1 Centre for Reproductive Medicine, Dutch-speaking Brussels Free University, Belgium, 2 Department of Obstetrics/Gynaecology of the Medical University of Lübeck, Germany, and 3 ASTA Medica AG, Frankfurt Main, Germany
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Abstract |
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Key words: human menopausal gonadotrophins/LHRH antagonist/cetrorelix/LHRH agonist, buserelin
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Introduction |
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Materials and methods |
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The study was approved by the Ethical Committees of the seven European centres involved. All couples were required to sign a written informed consent. The trial was performed in accordance with the principles of the Declaration of Helsinki and the European Note for Guidance on Good Clinical Practice. Prior to the start of stimulation, 10 patients in each group withdrew from the study, leaving totals of 188 and 85 patients in the cetrorelix and buserelin groups respectively.
In the cetrorelix group, ovarian stimulation was carried out with human menopausal gonadotrophins (HMG, Humegon®; Organon, Oss, The Netherlands; Menogon®; Ferring, Kiel, Germany; Pergonal®; Serono, Geneva, Switzerland), starting with two ampoules (150 IU) on day 2 or 3 of the menstrual cycle for 5 days. The dosage was adjusted thereafter, according to the individual ovarian response to the stimulation, as assessed by oestradiol values and ultrasound measurements of the follicles. Cetrorelix 0.25 mg was administered s.c. daily, starting from day 6 of the HMG treatment, up to and including the day of human chorionic gonadotrophin (HCG) administration. In the buserelin group, patients received daily doses of 4x150 µg of buserelin administered intranasally, starting in the mid-luteal phase of the menstrual cycle preceding the ovarian stimulation cycle, for 2 or 3 weeks. When pituitary desensitization was achieved, ovarian stimulation was started with two ampoules of HMG as described in the cetrorelix group. Prerequisites to starting with HMG were: oestradiol 50 pg/ml, progesterone
1 ng/ml, FSH
10 IU/l, LH
10 IU/l, and no ovarian cyst with a diameter
2 cm. Treatment with buserelin was continued up to and including the day of HCG administration. Final oocyte maturation was induced with 10 000 IU of HCG when at least one follicle with a mean diameter
20 mm was observed and the serum oestradiol concentration was
1200 pg/ml. To avoid the ovarian hyperstimulation syndrome (OHSS), HCG was not administered and the cycle was cancelled in case of the presence of more than 12 follicles with a mean diameter
15 mm and/or an oestradiol concentration
4000 pg/ml.
During the treatment, transvaginal ultrasound was performed on day 1 and on day 6 of the HMG treatment, optionally from day 6 of the HMG treatment onwards, and on the day of HCG administration in order to assess the follicular growth. Blood samples were taken for the measurement of FSH, LH, oestradiol and progesterone at each centre's laboratory, on the day of screening, on day 1 of HMG administration, and daily starting from day 6 of HMG administration. Furthermore, hormonal analysis was performed on the day of oocyte retrieval and embryo transfer, and on day 6 or 8 after embryo transfer. Additional serum samples were collected from each patient and frozen at 20°C to be analysed at the central clinical laboratory of ASTA Medica AG, Frankfurt, Germany.
Oocyte retrieval was performed by transvaginal needle-guided ultrasound aspiration 36 h after HCG injection. A maximum of three embryos was replaced into the uterine cavity 2 or 3 days after oocyte retrieval, and supernumerary embryos were cryopreserved for later use (Van Steirteghem et al., 1994). All patients received luteal phase support, either by HCG injection (if serum oestradiol concentrations were <2000 pg/ml) or by natural micronized progesterone given intravaginally according to the centres' rules. Clinical pregnancy was determined by ultrasound demonstration of a gestational sac and a fetus with cardiac activity.
Statistical methods
All statistical evaluations and analyses were performed using SAS 6.09 (SAS Institute Inc., SAS Campus Drive, Cary, NC, USA).
One-sided 95% lower confidence limits (CL) were calculated (Pearson-Clopper, 1985) for success rate (percentage of patients reaching the day of HCG). MantelHaenzel tests adjusted for centres were used for comparisons of rates except for OHSS, miscarriage, and ectopic pregnancy rates where, due to low incidence, no centre-adjusted analysis was performed but rather Fisher's exact test. For all other comparisons, the Wilcoxon rank test stratified by centre was used.
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Results |
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A total of 188 patients, aged 31.9 ± 3.7 years (mean ± SD) and a total of 85 patients, aged 31.6 ± 3.8 years, were analysed in the cetrorelix and buserelin groups respectively. Ultimately, 181 patients in the cetrorelix group (96.3%; 95% CL: 93.1%) and 77 patients in the buserelin group (90.6%; 95% CL: 83.7%) reached the day of the HCG injection (primary end-point). In seven patients of the cetrorelix group, HCG was not administered because they had a poor ovarian response (n = 3), were at risk of ovarian hyperstimulation (n = 3), or had a premature LH rise (10.6 IU/l) with a concomitant progesterone rise (1.0 ng/ml) during ovarian stimulation (n =1). In the buserelin group, HCG was not administered in eight patients because they had a poor ovarian response (n = 3) or were at risk of ovarian hyperstimulation (n = 5).
The stimulation outcome in the two groups of patients who reached the day of HCG is shown in Table I. The number of HMG ampoules administered was significantly less in the cetrorelix group than in the buserelin group, as was the duration of the ovarian stimulation with HMG (P < 0.01). On the day of the HCG administration, more follicles of a small diameter (1114 mm) were observed in the buserelin group than in the cetrorelix group (P = 0.02) and the mean serum oestradiol concentration was significantly higher in patients who received buserelin than in those who received cetrorelix (P < 0.01).
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The mean number of COC and the mean number of 2PN oocytes were significantly lower in the cetrorelix than in the buserelin group (P 0.01). However, the fertilization and cleavage rates were similar in the two groups (Table II
). The results in terms of clinical outcome in the cetrorelix and in the buserelin groups are summarized in Table III
. There were 42 conception cycles in the cetrorelix group (22.3%), including seven miscarriages and one ectopic pregnancy, resulting in 34 deliveries (18.1%) and 42 children born. In the buserelin group, 22 conception cycles (25.9%) were obtained, including two miscarriages, resulting in 19 deliveries (22.4%) and 21 children born. The outcome of one clinical pregnancy is unknown. The life birth rate (number of children born per embryos replaced) was 12.2% in the cetrorelix group and 14.3% in the buserelin group. These data were not significantly different.
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Discussion |
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In previous non-controlled studies, an advantage in reducing the number of HMG ampoules in cycles stimulated with the association of gonadotrophins and LHRH antagonists has been postulated (Diedrich et al., 1994; Olivennes et al., 1994
). However, in a phase II dose-finding study, where ovarian stimulation was carried out with HMG in combination with the LHRH antagonist cetrorelix 0.25 mg, a mean (± SD) of 33.4 ± 8.1 ampoules was used (Albano et al., 1997
). It is well known that a long desensitization protocol using LHRH agonists requires a large number of HMG ampoules varying from 30 to
40 (MacLachlan et al., 1989
; Smitz et al., 1992
). In the present study, significantly fewer ampoules of HMG were used in patients treated with cetrorelix than in those treated with buserelin (23.6 ± 8.5 versus 25.6 ± 7.6 respectively; P < 0.01). However, it must be noted that a small number of ampoules was used in both groups. This may be associated with the fact that a fixed dose of 2 ampoules of HMG was used for the first 5 days of treatment in both groups, and suggests that a `softer' approach to ovarian stimulation may decrease the number of HMG ampoules used, even with a long desensitization protocol, at least using a nasal spray preparation. Similar results were observed in a large randomized dose-finding study where the LHRH antagonist ganirelix was used in association with recombinant FSH. In the 0.25 mg group, 22 ampoules of recombinant FSH were used for ovarian stimulation (The ganirelix dose-finding group, 1998
).
Recently, cetrorelix has been used in natural cycles in patients undergoing IVF or ICSI procedure (Rongières-Bertrand et al., 1999). Cetrorelix (0.5 or 1 mg) was administered as a single injection when the serum oestradiol concentration was 100150 pg/ml and a leading follicle of 1214 mm was observed echographically. To avoid a reduction in serum oestradiol concentration after the antagonist administration, 150 IU of HMG were administered at the time of the first cetrorelix injection until the day of the HCG administration. The authors observed a very low cancellation rate (9%) compared with previous studies of natural cycles where 30% cancellation rate was reported. Moreover, a mean of 4.7 ± 1.4 HMG ampoules were used. Therefore, this treatment seems to be promising to simplify IVF/ICSI treatments, and to reduce the cost and the risk of OHSS.
The mean serum oestradiol concentration on the day of HCG injection was significantly higher in the buserelin group than in the cetrorelix group (P < 0.01), presumably due to the larger number of small follicles observed in the buserelin group (P = 0.02) (Table I). This finding may be the reason for the higher incidence of OHSS observed in the buserelin than in the cetrorelix group. A more profound pituitary suppression in the cetrorelix group than in the buserelin group may not be postulated as the serum LH concentration was similar in both groups (Figure 1
). In a controlled study which was conducted to compare the efficacy of the LHRH agonist leuprolide acetate with that of the LHRH antagonist Nal-Glu in suppressing LH secretion during ovarian stimulation in IVF, a higher serum oestradiol concentration was also observed in the LHRH agonist group (Minaretzis et al., 1995
).
Earlier studies have shown that the treatment with LHRH agonists reduces the incidence of endogenous LH surges to <2% (Wildt et al., 1986; Loumaye, 1990
). In a previous dose-finding study, 0.25 mg of cetrorelix was shown to be the minimal effective dose able to prevent LH surges during ovarian stimulation (Albano et al., 1997
). Unexpectedly, in the present study, eight patients (4.3%) in the cetrorelix group had an increase in serum LH concentration with a concomitant progesterone rise before HCG administration, according to the local laboratory's values. However, in only three patients (1.6%) were these results confirmed by the central laboratory. In one of the eight patients, one injection of cetrorelix was missed during ovarian stimulation. No pregnancies occurred in these eight patients. There is some evidence that high LH concentrations during the follicular phase of ovarian stimulation cycles have a negative impact on fertilization and implantation rates (Stanger and Yovich, 1985
; Howles et al., 1987
). In the present study, six patients in the cetrorelix group (3.2%) had a rise in serum LH concentration with no concomitant progesterone rise before the first cetrorelix administration. In these patients the antagonist was able to induce a decrease in LH levels after its injection. Embryo transfer was performed in all patients but one, and two clinical pregnancies occurred. This might suggest the irrelevance of a transient rise in LH on the quality and/or the maturity of the oocytes and on the IVF/ICSI outcome
Although the mean number of COC and 2PN was significantly lower in the cetrorelix group than in the buserelin group, the mean number of embryos available for transfer and for freezing was similar in both groups. This outcome is associated with the similar results obtained in terms of fertilization and cleavage rate in the two groups.
An apparent difference in pregnancy and delivery rate between the buserelin and cetrorelix groups was not statistically significant. Moreover, the percentage of babies born was similar in the two groups. Further investigations are necessary to confirm whether or not there is a significant difference in pregnancy rates.
In conclusion, the use of the LHRH antagonists may be considered more advantageous because of the short-term application required to inhibit gonadotrophin secretion and so allow a reduction in the treatment time in a clinically significant manner. Furthermore, the risk of OHSS appears to be reduced after the use of the LHRH antagonist cetrorelix, and this may be associated with the short treatment period with HMG.
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Acknowledgments |
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Notes |
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§ Prof. Dr Paul Devroey, Prof. Dr André Van Steirteghem and Dr Carola Albano, Centre for Reproductive Medicine, Academic Hospital, Free University Brussels, Laarbeeklaan 101, 1090 Brussels, Belgium; Prof. Dr Peter Brinsden and Dr F. Akagbosu, Bourn Hall Clinic, Cambridge CB3 7TR, UK; Dr Elizabeth Lenton, Dr Eswar Sundar, Dr S.E.Sugantha and Dr Medhat Fawzy, University of Sheffield, Sheffield Fertility Centre, 26 Glen Road, Sheffield S7 IRA, UK; Dr R.W.S.Yates, Prof. Dr R.Fleming and Dr E.Louis, University Department of Obstetrics and Gynaecology, Royal Infirmary, 10 Alexandra Parade, Glasgow G31 2ER, UK; Prof. Dr David Baird, Dr S.Lawson, Dr C.West and Dr D.Kinniburgh, University of Edinburgh, Centre of Reproductive Biology, 37 Chalmers Street, Edinburgh EH3 9EW, UK; Prof. Dr Johannes Evers, Dr J.A.Land, Dr J.W.M.Maas and Dr D.Courtar, Department of Obstetrics and Gynecology, Academic Hospital Maastricht, PO Box 5800, NL-6202 Maastricht, Netherlands; Prof. Dr Jarl Kahn and Dr F.Christensen, Ciconia Foundation, DK Copenhagen, Denmark.
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References |
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Submitted on June 11, 1999; accepted on November 22, 1999.