Adverse impact of elevated progesterone levels on human chorionic gonadotropin trigger day on blastocyst transfer outcomes in gonadotropin-releasing hormone agonist cycles

Relationship Between Estradiol Levels Measured on the Initiation Day of GnRH Antagonist Treatment and Pregnancy Outcomes in Patients Receiving the Antagonist Protocol

Background and Objectives: The aim of this study is to evaluate the relationship between serum estradiol (E2) levels measured on the day of antagonist administration and live birth rates (LBRs) in women undergoing IVF-ET with an antagonist protocol. Materials and Methods: Data from women who underwent IVF-ET with an antagonist protocol between 2011 and 2023 were retrospectively analyzed. Patients were divided into five groups on the basis of serum E2 levels measured on the day of antagonist administration (Group I: E2 < 400 pg/mL, Group II: 400 ≤ E2 < 650 pg/mL, Group III: 650 ≤ E2 < 800 pg/mL, Group IV:800 ≤ E2 < 1000 pg/mL, and Group V: E2 ≥ 1000 pg/mL). The independent effect of serum E2 levels on live birth was analyzed via an adjusted regression model. Results: A total of 1613 patients were included in the study. The overall LBR was 32.1%. The LBRs for Groups I, II, III, IV, and V were 28.9%, 37.8%, 26.4%, 32.2%, and 34.1%, respectively (p = 0.017). In the adjusted regression model, serum E2 levels measured on the day of antagonist administration < 400 pg/mL (OR: 0.752, 95% CI: 0.580-0.999, p = 0.048) and 650 ≤ E2 < 800 pg/mL (OR: 0.595, 95% CI: 0.388-0.911, p = 0.011) were identified as factors that reduce the likelihood of a live birth, adjusting for age, infertility duration, body mass index (BMI), cycle number, quality of embryo, and number of embryos transferred. Conclusions: The serum E2 level associated with the highest LBR in women undergoing IVF-ET with an antagonist protocol was found to be in the range of 400-650. Serum E2 levels < 400 pg/mL or in the range of 650-800 pg/mL were statistically significantly associated with a reduced LBR.

Effects of trigger-day progesterone in c-IVF/ICSI cycles on blastocyst culture outcomes

Objective

To assess whether trigger-day progesterone (P) levels in conventional in vitro fertilization (c-IVF)/intracytoplasmic sperm injection (ICSI) cycles are associated with blastocyst culture outcomes.

Methods

In this retrospective analysis, 747 eligible patients (747 cycles) who adopted the gonadotropin-releasing hormone (GnRH) antagonist protocol and underwent c-IVF/ICSI between January 2021 to June 2024 were recruited. The P cutoff values were 1.0 and 1.5 ng/ml when trigger-day serum P was measured, and 4177 day3 (D3) embryos for blastocyst culture were grouped according to trigger-day P levels. Furthermore, the effects of trigger-day P on blastocyst culture outcomes were evaluated.

Results

In total, 747 cycles, 4177 D3 embryos for blastocyst culture were analyzed. After adjustments, multivariate logistic regression analysis revealed that compared with those in the normal level group, available blastocyst rate (adjusted OR, 0.780; 95% CI, 0.645-0.942; P=0.010) and D5 available blastocyst rate (adjusted OR, 0.736; 95% CI, 0.604-0.898; P=0.003) in the high level group were significantly reduced. Subgroup analysis showed that when female age was less than 35 years old, compared with that (36.30%) in the normal level group, the D5 available blastocyst rate (36.92%, adjusted OR, 0.744; 95% CI, 0.602-0.920; P=0.006) in the high level group was significantly reduced. In ICSI cycles, compared with that (28.69%) in the normal level group, the D5 available blastocyst rate (19.13%, adjusted OR, 0.369; 95% CI, 0.194-0.703; P=0.002) in the high level group was significantly decreased.

Conclusions

This study demonstrated that in the c-IVF/ICSI population, the trigger-day slightly elevated P (1.0-1.5ng/ml) was not related to blastocyst culture outcomes, while the trigger-day elevated P (>1.5ng/ml) was an important factor affecting D5 available blastocyst rate, especially when the woman was younger than 35 years old or insemination type was ICSI.

Progesterone level in assisted reproductive technology: a systematic review and meta-analysis

Elevated progesterone (EP) or inadequate progesterone levels during ART cycle monitoring may lead to cycle cancellations or further progesterone supplementation, but practice varies. It remains controversial whether modifying clinical practice in the presence or absence of EP improves clinical outcomes. This systematic review aims to investigate if progesterone levels at different phases of fresh and frozen ART cycles influence pregnancy outcomes, in particular, that pertaining to day 3 versus day 5 embryo transfers. A systematic search of EMBASE, MEDLINE, CINAHL, PubMed, SCOPUS and Web of Science identified studies from the year 2000. We included studies with women undergoing fresh and frozen IVF/ICSI cycles; with extractable per woman data on pregnancy outcomes where serum progesterone measurement was performed. We excluded interventional studies that influence clinical decisions or studies with donor cycles. The Newcastle Ottawa Scale (NOS) was used to determine the risk of bias. The primary outcome was LBR, and the secondary outcomes were OPR, CPR and MR. PICOS study protocol was used to include non-randomized studies of interventions (NRSI). Analysis was done using RevMan5 and the studies were pooled using the DerSimonian and Laird for random effects meta-analysis. The study was registered with PROSPERO (registration ID CRD42022382423). 64 studies (N = 57,988 women) were included. In fresh cycles, there is no evidence that at baseline EP impacts LBR (P > 1.5 ng/ml, OR 0.76 [95% CI 0.39-1.49], 2 studies, N = 309) and CPR (P > 1.5 ng/ml, OR 0.81 [0.38-1.71], 2 studies, N = 309). EP at ovulation trigger is associated with a lower LBR (P > 1.0 ng/ml, OR 0.40 [0.23-0.69], 2 studies, N = 2805) and CPR (P > 1.0 ng/ml, OR 0.49 [0.42-0.58], 3 studies, N = 3323; P > 1.1 ng/ml, OR 0.66 [0.53-0.83], 2 studies, N = 2444; P > 1.2 ng/ml, OR 0.61 [0.39-0.96], 6 studies, N = 844; P > 1.5 ng/ml, OR 0.37 [0.17-0.81], 6 studies, N = 13,870; P > 2.0 ng/ml, OR 0.43 [0.31-0.59], 3 studies, N = 1949) with D3 embryo but not D5 [LBR (P > 1.5 ng/ml, OR 1.02 [0.74-1.39], 3 studies, N = 5174) and CPR (P > 1.5 ng/ml, OR 0.88 [0.67-1.14], 6 studies, N = 5705)]. We could not meaningfully meta-analyse studies on the day of egg collection in fresh cycles, embryo transfer in fresh cycles, at ovulation trigger or before ovulation in natural FET cycles and FET cycles due to significant study heterogeneity. We acknowledged the limitations on including studies post year 2000 and the exclusion of studies with multiple observations, which may result in inherent publication bias and some confounding factors uncontrolled for. In conclusion, in controlled ovarian stimulation, EP at baseline did not impact on LBR; EP at ovulation trigger is associated with a lower LBR for D3 but not for D5 embryo transfer. In FET cycles, as the studies were heterogeneous, we were unable to combine the data in a meaningful way. This review is sponsored by Complete Fertility and the Ministry of Health, Malaysia.

Progesterone peak influences embryonic developmental morphokinetics on trigger day? A retrospective study

OBJECTIVE

Premature Progesterone Rise (PPR) is characterized by elevated serum progesterone concentrations either towards the end of the follicular phase or on the trigger day, surpassing a pre-defined threshold value. Aim of the study is to evaluate the impact of PPR exceeding 1.5 ng/ml at the time of hCG-trigger on embryo morphokinetic parameters and to identify predictive biomarkers of in IntraCytoplasmic Sperm Injection (ICSI) cycles outcomes.

METHODS

It is a retrospective study including patients underwent ICSI cycles in the period 2020-2023. 58 patients were recruited in the study group showing P levels in the trigger day greater than or equal to 1.5 ng/ml. A matching control group of 58 patients with P levels below 1.5 ng/ml was after selected. The general characteristics of these patients, including age, Body Mass Index (BMI), antral follicle count (AFC), anti-Müllerian hormone (AMH) and follicle-stimulating hormone (FSH) levels, the type of infertility and smoking/non-smoking patients, were recorded on the day of their initial visit. Subsequently, data were collected regarding the number of eggs retrieved, mature eggs, successfully fertilized eggs, and embryos reaching the blastocyst stage. Additionally, the timing of embryonic development and the quality of obtained blastocysts, as assessed by the degree of expansion and the characteristics of the inner cell mass (ICM) and trophectoderm (TE), were evaluated using Time-Lapse technology.

RESULTS

Elevated P levels exceeding 1.5 ng/ml on the trigger day were directly associated with a significantly larger number of antral follicles, consequently leading to a higher count of retrieved eggs, mature eggs, successfully fertilized eggs and embryos reaching the blastocyst stage. Furthermore, the analysis of morphokinetic parameters indicated faster division times and a notably greater number of high-grade blastocysts in the study group compared to the control group.

CONCLUSIONS

P levels ≥ 1.5 ng/ml on the trigger day did not negatively impact embryonic morphokinetic parameters, instead resulting in faster embryo development in the initial stages.

Predictive Role of Progesterone Levels for IVF Outcome in Different Phases of Controlled Ovarian Stimulation for Patients With and Without Endometriosis: Expert View

The study aimed to review the role of basal, trigger, and aspiration day progesterone levels (PLs) as predictors of in vitro fertilization (IVF) success for patients with and without endometriosis. A non-systematic review was conducted by searching papers published in English during the period of 1990-2023 in MEDLINE and PubMed, Embase, The Cochrane Library (Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials, Cochrane Methodology Register), and Web of Science. The most widely used IVF predictor success was the trigger day progesterone serum level. Many studies utilize the threshold level of 1.5-2.0 ng/ml. However, the predictive power of only progesterone level failed to show high sensitivity and specificity. Contrary, progesterone level on the trigger day combined with the number of mature retrieved oocytes had the highest predictive power. High baseline progesterone level was associated with poor IVF outcomes. Research on progesterone and IVF success in patients with endometriosis is limited but indicates that endometriosis patients seem to benefit from higher progesterone concentrations (≥ 37.1 ng/ml) in IVF cycles. Currently, there is limited data for a definitive insight into the mportance of progesterone in the estimation of IVF success. Nonetheless, this summarized evidence could serve as up-to-date guidance for the role of progesterone in the prediction of IVF outcomes, both in patients with and without endometriosis.

Effect of Elevated Progesterone Levels on hCG Trigger Day on Clinical Pregnancy Outcome in Short-Acting GnRHa Downregulated Cycles

Background

Previous studies suggested higher serum progesterone (P) levels were strongly associated with a lower clinical pregnancy rate (CPR) for in vitro fertilization-embryo transfer (IVF-ET). However, the effect of increased serum P levels on the day of human chorionic gonadotropin (hCG) administration on clinical outcomes in short-acting gonadotropin-releasing hormone agonist (GnRHa) downregulated IVF-ET cycles remains unclear.

Methods

We conducted a retrospective cohort study from January 2017 to December 2021, which included a total of 1664 patients receiving their first short-acting GnRHa IVF-ET cycles at our reproductive medicine centre of Nanjing Drum Tower Hospital. The smooth curve fitting and interaction analysis were employed to analyse the association between the CPR and the serum P levels with different embryo types (cleavage-stage embryo or blastocyst). In addition, total cycles were grouped according to different P levels on the trigger day of hCG administration for further analysis.

Results

The CPR of patients with increased serum P level (higher than 1.5 ng/mL) on the hCG day did not decrease. A smoothing curve fitting showed that the CPR did not change obviously with the increase in serum P levels. Subgroup analysis of different types of embryos transferred showed that no correlation was observed between the CPR and serum P levels on the day of hCG administration in cleavage-stage embryo transfer cycles. However, the CPR of patients receiving blastocyst transfer showed a downward trend with the increase in serum P levels. At the same time, an interaction analysis also confirmed that the CPR of blastocyst transfer was more likely to be affected by elevated serum P levels on the hCG day.

Conclusion

In the luteal phase short-acting GnRHa downregulated IVF-ET cycles, the elevated serum P levels on the hCG day did not affect the CPR of cleavage-stage embryo transfer but reduced the CPR of blastocyst transfer.

Premature progesterone elevation during the early and mid-follicular phases in fresh in vitro fertilization (IVF) cycles is associated with lower live birth, clinical pregnancy, and implantation rates

PURPOSE

Evaluate follicular phase progesterone elevation (≥ 1.5 ng/mL) prior to trigger during IVF stimulation and its effects on live birth rate (LBR), clinical pregnancy rate (CPR), and implantation rate (IR) in fresh IVF cycles.

METHODS

This was a retrospective cohort study within an academic clinic. A total of 6961 fresh IVF and IVF/ICSI cycles from October 1, 2015 to June 30, 2021 were included and grouped by progesterone (PR) prior to trigger: PR < 1.5 ng/mL (low PR group) and PR ≥ 1.5 ng/mL (high PR group). Main outcome measures included LBR, CPR, and IR.

RESULTS

Among all cycle starts, 1568 (22.5%) were in the high PR group and 5393 (77.5%) were in the low PR group. Of the cycles which proceeded to an embryo transfer, 416 (11.1%) were in the high PR group and 3341 (88.9%) were in the low PR group. The high PR group had significantly lower IR (RR 0.75; 95% CI 0.64-0.88), CPR (aRR 0.74; 95% CI 0.64-0.87), and LBR (aRR 0.71; 95% CI 0.59-0.85) compared to the low PR group. When stratified by progesterone on the day of trigger (TPR), there was a clinically notable decrease in IR (16.8% vs 23.3%), CPR (28.1% vs 36.0%), and LBR (22.8% vs 28.9%) in the high PR group compared to the low PR group even when TPR < 1.5 ng/mL.

CONCLUSIONS

In fresh IVF cycles in which TPR < 1.5 ng/mL, progesterone elevation ≥ 1.5 ng/mL at any point in time prior to trigger negatively impacts IR, CPR, and LBR. This data supports testing of serum progesterone in the follicular phase prior to trigger, as these patients may benefit from a freeze-all approach.