The reproductive outcome of women with hypogonadotropic hypogonadism undergoing in vitro fertilization

Abstract

The aim of this study was to evaluate the reproductive outcome and assisted reproductive technology (ART) outcomes of patients with hypogonadotropic hypogonadism (HH) and to compare the results with male factor (MF) infertility patients. The reproductive outcome of 33 HH patients was evaluated retrospectively and compared with results of 47 patients with mild male factor infertility. For ovulation induction, human menopausal gonadotropin (hMG) was used in HH patients and recFSH was used in MF infertility patients. HH patients were divided into subgroups according to retrieved oocyte numbers and the groups were compared with each other. The main outcome measures were total gonadotropin dose used, duration of stimulation, human chorionic gonadotropin (hCG) day estradiol level and endometrial thickness, oocyte number retrieved, and rate of clinical pregnancy. ART outcomes and cycle characteristics of 33 HH patients were compared with 47 MF infertility patients. There was no difference in age and body mass index (BMI) between the groups, but mean follicle stimulating hormone FSH and luteinizing hormone LH levels were significantly lower in the HH group (p < 0.001). Duration of stimulation was 12.5 ± 2.06 days in the HH patients and 10.08 ± 1.62 days in the MF infertility patients and the difference was significant (p < 0.001). Total gonadotropin dose used was higher in the HH group than the MF infertility group (p < 0.001). However, there were no differences in hCG day estradiol levels, endometrial thickness on hCG day, total oocyte number retrieved, MII oocyte number, and pregnancy rate. In the HH subgroups, patient ages were significantly lower in the >15 oocyte retrieved group. Although patients with HH have a long-term estrogen deficiency, their response to controlled ovarian hyperstimulation treatment is similar to normal women. However, the HH group is heterogeneous and estimating the ovarian reserve before treatment is not always possible in this group.

• ART outcome
• clinical pregnancy rate
• estimating ovarian reserve
• hypogonadotropic hypogonadism

Introduction

Hypogonadotropic hypogonadism (HH) is a rare disease that is characterized by low levels of follicle stimulating hormone (FSH) and luteinizing hormone (LH). According to the World Health Organization (WHO), patients with this disorder were defined as Group I [Sungurtekin et al. 1995; Ulug et al. 2005]. Whatever the underlying cause, HH results in deep infertility. Therefore, many initiatives have been made to overcome the arrest of follicular growth and to establish normal ovulatory functions.

Due to the rare incidence of HH, there are a limited number of studies evaluating the reproductive capacity and infertility treatment outcome of women with HH. Pulsatile gonadotropin releasing hormone (GnRH) treatment is an appropriate and effective way to establish normal ovarian function [Crowley and McArthur 1980]. But many patients display psychological problems and are agitated by having to carry an electronic pump on their body for a long time. Daily injections of gonadotropins are more suitable and tolerated treatment options for ovulation induction, with comparable results [Balen et al. 1994]. However, an optimal HH patient infertility treatment protocol is not yet clear. In our study, we evaluated reproductive and assisted reproduction technology (ART) outcomes of HH patients retrospectively and compared the results to women with male partners presenting male factor (MF) infertility.

Results and Discussion

ART outcomes and cycle characteristics of 33 HH patients were compared with 47 MF infertility patients. Demographic and basal characteristics are shown in Table 1. There was no difference in age or body mass index (BMI), but mean FSH and LH levels were significantly lower in the HH group. ART cycle characteristics are shown in Table 2. Duration of stimulation was longer and total gonadotropin dose was higher in the HH group. However, there were no differences in human chorionic gonadotropin (hCG) day estradiol levels, endometrial thickness on hCG day, total oocyte number retrieved, MII oocyte number, or pregnancy rate.

Table 1. Demographic and basal characteristics of HH and MF infertility patients.

Variables	HH (n = 33)	MF (n = 47)	p Value
Age	32.5 ± 4.73	31.3 ± 3.94	0.236
Body mass index  (kg/m^2)	26 ± 3.81	25.93 ± 4.81	0.962
FSH	0.89 ± 0.73	6.9 ± 1.52	< 0.001
LH	0.40 ± 0.51	6.4 ± 2.63	< 0.001

HH: hypogonadotropic hypogonadism; MF: male factor; FSH: follicle stimulating hormone; LH: luteinizing hormone.

Table 2. ART cycle characteristics of HH and MF infertility patients.

Variables	Hypogonadotropic hypogonadism (n = 33)	Male factor infertility (n = 47)	p Value
Duration of stimulation (day)	12.5 ± 2.06	10.08 ± 1.62	<0.001
Hcg day estradiol level (pg/ml)	2387 ± 1340	2418 ± 1034	0.909
Endometrial thickness on hcg day (mm)	10.0 ± 1.84	10.2 ± 1.89	0.559
Total gonadotropin dose used (IU)	4741 ± 1912	2157 ± 1099	<0.001
Total oocytes retrieved (n)	10.0 ± 5.8	10.7 ± 5.8	0.602
MII oocyte number (n)	8.39 ± 5.3	8.44 ± 4.42	0.962
Pregnancy rate (%)	30% (10)	31.4% (15)	0.879

ART: assisted reproductive technology; HH: hypogonadotropic hypogonadism; MF: male factor.

Basal parameters and ART cycle characteristics in women with hypogonadotropic hypogonadism according to oocyte number retrieved are shown in Table 3. There were no differences in FSH and LH levels, BMI, duration of stimulation, or total gonadotropin dose used. However, HH patient ages were significantly lower in the >15 oocyte retrieved group (p = 0.004).

Table 3. Basal parameters and ART cycle characteristics in women with hypogonadotropic hypogonadism according to the oocyte number retrieved.

Variables	<5 oocytes retrieved (n = 8)	5–15 oocytes retrieved (n = 16)	>15 oocytes retrieved (n = 9)	p Value
Age (years)	34 ± 5.15	34.1 ± 4.05	28.3 ± 2.82	p = 0.004*
FSH (basal)	0.86 ± 0.95	0.92 ± 0.7	0.85 ± 0.64	p = 0.970
LH (basal)	0.37 ± 0.5	0.38 ± 0.42	0.46 ± 0.7	p = 0.919
Body mass index kg/m^2	26.5 ± 7.77	25.8 ± 2.73	26 ± 4.42	p = 0.981
Total gonadotropin dose used (IU)	5753 ± 2307	4665 ± 1943	3977 ± 1094	p = 0.158
Duration of stimulation (day)	13.2 ± 2.54	12.5 ± 2.15	10.8 ± 3.9	p = 0.193

ART: assisted reproductive technology; FSH: follicle stimulating hormone; LH: luteinizing hormone. Values are means ± standard deviation (SD). *p < 0.05 was considered significant.

There is a lack of gonadotropin throughout the life of patients with HH. The first question that comes to mind about these patients is whether long-term LH deficiency causes a deficiency in ovarian response and embryo implantation. Due to the very low incidence of HH, many studies have been done to evaluate the influence of LH on follicular growth and oocyte quality in down-regulated patients undergoing an IVF procedure [Fleming et al. 1998; Westergaard et al. 1996]. Several studies have shown that serum LH concentration on the first day of FSH stimulation is not predictive of pregnancy and the outcome of pregnancy in women who had received long-term down-regulation with a GnRH agonist [Bjercke et al. 2005]. 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. In recent years, there have been several studies to increase the success rate with FSH and LH. As a result of these studies, it seems that a combined stimulation with FSH and LH is the best treatment option. However, it was concluded that the FSH/LH ratio should be 2/1 in the first half of the stimulation cycle, and 1/2 in the second half [1998; Burgues and Spanish Collaborative Group on Female Hypogonadotrophic 2001; Chappel and Howles 1991; Shoham et al. 2008]. Because of the low incidence of HH, there has been no prospective study on this condition. However, retrospective studies showed that the results of ART in HH patients treated with HMG were comparable to those in women with tubal factor infertility and unexplained infertility [Ulug et al. 2005; Yildirim et al. 2010]. In addition, earlier meta-analysis showed that when a GNRH agonist long protocol was used, hMG was superior to using only rFSH in IVF/ intra-cytoplasmic sperm injection (ICSI) treatment [Jee et al. 2010; Van Wely et al. 2003]. In light of this information and although we had a limited number of patients, the data describing the ART outcomes in these patients should be considered. In our study, we compared HH patient ART outcomes with mild and moderate male factor infertility patients. Similar to the other studies in the literature, we found that the response to fertility treatment in these patients was at least as good as in the control group.

How can we measure the ovarian response or ovarian reserve of patients with HH? Mild ovarian stimulation protocols have been the focus of attention in recent years. To obtain acceptable rates of pregnancy with minimal side effects, determining the ovarian response before treatment is crucial. However, predicting the ovarian response to treatment of patients with HH is difficult. The lower level of gonadotropin, small ovaries, and amenorrhea render ovarian reserve tests unreliable. Sönmezer et al. [2012] found that the level of anti-Mullarian hormone (AMH) is correlated with ovarian response in patients with HH. Although a small number of patients were evaluated in this study, determining the level of AMH looks to be a hopeful marker for ovarian reserve in patients undergoing IVF. In our study, we divided the HH group into three subgroups as a function of the number of oocytes recruited. However, we found no predictive indicator of ovarian response in patients with HH except age.

As previously mentioned by Tsilchorozidou and Conway [2004] because of the lack of gonadotropin and low levels of estrogen, women with HH have a smaller uterine length and a smaller uterine cross-sectional area. In our clinic, patients with HH are given oral contraceptives for at least two months before controlled ovarian hyperstimulation treatment to change the hypoestrogenic environment and to improve endometrial development. In another study, the authors speculated that estrogen priming may reduce the total gonadotropin dose by stimulating gonadotropin receptor formation in granulosa cells [Lobb et al. 1998]. Although we have used estrogen pre-treatment, we found that gonadotropin was still greater in HH patients than in MF infertility patients.

In the HH group, three patients underwent coasting. Although a total of 10 HH patients had hCG day estradiol (E2) levels greater than 3,000 pg/mL, no severe ovarian hyperstimulation syndrome (OHSS) occurred. When we compared the day of stimulation between groups we found longer stimulation duration in HH patients, similar to previous studies. However, there were no differences in pregnancy rates nor in the total number of retrieved oocytes.

In conclusion, although patients with HH have a long-term estrogen deficiency, their response to controlled ovarian hyperstimulation treatment is similar to normal women. However, the HH group is heterogeneous and estimating their ovarian reserve is not always possible before treatment. Thus ART outcome of HH patients was as good as that for MF infertility patients. However, when we evaluated HH patients for prediction of the ovarian response, we did not find a usable predictive marker other than age.

Materials and Methods

Patients

The reproductive outcome of 33 HH patients who underwent ART in the Zekai Tahir Burak Women’s Health Training and Research Hospital between March 2008 and August 2013 were retrospectively evaluated. The study was approved by the Zekai Tahir Burak Women’s Health Training and Research Hospital ethics and research committee. Written informed consent was obtained from all patients for the use of data for scientific reporting purposes at the beginning of treatment. The diagnostic criteria for HH included serum levels of FSH <2.5 IU/L and primary or secondary amenorrhea with absence of withdrawal bleeding following progesterone challenge. All patients had normal serum prolactin and thyroid-stimulating hormone concentrations. Each HH patient had a normal uterus with thin endometrium (<5 mm) and small sized ovaries. As a control group, 47 patients with mild male factor infertility who underwent treatment with IVF/ICSI in the same center were evaluated. Mild MF infertility was defined as the presence of at least 1 million sperm after processing. None of the MF infertility patients had any coexisting infertility factor.

Ovulation induction protocols for HH and MF infertility patients

In patients with HH, pretreatment with an oral contraceptive was performed at least two cycles prior to the IVF/ICSI procedure to provide endometrial regeneration. All HH patients received daily human menopausal gonadotropin (hMG, Menogon, 75 IU, Ferring Pharmaceuticals) at 300-450 IU for 3 d, and were then evaluated for serum E2 levels by pelvic sonography. The hMG dose was adjusted according to the individual patient’s ovarian response. In patients with male factor infertility, leuprolide acetate (Lucrin Daily, Abbott Cedex, Istanbul) therapy was started on menstrual cycle d 21 to induce pituitary down-regulation. Treatment with recFSH (Gonal-F; Serono Istanbul) was then initiated subcutaneous (sc) with a starting dose of 150 IU daily for the first 3 d after which dosing was determined individually. Serial E2 levels and transvaginal ultrasonography (Logic 200 Pro, General Electric, Korea) were performed until at least two dominant follicles reached dimensions of 18 mm or greater in diameter. Human chorionic gonadotropin (Pregnyl, Organon, Netherlands, 10,000 IU, intramuscular (im) was then administered, followed by transvaginal oocyte retrieval 36 h later. IVF/ICSI procedures were performed. On d 3-5 after ovum pick-up, the embryo was transferred into the uterine cavity. The luteal phase was supplemented with vaginal progesterone gel (crinone gel 8%, Merck-Serono, Germany) twice daily, starting on the day of oocyte retrieval, and was continued until a negative pregnancy test was obtained, or if pregnancy occurred, it was continued for 12 w of gestation. Pregnancy was confirmed by ultrasonographic demonstration of an intrauterine gestational sac with heartbeat.

The HH group was divided into subgroups according to the number of oocytes retrieved (<5 oocytes as poor responder, 5–15 oocytes as normo-responder, >15 oocytes as hyper-responder). These three groups were compared to each other.

Statistical analysis

Distribution of the data was analyzed with Kolmogorov-Smirnov and Shapiro Wilk tests. The data are presented as mean with standard deviation (SD) or median with minimum and maximum values of ranges for continuous variables, and as number with percentage for categorical variables. The variables with normal distributions were compared between groups by the Independent Samples Test. The Mann–Whitney U test was used to analyze non-normally distributed data. The chi-square test was used to compare categorical variables. One way ANOVA was used to compare more than two groups. SPSS 21.0 was used for the statistical calculations (SPSS Inc., Chicago, IL, USA). p < 0.05 was considered significant.

Abbreviations
AMH	=	anti-Mullarian hormone
ART	=	assisted reproductive technology
BMI	=	body mass index
E2	=	estradiol
FSH	=	follicle stimulating hormone
GnRH	=	gonadotropin releasing hormone
hCG	=	human chorionic gonadotropin
HH	=	hypogonadotropic hypogonadism
hMG	=	human menopausal gonadotrin
ICSI	=	intra-cytoplasmic sperm injection
IVF	=	in vitro fertilization
LH	=	luteinizing hormone
MF	=	male factor
OHSS	=	ovarian hyperstimulation syndrome
SD	=	standard deviation
WHO	=	World Health Organization.

Acknowledgments

This paper was selected as an oral presentation and won the ‘Under 34 Competition’ award in the 18th World Congress on Controversies in Obstetrics, Gynecology & Infertility (COGI), Vienna, Austria, 24–27 October 2013.

Declaration of interest

The authors report no declarations of interest. There remain no relevant potential conflicts of interest related to this original article. Also, there remains no affiliation with any organization with a financial interest, direct or indirect, in the subject matter or materials discussed in the manuscript (such as consultancies, employment, paid expert testimony, honoraria, speakers bureaus, retainers, stock options or ownership, patents or patent applications or travel grants). We did not receive any funding and/ or financial support from any commercial or other association for this study.

Author contributions

Corresponding author, drafting the manuscript conception and design of the study, acquisition of data, analysis and interpretation of data, article draft and revising the manuscript critically for important intellectual content: SY; Drafting the manuscript conception and design of the study, analysis and interpretation of data, article draft and revising the manuscript critically for important intellectual content: ASO-E; Acquisition of data: OY, SK, BS; Conception and design of the study, drafting the manuscript, article draft and revising the manuscript critically for important intellectual content: NY.