Impact of leuprolide acetate on luteal phase function in women undergoing controlled ovarian hyperstimulation and intrauterine insemination

Hotspots and frontiers in luteal phase defect research: An in-depth global trend bibliometric and visualization analysis over a 52-year period

Luteal phase defect (LPD) is a common female reproductive endocrine defect，which is associated not only with certain diseases but also with the menstrual cycle and fertility in women. With the development of assisted reproductive technology (ART) in recent years, the incidence of luteal phase defect is high among patients using assisted reproductive technology. The aim of this study was to evaluate worldwide research on luteal phase defects using bibliometric analysis. A total of 631 documents related to the study of luteal phase defect were identified over the last 52 years. The current status and trend of globalization can be comprehended by analyzing the annual number of publications, institutions, authors, countries and regions of corresponding authors, journals, influential luteal phase defect publications (which were highly cited), highly cited references in luteal phase defect publications (cocitation analysis) and keywords. The study results provide a comprehensive overview of the development of scientific literature and are of great significance for the future development of the field，especially infertility and early pregnancy loss.

Effects of two different types of luteal support on pregnancy outcomes following antagonist fresh embryo transfer: a retrospective study

BACKGROUND

Only a small number of studies have reported the use of progesterone vaginal gel in combination with dydrogesterone as part of the antagonist protocol for fresh embryo transfer. Therefore, this study aimed to compare the effects of two types of luteal support on pregnancy outcomes following the antagonist protocol for fresh embryo transfer.

METHODS

We performed a retrospective analysis of clinical data from infertile patients who underwent fresh embryo transfer via the antagonist protocol (2785 cycles) between February and July 2019 and between February and July 2021 at the Peking University Third Hospital Reproductive Medicine Centre. According to the luteal support received, the cycle groups were divided into the progesterone vaginal gel group (single medication or VP group; 1170 cycles) and the progesterone vaginal gel plus dydrogesterone group (combination medication or DYD + VP group; 1615 cycles). After propensity score matching, the clinical pregnancy, ongoing pregnancy, early miscarriage, and ectopic pregnancy rates were compared between the two groups.

RESULTS

In total, 1057 pairs of cycles were successfully matched via propensity scores. The clinical and ongoing pregnancy rates in the combination medication group were significantly higher than those in the single medication group (P < 0.05), whereas no significant differences were noted in the early miscarriage and ectopic pregnancy rates between the two groups (both P > 0.05).

CONCLUSIONS

Combined luteal support after the antagonist protocol is preferred for patients undergoing fresh cycle embryo transfer.

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

BACKGROUND

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

OBJECTIVES

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

SEARCH METHODS

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

SELECTION CRITERIA

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

DATA COLLECTION AND ANALYSIS

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

AUTHORS' CONCLUSIONS

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

Midluteal Progesterone: A Marker of Treatment Outcomes in Couples With Unexplained Infertility

CONTEXT

Adequate luteal phase progesterone exposure is necessary to induce endometrial changes required for a successful pregnancy outcome. The relationship between low midluteal progesterone concentration and the outcome of live birth in ovarian stimulation with intrauterine insemination (OS-IUI) treatments is not defined.

OBJECTIVE

To determine the level of midluteal progesterone portending a low chance of live birth after OS-IUI in couples with unexplained infertility.

DESIGN AND SETTING

Secondary analyses of data from a prospective, randomized, multicenter clinical trial that determined pregnancy outcomes following OS-IUI with clomiphene citrate, letrozole, or gonadotropins for couples with unexplained infertility.

PARTICIPANTS

Couples (n = 900) underwent 2376 OS-IUI cycles during the Assessment of Multiple Intrauterine Gestations from Ovarian Stimulation clinical trial.

MAIN OUTCOME MEASURES

Live birth as it relates to midluteal progesterone level and thresholds below which no live births occur by treatment group.

RESULTS

Thresholds for non-live birth cycles were similar for clomiphene (14.4 ng/mL) and letrozole (13.1 ng/mL) yet were lower for gonadotropin (4.3 ng/mL) treatments. A midluteal progesterone level >10th percentile specific for each treatment group independently was associated with greater odds for a live birth in all OS-IUI cycles (adjusted OR: 2.17; 95% CI: 1.05, 4.48).

CONCLUSIONS

During OS-IUI, a low midluteal progesterone level was associated with a low probability of live birth. Thresholds differed by medication, with the lowest threshold for gonadotropin. Several pathophysiologic mechanisms may account for low progesterone levels. Refinement of the predictive range associated with particular ovarian stimulation medications during treatment of unexplained infertility may improve accuracy.

Luteal phase support in intrauterine insemination cycles: a prospective randomized study of 300 mg versus 600 mg intravaginal progesterone tablet

Vaginal progesterone (P) has been suggested to be used for luteal phase support (LPS) in controlled ovarian stimulation (COH)-intrauterine insemination (IUI) cycles, however, no concensus exists about the best P dose. Therefore, considering the fecundability rate as the primary end point, our main objective was to find the optimal dose of P in COH-IUI cycles, comparing the two groups of women, each of which comprised of 100 women either on 300 mg or 600 mg of intravaginal P tablets, in a prospective randomized study design. The mean age of the women, duration of infertility, basal and day of hCG injection hormone levels in the female and sperm parameters were similar in the two study groups. Also, duration and dose of gonadotropin given, number of follicles, endometrial thickness, the total, ongoing and multiple pregnancy rates were comparable in both groups. We, therefore, claim that 300 mg of intravaginal micronized P should be the maximum dose of LPS in IUI cycles.

Effect of luteal phase support after ovulation induction and intrauterine insemination

OBJECTIVE

This study aimed to evaluate the effect of luteal phase support on clinical pregnancy and live birth rates after ovulation induction and intrauterine insemination (IUI).

METHODS

579 cycles from 2010 to 2013 were retrospectively evaluated. Ovarian stimulation was performed with gonadotropins, and rHCG was used for ovulation triggering. All patients received IUI. 451 cycles were supported by receiving vaginal micronized progesterone capsules (142 cycles) or vaginal progesterone gel (309 cycles) whereas 128 cycles were not supported.

RESULTS

Clinical pregnancy (20.6 versus 9.4%; p = 0.004) and live birth rates (14 versus 7%; p = 0.036) were higher for supported group than for unsupported group. Progesterone gel and micronized progesterone subgroups achieved similar clinical pregnancy and live birth rates (21.4 versus 19%, p = 0.567 and 14.2 versus 13.4%, p = 0.807; respectively).

CONCLUSIONS

Luteal phase support improved the success of IUI cycles affecting both clinical pregnancy and live birth rates when gonadotropins were used for ovulation induction. The use of vaginal progesterone gel or micronized progesterone significantly improves clinical pregnancy rates. The live birth rates were higher in the progesterone gel group, but were similar in the micronized progesterone group compared to the unsupported group.

Progesterone luteal support after ovulation induction and intrauterine insemination: a systematic review and meta-analysis

OBJECTIVE

To evaluate the effect of luteal phase P support after ovulation induction IUI.

DESIGN

A systematic review and meta-analysis.

SETTING

Not applicable.

PATIENT(S)

Undergoing ovulation induction IUI.

INTERVENTION(S)

Any form of exogenous P in ovulation induction IUI cycles.

MAIN OUTCOME MEASURE(S)

Clinical pregnancy and live birth.

RESULT(S)

Five trials were identified that met inclusion criteria and comprised 1,298 patients undergoing 1,938 cycles. Clinical pregnancy (odds ratio [OR] 1.47, 95% confidence interval [CI] 1.15-1.98) and live birth (OR 2.11, 95% CI 1.21-3.67) were more likely in P-supplemented patients. These findings persisted in analyses evaluating per IUI cycle, per patient, and first cycle only data. In subgroup analysis, patients receiving gonadotropins for ovulation induction had the most increase in clinical pregnancy with P support (OR 1.77, 95% CI 1.20-2.6). Conversely, patients receiving clomiphene citrate (CC) for ovulation induction showed no difference in clinical pregnancy with P support (OR 0.89, 95% CI 0.47-1.67).

CONCLUSION(S)

Progesterone luteal phase support may be of benefit to patients undergoing ovulation induction with gonadotropins in IUI cycles. Progesterone support did not benefit patients undergoing ovulation induction with CC, suggesting a potential difference in endogenous luteal phase function depending on the method of ovulation induction.

The effect of progesterone supplementation on pregnancy rates in controlled ovarian stimulation and intrauterine insemination cycles: a randomized prospective trial

OBJECTIVE

To evaluate the effect of vaginal progesterone as luteal phase support on pregnancy rates in controlled ovarian stimulation and intrauterine insemination cycles in couples with unexplained or mild male factor infertility.

STUDY DESIGN

290 Patients who met the inclusion criteria were included in a prospective randomized controlled trial. All patients underwent controlled ovarian stimulation and intrauterine insemination: 148 patients were randomized to start with a supported cycle and 142 patients with an unsupported cycle. In supported cycles, patients received vaginal progesterone once daily from the day after insemination until 12 weeks of pregnancy or, in non-pregnant women, for 14 days. No progesterone was given during unsupported cycles. The main outcome measures were clinical pregnancy rates per cycle.

RESULTS

In total, 148 cycles with luteal phase support and 142 cycles without luteal phase support were performed. The clinical pregnancy rates per cycle were higher for cycles with luteal phase support than for the unsupported cycles (24.3% vs. 14.1% respectively, p=0.027).

CONCLUSION

The use of vaginal suppositories as luteal phase support significantly improved clinical pregnancy rates in controlled ovarian stimulation and intrauterine insemination in patients with unexplained or mild male factor infertility.

Does the addition of a gonadotropin-releasing hormone agonist improve the pregnancy rate in intrauterine insemination? A prospective controlled trial

OBJECTIVE

The purpose of the present study was to determine if the use of a gonadotropin-releasing hormone (GnRH) agonist can improve pregnancy and live-birth rates during superovulation and intrauterine insemination (IUI).

SUBJECTS AND METHODS

In this prospective study, which started in January 2004 and finished in October 2006, women aged 18-39 years underwent 500 cycles of superovulation/IUI with (n = 254) and without (n = 246) GnRH agonist.

SETTING

Saudi Center for Assisted Reproduction, Abha, Saudi Arabia.

RESULTS

There were no significant differences with regard to patient demographics between the studied groups. In addition, there was no statistically significant difference in the live-birth, ongoing and clinical pregnancy rates per cycle for patients who received GnRH agonist and patients who did not receive GnRH agonist.

CONCLUSION

Superovulation/IUI cycles using GnRH agonist produce similar pregnancy rates to superovulation/IUI cycles without using GnRH agonist.

Effects of gonadotropin-releasing hormone agonists and antagonists on luteal function

PURPOSE OF REVIEW

This review addresses the effects of gonadotropin-releasing hormone agonists and antagonists on various aspects of the luteal phase.

RECENT FINDINGS

Recent studies have shown that use of both gonadotropin-releasing hormone agonists and antagonists during in-vitro fertilization cycles leads to alterations in the hormonal profiles of the luteal phase as well as changes in endometrial histology. Gonadotropin-releasing hormone agonists are effective in triggering final oocyte maturation and reducing the incidence of ovarian hyperstimulation syndrome. Ongoing pregnancy rates are excellent after gonadotropin-releasing hormone agonist trigger when luteal phase and early pregnancy supplementation with estradiol and progesterone is provided. Gonadotropin-releasing hormone agonists have recently been used for luteal phase support in in-vitro fertilization cycles.

SUMMARY

Although gonadotropin-releasing hormone agonists and antagonists are clinically useful, they may have adverse effects on luteal function. Luteal phase supplementation significantly improves clinical outcomes in in-vitro fertilization cycles because it may correct some of these detrimental effects. Use of gonadotropin-releasing hormone agonist to induce oocyte maturation is beneficial to patients who are at increased risk for ovarian hyperstimulation syndrome. The key factor in achieving favorable ongoing pregnancy rates with use of gonadotropin-releasing hormone agonist to induce oocyte maturation appears to be adequate luteal phase support.