The effect of adding exogenous LH to IVF/ICSI cycles on pregnancy outcomes in elderly women with PCOS: a retrospective cohort study

doi:10.21203/rs.3.rs-2108106/v2

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The effect of adding exogenous LH to IVF/ICSI cycles on pregnancy outcomes in elderly women with PCOS: a retrospective cohort study

https://doi.org/10.21203/rs.3.rs-2108106/v2

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Background

Current findings on the necessity of adding exogenous luteinizing hormone (LH) to IVF/ICSI cycles in elderly women(≥ 35 years) with Polycystic ovary syndrome（PCOS）are controversial. This study investigated the clinical efficacy of adding exogenous LH to antagonist regimens in IVF/ICSI-assisted conception cycles for elderly patients with PCOS.

Methods

Clinical data of PCOS patients who underwent IVF/ICSI-assisted conception at Reproductive and Genetic Center, Affiliated Hospital of Shandong University of Traditional Chinese Medicine， between January 1, 2018, and April 30, 2022, were collected for retrospective cohort analysis. Groups 1 (exogenous follicle-stimulating hormone (FSH) only, n = 170) and 2 (exogenous FSH and LH, n = 265) were divided according to whether exogenous LH was added to the gonadotropin-releasing hormone antagonist (GnRH-ant) regimen. controlled ovarian hyperstimulation (COH) and conception outcomes were compared between the two groups， and binary logistic regression analysis was used to examine the association between the addition of exogenous LH and pregnancy outcome.

Results

The number of follicles ≥ 14 mm on trigger day（12.70±8.56 vs 11.08±6.84，P=0.025）, eggs obtained（13.28±9.02 vs 11.31±6.03，P=0.003）, fertilized eggs（10.79±7.87 vs 10.02±5.75，P=0.047）, normally fertilized eggs（8.07±6.47 vs 6.84±4.53，P=0.005）, and high-quality embryos（1.62±2.10 vs 1.01±1.41，P＜0.001）, and the cumulative clinical pregnancy rate（65.9% vs 49.1%，P=0.001）were significantly higher in group 1 than in group 2 (P < 0.05). The binary logistic regression indicated that adding exogenous LH was an independent risk factor for cumulative clinical pregnancy rate (OR = 2.024, P = 0.001).

Conclusion

For most elderly women with PCOS, particularly those with body mass index (BMI) < 25 kg/m2, the addition of exogenous LH during IVF/ICSI cycles resulted in decreased efficacy in assisted conception outcomes.

Advanced age

PCOS

r-HLH

HMG

GnRH-ant regimen

Polycystic ovary syndrome (PCOS)-related ovulation disorders are among the most prevalent causes of clinical infertility^[1]. In vitro fertilization (IVF) / intracytoplasmic single sperm injection (ICSI)-embryo transfer (ET) has been a boon for women who have tubal problems or male infertility. The average age of marriage for modern women is gradually increasing as society advances, but it is an accepted fact that women's fertility declines with age. The decrease in oocyte quality and embryonic potential due to aging and the increase in the incidence of aneuploidy are limiting factors for the success of IVF/ICSI in women of advanced age^[2]^-^[3].

In the early follicular phase, LH acts on follicular membrane cells and increases E2 production by granulosa cells by promoting androgen synthesis, which enhances the sensitivity of granulosa cells to FSH, thus improving ovarian responsiveness. During the natural cycle, the frequency of pulsatile luteinizing hormone (LH) secretion spikes during ovulation, initiating ovulation-related signaling pathways, follicle rupture, and oocyte discharge^[4]. Elevated LH concentrations are a common endocrine feature of PCOS^[5]^-^[6]. In PCOS, elevated endogenous LH levels result in a disrupted normal the hypothalamic–pituitary–adrenal axis (HTPA axis) and a decrease in follicle-stimulating hormone (FSH) levels, which manifests as impaired follicular development. In IVF/ICSI cycles with controlled ovarian hyperstimulation, the use of gonadotropin-releasing hormone antagonists (GnRH-ant) in late follicular phase prevents a premature LH surge, resulting in significantly lower LH levels than in natural cycles^[7]^-^[8]. However, the low LH level also raises concerns that pregnancy outcomes will not be optimal. In a retrospective analysis, women with a sustained serum LH of ≤ 0.8 mIU/mL were 1.55 times more likely to experience early pregnancy loss during ovulation-only cycles with recombinant FSH (r-FSH)^[9]. Another randomized controlled trial showed that trigger day serum LH ≤ 1.6 mIU/mL was associated with lower rates of sustained pregnancy and live births and increased rates of early miscarriage^[10]. Low serum LH levels can be corrected by adding exogenous LH^[11]. Some studies suggested that exogenous LH can induce an early endogenous LH peak before egg maturation, helping oocyte maturation, saving treatment costs, and is beneficial for women with poor ovarian response or repeated implantation failures^[12]^-^[13]. The 2011 Asia-Pacific Expert Consensus recommends the addition of recombinant-human luteinizing hormone (r-HLH) 6–8 days after Gn initiation for women with poor ovarian response in the previous cycle, especially for women aged >35 years with poor ovarian response^[14]. However, the results of studies about the necessity of increasing exogenous LH activity during IVF/ICSI cycles in older women with PCOS are inconclusive. Considering that the elderly PCOS patients usually show different endocrine characteristics and ovarian responses compared with other elderly patients, the previous study on the impact of adding exogenous LH in the IVF/ICSI cycle on the cycle outcome may not be applicable to this part of the population.This study examined the clinical efficacy of adding exogenous LH to antagonist regimens in advanced age (≥ 35 years) PCOS patients in IVF/ICSI-assisted conception cycles.

Patient selection

The clinical data of elderly PCOS patients who underwent IVF/ICSI-ET assisted conception at the Reproductive and Genetic Center of the Affiliated Hospital of Shandong University of Traditional Chinese Medicine between January 1, 2018, and April 30, 2022, were selected. The retrospective analysis of the study was approved by the hospital's reproductive medicine ethics committee. The patients provided informed consent.

Inclusion criteria were as follows: (1) female with PCOS^[15]; (2) age ≥ 35 years; (3) tubal or male factor; (4) GnRH-ant regimen; (5) signed informed consent; and (6) complete follow-up. Exclusion criteria were as follows: (1) patients having combined endometriosis or other reproductive disorders; (2) patients having other major diseases unsuitable for fertility; (3) chromosomal abnormalities in either spouse; (4) uterine malformations；(5) donor cycles; (6) Preimplantation genetic testing (PGT) was performed.

Study design

Groups 1 (exogenous FSH only, n = 170) and 2 (exogenous FSH with exogenous LH, n = 265) were divided according to whether exogenous LH was added to the GnRH-ant regimen, and binary logistic regression analysis was used to investigate the association between the addition of exogenous LH and pregnancy outcome. Groups 1 (exogenous follicle-stimulating hormone (FSH) only, n = 170) and 2 (exogenous FSH and LH, n = 265) were divided according to whether exogenous LH was added to the gonadotropin-releasing hormone antagonist (GnRH-ant) regimen, and binary logistic regression analysis was used to examine the association between the addition of exogenous LH and pregnancy outcome. Furthermore, subgroup analysis was performed on the clinical data of the group 2. Group 2A (recombinant-human luteinizing hormone, n = 30) and 2B (human menopausal gonadotropin(HMG) for injection, n = 235) were classified by exogenous LH additive type. Group 2C (75 u, n = 149) and 2D (150 u, n = 116) were classified by the additive amount of exogenous LH. Group 2E (exogenous LH added on Gonadotropins(Gn) initiation day, n = 137) and 2F (exogenous LH added after Gn initiation day, n = 128) were classified by whether exogenous LH was added on Gn initiation day one . The controlled ovarian hyperstimulation (COH) and conception outcomes were compared between the two groups. Since body mass index (BMI) is known to be an important factor influencing IVF/ICSI cycle outcome, this study divided subgroups by BMI 25 kg/m2, and further sensitivity analysis was performed on the results of group 1 vs. group 2 for group L (BMI < 25 kg/m2): subgroups L1 (exogenous FSH applied only, n = 117), and L2 (exogenous FSH with exogenous LH, n = 162); group H (BMI ≥ 25 kg/m2): subgroups H1 (exogenous FSH applied only, n = 53), and H2 (exogenous FSH with exogenous LH, n = 103).

Treatment protocols

All patients were examined on day two of the menstrual cycle for basal reproductive endocrinology and transvaginal ultrasonography, and treatment was initiated according to the patient's age, BMI, ovarian reserve, and follicle size. A total of 150~225 IU of r-FSH beta injection (r-FSH, Puregon®, 600 IU, Merck Sharp & Dohme) was administered daily in group 1, and the dose was adjusted according to the follicular development every 2~4 days until the trigger day. HMG (75u, Shanghai Livzon, China) or r-HLH alpha injection (r-HLH, Luveris®, 75 IU Merck KgaA) was used in addition to r-FSH until the trigger day in group 2. The follicular and sex hormone levels were tested every 2–4 days to adjust the dosage flexibly. When the dominant follicle reached 12–14 mm on ultrasound, 0.25 mg/d of ganirelix acetate (ORGALUTRAN®, 0.25 mg, Merck Sharp & Dohme) was administered subcutaneously until trigger day. When the target follicle reached 18 mm, 4000~10000 IU of recombinant human chorionic gonadotropin (HCG, 2000 IU, Zhuhai Livzon, China) injection with 0.1~0.2 mg of treprostinil acetate injection (Diphereline®, 0.1 mg, Ferring) was given at 9:00 pm, followed by ultrasound-guided egg harvesting 34~36 h later, followed by IVF or ICSI in men with severe oligo- and hypospermia. Embryo transfer was done after 3 d of embryo culture. The whole embryo was frozen if any of the following conditions were observed and transferred at a later date: (1) endometrial thickness ≤ 6 mm or ≥ 15 mm on the trigger date or endometrial polyps and cavity effusion; (2) progesterone ≥ 2 ng/ml on the trigger date; (3) estradiol ≥ 4800 pg/mL on the trigger date; (4) the number of eggs retrieved ≥ 15 and suspected tendency of ovarian hyperstimulation. Progesterone injection and oral dydrogesterone tablets were given for luteal support after transplantation and continued if blood β-hCG > 25 mIU/mL was detected on day 14 after transplantation. A gestational sac observed by transvaginal ultrasound 28~35 d after transplantation was considered a clinical pregnancy.

Statistical analysis

The data were processed with the software SPSS 25.0. The measurement data were expressed as mean ± standard deviation (SD). Student's t-test, analysis of variance, and Fisher's exact test were conducted to determine the differences between sample sizes. The count data were selected to perform the Chi-square (χ2) for rates. P < 0.05 was considered statistically significant.

Comparison of baseline information

We screened the clinical data of 4332 infertile women and included the clinical data of 435 elderly women with PCOS in this study, including 170 cases in group 1 and 265 cases in group 2 (Figure 1 ). There were no statistically significant differences between the two groups regarding age, type, and years of infertility, factors contributing to pregnancy, BMI, basal endocrine characteristics, and the number of sinus follicles (P > 0.05). There were also no statistically significant differences in baseline information in the subgroups divided by different dosage forms of LH, subgroups divided by the first additive amount, the timing of LH addition, and BMI = 25 kg/m2, as shown in Table 1. The comparison of basic data among subgroups is as shown in Supplementary Information.

Table 1 Comparison of demographic characteristics of the two groups

	Group 1（n=170）	Group 2（n=265）	P
Age	37.42±2.28	37.84±2.64	0.344
Years of infertility	4.15±3.43	3.95±3.24	0.497
Primary infertility	40(23.5%)	63(23.8%)	0.953
Infertility Factors
Fallopian tube factors	165(97.1%)	251(94.7%)	0.244
Male factor	27(15.9%)	53(20.0%)	0.279
Fallopian tube combined with male factor	23(13.5%)	42(15.8%)	0.508
BMI（Kg/m2）	23.80±3.72	24.64±4.01	0.286
FSH（mIU/ml）	7.11±1.75	7.04±2.17	0.067
LH（mIU/ml）	7.76±5.05	7.73±4.90	0.514
LH/FSH	1.15±0.80	1.21±0.91	0.113
E2(pg/ml)	37.89±7.36	37.90±7.37	0.937
P(ng/ml)	0.40±0.15	0.41±0.16	0.816
T(ng/ml)	0.66±0.27	0.68±0.30	0.154
AMH(ng/ml)	6.35±2.42	6.11±1.82	0.091
AFC	32.72±13.29	31.40±10.48	0.062

Note: All the above hormone levels are basal endocrine levels on the 2nd day of menstruation.

BMI Body Mass Index, FSH Follicle Stimulating Hormone, LH Luteinizing Hormone,E2 Estradiol，P Progesterone,T Testosterone,AMH Anti-Mullerian bormone,AFC Antral Follicle Count

Comparison of assisted conception outcome indicators

Table 2 depicts the clinical outcome characteristics of IVF/ICSI cycles in both groups 1 and 2. No significant differences were seen between the two groups in terms of reproductive endocrine hormone levels on trigger day, the number of cleaved embryos and transferable embryos, the incidence of mild and moderate to severe ovarian hyperstimulation syndrome (OHSS), and fresh cycle embryo transfer rate (P ≥ 0.05). However, the number of follicles ≥ 14 mm on trigger day (12.70 ± 8.56 vs. 11.08 ± 6.84, P = 0.025), the number of eggs obtained (13.28 ± 9.02 vs. 11.31 ± 6.03, P = 0.003), the number of fertilized eggs (10.79 ± 7.87 vs. 10.02 ± 5.75, P = 0.047), the number of normally fertilized eggs ( 8.07 ± 6.47 vs. 6.84 ± 4.53, P = 0.005), number of high-quality embryos (1.62 ± 2.10 vs. 1.01 ± 1.41, P < 0.001), and cumulative clinical pregnancy rate (65.9% vs. 49.1%, P = 0.001) in group 1 were significantly higher than those in group 2.

Table 2 Comparison of outcome indicators of assisted conception between the two groups

	Group 1（n=170）	Group 2（n=265）	P
Number of follicles ≥14mm on trigger day	12.70±8.56	11.08±6.84	0.025
Number of eggs obtained	13.28±9.02	11.31±6.03	0.003
Trigger day LH(mIU/mL)	3.02±2.51	2.93±2.18	0.119
Trigger day E2(pg/ml)	3108.89±1508.35	3143.74±1434.85	0.261
Trigger day P(ng/ml)	1.28±0.65	1.24±0.91	0.218
Number of fertilized eggs	10.79±7.87	10.02±5.75	0.047
Normal fertilized eggs count	8.07±6.47	6.84±4.53	0.005
Number of cleavage embryos	8.91±7.18	6.90±5.35	0.052
Number of embryos available for transfer	3.96±3.08	3.54±2.47	0.147
Number of good quality embryos	1.62±2.10	1.01±1.41	＜0.001
Incidence of mild OHSS (%)	5.9%(10/170)	2.3%(6/265)	0.067
Incidence of moderate to severe OHSS (%)	0	0.4%(1/265)	0.999
Fresh embryo transfer rate (%)	48.2%(82/170)	42.6%(113/225)	0.252
Cumulative clinical pregnancy rate (%)	65.9%(112/170）	49.1%(130/265)	0.001

Note: LH Luteinizing Hormone,E2 Estradiol，P Progesterone

The 265 cycles with the addition of exogenous LH source in group 2 were selected for subgroup analysis. The number of ≥ 14 mm follicles on trigger day, hormone levels on trigger day, number of eggs obtained, fertilized eggs, normally fertilized eggs, cleaved embryos, transferable embryos, and good quality embryos, and incidence of mild and moderate-to-severe OHSS incidence, fresh cycle embryo transfer rate, and cumulative clinical pregnancy rate were not significantly different (P ≥ 0.05)(Table 3,Table 4, Table 5).

Table 3 Comparison of outcome indicators of assisted conception between the two groups

	Group 2A（n=30）	Group 2B（n=235）	P
Number of follicles ≥14mm on trigger day	12.00±7.51	10.96±6.76	0.489
Number of eggs obtained	11.63±6.55	11.27±5.98	0.430
Trigger day LH(mIU/mL)	2.65±1.50	2.96±2.26	0.108
Trigger day E2(pg/ml)	2880.12±1525.90	3177.39±1422.73	0.538
Trigger day P(ng/ml)	1.08±0.61	1.26±0.94	0.507
Number of fertilized eggs	10.47±6.06	9.96±5.72	0.559
Normal fertilized eggs count	7.43±5.06	6.77±4.46	0.837
Number of cleavage embryos	7.47±5.75	6.83±5.30	0.773
Number of embryos available for transfer	3.50±2.54	3.55±2.47	0.558
Number of good quality embryos	0.90±1.00	1.03±1.46	0.440
Incidence of mild OHSS (%)	0	2.1%(5/235)	0.999
Incidence of moderate to severe OHSS (%)	0	0.4%(1/235)	0.999
Fresh embryo transfer rate (%)	46.7%(14/30)	42.1%(99/235)	0.636
Cumulative clinical pregnancy rate (%)	53.3%(16/30)	48.5%(114/235)	0.619

Note: LH Luteinizing Hormone,E2 Estradiol，P Progesterone

Table 4 Comparison of outcome indicators of assisted conception between the two groups

	2C组（n=149)	2D组（n=116）	P
Number of follicles ≥14mm on trigger day	10.82±6.20	11.41±7.60	0.480
Number of eggs obtained	11.25±5.61	11.39±6.56	0.721
Trigger day LH(mIU/mL)	2.97±2.22	2.87±2.15	0.693
Trigger day E2(pg/ml)	3017.89±1413.96	3305.39±1451.35	0.328
Trigger day P(ng/ml)	1.19±0.72	1.30±1.11	0.146
Number of fertilized eggs	10.11±5.24	9.90±6.36	0.389
Normal fertilized eggs count	6.93±4.24	6.73±4.89	0.316
Number of cleavage embryos	7.07±5.10	6.67±5.66	0.257
Number of embryos available for transfer	3.60±2.49	3.47±2.46	0.503
Number of good quality embryos	1.02±1.26	1.00±1.59	0.488
Incidence of mild OHSS (%)	0.7%(1/149)	4.3%(5/116)	0.089
Incidence of moderate to severe OHSS (%)	0	0.9%(1/116)	0.438
Fresh embryo transfer rate (%)	41.6%(62/149)	44.0%(51/116)	0.701
Cumulative clinical pregnancy rate (%)	50.3%(75/149)	47.4%(55/116)	0.637

Note: LH Luteinizing Hormone,E2 Estradiol，P Progesterone

Table 5 Comparison of outcome indicators of assisted conception between the two groups

	2E组（n=137）	2F组（n=128)	P
Number of follicles ≥14mm on trigger day	10.74±7.42	11.44±6.17	0.447
Number of eggs obtained	11.12±5.94	11.52±6.14	0.814
Trigger day LH(mIU/mL)	2.86±1.94	3.00±2.42	0.244
Trigger day E2(pg/ml)	3049.58±1471.82	3244.52±1392.89	0.388
Trigger day P(ng/ml)	1.26±0.94	1.22±0.89	0.634
Number of fertilized eggs	9.73±5.34	10.33±6.17	0.662
Normal fertilized eggs count	6.90±4.46	6.78±4.62	0.755
Number of cleavage embryos	6.81±5.29	6.99±5.43	0.460
Number of embryos available for transfer	3.57±2.46	3.52±2.50	0.645
Number of good quality embryos	1.12±1.60	0.90±1.17	0.081
Incidence of mild OHSS (%)	2.2%(3/137)	2.3%(3/128)	0.975
Incidence of moderate to severe OHSS (%)	0.7%(1/137)	0	0.458
Fresh embryo transfer rate (%)	40.9%(56/137)	44.5%(57/128)	0.548
Cumulative clinical pregnancy rate (%)	48.9%(67/137)	49.2%(63/128)	0.959

Note: LH Luteinizing Hormone,E2 Estradiol，P Progesterone

Among the subgroups divided by BMI, the L1 group had follicles ≥ 14 mm on trigger day (13.05 ± 8.61 vs. 11.06 ± 7.10, P = 0.015), the number of eggs obtained (13.92 ± 9.05 vs. 11.47 ± 5.94, P = 0.002), the number of fertilized eggs (11.32 ± 7.66 vs. 10.07 ± 5.72, P = 0.025), number of normally fertilized eggs (8.72 ± 6.54 vs. 6.80 ± 4.43, P = 0.001), number of cleavage embryos (9.32 ± 6.60 vs. 6.90 ± 5.28, P = 0.028), number of good quality embryos (1.81 ± 2.16 vs. 0.96 ± 1.35, P = 0.001), and cumulative clinical pregnancy rate (68.4% vs. 49.4%, P = 0.002) were significantly higher than those in the L2 group, with no significant differences in trigger-day hormone levels, number of transferable embryos, the incidence of mild and moderate-to-severe OHSS, and fresh cycle embryo transfer rates between the two subgroups (P ≥ 0.05). Trigger-day LH was significantly higher in the H1 group than in the H2 group (3.86 ± 2.80 vs. 3.08 ± 2.03, P = 0.002). There was no significant difference between the two subgroups in the number of ≥14 mm follicles on trigger day, Estradiol(E2) and Progesterone(P) on trigger day, number of eggs obtained, fertilized eggs, normally fertilized eggs, cleaved embryos, transferable embryos, and high-quality embryos, and fresh cycle embryo transfer rate, along with cumulative clinical pregnancy rate (P ≥ 0.05)(Table 6 ).

Table 6 Comparison of assisted conception outcome indicators among the four subgroups

	L1组（n=117）	L2组（n=162）	H1组（n=53）	H2组（n=103）	P
Number of follicles ≥14mm on trigger day	13.05±8.61	11.04±7.10*	11.92±8.49	11.14±6.44	L=0.015，H=0.736
Number of eggs obtained	13.92±9.05	11.47±5.94*	11.87±8.88	11.06±6.19	L=0.002，H=0.606
Trigger day LH(mIU/mL)	2.64±2.29	2.83±2.27	3.86±2.80	3.08±2.03**	L=0.812，H=0.015
Trigger day E2(pg/ml)	3223.32±1515.45	3326.05±1385.05	2858.44±1475.90	2857.00±1471.34	L=0.115，H=0.937
Trigger day P(ng/ml)	1.32±0.61	1.32±1.00	1.18±0.73	1.11±0.73	L=0.107，H=0.84
Number of fertilized eggs	11.32±7.66	10.07±5.72*	9.60±8.28	9.93±5.82	L=0.025，H=0.757
Normal fertilized eggs count	8.72±6.54	6.80±4.43*	6.64±6.11	6.90±4.70	L=0.001，H=0.892
Number of cleavage embryos	9.32±6.60	6.90±5.28*	8.02±8.33	6.90±5.48	L=0.028，H=0.662
Number of embryos available for transfer	4.30±2.97	3.50±2.38	3.21±3.21	3.61±2.62	L=0.116，H=0.721
Number of good quality embryos	1.81±2.16	0.96±1.35*	1.19±1.91	1.09±1.50	L＜0.001，H=0.16
Incidence of mild OHSS (%)	6.8%(8/117)	3.1%(5/162)	3.8%(2/53)	1.0%(1/103)	L=0.160，H=0.266
Incidence of moderate to severe OHSS (%)	0	0.6%(1/162)	0	0	L=0.999，H=0.999
Fresh embryo transfer rate (%)	47.9%(56/117)	42.0%(68/162)	49.1%(26/53)	43.7%(45/103)	L=0.329，H=0.524
Cumulative clinical pregnancy rate (%)	68.4%(80/117)	49.4%(80/162)*	60.4%(32/53)	48.5%(50/103)	L=0.002，H=0.161

Note:* Compared with the L1 group, P < 0.05, ** Compared with the H1 group, P < 0.05

Binary logistic regression analysis

A binary logistic regression model was used to determine whether adding exogenous LH had a greater effect on cumulative clinical pregnancy rates than r-FSH alone. The concurrent analysis included variables such as age, BMI, AMH, AFC, and LH/FSH that may influence pregnancy outcomes. Results suggested that adding LH is an independent risk factor for cumulative clinical pregnancy rates(Table 7).

Table 7 Results of binary logistic regression analysis

	Cumulative clinical pregnancy rate (%) OR	95% confidence interval	P
Age	0.936	[0.865,1.013]	0.101
BMI	1.01	[0.960,1.062]	0.712
AMH	0.934	[0.824,1.058]	0.283
AFC	1.003	[0.980,1.027]	0.780
LH/FSH	1.267	[0.980,1.639]	0.071
Group	2.024	[1.347,3.041]	0.001

At present, this study is the first study to explore the effect of exogenous LH addition on IVF/ICSI cycle outcome of elderly PCOS women. The clinical data of 435 elderly women with PCOS were included in this study. Asia-Pacific Expert Consensus 2011 recommends the addition of r-HLH for women aged >35 years with poor ovarian response^[14]. Previous studies have shown that exogenous LH supplementation increases the number of mature oocytes, high-quality fertilized eggs, and embryos and achieves higher implantation rates in the entire population compared to exogenous FSH alone^[16]^-^[17]. Two randomized controlled trials reported no significant differences in the number of eggs gained, the rate of fertilization, miscarriage, clinical pregnancy, or live birth in the r-FSH group compared to the exogenous LH supplementation in the ≥ 35-year-old group^[18]^-^[19]. However, these studies did not consider the endocrine characteristics of different populations.

The high LH levels were associated with the endocrine profile of PCOS patients^[20]^-^[21]. High insulin growth factor levels promote LH receptor expression^[22]^-^[23] and the presence of GnRH receptor-activating autoantibodies (GnRHR-AAb) in the body causes chronic stimulation of the GnRH receptor (GnRHR) in PCOS^[24]^-^[25]^. The addition of GnRH-ant counteracts the early LH peak to some extent and significantly reduces the incidence of OHSS, which is now widely used in IVF/ICSI cycles in PCOS patients. PCOS patients have higher AMH than the general population.A retrospective analysis showed that for women with anti-mullerian hormone (AMH) ≥ 5 μg/L, there was no difference in ovarian response and pregnancy outcome with exogenous LH supplementation in the GnRH-ant regimen^[26]. This suggests that it may not be necessary to add exogenous LH to the IVF/ICSI cycle of PCOS patients.

First, we found that the number of follicles ≥14 mm on trigger day, eggs obtained, fertilized eggs, normally fertilized eggs, and high-quality embryos, and the cumulative clinical pregnancy rate were significantly higher in group 1 than in group 2. Binary logistic regression analysis showed that the addition of LH was an independent risk factor affecting the cumulative clinical pregnancy rate. It is speculated that this may be related to the serum LH level after adding exogenous LH. In the natural cycle and ovulation induction cycle, there are LH receptors in the dominant follicles, and the LH concentration needs to be maintained at a certain threshold to meet the normal development of follicles until ovulation. Raffaella Depalo et al. believed that if the serum LH level was higher than the upper limit of the LH window, high concentration of LH would stimulate theca cells to continuously produce androgen, leading to follicular development stagnation in the small sinus follicle stage, stopping the continued division, premature luteinization, follicular growth stop or even atresia^[27].It has been previously shown that premature elevation of LH levels in the follicular phase can lead to premature follicular luteinization affecting oocyte quality^[28]^-^[29]. Nonetheless, the early addition of antagonists can stabilize LH levels in PCOS patients to improve pregnancy outcomes^[30]. Although the use of GnRH-ant in this study did not result in differences in LH between the two groups on the trigger day, this may be because the overall effect of exogenous LH supplementation on COH in elderly PCOS patients remains negative, and higher LH levels in vivo during the follicular phase induce eggs to mature. Moreover, premature maturation of the dominant follicle hinders the simultaneous null development of multiple follicles, as evidenced by a decrease in the number of eggs obtained, fertilization, and embryo quality.

In addition, we found that there was no effect of additive form in subgroup 2A/2B, the first additive amount of LH in subgroup 2C/2D, and the timing of the first addition of LH in subgroup 2E/2F on the outcome index of the assisted conception cycle. This indicated that there was no difference on dosage form, whether to add on the initiation day and the dose of exogenous LH in the Gn cycle. However, this conclusion may be related to the small sample size of this study and must be confirmed with a larger sample. In this study, we found that the number of follicles ≥ 14 mm on trigger day, fertilized eggs, normally fertilized eggs, cleaved embryos, and high-quality embryos, and the cumulative clinical pregnancy rate were significantly lower in group L2 than in group L1, indicating that the addition of exogenous LH leads to a decrease in fertility outcomes in non-obese PCOS women with BMI < 25 kg/m2. In contrast, the addition of exogenous LH in group H2 showed a decrease in LH levels only on trigger day (3.08 ± 2.03 vs. 3.86 ± 2.80, P = 0.002). Therefore, it is speculated that PCOS women with BMI < 25 kg/m2 were sensitive to exogenous LH supplementation.

However, this study has certain limitations: (1) This may also be related to the fact that this study is retrospective analysis and the sample size is small, and there may be selective bias. Therefore, it is necessary to carry out multicenter randomized controlled trials to verify these findings; (2) Various types of elderly PCOS women were included in this study. They may have differences in Gn reactivity, which affects the final outcome; (3) Lack of discussion on live birth rate, pregnancy disease rate and birth defect rate of offspring. Therefore, it is necessary to conduct a more comprehensive and rigorous experimental design and data to further confirm the conclusions in this study.

In conclusion, for most elderly women with PCOS, especially those with BMI < 25 Kg/m2, the addition of exogenous LH in IVF/ICSI cycles leads to decreased efficacy in assisted conception outcomes, and there is no evidence of differences in the effects of different additive forms, additive amounts, and timing of addition of exogenous LH on assisted conception outcomes. Therefore, it is recommended that only r-FSH should be used for superovulation in IVF/ICSI cycles in elderly women with PCOS. However, the results of this retrospective analysis need to be validated in a multicenter randomized controlled trial with a large sample.

AFC Antral follicle count

AMH Anti-mullerian bormone

ART Assisted reproductive techniques

BMI Body mass index

COH Controlled ovarian hyperstimulation

E2 Estradiol

ET Embryo transfer

FSH Follicle stimulating hormone

GnRH gonadotropin-releasing hormone

HCG Human chorionic gonadotropin

HMG Human menopausal gonadotropin

ICSI Intracytoplasmic sperm injection

IVF In vitro fertilization

LH Luteinizing hormone

OHSS Ovarian hyperstimulation syndrome

P Progesterone

PCOS Polycystic ovary syndrome

r-HLH recombinant-human luteinizing hormone

T Testosterone

Acknowledgements

Not applicable.

Authors’ contributions

WJ collected data and developed the manuscript. SX and JS guided the design and reviewed the manuscript. SZ and HW contributed to data collection. XL and LG assisted in data analysis. SX and FL guided the design and implementation of the study. All authors read and approved the final manuscript.

Funding

This study was funded by the Natural Science Foundation of China (Grant No. 81974577 and No.81774355), General project of China Post doctoral Fund(2021M702044) and Natural Science Foundation of Shandong Province (No.ZR2020QH313).

Availability of data and materials

The datasets generated and/or analyzed during the current study are not public due to ethical and legal requirements, but are available from the respective authors (Fang Lian: [email protected]) upon reasonable request.

Ethics approval and consent to participate

This study was approved by the Institutional Review Board and the Institutional Ethics Committee of the Reproductive Medical Center at the affiliated Hospital of Shandong University of traditional Chinese medicine (ref approval no. SDTCM20211101). All procedures were carried out per the relevant guidelines and regulations. Furthermore, informed consent was obtained from all participants before the study.

Consent for publication

Not applicable.

Competing interests

We declare that we do not have any commercial or associative interest that represents a conflict of interest in connection with the work submitted.

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No competing interests reported.

Schedule1.ComparisonofdemographiccharacteristicsofGroup2Aand2B.xlsx
Schdule1.Comparison of demographic characteristics of Group2A and 2B.xlsx
Schedule2.ComparisonofdemographiccharacteristicsofGroup2Cand2D.xlsx
Schdule 2.Comparison of demographic characteristics of Group2C and 2D.xlsx
Schedule3.ComparisonofdemographiccharacteristicsofGroup2Eand2F.xlsx
Schdule 3.Comparison of demographic characteristics of Group2E and 2F.xlsx

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The effect of adding exogenous LH to IVF/ICSI cycles on pregnancy outcomes in elderly women with PCOS: a retrospective cohort study

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