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Hendrickx S, De Vos M, De Munck N, Mackens S, Ruttens S, Tournaye H, Blockeel C. Progestin primed ovarian stimulation using dydrogesterone from day 7 of the cycle onwards in oocyte donation cycles: a longitudinal study. Reprod Biomed Online 2024; 48:103732. [PMID: 38458058 DOI: 10.1016/j.rbmo.2023.103732] [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: 07/19/2023] [Revised: 10/15/2023] [Accepted: 11/17/2023] [Indexed: 03/10/2024]
Abstract
RESEARCH QUESTION Does a progestin-primed ovarian stimulation (PPOS) protocol with dydrogesterone from cycle day 7 yield similar outcomes compared with a gonadotrophin-releasing hormone (GnRH) antagonist protocol in the same oocyte donors? DESIGN This retrospective longitudinal study included 128 cycles from 64 oocyte donors. All oocyte donors had the same type of gonadotrophin and daily dose in both stimulation cycles. The primary outcome was the number of cumulus-oocyte complexes (COC) retrieved. RESULTS The number of COC retrieved (mean ± SD 19.7 ± 10.8 versus 19.2 ± 8.3; P = 0.5) and the number of metaphase II oocytes (15.5 ± 8.4 versus 16.2 ± 7.0; P = 0.19) were similar for the PPOS and GnRH antagonist protocols, respectively. The duration of stimulation (10.5 ± 1.5 days versus 10.8 ± 1.5 days; P = 0.14) and consumption of gonadotrophins (2271.9 ± 429.7 IU versus 2321.5 ± 403.4 IU; P = 0.2) were also comparable, without any cases of premature ovulation. Nevertheless, there was a significant difference in the total cost of medication per cycle: €898.3 ± 169.9 for the PPOS protocol versus €1196.4 ± 207.5 (P < 0.001) for the GnRH antagonist protocol. CONCLUSION The number of oocytes retrieved and number of metaphase II oocytes were comparable in both stimulation protocols, with the advantage of significant cost reduction in favour of the PPOS protocol compared with the GnRH antagonist protocol. No cases of premature ovulation were observed, even when progestin was started later in the stimulation.
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Affiliation(s)
- S Hendrickx
- Brussels IVF, Universitair Ziekenhuis Brussel, Brussels, Belgium.
| | - M De Vos
- Brussels IVF, Universitair Ziekenhuis Brussel, Brussels, Belgium; Vrije Universiteit Brussel, Brussels, Belgium
| | - N De Munck
- Brussels IVF, Universitair Ziekenhuis Brussel, Brussels, Belgium
| | - S Mackens
- Brussels IVF, Universitair Ziekenhuis Brussel, Brussels, Belgium; Vrije Universiteit Brussel, Brussels, Belgium
| | - S Ruttens
- Brussels IVF, Universitair Ziekenhuis Brussel, Brussels, Belgium
| | - H Tournaye
- Brussels IVF, Universitair Ziekenhuis Brussel, Brussels, Belgium; Vrije Universiteit Brussel, Brussels, Belgium; Department of Obstetrics, Gynaecology, Perinatology and Reproduction, Institute of Professional Education, Sechenov First Moscow State Medical University of the Ministry of Health of the Russian Federation (Sechenov University), Moscow, Russia
| | - C Blockeel
- Brussels IVF, Universitair Ziekenhuis Brussel, Brussels, Belgium; Vrije Universiteit Brussel, Brussels, Belgium; Department of Obstetrics and Gynaecology, School of Medicine, University of Zagreb, Zagreb, Croatia
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Metello J, Tomás C, Ferreira P, Natário I, Santos-Ribeiro S. Impact of dydrogesterone use in cycles with low progesterone levels on the day of frozen embryo transfer. J Assist Reprod Genet 2024:10.1007/s10815-024-03118-5. [PMID: 38676842 DOI: 10.1007/s10815-024-03118-5] [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: 12/13/2023] [Accepted: 04/05/2024] [Indexed: 04/29/2024] Open
Abstract
PURPOSE This study aims to evaluate whether the clinical outcomes of cycles with frozen embryo transfer (FET) in hormonal replacement treatment supplemented with dydrogesterone (DYD) following detection of low circulating levels of progesterone (P4) were comparable to the results of cycles with otherwise normal serum P4 values. METHODS Extended analyses of a retrospective cohort that included FET cycles performed between July 2019 and March 2022 after a cycle of artificial endometrial preparation using valerate-estradiol and micronized vaginal P4 (400 mg twice daily). Whenever the serum P4 value was considered low on the morning of the planned transfer, 10 mg of DYD three times a day was added as a supplement. Only single-embryo transfers of a blastocyst were considered. The primary endpoint was live birth rate. RESULTS Five-hundred thirty-five FET cycles were analyzed, of which 136 (25.4%) underwent treatment with DYD. There were 337 pregnancies (63%), 207 live births (38.6%), and 130 miscarriages (38.5%). The P4 values could be modeled by a gamma distribution, with a mean of 14.5 ng/ml and a standard deviation of 1.95 ng/ml. The variables female age on the day of FET, ethnicity, and weight were associated with a variation in the serum P4 values. There were no differences in the results between cycles with or without the indication for DYD supplementation. CONCLUSIONS Live birth rate did not vary significantly in females with low and normal serum P4 levels on the day of FET when DYD was used as rescue therapy.
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Affiliation(s)
- Jose Metello
- Serviço de Ginecologia e Obstetricia, Hospital Garcia de Orta, Almada, Portugal.
| | | | | | - Isabel Natário
- NOVA MATH & Department of Mathematics, NOVA School of Science and Technology, NOVA University of Lisbon, Almada, Portugal
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Loreti S, Thiele K, De Brucker M, Olsen C, Centelles-Lodeiro J, Bourgain C, Waelput W, Tournaye H, Griesinger G, Raes J, Vieira-Silva S, Arck P, Blockeel C, Mackens S. Oral dydrogesterone versus micronized vaginal progesterone for luteal phase support: a double-blind crossover study investigating pharmacokinetics and impact on the endometrium. Hum Reprod 2024; 39:403-412. [PMID: 38110714 DOI: 10.1093/humrep/dead256] [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: 08/18/2023] [Revised: 11/06/2023] [Indexed: 12/20/2023] Open
Abstract
STUDY QUESTION How do plasma progesterone (P) and dydrogesterone (D) concentrations together with endometrial histology, transcriptomic signatures, and immune cell composition differ when oral dydrogesterone (O-DYD) or micronized vaginal progesterone (MVP) is used for luteal phase support (LPS)? SUMMARY ANSWER Although after O-DYD intake, even at steady-state, plasma D and 20αdihydrodydrogesterone (DHD) concentrations spiked in comparison to P concentrations, a similar endometrial signature was observed by histological and transcriptomic analysis of the endometrium. WHAT IS KNOWN ALREADY O-DYD for LPS has been proven to be noninferior compared to MVP in two phase III randomized controlled trials. Additionally, a combined individual participant data and aggregate data meta-analysis indicated that a higher pregnancy rate and live birth rate may be obtained in women receiving O-DYD versus MVP for LPS in fresh IVF/ICSI cycles. Little data are available on the pharmacokinetic (PK) profiles of O-DYD versus MVP and their potential molecular differences at the level of the reproductive organs, particularly at the endometrial level. STUDY DESIGN, SIZE, DURATION Thirty oocyte donors were planned to undergo two ovarian stimulation (OS) cycles with dual triggering (1.000 IU hCG + 0.2 mg triptorelin), each followed by 1 week of LPS: O-DYD or MVP, in a randomized, cross-over, double-blind, double-dummy fashion. On both the first and eighth days of LPS, serial blood samples upon first dosing were harvested for plasma D, DHD, and P concentration analyses. On Day 8 of LPS, an endometrial biopsy was collected for histologic examination, transcriptomics, and immune cell analysis. PARTICIPANTS/MATERIALS, SETTING, METHODS All oocyte donors were <35 years old, had regular menstrual cycles, no intrauterine contraceptive device, anti-Müllerian hormone within normal range and a BMI ≤29 kg/m2. OS was performed on a GnRH antagonist protocol followed by dual triggering (1.000 IU hCG + 0.2 mg triptorelin) as soon as ≥3 follicles of 20 mm were present. Following oocyte retrieval, subjects initiated LPS consisting of MVP 200 mg or O-DYD 10 mg, both three times daily. D, DHD, and P plasma levels were measured using liquid chromatography-tandem mass spectrometry. Histological assessment was carried out using the Noyes criteria. Endometrial RNA-sequencing was performed for individual biopsies and differential gene expression was analyzed. Endometrial single-cell suspensions were created followed by flow cytometry for immune cell typing. MAIN RESULTS AND THE ROLE OF CHANCE A total of 21 women completed the entire study protocol. Subjects and stimulation characteristics were found to be similar between groups. Following the first dose of O-DYD, the average observed maximal plasma concentrations (Cmax) for D and DHD were 2.9 and 77 ng/ml, respectively. The Cmax for D and DHD was reached after 1.5 and 1.6 h (=Tmax), respectively. On the eighth day of LPS, the first administration of that day gave rise to a Cmax of 3.6 and 88 ng/ml for D and DHD, respectively. For both, the observed Tmax was 1.5 h. Following the first dose of MVP, the Cmax for P was 16 ng/ml with a Tmax of 4.2 h. On the eighth day of LPS, the first administration of that day showed a Cmax for P of 21 ng/ml with a Tmax of 7.3 h. All 42 biopsies showed endometrium in the secretory phase. The mean cycle day was 23.9 (±1.2) in the O-DYD group versus 24.0 (±1.3) in the MVP group. RNA-sequencing did not reveal significantly differentially expressed genes between samples of both study groups. The average Euclidean distance between samples following O-DYD was significantly lower than following MVP (respectively 12.1 versus 18.8, Mann-Whitney P = 6.98e-14). Immune cell profiling showed a decrease of CD3 T-cell, γδ T-cell, and B-cell frequencies after MVP treatment compared to O-DYD, while the frequency of natural killer (NK) cells was significantly increased. LIMITATIONS, REASONS FOR CAUTION The main reason for caution is the small sample size, given the basic research nature of the project. The plasma concentrations are best estimates as this was not a formal PK study. Whole tissue bulk RNA-sequencing has been performed not correcting for bias caused by different tissue compositions across biopsies. WIDER IMPLICATIONS OF THE FINDINGS This is the first study comparing O-DYD/MVP, head-to-head, in a randomized design on a molecular level in IVF/ICSI. Plasma serum concentrations suggest that administration frequency is important, in addition to dose, specifically for O-DYD showing a rapid clearance. The molecular endometrial data are overall comparable and thus support the previously reported noninferior reproductive outcomes for O-DYD as compared to MVP. Further research is needed to explore the smaller intersample distance following O-DYD and the subtle changes detected in endometrial immune cells. STUDY FUNDING/COMPETING INTEREST(S) Not related to this work, C.Bl. has received honoraria for lectures, presentations, manuscript writing, educational events, or scientific advice from Abbott, Ferring, Organon, Cooper Surgical, Gedeon-Richter, IBSA, and Merck. H.T. has received honoraria for lectures, presentations, manuscript writing, educational events, or scientific advice from Abbott, Ferring, Cooper Surgical, Gedeon-Richter, Cook, and Goodlife. S.M. has received honoraria for lectures, presentations, educational events, or scientific advice from Abbott, Cooper Surgical, Gedeon-Richter, IBSA, and Merck and Oxolife. G.G. has received honoraria for lectures, presentations, educational events, or scientific advice from Merck, MSD, Organon, Ferring, Theramex, Gedeon-Richter, Abbott, Biosilu, ReprodWissen, Obseva, PregLem, Guerbet, Cooper, Igyxos, and OxoLife. S.V.-S. is listed as inventor on two patents (WO2019115755A1 and WO2022073973A1), which are not related to this work. TRIAL REGISTRATION NUMBER EUDRACT 2018-000105-23.
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Affiliation(s)
- S Loreti
- Brussels IVF, Centre for Reproductive Medicine, Universitair Ziekenhuis Brussel, Jette, Belgium
| | - K Thiele
- Division of Experimental Feto-Maternal Medicine, Department of Obstetrics and Fetal Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - M De Brucker
- Brussels IVF, Centre for Reproductive Medicine, Universitair Ziekenhuis Brussel, Jette, Belgium
| | - C Olsen
- Brussels Interuniversity Genomic High-Throughput Core Facility (BrightCore), Vrije Universiteit Brussel, Brussels, Belgium
- Vrije Universiteit Brussel (VUB), Universitair Ziekenhuis Brussel (UZ Brussel), Clinical Sciences, Research Group Reproduction and Genetics, Centre for Medical Genetics, Brussels, Belgium
- Interuniversity Institute of Bioinformatics in Brussels (IB)2, VUB-ULB, Brussels, Belgium
| | - J Centelles-Lodeiro
- Vlaams Instituut voor Biotechnologie (VIB), Katholieke Universiteit Leuven, Leuven, Belgium
| | - C Bourgain
- Reproductive Immunology and Implantation Research Group (REIM), Vrije Universiteit Brussel, Brussels, Belgium
| | - W Waelput
- Department of Pathology, Universitair Ziekenhuis Brussel, Brussels, Belgium
| | - H Tournaye
- Brussels IVF, Centre for Reproductive Medicine, Universitair Ziekenhuis Brussel, Jette, Belgium
| | - G Griesinger
- Department of Gynecological Endocrinology and Reproductive Medicine, University Hospital of Schleswig-Holstein, Campus Luebeck, Germany
| | - J Raes
- Vlaams Instituut voor Biotechnologie (VIB), Katholieke Universiteit Leuven, Leuven, Belgium
| | - S Vieira-Silva
- Institute of Medical Microbiology and Hygiene and Research Center for Immunotherapy (FZI), University Medical Center of the Johannes Gutenberg-University Mainz, Mainz, Germany
- Institute of Molecular Biology (IMB), Mainz, Germany
| | - P Arck
- Division of Experimental Feto-Maternal Medicine, Department of Obstetrics and Fetal Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - C Blockeel
- Brussels IVF, Centre for Reproductive Medicine, Universitair Ziekenhuis Brussel, Jette, Belgium
| | - S Mackens
- Brussels IVF, Centre for Reproductive Medicine, Universitair Ziekenhuis Brussel, Jette, Belgium
- Reproductive Immunology and Implantation Research Group (REIM), Vrije Universiteit Brussel, Brussels, Belgium
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Patki A. Role of Dydrogesterone for Luteal Phase Support in Assisted Reproduction. Reprod Sci 2024; 31:17-29. [PMID: 37488405 DOI: 10.1007/s43032-023-01302-z] [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: 12/14/2022] [Accepted: 07/10/2023] [Indexed: 07/26/2023]
Abstract
Clinical outcomes of in vitro fertilization (IVF) have significantly improved over the years with the advent of the frozen-thawed embryo transfer (FET) technique. Ovarian hyperstimulation during IVF cycles causes luteal phase deficiency, a condition of insufficient progesterone. Intramuscular or vaginal progesterone and dydrogesterone are commonly used for luteal phase support in FET. Oral dydrogesterone has a higher bioavailability than progesterone and has high specificity for progesterone receptors. Though micronized vaginal progesterone has been the preferred option, recent data suggest that oral dydrogesterone might be an alternative therapeutic option for luteal phase support to improve clinical outcomes of IVF cycles. Dydrogesterone has a good safety profile and is well tolerated. Its efficacy has been evaluated in several clinical studies and demonstrated to be non-inferior to micronized vaginal progesterone in large-scale clinical trials. Oral dydrogesterone may potentially become a preferred drug for luteal phase support in millions of women undergoing IVF.
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Affiliation(s)
- Ameet Patki
- Fertility Associates Khar, 4Th Floor, Gupte House, 81 SV Road, Khar West, Mumbai, 400052, Maharashtra, India.
- Hinduja Group of Hospitals, Khar West, Mumbai, India.
- Surya Hospital Mumbai, Mumbai, India.
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Muneeba S, Acharya N, Mohammad S. The Role of Dydrogesterone in the Management of Luteal Phase Defect: A Comprehensive Review. Cureus 2023; 15:e48194. [PMID: 38050524 PMCID: PMC10693668 DOI: 10.7759/cureus.48194] [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: 08/26/2023] [Accepted: 11/02/2023] [Indexed: 12/06/2023] Open
Abstract
The luteal phase of the menstrual cycle is a pivotal period characterized by hormonal intricacies that lay the foundation for successful embryo implantation and early pregnancy development. Luteal phase defect (LPD), marked by abnormalities in luteal function, presents challenges that can impede reproductive outcomes. This comprehensive review article explores the role of dydrogesterone in LPD management, elucidating its mechanisms of action, evidence of efficacy, safety profile, and potential in combination therapies. Dydrogesterone, a synthetic progestogen, closely mirrors natural progesterone's actions, effectively supplementing the luteal phase and enhancing endometrial receptivity. Clinical studies demonstrate improved pregnancy rates, extended luteal phase support, and enhanced reproductive outcomes with dydrogesterone supplementation. Its favorable safety profile, minimal side effects, and reduced risk of unwanted hormonal effects contribute to its appeal. Furthermore, dydrogesterone's inclusion in international guidelines solidifies its importance in LPD management. Combination therapies, leveraging synergistic effects, offer a comprehensive approach. As gaps in knowledge persist, future research directions and personalized treatment strategies pave the way for a future where dydrogesterone stands as a beacon of hope in conquering the challenges of LPD and achieving successful reproductive outcomes.
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Affiliation(s)
- Shaikh Muneeba
- Obstetrics and Gynecology, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
| | - Neema Acharya
- Obstetrics and Gynecology, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
| | - Shazia Mohammad
- Obstetrics and Gynecology, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
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Deng T, Lin Y, Chen L, Jiang JY. Comparison of Dydrogesterone and GnRH-a Effects After Laparoscopic Surgery in Patients with Stage III and IV Endometriosis. Int J Gen Med 2023; 16:4357-4364. [PMID: 37786803 PMCID: PMC10541528 DOI: 10.2147/ijgm.s429953] [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: 07/11/2023] [Accepted: 09/14/2023] [Indexed: 10/04/2023] Open
Abstract
Objective To compare the spontaneous pregnancy rates between dydrogesterone and Gonadotropin-releasing hormone agonist (GnRH-a) treatments in patients with endometriosis stage III and IV after laparoscopy. Methods The clinical data of patients with endometriosis stage III and IV administered laparoscopic surgery in our hospital from January 2018 to March 2020 were retrospectively analyzed. Totally 151 cases were divided into two groups according to postoperative medication, including the study (70 cases) and control (81 cases) groups treated with dydrogesterone and GnRH-a, respectively. The spontaneous pregnancy and subsequent pregnancy outcomes were assessed within 12 months. Results Totally 49 patients had spontaneous pregnancy. Among them, there were 31 cases in the dydrogesterone group (spontaneous pregnancy rate of 44.3%, 31/70), including 25 live birth cases (35.7%, 25/70), 4 miscarriage cases, and 2 ectopic pregnancy cases. The time to conception was 1-10 months (median value of 5 months). Totally 18 cases in the GnRH-a group had spontaneous pregnancy (22.2%, 18/81), including 16 live birth cases (19.8%, 16/81). 81) and 2 miscarriage cases; the time to conception was 3-11 months (median value of 6 months). There were significant differences in spontaneous pregnancy rate and cumulative spontaneous pregnancy rate between the two groups (P = 0.005 and 0.003, respectively). Conclusion Dydrogesterone after laparoscopic surgery in patients with endometriosis stage III and IV improved the natural pregnancy rate.
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Affiliation(s)
- Ting Deng
- Department of Obstetrics and Gynecology, Fujian Maternity and Child Health Hospital, College of Clinical Medicine for Obstetrics & Gynecology and Pediatrics, Fujian Medical University, Fuzhou, 350001, People’s Republic of China
| | - Yin Lin
- Department of Obstetrics and Gynecology, Fujian Maternity and Child Health Hospital, College of Clinical Medicine for Obstetrics & Gynecology and Pediatrics, Fujian Medical University, Fuzhou, 350001, People’s Republic of China
| | - Li Chen
- Department of Obstetrics and Gynecology, Fujian Maternity and Child Health Hospital, College of Clinical Medicine for Obstetrics & Gynecology and Pediatrics, Fujian Medical University, Fuzhou, 350001, People’s Republic of China
| | - Jun-Ying Jiang
- Department of Obstetrics and Gynecology, Fujian Maternity and Child Health Hospital, College of Clinical Medicine for Obstetrics & Gynecology and Pediatrics, Fujian Medical University, Fuzhou, 350001, People’s Republic of China
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Yu Y, Yu T, Ding W, Xiu Y, Zhao M, Sun K, Zhang Q, Xu X. Evaluation of allylestrenol for clinical pregnancies in patients treated with assisted reproductive techniques: a retrospective, propensity score matched, observational study. BMC Pregnancy Childbirth 2023; 23:660. [PMID: 37704955 PMCID: PMC10500903 DOI: 10.1186/s12884-023-05970-2] [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: 10/20/2022] [Accepted: 09/04/2023] [Indexed: 09/15/2023] Open
Abstract
BACKGROUND Allylestrenol is an oral progestogen being increasingly used for luteal phase support in assisted reproductive techniques. However, evidence of the clinical efficacy of allylestrenol in luteal phase support is lacking. Dydrogesterone is a representative drug used for luteal phase support, the efficacy of which has been clinically confirmed. As such, we aimed to compare the effects of allylestrenol with the standard dydrogesterone on clinical pregnancy rates and pregnancy outcomes. METHODS This retrospective study included 3375 assisted reproductive technique cycles using either allylestrenol or dydrogesterone between January 2015 and March 2020. Patients using either allylestrenol or dydrogesterone were matched in a 1:1 ratio using propensity scores. The primary outcomes were clinical pregnancy rate and pregnancy outcomes. RESULTS No significant difference was found in the clinical pregnancy rate (53.5% vs. 53.2%, P = 0.928) and pregnancy outcomes (all P > 0.05) between allylestrenol and dydrogesterone. Compared with dydrogesterone, the use of allylestrenol significantly reduced the rate of biochemical pregnancies (6.4% vs. 11.8%, P < 0.001) and multiple gestation rate (16.8% vs. 26.3%, P = 0.001). Moreover, endometrial thickness, morphology, and blood flow were significantly improved by allylestrenol treatment (all P < 0.05). CONCLUSIONS Allylestrenol exhibited similar effects on clinical pregnancy rates and pregnancy outcomes as dydrogesterone. Moreover, allylestrenol can significantly reduce the biochemical pregnancy rate and improve the endometrial receptivity.
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Affiliation(s)
- Yuexin Yu
- Department of Reproductive Medicine, General Hospital of Northern Theater Command, Shenyang, Liaoning, 110000, China.
| | - Tingting Yu
- Department of Reproductive Medicine, General Hospital of Northern Theater Command, Shenyang, Liaoning, 110000, China
| | - Weiping Ding
- Obstetrics and gynecology clinic of the 79th Army Group Hospital, Liaoyang, Liaoning, 111000, China
| | - Yinling Xiu
- Department of Reproductive Medicine, General Hospital of Northern Theater Command, Shenyang, Liaoning, 110000, China
| | - Mengsi Zhao
- Department of Reproductive Medicine, General Hospital of Northern Theater Command, Shenyang, Liaoning, 110000, China
| | - Kaixuan Sun
- Department of Reproductive Medicine, General Hospital of Northern Theater Command, Shenyang, Liaoning, 110000, China
| | - Qian Zhang
- Department of Reproductive Medicine, General Hospital of Northern Theater Command, Shenyang, Liaoning, 110000, China
| | - Xiaohang Xu
- Department of Reproductive Medicine, General Hospital of Northern Theater Command, Shenyang, Liaoning, 110000, China
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Naghshineh E, Ghasemi Tehrani H, Sharifian F, Haghighat S. A Comparison of Oral Dydrogesterone with Vaginal Progesterone for Luteal-Phase Support in In vitro Fertilization: A Randomized Controlled Trial. Adv Biomed Res 2023; 12:132. [PMID: 37434944 PMCID: PMC10331522 DOI: 10.4103/abr.abr_253_22] [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: 07/30/2022] [Revised: 11/21/2022] [Accepted: 11/26/2022] [Indexed: 07/13/2023] Open
Abstract
Background The quality of the luteal phase is the most important issue affecting pregnancy outcomes in assisted reproductive technology (ART). Luteal-phase support with the administration of gonadotropin-releasing hormone (GnRH) agonist or progesterone improves the likelihood of pregnancy in ART. Due to disagreements regarding the best pharmaceutical form of progesterone for success of in vitro fertilization (IVF) in ART methods, the present study aimed to compare the clinical efficacy of oral dydrogesterone with vaginal progesterone on the outcome of pregnancy in IVF. Materials and Methods This unblinded randomized clinical trial was conducted at the Shahid Beheshti Hospital, Obstetrics and Gynecology Centre in Isfahan, Iran, between june 2021 and September 2021. In total, 126 couples were included in the study. All patients underwent controlled ovarian stimulation and IVF. Patients were randomly divided into two groups (n = 63 per group). After embryo transfer, group I was treated with Cyclogest 400 mg twice daily, and group II was treated with oral Duphaston 10 mg twice daily. Results No significant differences were observed between the two groups in terms of the mean endometrial thickness (P = 0.613), the mean number of transferred embryos (P = 0.100), and the number of implanted embryos (P = 0.338). Additionally, no statistically significant differences in the pregnancy rate were detected between the two groups (P = 0.875). Conclusions The evidence from this study indicates that Duphaston is as effective as Cyclogest for luteal-phase support.
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Affiliation(s)
- Elham Naghshineh
- Department of Obstetrics and Gynecology, School of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Hatav Ghasemi Tehrani
- Department of Obstetrics and Gynecology, School of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Fatemeh Sharifian
- Department of Obstetrics and Gynecology, School of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Somayeh Haghighat
- Physiology Research Centre, Kashan University of Medical Sciences, Kashan, Iran
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Tetruashvili N, Domar A, Bashiri A. Prevention of Pregnancy Loss: Combining Progestogen Treatment and Psychological Support. J Clin Med 2023; 12:jcm12051827. [PMID: 36902614 PMCID: PMC10003391 DOI: 10.3390/jcm12051827] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2022] [Revised: 01/26/2023] [Accepted: 02/19/2023] [Indexed: 03/03/2023] Open
Abstract
Pregnancy loss can be defined as a loss before either 20 or 24 weeks of gestation (based on the first day of the last menstrual period) or the loss of an embryo or fetus less than 400 g in weight if the gestation age is unknown. Approximately 23 million pregnancy losses occur worldwide every year, equating to 15-20% of all clinically recognized pregnancies. A pregnancy loss is usually associated with physical consequences, such as early pregnancy bleeding ranging in severity from spotting to hemorrhage. However, it can also be associated with profound psychological distress, which can be felt by both partners and may include feelings of denial, shock, anxiety, depression, post-traumatic stress disorder, and suicide. Progesterone plays a key part in the maintenance of a pregnancy, and progesterone supplementation has been assessed as a preventative measure in patients at increased risk of experiencing a pregnancy loss. The primary objective of this piece is to assess the evidence for various progestogen formulations in the treatment of threatened and recurrent pregnancy loss, postulating that an optimal treatment plan would preferably include a validated psychological support tool as an adjunct to appropriate pharmacological treatment.
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Affiliation(s)
- Nana Tetruashvili
- V.I. Kulakov Obstetrics, National Medical Research Center for Obstetrics, Gynecology and Perinatology, Ministry of Healthcare of the Russian Federation, 117977 Moscow, Russia
| | - Alice Domar
- Inception Fertility, Houston, TX 77081, USA
- Obstetrics, Gynecology and Reproductive Biology, Harvard Medical School, Boston, MA 02115, USA
| | - Asher Bashiri
- Faculty of Health Science, Ben-Gurion University of the Negev, Be’er-Sheva 84101, Israel
- Maternity C Ward & Recurrent Pregnancy Loss Prevention Clinic, Maternal Fetal Medicine and Ultrasound, Soroka University Medical Center, Be’er-Sheva 84101, Israel
- Correspondence: ; Tel.: +972-08-6400842
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Pabuccu E, Kovanci E, Israfilova G, Tulek F, Demirel C, Pabuccu R. Oral, vaginal or intramuscular progesterone in programmed frozen embryo transfer cycles: a pilot randomized controlled trial. Reprod Biomed Online 2022; 45:1145-1151. [PMID: 36153226 DOI: 10.1016/j.rbmo.2022.06.027] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2022] [Revised: 06/09/2022] [Accepted: 06/30/2022] [Indexed: 12/31/2022]
Abstract
RESEARCH QUESTION What should be the optimal route of luteal support in programmed frozen embryo transfer (FET) cycles? DESIGN This was a randomized, parallel, phase IV pilot trial with three groups of women undergoing FET along with hormone replacement therapy for endometrial preparation at a tertiary private IVF centre (NCT03948022). Women with at least one autologous cryopreserved blastocyst were included. After preparing the endometrium with oestradiol, 151 women were randomly assigned to one of the following three progesterone arms before embryo transfer: oral (10 mg) dydrogesterone (DYD), total daily dose 40 mg (n = 52); 8% (90 mg) progesterone vaginal gel (VAG), total daily dose 180 mg (n = 55); or intramuscular progesterone (IMP) 50 mg/ml in oil, total daily dose 100 mg (n = 44). One or two vitrified-warmed blastocysts were transferred after 5 days' progesterone support. RESULTS Baseline demographic features and embryological data were comparable among the groups. Ongoing pregnancy rates (40.4%, 38.2% and 45.5% in the DYD, VAG and IMP arms; P = 0.76) and live birth rates (40.4%, 38.2% and 43.2% in the DYD, VAG and IMP arms, P = 0.61) were statistically similar. Biochemical pregnancy rates and clinical miscarriage rates were also statistically similar among the groups. Significantly more patients with at least one side effect and moderate-to-severe side effects were documented in the IMP arm than the other groups (P < 0.001). CONCLUSIONS Treatment with 40 mg/day oral DYD, 180 mg/day progesterone VAG gel or 100 mg/day IMP revealed similar reproductive outcomes in programmed FET cycles. Side effects were significantly more frequent in the IMP arm.
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Affiliation(s)
- Emre Pabuccu
- Department of Obstetrics and Gynecology, Ufuk University School of Medicine, Ankara, Turkey.
| | | | | | - Fırat Tulek
- Department of Obstetrics and Gynecology, Memorial Ataşehir Hospital, İstanbul, Turkey
| | - Cem Demirel
- Department of Obstetrics and Gynecology, Memorial Ataşehir Hospital, İstanbul, Turkey
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Metello J, Tomas C, Ferreira P, Santos-Ribeiro S. The Addition of Dydrogesterone after Frozen Embryo Transfer in Hormonal Substituted Cycles with Low Progesterone Levels. REVISTA BRASILEIRA DE GINECOLOGIA E OBSTETRÍCIA 2022; 44:930-937. [PMID: 36446559 PMCID: PMC9708401 DOI: 10.1055/s-0042-1751058] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2021] [Accepted: 04/18/2022] [Indexed: 12/03/2022] Open
Abstract
OBJECTIVE To determine whether a rescue strategy using dydrogesterone (DYD) could improve the outcomes of frozen embryo transfer cycles (FET) with low progesterone (P4) levels on the day of a blastocyst transfer. METHODS Retrospective cohort study including FET cycles performed between July 2019 and October 2020 following an artificial endometrial preparation cycle using estradiol valerate and micronized vaginal P4 (400 mg twice daily). Whenever the serum P4 value was below 10 ng/mL on the morning of the planned transfer, DYD 10 mg three times a day was added as supplementation. The primary endpoint was ongoing pregnancy beyond 10 weeks. The sample was subdivided into two groups according to serum P4 on the day of FET: low (< 10 ng/mL, with DYD supplementation) or normal (above 10 ng/mL). We performed linear or logistic generalized estimating equations (GEE), as appropriate. RESULTS We analyzed 304 FET cycles from 241 couples, 11.8% (n = 36) of which had serum P4 below 10 ng/mL on the FET day. Baseline clinical data of patients was comparable between the study groups.Overall, 191 cycles (62.8%) had a biochemical pregnancy, of which 131 (44,1%) were ongoing pregnancies, with a 29,8% miscarriage rate. We found no statistically significant differences in the hCG positive (63 vs 64%) or ongoing pregnancy rates (50 vs 43,3%) between those FETs with low or normal serum P4 values, even after multivariable logistic regression modelling. CONCLUSION Our results indicate that DYD 10 mg three times a day administered in women who perform FET with P4 serum levels < 10 ng/mL, allows this group to have pregnancy rates beyond 12 weeks at least as good as those with serum levels above 10 ng/mL.
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Affiliation(s)
- Jose Metello
- Hospital Garcia de Orta, Cirma, Almada, Portugal.
- Ginemed, Ginemed-Lisboa, Lisboa, Portugal.
| | | | - Pedro Ferreira
- Hospital Garcia de Orta, Cirma, Almada, Portugal.
- Ginemed, Ginemed-Lisboa, Lisboa, Portugal.
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Eggersmann TK, Wolthuis A, van Amsterdam PH, Griesinger G. Lack of analytical interference of dydrogesterone in progesterone immunoassays. Clin Chem Lab Med 2022; 60:1039-1045. [PMID: 35535412 DOI: 10.1515/cclm-2022-0174] [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: 02/25/2022] [Accepted: 04/06/2022] [Indexed: 11/15/2022]
Abstract
OBJECTIVES Progesterone, a sex steroid, is measured in serum by immunoassay in a variety of clinical contexts. One potential limitation of steroid hormone immunoassays is interference caused by compounds with structural similarity to the target steroid of the assay. Dydrogesterone (DYD), an orally active stereoisomer of progesterone, is used for various indications in women's health. Herein, we report a systematic in vitro investigation of potential interference of DYD and its active metabolite 20α-dihydrodydrogesterone (DHD) in seven widely used, commercially available progesterone assays. METHODS Routine human plasma samples were anonymized and pooled to create three graded concentration levels of progesterone (P4 high, P4 medium, P4 low). Each pooled P4 plasma sample (6-7 mL) was spiked at high, medium, and "none" concentration with DYD/DHD and was divided into 0.5 mL aliquots. The blinded aliquots were analyzed by seven different laboratories with their routine progesterone assay (six different immunoassays and one liquid chromatography-tandem mass spectrometry assay, respectively) within the Dutch working group on endocrine laboratory diagnostics of the Dutch Foundation for Quality Assessments in Medical Laboratories. RESULTS The sample recovery rate (P4 result obtained for sample spiked with DYD/DHD, divided by the result obtained for the corresponding sample with no DYD/DHD × 100) was within a ±10% window for the medium and high P4 concentrations, but more variable for the low P4 samples. The latter is, however, attributable to high inter- and intra-method variability at low P4 concentrations. CONCLUSIONS This study does not indicate any relevant interference of DYD/DHD within routinely used progesterone assays.
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Affiliation(s)
- Tanja K Eggersmann
- Department of Reproductive Medicine and Gynecological Endocrinology, University Hospital of Schleswig-Holstein, Campus Luebeck, Luebeck, Germany
| | - Albert Wolthuis
- Stichting Certe Medische Diagnostiek en Advies, Groningen, the Netherlands
| | | | - Georg Griesinger
- Department of Reproductive Medicine and Gynecological Endocrinology, University Hospital of Schleswig-Holstein, Campus Luebeck, Luebeck, Germany
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Abstract
OBJECTIVE To provide an evidence-based safety and tolerability overview of dydrogesterone under various progesterone-deficient conditions as a commemoration of its role in managing women's reproductive health over the past 60 years. METHODS To identify relevant publications, we used a semi-systematic approach, which included performing a structured search through the PubMed and Cochrane central databases as well as an unstructured search for publications published in English from 2010 onward with human clinical data. RESULTS A total of 32 relevant clinical studies were identified. Results were reported in the context of overall adverse events (AEs) and segregated according to various progesterone-deficient conditions. AEs concerning breasts (breast cancer risk), the endometrium (endometrial cancer risk), venous thromboembolism risk, and cardiovascular risk were found to be minimal when dydrogesterone was used as part of a menopausal hormone therapy regimen lasting ≤260 weeks. Vagina-related AEs, such as bleeding, discharge, irritation, and difficult coitus, occurred less frequently with dydrogesterone when used as luteal phase support in the context of assisted reproductive techniques (ARTs). However, other common AEs, such as headache, dizziness, abdominal pain, flatulence, and nausea, occurred more frequently with dydrogesterone. No maternal complications or congenital anomalies could be linked to dydrogesterone usage during ARTs or during early pregnancy to prevent recurrent miscarriages. Studies on dydrogesterone in endometriosis and premenstrual syndrome remain scarce. CONCLUSIONS Post-approval, dydrogesterone has displayed a favorable safety and tolerability profile during its 60-year use, which is reassuring, considering its important role in managing women's reproductive health.
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Affiliation(s)
- Johannes Ott
- Clinical Division of Gynecologic Endocrinology and Reproductive Medicine, Medical University of Vienna, Vienna, Austria
| | - Christian Egarter
- Clinical Division of Gynecologic Endocrinology and Reproductive Medicine, Medical University of Vienna, Vienna, Austria
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Simon V, Robin G, Keller L, Ternynck C, Jonard S, Robin C, Decanter C, Plouvier P. Systematic use of long-acting intramuscular progesterone in addition to oral dydrogesterone as luteal phase support for single fresh blastocyst transfer: A pilot study. Front Endocrinol (Lausanne) 2022; 13:1039579. [PMID: 36619564 PMCID: PMC9822263 DOI: 10.3389/fendo.2022.1039579] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2022] [Accepted: 12/12/2022] [Indexed: 12/24/2022] Open
Abstract
OBJECTIVE The need of luteal support after FET is no longer to be proven. Different routes of progesterone administration are available with interindividual differences in metabolization and serum progesterone levels, the latter being highly correlated with pregnancy and delivery rates. The administration of 2 different routes of progestogen significantly improves success rates in FET. The aim of the current study was to investigate the added value to combine intramuscular administration of progesterone to dydrogesterone in fresh embryo transfer. METHODS This is a retrospective study from prospectively collected data. Patient, aged between 18 and 43 years old, had received a fresh blastocyst transfer between January 2021 and June 2021. In the first group, all patients received only oral dydrogesterone 10mg, three times a day, beginning the evening of oocyte retrieval. In the second group, patients received, in addition to dydrogesterone, a weekly intramuscular injection of progesterone started the day of embryo transfer. Primary endpoint was ongoing pregnancy rate. RESULTS 171 fresh single blastocyst transfers have been performed during this period. 82 patients were included in "dydrogesterone only" and 89 patients in "dydrogesterone + IM". Our two groups were comparable except for body mass index. After adjustment on BMI, our two groups were comparable regarding implantation rate, early pregnancy rate (46.1 versus 54.9, OR 1.44 [0.78; 2.67], p=0.25) miscarriage rate, ongoing pregnancy rate (30.3 versus 43.9, OR 1.85 [0.97; 3.53] p= 0.06). CONCLUSION Using systematically long acting intramuscular progesterone injection in addition to oral dydrogesterone as luteal phase support seems to have no significant impact on IVF outcomes when a single fresh blastocyst transfer is performed.
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Affiliation(s)
- Virginie Simon
- Department of Assisted Reproductive Technologies and Fertility Preservation, Jeanne de Flandre Hospital, Lille, France
- Univ. Lille, Faculty of Medicine, Lille, France
- *Correspondence: Virginie Simon,
| | - Geoffroy Robin
- Department of Assisted Reproductive Technologies and Fertility Preservation, Jeanne de Flandre Hospital, Lille, France
- Univ. Lille, Faculty of Medicine, Lille, France
| | - Laura Keller
- Institut de Biologie de la Reproduction-Spermiologie-Centre d'étude et de Conservation des Oeufs et du Sperme Humain (CECOS), Hôpital Jeanne de Flandre, Centre Hospitalier Universitaire de Lille, Lille, France
| | - Camille Ternynck
- Univ. Lille, University Hospital Center (CHU) Lille, Research Unity (ULR) 2694-METRICS: Evaluation des Technologies de Santé et des Pratiques médicales, Lille, France
- University Hospital Center (CHU) Lille, Department of Biostatistics, Lille, France
| | - Sophie Jonard
- Department of Assisted Reproductive Technologies and Fertility Preservation, Jeanne de Flandre Hospital, Lille, France
- Univ. Lille, Faculty of Medicine, Lille, France
| | - Camille Robin
- Department of Assisted Reproductive Technologies and Fertility Preservation, Jeanne de Flandre Hospital, Lille, France
| | - Christine Decanter
- Department of Assisted Reproductive Technologies and Fertility Preservation, Jeanne de Flandre Hospital, Lille, France
| | - Pauline Plouvier
- Department of Assisted Reproductive Technologies and Fertility Preservation, Jeanne de Flandre Hospital, Lille, France
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Macedo LCGMD, Cavagna Neto M, Dzik A, Rocha ADR, Lima SMRR. Oral dydrogesterone in frozen-thawed embryo transfer cycles. REVISTA DA ASSOCIACAO MEDICA BRASILEIRA (1992) 2021; 68:100-105. [PMID: 34909972 DOI: 10.1590/1806-9282.20210874] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/08/2021] [Accepted: 09/08/2021] [Indexed: 11/22/2022]
Abstract
OBJECTIVE The aim of this study was to compare the use of micronized vaginal progesterone and oral dydrogesterone in the endometrial preparation for frozen-thawed embryo transfer. METHODS This was a randomized, controlled, open, two-armed clinical trial, with women undergoing frozen-thawed embryo transfer along with hormone replacement therapy for endometrial preparation, between September 2019 and February 2021. A total of 73 patients were randomly selected and orally administered 40 mg/day dydrogesterone (dydrogesterone group, n=36) or 800 mg/day micronized vaginal progesterone (micronized vaginal progesterone group, n=37), after endometrial preparation with transdermal estradiol. The main outcome was a viable ongoing pregnancy with 12 weeks of gestation as evaluated by ultrasound. RESULTS The reproductive outcomes in frozen-thawed embryo transfer cycles were similar, with pregnancy rates in the dydrogesterone and micronized vaginal progesterone treatment groups being, respectively, 33.3 and 32.4% at 12 weeks pregnancy (confidence interval= -22.4-20.6, p=0.196). CONCLUSIONS The use of oral dydrogesterone may be a more patient-friendly approach to endometrial preparation in frozen-thawed embryo transfer cycles, avoiding undesirable side effects and discomfort resulting from vaginal administration, while also providing similar reproductive results.
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Affiliation(s)
- Luma Caroline Gomes Mattos de Macedo
- Irmandade da Santa Casa de Misericórdia de São Paulo, School of Medical Sciences, Department of Obstetrics and Gynecology - São Paulo (SP), Brazil
| | - Mario Cavagna Neto
- Centro de Referência da Saúde da Mulher Hospital Pérola Byington, Human Reproduction - São Paulo (SP), Brazil
| | - Artur Dzik
- Centro de Referência da Saúde da Mulher Hospital Pérola Byington, Human Reproduction - São Paulo (SP), Brazil
| | - Andressa do Rosário Rocha
- Centro de Referência da Saúde da Mulher Hospital Pérola Byington, Human Reproduction - São Paulo (SP), Brazil
| | - Sônia Maria Rolim Rosa Lima
- Irmandade da Santa Casa de Misericórdia de São Paulo, School of Medical Sciences, Department of Obstetrics and Gynecology - São Paulo (SP), Brazil
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Sukhikh GT, Adamyan LV, Dubrovina SO, Baranov II, Bezhenar VF, Kozachenko AV, Radzinsky VE, Orazov MR, Yarmolinskaya MI, Olofsson JI. Prolonged cyclical and continuous regimens of dydrogesterone are effective for reducing chronic pelvic pain in women with endometriosis: results of the ORCHIDEA study. Fertil Steril 2021; 116:1568-1577. [PMID: 34465452 DOI: 10.1016/j.fertnstert.2021.07.1194] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2021] [Revised: 07/14/2021] [Accepted: 07/16/2021] [Indexed: 11/29/2022]
Abstract
OBJECTIVE To compare the effectiveness of two different treatment regimens of dydrogesterone in the management of endometriosis-related chronic pelvic pain. DESIGN Observational, prospective cohort study over six months. SETTING Twenty gynecology clinics in the Russian Federation. PATIENT(S) Three hundred fifty women from 18 to 45 years of age with endometriosis and chronic pelvic pain with or without dysmenorrhea. INTERVENTION(S) Dydrogesterone 10 mg 2 or 3 times daily, either between the 5th and 25th days of the menstrual cycle (prolonged cyclical treatment regimen) or continuously (continuous treatment regimen). For all patients, the data cutoff was at six months of treatment. MAIN OUTCOME MEASURE(S) Intensity of chronic pelvic pain on the 11-point numerical rating scale (after 6 months). RESULT(S) A marked reduction in chronic pelvic pain was observed with both the prolonged cyclical and continuous treatment regimens (mean ± standard deviation change from baseline -3.3 ± 2.2 and -3.0 ± 2.2, respectively), with no significant difference between the two groups. With both regimens, patients experienced significant improvements in the intensity of chronic pelvic pain, number of days in which analgesics were required, severity of dysmenorrhea, sexual well-being, and health-related quality-of-life parameters. A favorable safety profile of dydrogesterone was confirmed, and no serious adverse drug reactions were reported during the study. CONCLUSION(S) Prolonged cyclical and continuous treatment regimens of dydrogesterone therapy both demonstrated a pronounced and similar reduction in the severity of chronic pelvic pain and dysmenorrhea and led to marked improvements in all study parameters related to quality of life and sexual well-being. REGISTRATION NUMBER NCT03690765.
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Affiliation(s)
- Gennady T Sukhikh
- National Medical Research Center for Obstetrics, Gynecology and Perinatology, Moscow, Russian Federation
| | - Leila V Adamyan
- National Medical Research Center for Obstetrics, Gynecology and Perinatology, Moscow, Russian Federation; Department of Obstetrics and Gynecology, First Moscow State Medical University, Moscow, Russian Federation
| | - Svetlana O Dubrovina
- Scientific Research Institute of Obstetrics and Pediatrics, Rostov State Medical University, Rostov-on-Don, Russian Federation
| | - Igor I Baranov
- National Medical Research Center for Obstetrics, Gynecology and Perinatology, Moscow, Russian Federation
| | - Vitaly F Bezhenar
- Department of Obstetrics and Neonatology, Department of Obstetrics, Gynecology and Reproduction, Pavlov First Saint Petersburg State Medical University, Saint Petersburg, Russian Federation
| | - Andrey V Kozachenko
- National Medical Research Center for Obstetrics, Gynecology and Perinatology, Moscow, Russian Federation
| | - Viktor E Radzinsky
- Department of Obstetrics and Gynecology, Medical Institute of Peoples' Friendship University of Russia, Ministry of Education of Russia, Moscow, Russian Federation
| | - Mekan R Orazov
- Department of Obstetrics and Gynecology, Medical Institute of Peoples' Friendship University of Russia, Ministry of Education of Russia, Moscow, Russian Federation
| | - Maria I Yarmolinskaya
- Department of Gynecology and Endocrinology, Scientific Research Institute of Obstetrics, Gynecology and Reproduction named after D.O. Ott, Saint Petersburg, Russian Federation; Department of Obstetrics and Gynecology, North-Western State Medical University named after I.I. Mechnikov, Saint Petersburg, Russian Federation
| | - Jan I Olofsson
- Global Medical Affairs, Established Pharmaceuticals Division, Abbott Product Operations AG, Allschwil, Switzerland; Division of Obstetrics and Gynecology, Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden.
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Vuong LN, Pham TD, Le KTQ, Ly TT, Le HL, Nguyen DTN, Ho VNA, Dang VQ, Phung TH, Norman RJ, Mol BW, Ho TM. Micronized progesterone plus dydrogesterone versus micronized progesterone alone for luteal phase support in frozen-thawed cycles (MIDRONE): a prospective cohort study. Hum Reprod 2021; 36:1821-1831. [PMID: 33930124 DOI: 10.1093/humrep/deab093] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2020] [Revised: 03/16/2021] [Indexed: 12/14/2022] Open
Abstract
STUDY QUESTION Does the addition of oral dydrogesterone to vaginal progesterone as luteal phase support improve pregnancy outcomes during frozen embryo transfer (FET) cycles compared with vaginal progesterone alone? SUMMARY ANSWER Luteal phase support with oral dydrogesterone added to vaginal progesterone had a higher live birth rate and lower miscarriage rate compared with vaginal progesterone alone. WHAT IS KNOWN ALREADY Progesterone is an important hormone that triggers secretory transformation of the endometrium to allow implantation of the embryo. During IVF, exogenous progesterone is administered for luteal phase support. However, there is wide inter-individual variation in absorption of progesterone via the vaginal wall. Oral dydrogesterone is effective and well tolerated when used to provide luteal phase support after fresh embryo transfer. However, there are currently no data on the effectiveness of luteal phase support with the combination of dydrogesterone with vaginal micronized progesterone compared with vaginal micronized progesterone after FET. STUDY DESIGN, SIZE, DURATION Prospective cohort study conducted at an academic infertility center in Vietnam from 26 June 2019 to 30 March 2020. PARTICIPANTS/MATERIALS, SETTING, METHODS We studied 1364 women undergoing IVF with FET. Luteal support was started when endometrial thickness reached ≥8 mm. The luteal support regimen was either vaginal micronized progesterone 400 mg twice daily plus oral dydrogesterone 10 mg twice daily (second part of the study) or vaginal micronized progesterone 400 mg twice daily (first 4 months of the study). In women with a positive pregnancy test, the appropriate luteal phase support regimen was continued until 7 weeks' gestation. The primary endpoint was live birth after the first FET of the started cycle, with miscarriage <12 weeks as one of the secondary endpoints. MAIN RESULTS AND THE ROLE OF CHANCE The vaginal progesterone + dydrogesterone group and vaginal progesterone groups included 732 and 632 participants, respectively. Live birth rates were 46.3% versus 41.3%, respectively (rate ratio [RR] 1.12, 95% CI 0.99-1.27, P = 0.06; multivariate analysis RR 1.30 (95% CI 1.01-1.68), P = 0.042), with a statistically significant lower rate of miscarriage at <12 weeks in the progesterone + dydrogesterone versus progesterone group (3.4% versus 6.6%; RR 0.51, 95% CI 0.32-0.83; P = 0.009). Birth weight of both singletons (2971.0 ± 628.4 versus 3118.8 ± 559.2 g; P = 0.004) and twins (2175.5 ± 494.8 versus 2494.2 ± 584.7; P = 0.002) was significantly lower in the progesterone plus dydrogesterone versus progesterone group. LIMITATIONS, REASONS FOR CAUTION The main limitations of the study were the open-label design and the non-randomized nature of the sequential administration of study treatments. However, our systematic comparison of the two strategies was able to be performed much more rapidly than a conventional randomized controlled trial. In addition, the single ethnicity population limits external generalizability. WIDER IMPLICATIONS OF THE FINDINGS Our findings study suggest a role for oral dydrogesterone in addition to vaginal progesterone as luteal phase support in FET cycles to reduce the miscarriage rate and improve the live birth rate. Carefully planned prospective cohort studies with limited bias could be used as an alternative to randomized controlled clinical trials to inform clinical practice. STUDY FUNDING/COMPETING INTERESTS This study received no external funding. LNV has received speaker and conference fees from Merck, grant, speaker and conference fees from Merck Sharpe and Dohme, and speaker, conference and scientific board fees from Ferring; TMH has received speaker fees from Merck, Merck Sharp and Dohme, and Ferring; R.J.N. has received scientific board fees from Ferring and receives grant funding from the National Health and Medical Research Council (NHMRC) of Australia; BWM has acted as a paid consultant to Merck, ObsEva and Guerbet, and is the recipient of grant money from an NHMRC Investigator Grant. TRIAL REGISTRATION NUMBER NCT0399876.
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Affiliation(s)
- Lan N Vuong
- University of Medicine and Pharmacy at Ho Chi Minh City, Ho Chi Minh City, Vietnam.,IVFMD, My Duc Hospital and HOPE Research Center, Ho Chi Minh City, Vietnam
| | - Toan D Pham
- IVFMD, My Duc Hospital and HOPE Research Center, Ho Chi Minh City, Vietnam
| | - Khanh T Q Le
- IVFMD, My Duc Hospital and HOPE Research Center, Ho Chi Minh City, Vietnam
| | - Trung T Ly
- IVFMD, My Duc Hospital and HOPE Research Center, Ho Chi Minh City, Vietnam
| | - Ho L Le
- IVFMD, My Duc Hospital and HOPE Research Center, Ho Chi Minh City, Vietnam
| | - Diem T N Nguyen
- IVFMD, My Duc Hospital and HOPE Research Center, Ho Chi Minh City, Vietnam
| | - Vu N A Ho
- IVFMD, My Duc Hospital and HOPE Research Center, Ho Chi Minh City, Vietnam
| | - Vinh Q Dang
- IVFMD, My Duc Hospital and HOPE Research Center, Ho Chi Minh City, Vietnam
| | - Tuan H Phung
- IVFMD, My Duc Hospital and HOPE Research Center, Ho Chi Minh City, Vietnam
| | - Robert J Norman
- Robinson Research Institute and Adelaide Medical School, The University of Adelaide, Adelaide, South Australia, Australia
| | - Ben W Mol
- Monash University, Melbourne, Australia.,Aberdeen Centre for Women's Health Research, School of Medicine, University of Aberdeen, Aberdeen, UK
| | - Tuong M Ho
- IVFMD, My Duc Hospital and HOPE Research Center, Ho Chi Minh City, Vietnam
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Jeschke L, Santamaria CG, Meyer N, Zenclussen AC, Bartley J, Schumacher A. Early-Pregnancy Dydrogesterone Supplementation Mimicking Luteal-Phase Support in ART Patients Did Not Provoke Major Reproductive Disorders in Pregnant Mice and Their Progeny. Int J Mol Sci 2021; 22:5403. [PMID: 34065597 PMCID: PMC8161261 DOI: 10.3390/ijms22105403] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2021] [Revised: 05/17/2021] [Accepted: 05/19/2021] [Indexed: 01/26/2023] Open
Abstract
Progestogens are frequently administered during early pregnancy to patients undergoing assisted reproductive techniques (ART) to overcome progesterone deficits following ART procedures. Orally administered dydrogesterone (DG) shows equal efficacy to other progestogens with a higher level of patient compliance. However, potential harmful effects of DG on critical pregnancy processes and on the health of the progeny are not yet completely ruled out. We treated pregnant mice with DG in the mode, duration, and doses comparable to ART patients. Subsequently, we studied DG effects on embryo implantation, placental and fetal growth, fetal-maternal circulation, fetal survival, and the uterine immune status. After birth of in utero DG-exposed progeny, we assessed their sex ratios, weight gain, and reproductive performance. Early-pregnancy DG administration did not interfere with placental and fetal development, fetal-maternal circulation, or fetal survival, and provoked only minor changes in the uterine immune compartment. DG-exposed offspring grew normally, were fertile, and showed no reproductive abnormalities with the exception of an altered spermiogram in male progeny. Notably, DG shifted the sex ratio in favor of female progeny. Even though our data may be reassuring for the use of DG in ART patients, the detrimental effects on spermatogenesis in mice warrants further investigations and may be a reason for caution for routine DG supplementation in early pregnancy.
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Affiliation(s)
- Laura Jeschke
- Experimental Obstetrics and Gynecology, Medical Faculty, Otto-von-Guericke University, 39108 Magdeburg, Germany; (L.J.); (C.G.S.); (N.M.); (A.C.Z.)
| | - Clarisa Guillermina Santamaria
- Experimental Obstetrics and Gynecology, Medical Faculty, Otto-von-Guericke University, 39108 Magdeburg, Germany; (L.J.); (C.G.S.); (N.M.); (A.C.Z.)
- UFZ—Helmholtz Centre for Environmental Research Leipzig-Halle, Department of Environmental Immunology, 04318 Leipzig, Germany
| | - Nicole Meyer
- Experimental Obstetrics and Gynecology, Medical Faculty, Otto-von-Guericke University, 39108 Magdeburg, Germany; (L.J.); (C.G.S.); (N.M.); (A.C.Z.)
- UFZ—Helmholtz Centre for Environmental Research Leipzig-Halle, Department of Environmental Immunology, 04318 Leipzig, Germany
| | - Ana Claudia Zenclussen
- Experimental Obstetrics and Gynecology, Medical Faculty, Otto-von-Guericke University, 39108 Magdeburg, Germany; (L.J.); (C.G.S.); (N.M.); (A.C.Z.)
- UFZ—Helmholtz Centre for Environmental Research Leipzig-Halle, Department of Environmental Immunology, 04318 Leipzig, Germany
| | - Julia Bartley
- Reproductive Medicine and Gynecological Endocrinology, University Women’s Clinic, Medical Faculty, Otto-von-Guericke University, 39108 Magdeburg, Germany;
| | - Anne Schumacher
- Experimental Obstetrics and Gynecology, Medical Faculty, Otto-von-Guericke University, 39108 Magdeburg, Germany; (L.J.); (C.G.S.); (N.M.); (A.C.Z.)
- UFZ—Helmholtz Centre for Environmental Research Leipzig-Halle, Department of Environmental Immunology, 04318 Leipzig, Germany
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Griesinger G. Lutealphase – neue Entwicklungen im Kontext der assistierten Reproduktion. GYNAKOLOGISCHE ENDOKRINOLOGIE 2021. [DOI: 10.1007/s10304-020-00375-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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20
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Xu H, Zhang XQ, Zhu XL, Weng HN, Xu LQ, Huang L, Liu FH. Comparison of vaginal progesterone gel combined with oral dydrogesterone versus intramuscular progesterone for luteal support in hormone replacement therapy-frozen embryo transfer cycle. J Gynecol Obstet Hum Reprod 2021; 50:102110. [PMID: 33727207 DOI: 10.1016/j.jogoh.2021.102110] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2020] [Revised: 12/08/2020] [Accepted: 03/05/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND It remains under subject of debate regarding the optimal route of luteal support for hormone replacement therapy- frozen embryo transfer (HRT-FET) cycles. We compared efficacy of vaginal progesterone gel combined with oral dydrogesterone and intramuscular progesterone for HRT-FET lutein support. METHODS This is a retrospective observational study. After matching for propensity score of getting vaginal + oral treatment, a total of 208 FET cycles in the vaginal progesterone combined with oral dydrogesterone and 624 cycles in the intramuscular progesterone group were enrolled. Pregnancy outcomes and neonatal outcomes including chemical pregnancy rate, clinical pregnancy rate, implantation rate, spontaneous abortion rate, live birth rate, gestational weeks, pre-term delivery, birth weight, and congenital anomalies rate were compared. RESULTS No significant differences were observed in patient characteristics such as age, duration of infertility, type of infertility, or hormone level after matching. Chemical pregnancy rate (68.3 % versus 70.5 %), clinical pregnancy rate (64.9 % versus 64.4 %), implantation rate (52.3 % versus 50.2 %), spontaneous abortion rate (21.5 % versus 18.4 %), and live birth rate (49.0 % versus 51.3 %) were similar in both group without statistically significant difference. No significant differences in neonatal outcomes were observed between the two groups. CONCLUSION We observed similar pregnancy outcomes in both vaginal progesterone gel combined with oral dydrogesterone and intramuscular progesterone protocol. Vaginal progesterone gel combined with oral dydrogesterone can be substituted for intramuscular progesterone given that vaginal plus oral use has good safety and is more convenient and may be associated with less side effect caused by intramuscular injection.
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Affiliation(s)
- Hong Xu
- Reproductive Health and Infertility Department, Guangdong Woman and Children's Hospital, Guangzhou 511442, China
| | - Xi-Qian Zhang
- Reproductive Health and Infertility Department, Guangdong Woman and Children's Hospital, Guangzhou 511442, China
| | - Xiu-Lan Zhu
- Reproductive Health and Infertility Department, Guangdong Woman and Children's Hospital, Guangzhou 511442, China
| | - Hui-Nan Weng
- Reproductive Health and Infertility Department, Guangdong Woman and Children's Hospital, Guangzhou 511442, China
| | - Li-Qing Xu
- Reproductive Health and Infertility Department, Guangdong Woman and Children's Hospital, Guangzhou 511442, China
| | - Li Huang
- Reproductive Health and Infertility Department, Guangdong Woman and Children's Hospital, Guangzhou 511442, China
| | - Feng-Hua Liu
- Reproductive Health and Infertility Department, Guangdong Woman and Children's Hospital, Guangzhou 511442, China.
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21
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Deryabin P, Domnina A, Gorelova I, Rulev M, Petrosyan M, Nikolsky N, Borodkina A. "All-In-One" Genetic Tool Assessing Endometrial Receptivity for Personalized Screening of Female Sex Steroid Hormones. Front Cell Dev Biol 2021; 9:624053. [PMID: 33659249 PMCID: PMC7917288 DOI: 10.3389/fcell.2021.624053] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2020] [Accepted: 01/08/2021] [Indexed: 12/25/2022] Open
Abstract
Endometrium is the uterine lining that undergoes hundreds of cycles of proliferation, differentiation, and desquamation throughout a woman's reproductive life. Recently, much attention is paid to the appropriate endometrial functioning, as decreased endometrial receptivity is stated to be one of the concerns heavily influencing successes of embryo implantation rates and the efficacy of in vitro fertilization (IVF) treatment. In order to acquire and maintain the desired endometrial receptivity during IVF cycles, luteal phase support by various progestagens or other hormonal combinations is generally recommended. However, today, the selection of the specific hormonal therapy during IVF seems to be empirical, mainly due to a lack of appropriate tools for personalized approach. Here, we designed the genetic tool for patient-specific optimization of hormonal supplementation schemes required for the maintenance of endometrial receptivity during luteal phase. We optimized and characterized in vitro endometrial stromal cell (ESC) decidualization model as the adequate physiological reflection of endometrial sensitivity to steroid hormones. Based on the whole transcriptome RNA sequencing and the corresponding bioinformatics, we proposed that activation of the decidual prolactin (PRL) promoter containing ancient transposons MER20 and MER39 may reflect functioning of the core decidual regulatory network. Furthermore, we cloned the sequence of decidual PRL promoter containing MER20 and part of MER39 into the expression vector to estimate the effectiveness of ESC decidual response and verified sensitivity of the designed system. We additionally confirmed specificity of the generated tool using human diploid fibroblasts and adipose-derived human mesenchymal stem cells. Finally, we demonstrated the possibility to apply our tool for personalized hormone screening by comparing the effects of natural progesterone and three synthetic analogs (medroxyprogesterone 17-acetate, 17α-hydroxyprogesterone caproate, dydrogesterone) on decidualization of six ESC lines obtained from patients planning to undergo the IVF procedure. To sum up, we developed the "all-in-one" genetic tool based on the MER20/MER39 expression cassette that provides the ability to predict the most appropriate hormonal cocktail for endometrial receptivity maintenance specifically and safely for the patient, and thus to define the personal treatment strategy prior to the IVF procedure.
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Affiliation(s)
- Pavel Deryabin
- Mechanisms of Cellular Senescence Group, Institute of Cytology of the Russian Academy of Sciences, Saint-Petersburg, Russia
| | - Alisa Domnina
- Department of Intracellular Signaling and Transport, Institute of Cytology of the Russian Academy of Sciences, Saint-Petersburg, Russia
| | - Inga Gorelova
- Department of the Assisted Reproductive Technologies, Almazov National Medical Research Centre, Saint-Petersburg, Russia
| | - Maxim Rulev
- Department of the Assisted Reproductive Technologies, Almazov National Medical Research Centre, Saint-Petersburg, Russia
| | - Mariya Petrosyan
- Pharmacology Group of D.O. Ott Institute of Obstetrics, Gynecology and Reproductology, Saint-Petersburg, Russia.,The Laboratory of Myocardial Metabolism, Almazov National Medical Research Centre, Saint-Petersburg, Russia
| | - Nikolay Nikolsky
- Department of Intracellular Signaling and Transport, Institute of Cytology of the Russian Academy of Sciences, Saint-Petersburg, Russia
| | - Aleksandra Borodkina
- Mechanisms of Cellular Senescence Group, Institute of Cytology of the Russian Academy of Sciences, Saint-Petersburg, Russia
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22
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Ozer G, Yuksel B, Yucel Cicek OS, Kahraman S. Oral dydrogesterone vs. micronized vaginal progesterone gel for luteal phase support in frozen-thawed single blastocyst transfer in good prognosis patients. J Gynecol Obstet Hum Reprod 2020; 50:102030. [PMID: 33271319 DOI: 10.1016/j.jogoh.2020.102030] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2020] [Revised: 09/02/2020] [Accepted: 11/25/2020] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To investigate the efficacy of oral dydrogesterone for luteal phase support (LPS) in modified natural cycle frozen-thawed embryo transfers (mNC-FET) compared to micronized vaginal progesterone (MVP) gel. METHODS This was a randomized, single-center, parallel controlled trial conducted at an ART and Reproductive Genetics Centre within a private hospital between January and August 2019. A total of 134 women, aged below 38, were assigned randomly to receive oral dydrogesterone (n=67) or MVP (n=67) for LPS in mNC-FET. The primary outcome was ongoing pregnancy rate (OPR) and secondary outcomes were clinical pregnancy and miscarriage rates, patients' satisfaction and tolerability of oral and vaginal progesterone. A questionnaire was developed to compare patient satisfaction and side effect profiles. RESULTS There was no significant difference in demographic features such as female age, body mass index, AMH levels and fresh cycle characteristics between two groups (p>0.05). When mNC-FET outcomes were compared, OPR was 68.7 % in MVP gel group and 71.6 % in the dydrogesterone group respectively percentage difference, -2.99; 95 % CI: -17.96, 13.10) Biochemical and clinical pregnancy rates and biochemical and clinical miscarriage rates were also similar between two groups. A significantly higher patient tolerability score was present in the dydrogesterone arm (4.09 ± 0.96 vs 3.36 ± 1.23, p=0.001). CONCLUSION Our results suggest that oral dydrogesterone provides similar ongoing pregnancy rates compared to MVP gel as a LPS in mNC FET. Since dydrogesterone is an effective and easy-to-use option with fewer intolerable side effects including vaginal irritation, vaginal discharge, and preventing sexual intercourse, it can be used as LPS in mNC FET.
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Affiliation(s)
- Gonul Ozer
- Istanbul Memorial Hospital IVF and Reproductive Genetics Centre, 34385, Sisli, Istanbul, Turkey.
| | - Beril Yuksel
- Istanbul Memorial Hospital IVF and Reproductive Genetics Centre, 34385, Sisli, Istanbul, Turkey
| | - Ozge Senem Yucel Cicek
- Kocaeli University Faculty of Medicine, Department of Obstetrics and Gynecology, 41380, İzmit, Kocaeli, Turkey
| | - Semra Kahraman
- Istanbul Memorial Hospital IVF and Reproductive Genetics Centre, 34385, Sisli, Istanbul, Turkey
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23
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Griesinger G, Blockeel C, Kahler E, Pexman-Fieth C, Olofsson JI, Driessen S, Tournaye H. Dydrogesterone as an oral alternative to vaginal progesterone for IVF luteal phase support: A systematic review and individual participant data meta-analysis. PLoS One 2020; 15:e0241044. [PMID: 33147288 PMCID: PMC7641447 DOI: 10.1371/journal.pone.0241044] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2020] [Accepted: 10/07/2020] [Indexed: 12/13/2022] Open
Abstract
The aim of this systematic review and meta-analysis was to conduct a comprehensive assessment of the evidence on the efficacy and safety of oral dydrogesterone versus micronized vaginal progesterone (MVP) for luteal phase support. Embase and MEDLINE were searched for studies that evaluated the effect of luteal phase support with daily administration of oral dydrogesterone (20 to 40 mg) versus MVP capsules (600 to 800 mg) or gel (90 mg) on pregnancy or live birth rates in women undergoing fresh-cycle IVF (protocol registered at PROSPERO [CRD42018105949]). Individual participant data (IPD) were extracted for the primary analysis where available and aggregate data were extracted for the secondary analysis. Nine studies were eligible for inclusion; two studies had suitable IPD (full analysis sample: n = 1957). In the meta-analysis of IPD, oral dydrogesterone was associated with a significantly higher chance of ongoing pregnancy at 12 weeks of gestation (odds ratio [OR], 1.32; 95% confidence interval [CI], 1.08 to 1.61; P = 0.0075) and live birth (OR, 1.28; 95% CI, 1.04 to 1.57; P = 0.0214) compared to MVP. A meta-analysis combining IPD and aggregate data for all nine studies also demonstrated a statistically significant difference between oral dydrogesterone and MVP (pregnancy: OR, 1.16; 95% CI, 1.01 to 1.34; P = 0.04; live birth: OR, 1.19; 95% CI, 1.03 to 1.38; P = 0.02). Safety parameters were similar between the two groups. Collectively, this study indicates that a higher pregnancy rate and live birth rate may be obtained in women receiving oral dydrogesterone versus MVP for luteal phase support.
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Affiliation(s)
- Georg Griesinger
- Department of Gynecological Endocrinology and Reproductive Medicine, University Hospital of Schleswig-Holstein, Lübeck, Germany
- * E-mail:
| | - Christophe Blockeel
- Center for Reproductive Medicine, Universitair Ziekenhuis Brussel, Brussels, Belgium
| | - Elke Kahler
- Established Pharmaceuticals Division, Global Biometrics, Abbott Laboratories GmbH, Hannover, Germany
| | - Claire Pexman-Fieth
- Established Pharmaceuticals Division, Global Clinical Development, Abbott GmbH, Wiesbaden, Germany
| | - Jan I. Olofsson
- Established Pharmaceuticals Division, Global Medical Affairs, Abbott Products Operations AG, Allschwil, Switzerland
- Division of Obstetrics and Gynecology, Department of Women’s and Children’s Health, Karolinska Institutet, Stockholm, Sweden
| | - Stefan Driessen
- Global Biometrics, Established Pharmaceuticals Division, Abbott Healthcare Products BV, Weesp, The Netherlands
| | - Herman Tournaye
- Center for Reproductive Medicine, Universitair Ziekenhuis Brussel, Brussels, Belgium
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24
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Koren G, Barer Y, Cem Kaplan Y. Fetal safety of medications used in treating infertility. Expert Rev Clin Pharmacol 2020; 13:991-1000. [PMID: 32815747 DOI: 10.1080/17512433.2020.1803738] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
INTRODUCTION The medications used in assisted reproduction are given before and during early pregnancy, and hence, they may potentially result in adverse fetal effects. In this review we present an updated account of their fetal safety and discuss methodological challenges in interpretation of existing data. AREAS COVERED The fetal safety/risks of clomiphene citrate, aromatase inhibitors, metformin, gonadotropins and progestins are discussed. We searched PubMed, EMBASE, Cochrane, Google, and Google Scholar from inception to 30 April 2020 for publications pertinent to our topic. EXPERT OPINION There are several major challenges in studying fetal safety of medications used in assisted reproduction. The fact is that the rates of congenital malformations among infertile women giving birth spontaneously is higher than the rates among healthy women conceiving spontaneously. In most clinical studies of assisted reproduction, the primary endpoint is the success in inducing pregnancy, neglecting to report pregnancy outcome and adverse neonatal event. As an example for this reality, it has been estimated that between 1977 and 2005 around 10 million pregnancies were treated with dydrogesterone (DYD), yet till 2019 only very few studies, with a total sample size of less than 600 were reported with regards to fetal safety.
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Affiliation(s)
- Gideon Koren
- Adelson Faculty of Medicine, Ariel University , Ariel, Israel.,Department of pharmacology, Motherisk Israel.s , Turkey
| | - Yael Barer
- Maccabi Health Services , Tel Aviv, Turkey
| | - Yusuf Cem Kaplan
- Teratology Information Center, Terafar-Izmir Katip Celebi University , Izmir, Turkey.,Department of Pharmacology, Faculty of Medicine, Izmir Katip Celebi University , Izmir, Turkey
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25
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MPA given orally during the first trimester for threatened miscarriage carries no specific risk for foetal abnormalities albeit the rate is higher than non-threatened pregnancies. Reprod Biol 2020; 20:424-432. [PMID: 32389607 DOI: 10.1016/j.repbio.2020.03.008] [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: 01/25/2020] [Revised: 03/12/2020] [Accepted: 03/14/2020] [Indexed: 11/21/2022]
Abstract
This observational study examines the outcomes of pregnancies arising in women referred for infertility, where those who experienced threatened miscarriage were treated with medroxyprogesterone acetate (MPA) tablets. The 14-year study period covers comprehensive real-time data entries into the validated electronic database including details of the infertility management, pregnancy outcomes and any foetal anomalies among the infants, each being tracked and recorded. Of 4057 clinical pregnancies, 1343 received MPA for threatened miscarriage; 934 (69.6 %) of which continued to livebirths. These were compared with the remaining 2714 clinical pregnancies without threatened miscarriage or MPA and which resulted in 2075 (76.5 %) livebirths. There were 134 developmental abnormalities recorded among the 3009 livebirths of which 78 (2.6 %) were categorised appropriate for the Western Australian Developmental Abnormalities Register; WARDA. These comprised 55 in the MPA group, 36 of which were categorised as serious (being 2.7 % of clinical pregnancies and 3.9 % of births). In the group without MPA, there were 79 abnormalities, of which 42 were categorised as serious (being 1.7 % of clinical pregnancies and 2.2 % of births). Specifically, there were no cases of androgenisation noted among the female infants. The abnormality rates were low overall and well within the annual WARDA ranges. We cautiously suggest that oral MPA can be considered for studies throughout pregnancy including the early first trimester to assess a potential role in reducing miscarriage, as well as advanced pregnancies to evaluate a potential role in reducing stillbirths and preterm delivery.
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26
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Turkgeldi E, Hanege BY, Yildiz S, Keles I, Ata B. Subcutaneous versus vaginal progesterone for vitrified-warmed blastocyst transfer in artificial cycles. Reprod Biomed Online 2020; 41:248-253. [PMID: 32532668 DOI: 10.1016/j.rbmo.2020.04.007] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2020] [Revised: 04/05/2020] [Accepted: 04/09/2020] [Indexed: 11/17/2022]
Abstract
RESEARCH QUESTION Does subcutaneous progesterone provide similar live birth or ongoing pregnancy rates as vaginal progesterone in frozen embryo transfer (FET) cycles? DESIGN Retrospective cohort study (n = 214 women), consisting of 107 women who received subcutaneous progesterone for FET in artificial cycles and 107 women receiving vaginal progesterone who were matched for age and treatment cycle rank acted as controls. All embryos were transferred in an artificial cycle with 6 mg per day oral oestradiol valerate starting on the second or third day of the menstrual cycle. Patients underwent transvaginal ultrasound on the 10th day of priming, and subcutaneous progesterone (50 mg/day) or vaginal progesterone (180 mg/day) was started if the endometrium had a trilinear pattern regardless of its thickness. Embryo transfer was carried out on the sixth day of progesterone administration. Oestradiol and progesterone were continued until a negative pregnancy test, 10 days after the transfer, or until the completion of 10th gestational week. Main outcome measures were live birth or ongoing pregnancy rates. RESULTS Baseline characteristics were similar between the groups. Positive pregnancy test rates (64.5% versus 58.9%; P = 0.40; RR 1.1; 95% CI 0.89 to 1.35), live birth or ongoing pregnancy rates (39.3% versus 35.5%; P = 0.57; RR 1.11; 95% CI 0.78 to 1.56) and miscarriage rates (29% versus 25.5%; P = 0.68; RR 1.08; 95% CI 0.76 to 1.55) were similar in the subcutaneous progesterone and vaginal progesterone groups, respectively. CONCLUSIONS Subcutaneous progesterone seems to be an effective alternative to vaginal progesterone in patients undergoing FET. Randomized controlled trials comparing it with different progesterone preparations, routes and protocols are needed to better define its role.
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Affiliation(s)
- Engin Turkgeldi
- Assisted Reproduction Unit, Department of Obstetrics and Gynecology, Koc University Hospital, Davutpasa Cad No 4, Topkapi 34010, IstanbulTurkish Republic
| | - Burcu Yilmaz Hanege
- Assisted Reproduction Unit, Department of Obstetrics and Gynecology, Koc University Hospital, Davutpasa Cad No 4, Topkapi 34010, IstanbulTurkish Republic
| | - Sule Yildiz
- Assisted Reproduction Unit, Department of Obstetrics and Gynecology, Koc University Hospital, Davutpasa Cad No 4, Topkapi 34010, IstanbulTurkish Republic
| | - Ipek Keles
- Assisted Reproduction Unit, Department of Obstetrics and Gynecology, Koc University Hospital, Davutpasa Cad No 4, Topkapi 34010, IstanbulTurkish Republic
| | - Baris Ata
- Assisted Reproduction Unit, Department of Obstetrics and Gynecology, Koc University Hospital, Davutpasa Cad No 4, Topkapi 34010, IstanbulTurkish Republic; Department of Obstetrics and Gyneacology, Koç University School of Medicine, Rumelifeneri Yolu Sariyer 34450 Istanbul, Turkish Republic.
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27
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Yang DZ, Griesinger G, Wang W, Gong F, Liang X, Zhang H, Sun Y, Kahler E, Pexman-Fieth C, Olofsson JI, Tournaye H, Chen ZJ. A Phase III randomized controlled trial of oral dydrogesterone versus intravaginal progesterone gel for luteal phase support in in vitro fertilization (Lotus II): results from the Chinese mainland subpopulation. Gynecol Endocrinol 2020; 36:175-183. [PMID: 31397179 DOI: 10.1080/09513590.2019.1645110] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
Lotus II, a randomized, open-label, multicenter, international study compared the efficacy and safety of oral dydrogesterone versus micronized vaginal progesterone (MVP) gel for luteal support in IVF. A prespecified subgroup analysis was performed on 239 Chinese mainland subjects from the overall study population (n = 1034), who were randomized to oral dydrogesterone 30 mg or 8% MVP gel 90 mg daily from the day of oocyte retrieval until 12 weeks of gestation. The aim was to demonstrate non-inferiority of oral dydrogesterone to MVP gel, assessed by the presence of a fetal heartbeat at 12 weeks of gestation. In the Chinese mainland subpopulation, there was a numerical difference of 9.4% in favor of oral dydrogesterone, with ongoing pregnancy rates at 12 weeks of gestation of 61.4% and 51.9% in the oral dydrogesterone and MVP gel groups, respectively (adjusted difference, 9.4%; 95% CI: -3.4 to 22.1); in the overall population, these were 38.7% and 35%, respectively (adjusted difference, 3.7%; 95% CI: -2.3 to 9.7). In both the Chinese mainland subpopulation and the overall population, dydrogesterone had similar efficacy and safety to MVP gel. With convenient oral administration, dydrogesterone has potential to transform luteal support treatment.
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Affiliation(s)
- Dong-Zi Yang
- Department of Obstetrics and Gynecology, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou, China
| | - Georg Griesinger
- Department of Gynecological Endocrinology and Reproductive Medicine, University Hospital of Schleswig-Holstein, Lübeck, Germany
| | - Wei Wang
- State Key Laboratory of Reproductive Medicine, Clinical Center of Reproductive Medicine, First Affiliated Hospital, Nanjing Medical University, Nanjing, China
| | - Fei Gong
- Reproductive & Genetic Hospital of Citic-Xiangya, Changsha, China
| | - Xiaoyan Liang
- Reproductive Medicine Research Center, Sixth Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China
| | - Hanwang Zhang
- Reproductive Medicine Center, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Yingpu Sun
- Center for Reproductive Medicine, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | | | | | - Jan I Olofsson
- Abbott Products Operations AG, Allschwil, Switzerland
- Division of Obstetrics and Gynecology, Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden
| | - Herman Tournaye
- Center for Reproductive Medicine, University Hospital of the Brussels Free University, Brussels, Belgium
| | - Zi-Jiang Chen
- Center for Reproductive Medicine, Shandong University, Jinan, China
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Taş M, Uludag SZ, Aygen ME, Sahin Y. Comparison of oral dydrogesterone and vaginal micronized progesterone for luteal phase support in intrauterine insemination. Gynecol Endocrinol 2020; 36:77-80. [PMID: 31464143 DOI: 10.1080/09513590.2019.1655728] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/26/2022] Open
Abstract
This study aims to compare the pregnancy outcomes of vaginal micronized progesterone capsules with oral dydrogesterone in subjects with unexplained subfertility who are undergoing IUI in conjunction with ovarian stimulation by using rFSH. A total of 432 patients with unexplained subfertility who underwent IUI in conjunction with ovarian stimulation were enrolled in this retrospective study. Patients were randomized into two groups: (1) dydrogesterone or (2) vaginal micronized progesterone capsules, for luteal phase support. Clinical pregnancy and live birth were the primary outcome measures of the present study. Dydrogesterone was used in 233 participants (54%) and 337 cycles, while 199 participants (46%) and 233 cycles received vaginal micronized progesterone capsule treatment. The proportion of clinical pregnancies (7.4% vs. 10.2%, p = .213), live births (68% vs. 73%, p = .286) were similar in the two groups. Oral dydrogesterone and vaginal micronized progesterone provide similar pregnancy outcomes in terms of clinical pregnancy and live birth rates in women undergoing IUI in conjunction with ovarian stimulation with rFSH. Given the simple and easy administration, lack of safety concerns and better patient tolerability, we suggest that oral dydrogesterone might be preferred for luteal phase support in IUI.
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Affiliation(s)
- Mustafa Taş
- Department of Obstetrics and Gynecology, Acıbadem Mehmet Ali Aydınlar University, Acıbadem Kayseri Hospital, Kayseri, Turkey
| | - Semih Zeki Uludag
- Department of Obstetrics and Gynecology, Memorial Kayseri Hospital, Kayseri, Turkey
| | - Mustafa Ercan Aygen
- Department of Obstetrics and Gynecology, Erciyes University, Kayseri, Turkey
| | - Yılmaz Sahin
- Department of Obstetrics and Gynecology, Erciyes University, Kayseri, Turkey
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29
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Do early luteal serum progesterone levels predict the reproductive outcomes in IVF with oral dydrogesterone for luteal phase support? PLoS One 2019; 14:e0220450. [PMID: 31361764 PMCID: PMC6667136 DOI: 10.1371/journal.pone.0220450] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2019] [Accepted: 07/16/2019] [Indexed: 12/20/2022] Open
Abstract
Objective We sought to determine whether the early luteal serum progesterone (P4) level predicts the success of IVF treatment with oral dydrogesterone for luteal support. Method This retrospective monocentric cohort study included 242 women who underwent IVF treatment with fresh embryo transfer (ET) between July 2017 and June 2018. The population was unselected, and women were treated according to our unit’s usual stimulation protocols. For the luteal phase support (LPS), all women were supplemented with a 10 mg three-times-daily dose of oral dydrogesterone beginning on the day of oocyte pick-up (OPU). Blood sampling was performed on the day of ET (Day 2–3 after OPU) to determine the early luteal serum progesterone level. Results ROC curve analysis allowed us to determine two thresholds for the prediction of live birth using the early P4 level. Women who had early luteal P4 levels greater than 252 nmol/l had a significantly higher live birth rate (27.1%) than women with early luteal P4 between 115 and 252 nmol/l (17.2%) and women with early luteal P4 below 115 nmol/l (6.0%; p = 0.011). After a multiple regression analysis, an early luteal P4 level greater than 252 nmol/l was still associated with a higher chance of a live birth than a P4 between 115 and 252 nmol/l (OR = 0.40 [0.18–0.91]; p = 0.028) or a P4 below 115 nmol/l (OR = 0.10 [0.01–0.52]; p = 0.006). Conclusions Our study suggests a positive association between early P4 levels and reproductive outcomes in IVF using oral dydrogesterone for luteal support. The inconsistencies between our results and those of other studies suggest that extrapolation is impractical. Further larger prospective cohort studies should be conducted to determine reliable thresholds that could be used to personalize luteal phase support.
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30
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Mohammed A, Woad KJ, Mann GE, Craigon J, Raine-Fenning N, Robinson RS. Evaluation of progestogen supplementation for luteal phase support in fresh in vitro fertilization cycles. Fertil Steril 2019; 112:491-502.e3. [PMID: 31200970 DOI: 10.1016/j.fertnstert.2019.04.021] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2019] [Revised: 03/15/2019] [Accepted: 04/11/2019] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To evaluate the effectiveness of progestogen supplementation in improving clinical pregnancy rates in women undergoing fresh IVF cycles and to compare different routes, start times, durations, and estrogen coadministration regimen. DESIGN Comprehensive systematic review and meta-analysis. SETTING University. PATIENT(S) Women undergoing fresh IVF cycles who did and did not receive progestogen supplementation. INTERVENTION(S) Summary odds ratios (ORs) were calculated by binomial logistic regression. MAIN OUTCOME MEASURE(S) Clinical pregnancy rates. RESULT(S) Eighty-two articles (26,726 women) were included. Clinical pregnancy rates were increased by IM (OR = 4.57), vaginal (OR = 3.34), SC (OR = 3.36), or oral (OR = 2.57) progestogen supplementation versus no treatment. The greatest benefit was observed when progestogens were supplemented IM versus vaginally (OR = 1.37). The optimal time to commence administration was between oocyte retrieval and ET (OR = 1.31), with oocyte retrieval +1 day being most beneficial. Coadministration of estrogen had no benefit (OR = 1.33), whether progestogens were coadministered vaginally or IM. Clinical pregnancy rates were equivalent when progestogen supplementation was ceased after ≤3 weeks or continued for up to 12 weeks (OR = 1.06). CONCLUSION(S) This broad-ranging meta-analysis highlights the need to reevaluate current clinical practice. The use of progestogens in fresh IVF cycles is substantially beneficial to clinical pregnancy. Critically, the use of IM progestogens should not be dismissed, as it yielded the greatest clinical pregnancy rates. Pregnancy success was impacted by initiation of therapy, with 1 day after oocyte retrieval being optimal. There is little evidence to support coadministration of estrogen or prolonging progestogen treatment beyond 3 weeks.
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Affiliation(s)
- Amal Mohammed
- Division of Animal Sciences, School of Biosciences, University of Nottingham, Sutton Bonington Campus, Loughborough, United Kingdom; Department of Clinical Reproductive Physiology, High Institute of Infertility Diagnosis and Assisted Reproductive Technologies, Al-Nahrain University, Baghdad, Iraq
| | - Kathryn J Woad
- School of Veterinary Medicine and Science, University of Nottingham, Sutton Bonington Campus, Loughborough, United Kingdom
| | - George E Mann
- Division of Animal Sciences, School of Biosciences, University of Nottingham, Sutton Bonington Campus, Loughborough, United Kingdom
| | - Jim Craigon
- Division of Animal Sciences, School of Biosciences, University of Nottingham, Sutton Bonington Campus, Loughborough, United Kingdom
| | - Nick Raine-Fenning
- Division of Child Health, Obstetrics and Gynaecology, School of Medicine, University of Nottingham Medical School, Nottingham, United Kingdom; Nurture Fertility, The Fertility Partnership, Nottingham, United Kingdom
| | - Robert S Robinson
- School of Veterinary Medicine and Science, University of Nottingham, Sutton Bonington Campus, Loughborough, United Kingdom.
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Vitagliano A, Andrisani A, Alviggi C, Vitale SG, Valenti G, Sapia F, Favilli A, Martins WP, Raine-Ferring N, Polanski L, Ambrosini G. Endometrial scratching for infertile women undergoing a first embryo transfer: a systematic review and meta-analysis of published and unpublished data from randomized controlled trials. Fertil Steril 2019; 111:734-746.e2. [PMID: 30683590 DOI: 10.1016/j.fertnstert.2018.12.008] [Citation(s) in RCA: 50] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2018] [Revised: 12/06/2018] [Accepted: 12/10/2018] [Indexed: 02/08/2023]
Abstract
OBJECTIVE To investigate endometrial scratch injury (ESI) as an intervention to improve IVF outcome in women undergoing a first ET. DESIGN Systematic review and meta-analysis. SETTING Not applicable. PATIENT(S) Infertile women undergoing a first fresh/frozen embryo transfer. INTERVENTION(S) We included published and unpublished data from randomized controlled trials in which the intervention group received ESI and controls received placebo or no intervention. Pooled results were expressed as relative risk (RR) with 95% confidence interval (CI). The review protocol was registered in PROSPERO to start the data extraction (CRD42018087786). MAIN OUTCOME MEASURE(S) Ongoing pregnancy/live birth rate (OPR/LBR), clinical pregnancy rate (CPR), multiple pregnancy rate (MPR), miscarriage rate (MR), and ectopic pregnancy rate (EPR). RESULT(S) Seven studies were included (1,354 participants). We found a nonsignificant difference between groups in terms of OPR/LBR, CPR, MR, MPR, and EPR. Subgroup analysis found that ESI on the day of oocyte retrieval (achieved by a Novak curette) reduced OPR/LBR (RR 0.31, 95% CI 0.14-0.69) and CPR (RR 0.36, 95% CI 0.18-0.71), whereas ESI during the cycle preceding ET (performed through soft devices) had no effect on OPR/LBR and CPR. No difference in the impact of ESI was observed between fresh and frozen embryo transfer. CONCLUSION(S) Current evidence does not support performing ESI with the purpose of improving the success of a first ET attempt.
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Affiliation(s)
- Amerigo Vitagliano
- Unit of Gynecology and Obstetrics, Department of Women and Children's Health, University of Padua, Padua, Italy.
| | - Alessandra Andrisani
- Unit of Gynecology and Obstetrics, Department of Women and Children's Health, University of Padua, Padua, Italy
| | - Carlo Alviggi
- Department of Neuroscience, Reproductive Science, and Odontostomatology, University of Naples Federico II, Naples, Italy
| | - Salvatore Giovanni Vitale
- Department of General Surgery and Medical Surgical Specialties, University of Catania, Catania, Italy
| | - Gaetano Valenti
- Department of General Surgery and Medical Surgical Specialties, University of Catania, Catania, Italy
| | - Fabrizio Sapia
- Department of General Surgery and Medical Surgical Specialties, University of Catania, Catania, Italy
| | - Alessandro Favilli
- Section of Obstetrics and Gynecology, Department of Surgical and Biomedical Sciences, Santa Maria Della Misericordia Hospital, University of Perugia, Perugia, Italy
| | | | - Nick Raine-Ferring
- Division of Obstetrics and Gynaecology, Faculty of Medicine & Health Sciences, University of Nottingham, Nottingham, United Kingdom
| | - Lukasz Polanski
- Division of Obstetrics and Gynaecology, Faculty of Medicine & Health Sciences, University of Nottingham, Nottingham, United Kingdom; NURTURE Fertility, Nottingham, United Kingdom
| | - Guido Ambrosini
- Unit of Gynecology and Obstetrics, Department of Women and Children's Health, University of Padua, Padua, Italy
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