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

Pre-ovulatory hormones on day of human chorionic gonadotropin trigger and assisted reproductive technique outcomes in different ovarian response groups

Background:

Aims:

Setting and Design:

Materials and Methods:

Statistical Analysis:

Results:

Conclusion:

The curious case of premature luteinization

PURPOSE

Premature luteinization (PL) affects 12.3-46.7% of fresh in vitro fertilization cycles, and there is accumulating evidence confirming its negative effect on success rates. However, despite its clinical significance, PL is poorly understood and defined. This narrative review aims to provide a fresh look at the phenomenon of PL by summarizing the existing evidence and re-evaluating fundamental issues.

METHODS

A thorough electronic search was conducted covering the period from 1978 until January 2018 in PubMed, Embase, and Medline databases, and references of relevant studies were cross-checked. Meeting proceedings of the European Society of Human Reproduction and Embryology and the American Society for Reproductive Medicine were also hand searched.

RESULTS

In the curious case of PL, one should go back to the beginning and re-consider every step of the way. The pathogenesis, definition, measurement methods, clinical implications, and management strategies are discussed in detail, highlighting controversies and offering "food for thought" for future directions.

CONCLUSIONS

Authors need to speak the same language when studying PL in order to facilitate comparisons. The terminology, progesterone cut-off, measurement methods and days of measurement should be standardized and globally accepted; otherwise, there can be no scientific dialog. Future research should focus on specific patient profiles that may require a tailored approach. Progesterone measurements throughout the follicular phase possibly depict the progesterone exposure better than an isolated measurement on the day of hCG. Adequately powered randomized controlled trials should confirm which the best prevention and management plan of PL is, before introducing any strategy into clinical practice.

Progesterone rise on hCG day is negatively correlated with IVF-ET outcomes in natural cycles

OBJECTIVE

To investigate the effect of progesterone rise on hCG day on the laboratory and clinical outcomes in natural cycles and to explore the possible factors related to the occurrence of progesterone elevation.

PATIENTS AND STUDY METHODS

Retrospective analysis was performed in 1157 infertile women with decreased ovarian reserve. Eligible infertile women undergoing IVF in natural cycles were assigned to four groups according to serum progesterone levels on the day of hCG administration: group 1, P<2nmol/L; group 2, 2<P<2.9nmol/L; group 3, 3<P<3.9nmol/L; group 4, P≥4.0nmol/L. Data on clinical outcomes and LH level were collected and analyzed.

RESULTS

Number of retrieved oocytes, pronucleus cells, fertilized cells, and good embryos significantly decreased (p<0.05). A significant elevation of cancelled cycle rate, early follicle elimination rate and LH level on hCG day occurred when the serum progesterone levels were higher than 4.0nmol/L on the day of hCG administration (p<0.05).

CONCLUSION

In natural cycles, progesterone rise on the day of hCG administration (in this study, P≥4.0nmol/L) may negatively correlated with the quality of oocytes and embryos.

Top quality blastocyst formation rates in relation to progesterone levels on the day of oocyte maturation in GnRH antagonist IVF/ICSI cycles

Cycles with progesterone elevation during controlled ovarian stimulation (COS) for IVF/ICSI are commonly managed with a "freeze-all" strategy, due to a well-recognized detrimental effect of high progesterone levels on endometrial receptivity. However, also a detrimental effect of elevated progesterone on day-3 embryo quality has recently been found with regards to top quality embryo formation rate. Because blastocyst culture and cryopreservation are largely adopted, we deemed relevant to determine whether this detrimental effect is also seen on blastocyst quality on day 5-6. This issue was investigated through a large two-center retrospective study including 986 GnRH antagonist IVF/ICSI cycles and using top quality blastocyst formation rate as the main outcome. Results showed that on multivariate analysis sperm motility (p<0.01) and progesterone levels at ovulation triggering (p = 0.01) were the only two variables that significantly predicted top quality blastocyst formation rate after adjusting for relevant factors including female age, BMI, basal AMH and total dose of FSH used for COS. More specifically, progesterone levels at induction showed an inverse relation with top quality blastocyst formation (correlation coefficient B = -1.08, 95% CI -1.9 to -0.02) and ROC curve analysis identified P level >1.49 ng/ml as the best cut-off for identification of patients at risk for the absence of top quality blastocysts (AUC 0.55, p<0.01). Our study is the first to investigate the top quality blastocyst formation rate in relation to progesterone levels in IVF/ICSI cycles, showing that increasing progesterone is associated with lower rates of top quality blastocyst. Hence, the advantages of prolonging COS to maximize the number of collected oocytes might eventually be hindered by a decrease in top quality blastocysts available for transfer, if increasing progesterone levels are observed. This observation extends the results of two recent studies focused on day-3 embryos and deserves further research.

Is it the egg or the endometrium? Elevated progesterone on day of trigger is not associated with embryo ploidy nor decreased success rates in subsequent embryo transfer cycles

PURPOSE

The purpose of our study was to determine if progesterone (P4) values on day of trigger affect certain cycle outcome parameters, ploidy status of embryos, as well as pregnancy outcomes in the subsequent first frozen embryo transfer cycle.

METHODS

Two hundred thirty-eight patients undergoing pre-gestational screening and freeze all protocol at our fertility center from 2013 to 2014 were included. Excluded patients were those whom had cancelled cycles prior to egg retrieval as well as cycles utilizing donor eggs. Once patients were identified as eligible for this study, frozen serum from the day of trigger was identified and analyzed using the Siemens Immulite 2000. Number of eggs retrieved, number of available embryos for biopsy, and number of euploid/aneuploid embryos were analyzed. The first frozen embryo transfer cycle was linked to the initial egg retrieval and outcomes including pregnancy rates, and live birth/ongoing pregnancy rates were calculated and analyzed. A discriminatory P4 value of 1.5 ng/ml was set. Group A had P4 values of less than 1.5 ng/ml and group B had P4 values greater than or equal to 1.5 ng/ml. T tests and chi-squared tests were used for statistical analysis.

RESULTS

Group A had an average trigger P4 value of 0.87 +/- 0.3 and group B had an average trigger P4 of 2.1 +/- 0.8. Table 1 shows the baseline characteristics of both group A and group B. The only significant difference between the two groups was total gonadotropin dosage (IU) with a p value of 0.02 and estradiol (pg/ml) at trigger, also with a p value of 0.02 (Table 1). Number of eggs retrieved, number of embryos biopsied, number euploid/aneuploid, and non-diagnosis embryos were all non-significant. Chi-square analysis was used to compare pregnancy rates between the two groups after the first frozen embryo transfer cycle. Group A had a pregnancy rate of 72 % and Group B had a pregnancy rate of 66.7 %, which was not significant. Ongoing pregnancy/live birth rates were 65.6 % in group A and 66.67 % in group B, also not significant (Table 2).

CONCLUSIONS

P4 values on day of trigger do not affect number of eggs retrieved and number of chromosomally normal embryos available for transfer in a subsequent embryo transfer cycle. Elevated P4 values (≥1.5 ng/ml) also do not affect pregnancy rates or live birth/ongoing pregnancy rates in the first subsequent frozen embryo transfer cycle.

Late follicular progesterone to estradiol ratio is not influenced by protocols or gonadotropins used

OBJECTIVE

Increased progesterone level during follicular phase seemed to be associated with decreased pregnancy rate.

STUDY DESIGN AND METHODS

A prospective cohort study, 1.1.2012 - 31.8.13. The Progesterone (P) and Progesterone/Estrogen (P/E2) level on ovulation induction day were compared between the protocols and the different gonadotropins used. Roc analysis was calculated to determine the cutoff of P/E2 to predict delivery rates. P/E2 ratio was calculated as PX1000/e2 level.

MAIN RESULTS

One hundred thirty-nine patients were enrolled to the study. No difference in the P level at hCG stimulation day between different protocols, however, E2 and P/E2 ratio were significantly lower in the long protocol compare with antagonist protocol 1757.7 ± 923.2 vs. 1342.9 ± 1223; P = 0.003 and 0.48 ± 0.31 vs. 0.83 ± 0.87; P = 0.038). The endometrium was significantly thicker in the long group compare with short and antagonist. Significantly more top-quality embryos (TOP) were achieved in the antagonist group. Comparable results between the types of gonadotropins used in regards with cycle characteristics and pregnancy and delivery rates. The P/E2 ratio which can predict live birth rate was found to be 0.45, AUC = 0.632, p = 0.02 and 95 % CI 0.525-0.738 and a significantly higher pregnancy and delivery rates at a P/E2 bellow 0.45.

CONCLUSION

Endometrial receptivity is determined by the complex interactions of E2 and P.

Ongoing pregnancy rates in intrauterine insemination are affected by late follicular-phase progesterone levels

OBJECTIVE

To determine the relationship between serum P levels on the day of hCG administration and ongoing pregnancy rates.

DESIGN

Retrospective study.

SETTING

University-affiliated private IVF.

PATIENT(S)

A total of 2,458 couples undergoing IUI.

INTERVENTION(S)

Ovarian stimulation with human recombinant FSH.

MAIN OUTCOME MEASURE(S)

Ongoing pregnancy and miscarriage rates.

RESULT(S)

Progesterone concentrations were significantly higher given that the E2 concentration increased. Ongoing pregnancy rates were significantly decreased in women with P levels higher than 1.1 ng/mL; similar results were obtained in relation to miscarriage rates.

CONCLUSION(S)

Significant differences in ongoing pregnancy rates when P levels were elevated on the day of hCG administration may help clinicians to counsel patients about the reduced success rates with IUI and manage the timing of insemination to optimize implantation.

Do increased levels of progesterone and progesterone/estradiol ratio on the day of human chorionic gonadotropin affects pregnancy outcome in long agonist protocol in fresh in vitro fertilization/intracytoplasmic sperm injection cycles?

BACKGROUND:

The effect of elevated levels of serum progesterone (P₄) and estradiol (E₂) on the day of human chorionic gonadotropin and their cut-off value on in vitro fertilization (IVF) outcomes is still not clear.

AIMS:

The aim was to evaluate the association between serum P₄, E₂ and progesterone/estradiol ratio (P₄/E₂) on pregnancy outcome in IVF/intracytoplasmic sperm injection (ICSI) cycles with long agonist protocol.

SETTING AND DESIGN:

Retrospective, single center, cohort study.

MATERIALS AND METHODS:

A review of complete data of 544 women undergoing fresh IVF/ICSI cycles (539 cycles) with long agonist protocol from January 2012 to February 2014 was done. Data were stratified into Three groups according to the number of oocytes retrieved: low (≤4 oocytes obtained), intermediate (5–19 oocytes obtained), and high ovarian response (≥20 oocytes obtained).

STATISTICAL ANALYSIS:

Fishers exact test/Chi-square was carried for comparing categorical data. Receiver operating characteristics analysis was performed to determine the cut-off value for P₄ and P₄/E₂ detrimental for pregnancy.

RESULTS:

A negative association was observed between pregnancy rate (PR) and serum P₄ and P₄/E₂ levels with no effect on fertilization and cleavage rate. The overall cut-off value of serum P₄ and P₄/E₂ ratio detrimental for pregnancy was found to be 1.075 and ≥0.35, respectively. Different P₄ threshold according to the ovarian responders were calculated, 1.075 for intermediate and 1.275 for high responders. Serum E₂ levels were not found to be significantly associated with PR.

CONCLUSION:

Serum P₄ levels and P₄/E₂ ratio are a significant predictor for pregnancy outcome without affecting cleavage and fertilization rate while serum estradiol levels do not seem to affect PR.

High progesterone levels in women with high ovarian response do not affect clinical outcomes: a retrospective cohort study

BACKGROUND

The potentially detrimental role of progesterone during the follicular phase has been a matter of controversy for several years; however, few studies have analyzed the effects of combined raised estradiol and progesterone levels on pregnancy outcomes. The aim of the present study was to determine the influence of high progesterone levels on clinical outcomes in the context of high ovarian response.

METHODS

We performed a retrospective cohort study that included 2850 women classified as high responders. The women were subdivided into six groups depending on their progesterone concentration on the day of human chorionic gonadotropin (hCG) administration: <0.5 ng/ml (<p10), 0.50-0.70 ng/ml (p10-p25), 0.71-1.00 ng/ml (p25-p50), 1.01-1.40 ng/ml (p50-p75), 1.41-1.80 ng/ml (p75-p90) and >1.81 ng/ml (>p90). Ovarian response was classified as high when>=20 oocytes were retrieved or when estradiol was >=3000 pg/ml. Clinical outcomes of each subgroup were analyzed. We also examined data from frozen-thawed embryo transfers. Results were analyzed with Student's t- test to compare continuous variables and chi-squared test to compare proportions. A p-value of< =0.05 was considered statistically significant.

RESULTS

The progesterone concentration increased with ovarian response, and elevated progesterone did not show a significant clinical impact on implantation rate and pregnancy rates. These data provide evidence that progesterone levels higher than 1.8 ng/ml do not have detrimental effect on oocyte quality or endometrial receptivity.

CONCLUSIONS

These data allow us to conclude that high progesterone levels correlate significantly with high estradiol levels and that in high responder women; progesterone levels do not show a significant clinical impact on results.

Comparative study of pregnancy outcomes between day 3 embryo transfer and day 5 blastocyst transfer in patients with progesterone elevation

Objective

To explore the effects of progesterone (P) elevation on pregnancy outcomes of day 3 embryo and day 5 blastocyst transfer.

Methods

Clinical outcomes (pregnancy and ectopic pregnancy rates) following day 3 embryo and day 5 blastocyst transfer cycles were retrospectively analysed. Day 3 embryo and day 5 blastocyst transfer cycles were divided into normal P level (P ≤ 1.5 ng/ml) and P elevation group (P > 1.5 ng/ml), based on the serum P level on the day of human chorionic gonadotropin (hCG) administration.

Results

A total of 2868 cycles were analysed. In day 3 embryo transfer cycles ( n = 2345), the clinical pregnancy rate was significantly higher in the normal P level group compared with the P elevation group (55.4% versus 46.7%, respectively) and the ectopic pregnancy rate was significantly lower in the normal P level group compared with the P elevation group (2.8% versus 7.9%, respectively). In day 5 blastocyst transfer cycles ( n = 523), there were no significant differences in the clinical pregnancy and ectopic pregnancy rates between the two groups, based on the P level.

Conclusion

These preliminary findings suggest that day 5 blastocyst transfer should be adopted for patients with P elevation on the day of hCG administration.

The dynamics of endometrial growth and the triple layer appearance in three different controlled ovarian hyperstimulation protocols and their influence on IVF outcomes

The impact of endometrial growth to the triple layer, endometrial thickness, and echogenicity on IVF outcomes was investigated in the study. A retrospective analysis of 583 ICSI patients was conducted: 385 with a long GnRH agonist protocol, 114 with a short GnRH agonist, and 84 with a GnRH antagonist protocol. The progression of endometrial growth to the appearance of the triple layer, endometrial thickness, and echogenicity was compared between protocols. At least one high quality blastocyst was transferred in a double embryo transfer. The time of the appearance of the endometrial triple layer was statistically significant for the pregnancy rate only in the GnRH antagonist protocol. The endometrial thickness on the day of the appearance of the triple layer had a statistically significant influence on the pregnancy rate in the GnRH antagonist and in the long GnRH agonist protocols. The highest pregnancy rate for the long GnRH agonist and the GnRH antagonist protocols was observed when the endometrium thickness was 12-13 mm (61.6% and 58.8%, respectively). The endometrial echogenicity had a significant influence on the pregnancy rate only in the long GnRH agonist protocol. Endometrial features could be helpful parameters in IVF outcomes in particular controlled ovarian hyperstimulation protocols.

Preovulatory progesterone concentration associates significantly to follicle number and LH concentration but not to pregnancy rate

Using data from a large prospective randomized controlled trial that evaluated the effect of recombinant LH (rLH)co-administration for ovarian stimulation, the present study assessed whether progesterone concentration on the day of human chorionic gonadotrophin (HCG) administration was associated with pregnancy outcome. Progesterone concentration was measured on stimulation day 1 and on the day of HCG administration in 475 patients who underwent IVF/intracytoplasmic sperm injection treatment following ovarian stimulation with gonadotrophin-releasing hormone (GnRH) agonist and recombinant FSH with or without rLH administration from day 6 of stimulation. There was no significant association between the late-follicular-phase progesterone concentration and the clinical pregnancy rate. However, progesterone concentration was strongly associated with the number of follicles and retrieved oocytes. Late-follicular-phase LH concentration also showed a significant positive association with progesterone concentration (P = 0.018). Administration of rLH during ovarian stimulation did not affect progesterone concentration. The present study does not support an association between progesterone concentration on the day of HCG administration and the probability of clinical pregnancy in women undergoing ovarian stimulation with GnRH agonists and gonadotrophins for assisted reproduction treatment.Instead, late-follicular-phase progesterone concentration appears to be governed by the number of preovulatory follicles and LH concentration.