Simultaneous evaluation of basal FSH and oestradiol response to GnRH analogue (F-G-test) allows effective drug regimen selection for IVF
D.M. Ranieri,1,
P. Phophong,
I. Khadum,
F. Meo,
C. Davis and
P. Serhal
The Assisted Conception Unit, University College London Hospitals, London, UK
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Abstract
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To determine whether preliminary assessment of ovarian reserve by simultaneous evaluation of basal follicle-stimulating hormone (FSH) and oestradiol response to gonadotrophin releasing hormone (GnRH) analogue (F-G-test) can be used to tailor individually the drug regimen for ovarian stimulation, the in-vitro fertilization (IVF) results of 238 patients were retrospectively analysed. Sixty-two women with abnormal response to the test (
E2 <180 pmol/l and/or FSH >9.5 mIU/ml) had commenced buserelin nasal spray in the mid-luteal phase and discontinued it on cycle day 1. Ovarian stimulation was started on cycle day 3 with 375 IU/day of gonadotrophin. Fifty-three patients completed the treatment cycle (group A). A total of 176 women with normal response to the test (
E2 >180 pmol/l and FSH <9.5 mIU/ml) had continued the GnRH analogue throughout the stimulation cycle and a starting dose of 225 IU/day of gonadotrophin was used from cycle day 3. A total of 158 patients completed the treatment cycle (group B). Group A had significantly higher age (34.9 ± 4.2 versus 33.2 ± 4.2) (P < 0.05) and basal FSH (9.2 ± 3.8 versus 7.0 ± 2.2) (P < 0.05) and required a higher total dose of gonadotrophin. The numbers of oocytes retrieved and embryos transferred were significantly lower. However, fertilization, clinical pregnancies, and implantation rates were similar in both groups. It was concluded that simultaneous evaluation of basal FSH and oestradiol response to GnRH analogue can be useful in identifying subcategories of women with reduced ovarian reserve who may benefit from reduced GnRH analogue administration and a higher starting dose of gonadotrophin.
Key words:
drug-regimen/FSH/GnRHa test/IVF/ovarian reserve
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Introduction
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The selection of the drug regimen for ovarian stimulation is a crucial starting point for women undergoing IVF. The recruitment of a sufficient number of follicles yields a larger number of oocytes and provides a good choice of embryos for transfer (Roest et al., 1996
; Ranieri et al., 1998
). Age, basal follicle-stimulating hormone (FSH), basal oestradiol, dynamic tests such as clomiphene citrate challenge test and gonadotrophin releasing hormone (GnRH) analogue stimulation test (GAST) are used routinely to assess ovarian reserve and the likelihood of response to IVF. In turn, this allows for careful counselling of women with regard to their chances of a successful outcome (Scott and Hofmann, 1995
). Although women with reduced ovarian reserve may have higher chances of achieving a pregnancy in an oocyte donation programme, a significant proportion will achieve conception with their own oocytes (Padilla et al., 1996
; Faber et al., 1998
; Surrey et al., 1998
). Therefore, identification of this subgroup is important to tailor the drug regimen of each IVF treatment cycle to maximize follicular response (Karande and Gleicher, 1999
).
Previously we reported that simultaneous evaluation of basal FSH and 17ß-oestradiol response to GnRH analogue (F-G-test) is a sensitive predictor of ovarian response to stimulation (Ranieri et al., 1998
). The aim of this study was to determine whether preliminary assessment of ovarian reserve by F-G-test can be used to tailor the drug regimen individually for ovarian stimulation.
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Materials and methods
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The results of 238 patients who underwent their first treatment cycle from June 1997 until June 1999 were retrospectively analysed. A total of 130 were IVF cycles (54.6%) and 108 were IVF combined with intracytoplasmic sperm injection (ICSI) cycles (45.4%). On cycle day 2 all the women had an ultrasound scan to rule out the presence of ovarian cysts and a blood sample was taken to assess basal FSH and 17ß-oestradiol. The administration of buserelin nasal spray (Suprefact®; Hoechst, Hounslow, Middlesex, UK) 100 µg into each nostril 6 hourly (800 µg/day) was commenced immediately. A second blood sample was taken the following day to assess oestradiol concentrations. The women with abnormal response to the F-G-test, day 3 to day 2 oestradiol (
E2) <180 and/or FSH
9.5 mIU/ml (Ranieri et al., 1998
) had commenced down-regulation in the mid-luteal phase and discontinued the administration of the GnRH analogue on cycle day 1. Patients with FSH >15 IU/l and
E2 <180 were not included in the study. A basal ultrasound scan was performed on day 3 and ovarian stimulation commenced with a daily dose of 375 IU of human menopausal gonadotrophin (HMG) (Menogon®; Ferring Pharmaceuticals Ltd, Langley, Berkshire, UK) (group A). The women with normal assessment to the F-G-test (
E2 >180 and FSH <9.5 mIU/ml) had continued GnRH analogue administration and ovarian stimulation was commenced with 225 IU of gonadotrophin (group B). Follicular growth was monitored by ultrasound scans from day 7 of stimulation. The dose of gonadotrophin was adjusted according to the ovarian response in both groups. When at least two leading follicles reached a diameter of 18 mm, 10 000 IU of human chorionic gonadotrophin (HCG) (Choragon®; Ferring Pharmaceuticals Ltd) was administered. Transvaginal ultrasound controlled oocyte retrieval was performed 36 h later. When <3 follicles of 15 mm were present on the proposed day of HCG administration the cycle was cancelled. Fertilization was confirmed by the presence of two pronuclei 1620 h after insemination. Embryo transfer was performed 23 days after oocyte retrieval. In group A three embryos were routinely transferred, unless two embryos only were available. In group B two embryos were selectively transferred when patients were at high risk of multiple pregnancy. The luteal phase was supported with either progesterone vaginal pessaries (Cyclogest®; LD Collins & Co. Ltd, Mill Hill, London, UK), 400 mg twice daily or progesterone i.m. injection (Gestone®; Ferring Pharmaceuticals Ltd), 100 mg once daily. A quantitative serum ß-HCG was performed 16 days after embryo transfer. Women with a positive result underwent transvaginal sonography 2 weeks later. Only clinical pregnancies (positive result of quantitative ß-HCG with intrauterine gestation sac, fetal pole and heartbeat seen at 6 weeks scan) were considered for calculation of pregnancy rate. Oestradiol and FSH levels were measured by radioimmunoassay following the technique previously described (Ranieri et al., 1998
). Age, causes of infertility, duration of infertility, cycle day 2 FSH, dose of gonadotrophin used, number of days of stimulation, number of retrieved oocytes, fertilization rate, number of embryos transferred, clinical pregnancy rate as well as implantation rate were compared between the two groups. Statistical analysis was performed using the Epi-Info programme (version 6.0). Student's t-test,
2, and the Fisher's exact test were used when appropriate.
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Results
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Sixty-two women had an abnormal response to the F-G-test. Nine cycles (14.5 %) were cancelled because of poor response to stimulation and 53 patients completed the cycle (group A). A total of 176 had a normal response to the F-G-test. Eighteen cycles (10.2%) were cancelled, four because of the risk of hyperstimulation, five for inadequate response to IVF, three for failure of fertilization, and six for unavailability of spermatozoa. Therefore 158 patients completed their treatment cycle (group B). The women in group A were significantly older (34.9 ± 4.2 versus 33.2 ± 4.2, P < 0.05) and had significantly higher basal FSH (9.2 ± 3.8 versus 7.0 ± 2.2, P < 0.05). The duration and causes of infertility were similar in the two groups. Women in group A were administered a significantly higher number of ampoules of gonadotrophin (57.5 ± 20.2 versus 42.7 ± 19.5, P < 0.05), had a lower number of oocytes retrieved (7.8 ± 4.3 versus 9.5 ± 4.4, P < 0.05) and a lower number of embryos transferred (2.1 ± 1.1 versus 2.7 ± 0.7, P < 0.05). None of them had a premature LH surge.
No significant difference was noted in the number of days of stimulation between the two groups (10.9 ± 1.0 versus 11.2 ± 1.2, P > 0.05), fertilization rate (57.4 ± 30.0 versus 65.3 ± 25.1, P > 0.05), pregnancy rate (18.8 versus 25.3%, P > 0.05) and implantation rate (7.7 versus 13%, P > 0.05) (Table I
).
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Table I. Characteristics and outcomes of 211 women subdivided into two groups according to preliminary evaluation of F-G-test and drug regimen used for ovarian stimulation
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Discussion
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The development of a sufficient number of follicles during ovarian stimulation for IVF is a very important step towards a successful outcome. The ovarian dynamic from birth to menopause implies a progressive reduction of the oocytes stored, along with a change of sensitivity to gonadotrophin stimulation (Faddy and Gosden, 1995
). Women who will respond poorly cannot always be identified before undertaking IVF treatment and this can result in cancelled cycles.
We reported previously that simultaneous evaluation of basal FSH and oestradiol response to GnRH analogue administration is the most sensitive predictor available for response to ovarian stimulation (Ranieri et al., 1998
). In our study 29 out of 62 women in group A had normal basal FSH. These patients were identified at risk of low response only by the simultaneous evaluation of the
E2. This was confirmed by the significantly higher age, number of ampoules of gonadotrophin administered, lower number of oocytes retrieved and number of embryos available for transfer.
Receptors for the GnRH have been found in ovarian granulosa cells (Liscoviych and Amsterdam, 1989
). Hazout et al. showed that women undergoing ovarian stimulation using the long down-regulation drug regimen had a high dose of gonadotrophin and a lower number of oocytes retrieved (Hazout et al., 1993
). Excessive down-regulation can be detrimental to ovarian response for women with reduced ovarian reserve. Therefore from 1997 we decided to discontinue GnRH analogue in patients identified by F-G-test at risk of poor response. Cessation of GnRH analogue administration was probably important to improve the ovarian response of patients enrolled in group A of this study.
Dirnfeld, in a group of women with previous poor response to ovarian stimulation, found that cessation of administration of GnRH analogue was of no benefit. However, he suggested that `meticulous individualization of this drug regimen may be useful only in some subset of patients' (Dirnfeld et al., 1999
). In the current study the drug regimen was selected using the simultaneous evaluation of basal FSH and oestradiol response to GnRH analogue, which was useful in identifying subsets of women at risk of poor response. When the results of the F-G-test were abnormal, GnRH analogue administration was discontinued and ovarian stimulation started with high dose of gonadotrophin. This protocol enabled us to rescue some women who would otherwise have been cancelled if a conventional drug regimen were used. Although the pregnancy rate achieved in group A was not significantly different from group B, there was a trend for a lower implantation rate that could be related to reduced ovarian reserve. This difference may become significant if more patients were available to study. Unlike Dirnfeld, we used this drug regimen on women who had not previously received ovarian stimulation for IVF and who were selected after F-G-test.
In the present study, the higher starting dose of gonadotrophin used from the beginning of the stimulation can also be an important factor for the initial recruitment of a sufficient number of follicles. In a previous study (Ranieri et al., 1998
), 177 women underwent ovarian stimulation with a conventional long down-regulation drug regimen and a starting daily dose of 225 IU of gonadotrophin. Although the dose was progressively increased and a total mean number of ampoules of 67.9 ± 3.0 was used, 48 women with abnormal F-G-test results were cancelled because of inadequate response (27%). The overall cancellation rate for poor response to stimulation was higher than in our current study (6%).
It is also interesting to note that although GnRH analogue administration was discontinued no cycles were cancelled because of premature LH surge. This is in agreement with the findings of Faber and Karande that pituitary gland after discontinued GnRH analogue administration may remain in a refractory state of induced down regulation for a period of time sufficient to retrieve mature oocytes (Faber et al., 1998
; Karande and Gleicher, 1999
).
In conclusion simultaneous evaluation of basal FSH and oestradiol response to GnRH analogue administration (F-G-test) is useful for preliminary assessment of women undergoing IVF. Ovarian volume is another predictor of ovarian response to stimulation that can be used to tailor the drug regimen for assisted reproduction techniques (Syrop et al., 1999
). It would be interesting to investigate whether the combination of both these tests can improve their predictive value. Women identified with poor ovarian reserve and treated with shorter pituitary down-regulation and high starting dose of gonadotrophin may have a similar IVF outcome to those with normal ovarian reserve. This approach may reduce cancelled cycles, resource wastage, emotional stress to the patient and result in a reasonable pregnancy rate.
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Notes
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1 To whom correspondence should be addressed at: The Assisted Conception Unit, University College London Hospital,25 Grafton Way, Rosenheim Building, London WC1E 6DB, UK. E-mail: m.ranieri{at}aculond.fsnet.co.uk 
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Submitted on October 11, 2000;
accepted on January 4, 2001.