Serum progesterone on the day of human chorionic gonadotropin (hCG) trigger as a predictor of in-vitro fertilization (IVF) outcome - a retrospective analysis of seven years

Association Between Progesterone Level on Trigger Day to Basal Progesterone Ratio and in vitro Fertilization-Embryo Transfer Outcomes in Antagonist Protocols

Objective

To investigate the relationship between the progesterone level on trigger day (Ptrigger) to basal progesterone (bP) ratio and the outcomes of in vitro fertilization-embryo transfer (IVF-ET).

Methods

A retrospective analysis was conducted on women who received an antagonist protocol, with a Ptrigger less than 1.5 ng/mL and who underwent fresh embryo transfer. Based on the Ptrigger/bP ratio, participants were categorized into four groups: group A (Ptrigger/bP < 1, n = 284), group B (Ptrigger/bP ≥ 1 and < 2, n = 363), group C (Ptrigger/bP ≥ 2 and < 3, n = 165), and group D (Ptrigger/bP ≥ 3, n = 118). Recombinant follicle-stimulating hormone was used to stimulate ovulation. Receiver operating characteristic curve analysis was used to analyze the accuracy of the Ptrigger/bP ratio in predicting clinical pregnancy following fresh embryo transfer.

Results

A decreasing trend in bP levels was observed across groups (A > B > C > D), while Ptrigger levels showed an increasing trend (A < B < C < D). Groups A and B included significantly younger women and required lower doses of gonadotropin (Gn) compared to Groups C and D. The embryo implantation and clinical pregnancy rates in Group A were 34.93% and 49.30%, respectively, significantly higher than those in Group D (23.19% and 33.90%, respectively). After propensity score matching for age, the differences in implantation and clinical pregnancy rates were not statistically significant between Group A and D. The Ptrigger/bP ratio had limited accuracy in predicting clinical pregnancy, with an area under the curve of 0.538 (95% CI [confidence interval]: 0.501-0.575, P = 0.044).

Conclusion

A Ptrigger/bP ratio of less than 1 was associated with relatively favorable pregnancy outcomes in women undergoing IVF-ET with an antagonist protocol for ovulation induction.

Effect of progesterone concentration on hCG trigger day on clinical outcomes after high-quality single blastocyst transfer in GnRH antagonist cycles

Objective

To investigate whether progesterone levels on the human chorionic gonadotropin (hCG) trigger day are associated with clinical outcomes in fresh cycles and the first frozen-thawed cycles (the freeze-all strategy) following the transfer of a high-quality single blastocyst.

Methods

This single-center retrospective analysis was conducted on patients undergoing in vitro fertilization with the gonadotropin-releasing hormone (GnRH) antagonist protocol from January 2017 to December 2023. The study included the first and second oocyte retrieval cycles with progesterone levels ≤2 ng/ml on hCG trigger day. Clinical pregnancy rates and early miscarriage rates were compared among groups using curve fitting, threshold effect analysis, and multivariable regression.

Results

When progesterone levels were between 1 and 2 ng/ml, the pregnancy rate in fresh cycles was only 51% of that in cycles with progesterone levels ≤1 ng/ml (95% CI: 0.33, 0.79, p = 0.0028). And the pregnancy rate decreased by 25% (95% CI: 0.51, 1.09) for frozen cycles, although there was no statistically significant (p = 0.1273). When cycle types were used as a binary variable in multivariate regression analysis, it was found that the clinical pregnancy rate in frozen cycles was 1.84 times higher than in fresh cycles (OR = 1.84, 95% CI: 1.38-2.47). For progesterone levels between 1 and 2 ng/ml, the clinical pregnancy rate in frozen cycles was 2.90 times that of fresh cycles (OR = 2.90, 95% CI: 1.59, 5.29, p = 0.0015). Progesterone levels on hCG day had no impact on the clinical pregnancy rate in thaw cycles, nor did they affect miscarriage rates in fresh or thaw cycles (p > 0.05).

Conclusion

When progesterone levels on hCG trigger day were between 1 and 2 ng/ml, the clinical pregnancy rate for frozen-thawed cycles of high-quality single blastocyst transfer using an GnRH antagonist protocol significantly surpasses that of fresh cycles, thus elective frozen embryo transfer after the freeze-all strategy is recommended.

Predictive Role of Progesterone Levels for IVF Outcome in Different Phases of Controlled Ovarian Stimulation for Patients With and Without Endometriosis: Expert View

The study aimed to review the role of basal, trigger, and aspiration day progesterone levels (PLs) as predictors of in vitro fertilization (IVF) success for patients with and without endometriosis. A non-systematic review was conducted by searching papers published in English during the period of 1990-2023 in MEDLINE and PubMed, Embase, The Cochrane Library (Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials, Cochrane Methodology Register), and Web of Science. The most widely used IVF predictor success was the trigger day progesterone serum level. Many studies utilize the threshold level of 1.5-2.0 ng/ml. However, the predictive power of only progesterone level failed to show high sensitivity and specificity. Contrary, progesterone level on the trigger day combined with the number of mature retrieved oocytes had the highest predictive power. High baseline progesterone level was associated with poor IVF outcomes. Research on progesterone and IVF success in patients with endometriosis is limited but indicates that endometriosis patients seem to benefit from higher progesterone concentrations (≥ 37.1 ng/ml) in IVF cycles. Currently, there is limited data for a definitive insight into the mportance of progesterone in the estimation of IVF success. Nonetheless, this summarized evidence could serve as up-to-date guidance for the role of progesterone in the prediction of IVF outcomes, both in patients with and without endometriosis.

Premature Progesterone Elevation in in vitro Fertilisation Cycles - Current Perspectives

The impact of premature elevation of progesterone (PPE) on the day of the trigger on pregnancy outcome in in vitro fertilisation (IVF) cycles has been a matter of contention and debate for decades. Research over the last 30 years has indicated that PPE >1.5 ng/ml is associated with declining live birth rates following fresh embryo transfer. Freeze-only approach has become a universal solution to overcome the issue of PPE. However, the topic is still mired with controversy. Few studies have not shown a negative impact on pregnancy rates. The impact of PPE on embryological parameters such as oocyte and embryo quality and ploidy is still very controversial. An important contentious issue is the choice of the threshold P value above which it is considered abnormal and a freeze-all strategy would be cost-effective. Currently, though a cutoff of >1.5 ng/ml is widely used, practices are not uniform and varying thresholds from 0.4 to 3 ng/ml are utilised. This review addresses the current understanding of PPE in IVF and the above controversies. The incidence, aetiology and source of progesterone rise, impact on endometrial receptivity, oocyte and embryo quality, impact on live birth and cumulative live birth and impact on frozen embryo transfer and donor oocyte cycles are discussed. Current controversies regarding the optimal threshold, assay performance and future directions are addressed.