Interindividual variation of progesterone elevation post LH rise: implications for natural cycle frozen embryo transfers in the individualized medicine era.

BACKGROUND: The key to optimal timing of frozen embryo transfer (FET ) is to synchronize the embryo with the receptive phase of the endometrium. Secretory transformation of the endometrium is induced by progesterone. In contrast, detection of the luteinizing hormone (LH) surge is the most common surrogate used to determine the start of secretory transformation and to schedule FET in a natural cycle. The accuracy of LH monitoring to schedule FET in a natural cycle relies heavily on the assumption that the period between the LH surge and ovulation is acceptably constant. This study will determine the period between LH rise and progesterone rise in ovulatory natural menstrual cycles. METHODS: Retrospective observational study including 102 women who underwent ultrasound and endocrine monitoring for a frozen embryo transfer in a natural cycle. All women had serum LH, estradiol and progesterone levels measured on three consecutive days until (including) the day of ovulation defined with serum progesterone level exceeding 1ng/ml. RESULTS: Twenty-one (20.6%) women had the LH rise 2 days prior to progesterone rise, 71 (69.6%) had on the day immediately preceding progesterone rise and 10 (9.8%) on the same day of progesterone rise. Women who had LH rise 2 days prior to progesterone rise had significantly higher body mass index and significantly lower serum AMH levels than women who had LH rise on the same day with progesterone rise. CONCLUSION: This study provides an unbiased account of the temporal relationship between LH and progesterone increase in a natural menstrual cycle. Variation in the period between LH rise and progesterone rise in ovulatory cycles likely has implications for the choice of marker for the start of secretory transformation in frozen embryo transfer cycles. The study participants are representative of the relevant population of women undergoing frozen embryo transfer in a natural cycle.

Evolution of serum progesterone levels in the very early luteal phase of stimulated IVF/ICSI cycles post hCG trigger: a proof of concept study.

BACKGROUND: Studies have suggested that controlled ovarian hyperstimulation adversely affects endometrial receptivity due to advanced endometrial maturation. This adverse effect is mainly attributed to supraphysiological levels of both estrogen and progesterone identified in stimulated cycles. There is a paucity of published data investigating the very early luteal steroid profile following hCG trigger. AIM OF THE STUDY: This prospective, observational study was undertaken to determine the increase in serum progesterone levels after human chorionic gonadotrophin (hCG) trigger in stimulated IVF/ICSI cycles. MATERIALS AND METHODS: This proof-of-concept study included 11 patients requiring ovarian stimulation for IVF/ICSI and who planned to avail of pre-implantation genetic screening with embryo vitrification of their biopsied embryos at blastocyst stage. For each study participant, five additional blood samples were drawn at the following specific times in the stimulation cycle, on the morning (10.00-12.00) of the assigned day to induce final oocyte maturation with hCG trigger, immediately prior to administration of hCG for final oocyte maturation, 1 h, 2 h, and 36 h post hCG trigger. A prediction model, the Gompertz curve, was used to determine serum progesterone levels at intervals between the 2 h post hCG trigger sample and the day of oocyte retrieval. RESULTS: Statistically significant increases in serum progesterone levels were identified following hCG administration as early as 1 h following trigger (P4 0.57 ng/ml, p < 0.05), 2 h following trigger (P4 0.88 ng/ml, p < 0.001) and on the day of oocyte retrieval (P4 9.68 ng/ml, p < 0.001). According to our prediction model, the Gompertz curve, the projected serum progesterone level at 4 h post trigger would have achieved a level of 1.45 ng/ml, 8 h post trigger of 3.04 ng/ml, and 12 h post trigger of 4.8 ng/ml. The very early and significant increases in serum progesterone following hCG trigger are clearly demonstrated in this study. CONCLUSION: The endometrium is undoubtedly exposed to rapidly increasing serum progesterone levels post hCG trigger that would not be identified until much later in natural menstrual cycles. TRIAL REGISTRATION NUMBER: This study is registered with clinicaltrials.gov under the identifier NCT04417569.

Female parental consanguinity is associated with a reduced ovarian reserve.

RESEARCH QUESTION: Is parental consanguinity associated with a reduced ovarian reserve in women from the Arabian Peninsula, comparing anti-Müllerian hormone (AMH) and antral follicle count (AFC)? DESIGN: Retrospective large-scale observational study including 2482 women from the Arabian Peninsula, aged 19-49 years, who had their serum AMH and AFC measured as part of their fertility assessment, from May 2015 to November 2019. Consanguinity was defined as women whose parents were first-degree or second-degree cousins. Serum AMH was measured for all participants. RESULTS: A total of 2198 women were included: 605 in the consanguine group (27.53%), 1593 (72.47%) in the non-consanguine group. There were no significant differences between groups in terms of body mass index, years of infertility or smoking status. Women from the consanguine group were significantly younger (mean age 33.74 ± 6.64 years) compared with the non-consanguine group (mean age 34.78 ± 6.64 years, P < 0.0001). Median AMH and AFC for the consanguine group were 1.90 ng/ml (min-max: 0.01-23.8) and 11 (0-80), respectively, and for the non-consanguine group 1.84 ng/ml (min-max: 0.01-23.0) and 11 (0-60), respectively. AMH and AFC exhibit an age-dependent decline. As both parameters are age-dependent, the multivariate analysis showed that women from the consanguine group presented significantly lower AMH (coefficient of variation [CV] -0.07 ± 0.03, P = 0.036) and AFC (CV -0.16 ± 0.06, P = 0.003) compared with non-consanguine women, and the highest differences were found for women below 35 years of age (AMH median [min-max]: 2.82 ng/ml (0.01-23.80) versus 2.92 ng/ml (0.01-23.00); P = 0.035; AFC median [min-max]: 15 (0-80) versus 14 (0-80); P = 0.001). CONCLUSION: The adjusted analysis by age indicates that female parental consanguinity is associated with reduced ovarian reserve in the studied population. Clinical evaluation should include extensive family history and subsequent counselling of the affected couples.

Reintroducing serum FSH measurement during ovarian stimulation for ART.

RESEARCH QUESTION: What is the impact of systemic FSH concentrations during ovarian stimulation for IVF/intracytoplasmic sperm injection on systemic progesterone concentrations in the late follicular phase? DESIGN: Post-hoc analysis of a previously performed randomized controlled trial (RCT) performed between November 2017 and February 2020 in a tertiary IVF centre. The RCT included patients with infertility undergoing ovarian stimulation in a gonadotrophin-releasing hormone (GnRH) antagonist protocol. The GnRH antagonist was administered at 08:00 h and recombinant FSH at 20:00 h. Ultrasound and blood tests were performed 3-5 h after the GnRH antagonist. RESULTS: The subgroup analysis comprised 105 patients. Systemic FSH concentrations increased from Day 2/3 until initiation of GnRH antagonist and remained constant until the day of trigger (DoT). The total group was split according to the median FSH DoT concentration (12.95 IU/l; Group A <12.95 IU/l; Group B ≥12.95 IU/l). Significant differences, with the higher concentrations in Group B, were found for: systemic FSH concentration on Day 2/3 (P = 0.04), total gonadotrophin dosage (P = 0.03), progesterone on DoT (P = 0.001) and progesterone per follicle (P = 0.004). In the total group, systemic DoT FSH concentration was statistically significantly positively correlated with the DoT progesterone concentration and the ratio of progesterone per follicle (ρ = 0.37 and 0.38, respectively, both P < 0.001). No significant correlations were seen between the systemic DoT FSH concentration and the number of retrieved oocytes. CONCLUSION: While ovarian response seems to be independent from the systemic FSH concentrations on the DoT, high concentrations of circulatory FSH augment the production of progesterone.

Step-Down of FSH- Dosage During Ovarian Stimulation - Basic Lessons to Be Learnt From a Randomized Controlled Trial.

A rise in serum progesterone in the late follicular phase is a well described adverse effect of ovarian stimulation for IVF/ICSI. Previous data suggest, that enhanced gonadotropin stimulation causes progesterone elevation and the incidence of premature progesterone elevation can be reduced by declining gonadotropin dosages. This randomized controlled trial (RCT) aimed to achieve a significant reduction of the progesterone level on the day of final oocyte maturation by a daily reduction of 12.5 IU rec-FSH from a follicle size of 14 mm in a GnRH-antagonist protocol. A total of 127 patients had been recruited (Control group (CG): 62 patients; Study group (SG): 65 patients). Due to drop out, data from 108 patients (CG: 55 patients; SG: 53 patients) were included into the analysis. Patients' basic parameters, gonadotropin (Gn)-starting dose, total Gn-stimulation dosage, the number of retrieved and mature oocytes as well as in the hormonal parameters on the day of trigger (DoT) were not statistically significantly different. However, through stepwise Gn-reduction of 12.5 IU/day in the SG, there was a statistically highly significant difference in the Gn-stimulation dosage on the day of trigger (p < 0.0001) and statistically significant associations for the DoT-P4-levels with the DoT-FSH-levels for both groups (CG: p = 0.001; SG: p = 0.0045). The herein described significant associations between DoT-P4-levels and DoT-FSH-levels confirm the theory that enhanced FSH stimulation is the primary source of progesterone elevation on the day of final oocyte maturation in stimulated IVF/ICSI cycles. Given the pathophysiologic mechanism of progesterone elevation during ovarian stimulation, the use of an increased FSH step-down dosage should be studied in future RCTs, despite the fact that a step-down approach of daily 12.5 IU rec-FSH did not achieve a significantly reduced progesterone level on the DoT. Clinical Trial Registration: clinicaltrials.gov, identifier NCT03356964.

Euploidy rates are not affected when embryos are cultured in a continuous (CCM) or sequential culture medium (SCM): a sibling oocyte study.

PURPOSE: To determine if euploidy rates and embryo development differ when blastocysts are cultured in CCM or SCM. METHOD: A single-center retrospective observational study was performed from September 2018 to March 2019. Patients [23-46 years] with at least four fresh mature oocytes (MII) without severe male factor infertility were included. Sibling MII were injected and cultured in Global®Total®LP (CCM) or Sage Quinn's Advantage® Cleavage and Blastocyst media (SCM) under 6% CO2, 5% O2, and 89% N2. Fertilization, cleavage, day (D) 5 blastulation, usable blastocyst (blastocysts biopsied/normally fertilized oocytes), and euploidy rates were recorded. Blastocysts were graded prior to trophectoderm (TE) biopsy on D5, 6, or 7 for genetic testing and mitochondrial DNA (mtDNA) quantification. RESULTS: According to clinical practice, 1452 MII were randomly distributed: 751 in CCM and 701 in SCM. No differences were observed in fertilization and cleavages rates for CCM and SCM (77.4% vs 75.5%, p = 0.429 and 97.6% vs 99.1%, p = 0.094, respectively). Blastulation rate on D5 was higher in CCM (70.6% vs 62.2, p = 0.009); however, usable blastocyst rates were comparable (CCM: 58.3% vs SCM: 56.7%, p = 0.625). From a Poisson regression model adjusted for confounding factors, euploidy rates were not different between media (aOR = 1.18, [0.94-1.48], p = 0.157). Euploid blastocyst's mtDNA values were similar (CCM: 32.2, [30.5, 34.1] and SCM: 33.5, [31.8, 35.2], p = 0.345) and top-quality blastocysts (AA/BA) were increased in SCM (OR=1.04, [1.00-1.09], p = 0.037). CONCLUSION: Under controlled in vitro conditions, euploidy rates and embryo development are comparable when embryos are cultured in CCM or SCM.

Individualized luteal phase support.

PURPOSE OF REVIEW: The aim of this review is to summarize the different aspects of luteal phase deficiency in IVF treatment and the possibilities of individualized luteal phase support. RECENT FINDINGS: After the application of human chorionic gonadotrophin (hCG) for final oocyte maturation, the vaginal route for progesterone administration is sufficient to maintain an adequate luteal phase support. New data point toward the possibility of oral medication; however, those data have yet to be confirmed in larger studies. Luteolysis after gonadotropinrealzing hormone (GnRH) agonist trigger is patient specific and not always severe. According to the progesterone level, individualized low dosages of hCG can be applied as luteal phase support without the risk of ovarian hyperstimulation syndrome (OHSS) development. SUMMARY: It is the task of the reproductive medicine specialist to individualize luteal phase support according to the patient's specific characteristics, needs and desires and the type of treatment performed. The greatest indication for individualization of the luteal phase is following GnRH agonist trigger in high responder patients in order to tailor luteal phase support to the patient-specific pattern of luteolysis and minimize the risk of causing OHSS with unnecessary high hCG dosages.

What to do when good-quality embryos repeatedly fail to implant.

Recurrent implantation failure (RIF) is very distressing for couples and frustrating for their clinicians who seek to find a solution. RIF is defined as the failure to achieve a clinical pregnancy following the transfer of at least four good-quality embryos in a minimum of three fresh or frozen cycles in a woman of age below 40 years. An agreed local protocol regarding how couples with RIF should be further investigated and managed should be in place. Ovarian function should be assessed by measuring antral follicle count, FSH, and AMH. Chromosomal testing of the couple is advised to exclude genetic abnormalities that may lead to RIF. Various uterine pathologies including fibroids, endometrial polyps, congenital anomalies, and intrauterine adhesions should be excluded by ultrasonography and hysteroscopy. Hydrosalpinges are a recognized cause of implantation failure and should be excluded by hysterosalpingogram, and if necessary, laparoscopy should be performed to confirm or refute the diagnosis. Consideration should be given to preimplantation genetic screening (PGS) and the adoption of a "freeze-all" protocol. Treatment offered should be evidence based, aimed at improving embryo quality or endometrial receptivity. Gamete donation or surrogacy may be necessary if there is no realistic chance of success with further IVF attempts.

Factors affecting the outcome of "endometrial scratch" in women with recurrent implantation failure.

OBJECTIVE: To examine factors affecting the outcome of the endometrial scratch in women with recurrent implantation failure. STUDY DESIGN: A total of 57 eligible patients with a history of recurrent implantation failure underwent an endometrial biopsy in the luteal phase of the menstrual cycle in the month immediately preceding the embryo transfer cycle. The comparative group consisted of a retrospective cohort of 66 women with recurrent implantation failure but without endometrial biopsy. There were no significant differences between the intervention and control groups in terms of age, follicle-stimulating hormone (FSH), free androgen index, anti-Müllerian hormone, body mass index, the number of embryos transferred, and the number of embryo transfer cycles. RESULTS: The clinical pregnancy rate in the intervention group (53%) was significantly (p < 0.001) higher than that of the control group (15%). The only predictive factor was FSH. Women with FSH < or =10 IU/L had a pregnancy rate of 57.8%, significantly (p < 0.05) higher than that (20%) of women with FSH >10 IU/L. CONCLUSION: Women with a normal FSH are more likely to derive benefit from endometrial scratch.

Endometrial integrin expression in women with recurrent implantation failure after in vitro fertilization and its relationship to pregnancy outcome.

OBJECTIVE: To determine expression of integrins α1, α4, and αVß3 in the glandular and luminal epithelium, stroma, and cells in the blood vessel walls of the endometrium from women with recurrent implantation failure (RIF) and to determine if they are of prognostic value in determining pregnancy outcome. DESIGN: Prospective nonrandomized study. SETTING: Department of reproductive medicine. PATIENT(S): Forty-five women with RIF and six healthy fertile women were recruited. RIF was defined as the failure to conceive after the transfer of four good-quality embryos in three or more fresh or frozen cycles. INTERVENTION(S): Endometrial biopsy samples were obtained from women with RIF and control women on days LH+7-LH+9 of the cycle. Expression of integrins α1, α4, and αVß3 was determined by immunohistochemistry. MAIN OUTCOME MEASURE(S): A semiquantitative measurement of expression of each integrin protein in the luminal and glandular epithelium, stroma, and cells in the blood vessel walls was determined by H-score analysis. RESULT(S): Expression of integrins α1 and α4 was greatest in the luminal and glandular epithelial cells and the cells in the blood vessel wall, and significantly higher expression of integrins α1 and α4 was seen in the glandular epithelium compared with the luminal epithelium (H-scores: α1 293 ± 15 and 180 ± 12, α4 287 ± 14 and 191 ± 11, respectively). Expression of αVß3 in the epithelium and blood vessels was also greater than in the stroma but there was no significant difference in expression of αVß3 in glandular and luminal epithelium. No significant difference in H-scores was seen for α1, α4, and αVß3 expression in any of the endometrial compartments in tissue from women with RIF and control women. No significant difference in α1, α4, and αVß3 expression in any compartment was observed between those who achieved a clinical pregnancy after subsequent assisted conception treatment (n = 21) and those who were unsuccessful (n = 24). CONCLUSION(S): RIF, when defined as failure to achieve a clinical pregnancy after the transfer of at least four good-quality embryos in three transfer cycles, is not associated with abnormal endometrial integrin expression. In addition, the expression of integrins α1, α4, and αVß3 appears to have no prognostic value in subsequent IVF treatment.

What are the implications for the next delivery in primigravidae who have an elective caesarean section for breech presentation?

OBJECTIVE: To determine the mode of the next delivery for primigravid women who have an elective caesarean section for breech presentation. DESIGN: Retrospective cohort study. SETTING: University teaching hospital. POPULATION: All primigravid women who had an elective caesarean section for a singleton pregnancy in the years 1992 to 1997 and who delivered their next baby in the hospital before 1999. METHODS: Review of hospital computerised records. MAIN OUTCOME MEASURES: Mode of delivery and fetal presentation at next delivery. RESULTS: Of 194 women who had an elective caesarean section with a breech presentation as a primigravida, 19 (9.8%) had a breech presentation at the time of elective caesarean section for their next baby compared with only two (1.7%) in the 121 women who had an elective caesarean section with a cephalic presentation as a primigravida (RR 5.9 [95% CI 1.4-25.0]). Despite the increased likelihood of another breech presentation, the overall repeat section rate was 43.8% (n = 85) in women with a previous breech presentation (n = 194), compared with 61.2% (n = 74) in women with a previous cephalic presentation (n = 121) (RR 0.72 [95% CI 0.58-0.89]). Of those women allowed to labour after elective caesarean section as a primigravid, the vaginal birth rate was 109/130 (84%) if the presentation previously was breech compared with 47/69 (68%) if the presentation previously was cephalic (RR 1.2 [95% CI 1.03-1.50]). CONCLUSIONS: Women who have an elective caesarean section for a breech presentation in their first pregnancy have about a 1 in 10 chance of having an elective caesarean section for a breech presentation in their second pregnancy. Overall, the incidence of repeat caesarean section for their second baby was 43.8%, and of those allowed to labour, 84% achieved a vaginal delivery. These results compared favourably with women who had an elective caesarean section with a cephalic presentation in their first pregnancy. This information is important in advising primigravid women with a breech presentation about longer term implications of elective caesarean section. It also allows healthcare managers to anticipate the resource implications of any changes in clinical practice for women with a breech presentation in their first pregnancy.