Document Type : Original Article
1 Department of Obstetrics and Gynecology, McGill University, Montreal, Quebec, Canada
2 Department of Reproductive Endocrinology and Infertility, McGill Reproductive Center, McGill University, Montreal, Quebec, Canada
Multiple studies and meta-analyses have reported
the importance of luteinizing hormone
(LH) or LH mediated activity for
The current study compared stimulation parameters, pregnancy and clinical pregnancy rates of patients with normal ovarian reserve parameters treated with a long gonadotropin releasing hormone (GnRH) agonist protocol and received r-LH to those treated with hMG that contained hCG as an LH analogue. Both groups of participants also received daily FSH stimulation.
We performed a cohort study from data collected at the McGill Reproductive Center. An analysis of IVF cycles for a two-year period was undertaken to identify all patients treated at our institution that met the inclusion criteria. To be included in the study patients received FSH and either r-LH or HMG but not both forms of LH stimulation. Patients with maximum serum baseline FSH levels under 10 IU/L (drawn menstrual cycle days 2 to 5 inclusively) and baseline follicle counts of 6 follicles or more determined by transvaginal ultrasound (TVUS) as assessed on menstrual cycle days 2 to 5, inclusively, initiated treatment with a long GnRH agonist down-regulation protocol (n=122). A total of 65 women received r-LH whereas 57 received hMG. Cycles were excluded from analysis if the patient had hyperprolactinemia (morning fasting prolactin greater than 26 ng/mL), thyroid abnormalities (TSH below 0.39 or above 4.0 μIU/ mL), hypothalamic pituitary dysfunction, and ovarian failure (FSH below 2 IU/L or abover 20 IU/L and estradiol <66 pg/mL). The McGill University Committee for the Protection of Human Research Subjects approved this data collection. All subjects were de-identified in the database. Patients were allotted to their respective treatment regimens by clinic staff to maintain equivalent rates for prescription of different drugs produced by competing pharmaceutical companies. Patients that received hMG (Repronex, Ferring Canada, North York, ON) also received either follitropin beta (64%, Merck Canada, Inc., Pointe-Claire, QC), follitropin alfa (20%, EMD Serono Canada, Mississauga, ON), or purified urofollitropin (16%, Ferring Canada, North York, ON). All patients that received r-LH were treated with follitropin alfa (EMD Serono Canada, Mississauga, ON).
Patients treated with a GnRH agonist long downregulation protocol initially received stimulation with 112.5 to 225 units of FSH daily at the discretion of their treating physician. The physician selected the dose based on parameters of ovarian reserve noted during the planning of the cycle. After 5 days of FSH stimulation, we reassessed the doses which were titrated up or down depending on serum estradiol levels, as well as the numbers and diameters of follicles noted. Subsequently, patients were monitored at 1 to 3 day intervals with serum estradiol levels and transvaginal ultrasonographic follicle monitoring. Patients were prescribed LH activity such that the ratio of FSH to LH was 3:1 to 2:1 at the discretion of their treating physician. We measured peak serum estradiol levels and either 10000 IU or 5000 IU of hCG were given based on our center’s protocol 35 hours prior to egg retrieval. We followed the McGill Reproductive Center protocol for egg retrieval and embryo transfer using either a Cook (Cook Canada, Inc., Stouffville, ON) 17-gauge single lumen needle or a 16-gauge double lumen flushing needle and warmed saline flush. Pressure for aspiration was kept at 145 mmHg by a Cook Vacuum Pump (KMar 8200, Cook, Australia).
At 17 to 19 hours after insemination, embryo fertilization was evaluated for the presence of two pronuclei and two polar bodies. The zygotes were transferred to an IVF cleavage medium for further culture (Cook, Australia). The embryos were evaluated on days 2 (41-43 hours after insemination) and 3 (65-67 hours after insemination). Quality of development of the embryos was assessed according to the regularity of blastomeres, the percentage and pattern of anucleate fragments, and dysmorphic characteristics. Good quality embryos on day 2 had at least 2 cells and by day 3, they at least 6 cells with less than 20% anucleate fragments and no apparent morphological anomalies. Embryos were considered low quality if they showed blastomere multi-nucleation, poor cell adhesion, uneven cell division, and cytoplasmic anomalies. We transferred embryos of best quality based on cell number, degree of fragmentation, symmetry of blastomeres, degree of compaction, clarity and texture. Depending on age and physician orders, the transfer was performed on day 2 or 3.
Embryos were transferred under trans-abdominal ultrasound guidance and placed 2.5 to 1.5 cm from the uterine fundus using a Wallace embryo replacement catheter (Smith Medical International Ltd., UK). The number of embryos transferred varied between 2-5 depending on the patient’s age, embryo quality, and previous number of unsuccessful IVF cycles. Decisions were based according to recommendations by the American Society for Reproductive Medicine Committee Opinion (
Statistical analysis was done using SPSS 11.0 (SPSS Inc., Chicago, IL, USA). Continuous variables were evaluated for normal distribution using the Kolmogorov-Smirnov test. All continuous variables were normally distributed. We performed stepwise logistic regression on continuous and categorical variables to control for multiplicity and confounding effects. Rates for causes of infertility were analyzed by chi-squared tests. Data are presented as means ± SD with statistical significance as a two-sided P≤0.05. Controlled variables included patient age, basal serum FSH level, basal serum estradiol level, antral follicle count, previous pregnancies, previous full term pregnancies, previous miscarriages, previous IVF cycles, total LH and FSH stimulation doses, days of LH and FHS stimulation, as well as the number of oocytes and embryos obtained.
There were no cancelled cycles in any of the patients. Patients were good responders; hence, we did not anticipate any poor response. Ovarian hyperstimulation syndrome was avoided in all cases. No statistical differences in pregnancy rate (P=0.432) or clinical pregnancy rate (P=0.381) existed among the cycles that used follitropin alfa, follitropin beta or urofollitropin, which was combined in all cases with hMG. This result supported the combined analysis of these results. A comparison of patient demographics in subjects treated with the long GnRH agonist protocol is presented in Table 1. The two groups did not differ in any of the baseline characteristics studied, including basal serum FSH level, basal serum estradiol level, and baseline follicle count. The number of embryos transferred did not differ between r-LH (2.2 ± 0.6) versus hMG (2.3 ± 0.6, P=0.36).
Patient demographics (mean ± SD)
|Age (Y)||35.2 ± 4.2||36.0 ± 4.4||0.412|
|Basal serum FSH (IU/L)||7.7 ± 1.5||7.2 ± 1.7||0.134|
|Basal serum estradiol (pmol/L)||167 ± 85||183 ± 77||0.292|
|Antral follicle count||18 ± 10||16 ± 6||0.200|
|Previous pregnancies||0.8 ± 1.2||1.0 ± 1.2||0.833|
|Previous full term pregnancies||0.1 ± 0.4||0.3 ± 0.8||0.274|
|Previous miscarriages||0.7 ± 1.1||0.7 ± 0.9||0.701|
|Previous IVF cycles at McGill||1.7 ± 0.9||1.9 ± 1.1||0.203|
|Previous IVF cycles elsewhere||0.4 ± 1.0||0.3 ± 0.9||0.543|
Analysis performed with stepwise logistic regression.
r-LH; Recombinant human luteinizing hormone, hMG; Human menopausal gonadotropin, IVF;
There were similar rates for causes of infertility in subjects treated with the long GnRH agonist protocol that received either r-LH or hMG (P=0.469).
A comparison of the r-LH or hMG groups showed that the rates of male factor infertility were 54% (r-LH) and 39% (hMG), the unexplained infertility rates were 32% (r-LH) and 33% (hMG), the rates of endometriosis were 4% (r-LH) and 12% (hMG), and the anovulation rates were 2% in both groups. Tubal factor infertility did not occur in either group.
Table 2 shows treatment outcomes for the r-LH and hMG groups when treated with the long GnRH antagonist protocol. Patients treated with r-LH had a higher pregnancy rate per cycle start (P=0.0250) and implantation rate (P=0.001) after controlling for patient age, baseline FSH and estradiol levels, antral follicle count, previous pregnancies, full term deliveries and spontaneous abortions, number of previous IVF cycles, dose of FSH and LH administered, as well as days of stimulation. Patients treated with r-LH had a trend towards a higher clinical pregnancy rate per cycle start (P=0.0649). Patients that received r-LH compared to using hMG had more oocytes collected and more embryos created, even though the r-LH group used lower doses of FSH and LH. The number of days of stimulation did not differ between the r-LH and hMG groups.
IVF cycle characteristics and treatment outcomes
|Total FSH dose (IU)||3207 ± 1300||4213 ± 1576||0.0001|
|Days of FSH||8.7 ± 2.5||9.0 ± 1.7||0.248|
|Total LH dose (IU)||1332 ± 587||1938 ± 1110(obtained through hCG activity)||0.0001|
|Days of LH||7.9 ± 2.5||7.8 ± 2.6||0.997|
|Oocytes obtained||14.4 ± 6.3||11.0 ± 5.3||0.0100|
|Embryos obtained||7.9 ± 4.8||6.0 ± 3.7||0.0290|
|Percent of ICSI cases per group||72%||78%||0.663|
|Pregnancy rate per cycle start||49%||27%||0.0250|
|Clinical pregnancy rate per cycle start||39%||25%||0.0649|
Analysis performed with stepwise logistic regression.
In this study, there were lower FSH and LH doses required for stimulation in the long GnRH stimulation cycle with r-LH compared to hMG. r-LH treated subjects had larger numbers of oocytes and embryos obtained compared to hMG treated subjects. Pregnancy rates per cycle start and implantation rates were higher for patients in the r-LH group compared to the hMG group. There was a trend for increased clinical pregnancy rate in the r-LH group; however, this did not reach statistical significance when controlling for confounders. We observed these findings even after controlling for patient age, baseline FSH and estradiol levels, antral follicle count, previous pregnancies, full term deliveries, spontaneous abortions, and previous number of IVF cycles.
A systematic review and meta-analysis by Coomarasamy et al. (
To date, few
Our data suggests that r-LH might be beneficial compared to hCG in terms of LH mediated activity in long GnRH agonist cycles. This was a retrospective study, hence, further studies should be undertaken to confirm these results. It would have been interesting to compare follitropin-alpha and r-LH versus hMG and follitropin-alpha. The number of patients treated with this protocol was too small for comparison and should be reassessed in future studies.
FSH plus r-LH may offer benefit compared to FSH plus hMG for ovarian stimulation in long GnRH-agonist protocols performed in good responders. This may occur through different stimulation of the ovarian cumulous cells or endometrium. Further studies, both larger and prospective, are needed to confirm these results.