Lars G. Westergaard, M.D., D.M.Sc., Karin Erb, M.S., Steen B. Laursen, Ph.D., Sven Rex, M.D., and Per E. Rasmussen, M.D.

Transcription

1 FERTILITY AND STERILITY VOL. 76, NO. 3, SEPTEMBER 2001 Copyright 2001 American Society for Reproductive Medicine Published by Elsevier Science Inc. Printed on acid-free paper in U.S.A. Human menopausal gonadotropin versus recombinant follicle-stimulating hormone in normogonadotropic women down-regulated with a gonadotropin-releasing hormone agonist who were undergoing in vitro fertilization and intracytoplasmic sperm injection: a prospective randomized study Lars G. Westergaard, M.D., D.M.Sc., Karin Erb, M.S., Steen B. Laursen, Ph.D., Sven Rex, M.D., and Per E. Rasmussen, M.D. Fertility Clinic, Department of Obstetrics and Gynecology, Odense University Hospital, Odense, Denmark Objective: To evaluate clinical and endocrinological effects of intranasal (IN) vs. subcutaneous (SC) GnRH-a for pituitary down-regulation combined with hmg vs. rfsh. Design: Prospective, randomized study. Setting: University hospital, IVF unit. Patient(s): Three hundred seventy-nine normogonadotropic women eligible for IVF or ICSI. Intervention(s): Randomization to intranasal (IN) or SC GnRH-a and to hmg or rfsh. Main Outcome Measure(s): Oocytes retrieved, embryos developed, clinical pregnancy, and delivery rates. Serum hormone concentrations on stimulation days 1 (S1) and 8 (S8), and oocyte pick-up (OPU) day. Result(s): After randomization, four groups were formed: IN/hMG (n 100), IN/FSH (n 98), SC/hMG (n 89), and SC/FSH (n 92). Mean number of oocytes retrieved and of transferable and transferred embryos were similar in the four groups. Clinical pregnancy rate per started cycle was significantly higher in the IN/HMG group than in the SC/FSH group (P.05) and was intermediate in the two remaining groups. Se-LH on S8 in the two SC groups was significantly lower than in the two IN groups. Se-E2 on S8 in the SC/FSH group was significantly lower than in the other three groups. Conclusion(s): The clinical and endocrinological outcome in IVF and ICSI treated normogonadotropic women is significantly influenced by mode of down-regulation as well as gonadotropin formulation. (Fertil Steril 2001;76: by American Society for Reproductive Medicine.) Key Words: hmg, rfsh, GnRH-a down-regulation, midfollicular LH, IVF, ICSI, clinical outcome Received December 19, 2000; revised and accepted March 28, Supported in part by Ferring Pharmaceuticals A/S, Denmark. Reprint requests: Lars Westergaard, M.D., D.M.Sc., Fertility Clinic Trianglen, Lundevangsvej 12, DK-1900, Hellerup, Denmark (FAX: ; lw@trianglen.dk) /01/$20.00 PII S (01) Pituitary down-regulation with GnRH agonist (GnRH-a) followed by ovarian stimulation with exogenous gonadotropins has, for the last decade, been successfully used as standard hormonal treatment in women undergoing IVF in most clinics worldwide (1). During the same period, use of the classical urine-derived hmg preparations, which contain equal amounts of FSH and LH-like activity, has declined gradually, to be replaced by urinary FSH preparations (ufsh) with minimal LH activity and with recombinant human FSH (rfsh) preparations, which are completely devoid of any LHlike activity (2). Replacement of hmg with FSH in the standard long GnRH-a protocol results in more suppressed levels of circulating LH-like activity and in agreement with the two-gonadotropin, two-cell concept (3, 4) in a lower ovarian E 2 biosynthesis during ovarian stimulation (5, 6). During recent years, it has been much debated whether this suppression of LH levels during ovarian stimulation in normogonadotropic women is beneficial, harmless, or 543

2 even harmful in relation to the outcome of IVF (7, 8). These discrepancies probably reflect that the exact requirements of LH for normal follicular development and oocyte maturation are not known. However, the requirement of LH is likely to be low because 1% of follicular LH receptors need to be occupied to allow normal ovarian steroidogenesis (9). The good IVF results obtained with use of rfsh in GnRH-a down-regulated normogonadotropic women tend to support this notion and, thus, that there is no need for supplementation with exogenous LH (10). On the other hand, prospective, randomized trials comparing ufsh and hmg in the long GnRH-a protocol have shown that severe suppression of midfollicular LH levels in serum ( 1 IU/L) occurs in a substantial number of normogonadotropic women treated with FSH, resulting in significantly depressed levels of circulating E 2 as well as in a poorer outcome of IVF as compared with women treated with hmg (5, 6, 11). In a recent retrospective study, we showed that nearly half of 200 normogonadotropic women undergoing IVF and ICSI treatment in connection with long-protocol GnRH-a downregulation and rfsh experienced midfollicular levels of LH 0.5 IU/L and significantly lower se-e 2 than did the other half of the women with LH levels 0.5 IU/L (12). Despite similarity in gross ovarian response and similar rates of positive pregnancy tests in the two groups, the women with low midfollicular LH had a significantly higher risk of early pregnancy loss and consequently a significantly lower chance of delivering a child than did the women with midfollicular LH 0.5 IU/L. These findings indicate that detrimental effects of low LH may manifest themselves only after implantation (12). Taken together, there is evidence to suggest that there may be a subgroup of normogonadotropic women who, when treated with standard long-protocol GnRH-a downregulation, may benefit from supplementation with gonadotropin preparations containing LH activity, hmg, or recombinant LH during ovarian stimulation. Although there is a wealth of recent publications of prospective, randomized trials comparing the effects of ufsh and rfsh in IVF, no prospective, randomized trials comparing the effect of hmg and rfsh in GnRH-a down-regulated normogonadotropic women has to our knowledge as yet been published. The aim of the present prospective, randomized study was to compare the endocrinological and clinical outcome of IVF or ICSI in normogonadotropic women subjected to pituitary down-regulation with GnRH-a administered either intranasally (IN) or by SC injection, followed by ovarian stimulation with either hmg or rfsh. Thus, the study was designed to monitor both [1] the influence of endogenous LH by comparing two different modes of GnRH agonist administration with varying capacity to suppress pituitary gonadotropin secretion and [2] the influence of exogenous LH-like activity by comparing rfsh and hmg. The endocrinological outcome parameters were measurements of serum concentrations of E 2 and LH on stimulation days 1 and 8 and on the day of oocyte pickup. In addition, serum levels of hcg were also measured because 25% of the LH-like activity in hmg preparations derives from hcg (13) and because hcg binds to follicular LH receptors exerting LH-like biological effects, MATERIALS AND METHODS Patients During the period October 1998 to January 2000, a total of 379 women undergoing IVF or IVF and ICSI treatment at the fertility clinic of Odense University Hospital were recruited consecutively to participate in this study. Each woman was given oral and written information about the project before consenting to participate by signature. The ethics committee of the counties of Fyn and Vejle approved the project. The inclusion criteria were as follows: [1] female, age 40 years; [2] normal menstrual cycle ranging from 26 to 32 days; and [3] normal pretreatment basal serum concentrations of FSH and LH ( 12 IU/L) measured on cycle day 2. Exclusion criteria were infertility caused by endocrine abnormality, such as polycystic ovary syndrome. Study Design This prospective, randomized trial was designed to compare the separate and combined effects of two different GnRH-a regimens used for pituitary down-regulation and of two different gonadotropin formulations used for ovarian stimulation on the outcome of IVF or ICSI treatment in normogonadotropic women. Computer-generated random number tables were used to randomize the patients to the four treatment groups. Hormonal Treatment The hormonal treatment used in this study included the following elements. [1] Pituitary down-regulation with start in the midluteal phase was achieved with buserelin, allocating the patients to one of two different modes of administration. These were either SC injection (0.5 mg; Suprefact, Hoechst, Denmark) once daily or IN spray (0.6 mg per day; Suprecur, Hoechst, Copenhagen, Denmark) divided in four doses of 0.15 mg for a fixed period of 14 days. After the efficiency of pituitary desensitization was ascertained by vaginal ultrasound scanning and serum E 2 levels 200 pmol/l, doses of Suprefact and Suprecur were reduced (respectively, to 0.2 mg SC, once per day, and to 0.15 mg, t.i.d), and ovarian stimulation with gonadotropins started on the same day (stimulation day 1 S1). If down-regulation was not achieved during this 14-day period, the patient was excluded from the study. [2]. Independent of the method of down-regulation used (IN or SC), the patients were randomly allocated to ovarian stimulation with either intramuscular (IM) hmg (Menogon, Ferring, Denmark) or SC recombinant FSH (Gonal-F, Serono Nordic, Copenhagen, 544 Westergaard et al. hmg vs. rfsh in IVF Vol. 76, No. 3, September 2001

3 Denmark) in a fixed daily dose of 225 IU for 7 days. On stimulation day 8 (S8), ovarian response was monitored by vaginal ultrasound scanning, and if necessary, the daily dose of gonadotropins was individualized. When at least four follicles with diameter 17 mm were seen by ultrasound, an ovulatory dose of hcg (Profasi, 10,000 IU; Serono Nordic, Copenhagen, Denmark) was given by IM injection. Oocyte Retrieval, In Vitro Culture, and Preembryo Transfer Details have been described elsewhere (12). Briefly, oocytes were retrieved at 37 hours after hcg injection, inseminated 3 hours later by adding 150,000 or 500,000 spermatozoa to the culture medium, or subjected to ICSI. Fertilized eggs were cultured for 3 days. A maximum of two normally developed embryos were transferred to the uterine cavity on day 3 of culture using a Wallace embryo transfer catheter, and surplus transferable embryos were cryopreserved. Only embryos with between 6 and 12 even-sized blastomeres and 20% fragmentation on day 3 of culture were considered transferable. Embryos not meeting these criteria on day 3 were discarded. Luteal Phase Support For luteal support, each patient received micronized progesterone pills (Progestane; Organon, Skovlunde, Denmark; 100 mg, t.i.d.), administered intravaginally starting 2 days before pre-embryo transfer and continuing until the day of pregnancy test. Se-hCG levels above 50 IU/L on day 12 after embryo transfer defined a positive pregnancy test. Clinical pregnancy was verified by vaginal ultrasound scanning 3 weeks after a positive pregnancy test. Blood Sampling In all patients, blood was sampled as follows: [1] on the day down-regulation was confirmed and ovarian stimulation initiated (S1), before the first injection of gonadotropins was given; [2] on S8 before injection of that day s gonadotropins and about 18 hours after the previous day s injection; and [3] on the day of oocyte retrieval, in other words, 37 hours after injection of hcg and approximately 72 hours after the last injection of gonadotropins. The sera were frozen and stored at 80 C for later hormone analyses. Hormone Assays All frozen sera were thawed and analyzed in one run for measurement of LH, hcg, and E 2 using time-resolved immunofluorometric assays. Luteinizing hormone was measured using the B AutoDELFIA hlh kit (Wallac Oy, Turku, Finland), with a detection limit of 0.02 IU/L (14). The variation coefficients given by the manufacturer were as follows: intra-assay variation (%CV), 1.7% and interassay variation (%CV), 2.0%, giving a total variation (%CV) 2.7% when analyzing a serum containing 6.94 U/L (Wallac Oy). We previously investigated the detection limit and reliability of this assay and found the following using sera with varying concentrations of LH (mean concentration, %CV intra, %CV inter ): 0.16 IU/L, 2.2%, 2.3%; 0.13 IU/L, 1.7%, 2.2%; 0.08 IU/L, 6.9%, 11.1%; 0.01 IU/L, 12.4%, 22.2% (12). Human chorionic gonadotropin was measured using the B AutoDELFIA hcg kit (Wallac Oy) with a given detection of 0.5 U/L and intra-assay variation of 5.1% and interassay variation of 3.9%, giving a total variation of 6.4% on a serum sample containing 6.55 U/L. E 2 was measured using the B AutoDELFIA Estradiol kit (Wallac Oy) with a given detection limit 0.05 nmol/l (13.6 pg/ml). The total variation using this kit is approximately 5%. Statistical Analysis Data were expressed as the mean SEM. Between-group differences of continuous variables were assessed with the Wilcoxon rank sum test. The 2 test with Yates correction was used to compare clinical outcome between groups. Results were considered significant at a 5% level (P.05). RESULTS In total, 379 normogonadotropic women treated with IVF or ICSI in 379 cycles were included in this prospective randomized study. For GnRH-a, down-regulation IN buserelin was used in 197 cycles and SC buserelin in 182 cycles. For ovarian stimulation, hmg (Menogon) was used in 189 cycles, and recombinant FSH (Gonal-F), in 190 cycles. Thus, four treatment groups were formed according to the combination of GnRH-a down-regulation regimen and gonadotropin formulation: the IN/hMG group (n 100), the IN/FSH group (n 98), the SC/hMG group (n 89), and the SC/FSH group (n 92). The four groups were comparable with regard to age, infertility diagnosis, body mass index, proportion of first IVF attempt and pretreatment, and basal levels of se-fsh and se-lh (data not shown). Table 1 shows similarity among the four treatment groups with regard to mean number of oocytes retrieved, embryos and transferable embryos developed, and mean number of transferred embryos. By contrast, the mean number of stimulation days and mean number of gonadotropin ampules used were correlated to down-regulation regimen but not to gonadotropin formulation, being significantly lower in the IN/hMG and IN/FSH groups than in the SC/hMG and SC/ FSH groups (P.05). The mean concentrations of E 2 and LH on stimulation days 1 and 8 and on the days of OPU and of hcg on stimulation day 8 in the four treatment groups are shown in Table 2. On stimulation day 1, in other words, after 14 days of down-regulation and before the first injection of gonadotropin, levels of LH were significantly higher in the IN/hMG and IN/FSH groups as compared with in the SC/hMG and FERTILITY & STERILITY 545

4 TABLE 1 Ovarian stimulation, oocyte retrieval, pre-embryo development, and transfer in the four treatment groups. Variable IN/hMG IN/FSH SC/hMG SC/FSH Started cycles, n Stimulation days b b b b Consumption of c c c c ampoules (75 IU) Cycles with OPU, n Oocytes retrieved Pre-embryos Transferable embryos a Cycles with ET, n Embryos transferred Note: Values are mean SEM. IN pituitary down-regulation with intranasal buserelin; SC pituitary down-regulation with SC buserelin; hmg ovarian stimulation with human menopausal gonadotropin; FSH ovarian stimulation with recombinant human FSH. a Transferable pre-embryos are those with between 6 and 12 even-sized blastomers and 20% fragmentation on day 3 of culture. b P.05. c P.002. SC/FSH groups, indicating a less profound pituitary downregulation by IN buserelin than with an equivalent daily dose of SC buserelin (P.05 and.005, respectively). On stimulation day 8, levels of E 2 in the SC/FSH group were significantly lower than those in the other three groups (P.05), levels of LH were significantly lower (P.001) than those in the IN/HMG and IN/FSH groups, and levels of hcg were only detectable in the in the IN/HMG and SC/ HMG groups, indicating that circulating LH mainly derives from endogenous sources, whereas circulating hcg mainly derives from exogenous hmg. Because hcg binds to thecal LH receptors and exert LH-like activity in the ovary, the total circulating LH-like activity can be expressed by simple addition of se-hcg and se-lh. A significant correlation between se-e 2 and se-lh hcg on stimulation day 8 was found in the IN/hMG, IN/FSH, and SC/hMG groups (P.01), and one close to significance (P.06) was found in the SC/FSH group (data not shown). On the day of OPU, se-e 2 levels in the four groups were not significantly different from one another (Table 2). The clinical outcome in the four treatment groups is shown in Table 3. The number of positive pregnancy tests TABLE 2 Serum hormone concentrations on stimulation day 1 and 8 and on the day of oocyte pick-up (OPU) in the four treatment groups. Study day IN/hMG (n 100) IN/FSH (n 98) SC/hMG (n 89) SC/FSH (n 92) Stim. day 1 Se-E 2 (pmol/l) Se-LH (IU/L) a b a,b a,b Stim. day 8 Se-E 2 (pmol/l) 4, c 3, c 3, c 2, c Se-LH (IU/L) d d d d Se-hCG (IU/L) ND ND OPU day Se-E 2 (pmol/l) 3, , , , Se-LH (IU/L) Note: Values are mean SEM. IN pituitary down-regulation with intranasal buserelin; SC pituitary down-regulation with SC buserelin; hmg ovarian stimulation with human menopausal gonadotropin; FSH ovarian stimulation with recombinant human FSH; ND not detectable. a P.05. b P.005. c P.05. d P Westergaard et al. hmg vs. rfsh in IVF Vol. 76, No. 3, September 2001

5 TABLE 3 Clinical outcome of IVF/ICSI related to GnRH-a down-regulation regimen as well as to gonadotropin formulation. Variable IN/hMG IN/FSH SC/hMG SC/FSH Total Started cycles, n Cycles with OPU, n Cycles with ET, n Positive se-hcg, n (%) a 50 (51) b 39 (39) 36 (40) 30 (33) b 155 (41) Clinical pregnancy, n (%) a 44 (44) c 38 (39) 31 (34) 27 (29) c 140 (37) Twin pregnancies, % Live births, n (%) a 39 (39) 28 (29) 28 (31) 25 (27) 120 (32) Implanted/transferred embryos, n (%) a 60/173 (35) 46/164 (28) 48/149 (32) 36/139 (26) 190/625 (30) Note: IN pituitary down-regulation; SC pituitary down-regulation with SC buserelin; hmg ovarian stimulation with human menopausal gonadotropin; FSH ovarian stimulation with recombinant human FSH. a (%) % of started cycles. b P.025 compared with other values marked with an asterisk. c P.05 compared with other values marked with a dagger. and clinical pregnancies per started cycle was significantly higher in the IN/hMG group than in the SC/FSH group (P.025 and.05, respectively). There was not a statistically significant difference between the four groups with regard to number of live births per started cycle and to implantation rate, although there was a clear trend toward better results in the IN/hMG group compared with in the other three groups. However, when only women undergoing first-attempt IVF and ICSI were considered, the number of positive pregnancy tests, the number of clinical pregnancies, the number of live births, and the implantation rate in the IN/hMG group were all significantly higher than those in the other three groups (Table 4). DISCUSSION This prospective, randomized study demonstrates that the clinical outcome of IVF and ICSI in normogonadotropic women subjected to ovarian stimulation in the long GnRH-a protocol is significantly correlated both to the regimen of pituitary desensitization (IN vs. SC administration) and to the type of gonadotropin used (hmg vs. rfsh). Moreover, our results also demonstrate that these correlations depend on midfollicular levels of circulating E 2 and LH activity. Thus, the most favorable clinical outcome was found in the group (IN/hMG) showing the highest midfollicular serum levels of LH activity and E 2, whereas the least favorable outcome was seen in the group (SC/FSH) with the lowest levels of these hormones. Intermediate clinical outcome and levels of midfollicular LH and E 2 was seen in the two remaining treatment groups (IN/FSH and SC/HMG). Indeed, when only first-attempt IVF and ICSI was considered, the number of live births per started cycle as well as implantation rate in the IN/hMG group was significantly higher compared with the other three groups. TABLE 4 Clinical outcome of first IVF/ICSI attempt only related to GnRH-a down-regulation regimen as well as to gonadotropin formulation. Variable IN/hMG IN/FSH SC/hMG IN/FSH Started cycles, n Cycles with ET, n Positive se-hcg, n (%) a 42 (56) b 26 (39) b 26 (39) b 20 (32) b Clinical pregnancies, n (%) a 40 (53) c 24 (36) c 23 (35) c 18 (29) c Live births, n (%) a 36 (48) d 20 (30) d 22 (33) d 17 (27) d Implanted/transferred embryos, n (%) a 57/135 (42) e 28/109 (26) e 34/116 (29) e 25/90 (28) e a (%) % of started cycles. P values: b d.05. e.05. FERTILITY & STERILITY 547

6 The mean number of oocytes retrieved was similar in all of the four treatment groups, suggesting that the number of developing ovarian follicles was similar throughout stimulation. Because all patients, irrespective of treatment group, had received exactly the same amount of exogenous FSH (225 IU/d for 7 days) on stimulation day 8, it is conceivable that the differences in se-e 2 levels reflect differences in circulating levels of LH and LH-like activity in agreement with the two-cell, two-gonadotropin concept of ovarian E 2 biosynthesis (3, 4). Supporting this notion was the finding of a significant correlation between midfollicular se-lh and se-e 2. The circulating LH activity during the follicular phase in GnRH-a down-regulated and gonadotropin-stimulated women results from pituitary secretion (endogenous LH) and from the gonadotropin preparation administered, such as hmg or recombinant LH. Because rfsh is completely devoid of any LH activity, the se-lh levels measured in the IN/FSH and SC/FSH groups express exclusively endogenous LH levels. The present results demonstrate that one daily SC injection of buserelin suppresses endogenous LH secretion more effectively than does a similar daily dose administered by nasal spray and suggest that a more pronounced suppression of LH and consequently of E 2 production may be associated with a poorer reproductive outcome (Table 3). In a recent retrospective study, we showed that midfollicular se-lh levels of 0.5 IU/L occurred in 49% of 200 IVF-treated normogonadotropic women subjected to the SC/ FSH protocol. Se-E 2 was significantly lower and the frequency of early pregnancy loss significantly higher in these women than in the women with higher midfollicular LH levels (12). The present results confirm that midfollicular se-lh levels of 0.5 IU/L occur in the same proportion (48%) of women in the SC/FSH group, whereas this proportion in the SC/hMG, IN/FSH, and IN/hMG groups was 28%, 17%, and 8%, respectively (data not shown). The frequency of early pregnancy loss in the SC/FSH group (15% of positive pregnancy tests), however, was not significantly different from that in the other three treatment groups; this may have been due to the relatively low number of patients in each group. Interestingly, as in the retrospective study mentioned earlier and as confirmed by the present results, the possible detrimental effects of low follicular phase LH and E 2 levels are not reflected in the other parameters commonly used in IVF to characterize the quality of the stimulation protocol, for instance number of retrieved oocytes and fertilization and embryo development rates (Table 1). Fleming et al. (15) reported that the proportion of supernumerary embryos developing to blastocysts is not significantly affected by severe midfollicular LH suppression. This finding does not necessarily contradict the above notion because Schoolcraft et al. (16), in normogonadotropic women subjected to standard long-protocol GnRH-a down-regulation and to ovarian stimulation with a combination of FSH and LH or with FSH alone, found a significantly higher implantation rate of transferred blastocysts in the former group despite similar percentage of blastocyst formation in the two groups. In addition, it is now well recognized that treatment of women with hypogonadotropic hypogonadism with purified, urinary FSH or with rfsh alone allows multiple follicular development and oocyte retrieval but produces inadequate E 2 production, and no term pregnancies have yet been observed (17, 18). Furthermore, it has been shown that adding gonadotropin preparations containing LH activity (hmg or recombinant LH) to the stimulation protocol restores E 2 production in women with hypogonadotrophic hypogonadism and improves the reproductive outcome (19 21). The mechanism behind the detrimental effect of low LH levels is uncertain. It may be speculated that an intrafollicular environment with reduced E 2 concentration is created in women with low follicular-phase LH levels. This estrogendepleted intrafollicular environment may be less than optimal for normal oocyte maturation during the follicular phase, which later on is expressed as a reduced ability to form a viable conceptus. Previously published clinical and experimental data give some credit to this assumption. Studies in women have shown that a low estrogen-to-androgen ratio in follicular fluid is negatively correlated to a successful outcome of IVF (22), that estrogen receptors are identifiable within the human oocyte (23), and that estrogens apparently exert their actions, mostly if not exclusively on the oocyte ooplasm and cellular membrane and not on the nuclear, meiotic maturation (24, 25). Actual studies on oocytes and embryos from women with low and normal LH concentrations are needed to evaluate whether the nuclear maturation is insufficient or whether the intrafollicular cytoplasmic maturation is suboptimal. Another untested possibility is that low follicular phase levels of LH and E 2 affect endometrial receptivity during the luteal phase. The LH and FSH contents of hmg are equal, but the half-life of LH is considerably shorter. Therefore, although exogenous FSH is still present 24 hours after the injection, LH has been completely eliminated by that time (26). Consequently, during hmg administration in women who are down-regulated with GnRH-a, circulating LH levels decline, whereas FSH accumulates in the circulation (26). The present results demonstrate the decline of se-lh levels in all of the four treatment groups throughout ovarian stimulation, confirming that administration of exogenous LH is not reflected in serum sampled hours after the last injection of hmg (Table 2). However, 25% of the LH-like activity in hmg preparations derives from hcg (13), and, having a considerably longer half-life than LH, it accumulates in the circulation during ovarian stimulation with hmg, as demonstrated in the present study (Table 3). Binding to ovarian follicular LH receptors, hcg exerts LH-like effects such as 548 Westergaard et al. hmg vs. rfsh in IVF Vol. 76, No. 3, September 2001

7 enhancement of ovarian steroidogenesis, which may explain why se-e 2 on stimulation day 8 is higher in the SC/hMG group than in the SC/FSH group despite equally low mean levels of LH in the two groups (0.9 IU/L and 0.8 IU/L, respectively, Table 3). Whether or not this effect of exogenous hcg contributes to the improved reproductive outcome in the SC/hMG group as compared with the SC/FSH group is presently unclear, but support previously reported beneficial effects of supplementation with low-dose exogenous hcg (50 IU/d) during ovarian stimulation with rfsh in women undergoing IUI (27). In conclusion, the present prospective, randomized study demonstrates that the clinical outcome of IVF and ICSI in normogonadotropic women subjected to the standard longprotocol GnRH-a down-regulation is significantly influenced by the levels of circulation LH activity and thereby by E 2 production during ovarian stimulation. Endogenous LH levels are dependent on the mode of administration of GnRH analogue, and use of SC buserelin may suppress endogenous LH too profoundly in women treated with rfsh, with negative effects on reproductive outcome. This negative effect may be compensated for by use of IN administration. The hcg component present in hmg preparations may, through its LH-like activity, contribute to improvement of the reproductive outcome in women who are profoundly down-regulated by standard GnRH-a suppression. References 1. Hughes EG, Fedorkow DM, Daya S, Sagle MA, Van de Koppel P, Collins JA. The routine use of gonadotropin-releasing hormone agonists prior to in vitro fertilization and gamete intrafallopian transfer: a meta-analysis of randomized controlled trials. Fertil Steril 1992;58: Chappel S, Kelton C, Nugent N. Expression of human gonadotropins by recombinant DNA methods. In: Genazzi AR, Petraglia F, eds. Proceedings of the 3rd World Congress on Gynecological Endocrinology. United Kingdom: Parthenon Publishing Group, 1992: Fevold HL. Synergism of follicle stimulating and luteinizing hormones in producing estrogen secretion. Endocrinology 1941;28: Short RV. Steroids in the follicular fluid and the corpus luteum of the mare. A two-cell type theory of ovarian steroid synthesis. J Endocrinology 1962;24: Fleming R, Chung CC, Yates RWS, Coutts JRT. Purified urinary follicle stimulating hormone induces different hormone profiles compared to menotrophins, dependent upon the route of administration and endogenous luteinizing hormone activity. Hum Reprod 1996;11: Westergaard LG, Erb K, Laursen SB, Rex S, Rasmussen PE. The effect of human menopausal gonadotrophin and highly purified, urine-derived follicle stimulating hormone on the outcome of in-vitro fertilization in down-regulated normogonadotrophic women. Hum Reprod 1996;11: Howles CM. Role of LH and FSH in ovarian function. Mol Cell Endocrinol 2000;161: Lévy DP, Navarro JM, Schattman GL, Davis OK, Rosenwaks Z. The role of LH in ovarian stimulation. Exogenous LH: let s design the future. Hum Reprod 2000;15: Chappel SC, Howles CM. Re-evaluation of the roles of luteinizing hormone and follicle stimulating hormone in the ovulatory process. Hum Reprod 1991;6: Out HJ, Mannaerts BMJL, Driessen SGJA, Coelingh Bennink HJT. A prospective, randomized, assessor-blind, multicentre study comparing recombinant and urinary follicle-stimulating hormone (Puregon versus Metrodin) in in-vitro fertilization. Hum Reprod 1995;10: Söderström-Antilla V, Foudila T, Hovatta O. A randomized comparative study of highly purified follicle stimulating hormone and human menopausal gonadotrophin for ovarian hyperstimulation in an oocyte donation program. Hum Reprod 1996;11: Westergaard LG, Laursen SB, Yding Andersen C. Increased risk of early pregnancy loss by profound suppression of luteinizing hormone during ovarian stimulation in normogonadotrophic women undergoing assisted reproduction. Hum Reprod 2000;15: Stokman PGW, Leeuw R, van den Wijngaard HA, Kloosterboer HJ, Vemer HM, Sanders AL. Human chorionic gonadotrophin in commercial menopausal gonadotropin. Fertil Steril 1993;60: Apter D, Cacciatore B, Alfthan H, Stenman U-H. Serum luteinizing hormone concentrations increase 100-fold in females from 7 years of age to adulthood, as measured by time-resolved immunofluorometric assay. J Clin Endocrinol Metab 1989;68: Fleming R, Lloyd FL, Herbert M, Fenwick J, Griffiths, Murdoch A. Effects of profound suppression of luteinizing hormone during ovarian stimulation on follicular activity, oocyte and embryo function in cycles stimulated with purified follicle stimulating hormone. Hum Reprod 1998;13: Schoolcraft WB, Gardner DK, Lane M, Schlenker T, Hamilton F, Meldrum DR. Blastocyst culture and transfer: analysis of results and parameters affecting outcome in two in vitro fertilization programs. Fertil Steril 1999;72: Schoot DC, Coelingh Bennink HJT, Mannerts BMJL, Lamberts SWJ, Bouchart P, Fauser BCJM. Human recombinant follicle stimulating hormone induces growth of preovulatory follicles without concomitant increase in androgen and oestrogen biosynthesis in a woman with isolated gonadotropin deficiency. J Clin Endocrinol Metab 1992;74: Balasch J, Miro F, Burzaco I, Casamitjama R, Scivico S, Ballesca JL, et al. The role of luteinizing hormone in human follicle development and oocyte fertility: evidence from in-vitro fertilization in a women with long-standing hypogonadotrophic hypogonadism and using recombinant human follicle stimulating hormone. Hum Reprod 1995;10: Shoham Z, Balen A, Patel A, Jacobs HS. Results of ovulation induction using human menopausal gonadotropins or purified follicle-stimulating hormone in hypogonadotrophic hypogonadism patients. Fertil Steril 1991;56: Kousta E, White DM, Piazzi A, Loumaye E, Franks S. Successful induction ovulation and completed pregnancy using recombinant human luteinizing hormone and follicle stimulating hormone in a woman with Kalmann s syndrome. Hum Reprod 1996;11: The European Recombinant Human LH Study Group. Recombinant human luteinizing hormone (LH) to support recombinant human follicles stimulating hormone (FSH)-induced follicular development in LHand FSH-deficient anovulatory women: a dose-finding study. J Clin Endocrinol Metab 1998;85: Yding Andersen C. Characteristics of human follicular fluid associated with successful conception after in vitro fertilization. J Clin Endocrinol Metab 1993;77: Wu TC, Wang L, Wan YJ. Detection of estrogen receptor messenger ribonucleic acid in human oocytes and cumulus-oocyte complexes using reverse transcriptase-polymerase chain reaction. Fertil Steril 1993;59: Yoshimura Y, Wallach EE. Studies on the mechanism(s) of mammalian ovulation. Fertil Steril 1987;47: Tesarik J, Mendoza C. Nongenomic effects of 17 beta-estradiol on maturing human oocytes: relationship to oocyte developmental potential. J Clin Endocrinol Metab 1995;80: Yen SS, Llerena O, Little B, Pearson OH. Disappearance rates of endogenous luteinizing hormone and chorionic gonadotrophin in man. J Clin Endocrinol Metab 1968;28: Filicori M, Cognigni GE, Taraborelli S, Spettoli D, Ciampaglia W, Tabarelli de Fatis C, et al. Luteinizing hormone activity supplementation enhances follicle-stimulating hormone efficacy and improves ovulation induction outcome. J Clin Endocrinol Metab 1999;84: FERTILITY & STERILITY 549