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Addition of neither recombinant nor urinary luteinizing hormone was associated with an improvement in the outcome of autologous in vitro fertilization/intracytoplasmatic sperm injection cycles under regular clinical settings: a multicenter observational analysis

Published:September 24, 2016DOI:https://doi.org/10.1016/j.fertnstert.2016.09.003

      Objective

      To determine whether the addition of either urinary or recombinant LH in patients undergoing routine clinical care improved the outcome in terms of the number of oocytes recovered for insemination or the delivery rate per initiated cycle.

      Design

      Cohort analysis.

      Patient(s)

      Couples undergoing IVF/ICSI in 158 institutions in 15 countries in Latin America.

      Setting

      In vitro fertilization clinics.

      Intervention(s)

      We compared the outcome of three different protocols of COH, including rFSH only, rFSH plus rLH, and rFSH plus hMG.

      Main Outcome Measure(s)

      The number of mature oocytes recovered and inseminated; proportion of ETs at the blastocyst stage; clinical pregnancy, miscarriage, and delivery rates; proportion of cycles with embryo cryopreservation; and mean number of embryos cryopreserved.

      Result(s)

      After correcting for the age of the female partner, body mass index, number of embryos transferred, and stage of embryo development at transfer, we found that LH addition was not associated with an increase in the mean number of metaphase II oocytes inseminated or with an increase in the delivery rate or changes in the miscarriage rate.

      Conclusion(s)

      Our study strongly suggests that in routine clinical practice, the type of controlled ovarian stimulation—FSH alone or in combination with LH—has little impact on the outcome of assisted reproductive technology; therefore a more friendly and accessible alternative should be favored.

      Key Words

      Discuss: You can discuss this article with its authors and with other ASRM members at https://www.fertstertdialog.com/users/16110-fertility-and-sterility/posts/12241-22837
      Controlled ovarian stimulation (COS) is a fundamental step of assisted reproductive techniques (ART). Over the years, stimulation with antiestrogens was followed by the use of urinary gonadotropins containing a mixture of FSH and LH, generically referred to as human menopausal gonadotropin (hMG). Later, molecular biology technology introduced recombinant FSH (rFSH) and LH (rLH) (
      Recombinant Human FSH Product Development Group
      Recombinant follicle stimulating hormone: development of the first biotechnology product for the treatment of infertility.
      ,
      • Lehert P.
      • Kolibianakis E.M.
      • Venetis C.A.
      • Schertz J.
      • Saunders H.
      • Arriagada P.
      • et al.
      Recombinant human follicle-stimulating hormone (r-hFSH) plus recombinant luteinizing hormone versus r-hFSH alone for ovarian stimulation during assisted reproductive technology: systematic review and meta-analysis.
      ). Today it is possible to induce multifollicular development with a single gonadotropin such as rFSH or a mixture of FSH and LH, either combining rFSH and rLH or using urinary hMG.
      In the last decades, there had been much discussion regarding the optimal protocol for COS (
      • van Wely M.
      • Kwan I.
      • Burt A.L.
      • Thomas J.
      • Vail A.
      • van der Veen F.
      • et al.
      Recombinant versus urinary gonadotrophin for ovarian stimulation in assisted reproductive technology cycles.
      ,
      • Westergaard L.W.
      • Bossuyt P.M.
      • van der Veen F.
      • van Wely M.
      Human menopausal gonadotropin versus recombinant follicle stimulation hormone for ovarian stimulation in assisted reproductive cycles.
      ,
      • Revelli A.
      • Pettinau G.
      • Basso G.
      • Carosso A.
      • Ferrero A.
      • Dallan C.
      • et al.
      Controlled ovarian stimulation with recombinant-FSH plus recombinant-LH vs. human menopausal gonadotropin based on the number of retrieved oocytes: results from a routine clinical practice in a real-life population.
      ,
      • Ye H.
      • Huang G.
      • Pei L.
      • Zeng P.
      • Luo X.
      Outcome of in vitro fertilization following stimulation with highly purified hMG or recombinant FSH in downregulated women of advanced reproductive age: a prospective, randomized and controlled trial.
      ). Several systematic reviews compared diverse outcomes when COS was performed with rFSH or with urinary gonadotropins (hMG, purified FSH, highly purified FSH). The interpretation of the data available is quite difficult, because each of these reviews used different inclusion and exclusion criteria. The latest systematic review and meta-analysis found no significant difference between different COS protocols and concluded that clinical choice of gonadotropins should depend on their availability, convenience, and costs. Furthermore, the investigators concluded that further research on these comparisons is unlikely to identify substantive differences in effectiveness or safety (
      • van Wely M.
      • Kwan I.
      • Burt A.L.
      • Thomas J.
      • Vail A.
      • van der Veen F.
      • et al.
      Recombinant versus urinary gonadotrophin for ovarian stimulation in assisted reproductive technology cycles.
      ).
      Although randomized controlled trials are the most accurate methodological design to determine the efficacy or superiority of any given intervention, interpretation of results needs to consider that this type of trials are performed under strict inclusion criteria, both for selecting patients and administering the drugs. Therefore, the results will be applicable only to those falling within certain selection criteria and not to the general population (
      • Stang A.
      Randomized controlled trials-an indispensible part of clinical research.
      ).
      Thus, we decided to perform a cohort study to determine whether in nonselected patients, the addition of LH—either recombinant or urinary—to rFSH improved the outcome in women undergoing autologous IVF/intracytoplasmic sperm injection (ICSI).

      Materials and methods

      The Latin American Registry of ART collects multinational multicenter biomedical and social data in a cycle-based format, allowing the tracking of each treatment cycle performed in over 158 institutions in 15 countries in Latin America.
      The data analyzed in our manuscript were proportioned by the Latin American Registry of ART procedures. As part of the accreditation procedure performed regularly by two independent professionals, all centers members of Red Latinoamericana de Reproducción Asistida (REDLARA) must state in their consent form that the data collected may be published in epidemiological studies that will keep the anonymity of patients. If they wish, patients can ask for their data to be removed from the database. Therefore, no Institutional Review Board/Ethics Committee approval was asked.
      All cycles are registered from COS until birth or abortion (
      • Zegers-Hochschild F.
      • Schwarze J.E.
      • Crosby J.A.
      • Musri C.
      • Urbina M.T.
      Latin American Network of Assisted Reproduction (REDLARA).
      ). We extracted biomedical data of fresh autologous IVF/ICSI cycles initiated between January 1, 2012, and December 31, 2013. We restricted our analysis to cycles where premature LH rise was prevented by the use of GnrH antagonist, according to the practice of every center.
      We compared the outcomes of three different protocols of COH, including rFSH only, rFSH plus rLH, and rFSH plus hMG. The outcomes included were number of mature oocytes recovered and inseminated; proportion of ETs at blastocyst stage; clinical pregnancy, miscarriage, and delivery rates; proportion of cycles with embryo cryopreservation; and mean number of embryos cryopreserved.
      The Latin American registry uses the International Committee Monitoring Assisted Reproductive Technologies (ICMART)/World Health Organisation revised glossary of ART terminology (
      • Zegers-Hochschild F.
      • Nygren K.G.
      • Adamson G.D.
      • de Mouzon J.
      • Lancaster P.
      • Mansour R.
      • et al.
      The ICMART glossary on ART terminology.
      ). Informed consents acknowledge that the data will be used, anonymously, for epidemiological studies. Therefore, no other consent form was requested for the purposes of this study.
      We used the χ2-test to test for independence of association of categorical variables. To assess for normal distribution of variables, we used Shapiro-Wilk test. When variables were not normally distributed, we used Kruskal-Wallis one-way analysis. We performed linear regression analysis, adjusting for maternal age in completed years and body mass index (BMI), to determine the effect of COS protocol on the number of inseminated oocytes. To analyze the effect of COS protocol in the odds ratio of delivery and abortion, we performed logistic regression analysis adjusting for maternal age in completed years, number of embryos transferred, and stage of embryo development at transfer.
      All statistical analyses were performed with STATA (Statacorp). P<.05 was considered statistically significant.

      Results

      Overall, we analyzed 21,212 IVF/ICSI cycles, the majority of which (83%) were ICSI. COS protocols were distributed as follows: 11,431 cycles used rFSH and hMG; 2,463 cycles used rFSH and rLH; and 7,318 cycles used rFSH only.
      Table 1 summarizes biomedical characteristics as well as the outcome of each COS protocol. The group undergoing COS with only rFSH were, on average, 1 year younger. The more frequent diagnoses were unexplained infertility and male factor in the case of rFSH alone; male factor and premature ovarian insufficiency in the case of rFSH/rLH; and male factor and unexplained infertility in the case of rFSH/hMG. There were no differences in terms of BMI distribution among the different groups.
      Table 1Demographics and main outcomes according to COS of IVF/ICSI cycles, RLA 2012–2013.
      VariablerFSH and hMG (n = 11,431)rFSH and rLH (n = 2,463)rFSH (n = 7,318)
      Age of female partner (y), mean (SD)36.4 (4.4)36.7 (4.2)35.3 (4.6)
      BMI (%)
       <19.910.1311.0812.04
       20.0–24.956.9455.8756.20
       25.0–29.925.1826.5124.67
       ≥30.07.756.547.09
      Diagnosis,
      Each couple could have up to two diagnoses.
      %
       Anatomic female factor14.513.613.2
       Endocrine female factor7.06.37.1
       Endometriosis7.78.510.1
       Male factor29.330.926.7
       Ovarian insufficiency11.716.06.7
       Unexplained24.819.827.1
       Other5.05.06.7
      Oocytes recovered (n), mean (SD)8.9 (9.2)8.3 (6.3)10.0 (7.7)
      Oocytes inseminated (n), mean c (SD)6.8 (5.1)6.3 (4.8)7.2 (5.4)
      Embryos transferred (n), mean (SD)2.2 (0.7)2.1 (0.7)2.1 (0.7)
      Transfer at blastocyst stage, %14.113.228.4
      Embryos cryopreserved (n), mean (SD)3.1 (2.1)3.5 (2.8)3.5 (2.4)
      Clinical pregnancy rate per ET, %33.532.036.9
      Delivery rate per ET, %26.825.129.9
      Delivery rate per oocyte pick-up, %23.821.726.2
      Miscarriage rate, %18.519.817.4
      a Each couple could have up to two diagnoses.
      The group receiving FSH alone recovered more oocytes and had therefore more oocytes inseminated and more embryos cryopreserved. In this group, a larger proportion of embryos were transferred at the blastocyst stage. The mean number of embryos transferred was similar in the three COS protocols. To determine the effect of the protocol for COS on the mean number of oocytes recovered, we performed linear regression analysis correcting for the age of the female partner and BMI. We found that, compared with the use of rFSH alone, cycles that included hMG or rLH were associated with a lower mean number of metaphase II oocytes inseminated (regression coefficient, –0.47, 95% confidence interval [CI], –.50 to –.4; P<.001; Supplemental Table 1).
      We performed logistic regression analysis to determine the effect of COS protocol on the delivery rate per ET. Given that the three groups were not homogenous in several confounding factors, we performed a multivariable regression analysis. After correcting for the age of female partner, number of embryos transferred, and stage of embryo development upon transfer, we found that the type of COS was not associated with the delivery rate per oocyte pick-up. The same analysis was performed in a subgroup of women in whom less than four oocytes were inseminated, and it showed similar results (Table 2).
      Table 2Effect of age, embryo development stage, number of embryos transferred, and COS protocol on the delivery rate per ET, RLA 2012–2013.
      Group and variableOR95% CIP value
      All (n = 16,360)
       Age0.910.90–0.92<.0001
       Transfer in blastocyst stage1.591.46–1.74<.0001
       No. of embryos transferred1.361.29–1.43<.0001
       rFSH/hMG1.020.94–1.10.622
       rFSH/rLH0.960.85–1.09.569
       rFSHReference
      <4 Oocytes recovered (n = 2,325)
      Age0.890.86–0.91<.0001
       Transfer in blastocyst stage2.171.31–3.60.003
       No. of embryos transferred1.651.37–1.98<.0001
       rFSH/hMG0.920.71–1.20.534
       rFSH/rLH0.990.68–1.43.937
       rFSHReference
      Note: OR = odds ratio.
      To determine the effect of COS protocol on the rate of miscarriage, we performed logistic regression analysis, correcting for the age of female partner and BMI. We found that the type of COS was not associated with miscarriage rate. The only factor directly correlated with embryo loss was age of female partner (P<.0001; Table 3). Furthermore, we performed the same analysis restricted to the group when less than four oocytes were recovered. After correcting for age of the female partner, we found that the addition of LH either as recombinant LH or hMG was not associated with a change in the odds of abortion (Table 3).
      Table 3Effect of age, BMI, and COS protocol on spontaneous miscarriage rate in women undergoing autologous IVF/ICSI cycles, RLA 2012–2013.
      Group and variableOR95% CIP value
      All (n = 5,637)
       Age1.11.08–1.12<.0001
       BMI0.990.97–1.00.127
       rFSH/hMG0.990.83–1.32.877
       rFSH/rLH1.040.83–1.32.721
       rFSHReference
      <4 Oocytes recovered (n = 491)
       Age1.141.08–1.21<.0001
       BMI0.970.92–1.03.368
       rFSH/hMG1.070.66–1.74.785
       rFSH/rLH0.810.38–1.69.577
       rFSHReference
      Note: OR = odds ratio.
      We also analyzed the proportion of ETs in which at least one embryo was cryopreserved and the mean number of embryos cryopreserved according to the protocol for COS in women ages ≤34 years old, 35–30, 40–42, and ≥43 years (Table 4). The proportion of cycles with embryo and even blastocyst-stage cryopreservation was associated, as expected, with the age category of the female partner but not with the type of COS. Furthermore, only in women 40–42 years was there an association of type of COS and mean number of embryos cryopreserved, however, with little clinical significance.
      Table 4Proportion of cycles with embryo cryopreservation and mean number of embryos cryopreserved in each woman's age category according to COS protocol in IVF/ICSI cycles, RLA 2012–2013.
      Age, yProportion of ET with embryo cryopreservation (%)Proportion cryopreservation at blastocyst stage (%)Mean no. of embryos cryopreserved (SD)Mean no. of blastocysts cryopreserved (SD)
      ≤34 (n = 6,757)
       rFSH42.351.863.7 (2.6)2.8 (2.0)
       rFSH/rLH39.236.553.9 (2.9)2.7 (1.8)
       rFSH/hMG39.154.193.3 (2.2)3.2 (2.2)
      35–39 (n = 8,626)
       rFSH33.250.873.4 (2.2)2.6 (1.9)
       rFSH/rLH31.735.043.4 (2.6)2.7 (1.7)
       rFSH/hMG29.955.453.0 (2.0)2.9 (1.8)
      40–42 (n = 4,132)
       rFSH19.645.853.2 (2.2)2.3 (1.4)
       rFSH/rLH17.736.363.4 (2.7)2.4 (2.0)
       rFSH/hMG19.948.032.9 (1.8)2.7 (2.1)
      ≥43 (n = 1,696)
       rFSH7.536.963.7 (3.2)2.6 (2.6)
       rFSH/rLH8.930.772.8 (3.1)1. 0 (0)
       rFSH/hMG13.238.103.1 (1.7)2.6 (1.6)

      Discussion

      After analyzing 21,212 COS antagonist cycles for autologous IVF/ICSI, we found that the addition of LH—either rLH or hMG—to rFSH does not seem to improve or worsen the outcome of autologous IVF/ICSI cycles in terms of the mean number of oocytes recovered or inseminated or miscarriage or delivery rate, regardless of the age of the female partner.
      The majority of COS performed in Latin America consists of a combination of rFSH and hMG, which probably results from the belief that this combination improves the outcome. This is not consistent with our analysis. The principal strength of our study is that it corresponds to the analysis of a nonselected group of patients, treated in 158 centers throughout Latin America. Therefore, these results are a reflection of a routine clinical practice that physicians are confronted with in everyday practice.
      Our results support the conclusion presented by van Wely et al. that the clinical choice of gonadotropins does not influence the outcome of ART cycles and should rather depend on availability, convenience, and costs (
      • van Wely M.
      • Kwan I.
      • Burt A.L.
      • Thomas J.
      • Vail A.
      • van der Veen F.
      • et al.
      Recombinant versus urinary gonadotrophin for ovarian stimulation in assisted reproductive technology cycles.
      ). Van Wely analyzed a total of 9,606 cycles in 42 randomized controlled trials. We analyzed 21,212 cycles performed in 15 countries and also concluded that the choice of COS does not seem to influence the outcome of ART. We found that COS with rFSH alone was associated with a statistically significant increase in the mean number of oocytes recovered, however, with little clinical significance and with no impact on the proportion of cycles with embryo cryopreservation or the mean number of embryos cryopreserved for future attempts.
      The main drawback of our analysis is the lack of randomization of COS protocols. It is therefore possible that, within a certain age category, women—with an expected poorer ovarian response to COS—were preselected to use a combination of FSH and LH with the assumption that this could increase the chances of pregnancy. This would explain why young women using rFSH alone had more oocytes recovered than those using a combination of rFSH and hMG or rLH. Nevertheless, the other outcomes analyzed, namely, delivery rate and spontaneous miscarriage rate, should not vary in such conditions, and they did not. Furthermore, the thoroughness of Registro Latinoamericano's (RLA) database allows for a thorough statistical analysis, correcting for confounding factors, such as age, embryo development stage at transfer, number of embryos transferred, and BMI, thus accounting for possible biases.
      In spite of these shortcomings, our study strongly suggests that in routine clinical practice the type of COS (rFSH alone or in combination with LH) has little impact on the outcome of ART, such as the proportion of deliveries by oocyte pick-up. We agree with other authors, that it is availability, convenience, and costs what should play a major role in the process of deciding on COS. However, further study may be still necessary to clarify whether specific groups of patients may benefit from LH-containing drugs.

      Appendix

      Supplemental Table 1Effect of age, BMI, and COS protocol on the mean number of oocytes recovered in autologous IVF/ICSI initiated cycles, RLA 2012–2013.
      VariableRegression coefficient95% CIP value
      Age−0.47−0.50 to −0.48<.0001
      BMI−0.04−0.07 to −0.1.006
      rFSH/hMG−0.59−0.84 to −0.35<.0001
      rFSH/rLH−1.03−1.41 to −0.66<.0001
      rFSHReference

      References

        • Recombinant Human FSH Product Development Group
        Recombinant follicle stimulating hormone: development of the first biotechnology product for the treatment of infertility.
        Hum Reprod Update. 1998; 4: 862-881
        • Lehert P.
        • Kolibianakis E.M.
        • Venetis C.A.
        • Schertz J.
        • Saunders H.
        • Arriagada P.
        • et al.
        Recombinant human follicle-stimulating hormone (r-hFSH) plus recombinant luteinizing hormone versus r-hFSH alone for ovarian stimulation during assisted reproductive technology: systematic review and meta-analysis.
        Reprod Biol Endocrinol. 2014; 12: 1-14
        • van Wely M.
        • Kwan I.
        • Burt A.L.
        • Thomas J.
        • Vail A.
        • van der Veen F.
        • et al.
        Recombinant versus urinary gonadotrophin for ovarian stimulation in assisted reproductive technology cycles.
        Cochrane Database Syst Rev. 2011; : CD005354
        • Westergaard L.W.
        • Bossuyt P.M.
        • van der Veen F.
        • van Wely M.
        Human menopausal gonadotropin versus recombinant follicle stimulation hormone for ovarian stimulation in assisted reproductive cycles.
        John Wiley & Sons, Chichester, UK2003
        • Revelli A.
        • Pettinau G.
        • Basso G.
        • Carosso A.
        • Ferrero A.
        • Dallan C.
        • et al.
        Controlled ovarian stimulation with recombinant-FSH plus recombinant-LH vs. human menopausal gonadotropin based on the number of retrieved oocytes: results from a routine clinical practice in a real-life population.
        Reprod Biol Endocrinol. 2015; 13: 77
        • Ye H.
        • Huang G.
        • Pei L.
        • Zeng P.
        • Luo X.
        Outcome of in vitro fertilization following stimulation with highly purified hMG or recombinant FSH in downregulated women of advanced reproductive age: a prospective, randomized and controlled trial.
        Gynecol Endocrinol. 2012; 28: 540-544
        • Stang A.
        Randomized controlled trials-an indispensible part of clinical research.
        Dtsch Arztebl Int. 2011; 108: 661-662
        • Zegers-Hochschild F.
        • Schwarze J.E.
        • Crosby J.A.
        • Musri C.
        • Urbina M.T.
        Latin American Network of Assisted Reproduction (REDLARA).
        Assisted reproductive techniques in Latin America: the Latin American Registry, 2013. Reprod BioMed Online. 2016; 32: 614-625
        • Zegers-Hochschild F.
        • Nygren K.G.
        • Adamson G.D.
        • de Mouzon J.
        • Lancaster P.
        • Mansour R.
        • et al.
        The ICMART glossary on ART terminology.
        Hum Reprod. 2006; 21: 1968-1970