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Use of Synthetic Luteinizing Hormone-Releasing Hormone in Induction of Ovulation in Amenorrheic Patients
FERTILITY AND STERILITY 1975 The American Fertility Society
Vol. 26, No. 8, August 1975 Printed in U.S.A.
Copyright~
USE OF SYNTHETIC LUTEINIZING HORMONE-RELEASING HORMONE IN INDUCTION OF OVULATION IN AMENORRHEIC PATIENTS KO-EN HUANG, M.D. Department of Obstetrics and Gynecology, College of Medicine and the Hospital, National Taiwan University, Taipei, Taiwan, Republic of China
Recent studies on gonadotropin secretion from the pituitary gland in response to synthetic luteinizing hormonereleasing hormone (LH-RH) have indicated significant release of luteinizing hormone (LH) and, to lesser extent, follicle-stimulating hormone (FSH) in patients with hypothalamic amenorrhea. 1· 3 These results suggest that most amenorrhea is caused by hypothalamic disturbances. Therefore, it would be expected that synthetic LH-RH would be effective in inducing ovulation in these patients. A few studies have been made on induction of ovulation with synthetic LH-RH in amenorrheic patients. 4 ' 6 For achievement of follicular maturation, either LHRH6 or clomiphene 5 was used in continuous administration. The purpose of this communication is to present our experience with synthetic LH-RH (Hoechst) in the treatment of infertility in amenorrheic patients m whom clomiphene therapy had failed. MATERIALS AND METHODS ./
Response of Normal Subjects to LH-RH. Synthetic LH-RH was given, either as a 200-JLg intravenous infusion for 4 hours or as two 200-JLg intramuscular injections within a 4-hour interval, to two fertile women, ages 23 and 28, 1 or 2 days prior to the expected day of ovulation. Each subject was restudied 3 months later but was given one-half the dose administered Received August 15, 1974.
during the first study. These volunteers were healthy, fertile women who showed ovulatory basal body temperature patterns. Blood samples were obtained before the LH-RH injection and 30 minutes, every hour for 8 hours, and 24 hours after the beginning of the LH-RH injection. Sera were stored at - 20C C for FSH and LH determinations in simultaneous radioimmunoassay by the modified doubleantibody techniques 7 for human FSH 8 and LH. 9 All samples were tested in duplicate. The results were expressed in nanograms of LER 907 per milliliter of serum. Highly purified human pituitary FSH and LH, their antisera, and LER 907 were supplied by the National Pituitary Agency and the National Institute of Arthritis, Metabolism and Digestive Diseases. Induction of Ovulation in Amenorrheic, Infertile Subjects. Eighteen patients, ages 21 to 33, who had consulted this clinic with the primary complaint of infertility and who had secondary amenorrhea, were treated with synthetic LH-RH and studied for 48 months. All 18 patients had previously received clomiphene without resulting ovulation. All subjects were examined thoroughly to exclude any cause of infertility other than anovulation. Patients with high gonadotropin levels were also excluded. In order to stimulate follicular maturation, 100 mg of clomiphene/day were given for 5 days from the 5th day of each progesterone (Proluton, Schering)-induced bleeding. LH-RH,
796
Vol. 26, No.8
797
LH-RH IN OVULATION INDUCTION IN AMENORRHEA
ZOOpg x Z U!-
400
FSH .,.. __ ..
lOO)lg z ,......_ X
..,. __ ...
300
~zoo
I
~100
0
o.s
1
Z4 hrs.
FIG. 1. The mean serum levels of LH (--) and FSH (- - -) responding to 200 or 100 ILg of LH-RH, given intramuscularly twice in two normal subjects.
200 ILg or 100 /Lg intramuscularly twice within 4 hours, or 200 ILg or 100 /Lg in intravenous infusion for 4 hours, was given 6 days after administration of clomiphene. Basal body temperature curves and endometrial biOpsies dated according to the criteria of Noyes et al. 10 were studied for evaluation of ovulation. All subjects were advised to have sexual relations on the day of the LH-RH injections, after at least 3 days of abstinence.
Triggering of Ovulation. Synthetic LHRH (400 /Lg) was slowly infused intravenously to a 28-year-old woman (L. U .) who had been married for 6 years and clinically diagnosed as functionally steriie. This patieui; had receiveu humulogous artificial insemination for 4 months, three times per month at the approximate time of ovulation, but had failed to conceive. She had had somewhat irregular menstrual cycles. During the treatment
400
FSH ----
~~--~------~~--~--_.----~--------~~ 0 0.5 1 4 6 7 Z4 hrs.
FIG. 2. The mean serum levels of LH ( - ) and FSH (---) responding to 200 or 100 ILg of LH-RH, given by intravenous infusion, in two normal subjects.
HUANG
798
August 1975
cycle, homologous artificial insemination TABLE 1. The Results of Intramuscular Injections was performed on the 12th menstrual of LH-RH following Administration of Clomiphene, 100 Mg/Day for 5 Days, to Patients day, followed immediately by LH-RH with Secondary Amenorrhea infusion for 4 hours. Previous Present treatment treatment: no. of cycles Dose No. of cycles failed with treated/ of clomiphene LH-RH' ovulations
Age
yr
mo
H.W.Y. H.M. P.M. C. Y.W.
26 29 26 33
10 17 8 7
11
C. S. L.
21
18
7
H.K.M. 28
21
12
C.M. W.A.
11
10
6 6
RESULTS
As shown in Figure 1, the intramuscular injection of LH-RH induced a rapid increase in serum LH levels, followed by a gradual decrease, but the serum LH levels remained significantly high even after 4 hours. A second, identical, injection augmented circulating LH levels in almost the same pattern, although the levels were not as high as those produced by the first injection. The serum FSH levels were elevated significantly 1 hour after the injection and persisted at the high level for up to 8 hours. As shown in Figure 2, the slow intravenous infusion of LH-RH resulted in a gradual increase in serum LH levels; they reached a plateau by 2 hours, persisted until 5 hours from the initiation of infusion, then decreased slightly. However, the LH levels remained high, constituting a second plateau, until 8 hours after the infusion. The serum FSH levels increased gradually, reached a maximal level at 4 hours, and remained significantly high until 8 hours after infusion. The serum levels of gonadotropins were still elevated 24 hours after both intramuscular and intravenous injections of LH-RH. Three of the four women in six cycles ovulated on the day of LH-RH administration. Induction of ovulation was attempted with this synthetic LH-RH in 48 cycles of 18 amenorrheic patients, by intramuscular injections during 22 cycles of8 patients and by intravenous infusion during 26 cycles of 10 patients. The results are shown in Tables 1 and 2. Among those patients treated with two intramuscular injections, a dose of 400 1-tg induced ovulation in seven of thirteen cycles, and a dose of 200 1-tg induced ovulation in
Duration of amenorrhe a
Patient
27 26
p.g
4 5 4
200 200 200 200 100 200 100 200 100 100 100
2/1 3f2b
2/0 2/1 1/0 111 111 3/2 2/1 3/2 2/0
"Each dose of LH-RH was administered twice within 4 hours. bPregnancy ensued.
four of nine cycles. Pregnancy ensued in one patient (H. M.). By intravenous infusion, a 200-~-tg dose induced ovulation in eight of fourteen cycles, and a 100-~-tg dose induced ovulation in eight of twelve cycles. Three patients (Y. Y. L., F. B., T. R. T.) conceived. An infertile subject (L. U.), to whom LH-RH had been given immediately after homologous artificial insemination, conceived that month. In TABLE 2. The Results of Intravenous Infusion of LH-RH following Administration of Clomiphene, 100 Mg!Day for 5 Days, to Patients with Secondary Amenorrhea Previous Present treatment treatment: - - - - - no. of cycles Dose No. of cycles failed with of treated/ clomiphene LH-RH'1 ovulations
Patient
Age
Duration of amenorrhea
yr
mo
H. M.S. C. D. Y. Y.L. J. c. c.
31 25 28 23
8 12 6 7
5 5 4 5
F. B.
28
10
13
L. S.
24
8
7
T.H.M. T. R.T. C.N.Y. R. w.
32 26 28 33
10 9 13
6 8 5 7
11
"Pregnancy ensued.
p.g
200 200 200 200 100 200 100 200 100 100 100 100 100
3/2 4/2 111" 3/3 2/1 110 1/1" 2/0 110 3/2 2/2• 2/2 110
28 yrs
Y. Y. L.
36.7C
799
LH-RH IN OVULATION INDUCTION IN AMENORRHEA
Vol. 26, No.8
v~ t Gonavis ( +)
mid. prolif.
11)
20
30
40
so
60
FIG. 3. The basal body temperature curve of a patient with secondary amenorrhea (Y. Y. L.) in whom pregnancy ensued from ovulation induced by ti1e intravenous (JV) infusion of200 p..g ofLH-RH following clomiphene administration. Proge, Progesterone (Proluton, Schering); Gonavis ( +), positive hemagglutination inhibition test for pregnancy (Mochida, Japan).
all cases of successful induction of ovulation, the basal body temperature was found to be elevated on the 2nd day of LH-RH administration. A representative paLL~r11 i~ ~l~u.JVvJ.J.
iu :fig~;-\: 2.
DISCUSSION
It is difficult to induce ovulation in patients with secondary amenorrhea, particularly when clomiphene therapy has failed. Previous studies have shown that patients with so-called hypothalamic amenorrhea have the ability to respond to LH-RH as well as normal subjects.2· 3· 11 "13 The rapid injection ofLH-RH reportedly does not induce ovulation in the late follicular phase of normal subjects12 or in women with secondary amenorrhea. 14 Very recently, studies have been made on induction of ovulation with prolonged administration of LH-RH to amenorrheic patients. 4"6 In this study an attempt was made to induce ovulation with synthetic LH-RH in amenorrheic patients, in whom clomiphene therapy had failed, by elaborating the conditions necessary for maintaining LH and FSH concentrations at ovulatory
levels. For this purpose, synthetic LH-RH was given either in two intramuscular injections or by intravenous infusion tc evaluate the pituitary responsiveness nnring the late follicular phase of fertile volunteers, and the method was found capable of inducing ovulation. Follicular maturation, a prerequisite for ovulation by LH stimulation, was achieved by administering clomiphene to the amenorrheic patients. The subsequent administration of synthetic LH-RH, 6 days after clomiphene treatment, induced ovulation by intramuscular injections in 50% of these patients and by intravenous infusion in 61.5%. These results are comparable to those reported by Keller, 5 who administered LH-RH by intravenous infusion 5 to 8 days after clomiphene administration. In this study, there were no statistical differences between the two doses of LH-RH given either in two intramuscular injections (P = 0.664) or by intravenous infusion (P = 0.615) and the different routes of administration (P = 0.423), although higher incidences of ovulation and pregnancy ensued from intravenous infusion than from intramuscular injections.
800
HUANG
The conclusion is reached that, by prolonged administration, high doses of synthetic LH-RH can be used for induction of ovulation in amenorrheic patients when follicular maturation has been achieved. The method used in this study, clomiphene with subsequent LH-RH injection, is suggested for treatment of sterility caused by hypothalamic anovulatory amenorrhea. However, the minimal optimal dosage of synthetic LH-RH for induction of ovulation remains to be determined. The doses used, at least in four women in this study, seemed sufficient to induce the maximal release of pituitary gonadotropins, suggesting that a lower dose may be effective by these methods of administration. The triggering of ovulation in a woman with functional sterility, as demons"i;rated in this study, can be applied to those infertile patients in whom artificial insemination is considered to be necessary. Whether LH secretion remains within physiologic limits after administration of large doses of LH-RH5 is unknown. The occurrence of a mild hyperstimulation syndrome after the injection of small doses of LH-RH has been reported, 6 but, by careful periodic pelvic examination none of our patients had enlarged ovari~s. In our previous experience, HCG, 3000 IU given intramuscularly to amenorrheic patients for 3 days from the 5th day after clomiphene, induced ovulation on different days. With the use of LH-RH however, a definite ovulation day can b~ established. Thus it seems that the possibility of pregnancy is greater with this treatment than with other treatments such as HCG injections. ' The failure of LH-RH to induce ovulation in patients with secondary amenorrhea is considered to be due to insufficient follicular maturation prior to LHRH administration. Perhaps the use of HMG instead of clomiphene would result in a more reliable follicular maturation in those for whom clomiphene therapy
August 1975
has failed; a long-acting LH-RH preparation may simplify the method. SUMMARY
Luteinizing hormone-releasing hormone (LH-RH), administered to normal women in divided intramuscular doses or by intravenous infusion, resulted in a prolonged release of luteinizing hormone and follicle-stimulating hormone from the pituitary gland, reliably resulting in ovulation during the late follicular phase. LH-RH was administered 6 days after clomiphene to 18 amenorrheic, anovulatory, infertile women in whom clomiphene therapy had failed previously. When LHRH was administered intramuscularly in two divided doses, ovulation occurred in six of eight women and in 11 of 22 woman-months of stimulation (50%). One pregnancy occurred. When LH-RH was administered by intravenous infusion, ovulation occurred in nine of ten women and in 16 of 26 woman-months of stimulation (61.5%); three of the ten women became pregnant. Pregnancy also followed treatment with LH-RH in one patient with irregular menses and functional sterility. Acknowledgments. I wish to thank the National Pituitary Agency, National Institute of Arthritis Metabolism and Digestive Diseases, for the gener~ ous supply of human pituitary gonadotropins, antisera, an~ standard hormone for radioimmunoassay. Synthetic LH-RH was kindly supplied by Farbwerke Hoechst .AG, Frankfurt (Main), through Teh Hua Chemical & Pharmaceutical Co., Ltd., Taipei, Taiwan. I am grateful to Professor P. Y. W~i, of this department, for his encouragement in this study and his critical appraisal of the manuscript. REFERENCES 1. Nillius SJ, Wide L: The LH-releasing hormone test in 31 women with secondary amenorrhea. J Obstet Gynaecol Br Commonw 79:874, 1972 2. Yen SSC, Rebar R, Vandenberg G, Judd H: Hypothalamic amenorrhea and hypogonadism: response to synthetic LRF. J Clin Endocrinol Metab 36:811, 1973
Vol. 26, No.8
LH-RH IN OVULATION INDUCTION IN AMENORRHEA
3. Nakano R, Kotsuji F, Mizuno T, Hashiba N, Wahio M, Tojo S: Response to luteinizing hormone releasing factor in normal and anovulatory patients. Acta Obstet Gynecol Scand 52:171, 1973 4. Zarate A, Canales ES, Schally AV, AyalaValdes L, Kastin AJ: Successful induction of ovulation with synthetic luteinizing hormonereleasing hormone in anovulatory infertility. Fertil Steril 23:672, 1972 5. Keller PJ: Treatment of anovulation with synthetic luteinizing hormone-releasing hormone. Am J Obstet Gynecol 116:698, 1973 6. Zanartu J, Dabancens A, Kastin AJ, Schally AV: Effect of synthetic hypothalamic gonadotropinreleasing hormone (FSH/LH-RH) in anovulatory sterility . Fertil Steril 25:160, 1974 7. Seki K: Serum follicle stimulating hormone and luteinizing hormone in women of various endocrinological states. Acta Obstet Gynaecol Jap 19:25, 1972 8. Midgley AR Jr: Radioimmunoassay for human follicle-stimulating hormone. J Clin Endocrinol Metab 27:295, 1967
801
9. Midgley AR Jr: Radioimmunoassay: a method for human chorionic gonadotropin and luteinizing hormone. Endocrinology 79:10, 1966 10. Noyes RW, Hertig AT, Rock J: Dating of the endometrial biopsy. Fertil Steril1:13, 1950 11. Schneider HPG, Dahlen HG: Studies with synthetic LH-releasing hormone in the human. Life Sci [I] 11:623, 1972 12. Yen SSC, Vandenberg G, Rebar R, Ebara Y: Variation of pituitary responsiveness to synthetic LRF during different phases of the menstrual cycle. J Clin Endocrinol Metab 35:931, 1972 13. Nillius SJ, Wide L: Variation in LH and FSH response to LH-releasing hormone during the menstrual cycle. J Obstet Gynaecol Br Commonw 79:865, 1972 14. Kastin AJ, Schally AV, Gual C, Midgley AR Jr, Bowers CY, Gomez-Perez F: Administration of LH-releasing hormone to selected subjects. Am J Obstet Gynecol 108:117, 1970
Vol. 26, No. 8, August 1975 Printed in U.S.A.
Copyright~
USE OF SYNTHETIC LUTEINIZING HORMONE-RELEASING HORMONE IN INDUCTION OF OVULATION IN AMENORRHEIC PATIENTS KO-EN HUANG, M.D. Department of Obstetrics and Gynecology, College of Medicine and the Hospital, National Taiwan University, Taipei, Taiwan, Republic of China
Recent studies on gonadotropin secretion from the pituitary gland in response to synthetic luteinizing hormonereleasing hormone (LH-RH) have indicated significant release of luteinizing hormone (LH) and, to lesser extent, follicle-stimulating hormone (FSH) in patients with hypothalamic amenorrhea. 1· 3 These results suggest that most amenorrhea is caused by hypothalamic disturbances. Therefore, it would be expected that synthetic LH-RH would be effective in inducing ovulation in these patients. A few studies have been made on induction of ovulation with synthetic LH-RH in amenorrheic patients. 4 ' 6 For achievement of follicular maturation, either LHRH6 or clomiphene 5 was used in continuous administration. The purpose of this communication is to present our experience with synthetic LH-RH (Hoechst) in the treatment of infertility in amenorrheic patients m whom clomiphene therapy had failed. MATERIALS AND METHODS ./
Response of Normal Subjects to LH-RH. Synthetic LH-RH was given, either as a 200-JLg intravenous infusion for 4 hours or as two 200-JLg intramuscular injections within a 4-hour interval, to two fertile women, ages 23 and 28, 1 or 2 days prior to the expected day of ovulation. Each subject was restudied 3 months later but was given one-half the dose administered Received August 15, 1974.
during the first study. These volunteers were healthy, fertile women who showed ovulatory basal body temperature patterns. Blood samples were obtained before the LH-RH injection and 30 minutes, every hour for 8 hours, and 24 hours after the beginning of the LH-RH injection. Sera were stored at - 20C C for FSH and LH determinations in simultaneous radioimmunoassay by the modified doubleantibody techniques 7 for human FSH 8 and LH. 9 All samples were tested in duplicate. The results were expressed in nanograms of LER 907 per milliliter of serum. Highly purified human pituitary FSH and LH, their antisera, and LER 907 were supplied by the National Pituitary Agency and the National Institute of Arthritis, Metabolism and Digestive Diseases. Induction of Ovulation in Amenorrheic, Infertile Subjects. Eighteen patients, ages 21 to 33, who had consulted this clinic with the primary complaint of infertility and who had secondary amenorrhea, were treated with synthetic LH-RH and studied for 48 months. All 18 patients had previously received clomiphene without resulting ovulation. All subjects were examined thoroughly to exclude any cause of infertility other than anovulation. Patients with high gonadotropin levels were also excluded. In order to stimulate follicular maturation, 100 mg of clomiphene/day were given for 5 days from the 5th day of each progesterone (Proluton, Schering)-induced bleeding. LH-RH,
796
Vol. 26, No.8
797
LH-RH IN OVULATION INDUCTION IN AMENORRHEA
ZOOpg x Z U!-
400
FSH .,.. __ ..
lOO)lg z ,......_ X
..,. __ ...
300
~zoo
I
~100
0
o.s
1
Z4 hrs.
FIG. 1. The mean serum levels of LH (--) and FSH (- - -) responding to 200 or 100 ILg of LH-RH, given intramuscularly twice in two normal subjects.
200 ILg or 100 /Lg intramuscularly twice within 4 hours, or 200 ILg or 100 /Lg in intravenous infusion for 4 hours, was given 6 days after administration of clomiphene. Basal body temperature curves and endometrial biOpsies dated according to the criteria of Noyes et al. 10 were studied for evaluation of ovulation. All subjects were advised to have sexual relations on the day of the LH-RH injections, after at least 3 days of abstinence.
Triggering of Ovulation. Synthetic LHRH (400 /Lg) was slowly infused intravenously to a 28-year-old woman (L. U .) who had been married for 6 years and clinically diagnosed as functionally steriie. This patieui; had receiveu humulogous artificial insemination for 4 months, three times per month at the approximate time of ovulation, but had failed to conceive. She had had somewhat irregular menstrual cycles. During the treatment
400
FSH ----
~~--~------~~--~--_.----~--------~~ 0 0.5 1 4 6 7 Z4 hrs.
FIG. 2. The mean serum levels of LH ( - ) and FSH (---) responding to 200 or 100 ILg of LH-RH, given by intravenous infusion, in two normal subjects.
HUANG
798
August 1975
cycle, homologous artificial insemination TABLE 1. The Results of Intramuscular Injections was performed on the 12th menstrual of LH-RH following Administration of Clomiphene, 100 Mg/Day for 5 Days, to Patients day, followed immediately by LH-RH with Secondary Amenorrhea infusion for 4 hours. Previous Present treatment treatment: no. of cycles Dose No. of cycles failed with treated/ of clomiphene LH-RH' ovulations
Age
yr
mo
H.W.Y. H.M. P.M. C. Y.W.
26 29 26 33
10 17 8 7
11
C. S. L.
21
18
7
H.K.M. 28
21
12
C.M. W.A.
11
10
6 6
RESULTS
As shown in Figure 1, the intramuscular injection of LH-RH induced a rapid increase in serum LH levels, followed by a gradual decrease, but the serum LH levels remained significantly high even after 4 hours. A second, identical, injection augmented circulating LH levels in almost the same pattern, although the levels were not as high as those produced by the first injection. The serum FSH levels were elevated significantly 1 hour after the injection and persisted at the high level for up to 8 hours. As shown in Figure 2, the slow intravenous infusion of LH-RH resulted in a gradual increase in serum LH levels; they reached a plateau by 2 hours, persisted until 5 hours from the initiation of infusion, then decreased slightly. However, the LH levels remained high, constituting a second plateau, until 8 hours after the infusion. The serum FSH levels increased gradually, reached a maximal level at 4 hours, and remained significantly high until 8 hours after infusion. The serum levels of gonadotropins were still elevated 24 hours after both intramuscular and intravenous injections of LH-RH. Three of the four women in six cycles ovulated on the day of LH-RH administration. Induction of ovulation was attempted with this synthetic LH-RH in 48 cycles of 18 amenorrheic patients, by intramuscular injections during 22 cycles of8 patients and by intravenous infusion during 26 cycles of 10 patients. The results are shown in Tables 1 and 2. Among those patients treated with two intramuscular injections, a dose of 400 1-tg induced ovulation in seven of thirteen cycles, and a dose of 200 1-tg induced ovulation in
Duration of amenorrhe a
Patient
27 26
p.g
4 5 4
200 200 200 200 100 200 100 200 100 100 100
2/1 3f2b
2/0 2/1 1/0 111 111 3/2 2/1 3/2 2/0
"Each dose of LH-RH was administered twice within 4 hours. bPregnancy ensued.
four of nine cycles. Pregnancy ensued in one patient (H. M.). By intravenous infusion, a 200-~-tg dose induced ovulation in eight of fourteen cycles, and a 100-~-tg dose induced ovulation in eight of twelve cycles. Three patients (Y. Y. L., F. B., T. R. T.) conceived. An infertile subject (L. U.), to whom LH-RH had been given immediately after homologous artificial insemination, conceived that month. In TABLE 2. The Results of Intravenous Infusion of LH-RH following Administration of Clomiphene, 100 Mg!Day for 5 Days, to Patients with Secondary Amenorrhea Previous Present treatment treatment: - - - - - no. of cycles Dose No. of cycles failed with of treated/ clomiphene LH-RH'1 ovulations
Patient
Age
Duration of amenorrhea
yr
mo
H. M.S. C. D. Y. Y.L. J. c. c.
31 25 28 23
8 12 6 7
5 5 4 5
F. B.
28
10
13
L. S.
24
8
7
T.H.M. T. R.T. C.N.Y. R. w.
32 26 28 33
10 9 13
6 8 5 7
11
"Pregnancy ensued.
p.g
200 200 200 200 100 200 100 200 100 100 100 100 100
3/2 4/2 111" 3/3 2/1 110 1/1" 2/0 110 3/2 2/2• 2/2 110
28 yrs
Y. Y. L.
36.7C
799
LH-RH IN OVULATION INDUCTION IN AMENORRHEA
Vol. 26, No.8
v~ t Gonavis ( +)
mid. prolif.
11)
20
30
40
so
60
FIG. 3. The basal body temperature curve of a patient with secondary amenorrhea (Y. Y. L.) in whom pregnancy ensued from ovulation induced by ti1e intravenous (JV) infusion of200 p..g ofLH-RH following clomiphene administration. Proge, Progesterone (Proluton, Schering); Gonavis ( +), positive hemagglutination inhibition test for pregnancy (Mochida, Japan).
all cases of successful induction of ovulation, the basal body temperature was found to be elevated on the 2nd day of LH-RH administration. A representative paLL~r11 i~ ~l~u.JVvJ.J.
iu :fig~;-\: 2.
DISCUSSION
It is difficult to induce ovulation in patients with secondary amenorrhea, particularly when clomiphene therapy has failed. Previous studies have shown that patients with so-called hypothalamic amenorrhea have the ability to respond to LH-RH as well as normal subjects.2· 3· 11 "13 The rapid injection ofLH-RH reportedly does not induce ovulation in the late follicular phase of normal subjects12 or in women with secondary amenorrhea. 14 Very recently, studies have been made on induction of ovulation with prolonged administration of LH-RH to amenorrheic patients. 4"6 In this study an attempt was made to induce ovulation with synthetic LH-RH in amenorrheic patients, in whom clomiphene therapy had failed, by elaborating the conditions necessary for maintaining LH and FSH concentrations at ovulatory
levels. For this purpose, synthetic LH-RH was given either in two intramuscular injections or by intravenous infusion tc evaluate the pituitary responsiveness nnring the late follicular phase of fertile volunteers, and the method was found capable of inducing ovulation. Follicular maturation, a prerequisite for ovulation by LH stimulation, was achieved by administering clomiphene to the amenorrheic patients. The subsequent administration of synthetic LH-RH, 6 days after clomiphene treatment, induced ovulation by intramuscular injections in 50% of these patients and by intravenous infusion in 61.5%. These results are comparable to those reported by Keller, 5 who administered LH-RH by intravenous infusion 5 to 8 days after clomiphene administration. In this study, there were no statistical differences between the two doses of LH-RH given either in two intramuscular injections (P = 0.664) or by intravenous infusion (P = 0.615) and the different routes of administration (P = 0.423), although higher incidences of ovulation and pregnancy ensued from intravenous infusion than from intramuscular injections.
800
HUANG
The conclusion is reached that, by prolonged administration, high doses of synthetic LH-RH can be used for induction of ovulation in amenorrheic patients when follicular maturation has been achieved. The method used in this study, clomiphene with subsequent LH-RH injection, is suggested for treatment of sterility caused by hypothalamic anovulatory amenorrhea. However, the minimal optimal dosage of synthetic LH-RH for induction of ovulation remains to be determined. The doses used, at least in four women in this study, seemed sufficient to induce the maximal release of pituitary gonadotropins, suggesting that a lower dose may be effective by these methods of administration. The triggering of ovulation in a woman with functional sterility, as demons"i;rated in this study, can be applied to those infertile patients in whom artificial insemination is considered to be necessary. Whether LH secretion remains within physiologic limits after administration of large doses of LH-RH5 is unknown. The occurrence of a mild hyperstimulation syndrome after the injection of small doses of LH-RH has been reported, 6 but, by careful periodic pelvic examination none of our patients had enlarged ovari~s. In our previous experience, HCG, 3000 IU given intramuscularly to amenorrheic patients for 3 days from the 5th day after clomiphene, induced ovulation on different days. With the use of LH-RH however, a definite ovulation day can b~ established. Thus it seems that the possibility of pregnancy is greater with this treatment than with other treatments such as HCG injections. ' The failure of LH-RH to induce ovulation in patients with secondary amenorrhea is considered to be due to insufficient follicular maturation prior to LHRH administration. Perhaps the use of HMG instead of clomiphene would result in a more reliable follicular maturation in those for whom clomiphene therapy
August 1975
has failed; a long-acting LH-RH preparation may simplify the method. SUMMARY
Luteinizing hormone-releasing hormone (LH-RH), administered to normal women in divided intramuscular doses or by intravenous infusion, resulted in a prolonged release of luteinizing hormone and follicle-stimulating hormone from the pituitary gland, reliably resulting in ovulation during the late follicular phase. LH-RH was administered 6 days after clomiphene to 18 amenorrheic, anovulatory, infertile women in whom clomiphene therapy had failed previously. When LHRH was administered intramuscularly in two divided doses, ovulation occurred in six of eight women and in 11 of 22 woman-months of stimulation (50%). One pregnancy occurred. When LH-RH was administered by intravenous infusion, ovulation occurred in nine of ten women and in 16 of 26 woman-months of stimulation (61.5%); three of the ten women became pregnant. Pregnancy also followed treatment with LH-RH in one patient with irregular menses and functional sterility. Acknowledgments. I wish to thank the National Pituitary Agency, National Institute of Arthritis Metabolism and Digestive Diseases, for the gener~ ous supply of human pituitary gonadotropins, antisera, an~ standard hormone for radioimmunoassay. Synthetic LH-RH was kindly supplied by Farbwerke Hoechst .AG, Frankfurt (Main), through Teh Hua Chemical & Pharmaceutical Co., Ltd., Taipei, Taiwan. I am grateful to Professor P. Y. W~i, of this department, for his encouragement in this study and his critical appraisal of the manuscript. REFERENCES 1. Nillius SJ, Wide L: The LH-releasing hormone test in 31 women with secondary amenorrhea. J Obstet Gynaecol Br Commonw 79:874, 1972 2. Yen SSC, Rebar R, Vandenberg G, Judd H: Hypothalamic amenorrhea and hypogonadism: response to synthetic LRF. J Clin Endocrinol Metab 36:811, 1973
Vol. 26, No.8
LH-RH IN OVULATION INDUCTION IN AMENORRHEA
3. Nakano R, Kotsuji F, Mizuno T, Hashiba N, Wahio M, Tojo S: Response to luteinizing hormone releasing factor in normal and anovulatory patients. Acta Obstet Gynecol Scand 52:171, 1973 4. Zarate A, Canales ES, Schally AV, AyalaValdes L, Kastin AJ: Successful induction of ovulation with synthetic luteinizing hormonereleasing hormone in anovulatory infertility. Fertil Steril 23:672, 1972 5. Keller PJ: Treatment of anovulation with synthetic luteinizing hormone-releasing hormone. Am J Obstet Gynecol 116:698, 1973 6. Zanartu J, Dabancens A, Kastin AJ, Schally AV: Effect of synthetic hypothalamic gonadotropinreleasing hormone (FSH/LH-RH) in anovulatory sterility . Fertil Steril 25:160, 1974 7. Seki K: Serum follicle stimulating hormone and luteinizing hormone in women of various endocrinological states. Acta Obstet Gynaecol Jap 19:25, 1972 8. Midgley AR Jr: Radioimmunoassay for human follicle-stimulating hormone. J Clin Endocrinol Metab 27:295, 1967
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9. Midgley AR Jr: Radioimmunoassay: a method for human chorionic gonadotropin and luteinizing hormone. Endocrinology 79:10, 1966 10. Noyes RW, Hertig AT, Rock J: Dating of the endometrial biopsy. Fertil Steril1:13, 1950 11. Schneider HPG, Dahlen HG: Studies with synthetic LH-releasing hormone in the human. Life Sci [I] 11:623, 1972 12. Yen SSC, Vandenberg G, Rebar R, Ebara Y: Variation of pituitary responsiveness to synthetic LRF during different phases of the menstrual cycle. J Clin Endocrinol Metab 35:931, 1972 13. Nillius SJ, Wide L: Variation in LH and FSH response to LH-releasing hormone during the menstrual cycle. J Obstet Gynaecol Br Commonw 79:865, 1972 14. Kastin AJ, Schally AV, Gual C, Midgley AR Jr, Bowers CY, Gomez-Perez F: Administration of LH-releasing hormone to selected subjects. Am J Obstet Gynecol 108:117, 1970