The Comparison of Granulosa Cell Apoptosis Rates With or Without Luteinizing Hormone Administration in Poor Responders.
Condition: Fertilization in Vitro
Study type: Observational [Patient Registry]

Summary: 
      In Zeynep Kamil Women and Children's Education and Research Hospital which is a tertiary
      referral hospital, the investigators perform microdose flare-up gonadotropin-releasing
      hormone (GNRH) analogue or GNRH antagonist protocol to the poor responders. The investigators
      may or may not supplement luteinizing hormone (LH). Human chorionic gonadotropin (hCG)
      triggering is performed when at least 2 follicles diameter are above 17 mm and the serum
      estradiol level is above 500 pg / ml. 36 hours after hCG, ovarian aspiration is performed by
      the guidance of transvaginal ultrasound. Normally after oocyte separation process, the
      remaining follicle aspiration fluid is destroyed.

      n the present study, the follicle aspiration fluid is planned to be used with the patient's
      permission. The investigators are going to examine the granulosa cell apoptosis rate by using
      annexin-5 antibody in both groups 1 (LH added) and 2 (without LH).

      For this purpose, a total of 40 volunteer patients are planned to involve, the groups are
      designed as 20 LH added and 20 LH added women.

      In the present study, the investigators hypothesis that the rates of granulosa cell apoptosis
      in poor responders may be different between the group 1 (with LH) and group 2 (without LH),
      this will lead to IVF therapy in the near future.
    

Detailed description: 
      The supplementation of human menopausal gonadotropin (HMG) in terms of luteinizing hormone
      (LH) support in controlled ovarian stimulation (COS) is a controversial issue. Follicle
      stimulating hormone (FSH) and LH are required for ovarian steroidogenesis in anovulatory
      women with gonadotropin deficiency according to the two cell-two gonadotropin hypothesis. LH
      supplementation is needed to ensure adequate follicular estradiol (E2) production during the
      follicular phase, completion of oocyte maturation and development in the endometrium.
      Despite, the need for LH for ovarian stimulation in normogonadotropic women is controversial.
      Additional LH supplementation during stimulation with FSH may provide an advantage in
      increasing follicle development and thus may be shortening the duration of treatment. It has
      been suggested that the change of gonadotropins from FSH to LH in the presence of ovarian
      stimulation is beneficial in the development of a more homogeneous follicular cohort [1] [2].
      However, contrary opinions have reported that LH supplementation does not bring any
      additional benefit [3].

      In recent years, studies have been done to investigate the utility of the addition of LH as
      well as FSH to the cycle outcome. In a Cochrane review, the combination of recombinant
      follicle stimulating hormone (r-FSH) and recombinant luteinizing hormone (r-LH)
      administration in in vitro fertilization/intracytoplasmic sperm injection (IVF / ICSI) cycles
      compared to only r-FSH cycles in 14 randomized controlled trials [4]. When r-LH was added,
      there was no statistical difference in terms of pregnancy outcomes. However, due to the small
      size of the work, the net result was not achieved. The other study supported the treatment of
      rFSH alone, while the addition of r-LH was found to be beneficial only in one of the studies
      [5, 6] . As a result, there is no significant difference in live birth rates.

      However, the studies in only poor responders showed a significant increase in pregnancy rates
      with the addition of r-LH [5, 7]. In contrast, recently Bosch et al. reported that the
      addition of r-LH in the 36-39 age group of patients with GnRH antagonist protocol benefit
      from LH support, while patients under the age of 36 do not [8]. In conclusion, there is no
      consensus to administrate r-LH to the protocols of poor responders. Our hypothesis is LH
      administration may decrease granulosa apoptosis rate in follicular fluids and may be
      beneficial to poor responders and over age of 35.

      In Zeynep Kamil Women and Children's Education and Research Hospital where the data of study
      patients is going to be collected, the investigators are applying microdose flare-up GNRH
      analogue or GNRH antagonist protocol to the poor responders. The investigators may or may not
      supplement LH. hCG is performed when at least 2 follicles are 17 mm and the serum estradiol
      level is above 500 pg / ml. 36 hours after hCG, ovarian aspiration is performed by the
      guidance of transvaginal ultrasound. Normally after oocyte separation process, the remaining
      follicle aspiration fluid is destroyed.

      The follicle aspiration fluid is planned to be used within the permission of the patient in
      the present study. The investigators are going to examine the granulosa cell apoptosis rate
      with using annexin-5 antibody in group 1 (LH added) and group 2 (without LH).

      For this purpose, a total of 40 volunteer patients are planned to have 20 LH added and 20 LH
      added patient groups.

      Statistical analysis is going to be performed using SPSS 11 program. p <0.05 will be
      considered significant.

      In the present study, the investigators hypothesis that comparing the rates of granulosa cell
      apoptosis in poor responders as two different groups (with and without addition of LH) will
      lead to IVF therapy in the near future.
    

Observational model: Cohort
Time perspective: Prospective
Sampling method: Probability Sample
Study population: 
        18-49 aged females who undergoes IVF treatment and who are defined as poor responders
      
Biospecimen description: 
      folicular aspiration fluid sampling
    
Keywords: Fertilization in Vitro; Granulosa Cells; Apoptosis