**4.1. Summary points**

62 Enhancing Success of Assisted Reproduction

differences in pregnancy outcomes between the study arms.

improvement in pregnancy outcomes was demonstrated (99).

**Table 2.** Meta-analyses comparing rLH plus rFSH versus rFSH only.

Author, Year RTCs Number of

results.

Three RCT have shown higher implantation or pregnancy rates in women receiving rLH supplementation (24, 38, 94). Patients with an inadequate response to rFSH alone have also been shown to benefit from the addition of 150IU of rLH as compared to increasing the FSH dose by 150IU (39). However, the vast majority of RCT evaluating rLH have failed to show an improvement in clinical pregnancy when compared to rFSH alone (29, 30, 36, 37, 40, 41, 86-89, 91, 92, 95). The majority of these trials were underpowered to detect for small

Four meta-analyses have been done to compare the outcomes of RCTs evaluating the use of rLH in ovarian stimulation (96-99). Kolibianakis *et al.* demonstrated no difference in live birth with the use of rLH, including in sub-analysis of early and mid-follicular administration or GnRH antagonist and agonist administration (97). Baruffi *et al.* did demonstrated a higher serum estradiol on the day of hCG (+514 pg/ml) and a higher number of MII oocytes retrieved (+0.88) with the use or rLH, but these differences did not translate into improve clinical pregnancy (96). In the largest meta-analysis, Mochtar *et al.*  demonstrated a trend towards improved live birth with rLH, but the result did not reach statistical significance (OR 1.22, 95%CI 0.95-1.56) (98). However, pooled analysis did show an improvement in live birth for poor responders who were stimulated with rLH (OR 1.85, 95% CI1.10-3.11) (98). rLH was shown to have increased estradiol, fewer days of stimulation, and lower FSH administration in a fourth meta-analysis, although once again no

Patients

The data from the RCT and meta-analyses evaluating rLH is similar to that of hMG in showing a reduction in the amount of FSH required for stimulation and an increase in serum estradiol. However, these data differ in that they do not show a convincing increase in pregnancy outcomes. It is possible that this is due to the smaller numbers in the rLH meta-analysis. Only the Mochtar *et al.* paper had a power similar to that of the hMG metaanalysis to detect for live birth as an outcome. The heterogeneity within the design and results of the rLH studies themselves also is associated with a decreased power to detect for pregnancy outcomes and a wide confidence interval. It is also possible that the differences seen in the meta-analyses between rLH and hMG is not only statistical, but also due to the differences in the pharmaceuticals themselves. Differences in the glycosylation of LH between urinary and recombinant preparations and the addition of hCG to urinary preparations may lead to fundamental differences in biologic action which affect clinical

Baruffi, 2007 5 434 0.89 (0.57-1.36) Kolibianakis, 2007 7 701 0.92 (0.65-1.31) Mochtar, 2007 14 2612 1.22 (0.95-1.56) Oliveira, 2007 5 1225 1.10 (0.85-1.42)

Pregnancy Odds Ratio (95% CI)

