Increased implantation rate after intrauterine infusion of a small volume of human chorionic gonadotropin at the time of embryo transfer: a randomized, double-blind controlled study

Intramuscular injection of human chorionic gonadotropin as luteal phase support in artificial cycle frozen-thawed embryo transfer does not improve clinical outcomes: a parallel, open-label randomized trial

Background

Human chorionic gonadotropin (hCG) as one of the first signals secreted by the embryo to the mother may have a direct effect on the endometrium at implantation. The current study was aim to compare the clinical outcomes after frozen-thawed embryo transfer (FET) treated with artificial cycles (AC) between women who were administered intramuscular injection of human chorionic gonadotropin (hCG) as luteal phase support and the routine group.

Methods

A randomized controlled trial of 245 women was conducted at the Assisted Reproduction Center, Northwest Women's and Children's Hospital, Xi'an, China from January 2019 to January 2020. Women <40 years of age undergoing their first FET treated with AC were included. Patients were randomly allocated into either: (1) the hCG treatment group, who received intramuscular injection of hCG since the third day of progesterone administration, at a dose of 2000 IU once every two days, for a total of four times, (2) the control group, receiving routine protocol without placebo on these four days. Clinical outcomes of the two groups were analyzed.

Results

The primary outcome ongoing pregnancy rate in the hCG treatment group versus the control group was 73/124 (58.87%) versus 75/121 (61.98%), respectively (odds ratio [OR], 95% confidence interval [CI]:0.88, 0.53-1.47, P = 0.619). Secondary clinical outcomes including biochemical pregnancy, clinical pregnancy, early pregnancy loss, multiple pregnancy, live birth and preterm birth were also comparable between the two groups through the univariate analysis and multivariable regression analysis (P > 0.05).

Conclusion

In women undergoing AC-FET, there was no significant difference in the clinical outcomes between the hCG treatment group and the control group. Clinicians should be cautious about adding IM-hCG as luteal phase support to improve the clinical outcome after AC-FET.

Clinical trial registration

http://www.chictr.org.cn/showprojen.aspx?proj=32511, identifier ChiCTR1800020342.

Altered Molecular Pathways and Biomarkers of Endometrial Receptivity in Infertile Women with Polycystic Ovary Syndrome

Anovulation is the most prominent cause of infertility in polycystic ovary syndrome (PCOS) patients. Although ovulation can be corrected pharmacologically, the number of pregnancies remains low. Even if excellent embryos are transferred by IVF, it does not change the high miscarriage rate of PCOS patients. These facts collectively indicate that there is a disorder of endometrial development and receptivity to the embryo in PCOS patients, including the decrease of receptive ability, inhibition of embryo adhesion, undersupply of energy, poor blood perfusion, and pro-inflammatory status in the endometrium. However, it has never received the same attention as ovulatory dysfunction. Here we list some alternations of endometrial receptivity in women with PCOS, discuss the underlying intricate mechanisms, and try to find out the possible therapeutic targets, which may bring new perspectives to those who are able to provide high-quality embryos.

Jian-Pi-Yi-Shen decoction inhibits mitochondria-dependent granulosa cell apoptosis in a rat model of POF

As a widely applied traditional Chinese medicine (TCM), Jian-Pi-Yi-Shen (JPYS) decoction maybe applied in curing premature ovarian failure (POF) besides chronic kidney disease (CKD). In vivo experiments, 40 female SD (8-week-old) rats were randomized into four groups, namely, control group (negative control), POF model group, JPYS treatment group, and triptorelin treatment group (positive control). JPYS group was treated with JPYS decoction (oral, 11 g/kg) for 60 days, and the triptorelin group was treated with triptorelin (injection, 1.5 mg/kg) for 10 days before the administration of cyclophosphamide (CTX) (50 mg/kg body weight) to establish POF model. We examined apoptosis, mitochondrial function, and target gene (ASK1/JNK pathway and mitochondrial fusion/fission) expression. In vitro experiments, the KGN human granulosa cell line was used. Cells were pretreated with CTX (20, 40, and 60 μg/mL) for 24 h, followed by JPYS-containing serum (2, 4, and 8 %) for 24 h. Thereafter, these cells were employed to assess apoptosis, mitochondrial function, and target gene levels of protein and mRNA. In vivo, JPYS alleviated injury and suppressed apoptosis in POF rats. In addition, JPYS improved ovarian function. JPYS inhibit apoptosis of granulosa cells through improving mitochondrial function by activating ASK1/JNK pathway. In vitro, JPYS inhibited KGN cell apoptosis through inhibited ASK1/JNK pathway and improved mitochondrial function. The effects of GS-49977 were similar to those of JPYS. During POF, mitochondrial dysfunction occurs in the ovary and leads to granulosa cell apoptosis. JPYS decoction improves mitochondrial function and alleviates apoptosis through ASK1/JNK pathway.

Does Intrauterine Injection of hCG Improve IVF Outcome? A Systematic Review and a Meta-Analysis

Various interventions have been proposed to improve embryo implantation in IVF. Among these, intrauterine injections of human chorionic gonadotropin seem to have promising results. Consequently, we conducted a review and meta-analysis to assess IVF outcomes by comparing couples who underwent intrauterine hCG injection transfer versus those who underwent embryo transfer with intrauterine injection of placebo, or without any additional intervention. The primary outcome was the clinical pregnancy rate. Secondary outcomes were the implantation rate, miscarriage rate, and live birth rate. A meta-analysis was conducted using the random effects model, while bias within studies was detected using the Cochrane risk of bias tool. Ectopic pregnancies and stillbirths were also assessed. The clinical pregnancy (RR 1.38, 95% CI 1.17−1.62, p < 0.0001) and implantation rate (RR 1.40, 95% CI 1.12−1.75, p = 0.003) were significantly higher in women who underwent hCG injection than in the control group. These significant effects persisted only in women who underwent cleavage-stage embryo transfer. No significant differences between groups were observed in the other secondary outcomes. In conclusion, our systematic review and meta-analysis demonstrate that intrauterine injection of hCG could be a valuable approach in women who undergo cleavage-stage embryo transfer. Given the lack of data about the live birth rate, caution should be exercised in interpreting these data.

The effect of intrauterine hCG injection before embryo transfer on pregnancy rate in frozen embryo transfer cycles

Objective

HCG (human chorionic gonadotropin), which is secreted by cytotrophoblast cells, plays an important role in improving pregnancy outcomes among patients with infertility or related problems. In this study, we evaluate the effect of intrauterine hCG injection prior to frozen embryo transfer on pregnancy outcomes.

Methods

In this clinical trial study, among women with infertility problems referred to (XXX) and those with frozen embryos were included in the study. 155 patients in the intervention group received 500 units of hCG while 157 in control group received saline prior to embryo transfer. Along with demographic data, successful in vitro fertilization and clinical pregnancy, loss of pregnancy, successful transplantation, and biochemical parameters were compared among the two groups.

Results

The mean age of the patients included in the study was 32.97 ± 3.31 years. The level of anti-Mullerian hormone, follicle stimulating hormone and the grade of frozen embryos were not significantly different between the two groups (P > 0.05). The rate of laboratory pregnancy in the intervention group was significantly higher than in the control group (51% vs 35%), p = 0.006. The rate of successful implantation and clinical pregnancy in the intervention group was also significantly higher, p = 0.01 and p = 0.006, respectively. Overall loss of pregnancy in intervention group was 78.1% and 86.0% in control group which was not significantly different, p = 0.068.

Conclusion

The outcomes of our study showed that 500 IU of hCG prior to embryo transfer improves the rate of clinical and laboratory pregnancy. However, it does not reduce the rate of loss of pregnancy. Further studies are therefore required in this area.

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HCG (human chorionic gonadotropin), which is secreted by cytotrophoblast cells.

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HCG plays an important role in improving pregnancy outcomes among patients with infertility.

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500 IU of hCG prior to embryo transfer improves the rate of clinical and laboratory pregnancy.

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Negative outcomes might not be affected in these groups.

Interventions to optimize embryo transfer in women undergoing assisted conception: a comprehensive systematic review and meta-analyses

BACKGROUND

Several interventions and techniques are suggested to improve the outcome of embryo transfer (ET) in assisted conception. However, there remains no consensus on the optimal practice, with high variations among fertility specialists.

OBJECTIVE AND RATIONALE

We conducted a comprehensive systematic review and meta-analyses of randomized controlled trials (RCTs) aiming to identify effective interventions that could be introduced around the time of ET to improve reproductive outcomes.

SEARCH METHODS

We searched the electronic databases (MEDLINE, EMBASE and Cochrane CENTRAL) from inception until March 2021 using a multi-stage search strategy of MeSH terms and keywords, and included all RCTs that evaluated an intervention in the 24-h period before/after ET in women undergoing IVF/ICSI. Our primary outcome was clinical pregnancy rate post-ET confirmed as viable pregnancy on ultrasound scan. We assessed the risk of bias in included trials and extracted data in duplicate. We pooled data using a random-effect meta-analysis and reported using risk ratio (RR) with 95% CI. We explored publication bias and effect modifiers using subgroup analyses.

OUTCOMES

Our search yielded 3685 citations of which we included 188 RCTs (38 interventions, 59 530 participants) with a median sample size of 200 (range 26-1761). The quality of included RCTs was moderate with most showing a low risk of bias for randomization (118/188, 62.8%) and attrition (105/188, 55.8%) but there was a significant risk of publication bias (Egger's test P = 0.001). Performing ET with ultrasound guidance versus clinical touch (n = 24, RR 1.265, 95% CI 1.151-1.391, I2 = 38.53%), hyaluronic acid versus routine care (n = 9, RR 1.457, 95% CI 1.197-1.261, I2 = 46.48%) and the use of a soft versus hard catheter (n = 27, RR 1.122, 95% CI 1.028-1.224, I2 = 57.66%) led to higher clinical pregnancy rates. Other pharmacological add-ons also showed a beneficial effect including granulocyte colony-stimulating factor (G-CSF: n = 4, RR 1.774, 95% CI 1.252-2.512, I2 = 0), Atosiban (n = 7, RR 1.493, 95% CI 1.184-1.882, I2 = 68.27%) and hCG (n = 17, RR 1.232, 95% CI 1.099-1.382, I2 = 57.76%). Bed rest following ET was associated with a reduction in clinical pregnancy (n = 6, RR 0.857, 95% CI 0.741-0.991, I2 = 0.01%). Other commonly used interventions, such as non-steroidal anti-inflammatory drugs, prophylactic antibiotics, acupuncture and cervical mucus removal, did not show a significant benefit on reproductive outcomes. Our effect estimates for other important outcomes, including miscarriage and live birth, were limited by the varied reporting across included RCTs.

WIDER IMPLICATIONS

Using ultrasound guidance, soft catheters and hyaluronic acid at the time of ET appears to increase clinical pregnancy rates. The use of Atosiban, G-CSF and hCG showed a trend towards increased clinical pregnancy rate, but larger trials are required before adopting these interventions in clinical practice. Bed rest post-ET was associated with a reduction in clinical pregnancy and should not be recommended.

Human Chorionic Gonadotropin and Early Embryogenesis: Review

Human chorionic gonadotropin (hCG) has four major isoforms: classical hCG, hyperglycosylated hCG, free β subunit, and sulphated hCG. Classical hCG is the first molecule synthesized by the embryo. Its RNA is transcribed as early as the eight-cell stage and the blastocyst produces the protein before its implantation. This review synthetizes everything currently known on this multi-effect hormone: hCG levels, angiogenetic activity, immunological actions, and effects on miscarriages and thyroid function.

Intrauterine injection of HCG before embryo transfer: a parallel, double-blind randomized trial

RESEARCH QUESTION

Does intrauterine administration of HCG before embryo transfer improve live birth rate during IVF cycles?

DESIGN

A parallel, randomized controlled trial conducted between July 2018 and February 2020. Infertile women (n = 181) scheduled for fresh or vitrified-warmed embryo transfer after IVF carried out for any indication were randomized in a 1:1 ratio to receive either HCG (500 IU in 0.1 ml of tissue culture media) or culture media (0.1 ml of tissue culture media) via intrauterine injection 4 min before embryo transfer. In both groups, an intrauterine insemination catheter was used for administering the medication. Primary outcome was live birth, with ongoing pregnancy and clinical pregnancy as secondary outcomes. Analysis was based on intention-to-treat principle.

RESULTS

Baseline and cycle characteristics were comparable between the two groups. In the control group, one woman with a confirmed clinical pregnancy was lost to follow-up. Live birth rates were 24% (22/90) in the HCG group versus 19% (17/90) in the control group (RR 1.29, 95% CI 0.74 to 2.27). Clinical pregnancy and ongoing pregnancy rates were 34% versus 26% (RR 1.31, 95% CI 0.84 to 2.04) and 24% versus 19% (RR 1.29, 95% CI 0.74 to 2.27) in the HCG and the control groups, respectively.

CONCLUSION

Intrauterine injection of HCG before embryo transfer did not improve live birth rates in women undergoing IVF. As the study was designed to detect a 20% difference between groups, a smaller, clinically important difference could not be ruled out. Treatment outcomes were lower than expected in the control group.

Approaches to Improve Endometrial Receptivity in Case of Repeated Implantation Failures

Repeated implantation failures are a constant challenge in reproductive medicine with a significant impact both on health providers and on infertile couples. Several approaches have been proposed so far as effective; however, accumulative data have clarified that most of the treatment options do not have the evidence base for a generalized application to be suggested by the relevant societies. Implantation failures are attributed to either poor quality embryos or to defected endometrial receptivity. The current review aims to summarize in a systematic way all the new trends in managing RIF via interference with endometrial receptivity. The authors focus mainly, but not exclusively, on endometrial injury prior to embryo transfer and endometrial priming with autologous cells or biological agents. To this direction, a systematic search of the Pubmed database has been conducted taking into account the emerged evidence of the last two decades. All the suggested interventions are herein presented and analyzed in terms of reproductive outcomes. It is evident that properly powered and designed randomized trials are needed to support a new standard approach in RIF treatment that will safely be incorporated in national and international guidelines.

High grade trophectoderm is associated with monozygotic twinning in frozen-thawed single blastocyst transfer

BACKGROUND

The aim of this study was to explore specific factors that predispose to monozygotic twinning (MZT) at the blastocyst stage.

METHODS

This was a retrospective observational study of a cohort of 2863 pregnancies after single blastocyst transfer (SBT) between January 2011 and June 2019 in our hospital. MZT pregnancy was identified as the number of fetuses exceeded the number of gestational sacs (GSs) by transvaginal ultrasound at 6-7 gestational weeks. The incidences of MZT regarding the maternal age at oocyte retrieval, paternal age, ovarian stimulation protocol, fertilization method, endometrium preparation protocol, vitrified day, and the Gardner grading of the blastocyst were calculated. The serum estrogen (E₂), progesterone (P) levels, endometrium thickness and serum hCG levels on day 11 after embryo transfer (ET) were compared between the MZT and singleton pregnancies. Statistical analyses were used appropriately.

RESULTS

Fifty-one MZT pregnancies (1.78%) were identified. The only significant differences observed between MZT and singleton pregnancies were the proportion of TE grade (P = 0.022) and the hCG levels on day 11 after ET (P = 0.003). Multivariate logistic regression revealed that trophectoderm (TE) grade was an independent factor affecting MZT, the adjusted odds ratios (aORs) of grade A and B TE were 5.46 [95% confidential interval (CI) 1.48-20.16, P = 0.011) and 3.96 (95% CI 1.17-13.40, P = 0.027) compared to grade C respectively. There were no significant associations between the parental age, fertilization method, ovarian stimulation protocol, endometrium preparation protocol, vitrified day, expansion stage, inner cell mass (ICM) grade and MZT.

CONCLUSIONS

TE grade is associated with MZT at the blastocyst stage, potentially mediated via increased secretion of hCG from more well developed TE. Increased hCG secretion in turn may prolong the implantation window to support the embryo splitting.

Intramuscular injection of human chorionic gonadotropin prior to secretory transformation in patients undergoing frozen-thawed embryo transfer cycles

BACKGROUND

The major difference between a natural cycle and an artificially prepared cycle is the lack of luteinizing hormone (LH) peak in the latter. The LH/hCG receptors were identified to express in human endometrium and evidences of experiments also suggested the beneficial role of hCG in embryo implantation, indicating that the LH peak might be of clinical significance and the activation of LH/hCG receptors in the endometrium could improve embryo implantation. Hence, we postulated that the addition of hCG prior to secretory transformation in an artificial cycle might improve pregnancy outcomes.

METHODS

This retrospective cohort study was conducted at a Reproductive Medicine Center between 2016 and 2018. Patients aged ≤43 years at the (index) oocyte retrieval and undergoing artificially prepared frozen-thawed embryo transfer (FET) with at least one good-quality embryo transferred were included. The cycles were divided into two groups: The hCG group (n = 337) received an intramuscular injection of 10,000 IU hCG before secretory transformation; the control group (n = 364) performed FET without hCG administration. The primary endpoint was live birth delivery rate (LBR), secondary outcomes included implantation rate, clinical pregnancy rate (CPR) and ongoing pregnancy rate (OPR).

RESULTS

The LBR (49.9% vs 39.6%, P < 0.01), CPR (61.4% vs 50.5%, P < 0.01) and OPR (52.8% vs 43.1%, P < 0.05) were statistically significantly higher in the hCG group than the control group. The superiority in LBR after hCG administration remained significant after adjusting for confounding factors (OR 1.613, 95% CI 1.173-2.217; P < 0.01). In the subgroup analysis, the improvement in LBR was statistically significant after hCG administration for cleavage-stage embryo transfer cycles (51.2% vs 42.3%, P < 0.05), whereas for blastocyst transfer cycles, the improvement in LBR was not (45.7% vs 31.3%, P > 0.05).

CONCLUSIONS

Intramuscular hCG injection prior to secretory transformation may benefit LBR in patients undergoing artificially prepared FET cycles. But it should be noted that nonsignificant tendency towards higher LBR was observed after hCG administration in patients undergoing blastocyst transfer. So, future prospective randomized controlled studies are required to confirm, especially for blastocyst transfer cycles.

Effect of intrauterine injection of human chorionic gonadotropin before frozen-thawed embryo transfer on pregnancy outcomes in women with endometriosis

Objective

To investigate the effect of human chorionic gonadotropin (hCG) intrauterine injection before frozen–thawed embryo transfer (FET) in women with endometriosis.

Methods

This retrospective cohort study included 45 women with endometriosis who underwent hCG intrauterine injection before FET; each woman was matched with three patients with endometriosis who did not receive hCG intrauterine injection (controls). Data on pregnancy and prenatal outcomes were extracted from medical records and compared.

Results

Patients in the hCG intrauterine injection group had significantly higher rates of pregnancy and clinical pregnancy (64.4% and 57.8%, respectively) than controls (47.4% and 39.3%, respectively). Neonatal birth weight for both singletons and twins was significantly higher in the hCG group (3486 ± 458 g and 2710 ± 437 g, respectively) than in the control group (3195 ± 401 g and 2419 ± 370 g, respectively).

Conclusion

Pregnancy rate, clinical pregnancy rate, and birth weight were improved in women with endometriosis who underwent intrauterine hCG injection compared with those who did not receive hCG before FET.