Who needs LH in ovarian stimulation?

LH plays a key role in the intermediate-late phases of folliculogenesis. Although ovarian stimulation is efficiently achieved in most cases by the administration of exogenous FSH alone, specific subgroups of women may benefit from LH activity supplementation during ovarian stimulation. Some authors have found improved outcome with LH activity supplementation in advanced reproductive age women. Experience suggests that in about 10-12% of young normogonadotrophic patients treated with a gonadotrophin-releasing hormone agonist (GnRH-a) long protocol plus recombinant FSH human (r-hFSH), a 'steady response' is observed. In this subgroup of women, a higher number of oocytes is retrieved when daily LH activity supplementation is given from stimulation day 8, if compared with the standard FSH dose increase. Another subgroup of patients who may benefit from LH activity supplementation are those at risk for poor ovarian response treated with GnRH antagonist. Recent data demonstrate that in these women, when GnRH is administered in a flexible protocol, the concomitant addition of recombinant human LH improves the number of mature oocytes retrieved, when compared with the standard GnRH-a flare-up protocol. Thus, well calibrated LH administration improves the ovarian outcome in patients >35 years, in those showing an initial abnormal ovarian response to r-hFSH monotherapy, and in 'low prognosis' women treated with GnRH antagonists.

Suboptimal response to GnRHa long protocol is associated with a common LH polymorphism.

The aim of this observational preliminary trial was to estimate the association between the most common polymorphism of LH (LH-ß variant: v-ßLH), with different profiles of ovarian response to recombinant human FSH (rhFSH). A total of 60 normogonadotrophic patients undergoing a gonadotrophin-releasing hormone analogue long down-regulation protocol followed by stimulation with recombinant human FSH (rhFSH) for IVF/intracytoplasmic sperm injection, and in whom at least five oocytes were retrieved were retrospectively included. On the basis of the total rhFSH consumption, patients were divided into three groups: Group A: 22 women requiring a cumulative dose of rhFSH >3500 IU; Group B: 15 patients requiring 2000-3500 IU; Group C (control): 23 women requiring <2000 IU. The presence of v-ßLH was evaluated using specific immunoassays. Peak oestradiol concentrations were significantly lower in Group A when compared with both groups B (P < 0.05) and C (P < 0.001). Group A had a significantly lower (P < 0.05) number of oocytes retrieved (7.3 ± 1.5, 11.7 ± 2.4 and 14.7 ± 4.1 in the three groups, respectively). Seven carriers (31.8%) of v-ßLH were found in Group A, whereas only one variant (6.7%) was observed in Group B; no variant was detected in Group C. These preliminary results suggest that v-ßLH is more frequent in women with ovarian resistance to rhFSH.

Suboptimal response to GnRHa long protocol is associated with a common LH polymorphism.

The aim of this observational preliminary trial was to estimate the association between the most common polymorphism of LH (LH-beta variant: v-betaLH), with different profiles of ovarian response to recombinant human FSH (rhFSH). A total of 60 normogonadotrophic patients undergoing a gonadotrophin-releasing hormone analogue long down-regulation protocol followed by stimulation with recombinant human FSH (rhFSH) for IVF/intracytoplasmic sperm injection, and in whom at least five oocytes were retrieved were retrospectively included. On the basis of the total rhFSH consumption, patients were divided into three groups: Group A: 22 women requiring a cumulative dose of rhFSH >3500 IU; Group B: 15 patients requiring 2000-3500 IU; Group C (control): 23 women requiring <2000 IU. The presence of v-betaLH was evaluated using specific immunoassays. Peak oestradiol concentrations were significantly lower in Group A when compared with both groups B (P < 0.05) and C (P < 0.001). Group A had a significantly lower (P < 0.05) number of oocytes retrieved (7.3 +/- 1.5, 11.7 +/- 2.4 and 14.7 +/- 4.1 in the three groups, respectively). Seven carriers (31.8%) of v-betaLH were found in Group A, whereas only one variant (6.7%) was observed in Group B; no variant was detected in Group C. These preliminary results suggest that v-betaLH is more frequent in women with ovarian resistance to rhFSH.

Laparoscopic excision of endometriosis may require unilateral parametrectomy.

OBJECTIVE: We investigated the effects of laparoscopic excision of endometriosis with unilateral parametrectomy on bladder, rectal, and sexual function as well as patient satisfaction. METHODS: Women who underwent this procedure between February 1, 2006 and November 15, 2007 were enrolled. Patient characteristics, pre- and postoperative findings, and follow-up data were retrospectively collected from a computerized database. RESULTS: Twelve patients were enrolled in the study. All of the symptoms except dysuria improved after surgery, worsening long after the operation. It seems that all parameters including sexuality, micturition, and defecation are equally important in regards to the final judgement of satisfaction, with a trend towards amelioration long after the operation. CONCLUSIONS: Unilateral parametrectomy may offer successful results in terms of patient satisfaction despite some impairment in bladder, bowel, and sexual function. The risk of permanent functional impairment is high; therefore, surgeons need to maintain the integrity of the contralateral nerve pathway. This is highly important, because pain relief seems to be partially involved in the final judgement of postoperation satisfaction.

Intra-follicular leptin concentration as a predictive factor for in vitro oocyte fertilization in assisted reproductive techniques.

BACKGROUND: Granulosa-cells are able to produce and store leptin, suggesting that this hormone is locally involved in the regulation of follicular growth. In this study, the role of follicular fluid (FF) leptin concentration in predicting oocyte fertilization and embryo quality was evaluated in 35 normogonadotrophic women undergoing controlled ovarian stimulation (COS) for assisted reproductive techniques. MATERIALS AND METHODS: Leptin concentration was measured in 47 consecutively collected FF in which a mature oocyte had been found during the ovum pick-up. Embryos deriving from fertilized oocytes were submitted to quality scoring systems. RESULTS: Mean leptin concentration was significantly higher in FF whose oocytes showed 2 pronuclei (no. 25) when compared with those with no evidence of fertilization (no. 22) at the 16-18 h check (26.0+/-6.1 vs 15.3+/-10.6 ng/ml, respectively, p<0.01). Follicular mean diameters were similar in the two groups (21.4+/-3.4 and 21.0+/-5.1 mm, respectively). Logistic regression analysis identified FF leptin levels as the best predictive parameter for oocyte fertilization (p<0.001). When receiving operating characteristics curve was employed, a FF leptin concentration of 20.25 ng/ml was the most reliable cut-off in predicting fertilization of oocytes. FF with leptin concentrations higher than this value (no. 27) had an oocyte fertilization rate of 85.7%. In contrast, FF levels < or =20.25 ng/ml (no. 20) were associated with a rate of 16.7% (p<0.05). No correlation emerged between FF leptin and the score attributed to 15 valuable embryos at the zygote stage (r=-0.01) and at 48 h after insemination (r=0.1). CONCLUSIONS: FF leptin levels are a better predictor of oocyte fertilization success rates than follicular diameter. These results underline the relevance of FF variables in developing methods for oocyte selection.

Outlook: who needs LH in ovarian stimulation?

LH plays a key role in the intermediate-late phases of folliculogenesis. Although ovarian stimulation is efficiently achieved in most cases by the administration of exogenous FSH alone, specific subgroups of women may benefit from LH activity supplementation during ovarian stimulation. Some authors have found improved outcome with LH activity supplementation in advanced reproductive age women. Experience suggests that in about 10-12% of young normogonadotrophic patients treated with a gonadotrophin-releasing hormone agonist (GnRH-a) long protocol plus recombinant FSH human (r-hFSH), a 'steady response' is observed. In this subgroup of women, a higher number of oocytes is retrieved when daily LH activity supplementation is given from stimulation day 8, if compared with the standard FSH dose increase. Another subgroup of patients who may benefit from LH activity supplementation are those at risk for poor ovarian response treated with GnRH antagonist. Recent data demonstrate that in these women, when GnRH is administered in a flexible protocol, the concomitant addition of recombinant human LH improves the number of mature oocytes retrieved, when compared with the standard GnRH-a flare-up protocol. Thus, well calibrated LH administration improves the ovarian outcome in patients >35 years, in those showing an initial abnormal ovarian response to r-hFSH monotherapy, and in 'low prognosis' women treated with GnRH antagonists.

Exploiting LH in ovarian stimulation.

During intermediate-late phases of human folliculogenesis, LH plays a key role in promoting steroidogenesis and growth of the leading follicle. Ovarian stimulation for assisted reproduction techniques usually consists of administering exogenous FSH in a low LH environment. Although an impairment in LH-dependent paracrine activities would be expected, multiple follicular growth is efficiently achieved in almost all patients. Thus, there appears to be a discrepancy between classical folliculogenesis models and data from IVF. This study examines the 'interface' between basic endocrinological and clinical evidence, in an attempt to answer two questions: is there an LH therapeutic window, and if there is, how can this be exploited in the practice of assisted reproduction? It also reviews the evidence that specific subgroups of women may benefit from LH supplementation during ovarian stimulation.