The cumulative live birth rates of 18 593 women with progestin-primed ovarian stimulation-related protocols and frozen-thawed transfer cycles

Serum concentrations of medroxyprogesterone acetate were undetectable on OPU+5 days and had no effect on the serum progesterone level in patients undergoing the progestin-primed ovarian stimulation protocol

Objective

To evaluate the dynamics of serum medroxyprogesterone acetate (MPA) concentrations and their influence on serum progesterone (P) levels and pregnancy outcomes in the progestin-primed ovarian stimulation (PPOS) protocol. A total of 116 patients who underwent in vitro fertilization/intracytoplasmic sperm injection (IVF/ICSI) treatment using the PPOS protocol were included. Serum MPA levels were measured on the third, fifth, and seventh days of MPA use; on the day of human chorionic gonadotropin (hCG) trigger; and two and five days after oocyte pick-up (OPU).

Results

The serum MPA concentration was 2.26 ± 2.11 nmol/L on the hCG trigger day, 0.37 ± 0.40 nmol/L two days after OPU, and zero five days after OPU. There were no statistically significant differences in P levels on the hCG trigger day, total dosage of Gn, duration of Gn, number of oocytes retrieved, number of mature oocytes, fertilization rate, blastocyst progression rate, CPR, ectopic pregnancy rate, early pregnancy loss rate, or live birth rate (LBR) between the two cohorts (P > 0.05).

Conclusions

Serum concentrations of MPA had no effect on serum P levels or pregnancy outcomes in patients undergoing the PPOS protocol.

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

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

Exposure of antral follicles to medroxyprogesterone acetate during stimulation does not cause molecular perturbations in gonadotropin-responsiveness and steroidogenic function of granulosa cells in progestin-primed cycles

STUDY QUESTION

Does medroxyprogesterone acetate (MPA) exposure in progestin-primed ovarian stimulation (PPOS) cycles cause molecular perturbations in the steroidogenic function and gonadotropin responsiveness of the granulosa cells?

SUMMARY ANSWER

PPOS cycles are identical to traditional GnRH antagonist cycles not only for clinical IVF characteristics but also for gonadotropin receptor expression, response to gonadotropins, and steroidogenic function at the molecular level.

WHAT IS KNOWN ALREADY

PPOS is increasingly used as an alternative to GnRH antagonists due to the inhibitory effect of progesterone on LH release by reducing GnRH pulsatility at the hypothalamic level. Although a growing body of evidence from clinical studies did not indicate significant differences between PPOS and antagonist protocols for IVF cycle characteristics and obstetrical outcomes, it is still unknown whether exposure of the antral follicle cohort to progesterone or its synthetic derivatives during ovarian stimulation causes any subtle molecular aberrations in terms of steroidogenesis and gonadotropin responsiveness. To address this issue, detailed comparative molecular analyses were conducted in the luteinized mural granulosa cells (GCs) obtained from normal responding IVF patients undergoing PPOS and antagonist cycles.

STUDY DESIGN, SIZE, DURATION

A clinical translational research study was conducted with IVF patients.

PARTICIPANTS/MATERIALS, SETTING, METHODS

This study included 55 normal responding IVF patients who underwent ovarian stimulation with either PPOS using MPA (5 mg twice daily) or GnRH antagonist cetrorelix acetate. Recombinant forms of FSH and hCG were used for ovarian stimulation and ovulation triggering, respectively. Luteinized mural GCs obtained during the oocyte retrieval procedure were used for the experiments. Cell culture, quantitative real-time PCR, immunoblotting, confocal time-lapse live cell imaging, and hormone assays were used.

MAIN RESULTS AND THE ROLE OF CHANCE

Demographic and IVF cycle characteristics of the patients undergoing ovarian stimulation with PPOS and GnRH antagonist were similar, including ovarian response, mature oocyte yield, and fertilization rates. Molecular analyses revealed that the expression of the enzymes involved in sex-steroid synthesis (StAR, SCC, 3β-HSD, 17β-HSD, aromatase) and the uptake/storage/utilization of cholesterol (LDL receptor, Hormone-sensitive lipase, hydroxy-methyl glutaryl Co-enzyme-A reductase, and Sterol O-acyltransferase1) in the GCs of the PPOS cycles were comparable to those of the antagonist cycles. The expression of the receptors for gonadotropins, estrogen, and progesterone hormones was also similar. Basal and hCG-induced increases in 3β-HSD expression and progesterone production and basal and FSH-induced increases in aromatase expression and E2 output of the GCs from PPOS patients did not exhibit any meaningful differences when compared with GCs from antagonist cycles. Furthermore, basal and hCG-induced up-regulation in the LDL receptor expression and cholesterol uptake did not differ between the groups. Confocal imaging also revealed similar patterns of expression for the steroidogenic enzymes and their co-localization with mitochondria. Lastly, the expression of the other important genes regulating cumulus expansion, ovulation, and luteal function [Relaxin, ADAMTS-1, and epidermal growth factor (EGF)-like growth factor amphiregulin] in the GCs of the PPOS and antagonist cycles were similar.

LARGE SCALE DATA

N/A.

LIMITATIONS, REASONS FOR CAUTION

Caution should be exercised when interpreting our data which was derived from normally responding patients whose ovulation was triggered with hCG. It is unclear whether the molecular parameters assessed vary according to infertility etiologies, magnitude of ovarian response, mode of trigger, and any other underlying ovarian pathologies or systemic diseases. MPA was the progestin used for PPOS and whether these findings can be generalized to other progestins is unknown.

WIDER IMPLICATIONS OF THE FINDINGS

This study provides reassuring molecular evidence that exposure of antral follicle cohorts to MPA during the follicular growth phase does not have any detrimental effects on steroidogenic, ovulatory, and luteal functions when compared with GnRH antagonist cycles.

STUDY FUNDING/COMPETING INTEREST(S)

This study was funded by the School of Medicine, the Graduate School of Health Sciences of Koc University and Koç University Research Center for Translational Medicine (KUTTAM), and equally funded by the Republic of Turkey Ministry of Development Research Infrastructure Support Program. All authors declare no conflict of interest.

TRIAL REGISTRATION NUMBER

N/A.