Mid-luteal Progesterone Levels Research Articles

P-416 Good and bad news regarding low luteal-phase progesterone during natural cycle frozen embryo transfer: it’s rare, but rescue-therapy may not be enough to fix it

Abstract Study question Do low circulating luteal-phase progesterone levels during natural cycle frozen embryo transfer (NC-FET) affect live birth rates (LBR) and can rescue-therapy advert possible detrimental outcomes? Summary answer Low luteal-phase progesterone occurred in only approximately 3% of all FETs. However, when it occurred, LBR were lower despite the use of additional rescue-strategy. What is known already Low serum progesterone on the day of FET is known to be associated with a reduction in pregnancy rates and rescue-therapy (i.e. the increase and/or change in the route of administration of exogenous progesterone) has been shown to be useful in reducing its potential hindering effects. However, these findings are mostly limited to studies assessing artificial FET cycles. Following NC-FET, the data is not only scarce but also less clear regarding both the incidence of such low circulating levels and whether rescue-therapy may be useful in such cases or not. Study design, size, duration A total of 2292 patients (32.5% did an IVF with egg donation and 10,4% did an IVF with PGT-a) who underwent a NC-FET at blastocyst stage in a single infertility center between 2014 and 2021 were included in this retrospective cohort study. The cycles were subdivided into three groups of progesterone levels the day of FET: <10ng/ml, 10-20ng/ml and >20ng/ml. The primary outcome was LBR, with secondary outcomes including miscarriage and neonatal outcomes. Participants/materials, setting, methods Patients underwent endometrial preparation in either a true, modified or natural proliferative phase (NPP) NC-FET. Luteal-phase support was routinely provided using micronized vaginal progesterone. Rescue intramuscular progesterone was systematically administered whenever low midluteal progesterone (below 1 standard deviation of the center’s mean) levels were detected. Maternal age and body mass index (BMI), year of treatment, ovarian response, endometrial thickness, cause of infertility and embryo quality were controlled by means of a multivariable logistic regression. Main results and the role of chance The mean age (± standard deviation) of patients was 38.3±4.5 years, while mean weight and BMI were 62.6±10.7 kg and 23.3±3.7kg/m2, respectively. Only 72 (3.1%) cycles had FET day circulating progesterone below 10 ng/mL, while 1084 (47.3%) and 1136 (49.6%) had 10-20 ng/mL and >20 ng/mL, respectively. The unadjusted LBRs in the subgroup with progesterone <10ng/ml, 10-20ng/ml and >20ng/ml were, respectively, 43.5%, 52.7% and 49.6%, differences that were not statistically significant in this non-adjusted analysis (p = 0.151). However, following confounder adjustment using multivariable logistic regression, progesterone <10ng/ml was associated with a lower LBR (adjusted odds-ratio 0.568; 95% confidence interval 0.330-0.977), a finding that occurred despite the aforementioned use of rescue progesterone therapy in this subgroup. The miscarriage rate, in the <10ng/ml subgroup was higher (26.1%), but without statistically significance, comparing to other subgroups (19% and 20.5% respectively). Limitations, reasons for caution This study is limited by its retrospective design. Moreover, as different NC-FET protocols were included, further research should be performed to assess whether this effects differs according to each protocol. Also the number of embryos transfered varied also affecting the final conclusion. Wider implications of the findings This study raises the hypothesis that low midluteal progesterone may be rare in NC-FETs. However, to our knowledge, it is also the first to posit that rescue-therapy may be insufficient to restore adequate endometrial function. Further research should assess eventual pathophysiological differences between artificial and NCs to justify such findings. Trial registration number not applicable

P-692 Intra-subject variability of mid-luteal progesterone levels in natural/modified natural frozen embryo transfer cycles (NC/MNC): can we predict the need for luteal phase support?

Abstract Study question Are progesterone levels different in a NC versus a MNC? What is the predictive value of progesterone for the level in a next cycle? Summary answer Progesterone levels were not different in the mid-luteal phase of natural or modified natural cycles and only moderately agree with progesterone in a subsequent cycle. What is known already Progesterone is essential for successful implantation and pregnancy. Classical studies have shown considerable variability in progesterone levels during the luteal phase. More recently, progesterone levels during the mid-luteal phase have regained interest, in order to improve chances of pregnancy in frozen embryo transfer cycles. Several studies have suggested that if progesterone on the day of embryo transfer are below a certain cut off level, progesterone production would not be sufficient and luteal support should be provided. Study design, size, duration This was a prospective observational study at a tertiary fertility centre in Belgium, performed between January 2022 until March 2023. Serum progesterone on the day of frozen embryo transfer was measured in all patients undergoing frozen embryo transfer in a natural (NC) or modified natural cycle (MNC). Patients were eligible for the current study if at least two progesterone levels in two frozen embryo transfer cycles were available. Participants/materials, setting, methods A linear mixed model was used to calculate systematic differences in progesterone levels between NC and MNC. The intra-subject agreement was quantified by means of the intra-class correlation coefficient (ICC) with 95% confidence interval. The ICC ranges between 0 and 1, with high values (> 0.75) indicating a good to excellent level of agreement between measurements taken in the same subject. Progesterone levels were measured with COBAS Elecsys ECLIA progesteron assay by Roche Diagnostics. Main results and the role of chance All women were between 18 and 40 years of age. Forty patients with at least two frozen embryo transfers in NC and in MNC were included, i.e. 87 cycles. Their mean age was 32 (26-42) years, the mean BMI was 23.1 (16.9-34.5) kg/m2. Mean progesterone levels on the day of transfer were 13.0 ng/ml (11.0-15.0) in NC and 13.8 ng/ml (12.0-15.6) in MNC. These levels were not systematically different (P = 0.47). The intra-subject agreement showed an ICC of 0.66 in NC and 0.61 in MNC. Hence, our data indicate that progesterone levels in the mid-luteal phase of a NC are similar to those in a MNC. However, progesterone levels in one cycle only moderately agree with those in a next cycle. Limitations, reasons for caution Our data were obtained from women who had at least two frozen embryo transfer cycles and therefore may include progesterone levels different from those in good prognosis patients who got pregnant after a fresh embryo transfer or after a first frozen embryo. Wider implications of the findings Our data indicate that the moderate agreement of progesterone between cycles would imply assessment of progesterone in each cycle. In daily clinical practice, luteal phase support should be considered once a single progesterone measurement is below earlier described cut off levels predictive of ongoing pregnancy after frozen embryo transfer. Trial registration number not applicable

Relationship between Serum 25-Hydroxyvitamin D Levels and Hormonal Status in Infertile Women: A Retrospective Study.

(1) Background: Infertility is a prevalent issue that affects 10-18% of couples worldwide, and up to 30% in Eastern Europe. Infertility of unknown etiology is one of the most challenging forms of infertility. Vitamin D has recently been extensively studied and researchers are investigating its possible role in ovulation and pregnancy. While the evidence suggests a positive association between vitamin D and ovulation, more research is needed to understand the role that vitamin D plays in ovulation. (2) Methods: In this study, 86 infertile patients were studied retrospectively in a single center by analyzing their anthropometric (body mass index), biochemical (total cholesterol, insulin resistance) and hormonal data in correlation with their vitamin D status. (3) Results: It was found that the mid-luteal progesterone level was significantly related to the 25-hydroxy vitamin D level in a multivariate linear regression model. An analysis of subgroups of ovulatory and anovulatory patients suggests that serum 25-hydroxy vitamin D levels of approximately 20 ng/mL may be necessary to trigger ovulation or to support progesterone secretion. (4) Conclusions: Vitamin D deficiency should be considered when infertility of unknown etiology and progesterone-related disorders occur.

Does mid-luteal progesterone predict pregnancy in intrauterine insemination cycles following sequential clomiphene citrate and gonadotropin treatment?

This study aimed to determine whether serum mid-luteal progesterone (MLP) levels measured in the current treatment cycles of infertile women undergoing controlled ovarian hyperstimulation and intrauterine insemination following the sequential use of clomiphene citrate and gonadotropin may predict pregnancy. A total of 107 consecutive anovulatory women were included in this prospective cohort study. Patients with other causes of infertility were also excluded from the study. None of the patients received progesterone treatment for luteal phase support. The data recorded for each woman included age, body mass index, infertility type and duration, basal hormone levels, and previous and current cycle characteristics with MLP levels. Ovulation was confirmed using MLP and sonographic evaluation in all patients. An MLP level of > 3 ng/mL was regarded as a sign of ovulation. After treatment, the patients were divided into 2 groups according to the presence or absence of pregnancy, and the obtained data were compared between the groups. There were no significant differences in age, body mass index, or basal hormone levels between the 2 groups (all P > .05). However, the duration of infertility was significantly shorter in the pregnancy group (P = .003). The anovulation rate in this cohort was 18.7% (n = 20). A total of 15 (14%) were examined. MLP levels were 25.1 ± 13.8 ng/mL and 18.3 ± 14.5 ng/mL in the pregnant and nonpregnant groups, respectively (P:.089). Based on the receiver operating characteristic curve analysis, it was determined that there was no predictive value of the mid-luteal phase progesterone level for pregnancy in patients in whom ovulation was detected. Mid-luteal serum progesterone levels did not predict pregnancy in infertile women who underwent controlled ovarian hyperstimulation with sequential clomiphene citrate plus gonadotropin treatment and intrauterine insemination.

P-500 Relationship of midluteal serum progesterone levels and pregnancy outcomes after day-3 embryo-transfer(ET) in hormonal replacement therapy (HRT) cycles with intramuscular progesterone: a prospective cohort study

Abstract Study question Does midluteal(day-9 of progesterone) serum progesterone level in HRT cycles with intramuscular progesterone affect the clinical pregnancy rate (CPR)/early miscarriage rate(MR) and live birth rate(LBR)? Summary answer Midluteal serum progesterone between 32.2-43.7ng/ml results in significantly greater CPR versus that with lower/higher levels and significantly greater LBR compared to that with lower levels. What is known already Evidence points to low serum progesterone levels at the time of FET being associated with lower ongoing pregnancy rates. Recently, the relation of midluteal serum progesterone levels in HRT cycles with vaginal progesterone as luteal phase support (LPS) has been elaborated indicating better pregnancy outcomes with an optimum range of serum progesterone/higher levels. There is no data establishing the association of pregnancy outcomes with midluteal serum progesterone levels when intramuscular progesterone is used as LPS in HRT cycles. Study design, size, duration A prospective cohort study conducted between December 2019-March 2022 at a tertiary centre with 196 patients(204 cycles), both-autologus(AO)-56.3% and donor oocytes(DO)- 43.6%: fresh ET-16.6% and frozen ET(FET)-83.3% with similar ICSI, vitrification and ET protocols(2/3 Grade A day-3 embryos). CPR, early MR (≤13 weeks miscarriage/clinical pregnancy) and LBR (≥28 weeks, LBs/ETs) were compared. Serum progesterone was measured on the morning of day-5 post-ET(day 9th from the start of progesterone). Most patients delivered at the same institute. Participants/materials, setting, methods Patients were non-smokers with normal hysteroscopy. Oral estradiol 6-8mg was initiated from Day 1-2 (for 10-17 days). When ET ≥ 7mm and serum progesterone <1ng/ml, intramuscular progesterone 100mg/day was started (daily till day-4 post-ET, then every 3rd day till week 8). Vaginal progesterone gel was added from day 5 post-ET till week 10. Serum progesterone levels were categorized in tertiles. Chi-square, t-tests and multiple regression analysis was used for statistical analysis. Two-tailed P<.05 indicated statistical significance. Main results and the role of chance Mean age was 34.76±5.36 years with a mean BMI 26.4±4.38kg/m2 Overall, CPR was 106/204(51.9%), LBR 78/204(38.2%) and early MR 28/106(26.4%) Midluteal serum progesterone levels ranged from 11.1-261ng/ml and were divided into tertiles(T) T1<32.0ng/ml(n = 68),T2 32.2-43.7ng/ml(n = 68),T3 >43.7ng/ml (n = 68) Median progesterone levels of T1,T2,T3 were 27.7ng/ml(Interquartile range [IQR] 7.0), 38.4ng/ml (IQR 5.0) and 51.2ng/ml (IQR 12.6) respectively. Mean age and mean BMI was not significantly different across the tertiles P=.27, P=.20 respectively CPR was significantly different across T1 32/68(47%),T2 45/68(66.1%)and T3 29/68(42.6%) P=.014. CPR was significantly more in T2 versus T1 and T3, (OR:2.2, 95%CI:1.1-4.4 P =.02) and (OR:2.6,95%CI:1.3-5.3, P=.006), respectively. T3 versus T1, P =.60 LBR was also significantly different across the tertiles [T1 20/68(29.4%), T2 34/68(50%),T3 24/68(35.3%) P=.03] LBR in T2 was significantly more than in T1(OR: 2.4,95% CI:1.2-4.9, P=.02). There was no significant difference betweenT3 versus T1 and T2 versus T3, P=.46, P=.08, respectively. Early MR wasn’t significantly different across T1 12/32(37.5%), T2 11/45(24.4%) and T3 5/29(17.2%), P=.18 Serum progesterone levels were not significantly affected by age r = 0.0257, P=.71 or BMI r = 0.0097, P=.89 Multivariate logistic regression showed that age affected CPR after adjusting for BMI, midluteal serum progesterone levels, origin of oocytes, fresh ET/FET(AOR 0.92: 95% CI:0.86-0.98, P=.01). Limitations, reasons for caution This is a single centre study with limited sample size. Including the measurement of serum progesterone at the time of ET would have given a better perspective of the patient specific behavior of progesterone as LPS. Larger studies with different LPS protocols are needed to validate the results. Wider implications of the findings In HRT cycles with intramuscular progesterone, an optimum midluteal serum progesterone level is related to better pregnancy outcomes. Factors causing the wide variation of progesterone levels need to be evaluated so as to individualize the dose. Identifying the appropriate time frame for optimising the midluteal progesterone levels should be explored. Trial registration number not applicable

P-490 Impact of follicular phase characteristics on mid-luteal progesterone and ongoing pregnancy rates: Lessons learned from true natural cycle frozen embryo transfer

Abstract Study question Is there an association between follicular phase endocrine and ultrasonographic characteristics and ongoing pregnancy rates (OPRs) in true-natural cycle (t-NC) frozen embryo transfers (FETs)? Summary answer Endometrial thickness one day before ovulation is the only independent predictor of ongoing pregnancy (OP) in t-NC FET cycles. What is known already In ovulatory women, NC FET is currently being proposed instead of the hormonal replacement treatment (HRT) protocol since HRT is associated with increased maternal and obstetric risk factors, most probably due to the absence of a corpus luteum. However, the presence of ovulation in regularly cycling women does not guarantee a receptive endometrium. Currently, there is a lack of data regarding the impact of follicular phase endocrine and ultrasonographic parameters on mid-luteal progesterone (P4) levels and OPRs in t-NC FET cycles. Study design, size, duration A cohort study of 229 women who underwent warmed blastocyst transfer employing t-NC. Three strategies were adopted. During January 2017-June 2017, serum P4 was not monitored. During July 2017-June 2020, serum P4 was routinely monitored on the FET-1 day. During July 2020-August 2022, a rescue strategy with daily 25-mg subcutaneous progesterone was adopted for patients with P4 levels between 7-10 ng/mL. In patients with serum P4<7 ng/mL FET was cancelled. Participants/materials, setting, methods Staying in-town and having regular menstrual cycles, permitting intensive endocrine and ultrasonographic monitoring (daily serum estradiol [E2], luteinizing hormone [LH], P4, and transvaginal ultrasonography), starting mid-cycle until confirmation of ovulation was the only inclusion criteria. Only the first FET cycle per patient was included. The primary outcome measure was OPR. The impact of follicular phase endocrine and ultrasonographic parameters on serum P4 levels on the FET-1 day and OPRs were evaluated using regression analysis. Main results and the role of chance Follicular phase parameters, including follicular phase length, late follicular phase E2, LH, P4 levels, and maximal follicle diameter before ovulation, were not significant predictors of ongoing pregnancy (OP) in t-NC FET. In contrast, the endometrial thickness one day prior to ovulation was a significant independent predictor of OP (adjusted OR = 1.29, 95% CI:1.06-1.56). When endometrial thickness before ovulation was assessed in quartiles, univariate OPRs in the 25th (<9.1 mm), 25-50th (9.1-10.1mm), 51-75th (10.2-11.6 mm) and >75th (>11.6 mm) percentiles were 43.3%, 47.3%, 71.7%, and 54.7%, respectively (p=0.016). Following logistic regression analysis, the adjusted ORs for OPR of the 51-75th (3.69, 95% CI:1.42-9.56) and >75th (2.86, 95% CI: 1.06-7.73) percentiles were significantly higher when compared with that of < 25th. The three strategies for monitoring/acting (rescue if needed) based on serum P4 levels on the FET-1 day were associated with similar adjusted ORs for OP. Notably, cancellation of cycles with serum P4 <7 ng/mL and adopting a rescue policy for those with 7-10 ng/mL did not increase OPRs. After multivariate linear regression analysis, late follicular E2 levels (ß-coefficient: 0.399 ng/mL, 95% CI:0.007;0.021) and BMI (ß-coefficient: −0.292 ng/mL, 95% CI: −0.730;-0.222) were the only significant predictors of P4 levels on the FET-1 day. Limitations, reasons for caution Limitations include the cohort study design evaluating three different policies, the single point serum P4 assessment, and adopting an arbitrary lower cut-off of < 7 ng/mL for cycle cancellation and 7-10 ng/mL for a rescue strategy. Wider implications of the findings Endometrial thickness one day before ovulation was the only significant predictor of OP in t-NC FET cycles. Apart from endometrial thickness, none of the follicular phase parameters were significant predictors of OP. Single-point assessment of serum P4 may not be reliable when assessing reproductive outcomes in t-NC FET. Trial registration number Not applicable

P-376 Restoration of mRNA expression level of endometrial MEIS1, as a co-factor of HOXA10, after laparoscopic salpingectomy of women with hydrosalpinx

Abstract Study question Do salpingectomy could restore HOXA10 co-factor MEIS1 expression in endometrial tissues of hydrosalpinx patients? Summary answer Laparoscopic salpingectomy could restore endometrial HOXA10-cofactor- MEIS1 expression level, in addition to HOXA10, in hydrosalpinx women. What is known already Hydrosalpinx is defined as a distally blocked and dilated fallopian tube which has been filled with serous fluid. Evidence suggests that hydrosalpinx is associated with adverse effect on endometrial receptivity by abnormal expression of key molecules such as HOXA10 in the pre-implantation endometrium. Previous data showed salpingectomy results in statistically significant increase in endometrial HOXA10 expression. MEIS1 is a three-amino-acid loop extension (TALE) family homeobox gene which has been proven to be a novel coactivator of HOXA10 during human and mouse endometrial decidualization. MEIS1-HOXA10 complex binds to the promoters of the target genes which are beneficial for human stromal cell decidualization. Study design, size, duration This prospective study was conducted from January 2021 to January 2022 to determine whether salpingectomy would reverse HOXA10-cofactor- MEIS1 expression levels after salpingectomy. All women signed the informed consent and did not receive any hormonal medication during the last three months. In this study 10 infertile women with moderate to severe hydrosalpinx proven by hysterosalpingography or laparoscopy undergoing salpingectomy were recruited. Ten healthy fertile age-matched women considered as control group. Participants/materials, setting, methods Ten infertile women, aged 20-40, with sonovisible hydrosalpinx (diameter >10mm), AMH>1.2 ng/dL, BMI (18–28 kg/m2) and regular menstrual cycle indicated by mid-luteal progesterone levels of > 10 ng/mL were included. Ten healthy fertile age-matched women with a history of successful pregnancy considered as control group. Mid–luteal-phase endometrial sampling (by pipelle) was performed at the time of surgery and second sampling was obtained forth-post treatment cycle. RNA extraction and cDNA synthesis were done. Main results and the role of chance Quantitative mRNA expression of MEIS1 was determined by real-time PCR technique. Gene expression data were analyzed based on 2 –ΔΔCT to estimate the relative fold change value. The non-parametric Wilcoxon signed rank test was used for data analysis. P value less than 0.05 was considered statistically significant.There was a significant reduction in the expression levels of MEIS1 gene in the endometrial samples of hydrosalpinx group before surgical removal. The obtained data showed that salpingectomy resulted in a statistically significant increase (about 6-fold) in endometrial MEIS1 expression (P = 0.02). Moreover, there was not significant difference in MEIS1 mRNA expression of hydrosalpinx group after salpingectomy and the control group (P > 0.05). Limitations, reasons for caution Larger sample size for the confirmation of these data is needed. Epigenetic evaluation of hydrosalpinx endometrial tissues especially in HOXA10 promoter is recommended. Wider implications of the findings This study suggests that the restoration of MEIS1 gene expression observed in hydrosalpinx women after salpingectomy can be considered as a molecular mechanism by which salpingectomy results in improvement of pregnancy rate in IVF cycle. Trial registration number not applicable

Menstrual Cycle-Related Changes in Women with Schizophrenia: A Resting-State fMRI Study

Introduction: Different influences of ovarian hormones in schizophrenia (SCZ) have been reported, but no study to date has assessed their effects on the brain dynamics at rest. The present study aimed to examine the hormonal and clinical changes related to the menstrual cycle and alterations in the resting-state functional connectivity (RS-FC) depending on cycle phase and/or hormonal fluctuations in SCZ. Method: This study was conducted based on both between- and within-subject experimental designs, including 13 clinically stable female patients with SCZ (32 ± 7.7 years) and 13 healthy women (30 ± 7.3 years). RS-functional magnetic resonance imaging (fMRI) scanning, as well as hormonal and clinical assessments, was applied to each participant twice during two cycle phases: early follicular and mid-luteal. Results: A difference in mid-luteal progesterone levels was found between groups, with a large effect size (Cohen’s d) of 0.8 (p < 0.05). Also, the estradiol levels negatively correlated with the negative symptom severity of the patients during their mid-luteal phase. In the patients, estrogen positively correlated with the auditory network connectivity in the left amygdala during the early follicular phase. In the controls, progesterone had positive correlations with the connectivity of the posterior default mode and the left frontoparietal networks in the bilateral precuneus during the early follicular phase and had a negative correlation with the executive control network connectivity in the mid-luteal phase. Conclusion: The present study showed hormonal differences between groups and suggested that the levels of cycle-dependent hormones might be associated with the changes in clinical symptom severity and the RS-FC in the groups. Our RS-fMRI findings warrant further investigation.

O-229 Impact of letrozole co-treatment during ovarian stimulation with gonadotropins for in vitro fertilisation (IVF): a multicentre, randomised, double-blinded placebo-controlled trial

Abstract Study question Does reducing estradiol levels with letrozole co-treatment during ovarian stimulation with gonadotropins for IVF impact endocrinological and reproductive outcome markers in expected normal responders? Summary answer Letrozole co-treatment maintained follicular phase physiological serum estradiol levels, increased gonadotropin and androgen levels, and increased progesterone in the luteal phase. What is known already Ovarian stimulation for IVF causes supraphysiologic estradiol levels, which exert pituitary suppression reducing gonadotropin stimulation of the corpus luteum. Furthermore, stimulation may increase progesterone in the late follicular phase, reported to impair clinical outcomes, through a putative effect on endometrial maturation and embryo-endometrial asynchrony. Co-treatment with the highly selective aromatase inhibitor letrozole during ovarian stimulation has been shown to reduce estradiol levels and FSH consumption in poor responders, but conflicting data in relation to oocyte yield and implantation rates. The impact of letrozole co-treatment on hormonal changes and reproductive outcome after co-treatment in normal responders remains to be clarified. Study design, size, duration A multicentre double-blinded randomised placebo-controlled trial conducted in 4 fertility clinics at university hospitals in Denmark from August 2016 to November 2018. 159 women were randomised and 129 completed the study; 67 women in the letrozole group and 62 women in the placebo group. The study was conducted in accordance with the Helsinki Declaration and the ICH-Good-Clinical-Practice. Data collection and reporting followed the guidelines of CONSORT to achieve transparent reporting of trials. Participants/materials, setting, methods Women with expected normal ovarian reserve received an antagonist IVF protocol with fixed-dose FSH and fresh single embryo transfer. Co-treatment consisted of once-daily 5 mg letrozole or placebo from the start of stimulation until the day of triggering final oocyte maturation with human chorionic gonadotropin. Serum was collected on 7 visits from stimulation start to 8 days after oocyte retrieval. Clinical pregnancy was determined with a viable foetus by vaginal ultrasound at gestational week 7. Main results and the role of chance The proportion of patients with progesterone &amp;gt;1.5 ng/ml in the late follicular phase was similar in the letrozole versus placebo group with 6% versus 0%, respectively (OR 0, 95 % CI [0;1.6], P =.12). Mid-luteal progesterone levels &amp;gt;30 ng/ml were observed in 59% versus 31%, respectively, of subjects in the letrozole and placebo group (OR 3.3, 95% CI [1.4;7.1], P =.005). Letrozole treatment decreased estradiol levels by 69% (95 % CI [60%;75%], P &amp;lt;.0001) and increased luteinizing hormone (LH), testosterone, and androstenedione levels significantly in both the follicular and luteal phase. Follicle-stimulating hormone (FSH) concentration was elevated in the letrozole group at stimulation day 5 and at trigger day, and overall FSH consumption was diminished. The ongoing pregnancy rate did not differ between the letrozole and placebo group (31% versus 39% (risk-difference of 8%, 95% CI [-25%;11%], P =.55). Letrozole had no significant additional side effects apart from those frequently seen during ovarian stimulation, though a trend towards less nausea and vomiting was observed in the letrozole co-treated group versus the placebo group (28% versus 44% (risk-difference of 16%, 95% CI [-2%;33%], P =.11). Limitations, reasons for caution The diurnal variation of progesterone has been confirmed since this study was completed, hence the timing of the blood samples was not standardized . However, bias is unlikely due to the randomized design. The study was not powered to show an effect on ongoing pregnancy rates. Wider implications of the findings Letrozole co-treatment during ovarian stimulation with gonadotropins maintained serum estradiol at physiological levels, increased follicular phase levels of gonadotropins and androgens, and luteal progesterone levels. These data indicate that letrozole co-treatment may ameliorate the detrimental impacts of gonadotropin stimulation during IVF in normal responders. Trial registration number NCT02939898 and NCT02946684

The impact of preovulatory versus midluteal serum progesterone level on live birth rates during fresh embryo transfer.

Conflicting evidence still prevails concerning the effect of preovulatory elevated progesterone (EP4) on reproductive outcomes in fresh embryo transfer (ET). However, few studies have analyzed the effect of EP4 on the likelihood of pregnancy using multivariate regression approach. The potential confounding factors tested in these studies were limited to either patient's characteristics or to stimulation related parameters. Yet, several studies have shown that postovulatory parameters such as midluteal progesterone (P4) level may be considered as a proxy variable of endometrial receptivity as well. The aim of the present study was to estimate the independent effect of preovulatory P4 effect, if any, on the probability of live birth (LB) by considering the midluteal endocrine profile when controlling for the potential confounding factors. This is a secondary data analysis of a cohort of fresh IVF/ICSI cycles triggered with GnRH agonist (n = 328) performed in a single IVF center during the period 2014-2016. Patients contributed only one cycle and were stratified into four groups according to preovulatory P4 quartiles. We assessed the association between preovulatory P4 and the odds of LB calculated by logistic regression analysis after controlling for the most clinically relevant confounders. The primary outcome measure: Live birth rates (LBR). Both preovulatory and midluteal P4 were significantly correlated with the ovarian response. Logistic regression analysis showed that preovulatory serum P4 did not have a significant impact on LBR. In contrast, midluteal serum P4 level was an important independent factor associated with LBR. The optimal chance of LBR was achieved with midluteal serum P4 levels of 41-60 ng/ml, [OR: 2.73 (1.29-5.78); p< 0.008]. The multivariate analysis suggests that the midluteal P4 level seems to impact LBR more than the preovulatory P4 level in women undergoing IVF treatment followed by fresh ET.

Effect of Individualized Progesterone Supplementation for Luteal Support in Frozen-Thawed Cycles on Pregnancy Outcomes

Objective: In frozen-thawed embryo transfer (FET) cycles, preparing a synchronous endometrium for the embryo is essential. Aim of this study is to provide individualized luteal support in hormonally replaced FET cycles, and to evaluate mid-luteal serum progesterone levels and pregnancy outcomes.Study Design: In this prospective cohort study, 30 patients were included in a university hospital in six month-period. Serum progesterone level on embryo transfer day was monitored, and if it was found to be below the lower limits defined by previous studies (10 ng/mL), additional 100 mg intramuscular micronized progesterone was administered once.Mid-luteal progesterone levels and pregnancy outcomes were recorded.Results: There was no significant difference between mid-luteal progesterone levels of the patients whose transfer day progesterone was above and below 10 ng/mL (p=0.481). Although clinical pregnancy rate tended to be higher in patients whose mid-luteal progesterone was above 10 ng/mL, it was also not statistically significant.Conclusion: This is the first study in which vaginal progesterone treatment was supported by intramuscular progesterone according to serum progesterone values for the purpose of individualized progesterone support. Significant difference was not found in pregnancy outcomes. However, further studies are required to optimize management and improve pregnancy rates in hormonally treated FET cycles.

Are different markers of endometrial receptivity telling us different things about endometrial function?

To what extent do endocrine, immunological, gene expression and histological markers of endometrial receptivity correlate? Between November 2017 and September 2019, 121 women referred to a University Hospitals Fertility Clinic consented to inclusion in this cohort study. The women underwent timed endometrial biopsy followed by blood samples in a hormone-substituted cycle. Of these, 37 women had just started IVF treatment, and the remaining 84 had experienced recurrent implantation failure following IVF/ICSI. The hormone-substituted cycle consisted of initiation with oral oestradiol followed by addition of vaginal progesterone treatment for five full days. Endometrial biopsies were subject to histological examination, immune cell markers by immunohistochemistry (CD56+ , CD16+ , CD163+ , FoxP3) and gene expression microarray analyses with the endometrial receptivity array (ERA® ) test (Igenomix). Plasma progesterone and oestradiol were measured on the day of biopsy. CD56+ uterine natural killer (uNK) cell counts correlate with transcriptional markers of endometrial receptivity assessed by the ERA test. Endometrial maturation, receptivity and immunological markers were not correlated with mid-luteal blood plasma progesterone level. Mid-luteal serum oestradiol level correlated with markers of endometrial maturation and receptivity. The tests were carried out during a standard hormone substitution cycle, and the findings may not apply in the natural cycle. CD56+ uNK cell counts and endometrial receptivity assessed by the ERA test appear to be linked. Mid-luteal progesterone levels were not correlated to the tested markers of endometrial receptivity. In contrast, mid-luteal oestradiol level was inversely related to markers of endometrial receptivity and maturation.

GnRHa for trigger and luteal phase support in natural cycle frozen embryo transfer – A proof of concept study

We aimed to explore whether ovulation induced by a GnRH analogue (GnRHa), followed by daily GnRHa luteal support provides an efficient platform for natural cycle frozen embryo transfer (NC-FET).In this cohort study, included were normo-ovulatory women who underwent NC-FET cycles, under the age of 40, with an antral follicle count > eight. Ovulation was triggered with triptorelin (0.2 mg Decapeptyl; Ferring), and luteal support was initiated two days later, using a Nafarelin inhaler (Synarel, Pfizer), 200 μg twice daily. Main outcome measures were luteal estradiol and progesterone levels (three to five days following ovulation), implantation rate, ongoing pregnancy rate, early pregnancy loss rate, and live birth rate.Fifty-one patients treated between 2017 and 2018 were included. Mid luteal progesterone levels among study patients, were non-significantly different between patients who achieved pregnancy and those who did not, but differed significantly on day 14 following ovulation (86.0 ± 31.3 vs. 9.8 ± 9.5 nmol/L, respectively, p < 0.001). Twenty-three patients achieved a clinical pregnancy (45.1 %); interestingly, there were no chemical pregnancies. Three pregnancies ended in an early abortion at 6–7 weeks gestation, and 20 pregnancies continued as ongoing pregnancies (39.2 %). One patient had a late abortion at 16 weeks gestation, and 14 had a live birth.In conclusion, in this proof of concept study, inducing ovulation with a bolus of GnRHa in NC-FET, followed by repeated daily GnRHa administration, resulted in satisfactory luteal phase steroid levels and high ongoing pregnancy and live birth rates.

Mid-Luteal 17-OH Progesterone Levels in 614 Women Undergoing IVF-Treatment and Fresh Embryo Transfer-Daytime Variation and Impact on Live Birth Rates.

Introduction: Corpus luteum (CL) produces progesterone (P4) and 17-OH progesterone (17-OH P4) during the luteal phase. Contrary to P4, 17-OH P4 is not supplied as part of the luteal phase support following IVF-treatment. Therefore, measuring endogenous serum 17-OH P4 levels may more accurately reflect the CL function compared to monitoring serum P4 concentrations.Objective: To explore the correlation between mid-luteal serum 17-OH P4 levels and live birth rates and to explore the possible daytime variations in mid-luteal serum 17-OH P4.Design: Prospective cohort study.Patients: 614 women undergoing IVF-treatment and fresh embryo transfer.Intervention: All patients had serum 17-OH P4 measured 7 days after oocyte pick-up (OPU+7). Furthermore, on OPU+7, seven patients underwent repeated blood sampling during daytime to clarify the endogenous daytime secretory pattern of 17-OH P4.Outcome measure: Live birth rate.Secondary outcome measure: Daytime variation in serum 17-OH P4 levels.Results: The highest chance of a live birth was seen with mid-luteal 17-OH P4 between 6.0 and 14.0 nmol/l. The chance of a live birth was reduced below (RD −10%, p = 0.07), but also above the optimal range for 17-OH P4 (RD −12%, p = 0.04). Patients with diminished CL-function (17-OH P4 < 6 nmol/l) displayed clinically stable 17-OH P4 values, whereas patients with 17-OH P4 levels >6 nmol/l showed random 17-OH P4 fluctuations during daytime.Conclusion: The association between 17-OH P4 and reproductive outcomes is non-linear, and the negative effect of excessive CL-secretion seems to be just as strong as the negative effect of a reduced CL-function during the peri-implantation period.

Midluteal Progesterone: A Marker of Treatment Outcomes in Couples With Unexplained Infertility.

Adequate luteal phase progesterone exposure is necessary to induce endometrial changes required for a successful pregnancy outcome. The relationship between low midluteal progesterone concentration and the outcome of live birth in ovarian stimulation with intrauterine insemination (OS-IUI) treatments is not defined. To determine the level of midluteal progesterone portending a low chance of live birth after OS-IUI in couples with unexplained infertility. Secondary analyses of data from a prospective, randomized, multicenter clinical trial that determined pregnancy outcomes following OS-IUI with clomiphene citrate, letrozole, or gonadotropins for couples with unexplained infertility. Couples (n = 900) underwent 2376 OS-IUI cycles during the Assessment of Multiple Intrauterine Gestations from Ovarian Stimulation clinical trial. Live birth as it relates to midluteal progesterone level and thresholds below which no live births occur by treatment group. Thresholds for non-live birth cycles were similar for clomiphene (14.4 ng/mL) and letrozole (13.1 ng/mL) yet were lower for gonadotropin (4.3 ng/mL) treatments. A midluteal progesterone level >10th percentile specific for each treatment group independently was associated with greater odds for a live birth in all OS-IUI cycles (adjusted OR: 2.17; 95% CI: 1.05, 4.48). During OS-IUI, a low midluteal progesterone level was associated with a low probability of live birth. Thresholds differed by medication, with the lowest threshold for gonadotropin. Several pathophysiologic mechanisms may account for low progesterone levels. Refinement of the predictive range associated with particular ovarian stimulation medications during treatment of unexplained infertility may improve accuracy.

Impact of mid-luteal serum progesterone levels on pregnancy outcome in fresh and frozen embryo transfer cycles in women of Indian ethnicity

Context: Luteal phase defect has been identified in all assisted reproductive technology cycles, necessitating progesterone supplementation. Aims: The aim of our study was to assess whether mid-luteal serum progesterone (P) levels' impact pregnancy outcome in fresh and frozen embryo transfer (FET) cycles. Settings and Design: A total of 145 women undergoing embryo transfer (ET) were prospectively enrolled and received standard luteal phase support. Methodology: Serum progesterone levels were assessed for all the patients in the mid-luteal phase. Patients were divided into groups based on the type of ET performed. Group A – fresh ET and Group B – FET. These groups were further subdivided based on mid-luteal serum P levels being below (Groups A1/B1) or above 15 ng/mL (Groups A2/B2). Progesterone levels were correlated with the clinical pregnancy outcome. Statistical Analysis Used: Chi-square test was used for qualitative analysis, and student's t-test was used for comparison of means. Results: Patients with mid-luteal serum P levels Conclusions: This study suggests that, in Indian women, mid-luteal serum P levels biochemical pregnancies) cycles. Individualizing luteal phase support by measuring serum progesterone levels might help to enhance pregnancy outcomes.

Operative transvaginal hydrolaparoscopy improve ovulation rate after clomiphene failure in polycystic ovary syndrome

Aim of our study was to assess the ovulation rate, with mid-luteal progesterone level and ultrasound follicles monitoring, in PCOS CC-resistant patients undergone transvaginal hydrolaparoscopy ovarian drilling. A prospective observational study was carried out in 123 PCOS, infertile, CC-resistant patients who undergone THL ovarian drilling. Each woman was evaluated by hormonal measurement, and ultrasound evaluation during 6 months follow-up. Progesterone serum levels were assessed on days 20–24 of the cycle after surgical treatment. Pg levels >3 ng/mL were considered as ovulation. Ovulation frequency and the highest mean follicular diameters during the monitoring were recorded. 117 patients complete the study, since six patients were lost to follow-up. Mean follicular diameter during ovulation monitoring was 16.37 mm. Ovulation rate at the follow up was 64.1% one month after treatment, 79.5% after three months and 82.9% after six months. 28 patients conceived during follow-up period. Pregnancy rate was 70.1%. Our study has shown that THL ovarian drilling improves ovulation and pregnancy rate in women with CC-resistant PCOS. We believe that this approach should be offered as second-line therapy at all PCOS CC-resistant women who fail the medical methods of ovulation induction.

Daily low-dose hCG stimulation during the luteal phase combined with GnRHa triggered IVF cycles without exogenous progesterone: a proof of concept trial.

Can the luteal phase support be improved in terms of efficacy, hormonal profiles and convenience as compared with today's standard care? Daily low-dose rhCG supplementation in GnRHa triggered IVF cycles can replace the traditional used luteal phase support with exogenous progesterone. A bolus of hCG for final maturation of follicles in connection with COS may induce the risk of OHSS and the luteal phase progesterone levels rise very abruptly in the early luteal phase. This is a proof-of-concept study conducted as a three arm RCT with a total of 93 patients. First patient enrolled in January 2012 and the study finished in January 2014. Normal responder women undergoing IVF/ICSI treatment in a university hospital. One arm served as control, where women followed a standard antagonist protocol. Two study arms were included both having 125 IU hCG daily for luteal phase support without exogenous progesterone after using a GnRHa trigger for ovulation induction. In both study arms exogenous FSH was stopped on stimulation day 6 and replaced by exogenous hCG that was initiated on either stimulation day 2 or day 6. Blood samples were obtained on the day of ovulation induction, on the day of oocyte pickup (OPU) and day OPU + 7. The mean serum levels of hCG did not exceeded the normal physiological range of LH activity in any samples. Mid-luteal progesterone levels were significantly higher in the two study groups receiving daily low-dose hCG for luteal phase support as compared with the control group (control group: 177 ± 27 nmol/l; study group 1: 334 ± 42 nmol/l; study group 2: 277 ± 27 nmol/l; (mean ± SEM). No differences in reproductive outcome were seen between groups. The number of patients included is limited and conclusions need to be verified in a larger RCT. Endogenous production of progesterone may become more attractive as the luteal phase support with levels of LH-like activity only in the physiological range and may, from the patients' point of view, replace inconvenient exogenous progesterone preparation. Further hCG may reduce the cost of stimulation and may collectively be used for stimulation of the follicular phase, ovulation induction and for luteal phase support. An unrestricted grant from ARTS Biologics made this study possible. None of the authors has any competing interests to declare. ClinicalTrial.gov number: NCT01504139. 28 December 2011.

Polycystic Ovary Syndrome: An Apparently Simple yet Challenging Diagnosis.

Polycystic Ovary Syndrome: An Apparently Simple yet Challenging Diagnosis.

HCG (1500IU) administration on day 3 after oocytes retrieval, following GnRH-agonist trigger for final follicular maturation, results in high sufficient mid luteal progesterone levels - a proof of concept

BackgroundControlled ovarian hyperstimulation (COH) which combining GnRH antagonist co-treatment and GnRH agonist trigger with an additional 1500 IU hCG luteal rescue on day of oocytes retrieval, has become a common tool aiming to reduce severe ovarian hyperstimulation syndrome (OHSS). In the present, proof of concept study, we evaluate whether by deferring the hCG rescue bolus for 3 days, we are still able to rescue the luteal phase.MethodsPatients undergoing the GnRH-antagonist protocol, who were considered at high risk for developing severe OHSS and received GnRH-agonist for final oocyte maturation, were included. For luteal phase support, all patients received an “intense” luteal support. Those who had no signs of early moderate OHSS on day 3 after oocytes retrieval were instructed to inject 1500 IU of HCG bolus (hCG group). Ovarian stimulation characteristics and mid luteal progesterone levels were compared between those who received the HCG bolus and those who did not.ResultsEleven IVF cycles were evaluated, 5 in the hCG group and 6 in the intense luteal support only group. While no in-between group differences were observed in ovarian stimulation characteristics, significantly higher mid luteal progesterone levels (>127 nmol/L vs 42.1 ± 14.5 nmol/L, respectively) and a non-significant increase in pregnancy rate (40% vs 16.6%, respectively), were observed in those who receive the hCG bolus compared to those who did not.ConclusionshCG luteal rescue should be offered 3 days after oocytes retrieval only to those patients with no signs of early moderate OHSS. Further studies are required to elucidate the appropriate regimen of luteal HCG administration in patients undergoing final follicular maturation with GnRH-agonist.