Comparison of luteal-phase support with high- and low-dose progesterone therapy on pregnancy rates in an in vitro fertilization program

Novel injectable progesterone-loaded nanoparticles embedded in SAIB-PLGA in situ depot system for sustained drug release

Poly (lactic-co-glycolic acid) (PLGA) nanoparticles (NPs) have attracted considerable interest in the medical community as a sustained-release drug delivery system for localized treatment. However, it is currently a grand challenge to simultaneously achieve low-dose drugs, stable and prolonged drug release, and long-term retention circumventing uptake by macrophages. Here, we construct a solvent-exchange in-situ depot system by incorporating progesterone (PRG) loaded PLGA NPs into a sucrose acetate isobutyrate (SAIB) and PLGA matrix for the long term treatment of Assisted Reproductive Technology (ART). The results showed that different solvent and PLGA contents could affect the drug release rate of PRG NPs-SAIB-PLGA in-situ depot system (PSPIDS). When DMSO was used as solvent with the addition of 8% PLGA to the depot, PSPIDS could achieve a constant drug release with no burst for 2 weeks in vitro. After a single intramuscular injection, such PSPIDS showed higher drug concentration and AUC (6773.0 ± 348.8 μg/L·h) over the entire 7-day testing period compared with the commercial multiple-day-dosing intramuscular PRG-oil solution (1914.5 ± 180.7 μg/L·h) in vivo. Importantly, PSPIDS could be administered at a dose of 3.65 mg/kg, which was one fourth of dose required for PRG-oil solution. The results demonstrate that PRG NPs could successfully achieve both reduced administered dosage and burst release, and therefore that PSPIDS is a promising long-acting composite system for hydrophobic drugs.

Progesterone PLGA/mPEG-PLGA Hybrid Nanoparticle Sustained-Release System by Intramuscular Injection

PURPOSE

To prepare sustained-release PLGA/mPEG-PLGA hybrid nanoparticles of progesterone (PRG), and evaluate the descending required administration dosage in vivo.

METHODS

PRG hybrid nanoparticles (PRG H-NPs) based on PLGA/mPEG-PLGA were compared with PRG nanoparticles (PRG-NPs) of pure PLGA as the matrix and PRG-oil solutions. Nanoparticles (NPs) were formed by the method of nanoemulsion, and the pharmacokinetics of the sustained-release PRG H-NPs in male Sprague dawley (SD) rats were investigated. The rats were randomly divided into four groups, each group received: single dose of PRG H-NPs (14.58 mg/kg, i.m.) and PRG-NPs (14.58 mg/kg, i.m.), repeated dosing for 7 days of PRG-oil (2.08 mg/kg, i.m.) solution (Oil-L) and a higher dosage of PRG-oil (6.24 mg/kg, i.m.) solution (Oil-H), respectively.

RESULTS

In the pharmacokinetic test, the PRG H-NPs exhibited a comparatively good sustained-release effect against the PRG-NPs without mPEG-PLGA and PRG-oil solution. The pharmacokinetic parameters of the PRG H-NPs, PRG-NPs, Oil-L and Oil-H were AUC_0-t(ng·h·mL^-1) 8762.1, 1546.1, 1914.5, and 12,138.9, t_1/2 (h)52.7, 44.1, 8.4 and 44.6 respectively.

CONCLUSIONS

Owing to the modification of PEG, PRG H-NPs can act as safe delivery platforms for sustained-release of drugs with a lower dosage required.

Pharmaceutical and clinical development of a novel progesterone formulation

Progesterone plays an essential role in reproductive events. Its use for luteal support in patients undergoing infertility treatment is an established practice. The different routes used to administer progesterone impact on its efficacy in luteal support: oral administration has been shown to be ineffective due to an extensive first-pass metabolism in the liver; vaginal application has a good efficacy but has drawbacks such as vaginal leakage, irritation, discomfort and uncertainty about the real dose adsorbed; finally, intramuscular administration ensures a precise dosage but can be extremely painful with, in some cases, formation of sterile abscesses. A new progesterone preparation is now available in several European and extra-European countries that combines the precise dosage of the injectable formulation with the comfort of a well-tolerated subcutaneous self-administration. The pharmacokinetic and pharmacodynamic properties of this new product are reviewed here, together with the clinical evidence obtained in two multicenter randomized clinical trials.

Luteal supplementation in in vitro fertilization: more questions than answers

OBJECTIVE

To update clinicians on different regimens of luteal phase supplementation in IVF-stimulated cycles and to identify areas that need further research in this subject.

DESIGN

Literature review and critical analysis of published studies on luteal phase supplementation during the last 20 years.

CONCLUSION(S)

Luteal phase supplementation in IVF-stimulated cycles, both in gonadotropin releasing hormone agonist and antagonist protocols, is considered an essential requirement for optimal success rates. The date of initiation and discontinuation of supplemented hormones is not adequately studied in the literature. In most major controlled and randomized studies, there are no significant differences in success rates with progesterone supplementation alone, progesterone and estradiol, progesterone and human chorionic gonadotropin, and human chorionic gonadotropin alone. Success rates seem similar with intramuscular and vaginal progesterone administration with patient preference for the vaginal route. The optimal dose of progesterone has not been studied in a scientific way in the literature. The use of gonadotropin releasing hormone agonists for luteal phase supplementation in antagonist cycles appears to be promising, and is worthy of further investigation.

Drug intervention in early pregnancy after assisted reproductive technology

Implantation in humans is a complex, closely regulated, highly selective and relatively poorly understood process. Humans have the highest rate of miscarriage in mammals and various pharmacological manipulations have been used to minimize pregnancy losses in both spontaneous pregnancies and pregnancies resulting from assisted reproduction technology. The widespread application of protocols using numerous drugs in assisted reproduction treatment has led to an increasing number of pregnancies exposed to these drugs. The vast majority of these protocols have been based on data from a few observational and often retrospective clinical studies. This paper reviews the recent literature on drug interventions in early pregnancy after assisted reproduction treatment. It is concluded that there are still numerous issues about the safety of most drugs for both the women and their fetus. In many cases, the benefits are theoretical and the possible long-term side-effects are untested. There is an urgent need for more epidemiological studies and randomized controlled trials to explore the use, efficacy and side-effects of both old and new drugs in early pregnancy after assisted reproduction treatment.

The use of the donor oocyte program to evaluate embryo implantation

Pregnancy rates (PRs) are generally higher in most IVF programs when embryos derived from donor oocytes are transferred compared to the PRs of women undergoing IVF-ET. DeZiegler et al., using the transfer of frozen embryos (either patient or donor derived) in natural cycles, found a higher PR following donor oocyte derived ET and thus concluded that the lower PR in the non-donor cycles was not related to the controlled ovarian hyperstimulation (COH) regimen. Their data thus suggested the improved PR with donor embryos may be related to better quality oocytes used for recipients; however, a more receptive endometrium in the oocyte recipients could also explain the data. The studies presented herein further evaluated the latter hypothesis of improved endometrial environment for recipients by comparing PRs in donors vs recipients in a shared oocyte program. Also the study would determine if endometrial echo patterns (EP) and/or thickness (ET) help predict better PRs as they do in stimulated cycles. Finally studies would be performed to compare PRs in older vs younger oocyte recipients to see if there may be a uterine senescence in humans as in other animals and to see if age has an adverse effect on the endometrium as evidenced by sonographic studies. Study 1 compared the clinical PRs in donors vs recipients in a shared program from 1/1/92 to 12/31/92. PR for donors was 23.6% (17 pregnant in 72 transfers) compared to 34.6% for recipients (26/75). Mean age of the donors was 32 compared to 39.8 for recipients. If recipients > 40 were eliminated the PR for recipients was 44.1% (15/34). Study 2 evaluated PRs according to ET and EP in 58 transfers using donor oocytes (44 patients). There were only 2 clinical pregnancies of 22 transfers (9%/cycle) when ET was < 10 mm at the time of the donor's hCG injection compared to 14 pregnant of 36 transfers (38.7%) when ET was > or = 10 mm (p < 0.01). However, there were no differences in PR when the endometrium compared to myometrium was hypoechogenic, isoechogenic, or hyperechogenic. The respective PRs were 16.7% (1/6), 31% (9/39) and 26.1% (6/23). Study 3 evaluated PRs in donor oocyte recipients according to age (< 40 vs > or = 40 years). After evaluating PRs after the first 58 ETs to recipients of shared oocytes we found a much lower PR in women > or = 40 (2/23, 8.6%/cycle) vs 14/55 (25.4%) in those < 40.(ABSTRACT TRUNCATED AT 400 WORDS)

The role of luteal phase support in infertility treatment: a meta-analysis of randomized trials

OBJECTIVE

To determine whether the use of luteal phase support improves pregnancy rate (PR) in infertility.

DESIGN

A meta-analysis of randomized trials of luteal phase support. Search of the National Library of Medicine MEDLINE data base from 1971 using the words luteal, pregnancy, human, and comparative. Bibliography of relevant articles, reviews, and abstracts of scientific meetings were hand searched. All randomized controlled trials of luteal phase support in infertility were included. Luteal phase support for recurrent abortion and nonrandomized trials were excluded. The common odds ratio was calculated for each intervention using the Mantel-Haentzel test. Homogeneity of treatment effect was evaluated using the Breslow-Day test.

MAIN OUTCOME MEASURES

Pregnancy per cycle, rate of spontaneous abortion, and ovarian hyperstimulation syndrome rate.

RESULTS

Eighteen trials met the above criteria. Human chorionic gonadotropin improved PRs in IVF when GnRH agonist (GnRH-a) was used (n = 151) and was superior to P (n = 352). Its benefit in all IVF cycles, however, was not established because of significant heterogeneity of treatment effect. Progesterone improved the PR in all IVF cycles (n = 457). No significant reduction in spontaneous abortion was noted with luteal support (n = 200). Ovarian hyperstimulation syndrome occurred in 5% of patients with hCG. Combination of data from trials of luteal support with other infertility therapies was not possible because of the differences in patient populations.

CONCLUSIONS

The meta-analysis supports the routine use of hCG in IVF cycles using a GnRH-a. Progesterone was also beneficial for luteal phase support in IVF. For other infertility therapy, however, further research is needed to evaluate the role of luteal phase support.

The use of a shared donor oocyte program to evaluate the effect of uterine senescence

OBJECTIVE

To determine if there is reduced uterine receptivity after age 40 by the comparison of pregnancy rates (PRs) of donor oocyte recipients > or = 40 years to those under age 40.

SETTING

In vitro fertilization-ET facility of a university-based practice, Cooper Institute for In Vitro Fertilization.

PATIENTS

All patients registering for the shared donor oocyte program from November 1990 to September 1992. Most recipients were in ovarian failure.

INTERVENTIONS

Donors were treated with luteal phase leuprolide acetate (LA) and gonadotropins; recipients were treated with oral E2 in graduated doses and 50 mg IM daily P. Endometrial thickness was considered in the decision to continue with transfer or to freeze all embryos.

MAIN OUTCOME MEASURES

Pregnancy rates per transfer in recipients and live birth rates according to age > or = 40 or < 40.

RESULTS

The clinical PR per transfer was 29.2% for the younger women and 25.4% for the older recipients. The live birth rate was 29.2% for the younger women and 22.4% for the older recipients.

CONCLUSIONS

These data support the conclusion that, if there is a decline in uterine receptivity for embryo implantation with advancing age, it is at least remediable with hormonal adjustments.