Estradiol supplementation during the luteal phase may improve the pregnancy rate in patients undergoing in vitro fertilization-embryo transfer cycles

Comparison of luteal support protocols in fresh IVF/ICSI cycles: a network meta-analysis

Despite the proven superiority of various luteal phase support protocols (LPS) over placebo in view of improved pregnancy rates in fresh cycles of IVF (in vitro fertilization) and ICSI (intracytoplasmic sperm injection) cycles, there is ongoing controversy over specific LPS protocol selection, dosage, and duration. The aim of the present study was to identify the optimal LPS under six core aspects of ART success, clinical pregnancy, live birth as primary outcomes and biochemical pregnancy, miscarriage, multiple pregnancy, ovarian hyperstimulation syndrome (OHSS) events as secondary outcomes. Twelve databases, namely Embase (OVID), MEDLINE (R) (OVID), GlobalHealth (Archive), GlobalHealth, Health and Psychosocial Instruments, Maternity & Infant Care Database (MIDIRS), APA PsycTests, ClinicalTrials.gov, HMIC Health Management Information Consortium, CENTRAL, Web of Science, Scopus and two prospective registers, MedRxiv, Research Square were searched from inception to Aug.1st, 2023, (PROSPERO Registration: CRD42022358986). Only Randomised Controlled Trials (RCTs) were included. Bayesian network meta-analysis (NMA) model was employed for outcome analysis, presenting fixed effects, odds ratios (ORs) with 95% credibility intervals (CrIs). Vaginal Progesterone (VP) was considered the reference LPS given its' clinical relevance. Seventy-six RCTs, comparing 22 interventions, and including 26,536 participants were included in the present NMA. Overall CiNeMa risk of bias was deemed moderate, and network inconsistency per outcome was deemed low (Multiple pregnancy χ2: 0.11, OHSS χ2: 0.26), moderate (Clinical Pregnancy: χ2: 7.02, Live birth χ2: 10.95, Biochemical pregnancy: χ2: 6.60, Miscarriage: χ2: 11.305). Combinatorial regimens, with subcutaneous GnRH-a (SCGnRH-a) on a vaginal progesterone base and oral oestrogen (OE) appeared to overall improve clinical pregnancy events; VP + OE + SCGnRH-a [OR 1.57 (95% CrI 1.11 to 2.22)], VP + SCGnRH-a [OR 1.28 (95% CrI 1.05 to 1.55)] as well as live pregnancy events, VP + OE + SCGnRH-a [OR 8.81 (95% CrI 2.35 to 39.1)], VP + SCGnRH-a [OR 1.76 (95% CrI 1.45 to 2.15)]. Equally, the progesterone free LPS, intramuscular human chorionic gonadotrophin, [OR 9.67 (95% CrI 2.34, 73.2)] was also found to increase live birth events, however was also associated with an increased probability of ovarian hyperstimulation, [OR 1.64 (95% CrI 0.75, 3.71)]. The combination of intramuscular and vaginal progesterone was associated with higher multiple pregnancy events, [OR 7.09 (95% CrI 2.49, 31.)]. Of all LPS protocols, VP + SC GnRH-a was found to significantly reduce miscarriage events, OR 0.54 (95% CrI 0.37 to 0.80). Subgroup analysis according to ovarian stimulation (OS) protocol revealed that the optimal LPS across both long and short OS, taking into account increase in live birth and reduction in miscarriage as well as OHSS events, was VP + SCGnRH-a, with an OR 2.89 [95% CrI 1.08, 2.96] and OR 2.84 [95% CrI 1.35, 6.26] respectively. Overall, NMA data suggest that combinatorial treatments, with the addition of SCGnRH-a on a VP base result in improved clinical pregnancy and live birth events in both GnRH-agonist and antagonist ovarian stimulation protocols.

The impact of estradiol supplementation on endometrial thickness and intrauterine insemination outcomes

The impact of estrogen supplementation during the follicular/proliferative phase on the endometrial lining thickness (EMT) prior to intrauterine insemination (IUI) remains largely unstudied. Our study examined changes in EMT and rates of clinical pregnancy, miscarriage, and live birth for all patients who completed an IUI cycle at Stanford Fertility Center from 2017-2023 (n = 2281 cycles). Cycles with estradiol supplementation (n = 309) were compared to reference cycles without supplementation (n = 1972), with the reference cohort further categorized into cycles with a pre-ovulatory EMT of < 7 mm ("thin-lining", n = 536) and ≥ 7 mm ("normal-lining", n = 1436). The estradiol group had a statistically significant greater change in EMT from baseline to ovulation compared to the thin-lining reference groups (2.4 mm vs 1.9 mm, p < =0.0001). Similar rates of clinical pregnancy and live birth were observed. After adjusting for age, BMI, race/ethnicity, infertility diagnosis, and EMT at trigger, the estradiol cohort had a significantly increased odds of miscarriage versus the entire reference cohort (2.46, 95 % confidence interval [1.18, 5.14], p = 0.02). Thus, although estradiol supplementation had a statistically significant increase in EMT compared to IUI cycles with thin pre-ovulatory EMT (<7 mm), this change did not translate into improved IUI outcomes such as increased rates of clinical pregnancy and live birth or decreased rate of miscarriage. Our study suggests that supplemental estradiol does not appear to improve IUI outcomes.

Estrogen in Luteal Phase Support: Effects on IVF-ICSI Antagonist Protocol Pregnancy Results

Aim: This study aimed to investigate the effect of luteal phase support (LPS) with estradiol in addition to progesterone on pregnancy outcomes in patients who underwent ovulation induction with GnRH antagonist protocol in in vitro fertilization- intracytoplasmic sperm injection (IVF-ICSI). Materials and Methods: This retrospective study was carried out at reproductive medicine center of Necmettin Erbakan University Meram Medical Faculty. The study enrolled 128 patients undergoing ICSI on an antagonist protocol for controlled ovarian hyperstimulation. Study group administered 7.8 mg transdermal estradiol (E2) daily in addition to progesterone for LPS (n=64). Control group administered only progesterone for LPS (n=64). All women received 200 mg progesterone 3x1 intravaginal daily and 50 mg progesterone intramuscular injection per two days for LPS. Blood samples were drawn 12 days after embryo transfer for β-hCG. If the result is negative, treatment was discontinued, if positive, estradiol was discontinued and progesterone support was continued until the 10th week of gestation. Pregnancy outcomes were the main endpoint. Results: There was no difference between groups in terms of biochemical pregnancy, clinical pregnancy, abortus and ongoing pregnancy rates. Conclusion: In our study, the use of estrogen for luteal phase support in GnRH antagonist protocol did not show any difference on pregnancy outcomes.

The association between alcohol intake and fecundability during menstrual cycle phases

STUDY QUESTION

Is increased alcohol intake in different phases of the menstrual cycle associated with fecundability in women?

SUMMARY ANSWER

Heavy intake (>6 drinks/week) of alcoholic beverages in the luteal phase and ovulatory subphase was associated with reduced odds of conception; moderate intake (3-6 drinks/week) during the luteal phase was also associated with reduced fecundability.

WHAT IS KNOWN ALREADY

Despite strong indications for increased risk of infertility among drinking women with intention to conceive, inconsistencies in previous results point to possible residual confounding, and have not thoroughly investigated timing of drinking and other drinking patterns during the menstrual cycle.

STUDY DESIGN, SIZE, DURATION

Participants in The Mount Sinai Study of Women Office Workers (MSSWOW), a prospective cohort study of fertility, were recruited and followed between 1990 and 1994, and completed daily diaries reporting their alcohol intake (type and number of drinks) for a maximum of 19 months of follow-up (N = 413).

PARTICIPANTS/MATERIALS, SETTING, METHODS

Participants were between 19 and 41 years of age. After completion of baseline surveys, they were asked to record their alcoholic beverage intake as number of drinks of beer, wine, and liquor per day, in addition to other exposures such as caffeine and smoking. Furthermore, they submitted urine samples each month to assess pregnancy. Menstrual cycle phases were calculated using the Knaus-Ognio approach. Discrete survival analysis methods were employed to estimate the association between categories of alcohol intake in each phase of menstrual cycle and fecundability.

MAIN RESULTS AND THE ROLE OF CHANCE

In the luteal phase, both moderate drinking (3-6 drinks/week, Fecundability Odds Ratio (FOR)=0.56, CI: 0.31, 0.98) and heavy drinking (>6 drinks/week, FOR = 0.51, CI: 0.29, 0.89) were associated with a reduction in fecundability, compared to non-drinkers. For the follicular phase, heavy drinking in the ovulatory sub-phase (FOR = 0.39, CI: 0.19, 0.72) was similarly associated with reduced fecundability, compared to non-drinkers. For the pre-ovulatory sub-phase, heavy drinking (>6 drinks/week, FOR = 0.54, CI: 0.29, 0.97) was associated with reduction in fecundability, but this association was inconsistent when subjected to sensitivity tests. Each extra day of binge drinking was associated with 19% (FOR = 0.81, CI: 0.63, 0.98), and 41% (FOR = 0.59, CI: 0.33, 0.93) reduction in fecundability for the luteal phase and ovulatory sub-phase respectively, but no association was observed in the pre-ovulatory sub-phase. No meaningful differences in fecundability between beverages were observed in any menstrual phase.

LIMITATIONS, REASONS FOR CAUTION

Patterns of alcohol intake in this cohort suggest a lower average alcohol intake compared to more recent national averages for the same demographic group. Sample sizes were small for some subgroups, resulting in limited power to examine specific beverage types in different phases of the menstrual cycle, or to assess interaction. In addition, the influence of male partner alcohol intake was not assessed, the data relied on self-report, and residual confounding (e.g. unmeasured behaviors correlated with alcohol intake) is a possibility.

WIDER IMPLICATIONS OF THE FINDINGS

Results suggest an inverse association between alcohol and fecundability, and support the relevance of menstrual cycle phases in this link. More specifically, moderate to heavy drinking during the luteal phase, and heavy drinking in the ovulatory window, could disturb the delicate sequence of hormonal events, affecting chances of a successful conception.

STUDY FUNDING/COMPETING INTEREST(S)

Authors declare no conflict of interest. This work was supported by the National Institutes of Health grant, R01-HD24618.

TRIAL REGISTRATION NUMBER

N/A.

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.

Combined use of oestradiol and progesterone to support luteal phase in antagonist intracytoplasmic sperm injection cycles of normoresponder women: a case-control study

We evaluated the effect of combined use of oral oestrogen (E2) and vaginal progesterone (P) to support luteal phase in antagonist intracytoplasmic sperm injection (ICSI) cycles. We analysed data from 176 patients who underwent ICSI cycles with antagonist protocol. P 90 mg vaginal gel once a day and micronised E2 of 4 mg/day, were started from the day of oocyte pick up and continued to the 12th day of embryo transfer. Group 1 (n = 79) patients received E2 + P for luteal phase support. In group 2 (n = 97) patients, only P 90 mg vaginal gel was used for luteal phase support. There were no significant differences between group 1 and group 2 patients in terms of clinical pregnancy rates (PRs) (26.58% vs. 20.62%, p = .352), early pregnancy loss rates (6.33% vs. 6.19%, p = .969), incidence of luteal vaginal bleeding (8.86% vs. 8.25%, p = .885) and implantation rates (22.8% vs. 16.9%, p = .298). In conclusion, our study showed no beneficial effect of addition of E2 to luteal phase support on clinical PR in antagonist IVF cycles.Impact statementWhat is already known on this subject? Luteal phase deficiency is defined as a disruption in progesterone and oestrogen production after ovulation. It is clear that, luteal phase supplementation to improve the outcomes in in vitro fertilisation (IVF) cycles is mandatory. As an iatrogenic complication of assisted reproductive technique, decreased luteal oestrogen and progesterone levels lead to decreased pregnancy rates (PRs) and implantation rates.What the results of this study add? In this study, we aimed to present the role of luteal phase oestrogen administration in GnRH antagonist cycles. A total of 176 cases received progesterone vaginal gel form for luteal phase support. Study group received 4 mg oral oestradiol hemihydrate in addition to progesterone. Compared to previous studies, our study consisted of larger number of patients and we used oestradiol through oral route. We found out that luteal oestradiol support did not improve the clinical PR.What the implications are of these findings for clinical practice and/or further research? Our study showed no beneficial effect of addition of oestradiol to luteal phase support on clinical PR in antagonist IVF cycles.

A comparison of the effects of three luteal phase support protocols with estrogen on in vitro fertilization-embryo transfer outcomes in patients on a GnRH antagonist protocol

Objective:

This study aimed to evaluate the effects of three different luteal phase support protocols with estrogen on the pregnancy rates and luteal phase hormone profiles of patients undergoing in vitro fertilization-embryo transfer (IVF-ET) cycles. A secondary objective was to evaluate which ovarian reserve markers correlated with pregnancy rates.

Methods:

This retrospective observational study was carried out at a private tertiary reproductive medicine teaching and research center. The study enrolled 104 patients undergoing intracytoplasmic sperm injection (ICSI) on an antagonist protocol for controlled ovarian hyperstimulation (COH). The women were divided into three groups based on the route of administration of estrogen (E2) for luteal phase support: oral (Primogyna); transdermal patches (Estradott); or transdermal gel (Oestrogel Pump). The administration of estrogen provided the equivalent to 4 mg of estradiol daily. All women received 600mg of vaginal progesterone (P) per day (Utrogestan) for luteal phase support. Blood samples were drawn on the day of hCG administration and on the day of beta hCG testing to measure E2 and P levels. Clinical pregnancy rate (PR) was the main endpoint.

Results:

The patients included in the three groups were comparable. No significant differences were found in implantation rates, clinical PR, miscarriage rates, multiple-pregnancy rates, E2 or P levels on the day of beta hCG measurement. Concerning ovarian reserve markers, significant correlations between testing positive for clinical pregnancy and AMH (r = 0.66, p<0.0001) and E2 levels on beta hCG measurement day (r = 0.77; p<.0001) were observed.

Conclusions:

No significant differences were seen in the pregnancy rates of patients submitted to IVF-ET cycles with GnRH antagonists given oral, transdermal patches, or transdermal gel E2 during the luteal phase. A correlation was found between clinical pregnancy rate and AMH and E2 levels on beta hCG testing day.

Effects of oestradiol for luteal phase support in fresh embryo transfer cycles: A retrospective cohort study

OBJECTIVE

Any benefit of oestradiol supplementation with progesterone for luteal support after fresh embryo transfer in in vitro fertilisation/intracytoplasmic sperm injection (IVF/ICSI) cycles remains controversial. In this study, we further addressed this question in cycles using gonadotropin-releasing hormone (GnRH) agonist for ovarian stimulation.

DESIGN

A retrospective cohort study in a tertiary teaching and research hospital.

PATIENT(S)

A total of 1602 patients were given oestradiol valerate (E) in addition to progesterone (P) as luteal support. One thousand six hundred and two patients receiving progesterone alone were selected as the control group.

MAIN OUTCOME MEASURE(S)

Live birth rate. Secondary measures included clinical pregnancy rate, miscarriage rate and premature birth rate.

RESULT(S)

Clinical pregnancy and live birth rates were similar for the P alone vs the P+E group. In cycles with oestradiol (E2) levels less than 5000 pmol/L on the day of hCG trigger, E supplementation resulted in a significantly higher live birth rate (23.44% vs 32.92%, OR = 1.60 [95% CI 1.05 to 2.46]). In cycles with oestradiol levels 5000 to 10 000 pmol/L on the day of hCG trigger, E supplementation did not increase the live birth rate (34.43% vs 35.42%, OR = 0.90 [95% CI 0.80 to 1.01]). In cycles with oestradiol levels over 10 000 pmol/L on the day of hCG trigger, the live birth rate was significantly lower (36.83% vs 31.37%, OR = 0.78 [95% CI 0.62 to 0.99]) and the premature birth rate was significantly higher (19.66% vs 28.73%,OR = 1.65 [95% CI 1.05 to 2.59]) in the E supplementation group.

CONCLUSION(S)

Any benefit of oestradiol supplementation for luteal phase support appears to correlate with the serum oestradiol level on the day of hCG trigger. Oestradiol supplementation is beneficial for improving live birth rate in cycles with oestradiol levels less than 5000 pmol/L, but is not recommended in cycles with oestradiol levels over 10 000 pmol/L.

Luteal phase support with estradiol and progesterone versus progesterone alone in GnRH antagonist ICSI cycles: a randomized controlled study

In vitro fertilization (IVF) cycles are associated with a defective luteal phase. Although progesterone supplementation to treat this problem is standard practice, estrogen addition is debatable. Our aim was to compare pregnancy outcomes in 220 patients undergoing antagonist intracytoplasmic sperm injection (ICSI) cycles protocol. The patients were randomly assigned into two equal groups to receive either vaginal progesterone alone (90 mg once daily) starting on the day of oocyte retrieval for up to 12 weeks if pregnancy occurred or estradiol addition (2 mg twice daily) starting on the same day and continuing up to seven weeks (foetal viability scan). Primary outcomes were pregnancy and ongoing pregnancy rates per embryo transfer. Secondary outcomes were implantation and early pregnancy loss rates. Pregnancy rates showed no significant difference between group 1 (39.09%) and 2 (43.63%) (p value = 0.3). Similarly, both groups were comparable regarding ongoing pregnancy rate (32.7% group 1 and 36.3% group 2, p value = 0.1). Implantation rates showed no difference between group 1 (19.25%) and group 2 (23.44%) (p value = 0.2). Early pregnancy loss rates were comparable, with 6.3% and 7.2% in groups 1 and 2, respectively, (p value = 0.4). In conclusion, the addition of 4 mg estrogen daily to progesterone for luteal support in antagonist ICSI cycles is not beneficial for pregnancy outcome.

Vaginal use of micronized progesterone for luteal support.A randomized study comparing Utrogestan® and Crinone® 8

BACKGROUND AND OBJECTIVE

Luteal phase physiology is distorted by in vitro fertilization (IVF) cycles using gonadotropin-releasing hormone (GnRH) agonists and antagonists, Controlled ovarian hyperstimulation leads to luteal phase defect and for this reason, luteal phase support is now an integral part of IVF/ICSI-ET programs. The support is provided by hCG, progesterone or GnRH-a. This study compared the efficiency, safety and tolerance of two vaginal micronized progesterones, Utrogestan and Crinone 8%.

METHODS

111 women, 18-40 years old, FSH < 10 IU/L and normal uterus findings were included. The efficiency of the two preparations to provide luteal support was evaluated by the fertilization, implantation, pregnancy and take-home baby rates. The safety was compared through the results of vaginal findings and vaginal inflammation markers before and after treatment. Comparison of tolerance was made by evaluating 21 subjective patient questionnaire parameters.

RESULTS

There were no significant differences between the preparations in terms of efficiency or safety though Crinone 8% was better tolerated.

CONCLUSION

The outcomes of this study suggest that a vaginal gel with micronized progesterone (Crinone 8%) is the optimal choice at this time for luteal support.

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.

Estrogen supplementation to progesterone as luteal phase support in patients undergoing in vitro fertilization: systematic review and meta-analysis

Meta-analyses have found conflicting results with respect to the use of progesterone or progesterone plus estrogen as luteal phase support for in vitro fertilization (IVF) protocols involving gonadotropins and/or gonadotropin-releasing hormone analogs. The aim of the present study was to perform an updated meta-analysis on the efficacy of progesterone versus progesterone plus estrogen as luteal phase support. We searched the MEDLINE, Cochrane Library, and Google Scholar databases (up to March 18, 2014). The search terms were (estrogen OR estradiol OR oestradiol) AND (progesterone) AND (IVF OR in vitro fertilization) AND (randomized OR prospective). We did not limit the form of estrogen and included subjects who contributed more than 1 cycle to a study. The primary outcome was clinical pregnancy rate. Secondary outcomes were ongoing pregnancy rate, fertilization rate, implantation rate, and miscarriage rate. A total of 11 articles were included in the present analysis, with variable numbers of studies assessing each outcome measure. Results of statistical analyses indicated that progesterone plus estrogen treatment was more likely to result in clinical pregnancy than progesterone alone (pooled odds ratio 1.617, 95% confidence interval 1.059-2.471; P = 0.026). No significant difference between the 2 treatment regimens was found for the other outcome measures. Progesterone plus estrogen for luteal phase support is associated with a higher clinical pregnancy rate than progesterone alone in women undergoing IVF, but other outcomes such as ongoing pregnancy rate, fertilization rate, implantation rate, and miscarriage rate are the same for both treatments.

Meta-analysis of estradiol for luteal phase support in in vitro fertilization/intracytoplasmic sperm injection

OBJECTIVE

To evaluate whether the addition of E(2) for luteal phase support (LPS) in IVF/intracytoplasmic sperm injection (ICSI) could improve the outcome of clinical pregnancy.

DESIGN

Meta-analysis.

SETTING

University hospital center.

PATIENT(S)

Women underwent IVF or ICSI using the GnRH agonist or GnRH antagonist protocol.

INTERVENTION(S)

Progesterone alone or combined with E(2) for LPS.

MAIN OUTCOME MEASURE(S)

Clinical pregnancy rate per patient (CPR/PA), clinical pregnancy rate per ET, implantation rate, ongoing pregnancy rate per patient, clinical abortion rate, and ectopic pregnancy rate.

RESULT(S)

Fifteen relevant randomized controlled trials (RCTs) were identified that included a total of 2,406 patients. There was no statistical difference between E(2) + P group and P-only group regarding the primary outcome of CPR/PA for different routes of administration of E(2) (oral, vaginal, and transdermal) or other relevant outcome measures. No significant effect was observed for different daily doses of E(2) (6, 4, and 2 mg), even through oral medication in CPR/PA.

CONCLUSION(S)

The best available evidence suggests that E(2) addition during the luteal phase does not improve IVF/ICSI outcomes through oral medication, even with different daily doses. Furthermore, RCTs that study other administration routes are needed.

Which luteal phase support is better for each IVF stimulation protocol to achieve the highest pregnancy rate? A superiority randomized clinical trial

In vitro fertilization (IVF) cycles generate abnormalities in luteal-phase sex steroid concentrations and this represent an important limiting factor to achieve a good pregnancy rate. Although there are evidences about the usefulness of luteal phase support (LPS) after IVF cycles, no consensus exist about the best dose and way of progesterone (PG) administration, the advantages of estradiol (E2) supplementation and which IVF protocol could benefit from one more than other LPS scheme. Aim of the study was to assess the best LPS (low-dose PG, high-dose PG, high-dose PG and E2 supplementation) to achieve the highest clinical/ongoing pregnancy rate according to stimulation protocol, E2 at ovulation induction, endometrial thickness at pick-up and women's age. We conducted a randomized trial on 360 women undergoing IVF (180 treated by long-GnRH agonist, 90 by short-GnRH agonist and 90 by short-GnRH antagonist protocol) and stimulated by recombinant follicle-stimulating hormone alone. Our data demonstrated that high-dose PG is better than low-dose to increase both clinical and ongoing pregnancy rate. E2 supplementation are mandatory in case of short-GnRH antagonist protocol and strongly suggested in all protocols when E2max <5 nmol/l and endometrial thickness <10 mm. In long-GnRH agonist protocols, as well as in patients >35 years, the real advantages of E2 supplementation remain debatable and require further confirmation.

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.

Luteal estradiol supplementation in gonadotropin-releasing hormone antagonist cycles for infertile patients in vitro fertilization

Objective

To evaluate the effect of the addition of estradiol to luteal progesterone supplementation in GnRH antagonist cycles for infertile patients undergoing IVF/ICSI.

Methods

One hundred and ten infertile patients, aged 28 to 39 years, were recruited for this prospective randomized study. They were randomly assigned to receive vaginal progesterone gel (Crinone) along with 4 mg estradiol valerate (group 1, n=55) or only Crinone (group 2, n=55) for luteal support. A GnRH antagonist multiple dose protocol using recombinant human FSH was used for controlled ovarian stimulation (COS) in all of the subjects. The COS results and pregnancy outcomes of the two groups were compared.

Results

Group 1 and 2 were comparable with respect to the patient characteristics. The COS and IVF results were also comparable between the two groups. There were no differences in the clinical pregnancy rate (PR) and multiple PR between the two groups. However, the embryo implantation rate were significantly higher in group 1 than that in group 2 (22.2% vs. 13.3%, p=0.035). The incidence of luteal vaginal bleeding (LVB) was significantly lower in group 1 (7.4% vs. 27.8%, p=0.010).

Conclusion

The addition of estradiol to luteal progesterone supplementation in GnRH antagonist cycles reduces the incidence of LVB and increases the embryo implantation rate in infertile patients undergoing IVF/ICSI.

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.

Oestrogen and progesterone action on endometrium: a translational approach to understanding endometrial receptivity

Embryo attachment and implantation is critical to successful reproduction of all eutherian mammals, including humans; a better understanding of these processes could lead to improved infertility treatments and novel contraceptive methods. Experience with assisted reproduction, especially oocyte donation cycles, has established that despite the diverse set of hormones produced by the ovary in a cycle-dependent fashion, the sequential actions of only two of them, oestrogen and progesterone, are sufficient to prepare a highly receptive endometrium in humans. Further investigation on the endometrial actions of these two hormones is currently providing significant insight into the implantation process in women, strongly suggesting that an abnormal response to progesterone underlies infertility in some patients.

Estradiol supplementation in intracytoplasmic sperm injection cycles with thin endometrium

OBJECTIVE

To evaluate the efficacy of estradiol supplementation starting on the day of human chorionic gonadotrophin (hCG) in patients with thin endometrium in intracytoplasmic sperm injection (ICSI) cycles.

METHODS

A total of 117 consecutive patients with the endometrial thickness on the hCG day ≤ 8 mm were reviewed. Estradiol supplementation was given in 57 patients and the remaining 60 patients were accepted as control group. Estradiol supplemented (ES) group received estradiol hemihydrate 4 mg/day started on the day of hCG. Luteal phase was supported using the vaginal progesterone gel in both groups. Clinical pregnancy rate, implantation rate, miscarriage rate, endometrial thickness on the day of oocyte pick-up and on the day of embryo transferred were accepted as main outcome measures.

RESULTS

There were no statistical differences in terms of clinical pregnancy rate (28.1% vs. 23.3%), implantation rate (16% vs. 10.4%), miscarriage rate (21% vs. 31.6%), endometrial thickness on the oocyte pick-up day (8.5 ± 1.8 vs. 8.4 ± 1.4, mm) and embryo transferred day (9.6 ± 2.9 vs. 10.3 ± 2.4, mm) in the ES group vs. control group.

CONCLUSION

Estradiol supplementation starting on the hCG day for the patients with thin endometrium does not provide any benefit on the pregnancy outcome in ICSI cycles.

Oral oestradiol supplementation as luteal support in IVF/ICSI cycles: a prospective, randomized controlled study

OBJECTIVE

To explore whether oral oestradiol (E2) supplementation (6 mg) in the luteal phase is beneficial to the outcome of patients undergoing gonadotrophin-releasing hormone agonist (GnRHa) long protocol in vitro fertilization (IVF)/intracytoplasmic sperm injection (ICSI) cycles.

STUDY DESIGN

Prospective, randomized, controlled study at the IVF Clinic, Sun Yat-sen Memorial Hospital. In total, 402 patients with an indication for IVF or ICSI were recruited. Patients were prospectively randomized to receive either progesterone injection plus oral E2 supplementation (Group A, n=202) or progesterone injection alone (Group B, n=200) as luteal support after oocyte retrieval. The main outcome measure was the clinical pregnancy rate.

RESULTS

No significant difference in the clinical pregnancy rate or miscarriage rate was observed between Group A and Group B (50.9% vs 58.0%, 14.6% vs 11.2%; p>0.05). In different age subgroups (≤35 years and >35 years) all measurements were comparable in patients with or without E2 supplementation, as well as in subgroups with different E2 levels on the day of human chorionic gonadotrophin injection (E2≥3000 pg/ml and E2<3000 pg/ml).

CONCLUSION

Adding E2 as luteal support did not increase the clinical pregnancy rate or reduce the miscarriage rate. Routine use of a combination of E2 and progesterone as luteal support in GnRHa long protocol IVF/ICSI cycles is not recommended.

Endocrinological insights into different in vitro fertilization treatment aspects

The science of reproductive endocrinology/in vitro fertilization (IVF) has moved forward considerably since the first IVF baby was born in 1978. IVF was originally indicated for women with tubal factor infertility, but it has now become the treatment for couples with unexplained subfertility, male subfertility, cervical factor, failed ovulation induction, endometriosis or unilateral tubal pathology. IVF was initially performed with the single dominant ovarian follicle produced during a spontaneous menstrual cycle. This was very inefficient and pregnancy rates were dismal. Consequently, superovulation protocols using parenteral gonadotrophins to induce maturation of multiple follicles were soon adopted worldwide. In addition, any supernumerary embryos remaining after embryo transfer may be cryopreserved for future embryo transfers without the need for another fresh IVF cycle. A greater understanding of IVF endocrinology has led to improved IVF pregnancy outcomes and satisfaction for the anxious parents. However, with the greater success of IVF treatment, new complications associated with the treatment arise, namely the ovarian hyperstimulation syndrome. Ovarian hyperstimulation can be associated with severe morbidity and may be even fatal. Ovarian hyperstimulation syndrome is an iatrogenic condition secondary to medical stimulation of the ovary, and was virtually unknown until IVF treatment was initiated. This article will discuss the recent developments in IVF treatment endocrinology and protocols, as well as prevention/treatment of its complications.

Overt leptin response to controlled ovarian hyperstimulation negatively correlates with pregnancy outcome in in vitro fertilization--embryo transfer cycle

CONTEXT

A critical body mass of adipose tissue is essential for the normal development of female reproductive functions. Leptin, an adipocyte-derived hormone encoded by the 'Ob' gene has been proposed as a peripheral signal indicating the adequacy of nutritional status for reproductive functions. It is reported as a direct regulator of gametogenic and steroidogenic potential of ovary. Though leptin is widely present in reproductive tissues, its relationship to reproductive hormones is still poorly understood.

AIMS

Present investigation attempts to explore ovarian response to secretory profile of leptin and its impact on pregnancy outcome in women undergoing controlled ovarian hyperstimulation for in vitro fertilization and embryo transfer (IVF-ET).

SETTINGS AND DESIGN

Patients enrolled for IVF-ET underwent pituitary-ovarian suppression by 'Long Protocol' GnRH-agonist downregulation followed by ovarian stimulation.

MATERIALS AND METHODS

Sera were procured at different phases of IVF-ET for the assay of estradiol, progesterone, human chorionic gonadotropin, and for leptin. Ovarian follicular fluids were also assayed for leptin. Luteinized granulosa cells were cultured in vitro to evaluate their steroidogenic potential.

STATISTICAL ANALYSIS USED

Statistical analyses were done by student's t-test, ANOVA, and Chi-square tests as applicable. All results were expressed as Mean ± SE. P values < 0.05 were considered significant.

RESULTS

Positive correlation was observed between serum and ovarian follicular fluid leptin. A negative correlation was noted between the serum leptin levels and endometrial thickness.

CONCLUSIONS

Elevated leptin response may exert adverse impacts on pregnancy success during IVF-ET possibly by modulating uterine receptivity.

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.

Progesterone-regulated B4galnt2 expression is a requirement for embryo implantation in mice

OBJECTIVE

To investigate B4galnt2 gene regulation in the female mouse reproductive system (B4galnt2 encodes an enzyme, β1,4-N-acetylgalactosylaminyltransferase II, that catalyzes the addition of GalNAc to glycoproteins via a β1,4 linkage).

DESIGN

Experimental prospective study.

SETTING

Research institute and university.

ANIMAL(S)

Outbred Institute for Cancer Research (ICR) mice.

INTERVENTION(S)

Subcutaneous injection of P/E2; uterine tissues were collected after a 3-day injection period and were collected at different times during pregnancy.

MAIN OUTCOME MEASURE(S)

Gene expression was measured by quantitative real-time polymerase chain reaction after hormonal treatment of ovariectomized mice or pregnant mice. Primary endometrial cell cultivation and a gene promoter assay were used for P regulation analysis. The small interfering RNA (siRNA) technique was used to assess the gene function in embryo implantation in vivo.

RESULT(S)

Animal experiments, a primary endometrial cell cultivation assay, and a gene promoter assay indicated that B4galnt2 is regulated positively by P and negatively by estrogen. B4galnt2 was expressed in uterine tissue at peri-implantation (embryonic day 3.5) along with a sharp increase in placental P production at embryonic day 10.5, and declined as estrogen increased during pregnancy. Using the siRNA in vivo implantation assay, we have proved that B4galnt2 participated in embryonic implantation during pregnancy in mice.

CONCLUSION(S)

This study shows for the first time the expression of B4galnt2 in pregnant mice and its regulation by P. We conclude that the naturally occurring up-regulation of B4galnt2 during pregnancy contributes to normal embryo implantation but not to embryo development.

The effect of adding oral oestradiol to progesterone as luteal phase support in ART cycles - a randomized controlled study

INTRODUCTION

Luteal phase support in assisted reproductive technology (ART) cycles is still controversial. The present study was conducted to evaluate the effect of adding oral oestradiol to progesterone during ART cycles.

MATERIAL AND METHODS

In this prospective case control study, infertile women under 35 years old who were candidates for IVF/ICSI cycles in Royan Institute were enrolled. A long gonadotropin-releasing hormone (GnRH) agonist protocol was used for ovarian stimulation. Patients were randomly divided into two groups for luteal phase support: the control group received vaginal administration of progesterone supplementation alone starting on the day after oocyte retrieval and continued until the tenth week if the chemical pregnancy test was positive. In the oestradiol group, 2 mg of oestradiol valerate was initiated orally with progesterone. The control group received a placebo instead of oestradiol.

RESULTS

Ninety-eight women were studied as oestradiol (N = 47) and control groups (N= 51). There were no significant differences in the mean number of retrieved oocytes, number of transferred embryos, or chemical and clinical pregnancy rates between the two groups. Although the serum progesterone concentration was higher in the oestradiol group in comparison to the control group on day 7, 10 and 12 after embryo transfer, these differences were not statistically significant.

CONCLUSIONS

The results suggested that adding oral oestradiol to vaginal progesterone supplementation does not improve the chemical and clinical pregnancy rates of IVF/ICSI cycles.

Luteotrophic effects of relaxin, chorionic gonadotrophin and FSH in common marmoset monkeys (Callithrix jacchus)

In early pregnant primates, relaxin (RLX) is highly upregulated within the corpus luteum (CL), suggesting that RLX may have an important role in the implantation of the blastocyst. Therefore, the aim of the present study was to investigate the local effects of RLX and gonadotrophins on the maintenance of the CL using an in vitro microdialysis system. CLs of common marmoset monkeys were collected by luteectomy during different stages of the luteal phase and early pregnancy. Each CL was perfused with either Ringer's solution alone or Ringer's solution supplemented with either porcine RLX (250, 500 and 1000 ng/ml) or gonadotrophins (50 IU/ml). Application of RLX provoked a significant luteal response of progesterone (P(4)) and oestradiol (E(2)) secretions during the mid-luteal phase (500 ng/ml: P(4) 54+/-42%, E(2) 24+/-11%; 1000 ng/ml: E(2) 16+/-13%), and especially during the late luteal phase (250 ng/ml: P(4) 53+/-10%; 500 ng/ml: P(4) 44+/-15%; 1000 ng/ml: P(4) 62+/-15%, E(2) 18+/-7%). The effects of RLX on steroid secretion were irrespective of the RLX dosages. While treatment with human chorionic gonadotrophin did not affect luteal steroid or RLX secretion, the application of FSH resulted in a significant increase in the secretion of both P(4) (20+/-8%) and E(2) (37+/-28%), and a prominent rise in RLX during early pregnancy. In conclusion, our results demonstrate that RLX and FSH have a luteotrophic function in the marmoset monkeys; moreover, FSH has a function beyond its traditional role just as a follicle-stimulating hormone.

Effects of variations in serum estradiol concentrations on secretory endometrial development and function in experimentally induced cycles in normal women

Eighteen normal women underwent pituitary down-regulation with leuprolide, followed by a 10-day treatment with 0.2 mg/d transdermal estradiol (E(2)) with subsequent allocation to one of two 10-day estradiol regimens plus 40 mg daily intramuscular P: supraphysiologic (0.2 mg/d transdermal E(2) mg/d vaginal micronized E(2)) or subphysiologic (no exogenous E(2) treatment). Average E(2) and P in the supraphysiologic, physiologic, and subphysiologic groups were 1,175.9 pg/mL and 17.5 ng/mL, 136.9 pg/mL and 21.2 pg/mL, and 23.8 ng/mL and 22.0 ng/mL, respectively, and there were no differences between groups in endometrial histology or expression of biomarkers of receptivity.

Luteal support: progestogens for pregnancy protection

Following ovulation, the granulosa cells undergo luteinization and form part of the corpus luteum; this then secretes progesterone that causes secretory transformation of the endometrium so that implantation can occur. The ideal time for implantation is 6-10 days after the luteinizing hormone (LH) surge; implantation occurring outside this optimal window is associated with a higher likelihood of miscarriage. Before the placenta takes over progesterone production, the progesterone produced by the corpus luteum also provides the necessary support to early pregnancy. A defect in corpus luteum function is not only associated with implantation failure but also with miscarriage. In assisted reproduction, both the use of gonadotropin-releasing hormone analogues to prevent the LH surge and aspiration of granulosa cells during the oocyte retrieval may impair the ability of the corpus luteum to produce sufficient progesterone. This may be treated effectively with progestational agents such as progesterone or dydrogesterone, which have a very similar pharmacological profile. Studies indicate that an estrogen may be given during the luteal phase to optimise the estrogen:progestogen ratio to facilitate implantation, although the available evidence is inconsistent in its strength for this hypothesis. In addition to assisted reproduction, progestational agents have shown beneficial effects in the management of patients with recurrent spontaneous miscarriage of unknown cause. In conclusion, despite the wide-spread use and many years of clinical experience, the amount of data from well-controlled clinical trials is currently limited. Further studies are therefore required to establish the optimal treatment situation and type and dose of progestational agent.

[Views of each member of an Assisted Reproductive Technologies centre on the embryo transfer procedure]

The embryo transfer (ET) is probably the key step of Assisted Reproductive Technologies (ART), end point of the collaboration of a multidisciplinary clinical team and an infertile couple. Thus, a perfect knowledge of available data regarding ET is required to optimize the results of ART. Indeed, numerous published studies demonstrate the impact of defined parameters onto the effectiveness of ET procedure. The aim of this study is to provide views of physicians dealing with ART, i.e. endocrinologist, ultrasound scan specialist, surgeon and biologist to put in perspective questions and answers about ET.

The effect of luteal phase support protocol on cycle outcome and luteal phase hormone profile in long agonist protocol intracytoplasmic sperm injection cycles: a randomized clinical trial

OBJECTIVE

To study the effect of luteal phase support protocol on cycle outcome and luteal phase hormone profile, in long agonist protocol intracytoplasmic sperm injection (ICSI) cycles.

DESIGN

Prospective randomized trial.

SETTING

Private infertility center.

PATIENT(S)

Two hundred seventy-four women undergoing first ICSI cycles were randomized after ovum pickup into three groups of luteal support.

INTERVENTION(S)

Group I received IM P (P(4)) only, group II received P(4) + oral E(2) valerate, group III received P(4) + hCG.

MAIN OUTCOME MEASURE(S)

Pregnancy rate (PR), implantation rate, rates of multiple pregnancy and miscarriage, and midluteal serum E(2) and P(4), and midluteal E(2):P(4) ratio.

RESULT(S)

The PR and implantation rates were significantly higher in group II compared to group I and the miscarriage rate was significantly lower in group II compared with group I. Midluteal E(2) was significantly higher in group II compared with group I. The decline in E(2) after ovum pickup was lowest in group II, highest in group I. The midluteal E(2):P(4) ratio was significantly higher in group II compared with groups I and III.

CONCLUSION(S)

The E(2) luteal phase supplementation in long GnRH-agonist (GnRH-a) protocol ICSI cycles resulted in better cycle outcome and better luteal phase hormone profile.

Serum estradiol levels during controlled ovarian hyperstimulation influence the pregnancy outcome of in vitro fertilization in a concentration-dependent manner

OBJECTIVE

To determine an optimal serum E(2) level on the day of hCG administration in controlled ovarian hyperstimulation (COH) during IVF-ET without compromising pregnancy outcome.

DESIGN

Retrospective study.

SETTING

Large urban medical center.

PATIENT(S)

Data of 455 cycles of fresh IVF-ET with COH.

INTERVENTION(S)

Serum E(2) levels on the day of hCG administration were categorized into five groups: group A (<1000 pg/mL), group B (1000-2000 pg/mL), group C (2000-3000 pg/mL), group D (3000-4000 pg/mL), and group E (>4000 pg/mL).

MAIN OUTCOME MEASURE(S)

Serum E(2) levels, number of oocytes retrieved, pregnancy outcomes.

RESULT(S)

Of 455 cycles, 148 (32.5%) cycles resulted in clinical pregnancy. The implantation rate was 12.2%, and the delivery rate was 18.7%. The number of oocytes obtained increased with increasing serum E(2) levels. The pregnancy rate gradually increased from group A to D as E(2) levels increased but decreased in group E. In women <38 years, the IVF-ET outcomes were similar to those of total patients. However, in women >/=38 years old, pregnancy and delivery rates were higher in group C than in other groups.

CONCLUSION(S)

These results show that serum E(2) levels have a concentration-dependent effect on the pregnancy outcome, suggesting an optimal range of E(2) level for achieving a successful pregnancy. This optimal range of serum E(2) level in women is age dependent: 3000-4000 pg/mL for women <38 years and 2000-3000 pg/mL for women >/=38 years.

Does luteal estradiol supplementation have a role in long agonist cycles?

OBJECTIVE

To test the hypothesis that the addition of 6 mg estradiol (E2) valerate either orally or vaginally to progesterone (P) for luteal support, can increase the probability of pregnancy in intracytoplasmic sperm injection (ICSI) cycles using the long agonist protocol.

DESIGN

Prospective open-labeled randomized controlled trial.

SETTING

Private and university fertility centers.

PARTICIPANT(S)

Women undergoing ICSI cycles, with controlled ovarian hyperstimulation using long agonist protocol.

INTERVENTION(S)

On embryo transfer day, participants were randomized to receive, only P (group A, n = 90), P along with 6 mg E(2) valerate either orally (group B, n = 90), or vaginally (group C, n = 90) for luteal support.

MAIN OUTCOME MEASURE(S)

Clinical pregnancy was the main outcome. luteal serum E(2) and P profiles were the secondary outcomes.

RESULT(S)

Highest pregnancy rate was achieved in group C (45.56%), it was significantly higher than A (relative risk 1.52, 95% CI: 1.03 to 2.24). Day 0 (hCG day) E2 levels were similar in the three groups. Group A had lower E2 levels on days 7, 10, and 13 and a higher magnitude of E2 decline on days 7 and 10. Similar levels of luteal E2 were documented in groups B and C. P levels were similar in the three groups.

CONCLUSIONS(S)

Addition of 6 mg E(2) valerate to P support may encumber the sharp decline in luteal E(2) level. It may enhance the probability of pregnancy if administered vaginally.

The role of steroid hormones in ART

Steroid hormones hold a major role in female fertility and their proper utilisation and monitoring in modern assisted reproduction protocols is important. Oocyte maturation and endometrial receptivity are the two major factors that appear to be related to a successful outcome in Assisted Reproductive Technology (ART). Many reports suggest that oocyte immaturity accounts for a considerable loss of efficiency in ART, mainly due to the poor quality of the obtained embryos and their inability to develop normally. Oestrogen appears to exert its effects on the cytoplasmic maturation of the oocyte, while progesterone has been shown to accelerate meiotic resumption. Moreover, ovarian stimulation appears to affect the normal luteal function and shifts in the window of implantation as a response to hormonal supplementation have also been observed. The ethical limitations in conducting in vivo studies of human implantation, have led to an indirect hormonal- and morphologic-oriented assessment of endometrial receptivity. The two main protocols of luteal support involve either progesterone supplementation or hCG administration, whereas the combined supplementation with oestradiol remains controversial. This brief review aims to summarize the current knowledge on steroidal actions during the above processes and to address their potential use in the improvement of current ART protocols.

Luteal support for IVF/ICSI cycles with Crinone 8% (90 mg) twice daily results in higher pregnancy rates than with intramuscular progesterone

BACKGROUND

The use of progesterone for luteal support has been demonstrated to be beneficial in assisted reproductive cycles, yet the optimal route of progesterone administration has still not been established. This article is a retrospective study in a tertiary reproductive medical unit to compare luteal progesterone supplementation with vaginal gel or intramuscular progesterone.

METHODS

A total of 144 in vitro fertilization or intracytoplasmic sperm injection cycles were analyzed, 67 cycles using vaginal gel 90 mg twice daily and 77 cycles using intramuscular progesterone 50 mg daily as luteal support.

RESULTS

Both groups had similar mean age, cause of infertility, baseline hormone levels, dosage of recombinant follicle-stimulating hormone, number of retrieved and fertilized oocytes, and number of transferred embryos. The vaginal gel group had significantly lower mid-luteal serum progesterone levels but higher implantation rate (32.5% vs. 18.5%, p = 0.001) and ongoing pregnancy rate (55.2% vs. 32.5%, p = 0.006). Within each group, mid-luteal serum progesterone levels between pregnant or non-pregnant patients were comparable. For patients with serum estradiol levels on day of human chorionic gonadotropin greater than 5,000 pg/mL, vaginal gel still resulted in better ongoing pregnancy and implantation rates.

CONCLUSION

The use of vaginal progesterone gel twice daily for luteal support results in better pregnancy outcomes than intramuscular progesterone. A high local progesterone effect from vaginal gel might improve endometrial receptivity under extraordinarily high serum estradiol levels.

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.