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Garg A, Zielinska AP, Yeung AC, Abdelmalak R, Chen R, Hossain A, Israni A, Nelson SM, Babwah AV, Dhillo WS, Abbara A. Luteal phase support in assisted reproductive technology. Nat Rev Endocrinol 2024; 20:149-167. [PMID: 38110672 DOI: 10.1038/s41574-023-00921-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/31/2023] [Indexed: 12/20/2023]
Abstract
Infertility affects one in six couples, with in vitro fertilization (IVF) offering many the chance of conception. Compared to the solitary oocyte produced during the natural menstrual cycle, the supraphysiological ovarian stimulation needed to produce multiple oocytes during IVF results in a dysfunctional luteal phase that can be insufficient to support implantation and maintain pregnancy. Consequently, hormonal supplementation with luteal phase support, principally exogenous progesterone, is used to optimize pregnancy rates; however, luteal phase support remains largely 'black-box' with insufficient clarity regarding the optimal timing, dosing, route and duration of treatment. Herein, we review the evidence on luteal phase support and highlight remaining uncertainties and future research directions. Specifically, we outline the physiological luteal phase, which is regulated by progesterone from the corpus luteum, and evaluate how it is altered by the supraphysiological ovarian stimulation used during IVF. Additionally, we describe the effects of the hormonal triggers used to mature oocytes on the degree of luteal phase support required. We explain the histological transformation of the endometrium during the luteal phase and evaluate markers of endometrial receptivity that attempt to identify the 'window of implantation'. We also cover progesterone receptor signalling, circulating progesterone levels associated with implantation, and the pharmacokinetics of available progesterone formulations to inform the design of luteal phase support regimens.
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Affiliation(s)
- Akanksha Garg
- Section of Endocrinology and Investigative Medicine, Imperial College London, Hammersmith Hospital, London, UK
- Imperial College Healthcare NHS Trust, London, UK
| | - Agata P Zielinska
- Section of Endocrinology and Investigative Medicine, Imperial College London, Hammersmith Hospital, London, UK
- Imperial College Healthcare NHS Trust, London, UK
| | - Arthur C Yeung
- Section of Endocrinology and Investigative Medicine, Imperial College London, Hammersmith Hospital, London, UK
- Imperial College Healthcare NHS Trust, London, UK
| | - Rebecca Abdelmalak
- Section of Endocrinology and Investigative Medicine, Imperial College London, Hammersmith Hospital, London, UK
| | - Runzhi Chen
- Section of Endocrinology and Investigative Medicine, Imperial College London, Hammersmith Hospital, London, UK
| | - Aleena Hossain
- Section of Endocrinology and Investigative Medicine, Imperial College London, Hammersmith Hospital, London, UK
| | - Alisha Israni
- Section of Endocrinology and Investigative Medicine, Imperial College London, Hammersmith Hospital, London, UK
| | - Scott M Nelson
- School of Medicine, Dentistry & Nursing, University of Glasgow, Glasgow, UK
- NIHR Biomedical Research Centre, University of Bristol, Bristol, UK
- The Fertility Partnership (TFP), Oxford, UK
| | - Andy V Babwah
- Rutgers-Robert Wood Johnson Medical School, New Brunswick, NJ, USA
| | - Waljit S Dhillo
- Section of Endocrinology and Investigative Medicine, Imperial College London, Hammersmith Hospital, London, UK
- Imperial College Healthcare NHS Trust, London, UK
| | - Ali Abbara
- Section of Endocrinology and Investigative Medicine, Imperial College London, Hammersmith Hospital, London, UK.
- Imperial College Healthcare NHS Trust, London, UK.
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Duport Percier M, Brouillet S, Mollevi C, Duraes M, Anahory T, Ranisavljevic N. Serum progesterone concentration on pregnancy test day might predict ongoing pregnancy after controlled ovarian stimulation and fresh embryo transfer. Front Endocrinol (Lausanne) 2023; 14:1191648. [PMID: 37455896 PMCID: PMC10338216 DOI: 10.3389/fendo.2023.1191648] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2023] [Accepted: 06/01/2023] [Indexed: 07/18/2023] Open
Abstract
Progesterone (P4) is essential for pregnancy. A controlled ovarian stimulation (COS) leads to a iatrogenic luteal defect that indicates a luteal phase support (LPS) at least until pregnancy test day. Some clinicians continue the LPS until week 8 or later, when P4 is mainly secreted by syncytiotrophoblast cells.Measuring serum P4 on pregnancy test day after a fresh embryo transfer could help to identify women who might benefit from prolonged LPS. In women with LPS based on P4 administered by the rectal route, P4 concentration on pregnancy test day was significantly higher in patients with ongoing pregnancy than in patients with abnormal pregnancy.This monocentric retrospective study used data on 99 consecutive cycles of COS, triggered with human chorionic gonadotropin, followed by fresh embryo transfer resulting in a positive pregnancy test (>100 IU/L) (from November 2020 to November 2022). Patients undergoing preimplantation genetic screening or with ectopic pregnancy were excluded. All patients received standard luteal phase support (i.e. micronized vaginal progesterone 600 mg per day for 15 days). The primary endpoint was P4 concentration at day 15 after oocyte retrieval (pregnancy test day) in women with ongoing pregnancy for >12 weeks and in patients with miscarriage before week 12 of pregnancy.The median P4 concentration [range] at pregnancy test day was higher in women with ongoing pregnancy than in women with miscarriage (55.9 ng/mL [11.6; 290.6] versus 18.1 ng/mL [8.3; 140.9], p = 0.002). A P4 concentration ≥16.5 ng/mL at pregnancy test day was associated with higher ongoing pregnancy rate (OR = 12.5, 95% CI 3.61 - 43.33, p <0.001). A P4 concentration ≥16.5 ng/mL at pregnancy test day was significantly associated with higher live birth rate (OR = 11.88, 95% CI 3.30-42.71, p <0.001).After COS and fresh embryo transfer, the risk of miscarriage is higher in women who discontinue luteal support after 15 days, as recommended, but with P4 concentration <16.5 ng/mL. The benefit of individualized prolonged luteal phase support should be evaluated.
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Affiliation(s)
- Marie Duport Percier
- Department of Reproductive Medicine, Montpellier University Hospital, University of Montpellier, Montpellier, France
| | - Sophie Brouillet
- Department of Reproductive Biology-CECOS, Montpellier University Hospital, University of Montpellier, Montpellier, France
- Embryo Development Fertility Environment, University of Montpellier, INSERM 1203, Montpellier, France
| | - Caroline Mollevi
- Institute of Epidemiology and Public Health, Montpellier University Hospital, University of Montpellier, INSERM, Montpellier, France
| | - Martha Duraes
- Department of Reproductive Medicine, Montpellier University Hospital, University of Montpellier, Montpellier, France
| | - Tal Anahory
- Department of Reproductive Medicine, Montpellier University Hospital, University of Montpellier, Montpellier, France
| | - Noemie Ranisavljevic
- Department of Reproductive Medicine, Montpellier University Hospital, University of Montpellier, Montpellier, France
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Zhao J, Hao J, Li Y. Individualized luteal phase support after fresh embryo transfer: unanswered questions, a review. Reprod Health 2022; 19:19. [PMID: 35065655 PMCID: PMC8783459 DOI: 10.1186/s12978-021-01320-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2021] [Accepted: 12/23/2021] [Indexed: 12/20/2022] Open
Abstract
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.
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Affiliation(s)
- Jing Zhao
- Reproductive Medicine Center, Xiangya Hospital, Central South University, 87 Xiangya Road, Changsha City, Hunan Province, People's Republic of China.,Clinical Research Center For Women's Reproductive Health In Hunan Province, Hunan, People's Republic of China
| | - Jie Hao
- Reproductive Medicine Center, Xiangya Hospital, Central South University, 87 Xiangya Road, Changsha City, Hunan Province, People's Republic of China.,Clinical Research Center For Women's Reproductive Health In Hunan Province, Hunan, People's Republic of China
| | - Yanping Li
- Reproductive Medicine Center, Xiangya Hospital, Central South University, 87 Xiangya Road, Changsha City, Hunan Province, People's Republic of China. .,Clinical Research Center For Women's Reproductive Health In Hunan Province, Hunan, People's Republic of China.
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Implantation Failures and Miscarriages in Frozen Embryo Transfers Timed in Hormone Replacement Cycles (HRT): A Narrative Review. Life (Basel) 2021; 11:life11121357. [PMID: 34947887 PMCID: PMC8708868 DOI: 10.3390/life11121357] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2021] [Revised: 12/03/2021] [Accepted: 12/03/2021] [Indexed: 01/12/2023] Open
Abstract
The recent advent of embryo vitrification and its remarkable efficacy has focused interest on the quality of hormone administration for priming frozen embryo transfers (FETs). Products available for progesterone administration have only been tested in fresh assisted reproduction technologies (ARTs) and not in FET. Recently, there have been numerous concordant reports pointing at the inefficacy of vaginal preparations at delivering sufficient progesterone levels in a sizable fraction of FET patients. The options available for coping with these shortcomings of vaginal progesterone include (i) rescue options with the addition of injectable subcutaneous (SC) progesterone at the dose of 25 mg/day administered either solely to women whose circulating progesterone is <10 ng/mL or to all in a combo option and (ii) the exclusive administration of SC progesterone at the dose of 25 mg BID. The wider use of segmented ART accompanied with FET forces hormone replacement regimens used for priming endometrial receptivity to be adjusted in order to optimize ART outcomes.
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Abstract
PURPOSE OF REVIEW In a conventional IVF cycle, final oocyte maturation and ovulation is triggered with a bolus of hCG, followed by progesterone-based luteal support that spans several weeks if pregnancy is achieved. This article summarizes several approaches of the exogenous progesterone-free luteal support in IVF. RECENT FINDINGS Triggering ovulation with GnRH agonist may serve as an alternative to hCG, with well established advantages. In addition, the luteal phase can be individualized in order to achieve a more physiologic hormonal milieu, and a more patient friendly treatment, alleviating the burden of a lengthy exogenous progesterone therapy. SUMMARY GnRH agonist trigger followed by a 'freeze all' policy is undoubtedly the best approach towards the 'OHSS-free clinic'. If fresh embryo transfer is considered well tolerated after GnRH agonist trigger, rescue of the corpora lutea by LH activity supplementation is mandatory. Herein we discuss the different approaches of corpus luteum rescue.
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Affiliation(s)
- Shahar Kol
- IVF Unit, Elisha Hospital, Haifa, Israel
| | - Peter Humaidan
- The Fertility Clinic, Skive Regional Hospital, Skive
- Faculty of Health, Aarhus University, Aarhus
- Faculty of Health, University of Southern Denmark, Odense, Denmark
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Mizrachi Y, Raziel A, Weissman A. When Can We Safely Stop Luteal Phase Support in Fresh IVF Cycles? A Literature Review. FRONTIERS IN REPRODUCTIVE HEALTH 2020; 2:610532. [PMID: 36304703 PMCID: PMC9580666 DOI: 10.3389/frph.2020.610532] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2020] [Accepted: 11/20/2020] [Indexed: 11/13/2022] Open
Abstract
There is no consensus on the optimal duration of luteal phase support (LPS) in fresh IVF cycles. Although some clinicians withdraw LPS on the day of a positive pregnancy test, most clinicians continue its administration at least up to the 8th week of gestation. In this literature review, we included several randomized clinical trials comparing early and late cessation of LPS. Most studies have found no benefit in extended administration. These studies, however, were limited by their small sample size and selection bias. Until now, only a few attempts have been made to indicate when LPS can be safely stopped based on individual patient characteristics. In conclusion, the quality and quantity of the evidence regarding LPS duration in fresh IVF cycles is currently insufficient to justify early cessation in all patients. Individualization of LPS should receive high priority in future research.
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Pan SP, Chao KH, Huang CC, Wu MY, Chen MJ, Chang CH, Yang JH, Yang YS, Chen SU. Early stop of progesterone supplementation after confirmation of pregnancy in IVF/ICSI fresh embryo transfer cycles of poor responders does not affect pregnancy outcome. PLoS One 2018; 13:e0201824. [PMID: 30092070 PMCID: PMC6084928 DOI: 10.1371/journal.pone.0201824] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2018] [Accepted: 07/23/2018] [Indexed: 12/21/2022] Open
Abstract
Previous studies indicated that progesterone can be withdrawn at the time of the first positive β-hCG test without compromising the clinical pregnancy outcome in normal ovarian responder. However, the effect of early stop of progesterone supplementation for patients with poor ovarian response (POR) has not been investigated. This study retrospectively collected data from patients with POR in 156 IVF/ICSI fresh embryo transfer (ET) cycles in single tertiary center from January 2010 to June 2016. All the patients met ESHRE consensus, the Bologna criteria, of POR and had hCG injection for luteal phase support (LPS) on day 2, 5 and 8 after ovum pick-up. The pregnant patients were divided into two groups: early stop group represented those who stopped LPS from day of positive pregnancy test; control group represented those who kept progesterone supplementation till gestational age of 9 weeks. There were no significant differences in age, BMI, parity, hormone data, number of follicles>10(mm), endometrial thickness and number of embryos transferred between the two groups. After adjustment for possible confounders with multivariate logistic regression analysis, the clinical pregnancy rates (55.0% vs. 57.1%, P = 0.35), ongoing pregnancy rates (47.0% vs. 46.4%, P = 0.66), miscarriage rates (34.0% vs. 26.7%, P = 0.66) and live-birth rates (44.0% vs. 46.4%, P = 0.41) were not statistically different between early stop group and the control group. Our study indicates that early stop of progesterone supplementation on the day of positive pregnancy test for patients of POR using hCG as LPS in fresh ET cycles does not affect pregnancy outcome.
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Affiliation(s)
- Song-Po Pan
- Department of Obstetrics and Gynecology, National Taiwan University Hospital, Taipei, Taiwan
| | - Kuang-Han Chao
- Department of Obstetrics and Gynecology, National Taiwan University Hospital, Taipei, Taiwan
| | - Chu-Chun Huang
- Department of Obstetrics and Gynecology, National Taiwan University Hospital, Taipei, Taiwan
| | - Ming-Yih Wu
- Department of Obstetrics and Gynecology, National Taiwan University Hospital, Taipei, Taiwan
| | - Mei-Jou Chen
- Department of Obstetrics and Gynecology, National Taiwan University Hospital, Taipei, Taiwan
- Livia Shanyu Wan Scholar, College of Medicine, National Taiwan University
| | - Chin-Hao Chang
- Department of Medical Research, National Taiwan University Hospital, Taipei, Taiwan
| | - Jehn-Hsiahn Yang
- Department of Obstetrics and Gynecology, National Taiwan University Hospital, Taipei, Taiwan
| | - Yu-Shih Yang
- Department of Obstetrics and Gynecology, National Taiwan University Hospital, Taipei, Taiwan
| | - Shee-Uan Chen
- Department of Obstetrics and Gynecology, National Taiwan University Hospital, Taipei, Taiwan
- * E-mail:
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