EndocrinologyHormonal profile during the follicular phase in cycles stimulated with a combination of human menopausal gonadotrophin and gonadotrophin-releasing hormone antagonist (Cetrorelix)

A third-generation gonadotrophin-releasing hormone antagonist(Cetrorelix) was used during ovarian stimulation in 32 patientsundergoing assisted reproduction, in order to prevent the prematureluteinizing hormone (LH) surge. In all patients, ovarian stimulationwas carried out with two or three ampoules of human menopausalgonadotrophin (HMG), starting on day 2 of the menstrual cycle.In addition, 0.5 mg of Cetrorelix was administered daily fromday 6 of HMG treatment until the day of ovulation inductionby human chorionic gonadotrophin (HCG). A significant drop inplasma LH concentration was observed within a few hours of thefirst administration of Cetrorelix (P<0.005). Moreover, noLH surge was detected at any point in the treatment period inany of the 32 patients. A mean oestradiol concentration of 2122±935ng/1 was observed on the day of the HCG administration, indicatingnormal folliculogenesis. Like LH, progesterone concentrationalso dropped within a few hours of the first administrationof Cetrorelix (P< 0.005). A 0.5 mg daily dose of Cetrorelixprevented a premature LH surge in all the 32 patients treated.     

Andrology: Failure of oestrogen induced luteinizing hormone surge in women treated with mifepristone (RU 486) every day for 30 days

It has been demonstrated previously that administration of theantiprogestin mifepristone (RU 486; 1–5 mg daily) inhibitsor delays both the pre-ovulatory luteinizing hormone (LH) surgeand ovulation. To investigate this mechanism, dynamic testsof pituitary ovarian function were performed in six healthywomen before and during the administration of mifepristone (2mg daily for 30 days). On day 9 of the control and treatmentcycles, samples of blood were collected every 15 min over 12h for measurement of LH concentration. After 10 h, the responsivenessof the pituitary was tested by the i.v. injection of 10 µgof gonadotrophin-releasing hormone (GnRH). On day 10 of thecontrol and treatment cycles, two patches releasing 200 µg/dayof oestradiol were applied to skin on the abdomen for 3 days.Blood was collected at 24, 48, 59, 72, 81 and 96 h after applicationof the oestrogen patches for the measurement of gonadotrophinand ovarian hormone concentrations. Follicular development continuedin all women during their treatment with mifepristone, and ovulationwas suppressed (four women) or delayed (two women). There wasno significant difference in the basal concentration of LH betweenthe control and treatment cycles (mean ± SE; 5.5 ±0.4 versus 7.7 ± 0.4 IU/l respectively), or in the frequency(interpulse interval, 101 ± 12 versus 105 ± 13min respectively) and the amplitude (2.1 ± 0.4 versus2.6 ± 0.4 IU/l respectively) of LH pulses. The responseto GnRH was similar. On day 10, the basal concentrations ofLH, follicle-stimulating hormone (FSH), prolactin, oestradioland progesterone and the diameter of the dominant follicle (15.7± 1.8 versus 13.3 ± 1.9 mm) were similar duringcontrol and treatment cycles. In control cycles, there weresignificant increases in the concentrations of LH and FSH within72 h of application of the oestrogen patches. During treatmentcycles, concentrations of FSH and LH remained low, and weresignificantly lower than the values observed during controlcycles (P < 0.006). We conclude that the antiprogestin mifepristonedisrupts ovulation by inhibiting the positive feedback effectof oestrogens and, hence, prevents or delays the generationof a pre-ovulatory LH surge.     

Recovery of corpus luteum function after prolonged deprivation from gonadotrophin stimulation

Three women with hypogonadotrophic hypogonadism, all desiringpregnancy, participated in a prospective open study attemptingto assess the ability of the human corpus luteum to recoverafter 7 days of deprivation from gonadotrophin stimulation.Follicular growth was induced by gonadotrophins. An endogenousluteinizing hormone (LH) surge was induced by the s.c. injectionof a gonadotrophin-releasing hormone agonist For luteal support,10 mg/day oral medroxyprogesterone acetate were given for 7days, after which a single i.m. injection of human chorionicgonadotrophin (HCG) was administered. Monitoring during thefollicular phase consisted of daily measurements of serum oestradiol,LH and follicle stimulating hormone (FSH) concentrations, andof follicular growth by trans-vaginal ultrasonography. Duringthe luteal phase, monitoring consisted of measurements of serumconcentrations of LH, FSH, oestradiol, progesterone, 17-hydroxy-progesteroneand -HCG. Ovulation and luteinization occurred in two patients,demonstrated by transient marked increases in serum progesteroneand 117-hydroxy-progesterone concentrations which decreasedto basal pre-ovulatory values and increased again followingthe administration of HCG 7 days later. In the third patient,ovulation and luteinization did not occur, and the subsequentadministration of HCG did not result in an increase in progesteroneconcentration. Of the two patients who ovulated, one conceivedand the second had a luteal phase of 15 days duration. Our preliminaryresults suggest that the human corpus luteum can be ’rescued‘and can function normally after 7 days of deprivation from gonadotrophinstimulation in patients with hypogonadotrophic hypogonadism.     

Positive feedback effect of oestradiol in superovulated women.

To investigate the mechanism of blockage of the luteinizing hormone (LH) surge in superovulated women, six normally ovulating women were studied in three cycles: a spontaneous cycle treated with exogenous oestrogen (oestradiol benzoate cycle), a cycle treated with follicle stimulating hormone (FSH; 225 IU/day; FSH cycle) and a cycle treated with FSH plus exogenous oestrogen (FSH + oestradiol benzoate cycle). Oestradiol benzoate was injected i.m. on cycle days 4 (0800 and 2000 h), 5 (0800 h) and 6 (0800 h) at doses of 0.5, 1.0, 2.0 and 2.5 mg respectively to achieve supraphysiological levels of serum oestradiol. Exogenous oestrogen (supraphysiological oestradiol levels) induced an LH surge in all six women in the oestradiol benzoate cycles, but failed to stimulate an LH surge in three of the six patients during treatment with FSH. In three patients treated with FSH, an LH surge was stimulated both by supraphysiological (FSH + oestradiol benzoate cycles) and 'high normal' oestradiol levels (FSH cycles), while in three patients treated with FSH only, the LH surge was blocked, although the threshold level for the positive feedback effect had been exceeded by cycle day 9. We conclude that in women, supraphysiological concentrations of oestradiol exert a positive feedback effect on LH secretion. It is suggested that the occurrence of an LH surge in cycles superovulated with FSH is not dependent on serum oestradiol concentrations, but mainly on the strength of ovarian inhibitory substances.     

Serum oestrone, oestradiol and oestriol concentrations during oral oestradiol valerate and oestriol succinate therapy in ovariectomized women

Serum oestrone, oestradiol and oestriol concentrations were investigated during oral treatment with oestradiol valerate and oestriol succinate in ovariectomized women. The dosages used were 1 mg oestradiol valerate in the morning and 2 mg oestriol succinate in the evening of the first day and 2 mg oestradiol valerate in the morning of the second day of treatment. The other group of patients received the same therapy in reverse order. The variations in the serum oestrone and oestradiol concentrations with a daily dose of 1 or 2 mg of oestradiol valerate were considerable. 2 mg oestriol succinate caused a fairly small elevation of serum oestriol concentration. In both treatment groups the quotient E₃/(E₂ + E₁) was similar to that found at the 6–7th day and in the middle of the normal menstrual cycle, the quotient E₁/(E₂ + E₃) was somewhat higher than during normal cycle.     

Characteristics of urinary luteinizing hormone (LH) during the induction of LH surges of different magnitude in blood

Urinary luteinizing hormone (LH) testing has been proposed asa reliable method for the prediction of ovulation but its accuracyhas been challenged by some studies. To check how accuratelythe oscillations of urinary LH reflected the plasma changes,surges of LH of different magnitude and duration were artificiallyinduced in plasma and the hormone was measured simultaneouslyin urine. Post-menopausal women (n = 16) were stimulated during1 week with a combination of transdermal oestradiol (400 µg)and i.m. progesterone (25 mg on day 4, 50 mg on day 5) to obtainan LH discharge comparable with the pre-ovulatory LH peak. Ashort and moderate peak of LH was induced by the i.v. injectionof 100 µg gonadotrophin-releasing hormone (GnRH) in sixpre-menopausal women, whereas an LH discharge of higher amplitudeand longer duration was induced by a single dose of 0.3 mg s.c.buserelin. The total urine production of the day was fractionatedinto 8 h periods. LH was measured by a commercial radioimmunoassay.Unambiguous peaks of LH were detected in the urine of all thewomen stimulated with either oestradiol plus progesterone orbuserelin, but in only three out of the six women receivingGnRH. The urine LH reproduced the plasma changes of the hormonewith short delay since the peaks were mostly detected in thesame time fraction in which the serum discharge occurred.     

Endocrinology: Follicle stimulating hormone alone supports follicle growth and oocyte development in gonadotrophin-releasing hormone antagonist-treated monkeys

Both follicle stimulating hormone (FSH) and luteinizing hormone(LH) are proposed requirements for follicular growth and steroidogenesis;however, the role of LH in primate folliculogenesis is unclear.Follicular stimulation by recombinant human FSH (n = 5) withand without recombinant LH (1: 1; n = 6) following 90 days ofgonadotrophin-releasing hormone (GnRH) antagonist (Antide) treatmentin macaques was evaluated. Human chorionic gonadotrophin (HCG)was administered when six follicles >4 mm were observed.Oocytes were aspirated 27 h later and inseminated in vitro.Chronic Antide reduced serum oestradiol and bioactive LH toconcentrations observed in hypophysectomized rhesus monkeys.Multiple follicular growth required a longer interval followingrecombinant FSH (12 ± 1 days) than recombinant FSH +recombinant LH (9 ± 0.2 days), but the total number offollicles/animal did not differ between groups. The day priorto HCG, oestradiol concentrations were 4-fold less followingrecombinant FSH compared to recombinant FSH + recombinant LH.With recombinant FSH, more oocytes completed meiosis to metaphaseII(51%) and fertilized (89 ± 5%) relative to recombinantFSH + recombinant LH (12 and 52 ± 11% respectively).Follicular growth and maturation in LH-deficient macaques occurredwith FSH alone. Thus, LH is not required for folliculogenesisin primates. Higher fertilization rates following follicularstimulation with FSH alone suggest that the presence of LH withFSH (1: 1) during the pre-ovulatory interval impairs gametogenicevents in the periovulatory period.     

Subcutaneous low dose leuprolide acetate depot versus leuprolide acetate for women undergoing ovarian stimulation for in-vitro fertilization

A total of 100 women undergoing ovarian stimulation with gonadotrophin-releasinghormone agonist (GnRHa) and a human menopausal gonadotrophin(HMG) for in-vitro fertilization (IVF) participated in thisrandomized comparative study. Leuprolide acetate at a dose of0.5 mg/day s.c. (n = 52, group I), or low-dose leuprolide acetatedepot at a dose of 1.88 nig s.c. (n = 48, group II), was startedon days 21–23 of the cycle. Stimulation with 225 IU/dayHMG was started after pituitary desensitization had been achieved.The luteal phase was supported by human chorionic gonadotrophin(HCG) i.m. injection. There were nostatistical differences inbaseline oestradiol (24.5 ± 4.8 versus 21.9 ±4.5 pg/ml) and follicle stimulating hormone (FSH) concentrations(3.9 ± 1.9 versus 3.2 $ 1.8 mlU/ml), and concentrationson the day of HCG administration of oestradiol (1657 ±245 versus 1512$165 pg/ml), luteinizing hormone (LH; 6.2 ±4.8 versus 5.6 ± 4.3 mlU/ml) and FSH (10.6 ± 2.8versus 10.8 ± 3.6 mIU/ml). There were also no statisticaldifferences in the HMG dosage (26.8 ± 1.8 versus 28.5± 1.5), the number of oocytes retrieved (7.6 ±3.0 versus 8.1 ± 4.3), the number of oocytes fertilized(5.3 ± 2.1 versus 5.6 ± 3.0) and the number ofembryos transferred (3.5 ± 1.3 versus 3.4 ± 1.6).There was no evidence of a premature LH surge in either group,but two patients appeared to have a poor response in the leuprolideacetate group (group I). There were 11 pregnancies (21.2%) afterthe use of leuprolide acetate and 12 pregnancies (25.0%) inthose given leuprolide acetate depot; no statistical differenceexisted between these two groups. Thus, an s.c. low-dose leuprolideacetate depot injection may offer a useful alternative for pituitarysuppression in ovarian stimulation for IVF.     

Endocrine and follicle characteristics of cycles with and without endogenous luteinizing hormone surges during superovulation induction with pulsatile follicle-stimulating hormone

The induction of superovulation in women with human gonadotrophinsmay result in blockage of the endogenous luteinizing hormone(LH) surge, but the reasons for this are not known. Ten normallyovulating women with longstanding infertility volunteered forthis study. They were treated with 225 IU follicle-stimulatinghormone (FSH) daily s.c. in a pulsatile manner (28 IU every3 h) starting on cycle day 2. Serum FSH and oestradiol levelsincreased and serum LH levels decreased significantly duringthe FSH treatment, as compared to their spontaneous cycles.Only five women displayed an LH surge during the FSH treatment.Serum FSH and LH levels during treatment were significantlylower and the number of follicles 12–15 mm in diameterand their total fluid volume was significantly greater in thecycles without an endogenous LH surge. Basal LH levels in thecycles without an LH surge increased soon after the end of theFSH treatment (cycle day 18), while FSH levels were still verylow without any incremental tendency. These results suggestthat a high number of small follicles may have a suppressiveeffect on both tonic and mid-cycle gonadotrophin secretion.Furthermore, the LH suppressive mechanism seems to be differentfrom that of the FSH.     

Initiation of high dose gonadotrophin-releasing hormone antagonist treatment during the late follicular phase in the macaque abolishes luteal function irrespective of effects upon the luteinizing hormone surge

The determination of the efficacy of gonadotrophin-releasing hormone (GnRH) antagonists in blocking the luteinizing hormone (LH) surge and luteal function is important for our understanding of the control of the menstrual cycle and for clinical application. GnRH antagonists have failed to block the LH surge reliably in the non-human primate. The aim of the study was to utilize high dose GnRH antagonist treatment administered during the late follicular phase of the menstrual cycle to block the pre-ovulatory LH surge. It was postulated that the LH surge would be prevented in all animals, but if this failed subsequent luteal function would be blocked by continued suppression of LH, since the early corpus luteum is susceptible to inhibition by GnRH antagonist treatment. A group of 16 adult female stumptailed macaques (Macaca arctoides) with regular menstrual cycles were selected. The GnRH antagonist [N-Ac-D-Nal(2)1,D-pCl-Phe2,D-Pal(3)3,D-(Hci)6, Lys(iPr)8,D- Ala10]GnRH (Antarelix) (concentration 10 mg/ml) was administered as three daily s.c. injections, at a dose of 1 mg/kg on days 11, 12 and 13 of the follicular phase of the menstrual cycle. Of nine macaques in which it was judged that the treatment was commenced within 1 day of the expected LH surge (serum oestradiol >400 pmol/l), six demonstrated a decline in serum oestradiol concentrations, a total block of the LH/follicle stimulating hormone (FSH) surge and inhibition of ovulation as judged by an absence of a rise in progesterone concentrations. In the three other animals in this category, a partial LH surge occurred, but this failed to result in a functional corpus luteum. In a further three animals treatment was initiated on the day of the LH surge, and again there was absence of a subsequently functional corpus luteum. These results show that GnRH is involved at the time of the mid-cycle LH/FSH surge in the non-human primate. Initiation of high dose GnRH antagonist treatment during the periovulatory period abolishes luteal function irrespective of its effects upon the LH surge because of its long-term action and resultant withdrawal of luteal support.      

Endocrinology: Follicle stimulating hormone-granulosa cell axis involvement in the antifolliculotrophic effect of low dose mifepristone (RU486)

This study was designed to assess the involvement of folliclestimulating hormone (FSH)—granulosa and luteinizing hormone(LH)—theca axes in the antifolliculotrophic effect ofmifepristone. Plasma gonadotrophins, including plasma LH bioactivityand pulsatility, oestradiol, testosterone and inhibin concentrations,and follicular growth were monitored in volunteer women treatedwith placebo or mifepristone in two consecutive cycles. Mifepristonewas given either as a single dose of 5 mg (n = 7) when the leadingfollicle had reached a diameter between 12 and 14 mm, or asa multiple dose of 5 mg/day for 3 days, beginning when the leadingfollicle had reached a diameter between 14 and 16 mm (n = 5)or between 6 and 11 mm (n = 5). Following the single dose ofmifepristone, follicular growth and the accompanying increasein plasma oestradiol were arrested at 12 and 36 h respectivelywithout changes in gonadotrophin or testosterone serum concentrations.The 3 day regimen arrested follicular growth and oestradiolrise and decreased plasma inhibin concentrations when follicleswere larger than 12 mm at the onset of treatment. These resultsindicate that the antifolliculotrophic action of mifepristoneis associated with a selective compromise of the FSH—granulosaaxis of dominant follicles that have passed a critical stageof growth.     

Long-term post-menopausal hormone therapy and serum HDL-C, total cholesterol and triglycerides

Serum high-density lipoprotein cholesterol (HDL cholesterol), total cholesterol and triglyceride concentrations were determined in 158 post-menopausal women following long-term oral hormone replacement therapy. Oestradiol valerate (2 mg/day) was taken by 53 of the women and oestriol succinate (2 mg/day) by 42 others. The duration (means +/- SD) of the oestradiol valerate therapy was 6.4 (+/- 2.9) yr and of the oestriol succinate therapy 6.4 (+/- 2.3) yr. The remaining 63 women received oestradiol valerate (2 mg/day) combined sequentially with norgestrel (0.5 mg/day). The average duration of treatment with this combination was 3.3 (+/- 2.4) yr. The control group comprised 100 post-menopausal women who received no hormone therapy whatsoever. The HDL cholesterol levels in the women receiving oestradiol valerate were higher than those in the controls (P = 0.001) and in the women on oestradiol valerate plus norgestrel therapy (P less than 0.001). The HDL cholesterol levels in the oestriol succinate group did not differ significantly from those in the controls. The women receiving oestradiol valerate in combination with norgestrel had lower serum HDL cholesterol concentrations than the controls (P less than 0.05). Serum total cholesterol and triglyceride concentrations did not differ in either oestrogen group from those in the controls, but were lower in the oestradiol valerate-plus-norgestrel group than in the controls (P less than 0.001). There were no differences in serum total oestrogen, oestrone, oestradiol and oestriol levels between control subjects with normal HDL cholesterol concentrations and those with low concentrations.     

Endocrinology: Low dose transdermal oestradiol suppresses gonadotrophin secretion in breast-feeding women

The object of the study was to investigate the effect on gonadotrophinsecretion of a small increase in oestradiol concentration. Atotal of 13 fully breast-feeding women (12 weeks post-partum)underwent serial blood sampling at 10 min intervals for 12 hon 2 different days; day 1 untreated and day 5 after 3 daysof treatment with transcutaneous oestradiol (100 µg/day).On both days bolus gonadotrophin-releasing hormone (GnRH; 10µg i.v.) was given after a 10 h baseline period. In sixof the subjects, a naloxone infusion was administered duringthe second study day. Application of transdermal oestradiolraised the oestradiol concentration within the normal follicularphase range. The mean luteinizing hormone (LH) concentrationon day 5 was found to be significantly lower than that on day1 (P < 0.05). The LH response to GnRH was, however, significantlyhigher on day 5 than day 1 (P < 0.001). The mean folliclestimulating hormone (FSH) concentration on day 5 was also significantlylower than that on day 1 (P < 0.01), while the peak concentrationafter GnRH was unchanged. When the opioid antagonist naloxonewas infused after oestradiol treatment, the subjects with lowpre-study oestradiol concentrations exhibited no effect on LHconcentration, while in the subjects with higher oestradiolconcentrations the LH concentration was increased. It was concludedthat the administration of small doses of oestradiol causeda significant fall in gonadotrophin concentration in breast-feedingwomen. This indicates a heightened sensitivity to the negativefeedback effect of oestradiol on GnRH release from the hypothalamus,since the pituitary response to GnRH was unaltered. Furtherstudies are required to investigate the possibility that thesedoses of oestrogen may have some clinical value in inhibitingovulation after delivery.     

Single monthly administration of the anti-progestagen Org 31710 in users of the 75 microg desogestrel progestagen-only pill: effects on pituitary-ovarian activity

Endocrine and ultrasound effects were studied of an intermittent (every 28 days) oral administration of 150 mg of the anti-progestagen Org 31710 during the continued daily use of 75 microg desogestrel (DSG) for progestagen-only contraception. A randomized, double-blind, placebo-controlled two-centre study was conducted in 50 healthy volunteers. Serum luteinizing hormone (LH), follicle stimulating hormone (FSH), oestradiol and progesterone concentrations, and follicle number and size were studied, as well as endometrial thickness, which was assessed by transvaginal sonography at least twice weekly during a single medication cycle (cycle 3-5). Forty-eight women were evaluated (Org 31710, n = 25; placebo, n = 23). Seven ovulations were observed in the treated group versus none in the placebo group. LH concentrations were higher on days 9 and 11 and oestradiol concentrations lower on day 3 in the treated group, irrespective of whether ovulation occurred. No parameter could predict ovulation. Endometrial thickness was greater on cycle days 7-13 and 19 in the treated group. However, within the Org 31710 group, no significant differences were found in volunteers who did or did not ovulate. Observed differences may be attributed to a competitive effect of Org 31710 with progestagen-induced suppression of the pituitary-ovarian axis, altered oestradiol feedback mechanisms, and/or altered receptor availability.     

A double-blind, randomized, dose-finding study to assess the efficacy of the gonadotrophin-releasing hormone antagonist ganirelix (Org 37462) to prevent premature luteinizing hormone surges in women undergoing ovarian stimulation with recombinant follicle stimulating hormone (Puregon). The ganirelix dose-finding study group

A multicentre, double-blind, randomized dose-finding study of Org 37462 (ganirelix) was conducted in 333 women undergoing ovarian stimulation with recombinant follicle stimulating hormone (rFSH; Puregon) to establish the minimal effective dose preventing premature luteinizing hormone (LH) surges during ovarian stimulation. For ovarian stimulation, rFSH was given in a fixed daily dose of 150 IU for 5 days from days 2 to 6 of the menstrual cycle. From cycle day 7 onward, up to and including the day of human chorionic gonadotrophin (HCG), Org 37462 (dosages 0.0625, 0.125, 0.25, 0.5, 1.0 and 2.0 mg/0.5 ml) was administered once daily by s.c. injection, and the rFSH dose was adjusted depending on ovarian response. The lowest (0.0625 mg) and highest (2.0 mg) dose groups were terminated prematurely on the advice of an external independent advisory committee. Serum Org 37462 concentrations increased in a linear dose-proportional manner, whereas serum LH and increases of oestradiol fell with increasing Org 37462 dose. During Org 37462 treatment, serum LH concentrations > or =10 IU/l were observed in the lowest dose groups with incidences of 16% (0.0625 mg), 9% (0.125 mg) and 1.4 % (0.25 mg). On the day of HCG, the number of follicles > or =11, > or =15 and > or =17 mm were similar in the six dose groups, whereas serum oestradiol concentrations were highest in the 0.0625 mg group (1475 pg/ml) and lowest in the 2 mg group (430 pg/ml). The median daily dose of rFSH was between 150 and 183 IU and the overall median duration of Org 37462 treatment was approximately 5 days in the six treatment groups. Overall, Org 37462 treatment appeared to be safe and well tolerated. The mean number of recovered oocytes and good-quality embryos was similar in all dose groups and ranged from 8.6 to 10.0 and 2.5 to 3.8, respectively. The mean number of replaced embryos in the different dose groups ranged from 2.3 to 2.7. The implantation rate was highest in the 0.25 mg group (21.9%) and lowest in the 2 mg group (1.5%). The early miscarriage rates (first 6 weeks after embryo transfer) were 11.9 and 13% in the 1 and 2 mg group respectively, whereas in the other dose groups this incidence was zero (0.0625%) up to a maximum of 3.7% (0.5 mg group). The vital pregnancy rate (with heart activity) at 5-6 weeks after embryo transfer was highest in the 0.25 mg group, i.e. 36.8 % per attempt and 40.3 % per transfer, and resulted in an ongoing pregnancy rate 12-16 weeks after embryo transfer of 33.8% per attempt and 37.1% per transfer. In conclusion, a daily dose of 0.25 mg Org 37462 prevented LH surges during ovarian stimulation and resulted in a good clinical outcome.      

Two distinct two-step ranks of progesterone stimulation after three different levels of oestrogen priming. Effect on induction of luteinizing hormone surges in young and climacteric women

Age and menopausal status were evaluated as potential modulators of the progesterone action in the initiation of the mid-cycle luteinizing hormone (LH) surge in women. Three distinct levels of oestradiol priming were used, in combination with two different two-step ranks of progesterone stimulation (10/25 mg and 25/50 mg i.m. injections of progesterone in oil, over 2 consecutive days) in two groups of women, ten premenopausals, aged between 18 and 25 years, and 14 postmenopausals, aged between 48 and 57 years. The low, moderate and high levels of oestradiol priming were defined in the premenopausal group by days 5 and 9 of the cycle, and 0.4 mg transdermal oestradiol applied in the early follicular phase respectively. The corresponding situation in the postmenopausal women was defined by the absence of treatment, 0.1 mg transdermal oestradiol, and 0.4 mg transdermal oestradiol respectively. The oestradiol patches were maintained for 5 days, and the first progesterone dose administered on day 3 of treatment. Unambiguous LH surges, detected in serum and urine, were restricted to the protocols using 0.4 mg oestradiol in both groups, with an onset soon after progesterone administration. The surge was higher in the postmenopausal group in serum and urine. The percentage LH increase above baseline, however, was higher in the premenopausal women. The dose of progesterone did not result in any changes in pituitary LH release. Therefore, the oestradiol threshold for the progesterone stimulatory effect on LH release was similar in both groups. The postmenopausal women did not yield defective LH surges when adequately primed with oestradiol and progesterone.      

Dose-finding study of daily gonadotropin-releasing hormone (GnRH) antagonist for the prevention of premature luteinizing hormone surges in IVF/ICSI patients: antide and hormone levels

BACKGROUND: The aim of this study was to define the minimal effective dose of antide (Iturelix) to prevent premature luteinizing hormone (LH) surges in in vitro fertilization (IVF) patients. METHODS: In a prospective, single centre study, 144 IVF/ICSI patients were stimulated with r-hFSH from cycle day 2 and from cycle day 6 onwards, cotreated with daily 2 mg/2 ml (n=30), 1 mg/ml (n=30), 0.5 mg/ml (n=31), 0.5 mg/0.5 ml (n=23) and 0.25 mg/ml (n=30) GnRH antagonist (antide). Serum samples were taken three times daily during antide administration to assess antide and hormone levels. The minimal effective dose was defined as the lowest dose group with <2 LH surges (LH >12.4 IU/l and progesterone >2 ng/ml). RESULTS: Serum antide levels, mean LH and E2 levels per day and their area under the curves were dose-related to antide. The bioavailability of antide almost doubled after dilution in larger volumes. Pre-injection LH levels gradually increased during GnRH antagonist treatment. LH surges occurred in the lowest dose groups 0.5 mg/ml (3.2%), 0.5 mg/0.5 ml (6.7%) and 0.25 mg/ml (13.3%). Hence, 0.5 mg/ml is considered to be the minimal effective dose. Antide was overall well tolerated and safe. CONCLUSIONS: 0.5 mg/ml antide is the minimal effective dose to prevent an untimely LH surge in IVF patients stimulated with r-hFSH.     

The effect of human menopausal gonadotrophin and highly purified, urine-derived follicle stimulating hormone on the outcome of in-vitro fertilization in down-regulated normogonadotrophic women

It has been suggested that the luteinizing hormone (LH) activityof human menopausal gonadotrophin (HMG) preparations used forovarian stimulation in in-vitro fertilization (IVF) may haveadverse effects on reproductive outcome. In the present prospective,randomized trial of 218 infertile couples this notion was investigated.A total of 114 women were treated with Pergonal (HMG group)and 104 with Fertinorm HP (HP-FSH group). The two groups werecomparable with regard to duration of infertility, cause ofinfertility, age and number of previous IVF attempts and allhad normal basal gonadotrophin concentrations before treatmentwas started. A standard hormonal treatment consisting of pituitarydown-regulation with gonadotrophin-releasing hormone analogue(GnRHa) for 14 days starting on cycle day 21, followed by eitherHMG or highly purified follicle stimulating hormone (HP-FSH),three ampoules (225 IU) per day for 7 days, was used in allcases. The daily hormone dose was thereafter individualizedaccording to the ovarian response. A maximum of two pre-embryoswere transferred after 3 days of culture. Luteal support withprogesterone (300 mg per day intravaginally) was used in allcases. Serum concentrations of oestradiol, FSH and LH were measuredon days 1 and 8 of stimulation and on the day of oocyte retrieval.The mean number of days of stimulation, mean number of ampoulesof HMG or HP-FSH used, mean total motile sperm count on theday of oocyte retrieval and mean numbers of oocytes retrieved(13.4 versus 13.7) or pre-embryos transferred (1.8 versus 1.8)were similar for both groups. Significantly (P < 0.05) morecycles in the HP-FSH group (17 = 16%) were cancelled due tocomplete failure of fertilization than in the HMG group (7 =6%). The mean fertilization rate was significantly (P < 0.05)higher in the HMG group (56%) than in the HP-FSH group (50%),and significantly more transferable pre-embryos were obtainedin the HMG than in the HP-FSH group (mean: 4.0 versus 3.2; P< 0.01). Serum hormone concentrations were similar in thetwo groups on stimulation day 1, but differed significantlywith regard to FSH, LH and oestradiol on stimulation day 8.The clinical outcome was similar in the two groups, with anongoing pregnancy rate (>12 weeks of gestation) per startedcycle of 33% in the HMG group and 29% in the HP-FSH group. Theclinical abortion rates were similar(10 and 14%), and the implantationrate was 30% in each group. In conclusion, no detrimental effectof the LH activity of HMG on the clinical outcome of IVF inGnRHa down-regulated normogonadotrophic women was found. Tothe contrary, some beneficial effects of HMG on fertilizationrates and pre-embryo development as compared with HP-FSH weredemonstrated. These effects, as well as the differences in serumhormone concentrations during ovarian stimulation, may be causedby differences in LH content and/or in the composition of FSHisoforms of the HMG and HP-FSH preparations.     

Accumulation of human chorionic gonadotrophin in the serum of patients during in-vitro fertilization treatment cycles with Pergonal

We examined the possible contribution of human chorionic gonadotrophin(HCG) in Pergonal to the serum luteinizing hormone (LH)-likebioactivity in 10 patients (median age32 years, range 28–38)with tubal infertility who were undergoing in-vitro fertilization(IVF), together with 19 controls (median age30 years, range21–43). IVF patients were treated with clomiphene (50mg twice daily) over days 2–6 and Pergonal (150 IU i.m.)daily from day 5 until at least day 10. Serum LH was measuredby fluoro-immunometric assay (I-LH) and in-vitro Leydig cellbioassay (B-LH). Serum HCG was measured by fluoro-immunometricassay. The data were analysed by paired two-tailed t-test, followinglogarithmic transformation. From days 1–5, there was anincrease in serum B-LH (mean, 95% confidence intervals givenin parentheses) from 8.3 (6.8, 10.2) IU/1 to 11.7 (9.8, 13.9)IU/1 [P= 0.004], and in serum I-LH from 4.5 (3.7, 5.4) IU/1to 5.4 (4.6, 6.3) IU/1 [P= 0.002]. From days 5–8, therewas a rise in B-LH to 16.6 (12.6, 21.9) IU/1 [P= 0.023]. Therise in I-LH to 6.3 (5.1, 7.8) IU/1 [P= 0.081] failed to reachsignificance. Furthermore, serum HCG was <<0.75 IU/1 untilafter Pergonal was administered on day 5, then rose to a plateauon day 8 at 1.2(0.8, 1.6) IU/1. Serum HCG in the controls remained<<0.75 IU/1 throughout. We conclude there is a disproportionateincrease in serum B-LH compared to I-LH from days 5–8,corresponding with a rise in serum HCG and the commencementof treatment with Pergonal. The HCG in Pergonal may be contributingto an undesirable rise in serum LH-like bioactivity, which mightreduce the success rate of IVF.     

Prediction of the potentially fertile period by urinary hormone measurements using a new home-use monitor: comparison with laboratory hormone analyses

BACKGROUND: The study compared a new urinary hormone monitoring system, Clearview Primera Fertility Monitor (CPFM), with laboratory hormone analyses in the prediction of the potentially fertile period. METHODS: Thirty healthy female volunteers provided blood and early morning urine samples for one cycle. Serum oestradiol, progesterone and luteinizing hormone (LH), and urinary LH and oestrone-3-glucuronide (E3G) were measured. The fertility status of volunteers; Low, High or Peak, was collected from monitors and compared with the hormone measurements. RESULTS: There was agreement between the first day of peak fertility and the urinary LH peak day in 65.6% of cycles and detection 1 or 2 days before the urinary LH peak day in 24.1 and 6.9% of cycles respectively. In 58.6% of cycles the system detected up to 5 days of increased fertility prior to the urinary LH peak day. Warning days of the urinary LH peak were similarly determined using defined thresholds of E3G and oestradiol providing up to 5 days warning in 82.8 and 96.6% of cycles respectively. CONCLUSIONS: The system can provide couples attempting to conceive with information about the potentially fertile days in the cycle in order that they may time intercourse. It also has potential for use in evaluation and treatment of infertile couples.