The luteal phase during gonadotropin therapy: effects of two human chorionic gonadotropin regimens

Luteal phase support in intrauterine insemination cycles

Intrauterine insemination (IUI) treatment aims to increase the rate of conception by increasing the chances that the maximum number of healthy sperm reach the site of fertilization. IUI with controlled ovarian stimulation is frequently used in assisted reproduction practice. Although widely used, the efficacy of luteal support in IUI remains controversial. In this article, we aimed to review what we know regarding luteal support in IUI cycles and to adjudicate about the clinical use and benefits of this treatment. Based on the study results available in the literature, it appears to be beneficial to supplement the luteal phase in gonadotropin-stimulated IUI cycles that yield more than one follicle.

Effect of luteal phase support after ovulation induction and intrauterine insemination

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

The luteal phase after ovarian stimulation

Evaluation of the luteal phase after ovarian stimulation presents several difficulties. Until today, it has not been proved that in cycles stimulated with clomiphene citrate/human menopausal gonadotrophins, luteal supplementation with progesterone significantly increases implantation rate. On the contrary, it is accepted that in cycles stimulated with GnRH agonists/gonadotrophins, support of the luteal phase is essential for the achievement of pregnancy. In GnRH antagonist cycles luteal supplementation, although widely practised, is not at present supported by randomized controlled trials. Finally, it appears that the combination of gonadotrophin stimulation with human chorionic gonadotrophin results in an inadequate luteal phase with or without the use of either agonists or antagonists.

The effect of luteal phase support protocol on cycle outcome and luteal phase hormone profile in long agonist protocol intracytoplasmic sperm injection cycles: a randomized clinical trial

OBJECTIVE

To study the effect of luteal phase support protocol on cycle outcome and luteal phase hormone profile, in long agonist protocol intracytoplasmic sperm injection (ICSI) cycles.

DESIGN

Prospective randomized trial.

SETTING

Private infertility center.

PATIENT(S)

Two hundred seventy-four women undergoing first ICSI cycles were randomized after ovum pickup into three groups of luteal support.

INTERVENTION(S)

Group I received IM P (P(4)) only, group II received P(4) + oral E(2) valerate, group III received P(4) + hCG.

MAIN OUTCOME MEASURE(S)

Pregnancy rate (PR), implantation rate, rates of multiple pregnancy and miscarriage, and midluteal serum E(2) and P(4), and midluteal E(2):P(4) ratio.

RESULT(S)

The PR and implantation rates were significantly higher in group II compared to group I and the miscarriage rate was significantly lower in group II compared with group I. Midluteal E(2) was significantly higher in group II compared with group I. The decline in E(2) after ovum pickup was lowest in group II, highest in group I. The midluteal E(2):P(4) ratio was significantly higher in group II compared with groups I and III.

CONCLUSION(S)

The E(2) luteal phase supplementation in long GnRH-agonist (GnRH-a) protocol ICSI cycles resulted in better cycle outcome and better luteal phase hormone profile.

Impact of luteal phase support on pregnancy rates in intrauterine insemination cycles: a prospective randomized study

OBJECTIVE

To determine the impact of luteal phase support on pregnancy rates in ovarian stimulation and intrauterine insemination (IUI) cycles with gonadotropins in couples with unexplained infertility.

DESIGN

Prospective randomized controlled trial.

SETTING

University-based infertility clinic.

PATIENT(S)

Two hundred fourteen couples with unexplained infertility who were treated during 427 ovarian stimulation and IUI cycles with recombinant FSH.

INTERVENTION(S)

Patients underwent ovarian stimulation with recombinant FSH combined with IUI. Patients randomized into the study group (n = 109) received luteal phase support in the form of vaginal progesterone gel (Crinone 8% gel). Patients randomized into the control group (n = 105) received no luteal phase support.

MAIN OUTCOME MEASURE(S)

Clinical pregnancy and live birth rate per cycle and per patient.

RESULT(S)

Demographic data were found to be homogeneous between the study and control groups. Clinical pregnancy rates per cycle and per patient were significantly higher in the study group (21.1% and 39.4%, respectively) compared with the control group (12.7% and 23.8%, respectively). Live birth rate per cycle and per patient was also significantly higher in patients with luteal support (17.4% and 35.8%, respectively) compared with control subjects (9.3% and 18.1%, respectively).

CONCLUSION(S)

Luteal phase support with vaginal progesterone gel significantly affects the success of ovarian stimulation and IUI cycles in patients with unexplained infertility.

Reproductive biology and IVF: ovarian stimulation and endometrial receptivity

The influence of ovarian stimulation on endometrium receptivity has been inadequately addressed in medical literature. Hormonal effects of ovarian stimulation on endometrial changes as compared with the natural cycle should be elucidated and correlated with the potential of the embryo to implant. It is important to distinguish between the endometrial effect of induction of ovulation in anovulatory women and those of ovarian (super)ovulation in ovulatory women. Induction of ovulation leads to in vivo conception whereas ovarian stimulation results in in vitro fertilization. The available data in the field indicate that endometrial changes have an impressive negative influence on the potential of embryonic implantation. The aim of this review is to analyse the effects of gonadotropin, GnRH-agonist and GnRH-antagonist administration on endometrial behaviour, to highlight the gaps in current knowledge and to propose areas in which research is needed.

Ratio of oestradiol concentration on the day of human chorionic gonadotrophin administration to mid-luteal oestradiol concentration is predictive of in-vitro fertilization outcome

The role of luteal oestradiol for successful implantation in humans seems to be permissive rather than obligatory. Few studies have attempted to clarify the role of early luteal oestradiol in in-vitro fertilization (IVF) outcome, whether peri-implantation oestradiol is predictive of successful IVF outcome. We retrospectively analysed 106 women undergoing 106 IVF/embryo transfer cycles. Only the first treatment cycle per patient was analysed. Peak oestradiol denoted the concentration on the day of human chorionic gonadotrophin (HCG) administration. Mid-luteal oestradiol was obtained 3 days after embryo transfer (8 days after HCG administration). A total of 44 pregnancies were noted (41.51%). There were no differences in age, cycle day 3 follicle stimulating hormone (FSH), peak oestradiol, number of retrieved oocytes, number of embryo transfers, and mid-luteal oestradiol between pregnant and non-pregnant women. However, the ratio of day of HCG oestradiol to mid-luteal oestradiol was highly predictive of successful outcome: the ongoing pregnancy rate and implantation rate (sacs with fetal heart beat/embryo transfer) were 15.8 and 5.7% respectively if the above ratio exceeded 5.0 (n = 19), compared to 42.1 and 16.3%, and 53.3 and 26. 5% if the ratio was between 0.4 and 2.5 (n = 57), and between 2.5 and 5.0 (n = 30) respectively. Our study suggests that the magnitude of decline in oestradiol concentrations after oocyte retrieval may be important in predicting IVF success. We postulate that endometrial integrity may become compromised when a dramatic drop in oestradiol occurs by the mid-luteal period. Whether these women benefit from oestradiol supplementation after oocyte retrieval remains to be investigated.

Ovulation triggering in clomiphene citrate-stimulated cycles: human chorionic gonadotropin versus a gonadotropin releasing hormone agonist

PURPOSE

To compare the use of human chorionic gonadotropin (hCG) to a gonadotropin releasing hormone (GnRH) agonist, nafarelin, in initiating ovulation and supporting the luteal phase after priming with clomiphene.

METHODS

In 26 infertile women 50 mg clomiphene citrate produced a preovulatory-size follicle. Then, 11 women were randomized to receive two 400-micrograms doses of nafarelin intranasally 16 h apart, and 15 women were injected intramuscularly with 5000 IU of hCG (luteal day 0 = LD0). Starting on LD6, 7 more 400-micrograms doses of nafarelin were repeated on an every 16-h schedule or a single 2500 IU dose of hCG was given, respectively. Serum levels of follicle stimulating hormone (FSH), luteinizing hormone (LH), estradiol (E2), progesterone (P), and hCG were measured. On LD13, endometrium was evaluated with ultrasonography and biopsy in 19 nonpregnant women.

RESULTS

As judged by a threefold rise in serum LH, an LH surge was detected on LD1 in all 11 nafarelin patients, but in only 8 hCG patients (P = 0.01). LH and FSH levels were significantly higher on LD1, 7, and 8 and were significantly suppressed on LD13 in the nafarelin group. All patients had mid-luteal P levels greater than 10 ng/ml and luteal phases longer than 13 days. Significantly different luteal E2 or P levels were noted only on LD13, with lower values in the nafarelin group. Pregnancies were achieved in 3 of 11 nafarelin cycles and 2 of 15 hCG cycles. Luteal phase defects were also similar: 4 of 8 nafarelin patients and 7 of 11 hCG patients.

CONCLUSION

Nafarelin or hCG in conjunction with clomiphene can result in viable pregnancies, but is associated with low pregnancy rates and a high incidence of luteal phase defects.

The value of luteal support with progesterone in gonadotropin-induced cycles

OBJECTIVE

To evaluate the effect of luteal support with vaginal P suppositories in hMG- and hCG-induced cycles.

DESIGN

Between March 1988 and February 1989 patients did not receive luteal support, while between March 1989 and January 1990 P was given routinely in the luteal phase. Induction protocol and patient selection remained otherwise unchanged.

SETTING

Infertility clinic of a tertiary care hospital.

PATIENTS

Twenty-seven patients with hypogonadotropic amenorrhea (World Health Organization [WHO] group I) (11 women with luteal support, 16 women without) and 102 patients with euprolactinemic clomiphene citrate (CC)-resistant anovulation (WHO group II) (52 women with luteal support, 50 women without).

INTERVENTION

Vaginal P suppositories 200 mg/d in the luteal support group.

MAIN OUTCOME MEASURES

Pregnancy rate (PR), pregnancy outcome.

RESULTS

The overall PR in 118 cycles with luteal support was 26.3% whereas 10.4% pregnancies were achieved in 115 cycles of the control group. The influence of luteal support was more pronounced in patients with CC-resistant anovulation (25.2% versus 6.9%) than in patients with hypogonadotropic amenorrhea (33.3% versus 21.4%, not significant). The abortion rate was not significantly changed.

CONCLUSION

Luteal support with P increases the PR after hMG and hCG induction. The need for supplementary P seems to be related to the underlying cause of ovarian disturbance.

Comparative study of hormonal dynamics in pregnant and nonpregnant cycles during pulsatile subcutaneous administration of human menopausal gonadotropin in anovulatory infertile women

OBJECTIVE

To assess the clinical relevance of daily hormonal changes for achieving a successful pregnancy in anovulatory infertile women.

DESIGN

A comparative study of hormonal dynamics in pregnant and nonpregnant cycles during the pulsatile subcutaneous administration of hMG. Subjects received subcutaneous injection of either 9.375 IU or 14.0625 IU of hMG diluted in 50-microL physiological saline (total daily dose, 150 or 225 IU) at 90-minute intervals by means of a portable peristaltic pump.

SETTING

Kyorin University Hospital and Ichikawa General Hospital.

PATIENTS

We analyzed 18 pregnant and 42 nonpregnant cycles in 17 patients with secondary hypothalamic/pituitary amenorrhea who conceived after receiving pulsatile hMG treatment. Another 14 women with normal spontaneous ovulation, including 14 pregnant and 15 nonpregnant cycles, served as controls.

MEASUREMENTS

Serum concentrations of LH, FSH, E2, and P were measured, and the P:E2 ratio was determined.

RESULTS

Serum concentrations of LH and FSH did not differ significantly between the pregnant and nonpregnant cycles. Serum levels of P and E2 were significantly higher during the hMG treatments than those of the spontaneous ovulatory cycles throughout the follicular and luteal phases. Up to the midluteal phase, the P and E2 values in the nonpregnant cycles during the hMG treatments did not differ significantly from those in the pregnant cycles. The P:E2 ratios were comparable between the pulsatile stimulatory cycles and the normal spontaneous ovulatory cycles. However, the P:E2 ratio in the early and midluteal phases was significantly greater in the pregnant cycles than in the nonpregnant cycles.

CONCLUSION

The P:E2 ratio in the early and midluteal phases is a more important indicator of hormonal function for implantation than the absolute levels of either P or E2.

The step-down principle in gonadotrophin treatment and the role of GnRH analogues

This chapter has focused on the step-down principle for gonadotrophin induction of ovulation in women suffering from clomiphene-resistant anovulation. The physiological rationale of this approach has been highlighted. Under normal conditions, FHS levels surpassing the FSH threshold initiate gonadotrophin-dependent growth of a cohort of follicles (this process is referred to as 'recruitment'). Due to negative feedback actions, the FSH levels decrease and FSH is above the threshold for only a limited number of days (the 'FSH window'). Around the mid-follicular phase, selection of a dominant follicle takes place; in addition to relatively low serum FSH concentrations, intraovarian regulation appears to be important for this process. In the conventional step-up or low dose step-up protocols for gonadotrophin induction of ovulation, administered doses are kept constant once an 'adequate' ovarian response is observed, resulting in high FSH serum levels in the late follicular phase and a broad FSH window. This contradicts normal circumstances and may give rise to unintended interference with the selection process by continuously stimulating follicles to enter the growing pool. This may result in multiple follicle development which, in turn, may be related to higher rates of multiple pregnancies and ovarian hyperstimulation. Potential mechanisms underlying arrested follicle maturation in PCOS are also discussed since they appear to be of relevance for the induction of ovulation. Disturbed selection can be overcome in the majority of cases by elevating the serum FSH concentrations through the administration of exogenous gonadotrophins to surpass the elevated FSH threshold in these patients. Data obtained by our group so far suggest that in PCOS patients treated with gonadotrophins in a step-down fashion, follicles continue to mature and can be stimulated to ovulation. Moreover, the number of functionally active medium-sized follicles seems to be reduced. If monofollicular development is observed in these patients, growth rates and oestrogen serum levels are indistinguishable from unstimulated normal development of the dominant follicle. In our initial series of over 200 cycles of gonadotrophin treatment according to the step-down principle in clomiphene-resistant anovulatory patients, 84% of cycles were ovulatory and pregnancy was achieved in 18% of the cycles (giving a cumulative pregnancy rate of 51%). Moreover, the overall complication rate appears to be low. The potential advantages and critical points of adjuvant treatment with GnRH analogues is also discussed. It has been clearly demonstrated that premature luteinization can be prevented effectively. Various other potential advantages of cotreatment seems to justify adjuvant medication with GnRH agonists.(ABSTRACT TRUNCATED AT 400 WORDS)