- Email: [email protected]
IVF: Induction of ovulation in poor responders
J. sreroid Biortrem. Vol. 32, No. IB, pp. 171-173, 1989 Printed in Great Britain
IVF: INDUCTION
0022-4731,‘89$3.00 + 0.00 Pef8amon Press plc
OF OVULATION
IN POOR RESPONDERS
P. G. CROSIGNANI, G. RAGNI, G. C. LOMBROSO,C. SCARD~ELLI, L. DE LAURETIS, A. CACCAMO, L. DALPR& V. CAVIONI, C. CRISTIANI, H. WYSSLING and M. D. OLIVARES III Department of Obstetrics and Gynecology, University of Milan, Via M. Melloni 52,
20129 Milano, Italy
Summary-All IVF programs have a consistent rate of failure in inducing ovulations. Pharmacological induction of ovulation is otherwise crucial for an IVF program because of the need for more than one ovum. Since it is well known that the best candidates for HMG treatment are hypogonadotropic women a short reversible hypogonadotropic state was induced in IVF patients by LH-RH agonist (Buserelin). Superovulation was then achieved with very high initial doses of FSH (Metrodin) in order to maximize the ovarian response. This technique used in 116 IVF women induced a satisfactory follicle growth even in 70% of the patients already poorly responsive to HMG
stimulation.
INTRODUCI’ION
Suboptimal ovarian stimulation is one of the main factors in IVF failures. Poor responsiveness to human gonadotropins is quite frequent in the various IVF programmes [ 11. Small numbers of growing follicles and premature luteinization are the two major causes of un~tisfactory ovarian response to HMG [Z]. It is well known that the best candidates for HMG treatment are patients with hypogonadotropic hypogonadism and that cycling women are not [3]. A short, reversible hypogonadotropic state induced by LH-RH agonists gives better follicular responses and prevents a premature LH surge [4]. In this series, LH-RH treatment (Buserelin) was begun in the cycle preceding ovarian stimulation, and menstrual bleeding was controlled by giving a progestogen or an oral contraceptive. Superovulation was then induced with very high initial doses of FSH (Metrodin), in order to maximize the ovarian response. Our aims were to evalute the practicability of this procedure and its effectiveness in patients already known to be unresponsive to the usual superovulation procedures.
Patients and method One hundred and sixteen IVF patients (mean age 35.5, range 23-45) entered the trial. The indications for IVF were tubal in 75, male factor in 33, endometriosis in 6 and unexplained infertility in 12. Thirty of the patients had already been treated with Clomid
Proceedings of the XIII Meeting of the International Study Group for Steroid Hormones (Rome, Italy, 30 November-2 December 1987).
(100 mg/day, p.o., days 3-7) and Pergonal (2-3 ampoules/day, day 6 onward) in previoius IVF cycles, and 14 of them grew 3 or fewer follicles during those treatment cycles. We considered these patients to be poorly responsive to ovarian stimulation. In the cycle preceding ovarian stimulation the patients were treated with either: (A) Buserelin (200 pg, nasally 5 times a day}, starting on day 17 and Norethisterone (10 mg/day, p.o.) from day 17 to day 26; or (B) Buserelin at the same doses from day 7 and contraceptive pills from day 1 to 25. On day 2 of the following cycle an ultrasound scan was performed in order to exclude the presence of cystic follicles of more than 1 cm dia.; then Buserelin was continued until the day of HCG administration. At the same time ovarian stimulation was induced with Metrodin (5 ampoules/daily on days 2-S), then on days 6-10 with Metrodin (3 ampoules) and Pergonal (l-4 ampoules, per day). HCG (5000 IU i.m.) injection was programmed for day 11 but for more than 50% of the subjects was anticipated or postponed by 1 or 2 days according to the diameter of the leader follicle (16-17 mm). Echo-guided oocyte retrieval was done 35 h after HCG injection. No hormone assays were carried out in real time. The only method for monitoring was daily echographic measurement of the follicfes starting on day 5. The luteal phase was supplemented with daily progesterone (50 p&/day, i.m.) administration on the 15 days after pick-up, or with HCG (2000 IU, i.m.) on days 2, 4 and 6 after oocytes pick-up. RESULTS
Of the 116 patients who entered the trial, ovulation was induced in 92 (79%), 14 patients did not respond and had their treatment stopped for different reasons: mainly patient failure or the development of func171
172
P. G. CROSIONANI et al. Table 1. Responses to Clomi~HMG
and to Metr~in-~u~miin
Clomid: day 3-7 HMG: day 6 -+ Pergonal M 12.6 amp. (range 7-19)
Induction HMG doses
49 3.3’ 1.4 61 39% 61%
Cycles Follicles ner cvcle
in 30 IVF patients B~relin
Clomid + HMG
+ high FSH
Metrodin day 2-S Metr. + Pergonal day 6-10 Metrodin M 34 amp. (range 2243) Pergonal M 8.1 amp. (range 5-20) 30 9.2* 8.1 65 80% 20%
‘P < 0.0005. $3 follicles or fewer.
Table 2. Ovarian responses to Metrodin-Buserelin treatment of 14 IVF patients known to respond poorly to Clomid-HMG
Induction Cycles Follicles per cycle retrieved per cycle Oocytes cleaved (%)
Clomid-HMG
Buserelin + high FSH
Clomid: day 3-7 HMG: day 6 + 21 2.6’ 1.3 32
Metrodin day 2-5 Metr. + Pergonal day 610 14 8, 6.2 51
lP > 0.0005.
tional cysts before ovarian stimulation. Cysts were observed only in the patients pretreated with Norethisterone. The mean number of ovarian foliicles was 9.1, a mean of 6.5 oocytes were retrieved per patient and, as a consequence of 77 replacements, 9 pregnancies occurred. The results for the 30 patients who had previously been treated with Clomid-Pergonal are shown in Table 1. With the new method of ovarian stimulation, the number of follicles and the rate of good responders were significantly higher. The cleavage rate appeared to be very similar in both series. Table 2 compares the clinical results of the two methods of stimulation in the patients known to be poorly responsive to Clomid-HMG. The differences in numbers of follicles grown and oocytes retrieved are highly significant. There were striking differences in the rate of refractoriness (Table 3) and in the rate of maximal ovarian responsivity (Table 4) according to age of the patient. Programming with the Buserelin Metrodin treatment was not ideal, but choosing Wednesday as the eleventh day avoided week-end pick-ups in all except 17 cycles.
Table 3. Superovulation Buserelin-effects
for IVF with Metrodinof age of patients Cycles
Age
Started
138 238
83 33 Total
116
Induced
Table 4. Patients growing fewer than 5 or more than 6 follicles in response to Metrodin-Buserclin treatment (%)
Failed 13 II
92
The pregnancy rate of IVF is closely related to the number embryos replaced and thus to the number of oocytes collected. Therefore ovarian stimulation is an essential part of every IVF program [2]. Physiologically, in the early follicular phase follicles recruited during the previous cycle are drastically selected and only one goes on to the preovulatory state [S]. During ovarian stimulation on the contrary the extra amount of FSH overrides follicle selection, allowing the growth of several follicles [3], Nevertheless, in most IVF programs the rate of poor responders to human gonadotropin is quite high @O-50%) [il. Administration of an initial high dose of gonadotropin to a subject whose pituitary is concurrently suppressed by an LHRH analog increases the number of follicles that escape selection and drastically reduces the rate of poor responders. Norethisterone was initially added to Buserelin in the cycle preceding ovarian stimulation to control endometrial bleeding and to decrease the initial pituitary stimulation by the LHRH analog. Since functional ovarian cysts were occasionally observed with
24
(16%) (33%)
Age <38 ,38
Induced cycles 70 22
No. of follicles 36 65 21% 55%
79% 45%
IVF and ovulation
progestogen treatment before the start of ovarian stimulation, a contraceptive pill was then used to obtain more complete control of the pretreatment cycle. No cysts were observed in women on the Buserelin-pill therapy. Recent IVF data show that Metrodin is more effective than Pergonal in inducing ovulation [8]. The step-down schedule used for Metrodin administration mimics the physiological events that take place at the beginning of the natural cycle and, according to recent data for the monkey, Seems to induce more synchronous follicular growth [6]. The ability of Metrodin-Buserelin to overcome ovarian refractoriness is clearly shown by comparative results for the same women. Because of the limited number of observations, it seems correct to compare the numbers of follicles and oocytes retrieved after the old and the new method of ovarian stimulation rather than to compare the small numbers of pregnancies achieved. The deleterious effect of age on ovarian response to HMG is well known [7]. This negative effect is clearly seen in the patients treated with Metrodin-Buserelin, too; the number of failed ovulations is doubled after the age of 38 and fewer than 50% of the women in that age group produced more than 6 follicles per stimulation cycle. This study shows that initial high FSH doses given to pituitary suppressed patients can significantly lower the rate of poor responses. The separate contributions of the high FSH dose and the pituitary suppression to the improved results have not yet been evaluated when we compare our results with those of Frydmann et al. [9], the Metrodin-Buserelin treatment is as good for programming.
S.B
32,10-o
173 REFERENCES
1.
Kerin J. F., Warnes G. M., Quinn P., Kirby C., Godfrey B. and Cox L. W.: Endocrinology of ovarian stimulation for in oirro fertilization. Ausr. N.Z. J. Ohm.
Gynaec. 24 (1984) 121-126. 2. Meldrum D. R., Chetkowski R., Steingold K. A., de Ziegler D., Cedars M. I. and Hamilton M.: Evolution of a highly successful in oitro fertilization-embryo transfer program. Fert. Sreril. 48 (1987) 8693. 3. Hodgen G. D.: Ovarian functionfor multiple follicle maturation. Clin. Obsrer. Gvnec. 29 (1986) 127-140. 4. Fleming R. and Coutts J. d. T.: Induction of multiple follicular growth in normally menstruating women with endogenous gonadotropin suppression. Ferr. Sreril. 45 (1986) 226-230. 5. Richards J. D.: Maturation of ovarian follicles: actions and interactions of pituitary and ovarian hormones on follicular cell differentiation. Physiol. Rev. 60 (1980) 51-55. 6. Abbasi R., Kenigsberg D., Danforth D., Ialk R. J. and Hodgen G. D.: Cumulative ovulation rate in human menopausal/human chorionic gonadotropin-treated monkeys: “step-up” versus “step-down” dose regimens. Ferr. Sreril. 47 (1987) 1019-1024. 7. Romeu A., Mu&her’s, J., Acosta A. A., Veeck L. L., Diaz J., Jones G. S., Jones H. W. Jr and Rosenwaks Z.: Results of in virro fertilization attempts in women 40 years of age and older: the Norfolk experience. Fert. Steril. 47 (1987) 130-136. 8. Scoccia B., Blumenthal P., Wagner C., Prins G., Scommegna A. and Marut E. L.: Comparison of urinary human follicle-stimulating hormone and human menopausal gonadotropins for ovarian stimulation in an in vitro fertilization program. Fert. Steril. 48 (1987) 446-451. 9. Frydman R., Forman R., Rainhorm J. D., BelaischAllart J., Hazout A. and Testart J.: A new approach to follicular stimulation for in vitro fertilization: programmed oocyte retrieval. Ferr. Sreril. 46 (1986) 657-662.
IVF: INDUCTION
0022-4731,‘89$3.00 + 0.00 Pef8amon Press plc
OF OVULATION
IN POOR RESPONDERS
P. G. CROSIGNANI, G. RAGNI, G. C. LOMBROSO,C. SCARD~ELLI, L. DE LAURETIS, A. CACCAMO, L. DALPR& V. CAVIONI, C. CRISTIANI, H. WYSSLING and M. D. OLIVARES III Department of Obstetrics and Gynecology, University of Milan, Via M. Melloni 52,
20129 Milano, Italy
Summary-All IVF programs have a consistent rate of failure in inducing ovulations. Pharmacological induction of ovulation is otherwise crucial for an IVF program because of the need for more than one ovum. Since it is well known that the best candidates for HMG treatment are hypogonadotropic women a short reversible hypogonadotropic state was induced in IVF patients by LH-RH agonist (Buserelin). Superovulation was then achieved with very high initial doses of FSH (Metrodin) in order to maximize the ovarian response. This technique used in 116 IVF women induced a satisfactory follicle growth even in 70% of the patients already poorly responsive to HMG
stimulation.
INTRODUCI’ION
Suboptimal ovarian stimulation is one of the main factors in IVF failures. Poor responsiveness to human gonadotropins is quite frequent in the various IVF programmes [ 11. Small numbers of growing follicles and premature luteinization are the two major causes of un~tisfactory ovarian response to HMG [Z]. It is well known that the best candidates for HMG treatment are patients with hypogonadotropic hypogonadism and that cycling women are not [3]. A short, reversible hypogonadotropic state induced by LH-RH agonists gives better follicular responses and prevents a premature LH surge [4]. In this series, LH-RH treatment (Buserelin) was begun in the cycle preceding ovarian stimulation, and menstrual bleeding was controlled by giving a progestogen or an oral contraceptive. Superovulation was then induced with very high initial doses of FSH (Metrodin), in order to maximize the ovarian response. Our aims were to evalute the practicability of this procedure and its effectiveness in patients already known to be unresponsive to the usual superovulation procedures.
Patients and method One hundred and sixteen IVF patients (mean age 35.5, range 23-45) entered the trial. The indications for IVF were tubal in 75, male factor in 33, endometriosis in 6 and unexplained infertility in 12. Thirty of the patients had already been treated with Clomid
Proceedings of the XIII Meeting of the International Study Group for Steroid Hormones (Rome, Italy, 30 November-2 December 1987).
(100 mg/day, p.o., days 3-7) and Pergonal (2-3 ampoules/day, day 6 onward) in previoius IVF cycles, and 14 of them grew 3 or fewer follicles during those treatment cycles. We considered these patients to be poorly responsive to ovarian stimulation. In the cycle preceding ovarian stimulation the patients were treated with either: (A) Buserelin (200 pg, nasally 5 times a day}, starting on day 17 and Norethisterone (10 mg/day, p.o.) from day 17 to day 26; or (B) Buserelin at the same doses from day 7 and contraceptive pills from day 1 to 25. On day 2 of the following cycle an ultrasound scan was performed in order to exclude the presence of cystic follicles of more than 1 cm dia.; then Buserelin was continued until the day of HCG administration. At the same time ovarian stimulation was induced with Metrodin (5 ampoules/daily on days 2-S), then on days 6-10 with Metrodin (3 ampoules) and Pergonal (l-4 ampoules, per day). HCG (5000 IU i.m.) injection was programmed for day 11 but for more than 50% of the subjects was anticipated or postponed by 1 or 2 days according to the diameter of the leader follicle (16-17 mm). Echo-guided oocyte retrieval was done 35 h after HCG injection. No hormone assays were carried out in real time. The only method for monitoring was daily echographic measurement of the follicfes starting on day 5. The luteal phase was supplemented with daily progesterone (50 p&/day, i.m.) administration on the 15 days after pick-up, or with HCG (2000 IU, i.m.) on days 2, 4 and 6 after oocytes pick-up. RESULTS
Of the 116 patients who entered the trial, ovulation was induced in 92 (79%), 14 patients did not respond and had their treatment stopped for different reasons: mainly patient failure or the development of func171
172
P. G. CROSIONANI et al. Table 1. Responses to Clomi~HMG
and to Metr~in-~u~miin
Clomid: day 3-7 HMG: day 6 -+ Pergonal M 12.6 amp. (range 7-19)
Induction HMG doses
49 3.3’ 1.4 61 39% 61%
Cycles Follicles ner cvcle
in 30 IVF patients B~relin
Clomid + HMG
+ high FSH
Metrodin day 2-S Metr. + Pergonal day 6-10 Metrodin M 34 amp. (range 2243) Pergonal M 8.1 amp. (range 5-20) 30 9.2* 8.1 65 80% 20%
‘P < 0.0005. $3 follicles or fewer.
Table 2. Ovarian responses to Metrodin-Buserelin treatment of 14 IVF patients known to respond poorly to Clomid-HMG
Induction Cycles Follicles per cycle retrieved per cycle Oocytes cleaved (%)
Clomid-HMG
Buserelin + high FSH
Clomid: day 3-7 HMG: day 6 + 21 2.6’ 1.3 32
Metrodin day 2-5 Metr. + Pergonal day 610 14 8, 6.2 51
lP > 0.0005.
tional cysts before ovarian stimulation. Cysts were observed only in the patients pretreated with Norethisterone. The mean number of ovarian foliicles was 9.1, a mean of 6.5 oocytes were retrieved per patient and, as a consequence of 77 replacements, 9 pregnancies occurred. The results for the 30 patients who had previously been treated with Clomid-Pergonal are shown in Table 1. With the new method of ovarian stimulation, the number of follicles and the rate of good responders were significantly higher. The cleavage rate appeared to be very similar in both series. Table 2 compares the clinical results of the two methods of stimulation in the patients known to be poorly responsive to Clomid-HMG. The differences in numbers of follicles grown and oocytes retrieved are highly significant. There were striking differences in the rate of refractoriness (Table 3) and in the rate of maximal ovarian responsivity (Table 4) according to age of the patient. Programming with the Buserelin Metrodin treatment was not ideal, but choosing Wednesday as the eleventh day avoided week-end pick-ups in all except 17 cycles.
Table 3. Superovulation Buserelin-effects
for IVF with Metrodinof age of patients Cycles
Age
Started
138 238
83 33 Total
116
Induced
Table 4. Patients growing fewer than 5 or more than 6 follicles in response to Metrodin-Buserclin treatment (%)
Failed 13 II
92
The pregnancy rate of IVF is closely related to the number embryos replaced and thus to the number of oocytes collected. Therefore ovarian stimulation is an essential part of every IVF program [2]. Physiologically, in the early follicular phase follicles recruited during the previous cycle are drastically selected and only one goes on to the preovulatory state [S]. During ovarian stimulation on the contrary the extra amount of FSH overrides follicle selection, allowing the growth of several follicles [3], Nevertheless, in most IVF programs the rate of poor responders to human gonadotropin is quite high @O-50%) [il. Administration of an initial high dose of gonadotropin to a subject whose pituitary is concurrently suppressed by an LHRH analog increases the number of follicles that escape selection and drastically reduces the rate of poor responders. Norethisterone was initially added to Buserelin in the cycle preceding ovarian stimulation to control endometrial bleeding and to decrease the initial pituitary stimulation by the LHRH analog. Since functional ovarian cysts were occasionally observed with
24
(16%) (33%)
Age <38 ,38
Induced cycles 70 22
No. of follicles 36 65 21% 55%
79% 45%
IVF and ovulation
progestogen treatment before the start of ovarian stimulation, a contraceptive pill was then used to obtain more complete control of the pretreatment cycle. No cysts were observed in women on the Buserelin-pill therapy. Recent IVF data show that Metrodin is more effective than Pergonal in inducing ovulation [8]. The step-down schedule used for Metrodin administration mimics the physiological events that take place at the beginning of the natural cycle and, according to recent data for the monkey, Seems to induce more synchronous follicular growth [6]. The ability of Metrodin-Buserelin to overcome ovarian refractoriness is clearly shown by comparative results for the same women. Because of the limited number of observations, it seems correct to compare the numbers of follicles and oocytes retrieved after the old and the new method of ovarian stimulation rather than to compare the small numbers of pregnancies achieved. The deleterious effect of age on ovarian response to HMG is well known [7]. This negative effect is clearly seen in the patients treated with Metrodin-Buserelin, too; the number of failed ovulations is doubled after the age of 38 and fewer than 50% of the women in that age group produced more than 6 follicles per stimulation cycle. This study shows that initial high FSH doses given to pituitary suppressed patients can significantly lower the rate of poor responses. The separate contributions of the high FSH dose and the pituitary suppression to the improved results have not yet been evaluated when we compare our results with those of Frydmann et al. [9], the Metrodin-Buserelin treatment is as good for programming.
S.B
32,10-o
173 REFERENCES
1.
Kerin J. F., Warnes G. M., Quinn P., Kirby C., Godfrey B. and Cox L. W.: Endocrinology of ovarian stimulation for in oirro fertilization. Ausr. N.Z. J. Ohm.
Gynaec. 24 (1984) 121-126. 2. Meldrum D. R., Chetkowski R., Steingold K. A., de Ziegler D., Cedars M. I. and Hamilton M.: Evolution of a highly successful in oitro fertilization-embryo transfer program. Fert. Sreril. 48 (1987) 8693. 3. Hodgen G. D.: Ovarian functionfor multiple follicle maturation. Clin. Obsrer. Gvnec. 29 (1986) 127-140. 4. Fleming R. and Coutts J. d. T.: Induction of multiple follicular growth in normally menstruating women with endogenous gonadotropin suppression. Ferr. Sreril. 45 (1986) 226-230. 5. Richards J. D.: Maturation of ovarian follicles: actions and interactions of pituitary and ovarian hormones on follicular cell differentiation. Physiol. Rev. 60 (1980) 51-55. 6. Abbasi R., Kenigsberg D., Danforth D., Ialk R. J. and Hodgen G. D.: Cumulative ovulation rate in human menopausal/human chorionic gonadotropin-treated monkeys: “step-up” versus “step-down” dose regimens. Ferr. Sreril. 47 (1987) 1019-1024. 7. Romeu A., Mu&her’s, J., Acosta A. A., Veeck L. L., Diaz J., Jones G. S., Jones H. W. Jr and Rosenwaks Z.: Results of in virro fertilization attempts in women 40 years of age and older: the Norfolk experience. Fert. Steril. 47 (1987) 130-136. 8. Scoccia B., Blumenthal P., Wagner C., Prins G., Scommegna A. and Marut E. L.: Comparison of urinary human follicle-stimulating hormone and human menopausal gonadotropins for ovarian stimulation in an in vitro fertilization program. Fert. Steril. 48 (1987) 446-451. 9. Frydman R., Forman R., Rainhorm J. D., BelaischAllart J., Hazout A. and Testart J.: A new approach to follicular stimulation for in vitro fertilization: programmed oocyte retrieval. Ferr. Sreril. 46 (1986) 657-662.