Medroxyprogesterone acetate: an alternative to GnRH-antagonist in oocyte vitrification for social fertility preservation and preimplantation genetic testing for aneuploidy

Euploidy rate and pregnancy outcomes in preimplantation genetic testing for aneuploidy cycles using progestin-primed ovarian stimulation versus GnRH antagonist protocol

BACKGROUND

Previous studies has yielded contradictory findings regarding the relationship between controlled ovarian hyperstimulation (COH) protocol and euploid blastocyst rate. This study aimed to investigate whether progestin-primed ovarian stimulation (PPOS) influences the euploidy rate and pregnancy outcomes in preimplantation genetic testing for aneuploidy (PGT-A) cycles compared to GnRH antagonist protocol.

METHODS

The retrospective study analyzed data from 598 PGT-A cycles conducted between January 2017 and October 2022 utilizing either PPOS (medroxyprogesterone acetate) or the GnRH antagonist protocol. The biopsied trophectoderm from 2218 blastocysts was collected for euploidy analysis via next-generation sequencing.

RESULTS

Biopsied blastocyst number was comparable between PPOS group and GnRH antagonist group (3.51 ± 2.93 vs. 3.91 ± 3.19, P = 0.116), although PPOS yielded fewer MII oocytes (10.27 ± 6.59 vs. 11.60 ± 6.71, P = 0.015). The euploidy rate (43.3% vs. 45.0%, P = 0.423), aneuploidy rate (36.9% vs. 36.0%, P = 0.127), and mosaic rate (19.4% vs. 17.6%, P = 0.127) were similar between the PPOS and GnRH antagonist protocols. Additionally, PPOS demonstrated comparable pregnancy outcomes to GnRH antagonist protocol, including clinical pregnancy rates (58.1% vs. 59.8%, P = 0.713) and live birth rates (51.1% vs. 46.9%, P = 0.364). But lower miscarriage rate was shown in the PPOS protocol (7.9% vs. 16.8%, P = 0.019).

CONCLUSIONS

The PPOS protocol did not negatively impact euploid blastocyst formation or pregnancy outcomes compared to the GnRH antagonist protocol, indicating that medroxyprogesterone acetate was an alternate option to antagonists for women undergoing PGT-A.

Comparison of the euploidy rate in preimplantation genetic testing for aneuploidy cycles following progestin-primed versus gonadotropin-releasing hormone antagonist protocol: a randomized controlled study

BACKGROUND

Progestins can block endogenous luteinizing hormone secretion from the pituitary gland and have shown similar efficacy in terms of collecting competent oocytes and embryos; however, some inconsistencies have been proposed by the previous papers regarding the quality of oocytes and embryos obtained with the use of progestins. This study aimed to compare the euploidy rate between women treated with progestin-primed ovarian stimulation (PPOS) and the gonadotropin-releasing hormone (GnRH) antagonist protocol.

METHODS

This is a prospective randomized study of 240 infertile women undergoing PGT-A between August 2021 and July 2023. Infertile women with advanced maternal age (38-45 years), recurrent pregnancy loss (≥ 2 or 3 consecutive miscarriages), and repeated implantation failure (≥ 4 embryos replaced or ≥ 2 blastocysts replaced without success) undergoing PGT-A cycles were included. Women were randomly assigned into the PPOS group (n = 120) or the antagonist group (n = 120) according to a computer-generated randomization list. Dydrogesterone 20 mg per day was given from the start of ovarian stimulation until the trigger day in the PPOS group. In the antagonist group, an antagonist 0.25 mg was given daily from the sixth day of ovarian stimulation until the trigger day. The primary outcome measure was the euploidy rate, defined as the number of euploid blastocysts per injected oocyte.

RESULTS

No significant differences were observed in the demographic and ovarian stimulation characteristics between the two groups. The euploidy rate was comparable between the PPOS and antagonist group (12.5% vs. 16.0% respectively, P > 0.05). No significant differences were observed between the two groups in positive pregnancy test, clinical pregnancy, miscarriage, ectopic pregnancy, or live birth rates per transfer in the first frozen embryo transfer cycles.

CONCLUSION

Both PPOS and antagonist protocols had similar euploidy rates in PGT-A cycles.

TRIAL REGISTRATION

Clinicaltrials. gov identifier: NCT04989348 ( https://www.

CLINICALTRIALS

gov/ ). Trial registration date: Clinicaltrials. gov: 30 July 2021.

Progestin-primed ovarian stimulation (PPOS) in preimplantation genetic testing for aneuploidy: a retrospective study and meta-analysis

BACKGROUND

Information on the impact of Progestin-primed ovarian stimulation (PPOS) protocol on embryo euploid status and preimplantation genetic testing for aneuploidy (PGT-A) outcomes is limited compared with other ovarian stimulation protocols. We conducted a retrospective cohort study and a meta-analysis to evaluate the application value of the PPOS protocol in PGT-A cycles.

METHODS

In the cohort study, we retrospectively analyzed 962 ovarian stimulation cycles, including 413 cycles of PPOS protocol, 327 cycles of gonadotropin-releasing hormone antagonist (GnRH-ant) protocol, and 222 cycles of GnRH agonist (GnRH-a) protocol. In the meta-analysis, we searched PubMed, Embase, Cochrane Library, Web of Science, Sinomed, CNKI, Wanfang and VIP databases as well as clinical trial registration websites. Pooled or narrative analyses were performed on embryo and pregnancy outcomes according to whether baseline characteristics were balanced.

RESULTS

In our retrospective study, compared to the GnRH agonist protocol, patients receiving the PPOS and GnRH antagonist protocols were older, and there was a significant decrease in the number of antral follicles, Anti-Mullerian hormone (AMH) levels, stimulation duration, gonadotropin (Gn) dosage, as well as the number of retrieved oocytes and euploid blastocysts. Regression analysis showed that the ovarian stimulation protocol was not associated with the number of euploid blastocysts or the rate of euploid blastocysts per biopsy. There were no significant differences in the rates of biochemical pregnancy, clinical pregnancy, premature birth, live birth, or miscarriage per embryo transfer among the three groups. The meta-analysis included data from seven studies. There were no significant differences in stimulation duration, Gn dosage, number of oocytes retrieved, number of euploid blastocysts, euploid blastocyst rate, clinical pregnancy rate, or live birth rate between PPOS protocol and GnRH antagonist protocol, but the abortion rate of PPOS protocol decreased significantly.

CONCLUSIONS

Current findings indicate that the PPOS protocol is comparable to other ovarian stimulation protocols in embryo euploid status or pregnancy outcomes and may be an attractive option in PGT-A cycles, which needs to be validated in more well-designed RCTs and long-term follow-ups.

Optimizing advice and approaches for elective fertility preservation

Elective fertility preservation enables women to extend their reproductive window, potentially reducing the need for ineffective fertility treatments later in life. Oocyte cryopreservation (OC), an established fertility preservation technique, is often seen as a means of reproductive autonomy, though its impact remains debated. To avoid detrimental effects of aging it is suggested that OC should be done by 37 years. Freezing ≥20 mature oocytes before 38 years gives a 60-70°% possibility of pregnancy. Success of ovarian tissue cryopreservation and transplantation (OTCT) in cancer survivors has encouraged its use in reproductive aging. OTCT provides a longer reproductive window, allows for spontaneous conception and restores ovarian endocrine function but is highly invasive. Ethical concerns raised for elective fertility preservation include medicalization of reproduction, idealization of the right time for pregnancy, psychological effects of advanced age parenthood and promotion of social inequity. With an increasing demand for elective oocyte freezing there is an urgent need to create awareness about the pros and cons of the techniques, the risks of pregnancy complications at an advanced maternal age and long term health of children born. Gamete preservation cannot guarantee a child. Profertility counselling should be a part of the discussion as there is no substitute for spontaneous conception at a younger age.

Aneuploidy rates and clinical pregnancy outcomes after preimplantation genetic testing for aneuploidy using the progestin-primed ovarian stimulation protocol or the gonadotropin-releasing hormone antagonist protocol

OBJECTIVE

To investigate the chromosome abnormality rates and clinical pregnancy outcomes after preimplantation genetic testing for aneuploidy (PGT-A) using either the progestin-primed ovarian stimulation (PPOS) protocol or the gonadotropin-releasing hormone (GnRH) antagonist protocol.

METHODS

The study included 431 PGT-A cycles in which controlled ovarian stimulation was performed using the PPOS protocol (n = 320 cycles) or GnRH antagonist protocol (n = 111 cycles) between January 2018 and December 2021. Frozen embryo transfer was subsequently performed in 307 cycles with transferable blastocysts. The number of retrieved oocytes, embryo development, next-generation sequencing results, and clinical pregnancy outcomes were compared between the two protocols. The primary outcome measure was the aneuploidy rate. Secondary outcome measures were clinical pregnancy per first frozen-thawed embryo transfer cycle and cumulative live birth rates per PGT-A cycle.

RESULTS

There were no statistically significant between-group differences in the number of retrieved oocytes, available blastocysts, and high-quality blastocyst rate. The aneuploidy rates were similar between the two groups. There was no significant difference in clinical pregnancy outcomes, including the clinical pregnancy, implantation, miscarriage, live birth, or cumulative live birth rates, after frozen-thawed embryo transfer cycles (P>0.05).

CONCLUSIONS

The study found no significant differences in the aneuploidy rate, clinical pregnancy rate and cumulative live birth rate after PGT-A cycles between those using the PPOS protocol and those using the GnRH antagonist protocol.

Programming the onset of ovarian stimulation: from early follicular phase start to oral contraceptive pill, to luteal phase E2, Duostim, and random start oral contraceptive protocols

Ovarian stimulation has been the single most efficient measure ever taken in assisted reproductive technology for improving outcomes by harvesting multiple oocytes and ultimately, embryos. Today, ovarian stimulation protocols consist of administrating exogenous gonadotropins to override the natural mechanisms that control the ovulatory quota to one in humans. For practicality issues, there have been numerous attempts to control, or "program," when ovarian stimulation is initiated to improve functionality and in turn efficacy for assisted reproductive technology programs. The different options for controlling the onset of ovarian stimulation currently available are discussed here, as well as the novel possibility of using progestins for blocking premature ovulation.

A multicycle approach through DuoStim with a progestin-primed ovarian stimulation (PPOS) protocol: a valuable option in poor prognosis patients undergoing PGT-A

PURPOSE

This study is to evaluate the effectiveness of a PPOS protocol in poor prognosis patients undergoing IVF with DuoStim and PGT-A versus the conventional protocol with GnRH antagonist.

METHODS

Retrospective cohort study encompassing 444 couples obtained matching one PPOS-DuoStim with two antagonist-DuoStim cycles at a private IVF center between 2020 and 2023 (average maternal age: 40 years, average cumulus-oocyte complexes collected after the first stimulation: 5). The study was powered to exclude a two-sided different euploid blastocyst rate per MII oocytes (EBR per MII) in the two groups (alpha = 0.05, power = 0.9, effect size = 0.3). All cycles involved ICSI, blastocyst stage PGT-A, and single vitrified-warmed euploid transfers. We compared all embryological and clinical outcomes within each group (first vs. second stimulations), and among the two study arms (first stimulation vs. first stimulation; second stimulations vs. second stimulation; overall). The overall EBR per MII was the primary study outcome. The cumulative-live-birth-rate per concluded cycles (CLBR) was the main secondary outcome.

RESULTS

In the second stimulations, we obtained a greater number of COCs and MIIs in both antagonist- and PPOS-DuoStim groups. No difference was observed for all embryological and clinical outcomes when comparing the two stimulations within each group. All embryological and clinical outcomes were comparable also between the two groups, including the EBR per MII. To date, 285 and 121 antagonist- and PPOS-DuoStim cycles were concluded. The CLBR was comparable between the groups: 26% vs. 29%.

CONCLUSIONS

PPOS-DuoStim holds potential for being an efficient, patient-friendly, and possibly cost-effective approach that does not compromise treatment efficacy. Future investigations must explore PPOS effect on follicular recruitment, neonatal, and long-term outcomes.

Cytoplasmic sperm injection (ICSI) - A systematic review of the literature

Background: Progestin-primed ovarian stimulation (PPOS) stimulates ovaries to block the premature surge of luteinizing hormone (LH) by using micronized progesterone or a progestin during the follicular phase instead of the conventional gonadotropin-releasing hormone (GnRH) analogues or GnRH antagonists downregulating LH to obtain multi-follicle engagement. Current work aims to assess the influence of progestogen treatment on ovarian stimulation and the ability to control LH surge, its efficacy and suitability in retrieving oocytes, without affecting the embryo quality and its benefit among infertile women long-term outcomes on children compared to standard stimulation protocols. Materials and Methods: The literature review used the randomized control trials published in the Pubmed database from January 2015 to April 2021. To generate the citation list, the following keywords were used: 'progestin-primed ovarian stimulation', 'PPOS', 'micronized progesterone', 'medroxyprogesterone', and/or 'dydrogesterone'. The selected articles analyzed the cohort, intervention, and scheme of the progestin-primed ovarian stimulation protocol in controlled ovarian stimulation (COS) for in-vitro fertilization (IVF)/intra cytoplasmic sperm injection (ICSI) used in Assisted Reproductive Technologies (ART). Results: Overall we concluded that PPOS for IVF/ICSI in ART results in a higher number of obtained embryos, lower incidence of OHSS, equal duration of stimulation, number of retrieved oocytes, and number of MII oocytes. It is also suggested that long-term safety in children shows no significant difference between the study and control groups. Conclusions: Despite the outcomes of progestin stimulation cycles among all cohorts, we concluded that poor ovarian responders, patients with PCOS, women of advanced age and oocyte donors benefit the most from using PPOS.

Comparison of aneuploidy for patients of different ages treated with progestin-primed ovarian stimulation or GnRH antagonist protocols

RESEARCH QUESTION

Does euploidy status differ among patients of different ages treated with progestin-primed ovarian stimulation (PPOS) or gonadotrophin releasing hormone antagonist (GnRH-a) protocols?

DESIGN

Patients undergoing PGT-A (n = 418; 440 cycles) were enrolled and grouped according to female age (<35 years and ≥35 years). Protocols were as follows: PPOS: <35 years (n = 131; 137 cycles); ≥35 years (n = 72; 80 cycles); GnRH-a: <35 years (n = 149; 152 cycles); ≥35 years (n = 66; 71 cycles).

RESULTS

For cycles treated with PPOS in the older group, rates of euploid blastocyst per metaphase Ⅱ oocyte (15.48% versus 10.47%) and per biopsied blastocyst (54.94% versus 40.88%) were significantly higher than those treated with GnRH-a (P < 0.05). The mosaic rate per biopsied blastocyst was significantly lower for cycles treated with PPOS than cycles treated with GnRH-a (8.64% versus 23.36%) (P < 0.001). In the younger group, no significant difference was found between treatments (P > 0.05). In older and younger groups, the drug to inhibit LH surge was cheaper for cycles treated with PPOS compared with GnRH-a (P < 0.001). Generalized estimation equations based on binomial distribution female age and euploidy rate was significantly negatively correlated for all participants (β -0.109, 95% CI -0.183 to -0.035, P = 0.004), and between GnRH-a protocol (reference: PPOS) and the euploidy rate in the older group (β -0.126, 95% CI -0.248 to -0.004, P = 0.042). Multiple logistic regression indicated that ovarian stimulation protocol was not associated with ongoing pregnancy rate (OR 0.652, 95% CI 0.358 to 1.177; P = 0.14).

CONCLUSIONS

PPOS is suitable for patients undergoing PGT-A, particularly older patients for the higher euploid blastocyst rate attained by PPOS protocol.

Minimum number of mature oocytes needed to obtain at least one euploid blastocyst according to female age in in vitro fertilization treatment cycles

OBJECTIVE

To find a useful tool for estimating the minimum number of metaphase II (MII) oocytes needed to obtain at least one euploid blastocyst according to female age.

DESIGN

Retrospective analysis of in vitro fertilization (IVF) treatment cycles with preimplantational genetic testing for aneuploidies (PGT-A) performed over 5 years in IVIRMA Valencia (Spain), January 2017-March 2022. Approval from the Institutional Review Board of IVI Valencia (2204-VLC-040-CR).

SETTING

Private infertility clinic in Spain.

PATIENTS

Eligible patients were undergoing their first IVF-PGT-A treatment cycle, in which at least one MII oocyte was obtained, regardless of oocyte and semen origin. Oocyte donation cycles were included in the donor group (≤34 years old). Treatment cycles from women with their own oocytes were selected only when the oocytes were aged ≥35 years (patient group). Only trophoectoderm biopsies performed on days 5 or 6 of development and analyzed using next-generation sequencing were included. Preimplantational genetic testing for aneuploidy cycles because of a known abnormal karyotype were excluded.

INTERVENTION

Not applicable.

MAIN OUTCOME MEASURES

Number of MII oocytes needed to obtain one euploid blastocyst according to female age.

RESULTS

A total of 2,660 IVF-PGT-A treatment cycles were performed in the study period in the eligible population (patients group = 2,462; donors group =198). The mean number of MII oocytes needed to obtain one euploid blastocyst increased with age, as did the number of treatment cycles that did not get at least one euploid blastocyst. An adjusted multivariate binary regression model was designed using 80% of the patient group sample (n = 2,462; training set). A calculator for the probability of obtaining at least one euploid blastocyst was created using this model. The validation of this model in the remaining 20% of the patient group sample (n = 493; validation set) showed that it could estimate the event of having at least one euploid blastocyst with an accuracy of 72.0%.

CONCLUSIONS

Our results show a preliminary model capable of predicting the number of MII oocytes needed to obtain at least one euploid blastocyst according to female age, calculated with the largest database of IVF-PGT-A treatment cycles ever used for this purpose, including only treatment cycles using next-generation sequencing on trophoectoderm biopsies. Once this model has been properly validated, it could help with decision-making for both clinicians and patients coming to an infertility clinic.

Progestin-primed ovarian stimulation

PURPOSE OF REVIEW

The use of progestins as pituitary suppressors has increased progressively, along with more detailed indications for their use, thereby consolidating an alternative approach to the personalization of ovarian stimulation.

RECENT FINDINGS

Based on the ability of progesterone to inhibit ovulation, progestins have been used in ovarian stimulation (OS) follicular protocols to prevent a luteinizing hormone surge in patients undergoing in vitro fertilization (IVF), as an alternative to gonadotropin-releasing hormone (GnRH) analogue administration. This review explores the different types of progestogen protocols and their efficacy depending on the type of population or reproductive procedure in which they are administered and in comparison with that of GnRH analogues. Their effect on oocytes and embryos and their safety and cost-effectiveness are also analyzed.

SUMMARY

Progestins have proven their effectiveness as a gonadotropin adjuvant in terms of ovarian response, reproductive outcome, and safety. In addition, they offer the convenience of oral administration and a lower cost than GnRH analogues. Whereas oocytes or embryos should be vitrified as it displaces the receptive period with the consequent asynchrony between embryo and endometrium. The evidence endorses progestins as a more friendly approach to OS, especially when frozen-thawed embryo transfer is planned.

Oocyte competence is comparable between progestin primed ovarian stimulation with Norethisterone acetate (NETA-PPOS) and GnRH-antagonist protocols: A matched case-control study in PGT-A cycles

OBJECTIVE

To outline oocyte competence after progestin primed ovarian stimulation with Norethisterone acetate (NETA-PPOS) compared to conventional GnRH-antagonist protocol.

STUDY DESIGN

Retrospective matched case-control study involving advanced-maternal-age women undergoing ICSI with PGT-A. 89 NETA-PPOS were matched with 178 control patients based on maternal age and ovarian reserve biomarkers. Both groups underwent recombinant-FSH OS with GnRH-agonist ovulation trigger and collected ≥1 MII. In the study group, NETA (10 mg/day) was administered orally starting from day2 of the menstrual cycle. Euploid blastocyst rate per cohort of metaphase-II oocytes (EBR per MII) was the primary outcome. All other embryological and clinical outcomes were reported. Gestational age, birthweight and length were also assessed.

RESULTS

The EBR per MII was comparable among PPOS and control (13.9 % ± 19.3 % versus 13.3 % ± 17.9 %; the sample size allowed to exclude up to a 10 % difference). Blastocysts morphology and developmental rate were similar. No difference was reported for all clinical outcomes among the 61 and 107 vitrified-warmed euploid single blastocyst transfers respectively conducted. The cumulative live birth delivery rate per concluded cycles was also comparable (24.7 % versus 21.9 %). Neonatal outcomes were analogous.

CONCLUSIONS

Oocyte competence after NETA-PPOS and standard OS is comparable. This evidence is reassuring and, because of its lower cost and possibly higher patients' compliance, supports PPOS administration whenever the patients are indicated to freeze-all (e.g., fertility preservation, PGT-A, oocyte donation). More data are required about follicle recruitment, oocyte yield, gestational and perinatal outcomes. Randomized-controlled-trials are advisable to confirm our evidence.

Progestin-primed ovarian stimulation: for whom, when and how?

Progestin-primed ovarian stimulation (PPOS) is being increasingly used for ovarian stimulation in assisted reproductive technology. Different progestins have been used with similar success. The available studies suggest a similar response to ovarian stimulation with gonadotrophin-releasing hormone (GnRH) analogues. Any differences in the duration of stimulation or gonadotrophin consumption are minor and clinically insignificant. PPOS has the advantage of oral administration and lower medication costs than GnRH analogues. As such it is clearly more cost-effective for fertility preservation and planned freeze-all cycles, but when fresh embryo transfer is intended PPOS can be less cost-effective depending on the local direct and indirect costs of the additional initial frozen embryo transfer cycle. Oocytes collected in PPOS cycles have similar developmental potential, including blastocyst euploidy rates. Frozen embryo transfer outcomes of PPOS and GnRH analogue cycles seem to be similar in terms of both ongoing pregnancy/live birth rates and obstetric and perinatal outcomes. While some studies have reported lower cumulative live birth rates with PPOS, they have methodological issues, including arbitrary definitions of the cumulative live birth rate. PPOS has been used in all patient types (except progesterone receptor-positive breast cancer patients) with consistent results and seems a patient friendly and cost-effective choice if a fresh embryo transfer is not intended.