Oral versus intramuscular progesterone for in vitro fertilization: a prospective randomized study

Luteal phase support in assisted reproductive technology centers: Italian survey

BACKGROUND

In assisted reproductive cycles (ART), the fine balance of controlling corpus luteum function is severely disrupted. To challenge this iatrogenic deficiency, clinicians aim to provide exogenous support. Several reviews have investigated progesterone route of administration, dosage and timing.

METHODS

A survey about luteal phase support (LPS) after ovarian stimulation was conducted among doctors in charge in Italian II-III level ART centers.

RESULTS

With regards to the general approach to LPS, 87.9% doctors declare to diversify the approach; the reasons for diversifying (69.7%) were based on the type of cycle. For all the most important administration routes (vaginal, intramuscular, subcutaneous) it appears that in frozen cycles there is a shift towards higher dosages. The 90.9% of the centers use vaginal progesterone, and when a combined approach is required, in 72.7% of cases vaginal administration is combined with injective route of administration. When Italian doctors were asked about the beginning and duration of LPS, 96% of the centers start the day of the pickup or the day after, while 80% of the centers continue LPS until week 8-12. The rate of participation of the centers confirms the low perceived importance of LPS among Italian ART centers, while may be considered quite surprising the relatively higher percentage of centers that measures P level. Tailorization to women's needs is the new objective of LPS: self-administration, good tolerability are the main aspects for Italian centers.

CONCLUSIONS

In conclusion, results of Italian survey are consistent to results of main international surveys about LPS.

No additional risk of congenital anomalies after first-trimester dydrogesterone use: a systematic review and meta-analysis

STUDY QUESTION

Is exposure to dydrogesterone a risk factor for congenital anomalies when given in the first trimester for recurrent/threatened pregnancy loss or as luteal support in assisted reproductive technology (ART)?

SUMMARY ANSWER

Dydrogesterone, when given in the first trimester for recurrent/threatened pregnancy loss or as luteal support in ART, is not a relevant additional risk factor for congenital anomalies.

WHAT IS KNOWN ALREADY

Despite large clinical trials and meta-analyses that show no association between dydrogesterone and congenital anomalies, some recently retracted publications have postulated an association with teratogenicity. Dydrogesterone is also often rated as less safe than bioidentical progestins.

STUDY DESIGN SIZE DURATION

A systematic review was conducted according to a pre-specified protocol with searches on Medline, Embase, Cochrane Central Register of Controlled Trials (CENTRAL), and Clinicaltrials.gov. The search was limited to human studies, with no restrictions on language, geographical region, or date. The search algorithm used a PICO (Population, Intervention, Comparison, Outcome)-style approach combining both simple search terms and medical subject heading terms. As congenital anomalies are mostly reported as secondary outcomes, the search term 'safety' was added.

PARTICIPANTS/MATERIALS SETTING METHODS

Interventional study and observational study (OS) designs were eligible for inclusion. Inclusion criteria were: women >17 years old treated for threatened miscarriage, recurrent pregnancy loss, and/or ART; the use of dydrogesterone in the first trimester compared with placebo, no treatment or other interventions; and reporting of congenital anomalies in newborns or infants ≤12 months old (primary outcome). Two authors (A.K., M.R.N.) independently extracted the following data: general study information, study population details, intervention and comparator(s), and frequencies of congenital anomalies (classification, time of determination, and type). Risk of bias focused on the reporting of congenital malformations and was assessed using the Cochrane Risk of Bias Tool Version 2 or the ROBINS-I tool. The GRADEproGDT platform was used to generate the GRADE summary of findings table.

MAIN RESULTS AND THE ROLE OF CHANCE

Of the 897 records retrieved during the literature search, 47 were assessed for eligibility. Nine studies were included in the final analysis: six randomized controlled trials (RCTs) and three OSs. Among the RCTs, three had a low risk and three a high risk of bias. Two of the OSs were considered to have a serious risk of bias and one with critical risk of bias and was excluded for the evidence syntheses. The eight remaining studies included a total of 5070 participants and 2680 live births from 16 countries. In the meta-analysis of RCTs only, the overall risk ratio (RR) was 0.92 [95% CI 0.55; 1.55] with low certainty. When the two OSs were included, the overall RR was 1.11 [95% CI 0.73; 1.68] with low certainty.

LIMITATIONS REASONS FOR CAUTION

The studies included in the analysis do not report congenital anomalies as the primary outcome; reporting of congenital anomalies was often not standardized.

WIDER IMPLICATIONS OF THE FINDINGS

This systematic literature review and meta-analysis provide clear reassurance to both clinicians and patients that dydrogesterone is not associated with congenital anomalies above the rate that might be expected due to environmental and genetic factors. The results of this work represent the highest current level of evidence for the question of congenital anomalies, which removes the existing uncertainty caused by poor quality and retracted studies.

STUDY FUNDING/COMPETING INTERESTS

Editorial support was provided by Highfield Communication Consultancy, Oxford, UK, sponsored by Abbott Products Operations AG, Allschwil, Switzerland. A.K., J.A.G.-V., L.P.S., J.N.v.d.A., and J.F.S. received honoraria from Abbott for preparation and participation in an advisory board. J.A.G.-V. received grants and lecture fees from Merck, Organon, Ferring, Gedeon Richter, and Theramex. M.R.N. has no conflicts of interest. J.N.v.d.A. and J.A.G.-V. have no other conflicts of interest. A.K. received payment from Abbott for a talk at the IVF Worldwide congress on 22 September 2023. J.F.S. has received grants from the National Institutes of Health, royalties/licences from Elsevier and Prescient Medicine (SOLVD Health), consulting fees from Burroughs Wellcome Fund (BWF) and Bayer, honoraria from Magee Women's Research Institute, Wisconsin National Primate Research Centre, University of Kansas and Oakridge National Research Laboratory, Agile, Daiichi Sankyo/American Regent, and Bayer, and travel support to attend meetings for the International Academy of Human Reproduction (IAHR). J.F.S. has patents related to diagnosis and treatment of PCOS and prediction of preterm birth. J.F.S. participates on advisory boards for SOLVD Health, Wisconsin National Primate Research Centre, and FHI360, was the past President board member of the Society for Reproductive Investigation, has a leadership role for the following organizations: Scientific Advisory Board, SOLVD Health, EAB Chair for contraceptive technology initiative, FHI360, EAB member, Wisconsin National Primate Research Centre, Advisory Board for MWRI Summit, Chair of BWF NextGen Pregnancy Research Panel, Medical Executive Committee at the Howard, and Georgeanna Jones Foundation, and is Vice President, IAHR. L.P.S. has received consulting fees from Shield Pharmaceuticals, Scynexis, Organon, Natera, Celula China, AiVF, Agile, Daiichi Sankyo, American Regent, and Medicem, honoraria from Agile, Daiichi Sankyo/American Regent, and Bayer, and travel support from BD Diagnostics. L.P.S. participates on the data safety monitoring board for Astellas and is a Chair of DSMB for fezolinetant. Abbott played no role in the funding of the study or in study design, data collection, data analysis, data interpretation, or writing of the report.

TRIAL REGISTRATION NUMBER

PROSPERO 2022 CRD42022356977.

Progesterone: The Key Factor of the Beginning of Life

Progesterone is the ovarian steroid produced by the granulosa cells of follicles after the LH peak at mid-cycle. Its role is to sustain embryo endometrial implantation and ongoing pregnancy. Other biological effects of progesterone may exert a protective function in supporting pregnancy up to birth. Luteal phase support (LPS) with progesterone is the standard of care for assisted reproductive technology. Progesterone vaginal administration is currently the most widely used treatment for LPS. Physicians and patients have been reluctant to change an administration route that has proven to be effective. However, some questions remain open, namely the need for LPS in fresh and frozen embryo transfer, the route of administration, the optimal duration of LPS, dosage, and the benefit of combination therapies. The aim of this review is to provide an overview of the uterine and extra-uterine effects of progesterone that may play a role in embryo implantation and pregnancy, and to discuss the advantages of the use of progesterone for LPS in the context of Good Medical Practice.

Low serum progesterone affects live birth rate in cryopreserved blastocyst transfer cycles using hormone replacement therapy

RESEARCH QUESTION

Does serum progesterone concentration on the day of vitrified-warmed embryo transfer affect live birth rate (LBR) with hormonal replacement therapy (HRT) cycles?

DESIGN

Observational cohort study of patients (n = 915) undergoing single autologous vitrified-warmed blastocyst transfer under HRT using vaginal micronized progesterone. Women were included once, between January 2019 and March 2020. Serum progesterone concentration was measured by a single laboratory on the morning of embryo transfer. The primary end point was LBR. Univariate and multivariate logistic regression models were used for statistical analyses.

RESULTS

Median (25th-75th percentile) serum progesterone concentration on the day of embryo transfer was 12.5 ng/ml (9.8-15.3). The LBR was 31.5% (288/915) in the overall population. No significant differences were found in implantation rates (40.7% versus 44.9%); LBR was significantly lower in women with a progesterone concentration ≤25th percentile (≤9.8 ng/ml) (26.1% versus 33.2%, P = 0.045) versus women with a progesterone concentration >25th percentile. This correlated with a significantly higher early miscarriage rate (35.9% versus 21.6%, P = 0.005). After adjusting for potential confounding factors in multivariate analysis, low serum progesterone levels (≤9.8 ng/ml) remained significantly associated with lower LBR (OR 0.68 95% CI 0.48 to 0.97).

CONCLUSION

A minimum serum progesterone concentration is needed to optimize reproductive outcomes in HRT cycles with single autologous vitrified-warmed blastocyst transfer. Whether modifications of progesterone administration routes, dosage, or both, can improve pregnancy rates needs further study so that treatment of patients undergoing HRT cycles can be further individualized.

A review of conventional and sustained-release formulations of oral natural micronized progesterone in obstetric indications

Background

Exogenous progesterone is a treatment option for obstetric indications associated with reduced progesterone activity. Oral natural micronized progesterone (NMP) is effective, although it requires multiple daily doses and may cause adverse events due to its active metabolites. A sustained-release formulation of NMP (NMP-SR) has been developed to overcome the limitations of conventional oral NMP.

Methods

This narrative review examines the available evidence for oral NMP and NMP-SR in several obstetric indications of interest.

Results

Literature searches identified 17 studies of oral NMP (luteal phase support during assisted reproduction, prevention of threatened miscarriage, prevention of preterm delivery), and clinical studies supporting use of NMP-SR (luteal phase support during intrauterine insemination, maintenance of high-risk pregnancy). Oral NMP was effective for luteal phase support during in vitro fertilization and intrauterine insemination, prevention of threatened miscarriage, and prevention of preterm delivery. NMP-SR was comparable to dydrogesterone for luteal phase support during intrauterine insemination and effectively maintained high-risk pregnancies. Oral NMP-SR was well tolerated.

Conclusions

By releasing progesterone gradually and circumventing first-pass metabolism, NMP-SR elicits the desired therapeutic effect with benefits over conventional oral NMP in terms of bioavailability, once-daily dosing and improved tolerability. Oral NMP-SR appears to be a valuable option for treating obstetric conditions associated with insufficient progesterone exposure.

Luteal-phase support in assisted reproductive technology: An ongoing challenge

It has been shown that in controlled ovarian hyper stimulation cycles, defective luteal phase is common. There are many protocols for improving pregnancy outcomes in women undergoing fresh and frozen in vitro fertilization cycles. These approaches include progesterone supplements, human chorionic gonadotropin, estradiol, gonadotropin-releasing hormone agonist, and recombinant luteinizing hormone. The main challenge is luteal-phase support (LPS) in cycles with gonadotropin-releasing hormone agonist triggering. There is still controversy about the optimal component and time for starting LPS in assisted reproductive technology cycles. This review aims to summarize the various protocols suggested for LPS in in vitro fertilization cycles.

Imaging features of gluteal in vitro fertilization injection granulomas, with delayed clinical presentation simulating soft tissue sarcoma

OBJECTIVES

To review the clinical and imaging findings of patients with remote history of intramuscular (IM) in vitro fertilization (IVF) gluteal injections, presenting with signs and symptoms of a possible gluteal soft tissue sarcoma.

METHODS AND METHODS

Retrospective review of consecutive patients with a history of prior IVF therapy referred for MRI evaluation of a gluteal soft tissue mass was performed. Six patients were reviewed, with 5 patients meeting study inclusion criteria. Imaging exams (ultrasound n = 3, MRI n = 5) were assessed for lesion location, morphology, and intrinsic imaging characteristics. One case proceeded to percutaneous biopsy with histopathologic correlation.

RESULTS

Average patient age was 43 years (range 38-50). Mean time interval between IVF IM injections and MRI was 5.7 years (range 2.2-13 years). Clinical findings included palpable gluteal mass (5/5) and local pain (4/5). Ultrasound showed heterogeneous subcutaneous lesions with varying complex cystic/solid internal echogenicity. On MRI, each case illustrated an irregularly marginated lesion, mean maximal dimension 3.5 cm (range 1.5-5.9 cm), within the deep gluteal subcutaneous fat composed of solitary (1/5) or multifocal (4/5) lobules demonstrating internal areas of high T1 and homogeneous low T2 fat suppressed signal with surrounding peripheral reticular high T2 signal. Correlative histological assessment showed central areas with features of fat necrosis and a peripheral inflammatory rim.

CONCLUSIONS

In the setting of prior IVF therapy, imaging features of an irregularly marginated, deep subcutaneous gluteal lesion with inflammatory soft tissue changes surrounding solitary or multifocal areas of loculated fat signal may be seen as an inflammatory response to previous inadvertent subcutaneous injection(s).

Intramuscular progesterone optimizes live birth from programmed frozen embryo transfer: a randomized clinical trial

OBJECTIVE

To determine whether vaginal progesterone for programmed endometrial preparation is noninferior to intramuscular progesterone in terms of live birth rates from frozen embryo transfer (FET).

DESIGN

Three-armed, randomized, controlled noninferiority trial.

SETTING

Multicenter fertility clinic.

PATIENT(S)

A total of 1,346 volunteer subjects planning vitrified-warmed transfer of high-quality nonbiopsied blastocysts were screened, of whom 1,125 subjects were ultimately enrolled and randomly assigned to treatment.

INTERVENTION(S)

The subjects were randomly assigned to receive, in preparation for FET, 50 mg daily of intramuscular progesterone (control group), 200 mg twice daily of vaginal micronized progesterone plus 50 mg of intramuscular progesterone every third day (combination treatment), or 200 mg twice daily of vaginal micronized progesterone.

MAIN OUTCOME MEASURE(S)

The primary outcome was live birth rate per vitrified-warmed embryo transfer. The secondary outcomes were a positive serum human chorionic gonadotropin test 2 weeks after FET, biochemical pregnancy loss, clinical pregnancy, clinical pregnancy loss, total pregnancy loss, serum luteal progesterone concentration 2 weeks after FET, and patient's experience and attitudes regarding the route of progesterone administration, on the basis of a survey administered to the subjects between FET and pregnancy test.

RESULT(S)

A total of 1,060 FETs were completed. The live birth rate was significantly lower in women receiving only vaginal progesterone (27%) than in women receiving intramuscular progesterone (44%) or combination treatment (46%). Fifty percent of pregnancies in women receiving only vaginal progesterone ended in miscarriage.

CONCLUSION(S)

The live birth rate after vaginal-only progesterone replacement was significantly reduced, due primarily to an increased rate of miscarriage. Vaginal progesterone supplemented with intramuscular progesterone every third day was noninferior to daily intramuscular progesterone, offering an effective alternative regimen with fewer injections.

CLINICAL TRIAL REGISTRATION NUMBER

NCT02254577.

A 10-year follow-up on the practice of luteal phase support using worldwide web-based surveys

BACKGROUND

It has been demonstrated that luteal phase support (LPS) is crucial in filling the gap between the disappearance of exogenously administered hCG for ovulation triggering and the initiation of secretion of endogenous hCG from the implanting conceptus. LPS has a pivotal role of in establishing and maintaining in vitro fertilization (IVF) pregnancies. Over the last decade, a plethora of studies bringing new information on many aspects of LPS have been published. Due to lack of consent between researchers and a dearth of robust evidence-based guidelines, we wanted to make the leap from the bench to the bedside, what are the common LPS practices in fresh IVF cycles compared to current evidence and guidelines? How has expert opinion changed over 10 years in light of recent literature?

METHODS

Over a decade (2009-2019), we conducted 4 web-based surveys on a large IVF-specialist website on common LPS practices and controversies. The self-report, multiple-choice surveys quantified results by annual IVF cycles.

RESULTS

On average, 303 IVF units responded to each survey, representing, on average, 231,000 annual IVF cycles. Most respondents in 2019 initiated LPS on the day of, or the day after egg collection (48.7 % and 36.3 %, respectively). In 2018, 72 % of respondents administered LPS for 8-10 gestational weeks, while in 2019, 65 % continued LPS until 10-12 weeks. Vaginal progesterone is the predominant delivery route; its utilization rose from 64 % of cycles in 2009 to 74.1 % in 2019. Oral P use has remained negligible; a slight increase to 2.9 % in 2019 likely reflects dydrogesterone's introduction into practice. E2 and GnRH agonists are rarely used for LPS, as is hCG alone, limited by its associated risk of ovarian hyperstimulation syndrome (OHSS).

CONCLUSIONS

Our Assisted reproductive technology (ART)-community survey series gave us insights into physician views on using progesterone for LPS. Despite extensive research and numerous publications, evidence quality and recommendation levels are surprisingly low for most topics. Clinical guidelines use mostly low-quality evidence. There is no single accepted LPS protocol. Our study highlights the gaps between science and practice and the need for further LPS research, with an emphasis on treatment individualization.

Efficacy of four vaginal progesterones for luteal phase support in frozen-thawed embryo transfer cycles: A randomized clinical trial

PURPOSE

To investigate the efficacy of four vaginal progesterones, Lutinus, Utrogestan, Luteum, and Crinone, as luteal phase support (LPS) in frozen-thawed embryo transfer (Frozen-ET) cycles.

METHODS

Patients undergoing autologous Frozen-ET of one cleavage-stage embryo or one blastocyst. Two hundred fifty-nine Frozen-ET cycles were randomized to four groups for LPS: Lutinus, Utrogestan, Luteum, and Crinone. The clinical pregnancy rate (CPR), fetal heartbeat rate (FHR), and miscarriage rate (MR) were analyzed using the Mann-Whitney or Kruskal-Wallis test and Fisher exact test.

RESULTS

Two hundred thirty-five Frozen-ET cycles were analyzed: 63 cycles in the Lutinus group, 60 in the Utrogestan group, 56 in the Luteum group, and 56 in the Crinone group. No significant differences were observed between the four groups in CPR (Lutinus, Utrogestan, Luteum, and Crinone: 34.9%, 33.3%, 37.5%, and 35.7%, respectively; P = .976), FHR (26.9%, 31.6%, 30.3%, and 25.0%, respectively; P = .857), and MR (31.8%, 10.0%, 19.0%, and 30.0%, respectively; P = .306). Multivariate logistic regression analysis also revealed that there were no statistically significant differences between the four groups with regard to CPR, FHR, and MR.

CONCLUSION

There was no clinically significant difference in pregnancy outcomes between the four vaginal progesterone groups for LPS in Frozen-ET cycles.

Evaluation of progestogen supplementation for luteal phase support in fresh in vitro fertilization cycles

OBJECTIVE

To evaluate the effectiveness of progestogen supplementation in improving clinical pregnancy rates in women undergoing fresh IVF cycles and to compare different routes, start times, durations, and estrogen coadministration regimen.

DESIGN

Comprehensive systematic review and meta-analysis.

SETTING

University.

PATIENT(S)

Women undergoing fresh IVF cycles who did and did not receive progestogen supplementation.

INTERVENTION(S)

Summary odds ratios (ORs) were calculated by binomial logistic regression.

MAIN OUTCOME MEASURE(S)

Clinical pregnancy rates.

RESULT(S)

Eighty-two articles (26,726 women) were included. Clinical pregnancy rates were increased by IM (OR = 4.57), vaginal (OR = 3.34), SC (OR = 3.36), or oral (OR = 2.57) progestogen supplementation versus no treatment. The greatest benefit was observed when progestogens were supplemented IM versus vaginally (OR = 1.37). The optimal time to commence administration was between oocyte retrieval and ET (OR = 1.31), with oocyte retrieval +1 day being most beneficial. Coadministration of estrogen had no benefit (OR = 1.33), whether progestogens were coadministered vaginally or IM. Clinical pregnancy rates were equivalent when progestogen supplementation was ceased after ≤3 weeks or continued for up to 12 weeks (OR = 1.06).

CONCLUSION(S)

This broad-ranging meta-analysis highlights the need to reevaluate current clinical practice. The use of progestogens in fresh IVF cycles is substantially beneficial to clinical pregnancy. Critically, the use of IM progestogens should not be dismissed, as it yielded the greatest clinical pregnancy rates. Pregnancy success was impacted by initiation of therapy, with 1 day after oocyte retrieval being optimal. There is little evidence to support coadministration of estrogen or prolonging progestogen treatment beyond 3 weeks.

Dydrogesterone: pharmacological profile and mechanism of action as luteal phase support in assisted reproduction

The pharmacological and physiological profiles of progestogens used for luteal phase support during assisted reproductive technology are likely to be important in guiding clinical choice towards the most appropriate treatment option. Various micronized progesterone formulations with differing pharmacological profiles have been investigated for several purposes. Dydrogesterone, a stereoisomer of progesterone, is available in an oral form with high oral bioavailability; it has been used to treat a variety of conditions related to progesterone deficiency since the 1960s and has recently been approved for luteal phase support as part of an assisted reproductive technology treatment. The primary objective of this review is to critically analyse the clinical implications of the pharmacological and physiological properties of dydrogesterone for its uses in luteal phase support and in early pregnancy.

Effectiveness of high-dose transvaginal progesterone supplementation for women who are undergoing a frozen-thawed embryo transfer

PURPOSE

To evaluate the effectiveness of high-dose progesterone supplementation for women who are undergoing a frozen-thawed embryo transfer (FET).

METHODS

Among the 2010 FET cycles that were included in the present study, 1188 were 1200 mg/d of vaginal progesterone, while 822 were 900 mg/d. The dose of progesterone that was used was decided by the treatment period and additional progesterone supplementation was used when the serum progesterone levels were <9 ng/mL on luteal day 5.

RESULTS

The clinical pregnancy rate was higher in the 1200 mg group than in the 900 mg group. The mean serum progesterone level on luteal day 5 in the 1200 mg and 900 mg groups was 12.6 ng/mL and 13.4 ng/mL, respectively. The rate of additional progesterone supplementation was higher in the 1200 mg group. A logistic regression analysis identified a younger age (≤37 years) and the use of 1200 mg progesterone as independent predictive factors for the clinical pregnancy outcome. The analysis of the infant outcomes revealed no significant difference in the distribution of birth ages and weights.

CONCLUSION

High-dose transvaginal progesterone of 1200 mg/d as luteal support contributed to good pregnancy outcomes.

Preparation and Evaluation of Progesterone Nanocrystals to Decrease Muscle Irritation and Improve Bioavailability

Progesterone (PG) is a crucial immunomodulatory agent during early pregnancy, and nowadays PG oil-based injection (PG/OI) has a huge market all over the world. However, PG/OI may accumulate the local muscle and further cause irritations after long-term administration. In this study, PG nanocrystals (PG/NCs) injection was developed to decrease muscle toxicity. PG/NCs injection containing 10% (w/v) PG was first prepared using a wet grinding method. Then, particle size, zeta potential, morphology powder, X-ray diffraction (PXRD), differential scanning calorimetry (DSC), and Fourier transform infrared (FTIR) studies were carried out to evaluate the characteristics of dosage form. The rabbit muscle irritation, hemolysis, and rat pharmacokinetics tests were used to estimate the in vivo characteristics of PG/NCs. The results showed that the mean particle size and the zeta potentials of NCs were 299.5 ± 9.0 nm and - 36.8 ± 1.5 mV, respectively. The crystalline state of PG/NCs was not altered during particle size reduction according to PXRD, DSC, and FTIR results. Muscle irritation presented that PG/NCs had lower irritation than that of PG/OI. Hemolysis test suggested that PG/NCs injection was functioned without hemolysis and red cell agglutination. The pharmacokinetics study showed that the AUC_0-t and C_max of PG/NCs was 3.2-fold (p < 0.05) and 3.1-fold higher than PG/OI, which demonstrated that PG/NCs injection had greater bioavailability than PG/OI. Therefore, it was obvious that PG/NCs injection exhibited a lower muscle irritation, hemolysis rate, and higher bioavailability, which was a better dosage form than OI.

Vitrified blastocyst transfer cycles with the use of only vaginal progesterone replacement with Endometrin have inferior ongoing pregnancy rates: results from the planned interim analysis of a three-arm randomized controlled noninferiority trial

OBJECTIVE

To assess the noninferiority of vaginal P (Endometrin) compared with daily intramuscular P for replacement in programmed vitrified-warmed blastocyst transfer cycles and to assess the noninferiority of vaginal P in combination with intramuscular progesterone every third day compared with daily intramuscular P.

DESIGN

Three-arm randomized controlled noninferiority study. To enable early recognition of inferiority if present, an a priori interim analysis was planned and completed once ongoing pregnancy data were available for 50% of the total enrollment goal. The results of this interim analysis are presented here.

SETTING

Assisted reproduction technology practice.

PATIENT(S)

Women undergoing transfer of nonbiopsied high quality vitrified-warmed blastocyst(s) in a programmed cycle.

INTERVENTION(S)

Vitrified-warmed blastocyst transfer with mode of P replacement determined by randomization to either: (1) 50 mg daily intramuscular P only; (2) 200 mg twice daily vaginal Endometrin; or (3) 200 mg twice daily Endometrin plus 50 mg intramuscular P every 3rd day.

MAIN OUTCOME MEASURE(S)

Live birth. The primary outcome of this interim analysis was ongoing pregnancy.

RESULT(S)

A total of 645 cycles were randomly assigned to one of the three treatment arms, received at least one dose of P replacement therapy according to this assignment and underwent vitrified-warmed blastocyst transfer. These cycles were included in the intention-to-treat analysis. The study team, including the statistician, were blinded to the identity of the treatment arms, which were randomly labeled "A," "B," and "C" in the dataset. Ongoing pregnancy occurred in 50%, 47%, and 31% of cycles in arms A, B, and C respectively. Although arm C had an rate of positive hCG equivalent to the other two arms, the rate of pregnancy loss for arm C was significantly higher than for either of the two arms, resulting in a more than one-third lower rate of ongoing pregnancy. There were no statistically significant differences for any outcome tested between arms A and B. Results of a per-protocol analysis were nearly identical to those of the intention-to-treat analysis. On completion of these analyses, arm C was revealed to be the vaginal P only arm.

CONCLUSION(S)

Relative to regimens inclusive of intramuscular P, vaginal-only P replacement for vitrified-warmed blastocyst transfer results in decreased ongoing pregnancy, due to increased miscarriage, and should be avoided. Randomization to the vaginal-only arm was terminated with these findings. This trial is ongoing to assess the noninferiority of the vaginal plus every 3rd day intramuscular P arm compared with daily intramuscular P in terms of live birth.

CLINICAL TRIAL REGISTRATION NUMBER

NLM identifier NCT02254577.

The impact of progesterone supplementation on pregnancy rates after intrauterine insemination in patients developing a single follicle

The objective was to determine whether progesterone support affects pregnancy rates in patients who develop a single follicle. This was a non-randomized prospective controlled study performed on 591 intrauterine insemination (IUI) cycles that developed a single follicle; 337 women received 100 mg oral progesterone daily. The pregnancy rate was 24.3%, or 82 out of 337, in the group receiving progesterone support compared with 14.96%, or 254 out of 591, in the group with no progesterone support. IUI luteal phase supplementation with oral progesterone may improve clinical pregnancy rates when begun the day after insemination.

Pharmaceutical and clinical development of a novel progesterone formulation

Progesterone plays an essential role in reproductive events. Its use for luteal support in patients undergoing infertility treatment is an established practice. The different routes used to administer progesterone impact on its efficacy in luteal support: oral administration has been shown to be ineffective due to an extensive first-pass metabolism in the liver; vaginal application has a good efficacy but has drawbacks such as vaginal leakage, irritation, discomfort and uncertainty about the real dose adsorbed; finally, intramuscular administration ensures a precise dosage but can be extremely painful with, in some cases, formation of sterile abscesses. A new progesterone preparation is now available in several European and extra-European countries that combines the precise dosage of the injectable formulation with the comfort of a well-tolerated subcutaneous self-administration. The pharmacokinetic and pharmacodynamic properties of this new product are reviewed here, together with the clinical evidence obtained in two multicenter randomized clinical trials.

Luteal phase support for assisted reproduction cycles

BACKGROUND

Progesterone prepares the endometrium for pregnancy by stimulating proliferation in response to human chorionic gonadotropin(hCG) produced by the corpus luteum. This occurs in the luteal phase of the menstrual cycle. In assisted reproduction techniques(ART), progesterone and/or hCG levels are low, so the luteal phase is supported with progesterone, hCG or gonadotropin-releasing hormone (GnRH) agonists to improve implantation and pregnancy rates.

OBJECTIVES

To determine the relative effectiveness and safety of methods of luteal phase support provided to subfertile women undergoing assisted reproduction.

SEARCH METHODS

We searched databases including the Cochrane Menstrual Disorders and Subfertility Group (MDSG) Specialised Register, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, PsycINFO and trial registers. We conducted searches in November 2014, and further searches on 4 August 2015.

SELECTION CRITERIA

Randomised controlled trials (RCTs) of luteal phase support using progesterone, hCG or GnRH agonist supplementation in ART cycles.

DATA COLLECTION AND ANALYSIS

Three review authors independently selected trials, extracted data and assessed risk of bias. We calculated odds ratios (ORs) and 95%confidence intervals (CIs) for each comparison and combined data when appropriate using a fixed-effect model. Our primary out come was live birth or ongoing pregnancy. The overall quality of the evidence was assessed using GRADE methods.

MAIN RESULTS

Ninety-four women RCTs (26,198 women) were included. Most studies had unclear or high risk of bias in most domains. The main limitations in the evidence were poor reporting of study methods and imprecision due to small sample sizes.1. hCG vs placebo/no treatment (five RCTs, 746 women)There was no evidence of differences between groups in live birth or ongoing pregnancy (OR 1.67, 95% CI 0.90 to 3.12, three RCTs,527 women, I2 = 24%, very low-quality evidence, but I2 of 61% was found for the subgroup of ongoing pregnancy) with a random effects model. hCG increased the risk of ovarian hyperstimulation syndrome (OHSS) (1 RCT, OR 4.28, 95% CI 1.91 to 9.6, low quality evidence).2. Progesterone vs placebo/no treatment (eight RCTs, 875 women)Evidence suggests a higher rate of live birth or ongoing pregnancy in the progesterone group (OR 1.77, 95% CI 1.09 to 2.86, five RCTs, 642 women, I2 = 35%, very low-quality evidence). OHSS was not reported.3. Progesterone vs hCG regimens (16 RCTs, 2162 women)hCG regimens included comparisons of progesterone versus hCG and progesterone versus progesterone + hCG. No evidence showed differences between groups in live birth or ongoing pregnancy (OR 0.95, 95% CI 0.65 to 1.38, five RCTs, 833 women, I2 = 0%, low quality evidence) or in the risk of OHSS (four RCTs, 615 women, progesterone vs hCG OR 0.54, 95% CI 0.22 to 1.34; four RCTs,678 women; progesterone vs progesterone plus hCG, OR 0.34, 95% CI 0.09 to 1.26, low-quality evidence).4. Progesterone vs progesterone with oestrogen (16 RCTs, 2577 women)No evidence was found of differences between groups in live birth or ongoing pregnancy (OR 1.12, 95% CI 0.91 to 1.38, nine RCTs,1651 women, I2 = 0%, low-quality evidence) or OHSS (OR 0.56, 95% CI 0.2 to 1.63, two RCTs, 461 women, I2 = 0%, low-quality evidence).5. Progesterone vs progesterone + GnRH agonist (seven RCTs, 1708 women)Live birth or ongoing pregnancy rates were lower in the progesterone-only group and increased in women who received progester one and one or more GnRH agonist doses (OR 0.62, 95% CI 0.48 to 0.81, nine RCTs, 2861 women, I2 = 55%, random effects, low quality evidence). Statistical heterogeneity for this comparison was high because of unexplained variation in the effect size, but the direction of effect was consistent across studies. OHSS was reported in one study only (OR 1.00, 95% CI 0.33 to 3.01, 1 RCT, 300 women, very low quality evidence).6. Progesterone regimens (45 RCTs, 13,814 women)The included studies reported nine different comparisons between progesterone regimens. Findings for live birth or ongoing pregnancy were as follows: intramuscular (IM) versus oral: OR 0.71, 95% CI 0.14 to 3.66 (one RCT, 40 women, very low-quality evidence);IM versus vaginal/rectal: OR 1.24, 95% CI 1.03 to 1.5 (seven RCTs, 2309 women, I2 = 71%, very low-quality evidence); vaginal/rectal versus oral: OR 1.19, 95% CI 0.83 to 1.69 (four RCTs, 857 women, I2 = 32%, low-quality evidence); low-dose versus high-dose vaginal: OR 0.97, 95% CI 0.84 to 1.11 (five RCTs, 3720 women, I2 = 0%, moderate-quality evidence); short versus long protocol:OR 1.04, 95% CI 0.79 to 1.36 (five RCTs, 1205 women, I2 = 0%, low-quality evidence); micronised versus synthetic: OR 0.9, 95%CI 0.53 to 1.55 (two RCTs, 470 women, I2 = 0%, low-quality evidence); vaginal ring versus gel: OR 1.09, 95% CI 0.88 to 1.36 (oneRCT, 1271 women, low-quality evidence); subcutaneous versus vaginal gel: OR 0.92, 95% CI 0.74 to 1.14 (two RCTs, 1465 women,I2 = 0%, low-quality evidence); and vaginal versus rectal: OR 1.28, 95% CI 0.64 to 2.54 (one RCT, 147 women, very low-quality evidence). OHSS rates were reported for only two of these comparisons: IM versus oral, and low versus high-dose vaginal. No evidence showed a difference between groups.7. Progesterone and oestrogen regimens (two RCTs, 1195 women)The included studies compared two different oestrogen protocols. No evidence was found to suggest differences in live birth or ongoing pregnancy rates between a short and a long protocol (OR 1.08, 95% CI 0.81 to 1.43, one RCT, 910 women, low-quality evidence) or between a low dose and a high dose of oestrogen (OR 0.65, 95% CI 0.37 to 1.13, one RCT, 285 women, very low-quality evidence).Neither study reported OHSS.

AUTHORS' CONCLUSIONS

Both progesterone and hCG during the luteal phase are associated with higher rates of live birth or ongoing pregnancy than placebo.The addition of GnRHa to progesterone is associated with an improvement in pregnancy outcomes. OHSS rates are increased with hCG compared to placebo (only study only). The addition of oestrogen does not seem to improve outcomes. The route of progester one administration is not associated with an improvement in outcomes.

Progesterone and the luteal phase: a requisite to reproduction

Progesterone production from the corpus luteum is critical for natural reproduction. Progesterone supplementation seems to be an important aspect of any assisted reproductive technology treatment. Luteal phase deficiency in natural cycles is a plausible cause of infertility and pregnancy loss, though there is no adequate diagnostic test. This article describes the normal luteal phase of the menstrual cycle, investigates the controversy surrounding luteal phase deficiency, and presents the current literature for progesterone supplementation during assisted reproductive technologies.

Progesterone vaginal ring for luteal support

Progesterone supplementation is universally used and has been shown to be beneficial in supplementation of the luteal phase in IVF. There are multiple options and the most commonly used include intramuscular and vaginal progesterone. A progesterone vaginal ring is a novel system for luteal support with advantages of controlled release with less frequent dosing. This review examines options for progesterone luteal support focusing on the rationale for a progesterone vaginal ring. Pub-med search of the literature. A weekly vaginal ring, although not yet FDA approved, is an effective and safe alternative for luteal supplementation in IVF. Large prospective clinical trials are needed to determine the best protocols for replacement cycles.

Assisted reproductive techniques

Assisted reproductive technologies (ART) encompass fertility treatments, which involve manipulations of both oocyte and sperm in vitro. This chapter provides a brief overview of ART, including indications for treatment, ovarian reserve testing, selection of controlled ovarian hyperstimulation (COH) protocols, laboratory techniques of ART including in vitro fertilization (IVF), and intracytoplasmic sperm injection (ICSI), embryo transfer techniques, and luteal phase support. This chapter also discusses potential complications of ART, namely ovarian hyperstimulation syndrome (OHSS) and multiple gestations, and the perinatal outcomes of ART.

The role of progesterone and the progesterone receptor in human reproduction and cancer

Insufficient progesterone, effect possibly more on immune factors rather than adequate endometrial development, can be an easy remedial cause of infertility by simply supplementing the luteal phase with either vaginal or intramuscular or oral (dydrogesterone) progesterone. Progesterone will also help to reduce miscarriage rates when follicle maturing drugs are used for those with regular menses but follicular maturation defects, or women with recurrent miscarriages. One mechanism of action seems to be related to production of an immunomodulatory protein, the progesterone-induced blocking factor either in the cytoplasm or in the circulation. PIBF inhibits cytotoxicity of natural killer cells. Cancer cells may 'borrow' the same mechanism to escape NK cell immunosurveillance.

A randomized trial comparing the endometrial effects of daily subcutaneous administration of 25 mg and 50 mg progesterone in aqueous preparation

OBJECTIVE

To study the efficacy of a new P preparation in aqueous solution for subcutaneous injection for inducing the predecidual transformation of the endometrium.

DESIGN

Prospective, single-blinded, randomized, parallel pilot trial.

SETTING

University-affiliated clinical research center.

PATIENT(S)

Twenty-five regularly cycling female volunteers.

INTERVENTION(S)

Volunteers, aged 18-45 years, body mass index 19-25 kg/m(2), whose ovaries were suppressed with a GnRH agonist were estrogenized for 14 or 21 days with the use of transdermal systems delivering 0.1 mg/d E₂. After confirming that the endometrial thickness was >7 mm, the women were randomized to 25 mg or 50 mg of subcutaneous P injections daily for 11 days, after which the endometrium was sampled with the use of a Pipelle device. The endometrial biopsies were evaluated by two independent pathologists. Adverse events and subjective tolerance were checked every day by the study investigator.

MAIN OUTCOME MEASURE(S)

Predecidual changes in endometrial biopsies obtained after 11 days of subcutaneous administration of P.

RESULT(S)

Of 24 biopsies performed (one dropout), 22 provided tissue for histologic analysis. Evidence of predecidual changes in the endometrial stroma was found in 100% of the cases, with no differences between the two studied doses.

CONCLUSION(S)

Both doses of the new aqueous P preparation available for subcutaneous administration demonstrated predecidual changes in 100% of the interpretable endometrial biopsies in total absence of endogenous P. This offers good prospect of efficacy in luteal phase support for the lowest dose tested, 25 mg/d, the physiologic amount produced daily by the ovary during the midluteal phase.

CLINICAL TRIAL REGISTRATION NUMBER

NCT00377923.

Endometrin as luteal phase support in assisted reproduction

OBJECTIVE

To compare clinical pregnancy rate (PR) and live birth rate (LBR) between Endometrin monotherapy versus Endometrin and P in oil combination therapy in assisted reproductive technology (ART) cycles.

DESIGN

Retrospective analysis.

SETTING

Large private practice.

PATIENT(S)

Patients undergoing autologous fresh IVF cycles, autologous frozen ET cycles, and fresh oocyte donor cycles were included for analysis.

INTERVENTION(S)

Endometrin as a single agent for luteal support, Endometrin monotherapy or Endometrin with P in oil used at least once every 3 days for luteal support, Endometrin combination therapy.

MAIN OUTCOME MEASURE(S)

Clinical PR and LBR.

RESULT(S)

A total of 1,034 ART cycles were analyzed. Endometrin monotherapy was used in 694 of 1,034 (67%) cycles and Endometrin combination therapy was used in 340 of 1,034 (33%) cycles. In all fresh cycles, clinical PR was not significantly different (IVF autologous: Endometrin monotherapy 46.9% vs. Endometrin combination therapy 55.6%; donor oocyte endometrin monotherapy 45.2% vs. Endometrin combination therapy 52.0%). Frozen ET cycles had a significantly higher clinical PR and LBR with combination therapy group compared with monotherapy (clinical PR 47.9% vs. 23.5%; LBR 37.5% vs. 17.3%).

CONCLUSION(S)

Endometrin monotherapy was sufficient for the P component of luteal support and provided high PRs for fresh cycles in both autologous and donor oocyte cycles. Clinical PR and LBR in frozen ET cycles were significantly improved with the addition of IM P to Endometrin therapy. This may reflect the fact that lesser quality embryos are transferred in frozen ET cycles, and more intense P support is required for comparable PRs.

Duration of luteal support (DOLS) with progesterone pessaries to improve the success rates in assisted conception: study protocol for a randomized controlled trial

Background

Luteal support with progesterone is necessary for successful implantation of the embryo following egg collection and embryo transfer in an in-vitro fertilization (IVF) cycle. Progesterone has been used for as little as 2 weeks and for as long as 12 weeks of gestation. The optimal length of treatment is unresolved at present and it remains unclear how long to treat women receiving luteal supplementation.

Design

The trial is a prospective, randomized, double-blind, placebo-controlled trial to investigate the effect of the duration of luteal support with progesterone in IVF cycles. Following 2 weeks standard treatment and a positive biochemical pregnancy test, this randomized control trial will allocate women to a supplementary 8 weeks treatment with vaginal progesterone or 8 weeks placebo. Further studies would be required to investigate whether additional supplementation with progesterone is beneficial in early pregnancy.

Discussion

Currently at the Hewitt Centre, approximately 32.5% of women have a positive biochemical pregnancy test 2 weeks after embryo transfer. It is this population that is eligible for trial entry and randomization. Once the patient has confirmed a positive urinary pregnancy test they will be invited to join the trial. Once the consent form has been completed by the patient a trial prescription sheet will be sent to pharmacy with a stated collection time. The patient can then be randomized and the drugs dispensed according to pharmacy protocol. A blood sample will then be drawn for measurement of baseline hormone levels (progesterone, estradiol, free beta-human chorionic gonadotrophin, pregnancy-associated plasma protein-A, Activin A, Inhibin A and Inhibin B). The primary outcome measure is the proportion of all randomized women that continue successfully to a viable pregnancy (at least one fetus with fetal heart rate >100 beats/minute) on transabdominal/transvaginal ultrasound at 10 weeks post embryo transfer/12 weeks gestation (that is at the end of 8 weeks supplementary trial treatment).

Trial registration

ISRCTN05696887

Pregnancy outcomes in oocyte donation recipients: vaginal gel versus intramuscular injection progesterone replacement

PURPOSE

Compare outcomes with vaginal gel versus intramuscular progesterone replacement in donor oocyte recipients.

METHODS

A single-center retrospective analysis (January 2004-December 2006) evaluated pregnancy outcomes (serum human chorionic gonadotropin, implantation, clinical pregnancy, delivery, total pregnancy loss rates) for 225 recipients of embryos from donor (aged <32 years) oocytes. Vaginal progesterone gel (Crinone® 8%; 90 mg twice daily; n = 105) or intramuscular progesterone (50 mg once daily; n = 120) was started the afternoon of oocyte retrieval and continued until a negative pregnancy test or 10 weeks' gestation.

RESULTS

There were no statistically significant differences between groups for the five pregnancy outcomes; numerical results favored vaginal progesterone in all cases. Confidence intervals showed vaginal gel was within, or <1% from, a noninferiority limit of 10% versus intramuscular progesterone for four of five pregnancy outcomes.

CONCLUSIONS

Pregnancy outcomes were comparable for progesterone replacement with vaginal gel and intramuscular progesterone in an oocyte donation program.

Oral micronized progesterone combined with vaginal progesterone gel for luteal support

The aim of the present study was to compare the efficacy and satisfaction rate of combined therapy of oral micronized progesterone capsules and vaginal progesterone gel versus monotherapy with vaginal progesterone gel in luteal support. A case-control study was performed on a total number of 370 women aged <45 years undergoing IVF-ET treatment. The patients received either combination of Crinone 8% vaginal gel, 90 mg daily dose and Utrogestan oral capsules 3 x 100 mg, or Crinone 8% vaginal gel, 90 mg daily. Progesterone supplementation begun on the day of oocyte retrieval and continued until pregnancy was tested and in the case of pregnancy until week 8. The comparable rates of ongoing pregnancies were noted with use of combined-progesterone therapy (39.5%) and progesterone-monotherapy (33.5%). Abortion rate (6.4% vs. 15.6%) was significantly lower with the use of combined therapy. Tolerability and satisfaction of both supplements was almost equal but bleeding occurred more frequently in the progesterone-monotherapy group. In conclusion, the efficacy, satisfaction and tolerability of combined and vaginal progesterone supplements were comparable, but bleeding in early pregnancy and abortion rate presented more frequently with the use of vaginal progesterone.

Luteal phase support for assisted reproduction cycles

BACKGROUND

Progesterone prepares the endometrium for pregnancy by stimulating proliferation in response to human chorionic gonadotropin (hCG), which is produced by the corpus luteum. This occurs in the luteal phase of the menstrual cycle. In assisted reproduction techniques (ART) the progesterone or hCG levels, or both, are low and the natural process is insufficient, so the luteal phase is supported with either progesterone, hCG or gonadotropin releasing hormone (GnRH) agonists. Luteal phase support improves implantation rate and thus pregnancy rates but the ideal method is still unclear. This is an update of a Cochrane Review published in 2004 (Daya 2004).

OBJECTIVES

To determine the relative effectiveness and safety of methods of luteal phase support in subfertile women undergoing assisted reproductive technology.

SEARCH STRATEGY

We searched the Cochrane Menstrual Disorders and Subfertility Group (MDSG) Specialised Register, Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, PsycINFO, CINAHL, Database of Abstracts of Reviews of Effects (DARE), LILACS, conference abstracts on the ISI Web of Knowledge, OpenSigle for grey literature from Europe, and ongoing clinical trials registered online. The final search was in February 2011.

SELECTION CRITERIA

Randomised controlled trials of luteal phase support in ART investigating progesterone, hCG or GnRH agonist supplementation in in vitro fertilisation (IVF) or intracytoplasmic sperm injection (ICSI) cycles. Quasi-randomised trials and trials using frozen transfers or donor oocyte cycles were excluded.

DATA COLLECTION AND ANALYSIS

We extracted data per women and three review authors independently assessed risk of bias. We contacted the original authors when data were missing or the risk of bias was unclear. We entered all data in six different comparisons. We calculated the Peto odds ratio (Peto OR) for each comparison.

MAIN RESULTS

Sixty-nine studies with a total of 16,327 women were included. We assessed most of the studies as having an unclear risk of bias, which we interpreted as a high risk of bias. Because of the great number of different comparisons, the average number of included studies in a single comparison was only 1.5 for live birth and 6.1 for clinical pregnancy.Five studies (746 women) compared hCG versus placebo or no treatment. There was no evidence of a difference between hCG and placebo or no treatment except for ongoing pregnancy: Peto OR 1.75 (95% CI 1.09 to 2.81), suggesting a benefit from hCG. There was a significantly higher risk of ovarian hyperstimulation syndrome (OHSS) when hCG was used (Peto OR 3.62, 95% CI 1.85 to 7.06).There were eight studies (875 women) in the second comparison, progesterone versus placebo or no treatment. The results suggested a significant effect in favour of progesterone for the live birth rate (Peto OR 2.95, 95% CI 1.02 to 8.56) based on one study. For clinical pregnancy (CPR) the results also suggested a significant result in favour of progesterone (Peto OR 1.83, 95% CI 1.29 to 2.61) based on seven studies. For the other outcomes the results indicated no difference in effect.The third comparison (15 studies, 2117 women) investigated progesterone versus hCG regimens. The hCG regimens were subgrouped into comparisons of progesterone versus hCG and progesterone versus progesterone + hCG. The results did not indicate a difference of effect between the interventions, except for OHSS. Subgroup analysis of progesterone versus progesterone + hCG showed a significant benefit from progesterone (Peto OR 0.45, 95% CI 0.26 to 0.79).The fourth comparison (nine studies, 1571 women) compared progesterone versus progesterone + oestrogen. Outcomes were subgrouped by route of administration. The results for clinical pregnancy rate in the subgroup progesterone versus progesterone + transdermal oestrogen suggested a significant benefit from progesterone + oestrogen. There was no evidence of a difference in effect for other outcomes.Six studies (1646 women) investigated progesterone versus progesterone + GnRH agonist. We subgrouped the studies for single-dose GnRH agonist and multiple-dose GnRH agonist. For the live birth, clinical pregnancy and ongoing pregnancy rate the results suggested a significant effect in favour of progesterone + GnRH agonist. The Peto OR for the live birth rate was 2.44 (95% CI 1.62 to 3.67), for the clinical pregnancy rate was 1.36 (95% CI 1.11 to 1.66) and for the ongoing pregnancy rate was 1.31 (95% CI 1.03 to 1.67). The results for miscarriage and multiple pregnancy did not indicate a difference of effect.The last comparison (32 studies, 9839 women) investigated different progesterone regimens:intramuscular (IM) versus oral administration, IM versus vaginal or rectal administration, vaginal or rectal versus oral administration, low-dose vaginal versus high-dose vaginal progesterone administration, short protocol versus long protocol and micronized progesterone versus synthetic progesterone. The main results of this comparison did not indicate a difference of effect except in some subgroup analyses. For the outcome clinical pregnancy, subgroup analysis of micronized progesterone versus synthetic progesterone showed a significant benefit from synthetic progesterone (Peto OR 0.79, 95% CI 0.65 to 0.96). For the outcome multiple pregnancy, the subgroup analysis of IM progesterone versus oral progesterone suggested a significant benefit from oral progesterone (Peto OR 4.39, 95% CI 1.28 to 15.01).

AUTHORS' CONCLUSIONS

This review showed a significant effect in favour of progesterone for luteal phase support, favouring synthetic progesterone over micronized progesterone. Overall, the addition of other substances such as estrogen or hCG did not seem to improve outcomes. We also found no evidence favouring a specific route or duration of administration of progesterone. We found that hCG, or hCG plus progesterone, was associated with a higher risk of OHSS. The use of hCG should therefore be avoided. There were significant results showing a benefit from addition of GnRH agonist to progesterone for the outcomes of live birth, clinical pregnancy and ongoing pregnancy. For now, progesterone seems to be the best option as luteal phase support, with better pregnancy results when synthetic progesterone is used.

Luteal support in reproduction: when, what and how?

PURPOSE OF REVIEW

Luteal phase support (LPS) is an integral part of the IVF cycles treated by gonadotropin-releasing hormone analogues. There is a worldwide controversy concerning the type of hormones used for LPS, its dose, duration, when to start and when to stop. This review will cover original as well as recent data on this topic.

RECENT FINDINGS

There is a consensus in the literature among IVF centers that LPS is necessary for IVF cycles. Human chorionic gonadotropin is less commonly used than progesterone for LPS because of ovarian hyperstimulation syndrome risk. Several studies suggested that intramuscular progesterone is superior to vaginal progesterone for LPS; however, the majority of centers use vaginal progesterone to avoid side effects of intramuscular injection. There is no difference in pregnancy rate whether LPS is started on day of human chorionic gonadotropin, oocyte retrieval or embryo transfer. There is a strong evidence that LPS should be stopped either on the day of pregnancy test or the first ultrasound (6-7 weeks pregnancy). There is no evidence that addition of estrogen will improve pregnancy rate.

SUMMARY

Progesterone is the preferred option for LPS. It should start within 2 days from triggering ovulation and should end on day of beta human chorionic gonadotropin or the day of the first ultrasound (6-7 weeks pregnancy).

Duration of progesterone-in-oil support after in vitro fertilization and embryo transfer: a randomized, controlled trial

OBJECTIVE

To determine the efficacy of a short P-in-oil protocol (11 days) in comparison with a traditional P-in-oil protocol (6 weeks) after IVF and embryo transfer.

DESIGN

Prospective randomized, controlled trial.

SETTING

Tertiary referral reproductive medicine unit.

PATIENT(S)

The first IVF-embryo transfer cycle of women<or=37 years old.

INTERVENTION(S)

Either the standard protocol, 50 mg of IM P-in-oil daily for 6 weeks (group 1) or the study protocol, 50 mg of IM P-in-oil daily for 11 days (group 2).

MAIN OUTCOME MEASURE(S)

Clinical pregnancy, ongoing pregnancy, and live birth rates.

RESULT(S)

One hundred one patients were enrolled (48 in group 1, 53 in group 2). Mean age (31.8 years vs. 32.7 years) and reasons for infertility were not different between the groups. Despite higher embryo quality in group 1 than in group 2 (60.3 vs. 51.6), clinical (63.0% vs. 62.7%) and ongoing (58.7% vs. 51.0%) pregnancy rates (PR) were not significantly different. Live birth rates (52.2% vs. 49.0%) were not significantly different.

CONCLUSION(S)

Pregnancy and live birth rates were not different between the two groups, suggesting that the common practice of lengthy (>or=6 weeks) P support of IVF pregnancies may be unnecessary.

Luteal Phase Support in assisted reproductive technology treatment: focus on Endometrin(R) (progesterone) vaginal insert

Supplementation of progesterone in the luteal phase and continuance of progesterone therapy during the first trimester has been found in several studies to have benefits in promoting fertility, preventing miscarriages and even preventing pre-term labor. Though it can be administered orally, intramuscularly or even sublingually, a very effective route with fewer side effects can be achieved by an intravaginal route. The first vaginal preparations were not made commercially but were compounded by pharmacies. This had the disadvantage of lack of control by the Food and Drug Administration (FDA) ensuring efficacy of the preparations. Furthermore there was a lack of precise dosing leading to batch to batch variation. The first commercially approved vaginal progesterone preparation in the United States was a vaginal gel which has proven very effective. The main side effect was accumulation of a buildup of the vaginal gel sometimes leading to irritation. Natural micronized progesterone for vaginal administration with the brand name of Utrogestan A^® had been approved even before the gel in certain European countries. Endometrin^® vaginal tablets are the newest natural progesterone approved by the FDA. Comparisons to the vaginal gel and to intramuscular progesterone have shown similar efficacy especially in studies following controlled ovarian hyperstimulation and oocyte egg retrieval and embryo transfer. Larger studies are needed to compare side effects.

Progesterone supplementation during the luteal phase and in early pregnancy in the treatment of infertility: an educational bulletin

Exogenous progesterone supplementation is a common element of treatment regimens for infertility, particularly those relating to the assisted reproductive technologies.

WITHDRAWN: Luteal phase support in assisted reproduction cycles

BACKGROUND

The aspiration of the granulosa cells that surround the oocyte and the use of gonadotropin releasing hormone agonists (GnRHa) during assisted reproduction technology (ART) treatment can interfere with the production, during the luteal phase, of progesterone, which is necessary for successful implantation of the embryo. Providing hormonal supplementation during the luteal phase with either progesterone itself, or human chorionic gonadotropin (hCG), which stimulates progesterone production, may improve implantation and, thus, pregnancy rates.

OBJECTIVES

To determine (1) if luteal phase support after assisted reproduction increases the pregnancy rate, (2) the optimal hormone for luteal phase support, i.e. hCG, progesterone, or a combination of both, and (3) the optimal route of progesterone administration.

SEARCH STRATEGY

We searched the Cochrane Menstrual Disorders & Subfertility Group trials register, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE (1971 to Dec 2003), EMBASE (1985 to Dec 2003). We handsearched reference lists of relevant articles were scanned, and abstract books from scientific meetings up to December 2003.

SELECTION CRITERIA

Randomized controlled trials of luteal phase support after ART treatment, comparing hCG or progesterone with placebo or no treatment, comparing progesterone with hCG, progesterone plus hCG, or progesterone plus estrogen, or comparing different routes of progesterone administration. Quasi-randomized trials were excluded from the main analyses, but included in a secondary analysis for each comparison.

DATA COLLECTION AND ANALYSIS

For each comparison, data on live birth, ongoing and clinical pregnancy per embryo or gamete transfer procedure, miscarriage per clinical pregnancy, ovarian hyperstimulation syndrome (OHSS) per transfer, and multiple pregnancy per clinical pregnancy were extracted into 2 x 2 tables and subgrouped by use of GnRHa in the ovarian stimulation regimen. The odds ratio (OR) and risk difference (RD) were calculated.

MAIN RESULTS

Fifty-nine studies were included in the review. Luteal phase support with hCG provided significant benefit, compared to placebo or no treatment, in terms of increased ongoing pregnancy rates (odds ratio (OR) 2.38, 95% confidence interval (CI) 1.32 to 4.29) and decreased miscarriage rates (OR 0.12, 95% CI 0.03 to 0.50), but only when GnRHa was used. The odds of OHSS increased 20-fold when hCG was used in cycles with GnRHa. Progesterone use resulted in a small but significant increase in pregnancy rates (OR 1.34, 95% CI 1.01 to 1.79) when trials with and without GnRHa were grouped together, but no effect on the miscarriage rate was observed. No significant difference was found between progesterone and hCG or between progesterone and progesterone plus hCG or estrogen in terms of pregnancy or miscarriage rates, but the odds of OHSS were more than 2-fold higher with treatments involving hCG than with progesterone alone(OR 3.06, 95% CI 1.59 to 5.86). Comparing routes of progesterone administration, reductions in clinical pregnancy rate with the oral route, compared to the intramuscular or vaginal routes, did not reach statistical significance, but there was evidence of benefit of the intramuscular over the vaginal route for the outcomes of ongoing pregnancy and live birth. No significant difference in pregnancy rate was observed between vaginal progesterone gel and other types of vaginal progesterone.

AUTHORS' CONCLUSIONS

Luteal phase support with hCG or progesterone after assisted reproduction results in an increased pregnancy rate. hCG does not provide better results than progesterone, and is associated with a greater risk of OHSS when used with GnRHa. The optimal route of progesterone administration has not yet been established.

Matched-samples comparison of intramuscular versus vaginal progesterone for luteal phase support after in vitro fertilization and embryo transfer

OBJECTIVE

To evaluate vaginal compared to intramuscular (IM) progesterone supplementation for luteal phase support after in vitro fertilization and embryo transfer (IVF-ET).

DESIGN

Retrospective matched-samples comparative study.

SETTING

Private infertility center.

PATIENTS(S)

Two hundred forty patients undergoing IVF-ET.

INTERVENTION(S)

Patients received either vaginal progesterone supplementation in the form of Endometrin 100 mg twice a day (n = 12), Endometrin 100 mg three times a day (n = 11), or Crinone 8% gel 90 mg every day (n = 17), or 50 mg every day IM progesterone in oil (n = 200).

MAIN OUTCOME MEASURE(S)

Clinical intrauterine pregnancy rates, pregnancy loss, and live birth rates.

RESULT(S)

Among patients using vaginal progesterone, there were no statistically significant differences in patient characteristics and clinical outcomes, regardless of the type of vaginal progesterone used. There were no differences in outcomes between the vaginal and IM progesterone treatment groups. There were 20 pregnancies (50.0%) among patients treated with vaginal progesterone and 103 pregnancies (51.5%) among matched IM progesterone patients. The live birth rates were 47% in the IM versus 47.5% in the vaginal progesterone groups. There were no statistically significant differences in miscarriage rates between groups.

CONCLUSION(S)

There are no significant differences in treatment outcomes between vaginal and IM progesterone supplementation, yielding similar clinical pregnancy, miscarriage, and live birth rates.

Luteal supplementation in in vitro fertilization: more questions than answers

OBJECTIVE

To update clinicians on different regimens of luteal phase supplementation in IVF-stimulated cycles and to identify areas that need further research in this subject.

DESIGN

Literature review and critical analysis of published studies on luteal phase supplementation during the last 20 years.

CONCLUSION(S)

Luteal phase supplementation in IVF-stimulated cycles, both in gonadotropin releasing hormone agonist and antagonist protocols, is considered an essential requirement for optimal success rates. The date of initiation and discontinuation of supplemented hormones is not adequately studied in the literature. In most major controlled and randomized studies, there are no significant differences in success rates with progesterone supplementation alone, progesterone and estradiol, progesterone and human chorionic gonadotropin, and human chorionic gonadotropin alone. Success rates seem similar with intramuscular and vaginal progesterone administration with patient preference for the vaginal route. The optimal dose of progesterone has not been studied in a scientific way in the literature. The use of gonadotropin releasing hormone agonists for luteal phase supplementation in antagonist cycles appears to be promising, and is worthy of further investigation.

Oral progestogen versus intramuscular progesterone for luteal support after assisted reproductive technology treatment: a prospective randomized study

OBJECTIVES

To evaluate the efficacy of oral progestogen, chlormadinone acetate, and intramuscular (IM) progesterone for luteal support in patients, undergoing assisted reproductive technology (ART) treatment, who were treated with a gonadotropin-releasing hormone agonist (GnRHa).

METHODS

This was a prospective randomized study of 40 patients with normal and high response (serum estradiol > 2,000 pg/ml) in GnRHa down-regulation. Patients were randomized to receive either oral chlormadinone acetate or IM progesterone. The outcomes of ART treatment, including pregnancy and embryo implantation rates, were analyzed.

RESULTS

There were no significant differences in the clinical pregnancy rates (25 vs. 20%) and in the implantation rates (12.7 vs. 9.1%) of patients who received IM progesterone and oral chlormadinone acetate. Endometrial thickness was also comparable between oral chlormadinone acetate and IM progesterone.

CONCLUSION

Oral progestogen, chlormadinone acetate showed a comparable pregnancy rate and live birth rate with IM progesterone as luteal support for the high responders. The optimal methods for luteal support may be dependent on responses to stimulation with gonadotropin, although it is not concluded that oral chlormadinone acetate is recommended as an option for luteal support in high responders.

Comparison of Crinone 8% intravaginal gel and intramuscular progesterone supplementation for in vitro fertilization/embryo transfer in women under age 40: interim analysis of a prospective randomized trial

This study was performed to compare the efficacy of Crinone 8% intravaginal gel and intramuscular progesterone (IMP) supplementation for luteal phase support in women under age 40 undergoing IVF-ET. Results of the interim analysis of this rigorously designed prospective randomized controlled study are presented. Pregnancy rates, implantation rates, and early spontaneous abortion rates were similar for patients receiving Crinone or IMP, whereas fewer side effects and greater overall satisfaction were reported by women receiving Crinone.

Comparative study of the efficacy and tolerability of two vaginal progesterone formulations, Crinone⁎ 8% gel and Utrogestan† capsules, used for luteal support

OBJECTIVE

To compare the efficacy and tolerability of two different types of vaginal progesterone (P), Crinone 8% gel (Fleet Laboratories Ltd., Watford, United Kingdom) and Utrogestan capsules (Laboratories Besins International, Paris, France), used for luteal support after in vitro fertilization (IVF) cycles.

DESIGN

Cohort study.

SETTING

In Vitro Fertilization Polyclinic, Zagreb, Croatia.

PATIENTS

A total of 285 women aged < or =37 years undergoing IVF-embryo transfer treatment.

INTERVENTIONS

Patients were treated with either Crinone 8% vaginal P gel (90 mg) administered daily, or Utrogestan vaginal capsules (2 x 100 mg) administered three times daily. Progesterone was administered from the day of oocyte retrieval (day 0) to menses or, in a case of pregnancy, until week 12.

MAIN OUTCOME MEASURE

Clinical pregnancy rate. The tolerability and acceptability of both preparations were determined by a questionnaire given to patients.

RESULTS

The similar rates of clinical pregnancies (33.1% vs. 30.9%) [corrected] were obtained by using either Crinone 8% vaginal P gel or Utrogestan vaginal capsules. Overall tolerability and acceptability were significantly better in the Crinone group than in the Utrogestan group.

CONCLUSIONS

The efficacy of the two vaginal P formulations was nearly the same, but the tolerability and acceptability of Crinone 8% gel were superior, in the opinion of patients.

A randomized comparison of side effects and patient convenience between Cyclogest suppositories and Endometrin tablets used for luteal phase support in IVF treatment

OBJECTIVE

This study compared side effects and patient convenience of vaginal progesterone suppositories (Cyclogest) and vaginal progesterone tablets (Endometrin) used for luteal phase support in in vitro fertilization/embryo transfer (IVF/ET) cycles using pituitary downregulation.

STUDY DESIGN

One hundred and thirty-two infertile patients were randomized on the day of ET by a computer-generated randomization list in sealed envelopes to receive either Cyclogest 400mg or Endometrin 100mg twice daily for 14 days. On days 6 and 16 after ET, they rated side effects and patient convenience into four grades: none, mild, moderate and severe by completing a questionnaire.

RESULTS

No significant differences in perineal irritation were found on days 6 and 16 after ET between the two groups, although there was a trend of fewer patients with perineal irritation in the Endometrin group. Significantly more patients in the Endometrin group had difficulty of administration on day 6 after ET. There were no differences in the hormonal profile on day 6 after ET and IVF outcomes between the two groups.

CONCLUSION

There was no difference in perineal irritation after the use of Cyclogest suppositories or Endometrin tablets for luteal phase support although more patients found administration of Endometrin tablets difficult.

Different routes of progesterone administration and polycystic ovary syndrome: a review of the literature

Polycystic ovary syndrome (PCOS) is a common endocrine disorder in woman of reproductive age. Although extensive studies have been performed in past decades to investigate the pathobiological mechanisms underlying the unset of this disease, its etiology remains unknown. Progesterone is a hormone of paramount importance in ovulation, implantation and luteal phase support. Low levels of progesterone have been found in the early luteal phase in PCOS patients. Granulosa cells from polycystic ovaries show an altered progesterone production. Moreover, the lack of cyclical exposure to progesterone may have a role in the development of the gonadotropin and androgen abnormalities found in PCOS patients. Ovulation failure and progesterone deficiency may facilitate the hypothalamic-pituitary abnormalities causing the associated disordered luteinizing hormone secretion in PCOS. Progesterone may be administered to PCOS patients in the following cases: to induce withdrawal bleeding, to suppress secretion of luteinizing hormone, in ovulation induction in clomiphene citrate-resistant patients and in luteal phase support in assisted reproduction. We discuss the pharmacologic characteristics of the different routes of progesterone administration with reference to these diverse indications, the therapeutic objectives and patient compliance.

Greater implantation and pregnancy rates with vaginal progesterone in intracytoplasmic sperm injection but not in in vitro fertilization cycles: a retrospective study

OBJECTIVE

To compare the effectiveness of vaginal progesterone supplementation with intramuscular supplementation in assisted reproduction cycles.

DESIGN

Retrospective study.

SETTING

Physiopathology of Human Reproduction Unit, Pordenone, Italy, from July 2000 to June 2004.

PATIENT(S)

Three hundred and eight-five intracytoplasmic sperm injection (ICSI) procedures (188 with vaginal gel and 197 with intramuscular progesterone) and 373 in vitro fertilization (IVF) cycles (227 with vaginal and 146 with intramuscular progesterone).

INTERVENTION(S)

Progesterone luteal supplementation: vaginal gel (Crinone 8% 90 mg/day) or intramuscular (Prontogest 50 mg/day).

MAIN OUTCOME MEASURE(S)

Implantation rates, and total and clinical pregnancy rates.

RESULT(S)

Higher rates of implantation and total and clinical pregnancies were observed in the vaginal supplemented ICSI subgroup than in the intramuscular one. This difference was observed for all transfers (13.3% vs. 8.8%, 39.8% vs. 23.3%, and 28.7% vs. 18.6%) and for ultrasound-guided transfers (17.2% vs. 9.3%, 49% vs. 27%, and 36.9% vs. 21.1%, respectively).

CONCLUSION(S)

The vaginal route of luteal supplementation may be better than the intramuscular one, yielding higher implantation rates as well as total and clinical pregnancy rates in ICSI cycles but not in classic IVF treatments.

17 alpha-hydroxyprogesterone caproate versus intravaginal progesterone in IVF-embryo transfer cycles: a prospective randomized study

One of the main issues in the management of IVF and embryo transfer techniques is to ensure adequate concentrations of progesterone. The aim of this prospective, randomized study was to compare the effectiveness of 17 alpha -hydroxyprogesterone caproate (17-HPC) administered intramuscularly and intra-vaginal progesterone in gel in luteal phase support in patients undergoing IVF-embryo transfer cycles. A total of 320 patients were randomly treated with either 17-HPC (341 mg i. m. every 3 days) or progesterone vaginal gel (90 mg daily). The inclusion criteria were the use of gonadotrophin-releasing hormone down-regulation and age <40 years. The outcome of IVF in both study groups was evaluated for implantation rate, biochemical pregnancy, clinical pregnancy, miscarriage, and ongoing pregnancy rate. The results of this study showed that 17-HPC conferred more benefit to IVF-embryo transfer cycles compared with intra-vaginal progesterone, as demonstrated by the results of most of the main outcome parameters considered. The data showed that 17-HPC administered every 3 days appears to be more effective in providing luteal support in comparison to intra-vaginal progesterone.

Hormonal regulation of implantation

Implantation is a complex process that requires synchronization between the embryo and a receptive endometrium. Hormones, such as the female sex steroids, prostaglandins, and peptide hormones, regulate the cellular and molecular mediators of endometrial receptivity, which include pinopodes, cell adhesion molecules, cytokines, homeobox genes, and growth factors. These mediators can be altered, despite the presence of normal hormone levels and endometrial histology; this limits the usefulness of the luteal phase endometrial biopsy. Therefore, analysis of markers of endometrial receptivity may predict successful implantation better. Elevated androgen and estrogen levels, as seen with polycystic ovary syndrome and controlled ovarian hyperstimulation, respectively, also can have detrimental effects on the endometrium, and therefore, implantation.

Impaired fertility in T-stock female mice after superovulation

Superovulation of female mice with exogenous gonadotrophins is routinely used for increasing the number of eggs ovulated by each female in reproductive and developmental studies. We report an unusual effect of superovulation on fertilization in mice.In vivomatings of superovulated T-stock females with B6C3F1 males resulted in a two-fold reduction (P< 0.001) in the frequencies of fertilized eggs compared with control B6C3F1 matings. In addition, approximately 22 h after mating, only 15% of fertilized eggs recovered in T-stock females had reached the metaphase stage of the first cleavage division versus 87% in B6C3F1 females (P< 0.0001). Matings with T-stock males did not improve the reproductive performance of T-stock females. To investigate the possible cause(s) for the impaired fertilization and zygotic development, the experiments were repeated usingin vitrofertilization. Under these conditions, the frequencies of fertilized eggs were not different in superovulated T-stock and B6C3F1 females (51.7 ± 6.0 and 64.5 ± 3.8%,P= 0.10). There was a seven-fold increase in the frequencies of fertilized eggs that completed the first cell cycle of development afterin vitroversusin vivofertilization in T-stock females. These results rule out an intrinsic deficiency of the T-stock oocyte as the main reason for the impaired fertility afterin vivomatings, and suggest that superovulation of T-stock females may induce a hostile oviductal and uterine environment with dramatic effects on fertilization and zygotic development.