Use of combined exogenous gonadotropins and pulsatile gonadotropin-releasing hormone in patients with polycystic ovarian disease

We previously tested a combined regimen based on the administration of gonadotropin in the early follicular phase followed by pulsatile gonadotropin-releasing hormone (GnRH) until complete follicular maturation in patients suffering from polycystic ovarian disease. Despite good clinical results, a high rate of premature luteinization was observed with this approach. We therefore evaluated in this study whether starting pulsatile GnRH therapy before gonadotropin administration might reduce premature luteinization. Eight women underwent induction of ovulation with both combined therapy and pure exogenous follicle-stimulating hormone alone using a crossover scheme. No premature luteinization and a single follicular growth were recorded with the modified combined regimen. Clinical results (8/8 versus 3/7 ovulatory cycles; 3/8 versus 1/7 pregnancies) favor the combined approach over gonadotropin alone.     

The function of bone morphogenetic proteins in the human ovary

The gonadotropins, follicle-stimulating hormone (FSH), and luteinizing hormone (LH), are of particular importance in ovarian physiology. However, FSH receptors and LH receptors are not expressed until the secondary follicle stage, indicating that initiation of follicular growth is independent of the gonadotropins. Among many intra-ovarian growth factors, many studies have shown that bone morphogenetic proteins (BMPs) play pivotal roles in regulating the early phases of follicular growth. The BMP system induces the gonadotropin system by modulating gonadotropin receptors in early-stage follicles. Interestingly, the BMP system also prevents precocious maturation of the follicle by suppressing luteinization. Signals provoked by the preovulatory LH surge eliminate BMPs, enabling luteinization to progress. Thus, the BMP system and the gonadotropin system seem to cooperate in regulating follicular development, maturation, and luteinization.     

Ovarian follicular apparatus and hormonal parameters in patients with primary and secondary amenorrhea.

Correlation between ovarian follicular apparatus and hormonal parameters such as serum gonadotropin and urinary estrogen levels was investigated in patients with primary and secondary amenorrhea. Serum gonadotropin levels were elevated in amenorrheic patients without ovarian follicles or with follicles of low developmental stage and pituitary responsiveness to LH-RH in these patients were marked compared with patients with follicles of high developmental stage or normal ovulating women in the follicular phase of the menstrual cycle. The 24-hour urinary excretion of total estrogens was low in patients without follicles or with follicles of low developmental stage and ovarian responsiveness to exogenous gonadotropins was quite low in comparison with patients with highly developed follicles or normal control subjects. Thus, serum gonadotropin and urinary estrogen measurements and LH-RH and gonadotropin loading tests are diagnostic of the presence or absence and the state of development of ovarian follicles in the diagnosis and treatment of primary and secondary amenorrhea.     

Dynamics of follicle development in stimulated in vitro fertilization cycles--sonographic follow-up and findings following follicle puncture

Results of ultrasonical folliculometry during treatment by 5 different stimulation protocols were evaluated in 122 cycles of IVF-patients. Additionally, the structure of follicular population was investigated by measurement of follicular volume which was the basis of a follicular hierarchy. - Number of developing, sonographically detectable and punctured follicles increased significantly from stimulation by Clomiphene to stimulation by Folistiman. Only in stimulation by Clomiphene number of sonographical visible follicles was in accordance with laparoscopically punctured follicles. Development of relationship of the follicular classes during treatment supports hypothesis that exogenous gonadotropins do not increase follicular recruitment in the follicular phase but prevent atresia of follicles recruited earlier. Long lasting action of FSH as in stimulation by gonadotropins stimulates a greater number of follicles more intensively as demonstrated by an increased follicular volume in follicles with high rank numbers in gonadotropin treated patients compared with treatment by Clomiphene and Clomiphene/Anthrogon. Very high FSH-levels probably cause a heterogenous population of follicles with an increased number of small follicles at time of follicular puncture.     

Use of combined exogenous gonadotropins and pulsatile gonadotropin-releasing hormone in patients with polycystic ovarian disease: a new approach to induction of ovulation

A combined regimen based on exogenous gonadotropins followed by pulsatile gonadotropin-releasing hormone was attempted in order to induce ovulation in a group of patients with polycystic ovarian disease. The women were selected on the basis of previous unsuccessful treatment with clomiphene citrate, gonadotropin and pulsatile gonadotropin-releasing hormone used separately. At our first attempt at application of this new approach, in all patients follicular growth was recorded and ovulation was induced with exogenous chorionic gonadotropin, without hyperstimulation. Two clinical pregnancies were established. Retrospective hormonal evaluation showed the presence of two premature luteinizations. Pulsatile gonadotropin-releasing hormone administration following follicular recruitment with exogenous gonadotropin may therefore be considered an effective therapy for polycystic ovarian patients resistant to conventional treatment.     

Ovulation defects despite regular menses: Part III

OBJECTIVE: To describe subtle ovulatory defects that can contribute to infertility and/or miscarriage despite regular menses with apparent ovulation. METHODS: By using follicular maturation studies and measurement of serum estradiol, progesterone, and LH certain imperfections in the ovulatory process can be ascertained. RESULTS: Careful evaluation of follicular maturation was able to determine infertility factors, e.g., premature luteinization, luteinized unruptured follicle syndrome, and luteal phase defects. Effective treatment agents include follicular maturing drugs and gonadotropin releasing hormone antagonists in the follicular phase, human chorionic gonadotropins and leuprolide acetate at time of peak follicular maturation and progesterone in the luteal phase. CONCLUSIONS: Progesterone supplementation alone is more effective than follicle maturing drugs in women with luteal phase defects with mature follicles. Small doses of follicle stimulating hormone in the late follicular phase is most effective for luteal phase deficiency associated with immature follicles. Sometimes leuprolide acetate can allow egg release when hCG has failed.     

Absence of effect of adjuvant growth hormone therapy on follicular responses to exogenous gonadotropins in women: normal and poor responders.

OBJECTIVE: To examine the effects of growth hormone (GH) on ovarian responses to exogenous gonadotropins after pituitary desensitization in normal and poor responder patients undergoing in vitro fertilization. DESIGN: A prospective study with comparison of control and GH-treated cycles. PATIENTS: Poor responder patients (n = 10) required > 44 ampules of human menopausal gonadotropin (hMG) to achieve criteria for administration of human chorionic gonadotropin (hCG) on day 0 or cancellation in control cycles, and normal responder patients (n = 10) required < 45 ampules. MAIN OUTCOME MEASURES: Ovarian responses to hMG assessed by duration of stimulation required to achieve first significant estradiol (E2) response and hCG criteria. Total doses and duration of hMG, follicular development and E2 concentrations on day 0, and embryology were also assessed. RESULTS: Growth hormone showed no effect on any of the parameters studied in either patient group. CONCLUSION: Follicular recruitment, E2 secretion by mature follicles, and oocyte yield and quality were uninfluenced by GH treatment.     

Buserelin suppression of endogenous gonadotropin secretion in infertile women with ovarian feedback disorders given human menopausal/human chorionic gonadotropin treatment

Fifty infertile women with oligomenorrhea, anovulation, or luteal phase defects were selected for a combined therapy consisting of a gonadotropin-releasing hormone analog (Buserelin Hoechst AG, Frankfurt/Main, FRG) and human menopausal gonadotropin/human chorionic gonadotropin (hMG/hCG). Serving as their own controls, these women had been subjected to a total of 238 hMG/hCG treatment cycles with no pregnancy observed (average, 4.7 cycles; range 2 to 14). Of these 238 hMG/hCG cycles, only 98 (41.1%) appeared normal, while the others showed symptoms consistent with inadequate follicle maturation, luteal phase defects, and premature luteinization. In contrast, 89 cycles from 133 combined buserelin/hMG/hCG treatment cycles (66.9%) appeared to be normal, with no evidence of premature luteinization, and 21 patients became pregnant. These data indicate that the likelihood of group II World Health Organization (WHO) patients becoming pregnant with hMG/hCG therapy may be enhanced when endogenous gonadotropin secretion is suppressed at the same time.     

The use of gonadotropins for the induction of ovulation in women with polycystic ovarian disease

Ten infertile patients with polycystic ovarian disease were treated with 18 cycles of "pure" human pituitary follicle-stimulating hormone (HP-FSH) and 10 cycles of human menopausal gonadotropin (HMG) consisting of FSH and luteinizing hormone (LH) in a 1:1 ratio. Human chorionic gonadotropin was used to trigger ovulation when optimal follicular development was achieved as judged by urinary estrogen determinations. Of the 18 cycles utilizing HP-FSH, 14 were presumptively ovulatory, 2 were conceptual, and in 5 cycles ovarian enlargement was noted. Of the 10 HMG cycles, none was ovulatory, no conceptions resulted, and 6 instances of hyperstimulation were noted. Pretreatment serum LH levels were significantly higher than normal follicular phase values. These observations suggest that endogenous LH levels in patients with polycystic ovaries are quite adequate for follicular development so that the administration of exogenous LH is unwarranted. Furthermore, the data suggest that HP-FSH or low-LH-containing HMG may prove to be an additional safe and effective nonsurgical treatment modality for patients who are anovulatory because of polycystic ovaries.     

The use of a long-acting gonadotropin-releasing hormone analog(D-Trp-6-LHRH) for improvement of ovarian stimulation in assisted conception programs.

To assess the efficacy of gonadotropin-releasing hormone analog (GnRHa) as an adjuvant in controlled ovarian stimulation in assisted conception programs, 114 infertile patients, who were treated by in vitro fertilization and embryo transfer (n = 61) or tubal embryo transfer (n = 53), were randomized sequentially to receive ovarian stimulation according to two protocols. In protocol 1 (n = 57), long-acting GnRHa (D-Trp-6-LHRH) microcapsules were administered intramuscularly at menstruation and ovarian stimulation using follicle-stimulating hormone (FSH) and human menopausal gonadotropin (hMG) was started 2 to 3 weeks later when the pituitary was completely suppressed. In protocol 2 (n = 57), patients received FSH and hMG from day 3 of the cycle without GnRHa pre-treatment. We found that premature luteinization did not occur in patients treated with protocol 1, and the number of cycles cancelled was also decreased. The days of ovarian stimulation and the amount of hMG required to achieve adequate follicular development were significantly higher in protocol 1 than that in protocol 2. Similarly, the mean serum estradiol levels on the day of human chorionic gonadotropin administration, number of large follicles (mean diameter greater than 10 mm), number of oocytes recovered and number of embryos obtained were also significantly higher in patients treated with protocol 1. The data suggest that the use of D-Trp-6-LHRH as an adjuvant in ovarian stimulation is associated with a lower incidence of cycle cancellation and an improvement in ovarian response in assisted conception programs.     

Concomitant gonadotropin-releasing hormone agonist and menotropin treatment for the synchronized induction of multiple follicles

In an effort to overcome possible interference by endogenous gonadotropin-ovarian hormone dynamics, desensitization of the pituitary gonadotropins by a gonadotropin-releasing hormone agonist (GnRHa) was achieved in 12 women with repeatedly failed attempts at multiple follicular stimulation. Eight women were scheduled for in vitro fertilization (IVF) and embryo transfer (ET), and 4 for gamete intrafallopian transfer (GIFT). Stimulation failure was characterized by premature luteinization, poor estradiol (E2) response, or inadequate follicular growth. The agonist was administered by nasal spray 500 to 600 micrograms/day beginning on days 21 to 23 of the menstrual cycle. A rapid desensitization occurred by 7.6 +/- 0.6 days (mean +/- standard error [SE]) following the initial dose. Gonadotropin stimulation was begun when pituitary and ovarian suppression was judged to be adequate. In response to gonadotropin stimulation, a continuous rise of E2 was observed in all patients with a mean of 989 +/- 46 pg/ml on the day of hCG. A cohort of synchronized follicles was recruited and matured. The mean number of growing follicles per patient was significantly higher (P less than 0.0001) in combined therapy than in previously failed cycles (8.0 +/- 0.3 versus 3.2 +/- 0.1). All the patients underwent oocyte retrieval and 94.3% of the harvested oocytes were preovulatory. A high fertilization rate (89.7%) of the inseminated oocytes occurred in IVF patients.     

Induction of ovulation with luprolide acetate and human menopausal gonadotropin

Four women with unexplained infertility and two anovulatory oligomenorrheic women who experienced repeated premature luteinization when treated with human menopausal gonadotropin (hMG) or gonadotropin-releasing hormone (GnRH) were given the gonadotropin-releasing hormone agonist (GnRHa), luprolide acetate, in order to effect medical hypophysectomy. This was followed by hMG for induction of ovulation. Four of the six patients had hMG-only cycles, which were compared with the luprolide acetate/hMG cycles. The luprolide acetate/hMG cycles resulted in normal folliculogenesis with presumptive ovulation. In luprolide/hMG cycles, significantly more hMG was needed for induction of ovulation than in hMG-only cycles. Premature luteinization was abolished with luprolide acetate treatment.     

Levels of steroid and protein hormones in antral fluids of women treated with different combinations of gonadotropins, clomiphene citrate, and a gonadotropin-releasing hormone analog

Levels of luteinizing hormone (LH), follicle-stimulating hormone (FSH), estradiol, progesterone (P), and total protein in follicular fluids collected from 18 patients pretreated with a gonadotropin-releasing hormone analog (GnRHa), in association with human menopausal gonadotropin (hMG) and FSH, were compared with values for 69 patients treated with FSH, hMG, FSH/hMG, or clomiphene citrate (CC)/hMG in an in vitro fertilization (IVF) program. The authors have established a number of significant differences in chemical and physical properties of follicular fluids of patients treated by different regimen, and concur with earlier evidence that the volume of a follicle, and its P and total protein content, are related to the maturity of the oocyte nested within the follicle. Overall, however, differences in concentrations of gonadotropins in follicular fluids between groups were not consistent with differences in follicular fluid steroid levels, and levels of immunoactive gonadotropins in follicular fluids were not in accord with dosages of exogenous immunoactive gonadotropin administered during hyperstimulation. The most favorable outcomes of IVF (greater than 70% of oocytes fertilized) were established with oocytes collected from patients treated with FSH only or with CC/hMG, and patients treated with FSH only yielded the highest average number of oocytes which fertilized in vitro (6.2 per patient).     

GnRH-a治疗难治性排卵障碍不孕患者的初步观察

目的探讨常规诱导排卵失败后应用促性腺激素释放激素激动剂(GnRH-a)诱导排卵的临床效果.方法对常规促排卵治疗(氯米芬和HMG)失败的13例排卵障碍不孕患者,其中多囊卵巢综合症(PCOS)5例,小卵泡排卵8例.采用GnRH-a+HMG治疗,并于周期第8天开始B超监测卵泡发育并测定尿LH,当卵泡平均径线达18 mm或尿LH(+)时,给HCG诱发排卵.结果13例患者采用GnRH-a+HMG治疗19个周期,均有优势卵泡发育,其中16个周期(84.2%)卵泡平均径线达18 mm时尿LH仍为(-),给HCG诱发排卵;3个周期提前出现LH峰,取消使用HCG.36.8%的周期为单卵泡发育,75.0%为＜3个优势卵泡,8.3%为4～10个,18.8%为＞10个.妊娠率58.3%,周期妊娠率41.2%,其中单胎4例,双胎2例,4胎1例;自然流产的发生率为14.3%.结论GnRH-a可增强PCOS患者对HMG的反应性,防止内源性LH峰早现,并有良好的妊娠率及妊娠结局,可望作为治疗PCOS及小卵泡排卵患者的二线药物;低剂量HMG可使75%的治疗周期中卵泡发育数＜3个.     

GnRH antagonist does not prevent premature luteinization and ovulation in stimulated cycles with gonadotropins for IVF: two case reports

The use of GnRH antagonists (GnRHant) is increasing in the ovarian stimulation protocol. Among several other benefits, GnRHant should prevent a premature luteinization and premature ovulation, the first described either as a ‘reassuringly rare event’ or ‘frequent event’, while the second as occurring more frequently in women with decreased ovarian reserve, advanced age and poor ovarian response. Two cases of associated premature luteinization and premature ovulation, during treatment with gonadotropins and GnRHant in IVF cycles, are here reported. In both cases, premature luteinization occurred and ovulation took place during ovarian stimulation protocols with exogenous gonadotropins and GnRHant, before reaching the criteria of hCG administration, regardless of the age of the patients and their ovarian reserve. Ovulation was documented by the disappearance of most of the developing follicles, by the transformation of endometrium from a triple line picture into a uniform hyper-echogenic image, by the presence of fluid in the pouch of Douglas, by the increase of progesterone plasma levels and the simultaneous reduction of estradiol plasma levels. This evidence can be important for a correct counseling with infertile patients in preparation for an IVF cycle.     

IVF-ET中促性腺激素释放激素激动剂的超促排卵应用与剂量研究

促性腺激素释放激素激动剂(GnRH-a)是体外受精-胚胎移植(IVF-ET)技术中重要用药。GnRH-a与GnRH受体结合后,早期"突发"作用可刺激垂体促性腺激素急剧释放,持续应用后使垂体受抑制,内源性促性腺激素(Gn)水平下降,即所谓的降调节作用。利用这种生物学特性,GnRH-a联合Gn超促排卵可预防早发黄体生成素(LH)峰,避免卵泡过早黄素化。另外,GnRH-a代替人绒毛膜促性腺激素诱发排卵可降低卵巢过度刺激综合征(OHSS)发生率。探索既能有效抑制LH峰,又不使垂体过度抑制的GnRH-a有效低剂量对于超促排卵有重要意义。     

Human urinary follicle-stimulating hormone and human menopausal gonadotropin in induction of multiple follicle growth and ovulation

Five normally menstruating women were treated, in an attempt to induce development of multiple follicles, with pharmacologic doses of purified human urinary follicle-stimulating hormone (hU-FSH) and (in another instance) with human menopausal gonadotropin (hMG) administered on the second and third days after the onset of menses. All of the cycles were ovulatory: the follicular phase was short and the luteal phase length was normal in both hMG and hU-FSH treatment. No substantial differences were seen between the two types of treatment in regard to plasma values of FSH, luteinizing hormone (LH), estradiol (E2), testosterone, and progesterone (P). FSH, E2, and P increased to supraphysiologic levels, and LH fluctuated within the normal range. On ultrasound examination, a large number of growing and matured follicles were visualized during both treatments: at human chorionic gonadotropin administration, multiple preovulatory follicles (greater than or equal to 15 mm) and only a few small follicles (less than 10 mm) were imaged, without any difference between the two types of treatment. Multiple corpora lutea were often obtained. These data underline that pharmacologic doses of FSH alone are able to induce the growth of multiple preovulatory follicles when the initiation of stimulation is timed early. Besides this, exogenous LH does not seem to interfere with follicular recruitment, and it is not required for follicular maturation and ovarian steroidogenesis when endogenous normal LH mean values are present.     

Adjunctive leuprolide therapy does not improve cycle fecundity in controlled ovarian hyperstimulation and intrauterine insemination of subfertile women

Problems arising from controlled ovarian hyperstimulation for intrauterine insemination, such as premature luteinization and asynchronous ovarian follicular development, are identical to those encountered with controlled ovarian hyperstimulation for in vitro fertilization (IVF) and gamete intrafallopian transfer (GIFT). It has been suggested that the adjunctive use of GnRH agonists for controlled ovarian hyperstimulation improves the efficiency of GIFT and IVF cycles. We hypothesized that adjunctive use of leuprolide acetate, a GnRH agonist, would have a similarly beneficial effect on cycle quality and cycle fecundity in subfertile women treated with controlled ovarian hyperstimulation and intrauterine insemination. We randomly assigned the first cycle of controlled ovarian hyperstimulation and intrauterine insemination for each of 97 subfertile women to include either human menopausal gonadotropins (hMGs) alone or hMGs following midluteal pre-treatment with leuprolide. If a pregnancy did not occur in the first cycle, the woman was given the other treatment in the second cycle. Although the cycles that included leuprolide required a larger amount of hMGs and more days of stimulation per cycle, the mean estradiol concentrations and numbers of follicles were not different. Despite prevention of premature luteinization with leuprolide, the cycle fecundity was not different between groups (0.11 with adjunctive leuprolide treatment and 0.22 with hMGs alone). We conclude that in unselected subfertile patients, the adjunctive use of leuprolide for controlled ovarian hyperstimulation and intrauterine insemination does not improve cycle fecundity compared with treatment cycles that do not include adjunctive leuprolide therapy.     

Ovulation disorders: Part II. Anovulation associated with normal estrogen

PURPOSE: To present various types of anovulatory states associated with normal estrogen and various treatment options. METHODS: Evaluation and treatment of various conditions including polycystic ovarian syndrome, hyperprolactinemia, congenital adrenal hyperplasia are discussed as are methods to prevent certain complications of these therapies. RESULTS: Clomiphene citrate seems equally effective to gonadotropins at least for the first three cycles but has a frequent complication of adversely affecting the cervical mucus so intrauterine insemination is frequently needed. Glucocorticoid therapy and insulin receptor drugs can exert a primary or more commonly an ancillary benefit when used in combination with other follicle maturing drugs. Complications, e.g., adverse cervical mucus, luteinized unruptured follicle (LUF) syndrome, premature luteinization, luteal phase deficiency and treatment options are presented. CONCLUSIONS: Vaginal progesterone can correct luteal phase problems, human chorionic gonadotropin (hCG) and follicle stimulation hormone (FSH) and gonadotropin releasing hormone (GnRH) agonists can help LUF syndrome and GnRH agonists and antagonists can help the complication of premature luteinization.     

Clinical, immunologic, and genetic definitions of primary and secondary recurrent spontaneous abortions

Follicular fluid was obtained from anovulatory patients (n = 12), stimulated with human menopausal gonadotropin, clomiphene, and human chorionic gonadotropin to evaluate the relative responses of inhibin, follicle regulatory protein, and steroid levels in follicles from ovaries requiring exogenous stimulation for follicular development. Follicular fluid concentrations of estradiol, progesterone, androstenedione, testosterone, dihydrotestosterone, and 3 alpha-androstenediol were determined by radioimmunoassay. Follicular fluid inhibin activity was determined by suppression of rat pituicyte follicle-stimulating hormone, and follicle regulatory protein activity was determined by suppression of porcine granulosa cell aromatase. The mean level of steroids were progesterone (7529 +/- 1601 ng/ml), estradiol (1082 +/- 158 ng/ml), androstenedione (15.2 +/- 3.17 ng/ml), 3 alpha-androstenediol (0.90 +/- 0.13 ng/ml), testosterone (2.23 +/- 33 ng/ml), and dihydrotestosterone (0.77 +/- 0.11 ng/ml). Follicle regulatory protein activity was 16.6% +/- 4.3% and mean inhibin level was 62.9 +/- 7.52 U. These results are in contrast to reports of follicular fluid steroid levels from normal ovulatory patients treated with exogenous gonadotropin. Although altered levels of hormones were present within these follicles, they clearly were not atretic, as evidenced by elevated estradiol levels and estradiol/androstenedione ratios. Alterations in the normal follicular response to pharmacologic gonadotropin stimulation in the follicles of anovulatory women suggest the presence of granulosa cell dysynchrony .