1. The Top Five Problems You
Have With Ovulation Induction
and How to Solve Them
Sandro Esteves, M.D., Ph.D.
Director, ANDROFERT
Andrology & Human Reproduction Clinic
Campinas, BRAZIL
Khobar & Gassim, KSA – June, 2013

2. Esteves, 2
The Top Five Problems You Have
With Ovulation Induction and
How to Solve Them
Esteves SC – June 2013
Review this Lecture at:
http://www.androfert.com.br/review

3. Esteves, 3
Level Type of evidence
1a Obtained from meta-analysis of randomised trials
1b Obtained from at least one randomised trial
2a Obtained from one well-designed controlled
study without randomisation
2b Obtained from at least one other type of well-
designed quasi-experimental study
3 Obtained from well-designed non-experimental
studies (comparative and correlation studies, case
series)
4 Obtained from expert committee reports or opinions
or clinical experience of respected authorities
Modified from Sackett et al. Oxford Centre for EBM Levels of Evidence (2009)
Level of
Evidence
 Information applied to OI and IUI population
 Evidence-based Medicine
Grade A
recommendation
• Good and
consistent
scientific evidence

4. Esteves, 4
Is there a need to individualize the protocol
per patient?
Clomiphene citrate for how many cycles and
how?
Is there any advantage of recombinant versus
urinary gonadotropins?
Is there any advantage of recombinant versus
urinary hCG for triggering LH surge?
Is there a need of LH supplementation in OI
cycles?
What is in it for me?

5. Esteves, 5
Is There a Need to
Individualize the
Protocol per Patient?

6. Esteves, 6
Singleton
live birth at
term
Maximize
Treatment
Beneficial
Effects
1Delvigne & Rozenberg Hum Reprod Update. 2003;9:77-96; 2Cantineau et al., Cochrane Database
Syst Rev. 2007; 18:CD005356; 2Tur et al, Fertil Steril. 2005; 83: 116-121;
3Aboulghar. Fertil Steril. 2012;97:523-6.
Multiple
Pregnancy2
10-40%
Minimize Complications and
Risks in OI and IUI
Cycle
Cancellation1
2-8%
Risk of OHSS
OHSS3
Severe 2%
Moderate 3-6%

7.  Demographics and
anthropometrics
(Age, BMI, Race)
 Genetic profile
 Cause of Infertility
 Years of Infertility
 Health status
 Nutritional status
Esteves, 7

8. 1Reproductive Hormones Report - GCC Countries (Feb 2011)
2Bologna criteria: Ferraretti et al. Hum Reprod 2011.Esteves, 8
• Prevalence of Patients
with Poor Response to
Ovarian Stimulation2
0
5
10
15
20
25
30
35
40
< 30
years
30-35
years
36-39
years
40-42
years
>42
years
 Cancellation Rate
 < 4 oocytes
Up to
68%
Prevalence of Infertile
Patients (WHO II) with PCO
in Clinical Practice1
Up to 45% Infertility
Patients aged 35 or
above1

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); gonadotropin-independent
Low inter and intra-cycle variation
assessment at any cycle day in a
single measurement
AMHAFC
TVUS at early follicular phase (D2-D4)
2-10 mm (mean diameter); 2D-plane
Reflect No. AF at a given time that can be
stimulated by gonadotropins
Low inter-cycle variation

10. Esteves, 10
Evidence
Level
1a
Biomarkers

11. 1Lee et al. Hum Reprod 2008; 2Checa et al. Fertil Steril. 2010; 3Broer et al. Hum Reprod Update
2011; 3Nelson et al. Hum Reprod. 2009; *Bologna criteria: Ferraretti et al. Hum Reprod 2011Esteves, 11
Response to
Ovarian
Stimulation
Anti-
Mullerian
Hormone
(ng/mL)
Antral
Follicle
Count
False
Positive
Rate
Risk of OHSS1,2
≥ 3.4 > 16
~15%
Risk of Poor
Response*3 < 1.1 < 5
pmol/L X1000/140
Level
2a

12. Esteves, 12
Clomiphene Citrate for
How Many Cycles and
How?

13. Pituitary
GnRH
FSH/LH
estrogen
Hypothalamus
Ovary
ClomipheneCitrate
Esteves, 13
Structurally similar to estrogen
binds to estrogen receptors (ER)1
CC binds to ER for extended
periods of time
depleting ER concentrations1
Ovulatory women: CC increases
GnRH pulse frequency2
PCOS: CC increases GnRH pulse
amplitude3
frequency is already high
HowitWorks?
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

14. ClomipheneCitrate
Esteves, 14
How to Use?
2 3 4 5 76 8 9 10 11 12 131
Dose: 50 mg/d for 5 days
Menses
Start day
Ultrasound
CC
Adapted form the ASRM Practice Committee. Fertil Steril 2003;5:1302–8
Ultrasound

15. Points to ConsiderClomipheneCitrate
Esteves, 15
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 risk of OHSS.

16. 50 mg/d 100 mg/d 150 mg/d
OvulationOvulation
2 – 3 cycles with the same dose
Ovulation
No
Ovulation
No
Ovulation
No
Ovulation
How Many cycles?
No pregnancySuboptimal Endometrium
(Endometrial thickness <7mm)
Injectable
Gonadotropins
ClomipheneCitrate
Esteves, 16
Hypogonadotropic
Hypogonadism
Adapted from the ASRM Practice Committee. Fertil Steril 2003;5:1302–8

17. Esteves, 17 Cantineau et al., Cochrane Database Syst Rev. 2007; 18(2):CD005356
Higher PR with gonadotropins (28%)
compared with CC (18%)
without increased risks
Gonadotropins
inOI/IUI 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
(0.48 to 41.25)
Level
1a

18. Esteves, 18
Low Dose Step-up StimulationGonadotropins
inOI/IUI Starting dose: 37.5-50 IU (rec-hFSH); Adjust (by 37.5 IU) if no
follicles >10mm after 7-10 stimulation days;
Adjust 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
• >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)
Results
In
PCOS

19. Points to Consider
Esteves, 19
Gonadotropins
inOI/IUI
2. Be patient!
It may take 10 days or more for a dominant follicle to
appear during the first treatment cycle with low-dose
gonadotropin.
1. TVUS scan before starting:
if endometrium thickness >8 mm, a short course of a
progestin (medroxyprogesterone acetate, 5-10 mg/d) is
given to induce a withdrawal bleed.

20. Esteves, 20
Low Dose Step-up Stimulation
Cantineau et al., Cochrane Database Syst Rev. 2007; 18(2):CD005356
Conventional vs
low-dose step-up in
IUI; 2 RCT (n= 297)
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)
Similar PR and Lower Risk of OHSS by
Using Low dose step-up in IUI
Level
1a
Gonadotropins
inOI/IUI

21. Esteves, 21
In general, 3 to 6 cycles
Level
2a
But recent evidence shows that Additional Testing
should be offered after 3 unsuccessful cycles
Diagnostic
Laparoscopy
(LPS)
Sperm
Chromatin
Integrity Testing
Bonneau et al. Eur J Obstet Gynecol Reprod Biol. 2012; 163: 57-61; Bungum et al. Hum
Reprod 2007; 22: 174–9; Esteves et al. Arch Gynecol Obstet. 2012; 286: 217-29.

22. Sperm Chromatin Dispersion Test:
Sperm with absent “halos” have
DNA strand breaks
Semen/Spermatozoa
Quantitative (Normal <20%)
Esteves et al. Arch Gynecol Obstet. 2012; 286: 217-29.
19%
1.5%
Normal Elevated
Live Birth Rates with
Intrauterine Insemination
OR = 0.07
[95% CI: 0.01-0.48]
Bungum et al. Hum
Reprod 2007; 22: 74–9

23. Benefits of LPS:
Gold standard for diagnosing tubal pathology, adhesions and
endometriosis
Allow treatment of identified lesions  spontaneous conception
In poor prognosis, bypass OI/IUI IVF
Diagnostic
Laparoscopy(LPS)
Esteves, 23
Findings After 3 OI/IUI Failures in
Unexplained Infertility1,2
Pelvic disease 50 – 90%
Adhesions 10 – 48.4%
Endometriosis
I/II
II/IV
36 – 73%
22 – 50%
4.1 – 26.3%
Tubal Disease 1-27%
After LPS: PR = 68%1
14% - No treatment
17% - OI/IIU
37% - IVF/ICSI
1Bonneau C et al. Eur J Obstet Gynecol Reprod Biol. 2012; 163: 57-61;
2Jacobson. Cochrane Database of Systematic Reviews 2010;20;(1):CD001398.

24. Response to OI depends on patient profile.
Biomarkers, AMH and AFC, correctly
identify “Who is Who” before OI.
CC is usually the first line choice for OI/IIU.
Switch to injectable gonadotropins:
3 ovulatory cycles but no pregnancy
Suboptimal endometrium thickness (< 7mm)
No response with CC 150 mg/d
Esteves, 24

25. Esteves, 25
Injectable Gonadotropins yields Higher
PR than CC without Increased Risks.
Mild Stimulation with Low-dose Step-up
Protocol is Advantageous.
Consider Sperm Chromatin Testing and
Diagnostic LPS after 3 Failed OI/IUI
Cycles.

26. Is There Any Advantage of
Recombinant versus
Urinary Gonadotropins
for OI?

27. Recombinant hFSH is more potent than
HP-Urinary FSH
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)
Esteves, 27
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: 1.394 (95% CI: 1.00-1.96)

28. Esteves, 28
Up to 70%
impurities

29. 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, 29
Gonadotropins
inOI/IUI
*Follitropin alfa

30. Esteves, 30
68%
25%
Folitropin alfa
prefilled ready-to-
use pen
Needle-free
reconstitution,
conventional
syringe
Patient Preferences
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)

31. *Steelman-Pohley Rat Bioassay, 1953; Bassett et al. Reprod Biomed Online 2005;10:169–
177; Driebergen et al. Curr Med Res Opin 2003;19:41–46.
Conventional
Bioassay*
High
variability
Rat ovary
weight
gain
Urinary gonadotropins
Follitropin beta
Esteves, 31
Gonadotropins
inOI/IUI
Gonadotropin injected sc
1x 3days
Sacrifice day 4
and collect Ovaries
Ovaries are weighed and
data processed

32. 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
Minimal batch-to-
batch variability
(1.6%)
Follitropin alfa
Esteves, 32
Gonadotropins
inOI/IUI
Size Exclusion High
Performance Liquid
Chromatography
(SE- HPLC)
37.5
Mild Stimulation
with Precise
Dose
Adjustments
112.5
75.0

33. Is There Any Advantage of
Recombinant versus
Urinary hCG for
Triggering Ovulation?

34. Esteves, 34
hCG Presentation Via
Urinary lyophilized vials (5,000-10,000 IU) IM
Recombinant
choriogonadotropin alfa
pre-filled syringes (250 mcg ≅ 6,750 IU) SC
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.
Tsoumpou et al. Reprod Biomed Online. 2009;19:52-8
hCGtotrigger
ovulationinOI/IUI
Recommended Dose: 5,000 IU (250 mcg for rec-hCG)
Systematic review (2009) unable to define best hCG dose
When: 19–30 mm (~25 mm)1
2D TVUS
Dominant Follicle Size Mean Diameter
23-28 mm (988 IUIs with CC & Letrozole)2
≥16 mm (620 IUIs with gonadotropins)3

35. Recombinant vs
Urinary hCG for
Triggering Ovulation
RCT N Effect
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
OR: odds ratio; MD: mean difference
Youssef et al. Cochrane Database Syst Rev. 2011; 13(4):CD003719.Esteves, 35
ClinicalEfficacy

36. Is There Any Advantage of
Using Recombinant versus
Urinary Products in OI/IUI?
Recombinant products are more potent.
Similar pregnancy rates using 50% less rec-
hFSH.
Higher PR using the same dose.
Rec-hCG is better tolerated.
Fewer side effects.

37. Is There Any Advantage of
Using Recombinant versus
Urinary Products in OI/IUI?
Other advantages of recombinants vs
urinaries:
Allow SC self-injection
Higher purity and specific activity
Patient-friendly
Less time-consuming; less hospital/clinic visits
Allow mild stimulation by small dose
adjustments
Higher dose precision; FbM

38. Is There a Need for LH
Supplementation in OI
Cycles?

39. Esteves, 39
• Mild Stimulation
(low dose rec-hFSH +
GnRH ant.):
• 5 oocytes
retrieved;
• IR = 31%
• Conventional
Stimulation :
• 10 oocytes
retrieved;
• IR = 29%
Verberg et al.
Hum Reprod Update 2009; 15: 5–12.
Promotion of Steroidogenesis
(TCs) early Follicular Phase
• Adequate estrogen production
• Uterine/endometrial changes
Stimulation of final Follicular
Maturation (GCs) late FP
Esteves, 39 Alviggi et al. Reprod Biomed Online 2006;12:221.

40. Balasch J, Fábreques F. Curr Opin Obstet Gynecol 2002, 14:265.Esteves, 40
• 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

41. LH levels <1.2 UI/L (WHO group I)
Higher follicular development pts. receiving LH
(67% vs 20%; p=0.02): Shoham et al., 2008
Similar follicular development HMG vs FSH + rLH; Higher
cumulative PR after 3 cycles in FSH + rec-hLH
(56% vs 23%; p=0.01): Carone et al., 2012
Level
1b
Esteves, 41
WHO group II
Clomiphene-resistant: fewer intermediate-sized follicles and
OHSS in LH-supl. vs FSH group; similar ovulation rate;
Plateau, 2006
Previous over-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 OHSS (-7% difference); Segnella et al., 2011
LHSupplementation
inOI/IUI

42. Esteves, 42
• ~80% normogonadotropic women
undergoing Ovarian Stimulation1-3
Normal
• 15-20% of NG women have less
sensitive ovaries
• Older patients (≥35 years)4
• Poor responders5
• Slow/Hypo-responders6
• Deeply suppressed endogenous LH
levels (hypo-hypo; endometriosis treated with
GnRH-a)7
Low
1. Alviggi et al. Reprod Biomed Online 2006;12:221; 2. Tarlatzis et al. Hum Reprod
2006;21:90; 3. Esteves et al. Reprod Biol Endocrinol 2009;7:111; 4. Marrs et al. Reprod
Biomed Online 2004;8:175;5. Mochtar MH, Cochrane Database, 2007; 6. Alviggi, et al.
RBMOnline 2009; 7. De Placido et al. Clin Endocrinol (Oxf) 2004;60:637;
LHSupplementation
inOI/IUI

43. 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 in selected pts.
to recover oocyte quality.
LHSupplementation
inOI/IUI

44. 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, 44

45. Esteves, 45
1. PCOS w/previous excessive response
with low dose step-up stimulation
Add 75 IU LH activity starting from D1 (min. 7 days)
LHSupplementation
inOI/IUI
2. Hypo-hypo/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

46. *derives primarily from hCG, which is concentrated during
purification or added to achieve the desired LH-like
biological activity.
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)
Rec-hLH >99% 0 75 22,000 IU
hMG-HP 3% ~70 75* ≥ 60 IU
Adapted from ASRM Practice Committee. Fertil Steril. 2008; 90:S13-20.Esteves, 46

47. In Pts. Treated with HMG, expression of LH/hCG
receptor and other genes involved in steroids
biosynthesis in GCs are lowered
May reflect LH receptors down-regulation:
Constant ligand exposure during follicular phase due to longer half
life and higher binding affinity of hCG compared with rec-hLH
May explain the observed lower progesterone levels:
Caused by lower LH-induced cholesterol uptake, a decrease in
the novo cholesterol synthesis and a decrease in steroid
synthesis.
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, 47
Level
2a

48. Esteves, 48
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.
Mild stimulation with low-dose step-up gonadotropin
protocol is advantageous.
Is there a need to individualize the
protocol per patient?
The Top Five Problems With OI and
How to Solve Them

49. Esteves, 49
The Top Five Problems With OI and
How to Solve Them
CC for 3-6 cycles as the first line choice for OI/IIU.
Injectable gonadotropin 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
Injectable gonadotropins yields higher PR than CC
without increased risks.
Consider sperm chromatin testing and diagnostic
laparoscopy after 3 failed OI/IUI cycles with
gonadotropins.
Clomiphene citrate for how many cycles
and how?

50. Esteves, 50
The Top Five Problems With OI and
How to Solve Them
Recombinants are safer, purer and more potent than
urinary gonadotropins.
Similar pregnancy rates using 50% less rec-hFSH.
Higher PR using the same dose.
Recombinant, as pen injector devices, allows SC self-
administration and individualized stimulation using
small dose adjustments with great precision.
Recombinant hCG, as pre-filled syringes, allows SC
self-administration and is better tolerated than u-hCG.
Is there any advantage of recombinant
versus urinary products for OI and LH
surge trigger ?

51. Esteves, 51
The Top Five Problems With OI and
How to Solve Them
Is there a need of LH supplementation in
OI cycles?
Crucial for adequate follicular development and endometrial
proliferation in WHO I (~75 IU).
Promotes monofollicular growth and decreases cancellation in
WHO II (CC-resistent and hyper-responders).
Increase androgen production for aromatization to estrogen. May restore
follicular millieu in less responsive ovaries (>35y-o, diminished ovarian
reserve, slow responders).
LH activity is hCG-dependent in urinaries and pure LH-dependent in
recombinants.
Choice of formulations may influence oocyte and corpus luteum
competence.