Evaluation of an optimal luteal phase support protocol in IVF

Luteal Phase Support in IVF: Comparison Between Evidence-Based Medicine and Real-Life Practices

Background: Luteal phase support (LPS) in assisted reproduction cycles has been widely investigated in recent years. Although progesterone represents the preferential product for luteal phase supplementation in cycles with fresh embryo transfer, there is ongoing debate as to when to start, which is the best route, dosage and duration, and whether there is a place for additional agents. Nevertheless, fertility specialists do not always adhere to evidence-based recommendations in their clinical practice. The aim of this worldwide web-based survey is to document the currently used protocols for luteal phase support and appraisal tendencies of drug prescription behavior and to compare these to the existing evidence-based literature. Material and Methods: A questionnaire was developed and sent by secure e-mail to 1,480 clinicians involved in ART worldwide. One hundred and forty-eighth clinicians from 34 countries returned completed questionnaires. Results: Progesterone support is usually started on the day of oocyte retrieval. Eighty percent of clinicians applied the administration of vaginal progesterone only. Intramuscular progesterone was prescribed by 6%, while oral progestin or subcutaneous progesterone were each prescribed by 5% of clinicians, respectively. Progesterone was administered until 8-10 weeks' gestation by 35% and 12 weeks by 52% of respondents. Conclusions: Vaginal administration was the preferred route for luteal phase support. The reported emerging use of the oral route confirms the expected shift in clinical practice as a result of recent evidence showing a reassuring safety score of oral progestins. In spite of the lack of evidence supporting the continuation of luteal support until 12 weeks' gestation, this practice was adhered to by more than half of the clinicians surveyed, highlighting the difference between evidence-based medicine and real-life practices.

Patient experience in a randomized trial of a weekly progesterone vaginal ring versus a daily progesterone gel for luteal support after in vitro fertilization

OBJECTIVE

To assess patient experience and convenience of using progesterone vaginal ring (VR) versus vaginal gel for women requiring luteal phase support during in vitro fertilization (IVF).

DESIGN

Post hoc analysis of a prospective, randomized, single-blind, multicenter, phase 3 clinical trial.

SETTING

Twenty-two U.S. IVF centers.

PATIENT(S)

Women undergoing IVF (N = 1,297).

INTERVENTION(S)

Randomization to weekly VR or daily gel the day after egg retrieval for up to 10 weeks, with fresh embryo transfer IVF per site-specific procedures.

MAIN OUTCOME MEASURE(S)

Patient satisfaction questionnaire completed at final study visit.

RESULT(S)

In the women who were taking ≥1 dose of either VR (n = 647) or gel (n = 650), >97% reported that learning to use the formulation, remembering to take it at the correct time, and using it as prescribed was "easy" or "somewhat easy." More VR than gel users reported noninterference with daily activity (93.3% vs. 74.7%, P<.001), sexual comfort (80.3% vs. 67.8%, P<.001), and sexual desire (73.8% vs. 61.8%, P<.001), as well as not being bothered during sexual intercourse (66.9% vs. 39.2%, P<.001). More gel than VR users reported no difficulty with application (97.4% vs. 80.9%, P<.001). Among women who had previously used progesterone during IVF, more VR users than gel users preferred their currently assigned treatment to their previous treatment (91.4% vs. 83.0%, P=.03).

CONCLUSION(S)

Weekly progesterone VR and daily progesterone gel were easy to use, with limited impact on quality of life. Overall, the VR appeared to interfere less with daily life, social activities, and sexual activity although the gel was less difficult or stressful to apply.

CLINICAL TRIAL REGISTRATION NUMBER

NCT00615251.

Luteal-phase progesterone supplementation in non-IVF treatment: a survey of physicians providing infertility treatment

We sought to examine current use of, and indications for, progesterone supplementation in the luteal phase of non-in vitro fertilization (non-IVF) infertility treatments among Obstetrician Gynaecologists (OB/GYN) compared to Reproductive Endocrinology and Infertility (REI) Subspecialists. Using a web-based survey, the practices of U.S. REI and OB/GYN physicians practicing infertility from 2014-2016 were assessed. The main outcome measures were frequency of use and indications for progesterone supplementation for luteal-phase support in non-IVF infertility treatments. Comparisons between physicians groups by indication and treatment type were performed using Chi-square and Fisher's exact tests. Sixty-four REIs and 49 OB/GYNs completed the survey. One hundred per cent of REI and 73.5% of OB/GYN respondents prescribed progesterone for luteal-phase support as part of non-IVF infertility treatment. The majority of all respondents utilized progesterone supplementation for one or more indications in clomiphene citrate and letrozole treatment cycles. Treatment type was the primary decisional factor reported by REIs (56%) for prescription of luteal-phase progesterone support. Serum progesterone level was reported as the leading decisional factor for luteal-phase supplementation (66.7%) by OB/GYNs. Luteal-phase progesterone supplementation in non-IVF treatments appears common for both physician groups in the United States in spite of lack of evidence supporting its effectiveness.

Impact of luteal phase support with vaginal progesterone on the clinical pregnancy rate in intrauterine insemination cycles stimulated with gonadotropins: a randomized multicenter study

OBJECTIVE

To evaluate the effect of luteal phase support (LPS) in intrauterine insemination (IUI) cycles stimulated with gonadotropins.

DESIGN

Randomized multicenter trial.

SETTING

Academic tertiary care centers and affiliated secondary care centers.

PATIENT(S)

Three hundred and ninety-three normo-ovulatory patients, <43 years, with body mass index ≤30 kg/m², in their first IUI cycle, with at least one patent tube, a normal uterine cavity, and a male partner with total motile sperm count ≥5 million after capacitation.

INTERVENTION(S)

Gonadotropin stimulation, IUI, randomization to LPS using vaginal progesterone gel (n = 202) or no LPS (n = 191).

MAIN OUTCOME MEASURE(S)

Clinical pregnancy rate, live-birth rate, miscarriage rate, and duration of the luteal phase.

RESULT(S)

The primary outcome, the clinical pregnancy rate, was not statistically different between the treatment group (16.8%) and the control group (11%) (relative risk [RR] 1.54; 95% confidence interval [CI], 0.89-2.67). Similarly, the secondary outcome, the live-birth rate, was 14.9% in the treatment group and 9.4% in the control group (RR 1.60; 95% CI, 0.89-2.87). The mean duration of the luteal phase was about 2 days longer in the treatment group (16.6 ± 2.2 days) compared with the control group (14.6 ± 2.5 days) (mean difference 2.07; 95% CI, 1.58-2.56).

CONCLUSION(S)

Although a trend toward a higher clinical pregnancy rate as well as live-birth rate was observed in the treatment group, the difference with the control group was not statistically significant.

CLINICAL TRIAL REGISTRATION NUMBER

NCT01826747.

Progesterone supplementation in the frozen embryo transfer cycle

PURPOSE OF REVIEW

Currently, different modalities with regard to endometrial preparation for frozen-thawed embryo transfer (FTET) are used, the natural and artificial cycles being the most common approaches. This review is aimed to update the current knowledge about progesterone supplementation in both types of protocols.

RECENT FINDINGS

Natural cycle-frozen-thawed embryo transfer (NC-FTET) is the favored option for women with normal ovulatory menstrual cycles and may be programmed following two different protocols: the 'true NC-FTET', associated with daily blood or urine luteinizing hormone measurements, and 'modified NC-FTET', triggering ovulation with human chorionic gonadotropin. Both methods of endometrial preparation show comparable reproductive outcomes. In artificial cycle-frozen-thawed embryo transfer, estrogen and progesterone are sequentially administered, being the option of choice for women with irregular menstrual cycles. Nowadays, no differences between the different formulations of progesterone have been observed. Furthermore, there seems to be no agreement on doses and duration of progesterone supplementation during FTET.

SUMMARY

We conclude that, according to the current available data, there is no superiority of any one regimen over another with regard to reproductive outcomes. Therefore, the final decision must be based on individualization of the treatment while considering patient characteristics prior to FTET, convenience, optimization of clinical outcomes and cost efficiency of the procedure.

Progesterone vaginal ring for luteal support

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

Duration of luteal support after IVF is important, so why is there no consistency in practice? The results of a dynamic survey of practice in the United Kingdom

Luteal support is considered as an essential component of IVF treatment following ovarian stimulation and embryo transfer. Several studies have consistently demonstrated a benefit of luteal support compared with no treatment and whilst a number of preparations are available, no product has been demonstrated as superior. There is an emerging body of evidence which suggests that extension of luteal support beyond biochemical pregnancy does not confer a benefit in terms of successful pregnancy outcome. We performed two surveys separated by 5 years of practice evolution, with the latter reporting on the use of luteal support in all IVF clinics in the UK. All clinics reported utilising luteal support with the majority favouring the use of Cyclogest 400 mg twice daily. In contrast, there was no consensus on the optimal duration of luteal support. Whilst 24% of clinics withdrew luteal support at biochemical confirmation of pregnancy, 40% continued treatment until 12 weeks gestation. Several clinics even extended luteal support beyond 12 weeks gestation. We observed no difference in practice based on the size of the IVF unit or treatment funding source. Although there was some change in practice between surveys in many clinics, there was no uniformity in the direction of change.

The Effects of Progesterone Therapy on the Gestation Length and Reduction of Neonatal Complications in Patients who had Received Tocolytic Therapy for Acute Phase of Preterm Labor

Background

While tocolytic therapy can halt the process of delivery, some patients return before the 37th week of pregnancy with recurrence of preterm labor signs.

Objectives

This study was designed to evaluate the efficacy of progesterone in the prolonging of gestation and reduction of neonatal complications.

Material and Methods

In a clinical trial in 2010, 110 singleton pregnant women admitted at Imam Reza Hospital, Mashhad, Iran, with the diagnosis of preterm labor were divided into three groups: 400 mg/d vaginal progesterone suppositories; 250 mg/w 17-alpha-hydroxyl-progestrone-caproate; and a control group with no additional treatment. After delivery, we assessed the duration between the first phases of labor to the recurrence of preterm labor. The neonatal complications, apgar score, birth weight, need for admission to NICU, and congenital malformations were compared between groups.

Results

The mean gestational age was 34± 3 weeks in the first, 33.5 ± 3 weeks in the second and 32.5 ± 2 weeks in the control group. The duration of first phase of labor was 31 ± 17 days in the first, 36 ± 14 days in the second and 26 ± 22 days in the control group. The difference between study groups and the control group was significant (P < 0.005). The complications were lower in progesterone-receiving group in comparison to the control group.

Discussion

This study reveals that progesterone can significant reduce the rate of recurrent preterm labor and the several possible neonatal complications among women who had treated with tocolytics to suppress the acute phase.

IVF and breast cancer: a systematic review and meta-analysis

BACKGROUND

The effects of controlled ovarian hyperstimulation (COH) for IVF in terms of breast cancer risk remain controversial, despite the hormone-dependent nature of the latter.

METHODS

Eligible studies up to 15 February 2013 were identified and pooled effect estimates for relative risk (RR) were calculated separately for the investigations using the general population and those using infertile women, as a reference group. Fixed- or random-effects models were implemented and subgroup analyses were performed, as appropriate.

RESULTS

Eight cohort studies were synthesized, yielding a total cohort size of 1,554,332 women among whom 14,961 incident breast cancer cases occurred, encompassing 576 incident breast cancer cases among women exposed to IVF. No significant association between IVF and breast cancer was observed either in the group of studies treating the general population (RR = 0.91, 95% confidence interval (CI): 0.74-1.11) or infertile women (RR = 1.02, 95% CI: 0.88-1.18), as a reference group. Of note were the marginal associations, protective for pregnant and/or parous women after IVF (pooled effect estimate = 0.86, 95% CI: 0.73-1.01) and adverse for women <30 years at first IVF treatment (pooled effect estimate = 1.64, 95% CI: 0.96-2.80).

CONCLUSIONS

At present, COH for IVF does not seem to impart increased breast cancer risk. Longer follow-up periods, comparisons versus infertile women, subgroup analyses aiming to trace vulnerable subgroups, adjustment for various confounders and larger informative data sets are needed before conclusive statements for the safety of the procedure are reached.

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.

The optimal duration of progesterone supplementation in pregnant women after IVF/ICSI: a meta-analysis

can improve the rates of clinical pregnancy and live birth, but the optimal duration of treatment remains controversial. The objective of this meta-analysis was to investigate the effects of early progesterone cessation on pregnancy outcomes in women undergoing IVF/ICSI.

METHODS

We searched MEDLINE, EMBASE, the Cochrane Central Register of Controlled Trials (CENTRAL), the Chinese biomedicine (CBM) literature database, and the Wanfang database. The final search was performed in July 2012. All available randomised trials that compared the effects of early progesterone cessation with progesterone continuation during early pregnancy after IVF/ICSI were included. The main outcome measures were live birth rate, miscarriage rate and ongoing pregnancy rate. Fixed or random-effects models were chosen to calculate the risk ratio (RR).

RESULTS

Six eligible studies with a total of 1,201 randomised participants were included in the final analysis. No statistically significant differences were detected between patients who underwent early progesterone cessation and those who received progesterone continuation for luteal phase support in terms of live birth rate (RR: 0.95, 95% CI: 0.86-1.05), miscarriage rate (RR: 1.01, 95% CI: 0.74-1.38) or ongoing pregnancy rate (RR: 0.97, 95% CI: 0.90-1.05). These results did not change after a sensitivity analysis.

CONCLUSIONS

The currently available evidence suggests that progesterone supplementation beyond the first positive hCG test after IVF/ICSI might generally be unnecessary, although large-scale randomised controlled trials are needed to strengthen this conclusion.

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

Background

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

Design

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

Discussion

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

Trial registration

ISRCTN05696887

Early progesterone cessation after in vitro fertilization/intracytoplasmic sperm injection: a randomized, controlled trial

OBJECTIVE

To investigate the effect of stopping progesterone (P) support at week 5 versus week 8 on ongoing pregnancy rate after in vitro fertilization (IVF)/intracytoplasmic sperm injection (ICSI).

DESIGN

Prospective, randomized, controlled trial.

SETTING

University-affiliated infertility center.

PATIENT(S)

A total of 220 patients with intrauterine pregnancy demonstrated by transvaginal ultrasound after IVF/ICSI.

INTERVENTION(S)

Luteal phase support with micronized vaginal P was suspended at week 5 or at week 8.

MAIN OUTCOME MEASURE(S)

Ongoing pregnancy rate, miscarriage rate, and number of bleeding episodes.

RESULT(S)

Progesterone levels were similar on the day of the first pregnancy ultrasound exam (149 ± 108 vs. 167 ± 115 ng/mL). Significantly more bleeding episodes were observed in the first trimester in the group with early cessation of P supplementation (18.0 ± 2.6 vs. 7.2 ± 1.3 episodes). Miscarriage rates among singleton pregnancies were similar in the two groups (5/80 vs. 6/79).

CONCLUSION(S)

Vaginal P supplementation after IVF/ICSI can be safely withdrawn at 5 weeks' gestation, because cycle outcome was similar to conventional luteal phase support up to 8 weeks of pregnancy.

CLINICAL TRIAL REGISTRATION NUMBER

NCT01177904.

Progesterone support in IVF: is evidence-based medicine translated to clinical practice? A worldwide web-based survey

This worldwide web-based survey compared the clinical practice for luteal-phase supplementation (LPS) in stimulated IVF cycles to the current evidence-based literature. Eighty-four treatment centres in 35 countries, representing a total of 51,155 IVF cycles/year, responded. Vaginal progesterone alone was used for LPS in 64% of cycles and in another 16% of cycles in combination with either i.m. (15%) or oral progesterone (1%). As a single agent, i.m. progesterone was used in 13% of cycles, oral progesterone in another 2% and human chorionic gonadotrophin (HCG) was still used in 5% of cycles. Progesterone was administered until 10-12 weeks' gestation in 67% of cycles and in 22% and 12% it was discontinued when fetal heart pulsations are recognized or until βHCG was positive, respectively. In conclusion, in almost two-thirds of the assisted cycles represented in this survey, vaginal administration of progesterone is preferred for LPS. Nevertheless, despite the available literature on the disadvantages of oral progesterone, i.m. progesterone and HCG for LPS, these agents are still used routinely by many practitioners. Furthermore, although there is no firm evidence to support the continuation of LPS until 10-12 weeks' gestation, this practice is used in the majority of IVF cycles worldwide.

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.

Prospective randomized study comparing luteal phase support for ICSI patients up to the first ultrasound compared with an additional three weeks

BACKGROUND

There is a consensus that administration of progesterone to women after IVF for luteal phase support (LPS) is associated with a higher ongoing pregnancy rate. However there are few studies, including only one randomized study, which have examined the optimal duration of LPS.

METHODS

A questionnaire concerning details of LPS was returned from 21 leading IVF centres. We then randomized 257 women, who were pregnant after ICSI on day of first ultrasound, into two groups: to continue LPS for three more weeks or to stop on the day of ultrasound.

RESULTS

The duration of LPS in the questionnaire varied from the day of positive pregnancy test up to 12 weeks of pregnancy in different centres. In the randomized study, 132 patients in Group A continued LPS for 3 weeks after first ultrasound, whereas 125 patients in Group B stopped LPS on day of first ultrasound. After confirming pulsations, the miscarriage rate up to 20 weeks of gestation was 4.6% (6/132) in group A and 4.8% (6/125) in group B [odds ratios (OR) = 0.94; 95% confidence intervals (CI) = 0.3-3.1]. Bleeding episodes were 15.9% in Group A compared with 20.8% in group B (OR = 0.72; 95% CI = 0.38-1.36).

CONCLUSIONS

There is no international consensus about the duration of LPS; our single-centre randomized trial did not support extending the LPS beyond the day of first ultrasound demonstrating echoes and pulsations. Trials registry number-ISRCTN: 88722916.

An update of luteal phase support in stimulated IVF cycles

Stimulated IVF cycles are associated with luteal phase defect. In order to overcome this, different doses, durations and types of luteal phase support (LPS) have been evaluated. There is still no agreement regarding the optimal supplementation scheme. The aim of this paper is to assess the past and the current clinical practices of luteal supplementation in IVF. The databases of Medline and PubMed were searched to identify relevant publications. LPS with human chorionic gonadotrophin (hCG) [n=262, odds ratio (OR) 2.72 (95%), confidence interval (CI) 1.56-4.90, P<0.05] or progesterone (n=260, OR 1.57 CI 1.13, 2.17, P<0.05) results in an increased pregnancy rate compared with placebo, however, hCG is associated with increased risk of ovarian hyperstimulation syndrome. Natural micronized progesterone is not efficient if taken orally. The data on oral dydrogesterone are still conflicting. Vaginal and intra muscular progesterone have comparable outcomes. The addition of estradiol (E2) seems to be beneficial in long GnRH agonist protocol (implantation rate 39.6% with E2 compared with no E2; P<0.05) but not in the short GnRH agonist and GnRH antagonist protocol. Despite the early promising results, it is too early to recommend the use of GnRH agonist in LPS. LPS should cease on the day of positive HCG. Since the cause of luteal phase defect in IVF appears to be related to the supraphysiological levels of steroids, milder stimulation protocols should be advocated in order to eventually overcome the luteal phase defect.

Comparison between two forms of vaginally administered progesterone for luteal phase support in assisted reproduction cycles

The use of progesterone for luteal phase support has been demonstrated to be beneficial in assisted reproduction cycles using gonadotrophin-releasing hormone analogues (GnRHa). Two micronized progesterone preparations are available for vaginal administration: capsules and gel. The objective of this study was to compare the efficacy of these two forms for luteal phase support in assisted reproduction cycles. A total of 244 couples undergoing IVF/intracytoplasmic sperm injection cycles were included in the study and were randomly allocated (sealed envelopes) into two groups: group 1 (122) received vaginal capsules of 200 mg of micronized progesterone (Utrogestan), 3 times daily, and group 2 (122) received micronized progesterone in gel (Crinone 8%), once daily. Both groups received progesterone for 13 days beginning day 1 after oocyte retrieval, continuing until the pregnancy test was performed and until 12 weeks of pregnancy. Groups were compared by clinical data and assisted reproduction results and had similar ages and causes of infertility. Although the pregnancy rate was higher for those receiving progesterone gel than capsules (44.26 and 36.06% respectively), this difference was not statistically significant. The study showed that vaginal progesterone gel and capsules used for luteal phase support in assisted reproduction cycles with long protocol GnRHa result in similar pregnancy rates.

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

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

Downregulation of Human Endometrial IL-18 by Exogenous Ovarian Steroids

PROBLEM

To evaluate the influence of ovarian steroids on IL-18, IL-15 and angiopoietin-2 mRNA expression in the endometrium in the mid luteal phase.

METHOD OF STUDY

We quantified IL-18/GAPDH, IL-18 BP/GAPDH, IL-15/GAPDH and angiopoietin-2/GAPDH in the endometrium by quantitative polymerase chain reaction on day 21 of the cycle. We first compared cytokines expression over two natural cycles (n = 15) then between natural and oestrogen-progestin replacement treatment (n = 18).

RESULTS

Endometrial IL-18, IL-18 BP, IL-15 and angiopoietin-2 mRNA expression did not change over two natural cycles. Addition of exogenous hormones significantly decreased IL-18 and IL-18 BP mRNA expression but not influence IL-15 or angiopoietin-2 ratios. This was also observed with immunohistochemistry.

CONCLUSION

Exogenous oestro-progestative hormones influence endometrial IL-18 system expression involved in angiogenesis and in the uterine natural killer (uNK) cell activation pathway during the implantation process.

Addition of estradiol to progesterone for luteal supplementation in patients stimulated with GnRH antagonist/rFSH for IVF: a randomized controlled trial

BACKGROUND

The role of progesterone for luteal support in stimulated cycles for IVF is well established. However, controversy still surrounds the benefit of additional supplementation with estradiol (E2) in GnRH agonist (GnRHa) cycles, while no such data are available for GnRH antagonists. The aim of this randomized controlled trial (RCT) was to compare ongoing pregnancy rates in patients stimulated with recombinant FSH (rFSH) and GnRH antagonist for IVF, who received micronized progesterone for luteal phase supplementation, with or without the addition of E2.

METHODS

Two hundred and one patients underwent ovarian stimulation with a fixed dose of 200 IU rFSH and GnRH antagonist. Patients were randomized to receive, for luteal phase supplementation, either 600 mg of micronized progesterone vaginally (n=100, progesterone group) or 600 mg of micronized progesterone and 4 mg of E2 valerate orally (n=101, progesterone/E2 group). The main outcome measure was ongoing pregnancy at 12 weeks per patient randomized.

RESULTS

Demographics, stimulation parameters and embryological data were comparable for the two groups compared. Twenty-six ongoing pregnancies were achieved in the progesterone (26%) and 30 in the progesterone/E2 group (29.7%). (Difference: 3.7 and 95%, CI: -15.8 to 8.6%).

CONCLUSION

It appears that the addition of E2 to progesterone in the luteal phase after stimulation with rFSH and GnRH antagonist does not enhance the probability of pregnancy.

Oral dydrogesterone versus intravaginal micronised progesterone as luteal phase support in assisted reproductive technology (ART) cycles: results of a randomised study

The objective of this prospective, randomised study was to compare the efficacy, safety and tolerability of vaginal micronised progesterone with oral dydrogesterone as luteal phase support after in-vitro fertilisation (IVF). A total of 430 women underwent IVF/intracytoplasmic sperm injection (ICSI) treatment. Long protocol gonadotropin releasing hormone analogue down-regulation was followed by gonadotropin stimulation. Human chorionic gonadotropin was given when two or more follicles reached > or = 17 mm. After 36 h, oocytes were retrieved and IVF was performed. Embryo transfer was done at the 4-8 cell embryo stage. Luteal support was initiated from the day of embryo transfer and continued for up to 14 days. Patients were randomised to luteal supplementation with either intravaginal micronised progesterone 200 mg three times daily (n=351) or oral dydrogesterone 10 mg twice daily (n=79). In cases of a positive pregnancy test, luteal support was continued for 12 weeks. Both dydrogesterone and micronised progesterone were associated with similar rates of successful pregnancies. Vaginal discharge or irritation were reported by 10.5% of patients given micronised progesterone. Significantly (p<0.05), more patients given dydrogesterone than micronised progesterone were satisfied with the tolerability of their treatment. There were no differences between the treatments with regard to liver function tests.

Luteal Phase Support in in vitro Fertilization: Meta-Analysis of Randomized Trials

OBJECTIVE

To determine if luteal phase support improves the pregnancy rate in in vitro fertilization (IVF) cycles.

DESIGN

A meta-analysis of randomized trials of luteal phase support was carried out with the main outcome measure being the pregnancy rate per cycle.

RESULTS

Fifty-nine trials were evaluated. Eighteen trials met the inclusion criteria. Five main themes were identified: human chorionic gonadotropin (hCG) versus progesterone; progesterone versus progesterone and hCG; progesterone versus placebo; hCG versus placebo, and hCG versus progesterone versus no support.

CONCLUSION

Luteal phase support is definitely indicated in IVF treatment cycles. This meta-analysis favored hCG above progesterone as luteal phase support with respect to pregnancy rates. Further prospective randomized trials are needed to determine a definite consensus with respect to the duration of luteal phase support in IVF cycles.

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

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

The Evolution of in Vitro Fertilization: Integration of Pharmacology, Technology, and Clinical Care

For the couple having trouble achieving pregnancy, the options and opportunities for assistance have never been brighter. Options such as controlled ovarian hyperstimulation, in vitro fertilization, and intracytoplasmic sperm injection have been developed over the past five decades and provide hope for couples that previously would have been considered infertile. In vitro fertilization and intracytoplasmic sperm injection represent a coalescence of advances in physiology, endocrinology, pharmacology, technology, and clinical care. In vitro fertilization has assisted well over one million couples in their efforts to start or build a family, and the demand for such services continues to increase. The purpose of this manuscript is to review the pharmacological advances that made controlled ovarian hyperstimulation, and therefore in vitro fertilization and intracytoplasmic sperm injection, possible. We will discuss the early stages of gonadotropin use to stimulate ovarian production of multiple mature eggs, the advances in recombinant technology that allowed purified hormone for therapy, and the use of other hormones to regulate the menstrual cycle such that the likelihood of successful oocyte retrieval and embryo implantation is optimized. Finally, we will review current areas that require particular attention if we are to provide more opportunity for infertile couples.

Role of the endometrial tripod interleukin-18, -15, and -12 in inadequate uterine receptivity in patients with a history of repeated in vitro fertilization–embryo transfer failure

OBJECTIVE

To document in the endometrium the correlation among the interleukin (IL)-12, -15, and -18 mRNA and the correlation between cytokine levels, vascular status, and endometrial natural killer (NK) cell count in the context of recurrent implantation failure.

DESIGN

A pilot study.

SETTING

Department of Reproductive Immunology.

PATIENT(S)

Women who failed to become pregnant after repeated IVF-embryo transfer and fertile control subjects.

INTERVENTION(S)

Ultrasonic evaluation and endometrial biopsy in luteal phase.

MAIN OUTCOME MEASURE(S)

Uterine artery Doppler, count of uterine CD56 bright cells/field, and quantification by real-time polymerase chain reaction (PCR) to monitor IL-12 family (IL-12p40, IL-12p35, EBI3, IL-23), the IL-18 system (IL-18, IL-18R, IL18BP), and the IL-15 mRNA ratio.

RESULT(S)

The uterine artery Doppler and the CD56 bright cell counts were significantly different in fertile and infertile patients. The mean uterine artery pulsatility index correlated significantly negatively with the IL-18/actin ratio suggesting a defect of the cytokine-dependent vascular remodeling pathway. The number of uterine CD56 bright cells was significantly correlated with the IL-15/actin and IL-18/IL-18BP ratios. Thus, IL-18 and IL-15 seems to be involved in the local recruitment and the activation of uterine natural killer (uNK) cells. IL-18 was itself correlated with IL-15 and IL-12, suggesting a local control of uNK cells activation.

CONCLUSION(S)

The assessment of the tripod IL-12/-15/-18 shows distinct immune-related mechanisms that are involved in the broader context of inadequate uterine receptivity.

Phytoestrogens may improve the pregnancy rate in in vitro fertilization-embryo transfer cycles: a prospective, controlled, randomized trial

OBJECTIVE

To compare the effectiveness of i.m. P and i.m. P plus oral phytoestrogens for luteal phase support in patients undergoing IVF-ET cycles.

DESIGN

Prospective, controlled, randomized trial.

SETTING

University Hospital, Perugia, Italy.

PATIENT(S)

Two hundred thirteen infertile patients undergoing IVF-ET were included in the study. The inclusion criteria were use of a GnRH agonist for pituitary down-regulation and age <40 years. The total number of cycles performed was 274.

INTERVENTION(S)

Patients were assigned to receive either i.m. P (50 mg daily) plus placebo or P (50 mg daily) plus phytoestrogen supplementation (1,500 mg daily) for luteal phase support starting from the evening of oocyte retrieval until either a serum pregnancy test result was negative or embryonic heartbeat was sonographically confirmed.

MAIN OUTCOME MEASURE(S)

The outcomes of IVF-ET were evaluated in both study groups in terms of implantation rate, biochemical pregnancy rate (PR), clinical PR, spontaneous abortion rate, and ongoing pregnancy/delivered rate.

RESULT(S)

Statistically significant higher values for implantation rate, clinical PR, and ongoing pregnancy/delivered rate were recorded in the patients who received P plus phytoestrogens for luteal phase support in comparison with patients receiving P and placebo.

CONCLUSION(S)

Although the results of this study encourage the use of phytoestrogens for luteal phase support in patients undergoing IVF-ET program, more studies are necessary to support the hypothesis that phytoestrogens have a beneficial effect in IVF cycles.

Controlled natural in vitro fertilization may be an alternative for patients with repeated unexplained implantation failure and a high uterine natural killer cell count

Patients with a history of repeated and unexplained implantation failure after IVF-embryo transfer and a high uterine natural killer cell count during estrogen-progestin treatment may benefit from controlled natural IVF-ET.

A new role for natural killer cells, interleukin (IL)-12, and IL-18 in repeated implantation failure after in vitro fertilization

OBJECTIVE

To investigate the endometrial immunohistochemical staining of interleukin (IL)-12 and IL-18 and to quantify the CD56 bright natural killer (NK) cells in relation to Doppler vascular disorders.

DESIGN

Controlled clinical study.

SETTING

Research unit of a university hospital. PATIENT(S)": Thirty-five women with repeated implantation failure after ET in IVF and 12 fertile control patients.Ultrasound evaluation and endometrial biopsy on day 20.

MAIN OUTCOME MEASURE(S)

The balance between IL-12 and IL-18, the number of NK cells, and the vascular status among fertile and implantation failure patients.

RESULT(S)

The control patients displayed normal vascular parameters, a weak anti-IL-12 staining, a consistent moderate stromal anti-IL-18 staining, and fewer than 15 NK cells/field. This pattern was observed among only 17% (6/35) of the implantation failure group. The remaining patients fit into one of two patterns: [1] 37% (13/35) had more than 40 NK cells/field with a strong anti-IL-12 and/or anti-IL-18 staining, and [2] the remaining 46% (16/35) had a marked local depletion of IL-18 and IL-12. Respectively, 85% and 31% of two groups displayed abnormal vascular parameters.

CONCLUSION(S)

Distinctions between the different local dysregulations of the cytokine network may provide clues for further exploration and treatment.

Severe jaundice in early IVF pregnancy

Jaundice in early pregnancy after in vitro fertilization (IVF) is extremely rare. We report a case of severe jaundice in an IVF treated patient, with a clinical picture similar to intrahepatic cholestasis of pregnancy (ICP). We suggest strategies to prevent similar cases in the future.

Luteal support with vaginal micronized progesterone gel in assisted reproduction

The purpose of this study was to review the rationale for vaginal progesterone treatment as luteal support in IVF, and the clinical experience with vaginal micronized progesterone gel. It was found that luteal support with exogenous progesterone significantly improves implantation and pregnancy rates after IVF. Vaginal administration offers a number of potential advantages over intramuscular injection in terms of tolerability and convenience. The clinical experience with Crinone 8%, a vaginal gel containing 90 mg micronized progesterone in a polycarbophil base, indicates that the use of this preparation is associated with pregnancy rates comparable with those achieved after intramuscular administration of progesterone. Moreover, in studies in which patient preferences have been assessed, significantly higher preferences for vaginal micronized progesterone gel have been reported, compared with intramuscular administration or vaginal suppositories. In conclusion, the vaginal micronized progesterone gel used in this study provided effective and well-tolerated luteal support in women undergoing IVF.

Luteal phase support using either Crinone 8% or Utrogest: results of a prospective, randomized study

The Crinone 8% preparation makes it possible to administer natural progesterone (90 mg) vaginally once daily for luteal phase support (LPS). Until now, no prospective, randomized studies have directly compared this new preparation with widely used Utrogest capsules, which were originally designed for oral administration but are used routinely as a vaginal preparation. A prospective, randomized study investigated 126 patients undergoing cycles of in vitro fertilization (IVF) and IVF/intracytoplasmic sperm injection (ICSI). Patients received either Crinone 8% (n = 73) vaginally once daily or two Utrogest capsules (n=53) vaginally three times daily (600 mg). Clinical pregnancy rates were comparable (28.8 versus 18.9%), as were clinical abortion rates until 12 weeks of gestation (14.3 versus 10.0%) and clinical ongoing pregnancy rates (24.7 versus 17.0%) in the Crinone 8% and Utrogest groups, respectively. Forty-seven non-pregnant patients were randomly selected to answer questions regarding comfort during LPS. Crinone 8% had a clear advantage over Utrogest as it resulted in less vaginal discharge (P < 0.01) and fewer application difficulties (P<0.05). Twenty patients familiar with the alternative preparation from a previous cycle also noted that Crinone 8% was easier to apply (P < 0.01) and less time consuming (P < 0.05) to use than Utrogest.