The effect of luteal phase vaginal estradiol supplementation on the success of in vitro fertilization treatment: a prospective randomized study

Comparison of luteal support protocols in fresh IVF/ICSI cycles: a network meta-analysis

Despite the proven superiority of various luteal phase support protocols (LPS) over placebo in view of improved pregnancy rates in fresh cycles of IVF (in vitro fertilization) and ICSI (intracytoplasmic sperm injection) cycles, there is ongoing controversy over specific LPS protocol selection, dosage, and duration. The aim of the present study was to identify the optimal LPS under six core aspects of ART success, clinical pregnancy, live birth as primary outcomes and biochemical pregnancy, miscarriage, multiple pregnancy, ovarian hyperstimulation syndrome (OHSS) events as secondary outcomes. Twelve databases, namely Embase (OVID), MEDLINE (R) (OVID), GlobalHealth (Archive), GlobalHealth, Health and Psychosocial Instruments, Maternity & Infant Care Database (MIDIRS), APA PsycTests, ClinicalTrials.gov, HMIC Health Management Information Consortium, CENTRAL, Web of Science, Scopus and two prospective registers, MedRxiv, Research Square were searched from inception to Aug.1st, 2023, (PROSPERO Registration: CRD42022358986). Only Randomised Controlled Trials (RCTs) were included. Bayesian network meta-analysis (NMA) model was employed for outcome analysis, presenting fixed effects, odds ratios (ORs) with 95% credibility intervals (CrIs). Vaginal Progesterone (VP) was considered the reference LPS given its' clinical relevance. Seventy-six RCTs, comparing 22 interventions, and including 26,536 participants were included in the present NMA. Overall CiNeMa risk of bias was deemed moderate, and network inconsistency per outcome was deemed low (Multiple pregnancy χ2: 0.11, OHSS χ2: 0.26), moderate (Clinical Pregnancy: χ2: 7.02, Live birth χ2: 10.95, Biochemical pregnancy: χ2: 6.60, Miscarriage: χ2: 11.305). Combinatorial regimens, with subcutaneous GnRH-a (SCGnRH-a) on a vaginal progesterone base and oral oestrogen (OE) appeared to overall improve clinical pregnancy events; VP + OE + SCGnRH-a [OR 1.57 (95% CrI 1.11 to 2.22)], VP + SCGnRH-a [OR 1.28 (95% CrI 1.05 to 1.55)] as well as live pregnancy events, VP + OE + SCGnRH-a [OR 8.81 (95% CrI 2.35 to 39.1)], VP + SCGnRH-a [OR 1.76 (95% CrI 1.45 to 2.15)]. Equally, the progesterone free LPS, intramuscular human chorionic gonadotrophin, [OR 9.67 (95% CrI 2.34, 73.2)] was also found to increase live birth events, however was also associated with an increased probability of ovarian hyperstimulation, [OR 1.64 (95% CrI 0.75, 3.71)]. The combination of intramuscular and vaginal progesterone was associated with higher multiple pregnancy events, [OR 7.09 (95% CrI 2.49, 31.)]. Of all LPS protocols, VP + SC GnRH-a was found to significantly reduce miscarriage events, OR 0.54 (95% CrI 0.37 to 0.80). Subgroup analysis according to ovarian stimulation (OS) protocol revealed that the optimal LPS across both long and short OS, taking into account increase in live birth and reduction in miscarriage as well as OHSS events, was VP + SCGnRH-a, with an OR 2.89 [95% CrI 1.08, 2.96] and OR 2.84 [95% CrI 1.35, 6.26] respectively. Overall, NMA data suggest that combinatorial treatments, with the addition of SCGnRH-a on a VP base result in improved clinical pregnancy and live birth events in both GnRH-agonist and antagonist ovarian stimulation protocols.

The impact of estradiol supplementation on endometrial thickness and intrauterine insemination outcomes

The impact of estrogen supplementation during the follicular/proliferative phase on the endometrial lining thickness (EMT) prior to intrauterine insemination (IUI) remains largely unstudied. Our study examined changes in EMT and rates of clinical pregnancy, miscarriage, and live birth for all patients who completed an IUI cycle at Stanford Fertility Center from 2017-2023 (n = 2281 cycles). Cycles with estradiol supplementation (n = 309) were compared to reference cycles without supplementation (n = 1972), with the reference cohort further categorized into cycles with a pre-ovulatory EMT of < 7 mm ("thin-lining", n = 536) and ≥ 7 mm ("normal-lining", n = 1436). The estradiol group had a statistically significant greater change in EMT from baseline to ovulation compared to the thin-lining reference groups (2.4 mm vs 1.9 mm, p < =0.0001). Similar rates of clinical pregnancy and live birth were observed. After adjusting for age, BMI, race/ethnicity, infertility diagnosis, and EMT at trigger, the estradiol cohort had a significantly increased odds of miscarriage versus the entire reference cohort (2.46, 95 % confidence interval [1.18, 5.14], p = 0.02). Thus, although estradiol supplementation had a statistically significant increase in EMT compared to IUI cycles with thin pre-ovulatory EMT (<7 mm), this change did not translate into improved IUI outcomes such as increased rates of clinical pregnancy and live birth or decreased rate of miscarriage. Our study suggests that supplemental estradiol does not appear to improve IUI outcomes.

Comparison of the duration of estradiol administration and the effect on pregnancy outcome of day 3 vitrified-warmed embryo transfer cycle: a randomized controlled trial

Based on the fact that the follicular phase in the menstrual cycle has length variation, it has been assumed that the duration of oestrogen (E2) administration could also be variable; therefore, for the first time, this randomized clinical trial study was conducted to investigate and compare the duration of estradiol administration and the effect on pregnancy outcomes in the cleavage-stage frozen embryo transfer (FET) cycle. We included women aged 20-40 with a normal uterus on hysteroscopy between September and December 2022 and who were divided randomly into three groups: group A [n = 79; 8-11 days of oestrogen before progesterone (P4) supplementation], group B (n = 78; 12-14 days of oestrogen before P4 supplementation), and group C (n = 76; 15-18 days of estrogen before P4 supplementation). Serum levels for E2 on the initial progesterone day and P4 on the transfer day were measured. The effect of the duration of E2 administration on clinical pregnancy and pregnancy loss was investigated. We found no significant differences between the three groups in the clinical pregnancy rate (P = 0.696) and clinical abortion rate (P = 0.925) according to the duration of the E2. There was no significant difference in the E2, P4 levels, and endometrial thickness in pregnant vs. non-pregnant women. The mean of the E2 and P4 levels was 300.03 ± 22.21 and 25.36 ± 5.78, respectively. Our findings suggest that variation in the length of E2 administration (8-18 days) before progesterone initiation in day 3 FET cycles does not affect pregnancy outcome and transfer time can be flexibly arranged.

[No improvement in live birth rate after luteal phase support by GnRH agonist]

OBJECTIVES

To evaluate the impact of adding a GnRH agonist (GnRH-a) in luteal phase support (LPS) on live birth rates in IVF/ICSI in antagonist protocols.

METHODS

In total, 341 IVF/ICSI attempts are analyzed in this retrospective study. Patients were divided into two groups: A f: LPS with progesterone alone (179 attempts) between March 2019 and May 2020; B: LPS with progesterone and an injection of triptorelin (GnRH-a) 0.1mg 6 days after oocyte retrieval (162 attempts) between June 2020 and June 2021. The primary outcome was live birth rate. The secondary outcomes were miscarriage rate, pregnancy rate and ovarian hyperstimulation syndrome rate.

RESULTS

The baseline characteristic are identical between the two groups except the infertility duration (longer in the group B). There was no significant difference between the two groups in live birth rate (24.1% versus 21.2%), pregnancy rate (33.3% versus 28.1%), miscarriage rate (4.9% versus 3.4%) and no increase the SHSO rate. The multivariate regression analysis after adjustment for age, ovarian reserve and infertility duration did not reveal a significant difference in live birth rate between the two groups.

CONCLUSION

In this study, the results showed no statistically significant association with the single injection of a GnRH-a in addition to progesterone on live birth rate in luteal phase support.

Estrogen in Luteal Phase Support: Effects on IVF-ICSI Antagonist Protocol Pregnancy Results

Aim: This study aimed to investigate the effect of luteal phase support (LPS) with estradiol in addition to progesterone on pregnancy outcomes in patients who underwent ovulation induction with GnRH antagonist protocol in in vitro fertilization- intracytoplasmic sperm injection (IVF-ICSI). Materials and Methods: This retrospective study was carried out at reproductive medicine center of Necmettin Erbakan University Meram Medical Faculty. The study enrolled 128 patients undergoing ICSI on an antagonist protocol for controlled ovarian hyperstimulation. Study group administered 7.8 mg transdermal estradiol (E2) daily in addition to progesterone for LPS (n=64). Control group administered only progesterone for LPS (n=64). All women received 200 mg progesterone 3x1 intravaginal daily and 50 mg progesterone intramuscular injection per two days for LPS. Blood samples were drawn 12 days after embryo transfer for β-hCG. If the result is negative, treatment was discontinued, if positive, estradiol was discontinued and progesterone support was continued until the 10th week of gestation. Pregnancy outcomes were the main endpoint. Results: There was no difference between groups in terms of biochemical pregnancy, clinical pregnancy, abortus and ongoing pregnancy rates. Conclusion: In our study, the use of estrogen for luteal phase support in GnRH antagonist protocol did not show any difference on pregnancy outcomes.

Individualized luteal phase support after fresh embryo transfer: unanswered questions, a review

Background

Luteal phase support (LPS) is an important part of assisted reproductive technology (ART), and adequate LPS is crucial for embryo implantation. At present, a great number of studies have put emphasis on an individualized approach to controlled ovarian stimulation (COS) and endometrium preparation of frozen- thawed embryo transfer (FET); However, not much attention has been devoted to the luteal phase and almost all ART cycles used similar LPS protocol bases on experience.

Main body

This review aims to concisely summarize individualized LPS protocols in fresh embryo transfer cycles with hCG trigger or GnRH-a trigger. The PubMed and Google Scholar databases were searched using the keywords: (luteal phase support or LPS) AND (assisted reproductive technology or ART or in vitro fertilization or IVF). We performed comprehensive literature searches in the English language describing the luteal phase support after ART, since 1978 and ending in May 2019. Recent studies have shown that many modified LPS programs were used in ART cycle. In the cycle using hCG for final oocyte maturation, the progesterone with or without low dose of hCG may be adequate to maintain pregnancy. In the cycle using GnRH-a for trigger, individualized low dose of hCG administration with or without progesterone was suggested. The optimal timing to start the LPS would be between 24 and 72 h after oocyte retrieval and should last at least until the pregnancy test is positive. Addition of E₂ and the routes of progesterone administration bring no beneficial effect on the outcomes after ART.

Conclusions

Individualized LPS should be applied, according to the treatment protocol, the patients’ specific characteristics, and desires.

Luteal phase support (LPS) is an important part of assisted reproductive technology (ART). In the cycle using hCG for final oocyte maturation, the progesterone with or without low dose of hCG may be adequate to maintain pregnancy. In the cycle using GnRH-a for trigger, individualized low dose of hCG administration with or without progesterone was suggested. The optimal timing to start the LPS would be between 24 and 72 h after oocyte retrieval and should last at least until the pregnancy test is positive. Addition of E₂ and the routes of progesterone administration bring no beneficial effect on the outcomes after ART. Individualized LPS should be applied, according to the treatment protocol, the patients’ specific characteristics, and desires.

The exogenous progesterone-free luteal phase: two pilot randomized controlled trials in IVF patients

RESEARCH QUESTION

Is the reproductive outcome similar after gonadotrophin-releasing hormone agonist (GnRHa) trigger followed by luteal human chorionic gonadotrophin (HCG) boluses compared with HCG trigger and a standard luteal phase support (LPS)?

DESIGN

Two open-label pilot randomized controlled trials (RCT) with 250 patients from 2014 to 2019, with a primary outcome of ongoing pregnancy per embryo transfer. Patients with ≤13 follicles on the trigger day were randomized (RCT 1) to: Group A (n = 65): GnRHa trigger followed by a bolus of 1500 IU HCG s.c. on the oocyte retrieval day (ORD) and 1000 IU HCG s.c. 4 days later, and no vaginal LPS; or Group B (n = 65): 6500 IU HCG trigger, followed by a standard vaginal progesterone LPS. Patients with 14-25 follicles on the trigger day were randomized (RCT 2) to Group C (n = 60): GnRHa trigger followed by 1000 IU HCG s.c. on ORD and 500 IU HCG s.c. 4 days later, and no vaginal LPS; or Group D (n = 60): 6500 IU HCG trigger and a standard vaginal LPS.

RESULTS

In RCT 1, the ongoing pregnancy rate was 44% (22/50) in the GnRHa group versus 46% (25/54) in the HCG trigger group (RR 0.95, 95% CI 0.62-1.45). No ovarian hyperstimulation syndrome (OHSS) was seen in Groups A or B. In RCT 2, the ongoing pregnancy rate was 51% (25/49) in the GnRHa group versus 60% (31/52) in the HCG trigger group (RR 0.86, 95% CI 0.60-1.22). The OHSS rates were 3.3% and 6.7%, respectively.

CONCLUSIONS

Although a larger-scale study is needed before standard clinical implementation, the present study supports that the exogenous progesterone-free LPS is efficacious, simple and patient-friendly.

Combined use of oestradiol and progesterone to support luteal phase in antagonist intracytoplasmic sperm injection cycles of normoresponder women: a case-control study

We evaluated the effect of combined use of oral oestrogen (E2) and vaginal progesterone (P) to support luteal phase in antagonist intracytoplasmic sperm injection (ICSI) cycles. We analysed data from 176 patients who underwent ICSI cycles with antagonist protocol. P 90 mg vaginal gel once a day and micronised E2 of 4 mg/day, were started from the day of oocyte pick up and continued to the 12th day of embryo transfer. Group 1 (n = 79) patients received E2 + P for luteal phase support. In group 2 (n = 97) patients, only P 90 mg vaginal gel was used for luteal phase support. There were no significant differences between group 1 and group 2 patients in terms of clinical pregnancy rates (PRs) (26.58% vs. 20.62%, p = .352), early pregnancy loss rates (6.33% vs. 6.19%, p = .969), incidence of luteal vaginal bleeding (8.86% vs. 8.25%, p = .885) and implantation rates (22.8% vs. 16.9%, p = .298). In conclusion, our study showed no beneficial effect of addition of E2 to luteal phase support on clinical PR in antagonist IVF cycles.Impact statementWhat is already known on this subject? Luteal phase deficiency is defined as a disruption in progesterone and oestrogen production after ovulation. It is clear that, luteal phase supplementation to improve the outcomes in in vitro fertilisation (IVF) cycles is mandatory. As an iatrogenic complication of assisted reproductive technique, decreased luteal oestrogen and progesterone levels lead to decreased pregnancy rates (PRs) and implantation rates.What the results of this study add? In this study, we aimed to present the role of luteal phase oestrogen administration in GnRH antagonist cycles. A total of 176 cases received progesterone vaginal gel form for luteal phase support. Study group received 4 mg oral oestradiol hemihydrate in addition to progesterone. Compared to previous studies, our study consisted of larger number of patients and we used oestradiol through oral route. We found out that luteal oestradiol support did not improve the clinical PR.What the implications are of these findings for clinical practice and/or further research? Our study showed no beneficial effect of addition of oestradiol to luteal phase support on clinical PR in antagonist IVF cycles.

Evaluation of progestogen supplementation for luteal phase support in fresh in vitro fertilization cycles

OBJECTIVE

To evaluate the effectiveness of progestogen supplementation in improving clinical pregnancy rates in women undergoing fresh IVF cycles and to compare different routes, start times, durations, and estrogen coadministration regimen.

DESIGN

Comprehensive systematic review and meta-analysis.

SETTING

University.

PATIENT(S)

Women undergoing fresh IVF cycles who did and did not receive progestogen supplementation.

INTERVENTION(S)

Summary odds ratios (ORs) were calculated by binomial logistic regression.

MAIN OUTCOME MEASURE(S)

Clinical pregnancy rates.

RESULT(S)

Eighty-two articles (26,726 women) were included. Clinical pregnancy rates were increased by IM (OR = 4.57), vaginal (OR = 3.34), SC (OR = 3.36), or oral (OR = 2.57) progestogen supplementation versus no treatment. The greatest benefit was observed when progestogens were supplemented IM versus vaginally (OR = 1.37). The optimal time to commence administration was between oocyte retrieval and ET (OR = 1.31), with oocyte retrieval +1 day being most beneficial. Coadministration of estrogen had no benefit (OR = 1.33), whether progestogens were coadministered vaginally or IM. Clinical pregnancy rates were equivalent when progestogen supplementation was ceased after ≤3 weeks or continued for up to 12 weeks (OR = 1.06).

CONCLUSION(S)

This broad-ranging meta-analysis highlights the need to reevaluate current clinical practice. The use of progestogens in fresh IVF cycles is substantially beneficial to clinical pregnancy. Critically, the use of IM progestogens should not be dismissed, as it yielded the greatest clinical pregnancy rates. Pregnancy success was impacted by initiation of therapy, with 1 day after oocyte retrieval being optimal. There is little evidence to support coadministration of estrogen or prolonging progestogen treatment beyond 3 weeks.

Luteal phase support with GnRH agonist does not eliminate the risk for ovarian hyperstimulation syndrome

This study aims to report a case of early, severe ovarian hyperstimulation syndrome (OHSS) following GnRH agonist trigger for final oocyte maturation despite luteal support with a GnRH agonist. Contrary to the claim that luteal support using a GnRH agonist eliminates the risk for OHSS in high-risk patients, this report alerts practitioners to the risk of severe OHSS development despite GnRH agonist luteal support in patients receiving GnRH antagonist protocol with GnRH agonist triggering and cautions the practitioners to consider other measures of OHSS prevention.

Effects of oestradiol for luteal phase support in fresh embryo transfer cycles: A retrospective cohort study

OBJECTIVE

Any benefit of oestradiol supplementation with progesterone for luteal support after fresh embryo transfer in in vitro fertilisation/intracytoplasmic sperm injection (IVF/ICSI) cycles remains controversial. In this study, we further addressed this question in cycles using gonadotropin-releasing hormone (GnRH) agonist for ovarian stimulation.

DESIGN

A retrospective cohort study in a tertiary teaching and research hospital.

PATIENT(S)

A total of 1602 patients were given oestradiol valerate (E) in addition to progesterone (P) as luteal support. One thousand six hundred and two patients receiving progesterone alone were selected as the control group.

MAIN OUTCOME MEASURE(S)

Live birth rate. Secondary measures included clinical pregnancy rate, miscarriage rate and premature birth rate.

RESULT(S)

Clinical pregnancy and live birth rates were similar for the P alone vs the P+E group. In cycles with oestradiol (E2) levels less than 5000 pmol/L on the day of hCG trigger, E supplementation resulted in a significantly higher live birth rate (23.44% vs 32.92%, OR = 1.60 [95% CI 1.05 to 2.46]). In cycles with oestradiol levels 5000 to 10 000 pmol/L on the day of hCG trigger, E supplementation did not increase the live birth rate (34.43% vs 35.42%, OR = 0.90 [95% CI 0.80 to 1.01]). In cycles with oestradiol levels over 10 000 pmol/L on the day of hCG trigger, the live birth rate was significantly lower (36.83% vs 31.37%, OR = 0.78 [95% CI 0.62 to 0.99]) and the premature birth rate was significantly higher (19.66% vs 28.73%,OR = 1.65 [95% CI 1.05 to 2.59]) in the E supplementation group.

CONCLUSION(S)

Any benefit of oestradiol supplementation for luteal phase support appears to correlate with the serum oestradiol level on the day of hCG trigger. Oestradiol supplementation is beneficial for improving live birth rate in cycles with oestradiol levels less than 5000 pmol/L, but is not recommended in cycles with oestradiol levels over 10 000 pmol/L.

Plasmatic estradiol concentration in the mid-luteal phase is a good prognostic factor for clinical and ongoing pregnancies, during stimulated cycles of in vitro fertilization

Objective

To evaluate the predictive efficiency of serum estradiol (E₂) concentration in the mid-luteal phase regarding chemical, clinical, and ongoing pregnancies, in patients subjected to IVF/ICSI with fresh embryo transfer.

Methods

One hundred and forty-three patients undergoing IVF/ICSI met all the inclusion criteria for the present study. Most of the patients used antagonists, final maturation was achieved with recombinant chorionic gonadotrophin (HCG), and embryo transfer took place on days 3 to 5, but mostly on day 4. The luteal phase was supplemented with estradiol valerate 6 mg/day and vaginal micronized progesterone 600 mg/day. There was no exclusion of patients in the embryo transfer group due to age or ovarian reserve. All patients with estradiol and chorionic gonadotrophin (βHCG) dosage on the day of transfer, day 7, were included. We assessed the following variables, initially regarding age: number of eggs collected, formed embryos, embryos transferred, day of transfer, transfer type, estradiol and chorionic gonadotropin. Next, we evaluated these elements at three different ranges of estradiol concentrations (<200 pg/ml, 200-500 pg/ml, and >500 pg/ml), comparing these parameters in pregnant (P) and non-pregnant (NP) patients.

Results

Data analysis by age group in P and NP patients showed significant differences in the mean values of the variables E₂ and βHCG, TD7. Mean serum estradiol levels in P and NP in the three age groups were: <35years, 835/417 p=0.0006, 35-39 years 833/434 p=0.0118, >39 years, 841/394 p=0.0012. There was also a significant difference in pregnancy rates in the group >500 pg/ml of estradiol concentration (63.4%, p=0.0096). The likelihood of chemical and clinical abortions for the estradiol ranges were: 38.46%, involving the two first ranges versus 15.15% for a concentration >500 pg/ml, p=0.0412 and 5.26% for a concentration >900 pg/ml, p=0.0105. The Pearson correlation coefficient for HCG and estradiol was r = 0.5108.

Conclusion

This study showed the prognostic value of E₂ in the mid-luteal phase (TD7) for chemical, clinical, and ongoing pregnancies, and its concentration suggested that there is a moderately positive correlation with βHCG levels.

Luteal phase support with estradiol and progesterone versus progesterone alone in GnRH antagonist ICSI cycles: a randomized controlled study

In vitro fertilization (IVF) cycles are associated with a defective luteal phase. Although progesterone supplementation to treat this problem is standard practice, estrogen addition is debatable. Our aim was to compare pregnancy outcomes in 220 patients undergoing antagonist intracytoplasmic sperm injection (ICSI) cycles protocol. The patients were randomly assigned into two equal groups to receive either vaginal progesterone alone (90 mg once daily) starting on the day of oocyte retrieval for up to 12 weeks if pregnancy occurred or estradiol addition (2 mg twice daily) starting on the same day and continuing up to seven weeks (foetal viability scan). Primary outcomes were pregnancy and ongoing pregnancy rates per embryo transfer. Secondary outcomes were implantation and early pregnancy loss rates. Pregnancy rates showed no significant difference between group 1 (39.09%) and 2 (43.63%) (p value = 0.3). Similarly, both groups were comparable regarding ongoing pregnancy rate (32.7% group 1 and 36.3% group 2, p value = 0.1). Implantation rates showed no difference between group 1 (19.25%) and group 2 (23.44%) (p value = 0.2). Early pregnancy loss rates were comparable, with 6.3% and 7.2% in groups 1 and 2, respectively, (p value = 0.4). In conclusion, the addition of 4 mg estrogen daily to progesterone for luteal support in antagonist ICSI cycles is not beneficial for pregnancy outcome.

GnRH antagonist versus long agonist protocols in IVF: a systematic review and meta-analysis accounting for patient type

BACKGROUND

Most reviews of IVF ovarian stimulation protocols have insufficiently accounted for various patient populations, such as ovulatory women, women with polycystic ovary syndrome (PCOS) or women with poor ovarian response, and have included studies in which the agonist or antagonist was not the only variable between the compared study arms.

OBJECTIVE AND RATIONALE

The aim of the current study was to compare GnRH antagonist protocols versus standard long agonist protocols in couples undergoing IVF or ICSI, while accounting for various patient populations and treatment schedules.

SEARCH METHODS

The Cochrane Menstrual Disorders and Subfertility Review Group specialized register of controlled trials and Pubmed and Embase databases were searched from inception until June 2016. Eligible trials were those that compared GnRH antagonist protocols and standard long GnRH agonist protocols in couples undergoing IVF or ICSI. The primary outcome was ongoing pregnancy rate. Secondary outcomes were: live birth rate, clinical pregnancy rate, number of oocytes retrieved and safety with regard to ovarian hyperstimulation syndrome (OHSS). Separate comparisons were performed for the general IVF population, women with PCOS and women with poor ovarian response. Pre-planned subgroup analyses were performed for various antagonist treatment schedules.

OUTCOMES

We included 50 studies. Of these, 34 studies reported on general IVF patients, 10 studies reported on PCOS patients and 6 studies reported on poor responders. In general IVF patients, ongoing pregnancy rate was significantly lower in the antagonist group compared with the agonist group (RR 0.89, 95% CI 0.82-0.96). In women with PCOS and in women with poor ovarian response, there was no evidence of a difference in ongoing pregnancy between the antagonist and agonist groups (RR 0.97, 95% CI 0.84-1.11 and RR 0.87, 95% CI 0.65-1.17, respectively). Subgroup analyses for various antagonist treatment schedules compared to the long protocol GnRH agonist showed a significantly lower ongoing pregnancy rate when the oral hormonal programming pill (OHP) pretreatment was combined with a flexible protocol (RR 0.74, 95% CI 0.59-0.91) while without OHP, the RR was 0.84, 95% CI 0.71-1.0. Subgroup analysis for the fixed antagonist schedule demonstrated no evidence of a significant difference with or without OHP (RR 0.94, 95% CI 0.79-1.12 and RR 0.94, 95% CI 0.83-1.05, respectively). Antagonists resulted in significantly lower OHSS rates both in the general IVF patients and in women with PCOS (RR 0.63, 95% CI 0.50-0.81 and RR 0.53, 95% CI 0.30-0.95, respectively). No data on OHSS was available from trials in poor responders.

WIDER IMPLICATIONS

In a general IVF population, GnRH antagonists are associated with lower ongoing pregnancy rates when compared to long protocol agonists, but also with lower OHSS rates. Within this population, antagonist treatment prevents one case of OHSS in 40 patients but results in one less ongoing pregnancy out of every 28 women treated. Thus standard use of the long GnRH agonist treatment is perhaps still the approach of choice for prevention of premature luteinization. In couples with PCOS and poor responders, GnRH antagonists do not seem to compromise ongoing pregnancy rates and are associated with less OHSS and therefore could be considered as standard treatment.

Mid-luteal estradiol levels of poor/good responders and intracytoplasmic sperm injection

Objective:

To assess mid-luteal estradiol (E2) levels in poor and good responders and determine its effect on the outcome after intracytoplasmic sperm injection (ICSI).

Methods:

The current study was carried out in females who underwent ICSI from June 2011 to September 2013 in “Islamabad Clinic Serving Infertile Couples”. They were categorized into good and poor responders on the basis of female age ≤40 years, basal follicle stimulating hormone ≤12 mIU/ml, and antral follicle count >5, respectively. Their mid-luteal E2 measured on the day of embryo transfer was stratified into groups (A-E) on the basis of 20th, 40th, 60th and 80th percentile values. The outcome was categorized into non-pregnant with beta human chorionic Gonadotrophin (hCG) 5-25 m IU/ml, and clinical pregnancy with beta hCG>25 m IU/ml.

Results:

The conception rate was 12% (63/513) in poor responders and 72% (237/329) in good responders respectively. The mid-luteal E2 levels were higher in conception as compared to non-conception cycles (p<0.001) in good and poor responders.

Conclusion:

Maximum pregnancies in poor and good responders (53% and 98% respectively) with mid-luteal E2 levels above 80^th percentiles confirm the role of the increase in mid-luteal E2 for augmentation in conception rate of females after ICSI.

Gonadotrophin-releasing hormone antagonists for assisted reproductive technology

BACKGROUND

Gonadotrophin-releasing hormone (GnRH) antagonists can be used to prevent a luteinizing hormone (LH) surge during controlled ovarian hyperstimulation (COH) without the hypo-oestrogenic side-effects, flare-up, or long down-regulation period associated with agonists. The antagonists directly and rapidly inhibit gonadotrophin release within several hours through competitive binding to pituitary GnRH receptors. This property allows their use at any time during the follicular phase. Several different regimens have been described including multiple-dose fixed (0.25 mg daily from day six to seven of stimulation), multiple-dose flexible (0.25 mg daily when leading follicle is 14 to 15 mm), and single-dose (single administration of 3 mg on day 7 to 8 of stimulation) protocols, with or without the addition of an oral contraceptive pill. Further, women receiving antagonists have been shown to have a lower incidence of ovarian hyperstimulation syndrome (OHSS). Assuming comparable clinical outcomes for the antagonist and agonist protocols, these benefits would justify a change from the standard long agonist protocol to antagonist regimens. This is an update of a Cochrane review first published in 2001, and previously updated in 2006 and 2011.

OBJECTIVES

To evaluate the effectiveness and safety of gonadotrophin-releasing hormone (GnRH) antagonists compared with the standard long protocol of GnRH agonists for controlled ovarian hyperstimulation in assisted conception cycles.

SEARCH METHODS

We searched the Cochrane Menstrual Disorders and Subfertility Group Trials Register (searched from inception to May 2015), the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library, inception to 28 April 2015), Ovid MEDLINE (1966 to 28 April 2015), EMBASE (1980 to 28 April 2015), PsycINFO (1806 to 28 April 2015), CINAHL (to 28 April 2015) and trial registers to 28 April 2015, and handsearched bibliographies of relevant publications and reviews, and abstracts of major scientific meetings, for example the European Society of Human Reproduction and Embryology (ESHRE) and American Society for Reproductive Medicine (ASRM). We contacted the authors of eligible studies for missing or unpublished data. The evidence is current to 28 April 2015.

SELECTION CRITERIA

Two review authors independently screened the relevant citations for randomised controlled trials (RCTs) comparing different GnRH agonist versus GnRH antagonist protocols in women undergoing in vitro fertilisation (IVF) or intracytoplasmic sperm injection (ICSI).

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed trial eligibility and risk of bias, and extracted the data. The primary review outcomes were live birth and ovarian hyperstimulation syndrome (OHSS). Other adverse effects (miscarriage and cycle cancellation) were secondary outcomes. We combined data to calculate pooled odds ratios (ORs) and 95% confidence intervals (CIs). Statistical heterogeneity was assessed using the I(2) statistic. We assessed the overall quality of the evidence for each comparison using GRADE methods.

MAIN RESULTS

We included 73 RCTs, with 12,212 participants, comparing GnRH antagonist to long-course GnRH agonist protocols. The quality of the evidence was moderate: limitations were poor reporting of study methods.Live birthThere was no conclusive evidence of a difference in live birth rate between GnRH antagonist and long course GnRH agonist (OR 1.02, 95% CI 0.85 to 1.23; 12 RCTs, n = 2303, I(2)= 27%, moderate quality evidence). The evidence suggested that if the chance of live birth following GnRH agonist is assumed to be 29%, the chance following GnRH antagonist would be between 25% and 33%.OHSSGnRH antagonist was associated with lower incidence of any grade of OHSS than GnRH agonist (OR 0.61, 95% C 0.51 to 0.72; 36 RCTs, n = 7944, I(2) = 31%, moderate quality evidence). The evidence suggested that if the risk of OHSS following GnRH agonist is assumed to be 11%, the risk following GnRH antagonist would be between 6% and 9%.Other adverse effectsThere was no evidence of a difference in miscarriage rate per woman randomised between GnRH antagonist group and GnRH agonist group (OR 1.04, 95% CI 0.82 to 1.30; 33 RCTs, n = 7022, I(2) = 0%, moderate quality evidence).With respect to cycle cancellation, GnRH antagonist was associated with a lower incidence of cycle cancellation due to high risk of OHSS (OR 0.47, 95% CI 0.32 to 0.69; 19 RCTs, n = 4256, I(2) = 0%). However cycle cancellation due to poor ovarian response was higher in women who received GnRH antagonist than those who were treated with GnRH agonist (OR 1.32, 95% CI 1.06 to 1.65; 25 RCTs, n = 5230, I(2) = 68%; moderate quality evidence).

AUTHORS' CONCLUSIONS

There is moderate quality evidence that the use of GnRH antagonist compared with long-course GnRH agonist protocols is associated with a substantial reduction in OHSS without reducing the likelihood of achieving live birth.

Gonadotropin-releasing hormone agonist trigger is a better alternative than human chorionic gonadotropin in PCOS undergoing IVF cycles for an OHSS Free Clinic: A Randomized control trial

OBJECTIVE:

The objective of this study is to evaluate if gonadotropin-releasing hormone agonist (GnRHa) trigger is a better alternative to human chorionic gonadotropin (hCG) in polycystic ovary syndrome (PCOS) of Indian origin undergoing in vitro fertilization (IVF) cycles with GnRH antagonist for the prevention of ovarian hyperstimulation syndrome (OHSS).

DESIGN:

Prospective randomized control trial.

SETTING:

Tertiary care center.

MATERIALS AND METHODS:

A total of 227 patients diagnosed with PCOS, undergoing IVF in an antagonist protocol were recruited and randomly assigned into two groups: Group A (study group): GnRHa trigger 0.2 mg (n = 92) and Group B (control group): 250 μg of recombinant hCG as trigger (n = 101) 35 h before oocyte retrieval. We chose segmentation strategy, freezing all embryos in both the groups.

STATISTICAL ANALYSIS:

Continuous variables were expressed as mean ± standard deviation independent sample t-test and Kolmogorov-Smirnov test were used for continuous variables which were normally distributed and Mann-Whitney U-test for data not normally distributed.

MAIN OUTCOME MEASURES:

Primary outcome: OHSS (mild, moderate, and severe) rates. Secondary outcomes: Maturity rate of the oocytes, fertilization rate, availability of top quality embryos on day 3 (Grade 1 and Grade 2).

RESULTS

The incidence of moderate to severe OHSS in the hCG group was 37.6% and 0% in the GnRHa group with P < 0.001. The GnRHa group had significantly more mature oocytes retrieved (19.1 ± 11.7 vs. 14.1 ± 4.3), more fertilized oocytes (15.6 ± 5.6 vs. 11.7 ± 3.6), and a higher number of top quality cleavage embryos on day 3 (12.9 ± 4.7 vs. 7.5 ± 4.3) than the hCG group.

CONCLUSIONS:

The most effective strategy which significantly eliminates the occurrence of OHSS in PCOS following ovarian stimulation in antagonist IVF cycles is the use of GnRHa trigger yielding more mature oocytes and good quality embryos when compared with hCG trigger.

Luteal phase support for assisted reproduction cycles

BACKGROUND

Progesterone prepares the endometrium for pregnancy by stimulating proliferation in response to human chorionic gonadotropin(hCG) produced by the corpus luteum. This occurs in the luteal phase of the menstrual cycle. In assisted reproduction techniques(ART), progesterone and/or hCG levels are low, so the luteal phase is supported with progesterone, hCG or gonadotropin-releasing hormone (GnRH) agonists to improve implantation and pregnancy rates.

OBJECTIVES

To determine the relative effectiveness and safety of methods of luteal phase support provided to subfertile women undergoing assisted reproduction.

SEARCH METHODS

We searched databases including the Cochrane Menstrual Disorders and Subfertility Group (MDSG) Specialised Register, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, PsycINFO and trial registers. We conducted searches in November 2014, and further searches on 4 August 2015.

SELECTION CRITERIA

Randomised controlled trials (RCTs) of luteal phase support using progesterone, hCG or GnRH agonist supplementation in ART cycles.

DATA COLLECTION AND ANALYSIS

Three review authors independently selected trials, extracted data and assessed risk of bias. We calculated odds ratios (ORs) and 95%confidence intervals (CIs) for each comparison and combined data when appropriate using a fixed-effect model. Our primary out come was live birth or ongoing pregnancy. The overall quality of the evidence was assessed using GRADE methods.

MAIN RESULTS

Ninety-four women RCTs (26,198 women) were included. Most studies had unclear or high risk of bias in most domains. The main limitations in the evidence were poor reporting of study methods and imprecision due to small sample sizes.1. hCG vs placebo/no treatment (five RCTs, 746 women)There was no evidence of differences between groups in live birth or ongoing pregnancy (OR 1.67, 95% CI 0.90 to 3.12, three RCTs,527 women, I2 = 24%, very low-quality evidence, but I2 of 61% was found for the subgroup of ongoing pregnancy) with a random effects model. hCG increased the risk of ovarian hyperstimulation syndrome (OHSS) (1 RCT, OR 4.28, 95% CI 1.91 to 9.6, low quality evidence).2. Progesterone vs placebo/no treatment (eight RCTs, 875 women)Evidence suggests a higher rate of live birth or ongoing pregnancy in the progesterone group (OR 1.77, 95% CI 1.09 to 2.86, five RCTs, 642 women, I2 = 35%, very low-quality evidence). OHSS was not reported.3. Progesterone vs hCG regimens (16 RCTs, 2162 women)hCG regimens included comparisons of progesterone versus hCG and progesterone versus progesterone + hCG. No evidence showed differences between groups in live birth or ongoing pregnancy (OR 0.95, 95% CI 0.65 to 1.38, five RCTs, 833 women, I2 = 0%, low quality evidence) or in the risk of OHSS (four RCTs, 615 women, progesterone vs hCG OR 0.54, 95% CI 0.22 to 1.34; four RCTs,678 women; progesterone vs progesterone plus hCG, OR 0.34, 95% CI 0.09 to 1.26, low-quality evidence).4. Progesterone vs progesterone with oestrogen (16 RCTs, 2577 women)No evidence was found of differences between groups in live birth or ongoing pregnancy (OR 1.12, 95% CI 0.91 to 1.38, nine RCTs,1651 women, I2 = 0%, low-quality evidence) or OHSS (OR 0.56, 95% CI 0.2 to 1.63, two RCTs, 461 women, I2 = 0%, low-quality evidence).5. Progesterone vs progesterone + GnRH agonist (seven RCTs, 1708 women)Live birth or ongoing pregnancy rates were lower in the progesterone-only group and increased in women who received progester one and one or more GnRH agonist doses (OR 0.62, 95% CI 0.48 to 0.81, nine RCTs, 2861 women, I2 = 55%, random effects, low quality evidence). Statistical heterogeneity for this comparison was high because of unexplained variation in the effect size, but the direction of effect was consistent across studies. OHSS was reported in one study only (OR 1.00, 95% CI 0.33 to 3.01, 1 RCT, 300 women, very low quality evidence).6. Progesterone regimens (45 RCTs, 13,814 women)The included studies reported nine different comparisons between progesterone regimens. Findings for live birth or ongoing pregnancy were as follows: intramuscular (IM) versus oral: OR 0.71, 95% CI 0.14 to 3.66 (one RCT, 40 women, very low-quality evidence);IM versus vaginal/rectal: OR 1.24, 95% CI 1.03 to 1.5 (seven RCTs, 2309 women, I2 = 71%, very low-quality evidence); vaginal/rectal versus oral: OR 1.19, 95% CI 0.83 to 1.69 (four RCTs, 857 women, I2 = 32%, low-quality evidence); low-dose versus high-dose vaginal: OR 0.97, 95% CI 0.84 to 1.11 (five RCTs, 3720 women, I2 = 0%, moderate-quality evidence); short versus long protocol:OR 1.04, 95% CI 0.79 to 1.36 (five RCTs, 1205 women, I2 = 0%, low-quality evidence); micronised versus synthetic: OR 0.9, 95%CI 0.53 to 1.55 (two RCTs, 470 women, I2 = 0%, low-quality evidence); vaginal ring versus gel: OR 1.09, 95% CI 0.88 to 1.36 (oneRCT, 1271 women, low-quality evidence); subcutaneous versus vaginal gel: OR 0.92, 95% CI 0.74 to 1.14 (two RCTs, 1465 women,I2 = 0%, low-quality evidence); and vaginal versus rectal: OR 1.28, 95% CI 0.64 to 2.54 (one RCT, 147 women, very low-quality evidence). OHSS rates were reported for only two of these comparisons: IM versus oral, and low versus high-dose vaginal. No evidence showed a difference between groups.7. Progesterone and oestrogen regimens (two RCTs, 1195 women)The included studies compared two different oestrogen protocols. No evidence was found to suggest differences in live birth or ongoing pregnancy rates between a short and a long protocol (OR 1.08, 95% CI 0.81 to 1.43, one RCT, 910 women, low-quality evidence) or between a low dose and a high dose of oestrogen (OR 0.65, 95% CI 0.37 to 1.13, one RCT, 285 women, very low-quality evidence).Neither study reported OHSS.

AUTHORS' CONCLUSIONS

Both progesterone and hCG during the luteal phase are associated with higher rates of live birth or ongoing pregnancy than placebo.The addition of GnRHa to progesterone is associated with an improvement in pregnancy outcomes. OHSS rates are increased with hCG compared to placebo (only study only). The addition of oestrogen does not seem to improve outcomes. The route of progester one administration is not associated with an improvement in outcomes.

Contribution to More Patient-Friendly ART Treatment: Efficacy of Continuous Low-Dose GnRH Agonist as the Only Luteal Support-Results of a Prospective, Randomized, Comparative Study

Background. The aim of this pilot study was to evaluate intranasal buserelin for luteal phase support and compare its efficacy with standard vaginal progesterone in IVF/ICSI antagonist cycles. Methods. This is a prospective, randomized, open, parallel group study. Forty patients underwent ovarian hyperstimulation with human menopausal gonadotropin under pituitary inhibition with gonadotropin-releasing hormone antagonist, while ovulation trigger and luteal support were achieved using intranasal GnRH agonist (group A). Twenty patients had their cycle downregulated with buserelin and stimulated with hMG, while ovulation trigger was achieved using 10,000 IU human chorionic gonadotropin with luteal support by intravaginal progesterone (group B). Results. No difference was observed in estradiol levels. Progesterone levels on day 5 were significantly lower in group A. However, significantly higher levels of luteinizing hormone were observed in group A during the entire luteal phase. Pregnancy rates (31.4% versus 22.2%), implantation rates (22% versus 15.4%), and clinical pregnancy rates (25.7% versus 16.7%) were not statistically different between groups, although a trend towards higher rates was observed in group A. No luteal phase lasting less than 10 days was recorded in either group. Conclusion. Intranasal administration of buserelin is effective for providing luteal phase support in IVF/ICSI antagonist protocols.

Different gonadotropin releasing hormone agonist doses for the final oocyte maturation in high-responder patients undergoing in vitro fertilization/intra-cytoplasmic sperm injection

CONTEXT

Efficacy of gonadotropin releasing hormone agonists (GnRH-a) for ovulation in high-responders.

AIMS

The aim of the current study is to compare the impact of different GnRH-a doses for the final oocyte maturation on cycle outcomes and ovarian hyperstimulation syndrome (OHSS) rates in high-responder patients undergoing ovarian stimulation.

SETTINGS AND DESIGNS

Electronic medical records of a private in vitro fertilization center, a retrospective analysis.

SUBJECTS AND METHODS

A total of 77 high-responder cases were detected receiving GnRH-a. Group I consisted of 38 patients who received 1 mg of agonist and Group II consisted of 39 patients who received 2 mg of agonist.

STATISTICAL ANALYSIS

In order to compare groups, Student's t-test, Mann-Whitney U-test, Pearson's Chi-square test or Fisher's exact test were used where appropriate. A P < 0.05 was considered as statistically significant.

RESULTS

Number of retrieved oocytes (17.5 vs. 15.0, P = 0.510), implantation rates (46% vs. 55.1%, P = 0.419) and clinical pregnancy rates (42.1% vs. 38.5%, P = 0.744) were similar among groups. There were no mild or severe OHSS cases detected in Group I. Only 1 mild OHSS case was detected in Group II.

CONCLUSION

A volume of 1 or 2 mg leuprolide acetate yields similar outcomes when used for the final oocyte maturation in high-responder patients.

Estrogen supplementation to progesterone as luteal phase support in patients undergoing in vitro fertilization: systematic review and meta-analysis

Meta-analyses have found conflicting results with respect to the use of progesterone or progesterone plus estrogen as luteal phase support for in vitro fertilization (IVF) protocols involving gonadotropins and/or gonadotropin-releasing hormone analogs. The aim of the present study was to perform an updated meta-analysis on the efficacy of progesterone versus progesterone plus estrogen as luteal phase support. We searched the MEDLINE, Cochrane Library, and Google Scholar databases (up to March 18, 2014). The search terms were (estrogen OR estradiol OR oestradiol) AND (progesterone) AND (IVF OR in vitro fertilization) AND (randomized OR prospective). We did not limit the form of estrogen and included subjects who contributed more than 1 cycle to a study. The primary outcome was clinical pregnancy rate. Secondary outcomes were ongoing pregnancy rate, fertilization rate, implantation rate, and miscarriage rate. A total of 11 articles were included in the present analysis, with variable numbers of studies assessing each outcome measure. Results of statistical analyses indicated that progesterone plus estrogen treatment was more likely to result in clinical pregnancy than progesterone alone (pooled odds ratio 1.617, 95% confidence interval 1.059-2.471; P = 0.026). No significant difference between the 2 treatment regimens was found for the other outcome measures. Progesterone plus estrogen for luteal phase support is associated with a higher clinical pregnancy rate than progesterone alone in women undergoing IVF, but other outcomes such as ongoing pregnancy rate, fertilization rate, implantation rate, and miscarriage rate are the same for both treatments.

Meta-analysis of estradiol for luteal phase support in in vitro fertilization/intracytoplasmic sperm injection

OBJECTIVE

To evaluate whether the addition of E(2) for luteal phase support (LPS) in IVF/intracytoplasmic sperm injection (ICSI) could improve the outcome of clinical pregnancy.

DESIGN

Meta-analysis.

SETTING

University hospital center.

PATIENT(S)

Women underwent IVF or ICSI using the GnRH agonist or GnRH antagonist protocol.

INTERVENTION(S)

Progesterone alone or combined with E(2) for LPS.

MAIN OUTCOME MEASURE(S)

Clinical pregnancy rate per patient (CPR/PA), clinical pregnancy rate per ET, implantation rate, ongoing pregnancy rate per patient, clinical abortion rate, and ectopic pregnancy rate.

RESULT(S)

Fifteen relevant randomized controlled trials (RCTs) were identified that included a total of 2,406 patients. There was no statistical difference between E(2) + P group and P-only group regarding the primary outcome of CPR/PA for different routes of administration of E(2) (oral, vaginal, and transdermal) or other relevant outcome measures. No significant effect was observed for different daily doses of E(2) (6, 4, and 2 mg), even through oral medication in CPR/PA.

CONCLUSION(S)

The best available evidence suggests that E(2) addition during the luteal phase does not improve IVF/ICSI outcomes through oral medication, even with different daily doses. Furthermore, RCTs that study other administration routes are needed.

Use of gonadotropin-releasing hormone agonist trigger during in vitro fertilization is associated with similar endocrine profiles and oocyte measures in women with and without polycystic ovary syndrome

OBJECTIVE

To compare endocrine profiles and IVF outcomes after using GnRH agonists (GnRHa) to trigger final oocyte maturation in women with polycystic ovary syndrome (PCOS) with other hyper-responders.

DESIGN

Retrospective cohort study.

SETTING

Academic center.

PATIENT(S)

Forty women with PCOS and 74 hyper-responders without PCOS.

INTERVENTION(S)

GnRHa trigger.

MAIN OUTCOME MEASURE(S)

Number of oocytes.

RESULT(S)

Serum E2, LH, and P levels on the day of GnRHa trigger and the day after trigger did not differ significantly between groups. There were no significant differences in total number of oocytes or percent mature oocytes obtained between groups after controlling for age, antral follicle count, and total days of stimulation. The overall rate of no retrieval of oocytes after trigger was low (2.6%). Fertilization, implantation, clinical pregnancy, and live-birth rates were similar in the two groups. No patients developed ovarian hyperstimulation syndrome (OHSS).

CONCLUSION(S)

The similar post-GnRHa trigger hormone profiles and mature oocyte yield support the routine use of GnRHa trigger to prevent OHSS in women with PCOS.

Fresh versus frozen embryo transfer: backing clinical decisions with scientific and clinical evidence

BACKGROUND

Improvements in vitrification now make frozen embryo transfers (FETs) a viable alternative to fresh embryo transfer, with reports from observational studies and randomized controlled trials suggesting that: (i) the endometrium in stimulated cycles is not optimally prepared for implantation; (ii) pregnancy rates are increased following FET and (iii) perinatal outcomes are less affected after FET.

METHODS

This review integrates and discusses the available clinical and scientific evidence supporting embryo transfer in a natural cycle.

RESULTS

Laboratory-based studies demonstrate morphological and molecular changes to the endometrium and reduced responsiveness of the endometrium to hCG, resulting from controlled ovarian stimulation. The literature demonstrates reduced endometrial receptivity in controlled ovarian stimulation cycles and supports the clinical observations that FET reduces the risk of ovarian hyperstimulation syndrome and improves outcomes for both the mother and baby.

CONCLUSIONS

This review provides the basis for an evidence-based approach towards changes in routine IVF, which may ultimately result in higher delivery rates of healthier term babies.

Which luteal phase support is better for each IVF stimulation protocol to achieve the highest pregnancy rate? A superiority randomized clinical trial

In vitro fertilization (IVF) cycles generate abnormalities in luteal-phase sex steroid concentrations and this represent an important limiting factor to achieve a good pregnancy rate. Although there are evidences about the usefulness of luteal phase support (LPS) after IVF cycles, no consensus exist about the best dose and way of progesterone (PG) administration, the advantages of estradiol (E2) supplementation and which IVF protocol could benefit from one more than other LPS scheme. Aim of the study was to assess the best LPS (low-dose PG, high-dose PG, high-dose PG and E2 supplementation) to achieve the highest clinical/ongoing pregnancy rate according to stimulation protocol, E2 at ovulation induction, endometrial thickness at pick-up and women's age. We conducted a randomized trial on 360 women undergoing IVF (180 treated by long-GnRH agonist, 90 by short-GnRH agonist and 90 by short-GnRH antagonist protocol) and stimulated by recombinant follicle-stimulating hormone alone. Our data demonstrated that high-dose PG is better than low-dose to increase both clinical and ongoing pregnancy rate. E2 supplementation are mandatory in case of short-GnRH antagonist protocol and strongly suggested in all protocols when E2max <5 nmol/l and endometrial thickness <10 mm. In long-GnRH agonist protocols, as well as in patients >35 years, the real advantages of E2 supplementation remain debatable and require further confirmation.

Assisted reproductive techniques

Assisted reproductive technologies (ART) encompass fertility treatments, which involve manipulations of both oocyte and sperm in vitro. This chapter provides a brief overview of ART, including indications for treatment, ovarian reserve testing, selection of controlled ovarian hyperstimulation (COH) protocols, laboratory techniques of ART including in vitro fertilization (IVF), and intracytoplasmic sperm injection (ICSI), embryo transfer techniques, and luteal phase support. This chapter also discusses potential complications of ART, namely ovarian hyperstimulation syndrome (OHSS) and multiple gestations, and the perinatal outcomes of ART.

Luteal estradiol supplementation in gonadotropin-releasing hormone antagonist cycles for infertile patients in vitro fertilization

Objective

To evaluate the effect of the addition of estradiol to luteal progesterone supplementation in GnRH antagonist cycles for infertile patients undergoing IVF/ICSI.

Methods

One hundred and ten infertile patients, aged 28 to 39 years, were recruited for this prospective randomized study. They were randomly assigned to receive vaginal progesterone gel (Crinone) along with 4 mg estradiol valerate (group 1, n=55) or only Crinone (group 2, n=55) for luteal support. A GnRH antagonist multiple dose protocol using recombinant human FSH was used for controlled ovarian stimulation (COS) in all of the subjects. The COS results and pregnancy outcomes of the two groups were compared.

Results

Group 1 and 2 were comparable with respect to the patient characteristics. The COS and IVF results were also comparable between the two groups. There were no differences in the clinical pregnancy rate (PR) and multiple PR between the two groups. However, the embryo implantation rate were significantly higher in group 1 than that in group 2 (22.2% vs. 13.3%, p=0.035). The incidence of luteal vaginal bleeding (LVB) was significantly lower in group 1 (7.4% vs. 27.8%, p=0.010).

Conclusion

The addition of estradiol to luteal progesterone supplementation in GnRH antagonist cycles reduces the incidence of LVB and increases the embryo implantation rate in infertile patients undergoing IVF/ICSI.

Dual trigger with combination of gonadotropin-releasing hormone agonist and human chorionic gonadotropin significantly improves the live-birth rate for normal responders in GnRH-antagonist cycles

OBJECTIVE

To investigate whether dual triggering of final oocyte maturation with a combination of gonadotropin-releasing hormone (GnRH) agonist and human chorionic gonadotropin (hCG) can improve the live-birth rate for normal responders in GnRH-antagonist in vitro fertilization/intracytoplasmic sperm injection (IVF-ICSI) cycles.

DESIGN

Retrospective cohort study.

SETTING

Infertility unit of a university-affiliated medical center.

PATIENT(S)

Normal responders to controlled ovarian hyperstimulation who were undergoing IVF-ICSI with a GnRH antagonist protocol.

INTERVENTION(S)

Standard dosage of hCG trigger (6,500 IU of recombinant hCG) versus dual trigger (0.2 mg of triptorelin and 6,500 IU of recombinant hCG).

MAIN OUTCOME MEASURE(S)

Live-birth, clinical pregnancy, and implantation rates per cycle.

RESULT(S)

A total of 376 patients with 378 completed cycles with embryo transfer were enrolled (hCG trigger/control group: n = 187; dual trigger/study group: n = 191). The dual trigger group demonstrated statistically significantly higher implantation (29.6% vs. 18.4%), clinical pregnancy (50.7% vs. 40.1%), and live-birth (41.3% vs. 30.4%) rates as compared with the hCG trigger group. There was no statistically significant difference in terms of patient demographics, cycle parameters, or embryo quality.

CONCLUSION(S)

Dual trigger of final oocyte maturation with a GnRH-agonist and a standard dosage of hCG in normal responders statistically significantly improves implantation, clinical pregnancy, and live-birth rates in GnRH-antagonist IVF cycles.

Luteal phase support for assisted reproduction cycles

BACKGROUND

Progesterone prepares the endometrium for pregnancy by stimulating proliferation in response to human chorionic gonadotropin (hCG), which is produced by the corpus luteum. This occurs in the luteal phase of the menstrual cycle. In assisted reproduction techniques (ART) the progesterone or hCG levels, or both, are low and the natural process is insufficient, so the luteal phase is supported with either progesterone, hCG or gonadotropin releasing hormone (GnRH) agonists. Luteal phase support improves implantation rate and thus pregnancy rates but the ideal method is still unclear. This is an update of a Cochrane Review published in 2004 (Daya 2004).

OBJECTIVES

To determine the relative effectiveness and safety of methods of luteal phase support in subfertile women undergoing assisted reproductive technology.

SEARCH STRATEGY

We searched the Cochrane Menstrual Disorders and Subfertility Group (MDSG) Specialised Register, Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, PsycINFO, CINAHL, Database of Abstracts of Reviews of Effects (DARE), LILACS, conference abstracts on the ISI Web of Knowledge, OpenSigle for grey literature from Europe, and ongoing clinical trials registered online. The final search was in February 2011.

SELECTION CRITERIA

Randomised controlled trials of luteal phase support in ART investigating progesterone, hCG or GnRH agonist supplementation in in vitro fertilisation (IVF) or intracytoplasmic sperm injection (ICSI) cycles. Quasi-randomised trials and trials using frozen transfers or donor oocyte cycles were excluded.

DATA COLLECTION AND ANALYSIS

We extracted data per women and three review authors independently assessed risk of bias. We contacted the original authors when data were missing or the risk of bias was unclear. We entered all data in six different comparisons. We calculated the Peto odds ratio (Peto OR) for each comparison.

MAIN RESULTS

Sixty-nine studies with a total of 16,327 women were included. We assessed most of the studies as having an unclear risk of bias, which we interpreted as a high risk of bias. Because of the great number of different comparisons, the average number of included studies in a single comparison was only 1.5 for live birth and 6.1 for clinical pregnancy.Five studies (746 women) compared hCG versus placebo or no treatment. There was no evidence of a difference between hCG and placebo or no treatment except for ongoing pregnancy: Peto OR 1.75 (95% CI 1.09 to 2.81), suggesting a benefit from hCG. There was a significantly higher risk of ovarian hyperstimulation syndrome (OHSS) when hCG was used (Peto OR 3.62, 95% CI 1.85 to 7.06).There were eight studies (875 women) in the second comparison, progesterone versus placebo or no treatment. The results suggested a significant effect in favour of progesterone for the live birth rate (Peto OR 2.95, 95% CI 1.02 to 8.56) based on one study. For clinical pregnancy (CPR) the results also suggested a significant result in favour of progesterone (Peto OR 1.83, 95% CI 1.29 to 2.61) based on seven studies. For the other outcomes the results indicated no difference in effect.The third comparison (15 studies, 2117 women) investigated progesterone versus hCG regimens. The hCG regimens were subgrouped into comparisons of progesterone versus hCG and progesterone versus progesterone + hCG. The results did not indicate a difference of effect between the interventions, except for OHSS. Subgroup analysis of progesterone versus progesterone + hCG showed a significant benefit from progesterone (Peto OR 0.45, 95% CI 0.26 to 0.79).The fourth comparison (nine studies, 1571 women) compared progesterone versus progesterone + oestrogen. Outcomes were subgrouped by route of administration. The results for clinical pregnancy rate in the subgroup progesterone versus progesterone + transdermal oestrogen suggested a significant benefit from progesterone + oestrogen. There was no evidence of a difference in effect for other outcomes.Six studies (1646 women) investigated progesterone versus progesterone + GnRH agonist. We subgrouped the studies for single-dose GnRH agonist and multiple-dose GnRH agonist. For the live birth, clinical pregnancy and ongoing pregnancy rate the results suggested a significant effect in favour of progesterone + GnRH agonist. The Peto OR for the live birth rate was 2.44 (95% CI 1.62 to 3.67), for the clinical pregnancy rate was 1.36 (95% CI 1.11 to 1.66) and for the ongoing pregnancy rate was 1.31 (95% CI 1.03 to 1.67). The results for miscarriage and multiple pregnancy did not indicate a difference of effect.The last comparison (32 studies, 9839 women) investigated different progesterone regimens:intramuscular (IM) versus oral administration, IM versus vaginal or rectal administration, vaginal or rectal versus oral administration, low-dose vaginal versus high-dose vaginal progesterone administration, short protocol versus long protocol and micronized progesterone versus synthetic progesterone. The main results of this comparison did not indicate a difference of effect except in some subgroup analyses. For the outcome clinical pregnancy, subgroup analysis of micronized progesterone versus synthetic progesterone showed a significant benefit from synthetic progesterone (Peto OR 0.79, 95% CI 0.65 to 0.96). For the outcome multiple pregnancy, the subgroup analysis of IM progesterone versus oral progesterone suggested a significant benefit from oral progesterone (Peto OR 4.39, 95% CI 1.28 to 15.01).

AUTHORS' CONCLUSIONS

This review showed a significant effect in favour of progesterone for luteal phase support, favouring synthetic progesterone over micronized progesterone. Overall, the addition of other substances such as estrogen or hCG did not seem to improve outcomes. We also found no evidence favouring a specific route or duration of administration of progesterone. We found that hCG, or hCG plus progesterone, was associated with a higher risk of OHSS. The use of hCG should therefore be avoided. There were significant results showing a benefit from addition of GnRH agonist to progesterone for the outcomes of live birth, clinical pregnancy and ongoing pregnancy. For now, progesterone seems to be the best option as luteal phase support, with better pregnancy results when synthetic progesterone is used.

Estradiol supplementation during the luteal phase in poor responder patients undergoing in vitro fertilization: a randomized clinical trial

PURPOSE

This study was designed to evaluate the effects of adding Estradiol (E2) supplementation to progesterone (P) on improvement of pregnancy outcomes in poor responder patients who underwent in vitro fertilization (IVF).

METHODS

In a prospective randomized clinical trial, 118 poor responder patients, older than 38 years without contraindications of estradiol consumption from Infertility clinic of a university hospital were randomly divided (by computerized software) into two groups. Control group (59 patients) received only P and intervention group (59 patients) received P and E2 (4 mg/d). Supplementation was done with 4 mg E2 in the luteal phase. Fertilization rate, implantation rate, biochemical and clinical pregnancy rates, abortion rate, ongoing pregnancy, multiple pregnancy and ectopic pregnancy rates were documented for those who completed the study protocol in each group (per protocol analysis) and compared between groups.

RESULT

Fifty five patients in control group and 53 patients in intervention group successfully completed the study protocol. Treatment outcomes were not significantly different between two groups.

CONCLUSION

For poor responder women who underwent IVF, addition of E2 to P supplementation could not significantly improve pregnancy outcomes.

Gonadotrophin-releasing hormone antagonists for assisted reproductive technology

BACKGROUND

Gonadotrophin-releasing hormone (GnRH) antagonists can be used to prevent a luteinizing hormone (LH) surge during controlled ovarian hyperstimulation (COH) without the hypo-estrogenic side-effects, flare-up, or long down-regulation period associated with agonists. The antagonists directly and rapidly inhibit gonadotropin release within several hours through competitive binding to pituitary GnRH receptors. This property allows their use at any time during the follicular phase. Several different regimes have been described including multiple-dose fixed (0.25 mg daily from day six to seven of stimulation), multiple-dose flexible (0.25 mg daily when leading follicle is 14 to 15 mm), and single-dose (single administration of 3 mg on day 7 to 8 of stimulation) protocols, with or without the addition of an oral contraceptive pill. Further, women receiving antagonists have been shown to have a lower incidence of ovarian hyperstimulation syndrome (OHSS). Assuming comparable clinical outcomes for the antagonist and agonist protocols, these benefits would justify a change from the standard long agonist protocol to antagonist regimens. This is an update of a Cochrane review first published in 2001, and previously updated in 2006.

OBJECTIVES

To evaluate the effectiveness and safety of gonadotrophin-releasing hormone (GnRH) antagonists with the standard long protocol of GnRH agonists for controlled ovarian hyperstimulation in assisted conception cycle

SEARCH STRATEGY

We performed electronic searches of major databases, for example Cochrane Menstrual Disorders and Subfertility Group Specialised Register, CENTRAL, MEDLINE, EMBASE (from 1987 to April 2010); and handsearched bibliographies of relevant publications and reviews, and abstracts of major scientific meetings, for example the European Society of Human Reproduction and Embryology (ESHRE) and American Society for Reproductive Medicine (ASRM). A date limited search of Cochrane Menstrual Disorders and Subfertility Group Specialised Register, CENTRAL from April 2010 to April 2011 was run. Eighteen studies have been entered into the Classification pending references section of this update. These studies will be appraised for inclusion or exclusion in the next update of this review, due April 2012.

SELECTION CRITERIA

Two review authors independently screened the relevant citations for randomised controlled trials (RCTs) comparing different agonist versus antagonist protocols in women undergoing IVF or ICSI.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed trial risk of bias and extracted data. If relevant data were missing or unclear, the authors were contacted for clarification.

MAIN RESULTS

Forty-five RCTs (n = 7511) comparing the antagonist to the long agonist protocols fulfilled the inclusion criteria. There was no evidence of a statistically significant difference in rates of live-births (9 RCTs; odds ratio (OR) 0.86, 95% CI 0.69 to 1.08) or ongoing pregnancy (28 RCTs; OR 0.87, 95% CI 0.77 to 1.00). There was a statistically significant lower incidence of OHSS in the GnRH antagonist group (29 RCTs; OR 0.43, 95% CI 0.33 to 0.57).

AUTHORS' CONCLUSIONS

The use of antagonist compared with long GnRH agonist protocols was associated with a large reduction in OHSS and there was no evidence of a difference in live-birth rates.

GnRH agonist for triggering of final oocyte maturation: time for a change of practice?

BACKGROUND

GnRH agonist (GnRHa) triggering has been shown to significantly reduce the occurrence of ovarian hyperstimulation syndrome (OHSS) compared with hCG triggering; however, initially a poor reproductive outcome was reported after GnRHa triggering, due to an apparently uncorrectable luteal phase deficiency. Therefore, the challenge has been to rescue the luteal phase. Studies now report a luteal phase rescue, with a reproductive outcome comparable to that seen after hCG triggering.

METHODS

This narrative review is based on expert presentations and subsequent group discussions supplemented with publications from literature searches and the authors' knowledge. Moreover, randomized controlled trials (RCTs) were identified and analysed either in fresh IVF cycles with embryo transfer (ET), oocyte donation cycles or cycles without ET; risk differences were calculated regarding pregnancy rate and OHSS rate.

RESULTS

In fresh IVF cycles with ET (9 RCTs) no OHSS was reported after GnRHa triggering [0% incidence in the GnRHa group: risk difference 5% (with 95% CI: -0.07 to 0.02)]. Importantly, the delivery rate improved significantly after modified luteal support [6% risk difference in favour of the HCG group (95% CI: -0.14 to 0.2)] when compared with initial studies with conventional luteal support [18% risk difference (95% CI: -0.36 to 0.01)]. In oocyte donation cycles (4 RCTs) the OHSS incidence is 0% [10% risk difference (95% CI: 0.02-0.40)].

CONCLUSIONS

GnRHa triggering is a valid alternative to hCG triggering, resulting in an elimination of OHSS. After modified luteal support there is now a non-significant difference of 6% in delivery rate in favour of hCG triggering.

The effect of adding oral oestradiol to progesterone as luteal phase support in ART cycles - a randomized controlled study

INTRODUCTION

Luteal phase support in assisted reproductive technology (ART) cycles is still controversial. The present study was conducted to evaluate the effect of adding oral oestradiol to progesterone during ART cycles.

MATERIAL AND METHODS

In this prospective case control study, infertile women under 35 years old who were candidates for IVF/ICSI cycles in Royan Institute were enrolled. A long gonadotropin-releasing hormone (GnRH) agonist protocol was used for ovarian stimulation. Patients were randomly divided into two groups for luteal phase support: the control group received vaginal administration of progesterone supplementation alone starting on the day after oocyte retrieval and continued until the tenth week if the chemical pregnancy test was positive. In the oestradiol group, 2 mg of oestradiol valerate was initiated orally with progesterone. The control group received a placebo instead of oestradiol.

RESULTS

Ninety-eight women were studied as oestradiol (N = 47) and control groups (N= 51). There were no significant differences in the mean number of retrieved oocytes, number of transferred embryos, or chemical and clinical pregnancy rates between the two groups. Although the serum progesterone concentration was higher in the oestradiol group in comparison to the control group on day 7, 10 and 12 after embryo transfer, these differences were not statistically significant.

CONCLUSIONS

The results suggested that adding oral oestradiol to vaginal progesterone supplementation does not improve the chemical and clinical pregnancy rates of IVF/ICSI cycles.

Luteal support: progestogens for pregnancy protection

Following ovulation, the granulosa cells undergo luteinization and form part of the corpus luteum; this then secretes progesterone that causes secretory transformation of the endometrium so that implantation can occur. The ideal time for implantation is 6-10 days after the luteinizing hormone (LH) surge; implantation occurring outside this optimal window is associated with a higher likelihood of miscarriage. Before the placenta takes over progesterone production, the progesterone produced by the corpus luteum also provides the necessary support to early pregnancy. A defect in corpus luteum function is not only associated with implantation failure but also with miscarriage. In assisted reproduction, both the use of gonadotropin-releasing hormone analogues to prevent the LH surge and aspiration of granulosa cells during the oocyte retrieval may impair the ability of the corpus luteum to produce sufficient progesterone. This may be treated effectively with progestational agents such as progesterone or dydrogesterone, which have a very similar pharmacological profile. Studies indicate that an estrogen may be given during the luteal phase to optimise the estrogen:progestogen ratio to facilitate implantation, although the available evidence is inconsistent in its strength for this hypothesis. In addition to assisted reproduction, progestational agents have shown beneficial effects in the management of patients with recurrent spontaneous miscarriage of unknown cause. In conclusion, despite the wide-spread use and many years of clinical experience, the amount of data from well-controlled clinical trials is currently limited. Further studies are therefore required to establish the optimal treatment situation and type and dose of progestational agent.

Bibliography. Current world literature

This bibliography is compiled by clinicians from the journals listed at the end of this publication. It is based on literature entered into our database between 1 February 2008 and 31 January 2009 (articles are generally added to the database about two and a half months after publication). In addition, the bibliography contains every paper annotated by reviewers; these references were obtained from a variety of bibliographic databases and published between the beginning of the review period and the time of going to press. The bibliography has been grouped into topics that relate to the reviews in this issue.

Luteal support in reproduction: when, what and how?

PURPOSE OF REVIEW

Luteal phase support (LPS) is an integral part of the IVF cycles treated by gonadotropin-releasing hormone analogues. There is a worldwide controversy concerning the type of hormones used for LPS, its dose, duration, when to start and when to stop. This review will cover original as well as recent data on this topic.

RECENT FINDINGS

There is a consensus in the literature among IVF centers that LPS is necessary for IVF cycles. Human chorionic gonadotropin is less commonly used than progesterone for LPS because of ovarian hyperstimulation syndrome risk. Several studies suggested that intramuscular progesterone is superior to vaginal progesterone for LPS; however, the majority of centers use vaginal progesterone to avoid side effects of intramuscular injection. There is no difference in pregnancy rate whether LPS is started on day of human chorionic gonadotropin, oocyte retrieval or embryo transfer. There is a strong evidence that LPS should be stopped either on the day of pregnancy test or the first ultrasound (6-7 weeks pregnancy). There is no evidence that addition of estrogen will improve pregnancy rate.

SUMMARY

Progesterone is the preferred option for LPS. It should start within 2 days from triggering ovulation and should end on day of beta human chorionic gonadotropin or the day of the first ultrasound (6-7 weeks pregnancy).

Does luteal estradiol supplementation have a role in long agonist cycles?

OBJECTIVE

To test the hypothesis that the addition of 6 mg estradiol (E2) valerate either orally or vaginally to progesterone (P) for luteal support, can increase the probability of pregnancy in intracytoplasmic sperm injection (ICSI) cycles using the long agonist protocol.

DESIGN

Prospective open-labeled randomized controlled trial.

SETTING

Private and university fertility centers.

PARTICIPANT(S)

Women undergoing ICSI cycles, with controlled ovarian hyperstimulation using long agonist protocol.

INTERVENTION(S)

On embryo transfer day, participants were randomized to receive, only P (group A, n = 90), P along with 6 mg E(2) valerate either orally (group B, n = 90), or vaginally (group C, n = 90) for luteal support.

MAIN OUTCOME MEASURE(S)

Clinical pregnancy was the main outcome. luteal serum E(2) and P profiles were the secondary outcomes.

RESULT(S)

Highest pregnancy rate was achieved in group C (45.56%), it was significantly higher than A (relative risk 1.52, 95% CI: 1.03 to 2.24). Day 0 (hCG day) E2 levels were similar in the three groups. Group A had lower E2 levels on days 7, 10, and 13 and a higher magnitude of E2 decline on days 7 and 10. Similar levels of luteal E2 were documented in groups B and C. P levels were similar in the three groups.

CONCLUSIONS(S)

Addition of 6 mg E(2) valerate to P support may encumber the sharp decline in luteal E(2) level. It may enhance the probability of pregnancy if administered vaginally.