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Ozgur K, Tore H, Berkkanoglu M, Bulut H, Donmez L, Coetzee K. Comparable ongoing pregnancy and pregnancy loss rates in natural cycle and artificial cycle frozen embryo transfers with intensive method-specific luteal phase support; a retrospective cohort study. J Gynecol Obstet Hum Reprod 2024; 53:102797. [PMID: 38735575 DOI: 10.1016/j.jogoh.2024.102797] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2024] [Revised: 05/08/2024] [Accepted: 05/08/2024] [Indexed: 05/14/2024]
Abstract
STUDY OBJECTIVE The absence of corpus lutea in artificial cycle (AC) frozen embryo transfers (FET) may increase the chances of pregnancy loss. In this retrospective cohort study, the efficacy of AC endometrial preparation was compared natural cycle (NC) endometrial preparation in terms of ongoing pregnancy. METHODS One thousand six hundred and eighteen consecutive vitrified-warmed blastocyst FET performed between December 2021 and November 2022 were included, with 1023 compared after exclusions according to the endometrial preparation method; 293 NC-FET, 143 modified NC-FET, 204 unprogrammed AC-FET, and 383 oral contraceptive pill (OCP) programmed AC-FET. Intensive method-specific luteal phase support (LPS) was administered in NC- (human chorionic gonadotropin and micronized vaginal progesterone), mNC- (micronized vaginal progesterone), and in AC-FET (micronized vaginal progesterone, intramuscular progesterone, and oral dydrogesterone). RESULTS Clinician choice of endometrial preparation method resulted in the NC- or AC-FET groups having distinct differences, with female age, antral follicle count and body mass index as well as the percentage of DOR or PCOS diagnosed patients significantly different. The unadjusted ongoing pregnancy and total pregnancy loss rates for NC-, mNC-, AC-, and ocp-AC-FET were 61.8 %, 55.2 %, 57.4 %, and 58.5 %, and 19.2 %, 24.0 %, 23.5 % and 23.8 %, respectively. In multivariate logistic regressions to predict the dependent outcomes of ongoing pregnancy and total pregnancy loss, none of the FET methods were selected as independent predictors. CONCLUSION Patients undergoing NC- and AC-FET with method-specific progesterone LPS had comparable ongoing pregnancy rates as well as total pregnancy loss rates, with NC-FET ranked first in the regression analysis.
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Affiliation(s)
| | - Hande Tore
- Antalya IVF Centre, Antalya, 07080, Turkey
| | - Murat Berkkanoglu
- Antalya IVF Centre, Antalya, 07080, Turkey; Istanbul Atlas University, School of Medicine, Department of Gynecology and Obstetrics, Istanbul 34408, Turkiye
| | - Hasan Bulut
- Antalya IVF Centre, Antalya, 07080, Turkey; Antalya Bilim University, School of Medicine, Department of Health Science, Antalya 07190, Turkiye
| | - Levent Donmez
- Akdeniz University, School of Medicine, Department of Public Health, Antalya, 07058, Turkiye
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Santos-Ribeiro S, Godinho CM, Reis-Soares S. Nature (almost) always prevails - challenging the status quo of artificial cycle frozen embryo transfers. Reprod Biomed Online 2023; 47:103352. [PMID: 37804605 DOI: 10.1016/j.rbmo.2023.103352] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2023] [Revised: 08/15/2023] [Accepted: 08/15/2023] [Indexed: 10/09/2023]
Abstract
Frozen embryo transfers (FET) have become increasingly popular in assisted reproductive technology (ART) due to advancements in cryopreservation techniques and the implementation of the 'freeze-all' strategy. The choice between artificial or natural cycles for FET preparation has been a subject of debate, considering factors such as endometrial receptivity, flexibility of scheduling and pregnancy outcomes. While artificial cycle protocols offer convenience and flexibility, studies have suggested potential drawbacks, including higher miscarriage rates and a greater risk of hypertensive disorders during pregnancy. In contrast, natural cycle protocols involve a frequently demanding monitoring of both endometrial proliferation and follicular growth, which may lead to increased clinic visits and scheduling issues. Multiple strategies have been proposed to enhance the usage of natural cycle FET, including addressing anovulation through minimal stimulation, reducing cycle monitoring and exploring novel FET approaches. These novel approaches, such as widening the window for human chorionic gonadotrophin administration and the natural proliferative phase protocol, offer promising outcomes and increased convenience for patients. However, further research is needed to establish the optimal timing and effectiveness of these strategies. Overall, enhancing the practicality of natural cycle FETs is crucial for expanding their utilization during ART.
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Affiliation(s)
- Samuel Santos-Ribeiro
- IVIRMA Global Research Alliance, IVIRMA Lisboa, Lisbon, Portugal.; Department of Obstetrics and Gynecology, Faculty of Medicine, University of Lisbon, Lisbon, Portugal..
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Holder KN, Mormol JS, Bakkensen JB, Pavone ME, Goldman KN, Yeh C, Muhammad LN, Bernardi LA. Natural Cycle Frozen Embryo Transfer: Evaluating Optimal Protocols for Preparation and Timing. J Hum Reprod Sci 2023; 16:333-339. [PMID: 38322641 PMCID: PMC10841927 DOI: 10.4103/jhrs.jhrs_125_23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2023] [Revised: 12/05/2023] [Accepted: 12/11/2023] [Indexed: 02/08/2024] Open
Abstract
Background While natural cycle frozen embryo transfer (NC-FET) is becoming increasingly common, significant practice variation exists in the use of ovulation induction medications, administration of ovulation trigger, and timing of embryo transfer without consensus as to the optimal protocol. Aims The objective of this study is to evaluate the association of key aspects of the NC-FET protocol with implantation, pregnancy and live birth. Settings and Design This was a retrospective cohort study of blastocyst stage NC-FET cycles from October 2019 to July 2021 at a single academic fertility centre. Materials and Methods Protocols varied between cycles across three key parameters which were evaluated as primary predictors of cycle outcomes: (1) use of letrozole for mild ovarian stimulation/ovulation induction, (2) administration of exogenous ovulation trigger versus spontaneous luteinising hormone surge and (3) transfer timing based on ovulation trigger versus sequential progesterone monitoring. Primary outcomes included implantation rate, clinical pregnancy and ongoing pregnancy. Statistical Analysis Used Generalised estimating equations were fitted to obtain adjusted odds ratios or rate ratios as appropriate with 95% confidence intervals for each outcome across the three primary predictors. Results A total of 183 cycles from 170 unique patients were eligible for inclusion. The average implantation rate was 0.58, resulting in an overall clinical pregnancy and ongoing pregnancy rate of 59.0% and 51.4%, respectively. After adjusting for age at embryo freeze and history of a failed embryo transfer, there were no significant associations between any predictor and implantation rate, clinical pregnancy, ongoing pregnancy, or live birth. Conclusion In NC-FET, a variety of preparation and timing protocols may lead to comparable cycle outcomes, potentially allowing for flexibility on the basis of patient and physician preference. These findings warrant validation in a larger, randomised trial.
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Affiliation(s)
- Kai N. Holder
- Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Jessica S. Mormol
- Department of Obstetrics and Gynecology, The Ohio State University, Columbus, OH, USA
| | - Jennifer B. Bakkensen
- Department of Obstetrics and Gynecology, Division of Reproductive Endocrinology and Infertility, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Mary Ellen Pavone
- Department of Obstetrics and Gynecology, Division of Reproductive Endocrinology and Infertility, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Kara N. Goldman
- Department of Obstetrics and Gynecology, Division of Reproductive Endocrinology and Infertility, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Chen Yeh
- Department of Preventive Medicine, Division of Biostatistics, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Lutfiyya N. Muhammad
- Department of Preventive Medicine, Division of Biostatistics, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Lia A. Bernardi
- Department of Obstetrics and Gynecology, Division of Reproductive Endocrinology and Infertility, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
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Hsueh YW, Huang CC, Hung SW, Chang CW, Hsu HC, Yang TC, Lin WC, Su SY, Chang HM. Finding of the optimal preparation and timing of endometrium in frozen-thawed embryo transfer: a literature review of clinical evidence. Front Endocrinol (Lausanne) 2023; 14:1250847. [PMID: 37711892 PMCID: PMC10497870 DOI: 10.3389/fendo.2023.1250847] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2023] [Accepted: 08/08/2023] [Indexed: 09/16/2023] Open
Abstract
Frozen-thawed embryo transfer (FET) has been a viable alternative to fresh embryo transfer in recent years because of the improvement in vitrification methods. Laboratory-based studies indicate that complex molecular and morphological changes in endometrium during the window of implantation after exogenous hormones with controlled ovarian stimulation may alter the interaction between the embryo and endometrium, leading to a decreased implantation potential. Based on the results obtained from randomized controlled studies, increased pregnancy rates and better perinatal outcomes have been reported following FET. Compared to fresh embryo transfer, fewer preterm deliveries, and reduced incidence of ovarian hyperstimulation syndrome were found after FETs, yet there is a trend of increased pregnancy-related hypertensive diseases in women receiving FET. Despite the increased application of FET, the search for the most optimal priming protocol for the endometrium is still undergoing. Three available FET protocols have been proposed to prepare the endometrium: i) natural cycle (true natural cycle and modified natural cycle) ii) artificial cycle (AC) or hormone replacement treatment cycle iii) mild ovarian stimulation (mild-OS) cycle. Emerging evidence suggests that the optimal timing for FET using warmed blastocyst transfer is the LH surge+6 day, hCG administration+7 day, and the progesterone administration+6 day in the true natural cycle, modified natural cycle, and AC protocol, respectively. Although still controversial, better clinical pregnancy rates and live birth rates have been reported using the natural cycle (true natural cycle/modified natural cycle) compared with the AC protocol. Additionally, a higher early pregnancy loss rate and an increased incidence of gestational hypertension have been found in FETs using the AC protocol because of the lack of a corpus luteum. Although the common clinical practice is to employ luteal phase support (LPS) in natural cycles and mild-OS cycles for FET, the requirement for LPS in these protocols remains equivocal. Recent findings obtained from RCTs do not support the routine application of endometrial receptivity testing to optimize the timing of FET. More RCTs with rigorous methodology are needed to compare different protocols to prime the endometrium for FET, focusing not only on live birth rate, but also on maternal, obstetrical, and neonatal outcomes.
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Affiliation(s)
- Ya-Wen Hsueh
- Department of Obstetrics and Gynecology, China Medical University Hospital, Taichung, Taiwan
| | - Chien-Chu Huang
- Department of Obstetrics and Gynecology, China Medical University Hospital, Taichung, Taiwan
| | - Shuo-Wen Hung
- Department of Chinese Medicine, China Medical University Hospital, Taichung, Taiwan
| | - Chia-Wei Chang
- Department of Obstetrics and Gynecology, China Medical University Hospital, Taichung, Taiwan
| | - Hsi-Chen Hsu
- Department of Obstetrics and Gynecology, China Medical University Hospital, Taichung, Taiwan
| | - Tung-Chuan Yang
- Department of Obstetrics and Gynecology, China Medical University Hospital, Taichung, Taiwan
| | - Wu-Chou Lin
- Department of Obstetrics and Gynecology, China Medical University Hospital, Taichung, Taiwan
| | - Shan-Yu Su
- Department of Chinese Medicine, China Medical University Hospital, Taichung, Taiwan
| | - Hsun-Ming Chang
- Department of Obstetrics and Gynecology, China Medical University Hospital, Taichung, Taiwan
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Coughlan C, Ata B, Gallego RD, Lawrenz B, Melado L, Samir S, Fatemi H. Interindividual variation of progesterone elevation post LH rise: implications for natural cycle frozen embryo transfers in the individualized medicine era. Reprod Biol Endocrinol 2023; 21:47. [PMID: 37202769 DOI: 10.1186/s12958-023-01096-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2023] [Accepted: 05/02/2023] [Indexed: 05/20/2023] Open
Abstract
BACKGROUND The key to optimal timing of frozen embryo transfer (FET ) is to synchronize the embryo with the receptive phase of the endometrium. Secretory transformation of the endometrium is induced by progesterone. In contrast, detection of the luteinizing hormone (LH) surge is the most common surrogate used to determine the start of secretory transformation and to schedule FET in a natural cycle. The accuracy of LH monitoring to schedule FET in a natural cycle relies heavily on the assumption that the period between the LH surge and ovulation is acceptably constant. This study will determine the period between LH rise and progesterone rise in ovulatory natural menstrual cycles. METHODS Retrospective observational study including 102 women who underwent ultrasound and endocrine monitoring for a frozen embryo transfer in a natural cycle. All women had serum LH, estradiol and progesterone levels measured on three consecutive days until (including) the day of ovulation defined with serum progesterone level exceeding 1ng/ml. RESULTS Twenty-one (20.6%) women had the LH rise 2 days prior to progesterone rise, 71 (69.6%) had on the day immediately preceding progesterone rise and 10 (9.8%) on the same day of progesterone rise. Women who had LH rise 2 days prior to progesterone rise had significantly higher body mass index and significantly lower serum AMH levels than women who had LH rise on the same day with progesterone rise. CONCLUSION This study provides an unbiased account of the temporal relationship between LH and progesterone increase in a natural menstrual cycle. Variation in the period between LH rise and progesterone rise in ovulatory cycles likely has implications for the choice of marker for the start of secretory transformation in frozen embryo transfer cycles. The study participants are representative of the relevant population of women undergoing frozen embryo transfer in a natural cycle.
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Affiliation(s)
- Carol Coughlan
- ART Fertility Clinic, Dubai, UAE.
- ART Fertility Clinic, Abu Dhabi, UAE.
| | - Baris Ata
- ART Fertility Clinic, Dubai, UAE
- ART Fertility Clinic, Abu Dhabi, UAE
- Faculty of Medicine, Department of Obstetrics & Gynecology, Koc University, Istanbul, Turkey
| | | | - Barbara Lawrenz
- ART Fertility Clinic, Abu Dhabi, UAE
- Women's University Hospital, Tuebingen, Germany
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Zhang WY, Gardner RM, Johal JK, Beshar IE, Bavan B, Milki AA, Lathi RB, Aghajanova L. Pregnancy and neonatal outcomes of letrozole versus natural cycle frozen embryo transfer of autologous euploid blastocyst. J Assist Reprod Genet 2023; 40:873-881. [PMID: 36849755 PMCID: PMC10224882 DOI: 10.1007/s10815-023-02759-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2022] [Accepted: 02/20/2023] [Indexed: 03/01/2023] Open
Abstract
PURPOSE To investigate the pregnancy and neonatal outcomes of letrozole-stimulated frozen embryo transfer (LTZ-FET) cycles compared with natural FET cycles (NC-FET). METHODS Our retrospective cohort included all LTZ-FET (n = 161) and NC-FET (n = 575) cycles that transferred a single euploid autologous blastocyst from 2016 to 2020 at Stanford Fertility Center. The LTZ-FET protocol entailed 5 mg of daily letrozole for 5 days starting on cycle day 2 or 3. Outcomes were compared using absolute standardized differences (ASD), in which a larger ASD signifies a larger difference. Multivariable regression models adjusted for confounders: maternal age, BMI, nulliparity, embryo grade, race, infertility diagnosis, and endometrial thickness. RESULTS The demographic and clinical characteristics were overall similar. A greater proportion of the letrozole cohort was multiparous, transferred high-graded embryos, and had ovulatory dysfunction. The cohorts had similar pregnancy rates (67.1% LTZ vs 62.1% NC; aOR 1.31, P = 0.21) and live birth rates (60.9% LTZ vs 58.6% NC; aOR 1.17, P = 0.46). LTZ-FET neonates on average were born 5.7 days earlier (P < 0.001) and had higher prevalence of prematurity (18.6% vs. 8.0%NC, ASD = 0.32) and low birth weight (10.4% vs. 5.0%, ASD = 0.20). Both cohorts' median gestational ages (38 weeks and 1 day for LTZ; 39 weeks and 0 day for NC) were full term. CONCLUSION There were similar rates of pregnancy and live birth between LTZ-FET and NC-FET cycles. However, there was a higher prevalence of prematurity and low birth weight among LTZ-FET neonates. Reassuringly, the median gestational age in both cohorts was full term, and while the difference in gestational length of almost 6 days does not appear to be clinically significant, this warrants larger studies.
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Affiliation(s)
- Wendy Y Zhang
- Department of Obstetrics and Gynecology, Stanford University School of Medicine, Stanford, CA, USA.
- Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, Stanford University School of Medicine, Stanford, CA, USA.
| | - Rebecca M Gardner
- Department of Medicine, Quantitative Sciences Unit, Stanford University School of Medicine, Stanford, CA, USA
| | - Jasmyn K Johal
- Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, Weill Cornell Medicine, New York, NY, USA
| | - Isabel E Beshar
- Department of Obstetrics and Gynecology, Stanford University School of Medicine, Stanford, CA, USA
| | - Brindha Bavan
- Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, Stanford University School of Medicine, Stanford, CA, USA
| | - Amin A Milki
- Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, Stanford University School of Medicine, Stanford, CA, USA
| | - Ruth B Lathi
- Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, Stanford University School of Medicine, Stanford, CA, USA
| | - Lusine Aghajanova
- Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, Stanford University School of Medicine, Stanford, CA, USA
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Jiang WJ, Sun ZG, Song JY. Premature timing of progesterone luteal phase support initiation did not negatively impact live birth rates in modified natural frozen thawed embryo transfer cycles. Heliyon 2023; 9:e13218. [PMID: 36793963 PMCID: PMC9922970 DOI: 10.1016/j.heliyon.2023.e13218] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2022] [Revised: 01/20/2023] [Accepted: 01/20/2023] [Indexed: 01/26/2023] Open
Abstract
Study question In a modified natural cycle frozen-thawed embryo transfer (mNC-FET), does the premature timing of progesterone luteal phase support (LPS) initiation 24 h following human chorionic gonadotropin (hCG) trigger impact live birth? Summary answer Premature LPS initiation did not negatively affect the live birth rate (LBR) in mNC-FET cycles compared with conventional LPS initiation 48 h after hCG triggering. What is known already During natural cycle FET, human chorionic gonadotropin is routinely used to mimic endogenous luteinizing hormone (LH) surge to induce ovulation, which allows more flexibility in embryo transfer scheduling, thus relieving the burden of multiple visits by patients and laboratory workloads, which is also known as mNC-FET. Moreover, recent data demonstrates that ovulatory women undergoing natural cycle FETs have a lower risk of maternal and fetal complications due to the essential role of the corpus luteum in implantation, placentation and pregnancy maintenance. While several studies have confirmed the positive effects of LPS in mNC-FETs, the timing of progesterone LPS initiation is still unclear, as compared with fresh cycles where robust research has been conducted. To the best of our knowledge, no clinical studies comparing different beginning days in mNC-FET cycles have been published. Study design size duration This retrospective cohort study involved 756 mNC-FET cycles performed at a university-affiliated reproductive center between January 2019 and August 2021. The primary outcome measured was the LBR. Participants/materials setting methods Ovulatory women ≤42 years of age who were referred for their autologous mNC-FET cycles were included in the study. According to the timing of progesterone LPS initiation following the hCG trigger, patients were assigned into two categories: premature LPS group (progesterone initiation 24 h after hCG trigger, n = 182) versus conventional LPS group (progesterone initiation 48 h after hCG trigger, n = 574). Multivariate logistic regression analysis was used to control for confounding variables. Main results and the role of chance There were no differences in background characteristics between the two study groups, except for the proportion of assisted hatching (53.8% in premature LPS group versus 42.3% in conventional LPS group, p = 0.007). In the premature LPS group, 56 of 182 patients (30.8%) had a live birth, compared to 179 of 574 patients (31.2%) in the conventional LPS group, with no significant difference observed between groups (adjusted odds ratio [aOR] 0.98, 95% confidence interval [CI] 0.67-1.43, p = 0.913). In addition, there was no significant difference between the two groups in other secondary outcomes. A sensitivity analysis for LBR according to the serum LH and progesterone levels on hCG trigger day also confirmed the aforementioned findings. Limitations reasons for caution In this study, retrospective analysis was conducted in a single center and was therefore prone to bias. Additionally, we did not anticipate monitoring the patient's follicle rupture and ovulation after hCG triggering. Future prospective clinical trials remain necessary to confirm our results. Wider implications of the findings While exogenous progesterone LPS was added 24 h after hCG triggering, embryo-endometrium synchrony would not be adversely affected so long as sufficient time was allowed for endometrial exposure to exogenous progesterone. Our data support promising clinical outcomes following this event. As a result of our findings, clinicians and patients will be able to make better informed decisions. Study funding/competing interests No specific funding was available for this study. The authors have no personal conflicting interests to declare. Trial registration number N/A.
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Affiliation(s)
- Wen-Jing Jiang
- The First Clinical College, Shandong University of Traditional Chinese Medicine, Jinan, China
| | - Zhen-Gao Sun
- Reproductive Center of Integrated Medicine, The Affiliated Hospital of Shandong University of Traditional Chinese Medicine, Jinan, China,Corresponding author.
| | - Jing-Yan Song
- The First Clinical College, Shandong University of Traditional Chinese Medicine, Jinan, China,Reproductive Center of Integrated Medicine, The Affiliated Hospital of Shandong University of Traditional Chinese Medicine, Jinan, China,Corresponding author. The First Clinical College, Shandong University of Traditional Chinese Medicine, Jinan, China.
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Ye H, Shi L, Quan X, Xue X, Qian Y, Tian H, Xue S, Sun L. Frozen-thawed embryo transfer in modified natural cycles: a retrospective analysis of pregnancy outcomes in ovulatory women with vs. without spontaneous luteinizing hormone surge. BMC Pregnancy Childbirth 2022; 22:814. [PMCID: PMC9635083 DOI: 10.1186/s12884-022-05161-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2021] [Accepted: 10/26/2022] [Indexed: 11/06/2022] Open
Abstract
Background Timing of frozen embryo transfer (FET) in natural endometrial preparation cycles is often based on luteinizing hormone (LH) surge. However, some patients do not show spontaneous LH surge despite follicular maturation. The objective of this study was to evaluate the impact of spontaneous LH surge on pregnancy outcomes in modified natural cycles (mNC). Methods This retrospective analysis included 1897 FET cycles with modified natural endometrial preparation in normo-ovulatory women between January 1, 2015, to December 31, 2019, at our center: 920 cycles with spontaneous LH surge (≥ 20 IU/L) and 977 without. For cleavage embryos, FET was conducted 4 and 5 days after hCG injection in women with and without LH surge, respectively. For blastocysts, FET was conducted 6 and 7 days after hCG injection in women with and without LH surge, respectively. Multivariate regression was conducted to examine the factors associated with live birth. Results Live birth rate was 43.7% in patients with spontaneous LH surge vs. 43.8% in women without LH surge (P = 0.961). The two groups also had similar implantation rate (36.2% vs. 36.7%, P = 0.772), biochemical pregnancy rate (54.8% vs. 55.4%, P = 0.796) and clinical pregnancy rate (50.9% vs. 51.7%, P = 0.721). In multivariate regression, live birth was not associated with LH surge (aOR, 0.947, 95% CI, 0.769, 1.166). Conclusion Pregnancy outcomes were similar in mNC-FET in cycles with vs. without spontaneous LH surge if FET timing is adjusted.
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Affiliation(s)
- Hongjuan Ye
- grid.24516.340000000123704535School of Life Sciences and Technology, Tongji University, Shanghai, China ,grid.24516.340000000123704535Department of Reproductive Medicine Center, Shanghai East Hospital, Tongji University School of Medicine, Shanghai, China
| | - Liya Shi
- grid.24516.340000000123704535Department of Reproductive Medicine Center, Shanghai East Hospital, Tongji University School of Medicine, Shanghai, China
| | - Xinxin Quan
- grid.24516.340000000123704535Department of Reproductive Medicine Center, Shanghai East Hospital, Tongji University School of Medicine, Shanghai, China
| | - Xue Xue
- grid.24516.340000000123704535Department of Reproductive Medicine Center, Shanghai East Hospital, Tongji University School of Medicine, Shanghai, China
| | - Ying Qian
- grid.24516.340000000123704535Department of Reproductive Medicine Center, Shanghai East Hospital, Tongji University School of Medicine, Shanghai, China
| | - Hui Tian
- grid.24516.340000000123704535Department of Reproductive Medicine Center, Shanghai East Hospital, Tongji University School of Medicine, Shanghai, China
| | - Songguo Xue
- grid.24516.340000000123704535Department of Reproductive Medicine Center, Shanghai East Hospital, Tongji University School of Medicine, Shanghai, China
| | - Lihua Sun
- grid.24516.340000000123704535Department of Reproductive Medicine Center, Shanghai East Hospital, Tongji University School of Medicine, Shanghai, China
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Pregnancy outcomes after frozen-thawed embryo transfer using letrozole ovulation induction, natural, or programmed cycles. Fertil Steril 2022; 118:690-698. [PMID: 35863997 DOI: 10.1016/j.fertnstert.2022.06.013] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2021] [Revised: 06/10/2022] [Accepted: 06/13/2022] [Indexed: 01/13/2023]
Abstract
OBJECTIVE To evaluate and compare pregnancy outcomes between letrozole ovulation induction, natural, and programmed frozen-thawed embryo transfer (FET) cycles in a population based in the United States. DESIGN Retrospective cohort study. SETTING Single university-affiliated infertility practice. PATIENT(S) A total of 3,148 FET cycles consisting of patients aged ≤45 years transferring blastocysts that were created from autologous oocytes between January 2015 and July 2021. INTERVENTION(S) None. MAIN OUTCOME MEASURE(S) The primary outcome was the ongoing pregnancy rate (OPR) or live birth rate (LBR). The secondary outcomes included clinical pregnancy and clinical loss rates (CLRs). RESULT(S) The OPR/LBR was higher among letrozole FETs than among programmed FETs (adjusted risk ratio [aRR] 1.11, 95% confidence interval [CI] 1.02-1.21) but comparable to natural FETs (aRR 1.05, 95% CI 0.96-1.14). The OPR/LBR was comparable between natural and programmed FETs (aRR 1.06, 95% CI 0.99-1.13). The CLR was lower in the natural FET group than in the programmed FET group (aRR 0.62, 95% CI 0.46-0.84). There were no differences in CLRs between letrozole and programmed FETs and between letrozole and natural FETs. Among ovulatory women, the OPR/LBR among letrozole FETs was higher than that among programmed FETs (aRR 1.16, 95% CI 1.05-1.28). The CLR among ovulatory women was significantly lower in both letrozole FETs (aRR 0.44, 95% CI 0.22-0.87) and natural FETs (aRR 0.59, 95% CI 0.43-0.80) than in programmed FETs. Among anovulatory women, the OPR/LBR in the letrozole FET group was similar to that in the programmed FET group (aRR 0.95, 95% CI 0.79-1.13). CONCLUSION(S) Letrozole and natural FET clinical outcomes were improved compared with programmed FET outcomes.
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Timing of progesterone luteal support in natural frozen-thawed embryo transfer cycles - Back to basics. Reprod Biomed Online 2022; 45:63-68. [DOI: 10.1016/j.rbmo.2022.03.021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2022] [Revised: 03/14/2022] [Accepted: 03/18/2022] [Indexed: 11/20/2022]
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The impact of euploid blastocyst morphology and maternal age on pregnancy and neonatal outcomes in natural cycle frozen embryo transfers. J Assist Reprod Genet 2022; 39:647-654. [PMID: 35122177 PMCID: PMC8995226 DOI: 10.1007/s10815-022-02423-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2021] [Accepted: 01/31/2022] [Indexed: 10/19/2022] Open
Abstract
PURPOSE To evaluate whether morphology impacts the pregnancy and neonatal outcomes of euploid blastocysts, and whether maternal age still affects outcomes when top-graded, euploid blastocysts are used. METHODS This retrospective cohort study included all natural-cycle frozen embryo transfers (NC-FET) using an autologous, euploid blastocyst from June 2016 to June 2020 (n = 610). There were five groups based on embryo grade: AA, AB, BA, BB, and "any C". For analysis of only AA-graded embryos, there were three maternal age groups: < 35, 35-39, and 40 + years. The main outcomes measured were clinical pregnancy and live birth rates, while the secondary outcomes included neonatal outcomes such as gestational age at delivery and birthweight. Multivariable logistic regression models were performed to adjust for confounders. RESULTS Euploid blastocysts with poorer morphology had lower odds of pregnancy and live birth; specifically, embryos with inner cell mass (ICM) graded as "C" had statistically significant decreased odds of pregnancy (aOR 0.33, p = 0.04) and live birth (aOR 0.32, p = 0.03) compared with ICM grade "A". The differences in pregnancy rate between trophectoderm grades were not statistically significant. Even in cycles that transferred a top-graded (AA) euploid embryo, maternal age at transfer was independently associated with outcomes. Embryo grade and maternal age, however, did not significantly impact neonatal outcomes such as prematurity and birthweight. CONCLUSION The morphology of euploid blastocysts and maternal age at NC-FET both independently impact pregnancy outcomes. Neonatal outcomes were similar across embryo morphology and maternal age groups, suggesting that lower morphology euploid embryos not be discounted as viable options for transfer.
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OUP accepted manuscript. Hum Reprod Update 2022; 28:717-732. [DOI: 10.1093/humupd/dmac012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2021] [Revised: 01/05/2022] [Indexed: 11/14/2022] Open
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Huang C, Shen X, Shi Q, Shan H, Yan Y, Liu J, Kong N. Adverse impact of elevated serum progesterone and luteinizing hormone levels on the hCG trigger day on clinical pregnancy outcomes of modified natural frozen-thawed embryo transfer cycles. Front Endocrinol (Lausanne) 2022; 13:1000047. [PMID: 36531505 PMCID: PMC9751419 DOI: 10.3389/fendo.2022.1000047] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2022] [Accepted: 11/22/2022] [Indexed: 12/04/2022] Open
Abstract
RESEARCH QUESTION The relationship between serum progesterone (P) and luteinizing hormone (LH) levels on the human chorionic gonadotropin (hCG) trigger day and the clinical pregnancy outcomes in modified natural frozen-thawed embryo transfer (mNC-FET) cycles are controversial. DESIGN This was a retrospective study of 788 mNC-FET cycles. A smooth fitting curve and threshold effect analysis was performed to identify the effect of serum P and LH levels measured on the hCG day on the clinical pregnancy rate (CPR) and live birth rate (LBR) of mNC-FET cycles. RESULTS The CPR and LBR decreased significantly when the LH level on the hCG day was greater than or equal to 32 IU/L. Further subgroup analysis showed that the CPR decreased significantly when the P level on the hCG day was equal to or greater than 1 ng/mL. When the P level was lower (< 1 ng/mL), the patients with an LH level greater than or equal to 32 IU/L had reduced CPR and LBR in mNC-FET cycles. CONCLUSION Applying the hCG trigger on a day with a higher P level (≥ 1 ng/mL) leads to a decreased CPR and LBR. hCG administration with a higher LH level (≥ 32 IU/L) also leads to a decreased CPR and LBR in mNC-FET cycles when the P level is less than 1 ng/mL.
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Affiliation(s)
- Chenyang Huang
- Center for Reproductive Medicine and Obstetrics and Gynecology, Drum Tower Clinic Medical College of Nanjing Medical University, Nanjing, China
- Reproductive Medicine Center, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, China
- Center for Molecular Reproductive Medicine, Nanjing University, Nanjing, China
| | - Xiaoyue Shen
- Center for Reproductive Medicine and Obstetrics and Gynecology, Drum Tower Clinic Medical College of Nanjing Medical University, Nanjing, China
- Reproductive Medicine Center, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, China
- Center for Molecular Reproductive Medicine, Nanjing University, Nanjing, China
| | - Qingqing Shi
- Center for Reproductive Medicine and Obstetrics and Gynecology, Drum Tower Clinic Medical College of Nanjing Medical University, Nanjing, China
- Reproductive Medicine Center, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, China
- Center for Molecular Reproductive Medicine, Nanjing University, Nanjing, China
| | - Huizhi Shan
- Center for Reproductive Medicine and Obstetrics and Gynecology, Drum Tower Clinic Medical College of Nanjing Medical University, Nanjing, China
- Reproductive Medicine Center, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, China
- Center for Molecular Reproductive Medicine, Nanjing University, Nanjing, China
| | - Yuan Yan
- Center for Reproductive Medicine and Obstetrics and Gynecology, Drum Tower Clinic Medical College of Nanjing Medical University, Nanjing, China
- Reproductive Medicine Center, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, China
- Center for Molecular Reproductive Medicine, Nanjing University, Nanjing, China
| | - Jingyu Liu
- Center for Reproductive Medicine and Obstetrics and Gynecology, Drum Tower Clinic Medical College of Nanjing Medical University, Nanjing, China
- Reproductive Medicine Center, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, China
- Center for Molecular Reproductive Medicine, Nanjing University, Nanjing, China
- *Correspondence: Jingyu Liu, ; Na Kong,
| | - Na Kong
- Center for Reproductive Medicine and Obstetrics and Gynecology, Drum Tower Clinic Medical College of Nanjing Medical University, Nanjing, China
- Reproductive Medicine Center, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, China
- Center for Molecular Reproductive Medicine, Nanjing University, Nanjing, China
- *Correspondence: Jingyu Liu, ; Na Kong,
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Zhang WY, Gardner RM, Kapphahn KI, Ramachandran MK, Murugappan G, Aghajanova L, Lathi RB. The impact of estradiol on pregnancy outcomes in letrozole-stimulated frozen embryo transfer cycles. F S Rep 2021; 2:320-326. [PMID: 34553158 PMCID: PMC8441577 DOI: 10.1016/j.xfre.2021.05.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2021] [Revised: 05/20/2021] [Accepted: 05/24/2021] [Indexed: 10/25/2022] Open
Abstract
Objective To assess the impact of low estradiol (E2) levels in letrozole-stimulated frozen embryo transfer (FET) cycles on pregnancy and neonatal outcomes. Design Retrospective cohort. Setting University-affiliated fertility center. Patients All patients who underwent letrozole-stimulated FET cycles from January 2017 to April 2020 (n = 217). The "Low E2" group was defined as those with E2 serum levels on the day of trigger <10th percentile level (E2 <91.16 pg/mL, n = 22) and the "Normal E2" group was defined as those with E2 serum levels ≥10th percentile level (E2 ≥91.16 pg/mL, n = 195). Interventions None. Main Outcome Measures Pregnancy outcomes including rates of clinical pregnancy, clinical miscarriage, and live birth. Neonatal outcomes including gestational age at delivery, birth weight, and Apgar score. Results The mean ± SD estradiol level was 66.8 ± 14.8 pg/mL for the "Low E2" group compared with 366.3 ± 322.1 pg/mL for the "Normal E2" group. There were otherwise no substantial differences in cycle characteristics such as endometrial thickness on the day of ovulation trigger and progesterone levels in early pregnancy. The "Low E2" group had a significantly higher clinical miscarriage rate (36.4% vs. 8.8%, adjusted odds ratio 8.06) and lower live birth rate (31.8% vs. 57.9%, adjusted odds ratio 0.28). Neonatal outcomes such as gestational age at delivery, mean birth weight, Apgar scores, and incidence of newborn complications were not clinically different between the groups. Conclusion Low E2 levels were associated with a significantly higher miscarriage rate and lower live birth rate, suggesting that E2 levels in the follicular phase may have an effect on cycle outcomes. Given the rise in use of FET, further studies are needed to confirm our findings and understand the mechanisms.
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Affiliation(s)
- Wendy Y Zhang
- Department of Medicine, Stanford University School of Medicine, Stanford, California.,Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, Stanford University School of Medicine, Stanford, California
| | - Rebecca M Gardner
- Quantitative Sciences Unit, Department of Medicine, Stanford University School of Medicine, Stanford, California
| | - Kristopher I Kapphahn
- Quantitative Sciences Unit, Department of Medicine, Stanford University School of Medicine, Stanford, California
| | - Maya K Ramachandran
- Department of Medicine, Stanford University School of Medicine, Stanford, California
| | - Gayathree Murugappan
- Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, Stanford University School of Medicine, Stanford, California
| | - Lusine Aghajanova
- Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, Stanford University School of Medicine, Stanford, California
| | - Ruth B Lathi
- Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, Stanford University School of Medicine, Stanford, California
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Mumusoglu S, Polat M, Ozbek IY, Bozdag G, Papanikolaou EG, Esteves SC, Humaidan P, Yarali H. Preparation of the Endometrium for Frozen Embryo Transfer: A Systematic Review. Front Endocrinol (Lausanne) 2021; 12:688237. [PMID: 34305815 PMCID: PMC8299049 DOI: 10.3389/fendo.2021.688237] [Citation(s) in RCA: 36] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2021] [Accepted: 06/23/2021] [Indexed: 11/13/2022] Open
Abstract
Despite the worldwide increase in frozen embryo transfer, the search for the best protocol to prime endometrium continues. Well-designed trials comparing various frozen embryo transfer protocols in terms of live birth rates, maternal, obstetric and neonatal outcome are urgently required. Currently, low-quality evidence indicates that, natural cycle, either true natural cycle or modified natural cycle, is superior to hormone replacement treatment protocol. Regarding warmed blastocyst transfer and frozen embryo transfer timing, the evidence suggests the 6th day of progesterone start, LH surge+6 day and hCG+7 day in hormone replacement treatment, true natural cycle and modified natural cycle protocols, respectively. Time corrections, due to inter-personal differences in the window of implantation or day of vitrification (day 5 or 6), should be explored further. Recently available evidence clearly indicates that, in hormone replacement treatment and natural cycles, there might be marked inter-personal variation in serum progesterone levels with an impact on reproductive outcomes, despite the use of the same dose and route of progesterone administration. The place of progesterone rescue protocols in patients with low serum progesterone levels one day prior to warmed blastocyst transfer in hormone replacement treatment and natural cycles is likely to be intensively explored in near future.
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Affiliation(s)
- Sezcan Mumusoglu
- Department of Obstetrics and Gynecology, Hacettepe University School of Medicine, Ankara, Turkey
| | - Mehtap Polat
- Anatolia IVF and Women Health Centre, Ankara, Turkey
| | | | - Gurkan Bozdag
- Department of Obstetrics and Gynecology, Hacettepe University School of Medicine, Ankara, Turkey
| | | | - Sandro C. Esteves
- Androfert, Andrology and Human Reproduction Clinic, Referral Center for Male Reproduction, Campinas, Brazil
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Peter Humaidan
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
- The Fertility Clinic, Skive Regional Hospital Resenvej 25, Skive, Denmark
| | - Hakan Yarali
- Department of Obstetrics and Gynecology, Hacettepe University School of Medicine, Ankara, Turkey
- Anatolia IVF and Women Health Centre, Ankara, Turkey
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