Adjuvant growth hormone therapy in antagonist protocol in poor responders undergoing assisted reproductive technology

Arch Gynecol Obstet (2013) 287:1017 1021 DOI 10.1007/s00404-012-2655-1 REPRODUCTIVE MEDICINE Adjuvant growth hormone therapy in antagonist protocol in poor responders undergoing assisted reproductive technology Maryam Eftekhar Abbas Aflatoonian Farnaz Mohammadian Tahereh Eftekhar Received: 7 October 2011 / Accepted: 22 November 2012 / Published online: 4 December 2012 Ó Springer-Verlag Berlin Heidelberg 2012 Abstract Purpose The incidence of poor ovarian response in controlled ovarian stimulation (COH) has been reported in 9 24 % of IVF-ET cycles. Growth hormone augments the effect of gonadotropin on granulosa and theca cells, and plays an essential role in ovarian function, including follicular development, estrogen synthesis and oocyte maturation. The aim of this study was to assess IVF-ET cycle outcome after the addition of growth hormone in antagonist protocol in poor responders. Materials and methods Eighty-two poor responder patients selected for ART enrolled the study and were randomly divided into two groups. Group I (GH/HMG/ GnRHant group, n = 40) received growth hormone/gonadotropin/gnrh antagonist protocol and group II (HMG/ GnRHant group, n = 42) received gonadotropin/gnrh antagonist protocol. Results The number of retrieved oocytes was significantly higher in GH/ than HMG/ GnRHant group, 6.10 ± 2.90 vs. 4.80 ± 2.40 (p = 0.035) and the number of obtained embryos was also significantly M. Eftekhar A. Aflatoonian Research and Clinical Center for Infertility, Department of Obstetrics and Gynecology, Research and Clinical Center for Infertility, Shahid Sadoughi University of Medical Science, Yazd, Iran F. Mohammadian (&) Department of Obstetrics and Gynecology, Mousavi Hospital, Zanjan University of Medical Sciences, 4513956183 Zanjan, Iran e-mail: mohamadian@zums.ac.ir T. Eftekhar Tehran University of Medical Science, Tehran, Iran higher in GH/ than HMG/GnRHant group, 3.7 ± 2.89 as compared to 2.7 ± 1.29 (p = 0.018). There were no significant differences between groups regarding implantation, and chemical and clinical pregnancy rates. Conclusion Our study showed that co-treatment with growth hormone in antagonist protocol in patients with a history of poor response in previous IVF-ET cycles did not increase pregnancy rates. Keywords Assisted reproductive technology Poor responder Growth hormone Antagonist protocol Introduction The incidence of poor ovarian response in controlled ovarian stimulation (COH) has been reported in 9 24 % of in vitro fertilization and embryo transfer (IVF-ET) cycles [1, 2]. Poor ovarian response has been related to several factors, including advanced female age, high body mass index and history of ovarian and pelvic surgeries [3 6]. Although several strategies have been suggested for the treatment of poor responders in IVF-ET cycles, the improvement of pregnancy rate has been quite low [7 14]. One of these choices is adjuvant therapy with growth hormone (GH) [7, 15]. Growth hormone regulates the effect of follicle-stimulating hormone (FSH) on granulosa cells, by increasing the synthesis of insulin-like growth factor-i, augments the effect of gonadotropin on granulosa and theca cells, and plays an essential role in ovarian function, including follicular development, estrogen synthesis and oocyte maturation [7, 16]. Some studies demonstrated that growth hormone is associated with good quality embryo, and high concentration of growth hormone

1018 Arch Gynecol Obstet (2013) 287:1017 1021 in follicular fluid is related to good embryo morphology and increases embryo implantation [17, 18]. This study carried out to assess the effect of adjuvant growth hormone therapy in improving the ovarian response to controlled ovarian stimulation (COH) in women with a history of poor response in previous IVF-ET cycles. Materials and methods This randomized prospective study was done on 82 poor responders selected for assisted reproductive technology (ART) in Research and Clinical Center for Infertility, Yazd University of Medical Sciences between January 2009 and June 2011. The study was approved by ethics committee. Couples were counseled about the treatment protocols and a written informed consent was obtained from all couples. Women who had one or more previous failed IVF-ET cycles with three or fewer retrieved oocytes and with subsequent three or less obtained embryos using GnRH agonist long protocol, and/or E2 levels B 500 pg/ml on the day of human chorionic gonadotropin (hcg) injection enrolled the study. Exclusion criteria were BMI C 30 mg/m 2, FSH [ 15 IU/L, endocrine or metabolic disorders, such as diabetes, thyroid disorder, and polycystic ovary syndrome (PCOS), severe endometriosis and azospermia. There was no age limitation for selecting the subjects. Allocation of the patients into groups was done alongside by disclosing the sealed envelopes and the patients were divided into two groups: group I ( group, n = 40) received growth hormone/gonadotropin/ GnRH antagonist protocol and group II (HMG/GnRHant group, n = 42) received gonadotropin/gnrh antagonist protocol. Neither the patients nor the researcher were blinded to the treatment protocol. Patients in group I (GH/ ) received daily injection of 4 IU growth hormone (Eutropin, LG, Korea) from day 21 of previous cycle until the day of hcg injection. In both groups, ovarian stimulation was started from the second day of menstrual cycle with 300 IU of HMG (Merional, IBSA, Lugano, Switzerland). Ovarian response monitoring was performed using serial vaginal ultrasonography and measuring serum E2 levels; when dominant follicles reached to 14 mm in mean diameter, 0.25 mg/day of GnRH antagonist (Cetrotide; Sereno International S.A., Geneva, Switzerland) was started and was continued until the day of hcg injection in both groups. When at least two follicles with a mean diameter of 17 mm were observed, 10,000 IU hcg (Pregnyl, Organon, The Netherlands) was injected. Endometrial thickness and serum E2 levels were measured in the day of hcg injection. Oocyte retrieval was done 34 36 h after hcg injection using a 17-gauge needle under vaginal ultrasonography guidance, and conventional IVF or intra-cytoplasmic sperm injection (ICSI) was performed appropriately. Embryos were transferred using a labotect catheter (labotect, Gottingen, Germany) 48 72 h after oocytes retrieval. At most three embryos were transferred in each IVF-ET cycle and excess embryos were cryoprecipitated. Luteal phase support was started with progesterone in oil (progesterone, Aburaihan co, Tehran, Iran) 100 mg daily IM on the day of oocyte retrieval and was continued until the documentation of fetal heart activity by ultrasound in both groups. Fertilization of oocytes was defined with observation of at least one pronucleus or cleaved oocytes. Implantation was defined by the number of gestational sacs per 100 transferred embryos. Chemical pregnancy was defined as a serum beta hcg C 50 IU/L, 12 days after embryos transfer. Clinical pregnancy was identified as observation of fetal heart activity by trans-vaginal ultrasonography performed 5 weeks after positive beta hcg. Ongoing pregnancy was defined as pregnancy proceeding beyond the 12th gestational week. Abortion was defined as loss of pregnancy before 20 weeks of gestation. Cycle cancellation was identified when no embryo was transferred because of (1) failed oocyte retrieval (no obtained oocyte on the day of ovarian puncture), or (2) failed fertilization and/or cleavage (no obtained embryo after IVF/ICSI). Primary outcomes were chemical and clinical pregnancy rates and secondary outcomes were abortion and ongoing pregnancy rates. Statistical analysis Statistical analysis was performed by means of the statistical package for the social science version 15.0 for windows (SPSS Inc., Chicago, IL, USA). Differences between variables were analyzed using the Student s t test, Mann Whitney, and v 2 tests. p \ 0.05 was considered statistically significant. Results Eighty-two couples participated in this study and patients were divided into two groups: 40 couples were enrolled in GH/ (group I) and 42 patients in (group II). None of the patients lost to follow-up and 16 women in both groups did not transfer embryo due to cycle cancellation (Fig. 1). Demographic and infertility characteristics of patients are summarized in Table 1 regarding basal FSH, female age, BMI, duration of infertility and antral follicles count. The results of ovarian stimulation are shown in Table 2. The number of stimulation days, the doses of used gonadotropin, mean E2 levels on the day of hcg administration, endometrial thickness

Arch Gynecol Obstet (2013) 287:1017 1021 1019 and cycle cancellation were statistically similar in both groups. The number of retrieved oocytes was significantly higher in GH/ than HMG/GnRHant group, 6.1 ± 2.90 versus 4.8 ± 2.40 (p = 0.035) and the number of obtained embryos was also significantly higher in GH/ than, 3.7 ± 2.89 versus 2.7 ± 1.29 (p = 0.018). The reproductive outcomes are shown in Table 3. No statistically significant difference was observed in chemical and clinical pregnancy rates (15 and 12.5 % in GH/HMG/ GnRHant group vs. 14.3 and 11.2 % in HMG/GnRHant group, respectively). No case of ovarian hyperstimulation syndrome (OHSS), ectopic pregnancy or multiple pregnancies were reported. Discussion Our study demonstrated that co-treatment with growth hormone in GnRH antagonist protocol increased the number of retrieved oocytes and obtained embryos compared to standard GnRH antagonist protocol, however the chemical and clinical pregnancy rates were statistically similar in two groups. Experimental studies reported that growth hormone affects gametogenessis and steroid production via acting on the ovary. Growth hormone plays a significant role on growth hormone-binding activity peak during early phase of folliculogenesis, and enhances the growth of small follicles and prevents follicular atresia. In late follicular phase, growth hormone in combination with gonadotropins improves late folliculogenessis, luteinization and steroid production in the ovary [19 23]. Ovulation is a complex process and growth hormone plays a facilitating role in ovulation by increasing the sensitivity of the gonadotropins and decreasing the incidence of atresia in pre-ovulatory follicles [20, 24 26]. In a metaanalysis that were done by E.M. Kolibiankis and coworkers, they showed that the addition of growth hormone in poor responders undergoing COH with GnRH agonist and gonadotropins for ART, increases the clinical pregnancy and live birth rates [2]. In the Cochrane review, growth hormone co-treatment in previous poor responders produced better pregnancy rate comparing placebo and there was no significant difference among 4.8 or 12 IU of growth hormone in any outcome measured [27].In contrast to two previous studies, we did not conclude that growth hormone co-treatment significantly improved pregnancy rates, however the number of retrieved oocytes and obtained embryos were significantly higher in GH/HMG/ GnRHant group as compared to. Our results were in agreement with those of Tansu Kucuk et al. that concluded clinical pregnancy was not statistically higher in growth hormone co-treatment within a GnRH agonist long protocol in poor ovarian response compared to standard GnRH long protocol. They also showed that the number of retrieved oocytes was higher in growth hormone group. However, they added growth hormone at higher doses (12 IU/day) to GnRH agonist long protocol with 450 IU recombinant FSH and we added growth hormone with lower doses (4 IU/day) to GnRH antagonist protocol with 300 IU HMG [7]. A randomized controlled trial revealed that administration of GnRHa/HMG/GH (18 IU on alternative days) had Fig. 1 Consort statement flow diagram

1020 Arch Gynecol Obstet (2013) 287:1017 1021 Table 1 Basal characteristics of patients Age (years) 36 ± 4.6 36.2 ± 3.7 0.462 BMI (kg/m 2 ) 24.6 ± 2.5 25.2 ± 2.3 0.099 Duration of infertility (years) 7.90 ± 3.0 7.73 ± 2.5 0.794 Basal FSH (IUI/L) 9.1 ± 4.16 8.7 ± 4.39 0.794 No. of antral follicles 7.05 ± 2.88 6.38 ± 2.14 0.235 Table 2 Results of ovarian stimulation Stimulation days (days) 11.4 ± 1.30 11.4 ± 1.19 0.861 Total doses of gonadotropin (IU) 2246 ± 776 2182 ± 633 0.825 Endometrial thickness (mm) 8.47 ± 1.00 8.10 ± 0.87 0.158 E2 levels of hcg day (pg/ml) 995 ± 663 924 ± 640 0.628 Failed oocytes retrieval, n/n (%) 3/40 (7.5 %) 5/42 (11.9 %) 0.384 Failed fertilization, n/n (%) 4/40 (10 %) 4/42 (9.5 %) 0.616 Total cycle cancelation, n/n (%) 7/40 (17.5 %) 9/42 (21.4 %) 0.984 No. of MII oocytes 5.57 ± 3.24 4.29 ± 3.01 0.075 No. of retrieved oocytes 6.1 ± 2.90 4.8 ± 2.40 0.035 No. of two pronucleate 3.87 ± 2.28 3.02 ± 1.11 0.034 No. of obtained embryos 3.7 ± 2.89 2.7 ± 1.29 0.018 No. of transferred embryos 2.6 ± 0.90 2.3 ± 0.93 0.085 ICSI cycles (%) 61.70 % 69.50 % 0.459 IVF cycles (%) 38.30 % 30.50 % 0.457 Table 3 Reproductive outcomes Fertilization rate (%) 65 % 69 % 0.638 Implantation rate (%) 7.2 % 6.6 % 0.240 Chemical pregnancy rate/cycle, n/n (%) 6/40 (15 %) 6/42 (14.3 %) 1.000 Clinical pregnancy rate/cycle, n/n (%) 5/40 (12.5 %) 5/42 (11.2 %) 1.000 Chemical pregnancy rate/transfer, n/n (%) 6/33 (18.2 %) 6/33 (18.2 %) 1.000 Clinical pregnancy rate/transfer, n/n (%) 5/33 (16.2 %) 5/33 (15.2 %) 1.000 Abortion rate, n/n (%) 1/6 (16.7 %) 1/6 (16.7 %) 1.000 no advantage to GnRHa/HMG/placebo and no differences were found between two groups in the number of follicles [ 14 mm and serum estradiol concentration on the day of hcg injection, the number of retrieved oocytes and obtained embryos [28]. A study similar to ours demonstrated that adjuvant GH therapy significantly increased the number of retrieved oocytes and good quality embryos in poor responders [29]. In 2005, a study was done on 100 couples with female age [ 40 years and it showed a significant improvement in delivery and live birth rates by administration of exogenous GH during ovarian stimulation in ICSI program. They concluded that this effect appears to be mainly due to an improvement of oocyte development potential [30]. Our trial showed no significant increase in pregnancy rate by addition of GH to antagonist protocol in poor responders, although the number of oocytes and embryos was significantly higher in GH group. Decline in the number of oocytes and good quality embryos is known to be the important cause of assisted reproduction technology failure in poor responders [7]. Conclusion Our study showed that co-treatment with GH in antagonist protocol in patients with history of poor response in previous IVF-ET cycles did not increase pregnancy rate. So

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