Subtle rise in serum progesterone during the follicular phase as a predictor of the outcome of in vitro fertilization

Effect of prematurely elevated late follicular progesterone on pregnancy outcomes following ovarian stimulation-intrauterine insemination for unexplained infertility: secondary analysis of the AMIGOS trial

STUDY QUESTION

What is the relationship between late follicular phase progesterone levels and clinic pregnancy and live birth rates in couples with unexplained infertility undergoing ovarian stimulation with IUI (OS-IUI)?

SUMMARY ANSWER

Late follicular progesterone levels between 1.0 and <1.5 ng/ml were associated with higher live birth and clinical pregnancy rates while the outcomes in groups with higher progesterone levels did not differ appreciably from the <1.0 ng/ml reference group.

WHAT IS KNOWN ALREADY

Elevated late follicular progesterone levels have been associated with lower live birth rates after fresh embryo transfer following controlled ovarian stimulation and egg retrieval, but less is known about whether an association exists with outcomes in OS-IUI cycles. Existing studies are few and have been limited to ovarian stimulation with gonadotrophins, but the use of oral agents, such as clomiphene citrate and letrozole, is common with these treatments and has not been well studied.

STUDY DESIGN, SIZE, DURATION

The study was a prospective cohort analysis of the Assessment of Multiple Intrauterine Gestations from Ovarian Stimulation (AMIGOS) randomized controlled trial. Frozen serum was available for evaluation from 2121 cycles in 828 AMIGOS participants. The primary pregnancy outcome was live birth per cycle, and the secondary pregnancy outcome was clinical pregnancy rate per cycle.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Couples with unexplained infertility in the AMIGOS trial, for whom female serum from day of trigger with hCG was available in at least one cycle of treatment, were included. Stored frozen serum samples from day of hCG trigger during treatment with OS-IUI were evaluated for serum progesterone level. Progesterone level <1.0 ng/ml was the reference group for comparison with progesterone categorized in increments of 0.5 ng/ml up to ≥3.0 ng/ml. Unadjusted and adjusted risk ratios (RR) and 95% CI were estimated using cluster-weighted generalized estimating equations to estimate modified Poisson regression models with robust standard errors.

MAIN RESULTS AND THE ROLE OF CHANCE

Compared to the reference group with 110/1363 live births (8.07%), live birth rates were significantly increased in cycles with progesterone 1.0 to <1.5 ng/ml (49/401 live births, 12.22%) in both the unadjusted (RR 1.56, 95% CI 1.14, 2.13) and treatment-adjusted models (RR 1.51, 95% CI 1.10, 2.06). Clinical pregnancy rates were also higher in this group (55/401 clinical pregnancies, 13.72%) compared to reference group with 130/1363 (9.54%) (unadjusted RR 1.46, 95% CI 1.10, 1.94 and adjusted RR 1.42, 95% CI 1.07, 1.89). In cycles with progesterone 1.5 ng/ml and above, there was no evidence of a difference in clinical pregnancy or live birth rates relative to the reference group. This pattern remained when stratified by ovarian stimulation treatment group but was only statistically significant in letrozole cycles.

LIMITATIONS, REASONS FOR CAUTION

The AMIGOS trial was not designed to answer this clinical question, and with small numbers in some progesterone categories our analyses were underpowered to detect differences between some groups. Inclusion of cycles with progesterone values above 3.0 ng/ml may have included those wherein ovulation had already occurred at the time the IUI was performed. These cycles would be expected to experience a lower success rate but pregnancy may have occurred with intercourse in the same cycle.

WIDER IMPLICATIONS OF THE FINDINGS

Compared to previous literature focusing primarily on OS-IUI cycles using gonadotrophins, these data include patients using oral agents and therefore may be generalizable to the wider population of infertility patients undergoing IUI treatments. Because live births were significantly higher when progesterone ranged from 1.0 to <1.5 ng/ml, further study is needed to clarify whether this progesterone range may truly represent a prognostic indicator in OS-IUI cycles.

STUDY FUNDING/COMPETING INTEREST(S)

Oklahoma Shared Clinical and Translational Resources (U54GM104938) National Institute of General Medical Sciences (NIGMS). AMIGOS was funded by the Eunice Kennedy Shriver National Institute of Child Health and Human Development: U10 HD077680, U10 HD39005, U10 HD38992, U10 HD27049, U10 HD38998, U10 HD055942, HD055944, U10 HD055936, and U10HD055925. Research made possible by the funding by American Recovery and Reinvestment Act. Dr Burks has disclosed that she is a member of the Board of Directors of the Pacific Coast Reproductive Society. Dr Hansen has disclosed that he is the recipient of NIH grants unrelated to the present work, and contracts with Ferring International Pharmascience Center US and with May Health unrelated to the present work, as well as consulting fees with May Health also unrelated to the present work. Dr Diamond has disclosed that he is a stockholder and a member of the Board of Directors of Advanced Reproductive Care, Inc., and that he has a patent pending for the administration of progesterone to trigger ovulation. Dr Anderson, Dr Gavrizi, and Dr Peck do not have conflicts of interest to disclose.

TRIAL REGISTRATION NUMBER

N/A.

Does the ultrasound appearance of the endometrium during treatment with assisted reproductive technologies influence pregnancy outcomes?

We evaluated endometrial pattern, defined as the relative echogenicity of the endometrium on a longitudinal uterine ultrasonic section, as a surrogate for endometrial receptivity in an attempt to evaluate the association between endometrial pattern and pregnancy outcome in women who underwent ART treatment. The primary outcome was live birth and secondary outcomes were clinical intrauterine pregnancy and miscarriage. Potential associations were evaluated using cluster-weighted generalized estimating equations to account for within-couple correlation among repeated ART cycles while adjusting for potentially confounding variables. There were 1034 ART cycles with embryo transfer (778 fresh, 256 frozen) among 695 women (median age: 31.0 (6.0) years). The average number of embryos transferred per cycle was 2.1. The clinical intrauterine pregnancy rate per transfer was 56.0% for fresh and 54.3% for frozen cycles. The overall live birth rate per embryo transfer was 48.4%. Live birth rates were unchanged when the endometrium was semi-trilinear (RR:0.91 CI:0.74,1.12) or unilinear (RR:1.15 CI:0.89,1.49) in comparison to trilinear endometrium after controlling for potentially confounding variables. Results were similar when analysed separately for fresh and frozen cycles and when evaluating associations with clinical intrauterine pregnancy and miscarriage rates. It appears that endometrial pattern does not significantly affect live birth in ART and our data do not support cancelling an ART cycle if the endometrium is less than trilinear.

Association of raised serum progesterone and gene polymorphisms with risk of failure pregnancy and miscarriage

Balanced cytokine required for a healthy pregnancy to avoid miscarriage. There is yet no accord on the effect of raised progesterone on the endometrium, recurrent miscarriage and association with cytokines. The present study see the effect of raised serum progesterone level on ovulation, miscarriage, and association of selected Cytokines polymorphisms with recurrent miscarriage. In a controlled prospective study patients undergoing COS under controlled ovarian hyper stimulation were evaluated. On the day of trigger progesterone levels were measured and serum hormonal estimation assay was done on the day of ovulation trigger by automated immunoassay. Genotyping analysis using allelic discrimination method was conducted which detects SNPs base pair differences by comparing allele-specific fluorescence signal. There was no significant different between cases and controls in age, smoking habit and alcohol consumption habit. The ovulation trigger yielded >6 oocytes retrieval in majority of the patients. The mean stromal day were found to be statistically significant whereas the mean day of glands were insignificant. There is no significant difference observed between two groups for three studied polymorphisms. None of the polymorphisms deviated significantly from the Hardy Weinberg equilibrium, suggesting that the distribution in our subjects was representative of the actual population. The level of cytokines is guarded by various parameters, which are essential for a successful pregnancy. It is very complicated to predict the effect on endometrium and corresponding pregnancy rates due to increased progesterone.

Clinical strategies for ART treatment of infertile women with advanced maternal age

BACKGROUND

An ever-increasing number of women in our country with advanced maternal age are choosing to achieve pregnancy. This means effective strategies are needed for infertile patients. Questions arise, however, concerning the need for ovarian stimulation, and, if so, whether intracytoplasmic sperm injection (ICSI) is better than conventional insemination for those women who may have only one mature oocyte.

METHODS

We evaluated our data to answer these questions. Herein, we also introduce our strategy for patients who show unsynchronized follicular growth.

MAIN FINDINGS

Ovarian stimulation in ART treatment for patients with advanced maternal age has resulted in the achievement of higher pregnancy rates, and therefore, this form of stimulation is often selected. Based on our data, ICSI as an insemination procedure has not improved clinical pregnancy rates compared with conventional insemination and has actually decreased the clinical pregnancy rates.

CONCLUSION

In this article, we reviewed and compared the protocols and strategies that are available to increase the number of developed embryos for the patients with advanced maternal age. We hope that this review will be helpful for both patients and clinicians.

Placental growth factor (PlGF) as an angiogenic/inflammatory switcher: lesson from early pregnancy losses

Placental growth factor (PlGF) is an angiogenic factor which belongs to vascular endothelial growth factor (VEGF) family. In addition to the angiogenic function of PlGF, in some conditions such as preeclampsia and early pregnancy losses, it can induce inflammatory reactions which could be accompanied with reduced angiogenesis. Hence, it is crucial to investigate inflammatory and angiogenic switching states and understand underlying mechanisms. PlGF is expressed in endometrium, placenta and trophoblast cells and is involved in maturation of uterine NK cells. Up-regulation of PlGF directs VEGF to VEGFR-2 and reinforces angiogenesis. However, when VEGF/VEGFR-2 signaling pathway is impaired, PlGF may shift to severe inflammation and cause tissue damages which could lead to early pregnancy losses. Downregulation of PlGF has also been reported in pregnancy complications. In this review, we discussed the role of PlGF in embryo implantation failure and early pregnancy loss and also possible mechanisms regarding the role of PlGF in angiogenic/inflammatory switching in early pregnancy losses. Furthermore, we summarized the effects of various compounds on PlGF expression and briefly talked about its therapeutic potential that may be an opportunity for prevention of pregnancy loss.

Differential expression of vascular endothelial growth factor angiogenic factors in different endometrial compartments in women who have an elevated progesterone level before oocyte retrieval, during in vitro fertilization-embryo transfer treatment

OBJECTIVE

To investigate the relationship between endometrial expressions of angiogenic factors around the time of embryo implantation and P level before oocyte retrieval during IVF-ET treatment.

DESIGN

Retrospective study.

SETTING

University Assisted Reproductive Unit.

PATIENT(S)

Forty patients were recruited, 20 women with an elevated P level, and 20 women with a normal P level, into cancelled embryo transfer (ET) cycles.

INTERVENTION(S)

Endometrial biopsy samples were obtained from women who had an elevated or normal P level 7 days after human chorionic gonadotropin administration. The protein expression levels of VEGF-A, VEGF-C, and PLGF were examined using immunohistochemistry.

MAIN OUTCOME MEASURE(S)

A semiquantitative analysis was performed using histochemical-score analysis of staining intensity in the luminal epithelium, glandular epithelium, and stroma, separately.

RESULT(S)

Luminal epithelial expression of vascular endothelial growth factor (VEGF)-A, VEGF-C, and PLGF did not significantly differ in women with elevated or normal P levels before oocyte retrieval. Glandular epithelial expression of VEGF-A, VEGF-C, and PLGF was higher in women with elevated P levels, compared with those with normal P levels. A significantly higher stromal expression of VEGF-A and PLGF was found in women with elevated P levels.

CONCLUSION(S)

A high P level before oocyte retrieval was associated with expression of VEGF angiogenic factors in glandular epithelium and stromal compartment around the time of embryo implantation. Our findings suggest that the lower implantation rates observed in this group of women may relate to decreased endometrial receptivity arising from altered expression of angiogenic factors.

[The influence of exogenous LH/hCG activity on serum progesterone levels on the day of hCG administration in in vitro fertilization]

OBJECTIVES

Clarifying whether the addition of recombinant LH (rLH) to recombinant FSH (rFSH) leads to progesterone (P4) levels on dhCG comparable to those obtained with stimulation with FSH and hCG (HP-hMG) MATERIALS AND METHODS: Pituitary-desensitized patients, matched for age and follicle reserve, received rFSH+LH (n=729) or HP-hMG (n=729). In the rFSH+rLH group, rLH (75 UI/day) was started at day 6. To control for the influence of ovarian response on P4, we divided serum P4 levels by the number of growing follicles (13-22 mm; "per follicle" P4 levels) and performed a multivariate analysis.

RESULTS

Serum P4 levels on dHCG were lower in the HP-hMG (median: 0.63 ng/mL, max-min: 0.10-2.97) than in the rFSH+rLH group (0.91 ng/mL; 0.10-4.65, P<0.0001), as well as "per-follicle" P4 levels (0.055 ng/mL/growing follicle, 0.006-0.284 vs 0.077 ng/mL/growing follicle, 0.003-0.336; P<0.0001).

CONCLUSIONS

HP-hMG led to lower P4 levels on day hCG than rFSH+rLH irrespective of the intensity of the ovarian response and the adjunction of rLH (75 IU/day from day 6 onward).

Endometrial receptivity profile in patients with premature progesterone elevation on the day of HCG administration

The impact of a premature elevation of serum progesterone level, the day of hCG administration in patients under controlled ovarian stimulation during IVF procedure, on human endometrial receptivity is still debated. In the present study, we investigated the endometrial gene expression profile shifts during the prereceptive and receptive secretory stage in patients with normal and elevated serum progesterone level on the day of hCG administration in fifteen patients under stimulated cycles. Then, specific biomarkers of endometrial receptivity in these two groups of patients were tested. Endometrial biopsies were performed on oocyte retrieval day and on day 3 of embryo transfer, respectively, for each patient. Samples were analysed using DNA microarrays and qRT-PCR. The endometrial gene expression shift from the prereceptive to the receptive stage was altered in patients with high serum progesterone level (>1.5 ng/mL) on hCG day, suggesting accelerated endometrial maturation during the periovulation period. This was confirmed by the functional annotation of the differentially expressed genes as it showed downregulation of cell cycle-related genes. Conversely, the profile of endometrial receptivity was comparable in both groups. Premature progesterone rise alters the endometrial gene expression shift between the prereceptive and the receptive stage but does not affect endometrial receptivity.

Delaying the oocyte maturation trigger by one day leads to a higher metaphase II oocyte yield in IVF/ICSI: a randomised controlled trial

BACKGROUND

The negative impact of rising progesterone levels on pregnancy rates is well known, but data on mature oocyte yield are conflicting. We examined whether delaying the oocyte maturation trigger in IVF/ICSI affected the number of mature oocytes and investigated the potential influence of serum progesterone levels in this process.

METHODS

Between January 31, 2011, and December 31, 2011, 262 consecutive patients were monitored using ultrasound plus hormonal evaluation. Those with > =3 follicles with a mean diameter of > =18 mm were divided into 2 groups depending on their serum progesterone levels. In cases with a progesterone level < = 1 ng/ml, which was observed in 59 patients, 30-50% of their total number of follicles (only counting those larger than 10 mm) were at least 18 mm in diameter. These patients were randomised into 2 groups: in one group, final oocyte maturation was triggered the same day; for the other, maturation was triggered 24 hours later. Seventy-two patients with progesterone levels > 1 ng/ml were randomised in the same manner, irrespective of the percentage of larger follicles (> = 18 mm). The number of metaphase II oocytes was our primary outcome variable. Because some patients were included more than once, correction for duplicate patients was performed.

RESULTS

In the study arm with low progesterone (<= 1 ng/ml), the mean number of metaphase II oocytes (+/-SD) was 10.29 (+/-6.35) in the group with delayed administration of the oocyte maturation trigger versus 7.64 (+/-3.26) in the control group. After adjusting for age, the mean difference was 2.41 (95% CI: 0.22-4.61; p = 0.031). In the study arm with elevated progesterone (>1 ng/ml), the mean numbers of metaphase II oocytes (+/-SD) were 11.81 (+/-9.91) and 12.03 (+/-7.09) for the delayed and control groups, respectively. After adjusting for PCOS (polycystic ovary syndrome) and female pathology, the mean difference was -0.44 (95% CI: -3.65-2.78; p = 0.79).

CONCLUSIONS

Delaying oocyte maturation in patients with low progesterone levels yields greater numbers of mature oocytes.

Serum progesterone level effects on the outcome of in vitro fertilization in patients with different ovarian response: an analysis of more than 10,000 cycles

OBJECTIVE

To investigate the relationship between serum P levels on the day of hCG administration and pregnancy outcomes in different responders undergoing IVF.

DESIGN

Retrospective study.

SETTING

Teaching hospital.

PATIENT(S)

A total of 11,055 women who underwent their first IVF/intracytoplasmic sperm injection cycles and a subgroup of 4,021 women undergoing frozen-embryo transfer (FET) cycles.

INTERVENTION(S)

Patients underwent IVF-ET with the long GnRH agonist protocol. The ovarian response was classified as high (≥ 20 oocytes; n = 2,023), poor (≤ 4 oocytes; n = 827), or intermediate (remaining cases; n = 8,205) according to the number of oocytes retrieved. Clinical outcomes of IVF-ET and FET cycles were analyzed according to plasma P levels.

MAIN OUTCOME MEASURE(S)

Ongoing pregnancy rates (PRs).

RESULT(S)

Ongoing PRs in fresh cycle were inversely associated with serum P levels on the day of hCG administration for all patients. Different P threshold concentrations were determined according to different ovarian response: We proposed a serum P level of 1.5 ng/mL as the threshold for poor responders, 1.75 ng/mL for intermediate responders, and 2.25 ng/mL for high responders. Our study does not show negative results for elevated P levels on oocyte performance in terms of fertilization, cleavage rate, or PR of FET cycles within different ovarian responses, offering no evidence for a detrimental effect of high P on oocyte quality.

CONCLUSION(S)

Elevated P levels on the day of hCG administration negatively influence PR regardless of different ovarian responses, although increased P threshold concentration is associated with better ovarian responses. The detrimental effect of P elevation on PR seems to be unrelated to oocyte quality in all responders.

Progesterone rise on the day of HCG administration (premature luteinization) in IVF: an overdue update

Premature luteinization (PL) refers to a rise in serum progesterone (P) levels on the day of hCG administration. Most studies used an absolute P level on the day of hCG administration as an indicator of PL, and the cutoff level differed from 0.8 to 2 ng/mL. Some authors defined PL as a P/E2 ratio of >1. There is a marked variation in the incidence (13% to 71%), of PL due to discrepancies in definition, population characteristics and/or treatment protocols. The pathogenesis of PL in COH is still poorly understood. Several hypotheses may be considered to explain this phenomenon: elevation of follicular LH levels, serum accumulation of HCG from HMG, increased LH receptor sensitivity of the granulosa cells to FSH, or poor ovarian response with increased LH sensitivity. The consequences of this premature elevation of serum P on IVF outcome remain controversial. Attempts to prevent COH include: use of Low-dose hCG alone in the late COH stages, flexible antagonist protocol, use of mifepristone, aspiration of a single leading follicle, hCG administration when the levels of serum P exceeded 1.0 ng/mL.

Does subtle progesterone rise on the day of HCG affect pregnancy rate in long agonist ICSI cycles?

PURPOSE

To evaluate the impact of subtle progesterone (P4) rise on the day of HCG on pregnancy outcome in ICSI patients stimulated with long agonist protocol.

METHODS

One hundred forty-nine consecutive controlled ovarian hyperstimulation cycles for ICSI using long luteal agonist protocol.

RESULTS

Mean serum progesterone on day of hCG was 0.88+/-0.51 ng/mL values > or =1 ng/mL were found in 34.2% of cycles. Serum E2 on day of hCG and number of oocytes retrieved were significantly higher in the group with P4 > or = 1 ng/mL. The area under ROC for serum progesterone in prediction of pregnancy was 0.52, indicating that within the values studied, serum progesterone on day of hCG is not predictive of pregnancy outcome.

CONCLUSION

P4 values > or =1 ng/mL on day of hCG are common in long agonist ICSI cycles particularly with high response. Within the P4 values encountered in this study, implantation and pregnancy rates are not adversely affected.

Progesterone levels on oocyte retrieval day can predict the quantity of viable embryos but not pregnancy outcome of intracytoplasmic sperm injection

The present study aimed to determine whether serum progesterone (P) concentration on the day of oocyte retrieval (OR) affects the quantity of viable embryos and impacts the outcome of intracytoplasmic sperm injection (ICSI). A total of 289 women who underwent ICSI cycles after controlled ovarian hyperstimulation were divided in two groups based on P level (<11.7 and > or = 11.7 ng/ml) on OR day. Subjects did not differ significantly with respect to age, basal follicle-stimulating hormone levels, body mass index, or estradiol levels on day of administration of human chorionic gonadotropin or OR day. Women with ICSI cycles that had high P levels tended to have more retrieved oocytes, zygotes and embryos than women with lower levels, but the differences did not approach significance. However, the former group with higher P levels did have a significantly greater number of viable embryos (p = 0.003). Finally, the two groups did not show differences in pregnancy outcome in a new ICSI cycle. The study suggests that serum P levels on OR day are related to the quality of viable embryos but not to pregnancy outcome in fresh ICSI cycles.

Does high serum progesterone level on the day of human chorionic gonadotropin administration affect pregnancy rate after intracytoplasmic sperm injection and embryo transfer?

OBJECTIVE

The present study was conducted to evaluate the effect of serum progesterone (P) levels on the day of human chorionic gonadotropin (hCG) administration on embryo quality and pregnancy rate in intracytoplasmic sperm injection (ICSI) cycles.

DESIGN AND SETTING

This was a retrospective analysis conducted in the in vitro fertilization (IVF) unit of a tertiary hospital.

PATIENTS

Two hundred and one patients who underwent a total of 280 IVF treatment cycles allocated to ICSI during routine IVF/embryo transfer treatment. Results. In cycles with elevated serum P, higher estradiol levels were noted (1915 pg/ml vs. 1256 pg/ml; p<0.05), more oocytes were retrieved and manipulated, and more embryos were available for transfer. Embryo grading was comparable between the two groups. The average age was lower in the group with elevated P; but the pregnancy rate was significantly lower (16.4% vs. 27.6%, p = 0.03).

CONCLUSIONS

Our data demonstrate no deleterious effect of elevated P on embryo quality. However, high serum P adversely affects implantation and pregnancy rates.

Is progesterone elevation on the day of human chorionic gonadotrophin administration associated with the probability of pregnancy in in vitro fertilization? A systematic review and meta-analysis

The role of progesterone elevation on in vitro fertilization (IVF) outcome has remained a debatable issue for several years. The aim of this systematic review and meta-analysis was to evaluate whether progesterone elevation on the day of human chorionic gonadotrophin (hCG) administration is associated with the probability of pregnancy. Eligible studies were considered those in which patients did not participate more than once. A literature search in MEDLINE, EMBASE and CENTRAL identified 12 eligible studies, 10 of which were retrospective. The majority (n = 10) of these studies did not detect a statistically significant association between progesterone elevation and the probability of pregnancy. Meta-analysis was performed only for the studies (n = 5) that provided data on clinical pregnancy per patient reaching hCG administration for final oocyte maturation. No statistically significant association between progesterone elevation and the probability of clinical pregnancy was detected (Odds ratio: 0.75, 95% confidence interval 0.53-1.06; P = 0.10). This finding persisted in the sensitivity analyses performed, which excluded the studies that did not report clearly that measurement of progesterone did not affect patients' management and those that did not report definition of clinical pregnancy. In addition, subgroup analyses were conducted on the basis of type of gonadotrophin-releasing hormone GnRH analogue used and on the value of serum threshold used to classify patients in those with or without progesterone elevation. These analyses, however, did not materially change the results obtained. In conclusion, the best available evidence does not support an association between progesterone elevation on the day of hCG administration and the probability of clinical pregnancy in women undergoing ovarian stimulation with GnRH analogues and gonadotrophins for IVF.

The significance of premature luteinization in an oocyte-donation programme

BACKGROUND

Several evidences indicate that premature luteinization (PL) may affect IVF outcome. The primary end-point of the present study was to verify the effect of PL on the pregnancy rate (PR) of our oocyte-donation programme.

METHODS

PL was defined as serum progesterone > or = 1.2 ng/ml on the day of HCG. We analysed retrospectively 240 oocyte-donation cycles in which 120 women donated twice, with PL in the first donation cycle and no PL in the following one, acting as its own control. Recipients (n = 240) were divided in two groups according to the presence of PL (n = 120) or not (n = 120). Both groups were compared regarding donor cycle parameters and recipient cycle outcome.

RESULTS

There was no difference in PR between the groups (55.7 versus 54.4%, respectively). The number of total oocytes (18.2 +/- 0.6 versus 20.8 +/- 0.6; P = 0.003) and the number of mature oocytes retrieved (16.9 +/- 0.6 versus 19.4 +/- 0.6; P = 0.005) were different among donors with progesterone < 1.2 ng/ml and PL, respectively. There were no differences between the oocyte recipients in fertilization, cleavage, embryo division on day 3, blastocyst development or fragmentation rates. The number of embryos transferred, number of embryos cryopreserved, and implantation and miscarriage rates were similar between the groups.

CONCLUSION

PL does not appear to have a negative impact on ongoing PR in our oocyte-donation programme.

What is the ‘ideal’ duration of progesterone supplementation before the transfer of cryopreserved–thawed embryos in estrogen/progesterone replacement protocols?

Different studies dealing with the start of progesterone supplementation in assisted reproduction treatment cycles have shown that the problem apparently is the correct timing. We therefore would like to discuss the data on: (i) the start of progesterone replacement in oocyte donation programmes; (ii) the start of progesterone replacement in frozen-thawed hormone-supplemented cycles; (ii) the problem of too early a rise of progesterone in fresh IVF cycles as a model of too early an administration of progesterone; and (iv) the benefit of high progesterone levels on the day of embryo transfer in fresh IVF cycles. From the data reviewed in this paper it seems to be appropriate to start progesterone administration before transfer in oocyte donation programmes as well as transfer of cryopreserved/thawed cells as soon as the endometrium is developed sufficiently (> or =8 mm, trilaminar pattern), and to perform the embryo transfer not before day 3-4 of progesterone treatment, i.e. embryo development on day 2-3. Studies dealing with the influence of too early a rise of progesterone in fresh IVF cycles have shown different results. In fact high progesterone levels seem to reflect a high response but not a lower probability of conception. Furthermore, high progesterone levels on the day of embryo transfer in fresh IVF cycles could lower myometrial contractility and therefore increase implantation rates. Since the experience from oocyte donation programes shows the benefit of a longer preparation time using progesterone, and high progesterone levels seem to have a benefit during embryo transfer, this would suggest extending progesterone administration before transfer. However, we have to find the optimal individual transfer protocol after mock cycles, for example with pinopode detection or other methods applicable in routine IVF programmes. We need more studies to be sure whether reproductive outcome after transfer of cryopreserved-thawed cells in estrogen/progesterone supplement cycles is influenced by the duration of progesterone pretreatment. If this is so, we must look for practicable methods to modify the protocols according to the individual patient, the embryonic developmental stage during transfer and other variables.

New Tools for Optimizing Endometrial Receptivity in Controlled Ovarian Hyperstimulation: Aromatase Inhibitors and LH/minihCG

In the long history of controlled ovarian hyperstimulation (COH), two steps stand out as being the most important ones for providing the high efficacy of current treatments: the introduction of GnRH agonists for the prevention of premature ovulation and the widespread use of pretreatment with oral contraceptives before COH for in vitro fertilization. Interestingly, the benefits of both measures resulted largely from pure serendipity, as the discovery of these advantages was mostly fortuitous and/or unintended. Today, we believe that two areas of research have the highest potential for further improving the efficacy of COH: (1) switching the follicle-stimulating hormone stimulus to that of luteinizing hormone (or small amounts of hCG) in the last stages of COH; and (2) using the benefit of the new third-generation aromatase inhibitors that have recently become available. The effects of the latter products are to enhance the endogenous production of gonadotropins (mostly FSH). This article reviews the background data and rationale that justifies each of these two new developments and summarizes data currently available.

Elevated serum progesterone concentrations during the early follicular phase of the menstrual cycle: clinical significance and therapeutic implications

This study describes the incidence and clinical significance of hyperprogesteronemia in the early follicular phase of the menstrual cycle and the effects of prednisolone treatment in patients with this condition. Progesterone, testosterone and dehydroepiandrosterone sulfate (DHEAS) serum concentrations were determined in 316 consecutive patients admitted for infertility treatment. Elevated concentrations of progesterone in the early follicular phase could be detected in 36 cases (11.4%). In these patients, elevated testosterone and DHEAS concentrations could be detected in eight and ten cases, respectively. Serum concentrations of 17 alpha-hydroxyprogesterone and cortisol were normal in all patients. Treatment with 2.5-7.5 mg prednisolone/day normalized progesterone serum concentrations within 4-8 weeks. Twenty-four patients achieved a pregnancy either by timed intercourse or by intrauterine insemination (IUI) over the following 12 months.

Computerized assessment of endometrial echogenicity: clues to the endometrial effects of premature progesterone elevation

OBJECTIVE

To determine whether premature progesterone elevation affects the timing of hyperechogenic transformation of the endometrium during the early luteal phase of controlled ovarian hyperstimulation (COH) cycles.

DESIGN

Prospective analysis.

SETTING

Assisted Reproduction Unit, Hôpital Antoine Béclère, Clamart, France.

PATIENT(S)

Fifty-nine women undergoing 59 IVF-ET cycles.

INTERVENTION(S)

Patients underwent COH with a GnRH agonist and hMG. Endometrial echogenicity was assessed on the days of hCG administration, oocyte retrieval, and ET. Results are expressed as the extent of submyometrial hyperechogenic area in relation to the total endometrial surface as determined by a computer-assisted analysis system. Patients were sorted according to whether their plasma progesterone level exceeded 0.9 ng/mL (n = 26) or not (n = 33) on the day of hCG administration.

MAIN OUTCOME MEASURE(S)

Endometrial echogenicity.

RESULT(S)

On the day of hCG administration, the degree of endometrial echogenicity was similar in both groups (41% vs. 40%), but after hCG administration, it increased significantly faster in the high progesterone group than in the low progesterone group (70% vs. 63% at oocyte retrieval and 90% vs. 79% at ET, respectively).

CONCLUSION(S)

End-follicular phase elevation in plasma progesterone (>0.9 ng/mL on the day of hCG administration) was associated with a faster increase in endometrial echogenicity during the early luteal phase of COH cycles. This observation is consistent with the hypothesis that premature progesterone elevation hastens the secretory transformation of the endometrium.

Consequences of premature progesterone elevation on the outcome of in vitro fertilization: insights into a controversy

OBJECTIVE

To investigate whether the consequences of premature P elevation on IVF-ET outcome are modulated by the quality of the ovarian response to controlled ovarian hyperstimulation (COH).

DESIGN

Retrospective analysis.

SETTING

Assisted Reproduction Unit, Clamart, France.

PATIENT(S)

One thousand twelve women undergoing 1,189 IVF-ET cycles.

INTERVENTION(S)

Patients underwent COH with a time-released GnRH agonist and hMG. The ovarian response to COH was classified as strong (< or = 50 hMG ampules, peak E2 levels > 2,500 pg/mL, and > or = 10 mature oocytes; n = 340), weak (> 50 hMG ampules, peak E2 levels < or = 1,500 pg/mL, and < or = 5 mature oocytes; n = 285), or intermediate (remaining cases; n = 564). The IVF-ET outcome in each group was analyzed according to whether or not plasma P levels exceeded 0.9 ng/mL.

MAIN OUTCOME MEASURE(S)

Pregnancy rates (PRs).

RESULT(S)

Clinical PRs were similar irrespective of low or high P levels in the strong (30% and 34%, respectively) and intermediate (31% and 30%, respectively) groups. However, in the weak group, P levels > 0.9 ng/mL were associated with lower PRs (3.2% and 23%, respectively).

CONCLUSION(S)

In the presence of an adequate response to COH, P levels > 0.9 ng/mL were not associated with lower PRs, indicating that good embryo quality may compensate for the adverse endometrial effects of P. Conversely, when the response to COH was weak, premature P elevation led to drastically reduced PRs.

Premature progesterone elevation spares blastulation but not pregnancy rates in in vitro fertilization with coculture

OBJECTIVE

To clarify whether embryo development to the blastocyst stage may be affected by premature P elevation during controlled ovarian hyperstimulation (COH) for IVF-ET with embryo coculture.

DESIGN

Retrospective study.

SETTING

Tertiary care infertility center.

PATIENT(S)

One hundred thirty-one women undergoing 153 IVF-ET cycles with embryo coculture.

INTERVENTION(S)

Patients underwent COH with GnRH agonist and hMG. Embryos were cocultured up to the blastocyst stage. According to plasma P levels on the day of hCG, two groups were defined: low P (P < or = 0.9 ng/mL; conversion factor to SI unit, 3.180) and high P (P > 0.9 ng/mL).

MAIN OUTCOME MEASURE(S)

Blastulation (number of blastocysts/number of noncavitating embryos x 100) and pregnancy rates (PRs).

RESULT(S)

Blastulation rates were similar in the low and high P groups (51% and 48%, respectively). Moreover, patients included in the high P groups achieved significantly lower clinical and ongoing PRs (12% versus 29% and 7% versus 25%, respectively).

CONCLUSION(S)

The lack of difference in blastulation rates between the groups further supports the hypothesis that premature P elevation does not alter oocyte and embryo quality. Hence, the observed decrease in PRs is likely to reflect impaired endometrial receptivity in the high P group.

The effect of elevated serum progesterone during ovulation induction in in vitro fertilization-embryo transfer

OBJECTIVE

Our purpose was to determine whether elevated progesterone (P) during ovulation induction in IVF-ET cycles is a poor prognostic factor for achieving pregnancy.

DESIGN

We retrospectively reviewed 672 consecutive IVF-ET cycles in which ovulation was performed using luteal LA downregulation and hMG.

SETTING

The ART program at the Brigham & Women's Hospital, a tertiary care institution, was the study setting.

MAIN OUTCOME MEASURES

Patients were divided into groups by serum P levels at baseline, on stimulation day 5, on the day of hCG injection, and, on the day after hCG injection and the following parameters were compared: duration of luteal LA treatment, number of ampoules of hMG used, estradiol (E2) levels, number of follicles > or = 12 mm, number of follicles > or = 15 mm, number of oocytes, number of normal embryos, number of polyspermic embryos, fertilization rate, implantation rate, and clinical and ongoing/live birth pregnancy rates.

RESULTS

Based on serum P level, patients were divided into three groups: Group I, < or = 0.31 ng/ml (conversion factor to SIU, 3.180); Group II, and > 0.3 and < 1.0 ng/ml and Group III, > or = 1.0 ng/ml. Measureable P at baseline was associated with a higher cancellation rate, but no difference in other cycle outcome parameters. Progesterone > 0.31 ng/ml on stimulation day 5 was associated with a higher fertilization rate in Groups II and III, but there was no difference in the clinical pregnancy or ongoing/live birth rates among the three groups. Based on P on the day of hCG administration, Groups II and III had significantly more oocytes and higher fertilization rates than did Group I, however, clinical pregnancy and ongoing/live birth rates were not significantly different. On the day after hCG, there was a trend toward a higher clinical pregnancy rate in Group III, which had younger patients, better follicular recruitment, and more embryos than Groups I or II, but these differences did not reach statistical significance.

CONCLUSIONS

Serum P > 0.31 ng/ml during ovulation induction reflects good follicular recruitment, and is not a predictor of IVF outcome.

Premature progesterone elevation does not alter oocyte quality in in vitro fertilization

OBJECTIVE

To clarify whether premature P elevation during controlled ovarian hyperstimulation (COH) for IVF-ET affects adversely oocyte-embryo quality.

DESIGN

Controlled clinical study.

PATIENTS

We studied 102 fertile donors undergoing 106 oocyte retrievals and 117 recipients undergoing 162 ET.

INTERVENTIONS

Donors underwent COH with a time-release GnRH agonist and hMG. All recipients had inactive or absent ovaries and were primed with E2 and P.

MAIN OUTCOME MEASURES

Measurement of LH, P and E2; characteristics of COH; cleavage, pregnancy, and implantation rates.

RESULTS

According to donors' plasma P levels on the day of hCG, two groups were defined: P < or = 0.9 ng/mL (conversion factor to SI unit, 3.18), group A, and P > 0.9 ng/mL, group B. Similar results of cleavage (65% and 72%), clinical (30% and 29%), and ongoing pregnancy (20% and 18%), and implantation (14% and 15%) rates were observed in both groups, respectively.

CONCLUSIONS

The lack of difference in cleavage, pregnancy, and implantation rates between both groups suggests that preovulation increase in P production does not alter oocyte-embryo quality. Hence, the reported adverse effects on IVF outcome of pre-hCG elevation of P is likely to reflect an impaired endometrial receptivity in the high P group.

Elevated progesterone levels in the late follicular phase do not predict success of in vitro fertilization-embryo transfer

OBJECTIVE

To examine the effects of subtle elevation in P levels in late follicular phase on the outcome of IVF-ET cycles, using GnRH agonist (GnRH-a) and hMG +/- FSH protocol.

DESIGN

A retrospective analysis of data.

PATIENTS

Fifty-four patients who completed 63 IVF-ET cycles were treated with midluteal GnRH-a, followed by hMG +/- pure FSH. Depending on serum P levels on the day of hCG administration, patients were divided in two groups. In group 1, P levels were < or = 0.9 ng/mL (conversion factor to SI unit, 3.180) and in group 2, the levels were > 0.9 ng/mL.

RESULTS

Luteinizing hormone levels, on the day of hCG administration, as measured by RIA, were suppressed completely. In cycles with subtle P rise (71%), we observed a significantly higher serum E2 concentration, greater number of mature follicles, and greater number of oocytes retrieved. There were no differences between the two groups in fertilization rate, number of embryos transferred, clinical pregnancy rate, implantation rate, and miscarriage or delivery rates.

CONCLUSIONS

We conclude that in IVF-ET cycles, when pretreated with GnRH-a, P levels may increase on the day of hCG administration despite LH suppression and such elevation may not affect adversely the final outcome.

Altering the timing of human chorionic gonadotropin injection according to serum progesterone (P) concentrations improves embryo quality in cycles with subtle P rise

OBJECTIVE

To investigate the effect of earlier administration of hCG according to serum concentrations of P on the outcome of IVF-ET in cycles in which a subtle rise in serum P (1.0 to 2.0 ng/mL; conversion factor to SI unit, 3.180) occurred during the follicular phase.

DESIGN

Retrospective study.

PATIENTS

A total of 110 infertile women underwent 124 cycles of IVF-ET at Tottori University Hospital.

MAIN OUTCOME MEASURES

Serum was obtained daily or every 12 hours from day 7 until the administration of hCG. Serum E2 and P concentrations were measured by RIA. In 19 of 36 subtle P rise cycles, hCG injection was given when the levels of serum P exceeded 1.0 ng/mL ("rescued" subtle P rise). Parameters of IVF outcomes for the no P rise, the subtle P rise, and the rescued subtle P rise cycles were compared.

RESULTS

The mean day of hCG administration in the rescued cycles was 1 day earlier than those of the subtle P rise and no P rise cycles. The mean number of oocytes collected was significantly higher in the subtle P rise and rescued P rise cycles than in the no P rise cycles. The mean follicular diameter on the day of hCG administration was 13.9 mm in the rescued cycles, significantly smaller than those of the no P rise and subtle P rise cycles. However, there was no significant difference in the cleavage rates between the three groups. The rate of embryonic development beyond four-cell stage was increased significantly in the rescued cycles and no P rise cycles versus the subtle P rise cycles. Embryos obtained in the no P rise and rescued cycles were of better morphological quality than those obtained in the P rise cycles. The implantation rate was significantly higher in the rescued cycles than in the P rise cycles.

CONCLUSION

The data suggest that, if hCG is administered when a subtle P rise is detected, embryo quality and subsequent implantation rate can be improved.

Diminished alpha-inhibin messenger ribonucleic acid in in vitro fertilization-embryo transfer poor responders reflects declining follicle reserve

OBJECTIVES

To quantitate and compare granulosa cell alpha-inhibin messenger RNA (mRNA) levels in IVF-ET poor and good responders and thereby learn how alpha-inhibin mRNA levels change in states of diminished ovarian responsiveness.

DESIGN

Ribonucleic acid analysis of stored luteinized granulosa cell samples.

SETTING

Academic tertiary care institution.

PATIENTS

Fifty-three women undergoing follicle aspiration for IVF-ET were studied. Patients were classified as poor responders (n = 16) or good responders (n = 37) according to their E2 concentration on the day of hCG; the E2 of poor responders was < 1,000 pg/mL (3,671 pmol/L) and that of good responders was > or = 1,000 pg/mL (3,671 pmol/L).

MAIN OUTCOME MEASURES

Messenger RNA levels were measured using dot blot RNA analysis. The following parameters were determined or derived: total mRNA levels, total alpha-inhibin mRNA levels, alpha-inhibin mRNA per follicle, and proportional alpha-inhibin mRNA as the ratio of alpha-inhibin mRNA:total mRNA.

RESULTS

Proportional alpha-inhibin mRNA and alpha-inhibin mRNA per follicle were not significantly different between poor responders and good responders. Total mRNA and total alpha-inhibin mRNA levels, however, were diminished significantly in poor responders.

CONCLUSIONS

The observations that proportional alpha-inhibin mRNA and alpha-inhibin mRNA per follicle do not significantly change in poor responders, whereas total alpha-inhibin mRNA does, indicate that the decrease in total alpha-inhibin mRNA in poor responders reflects a decreased pool of total mRNA, likely because of a reduction in follicle number. These findings are in contrast to other recent reports that describe a change in granulosa cell function accompanying states of decreased ovarian responsiveness.

Physiopathology of premature progesterone elevation

OBJECTIVE

To determine the effects of the last hMG administration on plasma P and androgen profiles during controlled ovarian hyperstimulation (COH) for IVF-ET.

DESIGN

Controlled clinical study.

SETTING

The IVF-ET program of a tertiary outpatient care center, Hôpital A. Béclère, Clamart, France.

PATIENTS

Nine IVF-ET candidates aged 25 to 36 years having presented normal responses to COH in previous IVF-ET cycles.

INTERVENTIONS

Controlled ovarian hyperstimulation was induced for IVF-ET using hMG after endogenous gonadotropins were suppressed with a time-release GnRH agonist. Just before the last hMG administration (225 IU), the participants were hospitalized for 24 hours for serial blood sampling. These occurred before (baseline) and after hMG administration, every 30 minutes for 1 hour, hourly for 4 hours, and every 3 hours for the remaining part of a 24-hour post-hMG observation period.

MAIN OUTCOME MEASURE

Measurement of P, T, androstenedione (A), E2, FSH, and LH.

RESULTS

Plasma P and androgens (T and A) increased significantly, reaching peak values 12 to 15 hours after hMG administration and decreased progressively thereafter, to reach values not significantly different from baseline 24 hours after hMG administration. Plasma E2 levels increased progressively and steadily during the 24-hour observation period. Plasma FSH levels remained constant after hMG administration while LH stayed undetectable.

CONCLUSION

In COH cycles induced for IVF-ET, the hormonal profile after the last hMG injection suggests that hMG triggers an increase in plasma P and androgens that culminates 12 to 15 hours after hMG administration. This elevation in plasma P and androgens observed after hMG administration is likely to reflect a direct action of the LH and/or FSH components of hMG on granulosa cells. In some women these hormonal consequences of hMG treatment may impair endometrial receptivity in IVF-ET cycles.

The predictive value of serum progesterone and 17-OH progesterone levels on in vitro fertilization outcome

PURPOSE

In order to identify parameters which predict prognosis for success with in vitro fertilization, 17-hydroxyprogesterone and progesterone levels were evaluated in 254 patients undergoing 296 in vitro fertilization cycles. Selected response and outcome data were recorded.

RESULTS

Patients with intermediate values of serum progesterone (0.7-0.8 ng/ml) at the time of human chorionic gonadotropin administration achieved significantly higher pregnancy rates than patients with lower (< 0.7 ng/ml) or higher (> 0.8 ng/ml) levels. The clinical pregnancy rates were 46%, 31%, and 27% respectively (P = 0.02). There was no change in 17-hydroxyprogesterone concentration which predicted a higher pregnancy rate.

CONCLUSION

Excellent clinical pregnancy rates were noted in cycles with a progesterone level of 0.7-0.8 ng/ml, as well as good results in cycles above 0.8 ng/ml. There is therefore no reason to administer human chorionic gonadotropin at a smaller follicle size to prevent a rise in serum progesterone.

Confocal scanning laser microscopy of morphometric human sperm parameters: correlation with acrosin profiles and fertilizing capacity

OBJECTIVES

To develop quantitative criteria for assessing sperm morphology and to determine the correlation between the percentage of morphologically normal spermatozoa and the outcome of the sperm hypo-osmotic swelling test, sperm acrosin profile, and sperm capacity for fertilization.

DESIGN

The maximal length and width of the sperm head, the length of the midpiece and principal piece of the sperm tail, and the ratio of the surface of the acrosomal region to the total surface of the head were determined in specimens obtained from a group of infertile men and a group of fertile men using a confocal scanning laser microscope. Group A consisted of 53 infertile men who were participating in an IVF program, and group B consisted of 98 fertile men. The mean +/- 2 SD of the morphometric parameters in group B was established as representing the lowest and highest normal values in both groups. A normal spermatozoon was defined as one with morphometric parameters within normal levels. The lowest percentage of morphologically normal spermatozoa, hypo-osmotic swelling test result, and acrosin activity in group B were also taken as the lowest normal values in group A.

SETTING

In vitro fertilization program at the Tottori University School of Medicine, Yonago, Japan.

MAIN OUTCOME MEASURES

Sperm morphometric parameters, percentage of morphologically normal spermatozoa, hypo-osmotic swelling test, and acrosin activity.

RESULTS

The length of the midpiece, ratio (x 100) of the surface of the acrosomal region to the total surface of the sperm head, percentage of morphologically normal spermatozoa, outcome of hypo-osmotic swelling test, and acrosin activity were significantly higher in group B than in group A. The maximal width of the head was significantly lower in group B than in group A. Strongly positive correlations were observed between percentage of morphologically normal spermatozoa or length of midpiece and the proportion of fertilized oocytes in group A and between ratio (x 100) of the surface of the acrosomal region to the total surface of the head and acrosin activity in groups A and B. Sperm morphology showed high positive and negative predictive values for acrosin activity (normal/abnormal) and fertility potential (present/absent).

CONCLUSIONS

Using quantitative strict criteria, we found that sperm morphology was an important predictor of sperm fertilizing capacity. The confocal scanning laser microscope provided useful information about the sperm cytoskeleton and its importance in fertilization.

The effect of progesterone administration in the follicular phase of an artificial cycle on endometrial morphology: a model of premature luteinization

OBJECTIVE

To evaluate the effect of premature P administration on artificially prepared endometrium in women with ovarian failure.

DESIGN

To mimic premature luteinization, patients with ovarian failure were treated with continuous estrogen and episodic P during the follicular phase of artificial cycles.

SETTING

In vitro fertilization unit at a university hospital.

PATIENTS

The study group included 16 patients with ovarian failure who were randomly divided into two groups. Group A (8 patients) was treated by episodic P administration during the artificial follicular phase on days 2 and 7 (12.5 mg of P in oil IM), and in group B (8 patients), P (6.25 mg) was added on days 3, 4, and 5. Another 16 patients (group C), age matched to the study group, were arbitrarily allocated to serve as controls and had standard preparatory cycles without P supplementation in the follicular phase. Serum E2 and P levels and endometrial biopsies were taken on days 14 and 26.

RESULTS

Serum E2 levels were comparable between the study group (group A+B) and controls on both days 14 and 26. Although serum P levels did not differ between the groups on day 26, it was higher in the follicular phase of the study group than in the controls (1.9 +/- 4.0 and 0.2 +/- 0.1 ng/mL, respectively). In the study group, 8 of 16 patients demonstrated early secretory changes in the late follicular phase biopsies, and 9 of 16 women developed stromal-glandular discrepancy in the late luteal phase. This differed significantly from the controls in which only one late luteal biopsy was out of phase.

CONCLUSIONS

Episodic surges of P during the follicular phase may result in impaired endometrial development that cannot be corrected by P supplementation during the luteal phase. This unique model provides evidence for the potential detrimental effect of premature P secretion in the follicular phase on endometrial function.

Elevated serum progesterone levels on the day of human chorionic gonadotropin administration in in vitro fertilization cycles do not adversely affect embryo quality

OBJECTIVE

To assess the effect of an elevated serum P level on the day of hCG administration in an IVF cycle on resulting embryos by evaluating their performance at subsequent frozen ET.

DESIGN

A retrospective study.

PARTICIPANTS

Ninety-six consecutive patients undergoing frozen ET cycles were studied in a tertiary care center.

MAIN OUTCOME MEASURES

Serum obtained on the day of hCG administration in an IVF cycle was assayed for E2 and P by RIA. The main outcome measured was the development of a clinical pregnancy in a subsequent frozen ET cycle.

RESULTS

Using a previously described breakpoint in serum P concentration of 0.9 ng/mL (2.86 nmol/L), 8 of 69 (11.6%) frozen ETs in which embryos from low P level IVF cycles were transferred and 7 of 27 (25.9%) frozen ETs of embryos from elevated P level IVF cycles were transferred resulted in the development of clinical pregnancies. Although this does not clearly demonstrate superiority of embryos obtained from elevated P cycles, employing a power calculation, the probability that the pregnancy rate in the elevated serum P group is at least equal to the observed rate in the low P group is 92.8%.

CONCLUSION

These data suggest that an elevated serum P level on the day of hCG administration does not adversely affect the quality of oocytes or resulting embryos.

Pregnancy rates in donors versus recipients according to the serum progesterone level at the time of human chorionic gonadotropin in a shared oocyte program

Previous data suggested a subtle increase in serum P at the time of hCG injection without LH surge reduces the PR of women having oocyte retrievals for IVF; this study compared PRs of recipients in a shared oocyte program according to the donors' pre-hCG P level. There was no difference in viable PRs between recipients and donors when P < or = 1 ng/mL. The PR was similar for recipients when donors' P was > 1 ng/mL (12.7%). Donors with P > 1 ng/mL had the lowest PR: 7.2%. The data suggest that the adverse effect of higher serum P without LH surge may be on the endometrium rather than the oocyte.

Serum progesterone concentrations on the day after human chorionic gonadotropin administration and progesterone/oocyte ratios predict in vitro fertilization/embryo transfer outcome

PURPOSE

In gonadotropin-releasing hormone analogue-pretreated in vitro fertilization-embryo transfer cycles, pregnancy rates are inversely related to serum progesterone levels on the day of administration of human chorionic gonadotropin. The relationship of the progesterone concentration on other days in the periovulatory period to pregnancy rates in such cycles is little studied. We therefore retrospectively analyzed the relationship between progesterone concentrations on the day after human chorionic gonadotropin and pregnancy in 114 cycles, 28 and 23 of which produced clinical and ongoing/delivered pregnancies, respectively. To assess the effect of the extent of follicular luteinization on success, we also studied the relationship between the progesterone concentration per oocyte retrieved and pregnancy for the day of and day after human chorionic gonadotropin.

RESULTS

Progesterone concentrations on the day after human chorionic gonadotropin were inversely associated with clinical pregnancy by multiple logistic regression analysis (P < 0.05). Progesterone/oocyte ratios were inversely associated with clinical pregnancy (P < 0.05) and ongoing/delivered pregnancy (P < 0.02) for both the day of and the day after human chorionic gonadotropin.

CONCLUSION

The study results extend the window of time during which elevated progesterone concentration is associated with poor outcome to at least 2 days. This finding is consistent with hypothetical mechanisms attributing the link between progesterone concentration and outcome to either endometrial or follicle/oocyte events. The association of lack of follicular luteinization (low progesterone per oocyte ratios) and favorable outcome suggests a predominant effect of progesterone on follicle/oocyte quality. Further studies are needed to clarify the mechanisms underlying the association between progesterone and in vitro fertilization-embryo transfer outcome.

The range of subtle rise in serum progesterone levels following controlled ovarian hyperstimulation associated with lower in vitro fertilization pregnancy rates is determined by the source of manufacturer

Two previous studies found a correlation of higher pregnancy rates (PRs) with lower serum progesterone (P) levels at the time of human chorionic gonadotropin (hCG) injection in in vitro fertilization (IVF) cycles when luteal phase leuprolide acetate (LA)-human menopausal gonadotropin (hMG) was used for the controlled ovarian hyperstimulation (COH) regimen. In these two studies the radioimmunoassay (RIA) by Diagnostic Products Corporation (DPC) was used to measure P levels. This study attempted to corroborate these findings using a different RIA for P (Amersham) when the same COH regime was administered. The PR was significantly higher in the group where P was < or = 1 ng/ml at the time of hCG (43.2%) versus the groups where the P level ranged from 1.1 to 2 ng/ml (15.8%). Viable PRs were also significantly higher in the lower P group. In contrast to the previous data with the DPC assay, no differences were seen with P < 0.5 ng/ml (36.4%) versus 0.5-1 ng/ml (44.6%). Nevertheless, using the Amersham RIA, the data does suggest decreasing PRs with higher serum P levels at time of hCG when using luteal phase LA-hMG COH regimen.

The effect of gonadotropin-releasing hormone agonist on embryo quality and pregnancy rate following cryopreservation

OBJECTIVE

To examine the effect of GnRH analogue (GnRH-a) on the quality of frozen-thawed embryos and the pregnancy rate (PR) resulting from transfer.

DESIGN

A retrospective study of two groups of women undergoing transfers of frozen-thawed embryos. In group 1 ovulation induction with hMG was begun after hypophyseal desensitization with GnRH-a for 2 weeks. In group 2 ovulation was induced with hMG only. The freezing and thawing techniques were identical for both groups.

SETTING

In vitro fertilization unit at a university hospital.

PATIENTS

The study group (group 1) included 108 women who underwent 137 transfer cycles of frozen-thawed embryos, and the control group (group 2) included 44 women in 51 cycles of thawed ETs.

INTERVENTIONS

Ovum pick-up and ET techniques were the same for both groups. Methods of embryo freezing and thawing were identical, as were the morphological criteria for grading the embryos.

RESULTS

The morphology of embryos was similar in both groups, as was the number of embryos that had at least 50% intact blastomeres (83% +/- 23% and 78% +/- 30% for group 1 and group 2, respectively). The PR (16 of 137 [11.7%] and 6 of 51 [11.8%], respectively) as well as the abortion rate (30%) were similar for both groups.

CONCLUSIONS

The use of GnRH-a does not affect the quality of embryos nor the pregnancy outcome. Because the yield of frozen embryos per ovum pick-up is higher in cycles stimulated by GnRH-a/hMG, the PR per pick-up cycle is thus anticipated to be higher.

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.