Gonadotrophins in subfertility

Basal Scan-What are the possible abnormalities in basal Scan?

Day 2/Day 3 scan must: - a) if ET is < 6mm then one can initiate G. But if > 6mm do not initiate G-because there can be implantation failure. There can be poor response. But one can follow up ET after 3=-5 days in most cases ET shrinksà then one can initiate G.

b) Ovarian cyst:-There should not be any Ov cyst-complex. If an unruptured Follicular Cyst is visible àthen administer Cabergolin Tablets 0.25 mg weekly. This will prevent recurrence of occurrence of LUF. If Cyst diameter is < 10 mm then àestimate serum E2 & P value. The serum E2 should ideally be > 50 pg/ml and serum Progesterone should   ideally be < 0.9 ng/ml.  If Figure is otherwise do not initiate the cycle.

But if Cyst diameter is 10-20 mm –then with E2 < 50 & progesterone too is high i.e. > o.9 ngà then Rpt. USG after 48 hoursàHopefully the  endocrine parameters will  be normal—meaning  thereby that  CL of previous cycle has regressed meanwhile -therefore there is decrease  of P value and rise ofE2 due to fresh follicles now coming up. This time is congenial for initiating stimulation.

c) What is the AFC? If more than 8-10 antral follicles: it will be better not to initiate the G-because the response will be high with the resultant higher order multiple births.

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d) Estimate P value on day 2 of spont cycle- Precondition of optimum outcome is that on the day of initiation of stimulation Progesterone value will be ideally be > 0.9 ng/ml and E2 be > 50 pg.? If otherwise i.e. high P value or low E2 then do not initiate the cycle. Better re-estimate after 2 days & then decide. So then do not commence G because the here will be poor development of follicle. Endocrine parameters usually come to basal level on Day 3 of healthy fertile women. A rise of P value will impede the growth of follicle on the ipsilateral side.

e) Estimate E2:- If > 12 mIU/mL then do not initiate. Better re-estimate the FSH after 4-7 days .If < 10, and then only initiate G cycle.

f) Estimate FSH & LH:-If FSH is > 12 mIU no Gonadotrophin Cycle: Better to   Rpt FSH after every 5-7 days: reassess after 4-5 days-then start only if FSH is falls to < 10 mIU.

Relevance of LH value:  Normal LH values are as follows:- 1)Normal women of proven fertility- average day 3 LH will be 7.2+-2.1IU: PI group of women = 9+-2 IU but Sec subfertility, the average LH on day 3 is = 9+-2 IU.

 LH is essential for E2 production, optimal follicular growth, ovulation and Leutinisation. Serum LH below the level of < 0.8 to 1.2 mIU /mL during the entire phase of OI-may impede proper growth of follicles. Therefore we need LH in the first phase of cycle. By contrast, high levels of LH in late follicular phase may be beneficial for follicular-oocyte-endometrial maturation & also for Monofollicular ovulation. If persistently high LH (say->12-- then use Femilon 2 packs continuously. Before having last 4 Tablets of Novelon-administer Leuprolide Acetate0.4 mg in 0.4 ml. & later initiate Gonal Folligrafin(r-FSH). Pen is better. The other alternative treatment for high LH with obesity is LOD.

Ill effects of high LH? Any figure above > 8 IU can lead to menstrual disorders, subfertility and increase the rate of spontaneous abortion.

Low LH –What to do? If LH is low on day & so also FSH =then CC won’t work, better to go for gonadotrophins straightaway.

High LH what is the risk? Not only there will be failure of treatment (low cycle fecundity. Increased spont abortion rate but there is a real threat for OHSS. AS such it will be prudent to go for low dose Gonadotrophin cycle otherwise woman will be at increased risk of OHSS?

Role of FSH? Low FSHà goes for Gonadotrophin Cycle.

Initial Dose: Starting dose:

Usual starting dose is 37.5 IU or 75 IU of hMG –lyophilized (Brand Names: -            )                               or u-FSH (Brand Names:   HMG (Reprogon, Humegon, Pergonal) vs.  HP-HMG (Menopur); in these two preparations much of the LH & HCG activity are lost during the manufacturing process.                   ) or r-FSH 37.5 to 50 IU.Follisurg- Either sub cut/ IM. For 5-7 days.

Maintenance Dose:

One can combine the G after the completion of CC for 3 days on cycle days 7, 8, & day 9 of cycle.

One should remember that R-FSH takes long time to exhibit its action:-

What matters circulating FSH labels?-In the natural cycle there is a balance between the pit release, tissue binding and metabolic clearance. But in synthetic preparations- serum levels of FSH will depend on A) Type of preparation.

How to monitor the cycle?

Contraindications of initiating the cycle:-Basal scan- if ET is > 6mm does not initiate G:

 If there is clear cyst but size is big i.e. above 10mm, cyst is complex cyst or C L cyst with but the P level is > 0.9 ng/mL then one should not initiate G cycle. But in the same circumstances if P value is < 0.9 ng/mL then one can initiate the G cycle.

Increase the dose of Gonadotrophin:-

When to Supplement with G in addition to CC after the schedule CC course is completed? One can combine the Gonadotrophin after the completion of CC for 3 days on cycle days 7.8. & day 9 of cycle.

One will be surprised to know that the majority of follicles above 10-12mm will be able to yield good quality embryo (Dickey-pp.82). Therefore, though by convention HCG is administered after the DF is at about 18 mm but I one wrongly administers HCG while DF is only 14 mm then too most cases will lead to MII good embryo. This have also been seen in ICSI & as well as IVF-ET cycles :-retrieval sizes of follicles in ART programmes vis a vis yield of good quality of embryo MII oocytes( 13-15 DF = of these sizes of follicles à 72%:  those which DF were 16-18mmin them = 79% were   .Finally those DF which were > 18 mm in such cases 90% yielded MII oocytes.

Yield of good quality MII oocytes according to size of DF when retrieved.

Size of DF when  retrieved	How % finally yield to good quality MII
13-15 mm	72%
16-18mm	79%
>18mm	90%
Fertilization rate &	Rate à Dev to 8 cell stage	Per mature oocyte were similar to

Cancellation of cycle after initiation of G?

Types of gonadotrophins available: How to initiate & Dose selection:-

Types of gonadotrophins.

Choice of gonadotropins:-

HMG (lyophilized):- Brand Names:-Pergonal, Humegon, Reprogon,

U-FSH: Brand names:-Menopur,

R-FSH in solution:-r-FSH (alpha)-Gonal-F; r-FSH (beta) Follistin, Puregon,

R-FSH in solution:-r-FSH (alpha)-Gonal-F; r-FSH (beta) Follistin, Puregon..

There are basically 4 different types of gonadotrophins e.g. hMG, HP-HMG, HP-u-FSH & r-FSH of which hMG, HP-HMG behaves differently from HP-u-FSH & r-FSH.

As because former two gonadotropins (hMG, HP-HMG) lack the efficacy of LH activity. May have to add HCG 10 IU in late foll phase of cycle.

Natural pulses of GnRH & gonadotrophins in unstimulated cycles:- early foll phase( every 94 mts, late foll phase  every 71 minutes—therefore about total 15-20  pulses) and every 216 minutes in late luteal phases.

This not so in stimulated cycles those cycles which are down regulated.

Brand Names & Contents of proteins & costs.

All u-FSH/HMG contain some h-CG in addition to LH.

Brand	Company	FSH	LH	Protein content as impurity	bioactivity	Sialic acid	Simple/complex glycoforms
Pergonal	Serono	75	75	<5%
Humegon	Organon	75	75	<5%
Reprogon	Ferring	75	75	<5%
Menopur	Do			<0.1%
Bravelle	Do				u-FSH-HP
r-FSH						Few S acid residues.	More simple & intermediate .Glycoforms.

Details of rFSH (Gonal –F, Sereno:    ) & r-FSHβ (Puregon/Follistim): These types vary with other available gonadotrophins like u-FSH or even Natural FSH: - in that rec FSH are more intermediate & simple isoforms, fewer complex glycoforms and fewer sialic acid residues & prolonged bioactivity:-Of the two types of r-FSH the r-FSHβ (Puregon/Follistin) contains high proportion of oxidized FSH. But most studies have revealed that both types of r-FSH have same efficacy or side effects. R-FSHβ (Puregon/Follistim):

Why HCG is to be added in HMG/HP-HMG preparations in a case of OI. These r-FSH differ from natural FSH and also from U-FSH-(be it HMG or uFSH) in that rFSH have more intermediate and simple glycoforms, and fewer complex glycoforms. Additionally r-FSH has fewer sialic acid residues. R-FSH has prolonged activity compared to u-FSH and hMG,

HMG (Reprogon, Humegon, Pergonal) vs.  HP-HMG (Menopur); in these two preparations much of the LH & HCG activity are lost during the manufacturing process. Therefore, these Inj do not work properly in late foll Phase. 

As such therefore HCG has to be added so that balances between the LH: FSH is maintained. The bioactivity of (9 IU of HCG = 75 IU of LH.).

 P-FSH (Menopur, :-

Types of isoforms of FSH: -    FSH exists in multiple isoforms;

Isoforms of G as per cycle days:-

Normal Cycle days.	pH	Half life	In vivo bioactivity.
In folli. phase	More acidic	Long	High active.

Brand names of all gonadotrophins as per company.

HMG. (Humegon, Pergonal, Reprogon,)

Ferring
Serono	Pergonal
Bharat Serum
INCA
INTAS
LUPIN

HP-HMG (Menopur, Bravelle)

Ferring
Bharat Serum
INCA
INTAS
LUPIN

P-FSH

Ferring
Bharat Serum
INCA
INTAS
LUPIN

R-FSH.

Ferring
Bharat Serum
INCA
INTAS
LUPIN

Types of gonadotrophins preparations:-Does result vary?

The carbohydrate moiety: - The degree of sialylation and sulfation-changes in carbohydrate part of Gonadotrophin-modifies/ controls the bioactivity of Gonadotrophin molecules in diff batches. Receptor binding and metabolic clearance varies.

The degree of sialylation correlates with acidic moleculeàdifferent FSH isoforms. Now by using optimized chromatographic techniques –a predetermine & predefined isoforms can be prepared from u-FSH. (Bravelle).Bravelle contain less acidic residue. Less acidic form is better to yield good results as in Bravelle.

Protein content as purity:-

Few points as r-FSH: - Follitrophin-α   (Gonal-F)              β (                   ).

The efficacy of p-FSH vs. r-FSH in non-down regulated cycles and down regulated cycles were little evaluated so far.

How to judge & compare between two such types of agents? The primary end point is Ovulation, but secondary end points were a) whether Monofollicular? b) Size of follicles-How many 12,>15 & > 18 mm follicles are there? c)PR d)ET d) Incidence of OHSS f) Inj sires pain/ reactions’) Multiple preg rates

Choice of gonadotrophins? - Bothe p-urinary FSH (ovulation rate was 85%) & rFSH (91%) are equally effective.

Efficacy comparison between two types of gonadotrophins:-PR of singletons in u-FSH was 15% IN EACH GROUP.

Start with Gonadotrophins 75-150 I.U. OD from Day3:- better at evening hours. & on day 8 morning estimate serum E2. Once the serum E2 starts rising then, alt day

Conclusion:- U-p-FSH was not inferior as a method of OI  in ) WHO Group II Anovulatory PCOS who are resistant to CC

FM is essentialà to note no & size of follicles.  & alt. day Serum E2 estimation. The effective dose of gonadotrophins required in each cycle to have a response must be recorded so as to plan the future stimulation.

Chronic Low Dose Gonadotropin Protocol.

Low Dose Gonadotrophin IUI cycles: - 1) For whom. 2)  Basal Scan, Basal USG- 3) How to initiate & -Dose selection, 4) Monitoring, 5) Contraindications, 6) Side effects, 7) Cancellation of cycle.

           Part 1.   Indications of Gonadotropins:  Gonadotropins for whom?

Indication:- The main indication is CC resistant anovulation.

 A) However most appropriate indication is Hypo disorders of anovulation –WHO Class I-anovulation. This is first line of Ry in such diseases.

B) In cases where CC failure is due possibly thin endoà the first option will be TMX and not straight to G. At least 2-3 cycles of TMX should be tried before one jumps ob G for the presumptive cause of antiestrogenic effect on Endo/ Cx mucus.

 C) CC Resistant cases: after 4-6cycles of CC.

 D) Unexplained Infertility:-However causes severe OHSS or multiple pregnancy, therefore should not be used in “unexplained subfertility who ovulates but fail to conceive “ or for women who  have not given a fir trial of 34 cycles of CC.