GnRH agonist administration at the time of implantation does not improve pregnancy outcome in intrauterine insemination cycles: a randomized controlled trial

Luteal phase support for women trying to conceive by intrauterine insemination or sexual intercourse

BACKGROUND

Ovulation induction may impact endometrial receptivity due to insufficient progesterone secretion. Low progesterone is associated with poor pregnancy outcomes.

OBJECTIVES

To assess the effectiveness and safety of luteal phase support (LPS) in infertile women trying to conceive by intrauterine insemination or by sexual intercourse.

SEARCH METHODS

We searched the Cochrane Gynaecology and Fertility Group Specialised Register, CENTRAL, MEDLINE, Embase, PsycINFO, LILACS, trial registries for ongoing trials, and reference lists of articles (from inception to 25 August 2021).

SELECTION CRITERIA

Randomised controlled trials (RCTs) of LPS using progestogen, human chorionic gonadotropin (hCG), or gonadotropin-releasing hormone (GnRH) agonist supplementation in IUI or natural cycle.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by Cochrane. Our primary outcomes were live birth rate/ongoing pregnancy rate (LBR/OPR) and miscarriage.  MAIN RESULTS: We included 25 RCTs (5111 participants). Most studies were at unclear or high risk of bias. We graded the certainty of evidence as very low to low. The main limitations of the evidence were poor reporting and imprecision. 1. Progesterone supplement versus placebo or no treatment  We are uncertain if vaginal progesterone increases LBR/OPR (risk ratio (RR) 1.10, 95% confidence interval (CI) 0.81 to 1.48; 7 RCTs; 1792 participants; low-certainty evidence) or decreases miscarriage per pregnancy compared to placebo or no treatment (RR 0.70, 95% CI 0.40 to 1.25; 5 RCTs; 261 participants). There were no data on LBR or miscarriage with oral stimulation. We are uncertain if progesterone increases LBR/OPR in women with gonadotropin stimulation (RR 1.24, 95% CI 0.80 to 1.92; 4 RCTs; 1054 participants; low-certainty evidence) and oral stimulation (clomiphene citrate or letrozole) (RR 0.97, 95% CI 0.58 to 1.64; 2 RCTs; 485 participants; low-certainty evidence). One study reported on OPR in women with gonadotropin plus oral stimulation; the evidence from this study was uncertain (RR 0.73, 95% CI 0.37 to 1.42; 1 RCT; 253 participants; low-certainty evidence). Given the low certainty of the evidence, it is unclear if progesterone reduces miscarriage per clinical pregnancy in any stimulation protocol (RR 0.68, 95% CI 0.24 to 1.91; 2 RCTs; 102 participants, with gonadotropin; RR 0.67, 95% CI 0.30 to 1.50; 2 RCTs; 123 participants, with gonadotropin plus oral stimulation; and RR 0.53, 95% CI 0.25 to 1.14; 2 RCTs; 119 participants, with oral stimulation). Low-certainty evidence suggests that progesterone in all types of ovarian stimulation may increase clinical pregnancy compared to placebo (RR 1.38, 95% CI 1.10 to 1.74; 7 RCTs; 1437 participants, with gonadotropin; RR 1.40, 95% CI 1.03 to 1.90; 4 RCTs; 733 participants, with gonadotropin plus oral stimulation (clomiphene citrate or letrozole); and RR 1.44, 95% CI 1.04 to 1.98; 6 RCTs; 1073 participants, with oral stimulation). 2. Progesterone supplementation regimen  We are uncertain if there is any difference between 300 mg and 600 mg of vaginal progesterone for OPR and multiple pregnancy (RR 1.58, 95% CI 0.81 to 3.09; 1 RCT; 200 participants; very low-certainty evidence; and RR 0.50, 95% CI 0.05 to 5.43; 1 RCT; 200 participants, very low-certainty evidence, respectively). No other outcomes were reported for this comparison. There were three different comparisons between progesterone regimens. For OPR, the evidence is very uncertain for intramuscular (IM) versus vaginal progesterone (RR 0.59, 95% CI 0.34 to 1.02; 1 RCT; 225 participants; very low-certainty evidence); we are uncertain if there is any difference between oral and vaginal progesterone (RR 1.25, 95% CI 0.70 to 2.22; 1 RCT; 150 participants; very low-certainty evidence) or between subcutaneous and vaginal progesterone (RR 1.05, 95% CI 0.54 to 2.05; 1 RCT; 246 participants; very low-certainty evidence). We are uncertain if IM or oral progesterone reduces miscarriage per clinical pregnancy compared to vaginal progesterone (RR 0.75, 95% CI 0.43 to 1.32; 1 RCT; 81 participants and RR 0.58, 95% CI 0.11 to 3.09; 1 RCT; 41 participants, respectively). Clinical pregnancy and multiple pregnancy were reported for all comparisons; the evidence for these outcomes was very uncertain. Only one RCT reported adverse effects. We are uncertain if IM route increases the risk of adverse effects when compared with the vaginal route (RR 9.25, 95% CI 2.21 to 38.78; 1 RCT; 225 participants; very low-certainty evidence). 3. GnRH agonist versus placebo or no treatment  No trials reported live birth. The evidence is very uncertain about the effect of GnRH agonist in ongoing pregnancy (RR 1.10, 95% CI 0.70 to 1.74; 1 RCT; 291 participants, very low-certainty evidence), miscarriage per clinical pregnancy (RR 0.73, 95% CI 0.26 to 2.10; 2 RCTs; 79 participants, very low-certainty evidence) and clinical pregnancy (RR 1.00, 95% CI 0.68 to 1.47; 2 RCTs; 340 participants; very low-certainty evidence), and multiple pregnancy (RR 0.28, 95% CI 0.11 to 0.70; 2 RCTs; 126 participants). 4. GnRH agonist versus vaginal progesterone  The evidence for the effect of GnRH agonist injection on clinical pregnancy is very uncertain (RR 1.00, 95% CI 0.51 to 1.95; 1 RCT; 242 participants). 5. HCG injection versus no treatment  The evidence for the effect of hCG injection on clinical pregnancy (RR 0.93, 95% CI 0.40 to 2.13; 1 RCT; 130 participants) and multiple pregnancy rates (RR 1.03, 95% CI 0.22 to 4.92; 1 RCT; 130 participants) is very uncertain. 6. Luteal support in natural cycle No study evaluated the effect of LPS in natural cycle. We could not perform sensitivity analyses, as there were no studies at low risk of selection bias and not at high risk in other domains.

AUTHORS' CONCLUSIONS

We are uncertain if vaginal progesterone supplementation during luteal phase is associated with a higher live birth/ongoing pregnancy rate. Vaginal progesterone may increase clinical pregnancy rate; however, its effect on miscarriage rate and multiple pregnancy rate is uncertain. We are uncertain if IM progesterone improves ongoing pregnancy rates or decreases miscarriage rate when compared to vaginal progesterone. Regarding the other reported comparisons, neither oral progesterone nor any other medication appears to be associated with an improvement in pregnancy outcomes (very low-certainty evidence).

Single-administered GnRH agonist as luteal phase support in insemination cycles: a randomized controlled trial

OBJECTIVE

To find out whether a single-administered GnRH agonist improves the live birth rate in real-life patients undergoing intrauterine insemination (IUI) cycles.

STUDY DESIGN

A prospective, randomized controlled trial in a public single tertiary center in Tampere University Hospital, Finland. Altogether 251 IUI cycles in 163 patients were randomized to triptorelin and a control group between January 2017 and April 2019. In the triptorelin group, the participants had a single administration of a subcutaneous GnRH agonist triptorelin 0.1 mg at the time of implantation. In the control group, there was no luteal phase support. The primary outcome measure was the live birth rate (LBR). The secondary outcome measures were clinical pregnancy rate (CPR) and miscarriage rate.

RESULTS

Overall, the live birth rate was lower in the triptorelin group compared to the control group (7.9 vs. 12.1%; p = .297). The clinical pregnancy rates were 12.6 and 13.7%, respectively. There were 2.4% miscarriages in the triptorelin group and no miscarriages in the control group. Ovarian stimulation with letrozole was associated with lower LBR among the triptorelin group, in comparison to the control group (0 vs. 14.7%, p = .020). In contrast, when gonadotrophin was added to the letrozole, LBR was almost doubled compared to the control group (15.9 vs. 8.3%, p = .341).

CONCLUSION

A single administration of GnRH agonist in the luteal phase does not improve LBR in IUI cycles.

Intrauterine Insemination: Current Place in Infertility Management

Infertility has become a significant problem worldwide. Multiple management options are available nowadays, which include intrauterine insemination (IUI), in vitro fertilisation (IVF), and intracytoplasmic sperm injection. IUI is one of the oldest and most popular methods. After >50 years since it was first used, IUI has evolved through various innovations but still struggles to find its place in infertility management. After the introduction of revised guidelines from the National Institute for Health and Care Excellence (NICE) in 2013, there has been a surge in the use of IVF as a primary treatment modality. The aim of this evidence-based review is to highlight the factors associated with success of IUI and to find out whether IUI can be offered as a first-line treatment option for infertile couples.

Evaluation of Role of GnRH Antagonist in Intrauterine Insemination (IUI) Cycles with Mild Ovarian Hyperstimulation (MOH): A Prospective Randomised Study

AIMS AND OBJECTIVE

To evaluate the role of GnRH antagonist in prevention of premature LH surge and increasing pregnancy rates in IUI cycle with mild ovarian hyperstimulation (MOH).

STUDY DESIGN

Prospective parallel, randomised controlled study.

MATERIAL AND METHODS

Couples diagnosed with unexplained, male factor subfertility and with one or both tubes patent were randomised to receive either a GnRH antagonist (study group) or no intervention (control group). All women were treated with clomiphene citrate (D3-D7) followed by HMG. A GnRH antagonist was added when one or more follicles of 16 mm diameter or more were visualised in the study group. When at least one follicle reached a size of ≥18 mm, ovulation was induced by hCG injection. A single IUI was performed 36 h later. The primary outcome was premature LH surge and pregnancy rate. The secondary outcomes were the amount of gonadotropins used, duration of use of GnRH antagonist and incidence and severity of OHSS.

RESULTS

A total of seventy patients attending the infertility clinic in the outpatient department of Obstetrics and Gynecology, of a tertiary care centre, were recruited in the study which was carried out from August 2011 to March 2013. The study group included 34 women and 36 in the control arm. The incidence of premature LH surge was significantly lower in the antagonist group as compared to the control group 2.9 vs. 13.9 %, with a p value of <0.001. The clinical pregnancy rates were similar in both the groups 8.8 vs. 11.1 %, p value being 1.000. The amount of gonadotropins used in GnRH antagonist group was lower than in control group but not statistically significant. Duration of GnRH antagonist was 1.85 ± 0.61 days in the study group.

CONCLUSION

The delayed administration of GnRH antagonists in MOH with IUI cycles when follicle size is ≥16 mm is beneficial in terms of preventing the occurrence of premature LH surge but with no improvement in pregnancy rates.

GnRH agonist during luteal phase in women undergoing assisted reproductive techniques: systematic review and meta-analysis of randomized controlled trials

OBJECTIVE

To identify, evaluate and summarize the available evidence regarding the effectiveness and safety of administering a gonadotropin releasing hormone (GnRH) agonist during the luteal phase in women undergoing assisted reproductive techniques.

METHODS

In this systematic review and meta-analysis, we searched for randomized controlled trials (RCTs) comparing the addition of a GnRH agonist during the luteal phase, compared with standard luteal-phase support. We searched seven electronic databases and hand-searched the reference lists of included studies and related reviews. Our primary outcome was live birth or ongoing pregnancy per randomized woman. Our secondary outcomes were clinical pregnancy per randomized woman, miscarriage per clinical pregnancy, adverse perinatal outcome and congenital malformations.

RESULTS

The evidence from eight studies examining 2776 women showed a relative risk (RR) for live birth or ongoing pregnancy of 1.26 (95% CI, 1.04-1.53; I(2) = 58%). Sensitivity analysis when excluding the studies that did not report live birth and those at high risk of bias resulted in one study examining 181 women with an RR of 1.07 (95% CI, 0.73-1.58). Subgroup analysis separating the studies by single/multiple doses of GnRH agonists or by ovarian stimulation with GnRH agonist/antagonist was unable to explain the observed heterogeneity. The quality of the evidence was deemed to be very low: it was downgraded because of the limitation of the included studies, imprecision, inconsistency across the studies' results, and suspicion of publication bias. None of the included studies reported adverse perinatal outcomes or congenital malformations.

CONCLUSIONS

There is evidence that adding GnRH agonist during the luteal phase improves the likelihood of ongoing pregnancy. However, this evidence is of very low quality and there is no evidence for adverse perinatal outcome and congenital malformations. We therefore believe that including this intervention in clinical practice would be premature.

Progesterone luteal support after ovulation induction and intrauterine insemination: a systematic review and meta-analysis

OBJECTIVE

To evaluate the effect of luteal phase P support after ovulation induction IUI.

DESIGN

A systematic review and meta-analysis.

SETTING

Not applicable.

PATIENT(S)

Undergoing ovulation induction IUI.

INTERVENTION(S)

Any form of exogenous P in ovulation induction IUI cycles.

MAIN OUTCOME MEASURE(S)

Clinical pregnancy and live birth.

RESULT(S)

Five trials were identified that met inclusion criteria and comprised 1,298 patients undergoing 1,938 cycles. Clinical pregnancy (odds ratio [OR] 1.47, 95% confidence interval [CI] 1.15-1.98) and live birth (OR 2.11, 95% CI 1.21-3.67) were more likely in P-supplemented patients. These findings persisted in analyses evaluating per IUI cycle, per patient, and first cycle only data. In subgroup analysis, patients receiving gonadotropins for ovulation induction had the most increase in clinical pregnancy with P support (OR 1.77, 95% CI 1.20-2.6). Conversely, patients receiving clomiphene citrate (CC) for ovulation induction showed no difference in clinical pregnancy with P support (OR 0.89, 95% CI 0.47-1.67).

CONCLUSION(S)

Progesterone luteal phase support may be of benefit to patients undergoing ovulation induction with gonadotropins in IUI cycles. Progesterone support did not benefit patients undergoing ovulation induction with CC, suggesting a potential difference in endogenous luteal phase function depending on the method of ovulation induction.