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Zhang WY, Gardner RM, Johal JK, Beshar IE, Bavan B, Milki AA, Lathi RB, Aghajanova L. Pregnancy and neonatal outcomes of letrozole versus natural cycle frozen embryo transfer of autologous euploid blastocyst. J Assist Reprod Genet 2023; 40:873-881. [PMID: 36849755 PMCID: PMC10224882 DOI: 10.1007/s10815-023-02759-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2022] [Accepted: 02/20/2023] [Indexed: 03/01/2023] Open
Abstract
PURPOSE To investigate the pregnancy and neonatal outcomes of letrozole-stimulated frozen embryo transfer (LTZ-FET) cycles compared with natural FET cycles (NC-FET). METHODS Our retrospective cohort included all LTZ-FET (n = 161) and NC-FET (n = 575) cycles that transferred a single euploid autologous blastocyst from 2016 to 2020 at Stanford Fertility Center. The LTZ-FET protocol entailed 5 mg of daily letrozole for 5 days starting on cycle day 2 or 3. Outcomes were compared using absolute standardized differences (ASD), in which a larger ASD signifies a larger difference. Multivariable regression models adjusted for confounders: maternal age, BMI, nulliparity, embryo grade, race, infertility diagnosis, and endometrial thickness. RESULTS The demographic and clinical characteristics were overall similar. A greater proportion of the letrozole cohort was multiparous, transferred high-graded embryos, and had ovulatory dysfunction. The cohorts had similar pregnancy rates (67.1% LTZ vs 62.1% NC; aOR 1.31, P = 0.21) and live birth rates (60.9% LTZ vs 58.6% NC; aOR 1.17, P = 0.46). LTZ-FET neonates on average were born 5.7 days earlier (P < 0.001) and had higher prevalence of prematurity (18.6% vs. 8.0%NC, ASD = 0.32) and low birth weight (10.4% vs. 5.0%, ASD = 0.20). Both cohorts' median gestational ages (38 weeks and 1 day for LTZ; 39 weeks and 0 day for NC) were full term. CONCLUSION There were similar rates of pregnancy and live birth between LTZ-FET and NC-FET cycles. However, there was a higher prevalence of prematurity and low birth weight among LTZ-FET neonates. Reassuringly, the median gestational age in both cohorts was full term, and while the difference in gestational length of almost 6 days does not appear to be clinically significant, this warrants larger studies.
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Affiliation(s)
- Wendy Y Zhang
- Department of Obstetrics and Gynecology, Stanford University School of Medicine, Stanford, CA, USA.
- Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, Stanford University School of Medicine, Stanford, CA, USA.
| | - Rebecca M Gardner
- Department of Medicine, Quantitative Sciences Unit, Stanford University School of Medicine, Stanford, CA, USA
| | - Jasmyn K Johal
- Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, Weill Cornell Medicine, New York, NY, USA
| | - Isabel E Beshar
- Department of Obstetrics and Gynecology, Stanford University School of Medicine, Stanford, CA, USA
| | - Brindha Bavan
- Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, Stanford University School of Medicine, Stanford, CA, USA
| | - Amin A Milki
- Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, Stanford University School of Medicine, Stanford, CA, USA
| | - Ruth B Lathi
- Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, Stanford University School of Medicine, Stanford, CA, USA
| | - Lusine Aghajanova
- Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, Stanford University School of Medicine, Stanford, CA, USA
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Baksh S, Casper A, Christianson MS, Devine K, Doody KJ, Ehrhardt S, Hansen KR, Lathi RB, Timbo F, Usadi R, Vitek W, Shade DM, Segars J, Baker VL. Natural vs. programmed cycles for frozen embryo transfer: study protocol for an investigator-initiated, randomized, controlled, multicenter clinical trial. Trials 2021; 22:660. [PMID: 34579768 PMCID: PMC8477459 DOI: 10.1186/s13063-021-05637-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2021] [Accepted: 09/15/2021] [Indexed: 11/17/2022] Open
Abstract
Background Randomized trials of assisted reproductive technology (ART) have been designed for outcomes of clinical pregnancy or live birth and have not been powered for obstetric outcomes such as preeclampsia, critical for maternal and fetal health. ART increasingly involves frozen embryo transfer (FET). Although there are advantages of FET, multiple studies have shown that risk of preeclampsia is increased with FET compared with fresh embryo transfer, and the reason for this difference is not clear. NatPro will compare the proportion of preeclampsia between two commonly used protocols for FET,modified natural and programmed cycle. Methods In this two-arm, parallel-group, multi-center randomized trial, NatPro will randomize 788 women to either modified natural or programmed FET and follow them for up to three FET cycles. Primary outcome will be the proportion of preeclampsia in women with a viable pregnancy assigned to a modified natural cycle FET (corpus luteum present) protocol compared to the proportion of preeclampsia in pregnant women assigned to a programmed FET (corpus luteum absent) protocol. Secondary outcomes will compare the proportion of live births and the proportion of preeclampsia with severe features between the protocols. Conclusion This study has a potential significant impact on millions of women who pursue ART to build their families. NatPro is designed to provide clinically relevant guidance to inform patients and clinicians regarding maternal risk with programmed and modified natural cycle FET protocols. This study will also provide accurate point estimates regarding the likelihood of live birth with programmed and modified natural cycle FET. Trial registration ClinicalTrials.govNCT04551807. Registered on September 16, 2020 Supplementary Information The online version contains supplementary material available at 10.1186/s13063-021-05637-3.
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Affiliation(s)
- Sheriza Baksh
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, 415 N. Washington Street, 2nd Floor, Baltimore, MD, 21231, USA. .,Center for Clinical Trials and Evidence Synthesis, Johns Hopkins University, Baltimore, MD, 21205, USA.
| | - Anne Casper
- Center for Clinical Trials and Evidence Synthesis, Johns Hopkins University, Baltimore, MD, 21205, USA
| | - Mindy S Christianson
- Division of Reproductive Endocrinology and Infertility, Department of Gynecology and Obstetrics, Johns Hopkins University School of Medicine, Baltimore, MD, 21205, USA
| | - Kate Devine
- Shady Grove Fertility, Washington, DC, 20006, USA
| | | | - Stephan Ehrhardt
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, 415 N. Washington Street, 2nd Floor, Baltimore, MD, 21231, USA.,Center for Clinical Trials and Evidence Synthesis, Johns Hopkins University, Baltimore, MD, 21205, USA
| | - Karl R Hansen
- Section of Reproductive Endocrinoloogy and Infertility, Department of Obstetrics and Gynecology, University of Oklahoma College of Medicine, Oklahoma City, OK, 73104, USA
| | - Ruth B Lathi
- Department of Obstetrics and Gynecology, Stanford University Medical Center, Sunnyvale, CA, 94087, USA
| | - Fatmata Timbo
- Center for Clinical Trials and Evidence Synthesis, Johns Hopkins University, Baltimore, MD, 21205, USA
| | | | - Wendy Vitek
- University of Rochester Medical Center, Rochester, NY, 14642, USA
| | - David M Shade
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, 415 N. Washington Street, 2nd Floor, Baltimore, MD, 21231, USA.,Center for Clinical Trials and Evidence Synthesis, Johns Hopkins University, Baltimore, MD, 21205, USA
| | - James Segars
- Division of Reproductive Endocrinology and Infertility, Department of Gynecology and Obstetrics, Johns Hopkins University School of Medicine, Baltimore, MD, 21205, USA
| | - Valerie L Baker
- Division of Reproductive Endocrinology and Infertility, Department of Gynecology and Obstetrics, Johns Hopkins University School of Medicine, Baltimore, MD, 21205, USA
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Zhang WY, Gardner RM, Kapphahn KI, Ramachandran MK, Murugappan G, Aghajanova L, Lathi RB. The impact of estradiol on pregnancy outcomes in letrozole-stimulated frozen embryo transfer cycles. F S Rep 2021; 2:320-326. [PMID: 34553158 PMCID: PMC8441577 DOI: 10.1016/j.xfre.2021.05.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2021] [Revised: 05/20/2021] [Accepted: 05/24/2021] [Indexed: 10/25/2022] Open
Abstract
OBJECTIVE To assess the impact of low estradiol (E2) levels in letrozole-stimulated frozen embryo transfer (FET) cycles on pregnancy and neonatal outcomes. DESIGN Retrospective cohort. SETTING University-affiliated fertility center. PATIENTS All patients who underwent letrozole-stimulated FET cycles from January 2017 to April 2020 (n = 217). The "Low E2" group was defined as those with E2 serum levels on the day of trigger <10th percentile level (E2 <91.16 pg/mL, n = 22) and the "Normal E2" group was defined as those with E2 serum levels ≥10th percentile level (E2 ≥91.16 pg/mL, n = 195). INTERVENTIONS None. MAIN OUTCOME MEASURES Pregnancy outcomes including rates of clinical pregnancy, clinical miscarriage, and live birth. Neonatal outcomes including gestational age at delivery, birth weight, and Apgar score. RESULTS The mean ± SD estradiol level was 66.8 ± 14.8 pg/mL for the "Low E2" group compared with 366.3 ± 322.1 pg/mL for the "Normal E2" group. There were otherwise no substantial differences in cycle characteristics such as endometrial thickness on the day of ovulation trigger and progesterone levels in early pregnancy. The "Low E2" group had a significantly higher clinical miscarriage rate (36.4% vs. 8.8%, adjusted odds ratio 8.06) and lower live birth rate (31.8% vs. 57.9%, adjusted odds ratio 0.28). Neonatal outcomes such as gestational age at delivery, mean birth weight, Apgar scores, and incidence of newborn complications were not clinically different between the groups. CONCLUSION Low E2 levels were associated with a significantly higher miscarriage rate and lower live birth rate, suggesting that E2 levels in the follicular phase may have an effect on cycle outcomes. Given the rise in use of FET, further studies are needed to confirm our findings and understand the mechanisms.
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Affiliation(s)
- Wendy Y. Zhang
- Department of Medicine, Stanford University School of Medicine, Stanford, California
- Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, Stanford University School of Medicine, Stanford, California
| | - Rebecca M. Gardner
- Quantitative Sciences Unit, Department of Medicine, Stanford University School of Medicine, Stanford, California
| | - Kristopher I. Kapphahn
- Quantitative Sciences Unit, Department of Medicine, Stanford University School of Medicine, Stanford, California
| | - Maya K. Ramachandran
- Department of Medicine, Stanford University School of Medicine, Stanford, California
| | - Gayathree Murugappan
- Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, Stanford University School of Medicine, Stanford, California
| | - Lusine Aghajanova
- Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, Stanford University School of Medicine, Stanford, California
| | - Ruth B. Lathi
- Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, Stanford University School of Medicine, Stanford, California
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Wiegel RE, Jan Danser AH, Steegers-Theunissen RPM, Laven JSE, Willemsen SP, Baker VL, Steegers EAP, von Versen-Höynck F. Determinants of Maternal Renin-Angiotensin-Aldosterone-System Activation in Early Pregnancy: Insights From 2 Cohorts. J Clin Endocrinol Metab 2020; 105:5898239. [PMID: 32853347 PMCID: PMC7494245 DOI: 10.1210/clinem/dgaa582] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2020] [Accepted: 08/26/2020] [Indexed: 01/09/2023]
Abstract
CONTEXT The corpus luteum (CL) secretes prorenin, renin's inactive precursor. It may thus contribute to the renin-angiotensin-aldosterone-system (RAAS) activation that is required for maternal adaptation in pregnancy. Whether this activation is disturbed in pregnancies lacking a CL is unknown. OBJECTIVE The objective of this work is to investigate maternal RAAS determinants in early pregnancy. DESIGN AND SETTING Two observational prospective cohort studies. TOOK PLACE AT 2 tertiary referral hospitals. PATIENTS AND INTERVENTION(S) Pregnancies (n = 277) were stratified by CL number and in vitro fertilization (IVF) protocol: 0 CL (programmed cycle frozen embryo transfer [FET], n = 28), 1 CL (natural cycle FET, n = 41 and spontaneous conceptions, n = 139), and more than 1 CL (ovarian stimulation and fresh embryo transfer, n = 69). METHODS Quantification was performed for maternal prorenin, renin, and aldosterone blood levels at 5, 9, and 11 weeks of gestation. RESULTS Prorenin and renin were lower in the absence of a CL at all time points when compared to 1 CL, whereas prorenin, renin, and aldosterone were higher in the presence of more than 1 CL vs 1 CL (P < .05). Ovarian stimulation with menopausal gonadotropin resulted in higher prorenin, renin, and aldosterone concentrations during the late first trimester than recombinant follicle-stimulating hormone (P < .05). Prorenin, and to a lesser degree renin, correlated positively with serum progesterone and relaxin, but not serum estradiol. Total follicle diameter, body mass index (BMI), polycystic ovary syndrome (PCOS), and antimüllerian hormone (AMH) were additional determinants of circulating prorenin. Finally, pregnancies conceived in the absence of a CL were more disposed to develop preeclampsia. CONCLUSIONS CL number, IVF protocol, BMI, PCOS, and AMH affect maternal RAAS activation in early pregnancy, and may thus contribute to pregnancy complications.
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Affiliation(s)
- Rosalieke E Wiegel
- Department of Obstetrics and Gynecology, Erasmus MC University Medical Center, CA Rotterdam, the Netherlands
| | - A H Jan Danser
- Department of Internal Medicine, Erasmus MC University Medical Center, CA Rotterdam, the Netherlands
| | - Régine P M Steegers-Theunissen
- Department of Obstetrics and Gynecology, Erasmus MC University Medical Center, CA Rotterdam, the Netherlands
- Correspondence and Reprint Requests: R.P.M. Steegers-Theunissen, MD, PhD, Erasmus MC, University Medical Center Rotterdam, Department of Obstetrics and Gynecology, Room EE-2271a, PO Box 2040, 3000 CA Rotterdam, the Netherlands. E-mail:
| | - Joop S E Laven
- Department of Obstetrics and Gynecology, Erasmus MC University Medical Center, CA Rotterdam, the Netherlands
| | - Sten P Willemsen
- Department of Obstetrics and Gynecology, Erasmus MC University Medical Center, CA Rotterdam, the Netherlands
- Department of Biostatistics, Erasmus MC University Medical Center, CA Rotterdam, the Netherlands
| | - Valerie L Baker
- Department of Gynecology and Obstetrics, Johns Hopkins University School of Medicine, Lutherville, Maryland, USA
| | - Eric A P Steegers
- Department of Obstetrics and Gynecology, Erasmus MC University Medical Center, CA Rotterdam, the Netherlands
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Zhang WY, von Versen-Höynck F, Kapphahn KI, Fleischmann RR, Zhao Q, Baker VL. Maternal and neonatal outcomes associated with trophectoderm biopsy. Fertil Steril 2019; 112:283-290.e2. [PMID: 31103283 PMCID: PMC6527329 DOI: 10.1016/j.fertnstert.2019.03.033] [Citation(s) in RCA: 80] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2018] [Revised: 02/25/2019] [Accepted: 03/26/2019] [Indexed: 11/16/2022]
Abstract
OBJECTIVE To assess whether pregnancies achieved with trophectoderm biopsy for preimplantation genetic testing (PGT) have different risks of adverse obstetric and neonatal outcomes compared with pregnancies achieved with IVF without biopsy. DESIGN Observational cohort. SETTING University-affiliated fertility center. PATIENT(S) Pregnancies achieved via IVF with PGT (n = 177) and IVF without PGT (n = 180) that resulted in a live birth. INTERVENTION(S) None. MAIN OUTCOME MEASURE(S) Maternal outcomes including preeclampsia and placenta previa and neonatal outcomes including birth weight and birth defects. RESULT(S) There was a statistically significant increase in the risk of preeclampsia among IVF+PGT pregnancies compared with IVF without PGT pregnancies, with an incidence of 10.5% versus 4.1% (adjusted odds ratio [aOR] = 3.02; 95% confidence interval [95% CI], 1.10, 8.29). The incidence of placenta previa was 5.8% in IVF+PGT pregnancies versus 1.4% in IVF without PGT pregnancies (aOR = 4.56; 95% CI, 0.93, 22.44). Similar incidences of gestational diabetes, preterm premature rupture of membranes, and postpartum hemorrhage were observed. IVF+PGT and IVF without PGT neonates did not have a significantly different gestational age at delivery or rate of preterm birth, low birth weight, neonatal intensive care unit admission, neonatal morbidities, or birth defects. All trends, including the significantly increased risk of preeclampsia in IVF+PGT pregnancies, persisted upon stratification of analysis to only singleton live births. CONCLUSION(S) To date, this is the largest and most extensively controlled study examining maternal and neonatal outcomes after trophectoderm biopsy. There was a statistically significant three-fold increase in the odds of preeclampsia associated with trophectoderm biopsy. Given the rise in PGT use, further investigation is warranted.
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Affiliation(s)
- Wendy Y. Zhang
- Stanford University Medical Center, Department of Obstetrics and Gynecology, Division of Reproductive Endocrinology and Infertility, 1195 West Fremont Avenue, Sunnyvale, CA 94087, United States of America. , , ,
| | - Frauke von Versen-Höynck
- Stanford University Medical Center, Department of Obstetrics and Gynecology, Division of Reproductive Endocrinology and Infertility, 1195 West Fremont Avenue, Sunnyvale, CA 94087, United States of America. , , ,
- Hannover Medical School, Department of Obstetrics and Gynecology, Lower Saxony, Germany.
| | - Kristopher I. Kapphahn
- Stanford University School of Medicine, Quantitative Science Unit, Stanford, California, United States of America.
| | - Raquel R. Fleischmann
- Stanford University Medical Center, Department of Obstetrics and Gynecology, Division of Reproductive Endocrinology and Infertility, 1195 West Fremont Avenue, Sunnyvale, CA 94087, United States of America. , , ,
| | - Qianying Zhao
- Stanford University Medical Center, Department of Obstetrics and Gynecology, Division of Reproductive Endocrinology and Infertility, 1195 West Fremont Avenue, Sunnyvale, CA 94087, United States of America. , , ,
| | - Valerie L. Baker
- Johns Hopkins University School of Medicine, Baltimore, Maryland, United States of America.
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Albertini DF. On becoming accepting of the imperfectionsin mammalian embryogenesis. J Assist Reprod Genet 2017; 33:969-70. [PMID: 27448615 DOI: 10.1007/s10815-016-0777-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
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