HRT Cycles Research Articles

P-640 Impact of adding oral dydrogesterone (OD) in patients with low serum progesterone (P) levels in artificially prepared frozen embryo transfer cycles (FET-HRT)

Abstract Study question In case of low serum P on the day of FET (PFET), does the addition of OD to micronized vaginal progesterone (MVP) normalise reproductive outcomes? Summary answer In case of low serum PFET, adding OD results in ongoing pregnancy rates (OPR) comparable to those of patients who had normal serum PFET. What is known already Low serum PFET is associated with increased rates of early pregnancy loss (EPL) and reduced live birth rates in FET HRT cycles. While adding subcutaneous P injections to vaginal progesterone has been shown to normalize clinical outcomes in case of low serum PFET, it is unknown whether adding OD has a similar effect. Study design, size, duration This is a retrospective, single-centre cohort study in a tertiary IVF-clinic. 694 unique patients who had a single blastocyst transfer in an HRT cycle were included. As soon as an endometrial thickness of ≥ 6.5mm was reached following estradiol valerate priming, MVP (400mg,twice daily) was started, followed by FET on the 6thday of MVP. All patients underwent serum P measurement just prior to FET. Serum PFET was analysed using a validated electrochemiluminescence immunoassay (Cobas 6000®,Roche). Participants/materials, setting, methods Clinical outcomes of patients with normal serum PFET(≥8,8ng/dl) following the routine MVPsupplementation were compared with those of patients with low serum PFET(<8,8ng/dl) in whom OD(30mg TID) was added from FET onwards. Primary outcome was OPR, defined as a vital intra-uterine pregnancy at 8 weeks. EPL was defined as biochemical pregnancy loss or early miscarriage. A multivariate regression model was developed adjusting for age, BMI, endometrial thickness, embryo quality and estradiol level. Main results and the role of chance Mean age in the MVP-only versus the MVP+OD group was 34.6(±4.2) and 33.6(±4.3) years, respectively (p = 0.01). No other statistically significant differences were seen among both groups for BMI, endometrial thickness nor embryo quality. A normal serum PFET level was observed in 547/694 (78.8%) of patients, who continued MVP as planned, whereas a low serum PFET level was detected in 147/694 (21.2%) patients who received additional OD supplementation next to MVP from the day following FET onwards. The mean serum PFET level was 14.6 (±5.8) ng/ml in the MVP-only group and 7.0(±1.8) ng/ml in the MVP+OD group. The OPR was comparable between both groups: 40.8% for MVP only versus 40.0% for MVP+OD (p = 0.86). The biochemical pregnancy rates were 55.0% and 60.5% (p = 0.23) and the EPL rates were 14.4% and 21.1% (p = 0.05) in the MVP-only group vs. the MVP+OD group, respectively. Multivariate logistic regression analysis indicated that OPR was not associated with the investigated approaches (OR 0.92, SD 0.18, CI 0.63-1.35, p = 0.68). Only embryo quality was significantly associated with OPR (OR 3.03, SD 1.11, CI 1.48-6.21, p = 0.002). Limitations, reasons for caution The main limitation is the retrospective nature of this study with the risk of unmeasured confounder bias. While OPR is a less robust outcome parameter compared to LBR, LBR data will be presented once available. Wider implications of the findings Additional OD supplementation in patients with low P gives rise to comparable OPRs as observed in patients with normal P. Prospective studies are required to identify the individualized luteal phase support strategy that combines optimal LBR and low EPL rates. Trial registration number Not Applicable

P-572 Hormonal Monitoring and Progesterone Adjustment in Frozen Embryo Transfer Cycles

Abstract Study question We investigated the effect of monitoring and follow-up of serum progesterone, estradiol & luteinizing hormone levels and progesterone supplement adjustments on pregnancy outcomes for FET in programmed HRT cycles. Summary answer Monitoring and follow-up of different hormones in patient’s serum in programmed frozen embryo transfer cycles didn’t have an impact on overall pregnancy rate. What is known already Frozen Embryo transfer treatment rapidly expanded in recent years. FET can effectively prevent IVF associated complications, such as ovarian hyperstimulation syndrome and multiple pregnancy. In addition, FET serves as a safe & cost-effective way to increase cumulative pregnancy rate. Though progesterone levels on the day of transfer have not yet been studied extensively in humans, tailoring the time of transferring a frozen embryo based on serial P4 values rather than cycle day number alone results in higher pregnancy rates.The value of measuring the serum E2 levels on the day of embryo transfer as an indicator for clinical pregnancy is still doubtful. Study design, size, duration Six Hundred FETs were performed in a randomized prospective manner in an infertility center in Alexandria starting from 2019 till 2021.These were further subdivided based on computer randomization into Group I (Non-intervention) including300 patients with only ultrasound monitoring & Group II (intervention) including 300 patients with monitoring of serum level of progesterone, estrogen & luteinizing hormone as well as progesterone supplement adjustments. Participants/materials, setting, methods Group I (Non-intervention) including300 patients with only ultrasound monitoring & Group II (intervention) including 300 patients with monitoring of serum level of progesterone, estrogen & luteinizing hormone as well as progesterone supplement adjustments which are further subdivided into three groups depending on progesterone level in patient’s serum early in the morning prior to embryo transfer. Group II A: P4 levels < 5ng/dl, Group II B: P4 levels 5-10ng/dl, Group II C: P4 levels >10ng Main results and the role of chance Live birth and overall pregnancy rate showed no significant difference among group monitored with ultrasound only compared to the hormonal monitored group. However, on the day of embryo transfer, serum P4 > 11.83 ng/ml represented a cut-off value above which there is marked increase in OPR/LBR and a sensitivity of 53.7% & specificity of 51.2% in predicting pregnancy. Also, serum E2 value more than 292 pg/ml at day 18 demonstrated an increase in OPR/LBR.In our study, the cut off value of LH level less than of 10.8 IU/L at day13 had a sensitivity of 58.3% & specificity of 50.4% in predicting pregnancy. Regarding pregnancy outcome, monitoring of LH levels didn’t generate useful data with no added prognostic value.Conclusion: Monitoring and follow-up of different hormones in patient’s serum in programmed frozen embryo transfer cycles didn’t have an impact on live birth, overall pregnancy & abortion rate when compared to ultrasound only in non-intervention group. Limitations, reasons for caution Patients in non-intervention group didn’t have a hormonal pre-transfer assessment so it’s not possible to determine if the progesterone levels are suboptimal or not when compared to intervention group. Also, we didn’t have a post transfer hormonal assessment in case group to determine whether the progesterone dose reached desired levels. Wider implications of the findings Kofinas et al. proposed in his study that in order to optimize pregnancy and rate, P4 levels in FET cycles should be sustained between 10 and 20 ng/ml. This was in accordance to our study where the cut off value of P4 on day of 11.83 ng/ml optimized pregnancy rates. Trial registration number NCT05189145

P-620 Hormone replacement therapy with GnRH agonist pretreatment improves pregnancy outcomes in patients with previous intrauterine adhesions

Abstract Study question Is there an optimal endometrial preparation protocol of frozen-thawed embryo transfer (FET) for patients with history of intrauterine adhesions (IUAs)? Summary answer Hormone replacement therapy with GnRH agonist pretreatment (HRT+GnRHa) is superior to conventional HRT protocol to improve pregnancy outcomes in patients with IUAs. What is known already FET follow hysteroscopic adhesiolysis or therapeutic treatment is being widely adopted in patients with IUAs. Proper endometrial preparation plays a key role to maximize IVF success rate and improve pregnancy results. However, it remains unclear whether there is an optimal endometrial preparation protocol for patients with history of IUAs. Study design, size, duration This was a retrospective cohort study of 1002 FET cycles with history IUAs in our fertility center between January 2015 to December 2020. The study was approved by the hospital's Ethics Committee. Participants/materials, setting, methods Eight hundred and forty-two conventional HRT cycles and 160 HRT+GnRHa cycles met the inclusion criteria were enrolled. Pregnancy outcomes were compared between the two groups. Logistic regression analysis was performed to adjust for important confounders. P < 0.05 was considered statistically significant. Main results and the role of chance The HRT+GnRHa group was associated with higher cycle rank (1.79 vs 2.17, P =0.026) and longer infertility duration (3.04 vs 3.69, P =0.000) compared with conventional HRT group. While the latter had a higher proportion of blastocyst embryo transferred (P =0.024). There were no statistically significant differences regarding the parental age at oocyte retrieval, body mass index (BMI), number of total embryos transferred and top embryo transferred, proportion of nulliparity, indication of IVF treatment and fertilization method, and endometrial thickness. Logistic regression indicated that after controlling for potential confounders, the HRT+GnRHa group achieved higher incidence of clinical pregnancy (aOR 1.474, 95% CI: 1.002-2.170, P =0.049), ongoing pregnancy (aOR 1.823, 95% CI: 1.207-2.753, P =0.004), and live birth (aOR 1.975, 95% CI: 1.306-2.988, P =0.000) than the conventional HRT group. The miscarriage rate was comparable between the two groups (aOR 0.613, 95% CI: 0.293-1.283, P =0.194). Our results suggested that HRT+GnRHa is over conventional HRT protocol to improve pregnancy outcomes of patients with previous IUAs. Limitations, reasons for caution The primary limitation of this study was its retrospective nature, and it was difficult to distinguish some confounding factors. Besides, there was no grading of IUA severity as most adhesion separation surgeries were not performed in our hospital, and the detailed medical history was not available. Wider implications of the findings Our study offers evidence for the superiority of HRT with GnRH-a pretreatment to conventional HRT protocol in improving the pregnancy prognosis of patients with previous IUAs. Our finding deserves further confirmation in clinical practice. Trial registration number 2018YFC1003900/2018YFC1003904, SZSM201502035

Endometriosis does not seem to be an influencing factor of hypertensive disorders of pregnancy in IVF / ICSI cycles

IntroductionTo evaluate whether the incidence of hypertensive disorders of pregnancy (HDP) in pregnant women was related to endometriosis (EM), ovulation and embryo vitrification technology.MethodsA retrospective cohort study was conducted on the clinical data of 3674 women who were treated with IVF / ICSI in the Reproductive Medicine Center of the First Affiliated Hospital of Sun Yat-sen University and maintained clinical pregnancy for more than 20 weeks. All pregnancies were followed up until the end of pregnancy. The follow-up consisted of recording the course of pregnancy, pregnancy complications, and basic situation of newborns.ResultsCompared with NC-FET without EM, HRT-FET without EM was found to have a higher incidence of HDP during pregnancy (2.7% V.S. 6.1%, P<0.001); however, no significant difference was found in the incidence of HDP between NC-FET and HRT-FET combined with EM (4.0% V.S. 5.7%, P>0.05). In total frozen-thawed embryo transfer (total-FET), the incidence of HDP in the HRT cycle without ovulation (HRT-FET) was observed to be higher than that in the NC cycle with ovulation (NC-FET) (2.8% V.S. 6.1%, P<0.001). In patients with EM, no significant difference was found in the incidence of HDP between fresh ET and NC-FET (1.2% V.S. 4.0%, P>0.05).ConclusionEM does not seem to have an effect on the occurrence of HDP in assisted reproductive technology. During the FET cycle, the formation of the corpus luteum may play a protective role in the occurrence and development of HDP. Potential damage to the embryo caused by cryopreservation seems to have no effect on the occurrence of HDP.

GnRH agonist treatment regulates IL-6 and IL-11 expression in endometrial stromal cells for patients with HRT regiment in frozen embryo transfer cycles

To evaluate the effect of gonadotropin-releasing hormone agonist (GnRHa) pretreatment time on clinical outcomes of patients who underwent endometrial preparation in HRT cycles and the molecular mechanism in frozen-thawed embryo transfer (FET) cycles, we retrospectively chose 1143 cycles and separated four groups. Endometrial tissues were collected from 44 patients who were cancelled on the day of embryo transfer (there were 10 patients refused to collect endometrium) and were tested for endometrial receptivity marker mRNA and miR-124-3p expression. Furthermore, endometrial stromal cells (ESCs) were transfected to investigate the molecular mechanism. The clinical pregnancy rate and live birth rate were significantly high in group B. The endometrial expression of the IL-6 and IL-11 mRNAs was significantly increased in groups with GnRHa pretreatment compared with group A without the GnRHa pretreatment. Similar results were obtained for the endometrial receptivity markers LIF and integrin αvβ3. The groups treated with GnRHa exhibited a progressive and significant time-dependent decrease in the IL-6 and IL-11 mRNA. In contrast, the levels of LIF and integrin αvβ3 expression remained unaltered among group B-D. In addition, transfection of ESCs with miR-124-3p mimics significantly reduced levels of the IL-6 and IL-11 mRNAs and proteins. The luciferase report assay demonstrated that IL-6 and IL-11 is a target gene of miR-124-3p. The results showed that ultra-long GnRHa administration can improve outcomes, especially after 3 cycles of GnRHa pretreatment, and endometrial receptivity through IL-6 and IL-11 expression levels of ESC regulated by the miR-124-3p for patients with HRT, who underwent FET cycles.

CLINICAL UTILITY OF THE NEW ENDOMETRIAL RECEPTIVITY TEST IN ADVANCED MATERNAL AGE PATIENTS WITH RECURRENT IMPLANTATION FAILURE

Although aneuploid embryos account for the major cause of implantation failure, especially in cases of advanced maternal age (AMA), several studies have investigated that even euploid blastocysts fail to implant in about 40% of transfers. Failure of an euploid embryo to implant may suggest the importance of the synchronization between an embryo and the window of implantation as another potential cause of recurrent implantation failure (RIF). In this study, we assessed whether the ERPeakSM endometrial receptivity test is clinically useful even for AMA patients with RIF. A retrospective review was performed for 480 RIF patients who had 3 or more failed embryo transfers and underwent ERPeakSM testing in two private fertility clinics between April 2019 and June 2020. We evaluated clinical outcomes of 306 RIF patients who underwent personalized embryo transfer (pET) in an HRT cycle with morphologically good quality embryos after ERPeakSM testing. A receptive (R) or nonreceptive (NR) endometrial status according to ERPeak SM testing and reproductive outcomes were compared for patients aged 38 years and over (AMA group) versus those under 38 years (non-AMA group). The statistical analysis was performed by using chi-square analysis or Mann-Whitney U test where appropriate with significance determined by a p=0.05. In AMA group (n=326, average age: 41.8±2.6 years, range: 38-51), ERPeakSM testing showed a NR result in 144 patients (44.2%) and a R result in 182 patients (55.8%). In the NRgroup, 66.7% (96/144) indicated a pre-receptive state and 33.3% (48/144) resulted in post-receptive state. In non-AMA group (n=154, average age: 34.0±2.7 years, range: 20-37), ERPeakSM testing showed a NR result in 65 patients (42.2%) and a R result in 89 patients (57.8%). In the NR group, 52.3% (34/65) indicated a pre-receptive state and 47.7% (31/65) resulted in post-receptive state. The rate of pre-receptive state in the AMA group was significantly higher than the non-AMA group (p<0.05). After pET with morphologically good quality embryos for NR patients, we found that the clinical pregnancy rate (CPR) and implantation rate (IR) were similar between NR and R patients (37.4% vs. 37.9% and 30.3% vs. 25.3%, respectively), which is consistent with previous studies of pET based on the ERA test. Among NR patients, pET for AMA group (n=73, average age: 41.0±1.9 years) and non-AMA group (n=50, average age: 34.4±3.2 years) showed similar CPR (34.2% vs. 42.0%, p=0.38), IR (27.4% vs. 31.3%, p=0.58), miscarriage rate (20.0% vs. 19.0%, p=0.94) and live birth rate (75.0% vs. 82.4%, p=0.59), respectively. Although maternal age did not influence the frequency of NR, a pre-receptive status detected by ERPeakSM was more frequently observed in AMA patients. pET after ERPeakSM testing may improve reproductive outcomes of AMA patients with RIF.

Endometrial delay is found to be part of a normal individual dynamic transformation process

PurposeLimited information is clinically available concerning endometrial receptivity; assessing endometrial transformation status is therefore an urgent topic in assisted reproductive technology. This study aimed to investigate individual endometrial transformation rates during the secretory phase in subfertile patients using personal endometrial transformation analysis.MethodsMonitoring was carried out during the secretory phase to obtain endometrial receptivity profiles. For the investigation, two endometrial biopsies were taken within one menstrual cycle. The extended endometrial dating was based on the Noyes criteria, combined with immunohistochemical analyses of hormone receptors and proliferation marker Ki-67. Biopsies were taken mainly at days ovulation (OV, n = 76)/hormone replacement therapy (HRT, n = 58) + 5 and + 10.ResultsThe results of the two biopsies were correlated with the clinically expected day of the cycle and showed temporal delays or hypercompensations, diverging from the expected cycle days by 0.5–5 days. In comparison with the first biopsies, the transformation rate in the second biopsies showed compensation, augmented delay, or constant transformation in 48.69, 22.37, and 28.94% of cases for ovulation in natural cycles and 56.89, 25.85, and 17.26% for HRT cycles, respectively.ConclusionThe study revealed an individually dynamic transformation process of the endometrium, with the ability to compensate or enlarge an initial “delay”, which is now identified as a normal individual transformation process during the secretory phase. This information is of great importance for the scientific investigation of dynamic changes in endometrial tissue, as well as for the timing of embryo transfers.

Comparison of Pregnancy and Neonatal Outcomes of Single Frozen Blastocyst Transfer Between Letrozole-Induction and HRT Cycles in Patients With Abnormal Ovulation.

BackgroundThe use of frozen embryo transfer (FET) cycles has dramatically risen. The optimal endometrial preparation method for women undergoing FET is of utmost importance to provide the optimal chances of pregnancy. For patients with abnormal ovulation in particular, there have been few studies on FET protocols; notably, most of these studies focus only on the clinical pregnancy rate or live birth rate (LBR) and pay little attention to the regimen’s safety for offspring.MethodsIt was a retrospective cohort study. First FET cycle with a single blastocyst from whole embryo frozen IVF/ICSI at the Reproductive Center of Third Affiliated Hospital of Zhengzhou University between January 2016 and January 2020. The LBR was the primary outcome of interest. The secondary outcome measures were miscarriage rate and offspring safety, including preterm birth, low birthweight (LBW), small-for-gestational age (SGA), macrosomia and large-for-gestational age (LGA).ResultsIn total, 2782 FET cycles met the eligibility criteria for analysis. Additionally, there were 1178 singleton births from FET cycles. The clinical pregnancy rate was 58.4% in the L-FET group and 54.5% in the HRT group, with no statistical significance (P=.116). The miscarriage rate was higher in the HRT group than in the L-FET group (21.7% vs. 14.3%, P=.005). The LBR was significantly higher in the L-FET group than in the HRT group (49.6% vs. 41.7%, P=.001). Neonatal outcomes were similar between the two groups. After adjustments for confounding factors, the LBR was higher in the L-FET group (aOR 1.30, 95% CI 1.06-1.58). The rate of miscarriage was lower in the L-FET group (aOR 0.63, 95% CI 0.44-0.90).ConclusionFor patients with abnormal ovulation, the L-FET regimen has a higher LBR and lower miscarriage rate than HRT. The neonatal outcomes were similar between the two groups.

Frozen-warmed blastocyst transfer after 6 or 7 days of progesterone administration: impact on live birth rate in hormone replacement therapy cycles

To study the difference in live birth rate (LBR) between frozen-warmed blastocyst transfer (FET) on the 6th or the 7th day of progesterone administration in artificially prepared cycles. Retrospective cohort study. Tertiary university-based referral hospital. Patients who underwent FET between December 2015 and December 2017 in a hormone replacement therapy cycle (HRT). Group A included all eligible patients who underwent transfer of a vitrified-warmed blastocyst on the 6th day of progesterone administration; group B included patients who underwent blastocyst transfer on the 7th day of progesterone. The artificial HRT protocol in this study consisted of estrogen administration at a dose of 2 mg twice daily for 7 days followed by 2 mg three times daily for 6 days and micronized vaginal progesterone 200 mg three times daily from an adequately considered endometrial thickness onward. Live birth rate. The study included 619 patients, 346 in group A and 273 in group B. The LBRs were comparable between both groups (36.6% for group A and group B), even after adjustment for confounding factors (adjusted odds ratio 1.073, 95% confidence interval 0.740-1.556). Subgroup analysis revealed significantly higher miscarriage rates for day 6 blastocysts transferred on the 6th day of progesterone supplementation compared with transfer on the 7th day of progesterone supplementation (50.0% versus 21.4%, respectively). Additionally, there was a tendency toward a higher LBR when the 7-day progesterone supplementation protocol was used for transfer of a day 6 blastocyst (21.5% and 35.5% for group A and group B, respectively). Warmed blastocyst transfer on the 6th compared with the 7th day of progesterone administration in an HRT cycle results in similar LBR. Subgroup analysis of day 6 blastocysts showed significantly higher miscarriage rates when FET was performed on the 6th day of progesterone administration.

Evidence from three cohort studies on the expression of MUC16 around the time of implantation suggests it is an inhibitor of implantation.

To examine the expression of MUC16 in the endometrium peri-implantation period in three different cohort studies. This was a retrospective observational cohort study. A total of 245 participants were recruited in three separate cohort studies: (1) women with recurrent miscarriage (n = 50) and fertile controls (n = 29); (2) women who had high (n = 20) or normal (n = 20) progesterone on the day of hCG trigger in ovarian stimulation cycle for IVF; and (3) women who did (n = 95) or did not (n = 31) conceive following frozen embryo transfer in HRT cycles. All subjects had archived endometrial samples precisely taken on LH+7 in natural cycles, or hCG+6 in ovarian stimulation cycles, or P+5 in HRT cycles. The H-score (median, range) of MUC16 in the luminal epithelium and glandular epithelium was determined by using immunohistochemistry. The median (range) of H-score of MUC16 in the luminal epithelium (1) in women with recurrent pregnancy loss was 23.7 (0-300), which was significantly (P < 0.05) lower than that of 118.4 (7.7-300) in fertile controls; (2) in women with elevated progesterone on the day of hCG administration (147.8, 18.0-230.1), significantly (P < 0.05) higher than that of women with normal progesterone (61.0, 2.3-205.3); (3) in women who conceived (23.1, 0-250.3), significantly (P < 0.001) lower than that in women who did not conceive (58.4, 0-300). The expression of MUC16 in all three cohort studies is consistent with it being an inhibitor of implantation.

To study the effect of autologous platelet-rich plasma instillation on suboptimal endometrium and pregnancy outcomes in infertile women undergoing frozen embryo transfer cycle

Introduction:This pilot study was done to evaluate the effectiveness of intrauterineinstillation of autologous platelet rich plasma in the treatment of infertile woman with ≥2 IVF failures due to thin endometrium not responding to empirical medical therapies. Design: Prospective interventional study. Material and Methods: Intra uterine instillation of PRP was done in 50 women between 23 to 38 years with suboptimal endometrial receptivity, ≥ 2 IVF failures and HRT cycle cancellations over a course of 9 months. Frozen embryo transfer was done when optimal endometrial thickness and vascularity was achieved. Results: The mean endometrial thickness pre PRP was 5.78mm which increased to 7.20mm post-PRP (P value

Does dysbiotic endometrium affect blastocyst implantation in IVF patients?

PurposeTo analyze the pregnancy outcomes of IVF patients presenting eubiotic or dysbiotic endometrium at the time of embryo transfer and to analyze what bacterial profiles are suitable for embryo implantation.MethodsNinety-nine IVF patients under 40 years old undergoing vitrified-warmed blastocyst transfer in HRT cycle had concurrent endometrial microbiome analysis. Samples from the endometrium were taken from the participants at the time of mock transfer; the bacterial profiles at genus level and percentage of lactobacilli in the endometrium of the patients were analyzed.ResultsThirty-one cases (31.3%) had dysbiotic endometrium. The background profiles, pregnancy rates per transfer (52.9% vs 54.8%), and miscarriage rates (11.1% vs 5.9%) were comparable between patients with eubiotic or dysbiotic endometrium. Major bacterial genera other than Lactobacillus detected in the dysbiotic endometrium were Atopobium, Gardnerella, and Streptococcus. Some patients achieved ongoing pregnancies with 0% Lactobacillus in the endometrium. The endometrial bacterial profiles of pregnant cases with dysbiotic endometrium were comparable with those of non-pregnant cases.ConclusionAnalyzing microbiota at the species-level resolution may be necessary for identifying the true pathogenic bacteria of the endometrium and avoiding over-intervention against non-Lactobacillus microbiota. Further studies are necessary for analyzing the mechanism of how the pathogenic bacteria affect embryo implantation.

A non -receptive ERA test result in an HRT cycle may not be replicable in a natural cycle: A case report

A non -receptive ERA test result in an HRT cycle may not be replicable in a natural cycle: A case report

Progesterone levels on pregnancy test day after hormone replacement therapy-cryopreserved embryo transfer cycles and related reproductive outcomes.

Do serum progesterone levels determine ongoing pregnancy rates (OPR) in hormone replacement therapy frozen-thawed embryo transfer (HRT-FET) cycles? A cohort study of 244 HRT-FET cycles from a Danish public fertility centre. Data from patients undergoing HRT-FET from January 2016 to December 2017 were extracted from a clinical database. All patients had transfer in HRT cycles of autologous embryos frozen on day 5 or 6. Endometrial preparation was performed using 6 mg oestradiol valerate daily from the second day of the cycle followed by vaginal micronized progesterone (90 mg/8 h). All patients had serum progesterone measurement during the artificial luteal phase. The optimal cut-off for ongoing pregnancy was 35 nmol/l based on sensitivity analysis of different progesterone levels as a factor variable and its association with ongoing pregnancy. No significant differences regarding number of embryos transferred, embryo quality, age, body mass index (BMI) or smoking were found in the two groups of progesterone < 35 nmol/l and ≥ 35 nmol/l, respectively. A total of 51% of patients had a serum progesterone < 35 nmol/l. The range of all measurements was 0.3 to 110 nmol/l. The unadjusted OPR was significantly lower in the < 35 nmol/l group compared with the ≥ 35 nmol/l group (38% versus 51%;P = 0.04). A logistic regression analysis, adjusting for smoking, age, BMI, number of embryos transferred and blastocyst age showed a significant decrease in OPR when progesterone was < 35 nmol/l of 44% (95% confidence interval [CI] 35-54%) compared with ≥ 35 nmol/l of 58% (95% CI 48-68%), risk difference of 14% (95% CI 2-26%,P = 0.02). Serum progesterone levels < 35 nmol/l decrease the chance of OPR in HRT-FET cycles.

Identifying a possible factor for the increased newborn size in singleton pregnancies after assisted reproductive technology using cryopreserved embryos, in comparison with fresh embryos.

PurposeTo determine whether the cycle regimens that are used for endometrial preparation are associated with the birthweight (BW) after assisted reproductive technology (ART) using frozen‐thawed embryo transfer (FET).MethodsThe BW of singletons who were born by ART using FET was compared retrospectively, according to whether a FET was conducted in a hormone replacement therapy cycle (HRT, n = 403) or an ovulatory cycle (OVL, n = 117). The BW after timed intercourse (NAT, n = 162) also was investigated.ResultsThere were no significant differences in the age of the mothers, percentage of primiparas, gestational periods, Body Mass Index, and sex ratio between the HRT and OVL cycles. The average BW from HRT was significantly greater than that of OVL. The BW from HRT was also greater, compared with NAT, while statistical significance was not achieved between OVL and NAT. The putative factors affecting the BW, such as ovarian stimulation protocols, endometrial thickness, and the stage and quality of embryos, could not explain the difference in the BW between the HRT and OVL cycles.ConclusionAn increased BW from ART using FET seems to be ascribable to conditions of the endometrium, but not cryopreservation procedures per se, which might provide a mechanistic framework for understanding heavier neonates who are born by FET.

Pinopode score around the time of implantation is predictive of successful implantation following frozen embryo transfer in hormone replacement cycles

Is pinopode measurement of any prognostic value? Pinopode expression was significantly associated with the occurrence of pregnancy after frozen embryo transfer. Pinopodes are expressed in the endometrium during the implantation period. Pinopode measurement has been proposed as a marker of endometrial receptivity. A prospective cohort study was conducted at the Center of Reproductive Medicine, Sir Run Run Shaw Hospital, between 2014 and 2016, recruiting 172 women with infertility and undergoing frozen embryo transfer following IVF treatment. Among 172 participants, 46 women took part in the first study to quantify the daily changing pattern of pinopodes 3-7 days after the initiation of progesterone therapy in the hormone replacement cycles and the remaining 126 women with infertility participated in a study to examine the relationship between pinopode count and pregnancy outcome following frozen embryo transfer in hormone replacement cycles. The mean age of participants was 29 years old. All participants received an artificial hormone replacement protocol capable of supporting successful implantation. Endometrial biopsies from 46 women were obtained 3, 4, 5, 6 and 7 days after the initiation of progesterone therapy (P + 3, n = 6; P + 4, n = 6; P + 5, n = 11; P + 6, n = 13; P + 7, n = 10, respectively). Another 126 endometrial biopsies were obtained precisely 6 days after the initiation of progesterone. Scanning electron microscopy was used to capture the pinopode images, followed by use of the image J program to quantify the count and subtype of the pinopodes. We found that at least 60 microscopic fields were necessary to achieve a reproducible result. An intra-observer variability study showed good agreement between two measurements regarding the developing pinopode (DP) subtype (r = 0.95) and the fully developed pinopode (FDP) subtype (r = 0.86) but not for the regressing (RP) pinopode subtype (r = 0.39). The proportion of DP/total pinopodes (TP) declined rapidly form day P + 4 to a minimum on day P + 6. The percentage of FDP/TP increased rapidly from day P + 4 to reach a peak on day P + 6. On the other hand, the percentage of RP/TP reached a peak on day P + 7. Participants who conceived had a significantly (P = 0.011) higher percentage of FDP/TP on day P + 6 and significantly (P = 0.005) lower percentage of DP/TP on the same day compared with participants who did not become pregnant. Using a scoring system incorporating the percentages of DP and FDP, it was found that the pregnancy rate and the embryo implantation rate of women with a high pinopode score (82.3%; 63.0%) was significantly (P = 0.001; P = 0.046) higher than that of women with a low pinopode score (53.3%; 46.7%), respectively. There remains a possibility that the observations could have arisen due to chance. This study examined pinopode count and subtype in the HRT cycles, and it is uncertain whether the same observations apply to in natural cycles. Pinopodes have been questioned as a potential marker of endometrial receptivity for many years. Our results suggested that pinopode measurement may be of value in predicting pregnancy. The study was supported by the grants from the general project of medicine and health in Zhejiang Province of China (2015KYA142; 2018KY106), the Key Research and Development Program of Zhejiang Province (2017C03022) and the National Natural Science Foundation of China (81701514).The funders had no role in the study design, data collection and analysis, decision to publish or preparation of the manuscript. We have no competing interests to declare. ISRCTN26300668.

Frozen embryo transfer: a review on the optimal endometrial preparation and timing.

What is the optimal endometrial preparation protocol for a frozen embryo transfer (FET)? Although the optimal endometrial preparation protocol for FET needs further research and is yet to be determined, we propose a standardized timing strategy based on the current available evidence which could assist in the harmonization and comparability of clinic practice and future trials. Amid a continuous increase in the number of FET cycles, determining the optimal endometrial preparation protocol has become paramount to maximize ART success. In current daily practice, different FET preparation methods and timing strategies are used. This is a review of the current literature on FET preparation methods, with special attention to the timing of the embryo transfer. Literature on the topic was retrieved in PubMed and references from relevant articles were investigated until June 2017. The number of high quality randomized controlled trials (RCTs) is scarce and, hence, the evidence for the best protocol for FET is poor. Future research should compare both the pregnancy and neonatal outcomes between HRT and true natural cycle (NC) FET. In terms of embryo transfer timing, we propose to start progesterone intake on the theoretical day of oocyte retrieval in HRT and to perform blastocyst transfer at hCG + 7 or LH + 6 in modified or true NC, respectively. As only a few high quality RCTs on the optimal preparation for FET are available in the existing literature, no definitive conclusion for benefit of one protocol over the other can be drawn so far. Caution when using HRT for FET is warranted since the rate of early pregnancy loss is alarmingly high in some reports. S.M. is funded by the Research Fund of Flanders (FWO). H.T. and C.B. report grants from Merck, Goodlife, Besins and Abbott during the conduct of the study. Not applicable.

Long‐term effects of maternal separation on the responsiveness of the circadian system to melatonin in the diurnal nonhuman primate (Macaca mulatta)

Depression is often linked to early-life adversity and circadian disturbances. Here, we assessed the long-term impact of early-life adversity, particularly preweaning mother-infant separation, on the circadian system's responsiveness to a time giver or synchronizer (Zeitgeber). Mother-reared (MR) and peer-reared (PR) rhesus monkeys were subjected to chronic jet-lag, a forced desynchrony protocol of 22 hr T-cycles [11:11 hr light:dark (LD) cycles] to destabilize the central circadian organization. MR and PR monkeys subjected to the T-cycles showed split locomotor activity rhythms with periods of ~22 hr (entrained) and ~24 hr (free-running), simultaneously. Continuous melatonin treatment in the drinking water (20 μg/mL) gradually increased the amplitude of the entrained rhythm at the expense of the free-running rhythm, reaching complete entrainment by 1 wk. Upon release into constant dim light, a rearing effect on anticipation for both the predicted light onset and food presentation was observed. In MR monkeys, melatonin did not affect the amplitude of anticipatory behavior. Interestingly, however, PR macaques showed light onset and food anticipatory activities in response to melatonin treatment. These results demonstrate for the first time a rearing-dependent effect of maternal separation in macaques, imprinting long-term plastic changes on the circadian system well into late adulthood. These effects could be counteracted by the synchronizer molecule melatonin. We conclude that the melatonergic system is targeted by early-life adversity of maternal separation and that melatonin supplementation ameliorates the negative impact of stress on the circadian system.

Higher ongoing pregnancy rates in blastocyst transfer of frozen-thawed embryos in natural cycles than in hormone replacement therapy cycles

The aim of this study was to compare the outcome obtained from frozen-thawed embryo transfer in women submitted to two different protocols: natural cycle vs. HRT cycles. Retrospective study. This study comprised cryopreserved-thawed embryo transfer cycles performed at IVI Valencia from January 2000 to January 2006. Data were grouped in: Group I (n = 423) had frozen-thawed embryo transfer in a natural cycle and Group II (n = 707) frozen-thawed embryo transfer in a HRT cycle. The inclusion criteria were: (1) absence of uterine pathology, recurrent miscarriage and implantation failure; (2) non-severe sperm pathology; (3) endometrial thickness >6 mm at the day of the start of progesterone administration. The implantation, pregnancy and abortion rates of cryopreserved-thawed embryo were compared between the groups. We also analyzed these parameters depending on the day of the embryo transfer. Statistical analysis was performed by X2- test for categorical comparisons and Student's t-test to compare means between groups. A P value < 0.05 was considered significant. No differences were found in implantation and pregnancy rates between cryopreserved-thawed embryo in natural vs. HRT cycles (24%, IC 95% 20.3–28.3% vs. 22%, IC 95% 18.6%–26.1%) respectively. Pregnancy rate was 37.1%, IC 95% 32.5–41.7% vs. 39.7%, IC 95% 36.1–43.3) respectively. To evaluate if the stage of the embryo development may have some impact in the outcome, we compared 730 women (293 natural cycles vs. 437 HRT cycles) that were transferred at day 3 with 400 women (130 natural cycles vs. 270 HRT cycles) that were transferred at blastocyst stage. Pregnancy rate for cryopreserved embryo was 40% (IC 95% 34.4–45.6%) in a natural cycle and 45% (IC 95% 40.3–49.7%) in a HRT cycle. If cryopreserved blastocyst were transferred, pregnancy rate was 30% (IC 95% 22.1–37.9%) in a natural cycle and 38.5% (IC 95% 32.1–43.7%) in a HRT cycle, and no significant difference was found between both groups. However, abortion rate was 24% (39/157, IC 95% 17.3–30.7%) in women who had embryo transfer in a natural cycle and 39.4% (110/281; IC 95% 33.7–45.1%) in HRT. There were significant differences between the two groups with regard to the abortion rate (P<0.002). These findings suggest that both cryopreserved-thawed embryo transfer protocols are equally effective in terms of implantation and pregnancy rates. However, this is the first study that shows a significant difference regarding the abortion rate.

Effects of hormone replacement therapy on plasma pro-inflammatory and anti-inflammatory cytokines and some bone turnover markers in postmenopausal women

Objective The present study was undertaken to evaluate plasma TNFα, IL-1β, IL-10; and urinary hydroxyproline (Hyp) and calcium (Ca) as bone resorption markers in postmenopausal women compared with premenopausal ones; and to assess the effects of HRT upon these cytokines and bone turnover markers. Patients and methods The study involved 50 healthy postmenopausal women, and 25 healthy premenopausal women (control group). Postmenopausal women were randomly divided into two subgroups: women receiving cycle HRT schedule (0.625 mg conjugated estrogen from days 1 to 28 + 5 mg medroxyprogesterone acetate from days 18 to 28) for 2 months ( n = 25); and second subgroup consisted of women receiving continue HRT schedule (0.625 mg conjugated estrogen + 2.5 mg medroxyprogesterone acetate from days 1 to 28) for 2 months ( n = 25). Plasma TNFα, IL-1β and IL-10 concentrations were measured with ELISA kits. Fasting urinary Hyp was measured by Ehrlich's spectrophotometric reaction. Ca was determined by oxalate precipitation and the redox titration procedure. Statistical significance was analysed by Kruskal–Wallis plus post hoc Mann–Whitney U-tests for multiple comparisons, Wilcoxon signed ranks test for paired data, and Pearson correlation test. Results Compared with premenopausal individuals, postmenopausal women have increased plasma TNFα, IL-1β, IL-10 ( p < 0.0001, p < 0.0001, and p < 0.001, respectively); and increased urinary Hyp and Ca concentrations ( p < 0.05). HRT (both cycle and continue schedules) lead to a significant decrease in TNFα, IL-1β and urinary Hyp concentrations, and has no effect uppon IL-10 levels. HRT reverses increased urinary Hyp and Ca excretion to the premenopausal level. There is a significant positive correlation between pre- and post-HRT IL-1β levels in both cycle and continue subgroups ( r = 0.437, p < 0.05; and r = 0.656, p < 0.01, respectively), and between pre-HRT IL-1β and urinary Ca ( r = 0.509, p < 0.01; and r = 0.415, p < 0.05). There is a significant negative correlation between post-HRT IL-10 and TNFα levels in continue HRT receiving group ( r = −0.446, p < 0.05). Urinary Hyp in cycle and continue HRT received subgroups are correlated with post-treatment values ( r = 0.455, p < 0.05; and r = 0.776, p < 0.01). Conclusions Plasma TNFα, IL-1β, IL-10; and urinary Hyp and Ca increase with menopause. We suggest that the increase of IL-10 is secondary to the elevation of TNFα and IL-1β and that the increase of IL-10 is a compensatory mechanism, by which this anti-inflammatory cytokine counteracts to pro-inflammatory TNFα and IL-1β, and thus balances their osteoclast activating and oxidative stress-related effects. Two months duration HRT (cycle and continue schedule) lead to the significant decrease in plasma TNFα, IL-1β and urinary Hyp concentrations. HRT reverses increased Hyp and Ca excretion to the premenopausal level. So, HRT, decreasing Th1 cytokines (TNFα, IL-1β) probably improve the aberation of Th1/Th2 balance that is implicated in various pathological conditions. However, because of the relatively small number of participants and short duration of the therapy, further studies are necessary to establish a risk/benefit ratio for HRT to view effects on cytokine pattern and bone metabolism.