Should progesterone on the human chorionic gonadotropin day still be measured?

OBJECTIVE: To evaluate in our setting whether there is currently a level of P on the hCG day (P-hCG) predictive of no pregnancy. DESIGN: Observational study of prospectively collected data of the P-hCG levels of stimulated IVF cycles. SETTING: In vitro fertilization unit. PATIENT(S): All cycles of IVF/intracytoplasmic sperm injection with fresh embryo transfer performed between January 2009 and March 2014. INTERVENTION(S): None. MAIN OUTCOME MEASURE(S): Pregnancy rate. RESULT(S): Clinical pregnancy rate per ET was 38.7% and live birth rate was 29.1%. The P-hCG concentration was positively correlated to E2 on the hCG day, and the number of oocytes was negatively correlated to age. Progesterone on hCG day was higher among agonist- compared with antagonist-treated patients (mean ± SD: 1.13 ± 0.69 ng/mL vs. 0.97 ± 0.50 ng/mL) and among recombinant FSH compared with recombinant FSH + hMG stimulation (mean ± SD: 1.11 ± 0.58 ng/mL vs. 0.94 ± 0.50 ng/mL). Pregnancy rate was positively associated with the number of oocytes. There was no correlation between P-hCG value and pregnancy rate, overall or according to the type of treatment. CONCLUSION(S): In our setting there is no P-hCG value differentiating a good from a poor cycle success rate. CLINICAL TRIAL REGISTRATION NUMBER: NCT02323347.

Antagonist rescue of agonist IVF cycle at risk of OHSS: a case series.

We describe a series of in vitro fertilisation (IVF) long protocol cycles presenting a risk of ovarian hyperstimulation syndrome (OHSS) which were rescued with an antagonist at a university-based tertiary-care fertility centre. Nineteen IVF patients presenting a risk of OHSS during treatment with long protocol, between 2009 and November 2012 were included in the present study. After discussion of available options, the agonist was stopped and a daily gonadotropin-releasing hormone (GnRH) antagonist injection was initiated ("rescue protocol") and maintained until ovulation trigger. Fourteen patients were triggered with human chorionic gonadotropin (hCG) and five with GnRH agonist bolus, yielding competent oocytes. Seventeen embryo transfers were performed in the fresh cycles. One patient developed moderate OHSS. There were eight clinical pregnancies after the fresh IVF cycle (42% per patient), and six further pregnancies after frozen-thawed cycles, resulting in a 73% cumulative clinical pregnancy rate within one year. We conclude that the "rescue protocol with antagonist" of the long IVF cycle with a high risk of OHSS allows us to carry on with the cycle, without compromising its success or the patient safety, thus broadening the possibility of applying the long protocol.

GnRH antagonist rescue of a long-protocol IVF cycle and GnRH agonist trigger to avoid ovarian hyperstimulation syndrome: three case reports.

OBJECTIVE: To describe three clinical cases involving patients at high risk of severe ovarian hyperstimulation syndrome (OHSS) during IVF stimulation. DESIGN: Description of clinical management of IVF cycles and outcomes in patients at risk of developing OHSS. SETTING: Reproductive medicine unit, private hospital. PATIENT(S): Three infertile patients undergoing stimulation for IVF/intracytoplasmic sperm injection presenting high risk of OHSS. INTERVENTION(S): IVF patients treated under long protocol presenting high risk of OHSS had their cycles rescued by withdrawing the agonist and replacing it with an antagonist and triggering ovulation with an agonist bolus. MAIN OUTCOME MEASURE(S): OHSS symptoms, pregnancy. RESULT(S): None of the three patients developed OHSS. One patient got pregnant after fresh embryo transfer, one patient got pregnant after frozen embryo transfer, and one patient had no oocytes retrieved despite the detection of LH in urine after the GnRH bolus. CONCLUSION(S): When a patient undergoing an IVF cycle with long protocol is at high risk of severe OHSS, rescuing the cycle by withdrawing the agonist and replacing it with an antagonist and triggering ovulation with an agonist bolus could be considered without jeopardizing the safety of the patient while retaining the opportunity for success of the cycle. Further broader studies are needed.

Use of a prediction model for high-order multiple implantation after ovarian stimulation with gonadotropins.

OBJECTIVE: To determine prospectively the effectiveness in clinical practice of a prediction model for high-order multiple pregnancies (HOMP) (triplets or more). DESIGN: Prospective study. SETTING: University teaching hospital. PATIENT(S): Eight hundred forty-nine consecutive infertile patients undergoing a total of 1,542 treatment cycles. INTERVENTION(S): Gonadotropin ovarian stimulation or induction of ovulation without IVF MAIN OUTCOME MEASURE(S): Observed and predicted overall pregnancy rates and the incidence of HOMP. RESULT(S): The use of the prediction model (implying cancellation of all cycles at high risk for HOMP) would result in an 8% (95% confidence interval, 6.8%-9.2%) reduction of overall pregnancy rate but also in a 285% (95% CI, 279%-291%) reduction of HOMP. CONCLUSION(S): By using our prediction model, it was possible to maintain a low risk of HOMP with a good pregnancy rate in patients receiving gonadotropin ovarian stimulation or induction of ovulation without IVF.

Serum progesterone concentrations on the day of HCG administration cannot predict pregnancy in assisted reproduction cycles.

The effect of subtle rises of progesterone in the late follicular phase of cycles of ovarian stimulation with gonadotrophin-releasing hormone (GnRH) agonists on pregnancy outcome is controversial. This study used receiver-operating characteristic (ROC) analysis to gain further insight into the predictive value of serum progesterone concentrations on the day of human chorionic gonadotrophin (HCG) injection in normally responding patients receiving the long protocol of GnRH agonist (group L; n = 218) and in low responders receiving the short ('flare-up') protocol (group S; n = 159). ROC analysis showed that serum progesterone concentration on the HCG day was not indicative of conception and non-conception cycles in the whole population studied, in group L or in group S. To further assess the potential impact of 'high' concentrations of circulating progesterone on the day of HCG administration on pregnancy rates and outcome, the threshold value (<0.9 ng/ml) to discriminate between women with 'high' (group H; n = 197) and 'normal' (group N; n = 180) progesterone was applied. No significant differences were found with respect to pregnancy and miscarriage rates between these two groups. Serum progesterone concentrations on the day of HCG administration therefore cannot predict pregnancy in assisted reproduction cycles using GnRH agonists and gonadotrophins.