Ovarian Response to Purified FSH in Infertile Women with Long‐standing Hypogonadotrophic Hypogonadism

Abstract

EDITORIAL COMMENT: We accepted this paper to illustrate an important point, namely that purified FSH preparations may not be appmpriate for ovulation induction in women lacking adequate levels of endogenous luteinizing hormone. Furthermore, if these preparations are used then reliance on oestradiol determinations alone m y lead to inappropriate conclusions about the number of preovulatory follicles. Howevel; there is pmbably a place for preparations of purified FSH in women with high cimulating levels of endogenous Iuteinizing hormone. Summary: It has previously been proposed that all anovulatory women requiring 1. Consuitant Senior Lecturer. 2. Gyna~cological Registrar. Address for comspondcnce: D r Robert Fox.

The reproductive outcome of women with hypogonadotropic hypogonadism undergoingin vitrofertilization

“…But a number of clinical studies have shown that a low concentration of LH leads to reduced ovarian estradiol biosynthesis because of the reduced thecal production of androgen precursors and consequently causes higher implantation failure and early pregnancy loss rates [Balasch et al 2001;Lahoud et al 2006;Westergaard et al 2000]. LH is considered to be absolutely necessary in patients with HH [Berger and Taymor 1971;Fox et al 1997;Schoot et al 1994]. For this reason ovulation induction with human menopausal gonadotrin (hMG) (containing FSH and LH in equal proportion) has been the traditional practice.…”

Lutropin alpha, recombinant human luteinizing hormone, for the stimulation of follicular development in profoundly LH-deficient hypogonadotropic hypogonadal women: a review

“…All these studies showed clearly that a FSH-only stimulation posseses limited value because of an insufficient follicular growth53,70,104,106 and oocyte maturation74 with an increased number of midsized follicles48 and very low estradiol levels,69,70,73,104 and a subsequent low endometrial score 1,71. A clear correlation can be found apparently between the degree of LH depletion and the higher amount of FSH ampoules needed for the stimulation 103…”

Lutropin alpha, recombinant human luteinizing hormone, for the stimulation of follicular development in profoundly LH-deficient hypogonadotropic hypogonadal women: a review

“…Very early with the FSH-only stimulation strategy, the necessity of LH in HH women to achieve a normal follicular growth and oocyte maturation was questioned. 53,[68][69][70][71][72][73] These first studies demonstrated clearly that stimulation of ovulation induction with FSH alone in LH-depleted women leads to a much higher consumption of the gonadotropin combined with reduced follicular growth, dramatically lower estradiol levels and overall ovulation rates. These non-IVF studies left the unsolved question of whether or not the fertilization competence of the oocyte will be compromised.…”

“…In spite of these limitations, these first results showed clearly the necessity of a distinct amount of LH to achieve full oocyte maturation and ovulation competence. 53,[68][69][70][71]74 With respect to the studies discussed above on the influence of different gonadotropin preparations on oocyte quality in downregulated women undergoing an IVF procedure, a threshold level for LH was proposed, necessary for normal follicular development and oocyte maturation. 76,102 Therefore, with a threshold and "ceiling" level of LH, Shoham postulated the concept of a therapeutic window for LH.…”

“…In addition to the remaining circulating LH, the low LH activity was sufficient to sustain complete follicle maturation, since less than 1% of follicular LH receptors are needed to be stimulated by LH to maintain a proper follicular growth, 105 in the presence of sufficient FSH. 53 All these studies showed clearly that a FSH-only stimulation posseses limited value because of an insufficient follicular growth 53,70,104,106 and oocyte maturation 74 with an increased number of midsized follicles 48 and very low estradiol levels, 69,70,73,104 and a subsequent low endometrial score. 1,71 A clear correlation can be found apparently between the degree of LH depletion and the higher amount of FSH ampoules needed for the stimulation.…”