Day 14 maternal serum progesterone levels predict pregnancy outcome in IVF/ICSI treatment cycles: a prospective study

IAS-FET: An intelligent assistant system and an online platform for enhancing successful rate of in-vitro fertilization embryo transfer technology based on clinical features

BACKGROUND

Among all of the assisted reproductive technology (ART) methods, in vitro fertilization-embryo transfer (IVF-ET) holds a prominent position as a key solution for overcoming infertility. However, its success rate hovers at a modest 30% to 70%. Adding to the challenge is the absence of effective models and clinical tools capable of predicting the outcome of IVF-ET before embryo formation. Our study is dedicated to filling this critical gap by aiming to predict IVF-ET outcomes and ultimately enhance the success rate of this transformative procedure.

METHODS

In this retrospective study, infertile patients who received artificial assisted pregnancy treatment at Gansu Provincial Maternity and Child-care Hospital in China were enrolled from 2016 to 2020. Individual's clinical information were studied by cascade XGBoost method to build an intelligent assisted system for predicting the outcome of IVF-ET, called IAS-FET. The cascade XGBoost model was trained using clinical information from 2292 couples and externally tested using clinical information from 573 couples. In addition, several schemes which will be of help for patients to adjust their physical condition to improve their success rate on ART were suggested by IAS-FET.

RESULTS

The outcome of IVF-ET can be predicted by the built IAS-FET method with the area under curve (AUC) value of 0.8759 on the external test set. Besides, this IAS-FET method can provide several schemes to improve the successful rate of IVF-ET outcomes. The built tool for IAS-FET is addressed as a free platform online at http://www.cppdd.cn/ART for the convenient usage of users.

CONCLUSIONS

It suggested the significant influence of personal clinical features for the success of ART. The proposed system IAS-FET based on the top 27 factors could be a promising tool to predict the outcome of ART and propose a plan for the patient's physical adjustment. With the help of IAS-FET, patients can take informed steps towards increasing their chances of a successful outcome on their journey to parenthood.

Serum progesterone concentration on pregnancy test day might predict ongoing pregnancy after controlled ovarian stimulation and fresh embryo transfer

Progesterone (P4) is essential for pregnancy. A controlled ovarian stimulation (COS) leads to a iatrogenic luteal defect that indicates a luteal phase support (LPS) at least until pregnancy test day. Some clinicians continue the LPS until week 8 or later, when P4 is mainly secreted by syncytiotrophoblast cells.Measuring serum P4 on pregnancy test day after a fresh embryo transfer could help to identify women who might benefit from prolonged LPS. In women with LPS based on P4 administered by the rectal route, P4 concentration on pregnancy test day was significantly higher in patients with ongoing pregnancy than in patients with abnormal pregnancy.This monocentric retrospective study used data on 99 consecutive cycles of COS, triggered with human chorionic gonadotropin, followed by fresh embryo transfer resulting in a positive pregnancy test (>100 IU/L) (from November 2020 to November 2022). Patients undergoing preimplantation genetic screening or with ectopic pregnancy were excluded. All patients received standard luteal phase support (i.e. micronized vaginal progesterone 600 mg per day for 15 days). The primary endpoint was P4 concentration at day 15 after oocyte retrieval (pregnancy test day) in women with ongoing pregnancy for >12 weeks and in patients with miscarriage before week 12 of pregnancy.The median P4 concentration [range] at pregnancy test day was higher in women with ongoing pregnancy than in women with miscarriage (55.9 ng/mL [11.6; 290.6] versus 18.1 ng/mL [8.3; 140.9], p = 0.002). A P4 concentration ≥16.5 ng/mL at pregnancy test day was associated with higher ongoing pregnancy rate (OR = 12.5, 95% CI 3.61 - 43.33, p <0.001). A P4 concentration ≥16.5 ng/mL at pregnancy test day was significantly associated with higher live birth rate (OR = 11.88, 95% CI 3.30-42.71, p <0.001).After COS and fresh embryo transfer, the risk of miscarriage is higher in women who discontinue luteal support after 15 days, as recommended, but with P4 concentration <16.5 ng/mL. The benefit of individualized prolonged luteal phase support should be evaluated.

Early Serum Progesterone Measurement on 9th Day after Oocyte Retrieval can be used as a Predictor of Fresh Intracytoplasmic Sperm Injection Cycle Success

BACKGROUND: In intracytoplasmic sperm injection (ICSI) infertility treatment cycles, measuring serum Progesterone level at day 9 after oocyte retrieval could be used as a predictor of success. METHODS: Sixty-nine women were prospectively included in this study, treated with fresh embryo transfer ICSI cycles. Progesterone analyses were performed on the day of oocyte pick up (day 0) at serum and follicular fluid, then re-assessment at serum on day 9 after oocyte retrieval. The data were compared to evaluate the correlation among hormones measured on day 0 and day 9 with pregnancy rate. RESULTS: Pregnancy rate of Iraqi women was 22% (n = 15), mean serum progesterone on day 9 among pregnant ladies was (mean ± SD, 39.5 ± 13.0) which was significantly higher than that who failed to get pregnant (mean 23.2 ± 11, p = 0.001), then after adjustment of the baseline readings (day 0) estimated mean = 11.1. The differences were still significant, receiver operating characteristic curve area showed that serum Progesterone on day 9 after pick up can differentiate correctly between those who will conceive and those who will not, with a sensitivity = 0.933 and specificity = 0.519, at cut off point = 22.33 and above, (Area under the curve = 0.822, p = 0.001). CONCLUSION: Serum progesterone on day 9 could be one of the predictors of endometrial receptivity and pregnancy, which is actually of great value for both doctors and patients during that stressful period till the date of confirmation, which might negatively affect treatment outcome, as well as the psychosocial and pharmacological impact of medication and limited activity for a failed one.

Stratifying Cumulus Cell Samples Based on Molecular Profiling to Help Resolve Biomarker Discrepancies and to Predict Oocyte Developmental Competence

To increase the efficiency of assisted reproductive techniques (ART), molecular studies have been performed to identify the best predictive biomarkers for selecting the most suitable germ cells for fertilization and the best embryo for intra-uterine transfer. However, across different studies, no universal markers have been found. In this study, we addressed this issue by generating gene expression and CpG methylation profiles of outer cumulus cells obtained during intra-cytoplasmic sperm injection (ICSI). We also studied the association of the generated genomic data with the clinical parameters (spindle presence, zona pellucida birefringence, pronuclear pattern, estrogen level, endometrium size and lead follicle size) and the pregnancy result. Our data highlighted the presence of several parameters that affect analysis, such as inter-individual differences, inter-treatment differences, and, above all, specific treatment protocol differences. When comparing the pregnancy outcome following the long protocol (GnRH agonist) of ovarian stimulation, we identified the single gene markers (NME6 and ASAP1, FDR < 5%) which were also correlated with endometrium size, upstream regulators (e.g., EIF2AK3, FSH, ATF4, MKNK1, and TP53) and several bio-functions related to cell death (apoptosis) and cellular growth and proliferation. In conclusion, our study highlighted the need to stratify samples that are very heterogeneous and to use pathway analysis as a more reliable and universal method for identifying markers that can predict oocyte development potential.

Likelihood of live birth with extremely low β-hCG level 14 days after fresh embryo transfer

OBJECTIVE

To investigate the pregnancy outcomes of patients with low serum β-hCG level 14 days after day 3 embryo transfer.

METHODS

A retrospective study was performed with 723 patients with a serum β-hCG level between 5 and 100 mIU/ml 14 days after embryo transfer. Pregnancy outcomes (live birth, clinical pregnancy) were analyzed according to the female patients' age. ROC curves were plotted to indicate the threshold for prediction of clinical pregnancy and live birth.

RESULTS

Of the 723 patients with serum β-hCG level <100 mIU/mL, 85.6% (619) had biochemical pregnancy, and only 14.4% (104) had clinical pregnancy (including 4.3% with live birth, 3.7% with ectopic pregnancy, and 6.1% with early miscarriage). The rate of live birth was significantly lower in ≥38-year group ,compared with <38-year group (1.3% vs. 5.1%, p = 0.045). The rates of biochemical pregnancy in patients with serum β-hCG of 5-25 mIU/mL and 26-50 mIU/mL were 99.5% and 92.4%, respectively. The serum β-hCG level to predict clinical pregnancy was 44.8 mIU/ml (sensitivity, 90.4%; specificity, 82.1%). For live birth, the serum β-hCG level was 53.7 mIU/ml (sensitivity, 90.3%; specificity, 81.1%).

CONCLUSIONS

The likelihood of live birth was minimal with low serum β-hCG level 14 days after embryo transfer.

Serum Progesterone Profile Across the Mid and Late Luteal Phase in Artificial Cycles Is Associated With Pregnancy Outcome

INTRODUCTION

Recent studies have shown that low serum progesterone levels on the day of embryo transfer (ET) are associated with poorer pregnancy outcome in hormonal replacement therapy cycles. It is of interest to know if serum progesterone levels during late luteal phase (following days after ET) are also related with the chances of ongoing pregnancy.

OBJECTIVE

To evaluate the luteal phase endocrine profile through measurements of serum progesterone and estradiol on days ET+4, ET+7 and ET+11, to test their predictive value in relation to pregnancy outcome.

SETTING

Private infertility center, Valencia, Spain.

MATERIALS AND METHODS

Prospective cohort study performed between June 2017 and August 2018. Eligible patients were aged between 18-42 years, with a normal uterus, and being transferred 1-2 good quality blastocysts in a frozen ET cycle after an artificial endometrial preparation with estradiol valerate and vaginal micronized progesterone (400 mg/12 hours).

RESULTS

A total of 127 patients were included. Mean age = 38.0 ± 3.9 years; BMI = 23.6 ± 3.6 kg/m2; endometrial thickness = 9.1 ± 1.6mm. Overall ongoing pregnancy rate = 47.2% (95%CI:38.3-56.3). Significantly higher levels of serum progesterone were observed on ET+4 (13.6 ± 6.0 vs. 11.1 ± 4.6ng/ml, p = 0.03) and ET+11 (15.7 ± 1.2 vs. 10.3 ± 0.6ng/ml, respectively; p = 0.000) in ongoing pregnancies versus negative β-hCG (β-human chorionic gonadotrophin) cases. On ET+7, ongoing pregnancies also had higher serum progesterone levels (14.2 ± 0.9 vs. 11.7 ± 0.8ng/ml, but did not reach statistical significance (p = 0.07). Serum estradiol levels were not related with pregnancy outcome at any moment of the luteal phase (p > 0.05). On days ET+4, +7 and +11, the ROC analysis showed that serum progesterone levels were predictive of ongoing pregnancy, and Pearson's coefficient showed a significant association (p<0.05) of serum β-hCG levels with serum progesterone.

CONCLUSIONS

In hormonal replacement therapy cycles, serum progesterone levels across luteal phase days are associated with pregnancy outcome. Ongoing pregnancies were associated with a higher exposure to progesterone in comparison with pregnancy losses or negative β-hCG. Therefore, serum progesterone might be playing an important role not only during implantation, but also in pregnancy maintenance. It remains unknown if the variability in serum progesterone levels among patients, after receiving the exact same progesterone dose for luteal phase support, is the cause or just a consequence of pregnancy results.

The effect of early administration of rectal progesterone in IVF/ICSI twin pregnancies on the preterm birth rate: a randomized trial

BACKGROUND

The rate of multiple pregnancies in IVF/ICSI ranges from 20 to 30%. The incidence of preterm birth in multiple pregnancies is as high as 60% and is even higher in pregnancies conceived after IVF & ICSI. The effect of progesterone on prevention of preterm birth in twins is controversial. Our group has proven a positive effect in reduction of preterm birth, by starting progesterone from the mid-trimester, in exclusively IVF/ICSI singleton pregnancies but not twins. The purpose of our current study was to explore the effect of earlier administration of natural progesterone, in IVF/ICSI twin pregnancies starting at 11-14 weeks for prevention of preterm birth.

METHODS

This is a double-blind, placebo controlled, single center, randomized clinical trial. Women with dichorionic twin gestations, having an IVF/ICSI trial were randomized to receive natural rectal progesterone (800 mg daily) vs placebo, starting early from 11 to 14 weeks. They also received oral and vaginal antimicrobial agents as part of our routine treatment for vaginitis and urinary tract infection. They were randomized regardless of cervical length and had no previous history of preterm birth or known Mullerian anomalies. The primary outcome was spontaneous preterm birth rate before 37 weeks. The secondary outcome was; spontaneous preterm birth before 34, 32, 28 weeks and neonatal outcome.

RESULTS

A total of 203 women were randomized to both groups, final analysis included 199 women as 4 were lost to follow up. The base line characteristics as well as gestational age at delivery were not significantly different between the study and the placebo group (34.7 ± 3.6 vs 34.5 ± 4.5, P = 0.626). Progesterone administration was not associated with a significant decrease in the spontaneous preterm birth rates before 37 weeks (73.5% vs 68%, P = 0.551), before 34 (20.6% vs 21.6%, P = 0.649), before 32 (8.8% vs 12.4%, P = 0.46) & before 28 (4.9% vs 3.1%, P = 0.555) weeks.

CONCLUSIONS

Rectal natural progesterone starting from the first trimester in IVF/ICSI twin pregnancies did not reduce spontaneous preterm birth.

TRIAL REGISTRATION

The trial was registered on 31 January 2014 at www.ISRCTN.com, number 69810120.

Pregnancy stage determines the effect of chronic stress on ovarian progesterone synthesis

Although stress-induced glucocorticoid release is thought to be a primary driver by which maternal stress negatively impacts pregnancy outcomes, the downstream neuroendocrine targets mediating these adverse outcomes are less well understood. We hypothesized that stress-induced glucocorticoid secretion inhibits pituitary hormone secretion, resulting in decreased ovarian progesterone synthesis. Using a chronic restraint model of stress in mice, we quantified steroid hormone production, pituitary hormones, and expression of ovarian genes that support progesterone production at both early ( day 5) and midpregnancy ( day 10). Females subjected to daily restraint had elevated baseline glucocorticoids during both early and midpregnancy; however, lower circulating progesterone was observed only during early pregnancy. Lower progesterone production was associated with lower expression of steroidogenic enzymes in the ovary of restrained females during early pregnancy. There were no stress-related changes to luteinizing hormone (LH) or prolactin (PRL). By midpregnancy, circulating LH decreased regardless of treatment, and this was associated with downregulation of ovarian steroidogenic gene expression. Our results are consistent with a role for LH in maintaining steroidogenic enzyme expression in the ovary, but neither circulating PRL nor LH were associated with the stress-induced inhibition of ovarian progesterone production during early pregnancy. We conclude that chronic stress impacts endocrine networks differently in pregnant and nonpregnant mammals. These findings underscore the need for further studies exploring dynamic changes in endocrine networks participating in pregnancy initiation and progression to elucidate the physiological mechanisms that connect stress exposure to adverse pregnancy outcomes.

Progesterone and cyclic adenosine monophosphate down-regulate CD90 in the stromal cells of human decidua. In vitro evidence and in situ findings

OBJECTIVE

CD90 is a glycoprotein involved in leukocyte relocation and cell differentiation. CD90 is expressed in endothelial and stromal cells in human endometrium; however, its role in the remodeling of the decidual tissue during pregnancy is poorly understood. Here, we investigate how CD90 expression in decidual stromal cells (DSCs) is regulated.

METHOD OF STUDY

The native CD90 receptor in stromal cells in decidua was investigated via histology. We further develop in vitro culture of DSCs which allows us to test the effects of hormones and paracrine signals on CD90 expression.

RESULTS

Stromal cells in first-trimester human decidua display heterogeneous levels of CD90 expression. In vitro analyses reveal that progesterone, a factor normally secreted by trophoblast cells in the placenta, and extracellular cyclic adenosine monophosphate, a known downstream signaling messenger of progesterone, reduce CD90 expression in DSCs by ~30%. This reduction in CD90 expression correlates with a change toward a more highly differentiated cell state.

CONCLUSION

DSCs in early pregnancy show different levels of CD90 expression, suggesting different DSC differentiation and selective interactions with cells during decidual morphogenesis.

Early serum progesterone and prolactin analysis at day 9 of oocyte retrieval as a predictor of success in fresh ICSI cycles

Objective

To analyze progesterone and prolactin plasma levels nine days after oocyte retrieval and evaluate their correlation with pregnancy rates in in vitro fertilization cycles. To achieve pregnancy, several factors are analyzed before and during the in vitro fertilization cycle. Progesterone supplementation for adequate luteal phase support is indicated despite the presence of multiple corpus luteum in IVF stimulation cycles because of blockage caused by hypothalamic agonists and antagonists. The dosage of progesterone and prolactin on day 09 after follicular retrieval could function as a predictive marker of success in fertility treatments.

Methods

A retrospective study was performed using data from 238 patients submitted to intracytoplasmic sperm injection (ICSI) at a private infertility clinic from January 2013 to December 2015. Hormonal measurements were performed on day 09 after follicular uptake. The data was compared to assess the correlation between prolactin and progesterone dosages and pregnancy rates.

Results

The ICSI pregnancy rate was 40.8% (n=238). No statistically significant difference was observed when correlating the success of the procedure with the prolactin dosage (p=0.71). However, progesterone showed a significant difference (p=0.021). The cutoff point, indicated by the ROC curve fit according to which gestation would be identified, is 25.95ng/ml of progesterone. The sensitivity of this point is 61.9% and the specificity is 57.4%.

Conclusion

Progesterone dosage may be one of the indicators of gestation on day 09 after follicular uptake. Such data can help physicians to monitoring and provides suitable early gestational care. More studies are needed to corroborate the data found.

Luteal phase progesterone and oestradiol after ovarian stimulation: relation to response and prediction of pregnancy

Research has focused on optimizing luteal phase support and endometrial receptivity in ovarian stimulation cycles. In this study, serial endocrine measurements were taken in 600 patients after a gonadotrophin-releasing hormone antagonist stimulation protocol. On the day of blastocyst transfer, serum progesterone and oestradiol were similar irrespective of a subsequent positive or negative pregnancy test (median 99 ng/ml versus 103 ng/ml for progesterone, respectively) or a subsequent live birth or pregnancy loss. Serum progesterone was significantly correlated to each ovarian response parameter (total number of follicles, number of oocytes retrieved and oestradiol concentration; r = 0.45, 0.57 and 0.54 respectively, all P < 0.0001). These correlations were consistent irrespective of clinical outcome. On the day of the pregnancy test, these correlations had vanished except in the live birth subgroup showing a weaker correlation (r = 0.22, 0.27 and 0.32 respectively, all P < 0.005). The lowest HCG and progesterone levels associated with live birth were 59.3 IU/l and 12.3 ng/ml, respectively. Fourteen out of 92 patients (15.2%) with pregnancy loss had normal HCG but low progesterone levels (above and below their respective 5th percentile), and miscarried before the end of the 7th week, when the luteal-placental shift occurs.

Progesterone/estradiol ratio <0.25 on the day of human chorionic gonadotropin administration is associated with adverse pregnancy outcomes in prolonged protocols for in vitro fertilization/intracytoplasmic sperm injection

OBJECTIVE

It has been suggested that a progesterone/estradiol ratio (P/E2) ≥ 1.0 on the day of human chorionic gonadotropin (hCG) administration indicates premature luteinization and might be associated with an adverse pregnancy; however, a lower limit of this ratio has not been determined. We aimed to identify a lower limit of P/E2 that correlates significantly with an increase in adverse pregnancies in patients undergoing a prolonged in vitro fertilization/intracytoplasmic sperm injection therapy.

MATERIALS AND METHODS

This retrospective analysis involved 7451 patients who received the first cycle of in vitro fertilization/intracytoplasmic sperm injection therapy treatment at the Reproductive and Genetic Hospital of Citic-Xiangya between January 2008 and April 2012. Patients were stratified into six groups according to their P/E2 on the day of hCG administration. Primary pregnancy outcomes, rates of implantation, clinical pregnancy, ongoing pregnancies, spontaneous abortions, and live births were recorded. The association between P/E2 on the day of hCG administration and primary pregnancy outcomes was assessed using logistic regression analysis.

RESULTS

The rates of implantation (23.85-33.44%), clinical pregnancy (47.42-67.12%), ongoing pregnancy (40.83-61.48%), and live birth (34.40-57.65%) were significantly decreased in patients with a P/E2 < 0.25. These indicators were significantly associated with P/E2, but no significant correlation was observed between P/E2 and early spontaneous abortion rate.

CONCLUSION

P/E2 < 0.25 on the day of hCG administration was associated with adverse pregnancy outcomes in extended treatments of gonadotropin-releasing hormone agonist IVF/ICSI.

Progesterone for Luteal Phase Support in In Vitro Fertilization: Comparison of Vaginal and Rectal Pessaries to Vaginal Capsules: A Randomized Controlled Study

BACKGROUND

In IVF, Luteal phase support is usually performed using vaginal progesterone. A part of patients using this route reports being uncomfortable with this route. We tried to study whether the rectal route could be an effective alternative and associated with less discomfort.

PATIENTS AND METHODS

A prospective randomized controlled study. All patient were eligible for IVF treatment for infertility. After oocyte pickup, 186 patients were allocated to one the following protocols for luteal phase support: (i) rectal pessaries group: natural progesterone pessaries administered rectally 200 mg three times a day, (ii) vaginal pessaries group: natural progesterone pessaries administered vaginally 200 mg three times a day), and (iii) vaginal capsules group: natural micronized progesterone capsules administered vaginally 200 mg three times a day. On the day of pregnancy test, patients were asked to fill in a questionnaire conducted by an investigator in order to assess the tolerability and side effects of the LPS treatment taken. The primary endpoint was the occurrence of perineal irritation.

RESULTS

Fifty eight patients were assigned to the rectal pessaries group, 68 patients to the vaginal pessaries group, and 60 patients to the vaginal capsules group. All patients adhered to their allocated treatment. Implantation and clinical pregnancy rates per transfer did not differ between the three groups. Perineal irritation, which was our primary endpoint, was the same for all the three groups (respectively 1.7 % versus 5.9 % versus 11.7%). Regarding the other side effects, more patients experienced constipation and flatulence with the rectal route, whereas more patients reported vaginal discharge in the vaginal capsules group.

CONCLUSION

Rectal administration for luteal phase support is effective and well accepted alternative to vaginal route.

Serum human chorionic gonadotropin measured 7 days following day 3 embryo transfer might predict pregnancy outcome in IVF

This prospective study investigated the predictive value of pregnancy outcomes with serum human chorionic gonadotropin (hCG) 7 days after day 3 embryo transfer (D3 ET), and whether estradiol (E2) and progesterone (P) improved the diagnostic efficiency. The study comprised 280 in vitro fertilization and embryo transfer (IVF-ET) cycles. Serum samples were obtained 7 days after D3 ET to measure hCG, E2, and P concentrations. Statistical analyses were conducted to evaluate the predictive value for pregnancy outcomes. We found significant differences in hCG level between pregnancy and non-pregnancy, viable and non-viable pregnancy, biochemical and viable pregnancy, as well as singleton and multiple pregnancy. An hCG cutoff value of 2.5 mIU/mL is predictive of pregnancy with a positive predictive value (PPV) of 95.9% and a negative predictive value (NPV) of 92.4%. An hCG value of 10.8 mIU/mL is predictive of a multiple pregnancy with an NPV of 98.1%. The area under the hCG curve between pregnancy and non-pregnancy was not improved by adding E2, P, or combined E2/P. Our results suggest a predictive value of pregnancy outcome with serum hCG drawn 7 days after D3 ET in IVF, and the diagnostic accuracy is not improved by adding measurements of E2/P.

Occult abnormal pregnancies after first post-embryo transfer serum beta-human chorionic gonadotropin levels of 1.0-5.0 mIU/mL

OBJECTIVE

To assess the occult pregnancy rate after "negative" first post-embryo transfer (ET) serum β-hCG results.

DESIGN

Two-part retrospective cohort study and nested case series.

SETTING

University-based fertility center.

PATIENT(S)

A total of 1,571 negative first post-ET serum β-hCG results were included in the study; 1,326 results (primary cohort, June 2009-December 2013) were initially reported as <5 mIU/mL and 245 results (secondary cohort, January 2014-March 2015) were reported as discrete values from 1.0 to 5.0 mIU/mL.

INTERVENTION(S)

None.

MAIN OUTCOME MEASURE(S)

Rates of occult pregnancy, ectopic pregnancy, and complications after negative first post-ET serum β-hCG results.

RESULT(S)

A total of 88.8% (1,178/1,326) of the negative first post-ET results reported as <5 were actually <1.0 mIU/mL. Occult pregnancy was incidentally identified in 1.2% (12/1,041) of subjects with follow-up. Six had ectopic pregnancies, and seven experienced serious complications; 11 (91.7%) of the 12 occult pregnancies had a first post-ET serum β-hCG level of 1.0-5.0 mIU/mL and 1 (8.3%) <1.0 mIU/mL. All pregnancies with serious complications had initial β-hCG levels of 1.0-5.0 mIU/mL. Of the 245 results reported as discreet values, occult pregnancies were diagnosed in 5.5% (9/163) of subjects with follow-up. One had an ectopic pregnancy, which was treated with methotrexate. There were no serious complications in the secondary cohort.

CONCLUSION(S)

The majority of negative first post-ET serum β-hCG levels are <1.0 mIU/mL. Results from 1.0 to 5.0 mIU/mL may fail to exclude abnormal pregnancy and are associated with poor outcomes compared with β-hCG levels <1.0 mIU/mL. Serial serum β-hCG may be warranted in this population.

Apolipoprotein E (ApoE) polymorphism is related to differences in potential fertility in women: a case of antagonistic pleiotropy?

The alleles that are detrimental to health, especially in older age, are thought to persist in populations because they also confer some benefits for individuals (through antagonistic pleiotropy). The ApoE4 allele at the ApoE locus, encoding apolipoprotein E (ApoE), significantly increases risk of poor health, and yet it is present in many populations at relatively high frequencies. Why has it not been replaced by natural selection with the health-beneficial ApoE3 allele? ApoE is a major supplier of cholesterol precursor for the production of ovarian oestrogen and progesterone, thus ApoE has been suggested as the potential candidate gene that may cause variation in reproductive performance. Our results support this hypothesis showing that in 117 regularly menstruating women those with genotypes with at least one ApoE4 allele had significantly higher levels of mean luteal progesterone (144.21 pmol l(-1)) than women with genotypes without ApoE4 (120.49 pmol l(-1)), which indicates higher potential fertility. The hormonal profiles were based on daily data for entire menstrual cycles. We suggest that the finding of higher progesterone in women with ApoE4 allele could provide first strong evidence for an evolutionary mechanism of maintaining the ancestral and health-worsening ApoE4 allele in human populations.

Luteal phase support post IVF: individualized early stop

While the need for progesterone-based luteal phase support is well documented, the required treatment duration is not well established, and a practitioners' survey showed a wide range of empiric stopping points. It is suggested that an early stop can be based on assessing endogenous luteal activity on the day of pregnancy test. To examine this approach, data were retrospectively collected on 99 patients with positive pregnancy test and high serum concentrations of oestradiol and progesterone (≥ 1000 pmol/l and ≥ 110 nmol/l, respectively), whose luteal support was stopped, and compared with those of 85 patients who did not meet the above criteria, and so luteal support was continued until gestational week 9. Both groups were comparable in terms of live birth and miscarriage rates. We conclude that in the face of strong endogenous luteal activity, exogenous support can be stopped on pregnancy test day, without affecting pregnancy outcome. Further research is needed to substantiate this finding.

Serum estradiol and progesterone in the mid-luteal phase predict clinical pregnancy outcome in IVF/ICSI cycles

In this prospective study, we tested the hypothesis if E2 and P serum levels significantly differ during the luteal phase following in vitro-fertilization/intracytoplasmic sperm injection (IVF/ICSI) therapy in conception (CC) versus non-conception (NC) cycles, and their potential in the prediction of pregnancy at the earliest point in time. Serum was sampled from the day of embryo transfer (ET) and throughout the luteal phase until ET + 14 from patients consecutively enrolling for IVF/ICSI therapy. The luteal phase was supported by vaginal P suppositories only, clinical pregnancies were detected by ultrasound and followed up until the 20th week. Overall pregnancy rate was 30.9% constituting the two study groups of CC (n = 22) and NC cycles (n = 49). Significantly, higher E2 (3326 ± 804 versus 1072 ± 233 pmol/l, p = 0.014) and P (244 ± 68 versus 73 ± 10 nmol/l, p = 0.023) were present in CC versus NC from as early as ET + 7. In the CC group, patients with ongoing pregnancies (CC-OG) as compared with miscarriages (CC-MC) had significantly higher E2 and P from ET + 7, predicting ongoing pregnancy in receiver operator characteristics analysis.

Relation between single serum progesterone assay and viability of the first trimester pregnancy

OBJECTIVE

This study was designed to detect the relation between serum progesterone and viability of pregnancy during the first trimester.

MATERIAL AND METHODS

Two hundred and sixty women during the first trimester of their pregnancies were hospitalised due to vaginal bleeding and/or abdominal pain and were included in this study. Criteria for inclusion in this study were: certain dates, foetus conceived spontaneously with no history of infertility and a positive serum pregnancy test. Blood samples were taken from women included in this study for serum progesterone assay; the patients were followed by ultrasound until the end of the first trimester for the viability of the pregnancy and the outcome of their pregnancy was recorded.

RESULTS

BY THE END OF THE FIRST TRIMESTER, WOMEN INCLUDED IN THIS STUDY WERE CLASSIFIED INTO: viable pregnancy group (n=178; 68.5%) and non-viable pregnancy group (ended by miscarriage) (n=82; 31.5%). The mean serum progesterone of the studied population was significantly higher in the viable pregnancy group (46.5±7.4 ng/mL) compared to non-viable pregnancy group (9.9±4.8 ng/mL; p<0.05). The serum progesterone cut-off level of 10 ng/mL was 79.3% sensitive for diagnosing non-viable pregnancy and 93.3% specific for the diagnosis of viable pregnancy, while a cut-off level of 20 ng/mL was 95.1% sensitive for the diagnosis of non-viable pregnancy and 98.9% specific for diagnosing viable pregnancy.

CONCLUSION

Serum progesterone is a reliable marker for early pregnancy failure and a single assay of its serum level can differentiate between viable and non-viable pregnancies.

Relation between single serum progesterone assay and viability of the first trimester pregnancy

This study was designed to detect the relation between serum progesterone and viability of pregnancy during the first trimester. Prospective study carried out in Al-Rashid Maternity and Ahmadi Kuwait oil company hospitals, over three years from February 2009 to February 2012. Two hundred and Sixty (260) pregnant women were hospitalized due to vaginal bleeding and/or abdominal pain during the first trimester of their pregnancies and were included in this study. Women included in this study were; sure of dates, conceived spontaneously with no history of infertility and had a positive serum pregnancy test. 2 ml blood samples were taken for women included in this study for serum progesterone assay. Women included in this study were followed by ultrasound for the viability of the pregnancy till the end of first trimester and the outcome of their pregnancy were recorded, while women with exogenous progesterone support or multiple pregnancies or suspected ectopic pregnancy or Hydatiform mole were excluded from this study. Data were collected and statistically analyzed to detect the relationship between serum progesterone level and viability of pregnancy during the first trimester. The mean age of the studied population was 32.7 ± 5.1 years, the mean gestational age at progesterone assay was 9.7 ± 0.5 week and by the end of the first trimester, women included in this study were classified according to the viability of their pregnancies into; viable pregnancy group 178 (68.5%) cases and non-viable pregnancy group (ended by miscarriage) 82 (31.5%) cases. The mean serum progesterone of the studied population was significantly high in viable pregnancy group (46.5 ± 7.4 ng/ml) compared to non-viable pregnancy group (9.9 ± 4.8 ng/ml), (p <0.05). In this study; 6.7% of viable pregnancies had serum progesterone level <10 ng/ ml, while 20.7% of non-viable pregnancies had serum progesterone level >10 ng/ml, the serum progesterone at cut off level 10 ng/ml was 79.3% sensitive to diagnose non-viable pregnancy and was 93.3% specific to diagnose viable pregnancy. Also, in this study; 1.1% of viable pregnancies had serum progesterone level <20 ng/ ml, while 4.8% of non-viable pregnancies had serum progesterone level >20 ng/ml, the serum progesterone at cut off level 20 ng/ml was 95.1% sensitive to diagnose non-viable pregnancy and was 98.9% specific to diagnose viable pregnancy. Serum progesterone is a reliable marker for early pregnancy failure and single assay of its serum level can differentiate between viable and non-viable pregnancies.

A randomized comparison of the efficacy, side effects and patient convenience between vaginal and rectal administration of Cyclogest(®) when used for luteal phase support in ICSI treatment

PURPOSE

This study compares the efficacy, side effects and patient convenience of vaginal and rectal routes of administration of progesterone suppositories (Cyclogest) when used for luteal phase support during in vitro fertilization cycles, through the use of antagonist protocols.

METHODS

147 patients who underwent intra-cytoplasmic sperm injection cycle were randomized on the day of the embryo transfer (ET) by a computer-generated randomization program to receive 400 mg of Cyclogest either vaginally or rectally twice daily for up to 8 weeks. A pregnancy test was conducted 2 weeks after embryo transfer. If the pregnancy test was negative, the application was discontinued. On day 14th after embryo transfer, patient's acceptability and side effects were assessed using a questionnaire which was given to the patients on the day of ET prior to performing the pregnancy test. The clinical pregnancy rate at the 8th week of gestation and the level of luteal progesterone were evaluated.

RESULTS

There were no substantial differences in the demographics or other characteristics between the two groups. There were no significant differences in serum P concentration 6 days after ET, the clinical pregnancy and abortion rates. The difficulty of administration route, the discomforts experienced following administration, and the proportion leaking out on the 14th day were similar between the two groups. Significantly more patients administering the medication per vagina had perineal irritation (21.3 vs. 2.2 %). The prevalence of tenesmus (35.1 vs. 21.1 %) and rectal itching (26.7 vs. 2.8 %) were significantly more in rectal route.

CONCLUSIONS

This study demonstrates that the efficacy of Cyclogest is similar when administered via both the vaginal and rectal routes. Although their side effects differ, the ease of administration for patients and their preference are similar.

Serum biomarkers for predicting pregnancy outcome in women undergoing IVF: human chorionic gonadotropin, progesterone, and inhibin A level at 11 days post-ET

Objective

This study was performed to assess the prognostic value of serum hCG, progesterone, and inhibin A levels measured at 11 days post-ET for predicting pregnancy outcome in women participating in IVF.

Methods

Between May 2005 and April 2008, sera were obtained from 70 infertile women who underwent IVF-ET at 11 days post-ET and stored. HCG, progesterone, and inhibin A levels were measured by commercial enzyme-linked immunosorbent assay kits. The predictive accuracy of hCG, progesterone, and inhibin A levels for establishment of intrauterine pregnancy and ongoing pregnancy was calculated by receiver-operating characteristic curve analysis.

Results

For the prediction of intrauterine and ongoing pregnancy, serum hCG was better than progesterone and inhibin A. The predictive performance of progesterone and inhibin A was similar. The serum progesterone and inhibin A levels were significantly correlated each other (r=0.915, p=0.010).

Conclusion

A single measurement of the serum hCG level is sufficient to predict pregnancy outcome in IVF-ET patients.

Modulation of the endocannabinoid system in viable and non-viable first trimester pregnancies by pregnancy-related hormones

BACKGROUND

In early pregnancy, increased plasma levels of the endocannabinoid anandamide (AEA) are associated with miscarriage through mechanisms that might affect the developing placenta or maternal decidua.

METHODS

In this study, we compare AEA levels in failed and viable pregnancies with the levels of the trophoblastic hormones (beta-human chorionic gonadotrophin (beta-hCG), progesterone (P4) and (pregnancy-associated placental protein-A (PAPP-A)) essential for early pregnancy success and relate that to the expression of the cannabinoid receptors and enzymes that modulate AEA levels.

RESULTS

The median plasma AEA level in non-viable pregnancies (1.48 nM; n = 20) was higher than in viable pregnancies (1.21 nM; n = 25; P = 0.013), as were progesterone and beta-hCG levels (41.0 vs 51.5 ng/mL; P = 0.052 for P4 and 28,650 vs 6,560 mIU/L; P = 0.144 for beta-hCG, respectively, but were not statistically significant). Serum PAPP-A levels in the viable group were approximately 6.8 times lower than those in the non-viable group (1.82 vs 12.25 mg/L; P = 0.071), but again these differences were statistically insignificant. In the spontaneous miscarriage group, significant correlations between P4 and beta-hCG, P4 and PAPP-A and AEA and PAPP-A levels were observed. Simultaneously, immunohistochemical distributions of the two main cannabinoid receptors and the AEA-modifying enzymes, fatty acid amide hydrolase (FAAH) and N-acylphosphatidylethanolamine-phospholipase D (NAPE-PLD), changed within both the decidua and trophoblast.

CONCLUSIONS

The association of higher AEA levels with early pregnancy failure and with beta-hCG and PAPP-A, but not with progesterone concentrations suggest that plasma AEA levels and pregnancy failure are linked via a mechanism that may involve trophoblastic beta-hCG, and PAPP-A, but not, progesterone production. Although the trophoblast, decidua and embryo contain receptors for AEA, the main AEA target in early pregnancy failure remains unknown.

Predictive power of activin A levels in the prognosis of first trimester in vitro fertilization pregnancies

BACKGROUND

The present study aims to determine the predictive power of activin A levels in the prognosis of first trimester pregnancies conceived by in vitro fertilization (IVF).

METHODS

The study cohort included 23 biochemical, and 23 normal ongoing pregnancies conceived via IVF. Serum β-human chorionic gonadotropin (β-hCG), progesterone, and activin A levels were assessed 14 days after embryo transfer.

RESULTS

Serum activin A levels were significantly lower in biochemical pregnancies compared to normal ongoing pregnancies (0.57 vs. 0.81 ng/mL, p<0.001). The ability of activin A to predict normal ongoing pregnancies at a cutoff level of 0.695 ng/mL gave a sensitivity of 91.3%, a specificity of 100%, a positive predictive value of 100%, and a negative predictive value of 92%. Significant correlation was found between β-hCG and progesterone, β-hCG and activin A, and progesterone and activin A. Activin A, β-hCG, and progesterone were all found to be efficacious in prediction of early IVF pregnancies.

CONCLUSIONS

The present study indicates that single measurement of activin A can be suggested as a marker for the progress and outcome of early pregnancies conceived via IVF. However, further large-scale studies are required to determine the efficacy and reliability of activin A in prediction of early pregnancies achieved by assisted reproductive techniques (ART).

Progestogens for treatment and prevention of pregnancy disorders

Progesterone appears to be the dominant hormone not only establishing a proper secretory endometrial development but also adequate decidualization to establish pregnancy and sustain pregnancy development. Progesterone is the natural immunoregulator to control the maternal immune system and not to reject the allogeneic fetus. There are two sources of progesterone: corpus luteum first and placenta later. Three progestogens can be used in pregnancy: (i) progesterone (per os, intravaginal and intramuscular), (ii) dydrogesterone (per os), and (iii) 17α-hydroxyprogesterone caproate (intramuscular). There are three indications, for which these progestogens can be clinically used either for treatment or prevention: (i) first trimester threatened and recurrent (habitual) abortion, (ii) premature labor/premature birth, and (iii) pre-eclampsia (hypertension in pregnancy). The available data are limited and only partially randomized. In threatened abortion the use of progesterone, dydrogesterone and 17α-hydroxyprogesterone caproate leads to a significant improved outcome, when at the time of threatened abortion a viable fetus has been ascertained by ultrasound. For prevention of recurrent abortion there are also some data indicating a significant effect compared with women without progestogen treatment. Prevention of preterm birth by progestogens (progesterone vaginally, orally and 17α-hydroxyprogesterone caproate intramuscularly) was significantly effective. The main study groups include pregnant women with a previous history of premature birth. However, also in women with shortened cervix use of progesterone seems to be helpful. The studies done so far in women with risk factors for pre-eclampsia or established pre-eclampsia were based on parenteral progesterone application. However, new studies are urgently needed.

Effects of endocannabinoid 1 and 2 (CB1; CB2) receptor agonists on luteal weight, circulating progesterone, luteal mRNA for luteinizing hormone (LH) receptors, and luteal unoccupied and occupied receptors for LH in vivo in ewes

Thirty to forty percent of ruminant pregnancies are lost during the first third of gestation due to inadequate progesterone secretion. During the estrous cycle, luteinizing hormone (LH) regulates progesterone secretion by small luteal cells (SLC). Loss of luteal progesterone secretion during the estrous cycle is increased via uterine secretion of prostaglandin F(2α) (PGF(2α)) starting on days 12-13 post-estrus in ewes with up to 4-6 pulses per day. Prostaglandin F(2α) is synthesized from arachidonic acid, which is released from phospholipids by phospholipase A2. Endocannabinoids are also derived from phospholipids and are associated with infertility. Endocannabinoid-induced infertility has been postulated to occur primarily via negative effects on implantation. Cannabinoid (CB) type 1 (CB1) or type 2 (CB2) receptor agonists and an inhibitor of the enzyme fatty acid amide hydrolase, which catabolizes endocannabinoids, decreased luteal progesterone, prostaglandin E (PGE), and prostaglandin F(2α) (PGF(2α)) secretion by the bovine corpus luteum in vitro by 30 percent. The objective of the experiment described herein was to determine whether CB1 or CB2 receptor agonists given in vivo affect circulating progesterone, luteal weights, luteal mRNA for LH receptors, and luteal occupied and unoccupied LH receptors during the estrous cycle of ewes. Treatments were: Vehicle, Methanandamide (CB1 agonist; METH), or 1-(4-chlorobenzoyl)-5-methoxy-1H-indole-3-acetic acid morpholineamide (CB2 agonist; IMMA). Ewes received randomized treatments on day 10 post-estrus. A single treatment (500 μg; N=5/treatment group) in a volume of 1 ml was given into the interstitial tissue of the ovarian vascular pedicle adjacent to the luteal-containing ovary. Jugular venous blood was collected at 0 h and every 6-48 h for the analysis of progesterone by radioimmunoassay (RIA). Corpora lutea were collected at 48 h, weighed, bisected, and frozen in liquid nitrogen until analysis of unoccupied and occupied LH receptors and mRNA for LH receptors. Profiles of jugular venous progesterone, luteal weights, luteal mRNA for LH receptors, and luteal occupied and unoccupied LH receptors were decreased (P≤0.05) by CB1 or CB2 receptor agonists when compared to Vehicle controls. Progesterone in 80 percent of CB1 or CB2 receptor agonist-treated ewes was decreased (P≤0.05) below 1 ng/ml by 48 h post-treatment. It is concluded that the stimulation of either CB1 or CB2 receptors in vivo affected negatively luteal progesterone secretion by decreasing luteal mRNA for LH receptors and also decreasing occupied and unoccupied receptors for LH on luteal membranes. The corpus luteum may be an important site for endocannabinoids to decrease fertility as well as negatively affect implantation, since progesterone is required for implantation.

Clinical biochemistry of assisted conception

Assisted reproductive technology has shown rapid advancement since the birth of the first 'test-tube' baby in Oldham, UK, in 1978. Since April 2005, women between the ages of 23 and 39, who meet the described eligibility criteria, are able to get one free in vitro fertilization cycle funded by the National Health Service. Private treatment costs anything from pound4000 to pound8000 for a single cycle of treatment. Almost 15% of the couples in UK are affected by fertility problems and undergo detailed investigations before being offered assisted conception. Assisted reproduction is the collective name for treatments designed to lead to conception by means other than sexual intercourse. These include intrauterine insemination, in vitro fertilization, intracytoplasmic sperm injection and gamete donation. This review is intended to summarize the principles of assisted conception and examine the role of the biochemistry laboratory in: (A) the diagnosis and subsequent management of ovulatory disorders; (B) assessing ovarian reserve before initiating fertility treatment and (C) monitoring fertility treatment. It touches on the screening of potential gamete donors and follow-up of children born after assisted conception. This article was prepared at the invitation of the Clinical Sciences Reviews Committee of the Association of Clinical Biochemistry.

Early risk factors for miscarriage: a prospective cohort study in pregnant women

Many pregnancies are lost during early gestation, but clinicians still lack tools to recognize risk factors for miscarriage. Thus, the identification of risk factors for miscarriage during the first trimester in women with no obvious risk for a pregnancy loss was the aim of this prospective cohort trial. A total of 1098 women between gestation weeks 4 and 12 in whom no apparent signs of a threatened pregnancy could be diagnosed were recruited. Demographic, anamnestic, psychometric and biological data were documented at recruitment and pregnancy outcomes were registered subsequently. Among the cases with sufficiently available data, 809 successfully progressing pregnancies and 55 subsequent miscarriages were reported. In this cohort, risk of miscarriage was significantly increased in women at higher age (>33 years), lower body mass index (< or =20 kg/ m(2)) and lower serum progesterone concentrations (< or =12 ng/ml) prior to the onset of the miscarriage. Women with subsequent miscarriage also perceived higher levels of stress/demands (supported by higher concentrations of corticotrophin-releasing hormone) and revealed reduced concentrations of progesterone-induced blocking factor. These risk factors were even more pronounced in the subcohort of women (n = 335) recruited between gestation weeks 4 and 7. The identification of these risk factors and development of an interaction model of these factors, as introduced in this article, will help clinicians to recognize pregnant women who require extra monitoring and who might benefit from therapeutic interventions such as progestogen supplementation, especially during the first weeks of pregnancy, to prevent a miscarriage.

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.

Quality of reporting of test accuracy studies in reproductive medicine: impact of the Standards for Reporting of Diagnostic Accuracy (STARD) initiative

OBJECTIVE

To evaluate the extent to which test accuracy studies published in two leading reproductive medicine journals in the years 1999 and 2004 adhered to the Standards for Reporting of Diagnostic Accuracy (STARD) initiative parameters, and to explore whether the introduction of the STARD statement has led to an improved quality of reporting.

DESIGN

Structured literature search. Articles that reported on the diagnostic performance of a test in comparison with a reference standard were eligible for inclusion. For each article we scored how well the 25 items of the STARD checklist were reported. These items deal with the study question, study participants, study design, test methods, reference standard, statistical methods, reporting of results, and conclusions. We calculated the total number of reported STARD items per article, summary scores for each STARD item, and the average number of reported STARD items per publication year.

SETTING

Not applicable.

PATIENT(S)

Not applicable.

INTERVENTION(S)

Not applicable.

MAIN OUTCOME MEASURE(S)

Quality of reporting.

RESULT(S)

We found 24 studies reporting on test accuracy in reproductive medicine in 1999 and 27 studies in 2004. The mean number of reported STARD items for articles published in 1999 was 12.1 +/- 3.3 (range 6.5-20) and 12.4 +/- 3.2 (range 7-17.5) in 2004, after publication of the STARD statement. Overall, less than half of the studies reported adequately on 50% or more of the STARD items. The reporting of individual items showed a wide variation. There was no significant improvement in mean number of reported items for the articles published after the introduction of the STARD statement.

CONCLUSION(S)

Authors of test accuracy studies in the two leading fertility journals poorly report the design, conduct, methodology, and statistical analysis of their study. Strict adherence to the STARD guidelines should be encouraged.

Serum oestradiol and β-HCG measurements after day 3 or 5 embryo transfers in interpreting pregnancy outcome

The aim of this study was to assess the clinical value of serum oestradiol concentration 8 days after embryo transfer (D8E2) and beta-human chorionic gonadotrophin (HCG-beta) concentration 12 days after embryo transfer (D12HCG-beta) in the prediction of pregnancy and the outcome of pregnancy following assisted reproduction, taking into account the day of transfer, which was either day 3 (D3) or day 5 (D5). The objective was to improve patient counselling by giving quantitative and reliable predictive information instead of non-specific uncertainties. A total of 2035 embryo transfer cycles performed between January 2003 and June 2005 were analysed retrospectively. Biochemical pregnancy, ectopic pregnancy and first-trimester abortions were classified as non-viable pregnancies; pregnancies beyond 12 weeks gestation were classified as ongoing pregnancies (OP). Significantly higher D8E2 and D12HCG-beta were obtained in D5 transfers compared with D3 transfers with regard to pregnancy and OP (P<or=0.001). For D3 embryo transfers, the cut-off value of D8E2 in predicting OP was 130 pg/ml (sensitivity 80%, specificity 72%), compared with 98 mIU/ml (sensitivity 89%, specificity 69%) for D12HCG-beta. For D5 embryo transfers, the values were 179 pg/ml (sensitivity 79%, specificity 84%) and 257 mIU/ml (sensitivity 78%, specificity 81%) respectively. It appears that serum post-embryo transfer D8E2 and D12HCG-beta concentrations provided clear information regarding pregnancy and the outcome of pregnancy following IVF-embryo transfer.

Receiver operator characteristics and diagnostic value of progesterone and CA-125 in the prediction of ectopic and abortive intrauterine gestations

OBJECTIVE

The study was designed to investigate the predictive value of progesterone and CA-125 in the diagnosis of ectopic pregnancy (EP) and inevitable miscarriage.

METHODS

Forty women with EP, 20 with intrauterine (IU) abortive gestation and 20 regular pregnant women (controls) were studied. IU abortive and EP were confirmed and treated by surgery. Serum progesterone and CA-125 levels were measured at the time of presentation and 24h after surgery.

RESULTS

Women with EP had significantly lower progesterone concentrations, compared to both women with IU abortive pregnancy and controls. Women with IU abortion had significantly higher CA-125 levels, compared to the other two groups. When using a progesterone concentration of less than 10.75 ng/ml as a cut-point for the diagnosis of EP, sensitivity, specificity, positive and negative predictive values were 85%. When using CA-125 concentration of more than 41.9 U/ml as a threshold for the diagnosis of IU abortive pregnancy, sensitivity was 80%, specificity 87%, the positive predictive value was 66% and the negative predictive value 93%.

CONCLUSION

The measurement of progesterone and CA-125 levels is useful in discriminating ectopic and intrauterine abortive from normal gestations.

Comparative birth weights of singletons born after assisted reproduction and natural conception in previously infertile women

BACKGROUND

The possible interference of assisted reproduction techniques (ART) with epigenetic reprogramming during early embryo development has recently sparked renewed interest about the reported lower birth weight among infants born as a consequence of infertility treatments. However, the latter finding so far has relied on the comparison of the birth weight of infants conceived with ART to general population data. A more appropriate comparison group should involve pregnancies in infertile women after natural conception. Therefore, we compared neonatal birth weight data of infants born after various ART treatments, including intrauterine insemination (IUI), with those of previously infertile women achieving pregnancy after sexual intercourse.

METHODS

Between August 1996 and March 2004 the data of all infertile women presenting in the infertility unit of the University Women's Hospital of Basel, Switzerland, were collected prospectively, adding up to 995 intact pregnancies and deliveries. The birth weight of all infants resulting from 741 singleton pregnancies were analysed with regard to the patients' characteristics, the occurrence of complications during pregnancy and the type of infertility treatment with which the pregnancies were achieved.

RESULTS

Comparison of duration of pregnancy and birth weight of infants born after infertility treatment confirms a shorter pregnancy span and a lower mean birth weight in infants born after IVF and ICSI. If women with pregnancies after ART deliver before term, neonatal birth weight is significantly lower.

CONCLUSIONS

There is a specific effect of ART, mainly IVF and ICSI, on both shortening the duration of pregnancy and lowering neonatal birth weight. Both these parameters seem to be interrelated consequences of some modification in the gestational process induced by the infertility treatment. Freezing and thawing of oocytes in the pronucleate stage had a lesser impact on pregnancy span and on neonatal birth weight.

Human chorionic gonadotropin in cervical fluid as a predictor of miscarriage

OBJECTIVE

To determine whether the concentration of hCG in cervical fluid can predict miscarriage during early pregnancy.

DESIGN

Prospective clinical study.

SETTING

University hospital.

PATIENT(S)

Ninety-nine women with singleton pregnancies, 17 of whom suffered a miscarriage.

INTERVENTION(S)

None.

MAIN OUTCOME MEASURE(S)

Miscarriage and the cervical fluid/serum hCG concentration ratio.

RESULT(S)

With a cutoff value of 1.0, the sensitivity, specificity, and positive and negative predictive values of the cervical fluid/serum hCG concentration ratio for predicting miscarriage were 88.2%, 94.9%, 83.3%, and 96.6%, respectively.

CONCLUSION(S)

The cervical fluid/serum hCG concentration ratio might be a useful predictor of miscarriage during early pregnancy.