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Bourdon M, Sorel M, Maignien C, Guibourdenche J, Patrat C, Marcellin L, Jobin T, Chapron C, Santulli P. Progesterone levels do not differ between patients with or without endometriosis/adenomyosis both in those who conceive after hormone replacement therapy-frozen embryo transfer cycles and those who do not. Hum Reprod 2024; 39:1692-1700. [PMID: 38850031 DOI: 10.1093/humrep/deae114] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2024] [Revised: 04/19/2024] [Indexed: 06/09/2024] Open
Abstract
STUDY QUESTION Do women with endometriosis who achieve a live birth (LB) after HRT-frozen embryo transfer (HRT-FET) have different progesterone levels on the day of transfer compared to unaffected women? SUMMARY ANSWER In women achieving a LB after HRT-FET, serum progesterone levels on the day of the transfer did not differ between patients with endometriosis and unaffected patients. WHAT IS KNOWN ALREADY In HRT-FET, several studies have highlighted the correlation between serum progesterone levels at the time of FET and LB rates. In the pathophysiology of endometriosis, progesterone resistance is typically described in the eutopic endometrium. This has led to the hypothesis that women with endometriosis may require higher progesterone levels to achieve a LB, especially in HRT-FET cycles without a corpus luteum. STUDY DESIGN, SIZE, DURATION We conducted an observational cohort study at the university-based reproductive medicine center of our institution, focusing on women who underwent a single autologous frozen blastocyst transfer after HRT using exogenous estradiol and micronized vaginal progesterone for endometrial preparation between January 2019 and December 2021. Women were included only once during the study period. Serum progesterone levels were measured on the morning of the FET by a single laboratory. PARTICIPANTS/MATERIALS, SETTING, METHODS Patients were divided into groups based on whether they had endometriosis or not and whether they achieved a LB. The diagnosis of endometriosis was based on published imaging criteria (transvaginal sonography/magnetic resonance imaging) and/or confirmed histology. The primary outcome was progesterone levels on the day of the HRT-FET leading to a LB in patients with endometriosis compared to unaffected women. Subgroup analyses were performed based on the presence of deep infiltrating endometriosis or adenomyosis. MAIN RESULTS AND THE ROLE OF CHANCE A total of 1784 patients were included. The mean age of the women was 35.1 ± 4.1 (SD) years. Five hundred and sixty women had endometriosis, while 1224 did not. About 179/560 (32.0%) with endometriosis and 381/1224 (31.2%) without endometriosis achieved a LB. Among women who achieved a LB after HRT-FET, there was no significant difference in the mean progesterone level on the day of the HRT-FET between those with endometriosis and those without (13.6 ± 4.3 ng/ml vs 13.2 ± 4.4 ng/ml, respectively; P = 0.302). In the subgroup of women with deep infiltrating endometriosis (n = 142) and adenomyosis (n = 100), the mean progesterone level was 13.1 ± 4.1 ng/ml and 12.6 ± 3.7 ng/ml, respectively, with no significant difference compared to endometriosis-free patients. After adjusting for BMI, parity, duration of infertility, tobacco use, and geographic origin, neither the presence of endometriosis (coefficient 0.38; 95% CI: -0.63 to 1.40; P = 0.457) nor the presence of adenomyosis (coefficient 0.97; 95% CI: -0.24 to 2.19; P = 0.114) was associated with the progesterone level on the day of HRT-FET. Among women who did not conceive, there was no significant difference in the mean progesterone level on the day of the HRT-FET between those with endometriosis and those without (P = 0.709). LIMITATIONS, REASONS FOR CAUTION The primary limitation of our study is associated with its observational design. Extrapolating our results to other laboratories or different routes and/or dosages of administering progesterone also requires validation. WIDER IMPLICATIONS OF THE FINDINGS This study shows that patients diagnosed with endometriosis do not require higher progesterone levels on the day of a frozen blastocyst transfer to achieve a LB in hormonal replacement therapy cycles. STUDY FUNDING/COMPETING INTEREST(S) None declared. TRIAL REGISTRATION NUMBER N/A.
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Affiliation(s)
- M Bourdon
- Faculté de Santé, University of Paris Cité, Paris, France
- Department of Gynecology, Obstetrics II, and Reproductive Medicine, Assistance Publique-Hôpitaux de Paris (AP-HP), Hôpital Universitaire Paris Centre (HUPC), Centre Hospitalier Universitaire (CHU) Cochin, Paris, France
- Department of Development, Reproduction, and Cancer, Cochin Institute, INSERM U1016, Paris, France
| | - M Sorel
- Department of Gynecology, Obstetrics II, and Reproductive Medicine, Assistance Publique-Hôpitaux de Paris (AP-HP), Hôpital Universitaire Paris Centre (HUPC), Centre Hospitalier Universitaire (CHU) Cochin, Paris, France
| | - C Maignien
- Department of Gynecology, Obstetrics II, and Reproductive Medicine, Assistance Publique-Hôpitaux de Paris (AP-HP), Hôpital Universitaire Paris Centre (HUPC), Centre Hospitalier Universitaire (CHU) Cochin, Paris, France
| | - J Guibourdenche
- Faculté de Santé, University of Paris Cité, Paris, France
- Department of Biological Endocrinology, Assistance Publique-Hôpitaux de Paris (AP-HP), Hôpital Universitaire Paris Centre (HUPC), Centre Hospitalier Universitaire (CHU) Cochin, Paris, France
| | - C Patrat
- Faculté de Santé, University of Paris Cité, Paris, France
- Department of Histology and Reproductive Biology, Assistance Publique-Hôpitaux de Paris (AP-HP), Hôpital Universitaire Paris Centre (HUPC), Centre Hospitalier Universitaire (CHU) Cochin, Paris, France
| | - L Marcellin
- Faculté de Santé, University of Paris Cité, Paris, France
- Department of Gynecology, Obstetrics II, and Reproductive Medicine, Assistance Publique-Hôpitaux de Paris (AP-HP), Hôpital Universitaire Paris Centre (HUPC), Centre Hospitalier Universitaire (CHU) Cochin, Paris, France
- Department of Development, Reproduction, and Cancer, Cochin Institute, INSERM U1016, Paris, France
| | - T Jobin
- Department of Gynecology, Obstetrics II, and Reproductive Medicine, Assistance Publique-Hôpitaux de Paris (AP-HP), Hôpital Universitaire Paris Centre (HUPC), Centre Hospitalier Universitaire (CHU) Cochin, Paris, France
| | - C Chapron
- Faculté de Santé, University of Paris Cité, Paris, France
- Department of Gynecology, Obstetrics II, and Reproductive Medicine, Assistance Publique-Hôpitaux de Paris (AP-HP), Hôpital Universitaire Paris Centre (HUPC), Centre Hospitalier Universitaire (CHU) Cochin, Paris, France
- Department of Development, Reproduction, and Cancer, Cochin Institute, INSERM U1016, Paris, France
| | - P Santulli
- Faculté de Santé, University of Paris Cité, Paris, France
- Department of Gynecology, Obstetrics II, and Reproductive Medicine, Assistance Publique-Hôpitaux de Paris (AP-HP), Hôpital Universitaire Paris Centre (HUPC), Centre Hospitalier Universitaire (CHU) Cochin, Paris, France
- Department of Development, Reproduction, and Cancer, Cochin Institute, INSERM U1016, Paris, France
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Boynukalin FK, Tohma YA, Yarkıner Z, Gultomruk M, Bozdag G, Ozkavukcu S, Bahçeci M, Demir B. Individualized luteal phase support in frozen-thawed embryo transfer after intramuscular progesterone administration might rectify live birth rate. Front Endocrinol (Lausanne) 2024; 15:1412185. [PMID: 39006366 PMCID: PMC11239543 DOI: 10.3389/fendo.2024.1412185] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2024] [Accepted: 06/07/2024] [Indexed: 07/16/2024] Open
Abstract
Background The serum P concentrations are suggested to have an impact on pregnancy outcome. However there is no consensus about the optimal progesterone cut-off during the luteal phase. Few studies evaluated the effectiveness of a "rescue protocol" for low serum P concentrations and most of these studies used vaginal progesterone administration. There is paucity of data on the effectiveness of rescue protocol using intramuscular progesterone (IM-P) in frozen-thawed embryo transfer (FET). Methods This study is a retrospective cohort study included 637 single or double blastocyst FETs with artificially prepared endometrium receiving 100 mg IM progesterone (P) after incremental estrogen treatment. Serum P concentrations were evaluated using blood samples obtained 117-119 hours after the first IM-P administration and 21 ± 2 hours after the last IM-P administration. Patients with serum P concentrations <20.6 ng/ml on the ET day were administrated 400 mg vaginal progesterone for rescue. Results Demographic and cycle characteristics were similar between patients receiving rescue vaginal P (embryo transfer (ET)-day P concentration < 20.6 ng/ml) and patients who did not need rescue vaginal P (ET-day P concentration ≥ 20.6 ng/ml). Clinical pregnancy, miscarriage, and live birth rates were similar between two groups: 52.9%(45/85) vs 59.6%(326/552), p=0.287; 11.1%(5/45) vs 14.1%(46/326), p=0.583; and 47.1%(40/85) vs 50.7%(280/552), p=0.526, respectively. Logistic regression analysis revealed that the female age (p = 0.008, OR=0.942, 95% CI = 0.902-0.984) and embryo quality (ref: good quality for moderate: p=0.02, OR=0.469, 95% CI =0.269-0.760; for poor: p=0.013, OR= 0.269, 95% CI = 0.092-0.757) were independent variables for live birth. Following rescue protocol implementation, ET-day P concentration was not a significant predictor of live birth. Conclusions Rescue vaginal P administration for low ET day serum P concentrations following IM-P yields comparable live birth rates.
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Affiliation(s)
- Fazilet Kübra Boynukalin
- Infertility Department, Bahçeci Fulya IVF Center, Istanbul, Türkiye
- Department of Obstetrics and Gynecology, Faculty of Medicine, Üsküdar University, Istanbul, Türkiye
| | - Yusuf Aytac Tohma
- Infertility Department, Bahçeci Ankara IVF Center, Ankara, Türkiye
- Department of Obstetrics and Gynecology, Faculty of Medicine, Atılım University, Ankara, Türkiye
| | - Zalihe Yarkıner
- Department of Basic Sciences and Humanities, Faculty of Arts and Sciences, Cyprus International University, Nicosia, Cyprus
| | - Meral Gultomruk
- Infertility Department, Bahçeci Fulya IVF Center, Istanbul, Türkiye
| | - Gürkan Bozdag
- Infertility Department, Bahçeci Fulya IVF Center, Istanbul, Türkiye
| | - Sinan Ozkavukcu
- Infertility Department, Bahçeci Ankara IVF Center, Ankara, Türkiye
| | - Mustafa Bahçeci
- Infertility Department, Bahçeci Fulya IVF Center, Istanbul, Türkiye
| | - Berfu Demir
- Infertility Department, Bahçeci Ankara IVF Center, Ankara, Türkiye
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Alsbjerg B, Jensen MB, Elbaek HO, Laursen R, Povlsen BB, Anderson R, Yarali H, Humaidan P. Midluteal serum estradiol levels are associated with live birth rates in hormone replacement therapy frozen embryo transfer cycles: a cohort study. Fertil Steril 2024; 121:1000-1009. [PMID: 38604265 DOI: 10.1016/j.fertnstert.2024.04.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2023] [Revised: 04/03/2024] [Accepted: 04/03/2024] [Indexed: 04/13/2024]
Abstract
OBJECTIVE To study whether midluteal serum estradiol (E2) levels are associated with the live birth rate in hormone replacement therapy frozen embryo transfer (HRT-FET) cycles in patients with optimal midluteal serum progesterone (P4) levels. DESIGN Observational prospective cohort study. SETTING Public fertility clinic. PATIENTS A total of 412 women had an HRT-FET cycle single blastocyst transfer from January 2020 to November 2022. INTERVENTION The HRT-FET cycle priming regimen included oral E2 (6mg/24 h) administered in the evening, followed by vaginal P4 (400mg/12 h). Serum E2 and P4 levels were measured using a standardized method, 2-4 hours after the latest P4 administration and 9-14 hours after E4 administration on the day of blastocyst transfer, day 6 of P4 administration. Patients with serum P4 levels (<11 ng/mL [35 nmol/L]) on the day of transfer received additional rectal P4 (400mg/12 h). No additional E2 dose was administered. MAIN OUTCOME MEASURES The primary outcome was the live birth rate (LBR) in relation to E2 levels at blastocyst transfer day. RESULTS The optimal serum E2 levels correlating with ongoing pregnancy were ≥292 pg/mL and <409 pg/mL (≥1,070 pmol/L and <1,500 pmol/L). The LBR was 59% (60/102) when E2 levels were within this range, whereas a significantly lower LBR of 39% (101/260) was seen in patients when E2 levels were <292 pg/mL (<1,070 pmol/L) and of 28% (14/50) when E2 levels were ≥409 pg/mL (≥1,500 pg/mL). In a logistic regression analysis, adjusting for serum P4 level ≥11 ng/mL or <11 ng/mL (≥35 nmol or <35 nmol/L) on the day of transfer, body mass index, age at oocyte retrieval, day 5 or 6 vitrified blastocysts, and blastocyst score, the adjusted risk difference of live birth was -0.21 (-0.32; -0.10) when the E2 level was <292 pg/mL (<1,070 pmol/L) and -0.31 (-0.45; -0.18) when the E2 level was ≥409 pg/mL (≥1,500 pmol/L) compared with E2 levels ≥292 pg/mL and <409 pg/mL (≥1,070 and <1,500 pmol/L). Importantly, only 25% of patents had optimal levels. CONCLUSION The study shows a significant association between serum E2 levels and reproductive outcomes in an HRT-FET cohort in which optimal serum P4 levels were secured. Midluteal serum E2 levels are associated with the LBR in HRT-FET cycles, and E2 levels should neither be too high nor too low. CLINICAL TRIAL REGISTRATION NUMBER EudraCT No.: 2019-001539-29.
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Affiliation(s)
- Birgit Alsbjerg
- The Fertility Clinic, Skive Regional Hospital, Skive, Denmark; Department of Clinical Medicine, Aarhus University, Aarhus, Denmark.
| | | | | | - Rita Laursen
- The Fertility Clinic, Skive Regional Hospital, Skive, Denmark
| | | | - Richard Anderson
- Centre for Reproductive Health, Institute for Repair and Regeneration, University of Edinburgh, Edinburgh, United Kingdom
| | - Harkan Yarali
- Department of Obstetrics and Gynaecology, Hacettepe University School of Medicine, Ankara, Turkey; Anatolia IVF and Women Health Centre, Ankara, Turkey
| | - Peter Humaidan
- The Fertility Clinic, Skive Regional Hospital, Skive, Denmark; Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
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Bourdon M, Guihard C, Maignien C, Patrat C, Guibourdenche J, Chapron C, Santulli P. Intra-individual variability of serum progesterone levels on the day of frozen blastocyst transfer in hormonal replacement therapy cycles. Hum Reprod 2024; 39:742-748. [PMID: 38332539 DOI: 10.1093/humrep/deae015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2023] [Revised: 01/11/2024] [Indexed: 02/10/2024] Open
Abstract
STUDY QUESTION Is there a significant intra-individual variability of serum progesterone levels on the day of single blastocyst Hormone Replacement Therapy-Frozen Embryo Transfer (HRT-FET) between two consecutive cycles? SUMMARY ANSWER No significant intra-individual variability of serum progesterone (P) levels was noted between two consecutive HRT-FET cycles. WHAT IS KNOWN ALREADY In HRT-FET cycles, a minimum P level on the day of embryo transfer is necessary to optimise reproductive outcomes. In a previous study by our team, a threshold of 9.8 ng/ml serum P was identified as significantly associated with the live birth rates in single autologous blastocyst transfers under HRT using micronized vaginal progesterone (MVP). Such patients may benefit from an intensive luteal phase support (LPS) using other routes of P administration in addition to MVP. A crucial question in the way towards individualising LPS is whether serum P measurements are reproducible for a given patient in consecutive HRT-FET cycles, using the same LPS. STUDY DESIGN, SIZE, DURATION We conducted an observational cohort study at the university-based reproductive medicine centre of our institution focusing on women who underwent at least two consecutive single autologous blastocyst HRT-FET cycles between January 2019 and March 2020. PARTICIPANTS/MATERIALS, SETTING, METHODS Patients undergoing two consecutive single autologous blastocyst HRT-FET cycles using exogenous oestradiol and vaginal micronized progesterone for endometrial preparation were included. Serum progesterone levels were measured on the morning of the Frozen Embryo Transfer (FET), by a single laboratory. The two measurements of progesterone levels performed on the day of the first (FET1) and the second FET (FET2) were compared to evaluate the intra-individual variability of serum P levels. Paired statistical analyses were performed, as appropriate. MAIN RESULTS AND THE ROLE OF CHANCE Two hundred and sixty-four patients undergoing two consecutive single autologous blastocyst HRT-FET were included. The mean age of the included women was 35.0 ± 4.2 years. No significant intra-individual variability was observed between FET1 and FET2 (mean progesterone level after FET1: 13.4 ± 5.1 ng/ml vs after FET2: 13.9 ± 5.0; P = 0.08). The characteristics of the embryo transfers were similar between the first and the second FET. Forty-nine patients (18.6%) had discordant progesterone levels (defined as one progesterone measurement > and one ≤ to the threshold of 9.8 ng/ml) between FET1 and FET2. There were 37/264 women (14.0%) who had high intra-individual variability (defined as a difference in serum progesterone values >75th percentile (6.0 ng/ml)) between FET1 and FET2. No specific clinical parameter was associated with a high intra-individual variability nor a discordant P measurement. LIMITATIONS, REASONS FOR CAUTION This study is limited by its retrospective design. Moreover, only women undergoing autologous blastocyst HRT-FET with MVP were included, thereby limiting the extrapolation of the study findings to other routes of P administration and other kinds of endometrial preparation for FET. WIDER IMPLICATIONS OF THE FINDINGS No significant intra-individual variability was noted. The serum progesterone level appeared to be reproducible in >80% of cases. These findings suggest that the serum progesterone level measured on the day of the first transfer can be used to individualize luteal phase support in subsequent cycles. STUDY FUNDING/COMPETING INTEREST(S) No funding or competing interests. TRIAL REGISTRATION NUMBER N/A.
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Affiliation(s)
- M Bourdon
- Faculté de Médecine, Université de Paris Cité, Paris, France
- Department of Gynecology Obstetrics II and Reproductive Medicine (Professor Chapron), Assistance Publique-Hôpitaux de Paris (AP-HP), Hôpital Universitaire Paris Centre (HUPC), Centre Hospitalier Universitaire (CHU) Cochin, Paris, France
- Department "Development, Reproduction and Cancer", Cochin Institute, INSERM U1016, Paris, France
| | - C Guihard
- Faculté de Médecine, Université de Paris Cité, Paris, France
- Department of Gynecology Obstetrics II and Reproductive Medicine (Professor Chapron), Assistance Publique-Hôpitaux de Paris (AP-HP), Hôpital Universitaire Paris Centre (HUPC), Centre Hospitalier Universitaire (CHU) Cochin, Paris, France
| | - C Maignien
- Faculté de Médecine, Université de Paris Cité, Paris, France
- Department of Gynecology Obstetrics II and Reproductive Medicine (Professor Chapron), Assistance Publique-Hôpitaux de Paris (AP-HP), Hôpital Universitaire Paris Centre (HUPC), Centre Hospitalier Universitaire (CHU) Cochin, Paris, France
| | - C Patrat
- Faculté de Médecine, Université de Paris Cité, Paris, France
- Department "Development, Reproduction and Cancer", Cochin Institute, INSERM U1016, Paris, France
- Department of Reproductive Biology-CECOS (Professor Patrat), Assistance Publique-Hôpitaux de Paris (AP-HP), Hôpital Universitaire Paris Centre (HUPC), Centre Hospitalier Universitaire (CHU) Cochin, Paris, France
| | - J Guibourdenche
- Faculté de Médecine, Université de Paris Cité, Paris, France
- Department of Biological Endocrinology, Assistance Publique-Hôpitaux de Paris (AP-HP), Hôpital Universitaire Paris Centre (HUPC), Centre Hospitalier Universitaire (CHU) Cochin, Paris, France
| | - C Chapron
- Faculté de Médecine, Université de Paris Cité, Paris, France
- Department of Gynecology Obstetrics II and Reproductive Medicine (Professor Chapron), Assistance Publique-Hôpitaux de Paris (AP-HP), Hôpital Universitaire Paris Centre (HUPC), Centre Hospitalier Universitaire (CHU) Cochin, Paris, France
- Department "Development, Reproduction and Cancer", Cochin Institute, INSERM U1016, Paris, France
| | - P Santulli
- Faculté de Médecine, Université de Paris Cité, Paris, France
- Department of Gynecology Obstetrics II and Reproductive Medicine (Professor Chapron), Assistance Publique-Hôpitaux de Paris (AP-HP), Hôpital Universitaire Paris Centre (HUPC), Centre Hospitalier Universitaire (CHU) Cochin, Paris, France
- Department "Development, Reproduction and Cancer", Cochin Institute, INSERM U1016, Paris, France
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Lawrenz B, Kalafat E, Ata B, Del Gallego R, Melado L, Elkhatib I, Fatemi H. The combination of dydrogesterone and micronized vaginal progesterone can render serum progesterone level measurements on the day of embryo transfer and rescue attempts unnecessary in an HRT FET cycle. J Assist Reprod Genet 2024; 41:885-892. [PMID: 38372882 PMCID: PMC11052972 DOI: 10.1007/s10815-024-03049-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2023] [Accepted: 01/30/2024] [Indexed: 02/20/2024] Open
Abstract
PURPOSE To evaluate the role of serum progesterone (P4) on the day of embryo transfer (ET) when dydrogesterone (DYD) and micronized vaginal progesterone (MVP) are combined as luteal phase support (LPS) in a hormone replacement therapy (HRT) frozen ET (FET) cycles. METHODS Retrospective study, including single euploid HRT FET cycles with DYD and MVP as LPS and P4 measurement on ET day. Initially, patients with P4 levels < 10 ng/ml increased MVP to 400 mg/day; this "rescue" was abandoned later. RESULTS 560 cycles of 507 couples were included. In 275 women, serum P4 level was < 10 ng/ml on the ET day. Among those with low P4 levels, MVP dose remained unchanged in 65 women (11.6%) and was increased in 210 women (37.5%). Women with P4 levels ≥ 10 ng/ml continued LPS without modification. Overall pregnancy rates in these groups were 61.5% (40/65), 54.8% (115/210), and 48.4% (138/285), respectively (p = n.s.). Association of serum P4 levels with ongoing pregnancy rates was analyzed in women without any additional MVP regardless of serum P4 levels (n = 350); multivariable analysis (adjusted for age, BMI, embryo quality (EQ)) did not show a significant association of serum P4 levels with OPR (OR 0.96, 95% CI 0.90-1.02; p = 0.185). Using inverse probability treatment weights, regression analysis in the weighted sample showed no significant association between P4 treatment groups and OP. Compared to fair EQ, the transfer of good EQ increased (OR 1.61, 95% CI 1.22-2.15; p = 0.001) and the transfer of a poor EQ decreased the odds of OP (OR 0.73, 95% CI 0.55-0.97; p = 0.029). CONCLUSION In HRT FET cycle, using LPS with 300 mg/day MVP and 30 mg/day DYD, it appears that serum P4 measurement and increase of MVP in patients with P4 < 10 ng/ml are not necessary.
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Affiliation(s)
- B Lawrenz
- ART Fertility Clinic, Royal Marina Village, B22-23, POB: 60202, Abu Dhabi, UAE.
- Department of Reproductive Medicine, UZ Gent, Gent, Belgium.
| | - E Kalafat
- ART Fertility Clinic, Royal Marina Village, B22-23, POB: 60202, Abu Dhabi, UAE
- Faculty of Medicine, Department of Obstetrics & Gynecology, Koc University, Istanbul, Turkey
| | - B Ata
- Faculty of Medicine, Department of Obstetrics & Gynecology, Koc University, Istanbul, Turkey
- ART Fertility Clinic, Jumeirah St-Umm Suqeim-Umm Suqeim 3, Dubai, UAE
| | - R Del Gallego
- ART Fertility Clinic, Royal Marina Village, B22-23, POB: 60202, Abu Dhabi, UAE
| | - L Melado
- ART Fertility Clinic, Royal Marina Village, B22-23, POB: 60202, Abu Dhabi, UAE
| | - I Elkhatib
- ART Fertility Clinic, Royal Marina Village, B22-23, POB: 60202, Abu Dhabi, UAE
- School of Biosciences, University of Kent, Canterbury, UK
| | - H Fatemi
- ART Fertility Clinic, Royal Marina Village, B22-23, POB: 60202, Abu Dhabi, UAE
- ART Fertility Clinic, Jumeirah St-Umm Suqeim-Umm Suqeim 3, Dubai, UAE
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Loreti S, Roelens C, Drakopoulos P, De Munck N, Tournaye H, Mackens S, Blockeel C. Circadian serum progesterone variations on the day of frozen embryo transfer in artificially prepared cycles. Reprod Biomed Online 2024; 48:103601. [PMID: 37992522 DOI: 10.1016/j.rbmo.2023.103601] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2023] [Revised: 09/14/2023] [Accepted: 10/05/2023] [Indexed: 11/24/2023]
Abstract
RESEARCH QUESTION What is the intra-day variation of serum progesterone related to vaginal progesterone administration on the day of frozen embryo transfer (FET) in an artificial cycle? DESIGN A prospective cohort study was conducted including 22 patients undergoing a single blastocyst artificial cycle (AC)-FET from August to December 2022. Endometrial preparation was achieved by administering oestradiol valerate (2 mg three times daily) and consecutively micronized vaginal progesterone (MVP; 400 mg twice daily). A blastocyst FET was performed on the 6th day of MVP administration. Serum progesterone concentrations were measured on the day of transfer at 08:00, 12:00, 16:00 and 20:00 hours. The first and last blood samples were collected just before MVP was administered. RESULTS The mean age and body mass index of the study population were 33.95 ± 3.98 years and 23.10 ± 1.95 kg/m2. The mean P-values at 08:00, 12:00, 16:00 and 20:00 hours were 11.72 ± 4.99, 13.59 ± 6.33, 10.23 ± 3.81 and 9.28 ± 3.09 ng/ml, respectively. A significant decline, of 2.41 ng/ml (95% confidence interval 0.81-4.00), was found between the first and last progesterone measurements. CONCLUSION A statistically significant intra-day variation of serum progesterone concentrations on the day of FET in artificially prepared cycles was observed. This highlights the importance of a standardized procedure for the timing of progesterone measurement on the day of AC-FET. Of note, the study results are applicable only to women using MVP for luteal phase support; therefore it is necessary to confirm its validity in comparison with the different existing administration routes of progesterone.
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Affiliation(s)
- Sara Loreti
- Brussels IVF, Universitair Ziekenhuis Brussel, Brussels, Belgium; Infertility Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy.
| | - Caroline Roelens
- Brussels IVF, Universitair Ziekenhuis Brussel, Brussels, Belgium
| | - Panagiotis Drakopoulos
- Brussels IVF, Universitair Ziekenhuis Brussel, Brussels, Belgium; IVF Greece, Athens, Greece
| | - Neelke De Munck
- Brussels IVF, Universitair Ziekenhuis Brussel, Brussels, Belgium
| | - Herman Tournaye
- Brussels IVF, Universitair Ziekenhuis Brussel, Brussels, Belgium
| | - Shari Mackens
- Brussels IVF, Universitair Ziekenhuis Brussel, Brussels, Belgium
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Olgan S, Dirican EK, Ozsipahi AC, Sakinci M, Humaidan P. A model for predicting low progesterone levels on the day of embryo transfer in hormonally prepared vitrified-warmed embryo transfer cycles: A secondary analysis of a prospective cohort study. J Obstet Gynaecol Res 2023; 49:2962-2968. [PMID: 37814426 DOI: 10.1111/jog.15807] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2023] [Accepted: 09/24/2023] [Indexed: 10/11/2023]
Abstract
AIM To develop a model that predicts low progesterone (P) levels on the day of embryo transfer (ET) based on patient and cycle characteristics, including serum estradiol (E2 ) concentration after vaginal administration of micronized E2 for endometrial preparation. METHODS A prospective cohort of 193 patients scheduled for cryopreserved blastocyst transfer during an artificial endometrial preparation cycle, using micronized E2 vaginally for first 4 days (4 mg/day), followed by oral administration (6 mg/day). Blood sampling for E2 was performed prospectively on day-5 of vaginal administration and analysis was performed retrospectively. On sixth day of P treatment (daily 300 mg of vaginal micronized P tablets), P levels were measured on ET day. Primary outcome measure was serum P levels after vaginal E2 administration. RESULTS Patients with low P levels on the day of ET (<7.8 ng/mL, 25th percentile) were heavier (p < 0.001) and exhibited lower day 5 serum E2 levels (p < 0.001) compared with patients with adequate P levels. Multivariate linear regression analysis revealed that weight (p = 0.003) and day 5 E2 levels (p < 0.001) were independently associated with the P levels. The sensitivity, specificity, and positive and negative predictive values (%) were 71.4, 55.6, 35.4, and 85.1 for weight ≥ 65 kg; 71.4, 61.8, 38.9, and 86.4 for day 5 E2 ≤ 1615 pg/mL; 59.2, 83.3, 54.7, and 85.7 for the combination of these two variables; and 82.9, 62.5, 54.7, and 87.0 for the sequential inclusion of these variables, respectively. CONCLUSIONS Low day 5 E2 levels following vaginal administration and high weight are independently associated with low P levels on the day of ET. Predictive performance is enhanced when these variables are considered sequentially or in combination.
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Affiliation(s)
- Safak Olgan
- Fertility Clinic, Memorial Hospital, Antalya, Turkey
- Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, Akdeniz University School of Medicine, Antalya, Turkey
- Department of Obstetrics and Gynecology, Akdeniz University School of Medicine, Antalya, Turkey
- Department of Obstetrics and Gynecology, Uskudar University School of Medicine, Istanbul, Turkey
| | - Enver Kerem Dirican
- Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, Akdeniz University School of Medicine, Antalya, Turkey
- Department of Obstetrics and Gynecology, Akdeniz University School of Medicine, Antalya, Turkey
| | - Arif Can Ozsipahi
- Department of Obstetrics and Gynecology, Akdeniz University School of Medicine, Antalya, Turkey
| | - Mehmet Sakinci
- Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, Akdeniz University School of Medicine, Antalya, Turkey
- Department of Obstetrics and Gynecology, Akdeniz University School of Medicine, Antalya, Turkey
| | - Peter Humaidan
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
- The Fertility Clinic, Skive Regional Hospital, Resenvej, Skive, Denmark
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Alsbjerg B, Jensen MB, Povlsen BB, Elbaek HO, Laursen RJ, Kesmodel US, Humaidan P. Rectal progesterone administration secures a high ongoing pregnancy rate in a personalized Hormone Replacement Therapy Frozen Embryo Transfer (HRT-FET) protocol: a prospective interventional study. Hum Reprod 2023; 38:2221-2229. [PMID: 37759346 PMCID: PMC10628493 DOI: 10.1093/humrep/dead185] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2023] [Revised: 08/11/2023] [Indexed: 09/29/2023] Open
Abstract
STUDY QUESTION Can supplementation with rectal administration of progesterone secure high ongoing pregnancy rates (OPRs) in patients with low serum progesterone (P4) on the day of blastocyst transfer (ET)? SUMMARY ANSWER Rectally administered progesterone commencing on the ET day secures high OPRs in patients with serum P4 levels below 35 nmol/l (11 ng/ml). WHAT IS KNOWN ALREADY Low serum P4 levels at peri-implantation in Hormone Replacement Therapy Frozen Embryo Transfer (HRT-FET) cycles impact reproductive outcomes negatively. However, studies have shown that patients with low P4 after a standard vaginal progesterone treatment can obtain live birth rates (LBRs) comparable to patients with optimal P4 levels if they receive additionalsubcutaneous progesterone, starting around the day of blastocyst transfer. In contrast, increasing vaginal progesterone supplementation in low serum P4 patients does not increase LBR. Another route of administration rarely used in ART is the rectal route, despite the fact that progesterone is well absorbed and serum P4 levels reach a maximum level after ∼2 h. STUDY DESIGN, SIZE, DURATION This prospective interventional study included a cohort of 488 HRT-FET cycles, in which a total of 374 patients had serum P4 levels ≥35 nmol/l (11 ng/ml) at ET, and 114 patients had serum P4 levels <35 nmol/l (11 ng/ml). The study was conducted from January 2020 to November 2022. PARTICIPANTS/MATERIALS, SETTING, METHODS Patients underwent HRT-FET in a public Fertility Clinic, and endometrial preparation included oral oestradiol (6 mg/24 h), followed by vaginal micronized progesterone, 400 mg/12 h. Blastocyst transfer and P4 measurements were performed on the sixth day of progesterone administration. In patients with serum P4 <35 nmol/l (11 ng/ml), 'rescue' was performed by rectal administration of progesterone (400 mg/12 h) starting that same day. In pregnant patients, rectal administration continued until Week 8 of gestation, and oestradiol and vaginal progesterone treatment continued until Week 10 of gestation. MAIN RESULTS AND THE ROLE OF CHANCE Among 488 HRT-FET single blastocyst transfers, the mean age of the patients at oocyte retrieval (OR) was 30.9 ± 4.6 years and the mean BMI at ET 25.1 ± 3.5 kg/m2. The mean serum P4 level after vaginal progesterone administration on the day of ET was 48.9 ± 21.0 nmol/l (15.4 ± 6.6 ng/ml), and a total of 23% (114/488) of the patients had a serum P4 level lower than 35 nmol/l (11 ng/ml). The overall, positive hCG rate, clinical pregnancy rate, OPR week 12, and total pregnancy loss rate were 66% (320/488), 54% (265/488), 45% (221/488), and 31% (99/320), respectively. There was no significant difference in either OPR week 12 or total pregnancy loss rate between patients with P4 ≥35 nmol/l (11 ng/ml) and patients with P4 <35 nmol/l, who received rescue in terms of rectally administered progesterone, 45% versus 46%, P = 0.77 and 30% versus 34%, P = 0.53, respectively. OPR did not differ whether patients had initially low P4 and rectal rescue or were above the P4 cut-off. Logistic regression analysis showed that only age at OR and blastocyst scoring correlated with OPR week 12, independently of other factors like BMI and vitrification day of blastocysts (Day 5 or 6). LIMITATIONS, REASONS FOR CAUTION In this study, vaginal micronized progesterone pessaries, a solid pessary with progesterone suspended in vegetable hard fat, were used vaginally as well as rectally. It is unknown whether other vaginal progesterone products, such as capsules, gel, or tablet, could be used rectally with the same rescue effect. WIDER IMPLICATIONS OF THE FINDINGS A substantial part of HRT-FET patients receiving vaginal progesterone treatment has lowserum P4. Adding rectally administered progesterone in these patients increases the reproductive outcome. Importantly, rectal progesterone administration is considered convenient, and progesterone pessaries are easy to administer rectally and of low cost. STUDY FUNDING/COMPETING INTEREST(S) Gedeon Richter Nordic supported the study with an unrestricted grant as well as study medication. B.A. has received unrestricted grant from Gedeon Richter Nordic and Merck and honoraria for lectures from Gedeon Richter, Merck, IBSA and Marckyrl Pharma. P.H. has received honoraria for lectures from Gedeon Richter, Merck, IBSA and U.S.K. has received grant from Gedeon Richter Nordic, IBSA and Merck for studies outside this work and honoraria for teaching from Merck and Thillotts Pharma AB and conference expenses covered by Merck. The other co-authors have no conflict of interest to declare. TRIAL REGISTRATION NUMBER (25) EudraCT no.: 2019-001539-29.
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Affiliation(s)
- B Alsbjerg
- The Fertility Clinic, Skive Regional Hospital, Skive, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - M B Jensen
- The Fertility Clinic, Skive Regional Hospital, Skive, Denmark
| | - B B Povlsen
- The Fertility Clinic, Skive Regional Hospital, Skive, Denmark
| | - H O Elbaek
- The Fertility Clinic, Skive Regional Hospital, Skive, Denmark
| | - R J Laursen
- The Fertility Clinic, Skive Regional Hospital, Skive, Denmark
| | - U S Kesmodel
- Department of Obstetrics and Gynaecology, Aalborg University Hospital, Aalborg, Denmark
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - P Humaidan
- The Fertility Clinic, Skive Regional Hospital, Skive, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
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Yin H, Jiang H, Zhu J, Wang C, Cao Z, Luan K, Wu Y. Association of serum progesterone levels on the transfer day with pregnancy outcomes in hormone replacement frozen-thawed cycles with oral dydrogesterone for strengthened luteal phase support. Taiwan J Obstet Gynecol 2023; 62:817-822. [PMID: 38008499 DOI: 10.1016/j.tjog.2023.05.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/03/2023] [Indexed: 11/28/2023] Open
Abstract
OBJECTIVE To investigate the relationship between serum progesterone (P) levels on the day of blastocyst transfer and pregnancy outcomes in frozen-thawed embryo transfer (FET) cycles using hormone replacement therapy (HRT) with oral dydrogesterone for strengthened luteal phase support (LPS). MATERIALS AND METHODS This was a retrospective study including 1176 FET cycles. All patients received 40 mg of intramuscular (IM) P daily for endometrium transformation plus oral dydrogesterone 10 mg BID from transfer day for strengthened LPS. Pregnancy outcomes were compared between serum P levels on the transfer day ≥10 ng/ml and <10 ng/ml. Furthermore, cycles were divided into 10 groups by deciles of P and ongoing pregnancy rate (OPR) was calculated in each group. Analyses using deciles of serum P were completed to see if these could create further prognostic power. RESULTS No differences were observed in clinical pregnancy rates (CPRs), OPRs and live birth rates (LBRs) between serum P levels ≥10 ng/ml and <10 ng/ml. Patients with serum P levels <5.65 ng/ml (10th percentile) had a significantly lower OPR (48.31% vs. 58.98%, p = 0.03) and LBR (43.22% vs. 57.75%, p = 0.003) than the rest of the patients. Multivariate logistic regression analysis showed serum P levels on the transfer day were not associated with pregnancy outcomes. CONCLUSION Measuring serum P levels on the day of HRT-FET is of clinical importance. Lower serum P levels impact the success of HRT-FET cycles, suggesting that there may be a threshold below which it is difficult to improve pregnancy outcomes via oral dydrogesterone to strengthen LPS.
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Affiliation(s)
- Huiqun Yin
- Reproductive Medicine Center, The 901st Hospital of the Joint Logistics Support Force of PLA, Hefei, China.
| | - Hong Jiang
- Reproductive Medicine Center, The 901st Hospital of the Joint Logistics Support Force of PLA, Hefei, China
| | - Jie Zhu
- Reproductive Medicine Center, The 901st Hospital of the Joint Logistics Support Force of PLA, Hefei, China
| | - Cunli Wang
- Reproductive Medicine Center, The 901st Hospital of the Joint Logistics Support Force of PLA, Hefei, China
| | - Zhenyi Cao
- Reproductive Medicine Center, The 901st Hospital of the Joint Logistics Support Force of PLA, Hefei, China
| | - Kang Luan
- Reproductive Medicine Center, The 901st Hospital of the Joint Logistics Support Force of PLA, Hefei, China
| | - Yan Wu
- Reproductive Medicine Center, The 901st Hospital of the Joint Logistics Support Force of PLA, Hefei, China
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Massarotti C, Ammar OF, Liperis G, Uraji J, Drakopoulos P, Labarta E, Maheshwari A, Cheong Y, Makieva S, Fraire-Zamora JJ. Progesterone in HRT-FET cycles: a game of hide and seek. Hum Reprod 2023; 38:2039-2043. [PMID: 37528050 DOI: 10.1093/humrep/dead153] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/03/2023] Open
Affiliation(s)
- Claudia Massarotti
- DINOGMI Department, University of Genoa, Academic Unit of Obstetrics and Gynecology, Genoa, Italy
- Physiopathology of Human Reproduction Unit, IRCCS Ospedale Policlinico San Martino, Genoa, Italy
| | - Omar F Ammar
- Biomaterials Cluster, Bernal Institute, University of Limerick, Limerick, Ireland
- School of Engineering, Faculty of Science and Engineering, University of Limerick, Limerick, Ireland
| | - George Liperis
- Westmead Fertility Centre, Institute of Reproductive Medicine, University of Sydney, Westmead, NSW, Australia
| | - Julia Uraji
- IVF Laboratory, TFP Düsseldorf GmbH, Düsseldorf, Germany
| | - Panagiotis Drakopoulos
- Brussels IVF, Universitair Ziekenhuis Brussel, Brussels, Belgium
- Institute of Life, IVF Unit, Athens, Greece
| | - Elena Labarta
- Human Reproduction Department, IVI RMA, Valencia, Spain
| | - Abha Maheshwari
- Aberdeen Fertility Centre, NHS Grampian, Aberdeen, Scotland, UK
| | - Ying Cheong
- Complete Fertility Centre, Southampton, England, UK
- Human Development and Health, Faculty of Medicine, University of Southampton, Southampton, England, UK
| | - Sofia Makieva
- Kinderwunschzentrum, Department of Reproductive Endocrinology, University Hospital of Zurich, Zurich, Switzerland
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Shekhar B, Mittal S, Majumdar G, Tiwari N, Majumdar A. Low serum progesterone on day of transfer adversely impacts ongoing pregnancy rates in hormonally prepared single blastocyst frozen embryo transfer cycles. Eur J Obstet Gynecol Reprod Biol 2023; 289:55-59. [PMID: 37639815 DOI: 10.1016/j.ejogrb.2023.08.016] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2023] [Revised: 07/06/2023] [Accepted: 08/15/2023] [Indexed: 08/31/2023]
Abstract
OBJECTIVE To evaluate if serum progesterone (P) levels on the day of transfer influence ongoing pregnancy rate (OPR) in hormonally prepared single blastocyst frozen embryo transfer (FET) cycles? STUDY DESIGN Single center prospective cohort study conducted between June 2021 and August 2022 analyzed 217 single good quality blastocyst FET cycles hormonally prepared with oral estradiol valerate and micronized vaginal progesterone 400 mg twice daily. RESULTS Mean serum P on the day of embryo transfer (ET) was 9.76 ± 5.19 ng/ml. Receiver operator curve (ROC) showed a significant predictive value of serum P levels on the day of ET for OPR, with an area under curve (AUC) (95 %CI) = 0.58 (0.49-0.66). Optimal serum P threshold for OPR was 7.7 ng/ml (Sensitivity 76.8%, Specificity 43.7%). 35.9% patients had serum P below this threshold. BMI was significantly higher (26.8 ± 3.7 vs 25.6 ± 4.3; p = 0.048) in patients with serum P < 7.7 ng/ml vs ≥ 7.7 ng/ml. OPR was significantly lower (24.4% vs 45.3%; p = 0.002) and clinical miscarriage rates significantly higher (37.9% vs 19.2%; p = 0.042) if serum P < 7.72 ng/ml vs ≥ 7.7 ng/ml. CONCLUSION This study found that serum P level on the day of transfer in hormonally prepared FET cycles was a significant predictor of OPR.
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Affiliation(s)
- Bhawani Shekhar
- Centre of IVF and Human Reproduction, Sir Ganga Ram Hospital, Rajinder Nagar, New Delhi 110060, India.
| | - Shweta Mittal
- Centre of IVF and Human Reproduction, Sir Ganga Ram Hospital, Rajinder Nagar, New Delhi 110060, India
| | - Gaurav Majumdar
- Centre of IVF and Human Reproduction, Sir Ganga Ram Hospital, Rajinder Nagar, New Delhi 110060, India
| | - Neeti Tiwari
- Centre of IVF and Human Reproduction, Sir Ganga Ram Hospital, Rajinder Nagar, New Delhi 110060, India
| | - Abha Majumdar
- Centre of IVF and Human Reproduction, Sir Ganga Ram Hospital, Rajinder Nagar, New Delhi 110060, India
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González-Foruria I, García S, Álvarez M, Racca A, Hernández M, Polyzos NP, Coroleu B. Elevated serum progesterone levels before frozen embryo transfer do not negatively impact reproductive outcomes: a large retrospective cohort study. Fertil Steril 2023; 120:597-604. [PMID: 37142050 DOI: 10.1016/j.fertnstert.2023.04.038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2022] [Revised: 04/24/2023] [Accepted: 04/26/2023] [Indexed: 05/06/2023]
Abstract
OBJECTIVE To evaluate whether patients with high-serum progesterone levels before frozen embryo transfer (FET) under hormonal replacement therapy present with worse reproductive outcomes. DESIGN A cohort retrospective study. SETTING A university-affiliated fertility center. PATIENT(S) A total of 3,183 FET cycles in patients receiving hormonal replacement therapy between March 2009 and December 2020 were included. The luteal phase was covered with 200 mg per 8 hours of vaginal micronized progesterone either alone or in combination with a daily subcutaneous injection of 25 mg of progesterone. A total of 1,360 cycles corresponded to frozen homologous embryo transfer (ET) (hom-FET), 1,024 were euploid ET (eu-FET) after preimplantation genetic testing for aneuploidies, and 799 cycles were frozen heterologous ET (het-FET). All patients had adequate serum progesterone levels (≥10.6 ng/mL) before the procedure. INTERVENTION(S) Frozen embryo transfer cycles. MAIN OUTCOME MEASURE(S) Clinical pregnancy, miscarriage, and live birth rates (LBRs). RESULTS Median (P25; P75) serum progesterone level before FET was 14.39 (12.43-17.49) ng/mL. Progesterone levels were significantly higher in the group under vaginal plus subcutaneous progesterone (15.96 [13.74-21.60] vs. 14.09 [12.19-16.95]). No differences in clinical pregnancy, miscarriage, and LBR were observed based on the use of vaginal or vaginal plus subcutaneous progesterone for each of the groups (hom-FET, eu-FET, and het-FET). Live birth rates were comparable among patients in the highest centile of serum progesterone levels (≥p90) (22.33 ng/mL) and the rest of the patients (p<90) (43.9% vs. 41.3%). Patients with progesterone levels ≥p90 presented lower body mass index than those in the lower centiles ( CONCLUSIONS Elevated serum progesterone levels before FET do not impair reproductive outcomes in patients receiving artificially prepared cycles with vaginal or vaginal plus subcutaneous progesterone.
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Affiliation(s)
- Iñaki González-Foruria
- Department of Obstetrics Gynecology and Reproductive Medicine, Dexeus University Hospital, Barcelona, Spain; Universitat de Vic - Universitat Central de Catalunya, Vic, Spain.
| | - Sandra García
- Department of Obstetrics Gynecology and Reproductive Medicine, Dexeus University Hospital, Barcelona, Spain
| | - Manuel Álvarez
- Department of Obstetrics Gynecology and Reproductive Medicine, Dexeus University Hospital, Barcelona, Spain
| | - Annalisa Racca
- Department of Obstetrics Gynecology and Reproductive Medicine, Dexeus University Hospital, Barcelona, Spain
| | - María Hernández
- Department of Obstetrics Gynecology and Reproductive Medicine, Dexeus University Hospital, Barcelona, Spain
| | - Nikolaos P Polyzos
- Department of Obstetrics Gynecology and Reproductive Medicine, Dexeus University Hospital, Barcelona, Spain
| | - Buenaventura Coroleu
- Department of Obstetrics Gynecology and Reproductive Medicine, Dexeus University Hospital, Barcelona, Spain
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Zhang Y, Fu X, Gao S, Gao S, Gao S, Ma J, Chen ZJ. Preparation of the endometrium for frozen embryo transfer: an update on clinical practices. Reprod Biol Endocrinol 2023; 21:52. [PMID: 37291605 DOI: 10.1186/s12958-023-01106-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2023] [Accepted: 05/23/2023] [Indexed: 06/10/2023] Open
Abstract
Over the past decade, the application of frozen-thawed embryo transfer treatment cycles has increased substantially. Hormone replacement therapy and the natural cycle are two popular methods for preparing the endometrium. Hormone replacement therapy is now used at the discretion of the doctors because it is easy to coordinate the timing of embryo thawing and transfer with the schedules of the in-vitro fertilization lab, the treating doctors, and the patient. However, current results suggest that establishing a pregnancy in the absence of a corpus luteum as a result of anovulation may pose significant maternal and fetal risks. Therefore, a 'back to nature' approach that advocates an expanded use of natural cycle FET in ovulatory women has been suggested. Currently, there is increasing interest in how the method of endometrial preparation may influence frozen embryo transfer outcomes specifically, especially when it comes to details such as different types of ovulation monitoring and different luteal support in natural cycles, and the ideal exogenous hormone administration route as well as the endocrine monitoring in hormone replacement cycles. In addition to improving implantation rates and ensuring the safety of the fetus, addressing these points will allow for individualized endometrial preparation, also as few cycles as possible would be canceled.
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Affiliation(s)
- Yiting Zhang
- Center for Reproductive Medicine, the Second Hospital, Cheeloo College of Medicine, Shandong University, Jinan, 250012, Shandong, China
- Key laboratory of Reproductive Endocrinology of Ministry of Education, Shandong University, Jinan, 250012, Shandong, China
- Shandong Key Laboratory of Reproductive Medicine, Jinan, 250012, Shandong, China
- Shandong Provincial Clinical Research Center for Reproductive Health, Jinan, 250012, Shandong, China
- Shandong Technology Innovation Center for Reproductive Health, Jinan, 250012, Shandong, China
- National Research Center for Assisted Reproductive Technology and Reproductive Genetics, Shandong University, Jinan, 250012, Shandong, China
| | - Xiao Fu
- Center for Reproductive Medicine, the Second Hospital, Cheeloo College of Medicine, Shandong University, Jinan, 250012, Shandong, China
- Key laboratory of Reproductive Endocrinology of Ministry of Education, Shandong University, Jinan, 250012, Shandong, China
- Shandong Key Laboratory of Reproductive Medicine, Jinan, 250012, Shandong, China
- Shandong Provincial Clinical Research Center for Reproductive Health, Jinan, 250012, Shandong, China
- Shandong Technology Innovation Center for Reproductive Health, Jinan, 250012, Shandong, China
- National Research Center for Assisted Reproductive Technology and Reproductive Genetics, Shandong University, Jinan, 250012, Shandong, China
| | - Shuli Gao
- Center for Reproductive Medicine, the Second Hospital, Cheeloo College of Medicine, Shandong University, Jinan, 250012, Shandong, China
- Key laboratory of Reproductive Endocrinology of Ministry of Education, Shandong University, Jinan, 250012, Shandong, China
- Shandong Key Laboratory of Reproductive Medicine, Jinan, 250012, Shandong, China
- Shandong Provincial Clinical Research Center for Reproductive Health, Jinan, 250012, Shandong, China
- Shandong Technology Innovation Center for Reproductive Health, Jinan, 250012, Shandong, China
- National Research Center for Assisted Reproductive Technology and Reproductive Genetics, Shandong University, Jinan, 250012, Shandong, China
| | - Shuzhe Gao
- Center for Reproductive Medicine, the Second Hospital, Cheeloo College of Medicine, Shandong University, Jinan, 250012, Shandong, China
- Key laboratory of Reproductive Endocrinology of Ministry of Education, Shandong University, Jinan, 250012, Shandong, China
- Shandong Key Laboratory of Reproductive Medicine, Jinan, 250012, Shandong, China
- Shandong Provincial Clinical Research Center for Reproductive Health, Jinan, 250012, Shandong, China
- Shandong Technology Innovation Center for Reproductive Health, Jinan, 250012, Shandong, China
- National Research Center for Assisted Reproductive Technology and Reproductive Genetics, Shandong University, Jinan, 250012, Shandong, China
| | - Shanshan Gao
- Center for Reproductive Medicine, the Second Hospital, Cheeloo College of Medicine, Shandong University, Jinan, 250012, Shandong, China.
- Key laboratory of Reproductive Endocrinology of Ministry of Education, Shandong University, Jinan, 250012, Shandong, China.
- Shandong Key Laboratory of Reproductive Medicine, Jinan, 250012, Shandong, China.
- Shandong Provincial Clinical Research Center for Reproductive Health, Jinan, 250012, Shandong, China.
- Shandong Technology Innovation Center for Reproductive Health, Jinan, 250012, Shandong, China.
- National Research Center for Assisted Reproductive Technology and Reproductive Genetics, Shandong University, Jinan, 250012, Shandong, China.
| | - Jinlong Ma
- Center for Reproductive Medicine, the Second Hospital, Cheeloo College of Medicine, Shandong University, Jinan, 250012, Shandong, China
- Key laboratory of Reproductive Endocrinology of Ministry of Education, Shandong University, Jinan, 250012, Shandong, China
- Shandong Key Laboratory of Reproductive Medicine, Jinan, 250012, Shandong, China
- Shandong Provincial Clinical Research Center for Reproductive Health, Jinan, 250012, Shandong, China
- Shandong Technology Innovation Center for Reproductive Health, Jinan, 250012, Shandong, China
- National Research Center for Assisted Reproductive Technology and Reproductive Genetics, Shandong University, Jinan, 250012, Shandong, China
| | - Zi-Jiang Chen
- Center for Reproductive Medicine, the Second Hospital, Cheeloo College of Medicine, Shandong University, Jinan, 250012, Shandong, China
- Key laboratory of Reproductive Endocrinology of Ministry of Education, Shandong University, Jinan, 250012, Shandong, China
- Shandong Key Laboratory of Reproductive Medicine, Jinan, 250012, Shandong, China
- Shandong Provincial Clinical Research Center for Reproductive Health, Jinan, 250012, Shandong, China
- Shandong Technology Innovation Center for Reproductive Health, Jinan, 250012, Shandong, China
- National Research Center for Assisted Reproductive Technology and Reproductive Genetics, Shandong University, Jinan, 250012, Shandong, China
- Shanghai Key Laboratory for Assisted Reproduction and Reproductive Genetics, Shanghai, 200135, China
- Center for Reproductive Medicine, Ren Ji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, 200135, China
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Lawrenz B, Ata B, Kalafat E, Melado L, ElKhatib I, Del Gallego R, Fatemi H. Are systemic progesterone levels in true natural cycle euploid frozen embryo transfers with luteal phase support predictive for ongoing pregnancy rates? Hum Reprod 2023:7169440. [PMID: 37196321 DOI: 10.1093/humrep/dead104] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2023] [Revised: 04/24/2023] [Indexed: 05/19/2023] Open
Abstract
STUDY QUESTION Are serum progesterone (P4) levels on the embryo transfer (ET) day predictive of ongoing pregnancy (OP) following a single euploid blastocyst transfer in a natural cycle (NC) when luteal phase support is routinely given? SUMMARY ANSWER In single euploid frozen ETs in NC, P4 levels on ET day are not predictive for OP, when luteal phase support (LPS) is routinely added after the ET. WHAT IS KNOWN ALREADY In an NC frozen embryo transfer (FET), P4 produced by the corpus luteum initiates secretory transformation of the endometrium and maintains pregnancy after implantation. There are ongoing controversies on the existence of a P4 cutoff level on the ET day, being predictive for the chance of OP as well as of the possible role of additional LPS after ET. Previous studies in NC FET cycles, evaluating and identifying P4 cutoff levels did not exclude embryo aneuploidy as a possible reason for failure. STUDY DESIGN, SIZE, DURATION This retrospective study analyzed single, euploid FET in NC, conducted in a tertiary referral IVF centre between September 2019 and June 2022, for which measurement of P4 on the day of ET and the treatment outcomes were available. Patients were only included once into the analysis. Outcome was defined as OP (ongoing clinical pregnancy with heartbeat, >12 weeks) or no-OP (not pregnant, biochemical pregnancy, early miscarriage). PARTICIPANTS/MATERIALS, SETTING, METHODS Patients with an ovulatory cycle and a single euploid blastocyst in an NC FET cycle were included. Cycles were monitored by ultrasound and repeated measurement of serum LH, estradiol, and P4. LH surge was identified when a rise of 180% above the previous level occurred and P4 levels of ≥1.0 ng/ml were regarded as confirmation of ovulation. The ET was scheduled on the fifth day after P4 rise and vaginal micronized P4 was started on the day of ET after P4 measurement. MAIN RESULTS AND THE ROLE OF CHANCE Of 266 patients included, 159 (59.8%) patients had an OP. There was no significant difference between the OP- and no-OP-groups for age, BMI, and day of embryo biopsy/cryopreservation (Day 5 versus Day 6). Furthermore, P4 levels were not different between the groups of patients with OP (P4: 14.8 ng/ml (IQR: 12.0-18.5 ng/ml)) versus no-OP (P4: 16.0 ng/ml (IQR: 11.6-18.9 ng/ml)) (P = 0.483), and no differences between both groups, when P4 levels were stratified into categories of P4 levels of >5 to ≤10, >10 to ≤15, >15 to ≤20, and >20 ng/ml (P = 0.341). However, both groups were significantly different for the embryo quality (EQ), defined by inner cell mass/trophectoderm, as well as when stratified into three EQ groups (good, fair, and poor) (P = 0.001 and 0.002, respectively). Stratified EQ groups remained the only significant parameter influencing OP in the uni- and multivariate analyses (P = 0.002 and P = 0.004, respectively), including age, BMI, and P4 levels (each in categories) and embryo cryopreservation day. Receiver operator characteristic curve for the prediction of an OP revealed an AUC of 0.648 when age, BMI and EQ groups were included into the model. The inclusion of P4 measurement on ET day into the model did not add any benefit for OP prediction (AUC = 0.665). LIMITATIONS, REASONS FOR CAUTION The retrospective design is a limitation. WIDER IMPLICATIONS OF THE FINDINGS Monitoring serum P4 levels can be abandoned in NC FET cycles with routine LPS as they do not seem to be predictive of live birth. STUDY FUNDING/COMPETING INTEREST(S) No external funding was used for this study. The authors state that they do not have any conflicts of interest. TRIAL REGISTRATION NUMBER N/A.
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Affiliation(s)
- B Lawrenz
- ART Fertility Clinic, Abu Dhabi, United Arab Emirates
| | - B Ata
- ART Fertility Clinic, Dubai, United Arab Emirates
- Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, Koc University, Istanbul, Turkey
| | - E Kalafat
- ART Fertility Clinic, Abu Dhabi, United Arab Emirates
- Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, Koc University, Istanbul, Turkey
| | - L Melado
- ART Fertility Clinic, Abu Dhabi, United Arab Emirates
| | - I ElKhatib
- ART Fertility Clinic, Abu Dhabi, United Arab Emirates
| | - R Del Gallego
- ART Fertility Clinic, Abu Dhabi, United Arab Emirates
| | - H Fatemi
- ART Fertility Clinic, Abu Dhabi, United Arab Emirates
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15
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Melado L, Lawrenz B, Vitorino RL, Patel R, Ruiz F, Marques LM, Bayram A, Elkhatib I, Fatemi H. Clinical and laboratory parameters associated with pregnancy outcomes in patients undergoing frozen euploid blastocyst transfer. Reprod Biomed Online 2023:S1472-6483(23)00153-0. [PMID: 37062636 DOI: 10.1016/j.rbmo.2023.02.014] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2022] [Revised: 01/03/2023] [Accepted: 02/27/2023] [Indexed: 03/09/2023]
Abstract
RESEARCH QUESTION Which factors impact on clinical pregnancy rate (CPR) and live birth rates (LBR) in euploid frozen embryo transfer (eFET) cycles? DESIGN Retrospective observational study including 1660 eFET cycles with 2439 euploid blastocysts, from November 2016 to December 2020. The impact of clinical and laboratory parameters on CPR, biochemical miscarriage rate (BMR), clinical miscarriage rate (CMR) and LBR was evaluated. RESULTS CPR per transfer was 63.4%, LBR per transfer 51.6%. CPR and LBR were significantly higher when double embryo transfer (DET) was performed (71.6% versus 57.7%, P < 0.001; 55.2% versus 49.1%, P = 0.016, respectively). However, pregnancy loss was significantly higher in the DET group (28.8% versus 22.8%, P = 0.02). When patients were classified by body mass index (BMI), no differences were observed for CPR, but CMR was lower (P < 0.001) and LBR higher (p = 0.031) for the normal BMI group. The natural cycle protocol revealed lower CMR (P < 0.001) and lower pregnancy loss (P < 0.001); subsequently, higher LBR (57.6%, 48.8%, 45.0%, P = 0.001) compared with hormonal replacement protocol and stimulated cycle. Day of trophectoderm biopsy affected CPR (P < 0.001) and LBR (P < 0.001), yet no differences were observed for BMR, CMR or pregnancy loss. The multivariate analysis showed that day 6/7 embryos had lower probabilities for pregnancy; overweight and obesity had a negative impact on LBR, and natural cycle improved LBR (adjusted odds ratio 1.445, 95% confidence interval 0.519-0.806). CONCLUSIONS Day of biopsy affected CPR, while BMI and endometrial preparation protocol were associated with LBR in eFET. DET should be discouraged as it will increase the risk of pregnancy loss. Women with higher BMI should be aware of the higher risk of pregnancy loss and lower LBR even though a euploid blastocyst is transferred.
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16
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Mackens S, Pais F, Drakopoulos P, Amghizar S, Roelens C, Van Landuyt L, Tournaye H, De Vos M, Blockeel C. Individualized luteal phase support using additional oral dydrogesterone in artificially prepared frozen embryo transfer cycles: is it beneficial? Reprod Biomed Online 2023:S1472-6483(23)00116-5. [PMID: 37012101 DOI: 10.1016/j.rbmo.2023.02.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2022] [Revised: 02/15/2023] [Accepted: 02/17/2023] [Indexed: 04/04/2023]
Abstract
RESEARCH QUESTION Does additional supplementation with oral dydrogesterone improve reproductive outcomes in patients with low serum progesterone concentrations on the day of frozen embryo transfer (FET) after artificial (HRT) endometrial preparation? DESIGN Retrospective, single-centre cohort study including 694 unique patients performing single blastocyst transfer in an HRT cycle. For luteal phase support, intravaginal micronized vaginal progesterone (MVP, 400 mg twice daily) was administered. Serum progesterone concentrations were assessed prior to FET and outco-mes were compared among patients with normal serum progesterone (≥8.8 ng/ml) continuing the routine protocol and patients with low serum progesterone (<8.8 ng/ml) who received additional oral dydrogesterone supplementation (10 mg three times daily) from the day after FET onwards. Primary outcome was live birth rate (LBR), with a multivariate regression model correcting for relevant confounders. RESULTS Normal serum progesterone concentrations were observed in 547/694 (78.8%) of patients who continued only MVP as planned, whereas low (<8.8 ng/ml) serum progesterone concentrations were detected in 147/694 (21.2%) patients who received additional oral dydrogesterone supplementation on top of MVP from the day after FET onwards. LBR was comparable between both groups: 37.8% for MVP-only versus 38.8% for MVP+OD (P = 0.84). The multivariate logistic regression model indicated that LBR was not significantly associated with the investigated approaches (adjusted odds ratio 1.01, 95% confidence interval 0.69-1.47, P = 0.97). CONCLUSIONS The current findings suggest that additional oral dydrogesterone supplementation in patients with low serum progesterone concentrations at the moment of transfer could have the potential to rescue reproductive outcomes in HRT-FET cycles. This field of research, however, remains hampered by the absence of randomized controlled trials.
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17
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Uyanik E, Mumusoglu S, Polat M, Yarali Ozbek I, Esteves SC, Humaidan P, Yarali H. A drop in serum progesterone from oocyte pick-up +3 days to +5 days in fresh blastocyst transfer, using hCG-trigger and standard luteal support, is associated with lower ongoing pregnancy rates. Hum Reprod 2023; 38:225-236. [PMID: 36478179 DOI: 10.1093/humrep/deac255] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2022] [Revised: 10/22/2022] [Indexed: 12/13/2022] Open
Abstract
STUDY QUESTION Do early- and mid-luteal serum progesterone (P4) levels impact ongoing pregnancy rates (OPRs) in fresh blastocyst transfer cycles using standard luteal phase support (LPS)? SUMMARY ANSWER A drop in serum P4 level from oocyte pick-up (OPU) + 3 days to OPU + 5 days (negative ΔP4) is associated with a ∼2-fold decrease in OPRs. WHAT IS KNOWN ALREADY In fresh embryo transfer cycles, significant inter-individual variation occurs in serum P4 levels during the luteal phase, possibly due to differences in endogenous P4 production after hCG trigger and/or differences in bioavailability of exogenously administered progesterone (P) via different routes. Although exogenous P may alleviate this drop in serum P4 in fresh transfer cycles, there is a paucity of data exploring the possible impact on reproductive outcomes of a reduction in serum P4 levels. STUDY DESIGN, SIZE, DURATION Using a prospective cohort study design, following the initial enrollment of 558 consecutive patients, 340 fulfilled the inclusion and exclusion criteria and were included in the final analysis. The inclusion criteria were: (i) female age ≤40 years, (ii) BMI ≤35 kg/m2, (iii) retrieval of ≥3 oocytes irrespective of ovarian reserve, (iv) the use of a GnRH-agonist or GnRH-antagonist protocol with recombinant hCG triggering (6500 IU), (v) standard LPS and (vi) fresh blastocyst transfer. The exclusion criteria were: (i) triggering with GnRH-agonist or GnRH-agonist plus recombinant hCG (dual trigger), (ii) circulating P4 >1.5 ng/ml on the day of trigger and (iii) cleavage stage embryo transfer. Each patient was included only once. The primary outcome was ongoing pregnancy (OP), as defined by pregnancy ≥12 weeks of gestational age. PARTICIPANTS/MATERIALS, SETTING, METHODS A GnRH-agonist (n = 53) or GnRH-antagonist (n = 287) protocol was used for ovarian stimulation. Vaginal progesterone gel (Crinone, 90 mg, 8%, Merck) once daily was used for LPS. Serum P4 levels were measured in all patients on five occasions: on the day of ovulation trigger, the day of OPU, OPU + 3 days, OPU + 5 days and OPU + 14 days; timing of blood sampling was standardized to be 3-5 h after the morning administration of vaginal progesterone gel. The delta P4 (ΔP4) level was calculated by subtracting the P4 level on the OPU + 3 days from the P4 level on the OPU + 5 days, resulting in either a positive or negative ΔP4. MAIN RESULTS AND THE ROLE OF CHANCE The median P4 (min-max) on the day of triggering, day of OPU, OPU + 3 days, OPU + 5 days and OPU + 14 days were 0.83 ng/ml (0.18-1.42), 5.81 ng/ml (0.80-22.72), 80.00 ng/ml (22.91-161.05), 85.91 ng/ml (15.66-171.78) and 13.46 ng/ml (0.18-185.00), respectively. Serum P4 levels uniformly increased from the day of OPU to OPU + 3 days in all patients; however, from OPU + 3 days to OPU + 5 days, some patients had a decrease (negative ΔP4; n = 116; 34.1%), whereas others had an increase (positive ΔP4; n = 220; 64.7%), in circulating P4 levels. Although the median (min-max) P4 levels on the day of triggering, the day of OPU, and OPU + 3 days were comparable between the negative ΔP4 and positive ΔP4 groups, patients in the former group had significantly lower P4 levels on OPU + 5 days [69.67 ng/ml (15.66-150.02) versus 100.51 ng/ml (26.41-171.78); P < 0.001] and OPU + 14 days [8.28 ng/ml (0.28-157.00) versus 19.01 ng/ml (0.18-185.00), respectively; P < 0.001]. A drop in P4 level from OPU + 3 days to OPU + 5 days (negative ΔP4) was seen in approximately one-third of patients and was associated with a significantly lower OPR when compared with positive ΔP4 counterparts [33.6% versus 49.1%, odds ratio (OR); 0.53, 95% CI; 0.33-0.84; P = 0.008]; this decrease in OPR was due to lower initial pregnancy rates rather than increased overall pregnancy loss rates. For negative ΔP4 patients, the magnitude of ΔP4 was a significant predictor of OP (adjusted AUC = 0.65; 95% CI; 0.59-0.71), with an optimum threshold of -8.73 ng/ml, sensitivity and specificity were 48.7% and 79.2%, respectively. BMI (OR; 1.128, 95% CI; 1.064-1.197) was the only significant predictor of having a negative ΔP4; the higher the BMI, the higher the risk of having a negative ΔP4. Among positive ΔP4 patients, the magnitude of ΔP4 was a weak predictor of OP (AUC = 0.56, 95% CI; 0.48-0.64). Logistic regression analysis showed that blastocyst morphology (OR; 5.686, 95% CI; 1.433-22.565; P = 0.013) and ΔP4 (OR; 1.013, 95% CI; 0.1001-1.024; P = 0.031), but not the serum P4 level on OPU + 5 days, were the independent predictors of OP. LIMITATIONS, REASONS FOR CAUTION The physiological circadian pulsatile secretion of P4 during the mid-luteal phase is a limitation; however, blood sampling was standardized to reduce the impact of timing. WIDER IMPLICATIONS OF THE FINDINGS Two measurements (OPU + 3 days and OPU + 5 days) of serum P4 may identify those patients with a drop in P4 (approximately one-third of patients) associated with ∼2-fold lower OPRs. Rescuing these IVF cycles with additional P supplementation or adopting a blastocyst freeze-all policy should be tested in future randomized controlled trials. STUDY FUNDING/COMPETING INTEREST(S) None. S.C.E. declares receipt of unrestricted research grants from Merck and lecture fees from Merck and Med.E.A. P.H. has received unrestricted research grants from MSD and Merck, as well as honoraria for lectures from MSD, Merck, Gedeon-Richter, Theramex, and IBSA. H.Y. declares receipt of honorarium for lectures from Merck, IBSA and research grants from Merck and Ferring. The remaining authors declare that they have no conflict of interest. TRIAL REGISTRATION NUMBER The study was registered at clinical trials.gov (NCT04128436).
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Affiliation(s)
- Esra Uyanik
- Department of Obstetrics and Gynecology, Hacettepe University, Ankara, Turkey
| | - Sezcan Mumusoglu
- Department of Obstetrics and Gynecology, Hacettepe University, Ankara, Turkey
| | - Mehtap Polat
- Department of Obstetrics and Gynecology, Anatolia IVF and Women Health Center, Ankara, Turkey.,Department of Medical Services and Techniques, First and Emergency Aid Program, School of Health Services, Atılım University Vocational, Ankara, Turkey
| | - Irem Yarali Ozbek
- Department of Histology and Embryology, Anatolia IVF and Women Health Center, Ankara, Turkey
| | - Sandro C Esteves
- Androfert, Andrology and Human Reproduction Clinic, Referral Center for Male Reproduction, Campinas, SP, Brazil.,Department of Obstetrics and Gynecology, Aarhus University-Skive Hospital, Skive, Denmark
| | - Peter Humaidan
- Department of Obstetrics and Gynecology, Aarhus University-Skive Hospital, Skive, Denmark.,The Fertility Clinic, Skive Regional Hospital, Skive, Denmark
| | - Hakan Yarali
- Department of Obstetrics and Gynecology, Hacettepe University, Ankara, Turkey.,Department of Obstetrics and Gynecology, Anatolia IVF and Women Health Center, Ankara, Turkey
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18
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Melo P, Wood S, Petsas G, Chung Y, Easter C, Price MJ, Fishel S, Khairy M, Kingsland C, Lowe P, Rajkhowa M, Sephton V, Pandey S, Kazem R, Walker D, Gorodeckaja J, Wilcox M, Gallos I, Tozer A, Coomarasamy A. The effect of frozen embryo transfer regimen on the association between serum progesterone and live birth: a multicentre prospective cohort study (ProFET). Hum Reprod Open 2022; 2022:hoac054. [PMID: 36518987 PMCID: PMC9733530 DOI: 10.1093/hropen/hoac054] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2022] [Revised: 11/16/2022] [Indexed: 08/03/2023] Open
Abstract
STUDY QUESTION What is the association between serum progesterone levels on the day of frozen embryo transfer (FET) and the probability of live birth in women undergoing different FET regimens? SUMMARY ANSWER Overall, serum progesterone levels <7.8 ng/ml were associated with reduced odds of live birth, although the association between serum progesterone levels and the probability of live birth appeared to vary according to the route of progesterone administration. WHAT IS KNOWN ALREADY Progesterone is essential for pregnancy success. A recent systematic review showed that in FET cycles using vaginal progesterone for endometrial preparation, lower serum progesterone levels (<10 ng/ml) were associated with a reduction in live birth rates and higher chance of miscarriage. However, there was uncertainty about the association between serum progesterone levels and treatment outcomes in natural cycle FET (NC-FET) and HRT-FET using non-vaginal routes of progesterone administration. STUDY DESIGN SIZE DURATION This was a multicentre (n = 8) prospective cohort study conducted in the UK between January 2020 and February 2021. PARTICIPANTS/MATERIALS SETTING METHODS We included women having NC-FET or HRT-FET treatment with progesterone administration by any available route. Women underwent venepuncture on the day of embryo transfer. Participants and clinical personnel were blinded to the serum progesterone levels. We conducted unadjusted and multivariable logistic regression analyses to investigate the association between serum progesterone levels on the day of FET and treatment outcomes according to the type of cycle and route of exogenous progesterone administration. Our primary outcome was the live birth rate per participant. MAIN RESULTS AND THE ROLE OF CHANCE We studied a total of 402 women. The mean (SD) serum progesterone level was 14.9 (7.5) ng/ml. Overall, the mean adjusted probability of live birth increased non-linearly from 37.6% (95% CI 26.3-48.9%) to 45.5% (95% CI 32.1-58.9%) as serum progesterone rose between the 10th (7.8 ng/ml) and 90th (24.0 ng/ml) centiles. In comparison to participants whose serum progesterone level was ≥7.8 ng/ml, those with lower progesterone (<7.8 ng/ml, 10th centile) experienced fewer live births (28.2% versus 40.0%, adjusted odds ratio [aOR] 0.41, 95% CI 0.18-0.91, P = 0.028), lower odds of clinical pregnancy (30.8% versus 45.1%, aOR 0.36, 95% CI 0.16-0.79, P = 0.011) and a trend towards increased odds of miscarriage (42.1% versus 28.7%, aOR 2.58, 95% CI 0.88-7.62, P = 0.086). In women receiving vaginal progesterone, the mean adjusted probability of live birth increased as serum progesterone levels rose, whereas women having exclusively subcutaneous progesterone experienced a reduction in the mean probability of live birth as progesterone levels rose beyond 16.3 ng/ml. The combination of vaginal and subcutaneous routes appeared to exert little impact upon the mean probability of live birth in relation to serum progesterone levels. LIMITATIONS REASONS FOR CAUTION The final sample size was smaller than originally planned, although our study was adequately powered to confidently identify a difference in live birth between optimal and inadequate progesterone levels. Furthermore, our cohort did not include women receiving oral or rectal progestogens. WIDER IMPLICATIONS OF THE FINDINGS Our results corroborate existing evidence suggesting that lower serum progesterone levels hinder FET success. However, the relationship between serum progesterone and the probability of live birth appears to be non-linear in women receiving exclusively subcutaneous progesterone, suggesting that in this subgroup of women, high serum progesterone may also be detrimental to treatment success. STUDY FUNDING/COMPETING INTERESTS This work was supported by CARE Fertility and a doctoral research fellowship (awarded to P.M.) by the Tommy's Charity and the University of Birmingham. M.J.P. is supported by the NIHR Birmingham Biomedical Research Centre. S.F. is a minor shareholder of CARE Fertility but has no financial or other interest with progesterone testing or manufacturing companies. P.L. reports personal fees from Pharmasure, outside the submitted work. G.P. reports personal fees from Besins Healthcare, outside the submitted work. M.W. reports personal fees from Ferring Pharmaceuticals, outside the submitted work. The remaining authors have no conflict of interest to declare. TRIAL REGISTRATION NUMBER ClinicalTrials.gov: NCT04170517.
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Affiliation(s)
- Pedro Melo
- Correspondence address. Tommy’s National Centre for Miscarriage Research, Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham, Edgbaston B15 277, UK. Tel: +44-121-371-8202; E-mail:
| | | | | | - Yealin Chung
- Tommy’s National Centre for Miscarriage Research, Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham, Edgbaston, UK
- CARE Fertility Birmingham, Edgbaston, UK
| | - Christina Easter
- Institute of Applied Health Research, University of Birmingham, Edgbaston, UK
| | - Malcolm J Price
- Institute of Applied Health Research, University of Birmingham, Edgbaston, UK
- NIHR Birmingham Biomedical Research Centre, University Hospitals Birmingham NHS Foundation Trust and University of Birmingham, Birmingham, UK
| | - Simon Fishel
- CARE Fertility Nottingham, Nottingham, UK
- Liverpool John Moores University, School of Pharmacy and Biomolecular Sciences, Liverpool, UK
| | | | | | | | | | | | | | | | | | | | | | - Ioannis Gallos
- Tommy’s National Centre for Miscarriage Research, Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham, Edgbaston, UK
| | | | - Arri Coomarasamy
- Tommy’s National Centre for Miscarriage Research, Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham, Edgbaston, UK
- CARE Fertility Birmingham, Edgbaston, UK
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19
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Bulletti C, Bulletti FM, Sciorio R, Guido M. Progesterone: The Key Factor of the Beginning of Life. Int J Mol Sci 2022; 23:ijms232214138. [PMID: 36430614 PMCID: PMC9692968 DOI: 10.3390/ijms232214138] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2022] [Revised: 11/03/2022] [Accepted: 11/05/2022] [Indexed: 11/17/2022] Open
Abstract
Progesterone is the ovarian steroid produced by the granulosa cells of follicles after the LH peak at mid-cycle. Its role is to sustain embryo endometrial implantation and ongoing pregnancy. Other biological effects of progesterone may exert a protective function in supporting pregnancy up to birth. Luteal phase support (LPS) with progesterone is the standard of care for assisted reproductive technology. Progesterone vaginal administration is currently the most widely used treatment for LPS. Physicians and patients have been reluctant to change an administration route that has proven to be effective. However, some questions remain open, namely the need for LPS in fresh and frozen embryo transfer, the route of administration, the optimal duration of LPS, dosage, and the benefit of combination therapies. The aim of this review is to provide an overview of the uterine and extra-uterine effects of progesterone that may play a role in embryo implantation and pregnancy, and to discuss the advantages of the use of progesterone for LPS in the context of Good Medical Practice.
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Affiliation(s)
- Carlo Bulletti
- Extra Omnes, Assisted Reproductive Technology, ART Center, Via Gallinelli, 8, 47841 Cattolica, Italy
- Department of Obstetrics, Gynecology, and Reproductive Science, Yale University, New Haven, CT 06510, USA
- Correspondence:
| | | | - Romualdo Sciorio
- Edinburgh Assisted Conception Programme, Royal Infirmary of Edinburgh, Edinburgh EH16 4SA, UK
| | - Maurizio Guido
- Obstetrics and Gynecology Unit, Department of Life, Health and Environmental Sciences, University of L’Aquila, 67100 L’Aquila, Italy
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20
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Maignien C, Bourdon M, Marcellin L, Guibourdenche J, Chargui A, Patrat C, Plu-Bureau G, Chapron C, Santulli P. Clinical factors associated with low serum progesterone levels on the day of frozen blastocyst transfer in hormonal replacement therapy cycles. Hum Reprod 2022; 37:2570-2577. [PMID: 36125015 DOI: 10.1093/humrep/deac199] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2022] [Revised: 08/12/2022] [Indexed: 11/14/2022] Open
Abstract
STUDY QUESTION Which factors are associated with low serum progesterone (P) levels on the day of frozen embryo transfer (FET), in HRT cycles? SUMMARY ANSWER BMI, parity and non-European geographic origin are factors associated with low serum P levels on the day of FET in HRT cycles. WHAT IS KNOWN ALREADY The detrimental impact of low serum P concentrations on HRT-FET outcomes is commonly recognized. However, the factors accounting for P level disparities among patients receiving the same luteal phase support treatment remain to be elucidated, to help clinicians predicting which subgroups of patients would benefit from a tailored P supplementation. STUDY DESIGN, SIZE, DURATION Observational cohort study with 915 patients undergoing HRT-FET at a tertiary care university hospital, between January 2019 and March 2020. PARTICIPANTS/MATERIALS, SETTING, METHODS Patients undergoing single autologous blastocyst FET under HRT using exogenous estradiol and vaginal micronized progesterone for endometrial preparation. Women were only included once during the study period. The serum progesterone level was measured in the morning of the FET, in a single laboratory. Independent factors associated with low serum P levels (defined as ≤9.8 ng/ml, according to a previous published study) were analyzed using univariate and multivariate logistic regression models. MAIN RESULTS AND THE ROLE OF CHANCE Two hundred and twenty-six patients (24.7%) had a low serum P level, on the day of the FET. Patients with a serum P level ≤9.8 ng/ml had a lower live birth rate (26.1% vs 33.2%, P = 0.045) and a higher rate of early miscarriage (35.2% vs 21.5%, P = 0.008). Univariate analysis showed that BMI (P < 0.001), parity (P = 0.001), non-European geographic origin (P = 0.001), the duration of infertility (P = 0.018) and the use of oral estradiol for endometrial preparation (P = 0.009) were significantly associated with low serum P levels. Moreover, the proportion of active smokers was significantly lower in the 'low P concentrations' group (P = 0.002). After multivariate analysis, BMI (odds ratio (OR) 1.06 95% CI (1.02-1.11), P = 0.002), parity (OR 1.32 95% CI (1.04-1.66), P = 0.022), non-European geographic origin (OR 1.70 95% CI (1.21-2.39), P = 0.002) and active smoking (OR 0.43 95% CI (0.22-0.87), P = 0.018) remained independent factors associated with serum P levels ≤9.8 ng/ml. LIMITATIONS, REASONS FOR CAUTION The main limitation of this study is its observational design, leading to a risk of selection and confusion bias that cannot be ruled out, although a multivariable analysis was performed to minimize this. WIDER IMPLICATIONS OF THE FINDINGS Extrapolation of our results to other laboratories, or other routes and/or doses of administering progesterone also needs to be validated. There is urgent need for future research on clinical factors affecting P concentrations and the underlying pathophysiological mechanisms, to help clinicians in predicting which subgroups of patients would benefit from individualized luteal phase support. STUDY FUNDING/COMPETING INTEREST(S) No funding/no conflicts of interest. TRIAL REGISTRATION NUMBER N/A.
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Affiliation(s)
- C Maignien
- Faculté de Santé, Université de Paris, Paris, France.,Department of Gynecology Obstetrics II and Reproductive Medicine, Assistance Publique-Hôpitaux de Paris (AP-HP), Hôpital Universitaire Paris Centre (HUPC), Centre Hospitalier Universitaire (CHU) Cochin, Paris, France
| | - M Bourdon
- Faculté de Santé, Université de Paris, Paris, France.,Department of Gynecology Obstetrics II and Reproductive Medicine, Assistance Publique-Hôpitaux de Paris (AP-HP), Hôpital Universitaire Paris Centre (HUPC), Centre Hospitalier Universitaire (CHU) Cochin, Paris, France.,Department "Development, Reproduction and Cancer", Cochin Institute, INSERM U1016 (Professor Batteux), Paris, France
| | - L Marcellin
- Faculté de Santé, Université de Paris, Paris, France.,Department of Gynecology Obstetrics II and Reproductive Medicine, Assistance Publique-Hôpitaux de Paris (AP-HP), Hôpital Universitaire Paris Centre (HUPC), Centre Hospitalier Universitaire (CHU) Cochin, Paris, France.,Department "Development, Reproduction and Cancer", Cochin Institute, INSERM U1016 (Professor Batteux), Paris, France
| | - J Guibourdenche
- Faculté de Santé, Université de Paris, Paris, France.,Department of Biological Endocrinology, Assistance Publique-Hôpitaux de Paris (AP-HP), Hôpital Universitaire Paris Centre (HUPC), Centre Hospitalier Universitaire (CHU) Cochin, Paris, France
| | - A Chargui
- Faculté de Santé, Université de Paris, Paris, France.,Department of Histology and Reproductive Biology, Assistance Publique-Hôpitaux de Paris (AP-HP), Hôpital Universitaire Paris Centre (HUPC), Centre Hospitalier Universitaire (CHU) Cochin, Paris, France
| | - C Patrat
- Faculté de Santé, Université de Paris, Paris, France.,Department of Histology and Reproductive Biology, Assistance Publique-Hôpitaux de Paris (AP-HP), Hôpital Universitaire Paris Centre (HUPC), Centre Hospitalier Universitaire (CHU) Cochin, Paris, France
| | - G Plu-Bureau
- Faculté de Santé, Université de Paris, Paris, France.,Department of Gynecology Obstetrics II and Reproductive Medicine, Assistance Publique-Hôpitaux de Paris (AP-HP), Hôpital Universitaire Paris Centre (HUPC), Centre Hospitalier Universitaire (CHU) Cochin, Paris, France.,Equipe EPOPE, INSERM U1153, Paris, France
| | - C Chapron
- Faculté de Santé, Université de Paris, Paris, France.,Department of Gynecology Obstetrics II and Reproductive Medicine, Assistance Publique-Hôpitaux de Paris (AP-HP), Hôpital Universitaire Paris Centre (HUPC), Centre Hospitalier Universitaire (CHU) Cochin, Paris, France.,Department "Development, Reproduction and Cancer", Cochin Institute, INSERM U1016 (Professor Batteux), Paris, France
| | - P Santulli
- Faculté de Santé, Université de Paris, Paris, France.,Department of Gynecology Obstetrics II and Reproductive Medicine, Assistance Publique-Hôpitaux de Paris (AP-HP), Hôpital Universitaire Paris Centre (HUPC), Centre Hospitalier Universitaire (CHU) Cochin, Paris, France.,Department "Development, Reproduction and Cancer", Cochin Institute, INSERM U1016 (Professor Batteux), Paris, France
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21
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The importance of serum progesterone level at ET day on pregnancy outcomes and possible positive effect of rescue additional progesterone treatment for restoration of progesterone level during programmed-artificial FET cycles. Reprod Biomed Online 2022; 45:785-792. [DOI: 10.1016/j.rbmo.2022.05.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2022] [Revised: 05/25/2022] [Accepted: 05/27/2022] [Indexed: 11/22/2022]
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22
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Obese women exhibit reduced serum progesterone levels on the day of embryo transfer in artificially prepared cycles involving administration of vaginal progesterone. Reprod Biomed Online 2022; 45:679-687. [DOI: 10.1016/j.rbmo.2022.05.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2022] [Revised: 05/24/2022] [Accepted: 05/27/2022] [Indexed: 11/20/2022]
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23
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Haiyan L, Gang Y, Yu L, Lin L, Xiaoli C, Qingxue Z. Does serum progesterone level impact the ongoing pregnancy rate in frozen embryo transfer under artificial preparation with vaginal progesterone? Study protocol for a randomized controlled trial. Trials 2022; 23:3. [PMID: 34980220 PMCID: PMC8722157 DOI: 10.1186/s13063-021-05953-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2021] [Accepted: 12/20/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND In previous retrospective studies, low serum progesterone level on the embryo transfer day is associated with lower clinical pregnancy and ongoing pregnancy rates. Whether adding progesterone in low serum progesterone patients can rescue the outcome, there is no sufficient evidence from randomized controlled studies. METHODS This trial is a clinical randomized controlled study (high serum progesterone vs low serum progesterone 1:1, 1:1 randomization ratio of intervention vs the control group with low serum progesterone). The eligible hormone replacement therapy-frozen embryo transfer (HRT-FET) cycles, will be recruited and randomly assigned to two parallel groups when serum progesterone is < 7.24μg/l on the day of embryo transfer for D3. The intervention group will be extrally given intramuscular progesterone 40 mg per day from D3 to 8 weeks of gestation if clinical pregnancy. The primary outcome is the ongoing pregnancy (beyond 12 weeks of gestation) rate. DISCUSSION The findings of this study will provide strong evidence for whether the progesterone addition from the D3 in low serum progesterone patients can improve the outcome in the HRT-FET cycle. TRIAL REGISTRATION ClinicalTrials.gov NCT04248309 . Registered on January 28, 2020.
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Affiliation(s)
- Lin Haiyan
- Reproductive Center of Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, China
| | - Yang Gang
- Reproductive Center of Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, China
| | - Li Yu
- Reproductive Center of Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, China
| | - Li Lin
- Reproductive Center of Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, China
| | - Chen Xiaoli
- Reproductive Center of Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, China
| | - Zhang Qingxue
- Reproductive Center of Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, China.
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Ranisavljevic N, Huberlant S, Montagut M, Alonzo PM, Darné B, Languille S, Anahory T, Cédrin-Durnerin I. Low Luteal Serum Progesterone Levels Are Associated With Lower Ongoing Pregnancy and Live Birth Rates in ART: Systematic Review and Meta-Analyses. Front Endocrinol (Lausanne) 2022; 13:892753. [PMID: 35757393 PMCID: PMC9229589 DOI: 10.3389/fendo.2022.892753] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2022] [Accepted: 04/29/2022] [Indexed: 11/24/2022] Open
Abstract
UNLABELLED Progesterone plays a key role in implantation. Several studies reported that lower luteal progesterone levels might be related to decreased chances of pregnancy. This systematic review was conducted using appropriate key words, on MEDLINE, EMBASE, and the Cochrane Library, from 1990 up to March 2021 to assess if luteal serum progesterone levels are associated with ongoing pregnancy (OP) and live birth (LB) rates (primary outcomes) and miscarriage rate (secondary outcome), according to the number of corpora lutea (CLs). Overall 2,632 non-duplicate records were identified, of which 32 relevant studies were available for quantitative analysis. In artificial cycles with no CL, OP and LB rates were significantly decreased when the luteal progesterone level falls below a certain threshold (risk ratio [RR] 0.72; 95% confidence interval [CI] 0.62-0.84 and 0.73; 95% CI 0.59-0.90, respectively), while the miscarriage rate was increased (RR 1.48; 95% CI 1.17-1.86). In stimulated cycles with several CLs, the mean luteal progesterone level in the no OP and no LB groups was significantly lower than in the OP and LB groups [difference in means 68.8 (95% CI 45.6-92.0) and 272.4 (95% CI 10.8-533.9), ng/ml, respectively]. Monitoring luteal serum progesterone levels could help in individualizing progesterone administration to enhance OP and LB rates, especially in cycles without corpus luteum. SYSTEMATIC REVIEW REGISTRATION https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=139019, identifier 139019.
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Affiliation(s)
- Noemie Ranisavljevic
- Department of Reproductive Medicine, Centre Hospitalier Universitaire (CHU) and University of Montpellier, Montpellier, France
- *Correspondence: Noemie Ranisavljevic,
| | - Stephanie Huberlant
- Department of Reproductive Medicine, Centre Hospitalier Universitaire (CHU) Carémeau, Nîmes, France
| | - Marie Montagut
- Center for Human Reproduction-Institut Francophone de Recherche Et d’études Appliquées à la Reproduction Et Sexologie (IFREARES), Clinique Saint Jean du Languedoc, Toulouse, France
| | | | | | | | - Tal Anahory
- Department of Reproductive Medicine, Centre Hospitalier Universitaire (CHU) and University of Montpellier, Montpellier, France
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25
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du Boulet B, Ranisavljevic N, Mollevi C, Bringer-Deutsch S, Brouillet S, Anahory T. Individualized luteal phase support based on serum progesterone levels in frozen-thawed embryo transfer cycles maximizes reproductive outcomes in a cohort undergoing preimplantation genetic testing. Front Endocrinol (Lausanne) 2022; 13:1051857. [PMID: 36531476 PMCID: PMC9755854 DOI: 10.3389/fendo.2022.1051857] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2022] [Accepted: 11/14/2022] [Indexed: 12/04/2022] Open
Abstract
INTRODUCTION Low serum progesterone concentration on frozen embryo transfer (FET) day in hormone replacement therapy (HRT) cycles results in lower reproductive outcomes. Recent studies showed the efficiency of a "rescue protocol'' to restore reproductive outcomes in these patients. Here, we compared reproductive outcomes in HRT FET cycles in women with low serum progesterone levels who received individualized luteal phase support (iLPS) and in women with adequate serum progesterone levels who underwent in vitro fertilization for pre-implantation genetic testing for structural rearrangements or monogenic disorders. DESIGN This retrospective cohort study included women (18-43 years of age) undergoing HRT FET cycles with pre-implantation genetic testing at Montpellier University Hospital between June 2020 and May 2022. A standard HRT was used: vaginal micronized estradiol (6mg/day) followed by vaginal micronized progesterone (VMP; 800 mg/day). Serum progesterone was measured after four doses of VMP: if <11ng/ml, 25mg/day subcutaneous progesterone or 30mg/day oral dydrogesterone was introduced. RESULTS 125 HRT FET cycles were performed in 111 patients. Oral/subcutaneous progesterone supplementation concerned 39 cycles (n=20 with subcutaneous progesterone and n=19 with oral dydrogesterone). Clinical and laboratory parameters of the cycles were comparable between groups. The ongoing pregnancy rate (OPR) was 41.03% in the supplemented group and 18.60% in the non-supplemented group (p= 0.008). The biochemical pregnancy rate and miscarriages rate tended to be higher in the non-supplemented group versus the supplemented group: 13.95% versus 5.13% and 38.46% versus 15.79% (p=0.147 and 0.182 respectively). Multivariate logistic regression analysis found that progesterone supplementation was significantly associated with higher OPR (adjusted OR = 3.25, 95% CI [1.38 - 7.68], p=0.007). CONCLUSION In HRT FET cycles, progesterone supplementation in patients with serum progesterone concentration <11 ng/mL after four doses of VMP significantly increases the OPR.
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Affiliation(s)
- Bertille du Boulet
- Department of Reproductive Medicine, Montpellier University Hospital, University of Montpellier, Montpellier, France
- *Correspondence: Bertille du Boulet,
| | - Noemie Ranisavljevic
- Department of Reproductive Medicine, Montpellier University Hospital, University of Montpellier, Montpellier, France
| | - Caroline Mollevi
- Institute Desbrest of Epidemiology and Public Health, Montpellier University Hospital, University of Montpellier, INSERM, Montpellier, France
| | - Sophie Bringer-Deutsch
- 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
| | - Tal Anahory
- Department of Reproductive Medicine, Montpellier University Hospital, University of Montpellier, Montpellier, France
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26
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Maignien C, Bourdon M, Marcellin L, Laguillier-Morizot C, Borderie D, Chargui A, Patrat C, Plu-Bureau G, Chapron C, Santulli P. Low serum progesterone affects live birth rate in cryopreserved blastocyst transfer cycles using hormone replacement therapy. Reprod Biomed Online 2021; 44:469-477. [PMID: 34980570 DOI: 10.1016/j.rbmo.2021.11.007] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2021] [Revised: 11/01/2021] [Accepted: 11/10/2021] [Indexed: 01/25/2023]
Abstract
RESEARCH QUESTION Does serum progesterone concentration on the day of vitrified-warmed embryo transfer affect live birth rate (LBR) with hormonal replacement therapy (HRT) cycles? DESIGN Observational cohort study of patients (n = 915) undergoing single autologous vitrified-warmed blastocyst transfer under HRT using vaginal micronized progesterone. Women were included once, between January 2019 and March 2020. Serum progesterone concentration was measured by a single laboratory on the morning of embryo transfer. The primary end point was LBR. Univariate and multivariate logistic regression models were used for statistical analyses. RESULTS Median (25th-75th percentile) serum progesterone concentration on the day of embryo transfer was 12.5 ng/ml (9.8-15.3). The LBR was 31.5% (288/915) in the overall population. No significant differences were found in implantation rates (40.7% versus 44.9%); LBR was significantly lower in women with a progesterone concentration ≤25th percentile (≤9.8 ng/ml) (26.1% versus 33.2%, P = 0.045) versus women with a progesterone concentration >25th percentile. This correlated with a significantly higher early miscarriage rate (35.9% versus 21.6%, P = 0.005). After adjusting for potential confounding factors in multivariate analysis, low serum progesterone levels (≤9.8 ng/ml) remained significantly associated with lower LBR (OR 0.68 95% CI 0.48 to 0.97). CONCLUSION A minimum serum progesterone concentration is needed to optimize reproductive outcomes in HRT cycles with single autologous vitrified-warmed blastocyst transfer. Whether modifications of progesterone administration routes, dosage, or both, can improve pregnancy rates needs further study so that treatment of patients undergoing HRT cycles can be further individualized.
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Affiliation(s)
- Chloé Maignien
- Université de Paris, Faculté de Santé, 12 Rue de l'Ecole de Médecine 75006 Paris, France; Department of Gynecology Obstetrics II and Reproductive Medicine (Professor Chapron), Assistance Publique-Hôpitaux de Paris (AP-HP), Hôpital Universitaire Paris Centre (HUPC), Centre Hospitalier Universitaire (CHU) Cochin, 123 Boulevard de Port Royal 75014 Paris, France
| | - Mathilde Bourdon
- Université de Paris, Faculté de Santé, 12 Rue de l'Ecole de Médecine 75006 Paris, France; Department of Gynecology Obstetrics II and Reproductive Medicine (Professor Chapron), Assistance Publique-Hôpitaux de Paris (AP-HP), Hôpital Universitaire Paris Centre (HUPC), Centre Hospitalier Universitaire (CHU) Cochin, 123 Boulevard de Port Royal 75014 Paris, France; Department "Development, Reproduction and Cancer", Cochin Institute, INSERM U1016 (Professor Batteux), 27 Rue du Faubourg Saint-Jacques 75014 Paris, France
| | - Louis Marcellin
- Université de Paris, Faculté de Santé, 12 Rue de l'Ecole de Médecine 75006 Paris, France; Department of Gynecology Obstetrics II and Reproductive Medicine (Professor Chapron), Assistance Publique-Hôpitaux de Paris (AP-HP), Hôpital Universitaire Paris Centre (HUPC), Centre Hospitalier Universitaire (CHU) Cochin, 123 Boulevard de Port Royal 75014 Paris, France; Department "Development, Reproduction and Cancer", Cochin Institute, INSERM U1016 (Professor Batteux), 27 Rue du Faubourg Saint-Jacques 75014 Paris, France
| | - Christelle Laguillier-Morizot
- Université de Paris, Faculté de Santé, 12 Rue de l'Ecole de Médecine 75006 Paris, France; Department of Biological Endocrinology (Professor Guibourdenche), Assistance Publique-Hôpitaux de Paris (AP-HP), Hôpital Universitaire Paris Centre (HUPC), Centre Hospitalier Universitaire (CHU) Cochin, 27 Rue du Faubourg Saint-Jacques 75014 Paris, France
| | - Didier Borderie
- Université de Paris, Faculté de Santé, 12 Rue de l'Ecole de Médecine 75006 Paris, France; Department of Automated Biological Diagnosis (Professor Borderie), Assistance Publique-Hôpitaux de Paris (AP-HP), Hôpital Universitaire Paris Centre (HUPC), Centre Hospitalier Universitaire (CHU) Cochin, 27 Rue du Faubourg Saint-Jacques 75014 Paris, France
| | - Ahmed Chargui
- Université de Paris, Faculté de Santé, 12 Rue de l'Ecole de Médecine 75006 Paris, France; Department of Histology and Reproductive Biology (Professor Patrat), Assistance Publique-Hôpitaux de Paris (AP-HP), Hôpital Universitaire Paris Centre (HUPC), Centre Hospitalier Universitaire (CHU) Cochin, 123 Boulevard de Port Royal 75014 Paris, France
| | - Catherine Patrat
- Université de Paris, Faculté de Santé, 12 Rue de l'Ecole de Médecine 75006 Paris, France; Department of Histology and Reproductive Biology (Professor Patrat), Assistance Publique-Hôpitaux de Paris (AP-HP), Hôpital Universitaire Paris Centre (HUPC), Centre Hospitalier Universitaire (CHU) Cochin, 123 Boulevard de Port Royal 75014 Paris, France
| | - Geneviève Plu-Bureau
- Université de Paris, Faculté de Santé, 12 Rue de l'Ecole de Médecine 75006 Paris, France; Department of Gynecology Obstetrics II and Reproductive Medicine (Professor Chapron), Assistance Publique-Hôpitaux de Paris (AP-HP), Hôpital Universitaire Paris Centre (HUPC), Centre Hospitalier Universitaire (CHU) Cochin, 123 Boulevard de Port Royal 75014 Paris, France; Equipe EPOPE, INSERM U1153
| | - Charles Chapron
- Université de Paris, Faculté de Santé, 12 Rue de l'Ecole de Médecine 75006 Paris, France; Department of Gynecology Obstetrics II and Reproductive Medicine (Professor Chapron), Assistance Publique-Hôpitaux de Paris (AP-HP), Hôpital Universitaire Paris Centre (HUPC), Centre Hospitalier Universitaire (CHU) Cochin, 123 Boulevard de Port Royal 75014 Paris, France; Department "Development, Reproduction and Cancer", Cochin Institute, INSERM U1016 (Professor Batteux), 27 Rue du Faubourg Saint-Jacques 75014 Paris, France
| | - Pietro Santulli
- Université de Paris, Faculté de Santé, 12 Rue de l'Ecole de Médecine 75006 Paris, France; Department of Gynecology Obstetrics II and Reproductive Medicine (Professor Chapron), Assistance Publique-Hôpitaux de Paris (AP-HP), Hôpital Universitaire Paris Centre (HUPC), Centre Hospitalier Universitaire (CHU) Cochin, 123 Boulevard de Port Royal 75014 Paris, France; Department "Development, Reproduction and Cancer", Cochin Institute, INSERM U1016 (Professor Batteux), 27 Rue du Faubourg Saint-Jacques 75014 Paris, France.
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Labarta E, Mariani G, Rodríguez-Varela C, Bosch E. Individualized luteal phase support normalizes live birth rate in women with low progesterone levels on the day of embryo transfer in artificial endometrial preparation cycles. Fertil Steril 2021; 117:96-103. [PMID: 34548167 DOI: 10.1016/j.fertnstert.2021.08.040] [Citation(s) in RCA: 48] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2020] [Revised: 08/24/2021] [Accepted: 08/25/2021] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To analyze the impact on live birth rates (LBRs) of the individualized luteal phase support (termed iLPS) in patients with low serum progesterone (P) levels compared with patients without iLPS. DESIGN Retrospective cohort study, December 1, 2018, to May 30, 2019. SETTING Private medical center. PATIENT(S) A total of 2,275 patients checked for serum P on the day of blastocyst transfer were analyzed. During the study period, 1,299 patients showed serum P levels of ≥9.2 ng/mL, whereas 550 showed serum P levels of <9.2 ng/mL and received iLPS. Additionally, a historical group of 426 patients with serum P levels of <9.2 ng/mL but no iLPS were used for comparison. Eligible patients were aged ≤50 years with adequate endometrium morphology after receiving estrogens. Luteal phase support was provided with micronized vaginal P (MVP) to all women. Patients with personalized initiation of exogenous P according to the endometrial receptivity assay test, polyps, fibroids distorting the cavity, or hydrosalpinx were not included in the analysis. INTERVENTION(S) As routine practice since December 2018, patients with low serum P levels received an iLPS with a daily injection of 25 mg of subcutaneous P from the day of embryo transfer (ET) in addition to standard LPS (400 mg of MVP twice a day). MAIN OUTCOME MEASURE(S) Live birth rate. RESULT(S) The LBR was 44.9% in the iLPS cases vs. 45.0% in patients with normal serum P levels (crude odds ratio [OR], 1.0; 95% confidence interval [CI], 0.82-1.22). By regression analysis, low serum P levels did not affect the LBR after adjusting for possible confounders (age, oocyte origin, fresh vs. frozen, day of ET, embryo quality, number of embryos transferred) (adjusted OR, 0.99; 95% CI, 0.79-1.25). Similarly, no differences were observed in other pregnancy outcomes between groups. The LBR was significantly higher in the group of patients who received additional subcutaneous P (iLPS) compared with the historical group with low serum P levels and no iLPS (44.9% vs. 37.3%; OR, 1.37; 95% CI, 1.06-1.78). In the overall population, patients showing P levels of <9.2 ng/mL on the day of ET were slightly younger and had higher body mass index and lower estradiol and P levels during the proliferative phase compared with patients with P levels of ≥9.2 ng/mL. No differences were observed with regard to the time in between the last dose of MVP and the serum P determination. After a multivariable logistic regression analysis, only body mass index and estradiol levels in the proliferative phase reminded statistically significant. Significant differences in the LBR were observed between patients with serum P levels of <9.2 ng/mL without iLPS and patients with serum P levels of ≥9.2 ng/mL when using either own or donated oocytes. CONCLUSION(S) Individualized LPS for patients with low serum P levels produces LBRs similar to those of patients with adequate serum P levels.
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Affiliation(s)
- Elena Labarta
- IVIRMA Valencia, Valencia, Spain; IVI Foundation, Valencia, Spain.
| | - Giulia Mariani
- IVIRMA Valencia, Valencia, Spain; IVIRMA Roma, Roma, Italy
| | | | - Ernesto Bosch
- IVIRMA Valencia, Valencia, Spain; IVI Foundation, Valencia, Spain
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Beck-Fruchter R, Nothman S, Baram S, Geslevich Y, Weiss A. Progesterone and estrogen levels are associated with live birth rates following artificial cycle frozen embryo transfers. J Assist Reprod Genet 2021; 38:2925-2931. [PMID: 34537928 DOI: 10.1007/s10815-021-02307-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2021] [Accepted: 08/22/2021] [Indexed: 10/20/2022] Open
Abstract
PURPOSE Does an association exist between serum progesterone and estradiol levels and live birth rates in artificial cycle frozen embryo transfer (AC-FET)? METHODS Retrospective cohort study was based on prospectively collected data at a university-affiliated fertility center. Included were all cycles using an artificial endometrial preparation with estradiol hemihydrate (Estrofem, 2 mg/8 h) and vaginal progesterone (Endometrin 100 mg/8 h), autologous oocytes, and cleavage stage embryo transfers. Serum progesterone and estradiol levels were measured 14 days after FET. A total of 921 cycles in 568 patients from to December 2010 to June 2019 were investigated. Live birth was the primary outcome measure. RESULTS Significant association was found between live birth and progesterone as well as estradiol levels (progesterone 14.65 vs 11.62 ng/ml, p = 0.001; estradiol 355.12 vs 287.67 pg/ml, p = 0.001). A significant difference in live birth rate was found below and above the median progesterone level (10.9 ng/ml, p = 0.007). Lower estradiol level was significantly associated with lower live birth rate (< 188.2 pg/ml 8.3%, > 263.1 pg/ml 16%, p = 0.02). CONCLUSIONS Serum progesterone and estradiol levels impact live birth rate in AC-FET.
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Affiliation(s)
- Ronit Beck-Fruchter
- Fertility Unit, Department of Obstetrics and Gynecology, Emek Medical Center, Afula, Israel. .,Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel.
| | - Simon Nothman
- Fertility Unit, Department of Obstetrics and Gynecology, Emek Medical Center, Afula, Israel.,Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
| | - Shira Baram
- Fertility Unit, Department of Obstetrics and Gynecology, Emek Medical Center, Afula, Israel
| | - Yoel Geslevich
- Fertility Unit, Department of Obstetrics and Gynecology, Emek Medical Center, Afula, Israel
| | - Amir Weiss
- Fertility Unit, Department of Obstetrics and Gynecology, Emek Medical Center, Afula, Israel.,Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
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Serum luteal phase progesterone in women undergoing frozen embryo transfer in assisted conception: a systematic review and meta-analysis. Fertil Steril 2021; 116:1534-1556. [PMID: 34384594 DOI: 10.1016/j.fertnstert.2021.07.002] [Citation(s) in RCA: 48] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2021] [Revised: 06/30/2021] [Accepted: 07/02/2021] [Indexed: 12/16/2022]
Abstract
OBJECTIVE To investigate the association between luteal serum progesterone levels and frozen embryo transfer (FET) outcomes. DESIGN Systematic review and meta-analysis. SETTING Not applicable. PATIENT(S) Women undergoing FET. INTERVENTION(S) We conducted electronic searches of MEDLINE, PubMed, CINAHL, EMBASE, the Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials, Web of Science, ClinicalTrials.gov, and grey literature (not widely available) from inception to March 2021 to identify cohort studies in which the serum luteal progesterone level was measured around the time of FET. MAIN OUTCOME MEASURE(S) Ongoing pregnancy or live birth rate, clinical pregnancy rate, and miscarriage rate. RESULT(S) Among the studies analyzing serum progesterone level thresholds <10 ng/mL, a higher serum progesterone level was associated with increased rates of ongoing pregnancy or live birth (relative risk [RR] 1.47, 95% confidence interval [CI] 1.28 to 1.70), higher chance of clinical pregnancy (RR 1.31, 95% CI 1.16 to 1.49), and lower risk of miscarriage (RR 0.62, 95% CI 0.50 to 0.77) in cycles using exclusively vaginal progesterone and blastocyst embryos. There was uncertainty about whether progesterone thresholds ≥10 ng/mL were associated with FET outcomes in sensitivity analyses including all studies, owing to high interstudy heterogeneity and wide CIs. CONCLUSION(S) Our findings indicate that there may be a minimum clinically important luteal serum concentration of progesterone required to ensure an optimal endocrine milieu during embryo implantation and early pregnancy after FET treatment. Future clinical trials are required to assess whether administering higher-dose luteal phase support improves outcomes in women with a low serum progesterone level at the time of FET. PROSPERO NUMBER CRD42019157071.
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30
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Mumusoglu S, Polat M, Ozbek IY, Bozdag G, Papanikolaou EG, Esteves SC, Humaidan P, Yarali H. Preparation of the Endometrium for Frozen Embryo Transfer: A Systematic Review. Front Endocrinol (Lausanne) 2021; 12:688237. [PMID: 34305815 PMCID: PMC8299049 DOI: 10.3389/fendo.2021.688237] [Citation(s) in RCA: 49] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2021] [Accepted: 06/23/2021] [Indexed: 11/13/2022] Open
Abstract
Despite the worldwide increase in frozen embryo transfer, the search for the best protocol to prime endometrium continues. Well-designed trials comparing various frozen embryo transfer protocols in terms of live birth rates, maternal, obstetric and neonatal outcome are urgently required. Currently, low-quality evidence indicates that, natural cycle, either true natural cycle or modified natural cycle, is superior to hormone replacement treatment protocol. Regarding warmed blastocyst transfer and frozen embryo transfer timing, the evidence suggests the 6th day of progesterone start, LH surge+6 day and hCG+7 day in hormone replacement treatment, true natural cycle and modified natural cycle protocols, respectively. Time corrections, due to inter-personal differences in the window of implantation or day of vitrification (day 5 or 6), should be explored further. Recently available evidence clearly indicates that, in hormone replacement treatment and natural cycles, there might be marked inter-personal variation in serum progesterone levels with an impact on reproductive outcomes, despite the use of the same dose and route of progesterone administration. The place of progesterone rescue protocols in patients with low serum progesterone levels one day prior to warmed blastocyst transfer in hormone replacement treatment and natural cycles is likely to be intensively explored in near future.
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Affiliation(s)
- Sezcan Mumusoglu
- Department of Obstetrics and Gynecology, Hacettepe University School of Medicine, Ankara, Turkey
| | - Mehtap Polat
- Anatolia IVF and Women Health Centre, Ankara, Turkey
| | | | - Gurkan Bozdag
- Department of Obstetrics and Gynecology, Hacettepe University School of Medicine, Ankara, Turkey
| | | | - Sandro C. Esteves
- Androfert, Andrology and Human Reproduction Clinic, Referral Center for Male Reproduction, Campinas, Brazil
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Peter Humaidan
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
- The Fertility Clinic, Skive Regional Hospital Resenvej 25, Skive, Denmark
| | - Hakan Yarali
- Department of Obstetrics and Gynecology, Hacettepe University School of Medicine, Ankara, Turkey
- Anatolia IVF and Women Health Centre, Ankara, Turkey
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Labarta E, Mariani G, Paolelli S, Rodriguez-Varela C, Vidal C, Giles J, Bellver J, Cruz F, Marzal A, Celada P, Olmo I, Alamá P, Remohi J, Bosch E. Impact of low serum progesterone levels on the day of embryo transfer on pregnancy outcome: a prospective cohort study in artificial cycles with vaginal progesterone. Hum Reprod 2021; 36:683-692. [PMID: 33340402 DOI: 10.1093/humrep/deaa322] [Citation(s) in RCA: 63] [Impact Index Per Article: 21.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2020] [Revised: 10/14/2020] [Indexed: 02/06/2023] Open
Abstract
STUDY QUESTION Is there a serum progesterone (P) threshold on the day of embryo transfer (ET) in artificial endometrium preparation cycles below which the chances of ongoing pregnancy are reduced? SUMMARY ANSWER Serum P levels <8.8 ng/ml on the day of ET lower ongoing pregnancy rate (OPR) in both own or donated oocyte cycles. WHAT IS KNOWN ALREADY We previously found that serum P levels <9.2 ng/ml on the day of ET significantly decrease OPR in a sample of 211 oocyte donation recipients. Here, we assessed whether these results are applicable to all infertile patients under an artificial endometrial preparation cycle, regardless of the oocyte origin. STUDY DESIGN, SIZE, DURATION This prospective cohort study was performed between September 2017 and November 2018 and enrolled 1205 patients scheduled for ET after an artificial endometrial preparation cycle with estradiol valerate and micronized vaginal P (MVP, 400 mg twice daily). PARTICIPANTS/MATERIALS, SETTING, METHODS Patients ≤50 years old with a triple-layer endometrium ≥6.5 mm underwent transfer of one or two blastocysts. A total of 1150 patients treated with own oocytes without preimplantation genetic testing for aneuploidies (PGT-A) (n = 184), own oocytes with PGT-A (n = 308) or donated oocytes (n = 658) were analyzed. The primary endpoint was the OPR beyond pregnancy week 12 based on serum P levels measured immediately before ET. MAIN RESULTS AND THE ROLE OF CHANCE Women with serum P levels <8.8 ng/ml (30th percentile) had a significantly lower OPR (36.6% vs 54.4%) and live birth rate (35.5% vs 52.0%) than the rest of the patients. Multivariate logistic regression showed that serum P < 8.8 ng/ml was an independent factor influencing OPR in the overall population and in the three treatment groups. A significant negative correlation was observed between serum P levels and BMI, weight and time between the last P dose and blood tests and a positive correlation was found with age, height and number of days on HRT. Multivariate logistic regression showed that only body weight was an independent factor for presenting serum P levels <8.8 ng/ml. Obstetrical and perinatal outcomes did not differ in patients with ongoing pregnancy regardless of serum P levels being above/below 8.8 ng/ml. LIMITATIONS, REASONS FOR CAUTION Only women with MVP were included. Extrapolation to other P administration forms needs to be validated. WIDER IMPLICATIONS OF THE FINDINGS This study identified the threshold of serum P as 8.8 ng/ml on the day of ET for artificial endometrial preparation cycles necessary to optimize outcomes, in cycles with own or donated oocytes. One-third of patients receiving MVP show inadequate levels of serum P that, in turn, impact the success of the ART cycle. Monitoring P levels in the mid-luteal phase is recommended when using MVP to adjust the doses according to the needs of the patient. STUDY FUNDING/COMPETING INTEREST(S) None. TRIAL REGISTRATION NUMBER NCT03272412.
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Affiliation(s)
- Elena Labarta
- Human Reproduction Department, IVI RMA Valencia, Valencia 46015, Spain.,IVI Foundation, Health Research Institute La Fe, Valencia 46026, Spain
| | - Giulia Mariani
- Human Reproduction Department, IVI RMA Valencia, Valencia 46015, Spain
| | - Stefania Paolelli
- Human Reproduction Department, IVI RMA Valencia, Valencia 46015, Spain.,IVI Foundation, Health Research Institute La Fe, Valencia 46026, Spain
| | | | - Carmina Vidal
- Human Reproduction Department, IVI RMA Valencia, Valencia 46015, Spain.,IVI Foundation, Health Research Institute La Fe, Valencia 46026, Spain
| | - Juan Giles
- Human Reproduction Department, IVI RMA Valencia, Valencia 46015, Spain.,IVI Foundation, Health Research Institute La Fe, Valencia 46026, Spain
| | - José Bellver
- Human Reproduction Department, IVI RMA Valencia, Valencia 46015, Spain.,IVI Foundation, Health Research Institute La Fe, Valencia 46026, Spain
| | - Fabio Cruz
- Human Reproduction Department, IVI RMA Valencia, Valencia 46015, Spain.,IVI Foundation, Health Research Institute La Fe, Valencia 46026, Spain
| | - Alicia Marzal
- Human Reproduction Department, IVI RMA Valencia, Valencia 46015, Spain.,IVI Foundation, Health Research Institute La Fe, Valencia 46026, Spain
| | - Paula Celada
- Human Reproduction Department, IVI RMA Valencia, Valencia 46015, Spain.,IVI Foundation, Health Research Institute La Fe, Valencia 46026, Spain
| | - Ines Olmo
- Human Reproduction Department, IVI RMA Valencia, Valencia 46015, Spain.,IVI Foundation, Health Research Institute La Fe, Valencia 46026, Spain
| | - Pilar Alamá
- Human Reproduction Department, IVI RMA Valencia, Valencia 46015, Spain.,IVI Foundation, Health Research Institute La Fe, Valencia 46026, Spain
| | - José Remohi
- Human Reproduction Department, IVI RMA Valencia, Valencia 46015, Spain.,IVI Foundation, Health Research Institute La Fe, Valencia 46026, Spain
| | - Ernesto Bosch
- Human Reproduction Department, IVI RMA Valencia, Valencia 46015, Spain.,IVI Foundation, Health Research Institute La Fe, Valencia 46026, Spain
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Álvarez M, Gaggiotti-Marre S, Martínez F, Coll L, García S, González-Foruria I, Rodríguez I, Parriego M, Polyzos NP, Coroleu B. Individualised luteal phase support in artificially prepared frozen embryo transfer cycles based on serum progesterone levels: a prospective cohort study. Hum Reprod 2021; 36:1552-1560. [PMID: 33686413 DOI: 10.1093/humrep/deab031] [Citation(s) in RCA: 53] [Impact Index Per Article: 17.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2020] [Revised: 12/31/2020] [Indexed: 12/27/2022] Open
Abstract
STUDY QUESTION Does an individualised luteal phase support (iLPS), according to serum progesterone (P4) level the day prior to euploid frozen embryo transfer (FET), improve pregnancy outcomes when started on the day previous to embryo transfer? SUMMARY ANSWER Patients with low serum P4 the day prior to euploid FET can benefit from the addition of daily subcutaneous P4 injections (Psc), when started the day prior to FET, and achieve similar reproductive outcomes compared to those with initial adequate P4 levels. WHAT IS KNOWN ALREADY The ratio between FET/IVF has spectacularly increased in the last years mainly thanks to the pursuit of an ovarian hyperstimulation syndrome free clinic and the development of preimplantation genetic testing (PGT). There is currently a big concern regarding the endometrial preparation for FET, especially in relation to serum P4 levels around the time of embryo transfer. Several studies have described impaired pregnancy outcomes in those patients with low P4 levels around the time of FET, considering 10 ng/ml as one of the most accepted reference values. To date, no prospective study has been designed to compare the reproductive outcomes between patients with adequate P4 the day previous to euploid FET and those with low, but restored P4 levels on the transfer day after iLPS through daily Psc started on the day previous to FET. STUDY DESIGN, SIZE, DURATION A prospective observational study was conducted at a university-affiliated fertility centre between November 2018 and January 2020 in patients undergoing PGT for aneuploidies (PGT-A) IVF cycles and a subsequent FET under hormone replacement treatment (HRT). A total of 574 cycles (453 patients) were analysed: 348 cycles (leading to 342 euploid FET) with adequate P4 on the day previous to FET, and 226 cycles (leading to 220 euploid FET) under iLPS after low P4 on the previous day to FET, but restored P4 levels on the transfer day. PARTICIPANTS/MATERIALS, SETTING, METHODS Overall we included 574 HRT FET cycles (453 patients). Standard HRT was used for endometrial preparation. P4 levels were measured the day previous to euploid FET. P4 > 10.6 ng/ml was considered as adequate and euploid FET was performed on the following day (FET Group 1). P4 < 10.6 ng/ml was considered as low, iLPS was added in the form of daily Psc injections, and a new P4 analysis was performed on the following day. FET was only performed on the same day when a restored P4 > 10.6 ng/ml was achieved (98.2% of cases) (FET Group 2). MAIN RESULTS AND THE ROLE OF CHANCE Patient's demographics and cycle parameters were comparable between both euploid FET groups (FET Group 1 and FET Group 2) in terms of age, weight, oestradiol and P4 levels and number of embryos transferred. No statistically significant differences were found in terms of clinical pregnancy rate (56.4% vs 59.1%: rate difference (RD) -2.7%, 95% CI [-11.4; 6.0]), ongoing pregnancy rate (49.4% vs 53.6%: RD -4.2%, 95% CI [-13.1; 4.7]) or live birth rate (49.1% vs 52.3%: RD -3.2%, 95% CI [-12; 5.7]). No significant differences were also found according to miscarriage rate (12.4% vs 9.2%: RD 3.2%, 95% CI [-4.3; 10.7]). LIMITATIONS, REASONS FOR CAUTION Only iLPS through daily Psc was evaluated. The time for Psc injection was not stated and no serum P4 determinations were performed once the pregnancy was achieved. WIDER IMPLICATIONS OF THE FINDINGS Our study provides information regarding an 'opportunity window' for improved ongoing pregnancy rates and miscarriage rates through a daily Psc injection in cases of inadequate P4 levels the day previous to FET (P4 < 10.6 ng/ml) and restored values the day of FET (P4 > 10.6 ng/ml). Only euploid FET under HRT were considered, avoiding one of the main reasons of miscarriage and implantation failure and overcoming confounding factors such as female age, embryo quality or ovarian stimulation protocols. STUDY FUNDING/COMPETING INTEREST(S) No external funding was received. B.C. reports personal fees from MSD, Merck Serono, Ferring Pharmaceuticals, IBSA and Gedeon Richter outside the submitted work. N.P. reports grants and personal fees from MSD, Merck Serono, Ferring Pharmaceuticals, Theramex and Besins International and personal fees from IBSA and Gedeon Richter outside the submitted work. The remaining authors have no conflicts of interest to declare. TRIAL REGISTRATION NUMBER NCT03740568.
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Affiliation(s)
- Manuel Álvarez
- Department of Obstetrics, Gynaecology and Reproductive Medicine, Dexeus Mujer - Dexeus University Hospital, 08028 Barcelona, Spain
| | - Sofía Gaggiotti-Marre
- Department of Obstetrics, Gynaecology and Reproductive Medicine, Dexeus Mujer - Dexeus University Hospital, 08028 Barcelona, Spain
| | - Francisca Martínez
- Department of Obstetrics, Gynaecology and Reproductive Medicine, Dexeus Mujer - Dexeus University Hospital, 08028 Barcelona, Spain
| | - Lluc Coll
- Department of Obstetrics, Gynaecology and Reproductive Medicine, Dexeus Mujer - Dexeus University Hospital, 08028 Barcelona, Spain
| | - Sandra García
- Department of Obstetrics, Gynaecology and Reproductive Medicine, Dexeus Mujer - Dexeus University Hospital, 08028 Barcelona, Spain
| | - Iñaki González-Foruria
- Department of Obstetrics, Gynaecology and Reproductive Medicine, Dexeus Mujer - Dexeus University Hospital, 08028 Barcelona, Spain
| | - Ignacio Rodríguez
- Department of Obstetrics, Gynaecology and Reproductive Medicine, Dexeus Mujer - Dexeus University Hospital, 08028 Barcelona, Spain
| | - Mónica Parriego
- Department of Obstetrics, Gynaecology and Reproductive Medicine, Dexeus Mujer - Dexeus University Hospital, 08028 Barcelona, Spain
| | - Nikolaos P Polyzos
- Department of Obstetrics, Gynaecology and Reproductive Medicine, Dexeus Mujer - Dexeus University Hospital, 08028 Barcelona, Spain
| | - Buenaventura Coroleu
- Department of Obstetrics, Gynaecology and Reproductive Medicine, Dexeus Mujer - Dexeus University Hospital, 08028 Barcelona, Spain
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Yarali H, Polat M, Mumusoglu S, Ozbek IY, Erden M, Bozdag G, Humaidan P. Subcutaneous luteal phase progesterone rescue rectifies ongoing pregnancy rates in hormone replacement therapy vitrified-warmed blastocyst transfer cycles. Reprod Biomed Online 2021; 43:45-51. [PMID: 34016521 DOI: 10.1016/j.rbmo.2021.04.011] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2021] [Revised: 03/18/2021] [Accepted: 04/13/2021] [Indexed: 12/27/2022]
Abstract
RESEARCH QUESTION Will luteal phase rescue with additional progesterone increase serum progesterone concentrations and improve reproductive outcomes in patients with low serum progesterone concentrations undergoing hormone replacement therapy (HRT) cycles? DESIGN Case-control study including 40 consecutive patients with serum progesterone concentrations <8.75 ng/ml on the 5th day of progesterone supplementation who underwent rescue with a daily bolus of 25 mg s.c. progesterone, starting on the afternoon of the 5th day of progesterone administration. For every patient who underwent progesterone rescue, three patients matched by age, body mass index, number of previous attempts and number of blastocysts transferred, with serum progesterone concentration >8.75 ng/ml on the 5th day of progesterone administration served as controls (n = 120). The main outcome measure was ongoing pregnancy rate (OPR). RESULTS Baseline demographic features and embryological data of the rescue and control groups were comparable. As expected, the mean serum progesterone concentration was lower in the rescue group on the 5th day of progesterone administration (7.84 ± 0.92 versus 15.32 ± 5.02 ng/ml; P < 0.001). Following rescue, the mean serum progesterone concentration on the day of vitrified-warmed embryo transfer (6th day of progesterone administration) was 33.43 ± 10.83 ng/ml (range 14.61-82.64 ng/ml), and the OPR of the rescue and control groups were comparable. CONCLUSIONS In patients undergoing HRT vitrified-warmed blastocyst transfer with serum progesterone concentrations lower than 8.75 ng/ml 1 day prior to the scheduled embryo transfer (6th day of progesterone administration), additional supplementation with a 25 mg s.c. daily progesterone dose seems to rescue the cycle, resulting in OPR comparable to those of patients with serum progesterone >8.75 ng/ml.
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Affiliation(s)
- Hakan Yarali
- Anatolia IVF and Women's Health Centre, Ankara, Turkey; Hacettepe University School of Medicine, Department of Obstetrics and Gynecology, Ankara, Turkey.
| | - Mehtap Polat
- Anatolia IVF and Women's Health Centre, Ankara, Turkey
| | - Sezcan Mumusoglu
- Hacettepe University School of Medicine, Department of Obstetrics and Gynecology, Ankara, Turkey
| | | | - Murat Erden
- Hacettepe University School of Medicine, Department of Obstetrics and Gynecology, Ankara, Turkey
| | - Gurkan Bozdag
- Hacettepe University School of Medicine, Department of Obstetrics and Gynecology, Ankara, Turkey
| | - Peter Humaidan
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark; The Fertility Clinic, Skive Regional Hospital, Resenvej 25, Skive, Denmark
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Polyzos NP, Popovic Todorovic B. Reply: The evergreen conundrum of poor response: is the dose really irrelevant? Hum Reprod 2021; 36:1157-1158. [PMID: 33532856 DOI: 10.1093/humrep/deab005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- N P Polyzos
- Department of Obstetrics Gynecology and Reproductive Medicine, Dexeus Mujer, Dexeus University Hospital, Barcelona, Spain.,Faculty of Medicine and Health Sciences, Ghent University, Belgium
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Labrosse J, Peigné M, Eustache F, Sifer C, Grynberg M, Cedrin-Durnerin I. Women utilizing oocyte donation have a decreased live birth rate if they displayed a low progesterone level in a previous hormonal replacement mock cycle. J Assist Reprod Genet 2021; 38:605-612. [PMID: 33415529 DOI: 10.1007/s10815-020-02059-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2020] [Accepted: 12/29/2020] [Indexed: 10/22/2022] Open
Abstract
PURPOSE Is serum progesterone(P) level on day 2 of vaginal P administration in a hormonally substituted mock cycle predictive of live birth in oocyte donation(OD)? METHODS Retrospective analysis of 110 mock cycles from 2008 to 2016 of OD recipients having at least one subsequent embryo transfer (ET). Endometrial preparation consisted of sequential administration of vaginal estradiol, followed by transdermal estradiol and 600 mg/day vaginal micronized P. In mock cycles, serum P was measured 2 days after vaginal P introduction. OD was performed 1 to 3 years later, without P measurement. RESULTS In mock cycles, mean serum P level on day 2 was 12.8 ± 4.5 ng/mL (range: 4-28 ng/mL). A total of 32% patients had P < 10 ng/mL. At the time of first OD, age of recipients and donors, number of retrieved and attributed oocytes, and number of transferred embryos were comparable between patients with P < 10 ng/mL in their mock cycles compared with P ≥ 10 ng/mL. Pregnancy and live birth rate after first ET were significantly lower for patients with P < 10ng/mL (9% vs. 35 %; P = 0.002 and 9% vs. 32%; P = 0.008, respectively). Considering both fresh and subsequent frozen-thawed ET, cumulative live birth rate per-patient and per-transfer were significantly lower in patients with P < 10 ng/mL in their mock cycle (14% vs. 35%; P = 0.02 and 11% vs. 27%; P = 0.03). CONCLUSION A low P level in hormonally substituted cycles several years before ET performed with the same endometrial preparation is associated with a significantly lower chance of live birth. This suggests that altered vaginal P absorption is a permanent phenomenon. Monitoring serum P in hormonally substituted cycles appears mandatory to adjust luteal P substitution.
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Affiliation(s)
- Julie Labrosse
- AP-HP-Service de Médecine de la Reproduction et Préservation de la Fertilité, Hôpital Jean-Verdier, Avenue du 14 Juillet, 93140, Bondy, France
| | - Maeliss Peigné
- AP-HP-Service de Médecine de la Reproduction et Préservation de la Fertilité, Hôpital Jean-Verdier, Avenue du 14 Juillet, 93140, Bondy, France.,Université Sorbonne Paris Nord, Bobigny, France
| | - Florence Eustache
- AP-HP-Service de Biologie de la Reproduction, d'Histo-Embryologie et Cytogénétique, Hôpital Jean-Verdier, Avenue du 14 Juillet, 93140, Bondy, France
| | - Christophe Sifer
- AP-HP-Service de Biologie de la Reproduction, d'Histo-Embryologie et Cytogénétique, Hôpital Jean-Verdier, Avenue du 14 Juillet, 93140, Bondy, France
| | - Michael Grynberg
- AP-HP-Service de Médecine de la Reproduction et Préservation de la Fertilité, Hôpital Jean-Verdier, Avenue du 14 Juillet, 93140, Bondy, France
| | - Isabelle Cedrin-Durnerin
- AP-HP-Service de Médecine de la Reproduction et Préservation de la Fertilité, Hôpital Jean-Verdier, Avenue du 14 Juillet, 93140, Bondy, France.
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