| BackgroundEndometriosis is a common disease in reproductive women. It is a persistence process that is derived from cellular level and results in pelvic pain and infertility. Endometriosis may cause the poor quality of oocyte and early embryo, the reduction of implantation rate induced by lower endometrial receptivity. Pelvic adhesion in severe endometriosis affects the process of ovulation, ovum capture and zygote transfer. As a result, the incidence rate of infertility is much higher in women with endometriosis. The technique of in vitro fertilization-embryo transfer (IVF-ET) has become an important way to treat endometriosis-associated infertility. Many studies have demonstrated the outcome of IVF-ET in patients with endometriosis is poorer than other infertile ones. Therefore, a lot of scholars make efforts to improve the pregnancy rate of endometriosis-associated infertile people in IVF cycles.Gonadotropin-releasing hormone (GnRH) agonist may cause the down-regulation and desensitivity to GnRH receptor. Several studies have demonstrated that GnRH agonist could correct the pelvic internal environment inpatients with endometriosis. Accordingly, it has been suggested that pretreatment with GnRH agonist for a few months prior to IVF in patients with endometriosis may improve their outcome of pregnancy. A protocol that ovarian stimulation is taken immediately after administering GnRH agonist for three to six months prior to IVF -ET in women with endometriosis is called ultralong protocol of controlled ovarian hyperstimulation (COH). Its impact on ovarian response and outcome of pregnancy in IVF cycles are still in controversial. And its mechanism is still uncertain. With deep suppression of pituitary, the secretion of FSH is kept in a very low level by the ultralong protocol of COH. There is no reported whether the low FSH level will make changes on the expression of FSHR in ovary. ObjectiveThe purposes of this research were: l.To compare the ovarian response and IVF outcome of patients with severe endometriosis during IVF-ET cycles between the groups of ultralong protocol and standard long protocol. 2. To detect the expression of FSHR mRNA in luteinized granulosa cells with semiquantitative RT-PCR and compare the difference of the expression level between two groups. 3. To investigate the correlation between the expression levels of FSHR mRNA in luteinized granulosacells to the ovarian response and IVF outcome. Materials and methodsIVF-ET candidates were patients with surgically confirmed endometriosis of III to IV stage in the reproductive center of our hospital during July 2005 to March 2006. Eighteen patients received three courses of a long-acting GnRH agonist, 3.6 mg i.m. every 28 days, followed by standard controlled ovarian hyperstimulation (COH) immediately (ultralong protocol group). Twenty-four patients received standard COH with mid-luteal phase GnRH agonist down-regulation (standard protocol group). None was interfered with hormone treatment six months prior to IVF-ET program. Fasting blood samples and follicular fluid were collected on the day of oocytes retrieved. Theconcentration of serum E2 was measured by ECLIA. Granulosa cells were extracted from follicular fluid by Ficoll method, and RT-PCR was used to measure the expression level of FSHR mRNA. The total dosage and initial dose of rFSH, duration of ovarian stimulation, number of oocytes retrieved, fertilize eggs, cleavage eggs, high quality embryos and the outcomes of pregnancy were recorded. The rate of fertilization, cleavage, high quality embryo, implantation and pregnancy werecalculated. ResultsThe total dosage of rFSH was significantly higher in the ultralong group compared with that of standard group (PO.05), and no significance was found in initial dose of rFSH, duration of ovarian stimulation, serum E2 level and the number of oocytes retrieved between the two groups (P>=0.05)The high quality embryo rate was significantly higher in the ultralong group than that in the standard group (PO.05). The rate of fertilization and cleavage were at the same level in two groups . A trend toward higher implantation rate and pregnancy rate was found in the ultralong group, although no significant difference to standard group (P>0.05).FSHR mRNA was found positive in luteinized granulosa cells of all the patients, and had no significant difference in expression level between the two groups (P>0.05).The expression level of FSHR mRNA in luteinized granulosa cells had no correlation to the total dosage of rFSH, duration, serum E2 level and the number of oocytes retrieved (P>0.05).The expression level of FSHR mRNA in luteinized granulosa cells had no correlation to the fertilization rate, cleavage rate, high quality embryo rate and implantation rate (P>0.05). The expression of FSHR mRNA changed little wheneverpregnancy (P>0.05). ConclusionsThe ultralong protocol increased the total dosage of rFSH in IVF cycles in patients with stage III to IV endometriosis, but had no significant effects on the days of medication, serum E2 level and the number of oocytes retrieved.The ultralong protocol resulted in significantly higher rate of high quality embryo in patients with stage III to IV endometriosis, and may increase the implantation rate and pregnancy rate, but did no help in improving the fertilization rate and cleavage rate.The ultralong protocol did not change the expression of FSHR-mRNA in luteinized granulosa cells in patients with stage III to IV endometriosis and the expression of FSHR mRNA had no correlation to either the responsibility of ovary or outcome of pregnancy.
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