The significance of plasma progesterone levels during early pregnancies achieved after in vitro fertilization (IVF) treatment

Ectopic pregnancy

Ectopic pregnancy is an important cause of morbidity and mortality worldwide. Use of transvaginal ultrasonography and quantitative measurement of the beta subunit of human chorionic gonadotropin (beta-hCG) has led to a reduction in the need for diagnostic laparoscopy. Furthermore, with earlier diagnosis, medical therapy with methotrexate can be offered and surgery avoided in some women, though the best regimen remains unclear. In the surgical management of ectopic pregnancy, the benefits of salpingectomy over salpingostomy are uncertain. Although there have been advances in the management of ectopic pregnancy there are still questions to be answered.

Day 14 maternal serum progesterone levels predict pregnancy outcome in IVF/ICSI treatment cycles: a prospective study

BACKGROUND

Serum progesterone has been advocated as a tool in the diagnosis of early pregnancy failure. We conducted this prospective study in order to investigate the potential value of early (14 days after oocyte recovery) serum progesterone measurement, in women undergoing IVF/ICSI and receiving rectal progesterone supplements, in relation to pregnancy outcome.

METHODS

442 women consecutively treated by IVF or ICSI had serum progesterone and bhCG levels prospectively measured 14 days after oocyte retrieval (day 0). All women received natural progesterone 400 mg rectally until the pregnancy test on day 14. Pregnant women were followed up by serial transvaginal ultrasound scans to 8 weeks gestation.

RESULTS

115 women (26%) had a viable intra-uterine pregnancy at 8 weeks gestation, 80 (18.1%) had an abnormal pregnancy (biochemical, ectopic, miscarriage) and 247 (55.9%) failed to conceive. Women with on-going pregnancies had significantly higher serum progesterone levels (median: 430, 95%CI: 390-500 nmol/l) compared to those who had either an abnormal pregnancy (72, 48-96 nmol/l; P < 0.001) or failed to conceive (33, 28-37 nmol/l; P < 0.001). Receiver-operator curve analysis demonstrated that a single serum progesterone on day 14 post-oocyte retrieval, could highly differentiate between normal and abnormal pregnancies (area under the curve = 0.927, 95%CI = 0.89-0.96; P < 0.0001).

CONCLUSIONS

In spite of exogenous progesterone supplementation, serum progesterone levels, from as early as 4 weeks gestation (day 14 post-oocyte retrieval) were significantly elevated and predicted women destined to have viable intra-uterine pregnancies. These high levels are suggestive that endogenous progesterone is already sufficient in viable pregnancies and that exogenous progesterone administration will not rescue a pregnancy destined to result in a miscarriage. Single serum progesterone measurement could be a useful indicator of pregnancy outcome in women undergoing IVF or ICSI treatment.

Ectopic pregnancies after infertility treatment: modern diagnosis and therapeutic strategy

Ectopic pregnancy (EP) is a major event in a woman's reproductive life. It complicates infertility treatment and must be recognized early to simplify the treatment strategy, which must always be directed towards optimizing subsequent fertility. Epidemiological findings indicate that tubal history and smoking are the principal risk factors of those EP that are considered reproductive (rather than contraceptive) failures. Adding together the attributable risks for EP allows the construction of a risk scale to determine its probability for any given patient. This risk calculation makes it easier to establish a diagnostic strategy that uses abdominal and transvaginal ultrasound and hCG assays. Progesterone assays are useful only for determining the activity of the pregnancy but do not help to identify its site. Conservative treatment is to be preferred unless the EP occurs on a known hydrosalpinx. All the treatment trials and the Cochrane database meta-analysis show that medical treatment with methotrexate, preferably multidose, is equivalent in efficacy to conservative treatment with laparoscopy in the populations studied. Heterotopic pregnancies, which occur most often after assisted reproduction technology (1-3%), should preferably be treated by salpingectomy except in interstitial sites. There is no consensus that IVF is indicated after EP. The patient's age is probably the determining factor: fertility treatment should not be delayed to an age where the results would be altered, especially with the risk of a recurrent EP.

Down's syndrome screening in pregnancies after assisted reproductive techniques: an update

Assisted reproductive techniques have increased the number of pregnant women beyond the age of 35 years and the incidence of multiple pregnancies. Various non-invasive screening methods for Down's syndrome were introduced in clinical practice during the past two decades. Specific problems were encountered when these methods were applied for pregnancies achieved by assisted reproduction treatment and the aim of this review is to explore these issues and propose an adjusted methodological approach for this highly selected population. Overall, more women with assisted reproduction singleton pregnancies are found to be false-positive for Down's syndrome. This is because standard screening algorithms include maternal age. In addition, mid-trimester maternal serum screening is associated with a higher false-positive rate. This is due to changes in the feto-placental endocrinological metabolism in pregnancies achieved by assisted reproduction treatment. Ultrasound screening of Down's syndrome by means of nuchal translucency (NT) measurements at 10-14 weeks is associated with a lower false-positive rate than mid-trimester serum screening. The lowest false-positive rates reported in singleton pregnancies are observed when serum and nuchal translucency screening are combined at 10-14 weeks. In multiple pregnancies, mid-trimester maternal serum screening is of limited clinical value. Nuchal translucency measurement is among the best available and is the most efficient screening method for multiple pregnancies. This sonographical method for screening enables specific identification of those fetuses at high risk of Down's syndrome and other anomalies, and thus contributes to a better outcome. Therefore, it should be systematically performed before any fetal reduction in high-order multiple pregnancies is planned.

Comparison of triple serum screening and pregnancy outcome in oocyte donation versus IVF pregnancies

The current study compared triple serum screening results and outcomes in 37 oocyte donation (OD) and 46 self oocyte IVF-conceived singletons of similarly aged women (28.8 +/- 4.4 years and 30.7 +/- 4.5 years respectively). Both groups were followed from their embryo transfer and throughout pregnancy. Although the daily pattern of first-trimester serum beta-human chorionic gonadotrophin (HCG) was similar in both groups, higher mid-gestation HCG serum concentrations were found, i.e. 1.38 and 1.32 multiples of the median (median MoM) for IVF and OD respectively, in comparison with 0.99 median MoM from the same reference laboratory. Only the OD group had significantly increased alpha fetoprotein (AFP) concentrations (1.45 median MoM) (P = 0.002) compared with the reference laboratory. A total of 11% of the IVF and 13% of the OD women were found to be screen positive. In neither group were chromosomal abnormalities detected and no fetal or neonatal deaths were recorded. Seven (15%) of the OD and seven (19%) of the IVF women had an adverse obstetric outcome. Of those cases, six IVF and four OD women had serum HCG > or = 1.2 MoM and five OD women had AFP >1.2 MoM. Therefore, in those pregnancies the high serum HCG concentrations may alert for adverse obstetric outcome rather than indicating a high risk for Down's syndrome fetuses.