Principles and practices of LH administration in COS
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The document discusses the principles and practices of LH supplementation in controlled ovarian stimulation (COS) during assisted reproductive technology. It highlights the significance of LH in supporting follicular growth, maturation, and the clinical outcomes of various gonadotropin preparations. Key findings indicate that LH supplementation can improve clinical pregnancy rates in specific patient groups such as older women and poor responders.
![Among unselected patients treated with FSH and
GnRH analogues for IVF, LH supplementation is NOT
associated with a higher 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
Kolibianakis, et al. Hum Reprod Update 2007;13:445-452
ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION
S ESTEVES, 9
2015
ANDROFERT](https://image.slidesharecdn.com/v2estevesprinciplesandpracticesoflhuseincosisar2015-150419125124-conversion-gate01/85/Principles-and-practices-of-LH-administration-in-COS-9-320.jpg)
Principles and practices of LH administration in COS
- 1. Principles and Practices of LH administration in COS Sandro Esteves, MD., PhD. Medical Director, ANDROFERT Campinas, BRAZIL 20th Na(onal Conference of the Indian Society for Assisted Reproduc(on -‐ Chennai 2015
- 2. Learning objectives At the completion of this presentation, participants should be able to: 1. Review the principles of LH supplementation in reproductive cycles 2. Understand the molecular and functional differences in LH supplementation using the available gonadotropin preparations 3. Appraise the clinical outcome of using LH activity driven by these gonadotropin preparations ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION S ESTEVES, 2 2015 ANDROFERT
- 3. How do we practice? We use LH supplementation during COS in… i. All patients ii. Poor responders iii. Hypo-responders iv. Older women (>35) v. Hypo-hypo vi. GnRH antagonist protocol
- 4. What are the principles of LH supplementation in COS? ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION S ESTEVES, 4 2015 ANDROFERT
- 5. Early follicular phase Steroidogenesis (TC) Late follicular phase Steroidogenesis (TC) Up-regulates FSHr expression (GC) Sustains follicular growth and final follicular maturation (GC) LH physiology in reproductive cycles ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION S ESTEVES, 5 2015 ANDROFERT
- 6. What is the minimum level of LH needed to ensure adequate follicular growth and androgen production? 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 or hMG LH Cmax 75 IU 0.5 – 1.35 IU/l ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION S ESTEVES, 6 2015 ANDROFERT
- 7. 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 ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION S ESTEVES, 7 2015 ANDROFERT
- 8. u 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 Endogenous LH levels in natural and stimulated cycles 1.6 4.8 ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION S ESTEVES, 8 2015 ANDROFERT
- 9. Among unselected patients treated with FSH and GnRH analogues for IVF, LH supplementation is NOT associated with a higher 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 Kolibianakis, et al. Hum Reprod Update 2007;13:445-452 ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION S ESTEVES, 9 2015 ANDROFERT
- 10. There seems to be NO need of LH supplementation to unselected women treated with FSH and GnRH antagonists 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 ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION S ESTEVES, 10 2015 ANDROFERT
- 11. 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 ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION S ESTEVES, 11 2015 ANDROFERT
- 12. ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION S ESTEVES, 12 2015 ANDROFERT Androgen levels markedly lower in aged women Total Testosterone ↓ 55% DHEAS ↓ 77% Free Testosterone ↓ 49% Androstenedione ↓ 64% n = 1423 Davison SL et al JCEM 2005;90:3847
- 13. LH supplementation improves clinical pregnancy in women >35 yo. ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION S ESTEVES, 13 2015 ANDROFERT
- 14. Pregnancy rates increased by 30% in poor responders treated with r-hLH + r- hFSH Lehert et al Reprod Biol Endocrinol 2014, 12:17 ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION S ESTEVES, 14 2015 ANDROFERT
- 15. Lehert et al 2012 Significant increase of +0.75 oocytes in poor responders treated with r-hFSH + r-hLH Lehert et al Reprod Biol Endocrinol 2014, 12:17 rec-hLH improves oocyte yield in poor responders ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION S ESTEVES, 15 2015 ANDROFERT
- 16. 0% 5% 10% 15% 20% 25% 30% 35% 40% 45% 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 20 25 30 35 40 Livebirthrate(%) Oocyte number Observed live birth rate Predicted live birth rate Sunkara et al. Hum. Reprod., 2011 400,135 IVF cycles Every oocyte makes a difference to LBR in poor responders ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION S ESTEVES, 16 2015 ANDROFERT
- 17. Definition of hypo-responders (initial poor responders) Alviggi et al. RBM online 2006; 2009 • Normal ovarian reserve • Follicular growth stagnation D7-D10 with FSH-only stimulation • Achieve ‘adequate’ response at the expense of high FSH consumption • Likely to harbor genetic polymorphism of LH gene (V-LHβ) ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION S ESTEVES, 17 2015 ANDROFERT
- 18. 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) ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION S ESTEVES, 18 2015 ANDROFERT
- 19. • 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) ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION S ESTEVES, 19 2015 ANDROFERT
- 20. ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION S ESTEVES, 20 2015 ANDROFERT 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
- 21. How do we practice? We prescribe recombinant LH or hMG, which are the gonadotropin containing LH activity
- 22. What are the principles of LH supplementation using rec-hLH or hMG? ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION S ESTEVES, 22 2015 ANDROFERT
- 23. Gonadotropins containing LH activity Leao & Esteves. Clinics 2014; 69(4): 279–293. Product LH activity (IU/vial) LH content Purity hMG (FSH:LH ratio 1:1) 75 hCG* ~5% HP-hMG (FSH:LH ratio1:1) 75 hCG* ~70% Lutroprin alfa (rec-hLH) 75 LH >99% Follitropin alfa + lutroprin alfa 2:1 ratio (150IU r-hFSH + 75IU r-hLH) 75 LH >99% *95% LH bioactivity in hMG from hCG (concentrated or added during purification process; 8 IU hCG ~ 75 IU LH) ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION S ESTEVES, 23 2015 ANDROFERT
- 24. Fertil Steril 2012; 97(3): 561-72 ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION S ESTEVES, 24 2015 ANDROFERT
- 25. Human Chorionic Gonadotropin • Glycoprotein produced by syncytiotrophoblast cells of early embryo and by the pituitary in menopause women • In early pregnancy, hCG rescues the corpus luteum and maintains progesterone production until placental steroidogenesis is established ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION S ESTEVES, 25 2015 ANDROFERT
- 26. ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION S ESTEVES, 26 2015 ANDROFERT Extracellular fluid Cytoplasm Plasma membrane LH hCG LH/hCG receptor Sharing the same α subunit and 81% of AA residues of β subunit, LH and hCG bind to the same receptor Adapted from: Leao & Esteves. Clinics 2014; 69(4): 279–293.
- 27. How do we practice? In general, it is assumed that LH activity driven by either recLH or hCG (hMG) is similar, and many of us opt to prescribe the less costly medication.
- 28. What are the principles of LH activity driven by either rec-hLH or hMG? ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION S ESTEVES, 28 2015 ANDROFERT
- 29. ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION S ESTEVES, 29 2015 ANDROFERT 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 hCG LH Leao & Esteves. Clinics 2014;69(4):279–293.
- 30. Structural characteristics, half-life in serum and downstream effects of LH and hCG following receptor binding LH hCG Aminoacid number Alpha subunit Beta subunit 92 121 92 145 N-linked glycosilation sites Alpha subunit Beta subunit 2 1 2 2 O-linked glycosilation sites -- 4 Carboxyl-terminal segment non-existent present Half-life (hours) Initial, range of mean Terminal, range of mean Terminal (SC injection) 0.6-1.3 9-12 21-24 3.9-5.5 23-31 72-96 Response ED50 (pM)1 Time to maximal cAMP accumulation1 ERK 1/2 activation2 AKT activation2 CYP19A1 expression in presence of ERK1/2 pathway blockade2 530.0 ± 51.2 10 min strong strong increased 107.1 ± 14.3 1 h weak minimal unaffected 1 Effect on COS-7/LHCGR cells that constitutively express LH receptors 2 Effect on human granulosa cells Esteves & Alviggi. Principles and practices of COS in ART, Springer 2015 ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION S ESTEVES, 30 2015 ANDROFERT
- 31. Divergence in receptor-mediated signaling between LH and hCG Choi & Smitz Mol Cell Endocrinol 2014; 383(1-2):203–13. ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION S ESTEVES, 31 2015 ANDROFERT
- 32. • ERK/PKA & AKT cell survivor regulators and apoptosis blockers • In vitro ac(va(on of cAMP pathway associated with apopto(c events Ø ERK/PKA & AKT pathway (LH) Ø cAMP (hCG) ERK/PKA & AKT pathways Casarini et al., 2012; Grzesik et al., 2014 ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION S ESTEVES, 32 2015 ANDROFERT
- 33. • LH significanly more potent to induce EREG gene expression • Epiregulin plays a key role in oocyte matura(on Epiregulin (EREG) pathway Chin & Abayasekara, 2004; Sekiguchi et al., 2004 ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION S ESTEVES, 33 2015 ANDROFERT
- 34. What are the clinical outcomes of using LH activity driven by either rec-hLH or hMG? ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION S ESTEVES, 34 2015 ANDROFERT
- 35. • Cross-over study (n=66) comparing rec-hFSH + rec-hLH (2:1) vs. HP-hMG • All 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;29(5):430-5. Type of LH supplementation and number of oocytes retrieved 7.3 9.8 No. oocytes retrieved HP-HMG rec-FSH + rec-LH p<0.01 ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION S ESTEVES, 35 2015 ANDROFERT
- 36. 0" 20" 40" 60" 80" 100" 120" 2PN$ Preg.$ IR$ DNA$ fragmenta2on$ r4$FSH$ hMG$ r4FSH$+$r$LH$ *P<0.01 * * * Lower apoptosis rate (marker of oocyte quality) in human cumulus cells aUer r-‐hLH to women undergoing COS for IVF Ruvolo et al. Fertil Steril 2007; 87:542-6 ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION S ESTEVES, 36 2015 ANDROFERT
- 37. 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 patients P=0.02 Type of LH supplementation and pregnancy outcome ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION S ESTEVES, 37 2015 ANDROFERT
- 38. How we use LH supplementation in COS for IVF ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION S ESTEVES, 38 2015 ANDROFERT
- 39. Rec-hFSH + rec-hLH (2:1 ratio) from Sd1 Gonadotropin dose per day 450 IU: Ø rec-hFSH 300 IU + rec-hLH 150 IU GnRH antagonist (flexible): mean 13mm LH trigger with rec-hCG (mean 17-18 mm) Our preferred regimen in expected poor responders (AMH≤0.82 and/or history of POR) 2 3 4 5 7 6 8 9 10 11 1 Menses 13 ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION S ESTEVES, 39 2015 ANDROFERT 12
- 40. 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 r-hFSH) iCOS (GnRH Antag. with r-hFSH+r-hLH) 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 * * * ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION S ESTEVES, 40 2015 ANDROFERT
- 41. GnRH antagonist flexible protocol Rec-hFSH + rec-hLH (2:1 ratio) from Sd1 Gonadotropin dose/day 225 IU: Ø rec-hFSH 150 IU + rec-hLH 75 IU How tse LH in Coin SOur preferred regimen in women ≥35yr. and normal ovarian reserve (AMH>0.82) 2 3 4 5 7 6 8 9 10 1 Menses 13 ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION S ESTEVES, 41 2015 ANDROFERT 11 12
- 42. GnRH antagonist flexible protocol; i. r-hFSH + r-hLH (2:1 ratio) from Sd6-7 ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION S ESTEVES, 42 2015 ANDROFERT Our preference in hypo-responders (Age <35yr.; AMH >0.82; follicular stagnation (<10mm) Sd5-7) Gonadotropin dose per day: 225 IU ii. r-hFSH + r-hLH (2:1 ratio) from Sd1 2 3 4 5 7 6 8 9 10 1 13 11 12 2 3 4 5 7 6 8 9 10 11 1 Menses 14 12 13
- 43. Expected poor responders § AMH ≤ 0.82 ng/ml § History of previous IVF aaempt with poor response at a conven(onal s(mula(on Hypo responders § < 35 yr. § AMH >0.82 ng/ml § Follicular stagna(on aUer 6-‐7 days of s(mula(on with r-‐ hFSH 2 Start from Sd6-‐7 (1st cycle) Start Sd1 (subsequent cycles) (1 vial/day) Start from s(mula(on day 1 (2 vials/day) Our strategy for LH supplementa(on using 2:1 combina(on of r-‐hFSH + r-‐hLH § Expected normo-‐ responder (AMH >0.82 ng/ml and no history POR) Age ≥ 35 Start from s(mula(on day 1 (1 vial/day) 3 1 ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION S ESTEVES, 43 2015 ANDROFERT
- 44. 1. LH ac(vity has a crucial role in steroidogenesis, follicular growth and matura(on 2. LH supplementa(on to COS in IVF especially benefi(al to aged women (>35), and poor & hypo-‐responders 3. Significant differences exist between LH and hCG at boh the molecular and func(onal level 4. Preliminary evidence indicates that the choice of products containing LH ac(vity impact IVF clinical outcome ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION S ESTEVES, 44 2015 ANDROFERT Conclusions
- 45. Thank you This presentation is available at http://www.slideshare.net/ sandroesteves