Serum oestradiol and β-HCG measurements after day 3 or 5 embryo transfers in interpreting pregnancy outcome

Single day 14 serum hCG values allow prediction of viable pregnancy and are significantly higher in frozen as compared to fresh single blastocyst transfer

PURPOSE

To evaluate if single serum human chorionic gonadotropin (hCG) level measurements are sufficient for pregnancy monitoring after single embryo transfer (sET) and to compare the hCG levels between fresh (FRET) and frozen embryo transfers (FET) in medically assisted reproduction.

METHODS

This was a retrospective exploratory cohort study including all patients who met the inclusion criteria, who received a single FRET (n = 249) or FET (n = 410) of a day five blastocyst at the IVF clinic at the Johannes Kepler University Linz between 2011 and 2020. hCG levels were measured on day 14 after embryo transfer. Threshold values for the viability of pregnancies were determined using receiver operating characteristic (ROC) curves.

RESULTS

Significantly higher hCG levels were found in those who received FET than in those who received FRET (1222.8 ± 946.7 mU/ml vs. 862.7 ± 572.9 mU/ml; p < 0.001). Optimal threshold values predicting a viable pregnancy were 368.5 mU/ml and 523 mU/ml in the FRET and FET groups, respectively.

CONCLUSIONS

After FET, higher hCG values after 14 days of embryo transfer must be considered in pregnancy monitoring. Additionally, a single threshold hCG value seems to be sufficient for determining pregnancy viability. To exclude ectopic pregnancies, subsequent ultrasound examination is a mandatory requirement.

Association between the length of in vitro embryo culture, mode of ART, and the initial endogenous hCG rise in ongoing singleton pregnancies

STUDY QUESTION

Is there an association between the length of in vitro culture, mode of ART and the initial endogenous hCG rise, in cycles with a foetal heartbeat after single embryo transfer (ET) and implantation?

SUMMARY ANSWER

Both the length of in vitro culture and the mode of ART have an impact on the initial endogenous rise in hCG in singleton pregnancies.

WHAT IS KNOWN ALREADY

Different factors have been identified to alter the kinetics of hCG in pregnancies. Current studies show conflicting results regarding the kinetics of hCG after different types of ART (fresh vs frozen ET (FET)), the inclusion or not of preimplantation genetic testing (PGT), and the length of time in in vitro culture.

STUDY DESIGN, SIZE, DURATION

This was a multicentre cohort study, using prospectively collected data derived from 4938 women (5524 treatment cycles) undergoing IUI (cycles, n = 608) or ART (cycles, n = 4916) treatments, resulting a in singleton ongoing pregnancy verified by first-trimester ultrasound scan. Data were collected from the Danish Medical Data Centre, used by the three participating Danish public fertility clinics at Copenhagen University hospitals: Herlev Hospital, Hvidovre Hospital, and Rigshospitalet, from January 2014 to December 2021.

PARTICIPANTS/MATERIALS, SETTING, METHODS

The fresh ET cycles included cleavage-stage (2 or 3 days in vitro) and blastocyst (5 days in vitro) transfers. FET cycles included cleavage-stage (3 days in vitro before cryopreservation) or blastocyst (5 or 6 days in vitro before cryopreservation) transfers. The IUI cycles represented no time in vitro. To attain a comparable interval for serum-hCG (s-hCG), the ovulation induction time was identical: 35-37 h before oocyte retrieval or IUI. The conception day was considered as: the insemination day for pregnancies conceived after IUI, the oocyte retrieval day for fresh ET, or the transfer day minus 3 or 5 as appropriate for FET of Day 3 or 5 embryos. Multiple linear regression analysis was used, including days post-conception for the hCG measurement as a covariate, and was adjusted for the women's age, the cause of infertility, and the centre. For FET, a sensitivity analysis was used to adjust for endometrial preparation.

MAIN RESULTS AND THE ROLE OF CHANCE

The study totally includes 5524 cycles: 2395 FET cycles, 2521 fresh ET cycles, and 608 IUI cycles. Regarding the length of in vitro culture, with IUI as reference (for no time in in vitro culture), we found a significantly lower s-hCG in pregnancies achieved after fresh ET (cleavage-stage ET or blastocyst transfer). S-hCG was 18% (95% CI: 13-23%, P < 0.001) lower after fresh cleavage-stage ET, and 23% (95% CI: 18-28%, P < 0.001) lower after fresh blastocyst transfer compared to IUI. In FET cycles, s-hCG was significantly higher after blastocyst transfers compared to cleavage-stage FET, respectively, 26% (95% CI: 13-40%, P < 0.001) higher when cryopreserved on in vitro Day 5, and 14% (95% CI: 2-26%, P = 0.02) higher when cryopreserved on in vitro Day 6 as compared to Day 3. Regarding the ART treatment type, s-hCG after FET blastocyst transfer (Day 5 blastocysts) cycles was significantly higher, 33% (95% CI: 27-45%, P < 0.001), compared to fresh ET (Day 5 blastocyst), while there was no difference between cleavage-stage FET (Days 2 + 3) and fresh ET (Days 2 + 3). S-hCG was 12% (95% CI: 4-19%, 0.005) lower in PGT FET (Day 5 blastocysts) cycles as compared to FET cycles without PGT (Day 5 blastocysts).

LIMITATIONS, REASONS FOR CAUTION

The retrospective design is a limitation which introduces the risk of possible bias and confounders such as embryo score, parity, and ovarian stimulation.

WIDER IMPLICATIONS OF THE FINDINGS

This study elucidates how practices in medically assisted reproduction treatment are associated with the hCG kinetics, underlining a potential impact of in vitro culture length and mode of ART on the very early embryo development and implantation. The study provides clinicians knowledge that the type of ART used may be relevant to take into account when evaluating s-hCG for the prognosis of the pregnancy.

STUDY FUNDING/COMPETING INTEREST(S)

No funding was received for this study. AP has received consulting fees, research grants, or honoraria from the following companies: Preglem, Novo Nordisk, Ferring Pharmaceuticals, Gedeon Richter, Cryos, Merck A/S, and Organon. AZ has received grants and honoraria from Gedeon Richter. NLF has received grants from Gedeon Richter, Merck A/S, and Cryos. MLG has received honoraria fees or research grants from Gedeon Richter, Merck A/S, and Cooper Surgical. CB has received honoraria from Merck A/S. MB has received research grants and honoraria from IBSA. MPR, KM, and PVS all report no conflicts of interest.

TRIAL REGISTRATION NUMBER

The study was registered and approved by the Danish Protection Agency, Capital Region, Denmark (Journal-nr.: 21019857). No approval was required from the regional ethics committee according to Danish law.

The POPI-Plus tool: prediction model of outcome of pregnancy in in vitro fertilization from a large retrospective cohort

OBJECTIVE

To create a tool that accurately predicts live birth chances after a positive pregnancy test after elective single embryo transfer (ET).

DESIGN

Retrospective cohort.

SETTING

CHUM hospital and Ovo clinic in Montreal, Canada.

PATIENT(S)

Patients with a positive pregnancy test result who underwent their first single ET after in vitro fertilization (IVF) at the CHUM hospital and Ovo clinic in Montreal, Canada, from 2012 to 2016 were selected. A total of 1,995 patients were included in this study.

INTERVENTION(S)

The data from both centers were combined and divided into training (70%, n = 1,398) and validation (30%, n = 597) sets. The predictive model was developed using backward selection method for the following variables: age of patient at egg retrieval; log β-human chorionic gonadotropin (β-hCG) (β-hCG) 1; log β-hCG 2; and IVF treatment type. Moreover, the classification tree, random forest, and neural network models were generated.

MAIN OUTCOME MEASURE(S)

The measured outcomes were live birth (live fetus ≥24 weeks of gestation) and nonviable pregnancies. The performance of all models was evaluated by area under the receiver operating characteristic curve (AUC).

RESULT(S)

Advancing age was negatively correlated with live birth. The odds ratio (OR) of age of patient at the time of egg retrieval was 0.95 (95% confidence interval [CI], 0.91-0.99). The log β-hCG 1 and log β-hCG 2 were positively correlated with live birth in the univariate analysis (OR, 4.15 [95% CI, 3.19-5.39], and OR, 3.84 [95% CI, 2.99-4.93], respectively). The β-hCG 1 level needed for a successful pregnancy was lower in frozen ET and modified natural IVF than in simulated IVF (OR, 0.55 [95% CI, 0.34-0.91], and OR, 0.49 [95% CI, 0.26-0.95], respectively). The best performance in terms of the AUC was the updated logistic model: POPI-Plus. The AUC values were 0.76 (95% CI, 0.73-0.79) and 0.78 (95% CI, 0.74-0.82) for the training and validation data, respectively. The other models (classification tree, random forest, and neural network) also performed adequately, with an AUC of ≥0.7, but remained below POPI-Plus. An open-access calculator was generated and can be found on the website of the University of Montreal on the following link: https://deptobsgyn.umontreal.ca/departement/divisions/medecine-et-biologie-de-la-reproduction/the-popi-plus-tool/.

CONCLUSION(S)

The POPI-Plus tool offers individualized counseling for patients after an initial positive β-hCG test result. Future studies will assess its impact on patient anxiety while awaiting viability ultrasound and perform prospective validation on new patients.

The impact of fresh versus frozen-thawed embryos on maternal serum analyte levels in IVF singleton and twin pregnancies

PURPOSE

To determine whether embryo cryopreservation is associated with a difference in maternal serum analyte levels in singleton and twin pregnancies conceived via in vitro fertilization (IVF).

METHODS

This was a retrospective cohort study of singleton and twin pregnancies conceived via IVF from a university health system from 01/2014 to 09/2019. Patients with available first and second trimester serum analyte data were included and analyzed separately. Multiple of the median (MoM) values for free β-human chorionic gonadotropin (β-hCG), pregnancy-associated plasma protein A, alpha-fetoprotein (AFP), Inhibin A, and unconjugated estriol (uE3) were compared between two groups: pregnancies conceived after the transfer of fresh embryos versus pregnancies conceived after the transfer of frozen-thawed embryos. Multiple linear regression of log MoM values with F test was performed to adjust for potential confounders.

RESULTS

For singletons, fresh embryos were associated with a lower median first trimester free β-hCG (1.00 MoM vs. 1.14 MoM; parameter estimate [PE] 0.90, 95% CI 0.82-0.99, p = .03) compared to frozen-thawed embryos. Fresh embryos were also associated with a lower median second trimester uE3 (0.93 MoM vs. 1.05 MoM; PE 0.88, CI 0.83-0.95, p = .0004) and AFP (1.02 MoM vs. 1.19 MoM; PE 0.91, CI 0.84-0.99, p = .02) compared to frozen-thawed embryos in singletons. There were no significant differences between median first and second trimester serum analytes in twin pregnancies compared between the two groups.

CONCLUSION

Singleton pregnancies derived from fresh embryos had lower first (free β-hCG) and second (uE3 and AFP) trimester analytes compared to frozen-thawed embryos. Twin pregnancies demonstrated no difference between the groups.

The pathophysiological role of estrogens in the initial stages of pregnancy: molecular mechanisms and clinical implications for pregnancy outcome from the periconceptional period to end of the first trimester

BACKGROUND

Estrogens regulate disparate female physiological processes, thus ensuring reproduction. Altered estrogen levels and signaling have been associated with increased risks of pregnancy failure and complications, including hypertensive disorders and low birthweight babies. However, the role of estrogens in the periconceptional period and early pregnancy is still understudied.

OBJECTIVE AND RATIONALE

This review aims to summarize the current evidence on the role of maternal estrogens during the periconceptional period and the first trimester of pregnancies conceived naturally and following ART. Detailed molecular mechanisms and related clinical impacts are extensively described.

SEARCH METHODS

Data for this narrative review were independently identified by seven researchers on Pubmed and Embase databases. The following keywords were selected: 'estrogens' OR 'estrogen level(s)' OR 'serum estradiol' OR 'estradiol/estrogen concentration', AND 'early pregnancy' OR 'first trimester of pregnancy' OR 'preconceptional period' OR 'ART' OR 'In Vitro Fertilization (IVF)' OR 'Embryo Transfer' OR 'Frozen Embryo Transfer' OR 'oocyte donation' OR 'egg donation' OR 'miscarriage' OR 'pregnancy outcome' OR 'endometrium'.

OUTCOMES

During the periconceptional period (defined here as the critical time window starting 1 month before conception), estrogens play a crucial role in endometrial receptivity, through the activation of paracrine/autocrine signaling. A derailed estrogenic milieu within this period seems to be detrimental both in natural and ART-conceived pregnancies. Low estrogen levels are associated with non-conception cycles in natural pregnancies. On the other hand, excessive supraphysiologic estrogen concentrations at time of the LH peak correlate with lower live birth rates and higher risks of pregnancy complications. In early pregnancy, estrogen plays a massive role in placentation mainly by modulating angiogenic factor expression-and in the development of an immune-tolerant uterine micro-environment by remodeling the function of uterine natural killer and T-helper cells. Lower estrogen levels are thought to trigger abnormal placentation in naturally conceived pregnancies, whereas an estrogen excess seems to worsen pregnancy development and outcomes.

WIDER IMPLICATIONS

Most current evidence available endorses a relation between periconceptional and first trimester estrogen levels and pregnancy outcomes, further depicting an optimal concentration range to optimize pregnancy success. However, how estrogens co-operate with other factors in order to maintain a fine balance between local tolerance towards the developing fetus and immune responses to pathogens remains elusive. Further studies are highly warranted, also aiming to identify the determinants of estrogen response and biomarkers for personalized estrogen administration regimens in ART.

Initial β-hCG levels and 2-day-later increase rates effectively predict pregnancy outcomes in single blastocyst transfer in frozen-thawed or fresh cycles: A retrospective cohort study

To investigate whether the initial beta-human chorionic gonadotropin (β-hCG) levels and their rate of increase differ after single fresh and frozen blastocyst transfers, and whether these values effectively predict pregnancy outcomes. This retrospective cohort study was conducted at the Sisli Memorial Hospital, assisted reproductive technology, and Reproductive Genetics Center in Istanbul, Turkey, between January 2016 and January 2022. Three thousand two hundred thirty-eight single blastocyst transfers with positive pregnancy test results were evaluated. Of these, 738 were fresh transfer cycles and 2500 were frozen-thawed embryo transfer (FET) cycles. β-hCG test results from 9 days after fresh and FET cycles were compared between the groups with biochemical pregnancy, early pregnancy loss, and live birth outcomes. The threshold values were determined for each pregnancy outcome. The rate of increase between the first and second β-hCG tests performed 2 days apart was determined for each pregnancy outcome. Finally, the listed values were compared between the FET and fresh cycle. Mean baseline β-hCG levels were significantly higher in FET cycles than in fresh cycles, regardless of pregnancy outcomes (P < .005). Baseline β-hCG levels were higher in fresh cycles with live births (171.76 ± 109.64 IU/L) compared to biochemical and clinical pregnancy losses (50.37 ± 24.31 and 114.86 ± 72.42, respectively) (P < .001). Live births in FET cycles resulted in higher baseline β-hCG levels (193.57 ± 100.38 IU/L) compared to biochemical and clinical pregnancy loss groups (68.41 ± 51.85 and 149.29 ± 96.99 IU/L, respectively) (P < .001). The β-hCG threshold for live birth for fresh cycles was 116.5 IU/L (sensitivity 80%, specificity 70%, positive predictive value 90%, negative predictive value 54%) and 131.5 IU/L for FET cycles (sensitivity 71%, specificity 68%, positive predictive value 87%, negative predictive value 50%). The percentage of the area under the curve for single fresh blastocyst transfers was 0.81 and 0.76 for frozen transfers. The rate of increase in β-hCG was similar in fresh and FET cycles. Initial β-hCG levels and 2-day increases are effective parameters for diagnosing pregnancy in fresh and FET cycles. The initial β-hCG level was significantly higher in the FET cycles than in the fresh cycles. Predicting outcomes earlier helps clinicians to manage and follow high-risk pregnancies.

Early β-hCG levels predict live birth after single embryo transfer

PURPOSE

Specific serum beta human chorionic gonadotropin (β-hCG) parameters that can predict live birth after an embryo transfer have yet to be defined.

METHODS

We performed a retrospective cohort study of 1,028 patients with a detectable β-hCG who underwent a single embryo transfer between 2002 and 2019 at a large academic center. Two β-hCG parameters were examined in relation to live birth: 1) "doubling" defined as β-hCG doubling over 48 h and 2) "reaching 100" defined as a β-hCG ≥ 100 mIU/mL by 15 days after oocyte retrieval (AOR).

RESULTS

One thousand three hundred forty cycles involving a single embryo were analyzed. Two thirds were frozen embryos and 86% were blastocyst transfers. Preimplantation genetic testing was performed in almost 30% of cycles. When β-hCG levels "doubled," a live birth occurred in 80.7% of cycles and when β-hCG levels "reached 100" by 15 days AOR, live birth occurred in 81.6% of cycles. When β-hCG levels both doubled and reached 100 by 15 days, AOR 85.4% cycles resulted in live birth. A multiple logistic regression model to control for patient and cycle level factors revealed a live birth odds ratio (OR) of 8.0 (95% CI 5.7-11.1) when β-hCG "doubled" and an OR of 21.2 (95% CI 14.3-31.5) when β-hCG "reached 100." When both these latter parameters were met, the OR was 12.5 (95% CI 8.9-17.8).

CONCLUSION

β-hCG parameters of "doubling" and "reaching 100" by 15 days AOR are robust predictors of live birth and can aid in patient counseling regarding pregnancy outcomes soon after single embryo transfer.

Combined analysis of human chorionic gonadotrophin concentrations at different time points after frozen-thawed blastocyst transfer can improve our ability to predict the pregnancy outcomes of single gestations

In this study, we conducted a retrospective single-centre study of 1664 singleton pregnancies derived from frozen-thawed blastocyst transfer between January 2017 and December 2018. Analysis showed that there were 596 early pregnancy losses and 1068 ongoing pregnancies. We compared serum HCG (human chorionic gonadotophin) concentrations on days 12, 14, 19, and 21, between the pregnancy loss group and the ongoing pregnancy group. The cut-off level of HCG at each time point was calculated to predict pregnancy outcome. Joint analysis of two single HCG levels taken one week apart was carried out to improve predictive accuracy. The levels of HCG at four time points were significantly lower in the early pregnancy loss group than in the ongoing pregnancy group. According to the area under ROC (receiver operating characteristic curve) curves, all levels of HCG taken at four time points showed good ability to predict the outcome of pregnancy. The joint analysis of two single HCG levels taken one week apart further improved the accuracy of prediction.Impact statementWhat is already known on this subject? Multiple studies have shown that the maternal level of serum HCG is the best parameter for predicting the course of pregnancy.What do the results of this study add? The levels of HCG on days 12, 14, 19 and 21 were significantly lower in the early pregnancy loss group than in the group of ongoing pregnancies. According to the area under ROC curves, all levels of HCG taken at four time points showed a good ability to predict the outcome of pregnancy.What are the implications of these findings for clinical practice and/or further research? The joint analysis of two single HCG levels, taken one week apart, further improved the accuracy of prediction.

Blastocyst morphology has no relationship with serum β-hCG levels and live birth rates once pregnant

OBJECTIVE

What is the role of blastocyst morphology on day16 β-hCG serum levels and pregnancy outcomes among patients who conceived through IVF cycles with single fresh Gardner's scored blastocyst transfers.

STUDY DESIGN

A retrospective cohort study conducted at a single academic fertility center between January 2013 and December 2017. A total of 643 pregnancies were included in the study.

RESULTS

The patients were divided into 5 groups according to Gardner's blastocysts grade of the ICM and the TE (grade), and into 4 groups according to blastocyst Gardner's degree of blastocoel expansion (stage). No significant differences were found between the different morphologic groups and day16 β-hCG serum levels, clinical pregnancy rates and live births. A weak significant correlation was observed between Gardner's blastocysts grade and day 16 β-hCG (Correlation Coefficient r= -0.098, p = .014) this correlation remained significant after controlling for confounders. (r= -0.099 p = . 013). A weak significant correlation was observed between Gardner's stage and day 16 β-hCG (Correlation Coefficient r = 0.086, p = 0.029) this correlation lost significance after controlling for confounders. (r = 0.055, p = 0.340). When evaluating predictors of live birth using multivariate logistic regression, blastocyst grade (p = 0.33) and stage (p = 0.65), at transfer, were not associated with live births, when controlling for confounding effects.

CONCLUSION

Once the patient conceives after IVF with single blastocyst, none of the morphological parameters have a strong impact on the day16 serum level of β-hCG. Among women who conceived, blastocyst grade and stage were not associated with live births.

Early Serum hCG in IVF: Are We Trending in the Right Direction?

Human chorionic gonadotropin (hCG) measurements may be the earliest indicator of fertility cycle success, available several weeks before an ultrasound would be diagnostic for pregnancy. Outcomes of these cycles are high stakes for a couple, and the earliest reassurance of a normal pregnancy would be beneficial for their well-being. Additionally, earlier diagnosis can allow for more rapid management by providers in the case of abnormal pregnancies. Therefore, establishing normal values for initial hCG level and early hCG kinetics is of great interest. There are many factors involved in assisted reproductive techniques that may lead to alterations in hCG kinetics when compared with spontaneous pregnancies. We aim to characterize normal hCG values for in vitro fertilization (IVF) pregnancies and review how different aspects of the IVF process may alter these trends in order to establish how best to counsel patients during the waiting period.

What is the effect of embryo morphology on serum β-hCG levels?

OBJECTIVE

To determine the effect of embryonic factors on serum beta human chorionic gonadotropin (β-hCG) levels in pregnancy and live birth resulting after a single fresh cleavage embryo and blastocyst transfer.

STUDY DESIGN

This was a retrospective cohort study conducted at a tertiary care hospital. All fresh single embryo transfers (sETs) between September 2011 and December 2016 were included. The correlation analysis was performed to determine the association of embryo morphological parameters on mean serum β-hCG levels on day 12 after the transfer of a fresh single cleavage embryo and a fresh single blastocyst embryo.

RESULTS

Out of a total of 455 fresh sETs, 60 positive β-hCG results after the transfer of a single fresh cleavage-stage embryo and 82 after the transfer of a single fresh blastocyst. The mean β-hCG level resulting from a single fresh blastocyst ET was 371.7 ± 52.7 IU/L, which was similar to the mean β-hCG level resulting from a cleavage ET (314.5 ± 36.9 IU/L) (p = .70). Interestingly, serum β-hCG levels resulting from a single fresh blastocyst ET showed a correlation with day 5 blastocoele expansion, trophectoderm cell number and blastocyst quality score in ongoing pregnancy (r = .33, p = .02; r = .29, p = .04; and r = .31, p = .03, respectively). Moreover, day 5 blastocoele expansion and blastocyst quality score showed a correlation with the serum β-hCG levels resulting from a single fresh blastocyst ET in live birth (r = .36, p = .02; r = .31, p = .04, respectively).

CONCLUSION

Our study suggests that serum β-hCG levels resulting from a single fresh blastocyst ET showed a correlation with day 5 blastocoele expansion and blastocyst quality score in both ongoing pregnancy and live birth.

Initial maternal serum human chorionic gonadotropin levels in pregnancies achieved after assisted reproductive technology are higher after preimplantation genetic screening and after frozen embryo transfer: a retrospective cohort

PURPOSE

Few published articles have compared initial hCG values across all different types of ART cycles, including cycles with fresh or frozen embryo transfer. No articles have compared initial hCG values in cycles utilizing preimplantation genetic screening (PGS). The purpose of this study is to compare initial hCG values after fresh embryo transfer, frozen embryo transfer, and after PGS.

METHODS

This was a single-center retrospective cohort study at an academically affiliated private IVF center. All fresh and frozen embryo transfers between January 2013 and December 31, 2015 were included. We compared mean initial serum hCG values 14 days after oocyte retrieval for fresh cycles and 9 days after frozen embryo transfer. We examined cycles of single embryo transfer (SET) and double embryo transfer (DET).

RESULTS

Two hundred elven IVF (fresh embryo transfer), 128 FET (frozen embryo transfer cycles, no PGS), and 111 PGS cycles (ovarian stimulation with embryo cryopreservation, PGS, and frozen transfer in a subsequent estrogen-primed cycle) with initial positive hCG values were analyzed. In patients achieving a positive hCG after SET, initial hCG values were higher after PGS compared to FET (182.4 versus 124.0 mIU/mL, p = 0.02) and IVF (182.4 versus 87.1 mIU/mL, p < 0.001) as well as FET compared to IVF (124.0 versus 87.1 mIU/mL, p < 0.01). After DET, initial hCG values were higher after PGS (222.8 mIU/mL) compared to FET (182.1 mIU/mL, p = 0.02) and IVF (131.1 mIU/mL, p = 0.001).

CONCLUSIONS

Our study suggests that initial serum hCG values are higher after using PGS and higher after the transfer of a frozen embryo compared to a fresh embryo. This suggests that initial hCG values relate to the chromosomal status of embryos. Initial hCG values may help determine intervention and monitoring later in pregnancy.

Value of Post-transfer Day-12 Beta Human Chorionic Gonadotropin Levels for Pregnancy Outcome Prediction of Intracytoplasmic Sperm Injection Cycles

BACKGROUND

Several markers were studied previously in order to predict the pregnancy outcome of assisted reproductive techniques; however, serum beta human chorionic gonadotropin was found to be the most predictive marker.

AIMS

To evaluate the value of serum beta human chorionic gonadotropin levels in discriminating biochemical and clinical pregnancies 12 days after embryo transfer, while determining the factors predicting ongoing pregnancy was established as the secondary aim.

STUDY DESIGN

Retrospective cross-sectional study.

METHODS

A total of 445 pregnant cycles were retrospectively analysed in 2359 embryo transfer cycles. Patients were divided into two groups according to the outcome of pregnancy: biochemical and clinical.

RESULTS

The cut-off value of beta human chorionic gonadotropin levels on day 12 in predicting clinical pregnancies was 86.8 IU/mL with 65.1% sensitivity and 74.7% specificity [CI: 0.76 (0.71-0.81). Receiver operating characteristic curve analysis revealed different cut-off values for embryo transfer days (57 mIU/mL for day 3 embryo transfer CI: 0.59-0.79 and 87 mIU/mL for day 5 embryo transfer, CI: 0.74-0.86). Subgroup analysis of clinical pregnancies revealed a significant difference between ongoing pregnancies and early fetal losses regarding duration of infertility (81.3±54.4 vs. 100.2±62.2 months), serum oestradiol on hCG day (2667.4±1276.4 vs. 2094.6±1260.5 pg/mL), number of transferred embryos (1.9±0.8 vs. 1.5±0.7) and the prevalence of diminished ovarian reserve as an indication (2.3% vs 12.2%).

CONCLUSION

Beta human chorionic gonadotropin levels on day 12 following embryo transfer provide an important parameter for the prediction of clinical pregnancy; however, other stimulation parameters are indicated in the prediction of ongoing pregnancies.

Serum human chorionic gonadotropin measured 7 days following day 3 embryo transfer might predict pregnancy outcome in IVF

This prospective study investigated the predictive value of pregnancy outcomes with serum human chorionic gonadotropin (hCG) 7 days after day 3 embryo transfer (D3 ET), and whether estradiol (E2) and progesterone (P) improved the diagnostic efficiency. The study comprised 280 in vitro fertilization and embryo transfer (IVF-ET) cycles. Serum samples were obtained 7 days after D3 ET to measure hCG, E2, and P concentrations. Statistical analyses were conducted to evaluate the predictive value for pregnancy outcomes. We found significant differences in hCG level between pregnancy and non-pregnancy, viable and non-viable pregnancy, biochemical and viable pregnancy, as well as singleton and multiple pregnancy. An hCG cutoff value of 2.5 mIU/mL is predictive of pregnancy with a positive predictive value (PPV) of 95.9% and a negative predictive value (NPV) of 92.4%. An hCG value of 10.8 mIU/mL is predictive of a multiple pregnancy with an NPV of 98.1%. The area under the hCG curve between pregnancy and non-pregnancy was not improved by adding E2, P, or combined E2/P. Our results suggest a predictive value of pregnancy outcome with serum hCG drawn 7 days after D3 ET in IVF, and the diagnostic accuracy is not improved by adding measurements of E2/P.

Early maternal serum ß-human chorionic gonadotropin (ß-hCG) levels and sex-related growth difference of IVF embryos

PURPOSE

Maternal serum ß-human chorionic gonadotropin (ß-hCG) represents the trophoblastic cell mass and is an indirect measurement of embryo development at early implantation stage. Studies in animals and human embryos detected sex-related growth differences (SRGD) in favour of male embryos during the pre-implantation period. The purpose of our study was to correlate SRGD and maternal serum ß-hCG at 16 days after embryo transfer.

METHODS

We retrospectively analysed all (fresh and frozen) non-donor, single embryo transfers (SET), elective and not elective, that were performed between December 2008 and December 2013. We included ß-hCG values from day 16 after oocyte collection of pregnancies resulting in live birth. Neonatal gender was retrieved from patient files. Male and female embryos were further grouped to cleavage and blastocyst stage transfers. Regression analysis for confounding variables included maternal age, maternal body mass index (BMI), use of micromanipulation (ICSI), embryo quality (grade), assisted hatching, day of transfer and fresh or frozen embryo transfer.

RESULTS

Seven hundred eighty-six non-donor SETs resulted in live birth. After including only day 16 serum ß-hCG results, 525 SETs were analysed. Neonatal gender was available for 522 cases. Mean maternal serum ß-hCG levels were similar, 347 ± 191 IU/L in the male newborn group and 371 ± 200 IU/L in the female group. The difference between ß-hCG levels remained insignificant after adjusting for confounding variables.

CONCLUSIONS

Early maternal ß-hCG levels after embryo transfers did not represent SRGD in our study.

The prevention of ovarian hyperstimulation syndrome

OBJECTIVE

To review the clinical aspects of ovarian hyperstimulation syndrome and provide recommendations on its prevention.

OPTIONS

Preventative measures, early recognition, and prompt systematic supportive care will help avoid poor outcomes.

OUTCOMES

Establish guidelines to assist in the prevention of ovarian hyperstimulation syndrome, early recognition of the condition when it occurs, and provision of appropriate supportive measures in the correct setting.

EVIDENCE

Published literature was retrieved through searches of Medline, Embase, and the Cochrane Library from 2011 to 2013 using appropriate controlled vocabulary ([OHSS] ovarian hyperstimulation syndrome and: agonist IVF, antagonist IVF, metformin, HCG, gonadotropin, coasting, freeze all, agonist trigger, progesterone) and key words (ovarian hyperstimulation syndrome, ovarian stimulation, gonadotropin, human chorionic gonadotropin, prevention). Results were restricted to systematic reviews, randomized control trials/controlled clinical trials, and observational studies published in English. There were no date restrictions. Searches were updated on a regular basis and incorporated in the guideline to February 2013. Grey (unpublished) literature was identified through searching the websites of health technology assessment and health technology-related agencies, clinical practice guideline collections, clinical trial registries, and national and international medical specialty societies.

VALUES

The quality of evidence in this document was rated using the criteria described in the Report of the Canadian Task Force on Preventive Health Care (Table 1). Summary Statements 1. The particular follicle-stimulating hormone formulation used for ovarian stimulation does not affect the incidence of ovarian hyperstimulation syndrome. (I) 2. Coasting may reduce the incidence of severe ovarian hyperstimulation syndrome. (III) 3. Coasting for longer than 3 days reduces in vitro fertilization pregnancy rates. (II-2) 4. The use of either luteinizing hormone or human chorionic gonadotropin for final oocyte maturation does not influence the incidence of ovarian hyperstimulation syndrome. (I) 5. There is no clear published evidence that lowering the human chorionic gonadotropin dose will result in a decrease in the rate of ovarian hyperstimulation syndrome. (III) 6. Cabergoline starting from the day of human chorionic gonadotropin reduces the incidence of ovarian hyperstimulation syndrome in patients at higher risk and does not appear to lower in vitro fertilization pregnancy rates. (II-2) 7. Avoiding pregnancy by freezing all embryos will prevent severe prolonged ovarian hyperstimulation syndrome in patients at high risk. (II-2) 8. Pregnancy rates are not affected when using gonadotropin-releasing hormone (GnRH) agonists in GnRH antagonist protocols for final egg maturation when embryos are frozen by vitrification for later transfer. (II-2) Recommendations 1. The addition of metformin should be considered in patients with polycystic ovarian syndrome who are undergoing in vitro fertilization because it may reduce the incidence of ovarian hyperstimulation syndrome. (I-A) 2. Gonadotropin dosing should be carefully individualized, taking into account the patient's age, body mass, antral follicle count, and previous response to gonadotropins. (II-3B) 3. Cycle cancellation before administration of human chorionic gonadatropin is an effective strategy for the prevention of ovarian hyperstimulation syndrome, but the emotional and financial burden it imposes on patients should be considered before the cycle is cancelled. (III-C) 4. Gonadotropin-releasing hormone (GnRH) antagonist stimulation protocols are recommended in patients at high risk for ovarian hyperstimulation syndrome (OHSS). The risk of severe OHSS in patients on GnRH antagonist protocols who have a very robust ovarian stimulation response can be reduced by using a GnRH agonist as a substitute for human chorionic gonadotropin to trigger final oocyte maturation. (I-B) 5. A gonadotropin-releasing hormone (GnRH) antagonist protocol with a GnRH agonist trigger for final oocyte maturation is recommended for donor oocyte and fertility preservation cycles. (III-C) 6. Albumin or other plasma expanders at the time of egg retrieval are not recommended for the prevention of ovarian hyperstimulation syndrome. (I-E) 7. Elective single embryo transfer is recommended in patients at high risk for ovarian hyperstimulation syndrome. (III-C) 8. Progesterone, rather than human chorionic gonadotropin, should be used for luteal phase support. (I-A) 9. Outpatient culdocentesis should be considered for the prevention of disease progression in severe ovarian hyperstimulation syndrome. (II-2B).

Effect of vitrification versus slow freezing of human day 3 embryos on β-hCG levels

PURPOSE

The study was designed to investigate the effect of vitrification and slow freezing for the cryopreservation of human day 3 embryos on serum β-hCG levels in pregnancies established after frozen embryo transfer (FET).

METHODS

Of the 1384 FET cycles initiated, 1131 embryo transfers met study criteria and assigned to one of two groups: 797 slow-freezing embryo transfers or 334 vitrified embryo transfers. Median values of β-hCG and outcome of all pregnancies were compared between the two groups. Predictive values of serum β-hCG on day 12 after embryo transfer for establishing ongoing pregnancy and pregnancy failure were determined by receiver operating characteristic (ROC) curve analysis.

RESULTS

In the slow-freezing group, 383 ongoing pregnancies occurred (48.1 %), and transfers of vitrified embryos resulted in 154 pregnancies (46.1 %). Median β-hCG values (279.2 IU/L) for ongoing pregnancies after transfer of vitrified embryos were significantly lower than that of slow frozen embryos (320.5 IU/L). The median values of β-hCG for singleton in the two groups was statistically significant (P <0.05). For slow-freezing embryo transfers, the cut-off value of β-hCG in predicting ongoing pregnancy was 147 IU/L (sensitivity 88.3 %, specificity 80.7 %). For vitrified embryo transfers, the value was 135 IU/L (sensitivity 84.4 %, specificity 76.3 %).

CONCLUSIONS

Day 12 β-hCG levels after FET are significantly affected by the methods of embryo cryopreservation for ongoing pregnancies. Furthermore, when using β-hCG cut-off value to assess pregnancy outcome, the cryopreservation methods should be taken into account.

Hyperglycosylated human chorionic gonadotropin as an early predictor of pregnancy outcomes after in vitro fertilization

OBJECTIVE

To determine whether serum hyperglycosylated human chorionic gonadotropin (hhCG) measured as early as 9 days after egg retrieval can predict ongoing pregnancies after in vitro fertilization and fresh embryo transfer (IVF-ET).

DESIGN

Cohort

SETTING

Academic assisted reproduction center.

PATIENT(S)

Consecutive patients undergoing IVF-ET INTERVENTION(S): Serum hhCG and hCG levels measured 9 (D9) and 16 (D16) days after egg retrieval

MAIN OUTCOME MEASURE(S)

Ongoing pregnancy beyond 9 weeks of gestation.

RESULT(S)

Ongoing pregnancy (62 of 112 participants) was associated with higher D9 levels of hhCG and hCG. However, hhCG was detectable in all D9 OP samples, while hCG was detectable in only 22%. A D9 hhCG level of >110 pg/mL was 96% specific for an ongoing pregnancy, yielding a positive predictive value of 94%. Compared with the D9 hCG levels, hhCG was more sensitive and had a larger area under the curve (0.87 vs. 0.67, respectively). The diagnostic test characteristics were similar between the D16 hhCG and hCG levels.

CONCLUSION(S)

In patients undergoing assisted reproduction, a test to detect pregnancy early and predict outcomes is highly desirable, and hhCG is detectable in serum 9 days after egg retrieval IVF-ET cycles. In this early assessment, hhCG was superior to traditional hCG and highly predictive of ongoing pregnancies.

Human chorionic gonadotropin levels are equally predictive for pregnancy outcome after fresh and vitrified-warmed blastocyst transfer

PURPOSE

The aim of the present study was to evaluate if the live birth predictive values of β-hCG levels differ in fresh and vitrified-warmed blastocyst transfer cycles.

METHODS

In the retrospectively designed study, 775 cycles with positive β-hCG values 13 days after fresh blastocyst transfer (fresh ET; n = 568) or vitrified-warmed blastocyst transfer (FET; n = 207) were selected for analysis. Average β-hCG levels stratified according to pregnancy outcome (biochemical pregnancy, spontaneous abortion, ectopic pregnancy, and singleton or twin birth) were compared between fresh ET and FET cycles. To determine the optimal sensitivity and specificity of β-hCG levels for live birth prediction, a ROC curve was constructed. Fisher's exact test was used to compare the positive predictive values (PPV).

RESULTS

Average β-hCG levels stratified according to pregnancy outcome were not statistically different between fresh ET and FET cycles. In fresh ET and in FET group, the β-hCG levels were significantly higher in pregnancies resulting in live birth compared to non-viable pregnancies (1,035 vs. 462 IU/L, p < 0.001 and 968 vs. 411 IU/L, p < 0.001). Optimal cut-off level for live birth prediction was 495 IU/L (sensitivity 83.0 %, specificity 71.8 %) after ET and 527 IU/L (sensitivity 80.0 % and specificity 76.6 %) after FET. The PPV for live birth rate in the groups after ET and FET were 90.6 % and 84.9 % respectively, without statistically significant difference (p > 0.05).

CONCLUSION

Beta-hCG levels after fresh and vitrified-warmed blastocyst transfer are equally predictive for pregnancy outcome. Clinicians can be encouraged to interpret β-hCG results in the same manner.