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Introduction: Luteinizing hormone (LH) is critically involved in the physiological events that lead to the development of a reproductively competent preovulatory follicle. LH plays a key role in the intermediate-late phases of folliculogenesis (1). In the course of the follicular phase, FSH stimulates granulosa cells to express LH receptors (2). Thus, in the late stages of follicle development, once antral ovarian follicle diameter increases beyond roughly 10 mm, LH receptors are expressed by granulosa cells which become receptive to LH stimulation; LH is then capable of exerting its actions on both theca and granulosa cells (3). It has been postulated that the maturing follicle reduces its dependence on FSH by acquiring LH receptors (4, 5).
In patients on GnRH agonist long protocol, the impact of suppressed endogenous LH levels, on the outcome is still debatable. It was reported that lower estradiol synthesis (6, 7), lower oocyte and embryo yield (6, 8), lower fertilization rate (9), and higher frequency of early pregnancy wastage (10) were observed in women down regulated with a GnRH agonist and stimulated with pure FSH preparations. Conversely, some authors suggested that LH had a negative effect on oocyte quality and IVF outcome (11, 12). Others failed to detect any relationship between serum LH levels and stimulation outcome (13).
In this study we are evaluating the value of providing LH stimulation during the late stages of follicular development. We are testing the effect of such LH supplementation on the outcome of ICSI cycles.
Participants and methods: The present study was carried out during the period from May 2008 to August 2009 at a private hospital. Local institute approval was taken before starting the study. Informed consents were taken from participating patients.
Four hundred seventy three couples were recruited for this study. Inclusion criteria included; male factor infertility, or unexplained infertility, age less than 40 years, basal FSH less than 10 mIU/ml, BMI less than 35 kg/m2 , and regular menstrual cycles. Exclusion criteria included; clinical or ultrasound evidence of PCOS or endometriosis, previous poor response (less than 3 mature follicles on day of HCG), previous 3 failed ICSI trials, current smoking, and any systemic or local disease that could affect outcome, such as diabetes mellitus, ovarian neoplasm or uterine fibroids. Patients were quasi randomized into the study or the control group according to the file number; even numbers served as experimental group where as odd number served as control group.
On day 2-5 of the cycle prior to the start of the IVF program, all patients were exposed to history taking, clinical examination, transvaginal ultrasound assessment of the antral follicle count (AFC), and base line hormonal profile including FSH, LH TSH, PRL, and testosterone.
Controlled ovarian stimulation was done according to the long protocol. Patients received down regulation in the form of leuprolide depot I.M. (Lupron; Abbott Laboratories, IL, U.S.A.) on day 21 of the cycle. On the 2nd day of the treatment cycle, down regulation was confirmed by ultrasound examination of the ovaries as well as by serum assay of estradiol. Highly purified FSH preparation (Fostimon, IBSA Institut Biochimique Switzerland) was given daily in a dose of 150- 300 IU per day. The initial dose was given according to the age, BMI, basal FSH level, and the AFC. The dose was given daily for 7 days then adjusted according to the ultrasound findings. In the study group, Fostimon was replaced with HP-HMG (Merional, IBSA Institut Biochimique Switzerland) when the leading follicle is 10-12 mm. In the control group Fostimon was continued until the HCG injection. HCG (Choriomon, IBSA Institut Biochimique Switzerland) 10.000 IU was given I.M. once the leading follicle reached 18-20 mm. Ovarian stimulation was monitored every other day using a transvaginal ultrasound scanner (Accuvix XQ, Medison, Korea), with a 4-7 MHz probe. Cycles were cancelled if there were less than 3 follicles or more than 25 follicles > 16 mm on the day of HCG. Ovum pickup was scheduled 36 hours after the HCG shot. All patients underwent ICSI procedure. Two- three embryos were transferred on day 2-3 following the pickup using a soft embryo transfer catheter (Wallace Sure-Pro, UK). Embryos were graded according to cell equality, cytoplasmic appearance and degree of fragmentation (14, 15). Luteal support was given in the form of natural vaginal progesterone (Uterogestan, October Pharma, Egypt). Clinical pregnancy was diagnosed by ultrasound evidence of the presence of one or more gestational sacs with fetal heart pulsation.
The main outcome was the clinical pregnancy rate. Secondary outcomes included the number of stimulation days, total number of ampoules, total number of embryos, and number of cancelled cycles.
To calculate sample size, we expected a clinical pregnancy rate of 25% in the control group. We assumed a difference of 15% in either direction would be clinically significant. With an alpha level of 0.05 and statistical power of 90%, the calculated sample size would be 200 in each arm. To compensate for discontinuation, drop outs and cancellation, we aimed to recruit at least 210 patients in each arm. Data were expressed as mean, standard deviation (SD), and percentage. Independent samples were compared using the student t test or Mann Whitney test as appropriate. The chi square test was used for categorical data. P<0.05 was considered to indicate statistical significance. Statistical analysis was done using the MedCalc (MedCalc Software, Ghent, Belgium).
Results:A total of 473 couples participated in this study assigned into 2 groups; group A, the control group comprised 262 patients and group B; the study group comprised 211 patients. The basic characteristics of the patients were similar: no statistical differences were found in the age of the patients, duration of infertility, AFC, and BMI in either group.
This is shown in table (1).
Table 1: Basic characteristics of patients

The clinical pregnancy rate in group B, the study group was significantly higher than that of group A, the control group (40% versus 29%, p < 0.05). The odds ratio was 1.59 (95% CI 1.06-2.37). The number of stimulation days was significantly higher in the group B compared to group A (p < 0.01). The total number of ampoules used was significantly higher in group B compared to group A (56.97 ± 15.60 Vs 41.63 ± 9.81, p < 0.01). Regression analysis was done as pregnancy an dependent point and attributed these results to the use of purified hMG and to a difference in BMI.
There was no significant difference between the 2 groups regarding the total number of embryos, the number of good embryos transferred, number of fair embryos transferred, the number of freeze embryos, and the number of cancelled cycles. These data are shown in table (2). There was one case of ectopic pregnancy in the control group.

Table 2: Characteristics of the cycles:

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