Influence of human chorionic gonadotrophin during ovarian stimulation: an overview

Translational interdisciplinary research on human chorionic gonadotropin's enhancement of neuroendocrine crosstalk: a novel medical hypothesis for systemic adjunctive treatment of psychiatric disorders

Introduction

It is increasingly recognized that the brain continuously interacts with other body systems such as the immune system, the gut-brain axis, and the endocrine system. Dysfunctions in these systems can impact mental health by altering neurotransmitter levels and the neurochemical environment. This shift in understanding underscores the need for therapeutic strategies that address systemic health and mitochondrial function, alongside psychosocial aspects of the disease, offering a more personalized and adaptive approach to treatment.

Methodology

This study utilizes a translational research approach structured through the Work Breakdown Structure methodology, dividing the process into six interconnected Work Packages (WPs). These include systematic literature reviews on endocrine dysfunctions and hormonal therapies in mental disorders, application of Design Thinking for neuroendocrine innovation, and hypothesis exploration of hCG as a systemic adjunctive treatment for psychiatric disorders, culminating in result dissemination and evaluation.

Results

Work The study identified multiple mechanistic impacts of human chorionic gonadotropin (hCG) relevant to psychiatric treatment. Key findings from hCG Hormetic Therapy (HHT) include stimulation of sex hormone production, reduction of insulin resistance and systemic inflammation, enhancement of hypothalamic activity to regulate appetite, sleep, and emotions, and LH-like effects on cognition. HHT also increases IGF-1 availability, promoting neuroprotection, cognitive improvements, and reduced mitochondrial dysfunction, restoring cellular function critical for brain health.

Implications for Clinical Practice

The findings underscore the significance of enhancing endocrine and metabolic functions as a viable strategy for improving psychiatric care, aligning with trends that advocate holistic treatment strategies. The suggested dose for future research protocols is 500 IU IM per week for at least 10 weeks.

Conclusion

Supporting diverse and varied research is crucial for advancing medical knowledge. Continuous exploration of neuroendocrine dysfunctions in mental disorders using advanced tools from neuroscience, endocrinology, and psychiatry can provide new pathways for more effective and personalized treatments. The study of HHT effects offers insights into complex neuroendocrine interactions, underscoring the potential for innovative therapeutic strategies in psychiatry.

The proteomic landscape of trophoblasts unravels calcium-dependent syncytialization processes and beta-chorionic gonadotropin (ß-hCG) production

BACKGROUND

The syncytiotrophoblast (STB) layer of the placenta is formed by cell fusion of cytotrophoblasts, acts as a feto-maternal barrier, is required for the production of pregnancy hormones such as chorionic gonadotropin, estradiol and progesterone and is also responsible for feto-maternal mineral exchange such as calcium. Adequate mineral supply and placental hormone production are essential for the maintenance of pregnancy, and disturbances in trophoblast integrity are associated with pregnancy complications. Since knowledge about the identity and expression levels of proteins in trophoblast and syncytiotrophoblast cells is limited so far, we analyzed the proteomes of trophoblast-like and syncytiotrophoblast-like BeWo cells under different calcium conditions. The investigation of protein expression profiles in combination with hormone assays can provide a better understanding of calcium-dependent cellular processes in trophoblasts and syncytiotrophoblasts.

METHODS

Here, we combine human trophoblast model cell cultures, hormone assays, antibody-based detection methods and high-resolution mass spectrometry analyzes to assess changes in cellular processes during syncytialization.

RESULTS

We monitored the changes in protein expression profiles during forskolin induced syncytialization of trophoblast-like cells in an unbiased manner and show that the expression of numerous proteins is strongly altered. Among them are enzymes of the glucocorticoid and sex hormones synthesis pathways such as cytochrome P450 (CYP) 19A1, CYP11A1, adrenodoxin (FDX1), hydroxysteroid dehydrogenase (HSD) 11β2 and HSD17β1, whose expression is strongly induced by syncytialization. The production of beta human chorionic gonadotropin (ß-hCG), progesterone and estradiol increase during syncytialization, while the secretion and synthesis of ß-hCG and the expression of several protein syncytiotrophoblast markers show a clear calcium dependence.

CONCLUSION

The broad applicability of semi-quantitative proteome profiling of cytotrophoblast- and syncytiotrophoblast-like cells provides new insights into signaling processes that occur in cytotrophoblasts /syncytiotrophoblasts during pregnancy.

Effects of 100 IU versus 150 IU hCG supplementation on oocyte and embryo quality in patients aged ≥ 35 years: a propensity score-matched analysis

Background: The optimal dose of human chorionic gonadotropin (hCG) supplementation during controlled ovarian stimulation (COS) remains controversial, particularly in women of advanced reproductive age. Objective: To compare the efficacy and safety of 150 IU versus 100 IU daily hCG supplementation from stimulation day 6 in women aged ≥ 35 years undergoing in vitro fertilization/intracytoplasmic sperm injection (IVF/ICSI). Methods: In this retrospective cohort study, we analyzed data from 438 patients aged ≥ 35 years undergoing IVF at a single center. Propensity score matching was performed at a 1:1 ratio, yielding 192 patients per group who received either 100 IU or 150 IU daily hCG supplementation from stimulation day 6 during GnRH antagonist cycles. Results: After propensity score matching, baseline characteristics were comparable between groups. The 150 IU group yielded significantly more total oocytes (9.23±6.60 vs 7.79±5.52, p<0.001). However, the number of mature oocytes (6.25±5.12 vs 5.66±4.58) and day 3 embryos (5.22±4.62 vs 4.80±3.96) did not differ significantly between groups. Total FSH dose was similar (2664.84±141.91 vs 2666.02±142.51 IU, p=0.936). Only one case of moderate ovarian hyperstimulation syndrome occurred in the 150 IU group. Conclusions: In women aged ≥ 35 years, while 150 IU daily hCG supplementation from stimulation day 6 safely increased total oocyte yield compared to 100 IU, it did not significantly improve mature oocyte numbers or embryo development.

FSH/LH co-stimulation in Advanced Maternal Age (AMA) and hypo-responder patients - Arabian gulf delphi consensus group

Background

In a global effort to assess expert perspectives on the use of recombinant gonadotropins, recombinant human luteinizing hormone (r-hLH) and recombinant human follicle-stimulating hormone (r-hFSH), a consensus meeting was held in Dubai. The key aim was to address three critical questions: What are the factors that influence follicle response to gonadotropins? Which categories of patients are most likely to benefit from LH supplementation? And what are the optimal management strategies for these patients?

Methods

A panel of thirty-six experts reviewed and refined the initial statements and references proposed by the Scientific Coordinator. Consensus was defined as agreement or disagreement by more than two-thirds (66%) of the panel members for each statement.

Results

Thirty-five statements were formulated, of which thirty-one reached consensus. For patients with Hypo-Response to Gonadotropin Stimulation (20 statements), all identified risk factors, including advanced age, high BMI, and chronic conditions, achieved unanimous agreement. Diagnostic approaches, such as the inclusion of POSEIDON criteria and hormone level monitoring, were endorsed by the majority, with over 90% agreement. Management strategies, particularly individualized stimulation protocols and optimized scheduling, garnered broad consensus, with only one statement falling short of the threshold. Additionally, in cases of severe FSH and LH deficiency, combining r-hFSH with r-hLH was found to improve pregnancy rates and cost efficiency compared to human menopausal gonadotropin (hMG). For patients with Advanced Maternal Age (AMA) (15 statements), there was strong agreement on the use of oral contraceptive pills and estrogen priming. Recommendations concerning antagonist protocols and dosing of r-hLH and r-hFSH also achieved high levels of consensus. Significant agreement supported r-hLH supplementation and a tailored approach to luteal phase support. However, there were mixed opinions on the route of progesterone administration, with some experts expressing neutral or disagreeing views. Despite these differences, unanimous consensus was reached on markers of treatment success, particularly live birth rates, pregnancy rates, and embryo development, underscoring the importance of these outcomes in evaluating treatment efficacy.

Conclusion

This consensus provides a practical clinical perspective to a wide range of global professionals on the strategies employed during key phases of Assisted Reproductive Technology (ART) treatment. To further improve outcomes, incorporating additional clinical insights on ART approaches, alongside existing guidelines and policies, may offer valuable guidance for optimizing patient care.

Dual trigger versus human chorionic gonadotropin trigger for blastocyst quality and cumulative live birth

PURPOSE

To evaluate the difference in the number of euploid blastocysts and cumulative live birth rate (LBR) between dual and human chorionic gonadotropin (hCG) triggers in poor and normal ovarian responders undergoing preimplantation genetic testing (PGT) cycles.

METHODS

This retrospective cohort study was enrolled from July 2018 to December 2021 and followed up until June 2024 at a single reproductive medical center. Overall, 1040 in vitro fertilization (IVF)-PGT and 784 frozen-thawed embryo transfer (FET) cycles were assessed. Dual (triptorelin acetate 0.2 mg and recombinant hCG [rhCG] 250 µg) or hCG (rhCG 250 µg) trigger was used for oocyte maturation in the gonadotropin-releasing hormone antagonist protocol and PGT cycles. We assessed the embryo outcomes and FET cumulative pregnancy outcomes.

RESULTS

The number of oocytes retrieved (10.17 ± 5.22 vs 10.27 ± 5.14, P = 0.789), MII oocytes (8.24 ± 4.26 vs 8.28 ± 4.05, P = 0.888), blastocysts (2.16 ± 1.50 vs 2.12 ± 1.49, P = 0.729), euploid blastocysts (1.06 ± 1.14 vs 1.09 ± 1.23, P = 0.726), and the rate of cumulative LBR (24.9% vs 24.9%, P = 1.000) in the dual trigger group were comparable with those in the hCG group. The trigger method was not correlated with higher LBR based on logistic regression analysis (odds ratio[OR] = 1.040 [0.778-1.392], P = 0.790).

CONCLUSION

For poor and normal ovarian responders, the dual trigger, compared with the hCG trigger, did not improve the PGT embryo outcomes and FET cumulative pregnancy outcomes.

CART (Cocaine- and Amphetamine-Regulated Transcript): A New Identified Intrafollicular Mediator in Ovulation Induction Protocols

BACKGROUND/OBJECTIVES

This study investigates the relationship between cocaine- and amphetamine-regulated transcript (CART) expression, leptin, and hormone profiles-specifically progesterone, testosterone, androstenedione, estradiol, follicle-stimulating hormone (FSH), and human chorionic gonadotropin (hCG)-across four distinct ovulation induction protocols (HMG, HMG/hCG, rFSH, and rFSH/hCG). It also investigates the relationship between follicle-stimulating hormone receptor (FSHR) Ser680Asn polymorphisms, CART expression, and in vitro fertilization (IVF) results, with the goal of better understanding how CART and FSHR polymorphisms affect ovarian response and oocyte quality.

METHODS

Data were obtained from 94 women who underwent controlled ovarian stimulation (COS) as part of their IVF therapy. Hormone levels, CART expression, and FSHR polymorphisms were measured across all four ovulation induction procedures. Statistical studies were undertaken to investigate the relationships between CART expression, hormone levels, and IVF results.

RESULTS

The study found no significant difference in body mass index (BMI) amongst the four stimulation procedures (p-values varied from 0.244 to 0.909). CART expression did not show a significant correlation with hormone levels throughout the whole cohort (progesterone, testosterone, androstenedione, FSH, hCG, and estradiol; p > 0.05). However, CART levels were adversely linked with the number of follicles > 12 mm (r = -0.251, p = 0.018), total oocyte count (r = -0.247, p = 0.019), and oocyte maturity (r = -0.212, p = 0.048). Furthermore, there was a strong negative connection between CART expression and thyroid hormone T3 (r = -0.319, p = 0.048). Among FSHR polymorphisms, the SER/SER genotype was related to greater CART levels (mean 4.198 ± 2.257) than the SER/ASN and ASN/ASN genotypes (p = 0.031).

CONCLUSIONS

These data indicate that CART expression and FSHR polymorphisms may influence ovarian response and oocyte quality in IVF patients, possibly acting as biomarkers for evaluating ovarian outcomes in various ovulation induction procedures.

Meta-analysis of intrauterine hCG perfusion efficacy in recurrent implantation failure as defined by ESHRE guidelines

PURPOSE

This study evaluates the efficacy of intrauterine hCG perfusion for RIF, as defined by ESHRE 2023 guidelines, highlighting hCG as a cost-effective alternative to other immunotherapies, especially suitable for less developed regions. It aims to clarify treatment guidance amidst previous inconsistencies.

METHODS

This meta-analysis, registered with PROSPERO (CRD42024443241) and adhering to PRISMA guidelines, assessed the efficacy and safety of intrauterine hCG perfusion in enhancing implantation and pregnancy outcomes in RIF. Comprehensive literature searches were conducted through December 2023 in major databases including PubMed, Web of Science, Embase, the Cochrane Library, and key Chinese databases, without language restrictions. Inclusion and exclusion criteria were strictly aligned with the 2023 ESHRE recommendations, with exclusions for studies lacking robust control, clear outcomes, or adequate data integrity. The risk of bias was evaluated using the Newcastle-Ottawa Scale, ROBINS-I, and RoB2 tools. Data analysis was performed in R using the 'meta' package, employing both fixed and random effect models to account for study variability. Subgroup analyses by dosage, volume, hCG concentration, timing of administration, and type of embryo transfer were conducted to deepen insights, enhancing the reliability and depth of the meta-analysis in elucidating the role of hCG perfusion in RIF treatments.

RESULTS

Data from 13 studies, comprising six retrospective and six prospective studies from single centers, along with one multi-center RCT, totaling 2,157 participants, were synthesized to evaluate the effectiveness of intrauterine hCG perfusion in enhancing implantation and pregnancy outcomes in patients with RIF. Significant improvements were observed in clinical pregnancy and embryo implantation rates across various dosages, timing of administration, and embryo developmental stages, without impacting miscarriage rates. Notably, the most significant efficacy within subgroups occurred with a 500 IU dosage and perfusion parameters of ≤ 500µL volume and ≥ 2 IU/µL concentration. Additionally, a limited number of studies showed no significant increases in ectopic pregnancy or multiple pregnancy rates, and a modest improvement in live birth rates, although the small number of these studies precludes definitive conclusions.

CONCLUSIONS

The analysis suggests that intrauterine hCG perfusion probably enhances embryo implantation, clinical pregnancy, and live birth rates slightly in RIF patients. Benefits are indicated with a dosage of 500 IU and a maximum volume of 500µL at concentrations of at least 2 IU/µL. However, substantial heterogeneity from varying study types and the limited number of studies necessitate cautious interpretation. These findings underscore the need for more rigorously designed RCTs to definitively assess the efficacy and safety.

The effects of different endometrial preparation regimens on pregnancy outcomes in frozen-thawed embryo transfer cycles: a prospective randomized controlled study

OBJECTIVE

An increasing number of research have emerged to compare the pregnancy outcomes between the natural cycle and the hormone replacement therapy (HRT) cycle in preparing the endometrium for frozen-thawed embryo transfer (FET), but the results are controversial. This prospective randomized controlled study was hence designed to obtain more solid evidence.

MATERIALS AND METHODS

In this study, patients with regular menstrual cycle length (21-35 days) who underwent FET between January 2010 to December 2017 were recruited for this study. Upon further filtering with the selection criteria of patients being, a total of 405 patients were recruited and randomized. Finally, analysis was performed on 384 patients: 178 belonged to the natural cycle group whereas the remaining 206 were in the HRT group. The primary outcome was live birth rate, while the secondary outcomes were implantation rate, clinical pregnancy rate, early miscarriage rate, late miscarriage rate, multiple birth rate and low birth weight rate.

RESULTS

The live birth rate (37.6% vs 30.1%, p = 0.119) of natural cycle group were higher than those of the hormone replacement therapy group, although the difference was not significant. The secondary outcomes were not found to differ significantly between the two groups. Nonetheless, the endometrium was found to be thicker in the natural cycle group (10.75 mm) than the HRT group (9.00 mm) (p < 0.001).

CONCLUSION

No significant differences were observed between the pregnancy outcomes of the natural cycle group and the HRT group which comprised of patients with regular menstrual cycle length.

Low-dose human chorionic gonadotropin supplementation initiated at the onset of ovarian stimulation can improve oocyte quality without impairing endometrial receptivity: Case series

RATIONALE

Whether continuous low-dose human chorionic gonadotropin (hCG) supplementation during controlled ovarian hyperstimulation (COH) can improve oocyte and embryo quality is still controversial in clinical practice.

PATIENT CONCERNS

We report the first case series of inadvertent COH in luteal-phase stimulation in the presence of endogenous or exogenous low-dose hCG.

DIAGNOSES

Patients were diagnosed with infertility.

OUTCOMES

The first two cases had inadvertent COH during preexisting pregnancy, and one of which produced more high-quality embryos (5 vs 1) in the presence of low hCG. Both cases had a live birth. The third case had 7 repeated failures of IVF, during which a total of 55 oocytes were obtained, but only 3 developed into transferable embryo. However, supplementation of 330 IU hCG per day from the onset of COH resulted in the recovery of one high-quality embryo and subsequent delivery of a healthy baby following fresh embryo transfer in eighth attemption.

LESSONS

In conclude, supplementation with low-dose hCG from the onset of ovarian stimulation can improve oocyte quality without impairing endometrial receptivity.

Plumeria acuminata: A Systematic in vivo Evaluation for Its Anti-ovulatory and Anti-Implantation Features

Background:

Fertility control becomes necessary for under-developed and developing nations for the betterment of the economy, environment, and society. Plant Plumeria acuminata, “Temple tree or Frangipani”, of the Apocynaceae family has exhibited several activities similar to contraceptive medicine and is widely distributed in India.

Objective:

Present investigation aimed to study the anti-ovulatory and anti-implantation activities of ethanolic extract from P. acuminata leaves and roots in Wistar rats.

Methods:

Ethanolic extracts of P. acuminata leaves and roots were subjected to qualitative phytochemical analysis and acute toxicity test. Immature female rats were used to explore anti-ovulatory characteristics administering HCG as a standard ovulation-inducing drug. Mated females were used for exploring anti-implantation characteristics. Levonorgestrel and Ethinylestradiol were administered as standard anti-implantation drugs. Morphological, hematological, hormonal, and histological examinations were performed.

Results:

LD50 value i.e., 2000 mg/kg from acute toxicity test resulted in the selection of 100, 200, and 400 mg/kg dose values for both leaf and root extracts. Treatment with these brought ~2-54%, ~5-48%, and ~1-68% changes respectively in the hormonal, growth factors’ and cytokines’ profile. Ovarian histology revealed restricted follicle maturation and ovulation whereas uterine histology unveiled a ~5-28% decrease in the endometrium thickness making it unreceptive for implantation after treatment with PAL and PAR extracts.

Conclusion:

Anti-ovulatory and anti-implantation results obtained here can be attributed to the presence of plumericin, sterol as well as triterpene groups of phytochemicals from ethanolic extracts of leaves and roots, making them potent contestants for studies on future contraceptive medicines.

Tie1 contributes to the development of ovarian hyperstimulation syndrome under the regulation of EGR1 in granulosa cells

The expression of tyrosine kinase with immunoglobulin-like and epidermal growth factor-like domains 1 (Tie1), a transmembrane protein expressed almost exclusively by endothelial cells, has been reported in granulosa cells. However, its significance in ovarian hyperstimulation syndrome (OHSS), which can occur after the injection of gonadotropins in infertile women undergoing controlled ovarian stimulation, is unknown. Here, we report significantly increased Tie1 and vascular endothelial growth factor (VEGF) expression in cultured granulosa cells from OHSS patients, as well as ovaries from rats with experimentally established OHSS, compared to controls, with the levels of both proteins also increasing in granulosa and SVOG cells (a nontumorigenic human granulosa-lutein cell line) treated with an acute dose of human chorionic gonadotropin (hCG). Tie1 silencing abolished the hCG-induced VEGF level in SVOG cells and attenuated the progression of OHSS in rats, as determined by histological analysis. Further studies in SVOG cells revealed that the hCG-induced upregulation of Tie1 expression involved the phosphoinositide 3-kinase/protein kinase B signaling pathway. We also report that early growth response protein 1 (EGR1), whose expression was also upregulated by hCG, bound directly to the Tie1 promoter and activated its transcription. Taken together, our results indicate that Tie1 may be a therapeutic target in cases of moderate-to-severe OHSS. Further studies are needed to address its clinical relevance.

Recombinant follicular stimulating hormone plus recombinant luteinizing hormone versus human menopausal gonadotropins- does the source of LH bioactivity affect ovarian stimulation outcome?

OBJECTIVE

Luteinizing hormone (LH) and human chorionic gonadotropin (hCG) activate distinct intracellular signaling cascades. However, due to their similar structure and common receptor, they are used interchangeably during ovarian stimulation (OS). This study aims to assess if the source of LH used during OS affects IVF outcome.

PATIENTS AND METHODS

This was a cross sectional study of patients who underwent two consecutive IVF cycles, one included recombinant follicular stimulating hormone (FSH) plus recombinant LH [rFSH+rLH, (Pergoveris)] and the other included urinary hCG [highly purified hMG (HP-hMG), (Menopur)]. The OS protocol, except of the LH preparation, was identical in the two IVF cycles.

RESULTS

The rate of mature oocytes was not different between the treatment cycles (0.9 in the rFSH+rLH vs 0.8 in the HP-hMG, p = 0.07). Nonetheless, the mean number of mature oocytes retrieved in the rFSH+rLH treatment cycles was higher compared to the HP-hMG treatment cycles (10 ± 5.8 vs 8.3 ± 4.6, respectively, P = 0.01). Likewise, the mean number of fertilized oocytes was higher in the rFSH+rLH cycles compared with the HP-hMG cycles (8.5 ± 5.9 vs 6.4 ± 3.6, respectively, p = 0.05). There was no difference between the treatment cycles regarding the number of top-quality embryos, the ratio of top-quality embryos per number of oocytes retrieved or fertilized oocytes or the pregnancy rate.

CONCLUSION

The differences in treatment outcome, derived by different LH preparations reflect the distinct physiological role of these molecules. Our findings may assist in tailoring a specific gonadotropin regimen when assembling an OS protocol.

[Timing of HMG supplementation and clinical outcomes of advanced-age patients with diminished ovarian reserve receiving gonadotropin-releasing hormone antagonist protocol]

OBJECTIVE

To assess the effect and timing of human menopausal gonadotropin (HMG) supplementation in advancedage patients with diminished ovarian reserve (DOR) receiving gonadotropin-releasing hormone antagonist protocol.

OBJECTIVE

A total of 682 patients with DOR aged over 35 years undergoing IVF-ET treatment were included in this study. All the patients underwent a GnRH antagonist protocol, and controlled ovarian stimulation was initiated on day 2-3 of the menstrual cycle with follicle stimulation hormone (FSH). According to the timing of HMG supplementation, the patients were divided into no supplementation group (n=371) without HMG supplementation; early supplementation group (n=139), in which daily HMG supplementation started on the first day till the trigger day; and late supplementation group (n=172), in which HMG supplementation started when the leading follicle reached 10-14 mm in diameter and lasted until the trigger day. The pregnancy outcomes of the patients were compared among the 3 groups.

OBJECTIVE

The 3 groups showed no significant difference in hCG trigger day E2 and P levels, endometrial thickness, or the number of follicles with comparable fertilization rate and cleavage rate (P>0.05). Gn dose used was the lowest in no supplementation group, and the average number of oocytes retrieved was significantly smaller in early supplementation group than in late supplementation group (P < 0.05). The mean number of mature oocytes and embryos available were significantly higher in late supplementation group than in early supplementation group (P < 0.05). The clinical pregnancy rate of fresh embryo transfer cycle was significantly higher in late supplementation group than in no supplementation group (27.7% vs 45.1%, P < 0.05), but the implantation rate, early miscarriage rate, heterotopic pregnancy rate and live birth rate were comparable among the 3 groups (P>0.05). No significant differences were found among the 3 groups in the implantation rate, clinical pregnancy rate, early miscarriage rate, heterotopic pregnancy rate or live birth rate of the first frozen-thawed embryo transfer cycle with a freeze-all strategy (P>0.05).

OBJECTIVE

HMG supplementation in the middle and late follicular phase can improve the outcomes of controlled ovarian hyperstimulation and increase the clinical pregnancy rate of fresh embryo transfer cycle in advanced-age patients with DOR undergoing GnRH antagonist protocol.

Effect of Metformin on Premature Luteinization and Pregnancy Outcomes in Intracytoplasmic Sperm Injection-Fresh Embryo Transfer Cycles: A Randomized Double-Blind Controlled Trial

BACKGROUND

Premature luteinization (PL) is not unusual in in vitro fertilization (IVF) and could not be wholly avoided by using either gonadotropin-releasing hormone (GnRH) agonists or GnRH antagonist regimens. The study aims to evaluate metformin's efficacy in preventing PL in fresh GnRH antagonist intracytoplasmic sperm injection (ICSI) cycles with cleavage-stage embryo transfer.

MATERIALS AND METHODS

This randomized, double-blind, placebo-controlled trial was conducted in a tertiary university IVF center. We recruited infertile women who were scheduled to perform their first or second ICSI trial. Eligible women were recruited and randomized in a 1:1 ratio into two groups. Metformin was administered in a dose of 1500 mg per day since the start of contraceptive pills in the cycle antecedent to stimulation cycle until the day of ovulation triggering, while women in the placebo group received a placebo for the same regimen and duration. The primary outcome was the incidence of PL, defined as serum progesterone (P) on the triggering day ≥1.5 ng/mL. Secondary outcomes comprised the live birth, ongoing pregnancy, implantation, and good-quality embryos rates.

RESULTS

The trial involved 320 eligible participants (n=160 in each group). Both groups had comparable stimulation days, endometrial thickness, peak estradiol levels, number of oocytes retrieved, and number of mature oocytes. Metformin group experienced lower level of serum P (P<0.001) and incidence of PL (10 vs. 23.6%, P=0.001). Moreover, lower progesterone/estradiol (P/E) ratio and progesterone to mature oocyte index (PMOI) (P=0.002 and P=0.002, respectively) were demonstrated in women receiving metformin. Metformin group generated a better rate of goodquality embryos (P=0.005) and ongoing pregnancy (43.8 vs. 31.8%, P=0.026). A similar trend, though of borderline significance, was observed in the live birth rate in favor of metformin administration (38.15 vs. 27.5%, P=0.04).

CONCLUSION

Metformin could be used in patients with potential PL to improve fresh cycle outcomes by preventing PL (Registration number: NCT03088631).