r lh supplementation to rfsh in gnrh antagonist cycles
TRANSCRIPT
rLH SUPPLEMENTATION TO rFSH IN GnRH ANTAGONIST CYCLES:EFFECTS ON IMPLANTATION AND PREGNANCY RATE
A. Nazzaro, A Salerno
Two cell-two gonadotrophin
Physiology of follicular growth and differentiation
Pre-gonadotrophic folliculogenesis
KIT Ligand expression
It remains to be determined if activation can be influenced by gonadotrophins but it certainly seems to
proceed normally in their absence
Paracrine connectivity in ovarian follicles.
Hillier S G Mol. Hum. Reprod. 2009;15:843-850
© The Author 2009. Published by Oxford University Press on behalf of the European Society of Human Reproduction and Embryology. All rights reserved. For Permissions, please email: [email protected]
The follicle responds to FSH and LH as a functional syncytium integrated by paracrine signalling
PrimarySe
cond
ary
• oocyte expansion
• granulosa cell proliferation
• LH responsive Techa cells
Secondary
FSH
TGF-β
Gonadotrophin dependence
1) enhance granulosa cell sensitivity and responsiveness to FSH
2) suppress LH-responsive thecal androgen synthesis
FSH
1) promote androgen synthesis2) Androgens in turn synergize with FSH to augment inhibin synthesis
The principle requirement for LH is to sustain androgen synthesis, without which there is no estrogen synthesis
Follicular antrum formation and antral expansion are absolutely dependent on FSH.
Early follicular phase
Late follicular phase
Huang Z , and Wells D Mol. Hum. Reprod. 2010;16:715-725
© The Author 2010. Published by Oxford University Press on behalf of the European Society of Human Reproduction and Embryology. All rights reserved. For Permissions, please email: [email protected]
Follicular activation
Meiotic resumption in late follicular phase
Zhang M et al. Mol. Hum. Reprod. 2009;15:399-409
LH stimulated paracrine signals are thereby able to impact oocytes even in follicles whose granulosa
cells do not express LH-R
• costly
• time consuming
• potentially unhealty
Gonadotrophic manipulation of paracrine signalling
Paracrine signalling explains how gonadotrophins are potentially able to benefit oocyte function
and by extension how inappropriate use of exogenous gonadotrophins might be deleterious
closely mimic physiology
controlled ovarian stimulation regimes might be reverse engineered from the natural follicular life cycle
Understanding the role of LH: myths and facts
Too much or too little LH activitycan have negative outcomes
LH window
Gynecol Endocrinol. 2012 Sep;28(9):674-7. doi: 10.3109/09513590.2011.652716. Epub 2012 Feb 8.Recombinant luteinizing hormone priming in multiple follicular stimulation for in-vitro fertilization in downregulated patients.Lisi F, et al.
follicular priming with LH
J Clin Endocrinol Metab. 1999 Aug;84(8):2951-6.Androgen and follicle-stimulating hormone interactions in primate ovarian follicle development.Weil S, et al.
Li M et al. Mol. Hum. Reprod. 2009;15:149-154
Granulosa cells express androgen receptor (AR) through which theca-derived testosterone amplifies FSH-stimulated PKA signalling
LH-driven thecal androgen production may be a component of the natural mechanism through which antral follicles initially acquire sensitivity to FSH.
LH priming
Durnerin C I et al. Hum. Reprod. 2008;23:421-426
© The Author 2007. Published by Oxford University Press on behalf of the European Society of Human Reproduction and Embryology. All rights reserved. For Permissions, please email: [email protected]
revealed increased developmentof small antral follicles due to LH priming
a statistically significant increase in the number of normally fertilized embryos obtained after subsequent FSH treatment
no clinically important outcomes were significantly altered in the LH group versus controls
Evidence that LH priming can improve oocyte quality.
Hillier S G Mol. Hum. Reprod. 2009;15:843-850
© The Author 2009. Published by Oxford University Press on behalf of the European Society of Human Reproduction and Embryology. All rights reserved. For Permissions, please email: [email protected]
Evidence that follicular coasting with LH can promote mono-ovulation: a double-blind, placebo-controlled, multicentre pilot study in patients undergoing ovulation induction.
Hillier S G Mol. Hum. Reprod. 2009;15:843-850
© The Author 2009. Published by Oxford University Press on behalf of the European Society of Human Reproduction and Embryology. All rights reserved. For Permissions, please email: [email protected]
OSF regulation of CC function and oocyte quality Model depicting oocyte–CC interactions and their impact on subsequent oocyte developmental potential.
Gilchrist R B et al. Hum. Reprod. Update 2008;14:159-177
© The Author 2008. Published by Oxford University Press on behalf of the European Society of Human Reproduction and Embryology. All rights reserved. For Permissions, please email: [email protected]
Oocyte quality is assured by LH-driven nutritional and informational signals emanating in cumulus cells
biphasic stimulation regimes using FSH followed by LH activity to target the gold standard
oocyte and its nearest neighbours (in developmental terms) could have potential clinical merit
Schematic overview of expected FSH and LH concentrations in various GnRH analogue regimens a and b are regimens without oral contraceptive pill (OCP) pretreatment: (a) long GnRH agonist protocol and (b) fixed day 6 GnRH antagonist protocol.
Huirne J et al. Hum. Reprod. 2007;22:2805-2813
© The Author 2007. Published by Oxford University Press on behalf of the European Society of Human Reproduction and Embryology. All rights reserved. For Permissions, please email: [email protected]
P. Platteau MD, MRCOGCentre for Reproductive Medicine
Brussels Free UniversityBelgium
Antagonist study
A.Nazzaro, MDA.Salerno MSc, PhD
AORN “G. Rummo Italy
Devroey et al., 2009
Ideal antagonist protocol
• Estroprogestin till Wednesday (last pill)• GnRh-antagonist started on Monday for 3 days• Blood test (E2 + P4 + LH)
• rFSH oh Thursday
• GnRh-antagonist added-back on the 6th day of COH• Blood test (E2 + P4 + LH) + US Tuesday and Thursday• OPU between Monday and wednesday
if P4 >1 ng/ml one more antagonist ampule (rFSH started one day later)
Ideal antagonist protocol
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21
rFSH (Tailored)
GnRh-ant
HCG OPU ET
GnRh-ant
Menses
EP
rLH
rLH
Partially presented and awarded with first prize for scientific comunication at 2012 ASRM Annual Meeting – San Diego, Ca, 2012
Submitted for publication to Fertility and Sterility
Baseline characteristics of the two study groups.
rFSH (n=211) rFSH + rLH (n=211) P-value
Age (years) 36.7 ± 1.5 36.6 ± 1.6 NS
BMI (kg/m2) 22.6 ± 2.7 22.7 ± 2.8 NSInfertility duration (years) 4.4 ± 2.3 4.7 ± 2.4 NS
Basal plasma FSH (mIU/ml) 5.7 ± 2.4 5.1 ± 1.9 NS
Basal plasma LH (mIU/ml) 5.5 ± 2.3 4.0 ± 1.9 NS
Basal plasma oestradiol (pg/ml) 73.0 ± 29.1 66.9 ± 31.0 NS
r-FSH (n = 211) rFSH + rLH (n=211)
GnRH antagonist (days) 10.6 (1.8) 9.8 (1.3)
Duration of ovarian stimulation (days)
11.7 (0.9) 11.4 (1.1)
Cumulative r-HFSH dose (IU) 2562 (1187) 2453 (1884)
Plasma oestradiol (pg/ml) 2254 (989) 2325 (723)
follicle size (mm)
10 and <14 4.6 (2.8) 3.8 (1.6)
14 and <16 mm 3.4 (1.6) 4.6 (2.1)
16 and <18 mm 4.4 (1.2) 4.3 (1.1)
>18 mm 3 (1.2) 3 (1.1)
r-HFSH (n = 211) rFSH + rLH (n=211) P-value
Retrieved oocytes 8.9 + 4.9 11.8 + 4.3 0.036
Metaphase II oocytes 4.2 + 2.1 7.8 + 2.3 0.014
Fertilization rate 0.58 + 0,26 0.87 + 0.32 0.017
Embryos/cycle 5.4 + 2.1 9.6 + 1.2 0.092
Grade I-II embryos/cycle
4.3 + 0.8 7.6 + 1.3 0.086
Frozen embryo/cycle 1.0 + 0.4 4.3 + 1.2 0.008
Implantation rate (%) * 13 (105/829) 18 (148/826) 0.04
Clinical pregnancy rate (%) **
22 (84/380) 32 (98/305) 0.03
•GS/Embryo transferred• Pregnancy/Embryo Transfer
GnRH Antagonists vs. Agonists
LH, endometrium and embryo implantation
This scanning electron micrograph of a sample taken on day 7 after HCG administration from an oocyte donor in the ganirelix 2 mg group shows that the high-dose ganirelix treatment can produce the required epithelial response.
Simon C et al. Hum. Reprod. 2005;20:3318-3327
© The Author 2005. Published by Oxford University Press on behalf of the European Society of Human Reproduction and Embryology. All rights reserved. For Permissions, please email: [email protected]
Exogenous LH protects the endometrium from exposure to premature progesterone rises
Percentage of genes in common between stimulated and natural cycles during the receptive endometrium.
Haouzi D et al. Biol Reprod 2010;82:679-686
©2010 by Society for the Study of Reproduction
CONCLUSION
• The apparent beneficial effect of r-LH on implantation and pregnancy outcomes in our study could be explained by two different mechanisms:
1. Firstly, the embryo quality could be superior in the group supplemented with r-LH.
2. Secondly, there may be an effect of LH supplementation on the endometrium, which could promote implantation.
r-LH supplementation in GnRH-a cycles seems to improve implantation and pregnancy rates via an improvement in oocyte quality and/or uterine receptivity
Translational implications• The current emphasis on oocyte quality over quantity in ART procedures calls for a more intelligent approach to ovarian stimulation based on sound physiological principles
• Follicular responses in standard FSH/hMG alone regimes are inevitably asynchronous, yielding many oocytes that do not fertilize or are unable undergo normal embryonic development.
• We have highlighted paracrine pathways emanating in thecal cells and granulosa cells that potentially impact oocytes and which can be manipulated by sequential and/or combined use of FSH and LH
• We have to designe tactics to increase follicular responsiveness to FSH/LH, synchronize oocyte competence and maximize oocyte quality
There can be no one-size-fits-all approach to ovarian stimulation
Factors such as age, genotype and general health will always affect individual responses
However, treatment tailored to personal needs based on paracrine principles will always be more likely to achieve the desired outcome.