Luteal support in reproduction: when, what and how?

Clinical Outcomes in Hormone Replacement Therapy (HRT)-Frozen Embryo Transfer (FET) Protocol Increased by Administering Gonadotropin-Releasing Hormone Agonist (GnRH) in the Initial Stage of the Luteal Phase: A Retrospective Analysis

OBJECTIVE

The objective of this study was to determine if gonadotropin-releasing hormone agonist (GnRH) administration supporting the luteal phase in frozen embryo transfer (FET) improves clinical outcomes Methods and materials This is a retrospective cohort study and we analyzed 3515 cycles of FET at the Department of Reproductive Medicine in our hospital from February 2018 through December 2021. Patients were divided into the GnRH (triptorelin+progesterone and human chorionic gonadotropin (hCG)) group and the non-GnRHa (existing treatment without triptorelin) group. There were 1033 and 2485 cases in the above groups, respectively. Live birth rates (LBR) and clinical pregnancy rates (CPR) were contrasted in the two groups.

RESULTS

We found greater CPR (58.00% versus 48.40%, P-value = 0.003) and LBR (52.70% versus 45.60%, P-value = 0.001) for HRT-FET cycles, and found no clinical significance for natural cycle FET (NC-FET) (58.20% versus 52.90%, P-value = 0.364 and 54.40% versus 47.00%, P-value=0.211), GnRH+HRT-FET (53.00% versus 53.00%, P-value=0.176 and 46.20% versus 47.30%, P-value=0.794), and stimulation-FET (59.30% versus 52.90%, P-value=.00.566 and 59.30% versus 47.10%, P-value=.00.247) in terms of CPR and LBR in the two groups. There was a 47% increase in CPR in the GnRH group, and there was a 33% increase in LBR in the same group.

CONCLUSION

During HRT-FET cycles, administering triptorelin three to four times in the existing luteal support can improve CPR and LBR, and administering triptorelin during the initial stage of the luteal phase can prove a new option for luteal support.

Luteal phase support for women trying to conceive by intrauterine insemination or sexual intercourse

BACKGROUND

Ovulation induction may impact endometrial receptivity due to insufficient progesterone secretion. Low progesterone is associated with poor pregnancy outcomes.

OBJECTIVES

To assess the effectiveness and safety of luteal phase support (LPS) in infertile women trying to conceive by intrauterine insemination or by sexual intercourse.

SEARCH METHODS

We searched the Cochrane Gynaecology and Fertility Group Specialised Register, CENTRAL, MEDLINE, Embase, PsycINFO, LILACS, trial registries for ongoing trials, and reference lists of articles (from inception to 25 August 2021).

SELECTION CRITERIA

Randomised controlled trials (RCTs) of LPS using progestogen, human chorionic gonadotropin (hCG), or gonadotropin-releasing hormone (GnRH) agonist supplementation in IUI or natural cycle.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by Cochrane. Our primary outcomes were live birth rate/ongoing pregnancy rate (LBR/OPR) and miscarriage.  MAIN RESULTS: We included 25 RCTs (5111 participants). Most studies were at unclear or high risk of bias. We graded the certainty of evidence as very low to low. The main limitations of the evidence were poor reporting and imprecision. 1. Progesterone supplement versus placebo or no treatment  We are uncertain if vaginal progesterone increases LBR/OPR (risk ratio (RR) 1.10, 95% confidence interval (CI) 0.81 to 1.48; 7 RCTs; 1792 participants; low-certainty evidence) or decreases miscarriage per pregnancy compared to placebo or no treatment (RR 0.70, 95% CI 0.40 to 1.25; 5 RCTs; 261 participants). There were no data on LBR or miscarriage with oral stimulation. We are uncertain if progesterone increases LBR/OPR in women with gonadotropin stimulation (RR 1.24, 95% CI 0.80 to 1.92; 4 RCTs; 1054 participants; low-certainty evidence) and oral stimulation (clomiphene citrate or letrozole) (RR 0.97, 95% CI 0.58 to 1.64; 2 RCTs; 485 participants; low-certainty evidence). One study reported on OPR in women with gonadotropin plus oral stimulation; the evidence from this study was uncertain (RR 0.73, 95% CI 0.37 to 1.42; 1 RCT; 253 participants; low-certainty evidence). Given the low certainty of the evidence, it is unclear if progesterone reduces miscarriage per clinical pregnancy in any stimulation protocol (RR 0.68, 95% CI 0.24 to 1.91; 2 RCTs; 102 participants, with gonadotropin; RR 0.67, 95% CI 0.30 to 1.50; 2 RCTs; 123 participants, with gonadotropin plus oral stimulation; and RR 0.53, 95% CI 0.25 to 1.14; 2 RCTs; 119 participants, with oral stimulation). Low-certainty evidence suggests that progesterone in all types of ovarian stimulation may increase clinical pregnancy compared to placebo (RR 1.38, 95% CI 1.10 to 1.74; 7 RCTs; 1437 participants, with gonadotropin; RR 1.40, 95% CI 1.03 to 1.90; 4 RCTs; 733 participants, with gonadotropin plus oral stimulation (clomiphene citrate or letrozole); and RR 1.44, 95% CI 1.04 to 1.98; 6 RCTs; 1073 participants, with oral stimulation). 2. Progesterone supplementation regimen  We are uncertain if there is any difference between 300 mg and 600 mg of vaginal progesterone for OPR and multiple pregnancy (RR 1.58, 95% CI 0.81 to 3.09; 1 RCT; 200 participants; very low-certainty evidence; and RR 0.50, 95% CI 0.05 to 5.43; 1 RCT; 200 participants, very low-certainty evidence, respectively). No other outcomes were reported for this comparison. There were three different comparisons between progesterone regimens. For OPR, the evidence is very uncertain for intramuscular (IM) versus vaginal progesterone (RR 0.59, 95% CI 0.34 to 1.02; 1 RCT; 225 participants; very low-certainty evidence); we are uncertain if there is any difference between oral and vaginal progesterone (RR 1.25, 95% CI 0.70 to 2.22; 1 RCT; 150 participants; very low-certainty evidence) or between subcutaneous and vaginal progesterone (RR 1.05, 95% CI 0.54 to 2.05; 1 RCT; 246 participants; very low-certainty evidence). We are uncertain if IM or oral progesterone reduces miscarriage per clinical pregnancy compared to vaginal progesterone (RR 0.75, 95% CI 0.43 to 1.32; 1 RCT; 81 participants and RR 0.58, 95% CI 0.11 to 3.09; 1 RCT; 41 participants, respectively). Clinical pregnancy and multiple pregnancy were reported for all comparisons; the evidence for these outcomes was very uncertain. Only one RCT reported adverse effects. We are uncertain if IM route increases the risk of adverse effects when compared with the vaginal route (RR 9.25, 95% CI 2.21 to 38.78; 1 RCT; 225 participants; very low-certainty evidence). 3. GnRH agonist versus placebo or no treatment  No trials reported live birth. The evidence is very uncertain about the effect of GnRH agonist in ongoing pregnancy (RR 1.10, 95% CI 0.70 to 1.74; 1 RCT; 291 participants, very low-certainty evidence), miscarriage per clinical pregnancy (RR 0.73, 95% CI 0.26 to 2.10; 2 RCTs; 79 participants, very low-certainty evidence) and clinical pregnancy (RR 1.00, 95% CI 0.68 to 1.47; 2 RCTs; 340 participants; very low-certainty evidence), and multiple pregnancy (RR 0.28, 95% CI 0.11 to 0.70; 2 RCTs; 126 participants). 4. GnRH agonist versus vaginal progesterone  The evidence for the effect of GnRH agonist injection on clinical pregnancy is very uncertain (RR 1.00, 95% CI 0.51 to 1.95; 1 RCT; 242 participants). 5. HCG injection versus no treatment  The evidence for the effect of hCG injection on clinical pregnancy (RR 0.93, 95% CI 0.40 to 2.13; 1 RCT; 130 participants) and multiple pregnancy rates (RR 1.03, 95% CI 0.22 to 4.92; 1 RCT; 130 participants) is very uncertain. 6. Luteal support in natural cycle No study evaluated the effect of LPS in natural cycle. We could not perform sensitivity analyses, as there were no studies at low risk of selection bias and not at high risk in other domains.

AUTHORS' CONCLUSIONS

We are uncertain if vaginal progesterone supplementation during luteal phase is associated with a higher live birth/ongoing pregnancy rate. Vaginal progesterone may increase clinical pregnancy rate; however, its effect on miscarriage rate and multiple pregnancy rate is uncertain. We are uncertain if IM progesterone improves ongoing pregnancy rates or decreases miscarriage rate when compared to vaginal progesterone. Regarding the other reported comparisons, neither oral progesterone nor any other medication appears to be associated with an improvement in pregnancy outcomes (very low-certainty evidence).

Insights from clinical experience in treating IVF poor responders

'Poor responders' is a term used to describe a subpopulation of IVF patients who do not respond well to ovarian stimulation with gonadotrophins. While there is no standard definition of a poor responder, these patients tend to be of advanced maternal age (≥40 years), have a history of poor ovarian response with conventional stimulation protocols, and/or have low ovarian reserve. Despite the heterogeneity of this patient group, there are characteristics and needs common to many poor responders that can be addressed through a holistic approach. Stimulation during the earlier stages of follicle maturation may help synchronize follicle development for improved response to later gonadotrophin stimulation, and supplementation with dehydroepiandrosterone or human growth hormone may promote early follicle development in poor responders. IVF protocols should be specifically tailored to poor responders to complement the patient's natural cycle. Because poor responders tend to have high levels of stress and anxiety, patients should receive psychological counselling and support, both prior to and during IVF cycles, to ensure optimal outcomes and improve patients' experience. It is important to set realistic expectations with poor responders and their partners to help patients make informed decisions and better manage their distress and anxiety.

Estradiol use in the luteal phase and its effects on pregnancy rates in IVF cycles with GnRH antagonist: a systematic review

For all the steps of in vitro fertilization to occur successfully, factors such as the quality of retrieved oocytes and endometrial receptivity to the embryo must be ensured. Current studies have shown that endometrial receptivity can be optimized using dedicated exogenous progesterone for luteal phase support in assisted reproduction cycles. But it has not yet been established the benefits of additional use of estradiol in this support. Analyzing pituitary suppression protocols that employ GnRH antagonists, this review will address literature publications between the years 2000-2016, shedding light on this issue to answer questions about the benefits of supplementation.

Prenatal Exposure to Progesterone Affects Sexual Orientation in Humans

Prenatal sex hormone levels affect physical and behavioral sexual differentiation in animals and humans. Although prenatal hormones are theorized to influence sexual orientation in humans, evidence is sparse. Sexual orientation variables for 34 prenatally progesterone-exposed subjects (17 males and 17 females) were compared to matched controls (M age = 23.2 years). A case-control double-blind design was used drawing on existing data from the US/Denmark Prenatal Development Project. Index cases were exposed to lutocyclin (bioidentical progesterone = C₂₁H₃₀O₂; M _W : 314.46) and no other hormonal preparation. Controls were matched on 14 physical, medical, and socioeconomic variables. A structured interview conducted by a psychologist and self-administered questionnaires were used to collect data on sexual orientation, self-identification, attraction to the same and other sex, and history of sexual behavior with each sex. Compared to the unexposed, fewer exposed males and females identified as heterosexual and more of them reported histories of same-sex sexual behavior, attraction to the same or both sexes, and scored higher on attraction to males. Measures of heterosexual behavior and scores on attraction to females did not differ significantly by exposure. We conclude that, regardless of sex, exposure appeared to be associated with higher rates of bisexuality. Prenatal progesterone may be an underappreciated epigenetic factor in human sexual and psychosexual development and, in light of the current prevalence of progesterone treatment during pregnancy for a variety of pregnancy complications, warrants further investigation. These data on the effects of prenatal exposure to exogenous progesterone also suggest a potential role for natural early perturbations in progesterone levels in the development of sexual orientation.

Vaginal micronized progesterone capsule versus vaginal progesterone gel for lutheal support in normoresponder IVF/ICSI-ET cycles

OBJECTIVE

To compare the outcomes of luteal phase support by micronized progesteron vaginal capsule 600mg/day and progesterone vaginal gel 180mg/day in the normoresponder IVF/ICSI-ET cycles of the patients down-regulated via GnRH agonist long protocol or fixed antagonist protocol below 40 years of age.

METHODS

A total of 463 normoresponder cycles between January 2013 and December 2013 were retrospectively analyzed. Those with a BMI>28 kg/m(2), any kind of uterine, ovarian or adnexial pathology, any significant systemic, endocrine or metabolic disease or who were reported as azoospermia, were excluded from the study. The patients were grouped according to the usage of micronized progesterone vaginal capsule 600mg/day (Group 1) or progesterone vaginal gel 180mg/day (Group 2) as luteal phase support. Treatment cycle characteristics and pregnancy outcomes were compared between groups.

RESULTS

Group-I included 220 cycles and group 2 included 243 cycles. Although the MII oocyte percentage among the total number of MII oocytes was significantly higher in Group-II (77.5% and 80.2%; p=0.034), positive ß-hCG (32.3% and 21.8%; p=0.015) and clinical pregnancy (27.3% and 17.7%; p=0.018) rates were significantly higher in Group-I. No difference was observed between groups regarding the ongoing pregnancy rates (23.2% and 17.3%; p=0.143).

CONCLUSION

Micronized progesterone vaginal capsule 600mg daily used for luteal support in the IVF/ICSI-ET cycles was observed to significantly increase the biochemical and clinical pregnancy rates compared to progesterone vaginal gel 180mg daily. However, no difference was observed between two groups regarding ongoing pregnancy rates.

Addition of gonadotropin releasing hormone agonist for luteal phase support in in-vitro fertilization: an analysis of 2739 cycles

OBJECTIVE

Luteal phase is defective in in vitro fertilization (IVF) cycles, and many regimens were tried for the very best luteal phase support (LPS). Gonadotropin releasing hormone (GnRH) agonist use, which was administered as an adjunct to the luteal phase support in IVF cycles, was suggested to improve pregnancy outcome measures in certain randomized studies. We analyzed the effects of addition of GnRH agonist to standard progesterone luteal support on pregnancy outcome measures, particularly the live birth rates.

MATERIAL AND METHODS

This is a retrospective cohort study, including 2739 IVF cycles. Long GnRH agonist and antagonist stimulation IVF cycles with cleavage-stage embryo transfer were included. Cycles were divided into two groups: Group A included cycles with single-dose GnRH agonist plus progesterone LPS and Group B included progesterone only LPS. Live birth rates were the primary outcome measures of the analysis. Miscarriage rates and multiple pregnancy rates were the secondary outcome measures.

RESULTS

Live birth rates were not statistically different in GnRH agonist plus progesterone (Group A) and progesterone only (Group B) groups in both the long agonist and antagonist stimulation arms (40.8%/41.2% and 32.8%/34.4%, p<0.05 respectively). Moreover, pregnancy rates, implantation rates, and miscarriage rates were found to be similar between groups. Multiple pregnancy rates in antagonist cycles were significantly higher in Group A than those in Group B (12.0% and 6.9%, respectively).

CONCLUSION

A beneficial effect of a single dose of GnRH agonist administration as a luteal phase supporting agent is yet to be determined because of the wide heterogeneity of data present in literature. Well-designed randomized clinical studies are required to clarify any effect of luteal GnRH agonist addition on pregnancy outcome measures with different doses, timing, and administration routes of GnRH agonists.

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

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

The addition of gonadotrophin releasing hormone agonist to routine luteal phase support in intracytoplasmic sperm injection and embryo transfer cycles: a randomized clinical trial

OBJECTIVES

To determine the effects of addition of different dosages of gonadotrophin releasing hormone agonist (GnRH-a) to routine luteal phase support (LPS) on implantation and pregnancy rates.

STUDY DESIGN

Three hundred infertile couples who were treated by intracytoplasmic sperm injection and embryo transfer (ICSI-ET) following controlled ovarian stimulation (COS) with long luteal GnRH agonist protocol were enrolled. All women received 600 mg/day vaginal micronized progesterone plus 4 mg 17β estradiol for LPS starting from the day of oocyte retrieval. Patients (n=300) were randomized into three treatment groups. Group A (n=100) received leuprolide acetate 1 mg s.c. injection 3 days after ET in addition to routine LPS. Group B (n=100) received two sequential doses of leuprolide acetate 1 mg s.c. injections 3 and 6 days after ET in addition to routine LPS. Control group (n=100) received only the routine LPS.

RESULTS

A total of 279 patients completed the study. The groups were comparable in terms of baseline demographic parameters including age, duration of infertility and day 3 levels of FSH and estradiol. The cycle parameters of the groups were also comparable regarding the E2 level on day of hCG, number of retrieved oocytes, number of day 3 embryos, number of embryos transferred, and endometrial thickness on both days of OPU and ET. The implantation rates were similar in between the Groups A, B, and control group (20.7% and 25.8% vs. 13.3%, respectively; P=.099). The clinical pregnancy rates and miscarriage rates were similar in between the groups. The ongoing pregnancy rates were 27.4% in control group, 36% in Group A and 42.9% in Group B (P=.093). The OHSS rates were comparable in between the groups. The multiple pregnancy rates were significantly higher in Groups A and B than in control group (12% and 17.9% vs. 4.2%, respectively; P=.014).

CONCLUSIONS

The implantation, clinical pregnancy and ongoing pregnancy and multiple pregnancy rates seem to be increased with the addition of GnRH-a to routine luteal phase support.

Luteal phase support with estrogen in addition to progesterone increases pregnancy rates in in vitro fertilization cycles with poor response to gonadotropins

In this study, our objective was to determine the effect of adding estradiol hemihydrate (E2) to progestin (P) for luteal phase support on pregnancy outcome in in vitro fertilization (IVF) cycles with poor response to gonadotropins. Ninety-five women with poor ovarian response who underwent controlled ovarian hyperstimulation (COH) with gonadotropin releasing hormone (GnRH) agonist or GnRH antagonist plus gonadotropin protocol for IVF were prospectively randomized into three groups of luteal phase support after oocyte retrieval. Group 1 (n = 33) received only intravaginal progesterone gel (Crinone 8% gel). Group 2 (n = 27) and Group 3 (n = 35) received intravaginal progesterone plus oral 2 and 6 mg estradiol hemihydrate, respectively. Main outcome measures were overall and clinical pregnancy rates (PRs) per patient. Serum LH, E2 and P levels at 7th and 14th days of luteal phase were also measured. Overall and clinical PRs were significantly higher in 2 mg E2 + P than P-only group (44% versus 18% and 37% versus 12.1%, respectively). There were no statistically significant differences between 6 mg E2 + P versus P-only and 2 mg E2 + P versus 6 mg E2 + P groups regarding PRs. Addition of 2 mg/day E2 in addition to P for luteal support significantly increase overall and clinical PRs in cycles with poor response to gonadotropins after IVF.

A ray of hope for a woman with Sheehan's syndrome

A 25-year-old woman presented with a history of secondary amenorrhoea for the last 3 years, coinciding with her delivery. She delivered at home and had massive postpartum haemorrhage. She was brought in a state of circulatory collapse to the nearest teaching hospital, where she was resuscitated. She developed anaemia, septicaemia and extradural empyema. The complications were managed and the woman improved. Presently, she approached us for infertility. She was investigated and diagnosed with postpartum hypopituitarism, that is, Sheehan's syndrome. Her gonadotrophin levels, luteinising hormone/follicle-stimulating hormone, were normal, serum oestradiol was low and serum prolactin was also on the lower side. She had started with genital atrophy and was given three cycles of cyclic oestrogen +progesterone combination. Ovulation was induced. She conceived and her antenatal period was uneventful. She delivered a full-term baby vaginally. However, she had inadequate lactation after delivery and lost the baby at one-and-a-half months' age due to gastroenteritis.

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

INTRODUCTION

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

MATERIAL AND METHODS

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

RESULTS

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

CONCLUSIONS

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