Joelle Taieb, M.D.t Irving M. Spitz, M.D. Philippe Bouchard, M.D. II

Transcription

1 FERTILITY AND STERILITY Copyright 1991 The American Fertility Society Printed on acid-free paper in U.S.A. Prevention of premature luteinizing hormone and progesterone rise with a gonadotropin-releasing hormone antagonist, Nai-Giu, in controlled ovarian hyperstimulation* Rene Frydman, M.D.t:j: Cesar Cornel, M.D.t Dominique de Ziegler, M.D. t Joelle Taieb, M.D.t Irving M. Spitz, M.D. Philippe Bouchard, M.D. II Hopital Antoine Bectere, Clamart, Hopital Bicetre, Kremlin Bicetre, France, and Population Council, New York, New York Objective: To report a preliminary study on the efficacy of a gonadotropin-releasing hormone antagonist (Nal-Glu) for preventing premature luteining hormone (LH) and progesterone (P) rise in controlled ovarian hyperstimulation using clomiphene citrate (CC) and human menopausal gonadotropin (hmg). Design: Participants in the study formed two groups. Both groups received CC-hMG and Nal Glu. Group II differs from group I for receiving human chorionic gonadotropin (hcg) and blood samples for 1 days after the second Nal-Glu injection. Setting: Centre de Fecondation in Vitro, Hopital Antoine Beclere. Patients: Eleven women 25 to 34 years of age and having normal menstrual cycles using barrier method of contraception not attempting pregnancies participated in the study. Intervention: Daily blood samples, pelvic ultrasound, and CC-hMG/Nal-Glu/hCG administration. Main Outcome Measures: (1) Spontaneous LH surge and P rise, follicular growth, and plasma E 2 levels in cycles with CC-hMG/Nal-Glu administration and (2) luteal phase after hcg injection in subjects previously treated with CC-hMG/Nal-Glu. Results: Plasma E 2 level increased from 983 ± 8 pg/ml (mean ± SEM) on the day of the first Nal-Glu administration to 1,159 ± 12 and 1,61 ± 114 pg/ml (mean ± SEM) 24 and 48 hours later. In 1 women, LH and P remained low for at least 96 hours after the first Nal-Glu administration. In one subject, plasma LH was already elevated at the time of the first Nal-Glu injection. In women who received hcg, plasma E 2 and P reached a maximum of 1,258 ± 313 pg/ml and 5.3 ± 12.8 ng/ml (mean± SEM), respectively, on the 6th day of the luteal phase. Conclusion: Our results suggest that timely Nal-Glu injections can prevent LH and P rise for at least 96 hours, in spite of increasing levels of plasma E 2 Moreover, Nal-Glu had no adverse effect on the kinetic of E 2 rise, the follicular growth, or on the post-hcg hormonal profile. Fertil Steril 56:923, 1991 Controlled ovarian hyperstimulation has been largely adopted for in vitro fertilization (IVF) because of the improved efficiency resulting from re- - Received November 7, 199; revised and accepted June 24, * Presented in part at the 37th Annual Scientific Meeting, Society for Gynecologic Investigation, St. Louis, Missouri, March 21 to 24, 199. t Service de Gynecologie-Obstetrique et Laboratoire de Biochimie, Hopital Antoine Beclere. :j: Reprint requests: Rene Frydman, M.D., Hopital Antoine Beclere, Maternite, 157 rue de laporte de Trivaux, Clamart, France. trieving multiple oocytes at once. A common pitfall of controlled ovarian hyperstimulation using either a combination of clomiphene citrate (CC) and human menopausal gonadotropins (hmg) or hmg alone is the premature increases in plasma luteinizing hormone (LH) and progesterone (P) reported in up to 25% of the patients. 1 In the past few years, selective pituitary suppression using a long-acting The Population Council. II Service d'endocrinologie et des Maladies de la Reproduction Hopital Bicetre. Frydman et al. GnRH antagonists in IVF 923

2 gonadotropin-releasing hormone agonist (GnRH-a) has gained general favor for selected patients, 2 or for all IVF candidates 3 4 to prevent the unfavorable consequences of premature LH and P rise on IVF outcome. Pituitary desensitization with a GnRH -a increases, however, the need for hmg and augments the incidence of frank ovarian hyperstimulation. Recently, GnRH antagonists have become available for clinical use. 5 6 In a preliminary study, we have shown that administration of the GnRH antagonist (Ac-D2 NALl, 4C1D-Phe2,D3Pal3,Arg5,D Glu6 (AA), DAlalO) GnRH (Nal-Glu) during the follicular phase of the menstrual cycle resulted in delaying LH surge by 8 to 1 days but also interrupted the growth of the dominant ovarian follicle. 6 In the present study, we evaluated whether timely injections of this new antagonist analog of GnRH, Nal-Glu, deprived of the transitory stimulatory effect of GnRH -a, could be used to prevent LH and P rise when it is most worrisome, i.e., when plasma estradiol (E 2) exceeds LH triggering levels. This preliminary study also examined the effect of Nal Glu on the maturation of ovarian follicles induced by exogenous hmg. MATERIALS AND METHODS Eleven women 25 to 34 years of age were included in the study. All participants were normal cycling women using barrier method of contraception who volunteered for the study after being thoroughly informed and having signed appropriate consent forms. The study protocol had been reviewed and approved by the hospital ethic committee. All women received 1 mg of CC ( Clomid; Merrell Dow, Neuilly-Sur-Seine, France) daily orally from cycle days 2 to 6. In addition, 15 IU of hmg (Humegon; Organon, St-Denis, France) were administered intramuscularly on days 4, 6, and 8. Starting on cycle day 9, the daily dose of hmg was determined in a standard fashion according to E 2 levels and ultrasound findings. Blood samples were obtained daily starting on cycle day 9. When serum E 2 exceeded 6 pg/ml, Nal-Glu (5 mg) was administered subcutaneously on the same day (P.M.). A second Nal Glu injection was repeated 48 hours later. Starting on the morning after the first Nal-Glu injection, transvaginal pelvic US was performed daily, and blood samples were obtained twice a day. The administration of hmg was discontinued arbitrarily 48 hours after the second Nal-Glu injection. Six women continued daily blood sampling for 2 days after the discontinuation of hmg. The remaining 5 women received 5, IU of human chorionic go- nadotropin (hcg) (Gonadotrophine Chorionique "Endo"; Organon, St.-Denis, France) 48 hours after the second injection of Nal-Glu to study any possible impact of Nal-Glu on the luteal phase. In this latter group, blood samples were obtained 2, 4, 6, 8, and 1 days after hcg administration. Plasma E 2 and P were measured by radioimmunoassay as previously described. 1 Intra-assay and interassay coefficients ofvariation (CVs) were 4.8% and5.2%, respectively, for E 2 and 8.5% and 1.8% for P. Plasma LH was measured by an immunometric technique developed by Amersham Corporation (Amerline Laboratories, Paris, France). Results were expressed in miu/ml (First International Reference Preparation 68/4). Intra-assay and interassay CVs were 7% and 9.1 %, respectively. Results were expressed as means ± SEM. RESULTS At the time of the first Nal-Glu injection, plasma LH was low (2.8 ±.4 miu /ml) P was <.2 ng/ml in 1 of 11 women. Plasma E 2 was 983 ± 8 pg/ml. The first Nal-Glu injection scheduled when E 2 exceeded 6 pg/ml occurred between cycle days 1 and 14 (mean 11.2 ±.9). The first Nal-Glu injection scheduled when E 2 exceeded 6 pg/ml occurred between cycle days 1 and 14 (mean 11.2 ±.9). As seen in Figure 1, E 2 levels continued to rise after Nal-Glu administration to 1, and 1,61 ± 114 pg/ml (mean± SEM) 24 and 48 hours later. The mean number of hmg vials administered before Nal-Glu injection was 9.6 ± 1.7 (mean ± SEM). Plasma E 2, LH, and P observed for 96 hours after the first Nal-Glu injection are depicted in Figure 1. After the onset of Nal-Glu administration, the mean daily requirement for hmg was 18 IU (range of 15 to 3 IU). The mean number of follicles~ 15 mm of diameter on the 1st day of Nal-Glu injection was 2.3 ± 1.4 (mean diameter 17 ± 1.5 mm) and increased to 5. 7 ± 2.3 follicles (mean diameter 18 ± 2. mm) 4 days later. The E 2/follicular diameter ratio remained unaltered after Nal-Glu administration. In one subject, LH and P levels had already started to rise 12 hours before the first Nal-Glu administration when LH was 7.2 miu/ml and P was 1.1 ng/ml. In this woman, LH and P decreased after the first Nal-Glu administration and remained low for the next 72 hours. Ninety-six hours after the first Nal Glu injection, however, plasma LH and P started to reincrease in this subject and reached 3.9 miu /ml and 3.4 ng/ml, respectively. Plasma E 2 was 1,2 and 1,16 pg/ml 12 hours before and at the time of the first Nal-Glu injection, respectively. It decreased to 84 pg/ml 12 hours later and started to reincrease 924 Frydman et al. GnRH antagonists in IVF Fertility and Sterility

3 E2 pglml p ng/ml 1 5 E2 HH Nai-Oiu Nai-Oiu Nai-Giu Nai-Giu.l.l.1 1 I l l l o 24h 48h 72h 9Bh Firat dlly of Nai-Giu adminfatratlon (oyo day 11.2!.8) 2 1 LH mlj/ml Figure 1 Plasma levels of E 2 and LH (upper panel) and P (lower panel) during CC-hMG cycles in women whose plasma LH was low before Nal-Glu administration (n = 1). 24 hours after the first Nal-Glu administration and reached 1,61 and 2,164 pg/ml, respectively, 48 and 96 hours after. The hormonal profile observed in 5 women who received hcg (5, IU) 48 hours after the second Nal-Glu injection is shown on Figure 2. In these women, E 2 and P reached to a maximum level of 1,258 ± 313 pg/ml and 5.3 ± 12.8 ng/ml (mean ± SEM) on the 6th day after hcg administration. It decreased to 4 ± 11 pg/ml and 12.5 ± 4.5 ng/ml, respectively, on the loth day after hcg administration. Menstruation occurred 1 to 13 days after hcg (mean 11.8 days). In the women who did not receive hcg, 96 hours after the first Nal-Glu injection when hmg was discontinued, plasma E 2 was 2,254 ± 31 and 1,24 ± 345 pg/ml 24 and 48 hours later, respectively. In these women, LH started to rise immediately after discontinuation of hmg, i.e., 5 days after the first Nal-Glu injection and 3 days after the second, in whom it reached 5.3 miu/ml. On the same day, P levels increased to 2 ng/ml in 2 women. Menstruation occurred 6 to 18 days after the first Nal-Glu injection. its pituitary receptors. 7-1 Early GnRH antagonists resulted from substitutions in the GnRH molecule in positions 2, 3, and 6; more recently developed products are substituted in positions 1, 2, 3, 5, 6, and loy A single injection of the potent GnRH antagonist Nal-Glu produces an immediate dosedependent decrease of plasma LH (bioactive and immunoactive) and, to a lesser extent of plasma, follicle-stimulating hormone lasting 1 to 1 hours Gonadotropin-releasing hormone antagonists differ from GnRH -a in that their suppressive action on gonadotropin is immediate rather than occurring after the transitory stimulation seen with GnRH -a. 5 The recent availability of GnRH antagonists, having little histamine-releasing properties than earlier compounds, has opened new possible approaches for the use of GnRH antagonists as an adjunct to controlled ovarian hyperstimulation.11 Our results indicate that administration of Nal-Glu (5 mg} every 48 hours, starting when plasma E 2 exceeds 6 pg/ml in controlled ovarian hyperstimulation using CC and hmg, prevents premature elevation of LH and P for at least 4 days in spite of rapidly increasing plasma E 2 levels. This indicates that although Nal-Glu administration in the late follicular phase of the menstrual cycle resulted in the prompt demise of the maturing follicles, 6 multiple follicular growth induced by exogenous gonadotropins (hmg) is not disrupted by the antagonist administration. To be effective, however, GnRH antagonists should be administered before any increase in endogenous LH because Nal-Glu failed to prevent LH and P rise for the full 4 days of the study in the one woman in whom LH was slightly elevated 12 hours before the onset of Nal-Glu administration. Our results indicate that Nal-Glu should be administered early in the course of controlled ovarian E2 pg/ml 3 QE2 ~p p ng/ml DISCUSSION Antagonists of GnRH suppress gonadotropin secretion by competing with endogenous GnRH for VoL 56, No.5, November 1991 Figure 2 Luteal phase after hcg in cycles with CC-hMG stimulation and Nal-Glu administration (n = 5). Frydman et al. GnRH antagonists in IVF 925

4 hyperstimulation, i.e., before any LH rise to avoid premature LH and P rise. In the five subjects, who received hcg 4 days after the first Nal-Glu injection, the luteal phase length was similar to that seen in normal or hyperstimulated cycles. Moreover, in these five women, plasma P levels were not different from those observed in other controlled ovarian hyperstimulation cycles. Although GnRH antagonists have been used in conjuction with controlled ovarian hyperstimulation in primates, 14 previous study designs included a prolonged pituitary suppression very similar to that achieved with GnRH -a. Our protocol proposing timely injections of GnRH antagonist starting only when an LH surge is feared, i.e., when E2 levels increase, is however, original. The finding that timely administration of Nal Glu prevents premature LH and P rise without disrupting follicular growth is promising for a future role of GnRH antagonist in controlled ovarian hyperstimulation. One of the foreseen advantages of GnRH antagonists in controlled ovarian hyperstimulation is the possibility of using the lighter ovarian stimulation regimen, CC-hMG. In recent years, CC-hMG has been progressively abandoned because of its higher incidence of spontaneous LH and P rise. In support for the revival of interest for CC-hMG is the observation that GnRH agonisthmg regimens require more hmg14 and have more side effects than CC-hMG without providing an improvement of IVF results proportional to the spectacular increase in the number of oocytes retrieved. Indeed, when implantation rates per number of embryos transferred are compared, results of CC-hMG and GnRH agonist-hmg are fairly similar Finally, the possibility of using Nal-Glu in controlled ovarian hyperstimulation will have to be weighed against the more recent modalities for GnRH -a use in controlled ovarian hyperstimulation that have been recently proposed. Newly described GnRH-a administration for 3 or 7 days (ultrashort regimens) suppress LH surge and have overall good results.17-2 Long-acting GnRH antagonists recently have been developed that should also be evaluated in controlled ovarian hyperstimulation. 21 Therefore, the clinical value of using GnRH antagonist as an adjunct to controlled ovarian hyperstimulation should be weighted against new GnRH-a-hMG regimens (short and ultrashort). Gonadotropin-releasing hormone antagonists do not seem to be associated with any side effect other than a transient self-limited release of histamine at the injection site Newer GnRH antagonists seem to be de- void of histamine-releasing effects, but their longer half-life precludes their use in controlled ovarian hyperstimulation. Because of its short half-life, Nal Glu disappears from the system before fertilization, thereby protecting against the possibility of toxicity to the developing embryo. Nevertheless, significant toxicologic and teratogenic studies are needed before an extensive clinical use of Nal-Glu. The fact that GnRH antagonists block positive feedback of E2 on LH secretion suggests that endogenous GnRH is an obligatory intermediary step for this positive feedback of E2 that is not present solely at the pituitary level. In conclusion, Nal-Glu administration during late follicular phase of controlled ovarian hyperstimulation induced with CChMG prevents premature LH and P rise without interfering with E2 rise or with follicular growth. These preliminary results show a promising role for GnRH antagonists, such as Nal-Glu, in preventing premature LH and P rise and therefore lowering cancellation rates of controlled ovarian hyperstimulation induced with CC-hMG. REFERENCES 1. Eibschitz I, Belaisch-Allart JC, Frydman R: In vitro fertilization management and results in stimulated cycles with spontaneous luteinizing hormone discharge. 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