Endocrine changes in the late-follicular and postovulatory intervals as determinants of the in vitro fertilization pregnancy rate

Progesterone supplementation to prevent recurrent miscarriage and to reduce implantation failure in assisted reproduction cycles

Implantation failure has been questioned for many cases of recurrent miscarriage and unsuccessful assisted reproduction. The exact cause of implantation failure is not known, but luteal phase defect is encountered in many of these cases. Consequently, women with recurrent miscarriages have been treated with progesterone supplementation with various degrees of success, and a recent meta-analysis has shown trends for improved live birth rates in those women. Progesterone probably acts as an immunological suppressant blocking T-helper (Th)1 activity and inducing release of Th2 cytokines. Numerous studies have confirmed that ovarian stimulation used in assisted reproduction is associated with luteal phase insufficiency, even when gonadotrophin-releasing hormone antagonists are used. In those patients, advanced endometrial histological maturity and a decrease in the concentration of cytoplasmic progesterone receptors are observed. Progesterone supplementation results in a trend towards improved ongoing and clinical pregnancy rates, except in patients treated with human menopausal gonadotrophin-only regimens, in whom ongoing pregnancy rates increase significantly. More randomized controlled trials are needed to increase the power of the currently available meta-analyses to further evaluate progesterone supplementation in both conditions.

Embryo associated immunosuppressor factor (EASF) and serum estradiol synergism in pre-embryonic development after in vitro fertilization

The aim of this study was to test whether the level of serum immunosuppressor factor (EASF) and serum estradiol (E2) play a cooperative role in the pre-implantation early embryonic development in IVF-patients. Serum samples were collected from 80 patients undergoing IVF-ET and the level of EASF in patient's sera was assayed using a two-site sandwich enzyme linked immunosorbent assay (ELISA) system. Two-hundred fifty-one IVF-culture media were obtained from these patients and the EASF activity was measured using concanavalin A-induced lymphocyte proliferation assay. EASF activity in embryo growth media, quality of ova, number of cells in each pre-embryo at the time of embryo transfer, cycle day 3 serum E2 and peak E2 levels were correlated with pregnancy outcome. Thirty-three out of 80 patients had detectable levels of serum EASF. The number of pre-embryos with > 4 cell stage at the time of embryo transfer correlated with the total number of ova retrieved in patients positive for serum EASF (P = 0.01) and patients that had an ongoing pregnancy at 7-8 weeks (P < 0.01). Ratio of the number of pre-embryos with > 4 cell stage at the time of embryo transfer and total number of ova retrieved correlated with cycle day 3 serum E2 (P < 0.01) and peak E2 (P = 0.01) levels only in patients positive for EASF. The EASF activity of embryo growth media correlated with cycle day 3 serum E2 (P = 0.0001) and peak E2 (P = 0.007) levels only in patients that were positive for EASF and got pregnant after IVF-ET. This study suggests that the levels of serum EASF and E2 may act synergistically in the development of early embryo.

Estrogen biosynthesis--regulation, action, remote effects, and value of monitoring in ovarian stimulation cycles

OBJECTIVE

To review current knowledge regarding estrogen biosynthesis, its regulation and action, specifically concerning local as opposed to remote effects of this hormone, and to examine the effectiveness and prognostic value of monitoring hormone concentrations and endometrial response in cycles of controlled ovarian hyperstimulation.

DATA IDENTIFICATION AND SELECTION

Studied that relate specifically to estrogen biosynthesis, enzymatic pathways, estrogen receptor physiology, and the clinical aspects of estrogen monitoring were identified through literature and Medline searches.

RESULTS

Folliculogenesis is the basic unit of ovarian activity, which has a dual purpose: oocyte maturation and steroid production. Steroidogenic granulosa and theca cells cooperate under gonadotropin control to produced estrogens by stimulating synthesis of steroidogenic enzyme messenger RNAs. Steroid synthesis is amplified further by local growth factors and follicular cell multiplication. Estrogen synthesis is directed by FSH, and only small amounts of LH are needed to amplify the follicular estrogenic potential. However, the growth of preovulatory follicles can proceed without LH, under FSH regulation only, even in the presence of low peripheral estrogen levels. Oocyte maturation and fertilization may proceed independently of ambient estrogen levels, leading to the assumption that estrogen exerts a minimal autocrine-paracrine function. The notable effect of follicular estrogen production is to promote adequate receptive endometrium for embryo implantation. Clinical treatment cycles may be monitored more effectively by evaluating end-organ response to estrogen rather than by evaluating absolute serum E2 concentrations or sonographic follicular measurements.

CONCLUSION

Follicular estrogen production is regulated by a complex set of signals that synergize to produce optimal steroidogenesis. Most importantly, the effect of estrogen is truly an endocrine effect, as it prepares the endometrium for implantation. Therefore, the goal of effective treatment and monitoring strategies should focus on direct assessment of the biologic activity of estrogen as it optimizes endometrial receptivity in anticipation of subsequent implantation.

The significance of serum progesterone levels on the day of hCG administration on IVF pregnancy rates

The aim of the present study was to evaluate the relationship between serum progesterone level on the day of human chorionic gonadotropin (hCG) administration (day 0) and pregnancy rate among patients undergoing in vitro fertilization and embryo transfer. Serum progesterone levels were analyzed retrospectively in 160 cycles. In 56 women ovarian stimulation was induced by gonadotropins only (group A). In 104 cases a gonadotropin releasing hormone (GnRH) analog was given prior to gonadotropin administration (group B). At least three embryos were transferred in all cases. A significantly (p < 0.01) higher serum progesterone level (> or = 1 ng/ml) on day 0 was observed in the 43 patients of group A who did not conceive compared with the 13 who conceived. No significant difference in serum progesterone levels on day 0 was found between the 37 patients of group B who conceived and the 67 who did not. The pregnancy rate (0.36) in group B was significantly (p < 0.05) higher than that in group A (0.23). However, the pregnancy rate (0.35) in patients in group A with low progesterone levels (< or = 1 ng/ml) was not significantly lower than that in group B. We demonstrated that elevated progesterone levels (> or = 1 ng/ml) on day 0 in patients receiving stimulation with gonadotropin only, might be detrimental to pregnancy. In view of these results, we suggest that early oocyte retrieval should be considered in patients whose progesterone level on the day of hCG administration exceeds 1 ng/ml following stimulation with gonadotropin only.

A modest increase in serum progesterone levels on the day of human chorionic gonadotropin (hCG) administration may influence pregnancy rate and pregnancy loss in in vitro fertilization-embryo transfer (IVF-ET) patients

PURPOSE

Our purpose was to study the effect of a modest increase in preovulatory serum progesterone (P4) levels in hyperstimulated patients and its association with pregnancy rate and pregnancy loss following in vitro fertilization (IVF) and embryo transfer (ET).

PATIENTS

Only patients with mechanical factor and three transferred embryos were included in the present study. They were divided into two groups according to two critical breakpoints for P4 serum levels on the day of hCG administration: serum P4 below 0.6 ng/ml in 28 cycles (group I) and > 0.6 ng/ml in 80 cycles (group II).

SETTING

The setting was the IVF program at Carmel Medical Center, Haifa, Israel.

RESULTS

The pregnancy rate per embryo transfer was 53% (15/28) in group I and 10% (8/80) in group II (P < 0.025). Of 15 pregnancies achieved in group I, 14 were ongoing pregnancies, compared to 4 of 8 ongoing pregnancies in group II (P < 0.03).

CONCLUSIONS

Our findings suggest that a very modest increase in serum P4 levels on the day of hCG administration is associated with lower pregnancy and ongoing pregnancy rates in IVF-ET.

Embryo associated immunosuppressor factor(s) secreted by preembryo and serum estradiol levels are predictive of pregnancy outcome: effect of gonadotropin releasing hormone agonist (GnRHa) treatment of patients undergoing in vitro fertilization and embryo transfer (IVF-ET)

The aim of the present study was to determine whether (i) the secretion of embryo associated immunosuppressor factor (EASF) by preimplantation embryo and serum estradiol (E2) play a cooperative role in pregnancy outcome and (ii) whether this association was affected by gonadotropin releasing hormone agonist (GnRHa) pretreatment of IVF-patients for ovarian stimulation. EASF activity was measured using concanavalin A-induced lymphocyte proliferation assay in 251 IVF-culture media obtained from 59 patients undergoing IVF-ET. EASF activity in embryo growth media, cycle day 3 serum E2 level and peak E2 levels were correlated with pregnancy outcome. Results indicate that in GnRHa non-treated patients (i) the immunosuppressive activity of embryo growth media significantly (p less than 0.05) differed between the patients with varying concentration of day 3 serum E2, (ii) the presence of immunosuppressive activity in the embryo growth media was associated with success of pregnancy in patients with day 3 serum E2 level of 21-40 pg/ml (p less than 0.005) and in patients with peak E2 level in serum of less than = 1500 pg/ml (p less than 0.05). No association in immunosuppressive activity, serum E2 level and successful pregnancy was seen in GnRHa treated patients. This preliminary study suggests that the concentration of serum hormones and factors that are altered due to GnRHa pretreatment of IVF-patients may affect the cooperative role played by EASF, E2 and other factors in the success of pregnancy.

High preovulatory serum luteinizing hormone level is unfavorable to conception

Serum estradiol, progesterone and luteinizing hormone (LH) levels of 16 pregnant and 58 non-pregnant stimulated in vitro fertilization-embryo transfer (IVF-ET) or gamete intrafallopian transfer (GIFT) cycles have been compared with regard to their predictive value for achievement of pregnancy. Serum estradiol and progesterone pattern of the pregnant and non-pregnant group did not show any significant difference. Around the time of ovulation induction by human chorionic gonadotropin (hCG) the serum LH values proved to be higher in the non-pregnant group than in the pregnant one. In spite of having a permissive function, preovulatory serum estradiol and progesterone seem not to have a predictive value with regard to pregnancy. Elevated preovulatory serum LH is detrimental for pregnancy, therefore the measurement of serum LH beyond hCG administration also, and the cancellation of cycles with high serum LH levels shortly before oocyte retrieval is recommended.

The luteal phase in polycystic ovary syndrome during ovulation induction with human menopausal gonadotropin with and without leuprolide acetate

Little data exist on the effects of adjunctive therapy with leuprolide acetate (LA) in the luteal phase of women with polycystic ovary syndrome (PCOS) undergoing ovulation induction with human menopausal gonadotropin (hMG). Additionally, it is not known whether gonadal steroid concentrations in the luteal phase of induced cycles in PCOS are predictive of pregnancy. In this prospective, randomized study comparing cycles using hMG alone (n = 26) with cycles using hMG with LA (n = 33), no differences were noted between treatment groups in progesterone (P), estradiol (E2), and P:E2 ratios on luteal days 3, 6, and 9. When all treatment cycles were pooled, there were no differences in P, E2, or P:E2 ratios, comparing conception and nonconception cycles. We conclude that adjunctive therapy with LA in PCOS patients undergoing ovulation induction with hMG does not alter the luteal phase concentrations of P, E2, and P:E2. Furthermore, no correlation was found between the serum concentrations of these luteal phase steroids and cycle fecundity.

Trial of support treatment with human chorionic gonadotrophin in the luteal phase after treatment with buserelin and human menopausal gonadotrophin in women taking part in an in vitro fertilisation programme

OBJECTIVE

To evaluate the effect of support with human chorionic gonadotrophin in the luteal phase in women taking part in an in vitro fertilisation programme after buserelin and human menopausal gonadotrophin were used to hyperstimulate their ovaries.

DESIGN

Controlled group comparison.

SETTING

Outpatient department of a private hospital.

PATIENTS

115 Women with indications for in vitro fertilisation, all of whom had at least one embryo transferred.

INTERVENTIONS

After suppression of the pituitary with buserelin the ovaries of all the women were stimulated with human menopausal gonadotrophin on day 4 of the luteal phase. Human chorionic gonadotrophin (10,000 IU) was given to induce ovulation, and oocytes were recovered 34 hours later. Embryos were transferred 46 to 48 hours after insemination. Women who had received the 10,000 IU of human chorionic gonadotrophin on a date that was an uneven number (n = 61) were allocated to receive support doses of 2500 IU human chorionic gonadotrophin three and six days after that date. The remaining 54 women did not receive hormonal support.

END POINT

Determination of the rates of pregnancy. MEASUREMENTS and main results--Support with human chorionic gonadotrophin did not significantly alter the progesterone or oestradiol concentrations in the early or mid-luteal phase. The mean (range) progesterone concentrations in the late luteal phase in women who did not become pregnant were, however, significantly higher in those who received support (16(9-110) nmol/l nu 8(4-46) nmol/l), and the luteal phase was significantly longer in this group (14 days nu 12 days). The rate of pregnancy was significantly higher in the women who received support than in those who did not (25/61 nu 8/54).

CONCLUSIONS

When buserelin and human menopausal gonadotrophin are used to hyperstimulate ovaries support with human chorionic gonadotrophin in the luteal phase has a beneficial effect on in vitro fertilisation.

Super high estradiol response to gonadotropin stimulation in patients undergoing in vitro fertilization

The likelihood of establishment of a term pregnancy from in vitro fertilization (IVF) is related to the estradiol (E2) pattern and peak level. To examine the influence of super high E2 peak levels (greater than or equal to 2000 pg/ml), we reviewed the clinical outcomes of all IVF cycles with follicular phase E2 levels greater than 2000 pg/ml from May 1982 through June 1987. Among 1651 IVF cycles initiated during this time, 102 cycles (6.2%) had super high E2 levels. Twenty-seven of these cycles occurred in 34 IVF attempts in 12 women. Stimulation was performed with human menopausal gonadotropin (hMG) in 96 cycles and follicle-stimulating hormone (FSH) in 6 cycles. A mean of 9.3 +/- 0.7 oocytes per cycle was recovered, of which 5.5 +/- 0.5 fertilized and underwent cleavage. In 11 cycles, with a mean of 6.8 oocytes recovered, none fertilized. Polyploid fertilization occurred in 23 of 90 cycles (25.6%), and 40 of 558 fertilized oocytes (7.2%). From these cycles, 10 clinical pregnancies (9.8%) have resulted: 6 pregnancies in 59 cycles with luteal-phase progesterone support (10.2%) and 4 pregnancies in 31 cycles without luteal-phase progesterone support (12.9%). Among the 1549 cycles with peak E2 levels less than or equal to 2000 pg/ml, 143 (9.2%) resulted in clinical pregnancies. We conclude that there is a small subset of patients who will have super high E2 responses to gonadotropin stimulation and that there is a tendency to stimulate repetitively in this fashion.(ABSTRACT TRUNCATED AT 250 WORDS)

The effect of cycle length on the outcome of in vitro fertilization

In order to study the effect of cycle length on the pregnancy rate in an in vitro fertilization and embryo transfer (IVF-ET) program, 173 consecutive patients were divided into short menstrual cycle (mode 26 days or less) and normal cycle (mode 27 days or more) groups. Patients were randomly allocated to one of two treatments, commencing ovarian stimulation with human menopausal gonadotropin (hMG) on either day 2 or day 4 of their cycle. The number of oocytes retrieved and embryos transferred did not differ significantly. The amount of hMG used and day of human chorionic gonadotrophin administration both differed significantly (P less than 0.01) between regimens but was independent of cycle length. Both the clinical pregnancy rate (30.2% versus 9.4%, P less than 0.05) and the number of cleaved embryos giving rise to gestation sacs (16% versus 3.4%, P less than 0.02) was significantly higher in patients with a normal cycle length. Mode cycle length has a significant bearing on the outcome of IVF-ET cycles.

Influence of human chorionic gonadotropin (hCG) and hCG internalization by granulosa cells on the rate of in vitro fertilization and embryonic development of human oocytes

Follicular fluids and granulosa cells were obtained from 28 aspirated follicles of nine women undergoing laparoscopy in an in vitro fertilization program. Follicular growth was stimulated by a human menopausal gonadotropin regimen and laparoscopy was performed 32 hours after human chorionic gonadotropin (hCG) administration. Follicular fluid 17 beta-estradiol (E2) levels were higher and hCG levels were lower in follicles with oocytes that fertilized and cleaved beyond two blastomeres (greater than two-cell group) than in those with nonfertilizable oocytes (NF group) (P less than 0.05). Compared to those from the NF group, granulosa cells from the greater than two-cell group secreted less progesterone (P) in vitro and had a fourfold increase in percentage of cells with internalized hCG. These results demonstrate that the steroidogenic capacity of granulosa cells from follicles whose oocytes fertilize and undergo accelerated embryonic development in vitro differs from the capacity of granulosa cells from NF follicles. This difference may be due to their enhanced ability to bind and subsequently internalize hCG.

Follicular factors, serum estradiol, and outcome of pregnancy following in vitro fertilization and embryo transfer

Success rate of in vitro fertilization and embryo transfer (IVF-ET) depends upon clinical and laboratory variables. This study compared follicular measurements and serum estradiol (E2) between 23 delivered and 23 nonpregnant controls following IVF-ET. E2, number of large follicles (no.), E2/no. ratio, total diameter of large follicle (TD), and the E2/TD ratio were compared between the two groups and between 23 women who delivered and 10 who aborted. E2 (P = 0.03), E2/no. (P = 0.006), and E2/TD (P = 0.005) were found to differ significantly between delivered and controls and between delivered and those who aborted.