Does serum progesterone level impact the ongoing pregnancy rate in frozen embryo transfer under artificial preparation with vaginal progesterone? Study protocol for a randomized controlled trial

Background In previous retrospective studies, low serum progesterone level on the embryo transfer day is associated with lower clinical pregnancy and ongoing pregnancy rates. Whether adding progesterone in low serum progesterone patients can rescue the outcome, there is no sufficient evidence from randomized controlled studies. Methods This trial is a clinical randomized controlled study (high serum progesterone vs low serum progesterone 1:1, 1:1 randomization ratio of intervention vs the control group with low serum progesterone). The eligible hormone replacement therapy—frozen embryo transfer (HRT-FET) cycles, will be recruited and randomly assigned to two parallel groups when serum progesterone is < 7.24μg/l on the day of embryo transfer for D3. The intervention group will be extrally given intramuscular progesterone 40 mg per day from D3 to 8 weeks of gestation if clinical pregnancy. The primary outcome is the ongoing pregnancy (beyond 12 weeks of gestation) rate. Discussion The findings of this study will provide strong evidence for whether the progesterone addition from the D3 in low serum progesterone patients can improve the outcome in the HRT-FET cycle. Trial registration ClinicalTrials.govNCT04248309. Registered on January 28, 2020

Exploration of the value of progesterone and progesterone/estradiol ratio on the hCG trigger day in predicting pregnancy outcomes of PCOS patients undergoing IVF/ICSI: a retrospective cohort study

Background Polycystic ovary syndrome (PCOS) is a common endocrine disorder with the disorders of estrogen(E2) and progesterone(P) secretion. The purpose of this study was to evaluate the association between the progesterone level or progesterone/estradiol(P/E2) ratio on human chorionic gonadotropin (hCG) trigger day and the outcome of in vitro fertilization in PCOS patients and explore the value of progesterone and P/E2 ratio for predicting the clinical pregnancy. Methods The clinical data of 1254 PCOS patients who satisfied the inclusion criteria were retrospectively analyzed, including baseline characteristics such as age, body mass index, basal sex hormone levels, et al., as well as ovarian stimulation data and clinic outcome. Results The number of follicles larger than 14 mm in diameter (P < 0.001) and retrieved oocytes (P < 0.001) was greater in the high progesterone group (progesterone ≥ 0.92 ng/mL). In the high P/E2 group(P/E2 ratio ≥ 0.3), the number of follicles larger than 14 mm in diameter (P < 0.001) and retrieved oocytes (P < 0.001), as well as the rate of high-quality embryos (P = 0.040) were significantly decreased. In ultralong GnRH agonist protocol, the implantation rate(P < 0.001), hCG positive rate (P < 0.001), clinical pregnancy rate (P < 0.001) and live birth rate (P < 0.001) were all significantly higher than long GnRH agonist protocol and GnRH antagonist protocol. The clinical pregnancy rate of high progesterone group was significantly lower than that of low progesterone group in ultralong GnRH agonist (P = 0.008). The progesterone level could be used as an indicator to predict the positive clinical pregnancy (long GnRH agonist: P = 0.001; ultralong GnRH agonist: P < 0.001) except in cycles using GnRH antagonist (P = 0.169). In the ultralong GnRH agonist, the value of progesterone level in the prediction of clinical pregnancy was significantly higher than that of the P/E2 ratio (P = 0.021). Conclusions In PCOS patients, the progesterone level is associated with clinical pregnancy rate while P/E2 ratio is not. In subgroup analysis using three different COS protocols, a significant association between progesterone level and clinical pregnancy rate can be observed in the long GnRH agonist protocol and ultralong GnRH agonist protocol. The progesterone level is significantly better than the P/E2 ratio in predicting the pregnancy outcome of PCOS patients, especially in ultralong GnRH agonist cycles.

Serum Progesterone and Serial Beta-hcG Levels in Predicting the Outcome of Early Pregnancies With Doubtful Viability: A Prospective Observational Research

BACKGROUND: To evaluate the doubling rate of maternal serum serial β-hCG and a single initial serum progesterone level to predict fetal viability before ultrasonography in women diagnosed with intrauterine pregnancy of undetectable viability. METHODS: 336 pregnant women who applied to the outpatient clinic at Istanbul Okmeydanı City Hospital between March and December 2018 were evaluated on a “Prospective observational” basis. 236 women were excluded from the study for various reasons. The study was completed with 100 pregnant women diagnosed with intrauterine pregnancy (IUP) involving suspected fetal viability by transvaginal ultrasonography only, who met the inclusion criteria with CRL: < 7mm and mean gestational sac diameter: < 25mm. Serum β-hCG and progesterone were taken at the first admission. After 48 hours, control serum β-hCG was taken and the increase rates were calculated. Early pregnancy loss was diagnosed by (transvaginal) TV-USG performed after the days 7, 11 and 14. Patients were divided into two groups as fetal heart rate (FHR) positive (viable) and FHR negative (early pregnancy loss). Pregnancy results were compared with β-hCG increase rates and progesterone value. SPSS 22.0 software was used for statistical analysis and P<0.05 was accepted as statistically significant.RESULTS: No statistically significant result was obtained between the viable and early pregnancy loss (FHR +/-) groups in terms of maternal age, previous pregnancy anamnesis, nationality, presenting symptoms, or ultrasound findings. According to the last menstrual period, the mean gestational age was 45.1±14 days in the viable (FHR+) group and 51.3±14 days in the Early pregnancy loss (FHR-) group, and this difference was found to be statistically significant. Estimation modality was developed in terms of viability with the serum progesterone values and increase rates of β-hCG. The study, which was conducted with a confidence interval of 95%, found the viability rate to be 70% with a β-hCG increase rate of 31%, 80% in the case of an increase by 49%, 90% in the case of an increase by 73%, 95% in the case of an increase by 97%, and 100% in the case of an increase by 181%. For progesterone, when the value was 5.9 ng/ml, the viability rate was 49%, and it was 69% at 10.5 ng/ml, 80% at 13.4 ng/ml, 90% at 18.0 ng/ml, 95% at 21.7 ng/ml, 99% at 29.3 ng/ml, and 100% at 37.5 ng/ml and above. In conclusion, the significant efficacy values of β-hCG increase and first progesterone level in predicting viability were found to be ROC AUC: [0.748 (0.621-0.874)] and ROC AUC: [0.796 (0.685-0.907)], respectively.CONCLUSION: Either Serial β-hCG ratio or serum progesterone level can be used alone to predict pregnancy outcome in early pregnancy. With dissemination of similar studies, estimation modalities can be improved and TV-USG examinations can help shortening the waiting time for results to reduce anxiety of families, hospital admissions and health expenses.

Uterine Notch2 facilitates pregnancy recognition and corpus luteum maintenance via upregulating decidual Prl8a2

The maternal recognition of pregnancy is a necessary prerequisite for gestation maintenance through prolonging the corpus luteum lifespan and ensuring progesterone production. In addition to pituitary prolactin and placental lactogens, decidual derived prolactin family members have been presumed to possess luteotropic effect. However, there was a lack of convincing evidence to support this hypothesis. Here, we unveiled an essential role of uterine Notch2 in pregnancy recognition and corpus luteum maintenance. Uterine-specific deletion of Notch2 did not affect female fertility. Nevertheless, the expression of decidual Prl8a2, a member of the prolactin family, was downregulated due to Notch2 ablation. Subsequently, we interrupted pituitary prolactin function to determine the luteotropic role of the decidua by employing the lipopolysaccharide-induced prolactin resistance model, or blocking the prolactin signaling by prolactin receptor-Fc fusion protein, or repressing pituitary prolactin release by dopamine receptor agonist bromocriptine, and found that Notch2-deficient females were more sensitive to these stresses and ended up in pregnancy loss resulting from abnormal corpus luteum function and insufficient serum progesterone level. Overexpression of Prl8a2 in Notch2 knockout mice rescued lipopolysaccharide-induced abortion, highlighting its luteotropic function. Further investigation adopting Rbpj knockout and DNMAML overexpression mouse models along with chromatin immunoprecipitation assay and luciferase analysis confirmed that Prl8a2 was regulated by the canonical Notch signaling. Collectively, our findings demonstrated that decidual prolactin members, under the control of uterine Notch signaling, assisted pituitary prolactin to sustain corpus luteum function and serum progesterone level during post-implantation phase, which was conducive to pregnancy recognition and maintenance.

P–404 Low serum progesterone on the day of frozen blastocyst transfer is associated with a diminished ongoing pregnancy rate in hormonal replacement therapy cycles

Study question Is there a relationship between progesterone levels on the day of frozen blastocyst transfer and ongoing pregnancy rate (OPR), in hormonal replacement therapy (HRT) cycles? Summary answer Women undergoing HRT-frozen embryo transfer with progesterone levels≤9.76ng/ml on the day of blastocyst transfer had a significantly lower OPR than those with progesterone levels&gt;9.76 ng/ml. What is known already The importance of serum progesterone levels around the time of frozen embryo transfer (FET) is a burning issue, in view of the growing number of FET worldwide. However, the optimal range of serum progesterone levels is not clearly determined and discrepancies arise from the current literature. Study design, size, duration: Observational cohort study with 915 patients undergoing HRT-FET at a tertiary care university hospital, between January 2019 and March 2020. Participants/materials, setting, methods Patients undergoing single autologous blastocyst FET under HRT using exogenous estradiol and vaginal micronized progesterone for endometrial preparation. Women were only included once during the study period. The serum progesterone level was measured in the morning of the FET, in a single laboratory. The primary endpoint was OPR beyond pregnancy week 12. Statistical analysis was conducted using univariate and multivariate logistic regression models. Main results and the role of chance Mean serum progesterone level on the day of FET was 12.90 ± 4.89 ng/ml). The OPR was 35.5% (325/915) in the overall population. Patients with a progesterone level ≤ 25th percentile (≤9.76ng/ml) had a significantly lower OPR and a higher miscarriage rate (MR) compared with women with progesterone level over Centile 25 (29.6% versus 37.4%; p = 0.033 and 34.8% versus 21.3%; p = 0.008, respectively). After adjustment for the potential confounders in a multivariate analysis, a serum progesterone level ≤ 9.76 ng/ml on the day of FETand FET of a Day 6-blastocyst (versus Day 5-blastocyst) were found as independent risks factor of lower OPR. Limitations, reasons for caution The main limitation of our study is linked to its observational design. Extrapolation of our results to other laboratories, or other routes and/or doses of administering progesterone also needs to be validated. Wider implications of the findings: This study suggests that a minimum serum progesterone level is needed to optimize reproductive outcomes in autologous blastocyst FET, in HRT-cycles. Further studies are needed to evaluate if modifications of progesterone routes and/or doses may improve pregnancy chances, in an approach to individualize the management of ART patients. Trial registration number NA

P–665 Influence of premature progesterone elevation on embryo development

Study question Does a serum progesterone level higher than 1.3 ng/mL on the day of ovulation trigger have an impact on blastocyst development? Summary answer Elevated progesterone level has no significant impact on top blastocyst rate, usable blastocyst rate and on morphokinetics. What is known already Premature elevation of progesterone level on the day of ovulation trigger prior to IVF is common and causes a decrease in endometrial receptivity. A freeze all strategy is then recommended. However, cumulative live birth rates have also been described as lower in cases of high progesterone levels. Study design, size, duration This was a retrospective bicentric cohort follow-up study, including 1150 IVF/ICSI cycles performed between 2016 and 2018 with at least 1 day–5 blastocyst available for transfer or freezing. Among these cycles, 524 were performed with use of a time-lapse system (Embryoscope). Serum Progesterone level was measured on the day of ovulation trigger, and a value &gt;1.3 ng/ml was used to identify premature progesterone elevation. Participants/materials, setting, methods The cycles were divided into 2 groups according to serum progesterone level: 1335 cycles were allocated in the normal progesterone group (P &lt; 1,3) and 215 in the progesterone premature elevation group (P &gt; 1.3). Patient’s characteristics, ovarian stimulation characteristics, IVF cycles characteristics and embryology parameters were anonymously recorded and compared between the 2 groups. Main results and the role of chance Female age, smoking status, AFC and AMH levels were comparable between the 2 groups. Female BMI was significantly higher in the P &lt; 1,3 than in the P &gt; 1.3 group (26.1 versus 24.7 kg/m² respectively). Total FSH dose, estradiol level, number of follicles &gt;11mm and number of retrieved oocytes were significantly higher in the P &gt; 1.3 group than in P &lt; 1.3 group No difference was observed between the 2 groups in terms of top blastocyst rate per mature oocyte and usable blastocyst rate per mature oocyte. When morphokinetic analysis was available, time to blastulation was the only significantly different parameter between the 2 groups (110.4 hours in P &lt; 1.3 versus 107.9 hours in P &gt; 1.3, p = 0.04). Cumulative live birth rate per cycle was not statistically different between the two groups (23.1% for P &lt; 1.3 versus 28.7% for P &gt; 1.3) (p &gt; 0.05). Limitations, reasons for caution The retrospective design of the study should lead to careful analysis of the results. The progesterone threshold refers to a specific assay, and should not be generalized to other assays. Wider implications of the findings: Premature elevation of serum progesterone level on the day of ovulation trigger does not seem to affect embryo developmental competence. This further supports the relevance of freeze all strategy in this situation. Trial registration number Not applicable