|Year : 2018 | Volume
| Issue : 1 | Page : 44-50
Does growth hormone supplementation improve oocyte yield and pregnancy outcome in patients with poor ovarian reserve undergoing in vitro fertilization: A prospective randomized trial
Simrandeep Kaur, Nalini Mahajan
Department of Reproductive Medicine, Mother and Child Hospital, New Delhi, India
|Date of Web Publication||13-Feb-2018|
Mother and Child Hospital, D-59 Defence Colony, New Delhi - 110 024
Source of Support: None, Conflict of Interest: None
Context: Poor ovarian reserve (POR) results in poor ovarian response to controlled ovarian stimulation (COS) in in vitro fertilization (IVF) cycles. Despite various strategies, clinical pregnancy rates (PRs) remain low in patients with POR.
Aims: This study aims to assess if growth hormone (GH) supplementation in POR patients improves oocyte yield and PR in IVF-intracytoplasmic sperm injection (ICSI) cycles.
Settings and Design: Prospective, randomized controlled study.
Materials and Methods: Patients with anti-mullerian hormone ≤1.1 (ng/ml) and total antral follicle count ≤6 undergoing IVF-ICSI were enrolled in the study. Gonadotropin (GT) stimulation with GT-releasing hormone antagonist protocol was used for IVF. Patients were randomly divided into two groups: group A (n = 30) received recombinant GH 4 IU from the day of COS till the day of human chorionic gonadotropin trigger. Group B (n = 32) received COS and no GH.
Statistical Analysis Used: The unpaired t-test and Mann–Whitney test was used. Categorical variables were analyzed using either the Chi-square test or Fisher's exact test.
Results: Total dose of GT injections used were significantly less in GH group (Group A) compared to no GH group (Group B) (3000.89 ± 742.20), P = 0.009). There was no statistically significant difference in number of oocytes retrieved (OR), total days of stimulation, mean estradiol levels on the day of trigger and fertilization rates between the two groups. There was a nonsignificant increase in the clinical PR and chemical PR in the GH group.
Conclusions: GH cotreatment with antagonist protocol decreased the amount of GTs required for COS but did not improve the oocytes yield, fertilization or PR significantly in POR patients.
Keywords: Antagonist protocol, growth hormone, intra-cytoplasmic sperm injection, in vitro fertilization, poor ovarian reserve
|How to cite this article:|
Kaur S, Mahajan N. Does growth hormone supplementation improve oocyte yield and pregnancy outcome in patients with poor ovarian reserve undergoing in vitro fertilization: A prospective randomized trial. Onco Fertil J 2018;1:44-50
|How to cite this URL:|
Kaur S, Mahajan N. Does growth hormone supplementation improve oocyte yield and pregnancy outcome in patients with poor ovarian reserve undergoing in vitro fertilization: A prospective randomized trial. Onco Fertil J [serial online] 2018 [cited 2018 Sep 21];1:44-50. Available from: http://www.tofjonline.org/text.asp?2018/1/1/44/225411
| Introduction|| |
The main objective of individualization of treatment in in vitro fertilization (IVF) is to offer every couple the best treatment maximizing the chances of pregnancy. The number of oocytes retrieved (OR) after ovarian stimulation is related to the quantitative ovarian reserve, i.e., the quantity of oocytes remaining in the ovary at any given time, and has been related to pregnancy outcome., Although chronologic age is the most important predictor of both the qualitative and quantitative ovarian reserve, there is considerable variability in the timing of the female reproductive aging process., The incidence of poor ovarian response ranges from 9% to 24%, according to different studies.,
Antral follicle count (AFC) and anti-mullerian hormone (AMH) are the most sensitive markers of the functional ovarian reserve and predict poor response to ovarian stimulation during assisted reproductive techniques (ART) but do not prognosticate pregnancy, which is largely age-dependent., Celik et al. found that the AMH cutoff level ≤ 1.2 ng/mL had a 97.3% sensitivity, 31.3% specificity, 33.9% positive predictive value, and 96.9% negative predictive value for the identification of women at risk of poor response and cycle cancellation. Despite the use of different stimulation protocols clinical pregnancy rates (PRs) remain low in couples with poor ovarian reserve (POR). Several other strategies such as dehydroepiandrosterone and testosterone supplementation before IVF have been suggested to improve oocyte yield and pregnancy outcome; however, results are controversial., The addition of growth hormone (GH) as an adjuvant to stimulation protocols has also been advocated. GH enhances synthesis of insulin-like growth factor by regulating the effect of follicle-stimulating hormone on granulosa cells. GH plays a role in follicular development, estrogen synthesis, and oocyte maturation and also augments the effect of gonadotropins (GTs) on granulosa and theca cells.,,, Role of GH in improving IVF-intra-cytoplasmic sperm injection (ICSI) cycle outcome in poor responders is controversial owing to the limited number of studies with adequate number of participants or significant results. A 2003 Cochrane review suggested that GH role in IVF needed further research.
Aim of the study
The aim of the study was to assess if the addition of GH as an adjuvant treatment to the antagonist protocol in patients with poor reserve affects various outcomes of the IVF-ICSI cycle. Outcomes measured were total dose of GTs used, total days of stimulation required, serum estradiol (E2) levels on the day of human chorionic gonadotropin (hCG), number of OR, fertilization rate (FR), and PR.
| Materials and Methods|| |
Type of study
Randomized controlled, prospective study.
Ethics committee approval was obtained for the study.
Patients with AMH ≤1.1 ng/ml, total AFC ≤6 were included in the study.
Patients with severe endometriosis, severe male factor (oligoasthenoteratospermic OATS) and those who refused to enrolled in the study were excluded from the study.
Anti-mullerian hormone and antral follicle count measurement
AMH was measured by AMH gen 11 ELISA, (Beckman Coulter, Inc., High Wycombe, UK).
AFC was measured by a single operator. Counting all identifiable antral follicles of 2–10 mm in diameter by transvaginal transducer probe of 8 MHz using real-time two-dimensional imaging.
Patients were explained the treatment protocols in detail.
Written informed consent was taken from all the patients enrolled in the study.
Patients were randomly allocated into two groups (labeled A and B). Patients were randomly divided into two groups by disclosing the sealed envelopes before the start of stimulation: In all the patients, controlled ovarian stimulation (COS) was done with recombinant follicular stimulating hormone (FSH) and human menopausal gonadotropin (HMG) in a ratio of 2:1 and GT-releasing hormone (GnRH) antagonist was used to prevent the premature luteinizing hormone surge. Patients in Group A (n = 30) received recombinant GH 4 IU additionally while patients in Group B did not receive GH.
Patients and researcher were not blinded to the treatment protocol.
The GnRH antagonist protocol was given as follows: Flexible antagonist protocol was followed for the patients. All patients had a baseline scan on day 2 of menses. GT dose was individualized according to patient's age, AFC, AMH, and body mass index (BMI), with a starting dose ranging from 300 to 450 IU.
Recombinant FSH and HMG in a ratio of 2:1 were used for thefirst 5 days of COS as per our routine protocol for poor responders and changed to HMG only further till the day of ovulation trigger. Starting dose of GT varied between 300 IU – 450 IU based on age, BMI, AMH, and AFC dose was altered based on ovarian response after day 6 of COS. Recombinant FSH used was Gonal F (Recombinant follitropin alfa, Merck Serono, Germany) and HMG used was Menopur (Ferring pharmaceuticals, Saint-Prex, Switzerland). Monitoring of ovarian response was done by serial vaginal ultrasonography. When dominant follicles reached 14 mm in mean diameter, 0.25 mg/day of GnRH antagonist cetrorelix (Cetrolix, Intas pharmaceuticals Ltd., India) was started and continued till the day of trigger.
Group A patients received additional 4 IU of recombinant human GH (Zomacton, Ferring Pharmaceuticals, Saint-prex, Switzerland) from day 2 of the cycle along with GT injections till the day of hCG trigger. Ovulation was triggered with 10,000 IU of hCG injection given I/M (Fertigyn, Sun Rise International labs Ltd., Hyderabad, Telangana, India) when at least two follicles reached a mean diameter of 18 mm. Serum estradiol levels (E2), progesterone (P), were analyzed on the day of hCG trigger.
Oocyte retrieval was done 34–36 h after hCG injection under vaginal ultrasonography guidance using a 17-gauge needle. ICSI was performed on all the patients. Embryos transfer was done with soft embryo transfer (ET) catheter (Labotect, Gottingen, Germany) 48–72 h after oocytes retrieval. At most three embryos were transferred in each ET cycle and excess embryos were cryopreserved. Fertilization of oocytes was defined with the observation of two pronuclei 18–22 h after ICSI. Luteal phase support was started with injection micronized progesterone (injection Gestone, Ferring Pharmaceuticals, Saint-prex Switzerland) 50 mg IM on alternate days and Gestone 400 mg vaginal suppositories were administered twice daily.
The main outcomes of the study were as follows: Serum E2 levels on the day of hCG administration (trigger injection); mean number of OR, FR, total dose of GT injection used, number of days of stimulation, and reproductive outcomes such as chemical and clinical PR, miscarriage rate and ongoing PR.
Chemical pregnancy was defined as serum beta hCG (bhCG) >50 IU/ml 14-day post-ET. Clinical pregnancy was identified as observation of gestational sac by transvaginal ultrasonography performed 1 week after positive bhCG. Early miscarriage was defined as loss of pregnancy before 12-week gestation. Ongoing pregnancy was defined as pregnancy continuing beyond 12-week gestation.
Statistical analysis was performed by the SPSS statistical package (version 17.0; SPSS Inc., Chicago, IL, USA). Data were checked for normality before statistical analysis. Continuous variables are presented as mean ± standard deviation, and categorical variables are presented as absolute numbers and percentage. Normally distributed continuous variables were compared using the unpaired t-test, whereas the Mann–Whitney test was used for those variables that were not normally distributed. Categorical variables were analyzed using either the Chi-square test or Fisher's exact test. For all statistical tests, a P < 0.05 was taken to indicate a statistically significant difference.
| Results|| |
Our study included 62 patients who were randomized into two groups: Thirty patients were assigned to Group A and 32 patients to Group B. None of the patients were lost to follow-up and there was no cycle cancellation. No adverse effects of GH were observed.
Baseline characteristics of patients are displayed in [Table 1]; there was no difference observed between the two groups in Age, BMI, AMH levels, or AFCs.
Various outcomes of ICSI cycles are shown in [Table 2]. Total dose of GT injections used were significantly less in GH group (Group A) (mean dose, 2550.40 ± 578.74) compared to no GH patients (Group B) (mean dose 3000.89 ± 742.20, P = 0.009) while total days of stimulation were similar, 9.94 ± 1.88 vs. 9.50 ± 1.11, P = 0.402 [Table 2]. There were no statistically significant differences found in the number of OR and mean estradiol levels on the trigger day between the two groups [Table 2].
Although FR was higher in GH group (64.98 ± 31.41 vs. 57.97 ± 24.89), it did not differ significantly between the two groups [Table 2].
A total of nine patients in Group A had their embryos cryopreserved while in Group B, ten patients had cryopreserved embryos.
Chemical PR per cycle was little higher in GH group (42.9%, 13/30) versus 33.3% (11/32) but did not differ statistically [Table 3]. Clinical PR per cycle also did not differ statistically between the two groups (33.3% vs. 28%, P = 0.746) [Table 3].
Age-wise subgroup analysis between the two groups was also done as age can be a big confounding factor which can affect reproductive outcomes especially FR and pregnancy outcome.
Patients were divided into three groups; 21–30 years, 31–40 years, >40 years.
Frequency distribution of patients in each age group was similar between the two groups, P = 0.4813 [Table 4]. Maximum frequency of patients was in the age group 31–40 years, 66.7% and 71.1% in Group A and B, respectively [Table 4] and [Figure 1].
|Figure 1: Age-wise frequency distribution of patients between the two groups|
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Outcomes of ICSI cycle in 21–30 years of age is shown in [Table 5]. There was no significant differences in any of the cycle outcomes between the two groups.
|Table 5: Intracytoplasmic sperm injection cycle outcomes in 21–30 years of age group|
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[Table 6] shows cycle outcomes between 31 and 40 years of age. Maximum number of patients were in this age group in both groups. Total dose of gonadotroipns were significantly less in Group A compared to Group B, rest all parameters were similar between the two groups.
|Table 6: Intracytoplasmic sperm injection cycle outcomes in 31-40 years of age groups|
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[Table 7] shows cycle outcomes between >40 years of age. There was no significant differences in any of the cycle outcomes between the two groups.
|Table 7: Intracytoplasmic sperm injection cycle outcomes in >40 years of age group|
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For reproductive outcomes, the analysis was limited by the small numbers in each group. In 21–30 years of age group, 2 out of 3 in Group A and 2 out of 5 in Group B had a clinical pregnancy, showing no significant difference (P = 1.000) but the data was small for comparison.
Similarly, in 31–40 years of age group, 7 out of 20 (40%) in Group A and 6/23 (26.1%) had a clinical pregnancy, showing no significant difference (P = 0.788), but the limitation is small numbers in each group.
In age group >40 years, one patient had clinical pregnancy in both groups, but both of them landed in early miscarriage.
| Discussion|| |
The management for poor responders with diminished ovarian reserve is still a challenge. Poor responders with low ovarian reserve often fail to respond adequately despite the maximal dose of GTs administered, with the result that the number, as well as quality of oocytes harvested, may be very low. The limited number of eggs obtained is a problem for optimizing live birth rates as low number of OR results in fewer embryos for selection for transfer. Subsequently, these patients have lower PRs per transfer and lower cumulative PRs per started cycle compared with normal responders. Data from both human and animal studies suggest that GH play a critical role in the process of ovarian steroidogenesis and in the development of follicles. It is believed to play an important role in ovarian function, stimulating follicular development, estrogen production, and oocyte maturation. GH plays a facilitating role in ovulation by increasing the sensitivity of the GTs and decreasing the incidence of atresia in preovulatory follicles.,,
Kolibianakis et al. in 2009 in a meta-analysis, found that the addition of GH in poor responders undergoing COS with GnRH agonist and GTs for ART increases clinical pregnancy and live birth rates  but also concluded that the total number of patients analyzed was small, and thus, further RCTs are warranted to prove or disprove this finding.
Yu et al., in a meta-analysis in 2015 found that GH supplementation for IVF-ICSI in POR increases the probability of serum E2 level on the day of hCG, the number of M II oocyte, 2PN, and obtained embryos but GH addition does not increase implantation rate and clinical PRs. A recent study by Li et al., in 2017 in a meta-analysis showed that GH addition increased pregnancy and live birth rates. In the present study, we sought to find the effect of adding GH to the stimulation protocol in 62 patients with POR undergoing ICSI cycles using antagonist protocol. We found total dose of GT injections used were significantly less in GH group (Group A) (mean dose 2550.40 ± 578.74) compared to no GH group (Group B) (mean dose 3000.89 ± 742.20), P = 0.009) which is consistent with the results of Bassiouny et al., Kucuk et al., and of the European and Australian multicenter study, in which addition of GH led to a reduction in the GT dose and duration in hypogonadotropic hypogonadism patients.
There was no statistically significant difference in the total days of stimulation in the two groups in our study, (9.94 ± 1.88 vs. 9.50 ± 1.11, P = 0.402) while in a study by Bassiouny et al., there was a significant difference.
Similar to findings by Eftekhar et al., there was no statistically significant differences in the number of OR and mean estradiol levels on the trigger day between the two groups. This was in contrast to studies by Kucuk et al., and Bassiouny et al., who demonstrated a higher number of OR in GH group. It is possible that this could be due to the higher doses of GH used in their patients –12 IU and 8 IU, respectively. We used a dose of 4 IU which is similar to Eftekhar et al., as increased dose adds significantly to the cost. Eftekhar et al. and Bassiouny et al. found a significant increase in FR with the use of GH, but in our study, there was no statistical difference observed though FR was higher in GH group (64.89 vs. 57.97 respectively, P = 0.426). We did not find an increase in PR per cycle after addition of GH in our study, in this our findings are consistent with Eftekhar et al.,, Bassiouny et al., and meta-analysis by Yu et al.
We elected to do an age-wise analysis of the various outcomes as age is a major factor determining oocyte quality and hence various reproductive outcomes. So far no study using GH has reported an age-wise analysis. A maximum number of patients in our study were in 31–40 years of age group (66.7% and 71.9% in Group A and B, respectively), and total dose of GTs used were significantly less in GH group (Group A) compared to no GH group. In the 21–30 years of age group, there was no significant difference in cycle outcomes between the two groups; however, this could be attributed to the small numbers in this group – 10% patients in Group A and 15.6% patients in Group B were in this age group. The above 40 groups were also small and did not show a difference in any of the parameters studied. The major limiting factor of our study was the small numbers.
| Conclusions|| |
This study showed that GH co-treatment with the antagonist protocol in patients with poor reserve undergoing IVF-ICSI cycles significantly decreased the amount of GTs required for COS but did not significantly improve the number of oocytes collected, the number of fertilized oocytes, and the PR per cycle. Use of GH as an adjuvant treatment in IVF-ICSI cycles in patients with poor reserve should be treated prudently till larger studies and more meta-analyses are available as it also adds to the cost of the cycle.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
La Marca A, Sunkara SK. Individualization of controlled ovarian stimulation in IVF using ovarian reserve markers: From theory to practice. Hum Reprod Update 2014;20:124-40.
Broekmans FJ, de Ziegler D, Howles CM, Gougeon A, Trew G, Olivennes F, et al.
The antral follicle count: Practical recommendations for better standardization. Fertil Steril 2010;94:1044-51.
Bancsi LF, Broekmans FJ, Eijkemans MJ, de Jong FH, Habbema JD, te Velde ER, et al.
Predictors of poor ovarian response in in vitro
fertilization: A prospective study comparing basal markers of ovarian reserve. Fertil Steril 2002;77:328-36.
Broekmans FJ, Kwee J, Hendriks DJ, Mol BW, Lambalk CB. A systematic review of tests predicting ovarian reserve and IVF outcome. Hum Reprod Update 2006;12:685-718.
te Velde ER, Scheffer GJ, Dorland M, Broekmans FJ, Fauser BC. Developmental and endocrine aspects of normal ovarian aging. Mol Cell Endocrinol 1998;145:67-73.
Bassiouny YA, Dakhly DMR, Bayoumi YA, Hashish NM. Does the addition of growth hormone to the in vitro
fertilization/intracytoplasmic sperm injection antagonist protocol improve outcomes in poor responders? A randomized, controlled trial. Fertil Steril 2016;105:697-702.
Surrey ES, Schoolcraft WB. Evaluating strategies for improving ovarian response of the poor responder undergoing assisted reproductive techniques. Fertil Steril 2000;73:667-76.
Jayaprakasan K, Campbell B, Hopkisson J, Johnson I, Raine-Fenning N. A prospective, comparative analysis of anti-Müllerian hormone, inhibin-B, and three-dimensional ultrasound determinants of ovarian reserve in the prediction of poor response to controlled ovarian stimulation. Fertil Steril 2010;93:855-64.
Celik H, Bıldırcın D, Güven D, Cetinkaya MB, Alper T, Batuoǧlu AS, et al.
Random anti-Müllerian hormone predicts ovarian response in women with high baseline follicle-stimulating hormone levels: Anti-Müllerian hormone in poor responders in assisted reproductive treatment. J Assist Reprod Genet 2012;29:797-802.
Wiser A, Gonen O, Ghetler Y, Shavit T, Berkovitz A, Shulman A, et al.
Addition of dehydroepiandrosterone (DHEA) for poor-responder patients before and during IVF treatment improves the pregnancy rate: A randomized prospective study. Hum Reprod 2010;25:2496-500.
Kolibianakis EM, Venetis CA, Tarlatzis BC. DHEA administration in poor responders. Hum Reprod 2011;26:730-1.
Kucuk T, Kozinoglu H, Kaba A. Growth hormone co-treatment within a gnRH agonist long protocol in patients with poor ovarian response: A prospective, randomized, clinical trial. J Assist Reprod Genet 2008;25:123-7.
Eftekhar M, Aflatoonian A, Mohammadian F, Eftekhar T. Adjuvant growth hormone therapy in antagonist protocol in poor responders undergoing assisted reproductive technology. Arch Gynecol Obstet 2013;287:1017-21.
Bachelot A, Monget P, Imbert-Bolloré P, Coshigano K, Kopchick JJ, Kelly PA, et al.
Growth hormone is required for ovarian follicular growth. Endocrinology 2002;143:4104-12.
Mendoza C, Ruiz-Requena E, Ortega E, Cremades N, Martinez F, Bernabeu R, et al.
Follicular fluid markers of oocyte developmental potential. Hum Reprod 2002;17:1017-22.
Harper K, Proctor M, Hughes E. Growth hormone for in vitro
fertilization. Cochrane Database Syst Rev 2003;3:CD000099.
Kim CH. Strategies for poor responders in IVF cycles. Reprod Syst Sex Disord 2001;S5:001.
Ubaldi F, Vaiarelli A, D'Anna R, Rienzi L. Management of poor responders in IVF: Is there anything new? Biomed Res Int 2014;2014:352098.
Adashi EY, Resnick CE, D'Ercole AJ, Svoboda ME, Van Wyk JJ. Insulin-like growth factors as intraovarian regulators of granulosa cell growth and function. Endocr Rev 1985;6:400-20.
Erickson GF, Garzo VG, Magoffin DA. Insulin-like growth factor-I regulates aromatase activity in human granulosa and granulosa luteal cells. J Clin Endocrinol Metab 1989;69:716-24.
Hull KL, Harvey S. Growth hormone: Roles in female reproduction. J Endocrinol 2001;168:1-23.
Mason HD, Martikainen H, Beard RW, Anyaoku V, Franks S. Direct gonadotrophic effect of growth hormone on oestradiol production by human granulosa cells in vitro
. J Endocrinol 1990;126:R1-4.
Kolibianakis EM, Venetis CA, Diedrich K, Tarlatzis BC, Griesinger G. Addition of growth hormone to gonadotrophins in ovarian stimulation of poor responders treated by in-vitro
fertilization: A systematic review and meta-analysis. Hum Reprod Update 2009;15:613-22.
Yu X, Ruan J, He LP, Hu W, Xu Q, Tang J, et al.
Efficacy of growth hormone supplementation with gonadotrophins in vitro
fertilization for poor ovarian responders: An updated meta-analysis. Int J Clin Exp Med 2015;8:4954-67.
Li XL, Wang L, Lv F, Huang XM, Wang LP, Pan Y, et al.
The influence of different growth hormone addition protocols to poor ovarian responders on clinical outcomes in controlled ovary stimulation cycles: A systematic review and meta-analysis. Medicine (Baltimore) 2017;96:e6443.
Cotreatment with growth hormone and gonadotropin for ovulation induction in hypogonadotropic patients: A prospective, randomized, placebo-controlled, dose-response study. European and Australian Multicenter Study. Fertil Steril 1995;64:917-23.
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7]