الفهرس 
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Abstract
Although the role of follicle stimulating hormone (FSH) in ART cycles has been well established and FSH alone can lead to successful follicular development, the role of luteinizing hormone (LH) supplementation to the mid-follicular phase in ovarian stimulation, is still debatable.
The expression of LH receptors is induced by FSH on the granulosa cell membranes of developing follicles of >10 mm diameter. After that, LH could replace FSH as the principle regulator for follicular development during late follicular phase.
As LH is not normally present in follicular fluid until the midcycle, so if it is prematurely elevated in the plasma and follicular fluid, mitotic activity in the granulosa decreases, degenerative changes occur, and intrafollicular androgen levels rise.
The aim of this prospective study was to evaluate the effect of adding hp-hMG to ovarian stimulation from early follicular phase, on follicular apoptosis.
The study included 100 normal responder women who underwent ICSI and received either; group I (Concomitant protocol): Concomitant FSH and highly purified human menopausal gonadotropin (HP-HMG) from start of stimulation, or group II (Sequential protocol): FSH only at the beginning of ovarian stimulation then substitution of FSH by hp-hMG when the follicle reached 12mm or more, and was continued till the day of triggering of ovulation. Serum hCG was measured and follicular fluid sFas was measured as a marker for apoptosis.
All subjects were followed till confirmation of cardiac pulsations 3-4 weeks after embryo transfer.
The results showed that using the sequential protocol had significant better ICSI outcomes as regards MII percentage, fertilization rate, but no difference in top quality embryos and clinical pregnancy rate. Follicular fluid sFas was significantly lower with sequential protocol, and was associated with lower number of oocytes but not associated with poor oocyte quality.