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Wang N, Zhu W, Gong Y. Association of raised serum progesterone level with ovulation trigger and histology of endometrium in stimulated cycles. BRAZ J PHARM SCI 2022. [DOI: 10.1590/s2175-97902022e20151] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Affiliation(s)
- Na Wang
- Shanghai Jiao Tong University, China
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2
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Roque Fernandez MA, Alvarez Lleo C, Gonzalez Mirasol E, Resta Serra M, Garcia Garrido C, Sanchez Toledo M, Amezcua Recover A. Progesterone elevation on the day of oocyte retrieval and live birth rate after in vitro fertilisation treatment. J OBSTET GYNAECOL 2021; 42:1396-1400. [PMID: 34907863 DOI: 10.1080/01443615.2021.1983780] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
The objective of this study was to evaluate if progesterone elevation (PE) on the day of oocyte retrieval is associated with IVF outcome. A prospective cohort study of 400 IVF-ICSI cycles, with fresh embryo transfer on day 2-3 was performed. We proposed a serum progesterone (P) level on percentile (p) 90 as a threshold.Pregnancy rates were not affected, however there were more miscarriages (25.7% vs 43.8%) and lower live birth rate (LBR) (28% vs 23.1%) in the PE group (not statistically significant). We also found a positive correlation between P levels and retrieved and mature oocytes, total embryos, and good quality embryos. This is the first study to analyse LBR based on P levels on the day of oocyte retrieval. PE is not associated with the IVF outcome, but there is a trend to lower ongoing pregnancy rate and LBR and more miscarriages. Our results also show that P levels have no negative effects on oocyte and embryo quality.Impact statementWhat is already known on this subject? The influence of PE during IVF cycle on pregnancy rates remains controversial.What do the results of this study add? This is the first study to analyse LBR based on P levels on the day of oocyte retrieval.What are the implications of these findings for clinical practice and/or further research? We demonstrated that pregnancy rates were not affected by PE at oocyte retrieval, but there is a trend to lower ongoing pregnancy rate and LBR and more miscarriages. Randomised controlled trials are needed to offer more evidence of these relationships.
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Affiliation(s)
| | - Cristina Alvarez Lleo
- Department of Obstetrics and Gynaecology, Albacete University Hospital Complex, Albacete, Spain
| | - Esteban Gonzalez Mirasol
- Department of Obstetrics and Gynaecology, Albacete University Hospital Complex, Albacete, Spain.,Medical Science Department, University of Castilla la Mancha, Ciudad Real, Spain
| | - Maria Resta Serra
- Department of Obstetrics and Gynaecology, Albacete University Hospital Complex, Albacete, Spain
| | - Carmen Garcia Garrido
- Department of Obstetrics and Gynaecology, Albacete University Hospital Complex, Albacete, Spain
| | - María Sanchez Toledo
- Department of Obstetrics and Gynaecology, Albacete University Hospital Complex, Albacete, Spain
| | - Antonio Amezcua Recover
- Department of Obstetrics and Gynaecology, Albacete University Hospital Complex, Albacete, Spain.,Medical Science Department, University of Castilla la Mancha, Ciudad Real, Spain
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3
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Mitra S, Patil M, Patil M, Nayak P. Pre-ovulatory hormones on day of human chorionic gonadotropin trigger and assisted reproductive technique outcomes in different ovarian response groups. J Hum Reprod Sci 2021; 14:406-414. [PMID: 35197687 PMCID: PMC8812392 DOI: 10.4103/jhrs.jhrs_91_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2021] [Revised: 11/11/2021] [Accepted: 11/13/2021] [Indexed: 11/04/2022] Open
Abstract
Background: Aims: Setting and Design: Materials and Methods: Statistical Analysis: Results: Conclusion:
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4
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Novia D, Putri Lubis H, Halim B, Pustimbara A, Lestari R, Abinawanto A, Bowolaksono A. The impact of late follicular progesterone level on in vitro fertilization-intracytoplasmic sperm injection outcome: Case-control study. Int J Reprod Biomed 2020; 18:367-374. [PMID: 32637865 PMCID: PMC7306063 DOI: 10.18502/ijrm.v13i5.7157] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2019] [Revised: 09/07/2019] [Accepted: 12/02/2019] [Indexed: 12/03/2022] Open
Abstract
Background Studies have been conducted to improve the pregnancy rate through the in vitro fertilization (IVF) and intracytoplasmic sperm injection (ICSI) program. In recent years, researchers have been focusing on finding impact of high progesterone level on endometrial receptivity. However, data on whether progesterone level also affects the quality of the embryo is still limited. Objective The aim is to assess the effect of late follicular progesterone level on the outcome of in vitro fertilization-intracytoplasmic sperm injection (IVF-ICSI). Materials and Methods This was a case-control of 245 women who underwent in vitro fertilization cycle at Halim Fertility Center, Indonesia. The outcomes assessed were number of oocytes retrieved (OR), maturation rate (MR), fertilization rate (FR), number of good embryos (GE), number of fair embryos (FE), and number of poor embryos (PE). The progesterone (P4) and estradiol (E2) levels were analyzed on the day of human chorionic gonadotropin injection. Serum progesterone level was divided into three groups: 1. low progesterone (≤ 0.50 ng/ml), 2. normal progesterone (0.51-1.50 ng/ml), and 3. high progesterone (> 1.50 ng/ml). All outcomes were compared amongst the groups. Results Significant differences occurred between progesterone level on the day of human chorionic gonadotropin administration. The number of OR in group 1, 2, and 3 were 8.41 ± 5.88 vs. 12.99 ± 8.51 vs. 17.58 ± 9.52, respectively. Conclusion Progesterone level on the day of human chorionic gonadotropin injection may have an impact on the outcome of IVF-ICSI.
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Affiliation(s)
- Diana Novia
- Department of Biology, Faculty of Mathematics and Science, University of Indonesia, Depok, Indonesia.,Halim Fertility Center, Stella Maris Women and Children Hospital, Medan, Indonesia
| | - Hilma Putri Lubis
- Halim Fertility Center, Stella Maris Women and Children Hospital, Medan, Indonesia.,Faculty of Medicine University of Sumatera Utara, Haji Adam Malik General Hospital, Medan, Indonesia
| | - Binarwan Halim
- Halim Fertility Center, Stella Maris Women and Children Hospital, Medan, Indonesia.,Faculty of Medicine University of Sumatera Utara, Haji Adam Malik General Hospital, Medan, Indonesia
| | - Anantya Pustimbara
- Department of Biology, Faculty of Mathematics and Science, University of Indonesia, Depok, Indonesia
| | - Retno Lestari
- Department of Biology, Faculty of Mathematics and Science, University of Indonesia, Depok, Indonesia
| | - Abinawanto Abinawanto
- Department of Biology, Faculty of Mathematics and Science, University of Indonesia, Depok, Indonesia
| | - Anom Bowolaksono
- Department of Biology, Faculty of Mathematics and Science, University of Indonesia, Depok, Indonesia
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5
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Hussein RS, Elnashar I, Amin AF, Abou-Taleb HA, Abbas AM, Abdelmageed AM, Farghaly T, Zhao Y. Revisiting debates of premature luteinization and its effect on assisted reproductive technology outcome. J Assist Reprod Genet 2019; 36:2195-2206. [PMID: 31650455 PMCID: PMC6885458 DOI: 10.1007/s10815-019-01598-4] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2019] [Accepted: 09/25/2019] [Indexed: 11/29/2022] Open
Abstract
The impact of the prematurely elevated serum progesterone on the late follicular phase, commonly known as premature luteinization (PL), is a matter of continuing debate. Available evidence supports that serum progesterone ≥ 1.5 ng/ml on the day of ovulation triggering could reduce the pregnancy potential in fresh in vitro fertilization (IVF) cycles by jeopardizing endometrial receptivity. Causes of PL during ovarian stimulation are unclear. Recent studies point toward the daily follicle-stimulating hormone dosage, duration of controlled ovarian stimulation, number of oocytes retrieved, and peak estradiol level as factors affecting the incidence of PL. Emerging data show additional influence on embryo quality. The prevention of PL has been challenging. The key elements in preventing PL include individualization of ovarian stimulation according to patient's ovarian reserve, proper ovulation trigger timing, and use of medications such as corticosteroids and metformin. Embryo cryopreservation with deferred embryo transfer is the established strategy to overcome PL, yet it is an extra burden to the IVF laboratory and increased cost for patients. Herein, we review the up-to-date knowledge of this frequent IVF problem including causes, proposed diagnostic criteria, and its impact on endometrial receptivity, embryo quality, and pregnancy outcomes. The preventive measures and rescue strategies are also discussed.
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Affiliation(s)
- Reda S Hussein
- Department of Obstetrics and Gynecology, Mayo Clinic, Rochester, MN, USA
- Department of Obstetrics and Gynecology, Faculty of Medicine, Assiut University, Assiut, Egypt
| | - Ihab Elnashar
- Department of Obstetrics and Gynecology, Faculty of Medicine, Assiut University, Assiut, Egypt
| | - Ahmed F Amin
- Department of Obstetrics and Gynecology, Faculty of Medicine, Assiut University, Assiut, Egypt
| | - Hisham A Abou-Taleb
- Department of Obstetrics and Gynecology, Faculty of Medicine, Assiut University, Assiut, Egypt
| | - Ahmed M Abbas
- Department of Obstetrics and Gynecology, Faculty of Medicine, Assiut University, Assiut, Egypt.
- Women Health Hospital, Assiut, 71511, Egypt.
| | - Ahmed M Abdelmageed
- Department of Obstetrics and Gynecology, Faculty of Medicine, Assiut University, Assiut, Egypt
| | - Tarek Farghaly
- Department of Obstetrics and Gynecology, Mayo Clinic, Rochester, MN, USA
| | - Yulian Zhao
- Department of Obstetrics and Gynecology, Mayo Clinic, Rochester, MN, USA
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6
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Nagaraja N, Talwar P, Mukherjee B, Chakrabarty BK. Correlation between Serum Progesterone Level on the Day of Ovulation Trigger During In vitro Fertilization and Its Effect on Treatment Outcome. J Hum Reprod Sci 2019; 12:136-140. [PMID: 31293328 PMCID: PMC6594124 DOI: 10.4103/jhrs.jhrs_115_18] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Background: Premature luteinization (PL) is defined as a premature rise in serum progesterone concentration on or before the day of ovulation trigger with human chorionic gonadotropin. The incidence of PL varies between 5% and 30% during in vitro fertilization and embryo transfer (IVF-ET). Materials and Methods: The prospective observational study comprising 380 patients undergoing IVF-ET. Blood samples were collected for serum progesterone level estimation on the day of ovulation trigger. Ovum pickup was done 36 h later and serum progesterone levels were correlated with IVF-ET outcome. Study Outcome: To correlate serum progesterone level on the day of ovulation trigger during IVF and its effect on treatment outcome. Results: Mean serum progesterone level in the positive pregnancy group and negative pregnancy group was 0.892 ± 0.752 ng/ml and 0.91 ± 0.688 ng/ml, respectively (P = 0.961). The overall incidence of PL was 12.8% with 12.7% and 13.6% in the agonist and antagonist protocol respectively (P = 0.9001). PL incidence was 13.5% and 13.4% in positive pregnancy and negative pregnancy group (P = 0.223). Conclusion: PL has been associated with 12.8% of the IVF cycles. There was no statistically significant difference observed in the incidence of PL between different IVF stimulation protocols. PL does not seem to affect IVF outcome.
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Affiliation(s)
- N Nagaraja
- Department of ART, 151 Base Hospital, Guwahati, Assam, India
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7
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Kaponis A, Chronopoulou E, Decavalas G. The curious case of premature luteinization. J Assist Reprod Genet 2018; 35:1723-1740. [PMID: 30051348 DOI: 10.1007/s10815-018-1264-8] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2018] [Accepted: 07/11/2018] [Indexed: 12/26/2022] Open
Abstract
PURPOSE Premature luteinization (PL) affects 12.3-46.7% of fresh in vitro fertilization cycles, and there is accumulating evidence confirming its negative effect on success rates. However, despite its clinical significance, PL is poorly understood and defined. This narrative review aims to provide a fresh look at the phenomenon of PL by summarizing the existing evidence and re-evaluating fundamental issues. METHODS A thorough electronic search was conducted covering the period from 1978 until January 2018 in PubMed, Embase, and Medline databases, and references of relevant studies were cross-checked. Meeting proceedings of the European Society of Human Reproduction and Embryology and the American Society for Reproductive Medicine were also hand searched. RESULTS In the curious case of PL, one should go back to the beginning and re-consider every step of the way. The pathogenesis, definition, measurement methods, clinical implications, and management strategies are discussed in detail, highlighting controversies and offering "food for thought" for future directions. CONCLUSIONS Authors need to speak the same language when studying PL in order to facilitate comparisons. The terminology, progesterone cut-off, measurement methods and days of measurement should be standardized and globally accepted; otherwise, there can be no scientific dialog. Future research should focus on specific patient profiles that may require a tailored approach. Progesterone measurements throughout the follicular phase possibly depict the progesterone exposure better than an isolated measurement on the day of hCG. Adequately powered randomized controlled trials should confirm which the best prevention and management plan of PL is, before introducing any strategy into clinical practice.
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Affiliation(s)
- Apostolos Kaponis
- Department of Obstetrics and Gynaecology, Patras University School of Medicine, General University Hospital of Patras, Rio, 26504, Patras, Greece
| | - Elpiniki Chronopoulou
- Department of Obstetrics and Gynaecology, Patras University School of Medicine, General University Hospital of Patras, Rio, 26504, Patras, Greece.
| | - George Decavalas
- Department of Obstetrics and Gynaecology, Patras University School of Medicine, General University Hospital of Patras, Rio, 26504, Patras, Greece
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Bushaqer N, Mohawash W, Alrakaf F, Algaffli M, Rawah H, Dayoub N, Ayoub H, Alasmari N. Progesterone level significance in agonist versus antagonist protocols. MIDDLE EAST FERTILITY SOCIETY JOURNAL 2018. [DOI: 10.1016/j.mefs.2017.09.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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9
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Lepage J, Keromnes G, Epelboin S, Luton D, Yazbeck C. Premature progesterone rise on day of hCG negatively correlated with live birth rate in IVF cycles: An analysis of 1022 cycles. J Gynecol Obstet Hum Reprod 2018; 48:51-54. [PMID: 29783037 DOI: 10.1016/j.jogoh.2018.05.005] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2016] [Revised: 05/15/2018] [Accepted: 05/17/2018] [Indexed: 11/18/2022]
Abstract
OBJECTIVE To investigate the relationship between serum P levels on the day of hCG administration and pregnancy outcomes in patients undergoing IVF. DESIGN Retrospective study. SETTING Teaching hospital. PATIENTS A total of 1022 IVF-ICSI cycles, frozen embryo transfer excluded. INTERVENTION(S) Patients-all types of responder - underwent IVF with agonist or antagonist protocols. Clinical outcomes of IVF were analyzed according to plasma P levels. MAIN OUTCOME MEASURE(S) Ongoing pregnancy rates. RESULTS We proposed a serum P level of 1.57ng/ml on day of hCG as a threshold for all types of responders and all protocols combined. Ongoing implantation rates were not affected by elevated progesterone. Live birth rate was inversely associated with serum P levels on day of hCG and more miscarriages were associated with P>1.57ng/ml. We have not found the progesterone>1.57ng/ml on the day of hCG as a prognostic factor for pregnancy. CONCLUSION(S) Elevated P level on the day of hCG administration negatively influence live birth rate and is correlated to an increase of miscarriage. The detrimental effect of P elevation on pregnancy seems not to be related substantially to endometrium receptivity. Thus, despite a comparable clinical pregnancy rate and an initial implantation rate, we demonstrate more spontaneous abortion and it would seem that the effect of progesterone is later.
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Affiliation(s)
- Julien Lepage
- Bichat Claude Bernard Hospital, AP-HP, 46, rue Henri-Huchard, 75018 Paris, France.
| | - Gwenola Keromnes
- Groupe hospitalier Diaconesses Croix Saint-Simon, 12-18, rue du Sergent-Bauchat, 75012 Paris, France
| | - Sylvie Epelboin
- Bichat Claude Bernard Hospital, AP-HP, 46, rue Henri-Huchard, 75018 Paris, France
| | - Dominique Luton
- Bichat Claude Bernard Hospital, AP-HP, 46, rue Henri-Huchard, 75018 Paris, France; Paris 7 Denis Diderot University Paris, France
| | - Chadi Yazbeck
- Cherest Fertility Center, 5, rue Pierre-Cherest, 92200 Neuilly-Sur-Seine, France
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Mohawash W, Bushaqer N, Alrakaf F, Algaffli M, Rawah H, Dayoub N, Ayoub H, Alasmari N. Progesterone level on the day of triggering and pregnancy outcome in long GnRH agonist protocol. MIDDLE EAST FERTILITY SOCIETY JOURNAL 2018. [DOI: 10.1016/j.mefs.2017.08.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022] Open
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11
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Ozkaya E, Kutlu T, Abide Yayla C, Kayatas Eser S, Sanverdi I, Devranoglu B. Area under the curve of temporal estrogen and progesterone measurements during assisted reproductive technology: Which hormone is the main determinant of cycle outcome? J Obstet Gynaecol Res 2017; 44:263-269. [PMID: 29063651 DOI: 10.1111/jog.13492] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2017] [Accepted: 08/08/2017] [Indexed: 11/27/2022]
Abstract
AIM Is there any relationship between estrogen and progesterone concentrations during assisted reproductive technology (ART)? Which hormone is the main determinant of impaired endometrial receptivity? METHODS This study was conducted from July to December 2016 at the in vitro Fertilization/Intracytoplasmic Sperm Injection unit at Zeynep Kamil Women and Children's Health Training and Research Hospital. A total of 289 women who underwent ART were prospectively screened and areas under the curve of temporal estrogen (AUCEM) and progesterone measurements (AUCPM) were calculated for each participant. Women were included if they had regular menstrual cycles, normal serum prolactin levels and had not received hormone treatment within three months. ART was indicated in all patients for unexplained infertility. Patients were divided into two groups: with (n = 90) and without (n = 199) embryo implantation. The relationship between the two AUCs and ART success was assessed in terms of embryo implantation and clinical pregnancy. RESULTS Implantation was successful in 90 (31.1%) women, and a fetal heart rate was detected in 83 (28.7%) cases. There was a significant correlation between AUCEM and AUCPM (r = 0.525, P < 0.001). Multivariate regression analysis showed significant associations between failure of implantation, lack of clinical pregnancy and AUCEM (beta coefficient = 0.311, P < 0.001; beta coefficient = 0.297, P < 0.001, respectively) after adjusting for AUCPM. CONCLUSION Our data showed that the degree of endometrial estrogen exposure is the main factor functioning as a detrimental effect of ovarian stimulation on endometrial receptivity.
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Affiliation(s)
- Enis Ozkaya
- Department of Obstetrics and Gynecolgy, Zeynep Kamil Women and Children's Health Training and Research Hospital, Istanbul, Turkey
| | - Tayfun Kutlu
- Department of Obstetrics and Gynecolgy, Zeynep Kamil Women and Children's Health Training and Research Hospital, Istanbul, Turkey
| | - Cigdem Abide Yayla
- Department of Obstetrics and Gynecolgy, Zeynep Kamil Women and Children's Health Training and Research Hospital, Istanbul, Turkey
| | - Semra Kayatas Eser
- Department of Obstetrics and Gynecolgy, Zeynep Kamil Women and Children's Health Training and Research Hospital, Istanbul, Turkey
| | - Ilhan Sanverdi
- Department of Obstetrics and Gynecolgy, Zeynep Kamil Women and Children's Health Training and Research Hospital, Istanbul, Turkey
| | - Belgin Devranoglu
- Department of Obstetrics and Gynecolgy, Zeynep Kamil Women and Children's Health Training and Research Hospital, Istanbul, Turkey
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Ashmita J, Vikas S, Swati G. The Impact of Progesterone Level on Day Of hCG Injection in IVF Cycles on Clinical Pregnancy Rate. J Hum Reprod Sci 2017; 10:265-270. [PMID: 29430153 PMCID: PMC5799930 DOI: 10.4103/0974-1208.223278] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Background: Premature progesterone rise (PPR) has long been implicated as contributing to implantation failure. Despite the use of gonadotropin-releasing hormone (GnRH) analogues, subtle increases in serum progesterone (P4) levels beyond a threshold progesterone concentration were observed on the day of trigger in controlled ovarian hyperstimulation cycles. Aims: The purpose of the study was to evaluate the incidence of PPR on the day of trigger in conventional IVF/ICSI cycles and its impact on clinical pregnancy rate. Settings and Design: A total of 235 patients undergoing conventional IVF/IVF–ICSI by fresh embryo transfer cycles from January 2016 to December 2016 at the infertility unit of a tertiary care hospital were prospectively analyzed. Material and Methods: Patients included in the study were subjected to GnRH agonist long/antagonist protocol. Ovulation induction was given with rFSH and/or HMG in both the protocols. The cutoff for defining PPR was P4≥ 1.5 ng/ml, and an analysis of the role of P4on clinical pregnancy rate was performed. Statistical analysis was performed with the Statistical Package for the Social Sciences trial version 23.0 software for Windows and Primer software. Results and Conclusion: The overall clinical pregnancy rate per embryo transfer was 30.6%. The clinical pregnancy rate in the patients with P4 <1.5 ng/ml was significantly higher than those with elevated levels, P4≥ 1.5 ng/ml (33.3% vs. 12.9%; P = 0.037). Premature progesterone elevation in ART cycles is possibly associated with lower clinical pregnancy rates.
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Affiliation(s)
- Jawa Ashmita
- Department of Obstetrics and Gynecology, Mahatma Gandhi Medical College and Hospital, Jaipur, Rajasthan, India
| | - Swarankar Vikas
- Department of Obstetrics and Gynecology, Mahatma Gandhi Medical College and Hospital, Jaipur, Rajasthan, India
| | - Garg Swati
- Department of Obstetrics and Gynecology, Mahatma Gandhi Medical College and Hospital, Jaipur, Rajasthan, India
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