 10,65 r-hfsh + r-hlh hmg 11,28 r-hfsh + hmg

50 Bühler & Fischer (Gynecol Endocrinol 2011) 9 8,5 8 Number of oocytes retrieved * 9 7,8 8,8 20% 15% 10% Implantation rate (%) 19% 13,90 % 13,80 % * * 7,5 5% 7 r-hfsh + r-hlh hmg r-hfsh + hmg 0% r-hfsh + r-hlh hmg r-hfsh + hmg

51 MERIT Study: Anderson et al 2006 Progesterone concentrations in the follicular phase Progesterone > 4 nmol / L on day of HCG HP-hMG rfsh P<4 P>4 P<4 P>4 Incidence (11%) (23%) Oocytes Implantation 24% 19% 23% 11%

52 The Studies.. MERIT, more hcg decrease P4 at triggering and increase pregnancy Nordic study, more LH increase P4 and high P4 at triggering does not affect PR MEGASET, more hcg does no decrease P4 Thuessen study, more hcg increase P4.IT IS CONFUSING!

53 How is follicular progesterone production regulated Localisation of CYP17 ( P45017a) Exclusively to the Interstitial cells, extrafollicular compartment of the Ovary Picture by R.Leao & S.Esteves

Circulating Progesterone in the follicular phase Progesterone can derive from granulosa cells and theca cells, but theca cells have a further metabolic step.

54 Circulating Progesterone in the follicular phase Progesterone can derive from granulosa cells and theca cells, but theca cells have a further metabolic step. The circulating progesterone in the follicular phase of COS cycles derives from a number of factors. It is NOT premature luteinization. The main contributors are: The numbers of follicles ( ) The FSH drive ( ) The ability of LH to increase the catabolism of P4 in the theca cells ( ) At risk: Consequence: women with a high ovarian reserve endometrial / embryo asynchrony

55 How is follicular progesterone production regulated during controlled ovarian stimulation?

FCH icos Fischer s Concept rfsh + rlh (2:1) (inject in the morning) Dose: (105-300mIU/ml) The 3 A s: Combination of AMH, AFC and Age Monitoring: Day: 1; (5)6; 9-10 Ultrasound E2,LH, P4 Flexible

57 FCH icos Fischer s Concept rfsh + rlh (2:1) (inject in the morning) Dose: ( mIU/ml) The 3 A s: Combination of AMH, AFC and Age Monitoring: Day: 1; (5)6; 9-10 Ultrasound E2,LH, P4 Flexible Antagonist :Daily 0,25mg (inject at 23:00) (Start when lead-foll.12-14mm), the last injection on ovulation-triggering day hours before ovulation triggering (~11:00 am) Ovulation Triggering: Triptorelin 0,2mg s.c. When at least 2-3 Follikels => 17 mm (not before S.9) Withholding Gnoadotrophins on triggering day (free interval of hours) Egg retrieval: 35 hours after triggering

58 (ilps) Luteal Phase Support HCG 1500 I.U. (i.m.) after egg retrieval (recovery room) ( I.U. if more than 18 foll.>12 mm) No HCG and freeze-all if =>30 foll. >12mm Conventional Lut.Support start 48 hours after egg retrieval: 17ß E2 ( natural) 4mg (2x2mg) vaginal Progesterone vaginal gel 8% daily in the morning E.T. Day 3 (2-5) Repeat HCG 5 days after egg retrieval 750 i.u. if less than 10 foll.>12mm i.u. if foll.>12mm No HCG if 14 follicles or more >12mm Continue conventional Lut.Support untill Weeks of Pregnancy

59 (F)Results June2011-March.2015(Patient n=757) Age <= TOTAL 36.8(25-45) Cycles E2(pg/ml) ( ) ( ) ( ) ( ) ( ) Oocytes 12,4 12,5 9,5 8,4 10,25 (1-46) M II 78,4% 79,5% 80,0% 82,4% 80,1% Fert. 63,3% 63,4% 65,6% 65,2% 64,7% PBGS 3(2,6%) 69(18,2%) 328 (44,6%) 194 (61,0%) 594 (38,3%) ET 102(87,2%) 349 (91,8%) 619( 84,2%) 243 (76,6%) 1313(84,7%) Embryos 1,91 1,89 1,75 1,66 1,78

60 (F)Results June 2011-March 2015(Patient n.=757) Age <= TOTAL ßHCG pos /ET 68,6% 63,6 % 47,3% 26,8% 52,3% ( 650) Bioch./+ßHCG 2,8% 2,2% 7,8% 9,2% 5,5% (36) CPR./ET 66,7% 62,2% 43,6% 18,6% 47,0% (614) Misc. /CPR 14,7% 17,1% 24,1% 39% 20,3% (132) Ong. Preg./ET 56,9% 51,6% 33,6% 14,8% 36,7% (482) I.R. 58,5% 49,0% 34,0% 18,1% 37,6% (880/2343) OHSS(early) 0% 0% 0% 0% 0% OHSS(Late)/cycle 0% ( 6) 1,58% ( 3) 0,4% (1)0,3% 0,6% (10) (Mild+Moderate) No Late-onset OHSS in the last 2 ½ years!

61 (F) Day 5 Embryo Transfer (130/1313= 10% of ETs) <= >= 40 Total 1 Blastocyst CPR 1/1 8/14 (57%) 15/28 (54%) 4/6 (67%) 28/49 (57,1%) 2 Blastocysts CPR 8/9 (89%) 21/32 (66%) 24/33 (73%) 3/7 (43%) 56/81 (69,1%) IR 77% (14/18) IR 39% (25/64) IR 53% (35/66) IR:29% (4/14) IR:48% (78/162)

62 WHOLE CLINIC RESULTS RLR F Total ( ) ( ) ( ) PATIENTS CYCLES AGE 34,6 36,8 36,1 (25-45) E2 pg/ml ( ) ( ) ( ) OOCYTES 8,73 10,25 10,15(1-46) M II 79,4% 80,1% 80,0% FERTIL. 68,3% 64,7% 67,3% PBGS 571 (35,4%) 594(38,3%) 1165 (36,8%) ET 1216 (75,5%) 1313 (84,7%) 2529 (80,1%) EMBRYOS 1,78 1,78 1,78

63 WHOLE CLINIC RESULT RLR F Total ( ) ( ) ( ) ßHCG pos.(/et) 560 (46,0 %) 650 (52,3%) 1210 (47,8%) Biochem. Preg /Pos.ßHCG 36 (5,5%) 31 (5,5% ) 67 (5,5%) CPR. (/ET) 529 (43,5%) 614 (47,0%) 1143 (45,2%) Miscar. /CPR 93 (17,6%) 132 (20,3%) 219 (19,2%) Ongoing Preg./ET 436 (35,9%) 482 (36,7%) 918 (36,3%) I.R. 31,5% 37,6% 36,6% (680/2159) (880/2343) 1647/4502 Early OHSS/Cycle 0 % 0% 0% Late OHSS /cycle 10 (0,6%) 10 (0,6%) 20 (0,6%) (All Mild+Moderate) /Due to learning curve

64 Type of Gonadotrophins used <= >= 40 Total F 6/11-3/ rfsh 0% 1,3% 0 0,3% 0,4% rfsh+rlh 2:1 88,5% 85,2% 80,0% 83,0% 82,5% hmg 11,5% 13,5% 20,0% 16,6% 17,1% RLR 1/13-3/ rfsh 46,8% 42,5% 35,3% 18,0% 35,8% rfsh+rlh 2:1 43,5% 45,3% 50,6% 67,1% 51,0% rfsh/ hmg 9,7% 12,2% 14,1% 14,9% 13,2%

65 Conclusions LH is different than hcg at molecular, functional and clinical levels LH is the natural molecule to support follicular phase Consensus on benefit in patient sub-populations: Hypogonadotropic hypogonadism Profound LH suppression in GnRH agonist long protocol Poor responders Older than 35 years Suboptimal response to FSH (V-LHß ) One should give r-lh during stimulation for these patients Start LH Supplementation on First day of COS

66 Thank you for your time Hamburg

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