Individualized stimulation protocols maximize benefits and minimize risks in OI/IUI cycles. Biomarkers like AMH and AFC can help predict ovarian response. For CC stimulation, 50mg daily for 5 days is typically used for up to 3 cycles before considering injectables. Low-dose step-up gonadotropin stimulation starting at 37.5-50IU is effective with fewer risks than conventional protocols. Recombinant hormones provide similar outcomes to urinary products but with less impurities. Adding recombinant LH may benefit some patients, like those with low LH levels.

1. Is There a Best Stimulation
Protocol in OI/IUI Cycles?
Sandro Esteves, M.D., Ph.D.
Director, ANDROFERT
Andrology & Human Reproduction Clinic
Campinas, BRAZIL
ASPIRE III, Istanbul, September 2013

2. Esteves, 2
Is There a Best Stimulation
Protocol in OI/IUI Cycles?
Review this Lecture at:
http://www.androfert.com.br/review
ASPIREIII,Istanbul
September2013

3. Esteves, 3
Level Type of evidence
1a Meta-analysis of randomized trials
1b At least one randomized trial
2a Well-designed controlled study without
randomization
2b At least one other type of well-designed quasi-
experimental study
3 Well-designed non-experimental studies
(comparative and correlation studies, case series)
4 Expert committee reports or opinions or clinical
experience of respected authorities
Adapted from Sackett et al. Oxford Centre for EBM Levels of Evidence (2009)
Level of
Evidence
 OI and IUI population
 Grade A recommendation

4. Esteves, 4
Top Problems
Concerning Ovarian
Stimulation in OI/IUI
and How to Solve Them
What is in it for me?

5. Esteves, 5
Do We Need to
Individualize the
Protocol per Patient?

6. Esteves, 6
Singleton
live birth at
term
Maximize
Beneficial
Effects
1Delvigne & Rozenberg Hum Reprod Update. 2003;9:77-96; 2Cantineau et al.,
Cochrane Database Syst Rev. 2007; 18:CD005356;
3Aboulghar. Fertil Steril. 2012;97:523-6.
Multiple
Pregnancy2
10-40%
Cycle
Cancellation1
2-8%
Risk of OHSS
OHSS3
Severe 2%
Moderate 3-6%
Minimize Complications
and Risks

7.  Age, BMI, Race
 Genetic profile
 Cause
 Duration
 Health
 Nutrition
Esteves, 7

8. Reproductive Hormones Report - GCC Countries (Feb 2011)
Bologna criteria: Ferraretti et al. Hum Reprod 2011.
Esteves, 8
Up to
68%
Infertile Patients (WHO II)
with PCO in Clinical Practice
Up to 45% Patients
Aged ≥35 have Poor
Response to
Stimulation

9. Esteves, 9
La Marca et al, Hum Reprod 2009;24:2264; Fleming et al, Fertil Steril 2012;98:1097;
Broekmans et al. Fertil Steril, 2010; 94:1044-51; Scheffer et al. Hum Reprod 2003;18:700
Reflect No. Pre-antral and Small Antral
Follicles (≤4-8mm)
Low inter and intra-cycle variation
AMHAFC
2D-TVUS at early follicular phase
2-10 mm (mean diameter)
Reflect No. AF at a given time that can be
stimulated by medication
Relatively low inter-cycle variation

10. Esteves, 10
Evidence
Level
1a
Biomarkers

11. 1Nardo et al. Fertil Steril 2009; 2Checa et al. Fertil Steril 2010
Esteves, 11
AMH
(ng/mL)
AFC False
Result
Risk
OHSS1,2 >3.5 >16 ~15%
pmol/L X1000/140
Level
2a

12. Esteves, 12
Individualized approaches maximize treatment
beneficial effects and minimize complications
and risks.
Biomarkers, AMH and AFC, are useful to predict
ovarian response and to define an
individualized stimulation.

13. Esteves, 13
Clomiphene Citrate for
How Many Cycles and
How?

14. Pituitary
GnRH
FSH/LH
estrogen
Hypothalamus
Ovary
ClomipheneCitrate
Esteves, 14
Similar to estrogen
Extended binding depletes ER levels1
Ovulatory women
Increase GnRH pulse frequency2
PCOS
Increase GnRH amplitude3
1Clark & Markaverich. Pharmacol Ther 1982;15:467; 2Kerin JF et al. J Clin Endocrinol Metab
1985;61:265; 3Kettel et al. Fertil Steril 1993;59:532; 4Ibrahim et al. Arch Gynecol Obstet.
2012;286:1581; 5Annapurna et al. Int J Fertil Womens Med 1997;42:215.
Negative Effect on
Endometrium4 and
Cervical Mucus5

15. ClomipheneCitrate
Esteves, 15
How to Use?
Dose: 50 mg/d for 5 days
UltrasoundMenses
Start day
CC
2 3 4 5 76 8 9 10 11 12 131
Adapted form the ASRM Practice Committee. Fertil Steril 2003;5:1302–8
Ultrasound

16. Points to ConsiderClomipheneCitrate
Esteves, 16
PCOS: >75% of anovulatory infertility
~25% CC-resistant (mainly obese & hyperandrogenic)
~15% who ovulate have thin endometrium/poor mucus
Ultrasound monitoring
1. Dose can be adjusted, if necessary, in subsequent
cycles.
2. Allows endometrial evaluation.
In IUI, endometrial appearance/thickness more important than
follicle size for hCG administration
3. Assessment for the risk of OHSS.

17. 50 mg/d 100 mg/d 150 mg/d
OvulationOvulation
2 – 3 cycles with the same dose
Ovulation
No
Ovulation
No
Ovulation
No
Ovulation
No pregnancySuboptimal Endometrium
(thickness <7mm)
Injectable
Gonadotropins
ClomipheneCitrate
Esteves, 17
Hypogonadotropic
Hypogonadism
Adapted from the ASRM Practice Committee. Fertil Steril 2003;5:1302–8
How Many Cycles and How?

18. Esteves, 18
How to Use Injectable
Gonadotropins and
What to Expect?

19. Esteves, 19
Low Dose Step-up StimulationGonadotropins
Starting dose: 37.5 - 50 IU (rec-hFSH)
Step-up (by 37.5 IU) if no follicles >10mm after 7 days
Step-up every 7 days until dominant follicle appear
hCG ≥18mm and endometrium ≥7mm
2 3 4 5 76 8 9 10 11 12 131
Ultrasound
Menses
Start day
14 15

20. Gonadotropins
N = 968 Cycles
>70% ovulatory cycles
>85% monofollicular development
Threshold to produce a dominant follicle:
37.5 to 75 IU (~75%)
Average stimulation duration: 15 days
CPR after 6 cycles: ~60%
No OHSS; ~10-15% cancellation
(multifollicular development)
Low Dose Step-up Stimulation in PCO
Esteves, 20

21. Points to Consider
Esteves, 21
Gonadotropins
Be patient!
It may take 10 days or more for a dominant follicle to
appear during the first treatment cycle with low-dose
gonadotropin.
TVUS scan before starting:
if endometrium thickness >8 mm, we use progestin
(medroxyprogesterone acetate, 5-10 mg/d) to induce a
withdrawal bleed.

22. Esteves, 22 Cantineau et al., Cochrane Database Syst Rev. 2007; 18(2):CD005356
Gonadotropins
No.
Studies
No.
Participants
Odds-ratio
Pregnancy 7 556 OR: 1.76
(95% CI: 1.16 to 2.66)
Miscarriage 4 120 OR: 1.2
(95% CI: 0.67 to 1.9)
Multiple
Pregnancy
4 120 OR: 0.73
(95% CI: 0.32 to 1.67)
OHSS 2 200 OR: 4.44
(95% CI: 0.48 to 41.25)
Level
1a

23. Esteves, 23
Conventional vs Low Dose Step-up
Stimulation in IUI
Cantineau et al., Cochrane Database Syst Rev. 2007; 18(2):CD005356
2 RCT; n= 297
>75
IU/day
50-75
IU/day
Odds-ratio
OHSS 13% 2.7% 5.52
(95% CI: 1.85-16.52)
Pregnancy 31.1% 28.2% 1.15
(95% CI: 0.69-1.92)
Level
1aGonadotropins

24. Esteves, 24
Injectable gonadotropins when…
3 CC ovulatory cycles but no pregnancy
Suboptimal endometrium thickness (< 7mm) after CC-OI
No response with CC 150 mg/d
WHO I (hypo-hypo) anovulation
Yields higher PR than CC without increased
risks.
Low-dose (37.5 to 50 IU) step-up (every 7d)
stimulation is the best protocol.

25. Recombinant or Urinary
Gonadotropins?

26. Esteves, 26
Up to 70%
impurities

27. Bassett et al. Reprod Biomed Online 2005;10:169–177.
Purity
(protein
content)
Mean specific
activity
(IU/mg protein)
LH
activity
(IU/vial)
Injected
protein per
75 IU (mcg)
hMG < 5% ~100 75 ~750
hMG-HP < 70% 2,000–2,500 75 ~33
rec-hFSH* > 99% 13,645 0 6.1
Esteves, 27
RecombinantvsUrinary
*Follitropin alfa

28. Esteves, 28
Level
1a
Matorras et al. Fertil Steril. 2011;95(6):1937-42
3 RCT; “equal dose group”
Higher PR with rec-hFSH (16.4% vs 12.3%)
RR: 1.39 (95% CI: 1.00-1.96)
Meta-analysis Rec-hFSH vs HP-uFSH in IUI
6 RCT; (N=713 pts; 1,581 cycles)
Similar PR: 14.5% vs 14.9% with rec-FSH dose 50%
lower (RR: 0.970; 95% CI: 0.68-1.37)
Recombinantvs
Urinary

29. Esteves, 29
68%
25%
Folitropin alfa
prefilled ready-to-
use pen
Needle-free
reconstitution,
conventional
syringe
Easy of use 58%
Dosing mechanism 43%
Less chance of error 26%
Reasons
Weiss N. RBMonline 2007;15:31-7
Level
2a
• Allowed injections
at home
• Improved pts.
satisfaction (QOL)

30. ; Bassett et al. Reprod Biomed Online 2005;10:169–177;
Driebergen et al. Curr Med Res Opin 2003;19:41–46.
Steelman-Pohley
Bioassay
High
variability
Rat ovary
weight
gain
Esteves, 30
Gonadotropin injected sc
1x 3days
Sacrifice day 4
and collect Ovaries
Ovaries are weighed and
data processed
UrinaryProducts

31. Bassett et al. Reprod Biomed Online 2005;10:169–177;
Driebergen et al. Curr Med Res Opin 2003;19:41–46.
FbM: Novel analitycal
method
Protein content in
solution by mass
1.6% batch-to-batch
variability
Follitropin alfa
Esteves, 31
Size Exclusion High
Performance Liquid
Chromatography
(SE- HPLC)
37.5
62.5
50
RecombinantProducts

32. hCG for Triggering
Ovulation
Urinary
lyophilized vials
(5,000-10,000 IU)
IM
Recombinant
choriogonadotropin
alfa
pre-filled syringes
(250 mcg ≅ 6,750 IU)
SC
Recommended Dose: 5,000 IU (or 250 mcg rec-hCG)
ASRM Practice Committee. Fertil Steril. 2008;90(Suppl 5):S13-20; Tsoumpou et al. Reprod
Biomed Online. 2009;19:52-8
Recombinantvs
Urinary

33. Esteves, 33
When: 19–30 mm (~25 mm)1
2D TVUS
Mean Diameter of Dominant Follicle Size
23-28 mm (988 IUIs with CC & Letrozole)2
≥16 mm (620 IUIs with gonadotropins)3
hCG for Triggering
Ovulation
1ASRM Practice Committee. Fertil Steril. 2008;90(Suppl 5):S13-20;
2Palatnik et al, Fertil Steril 2012;97:1089–94;
3da Silva et al. Eur J Obstet Gynecol Reprod Biol. 2012;164:156-60.

34. Clinical Efficacy
LH Surge
RCT N Odds-ratio
Live birth 6 1,019 OR: 1.04 (95% CI 0.79 to 1.37)
Miscarriage 7 1,106 OR: 0.69 (95% CI: 0.41 to 1.18)
Severe OHSS 3 549 OR: 1.49 (95% CI: 0.54 to 4.1)
Side Effects 3 374 OR: 0.39 (95% CI: 0.25 to 0.61)
Level
1a
Youssef et al. Cochrane Database Syst Rev. 2011; 13(4):CD003719.Esteves, 34
Recombinantvs
Urinary

35. Esteves, 35
Better safety, purity and potency with
recombinants.
Similar PRs using 50% less dose with rec-hFSH;
Higher PR with the same dosage.
SC self-injection and individualized stimulation
using small dose adjustments with Pen
injectors.
Better tolerability with rec-hCG.

36. Do We Need to give
LH in OI/IUI Cycles?

37. Steroidogenesis
Steroidogenesis and
Final Follicular
Maturation
Alviggi et al. Reprod Biomed Online 2006;12:221.

38. Balasch J, Fábreques F. Curr Opin Obstet Gynecol 2002, 14:265.Esteves, 38
• Normal androgen and estrogen biosynthesis
• Normal follicular growth and development
• Normal oocyte maturation
Normal
• Suppression of GC proliferation
• Follicular atresia (non-dominant follicles)
• Premature luteinization
• Oocyte development compromised
High
• Insufficient androgen (and estrogen) synthesis
• Follicular maturation impaired
• Inadequate endometrial proliferation
Low

39. WHO group I (LH levels <1.2 UI/L)
Level
1b
Esteves, 39
LHinOI/IUI
Similar follicular development HMG vs FSH + rec-hLH;
Higher cumulative PR after 3 cycles in FSH + rec-hLH
(56% vs 23%; p=0.01)
Carone et al., 2012
Higher follicular
development pts.
receiving LH
(67% vs 20%; p=0.02)
Shoham et al., 2008

40. Level
1b
Esteves, 40
Clomiphene-resistant
Fewer intermediate-sized follicles and OHSS in LH-supl.
vs FSH group; similar ovulation rate. Plateau, 2006
Previous Excessive Response
Higher monofollicular development in LH group
(32% vs 13%; p=0.04). Hughes et al., 2005
IUI
Higher monofollicular development in LH group w/o
intermediate-size (42% vs 11%; p=0.03);
Lower cycle cancellation due to risk of OHSS (-7%
difference). Segnella et al., 2011
WHO group IILHinOI/IUI

41. Esteves, 41
• ~80% normogonadotropic women
undergoing Ovarian Stimulation1,2
Normal
• 15-20% of NG women have less
sensitive ovaries
• Older patients (≥35 years)3
• Poor responders4
• Slow/Hypo-responders5
• Deeply suppressed endogenous LH
levels (hypo-hypo; endometriosis treated with
GnRH-a)6
Low
1Tarlatzis et al. Hum Reprod 2006;21:90; 2Esteves et al. Reprod Biol Endocrinol 2009;7:111;
3Marrs et al. Reprod Biomed Online 2004;8:175;4Mochtar MH, Cochrane Database, 2007;
5Alviggi, et al. RBMOnline 2009; 6De Placido et al. Clin Endocrinol (Oxf) 2004;60:637
LHinOI/IUI

42. Reduced
ovarian
paracrine
activity
Hurwitz &
Santoro 2004
LH
receptor
poly-
morphisms
Alviggi et al.,
2006
Androgen
secretory
capacity
reduced
• Piltonen et al.,
2003
Decreased
numbers of
functional
LH
receptors
• Vihko et al. 1996
Reduced
LH
bioactivity
while
imnuno-
reactivity
unchanged
• Mitchell et al.
1995; Marama et
al 1984
Action of LH at the follicular level increases androgen
production for its later aromatization to estrogens;
May restore the follicular milieu with positive impact on
oocyte quality.
LHinOI/IUI

43. Mochtar et al,
2007
3 RCT (N=310)
r-hFSH+rLH vs.
r-hFSH alone*
OPR
OR 1.85
(95% CI: 1.10; 3.11)
Bosdou et al,
2012
7 RCT (N= 603)
r-hFSH+rLH vs.
r-hFSH alone*
CPR
LBR
(only 1 RCT)
RD: +6%,
(95% CI: -0.3; +13.0)
RD: +19%
(95% CI: +1.0; +36.0%)
Hill et al, 2012
7 RCT (N=902)
r-hFSH+rLH vs.
r-hFSH alone CPR
OR 1.37
(95% CI: 1.03; 1.83)
*long GnRH-a protocol; OR=odds-ratio; RD=risk difference
Mochtar MH et al. Cochrane Database Syst Rev. 2007;2:CD005070; Bosdou JK et al,
Hum Reprod Update 2012; 8(2):127-45. Hill MJ et al. Fertil Steril 2012; 97:1108-4.Esteves, 43

44. Esteves, 44
PCOS w/previous excessive response
Add 75 IU LH activity from D1 (min. 7 days)
Hypo-hypo
Add 75 IU LH activity from D1
Poor responders
1:1 or 2:1 FSH/LH ratio from stimulation D1
Add 75 IU LH activity starting on D6
2 3 4 5 76 8 9 10 11 12 131
Ultrasound
Menses
14 15
LHinOI/IUI

45. *derives from hCG
Beta unit Carboxyl terminal segment
Longer in hCG; higher
receptor affinity
Absent in LH and present in
hCG (Longer Half-life)
Purity
(LH
content)
hCG
content
(IU/vial)
LH
activity
(IU/vial)
Specific
activity
(LH/mg
protein)
>99% 0 75 22,000 IU
3% ~70 75* ≥ 60 IU
Adapted from ASRM Practice Committee. Fertil Steril. 2008; 90:S13-20.Esteves, 45
Rec-hLH
hMG-HP*

46. HMG: lower expression of LH/hCG
receptor and other genes involved
in steroids biosynthesis in GC
Down-regulation due to constant
ligand exposure of receptors to hCG
Trinchard-Lugan I et al. Reprod Biomed Online 2002; 4:106-115; Menon KM et al. Biol
Reprod 2004; 70:861-866; Grondal ML et al. Fertil Steril 2009; 91: 1820-1830.
Esteves, 46
Level
2a

47. Esteves, 47
Mandatory in anovulation WHO I (~75 IU).
WHO II CC-resistent and hyper-responders
Higher monofollicular growth and Lower cancellation
Diminished Ovarian Reserve
May restore follicular millieu and optimize oocyte quality
LH activity is different in HMG and rec-hLH
May influence oocyte and corpus luteum competence.

48. Esteves, 48
Yes, we should individualize the
stimulation protocol.
CC can be your first line, but move to
gonadotropins after 3 ovulatory cycles.
Low dose step-up when using
gonadotropins.
Better safety and pt. tolerability
Higher purity, potency and efficacy
with recombinants.
LH supplementation has a role in
selected patients.