Progesterone versus dehydrogesterone as replacement therapy in women with premature ovarian failure

An update of luteal phase support in stimulated IVF cycles

Stimulated IVF cycles are associated with luteal phase defect. In order to overcome this, different doses, durations and types of luteal phase support (LPS) have been evaluated. There is still no agreement regarding the optimal supplementation scheme. The aim of this paper is to assess the past and the current clinical practices of luteal supplementation in IVF. The databases of Medline and PubMed were searched to identify relevant publications. LPS with human chorionic gonadotrophin (hCG) [n=262, odds ratio (OR) 2.72 (95%), confidence interval (CI) 1.56-4.90, P<0.05] or progesterone (n=260, OR 1.57 CI 1.13, 2.17, P<0.05) results in an increased pregnancy rate compared with placebo, however, hCG is associated with increased risk of ovarian hyperstimulation syndrome. Natural micronized progesterone is not efficient if taken orally. The data on oral dydrogesterone are still conflicting. Vaginal and intra muscular progesterone have comparable outcomes. The addition of estradiol (E2) seems to be beneficial in long GnRH agonist protocol (implantation rate 39.6% with E2 compared with no E2; P<0.05) but not in the short GnRH agonist and GnRH antagonist protocol. Despite the early promising results, it is too early to recommend the use of GnRH agonist in LPS. LPS should cease on the day of positive HCG. Since the cause of luteal phase defect in IVF appears to be related to the supraphysiological levels of steroids, milder stimulation protocols should be advocated in order to eventually overcome the luteal phase defect.

Effect of oral administration of dydrogestrone versus vaginal administration of natural micronized progesterone on the secretory transformation of endometrium and luteal endocrine profile in patients with premature ovarian failure: a proof of concept

BACKGROUND

We aimed to explore the endometrial histology and endocrine profiles on day 21 of an artificial cycle in patients with premature ovarian failure (POF) treated with oral dydrogesterone (DG) or vaginal micronized progesterone.

METHODS

The study was designed as a prospective pilot study at an academic reproductive medicine unit. Six POF patients were included in the study. After estrogen endometrial priming, patients were randomized to receive DG or progesterone in two subsequent cycles. The main outcome measure was the endometrial histology and the endocrine profiles on day 21 of the cycle.

RESULTS

Development of endometrial glands corresponded to an early secretory phase in five out of six cases supplemented with DG (out-phase). In contrast, five out of six cases treated with micronized progesterone showed an endometrium corresponding to a mid-luteal phase (in-phase) (P = 0.021 versus DG). There was a significant difference in the mean progesterone value [8.6 versus 0.3 microg l(-1) (P = 0.013)], the mean LH value [12.9 versus 22.5 IU l(-1) (P = 0.049)] and the mean FSH value [13.0 versus 23.9 IU l(-1) (P = 0.047)] between the progesterone and DG group, respectively, on day 21 of the cycle.

CONCLUSIONS

After estrogen endometrial priming in POF patients, exogenous vaginal micronized progesterone is more effective than oral DG in creating an 'in-phase' secretory endometrium and induces significantly higher progesterone and lower LH and FSH serum concentrations on day 21 of the cycle.

Effect of conjugated equine estrogen in combination with two different progestogens on the risk factors of coronary heart disease in postmenopausal Chinese women in Taiwan: a randomized one-year study

BACKGROUND

To compare the effect of hormone replacement therapy (HRT) using estrogen plus dydrogesterone or estrogen plus medroxyprogesterone acetate (MPA) on the risk factors for coronary heart disease (CHD) in postmenopausal women.

METHODS

A randomized, prospective 1-year clinical trial was designed. All of the postmenopausal women (n = 279) received sequential conjugated equine estrogen (CEE) at a dose of 0.625 mg/day for 25 days (days 1-25) of each month. These women were also randomly assigned to receive either dydrogesterone 10 mg/day (E + D group, n = 140) or MPA 5 mg/day (E + P group, n = 139) for 14 days (days 12-25) of each month. Serum biochemical markers, lipoproteins, plasma prothrombin time (PT), partial prothrombin time (PPT) and antithrombin III-antigen (ATIII-Ag) were analyzed at baseline, and after 6 and 12 months of treatment.

RESULTS

Liver function, renal function, PT and PPT did not change significantly during the 12-month trial. The E + D group had a more pronounced increase in high density lipoprotein cholesterol (HDL-C) than the E + P group (10.6% vs. 2.7%) after 12 months of treatment (p < 0.05). Both groups showed reduced concentrations of total cholesterol (T-CHO), low density lipoprotein cholesterol (LDL-C) and ATIII, whereas triglyceride (TG) was increased at the end of the trial (without intergroup difference).

CONCLUSIONS

Our study demonstrated a favorable effect on lipoprotein profiles with both hormone replacement therapy regimens. Dydrogesterone appears to be superior to medroxyprogesterone acetate from the perspective of modification of coronary heart disease risk factors.

Endometrial responses to three different progestins in artificial cycles: a prospective, crossover study

We found that there was no significant difference in endometrial responses to vaginal or IM P. But the response was suboptimal in cycles treated with dydrogesterone, suggesting that dydrogesterone treatment is not the preferred progestin for use in artificial cycles.

Therapeutic maturation of endometrium in in vitro fertilization and embryo transfer

OBJECTIVE

To provide an up-to-date review of studies that have examined the relative role of endometrial development in in vitro fertilization (IVF) and embryo transfer (ET) treatment in relation to the treatment outcome.

DATA IDENTIFICATION

The most important published studies and personal communications related to this topic have been identified through a computerized bibliographical search (MEDLINE).

STUDY SELECTION

Studies that have evaluated the endometrial maturation in IVF and ET treatment with respect to different treatment protocols of ovarian stimulation. Clinical trials exploring the efficacy of various combinations of hormonal supplementation that aim to improve the endometrial environment and treatment outcome. Publications and personal communications reporting a variety of treatment protocols and drugs utilized for the creation of artificial endometrial cycles in IVF treatment employing donated eggs.

RESULTS

Ovarian stimulation frequently adversely affects the process of endometrial maturation. Various kinds of hormonal supplementation, used in clomiphene citrate- and/or human menopausal gonadotropin (hMG)-stimulated cycles have not improved treatment outcome. Human chorionic gonadotropin or natural progesterone (P) supplementation administered after controlled ovarian stimulation with gonadotropin-releasing hormone and hMG effectively corrected the luteal phase defect and resulted in an improved conception rate. The endometrium of agonadal women is highly conducive to hormonal manipulation. All estrogen preparations used effectively promoted endometrial growth and proliferation. Natural P is superior to synthetic progestins for induction of receptive secretory endometrium.

CONCLUSION

The development of adequately receptive endometrium is a major factor determining the outcome of IVF and ET treatment.

Endometrial responses in artificial cycles: a prospective, randomized study comparing three different progesterone dosages

OBJECTIVE

To examine the endometrial response to three different regimens of progesterone.

DESIGN

A prospective, randomized study.

SETTING

The Jessop Hospital for Women, Sheffield.

SUBJECTS

14 women with premature ovarian failure divided into two equal groups.

INTERVENTIONS

Three different regimens of hormone replacement therapy containing standard, high and low progesterone dosages. One group received the standard regimen in one cycle and high dosage regimen in another cycle. The second group received the standard regimen in one cycle and low dosage regimen in another cycle. The order of the two dosage regimens was randomized by lottery.

MAIN OUTCOME MEASURES

Ultrasonographic measurement of endometrial thickness and morphological study of endometrial biopsy specimens taken on day 19 of the cycle using the traditional dating criteria and morphometric techniques.

RESULTS

Compared with standard regimen cycles, the endometrial response in cycles treated with the low dosage regimen showed significant retardation of overall endometrial development and changes in a number of morphometric measurements. The response of endometrial glands to the high dosage regimen was similar to that of the standard regimen, although the stromal cell diameter was increased.

CONCLUSIONS

In women receiving hormone replacement therapy normal endometrial development depends on an adequate dosage of progesterone, but increased dosage above our standard regimen does not produce any further change in the glandular component of the endometrium.

In vitro fertilization as a diagnostic and therapeutic tool in a patient with partial 17,20-desmolase deficiency

OBJECTIVE

To present a case with 17,20-desmolase activity deficiency in which in vitro fertilization (IVF) served not only as a therapeutic approach but also as a diagnostic tool for the specificity of the enzymatic deficiency.

DESIGN

IVF in the patient under study compared with a control group. All women treated with pure follicle-stimulating hormone (FSH).

SETTING

IVF program at the Instituto Valenciano de Infertilidad.

PATIENTS, PARTICIPANTS

A patient with primary amenorrhea, who was the subject under study, and seven normally cycling control patients undergoing IVF in the same series.

INTERVENTIONS

IVF, steroidogenesis in vitro of granulosa-luteal cell obtained at ovum pick-up.

MAIN OUTCOME MEASURE(S)

Oocyte fertilization and embryo cleavage. Serum and follicular fluid (FF) levels of estradiol (E2), progesterone (P), testosterone (T), androstendione (A), 17 alpha-hydroxyprogesterone (17-OHP). In vitro accumulation of E2 and P.

RESULTS

Ovulation induction with FSH was successful in achieving follicular development despite low circulating E2. Fertilization and cleavage rates were similar to the control subjects. The patient developed ovarian hyperstimulation. The lack of 17,20-desmolase activity was detected by normal P levels in serum and FF, high 17-OHP, and low T, A, and E2 levels in serum and FF. Granulosaluteal cell cultures in the presence of T restored normal E2 and P production in response to gonadotropins.

CONCLUSIONS

In patients with 17,20-desmolase deficiency, follicular development, oocyte maturation, and fertilization can take place in a low estrogenic environment.