ovulation induction and controlled ovarian stimulation a...

Ovulation Inductionand ControlledOvarian StimulationA Practical GuideSecond Edition

Roy Homburg

123

Ovulation Induction and Controlled Ovarian Stimulation

Roy Homburg

Ovulation Induction and Controlled Ovarian Stimulation

A Practical Guide

Second Edition

ISBN 978-3-319-05611-1 ISBN 978-3-319-05612-8 (eBook) DOI 10.1007/978-3-319-05612-8 Springer Cham Heidelberg New York Dordrecht London

Library of Congress Control Number: 2014939003

© Springer International Publishing Switzerland 2014 This work is subject to copyright. All rights are reserved by the Publisher, whether the whole or part of the material is concerned, specifi cally the rights of translation, reprinting, reuse of illustrations, recitation, broadcasting, reproduction on microfi lms or in any other physical way, and transmission or information storage and retrieval, electronic adaptation, computer software, or by similar or dissimilar methodology now known or hereafter developed. Exempted from this legal reservation are brief excerpts in connection with reviews or scholarly analysis or material supplied specifi cally for the purpose of being entered and executed on a computer system, for exclusive use by the purchaser of the work. Duplication of this publication or parts thereof is permitted only under the provisions of the Copyright Law of the Publisher's location, in its current version, and permission for use must always be obtained from Springer. Permissions for use may be obtained through RightsLink at the Copyright Clearance Center. Violations are liable to prosecution under the respective Copyright Law. The use of general descriptive names, registered names, trademarks, service marks, etc. in this publication does not imply, even in the absence of a specifi c statement, that such names are exempt from the relevant protective laws and regulations and therefore free for general use. While the advice and information in this book are believed to be true and accu-rate at the date of publication, neither the authors nor the editors nor the pub-lisher can accept any legal responsibility for any errors or omissions that may be made. The publisher makes no warranty, express or implied, with respect to the material contained herein.

Printed on acid-free paper

Springer is part of Springer Science+Business Media (www.springer.com)

Roy Homburg Homerton Fertility Centre Homerton University Hospital London United Kingdom

www.springer.com

v

Contents

1 A Potted History of Ovulation Induction . . . . . . . . . 1References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4

2 Physiology of Ovulation . . . . . . . . . . . . . . . . . . . . . . . . 72.1 Hypothalamic-Pituitary-Ovarian Axis . . . . . . . . 8

2.1.1 Gonadotrophin Releasing Hormone (GnRH) . . . . . . . . . . . . . . . . . . 9

2.1.2 FSH . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 112.1.3 LH . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 132.1.4 Two Cells: Two Gonadotrophins . . . . . . . 142.1.5 Oestradiol . . . . . . . . . . . . . . . . . . . . . . . . . . 152.1.6 Progesterone . . . . . . . . . . . . . . . . . . . . . . . 17

2.2 Ovarian Morphology . . . . . . . . . . . . . . . . . . . . . . 172.3 Selection of the Dominant Follicle . . . . . . . . . . . 192.4 Ovulation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 202.5 Fine Tuning . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21

2.5.1 Inhibin. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 212.5.2 Activin and Follistatin. . . . . . . . . . . . . . . . 212.5.3 Growth Factors . . . . . . . . . . . . . . . . . . . . . 212.5.4 Anti-Mullerian Hormone (AMH) . . . . . 22

2.6 Ovarian Steroidogenesis . . . . . . . . . . . . . . . . . . . 22

3 Diagnosis and Causes of Anovulation . . . . . . . . . . . . 253.1 Prevalence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 263.2 Diagnosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27

3.2.1 Following the Diagnosis of Anovulation . . . . . . . . . . . . . . . . . . . . . . 31

3.3 Causes of Anovulation . . . . . . . . . . . . . . . . . . . . . 32

vi

3.3.1 Hypothalamic-Pituitary Failure (WHO Group I) . . . . . . . . . . . . . . . . . . . . 32

3.3.2 Hypothalamic-Pituitary Dysfunction (WHO Group II). . . . . . . . . . . . . . . . . . . . 33

3.3.3 Ovarian Failure (WHO Group III). . . . . 363.3.4 Hyperprolactinaemia

(WHO Group IV) . . . . . . . . . . . . . . . . . . . 373.4 Diagnostic Schemes . . . . . . . . . . . . . . . . . . . . . . . 383.5 Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41

4 General Factors Influencing Ovarian Function and the Prognosis for Ovulation Induction . . . . . . . . 434.1 Influence of Female Age . . . . . . . . . . . . . . . . . . . 44

4.1.1 Ovarian Reserve . . . . . . . . . . . . . . . . . . . . 454.1.2 Prognosis for Conception . . . . . . . . . . . . . 46

4.2 Influence of Obesity and Weight Loss . . . . . . . . 47References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48

5 Assessment of Ovarian Reserve . . . . . . . . . . . . . . . . . 515.1 Female Age . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 535.2 Day 3 FSH . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 535.3 Antral Follicle Count . . . . . . . . . . . . . . . . . . . . . . 545.4 Anti-Mullerian Hormone (AMH) . . . . . . . . . . . 545.5 Other Methods . . . . . . . . . . . . . . . . . . . . . . . . . . . 56References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56

6 Management of Hypogonadotrophic- Hypogonadism . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 596.1 Pulsatile Gonadotrophin-Releasing Hormone Therapy. . . . . . . . . . . . . . . . . . . . . . . . . 616.2 Gonadotrophin Therapy . . . . . . . . . . . . . . . . . . . 63References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 64

7 Understanding the Problems of Treating PCOS . . . . 657.1 Definition. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 667.2 Pathophysiology . . . . . . . . . . . . . . . . . . . . . . . . . . 677.3 Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 69

7.3.1 Weight Loss . . . . . . . . . . . . . . . . . . . . . . . . 69

Contents

vii

7.4 Anti-oestrogens. . . . . . . . . . . . . . . . . . . . . . . . . . . 697.5 Insulin Sensitisers . . . . . . . . . . . . . . . . . . . . . . . . . 707.6 Gonadotrophin Therapy . . . . . . . . . . . . . . . . . . . 717.7 Laparoscopic Ovarian Drilling . . . . . . . . . . . . . . 717.8 In-Vitro Fertilization (IVF) . . . . . . . . . . . . . . . . . 71

7.8.1 Long-Term Health Implications of PCOS . . . . . . . . . . . . . . . . . . . . . . . . . . . 72

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 72

8 Anti-oestrogens . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 738.1 Clomifene Citrate . . . . . . . . . . . . . . . . . . . . . . . . . 74

8.1.1 Mode of Action . . . . . . . . . . . . . . . . . . . . . 748.1.2 Dose . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 758.1.3 Results. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 758.1.4 Monitoring . . . . . . . . . . . . . . . . . . . . . . . . . 768.1.5 Possible Adjuvants to Clomifene

Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . 778.1.6 Unexplained Infertilty . . . . . . . . . . . . . . . 79

8.2 Aromatase Inhibitors . . . . . . . . . . . . . . . . . . . . . . 808.2.1 Mode of Action . . . . . . . . . . . . . . . . . . . . . 818.2.2 Possible Advantages of Letrozole . . . . . . 818.2.3 Results. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 828.2.4 Use of Letrozole in Controlled

Ovarian Hyperstimulation . . . . . . . . . . . . 828.2.5 Questions Remaining . . . . . . . . . . . . . . . . 838.2.6 Safety. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 84

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 84

9 Low-Dose Gonadotrophin Therapy for Ovulation Induction . . . . . . . . . . . . . . . . . . . . . . . . 879.1 Rationale . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 899.2 Chronic Low-Dose Regimen. . . . . . . . . . . . . . . . 909.3 Results . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 919.4 Variations on a Theme . . . . . . . . . . . . . . . . . . . . . 929.5 Starting Dose. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 929.6 Incremental Dose Rise. . . . . . . . . . . . . . . . . . . . . 929.7 Patience Is a Virtue. . . . . . . . . . . . . . . . . . . . . . . . 939.8 Gonadotrophin Preparations . . . . . . . . . . . . . . . 949.9 Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 94References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 94

Contents

viii

10 Insulin Lowering Agents. . . . . . . . . . . . . . . . . . . . . . . 9710.1 Weight Loss . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10010.2 Metformin . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10110.3 Restoration of Ovulation. . . . . . . . . . . . . . . . . 102

10.3.1 Metformin Alone . . . . . . . . . . . . . . . . . 10210.3.2 Metformin + Clomiphene . . . . . . . . . . 10310.3.3 Metformin + Low-Dose FSH . . . . . . . 10310.3.4 Metformin in IVF . . . . . . . . . . . . . . . . 10410.3.5 Metformin During Pregnancy . . . . . . 104

10.4 The Treatment of PCOS in Adolescence. . . . 10410.5 Other Insulin Lowering Drugs . . . . . . . . . . . . 105References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 105

11 Laparoscopic Ovarian Drilling . . . . . . . . . . . . . . . . . 10911.1 Surgical Methods . . . . . . . . . . . . . . . . . . . . . . . 11011.2 Results . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11111.3 Patient Selection and Mechanism

of Action . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11211.4 How Does It Work? . . . . . . . . . . . . . . . . . . . . . 11211.5 The Order of Treatment Options . . . . . . . . . . 113References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 113

12 Management of Hyperprolactinaemia . . . . . . . . . . . 11512.1 Aetiology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11612.2 Diagnosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11712.3 Indications for Treatment . . . . . . . . . . . . . . . . 11812.4 Treatment. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11912.5 Results of Treatment . . . . . . . . . . . . . . . . . . . . 120

13 Gonadotrophins for Ovulation Induction . . . . . . . . 12113.1 Principles . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12213.2 Preparations. . . . . . . . . . . . . . . . . . . . . . . . . . . . 12313.3 Urinary vs Recombinant: Safety. . . . . . . . . . . 12413.4 Urinary FSH vs Recombinant

FSH: Efficacy. . . . . . . . . . . . . . . . . . . . . . . . . . . 12413.5 FSH vs hMG . . . . . . . . . . . . . . . . . . . . . . . . . . . 12513.6 Treatment Protocols for Ovulation

Induction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 126References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 127

Contents

ix

14 Unexplained Infertility . . . . . . . . . . . . . . . . . . . . . . . . 12914.1 Diagnostic Tests. . . . . . . . . . . . . . . . . . . . . . . . . 13014.2 Definition. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13114.3 When to Intervene . . . . . . . . . . . . . . . . . . . . . . 13114.4 Treatment Options . . . . . . . . . . . . . . . . . . . . . . 132References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 135

15 Controlled Ovarian Stimulation for Intra-uterine Insemination . . . . . . . . . . . . . . . . . . 13715.1 Principles . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13815.2 Treatment Regimes for IUI. . . . . . . . . . . . . . . 13915.3 Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . 141References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 141

16 Controlled Ovarian Stimulation for IVF/ICSI . . . . 14316.1 Principles . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14416.2 Gonadotrophins in COH. . . . . . . . . . . . . . . . . 145

16.2.1 The Choice of Gonadotrophin Preparation . . . . . . . . . . . . . . . . . . . . . . 145

16.2.2 LH Content. . . . . . . . . . . . . . . . . . . . . . 14716.2.3 Starting Doses . . . . . . . . . . . . . . . . . . . 14816.2.4 Patient Comfort . . . . . . . . . . . . . . . . . . 14816.2.5 Triggering Ovulation . . . . . . . . . . . . . . 148

16.3 GnRH Agonists. . . . . . . . . . . . . . . . . . . . . . . . . 14916.3.1 Protocols . . . . . . . . . . . . . . . . . . . . . . . . 14916.3.2 Oral Contraceptives and the Long

GnRH Protocol . . . . . . . . . . . . . . . . . . 15116.3.3 Doses . . . . . . . . . . . . . . . . . . . . . . . . . . . 152

16.4 GnRH Antagonists . . . . . . . . . . . . . . . . . . . . . . 15216.4.1 Principles. . . . . . . . . . . . . . . . . . . . . . . . 15216.4.2 Protocols . . . . . . . . . . . . . . . . . . . . . . . . 15316.4.3 Single or Multiple Doses,

Fixed Day or Flexible? . . . . . . . . . . . . 156References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 157

17 Management of Poor Responders. . . . . . . . . . . . . . . 15917.1 Definition. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16017.2 Aetiology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 161

Contents

x

17.3 Predictive Markers . . . . . . . . . . . . . . . . . . . . . . 16217.4 Proposed Therapeutic Options . . . . . . . . . . . . 163

17.4.1 High Dose Gonadotrophins . . . . . . . . 16317.4.2 GnRH Agonist . . . . . . . . . . . . . . . . . . . 16417.4.3 GnRH Antagonist . . . . . . . . . . . . . . . . 16417.4.4 Natural Cycles . . . . . . . . . . . . . . . . . . . 16517.4.5 Adjuvant Therapies . . . . . . . . . . . . . . . 166

17.5 Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . 168References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 168

18 Management of High Responders . . . . . . . . . . . . . . 16918.1 Prediction of the High Responder . . . . . . . . . 17018.2 Preference of an Antagonist Protocol . . . . . . 17118.3 Starting Dose for Stimulation . . . . . . . . . . . . . 17218.4 Agonist Trigger . . . . . . . . . . . . . . . . . . . . . . . . . 17218.5 Oral Contraceptive Pre-treatment . . . . . . . . . 17418.6 Metformin . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17518.7 Carbergoline . . . . . . . . . . . . . . . . . . . . . . . . . . . 17518.8 In-Vitro Maturation (IVM). . . . . . . . . . . . . . . 175References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 176

19 Mild Stimulation Protocols . . . . . . . . . . . . . . . . . . . . 17719.1 Natural Cycles . . . . . . . . . . . . . . . . . . . . . . . . . . 17919.2 Modified Natural Cycles . . . . . . . . . . . . . . . . . 17919.3 Delayed Low-Dose FSH with GnRH

Antagonist . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18019.4 Clomifene Combined with

Gonadotrophins . . . . . . . . . . . . . . . . . . . . . . . . 18119.5 Aromatase Inhibitors Combined

with Gonadotrophins . . . . . . . . . . . . . . . . . . . . 18219.6 Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 182References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 182

20 Ovarian Hyperstimulation Syndrome. . . . . . . . . . . . 18520.1 Aetiology and Pathophysiology . . . . . . . . . . . 18720.2 Risk Factors . . . . . . . . . . . . . . . . . . . . . . . . . . . . 188

Contents

xi

20.3 Prevention (See Also Chap. 18) . . . . . . . . . . . 19120.3.1 Ovulation Induction

and COH for IUI . . . . . . . . . . . . . . . . . 19120.3.2 IVF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 192

20.4 Treatment. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19520.5 Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . 196References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 197

21 Multiple Pregnancies . . . . . . . . . . . . . . . . . . . . . . . . . 19921.1 Incidence of Multiple Pregnancies . . . . . . . . . 20021.2 Preventative Methods . . . . . . . . . . . . . . . . . . . 202

21.2.1 In Ovulation Induction . . . . . . . . . . . . 20221.2.2 In Ovarian Stimulation Preceding

Intra- uterine Insemination (IUI) (See Also Chap. 15) . . . . . . . . . . . . . . . 203

21.2.3 IVF/Embryo Transfer . . . . . . . . . . . . . 20521.3 Foetal Reduction. . . . . . . . . . . . . . . . . . . . . . . . 20621.4 Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . 207References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 207

22 Future Perspectives . . . . . . . . . . . . . . . . . . . . . . . . . . . 20922.1 Patient Comfort . . . . . . . . . . . . . . . . . . . . . . . . 210

22.1.1 Drug Delivery Systems . . . . . . . . . . . . 21122.1.2 Less Injections . . . . . . . . . . . . . . . . . . . 211

22.2 Less Complications. . . . . . . . . . . . . . . . . . . . . . 21222.3 Better Results . . . . . . . . . . . . . . . . . . . . . . . . . . 213

22.3.1 Improved Protocols . . . . . . . . . . . . . . . 21322.3.2 Time-Lapse Imaging . . . . . . . . . . . . . . 213

22.4 Less Optimistic Predictions . . . . . . . . . . . . . . . 21422.5 Utopia. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 215Suggested Further Reading on Time-Lapse Imaging . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 217

Contents

xiii

Ovulation induction and controlled ovarian stimulation lie at the very heart of the treatment for infertility. Ovulation induction for the anovulatory infertile woman is arguably the most successful treatment for infertility, boasting high preg-nancy rates, while controlled ovarian stimulation has become an integral part of protocols in preparation for in vitro fertil-ization and intra-uterine insemination. This has been a rap-idly advancing science and there are many variations on a theme, often confusing, and new ideas for improvements, not always scientifically sound, are proffered with startling regu-larity. This book puts some order into the field. It is neither a standard textbook nor an encyclopaedia of infertility but, as the title says, it is a practical guide to ovulation induction and controlled ovarian stimulation.

The book is written as a concise, no-nonsense, accurate practical guide to these complicated topics which can only be made simple by clearly written, logical, evidence- and experience- based solutions. As such, it is aimed at the general gynaecologist, fertility specialist whether established or in training, health worker and student.

An understanding of the basic physiology and anatomy of the ovary, the most dynamically changing organ in the body, last to become active and first to lose its basic functions, is an essential start to this guide. A scheme for the diagnosis of the aetiology of anovulation, once this has been established, is presented in a way which is treatment orientated. That is to say that once the aetiological diagnosis is cubby-holed, the therapeutic possibilities automatically open up. If anovulation

Introd uction

xiv

is not the problem causing the infertility or additional factors are involved, a simple algorithm for making the diagnosis and the consequent treatment is suggested.

The titles of ovulation induction and controlled ovarian stimulation should not be confused. The terms are often used interchangeably, and mistakenly, but they are distinctly dif-ferent entities with different aims. The object of ovulation induction is to restore the ovulatory state and restore fertility potential. This should ideally produce one ovulatory follicle. Controlled ovarian stimulation is applied to already ovulat-ing women to boost their ovulatory capacity, i.e. to produce multiple ovulating follicles. These different aims demand a completely different approach to how the ovary is stimulated. The pros and cons of all the applicable methods are consid-ered herein.

The ovary is not an island. It is strongly influenced by what is happening in the hinterland of the rest of the body. The prime example of this is age, the most important single factor affecting female fertility potential. An assessment of ovarian reserve and consequent fertility potential is becoming an integral part of the work-up in these modern days of a desire for pregnancy in the more advanced fertile age groups. Overweight and frank obesity may have a devastating effect on fertility potential, both for conception and the prevalence of miscarriage. This health curse of modern society is a matter of too much flesh preceding the way of all flesh. While its disturbing effect on fertility may not be its most catastrophic medical effect, it still gives the fertility specialist a headache.

While advancing age cannot be treated, the knowledge of its possible effects on the ovary and conception capabilities must be made more widely known to the general public. Similarly, the problem of obesity is an educational topic, the difference being that it is most definitely correctable by a change of lifestyle. A discussion of these two impeders pre-cedes details of ovulation inducing agents.

Both ovulation induction and controlled (sometimes uncontrolled) ovarian stimulation have two major complica-tions – multiple pregnancies and ovarian hyperstimulation

Introduction

xv

syndrome. Both are iatrogenic, both can be limited far better than is being done today. Relatively few multiple pregnancies will result from a low dose gonadotrophin protocol and virtu-ally no ovarian hyperstimulation syndrome. The replacement of one embryo following IVF is not going to produce many multiple pregnancies, and softer protocols required to pro-duce embryos from which a good quality single embryo can be chosen and replaced is the direction of the future.

Sandwiched between an enlightening look at the history of ovulation induction and stimulation and some crystal-ball gazing at future perspectives is the meat of the book which is replete with algorithms and explanatory tables. This guide is not over-referenced but relies on evidenced based medicine wherever this is available and, in particular, on almost 50 years of my own experience in this, surely the most fasci-nating and satisfying of medical sciences, the creation of a new life.

Since writing the first edition of this book, Robert (‘Bob’) Edwards has passed away. This gentle giant of a man changed history and not just in our profession. A stubborn Yorkshireman (as I am by birth), I found him incisive but polite, generous with praise and a kind man. One of Bob’s greatest attributes was his ability to foresee the next step before anyone else and to set about achieving it doggedly. Our conversations, rarely about medicine, revealed his in-depth knowledge of Yorkshire cricket, English rugby and the plight of Leeds United. Belatedly receiving the Nobel Prize and sparingly credited in his own country, he can rest assured that he will be fondly remembered.

Introduction

1R. Homburg, Ovulation Induction and Controlled Ovarian Stimulation, DOI 10.1007/978-3-319-05612-8_1,© Springer International Publishing Switzerland 2014

Abstract Since the early 1960s we have been privileged to witness one of the most amazing evolutions in modern medi-cal practice, that of infertility treatment. Up to that time we could do little to help the infertile couple and a consultation usually consisted of some wise nodding of the head and an explanation of the frequency and timing of intercourse. The 1960s, most famous for the introduction and widespread use of the oral contraceptive pill, paradoxically also brought about the possibility to treat anovulation and cure infertility emanating from this cause. Clomiphene citrate was the first agent to restore ovulation and this was soon followed by the extraction and purification of human menopausal gonado-trophins from urine. Today LH and FSH are produced by recombinant technology, shorn of impurities and very safe. The missing link connecting the hypothalamus and the pitu-itary, gonadotrophin-releasing hormone (GnRH) was eluci-dated in the 1970s eventually leading to today’s widespread use of GnRH agonists and antagonists. All the milestones in ovulation induction have been accompanied by brilliant technological advances. The advent of IVF, due to the fore-sight and stubborness of Steptoe and Edwards, and the ensu-ing technique of intra-cytoplasmic sperm injection (ICSI) have been incredible steps forward. In the last 50 years or so, we have progressed from helplessness to hopefulness for all infertile couples, only few of whom cannot conceive with

Chapter 1 A Potted History of Ovulation Induction

2

today’s knowledge and facilities. Can the next 50 years pos-sibly be as exciting for reproductive physicians?

Keywords Ovulation Induction • Infertility • Anovulation • Clomiphene citrate • Anti-oestrogen • FSH • Gonado-trophins • Amenorrheic women • Ovarian stimulation • IVF • ICSI • IUI • GnRH • Prolactin • Bromocryptine • Hyperprolactinaemia • hMG • LH

From the time I was a medical student in the early 1960s up to the present moment, I have been priviliged to witness one of the most amazing evolutions in modern medical practice, that of infertility treatment. Up to the beginning of the 1960s we could do little to help the infertile couple and a consulta-tion usually consisted of some wise nodding of the head and an explanation of the frequency and timing of intercourse. The 1960s, most famous for the introduction and widespread use of the oral contraceptive pill, paradoxically also brought about the possibility to treat anovulation and cure infertility emanating from this cause.

Clomiphene citrate was tested by Greenblatt et al. [ 1 ] in 1961 and found to be a safe and efficient way to induce ovula-tion. Since then an enormous number have benefitted from the unusual mode of action of this anti-oestrogen in indi-rectly releasing a spurt of FSH discharge and putting the ovulatory cycle back in correct order. The simplicity and inexpensive nature of this treatment have retained clomi-phene citrate until today in its position as the first line treat-ment for anovulation associated with normal concentrations of endogenous oestrogens.

Around this exiting time, the importance of being able to administer FSH in order to induce ovulation was being realised. This was first achieved in 1958 using human pitu-itary gonadotrophins by Gemzell [ 2 ] and the first resulting pregnancy was reported in 1960 [ 3 ]. The classical indication for this treatment was, of course, for those lacking gonad-otrophins. Subsequently pregnancies were achieved in

Chapter 1. A Potted History of Ovulation Induction

3

hypophysectomized patients, using human pituitary gonado-trophins [ 4 , 5 ]. This enormous breakthrough sparked the challenge to find a more amenable source for these valuable human gonadotrophins. Menopausal women were known to be excreting them in plenty in their urine and it was Lunenfeld and his group that succeeded in extracting them and inducing pregnancies in large series of amenorrheic women, reported by Lunenfeld [ 6 ] and Insler [ 7 ] in 1970. On a personal note, I am very proud that both these outstanding researchers were my teachers and instilled in me the enthu-siasm for this most fascinating of subjects. Urinary human menopausal gonadotrophins (hMG) have been very widely used up to the present day with extraordinary success, not only for ovulation induction, but also for ovarian stimulation for both IVF and IUI, It is hard to imagine where fertility treatment would be today without them.

The ‘missing link’ in the hypothalamic-pituitary ovarian axis, gonadotrophin releasing hormone (GnRH), was isolated and its structure established in the 1970s [ 8 – 10 ]. As the struc-ture was a relatively simple decapeptide, a synthetic GnRH soon became available for research and clinical purposes. The synthesis of GnRH may have been relatively simple, but dis-covering its mode of action and efficient clinical uses took some unravelling. It was Knobil, who in the seventies [ 11 ], discovered that GnRH was released from the hypothalamus in a pulsatile fashion and, in order to be effective as replace-ment therapy, had to be administered in a similar way. This has since been used as the classical treatment for hypotha-lamic hypogonadotrophic hypogonadism with outstanding success [ 12 , 13 ]. However, paradoxically, it was the early ‘failed’ experiments, showing that GnRH, when given con-tinuously, actually suppressed pituitary secretion of gonado-trophins, that led to the widespread use of GnRH agonists and later GnRH antagonists, in so-called controlled ovarian stimulation, in order to prevent premature luteinisation.

Another ‘corner’ of ovulation induction developed in the early 1970s, when prolactin was purified by Hwang et al. [ 14 ] and a specific assay was made available [ 15 ]. The discovery that


4

high concentrations of prolactin secreted by the anterior pitu-itary could cause anovulation, prompted the successful search for a prolactin lowering drug. Bromocryptine proved to be very efficient in lowering prolactin concentrations and subse-quently allowing the resumption of ovulation [ 16 – 18 ]. Since then several other prolactin lowering medications have been developed. They also have the remarkable ability to reduce the size, and often eliminate, micro- and macroadenomata of the pituitary, a common cause of hyperprolactinaemia.

Highly purified urinary hMG is now available and highly purified urinary FSH has also been relatively regularly used. The logistics of urine collection and the suspicion (so far thankfully unsubstantiated) that potentially harmful impuri-ties may exist in urinary preparations, prompted the now widespread use of recombinant human FSH (r-hFSH), pro-duced by recombinant DNA technology. Because of their lack of impurities, these pure FSH preparations can be self-administered subcutaneously and, in addition to their safety, this is a logistically important advantage. It did not take long, using the same technology, before recombinant human LH and hCG became available.

All these milestones in ovulation induction have been accompanied by brilliant technological advances. The advent of IVF, due to the foresight and stubborness of Steptoe and Edwards [ 19 ], and the ensuing technique of ICSI [ 20 ] have been incredible steps forward.

In the last 50 years or so, we have progressed from help-lessness to hopefulness for all infertile couples, only few of whom cannot conceive with today’s knowledge and facilities. Can the next 50 years possibly be as exciting for reproductive physicians?

References

1. Greenblatt RB, Barfield WE, Jungck EC, Ray AW. Induction of ovulation with MRL/41. JAMA. 1961;178:101–5.

2. Gemzell CA, Diczfalusy E, Tillinger KG. Clinical effects of human pituitary follicle stimulating hormone (FSH). J Clin Endocrinol Metab. 1958;18:138–48.


5

3. Gemzell CA, Diczfalusy E, Tillinger KG. Human pituitary folli-cle stimulating hormone. 1. Clinical effects of partly purified preparation. Ciba Foundation Colloqia Endocrinol. 1960;13:191.

4. Bettendorf G. Human hypophyseal gonadotropins in hypophy-sectomized women. Int J Fertil. 1963;8:799.

5. Gemzell CA. Treatment of infertility after partial hypophysec-tomy with human pituitary gonadotropins. Lancet. 1964;1:644–7.

6. Lunenfeld B, Insler V, Rabau E. Die Prinzipien der Gonadotropintherapie. Acta Endocrinol Suppl. 1970;148:52–101.

7. Insler V, Rabau E, Lunenfeld B. Comparison of ovarian response to different treatment schedules of human gonadotrophins. In: Butler JK, editor. Developments in the pharmacology and clini-cal uses of human gonadotrophins. High Wycombe: GD Searle; 1970. p. 87–100.

8. Matsuo H, Baba Y, Nair RMG, Arimura A, Schally AV. Structure of the porcine LH and FSH releasing factor: 1. The proposed amino acid sequence. Biochem Biophys Res Commun. 1971;43:1334–9.

9. Gullemin R. Peptides in the brain: the new endocrinology of the neuron. Science. 1978;202:390–402.

10. Schally AV, Coy DH, Meyers CA. Hypothalamic regulatory hor-mones. Ann Rev Biochem. 1978;47:89–128.

11. Knobil E. Neuroendocrine control of the menstrual cycle. Recent Prog Horm Res. 1980;36:53–88.

12. Crowley WF, McArthur JW. Stimulation of the normal men-strual cycle in Kallman’s syndrome by pulsatile administration of luteinizing hormone releasing hormone. J Clin Endocrinol Metab. 1980;51:173–7.

13. Leyendecker G, Wildt L, Hansmann M. Pregnancies following chronic intermittent (pulsatile) of GnRH by means of a portable pump – a new approach to the treatment of infertility in hypo-thalamic amenorrhea. J Clin Endocrinol Metab. 1980;51:1214–9.

14. Hwang P, Guyda H, Friesen HG. Purification of human prolactin. J Biol Chem. 1972;247:1955–8.

15. Friesen H, Belanger C, Guyda H, Hwang P. The synthesis and secretion of placental lactogen and pituitary prolactin. In: Wolstenholme GEW, Knight J, editors. Lactogenic hormones. Edinburgh/London: Churchill Livingstone; 1972. p. 83–103.

16. Del Pozo E, Varga L, Wyss H, et al. Clinical and hormonal response to bromocryptine (CB 154) in the galactorrhea syn-dromes. J Clin Endocrinol Metab. 1974;39:18–26.

References

6

17. Thorner MO, McNeilly AS, Hagan C, Besser GM. Long term treatment of galactorrhea and hypogonadism with bromocryp-tine. Br Med J. 1974;2:419–22.

18. Jacobs HS, Franks S, Murray MAF, Hull MGR, Steele SJ, Nabarro JDN. Clinical and endocrine features of hyperprolacti-naemic amenorrhea. Clin Endocrinol (Oxf). 1976;5:439–44.

19. Steptoe PC, Edwards RG. Birth after reimplantation of a human embryo. Lancet. 1978;2:366.

20. Palermo G, Joris H, Devroey P, van Steirteghem AC. Pregnacies after intracytoplasmic injection of single spermatozoon into an oocyte. Lancet. 1992;340:17–8.



Abstract The release of a mature, fertilizable egg from the dominant follicle is the culmination of a wonderfully inte-grated and synchronized succession of hormonal actions and morphological changes involving the hypothalamus, pituitary and ovaries. The major players in this system are gonadotro-phin releasing-hormone (GnRH), FSH, LH, oestrogen and progesterone but essential fine-tuning is provided by a large number of other factors. The steps involved in the process of ovulation, necessitating the exact sequence of so many events, leaves one in awe of the ingenuity of the system and a little surprised that its breakdown, i.e. anovulation, does not occur much more frequently. Normal functioning of this axis is dependent on the correct synchronization of release and quantity of the hormones involved. These change dra-matically throughout the cycle according to the stimulatory or inhibitory signals received. The ovary is a veritable pro-duction line for a vast number of steroid hormones but also, arguably, the most dynamically, constantly changing organ in the female body during the reproductive life span. Of the millions of primordial follicles that started life in the ovary, only about 400 will actually achieve ovulation. The key to being chosen as the month’s ovulatory follicle is sensitivity to FSH as only the most sensitive can survive, thrive and produce the most oestrogen and LH receptors. The oth-ers, starved of the possibility of FSH stimulation, become

Chapter 2 Physiology of Ovulation

8

atretic. The mid-cycle LH surge is the trigger for ovulation itself, activating a cascade of inflammatory responses in the dominant follicle leading to the breakdown of the follicular boundary wall and the escape of the oocyte with its cumulus oophorus.

Keywords Ovulation • Ovulation induction • Oocyte • Dominant follicle • Hormones • Gonadotrophin releasing hormone • GnRH • FSH • LH • Oestrogen • Progesterone • Ovarian hyperstimulation • IVF • Corpus luteum • Antral folli-cles • Androstendione • Testosterone • Oestradiol • Inhibin B • Granulosa cell • Follicular rupture • Luteinization • Inhibin • Activin • Follistatin • Insulin-like growth factors IGF • Anti-Mullerian hormone • AMH • Ovarian steroidogenesis

In order to appreciate the niceties of ovulation induction, a basic understanding of the mechanism of ovulation is essen-tial. In the normal course of events, ovulation occurs once a month between the time of menarche and menopause. The release of a mature, fertilizable oocyte from the dominant fol-licle is the culmination of a wonderfully integrated and syn-chronized succession of hormonal actions and morphological changes involving principally the anterior hypothalamus, ante-rior pituitary and ovaries. The major players in this system are gonadotrophin releasing-hormone (GnRH), FSH, LH, oestro-gen and progesterone but essential fine-tuning is provided by a large number of other factors including inhibin, activin and growth factors. An appreciation of the steps involved in the process of ovulation, necessitating the exact sequence of so many events, leaves one in awe of the ingenuity of the system and a little surprised that its breakdown, i.e. anovulation, does not occur much more frequently than is actually seen.

2.1 Hypothalamic-Pituitary-Ovarian Axis

The normal functioning of this axis is dependent on the cor-rect synchronization of the timing of release and the quantity of the hormones involved. These change dramatically

Chapter 2. Physiology of Ovulation

9

throughout the cycle as a result of the various feedback mechanisms involved. Firstly, we will consider the individual hormones involved, their target organs and actions, before piecing together the mosaic of the feedback mechanisms to complete the hormonal profile of the normal ovulatory cycle. Figure 2.1 provides a very simple representation of the origin, target organ and feedback mechanisms of the principal hor-mones involved in this axis.

2.1.1 Gonadotrophin Releasing Hormone (GnRH)

GnRH is a decapeptide which is synthesized and released by specific neuronal endings in the anterior and mediobasal

HYPOTHALAMUS

GnRH

PITUITARY

LH

OVARIES

EstradiolProgesterone

– –

FSH

+

+

Figure 2.1 A diagrammatic representation of the origin, target organ and feedback mechanisms of the principal hormones involved in the hypothalamus-pituitary-ovarian axis


10

hypothalamus. It is secreted into the portal vessels which run a very short course to the anterior pituitary. It is the compact-ness of the portal system which allows small quantities of GnRH to be concentrated enough to exert its action of gonadotrophin release from the pitiuitary and explains why GnRH is undetectable in the peripheral circulation. The dis-charge of the gonadotrophins, FSH and LH, induces the pro-duction of oestradiol and progesterone from the ovary which, in turn, through a feedback mechanism, influence the pattern of release of GnRH from the hypothalamus.

GnRH is released in a pulsatile fashion and it is the fre-quency and amplitude of these pulses, in addition to the sen-sitivity of the pituitary gonadotrophs, that dictate the pattern of the release of the two gonadotrophins. The GnRH pace-maker is principally influenced by the ovarian steroids but many other factors, including opiates, catecholamines, neuro-peptide Y, also play a role. If GnRH is released in a constant, non-pulsatile fashion, gonadotrophin release is suppressed due to an apparent desensitization of the pituitary GnRH receptors. Pulsatile release of GnRH and fluctuations in the pattern of this pulsatility are thus integral features in the nor-mal functioning of the ovulatory cycle.

As GnRH cannot be detected in human peripheral circu-lation, we have relied on the correlation with LH pulsatile release for our information on variations of pulsatility through the ovulatory cycle and in pathological conditions. Pulses of FSH are much more difficult to detect due to its longer half-life. In the follicular phase of a normal cycle, pulses of LH (reflecting GnRH) can be detected every 60–90 min.

Immediately preceding the pre-ovulatory LH surge, there is an enormous release of GnRH and following ovulation, under the influence of rising progesterone concentrations, the frequency of these pulses gradually decreases from one every 2–4 h in the early luteal phase to every 8–12 h towards the end of the cycle. The amplitude of LH pulses in the luteal phase is significantly greater than in the follicular phase. The fluctuations in the frequency and amplitude of GnRH


11

pulsatile release are central in dictating the pattern of release of FSH and LH and, in turn, the triggering of the ovulatory process and ovarian steroid production.

This knowledge of the basic physiology of the pattern of release and action of GnRH has brought with it many clinical implications. Induction of ovulation for women who have hypothalamic hypogonadrophic hypogonadism is very suc-cessful when GnRH is administered in a pulsatile fashion with one pulse every 60–90 min. This is an ideal example of pure substitution therapy. The search for an agonist to boost GnRH action proved to have exactly the opposite eventual effect due to desensitization of GnRH receptors. These com-pounds are now very widely used before and during ovarian hyperstimulation for IVF to prevent premature LH surges. The use of GnRH antagonists is now gradually taking the lead over the agonist during controlled ovarian stimulation for IVF as they do not induce an initial, fleeting gonadotro-phin release as do the agonists, but an immediate decrease in their concentrations. The comparison of the properties and clinical uses of GnRH agonists and antagonist is made in detail in a future chapter.

2.1.2 FSH

The amount and timing of FSH release by the anterior pitu-itary changes throughout the ovulatory cycle. This mechanism is influenced by many factors. With the sudden demise of the corpus luteum which immediately precedes menstruation, the negative feedback effects of oestradiol, progesterone and inhibin A on FSH secretion are suddenly lost so that FSH is secreted in relatively large quantities during menstruation itself. This rise in FSH concentrations stimulates the growth of antral follicles, granulosa cell proliferation and differentiation. It also encourages the action of the enzyme aromatase in the conversion of the basic androgens, androstendione and testos-terone to oestrogens. The sum total of these actions results in increasing oestradiol and inhibin B concentrations, feedback


12

mechanisms come into play and there is a consequent reduc-tion of FSH concentrations. At mid-cycle, in tandem with the LH surge, there is a temporary increase in FSH secretion, more like a blip, whose significance is not clear. It may be a mere bi-product of the GnRH surge or may have a function in preparing a cohort of antral follicles for the next cycle. With the formation of the corpus luteum and the outpouring of both oestradiol and progesterone, the negative feedback mechanism comes into play and continues its suppression of FSH release until just before the next menstruation.

FSH is a hormone of many roles. It is a promotor of:

1. Granulosa cell proliferation and differentiation 2. Antral follicle development 3. Oestrogen production 4. Induction of LH receptors on the dominant follicle 5. Inhibin synthesis

In addition to these functions, the decrease in FSH concen-trations with rising oestrogen concentrations is thought to play an important part in the selection of the dominant follicle. The declining secretion of FSH prevents multiple follicular devel-opment, as only the largest of the developing follicles stays above the FSH threshold, has the most FSH receptors, remains most sensitive to FSH and produces most oestrogen. It is then less affected by the declining FSH concentrations and can con-tinue to develop while others fade into atresia due to lack of enough FSH stimulation. The induction of LH receptors on the largest developing follicle(s) enables LH to take a part in the development of the dominant follicle in the late follicular phase and prepare it for the oncoming LH surge.

This basic knowledge of the mode of action of FSH, par-ticularly regarding the FSH threshold for follicular growth, has influenced a change in ovulation induction regimes. This has become particularly important in the development of a chronic low- dose regimen for the induction of monofollicular ovulation and the avoidance of multiple pregnancies and ovarian hyperstimulation syndrome.


13

2.1.3 LH

During the early and mid-follicular phase, the secretion of LH is relatively quiet with pulses every 60–90 min and a fairly constant low concentration of circulating LH. However, this is the calm before the storm. An enormous climax is reached with the onset of the LH surge in the late follicular phase, the central event of the ovulatory cycle (Fig. 2.2 ). Concentrations of LH rise to 10–20 times their resting level during the rest of the cycle. The duration of the surge is 36–48 h.

The LH surge, without which ovulation does not occur, is brought about by a combination of circumstances. Principally, there is a dramatic switch from a negative to a positive feed-back action of oestradiol at both the pituitary and hypotha-lamic level, triggered when persistently increasing oestradiol concentrations reach a critical point. LH secreting pituitary gonadotrophs clearly become highly sensitive to GnRH stimulation, probably by increasing their numbers of GnRH receptors, a GnRH surge occurs and a small rise in progester-one levels in the late follicular phase may also have a trigger-ing role.

FSH

Granulosa cell

Oestrogen Androgen

Aromatase

Androgen Cholesterol

Theca cell

LH

Figure 2.2 The two-cell, two-gonadotrophin hypothesis


14

The pre-ovulatory LH surge has a number of key functions:

1. Triggering of ovulation and follicular rupture about 36 h after the surge.

2. Disruption of the cumulus-oocyte complex. 3. Induction of the resumption of oocyte meiotic

maturation. 4. Luteinization of granulosa cells.

Following the formation of the corpus luteum, increasing concentrations of progesterone slow down the frequency of the LH (GnRH) pulses to one every 3 then one every 4 h. Concentrations of LH once again dip down to baseline levels. It is therefore, not clear what kind of influence LH levels have on the maintenance of the corpus luteum. This structure, which produces large quantities of hormones, seems to ‘have a mind of its own’ or a built-in programme which terminates in a very constant manner after 14 days. The luteal phase is thus the constant part of the ovulatory cycle whereas the fol-licular phase is much more likely to be prone to changes in duration.

2.1.4 Two Cells: Two Gonadotrophins

Outside the tumultuous events of the mid-cycle surge, the main function of LH is to encourage the production of andro-gens by theca cells. The androgens, androstendione and tes-tosterone, are then ‘passed on’ to the granulosa cells. Here they meet aromatase (CYP19), whose function it is to convert them into oestrogens, mainly oestradiol but also oestrone. Aromatase action, and therefore oestrogen production, is controlled by FSH. Hence, the function of theca cells and granulosa cells are controlled by LH and FSH respectively (Fig. 2.2 ). There is some overlap however as the LH receptors expressed by FSH on the granulosa cell membranes of devel-oping follicles of >10 mm diameter render LH capable of inducing oestradiol production and follicular growth in the mid-late follicular phase.


15

In clinical practice, hCG has been used as an excellent substitute for the LH surge in the triggering of ovulation as it binds to the LH receptor. It has a much longer half-life than LH. The current availability of pure, recombinant LH and recombinant FSH has enabled the further investigation of the physiology of the ovulatory cycle. High doses of recombi-nant LH are capable of triggering ovulation. The availability of these preparations as separate entities has prompted a large number of experiments to examine what is their exact function and necessity throughout the cycle.

2.1.5 Oestradiol

Oestrogens are the basic female hormones and oestradiol is the most important as far as the ovulatory cycle is concerned. The synthesis of oestradiol by granulosa cells is a function of the action of FSH. FSH stimulates the enzyme aromatase (CYP19) to convert the substrate of basic androgens, andro-stendione and testosterone, to oestradiol in granulosa cells. The production of this vital hormone thus requires the avail-ability of the androgen substrate whose production in theca cells is promoted by LH, followed by the action of FSH.

The key functions of oestradiol in the ovulatory cycle are:

1. As a cog in a negative feedback mechanism suppressing the secretion of FSH and so aiding in the selection of the dominant follicle and preventing multifollicular develop-ment in the mid-late follicular phase.

2. Triggering of the LH surge in mid-cycle by initiating a posi-tive feedback mechanism when its concentrations rise to a critical level.

3. As a ‘growth hormone’ for the development of the endometrium.

Oestradiol concentrations are at their lowest during men-struation. The FSH induced follicular development brings about rapidly rising oestradiol production in the mid- follicular phase. When oestradiol levels attain a persistently high criti-cal concentration in the late follicular phase, they induce the


16

LH surge. Following ovulation, oestradiol concentrations dip temporarily but are revived by corpus luteum activity. With the demise of the corpus luteum, oestradiol concentrations sink rapidly to their lowest levels and invoke the FSH rise immediately preceding menstruation (Fig. 2.3 ).

A mistake of nature, hypogonadotrophic hypogonadism, in which both FSH and LH secretion is essentially missing, has provided a learning tool for the understanding of ovula-tory physiology. The absence of FSH results in a lack of fol-licular development and oestrogen production and the absence of LH in a lack of androgen substrate production. When treatment with pulsatile GnRH is administered, pure substitution therapy, everything falls into place and ovulation can be successfully induced. If pure FSH is used to induce ovulation by direct stimulation of the ovaries, the lack of LH and therefore lack of production of androgen substrate, allows the growth of follicles but not oestradiol production. Even if ovulation can be triggered by hCG or recombinant LH when a large follicle is obtained, implantation cannot occur due to the lack of oestrogen stimulation on the endometrium.

Oestradiol

FSHLH

Follicle Corpus luteum

EndometriumDay 1 10 14 28

Follicular phase Ovulation Luteal phase

Progesterone

Figure 2.3 Hormonal, follicular and endometrial changes across the phases of the ovulatory cycle


17

2.1.6 Progesterone

Progesterone is produced by luteinized granulosa cells. Large quantities are synthesized by the corpus luteum following ovulation. Progesterone concentrations rise to a peak 7–8 days following ovulation and fall rapidly with the failure of the corpus luteum (Fig. 2.3 ). The main function of proges-terone from the corpus luteum is to fashion a secretory endo-metrium, capable of hosting the implantation of an embryo and to maintain this endometrium throughout the early weeks of pregnancy until trophoblastic/placental hormones take over this role. Under the influence of progesterone the endometrial glandular structures increase greatly in numbers and become more tortuous. Progesterone also plays a role in the expression of genes needed for implantation at the level of the endometrium.

Together with oestradiol, progesterone suppresses pitu-itary gonadotrophin release during the luteal phase. The increasing concentrations of progesterone following ovula-tion gradually reduce the frequency of the GnRH/LH pulses and increase their amplitude. During this phase, FSH is syn-thesized and stored ready for release when freed from the inhibition imposed by progesterone and oestradiol when the corpus luteum fails. The initial rise of progesterone concen-trations immediately preceding the LH surge may play a role in the triggering of this surge.

2.2 Ovarian Morphology

The ovary is, arguably, the most dynamically, constantly chang-ing organ in the female body during the reproductive life span (Fig. 2.4 ). The inner, medullary or stromal section, is made up of connective tissue inundated by small capillaries and adren-ergic nerves. The cortex, contains an enormous number of oocyte- containing follicles ranging from approximately 300,000 at menarche to 1,500 at menopause. There is a constant state of flux in the various stages of development of the follicles from

2.2 Ovarian Morphology

18

primordial (an oocyte with a single layer of granulosa cells around it), through primary and secondary stages with increas-ing numbers of layers of granulosa cells, antral stage containing follicular fluid, to a fully fledged, pre-ovulatory follicle. A cor-pus luteum can be seen in the luteal phase of the cycle and the picture is completed by the presence of corpora albicans (rem-nants of degenerate corpora lutea).

Although much of this changing picture of stages of fol-licular development is dependent on the stage of the (gonadotrophin- dependent) ovulatory cycle, there is a con-stant, non-FSH dependent, progression in development of primordial to potentially ovulatory follicles being available at the start of the ovulatory cycle, a process that may take about 10 weeks.

A diagrammatic representation of a pre-ovulatory follicle is illustrated in Fig. 2.5 .

Cumuluswith egg

Ovulation

Pre-ovulatory

folicle

Interstitialcells

Atretricfollicle

Early teriaryfollicle

Secondaryfollicle

Primary follicle

Primordialfollicles

Hilus cells

Medulla

CortexCorpus luteum

Corpus albicansAdreneric nerve

Spiral artery

Figure 2.4 Diagrammatic representation of ovarian morphology


19

2.3 Selection of the Dominant Follicle

Of the millions of primordial follicles that started life in the ovary, only about 400 will actually achieve ovulation during the reproductive life span. That means that more than 99.9 % of follicles become atretic. At the beginning of each cycle, a group of the most mature follicles of 2–5 mm diameter are recruited for further growth, granulosa cell differentiation and multiplication. The follicles more sensitive to FSH rather than those less mature are selected at the time of the FSH inter-cycle rise for further development (Fig. 2.6 ). The key to being chosen as the month’s ovulatory follicle is sensitivity to FSH. The follicles most sensitive to FSH will utilize it to increase aromatase activity and produce oestrogens and inhibin. As FSH concentrations fall in response to rising oes-trogen and inhibin B levels and become less available, only

Looseconnective

tissue

Capillaries

Antrum(follicular fluid)

Zonapellucida

Corona radiatagranulosa

cells

Cumulusoophorusgranulosa

cells

Membranagranulosa

cells

Thecaexterna

Theca interna

Thecainterstitial

cells

Basallamina

Figure 2.5 Morphology of the antral follicle

2.3 Selection of the Dominant Follicle

20

the most sensitive follicle to FSH, that with the lowest thresh-old for a response to FSH, can survive and continue to thrive and produce the most oestrogen and LH receptors. The rest, starved of the possibility of FSH stimulation, become atretic. The relative intra-follicular concentrations of oestrogens and androgen play an important role in deciding which follicles eventually become atretic. The selection of the dominant fol-licle is an example of survival of the fittest for which a good start in life is extremely important!

2.4 Ovulation

As well as playing a secondary role in follicular responsive-ness to FSH, LH is the trigger for ovulation itself. In response to the switch in oestrogen feedback from negative to positive, the LH mid-cycle surge is created. This activates a whole cas-cade of inflammatory responses in the dominant follicle lead-ing to the breakdown of the follicular boundary wall and the escape of the oocyte with its cumulus oophorus.

ooooooo

oooooooo

ooooo

oooo

oo

oooooooooooo

ooooooooo

FSH Level

Follicle Reserve

Cycle day

101 14

Dominant Follicle

O

0

Atresia

OOOO

oo

Figure 2.6 Selection of the dominant follicle in relation to FSH concentrations


21

2.5 Fine Tuning

Such an intricate process as ovulation would not be complete without a fine-tuning system. This involves a large number of compounds, endocrine, autocrine and paracrine factors including inhibin, follistatin, activin, IGF-I & II, IGF binding proteins 1–6, TGF-alpha & beta, epidermal growth factor and anti- Mullerian hormone.

2.5.1 Inhibin

Inhibin is secreted by granulosa cells. Inhibin A and inhibin B are dimers which differ in their pattern of secretion. Inhibin A concentrations are low during most of the follicular phase but start to rise during its latest stages and peak in the mid-luteal phase. In contrast, inhibin B concentrations start rising early in the follicular phase, paralleling but later than the FSH rise. Inhibin B negatively influences FSH concentration and also reflects the size of the follicle cohort. Oestrogens and inhibin B are both inhibitory factors for the secretion of FSH.

2.5.2 Activin and Follistatin

Activin is a promotor of many actions of FSH in that it increases FSH secretion, promotes ovarian follicular devel-opment and inhibits androgen production. Follistatin is an activin binding protein that neutralizes activin bioactivity.

2.5.3 Growth Factors

Many growth factors form a network of interactions within the ovary and its compartments. The most well known are the insulin-like growth factors (IGF’s) I and II which are very active and are counteracted by IGF binding proteins, six of which have been identified. Insulin, as well as binding to IGF receptors, has its own ovarian receptors and is known to

2.5 Fine Tuning

22

promote androgen production. The transformin growth fac-tor (TGF) family is also well represented in the ovary as is epithelial growth factor (EGF). All play a passive role in the regulation of gonadotrophin activity within the follicles.

2.5.4 Anti-Mullerian Hormone (AMH)

Anti-Mullerian hormone (AMH) is named so as it is pro-duced by the fetal testis and serves to suppress the formation of the female genital tract in the developing male fetus. However, the very same hormone is also produced by granu-losa cells of the ovary, specifically by pre-antral and small antral follicles up to the size of about 9 mm. It is known to modulate the progression of primordial follicles to develop further and appears to be part of a ‘tug-of-war’ with numer-ous other factors which encourage the early stages of follicu-lar development. While its function in the ovary is not yet completely clear, AMH is thought to have an inhibitory effect on the action of FSH and aromatase in promoting growth of pre-antral and small antral follicles. AMH is not produced by the larger pre-ovulatory follicles and it may have a reciprocal relationship with FSH.

2.6 Ovarian Steroidogenesis

The pathways of ovarian steroid production are diagram-matically illustrated in Fig. 2.7 . The enzymes involved in these complicated processes are also signified. A basic knowledge of these actions is necessary not only for the understanding of normal ovarian physiology but especially for pathological conditions such as polycystic ovary syndrome (PCOS).


23

Cholesterol

Pregnenolone 17OH pregnenolone

Progesterone 17OH progesterone

Oestrone

Testosterone

Dihydrotestosterone

CYP11A

3b OHSD

17OHase 17,20 lyase

5a reductasearomatase

CYP19

CYP17

Androstendione

Oestradiol

DHEA

Figure 2.7 Pathways of ovarian steroid production and some of the enzymes involved. DHEA dehydroepiandrosterone

2.6 Ovarian Steroidogenesis


Abstract The history and examination alone will often point toward the diagnosis and dictate the order in which examinations should be performed. Using this approach and good common sense, laboratory examinations, expense and time can be limited to a minimum. There are four major categories of causes of anovulation: hypothalamic-pituitary failure, hypothalamic- pituitary dysfunction, ovarian failure and hyperprolactinaemia. This classification has the advan-tage of being treatment orientated, i.e. once the diagnosis of anovulation has been made and its cause determined, the treatment for induction of ovulation in that particular condition will be clear. Hypothalamic-Pituitary Failure is a situation in which gonadotrophin concentrations are so low as to be completely unable to stimulate follicle development and oestrogen production from the ovaries – hypogonadotro-phic-hypogonadism. Hypothalamic-pituitary dysfunction is characterized by normal oestradiol and FSH concentrations and usually presents as oligo- or amenorrhea. Almost 90 % of ovulatory disorders are due to this type of dysfunction and a large majority of these are due to polycystic ovary syndrome (PCOS). Ovarian failure is characterized by amen-orrhea, hypo-oestrogenism and high concentrations of FSH. Hyperprolactinaemia may often, but not always, present with galactorrhea. Anovulation caused by hyperprolactinaemia is usually associated with prolactin concentrations more than

Chapter 3 Diagnosis and Causes of Anovulation

26

twice the upper limit of normal. Using the simple diagnostic scheme presented, not only can the cause of anovulation be found with a minimum of fuss but it will dictate the starting treatment required.

Keywords Anovulation • Oligo-ovulation • Plasma pro-gesterone • Progesterone • Oligomenorrhea • Basal body temperature • Vaginal ultrasound • Ovulation • Corpus luteum • Polycystic ovary syndrome • Amenorrhea • Oestrogen • Hypogonadotrophic • Hypergonadotrophic hypogonadism • Hyperandrogenism • Semen • Intra-uterine insemination • ICSI • IUI • IVF • Hystero- salpingography • Laporoscopy • Hypothalamic-Pituitary Failure • Gonadotrophin • Weight-related amenorrhea • Kallmann’s syndrome • GnRH • Hypothalamic-Pituitary Dysfunction • Oestradiol • FSH • PCOS • Ovarian drill-ing • Ovarian failure • Oocytes • Anti- Mullerian hor-mone • AMH • Hyperprolactinaemia

3.1 Prevalence

Infertility is thought to affect about 15–16 % of couples after 1 year of unprotected regular intercourse. After 2 years, with no treatment, about half of these will still not have conceived and after a further year, about 7 % in all will remain infertile. Most couples will turn for help after 1 year depending on their particular culture. That means that one in seven couples will look for advice after 1 year.

It has proved very difficult to estimate what proportion of infertility is due to anovulation. This prevalence is very much influenced by the particular specialization and indeed geographical location of the reporting centre. Thus esti-mates have varied between 20 and 40 % of the causes of infertility as due to anovulation or severe oligo-ovulation.

Chapter 3. Diagnosis and Causes of Anovulation

27

3.2 Diagnosis

The importance of a detailed gynaecological and medical his-tory cannot be emphasized enough. The clues should be sought by listening carefully and asking the correct direct questions. This should be followed by a thorough gynaeco-logical and general physical examination. The history and examination alone will often point toward the diagnosis and dictate the order in which examinations should be performed. Using this approach and good common sense, laboratory examinations, expense and time can be limited to a minimum. A suggested ‘check-list’ is presented in Table 3.1 .

Any form of menstrual irregularity, not within the limits of a 24–35 day cycle, strongly suggests anovulation or oligo- ovulation. The converse is not necessarily so as the occasional woman with regular bleeding may also be anovulatory. Painful menstruation usually indicates that ovulation is occurring.

Plasma progesterone concentrations are arguably, the most accurate way to estimate whether ovulation has occurred.

For women with a regular cycle of say 28 days, a plasma progesterone estimation on cycle day 20 or 21 of 8 ng/ml (25 nmol/l) or more, will rule out a diagnosis of anovulation.

If the usual cycle is say 35 days in length, then this exami-nation should be done around cycle day 28, i.e. about 7 days before the expected menstruation.

For women with mild oligomenorrhea (cycle length >35 days) progesterone can be measured on day 28 and then once a week following that until menstruation occurs.

If periods only occur less than once every 2 months or in cases of amenorrhea, there is little point in hunting for progesterone estimations as the diagnosis of severe oligo- or anovulation is self-apparent.

A basal body temperature ( BBT ) chart has been used for many years to estimate whether ovulation is occurring.

3.2 Diagnosis

28

Table 3.1 A suggested checklist for history taking and physical examination of the female partner of a couple seeking help for infer-tility at the fi rst clinic visit. Note that these are headings only, con-tain no further details and obviously, the answers to direct questioning should prompt further refl ex, relevant questions, e.g. a history of amenorrhea, is it primary or secondary? Hot fl ushes? Sense of smell? etc.

History

Age

Female partner

Male partner

Occupations

Previous pregnancies

Duration of infertility

Past medical history

Intercurrent illnesses/medications/drugs/alcohol

Family history

Previous contraception

Previous treatment for infertility

Age at menarche

Cycle regularity

Menstrual loss/pain/last menstrual period

Complaints of hirsutism, acne, galactorrhea

Sexual activity/problems

Examination

Body build

Weight, height, body mass index

General physical examination

Distribution of hair growth/hirsutism


29

The principle is that the secretion of progesterone following ovulation, into the circulation, will cause a rise in body tem-perature of about 0.5 °C. The typical BBT chart will thus be bi-phasic i.e. the temperature following ovulation will be higher than in the first part or follicular phase. The day before the temperature rise is usually denoted the day of ovulation. Although the BBT is a simple, cheap and non-invasive screening test, it suffers from many inaccuracies, particularly false negatives, and is open to much misinterpre-tation. It is very doubtful whether the BBT still has a place in the routine screening for ovulatory problems. Further, it has been found to be a niggling nuisance for many women as temperature must be measured every morning, immediately on waking. It could still be used for the timing of sampling for a progesterone estimation, about 7 days following the tem-perature rise or as a rough guide for timing of intercourse. This latter indication is also doubtful as once the BBT chart shows a rise, ovulation has been and gone!

A vaginal ultrasound examination before and after ovula-tion, should record a large developing dominant follicle which disappears following ovulation. In addition, most competent ultrasonographers are able to diagnose the presence of a cor-pus luteum if ovulation has occurred. This will be accompa-nied by a small amount of fluid in the pouch of Douglas which can also be spotted on ultrasound examination.

Physical examination can give many clues as to the cause of anovulation. Most obvious at first glance, is the weight of the patient. Weight and height should always be recorded and the body mass index (BMI) calculated. This is done with the following formula:

Breasts/galactorrhea

Acne

Gynaecological examination

Vulva, vagina, cervix, uterus, adnexae

Table 3.1 (continued)

3.2 Diagnosis

30

BMI

Weight kg

Height in metres=

( )2

A normal BMI is 20–25.

<20 is underweight, 25.1–30 is overweight >30 is frank obesity.

Some geographical variations in these diagnoses exist. For example, in most South-East Asian communities, any BMI > 25 is regarded as obesity.

Overweight and obesity is often associated with polycystic ovary syndrome (PCOS) and in turn PCOS is often charac-terized by hirsutism and/or acne, both of which are easily discernable on examination. In cases of suspected PCOS who are obese, acanthosis nigricans, dark discolouration of the skin in the axillary or nuchal regions, is a tell-tail sign of insu-lin resistance. Waist circumference should be measured at the level of the iliac crests in all overweight women as this again may be a good reflection of insulin resistance when >88 cm.

Women whose BMI is <20 may have irregular or absent ovulation due to so-called, weight - related amenorrhea . This may be due to loss of weight due to dieting and to anorexia nervosa in its extreme. Direct questioning regarding diet, alcohol or drug abuse are mandatory.

Physical examination can also reveal signs of oestrogen deficiency such as poor breast development, lack of develop-ment of the vulva, vaginal dryness, lack of additional second-ary sexual characteristics. These signs indicating oestrogen deprivation could be due to either hypo- or hypergonadotro-phic hypogonadism, when either is associated with primary amenorrhea. Although Turners syndrome is rare as a cause of amenorrhea, it can often be easily diagnosed by the typical body habitus; short stature, webbed neck, cubitus valgus and often a systolic cardiac murmur.

Distribution of hair growth should be noted. A male distri-bution would indicate hyperandrogenism and a lack of body


31

hair could be a sign of androgen insensitivity. Clitoral enlargement or lack of development would be in parallel to these respective conditions in their extreme.

3.2.1 Following the Diagnosis of Anovulation

Needless to say, having made a diagnosis of anovulation and before embarking on treatment, some basic examinations, notably a semen analysis, must be performed. It is not unusual to encounter a multifactorial cause for infertility. One normal semen examination should be enough to lay a possible male factor aside before starting ovulation induction. There is some controversy regarding the usefulness of a post coital test (PCT) but when a reasonable quantity of progressively motile sperm are seen in good quality cervical mucus, this can be very reassuring and also confirms that coitus is being prac-ticed and coital technique is normal. The results of at least two abnormal semen examinations, the second usually in a washed specimen, will usually dictate whether intra-uterine insemination is indicated with ovulation induction or whether there is an indication to forget an ovulation induction regi-men and proceed directly to IVF-ET or ICSI.

If there is a previous history in the female partner of sexu-ally transmitted disease, a complicated delivery, Caesarean section, pelvic inflammatory disease, endometriosis or surgi-cal interventions in the pelvic region, including appendicec-tomy, a screening test, usually hystero-salpingography (HSG), should be performed. If this confirms tubal patency and a normal uterine cavity, then treatment can be commenced. Abnormal findings in the HSG will dictate what steps are to be taken further. These may include a diagnostic laparoscopy and hysteroscopy which may be diagnostic or operative or gross tubal damage demonstrated on the HSG may indicate direct progress to IVF. Some centers use laparoscopy as a screening test if the history is suggestive of a possible mechanical factor but I have found that the HSG serves this purpose well and is certainly a less invasive technique.

3.2 Diagnosis

32

If the HSG is suggestive of a tubal lesion or peri-tubal adhe-sions, then resort to a laporoscopy is justified.

3.3 Causes of Anovulation

There are numerous conditions that can cause anovulation. Here I will give a brief description of each before classifying them into a scheme which can greatly simplify the individual diagnosis and has the advantage of being treatment orien-tated, i.e. once the diagnosis of anovulation has been made and its cause determined, the starting treatment for induction of ovulation in that particular condition will be clear. The classification of the causes of anovulation described here are based on a long- standing World Health Organisation (WHO) classification scheme which I have adapted slightly.

3.3.1 Hypothalamic-Pituitary Failure (WHO Group I)

This is a situation in which gonadotrophin concentrations are so low as to be completely unable to stimulate follicle devel-opment and oestrogen production from the ovaries – hypogonadotrophic- hypogonadism. Anovulation and amenorrhea are the consequences.

Weight - related amenorrhea is the commonest ‘hypotha-lamic’ cause of this condition – loss of weight due to a crash diet or frank anorexia nervosa.

Stress, in its extreme, including very strenuous exercise, e.g. marathon running, is not an uncommon cause.

Kallmann ’ s syndrome is a hypothalamic amenorrhea asso-ciated with anosmia.

Other causes include craniopharyngioma and debilitating systemic diseases. Not a few cases are idiopathic.

The commonest ‘ pituitary ’ causes are hypophysectomy, radiotherapy for pituitary tumours and severe post-partum haemorrhage (Sheehan’s syndrome).


33

If the pituitary is intact and the hypothalamus is failing to function, ‘replacement therapy’ with pulsatile GnRH is highly effective. Direct stimulation of the ovaries with gonad-otrophins also serves the purpose for ovulation induction whether the cause is of hypothalamic or pituitary origin. See Chap. 6 for a detailed description of ovulation induction for women with hypogonadotrophic-hypogonadism.

3.3.2 Hypothalamic-Pituitary Dysfunction (WHO Group II)

Hypothalamic-pituitary dysfunction is characterized by nor-mal oestradiol and FSH concentrations and usually presents as oligo- or amenorrhea. Almost 90 % of ovulatory disorders are due to this type of dysfunction and a large majority of these are due to PCOS. Although oestrogens are constantly being produced by the ovaries in this type of dysfunction, there is a loss of the ebb and flow of FSH and LH levels that are characteristic of the normal ovulatory cycle. Polycystic ovary syndrome may present in many ways. The heterogene-ity of its presentation and, indeed, of its laboratory findings, have made the definition and diagnosis of PCOS a conten-tious issue over the years. Following a meeting in Rotterdam in 2003, a consensus was reached and published and has since been widely adopted. This will hopefully now enable a much needed unification of the definition and the possibility to compare data for scientific and clinical purposes.

Polycystic ovary syndrome can be diagnosed when at least two of the three following criteria are present:

1. Oligo- or anovulation 2. Clinical and/or biochemical hyperandrogenism 3. Polycystic ovaries

Precise definitions of each of the above criteria are shown in Table 3.2 .

Polycystic ovary syndrome (PCOS) is a very heterogeneous syndrome, often first diagnosed when the patient presents


http://dx.doi.org/10.1007/978-3-319-05612-8_6

34

complaining of infertility. The syndrome is associated with approximately 75 % of the women who suffer from infertility due to anovulation. The majority of women with anovulation or oligo-ovulation due to PCOS have menstrual irregularities, usually oligo/amenorrhea, associated with clinical and/or bio-chemical evidence of hyperandrogenism. Almost all these women will have a typical ultrasonic appearance of the ova-ries. Making the diagnosis of PCOS is important as this will dictate the treatment plan, the prognosis and will serve in the avoidance of possible complications of treatment.

Practically, the diagnosis of PCOS can be made in almost every case without blood sampling. Although not essential for initial diagnostic or therapeutic decisions, for screening I usually take a blood sample for LH, FSH, total testosterone and fasting glucose and insulin concentrations. The ratio of fasting glucose to insulin levels gives only a fair indication of

Table 3.2 The diagnosis of polycystic ovary syndrome. Any two of the following three criteria serve to make the diagnosis

Oligo - or anovulation

Oligo-ovulation is the occurrence of ovulation no more than once every 35–180 days

Anovulation is no ovulation for at least six consecutive months

Hyperandrogenism – clinical and / or biochemical

Clinical signs include hirsutism, acne, alopecia (male pattern balding) and frank virilisation

Biochemical indicators include raised total testosterone, androstendione and free androgen index

Polycystic ovaries

The presence of 12 or more follicles in either ovary measuring 2–9 mm in diameter and/or increased ovarian volume (>10 mm)

Note that other similarly presenting aetiologies, e.g. congenital adrenal hyperplasia, androgen secreting tumours and Cushing’s syndrome should be excluded


35

insulin sensitivity but as hyperinsulinaemia is present in about 80 % of obese women and 30–40 % of women of nor-mal weight with PCOS and is strongly associated with anovu-lation, then it is certainly useful to know for possible therapeutic intervention. Except for research purposes, the attempted and often inaccurate estimation of insulin sensitiv-ity is best ignored in routine practice. The LH value may be expected to be high in about half of the women with PCOS and when high (>10 IU/L) is thought to be detrimental to successful ovulation induction and to the incidence of miscarriage.

When suggested by the history and physical examination, further laboratory examinations may be needed to exclude similarly presenting syndromes. Total testosterone concentra-tions, together with a history of rapid progress of hyperandro-genic symptoms are useful for the screening of androgen producing tumours and 17-hydroxy progesterone when highly elevated is pathognomonic for 21-hydroxylase defi-ciency, the commonest form of late onset congenital adrenal hyperplasia. If Cushing’s syndrome is suspected following the physical examination, it should be investigated using the accepted adrenal function tests. Many other, more sophisti-cated, examinations may be performed for research purposes; measuring sex hormone- binding globulin can be used in the calculation of the free androgen index, an oral or intravenous glucose tolerance test or even insulin clamp will give more accurate information on insulin metabolism and for more information regarding the metabolic status of the patient, lipids, homocysteine and plasminogen activator inhibitor-1 concentrations may be the subject of the particular investigation.

Women with oligomenorrhea obviously have endogenous oestrogen production and therefore an intact hypothalamus and pituitary, an adequate secretion of GnRH and FSH and ovaries that are capable of responding to FSH. The dysfunction lies in the coordination and synchronization of these elements and the aim of treatment, whether it be with anti-oestrogenic agents, life-style changes, insulin lowering


36

medications, laparoscopic ovarian drilling etc. is to rearrange correct synchronization in the timing and amount of hor-monal discharge. Another approach is to bypass these steps and stimulate the ovary directly with gonadotrophins.

See Chap. 7 and following chapters for a full account of the management and treatment of PCOS.

When amenorrhea is encountered, it should first be estab-lished whether endogenous oestrogen production is present. This can be done simply and cheaply by administering an oral progestin for about 5 days. If a withdrawal bleeding follows, endogenous oestrogen production is present and a WHO Group II type of anovulation is established.

3.3.3 Ovarian Failure (WHO Group III)

This group of anovulatory disorders is characterized by amenorrhea, hypo-oestrogenism and high concentrations of FSH. It is often accompanied at its onset by hot flushes.

The underlying cause is the inability of the ovaries to respond to FSH and may be due to:

The onset of a ‘natural’ menopause (>40 years of age) Premature menopause (<40 years old) A chromosomal abnormality (e.g. Turner’s syndrome).

In each case the ovaries are either completely devoid of oocytes or have a severely depleted number of oocytes. A premature menopause may be familial and therefore sus-pected from a family history or it may be the result of an auto-immune disease, chemotherapy or direct radiation of the ovaries. Very often the underlying cause remains obscure.

The definitive diagnosis of ovarian failure should be estab-lished simply by an estimation of FSH which is >25 IU/L. Simple as it may sound, there are pitfalls to making this definitive diagnosis. Concentrations of FSH have been known to fluctuate considerably and not once I have been embar-rassed by making a firm diagnosis, preaching doom and gloom to the unfortunate patient and then witnessing a


http://dx.doi.org/10.1007/978-3-319-05612-8_7

37

return of normal menstruation, ovulation and, rarely, sponta-neous pregnancy. Although this may be anticipated in some cases following recovery from chemotherapy, in others, rarely, this may also happen. An intermediate or transitional stage of this process may be termed impending ovarian failure. At this stage, menstruation and even ovulation may be occurring regularly, often with a short follicular phase and cycle length, but they are accompanied by infertility, poor or absent response to exogenous gonadotrophins and a raised FSH concentration on day 2–3 of the cycle. The finding of a very low or immeasurable values of serum anti-Mullerian hor-mone (AMH) may be a more reliable marker than FSH for the diagnosis of ovarian failure (see Chap. 5 ).

Except for the preservation of the cancer patient’s own ovarian tissue or oocytes before treatment or for the older patient who had the good sense to freeze eggs at an earlier age, oocyte donation is the only feasible treatment for infer-tility in these patients. Other treatments employing oestro-gens, GnRH analogues or cortisone have proved worthless. Replacement therapy with oestrogen and progesterone should be prescribed in this situation. This is especially important for the younger patients to avoid the long-term consequences of oestrogen deprivation.

3.3.4 Hyperprolactinaemia (WHO Group IV)

Hyperprolactinaemia is a not uncommon condition, which may often, but not always, present with galactorrhea. Anovulation caused by hyperprolactinaemia is usually asso-ciated with prolactin concentrations more than twice the upper limit of normal. It is not unusual to find mildly raised prolactin concentrations which are not associated with anovu-lation and these should not be treated. It should also be remembered that mildly raised prolactin concentrations may be seen in about 30 % of women with PCOS but again, there is no point in treating them specifically with prolactin lower-ing medications.


http://dx.doi.org/10.1007/978-3-319-05612-8_5

38

Major causes of hyperprolactinaemia are pituitary adeno-mas, hypothyroidism, medications such as the phenothiazines, some sedatives and hypotensive agents. It follows that when hyperprolactinaemia is found to be associated with anovula-tion, an examination of the pituitary gland by MRI or CT scan should be performed. In about 50 % of these cases a prolactin secreting adenoma will be found. If a macroadenoma (>10 mm) is visualized it is probably wise to extend the inves-tigation to include visual fields due to the close proximity of the optic chiasma on to which a large tumour may impinge. A microadenoma (<10 mm) is a commoner finding. In either case, prolactin lowering drugs are available today which are very effective in restoring ovulation and even in reducing the size of the adenoma. Thyroid stimulating hormone (TSH) concentrations should be estimated as a screening test for thyroid disorders and if raised should be followed up with more specific thyroid function tests. Stopping the offending medication, treating hypothyroidism or administering prolac-tin lowering drugs will decrease prolactin concentrations and restore ovulation in the vast majority of these women.

Unlike all the rest of the hormones secreted by the ante-rior pituitary which have releasing hormones secreted by the hypothalamus, prolactin has an inhibiting hormone (probably dopamine). This means that a hypothalamic lesion or hypo-thalamic suppression by drugs (e.g. phenothiazines), if suffi-ciently serious, will lower gonadotrophin secretion from the anterior pituitary but may well raise prolactin concentrations. Very often then, a hyperprolactinaemia sufficient to cause anovulation is associated with low LH concentrations and this is the probable connection between the two conditions.

See Chap. 12 for a detailed description of the management of hyperprolactinaemia.

3.4 Diagnostic Schemes

Having classified the possible causes of anovulation into four groups, diagnostic schemes will now be presented. These schemes point a very direct way to arrive at an accurate


http://dx.doi.org/10.1007/978-3-319-05612-8_12

39

diagnosis of the cause of the anovulation in the shortest pos-sible time and with the minimum of investigations.

Assuming anovulation or severe oligo-ovulation has been proven, Fig. 3.1 illustrates a rapid diagnostic method to clas-sify the cause of the ovulatory disturbance into one of the four groups described above. Minimal laboratory examina-tions are required in this scheme as endogenous oestrogen production can be estimated by a progestin withdrawal test in the case of amenorrhea/anovulation. This is unnecessary if oligo- rather than amenorrhea is the presenting complaint. This leaves only prolactin to be measured and, in the case of a negative progestin withdrawal, FSH concentrations are measured to find out if the problem is hypogonadotrophic or hypergonadotrophic hypogonadism.

If amenorrhea (no ovulation in 6 months) is the present-ing symptom, then the scheme in Fig. 3.2 can be easily applied to arrive at the diagnosis and indicate the way for-ward. For the sake of completeness, the diagnostic scheme for the causes of amenorrhea should include Outflow tract

Anovulation

Prolactin

High

HYPER-PROLACTINEMIA

HYPOTHALAMIC-PITUITARYDYSFUNCTION

HYPOTHALAMICPITUITARYFAILURE

Low

LowNormal

Normal

Oestradiol

FSH

High

OVARIANFAILURE

Figure 3.1 A rapid diagnostic method for the cause of an ovulatory disturbance

3.4 Diagnostic Schemes

40

defects ( WHO Group V ) which, while not usually associ-ated with anovulation, are a cause of amenorrhea which must be taken into possible consideration. This situation can be diagnosed if both progestin and oestrogen/progestin withdrawal do not produce bleeding and FSH levels are in the normal range. When the amenorrhea is primary, possi-ble diagnoses in this group include imperforate hymen and congenital absence of the uterus. When secondary, severe intrauterine adhesions (Ascherman’s syndrome) may be the cause.

If oligo-ovulation (one ovulation every 35–180 days) or regular anovulatory cycles is the presenting symptom, the scheme illustrated in Fig. 3.3 will be helpful. In any of these situations, the aim is to arrive at a correct diagnosis for the cause of the anovulation in the minimum amount of time and with a minimum of investigations. As this classification is very much treatment orientated, once the diagnosis is made it will indicate what is the correct treatment suitable for that spe-cific diagnosis.

Amenorrhea

NormalProlactin

High

Normal

Low

2° sex characteristicsWeight loss?Kalmann’s syndrome?Systemic diseases?

1° - karyotype2° - auto-immune antibodies

High


HYPOTHALAMICPITUITARYFAILURE

OVARIANFAILURE

HYPER-PROLACTINEMIA

Medications?TSHMRI

PCOS?see fig 3.3

Oestradiol Low FSH

Figure 3.2 Scheme for the diagnosis of the cause of amenorrhea. TSH thyroid stimulating hormone, MRI magnetic resonance imag-ing, PCOS polycystic ovary syndrome


41

3.5 Conclusions

1. Anovulation is a common cause of infertility and is almost invari-ably associated with menstrual irregularity.

2. A history of amenorrhea or severe oligomenorrhea needs no confi rmation of the diagnosis of anovulation by further investiga-tion beyond history taking and physical examination.

3. If anovulation is suspected in the presence of mild oligomenor-rhea or regular menstruation, an appropriately timed estimation of serum progesterone concentrations is the simplest way to con-fi rm the diagnosis.

4. There are four major categories in the classifi cation of anovulation: hypothalamic-pituitary failure, hypothalamic-pituitary dysfunction, ovarian failure and hyperprolactinaemia.

5. Using the simple diagnostic scheme presented, not only can the cause of anovulation be found with a minimum of fuss but it will dictate the starting treatment required.


Oligomenorrhea

Normal

High

Prolactin

PCOS?

FSH

High

IMPENDINGOVARIANFAILURE

Signs of hyperandrogensim-clinical or biochemicalU/S ovaries

*LH, FSH, TT, Free T, 17-OHprog., DHEAS, Fasting glucose & insulin

*not mandatory

If no PCOS

HYPER-PROLACTINEMIA

Figure 3.3 Scheme for the diagnosis of the cause of oligomenor-rhea. PCOS polycystic ovary syndrome, TT total testosterone, DHEAS dihydroepiandrosterone sulphate

3.5 Conclusions


Abstract Before any treatment for infertility, some impor-tant factors affecting the outcome of this treatment must be taken into account and in particular, female age and body mass index. Advancing female age is probably the single most important factor influencing fertility potential. Physiologically, from the age of about 35 years onwards, there is a steady downward trend in fertility capacity and this is a reflection of the declining number of follicles remaining, bio-logical aging and exposure to many deleterious influences on the ova remaining in the ovaries. As a result, following the age of 42, spontaneous pregnancy becomes quite a rare event and from the mid-thirties onwards, fertility potential decreases considerably. Public awareness of these facts is insufficient. In addition to the delaying of a wish for pregnancy until a later age, obesity is also an undesirable product of modern society and maternal weight seems to have a substantial effect on fer-tility potential. Obese women are less fertile and have higher rates of miscarriage than their counterparts of normal weight. The successful treatment of obesity is capable of reversing its deleterious effects on fertility potential. Weight loss is notori-ously difficult to achieve and maintain, particularly it seems for women with PCOS. It is not enough merely to tell these patients to lose weight and come back in say 3 months time. Referral to a clinic dedicated to instruct in life style changes, diet and exercise is a necessity to achieve the goal.

Chapter 4 General Factors Influencing Ovarian Function and the Prognosis for Ovulation Induction

44

Keywords Ovulation • Female age • Fertility • Primordial follicles • Oocytes • Assisted reproductive technologies • ART • Ovulation induction • Ovarian reserve • Primordial follicles Ovarian failure • LH • Premature ovulation • Early luteinisation • Oestrogen • Inhibin • Anti-Mullerian hormone • AMH • Antral follicle • Ovum • Body mass index • FSH • Obesity • PCOS • Hyperinsulinaemia • Hyperandro genism • Hyperandrogenemia • Gonadotrophins • Hyperstimulation Metformin

Before considering the treatment of anovulation, and indeed any treatment for infertility, some important factors affecting the outcome of this treatment must be taken into account and in particular, female age and body mass index. In addition to these, smoking is said to reduce ovarian reserve and fertility potential of the female and, possibly, the semen quality.

4.1 Influence of Female Age

Advancing female age is probably the single most important factor influencing fertility potential. Physiologically, from the age of about 35 years onwards, there is a steady downward trend in fertility capacity and this is probably a reflection of the declining number of primordial follicles remaining, bio-logical aging and exposure to many deleterious influences on the ova remaining in the ovaries. In addition to the persis-tently decreasing number of available, potentially fertilizable oocytes, it is also assumed that the best quality ova are prefer-entially recruited in the earlier stages of the reproductive period. As a result, following the age of 42, a spontaneous pregnancy becomes quite a rare event and from the mid-thir-ties onwards, fertility potential decreases considerably. Advancing female age not only affects natural conception but also the results of ovulation induction and assisted reproduc-tive technologies.

Public awareness of these facts is insufficient. It is sad that many, in this modern day and age of career women and

Chapter 4. General Factors Influencing Ovarian Function

45

delayed wish for conception, not only make life difficult for themselves and their physicians but may often “miss the boat” completely. The increasing phenomenon of the single woman who realizes that the prince on a white horse may not arrive after all but wants to conceive and increasing divorce rates followed by second marriages have also pushed up the mean age of women presenting with a problem of infertility. We have not yet succeeded in impressing the general public sufficiently with these facts. An awareness of the declining pregnancy rates with age at least allows an informed consid-eration of the timing of attempted conception when this is flexible.

In order to fully inform couples of their prognosis regard-ing fertility potential, especially if the female partner is in the more advanced age group, data on the state of ovarian func-tion is needed. This information should be utilized not only to forecast the chances on conception but, not infrequently, to decide whether treatment should be embarked upon at all.

To answer these questions, information regarding both the number of available oocytes (ovarian reserve) and their qual-ity is needed. Very frequently a dwindling ovarian reserve is accompanied by poor quality oocytes. When these two coin-cide, prognosis for pregnancy is poor. However, it is now becoming more apparent that these two factors do not always run in parallel and, similarly, the results of the static and dynamic tests available require accurate interpretation of their value before an informed discussion can be undertaken.

4.1.1 Ovarian Reserve

The total number of primordial follicles remaining in the ovary declines with age. Although this decline is a gradual process up to the age of 35, thereafter the slope becomes much steeper. This downward trend can occasionally occur before this age and is then related to an impending prema-ture ovarian failure.

4.1 Influence of Female Age

46

There are several suggestive symptoms and signs of a dwindling ovarian reserve: a shorter cycle on account of a shorter follicular phase, a premature LH surge, premature ovulation and early luteinisation. These are due to decreasing concentrations of inhibin, a consequent increase and even ‘overshoot’ of FSH release by the pituitary producing an accelerated rate of follicular growth and oestrogen concentrations.

The assessment of ovarian function is fully described in the following chapter.

4.1.2 Prognosis for Conception

If these clinical signs of a dwindling ovarian reserve are associated with a high intra-menstrual FSH concentration, low anti- Mullerian hormone (AMH) concentrations or severely reduced antral follicle count, these are gloomy por-tents not only of ovarian response to stimulation but also, often, of prognosis for pregnancy. In this case, serious con-sideration of a halt in further investigations and treatment should be made, especially if these have been accompanied by a very poor or non-response to maximal ovarian stimula-tion. Ovum donation, if acceptable, produces an excellent alternative in these situations. However, poor responders, even with moderately high FSH concentrations and low AMH/antral follicle count, in the younger age groups, have a better chance of conceiving than those with similar signs who are of advanced reproductive age [ 1 ]. In other words, age is an independent predictor for quality of oocytes and therefore pregnancy rates, whereas FSH, AMH concentra-tions and antral follicle count and the dynamic tests are indirect predictors of ovarian reserve. The worst prognosis for pregnancy is therefore predicted by advanced reproduc-tive age, high FSH concentrations, low AMH serum concen-trations, a low antral follicle count and a poor response to gonadotrophin stimulation.


47

4.2 Influence of Obesity and Weight Loss

In addition to the delaying of a wish for pregnancy until a later age, obesity is also an undesirable product of modern society and maternal weight seems to have a substantial effect on fertility potential. Obese women are less fertile in both natural and ovulation induction cycles and have higher rates of miscarriage than their counterparts of normal weight. Induction of ovulation in obese women requires higher doses of ovulation inducing agents.

Although obesity per se seems to be an independent factor in the aetiology of subfertility and the poor outcome of treat-ment in general, its predominance in women with associated PCOS further complicates the issue as 80 % of these women have insulin resistance and a consequent hyperinsulinaemia. They almost inevitably have the stigmata of hyperandrogen-ism and irregular or absent ovulation. Insulin stimulates LH and ovarian androgen secretion and decreases sex hormone binding globulin concentrations so increasing circulating free testosterone concentrations. Central obesity and body mass index (BMI) are major determinants of insulin resistance, hyperinsulinemia and hyperandrogenemia. More gonadotro-phins are required to achieve ovulation in insulin resistant women. Obese women being treated with low dose therapy have inferior pregnancy and miscarriage rates. Both obese and insulin resistant women with PCOS, even on low dose FSH stimulation, have a much greater tendency to a multifol-licular response and thus a relatively high cycle cancellation rate in order to avoid hyperstimulation.

The successful treatment of obesity, with or without insulin resistance, is capable of reversing its deleterious effects on fer-tility potential. In a study examining the effect of a change in life style programme on 67 anovulatory, obese (BMI >30) women who had failed to conceive with conventional treatment for 2 years or more, the mean weight loss was 10.2 kg after 6 months [ 2 ]. Following the loss of weight, 60 of the 67 resumed ovulation and 52 achieved a pregnancy, 18 of them spontaneously.

4.2 Influence of Obesity and Weight Loss

48

In addition to these impressive results, only 18 % of these preg-nancies miscarried compared with a 75 % miscarriage rate in pregnancies achieved before the weight loss [ 2 ]. This outstand-ing report emphasizes once again the strong connection between nutrition and fertility potential and particularly the strong association between obesity and infertility.

Obesity expresses and exaggerates the signs and symp-toms of insulin resistance in women with PCOS. Loss of weight can reverse this process, improve ovarian function and the associated hormonal abnormalities. Curiously, in obese women with PCOS, a loss of just 5–10 % of body weight is enough to restore reproductive function in 55–100 % within 6 months of weight reduction [ 3 ].

Weight loss is thus a cheap and effective way to restore ovula-tion in obese, anovulatory women. If medical ovulation induc-tion is needed, it is definitely facilitated by loss of weight and when pregnancy ensues, miscarriage rates are also greatly improved by weight loss. This should be the first line of treat-ment in obese women with anovulatory infertility. Metformin, an insulin sensitizing agent, is currently being widely used in infertile women with associated PCOS, particularly for those who are obese (see Chap. 10 ). It should not, however, be used as a first-line substitute for attempted weight loss which achieves similar, if not better results, does not involve medication or side- effects and most definitely provides long-term health benefits.

Weight loss is notoriously difficult to achieve and main-tain, particularly it seems for women with PCOS. It is not enough merely to tell these patients to lose weight and come back in say 3 months time. Referral to a clinic dedicated to instruct in life style changes, diet and exercise is a necessity to achieve the goal.

References

1. van Rooij JA, Bancsi LF, Broekmans FJ, Looman CW, Habbema JD, te Velde ER. Women older than 40 years of age and those with elevated follicle-stimulating hormone levels differ in poor response rate and embryo quality in in vitro fertilization. Fertil Steril. 2003;79:482–8.


http://dx.doi.org/10.1007/978-3-319-05612-8_10

49

2. Clark AM, Thornley B, Tomlinson L, Galletley C, NOrman RJ. Weight loss results in signifi cant improvement in reproductive outcome for all forms of fertility treatment. Hum Reprod. 1998;13:1502–5.

3. Kiddy D, Hamilton-Fairley D, Bush A, et al. Improvement in endocrine and ovarian function during dietary treatment of obese women with polycystic ovary syndrome. Clin Endocrinol. 1992;36:105–11.

References


Abstract The enormous rate of atresia of ovarian follicles will leave 10,000–25,000 at age 36 years with ovulatory potential and the rate of loss accelerates even further up to the age of menopause. The assessment of ovarian reserve is important as a guide for counseling patients regarding prog-nosis for pregnancy if used judiciously, roughly predict the age of menopause, help determine the protocol for ovarian stimulation. In practical terms, methods for the assessment of ovarian reserve are female age, serum concentrations of FSH and oestradiol estimated on day 2–4 of the menstrual cycle, antral follicle count (AFC), serum concentrations of anti-Mullerian hormone (AMH). Female age is an indepen-dent predictor of ovarian reserve. Although wide variations are seen, female age has the advantage of being indisputable and, particularly when used with a further parameter, is probably the most valuable predictor of ovarian reserve and prognosis for live birth. Day 3 FSH levels vary from cycle to cycle and are unreliable particularly in those <40 years old. The advantage of the antral follicle count is that it is a direct measure of the cohort of follicles available and capable of responding to stimulation. However, good ultrasound equipment is necessary and large intra-observer differences have been noted. The concentration of AMH in serum is a good indicator of the size of the ovarian antral follicle pool and consequently a good predictor of the ovarian response

Chapter 5 Assessment of Ovarian Reserve

52

to stimulation. It is now widely used in counseling patients and determining the protocol for ovarian stimulation.

Keywords Ovarian reserve • Germ cells • Primordial fol-licles • Ovulation • Menopause • Oocyte • Ovarian function • GnRH • Agonist • Antagonist • FSH • Serum estradiol • Antral follicle • Anti-Mullerian hormone • AMH • Gonadotrophins • IVF • Ovarian hyperstimulation

In mid-pregnancy, the ovaries of the female fetus contain approx-imately seven million germ cells. At birth, 1–2 million remain and such is the rate of loss of these primordial follicles that at men-arche 300,000 thousand follicles survive with the potential of providing an ovulatory follicle in the reproductive years to fol-low. Although only 400–500 will actually achieve ovulation, the enormous rate of atresia will leave 10,000–25,000 at the age of 36 years with ovulatory potential. Over this age, the rate of loss accelerates even further up to the age of menopause.

During the reproductive life span, in addition to the enor-mous loss of follicles in the aging process, those that survive are exposed to a number of deleterious environmental fac-tors that influence their reproductive potential. Due to the steady decrease in oocyte numbers and an apparent deterio-ration in their quality in the later years, live birth rates decrease steadily with increasing age but dip alarmingly after the age of 36. In addition, the chances of a live birth over the age of 40 years are severely hindered by a greatly increased miscarriage rate due to the prevalence rate of aneuploidy, directly attributed to the remaining oocytes.

The assessment of ovarian function is important for sev-eral reasons:

It can serve as a guide for the counseling of patients regard-ing the prognosis for pregnancy if used judiciously.

It can help determine the starting dose for ovarian stimula-tion before the first cycle of treatment. It can serve to determine the protocol to be used, e.g. long

GnRH agonist or a GnRH antagonist protocol.

Chapter 5. Assessment of Ovarian Reserve

53

Using a combination of female age and one or more of the examinations described below, women can be grouped into predicted low, normal or high responders and the ovarian stimulation protocol planned accordingly.

In practical terms, the following factors are used today for the assessment of ovarian reserve:

Female age. Serum concentration of FSH together with serum estradiol (E2)

concentrations estimated on day 2–4 of the menstrual cycle. Antral follicle count. Serum concentrations of anti-Mullerian hormone (AMH).

5.1 Female Age

The well documented deterioration in ovarian reserve with increasing female age has established age as an independent predictor of ovarian reserve. Although wide variations are seen, female age has the advantage of being indisputable and unequivocal. An upper limit is set in most countries as a cut-off point for access to treatment. Particularly when used with a further parameter, female age is probably the most valuable predictor of ovarian reserve and prognosis for pregnancy and live birth.

5.2 Day 3 FSH

The longest established biochemical predictor of ovarian reserve is serum FSH concentration. Blood must be sampled on day 2–4 of the menstrual cycle and preferably together with an estimation of serum E2 concentration. Although a reasonable predictor of ovarian response to stimulation, it is less reliable for the prognosis of attaining a pregnancy.

A detectable sign of deteriorating ovarian function is a high concentration of FSH on day 2–4 of the cycle. A level of FSH >15 IU/L is usually a bad prognostic factor for ovarian reserve, especially when associated with high estradiol

5.2 Day 3 FSH

54

concentrations (>75 pg/ml, >200 pmol/l) on the same day. Under the age of 40 years this is a much less reliable sign, especially as regards the prognosis for pregnancy, again emphasizing the importance of age for this assessment. Although still widely used, day 3 FSH estimation has several drawbacks:

Estimations taken on day three of successive cycles often vary considerably.

Blood sampling must be performed between day 2 and 4 of the cycle.

Under the age of 40 years, FSH estimation is much less reli-able as a predictive value.

It is less successful than AMH and the antral follicle count in delineating poor, normal and high responders.

5.3 Antral Follicle Count

Using trans-vaginal ultrasound at the beginning of the cycle, the number of antral follicles with diameters of 2–9 mm can be counted in each ovary. In our unit a grand total of 10–15 is thought of as normal, <5 indicates a poor ovarian reserve and >15 predicts a high responder. The advantage of the antral follicle count is that it is a direct measure of the cohort of fol-licles available and capable of responding to stimulation. However, good ultrasound equipment is a necessity and large intra- observer differences have been noted and must be taken into account. In series comparing antral follicle count and AMH for the estimation of ovarian reserve, there is little to choose between them in terms of predictive value.

5.4 Anti-Mullerian Hormone (AMH)

Anti-Mullerian hormone takes its name from its function in suppressing the development of the female reproductive tract in the male fetus where it is produced by the fetal testes. It is, however, also produced in the ovary where maximal


55

expression occurs in pre-antral and small antral follicles but disappears in maturing pre-ovulatory follicles. The concentra-tion of AMH in serum is, therefore, a good indicator of the size of the ovarian antral follicle pool and consequently a good predictor of the ovarian response to stimulation. It is now widely used in counseling patients and determining the protocol for ovarian stimulation and the starting dose of gonadotrophins before the first cycle of IVF.

The initial use of AMH for the assessment of ovarian reserve was confusing due to the different assays being used but the Beckman-Coulter Gen II assay is now in general use and, following some teething troubles, is now thought to be a good indicator of ovarian reserve. In our unit, an AMH serum concentration of <5 /L indicates a poor responder, 5–20 pmol/L a normal responder, >20 pmol/L a high responder and >40 pmol/L an excessive response. Division into these groups has proved very useful for determining the protocol and starting dose of gonadotrophins to be used, as suggested by [ 1 ], for example, a lower treatment burden in the predicted poor responder, a maximizing approach for the normal responder and a mild stimulation protocol for the high responder can be adopted [ 1 ]. They found the predic-tive value of AMH of an excessive response particularly useful in the avoidance of ovarian hyperstimulation syndrome.

Although highly predictive for the ovarian response, we are still reticent to advise against starting treatment on the strength of a low AMH concentration alone. It should be used in combination with the other factors mentioned, particularly female age, for this purpose. The AMH value is less reliable for predicting the chance of conception as sev-eral ‘surprises’ have been reported in the literature where conception was achieved despite a low AMH. It can be used as a guide for estimating ovarian reserve for women deliber-ating over the timing of attempting a pregnancy, particularly in the older age groups and also for those women considering social egg freezing. The value of AMH in predicting the age of menopause is still under investigation.

5.4 Anti-Mullerian Hormone (AMH)

56

The estimation of AMH for the prediction of ovarian reserve has some advantages over other methods. It can be measured at any time during the menstrual cycle [ 2 ] and clearly delineates groups of predicted response, both of which give it superiority over FSH. As a laboratory estima-tion, it is not dependent on individual interpretation or spe-cialized equipment as for the antral follicle count. Each unit should decide what works best for them as the recent litera-ture shows that there is little to choose between the predic-tive value of AMH and antral follicle count [ 3 ].

5.5 Other Methods

Dynamic tests have also been devised to estimate ovarian reserve including stimulation with clomiphene citrate, a GnRH agonist or directly with FSH (EFORT test), all of which involve the measurement of the increment of FSH and/or estradiol increase following stimulation. These tests are now outdated following the establishment of AMH and antral follicle count in routine practice. It should be added that diminished ovarian reserve can be very simply diagnosed by a poor or absent response to a sufficient dose of gonado-trophin stimulation (in our case 300 IU FSH) while attempt-ing treatment. This we found as a sign which even preceded the FSH rise, was the earliest sign of an impending ovarian failure and which can often be spotted during routine treat-ment for, so-called, unexplained infertility [ 4 ].

References

1. Nelson SM, Yates RW, Lyall H, Jamieson M, Traynor I, Gaudoin M, et al. Anti-Müllerian hormone-based approach to controlled ovarian stimulation for assisted conception. Hum Reprod. 2009;24:867–75.

2. La Marca A, Giulini S, Tirelli A, Bertucci E, Marsella T, Xella S, et al. Anti- Mullerian hormone measurement on any day of the menstrual cycle strongly predicts ovarian response in assisted reproductive technology. Hum Reprod. 2007;22:766–71.


57

3. Broer SL, Mol BW, Hendriks D, Broekmans FJ. The role of anti- Mullerian hormone in prediction of outcome after IVF: compari-son with the antral follicle count. Fertil Steril. 2009;91:705–14.

4. Farhi J, Homburg R, Ferber A, et al. Non-response to ovarian stimulation in normogonadotrophic, normogonadal women: a clinical sign of impending onset of ovarian failure pre-empting the rise in basal follicle-stimulating hormone. Hum Reprod. 1997;12:241–3.

References


Abstract Hypogonadotrophic-hypogonadism (hypothalamic- pituitary failure -WHO Group I), is a situation in which gonadotrophin concentrations are so low as to be com-pletely unable to stimulate follicle development and oestrogen production from the ovaries. Anovulation, amenorrhea and hypo- oestrogenism are the consequences. There are several possible causes for this condition which may be hypothalamic or pituitary. Hypothalamic causes include: Weight-related amenorrhea, stress, strenuous exercise, Kallmann’s syndrome, craniopharyngioma, debilitating systemic diseases, idiopathic. Pituitary causes: Hypophysectomy, radiotherapy, Sheehan’s syndrome. If infertility is not a concern, every patient with hypogonadotrophic- hypogonadism over the age of menarche should be treated with hormone replacement therapy with cyclical oestrogen and progestins. For those desiring a preg-nancy, if the pituitary is intact and the hypothalamus is failing to function, ‘replacement therapy’ with pulsatile GnRH is highly effective, if a little cumbersome. Direct stimulation of the ovaries with gonadotrophins serves the purpose for ovula-tion induction whether the cause is of hypothalamic or pitu-itary origin. If the cause of the amenorrhea is an extreme low body weight, every attempt should be made to increase weight before starting treatment.

Chapter 6 Management of Hypogonadotrophic- Hypogonadism

60

Keywords Hypogonadotrophic-hypogonadism • Gonado-trophin • Hypothalamic-pituitary failure • Oestrogen • Anovulation • Amenorrhea • Hypo-oestrogenism • Hypothalamic • Anorexia nervosa • Stress • Strenuous exer-cise • Kallmann’s syndrome • Craniopharyngioma debilitating systemic diseases • Idiopathic • Pituitary • Hypophysectomy • Radiotherapy • Sheehan’s syndrome • Haemorrhage • Progestins • Osteoporosis • GnRH • Gonadotrophin-Releasing Hormone • Neuro-hormone • Hypothalamus • FSH • LH • Gonadotrophins • Luteal phase • OHSS • Monofolliculicular ovulation • hCG • Granulosa cells

Hypogonadotrophic-hypogonadism (hypothalamic-pituitary failure -WHO Group I), is a situation in which gonadotrophin concentrations are so low as to be completely unable to stimu-late follicle development and oestrogen production from the ovaries. Anovulation, amenorrhea and hypo-oestrogenism are the consequences. There are several possible causes for this condition.

Hypothalamic Causes

Weight-related amenorrhea – loss of weight due to a crash diet or frank anorexia nervosa.

Stress. Strenuous exercise – e.g. marathon running, ballet

dancers. Kallmann’s syndrome – hypothalamic amenorrhea associ-

ated with anosmia. Other causes include craniopharyngioma, debilitating sys-

temic diseases, idiopathic.

Pituitary Causes

Hypophysectomy. Radiotherapy for pituitary tumours. Following severe post-partum haemorrhage (Sheehan’s

syndrome).

Chapter 6. Hypogonadotrophic-Hypogonadism

61

If infertility is not a concern, every patient with hypogonadotrophic- hypogonadism over the age of menarche should be treated with hormone replacement therapy with cyclical oestrogen and progestins. This serves the dual pur-pose of prevention of the consequences of oestrogen defi-ciency (e.g. osteoporosis and possibly cardio-vascular disease) and the preservation of uterine function with regard to future conception.

For those desiring a pregnancy, if the pituitary is intact and the hypothalamus is failing to function, ‘replacement therapy’ with pulsatile GnRH is highly effective. Direct stimulation of the ovaries with gonadotrophins also serves the purpose for ovulation induction whether the cause is of hypothalamic or pituitary origin.

If the cause of the amenorrhea is an extreme low body weight, every attempt should be made to increase weight before starting treatment. This will not only ease the treat-ment burden but is also very important for the successful outcome of an ensuing pregnancy.

6.1 Pulsatile Gonadotrophin-Releasing Hormone Therapy

Gonadotrophin-releasing hormone (GnRH) is a decapep-tide, made up of ten amino acids. It is a neuro-hormone syn-thesized by nerve endings in the anterior hypothalamus which courses the very short journey (about 1 cm) from the anterior hypothalamus to the anterior pituitary in the portal vessels. There it releases FSH and LH.

Because of its very short half-life and the inability to mea-sure its concentrations in the human peripheral circulation, the knowledge of the physiological action of gonadotrophin- releasing hormone has been learnt from charting the release of the gondotrophins, principally LH. It soon became appar-ent that GnRH is released in a pulsatile fashion and that the frequency and amplitude of the pulses can be changed by the

6.1 Pulsatile Gonadotrophin-Releasing Hormone

62

influence of various factors on the hypothalamic pulse gen-erator. In the follicular phase of a normal ovulatory cycle, pulses of LH, reflecting pulses of GnRH, are apparent about once an hour whereas in the luteal phase these are seen every 4 h. Pulses of FSH release are harder to detect as they are smaller and more infrequent. What has become apparent is that GnRH is a single hormone capable of releasing both LH and FSH from the pituitary gonadotrophs. The amount and timing of release of these hormones is critical for obtaining a normal ovulatory cycle and these are dependent not only on the amount, timing and pattern of pulsatile release of GnRH itself but also on the endocrine milieu of the anterior pituitary.

Once it was synthesized and made available for therapy, it became apparent that continuous infusion did not produce the desired release of gonadotrophins but, paradoxically, down- regulated their receptors and suppressed their release. When an agonist of GnRH was developed this had the same effect. This discovery proved to be extremely important and revolutionized reproductive physiology and eventually treat-ment. It also became apparent that pure, native GnRH, administered in a pulsatile fashion, could be utilized as excel-lent replacement therapy for hypothalamic-pituitary failure when the pituitary was intact.

When the cause of anovulation is hypothalamic failure, the classical replacement therapy is with pulsatile GnRH. This is administered through an infusion pump, very similar to an insulin pump apparatus, either subcutaneously or intrave-nously. The pump is set to give a bolus of 15–20 μg subcutane-ously or 5–10 μg intravenously every 60–90 min. Some prefer the subcutaneous route as very occasional thrombophlebitis has been experienced at the site of the indwelling needle. With either mode of delivery, this is extremely effective treat-ment for the induction of ovulation for women who have idiopathic hypothalamic hypogonadotrophic-hypogonadism, Kallmann’s syndrome or weight-related amenorrhea, yield-ing pregnancy rates well in excess of 80 % [ 1 ]. Following ovulation, the pump must be either continued into the luteal


63

phase or discontinued and luteal phase support given, until either pregnancy is established or menstruation ensues.

The advantages of this form of treatment are that almost no monitoring is required, OHSS does not occur and the very high rate of monofolliculicular ovulation ensures a multiple pregnancy rate of <5 %. Multiple pregnancies with this treat-ment are rare but most often occur in the first cycle of treat-ment or when hCG has been given to trigger ovulation [ 2 ]. The main disadvantages are the inconvenience of wearing the pump and accoutrements and consequently, limited patient acceptability as well as relatively high cost.

For women with hypothalamic-pituitary failure who have an intact pituitary gland, there is little doubt that results and safety dictate that I would prefer to treat their anovulation and infertility with pulsatile GnRH rather than exogenous gonadotrophin therapy. If this cumbersome treatment is accepted by the patient, the chances of obtaining a normal, singleton livebirth by treatment almost completely devoid of complications are extremely high. This form of treatment has, however, become almost extinct and treatment by direct stimulation of the ovaries with gonadotrophins has largely replaced it.

6.2 Gonadotrophin Therapy

Direct stimulation of the ovaries with gonadotrophins has the advantage in this condition that it is effective regardless of whether the cause of the hypogonadotrophic-hypogonadism is of hypothalamic or pituitary origin.

The gonadotrophin preparation used for the induction of ovulation in this condition must contain either LH or hCG to induce LH activity, in addition to FSH [ 3 ]. The use of FSH alone may well produce follicular development but no oes-trogen production will ensue and this severely limits the chances of a successful ovulation and does not allow the development of a receptive endometrium. The ‘two gonado-trophin, two cell hypothesis’ dictates that LH activity is


64

needed to produce androgens from theca cells which serve as the substrate for oestrogen production (see Chap. 2 ). As women with hypogadotrophic- hypogonadism do not dis-charge LH, no androgen substrate is available and hence, no oestrogen production is possible.

The ovaries of women with hypogonadotrophic- hypogonadism lack exposure to endogenous gonadotrophins and this probably limits the number of FSH receptors present in granulosa cells. This is the reason why the response to exogenous gonadotrophin therapy may often be slow, insinu-ating that a period of priming is involved during the first treatment cycle. Patience and a titration of the appropriate gonadotrophin dose is therefore required for optimal ovula-tion induction.

Due to the lack of endogenous LH activity in these women, a dose of 10,000 units of urinary hCG (500 mcg of recombinant hCG) should be used for ovulation triggering and this should be backed up with vaginal micronized proges-terone suppositories to support the luteal phase.

In summary, ovulation induction for the treatment of infertility due to hypogonadotrophic-hypogonadism has an excellent prognosis and pregnancy rates in excess of 80 % may be expected.

References

1. Homburg R, Eshel A, Armar NA, et al. One hundred pregnancies after treatment with pulsatile luteinising hormone releasing hor-mone to induce ovulation. Br Med J. 1989;298:809–12.

2. Braat DD, Schoemaker R, Schoemaker J. Life table analysis of fecundity of intravenously gonadotrophin-releasing hormone treated patients with normogonadotropic and hypogonadotropic amenorrhea. Fertil Steril. 1991;55:266–71.

3. The European Recombinant Human LH Study Group. Recombinant human luteinizing hormone (LH) to support human follicle- stimulating hormone (FSH)-induced follicular development in LH and FSH defi cient anovulatory women: a dose-fi nding study. J Clin Endocrinol Metab. 1998;83:1507–14.


http://dx.doi.org/10.1007/978-3-319-05612-8_2


Abstract Polycystic ovary syndrome (PCOS) is the most common female endocrinopathy affecting 5–10 % of women in their reproductive years and is associated with 75 % of all anovulatory disorders causing infertility. It is best diagnosed using the Rotterdam criteria in which any two of the fol-lowing three are sufficient to confirm the diagnosis: Oligo/anovulation, hyperandrogenism (biochemical or clinical), polycystic ovaries on ultrasound examination. The man-agement of PCOS depends on the presenting symptoms. Whether these are hirsutism or acne, oligo/amenorrhoea, or anovulatory infertility, the first-line treatment for the over-weight or frankly obese must be loss of weight. For infertile anovulatory patients, clomiphene citrate is the first-line medication of choice but letrozole is challenging for this position. Metformin is much less successful than clomifene for this purpose. Low-dose FSH therapy is the second-line of treatment but laparoscopic ovarian drilling is also successful particularly for normal weight women with high LH levels. Most women whose cause of infertility is purely anovulatory PCOS will successfully conceive with one of these treat-ments but for those who have failed (and probably have an additional factor) IVF is a relatively successful ‘last resort’ treatment.

Keywords Polycystic ovary syndrome PCOS • Endocrinopathy • Anovulatory • Infertility • Anovulation •

Chapter 7 Understanding the Problems of Treating PCOS

66

Hyperandrogenism • LH • FSH • Anti-Mullerian hor-mone • AMH • Antral follicles • Ovarian androgen • Hyperinsulinaemia • Obesity • Anti-oestrogens • Clomifene • Letrozole • Ovulation • Oestrogen • Metformin • Insulin sensi-tisers • Hypoglycaemia • Euglycaemia • Gonadotrophin ther-apy • Ovarian hyperstimulation syndrome • OHSS • Human menopausal gonadotrophin • hMG • Laparoscopic ovarian drilling • In-vitro fertilization • IVF • Hyperandrogenic

Polycystic ovary syndrome (PCOS) is the most common female endocrinopathy affecting 5–10 % of women in their reproductive years and is associated with 75 % of all anovula-tory disorders causing infertility. Polycystic ovaries can be found in 20 % of the female population but are not necessar-ily associated with the typical symptoms.

In 1935 Stein and Leventhal first described the polycystic ovary as a frequent cause of irregular ovulation or anovula-tion in obese women seeking treatment for subfertility. The initial management of the condition was surgical, with wedge resection of the ovaries resulting in restoration of ovulation in the majority of cases. In the last two decades, the polycystic ovary syndrome (PCOS) has been studied intensely and, although the exact aetiology still escapes us, considerable knowledge of the prevalence, pathophysiology and manage-ment of the syndrome has been gained.

7.1 Definition

The ESHRE/ASRM Rotterdam Consensus Meeting (2003) [ 1 ] proposed the following definition of PCOS which has been widely adopted.

Any two of the three are sufficient to confirm the diagnosis:

– Oligo- or anovulation. – Hyperandrogenism (biochemical or clinical). – Polycystic ovaries on ultrasound examination.

Chapter 7. Understanding the Problems of Treating PCOS

67

Syndromes with similar presenting features, e.g. congenital adrenal hyperplasia, androgen-secreting tumours or Cushing’s, should be excluded.

– Oligo- or anovulation Ovulation occurs at a frequency of less than once in 35 days.

– Hyperandrogenism Clinical signs of hyperandrogenism include hirsutism, acne, alopecia (male-pattern balding) and frank viriliza-tion. Biochemical indicators include raised concentra-tions of total testosterone and androstendione, and elevated free androgen index.

– Polycystic ovaries The presence of ≥12 follicles in either ovary measuring 2–9 mm in diameter and/or increased ovarian volume (>10 mL).

In practice, the diagnosis of PCOS can be made in almost every case without blood sampling. Although not essential for initial diagnosis or therapeutic decisions, for screening a blood sample for LH, total testosterone, FSH, fasting glucose and fasting insulin may be taken. Although rarely necessary to establish the clinical diagnosis, a serum concentration of anti-Mullerian hormone (AMH) >40 pmol/L will invariably be confirmatory. An oral glucose tolerance test is recom-mended for the obese, especially for the obese adolescent.

When suggested by the history of a rapid progress of hyperandrogenic symptoms, total testosterone concentration screens for androgen-producing tumours. For 21-hydroxylase deficiency, serum 17-hydroxy-progesterone concentration is an excellent screening test. If suspected, Cushing’s syndrome can be detected using a 24 h urinary cortisol or overnight dexamethasone suppression test.

7.2 Pathophysiology

In order to better understand the principles of management of PCOS, a very brief summary of some of the pathophysio-logical aspects is presented here.

7.2 Pathophysiology

68

PCOS is a very heterogeneous syndrome as regards both clinical presentation and laboratory manifestations. While the basic dysfunction seems to lie within the ovary, the clinical expression and severity of the symptoms are dependent on extra-ovarian factors such as obesity, insulin resistance and LH concentrations.

There are four main disturbances which may be involved in the pathophysiology of the syndrome:

– Abnormal ovarian morphology: 6–8 times more pre-antral and small antral follicles are present in the poly-cystic ovary compared with the normal ovary. They arrest in development at a size of 2–9 mm, have a slow rate of atresia and are sensitive to exogenous FSH stimulation. The greater the number of small follicles, (also reflected by serum AMH concentrations), the more severe the symptoms [ 2 ]. An enlarged stromal volume is invariably present and a total ovarian volume >10 mL is often witnessed.

– Excessive ovarian androgen production lies at the heart of the syndrome. Almost every enzymatic action within the polycystic ovary which encourages androgen pro-duction is accelerated. Both insulin and LH, alone and in combination, exacerbate androgen production.

– Hyperinsulinaemia due to insulin resistance occurs in 80 % of women with PCOS and central obesity, but also in 30–40 % of lean women with PCOS. This is thought to be due to a post-receptor defect affecting glucose transport and is unique to women with PCOS. Insulin resistance, significantly exacerbated by obesity, is a key factor in the pathogenesis of anovulation and hyperan-drogenism. An abnormality of pancreatic B-cell func-tion has also been described.

– Excessive serum concentrations of LH are detected on single spot blood samples in 40–50 % of women with PCOS. High LH concentrations are more commonly found in lean rather than obese women. Although FSH serum concentrations are often within the low normal range, an intrinsic inhibition of FSH action may be pres-ent. Prolactin concentrations may be slightly elevated.


69

7.3 Management

The management of PCOS depends on the presenting symp-toms. Whether these are symptoms of hyperandrogenism such as hirsutism and acne, oligo- or amenorrhoea, or anovulatory infertility, the first-line treatment for the overweight or frankly obese must be loss of weight. Here I will concentrate on the management of anovulatory infertility associated with PCOS.

7.3.1 Weight Loss

Obesity is a common feature in the majority of women with PCOS. Increased truncal–abdominal fat in women with PCOS exacerbates insulin resistance and hyperandrogenism, and, consequently, the severity of the symptoms. Fortunately, the reverse is also true in that diet and exercise (‘lifestyle changes’) are effective treatment. The loss of just 5 % or more of body weight is capable of considerably reducing not only the severity of hirsutism and acne but crucially restoring menstrual regularity and ovulation. A motivation-inducing explanation of these facts should be given at the first consul-tation and referral to a clinic dedicated to life-style changes is highly desirable.

7.4 Anti-oestrogens

Clomifene citrate has been the first-line medication for the induction of ovulation for the last 50 years. By blocking hypothalamic and pituitary oestrogen receptors, it induces a discharge of FSH which is frequently enough to restore ovu-lation. Given in a dose of 50–150 mg/day from day four to eight of a spontaneous or progestin-induced menstruation, clomifene will restore ovulation in 75 % and induce preg-nancy in 35–40 %. Failure to induce ovulation is more com-mon in the very obese and those with very high serum androgen, insulin or LH concentrations. Failure to respond

7.4 Anti-oestrogens

70

to 150 mg/day, an endometrial thickness of <7 mm at mid-cycle or failure to conceive following six ovulatory cycles require a change of treatment mode (For a detailed account, see Chap. 8 ).

Letrozole, a potent aromatase inhibitor, is proving to be as effective, if not more effective than clomifene for the induc-tion of ovulation [ 3 ]. By blocking the conversion of androgens to oestrogen, it also induces a discharge of FSH through the negative feedback mechanism and so is capable of restoring ovulation when given at the beginning of the cycle in a dose of 2.5–5 mg/day for 5 days [ 4 ]. Letrozole would probably have replaced clomifene were it not for an unfounded suspicion of an increased rate of congenital malformations, later refuted by a number of subsequent series. Unfortunately, the initial suspicion prompted the drug company to contra-indicate its use for ovulation induction and so it is unavailable for this indication in most countries (For further details, see Chap. 8 ).

7.5 Insulin Sensitisers

Metformin, a well-established oral anti-diabetic agent, is capable of increasing ovulatory frequency in women with PCOS, apparently by decreasing insulin and androgen con-centrations, in a dose of 1,500–2,500 mg/day. Its efficacy does not seem to depend on the presence of demonstrable insulin resistance, there is no evidence of teratogenicity and it does not induce hypoglycaemia in women with euglycaemia. Although clomifene is much more efficient and quicker in inducing ovulation and pregnancy as first-line treatment as a mono-agent [ 5 ], metformin in combination with clomifene or added to clomifene for women who have proved clomifene resistant may be a worthwhile strategy before having to pro-ceed to the more expensive gonadotrophin treatment (For further details, see Chap. 10 ).


http://dx.doi.org/10.1007/978-3-319-05612-8_8

http://dx.doi.org/10.1007/978-3-319-05612-8_8

http://dx.doi.org/10.1007/978-3-319-05612-8_10

71


Low-dose gonadotrophin therapy—designed to induce ovulation and conception while minimizing the complica-tions due to multifollicular development, ovarian hyper-stimulation syndrome (OHSS) and multiple pregnancies. Using a starting dose of 50–75 IU/day of FSH or human menopausal gonadotrophin (hMG) without a change of dose for the first 7–14 days and only small incremental dose rises of 25–37.5 IU for a minimum of 7 days where necessary, pregnancy rates of >20 % per cycle may be expected while OHSS is almost completely eliminated and multiple pregnancy rates are <6 %. Full details can be found in Chap. 9 .

7.7 Laparoscopic Ovarian Drilling

Laparoscopic ovarian drilling (LOD) using cautery or laser has proved effective in restoring ovulation and inducing pregnancy, particularly in women of normal weight and with high concentrations of LH. Multiple pregnancy rate is low. Some units employ LOD when clomifene resistance is appar-ent; most others following failure of gonadotrophin therapy (See Chap. 11 ).

7.8 In-Vitro Fertilization (IVF)

IVF can be successfully employed for anovulatory women with PCOS when a further infertility-causing factor is involved or when the above methods of ovulation induction have been unsuccessful (See Chap. 18 ).

A suggested algorithm for the induction of ovulation for women with PCOS is shown in Fig. 8.2 .

7.8 In-Vitro Fertilization (IVF)

http://dx.doi.org/10.1007/978-3-319-05612-8_9

http://dx.doi.org/10.1007/978-3-319-05612-8_11

http://dx.doi.org/10.1007/978-3-319-05612-8_18

http://dx.doi.org/10.1007/978-3-319-05612-8_8

72

7.8.1 Long-Term Health Implications of PCOS

Women with PCOS who are obese, hyperinsulinaemic and hyperandrogenic are at substantial risk for the development of metabolic syndrome (syndrome X). If they remain untreated, the risk of developing diabetes mellitus is seven times greater and hypertension four times greater than in the general population. Both these conditions, and the inevitable dyslipidaemia are all predisposing factors for cardio-vascular disease and demand attention, the earlier the better.

References

1. Fauser B, Tarlatzis B, Chang J, Azziz R, et al. The Rotterdam ESHRE/ASRM-sponsored PCOS consensus workshop group. Revised 2003 consensus on diagnostic criteria and long-term health risks related to polycystic ovary syndrome (PCOS). Hum Reprod. 2004;19:41–7.

2. Homburg R, Ray A, Bhide P, Gudi A, Shah A, Timms P, Grayson K. The relationship of serum anti-Mullerian hormone with poly-cystic ovarian morphology and polycystic ovary syndrome: a pro-spective cohort study. Hum Reprod. 2013;28:1077–83.

3. Legro R, NIH/NICHD Reproductive Network. Effect of letro-zole versus clomiphene on live birth in women with anovulatory infertility due to PCOS: a randomized double-blind multicenter trial. Fertil Steril. 2013;100(3 Suppl):S51, O-167.

4. Mitwally MF, Casper RF. Aromatase inhibitors for the treatment of inferftility. Expert Opin Investig Drugs. 2003;12:353–71.

5. Legro RS, Barnhart HX, Schlaff WD, et al. Clomiphene, metfor-min, or both for infertility in the polycystic ovary syndrome. N Engl J Med. 2007;356:551–66.



Abstract For the past 60 years clomifene citrate (CC) has been the first line treatment for those with absent or irregular ovulation but who have normal basal levels of endogenous oestradiol (almost all of whom have PCOS). The action of CC is by blocking hypothalamic oestrogen receptors, signaling a lack of circulating oestrogen to the hypothalamus and induc-ing a change in the pattern of pulsatile release of gonado-trophin releasing hormone (GnRH) and consequently a discharge of FSH. Although CC will restore ovulation in approximately 80 % of patients it will result in pregnancy in only about 35–40 % and 20–25 % will not respond at all and are considered to be ‘clomiphene resistant’. Aromatase inhibitors are non-steroidal compounds that suppress oestro-gen biosynthesis by blocking the action of the enzyme aroma-tase which converts androstendione to oestrogens. Letrozole, the most widely used aromatase inhibitor, is given orally in a dose of 2.5–5 mg/day and is almost free of side effects. In an RCT, 750 women with anovulatory PCOS were randomized to receive either clomifene or letrozole. A 44 % increase in pregnancy rate was achieved by letrozole over clomifene (27.5 % vs 19.5 %). Twinning rate was non-significantly higher in those who received clomifene (7.4 % vs 3.2 %) with no significant difference in the rate of congenital abnormali-ties. The conclusion would seem to be that letrozole can be regarded as a serious competitor to CC for first-line therapy for induction of ovulation.

Chapter 8 Anti-oestrogens

74

Keywords Anti-oestrogens • Clomifene citrate • Oestradiol • Hypothalamic-pituitary dysfunction • PCOS • FSH • Ovulation • Oestrogen • Gonadotrophin releasing hor-mone • GnRH • Follicular recruitment • Follicular growth • Anovulatory • LH • Clomiphene • Human chorionic gonado-trophin • hCG • Intra- uterine insemination • IUI • Ovarian hyperstimulation syndrome • Pregnancy • Endometrium • Endometrial thickness • Ovulation induction • Ultrasound • Cervical mucus • Dexamethazone • Dehydroepiandrosterone sulphate • Metformin • Androgen • Testosterone • Theca cells • Aromatase inhibitors • Letrozole • Monofollicular ovulation

8.1 Clomifene Citrate

For the past 50 years clomifene citrate (CC) has been the first line of treatment for those with absent or irregular ovulation but who have normal basal levels of endogenous oestradiol (hypothalamic- pituitary dysfunction – WHO Group II). The underlying cause of this type of ovulatory dysfunction is PCOS in a large majority of cases.

8.1.1 Mode of Action

Clomifene citrate is capable of inducing a discharge of FSH from the anterior pituitary and this is often enough to reset the cycle of events leading to ovulation into motion. The release of even small amounts of FSH into the system will often induce ovulation and pregnancy in a large proportion of eu-oestrogenic anovulatory women. This is achieved indi-rectly, through the action of CC, a non-steroidal compound closely resembling an oestrogen, in blocking hypothalamic oestrogen receptors, signaling a lack of circulating oestrogen to the hypothalamus and inducing a change in the pattern of pulsatile release of gonadotrophin releasing hormone (GnRH).

Chapter 8. Anti-oestrogens

75

8.1.2 Dose

Clomifene citrate is given orally in a dose of 50–250 mg per day for 5 days from day 2, 3, 4 or 5 of spontaneous or induced bleeding starting with the lowest dose and raising the dose in increments of 50 mg/day per cycle until an ovulatory cycle is achieved. The starting day of treatment, whether on day 2 or through day 5 of the cycle does not influence results [ 1 ]. Although 50 mg/day is the recommended dose in the first cycle, less than 50 % will respond to this dose so some practi-tioners often use a starting dose of 100 mg per day from day 4 or 5, only resorting to 50 mg/day in the case of exquisite sensitivity or persistent cyst formation. There is no apparent advantage of using a daily dose of more than 150 mg which seems neither to significantly increase the ovulation rate nor follicular recruitment [ 2 ]. The advantage of the ‘cutting cor-ners’ regimen of starting with a 100 mg daily dose rather than 50 mg, is that it will cut down the number of ‘superfluous’ cycles of treatment until ovulation is achieved and until those resistant to clomifene are identified. A course of six ovulatory cycles is usually sufficient to know whether pregnancy will be achieved using CC before moving on to more complex treat-ment as approximately 75 % of the pregnancies achieved with CC occur within the first three cycles of treatment [ 3 ]. From our own (unpublished) database, we noted that no fur-ther pregnancies at all were obtained with CC following seven ovulatory cycles.

8.1.3 Results

Although CC will restore ovulation in approximately 80 % of patients it will result in pregnancy in only about 35–40 % and 20–25 % of anovulatory women with normal FSH concentra-tions will not respond at all and are considered to be ‘clomi-phene resistant’ [ 4 ]. Inability of CC to induce ovulation is more likely in patients who are obese, insulin resistant and hyperandrogenic compared to those who do respond [ 4 ].


76

Women with high basal LH levels are also less likely to respond to clomiphene treatment [ 5 ].

As CC blocks the negative feedback mechanism which the eventually rising oestradiol levels would normally invoke, multiple follicle development is relatively common. The risk of multiple gestation is therefore increased and is estimated at about 8–10 % [ 6 ]. The vast majority of these are twin preg-nancies but the risk may be reduced considerably by ultra-sound monitoring and withholding hCG, IUI or intercourse if more than two follicles >14 mm diameter are seen.

The prevalence of congenital abnormalities [ 7 ] and spon-taneous abortion [ 8 ] following CC treatment are no different to those seen in spontaneously conceived pregnancies. While mild ovarian enlargement is relatively common, in almost 50 years of practice, I have never seen a full blown ovarian hyperstimulation syndrome as a result of CC treatment.

It is frustrating that the restoration of ovulation does not produce more than a 40 % pregnancy rate. This discrepancy between ovulation and pregnancy rates in patients treated with CC may be partly explained by the peripheral anti-oes-trogenic effects of CC at the level of the endometrium and cervical mucus. While the depression of the cervical mucus, occurring in about 15 % of patients, may be overcome by performing intrauterine insemination (IUI), suppression of endometrial proliferation, unrelated to dose or duration of treatment but apparently idiosyncratic, indicates a poor prog-nosis for conception if the endometrial thickness on ultra-sound scanning does not reach a thickness of 8 mm at ovulation. If endometrial suppression is noted in the first cycle of treatment with CC, it will almost certainly be seen in repeated cycles in the same woman. There is little point in persisting after even one cycle and a step-up to other forms of ovulation induction is recommended.

8.1.4 Monitoring

Monitoring of the clomifene treated cycle by ultrasound evaluation of follicular growth and endometrial thickness on day 12–14 of the cycle is justified by the identification of


77

those who are not responding or have depressed endometrial thickness and is helpful in the timing of natural intercourse or IUI. We found that ultrasound monitoring of CC cycles yielded a cumulative conception rate of 48 % compared with 35 % for those who had unmonitored cycles. Confirmation, or otherwise, of ovulation can be obtained with estimation of the progesterone concentration in the supposed mid-luteal phase. A basal body temperature chart may also be helpful for monitoring but, although cheaper than other methods, is less reliable and may be bothersome for the patients. The added expense of careful monitoring is neutralized by the prevention of protracted periods of possibly ineffective therapy and delay in the inception of more efficient treatment.

8.1.5 Possible Adjuvants to Clomifene Treatment

In order to improve the outcome of treatment with CC, sev-eral adjuvants to clomifene treatment have been suggested. A correctly timed ovulation triggering dose of human chori-onic gonadotrophin (hCG, 5,000–10,000 IU) is only theoreti-cally warranted when the reason for a non-ovulatory response is that the LH surge is delayed or absent despite the presence of a well developed follicle. Although the routine addition of hCG at mid- cycle seems to add little to the improvement of conception rates [ 9 ] we have found it very useful, given when an ultrasonically demonstrated leading follicle attains a diameter of 19–24 mm, for the timing of intercourse or IUI.

The addition of dexamethazone as an adjunct to clomifene therapy in a dose of 0.5 mg at bedtime, is said to suppress adrenal androgen secretion and induce responsiveness to CC in previous non-responders, mostly hyperandrogenic women with PCOS and elevated concentrations of dehydroepian-drosterone sulphate (DHEAS) [ 10 ]. However, glucocorticoid steroid therapy often induces side effects including increased appetite and weight gain and should probably be reserved for women who have congenital adrenal hyperplasia as a cause for their anovulation.


78

The main action of CC, indirectly stimulating GnRH secretion, not only increases the desired FSH release but also an undesirable increase in LH concentrations. This increase in LH, whose basal level is often already high in women with PCOS, may compromise pregnancy rates in those receiving CC. We have demonstrated that pre-treatment with micronised progesterone is capable of modulating LH pulsa-tility, reducing LH concentrations and inducing a more favourable environment for ovulation induction with CC [ 11 ]. This treatment improved response to CC and yielded consequent pregnancy rates.

Theoretically, metformin seemed to be a promising adju-vant to treatment with CC. The majority of patients who receive CC for anovulatory infertility have PCOS and the majority of these have some degree of insulin resistance. Metformin is said to increase insulin sensitivity and a conse-quent insulin lowering effect, producing a decrease in tes-tosterone and LH, increase in SHBG and a direct androgen lowering effect on the theca cells. However, the theoretical advantages of a combination treatment of CC and metfor-min have not been realised in practice. Two large ran-domised studies showed no significant advantage of the combination treatment compared with clomifene alone [ 12 , 13 ]. Subsequent large meta-analyses also failed to demon-strate a significant advantage of adjuvant treatment with metformin [ 14 , 15 ]. Although the results have been disap-pointing in treatment naive subjects, the addition of metfor-min to CC may have a place in the treatment of CC resistant women. In an interesting RCT, CC-resistant women with PCOS received either metformin for 6 months and then CC, or hMG alone for ovulation induction [ 16 ]. In this small study, as metformin + CC was equally as effective as hMG, less expensive and more convenient, it was suggested as an intermediary step for CC resistant patients, worth trying before resorting to hMG.

A flow chart suggesting possible algorithms for treatment with CC is illustrated in Fig. 8.1 .


79

8.1.6 Unexplained Infertilty

Clomifene has also been employed for ovarian stimulation in ovulating women, mainly for idiopathic (unexplained) infer-tility and often combined with IUI. The rationale is presum-ably that CC may overcome a subtle defect in ovulatory function and may increase the number of mature follicles so increasing the likelihood of pregnancy [ 17 ]. Here the success rate has been, understandably, notably less than in anovula-tory women. In a collection of data on the efficacy of treat-ment for unexplained infertility [ 17 ] the use of CC alone produced disappointing pregnancy rates of 5.6 % per cycle and CC combined with IUI 8.3 % per cycle. While this is sig-nificantly superior to timed intercourse alone, it should be remembered that the baseline level from merely expectant

Clomiphene citrate50–150mg/day for

5 daysPregnancy

Pregnancy

Pregnancy

Ovulationx 4–6

No ovulationon 150mg/day

Ovulation butdepressed endometrium

or cervical mucous

+/– Metformin

No pregnancy

Next level of treatment

Figure 8.1 A flow chart suggesting possible algorithms for the treatment of anovulation with clomiphene citrate


80

treatment in these cases ranges from 1.3 to 4.1 %. Treatment with CC for unexplained infertility cannot be recommended.

As most of the cases for which CC is used for the first line treatment of anovulation associated with PCOS, a suggested stepwise treatment for this cause of infertility is suggested in Fig. 8.2 .

8.2 Aromatase Inhibitors

Aromatase inhibitors are non-steroidal compounds that sup-press oestrogen biosynthesis by blocking the action of the enzyme aromatase which converts androstendione to oestro-gens. Letrozole, the most widely used aromatase inhibitor,

Oligo/anovulation +PCOS

Clomifenex4–6 ovulatory

cycles or no response

Clomiphene failure

+ metformin

Low-dose FSHx4–6 ovulatory cycles

IVF/ET

Pregnancy

Pregnancy

PregnancyLaparoscopicovarian drilling(± CC or FSH)

Weight loss± metformin

Figure 8.2 Suggested stepwise treatment scheme for infertility associated with PCOS. Details of low-dose FSH and laparoscopic ovarian drilling are given in Chaps. 9 and 11 respectively


http://dx.doi.org/10.1007/978-3-319-05612-8_9

http://dx.doi.org/10.1007/978-3-319-05612-8_11

81

has mainly been employed for the treatment of postmeno-pausal women with advanced breast cancer. It is given orally in a dose of 2.5–5 mg/day and is almost free of side effects.

8.2.1 Mode of Action

It was first hypothesized by Casper and Mitwally [ 18 ], that the efficient oestrogen lowering properties of the aromatase inhibitors could be utilised to temporarily release the hypo-thalamus from the negative feedback effect of oestrogen. This would allow an increased discharge of gonadotrophins, particularly FSH, from the pituitary. Although the final path-way, the sought after discharge of FSH, is common to both aromatase inhibitors and clomifene citrate (CC), their mech-anism of action is obviously very different and this would seem to confer several advantages to aromatase inhibitors for the induction of ovulation.

8.2.2 Possible Advantages of Letrozole

Whereas the main mode of action of CC is an oestrogen receptor blockade and depletion, aromatase inhibitors have no direct effect on these receptors. Aromatase inhibitors should, therefore, not have any deleterious effect on cervical mucus or endometrium, quite frequently a side effect of CC which interferes with the attainment of a pregnancy during ovulation induction therapy. This action of CC, although ben-eficial at the hypothalamic level, is probably the main reason for the gap between ovulation and pregnancy rates. This can theoretically be avoided when aromatase inhibitors are used for the same purpose.

A further hypothetical advantage of aromatase inhibitors is the fact that when oestrogen production is advanced by the FSH discharge, in contrast with the use of CC, the hypothala-mus is able to respond to the oestrogen feedback with a nega-tive feedback mechanism. This will modulate an overzealous discharge of FSH which in turn is more likely to result in a


82

monofollicular ovulation with moderate oestrogen concen-trations. This is all the more poignant as aromatase inhibitors have a much shorter half-life (about 2 days) than CC. The prevalence of multiple pregnancies could therefore be expected to be less than that witnessed with the use of CC for ovulation induction.

8.2.3 Results

Following the groundwork to examine the use of the aroma-tase inhibitor letrozole in reproductive medicine coming from the team of Casper, solid evidence-based data has now been produced to confirm these hypothetical advantages [ 19 – 21 ]. In a series of over 1,100 women who received 2.5–10 mg/day of letrozole, 368 pregnancies were achieved. Only two of these (0.5 %) were twin pregnancies and, very notably, only one (0.2 %) had a fetal anomaly [ 20 ]. A massive ran-domised trial conducted by Legro et al. [ 21 ] should close the discussion regarding the superiority of letrozole over clomi-fene. This RCT comprised 750 women with anovulatory PCOS who were randomized to receive either clomifene or letrozole. A 44 % increase in pregnancy rate was achieved by letrozole over clomifene (27.5 % vs 19.5 %). Twinning rate was non-significantly higher in those who received clomifene (7.4 % vs 3.2 %) with no significant difference in the rate of congenital abnormalities.

The conclusion would seem to be that letrozole can be regarded as a possible replacement for CC for the first line treatment of anovulatory infertility.

8.2.4 Use of Letrozole in Controlled Ovarian Hyperstimulation

The use of aromatase inhibitors should theoretically result in an accumulation of androgens whose conversion to oestro-gens is being blocked. This would, again theoretically, be an


83

unwanted bi-product, especially for women with PCOS who already have an excessive production of androgens. However, paradoxically, this may be a further advantage as androgens may have a stimulatory role in early follicular growth by aug-menting follicular FSH receptor expression and therefore amplifying FSH effects [ 22 ]. This may explain the relative success of combined letrozole and FSH for ovarian stimula-tion in improving the response to FSH, reported in two stud-ies. The first [ 23 ], is a report in which a group of poor responders to FSH for IUI were given cotreatment with letrozole, 2.5 mg/day from day 3–7 of the cycle. A lower FSH dose and a significantly higher number of mature follicles was achieved with the combined treatment. These prelimi-nary findings were confirmed in a large series, albeit retro-spective and non-randomized, comparing stimulation with FSH alone (145 cycles) or the combined therapy (60 cycles) [ 24 ]. The addition of letrozole to gonadotrophin treatment again decreased the dose of gonadotrophins and increased the number of pre-ovulatory follicles. Prospective, random-ized trials are needed to verify these interesting findings.

A sub-group of infertile women have been found to express high levels of aromatase P450 in the endometrium and this was associated with poor IVF outcomes [ 25 ]. This raises the interesting question of whether letrozole could alleviate this situation and improve results.

8.2.5 Questions Remaining

Many other questions regarding the use of aromatase inhibi-tors in the treatment of infertility still remain [ 26 ]. Trials with aromatase inhibitors have, reasonably, mimicked treatment with CC, being administered on day 3–7 of the cycle. Would treatment beyond day 7 interfere with the E2 rise induced by rising FSH concentrations and have a deleterious effect on the endometrium and oocyte quality? In his commentary, de Ziegler [ 26 ] also questions the timing of aromatase inhibitor administration when the intention is to enhance the sensitivity


84

to FSH receptors by increasing follicular androgen content. Would it not be more logical to prime with aromatase inhibi-tors before exposure to FSH? Further, although the dose of 2.5 mg of letrozole is standard for the treatment of breast cancer, should the same dose be used for the treatment of infertility? Biljan et al. [ 27 ], for example, found that a daily dose of 5 mg/day produced more mature follicles apparently by further extending the FSH window.

8.2.6 Safety

The use of letrozole for induction of ovulation has not yet been sanctioned due to questions of possible teratogenicity raised by one, unpublished, congress presentation of an increased incidence of locomotor and cardiac anomalies in infants whose pregnancy was induced with letrozole compared with a control group of spontaneously conceiving women with an absolutely normal pregnancy. Notwithstanding the scientific mistake in selection of the comparators, the incidence of all malforma-tions was not different between the two groups. A further study quashed these unsubstantiated doubts by reporting a lesser incidence of both minor and major congenital anomalies in a large group of women (n = 911) who conceived using letro-zole compared with those who used CC [ 28 ]. This valuable, reassuring information is further compounded by that pro-vided in further, very large series of women who received letrozole for ovulation induction with no preponderance of congenital abnormalities [ 20 , 21 ]. In the light of this data, it remains a mystery to me why letrozole is still contra-indicated for ovulation induction in almost every country in the world.

References

1. Wu CH, Winkel CA. The effect of therapy initiation on clomi-phene citrate therapy. Fertil Steril. 1989;52:564–8.

2. Dickey RP, Taylor SN, Curole DN, Rye PH, Lu PY, Pyrzak R. Relationship of clomiphene dose and patient weight to success-ful treatment. Hum Reprod. 1997;12:449–53.


85

3. Gysler M, March CM, Mishell DR, Bailey EJ. A decade’s experi-ence with an individualized clomiphene treatment regimen includ-ing its effects on the postcoital test. Fertil Steril. 1982;37:161–7.

4. Homburg R. Clomiphene citrate – end of an era? Hum Reprod. 2005;20:2043–51.

5. Homburg R, Armar NA, Eshel A, Adams J, Jacobs HS. Influence of serum luteinizing hormone concentrations on ovulation, con-ception and early pregnancy loss in polycystic ovary syndrome. Br Med J. 1988;297:1024–7.

6. Schenker JG, Jarkoni S, Granat M. Multiple pregnancies follow-ing induction of ovulation. Fertil Steril. 1981;35:105–23.

7. Correy JF, Marsden DE, Schokman FC. The outcome of preg-nancy resulting from clomiphene induced ovulation. Aust N Z J Obstet Gynaecol. 1982;22:18–21.

8. Dickey RP, Taylor SN, Curole DN, Rye PH, Pyrzak R. Incidence of spontaneous abortion in clomiphene pregnancies. Hum Reprod. 1996;11:2623–8.

9. Agrawal SK, Buyalos RP. Corpus luteum function and preg-nancy rates with clomiphene citrate therapy: comparison of human chorionic gonadotrophin- induced versus spontaneous ovulation. Hum Reprod. 1995;10:328–31.

10. Daly DC, Walters CA, Soto-Albors CE, Tohan N, Riddick DH. A randomized study of dexamethasone in ovulation induction with clomiphene citrate. Fertil Steril. 1984;41:844–8.

11. Homburg R, Weissglass L, Goldman J. Improved treatment for anovulation in polycystic ovary syndrome on the inappropriate gonadotrophin release and clomiphene response. Hum Reprod. 1988;3:285–8.


13. Moll E, Bossuyt PM, Korevaar JC, Lambalk CB, van der Veen F. Effect of clomifene citrate plus metformin and clomifene citrate plus placebo on induction of ovulation in women with newly diagnosed polycystic ovary syndrome: randomised double blind clinical trial. Br Med J. 2006;332:1485–8.

14. Tang T, Lord JM, Norman RJ, Yasmin E, Balen AH. Insulin-sensitising drugs (metformin, rosiglitazone, pioglitazone, D-chiro-inositol) for women with polycystic ovary syndrome, oligo amenorrhoea and subfertility. Cochrane Database Syst Rev. 2009;3:CD003053.

15. Palomba S, Pasquali R, Orio Jr F, Nestler JE. Clomiphene citrate, metformin or both as first-step approach in treating anovulatory

References

86

infertility in patients with polycystic ovary syndrome (PCOS): a systematic review of head-to-head randomized controlled stud-ies and meta- analysis. Clin Endocrinol (Oxf). 2009;70:311–21.

16. George SS, George K, Irwin C, et al. Sequential treatment of metformin and clomiphene citrate in clomiphene resistant women with polycystic ovary syndrome: a randomized, con-trolled trial. Hum Reprod. 2003;18:299–304.

17. Guzick DS, Sullivan MW, Adamson GD, et al. Efficacy of treat-ment for unexplained infertility. Fertil Steril. 1998;70:207–13.

18. Mitwally FM, Casper RF. Use of an aromatase inhibition for induction of ovulation in patients with an inadequate response to clomiphene citrate. Fertil Steril. 2001;75:305–9.

19. Homburg R. Oral agents for ovulation induction – clomiphene citrate versus aromatase inhibitors. Hum Fertil. 2008;22:261–4.

20. Aghassa MM, Asheghan H, Khazali S, Bagheri M. Aromatase inhibitors for ovulation induction in polycystic ovary syndrome. In: Allahbadia G, Agrawal R, editors. Polycystic ovary syndrome. Tunbridge Wells: Anshan; 2007. p. 341–5.

21. Legro R, NIH/NICHD Reproductive Network. Effect of letro-zole versus clomiphene on live birth in women with anovulatory infertility due to PCOS: a randomized double-blind multicenter trial. Fertil Steril. 2013;100(3 Suppl):S51, O-167.

22. Weil S, Vendola K, Zhou J, Bondy CA. Androgen and FSH inter-actions in primate ovarian follicle development. J Clin Endocrinol Metab. 1999;84:2951–6.

23. Mitwally MF, Casper RF. Aromatase inhibition improves ovar-ian response to follicle-stimulating hormone in poor responders. Fertil Steril. 2002;77:776–80.

24. Healey S, Tan SL, Tulandi T, Biljan MM. Effects of letrozole on superovulation with gonadotrophins in women undergoing intrauterine insemination. Fertil Steril. 2003;80:1325–9.

25. Brosens J, Verhoeven H, Campo R, et al. High endometrial aro-matase P450 nRNA expression is associated with poor IVF outcome. Hum Reprod. 2004;19:352–6.

26. de Ziegler D. The dawning of the non-cancer uses of aromatase inhibitors in gynaecology. Hum Reprod. 2003;18:1598–602.

27. Biljan MM, Tan SL, Tulandi T. Prospective randomized trial comparing the effects of 2.5 and 5.0 mg of letrozole (LE) on fol-licular development, endometrial thickness and pregnancy rates in patients undergoing superovulation. Fertil Steril. 2002;78:S55.

28. Tulandi T, Martin J, Al-Fadhli R, et al. Congenital malformations among 911 newborns conceived after infertility treatment with letrozole or clomiphene citrate. Fertil Steril. 2006;85:1761–5.



Abstract Gonadotrophin therapy is a highly successful way of inducing ovulation and pregnancy for women who have anovulation associated with PCOS who have failed to conceive with anti-oestrogens. The complications of gonad-otrophin therapy are multiple pregnancies and ovarian hyperstimulation syndrome (OHSS), both almost entirely dependent on a large number of follicles that develop as a result of ovarian stimulation. The principle of the classic chronic low dose regimen is to employ a low starting dose (maximum 75 IU) for a minimum of 14 days with no dose change and then use small incremental dose rises ( usually 25–37.5 IU) when necessary, at intervals of not less than 7 days, until follicular development is initiated. The purpose of this form of therapy is to achieve the development of a single dominant follicle rather than the development of many large follicles and so avoid the complications of OHSS and multiple pregnancies. It produces a remarkably consistent rate of uniovulatory cycles of around 70 %, a pregnancy rate of 40 % and an extraordinarily low prevalence of OHSS which was almost completely eliminated and a multiple preg-nancy rate of 5.7 %. The majority of patients (90 %) on a low dose protocol develop a single large follicle meeting hCG administration criteria within 14–16 days without any change in the initial dose for 14 days.

Chapter 9 Low-Dose Gonadotrophin Therapy for Ovulation Induction

88

Keywords Gonadotrophin • Ovulation induction • Pregnancy • Anovulatory • Hypogonadotrophic-hypogonadodism • Eu-oestrogenic anovulation • PCOS • Anti-oestrogens • Ovarian hyperstimulation syndrome • OHSS • hCG • Clomiphene • Dominant follicle • Polycystic ovaries • FSH • In-vitro fertilization • Embryo transfer • Superovulation • Monofollicular ovulation • Antral follicles • Gonadotrophin • Follicular growth

Gonadotrophin therapy is a highly successful way of inducing ovulation and pregnancy for women who are anovulatory due to hypogonadotrophic-hypogonadodism (WHO Group I) (See Chap. 6 ) or eu-oestrogenic anovulation (WHO Group II) associated with PCOS who have failed to conceive with anti- oestrogens. The complications of gonadotrophin therapy in the latter group are multiple pregnancies and ovarian hyper-stimulation syndrome (OHSS).

The prevalence of both multiple pregnancy and OHSS during ovulation induction is almost entirely dependent on the number of follicles that develop as a result of ovarian stimulation. The problem is that, the larger the number of follicles over 15 mm on the day of hCG, usually the higher the pregnancy rate and this tempts many practitioners to ‘go for it’ and hope for the best. However, the prevalence of multiple pregnancy increases from 12 % with 2 large follicles, 20 % with 3 and 50 % for >3 large follicles (Ares-Serono 1995, internal data, with permission). The first course of action, apparent from this data, is that if hCG is withheld when three or more large follicles develop or intercourse postponed, the multiple pregnancy rate during any form of ovulation induc-tion, be it with clomiphene or gonadotrophins, can be severely reduced. Much the same can be said for OHSS in which the number of intermediate and small follicles also contribute to its prevalence.

The best course of action to prevent these complications of gonadotrophin therapy for anovulation, would be to encour-age the growth of one dominant follicle only. This can be

Chapter 9. Low-Dose Gonadotrophin Therapy

http://dx.doi.org/10.1007/978-3-319-05612-8_6

89

largely achieved today by using a chronic low dose protocol in preference to the conventional protocol widely used up to some years ago. Conventional ‘step-up’ treatment with gonad-otrophins for women with PCOS who failed to conceive with clomiphene citrate yields an acceptable cumulative concep-tion rate. However, because of the peculiarly high sensitivity of polycystic ovaries to gonadotrophin stimulation, this form of treatment, mostly employing incremental dose rises of 75 IU every 5–7 days, characteristically induces multiple fol-licular development, resulting in a high frequency of multiple pregnancies and OHSS. Regarding ovulation induction with gonadotrophins, a collection of data from 14 large published series which was reported in 1990 [ 1 ] revealed a mean multiple pregnancy rate of 34 % and a rate of severe OHSS of 4.6 %. This rate of complications is entirely unacceptable today. All women in these series had undergone gonadotrophin induc-tion of ovulation, using a conventional protocol, due to either WHO Group I or Group II anovulation.

9.1 Rationale

Supraphysiological doses of FSH (as used in the conventional protocol) provoke an initial development of a large cohort, stimulate additional follicles, and even rescue those follicles destined for atresia. Multiple follicular development is induced by levels of FSH well above the threshold. This statement holds true for gonadotrophin stimulation of the ovaries in all groups of anovulatory patients and is actually utilized for the induction of superovulation for in-vitro fertilization and embryo transfer. However, for the induction of ovulation in women with PCOS, the problem of achieving the desired monofollicular ovulation is particularly difficult and acute due to the extreme sensitivity of the polycystic ovary to gonadotro-phic stimulation. The reason for this does not lie in a difference of FSH threshold levels of the polycystic ovaries but is proba-bly due to the fact that they contain about 6-times the number of available FSH-sensitive antral follicles in their cohort

9.1 Rationale

90

compared with the normal ovary [ 2 ]. Any dose of FSH over-stepping the threshold of the polycystic ovary will, therefore, produce multifollicular development and impending danger of multiple pregnancy and OHSS. The basic thinking behind this regimen of chronic low-dose gonadotrophin therapy is the ‘threshold theory’, which demands the attainment and mainte-nance of follicular development with exogenous FSH without exceeding the threshold requirement of the ovary.

9.2 Chronic Low-Dose Regimen

The principle of the classic chronic low dose regimen, shown in Fig. 9.1 , is to employ a low starting dose for a minimum of 14 days with no dose change and then use small incremental dose rises ( usually 25–37.5 IU) when necessary, at intervals of not less than 7 days, until follicular development is initi-ated [ 3 ]. The dose that initiates follicular development is continued until the criteria for giving hCG are attained. The purpose of this form of therapy is to achieve the development of a single dominant follicle rather than the development of many large follicles and so avoid the complications of OHSS and multiple pregnancies.

14 21 28DAYS

1

50–75 IU/day

+25–37.5IU/day

+25–37.5IU/day

Figure 9.1 A recommended scheme for the first cycle of low-dose, step- up, FSH administration


91

9.3 Results

A compilation of reported results from the literature (updated from Homburg and Howles [ 4 ]), using a chronic low dose protocol identical to that described above, is pre-sented in Table 9.1 . The prominent features include a remarkably consistent rate of uniovulatory cycles of around 70 % in each series. The pregnancy rate of 40 % of the patients and 20 % per cycle are acceptable judging from past experiences with conventional therapy and tak-ing into account that many of the patients comprising these series received only one cycle of therapy. However, the justification for the adoption of the chronic low dose protocol may be seen in the extraordinarily low prevalence of OHSS which was almost completely eliminated and a multiple pregnancy rate of 5.7 %. The majority of patients (90 %) on a low dose protocol develop a single large fol-licle meeting hCG administration criteria within 14–16 days without any change in the initial dose for 14 days [ 4 ]. In the relatively unusual case (often in very obese women) where a treatment cycle is abandoned after 28–35 days due to lack of response, a larger starting dose may, of course, be employed in a further attempt, starting the next cycle with the last dose used in the previous cycle.

Table 9.1 Results of treatment of clomiphene resistant patients with low dose, step-up FSH

No. of patients 841

No. of cycles 1,556

Pregnancies (% patients) 320 (38 %)

Fecundity/cycle 20 %

Uniovulation 70 %

OHSS 0.14 %

Multiple pregnancies 5.7 %

Updated from Homburg and Howles [ 4 ]

9.3 Results

92

9.4 Variations on a Theme

One variation of the chronic low dose step-up regimen is the step-down dose regimen which attempts to mimic more closely the events of the normal ovulatory cycle. The step-down dose regimen uses a starting dose of 150 IU FSH with a dose decrease of 37.5 IU ampoules when a follicle of 10 mm ensues and a decrease of the same amount every 3 days if fol-licular growth continues [ 5 ]. A comparison of this regimen with the classic step-up regimen demonstrated a significant reduction in the median duration of treatment and a mean of 450 IU less were needed with the step-down dose regimen. This was achieved, however, at the expense of a reduced rate of mono-ovulatory cycles. Initial enthusiasm for this method was tempered by the results of a randomized, French multi-center study comparing the step-up with the step-down proto-col which demonstrated superiority of the step-up regimen as regards the rates of monofollicular development, overstimula-tion and ovulation [ 6 ] clearly indicating the preferential use of the step-up protocol in terms of safety and efficiency.

9.5 Starting Dose

From a large, single-centre series of chronic low dose step-up therapy [ 7 ], the comparison of a starting dose of 75 IU with that of 52.5 IU for an initial 14-day period with an incremen-tal dose rise of 37.5 or 22.5 IU respectively demonstrated a pregnancy rate/patient, uni-ovulatory cycle rate and miscar-riage rate slightly in favour of the smaller starting dose.

A further study [ 8 ] demonstrated no difference in clinical outcome whether the starting dose was 37.5 or 50 IU of FSH.

9.6 Incremental Dose Rise

While employing a step-up protocol starting with doses of 50 IU/day of recombinant FSH for a minimum of 7 days, an RCT compared an incremental dose rise of 25 with 50 IU


93

when needed [ 9 ]. The smaller incremental dose rise was significantly more beneficial in terms of monofollicular development, ovulation rates and cancellation rates.

We have had very successful results using a starting dose of 50 IU FSH and an incremental dose rise of just 8.3 IU of FSH after 7 days of stimulation when needed [ 10 ]. This regimen produced a mono-follicular ovulation in 83 % of the 69 cycles, a pregnancy rate of 80 % (20/25 sub-jects) with just one cycle cancelled and one set of twins.

Similarly, the low-dose protocol may be adapted for specific populations. In a series from Vietnam [ 11 ] where the average BMI of the patients is obviously much smaller than that seen in Western countries, a starting dose of 25 IU FSH was employed for a minimum of 14 days with an incremental dose of 25 IU when needed. This regimen produced very satisfactory results in terms of pregnancy rates and lack of complications.

9.7 Patience Is a Virtue

Not infrequently, patients and practitioners alike have objected to the apparently protracted length of the initial phase of the classic chronic low-dose protocol of 14 days without a change of dose [ 3 ]. Many have reverted to an initial phase of 7 days instead. However, a few facts should be borne in mind. The FSH administered has a cumulative effect and the majority of patients (about 90 %) on the classic low dose protocol develop a single large follicle meeting hCG administration criteria within 14–16 days without any change in the initial dose for 14 days [ 4 ]. In a study we performed [ 4 ], 50 patients were divided into a group which allowed a dose rise after 7 days and a group with an allowed dose rise after 14 days only. Although the 7-day starter group had a shorter duration of stimulation and a reduced amount of FSH needed, this was at the expense of a number of multiple pregnancies in this group compared with none in the 14-day starters.

9.7 Patience Is a Virtue

94

9.8 Gonadotrophin Preparations

Much has been studied and published regarding the compari-son of the many gonadotrophin preparations on the market today (See Chap. 13 ). Whether recombinant or urinary, FSH alone or containing LH activity, regarding low-dose therapy, I have found little to choose between them as far as clinical results are concerned. The importance lies in how you give it rather than what you give!

9.9 Summary

There is now sufficient evidence to demonstrate that low-dose, step-up, gonadotrophin therapy is virtually the only correct way to utilize gonadotrophins for anovulatory patients with PCOS. Small starting doses in the first cycle, preferably for a 14-day initial period without a dose change and then a small incremental dose rise if required, produce the best results.

References

1. Hamilton-Fairley D, Franks S. Common problems in induction of ovulation. Ballieres Clin Obstet Gynaecol. 1990;4:609–25.

2. Van der Meer M, Hompes PGA, de Boer JA, Schats R, Schoemaker J. Cohort size rather than FSH threshold level determines ovarian sensitivity in polycystic ovary syndrome. J Clin Endocrinol Metab. 1998;83:423–6.

3. Polson DW, Mason HD, Saldahna MBY, Franks S. Ovulation of a single dominant follicle during treatment with low-dose pulsatile FSH in women with PCOS. Clin Endocrinol (Oxf). 1987;26:205–12.

4. Homburg R, Howles CM. Low dose FSH therapy for anovulatory infertility associated with polycystic ovary syndrome: rationale, reflections and refinements. Hum Reprod Update. 1999;5:493–9.

5. Van Santbrink EJP, Fauser BCJM. Urinary follicle-stimulating hormone for normogonadotropic clomiphene resistant anovula-tory infertility: prospective, randomized comparison between low dose step-up and step-down dose regimens. J Clin Endocrinol Metab. 1997;82:3597–602.


http://dx.doi.org/10.1007/978-3-319-05612-8_13

95

6. Christin-Maitre S, Hughes JN. A comparative randomized mul-tricentric study comparing the step-up versus the step-down protocol in polycystic ovary syndrome. Hum Reprod. 2003;18:1626–31.

7. White D, Polson DW, Kiddy D, et al. Induction of ovulation with low- dose gonadotrophins in polycystic ovary syndrome: an analysis of 109 pregnancies in 225 women. J Clin Endocrinol Metab. 1996;81:3821–4.

8. Balasch J, Fábregues F, Creus M, Casamitjana R, Puerto B, Vanrell JA. Recombinant human follicle-stimulating hormone for ovulation induction in polycystic ovary syndrome: a prospec-tive, randomized trial of two starting doses in a chronic low-dose step-up protocol. J Assist Reprod Genet. 2000;17:561–5.

9. Leader A, Monofollicular Ovulation Induction Study Group. Improved monofollicular ovulation in anovulatory or oligo- anovulatory women after a low-dose step-up protocol with weekly increments of 25 international units of follicle-stimulat-ing hormone. Fertil Steril. 2006;85:1766–73.

10. Orvieto R, Homburg R. Chronic ultra-low dose follicle-stimulat-ing hormone regimen for patients with polycystic ovary syn-drome: one click, one follicle, one pregnancy. Fertil Steril. 2009;91(4 Suppl):1533–5.

11. Lan VT, Norman RJ, Nhu GH, Tuan PH, Tuong HM. Ovulation induction using low-dose step-up rFSH in Vietnamese women with polycystic ovary syndrome. Reprod Biomed Online. 2009;18:516–21.

References


Abstract Polycystic ovary syndrome (PCOS) is associ-ated with about 75 % of all cases of anovulatory infertil-ity. Insulin resistance is frequently associated with PCOS, occurring in 80 % of women with PCOS and central obesity, but also in 30–40 % of lean women with PCOS. As a result of the reduction in insulin sensitivity, hyperinsulinaemia is invoked as a compensatory mechanism and this is of prime importance in the pathophysiology of PCOS as hyperin-sulinaemia, which is significantly exacerbated by obesity, is a key factor in the pathogenesis of hyperandrogenism. Weight loss often seems to be an unsurmountable object for the obese patient with PCOS and the alternative possibility of using insulin lowering drugs, particularly metformin, is theoretically attractive. Although metformin as a mono-agent is capable of improving menstrual frequency and restoring ovulation in patients who have oligo-anovulation and PCOS, when used as first line therapy and compared to clomifene (CC), it fairs very poorly. In a large North American randomised controlled trial, CC was found to be superior to metformin as there was a significant difference in the number of clinical pregnancies and live full-term singleton births (22.6 % vs 7.2 %) using CC and metformin respectively. Insulin sensitizers should not be used as first-choice agents for induction of ovulation in women with PCOS and their administration does not appear to decrease the incidence of early pregnancy losses. The combination

Chapter 10 Insulin Lowering Agents

98

of metformin and CC is no better than CC alone except perhaps in CC resistant patients. Evidence for a possible role for long-term metformin treatment for the prevention of the long-term sequelae of PCOS is awaited.

Keywords Insulin • Polycystic ovary syndrome PCOS • Hyperinsulinaemia • Hyperandrogenism • Obese • Body mass index • BMI • Hirsutism • Acne • Anovulation • Infertility • Multifollicular • Hyperstimulation • Weight loss • Androgen • Metformin • Biguanide • Theca cells • Anovulatory PCOS • LH • Oligomenorrheic • Oligo-anovulation • Clomiphene • Gonadotrophin • FSH • Oestradiol • Follicular development • Ovulation induc-tion • IVF • In vitro fertilization • OHSS • Pregnancy • Adolescence • Glitazones • Rosiglitazone • Pioglitazone

Polycystic ovary syndrome (PCOS) is associated with about 75 % of all cases of anovulatory infertility. Insulin resistance is frequently associated with PCOS, occurring in 80 % of women with PCOS and central obesity, but also in 30–40 % of lean women with PCOS. Unlike the insulin resistance associated with diabetes type II, the insulin resistance in women with PCOS is due to a post-receptor defect affecting glucose trans-port which is unique to women with PCOS. As a result of the reduction in insulin sensitivity, hyperinsulinaemia is invoked as a compensatory mechanism and this is of prime importance in the pathophysiology of PCOS as hyperinsulinaemia, which is significantly exacerbated by obesity, is a key factor in the pathogenesis of hyperandrogenism. In general, the more severe the insulin resistance, the more severe the ovulatory disturbance and the symptoms of hyperandrogenism.

An abnormality of pancreatic beta-cell function has also been described in women with PCOS in whom insulin dis-charge is exaggerated in response to a glucose load compared with non-PCOS women.

Assessing insulin resistance has not proved to be a rewarding experience. The gold standard is the insulin clamp

Chapter 10. Insulin Lowering Agents

99

technique which is extremely cumbersome, complicated and unsuitable for routine use. The performance of an oral glu-cose tolerance test with the measurement of insulin concen-trations under the curve similarly does not lend itself easily to routine practice. Other methods (HOMA, QUICKI), use various combinations of the values of fasting insulin and fast-ing glucose and are notoriously inaccurate. The ratio of fast-ing glucose to fasting insulin is probably the most commonly used but suffers from similar inaccuracies [ 1 ]. As a routine in every day practice, I do not estimate insulin resistance as this would help me little in the therapeutic decisions. It is fairly safe to assume that overweight and frankly obese women with PCOS suffer from some degree of insulin resistance.

The rate of insulin resistance in all women with PCOS is 50–80 % which means that a very large proportion of cases of anovulation and infertility is associated with hyperinsulinae-mia and that the lowering of insulin concentrations can pro-vide a therapeutic pathway.

Figure 10.1 illustrates the ways in which hyperinsulinaemia can cause anovulation and its effect on treatment.

A large majority of women who have PCOS and hyperin-sulinaemia are obese [ 1 , 2 ]. Obesity, in women with PCOS, exacerbates insulin resistance and its associated clinical sequelae as central obesity and body mass index (BMI) are

HYPERINSULINAEMIA

PCOS

Central obesity

Ovarian androgenproduction

+SHBG

+Free testosterone

+? LH

ANOVULATION

More FSH neededfor ovulation induction

Greater tendency toto multifollicularresponse

Inferior pregnancy andmiscarriage rates

+

Figure 10.1 The importance of hyperinsulinaemia in the genesis and treatment of anovulation


100

major determinants of insulin resistance, hyperinsulinaemia and hyperandrogenaemia. Insulin stimulates LH and ovarian androgen secretion and decreases SHBG concentrations therefore increasing the circulation of more, free, biologically active testosterone [ 3 ]. Now that obesity is reaching epidemic proportions in some countries, we tend to see more expres-sion of the stigmata of PCOS; hirsutism, acne, anovulation and infertility.

Ovulation induction therapy is negatively influenced by obesity and hyperinsulinism in women with PCOS. More gonadotrophins are required to achieve ovulation in insulin resistant women [ 4 , 5 ]. Obese women being treated with low dose therapy have inferior pregnancy and miscarriage rates [ 6 ]. Both obese [ 7 ] and insulin resistant [ 5 ] women with PCOS, even on low dose FSH stimulation, have a much greater tendency to a multifollicular response and thus a rela-tively high cycle cancellation rate in order to avoid hyperstimulation.

At least, in the short term, the deleterious effects of hyper-insulinaemia in these patients are reversible. This may be achieved by weight loss in the obese and with insulin lower-ing medications. An additional bonus is that in the long-term, prevention of the metabolic syndrome in PCOS patients by maintenance of a normal body weight and lifestyle changes seems to be an effective measure although the use of insulin lowering drugs for this purpose is still awaiting confirmation.

10.1 Weight Loss

The combination of PCOS, hyperinsulinaemia and obesity exacerbates the expression and severity of symptoms of PCOS, including the prevalence of anovulation. However, loss of weight can reverse this process by inducing a reduc-tion of insulin and androgen concentrations and an increase in sex hormone binding globulin, thus improving ovarian function [ 8 – 10 ].


101

This correction of the hormonal profile is reflected by sig-nificant improvement in the severity of the symptoms, whether they are hirsutism and acne, ovulatory dysfunction and infertility or features of the metabolic syndrome. A reduc-tion of 5–10 % in body weight improves hirsutism in 40–50 % of patients within 6 months of weight reduction [ 9 ]. For obese women with PCOS, a loss of just 5–10 % of body weight is also enough to restore reproductive function in 55–100 % within 6 months of weight reduction [ 8 – 10 ].

Weight loss has the undoubted advantages of being effec-tive and cheap with no side effects and should be the first line of treatment in obese women with any of the symptoms asso-ciated with PCOS and should be applied, in particular, for those wishing to conceive. Clinics dedicated to life-style changes are the best source of advice. It is no longer accept-able to send the subject away for 3 months and tell her to return when she has lost weight!

10.2 Metformin

The importance of decreasing the level of hyperinsulinaemia to improve results of treatment for PCOS, regardless of which of the presenting symptoms is the target, has become obvious [ 11 , 12 ]. Weight loss often seems to be an unsur-mountable object for the obese patient with PCOS and the alternative possibility of using insulin lowering drugs (par-ticularly metformin) has recently undergone a thorough examination.

Metformin is an oral biguanide, well established for the treatment of hyperglycaemia, that does not cause hypogly-caemia in normoglycaemic patients. It reduces insulin resis-tance and secretion and also seems to have a direct action on ovarian theca cells to decrease androgen production [ 13 ]. The sum total of its actions is a decrease in insulin levels and a lowering of circulating total and free androgen levels with a resulting improvement of the clinical sequelae of hyperandrogenism.

10.2 Metformin

102

Metformin is taken orally in a dose of 1,500–2,500 mg. About 15–20 % of patients may suffer from gastro-intestinal side effects, some of which may be avoided or lessened by a graduated starting dose. The indications for giving metformin to women with anovulatory PCOS have become progres-sively wider as it seems to be difficult to predict which indi-viduals will respond well with this medication [ 12 ]. The fact that metformin has been shown to have a direct action on ovarian cells in-vitro decreasing androgen production [ 13 ] and the difficulties of accurately measuring insulin sensitivity in all PCOS patients, has encouraged ‘blanket’ treatment with metformin to all PCOS patients in many centers. The wisdom of this strategy has not been ratified or, as noted by Harbourne et al. [ 14 ] in a critical review of the literature in 2003, clinical practice is ahead of the evidence. Today, we have the evidence and the initial enthusiasm for the use of metformin, particularly for ovulation induction, has been curtailed by the publication of a number of randomised con-trolled trials.

Here I will present the best available evidence for the treat-ment with metformin for anovulatory infertility and examine the proposal of administration throughout pregnancy.

10.3 Restoration of Ovulation

10.3.1 Metformin Alone

There are now a large number of studies published on the effect of metformin in a dose of 1,500–2,550 mg/day in women with PCOS. The majority of these studies have dem-onstrated an improvement in insulin concentrations, insulin sensitivity, and serum androgen concentrations accompanied by decreased LH and increased SHBG concentrations [ 15 ]. The restoration of regular menstrual cycles by metformin has been reported in the majority of published series with the reinstatement of ovulation [ 11 – 15 ]. Fleming et al. [ 12 ], in a randomized placebo-controlled trial, demonstrated a


103

significantly increased frequency of ovulation with metfor-min (850 mg, twice a day) compared to placebo in a group of 92 oligomenorrheic women with PCOS.

However, although metformin as a mono-agent is capable of improving menstrual frequency and restoring ovulation in patients who have oligo-anovulation and PCOS, when used as first line therapy and compared to CC, it fairs very poorly. In a large North American randomised controlled trial, CC was found to be superior to metformin as there was a signifi-cant difference in the number of clinical pregnancies and live full-term singleton births (22.6 % vs 7.2 %) when using CC [ 16 ] . Another large studies came to a similar conclusion [ 17 ]. A placebo controlled study did not show any benefit of met-formin in inducing ovulation in obese women with PCOS [ 18 ]. A meta-analysis examining the use of metformin for ovulation induction in women with PCOS concluded that it could not be recommended for this indication [ 19 ]. An ESHRE-ASRM consensus meeting therefore concluded that insulin sensitizers should not be used as first- choice agents for induction of ovulation in women with PCOS, while their administration does not appear to decrease the incidence of early pregnancy losses [ 20 ].

10.3.2 Metformin + Clomiphene

In a Dutch multicentre study, there was no advantage found when CC alone was compared with a combination of CC and metformin [ 21 ]. Despite this, metformin may be useful for women with clomifene resistance and this combination is worth trying before proceeding to the much more expensive low-dose gonadotrophin therapy [ 22 , 23 ].

10.3.3 Metformin + Low-Dose FSH

When women with clomiphene resistant PCOS are adminis-tered FSH following pretreatment with metformin for 1 month they develop significantly less large follicles, produce

10.3 Restoration of Ovulation

104

less oestradiol and have fewer cycles cancelled due to exces-sive follicular development. The reduction of insulin concen-trations induced by metformin seems to favour a more orderly follicular growth in response to exogenous gonado-trophins for ovulation induction [ 24 ].

10.3.4 Metformin in IVF

Early evidence suggested that when metformin was used pre-ceding and in conjunction with gonadotrophin stimulation in protocols for in vitro fertilization, there was an improvement in the outcome in normal weight women with PCOS [ 25 ]. However, this possible benefit is still debated although a reduction in the incidence of OHSS with the use of metfor-min now seems to be well established. It is very possible that subtle treatment with metformin will not have a substantial effect on the results of IVF in which large doses of gonado-trophins are administered to achieve ovarian stimulation.

10.3.5 Metformin During Pregnancy

Metformin seems to be safe when continued into pregnancy as no increase in congenital abnormalities; teratogenicity or adverse effects on infant development have been recorded. However, no advantage seems to be gained by pursuing this strategy as it helped neither the miscarriage rate, (confirming earlier data), nor the obstetric complications [ 26 ].

10.4 The Treatment of PCOS in Adolescence

The treatment of PCOS in adolescence with metformin is a vexing subject for which no one has an answer at the moment. The theoretical advantages are plain to see as met-formin, in addition to improving the disturbing unaesthetic symptoms and regulating ovulation, should also improve the insulinaemic and androgenic status of the teenager which,


105

again theoretically, should improve her chances of having ovulatory cycles when the age for a desired pregnancy arrives. However, there is next to no data to back this up. Many ques-tions still remain [ 27 ]. Will metformin truly prevent long-term sequelae? Will the long-term administration of metformin prove to be as safe as the reassuring short-term data that we presently have available suggest? How troublesome will the side effects be and, finally, is it justified to subject a teenager to a possible 20 years of preventative treatment?

10.5 Other Insulin Lowering Drugs

The glitazones, notably rosiglitazone and pioglitazone, which also lower insulin concentrations, have been investigated. They did not show any notable superiority over metformin. Rosiglitazone has since been withdrawn from the market due to undesirable side effects while pioglitazone has produced unwelcome weight gain. Neither is recommended for ovula-tion induction for PCOS. Further, d-chiro-inositol, which is also is said to have the property of lowering insulin concen-trations, has been investigated but has proved disappointing and withdrawn in most countries for this indication.

References

1. Legro RS, Finegood D, Dunaif A. A fasting glucose to insulin ratio is a useful measure of insulin sensitivity in women with polycystic ovary syndrome. J Clin Endocrinol Metab. 1998;83:2694–8.

2. Carmina E, Lobo RA. Polycystic ovary syndrome: arguably the most common endocrinopathy is associated with significant morbidity in women. J Clin Endocrinol Metab. 1999;84:1897–9.

3. Poretsky L, Cataldo NA, Rosenwaks Z, Giudice LA. The insulin- related ovarian regulatory system in health and disease. Endoc Rev. 1999;20:535–82.

4. Homburg R. Adverse effect of luteinizing hormone on fertility: fact or fantasy. Baillieres Clin Obstet Gynaecol. 1996;12:555.

5. Dale O, Tanbo T, Haug E, Abyholm T. The impact of insulin resistance on the outcome of ovulation induction with low-dose

References

106

FSH in women with polycystic ovary syndrome. Hum Reprod. 1998;13:567–70.

6. Hamilton-Fairley D, Kiddy D, Watson H, et al. Association of moderate obesity with a poor pregnancy outcome in women with polycystic ovary treated with low dose gonadotrophin. Br J Obstet Gynaecol. 1992;99:128–31.

7. White DM, Polson DW, Kiddy D, et al. Induction of ovulation with low-dose gonadotrophins in polycystic ovary syndrome: an analysis of 109 pregnancies in 225 women. J Clin Endocrinol Metab. 1996;81:3821–4.

8. Kiddy DS, Hamilton-Fairley D, Bush A, et al. Improvement in endocrine and ovarian function during dietary treatment of obese women with polycystic ovary syndrome. Clin Endocrinol (Oxf). 1992;36:105–11.

9. Pasquali R, Antenucci D, Casmirri F, et al. Clinical and hormonal characteristics of obese amenorrheic hyperandrogenic women before and after weight loss. J Clin Endocrinol Metab. 1989;68:173–9.

10. Clark AM, Ledger W, Galletly C, et al. Weight loss results in significant improvement in pregnancy and ovulation rates in anovulatory obese women. Hum Reprod. 1995;10:2705–12.

11. Velazquez EM, Acosta A, Mendoza SG. Menstrual cyclicity after metformin therapy in polycystic ovary syndrome. Obstet Gynecol. 1997;90:392–5.

12. Fleming R, Hopkinson ZE, Wallace AM, et al. Ovarian function and metabolic factors in women with oligomenorrhea treated with metformin in a randomized double blind placebo- controlled trial. J Clin Endocrinol Metab. 2002;87:569–74.

13. Mansfield R, Galea R, Brincat M, et al. Metformin has direct effects on human ovarian steroidogenesis. Fertil Steril. 2003;79:956–62.

14. Harbourne L, Fleming R, Lyall H, et al. Descriptive review of the evidence for the use of metformin in polycystic ovary syndrome. Lancet. 2003;361:1894–901.

15. Nestler JE, Stovall D, Akhter N, et al. Strategies for the use of insulin- sensitizing drugs to treat infertility in women with poly-cystic ovary syndrome. Fertil Steril. 2002;77:209–15.


17. Zain MM, Jamaluddin R, Ibrahim A, Norman R. Comparison of clomiphene citrate, metformin, or the combination of both for


107

first- line ovulation induction, achievement of pregnancy, and live birth in Asian women with polycystic ovary syndrome: a ran-domized controlled trial. Fertil Steril. 2009;91:514–21.

18. Tang T, Glanville J, Hayden CJ, White D, Barth JH, Balen AH. Combined lifestyle modification and metformin in obese patients with polycystic ovary syndrome. A randomized, placebo- controlled, double-blind multicentre study. Hum Reprod. 2006;21:80–9.

19. Tang T, Lord JM, Norman RJ, Yasmin E, Balen AH. Insulin-sensitising drugs (metformin, rosiglitazone, pioglitazone, D-chiro-inositol) for women with polycystic ovary syndrome, oligo amenorrhoea and subfertility. Cochrane Database Syst Rev. 2010;20(1):CD003053.

20. Thessaloniki ESHRE/ASRM- sponsored PCOS Consensus Workshop Group. Consensus on infertility treatment related to polycystic ovary syndrome. Hum Reprod. 2008;23:462–77.

21. Moll E, Bossuyt PM, Korevaar JC, Lambalk CB, van der Veen F. Effect of clomifene citrate plus metformin and clomifene citrate plus placebo on induction of ovulation in women with newly diagnosed polycystic ovary syndrome: randomised double blind clinical trial. Br Med J. 2006;332:1485–8.

22. Vandermolen DT, Ratts VS, Evans WS, et al. Metformin increases the ovulatory rate and pregnancy rate with clomiphene citrate in patients with polycystic ovary syndrome who are resistant to clomiphene citrate alone. Fertil Steril. 2001;75:310–5.

23. George SS, George K, Irwin C, et al. Sequential treatment of metformin and clomiphene citrate in clomiphene resistant women with polycystic ovary syndrome: a randomized, con-trolled trial. Hum Reprod. 2003;18:299–304.

24. De Leo V, la Marca A, Ditto A, et al. Effects of metformin on gonadotropin- induced ovulation women with polycystic ovary syndrome. Fertil Steril. 1999;72:282–5.

25. Kjotrod SB, von During V, Carlsen SM. Metformin treatment before IVF/ICSI in women with polycystic ovary syndrome: a prospective, randomized, double-blind study. Hum Reprod. 2004;19:1315–22.

26. Vanky E, Stridsklev S, Heimstad R, et al. Metformin versus pla-cebo from first trimester to delivery in polycystic ovary syn-drome: a randomized, controlled multicenter study. J Clin Endocrinol Metab. 2010;95:E448–55.

27. Homburg R. Polycystic ovary syndrome in adolescence – a therapeutic conundrum. Hum Reprod. 2004;19:1039–42.

References


Abstract The original treatment for PCOS, proposed by Stein and Levanthal in 1935, was bilateral wedge resection of the ovaries. This met with remarkable success regard-ing resumption of ovulation but was abandoned due to the high probability of inducing pelvic adhesions and the advent of medical means of inducing ovulation. Today the same effect of decreasing the amount of active ovarian tissue can be achieved by laparoscopic ovarian drilling (LOD) by diathermy or laser and this method now presents a further treatment option for women with anovulatory infertility associated with PCOS. No less than four and no more than ten punctures to a depth of 2–4 mm on each ovary should be made according to the size of the ovary. The main advantages of ovarian drilling are a very high prevalence of monofol-licular ovulation and therefore a significant reduction in multiple pregnancy rates compared with gonadotrophin therapy, a reported reduction in miscarriage rates and the fact that it is an often successful “one-off” procedure which may avoid the use of expensive medical therapy and the exclusion of ovarian hyperstimulation syndrome. If ovulation is not forthcoming within 2–3 months following LOD, then ovula-tion induction can often be more successfully employed than preceding the operation with clomifene or FSH if clomifene fails to induce ovulation. Follow-up after LOD showed that 49 % conceived spontaneously within a year and a further 38 % within 1–9 years following the operation. Women with

Chapter 11 Laparoscopic Ovarian Drilling

110

anovulatory PCOS who are of normal weight and have high LH concentrations seem to have the most favourable prog-nosis. LOD should not be employed merely for the treatment of other symptoms of PCOS.

Keywords Laparoscopic ovarian drilling • PCOS • Ovaries • Pelvic adhesions • Ovulation • Ovarian tis-sue • Diathermy • Laser • Anovulatory infertility • PCOS • Electro cautery • Gonadotrophin • FSH • Clomifene citrate • Pregnancy • Monofollicular ovulation • Ovarian hyperstimu-lation syndrome • Gonadotrophins • Anovulatory PCOS • LH • AMH • GnRH

The original treatment for PCOS, proposed by Stein and Levanthal in 1935, was bilateral wedge resection of the ova-ries. This met with remarkable success regarding resumption of ovulation but was abandoned due to the high probability of inducing pelvic adhesions and the advent of medical means of inducing ovulation. Thanks to modern technology, by which the same effect of decreasing the amount of active ovarian tissue is achieved, laparoscopic ovarian drilling (LOD) by diathermy or laser now presents a further treatment option for women with anovulatory infertility associated with PCOS.

11.1 Surgical Methods

Laparoscopic ovarian drilling has most popularly employed a bipolar coagulating current but unipolar diathermy is less traumatic to the ovary. Laser puncture of the ovary produces similar results. Using electrocautery, 40 W for 4 s for each puncture is a good rule of thumb. No less than four and no more than ten punctures to a depth of 2–4 mm on each ovary should be made. Less than four punctures on each ovary results in poorer pregnancy rates but more than ten may cause ovarian damage that will do more harm than

Chapter 11. Laparoscopic Ovarian Drilling

111

good. Ten punctures of the ovary should only be used on very large ovaries. Flushing of the ovaries with normal saline prevents over-heating and many use an anti- adhesion preparation.

11.2 Results

An analysis of the first 35 reports, mostly uncontrolled series, showed that 82 % of 947 patients ovulated following the opera-tion and 63 % conceived either spontaneously or after treat-ment with medications to which they had previously been resistant [ 1 ]. A Cochrane data base analysis of four randomized controlled trials comparing laparoscopic ovarian drilling with gonadotrophin therapy, showed similar cumulative ongoing pregnancy rates 6–12 months after LOD and after three to six cycles of gonadotrophin therapy [ 2 ]. However, when comparing ongoing cumulative pregnancy rates 6 months following ovar-ian cautery with six cycles of gonadotrophin therapy, then the latter was preferable with a significant odds ratio of 1.48. The largest of the studies included in this meta-analysis was a mul-ticenter study in The Netherlands, showed parity in the results of LOD and low-dose FSH therapy [ 3 ]. This was, however tem-pered by the fact that if ovarian cautery had not yielded ovula-tion after 8 weeks, clomifene citrate and even FSH was administered and these ‘evened-up’ the pregnancy rates.

Assuming, for the moment, equivalence of results, then the advantages and disadvantages of each procedure should be weighed up. The main advantages of ovarian drilling are a very high prevalence of monofollicular ovulation and therefore a significant reduction in multiple pregnancy rates compared with gonadotrophin therapy, a reported reduction in miscar-riage rates [ 4 ], and the fact that it is an often successful “one-off” procedure which may avoid the use of expensive medical therapy and the exclusion of ovarian hyperstimulation syn-drome. If ovulation is not forthcoming within 2–3 months fol-lowing LOD, then ovulation induction can often be more successfully employed than preceding the operation with

11.2 Results

112

clomifene or FSH if clomifene fails to induce ovulation. However, in a large number of cases spontaneous ovulation has been induced even for several years following LOD in a similar fashion to ovarian wedge resection, the “predecessor” of LOD [ 5 ]. A study of long- term follow-up after LOD showed that 54/110 women (49 %) conceived spontaneously within a year and a further 42 women (38 %) within 1–9 years following the operation [ 6 ]. For those who respond to LOD but relapse into anovulation, a repeat procedure has been shown to be effective [ 7 ] although this has not been widely adopted.

Taking into account clomiphene resistant patients and the possible additional cost of an increased multiple pregnancy rate with gonadotrophins, LOD would probably prove more cost effective in most countries. In countries with a far-flung popula-tion, this ‘one-off’ treatment may be better accepted to avoid repeat visits necessary for other forms of therapy. The draw-backs of LOD also have to be weighed up however. The imme-diate and long-term effects of a surgical procedure are few but exist nevertheless and we have encountered some reticence to undergo this procedure from patients who, on the whole, seem to prefer a medical induction of ovulation rather than an opera-tive procedure.

11.3 Patient Selection and Mechanism of Action

Women with anovulatory PCOS who are of normal weight and have high LH concentrations seem to have the most favourable prognosis [ 4 , 8 ]. LOD should not be employed merely for the treatment of other symptoms of PCOS.

11.4 How Does It Work?

Although the mechanism involved in the restoration of ovu-lation by LOD is not clear, the principle endocrine changes of a dramatic decrease in LH and AMH concentrations about


113

2 days after the operation, seem to be an integral ingredient. Either as a consequence of the decrease in LH concentra-tions or coinciding with this event, androgen concentrations also drop dramatically. This is followed by an increase of FSH levels. It is reasonable to assume that local destruction of androgen producing cells is the trigger for these changes but the decrease in AMH may well be involved in releasing an inhibition of FSH action and the decreasing LH concentra-tions indicate an equally dramatic change in hypothalamic GnRH activity. It is certainly not merely local ovarian changes that trigger ovulation but a consequent signal that courses to the hypothalamus that clicks the hypothalamic- pituitary-ovarian axis into correct synchrony.

11.5 The Order of Treatment Options

The place of LOD in the ‘hierarchy’ and order of possible therapeutic regimes has not yet been fully determined and often depends on the expertise and experience of the treating clinic. A proposed treatment scheme is illustrated in Fig. 8.2 . Here I have suggested that clomiphene resistant patients who have failed to conceive on four to six ovulatory cycles of low-dose FSH could be offered the alternative of LOD or IVF. Only a handful of women with PCOS as the only obvious factor causing infertility should arrive to this stage. This sug-gests that this handful have an additional undiscovered factor involved. LOD may be considered as a viable alternative to low-dose FSH administration following clomiphene resis-tance, especially for patients who are of normal weight with high LH concentrations.

References

1. Donesky BW, Adashi EY. Surgical ovulation induction: the role of ovarian diathermy in polycystic ovary syndrome. Baillieres Clin Endocrinol Metab. 1996;10:293–310.

References

http://dx.doi.org/10.1007/978-3-319-05612-8-8#Fig2

114

2. Farquhar C, Vandekerkhove P, Lilford R. Laparoscopic “drilling” by diathermy or laser for ovulation induction in anovulatory polycystic ovary syndrome. Cochrane Database Syst Rev. 2001;(4):CD001122.

3. Bayram N, van Wely M, Kaaijk EM, Bossuyt P, van der Veen F. Using an electrocautery strategy & recombinant FSH: random-ized controlled trial of laparoscopic electrocautery of theovaries vrsus recombinant FSH in clomiphene resistant polycystic ovary syndrome. BMJ. 2004;328:192–6.

4. Abdel Gadir A, Mowafi RS, Alnaser HMI, et al. Ovarian electro-cautery versus human gondotrophins and pure follicle stimulat-ing hormone therapy in the treatment of patients with polycystic ovarian disease. Clin Endocrinol. 1990;33:585–92.

5. Lunde O, Djoseland O, Grottum P. Polycystic ovary syndrome: a follow- up study on fertility and menstrual pattern in 149 patients 15–25 years after ovarian wedge resection. Hum Reprod. 2001;16:1479–85.

6. Amer SA, Gopalan V, Li TC, et al. Long term follow-up of patients with polycystic ovarian syndrome after laparoscopic ovarian drilling: clinical outcome. Hum Reprod. 2002;17:2035–42.

7. Amer SA, Li TC, Cooke ID. Repeated laparoscopic ovarian dia-thermy is effective in women with anovulatory infertility due to polycystic ovary syndrome. Fertil Steril. 2003;79:1211–5.

8. Gjonnaess H. Ovarian electrocautery in the treatment of women with polycystic ovary syndrome. Factors affecting results. Acta Obstet Gynecol Scand. 1994;73:1–5.



Abstract Excessive prolactin secretion is a not infrequent cause of anovulation and consequent infertility, often associ-ated with amenorrhea or oligomenorrhea. Only hyperprolac-tinaemia causing ovulatory disturbance deserves treatment. Clinically, galactorrhea may be a sign of hyperprolactinaemia but galactorrhea may often occur without associated hyper-prolactinaemia and vice-versa. Oligo/amenorrhea is a more important symptom which demands a serum prolactin estima-tion. Any disruption in the hypothalamic-pituitary pathway, (e.g. dopamine reducing medications, space occupying lesions) will raise prolactin concentrations and if these reach a certain level, ovulatory dysfunction will result. A further cause of hyperprolactinaemia is a prolactin-secreting tumour (prolacti-noma) of the anterior pituitary which is autonomous in nature and may be a micro or a macroadenoma. Hypothyroidism is a further possible cause of hyperprolactinaemia as thyroid releasing hormone, secreted by the hypothalamus as a com-pensatory mechanism, has the property of prolactin release from the pituitary. The work-up following the finding of hyperprolactinaemia associated with oligo- or anovulation should include neuro-radiological visualization of the hypo-thalamic pituitary region by MRI or CT to look for a micro- or macroadenoma, empty sella syndrome or a para-sellar tumour. Serum TSH, FSH and LH should also be estimated. Visual disturbances associated with a visualized tumour should also prompt an examination of visual fields. A pituitary

Chapter 12 Management of Hyperprolactinaemia

116

tumour impinging on the optic chiasma characteristically causes a bitemporal hemianopia. When hyperprolactinaemia and anovulatory infertility are associated with medication, the benefits and disadvantages of reducing dosage or withdrawing medication must be carefully weighed up. Hypothyroidism as a cause should be treated with the appropriate medication for correction of thyroid function rather than with specific prolactin-lowering agents. Many dopamine agonists are in use for the treatment of infertility associated with hyperprolacti-naemia: bromocriptine carbergoline, quinagolide

Keywords Hyperprolactinaemia • Anovulation • Hypo-gonadism • Amenorrhea • Oligomenorrhea • Ovulation • Infertility • Prolactin • Hypothyroidism • Galactorrhea • Psychiatric drugs neuroleptics • Chlorpromazines • Hypotensive agents • Pregnancy • Oral contraceptives • PCOS • Headaches • Thyroid disorders • Prolactinomas • Macroprolactinoma • Neuro- radiological visualization • MRI • CT • TSH • FSH • LH • Tumour • Stress • Non-secreting pituitary adenomas • Para-sellar tumours • Pan-hypopituitarism • Dopamine • Bromocriptine • Carbergoline • Quinagolide

Excessive prolactin secretion is a not infrequent cause of anovulation and consequent infertility. It is often associated with hypogonadism and amenorrhea or oligomenorrhea. However, mild or moderate hyperprolactinaemia is a fairly common finding which is not necessarily associated with oligo- or anovulation. Only hyperprolactinaemia causing ovu-latory disturbance deserves treatment. If associated with nor-mal ovulation it can safely be ignored as a cause of infertility.

12.1 Aetiology

Unlike other pituitary hormones whose release is controlled by hypothalamic stimulatory hormones, prolactin has an inhibitory signal (dopamine) controlling its release from the

Chapter 12. Management of Hyperprolactinaemia

117

pituitary. Any interference with this pathway, (e.g. dopamine reducing medications, space occupying lesions) will thus raise prolactin concentrations and if these reach a certain level, ovulatory dysfunction will result.

A further, and probably commonest, cause of hyperprolac-tinaemia is a prolactin-secreting tumour (prolactinoma) of the anterior pituitary which is autonomous in nature and may be a microadenoma (up to 10 mm in diameter) or a macroad-enoma (>10 mm diameter).

Hypothyroidism is a further possible cause of hyperprolac-tinaemia as thyroid releasing hormone, secreted by the hypo-thalamus as a compensatory mechanism, has the property of prolactin release from the pituitary.

Finally, physiologically, prolactin is secreted in higher con-centrations during pregnancy and lactation. Idiopathic hyper-prolactinaemia demanding treatment is not unusual (30 % of all cases). Also physiologically, prolactin is high during sleep. For this reason, blood samples for prolactin estimation should be drawn at least 2 h after awakening.

12.2 Diagnosis

Clinically, galactorrhea may be a sign of hyperprolactinaemia. However, galactorrhea may often occur without associated hyperprolactinaemia and hyperprolactinaemia may often occur without associated galactorrhea. Oligo- or amenorrhea is a more important symptom which demands a serum prolac-tin estimation.

Either of the above symptoms, when associated with hyperp-rolactinaemia, should prompt the use of the following check list:

• Medications – particularly the use of psychiatric drugs, neuroleptics, chlorpromazines and hypotensive agents.

• Pregnancy or use of oral contraceptives. • PCOS – frequently associated with a mild

hyperprolactinaemia. • Headaches, visual field disturbaces. • Thyroid disorders.

12.2 Diagnosis

118

The upper limit of normal for serum prolactin depends somewhat on the individual laboratory and in our laboratory is 600 mIU/ml (30 ng/ml). Prolactin concentrations exceeding 2,000 mIU/ml (100 ng/ml) are almost always due to prolacti-nomas and >10,000 mIU/ml (500 ng/ml) almost certainly indicates a macroprolactinoma.

The work-up following the finding of hyperprolactinaemia associated with oligo- or anovulation should therefore include neuro-radiological visualization of the hypothalamic pitu-itary region by MRI or CT to look for a micro- or macroad-enoma, empty sella syndrome or a para-sellar tumour. Serum TSH, FSH and LH should also be estimated. Visual distur-bances associated with a visualized tumour should also prompt an examination of visual fields. A pituitary tumour impinging on the optic chiasma characteristically causes a bitemporal hemianopia.

12.3 Indications for Treatment

Hyperprolactinaemia not associated with ovulatory dys-function does not require treatment for infertility. Similarly, the mild hyperprolactinaemia often associated with PCOS requires no treatment. Stress can cause a mild hyperpro-lactinaemia. Expectant rather than medical treatment is usually recommended for infertility. When hyperprolacti-naemia and anovulatory or oligo-ovulatory infertility are associated with medication, the benefits and disadvantages of reducing dosage or withdrawing medication must be carefully weighed up.

Hypothyroidism as a cause should be treated with the appropriate medication for correction of thyroid function rather than with specific prolactin-lowering agents.

All other cases of hyperprolactinaemia associated with ovulatory dysfunction and infertility, whether idiopathic or from a pituitary tumour, require treating.


119

12.4 Treatment

Neuro-surgical treatment for the treatment of hyperprolacti-naemia, is today, thankfully, very rarely required. For both micro- and macroprolactinomas prolactin-lowering drugs are safer, more efficient and often capable of causing tumour shrinkage without recourse to surgery. Surgery often results in pan- hypopituitarism, high recurrence rates and general morbidity. It should be reserved only for the very rare case completely resistant to medication, for non-secreting pitu-itary adenomas or para-sellar tumours and in those who have severe visual disturbances which fail to improve with medica-tion. For all the rest, prolactin lowering medication will serve the purpose adequately.

Many dopamine agonists are in use for the treatment of infertility associated with hyperprolactinaemia. The original and probably still most widely used drug is bromocriptine. It is provided in tablets of 2.5 mg but I usually start with half a tablet, at bedtime, taken with toast or dry biscuit, for the first week to 10 days of treatment. This tends to help avoid the rather unpleasant, not infrequent side effects of this drug, nau-sea, vomiting, diarrhoea and postural hypotension. Following this initial dosage regime, 2.5 mg nightly can be given. This may need to be titrated up to a maximum dose of even 20 mg/day but this is rarely needed for restoration of ovulation. The best way of gauging the dose is restoration of ovulation and regular menstruation. This is, after all, the aim of the treatment and is a better indication than the serum prolactin concentration itself that the correct dose is being administered. Follow-up of tumour size by MRI or CT is only really needed when a response of either the return of regular ovulation or at least by a reduction in serum prolactin concentrations is not forthcom-ing. If pregnancy does not ensue within a reasonable period, the addition of clomiphene citrate therapy may be helpful. The dose of bromocriptine which produces a positive response should be continued until pregnancy is achieved.

12.4 Treatment

120

A further dopamine agonist, carbergoline, is at the least, equally as effective as bromocriptine and has the added advantage that it is long-acting. A single oral dose can lower prolactin concentrations for 1–2 weeks. For the resumption of ovulatory cycles, the recommended dose is 0.5–2.0 mg/week, usually divided into a twice- weekly dosage.

In contrast to the others, quinagolide is a non-ergot deriv-erative and seems, for that reason, to have less side effects than the ergot derivatives referred to above. The starting dose is 25 μg for the first 3 days followed by 50 μg for 3 days and then 75 μg daily.

12.5 Results of Treatment

Pregnancy rates using bromocriptine alone, in an average required dose of 5.0–7.5 mg/day should be around 70–80 % once ovulation is resumed. Ovulation is achieved in about 85 % of cases, even including those with a macroprolactinoma. This is a remarkably successful and simple treatment and has the additional advantage that it is capable of reducing the size of prolactinomas and, often, with continued treatment, micro-prolactinomas will disappear altogether. Both carbergoline and quinagolide produce similar results. Outcome of preg-nancy following induction of ovulation with prolactin lower-ing drugs is similar to that in the normal population.



Abstract The availability of injectable gonadotrophin prepa-rations provides a direct route for ovarian stimulation and ovulation induction as opposed to the indirect route of provoking endogenous FSH release taken by clomifene and letrozole. As far as the outcome of treatment for anovula-tion is concerned, no clear clinical superiority has been demonstrated between urinary and recombinant products nor between hMG and pure FSH. Recombinant products are purer and therefore, theoretically at least, safer than urinary products. The one group of patients in which the addition of LH seems to be critical is that of women with hypogonado-trophic-hypogonadism who have no endogenous LH. These women need exogenous hCG or recombinant LH to maintain adequate oestradiol biosynthesis and follicle development.

Keywords Gonadotrophins • Ovulation induction • Clomi-phene citrate • Aromatase inhibitors • GnRH • FSH • LH • Anovulatory women • Ovarian stimulation • Hypo-gonadotrophic hypogonadism • Hypothalamic-pituitary failure • Eu-oestrogenic women • Hypothalamic-pituitary dysfunction • Follicle • Ovarian hyperstimulation • In-vitro fertilization • Oocytes • hMG • hCG • Recombinant FSH • PCOS • Oestrogen • Oestradiol • Follicular development • Atretic • OHSS • Antral follicles

Chapter 13 Gonadotrophins for Ovulation Induction

122

13.1 Principles

Clomiphene citrate, aromatase inhibitors and pulsatile GnRH therapy all provoke an endogenous production and discharge of FSH in order to induce ovulation in anovulatory women. In contrast to this indirect stimulation of the ovaries, the availability of injectable gonadotrophin preparations pro-vides a direct route for ovarian stimulation and ovulation induction.

Gonadotrophin therapy is indicated for hypogonadotro-phic hypogonadism, (hypothalamic-pituitary failure, WHO Group I) where it can be regarded as substitution therapy for the absent endogenous stimulation by FSH and LH. More commonly, gonadotrophins are administered for ovulation induction for eu-oestrogenic women who have hypothalamic-pituitary dysfunction (WHO Group II) and who have failed to ovulate or conceive following the usual first-line treatment with clomiphene citrate.

In order to develop, mature and ovulate, follicles need FSH. When this is completely lacking (hypogonadotrophic hypogonadism) or does not attain a sufficient stimulatory threshold due to intrinsic inhibitors of action and/or a dys-functional feedback mechanism (as in PCOS), exogenous FSH can provide the stimulus for follicle development. At any one time, these anovulatory women have a limited cohort of follicles which are sensitive to FSH. In order for a follicle to grow, the threshold of its sensitivity needs to be reached and in order to develop and mature, continued stimulation with FSH is required. Physiologically, in a normal ovulatory cycle, only one follicle will become dominant and ovulate due to a sophisticated mechanism which provides it with a great enough sensitivity to dwindling levels of FSH in order to maintain its development while, all around, smaller follicles do not achieve this level of sensitivity to FSH, are not stimu-lated and fall into atresia (Fig. 2.7 ). Stimulation with FSH for ovulation induction should follow similar principles i.e. enough FSH should be given exogenously to reach a thresh-old sufficient to initiate growth and development of a number

Chapter 13. Gonadotrophins for Ovulation Induction

http://dx.doi.org/10.1007/978-3-319-05612-8_2#Fig7

123

of follicles but only overstepping the threshold sufficiently to maintain the growth of one follicle and certainly, not more than three. This principle should be separated from that of controlled ovarian hyperstimulation in which larger doses of FSH are administered with the very purpose of producing more follicles and oocytes in sufficient numbers for in-vitro fertilization.

13.2 Preparations

The original gonadotrophin preparations, containing equal quantities of FSH and LH, were extracted from menopausal urine and purified. Although these preparations have been extremely successful in inducing ovulation, the production technique is laborious, requires enormous amounts of urine and includes some unwanted proteins. Improvements in puri-fication techniques enabled the production of preparations containing more active ingredients, less undesirable proteins and almost no LH so that purified and highly purified urinary FSH became available from 1983. Later, a highly purified urinary preparation containing hMG (FSH:LH activity in a ratio of 1:1) became available in which hCG mainly acts as an LH surrogate [ 1 ].

However, successful as these compounds are, the large quantities of urine required and ever increasing production demands in the early 1990s led to the use of recombinant DNA technology to produce human recombinant FSH. Recombinant FSH (follitropin-α and follitropin-β) has been clinically available since 1996 and now dominates the market. Similar technology has now made both recombinant LH and recombinant hCG available for clinical use and a preparation containing both recombinant FSH and recombinant LH has recently come on to the market.

Technically, in comparison with the urinary preparations, recombinant FSH is purer allowing safe subcutaneous self- administration, is said to have an improved batch-to-batch con-sistency and contains no LH. In addition, the recombinant DNA

13.2 Preparations

124

technology should promise unlimited availability. Regarding clinical results, no significant differences between urinary and recombinant preparations of gonadotrophins have been demon-strated despite a multitude of studies and meta-analyses.

13.3 Urinary vs Recombinant: Safety

As far as safety is concerned, the recombinant products theoreti-cally, should have the edge as they contain less protein and other contaminants. However, in more than 40 years of use, not a single case of infection by prions or slow viruses has been reported [ 2 ]. The theoretically immunogenic potential of the contamination in urinary products has been expressed in the very occasional local allergic reaction with intramuscular administration. Uneven bio-logical potency of the urinary products has been quoted as a safety factor to the advantage of the recombinant products. However, similar concerns regarding uneven biopotency of the recombinant products have also been raised. Using the Steelman-Pohley ovarian weight augmentation assay for FSH has shown that an ampoule labeled to contain 75 IU may range in true activ-ity from 50 to 120 IU FSH [ 3 ]! This has prompted the production of a “filled by mass” packaging of recombinant FSH employing size exclusion high performance liquid chromatography [ 4 ]. Whatever the case, it has been clearly shown several times that, unit for unit, recombinant FSH is more potent than urinary FSH and, therefore, slightly lower overall doses are required. If this is remembered, there should not be and neither has there been demonstrated, any difference in the incidence of ovarian hyper-stimulation syndrome between the two products during ovulation induction.

13.4 Urinary FSH vs Recombinant FSH: Efficacy

For ovulation induction, a randomized trial failed to show a difference between these two preparations as regards ovula-tion and pregnancy rates, miscarriage, hyperstimulation or


125

multiple pregnancy rates [ 5 ]. A meta-analysis of randomized controlled trials comparing urinary and recombinant FSH for ovulation induction in women with PCOS has confirmed these findings [ 6 ]. The only difference between the prepara-tions seems to be an increased unit-to-unit potency of recom-binant FSH.

13.5 FSH vs hMG

Both high and very low levels of LH have been suggested as interfering with potential fertility. The LH content of hMG and the absence of LH in recombinant FSH have therefore come under scrutiny. Firstly, the LH content of hMG does not have any detrimental effect compared with recombinant FSH in ovulation induction whether this is for patients with pre-dominately high LH (PCOS) or any others. The fact is that the administration of both hMG and pure FSH decrease LH con-centrations so hMG is certainly not capable of pushing LH levels up to a ‘danger’ zone. The hope that the redressing of a high LH:FSH ratio, prevalent in many women with PCOS, by giving pure FSH rather than hMG, would improve clinical results has also proved unfounded [ 7 ]. As GnRH agonists or antagonists are rarely used for pure ovulation induction, very low concentrations of LH are not encountered in anovulatory women with normal oestrogen levels. The one group of patients in which the addition of LH seems to be critical is that of women with hypogonadotrophic- hypogonadism who have no endogenous LH. These women need exogenous hCG or recombinant LH to maintain adequate oestradiol biosynthesis and follicle development [ 8 ]. This study found that a dose of 75 IU/day of recombinant LH to support recombinant FSH was effective in promoting optimal follicular development. Conversely, there is preliminary clinical evidence for an LH ‘ceiling’ effect. In a pilot study, the addition of relatively large doses of recombinant LH to FSH administration in the late follicular phase seemed to be capable of causing the arrest of growth of non-dominant follicles in a number of patients undergoing ovulation induction [ 9 ].

13.5 FSH vs hMG

126

In summary, as far as the outcome of treatment for anovu-lation is concerned, no clear clinical superiority has been demonstrated between urinary and recombinant products nor between hMG and pure FSH. Recombinant products are purer and therefore, theoretically at least, safer than urinary products.

13.6 Treatment Protocols for Ovulation Induction

The main complications of gonadotrophin therapy in ovula-tion induction, ovarian hyperstimulation syndrome (OHSS) and multiple pregnancies, are both caused by multiple follicu-lar development. Doses of FSH well above the threshold provoke an initial development of a large cohort, stimulate additional follicles, and even rescue those follicles that with-out stimulation would have become atretic. The conventional step-up treatment with gonadotrophins employing incremen-tal dose rises of 75 IU every 5–7 days, characteristically induces multiple follicular development, resulting in a high frequency of multiple pregnancies and OHSS. A review by Hamilton-Fairley & Franks in 1990 [ 10 ] reported a mean multiple pregnancy rate of 34 % and severe OHSS of 4.6 % using the conventional regimen in a large collection of WHO Group I and II anovulatory women. These results are unac-ceptable today. The problem is particularly acute in women who have polycystic ovaries due to the fact that these ovaries contain twice the number of available FSH- sensitive antral follicles in their cohort compared with the normal ovary [ 11 ].

The chronic low dose regimen of FSH administration, pio-neered and developed by Franks and colleagues, is aimed to avoid over-stimulation of follicles, multiple follicle develop-ment and prevent the complications of OHSS and multiple pregnancies. The low-dose regimens, both step-up and step-down variations, are fully described in Chap. 9 but, briefly, the classic low dose regimen employs a low starting dose for 14 days and then uses small incremental dose rises when


http://dx.doi.org/10.1007/978-3-319-05612-8_9

127

necessary, at intervals of not less than 7 days, until follicular development is initiated [ 12 ]. Once follicular development is underway, the dose required is continued until the criteria for giving hCG are attained. The aim of achieving the develop-ment of a single dominant follicle can be accomplished in about 70 % of cycles, OHSS can be completely eliminated and the multiple pregnancy rate is <6 % while pregnancy rates are no different to those using the conventional proto-col [ 13 ].

Many variations on the theme of low-dose therapy have been examined including a step-down rather than a step-up regimen [ 14 ], various different starting doses [ 15 ] and smaller dose rise increments. The results are fully described in Chap. 9 but whatever variation is employed, it is now very clear that low- dose, step-up gonadotrophin therapy should be pre-ferred to the now outdated conventional therapy for anovu-latory patients and particularly for those with PCOS. The classical low-dose protocol of small starting doses in the first cycle for a 14-day initial period without a dose change and then a small incremental dose rise if required, seem to give the best results.

References

1. The European and Israeli Study Group on Highly Purified Menotropin Versus Recombinant Follicle-Stimulating Hormone. Efficacy and safety of highly purified menotropin versus recom-binant follicle- stimulating hormone in in vitro fetilization/intra-cytoplasmic sperm injection cycles: a randomized, comparative trial. Fertil Steril. 2002;78:520–8.

2. Balen A. Bye-bye urinary gonadotrophins? Is there a risk of prion disease after administration of urinary-derived gonadotro-phins? Hum Reprod. 2002;17:1676–80.

3. European pharmacopoeia. 4th ed. 2002. p. 2101–3. 4. Driebergen R, Baer G. Quantification of follicle stimulating

hormone (follitropin alfa): is in vivo bioassay still relevant in the recombinant age? Curr Med Res Opin. 2003;19:41–6.

5. Yarali H, Bukulmez O, Gurgan T. Urinary follicle stimulating hormone (FSH) versus recombinant FSH in clomiphene

References

http://dx.doi.org/10.1007/978-3-319-05612-8_9

128

citrate- resistant, normogonaotrophic, chronic anovulation: a prospective randomized study. Fertil Steril. 1999;72:276–81.

6. Bayram N, van Wely M, van der Veen F. Recombinant FSH ver-sus urinary gonadotrophins or recombinant FSH for ovulation induction in subfertility associated with polycystic ovary syn-drome. Cochrane Database Syst Rev. 2002;(1):CD002121. Oxford: Update Software.

7. Hughes E, Collins J, Vandekerckhove P. Ovulation induction with urinary follicle stimulating hormone vs human menopausal gonadotrophin for clomiphene resistant polycystic ovary syn-drome. Cochrane Library. 1996;(3). Oxford: Update Software.

8. The European Recombinant Human LH Study Group. Recombinant human luteinizing hormone (LH) to support human follicle- stimulating hormone (FSH)-induced follicular development in LH and FSH deficient anovulatory women: a dose-finding study. J Clin Endocrinol Metab. 1998;83:1507–14.

9. Loumaye E, Engrand P, Shoham Z, Hillier S, Baird D. Clinical evidence for an LH ‘ceiling’ effect induced by administration of recombinant human LH during the late follicular phase of stimulated cycles in WHO type I and type II anovulation. Hum Reprod. 2003;18:314–22.

10. Hamilton-Fairley D, Franks S. Common problems in induction of ovulation. Baillieres Clin Obstet Gynaecol. 1990;4:609–25.

11. Van der Meer M, Hompes P, de Boer J, Schats R, Schoemaker J. Cohort size rather than follicle-stimulating hormone threshold levels determines ovarian sensitivity in polycystic ovary syn-drome. J Clin Endocrinol Metab. 1988;83:423–6.



14. Van Santbrink EJP, Fauser BCJM. Urinary follicle-stimulating hormone for normogonadotropic clomiphene resistant anovula-tory infertility: prospective, randomized comparison between low dose step-up and step-down dose regimens. J Clin Endocrinol Metab. 1997;82:3597–602.

15. White DM, Polson DW, Kiddy D, et al. Induction of ovulation with low-dose gonadotrophins in polycystic ovary syndrome: an analysis of 109 pregnancies in 225 women. J Clin Endocrinol Metab. 1996;81:3821–4.



Abstract Unexplained or idiopathic infertility can hardly be regarded as a diagnosis but more as a lack of diagnosis and basically one of exclusion. This label is attached to couples in whom all the standard investigations such as tests of ovula-tion, tubal patency and semen analysis are normal and has been applied to as many as 30–40 % of infertile couples depending on the duration of the infertility from 1 to 3 years. Intervention is generally indicated if the duration of infer-tility is >2 years or the female age is >35 years. Otherwise, some would recommend expectant treatment. Female age is critical in deciding when to intervene. Treatment with IUI, clomifene and aromatase inhibitors alone are relatively ineffective and the decision usually rests between controlled ovarian stimulation (COS) with gonadotrophins + IUI or IVF. Despite recent guideline recommendations, COS + IUI is a viable option with female age <38 and <3 years infertility (pregnancy rate 8–20 %) before resorting to IVF (15–40 %).

Keywords Infertility • Unexplained infertility • Ovulation • Tubal patency • Semen analysis • Sperm • Zona pellucida • Ovum • Laparoscopy • Spontaneous pregnancy • Partner’s age • Female age • Male age • Ovarian reserve • Ovulation-inducing agents • Clomiphene citrate • Aromatase inhibi-tors gonadotrophins • Controlled ovarian stimulation • Intrauterine insemination IUI • In-vitro fertilization •

Chapter 14 Unexplained Infertility

130

IVF • Ovarian stimulation • Tubal flushing • Perturbation • Fallopian tube sperm perfusion • Gamete intra- Fallopian transfer

Unexplained or idiopathic infertility can hardly be regarded as a diagnosis but more as a lack of diagnosis and basically one of exclusion. This label is attached to couples in whom all the standard investigations such as tests of ovulation, tubal patency and semen analysis are normal. Unexplained infertil-ity is a term that has been applied to as many as 30–40 % of infertile couples depending on the duration of the infertility in the definition of unexplained infertility that was applied.

14.1 Diagnostic Tests

The high prevalence of unexplained infertility is a reminder of the lack of accuracy and subtlety of the diagnostic examinations employed. For example, tubal patency does not necessarily indicate normal tubal function, a normal routine semen exami-nation tells us little about the functional capacity of the sperm and its ability to penetrate the zona pellucida and proof of ovulation tells us nothing about the quality of the ovum. The label of unexplained infertility, it could be argued, is dependent on the quality and quantity of the diagnostic tests employed, e.g. the performance of a laparoscopy rather than less invasive tests of tubal patency. The most frequently ‘missed’ diagnoses are probably endometriosis, mild degrees of tubal infertility and impending premature ovarian failure. Though these subtle causes may be responsible for so-called unexplained infertility, it may not be in the best interests of the couples to subject them to a battery of invasive or often very expensive tests. The results may well only fulfil clinical curiosity without helping in better clinical decision making. In the present climate of therapeutic ‘corner-cutting’, regardless of the results of the more sophisti-cated tests, the decision regarding the treatment options will most often be the same.

Chapter 14. Unexplained Infertility

131

14.2 Definition

Most official definitions (e.g. NICE Guidelines [ 1 ]), state that a failure to conceive after a period of 2 years of normal, regu-lar, unprotected intercourse should be defined as infertility. A large variation in suggested definitions is seen in the litera-ture including a failure to conceive over a period ranging from 1 to 3 years of unprotected intercourse in the face of normal baseline investigations. Controversially, Gnoth et al. [ 2 ] defined infertility as failure to conceive after six cycles of unprotected intercourse irrespective of age.

For the infertile couple, a “diagnosis” of unexplained infertility may be very frustrating and is often interpreted by them as meaning that if there is no explanation for the cause of infertility, there is, therefore, no effective treatment. It may often be difficult for the practitioner to encourage expectant treatment after 1 year’s infertility. Although statistically this may be correct advice, as in the general population of couples attempting conception, 84 % will conceive after one year and 92 % will conceive after 2 years, I have not met many couples who agree to do nothing and wait.

14.3 When to Intervene

It is rare for couples to wait for 2 years before consulting help and they should be referred for investigations after 1 year. If, as a result of the consultation and basic examinations, no cause for the infertility has been forthcoming, a decision as to if and when to start empirical treatment or to employ an expectant policy (i.e. do nothing), has to be taken. In general, prognostic factors related to a higher cumulative spontane-ous pregnancy rate during an expectant period are infertility <24 months, a previous pregnancy in the same relationship and female age <30 years. In this case, the couple may be encouraged to wait because they probably have a similar chance of achieving pregnancy with or without any treat-ment. Treatment is generally indicated if the duration of

14.3 When to Intervene

132

infertility is >2 years or the female age is >35 year [ 3 , 4 ]. Importantly, the prognosis is worse when the duration of infertility exceeds 3 years and the female partner is >35 years of age [ 4 ]. Female age is critical in deciding when to inter-vene. For each year of the female partner’s age beyond 30 the pregnancy rate is reduced by 9 %. The definition of unex-plained infertility is often a mistaken one in women more than 40 years of age. The main factor for infertility in this group is reduced ovarian reserve which, if found on testing, no longer renders a diagnosis of ‘unexplained’ feasible.

Following a duration of 1 year of infertility, a spontaneous pregnancy rate of 5.9 % was quoted in an unexplained infer-tility group while on the waiting list [ 5 ]. Pragmatically, what is occurring in the field despite some statistically based recom-mendations that expectant treatment is as effective as various treatment interventions, is that couples with unexplained infertility are being treated, regardless of female age, after 1 year of unexplained infertility in the majority of centres.

14.4 Treatment Options

Traditional treatment options in this group of patients have been expectant management (EM), ovulation-inducing agents (clomiphene citrate, aromatase inhibitors), gonadotro-phins (controlled ovarian stimulation, COS) with or without intrauterine insemination (IUI) and in-vitro fertilization (IVF). Currently there is a lack of agreement among infertil-ity specialists with regard to first line treatment of couples with unexplained infertility. Some consider expectant man-agement for young couples with a short period of infertility (1 year). Others consider a short trial of IUI with or without COS with gonadotrophins followed by IVF. Some directly offer IVF, especially to older women or those with a long duration of infertility. Although these couples are tolerant of a short period of expectant management, the majority opts for more active treatment if it proved unsuccessful within a given time period. Although for women >35 years of age and


133

those with poor ovarian reserve and long duration infertility, IVF seems a reasonable first line option, the use of gonado-trophins for COS + IUI is presently widely accepted for all instances of unexplained infertility except for women of age 40 years or more.

Assuming that the female partner of the couple with unex-plained infertility is <40 years old, has a duration of infertility <3 years and has an acceptable ovarian reserve, the treatment options employed are listed here in a tentative order of effi-ciency according to estimated pregnancy rates/cycle.

• Expectant management (1.8–6 %) • IUI (4–8.4 %) • IUI with clomifene stimulation (6–7 %) • IUI with gonadotrophin stimulation (8–20 %) • IVF (15–40 %)

These may be regarded as ‘wild’ estimates taken from a very large number of very heterogeneous trials. They do, however, indicate a rough ‘pecking order’.

The new National Institute for Health and Clinical Excellence (NICE) guidelines on fertility (2012) [ 1 ] suggests that COS + IUI should not be offered to women with unex-plained infertility of more than 2 years standing through the NHS [ 1 ]. They proposed to offer IVF to these couples. A fur-ther call for the abandonment of gonadotrophin/IUI treat-ment for unexplained infertility in favour of IVF has been made recently [ 6 ]. However, the evidence on which these recommendations are based is not robust. The possible increase in effectiveness of IVF over IUI + COS should be considered carefully after evaluating its invasiveness and the incremental cost per cycle. Also IUI + COS might be more acceptable to some patients over IVF, medically or financially. Strengthening this point of view, a study from The Netherlands randomised 116 couples with unexplained infertility and a poor prognosis for natural conception into groups receiving either three cycles of IUI-ovarian stimulation or one cycle of IVF with elective single embryo transfer (eSET) [ 7 ]. Ongoing pregnancy rates were 24 and 21 % in the IVF and IUI groups

14.4 Treatment Options

134

respectively with no difference in the number of multiple pregnancies, two and three respectively. The one cycle of IVF was significantly more expensive than three cycles of IUI. The authors concluded that IUI-ovarian stimulation is the pre-ferred treatment and, interestingly, calculated that until IVF eSET results reach >38 % for ongoing pregnancies, this con-clusion would hold good.

Details of ovarian stimulation used with IUI and the results are set out in the next chapter. A suggested algorithm for the treatment of unexplained infertility is shown in Fig. 14.1 .

No mention has been made here on the treatment of unex-plained infertility by tubal flushing or perturbation, Fallopian tube sperm perfusion or gamete intra-Fallopian transfer (GIFT) as these are methods rarely used today.

Expectantmanagement up

to 2 years ofinfertility

HMG StimulatedIUI X 3–4 cycles

IVF

HMG stimulated IUI X 3cycles

IVF

UNEXPLAINED INFERTILITY

< 35 YRS 35–39 YEARS > 40 YRS

< 2yrs > 2yrs> 1yr IVF

Figure 14.1 A suggested algorithm for the management of unex-plained infertility


135

References

1. NICE Guideline. Fertility: assessment and treatment for people with fertility problems. NICE Clinical Guideline 156. 2013, 1.8.1.3 –4.

2. Gnoth C, Frank-Herrmann P, Freundl G, Godehardt D, Godehardt E. Time to pregnancy: results of the German prospective study and impact on the management of infertility. Hum Reprod. 2003;18:1959–66.

3. Bhattacharya S, Harrild K, Mollison J, et al. Clomifene citrate or unstimulated intrauterine insemination compared with expectant management for unexplained infertility: pragmatic randomised controlled trial. BMJ. 2008;337:716.

4. Collins JA, Burrows EA, Wilan AR. The prognosis for live birth among untreated infertile couples. Fertil Steril. 1995;64:22–8.

5. de Evers JL, Haas HW, Land JA, Dumoulin JC, Dunselman GA. Treatment-independent pregnancy rates in patients with severe reproductive disorders. Hum Reprod. 1998;13:1206–9.

6. Laufer N, Tsafrir A. In vitro fertilization on the front line: begin-ning infertility or gonadotropin treatments with in vitro fertiliza-tion. Fertil Steril. 2014;101:330–1.

7. van Rumste MM, Custers IM, van Wely M, et al. IVF with planned single- embryo transfer versus IUI with ovarian stimulation in cou-ples with unexplained subfertility: an economic analysis. Reprod Biomed Online. 2014;28(3):336–42. pii: S1472-6483(13)00574-9.

References


Abstract When intra-uterine insemination (IUI) is chosen for the treatment of mild male factor infertility or idiopathic (unexplained) infertility, there are a number of options for ovarian stimulation for these women who are usually ovulating spontaneously. There is now general agreement that for pure mild male factor infertility (sperm concentration 5–15 million/ml and/or progressive motility 20–32 %), whether the ovaries are stimulated or not before IUI makes very little difference to the results. For unexplained infertility, stimulated cycles in combination with IUI are more effective than unstimulated cycles as regards pregnancy rates. The combination of IUI with stimulated cycles, although improving pregnancy rates, is often accompanied by unacceptable multiple pregnancy rates. With ovarian stimulation with gonadotrophins, I aim to achieve a maximum of two ovulatory follicles and this with strict criteria for administering hCG seems to give optimal results with minimal twinning rates.

Keywords Ovarian Stimulation • Intra-uterine Insemination • Ovulation • Dominant ovulatory follicle • FSH • Ovulation induction • Multifollicular • Ovarian response • Multiple pregnancies • Ovarian hyperstimulation syndrome • IVF • Oocytes • Fertilization • Embryo replacement • Oestradiol • GnRH agonist • Antagonist • ICSI • Intra-uterine insemina-tion IUI • Letrozole • Gonadotrophin • Idiopathic infertility •

Chapter 15 Controlled Ovarian Stimulation for Intra-uterine Insemination

138

hMG • Monofollicular • Multiple pregnancy rate • Ovulatory follicles • Premature luteinization • Unexplained infertility

15.1 Principles

The previous chapters have primarily dealt with induction of ovulation for women with anovulatory infertility in which the aim was to stimulate the ovary just enough to produce, preferably, one dominant ovulatory follicle. When using an FSH preparation for ovulation induction, the prin-ciple is to estimate and administer the threshold dose for an ovarian response but not to exceed it. This, theoretically, avoids a multifollicular response and the associated com-plications of multiple pregnancies and ovarian hyperstimu-lation syndrome.

The object of controlled ovarian (hyper)stimulation used for IVF is very different to that of ovulation induction. For IVF, it is the deliberate intention to produce multifollicular development in order to harvest a significant number of oocytes for fertilization and eventual embryo replacement. This can only be done by a much stronger stimulation with FSH, well over the threshold dose. In order to avoid prema-ture luteinization induced by high oestradiol levels, a GnRH agonist or antagonist is almost invariably incorporated into the stimulation regimen. The starting dose of the FSH con-taining preparation and the size of the incremental dose rise, if necessary, can all be adjusted and tailored individually. There are then, a variety of ovarian stimulation protocols that can be applied for purposes of egg collection for IVF/ICSI.

When intra-uterine insemination (IUI) is chosen for the treatment of mild male factor infertility or idiopathic (unex-plained) infertility, there are a number of options for ovarian stimulation for these women who are usually ovulating spon-taneously. Some prefer not to use any ovarian stimulation at all, some clomiphene citrate or letrozole and some, stimula-tion with FSH. Here, the pros and cons and results of these various options will be discussed.

Chapter 15. Controlled Ovarian Stimulation for IUI

139

15.2 Treatment Regimes for IUI

Since its inception, the indications for the use of IUI have gradually broadened. The aims of its original use for the treat-ment of mild male factor infertility are quite clear – increasing the density of motile sperm available and placing them close to the available egg(s). In this respect, IUI has proved more suc-cessful than timed intercourse [ 1 ] whether in stimulated (preg-nancy rate 13.7 % per cycle) or unstimulated cycles (8.4 % per cycle). There is now general agreement that for pure mild male factor infertility (sperm concentration 5–15 million/ml and/or progressive motility 20–32 %), whether the ovaries are stimu-lated or not before IUI makes very little difference to the results. This is not the case for unexplained infertility.

For the treatment of unexplained infertility, IUI has also made a contribution. Stimulated cycles in combination with IUI are more effective than unstimulated cycles as regards pregnancy rates [ 1 , 2 ]. The combination of IUI with stimu-lated cycles, although improving pregnancy rates, is often accompanied by unacceptable multiple pregnancy rates. This suggests that the additional efficacy of stimulating the ovaries before IUI is due to multiple follicular development although correction of an undetected subtle defect in ovulatory func-tion is also a possible contributory factor.

Firstly, it has been firmly established that IUI with gonado-trophin stimulation has proved to be more effective than gonadotrophins alone [ 2 ].

The main question to be settled regarding treatment with IUI for idiopathic infertility is if and when ovarian stimulation is justified. In an analysis of 45 reports [ 3 ], IUI + hMG (preg-nancy rate 18 % per cycle) was found to be more effective than IUI + CC (6.7 % per cycle) and IUI in a natural cycle (4 %). It is also our experience that when combined with IUI, FSH yields much superior results compared with CC. Personally, I have abandoned the use of CC for unexplained infertility as it is little better than expectant treatment.

In a large American RCT [ 4 ], 231 couples treated with superovulation and IUI had a higher pregnancy rate (33 %)

15.2 Treatment Regimes for IUI

140

than in the 234 couples receiving IUI in a natural cycle (18 %). But, and it is a big ‘but’, whereas there were no mul-tiple pregnancies in the 42 pregnancies resulting from IUI in natural cycles, of the 77 pregnancies following stimulation + UI, there were 2 sets of quadruplets, 3 sets of triplets and 17 sets of twins. This is too big a price to pay for an increased pregnancy rate. However, in my opinion, the solution is not to resort to completely unstimulated cycles but to find the golden mean, i.e. mild stimulation and strict criteria for the withholding of hCG. In the study just referred to, stimulation was started with 150 IU of FSH from day 3–7 of the cycle and could be adjusted on day 8 according to ultrasound and oes-tradiol examinations.

The importance of the type of stimulation protocol in the generation of multiple pregnancies can be further illustrated from published results. Goverde et al. [ 5 ] employed a low dose protocol with a constant dose of 75 IU FSH in the first cycle, withholding hCG when there were more than three follicles of >17 mm or six follicles >13 mm. However, if monofollicular development was seen in the first cycle, the dose for the sec-ond cycle was increased by 37.5 IU. Live birth rates per mono-follicular cycle were 7 % and in cycles in which more than one follicle >13 mm developed the live birth rate was 10 %.

An unpublished study from the UK, reported by the National Institute of Clinical Excellence in 2004, involved the outcome of 1,580 stimulated IUI cycles. There were 11 twins, 2 triplets and 1 quadruplet pregnancy from 126 pregnancies, a multiple pregnancy rate of 11 %. While maintaining a preg-nancy rate of 8 % per cycle, the milder stimulation regimen in the UK, compared with the more aggressive regimes in the USA, yielded a much more acceptable multiple pregnancy rate.

Clearly, multiple pregnancy rates increase with multiple follicular development. This was emphasized in an evaluation of prognostic factors [ 6 ] in which it was seen that more than four mature follicles at the time of hCG administration was associated with a very high rate of multiple pregnancies. With ovarian stimulation with gonadotrophins, I aim to achieve a maximum of two ovulatory follicles. This seems to give opti-mal results with minimal twinning rates.


141

Another innovation is the introduction of a GnRH antag-onist into a mild FSH stimulation protocol in preparation for IUI in order to prevent premature luteinization and increase treatment efficiency. However, a large randomised trial did not show any advantage of introducing a GnRH antagonist into the protocol [ 7 ].

Recent calls to completely abandon gonadotrophin/IUI treatment for unexplained infertility [ 8 , 9 ] are being eagerly adopted by IVF orientated practitioners but they are based on flimsy evidence (See Chap. 14 ). Trials directly comparing these two modes of treatment are still needed to settle the argument.

15.3 Conclusions

1. Intra-uterine insemination is a reasonably effective treat-ment for mild male factor and idiopathic infertility.

2. Whereas for mild male factor infertility, IUI in an unstimu-lated cycle will suffi ce, it is generally (but not unanimously) agreed that ovarian stimulation improves results when combined with IUI for unexplained infertility. This combi-nation is superior to gonadotrophins alone or IUI alone.

3. Stimulation with gonadotrophins is more effective than with clomiphene in IUI cycles.

4. The problem of unacceptable multiple pregnancy rates using gonadotrophin stimulation with IUI may be over-come by using a mild stimulation protocol and strict crite-ria for withholding hCG.

References

1. Cohlen BJ, Vandekerchove P, te Velde ER, Habbema JD. Timed intercourse versus intra-uterine insemination with or without ovarian hyperstimulation for subfertility in men. Cochrane Database Syst Rev. 2000;(2):CD000360.

2. Hughes EG. The effectiveness of ovulation induction and intrauterine insemination in the treatment of persistent infertility: a meta-analysis. Hum Reprod. 1997;12:1865–72.

References

http://dx.doi.org/10.1007/978-3-319-05612-8_14

142

3. Guzick DS, Sullivan MW, Adamson GD, et al. Effi cacy of treat-ment for unexplained infertility. Fertil Steril. 1998;70:207–13.

4. Guzick DS, Carson SA, Coutifaris C, et al. Effi cacy of superovula-tion and intra-uterine insemination in the treatment of infertility. National Cooperative Reproductive Medicine Network. N Engl J Med. 1999;340:177–83.

5. Goverde AJ, McDonnell J, Vermeiden JPW, Schats R, Rutten FFH, Schoemaker J. Intrauterine insemination or in-vitro fertil-ization in idiopathic and male subfertility: a randomized trial and cost- effectiveness analysis. Lancet. 2000;355:13–8.

6. Khalil MR, Rasmussen PE, Erb K, Laursen SB, Rex S, Westergaard L. Homologous intrauterine insemination. An evaluation of prognostic factors based on a review of 2473 cycles. Acta Obstet Gynecol Scand. 2001;80:74–81.

7. Crosignani PG, Somigliana E, Intrauterine Insemination Study Group. Effect of GnRH antagonists in FSH mildly stimulated intrauterine insemination cycles: a multicentre randomized trial. Hum Reprod. 2007;22:500–5.

8. NICE Guideline. Fertility: assessment and treatment for people with fertility problems. NICE Clinical Guideline 156. 2013, 1.8.1.3 –4.

9. Laufer N, Tsafrir A. In vitro fertilization on the front line: begin-ning infertility or gonadotropin treatments with in vitro fertiliza-tion. Fertil Steril. 2014;101:330–1.



Abstract The aim of controlled ovarian hyperstimulation (COH) for IVF is to produce multiple follicular develop-ment in order to harvest a suitable number of oocytes which can be fertilised and allow a selection of embryos which can be replaced into the uterus. Premature luteinisation is avoided by suppressing pituitary gonadotrophin production by co-treating with a GnRH agonist or antagonist, each with its own pros and cons. Individually tailoring the programme attempts to achieve the best live birth rates while taking into account the avoidance of ovarian hyperstimulation syndrome and the promotion of patient comfort, performed by utilizing several known facts such as ovarian response in any previous cycles, age, AMH or other predictors of ovarian reserve. The choice of gonadotrophin preparation for COH makes little if any difference regarding live birth rates while the antagonist is preferred over the agonist as regards patient comfort. Pre- treatment predictions of high, low and normal responders (using age, AMH and/or AFC) determines the protocol to be used and the starting dose of stimulation.

Keywords Controlled Ovarian Stimulation • IVF • ICSI • Ovarian hyperstimulation • Follicular development • Oocytes • Embryos • Uterus • Ovarian stimulation • Ovulation induction • Anovulatory patients • Monofollicular ovula-tion • Gonadotrophins • Oestradiol • LH • Luteinisation • Follicles • GnRH • Ovarian hyperstimulation syndrome •

Chapter 16 Controlled Ovarian Stimulation for IVF/ICSI

144

OHSS • Frozen-thawed cycles • recFSH • recLH • ART • AMH • FSH • hMG • Minimal stimulation • Natural cycle • Follitropin-α • Follitrophin-β • Hypogonadotrophic- hypogonadism • Follicles • Antral follicle • Luteal phase • Oestrogen • Oral contraceptives • Ovarian cysts • Cetrorelix • Ganirelix • Premature luteinisation

16.1 Principles

The aim of controlled ovarian hyperstimulation (COH) for IVF is to produce multiple follicular development in order to harvest a suitable number of oocytes which can be fertilised and allow a selection of embryos which can be replaced into the uterus. This is in sharp contrast to ovarian stimulation for ovulation induction in anovulatory patients in which the aim is to produce a monofollicular ovulation. The difference is therefore in the strength of stimulation needed and, obvi-ously, more gonadotrophins are needed to produce more follicles for COH in IVF.

Because of the high oestradiol concentrations produced by COH, in about 15–25 % of patients a positive feedback mechanism will produce a premature LH rise causing prema-ture luteinisation of the developing follicles and abandon-ment of the cycle. Today this is avoided by suppressing pituitary gonadotrophin production by co-treating with a GnRH agonist or antagonist. The use of the agonist brought with it a number of advantages and some disadvantages and various protocols involving the use of a GnRH agonist have been developed to tailor individual requirements.

Later, GnRH antagonists appeared on the market for the same purpose of providing a temporary reduction of, primar-ily, LH production during COH with gonadotrophins. Their properties differ in several respects from those of GnRH agonists and each has its own pros and cons.

These improvements in protocols for COH in preparation for IVF have given us a variety of programmes from which to choose. While some centres use a permanent protocol for

Chapter 16. Controlled Ovarian Stimulation for IVF/ICSI

145

all patients, most individually tailor their programme in an attempt to achieve the best live birth rates while taking into account the avoidance of ovarian hyperstimulation syn-drome and the promotion of patient comfort. Tailoring is performed by utilizing several known facts such as ovarian response in any previous cycles, age, AMH or other predic-tors of ovarian reserve, etc. All these can help determine the type of GnRH analogue to be used and the starting dose of FSH or hMG for stimulation. The choice of protocol may range from natural cycle IVF, modified natural cycle, mini-mal stimulation, so- called ‘soft’ stimulation protocols to full-blown COH. Each has its own advantages and disadvantages for the individual patient.

16.2 Gonadotrophins in COH

16.2.1 The Choice of Gonadotrophin Preparation

A number of gonadotrophin preparations are available for COH in assisted reproductive technologies. They all contain FSH whether derived from menopausal urine and purified or from recombinant DNA technology, or urinary preparations of highly purified human menopausal gonadotrophins (hMG) containing both FSH and LH or a combination of recombi-nant FSH and LH. The attributes of the various preparations have been discussed in respect to ovulation induction in Chap. 13 and the basic properties are, of course, applicable to COH for IVF.

Much discussion, debate, clinical research and scientific papers have been presented in the last few years regarding the suitability of these various preparations for COH in assisted reproductive technologies. As IVF is now so widespread and relatively expensive then commercial interests have also been involved. The main debates have centred around urinary ver-sus recombinant and LH (or hCG) containing versus pure FSH preparations. The most poignant end-point to use in this discussion is that of the live birth rate. Here the differences, if


http://dx.doi.org/10.1007/978-3-319-05612-8_13

146

any, are extremely subtle. As so much individual research has been published, it is probably wisest to heed large indepen-dent meta-analyses such as that performed by the National Institute of Clinical Excellence of the UK in 2004 [ 1 ]. A total number of 21 RCT’s involving 4,727 women were examined. When comparing recombinant FSH to any urinary derived FSH-containing preparation using a long GnRH agonist pro-tocol, no significant differences were found in live birth rates, ongoing or clinical pregnancies. Recombinant FSH seems to be more efficient than urinary FSH in that, in the majority of studies, less ampoules are needed, i.e. 1 IU of recFSH is more potent than 1 IU of urinary FSH. This difference may be offset by the increased price of the recombinant product but its superiority as regards purity and batch-to-batch consistency are not disputed.

Meta-analyses of RCT’s comparing FSH with hMG prepa-rations have shown contrasting results. Using clinical preg-nancy rates as the end-point, one study from 2000 [ 2 ] showed in favour of hMG but the same authors updated this analysis 10 years later and, following the myriad studies on this sub-ject which are still appearing (almost ad nauseam !), we have put our faith in this, one of the latest and most comprehensive of the Cochrane reviews by van Wely et al. in 2012 [ 3 ]. Comparing the effectiveness of recombinant FSH (recFSH) with three urinary gonadotrophins; hMG, purified and highly purified FSH, there was no difference in pregnancy outcomes, live birth rates or incidence of OHSS both in fresh and frozen- thawed cycles. Although recFSH was slightly inferior to hMG regarding live birth rate, the authors concluded that all available gonadotrophins seem equally effective and safe.

The overall conclusion regarding the use of the various gonadotrophin preparations in COH for ART must be that there is little if any difference between them regarding clini-cal pregnancy and live birth rates. As costs vary in each coun-try, it is difficult to comment on cost efficiency. Finally, unsurprisingly, no difference has been found between the two clinically available recombinant FSH preparations, follitropin-α and follitrophin-β [ 4 ].


147

16.2.2 LH Content

The need for some LH content in COH protocols, whether of recombinant or urinary origin, is still under discussion. The fact that some LH, albeit in small amounts, is necessary both physiologically and for efficient induction of ovulation for women who have hypogonadotrophic-hypogonadism and virtually no endogenous LH, raised the question of whether over-suppression of pituitary LH secretion can affect the results of COH with FSH alone. This is a contentious issue as excessive suppression of LH concentrations with GnRH ago-nists has been associated with a detrimental effect on the outcome of IVF [ 5 ], while others comparing urinary FSH with hMG suggested that resting levels of LH following down-regulation are sufficient to support development and maturation of follicles and oocytes in normo-gonadotrophic women [ 6 ]. The truth probably lies somewhere in between as some studies [ 7 ], suggest that mid-follicular LH serum con-centrations of <0.5 IU/l are likely to be detrimental to IVF outcome. This probably only occurs in a very small minority of cases as only 1 % of LH receptors need to be occupied in order to produce a full LH effect but nevertheless, opens the door for less aggressive doses of GnRH analogues or, possi-bly, the addition of LH to COH protocols, whether recombi-nant or urinary, in certain cases. A Cochrane review [ 8 ] included a heterogeneous collection of studies examining the effectiveness of a combination of recFSH and recLH com-pared with recFSH in both GnRH agonist and antagonist cycles. When this data was pooled, no significant difference in live birth rates emerged and no benefit of LH supplementa-tion for COH was seen in an unselected population. Although there was some suggestion that higher concentrations of LH in the mid- and late follicular phase of cycles stimulated with pure FSH under GnRH analogue pituitary suppression are beneficial to the older age groups or poor responders under-going COH for IVF [ 8 ] subsequent large RCT’s comparing FSH + LH and FSH alone (now in press) have not substanti-ated this claim.


148

16.2.3 Starting Doses

The starting dose for gonadotrophin stimulation of the ovaries for the first IVF cycle should be determined by the AMH serum concentrations and/or antral follicle count in combination with age and BMI. This is a far more accurate method, certainly for the first cycle, than guessing on the strength of age alone. These are particularly good for predicting both high and low respond-ers, which after all, are the two groups which are important to predict ahead of treatment. For the predicted high responders, a low dose of FSH should be used in the first cycle (not more than 150 IU) in order to avoid multiple follicular development and possible OHSS. For predicted low responders, a relatively high dose of FSH can safely be used in the hope of cutting down the duration of stimulation. For predicted normal responders (who do not have polycystic ovaries), a starting dose of 150 or 250 IU makes little difference in the number of oocytes retrieved or pregnancies achieved. See Chaps. 17 and 18 for more details on the management of poor and high responders respectively.

16.2.4 Patient Comfort

Regarding patient comfort, an important advance has been made in delivery systems. The development of injection ‘pens’ by three major companies has provided an almost foolproof system by which the patient can self-inject the prescribed amount of daily FSH with much greater accuracy and without recourse to daily advice from the medical staff. A further advance to enhance patient convenience is the use of a long-acting FSH preparation whose aim is to reduce the number of injections required to achieve the required stimulation in COH. These novel delivery systems are more fully described in Chap. 22 .

16.2.5 Triggering Ovulation

Traditionally hCG is used for the triggering of ovulation fol-lowing COH when the appropriate criteria are attained. In a single dose of 5,000–10,000 IU, urinary hCG has proved an


http://dx.doi.org/10.1007/978-3-319-05612-8_17

http://dx.doi.org/10.1007/978-3-319-05612-8_18

http://dx.doi.org/10.1007/978-3-319-05612-8_22

149

excellent substitute for the LH surge. With the emergence of recombinant technology, recombinant LH has been com-pared with the standard doses of urinary hCG for triggering of ovulation. A single dose of recombinant LH of between 15,000 and 30,000 IU was found to be equally effective as 5,000 IU of hCG in inducing final follicular maturation and luteinisation [ 9 ]. Because of its much shorter half-life than hCG, the use of recombinant LH for this purpose reduces the incidence of ovarian hyperstimulation syndrome but it is no longer used for triggering ovulation as large repeated doses are needed to support the luteal phase and this is much more expensive than hCG and standard progestin vaginal pessaries. .

When a GnRH antagonist is used for pituitary down- regulation, then a single injection of an agonist can also be utilized to trigger ovulation. This employs the immediate temporary discharge of LH following the injection and with the aim of preventing OHSS in susceptible cases, it has found a place in the armamentarium. Heavy luteal phase support is needed to maintain pregnancy rates. Alternatively, a ‘freeze all’ policy with replacement in a consequent cycle has pro-duced the best results. See Chap. 18 for a detailed description of management of the predicted high responder.

16.3 GnRH Agonists

16.3.1 Protocols

The use of GnRH agonists concomitant with gonadotrophin stimulation for IVF has the primary purpose of blocking the oestrogen initiated positive feedback mechanism and pre-venting release of LH. Following a short initial discharge of both FSH and LH, it induces down-regulation and densensi-tisation of the GnRH receptors in the anterior pituitary. A GnRH agonist can be administered daily by the subcutaneous or intra-nasal routes. A depot preparation (micro-capsules) given by deep intra-muscular injection is also available which has a duration of action of about 28 days and, although saving daily use, may induce a more severe suppression

16.3 GnRH Agonists

http://dx.doi.org/10.1007/978-3-319-05612-8_18

150

than is really required and hence, increased gonadotrophin requirements and duration of stimulation.

There are many ways of using these compounds, the two most popular of which, the long (luteal) and the short proto-col, are illustrated in Fig. 16.1 .

In the long (luteal) protocol, GnRH agonist is started on day 21 of the cycle preceding treatment and continued in a constant dose until the day of hCG administration. It is con-tinued in parallel with gonadotrophin treatment which is usually started on the first days of an ensuing menstruation, after two weeks of agonist treatment or following demonstra-tion of pituitary down regulation by measuring low (<200 pmol/l) oestradiol levels. Although this is the most widely used long protocol, some variations on this theme are being used. In the long follicular protocol, the GnRH agonist is started on the first day of the preceding cycle. Some centres prefer to reduce the dosage of the agonist once gonadotro-phin stimulation is started rather than giving a constant dose throughout in an attempt to cut down gonadotrophin dosage, the ‘early cessation’ protocols.

21 Cycle Day 1 hCG

1 hCG

a

b

FSH

FSH

Cycle day

Figure 16.1 The two most widely used protocols involving GnRH agonists in controlled ovarian stimulation for IVF. ( a ) The long (luteal) protocol, ( b ) the short protocol. The arrows denote the days of GnRH agonist administration


151

The short or ‘flare-up’ protocol of GnRH administration is an attempt to utilize the initial, temporary FSH releasing properties of the agonist to promote follicular recruitment during menstruation before the suppressive action takes over. The agonist is given from day 2 of the cycle until the day of hCG administration in a constant dose and gonadotro-phins are started on cycle day 3. The short protocol is mainly used for the older patients or poor responders. A further alternative, touted for poor responders, is the ultra-short pro-tocol in which the GnRH agonist is given only for the first 3 days of the cycle and then discontinued and gonadotrophins are started on cycle day 3.

The long protocol starting in the mid-luteal phase has con-sistently been reported to be more effective than the short and ultra-short protocols as far as pregnancy rates are con-cerned [ 10 , 11 ] and the most recent Cochrane review [ 12 ] has confirmed these findings. The higher clinical pregnancy rate achieved with the long protocol comes with a higher cost as more gonadotrophins are needed to reach the criteria for the triggering of ovulation. There is no obvious difference in the results of the long protocol between intra-nasal or subcutaneous administration, luteal or follicular start or the use of a stop or reduced dose protocol. For poor responders, the short and early cessation protocols may have a place. The advantages and disadvantages of the long protocol for administration of a GnRH agonist are listed in Table 16.1 .

16.3.2 Oral Contraceptives and the Long GnRH Protocol

Pre-treatment with the oral contraceptive pill, before starting the GnRH agonist, may offer several advantages. It is effective in preventing ovarian cysts, which may be a troublesome side effect of GnRH agonist therapy in some patients. This dual suppression of pituitary gonadotrophin release has shown good results in high responder patients and also allows accu-rate programming, especially important in a busy IVF centre.

16.3 GnRH Agonists

152

16.3.3 Doses

The doses of GnRH agonists used in IVF today are, in the main, probably much higher than needed for their principal purpose, i.e. to merely suppress LH concentrations enough to prevent premature luteinisation. There is a curious lack of dose finding studies and overdosing increases gonadotrophin requirements and the duration of administration. The optimal minimal effective dose of each agonist preparation needs to be sought in order to make their use more efficient and effective.

16.4 GnRH Antagonists

16.4.1 Principles

After many years involved in their development, two GnRH antagonists, cetrorelix and ganirelix, are now available for clinical use. The mode of action of the antagonists is com-pletely different from that of the agonists in that they cause pituitary suppression of gonadotrophin release by receptor competition. The GnRH antagonists bind competitively to GnRH receptors so that endogenous GnRH cannot act. The result is an immediate decrease in gonadotrophin concentra-tions, within hours after administration, without any flare-up effect as seen with the agonists. Because the principle of the

Table 16.1 Use of GnRH agonist in ART: advantages (+) and dis-advantages (−) + − Prevent LH surges and premature luteinisation

Long duration of administration

Increase number of available oocytes

Increase FSH requirements

Allow programming Increase incidence of OHSS

Improve pregnancy rates Oestrogen withdrawal symptoms


153

GnRH antagonists’ action is competition for a place on the GnRH receptors, their duration of action is dose dependent. The differences in the mode of action and properties of the GnRH agonists and antagonists make for differences in their use for gonadotrophin suppression during ovarian stimulation for IVF/ICSI.

Table 16.2 contrasts agonists and antagonists with respect to their mode of action and use in ART. The theoretical and proven advantages of the antagonist compared with the ago-nist, shown in Table 16.3 , include a shorter stimulation period and a decreased requirement for gonadotrophins, a reduced incidence of OHSS, no flare-up effect and an absence of oes-trogen withdrawal symptoms.

16.4.2 Protocols

Two issues are relevant to the design of protocols for the use of the GnRH antagonists during COH for IVF/ICSI:

1. The use of a single or multiple doses. 2. The timing of administration, whether fi xed or fl exible.

The possibilities and combinations which have been suggested and are in use are presented in Figs. 16.2 and 16.3 .

Table 16.2 Comparison of GnRH agonists and antagonists Agonist Antagonist Act by down-regulation and desensitization of GnRH receptors

Act by GnRH receptor competition

Suppress LH release after flare-up

Suppress LH release, immediate

No flare-up

Administered by subcutaneous daily injection or depot preparation i.m.

Administered subcutaneously as depot or daily injection

Best results starting mid- luteal phase, long protocol

Given on day 5–6 of stimulation (fixed) or when lead follicle is 14 mm (flexible)


154

Table 16.3 Comparison of GnRH agonists and antagonists: advan-tages perceived are signifi ed as +

Agonist Antagonist Duration of action dose dependent +

FSH requirement +

Number of retrievable oocytes +

Incidence of OHSS +

Programming +

Side effects +

Clinical pregnancy rates

Triggering of ovulation with GnRH or GnRH agonist

+

Reversibility +

Monitoring +

8–9 hCG

Stimulation day 6 hCG

a

b

3mg cetrorelix

0.25mg/day

FSH

FSH

Stimulation day

Figure 16.2 The use of a GnRH antagonist in a fixed day protocol. ( a ) With a single, slow release injection of cetrorelix; ( b ) a multiple dose protocol using either cetrorelix or ganirelix


155

Either cetrorelix or ganirelix may be used in the multi-ple dose protocol whereas only cetrorelix is presently available as a depot preparation which can be used in a single dose scheme. In the single dose regimen, the optimal dose to prevent a premature rise of LH seems to be 3 mg of cetrorelix. This is given either on a fixed day, usually day 6–8 of gonadotrophin stimulation or, in a flexible protocol, usually when the leading follicle reaches a diameter of 14 mm. A repeat injection is sometimes required if the criteria for administration of hCG have not been reached within 72–96 h following the initial injection.

For the more popular multiple dose protocol, the opti-mal daily dose for either cetrolerix or ganirelix is 0.25 mg given sub-cutaneously. This again may be applied from a fixed day of gonadotrophin stimulation, usually day 5 or 6, or more flexibly, according to the diameter of the leading follicle, usually 14 mm. In either case, the antago-nist is continued up to and including, the day of hCG administration.

14 hCG

Follicle size - mm 14 hCG

a

b

3mg cetrorelix

0.25mg/day

FSH

FSH

Follicle size - mm

Figure 16.3 The use of a GnRH antagonist in a flexible protocol. ( a ) With a single, slow release injection of cetrorelix; ( b ) a multiple dose protocol using either cetrorelix or ganirelix


156

16.4.3 Single or Multiple Doses , Fixed Day or Flexible?

Two studies assessing the multiple dose and the single dose use of cetrorelix have been analysed [ 13 ], the first in a dose of 0.25 mg/day (n = 1,066) and the second in a single dose of 3 mg (n = 541). The results of each were comparable as regards pregnancy rates/embryo transfer (27 % vs 28 % respectively), numbers undergoing oocyte retrieval and embryo transfer and the number of embryos obtained and transferred. The prevalence of OHSS in each case was negli-gible. Of the patients in the single dose protocol, 27 % needed a repeat injection. Although it would seem that, all things being equal, a single injection protocol is preferable to daily injections, daily injections are much more widely used.

A fixed day of administration (usually day 5 or 6 of gonad-otrophin stimulation) or a flexible protocol in which the antagonist is usually given when the dominant follicle reaches a diameter of 14 mm, have little to choose between them as far as results are concerned. A comparison of these two alterna-tives in a multiple dose protocol [ 14 ] found no significant dif-ferences in efficacy. Pregnancy rates were equally high (44.4 and 51 % in day 6 and flexible protocols respectively) but, as the authors pointed out, this was a selected group of ovulating healthy patients under the age of 36 years. Lately, my personal preference is the fixed protocol (starting on day 5 of stimula-tion) which had a slight edge in results compared with flexible and has the added advantage that it is simpler for patient and practitioner alike to predetermine the starting day. There is a modern tendency to start the antagonist as early as day 2 of stimulation which, although more expensive, is said to involve less premature luteinisation and better results.

Agonist Versus Antagonist

Since its inception, pregnancy rates with the use of the antagonist were consistently reported to be inferior to those when using a long agonist protocol and this deterred many


157

practitioners from using them. In the first edition of this book (2005), I suggested that the most likely reason for this was the fact that we were still on a learning curve regard-ing the use of the antagonist and that as our experience with their use mounts, the antagonist will be equally, if not more effective than the agonists and their added advantages will be more widely appreciated. I am pleased to see that this observation has come to fruition. The latest Cochrane analysis has shown no significant difference in live birth rates between a long agonist and an antagonist protocol and a significantly lower risk of OHSS using an antagonist protocol [ 15 ]. This, together with the advantages of the antagonist mentioned above (particularly a shorter cycle, less gonadotrophin consumption and more patient comfort) has persuaded many centres to prefer an antagonist protocol for the majority of their treatment cycles.

References

1. National Institute for Clinical Excellence Guideline. Fertility: assessment and treatment for people with fertility problems. 2004; 60–2. RCOG Press. ISBN 1-900364-97-2.

2. van Wely M, Westergaard LG, van der Veen F, Bossuyt PMM. Effectiveness of human menopausal gonadotrophin versus recombinant follicle-stimulating hormone for controlled ovarian hyperstimulation in assisted reproductive cycles: a meta-analysis. Fertil Steril. 2003;80:1086–93.

3. van Wely M, Kwan I, Burt AL, Thomas J, Vail A, van der Veen F, Al-Inany HG. Recombinant versus urinary gonadotrphin for ovarian stimulation in assisted reproductive technology cycles. Hum Reprod Update. 2012;18:111.

4. Harlin J, Aanesen A, Csemiczky G, et al. Delivery rates following IVF treatment, using two recombinant FSH preparations for ovarian stimulation. Hum Reprod. 2002;17:304–9.

5. Fleming R, Lloyd F, Herbert M, et al. Effects of profound sup-pression of luteinizing hormone during ovarian stimulation on follicular activity, oocyte and embryo function in cycles stimu-lated with purified follicle stimulating hormone. Hum Reprod. 1998;13:1788–92.

References

158

6. Daya S, Gunby J, Hughes EG, et al. Follicle-stimulating hormone versus human menopausal gonadotrophin for in-vitro fertiliza-tion cycles: a mets-analysis. Fertil Steril. 1997;67:889–99.

7. Humaidan P, Bungum L, Bungum M, et al. Ovarian response and pregnancy outcome related to mid-follicular LH levels in women undergoing assisted reproduction with GnRH agonist down-regulation and recombinant FSH stimulation. Hum Reprod. 2002;17:2016–21.

8. Mochtar MH, van der Veen F, Ziech M, van Wely M, Musters A. Recombinant LH for controlled ovarian hyperstimulation in assisted reproductive cycles. Cochrane Database Syst Rev. 2007;(2):CD005070.

9. The European Recombinant LH Study Group. Human recombi-nant luteinizing hormone is as effective as, but safer than, uri-nary human chorionic gonadotrophin in inducing final follicular maturation and ovulation in in-vitro fertilization procedures: results of a multicenter double-blind. J Clin Endocrinol Metab. 2001;86:2607–18.

10. Daya S. Gonadotropin releasing hormone agonist protocols for pituitary desensitization in in-vitro fertilization and gamete intra-fallopian transfer cycles. Cochrane Library, Cochrane Collaboration. 2000;(2). Oxford: Update Software.

11. Pellicer A, Simon C, Miro F, et al. Ovarian response and outcome of in-vitro fertilization in patients treated with gonadotrophin- releasing hormone analogues in different phases of the men-strual cycle. Hum Reprod. 1989;4:285–9.

12. Maheshwari A, Caserta D, Siristatidis CS, Bhattacharya S. Gonadotrophin-releasing hormone agonist protocols for pitu-itary suppression in assisted reproduction. Cochrane Database Syst Rev. 2011;(8):CD006919.

13. Oliviennes F, Diedrich K, Frydman R, Felberbaum RE, Howles CM, Cetrotide Multiple Dose International Study Group. Safety and efficacy of a 3 mg dose of the GnRH antagonist cetrorelix in preventing premature LH surges: report of two large multicen-tre, multinational, phase IIIb clinical experiences. Reprod Biomed Online. 2003;6:432–8.

14. Escudero E, Bosch E, Crespo J, Simon C, Remohi J, Pellicer A. Comparison of two different starting multiple dose gonadotropin- releasing hormone antagonist protocols in a selected group of in vitro fertilization-embryo transfer patients. Fertil Steril. 2004;81:562–6.

15. Al-Inany HG, Youssef MA, Aboulgar M, et al. Gonadotrophin- releasing hormone antagonists for assisted reproductive technol-ogy. Cochrane Database Syst Rev. 2011;(1):CD008046.



Abstract Few problems in IVF are more frustrating than the poor responder to gonadotrophin stimulation, most com-monly seen in advanced fertile age but also after ovarian surgery, advanced endometriosis, endometriomas, obesity, previous pelvic infection/adhesions, smoking, post chemo-therapy/radiotherapy. Many definitions have been proposed but the most widely accepted definition of a poor response is <3 oocytes retrieved using maximal ovarian stimulation. An AMH <3 pmol/l or antral follicle count of <5 is predic-tive of low response which, depending on female age, would generally also predict a low chance of pregnancy. An age of >37 years is by far the most important predictor of a low response and consequently a low live birth rate. From this age on there is a steep downward slope in the number of follicles in the cohort available that are able to respond to stimulation. There is a plethora of treatment modalities that have been proposed for the poor responder, bearing witness that none of them have been successful and that you cannot stimulate follicles that aren’t there. Only testosterone patches and letrozole have offered some glimmer of hope for treating the poor responder but evidence is inconsistent and flimsy.

Keywords IVF • Gonadotrophin • Pre-ovulatory follicles • Oocytes • Oestradiol • FSH • Inhibin-B • Antral fol-licle • Anti- Mullerian hormone • AMH • GnRH • Ovarian stimulation • Ovarian reserve • Follicles • Endometriosis

Chapter 17 Management of Poor Responders

160

• Endometriomas • Body mass index • Pelvic adhesions • Pelvic infection • Smoking • Chemotherapy • Radiotherapy • Anti-Mullerian hormone • AMH • Antral follicles • Oestradiol • Inhibin-B • Luteal phase • hMG • Natural cycle • ICSI • OHSS • Adjuvant therapies • Insulin like growth factor • Hypogonadotrophic-hypogonadism • Antral follicles • Ovarian sensitivity • Letrozole • Dehydroepiandrosterone • Androgen • Premature ovarian failure • Folliculogenesis • Stimulation protocol • rFSH • Aspirin

Few problems in IVF are more frustrating than the poor responder to gonadotrophin stimulation, especially when this is unexpected and the patient young. A poor response is most commonly seen in advanced age, obesity or following ovarian surgery. It is a well known fact that there is a direct relation-ship between the number of embryos available for transfer and pregnancy rates and it follows that poor responders have low pregnancy rates. However, this generalization is tempered by the ongoing debate of the definition of a poor responder, the fact that some poor responders who are young will con-ceive with relative ease and that the quantity of oocytes obtained does not always reflect quality. Optimal stimulation of the poor responder remains a challenge and requires par-ticular attention to achieve a good reproductive outcome.

17.1 Definition

The most widely accepted definitions of a poor response have been based on the number of pre-ovulatory follicles develop-ing or number of oocytes retrieved, <3 developing pre-ovula-tory follicles and <3 oocytes retrieved being the most popular [ 1 ]. These are often linked with maximum oestradiol concen-trations achieved, <500 pg/ml often being taken as a marker. Although predictors of ovarian response such as day 3 FSH levels, inhibin- B, day 3 oestradiol, antral follicle count, anti-Mullerian hormone and dynamic tests with clomiphene and

Chapter 17. Management of Poor Responders

161

GnRH agonists are all in use, it would seem eminently sen-sible to make the diagnosis while actually administering gonadotrophins in a treatment cycle, whatever criteria are used. Common sense also dictates that the definition of poor responders should include the degree of ovarian stimulation used and this over two cycles as a low response in one cycle may be coincidental. A low oocyte number has only been found to be detrimental to pregnancy rates if the cumulative dose was >3,000 IU FSH in patients aged <40 years [ 2 ]. Cancellation of a cycle due to poor response to 300 IU/day or more of FSH was associated with a significantly worse prog-nosis in these patients. The official ESHRE Consensus defini-tion states that the presence of two of the three following features is deemed necessary to define poor response:

1. Advanced maternal age or any other risk factor for POR (Poor Ovarian Response)

2. A previous poor response to stimulation 3. Abnormal test of ovarian reserve

The definition was modified to add “expected” in those cases where no previous response had been recorded or had not been through ovarian stimulation. In the risk factors retrieval of four or less oocytes was accepted as a cut off point for POR. My feeling is that this definition is far too broad and will include too large a number of the present day IVF population to be useful clinically or for research.

17.2 Aetiology

An age of >37 years is by far the most important predictor of a low response and consequently a low live birth rate. From this age on there is a steep downward slope in the number of follicles in the cohort available that are able to respond to stimulation (Table 17.1 ). As a wise man coined it: “You can-not stimulate follicles that aren’t there!” In the younger age group, aetiological factors include previous ovarian surgery, advanced endometriosis, endometriomas, high body mass

17.2 Aetiology

162

index, previous pelvic infection/adhesions, smoking, post chemotherapy/radiotherapy and, rarely, FSH receptor polymorphisms.

17.3 Predictive Markers

Forearmed is forewarned. If a poor response is predicted before the first stimulation cycle, then appropriate planning of the protocol can be made. This can limit the number of cycles can-celled and shorten the cycle so avoiding undue discomfort. In addition to the woman’s age there are several markers that can aid this prediction (See Chap. 5 ). Anti-Mullerian hormone (AMH) serum concentrations are among the best of these. They have a low inter-cycle variation and so can be measured at any point during the cycle and correlate strongly with the number of antral follicles available for stimulation. Antral fol-licle count (AFC) is similarly predictive although, unlike AMH, is observer dependent. An AMH level of <3 pmol/l and a total AFC of <5 can usually be relied upon to predict a poor responder. An estimation of FSH serum concentrations on day 2–4 of the cycle has been the traditional way to estimate ovar-ian reserve. This route is falling out of favour as often large intra-cycle variations are seen, it must be measured on specific cycle days and it less reliable in those aged <40 years old. If day3 FSH is used, an oestradiol estimation should be made at the same time and if found to be >200 pmol/l combined with a high FSH, the predictive value for a poor response is enhanced. Other tests, much more rarely used are inhibin-B serum

Table 17.1 The aging ovary Birth 1–2 million germ cells

Menarche 300,000 follicles

35–37 years 10,000–25,000 follicles

50 years 1,500 follicles

Menopause +3 years 0


http://dx.doi.org/10.1007/978-3-319-05612-8_5

163

concentrations, ovarian volume and assessment of ovarian vas-cularity. Dynamic tests involving the FSH response to clomi-fene or to one injection of GnRH analog or simply to see the response to exogenous FSH, have been largely abandoned with the introduction of AMH and AFC to the armamentarium.

17.4 Proposed Therapeutic Options

There are a plethora of treatment modalities that have been proposed for the poor responder (Table 17.2 ). The length of this list illustrates the profound lack of success of any of them to corner the market. There is a notable lack of large ran-domised trials and the heterogeneity of the definition of the poor responder has made interpretation even more difficult. In the recent Cochrane review, out of the ten trials, only one reported live birth rate [ 1 ]. Some of these proposed methods will be described briefly here.

17.4.1 High Dose Gonadotrophins

The first instinct on spotting a poor responder is to increase the dose of FSH or try starting a new cycle with a higher dose.

Table 17.2 Treatment options proposed for poor responders High dose gonadotrophins GnRH antagonists

Low dose GnRH agonist Oral contraceptives

Flare-up DHEA

Stop protocol Testosterone

Ultra-short protocol Letrozole

Short protocol Growth hormone

Pyridostigmine LH

Oral L-arginine Natural cycle

Aspirin


164

Up to a daily dose of 300 IU FSH this may be of help as it is possible that the increase in dose was needed to reach the individual threshold. However, it is highly unlikely that daily doses above 300 IU/day will improve the prognosis.

17.4.2 GnRH Agonist

Manipulation in the use of the GnRH agonist has been tried in several directions: Short (flare-up) protocol, mini-dose, stopping the agonist before gonadotrophin stimulation (ces-sation protocol), micro-dose flare-up. Of these, only the short flare-up protocol (short and ultra-short) have been widely accepted. Advantages with this approach are that the ovarian suppression is not excessive and the initial stimulation of the GnRH receptors and consequent secretion of endogenous gonadotrophins enhances the effects of the exogenously administered gonadotrophins. However, there is little con-vincing evidence of its efficacy. Late luteal phase initiation of a short course of low-dose agonist discontinued before gonadotrophin stimulation has also been proposed.

17.4.3 GnRH Antagonist

With the more widespread use of the antagonists today, the clinician may now address the poor responder patient from a new perspective. The addition of the GnRH antagonist to stimulation protocols prevents premature LH surges while not causing prolonged suppression in the early follicular phase, a crucial time for poor responder patients. Only few prospective randomized trials have compared GnRH antago-nists to various agonist protocols in groups of variously defined poor responders. These include trials of the antagonist compared with microdose agonist flare, full dose agonist flare and a standard long agonist protocol. None of these demon-strated a significance advantage in pregnancy rates of the antagonist. However, an antagonist protocol is now often


165

selected for the poor responder as it usually involves the requirement of significantly less gonadotrophins and a shorter duration of stimulation compared with the long agonist.

The use of protocols involving clomiphene, with or without gonadotrophins, has been disappointing for poor responders and the use of recombinant, rather than urinary FSH or hMG has done little to improve results.

17.4.4 Natural Cycles

Such is the predicament of the poor responder to conventional stimulation for IVF that a movement to promote the use of natural cycles (usually combined with ICSI) has taken root lately. This is a direction whose logic fails me. The main reason given for this strategy is that if there is little response to stimu-lation then a cycle not involving medication for a woman who is an ovulating naturally would produce the same results, save expense and increase patient comfort and avoid OHSS and multiple pregnancies. However, the success rate with natural cycles is very low per treatment cycle started and is a much less effective treatment option not only due to high cancellation rates because of a premature LH surge and also high risk of failure to retrieve an oocyte but also the fact that these patients have only one embryo available for transfer if they are lucky. The number of cycles women need to go through in order to achieve successful oocyte retrieval, fertilisation and embryo transfer is high when compared to a conventional stimulation cycle. This can give unrealistic hopes for women who keep try-ing cycle after cycle for a long time if not counselled adequately. This can have a huge psychological impact. With the best avail-able evidence this seems to be an unrealistic option, but can be considered only as a last resort before egg donation after coun-selling the patients. Egg donation no doubt offers the most effective treatment for this subset of patients. The fact that gonadotrophin stimulation is saved is no reason to suggest that the probability of success with a maximum of one egg is better than in those who have responded poorly to stimulation.


166

17.4.5 Adjuvant Therapies

The number of adjuvant therapies that have been suggested to improve the lot of the poor responder is enough to fill a separate book (Table 17.2 ).

There is a complex intra-ovarian regulating system involv-ing insulin like growth factor (IGF-1) with ligands, receptors and binding proteins. The presence of receptors for GH and IGF-1 in the ovary and the ability of IGF-1 to improve the response of granulosa cells to FSH suggested a role for GH in human reproduction. Based on the theory that growth hormone could act as a co-gonadotrophin, we first tried to show that treatment with GH could have the potential to improve the ovarian response to gonadotrophin stimulation in women with ovaries that are relatively resistant to human menopausal gonadotrophin (hMG) therapy. However further randomised, well controlled studies using GH failed to dem-onstrate any significant beneficial effects on the outcome of IVF cycles in poor responders. The use of GH was really only found to be successful for GH-deficient patients in increasing ovarian sensitivity to gonadotrophin stimulation and in par-ticular, those who had hypogonadotrophic- hypogonadism. A recent resurge of interest in the use of growth hormone for poor responders has been sparked by a very heterogeneous collection of studies containing small numbers of subjects. I remain unconvinced that the enormous expense involved in administering growth hormone co-treatment is justified for poor responders except for those who are deficient in IGF-1. Based on similar principles, the use of growth hormone releasing factor and pyrostigmine have been tried with no or very limited success.

The fact that androgens play a critical part in follicular growth and that androgen receptors are present in the human ovary suggests that the use of androgens during the early fol-licular phase might have a beneficial effect on the number of small antral follicles and improve the ovarian sensitivity to FSH. The impression from the first few trials employing trans-dermal testosterone patches is positive. If further large


167

RCT’s confirm the findings of these initial studies, the logical use of androgens to promote follicular growth may well be the most promising treatment so far suggested for the poor responder. As letrozole, an aromatase inhibitor, blocks the production of oestrogens from androgen, there is a small build up of androgens within the follicle. On the same prin-ciple of androgen stimulation of early follicular growth, letro-zole has been tried to improve the response to gonadotrophins by previous poor responders. So far, the results have been mixed and there is also the problem that letrozole is off-label for this indication in most countries. Dehydroepiandrosterone (DHEA) is a weak androgen which is sold over the counter in the USA and is being strongly promoted as a rejuvenator. Over the last decade, DHEA has been widely employed by numerous specialists for the treatment of premature ovarian failure, premature ovarian aging or diminished ovarian reserve sufferers wishing to achieve pregnancy. There is no firm evidence base for this treatment as all the studies so far have been observational and mainly from one group. A num-ber of independent randomised controlled trials now being performed will demonstrate the worth, or otherwise, of this mode of treatment. Its widespread adoption despite the lack of solid evidence once again demonstrates the desperate plight of the poor responder.

It has been proposed that small doses of LH, when used early in ovarian stimulation in IVF cycles, have a beneficial effect on the quality of oocytes, a very important factor espe-cially in cases in which few embryos are available for transfer. In poor responders, it was thought that LH administration in the early phase of folliculogenesis, early during the stimula-tion protocol, may have a beneficial effect on the maturity and fertilisability of oocytes. However, several recent ran-domised trials have failed to show that increased pregnancy rates are achieved in patients for whom LH was added to rFSH for ovarian stimulation in poor responders or indeed in women over the age of 35 years.

The use of aspirin to improve ovarian blood flow and hopefully ovarian response has been equally disappointing.


168

17.5 Conclusions

The poor response to ovarian stimulation for IVF, especially in the older women, remains the bête noir of this procedure. This is reflected in the literature, whether from meta-analyses or consensus meetings, which repeatedly states that there is insufficient evidence to support the use of any particular intervention in the management of poor responders. A poor responder usually carries a poor prognosis for an ongoing pregnancy. The exception to this rule is the young poor responder with whom it is often worth persisting, even with limited embryos for transfer. This is further fuel to the notion that age is the best predictor of oocyte quality while ovarian response to gonadotrophins is the best predictor of ovarian reserve. A combination of advanced age and a poor ovarian response to gonadotrophins carries the worst prognosis for pregnancy.

References

1. Pandian Z, McTavish AR, Aucott L, Hamilton MP, Bhattacharya S. Interventions for ‘poor responders’ to controlled ovarian hyper stimulation (COH) in in-vitro fertilisation (IVF). Cochrane Database Syst Rev. 2010;(1):CD004379.

2. Kailasam C, Keay SD, Wilson P, Ford WCL, Jenkins JM. Defi ning poor ovarian response during IVF cycles, in women aged <40 years, and its relationship with treatment outcome. Hum Reprod. 2004;19:1544–7.



Abstract The prevention of ovarian hyperstimulation syn-drome (OHSS) should be of paramount importance as it is by far the most serious complication of both ovulation induction and IVF. OHSS is an iatrogenic condition caused by overdos-ing with gonadotrophin stimulation and is therefore almost totally preventable. High responders to gonadotrophin stim-ulation are the group who are susceptible (age <30 years, polycystic ovaries, lean body habitus, previous cycle with a high response) as they will produce a large number of fol-licles which predispose to OHSS. Both AMH and AFC have a high predictive value for the high responder and correlate well with each other. The secret of management for the high responder is to anticipate which women are likely to fall into this category and adjust the starting dose and stimulation protocol accordingly. In ovulation induction, only a chronic low-dose protocol should be used and for IVF, a GnRH antagonist protocol is preferred as this demands less gonado-trophins, is more patient friendly and allows the use of a GnRH agonist trigger of ovulation. This latter action, in place of an hCG trigger, will prevent OHSS but needs strong luteal support or a ‘freeze-all’ policy to maintain pregnancy rates.

Keywords Ovarian hyperstimulation syndrome • OHSS • Ovulation induction • IVF • Gonadotrophin • Follicles • Polycystic ovaries • Anti-Mullerian hormone • AMH • Antral follicle • GnRH • Antagonist • Oestradiol • LH • Ovulation

Chapter 18 Management of High Responders

170

• Stimulation • Agonist • hCG • Luteotrophic effect • Ovulation • FSH • Oocyte donors • Oocyte • Endometrium • Corpora lutea • Luteal phase • Progesterone • Vitrification • Embryos • Frozen-thawed cycles • Fresh transfer cycles • Egg-freezing • PCOS • Metformin • Hyperinsulinaemia • Insulin resistance • Carbergoline • In-vitro maturation

The prevention of ovarian hyperstimulation syndrome (OHSS) should be of paramount importance for the fertility practitioner as it is by far the most serious complication of both ovulation induction and IVF. OHSS is an iatrogenic con-dition caused by overdosing with gonadotrophin stimulation and is therefore almost totally preventable. High responders to gonadotrophin stimulation are the group who are suscep-tible as they will produce a large number of follicles which predispose to OHSS. The secret of management for the high responder is to anticipate which women are likely to fall into this category and adjust the starting dose and stimulation pro-tocol accordingly. This applies to both ovulation induction and ovarian stimulation for IVF. The approach to the high responder undergoing ovulation induction has been described in Chap. 9 on chronic low-dose gonadotrophin therapy. Here we will concentrate on the management of the potential high responder who is about to undergo IVF and those who have a high response during stimulation.

18.1 Prediction of the High Responder

Clinically, those who can be anticipated to have a high response are those who have:

• Age <30 years • Polycystic ovaries • Lean body habitus • Previous cycle with a high response

In addition to these clinical pointers, an examination of anti- Mullerian hormone (AMH) and an antral follicle count

Chapter 18. Management of High Responders

http://dx.doi.org/10.1007/978-3-319-05612-8_9

171

(AFC) can be highly predictive of a high response. The fol-lowing are the cut-off values that our department finds useful to predict a high response but these may vary in different units according to the assay or equipment used.

• AMH >30 pmol/l • AFC >12

Both AMH and AFC have a high predictive value for the high responder and correlate well with each other. Once the prediction of a high responder has been made, the stimula-tion protocol can be individually tailored. This mainly involves a choice of a GnRH agonist or antagonist and the starting dose of FSH for stimulation.

18.2 Preference of an Antagonist Protocol

Controlled ovarian stimulation for IVF involves the develop-ment of a number of follicles which produce rising levels of oestradiol. Without pituitary suppression, these would induce a surge of endogenous LH release. Traditionally, a long GnRH agonist protocol has been used to prevent this but today the tide has changed and the antagonist is now widely used, par-ticularly for the high responder. There are several reasons for this change of attitude. According to the latest Cochrane analysis, the antagonist is now yielding a similar live birth rate to the agonist. This, after a long learning curve, has persuaded many units to switch to the antagonist which has some advan-tages over the agonist in that cycles are shorter, less gonado-trophins are required and there are no hypo-oestrogenic side effects, all of which are more patient friendly. Most impor-tantly for the high responder, the use of an antagonist proto-col enables the use of a single-shot GnRH agonist trigger of ovulation in place of the conventional hCG. This, of course, cannot be used when an agonist has been given as the GnRH receptors have been down regulated. The importance of this will be described below but clearly the antagonist protocol should be used for the predicted high responder.

18.2 Preference of an Antagonist Protocol

172

18.3 Starting Dose for Stimulation

The starting dose of gonadotrophin stimulation for the pre-dicted high responder must necessarily be lower than the dose used in conventional protocols for the predicted normal or low responders. We would recommend a daily starting dose of not more than 150 IU.

18.4 Agonist Trigger

In a conventional IVF cycle hCG is used to trigger ovulation usually when three or more follicles reach a diameter of 17 mm. hCG acts as a surrogate for the LH surge which trig-gers ovulation in a normal cycle. The hCG trigger has a half life of about 34 h and has a prolonged luteotrophic effect. However, although this prolonged effect is good for implan-tation, in susceptible patients such as high responders, it may induce OHSS. If hCG is withheld from these overstimulated cases, OHSS does not occur.

The substitution of hCG by a GnRH agonist produces an LH (and FSH) surge with amplitudes similar to those seen in a normal ovulatory cycle, sufficient to trigger ovulation but with a much less prolonged action than hCG. This led to the idea that using an agonist rather than an hCG trigger could prevent OHSS [ 1 ] (Fig. 18.1 ). It was also thought the FSH

Day 5

start

FSH

GnRH agonist

0.25mg/day antagonist

Figure 18.1 The agonist trigger for ovulation


173

release induced would be an additional bonus as it may improve embryo quality.

However initial clinical trials, summarised in an updated Cochrane analysis in 2011 [ 2 ], proved disappointing. Although no OHSS was recorded in the agonist trigger group, live birth rates were very significantly decreased when compared with antagonist cycles with an hCG trigger. In an attempt to find the reason for this, oocyte donors were given either an agonist or hCG trigger in an antagonist cycle. As these produced simi-lar outcomes in the recipients, it became clear that the miser-able pregnancy rate seen in the clinical trials was not due to a detrimental effect on oocyte quality or endometrium but an insufficient stimulation of the corpora lutea and a consequent insufficiency of the luteal phase. A successful attempt to over-come this was made by employing massive luteal support (daily oestradiol patches with 50 mg of progesterone in oil) [ 3 ]. This maintained a good pregnancy rate while eliminating OHSS. Humaidan’s group then took up the challenge of boosting luteal support and examined the administration of 1,500 IU of hCG on the day of oocyte retrieval following the agonist trigger [ 4 ] (Fig. 18.2 ). This regime produced equivalent pregnancy rates to those using an hCG trigger.

FSH

GnRHagonist

0.25mg/day antagonist

Day 5start

Luteal phase support:

1500 IU hCGon day OPU

Figure 18.2 Agonist trigger with luteal phase support with 1,500 IU hCG on the day of ovum pick-up ( OPU ) (Humaidan et al. [ 4 ]). No significant difference in outcome compared with hCG trigger

18.4 Agonist Trigger

174

Despite the success of strengthening luteal support in agonist triggered cycles, an agonist trigger followed by a ‘freeze-all’ policy is undoubtedly the most successful. A mul-ticentre study recruited women at risk of developing OHSS during an antagonist cycle [ 5 ]. They were given an agonist trigger followed by vitrification of all 2-pro-nucleate embryos. Thawed embryos transferred in a subsequent cycle produced an excellent live birth rate. Assuming that frozen-thawed cycles are now producing similar pregnancy rates to fresh transfer cycles, this method does seem to be the future in eliminating OHSS in susceptible cases while maintaining good pregnancy rates. The fact that embryos are transferred to a non-stimulated endometrium rather than one stimulated by possibly detrimentally high levels of oestradiol also adds to its attraction.

Although severe OHSS occurs in “only” 2 % of cycles, its consequences demand the utmost attention for its avoidance. The use of an antagonist protocol with an agonist trigger, especially using a ‘freeze-all’ policy, is capable of completely eliminating OHSS and maintaining good pregnancy rates. As well as for high-responding women, its use has become virtu-ally mandatory for cases in which OHSS must be avoided and the luteal phase is inconsequential; oocyte donors and cycles for egg-freezing.

18.5 Oral Contraceptive Pre-treatment

Pre-treatment with combined oral contraceptives is mainly used for help in the timing of the treatment cycle, mainly for the avoidance of egg collection during weekend breaks, as a withdrawal bleeding can be easily programmed. However, it has been reported that this method adversely affects preg-nancy rates in antagonist cycles [ 6 ]. Although this was found in all- comers, we have found it useful for predicted high responders, particularly those with PCOS, in dampening the response. This is however merely observational and trials are warranted.


175

18.6 Metformin

Women with PCOS have a high incidence of insulin resis-tance and hyperinsulinaemia. This makes them even more susceptible for an exaggerated response to FSH stimulation. Metformin, an insulin lowering medication, has been employed as pre- treatment before and during stimulation for this group of women undergoing IVF. Initial trials demon-strated a decrease in the incidence of OHSS and even improved pregnancy and livebirth rates. Further trials are needed to confirm these findings.

18.7 Carbergoline

Recently, the dopamine agonist carbergoline has been used as a secondary prevention intervention for women at high risk of OHSS undergoing IVF. A meta-analysis of seven stud-ies showed that carbergoline reduces the occurrence of moderate-severe OHSS without any apparent negative impact on the outcome of treatment [ 7 ].

18.8 In-Vitro Maturation (IVM)

IVM naturally avoids the need for stimulation or at least involves minimal medication for women with PCOS under-going IVF. Oocytes recovered from unstimulated or mini-mally stimulated cycles are matured in culture, fertilised and the embryos replaced or frozen. This of course eliminates any chance of OHSS and reduces the cost of medication. Results however have, in the main, been disappointing and only spe-cialised centres are using IVM as a routine procedure for these cases. With the inception of the agonist trigger to avoid OHSS and the good results obtained in general for women with PCOS undergoing IVF, I remain unconvinced that IVM with its hard work for the embryologist and disappointing results, is the treatment of choice for the high responder.

18.8 In-Vitro Maturation (IVM)

176

References

1. Itskovitz J, Boldes R, Levron J, Erlik Y, Kahana I, Brandes J. Induction of pre-ovulatory luteinizing hormone surge and pre-vention of ovarian hyperstimulation syndrome by gonadotropin-releasing hormone agonist. Fertil Steril. 1991;56:213–20.

2. Youssef MA, van der Veen F, Al-Inany HG, Griesinger G, Mochtar MH, van Wely M. Gonadotropin-releasing hormone agonist versus hCG for oocyte triggering in antagonist assisted reproductive technology cycles. Cochrane Database Syst Rev. 2010;(11):CD008046.

3. Engmann L, DiLuigi A, Schmidt D, et al. The use of gonadotropin- releasing hormone agonist to induce oocyte maturation after cotreatment with GnRH antagonist in high-risk patients undergoing in-vitro fertilization prevents the risk of ovarian hyperstimula-tion syndrome: a prospective randomized controlled study. Fertil Steril. 2008;89:84–91.

4. Humaidan P, Bredkjaer HE, Westergaard LG, Andersen CY. 1,500 IU human chorionic gonadotropin administerd at oocyte retrieval rescues the luteal phase when gonadotropin-releasing hormone agonist is used for ovulation induction: a prospective, randomized, controlled study. Fertil Steril. 2010;93:847–54.

5. Griesinger G, Schultz L, Bauer T, Broessner A, Frambach T, Kissler S. Ovarian hyperstimulation syndrome prevention by gonadotropin- releasing hormone agonist triggering of fi nal oocyte maturation in a gonadotropin-releasing hormone antago-nist protocol in combination with a ‘freeze-all’ strategy: a pro-spective multicentric study. Fertil Steril. 2011;95:2029–33.

6. Griesinger G, Kolibianakis EM, Venetis C, Diedrich K, Tarlatzis B. Oral contraceptive pre-treatment signifi cantly reduces ongo-ing pregnancy likelihood in gonadotropin-releasing hormone antagonist cycles: an updated meta-analysis. Fertil Steril. 2010;94:2382–4.

7. Leitao VM, Moroni RM, Seko LM, Nastri CO, Martins WP. Carbergoline for the prevention of ovarian hyperstimulation syn-drome: systematic review and meta-analysis of randomized con-trolled trials. Fertil Steril. 2014;101:664–75.



Abstract For many years the principle adopted was that the greater the number of eggs retrieved, the greater the chance of a pregnancy. To achieve this aim, large doses of gonadotrophins are used, most commonly with a long GnRH agonist protocol. This regimen is long, expensive, requiring high gonadotrophin dosage and frequent monitoring and pre-disposes to ovarian hyperstimulation syndrome or, at the least, abdominal discom-fort. Unsurprisingly, it was the foresight of Robert Edwards that first called for the use of milder stimulation protocols and a more patient-friendly and safer approach in 1996. Since then much attention has been paid to this proposed change in think-ing and many different protocols have been devised with the purpose of easing the patient burden with increased safety and efficiency. It is difficult to recommend a natural cycle as results are so poor especially in older patients. A so-called modified natural cycle employing mild stimulation and a GnRH antago-nist has also produced disappointing results. The integration of clomifene and of letrozole into protocols has decreased gonad-otrophin consumption but little else. The principles involved in the search for an efficient mild stimulation protocol are both honourable and logical. The balance between patient comfort and cost and live birth rates has to be taken into account. This very much depends on the characteristics of the subject. While few have faith in natural cycles, other protocols described here show some promise in good prognosis patients and more well- conducted trials should establish their worth.

Chapter 19 Mild Stimulation Protocols

178

Keywords Mild stimulation • IVF • Fertilisation Ovarian stimulation gonadotrophins • GnRH • Ovarian hyperstimu-lation syndrome • OHSS • Pregnancy • Stimulation proto-cols • Natural cycles • LH • Oocyte • Premature ovulation • GnRH • Mini IVF • Late follicular phase • Follicle diameter • Dominant follicle • Male infertility • FSH • Follicular phase • Embryo • Multifollicular development • Endometrial • Clomifene • Aromatase inhibitors • Letrozole • Estradiol • Ovary • Androgens • Pre-antral follicles • Antral follicles

Steptoe and Edwards achieved the first successful IVF live birth in 1978 using an unstimulated cycle. Shortly following this milestone, it became obvious that increasing the num-ber of eggs retrieved and available for fertilisation would increase the pregnancy rate. Ovarian stimulation with gonadotrophins rapidly replaced natural cycles and preg-nancy rates grew considerably. For many years the princi-ple adopted was that the greater the number of eggs retrieved, the greater the chance of a pregnancy. To achieve this aim, large doses of gonadotrophins are used, most commonly with a long GnRH agonist protocol. This regi-men is long, often involving weeks of daily injections, is expensive, requiring high gonadotrophin dosage and fre-quent monitoring and pre-disposes to ovarian hyperstimu-lation syndrome or, at the least, abdominal discomfort. With the addition of the emotional stress involved in this relatively complex process, it is a testing ordeal for the couples to undergo which, in more cases than not, will not result in a pregnancy.

Unsurprisingly, it was the foresight of Robert Edwards that first called for the use of milder stimulation protocols and a more patient-friendly and safer approach in 1996. Since then much attention has been paid to this proposed change in thinking and many different protocols have been devised. The improvement in laboratory efficiency has made these advances feasible but each protocol has its distinct plusses and minuses.

Chapter 19. Mild Stimulation Protocols

179

19.1 Natural Cycles

The use of natural cycles for IVF is turning full circle back to the days of Edwards and Steptoe in the late 1970s. They com-prise of monitoring the cycle until the onset of the LH surge and the retrieval of one oocyte. Natural cycles can certainly be described as ‘patient-friendly’ as they are less demanding physically, cheap (less than 25 % the cost of a conventional cycle), and safe. But have we forgotten that the object of the exercise is to achieve a pregnancy? The problems that affect the success of natural cycles are many and include premature LH rises and premature ovulation (causing cancellation in 20 % of cycles) and a too large percentage of cycles in which no egg is retrieved. Problems in planning and coordination with the laboratory only add to these. A top ongoing preg-nancy rate of around 7 % per cycle is commonly quoted [ 1 ].

I have written of my perplexity and inability to understand the use of natural cycles for poor responders (Chap. 17 ) but what of other patient groups? With whatever protocol to which they have been compared, the results of natural cycles have been much the worse [ 2 ]. This led to the idea of offering natural cycles as a series of treatments. In studies of well selected patients, 4–11 natural cycles are variously calculated to produce the same live birth rate as one conventional cycle. Considering the time invested in oocyte retrievals and not least, the stress of the couples awaiting the results of the preg-nancy test and their frequent disappointments, it is difficult to condone natural cycles as the protocol of choice.

19.2 Modified Natural Cycles

The relatively disappointing results when employing a natu-ral cycle led to the development of a ‘modified natural cycle’. This ‘mini IVF’ stimulation protocol involves the administra-tion of a GnRH antagonist during the late follicular phase, usually with a dominant follicle diameter of about 14 mm, and then daily 75–300 IU of gonadotrophins to boost the

19.2 Modified Natural Cycles

http://dx.doi.org/10.1007/978-3-319-05612-8_17

180

growth of the dominant follicle (Fig. 19.1 ). This regimen, com-pared with the natural cycle approach reduced the number of cancelled cycles from 20 to 30 %. However, in a large group of young, good prognosis women undergoing their first IVF cycle, the ongoing pregnancy rate was 8.3 % per cycle using this protocol [ 3 ]. Although this is a safe and relatively patient-friendly protocol, results are again disappointing. It may find a place for young couples with severe male infertility.

19.3 Delayed Low-Dose FSH with GnRH Antagonist

Taking one step up from a modified natural cycle, in an attempt to improve pregnancy rates while achieving an improved degree of patient comfort compared with conven-tional protocols, FSH stimulation is started later in the

hCG

a 3mg cetrorelix

FSH/hMG

b 0.25mg/day

FSH/hMG

Follicle size – mm 14

Follicle size – mm 14 hCG

Figure 19.1 The suggested use of a GnRH antagonist in a modified natural cycle. ( a ) In a single dose; ( b ) in a multiple dose protocol


181

follicular phase (day 5–7), usually in a dose of 150 IU. An antagonist is given to prevent premature LH surges and a single embryo transfer is performed. The reasoning behind this protocol is that exogenous FSH will prevent a decrease in endogenous levels and that this is enough to induce multifol-licular development. Compared with conventional long ago-nist protocols less oocytes are harvested but their quality and implantation potential may be superior. The reasons for this are that high levels of oestrogens seem to have a negative effect on endometrial, oocyte and embryo quality. In addition, the trend towards single embryo transfer in good prognosis patients places less demand on the number of oocytes needed. A randomised, non-inferiority trial studied a late-start, low-dose FSH stimulation in an antagonist protocol with a single embryo transfer compared with a standard long agonist regi-men with transfer of two embryos [ 4 ]. There was no difference between the two protocols in terms of cumulative live birth rates or patients’ discomfort but the mild protocol had less multiple pregnancy and was overall, less expensive.

19.4 Clomifene Combined with Gonadotrophins

The main purpose in the use of clomifene citrate, usually given in a dose of 100 mg/day from the early follicular phase and combined with gonadotrophin administration, is to decrease the amount of gonadotrophins required. This utilises the property of clomifene to cause a release of endogenous FSH early in the cycle. The trials of this regi-men are very heterogeneous and it is difficult to formulate a conclusion regarding its’ worth. A Cochrane analysis [ 5 ] suggested that the combination of clomifene with gonado-trophins (with or without a GnRH antagonist) did not dif-fer significantly from gonadotrophins in agonist protocols in terms of pregnancy rates but had reduced rates of OHSS. More trials were called for.

19.4 Clomifene Combined with Gonadotrophins

182

19.5 Aromatase Inhibitors Combined with Gonadotrophins

The aromatase inhibitor letrozole has two properties that could suggest its’ use in mild stimulation protocols. Similarly to clomifene, it induces an endogenous FSH release but also, the blocking of estradiol production from androgens induces an increased concentration of androgens in the ovary. As androgens promote the early development of follicles, they increase the number of pre-antral and small antral follicles available for stimulation (See Chap. 8 ). Small trials in poor responders have shown mixed results when letrozole adminis-tration in a dose of 2.5–5 mg/day was combined with gonado-trophins but have shown some promise in normal responders. The use of letrozole for this purpose has been severely limited due to the restrictions placed on its use for this indication by the drug company due to unsubstantiated data regarding pos-sible teratogenicity. It is hoped that further large controlled trials of the use of letrozole in IVF will be forthcoming.

19.6 Summary

The principles involved in the search for an efficient mild stimulation protocol are both honourable and logical. The balance between patient comfort and cost and live birth rates has to be taken into account. This very much depends on the characteristics of the subject. While I have little faith in natu-ral cycles, other protocols described here show some promise in good prognosis patients and more well-conducted trials should establish their worth.

References

1. Pelinck MJ, Hoek A, Simons AH, Heineman MJ. Effi cacy of natu-ral cycle IVF: a review of the literature. Hum Reprod Update. 2002;8:129–39.


http://dx.doi.org/10.1007/978-3-319-05612-8_8

183

2. Verberg MFG, Macklon NS, Nargund G, et al. Mild ovarian stimulation for IVF. Hum Reprod Update. 2009;15:13–29.

3. Pelinck MJ, Vogel NE, Hoek A, et al. Cumulative pregnancy rates after three cycles of minimal stimulation IVF and results accord-ing to subfertility diagnosis: a multicentre cohort study. Hum Reprod. 2006;21:2375–83.

4. Heijnen EM, Eijkemans MJ, De Klerk C, et al. A mild treatment strategy for in-vitro fertilisation: a randomised non-inferiority trial. Lancet. 2007;369:743–9.

5. Gibreel A, Maheshwari A, Bhattacharya S. Clomiphene citrate in combination with gonadotrophins for controlled ovarian stimula-tion in women undergoing in vitro fertilization. Cochrane Database Syst Rev. 2012;(11):CD008528.

References


Abstract Ovarian hyperstimulation syndrome (OHSS) is brought about by overstimulating the ovaries with gonado-trophins, whether during ovulation induction or so-called controlled ovarian hyperstimulation before intra-uterine insemination (IUI) or IVF. It is a purely iatrogenic condition which is largely preventable and often foreseeable. Those at risk to develop OHSS are young, lean and/or have polycystic ovaries, high serum AMH concentrations and a high antral follicle count and patients who have had OHSS in a previous cycle. For ovulation induction only a low-dose gonadotrophin protocol should be used as this will eliminate the incidence of OHSS. For IVF in patients predicted to be at high risk for OHSS, a GnRH antagonist protocol is recommended with the use of a GnRH agonist trigger. OHSS does not occur if hCG is withheld and it may be classified as early, due solely to the hCG injection or late, due to the added effect of hCG secreted by the developing pregnancy. Monitoring, accord-ing to the severity of the symptoms, should include fluid and electrolyte balance with detailed recording of fluid input and output, measurement of the extent of intravascular volume decrease including frequent measurements of haematocrit and arterial pressure. Central venous pressure measurement is essential for the more severe cases. Baseline renal and liver function tests should be monitored. Treatment is sup-portive, according to severity, mainly re-hydration and the

Chapter 20 Ovarian Hyperstimulation Syndrome

186

maintenance of intravascular fluid volume and blood vol-ume expanders when indicated. Relief of ascites and pleural effusions may be necessary.

Keywords Ovarian Hyperstimulation Syndrome • OHSS • Controlled ovarian hyperstimulation • Multiple pregnancy • Gonadotrophins • Ovaries • Intra-uterine insemination IUI • IVF • hCG • Trophoblast • Ovulation • Follicles • Dominant follicle • Mild stimulation • Ovum pick-up • FSH • Oestradiol • Vascular endothelial growth factor • VEGF • Angiotensin II • Interleukin 6 • Ascitic fluid • Intravascular hypovolaemia • Arterial hypotension • Arterial vasoconstric-tion • Haemoconcentration • Thromboembolic • AMH • Antral follicle • Luteotrophic effect • Luteal phase • Embryos • Progesterone • Intravenous albumin • In-vitro maturation • Corpus luteum • recLH • Metformin • Carbergoline • Ovarian electrocautery follicular aspiration • Haematocrit • Haemoconcentration • Arterial pressure • Dyspnea • Renal function • Frusomide

Two major complications plague ovulation induction and so- called controlled ovarian hyperstimulation (COH): ovarian hyperstimulation syndrome (OHSS) and multiple pregnan-cies. Both are regarded as serious complications in their own way. OHSS can be so serious that it may even be life threat-ening to the patient and multiple pregnancy may also be life threatening but to the fetuses. Both are very largely prevent-able. Awareness of the possibilities that either may occur is the first step in their prevention. Having this awareness, steps can be taken to minimize their occurrence. The main aim of this chapter is to emphasize this awareness and preventative steps that can be taken as well as management for OHSS.

Ovarian hyperstimulation syndrome (OHSS) is brought about by overstimulating the ovaries with gonadotrophins, whether during ovulation induction or so-called controlled ovarian hyperstimulation before intra-uterine insemination (IUI) or IVF. It is a purely iatrogenic condition which is

Chapter 20. Ovarian Hyperstimulation Syndrome

187

largely preventable and often foreseeable. It does not occur if hCG is withheld. OHSS may be classified as early, due solely to the hCG injection or late, due to the added effect of hCG secreted by the trophoblast of the developing pregnancy.

20.1 Aetiology and Pathophysiology

While the exact aetiology of OHSS is still unknown, clearly it is basically due to over-stimulation of the ovaries by exoge-nous gonadotrophins followed by hCG to trigger ovulation. This may occur during ovulation induction and during ovar-ian stimulation before IUI or IVF. As the aims of these three treatment modes are different, the amount of gonadotro-phins administered differs, ranging from gentle stimulation to ideally produce one dominant follicle, mild stimulation to produce 2–3 large follicles and stronger stimulation to pro-duce say, 5–15 follicles respectively. It therefore would be expected that the incidence of OHSS during IVF cycles would be the highest but this is not necessarily the case. The plausible explanation for this is that during puncture of the follicles and ovum pick-up, follicular fluid containing many of the probable aetiological ingredients of OHSS are extracted from the ovary. This is obviously not the case during ovula-tion induction or stimulation for IUI.

In addition, there is a great individual variation involved, not only in the ovarian threshold for FSH required for stimu-lation but also in those who will develop OHSS and those who will not, despite receiving equivalent or even greater amounts of FSH and producing more follicles and oestradiol. Although certain risk factors do predispose to the likelihood of developing OHSS and should be well heeded, accurate prediction remains elusive.

Clearly, hCG, whether exogenous or endogenous, is the trigger releasing a factor or factors which initiate the progress of the syndrome. As the syndrome is basically one principally affecting the vascular department initially, the suspected fac-tors are naturally those that are released by hCG following

20.1 Aetiology and Pathophysiology

188

ovarian stimulation with gonadotrophins. The usual suspects include oestradiol, renin and angiotensin II, interleukin 6 and, probably the most important, vascular endothelial growth factor (VEGF). All these have the property of causing vaso-dilatation and capilliary hyperpermiability and all are pro-duced in much increased quantities when the ovary is stimulated and ovulation triggered by hCG. Although a high oestradiol level can affect capilliary permeability, it is not capable of producing OHSS without hCG. In contrast, angio-tensin II, interleukin 6 and VEGF are all produced by the ovary, their concentrations greatly enhanced by hCG, concen-trations are extremely high in OHSS and all cause important changes in the vascular system.

The changes in the vascular system at the onset of OHSS are primarily vascular dilatation and increased permeability. These changes initiate a cascade of events starting with a loss of fluid and proteins from intra- to extravascular (third) space so reducing intravascular volume. Accumulating ascitic fluid in the abdominal cavity and, more extremely, in the pleural cavity, may be the result. Changes in osmotic fluid gradient intensify the intravascular hypovolaemia and the arterial hypotension can induce arterial vasoconstriction. As a result, renal function may be affected and sodium and water are retained. Increasing haemoconcentration is the key aetio-logical feature of life- threatening OHSS. Oliguria, renal fail-ure and blood hypercoagulability leading to thromboembolic phenomena, the commonest cause of death from OHSS, are to be feared.

According to the severity of these symptoms and signs, a simple classification has been proposed (Table 20.1 ).

20.2 Risk Factors

Knowing the risk factors predisposing to OHSS is an essen-tial ingredient in the prevention of the syndrome (Table 20.2 ). In the first cycle, at least, gonadotrophin stimulation, i.e. dos-age and rate of dose increments, should be undertaken cau-tiously in those patients who are at risk.


189

Table 20.1 Classifi cation of ovarian hyperstimulation syndrome

Mild

Abdominal bloating and discomfort

Ovarian enlargement up to 8 cm

Moderate

Criteria for Mild + nausea, vomiting or diarrhoea

Ultrasound evidence of ascites

Ovarian enlargement up to 12 cm

Severe

Criteria for Moderate +

Oliguria <500 ml/24 h

Serum creatinine 1.0–1.5 mg/dl

Haematocrit >45 %, leucocytosis >15,000/ml

Clinically evident ascites +/− pleural effusion

Critical

Tense ascites with pleural and/or pericardial effusions

Haematocrit >55 %, leukocytosis >25,000/ml

Oliguria with serum creatinine >1.5 ml/dl

Renal failure, liver dysfunction

Thromboembolic phenomena

Those at risk to develop OHSS are young, lean and/or have polycystic ovaries, high serum AMH concentrations and a high antral follicle count. Patients who have had OHSS in a previous cycle should also be approached cautiously.

A suspicion of impending OHSS can also be made during gonadotrophin stimulation. Multiple follicle development is a serious warning sign. In ovulation induction and stimulation before IUI, the development of more than five to six follicles

20.2 Risk Factors

190

>9 mm diameter or in IVF, >30 such follicles should set the alarm bells ringing and urge a consideration of some preven-tive action. With or without this number of follicles, in ovula-tion induction (or COH for IUI) and in IVF, oestradiol concentrations of >1,500 pg/ml (5,500 pmol/l) and >3,000 pg/ml (11,000 pmol/l) respectively should provide a similar warning. These are merely pointers which urge, at the least, awareness and watchfulness. Their actual predictive value is not high. The contribution of small developing follicles is surprisingly large and this often goes unheeded. Monitoring must be more intensive than usual and same–day oestradiol measurements are needed in these cases, even if not per-formed routinely.

Table 20.2 Risk factors for ovarian hyperstimulation syndrome

Before starting treatment

<30 years old

Lean body habitus

Polycystic ovaries

Previous OHSS

Serum AMH >30 pmol/l

Antral follicle count >12

During treatment

Rapidly rising oestradiol concentrations

Very high oestradiol concentrations

Large number of developing follicles

Luteal support with hCG

Pregnancy, particularly multiple pregnancy


191

20.3 Prevention (See Also Chap. 18 )

20.3.1 Ovulation Induction and COH for IUI

1. For patients who have any of the predisposing factors men-tioned in Table 20.2 , use a smaller starting dose than rou-tine and use small incremental dose rises when necessary. For example, for patients who have one or more of the above criteria, for ovulation induction use a chronic low-dose protocol starting with 25–75 IU of FSH with incre-mental dose rises of 12.5–37.5 IU FSH only after 14 days and then at weekly intervals when necessary (See Chap. 9 for full details). In a further cycle, the starting dose can be adjusted if necessary according to the response in the fi rst cycle. For COH before IUI in such patients, we also use the same starting doses as in the chronic low dose protocol. If the danger of OHSS looks imminent during ovarian stimu-lation, i.e. a large number of developing follicles, rapidly rising oestradiol levels, very high oestradiol levels, with-holding hCG is the surest way to prevent OHSS. Alternative strategies are mentioned below.

2. Coasting is a possible alternative to abandoning the cycle and may save the frustration and depression incurred. This method is not widely used as results have proved to be mis-erable as far as the pregnancy rate is concerned but it can be applied when ovarian stimulation overshoots e.g. in ovu-lation induction when oestradiol levels reach 1,500 mg/ml (5,500 pmol/l) or more and/or more than three dominant follicles or a large number of intermediate size follicles develop. The principle behind coasting is that when tem-porarily deprived of FSH stimulation, many of the smaller follicles and some of the leading follicles will regress with a consequential decrease in oestradiol levels to a point where hCG can be given more safely. While this method does not completely eliminate OHSS, in many cases it saves the cycle. It does however compromise pregnancy

20.3 Prevention

http://dx.doi.org/10.1007/978-3-319-05612-8_18

http://dx.doi.org/10.1007/978-3-319-05612-8_9

192

rates. Timing of hCG administration is the key to success and intensive monitoring of oestradiol concentrations and ultrasound is needed every 1–2 days. Once oestradiol lev-els have normalized, depending on the number and size of follicles seen, hCG can be given or FSH stimulation renewed. Coasting cannot continue for more than 2 days, after which pregnancy rates are almost nil.

3. If overstimulation occurs during ovulation induction, some would advocate recourse to follicular puncture, oocyte retrieval and IVF in order to prevent OHSS without aban-doning the cycle, so-called rescue IVF. The problem of this approach is that a snap decision has to be taken by both patient and doctor without the usual preparation, both emotional and physical, for an IVF procedure.

20.3.2 IVF

1. For IVF in patients predicted to be at high risk for OHSS, a GnRH antagonist protocol is recommended. Compared with the long agonist protocol, the chance of OHSS is considerably reduced as the gonadotrophin requirement is less. In addition to the other advantages of the antago-nist regarding patient comfort, essentially the use of the antagonist allows the possibility of employing an agonist trigger of ovulation instead of hCG, eliminating the pos-sibility of OHSS (see below).

2. For women undergoing IVF and predicted to be at high risk to develop OHSS, a starting dose of 100–150 IU is recommended. The tendency to use minimally stimulated cycles for IVF in high risk patients reduces the incidence of OHSS considerably and despite a lower yield of recov-ered oocytes, pregnancy rates should not be affected.

3. Giving one shot of a GnRH agonist to trigger an LH release instead of hCG has revolutionised the treatment of women undergoing ovarian stimulation for IVF. The rationale and management have been fully described in Chap. 18 but will briefl y be repeated here. In a conven-tional IVF cycle hCG is used to trigger ovulation as a


http://dx.doi.org/10.1007/978-3-319-05612-8_18

193

surrogate for the LH surge which triggers ovulation in a normal cycle. The hCG trigger has a half life of about 34 h and has a prolonged luteotrophic effect. In susceptible patients it may induce OHSS. The substitution of hCG by a GnRH agonist produces an LH (and FSH) surge with amplitudes similar to those seen in a normal ovulatory cycle, suffi cient to trigger ovulation but with a much less prolonged action than hCG. This led to the idea that using an agonist rather than an hCG trigger in an antagonist cycle could prevent OHSS. Although totally preventing OHSS, the luteal phase is rendered insuffi cient and con-ventional luteal phase support with progesterone is not enough to maintain pregnancy rates. There are three pos-sible ways to overcome this: (1) Administer massive luteal support with oestrogen patches and daily injections of progesterone. (2) Inject 1,500 IU hCG on the day of ovum pick- up and continue with progesterone vaginal supposi-tories [ 1 ] or (3) Adopt a ‘freeze-all’ policy and replace embryos in a subsequent cycle, the most effi cient method of totally eliminating OHSS while maintaining excellent pregnancy rates [ 2 ].

This method is not applicable for IVF cycles in which the GnRH agonist is used for down regulation.

4. Embryo cryopreservation is a viable method to prevent late onset OHSS caused by the hCG of a pregnancy in a cycle destined for OHSS. Embryos obtained are frozen and rather than being replaced in the same cycle, are replaced in a non-stimulated cycle.

5. The avoidance of giving hCG as luteal support in a poten-tial case of OHSS is a must. Progesterone administered vaginally serves the purpose just as well without any increase in risk.

6. The administration of intravenous albumin around the time of hCG administration as a preventative measure to avoid OHSS found some initial enthusiasm but cannot be recommended on present available evidence. While one mode of action is to temporarily preserve intravas-cular volume, this may work as a double-edged sword if the albumin leaks into the third, extravascular space.

20.3 Prevention

194

Additionally, albumin apparently binds vasoactive sub-stances. It has a short half-life and may cause an allergic reaction. Other plasma expanders are being examined for the same purpose.

7. In-vitro maturation of oocytes (IVM) could provide a very satisfactory reduction in OHSS rates for patients particularly susceptible to OHSS. However, pregnancy rates have proved disappointing and this procedure is probably best restricted to specialist centres.

8. Recombinant LH used to trigger ovulation instead of hCG has been suggested as a viable alternative to avoid OHSS. It has a much shorter half-life than hCG and a repeat dose(s) in the luteal phase is required to maintain the corpus luteum. The use of an agonist trigger has super-ceded the use of recLH and is also cheaper.

9. Although according to the LH ceiling hypothesis, prepa-rations containing LH or hCG decrease the development of small and intermediate follicles, little advantage regarding the incidence of OHSS has been found by using urinary hMG rather than recombinant FSH.

10. Metformin, an insulin lowering medication, has been employed as pre-treatment before and during stimulation for women with PCOS undergoing IVF. Initial trials dem-onstrated a decrease in the incidence of OHSS and even improved pregnancy and live-birth rates. Further trials are needed to confi rm these fi ndings.

11. Recently, the dopamine agonist carbergoline has been used as a secondary prevention intervention for women at high risk of OHSS undergoing IVF. A meta-analysis of seven studies showed that carbergoline reduces the occur-rence of moderate-severe OHSS without any apparent negative impact on the outcome of treatment [ 3 ].

12. Coasting can be tried when oestradiol concentrations rise to more than 2,750 pg/ml (10,000 pmol/l). This method is limited for reasons mentioned above.

13. Two further methods to prevent OHSS have been pro-posed, ovarian electrocautery and follicular aspiration from one ovary. Both work on the principle of reducing


195

hormonal and presumed OHSS aetiological factors pro-duced by the ovary by destroying follicles and other ovar-ian structures. Presently, there is not enough solid evidence to recommend these invasive procedures.

20.4 Treatment

Mild OHSS is fairly common during both ovulation induction and stimulation for IUI and IVF. It does not usually require hospitalization and can be treated expectantly as OHSS is a self- limiting syndrome. When hCG levels regress, after a week in the non-pregnant and after 2–3 weeks in the preg-nant, symptoms also start to regress. I always recommend a high fluid intake, even in the mildest of cases in the hope that this may prevent the progression of symptoms. Patients com-plaining of abdominal bloating and discomfort should never be ignored and always examined.

Moderate to severe cases of OHSS need hospitalization and intensive monitoring. Monitoring, according to the sever-ity of the symptoms, should include fluid balance and electro-lyte concentrations with detailed recording of fluid input and output, measurement of the extent of intravascular volume decrease including frequent measurements of haematocrit as a measure of haemoconcentration and arterial pressure. Central venous pressure measurement is essential for the more severe cases. Baseline renal and liver function tests should be performed on admission and repeated frequently with any deterioration in the condition.

Treatment is supportive, according to the severity until the syndrome starts to improve spontaneously with the appear-ance of the next menstruation or after several weeks in the presence of pregnancy. The essential feature of the supportive treatment is re-hydration and the maintenance of intravascu-lar fluid volume. Initially, this can be done with an intrave-nous infusion of normal saline or Hartman’s solution, while carefully monitoring blood pressure, haemoconcentration and urinary output. Various blood volume expanders are also

20.4 Treatment

196

recommended when indicated: crystalloids are usually the first step and, if not successful, dextran, fresh frozen plasma or low-salt albumin in doses and frequency titrated against the fluid balance.

A tense ascites, especially when causing abdominal dis-comfort and dyspnea and associated with decreased renal function, should be relieved by paracentesis if the patient is haemodynamically stable. It may be done trans-abdominally or trans- vaginally and, in either case, should be ultrasound guided. Rapid drainage is not advised as this may induce a rapid deterioration in intravascular volume. This can be avoided by using a closed system catheter with a locking device which is also very useful for avoiding repeated punc-tures. Pleural effusions should be tapped if thought to be causing symptoms.

The use of diuretics is not generally advised as they will cause a further deterioration in the intravascular fluid vol-ume. The exception to this rule is when the patient has been fully hydrated but oliguria persists. Even then, it should be given cautiously, e.g. frusomide, 10 mg intravenously, every 4–6 h, and stopped once urinary output improves.

The ultimate aim of all this supportive treatment is the prevention of deterioration into the life-threatening stage, in particular correcting a haematocrit of >55 %, electrolyte imbalance, oliguria, serum creatinine of >1.6 mg/dl, respira-tory distress and the avoidance of thromboembolic phenom-ena involving anti- coagulant medications. If the syndrome arrives to this stage, it is not a loss of face to the treating physician if the services of experts in intensive care, renal, anaesthetic and cardiac medicine are called for, especially if they are familiar with the peculiarities of OHSS.

20.5 Conclusions

The majority of cases of moderate to severe OHSS are pre-ventable. The possible seriousness of this condition demands a lowering of the ambition of the practitioner to achieve a


197

pregnancy “at all costs”. The use of an antagonist protocol and an agonist trigger in predicted high responders at risk of OHSS, preferably followed by a ‘freeze-all’ strategy, should permit the ideal of an OHSS free unit. If this is not possible, an additional month of treatment is worth more than weeks or more of intense suffering and danger to maternal health.

References

1. Humaidan P, Bredkjaer HE, Westergaard LG, Andersen CY. 1,500 IU human chorionic gonadotropin administerd at oocyte retrieval rescues the luteal phase when gonadotropin-releasing hormone agonist is used for ovulation induction: a prospective, randomized, controlled study. Fertil Steril. 2010;93:847–54.

2. Griesinger G, Schultz L, Bauer T, Broessner A, Frambach T, Kissler S. Ovarian hyperstimulation syndrome prevention by gonadotropin- releasing hormone agonist triggering of fi nal oocyte maturation in a gonadotropin-releasing hormone antago-nist protocol in combination with a ‘freeze-all’ strategy: a pro-spective multicentric study. Fertil Steril. 2011;95:2029–33.

3. Leitao VM, Moroni RM, Seko LM, Nastri CO, Martins WP. Carbergoline for the prevention of ovarian hyperstimulation syn-drome: systematic review and meta-analysis of randomized con-trolled trials. Fertil Steril. 2014;101:664–75.

References


Abstract The problem of multiple pregnancies hangs like a millstone around the neck of ovulation induction and ovarian stimulation for IUI and for IVF/embryo transfer. Multiple pregnancies carry an increased risk of premature delivery (×5), perinatal morbidity and mortality and psychological (and financial) implications for the parents. In ovulation induction the predisposing factor is multiple follicular devel-opment as it is for gonadotrophin stimulation before IUI whereas in IVF/embryo transfer, it is purely a reflection of the number of embryos transferred. The use of low-dose gonado-trophin protocols minimizes the risk of multiple pregnancies in ovulation induction and stimulation for IUI whereas in IVF/embryo transfer, the high multiple pregnancy rate can be considerably reduced by employing a selective single embryo transfer (eSET) policy without seriously affecting pregnancy rates in suitable candidates especially when frozen/thawed embryos are utilized in subsequent cycles.

Elective single embryo transfer will hopefully be more widely adopted as methods for embryo selection improve as it is the obvious solution for the reduction of the present unacceptable multiple pregnancy rates.

Keywords Multiple Pregnancies • Ovulation induction • Ovarian stimulation • IUI • IVF • ICSI • Embryo trans-fer • Perinatal morbidity • Mortality • Gonadotrophin • Iatrogenic • Assisted reproductive technologies • Multiple

Chapter 21 Multiple Pregnancies

200

embryo transfers • Selective single embryo transfer • eSET • Mature follicles • hCG • Clomiphene • Dominant follicle • OHSS • Anovulatory patients • PCOS • Intra-uterine insemi-nation • Male infertility • Controlled ovarian stimulation • Mild stimulation • Monofollicular ovulation • Freezing • Embryos • Frozen-thawed SET • Foetal reduction

The problem of multiple pregnancies hangs like a millstone around the neck of ovulation induction and ovarian stimula-tion for IUI and for IVF/embryo transfer. While a multiple pregnancy may be regarded by some patients as a blessing or a way of completing their family “in one go”, if they knew of the increased risk of premature delivery (×5), perinatal mor-bidity and mortality and the psychological (and financial) implications for the parents, their joy may be quelled.

The annoying point regarding the high multiple pregnancy rates in all forms of gonadotrophin driven ovarian stimulation is that it is very largely iatrogenic and preventable. The driving ambition of both doctor and patient to achieve a pregnancy (and this is pressure emanating from either or both sides) often encourages caution to be thrown to the winds with an “all or nothing” mentality. In ovulation induction the predis-posing factor is multiple follicular development as it is for gonadotrophin stimulation before IUI whereas in IVF/embryo transfer, it is purely a reflection of the number of embryos transferred. In all of these treatment modes, particularly in IVF/embryo transfer, the high multiple pregnancy rate can be reduced by taking the correct measures which, on the whole, will not significantly reduce the overall pregnancy rate.

21.1 Incidence of Multiple Pregnancies

The incidence of spontaneous multiple pregnancies is about 1 in 80. Predisposing factors are familial and a later reproduc-tive age. These factors are hardly preventable.

Chapter 21. Multiple Pregnancies

201

With the inception of gonadotrophin induction of ovula-tion and then various assisted reproductive technologies, twinning and, more disturbingly, high order multiple preg-nancy rates grew remarkably. It is only in the last few years that it has been realized that inducing multiple pregnancy cannot necessarily be regarded as a “success”.

Regarding ovulation induction with gonadotrophins, a col-lection of data from 14 large published series which was reported in 1990 [ 1 ] revealed a mean multiple pregnancy rate of 34 %. All women in these series had undergone gonado-trophin induction of ovulation, using a conventional protocol, due to either WHO Group I or Group II anovulation. This multiple pregnancy rate has been drastically reduced to below 6 % by the introduction of the low-dose protocol for gonadotrophin induction of ovulation (See Chap. 9 ).

Results for IUI preceded by gonadotrophin stimulation of the ovaries are a cause for concern. Whether the indication is unexplained infertility or a mild sperm deficiency, multiple pregnancy rates for IUI with gonadotrophin stimulation in 2001 ranged from 18.1 to 29 % [ 2 , 3 ]. In one of these studies it was specifically noted that multiple pregnancy was a fre-quent result when more than four mature follicles were induced. This fact gives the clue to their prevention. Taking heed of this in Europe, in 2009 the twin and triplet rates from IUI were 10.4 and 0.6 % respectively [ 4 ].

Data collections for IVF/ICSI for all indications in Europe demonstrate an impressive reduction in multiple birth rates due to a decrease in the number of multiple embryo transfers and the adoption of a selective single embryo transfer (eSET) policy in a number of countries. In 1999 the multiple birth rate in Europe from IVF procedures was 26.3 %, made up of 24 % twins, 2.2 % triplets and 0.1 % higher order [ 5 ]. Ten years later, the multiple birth rate was 20.2 %, made up of 19.4 % twins and 0.8 % triplets [ 4 ]. The U.S.A. still lags way behind Europe. In 2010, in the USA, 46.4 % of ART infants were multiples made up of 43.4 % twins and 3.0 % triplets and higher order [ 6 ].

21.1 Incidence of Multiple Pregnancies

http://dx.doi.org/10.1007/978-3-319-05612-8_9

202

21.2 Preventative Methods

21.2.1 In Ovulation Induction

The prevalence of multiple pregnancy during ovulation induc-tion is almost entirely dependent on the number of large, mature follicles that develop as a result of ovarian stimulation. The problem is that, the larger the number of follicles over 15 mm on the day of hCG, usually the higher the pregnancy rate (Table 21.1 ) and this tempts many practitioners to ‘go for it’ and hope for the best. However, from the table, it can be seen clearly that the prevalence of multiple pregnancy increases from 5.1 % with 1 large follicle, 11.7 % with 2, 20 % with 3 and so on. The first course of action, apparent from this data, is that if hCG is withheld when 3 or more large follicles develop or intercourse postponed, the multiple pregnancy rate during any form of ovulation induction, be it with clomi-phene or gonadotrophins, can be severely reduced.

The second course of action would be to encourage the growth of one dominant follicle only. This can be largely achieved today by using a chronic low dose protocol in prefer-ence to the conventional protocol widely used up to some years ago. This regimen, the rationale behind it and the results achieved have been described in detail in Chap. 9 so will only be

Table 21.1 Multiple birth rate related to the number of follicles >15 mm on hCG day

No. of follicles on dhCG

No. of cycles

Clinical pregnancies Births Multiple

birth rate (%) No.

Rate/cycle (%) No. Twins

1 277 47 17.1 39 2 5.1

2 77 20 26.0 17 2 11.7

3 32 11 34.4 10 2 20.0

>3 19 5 26.3 4 2 50.0

Ares-Serono (1995), with permission


http://dx.doi.org/10.1007/978-3-319-05612-8_9

203

dealt with very briefly here. Conventional ‘step- up’ treatment involving relatively high starting doses and frequent incremental dose rises with gonadotrophins characteristically induces multi-ple follicular development by overstepping the FSH threshold and results in a high frequency of multiple pregnancies and OHSS. Chronic low-dose gonadotrophin therapy demands the attainment and maintenance of follicular development with exogenous FSH without exceeding the threshold requirement of the ovary. The principle of the classic chronic low dose regi-men, shown in Fig. 9.1 , is to employ a low starting dose for 14 days and then use small incremental dose rises (25–37.5 IU) when necessary, at intervals of not less than 7 days, until follicu-lar development is initiated [ 7 ]. The dose that initiates follicular development is continued until the criteria for giving hCG are attained. A single dominant follicle, rather than the develop-ment of many large follicles, can be achieved in at least 70 % of cycles so completely avoiding OHSS and keeping the multiple pregnancy rate below 6 % while maintaining a good pregnancy rate [ 8 ]. The majority of patients on a low dose protocol develop a single large follicle meeting hCG administration criteria within 14–16 days without any change in the initial dose for 14 days.

There is now sufficient evidence to demonstrate that low dose, step-up gonadotrophin therapy should be the only treatment of choice for anovulatory patients and particularly for those with PCOS. Small starting doses in the first cycle for a 14-day initial period without a dose change and then a small incremental dose rise if required, are the secrets for success as they produce the best results.

21.2.2 In Ovarian Stimulation Preceding Intra- uterine Insemination (IUI) (See Also Chap. 15 )

The overly high multiple pregnancy rate presently being obtained in ovarian stimulation protocols for IUI, whether for idiopathic infertility or for a minimal sperm deficiency, can be overcome in two possible ways:


http://dx.doi.org/10.1007/978-3-319-05612-8_9#Fig1

http://dx.doi.org/10.1007/978-3-319-05612-8_15

204

1. Using natural cycles without any stimulation 2. Using minimal stimulation similar to that in a low dose

protocol.

Multiple pregnancy rates for IUI in a natural cycle with no stimulation are obviously at an absolute minimum level. However, the majority of large studies and meta-analyses [ 9 , 10 ], have shown the superiority of ovulation stimulation in terms of pregnancy rates but this has been at the expense of very much increased multiple pregnancy rates compared with IUI on a natural cycle. There is an ascending pregnancy rate and ascending multiple pregnancy rate, in order, from natural cycles, clomiphene stimulated to gonadotrophin stimulated. However, two studies, both well controlled, the first treating mild male factor infertility [ 11 ] and the other [ 3 ] both idiopathic and mild male infertility, found no signifi-cant difference in the pregnancy rate between natural and gonadotrophin stimulated cycles for IUI. In my own experi-ence, gonadotrophin stimulated cycles are preferable regard-ing pregnancy rates for unexplained infertility. The ideal then, would seem to be a cross between the two, i.e. our second alternative to lower multiple pregnancy rates, mini-mal stimulation with gonadotrophins. For mild male infertil-ity, gonadotrophin stimulation adds little to the results obtained using a natural cycle.

Mild, controlled ovarian stimulation (COH) before IUI sounds something of a paradox as one of the explanations why the combination of COH yields results in idiopathic and mild male factor infertility is an increased production of large mature follicles. However, the additional theories explaining why gonadotrophin adds to the success include correction of a subtle, undiscovered ovulatory defect, improved endocrine environment and uterine receptivity. If, therefore, we can keep the number of large mature follicles on the day of hCG below 3 or 4, we may be able to reap the benefits of stimula-tion without an unacceptable multiple pregnancy rate. This can be achieved by using a low daily dose (50–75 IU), at least in the first cycle and increasing by only one half of this amount in the next cycle if monofollicular ovulation only was


205

achieved in the first attempt. While this approach may seem cautious and certainly not foolproof, it must surely improve multiple pregnancy rates in IUI treatment cycles without significant detriment to pregnancy rates. As I have repeated several times in this book, taking a further month or so to achieve a healthy singleton pregnancy is preferable to the possible agonies involved in a multiple pregnancy, especially if it is of high order.

21.2.3 IVF/Embryo Transfer

The aetiology of multiple pregnancies following IVF is com-pletely different from that of ovulation induction or stimulation for IUI. The way to reduce multiple pregnancy rates in IVF is, therefore, also completely different. In IVF the number of embryos transferred has a direct bearing on the number of result-ing multiple pregnancies – the more embryos transferred, the more multiple pregnancies result. It follows that a reduction in the number of embryos transferred will bring down the multiple pregnancy rate. Although many countries have implemented strict laws regarding the number of embryos that may be trans-ferred, at least in the under 40 year-olds, the tardiness in arriving at the ideal, elective single embryo transfer, is due to the accom-panying reduction in pregnancy rates. Much of this suspicion has been overcome thanks to pioneering schemes in Scandinavia and Belgium where eSET is being applied successfully for young, good prognosis patients with a consequent dramatic reduction in multiple pregnancy rates. However, logic dictates that for eSET to produce good results, superior methods to select the single embryo to be transferred must be found. This is now the subject of intensive research, much of it directed at time- lapse imaging of embryo growth (see Chap. 22 ), and, more controversially, revolv-ing around methods of pre- implantation genetic survey.

While single embryo transfer (SET) is the obvious solu-tion to reduce multiple pregnancy rates, the question remains whether, while obviously drastically reducing multiple preg-nancy rates, it can produce results similar to that of a two- embryo transfer. An old systematic review of the literature


http://dx.doi.org/10.1007/978-3-319-05612-8_22

206

[ 12 ] involving three randomized trials and 17 cohort studies did indeed show that SET is associated with a decreased inci-dence of clinical pregnancy. However, when considering sin-gleton pregnancy or singleton life birth as the end-points, then SET did not alter this likelihood compared with transfer of two or more embryos. In other words, the difference in pregnancy rates is mostly made up by the addition of the number of multiple pregnancies from the transfer of two or more embryos. This point is well illustrated from a model comparing single with double embryo transfer [ 13 ] in which the assumption was that with SET the chance of having a child was 21 % with virtually no multiples compared with a 24.8 % chance of a singleton child and a 7.8 % chance of twins when two embryos are transferred.

A sensible suggestion [ 14 ] seems to be to select for eSET those patients who are at the highest risk for a multiple preg-nancy i.e. young, first or second cycle of IVF with a good number of high quality embryos.

When eSET is performed in young, good prognosis patients, almost invariably embryos are available for freezing. This could be a game changer as there is no evidence of a significant difference in the cumulative live birth rate when a single cycle of double embryo transfer is compared with a repeated frozen-thawed SET cycle [ 15 ]. This policy minimizes the risk of multiple pregnancy without substantially reducing the likelihood of achieving a live birth.

It is easy to foresee that eSET will be become a much more acceptable, and, therefore, more widespread practice with the enormous benefit of a drastic reduction in multiple pregnancies.

21.3 Foetal Reduction

The availability of methods for the culling of foetuses in utero, euphemistically named foetal reduction, is not in any shape or form, an excuse for ‘taking a chance’ and replacing an inordi-nate number of embryos to increase the chances of pregnancy.


207

If ever there was a case for ‘prevention is better than cure’ this is it! The procedure, in addition to being repulsive and psycho-logically damaging, whether performed at 8 or 14 weeks or later, often presents an agonising choice of which foetus(es) are to be destroyed. The chances of losing the whole preg-nancy as a result of the procedure are not small. While real-izing the inevitability of having to use such a procedure in some exceptional cases, the preventative measures detailed here will, hopefully, severely limit its use in future.

21.4 Conclusions

1. The high multiple pregnancy rates still being recorded for ovulation induction and ovarian stimulation for IUI and IVF procedures must be dealt with.

2. The fi rst step is a recognition of those at risk, both before and during stimulation.

3. For ovulation induction, certainly for those with PCOS, a chronic low-dose protocol should be used.

4. Stimulation with gonadotrophins before IUI should be mild. As in 3 above, hCG should be withheld if more than two follicles of >15 mm develop.

5. Elective single embryo transfer will hopefully be more widely adopted as methods for embryo selection improve as it is the obvious solution for the reduction of the present unacceptable multiple pregnancy rates.

References

1. Hamilton-Fairley D, Franks S. Common problems in induction of ovulation. Baillieres Clin Obstet Gynaecol. 1990;4:609–25.

2. Khalil MR, Rasmussen PE, Erb K, Laursen SB, Rex S, Westergaard LG. Homologous intrauterine insemination. An evaluation of prognostic factors based on a review of 2473 cycles. Acta Obstet Gynecol Scand. 2001;80:74–81.

3. Goverde AJ, McDonnell J, Vermeiden JW, Schats R, Rutten FH, Schoemaker J. Intrauterine insemination or in-vitro fertilization

References

208

in idiopathic subfertility and male subfertilit: a randomized trial and cost effectiveness analysis. Lancet. 2002;355:13–8.

4. Ferraretti AP, Goossens V, Kupka M, et al. Assisted reproductive technology in Europe, 2009. Results generated from European registers by ESHRE. Hum Reprod. 2013;28:2318–31.

5. Nygren KG, Andersen AN. Assisted reproductive technology in Europe, 1999. Results generated from European registers by ESHRE. Hum Reprod. 2002;17:3260–74.

6. Assisted reproductive technology surveillance – United States, 2010. MMWR Surveill Summ. 2013;62:1–24.



9. Guzick DS, Sullivan MW, Adamson GD, et al. Efficacy of treat-ment for unexplained infertility. Fertil Steril. 1998;70:207–13.

10. Hughes EG. The effectiveness of ovulation induction and intra-uterine insemination in the treatment of persistent infertility: a meta-analysis. Hum Reprod. 1997;12:1865–72.

11. Cohlen BJ, te Velde ER, van Kooij RJ, Looman CW, Habbema JD. Controlled ovarian hyperstimulation and intrauterine insem-ination for treating male subfertility: a controlled trial. Hum Reprod. 1998;13:1553–8.

12. Dare MR, Crowther CA, Dodd JM, Norman RJ. Single or mul-tiple embryo transfer following in-vitro fertilization for improved neonatal outcome: a systematic review. Aust N Z J Obstet Gynaecol. 2004;44:283–91.

13. Wolner-Hanssen P, Rydhstroem H. Cost-effectiveness analysis of in-vitro fertilization: estimated costs per successful pregnancy after transfer of one or two embryos. Hum Reprod. 1998;13:88–94.

14. Hunault CC, Eijkmanans MJ, Pieters MH, et al. A prediction model for selecting patients undergoing in vitro fertilization for elective single embryo transfer. Fertil Steril. 2002;77:725–32.

15. Pandian Z, Marjoribanks J, Oztrk O, Serour G, Bhattacharya S. Number of embryos fro transfer following in vitro fertilization or intra-cytoplasmic sperm injection. Cochrane Database Syst Rev. 2013;(7):CD003416.



Abstract The stresses and strains, trials and tribulations, expectations and disappointments that infertile couples must endure still need to be lessened. The adoption of ‘softer’ pro-tocols for ovarian stimulation is becoming more widespread and the more patient-friendly GnRH antagonist protocol is taking over from the traditional long agonist protocol. Ovarian stimulating agents free from extraneous proteins are now self-injected from pen devices and slow-release prepara-tions of FSH lessen the number of injections. The develop-ment of an oral preparation of FSH is proving more than a stern challenge but is, nevertheless, expected to materialize sometime in the future. Oral preparations of a GnRH ana-logue are maybe more of a pipe dream whereas an OHSS-free clinic is a distinct possibility. The widespread use of time lapse imaging is expected to considerably improve embryo selection for transfer and this will surely increase the use of elective single embryo transfer. A whimsical prediction for an IVF protocol in 2025 would include oral preparations of FSH and GnRH antagonist, an oral agonist trigger with a ‘freeze-all’ regimen and replacement of embryos, one at a time, in a subsequent natural cycle. More seriously, until infertility is recognized as a health problem by governing authorities, in these days of rising costs of medication and technology, not a small number of couples will find themselves childless and denied treatment simply because of a lack of funds. This

Chapter 22 Future Perspectives

210

prevention of a basic human right on these grounds, I find immoral and unacceptable. If we have the capability to treat, this should not be denied the patients.

Keywords Ovarian function • Psychologist • Social worker • Mild protocols • Ovarian stimulation • GnRH antagonist • GnRH agonists • FSH • Freeze-dried lyosphere • Gonadotrophin • Human recombinant FSH agonist • Corifollitropin • IVF • hCG • Ovarain hyperstimulation syndrome • OHSS • Kisspeptin agonist • Kisspeptin antagonist • Mild stimulation • Ovulation • Agonist trigger • Elective single embryo transfer • Frozen-thawed natural cycle • Multiple pregnancies • Time-lapse imag-ing • ICSI • Embryo morphology • Morphokinetics • Morula • Blastocyst • Euploidy • Egg donation • Social egg freezing • Vitrification • Donor eggs • Stem-cell technology • Anovulatory • Obstructed Fallopian tubes • Sub-standard sperm • Ovulation induction • Ovarian stimulation • Morbidity • Multiple preg-nancy rates • IUI • Embryo selection

22.1 Patient Comfort

Over the years the efficiency and efficacy of both ovulation induction and controlled ovarian stimulation have improved considerably. Protocols have been modified and ovarian function manipulated to achieve the best pregnancy rates. The stresses and strains, trials and tribulations, expectations and disappointments that infertile couples must endure still need to be lessened. Most units now employ a psychologist/social worker who is available to relieve some of the tensions involved. The adoption of ‘softer’ protocols for ovarian stimulation is becoming more widespread and slowly but surely, the more patient-friendly GnRH antagonist protocol is taking over from the traditional long agonist protocol. Less close monitoring and hospital visits are now the rule and the advent of ovarian stimulating agents that, due to their purity and freedom from extraneous proteins, can be self-injected

Chapter 22. Future Perspectives

211

sub-cutaneously, has gone some way to increasing patient comfort. The emphasis of the drug companies has now turned to improved delivery systems on the one hand and ways to lessen the number of injections on the other.

22.1.1 Drug Delivery Systems

Traditionally, FSH for injection has been provided as a freeze- dried lyosphere to be dissolved in water for injection before being drawn into the injection syringe. Most gonadotrophin preparations are now available as ready-to-use preparations, provided in a pen injection device which comes preloaded and can be used for multiple injections. The use of a pen device has a number of tangible advantages over the usual syringe injec-tions. The FSH dose can be accurately titrated and so drug doses can be individualized for each patient. Injection pain is generally experienced less frequently using a pen device and in surveys conducted by the industry, most importantly, the patients have found a pen device to be more user-friendly then the conventional syringe.

Multiple injections remain one of the most tiresome parts of most infertility treatments. While it is too much to expect the development of an injection without a needle, we can expect less injections or, looking not too far into the future, the development of oral preparations of FSH, GnRH ago-nists and antagonists!

22.1.2 Less Injections

Now on the market is a chimeric long-acting human recombi-nant FSH agonist (corifollitropin). The mean half-life of the standard FSH preparations is around 32 h, necessitating daily injections, whereas the half-life of the long-acting prepara-tions is extended to 4 days or more. The advantage is that a single injection of this new preparation could provide suffi-cient ovarian stimulation over a period of 7 days. Although

22.1 Patient Comfort

212

this is not suitable for low-dose, subtle ovulation induction protocols, it will find a place at the beginning of controlled ovarian stimulation in preparation for IVF. Saving even five daily injections makes this drug more user-friendly. Topping-up with daily injections of the present recombinant preparations, if necessary following the approach of the termination of action of the long-acting preparation, until criteria for admin-istering hCG are reached seems a feasible proposition. My personal feeling of a loss of control using long-acting prepa-rations such as this is purely psychological, as long as the rate of OHSS can be maintained at zero levels.

As far as the GnRH agonists are concerned, the trend has been to prefer daily injections to a depot, slow release prepa-ration, mainly due to the fact that the depot induces over- suppression and has an over-long duration of action. Regarding the GnRH antagonist, there is little to choose between com-parisons of a single slow release dose or a multiple dose pro-tocol requiring daily injections as far as outcome is concerned but it is the daily injection that has been preferred.

Rumour has it that the development of an oral prepara-tion of FSH is proving more than a stern challenge but is, nevertheless, expected to materialize sometime in the future. Oral preparations of a GnRH analogue are maybe more of a pipe dream but in these days of rapidly advancing pharma-ceutical techniques, just as recombinant technology has pro-duced FSH, LH and hCG, then there may be some room for optimism. Looking further afield, is a kisspeptin agonist or antagonist a viable proposition?

22.2 Less Complications

Ovarain hyperstimulation syndrome (OHSS) and multiple pregnancies remain the scourge of the IVF practitioner. It does not take too much imagination to envisage an OHSS free clinic. Mild stimulation protocols employing a low dose of FSH in an antagonist protocol have already gone a long way to achieving this aim. The concept of using an agonist trigger


213

of ovulation in place of hCG has made this wish a reality. If this protocol is combined with an elective single embryo transfer then not only will OHSS be eliminated but multiple pregnancy rates will be close to zero. While ideal for the young, good prognosis patients, an ideal individual protocol for the woman with poor ovarian reserve has yet to be found.

22.3 Better Results

22.3.1 Improved Protocols

Reported live birth outcomes are, at the best, on a par with natural conception and live birth rates per cycle. While this may be thought of as satisfactory, there is surely room for improvement. Milder stimulation protocols seem to counter-act the deleterious effect of high oestrogen levels on the implantation capability of the endometrium. Although smaller numbers of oocytes are harvested with milder stimu-lation, the embryos formed are thought to be of better quality and heightened implantation potential. A further alternative would be to trigger ovulation with an agonist following stimulation in an antagonist cycle and freeze all embryos. These can then be transferred, one-by-one of course, in a frozen-thawed natural cycle. While eliminating the possibility of both OHSS and multiple pregnancies, the transfer of a well selected single embryo in a cycle devoid of endocrine disrup-tions surely promises an excellent pregnancy rate. My unwith-ered optimism would predict a cumulative conception rate of around 80 % for women under the age of 35 years.

22.3.2 Time-Lapse Imaging

Key to this ideal is the selection of the best embryo to trans-fer. Here we come to what may well turn out be the single most significant step forward in the field since ICSI. Time-lapse imaging of embryo development provides a wealth of

22.3 Better Results

214

information not only on the embryo morphology but also on the kinetics of cellular processes forming the morphology, known as morphokinetics. Up to now, the embryologist must remove the embryos from the incubator maybe once or twice on crucial days and select the embryo(s) to be transferred using morphological criteria which do not always correlate well with outcome. Time- lapse imaging provides a video of the embryo development and morphology and crucially dem-onstrates the rate of development. Predictive morphokinetic variables for identifying embryos with the best implantation potential have been defined for embryo cleavage points up to the 8-cell stage, and for morula and blastocyst formation, duration and synchrony of the cell cycles. While early studies have demonstrated variables for the prediction of embryos with implantation potential, for the superior prediction of day 3 embryos that will develop into blastocysts over and above that of senior embryologists and even for euploidy according to morphokinetics, the subject is still in its infancy. The incoming data will be further computerised and improve-ments made but I believe that this will prove to be a giant step in identifying the best embryo to transfer, especially important for the holy grail of elective single embryo trans-fer. Further reading is suggested at the end of this chapter for those interested in the details.

22.4 Less Optimistic Predictions

The increasing tendency to delay conception to an advanced female age is increasing the demand for egg donation. While public awareness of the availability of so-called ‘social egg freezing’ is growing and although vitrification techniques are a distinct improvement for egg survival, the demand for donor eggs is predicted to grow and legislation is predicted to stiffen so that demand may well shortly outstrip availability. Much effort is being invested in stem-cell technology to produce oocytes but I fear that in view of the obstacles so far encoun-tered, this is still a long way from being a viable proposition.


215

Finally, we have not yet discovered how to lower female age! More precisely, how to deal with the aging female with a rapidly diminishing ovarian reserve. Despite the myriad pro-posals tried and tested, itself a testimony of the depth of the problem, I cannot see a solution being produced in the near future if at all.

22.5 Utopia

There is no reason to suspect that rates of infertility will decrease in the future. A certain proportion of women will be anovulatory and some will have obstructed Fallopian tubes while some male partners (projected to be more than today) will have sub- standard sperm. Efforts to improve their lot can safely be predicted to continue.

Diagnostic tests need to be streamlined, made less invasive and to produce results more speedily. I can see no reason why a full diagnostic work-up should not be completed within 1 month. With the improvement and widespread publicity of advances in treatment, the public is less patient. They want to know where they stand and what the treatment possibilities are. As regards ovulation induction and ovarian stimulation, more consideration for the safety of the patient, e.g. the avoid-ance of ovarian hyperstimulation, is essential. Nobody should have to suffer severe morbidity as a result of fertility treatment which is, after all, almost always performed on patients who are in good general health. The reduction of multiple pregnancy rates, whether involving ovulation induction or ovarian stimu-lation for IUI or IVF, simply must be reduced. I believe that the advent of a widespread practice of using only low-dose gonadotrophin schemes for ovulation induction and single embryo transfer, made possible by improved methods of embryo selection, have already arrived but are not being uti-lized everywhere.

Despite the increasing demands and pressure from infertile couples (and some practitioners), there is no excuse for a ‘blunderbus’ approach, e.g. rushing patients

22.5 Utopia

216

through to IVF as a first line treatment despite the lack of an indication. The diagnosis and treatment of infertility and anovulation in particular, remain very logical, scien-tific subjects. Adhering to diagnostic schemes and logical treatment protocols while taking into account every cou-ple’s individual needs and psychological approach to their problem, will bring the required results.

Inevitably, the question of finance arises. Until infertility is recognized as a health problem by governing authorities, in these days of rising costs of medication and technology, not a small number of couples will find themselves childless and denied treatment simply because of a lack of funds. This prevention of a basic human right on these grounds, I find immoral and unacceptable. If we have the capability to treat, this should not be denied the patients.

Finally, I have used my crystal ball to devise the ideal pro-tocol that we will be using in maybe 10 years time. Whimsical or realistic? Time will tell (Fig. 22.1 ).

Oral FSH

Oral agonist trigger

Oral antagonist OPU

Time-lapseimaging +Vitrificationof embryos

Frozen/thawedeSET

Naturalcycle

Figure 22.1 Imaginative IVF protocol in the year 2025. OPU ovum pick-up, eSET elective single embryo transfer


217

Suggested Further Reading on Time-Lapse Imaging

Conaghan J, Chen AA, Willman SP, et al. Improving embryo selec-tion using a computer-automated time-lapse image analysis test plus day 3 morphology: results from a prospective multicenter trial. Fertil Steril. 2013;100:412–9.

Herrero J, Meseguer M. Selection of high potential embryos using time- lapse imaging: the era of morphokinetics. Fertil Steril. 2013;99:1030–4.

Herrero J, Tejera A, Albert C, Vidal C, de los Santos MJ, Meseguer M. A time to look back: analysis of morphokinetic characteristics of human embryo development. Fertil Steril. 2013;100:1602–9.

Swain JE. Could time-lapse embryo imaging reduce the need for biopsy and PGS? J Assist Reprod Genet. 2013;30:1081–90.

Suggested Further Reading on Time-Lapse Imaging

ovulation induction and controlled ovarian stimulation a...

Documents