1. Sandro C. Esteves
Director, ANDROFERT
Campinas, Brazil
LH in Human
Reproduction
Sesiones Científicas - Sociedad Peruana de Fertilidad
Junio 2014 - Lima PERU
2. http://www.androfert.com.br/review
LH in Human Reproduction
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Junio 2014 - Lima PERU
3. Learning objectives
At the completion of this presentation,
participants should be able to:
1. Understand the role of LH in reproductive
cycles
2. Identify patient subgroups to whom LH
supplementation is beneficial
3. Understand the differences in LH
supplementation according to
gonadotropin preparations
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4. Is LH important
in reproductive
cycles?
a. Absolutely true
b. Maybe true
c. False
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5. 0
9
Endometrium (mm)
0
5
10
15
0 5 10 15 20
Days of Stimulation
50
100
Folliclesize(mm)
andFSH(IU/L)
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6. 0
25
75
225
0
500
1000
1500
2000
2500
3000
Day 1 Day 5 Day 10 hCG
0 25 75 225
The European Recombinant Human LH Study Group, JCEM 1998; 83:1507
Rec-hLH administration (IU):
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7. 0
25
75
225
0
2
4
6
8
Day 1 Day 5 Day 10 hCG
0 25 75 225 rLH
The European Recombinant Human LH Study Group, JCEM 1998; 83:1507
Rec-hLH (IU):
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8. Early follicular phase
Steroidogenesis (TC)
Late follicular phase
Steroidogenesis (TC)
Up-regulates FSHr expression (GC)
Sustains follicular growth and final follicular
maturation (GC)
Role of LH in reproductive cycles
Physiology
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9. Balasch & Fábreques 2002
•Adequate androgen and estrogen
biosynthesis, normal follicular
development and oocyte maturation
Normal
•Follicular atresia
•Premature luteinization
•Oocyte development compromised
High
•Low (and estrogen) synthesis
•Impaired follicular maturation
•Inadequate endometrial proliferation
Low
LH Window
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10. What is the minimum needed
LH level?
SerumLHUI/L
1.5
1.0
0.5 0.5 Westergaard 2001
0.7 Fleming 1998
1.2 O’Dea 2000
1.35 Mahmoud 2001
Injected rec-hLH LH Cmax
75 UI 0.5 – 1.35 UI/L
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11. Is LH important in
reproductive cycles?
a. Absolutely true
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12. Who need LH
supplementation
during ovarian
stimulation?a. All patients
b. Poor responders
c. Hypo-responders
d. Older women (>35)
e. GnRH antagonist protocol
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13. Natural cycle
5.4
3.1
1.68
0.75
0
1
2
3
4
5
6
SerumLHIU/l
Sd1 Sd8 hCG OPU
0.15
GnRH agonist
Hypo-hypo
GnRH antagonist
LH levels in natural and
stimulated cycles
1.6
4.8
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threshold
14. Among patients treated with FSH and GnRH analogues for
in vitro fertilization, is the addition of recombinant LH
associated with the probability of live birth?
0.01 0.1 10 100
Study FSH + LH FSH OR (fixed) Weight OR (fixed)
n/N n/N 95% CI % 95% CI
Agonist
Sills 1999 3/13 10/17 10.00 0.21 [0.04, 1.05]
Balasch 2001 0/16 1/14 2.32 0.27 [0.01, 7.25]
Humaidan 2004 39/116 31/115 31.00 1.37 [0.78, 2.41]
Fabregues 2006 24/60 25/60 22.50 0.93 [0.45, 1.93]
Tarlatzis 2006 6/55 10/59 12.90 0.60 [0.20, 1.78]
Subtotal (95% CI) 72/260 77/265 78.72 0.94 [0.64,1.39]
Antagonist
Sauer 2004 9/25 10/24 9.80 0.79 [0.25, 2.49]
Griesinger 2005 8/62 9/65 11.48 0.92 [0.33, 2.56]
Subtotal (95% CI) 17/87 19/89 21.28 0.86 [0.40,1.85]
Total (95% CI) 89/347 96/354 100.00
]
advantage r-hFSH Advantage r-hFSH + r-hLH
No patient preselection
Kolibianakis, et al. Hum Reprod Update 2007;13:445-452
15. Is LH needed in unselected women
treated with FSH and GnRH
antagonists in IVF?
Mochtar et al.
3 RCT (N=216)
Baruffi et al.
5 RCT (N= 434)
Estradiol on hCG day
(pg/ml)
WMD 571
(95% CI 259; 882)
WMD 514
(95% CI 368; 660)
No. retrieved oocytes
WMD 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 0.89
(95% CI: 0.57; 1.39)
Mochtar et al. Cochrane Database Syst Rev. 2007;2:CD005070;
Baruffi et al, Reprod Biomed Online. 2007;14:14-25.
WMD weight mean difference
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16. Total Dose per Live Birth
(IU)*
0
3,000
7,000
10,000
21.6%
Rec-FSHHP-hMG
6,324
7,739
hMG
9,69052.2%
*Mean total dose per cycle/Live
birth rate (≤35 years)
Esteves SC et al. Reprod Biol Endocrinol 2009
N=865; GnRH agonist cycles
30.1 32.4
24.4
rec-FSH HP-HMG HMG
LBR (%)
p=NS
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17. Who need LH supplementation
during ovarian stimulation?
Key points (1)
Mandatory in the hypogonadotrophic
hypogonadal (HH) patients
(FSH and LH<1.2 IU/l)
For most women in IVF, endogenous
LH levels, irrespective of the GnRH
analogue, is sufficient to support
follicular development and
steroidogenic activity, so «FSH-
only« stimulation is enough
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18. Bioactive LH Levels
30-45% have less sensitive ovaries
Older patients (≥35 years)3
Poor responders4
Slow/Hypo-responders5
Deeply suppressed endogenous LH levels
(hypo-hypo; endometriosis treated with GnRH-a)6
Low
1Tarlatzis et al. Hum Reprod 2006; 2Esteves et al. Reprod Biol Endocrinol 2009; 3Marrs et al. Reprod
Biomed Online 2004;4Mochtar MH, Cochrane Database, 2007; 5Alviggi, et al. RBMOnline 2009;
6De Placido et al. Clin Endocrinol (Oxf) 2004
Normal
~55-70% normogonadotropic women
undergoing COS1,2
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19. Impaired oocyte quality
Decreased fertilization rate
Reduced embryo quality
Increased miscarriage rates
Reduced
ovarian
paracrine
activity
Hurwitz &
Santoro 2004
Androgen
secretory
capacity
reduced
Piltonen et al.,
2003
Decreased
number of
functional LH
receptors
Vihko et al.
1996
Reduced LH
bioactivity
Mitchell et al. 1995;
Marama et al 1984
3-5 in every 10 treated women
have “aged” ovaries
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20. LH supplementation improves
outcome in women >35 yo
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21. Fertil Steril 2011
Implantation
rate(%)
p=0.03
OR: 1.56 (1.04-2.33)
p=0.84
OR: 1.03 (0.73-1.47)
27.8
18.9
28.6
26.7
<=35
36-39
FSH+LH FSH
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22. Bologna Criteria for Poor Responders
Ferraretti et al. ESHRE Consensus, Hum Reprod 2011
At least 2 of the following:
1. Advanced maternal age
≥40 years or risk factor for POR
2. Previous POR
≤3 oocytes with conventional stimulation
3. Abnormal ovarian reserve biomarker
AFC<5-7; AMH <0.5-1.1ng/mL
Or Two episodes of POR after maximal
stimulation
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23. Pregnancy
rates
increase by
30% in poor
responders
treated with
rec-hLH
Lehert et al 2012
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24. rec-hLH improves oocyte yield in
Poor Responders
Significant
increase of
0.75 oocytes
per 1,000 UI
gonadotropin
administered
Lehert et al 2012
Lehert et al 2012
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25. Why is LH beneficial in aged women
and poor responders?
Total
Testosterone
55%
DHEAS
77%
Free
Testosterone
49%
Androstenedione
64%
n = 1423
Davison SL et al JCEM 2005;90:3847
It seems
to be in
part a
matter
of
androgen
s
26. • Action of LH at the
follicular level in a dose
dependent manner
increases androgen
production
• Androgens are then
aromatized to estrogens
and help restore the
follicular milieu
Rationale of LH supplementation (1)
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27. Rationale of LH supplementation (2)
Anti-apoptotic
effect on
granulosa
cells
Up-regulate
growth factors
Increase FSH
receptor
responsiveness
Act
synergistically
with IGF-1
Rimon E et al., 2004; Robinson RS et al., 2007; Tilly JL
et al., 1992; Peluso JJ et al., 2001, Ben-Ami I et al., 2009
28. Evidence of a beneficial effect in older
women (≥35 yrs.) and poor responders
Benefit related to increased androgen
production and direct efect on the
ovary
better follicular recruitment
higher number of oocytes
better implantation rate
Who need LH supplementation
during ovarian stimulation?
Key points (2)
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29. Definition of hypo-responders (initial
poor responders) Alviggi et al. RBM online 2006;
2009
• Normal ovarian reserve
• May present follicular growth plateau
on D7-D10
• Achieve ‘adequate’ number of oocytes
retrieved and estradiol production
• But at the expense of an increased
cumulative rFSH dose (i.e. >3000 IU)
and duration of stimulation
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30. Why is there a suboptimal
response to exogenous FSH in
hypo-responders?
LH gene polymorphism: V-LHb
Carrier frequency 0-52% in various ethnic groups
13 % in Sweden
12-13 % in Denmark and Italy
Associated with reduced bioactivity of LH
Huhtaniemi et al., 1999; Jiang et al., 1999; Ropelato et al., 1999
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31. The cumulative FSH consumption
is higher in carriers of v-beta LH
polymorphism
Alviggi et al. Reproductive Biology and Endocrinology, 2013
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32. Hypo-responders benefit from LH
Cochrane review 2007
Mochtar MH, Cochrane Database, 2007 issue 2
Favours r-hFSH Favours r-hFSH + r-hLH
Ongoing PR per woman randomized
(COS in a GnRH-agonist dow-regulated IVF/ICSI cycle)
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33. 6 9 1110 14 18
22
32
40
FSH step-up (+150
UI)
LH
supplementation
(+150 UI)
Normal
Responders
Mean No. oocytes retrieved IR (%) OPR (%)
De Placido et al. Hum Reprod. 2004; 20: 390-6.
RCT 260 pts. with “steady” response on
stimulation D8 (E2 <180pg/mL; >6 follicles <10mm)
LH supplementation in
Hypo-responders
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34. Evidence of a beneficial effect of LH
supplementation in hypo-responders
(initial poor responders)
Dose-related increased LH bioactivity
with a positive effect on androgen
production and ovarian function
Who need LH supplementation
during ovarian stimulation?
Key points (3)
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35. Who need LH
supplementation
during ovarian
stimulation?a. All patients
b. Poor responders
c. Hypo-responders
d. Older women (>35 yrs.)
e. GnRH antagonist protocol
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36. What product to
use for LH
supplementation?
a. hMG/HP-hMG
b. rec-hLH
c. Either of the above; they
are similar
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37. Products containing LH Activity
Leao & Esteves. Clinics 2014; 69(4): 279–293.
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38. Fertil Steril 2012; 97(3): 561-72
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39. ANDROFERT
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Beta unit Carboxyl
terminal
segment
Longer in
hCG
Higher
receptor
affinity in hCG
Absent in LH
and present
in hCG
Longer half-life in
hCG
Sources of LH ActivitySources of LH
LH
Leao & Esteves. Clinics 2014; 69(4): 279–293.
LH
hCG
40. Although they attach to the
same receptor (LHCG-R)…
Courtesy of Xuliang Jiang, EMD Serono Research
Institute, Inc
Sharing the same α subunit and
81% of the aminoacid residues
of the β subunit, LH and hCG
bind to the same receptor:
LH/hCG receptor (Kessler
et al., 1979)
Constitutively
expressed on
theca cells
Expressed on
granulosa cells at
a follicle size of 8-
12 mm
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41. …LH and hCG downstream
cascade pathways are different
LH hCG
LHR and FSHR expression
(Trafficking of retinoic acid : RXRB, TTR, ALDH8A1)
Meiosis and follicular maturation
(TRA : RXRB, TTR, ALDH8A1; IL11; AKT3)
Follicular development (IL11; AKT3)
Cellular growth (RXRB, TTR, ALDH8A1;
IL11;AKT3)
Ovarian steroidogenesis
(TRA : RXRB, TTR, ALDH8A1)
Embryo development & survival
(AKT3)
Aromatase
inhibition
(PPARS)
Apoptosis
enhancement
(DNAsi)
LH hCG
Grondal ML et al. Fertil Steril 2009; Menon KM et al. Biol Reprod 2004;; Ruvolo et al. Fertil Steril 2007
42. 19
14 14
31
26 25
0
5
10
15
20
25
30
35
Fixed 2:1 r-hFSH
(150IU)/r-hLH
(75IU)
HMG rec-hFSH + HMG
Duration of
Stimulation
(days)
Mean No.
oocytes
retrieved
IR (%)
CPR per
transfer (%)
Buhler KF, Fisher R. Gynecol Endocrinol 2011
Matched case-control study; N=4,719 IVF pts.
P=0.02
Does it matter whether hMG hCG
(hMG) or rec-hLH?
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43. • RCT comparing rec-hFSH + rec-hLH
(2:1) vs. HP-hMG
• Higher No. oocytes retrieved in the rFSH
+ rLH (2:1) group (9.8 vs 7.3; p<0.01)
• 2/3 of the patients in rFSH+rLH group
(vs. 1/3 hMG group) had frozen embryos
to transfer if fresh transfer failed
Fábregues F et al. Gynecol Endocrinol. 2013 May;29(5):430-5.
Does it matter whether hMG hCG
(hMG) or rec-hLH?
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44. Significant differences exist between
LH and hCG at boh the molecular and
functional level
Limited evidence indicates that the
choice of products containing LH
activity impact IVF clinical outcome
What product to use for LH
supplementation?
Key points
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45. What product to
use for LH
supplementation?
a. hMG/HP-hMG
b. rec-hLH
c. Either of the above; they
are similar
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48. Population Cut-off Sensitivity Specificity Accuracy
AMH*
ng/m
L
High-
responder1 2.1 85% 79% 0.82
Poor
responder2 0.82 76% 86% 0.88
*Beckman-Couter generation II assay; 1>20 oocytes retrieved; 2≤4 oocytes retrieved
Leão RBF, Nakano FY, Esteves SC. Fertil Steril 2013; 100 (Suppl.): S16
Biomarkers of
ovarian response
AMH
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49. Rec-hFSH + rec-hLH (2:1 ratio) from stimulation D1
Total dose: 300 IU FSH + 150 IU LH
GnRH antagonist (flexible): mean diameter 13mm
LH trigger with rec-hCG (mean diameter 17-18 mm)
Our Preferred Stimulation Regimen
in Expected Poor Responders
2 3 4 5 76 8 9 10 111
Menses
12
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50. Individualized vs. Conventional COS
in Expected Poor Responders (N=118)
72.0
3.5
45.0
20.0
46.6
4.8
23.3 26.8
0
20
40
60
80
Observed Poor
Response (%)
Oocytes
retrieved (N)
Cancellation (%) Pregnancy/cycle
(%)
cCOS (Long GnRH with recFSH)
iCOS (GnRH Antag. with rFSH+rLH)
Expected poor response: AMH<0.82 ng/dL; Observed poor response <5 oocytes retrieved;
Leão RBF, Nakano FY, Esteves SC. Fertil Steril 2013; 100 (Suppl.): S16.
*p<0.05
*
*
*
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51. GnRH antagonist flexible protocol
Rec-hFSH + rec-hLH (2:1 or 3:1 ratio) from D1
Total dose: 150-225 IU FSH + 75 IU LH
How tse LH in Coin SLH supplementation in women ≥35 years
and hypo-responders
(normal ovarian biomarkers)
2 3 4 5 76 8 9 10 111
Menses
12
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52. LH in Human Reproduction
Conclusions
Adequate LH levels critical for
steroidogenesis, follicular development
and oocyte maturation
Androgen secretory capacity decreases
with ovarian aging
Mechanisms include decreased number of
functional LH receptors and ovarian
paracrine activity. LHr polymorphisms
involved in hypo-responders
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53. Patients that could benefit from LH
supplementation during COS:
Poor/hypo responders
Age >35 years; hypo-hypo
Sources are rec-hLH and hMG
LH and hCG differ at molecular, functional
and clinical levels
iCOS with rec-hLH is one of our
strategies to maximize pregnancy in IVF
LH in Human Reproduction
Conclusions
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There is no need to take notes. I’ve made this lecture available for those willing to review it later. You can find these slides at the website indicated here.
I will dedicate the last few minutes of this lecture to explore how we can improve patient care by adapting ovarian stimulation regimens according to biomarkers’ results.
The two-cell system, first proposed by Falck in 1959, is a logical explanation for the events involved in ovarian steroidogenesis. In patients with hypogonadotropic hypogonadism, r-hFSH alone, even when administered continuously and in dose increments of 75UI every 7 days during follicular phase, estradiol production is inadequate despite being adequate to induce follicular growth (as shown by the white dots in the graph). Consequently, endometrium proliferation was also inadequate.
It was shown that during the follicular phase, a clear relationship was observed between the dose of rLH and serum estradiol levels.
As a consequence, endometrial growth was obtained only if the two higher doses of LH were used. Interestingly, endometrial growth correlated to the estradiol levels up to 75 UI of rLH. No increment was seen by using 225UI of rLH, although serum estradiol levels were twice as high in the 225UI group compared to the 75UI one.
In the late stages of follicular development (when the follicle reaches the antral stage), FSH stimulates GCs to express LH receptors. GCs become receptive to LH stimulation.
To summarize the role of LH in reproductive cycles, it can be said that:
1 - During the early follicular phase, LH plays a key role in promoting steroidogenesis. Androgens, which are produced in theca cells under LH stimulation, are transferred to GCs and transformed into estrogens via aromatization. Estrogens, in turn, induce uterine changes needed for embryo implantation.
2 - During the late follicular phase, LH promotes final follicular maturation through direct effects on the follicle.
In the ovary, granulosa cells are the only target cells of FSH action, whereas both theca and late-stage (In the ovary, granulosa cells are the only target cells of FSH action, whereas both theca and late-stage (luteinizing) granulosa cells contain LH receptors. Increased FSH drive has been shown to be of only limited value in the less gonadotrophin-sensitive ovary, and there is a potential need for LH activity to be part of an individualized treatment regimen tailored for the biologically older ovary.
FSH receptors are present only on the granulosa cells. LH receptors are present on the theca cells and initially absent on the granulosa cells. In response to LH, theca cells convert cholesterol in androgen (testosterone and androstenedione). Since, CYP17 is located exclusively in thecal cells whereas CYP19 (aromatase) is expressed only in the granulosa. Thus, androgens must diffuse into the granulosa layer to be converted to estrogen via aromatization induced by FSH. Both FSH and LH act via AMPc production. In late follicular phase, FSH induces LH receptor formation on granulosa cells, which acquire LH responsiveness. In granulosa, LH enhances FSH action (increasing estrogen production). At first, estrogens’ levels rise slowly during the late follicular phase. It is then followed by a rapid rise that reaches its peak approximately 24–36 hours prior to ovulation. The LH surge occurs when the peak of estradiol is achieved.
Most circulating progesterone (~95%) is produced in the intrafollicular compartment by the granulosa cells via the action of 3b-HSD that catalyzes conversion of pregnonolone (delta-4 pathway) under LH influence. The preovulatory rise in progesterone facilitates the positive feedback action of estrogen on the pituitary; the latter is the key factor to induce the midcycle LH peak. Progesterone also stimulates midcycle FSH surge, important to support the full expression of LH receptors in the granulosa layer.
Ovulation
The LH surge triggers resumption of oocyte meiosis that had been halted at prophase I (germinal vesicle stage). Also, it promotes luteinization of granulosa cells and synthesis of prostaglandins and other eicosanoids essential for follicle rupture. FSH, LH, and progesterone stimulate the activity of proteolytic enzymes, such as matrix metalloproteinases, disintegrin and metalloproteinase with thrombospondin-like repeats (adamts), which digest collagen in the follicular wall and increase its distensibility [21, 45, 46]. The LH surge also triggers the release of histamine, which has been shown to fully support follicle rupture in some experimental models.
Granulosa and theca cells also produce plasminogen activator in response to the LH surge, which activates plasminogen in the follicular fluid to produce plasmin. Plasmin, in turn, generates active collagenase that disrupts the follicular wall. After ovulation, the corpus luteum is formed. Hormonal production by luteinized granulosa layer is dependent on the number of LH receptors expressed during the preovulatory phase. Luteal cells derived from the theca compartment continue to produce androgens for aromatization into estrogens by luteal cells derived from the granulosa compartment. In addition, progesterone is produced in both luteinized theca and granulosa cells. As such, the corpus luteum produces estradiol and progesterone under the influence of endogeneous LH activity. As the luteal phase progresses, progesterone inhibits LH release via negative feedback. During the luteal-follicular transition, the LH decline causes the corpus luteum to involute and demise [
According to this concept, in the absence of a minimum level of serum LH, E2 production will be insufficient for optimal follicular development and endometrial proliferation. On the other hand, exposure of the developing follicle to excessive LH (beyond a ceiling level) results in atresia and cessation of normal development.
Evidence suggests that optimal follicular development occurs within an ‘LH window’, above a certain ‘LH threshold’ and below an ‘LH ceiling’.
I will dedicate the last few minutes of this lecture to explore how we can improve patient care by adapting ovarian stimulation regimens according to biomarkers’ results.
I will dedicate the last few minutes of this lecture to explore how we can improve patient care by adapting ovarian stimulation regimens according to biomarkers’ results.
In which we examined the clinical efficacy of different gonadotropin products used for ovarian stimulation in our clinical practice.
We compared the efficacy of rec-hFSH (n=236), hMG (n=299) and HP-hMG (n=330) in a subset of normogonadotropic down-regulated women undergoing IVF/ICSI. UI (19).
This difference in favour of r-hFSH was reflected for the amount of gonadotropin used per live birth. To achieve a live birth significantly less r-hFSH was required than hMG (52% reduction) and HP-hMG (21% reduction). One practical implication of this observation is that this marked difference neutralizes part of the cost difference between r-hFSH and hMG preparations. We observed that it was far more common to step the rec-hFSH dose down during ovarian stimulation as compared to hMG.
We discovered that in our practice, it was far more common to step the rec-hFSH dose down during ovarian stimulation as compared to hMG. The clinicians stated that they felt comfortable with the pen device that allow small dose reductions of 37.5UI , after perceiving a better response with rec-hFSH compared to u-HMG using the same starting doses.
The clinicians involved in this study stated that they felt comfortable with the pen device, which allowed more precise small dose reductions of 37.5 UI rather the 75UI reductions in the HMG preparations.
I will dedicate the last few minutes of this lecture to explore how we can improve patient care by adapting ovarian stimulation regimens according to biomarkers’ results.
The general consensus regarding LH is that most women have sufficient levels of endogenous LH and do not require supplementation. However, certain subgroups with low levels of LH may benefit from additional LH.
Early studies identified a subgroup of normogonadotrophic patients who have normal estimated ovarian reserves but suboptimal responses to FSH stimulation (De Placido et al., 2001, 2004, 2005;
Mochtar et al., 2007). Such women express ovarian resistance to FSH but seem to be distinct from classical poor responders because some investigators suggest that luteinizing hormone (LH) supplementation improves their ART treatment outcomes (Alviggi et al., 2006).
The subgroups which may benefit from LH supplementation include women over the age of 35 years, those with a poor response to ovarian stimulation or women with highly suppressed levels of endogenous LH. The general consensus regarding LH is that most women have sufficient levels of endogenous LH and do not require supplementation, although certain subgroups with low levels of LH may benefit from additional LH (Alviggi et al. Reprod Biomed Online 2006;12:221–233; Tarlatzis et al. Hum Reprod 2006;21:90–94; Esteves et al. Reprod Biol Endocrinol 2009;7:111; Marrs et al. Reprod Biomed Online 2004;8:175–182). The subgroups which may benefit from LH supplementation include women over the age of 35 years, those with a poor response to ovarian stimulation or women with highly suppressed levels of endogenous. It has been suggested that a subgroup of women with adequate AFC and FSH levels with hypo-response to ovarian stimulation may also benefit from LH supplementation (Alviggi, et al. RBMOnline 2009). These patients harbor single nucleotide polymorphisms of FSH and LH receptors.
After pituitary suppression, residual circulating levels of endogenous LH are usually adequate to support multiple follicular growth and oocyte development, also even when drugs containing FSH with low or absent LH activity are administered (Loumaye et al., 1997; Sills et al., 1999). It has been demonstrated that only 1% of LH receptors need to be occupied to drive adequate ovarian steroidogenesis for reproduction. Nevertheless, in a subset of normogonadotrophic patients, the ovarian response to this association is suboptimal.
It has been suggested that this may be due to a profound suppression of endogenous LH in some women whose activity may fall below an hypothetical threshold value. Thus, it could be hypothesized that those subjects may benefit from the use of LH-containing gonadotrophin preparations (Laml et al., 1999; Fleming et al., 2000; Lèvy et al., 2000; Westergaard et al., 2000; De Placido et al., 2001). Nagawa, 2008: pts with very low LH levels after down-regulation had lower pregnancy and implantaion rates.
A possible mechanism behind the beneficial effect of exogenous LH supplementation in older women may relate to decreasing numbers of functional LH receptors with increasing age (Vihko et al. 1996). It suggests that younger women, due to a higher number of LH receptors, do not require exogenous LH, while supplementation with exogenous LH in the older woman secures a sufficient LH-induced response. In addition, Piltonen et al. (2003) found that ovarian androgen secretion, i.e. oestrogen precursor secretion capacity, starts to decline as early as before the age of 30 years, again suggesting a diminished capacity of the ovary to respond to LH stimulus with age.
Another subgroup of women that seems to benefit from exogenous LH supplementation is the group of women with high endogenous LH concentrations on day 8 of stimulation (i.e. >1.99 IU/l). r-hLH supplementation in this subgroup resulted in a significantly higher implantation rate and a marginally higher pregnancy rate (P = 0.07) as compared with the non-supplemented subgroup. This is an interesting and surprising finding. A possible explanation for this phenomenon could be a desensitization of the ovarian LH receptor due to high concentrations of circulating endogenous LH, leading to receptor down-regulation (Zor et al., 1976; Amsterdam et al.. 2002).
LH receptor polymorphism also seems to play a role.
In summary: less LH receptors, less sensitive LH receptors, Low LH levels.
21
In the late stages of follicular development (when the follicle reaches the antral stage), FSH stimulates GCs to express LH receptors. GCs become receptive to LH stimulation.
To summarize the role of LH in reproductive cycles, it can be said that:
1 - During the early follicular phase, LH plays a key role in promoting steroidogenesis. Androgens, which are produced in theca cells under LH stimulation, are transferred to GCs and transformed into estrogens via aromatization. Estrogens, in turn, induce uterine changes needed for embryo implantation.
2 - During the late follicular phase, LH promotes final follicular maturation through direct effects on the follicle.
In the ovary, granulosa cells are the only target cells of FSH action, whereas both theca and late-stage (In the ovary, granulosa cells are the only target cells of FSH action, whereas both theca and late-stage (luteinizing) granulosa cells contain LH receptors. Increased FSH drive has been shown to be of only limited value in the less gonadotrophin-sensitive ovary, and there is a potential need for LH activity to be part of an individualized treatment regimen tailored for the biologically older ovary.
FSH receptors are present only on the granulosa cells. LH receptors are present on the theca cells and initially absent on the granulosa cells. In response to LH, theca cells convert cholesterol in androgen (testosterone and androstenedione). Since, CYP17 is located exclusively in thecal cells whereas CYP19 (aromatase) is expressed only in the granulosa. Thus, androgens must diffuse into the granulosa layer to be converted to estrogen via aromatization induced by FSH. Both FSH and LH act via AMPc production. In late follicular phase, FSH induces LH receptor formation on granulosa cells, which acquire LH responsiveness. In granulosa, LH enhances FSH action (increasing estrogen production). At first, estrogens’ levels rise slowly during the late follicular phase. It is then followed by a rapid rise that reaches its peak approximately 24–36 hours prior to ovulation. The LH surge occurs when the peak of estradiol is achieved.
Most circulating progesterone (~95%) is produced in the intrafollicular compartment by the granulosa cells via the action of 3b-HSD that catalyzes conversion of pregnonolone (delta-4 pathway) under LH influence. The preovulatory rise in progesterone facilitates the positive feedback action of estrogen on the pituitary; the latter is the key factor to induce the midcycle LH peak. Progesterone also stimulates midcycle FSH surge, important to support the full expression of LH receptors in the granulosa layer.
Ovulation
The LH surge triggers resumption of oocyte meiosis that had been halted at prophase I (germinal vesicle stage). Also, it promotes luteinization of granulosa cells and synthesis of prostaglandins and other eicosanoids essential for follicle rupture. FSH, LH, and progesterone stimulate the activity of proteolytic enzymes, such as matrix metalloproteinases, disintegrin and metalloproteinase with thrombospondin-like repeats (adamts), which digest collagen in the follicular wall and increase its distensibility [21, 45, 46]. The LH surge also triggers the release of histamine, which has been shown to fully support follicle rupture in some experimental models.
Granulosa and theca cells also produce plasminogen activator in response to the LH surge, which activates plasminogen in the follicular fluid to produce plasmin. Plasmin, in turn, generates active collagenase that disrupts the follicular wall. After ovulation, the corpus luteum is formed. Hormonal production by luteinized granulosa layer is dependent on the number of LH receptors expressed during the preovulatory phase. Luteal cells derived from the theca compartment continue to produce androgens for aromatization into estrogens by luteal cells derived from the granulosa compartment. In addition, progesterone is produced in both luteinized theca and granulosa cells. As such, the corpus luteum produces estradiol and progesterone under the influence of endogeneous LH activity. As the luteal phase progresses, progesterone inhibits LH release via negative feedback. During the luteal-follicular transition, the LH decline causes the corpus luteum to involute and demise [
I will dedicate the last few minutes of this lecture to explore how we can improve patient care by adapting ovarian stimulation regimens according to biomarkers’ results.
A common variant of the β subunit of the LH molecule (v-LH) is identified by an additional sulphonated sugar at asparagine (Asn)-13
Polymorphism:
Gene DNA variant existing in the normal population at a frequency of 1% or more
Mutation:
Gene DNA variant existing in the normal population at a frequency of less than 1%
De Placido et al. studied the effects of LH supplementation in women showing a poor response to ovarian stimulation. ‘Slow responders’ were defined as those who had serum oestradiol levels below 180 pg/ml and no follicles over 10 mm on day 8. These women were randomized to a daily dose of either 75 IU or 150 IU r-hLH. Women classified as ‘good responders’ received no additional r-hLH (control group).
They found that the high dose of r-hLH was significantly more effective in terms of oocyte development and maturation than the increasing FSH drive. Furthermore, there was no significant difference between the high-dose group and controls in terms of these outcomes.
I will dedicate the last few minutes of this lecture to explore how we can improve patient care by adapting ovarian stimulation regimens according to biomarkers’ results.
I will dedicate the last few minutes of this lecture to explore how we can improve patient care by adapting ovarian stimulation regimens according to biomarkers’ results.
I will dedicate the last few minutes of this lecture to explore how we can improve patient care by adapting ovarian stimulation regimens according to biomarkers’ results.
hCG - α 92 aa - β 145 aa
8 Glycosylation sites - 37 kDa
Trophoblastic embryonic cells
LH - α 92 aa - β 121 aa
3 Glycosylation sites – 28kDa
Anterior Pituitary Gland
Luteinizing Hormone/Choriogonadotropin Receptor (LHCGR) LGR2; HLHR; LCGR; LHR; Lutropin/Choriogonadotropin Receptor; Luteinizing Hormone Receptor:
Both hormones bind to the same receptor, which is a transmembrane glycoprotein that belongs to the G-protein-coupled receptor superfamily and is present in the ovarian theca cells in females and in the testicular Leydig cells in males (Kessler et al., 1979). Constitutively expressed on theca cells and granulosa cells at a follicle size of 8-12 mm
LHCGR is found in ovary, testis and extragonodal organs like uterus, that receptor interacts with both luteinizing hormone (LH) and chorionic gonadotropins (such as hCG in humans) and represents a G protein-coupled receptor (GPCR). Its activation is necessary for the hormonal functioning during reproduction. LHCGRs are found in the ovary, testis, and many extragonadal tissues. The gene for the LHCGR is found on chromosome 2 p21 in humans, close to the FSH receptor gene. It consists of 70 kbp (versus 54 kpb for the FSHR). The gene is similar to the gene for the FSH receptor and the TSH receptor.The LHCGR consists of 674 amino acids and has a molecular mass of about 85-95 kDA based on the extent of glycolization.
30 IVF/ICSI patients randomized to rFSH or HMG treatment At aspiration granulosa cells collected for gene expression analysis
Results: 85 genes statistically significantly different in expression
Results: Expression levels of LH/hCG receptor gene and genes involved in biosynthesis of cholesterol and steroids were expressed at a lower level in HMG-treated granulosa cells
Conclusion: Preparation used for COS significantly influences the developmental competence of the oocyte and the function of the corpus luteum
I will dedicate the last few minutes of this lecture to explore how we can improve patient care by adapting ovarian stimulation regimens according to biomarkers’ results.
I will dedicate the last few minutes of this lecture to explore how we can improve patient care by adapting ovarian stimulation regimens according to biomarkers’ results.
I will dedicate the last few minutes of this lecture to explore how we can improve patient care by adapting ovarian stimulation regimens according to biomarkers’ results.
In this study from our group, aimed to determine the usefulness of AMH to identify women at risk of excessive and poor response, we studied a group of women undergoing conventional COS for IVF to determine the best cut-off points of AMH.
ROC analysis revealed that the cutpoints of 2.1 and 0.82 were the best to discriminate excessive and poor-response, with an accuracy of about 90%.
POOR <=0.82; PPV = 72.5% before and 46.6% after iCOS; p= 0.0280.
a taxa de cancelamento foi de 22.5% para 10%
a taxa de nao transferencia por nao ter embriao foi de 40.5% para 28.6%
a taxa de gravidez clinica por ciclo comecado foi de 21.6% para 25%
e de gravidez clinica por transferencia foi de 36.3 para 35% (essas todas nao significativas)
Then, we used these cutpoints to individualize COS in another group of patients undergoing IVF.
Mild stimulation using low doses of rec-FSH was given for pts. identified as at risk of excessive response, and rec-hFSH in association with rec-hLH supplementation was given for those identified as at risk of poor response, and in both conditions GnRH antagonists were used.