European Journal of Obstetrics & Gynecology and

Reproductive Biology 126 (2006) 77–80

www.elsevier.com/locate/ejogrb

Pituitary desensitization for eight weeks after the administration

of two distinct gonadotrophin-releasing hormone agonists
Maria Matteo a,*, Ettore Caroppo b, Orion Gliozheni c, Domenico Carone b,
Luca Maria Schonauer b, Giovanni Vizziello b,
Pantaleo Greco a, Giuseppe D’Amato b
a
Operative Unit of Obstetric and Gynecology, Department of Surgical Sciences, University of Foggia, Foggia, Italy
b
Operative Unit of Physiopathology of Human Reproduction, I.R.C.C.S. ‘‘Saverio de Bellis’’, Castellana Grotte (Ba), Italy
c
Department of Obstetrics and Gynecology, University of Tirana, Tirana, Albania
Received 5 January 2005; received in revised form 17 August 2005; accepted 21 September 2005

Abstract

Objective(s): The objective was to evaluate the duration of pituitary desensitization after the administration of 3.5 mg of triptorelin (T) and
leuprolin (L) depot preparations in patients with endometriosis.
Study design: Two groups of 30 patients received, on 21st day of the cycle, 3.75 mg i.m. of triptorelin (T group), and of leuprolin acetate (L
group). From the first to the eighth week following gonadotrophin-releasing hormone agonists (GnRH-a) administration both groups
underwent pelvic ultrasound and serum follicle-stimulating hormone (FSH), luteinizing hormone (LH) and estradiol (E2) evaluation.
Statistical analysis was performed using the ANOVA test and the median test. A p-value < 0.05 was considered significant.
Results: Pituitary suppression was achieved from two to six and from two to seven weeks after the administration of 3.75 mg of leuprolin and
triptorelin, respectively. FSH and LH serum levels were significantly higher in the L group than in the T group after the fourth week.
Conclusions: Leuprolin and triptorelin depots (3.75 mg) promote satisfactory ovarian suppression lasting for six and seven weeks,
respectively, after administration, with significantly different ambient levels of endogenous LH.
# 2005 Elsevier Ireland Ltd. All rights reserved.

Keywords: GnRH analogues; Pituitary desensitization; LH; Triptorelin; Leuprolin

1. Introduction profound pituitary suppression and to induce luteal phase

Several studies have evaluated the use of gonadotrophin-
releasing hormone agonists (GnRH-a) in various prepara-
tions for the achievement of pituitary desensitization during
ovarian stimulation protocols prior to IVF cycles. Depot
preparations have been found to be likewise effective as
daily administration of GnRH-a with regard to the
promotion of pituitary suppression, with the additional
advantage of improved patient compliance [1,2]. Short-
acting depot preparations have been preferred to long-acting
ones, because the latter were found to be responsible for
* Corresponding author. Present address: Via G. Zanardelli no. 83, 70100
Bari, Italy. Tel.: +39 347 3692296; fax: +39 0881 732350.
E-mail address: m.matteo@unifg.it (M. Matteo).
defects, adversely affecting the pregnancy rate and increas-
ing the miscarriage rate [3].
However, most of the studies comparing distinct GnRH-a
depot preparations were carried out to evaluate their
therapeutic role in patients with prostate cancer and
endometriosis, restricting their analysis to the first four
weeks after the administration of the analogue [4].
The aim of this study was to evaluate pituitary
desensitization over the subsequent eight weeks after a
single dose of triptorelin (T) and leuprolin (L) depot
preparations in patients affected by endometriosis, in order
to assess the effective duration of the ovarian suppression
and the differences in follicle-stimulating hormone (FSH)
and luteinizing hormone (LH) suppression profiles pro-
moted by the two distinct GnRH analogues.

0301-2115/$ – see front matter # 2005 Elsevier Ireland Ltd. All rights reserved.
doi:10.1016/j.ejogrb.2005.09.018
78 M. Matteo et al. / European Journal of Obstetrics & Gynecology and Reproductive Biology 126 (2006) 77–80

2. Materials and methods

Sixty patients referred to our infertility center, aged 25–

34 years, with pelvic endometriosis American Fertility
Society stages I and II diagnosed at laparoscopy, were
enrolled in the study. Written informed consent was obtained
from each patient before entering the protocol.
All patients were comparable with regard to age, body
mass index (BMI) and grade of endometriosis. None had
endocrine abnormalities or received hormonal treatment
over the past three months. Computer-assisted randomiza-
tion was performed, and the patients recruited were
randomly allocated into two groups. Thirty patients (T
group) received a single dose of 3.75 mg i.m. of triptorelin
(Decapeptyl; Ipsen, France) on the 21st day of the
menstrual cycle; the other 30 patients (L group) received
a comparable dose of leuprolin acetate (Enantone; Takeda
IMC, Japan) on the same day of the menstrual cycle.
Patients underwent ultrasound pelvic examination and
evaluation of the FSH, LH and estradiol (E2) serum levels
before starting the treatment, on day 3 of the menstrual
cycle, and from the first to the eighth week following
GnRH-a administration.
Cut-off limits for satisfactory ovarian suppression were:
LH  1 mUI/ml, E2  50 pg/ml, absence of ovarian folli-
cles with diameters >10 mm and endometrial thickness of
3 mm at transvaginal US examination. The sample size for
the study was calculated in order to be 90% certain to detect
a difference as small as 25% between the two treatment
groups.
Statistical analysis was performed by means of the
ANOVA test and the median test. Results were expressed as
means  S.D. In all analyses a p-value < 0.05 was
considered to be statistically significant.
3. Results
The treatment and all the procedures performed were well
tolerated; only two patients from each group dropped out.
The clinical features and basal hormonal profile of the
patients enrolled are displayed in Table 1.
Table 1
Clinical features and basal hormonal profile of patients enrolled in the study,
expressed as means  S.D.
Triptorelin
group (n = 30)
Age (years) 28  3.00
Weight (kg) 65  6.23
BMI (kg/m2) 27  3.00
Cycle length (days) 29.4  0.63
E2 day 3 (pg/ml) 60  15.02
FSH day 3 (IU/ml) 4.7  0.93
LH day 3 (IU/ml) 3.6  1.05
Fig. 1. FSH (A) and LH (B) serum levels during eight week after the
administration of a single dose of triptorelin and leuprolin depot prepara-
tion. Values are in means  S.D.
There was no significant difference between the two
groups in terms of age, BMI, cycle length and hormonal
profile on day 3 of the menstrual cycle. The weekly
determinations of serum FSH and LH expressed as means
against time (weeks), are shown in Fig. 1. Complete ovarian
suppression was achieved from the second to the sixth week
after the administration of a single dose of L depot
preparation, as well as from the second until the seventh
week after a single dose of T depot preparation, since no rise
in LH serum levels up to the defined threshold values was
observed (Fig. 1B) and E2 serum levels, the endometrial
thickness and ovarian follicles did not differ from the cut-off
limits for suppression. The ANOVA test revealed significant
differences in the overall time-related variation of FSH and
LH levels between the two groups over eight weeks after T
and L depot administration (F = 5.68, p < 0.05 for FSH;
F = 10.40, p < 0.05 for LH). Moreover, by means of the
median test the curves of each group were independently
analyzed and then compared at each time-point. There was
no significant difference between the two groups in the
suppression curve for FSH until the fourth week after
Leuprolin
group (n = 30) administration. From the fifth to the eighth week, FSH
increased and had significantly higher results in the L group
28  3.70
67  4.21 than in the T group (Fig. 1A; Table 2). LH serum levels in the
26  3.72 L group did not differ during the second, third and fourth
28.9  0.91 weeks compared with the T group, but had significantly
58  10.00 higher results after one week, and five to eight weeks after
4.5  1.23
GnRH-a administration compared with the T group (Fig. 1B;
3.8  0.82
Table 2).
 M. Matteo et al. / European Journal of Obstetrics & Gynecology and Reproductive Biology 126 (2006) 77–80
Table 2
FSH and LH serum levels of each group expressed as means  S.D. during eight weeks after administration of L and T depot GnRH-a, compared at each time-
point by mean of median test
FSH levels (mUI/ml)
Weeks T group L group
1 2.28  0.19 2.17  0.12
2 1.48  0.23 1.52  0.34
3 1.19  0.19 1.36  0.11
4 1.16  0.16 1.64  0.15
5 3.39  0.26 4.50  0.18
6 3.81  0.24 4.85  0.19
7 6.38  0.30 7.15  0.33
8 5.29  0.65 6.57  0.52
4. Discussion
Over the last decade GnRH-a have been largely
employed in IVF centers. GnRH-a derive from modifica-
tions of the parent decapeptide, GnRH and their action is
based upon a reversible blockade of pituitary gonadotrophin
release, resulting in stable suppression of the ovarian
function [3]. The selection of which long-acting preparation
of GnRH-a to use should depend on its potency, duration of
action, side effects and IVF outcome.
Studies comparing the IVF outcome of different GnRH-a
depot preparations showed that the use of triptorelin was
associated with a lower frequency of ovarian hyperstimula-
tion, lower embryo production and a lower number of IVF
cycles with cryopreservation of supernumerary embryos
compared with those cycles employing leuprolin [5],
suggesting a difference in the potency and the duration of
action of the two GnRH-a molecules. To the best of our
knowledge this is the first study in the literature in which the
duration of pituitary desensitization and the relative efficacy
of FSH and LH suppression over eight weeks after the
administration of two distinct GnRH analogues have been
compared. The results of this study demonstrate that
satisfactory ovarian suppression was achieved from the
second to the sixth and from the second to the seventh week
after the administration of a single dose of leuprolin and
triptorelin depot preparations, respectively, since no rise in
LH serum levels over the defined threshold value was
observed (Fig. 1B) and E2 serum levels, the endometrial
thickness and ovarian follicles did not differ from the cut-off
limits for suppression.
Our findings agree with data reported in literature that
demonstrated that depot preparations had a duration of
action of almost seven weeks [6], and that T depots were as
capable as L depots of inducing pituitary suppression, T
having a longer duration of action that allows its
administration at longer intervals in patients with endome-
triosis [4]. Another interesting finding arising from this
study is the different suppression regimens of FSH and LH
produced by the two GnRH analogues. There was no
difference in FSH suppression until the fourth week after L
and T administration, then FSH levels rose in both groups,
79
LH levels (mUI/ml)
p-Value T group L group p-Value
NS 1.58  0.12 1.46  0.09 <0.05
NS 1.02  0.10 1.07  0.08 NS
NS 0.52  0.08 0.58  0.11 NS
NS 0.45  0.09 0.53  0.13 NS
<0.05 0.21  0.07 0.73  0.18 <0.05
<0.05 0.19  0.06 0.80  0.13 <0.05
<0.05 1.28  0.10 1.80  0.17 <0.05
<0.05 1.27  0.07 2.68  0.11 <0.05
but produced significantly higher results in the L group than
in the T group (Table 2). With regard to the LH suppression
profile, in the T group we observed a profound suppression
of LH (<0.5 mIU/ml) from the third until the sixth week
after triptorelin administration, then LH increased and rose
up over its threshold value for suppression at the eighth week
after triptorelin administration (Fig. 1B). On the contrary,
only in the third and fourth week after leuprolin adminis-
tration did L group women show comparable LH levels to
those of the T group women. After the fourth week, LH
serum levels increased over 0.5 mUI/ml and were sig-
nificantly higher than those observed in the T group, rising
up over their threshold value in the seventh week after
administration (Fig. 1B). These findings could be explained
by the different sensitivity of the gonadotrophin cells to the
desensitization induced by these GnRH analogues, suggest-
ing that triptorelin and leuprolin exert different down-
regulation effects on FSH and LH secretion.
Our data could support the evidence regarding the
different influence of these long-acting GnRH analogues
on implantation and pregnancy rates in IVF cycles. In
more detail, a significant increase in both implantation and
pregnancy rates was found when L depots were compared
with T depots in controlled ovarian hyperstimulation
(COH) for IVF by several authors [7,8]. Whether the
increase in implantation and pregnancy rates could be
attributable to a significant improvement in oocyte quality,
to a better endometrial receptivity or to an increased
oocyte number is still unknown [8], but we can
hypothesize that the difference in ambient levels of
endogenous LH during ovarian stimulation might play a
crucial role in these parameters. LH is a glycoprotein
hormone necessary for steroidogenesis [9], which peaks
mid-cycle and is responsible for reinitiating meiosis I in
the preovulatory follicle [10]. This timing is crucial to
ensure egg maturity, successful fertilization and proper
embryo development. Recent reports demonstrated that
follicular fluid (FF) estradiol levels, oocyte yield and
fertilization improved when LH levels were higher than
0.5–1 mIU/ml [11,12]. Studies on normogonadotropic
women undergoing IVF or ICSI found that the risk of
early pregnancy loss was significantly higher in the group
80 M. Matteo et al. / European Journal of Obstetrics & Gynecology and Reproductive Biology 126 (2006) 77–80
of patients with mid-follicular LH serum levels lower than
0.5 mIU/ml on stimulation day 8, suggesting the addition
of recombinant LH to an ovarian stimulation protocol
when periovulatory LH concentration is low [13–15].
Since our results demonstrate satisfactory ovarian sup-
pression until the seventh week in the T group and until the
sixth week in the L group, an increase in the ambient level
of endogenous LH could be achieved, postponing the
ovarian stimulation in the fifth and in the sixth week after
the administration of a single dose of leuprolin or
triptorelin depot preparation, respectively, in order to
achieve the mean LH concentration of >0.5 mIU/ml
required for a proper oocyte maturation, as previously
suggested [13].
In conclusion, the results of this study demonstrate that
satisfactory ovarian suppression could be achieved for sixth
and seven weeks after the administration of a single dose of
3.75 mg of L and T depot preparations, respectively. The
demonstrated difference in LH suppression produced by the
two GnRH analogues may be of importance for obtaining
the best endogenous hormonal profile during controlled
ovarian stimulation for IVF cycles.
References
[1] Balasch J, Jove IC, Moreno V, Civico S, Puerto B, Vanrell JA. The
comparison of the two GNRH-a in an in vitro fertilization program.
Fertil Steril 1992;58:991–4.
[2] Porcu E, Filicori M, Dal Parto L, Fabbin R, Serachioli R, Colombi C,
et al. Comparison between depot leuprorelin and daily buserelin in
IVF. J Assist Reprod Genet 1995;12:15–9.
[3] Dada T, Salha O, Baillie HS, Sharma VS. A comparison of three
gonadotrophin-releasing hormone analogues in an in vitro fertilization
programme: a prospective randomized study. Hum Reprod
1999;14:288–93.
[4] Cheung T, Lo KW, Lam CW, Lau W, Lam PK. A crossover study of
triptorelin and leuprorelin acetate. Fertil Steril 2000;74:299–305.
[5] Vauthier-Brouzes D, Lefebvre G. Comparison of 3 long ovarian
stimulation protocols for in vitro fertilization using a delayed acting
GnRH analogue. Contracept Fertil Sex 1993;21:209–12.
[6] Broekmans FJ, Bernardus RE, Berkhout G, Shoemaker J. Pituitary and
ovarian suppression after early follicular and mid-luteal administration
of a LHRH agonist in a depot formation: decapeptyl CR. Gynaecol
Endocrinol 1992;6:153–61.
[7] Neuspiller F, Levy M, Remhoi J, Ruiz A, Simon C, Pellicer A. The use
of long and short acting forms of gonadotrophin releasing hormone
analogues in women undergoing oocyte donation. Hum Reprod
1998;13:1148–51.
[8] Orvieto R, Kerner R, Krissi H, Ashkenazi J, Ben Rafael Z, Bar-Hava I.
Comparison of leuprolide acetate and triptorelin in assisted reproduc-
tive technology cycles: a prospective randomized study. Fertil Steril
2002;78:1268–71.
[9] Speroff L, Glass RH, Kase NG. Hormone biosynthesis, metabolism,
and mechanism of action. In: Clinical gynecologic endocrinology
and infertility. 5th ed., Baltimore: Williams & Wilkins editors; 1994.
p. 69.
[10] Shoham Z, Jacobs HS, Insler V. Luteinizing hormone: its role,
mechanism of action, and detrimental effects when hypersecreted
during the follicular phase. Fertil Steril 1993;59:1153–61.
[11] Fleming R, Chung CC, Yates RW, Coutts JR. Purified urinary follicle
stimulating hormone induces different hormonal profiles compared
with menotrophins, dependent upon the route of administration and
endogenous luteinizing hormone activity. Hum Reprod
1996;11:1854–8.
[12] Loyd F, Herbert M, Fenwick J, Griffiths T, Murdoch A, Fleming R.
Prospective determination of the effects of profound LH suppression
on follicular activity and oocyte and embryo function in cycles
stimulated with purified FSH. Hum Reprod 1997;12:101–2.
[13] Westergaard LG, Laursen SB, Yding Andersen C. Increased risk of
early pregnancy loss by profound suppression of luteinizing hormone
during ovarian stimulation in normogonadotrophic women undergoing
assisted reproduction. Hum Reprod 2000;15:1003–8.
[14] Esposito MA, Barnhart KT, Coutifaris C, Patrizio P. Role of perio-
vulatory luteinizing hormone concentrations during assisted repro-
ductive technology cycles stimulated exclusively with recombinant
follicle stimulating hormone. Fertil Steril 2001;75:519–24.
[15] Tesarik J, Mendoza C. Effects of exogenous LH administration during
ovarian stimulation of pituitary down-regulated young oocyte donors
on oocyte yield and developmental competence. Hum Reprod
2002;17:3129–36.