Serum progesterone levels greater than 32.5 ng/ml on the day of embryo transfer are associated with lower live birth rate after artificial endometrial preparation: a prospective study

Serum Progesterone Level on the Day of Embryo Transfer Is Not a Reliable Predictor for Frozen-Thawed Embryo Transfer Outcomes With Euploid Blastocyst Transfer: A Retrospective Cohort Study

OBJECTIVE

To investigate whether serum progesterone (P4) levels on embryo transfer (ET) day correlate with the likelihood of live birth in artificial frozen-thawed transfer cycles using intramuscular progesterone.

DESIGN

Retrospective cohort study.

SETTING

University-affiliated hospital.

POPULATION

Patients undergoing single euploid blastocyst transfer after preimplantation genetic testing.

METHODS

Live birth rate (LBR) was calculated in each percentile of serum P4 to detect a threshold associated with an increased probability of LB. The association between serum P4 and pregnancy outcomes was evaluated using multivariable logistic regression analysis.

MAIN OUTCOME MEASURES

LBR was the primary outcome. Secondary outcomes included clinical pregnancy rate (CPR) and early pregnancy loss (EPL) rate.

RESULTS

In total, 761 patients were included, and the overall LBR was 55.72%. For LBR, each percentile group of serum P4 did not significantly differ. The distributions of P4 were comparable between the LB and non-LB groups, with an average of 12.62 ± 4.05 and 12.84 ± 4.39 ng/mL, respectively. The multivariate analysis revealed that serum P4 did not affect the LBR, whereas the day of the blastocyst (D5 vs. D6: adjusted odds ratio [aOR] 2.15, 95% confidence interval [CI] 1.52-3.03) and embryo quality (good vs. viable embryo: aOR 1.88, 95% CI 1.37-2.58) were independently associated with LBR. Similarly, serum P4 was not associated with CPR and EPL rates.

CONCLUSIONS

Serum P4 levels on ET day do not predict LBR in artificial cycles with intramuscular progesterone.

Progesterone level in assisted reproductive technology: a systematic review and meta-analysis

Elevated progesterone (EP) or inadequate progesterone levels during ART cycle monitoring may lead to cycle cancellations or further progesterone supplementation, but practice varies. It remains controversial whether modifying clinical practice in the presence or absence of EP improves clinical outcomes. This systematic review aims to investigate if progesterone levels at different phases of fresh and frozen ART cycles influence pregnancy outcomes, in particular, that pertaining to day 3 versus day 5 embryo transfers. A systematic search of EMBASE, MEDLINE, CINAHL, PubMed, SCOPUS and Web of Science identified studies from the year 2000. We included studies with women undergoing fresh and frozen IVF/ICSI cycles; with extractable per woman data on pregnancy outcomes where serum progesterone measurement was performed. We excluded interventional studies that influence clinical decisions or studies with donor cycles. The Newcastle Ottawa Scale (NOS) was used to determine the risk of bias. The primary outcome was LBR, and the secondary outcomes were OPR, CPR and MR. PICOS study protocol was used to include non-randomized studies of interventions (NRSI). Analysis was done using RevMan5 and the studies were pooled using the DerSimonian and Laird for random effects meta-analysis. The study was registered with PROSPERO (registration ID CRD42022382423). 64 studies (N = 57,988 women) were included. In fresh cycles, there is no evidence that at baseline EP impacts LBR (P > 1.5 ng/ml, OR 0.76 [95% CI 0.39-1.49], 2 studies, N = 309) and CPR (P > 1.5 ng/ml, OR 0.81 [0.38-1.71], 2 studies, N = 309). EP at ovulation trigger is associated with a lower LBR (P > 1.0 ng/ml, OR 0.40 [0.23-0.69], 2 studies, N = 2805) and CPR (P > 1.0 ng/ml, OR 0.49 [0.42-0.58], 3 studies, N = 3323; P > 1.1 ng/ml, OR 0.66 [0.53-0.83], 2 studies, N = 2444; P > 1.2 ng/ml, OR 0.61 [0.39-0.96], 6 studies, N = 844; P > 1.5 ng/ml, OR 0.37 [0.17-0.81], 6 studies, N = 13,870; P > 2.0 ng/ml, OR 0.43 [0.31-0.59], 3 studies, N = 1949) with D3 embryo but not D5 [LBR (P > 1.5 ng/ml, OR 1.02 [0.74-1.39], 3 studies, N = 5174) and CPR (P > 1.5 ng/ml, OR 0.88 [0.67-1.14], 6 studies, N = 5705)]. We could not meaningfully meta-analyse studies on the day of egg collection in fresh cycles, embryo transfer in fresh cycles, at ovulation trigger or before ovulation in natural FET cycles and FET cycles due to significant study heterogeneity. We acknowledged the limitations on including studies post year 2000 and the exclusion of studies with multiple observations, which may result in inherent publication bias and some confounding factors uncontrolled for. In conclusion, in controlled ovarian stimulation, EP at baseline did not impact on LBR; EP at ovulation trigger is associated with a lower LBR for D3 but not for D5 embryo transfer. In FET cycles, as the studies were heterogeneous, we were unable to combine the data in a meaningful way. This review is sponsored by Complete Fertility and the Ministry of Health, Malaysia.

Higher serum progesterone level has no negative impact on live birth rate in frozen embryo transfer

Optimal synchronisation between the endometrium and the embryo is key to the success of frozen embryo transfers (FET). It is achieved by administering different doses of exogenous oestrogen and progesterone (P4). The negative impact of low levels of P4 on FET has been reported, but there is a lack of knowledge about which levels are most appropriate. We aimed to evaluate whether high serum P4 levels measured on FET day affect the probability of having a baby at home. This retrospective cohort study includes 7546 FET cycles performed with hormone replacement therapy (HRT) for artificial endometrial preparation. Patients were divided into three groups according to P level on FET day (ng/mL): P4 < 20(n = 6623), P4 ≥ 20-40 (n = 770) and P > 40 (n = 146). Female age was per group P4 < 20 = 38.7 ± 3.1, P ≥ 20-40 = 39.0 ± 3.0, and P4 > 40 = 38.1 ± 2.9 years old (p = 0.53). The group with the highest progesterone levels found lower ongoing pregnancy rates without statistical significance (56.3 % (P4 < 20) vs 56.8 % (P4 ≥ 20-<40) vs 51.4 % (P4 > 40); p = 0.5). Miscarriage rate was also higher, although not significantly: 16.2 % (P4 < 20) vs 15.0 % (P4 ≥ 20-<40) vs 18.0 % (P4 > 40) (p = 0.6). These findings were explored with an adjusted analysis. A higher, but not significant, odds of miscarriage was observed when P4 > 40 ng/ml, aOR = 1.14 (0.75-1.74) (p = 0.55) whereas no such association was found with P4 ≥ 20-40 ng/ml (aOR = 0.92 (0.74-1.15) (p = 0.46)). The probability of livebirth is similar when the patient was P4 > 40 (aOR = 0.77 (0.51-1.15) (p = 0.20)) than when P4 ≥ 20-<40 (aOR = 0.94 (0.79-1.11) (p = 0.47). In conclusion, women with elevated serum P4 levels on the day of FET after HRT do not find their probability of live birth impaired.

Serum Progesterone Levels on the Day of Oocyte Retrieval as a Predictor of Pregnancy Outcomes in Fresh Embryo Transfer Cycles

Background

Progesterone levels are critical for endometrial receptivity and implantation success in assisted reproductive technology (ART). The purpose of the current study was to determine whether serum progesterone levels on oocyte retrieval day predict pregnancy success in fresh embryo transfers.

Methods

This cross-sectional study was conducted at a university-affiliated infertility clinic in Tehran, Iran, in 2024. Blood samples were collected to analyze serum levels of estradiol (E2), progesterone (P4), follicle-stimulating hormone (FSH), luteinizing hormone (LH), and anti-Müllerian hormone (AMH) using standardized methods. Student's t-test and the Mann-Whitney U test and Logistic regression were applied for statistical analyses participants. The optimal progesterone cutoff was calculated by receiver operating characteristic (ROC) curve with level of statistical significance of 0.05.

Results

The mean age of participants was 35.56±4.45 years and their mean BMI was 25.98±2.2. Among those who underwent fresh embryo transfer (n=63), 21 had positive serum β-hCG results, and fetal heart rate was detected via ultrasound in 17 patients at six weeks. Progesterone levels were significantly higher in the pregnancy-confirmed group (8.46 ng/ml) in comparison to the non-pregnant group (5.95 ng/ml, p=0.005). Similarly, patients with clinically confirmed pregnancies had significantly higher progesterone levels (8.38 ng/ml) compared to those without clinical pregnancy (6.19 ng/ml, p=0.02). A cutoff of 7.1 ng/ml predicted chemical pregnancy with 76.2% sensitivity and a cutoff of 7.55 ng/ml predicted clinical pregnancy with 71% sensitivity.

Conclusion

Elevated serum progesterone levels on the day of oocyte retrieval may predict positive pregnancy outcomes, highlighting the importance of monitoring progesterone to optimize the success rate of ART.

High serum progesterone levels on the day of embryo transfer in patients undergoing artificial frozen-thawed blastocyst transfer: Is there a ceiling effect?

Objective

To evaluate the potential ceiling effect of high serum progesterone levels on the day of embryo transfer for pregnancy outcomes in patients undergoing artificial frozen-thawed blastocyst transfer (FET) cycles.

Materials and Methods

This retrospective cohort study included 595 patients who underwent artificial FET cycles. We evaluated progesterone levels and found that 40.6 ng/mL corresponded to the 90th percentile and 23.9 ng/mL corresponded to the 50th percentile. Based on these findings, we categorized progesterone levels as <20 ng/mL (n=220, 37.0%), 20-40 ng/mL (n=312, 52.4%), and ≥40 ng/mL (n=63, 10.6%). The primary outcome measures were the clinical pregnancy rate (CPR) and live birth rate (LBR).

Results

Blastocyst morphology grades, including expansion, trophectoderm, and inner cell mass grades, were significantly associated with clinical pregnancy (p<0.001 for all). Progesterone levels between 20 and 40 ng/mL were associated with higher CPR (p=0.043). In the multivariate analysis, only blastocyst expansion and inner cell mass grades were independently and significantly associated with CPR [p=0.011, odds ratio (OR)=1.6, (confidence interval) CI 95%=1.13-2.39, and p=0.007, OR=1.65, CI 95%=1.14-2.39, respectively]. The progesterone level and trophectoderm grade were not statistically significant. Regarding LBR, only blastocyst expansion grades 4 and trophectoderm grades A or B were significantly associated.

Conclusion

Based on these data, we speculate that if serum progesterone levels exceed 40 ng/mL on the day of embryo transfer in patients undergoing artificial FET cycles, there is no need to reduce the progesterone dose.

Comparable ongoing pregnancy and pregnancy loss rates in natural cycle and artificial cycle frozen embryo transfers with intensive method-specific luteal phase support; a retrospective cohort study

STUDY OBJECTIVE

The absence of corpus lutea in artificial cycle (AC) frozen embryo transfers (FET) may increase the chances of pregnancy loss. In this retrospective cohort study, the efficacy of AC endometrial preparation was compared natural cycle (NC) endometrial preparation in terms of ongoing pregnancy.

METHODS

One thousand six hundred and eighteen consecutive vitrified-warmed blastocyst FET performed between December 2021 and November 2022 were included, with 1023 compared after exclusions according to the endometrial preparation method; 293 NC-FET, 143 modified NC-FET, 204 unprogrammed AC-FET, and 383 oral contraceptive pill (OCP) programmed AC-FET. Intensive method-specific luteal phase support (LPS) was administered in NC- (human chorionic gonadotropin and micronized vaginal progesterone), mNC- (micronized vaginal progesterone), and in AC-FET (micronized vaginal progesterone, intramuscular progesterone, and oral dydrogesterone).

RESULTS

Clinician choice of endometrial preparation method resulted in the NC- or AC-FET groups having distinct differences, with female age, antral follicle count and body mass index as well as the percentage of DOR or PCOS diagnosed patients significantly different. The unadjusted ongoing pregnancy and total pregnancy loss rates for NC-, mNC-, AC-, and ocp-AC-FET were 61.8 %, 55.2 %, 57.4 %, and 58.5 %, and 19.2 %, 24.0 %, 23.5 % and 23.8 %, respectively. In multivariate logistic regressions to predict the dependent outcomes of ongoing pregnancy and total pregnancy loss, none of the FET methods were selected as independent predictors.

CONCLUSION

Patients undergoing NC- and AC-FET with method-specific progesterone LPS had comparable ongoing pregnancy rates as well as total pregnancy loss rates, with NC-FET ranked first in the regression analysis.

Comparison of pregnancy outcomes between 4th day morula and 5th day blastocyst after embryo transfer: a retrospective cohort study

BACKGROUND

This study was designed to evaluate pregnancy outcomes between morulae transferred on day 4 (D4) and blastocysts transferred on day 5 (D5).

METHODS

From September 2017 to September 2020, 1963 fresh transfer cycles underwent early follicular phase extra-long protocol for assisted conception in our fertility center were divided into D4 (324 cases) and D5 (1639 cases) groups, and the general situation and other differences of patients in both groups were compared. To compare the differences in pregnancy outcomes, the D4 and D5 groups were further divided into groups A and B based on single and double embryo transfers. Furthermore, the cohort was divided into two groups: those with live births (1116 cases) and those without (847 cases), enabling a deeper evaluation of the effects of D4 or D5 transplantation on assisted reproductive outcomes.

RESULTS

In single embryo transfer, there was no significant difference between groups D4A and D5A (P > 0.05). In double embryo transfer, group D4B had a lower newborn birthweight and a larger proportion of low birthweight infants (P < 0.05). The preterm delivery rate, twin delivery rate, cesarean delivery rate, and percentage of low birthweight infants were lower in the D5A group than in the D5B group (P < 0.05). Analysis of factors influencing live birth outcomes further confirmed the absence of a significant difference between D4 and D5 transplantation in achieving live birth (P > 0.05).

CONCLUSION

When factors such as working life and hospital holidays are being considered, D4 morula transfer may be a good alternative to D5 blastocyst transfer. Given the in vitro fertilization/intracytoplasmic sperm injection (IVF/ICSI) success rate and risk of twin pregnancy, D4 morula transfer requires an adapted decision between single and double embryo transfer, although a single blastocyst transfer is recommended for the D5 transfer in order to decrease the twin pregnancy rate. In addition, age, endometrial thickness and other factors need to be taken into account to personalize the IVF program and optimize pregnancy outcomes.

Rectal progesterone administration secures a high ongoing pregnancy rate in a personalized Hormone Replacement Therapy Frozen Embryo Transfer (HRT-FET) protocol: a prospective interventional study

STUDY QUESTION

Can supplementation with rectal administration of progesterone secure high ongoing pregnancy rates (OPRs) in patients with low serum progesterone (P4) on the day of blastocyst transfer (ET)?

SUMMARY ANSWER

Rectally administered progesterone commencing on the ET day secures high OPRs in patients with serum P4 levels below 35 nmol/l (11 ng/ml).

WHAT IS KNOWN ALREADY

Low serum P4 levels at peri-implantation in Hormone Replacement Therapy Frozen Embryo Transfer (HRT-FET) cycles impact reproductive outcomes negatively. However, studies have shown that patients with low P4 after a standard vaginal progesterone treatment can obtain live birth rates (LBRs) comparable to patients with optimal P4 levels if they receive additionalsubcutaneous progesterone, starting around the day of blastocyst transfer. In contrast, increasing vaginal progesterone supplementation in low serum P4 patients does not increase LBR. Another route of administration rarely used in ART is the rectal route, despite the fact that progesterone is well absorbed and serum P4 levels reach a maximum level after ∼2 h.

STUDY DESIGN, SIZE, DURATION

This prospective interventional study included a cohort of 488 HRT-FET cycles, in which a total of 374 patients had serum P4 levels ≥35 nmol/l (11 ng/ml) at ET, and 114 patients had serum P4 levels <35 nmol/l (11 ng/ml). The study was conducted from January 2020 to November 2022.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Patients underwent HRT-FET in a public Fertility Clinic, and endometrial preparation included oral oestradiol (6 mg/24 h), followed by vaginal micronized progesterone, 400 mg/12 h. Blastocyst transfer and P4 measurements were performed on the sixth day of progesterone administration. In patients with serum P4 <35 nmol/l (11 ng/ml), 'rescue' was performed by rectal administration of progesterone (400 mg/12 h) starting that same day. In pregnant patients, rectal administration continued until Week 8 of gestation, and oestradiol and vaginal progesterone treatment continued until Week 10 of gestation.

MAIN RESULTS AND THE ROLE OF CHANCE

Among 488 HRT-FET single blastocyst transfers, the mean age of the patients at oocyte retrieval (OR) was 30.9 ± 4.6 years and the mean BMI at ET 25.1 ± 3.5 kg/m2. The mean serum P4 level after vaginal progesterone administration on the day of ET was 48.9 ± 21.0 nmol/l (15.4 ± 6.6 ng/ml), and a total of 23% (114/488) of the patients had a serum P4 level lower than 35 nmol/l (11 ng/ml). The overall, positive hCG rate, clinical pregnancy rate, OPR week 12, and total pregnancy loss rate were 66% (320/488), 54% (265/488), 45% (221/488), and 31% (99/320), respectively. There was no significant difference in either OPR week 12 or total pregnancy loss rate between patients with P4 ≥35 nmol/l (11 ng/ml) and patients with P4 <35 nmol/l, who received rescue in terms of rectally administered progesterone, 45% versus 46%, P = 0.77 and 30% versus 34%, P = 0.53, respectively. OPR did not differ whether patients had initially low P4 and rectal rescue or were above the P4 cut-off. Logistic regression analysis showed that only age at OR and blastocyst scoring correlated with OPR week 12, independently of other factors like BMI and vitrification day of blastocysts (Day 5 or 6).

LIMITATIONS, REASONS FOR CAUTION

In this study, vaginal micronized progesterone pessaries, a solid pessary with progesterone suspended in vegetable hard fat, were used vaginally as well as rectally. It is unknown whether other vaginal progesterone products, such as capsules, gel, or tablet, could be used rectally with the same rescue effect.

WIDER IMPLICATIONS OF THE FINDINGS

A substantial part of HRT-FET patients receiving vaginal progesterone treatment has lowserum P4. Adding rectally administered progesterone in these patients increases the reproductive outcome. Importantly, rectal progesterone administration is considered convenient, and progesterone pessaries are easy to administer rectally and of low cost.

STUDY FUNDING/COMPETING INTEREST(S)

Gedeon Richter Nordic supported the study with an unrestricted grant as well as study medication. B.A. has received unrestricted grant from Gedeon Richter Nordic and Merck and honoraria for lectures from Gedeon Richter, Merck, IBSA and Marckyrl Pharma. P.H. has received honoraria for lectures from Gedeon Richter, Merck, IBSA and U.S.K. has received grant from Gedeon Richter Nordic, IBSA and Merck for studies outside this work and honoraria for teaching from Merck and Thillotts Pharma AB and conference expenses covered by Merck. The other co-authors have no conflict of interest to declare.

TRIAL REGISTRATION NUMBER (25)

EudraCT no.: 2019-001539-29.

Association of serum progesterone levels on the transfer day with pregnancy outcomes in hormone replacement frozen-thawed cycles with oral dydrogesterone for strengthened luteal phase support

OBJECTIVE

To investigate the relationship between serum progesterone (P) levels on the day of blastocyst transfer and pregnancy outcomes in frozen-thawed embryo transfer (FET) cycles using hormone replacement therapy (HRT) with oral dydrogesterone for strengthened luteal phase support (LPS).

MATERIALS AND METHODS

This was a retrospective study including 1176 FET cycles. All patients received 40 mg of intramuscular (IM) P daily for endometrium transformation plus oral dydrogesterone 10 mg BID from transfer day for strengthened LPS. Pregnancy outcomes were compared between serum P levels on the transfer day ≥10 ng/ml and <10 ng/ml. Furthermore, cycles were divided into 10 groups by deciles of P and ongoing pregnancy rate (OPR) was calculated in each group. Analyses using deciles of serum P were completed to see if these could create further prognostic power.

RESULTS

No differences were observed in clinical pregnancy rates (CPRs), OPRs and live birth rates (LBRs) between serum P levels ≥10 ng/ml and <10 ng/ml. Patients with serum P levels <5.65 ng/ml (10th percentile) had a significantly lower OPR (48.31% vs. 58.98%, p = 0.03) and LBR (43.22% vs. 57.75%, p = 0.003) than the rest of the patients. Multivariate logistic regression analysis showed serum P levels on the transfer day were not associated with pregnancy outcomes.

CONCLUSION

Measuring serum P levels on the day of HRT-FET is of clinical importance. Lower serum P levels impact the success of HRT-FET cycles, suggesting that there may be a threshold below which it is difficult to improve pregnancy outcomes via oral dydrogesterone to strengthen LPS.

Elevated serum progesterone levels before frozen embryo transfer do not negatively impact reproductive outcomes: a large retrospective cohort study

OBJECTIVE

To evaluate whether patients with high-serum progesterone levels before frozen embryo transfer (FET) under hormonal replacement therapy present with worse reproductive outcomes.

DESIGN

A cohort retrospective study.

SETTING

A university-affiliated fertility center.

PATIENT(S)

A total of 3,183 FET cycles in patients receiving hormonal replacement therapy between March 2009 and December 2020 were included. The luteal phase was covered with 200 mg per 8 hours of vaginal micronized progesterone either alone or in combination with a daily subcutaneous injection of 25 mg of progesterone. A total of 1,360 cycles corresponded to frozen homologous embryo transfer (ET) (hom-FET), 1,024 were euploid ET (eu-FET) after preimplantation genetic testing for aneuploidies, and 799 cycles were frozen heterologous ET (het-FET). All patients had adequate serum progesterone levels (≥10.6 ng/mL) before the procedure.

INTERVENTION(S)

Frozen embryo transfer cycles.

MAIN OUTCOME MEASURE(S)

Clinical pregnancy, miscarriage, and live birth rates (LBRs).

RESULTS

Median (P25; P75) serum progesterone level before FET was 14.39 (12.43-17.49) ng/mL. Progesterone levels were significantly higher in the group under vaginal plus subcutaneous progesterone (15.96 [13.74-21.60] vs. 14.09 [12.19-16.95]). No differences in clinical pregnancy, miscarriage, and LBR were observed based on the use of vaginal or vaginal plus subcutaneous progesterone for each of the groups (hom-FET, eu-FET, and het-FET). Live birth rates were comparable among patients in the highest centile of serum progesterone levels (≥p90) (22.33 ng/mL) and the rest of the patients (p<90) (43.9% vs. 41.3%). Patients with progesterone levels ≥p90 presented lower body mass index than those in the lower centiles (

CONCLUSIONS

Elevated serum progesterone levels before FET do not impair reproductive outcomes in patients receiving artificially prepared cycles with vaginal or vaginal plus subcutaneous progesterone.

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Key Words

• Serum progesterone levels
• artificial endometrial preparation
• frozen embryo transfer
• hormonal replacement therapy
• luteal phase support

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MESH Headings

• Pregnancy
• Humans
• Female
• Progesterone
• Retrospective Studies
• Abortion, Spontaneous/diagnosis
• Abortion, Spontaneous/etiology
• Embryo Transfer/methods
• Cohort Studies
• Pregnancy Rate
• Live Birth

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Affiliation(s)

Iñaki González-Foruria Department of Obstetrics Gynecology and Reproductive Medicine, Dexeus University Hospital, Barcelona, Spain; Universitat de Vic - Universitat Central de Catalunya, Vic, Spain.
Sandra García Department of Obstetrics Gynecology and Reproductive Medicine, Dexeus University Hospital, Barcelona, Spain
Manuel Álvarez Department of Obstetrics Gynecology and Reproductive Medicine, Dexeus University Hospital, Barcelona, Spain
Annalisa Racca Department of Obstetrics Gynecology and Reproductive Medicine, Dexeus University Hospital, Barcelona, Spain
María Hernández Department of Obstetrics Gynecology and Reproductive Medicine, Dexeus University Hospital, Barcelona, Spain
Nikolaos P Polyzos Department of Obstetrics Gynecology and Reproductive Medicine, Dexeus University Hospital, Barcelona, Spain
Buenaventura Coroleu Department of Obstetrics Gynecology and Reproductive Medicine, Dexeus University Hospital, Barcelona, Spain

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Comparison of the efficacy of subcutaneous versus vaginal progesterone using a rescue protocol in vitrified blastocyst transfer cycles

RESEARCH QUESTION

Does administration of subcutaneous (s.c.) progesterone support ongoing pregnancy rates (OPR) similar to vaginal progesterone using a rescue protocol in hormone replacement therapy frozen embryo transfer cycles?

DESIGN

Retrospective cohort study. Two sequential cohorts - vaginal progesterone gel (December 2019-October 2021; n=474) and s.c. progesterone (November 2021-November 2022; n=249) -were compared. Following oestrogen priming, s.c. progesterone 25 mg twice daily (b.d.) or vaginal progesterone gel 90 mg b.d. was administered. Serum progesterone was measured 1 day prior to warmed blastocyst transfer (i.e. day 5 of progesterone administration). In patients with serum progesterone concentrations <8.75 ng/ml, additional s.c. progesterone (rescue protocol; 25 mg) was provided.

RESULTS

In the vaginal progesterone gel group, 15.8% of patients had serum progesterone <8.75 ng/ml and received the rescue protocol, whereas no patients in the s.c. progesterone group received the rescue protocol. OPR, along with positive pregnancy and clinical pregnancy rates, were comparable between the s.c. progesterone group without the rescue protocol and the vaginal progesterone gel group with the rescue protocol. After the rescue protocol, the route of progesterone administration was not a significant predictor of ongoing pregnancy. The impact of different serum progesterone concentrations on reproductive outcomes was evaluated by percentile (<10th, 10-49th, 50-90th and >90th percentiles), taking the >90th percentile as the reference subgroup. In both the vaginal progesterone gel group and the s.c. progesterone group, all serum progesterone percentile subgroups had similar OPR.

CONCLUSIONS

Subcutaneous progesterone 25 mg b.d. secures serum progesterone >8.75 ng/ml, whereas additional exogenous progesterone (rescue protocol) was needed in 15.8% of patients who received vaginal progesterone. The s.c. and vaginal progesterone routes, with the rescue protocol if needed, yield comparable OPR.

Preparation of the endometrium for frozen embryo transfer: an update on clinical practices

Over the past decade, the application of frozen-thawed embryo transfer treatment cycles has increased substantially. Hormone replacement therapy and the natural cycle are two popular methods for preparing the endometrium. Hormone replacement therapy is now used at the discretion of the doctors because it is easy to coordinate the timing of embryo thawing and transfer with the schedules of the in-vitro fertilization lab, the treating doctors, and the patient. However, current results suggest that establishing a pregnancy in the absence of a corpus luteum as a result of anovulation may pose significant maternal and fetal risks. Therefore, a 'back to nature' approach that advocates an expanded use of natural cycle FET in ovulatory women has been suggested. Currently, there is increasing interest in how the method of endometrial preparation may influence frozen embryo transfer outcomes specifically, especially when it comes to details such as different types of ovulation monitoring and different luteal support in natural cycles, and the ideal exogenous hormone administration route as well as the endocrine monitoring in hormone replacement cycles. In addition to improving implantation rates and ensuring the safety of the fetus, addressing these points will allow for individualized endometrial preparation, also as few cycles as possible would be canceled.

Endometriosis patients benefit from high serum progesterone in hormone replacement therapy-frozen embryo transfer cycles: a cohort study

RESEARCH QUESTION

What is the optimal serum progesterone cut-off level in patients with endometriosis undergoing hormone replacement therapy frozen embryo transfer (HRT-FET) with intensive progesterone luteal phase support?

DESIGN

A cohort study, including 262 HRT-FET cycles in 179 patients all diagnosed with endometriosis either by laparoscopy or by ultrasound in patients with visible endometriomas. Pre-treatment consisted of 42 days of oral contraceptive pills and 5 days' wash-out, followed by 6 mg oral oestrogen daily. Exogenous progesterone supplementation with vaginal progesterone gel 90 mg/12h commenced when the endometrium was 7 mm or thicker. From the fourth day of vaginal progesterone supplementation, patients also received intramuscular progesterone 50 mg daily. Blastocyst transfer was scheduled for the sixth day of progesterone supplementation.

RESULTS

The overall positive HCG, live birth (LBR) and total pregnancy loss rates were 60%, 39% and 34%, respectively. The optimal progesterone cut-off level was 118 nmol/l (37.1 ng/ml) defined as the maximum of the Youden index. The unadjusted LBR was significantly higher in patients with progesterone measuring 118 nmol/l or above compared with patients with progesterone measuring less than 118 nmol/l (51% [44/86] versus 34% [59/176], P = 0.01), whereas the adjusted odds ratio for a live birth was 2.1 (95% CI 1.2 to 3.7) after adjusting for age, body mass index, blastocyst score, blastocyst age, quality and number of blastocysts transferred.

CONCLUSIONS

Serum progesterone levels above 118 nmol/l (37.1ng/ml) resulted in significantly higher LBR compared with lower serum progesterone levels, suggesting that a threshold for optimal serum progesterone exists.

Placental Dysfunction in Assisted Reproductive Pregnancies: Perinatal, Neonatal and Adult Life Outcomes

Obstetric and newborn outcomes of assisted reproductive technology (ART) pregnancies are associated with significative prevalence of maternal and neonatal adverse health conditions, such as cardiovascular and metabolic diseases. These data are interpreted as anomalies in placentation involving a dysregulation of several molecular factors and pathways. It is not clear which extent of the observed placental alterations are the result of ART and which originate from infertility itself. These two aspects probably act synergically for the final obstetric risk. Data show that mechanisms of inappropriate trophoblast invasion and consequent altered vascular remodeling sustain several clinical conditions, leading to obstetric and perinatal risks often found in ART pregnancies, such as preeclampsia, fetal growth restriction and placenta previa or accreta. The roles of factors such as VEGF, GATA3, PIGF, sFLT-1, sEndoglin, EGFL7, melatonin and of ART conditions, such as short or long embryo cultures, trophectoderm biopsy, embryo cryopreservation, and supraphysiologic endometrium preparation, are discussed. Inflammatory local conditions and epigenetic influence on embryos of ART procedures are important research topics since they may have important consequences on obstetric risk. Prevention and treatment of these conditions represent new frontiers for clinicians and biologists involved in ART, and synergic actions with researchers at molecular levels are advocated.

Low Luteal Serum Progesterone Levels Are Associated With Lower Ongoing Pregnancy and Live Birth Rates in ART: Systematic Review and Meta-Analyses

Progesterone plays a key role in implantation. Several studies reported that lower luteal progesterone levels might be related to decreased chances of pregnancy. This systematic review was conducted using appropriate key words, on MEDLINE, EMBASE, and the Cochrane Library, from 1990 up to March 2021 to assess if luteal serum progesterone levels are associated with ongoing pregnancy (OP) and live birth (LB) rates (primary outcomes) and miscarriage rate (secondary outcome), according to the number of corpora lutea (CLs). Overall 2,632 non-duplicate records were identified, of which 32 relevant studies were available for quantitative analysis. In artificial cycles with no CL, OP and LB rates were significantly decreased when the luteal progesterone level falls below a certain threshold (risk ratio [RR] 0.72; 95% confidence interval [CI] 0.62-0.84 and 0.73; 95% CI 0.59-0.90, respectively), while the miscarriage rate was increased (RR 1.48; 95% CI 1.17-1.86). In stimulated cycles with several CLs, the mean luteal progesterone level in the no OP and no LB groups was significantly lower than in the OP and LB groups [difference in means 68.8 (95% CI 45.6-92.0) and 272.4 (95% CI 10.8-533.9), ng/ml, respectively]. Monitoring luteal serum progesterone levels could help in individualizing progesterone administration to enhance OP and LB rates, especially in cycles without corpus luteum.

SYSTEMATIC REVIEW REGISTRATION

https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=139019, identifier 139019.

Low serum progesterone affects live birth rate in cryopreserved blastocyst transfer cycles using hormone replacement therapy

RESEARCH QUESTION

Does serum progesterone concentration on the day of vitrified-warmed embryo transfer affect live birth rate (LBR) with hormonal replacement therapy (HRT) cycles?

DESIGN

Observational cohort study of patients (n = 915) undergoing single autologous vitrified-warmed blastocyst transfer under HRT using vaginal micronized progesterone. Women were included once, between January 2019 and March 2020. Serum progesterone concentration was measured by a single laboratory on the morning of embryo transfer. The primary end point was LBR. Univariate and multivariate logistic regression models were used for statistical analyses.

RESULTS

Median (25th-75th percentile) serum progesterone concentration on the day of embryo transfer was 12.5 ng/ml (9.8-15.3). The LBR was 31.5% (288/915) in the overall population. No significant differences were found in implantation rates (40.7% versus 44.9%); LBR was significantly lower in women with a progesterone concentration ≤25th percentile (≤9.8 ng/ml) (26.1% versus 33.2%, P = 0.045) versus women with a progesterone concentration >25th percentile. This correlated with a significantly higher early miscarriage rate (35.9% versus 21.6%, P = 0.005). After adjusting for potential confounding factors in multivariate analysis, low serum progesterone levels (≤9.8 ng/ml) remained significantly associated with lower LBR (OR 0.68 95% CI 0.48 to 0.97).

CONCLUSION

A minimum serum progesterone concentration is needed to optimize reproductive outcomes in HRT cycles with single autologous vitrified-warmed blastocyst transfer. Whether modifications of progesterone administration routes, dosage, or both, can improve pregnancy rates needs further study so that treatment of patients undergoing HRT cycles can be further individualized.

GnRH agonist supplementation in hormone replacement therapy-frozen embryo transfer cycles: a randomized controlled trial

RESEARCH QUESTION

Will two boluses of gonadotrophin-releasing hormone agonist (GnRHa) during hormone replacement therapy-frozen embryo transfer (HRT-FET) cycles reduce the total pregnancy loss rate?

DESIGN

Randomized controlled trial including a total of 287 HRT-FET cycles performed between 2013 and 2019. After randomization participants allocated to the GnRHa group (n = 144) underwent a standard HRT protocol, supplemented with a total of two boluses of triptorelin 0.1 mg; one bolus 2 days before starting vaginal progesterone and one bolus on the 7th day of progesterone. The control group (n = 143) underwent a standard HRT-FET protocol only.

RESULTS

The intention-to-treat analysis showed no significant difference in total pregnancy loss between the GnRHa group and the control group (21% versus 33%; relative risk [RR] 0.63, 95% confidence interval [CI] 0.35-1.11), nor was the biochemical pregnancy loss per positive human chorionic gonadotrophin (HCG) significantly lower in the GnRHa group (12%, 8/67) compared with the control group (25%, 18/72) (RR 0.48, 95% CI 0.22-1.02). Participants with a live birth had a significantly higher mean progesterone concentration compared with participants without a live birth (25.0 ± 12.2 versus 23.8 ± 8.9 nmol/l; P = 0.001). Furthermore, a trend for a higher live birth rate (LBR) correlated with the highest oestradiol quartile concentration (oestradiol >0.957 nmol/l).

CONCLUSIONS

Although a difference of 14% in biochemical loss and 12% in total pregnancy loss in favour of GnRHa supplementation was seen this did not reach statistical difference. Luteal progesterone and oestradiol concentrations correlate with LBR in the HRT-FET cycle, emphasizing the importance of luteal serum progesterone and oestradiol monitoring.

Serum luteal phase progesterone in women undergoing frozen embryo transfer in assisted conception: a systematic review and meta-analysis

OBJECTIVE

To investigate the association between luteal serum progesterone levels and frozen embryo transfer (FET) outcomes.

DESIGN

Systematic review and meta-analysis.

SETTING

Not applicable.

PATIENT(S)

Women undergoing FET.

INTERVENTION(S)

We conducted electronic searches of MEDLINE, PubMed, CINAHL, EMBASE, the Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials, Web of Science, ClinicalTrials.gov, and grey literature (not widely available) from inception to March 2021 to identify cohort studies in which the serum luteal progesterone level was measured around the time of FET.

MAIN OUTCOME MEASURE(S)

Ongoing pregnancy or live birth rate, clinical pregnancy rate, and miscarriage rate.

RESULT(S)

Among the studies analyzing serum progesterone level thresholds <10 ng/mL, a higher serum progesterone level was associated with increased rates of ongoing pregnancy or live birth (relative risk [RR] 1.47, 95% confidence interval [CI] 1.28 to 1.70), higher chance of clinical pregnancy (RR 1.31, 95% CI 1.16 to 1.49), and lower risk of miscarriage (RR 0.62, 95% CI 0.50 to 0.77) in cycles using exclusively vaginal progesterone and blastocyst embryos. There was uncertainty about whether progesterone thresholds ≥10 ng/mL were associated with FET outcomes in sensitivity analyses including all studies, owing to high interstudy heterogeneity and wide CIs.

CONCLUSION(S)

Our findings indicate that there may be a minimum clinically important luteal serum concentration of progesterone required to ensure an optimal endocrine milieu during embryo implantation and early pregnancy after FET treatment. Future clinical trials are required to assess whether administering higher-dose luteal phase support improves outcomes in women with a low serum progesterone level at the time of FET.

PROSPERO NUMBER

CRD42019157071.

Preparation of the Endometrium for Frozen Embryo Transfer: A Systematic Review

Despite the worldwide increase in frozen embryo transfer, the search for the best protocol to prime endometrium continues. Well-designed trials comparing various frozen embryo transfer protocols in terms of live birth rates, maternal, obstetric and neonatal outcome are urgently required. Currently, low-quality evidence indicates that, natural cycle, either true natural cycle or modified natural cycle, is superior to hormone replacement treatment protocol. Regarding warmed blastocyst transfer and frozen embryo transfer timing, the evidence suggests the 6th day of progesterone start, LH surge+6 day and hCG+7 day in hormone replacement treatment, true natural cycle and modified natural cycle protocols, respectively. Time corrections, due to inter-personal differences in the window of implantation or day of vitrification (day 5 or 6), should be explored further. Recently available evidence clearly indicates that, in hormone replacement treatment and natural cycles, there might be marked inter-personal variation in serum progesterone levels with an impact on reproductive outcomes, despite the use of the same dose and route of progesterone administration. The place of progesterone rescue protocols in patients with low serum progesterone levels one day prior to warmed blastocyst transfer in hormone replacement treatment and natural cycles is likely to be intensively explored in near future.