The relationship of premature progesterone rise with serum estradiol levels and number of follicles in GnRH antagonist/recombinant FSH-stimulated cycles

Premature Progesterone Rise Is Associated with Higher Cumulative Live Birth Rate with Freeze-All Strategy

Background/Objectives: This paper undertakes an investigation into the implications of premature progesterone rise (PPR) on pregnancy outcomes in freeze-all strategy cycles. Methods: A retrospective cohort study encompassing 675 IVF/ICSI cycles using a freeze-all strategy was enrolled. The cycles were categorized into two groups based on serum progesterone levels at the time of hCG administration: 526 cycles had levels below 1.5 ng/mL, while 149 cycles had levels equal to or above 1.5 ng/mL. Results: The findings revealed a significantly higher number of mature follicles and retrieved oocytes in patients with PPR across all AMH categories. Multiple analyses revealed factors influencing PPR, including the duration of induction and the number of retrieved oocytes. Within the same oocyte retrieval number group, patients with PPR demonstrated non-inferior pregnancy outcomes compared to non-PPR patients. Upon adjustment for age, AMH, and total follicle-stimulating hormone (FSH) dosage, PPR maintained a positive correlation with the cumulative live birth rate (LBR). Conclusions: The study showed that PPR correlates with an increase in retrieved oocytes while maintaining similar embryo quality and oocyte retrieval rates and results in a higher cumulative LBR.

Progesterone levels on hCG day and oocyte maturation in a Mexican IVF program

OBJECTIVE

Does progesterone levels on hCG day influence maturation rates and number of mature oocytes during ovarian stimulation for IVF/ICSI cycles?.

METHODS

A retrospective, observational, analytic, cross-sectional and cohort study was performed at the Reproductive Endocrinology Department of the Centro Médico Nacional 20 de Noviembre in Mexico City between 2015 to 2020. All female patients underwent an ovarian stimulation cycle for IVF/ICSI, either with a mild or conventional stimulation protocol. Patients were classified according to their progesterone levels, Group 1 <1.5ng/ml and Group 2 >1.5mg/ml. A Spearman Rho test, a simple linear regression model, a Principal Component Analysis and a Student's T-test, were performed.

RESULTS

A total of 600 patients were included. The overall results showed that there is a positive correlation between the number of retrieved, mature oocytes and progesterone levels on HCG day. After the Principal Component Analysis we observed that poor ovarian responders had the lowest maturation rate and number of mature oocytes. While the Student's t test showed that progesterone levels beyond 1.5ng/ml are associated to a higher number of mature oocytes but not a better maturation rate.

CONCLUSIONS

Higher serum progesterone levels are associated with increased retrieved and mature oocytes in high responders. At the same time, higher progesterone levels in lower responders are not associated with optimal ovarian response.

Proof of concept use of progesterone/estradiol ratio to investigate late follicular progesterone in women with low number of preovulatory follicles

BACKGROUND

The aim of this study was to investigate late follicular progesterone (P) serum levels in women with a low number of preovulatory follicles in the assisted reproductive technologies (ART) setting.

METHODS

Fifty-five consecutive women having four or fewer preovulatory follicles of >14 mm on the day of human chorionic gonadotropin (hCG) administration were prospectively evaluated. Spearman correlation tests were performed between serum estradiol (E2) level, serum P level, P/E2 ratio, number of preovulatory follicles, oocytes and embryos. Women enrolled were further divided into two groups in accordance with the P/E2 ratio on the day of hCG administration and compared.

RESULTS

Serum E2 level correlated positively with P serum level (rs=0.36, P<0.01), number of mature follicles (rs=0.50, P<0.01) and number of oocytes retrieved (rs=0.36, P<0.05), whereas negatively with P/E2 ratio (rs=- 0.68, P<0.01). Likewise, number of preovulatory follicles correlated positively with E2 level (rs=0.50, P<0.01), P level (rs=0.27, P<0.05) and number of oocytes retrieved (rs=0.33, P<0.05), while it correlated negatively with P/E2 ratio (rs=-0.33, P<0.05). Furthermore, women with P/E2 ratio >1 on the day of hCG administration received considerably higher total follicular stimulating hormone (FSH) dosage and achieved significantly lower number of oocytes and embryos as compared to controls.

CONCLUSIONS

The reverse relationship between number of preovulatory follicles and P/E2 ratio implies that P rise is not only the result of increased steroidogenic activity, but other oocyte-follicle disrupted mechanisms seem to be involved. An exaggerated FSH stimulation appears to disrupt further these mechanisms.

Do women with severely diminished ovarian reserve undergoing modified natural-cycle in-vitro fertilization benefit from earlier trigger at smaller follicle size?

OBJECTIVE

To evaluate whether trigger and oocyte collection at a smaller follicle size decreases the risk of premature ovulation while maintaining the reproductive potential of oocytes in women with a severely diminished ovarian reserve undergoing modified natural-cycle in-vitro fertilization.

METHODS

This was a retrospective cohort study including women who had at least one unsuccessful cycle (due to no response) of conventional ovarian stimulation with a high dosage of gonadotropins and subsequently underwent a modified natural cycle with a solitary growing follicle (i.e. only one follicle > 10 mm at the time of trigger). The association between follicle size at trigger and various cycle outcomes was tested using regression analyses.

RESULTS

A total of 160 ovarian stimulation cycles from 110 patients were included in the analysis. Oocyte pick-up (OPU) was performed in 153 cycles and 7 cycles were canceled due to premature ovulation. Patients who received their trigger at smaller follicle sizes (≤ 15 mm) had significantly lower rates of premature ovulation and thus higher rates of OPU (98.9% vs 90.8%; odds ratio, 9.56 (95% CI, 1.58-182.9); P = 0.039) compared with those who received their trigger at larger follicle sizes (> 15 mm). On multivariable analysis, smaller follicle sizes at trigger (> 10 to 13 mm, > 13 to 15 mm, > 15 mm to 17 mm) were not associated significantly with a lower rate of cumulus-oocyte complex (COC) retrieval, metaphase-II (MII) oocytes or blastulation when compared to the > 17-mm group. On sensitivity analysis including only the first cycle of each couple, the maturity rate among those with COC retrieval was highest in follicle sizes > 15 to 17 mm (92.3%) and > 13 to 15 mm (91.7%), followed by > 10 to 13 mm (85.7%) and lowest in the > 17-mm group (58.8%). During the study period, five euploid blastocysts developed from 48 fertilized MII oocytes with follicle sizes of 12 mm (n = 3), 14 mm (n = 1) and 16 mm (n = 1) at trigger. Of those, four were transferred and resulted in two live births, both of which developed from follicles with a size at trigger of 12 mm.

CONCLUSIONS

The ideal follicle size for triggering oocyte maturation may be smaller in women with a severely diminished ovarian reserve managed on a modified natural cycle when compared to conventional cut-offs. The risk of OPU cancellation was significantly higher in women triggered at follicle size > 15 mm and the yield of mature oocytes was not adversely affected in women triggered at follicle size > 13 to 15 mm compared with > 15 to 17 mm. Waiting for follicles to reach sizes > 17mm may be detrimental to achieving optimal outcome. © 2024 International Society of Ultrasound in Obstetrics and Gynecology.

hMG addition affects the change in progesterone level during IVF stimulation and LBR: a retrospective cohort study

BACKGROUND

Premature progesterone (P) rise during IVF stimulation reduces endometrial receptivity and is associated with lower pregnancy rates following embryo transfer (ET), which can influence provider recommendation for fresh or frozen ET. This study aimed to determine whether change in P level between in IVF baseline and trigger (𝚫P) is predictive of pregnancy outcome following fresh ET, and whether the ratio of gonadotropins influences P rise and, as a result, clinical pregnancy outcomes: clinical pregnancy rate (CPR) and live birth rates (LBR).

METHODS

Retrospective cohort study at a single fertility center at an academic institution. The peak P level and 𝚫P were modeled in relation to prediction of CPR and LBR, and the ratios of hMG:rFSH were also modeled in relation to prediction of peak P level on day of trigger, 𝚫P, and CPR/LBR in a total of 291 patients undergoing fresh embryo transfer after controlled ovarian hyperstimulation-IVF (COH-IVF).

RESULTS

𝚫P correlates with CPR, with the most predictive range for success as 𝚫P 0.7-0.85 ng/mL (p = 0.005, 95% CI 0.635, 3.636; predicting CPR of 88.9%). The optimal range for peak P in regard to pregnancy outcome was 0.15-1.349 ng/mL (p = 0.01; 95% CI for coefficient in model 0.48-3.570). A multivariable logistic model for prediction of CPR and LBR using either peak or 𝚫P supported a stronger association between 𝚫P and CPR/LBR as compared to peak P. Furthermore, an hMG:rFSH ratio of > 0.6 was predictive of lowest peak P (p = 0.010, 95% CI 0.035, 0.256) and smallest 𝚫P (p = 0.012, 95% CI 0.030, 0.243) during COH-IVF cycles. Highest CPRs were observed within hMG:rFSH ratios of 0.3-0.4 [75.6% vs. 62.5% within and outside of the range, respectively, (p = 0.023, 95% CI 0.119, 1.618)]. Highest LBRs were seen within the range of 0.3-0.6 hMG:rFSH, [LBR of 55.4% vs. 41.4% (p = 0.010, 95% CI 0.176, 1.311)].

CONCLUSIONS

Our data supports use of 𝚫P to best predict pregnancy rates and therefore can improve clinical decision making as to when fresh ET is most appropriate. Furthermore, we found optimal gonadotropin ratios can be considered to minimize P rise and to optimize CPR/LBR, emphasizing the importance of luteinizing hormone (LH) activity in COH-IVF cycles.

Effects of different progesterone levels on reproductive outcomes in assisted reproductive technologies: from molecular basis to treatment strategies

PURPOSE

The aim of this narrative review is to offer an overview about the role of progesterone levels on pregnancy outcome in patients undergoing assisted reproductive technologies (ARTs).

METHODS

A detailed computerized search of the literature was performed in the main electronic databases (MEDLINE, EMBASE, Web of Science) to determine the importance of elevated progesterone levels at different stages of the cycle for pregnancy rates in the in vitro fertilization (IVF) cycle. Our review also provides information on the differences between elevated progesterone levels and their interpretation in normal and in poorly responding women.

RESULTS

After careful evaluation, our search strategy yielded a total of 15 included articles, showing the possible factors that may have had an impact on the increased progesterone level before human chorionic gonadotropin (HCG) injection and the different thresholds above which the pregnancy rate was lower. Furthermore, increased progesterone on cycle day 2 or 3 could serve as a marker for increased progesterone in the late follicular phase, which is associated with a lower pregnancy rate.

CONCLUSION

Despite the literature data that support the negative effect of elevated progesterone on fresh cycles, due to lack of randomized controlled trials, the value of measuring progesterone in daily practice is questionable. Available evidence supports the detrimental effect of elevated progesterone in different subgroups of women, although there is still the need for defining different thresholds and durations of high progesterone exposure. The need for various thresholds for different cohorts of women, the inter-assay variability is making this decision harder.

Progesterone levels during ovarian stimulation in segmented ART cycles inversely correlate with normalized birthweight of neonates conceived through subsequent frozen-thawed embryo transfer

PURPOSE

To evaluate the association between serum progesterone (P) at the day of ovulation trigger and neonatal birthweight in singletons born after frozen-thawed embryo transfer in segmented ART cycles.

METHODS

A retrospective multicenter cohort study involving data from patients who achieved uncomplicated pregnancy and term delivery of ART-conceived singleton babies following a segmented GnRH antagonist cycle. The main outcome was birthweight's z-score of the neonate. Univariate and multivariate linear logistic regression analyses were made to investigate the relation of z-score with variables inherent to the patient and to the ovarian stimulation. The variable P per oocyte was created by dividing the value of progesterone at ovulation trigger by the number of oocytes retrieved at oocyte retrieval.

RESULTS

A total of 368 patients were included in the analysis. At univariate linear regression, the birthweight z-score of the neonate appeared to be inversely related to both P levels at the ovulation trigger (- 0.101, p = 0.015) and P levels per oocyte at trigger (- 1.417, p = 0.001), while it was directly related to the height of the mother (0.026, p = 0.002) and to the number of previous live births (0.291, p = 0.016). In multivariate analysis, both serum P (- 0.1; p = 0.015) and P per oocyte (- 1.347, p = 0.002) maintained the significant inverse association with birthweight z-score after adjusting for height and parity.

CONCLUSIONS

Serum progesterone level on the day of ovulation trigger inversely correlates with normalized birthweight of neonates in segmented GnRH antagonist ART cycles.

Effects of reduced follicle-stimulating hormone dosage before human chorionic gonadotropin trigger on in vitro fertilization outcomes

OBJECTIVE

To determine whether a reduced dose of follicle-stimulating hormone (FSH) before human chorionic gonadotropin (hCG) trigger during ovarian stimulation can affect in vitro fertilization (IVF) outcomes.

METHODS

This study included 347 patients with a normal ovarian response who received a reduced dose of FSH before hCG trigger for 2-3 days (Group A) and 671 patients who did not receive a reduced dose (Group B) from a university-affiliated IVF center between January 2021 and December 2022. The primary endpoint was estrogen (E2) and progesterone (P) levels on the day of hCG trigger, fresh embryo transfer cycles, laboratory outcomes, and clinical outcomes between the two groups.

RESULTS

On the day of hCG trigger, Group A had significantly lower E2 and P levels than those in Group B (3454.95 ± 1708.14 pg/mL versus 3798.70 ± 1774.26 pg/mL, p = 0.003; and 1.23 ± 0.53 ng/mL versus 1.37 ± 0.59 ng/mL, p < 0.001, respectively). The proportion of patients with P levels ≥ 1.5 ng/mL was 22.48% in Group A compared to 34.58% in Group B (p < 0.001), while the proportion of patients with E2 ≥ 5000 pg/mL was 15.27% in Group A compared to 25.93% in Group B (p < 0.001). The fresh embryo-transfer cycle rate in Group A was higher than that in group B (54.47% and 32.64%, respectively; p < 0.001). Despite the reduction in FSH dosage, there were no significant differences between groups regarding the number of oocytes retrieved, total number of mature oocytes, normal fertilization rate, cleavage rate, Day 3 top-quality rate, implantation rate, pregnancy rate per cycle, and early pregnancy loss rate.

CONCLUSION

While a reduced dose of FSH prior to hCG trigger during ovarian stimulation did not significantly affect IVF outcomes, it was associated with lower E2 and P levels, resulting in fewer cycles with E2 ≥ 5000 pg/mL and P ≥ 1.5 ng/mL on the day of the hCG trigger.

Independent value of PMOI on hCG day in predicting pregnancy outcomes in IVF/ICSI cycles

OBJECTIVES

The aim of this study was to determine whether, on the day of human chorionic gonadotropin (hCG) injection, the progesterone to number of mature oocytes index (PMOI) can be used alone or together with other parameters in a fresh embryo transfer in vitro fertilization (IVF)/intracytoplasmic sperm injection (ICSI) cycle to predict pregnancy outcome.

METHODS

This was a retrospective cohort study of all couples who underwent a clinical pregnancy and received a fresh IVE/ICSI cycle at a single large reproductive medical center between June 2019 and March 2022. The study involved a total of 1239 cycles. To analyze risk factors associated with pregnancy outcomes on the day of HCG injection, univariate and multivariate logistic regression analyses were used. The area under the curve (AUC) was determined, and PMOI and other factors were compared using receiver operating characteristic (ROC) curves.

RESULTS

The clinical pregnancy rate was significantly higher in group A (60.76%) than in the other groups (Group B: 52.92% and Group C:47.88%, respectively, p =0.0306). Univariate and multivariate logistic regression revealed that PMOI levels were significantly correlated with the probability of pregnancy outcome, independent of other risk factors. More importantly, PMOI levels independently predict the occurrence of pregnancy outcome, comparable to the model combining age. The optimal serum PMOI cutoff value for pregnancy outcome was 0.063 ug/L.

CONCLUSION

Our results suggest that PMOI levels have an independent predictive value for pregnancy outcome in fresh IVF/ICSI cycles.

The effect of the ratio of serum progesterone level to oocyte count on the day of IVF-ICSI injection on pregnancy outcomes in HCG cycles

BACKGROUND

There has been several discussion and debates regarding the possible setremental influence of elevated serum progesterone (SP) on the day of human chorionic gonadotropin (hCG) administration. Our study aims to assess progestron to oocyte rates for assessing CPR and live birth rate (LBR) in IVF cycles and review previous articles.

METHODS

In this prospective cohort study, women under ovulation induction through IVF-ICSI using the GnRH-antagonist protocol were studied. Five specific indicators were considered to assess pregnancy outcome. The statistical analysis was done using SPSS software.

RESULTS

In the present research, 78 patients underwent IVF. The cut-off points for each of the three parameters were 1.2 (with a sensitivity of 65.4% and a specificity of 54%), 6.5 (with a sensitivity of 73.1% and a specificity of 56%), and 0.16 (with a sensitivity of 65.4% and a specificity of 60%, respectively). Only the number of oocytes (area below the curve of 0.64) was able to predict clinical pregnancy. The cut-off point for this parameter was 6.5 (with a sensitivity of 74.1% and a specificity of 66%). On the other hand, none of the parameters were able to predict live birth.

CONCLUSIONS

The findings of this study should assist in the clinical management of patients with high SP on the day of HCG administration. We recommend, that the ratio of SP to oocyte is a useful parameter for refining the criteria of patients who have had embryo freezing of all embryos (by selective freezing) and subsequent transfer of frozen embryos.

Effect of early GnRH antagonist administration on assisted reproductive technique outcomes in normal responders

One of the main questions in assisted reproductive techniques is how to prevent premature LH surge using a variety of protocols depending on either pituitary down-regulation, in GnRH agonist protocols, or by receptors blockage, in GnRH protocols. It is possible to say that GnRH protocols are most popular nowadays. The study aimed to assess the effectiveness of early antagonist administration during days ≤6 and later antagonist administration on days >6 on assisted reproductive outcomes. Women admitted to the ART Department at the High Institute for Infertility Diagnosis and ART, Al-Nahrain University, Baghdad, Iraq were included in the study. Reproductive outcomes were evaluated in early ≤6 and late >6 antagonist administration in a total of 44 normal responders, as follows. Sandwich protocols in 14 patients that received antagonists in the first 3 days of the follicular phase and conventional flexible antagonist protocol in 30 patients. We compared the outcomes between the two groups. There were no differences between early antagonist administration ≤6 and late >6 days in the number of MII oocytes, 2PN, the number of transferred embryos, grades of the embryos, and pregnancy rates. However, there were statistically significant differences between the duration of stimulation and the total Gonadotropin dose required. There was no effect of antagonist administration on days ≤6 and >6 on controlled ovarian stimulation on assisted reproductive outcomes.

A short length of gonadotropin hyperstimulation is sufficient to achieve an optimal IVF outcome in advance-aged women

OBJECTIVE

To analyze the duration of gonadotropin hyperstimulation's impacts on oocyte quality and clinical outcomes in aged in vitro fertilization (IVF) patients.

MATERIALS AND METHODS

This retrospective study was carried out using IVF records of the Chang Gung Memorial Hospital IVF center from January 2017 to December 2019. A total of 308 IVF cycles with patients aged 40-44 years were included. Clinical characteristics of patients who received a short controlled ovarian hyperstimulation (COH) (i.e., 6-7 days; s-COH group) or a long COH treatment (i.e., 9-10 days; l-COH group) were compared. In addition, analysis was conducted using data within two age subgroups: 40-42 years and 42-44 years subgroups.

RESULTS

The s-COH group received significantly lower total doses of gonadotropin and had smaller leading follicles at the time of ovulation trigger when compared to the l-COH group. The s-COH group also produced a significantly lower number of oocytes, mature metaphase II (MII) oocytes, and 2 PN zygotes compared to the l-COH group. However, there was no significant difference in the number of transferable and good-quality embryos between the two treatment groups. Likewise, the pregnancy rate and live birth rate were comparable in the s-COH and l-COH groups. Similar results were obtained when the analysis was limited to select age subgroups (i.e., 40-42 and 42-44 years subgroups).

CONCLUSION

While a long COH generates more oocytes per cycle, a 6-7 days COH treatment, which is at the lower end of the recommended window of stimulation, could achieve a pregnancy outcome comparable to that applied 9-10 days of COH in aged patients.

Impact of letrozole co-treatment during ovarian stimulation with gonadotrophins for IVF: a multicentre, randomized, double-blinded placebo-controlled trial

STUDY QUESTION

Does letrozole co-treatment during ovarian stimulation with gonadotrophins for IVF reduce the proportion of women with premature progesterone levels above 1.5 ng/ml at the time of triggering final oocyte maturation?

SUMMARY ANSWER

The proportion of women with premature progesterone above 1.5 ng/ml was not significantly affected by letrozole co-treatment.

WHAT IS KNOWN ALREADY

IVF creates multiple follicles with supraphysiological levels of sex steroids interrupting the endocrine milieu and affects the window of implantation. Letrozole is an effective aromatase inhibitor, normalizing serum oestradiol, thereby ameliorating some of the detrimental effects of IVF treatment.

STUDY DESIGN, SIZE, DURATION

A randomized, double-blinded placebo-controlled trial investigated letrozole intervention during stimulation for IVF with FSH. The trial was conducted at four fertility clinics at University Hospitals in Denmark from August 2016 to November 2018.

PARTICIPANTS/MATERIALS, SETTING, METHODS

A cohort of 129 women with expected normal ovarian reserve (anti-Müllerian hormone 8-32 nmol/l) completed an IVF cycle with fresh embryo transfer and received co-treatment with either 5 mg/day letrozole (n = 67) or placebo (n = 62), along with the FSH. Progesterone, oestradiol, FSH, LH and androgens were analysed in repeated serum samples collected from the start of the stimulation to the mid-luteal phase. In addition, the effect of letrozole on reproductive outcomes, total FSH consumption and adverse events were assessed.

MAIN RESULTS AND THE ROLE OF CHANCE

The proportion of women with premature progesterone >1.5 ng/ml was similar (6% vs 0% (OR 0.0, 95% CI [0.0; 1.6], P = 0.12) in the letrozole versus placebo groups, respectively), whereas the proportion of women with mid-luteal progesterone >30 ng/ml was significantly increased in the letrozole group: (59% vs 31% (OR 3.3, 95% CI [1.4; 7.1], P = 0.005)). Letrozole versus placebo decreased oestradiol levels on the ovulation trigger day by 68% (95% CI [60%; 75%], P < 0.0001). Other hormonal profiles, measured as AUC, showed the following results. The increase in LH in the letrozole group versus placebo group was 38% (95% CI [21%; 58%], P < 0.0001) and 34% (95% CI [11%; 61%], P = 0.006) in the follicular and luteal phases, respectively. In the letrozole group versus placebo group, testosterone increased by 79% (95% CI [55%; 105%], P < 0.0001) and 49% (95% CI [30%; 72%], P < 0.0001) in the follicular and luteal phases, respectively. In the letrozole group versus placebo group, the increase in androstenedione was by 85% (95% CI [59%; 114%], P < 0.0001) and 69% (95% CI [48%; 94%], P < 0.0001) in the follicular and luteal phases, respectively. The ongoing pregnancy rate was similar between the letrozole and placebo groups (31% vs 39% (risk-difference of 8%, 95% CI [-25%; 11%], P = 0.55)). No serious adverse reactions were recorded in either group. The total duration of exogenous FSH stimulation was 1 day shorter in the intervention group, significantly reducing total FSH consumption (mean difference -100 IU, 95% CI [-192; -21], P = 0.03).

LIMITATIONS, REASONS FOR CAUTION

Late follicular progesterone samples were collected on the day before and day of ovulation triggering for patient logistic considerations, and the recently emerged knowledge about diurnal variation of progesterone was not taken into account. The study was powered to detect hormonal variations but not differences in pregnancy outcomes.

WIDER IMPLICATIONS OF THE FINDINGS

Although the use of letrozole has no effect on the primary outcome, the number of women with a premature increase in progesterone on the day of ovulation triggering, the increased progesterone in the mid-luteal phase due to letrozole may contribute to optimizing the luteal phase endocrinology. The effect of letrozole on increasing androgens and reducing FSH consumption may be used in poor responders. However, the effect of letrozole on implantation and ongoing pregnancy rates should be evaluated in a meta-analysis or larger randomized controlled trial (RCT).

STUDY FUNDING/COMPETING INTEREST(S)

Funding was received from EU Interreg for ReproUnion and Ferring Pharmaceuticals, and Roche Diagnostics contributed with assays. N.S.M. and A.P. have received grants from Ferring, Merck Serono, Anecova and Gedeon Richter, and/or personal fees from IBSA, Vivoplex, ArtPred and SPD, outside the submitted work. The remaining authors have no competing interests.

TRIAL REGISTRATION NUMBERS

NCT02939898 and NCT02946684.

TRIAL REGISTRATION DATE

15 August 2016.

DATE OF FIRST PATIENT’S ENROLMENT

22 August 2016.

The efficiency of progesterone/estradiol and progesterone/follicle ratio without elevated trigger-day progesterone levels on the reproductive outcomes of GnRH antagonist IVF/ICSI cycles

AIM

To assess the predictive value of serum progesterone/estradiol (P/E₂) and serum progesterone/follicle (P/F) ratios on the reproductive outcomes of women without elevated trigger-day progesterone levels undergoing GnRH-antagonist IVF (in vitro fertilization)/ICSI (intracytoplasmic sperm injection) cycles.

MATERIALS AND METHODS

This was a retrospective cohort study in a university teaching hospital conducted between January 2017 and December 2019. Couples who underwent assisted reproduction cycles were evaluated. Initially, 978 cycles were evaluated and only GnRH antagonist cycles (n = 505) without elevated trigger-day progesterone levels were analyzed after respecting exclusion criteria.

RESULTS

A total of 505 cycles were analyzed after the exclusion criteria were met. The clinical pregnancy rate, ongoing pregnancy rate, and live birth rate were 45.5%, 30.9%, and 27.8%, respectively. Cutoff values of P/E₂ and P/F ratios that were discriminative for achieving or not achieving clinical pregnancy were 0.36 and 0.17, respectively. The clinical pregnancy rates were found to be significantly different between below and above P/E₂ cutoff values (49.8% vs. 40.1%, respectively, p = .031), while there were no significant differences between below and above P/F cutoff values regarding the pregnancy outcomes.

CONCLUSION

The P/E₂ and P/F ratios were found to be more efficient and reliable markers than serum progesterone level alone in predicting the reproductive outcomes of assisted reproduction cycles without a premature rise in serum progesterone levels. A P/E₂ ratio ≤0.36 and a P/F ratio ≤0.17 significantly improved the cycle outcomes.

Progesterone levels on the human chorionic gonadotropin trigger day affect the pregnancy rates for embryos transferred at different stages of development in both general and selected IVF/ICSI populations

Background

Two meta-analyses have shown that pregnancy and birth rates are significantly higher after blastocyst transfer than after cleaved embryo transfer. Other studies have revealed that a serum progesterone level > 1.5 ng/ml on the trigger day is responsible for premature luteinization and is associated with a low pregnancy rate. The objectives of this retrospective study were to determine whether blastocyst transfer gave higher pregnancy rates than cleaved embryo transfer at day 3 in both the general and selected IVF/ICSI populations, and whether the serum progesterone level influenced the pregnancy rate.

Method

We studied IVF/ICSI cycles with GnRH antagonist - FSH/hMG protocols in a general population (n = 1210) and a selected “top cycle” population (n = 677), after blastocyst transfer on day 5 or cleaved embryo transfer on day 3. The selected couples had to meet the following criteria: female age < 35, first or second cycle, and one or two embryos transferred. We recorded predictive factors for pregnancy and calculated the progesterone to oocyte index (POI), the progesterone:estradiol ratio (P:E2 ratio), and the progesterone to follicle (> 14 mm) index (PFI).

Results

In the general population, the clinical pregnancy rate was significantly higher after blastocyst transfer (33.3%) than after cleaved embryo transfer (25.3%; p <  0.01); the same was true for the birth rate (32.1 and 22.8%, respectively, p <  0.01). The differences between blastocyst and embryo transfer groups were not significant in the selected population (respectively 35.7% vs. 35.8% for the clinical pregnancy rate, and 33.9 and 34.9% for the birth rate). The serum progesterone levels on the eve of the trigger day and on the day itself were significantly lower in the pregnant women (p <  0.01). We found a serum progesterone threshold of 0.9 ng/ml, as also reported by other researchers. The POI and the PFI appear to have predictive value for cleaved embryos transfers.

Conclusions

Blastocyst transfers were associated with higher clinical pregnancy and birth rates than cleaved embryo transfers in a general population but not in a selected population. The serum progesterone levels on the eve of the trigger day and on the day itself predicted the likelihood of pregnancy.

Effect of Dexamethasone Co-Treatment During Ovarian Stimulation in Women of Different Reproductive Age With Elevated Early Follicular Phase Progesterone Level: a Prospective Longitudinal Study

The aim of this paper was to estimate the effect of dexamethasone during ovarian stimulation in women of different reproductive age with elevated early follicular phase progesterone level undergoing fresh IVF cycle. This study is a prospective longitudinal analysis of consecutive women who underwent fresh IVF cycles at a single center, between January 2012 to December 2013. Women with early follicular phase progesterone above 0.50 ng/ml, assessed in day 0 or day 5 of stimulation, were included. Study group (n = 113) included women who underwent dexamethasone supplementation until the day of triggering. Women who did not undergo dexamethasone treatment formed the control group (n = 109). We further stratified our study population according to age ranges: (1) ≤ 34 years, (2) between 35 and 39 years, and (3) ≥ 40 years. Significantly lower progesterone levels were observed in study than in control group (0.59 ± 0.21 vs 0.94 ± 0.42, p < 0.001). Such difference is not observed in women above 39 years old. Higher, albeit not significant, live birth rate was detected in the study versus control group, considering the overall population. In women ≤ 34 years old, a significantly higher live birth rate was observed in women who underwent dexametasone treatment than in the control group (67.5% vs 47.2%, p = 0.04). Conversely, live birth rates were similar between groups in women above 34 years old. Our data suggest that dexamethasone helps to modulate progesterone levels during the follicular phase and might improve live birth rate of women below 34 years old.

The value of serum progesterone level on day of human chorionic gonadotrophin administration / metaphase II oocyte ratio in predicting IVF/ICSI outcome in patients with normal ovarian reserve

Background

The clinical implication of the increased serum progesterone level on the day of HCG administration in assisted reproduction treatment (ART) is still controversial. The current study aimed to compare the predictive value of serum progesterone on day of HCG administration / metaphase II oocyte (P/MII) ratio on IVF/ ICSI outcome to serum progesterone (P) level alone and the ratio of serum progesterone/estradiol level (P/E2) ratio in prediction of pregnancy rates after ART.

Material & methods

Two hundred patients admitted to the IVF/ICSI program at Minia IVF center in Egypt in the period from October 2016 to May 2018 were included in this study. Serum Progesterone (P) and Estradiol (E2) levels were estimated on the day of HCG administration. The ratio between serum P and the number of MII oocytes (P/MII ratio) was calculated and the predictive values of the three parameters (P, P/E2 ratio and P/MII ratio) in prediction of cycle outcomes were measured.

Results

P/ MII oocyte ratio was significantly lower in patients who attained clinical pregnancy (n = 97) as compared with those who couldn’t whilst there was no significant difference in P and P/E2 ratio between the two groups. Using a cut off value of 0.125, the sensitivity and specificity of progesterone/ MII ratio in prediction of no pregnancy in IVF/ICSI were 75.7 and 77.1% respectively with the area under The Receiver operating curve (ROC-AUC) = 0.808. The respective values of the ROC-AUC for the P and P/E2 ratio were 0.651 and 0.712 with sensitivity and specificity of 71.2 and 73.5%for P level and of 72.5 and 75.3% for P/E2 ratio. Implantation or clinical pregnancy rates were significantly different between patients with high and low P/MII ratio irrespective of day of embryo transfer (day 3 or 5).

Conclusions

In patients with normal ovarian response, serum progesterone on day of HCG / MII oocyte ratio can be a useful predictor of pregnancy outcomes and in deciding on freezing of all embryos for later transfer instead of high progesterone level alone.

Step-Down of FSH- Dosage During Ovarian Stimulation - Basic Lessons to Be Learnt From a Randomized Controlled Trial

A rise in serum progesterone in the late follicular phase is a well described adverse effect of ovarian stimulation for IVF/ICSI. Previous data suggest, that enhanced gonadotropin stimulation causes progesterone elevation and the incidence of premature progesterone elevation can be reduced by declining gonadotropin dosages. This randomized controlled trial (RCT) aimed to achieve a significant reduction of the progesterone level on the day of final oocyte maturation by a daily reduction of 12.5 IU rec-FSH from a follicle size of 14 mm in a GnRH-antagonist protocol. A total of 127 patients had been recruited (Control group (CG): 62 patients; Study group (SG): 65 patients). Due to drop out, data from 108 patients (CG: 55 patients; SG: 53 patients) were included into the analysis. Patients' basic parameters, gonadotropin (Gn)-starting dose, total Gn-stimulation dosage, the number of retrieved and mature oocytes as well as in the hormonal parameters on the day of trigger (DoT) were not statistically significantly different. However, through stepwise Gn-reduction of 12.5 IU/day in the SG, there was a statistically highly significant difference in the Gn-stimulation dosage on the day of trigger (p < 0.0001) and statistically significant associations for the DoT-P4-levels with the DoT-FSH-levels for both groups (CG: p = 0.001; SG: p = 0.0045). The herein described significant associations between DoT-P4-levels and DoT-FSH-levels confirm the theory that enhanced FSH stimulation is the primary source of progesterone elevation on the day of final oocyte maturation in stimulated IVF/ICSI cycles. Given the pathophysiologic mechanism of progesterone elevation during ovarian stimulation, the use of an increased FSH step-down dosage should be studied in future RCTs, despite the fact that a step-down approach of daily 12.5 IU rec-FSH did not achieve a significantly reduced progesterone level on the DoT. Clinical Trial Registration: clinicaltrials.gov, identifier NCT03356964.

Diminished Ovarian Reserve Predisposes to Premature Luteinizing Hormone Surges in Gonadotropin-Releasing Hormone Antagonist Cycles in In vitro Fertilization

Context/Background:

A premature luteinizing hormone (LH) surge, in in vitro fertilization (IVF) cycles with gonadotropin-releasing hormone (GnRH)-antagonist downregulation, leads to cycle cancellation. Currently, risk factors for the development of premature LH surge remain unknown.

Objective:

The aim of the study was to determine the incidence and identify the contributing factors for premature LH surge in IVF cycles with GnRH antagonist suppression.

Design:

This was a retrospective cohort study.

Setting:

IVF-embryo transfer program at a fertility and research center.

Materials and Methods:

The study included all patients undergoing IVF from December 1, 2014, to November 30, 2018, in whom GnRH-antagonist (cetrorelix 0.25 mg/d) flexible protocol was used. The primary outcome measure was the identification of premature LH surges (documented by a 2.5-fold increase in LH from the baseline above a threshold of 17 mIU/mL) with or without a decrease in E₂ and appearance of free fluid on ultrasound.

Results:

Premature LH surges occurred in 15 (2.16%) of 692 patients undergoing IVF with GnRH-antagonist suppression. Patients with premature surges had significantly lower ovarian reserve as compared to the controls (as seen from their higher age group, higher day 2 follicle-stimulating hormone (FSH), lower antral follicle counts, and lower anti-Müllerian hormone).

Conclusions:

Premature LH surge in a GnRH-antagonist cycle can lead to cycle cancellation and disappointment. Although this is a rare event, the incidence is higher in patients with diminished ovarian reserve. Further studies are needed to determine if giving the human chorionic gonadotropin trigger a day earlier or giving higher doses of GnRH-antagonist can benefit such cases.

The relationship between a novel evaluation parameter of premature luteinization and IVF outcomes

RESEARCH QUESTION

Can premature luteinization of granulosa cells (PLGC) act as a novel parameter of premature luteinization and affect IVF outcomes?

STUDY DESIGN

In this retrospective cohort study, infertile patients undergoing fresh IVF cycles between January 2006 and December 2016 at the Reproductive Medicine Center in Tongji Hospital were included. A total of 42,468 cycles were conducted. Propensity score matching was carried out to match the baseline characteristics, and participants were assigned to the PLGC group and control group. The main outcomes were pregnancy rate and live birth rate.

RESULTS

Patient characteristics and clinical outcomes were compared before and after matching. In general, the fate of oocytes in the PLGC group was much worse than those in the control group after matching, including metaphase II rate, two-pronuclei rate, available embryo rate, blastocyst formation rate, high-quality blastocyst rate, pregnancy rate, implantation rate and live birth rate. Among those potential risk factors, gonadotrophin duration, oestradiol and progesterone on HCG day were positively associated with the occurrence of PLGC in the multivariate logistic regression model, with gonadotrophin dosage negatively related. Moreover, cumulus-oocyte complexes with PLGC showed a high correlation with elevated progesterone levels over 1.5 ng/ml.

CONCLUSIONS

Our findings demonstrated the adverse effect of PLGC on oocyte competency. In evaluating cumulus-oocyte complexes, PLGC provide an available novel parameter for premature luteinization judgement in clinical and individualized precise treatment. Close monitoring of progesterone level as well as critical analysis of progesterone elevation can reduce the occurrence of premature luteinization.

There is a cycle to cycle variation in ovarian response and pre-hCG serum progesterone level: an analysis of 244 consecutive IVF cycles

We aimed to answer one key question, that was not previously addressed as to whether serum progesterone (P_4-hCG day) and its co-variates (estradiol (E_{2-hCG day}) and the number of retrieved oocytes) of a given cycle can be predictive of the subsequent cycle when both cycles are consecutive and comparable for the stimulation protocol, gonadotropin dose and duration of stimulation. We analyzed such 244 consecutive (< 6 months) IVF cycles in 122 patients with GnRH agonist long protocol and found that P₄, E₂ and the number of retrieved oocytes significantly vary between the two cycles. Although P₄ increased (ranging from 4.7 to 266.7%) in the 2nd cycle in 61 patients, E₂ and the number of retrieved oocytes, which are normally positively correlated with P₄ paradoxically decreased in the 41% and 37.7% respectively, of these same 61 patients. When a similar analysis was done in the 54 out of 122 patients (44.3%) in whom serum P₄ was decreased in the 2nd cycle, the mean decrease in P₄ was − 34.1 ± 23.3% ranging from − 5.26 to − 90.1%. E₂ and the number of retrieved oocytes paradoxically increased in the 42.3% and 40.7% of these 54 patients respectively. P₄ remained the same only in the 7 (5.7%) of these 122 patients. These findings indicate that late follicular phase serum P₄ may change unpredictably in the subsequent IVF cycle. The changes are not always necessarily proportional with ovarian response of previous cycle suggesting that growth characteristics and steroidogenic activities of antral cohorts may exhibit considerable cycle to cycle variations.

Response to ovulation trigger is correlated to late follicular phase progesterone levels: A hypothesis explaining reduced reproductive outcomes caused by increased late follicular progesterone rise

STUDY QUESTION

Is there an association between progesterone (P4) levels on the day of hCG or GnRH trigger and on the day of oocyte retrieval in IVF/ICSI cycles?

SUMMARY ANSWER

A significant positive correlation between P4 levels on the day of trigger and the day of oocyte retrieval is seen; HCG trigger induces a steeper P4 increase than GnRHa trigger.

WHAT IS KNOWN ALREADY

FSH induces LH receptor (LHR) expression on granulosa cells, and LHR produces progesterone when exposed to LH-like activity. FSH per se also to some extent induces P4 secretion. Late follicular phase progesterone rise has been associated with reduced reproductive outcomes.

STUDY DESIGN, SIZE, DURATION

This study is based on data from a previously published RCT conducted from 2009 to 2011.

PARTICIPANTS/MATERIALS, SETTING, METHODS

A total of 384 participants were enrolled; 199 received 5000 IU hCG and 185 received buserelin 0.5 mg for triggering ovulation. P4 was measured on the day of ovulation induction and on the day of oocyte retrieval. FSH consumption and number of retrieved follicles were recorded.

MAIN RESULTS AND THE ROLE OF CHANCE

A significant linear relationship between P4 on the day of ovulation induction and oocyte retrieval was seen in the hCG trigger group (P < 0.00001) as well as in the GnRHa trigger group (P < 0.00001). The P4 ratio (the increase in P4 between ovulation induction and oocyte retrieval) was significantly higher in the group of patients with <5 follicles compared to those with 5-15 and >15 follicles (P < 0.0001). The FSH consumption per follicle was significantly higher in the group of patients with <5 follicles compared to those with 5-15 and >15 follicles (P < 0.0001).

LIMITATIONS, REASONS FOR CAUTION

Although the study demonstrates a significant correlation between P4 levels before and after ovulation trigger, it does not demonstrate a causal relation to the number of LHRs present on granulosa cells.

WIDER IMPLICATIONS OF THE FINDINGS

The findings of this study support the proposed hypothesis that follicles exposed to high levels of FSH during ovarian stimulation will respond with an inappropriately high LHR expression. This in turn causes a high P4 output in response to the trigger. This study further expands our understanding of the underlying mechanisms affecting reproductive outcomes in relation to ovarian stimulation.

STUDY FUNDING/COMPETING INTEREST(S)

The authors received no specific funding for this work and disclose no conflicts of interest.

TRIAL REGISTRATION NUMBER

N/A.

Role of gene polymorphisms related to progesterone elevation in women undergoing long GnRH agonist protocols

RESEARCH QUESTION

Can single-nucleotide polymorphisms (SNP) of genes related to progesterone synthesis predict the risk of premature serum progesterone elevation in women undergoing gonadotrophin-releasing hormone agonist protocols for ovarian stimulation?

DESIGN

A total of 765 women were divided into high progesterone and normal progesterone groups according to progesterone concentration on the day of human chorionic gonadotrophin (HCG) administration, with the 75th percentile as the threshold between the group. Associations were analysed of genetic information from whole exome sequencing and the clinical characteristics of the two groups to identify the relationship between SNP, haplotypes and serum progesterone elevation.

RESULTS

Among 40 common SNP of eight genes (FSHR, LHCGR, ESR1, ESR2, PGR, HSD3B1, CYP11A1 and CYP17A1), no statistical significance between the high and normal progesterone groups was identified in the distribution of genotypes and allele frequencies after multiple test correction to adjust the false discovery rate (P_FDR > 0.05). When compared with the most common haplotypes of each gene, haplotype GAAG in CYP17A1 was associated with a 1.44-fold increased risk of progesterone elevation (95% confidence interval [CI] 1.22-1.69, P_FDR < 0.001), while haplotypes of the following genes showed a decreased risk of progesterone elevation: haplotype CC in FSHR and LHCGR (0.66-fold, P_FDR = 0.020, and 0.64-fold, P_FDR < 0.001, respectively), CA in ESR1 (0.90-fold, P_FDR < 0.001), TCTGG in ESR2 (0.92-fold, P_FDR = 0.007) and GAACC in HSD3B1 (0.42-fold, P_FDR < 0.001).

CONCLUSIONS

Polymorphism in genes involved in enzymes or hormone receptors in the progesterone synthesis pathway may have a role in modifying risk of serum progesterone elevation.

Association of raised serum progesterone and gene polymorphisms with risk of failure pregnancy and miscarriage

Balanced cytokine required for a healthy pregnancy to avoid miscarriage. There is yet no accord on the effect of raised progesterone on the endometrium, recurrent miscarriage and association with cytokines. The present study see the effect of raised serum progesterone level on ovulation, miscarriage, and association of selected Cytokines polymorphisms with recurrent miscarriage. In a controlled prospective study patients undergoing COS under controlled ovarian hyper stimulation were evaluated. On the day of trigger progesterone levels were measured and serum hormonal estimation assay was done on the day of ovulation trigger by automated immunoassay. Genotyping analysis using allelic discrimination method was conducted which detects SNPs base pair differences by comparing allele-specific fluorescence signal. There was no significant different between cases and controls in age, smoking habit and alcohol consumption habit. The ovulation trigger yielded >6 oocytes retrieval in majority of the patients. The mean stromal day were found to be statistically significant whereas the mean day of glands were insignificant. There is no significant difference observed between two groups for three studied polymorphisms. None of the polymorphisms deviated significantly from the Hardy Weinberg equilibrium, suggesting that the distribution in our subjects was representative of the actual population. The level of cytokines is guarded by various parameters, which are essential for a successful pregnancy. It is very complicated to predict the effect on endometrium and corresponding pregnancy rates due to increased progesterone.

Factors associated with extremely high progesterone concentrations on the day of HCG administration

OBJECTIVE

Progesterone elevation on the day of human chorionic gonadotropin (hCG) administration remains one of the most controversial topics in reproductive endocrinology. Factors associated with these increases have not been fully determined. The purpose of our study is to investigate factors associated with extreme progesterone elevation on the day of human chorionic gonadotropin (hCG) administration.

MATERIALS AND METHODS

This retrospective observational, single-center cohort study recruited 2000 fresh in vitro fertilization (IVF) and/or intracytoplasmic sperm injection(ICSI)-embryo transfer cycles from January 2000 to December 2014 in our institution.

RESULTS

When cycles were divided into those with progesterone <1.94 ng/mL (n = 1791) and ≧1.94 ng/mL (n = 209) on the day of hCG administration, five factors were positively associated with highly elevated progesterone concentration: protocol (GnRH agonist versus antagonist; odds ratio [OR = 2.786]), number of dominant follicles (OR = 1.098), total dose of follicle stimulating hormone (FSH) used (OR = 1.023), elevated luteinizing hormone (LH) (OR = 1.085) and estradiol (E2; OR = 1.001) concentrations on the day of hCG administration (p < 0.001 each). After omitting the protocol effect, the remaining factors showed limited contributions to highly elevated progesterone (ORs = 0.95-1.2).

CONCLUSIONS

The factor showing the greatest association with extreme progesterone elevation was use of the GnRH agonist protocol.

Revisiting debates of premature luteinization and its effect on assisted reproductive technology outcome

The impact of the prematurely elevated serum progesterone on the late follicular phase, commonly known as premature luteinization (PL), is a matter of continuing debate. Available evidence supports that serum progesterone ≥ 1.5 ng/ml on the day of ovulation triggering could reduce the pregnancy potential in fresh in vitro fertilization (IVF) cycles by jeopardizing endometrial receptivity. Causes of PL during ovarian stimulation are unclear. Recent studies point toward the daily follicle-stimulating hormone dosage, duration of controlled ovarian stimulation, number of oocytes retrieved, and peak estradiol level as factors affecting the incidence of PL. Emerging data show additional influence on embryo quality. The prevention of PL has been challenging. The key elements in preventing PL include individualization of ovarian stimulation according to patient's ovarian reserve, proper ovulation trigger timing, and use of medications such as corticosteroids and metformin. Embryo cryopreservation with deferred embryo transfer is the established strategy to overcome PL, yet it is an extra burden to the IVF laboratory and increased cost for patients. Herein, we review the up-to-date knowledge of this frequent IVF problem including causes, proposed diagnostic criteria, and its impact on endometrial receptivity, embryo quality, and pregnancy outcomes. The preventive measures and rescue strategies are also discussed.

Lipid Profiling of Peri-implantation Endometrium in Patients With Premature Progesterone Rise in the Late Follicular Phase

CONTEXT

Late follicular phase elevation in serum progesterone (P) during controlled ovarian hyperstimulation negatively affects the outcome of assisted reproductive technology by contributing to endometrial-embryo asynchrony. There are still no data on lipid metabolite alterations during this process.

OBJECTIVES

To investigate alterations in the lipid profile during the window of implantation in patients with premature P rise.

DESIGN

Lipidomic variations in the endometrium were evaluated by ultrahigh-performance liquid chromatography coupled with electrospray ionization high-resolution mass spectrometry.

SETTING

University assisted reproductive medicine unit.

PATIENTS OR OTHER PARTICIPANTS

Forty-three patients undergoing in vitro fertilization/intracytoplasmic sperm injection because of a tubal factor or male factor infertility were included in this study. The patients were divided into a high P group (P ≥ 1.5 ng/mL, 15 patients) and a normal P group (P < 1.5 ng/mL, 28 patients) on the day of human chorionic gonadotropin administration.

INTERVENTIONS

The endometrial tissues were obtained by Pipelle biopsy 7 days after human chorionic gonadotropin administration.

MAIN OUTCOME MEASURES

Alterations in lipid metabolites.

RESULTS

A total of 1026 ions were identified, and 25 lipids were significantly upregulated. The endometrial lipid profile was characterized by substantial increases in the concentrations of phosphatidylcholine, phosphatidylethanolamine, lysophosphatidylcholine, diacylglycerol, ceramide, phosphatidylinositol, and phosphatidylserine in patients with a premature P rise at the end of the follicular phase. The correlation analysis between P levels and lipids showed a stronger negative correlation between phosphatidylethanolamine or phosphatidylserine and P levels.

CONCLUSIONS

Premature P elevation disrupts the lipid homeostasis of the endometrium during the peri-implantation period. The altered lipid levels may impair endometrial receptivity and early embryo implantation.

Increased Progesterone on the Day of Administration of hCG in Controlled Ovarian Hyperstimulation Affects the Expression of HOXA10 in Primates' Endometrial Receptivity

The increase in progesterone (P4) levels on the day of human chorionic gonadotropin (hCG) administration have a negative effect on endometrial receptivity. There are few reports regarding the expression of homeobox A10 (HOXA10) as one of many biomolecular factors of endometrial receptivity. To evaluate the effect of increased P4 concentration on the day of hCG administration on HOXA10, a total of 16 Macaca nemestrina were divided into three dose groups of recombinant-follicle stimulating hormone (rFSH) (30IU, 50IU, and 70IU) and one control group. Injection of rFSH combined with gonadotropin release hormone (GnRH) at 160 ug/day was given subcutaneously using a long protocol technique. Blood samples for estradiol (E2) and (P4) concentration measurements were taken on the day of injecting hCG in the final follicular phase, while the collection of endometrial tissue for HOXA10 measurement was carried out 8 to 10 days after hCG administration. E2 and P4 were measured by ELISA, whereas HOXA10 expression was measured with immunohistochemical (IHC) techniques. The concentration of E2 and P4 was found to be higher in dose groups compared with the natural group, but no significant differences were found within the group. For the Hscore for HOXA10 expression, no significant differences within dose groups were found. In addition, no significant differences for the Hscore for HOXA10 were found when compared to E2 groups. Significantly, the Hscore of HOXA10 was found to be >1 ng/mL in the P4 group compared with the Hscore HOXA10 in the P4 natural group (p = 0.022). The high concentration of P4 caused by ovarian hyperstimulation in the follicular phase stimulates the expression of HOXA10 in the secretion phase.

The Enigma of Early Progesterone Rise: Is It Associated with the Type of Gonadotropin Used?

Background

It is debated whether the use of recombinant follicle-stimulating hormone (r-FSH) or human menopausal gonadotropin (HMG) is associated with progesterone (P) elevation in the late follicular phase.

Aims

The aim is to determine whether the type of gonadotropin used for controlled ovarian stimulation (COS) in in vitro fertilization (IVF) is associated with P elevation in the late follicular phase using antagonist protocol.

Setting and Design

This was a retrospective data analysis in the IVF unit.

Methods

Data of women who underwent COS between January 2005 and December 2017.

Statistical Analysis

Chi-square and unpaired Student's t-test in SPSS 20.

Results

Data of 439 women was analyzed. Mean age was 31.45 ± 4.6 years. HMG was used in 193 (44%), r-FSH in 232 (52.8%), and a combination of both in 14 (3.2%) women. Proportion of women with elevated P was significantly higher in r-FSH group as compared to HMG group (19/232 [8.2%] vs. 6/193 [3.1%]; P = 0.027). Mean P levels were significantly higher in r-FSH group (0.75 ng/ml vs. 0.59 ng/ml; P = 0.049). Mean estradiol (E2) levels at trigger were significantly higher in women with elevated P as compared to normal P (2893.4 ± 2091.8 pg/ml vs. 1668.3 ± 1508.6 pg/ml respectively; P < 0.000). Fresh embryo transfers performed in 18/27 women with elevated P resulted in pregnancy in three (16.7%) women. Two had biochemical pregnancies and one was lost to follow-up.

Conclusions

Use of r-FSH and E2 levels at trigger are associated with elevated P levels in the late follicular phase. Fresh embryo transfers performed in spite of elevated P levels were associated with low pregnancy rates and unfavorable outcomes.

Worth the wait? Day 7 blastocysts have lower euploidy rates but similar sustained implantation rates as Day 5 and Day 6 blastocysts

STUDY QUESTION

Does the reproductive potential of embryos change when blastocyst development takes longer than the traditionally accepted 5 days when accounting for aneuploidy and endometrial-embryo asynchrony?

SUMMARY ANSWER

Aneuploidy increases with increasing duration of blastulation, but if blastocyst morphologic quality and endometrial-embryo asynchrony are controlled for, euploid Day 7 embryos have similar sustained implantation as compared to Days 5 and 6 euploid blastocysts.

WHAT IS KNOWN ALREADY

The relative contributions of diminished embryo quality versus endometrial and embryo asynchrony to poor outcomes associated with embryos cultured past Day 6 are not clear. Asynchrony can be eliminated by embryo vitrification with transfer in a subsequent month after retrieval.

STUDY DESIGN, SIZE, DURATION

Retrospective cohort study of patients from a single center attempting conception through ICSI and utilizing preimplantation genetic testing for aneuploidy screening (PGT-A) from January 2017 to September 2018. Cycles were excluded if they utilized surgical sperm or preimplantation genetic testing for monogenetic/single gene defects. ICSI cycle outcomes from 2586 patients were evaluated for ploidy status of embryos.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Only patients undergoing single, euploid frozen embryo transfer were included when analyzing cycle outcomes by day of blastocyst expansion of the transferred embryo (n = 2130). Ploidy rates by the day upon which an embryo was considered to be usable (denoted, ‘usable blastulation day’) were determined so as to assess the contribution of aneuploidy to slow embryo development. Outcomes of euploid frozen single embryo transfers (SET) of Day 7 embryos were evaluated to assess the reproductive potential associated with embryos that were slowly developing for reasons other than aneuploidy. Analyses were adjusted by maternal age and blastocyst morphology.

MAIN RESULTS AND THE ROLE OF CHANCE

Overall, 67.7% (n = 3508) of usable Day 5 blastocysts were euploid, 52.1% (n = 5560) of usable Day 6 blastocysts were euploid and 43.1% (n = 229) of usable Day 7 embryos were euploid (Day 5 versus Day 6: odds ratio (OR) 0.7 (95% CI, 0.64–0.76), P < 0.001; Day 5 versus Day 7: OR 0.56 (95% CI, 0.46–0.69), P < 0.001; Day 6 versus Day 7: OR 0.81 (95% CI, 0.67–0.99), P = 0.036). Stratified by Society for Assisted Reproductive Technology maternal age groups, a reduction in the prevalence of euploidy by increasing time to embryo blastulation was still seen. The sustained implantation rate (SIR) was similar after euploid SET of Days 5 and 6 embryos (overall, 68.9% (95% CI, 66.0–71.6) and 66.8% (95% CI, 63.8–69.7), respectively; P = 0.81). SIR after euploid Day 7 SET appeared slightly lower than that of Days 5 and 6 embryos (52.6% (95% CI, 35.8–69.0); (Day 5 versus Day 7: OR, 0.67 (95% CI, 0.32–1.41), P = 0.29; Day 6 versus Day 7: OR 0.58 (95% CI, 0.28–1.2), P = 0.14)) but did not achieve statistical significance.

LIMITATIONS, REASONS FOR CAUTION

The primary limitation is the low number of Day 7 blastocyst transfers that limits statistical power. Additionally, the retrospective nature of this study may prevent full elucidation of potential biases with respect to culture, morphologic assessment and selection of Day 7 embryos for transfer.

WIDER IMPLICATIONS OF THE FINDINGS

Routine culture through Day 7 may successfully increase the pool of transferrable embryos for patients who would otherwise have no usable embryos if culture terminated on Day 6. This is particularly true for older patients (i.e. greater than 35 years of age), whose embryos take longer to blastulate and, therefore, are more susceptible to cycle cancelation. Additionally, as evidenced by an adequate overall SIR of 52.6% after euploid SET of Day 7 blastocysts, embryos developing to a usable blastocyst on Day 7 are likely within the ‘window of blastulation.’

STUDY FUNDING/COMPETING INTEREST(S)

None.

Both high and low HCG day progesterone concentrations negatively affect live birth rates in IVF/ICSI cycles

RESEARCH QUESTION

Can previous reports of a decreased probability of success in stimulated IVF cycles with premature rise of progesterone, as determined by progesterone concentration on HCG day (PHCG), be confirmed?

DESIGN

Retrospective, observational, single-centre cohort study conducted on 5447 IVF and intracytoplasmic (ICSI) cycles carried out among 2192 patients between 2009 and 2015, with conventional ovarian stimulation. This large database was used to develop a non-linear mixed prognosis model of live birth rate (LBR) incorporating PHCG as a predictor.

RESULTS

In addition to known predictors (age, body mass index, anti-Müllerian hormone, type of infertility), PHCG was associated with a linear effect (OR 0.78 per Log[PHCG]ng/ml, 95% CI 0.611 to 0.997, P = 0.047) combined with a strong quadratic effect (OR 0.585 per Log²(PHCG)ng/ml, 95% CI 0.444 to 0.775, P < 0.001) resulting into a parabolic reverse-U curve. A significant interaction (P = 0.038) was found between PHCG and number of oocytes if three or less, but the effect of PHCG remains modest. For higher oocyte numbers, LBR rapidly increases with number of retrieved oocytes; however, LBR becomes more sensitive to PHCG as the number of oocytes increases. Higher live birth prognoses occur for optimal PHCG but are sharply reduced for lower or higher PHCG.

CONCLUSIONS

Evidence is provided of an important negative effect of PHCG at lower and higher values, independent of oocyte number, thus defining appropriate ranges for fresh embryo transfer or freeze-all strategy. In poor responders, premature progesterone rise may be ignored, thus avoiding unnecessary cancellations or embryo freezing. Conversely, in higher responders, the negative effect of progesterone elevation is more pronounced, suggesting that freeze-all policy should be applied more widely.

Impact of estradiol and progesterone levels during the late follicular stage on the outcome of GnRH antagonist protocols

The study aimed to assess the impacts and the targets of progesterone (P4) and estradiol (E2) levels on IVF outcomes in GnRH antagonist protocols. The study was retrospective and concerned patients for their first fresh embryo transfers, after stimulation by a recombinant FSH (rFSH)-GnRH antagonist protocol, between September 2012 and July 2017 in the Toulouse University Hospital. Multivariable analysis, taking into account female age and the ovarian stimulation index, showed that E2 levels had no impact on IVF outcomes, while high P4 levels (>1.10 ng/mL) were associated to low pregnancy rate. The P4 concentrations were significantly negatively correlated to the percentage of top embryos and to the implantation rate. Therefore, the deleterious effect of high levels P4 could to act mainly by impairing embryo quality, which questions the place of the freeze-all strategy in these cases.

Letrozole supplementation during controlled ovarian stimulation in expected high responders: a pilot randomized controlled study

BACKGROUND

Almost all of the previous studies related with co-administration of letrozole in IVF cycles were performed in poor responders and letrozole may reduce the total gonadotropin dose required for ovarian stimulation, and the pregnancy rate did not decrease in poor responders. This study aimed to assess whether high responders co-treatment with letrozole reduced supraphysiological late follicular phase estradiol levels and the incidence of premature progesterone elevated at the end of the follicular phase, thereby impacting positively on endometrial receptivity.

METHODS

A randomized parallel controlled study in a university-affiliated center include 130 high responders between October 2015 and August 2016. The patients were randomized on the first stimulation day of the IVF cycle and from stimulation day 5 receive letrozole (group A) or without letrozole treatment (group B).

RESULTS

Although estradiol levels were significantly lower in the letrozole group (group A) (P < 0.001), progesterone elevation (> 1.5 ng/mL was considered as a rise) on the day of hCG triggering (15.4, 7.7%) was not statistically significant (P = 0.170). RecFSH, the recovery rate of eggs, the high-quality embryo rate, and the thickness of endometrium (P = 0.776) were similar between the letrozole group(group A) and control groups (group B). Clinical pregnancy rates were 53.1% (26/49) and 72.9% (35/48) in the letrozole and control groups, respectively, with a statistical significance (P = 0.043).Live birth rates were 42.9% (21/49) and 62.5% (30/48),showed a marginally significant difference (P = 0.053). The miscarriage rate did not significantly differ between the two groups.

CONCLUSIONS

In this pilot study, letrozole supplementation could not reduce the incidence of premature progesterone rise during the late follicular phase in stimulated in vitro fertilization cycles in expected high responders, producing a harmful effect on the pregnancy outcome.

TRIAL REGISTRATION

China Clinical Trial Registration Center: ChiCTR-IPR-15006211 URL of the trial registry record: http://www.chictr.org.cn/showproj.aspx?proj=10731 . Trial registration date: 8 April, 2015. Date of first patient's enrolment: 5 October, 2015.

Comparison of recombinant and urinary follicle-stimulating hormones over 2000 gonadotropin-releasing hormone antagonist cycles: a retrospective study

The objective of this paper was to compare the effect of recombinant follicle-stimulating hormone (rFSH) and urinary follicle-stimulating hormone (uFSH) on pregnancy rates and live birth rates with the gonadotropin-releasing hormone (GnRH) antagonist protocol in China. This retrospective study was conducted from January 2014 through August 2017. Patients treated with uFSH had significantly higher levels of luteinizing hormone (3.79 mIU/ml vs. 3.09 mIU/ml) and progesterone (0.93 ng/ml vs. 1.16 ng/ml) on the day of human chorionic gonadotropin (HCG) administration, and they also had higher pregnancy rates (24.19% vs. 22.86%). There was no significant difference in the rate of live births. In the logistic regression results of the rFSH group, the pregnancy rate was positively correlated with the level of luteinizing hormone, with an odds ratio (OR) of 1.09 (95% confidence interval [CI]: 1.00-1.18; P = 0.048). In the uFSH group, the pregnancy rate was negatively correlated with the progesterone level on the day of HCG administration, with an OR of 0.47 (95% CI: 0.27-0.77; P = 0.004). Our research concluded that uFSH performed better than rFSH in terms of pregnancy rates when it was associated with the GnRH antagonist protocol. Meanwhile, no significant differences in the rate of live births were observed between the two groups.

Cumulative Live Birth Rates Following Stimulation With Corifollitropin Alfa Compared With hp-hMG in a GnRH Antagonist Protocol in Poor Ovarian Responders

Background: Bologna criteria poor ovarian responders have a very low prognosis. Although, it has been proposed that LH supplementation could be beneficial in women with previous hypo-response to FSH. There are no studies comparing the cumulative live birth rates (LBRs) between corifollitropin alfa (CFA) and highly purified human menopausal gonadotrophin (hp-hMG). Objective: To compare cumulative LBRs in Bologna poor ovarian responders undergoing ovarian stimulation with CFA followed by hp-hMG vs. hp-hMG alone in a GnRH antagonist protocol. Design: This is a retrospective cohort study. We included in total 917 poor responders fulfilling the Bologna criteria for poor ovarian response (POR) at a university-affiliated tertiary center from January 2011 until March 2017. Patients were administered either fixed daily doses of 300-450 IU of hp-hMG (group A) or a single dose of 150 μg of CFA followed by daily injections of ≥300 IU of hp-hMG from Day 8 of stimulation until the day of ovulation trigger (group B), in a fixed GnRH antagonist protocol. Results: LBRs after fresh embryo transfer (ET) were similar in group A 71/510 (14%) and B 42/407 (10%). Cumulative LBR per cycle was significantly higher in group A (16.9%) compared to group B (11.8%); (P = 0.03). However, logistic regression analysis showed no association between the type of gonadotropin administered and cumulative LBR. Only age was significantly associated with cumulative LBR (OR = 0.93, P = 0.007). Conclusion: Cumulative LBRs are similar in Bologna poor responders stimulated with CFA followed by hp-hMG compared to hp-hMG monotreatment in an antagonist protocol.

The role of progesterone/estradiol ratio in exploring the mechanism of late follicular progesterone elevation in low ovarian reserve women

Late follicular progesterone (P) elevation continues to complicate a significant part of assisted reproductive technologies (ART) cycles, despite the ardent employment of gonadotropin releasing hormone (GnRH) analogues. In women with good ovarian reserve, late follicular P elevation is believed to be the result of the controlled ovarian stimulation (COS) itself, multiple follicular development and excessive ovarian steroidogenic activity. These mechanisms do not seem to be plausible in women with low ovarian reserve. In these women, excessive COS achieve a small number of pre-ovulatory follicles, which is not coupled to considerable ovarian steroidogenic activity. Therefore, other mechanisms should be pursued and explored. Delicate paracrine and autocrine mechanisms within the oocyte-cumulus complex were suggested to preserve the integrity of the pre-ovulatory follicle, including inhibition of P increase and follicular luteinization. However, clinical studies to demonstrate the disruption of these mechanisms in cases with low ovarian reserve and ageing oocytes are still lacking. Late follicular progesterone/estradiol (P/E₂) ratio was introduced into clinical practice as a more appropriate way to analyze P rise in women undergoing COS to control for the E₂ increase. The current hypothesis claims that in a follicular environment were the mechanism that prevent premature luteinization is disrupted, independent to LH surge; P rise at the late follicular phase may relatively bypass normal E₂ production, at the pre-ovulatory stage of steroidogenesis, causing a rise in the P/E₂ ratio. Therefore, in women with low ovarian reserve and few pre-ovulatory follicles, undergoing conventional COS, a negative (reverse) correlation between number of maturing follicles and P/E₂ ratio may support the existence of such a mechanism as its disruption, while a no or a positive correlation may disapprove it.

Significant Serum Progesterone Variations on the Day of Final Oocyte Maturation in Stimulated IVF Cycles

Objective: To evaluate intraday serum progesterone levels on the day of final oocyte maturation in women undergoing ovarian stimulation in a GnRH-antagonist protocol. Study design, size, and duration: The study was done as a prospective observational study at a Private IVF centre in Muscat, Oman. 30 patients were recruited from May 2018 to March 2019. Patients: Thirty patients with primary/secondary infertility and an indication for ovarian stimulation for IVF/ICSI treatment. The study was registered at the clinicaltrials.gov under the number: NCT03519776. Main outcome measures: Progesterone levels at 4 time points (8 a.m., 11 a.m., 2 p.m. and 5 p.m.) on the day of final oocyte maturation. Results: A total of 120 samples from 30 patients were included in this prospective study. Progesterone levels on the day of final oocyte maturation showed a significant decline over the day with the mean values at 8 a.m.:1.0 ng/ml, at 11 a.m.:0.8 ng/ml, at 2 a.m.: 0.7 ng/ml and at 5 p.m.:0.6 ng/ml. The difference between the first and the last progesterone level was 0.4 ng/ml, reflecting a 37.8% decline of the progesterone level within 9 h and there was a highly significant decrease in the progesterone levels recorded between 8 a.m. and 11 a.m., between 8 a.m. and 2 p.m., between 8 a.m. and 5 p.m. and 11 a.m. and 5 p.m. (p < 0.001). Conclusion: The study findings have two clinically important conclusions: Firstly, progesterone levels on the day of final oocyte maturation decline significantly from the morning to the afternoon in patients, questioning the reliability of one arbitrarily taken progesterone level regarding the decision to perform a fresh embryo transfer or to cryopreserve the embryos. Secondly, declining progesterone levels 12 h after the last administration of gonadotropins support the theory that enhanced ovarian stimulation at the end of the follicular phase leads to an overload of the capacity of the enzymes metabolizing progesterone further on, therefore resulting in elevated progesterone levels in circulation.

Low LH Level on the Day of GnRH Agonist Trigger Is Associated With Reduced Ongoing Pregnancy and Live Birth Rates and Increased Early Miscarriage Rates Following IVF/ICSI Treatment and Fresh Embryo Transfer

Objective: To examine the correlation between serum luteinizing hormone (LH) levels on the day of GnRH agonist (GnRH-a) trigger and reproductive outcomes following in vitro fertilization/intracytoplasmic sperm injection (IVF/ICSI) treatment and fresh embryo transfer, and to identify a pre-trigger serum LH threshold which would be compatible with the most optimal cycle outcome. Design: This study is based on data from a previously published randomized controlled trial conducted from 2014 to 2016. Patients: A total of 322 participants were enrolled. Setting: Private IVF center. Intervention(s): GnRH-antagonist-based IVF cycles triggered with GnRH-a. For the purpose of the study, patients were stratified according to preovulatory LH quartiles (Q1-Q4). Main Outcome Measure(s): Ongoing pregnancy rates (OP), live birth rates (LB) and early pregnancy loss (EPL) rates. Results: The results of the present study showed increasing OP as well as LB rates and decreasing EPL rates with increasing pre-trigger serum LH levels (P for trend < 0.06, 0.07, and 0.02), respectively. The absolute difference between the highest LH(Q4) and the lowest LH (Q1) group was 13.4%, 12.1%, and 12% in OP, LB, and EPL rates, respectively. In multivariate regression analysis, a pre-trigger serum LH level of 1.60 mIU/ml was identified as a threshold below which reproductive outcomes decreased. The ROC curve values were statistically significant for OP, LB, and EPL; the AUC (95% CI) = [0.57 (0.50-0.63) P < 0.04; 0.57 (0.50-0.63) P < 0.05, and 0.60 (0.51-0.70) P < 0.04], respectively. A significant positive correlation was found on the day of GnRH-a trigger between serum LH, the number of follicles, serum P4, and serum E2, p < 0.03; P < 0.03; and P < 0.001, respectively. Conclusion: Low serum LH levels on the day of GnRH-a trigger is associated with reduced ongoing pregnancy and live birth rates and increased early miscarriage rates. Our findings suggest a lower threshold of serum LH values on the day of GnRH-a trigger necessary to optimize reproductive outcomes in fresh embryo transfer cycles. Clinical Trial Registration: www.ClinicalTrials.gov, Number: 02053779.

High responders are not exempt from detrimental effects of prematurely rising progesterone levels in fresh embryo transfer cycles

RESEARCH QUESTION

Are high-responder IVF patients protected from the deleterious effect of prematurely elevated serum progesterone level on the probability of pregnancy?

DESIGN

In this retrospective cohort study, 2971 autologous fresh embryo transfer IVF cycles with gonadotrophin-releasing hormone agonist long protocol were analysed to investigate whether the detrimental effect of prematurely rising progesterone levels on clinical pregnancy rate (CPR) varies depending on the magnitude of ovarian response. Nine different evenly spaced intervals were constructed for serum progesterone level on the human chorionic gonadotrophin day (<0.5/0.5-0.9/1-1.4/1.5-1.9/2-2.4/2.5-2.9/3-3.4/3.5-3.9/>4 ng/ml). Then, IVF cycles in each of these intervals were further divided into low (≤3 oocytes), normal (4-15 oocytes) and high responders (≥16 oocytes).

RESULTS

The progressive rise of serum progesterone from the <0.5 to the >4 ng/ml interval caused a gradual and continuous decline in the CPR of all three types of ovarian response. The absolute difference in the CPR between the lowest and the highest progesterone groups was not related to the magnitude of ovarian response (-26.6%, -37.7% and -40.7% for the low, normal and high responders, respectively). On multivariate logistic regression analysis, the detrimental effect of progesterone started at 1.5-1.9 ng/ml, 3.0-3.4 ng/ml and 4.0-4.4 ng/ml intervals for the low, normal and high responders, respectively.

CONCLUSION

High responders are not exempt from the detrimental effects of prematurely rising serum progesterone levels but the threshold interval where the detrimental effect begins is higher in the high responders compared with the low and normal responders.

Impact of stimulation duration and gonadotropin type on the incidence of premature progesterone elevation - a retrospective analysis of the Ensure data

Elevated progesterone levels on the day of trigger negatively impact the outcome of assisted reproductive technique (ART) treatment and forced ovarian stimulation might be a cause of progesterone elevation during ovarian stimulation. To analyze the impact of forced and prolonged stimulation on the progesterone elevation, this data analysis from the Ensure study compared hormonal stimulation with corifollitropin alpha (CFA)-only with CFA plus recombinant (rec) follicle-stimulating hormone (FSH) after day 8 (CFA-plus group) of ovarian stimulation. In the Ensure study, 268 patients underwent ovarian stimulation with 100 µg CFA and 128 patients with recombinant FSH. A total of 35 patients (13.1%) from the CFA-arm received the hCG trigger after stimulation with CFA-only, 233 patients (86.9%) needed additional rec FSH from day 8 onwards to meet the criteria for trigger. Progesterone levels >0.8 ng/ml on the trigger day occurred in 90 patients (38.6%) from the CFA plus FSH group and only in one patient (2.8%) in the CFA-only group (p < .001). The ongoing pregnancy rate (OPR) was 31.4% (11/35) for patients in the CFA-only group and 24.5% (57/233) for patients CFA-plus group with additional recFSH after day 8 (p = .378). This set of data demonstrates that prolongation of stimulation in combination with intense stimulation leads to a statistically significant increased incidence of progesterone elevation on the day of trigger.

Effect of progesterone/estradiol ratio on pregnancy outcome of patients with high trigger-day progesterone levels undergoing gonadotropin-releasing hormone antagonist intracytoplasmic sperm injection cycles: a retrospective cohort study

This study investigates the predictive power of serum progesterone/estradiol (P/E₂) level for estimating the live birth rate in patients who had a serum progesterone (P) rate ≥ 1.5 ng/mL on the human chorionic gonadotropin (hCG) administration day and who received the gonadotropin-releasing hormone (GnRH) antagonist protocol and intracytoplasmic sperm injection (ICSI). This retrospective cohort study included 176 cycles. The P/E₂ ratio was lower in patients with a live birth (0.73 ± 0.54) than those without a live birth (1.05 ± 1.38), but the difference was not statistically significant (p = .158). According to the receiver operating characteristic curve analysis of the hCG day P/E₂ ratio, the area under the curve was 0.579 (95% confidence interval: 0.478 - 0.680, p = .158) for predicting live birth. In conclusion, this study suggests that a P/E₂ ratio is not a significant predictor of a live birth rate in the patients with an hCG-day serum progesterone level of ≥1.5 ng/mL undergoing GnRH antagonist ICSI cycles with a fresh embryo transfer. Impact statement What is already known on this subject? As the progesterone (P) levels in the late follicular phase correlate with the estradiol (E₂) levels and the increase in mature follicles, earlier studies have proposed the trigger-day progesterone/estradiol (P/E₂) ratio as a potential new marker for a premature luteinisation and live birth success. Most of these studies were conducted on long agonist cycles, and found that arbitrarily defined P/E₂ ratio of >1 to be associated with poor pregnancy outcomes. What do the results of this study add? This study retrospectively examines the gonadotropin-releasing hormone (GnRH) antagonist cycles with a trigger-day serum P value of ≥1.5 ng/mL undergoing the intracytoplasmic sperm injection (ICSI) treatment. The receiver operating characteristic (ROC) curve analysis did not identify a statistically significant threshold value for the trigger-day P/E₂ ratio that was beneficial in predicting a live birth. The P/E₂ ratio was also lower in the cycles with a live birth than those without a live birth, although the difference was not statistically significant. What are the implications of these findings for clinical practice and/or further research? The trigger-day P/E₂ ratio does not seem to be an efficient prognostic factor for a live birth in the GnRH antagonist ICSI cycles with a trigger-day serum progesterone level of ≥1.5 ng/mL. Further studies are needed to clarify the association of the trigger-day P/E₂ ratio and the pregnancy outcomes in GnRH antagonist ICSI cycles.

High estrogen exposure may not be detrimental on endometrial receptivity in women with PCOS

The study aimed to assess the effect of high estrogen exposure and coasting on cycle outcome in women at risk for developing ovarian hyperstimulation syndrome (OHSS). Retrospective case-control study was conducted to figure out the outcomes of GnRH antagonist cycles in which women were at risk to develop OHSS. Women who underwent coasting (n = 100) were compared with a control group of women who did not undergo coasting (n = 287). Effect of endometrial estrogen exposure was determined by calculating area under curve of temporal estrogen measurements (AUCEM) through the cycle. Among 387 women with PCOS, 100 cases were required to undergo coasting to avoid OHSS. All participants reached to embryo transfer stage and clinical pregnancy rate was 44% in group with coasting whereas 39% in group without coasting (p > .05). AUCEM was a significant predictor for the cases who required coasting to avoid OHSS (AUC = 0.754, p < .001). Optimal cut off value was calculated to be 6762 with 71% sensitivity and 67% specificity. ROC analysis showed no predictive value of AUCEM for clinical pregnancy in subgroup of women with coasting (AUC = 0.496, p > .05). Consistently, ROC analysis showed no predictive value of AUCEM for clinical pregnancy in subgroup of women without coasting (AUC = 0.494, p > .05). In conclusion, neither coasting nor the high endometrial estrogen exposure was found to have detrimental effect on endometrial receptivity and cycle outcome in PCOS.

The curious case of premature luteinization

PURPOSE

Premature luteinization (PL) affects 12.3-46.7% of fresh in vitro fertilization cycles, and there is accumulating evidence confirming its negative effect on success rates. However, despite its clinical significance, PL is poorly understood and defined. This narrative review aims to provide a fresh look at the phenomenon of PL by summarizing the existing evidence and re-evaluating fundamental issues.

METHODS

A thorough electronic search was conducted covering the period from 1978 until January 2018 in PubMed, Embase, and Medline databases, and references of relevant studies were cross-checked. Meeting proceedings of the European Society of Human Reproduction and Embryology and the American Society for Reproductive Medicine were also hand searched.

RESULTS

In the curious case of PL, one should go back to the beginning and re-consider every step of the way. The pathogenesis, definition, measurement methods, clinical implications, and management strategies are discussed in detail, highlighting controversies and offering "food for thought" for future directions.

CONCLUSIONS

Authors need to speak the same language when studying PL in order to facilitate comparisons. The terminology, progesterone cut-off, measurement methods and days of measurement should be standardized and globally accepted; otherwise, there can be no scientific dialog. Future research should focus on specific patient profiles that may require a tailored approach. Progesterone measurements throughout the follicular phase possibly depict the progesterone exposure better than an isolated measurement on the day of hCG. Adequately powered randomized controlled trials should confirm which the best prevention and management plan of PL is, before introducing any strategy into clinical practice.

Adverse effect of prematurely elevated progesterone in in vitro fertilization cycles: a literature review

Premature progesterone (P) elevation was commonly seen in IVF prior to the utilization of GnRH analogues for suppression of endogenous gonadotropin release. The cause and effect of premature P elevation has finally been better elucidated in the past decade. Although still occurring in 5-38% of all IVF cycles, the adverse effects of premature P elevation on pregnancy outcomes are now well known.

Oocyte-triggering day progesterone levels and endometrial appearance in normoresponders undergoing IVF/ICSI cycles: a hypothesis and a study protocol

In this report, we propose a study protocol capable of improving IVF outcomes in subfertile women with expected normal ovarian response. This proposal derives from conflicting published data and observations in our daily practice, concerning the negative impact of progesterone (P4) elevation at the day of oocyte triggering on pregnancy outcomes. Our hypothesis points to the combination of two previous "suspects" of reduced success after assisted reproduction techniques (ART) - the endometrium ultrasonographic parameters and P4 elevation at the day of oocyte triggering on their impact on pregnancy outcomes. Up-to-the minute data show that, there is a different impact of elevated P4 in fresh, frozen and donor cycles, whereas there are plenty of reports pointing to a different endometrial gene expression on different P4 measurements. Gaps in the literature are linked with a variation of the measurements of P4, its cycle-to-cycle reproducibility, the different cut-off levels used, the impact of various protocols of ovarian stimulation and the limitations of systematic reviews originating from the initial studies. Our hypothesis states that the combination of P4 values and endometrial ultrasound parameters at the day of oocyte triggering can affect clinical pregnancy rates in normal responders undergoing ART.