Journal of in Vitro Fertilization and Embryo Transfer, Vol. 7, No. 5, 1990
Ovarian Stimulation for in Vitro Fertilization in Low-Responder Patients Using Pulsatile Intravenous Follicle Stimulating Hormone MICHAEL C. EDELSTEIN, 1'2 ROBERT G. BRZYSKI, 1 GEORGEANNA S. JONES, 1 and SUHEIL J. MUASHER 1
Submitted: March 12, 1990 Accepted: May 17, 1990
leasing hormone (GnRH) (4) have been used alone or in combination by different programs. Despite all the regimens available, a subset of patients still fails to respond adequately to exogenous stimulation. These low-responder patients exhibit a perimenopausal pattern marked by a failure of progressive increase in serum estradiol (E2) despite adequate stimulation, a failure of multiple follicular development, and a tendency for the triggering of a premature luteinizing hormone (LH) surge (5). These patients are often identified by an elevated serum FSH on cycle day 3 (6). Secretion of endogenous gonadotropins--LH and FSH--is controlled by the pulsatile release of GnRH from the hypothalamus. Experimental evidence indicates that in the nonhuman primate (7), as well as in the human (8), gonadotropins are secreted in a pulsatile manner. LH and FSH are released intermittently, at a frequency of approximately 20 gonadotropin surges per 24 hr in the follicular phase of the menstrual cycle (9). Many investigators have utilized the pulsatile administration of gonadotropin for ovulation induction in patients with such disorders as hypothalamic amenorrhea, polycystic ovarian disease (10,1 I), and luteinized unruptured follicle syndrome (LUF) (12) or in patients undergoing IVF (13)---all with promising results. We hypothesized that pulsatile gonadotropin therapy might benefit the low-responder patient with incipient ovarian failure who is attempting IVF. Pulsatile administration of gonadotropin would better mimic physiologic events than a single daily injection and might result in higher s e r u m E 2 levels, leading to better ovarian stimulation. To test this hypothesis, we treated low-responder IVF patients with pulsatile intravenous (iv) gonad-
There is a subset of patients who fail to respond adequately to exogenous gonadotropin stimulation for in vitro fertilization (IVF). In this study, six such Iowresponder patients who had inadequate stimulations with high-dose intramuscular (im) follicle stimulating hormone (FSH) were treated in a subsequent cycle with pulsatile intravenous (iv) FSH. A paired analysis was performed to compare the cycles using high-dose im FSH with those using pulsatile iv FSH. Trough serum FSH levels were significantly higher with pulsatile iv FSH. No significant difference was noted in the stimulation characteristics or the number or quality of oocytes retrieved and embryos transferred. No pregnancies occurred in either group. While pulsatile iv administration of gonadotropin increases serum FSH levels, it does not appear to have a major impact on follicular stimulation or outcome in low-responder patients undergoing IVF. KEY WORDS: follicle stimulating hormone; in vitro fertilization; low responder; pulsatile gonadotropins.
INTRODUCTION Various methods of ovarian stimulation are used in in vitro fertilization (IVF) in an effort to obtain multiple fertilized oocytes. Oral clomiphene citrate (1), intramuscular human menopausal gonadotropin (hMG) (2), intramuscular follicle stimulating hormone (FSH) (3), and intravenous gonadotropin re-
t The Jones Institute for Reproductive Medicine, Department of Obstetrics and Gynecology, Eastern Virginia Medical School, 825 Fairfax Avenue, Norfolk, Virginia 23507. 2 To whom correspondence should be addressed.
275
0740-7769/90/1000-0275506.00/0 9 1990PlenumPublishingCorporation
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EDELSTEIN, BRZYSKI, JONES, AND MUASHER
otropin and compared the stimulation data and oocyte and embryo characteristics with those from a prior IVF cycle in which the patients had been treated with intramuscular (im) gonadotropin.
MATERIALS AND METHODS Patient Selection The study population consisted of six patients who presented to our institution for repeat IVF attempts. All were classified as low responders, having had a peak E2 15 mm in diameter, according to published criteria for serum E 2 and clinical parameters (2). Thirty-four to 36 hours after hCG administration, oocytes were retrieved by ultrasound-guided transvaginal aspiration. The maturational status of the oocytes was recorded according to published criteria (14). Sperm processing, fertilization procedures, and embryo transfers were performed as previously described (15). Patients began progesterone (P) supplementation (25 mg im) on the day after aspiration. Beta-hCG levels were determined on luteal days 11 to 15. If the beta-hCG was negative, P injections were discontinued. Statistical Analysis Comparisons between the im and the iv cycles with regard to stimulation data and oocyte and embryo characteristics were made using Student's paired t test with a Bonferroni correction for multiple comparisons. Trough FSH levels during the im and iv cycles were compared using two-way analysis of variance (ANOVA) followed by Duncan's mean comparison test.
RESULTS
Blood was drawn in the morning, starting on cycle day 3, for determination of serum E2, LH, and FSH by radioimmunoassay (RIA). Blood was sampled just before an im FSH injection or just prior to administratfon of an intravenous pulse of FSH. Monitoring of all cycles was identical. The dosage of FSH was decreased appropriately after an adequate E2 response was observed. Commercially available RIA kits (Leeco Diagnostics, Southfield, MI) were used to determine LH and FSH levels.
Table I describes the six study patients. All were nulliparous. Excluding the IVF cycle using pulsatile iv gonadotropin, the patients had undergone a mean of 4.6 IVF cycles at our institution. All but one of the patients had a baseline (day 3) FSH level > 15 mlU/ml. Table II compares the stimulation characteristics of the im and iv gonadotropin cycles. The cycles were similar in baseline E2 level, day of hCG ad-
Journal of in Vitro Fertilization and Embryo Transfer, Vol. 7, No. 5, 1990
PULSATILE IV FSH FOR IVF
277
Table I. Characteristics of the Six Patients Stimulated with Pulsatile iv FSH Patient No.
Age
Etiology of infertility
Day 3 FSH (mlU/ml)
Day 3 LH (mlU/ml)
Gravida
Para
Prior IVF attempts
1 2 3 4 5 6
35 38 37 34 34 38
Tubal Unexplained Tubal Tubal Tubal Tubal
33.7 11.4 24.3 17.6 15.7 24.4
18.6 7.2 17.8 11.5 11.4 12.5
0 1 2 0 0 3
0 0 0 0 0 0
5 3 3 5 6 6
m i n i s t r a t i o n , E 2 level on the day of hCG administration, peak E2 level, and number of ampoules of medication administered. Table III shows the oocyte and embryo characteristics of the patients during the im and iv cycles. There was no significant difference in mean total number of oocytes retrieved, type of oocytes retrieved, or number of oocytes fertilized, mature oocytes fertilized, embryos transferred, or embryos transferred that originated from mature oocytes. With each protocol, one patient did not undergo oocyte retrieval because of inadequate follicular response. No pregnancies occurred in either group. Figure 1 compares the mean trough FSH levels with regard to the day of hCG administration during cycles using im and pulsatile iv FSH. The serum F S H level was significantly higher (P < 0.0001) during the iv FSH cycles. In all patients the pulsatile iv FSH therapy was tolerated well. There were no local or systemic reactions, no extravasation of medication, no instances of superficial phlebitis, and no instances of pump failure.
DISCUSSION The purpose of this study was to determine whether there was a significant difference in the ovarian stimulation of low-responder IVF patients when gonadotropin was administered in a pulsatile iv fashion instead of by standard daily im injection. Table II. Characteristics of Cycles Stimulated with im FSH and Pulsatile iv FSH im FSH (mean _+ SD) E 2 o n day 3 (pg/ml) Ampoules of gonadotropins Day of hCG Ez on day of hCG (pg/ml) Peak E2 (pg/ml)
35.3 32.3 8,7 273 327
-+ 15.3 - 6.1 -+ 1.5 -+ 84 -+ 61
iv FSH (mean - SD) 28.8 40.7 9.3 348 407
-+ 10.5 -+ 8.7 --- 1.5 -+ 99 -+ 142
Since in normal ovulatory women pituitary gonadotropins are released in a pulsatile manner (9), it was hypothesized that the ovary might be more responsive to pulsatile gonadotropin than to a single daily injection. The pulsatile manner of gonadotropin secretion in the human menstrual cycle was documented more than 15 years ago (8); in premenopausal women an LH pulse frequency of 60-120 min throughout the menstrual cycle was observed. Oscillations in FSH values were also noted during the normal menstrual cycle. In contrast, in postmenopausal women a pulse frequency of 60-120 min was observed for both L H and FSH. Reame et al., by performing serum sampling of volunteers every 10 min at different times in the menstrual cycle, demonstrated a pulse frequency of 20-30 pulses per day (16). FSH pulses were evident only in some subjects; this finding was attributed to the longer half-life of FSH, which tends to obscure individual pulses. Many investigators have used pulsatile gonadotropin therapy for superovulation. Afnan et al. were the first to report a pregnancy in an IVF patient treated with pulsatile gonadotropin (13). Clomiphene citrate and intravenous hMG were administered to a woman with four prior failed IVF attempts, and a singleton pregnancy was achieved. Using subcutaneous (sc) or iv pulsatile gonadotropin delivery, investigators have induced ovulation in patients refractory to more conventional techniques. Nakamura et al. treated 15 patients with various ovulatory disorders with sc pulsatile hMG, and 93% of the cycles were ovulatory (I0). All patients had basal FSH levels < 12 mIU/ml, suggesting they did not have incipient ovarian failure as did the patients in our study. Yuen and co-workers, using pulsatile iv gonadotropin, were able to induce ovulation in eight of eight cycles in women with hypothalamic amenorrhea and in 86% of 99 cycles in anovulatory women with evidence of endogenous estrogen (11). In our study, six patients who had a history of
Journal of in Vitro Fertilization and Embryo Transfer, Vol. 7, No. 5, 1990
278
EDELSTEIN~ BRZYSKI, JONES, AND MUASFIER
Table III. Classification and Outcome of Oocytes retrieved in Cycles Stimulated with im FSH and Pulsatile iv FSH im FSH Total oocytes retrieved per cycle +- SD Preovulatory oocytes retrieved per cycle - SD Immature oocytes retrieved per cycle -+ SD Oocytes fertilized per cycle -+ SD Preovulatory oocytes fertilized per cycle --- SD Embryos transferred per cycle -+ SD Embryos from preovulatory oocytes transferred per cycle -+ SD Embryos cryopreserved per cycle Pregnancies
poor E 2 response and follicular development with im gonadotropin were treated in a subsequent cycle with pulsatile iv therapy. All patients had a peak E2 level 15 mIU/ml. Elevated baseline FSH values identify those patients with incipient ovarian failure who respond poorly to ovarian stimulation, and they are highly predictive of low peak Ez levels, recruitment of fewer follicles, and a less successful IVF outcome (6). We elected to treat our low-responder patients with pure FSH. It has been shown that FSH stimulation may benefit patients who respond poorly to an hMG protocol (3). Another study found higher fertilization and pregnancy rates using FSH in patients randomized to hMG or FSH stimulation (17). Work at our institution indicates that high-dosage FSH (6 ampoules/day) may improve ovarian stimulation in low-responder patients compared to more conventional, lower dose regimens (18). We hypothesized that pulsatile iv administration of gonadotropin may benefit the low-responder IVF patients because this method (i) would better mimic Puloatlle IV FSH
120| 110
-
1 IM
FSH
= 100
-
~ ~--.
8070-
-T ff~
5o-
U_
4e-
30201e-
Day of stimulation with regard to day of hCG administration Fig. 1. Mean trough FSH levels (-+standard deviation) with regard to the day of hCG administration during cycles stimulated with im FSH and pulsatile iv FSH.
3.6 2.2 0.6 2.4 1.8 1.6 1.4
-+ 1.9 _+ 0.7 _+ 0.8 -+ 1.6 --- 1.2 -+ 1.2 +_ 1.0 0 0
iv FSH 3.6 2.2 1.4 3.0 2.2 2.6 2.0
-+ 2.7 -+ 1.3 -+ 1.5 -+ 1.8 + 1.3 - 1.5 -+ 1.1 0 0
physiological events than daily im injection of gonadotropin and (ii) might increase serum FSH levels during ovarian stimulation. Steingold et al. performed frequent blood sampling on volunteers receiving im or iv hMG in a randomized, crossover fashion (19). They showed a more rapid increase in FSH levels after initial treatment in the iv cycles and significantly higher serum levels of FSH with pulsatile iv treatment. Although we did not perform serial blood samples during the iv cycles, we showed that the trough FSH levels were significantly higher with iv therapy. Despite the increase in serum F S H levels during ' stimulation, we found little improvement in follicular response or outcome with pulsatile iv F S H therapy. There was no significant difference in E 2 levels on the day of hCG administration, peak E 2 levels, or the day of hCG administration. Although it has been reported recently that smaller doses of pulsatile iv gonadotropin result in the same E2 levels as higherdose im administration (11), we found that in our patients with incipient ovarian failure the same number of ampoules of F S H administered iv or im resulted in a similar E 2 response. Furthermore, no difference was seen in the number and type of oocytes retrieved or in fertilization rates during the im and iv cycles. Thus, it appears that in lowresponder patients the ovary responds similarly to a single injection or a pulsatile administration of gonadotropin. In summary, we found no significant difference in any of the stimulation characteristics or oocyte and embryo data in patients treated with im or iv gonadotropin. Only six patients were investigated in this study; it is possible that a significant difference could have been present and went undetected. However, because of the cumbersome nature of the gonadotropin therapy with the pump, and the fact that we were investigating low-responder patients with a history of multiple failed IVF attempts, we
Journal of in Vitro Fertilization and Embryo Transfer, Vol. 7, No. 5, 1990
PULSATILE IV FSH FOR IVF
elected to discontinue this form of therapy once it was determined that a very large improvement did not occur with pulsatile iv therapy. We conclude that pulsatile iv gonadotropin is not of major benefit for the stimulation of lowresponder IVF patients. Such patients may be better served by performing IVF during a natural cycle or by offering donor oocytes.
ACKNOWLEDGMENTS
We would like to thank Charlotte Schrader, Ph.D., for her editorial assistance and Mrs. Beverly Cox, Mrs. Shirley Robinson, and Mrs. Ruth Shaw for assistance with the radioimmunoassays. We also thank Ms. Pam Zimmerman and Pharmacia Deltec for supplying the ambulatory pump used in this study.
REFERENCES 1. Quigley MM, Schmidt CL, Beauchamp PS, Pace-Owens S, Berkowitz AS, Wolf DP: Enhanced follicular recruitment in an in vitro fertilization program: Clomiphene alone versus a clomiphene-human menopausal gonadotropin combination. Fertil Steril 1984;42:25-33 2. Jones HWJr, Jones GS, Andrews MC, Acosta AA, Bundren C, Garcia J, Sandow B, Veeck L, Wilkes C, Witmyer J, Wortham JE, Wright G: The program for in vitro fertilization at Norfolk. Fertil Steril 1982;38:14-21 3. Jones GS, Acosta AA, Garcia JE, Bernardus RE, Rosenwaks Z: The effect of follicle-stimulating hormone without additional luteinizing hormone on follicular stimulation and oocyte development in a normal ovulatory women. Fertil Steril 1985;43:696-702 4. Shaw RW, Ndukwe G, Imoedemhe D, Burford G, Chan R: Stimulation of multiple follicular growth for in vitro fertilization by administration of pulsatile luteinizing hormonereleasing hormone during the midfollicular phase. Fertil Steril 1986;46:135-137 5. Muasher SJ: Stimulation protocols for patients with "atypical response." Ann NY Acad Sci 1988;541:82-95 6. Scott RT, Toner JP, Muasher SJ, Oehninger S, Robinson S, Rosenwaks Z: Follicle-stimulating hormone levels on cycle day 3 are predictive of in vitro fertilization outcome. Fertil Steril 1989;51:651-654
279
7. Dierschke DJ, Bhattacharya LE, Atkinson LE, Knobil E: Circhoral oscillations of plasma LH levels in the ovariectomized rhesus monkey. Endocrinology 1970;87:850-853 8. Yen SSC, Tsai CC, Naftolin F, Vandenberg G, Ajabor L: Pulsatile patterns of gonadotropin release in subjects with and without ovarian function. J Clin Endocrinol Metab 1972; 34:671--675 9. Archer DF: Endocrinology of the menstrual cycle. Clin Obstet Gynecol 1984;27:919-926 10. Nakamura Y, Yoshimura Y, Tanabe K, Iizuka R: Induction of ovulation with pulsatile subcutaneous administration of human menopausal gonadotropin in anovulatory infertile women. Fertil Steril 1986;46:46-54 11. Yuen BH, Pride SM, Callegari PB, Leroux A-M, Moon YS: Clinical and endocrine response to pulsatile intravenous gonadotropins in refractory anovulation. Obstet Gynecol 1989; 74:763-768 12. Friedler S, Diamant YZ: Ovulation induction with pulsatile human menopausal gonadotropin (HMG) administration. Eur J Obstet Gynecol Reprod Biol 1987;25:303-313 13. Afnan AMA, Hillier SG, Margara RA, Franks S, Winston RML: Pulsatile gonadotropin administration in in-vitro fertilization. Lancet 1984;1:1239 14. Veeck LL, Wortham JWE, Witmyer J, Sandow BA, Acosta AA, Garcia JE, Jones GS, Jones HW Jr: Maturation and fertilization of morphologically immature human oocytes in a program of in vitro fertilization. Fertil Steril 1983 ;39:594-602 15. Muasher SJ, Garcia JE, Rosenwaks Z: The combination of follicle-stimulating hormone and human menopausal gonadotropin for the induction of multiple follicular maturation for in vitro fertilization. Fertil Steril 1985;44:62-69 16. Reame N, Sauder SE, Kelch RP, Marshall JC: Pulsatile gonadotropin secretion during the human menstrual cycle: Evidence for altered frequency of gonadotropin-releasing hormone secretion. J Clin Endocrinol Metab 1984;59:328-337 17. Russell JB, Polan ML, DeCherney AH: The use of pure follicle-stimulating hormone for ovulation induction in normal ovulatory women in an in vitro fertilization program. Fertil Steril 1986;45:829-833 18. Hofmann GE, Toner JP, Muasher SJ, Jones D, Liu H-C, Jones GS: High-dosage follicle stimulating hormone ovarian stimulation in low-responder patients with high basal serum FSH for in vitro fertilization. Presented at the 44th Annual Meeting of the American Fertility Society, October 10-13, 1988. In Program Supplement American Fertility Society, p S18 (abstr) 19. Steingold KA, Reznikov S, Matt DW: Increased FSH levels achieved with intravenous pergonal administration. Presented at the 45th Annual Meeting of the American Fertility Society, November 13-16, 1989. In Program Supplement, American Fertility Society, p $60 (abstr)
Journal o f in Vitro Fertilization and Embryo Transfer, Vol. 7, No. 5, 1990
Ovarian Stimulation for in Vitro Fertilization in Low-Responder Patients Using Pulsatile Intravenous Follicle Stimulating Hormone MICHAEL C. EDELSTEIN, 1'2 ROBERT G. BRZYSKI, 1 GEORGEANNA S. JONES, 1 and SUHEIL J. MUASHER 1
Submitted: March 12, 1990 Accepted: May 17, 1990
leasing hormone (GnRH) (4) have been used alone or in combination by different programs. Despite all the regimens available, a subset of patients still fails to respond adequately to exogenous stimulation. These low-responder patients exhibit a perimenopausal pattern marked by a failure of progressive increase in serum estradiol (E2) despite adequate stimulation, a failure of multiple follicular development, and a tendency for the triggering of a premature luteinizing hormone (LH) surge (5). These patients are often identified by an elevated serum FSH on cycle day 3 (6). Secretion of endogenous gonadotropins--LH and FSH--is controlled by the pulsatile release of GnRH from the hypothalamus. Experimental evidence indicates that in the nonhuman primate (7), as well as in the human (8), gonadotropins are secreted in a pulsatile manner. LH and FSH are released intermittently, at a frequency of approximately 20 gonadotropin surges per 24 hr in the follicular phase of the menstrual cycle (9). Many investigators have utilized the pulsatile administration of gonadotropin for ovulation induction in patients with such disorders as hypothalamic amenorrhea, polycystic ovarian disease (10,1 I), and luteinized unruptured follicle syndrome (LUF) (12) or in patients undergoing IVF (13)---all with promising results. We hypothesized that pulsatile gonadotropin therapy might benefit the low-responder patient with incipient ovarian failure who is attempting IVF. Pulsatile administration of gonadotropin would better mimic physiologic events than a single daily injection and might result in higher s e r u m E 2 levels, leading to better ovarian stimulation. To test this hypothesis, we treated low-responder IVF patients with pulsatile intravenous (iv) gonad-
There is a subset of patients who fail to respond adequately to exogenous gonadotropin stimulation for in vitro fertilization (IVF). In this study, six such Iowresponder patients who had inadequate stimulations with high-dose intramuscular (im) follicle stimulating hormone (FSH) were treated in a subsequent cycle with pulsatile intravenous (iv) FSH. A paired analysis was performed to compare the cycles using high-dose im FSH with those using pulsatile iv FSH. Trough serum FSH levels were significantly higher with pulsatile iv FSH. No significant difference was noted in the stimulation characteristics or the number or quality of oocytes retrieved and embryos transferred. No pregnancies occurred in either group. While pulsatile iv administration of gonadotropin increases serum FSH levels, it does not appear to have a major impact on follicular stimulation or outcome in low-responder patients undergoing IVF. KEY WORDS: follicle stimulating hormone; in vitro fertilization; low responder; pulsatile gonadotropins.
INTRODUCTION Various methods of ovarian stimulation are used in in vitro fertilization (IVF) in an effort to obtain multiple fertilized oocytes. Oral clomiphene citrate (1), intramuscular human menopausal gonadotropin (hMG) (2), intramuscular follicle stimulating hormone (FSH) (3), and intravenous gonadotropin re-
t The Jones Institute for Reproductive Medicine, Department of Obstetrics and Gynecology, Eastern Virginia Medical School, 825 Fairfax Avenue, Norfolk, Virginia 23507. 2 To whom correspondence should be addressed.
275
0740-7769/90/1000-0275506.00/0 9 1990PlenumPublishingCorporation
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EDELSTEIN, BRZYSKI, JONES, AND MUASHER
otropin and compared the stimulation data and oocyte and embryo characteristics with those from a prior IVF cycle in which the patients had been treated with intramuscular (im) gonadotropin.
MATERIALS AND METHODS Patient Selection The study population consisted of six patients who presented to our institution for repeat IVF attempts. All were classified as low responders, having had a peak E2 15 mm in diameter, according to published criteria for serum E 2 and clinical parameters (2). Thirty-four to 36 hours after hCG administration, oocytes were retrieved by ultrasound-guided transvaginal aspiration. The maturational status of the oocytes was recorded according to published criteria (14). Sperm processing, fertilization procedures, and embryo transfers were performed as previously described (15). Patients began progesterone (P) supplementation (25 mg im) on the day after aspiration. Beta-hCG levels were determined on luteal days 11 to 15. If the beta-hCG was negative, P injections were discontinued. Statistical Analysis Comparisons between the im and the iv cycles with regard to stimulation data and oocyte and embryo characteristics were made using Student's paired t test with a Bonferroni correction for multiple comparisons. Trough FSH levels during the im and iv cycles were compared using two-way analysis of variance (ANOVA) followed by Duncan's mean comparison test.
RESULTS
Blood was drawn in the morning, starting on cycle day 3, for determination of serum E2, LH, and FSH by radioimmunoassay (RIA). Blood was sampled just before an im FSH injection or just prior to administratfon of an intravenous pulse of FSH. Monitoring of all cycles was identical. The dosage of FSH was decreased appropriately after an adequate E2 response was observed. Commercially available RIA kits (Leeco Diagnostics, Southfield, MI) were used to determine LH and FSH levels.
Table I describes the six study patients. All were nulliparous. Excluding the IVF cycle using pulsatile iv gonadotropin, the patients had undergone a mean of 4.6 IVF cycles at our institution. All but one of the patients had a baseline (day 3) FSH level > 15 mlU/ml. Table II compares the stimulation characteristics of the im and iv gonadotropin cycles. The cycles were similar in baseline E2 level, day of hCG ad-
Journal of in Vitro Fertilization and Embryo Transfer, Vol. 7, No. 5, 1990
PULSATILE IV FSH FOR IVF
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Table I. Characteristics of the Six Patients Stimulated with Pulsatile iv FSH Patient No.
Age
Etiology of infertility
Day 3 FSH (mlU/ml)
Day 3 LH (mlU/ml)
Gravida
Para
Prior IVF attempts
1 2 3 4 5 6
35 38 37 34 34 38
Tubal Unexplained Tubal Tubal Tubal Tubal
33.7 11.4 24.3 17.6 15.7 24.4
18.6 7.2 17.8 11.5 11.4 12.5
0 1 2 0 0 3
0 0 0 0 0 0
5 3 3 5 6 6
m i n i s t r a t i o n , E 2 level on the day of hCG administration, peak E2 level, and number of ampoules of medication administered. Table III shows the oocyte and embryo characteristics of the patients during the im and iv cycles. There was no significant difference in mean total number of oocytes retrieved, type of oocytes retrieved, or number of oocytes fertilized, mature oocytes fertilized, embryos transferred, or embryos transferred that originated from mature oocytes. With each protocol, one patient did not undergo oocyte retrieval because of inadequate follicular response. No pregnancies occurred in either group. Figure 1 compares the mean trough FSH levels with regard to the day of hCG administration during cycles using im and pulsatile iv FSH. The serum F S H level was significantly higher (P < 0.0001) during the iv FSH cycles. In all patients the pulsatile iv FSH therapy was tolerated well. There were no local or systemic reactions, no extravasation of medication, no instances of superficial phlebitis, and no instances of pump failure.
DISCUSSION The purpose of this study was to determine whether there was a significant difference in the ovarian stimulation of low-responder IVF patients when gonadotropin was administered in a pulsatile iv fashion instead of by standard daily im injection. Table II. Characteristics of Cycles Stimulated with im FSH and Pulsatile iv FSH im FSH (mean _+ SD) E 2 o n day 3 (pg/ml) Ampoules of gonadotropins Day of hCG Ez on day of hCG (pg/ml) Peak E2 (pg/ml)
35.3 32.3 8,7 273 327
-+ 15.3 - 6.1 -+ 1.5 -+ 84 -+ 61
iv FSH (mean - SD) 28.8 40.7 9.3 348 407
-+ 10.5 -+ 8.7 --- 1.5 -+ 99 -+ 142
Since in normal ovulatory women pituitary gonadotropins are released in a pulsatile manner (9), it was hypothesized that the ovary might be more responsive to pulsatile gonadotropin than to a single daily injection. The pulsatile manner of gonadotropin secretion in the human menstrual cycle was documented more than 15 years ago (8); in premenopausal women an LH pulse frequency of 60-120 min throughout the menstrual cycle was observed. Oscillations in FSH values were also noted during the normal menstrual cycle. In contrast, in postmenopausal women a pulse frequency of 60-120 min was observed for both L H and FSH. Reame et al., by performing serum sampling of volunteers every 10 min at different times in the menstrual cycle, demonstrated a pulse frequency of 20-30 pulses per day (16). FSH pulses were evident only in some subjects; this finding was attributed to the longer half-life of FSH, which tends to obscure individual pulses. Many investigators have used pulsatile gonadotropin therapy for superovulation. Afnan et al. were the first to report a pregnancy in an IVF patient treated with pulsatile gonadotropin (13). Clomiphene citrate and intravenous hMG were administered to a woman with four prior failed IVF attempts, and a singleton pregnancy was achieved. Using subcutaneous (sc) or iv pulsatile gonadotropin delivery, investigators have induced ovulation in patients refractory to more conventional techniques. Nakamura et al. treated 15 patients with various ovulatory disorders with sc pulsatile hMG, and 93% of the cycles were ovulatory (I0). All patients had basal FSH levels < 12 mIU/ml, suggesting they did not have incipient ovarian failure as did the patients in our study. Yuen and co-workers, using pulsatile iv gonadotropin, were able to induce ovulation in eight of eight cycles in women with hypothalamic amenorrhea and in 86% of 99 cycles in anovulatory women with evidence of endogenous estrogen (11). In our study, six patients who had a history of
Journal of in Vitro Fertilization and Embryo Transfer, Vol. 7, No. 5, 1990
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EDELSTEIN~ BRZYSKI, JONES, AND MUASFIER
Table III. Classification and Outcome of Oocytes retrieved in Cycles Stimulated with im FSH and Pulsatile iv FSH im FSH Total oocytes retrieved per cycle +- SD Preovulatory oocytes retrieved per cycle - SD Immature oocytes retrieved per cycle -+ SD Oocytes fertilized per cycle -+ SD Preovulatory oocytes fertilized per cycle --- SD Embryos transferred per cycle -+ SD Embryos from preovulatory oocytes transferred per cycle -+ SD Embryos cryopreserved per cycle Pregnancies
poor E 2 response and follicular development with im gonadotropin were treated in a subsequent cycle with pulsatile iv therapy. All patients had a peak E2 level 15 mIU/ml. Elevated baseline FSH values identify those patients with incipient ovarian failure who respond poorly to ovarian stimulation, and they are highly predictive of low peak Ez levels, recruitment of fewer follicles, and a less successful IVF outcome (6). We elected to treat our low-responder patients with pure FSH. It has been shown that FSH stimulation may benefit patients who respond poorly to an hMG protocol (3). Another study found higher fertilization and pregnancy rates using FSH in patients randomized to hMG or FSH stimulation (17). Work at our institution indicates that high-dosage FSH (6 ampoules/day) may improve ovarian stimulation in low-responder patients compared to more conventional, lower dose regimens (18). We hypothesized that pulsatile iv administration of gonadotropin may benefit the low-responder IVF patients because this method (i) would better mimic Puloatlle IV FSH
120| 110
-
1 IM
FSH
= 100
-
~ ~--.
8070-
-T ff~
5o-
U_
4e-
30201e-
Day of stimulation with regard to day of hCG administration Fig. 1. Mean trough FSH levels (-+standard deviation) with regard to the day of hCG administration during cycles stimulated with im FSH and pulsatile iv FSH.
3.6 2.2 0.6 2.4 1.8 1.6 1.4
-+ 1.9 _+ 0.7 _+ 0.8 -+ 1.6 --- 1.2 -+ 1.2 +_ 1.0 0 0
iv FSH 3.6 2.2 1.4 3.0 2.2 2.6 2.0
-+ 2.7 -+ 1.3 -+ 1.5 -+ 1.8 + 1.3 - 1.5 -+ 1.1 0 0
physiological events than daily im injection of gonadotropin and (ii) might increase serum FSH levels during ovarian stimulation. Steingold et al. performed frequent blood sampling on volunteers receiving im or iv hMG in a randomized, crossover fashion (19). They showed a more rapid increase in FSH levels after initial treatment in the iv cycles and significantly higher serum levels of FSH with pulsatile iv treatment. Although we did not perform serial blood samples during the iv cycles, we showed that the trough FSH levels were significantly higher with iv therapy. Despite the increase in serum F S H levels during ' stimulation, we found little improvement in follicular response or outcome with pulsatile iv F S H therapy. There was no significant difference in E 2 levels on the day of hCG administration, peak E 2 levels, or the day of hCG administration. Although it has been reported recently that smaller doses of pulsatile iv gonadotropin result in the same E2 levels as higherdose im administration (11), we found that in our patients with incipient ovarian failure the same number of ampoules of F S H administered iv or im resulted in a similar E 2 response. Furthermore, no difference was seen in the number and type of oocytes retrieved or in fertilization rates during the im and iv cycles. Thus, it appears that in lowresponder patients the ovary responds similarly to a single injection or a pulsatile administration of gonadotropin. In summary, we found no significant difference in any of the stimulation characteristics or oocyte and embryo data in patients treated with im or iv gonadotropin. Only six patients were investigated in this study; it is possible that a significant difference could have been present and went undetected. However, because of the cumbersome nature of the gonadotropin therapy with the pump, and the fact that we were investigating low-responder patients with a history of multiple failed IVF attempts, we
Journal of in Vitro Fertilization and Embryo Transfer, Vol. 7, No. 5, 1990
PULSATILE IV FSH FOR IVF
elected to discontinue this form of therapy once it was determined that a very large improvement did not occur with pulsatile iv therapy. We conclude that pulsatile iv gonadotropin is not of major benefit for the stimulation of lowresponder IVF patients. Such patients may be better served by performing IVF during a natural cycle or by offering donor oocytes.
ACKNOWLEDGMENTS
We would like to thank Charlotte Schrader, Ph.D., for her editorial assistance and Mrs. Beverly Cox, Mrs. Shirley Robinson, and Mrs. Ruth Shaw for assistance with the radioimmunoassays. We also thank Ms. Pam Zimmerman and Pharmacia Deltec for supplying the ambulatory pump used in this study.
REFERENCES 1. Quigley MM, Schmidt CL, Beauchamp PS, Pace-Owens S, Berkowitz AS, Wolf DP: Enhanced follicular recruitment in an in vitro fertilization program: Clomiphene alone versus a clomiphene-human menopausal gonadotropin combination. Fertil Steril 1984;42:25-33 2. Jones HWJr, Jones GS, Andrews MC, Acosta AA, Bundren C, Garcia J, Sandow B, Veeck L, Wilkes C, Witmyer J, Wortham JE, Wright G: The program for in vitro fertilization at Norfolk. Fertil Steril 1982;38:14-21 3. Jones GS, Acosta AA, Garcia JE, Bernardus RE, Rosenwaks Z: The effect of follicle-stimulating hormone without additional luteinizing hormone on follicular stimulation and oocyte development in a normal ovulatory women. Fertil Steril 1985;43:696-702 4. Shaw RW, Ndukwe G, Imoedemhe D, Burford G, Chan R: Stimulation of multiple follicular growth for in vitro fertilization by administration of pulsatile luteinizing hormonereleasing hormone during the midfollicular phase. Fertil Steril 1986;46:135-137 5. Muasher SJ: Stimulation protocols for patients with "atypical response." Ann NY Acad Sci 1988;541:82-95 6. Scott RT, Toner JP, Muasher SJ, Oehninger S, Robinson S, Rosenwaks Z: Follicle-stimulating hormone levels on cycle day 3 are predictive of in vitro fertilization outcome. Fertil Steril 1989;51:651-654
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7. Dierschke DJ, Bhattacharya LE, Atkinson LE, Knobil E: Circhoral oscillations of plasma LH levels in the ovariectomized rhesus monkey. Endocrinology 1970;87:850-853 8. Yen SSC, Tsai CC, Naftolin F, Vandenberg G, Ajabor L: Pulsatile patterns of gonadotropin release in subjects with and without ovarian function. J Clin Endocrinol Metab 1972; 34:671--675 9. Archer DF: Endocrinology of the menstrual cycle. Clin Obstet Gynecol 1984;27:919-926 10. Nakamura Y, Yoshimura Y, Tanabe K, Iizuka R: Induction of ovulation with pulsatile subcutaneous administration of human menopausal gonadotropin in anovulatory infertile women. Fertil Steril 1986;46:46-54 11. Yuen BH, Pride SM, Callegari PB, Leroux A-M, Moon YS: Clinical and endocrine response to pulsatile intravenous gonadotropins in refractory anovulation. Obstet Gynecol 1989; 74:763-768 12. Friedler S, Diamant YZ: Ovulation induction with pulsatile human menopausal gonadotropin (HMG) administration. Eur J Obstet Gynecol Reprod Biol 1987;25:303-313 13. Afnan AMA, Hillier SG, Margara RA, Franks S, Winston RML: Pulsatile gonadotropin administration in in-vitro fertilization. Lancet 1984;1:1239 14. Veeck LL, Wortham JWE, Witmyer J, Sandow BA, Acosta AA, Garcia JE, Jones GS, Jones HW Jr: Maturation and fertilization of morphologically immature human oocytes in a program of in vitro fertilization. Fertil Steril 1983 ;39:594-602 15. Muasher SJ, Garcia JE, Rosenwaks Z: The combination of follicle-stimulating hormone and human menopausal gonadotropin for the induction of multiple follicular maturation for in vitro fertilization. Fertil Steril 1985;44:62-69 16. Reame N, Sauder SE, Kelch RP, Marshall JC: Pulsatile gonadotropin secretion during the human menstrual cycle: Evidence for altered frequency of gonadotropin-releasing hormone secretion. J Clin Endocrinol Metab 1984;59:328-337 17. Russell JB, Polan ML, DeCherney AH: The use of pure follicle-stimulating hormone for ovulation induction in normal ovulatory women in an in vitro fertilization program. Fertil Steril 1986;45:829-833 18. Hofmann GE, Toner JP, Muasher SJ, Jones D, Liu H-C, Jones GS: High-dosage follicle stimulating hormone ovarian stimulation in low-responder patients with high basal serum FSH for in vitro fertilization. Presented at the 44th Annual Meeting of the American Fertility Society, October 10-13, 1988. In Program Supplement American Fertility Society, p S18 (abstr) 19. Steingold KA, Reznikov S, Matt DW: Increased FSH levels achieved with intravenous pergonal administration. Presented at the 45th Annual Meeting of the American Fertility Society, November 13-16, 1989. In Program Supplement, American Fertility Society, p $60 (abstr)
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