Department of Obstetrics and Gynecology, IVF Unit, Rambam Medical Center, and Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
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Abstract |
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Key words: cryopreservation/human embryos/natural progesterone/thaw cycle/vaginal route of administration
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Introduction |
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The outcome of a thaw cycle relies on several factors: quality of the embryos that were cryopreserved, laboratory freezing and thawing procedures, uterine receptivity on the day the thawed embryos are transferred and adequate luteal support. Uterine receptivity depends on the way the endometrium was prepared for embryo transfer. Basically, three methods are used for endometrial preparation: natural cycle, programmed cycle, ovarian stimulation cycle. Based on our data (Lightman et al., 1997), and that of others (Sathanandan et al., 1991
; Pattinson et al., 1992
), these three approaches result in comparable pregnancy rates. Since the programmed cycle method described (Serhal and Craft, 1987
) for ovum donation is the simplest approach as far as the patient is concerned, our general policy is to choose this method. The major advantages of this approach are that prior gonadotrophin-releasing hormone agonist (GnRHa) suppression is not needed (Lelaidier et al., 1992
, 1995
; Pattinson et al., 1992
; Queenan et al., 1997
; Simon et al., 1998
), and that there is full control of the timing of embryo transfer.
Typically in these cycles, progesterone is given as i.m. injections of natural progesterone in oil (Queenan et al., 1997). This route of administration of an oily preparation is not met with great enthusiasm by most patients, as it is often associated with painful injections and rash. Therefore, we sought an alternative preparation that can supplement the required progesterone. Based on prior data (Smitz et al., 1992
), it appears that vaginal progesterone may present such a desirable alternative. These researchers compared i.m. and intravaginal luteal phase supplementation during `fresh' IVF cycles using fresh embryos. Despite lower plasma progesterone concentrations, the outcome in the group receiving intravaginal progesterone was as favourable as that in the group receiving i.m. progesterone. Similar results were described in stimulated cycles (Bourgain et al., 1994
), and in a donor oocyte programme (Gibbons et al, 1998
). However, other researchers recommend the use of injectable progesterone based on better outcome compared to vaginal progesterone (Perino et al., 1997
).
The purpose of the current study, therefore, was to compare, in a prospective randomized fashion, the outcome of programmed freezethaw cycles during which either i.m. or vaginal progesterone was used.
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Materials and methods |
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Freezing and thawing protocols
Embryo freezing and thawing were performed as previously published (Lightman et al., 1997). Briefly, day 2 or 3 embryos were exposed to a graded series (0.5, 1, 1.5 mol/l) of propanediol (PROH) in modified Dulbecco's phosphate-buffered saline (Sigma, St Louis, MO, USA) or HEPES-HTF (Irvine Scientific, Irvine, CA, USA) with 15% Synthetic Serum Substitute (Irvine Scientific). Embryos were then loaded into Nunc cryovials (Nunc, Roskilde, Denmark) containing 1.5 mol/l PROH and 0.2 mol/l sucrose and frozen in the Planer freezer (Planer Products, London, UK). Embryos were cooled from room temperature to 6.5°C at 2°C/min, held for 10 min after seeding, and cooled to 30°C at 0.3°C/min. After holding for 5 min at 30°C, embryos were cooled to 180°C at 50°C/min and plunged into liquid nitrogen for storage. For thawing, the vials were immersed in a 37°C water bath for a few minutes until all ice disappeared. The cryoprotectant was then removed in a stepwise fashion by decreasing the propanediol concentrations at 5 min intervals. The embryos were then evaluated, graded and transferred after 14 h in culture.
Clinical pregnancy confirmation
A pregnancy test was done 12 days after embryo transfer. If positive, transvaginal ultrasound was performed 2 weeks later to confirm clinical pregnancy [defined as demonstrable gestational sac(s)].
Statistics
Statistical analysis of the results was carried out using Student's t-test and 2 analyses The 5% significance level was considered as significant.
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Results |
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Discussion |
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Our data seem to be in agreement with this line of evidence. Despite significantly lower plasma progesterone concentration, vaginal progesterone resulted in a pregnancy rate comparable to that achieved with i.m. progesterone. On the other hand, higher pregnancy rates have been reported with injectable progesterone compared with micronized vaginal progesterone used for luteal phase support (Perino et al., 1997). It should be noted that Perino and coworkers used only one-third of the vaginal progesterone dose used in our study (i.e. 200 mg/day versus 600 mg/day). This significant difference may explain the less favourable outcome reported.
Although the two routes of administration did not differ significantly in terms of abortion rate (Table III), the numbers of patients in each group were quite small. Further studies with larger numbers of patients are required to confirm this lack of association.
Being an open study, our non-biased randomization was strictly enforced as evidenced by the similarity between the two groups in the relevant clinical aspects (age at freezing and thawing, diagnosis, number of embryos replaced and their quality etc.). We also ruled out a possible bias of using embryos originating from a successful previous fresh cycle. The strategy in planning programmed thaw cycles should be based on success rate, patient comfort and cost. Using prior GnRHa suppression increases the cost considerably, but does not contribute to higher success rate (Simon et al., 1998). Injectable progesterone in oil is clinically acceptable, although we frequently observe disturbing side-effects (local reaction, fever, urticaria) after its use. Patients often express their desire to have an alternative treatment, especially as extended progesterone supplementation in these cycles is imperative if pregnancy is to be achieved. Oral micronized progesterone is a valid option, although the direct endometrial effect does not take place, and its bioavailability is only 10% of that found after i.m. progestrone (Simon et al., 1993
). Moreover, patients receiving oral progesterone often complain of disturbing side effects, mainly drowsiness. Based on these considerations, we suggest that a programmed cycle based on vaginal progesterone, as described herein, is not only simple and successful, but also more convenient to the patients. The apparently alarming low plasma progesterone concentrations achieved by the vaginal route should be regarded in the light of the probable higher endometrial concentrations.
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Acknowledgments |
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Notes |
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References |
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Bourgain, C., Smitz, J., Camus, M. et al. (1994) Human endometrial maturation is markedly improved after luteal supplementation of gonadotrophin-releasing hormone analogue/human menopausal gonadotrophin stimulated cycles. Hum. Reprod., 9, 3240.[Abstract]
Bulletti, C., de Ziegler, D., Flamigni, C. et al. (1997) Targeted drug delivery in gynaecology: the first uterine pass effect. Hum. Reprod., 12, 10731079.[ISI][Medline]
Fanchin, R., de Ziegler, D., Bergeron, C. et al. (1997) Trans-vaginal administration of progesterone. Obstet. Gynecol., 90, 396401.
Gibbons, W.E., Toner, J.P., Hamacher, P. and Kolm, P. (1998) Experience with novel vaginal progesterone preparation in a donor oocyte program. Fertil. Steril., 69, 96101.[ISI][Medline]
Lelaidier, C., de Ziegler, D., Gaetano, J. et al. (1992) Controlled preparation of the endometrium with exogenous estradiol and progesterone: a novel regimen not using a gonadotrophin-releasing hormone agonist. Hum. Reprod., 7, 13531356.[Abstract]
Lelaidier, C., de Ziegler, D., Freitas, S. et al. (1995) Endometrium preparation with exogenous estradiol and progesterone for the transfer of cryopreserved blastocysts. Fertil. Steril., 63, 919921.[ISI][Medline]
Lightman, A., Kol, S., Wayner, V. et al. (1997) The presence of a sponsoring embryo in a batch of poor quality thawed embryos significantly increases pregnancy and implantation rate. Fertil. Steril., 67, 711716.[ISI][Medline]
Miles, R.A., Paulson, R.J., Lobo, R.A. et al. (1994) Pharmacokinetics and endometrial tissue levels of progesterone after administration by i.m. and vaginal routes: a comparative study. Fertil. Steril., 62, 485490.[ISI][Medline]
Pattinson, H.A., Greene, C.A., Fleetham, J. and Anderson-Sykes, S.J. (1992) Exogenous control of the cycle simplifies thawed embryo transfer and results in pregnancy rate similar to that for natural cycles. Fertil. Steril., 58, 627629.[ISI][Medline]
Perino, M., Brigandi, F.G., Abate, F.G. et al. (1997) Intramuscular versus vaginal progesterone in assisted reproduction: a comparative study. Clin. Exp. Obstet. Gynecol., 24, 228231.[Medline]
Queenan, J.T. Jr, Ramey, J.W., Seltman, H.J. et al. (1997) Transfer of cryopreservedthawed pre-embryos in a cycle using exogenous steroids without prior gonadotrophin-releasing hormone agonist suppression yields favorable pregnancy results. Hum. Reprod., 12, 11761180.[ISI][Medline]
Sathanandan, M., Macnamee, M.C., Rainsbury, P. et al. (1991) Replacement of frozenthawed embryos in artificial and natural cycles: a prospective semi-randomized study. Hum. Reprod., 6, 685687.[Abstract]
Sauer, M.V., Stein, A.L., Paulson, R.J. and Moyer, D.L. (1991) Endometrial responses to various hormone replacement regimens in ovarian failure patients preparing for embryo donation. J. In Vitro. Fert. Embryo. Trans., 35, 6168.
Serhal, P. and Craft, I. (1987) Simplified treatment for ovum donation. Lancet, i, 687688.
Simon, A., Hurwitz, A., Zentner, B.S. et al. (1998) Transfer of frozenthawed embryos in artificially prepared cycles with and without prior gonadotrophin-releasing hormone agonist suppression: a prospective randomized study. Hum. Reprod., 13, 27122717.
Simon, J.A., Robinson, D.E., Andrews, M.C. et al. (1993) The absorption of oral micronized progesterone: the effect of food, dose proportionality, and comparison with i.m. progesterone. Fertil. Steril., 60, 2633.[ISI][Medline]
Smitz, J., Devroey, P., Faguer, B. et al. (1992) A prospective randomized comparison of i.m. or intravaginal natural progesterone as a luteal phase and early pregnancy supplement. Hum. Reprod., 7, 168175.[Abstract]
Templeton, A., and Morris, J.K. (1998) Reducing the risk of multiple births by transfer of two embryos after in vitro fertilization. N. Engl. J. Med., 339, 573577.
Veeck, L.L. (1990) The morphological assessment of human oocytes and early concepti. In Keel, B.A., Webster, B.W. (eds), CRC Handbook of the Laboratory Diagnosis and Treatment of Infertility. CRC Press, Boca Raton, pp. 365367.
Submitted on March 3, 1999; accepted on June 30, 1999.