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Ovarian Stimulation: Optimizing Response in Women with Elevated Basal Blood LH Levels
by Geoffrey Sher, M.D.
Women, who are over 40 years and/or those who have diminished ovarian reserve requiring ovarian stimulation, are traditionally labeled as being producers of “poor quality eggs and embryos, often leading them to resort to ovum donation prematurely. In fact, such is not inevitable, provided that the “recipe” or “one size fits all” attitude towards ovarian stimulation is supplanted by one that embraces a customized approach that addresses specific individualized needs on a case by case basis. This article addresses several concepts that must be considered in order to arrive at a rational and individualized approach to ovarian stimulation.
Luteinizing hormone (LH) and Follicle stimulating hormone (FSH) are both produced by the pituitary gland. Upon reaching the ovaries, LH produced by the pituitary gland elicits the production of Testosterone and other androgens by ovarian connective tissue known as stroma or theca. The testosterone is delivered to the follicle where it is converted by FSH to estrogen (estradiol/E2). Accordingly some LH is essential for testosterone “fueling” of follicle and egg development. However, too much testosterone represents an “overdose” and is very prejudicial to normal follicle and egg development, leading to poor embryo quality and failed ART.
Women who have diminished ovarian reserve (elevated FSH, low Inhibin B, abnormal clomiphene challenge tests, history of poor response to gonadotropins), older women (>40 years tend to produce increased amounts of LH (with increased biological potency) and also often have an overgrowth of testosterone producing ovarian stroma ( the ovarian “LH target”). Such women accordingly have a higher susceptibility to LH-mediated ovarian testosterone production. Unless their ovarian exposure to LKH is regulated through the application of very individualized ovarian stimulation protocols, they will be predisposed to producing poor quality eggs and embryos and to having poor IVF birth rates.
1. Use of Agonist- “Flare protocols” in women who have diminished ovarian and/or and some women who are high responders (those with polycystic ovarian syndrome (PCOS)).