FSH Stimulation Research Articles

GnRH antagonist cetrorelix decreases the required dose of FSH and the length of ovarian stimulation in comparison to leuprolide in IVF cycles

OBJECTIVE: Since late 1990s, GnRH antagonists have been used to inhibit pituitary function and avoid premature luteinization and ovulation in IVF cycles. Differently from GnRH agonists, antagonists provide immediate inhibition of pituitary receptors. Our aim was to compare IVF cycles in which pituitary inhibition was achieved by either GnRH agonist (leuprolide) or antagonist (cetrorelix). DESIGN: Retrospective analysis at a private infertility center. MATERIALS AND METHODS: 257 IVF cycles performed in patients < 37 years old were retrospectively analyzed and compared considering the modality of pituitary inhibition: GnRH agonist (leuprolide; n=119) or antagonist (cetrorelix; n=138). Leuprolide was started in the luteal phase of the previous menstrual cycle, whereas cetrorelix was prescribed when at least one follicle ≥ 15mm was detected. Controlled ovarian hyperstimulation was performed with recombinant FSH for all patients. Oocyte maturation was induced with recombinant-hCG when there was at least one follicle ≥ 18mm and oocyte retrieval was performed 35 hours later. Outcomes were compared and p values <0.05 were considered significant. RESULTS: The length of ovarian stimulation was shorter and the total required amount of r-FSH was lower for antagonist cycles (table). The other outcomes showed no statistically significant difference.Table 1ResultsGnRH AGONISTGnRH ANTAGONISTpcycles with ET119138age (mean)32.7732.040.087∗days of stimulation (mean)11.0210.11<0.0001∗number of oocytes (mean)9.5111.430.05∗M2 (mean)7.078.540.039∗fertilization rate78.4%80.4%0.312∗∗transferred embryos (mean)2.462.300.060∗total r-FSH dose (mean)2,304.21,760.3<0.0001∗implantation rate18.4%19.9%0.681∗∗clinical pregnancy rate35.3%34.1%0.895∗∗clinical miscarriage rate19.0%19.1%1.0∗∗ongoing pregnancy rate28.6%27.5%0.889∗∗∗ Mann-Whitney test, ∗∗ Fisher's exact test. Open table in a new tab ∗ Mann-Whitney test, ∗∗ Fisher's exact test. CONCLUSIONS: Our findings are in concordance with previous reports that evaluated the use of GnRH antagonists in IVF cycles. There was no difference in the total number of oocytes retrieved, although the mean number of mature oocytes turned to be higher for patients treat with cetrorelix. Pregnancy and miscarriage rates were also equivalent between both groups. Finally, our results suggest that the use of the GnRH antagonist cetrorelix correlates to shorter ovarian stimulation and lower total requirement of exogenous FSH.

The role of the follicle stimulating hormone receptors genotype in the response to FSH in women undergoing controlled ovarian stimulation

OBJECTIVE: To investigate the role of follicle stimulating hormone receptor (FSHR) genotype, in response to FSH in women undergoing controlled ovarian stimulation and to examine the association of ovarian response variables with the total HMG dose in different allelic variant genotypes.DESIGN: Prospective clinical trial.MATERIALS AND METHODS: Women undergoing controlled ovarian hyperstimulation were subjected molecular studies DNA isolation, DNA amplification and RFLP analysis. Through this molecular study, the studied women are classified into three groups: Asn680Ser variant, namely, aa (680Asn/Asn), as (680Asn/Ser) and ss (680Ser/Ser), of the FSHR gene. follicular development was monitored by transvaginal ultrasonography after 6 days of stimulation and then every other day. Sonography was performed daily when the leading follicle exceeded 14 mm in diameter. Ovulation was induced by 10,000 IU human CG (hCG), IM, when at least two follicle was 20 mm in diameter. Oocytes were collected by transvaginal Ultrasound-guided aspiration under general anesthesia was generally performed approximately 36 hours after hCG administration. Intracytoplasmic sperm injection was performed in all patients.RESULTS: The frequency distributions of FSHR allelic variants were 20 patients (37%) for the allelic variant (aa), 20 patients (37%) for allelic variant (ss) and 14 patients (26%) for the allelic variant (as) patients. The mean number of HMG ampoules given to the studied patients was 24.6 ± 5.1 in allelic (aa) patients, 41.3 ± 4.8 in allelic (ss) patients, and 37.5 ± 6.3 in allelic (as) patients and showed statistically significant difference (p <.0001). In patients belonging to allelic variant (aa), the larger the HMG dose, the less the oocytes number will the patient develop, the more the E2HCG will the patient produce and the more the MII oocytes that will develop. In patients belonging to allelic variant (ss), the larger the dose of HMG, the more the oocytes number will the patient develop, the more the E2HCG will the patient produce and the more the MII oocytes that will develop. In patients belonging to allelic variant (as), the results are roughly similar to that observed in allelic (aa) group.CONCLUSIONS: We can conclude that a different ovarian response to FSH stimulation do occur, depending on the FSHR genotype and indicates that subtle genetic changes might fine-tune the hormonal regulation of reproduction. knowing the different sensitivity to FSH, depending on the FSHR genotype, could be important to prevent OHSS. OBJECTIVE: To investigate the role of follicle stimulating hormone receptor (FSHR) genotype, in response to FSH in women undergoing controlled ovarian stimulation and to examine the association of ovarian response variables with the total HMG dose in different allelic variant genotypes. DESIGN: Prospective clinical trial. MATERIALS AND METHODS: Women undergoing controlled ovarian hyperstimulation were subjected molecular studies DNA isolation, DNA amplification and RFLP analysis. Through this molecular study, the studied women are classified into three groups: Asn680Ser variant, namely, aa (680Asn/Asn), as (680Asn/Ser) and ss (680Ser/Ser), of the FSHR gene. follicular development was monitored by transvaginal ultrasonography after 6 days of stimulation and then every other day. Sonography was performed daily when the leading follicle exceeded 14 mm in diameter. Ovulation was induced by 10,000 IU human CG (hCG), IM, when at least two follicle was 20 mm in diameter. Oocytes were collected by transvaginal Ultrasound-guided aspiration under general anesthesia was generally performed approximately 36 hours after hCG administration. Intracytoplasmic sperm injection was performed in all patients. RESULTS: The frequency distributions of FSHR allelic variants were 20 patients (37%) for the allelic variant (aa), 20 patients (37%) for allelic variant (ss) and 14 patients (26%) for the allelic variant (as) patients. The mean number of HMG ampoules given to the studied patients was 24.6 ± 5.1 in allelic (aa) patients, 41.3 ± 4.8 in allelic (ss) patients, and 37.5 ± 6.3 in allelic (as) patients and showed statistically significant difference (p <.0001). In patients belonging to allelic variant (aa), the larger the HMG dose, the less the oocytes number will the patient develop, the more the E2HCG will the patient produce and the more the MII oocytes that will develop. In patients belonging to allelic variant (ss), the larger the dose of HMG, the more the oocytes number will the patient develop, the more the E2HCG will the patient produce and the more the MII oocytes that will develop. In patients belonging to allelic variant (as), the results are roughly similar to that observed in allelic (aa) group. CONCLUSIONS: We can conclude that a different ovarian response to FSH stimulation do occur, depending on the FSHR genotype and indicates that subtle genetic changes might fine-tune the hormonal regulation of reproduction. knowing the different sensitivity to FSH, depending on the FSHR genotype, could be important to prevent OHSS.

A prospective evaluation of antral follicle function in women with spontaneous 46,xx primary ovarian insufficiency (hypergonadotropic hypogonadism)

OBJECTIVE: We have demonstrated histologically that women with spontaneous primary ovarian insufficiency (sPOI) develop lutienized graafian follicles. Normal human follicles ≥ 8 mm express aromatase and should theoretically secrete estradiol (E2) in response to FSH stimulation. We assess the function of ovarian follicles in women with sPOI. DESIGN: Prospective, controlled. MATERIALS AND METHODS: We recruited 97 women with sPOI and 42 control women, assayed basal serum levels for FSH, LH, E2, and performed transvaginal sonogram (day 3 in control cycles, off HRT for 2 weeks in patients). Intervention: single injection of 300 IU of hrFSH and repeat serum sampling at 24 hours. Analysis done by SAS version 9.0 (Cary, NC): compare response of patients to controls, and also patients with and without the presence of an antral follicle ≥ 8 mm. RESULTS: A follicle ≥ 8 mm was detected in 37/97 patients (38%). Antral follicular diameter significantly correlated with serum estradiol level in patients (r = 0.39, p < 0.001). See Table 1, Table 2. CONCLUSIONS: Antral follicles in women with sPOI fail to demonstrate an E2 response to FSH stimulation. Our findings are consistent with the hypothesis that follicles in these women fail to respond due to inappropriate luteinization. Prospective studies seeking to improve follicle function in these women by suppressing LH levels to normal are indicated.Table 1No estradiol response to FSH in patients with POIParameterControl (n=42)POI (n=97)P valueAge (yrs)36.232.20.004Endometrium (mm)42<0.0001Total follicular count115<0.001Basal FSH (IU/L)881<0.001Basal Estradiol (pg/mL)36.3270.02Estradiol 24 hrs after FSH injection (pg/mL)94.128.4<0.0001Change in estradiol after FSH injection (pg/mL)410<0.0001Change in FSH after FSH injection (IU/L)340.66 Open table in a new tab Table 2No estradiol response to FSH in patients with antral follicles (≥8 mm)Parameter<8 mm follicle≥8 mm follicleP valueAge (yrs)31340.02Duration of mestrual abnormality (months)40.941.40.24Basal Estradiol (pg/mL)23.240.10.0006Basal FSH (IU/L)93470.0001Basal LH (IU/L)5635.50.008Estradiol 24 hrs after FSH injection (pg/mL)24.841.80.005Change in Estradiol level after FSH injection (pg/mL)0.20.00.5Change in FSH after FSH injection (IU/L)640.49 Open table in a new tab

Change and significance of the expression of c-kit and SCF following recovery from unilateral testicular torsion in rats

To investigate the change in expression levels of c-kit and SCF, and the protective effects of FSH on ischemia-reperfusion injury due to testicular torsion-detorsion. 24 adult male SD rats were divided into three groups of 8: control group, testicular torsion group and FSH-treated group. The control group was treated with sham-operation. Animals in the testicular torsion and FSH-treated groups were subjected to unilateral 720 degrees counterclockwise testicular torsion for 2 hours and then reperfusion was allowed after detorsion. The FSH-treated group received intraperitoneal injection of FSH 15min before detorsion. Then, the rats were sacrificed and the testes were harvested. Histopathological changes were observed by light microscope, and the expression levels of c-kit, SCF in testicular tissue in the different groups were detected by Immunohistochemical assay and Quantitative Real-time RT-PCR analysis. Finally, the relative proportions of germ cells were measured by FCM. c-kit and SCF were positive expressed in 52.58% and 61.16% of testicular cells of control tissues, respectively. Decreases of c-kit and SCF positive cells (15.01% and 9.18%) were found in the testicular torsion group. After being treated by FSH, the number of positive cells increased (31.25% and 20.01%). Moreover, the c-kit and SCF mRNA expression was increased dramatically (P < 0.01) in response to FSH stimulation. Furthermore, the number of haploid, diploid and tetraploid cells has also increased significantly in drug-treated testes (P < 0.01). The mechanism of tissue damage in the testicular torsion model, includes changes in the expression of c-kit and SCF following torsion. Also, FSH has a protective effect on germ cells after unilateral testicular torsion, which was reflected by increased c-kit and SCF levels.

Myo-inositol may improve oocyte quality in intracytoplasmic sperm injection cycles. A prospective, controlled, randomized trial

To determine the effects of myo-inositol on oocyte quality in polycystic ovary syndrome (PCOS) patients undergoing intracytoplasmic sperm injection (ICSI) cycles. A prospective, controlled, randomized trial. Assisted reproduction centers. Sixty infertile PCO patients undergoing ovulation induction for ICSI. All participants underwent standard long protocol. Starting on the day of GnRH administration, 30 participants received myo-inositol combined with folic acid (Inofolic) 2 g twice a day and 30 control women received folic acid alone, administrated continuously. Primary end points were number of morphologically mature oocytes retrieved, embryo quality, and pregnancy and implantation rates. Secondary end points were total number of days of FSH stimulation, total dose of gonadotropin administered, E(2) level on the day of hCG administration, fertilization rate per number of retrieved oocytes, embryo cleavage rate, live birth and miscarriage rates, cancellation rate, and incidence of moderate or severe ovarian hyperstimulation syndrome. Total r-FSH units (1,958 +/- 695 vs. 2,383 +/- 578) and number of days of stimulation (11.4 +/- 0.9 vs. 12.4 +/- 1.4) were significantly reduced in the myo-inositol group. Furthermore, peak E(2) levels (2,232 +/- 510 vs. 2,713 +/- 595 pg/mL) at hCG administration were significantly lower in patients receiving myo-inositol. The mean number of oocytes retrieved did not differ in the two groups, whereas in the group cotreated with myo-inositol the mean number of germinal vesicles and degenerated oocytes was significantly reduced (1.0 +/- 0.9 vs. 1.6 +/- 1.0), with a trend for increased percentage of oocytes in metaphase II (0.82 +/- 0.11% vs. 0.75 +/- 0.15%). These data show that in patients with PCOS, treatment with myo-inositol and folic acid, but not folic acid alone, reduces germinal vesicles and degenerated oocytes at ovum pick-up without compromising total number of retrieved oocytes. This approach, reducing E(2) levels at hGC administration, could be adopted to decrease the risk of hyperstimulation in such patients.

Comparison of daily and alternate day recombinant follicle-stimulating hormone stimulation protocols for intrauterine insemination

To determine the efficacy of daily versus alternate-day stimulation for patients undergoing intrauterine insemination (IUI). Retrospective comparative study. University tertiary care center for infertility. Women with anovulatory or unexplained infertility for over 12 months who had not responded to or not conceived with clomiphene citrate treatment. Ovarian stimulation with recombinant follicle-stimulating hormone (FSH; follitropin-beta) given either daily or on alternate days before IUI. Clinical pregnancy at ultrasound 4 weeks after IUI. Secondary outcome measures were duration of stimulation, total gonadotropin dose, ovarian response, and multiple pregnancy rate. Of the 212 women who underwent a first cycle of gonadotropin stimulation, 28 had daily injections and 117 had alternate-day injections of follitropin-beta only for IUI. Female age, antral follicle count, and day-3 serum FSH were comparable. The median duration of stimulation (8 days vs. 8 days) and the median number of follicles over 14 mm (3.5 vs. 3.0) were similar in both groups. However, the total recominbinant FSH dose (825 vs. 625 IU) and endometrial thickness (10.1 vs. 9.3 mm) were greater in the daily injection group. The clinical pregnancy rate per cycle was 42% (12 out of 28) in the daily injection group and 19% (22 out of 117) in the alternate-day group. Daily recombinant FSH stimulation for IUI seems to be associated with a higher clinical pregnancy rate than alternate-day FSH stimulation. Prospective randomized trials would be needed to determine whether this is indeed the case.

Effects of Ovum Pick‐up Frequency and FSH Stimulation: A Retrospective Study on Seven Years of Beef Cattle In Vitro Embryo Production

The aim of this retrospective study was to compare the number of follicles, cumulus oocyte complexes (COCs) and cultured In Vitro Produced (IVP) embryos obtained from 1396 non-stimulated Ovum Pick-up (OPU) sessions on 81 donor animals in a twice weekly OPU scheme. Results were obtained from 640 sessions following FSH-LH superstimulation, on 112 donors subjected to OPU once every 2 weeks. The stimulation protocol started with the insertion of an ear implant containing 3 mg norgestomet (Crestar, Intervet, Belgium) 8 days before puncture (day -8). The dominant follicle was ablated by ultrasound-guided follicle puncture on day -6. On day -3 and day -2, cows were injected with FSH (Ovagen, ICP) twice daily (8 am to 8 pm), i.e. a total dose of 160 mug FSH and 40 mug LG per donor per stimulation cycle. Animals were punctured 48 h after the last FSH injection (day 0). Progesterone implants were removed the next day. Stimulated donor cows were treated with this protocol at 14-day intervals. Follicles were visualized with a Dynamic Imaging ultrasound scanner, equipped with a 6.5 MHz sectorial probe. Follicles were punctured with 55 cm long, 18 gauge needles at an aspiration pressure corresponding to a flow rate of 15 ml/min. Cumulus oocyte complexes were recovered and processed in a routine IVF set-up. Results demonstrate that, expressed per session, FSH stimulation prior to OPU increases production efficiency with significantly more follicles punctured and oocytes retrieved. However, when overall results during comparable 2-week periods are considered (four non-stimulated sessions vs one stimulated), more follicles are punctured and more oocytes are retrieved using the non-stimulated protocol. No significant differences in the number of cultured embryos could be detected, indicating that FSH/LH stimulation prior to OPU might have a positive effect on in vitro oocyte developmental competence as more embryos are cultured with less, presumably better-quality, oocytes.

Lipid Rafts play a role in human normal follicle stimlating hormone receptor (hFSHR) Signaling

The hFSHR is a member of the family of g protein‐coupled receptors that has been shown to signal through both g protein linked and MAP kinase pathways. Little is known about the importance of the membrane microenvironment in normal signaling. To study the role of lipid rafts in hFSHR signaling, cholesterol depletion experiments were carried out with methyl‐â‐cyclodextrin (MBCD) in HEK293 cells expressing hFSHR. Cells were treated with MBCD prior to stimulation with FSH for 0, 15, and 30 minutes. Cells were harvested and activation of MAP kinase enzymes (p38 and p44/42) were measured by western blot. MBCD treatment resulted in constant phosphorylation for p38 and a decrease in phosphorylation for p44/42 in response to FSH. In parallel experiments, cells were treated with MBCD prior to FSH stimulation to measure cAMP accumulation. cAMP production in MBCD treated cells was almost completely abolished, although hormone binding remained normal. One interpretation of the data suggests that the disruption of lipid rafts by depleting cholesterol disturbs the membrane microevironment sufficiently to disturb hFSHR signaling. Currently, a cholesterol add‐back experiment is being carried out to follow up on the cholesterol depletion to see if signaling is restored.

The impact of LH-containing gonadotropins on diploidy rates in preimplantation embryos: long protocol stimulation

The aim of this study was to evaluate the effect of ovarian stimulation with LH-containing gonadotropins (human menopausal gonadotropin, hMG), on ploidy of human cleavage-stage-embryos. A total of 104 women, at ages 27-43 years, undergoing one cycle of controlled ovarian hyperstimulation for IVF in combination with preimplantation genetic diagnosis, were eligible for enrollment in this retrospective, controlled cohort study. Ovarian stimulation included down-regulation with long agonist and stimulation with either recombinant FSH or hMG. Since the ploidy of embryos changes with female age, patients were matched for age and dosage of the respective gonadotropin. Despite similar numbers of chromosomally normal embryos in both groups, women undergoing hMG stimulation demonstrated significantly higher percentages of diploid embryos than did the FSH-stimulated patients (69.8 versus 45.3%; P < 0.01). Long protocol LH-containing ovarian stimulation improves embryonic ploidy in comparison to pure FSH stimulation. This observation may explain higher IVF pregnancy rates, reported for hMG stimulation in some studies.

Development of antral follicles after xenografting of isolated small human preantral follicles

Small human pre-antral follicles can be enzymatically isolated from the surrounding stroma, and are able to survive after 7 days of xenografting. The aim of the present study was to assess the developmental capacity of enzymatically isolated human follicles after long-term xenografting to severe combined immunodeficient (SCID) mice. Ovarian biopsies were obtained from three women 26-29 years of age. Human ovarian tissue was enzymatically dissociated using collagenase or a purified collagenase blend to obtain isolated follicles that were xenografted to SCID mice for 5 months. Recombinant FSH was given to the mice for the last 2 weeks. Five months after xenografting, follicular morphology was assessed by histology, and follicular proliferation by Ki-67 immunohistochemistry. Four grafts containing a total of 84 follicles were recovered. This follicular population was composed of 11 primordial follicles, 38 primary follicles, 31 secondary follicles and four antral follicles. Ki-67 was found to stain granulosa cells in antral follicles intensively. The results demonstrate, for the first time, that isolated human follicles are able to survive after long-term xenografting, and can develop into antral follicles after FSH stimulation.

Anti-FSH antibodies associate with poor outcome of ovarian stimulation in IVF

FSH is required for spontaneous folliculogenesis and is widely used in ovarian stimulation in IVF. Previously, increased concentrations of antibodies against FSH (anti-FSH) have been demonstrated in infertile women. This study aimed to: (i) assess the possible association of anti-FSH with an adverse outcome of IVF with regard to clinical parameters characterizing the ovarian reserve; and (ii) compare serum and follicular fluid (FF) anti-FSH concentrations in relation to follicle size and endocrine markers. IVF patients ( n = 182) subjected to gonadotrophin-releasing hormone-antagonist protocol were assessed for anti-FSH using enzyme-linked immunosorbent assay. Increased concentrations of serum anti-FSH immunoglobulin (Ig)G and IgA were associated with impaired ovarian stimulation outcome, with cut-off values >1.0 arbitrary units predicting poor ovarian response (≤3 oocytes) (adjusted odds ratio for IgG = 6.95, P = 0.005 and IgA = 3.60, P = 0.039). FF anti-FSH IgG and IgA were positively associated with serum anti-FSH concentrations and FSH concentration in FF. Additionally, FF anti-FSH IgG increased with follicle growth (linear regression coefficient = 0.02, P = 0.022). Collectively, these data suggest that serum anti-FSH antibodies are associated with poor ovarian response to FSH stimulation in IVF, with anti-FSH IgA and IgG potentially exerting a local FSH antagonizing effect in maturing follicles.

Infertility, bilateral multicystic serous cystadenoma and pregnancy

This article presents a case of bilateral and multicystic serous cystadenoma that appears to return immediately after complete excision of the cysts. Its presence did not impair ovarian response to FSH stimulation, or the occurrence of pregnancy and delivery.

Randomized controlled pilot trial of luteal phase recombinant FSH stimulation in poor responders

This study investigated whether luteal phase initiation of FSH supplementation would improve oocyte yield compared with follicular phase administration in women with poor ovarian response (POR). A two-arm, randomized, open-label pilot trial was performed at a university-based infertility centre. In nine of 18 infertile women with a history of POR in a previous cycle [<5 follicles on day of human chorionic gonadotrophin (HCG) administration; <5 oocytes retrieved; previous IVF cycle cancellation due to POR] FSH was administered during the mid-luteal phase of the preceding menstrual cycle. The primary outcome measure was the number of oocytes retrieved. Secondary endpoints included: follicles >10 mm and >16 mm and oestradiol concentration on the day of HCG administration, peak oestrogen concentration, pregnancy and live birth rates. All endpoints comparing luteal versus follicular stimulation were similar. In paired analysis of patients in the luteal arm compared with the prior cycle, there was a significant increase in days of stimulation ( P = 0.01) and number of follicles >10 mm ( P = 0.02) and >16 mm ( P = 0.02) on day of HCG administration. IVF outcomes with luteal phase FSH compared with follicular phase FSH were similar. Luteal phase initiation of FSH is a safe and potential alternative protocol in poor responders.

Does elevated human chorionic gonadotropin alone trigger spontaneous ovarian hyperstimulation syndrome?

To test whether elevated hCG alone triggers spontaneous ovarian hyperstimulation syndrome (sOHSS). Retrospective analysis. Departments of obstetrics and gynecology and of medical genetics in an academic medical center. A patient with sOHSS and 109 patients with elevated hCG. Collecting blood samples. Follicle-stimulating hormone receptor gene sequence, levels of TSH and hCG. We described a case of sporadic, nonfamilial sOHSS. Sequencing of the entire coding region the FSH gene revealed wild-type alleles for all the known mutations, and the A919G and A2039G polymorphisms, previously associated with good response to FSH stimulation and severe iatrogenic OHSS. We ruled out hypothyroidism. The level of hCG reached a peak of 344,350 IU/L (95th percentile). One hundred nine pregnancies with hCG of >150,000 IU/L were identified from 2001-2006. After patients with gestational trophoblastic diseases, multiple pregnancies, and iatrogenic OHSS were excluded, 27 patients remained. None of those patients experienced OHSS. Elevated hCG cannot be responsible for sOHSS as a single factor. Factors other than the hCG-FSH-receptor interaction additionally are involved in the pathogenesis of this syndrome. A combination of mechanisms may allow understanding of this enigmatic disorder. The pathophysiology of sOHSS, a rare phenomenon, has not yet been elucidated.

Effects of recombinant LH treatment on folliculogenesis and responsiveness to FSH stimulation

The role of LH in sensitizing antral follicles to FSH is unclear. LH is required for normal hormone production and normal oocyte and embryo development, but follicular responses to LH may depend upon the stage of development. Potential roles at the early follicular phase were explored in a clinical setting by employing a sequential approach to stimulation by recombinant human (r-h) LH followed by r-hFSH in women who were profoundly down-regulated by depo GnRH agonist. We employed a multi-centre, prospective, randomized approach. Women (n = 146) were treated in a long course high-dose GnRH agonist (Decapeptyl, 4.2 mg s.c.) protocol and were randomized to receive r-hLH (Luveris, 300 IU/day) for a fixed 7 days, or no r-hLH treatment. This was followed by a standard r-hFSH stimulation regime (Gonal-F, 150 IU/day). Ultrasound and hormone assessments of responses were measured at the start of r-hLH treatment, on FSH stimulation Days 0 and 8 and at the time of HCG administration. The LH treatment was associated with increased small antral follicles prior to FSH stimulation (P = 0.007), and an increased yield of normally fertilized (2 PN) embryos (P = 0.03). There was no influence of the r-hLH pretreatment upon hormone profiles or ultrasound assessments during the FSH phase. Anti-mullerian hormone increased in both groups during the week prior to FSH stimulation (P = 0.002). This sequential approach to the use of r-hLH in standard IVF showed a possible modest clinical benefit. The results support other recent work exploring up-regulated androgen drive upon follicular metabolism indicating that clinical benefit may be obtainable after further practical explorations of the concept.

Toward gene therapy of primary ovarian failure: adenovirus expressing human FSH receptor corrects the Finnish C566T mutation

Resistance ovarian syndrome is a heterogeneous disorder inherited as a Mendelian recessive trait and characterized by infertility, primary amenorrhea, normal karyotype and elevated serum FSH and LH levels. An inactivating mutation, C566T, in FSH receptor gene (FSHR) has been identified initially in Finland. We investigated if an adenovirus expressing a normal copy of human FSHR (Ad-hFSHR) has the ability to: (i) transfect granulosa cell lines, (ii) render the transfected cell lines responsive to FSH stimulation and (iii) transcomplement the malfunctioning form of human FSHR gene with C566T mutation. COS-7, JC-410, JC-410-P450-scc-luc and JC-410-StAR-luc cell lines were infected by Ad-hFSHR followed by treatment with FSH. Functional activity of the Ad-hFSHR was tested by measuring cyclic adenosine monophosphate (cAMP) or luciferase activity in response to FSH stimulation, and showed 2-4.6-fold increases in Ad-hFSHR transfected cells compared with untransfected or Ad-LacZ transfected cells, indicating that Ad-hFSHR is functionally active and expressing hFSHR. Generation of cAMP in cells expressing only mutated hFSHR-T566 showed minimal increase after FSH stimulation. Co-transfection of Ad-hFSHR in these cells carrying the malfunction form of human FSHR caused significant increases of 2.2-7.4-fold in FSH dependent cAMP generation (P = 0.0007). We concluded that adenovirus expressing a normal human FSHR can compensate the inactivating human FSHR-C566T mutation and restore FSH responsiveness.

Molecular pathology of the FSH receptor: New insights into FSH physiology

Manipulations of mouse genome have helped to elucidate gonadotrophin function but important differences subsist between rodent and human reproduction. Studies of patients with mutations of gonadotrophins or gonadotrophin receptors genes allow understanding their physiological effects in humans. The correlation of the clinical phenotypes of patients with in vitro studies of the mutated receptor residual function and histological and immunohistological studies of the ovarian biopsies permits to understand which stages of follicular development are under FSH control. Total FSH receptor (FSHR) inactivation causes infertility with an early block of follicular maturation remarkably associated with abundant small follicles as in prepubertal ovaries and demonstrates the absolute requirement of FSH for follicular development starting from the primary stage. Partial FSHR inactivation, characterized by normal-sized ovaries, can sustain follicular development up to the early antral stages but incremental levels of FSH stimulation seem to be required for antral follicular growth before selection. These findings contrast with the traditional view of an initial gonadotrophin-independent follicular growth prior to the preantral–early antral stages. The presence of numerous reserve follicles in the ovaries of these patients may permit a future treatment of their infertility. The study of reduced FSHβ or FSHR activity in genetically modified male mice models and in men suggests a minor impact of the FSHR on masculine fertility. Further studies on patients with a demonstrated total FSHβ or FSHR inactivation are required to elucidate reported differences in spermatogenesis impairment. Finally, the studies of mutations of gonadotrophins and their receptors demonstrate differences in gonadotrophin function between genetically modified rodents and humans which suggest prudence in extrapolating observations in rodents to human reproduction. Ovarian hyperstimulation syndrome (OHSS) can infrequently arise spontaneously during pregnancy, but most often it is an iatrogenic complication of ovarian stimulation treatments with ovulation drugs for in vitro fertilization. The first genetic cause of familial recurrent spontaneous OHSS was identified as a broadening specificity of the FSHR for hCG due to naturally occurring heterozygous mutations located unexpectedly in the transmembrane domain of the FSHR. Broadening specificity of a G protein-coupled receptor is extremely rare. These observations led to the identification of the etiology of this previously unexplained syndrome and permitted to conceive novel models of FSHR activation. Susceptibility to iatrogenic OHSS or its clinical severity may be associated with FSHR polymorphisms with slightly different activities in vivo as suggested by several studies. The study of larger cohorts is needed to evaluate the clinical impact of these observations in the management of patients undergoing IVF protocols.

Influence of follicular growth dynamics on pregnancy rates in controlled ovarian stimulation cycles

During FSH stimulation, follicles present a controlled rate of growth and expansion. It has previously been shown that long cycles lead to a slower growth rate than short cycles. An uncontrolled fast follicular growth may lead to early LH surges and apoptosis of cummulus cells and the oocyte itself. In natural cycles, follicular growth rate is much slower than in stimulated cycles. Therefore, we set out to assess if follicular growth dynamics may impact pregnancy rates in in vitro- fertilization cycles.

IVF treatment cancellation following prolonged GnRH agonist for endometriosis

Prolonged GnRH agonist suppression prior to IVF treatment for endometriosis has been suggested to improve pregnancy success. However, in clinical practice, prolonged GnRHa suppression can also lead to IVF treatment cancellation from suboptimal ovarian response to FSH stimulation. The current study was undertaken to determine the prevalence of treatment cancellation and any predictors for such occurrences.

Comparison of ovarian stimulation using daily and alternate day FSH protocols for intrauterine insemination

For historical reasons, ovarian stimulation for intra-uterine insemination (IUI) with injected gonadotropins was by alternate day injection. Since the development of variable dose delivery systems it is possible to give a smaller dose every day. It is unknown whether daily FSH has any improvement over alternate-day FSH. The objective of this study was to determine the effectiveness of daily vs. alternate day FSH stimulation protocols for infertile patients undergoing intrauterine insemination (IUI).