Very high serum estradiol levels are not detrimental to clinical outcome of in vitro fertilization

High estradiol levels in fresh embryo transfer cycles are not associated with detrimental impact on birth outcomes

PURPOSE

There is an unclear relationship between estradiol levels and fresh embryo transfer (ET) outcomes. We determined the relationship between estradiol on the day of trigger, in fresh ET cycles without premature progesterone elevation, and good birth outcomes (GBO).

METHODS

We identified autologous fresh ET cycles from 2015 to 2021 at multiple clinics in the USA. Patients with recurrent pregnancy loss, uterine factor, and elevated progesterone on the day of trigger (progesterone > 2 ng/mL or 3-day area under the curve > 4.5 ng/mL) were excluded. The primary outcome was GBO (singleton, term, live birth with appropriate weight). Log-binomial generalized estimating equations determined the likelihood of outcomes.

RESULTS

Of 17,608 fresh ET cycles, 5025 (29%) yielded GBO. Cycles with estradiol ≥ 4000 pg/mL had a greater likelihood of GBO compared to cycles < 1000 pg/mL (aRR = 1.32, 95% CI 1.13-1.54). Pairwise comparisons of estradiol between < 1000 pg/mL versus 1000-1999 pg/mL and 1000-1999 pg/mL versus 2000-2999 pg/mL revealed a higher likelihood of GBO with higher estradiol (aRR 0.83, 95% CI 0.73-0.95; aRR 0.91, 95% CI 0.85-0.97, respectively). Comparisons amongst more elevated estradiol levels revealed that the likelihood of GBO remained similar between groups (2000-2999 pg/mL versus 3000-3999 pg/mL, aRR 1.04, 95% CI 0.97-1.11; 3000-3999 pg/mL versus ≥ 4000 pg/mL, aRR 0.96, 95% CI 0.9-1.04).

CONCLUSION

In fresh ET cycles, higher estradiol levels were associated with an increased prevalence of GBO until estradiol 2000-2999 pg/mL, thereafter plateauing. In fresh ET candidates, elevated estradiol levels should not preclude eligibility though premature progesterone rise, and risk of ovarian hyperstimulation syndrome must still be considered.

Roles of estradiol levels on the day of human chorionic gonadotrophin administration in the live birth of patients with frozen embryo transfer

Background

Estradiol (E₂) is an important hormone in women. Changes of serum E₂ levels may affect the endometrial receptivity for embryo implantation and thus affect pregnancy outcomes. This study was to assess the association between serum E₂ levels on the day of human chorionic gonadotrophin (HCG) administration and live‐birth rates in patients with frozen embryo transfer (FET).

Methods

Totally 2071 women receiving long protocols of long‐acting gonadotropin‐releasing hormone (GnRH) agonists were enrolled. According to the E₂ levels on the day of HCG administration, these patients were divided into four groups: 676 cases of E₂ ≤ 3051 pg/mL in Q₁ group, 676 cases of 3051 pg/mL < E₂ ≤ 4558 pg/mL in Q₂ group, 675 cases of 4558 pg/mL < E₂ ≤ 6718 pg/mL in Q₃ group, and 674 cases of E₂ > 6718 pg/mL in Q₄ group. The clinical indicators including female age, body mass index (BMI), duration of infertility, infertility styles, treatment protocols, hormone levels, total antral follicle count, endometrial thickness, top‐level embryos, and live‐birth rates were analyzed, and multivariable logistic model was conducted to select significant variables.

Results

Significant differences were observed for the female age (OR = 0.965, 95% CI: 0.946‐0.985, P < .001), total antral follicle counts (OR = 1.025, 95% CI: 1.008‐1.043, P = .004), transferring what day of embryos (OR = 1.242, 95% CI: 1.137‐1.356, P < .001), endometrial thickness (OR = 1.058, 95% CI: 1.004‐1.115, P = .035), top‐level embryos (OR = 1.416, 95% CI: 1.157‐1.731, P = .001), and E₂ levels on HCG day >6781 pg/mL (OR = 1.344, 95% CI: 1.069‐1.690, P = .011) between live‐birth and non‐live‐birth groups. The area under the curve (AUC) for E₂ levels on HCG day was 0.558, the sensitivity was 54.75%, and the specificity was 55.10%.

Conclusion

Serum E₂ level on HCG day was an independent predictor of live‐birth achievement in patients with FET.

AQP2 is regulated by estradiol in human endometrium and is associated with spheroid attachment in vitro

17β‑estradiol (E2) and aquaporin 2 (AQP2) are associated with endometrial receptivity, and E2 directly regulates AQP2 expression in endometrial cancer cells. The present study aimed to investigate the role of AQP2 in embryo implantation. Normal endometrial samples were collected at the Women's Hospital (Hangzhou, China) from women seeking in vitro fertilization and embryo transfer; women with endometrial abnormalities were excluded from the study. Samples were categorized into early‑mid proliferative, late proliferative, early secretory, mid‑secretory and late secretory phase groups, according to the menstrual cycle. The mRNA and protein expression levels of AQP2 were assessed in normal human endometrium in response to E2 via reverse transcription‑quantitative polymerase chain reaction and western blotting, respectively. The effects of AQP2 on spheroid attachment were assessed using an in vitro co‑culture assay with small interfering (si)RNA against AQP2. The highest expression levels of AQP2 were observed in the late proliferative and mid‑secretory phases, with the lowest levels detected in the early proliferative and late secretory phases. In addition, treatment with 10‑9 or 10‑7 M E2 for 24 h upregulated AQP2 in the cultured endometrium. Knockdown of AQP2 by siRNA significantly decreased JAr spheroid attachment; however, this effect was significantly reversed when AQP2 siRNA‑transfected cells were treated with 10‑7 M E2. The results of the present study suggested that AQP2 expression levels in human endometrium may be mediated by estrogen, and low AQP2 expression levels may be a potential cause of impaired uterine receptivity.

High estrogen exposure may not be detrimental on endometrial receptivity in women with PCOS

The study aimed to assess the effect of high estrogen exposure and coasting on cycle outcome in women at risk for developing ovarian hyperstimulation syndrome (OHSS). Retrospective case-control study was conducted to figure out the outcomes of GnRH antagonist cycles in which women were at risk to develop OHSS. Women who underwent coasting (n = 100) were compared with a control group of women who did not undergo coasting (n = 287). Effect of endometrial estrogen exposure was determined by calculating area under curve of temporal estrogen measurements (AUCEM) through the cycle. Among 387 women with PCOS, 100 cases were required to undergo coasting to avoid OHSS. All participants reached to embryo transfer stage and clinical pregnancy rate was 44% in group with coasting whereas 39% in group without coasting (p > .05). AUCEM was a significant predictor for the cases who required coasting to avoid OHSS (AUC = 0.754, p < .001). Optimal cut off value was calculated to be 6762 with 71% sensitivity and 67% specificity. ROC analysis showed no predictive value of AUCEM for clinical pregnancy in subgroup of women with coasting (AUC = 0.496, p > .05). Consistently, ROC analysis showed no predictive value of AUCEM for clinical pregnancy in subgroup of women without coasting (AUC = 0.494, p > .05). In conclusion, neither coasting nor the high endometrial estrogen exposure was found to have detrimental effect on endometrial receptivity and cycle outcome in PCOS.

Serum estradiol levels in controlled ovarian stimulation directly affect the endometrium

Previous studies have shown that increasing estradiol concentrations had a toxic effect on the embryo and were deleterious to embryo adhesion. In this study, we evaluated the physiological impact of estradiol concentrations on endometrial cells to reveal that serum estradiol levels probably targeted the endometrium in controlled ovarian hyperstimulation (COH) protocols. An attachment model of human choriocarcinoma (JAr) cell spheroids to receptive-phase endometrial epithelial cells and Ishikawa cells treated with different estradiol (10^-9 M or 10^-7 M) concentrations was developed. Differentially expressed protein profiling of the Ishikawa cells was performed by proteomic analysis. Estradiol at 10^-7 M demonstrated a high attachment rate of JAr spheroids to the endometrial cell monolayers. Using iTRAQ coupled with LC-MS/MS, we identified 45 differentially expressed proteins containing 43 significantly upregulated and 2 downregulated proteins in Ishikawa cells treated with 10^-7 M estradiol. Differential expression of C₃, plasminogen and kininogen-1 by Western blot confirmed the proteomic results. C₃, plasminogen and kininogen-1 localization in human receptive endometrial luminal epithelium highlighted the key proteins as possible targets for endometrial receptivity and interception. Ingenuity pathway analysis of differentially expressed proteins exhibited a variety of signaling pathways, including LXR/RXR activation pathway and acute-phase response signaling and upstream regulators (TNF, IL6, Hmgn3 and miR-140-3p) associated with endometrial receptivity. The observed estrogenic effect on differential proteome dynamics in Ishikawa cells indicates that the human endometrium is the probable target for serum estradiol levels in COH cycles. The findings are also important for future functional studies with the identified proteins that may influence embryo implantation.

Effect of elevated estradiol levels on the hCG administration day on IVF pregnancy and birth outcomes in the long GnRH-agonist protocol: analysis of 3393 cycles

INTRODUCTION

This retrospective study aimed to evaluate the association between elevated serum estradiol (E ₂) levels on the human chorionic gonadotrophin (hCG) administration day and in vitro fertilization (IVF) pregnancy and birth outcomes in the long GnRH-agonist protocol.

METHODS

This study analyzed the data of 3393 infertile women who underwent initial fresh IVF. The patients were categorized into high and low E ₂ groups based on their serum E ₂ levels on the hCG day. Pregnancy and birth outcomes were compared.

RESULTS

The implantation rate, clinical pregnancy rate, and live birth rate were all significantly higher in the high E ₂ group than in the low E ₂ group (p < 0.05). The good-quality embryo rate and abortion rate did not significantly differ between the two groups. There were no significant differences in the mode of delivery, gestational age, birth weight, and fetal gender between the two groups. Furthermore, there were no differences in the risk of preterm birth, low birth weight, and fetal malformation between the two groups in 860 single live births. Subgroup analysis of singleton pregnancies in the high E ₂ (E ₂ ≥ 3757 pg/mL) group revealed a significant increase in abortion rate in the age group of ≥37 years.

CONCLUSIONS

Elevated serum E ₂ levels associated with controlled ovarian stimulation did not increase the risks of preterm birth, low birth weight, and fetal malformation. High E ₂ on the hCG day had no detrimental effect on the implantation rate, clinical pregnancy rate, and live birth rate.

Estradiol Elicits Proapoptotic and Antiproliferative Effects in Human Trophoblast Cells

During the first trimester of pregnancy, appropriate regulation of estradiol (E2) is essential for normal placental development. Previous studies demonstrate that premature elevation in E2 concentrations can lead to abnormal placentation, but have not fully elaborated the mechanism of this effect in the first-trimester trophoblast. Our aim was to determine whether E2 elicits trophoblast cell death or inhibits proliferation. The first-trimester human cytotrophoblast cell line HTR-8/SVneo was cultured in phenol red-free medium containing charcoal-stripped serum and treated with 17beta-E2 at concentrations between 0 and 100 nM. TUNEL and invasion assays indicated that E2 significantly increased cell death and reduced cell invasion at 10 nM, and nuclear Ki67 expression revealed that it decreased cell proliferation at 1 nM. A similar effect on cell death was observed in first-trimester placental explants. The E2 antagonist fulvestrant blocked all effects of E2. Immunohistochemistry showed that protein expression of proapoptotic caspases 3, 8, and 9 increased at E2 concentrations of 25 nM and greater, whereas expression of antiapoptotic BCL2-alpha decreased at E2 concentrations of 10 nM and greater. Additionally, treatments with estrogen receptor (ER) alpha-specific and ERbeta-specific agonists at concentrations between 0 and 1000 nM indicated that only ERalpha mediates E2's effects, although immunohistochemistry and Western immunoblotting showed that HTR-8/SVneo cells and placental explants express both ERalpha and ERbeta. Taken together, these findings reveal the interplay between elevated serum E2 and apoptosis in the first trimester of pregnancy. These factors could be associated with pregnancy complications including infertility and uteroplacental insufficiency.

In high responding patients undergoing an initial IVF cycle, elevated estradiol on the day of hCG has no effect on live birth rate

BACKGROUND

The impact of elevated estradiol on the day of human chorionic gonadotropin (hCG) administration on in vitro fertilization (IVF) outcomes has been debated for over 25 years. Some investigators have shown a positive effect, others a negative effect; while most have shown no effect. Few studies have expressed their findings based on live birth. This study examined the relationship between estradiol level and other IVF cycle response parameters in relation to pregnancy, with a focus on live births after controlling for embryo quality.

METHODS

We performed a retrospective cohort study on 489 patients <40 years old that underwent an initial IVF cycle. Estradiol concentration on the day of hCG was categorized as; low <2000 pg/ml), mid (2001-4000 pg/ml) and high (>4000 pg/ml) to determine how estradiol level on the day of hCG affected response variables during the IVF cycle. We performed a subgroup analysis restricted to patients with good/fair quality embryos transferred (n=428), to control for embryo quality and assessed pregnancy outcome. The association between estradiol and live birth (LB) was then evaluated after identifying and controlling for confounding factors. Multivariate analysis was used to identify significant main effects and interactions in the model. Estradiol levels were also compared in patients having a LB or not (NLB) in both populations.

RESULTS

We found that estradiol was significantly related to + hCG, clinical pregnancy rate, age, and most other IVF cycle response variables. After performing the subgroup analysis controlling for embryo quality, we found that LB rates were not different. Only the main effects of average embryo quality at transfer (AEQS), age and transferring two embryos influenced LB. Estradiol levels were also compared in patients having a LB or NLB in both populations and was found to be higher/not different in LB patients. LB rates and AEQS were also not different in a subgroup of patients having an elevated level of estradiol (>4200 pg/ml) on the day of hCG in patients having embryo transfer on day 3 or day 5.

CONCLUSIONS

After controlling for embryo quality, elevated estradiol on the day of hCG had no effect on LB.

Impact of peak estradiol levels on reproductive outcome of intracytoplasmic sperm injection

Objective: To observe effect of peak estradiol (E2) levels on outcome after intra cytoplasmic sperm injection (ICSI).

Methods: Quasi experimental design conducted in “Islamabad Clinic Serving Infertile Couples” from June 2010 till August 2011. Down regulation with mid luteal suppression of 564 females aged 18-41 years was done with gonadotrophin releasing hormone agonist followed by controlled ovarian stimulation, ovulation induction (OI), oocytes pickup and embryo transfer. Samples for peak serum E2 at the time of OI was estimated by Enzyme Linked Immuno Sorbent Assay. The association of peak E2 with outcome groups of Intracytoplasmic sperm injection (ICSI) (Group I) beta hCG <5 m IU/ml, (Group II) with beta hCG>5 mI U/ml and no cardiac activity and (Group III) with beta hCG>5mIU/ml and cardiac activity on trans vaginal scan was identified. Statistical comparison by one way analysis of variance (ANOVA) via SPSS version 15 was done.

Results: A clinical pregnancy rate of 36% was achieved, pregnant females(Group III) had higher peak E2 2269 ± 80.97 as compared to 1419 ± 37.07 and 1807±90.28 pg/ml (mean ± SD) in Groups I and II respectively (p<0.0001) Elevated serum E2 was significantly associated with better oocyte recovery, fertilization, cleavage and implantation rates (p<0.0001) .

Conclusion: A high serum E2 measured on OI day can predict success of treatment after ICSI. Females who had high peak E2 had greater number of retrieved, mature and fertilized oocytes with thick endometrial lining that helped in implantation and clinical pregnancy.

Correlation between steroid hormonal levels and cardiac function in women during controlled ovarian hyperstimulation

During in vitro fertilization-embryo transfer (IVF-ET) treatment, most women require controlled ovarian hyperstimulation (COH). COH with gonadotropins results in an increase in steroid hormonal levels; however, it is unclear what impact these high concentrations of steroid hormones have on cardiac heart function. The purpose of this study was to examine the effect of high levels of estradiol (E2) and progesterone (P) during COH treatment on cardiac function in women undergoing IVF-ET. A total of 34 women with infertility due to tubal or male factors treated with COH and 28 women with normal menstrual cycles who underwent ovulation monitoring only were enrolled in this study. The serum levels of steroid hormones and the parameters of echocardiography at different time points during the natural menstrual cycles of the control group and the corresponding time points during COH treatment of the study group were compared. The independent sample with the t test, the paired sample with t test, χ(2) test, and Pearson correlation analysis were applied. The steroid hormonal levels were significantly different between natural menstrual cycles and COH treatment cycles. Left ventricular end-diastolic volume (LVEDV) reached the highest level on day 7 after oocyte pickup; in contrast, ejection fraction (LVEF) was the lowest level on the same day. On day 16 after ET, E2 and P levels were maintained in the pregnant women in the study group; however, the levels of those hormones returned to those of a natural menstrual cycle in non-pregnant women. The parameters of LVEF and LVEDV significantly correlated with E2 concentrations. High levels of E2 during COH treatment may temporarily affect cardiac function, suggesting that COH intervention is relatively safe; however, a certain level of risk might exist.

The impact of supraphysiologic serum estradiol levels on peri-implantation embryo development and early pregnancy outcome following in vitro fertilization cycles

PURPOSE

To determine the impact of elevated serum estradiol levels (EE2-defined as levels > 90th percentile) on the day of hCG administration during IVF on oocyte fertilization, embryo development, implantation, clinical pregnancy and miscarriage rates.

METHODS

A total of 2,995 consecutive IVF cycles in 1,889 patients with non-donor oocyte retrieval resulting in fresh embryo transfer between 1/1/2005 and 12/31/2011 were analyzed. Cycles were stratified by serum E2 level on the day of hCG administration into those with levels >90th percentile and ≤ 90th percentile. Rates of normal fertilization, embryo development, positive pregnancy test, implantation, clinical pregnancy and spontaneous miscarriage were compared.

RESULTS

Serum estradiol above the 90th percentile on the day of hCG administration was associated with a significantly lower rate of normal fertilization (68.6 ± 20 vs. 71.6 ± 21, p = 0.02) when compared with patients with a lower serum estradiol threshold. The proportion of embryos that progressed from 2PN to 6-8 cell on day 3 was not different between the two groups. Although rates of positive pregnancy test (55.2 % vs. 57 %), implantation (26.4 % vs. 28.5 %) and clinical pregnancy (45.5 % vs. 49.4 %) were lower in patients with a higher estradiol threshold, these differences were not statistically significant. Similarly, there was no difference in the spontaneous miscarriage rates between the two groups (8.4 % vs. 7.1 %).

CONCLUSIONS

Serum estradiol levels above the 90th percentile on the day of hCG administration is associated with lower oocyte fertilization rate; however, such levels do not impact embryo development, implantation, clinical pregnancy or spontaneous miscarriage rates.

Serum estradiol as a predictor of success of in vitro fertilization

AIM

The aim of this study was to assess the role of total serum estradiol on the day of injection HCG, estradiol per mature follicle, and estradiol per oocytes retrieved (OR) on clinical pregnancy rate (CPR) and oocyte/embryo quality in assisted reproduction.

MATERIALS AND METHODS

A retrospective review of 342 in vitro fertilization cycles with normal ovarian reserve in women who underwent long GnRH agonist protocol was included. The outcomes assessed are number of OR, number of mature oocytes (MO), number of oocytes fertilized (FO), fertilization rate, number of embryos cleaved (EC), cleavage rate (CR), number of Grade I embryos (E), number of cryopreserved embryos (CPE), and CPR. The Estradiol/follicle ratio (E2/fol) was defined as estradiol level per mature follicle >14 mm in diameter. Estradiol/oocyte (E2/O) ratio was defined as estradiol level per OR. These two ratios were categorized by the 25th percentile into four groups.

RESULTS

A positive correlation was seen between E2/fol and OR (r = .334, p value = .0001), MO (r = .335, p value = .0001), FO (r = .222, p value = .002), and CPE (r = .289, p value = .0001). Increased CPR was seen in Group C (E2/fol = 200-299.99) compared to Group A, B, and D (p value = .033). With E2/O ratio, negative correlation was seen between E2/O and OR (r = -.281, p value = .002), MO (r = -.296, p value = .008), FO (r = -.220, p value = .003), EC (r = -.211, p value = .004), Grade 1 embryo (r = -.216, p value = .001), and CPE (r = -.206, p value = .005). No difference in FR, CR, or CPR was seen. No difference was seen in CPR with total serum estradiol.

CONCLUSIONS

In conclusion, serum estradiol is an important determinant of IVF success. While total serum estradiol does not exert any positive or negative influence on IVF outcome, estradiol per mature follicle and retrieved oocytes do have an impact. Pregnancy rate is better when E2/fol is between 200 and 299.99 pg/ml. Also, increasing serum E2/fol positively correlates with better oocytes and embryo quality. In contrast, E2/O negatively correlates with oocytes and embryo quality parameters.

Association of serum estradiol levels on the day of hCG administration with pregnancy rates and embryo scores in fresh ICSI/ET cycles down regulated with either GnRH agonists or GnRH antagonists

PURPOSE

To investigate the interrelation between serum E2 level on hCG day, score of transferred embryos and pregnancy achievement.

METHODS

Records of 350 women aged 18-40 years who underwent ovarian hyperstimulation in fresh cycles down regulated either with GnRH agonist (n = 70) or GnRH antagonist (n = 280) followed by oocyte pick-up, ICSI and embryo transfer are retrospectively analyzed.

RESULTS

Median E2 levels on hCG day of cycles ending with and without pregnancy were similar (p = 0.308). ROC curve for AUC of E2 on hCG day with dependent variable pregnancy rate also demonstrated that the E2 level on hCG day cannot be used to predict pregnancy in IVF/ICSI cycles (AUC 0.532, 95 % confidence interval: 0.471-0.593). Grouping cycles according to their E2 levels on hCG day also did not demonstrate any detrimental effect of either low or high E2 levels on hCG day both in agonist and antagonist cycles. Pregnancy rates are strongly correlated with mean and total score of transferred embryos. Interrelation of E2 on hCG day and pregnancy rate is independent from score of transferred embryos.

CONCLUSIONS

E2 on hCG day is not correlated with pregnancy rates and cannot be used to predict pregnancy in neither agonist nor antagonist cycles, no matter its level or percentile is used.

Relationship between the oestradiol/oocyte ratio and the outcome of assisted reproductive technology cycles with gonadotropin releasing hormone agonist

The aim of this study was to evaluate the relationship of oestradiol level on the day of hCG (peak E2)/oocyte ratio and the outcome of ART cycles. Of the patients who underwent IVF-ET, 600 normal and high responders to the first cycle of COH with gonadotropin releasing hormone (GnRH)-agonist were included in the study. Patients were designated into three groups based on peak E2/oocyte ratio (Group A: <100 pg/ml per oocyte, Group B: 100-200 pg/ml per oocyte, Group C: >200 pg/ml per oocyte). A comparison among groups was made regarding ovarian stimulation characteristics, fertilisation, implantation and pregnancy rates. After the division based on E2/oocyte ratio, in Group C, the number of oocytes retrieved, 2PN and M2 oocyte were statistically lower than both of the other two groups (p = 0.001, 0.001, 0.001, 0.045). HCG day E2 level was significantly different in all groups (p = 0.001), and fertilisation rate was meaningfully highest in Group C and lowest in Group A (p = 0.001). No difference existed among the three groups with respect to the number of embryos transferred and implantation rates. However, clinical pregnancy rate was significantly lower in Group A than others (p = 0.04). In ART cycles suppressed by GnRH-agonist, IVF outcomes are lower in patients with an E2/oocyte proportion of <100 pg/ml per oocyte.

Can serum oestradiol be a predictor of quality of oocytes and embryos, maturation of oocytes and pregnancy rate in ICSI cycles?

Our aim was to assess the influence of ratios of oestradiol (E2) to either number of follicles ≥ 14 mm on the day of human chorionic gonadotropin administration (E2/fol) or the number of oocytes retrieved (E2/o) during oocyte pick up and total serum E2 levels on the day of embryo transfer (ETE2) on the outcome of ICSI cycles. The assessed outcomes were number of oocytes retrieved (NRO), number of mature oocytes (NMO), number of fertilised oocytes (NFO), number of transferred embryos (NTE), qualities of oocytes (OQS), qualities of embryos (EQS) and pregnancy rates (PR). Two hundred and twenty-seven ICSI-ET cycles admitted to our IVF clinic during a 2-year period with normal ovarian reserve receiving long luteal GnRH agonist protocol were included. The E2/fol levels correlated positively with NRO (r = 0.202, p = 0.002), NMO (r = 0.199, p = 0.003) and NFO (r = 0.159, p = 0.018). However, we observed negative correlations between E2/o and NMO (r = -0.329, p <0.001), NFO (r = -0.219, p = 0.001), EQ5 (r = -0.203, p = 0.040). Oocyte quality scores were not affected from either E2/fol or E2/o levels. Implantation, clinical and ongoing PRs were comparable between groups categorised due to E2/fol, E2/o and ETE2. It seems that high E2/fol ratio may have beneficial effects on NRO, NMO and NFO while E2/o may adversely affect these parameters. Neither of the E2 levels is associated with pregnancy rates in women with normal ovarian reserve.

Asian ethnicity in anonymous oocyte donors is associated with increased estradiol levels but comparable recipient pregnancy rates compared with Caucasians

OBJECTIVE

To determine if differences exist in ovarian response and pregnancy rates between Asian and Caucasian donors.

DESIGN

Retrospective cohort study.

SETTING

University-based clinic.

PATIENT(S)

Anonymous oocyte donors of self-reported Asian (n=63) or Caucasian (n=156) ethnicity who began ovarian stimulation between February 2000 and March 2008 and their matched recipients.

INTERVENTION(S)

None.

MAIN OUTCOME MEASURE(S)

Recipient pregnancy rates and oocyte donor ovarian responsiveness.

RESULT(S)

Baseline characteristics were similar between Asian and Caucasian donors. Asian donors had peak serum estradiol levels that were 23% higher than their Caucasian counterparts (3715±220 vs. 3013±114 pg/mL). Adjusted estradiol levels per follicle measured and per oocyte retrieved were elevated in Asian donors (17% and 23% higher, respectively), and these differences were unchanged after adjusting for body mass index. No differences were noted in implantation rates (47.4% vs. 40.9%), clinical pregnancy rates (60.3% vs. 62.4%), or live-birth rates (55.5% vs. 59.9%) achieved using Asian vs. Caucasian oocyte donors.

CONCLUSION(S)

In contrast to autologous fresh in vitro fertilization cycles, Asian ethnicity is not associated with a lower pregnancy rate in recipient women using controlled hormone replacement when anonymous donor oocytes are used. Asian donors achieved statistically significantly higher serum estradiol levels during gonadotropin stimulation, suggesting an ethnic difference in steroid production and/or metabolism.

The effect of elevated serum estradiol levels on the day of human chorionic gonadotropin injection on pregnancy outcomes in an assisted reproduction program

BACKGROUND

Women who have a high estradiol level on the day of human chorionic gonadotropin injection are considered to have their in vitro fertilisation treatments compromised. How this really affects the pregnancy rates needs to be questioned.

AIM

To determine if elevated serum estradiol levels on the day of human chorionic gonadotropin injection have a deleterious effect on clinical and ongoing pregnancy rates in an assisted reproduction program.

METHODS

A retrospective analysis was done of women with estradiol levels higher than 10,000 pmol/L and women with estradiol levels between 8000-10,000 pmol/L on the day of ovulation trigger undergoing in vitro fertilisation treatment at the Fertility Unit of the Royal Prince Alfred Hospital, University of Sydney, Australia. Pregnancy rates were compared for those having fresh embryo transfers and those having frozen thawed embryo transfers in subsequent cycles.

RESULTS

There was no difference between the groups in terms of clinical and ongoing pregnancy rates.

CONCLUSION

Frozen thawed embryos obtained from controlled ovarian hyperstimulation cycles resulted in similar clinical and ongoing pregnancy rates as those obtained in previous fresh embryo transfer cycles.

Effect of estradiol on oocyte development

OBJECTIVE

To determine whether elevated serum estradiol (E(2)) concentrations in oocyte donors affect assisted reproduction outcome.

METHOD

In a retrospective cohort study of 58 consecutive oocyte donation cycles, donors were stratified into 2 groups according to E(2) concentration, group 1 (n=32; E(2)<or=2000 pg/mL [range 456-2000 pg/mL]) and group 2 (n=27; E(2)>2000 pg/mL [range, 2062-6957 pg/mL]). Data were analyzed using the t test and chi(2) test.

RESULTS

Donors in group 1 produced significantly less oocytes than donors in group 2 (19.3+/-1.7 vs 12.0+/-1.4; P<0.001), and recipients of oocytes from group 1 had significantly fewer numbers of embryos available for transfer (10.4+/-1.1 vs 6.4+/-0.8; P=0.003). However, the mean number (3.3) of embryos transferred and the pregnancy rate were the same in both groups.

CONCLUSION

Elevated estradiol concentration in oocyte donors did not affect pregnancy outcome, suggesting that estradiol levels in donors do not affect oocyte development.

The role of steroid hormones in ART

Steroid hormones hold a major role in female fertility and their proper utilisation and monitoring in modern assisted reproduction protocols is important. Oocyte maturation and endometrial receptivity are the two major factors that appear to be related to a successful outcome in Assisted Reproductive Technology (ART). Many reports suggest that oocyte immaturity accounts for a considerable loss of efficiency in ART, mainly due to the poor quality of the obtained embryos and their inability to develop normally. Oestrogen appears to exert its effects on the cytoplasmic maturation of the oocyte, while progesterone has been shown to accelerate meiotic resumption. Moreover, ovarian stimulation appears to affect the normal luteal function and shifts in the window of implantation as a response to hormonal supplementation have also been observed. The ethical limitations in conducting in vivo studies of human implantation, have led to an indirect hormonal- and morphologic-oriented assessment of endometrial receptivity. The two main protocols of luteal support involve either progesterone supplementation or hCG administration, whereas the combined supplementation with oestradiol remains controversial. This brief review aims to summarize the current knowledge on steroidal actions during the above processes and to address their potential use in the improvement of current ART protocols.

Gene expression profiling of human peri-implantation endometria between natural and stimulated cycles

OBJECTIVE

To investigate the effect of high serum E(2) levels in gonadotropin-stimulated cycles (hCG+7) on the gene expression patterns of human endometrium compared with natural cycles on the seventh day of LH surge (LH+7) and elucidate the underlying molecular changes that may be related to endometrial receptivity.

DESIGN

Observational study.

SETTING

University Hospital.

PATIENTS(S)

Infertile patients with normal menstrual cycles undergoing IVF treatment.

INTERVENTION(S)

Gonadotropin stimulation and endometrial biopsy.

MAIN OUTCOME MEASURE(S)

Gene expression by microarray and quantitative polymerase chain reaction (qPCR).

RESULT(S)

Endometrial samples from natural (n = 5) and stimulated (n = 8) cycles were collected. Patients in the stimulated cycles were classified as moderate (n = 4) or excessive (n = 4) responders if their serum E(2) levels on the day of administration of hCG were <or=20,000 pmol/L or >20,000 pmol/L, respectively. The RNA transcripts were profiled by Affymetrix HG-U133A microarray. Clustering and principal component analysis demonstrated a significant difference (>or=2-fold) in the expression patterns of 411 genes among the three groups. Putative estrogen response elements or progesterone response elements were identified in the promoter regions of 49 differentially expressed genes of diverse biologic functions. The qPCR confirmed the microarray result in 47 endometrial samples.

CONCLUSION(S)

High serum E(2) and/or progesterone modulate the gene expression profiles of human endometrium and may affect endometrial receptivity.

Luteal estrogen supplementation in stimulated cycles may improve the pregnancy rate in patients undergoing in vitro fertilization/intracytoplasmic sperm injection-embryo transfer

OBJECTIVE

To evaluate the effect of estradiol addition to progesterone supplementation during the luteal phase on pregnancy and implantation rates in patients undergoing in vitro fertilization/intracytoplasmic sperm injection-embryo transfer (IVF/ICSI-ET) cycles.

METHODS

In this prospective, randomized study, carried out in an IVF unit of a university hospital, we studied patients who were undergoing IVF/ICSI with controlled ovarian hyperstimulation using a gonadotropin-releasing hormone agonist/human recombinant gonadotropin long protocol. The main outcome measures were the pregnancy and implantation rates measured in the two groups.

RESULTS

Our results suggest higher pregnancy and implantation rates in IVF/ICSI-ET cycles that were supplemented with estradiol in the luteal phase.

CONCLUSIONS

Estradiol supplementation during the luteal phase in women undergoing IVF/ICSI-ET has a beneficial effect on the outcome without (at least, as seems from this study) having any adverse effects.

High Serum Estradiol Levels are not Detrimental to In Vitro Fertilization Outcome

OBJECTIVE

To evaluate the impact of high estradiol (E2) levels and a high number of retrieved oocytes on the outcome of in vitro fertilization (IVF) cycles.

MATERIALS AND METHODS

We retrospectively reviewed 274 IVF cycles. These patients were divided into five groups according to their peak E2 levels on the human chorionic gonadotropin day: < or = 2,000 pg/mL (130 cycles); 2,001-3,000 pg/mL (53 cycles); 3,001-4,000 pg/mL (46 cycles); 4,001-5,000 pg/mL (29 cycles); > 5,000 pg/mL (16 cycles). Fertilization, pregnancy, and implantation rates were analyzed between these groups. We also compared the outcome of IVF for high responders (> 15 retrieved oocytes) and normal responders (< or = 15 retrieved oocytes).

RESULTS

The oocyte fertilization and embryo cleavage rates were not significantly different among these five groups. Although decrease in pregnancy and implantation rates was observed when E2 levels were > 5,000 pg/mL compared with those having lower E2 levels, there were no statistically significant differences between these five groups. In addition, similar IVF outcome was detected for those cycles with > 15 oocytes and < or = 15 oocytes obtained.

CONCLUSION

High serum E2 levels and high oocyte yield are not detrimental to IVF outcome. More studies are needed to characterize the threshold E2 levels above which implantation rates are reduced.

Cumulative exposure to high estradiol levels during the follicular phase of IVF cycles negatively affects implantation

PURPOSE

To investigate the effect of the cumulative exposure to estradiol (E(2)) during the follicular phase on IVF outcome.

METHODS

Patients were stimulated with recombinant FSH after GnRH agonist suppression and had a day 3-embryo transfer. Estrogen exposure was determined as the area under the curve (AUC) for serum E(2) levels measured from the first day of stimulation through the day after hCG administration.

RESULTS

E(2) AUC thresholds for 10th and 90th percentiles were 4704 pg/ml and 16338 pg/ml, respectively. The pregnancy and implantation rates were highest in the 10th-90th percentile group, and were statistically higher in this group than in the >90th percentile group (54.6% vs. 33.3% and 24.8% and 12.9%, respectively, for pregnancy and implantation rates, P < 0.05). Recovered mature oocytes, fertilization, and number and mean score of transferred embryos were similar.

CONCLUSIONS

High cumulative E(2) exposure during the follicular phase of IVF cycles has detrimental effects on implantation.

Estradiol production during controlled ovarian hyperstimulation correlates with treatment outcome in women undergoing in vitro fertilization–embryo transfer

OBJECTIVE

To study the value of E(2) production during controlled ovarian hyperstimulation (COH) in predicting IVF-ET outcome.

DESIGN

Historical cohort.

SETTING

Academic infertility center.

PATIENT(S)

A cohort of 270 patients who completed 324 consecutive IVF-ET treatment cycles.

INTERVENTION(S)

None.

MAIN OUTCOME MEASURE(S)

Area under the curve for E(2) levels (AUC-E(2)) from the first day of COH until the day of hCG administration was calculated and cycles grouped into low, average, and high AUC-E(2) groups. Clinical pregnancy rates per cycle were compared among the three groups, and correlations with AUC-E(2) values were calculated for all patients and after sub-grouping according to age, COH protocol and infertility diagnosis.

RESULT(S)

Cycles with low and high AUC-E(2) values had significantly lower pregnancy rates particularly in patients 35 years or older. There was a positive correlation between AUC-E(2) and pregnancy rates up to a certain AUC-E(2) level above which a negative correlation was found. The turning point between positive and negative correlations occurred at a significantly lower AUC-E(2) level in patients 35 years or older.

CONCLUSIONS

Estradiol production during COH correlates with IVF-ET outcome. Women >35 years of age seem more vulnerable to high E(2) levels.

Oocyte and embryo donation 2006: reviewing two decades of innovation and controversy

For over 21 years, oocyte and embryo donation have been used to treat infertility caused by a variety of conditions affecting the ovary. Many disorders, including premature ovarian failure, advanced reproductive age, unexplained recurrent implantation failure and inherited conditions, are amenable to gamete donation, with high pregnancy rates and good obstetrical outcomes observed in recipients. Protocols for the medical screening of recipients and donors, as well as infectious disease and genetic testing, have become relatively uniform and well accepted. Established guidelines allow synchronization of the menstrual cycles of both women to ensure that embryos are transferred to a receptive endometrium. The high demand for donor services has led to escalating costs and long waiting lists. American programmes bid against each other to secure the participation of young women often motivated as much by financial reward as altruism. In the United States, where the majority of oocyte donation is practised, more than 100,000 treatment cycles have occurred. However, to date no meaningful longitudinal studies detailing the long term effects of treatment on donors, recipients, children born, or families created have been published. Throughout its history, oocyte and embryo donation has proven to be both efficacious and clinically innovative, yet remains highly controversial.

Novel males' capacity to disrupt early pregnancy in mice (Mus musculus) is attenuated via a chronic reduction of males' urinary 17beta-estradiol

Mature male mice of proven fertility were administered chronic oral doses of anastrozole, a potent aromatase inhibitor, and also given a low-phytoestrogen diet. Urine was taken non-invasively from such males and from untreated control males and assayed for 17beta-estradiol and testosterone via ELISA procedures. After 8 weeks of drug or vehicle administration, urinary 17beta-estradiol declined to significantly lower levels in anastrozole-treated males than in non-treated males, whereas testosterone levels were comparable in the two groups. Inseminated females were exposed to drug-treated, vehicle-treated, or no males during days 1-6 of gestation, around intrauterine implantation of fertilized ova. Females exposed to vehicle-treated males produced fewer litters than did those kept in isolation. Females exposed to anastrozole-treated males produced significantly more litters than did those exposed to vehicle-treated males. These data support the notion that male excretions of estrogens may in part mediate novel-male-induced pregnancy disruptions, although other influences of aromatization on behaviour and metabolism remain possibilities.

Area under the curve for estradiol levels do not consistently reflect estradiol levels on the day of hCG administration in patients undergoing controlled ovarian hyperstimulation for IVF-ET

PURPOSE

Most studies reported estradiol (E2) levels attained on day of hCG administration when investigating effect of E2 on IVF outcome. We studied whether a relationship exists between the area under the curve for E2 levels (AUC-E2) and E2 levels on hCG day during IVF-ET.

METHODS

Retrospectively, we analyzed data for 313 patients who completed one IVF-ET cycle each. Patients were sorted according to AUC-E2 levels. Then we compared between each patient's own AUC-E2 and the corresponding E2 level on hCG day for the same patient.

RESULTS

Although overall AUC-E2 correlated positively with E2 levels on hCG day, there was no consistent correlation between individual patients.

CONCLUSIONS

AUC-E2 reflects more accurately the amount of E2 produced by the follicles during controlled ovarian hyperstimulation. The absence of a uniform correlation between AUC-E2 and E2 on hCG day may result in different conclusions when studying outcomes of IVF treatment.

Estradiol and leptin as conditional prognostic IVF markers

We studied the concentration of serum estradiol and serum and follicular fluid leptin in 200 women undergoing their first in vitro fertilization with embryo transfer (IVF-ET) program at the time of human chorionic gonadotrophin administration and oocyte retrieval, in an attempt to assess their concerted role on embryo quality and the prognosis of IVF outcome. Low serum (46.49 ± 8.4 ng/ml) and follicular fluid (52 ± 9.8 ng/ml) leptin levels were associated with a high number of ‘good-quality’ embryos (73.6%) and high implantation (11.2%) and pregnancy (35.8%) rates and were observed in women with normal peak estradiol levels of between 1000 and 2000 pg/ml. It appears that leptin and estradiol interact coordinately in a concentration-dependent manner to control IVF outcome. Further studies will be required to substantiate and clarify the mechanism of proposed conditional interaction between the two hormonal systems.

Recurrent implantation failure in assisted reproduction: how to counsel and manage. A. General considerations and treatment options that may benefit the couple

Recurrent implantation failure is a distressing phenomenon, both for the infertile couple and for the physician responsible for their treatment. Aetiology is often not clear and treatment options are vague. Particularly when transferred embryos are of good quality, recurrent implantation failure may be attributed to less than optimal embryo transfer technique, pathological lesions of the uterine cavity, the presence of hydrosalpinges, fibroids and endometriosis. Poor embryo quality, especially when repetitive, is a major impediment to successful implantation and cannot be corrected at the present time. Molecular abnormalities at the endometrial level and abnormal embryo-endometrium dialogue may be responsible for some cases of recurrent implantation failure. Furthermore, there may be over- or under-expressed genes that may be related to successful implantation. At the present time, the physician confronted with a couple presenting with recurrent implantation failure should discuss openly the potential causes of this phenomenon, with special emphasis on correctable causes, and offer remedies that are evidence based.

The midluteal decline in serum estradiol levels is drastic but not deleterious for implantation after in vitro fertilization and embryo transfer in patients with normal or high responses

OBJECTIVE

To determine the impact of the peak E(2) level and its midluteal decline on IVF-ET outcome in a group of normal- and high-responding patients.

DESIGN

Retrospective analysis of IVF-ET data.

SETTING

Tertiary-care, university-affiliated teaching hospital.

PATIENT(S)

A total of 100 patients aged </=38 years and receiving up to three embryos per transfer who underwent a similar standard controlled ovarian hyperstimulation for IVF-ET.

INTERVENTION(S)

Morning blood was collected on days 0 (hCG day), +9, and +14.

MAIN OUTCOME MEASURE(S)

Treatment cycle hormonal characteristics and percent midluteal E(2) decline in conception and nonconception cycles.

RESULT(S)

Among all cycles, a mean decline of 95.0% in serum E(2) was observed at the midluteal phase. No significant differences were found in various parameters comparing conception with nonconception cycles. Occurrence of conception did not correlate with the absolute E(2) level or with percent E(2) decline in good and high responders. Early spontaneous abortion occurred more frequently in high responders with >98% E(2) decline; however, the difference did not reach statistical significance.

CONCLUSION(S)

Multifactorial analysis refutes the negative role of supraphysiologic levels of E(2) on the day of hCG administration or its dramatic decline at the midluteal phase on the success rate after embryo transfer. A possibly increased rate of early spontaneous abortion in the high-response group warrants further verification.

Association of estradiol levels on the day of hCG administration and pregnancy achievement in IVF: a systematic review

BACKGROUND

Evaluation of the association between estradiol (E2) levels on the day of hCG administration and pregnancy achievement in IVF has so far yielded conflicting results. The purpose of the present study was to systematically review the above association in cycles down-regulated with GnRH analogues.

METHODS

Literature search was performed using Medline, Embase (1978-2004) and the Cochrane Library. Additionally, references of retrieved articles were hand-searched. Only full articles published in peer-reviewed medical journals were considered for analysis.

RESULTS

All the eligible studies (n=9) involved the use of GnRH agonists and were retrospective. Two studies (including 191 patients) suggested that the higher the E2 levels on the day of hCG administration, the higher the probability of pregnancy. However, five studies (including 1875 patients), did not support an association between E2 levels on the day of hCG administration and pregnancy rates. Moreover, two of the studies including (1286 patients) suggested that high E2 levels on the day of hCG administration are associated with a decreased probability of pregnancy. If we consider only studies in which criteria used for administering hCG include follicular development but not E2 levels (including 2687 patients), there is no study suggesting a positive association between E2 levels on the day of hCG administration and pregnancy achievement.

CONCLUSIONS

Currently there is no high-quality evidence to support or deny the value of E2 determination on the day of hCG administration for pregnancy achievement in IVF cycles, where pituitary down-regulation is performed with GnRH agonists. Existing retrospective studies suggest that there is no positive association. However, in order to arrive at recommendations for clinical practice, there is a need to perform well-designed prospective studies in both agonist and antagonist cycles.

Comparison of Pregnancy Outcomes of Progesterone or Progesterone + Estradiol for Luteal Phase Support in ICSI-ET Cycles

OBJECTIVE

To find out the effect of estradiol with progesterone for luteal phase support in IVF-ICSI cycles.

MATERIALS AND METHODS

Patients were accepted for treatment in the ART unit of Selcuk University, Meram Faculty of Medicine, between January 2001 and March 2003. The study was done in a prospective manner. The age range of 252 women was 19-41 years and the total number of cycles was 310. All patients were treated with a long ovulation induction protocol. Patients were treated and divided into two groups in a randomized manner: group I used only 600 mg/day divided into three equal doses of micronized progesterone vaginally, and group II used transdermal estradiol 100 microg/day + 600 mg/day vaginal micronized progesterone.

RESULTS

310 ICSI cycles were carried out in 252 infertile couples between January 2001 and March 2003. From 22 of these cycles, oocytes were retrieved but no embryos were developed. In the remaining 288 cycles there were embryo transfers. All embryo development was achieved by ICSI treatment. In 148 out of 288 cycles, the luteal phase was supported only by vaginal micronized progesterone (group I). On the other hand, the remaining 140 cycles received vaginal micronized progesterone plus transdermal estradiol 100 microg/day (group II). The number of beta-hCG-positive results in group I and group II were 20 (13.5 %) and 54 (38.5%) respectively.

CONCLUSION

Adding estradiol to progesterone for luteal phase support in ICSI-ET cycles may increase implantation and pregnancy rates.

Accelerated endometrial maturation in the luteal phase of cycles utilizing controlled ovarian hyperstimulation: impact of gonadotropin-releasing hormone agonists versus antagonists

OBJECTIVE

To evaluate the endometrium obtained during the luteal phase of controlled ovarian hyperstimulation (COH) cycles utilizing gonadotropin-releasing hormone (GnRH) antagonists, and to compare these findings with those obtained in cycles utilizing a GnRH agonist and with artificial cycles among recipients.

DESIGN

Prospective evaluation of oocyte donors.

SETTING

University-based in vitro fertilization (IVF) center.

PATIENT(S)

Fifteen oocyte donors undergoing standard COH were enrolled in 1 of 3 COH groups, and 40 recipients of oocyte donation were used as a control group.

INTERVENTION(S)

Controlled ovarian hyperstimulation and endometrial biopsy.

MAIN OUTCOME MEASURE(S)

Histological dating of endometrial biopsies, serum estradiol (E(2)) and progesterone levels.

RESULT(S)

On the day of oocyte retrieval, endometrial maturation was advanced by an average of 5.8 +/- 0.4 days in the antagonist group and 5.9 +/- 0.7 days in the agonist group. This advancement persisted on day 7 postoocyte retrieval. Serum progesterone levels were elevated before human chorionic gonadotropin (hCG) administration, but remained similar in both groups.

CONCLUSION(S)

Controlled ovarian hyperstimulation is associated with elevated progesterone levels in the late follicular phase and accelerated endometrial maturation in the subsequent luteal phase. No significant differences exist between preretrieval serial serum progesterone levels and luteal phase endometrial histology between cycles utilizing GnRH agonists or antagonists.

Serum estradiol positively predicts outcomes in patients undergoing in vitro fertilization

In patients undergoing in vitro fertilization, the presence of higher E(2) levels at the time of hCG administration predict a greater likelihood of ongoing pregnancy.

Assisted reproduction in the treatment of polycystic ovarian syndrome

Treatment of patients with polycystic ovary syndrome (PCOS) with assisted reproductive techniques is a great challenge for the infertility specialist. Patients with PCOS demonstrate many problems, such as excessive body weight and hyperinsulinaemia, that render management more complex. Prior to treatment with IVF, the PCOS patient should be thoroughly evaluated for disclosure of endometrial neoplasia, hyperinsulinaemia, and other general health related problems. Ovarian stimulation for IVF carries the risks of overstimulation and severe hyperstimulation, which should be avoidable in most cases with preventive measures. The outcome in terms of pregnancy and implantation rates is similar for patients with PCOS when compared with patients undergoing IVF for other indications. There are some questions regarding oocyte and embryo quality in women with PCOS. This manifests itself in lower fertilization rate and decreased embryo quality in some studies. However, increased numbers of oocytes available for insemination or ICSI compensate for decreased fertilization rates and embryo quality. More recent studies suggest higher cumulative conception rates in women with PCOS when compared with controls. In-vitro maturation (IVM) of oocytes retrieved from non-stimulated or minimally stimulated cycles represents a viable option that should be considered seriously when assisted conception is attempted. Results of IVM, however, should be improved further and generalized before the technique can be advocated as the initial treatment approach in these patients.

Statistical analysis of factors affecting fertilization rates and clinical outcome associated with intracytoplasmic sperm injection

OBJECTIVE

To identify and evaluate the statistically significant predictors of intracytoplasmic sperm injection (ICSI) fertilization rates and clinical pregnancy in a single population using appropriate statistical techniques.

DESIGN

Retrospective study.

SETTING

Fertility and Endocrinology Center, University of Washington Medical Center, Seattle, Washington.

PATIENT(S)

Four hundred forty-one patients undergoing their first attempt at IVF-ICSI from January 1, 1999, to May 21, 2001.

INTERVENTION(S)

Each ICSI procedure for an individual patient was performed by a single operator. Sperm parameters, oocyte age, culture condition, ICSI technique, and ICSI operator were assessed as variables influencing the fertilization rate. We also assessed the impact of patient age, serum E(2) concentration on the day of hCG administration, embryo quality, and number of embryos transferred on the probability of achieving a clinical pregnancy.

MAIN OUTCOME MEASURE(S)

Fertilization rate and clinical pregnancy.

RESULT(S)

The 2 pronuclei (2PN) rate was significantly correlated with sperm motility, and there were significant differences in the 2PN rates among the ICSI operators. There was no difference in the 2PN rate among different sperm types or among the eight laboratory incubators or whether the eggs were cultured individually or in groups. Patient age, serum E(2) concentration on the day of hCG administration, embryo quality, and number of embryos transferred were all statistically significant predictors of clinical pregnancy.

CONCLUSION(S)

In our program, sperm motility and ICSI operator are the two most important predictors for the ICSI fertilization rate in vitro. Patient age, serum E(2) concentration on the day of hCG administration, embryo quality, and number of embryos transferred were all statistically significant predictors of clinical pregnancy.

Percentile curves of serum estradiol levels during controlled ovarian stimulation in 905 cycles stimulated with recombinant FSH show that high estradiol is not detrimental to IVF outcome

BACKGROUND

High, normal and poor responders are usually defined by reference to subjectively selected estradiol E2 levels at days 4-6 and the day of hCG administration (d-hCG). The purpose of this study was to use E2 percentile curves from day 5 until d-hCG to determine high, normal and poor responders, and to predict IVF outcome.

METHODS

In this retrospective study, 762 patients underwent 905 cycles with a GnRH agonist/recombinant FSH short protocol. They were divided into three groups according to their age. Percentile E2 curves according to E2 levels were plotted. High responders were those patients with E2 levels above the 90th percentile, normal responders had E2 between the 10th and 90th percentiles, and poor responders had E2 below the 10th percentile.

RESULTS

IVF outcome, expressed as number of oocytes, total embryos obtained and number of high grade embryos, was significantly better for patients with E2 above the 90th percentile at d-hCG for the three age groups and at day 5 for group A (<35 years). Pregnancy rates were higher for high responders, but the difference did not reach statistical significance.

CONCLUSIONS

Percentile curves can be useful in controlled ovarian stimulation cycles to define high, normal and poor responders, and also to predict IVF outcome.

The value of routine estradiol monitoring in assisted conception cycles

BACKGROUND

Traditional monitoring of an in vitro fertilization (IVF) treatment cycle includes regular estradiol levels and ultrasound scans in an attempt to reduce the risk of ovarian hyperstimulation syndrome (OHSS). The need for estradiol monitoring remains controversial.

METHODS

We reviewed 538 consecutive cycles of IVF that were carried out in our unit to ascertain whether routine estradiol monitoring was of help in preventing OHSS and could be used to predict treatment outcome. Two hundred and sixty-eight patients had their ovarian response monitored with ultrasound (USS) and estradiol levels on the day of hCG administration. The following 270 had USS monitoring but only had an estradiol level checked if they were deemed to be at high risk of OHSS (> 20 follicles on USS or symptomatic).

RESULTS

Pregnancy rates per treatment cycle and per embryo transfer were similar in the two groups (all p > 0.05). There were two patients in each group requiring admission to hospital for OHSS.

CONCLUSIONS

Estradiol levels did not correlate with IVF outcome. In summary therefore estradiol levels are a poor predictor of treatment success and done routinely do not reduce the incidence of OHSS. It is only necessary to measure the estradiol level in those patients at risk of OHSS on USS monitoring.

Oocyte donation

Oocyte donation affords women with ovarian failure, advanced reproductive age, heritable conditions or recurrent implantation failure the ability to conceive. Recipients must be medically screened carefully prior to attempting pregnancy. Egg donors should also be healthy and pose no infectious or genetic risk to the recipient or offspring. Donor and recipient menstrual cycles are synchronized so that embryos are transferred to a receptive endometrium. Donors are prescribed injectible gonadotrophins to achieve multifollicular growth. Recipient endometrial priming begins with 2 weeks (or more) of oestradiol, with progesterone added to the regimen 3-4 days prior to the transfer of embryos. Pregnancy rates following egg donation are among the highest observed following assisted reproduction. Despite advanced reproductive age, perinatal and obstetric outcomes are generally good. Techniques (i.e. germinal vesicle transfer, donor ooplasm, and ovarian cryopreservation and transplantation techniques) may permit the recipient to provide some genetic contribution to offspring and are currently under investigation.

Increasing levels of estradiol are deleterious to embryonic implantation because they directly affect the embryo

OBJECTIVE

To investigate whether the deleterious effect of E(2) on embryonic implantation is due to a direct effect on the endometrium, on the embryo, or both.

DESIGN

Prospective, controlled in vitro study.

SETTING

Tertiary infertility center.

PATIENT(S)

Fertile patients in the luteal phase with histologically normal endometrium who were attending the infertility clinic as oocyte donors (n = 14).

INTERVENTION(S)

E(2) dose-response (0, 10(-8), 10(-7), 10(-6), 10(-5), and 10(-4) M) and time course (day 2 vs. day 5) experiments were performed in an in vitro embryo adhesion assay composed of human polarized endometrial epithelial cells obtained from fertile patients and mouse embryos.

MAIN OUTCOME MEASURE(S)

Blastocyst formation rate and embryo adhesion rate.

RESULTS

Monolayers of polarized endometrial epithelial cells expressed ERalpha at the mRNA level. The E(2) dose response of blastocysts with polarized endometrial epithelial cells (n = 235) demonstrated a progressive reduction in embryonic adhesion that was statistically significant at 10(-6) M. When polarized endometrial epithelial cells were treated alone with increasing doses of E(2) for 3 days and E(2) was then removed and blastocysts added (n = 410), embryonic adhesion was not significantly reduced, except at 10(-4) M. When 2-day mouse embryos (n = 609) were treated with increasing E(2) concentrations until day 5, the rate of blastocyst formation significantly decreased at a concentration >or= 10(-6) M, and embryonic adhesion decreased when blastocysts (n = 400) were obtained at a concentration >or= 10(-7) M. Time course experiments of embryos cultured for 2 days with polarized endometrial epithelial cells (n = 426) showed that the adhesion rate was higher at E(2) levels of 10(-7), 10(-6) and 10(-5) M compared with embryos cultured for 5 days (n = 495).

CONCLUSION(S)

High E(2) levels are deleterious to embryo adhesion in vitro, mainly because they have a direct toxic effect on the embryo that may occur at the cleavage stage.

Colour Doppler analysis of peri-implantation utero-ovarian haemodynamics in women with excessively high oestradiol concentrations after ovarian stimulation

BACKGROUND

Gonadotrophins are used in many assisted reproduction units to achieve a better success rate by increasing the number of replaced embryos. However, high oestradiol concentrations are associated with altered physiological functions and its complications. We investigated whether high oestradiol concentrations (> or =20 000 pmol/l) after ovarian stimulation in infertile women would affect the uterine haemodynamics at the time of embryo transfer.

METHODS

Colour Doppler indices of utero-ovarian arteries and endometrial colour signals were measured. Fifty-eight women undergoing ovarian stimulation for IVF were classified according to serum oestradiol concentrations on the day of human chorionic gonadotrophin injection into moderate responders (oestradiol <20 000 pmol/l; n = 39) and high responders (oestradiol > or =20 000 pmol/l; n = 19).

RESULTS

Haemodynamic parameters were significantly lower in high responders; the uterine arterial pulsatility index (PI) and resistance index (RI) were (median; range) 1.87 (0.84-2.82) and 0.79 (0.57-0.90) respectively; ovarian artery PI was 0.57 (0.40-1.12) and RI was 0.43 (0.33-0.64). In moderate responders the uterine PI and RI were 2.63 (1.46-5.92) and 0.88 (0.77-1.10) respectively. Ovarian PI was 0.81 (0.32-3.72) and RI was 0.55 (0.23-0.97). The number of women showing endometrial colour signals was significantly lower in high responders (63%) than in moderate responders (92%) (P < 0.05). A further increase in oestradiol (> or =25 000 pmol/l; n = 8) showed significantly (P = 0.03) fewer endometrial colour signals [1.5 (0-8)] compared with moderate responders [4 (0-14)].

CONCLUSION

Despite low uterine PI and RI, the endometrial blood flow in high responders appears to be impaired. This may contribute to the decline in implantation efficiency noted in high responders.

Controlled ovarian hyperstimulation does not adversely affect endometrial receptivity in in vitro fertilization cycles

OBJECTIVE

To determine whether exposure of developing endometrium to supraphysiologic E2 levels during controlled ovarian hyperstimulation (COH) in IVF cycles inhibits endometrial receptivity.

DESIGN

Retrospective analysis of IVF-ET and ovum donation data.

SETTING

Tertiary-care teaching hospital.

PATIENT(S)

Four hundred ten patients <33 years of age undergoing IVF-ET and 181 anonymous ovum donors (<33 years of age) and their associated ovum recipients.

MAIN OUTCOME MEASURE(S)

Implantation, pregnancy, and delivery rates.

RESULT(S)

Ovarian response to COH (duration of stimulation, peak E2 level, area under the curve for E2 exposure, and number of oocytes retrieved) was similar for IVF-ET patients and ovum donors. Donors were younger than IVF-ET patients (mean age, 27.5 +/- 0.2 years vs. 30.4 +/- 0.1 years). A similar number of embryos with similar number of blastomeres were transferred in IVF-ET patients and ovum recipients. The fragmentation rate at time of transfer differed slightly between groups (5.2 +/- 0.2% vs. 4.3 +/- 0.3%). Implantation, pregnancy, and delivery rates did not differ between IVF-ET patients and recipients of donor oocytes.

CONCLUSION(S)

Exposure of the developing endometrium to controlled ovarian hyperstimulation during IVF cycles does not inhibit embryo implantation or affect pregnancy and delivery rates.

Assessing fertility in women of advanced reproductive age

Reproductive capacity in women declines dramatically beyond the fourth decade of life. Oocyte quality seems to be the primary determinant of reproductive potential, although age-related uterine changes may also contribute. Underlying reasons for reproductive decline in women remain unclear, and both ovarian and neuroendocrine mechanisms have been proposed.A number of age-related endocrinologic changes precede menopause and predict diminished reproductive capacity. Thus, "ovarian reserve" screening may identify patients in whom attempts at conventional assisted reproduction is warranted before proceeding with ovum donation. Techniques to preserve the maternal genetic contribution to offspring (in lieu of egg donation), including germinal vesicle transfer and donor ooplasm, are under investigation.