Altering the timing of human chorionic gonadotropin injection according to serum progesterone (P) concentrations improves embryo quality in cycles with subtle P rise

Effects of different progesterone levels on reproductive outcomes in assisted reproductive technologies: from molecular basis to treatment strategies

PURPOSE

The aim of this narrative review is to offer an overview about the role of progesterone levels on pregnancy outcome in patients undergoing assisted reproductive technologies (ARTs).

METHODS

A detailed computerized search of the literature was performed in the main electronic databases (MEDLINE, EMBASE, Web of Science) to determine the importance of elevated progesterone levels at different stages of the cycle for pregnancy rates in the in vitro fertilization (IVF) cycle. Our review also provides information on the differences between elevated progesterone levels and their interpretation in normal and in poorly responding women.

RESULTS

After careful evaluation, our search strategy yielded a total of 15 included articles, showing the possible factors that may have had an impact on the increased progesterone level before human chorionic gonadotropin (HCG) injection and the different thresholds above which the pregnancy rate was lower. Furthermore, increased progesterone on cycle day 2 or 3 could serve as a marker for increased progesterone in the late follicular phase, which is associated with a lower pregnancy rate.

CONCLUSION

Despite the literature data that support the negative effect of elevated progesterone on fresh cycles, due to lack of randomized controlled trials, the value of measuring progesterone in daily practice is questionable. Available evidence supports the detrimental effect of elevated progesterone in different subgroups of women, although there is still the need for defining different thresholds and durations of high progesterone exposure. The need for various thresholds for different cohorts of women, the inter-assay variability is making this decision harder.

Double daily doses of cetrorelix may raise follicular phase progesterone more compared to single doses in poor ovarian response patients

PURPOSE

There is evidence that follicular phase progesterone rise [FPPR] adversely affects fresh in vitro fertilization [IVF] cycles. A single daily dose of cetrorelix has been used to prevent early luteinizing Hormone (LH) surge. We speculated that doubling the daily dose might have a positive effect in patients who have early LH surges despite receiving the single daily dose treatment. However, a double daily dose of cetrorelix seems to cause FPPR in poor ovarian response (POR) patients.

MATERIALS AND METHODS

On human chorionic gonadotropin [hCG] injection days, the progesterone levels of POR patients who received a single daily dose of cetrorelix (group 1, n = 59) were compared with progesterone levels of the patients who received a double daily dose of cetrorelix (group 2, n = 75). The two groups had statistically similar demographic data. The patients who had FPPR were detected, and a comparison of progesterone levels, using 0.8, 1.0, and 1.2 [ng/mL] of progesterone as cut-off levels, was made between patients of both groups.

RESULTS

FPPR patients in group 2 had significantly higher progesterone levels during hCG day, contrary to expectations. When progesterone cut-off levels of 0.8, 1.0, and 1.2 [ng/mL] were used for group 1 patients, 15.3%, 13.6%, and 6.8% of the patients developed FPPR, respectively When the progesterone cut-off levels of 0.8, 1.0, and 1.2 [ng/mL] were used for group 2, the results detected were 45.3%, 30.7%, and 21.3%, respectively. A significant statistical difference in progesterone levels was observed between the groups.

CONCLUSION

While the double daily dose of cetrorelix was initially thought to more effectively suppress early LH rise by some authors, we have seen that it increases the FPPR more when compared to a single daily dose regime. We suggest using frozen cycles instead of fresh cycles in order to have better endometrial receptivity in patients who seem to benefit from higher daily doses of cetrorelix.

Factors associated with extremely high progesterone concentrations on the day of HCG administration

OBJECTIVE

Progesterone elevation on the day of human chorionic gonadotropin (hCG) administration remains one of the most controversial topics in reproductive endocrinology. Factors associated with these increases have not been fully determined. The purpose of our study is to investigate factors associated with extreme progesterone elevation on the day of human chorionic gonadotropin (hCG) administration.

MATERIALS AND METHODS

This retrospective observational, single-center cohort study recruited 2000 fresh in vitro fertilization (IVF) and/or intracytoplasmic sperm injection(ICSI)-embryo transfer cycles from January 2000 to December 2014 in our institution.

RESULTS

When cycles were divided into those with progesterone <1.94 ng/mL (n = 1791) and ≧1.94 ng/mL (n = 209) on the day of hCG administration, five factors were positively associated with highly elevated progesterone concentration: protocol (GnRH agonist versus antagonist; odds ratio [OR = 2.786]), number of dominant follicles (OR = 1.098), total dose of follicle stimulating hormone (FSH) used (OR = 1.023), elevated luteinizing hormone (LH) (OR = 1.085) and estradiol (E2; OR = 1.001) concentrations on the day of hCG administration (p < 0.001 each). After omitting the protocol effect, the remaining factors showed limited contributions to highly elevated progesterone (ORs = 0.95-1.2).

CONCLUSIONS

The factor showing the greatest association with extreme progesterone elevation was use of the GnRH agonist protocol.

The curious case of premature luteinization

PURPOSE

Premature luteinization (PL) affects 12.3-46.7% of fresh in vitro fertilization cycles, and there is accumulating evidence confirming its negative effect on success rates. However, despite its clinical significance, PL is poorly understood and defined. This narrative review aims to provide a fresh look at the phenomenon of PL by summarizing the existing evidence and re-evaluating fundamental issues.

METHODS

A thorough electronic search was conducted covering the period from 1978 until January 2018 in PubMed, Embase, and Medline databases, and references of relevant studies were cross-checked. Meeting proceedings of the European Society of Human Reproduction and Embryology and the American Society for Reproductive Medicine were also hand searched.

RESULTS

In the curious case of PL, one should go back to the beginning and re-consider every step of the way. The pathogenesis, definition, measurement methods, clinical implications, and management strategies are discussed in detail, highlighting controversies and offering "food for thought" for future directions.

CONCLUSIONS

Authors need to speak the same language when studying PL in order to facilitate comparisons. The terminology, progesterone cut-off, measurement methods and days of measurement should be standardized and globally accepted; otherwise, there can be no scientific dialog. Future research should focus on specific patient profiles that may require a tailored approach. Progesterone measurements throughout the follicular phase possibly depict the progesterone exposure better than an isolated measurement on the day of hCG. Adequately powered randomized controlled trials should confirm which the best prevention and management plan of PL is, before introducing any strategy into clinical practice.

Assessing predictors for the success of GnRH antagonist protocol in reproductive women in IVF/ICSI - in fresh cycles

The aim of the present study was to evaluate the factors that affect the success rate of gonadotropin-releasing hormone antagonist on in vitro fertilization/intracytoplasmic sperm injection cycles. Multivariate analysis was performed to assess the factors that influence the outcomes, such as oocytes retrieved, and the success of pregnancy. The results showed that E₂, P on human chorionic gonadotropin (HCG) day and body mass index (BMI) were positively correlated with the number of oocytes retrieved (P=0.001, P=0.024, P=0.017, respectively). The duration of infertility as well as the luteinizing hormone on HCG day were negatively correlated with the number of oocytes (P=0.048, P=0.002, respectively). The age of the women and P on HCG day were negatively correlated with successful pregnancy (P<0.001, P=0.022). In conclusion, some parameters, such as E₂, P, and LH on the HCG day, as well as age and BMI, may affect treatment outcomes.

Are extremely high progesterone levels still an issue in IVF?

BACKGROUND

Premature luteinization of one or more developing follicles complicates 1-2 % of controlled ovarian stimulation cycles for assisted reproduction. The management of this complication is controversial, with cycle cancellation likely representing the most commonly used strategy. The aim of this study was to evaluate the efficacy of the "freeze-all" policy-where the entire cohort of blastocysts is cryopreserved for subsequent frozen-thawed embryo transfer-in treating cases of premature luteinization.

METHODS

Patients experiencing premature luteinization during controlled ovarian stimulation-identified by extremely high progesterone levels at induction (P levels ≥3.0 ng/ml and/or P/estradiol ratio ≥1, n = 42)-were included in a "freeze-all" program and compared to controls undergoing a "freeze-all" program with normal progesterone levels at induction (P < 1.5 ng/ml, n = 67).

RESULTS

Blastulation rate was comparable between patients with premature luteinization and controls (48.1 ± 20.5 % in Cases vs. 52.3 ± 24.9 % in Controls, p = 0.36). Ongoing pregnancy rates after the first frozen-thawed embryo transfer (38.1 % in Cases and 41.0 % in Controls, p = 0.83) and cumulative ongoing pregnancy rates after three frozen-thawed embryo transfer cycles (40.5 % in Cases vs. 47.8 % in Controls, p = 0.55) were also similar.

CONCLUSIONS

These results show that extremely marked progesterone elevation throughout controlled ovarian stimulation does not impair blastocyst development and implantation potential in the context of a "freeze-all" strategy. Based on this, adoption of the "freeze-all" strategy represents a valuable tool in treating premature luteinization. In contrast, cycle cancellation-likely the most frequently used method for management of this complication-currently represents a misconduct.

Do increased levels of progesterone and progesterone/estradiol ratio on the day of human chorionic gonadotropin affects pregnancy outcome in long agonist protocol in fresh in vitro fertilization/intracytoplasmic sperm injection cycles?

BACKGROUND:

The effect of elevated levels of serum progesterone (P₄) and estradiol (E₂) on the day of human chorionic gonadotropin and their cut-off value on in vitro fertilization (IVF) outcomes is still not clear.

AIMS:

The aim was to evaluate the association between serum P₄, E₂ and progesterone/estradiol ratio (P₄/E₂) on pregnancy outcome in IVF/intracytoplasmic sperm injection (ICSI) cycles with long agonist protocol.

SETTING AND DESIGN:

Retrospective, single center, cohort study.

MATERIALS AND METHODS:

A review of complete data of 544 women undergoing fresh IVF/ICSI cycles (539 cycles) with long agonist protocol from January 2012 to February 2014 was done. Data were stratified into Three groups according to the number of oocytes retrieved: low (≤4 oocytes obtained), intermediate (5–19 oocytes obtained), and high ovarian response (≥20 oocytes obtained).

STATISTICAL ANALYSIS:

Fishers exact test/Chi-square was carried for comparing categorical data. Receiver operating characteristics analysis was performed to determine the cut-off value for P₄ and P₄/E₂ detrimental for pregnancy.

RESULTS:

A negative association was observed between pregnancy rate (PR) and serum P₄ and P₄/E₂ levels with no effect on fertilization and cleavage rate. The overall cut-off value of serum P₄ and P₄/E₂ ratio detrimental for pregnancy was found to be 1.075 and ≥0.35, respectively. Different P₄ threshold according to the ovarian responders were calculated, 1.075 for intermediate and 1.275 for high responders. Serum E₂ levels were not found to be significantly associated with PR.

CONCLUSION:

Serum P₄ levels and P₄/E₂ ratio are a significant predictor for pregnancy outcome without affecting cleavage and fertilization rate while serum estradiol levels do not seem to affect PR.

Effects of high progesterone on outcomes of in vitro fertilization-embryo transfer in patients with different ovarian responses

The data of 3,841 cycles undergoing in vitro fertilization-embryo transfer (IVF-ET) in our reproductive Center between January 2003 and December 2013 were retrospectively analyzed. According to the number of oocytes retrieved, this study was divided into the high ovarian response group (oocyte retrieval≥20, 842 cycles), the moderate ovarian response group (5<oocyte retrieval<20, 2008 cycles), and the low ovarian response group (oocyte retrieval≤5, 991 cycles). The treatment outcomes were compared between the patients with an increased progesterone (P) level and the patients where the P level did not increase. With increase in ovarian response, the cut-off values of serum P on the day of human chorionic gonadotrophin (hCG) rose, and respectively were 2.5 ng/ml in the high ovarian response group, 2.25 ng/ml in the moderate ovarian response group, and 1.5 ng/ml in the low ovarian response group. In each group, the clinical pregnancy rate and embryo implantation rate were lower in the patients with an increased P level compared to those where the P level did not increase (all p<0.05). However, there were no significant difference in the fertilization rate, cleavage rate, and high-quality embryo rate (all p>0.05). The increased level of P on the day of hCG may affect the treatment outcomes of IVF-ET. The cut-off values of serum P seem to be associated with ovarian response. Increased ovarian response causes the cut-off values of serum P to rise.

Serum progesterone level effects on the outcome of in vitro fertilization in patients with different ovarian response: an analysis of more than 10,000 cycles

OBJECTIVE

To investigate the relationship between serum P levels on the day of hCG administration and pregnancy outcomes in different responders undergoing IVF.

DESIGN

Retrospective study.

SETTING

Teaching hospital.

PATIENT(S)

A total of 11,055 women who underwent their first IVF/intracytoplasmic sperm injection cycles and a subgroup of 4,021 women undergoing frozen-embryo transfer (FET) cycles.

INTERVENTION(S)

Patients underwent IVF-ET with the long GnRH agonist protocol. The ovarian response was classified as high (≥ 20 oocytes; n = 2,023), poor (≤ 4 oocytes; n = 827), or intermediate (remaining cases; n = 8,205) according to the number of oocytes retrieved. Clinical outcomes of IVF-ET and FET cycles were analyzed according to plasma P levels.

MAIN OUTCOME MEASURE(S)

Ongoing pregnancy rates (PRs).

RESULT(S)

Ongoing PRs in fresh cycle were inversely associated with serum P levels on the day of hCG administration for all patients. Different P threshold concentrations were determined according to different ovarian response: We proposed a serum P level of 1.5 ng/mL as the threshold for poor responders, 1.75 ng/mL for intermediate responders, and 2.25 ng/mL for high responders. Our study does not show negative results for elevated P levels on oocyte performance in terms of fertilization, cleavage rate, or PR of FET cycles within different ovarian responses, offering no evidence for a detrimental effect of high P on oocyte quality.

CONCLUSION(S)

Elevated P levels on the day of hCG administration negatively influence PR regardless of different ovarian responses, although increased P threshold concentration is associated with better ovarian responses. The detrimental effect of P elevation on PR seems to be unrelated to oocyte quality in all responders.

Impact of 'LH activity' supplementation on serum progesterone levels during controlled ovarian stimulation: a systematic review

BACKGROUND

The influence of LH on serum progesterone rise during gonadotrophin stimulation is a matter of debate. The purpose of this analysis was to assess the impact of supplementation with 'LH activity' products on serum progesterone changes before hCG administration in GnRH analog-treated women.

METHODS

A computerized literature search was performed to identify studies comparing FSH treatment alone to those that provided supplementation with 'LH activity' using hMG, recombinant (r)LH (rLH) or hCG in GnRH analog protocols. Data regarding stimulation regimens were extracted from those that reported serum progesterone levels at the time of hCG in order to assess the specific role of LH activity products.

RESULTS

Serum progesterone determination at the time of hCG administration was performed in 34 out of 108 studies comparing the effects of FSH alone or in combination with LH activity products. In a vast majority, no significant difference in serum progesterone could be found between stimulation regimens. However, in four studies where LH activity (three hMG and one rLH) was administered from the beginning of ovarian stimulation, serum P-values were significantly decreased. In contrast, in two studies where LH activity (hCG) was provided during the late follicular phase, serum P-values were significantly increased. Analysis of confounding factors showed that the intensity of ovarian stimulation is the most important determining factor to explain serum progesterone elevation at the time of hCG administration,

CONCLUSIONS

This systematic review shows that providing LH activity supplementation in combination with FSH during ovarian stimulation does not have a consistent effect on serum progesterone concentrations at the time of hCG administration. However, these data also suggest that, in accordance with physiological concept, the timing of LH activity administration could influence the impact on serum progesterone changes.

Preovulatory progesterone concentration associates significantly to follicle number and LH concentration but not to pregnancy rate

Using data from a large prospective randomized controlled trial that evaluated the effect of recombinant LH (rLH)co-administration for ovarian stimulation, the present study assessed whether progesterone concentration on the day of human chorionic gonadotrophin (HCG) administration was associated with pregnancy outcome. Progesterone concentration was measured on stimulation day 1 and on the day of HCG administration in 475 patients who underwent IVF/intracytoplasmic sperm injection treatment following ovarian stimulation with gonadotrophin-releasing hormone (GnRH) agonist and recombinant FSH with or without rLH administration from day 6 of stimulation. There was no significant association between the late-follicular-phase progesterone concentration and the clinical pregnancy rate. However, progesterone concentration was strongly associated with the number of follicles and retrieved oocytes. Late-follicular-phase LH concentration also showed a significant positive association with progesterone concentration (P = 0.018). Administration of rLH during ovarian stimulation did not affect progesterone concentration. The present study does not support an association between progesterone concentration on the day of HCG administration and the probability of clinical pregnancy in women undergoing ovarian stimulation with GnRH agonists and gonadotrophins for assisted reproduction treatment.Instead, late-follicular-phase progesterone concentration appears to be governed by the number of preovulatory follicles and LH concentration.

Progesterone rise on the day of HCG administration (premature luteinization) in IVF: an overdue update

Premature luteinization (PL) refers to a rise in serum progesterone (P) levels on the day of hCG administration. Most studies used an absolute P level on the day of hCG administration as an indicator of PL, and the cutoff level differed from 0.8 to 2 ng/mL. Some authors defined PL as a P/E2 ratio of >1. There is a marked variation in the incidence (13% to 71%), of PL due to discrepancies in definition, population characteristics and/or treatment protocols. The pathogenesis of PL in COH is still poorly understood. Several hypotheses may be considered to explain this phenomenon: elevation of follicular LH levels, serum accumulation of HCG from HMG, increased LH receptor sensitivity of the granulosa cells to FSH, or poor ovarian response with increased LH sensitivity. The consequences of this premature elevation of serum P on IVF outcome remain controversial. Attempts to prevent COH include: use of Low-dose hCG alone in the late COH stages, flexible antagonist protocol, use of mifepristone, aspiration of a single leading follicle, hCG administration when the levels of serum P exceeded 1.0 ng/mL.

Is progesterone elevation on the day of human chorionic gonadotrophin administration associated with the probability of pregnancy in in vitro fertilization? A systematic review and meta-analysis

The role of progesterone elevation on in vitro fertilization (IVF) outcome has remained a debatable issue for several years. The aim of this systematic review and meta-analysis was to evaluate whether progesterone elevation on the day of human chorionic gonadotrophin (hCG) administration is associated with the probability of pregnancy. Eligible studies were considered those in which patients did not participate more than once. A literature search in MEDLINE, EMBASE and CENTRAL identified 12 eligible studies, 10 of which were retrospective. The majority (n = 10) of these studies did not detect a statistically significant association between progesterone elevation and the probability of pregnancy. Meta-analysis was performed only for the studies (n = 5) that provided data on clinical pregnancy per patient reaching hCG administration for final oocyte maturation. No statistically significant association between progesterone elevation and the probability of clinical pregnancy was detected (Odds ratio: 0.75, 95% confidence interval 0.53-1.06; P = 0.10). This finding persisted in the sensitivity analyses performed, which excluded the studies that did not report clearly that measurement of progesterone did not affect patients' management and those that did not report definition of clinical pregnancy. In addition, subgroup analyses were conducted on the basis of type of gonadotrophin-releasing hormone GnRH analogue used and on the value of serum threshold used to classify patients in those with or without progesterone elevation. These analyses, however, did not materially change the results obtained. In conclusion, the best available evidence does not support an association between progesterone elevation on the day of hCG administration and the probability of clinical pregnancy in women undergoing ovarian stimulation with GnRH analogues and gonadotrophins for IVF.

Interleukin-8 gene and protein expression are up-regulated by interleukin-1beta in normal human ovarian cells and a granulosa tumor cell line

OBJECTIVE

To evaluate the expression, regulation, and role of interleukin (IL)-8 in human ovary.

DESIGN

Prospective study.

SETTING

University hospital.

PATIENT(S)

Sixteen premenopausal women.

INTERVENTION

Follicular fluid and granulosa lutein cells (GLCs) were collected during IVF cycles. Ovarian stromal and theca cells were obtained from women underwent surgery. KGN cells, the human granulosa cell tumor cell line, were also used.

MAIN OUTCOME MEASURES

The levels of IL-8 and IL-1beta in follicular fluid and IL-8 protein production were determined using ELISA. Interleukin-8 and IL-8 receptor gene expression in ovarian cells and the effect of IL-8 on the proliferation of stromal cells were determined. The expression of pIkappaB was evaluated by Western blot, and the effect of NF-kappaB inhibitor APDC was examined by Northern blot analysis and ELISA in KGN cells. The levels of IL-8 and IL-1beta in follicular fluid; each concentration and the volume showed a positive correlation. Reverse transcription polymerase chain reaction showed the presence of IL-8 mRNA in all ovarian cells. In contrast, IL-8 receptor mRNA was only detected in stromal cells. The expression of IL-8 in GLCs and KGN cells was increased by addition of IL-1beta and TNFalpha. Interleukin-8 increased the proliferation of ovarian stromal cells. The expression of pIkappaB in KGN cells was induced by IL-1beta, and the effects were reduced by APDC.

CONCLUSION(S)

Interleukin 8 induced by IL-1beta via activation of NF-kappaB in granulosa cells may have a role in the periovulatory period of follicular maturation.