Determinant Factors for Ongoing Pregnancy in Homologous Intrauterine Insemination Cycles - A Prospective Study

BACKGROUND/AIM

Intrauterine insemination (IUI) is the most common assisted-reproduction treatment. However, it has lower success rate in comparison to other treatments. Therefore, determining factors that contribute to IUI success is of particular interest and this was the purpose of this prospective study.

PATIENTS AND METHODS

In this study, only homologous inseminations with fresh semen samples were included. All women received mild ovarian stimulation with clomiphene citrate and gonadotropins. Before IUI, basic semen analysis, evaluation of DNA fragmentation index (DFI), as well as measurement of sperm redox potential, were performed on each semen sample. Semen was processed with density-gradient centrifugation and 500 μl of processed sperm was used for insemination.

RESULTS

In 200 cycles, there were 36 pregnancies, six of them ectopic. Cycles with ongoing pregnancies were characterized by younger male and female age and higher number of follicles. Multivariate logistic regression analysis showed that only female age was significantly associated with ongoing pregnancy. DFI was positively correlated with male age and negatively correlated with sperm concentration and progressive motility. Semen redox potential showed a strong negative correlation with sperm concentration and positive correlation with DFI.

CONCLUSION

Female age seems to be the most important determinant factor for the achievement of an ongoing pregnancy in homologous IUI cycles with fresh semen.

Midluteal serum estradiol levels are associated with live birth rates in hormone replacement therapy frozen embryo transfer cycles: a cohort study

OBJECTIVE

To study whether midluteal serum estradiol (E2) levels are associated with the live birth rate in hormone replacement therapy frozen embryo transfer (HRT-FET) cycles in patients with optimal midluteal serum progesterone (P4) levels.

DESIGN

Observational prospective cohort study.

SETTING

Public fertility clinic.

PATIENTS

A total of 412 women had an HRT-FET cycle single blastocyst transfer from January 2020 to November 2022.

INTERVENTION

The HRT-FET cycle priming regimen included oral E2 (6mg/24 h) administered in the evening, followed by vaginal P4 (400mg/12 h). Serum E2 and P4 levels were measured using a standardized method, 2-4 hours after the latest P4 administration and 9-14 hours after E4 administration on the day of blastocyst transfer, day 6 of P4 administration. Patients with serum P4 levels (<11 ng/mL [35 nmol/L]) on the day of transfer received additional rectal P4 (400mg/12 h). No additional E2 dose was administered.

MAIN OUTCOME MEASURES

The primary outcome was the live birth rate (LBR) in relation to E2 levels at blastocyst transfer day.

RESULTS

The optimal serum E2 levels correlating with ongoing pregnancy were ≥292 pg/mL and <409 pg/mL (≥1,070 pmol/L and <1,500 pmol/L). The LBR was 59% (60/102) when E2 levels were within this range, whereas a significantly lower LBR of 39% (101/260) was seen in patients when E2 levels were <292 pg/mL (<1,070 pmol/L) and of 28% (14/50) when E2 levels were ≥409 pg/mL (≥1,500 pg/mL). In a logistic regression analysis, adjusting for serum P4 level ≥11 ng/mL or <11 ng/mL (≥35 nmol or <35 nmol/L) on the day of transfer, body mass index, age at oocyte retrieval, day 5 or 6 vitrified blastocysts, and blastocyst score, the adjusted risk difference of live birth was -0.21 (-0.32; -0.10) when the E2 level was <292 pg/mL (<1,070 pmol/L) and -0.31 (-0.45; -0.18) when the E2 level was ≥409 pg/mL (≥1,500 pmol/L) compared with E2 levels ≥292 pg/mL and <409 pg/mL (≥1,070 and <1,500 pmol/L). Importantly, only 25% of patents had optimal levels.

CONCLUSION

The study shows a significant association between serum E2 levels and reproductive outcomes in an HRT-FET cohort in which optimal serum P4 levels were secured. Midluteal serum E2 levels are associated with the LBR in HRT-FET cycles, and E2 levels should neither be too high nor too low.

CLINICAL TRIAL REGISTRATION NUMBER

EudraCT No.: 2019-001539-29.

Optimal antimüllerian hormone levels in oocyte donors: a national database analysis

OBJECTIVE

To study the relationship between high antimüllerian hormone (AMH) levels in oocyte donors and embryo development and pregnancy outcomes among donor oocyte recipients.

DESIGN

Retrospective cohort study.

SETTING

Donor Egg Bank Database.

PATIENTS

Patients undergoing in vitro fertilization using vitrified donor oocytes from 35 in vitro fertilization centers in the United States between 2013 and 2021. For each recipient, the first oocyte lot that was received with a planned insemination and embryo transfer (ET) was included.

INTERVENTION

Oocyte donor-recipient cycles.

MAIN OUTCOME MEASURES

Ongoing pregnancy rate (OPR) per ET.

RESULTS

A total of 3,871 donor oocyte-recipient thaw cycles were analyzed. On the basis of donor AMH serum concentration, cycles were stratified into the high AMH group (AMH ≥5 ng/mL; n = 1,821) and the referent group (AMH <5 ng/mL; n = 2,050). Generalized estimating equation models were used to account for donors that contributed more than one lot of oocytes. The number of usable embryos per lot (median [interquartile range]) was significantly increased in the high AMH group (2 [2-4]) compared with the referent group (2 [1-3]) (relative risk [RR] 1.06; confidence interval [CI] 1.01-1.12). Among recipients with a planned ET, there was no difference in OPR between the high AMH group (45.4%) and the referent group (43.5%) (RR 1.04; 95% CI 0.94-1.15). Among preimplantation genetic testing for aneuploidy cycles, the embryo euploidy rate per biopsy was similar at 66.7% (50%-100%) in both groups (RR 1.04; CI 0.92-1.17). The OPR per euploid ET among patients who used preimplantation genetic testing for aneuploidy was also comparable, at 52% in the high AMH group and 54.1% in the referent group (RR 0.95; CI 0.74-1.23).

CONCLUSION

This large national database study observed that there was no association between a high level of AMH (≥5 ng/mL) in oocyte donors and an OPR in the recipient after the first ET. On the basis of these findings, recipients and physicians can be reassured that oocyte donors with a high AMH level can be expected to produce outcomes that are at least as good as donors with an AMH level (<5 ng/mL).

Early pregnancy bleeding after assisted reproductive technology: a systematic review and secondary data analysis from 320 patients undergoing hormone replacement therapy frozen embryo transfer

STUDY QUESTION

How common is bleeding in early pregnancy after Hormone Replacement Therapy (HRT) Frozen Embryo Transfer (FET) and does bleeding affect the reproductive outcome?

SUMMARY ANSWER

A total of 47% of HRT-FET patients experience bleeding before the eighth week of gestation, however, bleeding does not affect the reproductive outcome.

WHAT IS KNOWN ALREADY

Bleeding occurs in 20% of spontaneously conceived pregnancies, although most will proceed to term. However, our knowledge regarding bleeding in early pregnancy after HRT-FET and the reproductive outcome is sparse.

STUDY DESIGN, SIZE, DURATION

We performed a systematic review of the existing literature on early pregnancy bleeding after assisted reproductive technology (ART) to evaluate the bleeding prevalence and resulting reproductive outcome in this population. A random-effects proportional meta-analysis was conducted. Subsequently, we performed a prospective cohort study including 320 pregnant patients undergoing HRT-FET and a secondary analysis of the cohort study was performed to evaluate bleeding prevalence and reproductive outcome. The trial was conducted from January 2020 to November 2022 in a public fertility clinic.

PARTICIPANTS/MATERIALS, SETTING, METHODS

A systematic literature search was performed, using MESH terms and included studies with data from ART patients and with early pregnancy bleeding as a separate outcome. The cohort study included patients with autologous vitrified blastocyst transfer treated in an HRT-FET protocol. In the event of a positive HCG-test, an early pregnancy scan was performed around 8 weeks of gestation. During this visit, patients answered a questionnaire regarding bleeding or spotting and its duration after the positive pregnancy test. The information was verified through medical files, and these were used to obtain information on reproductive outcomes.

MAIN RESULTS AND THE ROLE OF CHANCE

The review revealed a total of 12 studies of interest. The studies reported a prevalence of early pregnancy bleeding ranging from 2.1% to 36.2%. The random effects proportional meta-analysis resulted in a pooled effect estimate of the prevalence of early pregnancy bleeding in the ART population of 18.1% (95% CI (10.5; 27.1)). Four of the included studies included data on miscarriage rate following an episode of bleeding. All four studies showed a significantly increased risk of miscarriage in patients with early pregnancy bleeding as compared to patients with no history of bleeding. No studies investigated bleeding after HRT-FET specifically. In our HRT-FET cohort study, we found that a total of 47% (149/320) of patients with a positive pregnancy test experienced bleeding before 8 weeks of gestation. Generally, the bleeding was described as spotting with a median of 2 days (range 0.5-16 days). Out of 149 patients with one or several bleeding episodes, a total of 106 patients (71%) had an ongoing pregnancy at 12 weeks of gestation. In comparison, 171 patients reported no bleeding episodes and a total of 115 (67%) of these patients had an ongoing pregnancy at 12 weeks of gestation. This difference was not significant (P = 0.45). Furthermore there was no difference in the live birth rate between the two groups (P = 0.29).

LIMITATIONS, REASONS FOR CAUTION

Most studies included in the review were older and not all studies specified the type of ART. Moreover, the studies were of moderate methodological quality. The patients in the cohort study were treated in a personalized HRT-FET protocol using a rectal supplementary rescue regimen if serum progesterone levels were <35 nmol/l at embryo transfer. The results may not be applicable to other FET protocols, and the present data were based on self-reported symptoms. The systematic review revealed an increased risk of miscarriage following an episode of early pregnancy bleeding. However our cohort study found no such association. This discrepancy can partly be due to the fact, that the four studies in the review only included episodes of heavy bleeding. Also, none of the four studies included data on HRT-FET cycles making them unfit for direct comparison.

WIDER IMPLICATIONS OF THE FINDINGS

Episodes of early bleeding during pregnancy are associated with distress for the pregnant woman, especially in a cohort of infertile patients. Our cohort study showed that at least minor bleeding seems to be a common adverse event of early pregnancy after HRT-FET. From the systematic review, it seems that this prevalence is higher than what has previously been described in relation to other types of ART. However, minor bleeding during early pregnancy after HRT-FET does not seem to affect the reproductive outcome. Knowledge regarding the frequent occurrence of bleeding during early pregnancy after HRT-FET and the fact that this should not be used as a prognostic parameter will help the clinician in counselling patients.

STUDY FUNDING/COMPETING INTEREST(S)

Gedeon Richter Nordic supported this investigator-initiated study with an unrestricted grant as well as study medication (Cyclogest). B.A. has received an unrestricted grant from Gedeon Richter Nordic and Merck and honoraria for lectures from Gedeon Richter, Merck, IBSA, and Marckyrl Pharma. P.H. received honoraria for lectures from Merck, Gedeon Richter, Institut Biochimique SA (IBSA), and Besins as well as unrestricted research grants from Merck, Gedeon Richter, and Institut Biochimique SA (IBSA). The other authors have no conflict of interest to declare.

TRIAL REGISTRATION NUMBER

EudraCT no.: 2019-001539-29.

Impact of having surplus blastocysts cryopreserved on the ongoing pregnancy rate following a fresh transfer

PURPOSE

This study aimed to investigate whether a surplus of vitrified blastocysts correlated with ongoing pregnancy by analyzing the clinical outcomes of fresh transfer cycles with/without a surplus of vitrified blastocysts.

METHODS

This was a retrospective analysis carried out in the Reproductive Medicine Center of Guizhou Medical University Affiliated Hospital between January 2020 and December 2021. Overall, 2482 fresh embryo transfer cycles were included in this study, including 1731 cycles with a surplus of vitrified blastocysts (group A) and 751 cycles with no surplus of vitrified blastocysts (group B). The clinical outcomes of fresh embryo transfer cycles were analyzed and compared between the two groups.

RESULTS

In total, the clinical pregnancy rate (CPR) and ongoing pregnancy rate (OPR) after fresh transfer in group A were significantly higher than those in group B (59% vs. 34.1%, p < .001; 51.9% vs. 27.8%, p < .001, respectively). Moreover, the miscarriage rate was significantly lower in group A when compared to that in group B (10.8% vs. 16.8%, p = .008). When grouped by either female age or the number of good-quality embryos transferred, the same trends for CPR and OPR were seen in all subgroups. After adjusting for potential confounding factors in multivariate analysis, a surplus of vitrified blastocysts remained significantly associated with a higher OPR (OR: 1.52; 95% CI:1.21-1.92).

CONCLUSION

Ongoing pregnancy outcome increases significantly in fresh transfer cycle with a surplus of vitrified blastocysts.

Oral micronized progesterone versus vaginal progesterone for luteal phase support in fresh embryo transfer cycles: a multicenter, randomized, non-inferiority trial

STUDY QUESTION

Does oral micronized progesterone result in a non-inferior ongoing pregnancy rate compared to vaginal progesterone gel as luteal phase support (LPS) in fresh embryo transfer cycles?

SUMMARY ANSWER

The ongoing pregnancy rate in the group administered oral micronized progesterone 400 mg per day was non-inferior to that in the group administered vaginal progesterone gel 90 mg per day.

WHAT IS KNOWN ALREADY

LPS is an integrated component of fresh IVF, for which an optimal treatment regimen is still lacking. The high cost and administration route of the commonly used vaginal progesterone make it less acceptable than oral micronized progesterone; however, the efficacy of oral micronized progesterone is unclear owing to concerns regarding its low bioavailability after the hepatic first pass.

STUDY DESIGN, SIZE, DURATION

This non-inferiority randomized trial was conducted in eight academic fertility centers in China from November 2018 to November 2019. The follow-up was completed in April 2021.

PARTICIPANTS/MATERIALS, SETTING, METHODS

A total of 1310 infertile women who underwent their first or second IVF cycles were enrolled. On the day of hCG administration, the patients were randomly assigned to one of three groups for LPS: oral micronized progesterone 400 mg/day (n = 430), oral micronized progesterone 600 mg/day (n = 440) or vaginal progesterone 90 mg/day (n = 440). LPS was started on the day of oocyte retrieval and continued till 11-12 weeks of gestation. The primary outcome was the rate of ongoing pregnancy.

MAIN RESULTS AND THE ROLE OF CHANCE

In the intention-to-treat analysis, the rate of ongoing pregnancy in the oral micronized progesterone 400 mg/day group was non-inferior to that of the vaginal progesterone gel group [35.3% versus 38.0%, absolute difference (AD): -2.6%; 95% CI: -9.0% to 3.8%, P-value for non-inferiority test: 0.010]. There was insufficient evidence to support the non-inferiority in the rate of ongoing pregnancy between the oral micronized progesterone 600 mg/day group and the vaginal progesterone gel group (31.6% versus 38.0%, AD: -6.4%; 95% CI: -12.6% to -0.1%, P-value for non-inferiority test: 0.130). In addition, we did not observe a statistically significant difference in the rate of live births between the groups.

LIMITATIONS, REASONS FOR CAUTION

The primary outcome of our trial was the ongoing pregnancy rate; however, the live birth rate may be of greater clinical interest. Although the results did not show a difference in the rate of live births, they should be confirmed by further trials with larger sample sizes. In addition, in this study, final oocyte maturation was triggered by hCG, and the findings may not be extrapolatable to cycles with gonadotropin-releasing hormone agonist triggers.

WIDER IMPLICATIONS OF THE FINDINGS

Oral micronized progesterone 400 mg/day may be an alternative to vaginal progesterone gel in patients reluctant to accept the vaginal route of administration. However, whether a higher dose of oral micronized progesterone is associated with a poorer pregnancy rate or a higher rate of preterm delivery warrants further investigation.

STUDY FUNDING/COMPETING INTEREST(S)

This research was supported by a grant from the National Natural Science Foundation of China (82071718). None of the authors have any conflicts of interest to declare.

TRIAL REGISTRATION NUMBER

This trial was registered at the Chinese Clinical Trial Registry (http://www.chictr.org.cn/) with the number ChiCTR1800015958.

TRIAL REGISTRATION DATE

May 2018.

DATE OF FIRST PATIENT’S ENROLMENT

November 2018.

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

STUDY QUESTION

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

SUMMARY ANSWER

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

WHAT IS KNOWN ALREADY

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

STUDY DESIGN, SIZE, DURATION

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

PARTICIPANTS/MATERIALS, SETTING, METHODS

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

MAIN RESULTS AND THE ROLE OF CHANCE

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

LIMITATIONS, REASONS FOR CAUTION

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

WIDER IMPLICATIONS OF THE FINDINGS

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

STUDY FUNDING/COMPETING INTEREST(S)

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

TRIAL REGISTRATION NUMBER (25)

EudraCT no.: 2019-001539-29.

Does maternal age affect Assisted Reproduction Technology success rates after euploid embryo transfer? A systematic review and meta-analysis

IMPORTANCE

Maternal age-related embryo aneuploidy is considered the most significant limiting factor for a favourable outcome following Assisted Reproduction Technology (ART) procedures. Thus, preimplantation genetic testing for aneuploidies (PGT-A) has been proposed as a strategy to genetically evaluate embryos before transfer to the uterus. However, whether embryo ploidy justifies all the aspects of age-related fertility decline remains controversial.

OBJECTIVE

To investigate the effect of different maternal ages on ART success rates following transfer of euploid embryos.

DATA SOURCES

Sciencedirect, Pubmed, Scopus, Embase, the Cochrane library, Clinicaltrials.gov, EU Clinical Trials Register and World Health Organization International Clinical Trials Registry were searched from inception until November 2021 using combinations of relevant keywords.

STUDY SELECTION AND SYNTHESIS

Observational and randomized controlled studies were included if they investigated the impact of maternal age on ART outcomes after the transfer of euploid embryos and reported frequencies of women achieving ongoing pregnancy or live birth (OPR/LBR).

MAIN OUTCOMES

The OPR/LBR after euploid embryo transfer comparing women <35 versus women ≥35 was the primary outcome. Secondary outcomes included implantation rate (IR) and miscarriage rate. Subgroup and sensitivity analyses were also planned in order to explore the sources of inconsistency among studies. The quality of studies was assessed using a modified version of the Newcastle-Ottawa Scale and body of evidence was evaluated using GRADE.

RESULTS

A total of 7 studies were included (n=11,335 ART embryo transfers of euploid embryos). A higher OPR/LBR (OR 1.29, 95% CI 1.07-1.54, I²=40%, p=0.006) in women aged <35 years compared to women ≥35 with a risk difference equal to 0.06 (95% CI 0.02-0.09) was found. In line, IR was higher in the youngest group (OR 1.22, 95% CI 1.12-1.32, I²=0%, p<0.00001). A statistically significant higher OPR/LBR was also found comparing women aged <35 to women 35-37, 38-40 or 41-42. A gradient relationship between age and OPR/LBR could be observed in proportion meta-analysis, especially if restricted to studies with low risk of bias.

CONCLUSION

AND RELEVANCE: Increasing maternal age is associated with a decline in ART success rates independently from embryo ploidy. This message contributes to an appropriate patient's counselling before starting PGT-A procedures.

Is gestational age at term a risk factor for ongoing pregnancies in nulliparous women: A prospective cohort study

BACKGROUND

The results of American observational studies and 1 large, randomized trial show that elective induction of labor among nulliparous women can reduce cesarean delivery rates and suggest that gestational age at delivery may be a risk factor for cesarean delivery in pregnancies managed expectantly. However, data on the risk of cesarean delivery at term in ongoing pregnancies are sparse, especially in high-income countries, and further information is needed to explore the external validity of these previous studies.

OBJECTIVE

This study aimed to evaluate the risk of cesarean delivery for each gestational week of ongoing pregnancy in nulliparous women with a singleton fetus in the cephalic presentation at term in a French population.

STUDY DESIGN

This retrospective study was conducted in a perinatal network of 10 maternity units from January 1, 2016, to December 31, 2017, and included all nulliparous women with a singleton fetus in the cephalic presentation who gave birth at term (≥37 0/7 weeks of gestation). From the start of term (37 completed weeks) and at the start of each subsequent week of completed gestation (each week + 0 days), ongoing pregnancy was defined as that of a woman who was still pregnant and who gave birth at any time after that date. For each week of gestation for these ongoing pregnancies, the cesarean delivery rate was defined as the number of cesarean deliveries performed in each ongoing pregnancy group divided by the number of women in this group. Separate models for each week of gestation, adjusted by maternal characteristics and hospital status, were used to compare the cesarean delivery risk between ongoing pregnancies and those delivered the preceding week. The same methods were applied to subgroups defined according to the mode of labor onset. Odds ratios were calculated after adjusting for maternal age and educational level, presence of severe preeclampsia, and maternity unit status.

RESULTS

The study included 11,308 nulliparous women, 2544 (22.5%) of whom had a cesarean delivery. These rates remained stable for ongoing pregnancies at 37 0/7, 38 0/7, and 39 0/7 weeks of gestation; the rates were 22.5% (95% confidence interval, 21.7-23.2), 22.6% (95% confidence interval, 21.8-23.3); and 22.7% (95% confidence interval, 21.9-23.6), respectively. The risk of cesarean delivery started to increase in ongoing pregnancies at 40 0/7 weeks of gestation (24.3%; 95% confidence interval, 23.1-25.4) and especially at 41 0/7 weeks of gestation (30.7%; 95% confidence interval, 28.9-32.5). Similar trends were also shown for all modes of labor onset and in every maternity unit. In univariate and multivariate analyses, ongoing pregnancy at or beyond 40 0/7 weeks of gestation was associated with a higher risk of cesarean delivery than pregnancy delivered the previous week: 24.3% of ongoing pregnancies at 40 0/7 weeks of gestation vs 19.9% of deliveries between 39 0/7 weeks of gestation and 39 6/7 weeks of gestation. The odds ratios were 1.28 (95% confidence interval, 1.15-1.44) or 30.4% of ongoing pregnancies at 41 0/7 weeks of gestation vs 1.73 (95% confidence interval, 1.51-1.96) or 19.6% of deliveries between 40 0/7 weeks of gestation and 40 6/7 weeks of gestation.

CONCLUSION

Cesarean delivery rates increased starting at 40 0/7 weeks of gestation in ongoing pregnancies regardless of the mode of labor onset.

A drop in serum progesterone from oocyte pick-up +3 days to +5 days in fresh blastocyst transfer, using hCG-trigger and standard luteal support, is associated with lower ongoing pregnancy rates

STUDY QUESTION

Do early- and mid-luteal serum progesterone (P4) levels impact ongoing pregnancy rates (OPRs) in fresh blastocyst transfer cycles using standard luteal phase support (LPS)?

SUMMARY ANSWER

A drop in serum P4 level from oocyte pick-up (OPU) + 3 days to OPU + 5 days (negative ΔP4) is associated with a ∼2-fold decrease in OPRs.

WHAT IS KNOWN ALREADY

In fresh embryo transfer cycles, significant inter-individual variation occurs in serum P4 levels during the luteal phase, possibly due to differences in endogenous P4 production after hCG trigger and/or differences in bioavailability of exogenously administered progesterone (P) via different routes. Although exogenous P may alleviate this drop in serum P4 in fresh transfer cycles, there is a paucity of data exploring the possible impact on reproductive outcomes of a reduction in serum P4 levels.

STUDY DESIGN, SIZE, DURATION

Using a prospective cohort study design, following the initial enrollment of 558 consecutive patients, 340 fulfilled the inclusion and exclusion criteria and were included in the final analysis. The inclusion criteria were: (i) female age ≤40 years, (ii) BMI ≤35 kg/m2, (iii) retrieval of ≥3 oocytes irrespective of ovarian reserve, (iv) the use of a GnRH-agonist or GnRH-antagonist protocol with recombinant hCG triggering (6500 IU), (v) standard LPS and (vi) fresh blastocyst transfer. The exclusion criteria were: (i) triggering with GnRH-agonist or GnRH-agonist plus recombinant hCG (dual trigger), (ii) circulating P4 >1.5 ng/ml on the day of trigger and (iii) cleavage stage embryo transfer. Each patient was included only once. The primary outcome was ongoing pregnancy (OP), as defined by pregnancy ≥12 weeks of gestational age.

PARTICIPANTS/MATERIALS, SETTING, METHODS

A GnRH-agonist (n = 53) or GnRH-antagonist (n = 287) protocol was used for ovarian stimulation. Vaginal progesterone gel (Crinone, 90 mg, 8%, Merck) once daily was used for LPS. Serum P4 levels were measured in all patients on five occasions: on the day of ovulation trigger, the day of OPU, OPU + 3 days, OPU + 5 days and OPU + 14 days; timing of blood sampling was standardized to be 3-5 h after the morning administration of vaginal progesterone gel. The delta P4 (ΔP4) level was calculated by subtracting the P4 level on the OPU + 3 days from the P4 level on the OPU + 5 days, resulting in either a positive or negative ΔP4.

MAIN RESULTS AND THE ROLE OF CHANCE

The median P4 (min-max) on the day of triggering, day of OPU, OPU + 3 days, OPU + 5 days and OPU + 14 days were 0.83 ng/ml (0.18-1.42), 5.81 ng/ml (0.80-22.72), 80.00 ng/ml (22.91-161.05), 85.91 ng/ml (15.66-171.78) and 13.46 ng/ml (0.18-185.00), respectively. Serum P4 levels uniformly increased from the day of OPU to OPU + 3 days in all patients; however, from OPU + 3 days to OPU + 5 days, some patients had a decrease (negative ΔP4; n = 116; 34.1%), whereas others had an increase (positive ΔP4; n = 220; 64.7%), in circulating P4 levels. Although the median (min-max) P4 levels on the day of triggering, the day of OPU, and OPU + 3 days were comparable between the negative ΔP4 and positive ΔP4 groups, patients in the former group had significantly lower P4 levels on OPU + 5 days [69.67 ng/ml (15.66-150.02) versus 100.51 ng/ml (26.41-171.78); P < 0.001] and OPU + 14 days [8.28 ng/ml (0.28-157.00) versus 19.01 ng/ml (0.18-185.00), respectively; P < 0.001]. A drop in P4 level from OPU + 3 days to OPU + 5 days (negative ΔP4) was seen in approximately one-third of patients and was associated with a significantly lower OPR when compared with positive ΔP4 counterparts [33.6% versus 49.1%, odds ratio (OR); 0.53, 95% CI; 0.33-0.84; P = 0.008]; this decrease in OPR was due to lower initial pregnancy rates rather than increased overall pregnancy loss rates. For negative ΔP4 patients, the magnitude of ΔP4 was a significant predictor of OP (adjusted AUC = 0.65; 95% CI; 0.59-0.71), with an optimum threshold of -8.73 ng/ml, sensitivity and specificity were 48.7% and 79.2%, respectively. BMI (OR; 1.128, 95% CI; 1.064-1.197) was the only significant predictor of having a negative ΔP4; the higher the BMI, the higher the risk of having a negative ΔP4. Among positive ΔP4 patients, the magnitude of ΔP4 was a weak predictor of OP (AUC = 0.56, 95% CI; 0.48-0.64). Logistic regression analysis showed that blastocyst morphology (OR; 5.686, 95% CI; 1.433-22.565; P = 0.013) and ΔP4 (OR; 1.013, 95% CI; 0.1001-1.024; P = 0.031), but not the serum P4 level on OPU + 5 days, were the independent predictors of OP.

LIMITATIONS, REASONS FOR CAUTION

The physiological circadian pulsatile secretion of P4 during the mid-luteal phase is a limitation; however, blood sampling was standardized to reduce the impact of timing.

WIDER IMPLICATIONS OF THE FINDINGS

Two measurements (OPU + 3 days and OPU + 5 days) of serum P4 may identify those patients with a drop in P4 (approximately one-third of patients) associated with ∼2-fold lower OPRs. Rescuing these IVF cycles with additional P supplementation or adopting a blastocyst freeze-all policy should be tested in future randomized controlled trials.

STUDY FUNDING/COMPETING INTEREST(S)

None. S.C.E. declares receipt of unrestricted research grants from Merck and lecture fees from Merck and Med.E.A. P.H. has received unrestricted research grants from MSD and Merck, as well as honoraria for lectures from MSD, Merck, Gedeon-Richter, Theramex, and IBSA. H.Y. declares receipt of honorarium for lectures from Merck, IBSA and research grants from Merck and Ferring. The remaining authors declare that they have no conflict of interest.

TRIAL REGISTRATION NUMBER

The study was registered at clinical trials.gov (NCT04128436).

Combined analysis of human chorionic gonadotrophin concentrations at different time points after frozen-thawed blastocyst transfer can improve our ability to predict the pregnancy outcomes of single gestations

In this study, we conducted a retrospective single-centre study of 1664 singleton pregnancies derived from frozen-thawed blastocyst transfer between January 2017 and December 2018. Analysis showed that there were 596 early pregnancy losses and 1068 ongoing pregnancies. We compared serum HCG (human chorionic gonadotophin) concentrations on days 12, 14, 19, and 21, between the pregnancy loss group and the ongoing pregnancy group. The cut-off level of HCG at each time point was calculated to predict pregnancy outcome. Joint analysis of two single HCG levels taken one week apart was carried out to improve predictive accuracy. The levels of HCG at four time points were significantly lower in the early pregnancy loss group than in the ongoing pregnancy group. According to the area under ROC (receiver operating characteristic curve) curves, all levels of HCG taken at four time points showed good ability to predict the outcome of pregnancy. The joint analysis of two single HCG levels taken one week apart further improved the accuracy of prediction.Impact statementWhat is already known on this subject? Multiple studies have shown that the maternal level of serum HCG is the best parameter for predicting the course of pregnancy.What do the results of this study add? The levels of HCG on days 12, 14, 19 and 21 were significantly lower in the early pregnancy loss group than in the group of ongoing pregnancies. According to the area under ROC curves, all levels of HCG taken at four time points showed a good ability to predict the outcome of pregnancy.What are the implications of these findings for clinical practice and/or further research? The joint analysis of two single HCG levels, taken one week apart, further improved the accuracy of prediction.

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

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

SYSTEMATIC REVIEW REGISTRATION

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

Individualized luteal phase support based on serum progesterone levels in frozen-thawed embryo transfer cycles maximizes reproductive outcomes in a cohort undergoing preimplantation genetic testing

INTRODUCTION

Low serum progesterone concentration on frozen embryo transfer (FET) day in hormone replacement therapy (HRT) cycles results in lower reproductive outcomes. Recent studies showed the efficiency of a "rescue protocol'' to restore reproductive outcomes in these patients. Here, we compared reproductive outcomes in HRT FET cycles in women with low serum progesterone levels who received individualized luteal phase support (iLPS) and in women with adequate serum progesterone levels who underwent in vitro fertilization for pre-implantation genetic testing for structural rearrangements or monogenic disorders.

DESIGN

This retrospective cohort study included women (18-43 years of age) undergoing HRT FET cycles with pre-implantation genetic testing at Montpellier University Hospital between June 2020 and May 2022. A standard HRT was used: vaginal micronized estradiol (6mg/day) followed by vaginal micronized progesterone (VMP; 800 mg/day). Serum progesterone was measured after four doses of VMP: if <11ng/ml, 25mg/day subcutaneous progesterone or 30mg/day oral dydrogesterone was introduced.

RESULTS

125 HRT FET cycles were performed in 111 patients. Oral/subcutaneous progesterone supplementation concerned 39 cycles (n=20 with subcutaneous progesterone and n=19 with oral dydrogesterone). Clinical and laboratory parameters of the cycles were comparable between groups. The ongoing pregnancy rate (OPR) was 41.03% in the supplemented group and 18.60% in the non-supplemented group (p= 0.008). The biochemical pregnancy rate and miscarriages rate tended to be higher in the non-supplemented group versus the supplemented group: 13.95% versus 5.13% and 38.46% versus 15.79% (p=0.147 and 0.182 respectively). Multivariate logistic regression analysis found that progesterone supplementation was significantly associated with higher OPR ​​ (adjusted OR = 3.25, 95% CI [1.38 - 7.68], p=0.007).

CONCLUSION

In HRT FET cycles, progesterone supplementation in patients with serum progesterone concentration <11 ng/mL after four doses of VMP significantly increases the OPR.

Pregnancy outcome prediction after embryo transfer based on serum human chorionic gonadotrophin concentrations

OBJECTIVE

The aim of the study was to evaluate the predictive value of the human chorionic gonadotropin (hCG) concentration on the 14th and 16th post-ovulation day after embryo transfer/cryoembryo transfer as well as the dynamics of its increase with respect to the outcome of pregnancy.

MATERIALS AND METHODS

In total, 130 embryo transfers and cryoembryo transfers in women aged 22 to 38 years who experienced a single embryo transfer or single cryoembryo transfer with confirmed pregnancy (hCG level over 15 IU/l on 14th post-ovulation day - D14) were selected. The input parameters (hCG D14, hCG D16, hCG D16-D14, hCG D16/D14 and positivity of at least 2.5-fold increase in hCG D16 compared to hCG D14) were evaluated by regression analysis in relation to the outcome parameters (bio-chemical pregnancy, clinical pregnancy, clinical pregnancy terminated by abortion up to 12 weeks of gestation, clinical pregnancy terminated by childbirth).

RESULTS

Single concentrations of hCG D14 and D16, as well as the difference between these concentrations, were a statistically significant indicator of the prediction of bio-chemical pregnancy (P = 0.000215, P = 0.000227 and P = 0.000421). Contrary to expectations, the proportion of hCG D16 and D14 concentrations did not show statistical significance for either parameter, as well as the fulfilment of the condition of at least a 2.5fold increase in hCG D16 compared to D14. None of the studied input parameters was confirmed as a statistically significant marker for the prediction of miscarriage in the whole group of patients. However, in the group of confirmed clinical pregnancies, the serum concentration of hCG D16 (P = 0.0248) and the difference between concentrations D16 and D14 (P = 0.0185) were confirmed as a positive predictor of the progression of pregnancy until delivery.

CONCLUSIONS

Single hCG concentrations are a good prognostic factor for predicting the outcome of pregnancy, but the determination of the cut-off limit is limited by inter-laboratory deviation as well as by timing of blood collection for hCG determination on the exact post-ovulatory day. The results of individual studies are therefore difficult to use in clinical practice. The dynamics of hCG concentrations appear to be a more reliable predictor of pregnancy outcome. In our cohort, we confirmed the statistical significance of the difference in hCG concentration between the 16th and 14th post-ovulation day not only for the prediction of bio-chemical pregnancy, but also as a predictor of the progression of clinical pregnancy into childbirth. To determine the optimal values of this difference, it is necessary to evaluate a larger group of patients. Conversely, the statistical significance of the proportion of hCG concentrations between the 16th and 14th post-ovulation day was not  confirmed.

Immediate versus delayed frozen embryo transfer in patients following a stimulated IVF cycle: a randomised controlled trial

STUDY QUESTION

Is there any difference in the ongoing pregnancy rate after immediate versus delayed frozen embryo transfer (FET) following a stimulated IVF cycle?

SUMMARY ANSWER

Immediate FET following a stimulated IVF cycle produced significantly higher ongoing pregnancy and live birth rate than did delayed FET.

WHAT IS KNOWN ALREADY

Embryo cryopreservation is an increasingly important part of IVF, but there is still no good evidence to advise when to perform FET following a stimulated IVF cycle. All published studies are retrospective, and the findings are contradictory.

STUDY DESIGN, SIZE, DURATION

This was a randomised controlled non-inferiority trial of 724 infertile women carried out in two fertility centres in China between 9 August 2017 and 5 December 2018.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Infertile women having their first FET cycle after a stimulated IVF cycle were randomly assigned to either (1) the immediate group in which FET was performed in the first menstrual cycle following the stimulated IVF cycle (n = 362) or (2) the delayed group in which FET was performed in the second or later menstrual cycle following the stimulated IVF cycle (n = 362). All FET cycles were performed in hormone replacement cycles. The randomisation sequence was generated using an online randomisation program with block sizes of four. The primary outcome was the ongoing pregnancy rate, defined as a viable pregnancy beyond 12 weeks of gestation. The non-inferiority margin was -10%. Analysis was performed by both per-protocol and intention-to-treat approaches.

MAIN RESULTS AND THE ROLE OF CHANCE

Women in the immediate group were slightly younger than those in the delayed group (30.0 (27.7-33.5) versus 31.0 (28.5-34.2), respectively, P = 0.006), but the proportion of women ≤35 years was comparable between the two groups (308/362, 85.1% in the immediate group versus 303/362, 83.7% in the delayed group). The ongoing pregnancy rate was 49.6% (171/345) in the immediate group and 41.5% (142/342) in the delayed group (odds ratios 0.72, 95% CI 0.53-0.98, P = 0.034). The live birth rate was 47.2% (163/345) in the immediate group and 37.7% (129/342) in the delayed group (odds ratios 0.68, 95% CI 0.50-0.92, P = 0.012). The miscarriage rate was 13.2% (26 of 197 women) in the immediate group and 24.2% (43 of 178 women) in the delayed group (odds ratios 2.10; 95% CI 1.23-3.58, P = 0.006). The multivariable logistic regression, which adjusted for potential confounding factors including maternal age, number of oocytes retrieved, embryo stage at transfer, number of transferred embryos/blastocysts, reasons for FET, ovarian stimulation protocol and trigger type, demonstrated that the ongoing pregnancy rate was still higher in the immediate group.

LIMITATIONS, REASON FOR CAUTION

Despite randomisation, the two groups still differed slightly in the age of the women at IVF. The study was powered to consider the ongoing pregnancy rate, but the live birth rate may be of greater clinical interest. Conclusions relating to the observed differences between the treatment groups in terms of live birth rate should, therefore, be made with caution.

WIDER IMPLICATIONS OF THE FINDINGS

Immediate FET following a stimulated IVF cycle had a significantly higher ongoing pregnancy and live birth rate than delayed FET. The findings of this study support immediate FET after a stimulated IVF cycle.

STUDY FUNDING/COMPETING INTEREST(S)

No external funding was used and no competing interests were declared.

TRIAL REGISTRATION NUMBER

ClinicalTials.gov identifier: NCT03201783.

TRIAL REGISTRATION DATE

28 June 2017.

DATE OF FIRST PATIENT’S ENROLMENT

9 August 2017.

Effect of the oxytocin receptor antagonist nolasiban on pregnancy rates in women undergoing embryo transfer following IVF: analysis of three randomised clinical trials

STUDY QUESTION

Does a single oral dose of nolasiban 900 mg administered 4 h before embryo transfer (ET) increase pregnancy rates in women undergoing IVF?

SUMMARY ANSWER

In an individual patient data (IPD) meta-analysis of three clinical trials, a single oral dose of nolasiban 900 mg was associated with an increased ongoing pregnancy rate of an absolute 5% (relative 15%).

WHAT IS KNOWN ALREADY

Several clinical studies have shown that blocking activation of oxytocin receptors by an oxytocin receptor (OTR) antagonist has the potential to decrease uterine contractions, increase endometrial perfusion and enhance endometrial decidualisation and other parameters of endometrial receptivity. It has been hypothesised that antagonism of oxytocin receptors could improve the likelihood of successful embryo implantation and thus increase pregnancy and live birth rates following ET.

STUDY DESIGN, SIZE, DURATION

This is an analysis of three randomised, double-blind, placebo-controlled trials, which randomised 1836 subjects between 2015 and 2019. We describe the results of a meta-analysis of individual participant data (IPD) from all three trials and the pre-specified analyses of each individual trial.

PARTICIPANT/MATERIAL, SETTING, METHODS

Participants were patients undergoing ET following IVF/ICSI in 60 fertility centres in 11 European countries. Study subjects were below 38 years old and had no more than one previously failed cycle. They were randomised to a single oral dose of nolasiban 900 mg (n = 846) or placebo (n = 864). In IMPLANT 1, additional participants were also randomised to nolasiban 100 mg (n = 62) or 300 mg (n = 60). Fresh ET of one good quality embryo (except in IMPLANT 1 where transfer of two embryos was allowed) was performed on Day 3 or Day 5 after oocyte retrieval, approximately 4 h after receiving the study treatment. Serum hCG levels were collected at 14 days post oocyte retrieval (Week 2) and for women with a positive hCG result, ultrasound was performed at Week 6 post-ET (clinical pregnancy) and at Week 10 post-ET (ongoing pregnancy). Pregnant patients were followed for maternal (adverse events), obstetric (live birth, gestational age at delivery, type of delivery, incidence of twins) and neonatal (sex, weight, height, head circumference, Apgar scores, congenital anomalies, breast feeding, admission to intensive care and specific morbidities e.g. jaundice, respiratory distress syndrome) outcomes.

MAIN RESULTS AND THE ROLE OF CHANCE

In an IPD meta-analysis of the clinical trials, a single oral dose of nolasiban 900 mg was associated with an absolute increase of 5.0% (95% CI 0.5, 9.6) in ongoing pregnancy rate and a corresponding increase of 4.4% (95% CI -0.10, 8.93) in live birth rate compared to placebo. Similar magnitude increases were observed for D3 or D5 transfers but were not significantly different from the placebo. Population pharmacokinetics (PK) demonstrated a correlation between higher exposures and pregnancy.

LIMITATIONS, REASON FOR CAUTION

The meta-analysis was not a pre-specified analysis. While the individual trials did not show a consistent significant effect, they were not powered based on an absolute increase of 5% in ongoing pregnancy rate. Only a single dose of up to 900 mg nolasiban was administered in the clinical trials; higher doses or extended regimens have not been tested. Only fresh ET has been assessed in the clinical trials to date.

WIDER IMPLICATIONS OF THE FINDINGS

The finding support the hypothesis that oxytocin receptor antagonism at the time of ET can increase pregnancy rates following IVF. The overall clinical and population PK data support future evaluation of higher doses and/or alternate regimens of nolasiban in women undergoing ET following IVF.

STUDY FUNDING/COMPETING INTERESTS

The trials were designed, conducted and funded by ObsEva SA. A.H., O.P., E.G., E.L. are employees and stockholders of ObsEva SA. E.L. is a board member of ObsEva SA. G.G. reports honoraria and/or non-financial support from ObsEva, Merck, MSD, Ferring, Abbott, Gedeon-Richter, Theramex, Guerbet, Finox, Biosilu, Preglem and ReprodWissen GmbH. C.B. reports grants and honoraria from ObsEva, Ferring, Abbott, Gedeon Richter and MSD. P.P. reports consulting fees from ObsEva. H.T. reports grants and or fees from ObsEva, Research Fund of Flanders, Cook, MSD, Roche, Gedeon Richter, Abbott, Theramex and Ferring. H.V. reports grants from ObsEva and non-financial support from Ferring. P.T. is an employee of Cytel Inc., who provides statistical services to ObsEva. J.D. reports consulting fees and other payments from ObsEva and, Scientific Advisory Board membership of ObsEva.

TRIAL REGISTRATION NUMBERS

ClinicalTrials.gov: NCT02310802, NCT03081208, NCT03758885.

TRIAL REGISTRATION DATES

December 2014 (NCT02310802), March 2017 (NCT03081208), November 2018 (NCT03758885).

FIRST PATIENT’S ENROLMENT

January 2015 (NCT02310802), March 2017 (NCT03081208), November 2018 (NCT03758885).

Comparison of Subcutaneous and Vaginal Progesterone Used for Luteal Phase Support in Patients Undergoing Intracytoplasmic Sperm Injection Cycles

Objective:

Luteal phase defect in patients undergoing assisted reproductive technology (ART) is a sign of uterine failure due to insufficient progesterone effects on the endometrium. This study aims to compare the success rate and side effects of subcutaneous progesterone and vaginal progesterone to support the luteal phase in ART cycles.

Methods:

In this prospective randomized study, we used the traditional intracytoplasmic sperm injection (ICSI), and we transferred one or two 4-8 cell fetuses based on the patient’s age on the third day of inoculation. We started with luteal phase support from the day of oocyte recovery and the patients randomly received either a daily dose of 25mg subcutaneous progesterone (Prolutex, IBSA Switzerland) or a 400mg dose of vaginal progesterone (Cyclogest, Actoverco, United Kingdom) every 12 hours. If blood BHCG pregnancy test was positive, support for the luteal phase continued until week 10 of gestation. The measured outcomes were the clinical, chemical and ongoing pregnancy rates as well as the rate of early abortion, patients’ acceptance, tolerance and satisfaction.

Results:

The results of the present study showed that there was no statistically significant difference between clinical, chemical and ongoing pregnancy rates - as well as the rate of early abortion, and patients’ satisfaction when comparing the two treatment Groups.

Conclusions:

it seems that the subcutaneous form of progesterone can be used in patients who are not willing to use vaginal progesterone, with similar treatment results and patient satisfaction, when compared to vaginal progesterone.

Day 3 time lapse selection is beneficial for the patients with no good-quality embryos

We aimed to evaluate whether or not time lapse selection was beneficial for the cleavage-stage embryo transfers. The study included 838 infertile women with good ovarian reserve (obtaining more than 8 oocytes) from January 2018 to August 2019. Based on the transferred embryos with different grades (grade I, II and III), the patients were divided into day 3 selection with conventional morphology (CM) and day 3 selection with time lapse (TL) groups. For the grade I and II embryos, we observed that CM and TL had similar implantation, clinical pregnancy and ongoing pregnancy (p > .05) rates. For the grade III embryos, we observed that CM group showed slightly lower implantation (36.74 versus 41.03%, p = .261) and clinical pregnancy (56.82 versus 64.10%, p = .182) rates than TL group. CM group showed significantly lower ongoing pregnancy (47.35 versus 59.83%, p = .025) rate than TL group. And we observed that CM group had significantly higher blastulation (38.93 versus 26.61%, p = .019) rate than TL group. We concluded that TL selection was beneficial to the patients with no good-quality embryos in the first cleavage-stage embryo transfers.

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.

Tubal flushing with oil-based or water-based contrast at hysterosalpingography for infertility: long-term reproductive outcomes of a randomized trial

OBJECTIVE

To determine the impact of oil-based versus water-based contrast on pregnancy and live birth rates ≤5 years after hysterosalpingography (HSG) in infertile women.

DESIGN

A 5-year follow-up study of a multicenter randomized trial.

SETTING

Hospitals.

PATIENT(S)

Infertile women with an ovulatory cycle, 18-39 years of age, and having a low risk of tubal pathology.

INTERVENTION(S)

Use of oil-based versus water-based contrast during HSG.

MAIN OUTCOME MEASURE(S)

Ongoing pregnancy, live births, time to ongoing pregnancy, second ongoing pregnancy.

RESULT(S)

A total of 1,119 women were randomly assigned to HSG with oil-based contrast (n = 557) or water-based contrast (n = 562). After 5 years, 444 of 555 women in the oil group (80.0%) and 419 of 559 women in the water group (75.0%) had an ongoing pregnancy (relative risk [RR] 1.07; 95% confidence interval [CI] 1.00-1.14), and 415 of 555 women in the oil group (74.8%) and 376 of 559 women in the water group (67.3%) had live births (RR 1.11; 95% CI 1.03-1.20). In the oil group, 228 pregnancies (41.1%) were conceived naturally versus 194 (34.7%) pregnancies in the water group (RR 1.18; 95% CI 1.02-1.38). The time to ongoing pregnancy was significantly shorter in the oil group versus the water group (10.0 vs. 13.7 months; hazard ratio, 1.25; 95% CI 1.09-1.43). No difference was found in the occurrence of a second ongoing pregnancy.

CONCLUSION(S)

During a 5-year time frame, ongoing pregnancy and live birth rates are higher after tubal flushing with oil-based contrast during HSG compared with water-based contrast. More pregnancies are naturally conceived and time to ongoing pregnancy is shorter after HSG with oil-based contrast.

CLINICAL TRIAL REGISTRATION NUMBER

Netherlands Trial Register (NTR) 3270 and NTR6577(www.trialregister.nl).

Follow-up strategies to confirm the success of medical abortion of pregnancies up to 10 weeks' gestation: a systematic review with meta-analyses

OBJECTIVE

To compare the effectiveness, safety, and acceptability of in-clinic and remote/self-assessment, as well as different remote/self-assessments, for confirming the success of medical abortion at ≤10⁺⁰ weeks' gestation.

DATA SOURCES

Ovid Embase Classic and Embase; Ovid MEDLINE(R) and Epub Ahead-of-Print, In-Process & Other Non-Indexed Citations and Daily; and the Cochrane Library. We also consulted experts in this field for any ongoing or missed trials.

STUDY ELIGIBILITY CRITERIA

Randomized controlled trials published in English from 2000 onward, comparing in-clinic assessment with ultrasound to remote or self-assessment or comparing different remote or self-assessment strategies to confirm the success of medical abortion of pregnancies up to and including 10⁺⁰ weeks gestation, reporting any of the following outcomes: "missed ongoing pregnancy," "correct implementation of the follow-up strategy," patient satisfaction/preference, "adherence to follow-up strategy," "unscheduled visits/telephone calls to the abortion service," and surgical intervention.

STUDY APPRAISAL AND SYNTHESIS METHODS

One author assessed the risk of bias in the studies using the Cochrane Collaboration checklist for randomized controlled trials. All outcomes were analyzed as risk ratios and meta-analysed in Review Manager 5.3 using the Mantel-Haenszel statistical method and a fixed effect model. The overall quality of the evidence was assessed using GRADE.

RESULTS

Four randomized controlled trials (n = 5761) compared in-clinic to remote self-assessment and found no clinically significant differences apart from higher preference rates for remote follow-up, especially in the remote follow-up groups. The quality of this evidence was compromised by attrition, no blinding, inconsistency, indirectness, and low event rates. Two randomized controlled trials (n = 1125) compared different remote assessment strategies (using urine pregnancy tests) and also found no clinically significant differences apart from a clinically significantly lower rate of unscheduled visits to the abortion service in the remote follow-up group using a multilevel urine pregnancy test compared to remote follow-up using a high-sensitivity urine pregnancy test. The quality of this evidence was compromised by small event rates, lack of blinding, indirectness and high attrition rates.

CONCLUSION

The published data support offering women who have had a medical abortion up to and including 10⁺⁰ weeks' gestation the choice of self-assessment, remote assessment, or clinic follow-up.

Does the endometrial thickness on the day of the trigger affect the pregnancy outcomes after fresh cleaved embryo transfer in the clomiphene citrate-based minimal stimulation cycle?

PURPOSE

Thin endometrium is often observed after clomiphene citrate (CC) administration for follicular development and is one of the reasons for embryo transfer (ET) cancelation or implantation failure. We retrospectively analyzed whether the endometrial thickness (EMT) on the days of the maturation trigger and ET are predictive factors of pregnancy outcomes after fresh cleaved ET in a CC-based minimal stimulation cycle (CC-cycle).

METHODS

A total of 746 CC-cycles in vitro fertilization (IVF), followed by fresh cleaved ET, from November 2018 to March 2019 were analyzed. Associations between the pregnancy outcomes and EMT on the days of the trigger and ET were statistically evaluated.

RESULTS

Although the EMT on the day of ET was not significantly associated with the ongoing pregnancy rate (adjusted odds ratio [AOR], 1.043; P = .3251), a decreased EMT on the day of the trigger was significantly associated with a low ongoing pregnancy rate (AOR, 1.154; P = .0042). Furthermore, the clinical pregnancy rate was significantly lower when the EMT was <7 mm on the day of the trigger during the CC-cycle.

CONCLUSIONS

These results suggest that measurement of the EMT on the day of the trigger could be effective for predicting the pregnancy outcomes after fresh cleaved ET during the CC-cycle.

Does Endometriosis Influence the Embryo Quality and/or Development? Insights from a Large Retrospective Matched Cohort Study

In vitro fertilization can be an effective tool to manage the endometriosis-associated infertility, which accounts for 10% of the strategy indications. Nevertheless, a negative effect of endometriosis on IVF outcomes has been suggested. The aim of this study was to evaluate the potential effect of endometriosis in the development of embryos at cleavege stage in assisted reproduction treatment cycles. A total of 429 cycles from women previously operated for moderate/severe endometriosis were compared with 851 cycles from non-affected women. Patients were matched by age, number of oocyte retrieved and study period. A total of 3818 embryos in cleavage stage have been analyzed retrospectively. Overall, no difference was found between women with and without endometriosis regarding the number of cleavage stage embryos obtained as well as the percentage of good/fair quality embryos. Excluding cycles in which no transfers were performed or where embryos were frozen in day three, no difference was observed for blastulation rate or the percentage of good/fair blastocysts obtained. Despite similar fertilization rate and number/quality of embryos, a reduction in ongoing pregnancy rate was observed in patients affected, possibly due to an altered endometrial receptivity or to the limited value of the conventional morphological evaluation of the embryo.

Corifollitropin alfa for ovarian stimulation in in vitro fertilization: a systematic review and meta-analysis of randomized controlled trials

OBJECTIVE

To evaluate the effectiveness of corifollitropin alfa in improving the success of IVF.

DESIGN

Systematic review and meta-analysis.

SETTING

Not applicable.

PATIENT(S)

Infertile women undergoing conventional IVF or intracytoplasmic sperm injection (ICSI).

INTERVENTION(S)

Randomized controlled trials (RCTs) of infertile women undergoing a single IVF/ICSI cycle with either corifollitropin alfa or a conventional ovarian stimulation protocol based on daily injections. The review protocol was registered in PROSPERO before starting the data extraction (CRD42018088605).

MAIN OUTCOME MEASURE(S)

Primary outcomes were live birth rate and/or ongoing pregnancy rate. Clinical pregnancy rate, miscarriage rate, multiple pregnancies, number of oocytes and embryos obtained, cancellation rate, and rate of ovarian hyperstimulation syndrome and ectopic pregnancy were considered as secondary outcomes.

RESULT(S)

Eight randomized controlled trials were included; 2,345 women were assigned to the intervention group and 1,995 to the control group. The analysis of 4,340 IVF cycles did not reveal any difference in live birth rate and/or ongoing pregnancy rate between groups (risk ratio [RR], 0.92; 95% confidence interval [CI], 0.80-1.05). Similarly, no difference was found in clinical pregnancy rate (RR, 0.96; 95% CI, 0.88-1.05; I² = 0%), miscarriage rate (RR, 0.94; 95% CI, 0.71-1.25; I² = 0%), or multiple pregnancy rate (RR, 1.22; 95% CI, 0.99-1.50; I² = 0%). Also, the rates of cycle cancellation, ovarian hyperstimulation syndrome, and ectopic pregnancy were similar in both groups. Sensitivity and subgroup analyses did not provide statistical changes to pooled results.

CONCLUSION(S)

Corifollitropin alfa seems to be an alternative for daily recombinant FSH injections in normal and poor responder patients undergoing ovarian stimulation in IVF/ICSI treatment cycles.

Comprehensive mitochondrial DNA analysis and IVF outcome

STUDY QUESTION

Do mitochondrial DNA (mtDNA) copy number and heteroplasmy in human embryos affect the ongoing pregnancy rate?

SUMMARY ANSWER

Our study suggests that mtDNA copy number above a specific threshold is associated with the ongoing pregnancy rate.

WHAT IS KNOWN ALREADY

Mitochondria play a vital role in cell function. Recently, there has been increasing research on mtDNA as a biomarker of embryo implantation. Although reports showed that high levels of mtDNA in the blastocyst are associated with low implantation potential, other publications were unable to confirm this. Confounding factors may influence the mtDNA copy number in euploid embryos. On the other hand it has been speculated that both mtDNA heteroplasmy and copy number contribute to mitochondrial function. Next generation sequencing (NGS) allows us to study in depth mtDNA heteroplasmy and copy number simultaneously.

STUDY DESIGN, SIZE, DURATION

A prospective non-selection study was performed. We included 159 blastocyst biopsies from 142 couples who attended our clinic for preimplantation genetic testing for aneuploidies (PGT-A), from January 2017 to December 2017. All embryos were biopsied on Day 5 or Day 6. The aneuploid testing was performed by NGS. All blastocysts were diagnosed as euploid non-mosaic and were transferred. The mtDNA analysis was performed once the embryo diagnosis was known.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Sequencing reads mapping to the mtDNA genome were extracted from indexed bam files to identify copy number and heteroplasmy. The relative measure of mtDNA copy number was calculated by dividing the mtDNA reads by the nuclear DNA value to normalize for technical variants and the number of cells collected at the biopsy. All the results were subjected to a mathematical correction factor according to the embryo genome. Heteroplasmy was assigned by MitoSeek.

MAIN RESULTS AND THE ROLE OF CHANCE

The mean average copy number and SD of mtDNA per genome was 0.0016 ± 0.0012. Regarding heteroplasmy, 40 embryos were heteroplasmy carriers (26.32%). MtDNA variants were detected in coding and non-coding regions and the highest number of variants in an embryo was eight. With respect to IVF outcome for mtDNA copy number analysis, we set a threshold of 0.003 for the following analysis. The vast majority of the embryos were below the threshold (142/159, 89.31%) and 17 embryos were classified as having higher mtDNA levels. We showed a reduction in ongoing pregnancy rate associated with elevated mtDNA copy number (42.96% versus 17.65%, P < 0.05). This result was independent of maternal age and day of the biopsy: these factors were included as confounding factors because mtDNA copy number was negatively correlated with female age (25 –30 y: 0.0017 ± 0.0011, 30 –35 y: 0.0012 ± 0.0007, 35 –40 y: 0.0016 ± 0.0009, over 40 y: 0.0024 + 0.0017, P < 0.05). Embryos biopsied on Day 5 were more likely to have higher quantities of mtDNA compared with those biopsied on Day 6 (0.0017 versus 0.0009, P < 0.001). According to IVF outcome and heteroplasmy, a lower ongoing pregnancy rate was reported for embryos that carried more than two variants. However, this did not reach statistical significance when we compared embryos with a number of variants lower or higher than two (39.15 versus 20.0, P = 0.188). Finally, a clear positive association between the mtDNA variants and copy number was reported when we compare embryos with or without heteroplasmy (0.0013 ± 0.0009 versus 0.0025 ± 0.0014, P < 0.001) and among different numbers of variants (0:0.0013 ± 0.0009, 1–2:0.0023 ± 0.0012, >2:0.0043 ± 0.0014, P < 0.05).

LIMITATIONS, REASONS FOR CAUTION

A limitation may be the size of the sample and the high-throughput sequencing technology that might not have detected heteroplasmy levels below 2% which requires high sequence depth A clinical randomized trial comparing the clinical outcome after the transfer of embryos selected according to mtDNA levels or only by morphological evaluation will be necessary. More research into the impact of mtDNA heteroplasmy and copy number on IVF outcome is needed.

WIDER IMPLICATIONS OF THE FINDINGS

Our results demonstrate that embryos with elevated mtDNA copy number have a lower chance of producing an ongoing pregnancy. MtDNA copy number is higher in older women and is dependent upon the number of cell divisions that preceded biopsy. Moreover, our data suggest that mitochondrial activity could be a balance between functional capacity and relative mtDNA copy number.

STUDY FUNDING/COMPETING INTEREST(S)

There are no conflicts of interest or sources of funding to declare.

Trial registration number

Not applicable.

Effectiveness and safety of in vitro maturation of oocytes versus in vitro fertilisation in women with high antral follicle count: study protocol for a randomised controlled trial

INTRODUCTION

In vitro maturation (IVM) is a potential alternative to conventional in vitro fertilisation (IVF) to avoid ovarian hyperstimulation syndrome (OHSS). This is particularly relevant in women with a high antral follicle count (AFC) and/or polycystic ovary syndrome (PCOS), who are at increased risk for OHSS. However, no randomised controlled trials of IVM versus IVF in women with high AFC have reported both pregnancy and OHSS rates. The aim of this study is to compare the effectiveness and safety of one IVM cycle and one IVF with segmentation cycle within women with PCOS or high AFC-related subfertility.

METHODS AND ANALYSIS

This randomised controlled trial will be conducted at a specialist IVF centre in Vietnam. Eligible subfertile women with PCOS and/or high AFC will be randomised to undergo either IVM or IVF. The primary outcome is live birth after the first embryo transfer of the started treatment cycle. Cycles in which no embryo is available for transfer will be considered as failures. The study has a non-inferiority design, with a maximal acceptable between-group difference of 5%. Rates of OHSS will also be reported.

ETHICS AND DISSEMINATION

Ethical approval was obtained from the participating centre, and informed patient consent was obtained before study enrolment. Results of the study will be submitted for publication in a peer-reviewed journal.

TRIAL REGISTRATION NUMBER

NCT03405701; Pre-results.

Predictive value of basal androgen levels on ongoing pregnancy rates during in vitro fertilization cycles

We aimed to evaluate the impact of elevated basal androgen levels on the endometrial receptivity. This study retrospectively enrolled 5278 fresh in vitro fertilization (IVF) cycles and sought to determine whether increased basal androgen levels are associated with adverse outcomes in regard to ongoing pregnancy rates. The results showed that the average age of our sample was 29.31 years. Almost 61.6% of all embryo transfers were with Day 3 embryos and the remaining 38.4% were with Day 5 embryos. The ongoing pregnancy rate was 56.4%. The ongoing pregnancy rates according to the various ordinal serum androgen intervals (<10.00, 10.00-19.99, 20.00-29.99, 30.00-39.99, and ≥40.00 ng/dL) were 60.12, 56.62, 58.64, 55.48, and 50.17%, respectively. The ongoing pregnancy rates were significantly lower in patients with high basal androgen levels (e40 ng/dL) (p < .05). Multivariate regression analysis showed that age, BMI, and endometrial thickness were inversely associated with basal androgen levels (p < .0001 for all). In conclusion, elevated serum basal androgen levels on cycle Day 3 before IVF is associated with reduced ongoing pregnancy rates.

Are age and anti-Müllerian hormone good predictors of ovarian reserve and response in women undergoing IVF?

Objective

Ovarian reserve evaluation has been the focus of substantial clinical research for several years. This study aimed to examine the associations between markers of ovarian reserve and ovarian response.

Methods

This prospective study included 132 infertile women aged 24-48 years undergoing routine exploration during unstimulated cycles prior to the start of assisted reproductive technology (ART) treatments at our center from July 2015 to January 2017. Descriptive parameters and patient characteristics were reported as mean (SD) or median (range) values depending on the data distribution pattern. Student’s t-test was performed for continuous variables; the Wilcoxon and Pearson’s test were used for data not following a normal distribution; and Fisher’s test was used for categorical variables. p<0.05 was considered statistically significant.

Results

At the time of the study, the patients had a mean age of 35.7±3.84 years. On day 3 of the cycle, the mean anti-Müllerian hormone (AMH) serum level was 2.84±1.57 ng/mL and the patients had 14.68±4.2 antral follicles (AFC). A significant correlation was observed between AMH and age (r=-0.34 p<.01), follicle stimulating hormone (FSH) serum levels (r=-0.32, p<.01), AFC (r=0.81, p<.00001), total dose of medication during ovarian stimulation (r=-0.28, p<.0003), and ongoing pregnancy rate (p<.05). Age was significantly correlated with FSH (r=0.46, p<.01), AFC (r=-0.34, p<.00001), total dose of medication during ovarian stimulation (r=0.43, p<.0003), and ongoing pregnancy rate (p<.04).

Conclusion

Serum AMH and age are independent predictors of ovarian reserve and ovarian stimulation outcome in infertile women. Age and serum AMH level may be used to advise subfertile couples of their pregnancy prospects.

Pituitary block with gonadotrophin-releasing hormone antagonist during intrauterine insemination cycles: a systematic review and meta-analysis of randomised controlled trials

BACKGROUND

Several randomised controlled trials (RCTs) have investigated the usefulness of pituitary block with gonadotrophin-releasing hormone (GnRH) antagonists during intrauterine insemination (IUI) cycles, with conflicting results.

OBJECTIVE

The aim of the present systematic review and meta-analysis of RCTs was to evaluate the effectiveness of GnRH antagonist administration as an intervention to improve the success of IUI cycles.

SEARCH STRATEGY

Electronic databases (MEDLINE, Scopus, EMBASE, Sciencedirect) and clinical registers were searched from their inception until October 2017.

SELECTION CRITERIA

Randomised controlled trials of infertile women undergoing one or more IUI stimulated cycles with GnRH antagonists compared with a control group.

DATA COLLECTION AND ANALYSIS

The primary outcomes were ongoing pregnancy/live birth rate (OPR/LBR) and clinical pregnancy rate (CPR). Pooled results were expressed as odds ratio (OR) or mean differences with 95% confidence interval (95% CI). Sources of heterogeneity were investigated through sensitivity and subgroups analysis. The body of evidence was rated using GRADE methodology. Publication bias was assessed with funnel plot, Begg's and Egger's tests.

MAIN RESULTS

Fifteen RCTs were included (3253 IUI cycles, 2345 participants). No differences in OPR/LBR (OR 1.14, 95% CI 0.82-1.57, P = 0.44) and CPR (OR 1.28, 95% CI 0.97-1.69, P = 0.08) were found. Sensitivity and subgroup analyses did not provide statistical changes in pooled results. The body of evidence was rated as low (GRADE 2/4). No publication bias was detected.

CONCLUSION

Pituitary block with GnRH antagonists does not improve OPR/LBR and CPR in women undergoing IUI cycles.

TWEETABLE ABSTRACT

Pituitary block with GnRH antagonists does not improve the success of IUI cycles.

No common denominator: a review of outcome measures in IVF RCTs

STUDY QUESTION

Which outcome measures are reported in RCTs for IVF?

SUMMARY ANSWER

Many combinations of numerator and denominator are in use, and are often employed in a manner that compromises the validity of the study.

WHAT IS KNOWN ALREADY

The choice of numerator and denominator governs the meaning, relevance and statistical integrity of a study's results. RCTs only provide reliable evidence when outcomes are assessed in the cohort of randomised participants, rather than in the subgroup of patients who completed treatment.

STUDY DESIGN, SIZE, DURATION

Review of outcome measures reported in 142 IVF RCTs published in 2013 or 2014.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Trials were identified by searching the Cochrane Gynaecology and Fertility Specialised Register. English-language publications of RCTs reporting clinical or preclinical outcomes in peer-reviewed journals in the period 1 January 2013 to 31 December 2014 were eligible. Reported numerators and denominators were extracted. Where they were reported, we checked to see if live birth rates were calculated correctly using the entire randomised cohort or a later denominator.

MAIN RESULTS AND THE ROLE OF CHANCE

Over 800 combinations of numerator and denominator were identified (613 in no more than one study). No single outcome measure appeared in the majority of trials. Only 22 (43%) studies reporting live birth presented a calculation including all randomised participants or only excluding protocol violators. A variety of definitions were used for key clinical numerators: for example, a consensus regarding what should constitute an ongoing pregnancy does not appear to exist at present.

LIMITATIONS, REASONS FOR CAUTION

Several of the included articles may have been secondary publications. Our categorisation scheme was essentially arbitrary, so the frequencies we present should be interpreted with this in mind. The analysis of live birth denominators was post hoc.

WIDER IMPLICATIONS OF THE FINDINGS

There is massive diversity in numerator and denominator selection in IVF trials due to its multistage nature, and this causes methodological frailty in the evidence base. The twin spectres of outcome reporting bias and analysis of non-randomised comparisons do not appear to be widely recognised. Initiatives to standardise outcome reporting, such as requiring all effectiveness studies to report live birth or cumulative live birth, are welcome. However, there is a need to recognise that early outcomes of treatment, such as stimulation response or embryo quality, may be appropriate choices of primary outcome for early phase studies.

STUDY FUNDING/COMPETING INTERESTS

J.W. is funded by a Doctoral Research Fellowship from the National Institute for Health Research. The views expressed in this publication are those of the authors and not necessarily those of the NHS, the National Institute for Health Research or the Department of Health. J.W. also declares that publishing research is beneficial to his career. J.W. and A.V. are statistical editors, and M.S. is Information Specialist, for the Cochrane Gynaecology and Fertility Group, although the views expressed here are not necessarily those of the group. D.R.B. is funded by the NHS as Scientific Director of a clinical IVF service. The authors declare no other conflicts of interest.

Ongoing pregnancy rates in intrauterine insemination are affected by late follicular-phase progesterone levels

OBJECTIVE

To determine the relationship between serum P levels on the day of hCG administration and ongoing pregnancy rates.

DESIGN

Retrospective study.

SETTING

University-affiliated private IVF.

PATIENT(S)

A total of 2,458 couples undergoing IUI.

INTERVENTION(S)

Ovarian stimulation with human recombinant FSH.

MAIN OUTCOME MEASURE(S)

Ongoing pregnancy and miscarriage rates.

RESULT(S)

Progesterone concentrations were significantly higher given that the E2 concentration increased. Ongoing pregnancy rates were significantly decreased in women with P levels higher than 1.1 ng/mL; similar results were obtained in relation to miscarriage rates.

CONCLUSION(S)

Significant differences in ongoing pregnancy rates when P levels were elevated on the day of hCG administration may help clinicians to counsel patients about the reduced success rates with IUI and manage the timing of insemination to optimize implantation.

Predictive value of early serum beta-human chorionic gonadotrophin for the successful outcome in women undergoing in vitro fertilization

AIMS:

Pregnancies achieved by in vitro fertilization (IVF) are at increased risk of adverse outcome. The main objective of this study was to evaluate the predictive value of β-human chorionic gonadotrophin (β-HCG) and age of the patient for the successful outcome in IVF.

MATERIALS AND METHODS:

A retrospective study was done in 139 pregnancies after IVF at single IVF center from June 2007 to July 2012. The age of the patient and initial serum values of β-HCG on day 14 of embryo transfer were correlated with ongoing pregnancy (>12 weeks gestation).

RESULTS:

The β-HCG level on day 14 of more than 347 mIU/ml has a sensitivity of 72.2% and specificity of 73.6% in prediction of pregnancy beyond 12 weeks period of gestation. Positive likelihood ratio (LR) is 2.74 and negative LR is 0.37, (receiver operating characteristic area = 0.79).

DISCUSSION:

In IVF cycles, there is a lot of stress on the couples while the cycle is going on. There was a positive correlation between the higher values of early serum β-HCG levels and ongoing pregnancy. Hence, it can be used as an independent predictor of a successful outcome of IVF cycle.

CONCLUSION:

We concluded from our study that early serum β-HCG can be used as a predictor of a successful outcome in IVF.

Evaluation of the impact of gonadotropin-releasing hormone agonist as an adjuvant in luteal-phase support on IVF outcome

OBJECTIVES:

To evaluate whether three daily doses of GnRH agonist (Inj. Lupride 1 mg SC) administered 6 days after oocyte retrieval increases ongoing pregnancy rates following embryo transfer (ET) in cycles stimulated with the long GnRH agonist protocol.

SETTINGS AND DESIGN:

Prospective randomized controlled study in a tertiary care center.

MATERIALS AND METHODS:

Four hundred and twenty six women undergoing ET following controlled ovarian stimulation with a long GnRH agonist protocol were included. In addition to routine luteal-phase support (LPS) with progesterone, women were randomized to receive three 1 mg doses of Lupride 6 days after oocyte retrieval. Computer-generated randomization was done on the day of ET. Ongoing pregnancy rate beyond 20^th week of gestation was the primary outcome measure. The trial was powered to detect a 13% absolute increase from an assumed 27% ongoing pregnancy rate in the control group, with an alpha error level of 0.05 and a beta error level of 0.2.

RESULTS:

There were 59 (27.69%) ongoing pregnancies in the GnRHa group, and 56 (26.29%) in the control group (P = 0.827). Implantation, clinical pregnancy and multiple pregnancy rates were likewise similar in the GnRHa and placebo groups.

CONCLUSIONS:

Three 1 mg doses of Lupride administration 6 days after oocyte retrieval in the long protocol cycles does not result in an increase in ongoing pregnancy rates.

The degree of serum estradiol decline in early and midluteal phase had no adverse effect on IVF/ICSI outcome

BACKGROUND:

Estradiol levels fall rapidly in the luteal phase of ART cycles. So far, the effect of this estradiol decline on pregnancy outcome has remained controversial.

AIM:

To study the effect of early and midluteal estradiol decline on pregnancy and miscarriage rate. We also sought to determine whether estradiol fall was related to increased risk of bleeding per vagina in the first trimester among pregnancies which crossed 12 weeks.

SETTING:

Tertiary Assisted conception center.

DESIGN:

Retrospective study.

MATERIALS AND METHODS:

We analyzed data of 360 consecutive patients who underwent IVF-ET/ICSI cycles using one of the three protocols: Midluteal downregulation, short flare, and antagonist protocol.

STATISTICAL METHODS:

Statistical evaluation was performed with the Student's t test, Chi square, Fischer's exact test, analysis of variance, and Mann-Whitney tests were appropriate using SPSS for Windows, Standard version 11.0.

RESULTS:

The mean % EL-E2 and % ML-E2 declines were not significantly different in the pregnant and nonpregnant groups when analyzed separately in the three protocols. Also, the degree of midluteal estradiol decline did not correlate with pregnancy outcome. Moreover, the mean % early and midluteal estradiol decline did not differ significantly in patients with preclinical, clinical abortions, and ongoing pregnancy. The estradiol decline was not found to influence the risk of bleeding in the first trimester.

CONCLUSIONS:

Our results show that the degree of estradiol fall in the luteal phase of ART cycles does not influence pregnancy and first trimester miscarriage rate.

Critical reappraisal of embryo quality as a predictive parameter for pregnancy outcome: a pilot study

AIM OF THE STUDY

Pilot study to analyse the efficacy and embryo morphology using a new human embryo culture medium (GM501) versus the conventional used medium (ISM1).

METHODS

Over a four-month period, all patients at the Leuven Institute of Fertility and Embryology (LIFE) were -randomly allocated to have their embryos cultured in either the standard sequential culture medium ISM1 (control) or in a new universal medium (GM501) (study group). Primary outcome parameters were clinical pregnancy and live birth rate. The secondary outcome parameter was the correlation of embryo fragmentation rate with pregnancy outcome.

RESULTS

We did not observe any differences between the ISM1 control group and GM501 study group with regard to fertilization, pregnancy, implantation rates, ongoing pregnancy, and babies born. The number of embryos with a minimal fragmentation rate (less than 30%) was significantly higher in the GM501 study group.

CONCLUSION

Although a significant higher embryo fragmentation rate was seen in In vitro culture of embryos in GM501, pregnancy outcome results were comparable to those of embryos cultured in ISM1. According to our results the value of embryo morphological criteria as a parameter for pregnancy outcome should be examined and discussed again.