Assessment of progesterone levels on the day of pregnancy test determination: A novel concept toward individualized luteal phase support

RESEARCH QUESTION

The main objective of the study is to define the optimal trade-off progesterone (P4) values on the day of embryo transfer (ET), to identify low P4-human chorionic gonadotropin (hCG), and to establish whether P4 supplementation started on the hCG day can increase the success rate of the frozen embryo transfer (FET) cycle.

DESIGN

A single-center, cohort, retrospective study with 664 hormone replacement therapy (HRT)-FET cycles analyzed female patients who received vaginal 600 mg/day of P4 starting from 6 days before the FET, had normal P4 values on the day before ET, and whose P4 on the day of the pregnancy test was assessed.

RESULTS

Of the 664 cycles, 69.6% of cycles showed P4 ≥ 10.6 ng/ml, while 30.4% showed P4 < 10.6 ng/ml on the day of the hCG. Of the 411 chemical pregnancies detected, 71.8% had P4-hCG ≥ 10.6 ng/ml (group A), while 28.2% had P4-hCG < 10.6 ng/ml. Of the cycles with P4-hCG < 10.6 ng/ml, 64.7% (group B) were supplemented with a higher dose of vaginal P4 (1,000 mg/day), while 35.3% (group C) were maintained on the same dose of vaginal micronized P4. The live birth rate was 71.9%, 96%, and 7.3% for groups A, B, and C, respectively.

CONCLUSION

The likelihood to detect P4-hCG < 10.6 ng/ml decreased as the level of serum P4 the day before ET increased. The live birth rate (LBR) was shown to be significantly lower when P4 was low and not supplemented.

O-241 Elevated serum progesterone levels before frozen embryo transfer do not negatively impact reproductive outcomes: a large retrospective cohort study

Study question

Do patients with high serum progesterone levels before frozen embryo transfer (FET) under hormonal replacement therapy (HRT) present worse reproductive outcomes?

Summary answer

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

What is known already

Low serum progesterone levels before FET do negatively affect reproductive outcomes in terms of live birth rate. However, there is not robust data regarding the impact of high serum progesterone levels in the luteal phase of patients who undergo HRT for FET.

Study design, size, duration

Retrospective cohort study of 3183 blastocyst FET cycles under HRT performed in a university-affiliated fertility centre between March 2009 and December 2020. All the cycles presented adequate serum progesterone levels before FET (≥10.6 ng/ml). A total of 1360 cycles corresponded to frozen homologous embryo transfer (ET) (hom-FET), 1024 were euploid ET (eu-FET) after preimplantational genetic testing for aneuploidies (PGT-A), and 799 cycles were frozen heterologous ET (het-FET). The primary objective was live birth rate (LBR).

Participants/materials, setting, methods

Standard HRT was used. Luteal phase was covered with vaginal progesterone 200 mg/8h, or vaginal plus a daily subcutaneous injection of progesterone (25 mg). Serum progesterone levels were measured the day before FET. Elevated progesterone levels were considered in the 90th and 95th centiles. A generalized additive model (GAM) was performed to study the functional relationships between progesterone and LBR. A multivariable logistic regression was used to evaluate the effect of high progesterone over LBR.

Main results and the role of chance

Mean serum progesterone level before FET was 16.77±8.43 ng/ml. Progesterone levels were significantly higher in the group under vaginal plus subcutaneous progesterone (21.87±14.17 vs. 15.56±5.72, p &lt; 0.001). No differences in clinical pregnancy, miscarriage and LBR were found according to 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 patients (p &lt; 90) (43.9 vs 41.3%; p = 0.381). Patients with progesterone levels ≥p90 presented lower BMI compared to those in the lower centiles (&lt;p90) (22.62±3.82 vs. 23.32±4.06; P = 0.009). After dividing patients in deciles according to serum progesterone levels before, no differences in LBR were observed among groups (P = 0.938). No association was observed with GAM model between progesterone levels and LBR. A multivariable logistic regression adjusted by oocyte age, type of treatment and number of embryos transferred was applied for centile 90 and centile 95 of progesterone, and showed that serum progesterone in their highest levels did not negatively impact LBR.

Limitations, reasons for caution

The main limitation of this study is its retrospective design. The results only apply for patients under HRT with vaginal micronized progesterone alone or plus subcutaneous progesterone. Progesterone determination was measured before blastocyst FET. Extrapolation to other HRT protocols or timings of progesterone measurement needs to be validated.

Wider implications of the findings

The results of this study suggest that once a threshold of serum progesterone before FET is achieved, progesterone levels are not predictive of the clinical outcome. Actually, LBR are not negatively affected when progesterone levels are found in their highest centiles after luteal phase rescue with vaginal plus subcutaneous progesterone.

Trial registration number

Not applicable

P-403 Progesterone supplementation in frozen embryo transfer with hormonal replacement therapy is associated with a higher incidence of macrosomia

Study question

Is there an impact of increased progesterone (P4) supplementation in hormone replacement therapy (HRT) frozen embryo transfer (FET) on obstetrical and neonatal outcomes?

Summary answer

Increased P4 supplementation from the day of FET is associated with a significantly higher risk of macrosomia and a slightly higher risk of preeclampsia.

What is known already

The most widely used method for endometrial preparation prior to FET is HRT, a sequential regimen with E2 and P4, which aims to mimic the endocrine exposure of the endometrium of the physiological cycle. However, in ∼40% of the patients undergoing HRT-FET cycles P4 levels before FET remain low and this may negatively affect pregnancy rates. Although recent prospective studies have shown that additional P4 supplementation in case of low serum P4 levels results in excellent reproductive outcomes, no data exist concerning the potential effect of this extra amount of P4 on obstetrical and neonatal outcomes

Study design, size, duration

This is a single-centre, retrospective-observational study. Women undergoing HRT-FET treatment meeting the inclusion criteria were allocated to one of the 2 study groups according to the P4 supplementation. Group A (277) included women with adequate levels (&gt;10.6 ng/ml) of P4, while group B (129) included women who received P4 supplementation due to inadequate levels of P4 (&lt;10.6 ng/ml) on the day before the FET. All FET-HRT cycles were performed between February 2018 and December 2020.

Participants/materials, setting, methods

All patients received micronized P4 (200 mg trice a day) starting six days prior to the FET and continued until 10 weeks of pregnancy. In case P4&lt;10.6 ng/ml, P4 supplementation was initiated rather with 400mg more micronized P4 (15%) or with subcutaneous P4 (25mg more/once a day) (85%). Only patients with day5-embryos, known P4 levels prior to FET, known obstetrical and neonatal outcomes were included. Multivariable-logistic-model was fitted for macrosomia after adjusting for confounding variables.

Main results and the role of chance

Patients’ age at oocyte retrieval was 33.5 and 33.6 years (p = 0.833), while the age at delivery was 39.9 and 39.1 years (p = 0.099), respectively for groups A and B. The incidence of diabetes, hypertension, autoimmune diseases, coagulation, and kidney disorders was comparable for both arms. The mean value of P4 was 16 ± 7.7 and 8.2 ± 1.9, respectively for groups A and B. The mean gestational length was 39 weeks in both arms, with comparable rates of premature deliveries (delivery &lt;37 weeks respectively 4.3% and 3.1 % for group A and B; p = 0.553). The rate of cesarean-section was 56% vs 47.3%, respectively for groups A and B (p = 0.103); there were 5 cases of pre-eclampsia in group A and 7 in group B (1.8% vs 5.4%; p = 0.059). The incidence of macrosomia was significantly higher in group B (6.1% vs 12.4%; P = 0.031). Similarly, group B had a higher rate of BGA-big for gestational age- babies (9.7 vs 15.5, p = 0.091). In terms of weight at delivery, pH, Apgar, and sex the two groups were comparable. Multivariable-logistic regression showed an association between macrosomia and P4 supplementation, adjusting for potential confounders such as sex, gestational diabetes, and weeks of gestation (OR 2.3, 95% CI 1.1-4.8).

Limitations, reasons for caution

The main limitation of this study is its retrospective nature. Other potential limitations are the small sample size to detect obstetrical diseases with low incidence, such as preeclampsia. Furthermore, in our study population the PE rate is lower than in the general population, due to socioeconomic-conditions, race, and previous morbidity.

Wider implications of the findings

P4-supplemented patients have a higher risk of macrosomia and a tendency for a higher risk of preeclampsia. However, more studies are needed to confirm the present exploratory findings and explain the possible physiological mechanisms underlying the association between progesterone supplementation on macrosomia and preeclampsia.

Trial registration number

NA

P–672 Higher pregnancy outcomes in patients undergoing embryo transfer-under hormonal replacement therapy where an individualised Progesterone supplementation was applied on the day of β-hCG

Study question

Does progesterone-supplementation (PS) from the day of β-hCG assessment improve pregnancy rates in embryo transfer-under hormonal replacement therapy (ET-HRT) in patient with Progesterone (P)&lt;10.6 ng/mL?

Summary answer

Reduced P on the β-hCG day is associated with lower pregnancy-rates and higher miscarriage-rate. PS from the same day showed significant increase of reproductive outcomes.

What is known already

Up until now, in ART, very little has been done to understand whether the P intake should be personalized during the luteal phase. Most recent studies on the topic showed that low P levels on the day of ET-HRT or on the day before are associated with decreased pregnancy rates; however, when low P values are supplemented from the day before embryo-transfer (ET), similar results to cases with adequate P are reported. Nevertheless, little is known about the association between low P level, on the day of β-hCG (P- β-hCG) and PS from this day in ET-HRT, and pregnancy outcomes.

Study design, size, duration

This is a single centre, cohort, retrospective study conducted at a university-affiliated fertility centre between January 2018 and June 2020 where PS took place from the day of positive β-hCG determination when P &lt; 10.6 ng/mL. In total 789 ET-HRT cycles were analysed of which 239 were performed in both fresh and frozen heterologous ET-HRT (het-ET), 336 in homologous ET-HRT (hom-FET) and 214 in euploid ET-HRT (eu-FET) after preimplantation genetic testing for aneuploidies IVF cycles (PGT-A).

Participants/materials, setting, methods

Women undergoing ET-HRT with normal P (&gt;10.6ng/mL) on the day before ET were screened for P on the day of β-hCG. All women received vaginal P 200 mg/8 hours for the second part of HRT. PS was performed by adding P to the HRT when P- β-hCG was considered low (&lt;10.6 ng/mL). Primary outcome: ongoing-pregnancy-rate (OPR); secondary outcome: miscarriage-rate (MR). Both were evaluated by considering PS on the day of β-hCG as a categorical variable.

Main results and the role of chance

Patients characteristics were comparable between groups (het-ET, hom-FET and eu-FET) although significantly lower body mass index was found when P- β-hCG&gt;10.6 ng/mL compared to the subgroup with P- β-hCG&lt;10.6 ng/mL and no PS (p = 0.012). Overall clinical pregnancy rate was 52.1% with no-significant differences between groups (48.5% in het-ET, 52.9% in hom-FET and 54.7% in eu-FET). P- β-hCG was considered as adequate in 75.7% (311/411) ET-HRT with positive β-hCG and low in 24.3% (100/411), with no differences between groups. In case of positive β-hCG and P- β-hCG &gt;10.6 ng/mL, OPR was 83.6% and MR was 16.4%, with no-significant differences between groups. Among the 100 low P- β-hCG, 80 ET-HRT received PS. In this subgroup OPR was 96.2% and MR was 3.8%, with no-significant differences between groups. In 20 out of 100 ET with P- β-hCG &lt;10.6 ng/mL, no PS was added for different reasons. This group showed the lowest OPR (30%) and the highest MR (70%), again with no between-group differences according to het-ET, hom-FET or eu-FET. Miscarriage rate was significantly higher (p &lt; 0.001) when P- β-hCG was &lt;10.6 ng/mL and no PS was added to HRT compared to P- β-hCG &lt;10.6 ng/mL but with PS, and also compared to the P- β-hCG &gt;10.6 ng/mL group.

Limitations, reasons for caution

The main limitation of the study is due to its retrospective nature and the small sample of patients with P- β-hCG&lt;10.6 ng/mL that was not supplemented. Furthermore, the cut-off of P- β-hCG was arbitrarily decided upon previous studies, and lastly different routes of administration were considered for the PS.

Wider implications of the findings: The results of this study showed that individualization of Progesterone supplementation in ET-HRT may be a crucial turn point in order to increase the pregnancy rates and decrease the miscarriage rates. An adequate PS should be considered in case of low P- β-hCG levels for both het-ET, hom-FET and eu-FET.

Trial registration number

Not applicable

Clinically significant intra-day variability of serum progesterone levels during the final day of oocyte maturation: a prospective study with repeated measurements

STUDY QUESTION

Is there significant variability in progesterone levels during the final day of oocyte maturation in women undergoing ovarian stimulation?

SUMMARY ANSWER

Progesterone levels drop from the basal level up to 44% during the final day of oocyte maturation in women undergoing ovarian stimulation.

WHAT IS KNOWN ALREADY

It has been suggested that elevated progesterone levels on the final day of ovarian stimulation may be related to poorer outcomes in in vitro fertilization fresh cycles due to a negative impact on the endometrium. However, despite conflicting results regarding the actual effect of progesterone on pregnancy rates and the lack of a well-established cut off, currently many IVF patients have their embryo transfer deferred when progesterone values surpass a threshold of 1.5 ng/ml on the day of ovulation triggering.

STUDY DESIGN, SIZE, DURATION

This was a prospective cohort study conducted in 22 oocyte donors of a university-affiliated fertility centre between November 2017 and January 2018. We calculated the sample size to detect a difference of 15% between the first and last progesterone measurements with a 5% false-positive rate in a two-sided test with 80% statistical power and a 95% confidence interval (CI).

PARTICIPANTS/MATERIALS, SETTING, METHODS

Progesterone circulating levels were evaluated at four different times during the final day of oocyte maturation (08:00, 12:00, 16:00 and 20:00) before ovulation triggering in healthy oocyte donors. A flexible antagonist protocol was used, and ovarian stimulation was achieved with recombinant follicle-stimulating hormone (FSH) in all cases. The pairwise percentage differences in progesterone levels for each patient were calculated. Univariate linear regression analysis was adopted in order to evaluate variables associated with progesterone levels on the first measurement. The intra-day variability of progesterone was analysed using mixed models.

MAIN RESULTS AND THE ROLE OF CHANCE

Mean serum progesterone values at 08:00, 12:00, 16:00 and 20:00 were 1.75 ng/ml, 1.40 ng/ml, 1.06 ng/ml and 0.97 ng/ml. The progesterone difference between 08:00 and 20:00 was 0.77 (95% CI, 0.56–0.99), which is equivalent to a 44% decline in the mean progesterone values between the first (08:00) and the last determination (20:00; P < 0.001). Among those patients with basal (08:00) progesterone levels >1.5 ng/ml (n = 10), 70% (n = 7) showed levels reduced to <1.5 ng/ml on the last determination of the day (20:00). A mixed model analysis revealed that the progesterone reduction during the day was significantly associated with time and total recombinant FSH dose administered.

LIMITATIONS, REASONS FOR CAUTION

Only young healthy oocyte donors stimulated with an antagonist protocol using recombinant FSH were included. Extrapolation to the general IVF population, with different stimulation protocols and gonadotropins, needs to be confirmed.

WIDER IMPLICATIONS OF THE FINDINGS

This study suggests that a single progesterone determination on the final day of oocyte maturation is not reliable enough to make clinical decisions due to the enormous variation in progesterone during the day. Further studies are needed to better define the impact of the follicular progesterone rise on the endometrium of IVF cycles.

STUDY FUNDING/COMPETING INTEREST(S)

Funding was granted from Fundació Santiago Dexeus Font. N.P.P. received unrestricted grants and/or lectures fees from Roche Diagnostics, MSD, Merck, Ferring Pharmaceuticals, IBSA, Theramex and BESINS International, not associated with the current study. The remaining authors have no competing interests.

TRIAL REGISTRATION NUMBER

Clinicaltrials.gov NCT03366025.

Low serum progesterone the day prior to frozen embryo transfer of euploid embryos is associated with significant reduction in live birth rates

A retrospective cohort study was performed to examine whether, in artificial endometrial preparation for frozen embryo transfer (FET) cycles, progesterone (P) levels the day prior to embryo transfer of euploid embryos have an impact on pregnancy outcomes. In a private university clinic, 244 FETs between January 2016 and June 2017 were analyzed. Endometrial preparation was achieved with estradiol valerate and vaginal micronized progesterone. Serum P and estradiol levels the day prior to embryo transfer were measured. A multivariable analysis to assess the relationship between serum P level and pregnancy outcomes was performed, adjusted for confounding variables. Mean P value was 11.3 ± 5.1 ng/ml. Progesterone levels were split in quartiles: Q1: ≤ 8.06 ng/ml; Q2: 8.07-10.64 ng/ml; Q3: 10.65-13.13 ng/ml; Q4: > 13.13 ng/ml. Patients included in the lower P quartile had a significantly higher miscarriage rate and significantly lower live birth rate (LBR) compared to the higher ones. A low serum P level (≤ 10.64 ng/ml) one day before FET is associated with a lower pregnancy and LBR following FET of euploid embryos.

Assisted reproductive technology and ovarian cancer

Ovarian cancer has the highest mortality among all gynaecological cancers, being multiparity and oral contraceptive use the most important protective factors. According to both the "incessant ovulation" and "increased gonadotrophin" theories, fertility drugs might have an association with the development of ovarian cancer, as has been reported by some studies. However, infertility and nulliparity may act as confounding factors and most studies regarding this issue are hampered by methodological limitations. It seems that female infertility may be associated with a modest increase in ovarian cancer risk in those patients who remain nulligravid despite long periods of unprotected intercourse. Globally, most studies are reassuring in not showing a link between the use of fertility drugs and an increased risk of ovarian cancer. Nonetheless, further research in well-designed studies is warranted.

Comparison of IVF cycles reported in a voluntary ART registry with a mandatory registry in Spain

BACKGROUND

Monitoring assisted reproductive technology (ART) is essential to evaluate the performance of fertility treatment and its impact on birth rates. In Europe, there are two kinds of ART registers: voluntary and mandatory. The validity of register data is very important with respect to the quality of register-based observational studies. The aim of this paper is to determine the degree of agreement between voluntary and mandatory ART registers.

METHODS

The two sources for the data compared in this study (referring to 2005 and 2006) were FIVCAT.NET (an official compulsory Assisted Reproduction Registry within the Health Ministry of the Regional Government of Catalonia, to which all authorized clinics, both public and private, performing assisted reproduction in the region are obliged to report) and the register of the Spanish Fertility Society (SEF), to which data are provided on a voluntary basis. The SEF register data were divided into two groups: (i) data from clinics in Catalonia (SEF-CAT); (ii) data from the rest of Spain, excluding Catalonia (SEF-wCAT). The techniques compared were IVF cycle using patients' own eggs (IVF cycle) versus donor egg cycles.

RESULTS

For IVF cycles, the voluntary ART register reflected 77.2% of those on the official one, but the corresponding figure was only 34.4% with respect to donated eggs. The variables analysed in the IVF cycle (insemination technique used, patients' age, number of embryos transferred, pregnancy rates, multiple pregnancies and deliveries) were similar in the three groups studied. However, we observed significant differences in donor egg cycles with regard to the insemination technique used, pregnancy rates and multiple pregnancies between the voluntary and the official register.

CONCLUSIONS

Data from the voluntary ART register for IVF cycles are valid, but those for donor egg cycles are not. Further study is necessary to determine the reasons for this difference.

Assisted reproductive technologies in public and private clinics

The aim of this study was to analyse the influence of the type of service provided by assisted reproduction clinics. The activities, treatment patterns and results achieved by assisted reproduction centres in Spain were examined, comparing public and private clinics. A retrospective study was carried out using the Assisted Reproductive Technology Register of the Spanish Fertility Society for 2002-2004. The results showed that 74%, 96% and 99% of IVF/intracytoplasmic sperm injection, oocyte donation and preimplantation genetic diagnosis cycles, respectively, were carried out in the private sector. Public clinics performed proportionally more transfers of three embryos than the private clinics (48.1% versus 41.7%). More elective transfers were performed in private clinics. Pregnancy rates per cycle started, per puncture and per transfer were significantly higher among private than public clinics (29.1%, 32.7% and 35.9% versus 25.2%, 28.5% and 32.6%, respectively) (P < 0.05). Implantation rate has risen year on year in both types of clinic and was significantly higher (P < 0.05), every year, among the private clinics. The multiple-pregnancy rate was significantly higher among the private clinics (30.8% versus 26.4%) (P < 0.05). In conclusion, differences exist between public and private clinics as regards to their volume of activity, the range of services offered, clinical practice and results achieved.

A prospective trial comparing oocyte donor ovarian response and recipient pregnancy rates between suppression with gonadotrophin-releasing hormone agonist (GnRHa) alone and dual suppression with a contraceptive vaginal ring and GnRH

BACKGROUND

Contraceptive treatment before gonadotrophin-releasing hormone agonist administration presents advantages in women with a tendency to hyper-response and simplifies donor-recipient treatment synchronization. This study compares response to gonadotrophin stimulation under hypophyseal suppression in oocyte donors with or without vaginal contraceptive pretreatment.

METHODS

One hundred and ninety oocyte donors were recruited in a single centre and prospectively assigned to one of two treatment groups, according to the day of the week menstruation initiated: Group VC-, no prior vaginal contraceptive and Group VC+, prior vaginal contraceptive.

RESULTS

VC+ patients presented a significantly higher cancellation rate, lower plasma estradiol levels and fewer follicles >12 mm on the day of hCG, versus the VC- group. Number of oocytes recovered was significantly lower in the VC+ group. All the cases of severe ovarian hyperstimulation syndrome (SOHSS) were in the VC- group. Pregnancy rates by embryo transfer to synchronic recipients were similar between VC+ and VC- (59.5 versus 57.9%, respectively).

CONCLUSIONS

Vaginal contraceptive pretreatment resulted in a higher ovarian suppression, whereas SOHSS rate was lower than in donors who did not receive pretreatment. There were no differences in pregnancy rates between the two groups of synchronic oocyte recipients.

Prevention of multiple pregnancy following IVF in Spain

Since the development of assisted reproduction techniques most countries have witnessed increased rates of multiple pregnancy. Despite the guidelines proposed by various scientific societies these rates continue to be abnormally high. In Spain, as in other Mediterranean countries, a greater number of embryos are transferred than in northern and central European countries and the incidence of multiple pregnancies is greater in comparison. Effective strategies must be established to prevent multiple pregnancy without reducing overall pregnancy rates. In the authors' institute, taking into account the authors' experience, the relevant literature, and despite the limitation of retrospective studies, it is recommended that a maximum of two embryos are transferred in young women with good quality embryos at the time of transfer. The transfer of three embryos is only recommended in women >or=38 years who have one or no good quality embryos available at the time of transfer. The responsibility for preventing multiple pregnancy lies with health professionals, who must be aware of the risks involved in twin and triplet pregnancy. Couples must be provided with objective information before starting an IVF cycle. Professional societies should highlight the problem and make suitable recommendations.

Human seminal plasma allergy and successful pregnancy

Human seminal plasma allergy in women is an uncommon phenomenon. A great variety of reactions ranging from local swelling to generalized systemic reactions have been described, and local symptoms have often been misdiagnosed as chronic vulvovaginitis. Sperm barriers, such as condoms, are the most widely advocated method for avoiding these reactions; however this is not acceptable to couples who wish to have children. We present a case of a woman with human seminal plasma allergy who became pregnant after a fourth cycle of artificial insemination. Sodium dodecyl sulfate polyacrylamide gel electrophoresis immunoblotting showing an IgE binding band at 28kDa in the husband's seminal fluid identified the culprit allergen. Artificial insemination is an effective way to achieve a pregnancy in patients with seminal plasma allergy.

Women with poor response to IVF have lowered circulating gonadotrophin surge-attenuating factor (GnSAF) bioactivity during spontaneous and stimulated cycles

BACKGROUND

Up to 13% of IVF cancellations are due to poor responses during down-regulated cycles. Because premature luteinization occurs more frequently in older or "poor responder" patients, defective production of gonadotrophin surge-attenuating factor (GnSAF) may be involved.

METHODS

Nine women with normal previous IVF response (NORM) and 9 with previous poor IVF response (POOR) were monitored in a spontaneous cycle (blood samples: days 2, 7, 11, 15 and 20) and then stimulated with recombinant human FSH (rFSH) under GnRH agonist (blood samples: treatment days GnRH agonist + 2, GnRH agonist + 7, day of HCG administration and days HCG + 1 and HCG + 8). LH, FSH, estradiol, progesterone and inhibin-A and -B were assayed in individual samples while GnSAF bioactivity was determined in samples pooled according to day, cycle and IVF response.

RESULTS

During spontaneous cycles LH, steroids and inhibins were similar between NORM and POOR women, FSH was elevated in POOR women (4.9 +/- 0.3 versus 6.7 +/- 0.6 mIU/l, P < 0.01) and GnSAF bioactivity was detectable on days 2, 7 and 11 in NORM women only. During IVF cycles inhibin-A and -B rose more markedly in NORM than POOR women. Similarly GnSAF production peaked on day GnRH agonist + 7 in NORM women, but on the day of HCG administration in POOR women.

CONCLUSIONS

Defects in ovarian responsiveness to FSH include reduced GnSAF production. This suggests that GnSAF should be investigated as a marker of ovarian reserve once an immunoassay becomes available.

Risk factors for high-order multiple implantation after ovarian stimulation with gonadotrophins: evidence from a large series of 1878 consecutive pregnancies in a single centre

BACKGROUND

High-order multiple pregnancies (triplets or more) have a large adverse impact on perinatal morbidity and mortality as well as important economic consequences. Most triplets and higher births are due to ovulation induction alone or in combination with intrauterine insemination (IUI) rather than to in-vitro fertilization (IVF). The present investigation was undertaken to determine whether there were specific variables that related to patient clinical characteristics (age of the woman, duration of infertility, type of infertility, body mass index, basal FSH and LH concentrations), treatment characteristics (initial dose of gonadotrophins, total dose of gonadotrophins administered, number of days of ovarian stimulation, insemination procedure, number of spermatozoa inseminated in patients undergoing IUI, type of luteal support), and ovarian response (oestradiol serum concentrations, number and size of follicles) that might be associated with the occurrence of high-order multiple implantation in order to develop a prediction model.

METHODS

This study employed univariate, multivariate and receiver-operating characteristic (ROC) analysis of a large series of 1878 consecutive pregnancies obtained in cycles stimulated with gonadotrophins. Of them, 1771 (94.3%) were low-order pregnancies (1477 singletons and 294 pairs of twins) and 107 (5.7%) were high-order pregnancies.

RESULTS

Predictive variables in the multivariate analysis were age of the woman, serum oestradiol concentrations and number of follicles >10 mm on the day of HCG injection. Stratification of the number of follicles into three categories (1 to 3, 4 to 5, and >5 follicles respectively), peak serum oestradiol and woman's age according to the ROC curves, showed that the risk of high-order multiple implantation correlated significantly with increasing total number of follicles and was significantly increased in women with a serum oestradiol >862 pg/ml and aged < or =32 years.

CONCLUSIONS

This three-variable model can help to identify patients at high-risk for high-order multiple pregnancy in ovulation induction cycles.

Ultrasound-guided embryo transfer: immediate withdrawal of the catheter versus a 30 second wait

It is essential to deposit embryos as gently as possible during IVF, avoiding manoeuvres that might trigger uterine contractions which could adversely affect the results of this treatment. The time during which the embryo transfer catheter remains in the cervical canal might be related to stimulation of contractions. This study investigates the influence that the time interval before withdrawal of the catheter after ultrasound (US)-guided embryo deposit might have on the pregnancy rate in patients under IVF cycles. A total of 100 women about to undergo transfer of at least two optimal embryos was studied. The women were prospectively randomized into two groups: (i) slow withdrawal of the catheter immediately after embryo deposit (n = 51); and (ii) a 30 s delay before catheter withdrawal (n = 49). The pregnancy rates for transfer in the two groups were 60.8 and 69.4% respectively, with no significant differences. There were no statistically significant differences in pregnancy rates between the two patient groups. The results indicate either that the waiting interval was insufficient to detect differences, or that the retention time before withdrawing the catheter is not a factor that influences pregnancy rate.

Human chorionic gonadotropin and intravaginal natural progesterone are equally effective for luteal phase support in IVF

This prospective randomized study compared human chorionic gonadotropin (hCG) and micronized transvaginal progesterone for luteal support in 310 in vitro fertilization (IVF) patients treated with leuprolide acetate and gonadotropins in a long protocol, and showing normal ovarian response. Both treatment groups were homogeneous for age, BMI, stimulation treatment and ovarian response. Pregnancy rates per embryo transfer were not significantly different (33.1% for the hCG group versus 38.7% for the progesterone group). For IVF patients with a normal response to stimulation under pituitary suppression, the use of hCG or progesterone for luteal support does not seem to have any effect on pregnancy rate. The choice of luteal treatment must balance medical hazard and patient convenience, as both therapeutic regimens seem equally effective.

Stimulation protocols for poor responders and aged women

There is a general consensus on the clinical fact that the more embryos replaced the higher pregnancy rates are achieved. For this reason those IVF cycles with a low response and a reduced number of oocytes and embryos will have very few chances of producing a pregnancy. It is very important to diagnose, by means of the anamnesis and hormonal tests which patients are most likely to present a poor response to conventional ovarian stimulation protocols. It is mandatory to know the patient's plasmatic levels of FSH and estradiol together with personal data such as the age and the previous history of the patient. Only young poor responders with a normal basal hormonal profile will have some chances that by applying new protocols and combining new drugs, improve their response and have higher pregnancy rates. For the old poor responders who have already failed to alternative protocols including natural cycles, oocyte donation is the last and best hope.

Embryo transfer under ultrasound guidance improves pregnancy rates after in-vitro fertilization

Between October 1998 and January 1999, we examined the influence of ultrasound guidance in embryo transfer on pregnancy rate in 362 patients from our in-vitro fertilization (IVF)-embryo transfer programme. These patients were prospectively randomized into two groups: 182 had ultrasound-guided embryo replacement, and 180 had clinical touch embryo transfer. There were no statistically significant differences between the two groups with respect to age, cause of infertility and in the characteristics of the IVF cycle. The pregnancy rate was significantly higher among the ultrasound-guided embryo transfer group (50%) compared with the clinical touch group (33.7%) (P < 0.002). Furthermore, there was also a significant increase in the implantation rate: 25.3% in the ultrasound group compared with 18.1% in the clinical touch group (P < 0.05). In conclusion, ultrasound assistance in embryo transfer significantly improved pregnancy and implantation rates in IVF.

Use of co-culture of human embryos on Vero cells to improve clinical implantation rate

Co-culture of human embryos (n = 384 cycles) to the blastocyst stage using Vero cell monolayers was carried out between August 1995 and December 1997. A total of 2868 zygotes were co-cultured and 1027 embryos reached the blastocyst stage (blastocyst formation rate 35.8%). The blastocysts were frozen in 43.7% of patients. A mean of 1.8 blastocysts was transferred per patient and 95 pregnancies were obtained (pregnancy rate/cycle 24.7%). The blastocyst implantation rate was 23.6%. Miscarriage occurred in 15 patients (15.7%) and ectopic pregnancy in three (3.1%) patients. The multiple pregnancy rate was 32.6%. No differences were observed in the blastocyst rate between poor, normal or high response patients. Blastocyst formation was significantly lower when frozen donor spermatozoa were used. Significantly higher pregnancy rates per transfer and blastocyst implantation rates were attained when embryos were transferred on days 5 or 6 compared with day 7. No advantage was observed when co-culture was used in first cycle IVF patients, in comparison with conventional day 2 replacements. The use of blastocysts for preimplantation genetic diagnosis (PGD) increases the diagnostic reliability and widens diagnostic possibilities. A total of 215 cycles with frozen-thawed co-cultured blastocysts were carried out, with a pregnancy rate of 22.7% per replacement.

Ureteral lesion secondary to vaginal ultrasound follicular puncture for oocyte recovery in in-vitro fertilization

Techniques of oocyte retrieval have progressed from laparoscopy to transvaginal follicular aspiration under ultrasonographic control. This highly efficient method, routinely used nowadays, is not free of complications. We present a case of a ureteral lesion secondary to vaginal ultrasound follicular puncture for oocyte recovery in in-vitro fertilization. Despite the surgical procedure to reimplant the ureter, the patient achieved a twin pregnancy which is ongoing uneventfully.

Comparison of the role of cervical and intrauterine insemination techniques on the incidence of multiple pregnancy after artificial insemination with donor sperm

PURPOSE

Our purpose was to investigate the role of the insemination technique used in an artificial insemination program with donor sperm (AID) in multiple pregnancy rates.

METHODS

We carried out a retrospective nonrandom analysis of 300 pregnancies corresponding to 300 cycles in women from our Artificial Insemination Donor Sperm Program. All cycles were stimulated with gonadotropins. Single and multiple pregnancy cycles and intracervical and intrauterine pregnant cycles were compared.

RESULTS

Intracervical insemination was performed in 173 cycles (58%), and intrauterine insemination in 127 (42%). Two hundred twenty-three pregnancies were single (74%), and 77 multiple (26%). In multiple pregnancy cycles, initial dose and mean total daily dose of gonadotropins, plasma estradiol levels, and number of follicles > or = 14 mm were significantly higher compared to those in single pregnancy cycles. Multiple pregnancy rte was significantly higher among pregnancies after intrauterine insemination (32%) than after intracervical insemination (21%).

CONCLUSIONS

The intrauterine technique of insemination in AID-stimulated cycles with gonadotropins is related to multiple pregnancy risk.

Treatment of polycystic ovary patients undergoing IVF

We believe that PCO patients can achieve good results in IVF cycles, provided that stimulation protocols appropriate to their hormonal profiles are used.

The dose of gonadotropin used seems to be more important than the type of gonadotropin. If there is a risk of ovarian hyperstimulation, it is useful to employ one of the strategies recommended to prevent development of genuine OHS, which may endanger the patient’s health.

Inadvertent gonadotrophin-releasing hormone agonist (GnRHa) administration in the luteal phase may improve fecundity in in-vitro fertilization patients

Spontaneous pregnancies associated with inadvertent periconceptional administration of a gonadotrophin-releasing hormone agonist (GnRHa) occur in approximately 1% of in-vitro fertilization (IVF) cycles. The two main issues to be considered in these circumstances are the luteolytic effect of the agonist and embryotoxicity. In addition, some authors have suggested a higher incidence of ectopic implantations. In view of these concerns, we report on 15 patients who conceived during pituitary desensitization with a GnRHa in the luteal phase of the menstrual cycle, and review the literature on the subject. A detailed analysis of the data available so far, which include 59 pregnancies exposed to GnRHa, shows that: (i) there is no clinical evidence for impaired luteal function, and hormonal supplementation does not improve pregnancy outcome; (ii) with only two cases of reported minor malformations among 37 deliveries, both having a genetic component, there is no evidence of teratogenic effects; and (iii) ectopic implantations in these circumstances are related to tubal disease but not to the drug. Considering the long history of infertility in these patients who had previously been treated unsuccessfully by different therapeutic modalities, it is likely that the occurrence of those pregnancies is not merely coincidental and that GnRHa might have a positive role in fecundity. The improved fecundity may be explained by the mechanisms of luteinizing hormone action in the corpus luteum.

Indications for oocyte donation

Donated oocytes were transferred on 92 occasions to 87 women without gonadal function and 5 with functional ovaries. Twenty-three pregnancies were established (25% pregnancy rate), 9 after transfer of fresh embryos in 30 synchronous donor and recipient cycles and 14 after transfers of frozen-thawed embryos in 62 asynchronous donor and recipient cycles. Twenty-two pregnancies were obtained in agonadal patients (25.3% pregnancy rate) and 1 in a gonadal woman (20% pregnancy rate). Pregnant women were younger than those who did not become pregnant, but the difference was not significant. The pregnancy rate was higher when intra-Fallopian transfer was performed (46%) as compared with intrauterine transfer (21.5%) and when micronized progesterone was given intravaginally (pregnancy rate 30.3%) as compared to intramuscularly injected natural progesterone in oil (pregnancy rate 22%). Twenty healthy infants have been born including one set of twins; four pregnancies miscarried.