Review this Lecture at:http://www.androfert.com.br/reviewEsteves, 4Esteves SC – June 2013
Esteves, 5 Modified from Sackett et al. Oxford Centre for EBM Levels of Evidence (2009)Level Type of evidence1a Obtained from meta-analysis of randomised trials1b Obtained from at least one randomised trial2a Obtained from one well-designed controlledstudy without randomisation2b Obtained from at least one other type of well-designed quasi-experimental study3 Obtained from well-designed non-experimentalstudies (comparative and correlation studies, caseseries)4 Obtained from expert committee reports or opinionsor clinical experience of respected authoritiesGrade Arecommendation• Good andconsistentscientific evidence Information concerning IVF population Evidence-based medicine
Esteves, 6Role of LH in ReproductiveCycles23Who Need LH?
Esteves, 1102575225050010001500200025003000Day 1 Day 5 Day 10 hCG0 25 75 225The European Recombinant Human LH Study Group, JCEM 1998; 83:1507Addition of LH (UI):
Esteves, 120257522502468Day 1 Day 5 Day 10 hCG0 25 75 225 rLHThe European Recombinant Human LH Study Group, JCEM 1998; 83:1507Evidence for LH threshold (2)Injected rec-hLH LH Cmax75 UI 0.5 – 1.35 UI/L
Esteves, 13LH is essential for normal ovarian steroidogenesis.75 UI rec-hLH is sufficient to promote optimalfollicular and endometrial growth, as well asandrogen production, in HH women (WHO I).In reproductive cycles optimal folliculardevelopment occurs within an ‘LH window’,above a certain ‘LH threshold’ and below an ‘LHceiling’ (1.1 to 5.1 UI/L).
Esteves, 151. Alviggi et al. Reprod Biomed Online 2006;12:221; 2. Tarlatzis et al. Hum Reprod2006;21:90; 3. Esteves et al. Reprod Biol Endocrinol 2009;7:111; 4. Marrs et al. ReprodBiomed Online 2004;8:175;5. Mochtar MH, Cochrane Database, 2007; 6. Alviggi, et al.RBMOnline 2009; 7. De Placido et al. Clin Endocrinol (Oxf) 2004;60:637;• Most normogonadotropic womenundergoing Ovarian Stimulation1-3Normal• ~20% of NG women have less sensitiveovaries• Older patients (≥35 years)4• Poor responders5• Slow/Hypo-responders6• Deeply suppressed endogenous LH levels(hypo-hypo; endometriosis treated with GnRH-a)7Low
Esteves, 16• Older patients (≥35 years)• Poor responders• Slow/Hypo-responders• Deeply suppressed LHLessSensitiveOvariesMarrs et al. Reprod Biomed Online 2004;8:175; De Placido et al. Clin Endocrinol (Oxf)2004;60:637; Ferraretti et al. Fertil Steril. 2004; 82:1521-6; Alviggi, et al. RBMOnline 2012Poor RespondersAt least 2 of the following:Maternal age ≥40 yearsPrevious DOR (≤3 oocytes with aconventional stimulation)Abnormal ovarian reservebiomarker (AFC<5; AMH <1.1)Or:2 episodes of DOR after maximalstimulationHypo/Slow RespondersNormal markers of ovarian reserveHypo-responders:D1-D7: normal follicular recruitmentusing fixed dose of FSH;D7-D10: follicular growth plateaudespite stimulation with FSH.Slow responders:Require high doses of FSH (>3,000UI)to achieve follicular growth;May indicate genetic polymorphisms ofLH and/or FSH receptors.Prevalence ofinfertility patientsaged 35 or aboveis growing
Impaired Oocyte QualityReduced Fertilization RateReduced Embryo QualityIncreased Miscarriage RatesReducedovarianparacrineactivityHurwitz &Santoro 2004LHreceptorpoly-morphismsAlviggi et al.,2006Androgensecretorycapacityreduced• Piltonen et al.,2003Decreasednumbers offunctionalLHreceptors• Vihko et al. 1996ReducedLHbioactivitywhileimmuno-reactivityunchanged• Mitchell et al.1995; Marama etal 1984Esteves, 17LessSensitiveOvariesWestergaard et al., 2000; Esposito et al.,2001; Humaidan et al., 2002
Mochtar et al,20073 RCT (N=310)r-hFSH+rLH vs.r-hFSH alone*OPROR 1.85(95% CI: 1.10; 3.11)Bosdou et al,20127 RCT (N= 603)r-hFSH+rLH vs.r-hFSH alone*CPRLBR(only 1 RCT)RD: +6%,(95% CI: -0.3; +13.0)RD: +19%(95% CI: +1.0; +36.0%)Hill et al, 20127 RCT (N=902)r-hFSH+rLH vs.r-hFSH alone CPROR 1.37(95% CI: 1.03; 1.83)*long GnRH-a protocol; OR=odds-ratio; RD=risk differenceMochtar MH et al. Cochrane Database Syst Rev. 2007;2:CD005070; Bosdou JK et al,Hum Reprod Update 2012; 8(2):127-45. Hill MJ et al. Fertil Steril 2012; 97:1108-4.Esteves, 18
FSHTheca cellsGranulosacellsEsteves, 21Pregnancyrates% CyclecancellationNumberoocytesretrievedIncreasing theStimulation Doseof FSH……is not associated withbetter IVF outcomeManzi et al, 1994Klinkert et al, 2004Berkkanoglu & Ozgur, 2010
Jamnongjit M et al. PNAS 2005;102:16257-16262Action of LH at the follicular level that increasesandrogen production for its later aromatizationto estrogens in a dose dependent manner mayrestore the follicular milieu in selected patientsto recover oocyte quality and, therefore, embryoquality and implantation rates.
Esteves, 23Androgen secretory capacity decreases with ovarian aging.Mechanisms include decreased number of functional LHreceptors and ovarian paracrine activity. LH-rpolymorphisms possibly involved in hypo-responders.LH supplementation in COS is an evidence-based strategyto maximize pregnancy results.4 subgroups benefit of LH supplementation in COS:Women with less sensitive ovaries (ovarianaging) have poor IVF outcomes.
Esteves, 24Role of LH in Reproductive CyclesWho Need LH
How much LH should be used?Should the dose be fixed or flexible?At what stage of the cycle should LHbe administered?Is LH needed in a GnRH antagonistprotocol?What kind of LH – recombinant LH orHMG?
Mochtar et al.3 RCT(N=216)Kolibianakis etal. 2 RCT(N=176)Baruffi et al.5 RCT (N= 434)Estradiol onhCG day (pg/ml)WMD 571(95% CI 259; 882)- WMD 514(95% CI 368; 660)No. retrievedoocytesWMD 0.50(95% CI -0.68; 1.68)-WMD 0.41(95% CI -0.44; 1.3)CPR†/LBR*†OR 0.79(95% CI: 0.26; 2.43)*OR 0.86(95% CI: 0.04; 1.85)†OR 0.89(95% CI: 0.57; 1.39)Unselected women undergoing COS;r-hFSH+r-hLH vs. r-hFSH alone in antagonist cyclesMochtar et al. Cochrane Database Syst Rev. 2007;2:CD005070; Kolibianakis et al, HumReprod Update. 2007;13:445-52; Baruffi et al, Reprod Biomed Online. 2007;14:14-25.Esteves, 26WMD weight mean difference
Yes, for women aged >35 yo61%25%19%68%33%27%%2PN Ongoing PR Implantation300 rec-hFSH 225 IU rec-hFSH + 75 IU rec-hLHEsteves, 27RCT; 292 NG women aged 36-39; GnRH antagonist D6 (fixed)LH started on day 1Bosch et al. Fertil Steril. 2011; 95:1031-6.
*Steelman-Pohley Rat Bioassay, 1953; Bassett et al. Reprod Biomed Online 2005;10:169–177; Driebergen et al. Curr Med Res Opin 2003;19:41–46.ConventionalBioassay*HighvariabilityRat ovaryweightgainUrinaryEsteves, 29FbM: Novelanalitycal methodProtein content insolution by massMinimal batch-to-batch variability(1.6%)RecombinantSize ExclusionHigh PerformanceLiquidChromatography
Beta unit Carboxyl terminal segmentLonger in hCG; higherreceptor affinityAbsent in LH and present inhCG (Longer Half-life)Purity(LHcontent)hCGcontent(IU/vial)LHactivity(IU/vial)Specificactivity(LH/mgprotein)Rec-hLH >99% 0 75 22,000 IUhMG-HP 3% ~70 75* ≥ 60 IUAdapted from ASRM Practice Committee. Fertil Steril. 2008; 90:S13-20.Esteves, 30*derives primarily from hCG, which is concentrated duringpurification or added to achieve the desired LH-likebiological activity.
In pts. treated with HMG (hCG-LH activity),expression of LH/hCG receptor and other genesinvolved in steroids biosynthesis in GCs islowered:Reflect LH receptors down-regulation:May explain the observed lower progesterone levels:Trinchard-Lugan I et al. Reprod Biomed Online 2002; 4:106-115; Menon KM et al. BiolReprod 2004; 70:861-866; Grondal ML et al. Fertil Steril 2009; 91: 1820-1830.Esteves, 31
Esteves, 32Population Biomarker Cut-off Sensitivity Specificity AccuracyDOR1AMH 0.82 76% 88% 0.88AFC 5 92% 58% 0.75*Beckman-Couter generation II assay; 1DOR: diminished ovarian response(≤4 oocytes retrieved)Leão RBF, Nakano FY, Esteves SC. ASRM 2013, submittedDefine “Who isWho” BeforeCOS UsingBiomarkers• Group of 131 womenundergoingconventional COSafter pituitary down-regulation for IVFIndividualizationof COS strategy
Esteves, 33La Marca et al, Hum Reprod 2009;24:2264; Fleming et al, Fertil Steril 2012;98:1097;Broekmans et al. Fertil Steril, 2010; 94:1044-51; Scheffer et al. Hum Reprod 2003;18:700Reflect No. Pre-antral and Small AntralFollicles(≤4-8mm); gonadotropin-independentLow inter and intra-cycle variationassessment at any cycle day in asingle measurementAMHAFCTVUS at early follicular phase (D2-D4)2-10 mm (mean diameter); 2D-planeReflect No. AF at a given time that can bestimulated by gonadotropinsLow inter-cycle variation
Esteves, 34Define “Who isWho” Before COSUsing BiomarkersAMH ≤ 0.82“PoorResponders”0.25 mg/day GnRHAntagonist (flexible)Rec-hLH (75-150 IU)FSH dose decreasedby the same amountLH addedOCPVaginalProgesteronegel 8%2 3 4 5 76 8 9 10 11 12 131MensesStart day14 15rec-FSH (Fbm)262.5 - 375 IU16 17D2 or D3 ETor FET (basedon P4 levelshCG day)Individualizationof COS strategy
Esteves, 35PoorRespondersAMH ≤ 0.82rec-hFSH FbM + rec-hLH 75 IU (D6)+ GnRH antagonist• Total daily dose: 262.5 to 375 IU1Poor response: ≤4 oocytes retrievedLeão RBF, Nakano FY, Esteves SC. ASRM 2013, submittedProspective study involving 118 womenundergoing IVF/ICSIResponse toCOSConventionaldown-regulationCOS (n=131)IndividualizedCOS(n=118)PvaluePoor1 64.2% 34.0% 0.02CPR per ETCancellation35.0%22.5%36.3%10.0%0.920.21
Esteves, 36A fixed dose of 75-150 IU rec-hLH seems adequateto restore androgen secretory capacity in mostpatients with ovarian aging.LH supplementation can start either fromstimulation day 1 or day 6; maximum beneficialeffect yet to be determined;LH supplementation is beneficial to women aged>35 in a GnRH antagonist protocol.
Esteves, 37Recombinant LH has 3 major differences compared tourinary LH (HMG):1. Higher purity and specific activity in rec-hLHSC delivery in very small volumes2. Higher dose precision in rec-hLHProtein content in solution by mass (FbM)3. LH activity is hCG dependent in u-HMGhCG concentrated/added to achieve LH-like biological activity;hCG has higher half-life and biological activity than rec-hLH;Lower expression of LH receptor gene (down-regulation) afterhCG exposure; may influence GC function.
AMH seems to be the best biomarker to identifypatients at risk of poor response in COS.AMH results can be used to individualize COS.Our experience with poor responders shows thatiCOS using rec-hLH supplementation inassociation with GnRH antagonists is a validstrategy to maximize the beneficial effects oftreatment while minimizing the risk of cyclecancellation.