Gonadotropin Treatment Research Articles

In Vitro Activation of Follicles and Fresh Tissue Auto-transplantation in Primary Ovarian Insufficiency Patients.

Context:Recently, two patients with primary ovarian insufficiency (POI) delivered healthy babies after in vitro activation (IVA) treatment followed by auto-transplantation of frozen-thawed ovarian tissues.Objective:This study sought to report the first case of live birth after IVA treatment following fresh ovarian tissue grafting in patients with POI, together with monitoring of follicle development and serum hormonal changes.Design:This was a prospective observational cohort study.Setting:We performed IVA treatment in 14 patients with POI with mean age of 29 years, mean duration since last menses of 3.8 years, and average basal FSH level of 94.5 mIU/mL.Interventions:Prior to IVA treatment, all patients received routine hormonal treatments with no follicle development. We removed one ovary from patients with POI and treated them with Akt stimulators. We improved upon early procedures by grafting back fresh tissues using a simplified protocol.Main Outcome Measures:In six of the 14 patients (43%), a total of 15 follicle development waves were detected, and four patients had successful oocyte retrieval to yield six oocytes. For two patients showing no spontaneous follicle growth, human menopausal gonadotropin treatment induced follicle growth at 6–8 months after grafting. After vitro fertilization of oocyte retrieved, four early embryos were derived. Following embryo transfer, one patient became pregnant and delivered a healthy baby boy, with three other embryos under cryopreservation.Conclusion:IVA technology can effectively activate residual follicles in some patients with POI and allow them to conceive their own genetic offspring. IVA may also be useful for treating patients with ovarian dysfunction including aging women and cancer survivors.

HCG-mediated activation of mTORC1 signaling plays a crucial role in steroidogenesis in human granulosa lutein cells.

Luteinizing hormone/human chorionic gonadotropin stimulates progesterone biosynthesis in the corpus luteum by activating cyclic adenosine monophosphate/protein kinase A cascade. Recent studies have shown that cyclic adenosine monophosphate-mediated activation of protein kinase A interacts with the mammalian target of rapamycin signaling pathways. Furthermore, the use of mammalian target of rapamycin inhibitors for immunosuppression in transplant patients has shown adverse effects in reproductive functions. This study examined whether the mammalian target of rapamycin pathway plays any role in luteinizing hormone-mediated regulation of progesterone production. Human granulosa lutein cells were isolated from follicular aspirates of women undergoing in vitro fertilization. Cells were cultured for 72 h and treated with human chorionic gonadotropin (50 ng/ml) for different time periods with or without pretreatment with mammalian target of rapamycin complex 1 inhibitor, rapamycin, (20 nM) for 1 h. Expression of steroidogenic enzymes, including steroidogenic acute regulatory protein, cholesterol side chain cleavage enzyme, and 3β-hydroxysteroid dehydrogenase type 1 messenger RNA, were examined by real-time polymerase chain reaction after 6 h of human chorionic gonadotropin treatment. Expressions of phospho-ribosomal protein S6 kinase and cholesterol side chain cleavage enzyme were analyzed after 15 min and 24 h of human chorionic gonadotropin treatment, respectively. Progesterone production was analyzed by an enzyme immunoassay kit after human chorionic gonadotropin (50 ng/ml) or forskolin (10 μM) treatment for 24 h. Treatment with human chorionic gonadotropin increased the expression of downstream targets of mammalian target of rapamycin complex 1, as well as cholesterol side chain cleavage enzyme, 3β-hydroxysteroid dehydrogenase type 1 and steroidogenic acute regulatory protein messenger RNAs. These increases were inhibited by rapamycin pretreatment. Increased progesterone production in response to treatment with human chorionic gonadotropin or forskolin was also blocked by rapamycin pretreatment. Our findings support a role for mammalian target of rapamycin complex 1 in regulating steroidogenesis in human granulosa lutein cells.

Elevated progesterone on the trigger day does not impair the outcome of Human Menotrophins Gonadotrophin and Medroxyprogesterone acetate treatment cycles.

To demonstrate the incidence and effects of elevated progesterone (P) on the trigger day on the outcome of in-vitro fertilization (IVF)/intracytoplasmic sperm injection (ICSI) cycles using Medroxyprogesterone acetate (MPA) co-treated with Human Menotrophins Gonadotrophin (hMG + MPA), we performed a retrospective analysis including 4106 IVF/ICSI cycles. The cycles were grouped according to the P level on the trigger day: <1 ng/mL, between 1–1.5 ng/ml (including 1), between 1.5–2 ng/mL (including 1.5), and ≥2 ng/mL. The primary outcome measure was live birth rate. The prevalence of P level categories was 12.93% (531/4106), 2.92% (120/4106), and 1.92% (79/4106) in women with P between 1–1.5 ng/mL, between 1.5–2 ng/mL, and ≥2 ng/mL, respectively. The mean stimulation duration, total hMG dose, serum follicle stimulating hormone (FSH), estrogen(E2) on the trigger day and the number of oocytes in patients with elevated P were significantly higher than patients with P < 1 ng/mL (P < 0.05). However, there were no significant differences in the oocyte retrieval rates, fertilization rates, implantation rates, clinical pregnancy rates and live birth rates between the groups based on frozen embryo transfer (FET). We concluded that elevated P on the trigger day had no negative effect on the final outcome of the hMG + MPA treatment cycles based on FET.

Growth hormone co-treatment within a GnRH agonist long protocol improves implantation and pregnancy rates in patients undergoing IVF-ET.

The efficacy of growth hormone (GH) co-treatment within a GnRH agonist long regimen, in women with a normal ovarian response to controlled ovarian hyperstimulation (COH), for IVF was assessed. This retrospective clinical trial was performed in a private-assisted reproduction centre. The study involved 1114 patients who responded normally to high-dose gonadotropin treatment. The study group of 556 patients was given in a daily subcutaneous injection of 4.5IU of GH co-treatment, starting from the initial day of gonadotropin treatment and lasting for 5days. The control group of 558 patients received the same treatment protocol without the GH co-treatment. The participants were further divided into two subgroups: age ≥35years and age <35years. The primary endpoint of the study was IVF-ET outcomes. The demographic characteristics did not significantly differ between the groups. The implantation rate (36.7 vs. 20.4%, P<0.05) and clinical pregnancy rate (57.3 vs. 30.1%, P<0.05) were significantly higher in the study group than in the control group. An analysis using a multivariate logistic regression model showed that GH was a significant factor for predicting pregnancy outcomes (OR 3.125, 95% CI 2.441-4.000). Furthermore, for the ≥35-year-old group, the endometrial thickness was significantly greater (11.99±2.21 vs. 11.62±2.45, P<0.05) in the study group than in the control group; in contrast, for the <35-year-old group, the high-quality embryo rate was significantly higher (71.7 vs. 68.3%, P<0.05) in the study group than in the control group. Our study showed that co-treatment with GH in a GnRH agonist long protocol in patients who responded normally while undergoing IVF-ET could increase the implantation and pregnancy rates.

Effects of periovulatory gonadotrophin treatment on luteal function and endometrial expression of selected genes in cyclic pony mares

Progestin concentration in plasma during the early luteal phase is crucial for endometrial function and conceptus development. We hypothesized that periovulatory gonadotrophin treatment via support of luteal function affects endometrial gene expression in horses. Effect of age was analyzed as well. Shetland mares (n = 8, age 4–25 years) were assigned to the following treatments during five consecutive cycles in alternating order following a cross-over design: treatment hCG/-: preovulatory injection of hCG, but no gonadotrophin injection at detection of ovulation, treatment -/hCG: no preovulatory gonadodrophin injection, but injection of hCG at detection of ovulation, treatment eCG/-: preovulatory injection of eCG, but no gonadotrophin injection at detection of ovulation, treatment -/eCG: no preovulatory gonadotrophin injection, but injection of eCG at detection of ovulation, treatment control: no treatment. Concentration of progestin was analyzed by ELISA from the day of ovulation until Day 10. On Day 10, endometrial cells were collected transvaginally by cytobrush technique. Expression of mRNA of cyclooxygenase-2 (COX-2), prostaglandin F2α-synthase, prostaglandin E-synthase, progesterone receptor (PR), estradiol receptor (E2R), acyl-CoA-dehydrogenase (ACAD), uteroglobin (UGB), uteroferrin, and uterocalin was analyzed by RT qPCR. Immunohistological staining of endometrial tissue, obtained via biopsy, was performed for COX-2, PR and UGB. The P4 concentration was influenced by day of cycle (P < 0.01), but not by treatment. No effects of age on gene expression were determined. Neither of the periovulatory gonadotrophin treatments nor age influenced mRNA expression of the genes of interest. Treatment did also not affect immunohistological staining of the endometrium. In contrast, age affected the percentage of PR positive stromal cells (e.g. mare 1 (4 years): 65.5 ± 2.6, mare 2 (24 years): 82.7 ± 2.2%, P < 0.05) and COX-2 positive stained ciliated cells (e.g. mare 1: 15.8 ± 2.9, mare 2: 33.4 ± 6.0%, P < 0.05). In conclusion, no effects of periovulatory gonadotrophin treatment and age on endometrial gene expression in luteal phase pony mares were reported. A lack of treatment effects on luteal function and expression of PRs in the endometrium can at least in part be explained by differences in the reproductive physiology between horses and ponies.

Recurrent ischemic priapism: A rare adverse event after human chorionic gonadotropin treatment in a three years-old boy with cryptorchidism

We present the first case of human chorionic gonadotropin (hCG) induced recurrent ischemic priapism in a 3 years-old boy in the English literature. The patient underwent second right orchidopexy and hCG treatment (1500 IU twice a week for three weeks) was initiated the day after the operation. Twenty-three days after the last injection, he presented to our clinic with the complaint of painless erections. After the diagnosis of ischemic priapism, conservative management and oral diazepam therapy was initiated and the result was successful. hCG therapy may rarely cause recurrent ischemic priapism in children.

Equine Chorionic Gonadotropin and Human Chorionic Gonadotropin Stimulation Increase the Number of Luteinized Follicles and the Progesterone Level Compared with Cabergoline Stimulation in Anoestrus Bitches.

In this study, ovarian morphologies and blood progesterone concentrations following oestrous induction in bitches were examined. Fifty-three clinically healthy anoestrus bitches received cabergoline at a daily dose of 5μg/kg of body weight per os for 21days (group I) or subcutaneous equine chorionic gonadotropin at a dose of 20 IU/kg of body weight for five consecutive days with an additional 500 IU s.c. per bitch of human chorionic gonadotropin on the last day of treatment (group II). Twenty bitches that spontaneously displayed oestrous signs were left untreated and served as controls (group III). The induced oestrous rates and ovulation rates in groups I and II were 60.0% vs 64.3% and 86.7% vs 83.3%, respectively. Morphological assessments of the ovarian structures after ovariohysterectomy revealed an increase in the number of luteinized follicles and cysts in group II compared with the two other groups (p<0.001). In contrast, the numbers of corpora lutea and follicles were similar in all groups. In accordance with the above-mentioned alteration, the progesterone concentration in the gonadotropin group (II) was increased (p<0.001) in the periovulatory period compared with the other two groups. During the entire sampling period, the progesterone profiles in the cabergoline (I) and control (III) groups were similar and typical of normally cycling bitches. In conclusion, gonadotropin treatment is associated with an increased progesterone level during the periovulatory period that probably originates from luteinized follicles, whereas cabergoline treatment induces cycles with both physiological progesterone concentrations and ovarian morphologies.

Conditional Ablation of Progesterone Receptor Membrane Component 1 Results in Subfertility in the Female and Development of Endometrial Cysts.

Progesterone (P4) is essential for female fertility. The objective of this study was to evaluate the functional requirement of the nonclassical P4 receptor (PGR), PGR membrane component 1, in regulating female fertility. To achieve this goal, the Pgrmc1 gene was floxed by insertion of loxP sites on each side of exon 2. Pgrmc1 floxed (Pgrmc1(fl/fl)) mice were crossed with Pgr(cre) or Amhr2(cre) mice to delete Pgrmc1 (Pgrmc1(d/d)) from the female reproductive tract. A 6-month breeding trial revealed that conditional ablation of Pgrmc1 with Pgr(cre/+) mice resulted in a 40% reduction (P = .0002) in the number of pups/litter. Neither the capacity to ovulate in response to gonadotropin treatment nor the expression of PGR and the estrogen receptor was altered in the uteri of Pgrmc1(d/d) mice compared with Pgrmc1(fl/fl) control mice. Although conditional ablation of Pgrmc1 from mesenchymal tissue using Amhr2(cre/+) mice did not reduce the number of pups/litter, the total number of litters born in the 6-month breeding trial was significantly decreased (P = .041). In addition to subfertility, conditional ablation of Pgrmc1 using either Amhr2(cre/+) or Pgr(cre/+) mice resulted in the development of endometrial cysts starting around 4 months of age. Interestingly, pregnancy attenuated the formation of these uterine cysts. These new findings demonstrate that PGR membrane component 1 plays an important role in female fertility and uterine tissue homeostasis.

Clinical definition paper on in vitro maturation of human oocytes.

In vitro maturation (IVM) of human oocytes is a reproductive technique which has been practiced for 25 years and is gaining popularity. However, the techniques used for IVM differ substantially across clinics and they result in extremely variable pregnancy rates, partially due to some of these differences in protocols. Such differences include the use in some cycles of hCG triggering prior to oocyte retrieval and the use of a few days of gonadotrophin treatment to support moderate follicle growth. Other important factors are patient selection (including those with polycystic ovaries or decreased ovarian reserve), the number of embryos transferred and cleavage-stage embryo or blastocyst transfer. There are also substantial differences of opinion among clinicians regarding IVM and what it implies. Due to the large variation in protocols, a decision was made to write this paper in an attempt to introduce uniformity when comparing treatments and outcomes of IVM. A clinical definition of IVM was developed: The retrieval of oocytes from small and intermediate sized follicles in an ovary before the largest follicle has surpassed 13 mm in mean diameter. The use of short gonadotrophin stimulation should be acknowledged. However, it should be stated that metaphase II oocytes also have the potential to be collected at that time in the cycles associated with either hCG or GnRH agonist priming. Many feel this is not IVM because some mature oocytes are retrieved, therefore, we recommend renaming this procedure either natural cycle IVF or modified natural cycle IVF (if gonadotrophin stimulation is given) with early triggering, combined with IVM The percentage as well as the absolute number of mature oocytes at retrieval should be indicated. The use of these titles will allow transparency when comparing results of IVM cycles.

Gonadotropin ratio affects the in vitro growth of rhesus ovarian preantral follicles

In vitro follicle growth (IVFG) strategy is critical in the fertility preservation of cancer survivors; however, its optimal protocol needs to be developed using primate models since the availability of...

Fixed-time induction of ovulation in camels superovulated by different eCG modalities during the transition period in Egypt : Superovulation in camels during the transition period.

The current investigation aimed to establish a fixed-time induction of ovulation/ insemination protocol in camels superovulated by different equine chorionic gonadotropin (eCG) regimens during the transition period in Egypt (mid-October to mid-November). Seventeen pluriparous camels, Camelus dromedarius, were used. All females retained controlled intra-vaginal drug releasers (CIDRs) for 13 consecutive days, and at CIDR withdrawal, the camels were randomly divided into three groups. The control group (n = 5) received 1 ml saline intra-muscularly (i.m.), whereas remaining camels were superovulated by 2500 IU eCG either in a single shot (SS, n = 6) or in serial decreasing doses over 3 days (DD, n = 6). Ovarian dynamics were monitored by transrectal ultrasonography at 2-day intervals, and ovulation was induced by 5000 IU hCG i.m. The changes in reproductive hormones throughout the period of the study were determined. The results showed that mean values of total no. of follicles and size of dominant follicles remained low (P < 0.05) in all groups until day of CIDR removal. Thereafter, total follicle no. increased (P < 0.05) in both superovulated groups compared to the control, where the dominant follicles attained the highest (P < 0.05) diameter 12 days after the eCG treatment. Double-ovulation rate was higher (P < 0.05) in SS (50%) and DD (66.6%) groups compared to that of control (0.0%). However, 33.3% of the SS group developed large anovulatory follicles (ø > 25 mm), which did not respond to induction to ovulation. These results elucidate that eCG administration in serial decreasing doses generates a reliable superovulatory response in camels, and ovulation can be blindly induced 12 days after the gonadotropin treatment. This fixed-time hormonal protocol represents a sufficient alternative to conventional day-to-day ultrasonography and would have profound implication for enhanced fertility in dromedary camels by facilitating infield application of embryo transfer technique.

Electroacupuncture decreases the progression of ovarian hyperstimulation syndrome in a rat model

This study aimed to elucidate the effect of electroacupuncture treatment on preventing early ovarian hyperstimulation syndrome (OHSS) and the potential mechanisms involved using an induced rat model. The ovarian response was examined by measuring ovary weight, vascular permeability, levels of inflammation (interleukin-6), tumour necrosis factor alpha, chemokine ligand 2 (also known as monocyte chemoactic protein 1), vascular endothelial growth factor and hormone concentrations (oestradiol, progesterone, testosterone and prolactin). Sprague–Dawley female rats underwent ovarian stimulation to induce OHSS. Hyperstimulated rats received consecutive electroacupuncture treatment from 3 days before the beginning of pregnant mare serum gonadotrophin treatment or the time point of pregnant mare serum gonadotrophin treatment respectively, and last until 3 days after HCG administration. Electroacupuncture treatment reduced ovary weight and vascular permeability in hyperstimulated rats. Electroacupuncture treatment also reduced the levels of serum steroid hormones (progesterone and testosterone), inflammatory cytokines (interleukin-6, tumour necrosis factor alpha and monocyte chemotactic protein 1 and vascular endothelial growth factor in hyperstimulated rats. The results indicate that electroacupuncture can modulate endocrine hormone secretion and affect the secretion of inflammatory cytokines and vascular endothelial growth factor, and thus prevent the progress of OHSS. Electroacupuncture may provide a simple and effective method for the prevention and treatment of OHSS.

Efficacy and Outcome Predictors of Gonadotropin Treatment for Male Congenital Hypogonadotropic Hypogonadism: A Retrospective Study of 223 Patients.

Gonadotropin induces masculinization and spermatogenesis in men with congenital hypogonadotropic hypogonadism (CHH). However, large cohort studies for the efficacy and reliable predictors of this therapy need to be conducted. The aim of this study was to investigate the efficacy of gonadotropin treatment in a large cohort of male CHH patients and analyze putative predictors for successful spermatogenesis. This retrospective study included 223 CHH azoospermic patients without puberty development treated between 2005 and 2014. All patients received combined human chorionic gonadotropin (HCG) and human menopausal gonadotropin (HMG) and were followed up for >6 months (5109 person-months). Serum total testosterone level, testicular size, spermatogenesis, and pregnancy outcome were recorded at each visit. After gonadotropin therapy, testicular size was enlarged from 2.1 ± 1.6 to 8.1 ± 4.6 mL (P < 0.001) and serum total testosterone was elevated from 0.9 ± 0.5 to 15.1 ± 8.2 nmol/L (P < 0.001). Spermatogenesis (>0/mL) occurred at a median period of 15 months (95% confidence interval 13.5-16.5). Larger basal testicular volume (P = 0.012) and noncryptorchidism history (P = 0.028) are independent predictors for earlier sperm appearance. Sixty four percent (143/223) of patients succeeded in producing sperms and the average time for initial sperm detection was 14 ± 8 months. However, their sperm concentrations (11.7 [2.1, 24.4] million/mL) and sperm progressive motility (A + B 36.9% ± 20.2%) are significantly lower than World Health Organization standards. Of the 34 patients who desired for fathering children, 19 patients impregnanted their partners during the treatment. Gonadotropin therapy induces spermatogenesis in male CHH patients. A larger basal testicular size and noncryptorchidism history are favorable indicators for earlier spermatogenesis.

Moderate increase of reactive oxygen species triggers meiotic resumption in rat follicular oocytes

The mammalian ovary generates reactive oxygen species (ROS) on an extraordinary scale; however, the role of ROS during meiotic cell cycle progression in follicular oocytes remains poorly understood. The present study was aimed to determine whether a moderate increase of ROS level in the ovary is beneficial for meiotic resumption from diplotene arrest in follicular oocytes. Cumulus oocyte complexes were collected from the ovaries of female rats that had been treated with either: (i) pregnant mare's serum gonadotrophin; or (ii) pregnant mare's serum gonadotrophin + human chorionic gonadotrophin. We analyzed morphological changes, ROS and hydrogen peroxide levels, catalase activity, 3',5'-cyclic adenosine monophosphate and 3',5'-cyclic guanosine monophosphate levels, Thr14/Tyr15, Th-161, total cyclin-dependent kinase 1 (Cdk1) and cyclin B1 levels. Human chorionic gonadotrophin treatment induced meiotic resumption from diplotene arrest and extrusion of first polar body in cumulus oocyte complexes collected from ovaries and cultured for 3h in vitro. Meiotic resumption from diplotene arrest was associated with increased ROS and hydrogen peroxide levels but decreased 3',5'-cyclic adenosine monophosphate as well as 3',5'-cyclic guanosine monophosphate levels. The reduced cyclic nucleotide levels were associated with decreased Thr161 phosphorylated Cdk1 and cyclin B1 level but increased Thr14/Tyr15 phosphorylated Cdk1 level leading to maturation promoting factor destabilization. Destabilized maturation-promoting factor triggered meiotic resumption from diplotene arrest and progression to metaphase-I as well as metaphase-II stage in follicular oocytes. Our findings suggest that a moderate increase of ROS in the ovary is beneficial for meiotic resumption from diplotene arrest and extrusion of first polar body in follicular oocytes.

Is clomiphene citrate stair-step protocol a good alternative to gonadotrophins in clomiphene-resistant PCO patients? Prospective study.

To compare the efficacy and safety of the clomiphene citrate (CC) stair-step protocol with standard gonadotrophin (follicle-stimulating hormone) treatment in clomiphene-resistant polycystic ovary syndrome (PCOS) patients. The study was a prospective cohort study in a tertiary infertility center in Abu Dhabi, United Arab Emirates (UAE). The subjects consisted of 100 PCOS CC-resistant patients who attended between January 2014 and January 2015. Fifty received CC again but in accordance with the stair-step protocol, and the other 50 received the standard gonadotrophin treatment used in the center in which the study was conducted. The primary outcome measure was dominant follicle achievement; the secondary outcome measures were (i) clinical pregnancy rate; (ii) time to ovulation measured from treatment initiation to sonographic confirmation of a dominant follicle in days; and (iii) adverse effect occurrence. There was no difference between the two treatment modalities concerning the ability to achieve a dominant follicle or the clinical pregnancy rate. The time to ovulation was significantly shorter with the CC stair-step protocol than with gonadotrophin treatment. Ovarian hyperstimulation syndrome and ovarian cyst formation were more likely to occur with gonadotrophin treatment. Clomiphene citrate stair-step protocol can be offered to PCOS CC-resistant patients as an alternative to gonadotrophin therapy with similar efficacy.

Combined assessment of polymorphisms in the LHCGR and FSHR genes predict chance of pregnancy after in vitro fertilization.

Can gonadotrophin receptor variants separately or in combination, be used for the prediction of pregnancy chances in in vitro fertilization (IVF) trials? The luteinizing hormone/human chorionic gonadotrophin receptor (LHCGR) variant N312S and the follicle-stimulating hormone receptor (FSHR) variant N680S can be utilized for the prediction of pregnancy chances in women undergoing IVF. The FSHR N680S polymorphism has been shown to affect the ovarian response in response to gonadotrophin treatment, while no information is currently available regarding variants of the LHCGR in this context. Cross-sectional study, duration from September 2010 to February 2015. Women undergoing IVF were consecutively enrolled and genetic variants compared between those who became pregnant and those who did not. The study was subsequently replicated in an independent sample. Granulosa cells from a subset of women were investigated regarding functionality of the genetic variants. Women undergoing IVF (n = 384) were enrolled in the study and genotyped. Clinical variables were retrieved from medical records. For replication, an additional group of n = 233 women was utilized. Granulosa cells from n = 135 women were isolated by flow cytometry, stimulated with Follitropin alpha or Menotropin, and the downstream targets 3',5'-cyclic adenosine monophosphate (cAMP) and inositol 1,4,5-trisphosphate (IP3) measured with enzyme-linked immunosorbent assay. Women homozygous for serine (S) in both polymorphisms displayed higher pregnancy rates than women homozygous asparagine (N) (OR = 14.4, 95% CI: [1.65, 126], P = 0.016). Higher pregnancy rates were also evident for women carrying LHCGR S312, regardless of FSHR variant (OR = 1.61, 95% CI: [1.13, 2.29], P = 0.008). These women required higher doses of FSH for follicle recruitment than women homozygous N (161 versus 148 IU, P = 0.030). When combining the study cohort with the replication cohort (n = 606), even stronger associations with pregnancy rates were noted for the combined genotypes (OR = 11.5, 95% CI: [1.86, 71.0], P = 0.009) and for women carrying LHCGR S312 (OR = 1.49, 95% CI: [1.14, 1.96], P = 0.004). A linear significant trend with pregnancy rate and increasing number of G alleles was also evident in the merged study population (OR = 1.34, 95% CI: [1.10, 1.64], P = 0.004). A lower cAMP response in granulosa cells was noted following Follitropin alpha stimulation for women homozygous N in both polymorphisms, compared with women with other genotypes (0.901 pmol cAMP/mg total protein versus 2.19 pmol cAMP/mg total protein, P = 0.035). Due to racial differences in LHCGR genotype distribution, these results may not be applicable for all populations. Despite that >250 000 cycles of gonadotrophin stimulations are performed annually worldwide prior to IVF, it has not been possible to predict neither the pregnancy outcome, nor the response to the hormone with accuracy. If LHCGR and FSHR variants are recognized as biomarkers for chance of pregnancy, more individualized and thereby more efficient treatment modalities can be developed. This work was supported by Interreg IV A, EU (grant 167158) and ALF governments grant (F2014/354). Merck-Serono (Darmstadt, Germany) supported the enrollment of the subjects. The authors declare no conflict of interest.

Role of testosterone pretreatment in poor ovarian responders undergoing in vitro fertilization/intracytoplasmic injection in comparison with growth hormone

Objective: Androgen can play a synergistic role with follicle-stimulating hormone in promoting the early follicular recruitment, which is critical in Assisted Reproduction Technique program. In patients with poor ovarian response (POR) and poor ovarian reserve may benefit from testosterone gel application and growth hormone. This study was done to assess whether poor responders can benefit from androgen therapy before in vitro fertilization/intracytoplasmic sperm injection and from growth hormone. Study Design: It is a prospective pilot study on 35 patients with previous POR and poor ovarian reserve attending IRM, OPD between January 2015 and December 2015 for 1 year. Materials and Methods: Selected women received transdermal therapy of testosterone gel 12.5 mg over the skin of shoulder and upper arm for 21 days from day 7 to day 27 of cycle during oral contraceptive pills if the cycle was not regular and gel treatment before gonadotropin stimulation cycle for next one cycle. Hormone assessment (total testosterone, sex hormone-binding globulins, and androstenedione level) was done at the beginning and at the end of the gel application. Ovarian stimulation with fixed antagonist protocol was used. The primary outcome is improvement in antral follicle count (AFC), the total number of oocyte retrieved, number of mature oocytes, and good quality of embryos. In this study, implantation rate and clinical pregnancy rate were also assessed. If patient did not respond to testosterone gel, growth hormone was used in next cycle with gonadotropins and same parameters were used. Results: In this study, we found that two drugs are comparable in terms of clinical pregnancy rate, ongoing pregnancy rate, and live-birth rate. We found that number of cryopreserved embryos and cumulative pregnancy rate are more in testosterone group. Fertilization rate and cleavage arrest were similar in both groups. Cancellation rate was less, and duration of gonadotropins treatment was more in testosterone-only group. Significantly increased androstenedione level was seen in improved cycles of testosterone gel treatment. Out of 35 patients with testosterone gel treatment, in 42.9% cases, AFC improved. Conclusion: Testosterone gel treatment is useful in patients with poor ovarian reserve or poor ovarian responders in terms of improving AFC, more number of oocytes, increased number of embryos and increased number of cryopreserved embryos, and hence cumulative pregnancy rate. Growth hormone had equivalent results with testosterone gel with less number but good-quality oocytes and embryos. This is a pilot study, including a small number of patients; hence, further randomized trials are needed before using expensive and injectable drug, i.e., growth hormone in poor responders.

The Effect of Human Chorionic Gonadotropin Treatment Before Testicular Sperm Extraction in Non-Obstructive Azoospermia

The Effect of Human Chorionic Gonadotropin Treatment Before Testicular Sperm Extraction in Non-Obstructive Azoospermia

Causes of hypogonadotropic hypogonadism predict response to gonadotropin substitution in adults.

Germ cell and Sertoli cell proliferation and maturation in human testes occur in three main waves, during the late fetal and early neonatal period and at early puberty. They are triggered by periods of increased activity of the hypothalamic-pituitary-gonadal (HPG) axis. In hypogonadotropic hypogonadism (HH), these processes are variably disturbed. The objective of this study was to explore whether success of gonadotropin replacement in HH men is predictable by the origin of HH, indicating time of onset and severity of GnRH/gonadotropin deficiency. The data of 51 adult HH patients who had undergone one cycle of hCG/FSH treatment were reviewed. Five groups were established, according to the underlying HH origin. Therapeutic success by final bi-testicular volumes (BTVs) final sperm concentrations (SC) and conception rates were compared and related to baseline parameters, indicative of the degree of HPG-axis disruption. Overall, BTVs rose from 13 ± 15 to 27 ± 15 mL, spermatogenesis was induced in 98%, with mean SCs of 15 ± 30 mill/mL, spontaneous pregnancies in 37% and additional 18% via intracytoplasmic sperm injection. Kallmann syndrome patients had the poorest responses (BTV: 16.9 ± 10 mL; SC: 3.5 ± 5.6 mill/mL), followed by patients with congenital/infancy-acquired multiple pituitary hormone deficiencies (MPHD) and patients with HH+absent puberty (BTV: 21 ± 14/24 ± 9 mL; SC: 5.5 ± 6.5/ 14.5 ± 23.8 mill/mL). HH men with pubertal arrest and with post-pubertally acquired MPHD had the best results (BTV: 36 ± 14/38 ± 16 mL; SC: 25.4 ± 34.2/29.9 ± 50.5 mill/mL). Earlier conception after 20.3 ± 11.5 months (vs. 43.1 ± 43.8; p = 0.047) of gonadotropin treatment with higher pregnancy rates (62% vs. 42%) was achieved in the two post-pubertally acquired HH subgroups, compared to the three pre-pubertally acquired. Therapeutic success was higher in patients without previously undescended testes, with higher baseline BTVs (pre- vs. post-pubertal HH: 5 ± 4 mL vs. 26 ± 16 mL; p < 0.0001) and higher baseline inhibinB levels (pre- vs. post-pubertal HH: 16.6 vs. 144.5 pg/mL; p = 0.0004). The cause of HH is a valuable predictor of outcome of gonadotropin replacement in adults.

Sex Steroid and Gonadotropin Treatment in Male Delayed Puberty.

Male delayed puberty is common, affecting up to 3% of the population. Management of patients with pubertal delay is dependent on the underlying cause. The main differential diagnoses of delayed puberty in males include constitutional delay of growth and puberty (CDGP), idiopathic hypogonadotropic hypogonadism and hypergonadotropic hypogonadism. Treatment of isolated CDGP involves expectant observation or short courses of low-dose sex steroid supplementation. More complex and involved management is required in males with hypogonadism to achieve both development of secondary sexual characteristics and to maximise the potential for fertility. This review will cover the options for management involving androgen or gonadotropin therapy, with discussion of benefits, limitations and specific considerations of the different treatment options.