Centre for Reproductive Medicine, Dutch-Speaking Brussels Free University, Laarbeeklaan 101, 1090 Brussels, Belgium
1 To whom correspondence should be addressed. e-mail: stratis{at}easynet.be
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Abstract |
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Key words: GnRH antagonists/IVF/ongoing pregnancy rate/progesterone elevation/recombinant FSH
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Introduction |
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No information is available on IVF outcome regarding the role of elevated progesterone levels at the time stimulation should commence, probably due to the universal use of the long GnRH agonist protocol in IVF in the last decade. The long agonist protocol demands the suppression of gonadotropins and achievement of basal levels of steroid hormones prior to initiation of stimulation. Therefore, all patients treated under this scheme start stimulation with normal progesterone levels (Huang et al., 1996).
Under the short GnRH protocol, however, or by using GnRH antagonists for premature LH surge inhibition, elevated progesterone levels at the time stimulation should begin can still be observed. In GnRH antagonist cycles, delaying administration of gonadotropins for 12 days usually results in normalization of progesterone values in healthy patients. It is not known, however, if the chance of pregnancy after IVF is different from that in patients with normal progesterone levels on day 2 of the cycle.
In phase III comparative studies between GnRH antagonists and GnRH agonists, no information is available in the antagonist arm either for the incidence of abnormal steroid levels on the day stimulation should start or for the management and outcome of these patients (Albano et al., 2000; Borm and Mannaerts, 2000
; Olivennes et al., 2000
; European and Middle East Orgalutran Study Group, 2001
; Fluker et al., 2001
).
The purpose of this study was to prospectively compare the ongoing pregnancy rates in patients with normal or elevated progesterone levels on day 2 of the cycle treated by GnRH antagonist and recombinant FSH (rFSH) for IVF.
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Materials and methods |
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Ovarian stimulation and IVF procedure
Stimulation was initiated on day 2 of the cycle when estradiol (E2) and progesterone levels were normal (E2 80 pg/ml, progesterone
1.6 ng/ml; normal-P group).
When progesterone was >1.6 ng/ml on day 2 of the cycle, initiation of stimulation was postponed for 12 days and progesterone levels were followed daily (high-P group). If progesterone levels were normalized within 2 days, stimulation with rFSH was initiated. If however, progesterone remained elevated after 2 days, the cycle was cancelled.
Stimulation was performed with rFSH (Puregon; NV Organon, Oss, The Netherlands) at a dose determined according to patients age and/or previous response to ovarian stimulation (range 100500 IU). The dose of rFSH remained constant during stimulation unless there was no increase in serum E2 levels after 5 days of stimulation. Daily GnRH antagonist 0.25 mg (Orgalutran; NV Organon) was used to inhibit premature LH surge and was always started on the morning of day 6 of stimulation.
Final oocyte maturation was achieved by 10 000 IU of HCG (Pregnyl; NV Organon) when at least three follicles of 17 mm were present at ultrasound.
Oocyte retrieval was carried out 36 h after HCG administration by transvaginal ultrasound-guided puncture of follicles. Conventional IVF was performed in 109 couples, ICSI in 277 couples and both conventional IVF and ICSI in 24 couples. ICSI and IVF procedures have been described in detail previously (Van Steirteghem et al., 1993; Devroey et al., 1995
). As a matter of principle, two embryos were transferred on day 3 or day 5 after oocyte retrieval. Embryos were classified as top quality (score 1) medium quality (score 2) or low quality (score 3), as described previously (Staessen et al., 1992
; Gardner et al., 1999
). The mean score of the embryos transferred to each patient was used for the calculation of the mean quality score of all embryos transferred.
Luteal supplementation
The luteal phase was supplemented with vaginal administration of 600 mg natural micronized progesterone in three separate doses (Utrogestan; Besins, Brussels, Belgium), starting 1 day after oocyte retrieval and continued until 7 weeks of gestation if pregnancy was achieved.
Hormonal measurements
Hormonal assessment was performed on day 2 of the cycle, at initiation of stimulation, on day 6 and 8 of rFSH stimulation and on the day of HCG administration. Additional blood samples were taken as necessary between antagonist initiation and HCG administration. Serum LH, FSH, HCG, E2 and progesterone levels were measured by means of the automated Elecsys Immunoanalyser (Roche Diagnostics, Mannheim, Germany). Intra-assay and inter-assay coefficients of variation were <3% and <4% for LH, <3% and <6% for FSH, <5% and <7% for HCG, <5% and <10% for E2 and <3% and <5% for progesterone, respectively.
Outcome measures
Pregnancies progressing beyond the 12th week of gestation were considered to be ongoing. Ongoing implantation rate was calculated by dividing the number of gestational sacs with fetal heartbeat present at 12 weeks of gestation by the number of embryos transferred.
Statistical analysis
Fishers exact test was used to analyse nominal variables in the form of frequency tables. Metric variables were analysed by the MannWhitney U-test. Values are expressed as median (interquartile range), unless stated otherwise.
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Results |
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Delaying initiation of stimulation resulted in normalization of progesterone values in 16 patients (80%) after a mean period of 1 (1) day. In four patients, progesterone levels remained elevated, despite a drop compared with the initially recorded values. In these patients the cycle was cancelled.
Similar indications for IVF treatment were present in patients with normal and high progesterone levels on day 2 of the cycle (Table I).
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A significantly lower ongoing pregnancy rate per started cycle, per oocyte retrieval and per embryo transfer was present in the high-P compared with the normal-P group (Table III).
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Discussion |
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This was a prospective study in which all participants were stimulated with rFSH and GnRH antagonists. Patients with elevated progesterone levels on day 2 of the cycle were always postponed for 12 days, and stimulation was started only if progesterone levels returned to normal range.
To our knowledge, no information is available in the literature on the incidence of elevated progesterone levels in healthy patients prior to initiation of stimulation for IVF, although it should be expected that this information would have been available in cycles treated with the short GnRH agonist protocol. In infertile couples, Keck et al. (1999) reported the presence of elevated progesterone levels in 11.4% of patients assessed on day 45 of the cycle (36/316) patients).
Moreover, little information is available on the association of progesterone levels prior to initiation of stimulation with IVF outcome. In GnRH agonist cycles using the long protocol, Huang et al. (1996) showed that elevated progesterone levels after 10 days of analogue treatment were associated with significantly lower E2 levels on day 5 of stimulation and on the day of HCG administration. In these patients, for whom stimulation was started after normalization of progesterone values by extending the period of down-regulation, a significantly higher cancellation rate was also observed.
Limited information is also available on the effect of elevated progesterone levels in the early follicular phase on IVF outcome. Sims et al. (1994), using a short GnRH agonist protocol, showed that following analogue administration elevated progesterone levels during cycle days 26 were associated with a higher requirement for gonadotropins, lower peak E2 concentrations and fewer mature oocytes retrieved.
In the current study, the presence of elevated progesterone levels did not identify a subpopulation of women undergoing IVF in terms of age, diagnosis, FSH levels at initiation of stimulation, starting dose of FSH or duration of stimulation (Table I).
No significant differences were observed in the number of follicles present on the day of HCG administration or the number of cumulusoocyte complexes retrieved, which however, tended to be higher in patients with normal progesterone levels on day 2 of the cycle.
However, it is clear that patients with elevated progesterone levels on day 2 of the cycle had been exposed to a significantly different hormonal environment compared with those with normal progesterone levels.
Progesterone levels, despite normalization, were significantly higher on day 1 of stimulation, as well as on days 6 and 8 of stimulation, in patients with elevated progesterone values on day 2 of the cycle compared with those with normal levels.
This might be attributed to progesterone production by a corpus luteum that did not undergo functional luteolysis completely, and might have retained partially its ability to produce progesterone under stimulation by endogenous and exogenous gonadotropins in the treatment cycle. As follicular development occurred, progesterone was also produced by the developing follicles, which might have led to the similar levels of serum progesterone on the day of HCG administration in the two groups compared.
Moreover, E2 levels were significantly lower in the high-P group on days 6 and 8, and on the day of HCG administration. This might be a reflection of the tendency for an increased number of follicles observed in the normal-P group.
The potential influence of these hormonal differences on pregnancy rates might be exerted at the level of oocyte/embryo and/or at the level of endometrium. However, no evidence is provided by the current study that the difference observed in ongoing pregnancy rates can be attributed to reduced oocyte/embryo quality in patients with elevated progesterone on day 2 of the cycle. Fertilization rates and number of transferred embryos were similar between the two groups, while the quality of the transferred embryos, using established criteria for morphological evaluation, was identical. It is thus possible that the different hormonal environment during the follicular phase between the two groups compared might result in different endometrial receptivity. It is therefore interesting to assess in GnRH antagonist cycles whether high exposure to progesterone levels from initiation of stimulation results in a histologically more advanced endometrium, known to be associated with a lower chance of pregnancy (Kolibianakis et al., 2002).
The current study suggests that if elevated progesterone levels are present on day 2 of the cycle in which premature LH inhibition is achieved using GnRH antagonists, the cycle should be cancelled. This might represent a coincidental event that will not reoccur in the next cycle.
In conclusion, the presence of elevated serum progesterone on day 2 of the cycle is associated with a decreased chance of pregnancy in patients treated with rFSH and GnRH antagonists.
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Acknowledgements |
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References |
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Borm G and Mannaerts B (2000) Treatment with the gonadotropin-releasing hormone antagonist ganirelix in women undergoing ovarian stimulation with recombinant follicle stimulating hormone is effective, safe and convenient: results of a controlled, randomized, multicentre trial. The European Orgalutran Study Group. Hum Reprod 7,14901498.[CrossRef]
Devroey P, Tjandraprawira K, Mannaerts B, Coelingh Bennink H, Smitz J, Bonduelle M, De Brabanter A and Van Steirteghem AC (1995) A randomized, assessor-blind, group-comparative efficacy study to compare the effects of Normegon and Metrodin in infertile female patients undergoing in-vitro fertilization. Hum Reprod 2,332337.
European and Middle East Orgalutran Study Group (2001) Comparable clinical outcome using the GnRH-antagonist ganirelix or a long protocol of the GnRH-agonist triptorelin for the prevention of premature LH surges in women undergoing ovarian stimulation. Hum Reprod 16,644651.
Fluker M, Grifo J, Leader A, Levy M, Meldrum D, Muasher SJ, Rinehart J, Rosenwaks Z, Scott RT Jr, Schoolcraft W et al. (2001) Efficacy and safety of ganirelix acetate versus leuprolide acetate in women undergoing controlled ovarian hyperstimulation. Fertil Steril 1,3845.
Gardner DK and Schoolcraft WB (1999) In-vitro culture of human blastocysts. In Jansen R and Mortimer D (Eds) Towards Reproductive Certainty: Infertility and Genetics Beyond 1999. Parthenon Press, Carnforth, UK, pp. 377388.
Huang JC, Jackson KV, Hornstein MD and Ginsburg ES (1996) The effect of elevated serum progesterone during ovulation induction in in-vitro fertilizationembryo transfer. J Assist Reprod Genet 13,617624.[Medline]
Keck C, Neulen J, Breig-Lauel S and Breckwoldt M (1999) Elevated serum progesterone concentrations during the early follicular phase of the menstrual cycle: clinical significance and therapeutic implications. Gynecol Endocrinol 13,161165.[Medline]
Kolibianakis E, Bourgain C, Albano C, Osmanagaoglu K, Smitz J, Van Steirteghem A and Devroey P (2002) Effect of ovarian stimulation with recombinant follicle-stimulating hormone, gonadotropin releasing hormone antagonists, and human chorionic gonadotropin on endometrial maturation on the day of oocyte pick-up. Fertil Steril 78,10251029.[CrossRef][Medline]
McCracken JA, Custer EE and Lamsa JC (1999) Luteolysis: a neuroendocrine-mediated event. Physiol Rev 79,263323.
Olivennes F, Belaisch-Allart J, Emperaire JC, Dechaud H, Alvarez S, Moreau L, Nicollet B, Zorn JR, Bouchard P and Frydman R (2000) Prospective, randomized, controlled study of in vitro fertilizationembryo transfer with a single dose of a luteinizing hormone-releasing hormone (LH-RH) antagonist (cetrorelix) or a depot formula of an LH-RH agonist (triptorelin). Fertil Steril 2,314320.[CrossRef]
Sims JA, Seltman HJ and Muasher SJ (1994) Early follicular rise of serum progesterone concentration in response to a flare-up effect of gonadotropin-releasing hormone agonist impairs follicular recruitment for in-vitro fertilization. Hum Reprod 9,235240.[Abstract]
Staessen C, Camus M, Bollen N, Devroey P and Van Steirteghem AC (1992) The relationship between embryo quality and the occurrence of multiple pregnancies. Fertil Steril 57,626630.[Medline]
VanSteirteghem AC, Nagy Z, Joris H, Liu J, Staessen C, Smitz J, Wisanto A and Devroey P (1993) High fertilization and implantation rates after intracytoplasmic sperm injection. Hum Reprod 7,10611066.
Submitted on February 10, 2004; accepted on March 24, 2004.