Mid-luteal Progesterone Research Articles

Exogenous progesterone rescue in patients with low mid-luteal serum progesterone levels undergoing true natural vitrified-warmed blastocyst transfer.

To explore whether a 25mg subcutaneous progesterone daily rescue daily improves the reproductive outcomes in patients with low serum progesterone (P4) levels (7-10ng/mL), measured one day before true natural cycle (t-NC) frozen embryo transfer (FET). A cohort study of 192 women undergoing t-NC warmed blastocyst transfer. Patients were stratified into three different groups based on serum P4 levels on the FET-1day: patients who had serum P4 levels of 7-10ng/mL and underwent rescue progesterone administration (rescue group), patients with serum P4 levels of 7-10ng/mL without progesterone administration (non-rescue group), and patients with serum P4 > 10ng/mL on FET-1day (control group). The primary outcome was possible differences in live birth rate (LBR) between groups. The LBRs for the serum P4 7-10ng/mL without rescue, 7-10ng/mL with rescue, and > 10ng/mL (control) groups were 41%, 46%, and 52%, respectively (p = 0.61). The estimated adjusted probability of live birth for serum P4 7-10ng/mL without rescue, 7-10ng/mL with rescue, and > 10ng/mL (control) groups were also comparable: 43.5% (95% CI, 20.0-70.4%), 49.8% (95% CI, 28.1-71.6%), and 57.4% (95% CI, 44.0-69.8%), respectively. Serum P4 levels higher than 7ng/mL seem to secure LBRs in patients undergoing t-NC FET. A rescue policy consisting of a daily subcutaneous 25mg progesterone dose in patients with serum P4 levels 7-10ng/mL does not further enhance LBRs when compared to those patients with similar serum P4 levels without rescue.

P-614 The use of home ovulation prediction kits (OPKs) in true natural cycle frozen embryo transfer (NC FET)

Abstract Study question Do urinary OPKs have inferior ability to detect the LH surge compared to daily serum monitoring among patients undergoing true NC FET? Summary answer OPKs are highly accurate and may serve as reliable tests to detect the LH surge among patients undergoing NC FET. What is known already Frozen embryo transfers continue to increase worldwide and recent evidence suggests natural cycle protocols may be superior to hormone replacement protocols because of lower risk of miscarriage and lower risk of pregnancy complications. Patients undergoing NC FET attend multiple clinic appointments which has been associated with increased patient stress levels during fertility treatment. OPKs have been found to be accurate at detecting the LH surge in the trying to conceive population and have high user acceptability. Study design, size, duration A prospective single cohort study including 139 fertility seeking participants was completed at an academic-affiliated fertility center for a duration of 12 months. Participants/materials, setting, methods Patients scheduled for NC FET (regular cycles 27-35 days, mid luteal progesterone >30 nmol/L, no luteal phase concern) with the ability to provide informed consent and access to SMS texting devices were eligible for participation. On the same day they started daily morning bloodwork as per the standard protocol (2-3 days prior to anticipated LH surge), participants began twice daily OPK testing. Upon exiting the study, patients completed a questionnaire on satisfaction with OPK use. Main results and the role of chance LH surge detection rate was 85.6% (n = 119/139) with serum monitoring and 93.5% (130/139) with OPK use (Kappa agreement 90.7%, K = 0.51, p < 0.001). Among patients with a serum-detected LH surge, OPK was positive within +/- 12 hours of the serum LH surge detection in 84.8% of patients. In 23.7% of cycles, OPK was positive the same morning as serum blood work. In 27.1% of cycles, OPK was positive 12h prior and in 33.9% of cycles, OPK was positive 12h after serum LH surge detection. Actual NC FET cycle cancellation rate was 16.6% (n = 23/139) compared to an anticipated cycle cancellation rate of 20.9% (29/139) if OPKs had been used to initiate serum monitoring. The average reduction in the number of serum monitoring visits and distance travelled in kilometers with OPK use was 3.9 visits (SD 2.1) and 155km (SD 174), respectively. The majority of participants reported satisfaction with OPK use. Of 135 patients, 110 (81.5%) strongly agreed the OPK was easy to use, 100 (74.1%) strongly agreed they would be open to using OPKs in future fertility treatments and 120 (88.9%) reported a reduction or no impact on stress levels associated with fertility treatments. Limitations, reasons for caution This study only used Clearblue Digital Ovulation Tests and the reported reliability in our study cannot be extrapolated to all OPKs. Additionally, the accuracy of the reported serum LH surge detection rate may be limited by physician specific definitions of serum LH surge. Wider implications of the findings OPKs are highly accurate and may serve as a reliable trigger for serum monitoring in NC FET. While their use would reduce the number of clinic appointments and distance travelled for patients undergoing NC FET cycles, patients should be advised OPK use may be associated with higher cycle cancellation rates. Trial registration number Not applicable

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

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

ObjectiveTo study whether mid-luteal serum estradiol (E2) levels are associated with the Live Birth Rate in Hormone Replacement Therapy FET cycles in patients with optimal mid-luteal serum progesterone (P4) levels. DesignObservational prospective cohort study of 412 women having a Hormone Replacement Therapy FET single blastocyst transfer from January 2020 to November 2022. SubjectsThe Hormone Replacement Therapy FET priming regimen included oral estradiol (6mg/24h) administered in the evening, followed by vaginal progesterone (400mg/12h). Serum E2 and P4 levels were measured in a standardized manner, 2-4 hours after the latest progesterone administration and 9-14 hours after estradiol administration on the day of blastocyst transfer, day 6 of progesterone administration. Patients with serum P4 <11ng/mL (35nmol/l) on the day of transfer received additional rectal progesterone (400mg/12h). No additional estradiol was administered. Main Outcome MeasuresThe primary outcome was Live Birth Rate in relation to E2 levels at blastocyst transfer day. ResultsThe optimal serum E2 range correlating with ongoing pregnancy was ≥292pg/ml <409pg/ml (≥1070pmol/l and <1500pmol/l). The Live Birth Rate was 59% (60/102) if E2 levels were within this range, whereas a significantly lower Live Birth Rate of 39% (101/260, p=0.001) was seen in patients if E2 levels were <292pg/ml (<1070pmol/l), and of 28% (14/50, p<0.001) if E2 levels were ≥409pg/ml (≥1500pg/mL). In a logistic regression analysis, adjusting for serum progesterone level ≥11ng/mL or <11ng/mL (≥35nmol or <35nmol/l) on the day of transfer, BMI, age at oocyte retrieval, day 5 or 6 vitrified blastocyst and blastocyst score, the adjusted risk difference (RD) of a live birth was -0.21 [-0.32; -0.10] when the E2 level was <292pg/mL (<1070pmol/l) and -0.31 [-0.45; -0.18] if the E2 level was ≥409pg/ml (≥1500pmol/l) compared to E2 levels ≥292pg/ml <409pg/ml (≥1070 <1500pmol/l). Importantly, only 25% of patents had optimal levels. ConclusionThe study shows a significant association between serum E2 levels and reproductive outcomes in a Hormone Replacement Therapy FET cohort in which optimal serum progesterone levels were secured. Mid-luteal serum E2 levels are associated with Live Birth Rate in Hormone Replacement Therapy FET cycles and E2 levels should neither be too high nor too low.

Unveiling the Influence of the Menstrual Cycle on Mental Rotation Abilities: A Comparative Analysis of Three-Dimensional vs. Two-Dimensional Tasks

The activational effects of sex hormones on spatial ability have been well documented. It has been suggested that these effects might be related to hormonally induced changes in interhemispheric communication. In this EEG study, we opted to explore menstrual cycle-related changes in the efficacy of solving mental rotation tasks and laterality indices while participants were engaged with the tasks. We compared 2D and 3D mental rotation tasks, as they differ both psychometrically and in terms of lateralization. A group (n = 39) of healthy young women was tested twice, once during the mid-luteal (high estrogen and progesterone) and once during the early follicular (low levels of sex hormones) phase of menstrual cycle. The differences in power within the same frequency band on homologous sites of the left and right hemispheres were then calculated. Participants were faster, more accurate, and showed higher laterality scores when solving 3D mental rotation tasks in the early follicular phase compared to the mid-luteal phase. This indicates a higher lateralization of this specific spatial function when the levels of sex hormones are low. However, for 2D mental rotation tasks, participants showed neither shifts in efficacy nor in hemispheric laterality as a function of the menstrual cycle. This pattern of results provides further support for the notion that fluctuations in sex hormones affect laterality, and consequently, the expression of lateralized cognitive abilities.

Menstrual-Cycle and Hormonal-Contraceptive Tracking in Gaelic Football: From the Lab to the Field

Purpose: The purpose of this study was to describe the implementation of menstrual-cycle (MC) and hormonal-contraceptive (HC) tracking among Gaelic Football players, including the characterization of MC status and symptomatology, and to examine the effect of MC and oral-contraceptive-pill phases on daily wellness. Methods: Fourteen highly trained players (age 24.2 [3.5] y), including non-HC (n = 6), oral contraceptive pill (n = 7), and intrauterine system (n = 1) users, prospectively tracked their MC or HC alongside daily self-reported wellness measures for 4 months. A combination of calendar-based counting, urinary ovulation prediction testing, and a midluteal serum progesterone measurement was used to assess MC status. Results: Only 2 non-HC players were eumenorrheic. Two players exhibited oligomenorrhea (cycle length, 39 [4] d), and ovulation was not detected in one of them. Luteal phase deficiency was indicated in 2 players (serum progesterone range &lt;1.0–7.5 nmol·L−1). All players except 1 reported at least 1 negative MC-related symptom or HC side effect. Linear mixed-model analyses revealed that wellness measures were not affected by oral contraceptive pill phase (P &gt; .05). Linear mixed-model analysis was not performed in non-HC users due to the small sample of eumenorrheic players (n = 2). Conclusions: Diverse reproductive profiles were observed, including HC use and subtle MC irregularities that would likely go undetected without prospective MC tracking using biochemical outcomes. This highlights the value of incorporating ovulation testing and blood sampling when establishing the MC status of athletes in applied research and practice where feasible. Applied researchers should anticipate practical challenges, including inconsistencies in ovulation testing timings and the time scale required to assess MC status among athletes.

Agreement Between the 2- and 3-Step Methods for Identifying Subtle Menstrual Disturbances.

To investigate the agreement between the 2- and 3-step methods for the detection of SMDs. Menstrual cycles (MCs, 98) of 59 athletes were assessed using the 2- and 3-step methods. Regular-length MCs (ie,≥21 and ≤35d) were classified as either having no SMD (luteal phase length ≥10d, midluteal progesterone concentration ≥16nmol·L-1, and being ovulatory) or having an SMD (eg,short luteal phase [<10d], inadequate luteal phase [midluteal progesterone concentration <16nmol·L-1], or being anovulatory). Method agreement was assessed using theMcNemar test and Cohen kappa (κ). Substantial agreement was observed between methods (κ = .72; 95% CI, .53-.91), but the 2-step method did not detect all MCs with an SMD, resulting in evidence of systematic bias (χ2 = 5.14; P = .023). The 2-step method detected 61.1% of MCs that had an SMD ([51.4, 70.8]), as verified using the 3-step method, and correctly identified 100% of MCs without an SMD. MCs classified as being disturbed using the 2-step method could be considered valid evidence of SMDs. However, MCs classified without SMDs do not definitively confirm their absence, due to the proven underdetection via the 2-step method.

The definition of unexplained infertility: A systematic review.

There is no consensus on tests required to either diagnose unexplained infertility or use for research inclusion criteria. This leads to heterogeneity and bias affecting meta-analysis and best practice advice. This systematic review analyses the variability of inclusion criteria applied to couples with unexplained infertility. We propose standardised criteria for use both in future research studies and clinical diagnosis. CINAHL and MEDLINE online databases were searched up to November 2022 for all published studies recruiting couples with unexplained infertility, available in full text in the English language. Data were collected in an Excel spreadsheet. Results were analysed per category and methodology or reference range. Of 375 relevant studies, only 258 defined their inclusion criteria. The most commonly applied inclusion criteria were semen analysis, tubal patency and assessment of ovulation in 220 (85%), 232 (90%), 205 (79.5%) respectively. Only 87/220 (39.5%) studies reporting semen analysis used the World Health Organization (WHO) limits. Tubal patency was accepted if bilateral in 145/232 (62.5%) and if unilateral in 24/232 (10.3%). Ovulation was assessed using mid-luteal serum progesterone in 115/205 (56.1%) and by a history of regular cycles in 87/205 (42.4%). Other criteria, including uterine cavity assessment and hormone profile, were applied in less than 50% of included studies. This review highlights the heterogeneity among studied populations with unexplained infertility. Development and application of internationally accepted criteria will improve the quality of research and future clinical care.

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.

Women in their mid-follicular phase outcompete hormonal contraceptive users, an effect partially explained by relatively greater progesterone and cortisol reactivity to competition

Early evidence suggests that hormonal contraceptive (HC) use alters psychological functioning and competitive behavior. Yet, there is limited data on endocrine models for explaining how HC use affects these outcomes. In this pre-registered and open-data study, we test if HC users and naturally cycling (NC) females in their low (mid-follicular) and high (mid-luteal) progesterone phase differ in competitive persistence and whether progesterone and cortisol reactivity mediate of this effect. HC users (N = 73) in the active hormone-exposure phase and NC participants in the mid-follicular (N = 69) or mid-luteal (N = 72) phase completed two behavioral measures of competitive persistence, holding up a weight for time followed by attempting to solve an unsolvable anagram. Participants also completed measures of handgrip strength and self-reported competitiveness as well as gave saliva samples before and after the tasks for hormone assay. Results showed that NC-follicular group had greater competitive persistence in the weight-holding task compared to both NC-luteal (d = 0.38) and HC use (d = 0.43) groups independent of physical strength and self-reported competitiveness covariates. Although anagram task performance showed similar trends for group differences, analyses for this task were inconclusive. Baseline progesterone did not mediate the effect of cycle phase group on competitive persistence. HC users showed relatively blunted cortisol and progesterone reactivity, and this effect partially mediated the difference in competitive persistence between HC users and the NC-follicular group. In sum, results suggest that HC use could downregulate competitive behavior at least partly by dampening cortisol-progesterone reactivity. These findings offer a new endocrine model for understanding HC use and cycle phase effects on motivational and energetic outcomes required for optimal performance in competitive contexts.

The relation between vitamin D and the adolescents' mid-luteal estradiol and progesterone.

The aim of this study was to detect the effect of vitamin D (Vit. D) intake on the mid-luteal estradiol (E2), and progesterone (P), and the relation between vit. D, and the adolescents' mid-luteal E2, and P. Eighty-five (85) adolescents were recruited for this cohort study after obtaining informed consent. After a detailed history and clinical examination, the body mass index (BMI) of the studied participants was calculated, followed by pelvic sonography to exclude any pelvic pathology. Participants' blood samples were collected on days 21-22 of the menstrual cycle (mid-luteal) to measure the thyrotropin (TSH) (i.e., to exclude hypothyroidism), prolactin (i.e., to exclude hyperprolactinemia), glycosylated hemoglobin (HbA1C), (i.e., to exclude diabetes), E2, P, and 25(OH)D. Participants received 50,000 IU of vit. D weekly for two months, and on the 3rd month, the mid-luteal E2, P, and 25(OH)D were measured. The mid-luteal E2, P, and 25(OH)D were compared before and after the vit. D intake to detect the effect of vit. D intake (50,000 IU weekly for 2 months) on the mid-luteal E2 and P (primary outcome). Additionally, the relations between vit. D and the adolescents' mid-luteal E2 and P were detected as secondary outcomes using the correlation analysis (Pearson's correlation). The mid-luteal E2 and P statistically decreased from 109.3±15.7 pg/mL and 9.8±1.01 ng/mL, respectively to 40.7±10.52 pg/mL, and 5.2±0.73 ng/mL, respectively, after vit. D intake (p=0.00015; 95% CI: 64.5, 68.6, 72.7, and p=0.0016; 95% CI: 4.3, 4.6, 4.87, respectively). Significant negative correlations between the 25(OH)D, and both the mid-luteal E2 (r -0.661; p<0.00001), and P (r -0.521; p<0.00001) were detected in this study. The mid-luteal E2 and P statistically decreased after vit. D intake (50,000 IU of vit. D weekly for 2 months). Significant negative correlations between the 25(OH)D, and both the mid-luteal E2 and P were detected in this study. The relation between vit. D and ovarian steroids, and the effect of vit. D intake on ovarian steroids need further larger studies.

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 &amp;lt;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&amp;lt;.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&amp;lt;32.0ng/ml(n = 68),T2 32.2-43.7ng/ml(n = 68),T3 &amp;gt;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&amp;lt;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 (&amp;lt;9.1 mm), 25-50th (9.1-10.1mm), 51-75th (10.2-11.6 mm) and &amp;gt;75th (&amp;gt;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 &amp;gt;75th (2.86, 95% CI: 1.06-7.73) percentiles were significantly higher when compared with that of &amp;lt; 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 &amp;lt;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 &amp;lt; 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 &amp;gt;10mm), AMH&amp;gt;1.2 ng/dL, BMI (18–28 kg/m2) and regular menstrual cycle indicated by mid-luteal progesterone levels of &amp;gt; 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 &amp;gt; 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

Mid-Luteal Progesterone Is Inversely Associated with Premenstrual Food Cravings.

It is not clear whether progesterone and estradiol associate with premenstrual food cravings, which significantly contribute to cardiometabolic adverse effects associated with obesity. We sought to investigate this question in the present study based on the prior literature showing a protective effect of progesterone on drug craving and extensive neurobiological overlaps between food and drug cravings. We enrolled 37 non-illicit drug- or medication-using women in the study to provide daily ratings of premenstrual food cravings and other symptoms across two-three menstrual cycles, based on which we classified them as premenstrual dysphoric disorder (PMDD) or control participants. In addition, the participants provided blood samples at eight clinic visits across the menstrual cycle. We aligned their mid-luteal progesterone and estradiol using a validated method which relies upon the peak serum luteinizing hormone and analyzed estradiol and progesterone using ultraperformance liquid chromatography tandem mass spectrometry. Hierarchical modeling, adjusted for BMI, showed a significant inverse effect of progesterone (p = 0.038) but no effect of estradiol on premenstrual food cravings. The association was not unique to PMDD or control participants. Results of research to date in humans and rodents showing that progesterone has dampening effects on the salience of the reinforcer translate to premenstrual food cravings.

Endogenous progesterone in unexplained infertility: a systematic review and meta-analysis

PurposeTo investigate the possibility that altered actions of endogenous progesterone affect receptivity and contribute to unexplained infertility (UI).MethodsTwo authors electronically searched MEDLINE, CINAHL and Embase databases from inception to 6 July 2022 and hand-searched according to Cochrane methodology. We included all published primary research reporting outcomes related to endogenous progesterone in natural cycles in women with UI. Studies were assessed for risk of bias using a modified Newcastle–Ottawa Score or NHLBI Score. We pooled results where appropriate using a random-effects model. Findings were reported as odds ratios or mean differences.ResultsWe included 41 studies (n = 4023). No difference was found between the mid-luteal serum progesterone levels of women with UI compared to fertile controls (MD 0.74, − 0.31–1.79, I2 36%). Women with UI had significantly higher rates of ‘out-of-phase’ endometrium than controls. Nine out of 10 progesterone-mediated markers of endometrial receptivity were significantly reduced in women with UI compared to fertile controls (the remaining 1 had conflicting results). Resistance in pelvic vessels was increased and perfusion of the endometrium and sub-endometrium reduced in UI compared to fertile controls in all included studies. Progesterone receptor expression and progesterone uptake were also reduced in women with unexplained infertility.ConclusionsEnd-organ measures of endogenous progesterone activity are reduced in women with UI compared to fertile controls. This apparently receptor-mediated reduction in response affects endometrial receptivity and is implicated as the cause of the infertility. Further research is required to confirm whether intervention could overcome this issue, offering a new option for treating unexplained infertility.Trial registrationPROSPERO registration: CRD42020141041 06/08/2020.

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

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

Impact of Serum P Levels on Pregnancy Outcome in ART

Background: The role of mid luteal progesterone (P) levels has gained interest in the last years. Low serum P levels significantly decrease the chances of ongoing pregnancy, mainly in artificial cycles for embryo transfer. Our prospective studies have found that patients with low serum P levels on the day of ET had a significantly lower live birth rate, either when using own or donated oocytes. Aim: To summarize the current evidence about the impact of serum P levels on pregnancy outcome in ART; and the proposed strategies to overcome this situation. To differentiate the PK and PD of the different routes of exogenous P and how this influence on the interpretation of results. Method: Review of the literature. The research leaded by the lecturer will be presented. Results: In artificial cycles, there is a minimum threshold of serum P levels that needs to be reached. Approximately 30% of women show inadequate levels of serum P after receiving the standard dose of vaginal P. Individualization of luteal phase support by routinely measuring P levels, allows to detect which patients need raised P in order to optimise their outcome. Addition of extra doses of P seems to overcome this detrimental effect, ideally associating other routes of P. Conclusion: Low P levels on the day of ET decrease live birth rates. If outcomes are to be optimised, a minimal threshold of serum P values on the day of ET must be reached. Personalization of luteal phase support is advisable to optimize the results.