Effects of Growth Hormone Supplementation in Patients Undergoing IVF/ICSI-ET with Poor Ovarian Response to Gonadotropin
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Journal of Reproduction & Contraception doi: 10.7669/j.issn.1001-7844.2014.01.0032
2014 Mar.; 25(1):32-40 E-mail: randc_journal@163.com
Effects of Growth Hormone Supplementation in Patients
Undergoing IVF/ICSI-ET with Poor Ovarian Response to
Gonadotropin
Zhi-ping HU, Ying WANG, Xiao-guo DU, Rong LI, Xin-na CHEN, Hai-yan WANG,
Ping LIU, Cai-hong MA, Jie QIAO
Reproductive Medical Center, Peking University Third Hospital, Beijing 100191, China
Objective To analyze the effects of growth hormone (GH) supplementation during IVF/
ICSI-ET in Chinese patients who had prior IVF cycle with poor response to gonadot-
ropin (Gn).
Methods Ovulation was stimulated in 389 consecutive patients who all had poor ovarian
response, among them, 102 patients (GH cycle) received 4 IU GH and the other 287
patients (non-GH cycle) underwent IVF without GH. Fisher’s exact test, Chi square test
and Student’s t-test were used to analyze IVF/ICSI-ET outcomes.
Results After GH treatment, 102 patients had significantly more large- and medium-
sized follicles, oocytes retrieved, 2 pronucleus oocytes, metaphase II stage (MII) oocytes,
and high-quality embryos than in previous cycles without GH. However, the number of
embryos transferred, clinical pregnancy rate, transfer rate and biochemical pregnancy
rate were not significantly different. Furthermore, the 102 patients given GH had
significantly lower luteinizing hormone levels and biochemical pregnancy rates; thicker
endometrium and more Gn administration days; and more large- and medium-sized
follicles and MII oocytes than 287 other patients undergoing IVF/ICSI-ET without GH.
However, these groups did not differ significantly in clinical pregnancies, high-quality
embryos, MII oocytes, and embryo implantation rates.
Conclusion GH may improve some IVF/ICSI-ET outcomes for women with poor ovarian
response.
Key words: assisted reproductive technology (ART); growth factor; in vitro fertilization
(IVF); superovulation
Corresponding author: Ying WANG; Tel: +86-13911688652; E-mail: wangying02114@bjmu.edu.cn
32During in vitro fertilization and embryo transfer (IVF-ET), 9%-24% patients have
poor ovarian response (POR)[1-3]. POR is defined according to the Bologna consensus
criteria by two of three factors: 1) maternal age ≥ 40 years or another risk factor for poor
ovarian response, 2) previous POR, and 3) an abnormal ovarian reserve test[4]. In this patho-
logical condition, the ovary responds poorly to the standard protocol of stimulating ovulation
with gonadotropin-releasing hormone (GnRH). This poor response leads to few developing
follicles, low peak 17-β estradiol (E2) levels, increased requirement for gonadotropin (Gn), a
high cycle cancellation rate, few oocytes harvested, and low pregnancy and live birth rates[5].
Poor ovarian function remains an issue in IVF-ET, which often leads to couples giving up the
treatment or using donated eggs. As assisted reproductive techniques (ART) have become
more advanced, POR has presented a greater challenge to infertility treatment.
Despite several interventions to improve POR, the pregnancy rate after IVF-ET in
these patients is still quite low[3,6]. A common approach is to increase the dose of Gn; however,
this treatment remains controversial because of its negative effects on implantation and fetal
development [7]. In some IVF-ET protocols, a treatment considered beneficial is growth
hormone (GH)[8]. Administering GH during ovarian stimulation increased the number of
oocytes and fertilization rate in patients with poor response to GnRH agonists (GnRH-a) or
human menopausal gonadotropin (hMG), but not the clinical pregnancy rate[9]. However, a
Meta-analysis of 22 randomized clinical trials on improving pregnancy in poor responders
found evidence suggesting that GH treatment combined with embryo transfer on day 2
instead of day 3 increased the probability of pregnancy[6]. In that Meta-analysis, only 5
randomized clinical trials assessed the effect of GH on pregnancy rate. Additionally, these 5
trials were relatively small scale, limiting their statistical power. Thus, the ability of GH to
increase pregnancy rates during stimulation of ovulation in IVF-ET requires further research.
In this study, we investigated the effects of adding GH as an adjuvant treatment on IVF/
ICSI-ET outcomes in 102 patients with POR.
Materials & Methods
Patient selection
For this retrospective study, we analyzed the outcomes of 389 consecutive, infertile
female Chinese patients with POR who visited the Reproductive Medical Center of Peking
University Third Hospital from January 1, 2008 to December 31, 2011 for IVF-ET or intra-
cytoplasmic sperm injection (ICSI) treatment. The main reasons for infertility were tubal
problems, male infertility, endometriosis, and other factors (including ovulation failure and
unexplained infertility); all patients had normal uterine and cervical morphology. All 389
patients had POR in the prior IVF cycle, as defined by the Bologna consensus criteria[4].
33Stimulation of ovulation
In fact, no protocol is effective to patients with POR, including long, ultralong, antagonists,
short and mild stimulation approach. Each protocol with GH was used in our center according
to doctor experience. Long GnRH protocol is used mostly and the clinical data are the most
complete. Our study was a retrospective study, so we select the patients who underwent
long GnRH protocol, with 0.1 mg GnRH-a (diphereline; Ipsen, Paris, France) per day or
1.8 mg one time if injected during the midterm luteal phase of the previous menstrual period.
Ovulation was stimulated 14 d later by recombinant FSH (Gonal-f; Merck Serono, Geneva,
Switzerland and Purigon, Organon, P.O. Box 20 OssNL5340BH, Netherlands) or hMG
(Livzon Pharmaceutical Group, Zhuhai, China). The 389 patients were divided into two
groups: those who received GH (n=102, GH cycle) and those who did not (n=287, non-GH
cycle). Patients in GH group received 4 IU/d of GH (Saizen; Merck Serono, Geneva,
Switzerland)[10,11], beginning on the initial day of Gn until the day of human chorionic
gonadotropin (hCG) injection.
Except for GH administration, each group received the same protocol to induce ovulation.
Follicle development was monitored by ultrasound. On the fifth day after Gn administration,
the serum was assessed for concentrations of E2, progesterone (P) and luteinizing hormone
(LH). The blood serum concentrations of these hormones were measured again when 3
follicles were detected with diameters>17 mm. At 8 pm on the same day, patients received
250 µg hCG (Ovidrio; Merck Serono, Geneva, Switzerland) via intramuscular injection, and
the ova were harvested 36 h later.
Oocyte harvest and fertilization
Oocytes were harvested under anesthesia by venous administration of propofol
(Fresenius Kabi, Hombury, Germany) and ultrasound guidance. After harvest, granular cells
and corona radiata of the cumulus oophorus were removed, the maturity of the ova were
evaluated, and ova were naturally fertilized or ICSI treated, depending on the semen condition.
After fertilization, the zygote was incubated for 18 h in IVF nutrient solution at 37 ℃ with a
5% CO2 atmosphere. Fertilization status was observed at 24 h and the nutrient solution was
renewed. Three days after natural fertilization or ICSI, embryos were transplanted. The
number of available embryos was defined as the sum of the number of embryos transferred
and the number of embryos frozen. Clinical pregnancy was defined as a positive pregnancy
test at 14 d post transfer, followed by a vaginal ultrasound 2 weeks later demonstrating an
embryonic cardiac pulse.
Statistical analysis
The results were expressed as mean ± standard deviation (x- ± s) or percentage (%).
SPSS 13.0 (SPSS Inc., Chicago, IL, USA) was used to analyze numerical data. Student’s
t test was used to compare paired data and χ2 test was used for proportional data. Pwas considered to be significantly different.
Results
Patient characteristics
Patients in the two groups did not differ significantly in age, body mass index (BMI),
duration of infertility, baseline hormone levels, and baseline antral follicles (Table 1). The
102 patients who underwent several cycles of IVF/ICSI-ET with and without GH did not
differ significantly in any factor related to controlled ovarian hyperstimulation status (Table 2).
Comparison of IVF/ICSI-ET outcomes in patients before and after treatment with GH
The 102 patients who received GH during IVF/ICSI-ET had significantly more large-
and medium-sized follicles on the day of hCG injection (PTable 2 Controlled ovarian hyperstimulation status of patients before and after receiving GH during
IVF/ICSI-ET (n=102) (x- ± s)
IVF/ICSI-ET parameter GH cycle Non-GH cycle Z(t) or χ2 P
FSH on Gn initiation day (mIU/L) 7.55 ± 5.36 7.07 ± 4.43 -0.609 0.544
LH on Gn initiation day (mIU/L) 2.26 ± 2.09 3.09 ± 5.92 1.364 0.176
E2 on Gn initiation day (pmol/L) 124.45 ± 49.43 134.22 ± 58.68 1.302 0.196
P on the initiation day (nmol/L) 1.31 ± 0.63 1.45 ± 0.92 1.311 0.194
Total follicles on Gn initiation day (n) 4.1 ± 2.0 4.0 ± 2.4 -0.254 0.800
Gn days (d) 11.8 ± 3.0 11.3 ± 3.1 -0.971 0.334
Total Gn dose (IU) 4 544.12 ± 1 696.62 4 596.54 ± 1 625.65 0.229 0.820
E2 on hCG injection day (pmol/L) 5 240.45 ± 3 955.27 4 643.69 ± 2 591.66 -1.596 0.114
LH on hCG injection day (mIU/L) 2.27 ± 2.98 2.49 ± 2.72 0.607 0.545
P on hCG injection day (nmol/L) 2.46 ± 1.33 2.47 ± 1.24 0.059 0.953
Endometrial thickness on hCG injection day (mm) 10.5 ± 1.5 10.3 ± 1.6 -1.411 0.161
Table 3 IVF/ICSI-ET outcomes for patients before and after receiving growth hormone (n=102) (x- ± s)
Outcome GH cycle Non-GH cycle Z(t) or χ2 P
Large- and medium-sized follicles 4.2 ± 2.2 3.0 ± 1.3 -5.224Table 4 Controlled ovarian hyperstimulation status of patients who received and did not receive GH
during IVF/ICSI-ET (x- ± s)
Status GH cycle Non-GH cycle Z(t) or χ2 P
n 102 287
FSH on Gn initiation day (mIU/L) 7.48 ± 5.28 7.93 ± 4.80 -1.145 0.252
LH on Gn initiation day (mIU/L) 2.35 ± 2.12 2.66 ± 1.98 -1.740 0.082
E2 on Gn initiation day (pmol/L) 126.26 ± 54.63 142.95 ± 72.34 -1.809 0.070
P on Gn initiation day (nmol/L) 1.31 ± 0.63 1.22 ± 0.56 -0.928 0.353
Gn days (d) 11.8 ± 3.0 11.1 ± 2.7 -2.022 0.043
Total GnRH dose (IU) 4 537.88 ± 1 710.25 4 194.32 ± 1 784.97 1.677 0.094
E2 on hCG injection day (pmol/L) 5 264.87 ± 3 940.70 4 939.83 ± 4 085.99 -1.069 0.285
LH on hCG injection day (mIU/L) 2.30 ± 3.00 3.09 ± 4.28 -2.464 0.014
P on hCG injection day (nmol/L) 2.47 ± 1.34 2.55 ± 1.50 -0.254 0.800
Endometrial thickness on hCG injection day (mm) 10.5 ± 1.5 10.1 ± 1.5 -2.773 0.006
Table 5 IVF/ICSI-ET outcomes for patients who received and did not receive GH (x- ± s)
Outcome GH cycle Non-GH cycle Z(t) or χ2 P
n 102 287
Large- and medium-sized 4.2 ± 2.2 3.7 ± 2.4 -2.196 0.028
follicles on hCG injection day (n)
Number of oocytes retrieved (n) 4.6 ± 3.0 4.4 ± 3.3 -1.080 0.280
Number of 2PN oocytes (n) 2.3 ± 1.9 2.5 ± 2.4 -0.158 0.875
2PN oocyte rate* 0.79 ± 0.31 0.78 ± 0.33 -0.114 0.909
MII oocytes (n) 3.8 ± 2.7 2.6 ± 1.9 -2.412 0.016
Number of high-quality embryos (n) 1.5 ± 1.6 1.5 ± 1.8 -0.004 0.997
Number of embryos transferred (n) 2.2 ± 0.8 2.1 ± 0.8 -0.692 0.489
Cycle outcome (transfer rate) (%) 80.00 (80/100) 77.16 (223/289) 0.347 0.556
Biochemical pregnancy rate (%) 20.00 (16/80) 32.58 (72/221) 4.493 0.034
Clinical pregnancy rate (%) 17.50 (14/80) 25.79 (57/221) 2.241 0.134
Implantation rate** 0.51 ± 0.23 0.61 ± 0.28 -1.040 0.298
*: 2PN oocyte rate is the value, which is calculated from 2PN oocyte (oocyte fertilized normally) number divided
by oocyte fertilized number in each subject
**: Implantation rate is the value, which is calculated from surviving embryo number divided by transferred
embryo number in each subject
Note: Because our study is retrospective study, some clinical data is not very complete, there is some lacunary
in data, which were disposaled in statistics process. There are some tiny variances in GH cycle results
between Table 4 and Table 2, between Table 5 and Table 3, according to different comparison
oocytes and E2 level on the day of hCG injection. The results of this study showed that patients
who had poor response to Gn during IVF/ICSI-ET without GH treatment perhaps had better
outcomes in later cycles when they were treated with GH. These patients had more large-
and medium-sized follicles on the day of hCG injection, more oocytes retrieved and MII oocytes
which facilitate better IVF/ICSI-ET outcomes in GH cycle than in non-GH cycle. These GH-
37treated patients also had significantly more large- and medium-sized follicles and MII oocytes
than other patients without GH treated. Our results echo another study showing that GH
significantly increased the number of mature oocytes, suggesting that GH reduces follicular
atresia and stimulates antral follicular recruitment and growth, enhances the responsiveness
of the antral follicles to Gn[9,10]. Similarly, adjuvant GH during ovarian stimulation in patients
with polycystic ovary syndrome (PCOS) increased the number of dominant follicles[11]. This
possible explanation is supported by a report that GH selectively increased the FSH sensitivity
of the dominant follicle and promoted oocyte maturation[12].
In addition to the proposed ability of GH to improve ovarian responsiveness, GH
increases oocyte and embryo quality in IVF-ET cycles[10]. We found that patients treated
with GH had significantly more 2PN oocytes and high-quality embryos than in IVF-ET cycles
without GH, but no significant change in the number of embryos transferred. Furthermore,
GH-treated patients had a clinical pregnancy rate that was 2.3 times higher than during IVF-
ET cycles without GH, but this difference was only borderline significant (P=0.054). The rate
of clinical pregnancy probably improves significantly by optimizing the dose or timing of GH
according to the situation in the body or by changing some other part of the IVF-ET treatment.
Furthermore, our result on clinical pregnancy is consistent with previous reports that GH did
not improve the clinical pregnancy rate[9,13], but it may improve this rate if embryos are
transferred on day 2 instead of day 3[6].
Our results indicated that GH controlled follicle growth at an appropriate rate, and
maintained a relatively low LH level during controlled ovarian hyperstimulation. These results
were consistent with a report that GH-treated patients had significantly higher levels of IGF-1
in follicular fluid than in the control, suggesting that GH can increase estrogen synthesis by
increasing IGF-1 levels in follicular fluid, which promoted the synthesis of granular cell
steroidogenic acute regulatory protein and effects of FSH[10]. A study to evaluate the effects
of equine growth hormone (eGH) on nuclear and cytoplasmic maturation of equine oocytes
in vitro, steroid production by cumulus cells, revealed that cumulus cells incubated with eGH
had more oocytes that reached metaphase II; greater concentrations of oestradiol in the
culture medium, concluded that addition of eGH to maturation medium increased rates of
cytoplasmic maturation and had an important role in equine oocyte maturation[14]. These data
indicated that GH directly impacts the ovum, which in turn affects embryo quality[15].
In a previous study, GH treatment led to a lower recurrent pregnancy loss rate, and higher
parturition and live birth rates than a placebo group[16]. These effects were not observed in our
parallel comparison with other patients undergoing IVF-ET during the same time period,
which may be related to influencing factors such as variance in the general characteristics of
the two patient groups. These results also suggest that follicle growth and embryo development
are influenced by a variety of factors, so that simply adding GH or IGF-I is not sufficient to
improve the outcomes of IVF-ET.
38Our patients treated with GH during IVF/ICSI-ET had significantly greater endometrial thickness than those patients who did not receive GH, suggesting that GH improved the endometrial receptivity, which had potential promotion on endometrial adhesion, blastocyst- endometrium communication, and embryo implantation. This possibility is supported by a report that adding GH during IVF/ICSI-ET of women with underdeveloped endometrium (
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(Received on December 14, 2013)
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