- Email: [email protected]
Gonadotropin-releasing hormone (GnRH) antagonist plus recombinant luteinizing hormone vs. a standard GnRH agonist short protocol in patients at risk for poor ovarian response
Gonadotropin-releasing hormone (GnRH) antagonist plus recombinant luteinizing hormone vs. a standard GnRH agonist short protocol in patients at risk for poor ovarian response Various studies have compared the efficacy of GnRH agonists (GnRH-a) and antagonists (GnRH-ant) for controlled ovarian stimulation (COS) in women undergoing IVF. Nevertheless, few data are available about the use of GnRH-ant in poor responders. Here, a flexible protocol providing a gradual increase in the dose of GnRH-ant in association with recombinant LH (rec-LH) administration is compared with the standard GnRH-a flare-up protocol in 133 women at risk for poor ovarian response. The mean number of metaphase 2 oocytes (primary end point) was significantly higher in the antagonist group (5.73 ⫾ 3.57 vs. 4.64 ⫾ 2.23, respectively; P⬍.05). (Fertil Steril威 2006;85:247–50. ©2006 by American Society for Reproductive Medicine.)
Poor ovarian response to COS occurs in 9%–24% of women undergoing IVF programs (1). The GnRH-a short protocol appears to improve the ovarian outcome in patients at risk for reduced ovarian responsiveness (2, 3) and represents a less costly procedure. This strategy, in association with recombinant FSH (rec-FSH), is considered a first-choice treatment for patients in our IVF unit (4). Nevertheless, these protocols lead to an increase in the LH levels during the early follicular maturation (i.e., flare effect), which in turn may affect oocyte quality (5). The administration of GnRH-ant is not associated with endogenous gonadotropin release, induces a rapid and profound suppression of the pituitary function, and can be limited in the last days of gonadotropin therapy (6). On this basis, GnRH-ant protocols have been recently proposed as a new option for treating poor responders (7–10). Recent data from the donor oocyte model indicate that GnRH-ant administration followed by a decline in serum LH and estradiol (E2) affects the oocyte/embryo quality and results in adverse outcomes in recipients (11). As expected, a significant increase in the percentage of mature oocytes and implantation rate was found in recipients whose embryos originate from donors receiving GnRH-ant administration plus LH supplementation when compared with donors treated with GnRH-ant alone (12). The aim of this prospective randomized trial was to compare a personalized flexible protocol that provides both a gradual increase in the dose of GnRH-ant and the addition of rec-LH, with the standard GnRH-a short protocol, in patients at risk for poor ovarian response when undergoing intracytoplasmic sperm injection (ICSI). Received June 14, 2004; revised and accepted July 8, 2005. Reprint requests: Carlo Alviggi, M.D., University of Naples, Obstetrical and Gynaecological Sciences, 132 via Luigi Caldieri, Naples 80128, Italy (FAX: ⫹39-081-7463747; E-mail: [email protected]).
0015-0282/06/$32.00 doi:10.1016/j.fertnstert.2005.07.1280
Our institutional review board approved the study protocol, and all the patients signed a consent form before entering in the study. On the basis of our previous results (13) and having the mean number of mature oocytes as the primary end point, it has been calculated that a sample size of 58 patients in each group will have an 80% power to detect a difference in means of 1.0, using a one-way analysis of variance (ANOVA), with a .05 two-sided significance level. To allow for dropouts, we enrolled a total of 140 patients, who were at risk for poor ovarian responsiveness when undergoing the first COS/ICSI attempt, at our institution between July 2002 and February 2004. The following inclusion criteria were used: age ⱖ37 years or day 2 FSH (basal FSH) serum concentration ⱖ 9 IU/L; menstrual cycles ranging from 24 –35 days (intraindividual variability ⫾ 3 days), and hysteroscopic evidence of a normal uterine cavity. Only couples undergoing ICSI were included because we chose the mean number of mature oocyte as the primary end point. In fact, this technique requires removal of the cumulus oophorus, which in turn allows the assessment of gametes maturation. The following exclusion criteria were adopted: body mass index (BMI ⫽ weight [kg]/ height [m2]) ⬎26; biochemical or ultrasonographic (USG) evidence of polycystic ovary syndrome, and stage III–IV endometriosis according to the revised American Fertility Society classification (rAFS, 1985); inflammatory, autoimmune, and chromosomal disorders; endocrine and metabolic disease, including hyperprolactinemia; or the presence of only one ovary. All the patients received a daily dose of 300IU of recFSH (Gonal F; Industria Farmaceutica Serono, Rome, Italy), beginning on the second day of their cycles. The rec-FSH daily dose was adjusted on the basis of the ovarian response beginning on the fifth day of stimulation. Patients were randomized into two groups using a computergenerated list. In the antagonist group, a dose of 0.125
Fertility and Sterility姞 Vol. 85, No. 1, January 2006 Copyright ©2006 American Society for Reproductive Medicine, Published by Elsevier Inc.
247
mg/day of the GnRH-ant cetrorelix (Cetrotide; Industria Farmaceutica Serono, Rome, Italy) was administered for 2 days, beginning when at least one follicle ⱖ14 mm was present; thereafter, the GnRH-ant full dose of 0.25 mg/day was given until the day of the exogenous hCG administration. Beginning on the same day of GnRH-ant administration, a daily dose of 150 IU of rec-LH (Luveris; Industria Farmaceutica Serono, Rome, Italy) was also added until the day of hCG. Controls (agonist group) received daily a dose of triptorelin (Decapeptyl 0.1 mg.; Ipsen S.p.A., Milan, Italy) of 0.1 mg SC, beginning on the same day of the first rec-FSH administration. In addition, in this group, a dose of 150 IU/day of rec-LH was added when at least one follicle reached 14 mm. When at least one follicle reached 18 –20 mm in diameter, the standard dose (10,000 IU IM) of hCG (Gonasi; AMSA, Roma, Italy) was administered to trigger ovulation. Transvaginal oocyte retrieval was performed 34 –36 hours later. Of the 140 patients included in the study, 7 did not begin stimulation for personal reasons. Thus, a total of 133 subjects underwent ovarian stimulation (antagonist group: n ⫽ 67; agonist group: n ⫽ 66). Baseline characteristics of the patients were similar in the two groups. In particular, the mean age of the women was 37.16 ⫾ 4.14 years for the antagonist group and 37.32 ⫾ 3.72 years for the agonist group. The FSH mean levels measured on day 2 of the cycle were 7.64 ⫾ 4.12 IU/L in the antagonist group and 8.45 ⫾ 4.23 IU/L in the agonist group. Indications for IVF were also homogeneously distributed in the two groups. Four patients in the antagonist group and five women in the agonist group had their cycles cancelled because of an inadequate ovarian response. In Table 1, stimulation data, endocrine parameters, and cycle results are separately listed per started cycles (i.e., intention to treat) and completed cycles. No premature LH surge was observed in the two groups. The mean number of mature oocytes retrieved per started cycle was significantly higher (P⬍.05) in the antagonist group (5.73 ⫾ 3.57 vs. 4.64 ⫾ 2.23). Conversely, no statistically significant difference in the total number of cumulus oocyte complexes (COCs) retrieved (6.79 ⫾ 3.89 vs. 6.54 ⫾ 3.08, respectively) was observed between groups. Serum E2 levels on day 5 of stimulation were 325.92 ⫾ 251.45 pg/mL and 439.80 ⫾ 266.91 in the antagonist and agonist groups, respectively (P⬍.05). Implantation rate, pregnancy rate, and ongoing pregnancy rate per started cycle were comparable in the antagonist and agonist groups (10.93% vs. 9.28%; 25.37% vs. 21.21%; 24.24% vs. 17.91%, respectively). In the present study, a new flexible GnRH-ant protocol, based on both progressive increase in the cetrorelix dose and LH supplementation, has been compared with a standard GnRH-a short protocol in patients at risk for poor ovarian response. The main finding of the study was a 248
De Placido et al.
Correspondence
significant increase in the mean number of mature oocytes (primary end point) in the GnRH-ant group. The explanation for this evidence may be related to the fact that this protocol provides a physiological LH environment during follicular maturation. In fact, LH activity is relatively low during the menstrual period and progressively increases throughout the mid- to late-follicular phase (14). At that stage, LH induces granulosa cell growth and differentiation by promoting local peptide synthesis and release. Moreover, LH induces epidermal growth factor (EGF) production in the theca interstitial cells and indirectly promotes E2 release by granulosa cells. These variables appear to be part of a complex signalling for oocyte maturation (9, 12). On this basis, it could be concluded that both the GnRH-a short protocol and GnRH-ant administration for COS are related to less physiological patterns of LH activity throughout follicular maturation. The former usually leads to an excessive increase in LH levels during the early stages of follicular development, which in turn may impair the normal process of oocyte maturation and cause atretic degeneration (5); the latter is associated with a physiological environment during the early stages of folliculogenesis. Nevertheless, a decline in both LH and E2 production usually follows the administration of the GnRH-ant, which in turn may affect crucial mechanisms of autocrine or paracrine regulation of granulosa cell maturation and oocyte differentiation (11). In contrast, our study protocol may have modulated a decline in endogenous gonadotropins by progressively increasing the GnRH-ant dose; furthermore, this decline may have contemporarily been balanced by the exogenous LH supplementation. In the present study, implantation and pregnancy rates were 10.93% and 25.37%, respectively, in the antagonist group and 9.28% and 21.21% in the agonist group. The lack of statistically significant differences may be because the power analysis had not been performed having one of these categorical variables as primary end point. Our results are in contrast with the only published prospective randomized trial comparing GnRH-ant and standard GnRH-a short protocols in poor responders (8). In fact, these authors failed to find significant differences in both ovarian and IVF outcomes between groups. This discrepancy may derive from the lack of LH supplementation. This interpretation is consistent with other data derived from the oocyte donor model. Acevedo et al. (12) have recently demonstrated that LH supplementation in donors receiving a GnRH-ant plus rec-FSH protocol can improve the percentage of mature oocytes. Furthermore, the association of GnRH-ant and rec-LH provided a significant increase in the implantation rate in recipients in comparison with the standard GnRH-ant protocol. The authors concluded that their results could be related to the fact that in GnRH-ant cycles (where ⬎ 80% of LH release is abolished in the first 24 hours), the addition of LH could be crucial for sustaining E2 synthesis and paracrine proVol. 85, No. 1, January 2006
TABLE 1 Ovarian and IVF outcome of the 133 patients who started the cycles and 124 women who underwent OR and embryo transfer. Started cycles Antagonist group
Agonist group
Completed cycles Antagonist group
Agonist group
No. of patients 66 67 62 62 Cancelled cycles 4 5 Duration of stimulation (days) — — 11.73 ⫾ 2.04 11.27 ⫾ 2.10 No. of rFSH ampoules — — 42.31 ⫾ 10.19 41.37 ⫾ 8.00 No. of rLH ampoules — — 7.13 ⫾ 2.05 7.19 ⫾ 2.03 Duration of GnRH-antagonist — — 3.74 ⫾ 0.65 — administration (days) No. of GnRH-antagonist — — 2.73 ⫾ 0.68 — ampoules No. of GnRH-agonist — — — 11.27 ⫾ 2.11 ampoules 325.92 ⫾ 251.45a 439.8 ⫾ 266.91a 348.63 ⫾ 248.36a 463.18 ⫾ 260.25a Day 5 E2 concentration (pg/mL) — — 1303.27 ⫾ 770.33 1436.73 ⫾ 725.34 E2 when follicle ⱖ 14 mm was present (pg/mL) LH when follicle ⱖ 14 mm — — 2.48 ⫾ 2.11 3.11 ⫾ 2.67 was present (IU/L) E2 at hCG day (pg/mL) — — 1857.43 ⫾ 912.28 2158.9 ⫾ 1041.36 No. of COCs retrieved 6.79 ⫾ 3.89 6.54 ⫾ 3.08 7.23 ⫾ 3.60 7.06 ⫾ 2.55 No. of mature oocyte (M2) 5.73 ⫾ 3.57a 4.64 ⫾ 2.23a 6.09 ⫾ 3.36a 5.02 ⫾ 1.86a Fertilization rate (%) 90.78 89.42 — — No. of 2PN oocytes 4.62 ⫾ 2.88a 3.69 ⫾ 1.92a 4.91 ⫾ 2.71a 3.98 ⫾ 1.66a No. of embryos per transfer 2.87 ⫾ 0.86 2.77 ⫾ 0.88 — — Implantation rate (%) 10.93 9.28 — — Pregnancy rate (%) 25.37 21.21 27.42 22.58 Ongoing pregnancy rate (%) 24.24 17.91 25.81 19.35 Note: Values expressed as mean ⫾ SD. a Antagonist group vs. agonist group: P ⬍ .05. De Placido. GnRH-ant plus rec-LH in poor responders. Fertil Steril 2006.
duction of peptides that are necessary for oocyte differentiation. In this context, it should be emphasized that the donor oocyte cycles provide an optimal “in vivo” model for evaluating the impact of hormonal variables on sole oocyte/ embryo quality and excluding the endometrium as covariable. A recent prospective randomized trial (15) did not evidence significant improvement in the ovarian response by adding rec-LH in a GnRH-ant protocol. Nevertheless, a comparison between our results and these results is not feasible due to the following methodological differences. First, the study was performed in young normogonadotropic women who were not selected as poor responders. Moreover, patients undergoing a standard GnRH-a long protocol represented the control population. Finally, Fertility and Sterility姞
rec-LH supplementation was provided with a daily dose of 75 IU. In conclusion, our study demonstrates that the proposed protocol for COS can be usefully administered in patients at risk for poor ovarian response, such as older women and subjects with high FSH basal levels. When compared with a standard GnRH-a short protocol, this strategy led to a significant improvement of the oocyte quality and maturation process, which in turn resulted in a significant increase in the mean number of mature oocytes. These results are encouraging for the design of further and adequately sized prospective randomized trials, aimed to evaluate the effect of such a protocol on ongoing pregnancy rates. Acknowledgments: We thank Pierluigi Russo, M.D., for advice concerning statistical analysis, and Colin Howles, Ph.D., and Valeria Amato,
249
M.D., for their helpful suggestions and comments. This study was supported by grants from the Ministero dell’Istruzione, dell’Università e della Ricerca (PRIN annualitá 2004 prot. 2004061475_003).
Giuseppe De Placido, M.D. Antonio Mollo, M.D. Roberto Clarizia, M.D. Ida Strina, M.D. Salvatore Conforti, M.D. Carlo Alviggi, M.D. Dipartimento Universitario di Scienze Ostetriche Ginecologiche e Medicina della Riproduzione, Area Funzionale di Medicina della Riproduzione ed Endoscopia Ginecologica, Università degli Studi di Napoli Federico II, Naples, Italy
REFERENCES 1. Keay SD, Liversedge NH, Mathur RS, Jenki. Assisted conception following poor ovarian response to gonadotrophin stimulation. Br J Obstet Gynaecol 1997;104:521–7. 2. Padilla SL, Dugan K, Maruschak V, Shalika S, Smith R. Use of the flare-up protocol with high dose human follicle stimulating hormone and human menopausal gonadotrophins for in vitro fertilization in poor responders. Fertil Steril 1996;65:796 –9. 3. Tasdemir M, Tasdemir I, Kodama H, Fukuda J, Tanaka T. Short protocol of gonadrotopin-releasing hormone agonist administration gave better results in long protocol poor responders in IVF-ET. J Obstet Gynecol Res 1996;22:73–7. 4. De Placido G, Alviggi C, Mollo A, Strina I, Varricchio MT, Molis M. Recombinant follicle stimulating hormone is effective in poor responders to highly purified follicle stimulating hormone. Hum Reprod 2000;15:17–20. 5. Shoham Z, Jacobs HS, Insler V. Luteinizing hormone: its role, mechanism of action, and detrimental effects when hypersecreted during the follicular phase. Fertil Steril 1993;59:1153– 61.
250
De Placido et al.
Correspondence
6. Al-Inany H., Aboulghar M. Gonadotropin-releasing hormone antagonists for assisted conception. Cochrane Database Syst Rev 2001;4: CD001750. 7. Craft I, Gorgy A, Hill J, Menon D, Podsiadly B. Will GnRH antagonists provide new hope for patients considered difficult responders to GnRH agonist protocols? Hum Reprod 1999;12:2559 – 62. 8. Akman MA, Erden HF, Tosun SB, Bayazit N, Aksoy E, Bahceci M. Comparison of agonistic flare-up-protocol and antagonistic multiple dose protocol in ovarian stimulation of poor responders: results of a prospective randomized trial. Hum Reprod 2001;16:868 –70. 9. D’Amato G, Caroppo E, Pasquadibisceglie A, Carone D, Vitti A, Vizziello GM. A novel protocol of ovulation induction with delayed gonadotropin-releasing hormone antagonist administration combined with high-dose recombinant follicle-stimulating hormone and clomiphene citrate for poor responders and women over 35 years. Fertil Steril 2004;81:1572–7. 10. Cheung LP, Lam PM, Lok IH, Chiu TT, Yeung SY, Tjer CC, et al. GnRH antagonist versus long GnRH agonist protocol in poor responders undergoing IVF: a randomized controlled trial. Hum Reprod 2005;20:616 –21 [Epub 2004 Dec 17]. 11. Lindheim SR, Morales AJ. GnRH antagonists followed by a decline in serum estradiol results in adverse outcomes in donor oocyte cycles. Hum Reprod 2003;18:2048 –51. 12. Acevedo B, Sanchez M, Gomez JL, Cuadros J, Ricciarelli E, Hernandez ER. Luteinizing hormone supplementation increases pregnancy rates in gonadotropin-releasing hormone antagonist donor cycles. Fertil Steril 2004;82:343–7. 13. Strina I, Mollo A, Alviggi C, Varricchio MT, D’Uva M, Schiattarella C, et al. Personalized GnRH antagonist protocol versus GnRH agonist flare-up in patients at risk for poor ovarian response. In: Abstracts of the 19th Annual Meeting of the ESHRE, Madrid, Spain 2003. Hum Reprod 2003;18(Supp 1):109. 14. Filicori M, Cognigni GE, Pocognoli P, Ciampaglia W, Bernardi S. Current concepts and novel applications of LH activity in ovarian stimulation. Trends Endocrinol Metab 2003;14:267–73. 15. Cedrin-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;19:1979 – 84 [Epub 2004 Jun 10].
Vol. 85, No. 1, January 2006
Poor ovarian response to COS occurs in 9%–24% of women undergoing IVF programs (1). The GnRH-a short protocol appears to improve the ovarian outcome in patients at risk for reduced ovarian responsiveness (2, 3) and represents a less costly procedure. This strategy, in association with recombinant FSH (rec-FSH), is considered a first-choice treatment for patients in our IVF unit (4). Nevertheless, these protocols lead to an increase in the LH levels during the early follicular maturation (i.e., flare effect), which in turn may affect oocyte quality (5). The administration of GnRH-ant is not associated with endogenous gonadotropin release, induces a rapid and profound suppression of the pituitary function, and can be limited in the last days of gonadotropin therapy (6). On this basis, GnRH-ant protocols have been recently proposed as a new option for treating poor responders (7–10). Recent data from the donor oocyte model indicate that GnRH-ant administration followed by a decline in serum LH and estradiol (E2) affects the oocyte/embryo quality and results in adverse outcomes in recipients (11). As expected, a significant increase in the percentage of mature oocytes and implantation rate was found in recipients whose embryos originate from donors receiving GnRH-ant administration plus LH supplementation when compared with donors treated with GnRH-ant alone (12). The aim of this prospective randomized trial was to compare a personalized flexible protocol that provides both a gradual increase in the dose of GnRH-ant and the addition of rec-LH, with the standard GnRH-a short protocol, in patients at risk for poor ovarian response when undergoing intracytoplasmic sperm injection (ICSI). Received June 14, 2004; revised and accepted July 8, 2005. Reprint requests: Carlo Alviggi, M.D., University of Naples, Obstetrical and Gynaecological Sciences, 132 via Luigi Caldieri, Naples 80128, Italy (FAX: ⫹39-081-7463747; E-mail: [email protected]).
0015-0282/06/$32.00 doi:10.1016/j.fertnstert.2005.07.1280
Our institutional review board approved the study protocol, and all the patients signed a consent form before entering in the study. On the basis of our previous results (13) and having the mean number of mature oocytes as the primary end point, it has been calculated that a sample size of 58 patients in each group will have an 80% power to detect a difference in means of 1.0, using a one-way analysis of variance (ANOVA), with a .05 two-sided significance level. To allow for dropouts, we enrolled a total of 140 patients, who were at risk for poor ovarian responsiveness when undergoing the first COS/ICSI attempt, at our institution between July 2002 and February 2004. The following inclusion criteria were used: age ⱖ37 years or day 2 FSH (basal FSH) serum concentration ⱖ 9 IU/L; menstrual cycles ranging from 24 –35 days (intraindividual variability ⫾ 3 days), and hysteroscopic evidence of a normal uterine cavity. Only couples undergoing ICSI were included because we chose the mean number of mature oocyte as the primary end point. In fact, this technique requires removal of the cumulus oophorus, which in turn allows the assessment of gametes maturation. The following exclusion criteria were adopted: body mass index (BMI ⫽ weight [kg]/ height [m2]) ⬎26; biochemical or ultrasonographic (USG) evidence of polycystic ovary syndrome, and stage III–IV endometriosis according to the revised American Fertility Society classification (rAFS, 1985); inflammatory, autoimmune, and chromosomal disorders; endocrine and metabolic disease, including hyperprolactinemia; or the presence of only one ovary. All the patients received a daily dose of 300IU of recFSH (Gonal F; Industria Farmaceutica Serono, Rome, Italy), beginning on the second day of their cycles. The rec-FSH daily dose was adjusted on the basis of the ovarian response beginning on the fifth day of stimulation. Patients were randomized into two groups using a computergenerated list. In the antagonist group, a dose of 0.125
Fertility and Sterility姞 Vol. 85, No. 1, January 2006 Copyright ©2006 American Society for Reproductive Medicine, Published by Elsevier Inc.
247
mg/day of the GnRH-ant cetrorelix (Cetrotide; Industria Farmaceutica Serono, Rome, Italy) was administered for 2 days, beginning when at least one follicle ⱖ14 mm was present; thereafter, the GnRH-ant full dose of 0.25 mg/day was given until the day of the exogenous hCG administration. Beginning on the same day of GnRH-ant administration, a daily dose of 150 IU of rec-LH (Luveris; Industria Farmaceutica Serono, Rome, Italy) was also added until the day of hCG. Controls (agonist group) received daily a dose of triptorelin (Decapeptyl 0.1 mg.; Ipsen S.p.A., Milan, Italy) of 0.1 mg SC, beginning on the same day of the first rec-FSH administration. In addition, in this group, a dose of 150 IU/day of rec-LH was added when at least one follicle reached 14 mm. When at least one follicle reached 18 –20 mm in diameter, the standard dose (10,000 IU IM) of hCG (Gonasi; AMSA, Roma, Italy) was administered to trigger ovulation. Transvaginal oocyte retrieval was performed 34 –36 hours later. Of the 140 patients included in the study, 7 did not begin stimulation for personal reasons. Thus, a total of 133 subjects underwent ovarian stimulation (antagonist group: n ⫽ 67; agonist group: n ⫽ 66). Baseline characteristics of the patients were similar in the two groups. In particular, the mean age of the women was 37.16 ⫾ 4.14 years for the antagonist group and 37.32 ⫾ 3.72 years for the agonist group. The FSH mean levels measured on day 2 of the cycle were 7.64 ⫾ 4.12 IU/L in the antagonist group and 8.45 ⫾ 4.23 IU/L in the agonist group. Indications for IVF were also homogeneously distributed in the two groups. Four patients in the antagonist group and five women in the agonist group had their cycles cancelled because of an inadequate ovarian response. In Table 1, stimulation data, endocrine parameters, and cycle results are separately listed per started cycles (i.e., intention to treat) and completed cycles. No premature LH surge was observed in the two groups. The mean number of mature oocytes retrieved per started cycle was significantly higher (P⬍.05) in the antagonist group (5.73 ⫾ 3.57 vs. 4.64 ⫾ 2.23). Conversely, no statistically significant difference in the total number of cumulus oocyte complexes (COCs) retrieved (6.79 ⫾ 3.89 vs. 6.54 ⫾ 3.08, respectively) was observed between groups. Serum E2 levels on day 5 of stimulation were 325.92 ⫾ 251.45 pg/mL and 439.80 ⫾ 266.91 in the antagonist and agonist groups, respectively (P⬍.05). Implantation rate, pregnancy rate, and ongoing pregnancy rate per started cycle were comparable in the antagonist and agonist groups (10.93% vs. 9.28%; 25.37% vs. 21.21%; 24.24% vs. 17.91%, respectively). In the present study, a new flexible GnRH-ant protocol, based on both progressive increase in the cetrorelix dose and LH supplementation, has been compared with a standard GnRH-a short protocol in patients at risk for poor ovarian response. The main finding of the study was a 248
De Placido et al.
Correspondence
significant increase in the mean number of mature oocytes (primary end point) in the GnRH-ant group. The explanation for this evidence may be related to the fact that this protocol provides a physiological LH environment during follicular maturation. In fact, LH activity is relatively low during the menstrual period and progressively increases throughout the mid- to late-follicular phase (14). At that stage, LH induces granulosa cell growth and differentiation by promoting local peptide synthesis and release. Moreover, LH induces epidermal growth factor (EGF) production in the theca interstitial cells and indirectly promotes E2 release by granulosa cells. These variables appear to be part of a complex signalling for oocyte maturation (9, 12). On this basis, it could be concluded that both the GnRH-a short protocol and GnRH-ant administration for COS are related to less physiological patterns of LH activity throughout follicular maturation. The former usually leads to an excessive increase in LH levels during the early stages of follicular development, which in turn may impair the normal process of oocyte maturation and cause atretic degeneration (5); the latter is associated with a physiological environment during the early stages of folliculogenesis. Nevertheless, a decline in both LH and E2 production usually follows the administration of the GnRH-ant, which in turn may affect crucial mechanisms of autocrine or paracrine regulation of granulosa cell maturation and oocyte differentiation (11). In contrast, our study protocol may have modulated a decline in endogenous gonadotropins by progressively increasing the GnRH-ant dose; furthermore, this decline may have contemporarily been balanced by the exogenous LH supplementation. In the present study, implantation and pregnancy rates were 10.93% and 25.37%, respectively, in the antagonist group and 9.28% and 21.21% in the agonist group. The lack of statistically significant differences may be because the power analysis had not been performed having one of these categorical variables as primary end point. Our results are in contrast with the only published prospective randomized trial comparing GnRH-ant and standard GnRH-a short protocols in poor responders (8). In fact, these authors failed to find significant differences in both ovarian and IVF outcomes between groups. This discrepancy may derive from the lack of LH supplementation. This interpretation is consistent with other data derived from the oocyte donor model. Acevedo et al. (12) have recently demonstrated that LH supplementation in donors receiving a GnRH-ant plus rec-FSH protocol can improve the percentage of mature oocytes. Furthermore, the association of GnRH-ant and rec-LH provided a significant increase in the implantation rate in recipients in comparison with the standard GnRH-ant protocol. The authors concluded that their results could be related to the fact that in GnRH-ant cycles (where ⬎ 80% of LH release is abolished in the first 24 hours), the addition of LH could be crucial for sustaining E2 synthesis and paracrine proVol. 85, No. 1, January 2006
TABLE 1 Ovarian and IVF outcome of the 133 patients who started the cycles and 124 women who underwent OR and embryo transfer. Started cycles Antagonist group
Agonist group
Completed cycles Antagonist group
Agonist group
No. of patients 66 67 62 62 Cancelled cycles 4 5 Duration of stimulation (days) — — 11.73 ⫾ 2.04 11.27 ⫾ 2.10 No. of rFSH ampoules — — 42.31 ⫾ 10.19 41.37 ⫾ 8.00 No. of rLH ampoules — — 7.13 ⫾ 2.05 7.19 ⫾ 2.03 Duration of GnRH-antagonist — — 3.74 ⫾ 0.65 — administration (days) No. of GnRH-antagonist — — 2.73 ⫾ 0.68 — ampoules No. of GnRH-agonist — — — 11.27 ⫾ 2.11 ampoules 325.92 ⫾ 251.45a 439.8 ⫾ 266.91a 348.63 ⫾ 248.36a 463.18 ⫾ 260.25a Day 5 E2 concentration (pg/mL) — — 1303.27 ⫾ 770.33 1436.73 ⫾ 725.34 E2 when follicle ⱖ 14 mm was present (pg/mL) LH when follicle ⱖ 14 mm — — 2.48 ⫾ 2.11 3.11 ⫾ 2.67 was present (IU/L) E2 at hCG day (pg/mL) — — 1857.43 ⫾ 912.28 2158.9 ⫾ 1041.36 No. of COCs retrieved 6.79 ⫾ 3.89 6.54 ⫾ 3.08 7.23 ⫾ 3.60 7.06 ⫾ 2.55 No. of mature oocyte (M2) 5.73 ⫾ 3.57a 4.64 ⫾ 2.23a 6.09 ⫾ 3.36a 5.02 ⫾ 1.86a Fertilization rate (%) 90.78 89.42 — — No. of 2PN oocytes 4.62 ⫾ 2.88a 3.69 ⫾ 1.92a 4.91 ⫾ 2.71a 3.98 ⫾ 1.66a No. of embryos per transfer 2.87 ⫾ 0.86 2.77 ⫾ 0.88 — — Implantation rate (%) 10.93 9.28 — — Pregnancy rate (%) 25.37 21.21 27.42 22.58 Ongoing pregnancy rate (%) 24.24 17.91 25.81 19.35 Note: Values expressed as mean ⫾ SD. a Antagonist group vs. agonist group: P ⬍ .05. De Placido. GnRH-ant plus rec-LH in poor responders. Fertil Steril 2006.
duction of peptides that are necessary for oocyte differentiation. In this context, it should be emphasized that the donor oocyte cycles provide an optimal “in vivo” model for evaluating the impact of hormonal variables on sole oocyte/ embryo quality and excluding the endometrium as covariable. A recent prospective randomized trial (15) did not evidence significant improvement in the ovarian response by adding rec-LH in a GnRH-ant protocol. Nevertheless, a comparison between our results and these results is not feasible due to the following methodological differences. First, the study was performed in young normogonadotropic women who were not selected as poor responders. Moreover, patients undergoing a standard GnRH-a long protocol represented the control population. Finally, Fertility and Sterility姞
rec-LH supplementation was provided with a daily dose of 75 IU. In conclusion, our study demonstrates that the proposed protocol for COS can be usefully administered in patients at risk for poor ovarian response, such as older women and subjects with high FSH basal levels. When compared with a standard GnRH-a short protocol, this strategy led to a significant improvement of the oocyte quality and maturation process, which in turn resulted in a significant increase in the mean number of mature oocytes. These results are encouraging for the design of further and adequately sized prospective randomized trials, aimed to evaluate the effect of such a protocol on ongoing pregnancy rates. Acknowledgments: We thank Pierluigi Russo, M.D., for advice concerning statistical analysis, and Colin Howles, Ph.D., and Valeria Amato,
249
M.D., for their helpful suggestions and comments. This study was supported by grants from the Ministero dell’Istruzione, dell’Università e della Ricerca (PRIN annualitá 2004 prot. 2004061475_003).
Giuseppe De Placido, M.D. Antonio Mollo, M.D. Roberto Clarizia, M.D. Ida Strina, M.D. Salvatore Conforti, M.D. Carlo Alviggi, M.D. Dipartimento Universitario di Scienze Ostetriche Ginecologiche e Medicina della Riproduzione, Area Funzionale di Medicina della Riproduzione ed Endoscopia Ginecologica, Università degli Studi di Napoli Federico II, Naples, Italy
REFERENCES 1. Keay SD, Liversedge NH, Mathur RS, Jenki. Assisted conception following poor ovarian response to gonadotrophin stimulation. Br J Obstet Gynaecol 1997;104:521–7. 2. Padilla SL, Dugan K, Maruschak V, Shalika S, Smith R. Use of the flare-up protocol with high dose human follicle stimulating hormone and human menopausal gonadotrophins for in vitro fertilization in poor responders. Fertil Steril 1996;65:796 –9. 3. Tasdemir M, Tasdemir I, Kodama H, Fukuda J, Tanaka T. Short protocol of gonadrotopin-releasing hormone agonist administration gave better results in long protocol poor responders in IVF-ET. J Obstet Gynecol Res 1996;22:73–7. 4. De Placido G, Alviggi C, Mollo A, Strina I, Varricchio MT, Molis M. Recombinant follicle stimulating hormone is effective in poor responders to highly purified follicle stimulating hormone. Hum Reprod 2000;15:17–20. 5. Shoham Z, Jacobs HS, Insler V. Luteinizing hormone: its role, mechanism of action, and detrimental effects when hypersecreted during the follicular phase. Fertil Steril 1993;59:1153– 61.
250
De Placido et al.
Correspondence
6. Al-Inany H., Aboulghar M. Gonadotropin-releasing hormone antagonists for assisted conception. Cochrane Database Syst Rev 2001;4: CD001750. 7. Craft I, Gorgy A, Hill J, Menon D, Podsiadly B. Will GnRH antagonists provide new hope for patients considered difficult responders to GnRH agonist protocols? Hum Reprod 1999;12:2559 – 62. 8. Akman MA, Erden HF, Tosun SB, Bayazit N, Aksoy E, Bahceci M. Comparison of agonistic flare-up-protocol and antagonistic multiple dose protocol in ovarian stimulation of poor responders: results of a prospective randomized trial. Hum Reprod 2001;16:868 –70. 9. D’Amato G, Caroppo E, Pasquadibisceglie A, Carone D, Vitti A, Vizziello GM. A novel protocol of ovulation induction with delayed gonadotropin-releasing hormone antagonist administration combined with high-dose recombinant follicle-stimulating hormone and clomiphene citrate for poor responders and women over 35 years. Fertil Steril 2004;81:1572–7. 10. Cheung LP, Lam PM, Lok IH, Chiu TT, Yeung SY, Tjer CC, et al. GnRH antagonist versus long GnRH agonist protocol in poor responders undergoing IVF: a randomized controlled trial. Hum Reprod 2005;20:616 –21 [Epub 2004 Dec 17]. 11. Lindheim SR, Morales AJ. GnRH antagonists followed by a decline in serum estradiol results in adverse outcomes in donor oocyte cycles. Hum Reprod 2003;18:2048 –51. 12. Acevedo B, Sanchez M, Gomez JL, Cuadros J, Ricciarelli E, Hernandez ER. Luteinizing hormone supplementation increases pregnancy rates in gonadotropin-releasing hormone antagonist donor cycles. Fertil Steril 2004;82:343–7. 13. Strina I, Mollo A, Alviggi C, Varricchio MT, D’Uva M, Schiattarella C, et al. Personalized GnRH antagonist protocol versus GnRH agonist flare-up in patients at risk for poor ovarian response. In: Abstracts of the 19th Annual Meeting of the ESHRE, Madrid, Spain 2003. Hum Reprod 2003;18(Supp 1):109. 14. Filicori M, Cognigni GE, Pocognoli P, Ciampaglia W, Bernardi S. Current concepts and novel applications of LH activity in ovarian stimulation. Trends Endocrinol Metab 2003;14:267–73. 15. Cedrin-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;19:1979 – 84 [Epub 2004 Jun 10].
Vol. 85, No. 1, January 2006