The role of steroid hormone supplementation in non–assisted reproductive technology treatments for unexplained infertility

Understanding the Associations of Urogenital Microbiomes With Fertility and In Vitro Fertilization

Infertility, defined as the inability to establish a clinical pregnancy after a year of regular, unprotected sexual intercourse, impacts 8%-12% of couples worldwide. Many of these couples turn to in vitro fertilization (IVF) to build their families. The success rate of IVF procedures is variable, with estimates of up to 40% of embryo transfers being unsuccessful. Herein we review the existing literature on the role of the female and male urogenital microbiomes and genital inflammation on fertility and IVF outcomes. We discuss the microbiome across the female reproductive tract (FRT) and identify associations with female infertility, female genital tract inflammation, and success of IVF procedures. We also discuss the male urogenital microbiome and the associations between microbial taxa, genital inflammation, and male fertility parameters. Finally, we consider microbial transfer within couples and the impact this may have on fertility and the success of IVF procedures.

Liquid chromatography-mass spectrometry applications for quantification of endogenous sex hormones

Liquid chromatography, coupled with tandem mass spectrometry, presents a powerful tool for the quantification of the sex steroid hormones 17-β estradiol, progesterone and testosterone from biological matrices. The importance of accurate quantification with these hormones, even at endogenous levels, has evolved with our understanding of the role these regulators play in human development, fertility and disease risk and manifestation. Routine monitoring of these analytes can be accomplished by immunoassay techniques, which face limitations on specificity and sensitivity, or using gas chromatography-mass spectrometry. LC-MS/MS is growing in capability and acceptance for clinically relevant quantification of sex steroid hormones in biological matrices and is able to overcome many of the limitations of immunoassays. Analyte specificity has improved through the use of novel derivatizing agents, and sensitivity has been refined through the use of high-resolution chromatography and mass spectrometric technology. This review highlights these innovations, among others, in LC-MS/MS steroid hormone analysis captured in the literature over the last decade.

Maternal age at delivery and fertility of the next generation

BACKGROUND

While most known causes of infertility relate to the health of the woman and/or her partner, questions have been raised regarding the possible contributions of transgenerational or epigenetic factors.

OBJECTIVE

The goal of this hypothesis-generating work was to examine whether Generation 1's (G1's) age at the delivery of G2 (Generation 2) was associated with G2's fertility in later life.

METHODS

We conducted a retrospective cohort study of women (G2s) recruited online in 2016. A questionnaire queried G2s regarding demographics and fertility. The primary exposure was G1's age at G2's birth. Outcome measures included the following: 12-month infertility, time to pregnancy, and childlessness. The adjusted relative risk (RR) of G2 infertility and childlessness by G1 age at G2's birth was estimated through a modified Poisson regression approach. The fecundity odds ratio (FOR) for the association between G1's age at G2 birth and time to pregnancy for G2 was estimated by discrete-time survival models, with complementary log-log link.

RESULTS

A total of 2,854 women enrolled. We found no association between G1 age at G2's birth and G2 infertility. Being born to a G1 aged 15-19 years was associated with a longer time to pregnancy for G2 (FOR 0.84, 95% confidence interval 0.72, 0.99), relative to being born to a G1 aged 20-24 years. We observed the suggestion of a possible increased risk of childlessness among G2s born to older G1s, but the estimate was imprecise.

CONCLUSIONS

While being born to a G1 who was 15-19 years old was associated with an increase in G2 time to pregnancy, we found no association between G1 age at G2's birth and infertility and only the suggestion of a modest association with childlessness. These data suggest a possible subtle effect of G1 age at G2's birth on G2 fertility, which warrants further study.

Prospective evaluation of uterine receptivity in mice

In current infertility treatments it is necessary to evaluate uterine receptivity in each menstrual cycle. During the implantation period, the uterus goes through many complex orchestrated changes, including changes to the glycocalyx. The changes to the glycocalyx are due to sialylation, sulfation and fucosylation. Can the measurement of in-vivo uterine pH and/or oxidation-reduction potential (ORP) determine the alterations of uterine endometrium for implantation and evaluate prospective uterine receptivity? In the present study we assessed in vivo uterine pH and ORP during the early stages of pregnancy in naïve mice, as well as in a murine model of implantation failure created by local and transient suppression of signal transducer and activator of transcription 3. There was no change in the in vivo uterine pH between post-coitus Days 2 and 6. In vivo uterine ORP was significantly higher compared to the day before. One day before implantation began, uterine ORP was significantly decreased in the implantation failure group compared with the naïve and control groups. Receiver operator characteristic (ROC) curve analysis of uterine ORP as a predictor of non-conception showed an area under the ROC curve of 0.96 (95% confidence interval 0.92-1.00). Thus, in vivo uterine ORP could be a parameter to prospectively evaluate uterine receptivity.

Luteal-phase progesterone supplementation in non-IVF treatment: a survey of physicians providing infertility treatment

We sought to examine current use of, and indications for, progesterone supplementation in the luteal phase of non-in vitro fertilization (non-IVF) infertility treatments among Obstetrician Gynaecologists (OB/GYN) compared to Reproductive Endocrinology and Infertility (REI) Subspecialists. Using a web-based survey, the practices of U.S. REI and OB/GYN physicians practicing infertility from 2014-2016 were assessed. The main outcome measures were frequency of use and indications for progesterone supplementation for luteal-phase support in non-IVF infertility treatments. Comparisons between physicians groups by indication and treatment type were performed using Chi-square and Fisher's exact tests. Sixty-four REIs and 49 OB/GYNs completed the survey. One hundred per cent of REI and 73.5% of OB/GYN respondents prescribed progesterone for luteal-phase support as part of non-IVF infertility treatment. The majority of all respondents utilized progesterone supplementation for one or more indications in clomiphene citrate and letrozole treatment cycles. Treatment type was the primary decisional factor reported by REIs (56%) for prescription of luteal-phase progesterone support. Serum progesterone level was reported as the leading decisional factor for luteal-phase supplementation (66.7%) by OB/GYNs. Luteal-phase progesterone supplementation in non-IVF treatments appears common for both physician groups in the United States in spite of lack of evidence supporting its effectiveness.

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.

A novel high-throughput assay for the measurement of salivary progesterone by liquid chromatography tandem mass spectrometry

Background

Liquid chromatography tandem mass spectrometry (LC-MS/MS) enables specific and sensitive quantification of steroids with a high throughput. Saliva sampling is advantageous for multisample profiling over longer periods of time, as it is non-invasive, cheap, can be carried out at home and does not require the attendance of clinical personnel. We developed a rapid LC-MS/MS for the measurement of salivary progesterone, frequently assessed as ovulation marker in patients desiring fertility.

Methods

Samples (300 μL) were prepared by supported liquid extraction using dichloromethane and were reconstituted in 40% methanol. Chromatography was performed using a C8 column with a water/methanol gradient containing 0.1% formic acid and 2 mmol/L ammonium acetate. Quantification was performed with a Waters TQ-S mass spectrometer.

Results

Total run time was 5.5 min. The lower limit of quantification was 20 pmol/L (1.2 fmol on column). Inter- and intra-assay comparison showed coefficients of variation and bias between measured and nominal concentrations of less than 11%. Mean recovery was 91%. Interference with a large set of natural and synthetic steroids was excluded. The assay was successfully applied to measure progesterone variation during the menstrual cycle ( n = 9) and diurnal variations during luteal phase ( n = 7) in regularly cycling women.

Discussion

We present a novel LC-MS/MS assay for the determination of salivary progesterone with high-throughput potential. The applicability of the assay for progesterone profiling during the menstrual cycle is demonstrated.

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

OBJECTIVE

To evaluate the effect of progesterone (P) for luteal phase support after ovulation induction (OI) and intrauterine insemination (IUI).

DESIGN

An updated systematic review and meta-analysis.

SETTING

Not applicable.

PATIENT(S)

Patients undergoing OI-IUI for infertility.

INTERVENTION(S)

Exogenous P luteal support after OI-IUI.

MAIN OUTCOME MEASURE(S)

Live birth.

RESULT(S)

Eleven trials were identified that met inclusion criteria and constituted 2,842 patients undergoing 4,065 cycles, more than doubling the sample size from the previous meta-analysis. In patients receiving gonadotropins for OI, clinical pregnancy (relative risk [RR] 1.56, 95% confidence interval [CI] 1.21-2.02) and live birth (RR 1.77, 95% CI 1.30-2.42) were more likely in P supplemented patients. These findings persisted in analysis of live birth per IUI cycle (RR 1.59, 95% CI 1.24-2.04). There were no data on live birth in clomiphene citrate or clomiphene plus gonadotropin cycles. There was no benefit on clinical pregnancy with P support for patients who underwent OI with clomiphene (RR 0.85, 95% CI 0.52-1.41) or clomiphene plus gonadotropins (RR 1.26, 95% CI 0.90-1.76).

CONCLUSION(S)

Progesterone luteal phase support is beneficial to patients undergoing ovulation induction with gonadotropins in IUI cycles. The number needed to treat is 11 patients to have one additional live birth. Progesterone support did not benefit patients undergoing ovulation induction with clomiphene citrate or clomiphene plus gonadotropins.