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Serum luteinizing hormone in patients undergoing ovarian stimulation with gonadotropin-releasing hormone antagonists and recombinant follicle-stimulating hormone and its relationship with cycle outcome

2005; Elsevier BV; Volume: 84; Issue: 5 Linguagem: Inglês

10.1016/j.fertnstert.2005.05.040

1556-5653

Ernesto Bosch, Ernesto Escudero, Juana Crespo, Carlos Simón, José Remohı́, António Pellicer,

Growth Hormone and Insulin-like Growth Factors

The serum LH was determined on days 3, 6, and 8 of stimulation and on the day of hCG in 110 normogonadotropic patients undergoing controlled ovarian hyperstimulation (COH) for IVF induced with GnRH antagonists and recombinant FSH, creating three groups of patients according to Tukey's hinges (percentiles 25 and 75) for each determination. No differences were observed between the number of oocytes recovered or the fertilization, implantation, and pregnancy rates (PR) of the groups, although patients with high serum LH levels during stimulation showed significantly higher serum E2 levels on the day of hCG. The serum LH was determined on days 3, 6, and 8 of stimulation and on the day of hCG in 110 normogonadotropic patients undergoing controlled ovarian hyperstimulation (COH) for IVF induced with GnRH antagonists and recombinant FSH, creating three groups of patients according to Tukey's hinges (percentiles 25 and 75) for each determination. No differences were observed between the number of oocytes recovered or the fertilization, implantation, and pregnancy rates (PR) of the groups, although patients with high serum LH levels during stimulation showed significantly higher serum E2 levels on the day of hCG. Basic research and clinical data show that LH is essential for normal follicular development and oocyte maturation in the natural menstrual cycle (1Hillier S.G. Gonadotropic control of ovarian follicular growth and development.Mol Cell Endocrinol. 2001; 179: 39-46Crossref PubMed Scopus (287) Google Scholar). Similarly, there is no doubt that exogenous LH supplementation is necessary for inducing ovulation in cases of hypogonadotropic hypogonadism (2Shoham Z. Balen A. Patel A. Jacobs H.S. Results of ovulation induction using human menopausal gonadotropin or purified follicle-stimulating hormone in hypogonadotropic hypogonadism patients.Fertil Steril. 1991; 56: 1048-1053Abstract Full Text PDF PubMed Scopus (162) Google Scholar, 3Shoham Z. Mannaerts B. Insler V. Coelingh-Bennink H. Induction of follicular growth using recombinant human follicle-stimulating hormone in two volunteer women with hypogonadotropic hypogonadism.Fertil Steril. 1993; 59: 738-742Abstract Full Text PDF PubMed Google Scholar, 4Schoot D.C. Harlin J. Shoham Z. Mannaerts B.M. Lahlou N. Bouchard P. et al.Recombinant human follicle-stimulating hormone and ovarian response in gonadotrophin-deficient women.Hum Reprod. 1994; 9: 1237-1242Crossref PubMed Scopus (135) Google Scholar, 5Balasch J. Miro F. Burzaco I. Casamitjana R. Civico S. Ballesca J.L. et al.The role of luteinizing hormone in human follicle development and oocyte fertility evidence from in-vitro fertilization in a woman with long-standing hypogonadotrophic hypogonadism and using recombinant human follicle stimulating hormone.Hum Reprod. 1995; 10: 1678-1683PubMed Google Scholar, 6The European Recombinant Human LH Study GroupRecombinant human luteinizing hormone (LH) to support recombinant human follicle-stimulating hormone (FSH)-induced follicular development in LH- and FSH-deficient anovulatory women a dose-finding study.J Clin Endocrinol Metab. 1998; 83: 1507-1514Crossref PubMed Scopus (247) Google Scholar). However, this area remains highly controversial with regard to controlled ovarian hyperstimulation (COH) in IVF, either in patients undergoing pituitary down-regulation with the classic GnRH agonist long protocol (7Loumaye E. Engrand P. Howles C.M. O'Dea L. Assessment of the role of serum luteinizing hormone and estradiol response to follicle-stimulating hormone on in vitro fertilization treatment outcome.Fertil Steril. 1997; 67: 889-899Abstract Full Text PDF PubMed Scopus (126) Google Scholar, 8Fleming R. Lloyd F. Herbert M. Fenwick J. Griffiths T. 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: 1778-1792Crossref PubMed Scopus (145) Google Scholar, 9Westergaard L.G. Laursen S.B. Andersen C.Y. 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: 1003-1008Crossref PubMed Scopus (259) Google Scholar, 10Esposito M.A. Barnhart K.T. Coutifaris C. Patrizio P. Role of periovulatory luteinizing hormone concentrations during assisted reproductive technology cycles stimulated exclusively with recombinant follicle-stimulating hormone.Fertil Steril. 2001; 75: 519-524Abstract Full Text Full Text PDF PubMed Scopus (84) Google Scholar, 11Humaidan P. Bungum L. Bungum M. Andersen C.Y. Ovarian response and pregnancy outcome related to mid-follicular LH levels in women undergoing assisted reproduction with GnRH agonist down-regulation and recombinant FSH stimulation.Hum Reprod. 2002; 7: 2016-2021Crossref Scopus (100) Google Scholar, 12Tesarik J. Mendoza C. Effects of exogenous LH administration during ovarian stimulation of pituitary down-regulated young oocyte donors on oocyte yield and developmental competence.Hum Reprod. 2002; 17: 3129-3137Crossref PubMed Scopus (85) Google Scholar, 13Balasch J. Vidal E. Peñarrubia J. Casamitjana R. Carmona F. Creus M. et al.Suppression of LH during ovarian stimulation analysing threshold values and effects on ovarian response and the outcome of assisted reproduction in down-regulated women stimulated with recombinant FSH.Hum Reprod. 2001; 16: 1636-1643Crossref PubMed Scopus (120) Google Scholar, 14Peñarrubia J. Fábregues F. Creus M. Manau D. Casamitjana R. Guimerá M. et al.LH serum levels during ovarian stimulation as predictors of ovarian response, and assisted reproduction outcome in down-regulated women stimulated with recombinant FSH.Hum Reprod. 2003; 18: 2689-2697Crossref PubMed Scopus (47) Google Scholar), or more recently, in patients after GnRH antagonist (GnRH-a) protocols (15Cédrin-Durnerin I. Grange-Dujardin D. Laffy A. Parneix I. Massin N. Galey J. et al.Recombinant human LH supplementation during GnRH antagonist administration in IVF/ICSI cycles a prospective randomized study.Hum Reprod. 2004; 19: 1979-1984Crossref PubMed Scopus (108) Google Scholar, 16Merivel P. Antoine J.M. Mathieu E. Millot F. Mandelbaum J. Uzan S. Luteinizing hormone concentrations after gonadotropin-releasing hormone antagonist administration do not influence pregnancy rates in in vitro fertilization-embryo transfer.Fertil Steril. 2004; 82: 119-125Abstract Full Text Full Text PDF PubMed Scopus (56) Google Scholar, 17Kolibianakis E.M. Zikopoulos K. Schiettecatte J. Smitz J. Tournaye H. Camus M. et al.Profound LH suppression after GnRH antagonist administration is associated with a significantly higher ongoing pregnancy rate in IVF.Hum Reprod. 2004; 19: 2490-2496Crossref PubMed Scopus (88) Google Scholar, 18Frydman R. Cornel C. de Ziegler D. Taieb J. Spitz I.M. Bouchard P. Prevention of premature luteinizing hormone and progesterone rise with a gonadotropin-releasing hormone antagonist, Nal-Glu, in controlled ovarian hyperstimulation.Fertil Steril. 1991; 56: 923-927Abstract Full Text PDF PubMed Google Scholar). The use of a GnRH-a together with an FSH-only preparation provides the ideal conditions for evaluating the influence of LH in the follicular phase, as an antagonist causes a pronounced LH suppression during ovarian stimulation (19Diedrich K. Diedrich C. Santos E. Zoll C. Al-Hasani S. Reissmann T. Suppression of the endogenous luteinizing hormone surge by the gonadotrophin-releasing hormone antagonist Cetrorelix during ovarian stimulation.Hum Reprod. 1994; 9: 788-791PubMed Google Scholar), which may affect follicular development, oocyte maturation and subsequent embryo cleavage, and IVF outcome in general. This issue has already been analyzed on stimulation day 8, after a single (16Merivel P. Antoine J.M. Mathieu E. Millot F. Mandelbaum J. Uzan S. Luteinizing hormone concentrations after gonadotropin-releasing hormone antagonist administration do not influence pregnancy rates in in vitro fertilization-embryo transfer.Fertil Steril. 2004; 82: 119-125Abstract Full Text Full Text PDF PubMed Scopus (56) Google Scholar) or multiple dose GnRH administration (17Kolibianakis E.M. Zikopoulos K. Schiettecatte J. Smitz J. Tournaye H. Camus M. et al.Profound LH suppression after GnRH antagonist administration is associated with a significantly higher ongoing pregnancy rate in IVF.Hum Reprod. 2004; 19: 2490-2496Crossref PubMed Scopus (88) Google Scholar). The purpose of this prospective cohort study was to identify patients with low, medium, and high serum LH levels at the early, mid, and late follicular phases of COH induced with an LH-free preparation with a multiple dose GnRH-a protocol, and relate each of these groups of patients with IVF outcome. One hundred ten patients aged between 18 and 35 years undergoing their first IVF treatment were enrolled. All of them had body mass index (BMI) between 18 and 29 kg/m2, regular menstrual cycles, no existence of polycystic ovaries, no presence of endometriosis or uterine abnormalities in the ultrasound, no previous adnexal surgery, and normal basal hormonal levels during the cycle before stimulation (cycle day 3: FSH <10 IU/L; LH <10 IU/L; E2 <60 pg/mL). Indications for IVF were sperm abnormalities (65.7%), history of failed IUI(18.1%), mixed infertility (9.7%), unexplained infertility (4.2%), and other (2.3%). Of those cycles undergoing oocyte pick-up, 59 (61.5%) were intracytoplasmic sperm injection (ICSI) procedures, whereas 37 (38.5%) were IVF. Recombinant FSH (Gonal F; Serono S.A., Madrid, Spain) and GnRH-a cetrorelix 0.25 mg (Cetrotide; Serono S.A.) were used for ovarian stimulation, with daily administration of 300 IU of recombinant FSH beginning on day 2 of the menstrual cycle and continuing for 2 days. On day 3 of stimulation, the serum E2 level was assessed and the FSH dose adjusted as follows: increasing to 450 IU/d if the serum E2 levels were less than 100 pg/mL; maintaining at 300 IU/d if the levels were between 100 and 200 pg/mL; decreasing to 150 IU/d if the level was higher than 200 pg/mL. From day 6 of stimulation onward, 0.25 mg of the GnRH-a was administered daily. Vaginal ultrasound and serum E2 determinations were performed every other day from stimulation day 6, and the FSH dose was adjusted to each individual response until ovulation was triggered using 6,500 IU of recombinant hCG (Ovitrelle; Serono S.A.) when three or more follicles reached 18 mm in diameter and oocyte retrieval was scheduled 36 hours later. The standard IVF procedures followed are described elsewhere (20Olivennes F. Franchin R. Bouchard P. Taieb J. Selva J. Frydman R. Scheduled administration of GnRH antagonist (Cetrorelix) on day 8 of in vitro fertilization cycles a pilot study.Hum Reprod. 1995; 10: 1382-1386PubMed Google Scholar). A maximum of three embryos were transferred on day 3 under ultrasound guidance. For luteal phase support, all patients received a daily dose of 400 mg of vaginal micronized P (Progeffik; Effik, Madrid, Spain). A pregnancy test was done 11 days after ET and ultrasound scans were performed 4 and 5 weeks after oocyte retrieval to confirm a clinical pregnancy, which was defined as the presence of a gestational sac showing a positive heartbeat. For the purpose of the study, four serum LH determinations were performed during ovarian stimulation: on day 3 of stimulation, on day 6 of stimulation before starting GnRH-a administration, on day 8 of stimulation, and on the day of hCG administration. Samples were stored at −20°C for subsequent measurement of LH with a microparticles enzyme immunometric assay (Immulite 2000 LH, Diagnostic Products Corporation, Los Angeles, CA). The sensitivity of the assay was 0.05 IU/L, with an intra-assay variation coefficient of 3.6% at an LH of 8.7 IU/L, 3.7% at an LH of 1.89 IU/L, 3.0% at an LH of 1.04 IU/L, 5.1% at an LH of 0.29 IU/L, and 13.1% at an LH of 0.15 IU/L. To analyze the relationship between serum LH levels and cycle outcome, three groups of patients were formed based on the serum LH determination, according to Tukey's hinges (percentiles 25 and 75). The first group consisted of patients with low serum LH levels (below percentile 25), the second group consisted of patients with medium serum LH levels (between percentiles 25 and 75), and the third group consisted of patients with high serum LH levels (over percentile 75). The number of patients included was calculated based on the detection of a 15% difference in pregnancy rate (PR) (45% vs. 30%) with an α error of 0.05 and a β error of 0.2 between the group with medium serum LH levels and the groups with low or high serum LH levels. Power analysis showed that a population of 100 patients was required. As a 10% rate of dropouts were initially predicted, 110 patients were finally recruited. Analysis of variance with Bonferroni's correction was used for comparing cycle outcome variables across groups. To assess the accuracy of serum LH measurements to predict pregnancy, the area under the receiver operating characteristic curve (AUCROC) was computed. A P value of <.05 was considered statistically significant. Statistical analysis was performed using the Statistical Package for Social Sciences for Windows, version 11.0 (SPSS, Chicago, IL). Fourteen patients (12.7%) were cancelled during ovarian stimulation because of low response (n = 9; 8.2%) or risk of ovarian hyperstimulation syndrome (OHSS) (n = 5; 4.5%). Thus, 96 patients (87.3%) underwent ovum pick-up and ET. One patient was excluded because serum determinations were not obtained correctly. The median (interquartile range) of serum LH at each stage were 3.7 IU/L (2.4–5.6 IU/L) on day 3, 1.8 IU/L (1.2–3.8 IU/L) on day 6, 0.7 IU/L (0.5–1.7 IU/L) on day 8, and 0.6 IU/L (0.5–1.2 IU/L) on the day of hCG administration. Table 1 shows age, days of stimulation, total dose of FSH used (ampules of 75 IU), serum P on day of hCG, serum E2 on day of hCG administration, number of oocytes retrieved, fertilization rate, number of embryos transferred, implantation rate and PR in the three groups established according to serum LH levels. To determine whether any of the serum LH measurements was a valid predictor of pregnancy, the AUCROC of the four hormonal determinations was calculated. Day 3 serum LH AUCROC was 0.59 (95% confidence interval [CI] 0.47–0.71; P=.14); day 6 LH AUCROC was 0.45 (95% CI 0.33–0.57; P=.46); on stimulation day 8, serum LH AUCROC was 0.42 (95% CI 0.30–0.54; P=.20), and on day of hCG it was 0.41 (95% CI 0.29–0.53; P=.13). The difference between these areas and the reference line (area 0.5) was not statistically significant for any of the serum LH measurements.TABLE 1In vitro fertilization cycle characteristics based on LH level.Day 3Day 6Day 8Day of hCG< p 25 ( p 75 (>5.7)< p 25 ( p 75 (>3.8)< p 25 ( p 75 (>1.7)< p 25 ( p 75 (>1.2)Age (y)31.7 ± 2.730.9 ± 3.532.2 ± 1.931.2 ± 2.531.0 ± 3.532.4 ± 1.631.3 ± 3.631.3 ± 2.532.0 ± 2.431.5 ± 2.430.8 ± 3.232.5 ± 2.4Days of stimulation10.6 ± 1.210.3 ± 1.510.6 ± 1.910.8 ± 1.5a10.6 ± 1.5a9.7 ± 1.3b11.3 ± 1.6a10.3 ± 1.3b9.8 ± 1.2b11.5 ± 1.5a9.9 ± 1.2b9.9 ± 1.2bTotal dose of FSH (amps.)41.7 ± 19.0b31.8 ± 16.4b32.2 ± 13.5b38.4 ± 17.1a35.8 ± 16.4a24.8 ± 10.1b40.5 ± 19.0b34.3 ± 16.0a25.3 ± 9.0b40.5 ± 16.4a32.5 ± 15.6a26.5 ± 11.8bP day of hCG (ng/mL)1.0 ± 0.881.0 ± 0.71.1 ± 0.91.1 ± 0.91.0 ± 0.81.0 ± 0.61.2 ± 0.81.0 ± 0.90.9 ± 0.51.3 ± 1.00.9 ± 0.60.9 ± 0.6E2 day of hCG (pg/mL)1,621 ± 735b1,595 ± 696b2,131 ± 848a1,246 ± 546b1,755 ± 769a2,413 ± 886a1,341 ± 560b1,800 ± 779a2,455 ± 915a1,454 ± 641b1,958 ± 801a2,060 ± 837aOocytes retrieved18.8 ± 9.117.0 ± 7.414.1 ± 6.218.7 ± 8.915.9 ± 7.118.5 ± 8.621.1 ± 9.616.2 ± 6.914.8 ± 6.419.6 ± 9.317.1 ± 7.914.9 ± 6.3% Fertilization (95% CI)65.9 (55.2–76.5)65.7 (57.1–74.3)64.9 (54.3–75.5)68.8 (60.1–76.2)67.9 (60.2–75.6)62.5 (56.2–69.1)68.9 (62.7–75.0)67.8 (61.0–76.4)62.4 (54.8–70.5)68.9 (62.5–75.2)64.6 (57.8–71.3)62.5 (52.7–72.4)Embryos transferred2.3 ± 0.82.4 ± 0.82.1 ± 1.22.1 ± 0.92.4 ± 0.92.3 ± 1.12.0 ± 1.02.4 ± 0.82.4 ± 0.92.0 ± 0.92.4 ± 0.92.3 ± 0.9Implantation (%)26.4 (6.1–47.2)29.4 (8.0–50.2)28.3 (7.8–49.0)34.4 (11.4–57.5)28.3 (14.6–41.9)26.6 (10.7–44.6)31.2 (14.1–48.9)30.6 (16.4–44.2)23.2 (11.6–35.8)34.4 (17.7–50.1)26.6 (15.2–41.0)32.5 (16.5–18.9)Clinical pregnancy n9/2027/559/2010/2026/559/2011/2225/539/209/1726/5710/21% (CI 95%)45.0 (21.1–68.9)49.1 (35.4–62.7)45.0 (21.1–68.9)50.0 (26.0–74.0)47.2 (33.7–60.9)45.0 (21.1–68.9)50.0 (27.3–72.7)47.2 (33.3–61.1)45.0 (21.1–68.9)52.9 (23.5–79.4)45.6 (32.3–58.9)47.6 (24.3–70.9)Note: Values are means ± SD or % (95% CI).a>b: P < .05.Bosch. LH and cycle outcome in GnRH antagonist cycles. Fertil Steril 2005. Open table in a new tab Note: Values are means ± SD or % (95% CI). a>b: P < .05. Bosch. LH and cycle outcome in GnRH antagonist cycles. Fertil Steril 2005. This study demonstrates that the varying serum LH levels detected after ovarian stimulation with recombinant FSH and a GnRH-a are not indicative of IVF–ET cycle outcome in young and normogonadotropic women in terms of implantation rate and clinical PR. None of the serum LH measurements taken before or after GnRH-a administration, when submitted to an AUCROC analysis, were able to discriminate between pregnancy and nonpregnancy cycles. Moreover, profound LH suppression once the GnRH-a was introduced was shown to have no association with cycle outcome. Nevertheless, serum LH levels throughout ovarian stimulation were related to differences in ovarian response, with high levels being associated with shorter ovarian stimulation, lower FSH requirements, and higher serum E2 levels on the day of hCG administration. On the other hand, patients that showed considerably low LH concentrations (<0.5 IU/L) once GnRH-a administration, needed a significantly longer stimulation and higher amounts of FSH when compared to those with high serum LH. However, a similar number of oocytes were recovered from this group and it showed a similar outcome to the rest of the patients, despite the significantly lower E2 levels on the day of hCG administration. In any case, it has to be considered that the subjects included in the present study may not be representative of the general population undergoing COH for IVF, as only young and normogonadotropic women were included, and patients with any background of ovarian dysfunction or pathology were excluded. It also remains questionable the reliability of single LH measurements, as biochemical assay methods do not determine directly its bioactivity. It can be concluded that stimulation with an FSH-only preparation and a GnRH-a in women of this profile does not impair follicular development and oocyte maturation, as patients with high and low LH levels throughout the follicular phase presented similar cycle outcomes.