Does exogenous LH in ovarian stimulation improve assisted reproduction success? An appraisal of the literature

Reproductive BioMedicine Online (2012) 24, 261– 271

www.sciencedirect.com www.rbmonline.com

REVIEW

Does exogenous LH in ovarian stimulation improve assisted reproduction success? An appraisal of the literature Micah J Hill a, Gary Levy a, Eric D Levens

a,b,*

a

Program in Reproductive and Adult Endocrinology, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, MD 20892, United States; Grove Fertility Reproductive Science Center, Rockville, MD, United States

b

Shady

* Corresponding author. E-mail address: [email protected] (ED Levens). Eric Levens is a board-certified reproductive endocrinology and infertility specialist and an assistant professor of obstetrics and gynaecology at the Uniformed Services University of the Health Sciences in Bethesda. Prior to joining Shady Grove Fertility, he was a lieutenant commander in the US Public Health Service and served as a staff clinician at the National Institutes of Health and the Walter Reed Army Medical Centre for 5 years.

Abstract A review of the scientific literature on the use of exogenous LH in assisted reproductive technology was performed by

searching the MEDLINE, PubMed and Cochrane online databases. Scientific evidence was reviewed comparing recombinant FSH-only protocols to protocols supplemented with exogenous LH activity: human menopausal gonadotrophin (HMG), recombinant LH and mid-follicular human chorionic gonadotrophin (HCG). Studies were further compared based on pituitary suppression with gonadotrophin-releasing hormone (GnRH) antagonist and agonist protocols. Primary focus was given to randomized controlled trials and meta-analyses. Data from hypogonadotrophic hypogonadal patients demonstrated the importance of LH activity for success of assisted reproduction treatment. However, the majority of normogonadotrophic patients had adequate endogenous LH to successfully drive ovarian steroidogenesis and oocyte maturation. Exogenous LH supplementation was consistently associated with higher peak oestradiol concentrations. The use of HMG in long GnRH agonist cycles was associated with a 3–4% increase in live birth rate. There was insufficient evidence to make definitive conclusions on the need for exogenous LH activity in GnRH antagonist cycles or the benefit of recombinant LH and HCG protocols. Poor responders and patients 35 years of age and older may benefit from exogenous LH. RBMOnline ª 2012, Reproductive Healthcare Ltd. Published by Elsevier Ltd. All rights reserved. KEYWORDS: assisted reproductive technology, follicle-stimulating hormone, human chorionic gonadotrophin, human menopausal gonadotrophin, luteinizing hormone

1472-6483/$ - see front matter ª 2012, Reproductive Healthcare Ltd. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.rbmo.2011.12.005

262

Introduction Among the key controversies in assisted reproductive technology has been to what extent ovarian stimulation protocols contribute to assisted reproduction success (Filicori, 2003). In particular, it remains unclear what the importance of exogenous LH supplementation may be in assisted reproduction treatment. The role of LH and FSH in the natural menstrual cycle have been well described. FSH is essential for follicular recruitment and development, as well as for inducing many enzymes and hormones (e.g. aromatase, inhibin) that are subsequently controlled by LH and required for continued follicle maturation (Hillier, 1994, 2001). For example, LH stimulates adenylate cyclase and cyclic AMP production resulting in mitochondrial cholesterol transport and steroidogenesis (Shoham, 2002), essential events leading to oocyte maturation and ovulation. Not only does LH play an important function in the peri-ovulatory and ovulatory events within the ovary, but also LH receptors have been identified in the human endometrium, raising the possibility that LH has a necessary function in implantation (Reshef et al., 1990; Shemesh, 2001). The importance of LH supplementation in studies of ovulation induction has been shrouded by conflicting data. The best evidence for a critical role of LH in ovulation induction has come from studies evaluating pregnancy outcomes in women with hypogonadotrophic hypogonadism (WHO class I). In the presence of low endogenous LH production, particularly among women with LH concentrations <1.2 mIU/ml, studies utilizing FSH alone for ovulation induction have found poor pregnancy outcomes (Lahoud et al., 2006; O’Dea et al., 2008). Consequently, both FSH and LH supplementation appear to be critical for optimal follicular development, implantation and pregnancy (Couzinet et al., 1988; Crowley and McArthur, 1980; Kaufmann et al., 2007; Schoot et al., 1994; Shoham et al., 2008). At the other extreme, elevated LH concentrations have likewise been associated with poor fertilization, poor implantation and detrimental effects on pregnancy rates (Hillier, 1994; Homburg et al., 1988; Regan et al., 1990; Shoham, 2002; Stanger and Yovich, 1985). While insufficient LH results in inadequate steroidogenesis (Shoham, 2002), excessive LH may suppress aromatase activity and inhibit cell growth (Overes et al., 1992; Shoham, 2002; Yong et al., 1992). Taken together, this evidence supports the theory that a therapeutic window exists for LH, above or below which maximum reproductive outcomes may be negatively impacted (Hillier, 1994; Shoham, 2002; Tesarik and Mendoza, 2002). Extrapolating from the aforementioned data, an important question arises: do women undergoing gonadotrophin-releasing hormone (GnRH) analogue or antagonist pituitary down-regulation as part of assisted reproduction protocols have sufficient endogenous LH concentrations to support the essential follicular developmental events required for optimal ovulation and pregnancy outcomes? Previously, it has been shown that normal ovarian steroidogenesis can occur despite having less than 1% of LH receptors occupied (Chappel and Howles, 1991), resulting in successful ovarian stimulation in FSH-only protocols. The majority of patients undergoing ovarian stimulation can be successfully stimulated with exogenous FSH alone,

MJ Hill et al. presumably because sufficient endogenous LH is produced to bind at least 1% of the LH receptors despite the pituitary down-regulation. This ‘quiescent state’ of LH concentration may be sufficient to maintain normal steroidogenesis and folliculogenesis in most patients. However, it remains unclear whether LH supplementation provides benefit in terms of improved pregnancy outcomes among those undergoing ovarian stimulation as part of assisted reproduction treatment (Chappel and Howles, 1991). This review examines recent literature surrounding the role of exogenous LH in assisted reproduction outcomes.

The role of human menopausal gonadotrophins Human menopausal gonadotrophins (HMG) are urinaryderived gonadotrophins containing roughly equivalent amounts of LH and FSH bioactivity (approximately 75 IU of each). For many years, HMG was the only gonadotrophin available. Despite their widespread use, there have been several proposed disadvantages of these compounds, including protein contamination leading to local allergic reactions and batch-to-batch inconsistencies, as well as supply limitations. Some studies show intermediate outcomes (proportion of metaphase-II oocytes, zona pellucida/polar body morphology, number of high-quality embryos) have been similar whether utilizing protocols containing HMG or recombinant rFSH alone (Table 1) (Jansen et al., 1998; Kilani et al., 2003; Ng et al., 2001; Rashidi et al., 2005). Numerous studies have found that HMG protocols yield fewer developing follicles and subsequent oocytes (Andersen et al., 2006; Balasch et al., 2003; Bosch et al., 2008; Hompes et al., 2008; Jansen et al., 1998; Platteau et al., 2006; Strehler et al., 2001). Despite the presence of fewer follicles, HMG administration has consistently led to higher peak serum and follicular fluid oestradiol, androstenedione and testosterone concentrations, as well as lower progesterone concentrations on day of oocyte retrieval (Andersen et al., 2006; Bosch et al., 2008; Diedrich et al., 2002; Fleming et al., 1996; Hompes et al., 2008; Kilani et al., 2003; Smitz et al., 2007; Westergaard et al., 2001) (Figure 1). These findings suggest that LH may increase the quality and reproductive potential of the oocytes retrieved. LH administration may induce atresia of smaller follicles and the remaining larger follicles may represent those with greater reproductive competence (Filicori et al., 2003). Improved endometrial receptivity may also be produced as implantation rates have been shown to positively correlate with increasing doses of LH (Gordon et al., 2001). Nevertheless, whether the LH component of HMG for ovarian stimulation is advantageous, disadvantageous or inconsequential to the ultimate outcome of interest, pregnancy rates, has been a matter of controversy. Owing to the controversial nature of the topic, in the past decade, five meta-analyses have contributed to the current understanding of the effect of HMG compared with FSH-only protocols on assisted reproduction outcomes (Al-Inany et al., 2003, 2005, 2008; Coomarasamy et al., 2008; van Wely et al., 2003). Two analyses combined data from trials utilizing highly purified urinary FSH with no LH activity and HMG in an effort to compare urinary gonadotrophins to rFSH (Al-Inany et al., 2003; van Wely et al., 2003). A

LH supplementation and assisted reproduction outcome

263

Table 1 Data from randomized controlled trials comparing human menopausal gonadotrophin (HMG) to recombinant FSH in ovarian stimulation. Trial

Protocol

No. of Patients

Total gonadotrophins (IU or ampoules)

Peak oestradiol (pg/ml or nmol/l)

Oocytes retrieved

Fertilization rate (%)

Jansen et al. (1998) Westergaard et al. (2001) Strehler et al. (2001) Ng et al. (2001) Gordon et al. (2001) European and Israeli Study Group (2002) Kilani et al. (2003) Rashidi et al. (2005) Andersen et al. (2006) Hompes et al. (2008) Bosch et al. (2008)

HMG FSH HMG FSH

43 66 89a 92a

1365 1410 32.1 30.8

3145 3889 3081b 2328b

8.3 11.2 12.3 12.8

61.8 46.2 NR NR

HMG FSH

248 259

20.2c 28.6c

NR NR

9.7c 12.2c

NR NR

HMG FSH HMG FSH HMG FSH

20 20 29 39 373 354

1800 1650 2025 1800 36.9 37

11.4 11.8 4410 5402 +1265d

14 14.5 10 12 12.8 14

HMG FSH HMG FSH HMG FSH

50 50 30 30 363 368

NR NR 28.5 30.5 2508f 2385f

3491b 2602b NR NR 7.2b 6.6b

HMG FSH

312 317

1821 1759

HMG FSH

140 140

2481 2642

Implantation rate (%)

Clinical pregnancy rate (%)

Live birth rate (%)

22.9 24.1 34 29

NR NR 31 27

NR NR

32.3 30.1

NR NR

70.3 57.7 NR NR NSe NSe

19.4 11.4 28b 18b NR NR

25 20 38 28 29.6 25.4

NR NR 31 23 NR NR

7.9 6.8 7 6.5 10.0c 11.8c

76 87 55 50 51.6 52.5

NR NR 8.8 8.3 24 20

30 28 NR NR 28 24

24 22 13 10 21 17

6.3b 7.0b

7.7c 10.5c

63.1 60.5

29.3 25.8

26.3 25.8

28.0 26.2

2066c 1750c

11.3c 14.4c

69.8 68.9

37.6 30.8

42.1 39.3

34.3 31.4

16.7 27.5 26 30

NR = not reported; NS = not statistically significant. a Groups for subcutaneous administration reported (groups with nasal preparations omitted). b P < 0.05. c P < 0.001. d Mean oestradiol difference reported as +1265 in the HMG group (P < 0.0001). Exact group means not reported. e Exact percentages of fertilization rates not reported but said to be non-significant in the text. f P < 0.01.

concern with these analyses was that the inclusion of urinary FSH in the HMG group may have diluted the ability to detect a treatment effect of the additional LH activity as the outcomes with urinary FSH were also included in this group. A subgroup analysis of a study by Al-Inany et al. (2003) compared HMG alone versus rFSH. This study suggested a lower clinical pregnancy rate among those receiving rFSH alone (odds ratio, OR, 0.81, 95% CI 0.63 to 1.05). Another group of investigators published two separate meta-analyses specifically examining trials that compared rFSH and HMG (Al-Inany et al., 2005, 2008). Al-Inany et al. (2005) evaluated eight randomized trials, identifying no difference in live birth, clinical pregnancy or multiple gestation rates. A subsequent meta-analysis by the same group was performed later (Al-Inany et al., 2008). Four additional studies became available in the interim and were included.

This inclusion raised the total to 12 randomized trials, examining 2937 patient cycles. In 11 of the 12 studies analysed, polycystic ovary syndrome was excluded and the populations were otherwise unselected infertility diagnoses. All but one of the trials utilized a long luteal GnRH agonist for pituitary suppression. The use of HMG yielded a higher live birth rate as compared with rFSH (OR 1.2, 95% CI 1.01 to 1.42). The authors calculated that 32 (95% CI 16 to 1145) patients would need to be treated with HMG to produce one additional live birth. Rates of poor ovarian response (OR 1.08, 95% CI 0.76 to 1.53), oocytes retrieved (OR 0.80, 95% CI 0.56 to 1.05) and ovarian hyperstimulation syndrome (OR 1.21, 95% CI 0.78 to 1.86) were similar between the groups. Additional subanalyses including only long luteal GnRH agonist down-regulation produced similar results with the use of HMG (Al-Inany et al., 2008).

264

MJ Hill et al.

Levi-Setti et al. 2006

Bosch et al. 2008

Tarlatzis et al. 2006 Hompes et al. 2008 Griesinger et al. 2005

Lisi et al. 2005

Andersen et al. 2006 rLH + rFSH

De Placido et al.2005

rFSH

HMG rFSH

Kilani et al. 2003

Sauer et al. 2004 Westergaard et al. 2001

Cedrin-Durnerin et al. 2004

0

1000

2000

3000

4000

Estradiol (pg/L)

0

1000

2000

3000

4000

Estradiol (pg/L)

Figure 1 Comparison of peak oestradiol concentrations in studies evaluating human menopausal gonadotrophin (HMG) or recombinant (r) LH and rFSH with rFSH only. All values in the figure are statistically significantly different (P < 0.05).

Coomarasamy et al. (2008) conducted another meta-analysis comparing HMG to rFSH including only those trials utilizing a long agonist down-regulation protocol in assisted cycles. As a result of differing selection criteria, five trials included in the Al-Inany et al. (2008) meta-analysis were subsequently excluded from this study. In total, seven randomized trials, evaluating 2179 patient cycles, were analysed. The pooled absolute risk difference for live birth was 4% (95% CI 1 to 7%) with a relative increase (relative risk, RR) in live birth of 18% (RR 1.18, 95% CI 1.02 to 1.38) in the HMG group. Interestingly, despite the differences in exclusion criteria between the aforementioned meta-analyses, the resultant improvement in live birth outcome with HMG was similar (3–4% increase) (Al-Inany et al., 2008; Coomarasamy et al., 2008). With regard to the type of pituitary down-regulation, data showing that HMG cycles yield a 3–4% higher live birth rate than rFSH-only cycles have come from trials utilizing long GnRH agonists (Al-Inany et al., 2008; Coomarasamy et al., 2008). In a single randomized controlled trial comparing HMG to rFSH while using a GnRH antagonist, Bosch et al. (2008) demonstrated a 3% higher live birth rate in the HMG group. While this finding was non-significant (RR 1.09, 95% CI 0.78 to 1.51), the point estimate was consistent with that seen in live birth rates in GnRH agonist cycles utilizing HMG (3–4%) (Al-Inany et al., 2008; Coomarasamy et al., 2008). While the similar increase in live birth rates is notable, the data on HMG use in GnRH antagonist cycles is too limited to make definitive conclusions. In summary, studies have estimated that HMG protocols may provide a small (3–4%) but significant improvement in live birth rate compared with rFSH-only protocols when a long GnRH agonist protocol was utilized. While statistically significant, the clinical significance of this finding remains controversial. An important patient consideration has been that significantly fewer ampoules of gonadotrophins were required among those receiving HMG as compared with rFSH-only protocols, resulting in a lower cost

per live birth among the HMG group without compromising patient safety (Andersen et al., 2006; Kilani et al., 2003; Strehler et al., 2001; Wechowski et al., 2009; Westergaard et al., 2001). With the potential for lower treatment costs, there seems to be a benefit to the inclusion of HMG in treatment protocols.

The role of recombinant LH supplementation and assisted reproduction outcomes With the availability of recombinant LH (rLH), stimulation protocols have incorporated its use in place of HMG. Pharmacodynamic studies of rLH have shown it to have a similar volume of distribution, half-life and bioactivity to urinary products (European Recomb Human, 1998; Kaufmann et al., 2007; O’Dea et al., 2008; Shoham et al., 2008). These profiles have not differed whether rLH was administered s.c. or i.m. and have not been shown to affect FSH pharmacodynamics when co-administered (le Cotonnec et al., 1998a,b,c). Several randomized trials evaluated the use of rLH in assisted cycles (Balasch et al., 1995, 2001; Barrenetxea et al., 2008; Cedrin-Durnerin et al., 2004; De Placido et al., 2004, 2005; Durnerin et al., 2008; Fabregues et al., 2006; Griesinger et al., 2005; Humaidan et al., 2004; Kovacs et al., 2010; Lisi et al., 2005; Marrs et al., 2004; Matorras et al., 2009; NyboeAndersen et al., 2008; Sauer et al., 2004; Sills et al., 1999; Tarlatzis et al., 2006). Heterogeneity in study protocol design has made direct comparison of these trials challenging. For example, studies have varied greatly with regards to the type of down-regulation, rLH starting dose and the timing of initial rLH administration. Two randomized trials have shown higher pregnancy rates among those receiving rLH, supporting the possibility that the addition of LH may improve outcomes (Lisi et al., 2005; Matorras et al., 2009). In another study, patients with inadequate response to rFSH stimulation alone were randomized to receive a step-up protocol of rFSH by 150 IU or rLH

LH supplementation and assisted reproduction outcome supplementation of 150 IU (De Placido et al., 2005). Patients in the rLH group had a similar ongoing pregnancy rate to patients demonstrating a normal response, while those with an inadequate response receiving rFSH alone had a significantly lower pregnancy rate than those with normal response (rLH 32.5%, rFSH step up 22%, normal response 40.2%) This study suggests that rLH is more effective than increasing the dose of rFSH in patients with inadequate initial response to rFSH stimulation. While these studies have demonstrated improved pregnancy outcomes with rLH administration, the majority of randomized trials have failed to demonstrate improved pregnancy outcome (Balasch et al., 1995, 2001; Barrenetxea et al., 2008; Cedrin-Durnerin et al., 2004; De Placido et al., 2004, 2005; Durnerin et al., 2008; Fabregues et al., 2006; Griesinger et al., 2005; Humaidan et al., 2004; Kovacs et al., 2010; Lisi et al., 2005; Matorras et al., 2009; NyboeAndersen et al., 2008; Sauer et al., 2004; Sills et al., 1999; Tarlatzis et al., 2006). Like the trials evaluating HMG, these studies showed a consistent increase in peak oestradiol in patients given rLH compared with those receiving rFSH, supporting the concept of LH driving oestradiol production (Cedrin-Durnerin et al., 2004; De Placido et al., 2005; Griesinger et al., 2005; Levi-Setti et al., 2006; Lisi et al., 2005; Marrs et al., 2004; Sauer et al., 2004; Tarlatzis et al., 2006) (Figure 1). Four randomized trials have specifically noted that rLH may be beneficial in patients 35 years by increasing implantation rates (Bosch et al., 2011; Humaidan et al., 2004; Marrs et al., 2004; Matorras et al., 2009). However, these results could not be confirmed in another randomized trial (Fabregues et al., 2006). In the study by Bosch et al. (2011), patients were randomized to receive both rFSH and rLH or rFSH alone in GnRH antagonist cycles. Among patients <35 years, differences in implantation or pregnancy rates were not seen. However, among patients 35 years, the combination of rFSH and rLH resulted in higher implantation rates (OR 1.56, 95% CI 1.14 to 2.33) and the suggestion of a higher ongoing pregnancy rate (OR 1.49, 95% CI 0.93 to 2.38) (Bosch et al., 2011). Four meta-analyses have been published comparing rFSH alone to rFSH with rLH (Baruffi et al., 2007; Kolibianakis et al., 2007; Mochtar et al., 2007; Oliveira et al., 2007). In one of these meta-analyses, the use of rLH required fewer days of stimulation (P < 0.001, weighted mean difference 0.198, 95% CI 0.24 to 0.16) and fewer ampules of rFSH (P < 0.0001, weighted mean difference 192, 95% CI 220 to 164) (Oliveira et al., 2007). rLH administration was associated with higher serum oestradiol concentrations on the day of human chorionic gonadotrophin (HCG) administration (Baruffi et al., 2007; Oliveira et al., 2007). However, there was no difference in implantation, spontaneous abortion, clinical pregnancy or live birth rates in any of these studies (Baruffi et al., 2007; Kolibianakis et al., 2007; Mochtar et al., 2007; Oliveira et al., 2007). When considering pituitary down-regulation protocols, two meta-analyses of rLH in GnRH agonist cycles have not shown benefit to rLH supplementation (Kolibianakis et al., 2007; Oliveira et al., 2007). In trials utilizing GnRH antagonist, a meta-analysis showed an increase in peak oestradiol concentrations and a higher number of mature oocytes; however, there was no benefit in primary endpoints, namely implantation and pregnancy rates (Baruffi et al., 2007). It

265 remains unclear at this time whether rLH is beneficial in either GnRH agonist or antagonist cycles. In patients 35 years, four randomized trials suggest that rLH may be beneficial by increasing implantation rates (Humaidan et al., 2004; Marrs et al., 2004; Matorras et al., 2009); however, these results were not reproducible in another trial (Fabregues et al., 2006). In a study by Bosch et al. (2011), rLH was shown to benefit patients >35 years in GnRH antagonist cycles through higher implantation rates. However, patients 35 years old did not receive this same benefit. It is possible that assisted reproduction patients 35 years are more susceptible to profound LH suppression in GnRH antagonist cycles and are therefore the most likely to benefit from exogenous LH. Data from a Cochrane review (Mochtar et al., 2007) suggests that poor responders may also benefit from the addition of rLH. The authors of this review also suggested that women of advanced maternal age with an increased risk of pregnancy loss may benefit from the addition of rLH. Despite these suggestions, the data in this meta-analysis were of borderline significance and several of the studies analysed were missing data on miscarriage rates (Mochtar et al., 2007). Therefore these results should be interpreted with caution. While there is biological plausibility that the addition of LH may be beneficial to poor responders and women of advanced reproductive age, there is insufficient data to confirm this presently. In conclusion, the majority of the data demonstrate that, like HMG, rLH results in higher oestradiol concentrations and decreased usage of rFSH, but the data does not demonstrate convincing evidence that rLH improves pregnancy outcomes over rFSH alone. There are several possible explanations for why there may be demonstrable evidence of benefit with HMG but not when utilizing rLH. First, the studies performed to date utilizing rLH have had much smaller patient populations. The meta-analysis evaluating HMG versus rFSH failed to show a difference until more than 2200 patients were included, highlighting the limited absolute treatment effect (Al-Inany et al., 2008; Coomarasamy et al., 2008). The rLH meta-analyses have a much smaller pooled patient population (434–1227 patients) and therefore less power to detect a difference between treatment groups (Baruffi et al., 2007; Kolibianakis et al., 2007; Oliveira et al., 2007). Secondly, the studies evaluating rLH represented a much more heterogeneous group than those evaluating HMG. Thirdly, rLH and HMG may differ in their biological activity due to differences in LH glycosylation patterns and because of the addition of HCG in HMG. Finally, because of the fixed ratio of LH:FSH found in HMG, any addition of LH is coincident to the addition of FSH. Finally, due to its cost, studies have estimated that rLH may add 45% to the cost of ovarian stimulation despite the reduction in rFSH use (Mochtar et al., 2007).

The role of HCG in the mid- to late follicular phase Four randomized trials demonstrated that the use of HCG in the mid-follicular phase could significantly reduce FSH dosage without a reduction in pregnancy rates and may represent a decrease in stimulation-associated costs (Filicori et al., 2005; Gomes et al., 2007; Koichi et al., 2006; Serafini et al., 2006). However, these studies were not powered to

266 detect pregnancy or live birth rates as primary endpoints. In all but one study, the HCG protocol was associated with higher oestrogen concentrations on the day of HCG trigger. It is unclear if this protocol is associated with changes in risks of ovarian hyperstimulation syndrome as these studies were not powered for this outcome. In the HCG protocols, the partial reduction or complete withdrawal of FSH was associated with a reduction in small FSH-dependant follicles (Filicori et al., 2005; Koichi et al., 2006); however, the total oestradiol concentrations tended to be significantly higher (Filicori et al., 2005; Serafini et al., 2006). Taken together, these data and numerous other data from non-randomized controlled trials support the conclusion that HCG or LH in the mid- to late follicular phase can support continued follicular progression and oestradiol production in the face of partial or complete FSH withdrawal (Filicori et al., 1999, 2002a,b,c, 2005; Gomes et al., 2007; Koichi et al., 2006; Serafini et al., 2006; Venetis et al., 2009). The potential advantage of this protocol is the consumption of less FSH for ovarian stimulation, potentially leading to a cost saving. However, convincing cost analyses of mid-cycle HCG protocols are lacking. The data show mid-cycle HCG to be equivalent to FSH protocols and no advantages to outcomes have been reported. If these protocols are to gain widespread use, larger studies are needed which are powered to evaluate endpoints such as pregnancy and live birth.

FSH/LH ratio Day-3 gonadotrophin and oestradiol testing is typically included in the evaluation of ovarian reserve and the prediction of response to ovarian stimulation. Several authors have proposed utilizing the basal FSH:LH ratio as a predictor of ovarian response and assisted reproduction success. Noci et al. (2000) did not find any differences in outcomes between patients with an FSH:LH ratio >3:1 versus those <3:1. This is in contrast to several other retrospective studies which have shown significantly better outcomes in patients with an FSH:LH ratio <3:1, with more oocytes retrieved, more metaphase-II oocytes, higher fertilization rates and increased pregnancy rates (Barroso et al., 2001; Mukherjee et al., 1996; Orvieto et al., 2008; Shrim et al., 2006). Orvieto et al. (2009) retrospectively evaluated patients with FSH:LH ratios of >2:1 and >3:1 who had undergone treatment with two assisted cycles, once with an HMG-only protocol and once with a rFSH-only protocol. When the HMG cycles were compared with rFSH cycles, the HMG cycles resulted in significantly higher peak oestradiol, a higher oocyte maturity rate, more top-quality embryos, a higher implantation rate and a higher clinical pregnancy rate (44 versus 11%, P < 0.02). It is important to note that all of these studies have been retrospective and there is no randomized controlled data to demonstrate if the use of LH is beneficial for patients with an elevated FSH:LH ratio. More research is required to determine if pre-cycle testing can yield predictors that identify patients most likely to benefit from additional exogenous LH.

How much LH to supplement? When considering how much LH is needed for follicular development, the best data available is in truly hypogonadotrophic

MJ Hill et al. hypogonadal women. A dosing study of rLH in such patients suggested that 75 IU rLH is an appropriate dose to drive follicular development, oestradiol production and endometrial development (European Recomb Human, 1998). While this dose is sufficient in hypogonadotrophic patients, it is unclear if higher doses are optimal in assisted reproduction patients: studies of normal assisted reproduction populations have failed to clearly demonstrate the ideal LH dose. As mentioned, papers evaluating HMG show a 3–4% increase in live birth rate when pooled together. All of these studies utilizing HMG are essentially evaluating a 1:1 dose of FSH:LH; however they did not use a consistent approach to the amount of HMG given to generate a recommendation on dosing. When looking at studies using rLH, it is possible for investigators to become more flexible with the FSH:LH ratios (Table 2). However, there are insufficient studies evaluating these different ratios to make significant conclusions. From the available data, 75 IU LH is sufficient to develop follicles, oestradiol and endometrial growth in even the most profoundly LH-suppressed patients. Further studies are required to determine if higher doses are beneficial or in fact harmful.

Conclusions The data from numerous assisted reproduction studies confirm that most patients will respond to gonadotrophin preparations containing only FSH. However, 10–12% of patients may fail to respond adequately to this type of ovarian stimulation. Presumably these patients lack adequate concentrations of endogenous LH after pituitary down-regulation and would benefit from the addition of LH to ovarian stimulation. Clearly, patients with hypogonadotrophic hypogonadism require exogenous LH to achieve optimal assisted reproduction outcomes. A growing body of evidence also suggests that patients 35 years may have improved assisted reproduction outcomes with the addition of exogenous LH. Beyond that, clinicians have few tools available to identify either before or during ovarian stimulation which patients may benefit from additional LH activity. Providing some form of exogenous LH activity (HMG or rLH) for all assisted reproduction patients may represent the best way to ensure all patients in need of additional LH receive it. There is good clinical evidence to support using HMG in ovarian stimulation. Stimulation with HMG results in 3–4% higher live birth rate than rFSH alone. It is unclear if rLH is also beneficial. Similarly, HCG has been successfully used to completely replace FSH in the late follicular phase, but it is yet to be established whether this offers any distinct advantages over FSH stimulation alone. The use of both rLH and HCG to supplement ovarian stimulation may be associated with a substantial increase in stimulation cost and therefore more studies are needed to establish benefit both in terms of outcomes and cost effectiveness. Whatever type of LH activity is used in ovarian stimulation, it is clear from studies in hypogonadotrophic patients that 75 IU of LH activity has demonstrable biological activity. However, studies have not established an optimal dose of LH or an optimal ratio of FSH:LH supplementation to maximize outcomes in a typical assisted reproduction population. It is possible that such doses or ratios are patient specific and should be adjusted on a case-by-case basis as determined

Comparison of four randomized controlled trials evaluating mid- to late follicular-phase HCG with removal or decrease of FSH supplementation.

Trial

Protocol

Protocol details

Filicori et al. (2005)

HCG FSH or HMG HCG

200 IU/day HCG after 12 mm follicle growth 225-300 IU/day FSH or HMG

Koichi et al. (2006)

Antagonist

Serafini et al. (2006)

Agonist HCG Antagonist

Gomes et al. (2007)

Agonist HCG HMG FSH

200 IU/day HCG after 14 mm follicle growth plus 75 IU/day FSH and 0.25 mg/day cetrolix 0.25 mg/day cetrolix added to 300 IU/day FSH after 14 mm follicle growth Nasal GnRH then 225–300 IU/day FSH 200 IU/day HCG after 13–14 mm follicle growth plus 75 IU/day FSH and 0.25 mg/day cetrolix 0.25 mg/day cetrolix added to 300 IU/day FSH after 13–14 mm follicle growth 0.5 mg leuprolide then FSH 200 IU/day HCG after 12–13 mm follicle growth 225 IU/day HMG 200 IU/day FSH

No. of patients

Oestradiol on HCG day (pg/ml)

Fertilization rate (%)

Implantation rate (%)

Pregnancy rate (%)

48

3200a 2300a

74b 48b

12 11

25 21

192

2565c,d

73

24

39

1872c,d

77

25

37

2764c 4231e

73 NR

35 25

57 56

2411e

NR

18

35

2352e 3238 2164 2057

NR 71 59 55

20 70 80 39

41 35 33 53

323

51

LH supplementation and assisted reproduction outcome

Table 2

GnRH = gonadotrophin-releasing hormone; HCG = human chorionic gonadotrophin; HMG = human menopausal gonadotrophin. a P < 0.05 comparing HCG to HMG protocol. b P < 0.001 comparing HCG to HMG protocol. c P < 0.001 comparing agonist to both HCG and antagonist protocols. d P < 0.01 comparing HCG to antagonist protocol. e P < 0.001 when comparing HCG to both antagonist and agonist protocols.

267

268 by patient response to medication (i.e. oestradiol concentrations and follicle growth). GnRH antagonist and long GnRH agonist protocols result in distinctly different gonadotrophin hormone profiles. Despite this, both protocols result in profound exogenous LH suppression. Good data exists to support the use of HMG to improve outcomes in long GnRH agonist cycles. Data on using LH or HMG in GnRH antagonist cycles is currently limited, but substantial biological plausibility exists for LH supplement use in these cycles due to the profound and rapid LH suppression that occurs at a time in follicle development dominated by LH activity. In conclusion, the importance of LH in the biological process of follicular development and oocyte maturation should not be forgotten. The assisted reproduction practitioner should always bear the importance of adequate LH stimulation in mind. Future research should focus on several areas: (i) the benefits and cost effectiveness of rLH and human chorionic gonadotrophin (HCG); and (ii) methods for identifying patients who are most likely to benefit from LH supplementation, with either pre-stimulation or intra-stimulation parameters. Until such studies elicit a good method for identifying patients most likely to benefit from LH supplementation, the best way to improve assisted reproduction outcomes is to include some form of LH supplementation for all patients.

Acknowledgements This work was supported in part by the Program in Reproductive and Adult Endocrinology, NICHD, NIH, Bethesda, MD, USA. The authors would like to thank Mary E Ryan, MLS, National Institutes of Health Library, Bethesda for her assistance in performing literature searches for this manuscript.

References Al-Inany, H.G., Abou-Setta, A.M., Aboulghar, M.A., Mansour, R.T., Serour, G.I., 2008. Efficacy and safety of human menopausal gonadotrophins versus meta-analysis recombinant FSH: a mate-analysis. Reprod. BioMed. Online 16, 81–88. Al-Inany, H., Aboulghar, M.A., Mansour, R.T., Serour, G.I., 2005. Ovulation induction in the new millennium: recombinant follicle-stimulating hormone versus human menopausal gonadotropin. Gynecol. Endocrinol. 20, 161–169. Al-Inany, H., Aboulghar, M., Mansour, R., Serour, G., 2003. Meta-analysis of recombinant versus urinary-derived FSH: an update. Hum. Reprod. 18, 305–313. Andersen, A.N., Devroey, P., Arce, J.C., Grp, M., 2006. Clinical outcome following stimulation with highly purified hMG or recombinant FSH in patients undergoing IVF: a randomized assessor-blind controlled trial. Hum. Reprod. 21, 3217–3227. Balasch, J., Pen ˜arrubia, J., Fa ´bregues, F., Vidal, E., Casamitjana, R., Manau, D., Carmona, F., Creus, M., Vanrell, J.A., 2003. Ovarian responses to recombinant FSH or HMG in normogonadotrophic women following pituitary desensitization by a depot GnRH agonist for assisted reproduction. Reprod. BioMed. Online 7, 35–42. Balasch, J., Creus, M., Fabregues, F., Civico, S., Carmona, F., Puerto, B., Casamitjana, R., Vanrell, J.A., 2001. The effect of exogenous luteinizing hormone (LH) on oocyte viability: evidence from a comparative study using recombinant human

MJ Hill et al. follicle-stimulating hormone (FSH) alone or in combination with recombinant LH for ovarian stimulation in pituitary-suppressed women undergoing assisted reproduction. J. Assist. Reprod. Genet. 18, 250–256. Balasch, J., Miro, F., Burzaco, I., Casamitjana, R., Civico, S., Ballesca, J.L., Puerto, B., Vanrell, J.A., 1995. The role of luteinizing-hormone in human follicle development and oocyte fertility–evidence from in-vitro fertilization in a woman with long-standing hypogonadotropic hypogonadism and using recombinant human follicle-stimulating-hormone. Hum. Reprod. 10, 1678–1683. Barrenetxea, G., Agirregoikoa, J.A., Jimeenez, M.R., De Larruzea, A.L., Ganzabal, T., Carbonero, K., 2008. Ovarian response and pregnancy outcome in poor responder women: a randomized controlled trial on the effect of luteinizing hormone supplementation on in vitro fertilization cycles. Fertil. Steril. 89, 546–553. Barroso, G., Oehninger, S., Monzo, A., Kolm, P., Gibbons, W.E., Muasher, S.J., 2001. High FSH: LH ratio and low LH levels in basal cycle day 3: impact on follicular development and IVF outcome. J. Assist. Reprod. Genet. 18, 499–505. Baruffi, R., Mauri, A.L., Petersen, C., Felipe, V., Martins, A., Cornicelli, J., Cavagna, M., Oliveira, J., Franco, J., 2007. Recombinant LH supplementation to recombinant FSH during induced ovarian stimulation in the GnRH-antagonist protocol: a meta-analysis. Reprod. BioMed. Online 14, 14–25. Bosch, E., Labarta, E., Crespo, J., Simo ´n, C., Remohı´, J., Pellicer, A., 2011. Impact of luteinizing hormone administration on gonadotropin-releasing hormone antagonist cycles: an age-adjusted analysis. Fertil. Steril. 95, 1031–1036. Bosch, E., Vidal, C., Labarta, E., Simon, C., Remohi, J., Pellicer, A., 2008. Highly purified hMG versus recombinant FSH in ovarian hyperstimulation with GnRH antagonists – a randomized study. Hum. Reprod. 23, 2346–2351. Cedrin-Durnerin, I., Grange-Dujardin, D., Laffy, A., Parneix, I., Massin, N., Galey, J., Theron, L., Wolf, J.P., Conord, C., Clement, P., Jayot, S., Hugues, J.N., 2004. Recombinant human LH supplementation during GnRH antagonist administration in IVF/ICSI cycles: a prospective randomized study. Hum. Reprod. 19, 1979–1984. Chappel, S.C., Howles, C., 1991. Reevaluation of the roles of luteinizing-hormone and follicle-stimulating-hormone in the ovulatory process. Hum. Reprod. 6, 1206–1212. Coomarasamy, A., Afnan, M., Cheema, D., Van Der Veen, F., Bossuyt, P.M.M., Van Wely, M., 2008. Urinary hMG versus recombinant FSH for controlled ovarian hyperstimulation following an agonist long down-regulation protocol in IVF or ICSI treatment: a systematic review and meta-analysis. Hum. Reprod. 23, 310–315. Couzinet, B., Lestrat, N., Brailly, S., Forest, M., Schaison, G., 1988. Stimulation of ovarian follicular maturation with pure follicle-stimulating-hormone in women with gonadotropin-deficiency. Journal of Clinical Endocrinology and Metabolism 66, 552–556. Crowley, W.F., Mcarthur, J.W., 1980. Simulation of the normal menstrual-cycle in kallman syndrome by pulsatile administration of luteinizing-hormone-releasing hormone (LHRH). J. Clin. Endocrinol. Metab. 51, 173–175. De Placido, G., Alviggi, C., Perino, A., Strina, I., Lisi, F., Fasolino, A., De Palo, R., Ranieri, A., Colacurci, N., Mollo, A.Italian Collaborative Grp, R., 2005. Recombinant human LH supplementation versus recombinant human FSH (rFSH) step-up protocol during controlled ovarian stimulation in normogonadotrophic women with initial inadequate ovarian response to rFSH. A multicentre, prospective, randomized controlled trial. Hum. Reprod. 20, 390–396. De Placido, G., Alviggi, C., Mollo, A., Strina, I., Ranieri, A., Alviggi, E., Wilding, M., Varricchio, M.T., Borrelli, A.L., Conforti, S.,

LH supplementation and assisted reproduction outcome 2004. Effects of recombinant LH (rLH) supplementation during controlled ovarian hyperstimulation (COH) in normogonadotrophic women with an initial inadequate response to recombinant FSH (rFSH) after pituitary downregulation. Clin. Endocrinol. 60, 637–643. Diedrich, K., Devroey, P., Engels, S., Quartarolo, J.P., Hiller, K.F., Rudolf, K., Sterzik, K., Van Der, V., Verhoeven, H.C., Dirnfeld, M., Dor, J., Ron-El, R., Laufer, N., Levran, D., Shalev, E., Jansen, C., Schmoutziguer, A., Germound, M., Haeberle, M., Kingsland, C., Johnson, M., Klentzeris, L., Murdoch, A., Sathanandan, S., Sharp, N.European Israeli Study Grp, H., 2002. Efficacy and safety of highly purified menotropin versus recombinant follicle-stimulating hormone in in vitro fertilization/intracytoplasmic sperm injection cycles: a randomized, comparative trial. Fertil. Steril. 78, 520–528. Durnerin, C.I., Erb, K., Fleming, R., Hillier, H., Hillier, S.G., Howles, C.M., Hugues, J.N., Lass, A., Lyall, H., Rasmussen, P., Thong, J., Traynor, I., Westergaard, L., Yates, R., Luveris Pretreatment, G., 2008. Effects of recombinant LH treatment on folliculogenesis and responsiveness to FSH stimulation. Hum. Reprod. 23, 421–426. European Recomb Human, L.H.S.G., 1998. Recombinant 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. 83, 1507–1514. The European and Israeli Study Group on Highly Purified Menotropin versus Recombinant Follicle-Stimulating Hormone, 2002. Efficacy and safety of highly purified menotropin versus recombinant follicle stimulating hormone in in vitro fertilization/intracytoplasmic sperm injection cycles: a randomized, comparative trial. Fertil. Steril. 78, 520–528. Fabregues, F., Creus, M., Penarrubia, J., Manau, D., Vanrell, J.A., Balasch, J., 2006. Effects of recombinant human luteinizing hormone supplementation on ovarian stimulation and the implantation rate in down-regulated women of advanced reproductive age. Fertil. Steril. 85, 925–931. Filicori, M., Cognigni, G.E., Gamberini, E., Parmegiani, L., Troilo, E., Roset, B., 2005. Efficacy of low-dose human chorionic gonadotropin alone to complete controlled ovarian stimulation. Fertil. Steril. 84, 394–401. Filicori, M., Cognigni, G.E., Pocognoli, P., Ciampaglia, W., Bernardi, S., 2003. Current concepts and novel applications of LH activity in ovarian stimulation. Trends Endocrinol. Metab. 14, 267–273. Filicori, M., 2003. Use of luteinizing hormone in the treatment of infertility: time for reassessment? Fertil. Steril. 79, 253–255. Filicori, M., Cognigni, G.E., Samara, A., Melappioni, S., Perri, T., Cantelli, B., Parmegiani, L., Pelusi, G., Dealoysio, D., 2002a. The use of LH activity to drive folliculogenesis: exploring uncharted territories in ovulation induction. Hum. Reprod. Update 8, 543–557. Filicori, M., Cognigni, G.E., Tabarelli, C., Pocognoli, P., Taraborrelli, S., Spettoli, D., Ciampaglia, W., 2002b. Stimulation and growth of antral ovarian follicles by selective LH activity administration in women. J. Clin. Endocrinol. Metab. 87, 1156–1161. Filicori, M., Cognigni, G.E., Taraborrelli, S., Parmegiani, L., Bernardi, S., Ciampaglia, W., 2002c. Intracytoplasmic sperm injection pregnancy after low-dose human chorionic gonadotropin alone to support ovarian folliculogenesis. Fertil. Steril. 78, 414–416. Filicori, M., Cognigni, G.E., Taraborrelli, S., Spettoli, D., Ciampaglia, W., De Fatis, C.T., Pocognoli, P., 1999. Luteinizing hormone activity supplementation enhances follicle-stimulating hormone efficacy and improves ovulation induction outcome. J. Clin. Endocrinol. Metab. 84, 2659–2663.

269 Fleming, R., Chung, C.C., Yates, R.W.S., Coutts, J.R.T., 1996. Purified urinary follicle stimulating hormone induces different hormone profiles compared with menotrophins, dependent upon the route of administration and endogenous luteinizing hormone activity. Hum. Reprod. 11, 1854–1858. Gomes, M.K.O., Vieira, C.S., Moura, M.D., Manetta, L.A., Leite, S.P., Reis, R.M., Ferriani, R.A., 2007. Controlled ovarian stimulation with exclusive FSH followed by stimulation with hCG alone, FSH alone or hMG. Eur. J. Obstet. Gynecol. Reprod. Biol. 130, 99–106. Gordon, U.D., Harrison, R.F., Fawzy, M., Hennelly, B., Gordon, A.C., 2001. A randomized prospective assessor-blind evaluation of luteinizing hormone dosage and in vitro fertilization outcome. Fertil. Steril. 75, 324–331. Griesinger, G., Schultze-Mosgau, A., Dafopoulos, K., Schroeder, A., Schroer, A., Von Otte, S., Hornung, D., Diedrich, K., Felberbaum, R., 2005. Recombinant luteinizing hormone supplementation to recombinant follicle-stimulating hormone induced ovarian hyperstimulation in the GnRH-antagonist multiple-dose protocol. Hum. Reprod. 20, 1200–1206. Hillier, S.G., 2001. Gonadotropic control of ovarian follicular growth and development. Mol. Cell. Endocrinol. 179, 39–46. Hillier, S.G., 1994. Current concepts of the roles of follicle-stimulating-hormone and luteinizing-hormone in folliculogenesis. Hum. Reprod. 9, 188–191. Homburg, R., Armar, N.A., Eshel, A., Adams, J., Jacobs, H.S., 1988. Influence of serum luteinizing-hormone concentrations on ovulation, conception, and early-pregnancy loss in polycystic ovary syndrome. Br. Med. J. 297, 1024–1026. Hompes, P.G.A., Broekmans, F.J., Hoozemans, D.A., Schats, R., Grp, F., 2008. Effectiveness of highly purified human menopausal gonadotropin vs. recombinant follicle-stimulating hormone in first-cycle in vitro fertilization-intracytoplasmic sperm injection patients. Fertil. Steril. 89, 1685–1693. Humaidan, P., Bungum, M., Bungum, L., Andersen, C.Y., 2004. Effects of recombinant LH supplementation in women undergoing assisted reproduction with GnRH agonist down-regulation and stimulation with recombinant FSH: an opening study. Reprod. BioMed. Online 8, 635–643. Jansen, C.A.M., Van Os, H.C., Out, H.J., Bennink, H., 1998. A prospective randomized clinical trial comparing recombinant follicle stimulating hormone (Puregon) and human menopausal gonadotrophins (Humegon) in non-down-regulated in-vitro fertilization patients. Hum. Reprod. 13, 2995–2999. Kaufmann, R., Dunn, R., Vaughn, T., Hughes, G., O’brien, F., Hemsey, G., Thomson, B., O’dea, L.S.L., 2007. Recombinant human luteinizing hormone, lutropin alfa, for the induction of follicular development and pregnancy in profoundly gonadotrophin-deficient women. Clin. Endocrinol. 67, 563–569. Kilani, Z., Dakkak, A., Ghunaim, S., Cognigni, G.E., Tabarelli, C., Parmegiani, L., Filicori, M., 2003. A prospective, randomized, controlled trial comparing highly purified hMG with recombinant FSH in women undergoing ICSI: ovarian response and clinical outcomes. Hum. Reprod. 18, 1194–1199. Koichi, K., Yukiko, N., Shima, K., Sachiko, S., 2006. Efficacy of low-dose human chorionic gonadotropin (hCG) in a GnRH antagonist protocol. J. Assist. Reprod. Genet. 23, 223–228. Kolibianakis, E.M., Kalogeropoulou, L., Griesinger, G., Papanikolaou, E.G., Papadimas, J., Bontis, J., Tarlatzis, B.C., 2007. Among patients treated with FSH and GnRH analogues for in vitro fertilization, is the addition of recombinant LH associated with the probability of live birth? A systematic review and meta-analysis. Hum. Reprod. Update 13, 445–452. Kovacs, P., Kovats, T., Kaali, S.G., 2010. Results with early follicular phase recombinant luteinizing hormone supplementation during stimulation for in vitro fertilization. Fertil. Steril. 93, 475–479.

270 Lahoud, R., Al-Jefout, M., Tyler, J., Ryan, J., Driscoll, G., 2006. A relative reduction in mid-follicular LH concentrations during GnRH agonist IVF/ICSI cycles leads to lower live birth rates. Hum. Reprod. 21, 2645–2649. Le Cotonnec, J.Y., Loumaye, E., Porchet, H.C., Beltrami, V., Munafo, A., 1998a. Pharmacokinetic and pharmacodynamic interactions between recombinant human luteinizing hormone and recombinant human follicle-stimulating hormone. Fertil. Steril. 69, 201–209. Le Cotonnec, J.Y., Porchet, H.C., Beltrami, V., Munafo, A., 1998b. Clinical pharmacology of recombinant human luteinizing hormone: Part I. Pharmacokinetics after intravenous administration to healthy female volunteers and comparison with urinary human luteinizing hormone. Fertil. Steril. 69, 189–194. Le Cotonnec, J.Y., Porchet, H.C., Beltrami, V., Munafo, A., 1998c. Clinical pharmacology of recombinant human luteinizing hormone: Part II. Bioavailability of recombinant human luteinizing hormone assessed with an immunoassay and an in vitro bioassay. Fertil. Steril. 69, 195–200. Levi-Setti, P.E., Cavagna, M., Bulletti, C., 2006. Recombinant gonadotrophins associated with GnRH antagonist (cetrorelix) in ovarian stimulation for ICSI: comparison of r-FSH alone and in combination with r-LH. Eur. J. Obstet. Gynecol. Reprod. Biol. 126, 212–216. Lisi, F., Rinaldi, L., Fishel, S., Caserta, D., Lisi, R., Campbell, A., 2005. Evaluation of two doses of recombinant luteinizing hormone supplementation in an unselected group of women undergoing follicular stimulation for in vitro fertilization. Fertil. Steril. 83, 309–315. Marrs, R., Meldrum, D., Muasher, S., Schoolcraft, W., Werlin, L., Kelly, E., 2004. Randomized trial to compare the effect of recombinant human FSH (follitropin alfa) with or without recombinant human LH in women undergoing assisted reproduction treatment. Reprod. BioMed. Online 8, 175–182. Matorras, R., Prieto, B., Exposito, A., Mendoza, R., Crisol, L., Herranz, P., Burgues, S., 2009. Mid-follicular LH supplementation in women 35–39 years undergoing ICSI cycles: a randomized controlled study. Reprod. BioMed. Online 19, 879–887. Mochtar, M.H., Van Der, V., Ziech, M., Van Wely, M., 2007. Recombinant luteinizing hormone (rLH) for controlled ovarian hyperstimulation in assisted reproductive cycles. Cochrane Database Syst. Rev. 18, CD005070. Mukherjee, T., Copperman, A.B., Lapinski, R., Sandler, B., Bustillo, M., Grunfeld, L., 1996. An elevated day three follicle-stimulating hormone luteinizing hormone ratio (FSH:LH) in the presence of a normal day 3 FSH predicts a poor response to controlled ovarian hyperstimulation. Fertil. Steril. 65, 588–593. Ng, E.H.Y., Lau, E.Y.L., Yeung, W.S.B., Ho, P.C., 2001. Hmg is as good as recombinant human FSH in terms of oocyte and embryo quality: a prospective randomized trial. Hum. Reprod. 16, 319–325. Noci, I., Maggi, M., Fuzzi, B., Biagiotti, R., Ricci, F., Marchionni, M., 2000. Effects of low day 3 luteinizing hormone levels on in vitro fertilization treatment outcome. Gynecol. Endocrinol. 14, 321–326. Nyboeandersen, A., Humaidan, P., Fried, G., Hausken, J., Antila, L., Bangsboll, S., Rasmussen, P.E., Lindenberg, S., Bredkjaer, H.E., Meinertz, H., Nordic, L.H.S.G., 2008. Recombinant LH supplementation to recombinant FSH during the final days of controlled ovarian stimulation for in vitro fertilization. A multicentre, prospective, randomized, controlled trial. Hum. Reprod. 23, 427–434. O’dea, L., O’brien, F., Currie, K., Hemsey, G., 2008. Follicular development induced by recombinant luteinizing hormone (LH) and follicle-stimulating hormone (FSH) in anovulatory women with LH and FSH deficiency: evidence of a threshold effect. Curr. Med. Res. Opin. 24, 2785–2793.

MJ Hill et al. Oliveira, J.B.A., Mauri, A.L., Petersen, C.G., Martins, A.M.C., Cornicelli, J., Cavanha, M., Pontes, A., Baruffi, R.L.R., Franco, J.G., 2007. Recombinant luteinizing hormone supplementation to recombinant follicle-stimulation hormone during induced ovarian stimulation in the GnRH-agonist protocol: a meta-analysis. J. Assist. Reprod. Genet. 24, 67–75. Orvieto, R., Homburg, R., Meltcer, S., Rabinson, J., Anteby, E.Y., Nahum, R., 2009. HMG improves IVF outcome in patients with high basal FSH/LH ratio: a preliminary study. Reprod. BioMed. Online 18, 205–208. Orvieto, R., Meltzer, S., Rabinson, J., Gemer, O., Anteby, E.Y., Nahum, R., 2008. Does day 3 luteinizing-hormone level predict IVF success in patients undergoing controlled ovarian stimulation with GnRH analogues? Fertil. Steril. 90, 1297–1300. Overes, H., Deleeuw, R., Kloosterboer, H.J., 1992. Regulation of aromatase-activity in FSH-primed rat granulosa-cells invitro by follicle-stimulating-hormone and various amounts of human chorionic-gonadotropin. Hum. Reprod. 7, 191–196. Platteau, P., Andersen, A.N., Balen, A., Devroey, P., Sorensen, P., Helmgaard, L., Arce, J.C., Grp, M.O.I.S., 2006. Similar ovulation rates, but different follicular development with highly purified menotrophin compared with recombinant FSH in WHO Group II anovulatory infertility: a randomized controlled study. Hum. Reprod. 21, 1798–1804. Rashidi, B.H., Sarvi, F., Tehrani, E.S., Zayeri, F., Movahedin, M., Khanafshar, N., 2005. The effect of HMG and recombinant human FSH on oocyte quality: a randomized single-blind clinical trial. Eur. J. Obstet. Gynecol. Reprod. Biol. 120, 190–194. Regan, L., Owen, E.J., Jacobs, H.S., 1990. Hypersecretion of luteinizing-hormone, infertility, and miscarriage. Lancet 336, 1141–1144. Reshef, E., Lei, Z.M., Rao, C.V., Pridham, D.D., Chegini, N., Luborsky, J.L., 1990. The presence of gonadotropin receptors in nonpregnant human uterus, human placenta, fetal membranes, and decidua. J. Clin. Endocrinol. Metab. 70, 421–430. Sauer, M.V., Thornton, M.H., Schoolcraft, W., Frishman, G.N., 2004. Comparative efficacy and safety of cetrorelix with or without mid-cycle recombinant LH and leuprolide acetate for inhibition of premature LH surges in assisted reproduction. Reprod. BioMed. Online 9, 487–493. Schoot, D.C., Harlin, J., Shoham, Z., Mannaerts, B., Lahlou, N., Bouchard, P., Bennink, H., Fauser, B., 1994. Recombinant human follicle-stimulating-hormone and ovarian response in gonadotropin-deficient women. Hum. Reprod. 9, 1237–1242. Serafini, P., Yadid, I., Motta, E.L.A., Alegretti, J.R., Fioravanti, J., Coslovsky, M., 2006. Ovarian stimulation with daily late follicular phase administration of low-dose human chorionic gonadotropin for in vitro fertilization: a prospective, randomized trial. Fertil. Steril. 86, 830–838. Shemesh, M., 2001. Actions of gonadotrophins on the uterus. Reproduction 121, 835–842. Shoham, Z., Smith, H., Yeko, T., O’brien, F., Hemsey, G., O’dea, L., 2008. Recombinant LH (lutropin alfa) for the treatment of hypogonadotrophic women with profound LH deficiency: a randomized, double-blind, placebo-controlled, proof-of-efficacy study. Clin. Endocrinol. 69, 471–478. Shoham, Z., 2002. The clinical therapeutic window for luteinizing hormone in controlled ovarian stimulation. Fertil. Steril. 77, 1170–1177. Shrim, A., Elizur, S.E., Seidman, D.S., Rabinovici, J., Wiser, A., Dor, J., 2006. Elevated day 3 FSH/LH ratio due to low LH concentrations predicts reduced ovarian response. Reprod. BioMed. Online 12, 418–422. Sills, E.S., Levy, D.P., Moomjy, M., Mcgee, M., Rosenwaks, Z., 1999. A prospective, randomized comparison of ovulation induction using highly purified follicle-stimulating hormone alone and with

LH supplementation and assisted reproduction outcome recombinant human luteinizing hormone in in-vitro fertilization. Hum. Reprod. 14, 2230–2235. Smitz, J., Andersen, A.N., Devroey, P., Arce, J.C., 2007. Endocrine profile in serum and follicular fluid differs after ovarian stimulation with HP-hMG or recombinant FSH in IVF patients. Hum. Reprod. 22, 676–687. Stanger, J.D., Yovich, J.L., 1985. Reduced invitro fertilization of human oocytes from patients with raised basal luteinizing-hormone levels during the follicular phase. Br. J. Obstet. Gynaecol. 92, 385–393. Strehler, E., Abt, M., El-Danasouri, I., De Santo, M., Sterzik, K., 2001. Impact of recombinant follicle-stimulating hormone and human menopausal gonadotropins on in vitro fertilization outcome. Fertil. Steril. 75, 332–336. Tarlatzis, B., Tavmergen, E., Szamatowicz, M., Barash, A., Amit, A., Levitas, E., Shoham, Z., 2006. The use of recombinant human LH (lutropin alfa) in the late stimulation phase of assisted reproduction cycles: a double-blind, randomized, prospective study. Hum. Reprod. 21, 90–94. Tesarik, J., Mendoza, C., 2002. Effects of exogenous LH administration during ovarian stimulation of pituitary down-regulated young oocyte donors on oocyte yield and developmental competence. Hum. Reprod. 17, 3129–3137. Van Wely, M., Bayram, N., Van Der Veen, F., 2003. Recombinant FSH in alternative doses or versus urinary gonadotrophins for ovulation induction in subfertility associated with polycystic ovary syndrome: a systematic review based on a Cochrane review. Hum. Reprod. 18, 1143–1149.

271 Venetis, C.A., Kolibianakis, E.M., Tarlatzi, T.B., Tarlatzis, B.C., 2009. Benefits of luteinizing hormone activity in ovarian stimulation for IVF. Reprod. BioMed. Online 18, S31–S36. Wechowski, J., Connolly, M., Schneider, D., Mcewan, P., Kennedy, R., 2009. Cost-saving treatment strategies in in vitro fertilization: a combined economic evaluation of two large randomized clinical trials comparing highly purified human menopausal gonadotropin and recombinant follicle-stimulating hormone alpha. Fertil. Steril. 91, 1067–1076. Westergaard, L.G., Erb, K., Laursen, S.B., Rex, S., Rasmussen, P.E., 2001. 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. Fertil. Steril. 76, 543–549. Yong, E.L., Baird, D.T., Yates, R., Reichert, L.E., Hillier, S.G., 1992. Hormonal-regulation of the growth and steroidogenic function of human granulosa-cells. J. Clin. Endocrinol. Metab. 74, 842–849. Declaration: The authors report no financial or commercial conflicts of interest.Disclaimer: The views expressed in this manuscript are those of the authors and do not reflect the official policy or position of the Department of the Army, Department of Defense or the US Government. Received 10 August 2011; refereed 11 November 2011; accepted 14 December 2011.