Head of Department of Obs/Gynae

University of Thessaly, Larissa, Greece

Professor IOANNIS E. MESSINIS

MD, PhD (Aberdeen, UK), FRCOG (UK)

Disclosure of interest:

Nothing to disclose

LH IN THE STIMULATION PROTOCOL.

Is it necessary? To whom? Would

adding LH increase OHSS risk?

Is LH necessary?

From a physiological point of view:

• LH contributes to follicle maturation

– by stimulating steroids production

– by sustaining the growth of the selected

dominant follicle

A

T

Chole-

sterole

cAMP

A T

E1

E2 LH

FSH FSH

Induction of

FSHR aromatase

5α-reductase 5α-reduced A

Theca

cell Granulosa

cell

(-)

R

R R

TWO-CELL TWO-GONADOTROPHIN THEORY

(Early follicular phase)

CLASS 5 CLASS 6 CLASS 8

Intercycle rise

of FSH

Follicles

10-12 mm

CYCLIC

RECRUITMENT

SELECTION

DOMINANCE

18 mm

GROWTH OF THE DOMINANT

FOLLICLE

Messinis et al., 2010

Ann. N.Y. Acad. Sci.

1205, 5-11

A

T

Chole-

sterole

cAMP

A T

E1

E2 LH

FSH FSH

Induction of

FSHR aromatase

5α-reductase 5α-reduced A

Theca

cell Granulosa

cell

(-)

R

R R

TWO-CELL TWO-GONADOTROPHIN THEORY

(Mid- to late follicular phase)

LH

R

Is LH necessary

during ovarian stimulation?

Endogenous LH: Yes

Exogenous LH: ???

Exogenous LH: To whom?

• Are there any subgroups of infertile

women who might get an extra

benefit from the use of LH at any

stage of ovarian stimulation?

A) SINGLE FOLLICLE SELECTION

B) MULTIPLE FOLLICLE SELECTION

FSH WINDOW

OVARY

GnRH

E2

Inhibin

LH

FSH

(basal)

Negative

feedback

(-)

Messinis, 2006

Hum. Reprod. Update 12, 557-571

MULTIPLE FOLLICULAR DEVELOPMENT

Cycle days 2 3 4 5 6 7 8 9 10

Control

rFSH/uFSH

uFSH

rFSH (Gonal-f)

Messinis et al.,

1998

Hum. Reprod.

13, 2415-20

20

10

0 7

0 10000

1000

100

FSH

IU/l

LH

IU/l

E2

pmol/l

OVARIAN STIMULATION

100

80

60

40

20

0 3000 6000 9000 12000 15000

LH

IU/l

Estradiol (pmol/l)

r=-0.44

P<0.05

0

LH SUPPRESSION DURING

OVARIAN HYPERSTIMULATION

Messinis et al., 1986; Clin. Endocrinol. 25, 393-400

Is LH suppressed in all

treatment cycles?

NO

It depends on the treatment protocol

7

6

5

4

3

2

1 0

2000

1500

1000

500

0

LH

IU/l

E2

pg/ml

6 7 8 9 10 11 -2 -1 HCG

Up to day 7 (n=115)

Up to day of HCG (n=115)

LH IS NOT SUPPRESSED

Cedrin-Durnerin et al., 2000, Hum. Reprod. 15, 1009-1014

8

6

4

2

0

2000

1000

0

Decapeptyl

GnRH ag. short protocol

7

3

6

5

4

2

1

0

Screen 1 6 7 8 9 10 11 HCG ET final

OPU after ET

HMG days

n=228 278 302 291 291 225 161 103 298 253 235 222 55

Felberbaum et al., 2000; Hum. Reprod. 15, 1015-1020

MEDIAN

VALUE

8

6

4

2

0

LH

IU/l

FSH PLUS A GnRH ANTAGONIST

(cetrorelix)

6 8

4 2

10

6

2

1000

800

200

3

2 1

0 24 48

E2

pg/ml

FSH

mIU/ml

LH

mIU/ml

P4

ng/ml

HOURS

E2 patches Ganirelix

LH IS SUPPRESSED BY E2

(but not....... by the antagonist)

Messinis et al., 2010

Fertil. Steril.

94, 1554-6

1 6 8 10

Stimulation day

1 6 8 10

Stimulation day

LH IU/L FSH IU/L

FSH PLUS A GnRH AGONIST (LONG)

Ganirelix

Buserelin (LONG)

Borm & Mannaerts, 2000

Hum. Reprod. 15, 1490-1498

8

6

4

2

0

20

15

10

5

0

HOW MUCH LH?

LH thresholds studied

• 3.0 mIU/ml (Esposito et al., 2001)

• 1.2 mIU/ml (O’Dea et al., 2008)

• 1.0 mIU/ml (Cabrera et al/. 2005)

• 0.7 mIU/ml (Balasch et al., 2001)

• 0.5 mIU/ml (Westergaard et al., 2000)

<0.5 IU/L

(n=20)

Normal LH

(n=41)

E2 on HCG (pg/ml) 1778±1762 2923±2213 NS

E2/mm of FD (pg/ml) 7.2±3.6 10.4±4.3 0.03

No. of oocytes 185 536

Fertilization rate (%) 75.7 84.2 <0.02

Supernumerary

embryos/patient 5.1±4.4 7.8±5.4 0.05

OVARIAN STIMULATION

(Midfollicular LH)

P

Fleming, 1998

Hum. Reprod. 13, 1788-92

Long GnRH ag

LH VALUES IN IVF CYCLES

• Better outcome if day 8 LH0.5 IU/l in rFSH/ganirelix cycles (Kolibianakis et al., 2004)

• Higher rate of early pregnancy loss (Westergaard et al., 2000) if day 8 LH<0.5 IU/l

• Lower live birth rate if LH0.5 IU/l (Propst et al., 2011)

• Serum LH (rFSH/triptorelin) cannot predict ovarian response and outcome (Penarrubia et al., 2003)

To maintain adequate

amounts of LH,

• apply milder ovarian stimulation

protocols!

• use lower doses of the GnRH

agonist!

• supplement with exogenous LH!

Supplementation with

exogenous LH

To whom?

• Non-selected patients

• Poor responders

• Hypogonadotrophic hypogonadism

Supplementation with

exogenous LH

To whom?

• Non-selected patients

• Poor responders

• Hypogonadotrophic hypogonadism

r-FSH r-FSH + rLH P-value

All patients 28.7% 27.2% 0.699

(n=261) (n=265)

Patients 35 y 27.6% 29.6% 0.699

(n=210) (n=216)

Patients >35 y 33.3% 16.3% 0.065

(n=51) (n=49)

rFSH vs rFSH+rLH (MID-FOLLICULAR rLH SUPPLEMENTATION)

NyboeAndersen et al., 2008

Hum. Reprod. 23, 427-34

GnRH-ag long (IVF/ICSI)

(ongoing live gestation

10-12 weeks)

244 WOMEN IN TWO GROUPS:

Group I (n=122): GnRH-ag/rFSH

Group II (n=122): GnRH-ag/rFSH+rLH

- More oocytes, higher implantation rate

in Group II than in Group I

- No differences in clinical results

Franco et al., 2009

Reprod. Biol. Endocrinol. 7, 58

rFSH vs rFSH+rLH (from the beginning of treatment)

Kolibianakis et al., Hum Reprod Update. 2007, 13, 445-52

Favours FSH Favours FSH+LH

FSH vs FSH+rLH

Live birth rate

IVF

ICSI

Al-Inany et al., 2009; Gynecol Endocrinol 25, 372-8

Ongoing pregnancy / live birth rate

Favours HP-HMG Favours FSH

HP-HMG vs rFSH

28 trials, 7339 couples:

Odds ratio 0.97, 95% CI 0.87 to 1.08

Van Wely et al., 2011

Cochrane Database Syst. Rev. Feb 16;(2):CD005354.

rFSH vs URINARY

(HMG, P-FSH, HP-FSH)

LIVE BIRTH RATE (IVF/ICSI)

NO DIFFERENCE

Dose 0

(n=16)

Dose 50

(n=20)

Dose 100

(n=16)

Dose 150

(n=15)

Treatment

Days........... 10.3±1.4 9.3±1.4 9.9±1.3 10.4±1.1

Total dose

FSH............ 1538±209 1385±232 1475±195 1562±163

Oocytes

retreived.... 9.3±6.3 8.5±4.4 9.2±4.2 11.3±5.7

Cl. Preg./

cycle.......... 25% 27% 38% 31%

Live birth

rate............. 25% 27% 25% 31%

Thuesen et al. 2012

Hum. Reprod. 27, 3074-84

Prospective RCT

HCG in IU from day 1

ADDITION OF HCG TO rFSH

18

16

14

12

10

8

6

4

2

0 12-14 mm 14-17 mm >17 mm

No of follicles

Mean diameter

2.6 2.4

6.2 5.5

16.5 14.7

rFSH+rLH

HP-hMG+uFSH

Oocyte

donors

Requena et al., 2014; Reprod. Biol. Endocrinol. 12, 10

OVARIAN STIMULATION

Supplementation with

exogenous LH

To whom?

• Non-selected patients

• Poor responders

• Hypogonadotrophic hypogonadism

• Meta-analysis of 3 RCTs:

Higher pregnancy rate in favour of co-

administering rLH

OR 1.85 (95% CI 1.10-3.11)

Mochtar et al., Cochrane Database Syst Rev 2007

rLH IN POOR RESPONDERS

(Pooled pregnancy estimates)

r-FSH

(n=68)

r-FSH + rLH

(n=63) ITT Population

Analysis

Implantation rate 11.3 18.1 0.049

Live birth/started cycle 7.4 19.0 0.047

Live birth rate/ET 9.3 21.4 NS

P-value

PP Population

Analysis

Implantation rate 10.0 17.4 NS

Live birth/started cycle 7.7 17.5 NS

Live birth rate/ET 9.6 19.6 NS

MID-FOLLICULAR rLH

SUPPLEMENTATION (35-39 y)

ICSI results Matorras et al., 2009

RBMOnline 19, 879-887 GnRH-ag long

35 y (n=172 vs 161) 36-39 y (n=142 vs 150)

IR

CPR

PLR

OPR/ET

OPR(ITT)

1.00 1.50 0.50 1.00 2.00 0.00

rFSH vs rFSH+rLH

GnRH-antag. Bosch et al., 2011

Fertil. Steril. 95, 1031-6

RCT

rFSH vs rFSH+rLH

Meta-analysis

Women 35 years Hill et al., 2012

Fertil. Steril. 97, 1108-14

Favors rFSH Favors rLH + rFSH

Clinical pregnancy rate

Early LH

(from day 1)

(n=264)

Late LH

(from day 7)

(n=266)

Total FSH dose (IU) 4090±934 4223±1086

Total LH dose (IU) 2163±285 1042±348

Retrieved oocytes 3.7±2.1 3.5±2.4

Preg. Rate/ET (%) 17.6 19.9

Ong./delivered (%) 12.6 14.9

SUPPLEMENTATION OF

recFSH WITH recLH

Revelli et al., 2012

JARG 29, 869-75

Poor responders

Prospective RCT

rFSH

(n=128)

rFSH+rLH

(n=125)

FSH 12.8±3.9 12.1±3.4 NS

LH 1.6±1.2 3.0±1.2 0.00

E2 5135±3179 6524±3802 0.01

P

FSH 2.0±1.7 1.8±0.7 NS

LH 0.5±0.5 0.6±1.0 NS

E2 2941±1809 2879±1875 NS

Day

of

HCG

Day

of

ET

rLH SUPPLEMENTATION

(from day 6 of stimulation)

RCT (women ≥35 y)

GnRH ant. (IVF/ICSI)

Mean±SD

Konig et al., 2013

Hum. Reprod. 28, 2804-12

rFSH

(n=128)

rFSH+rLH

(n=125)

Total oocytes 10.9±6.4 10.2±6.1

Cl. Preg. (ITT) 29.7% 28.0%

Ong. Preg. (ITT) 21.9% 20.0%

Cl. Preg. (per Prot.) 33.6% 30.2%

Ong. Preg. (per Prot.) 24.8% 21.6%

Ong. Preg. including

frozen-thawed 27.4% 25.9%

rLH SUPPLEMENTATION

(from day 6 of stimulation)

Konig et al., 2013

Hum. Reprod. 28, 2804-12

RCT (women ≥35 y)

GnRH ant. (IVF/ICSI)

Mean±SD

POOR RESPONDERS rFSH+rLH vs rFSH

No of oocytes 0.75 (95% CI 0.14-1.36) ITT (n=12 studies)

0.75 (95% CI 0.13-1.36) PP

Clinical Pregnancy 1.30 (95% CI 1.01-1.67) ITT (n=14 studies)

Ongoing pregnancy rate 1.36 (95% CI 1.04-1.79) ITT (n=11 studies)

Live birth rate NS

Lehert et al., 2014

Reprod. Biol. Endocrinol. 12, 17

rFSH

rFSH+rLH

or HMG

- Nyboeandersen et al., 2008

(RCT) 3.8% 2.6%

- Al-Inany et al., 2008

(Meta-analysis) OR: 1.21 (95% CI 0.78-1.86)

- Coomarasamy et al., 2008

(Meta-analysis) OR: 1.39 (95% CI 0.72-2.69)

- Bosch et al., 2011

(RCT) ≤35y 5.3% 7.0%

35-39y 5.0% 3.0%

LH AND OHSS

LH AND OHSS

• Low dose HCG supplementation to

FSH

– Less in the antagonists vs agonists OR:

0.30 (95% CI 0.09-0.96)

Meta-analysis

Kosmas et al., 2009

RBMOnline 19, 619-30

Supplementation with

exogenous LH

To whom?

• Non-selected patients

• Poor responders

• Hypogonadotrophic hypogonadism

75 IU

recFSH

5

10

15

20

FSH (IU/L)

Follicle

diameter (mm) E2 (pmol/L)

Follicle

FSH

E2

200

100

7 14 21

0 6 10 15 20 25 30 35 Days

Shoham et al., 1993

Fertil. Steril. 59, 738-42

HYPO-, HYPO-

HYPOGONADOTROPHIC

HYPOGONADISM

(Usage of HMG or rFSH with rLH)

FSH LH E2

IU IU (pmol/l)

Couzinet et al., 1988 225 225 2753

(HMG) (HMG)

Kousta et al.,1996 150 225 780

El-Shawarby et al., 2004 50-75 75 3155

Based on a review by: Messinis, 2005

Hum. Reprod. 20, 2688-97

CLINICAL RESULTS

(starting dose 150 IU/day)

50 patients were treated in 167 cycles:

- All women ovulated - 33 pregnant (66%)

- 39 pregnancies (9 multiples, 31%,

10 aborted, 26%)

- Patients who took home at least one baby

28 (56%)

Messinis et al., 1988

Fertil. Steril. 50, 31-35 ~4 cycles

CONCLUSIONS (1)

Additional LH is possibly

not needed

• In the majority of IVF/ICSI unselected

cycles with multiple follicular

development

Additional LH is possibly

needed (still debatable)

• In poor responders

• In older women

CONCLUSIONS (2)

CONCLUSIONS (3)

Additional LH is needed

(absolutely necessary)

• In women with hypogonadotrophic

hypogonadism during ovulation

induction or ovarian stimulation for

IVF/ICSI (from the beginning of the

treatment)

STILL EXPERIMENTAL

• The administration of rLH

– to substitute rFSH and sustain the

follicle growth in IVF cycles

– to attain a ‘ceiling effect’ in ovulation

induction facilitating mono-follicular

development