http://informahealthcare.com/gye ISSN: 0951-3590 (print), 1473-0766 (electronic) Gynecol Endocrinol, 2014; 30(12): 909–912 ! 2014 Informa UK Ltd. DOI: 10.3109/09513590.2014.947567
LUTEAL PHASE SUPPORT
Effect of luteal phase support after ovulation induction and intrauterine insemination Mesut Oktem1, S. Ozlem Altinkaya2, Setenay Arzu Yilmaz3, Nuray Bozkurt1, Mehmet Erdem1, Ahmet Erdem1, and Seyhan Gumuslu1 Gynecol Endocrinol Downloaded from informahealthcare.com by UMEA University Library on 04/06/15 For personal use only.
1
Department of Gynecology & Obstetrics, Faculty of Medicine, Gazi University, Ankara, Turkey, 2Department of Gynecology & Obstetrics, Faculty of Medicine, Adnan Menderes University, Aydın, Turkey, and 3Department of Gynecology & Obstetrics, Faculty of Medicine, Selc¸uk University, Konya, Turkey Abstract
Keywords
Objective: This study aimed to evaluate the effect of luteal phase support on clinical pregnancy and live birth rates after ovulation induction and intrauterine insemination (IUI). Methods: 579 cycles from 2010 to 2013 were retrospectively evaluated. Ovarian stimulation was performed with gonadotropins, and rHCG was used for ovulation triggering. All patients received IUI. 451 cycles were supported by receiving vaginal micronized progesterone capsules (142 cycles) or vaginal progesterone gel (309 cycles) whereas 128 cycles were not supported. Results: Clinical pregnancy (20.6 versus 9.4%; p ¼ 0.004) and live birth rates (14 versus 7%; p ¼ 0.036) were higher for supported group than for unsupported group. Progesterone gel and micronized progesterone subgroups achieved similar clinical pregnancy and live birth rates (21.4 versus 19%, p ¼ 0.567 and 14.2 versus 13.4%, p ¼ 0.807; respectively). Conclusions: Luteal phase support improved the success of IUI cycles affecting both clinical pregnancy and live birth rates when gonadotropins were used for ovulation induction. The use of vaginal progesterone gel or micronized progesterone significantly improves clinical pregnancy rates. The live birth rates were higher in the progesterone gel group, but were similar in the micronized progesterone group compared to the unsupported group.
Clinical pregnancy, intrauterine insemination, live birth, luteal support, progesterone
Introduction Luteal phase defects have been attributed principally to inadequate production of progesterone, the major product of corpus luteum, which is essential for the establishment and maintenance of early pregnancy [1]. Both in gonadotropin releasing hormone (GnRH) agonist and antagonist in vitro fertilization (IVF) cycles, defective luteal phase have been detected due to low luteinizing hormone (LH) levels [2,3]. One of the most popular reasons for this defective luteal phase is the development of multiple follicles as well as corpora lutea resulting in supra-physiological concentration of steroid hormones in the luteal phase, leading to decreased LH secretion and premature luteolysis, which in turn result with inadequate progesterone concentrations. The significant effect in favor of progesterone for luteal phase support has been well documented with better pregnancy results in IVF cycles [3–7]. Intrauterine insemination (IUI) generally with ovarian stimulation is still a common treatment for infertility and subfertility. It is considered to be indicated for a broad range of diagnostic conditions, especially for all categories of unexplained infertility and for couples with mild male factor infertility. IUI in stimulated
Address for Gynecology ¨ niversitesi, U Dalı, Aydin, yahoo.com
correspondence: S. Ozlem Altinkaya, Department of & Obstetrics, Faculty of Medicine, Adnan Menderes Tıp Faku¨ltesi, Kadın Hastalıkları ve Dog˘um Anabilim Turkey. Tel: +90(505)3904529. E-mail: altinkayaozlem@
History Received 19 March 2014 Revised 2 July 2014 Accepted 20 July 2014 Published online 7 August 2014
cycles may also be considered while waiting for IVF, or when in women with patent tubes IVF is not affordable. There are limited data and little consensus about the quality of luteal phase and the use of luteal phase support in IUI cycles, where a mild ovarian stimulation is recommended and ovulation is stimulated without GnRH analogs. Luteal phase support was not recommended by the ESHRE Capri Workshop Group, as a major requirement in mildly stimulated (1–2 follicles) IUI cycles; nevertheless the addition of progesterone, human chorionic gonadotropin (hCG) and/or other substances became established clinical practice [8]. However, short luteal phases were reported in 20% of stimulated cycles for induction of ovulation by gonadotropins and the length of luteal phase was reported to be normalized by administering hCG at the midluteal phase [9,10]. The aim of the present study was to evaluate the effect of luteal phase support by using vaginal progesterone on clinical pregnancy and live birth rates after ovulation induction with gonadotropins and IUI. The effects of vaginal progesterone gel and micronized progesterone were also evaluated with regard to clinical pregnancy and live birth rates.
Materials and methods The design of the present study was approved by the Ethical Committee and Institutional Review Board of Gazi University Faculty of Medicine, where the study was conducted. A total of 579 cycles from 2010 to 2013 were retrospectively evaluated. Ovarian stimulation was performed with gonadotropins, either with recombinant follicle stimulating hormone (rFSH) or human menopausal gonadotropin (hMG), and rHCG was used for
Gynecol Endocrinol Downloaded from informahealthcare.com by UMEA University Library on 04/06/15 For personal use only.
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M. Oktem et al.
ovulation triggering. All patients received IUI. 451 cycles were supported by receiving vaginal micronized progesterone capsules (142 cycles) or vaginal progesterone gel (309 cycles), whereas 128 cycles were not supported. Medical records were reviewed for demographic characteristics including age, body mass index (BMI), duration and the cause of infertility. All subjects had normal uterine cavities in transvaginal ultrasonography (TVUSG) and hysterosalpingography, patency of both fallopian tubes assessed by hysterosalpingography or laparoscopy with chromosalpingography and optimal ovarian reserve: day 3 serum FSH510 mIU/mL and estradiol (E2)575 pg/mL, at the initiation of the stimulation. Only stimulated cycles using gonadotropins were included. GnRH analogs were not used in any of the cycles. Ovarian stimulation was started between 2nd and 3rd day of the cycle. Before starting ovulation induction, all women underwent TVUSG on day 2–3 of the menstrual cycle in order to exclude any ovarian pathology. Ovarian response was monitored by TVUSG starting from the 5th stimulation day. When one to three dominant follicles reached 17 mm, ovulation was triggered by 6500 IU rhCG (OvitrelleÕ , Serono, Italy). Semen samples were collected by masturbation in sterile containers. Liquefaction of semen was performed at 37 C, and then the concentration, volume and motility of sperm were evaluated according to World Health Organization criteria [11]. The method for semen preparation was the density gradient centrifugation. The liquefied semen sample was overlaid on 90 and 40% density gradients made from a 100% stock solution (Sperm Grad, Vitrolife, Gothenburg, Sweden). After centrifugation at 1400g for 10 min the supernatant was discarded. Then the pellet was re-suspended in 3 mL medium (sperm rinse, Vitrolife, Sweden). After one more centrifugation at 1400g for 10 min and discarding the supernatant, total sperm number was evaluated and the final pellet was used for IUI. IUI was performed 36 h after rhCG administration with a disposable cannula (Insemi-CathÕ , Cook Medical Technologies, Bloomington, IN). In the supported cycles, vaginal micronized progesterone capsules 200 mg three times daily (ProgestanÕ , Koc¸ak Farma, Istanbul, Turkey) or vaginal progesterone gel (Crinone 8%, 90 mg vaginal gel, MerckSerono, Bedford, UK) were administered beginning two days after insemination until pregnancy testing. Patients in the unsupported group did not receive any luteal phase support. Pregnancy testing was performed at 14th day after the IUI, and all patients with positive pregnancy test results underwent TVUSG at 6–7 weeks of gestation, and detect the number of sacs and embryonic viability. Luteal phase support was continued through the 12th week of pregnancy if the patient conceived. A clinical pregnancy was defined as the presence of the gestational sac on TVUSG or by histologic examination of products of conception in patients who were aborted. Live birth rate was defined as having a child who was living at 1 week after birth. Data analysis was performed by using SPSS for Windows, version 18 (SPSS Inc., Chicago, IL). Whether the metric discrete and continuous variables were normally distributed or not were determined by using the Kolmogorov–Smirnov test. Metric discrete and continuous variables were shown as mean ± standard deviation or median (min–max), where applicable. While, the mean differences between groups were compared by Student’s t-test, otherwise, Mann–Whitney U-test was applied for comparisons of the median values. Nominal data were analyzed by Pearson’s Chi-square test. A p value less than 0.05 was considered statistically significant.
Results A total of 579 cycles from 2010 to 2013 were evaluated. All patients received IUI. 451 cycles were supported by receiving
Gynecol Endocrinol, 2014; 30(12): 909–912
Table 1. Demographic, baseline characteristics and stimulation data of the groups.
Characteristics
Unsupported (n ¼ 128)
Female age 28.2 ± 4.6 Male age 31.4 ± 4.4 Female BMI (kg/m2) 24.5 ± 3.7 Infertility duration (months) 36 (12–98) Infertility diagnosis Unexplained 112 (87.5%) Mild male factor 16 (12.5%) Capacitated sperm (106/mL) 56 (9–220) Capacitated sperm 78 (13–98) (motility%) Dominant follicles 1 85 (66.4%) 2 38 (29.7%) 3 5 (3.9%) Drugs used for OI rFSH 72 (56.3%) hMG 56 (43.7%) Total dose (units) 750 (250–1800) FSH (mIU/mL) 5 (3–9.6) LH (mIU/mL) 4.7 (2.8–9.8) Estradiol (pg/mL) 39.5 (22–74) Prolactin (mIU/mL) 16 (4.3–27) TSH (mIU/mL) 1.4 (0.2–4.7) Free testosterone (pg/mL) 0.9 (0.2–4.5) DHEA-SO4 (mg/dL) 188.5 (71–520) 17-OH-P (ng/mL) 1.2 (0.2–3.9) Endometrial thickness 9 (6–14) on hCG day (mm)
Supported (n ¼ 451) 28.6 ± 5.0 31.2 ± 5.2 23.9 ± 2.9 36 (12–98) 400 51 50 80
(88.7%) (11.3%) (6–280) (18–98)
p 0.462 0.591 0.119 0.227 0.710 0.663 0.078 0.797
288 (63.8%) 140 (31.1%) 23 (5.1%) 0.699 245 206 750 4.8 5 39 14 1.5 1.1 180 1.1 9
(54.3%) (45.7%) (300–3300) (2.6–9.9) (2.7–9.9) (21–72) (3.8–29) (0.1–5.3) (0.1–4.9) (37–615) (0.1–3.4) (6–15)
0.120 0.321 0.290 0.554 0.147 0.651 0.418 0.327 0.233 0.644
BMI: body mass index, OI: ovulation induction, rFSH: recombinant follicle stimulating hormone, hMG: human menopausal gonadotropin, FSH: follicle stimulating hormone, LH: luteinizing hormone, TSH: thyroid stimulating hormone, DHEA-SO4: dehydroepiandrosterone sulphate, 17-OH-P: 17hydroxiprogesterone.
Table 2. Pregnancy outcomes of supported and unsupported cycles.
Pregnancy outcome Clinical pregnancy rate Live birth rate Early miscarriage rate Multiple pregnancy rate
Unsupported (n ¼ 128) 12 9 3 2
(9.4%) (7.0%) (2.3%) (1.5%)
Supported (n ¼ 451) 93 63 30 5
(20.6%) (14.0%) (6.6%) (1.1%)
p 0.004 0.036 0.064 0.678
vaginal micronized progesterone capsules (142 cycles) or vaginal progesterone gel (309 cycles), whereas 128 cycles were not supported. Demographic, baseline characteristics and stimulation data of the patients are shown in Table 1. Data were similar among the supported and unsupported groups in female and male age, female BMI, duration of infertility, concentration and motility of capacitated sperm, and baseline hormones at day 3. The infertility diagnosis, number of dominant follicles and drugs used for ovarian stimulation in each group were also comparable. Pregnancy outcomes are shown in Table 2 and Figure 1. Of the 579 cycles, a total of 105 clinical pregnancies occurred. There were 93 pregnancies in the group with luteal phase support and 12 pregnancies in the unsupported group. 63 live births occurred in the supported group whereas nine live births occurred in the group without luteal phase support. Clinical pregnancy (20.6 versus 9.4%; p ¼ 0.004) and live birth rates (14 versus 7%; p ¼ 0.036) were higher for the supported group than for the
Luteal phase support in intrauterine insemination
DOI: 10.3109/09513590.2014.947567
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Figure 1. Pregnancy outcomes for IUI cycles.
Table 3. Clinical pregnancy and live birth rates regarding subgroups. Micronized Unsupported progesterone Progesterone (n ¼ 142) gel (n ¼ 309) Pregnancy outcome (n ¼ 128) Clinical pregnancy rate Live birth rate
12 (9.4%)*,y 9 (7%)z
p
27 (19%)*
66 (21.4%)y
0.012
19 (13.4%)
44 (14.2%)z
0.107
*Significant difference between the unsupported group and the micronized progesterone group (p ¼ 0.024). ySignificant difference between the unsupported group and the progesterone gel group (p ¼ 0.003). zSignificant difference between the unsupported group and the progesterone gel group (p ¼ 0.036).
unsupported group. Progesterone gel and micronized progesterone subgroups achieved similar clinical pregnancy and live birth rates (21.4 versus 19%, p ¼ 0.567 and 14.2 versus 13.4%, p ¼ 0.807; respectively). When the progesterone gel subgroup was compared with the unsupported group, both clinical pregnancy and live birth rates were higher in the supported group (21.4 versus 9.4% and p ¼ 0.003; 14.2 versus 7%, p ¼ 0.036; respectively). However, despite micronized progesterone subgroup achieved both higher clinical pregnancy and live birth rates than unsupported group (19 versus 9.4%, p ¼ 0.024 and 13.4 versus 7%, p ¼ 0.088; respectively) live birth rates did not reach statistical significance (Table 3). An early miscarriage rate of 6.6% was observed in the supported cycles and 2.3% in the unsupported cycles, with no significant differences between groups (p ¼ 0.064). Twin pregnancy rates were also similar between groups, with five (1.1%) twin pregnancies in the supported and two (1.5%) twin pregnancies in the unsupported cycles (p ¼ 0.678).
Discussion The data of the present study suggested that in patients with unexplained and mild male factor infertility treated with ovulation induction with gonadotropins and IUI, luteal phase support with vaginal progesterone improved the pregnancy outcomes as compared with patients with no luteal phase support. It is well established that luteal phase support is an essential aspect of assisted reproduction techniques. Initially, the removal of large quantities of granulosa cells during oocyte retrieval in IVF cycles was thought to cause a decrease in progesterone secretion by the corpora lutea, resulting in a luteal phase defect. However, this hypothesis is disproven; as it is indicated that in natural IVF cycles aspiration of pre-ovulatory follicle do
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not cause a decrease in steroid secretion or shorten the luteal phase [12]. Both in GnRH agonist and antagonist IVF cycles, defective luteal phase have been detected due to low LH levels [2,3]. In IVF cycles, the use of GnRH analogs causes suppression of pituitary LH secretion even after the last dosage, and without a sufficient LH signal the corpus luteum is compromised, resulting in an iatrogenic luteal phase defect [13]. In GnRH antagonist cycles, there is also premature luteolysis causing a reduction in the length of luteal phase and reducing the chance of pregnancy [14]. Recently, it has been observed that the primary cause of luteal phase defect in IVF cycles is the supraphysiological levels of steroids secreted by the high number of corpora lutea during the early luteal phase directly inhibiting LH release through negative feedback effects at the level of hypothalamic–pituitary axis [3,15]. Although the necessity of luteal phase support is well established in IVF cycles, there is still debate in IUI cycles. The queries about the quality of luteal phase and the necessity of luteal phase support in IUI cycles, whose aim is to produce a small number of follicles (one to three), thereby lesser number of corpora lutea, with mild ovarian stimulation, still remain unresolved. Two previous studies reported shortened luteal phase and luteal phase deficiency in 20 and 11.9% of cycles mildly stimulated with hMG or rFSH and with hMG alone, respectively [9,16]. Up until this time, six prospective randomized studies evaluated the effect of luteal phase support in IUI cycles. Kyrou et al. [1] stated that routine supplementation of the luteal phase with vaginal micronized progesterone does not seem to improve pregnancy rates in normo-ovulatory women stimulated with clomiphene citrate (CC) for IUI. Similarly, Ebrahimi et al. [17] evaluated the effect of luteal phase progesterone supplementation in IUI cycles with CC plus hMG. They demonstrated that luteal phase support has no beneficial effect on pregnancy rates. In contrast, the data of the two previous prospective studies [3,18] suggested that both clinical pregnancy and live birth rates were higher in the supported cycles with vaginal progesterone gel, when rFSH was used for ovulation induction, similar to our findings. Another study by Agha-Hosseini et al. [19] also reported that the use of vaginal progesterone suppositores as luteal phase support significantly improved clinical pregnancy rates in controlled ovarian stimulation and IUI in patients with unexplained or mild male factor infertility. However, in their study population, ovulation induction was yielded by CC and/or letrozole with or without hMG. Recently a meta-analysis by Hill et al. [20] was published reviewing the data of the aforementioned prospective studies [1,3,17–19]. They concluded that progesterone luteal phase support may be of benefit to patients undergoing ovulation induction with gonadotropins in IUI cycles, whereas it was not beneficial in patients undergoing ovulation induction with CC, suggesting a potential difference in endogenous luteal phase function depending on the method of ovulation induction. However, there is a lack of homogeneity between these studies and they reach different conclusions. Lastly, Romero Nieto et al. [7] conducted a prospective study including 893 cycles and stated that in infertile patients treated with mildly ovarian stimulation with gonadotropins and IUI, luteal phase support with vaginal micronized progesterone is not associated with higher live birth rate or clinical pregnancy rate compared with unsupported patients. Discrepant results may be attributed to the design and sample size and the demographic and genetic characteristics of the different populations as well as the different methods used for ovulation induction and luteal phase support. In this study, we also compared the two different methods for luteal phase support with either vaginal progesterone gel or vaginal micronized progesterone capsulas. Currently, vaginal
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progesterone is considered as the first-line therapy for luteal phase support with the least side effects in IVF cycles. Bergh et al. [21] reported in their multicenter study that there is no substantial difference in ongoing pregnancy rate between vaginal progesterone gel and vaginal micronized progesterone tablets. Their results also showed that progesterone gel is considered more convenient for the patient. For IVF cycles, Cochrane review [5] showed a significant effect in favor of progesterone for luteal phase support, favoring synthetic progesterone over micronized progesterone. To the best of our knowledge, the present study is the first in which vaginal progesterone gel or micronized progesterone capsulas are compared in IUI cycles. Our data suggested that the use of vaginal progesterone gel or micronized progesterone significantly improved clinical pregnancy rates. However; despite micronized progesterone subgroup achieved both higher clinical pregnancy and live birth rates than the unsupported group, live birth rates did not reach statistical significance. Progesterone gel and micronized progesterone subgroups achieved similar clinical pregnancy and live birth rates. Taken together, the data of the present study revealed that luteal phase support improved the success of IUI cycles affecting both clinical pregnancy and live birth rates when gonadotropins were used for ovulation induction. Additionally, this study is the first one comparing the two different methods for luteal phase support with either vaginal progesterone gel or micronized progesterone capsules. The retrospective design may be a limitation whereas the large sample size may provide advantages. It now appears that stimulated IVF cycles need luteal phase support. For IUI cycles, further randomized trials with different subgroups are needed to establish which patients and stimulation protocols may benefit from luteal phase support as well as to determine the dose and duration for progesterone administration.
Declaration of interest The authors report no declaration of interest.
References 1. Kyrou D, Fatemi HM, Tournaye H, Devroey P. Luteal phase support in normo-ovulatory women stimulated with clomiphene citrate for intrauterine insemination: need or habit? Hum Reprod 2010;25: 2501–6. 2. Kolibianakis EM, Devroey P. The luteal phase after ovarian stimulation. Reprod Biomed Online 2002;5:26–35. 3. Fauser BC, Devroey P. Reproductive biology and IVF: ovarian stimulation and luteal phase consequences. Trends Endocrinol Metab 2003;14:236–42. 4. Practice Committee of American Society for Reproductive Medicine in collaboration with Society for Reproductive Endocrinology and Infertility. Progesterone supplementation during the luteal phase and in early pregnancy in the treatment of infertility: an educational bulletin. Fertil Steril 2008;90:S150–3. 5. van der Linden M, Buckingham K, Farquhar C, et al. Luteal phase support for assisted reproduction cycles. Cochrane Database Syst Rev 2011;CD009154.
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6. Check JH. Luteal phase support for in vitro fertilization-embryo transfer – present and future methods to improve successful implantation. Clin Exp Obstet Gynecol 2012;39:422–8. 7. Romero Nieto MI, Lorente Gonza´lez J, Arjona-Berral JE, et al. Luteal phase support with progesterone in intrauterine insemination: a prospective randomized study. Gynecol Endocrinol 2014;30: 197–201. 8. ESHRE Capri Workshop Group. Intrauterine insemination. Hum Reprod Update 2009;15:265–77. 9. Olson JL, Rebar RW, Schreiber JR, Vaitukaitis JL. Shortened luteal phase after ovulation induction with human menopausal gonadotropin and human chorionic gonadotropin. Fertil Steril 1983;39: 284–91. 10. Grazi RV, Taney FH, Gagliardi CL, et al. The luteal phase during gonadotropin therapy: effects of two human chorionic gonadotropin regimens. Fertil Steril 1991;55:1088–92. 11. De Jonge C. Semen analysis: looking for an upgrade in class. Fertil Steril 2012;97:260–6. 12. Kerin JF, Broom TJ, Ralph MM, et al. Human luteal phase function following oocyte aspiration from the immediately preovular graafian follicle of spontaneous ovular cycles. Br J Obstet Gynaecol 1981;88: 1021–8. 13. Erdem A, Erdem M, Atmaca S, Guler I. Impact of luteal phase support on pregnancy rates in intrauterine insemination cycles: a prospective randomized study. Fertil Steril 2009;91:2508–13. 14. Beckers NG, Macklon NS, Eijkemans MJ, et al. Nonsupplemented luteal phase characteristics after the administration of recombinant human chorionic gonadotropin, recombinant luteinizing hormone, or gonadotropin-releasing hormone (GnRH) agonist to induce final oocyte maturation in in vitro fertilization patients after ovarian stimulation with recombinant follicle-stimulating hormone and GnRH antagonist cotreatment. J Clin Endocrinol Metab 2003;88: 4186–92. 15. Fatemi HM. The luteal phase after 3 decades of IVF: what do we know? Reprod Biomed Online 2009;19:4331. 16. Duffy DA, Manzi D, Benadiva C, et al. Impact of leuprolide acetate on luteal phase function in women undergoing controlled ovarian hyperstimulation and intrauterine insemination. Fertil Steril 2006; 85:407–11. 17. Ebrahimi M, Asbagh FA, Dervish S. The effect of luteal phase support on pregnancy rates of the stimulated intrauterine insemination cycles in couples with unexplained infertility. Int J Fertil Steril 2010;4:51–6. 18. Maher MA. Luteal phase support may improve pregnancy outcomes during intrauterine insemination cycles. Eur J Obstet Gynecol Reprod Biol 2011;157:57–62. 19. Agha-Hosseini M, Rahmani M, Alleyassin A, et al. The effect of progesterone supplementation on pregnancy rates in controlled ovarian stimulation and intrauterine insemination cycles: a randomized prospective trial. Eur J Obstet Gynecol Reprod Biol 2012; 165:249–53. 20. Hill MJ, Whitcomb BW, Lewis TD, et al. Progesterone luteal support after ovulation induction and intrauterine insemination: a systematic review and meta-analysis. Fertil Steril 2013;100: 1373–80. 21. Bergh C, Lindenberg S; Nordic Crinone Study Group. A prospective randomized multicentre study comparing vaginal progesterone gel and vaginal micronized progesterone tablets for luteal support after in vitro fertilization/intracytoplasmic sperm injection. Hum Reprod 2012;27:3467–73.
LUTEAL PHASE SUPPORT
Effect of luteal phase support after ovulation induction and intrauterine insemination Mesut Oktem1, S. Ozlem Altinkaya2, Setenay Arzu Yilmaz3, Nuray Bozkurt1, Mehmet Erdem1, Ahmet Erdem1, and Seyhan Gumuslu1 Gynecol Endocrinol Downloaded from informahealthcare.com by UMEA University Library on 04/06/15 For personal use only.
1
Department of Gynecology & Obstetrics, Faculty of Medicine, Gazi University, Ankara, Turkey, 2Department of Gynecology & Obstetrics, Faculty of Medicine, Adnan Menderes University, Aydın, Turkey, and 3Department of Gynecology & Obstetrics, Faculty of Medicine, Selc¸uk University, Konya, Turkey Abstract
Keywords
Objective: This study aimed to evaluate the effect of luteal phase support on clinical pregnancy and live birth rates after ovulation induction and intrauterine insemination (IUI). Methods: 579 cycles from 2010 to 2013 were retrospectively evaluated. Ovarian stimulation was performed with gonadotropins, and rHCG was used for ovulation triggering. All patients received IUI. 451 cycles were supported by receiving vaginal micronized progesterone capsules (142 cycles) or vaginal progesterone gel (309 cycles) whereas 128 cycles were not supported. Results: Clinical pregnancy (20.6 versus 9.4%; p ¼ 0.004) and live birth rates (14 versus 7%; p ¼ 0.036) were higher for supported group than for unsupported group. Progesterone gel and micronized progesterone subgroups achieved similar clinical pregnancy and live birth rates (21.4 versus 19%, p ¼ 0.567 and 14.2 versus 13.4%, p ¼ 0.807; respectively). Conclusions: Luteal phase support improved the success of IUI cycles affecting both clinical pregnancy and live birth rates when gonadotropins were used for ovulation induction. The use of vaginal progesterone gel or micronized progesterone significantly improves clinical pregnancy rates. The live birth rates were higher in the progesterone gel group, but were similar in the micronized progesterone group compared to the unsupported group.
Clinical pregnancy, intrauterine insemination, live birth, luteal support, progesterone
Introduction Luteal phase defects have been attributed principally to inadequate production of progesterone, the major product of corpus luteum, which is essential for the establishment and maintenance of early pregnancy [1]. Both in gonadotropin releasing hormone (GnRH) agonist and antagonist in vitro fertilization (IVF) cycles, defective luteal phase have been detected due to low luteinizing hormone (LH) levels [2,3]. One of the most popular reasons for this defective luteal phase is the development of multiple follicles as well as corpora lutea resulting in supra-physiological concentration of steroid hormones in the luteal phase, leading to decreased LH secretion and premature luteolysis, which in turn result with inadequate progesterone concentrations. The significant effect in favor of progesterone for luteal phase support has been well documented with better pregnancy results in IVF cycles [3–7]. Intrauterine insemination (IUI) generally with ovarian stimulation is still a common treatment for infertility and subfertility. It is considered to be indicated for a broad range of diagnostic conditions, especially for all categories of unexplained infertility and for couples with mild male factor infertility. IUI in stimulated
Address for Gynecology ¨ niversitesi, U Dalı, Aydin, yahoo.com
correspondence: S. Ozlem Altinkaya, Department of & Obstetrics, Faculty of Medicine, Adnan Menderes Tıp Faku¨ltesi, Kadın Hastalıkları ve Dog˘um Anabilim Turkey. Tel: +90(505)3904529. E-mail: altinkayaozlem@
History Received 19 March 2014 Revised 2 July 2014 Accepted 20 July 2014 Published online 7 August 2014
cycles may also be considered while waiting for IVF, or when in women with patent tubes IVF is not affordable. There are limited data and little consensus about the quality of luteal phase and the use of luteal phase support in IUI cycles, where a mild ovarian stimulation is recommended and ovulation is stimulated without GnRH analogs. Luteal phase support was not recommended by the ESHRE Capri Workshop Group, as a major requirement in mildly stimulated (1–2 follicles) IUI cycles; nevertheless the addition of progesterone, human chorionic gonadotropin (hCG) and/or other substances became established clinical practice [8]. However, short luteal phases were reported in 20% of stimulated cycles for induction of ovulation by gonadotropins and the length of luteal phase was reported to be normalized by administering hCG at the midluteal phase [9,10]. The aim of the present study was to evaluate the effect of luteal phase support by using vaginal progesterone on clinical pregnancy and live birth rates after ovulation induction with gonadotropins and IUI. The effects of vaginal progesterone gel and micronized progesterone were also evaluated with regard to clinical pregnancy and live birth rates.
Materials and methods The design of the present study was approved by the Ethical Committee and Institutional Review Board of Gazi University Faculty of Medicine, where the study was conducted. A total of 579 cycles from 2010 to 2013 were retrospectively evaluated. Ovarian stimulation was performed with gonadotropins, either with recombinant follicle stimulating hormone (rFSH) or human menopausal gonadotropin (hMG), and rHCG was used for
Gynecol Endocrinol Downloaded from informahealthcare.com by UMEA University Library on 04/06/15 For personal use only.
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ovulation triggering. All patients received IUI. 451 cycles were supported by receiving vaginal micronized progesterone capsules (142 cycles) or vaginal progesterone gel (309 cycles), whereas 128 cycles were not supported. Medical records were reviewed for demographic characteristics including age, body mass index (BMI), duration and the cause of infertility. All subjects had normal uterine cavities in transvaginal ultrasonography (TVUSG) and hysterosalpingography, patency of both fallopian tubes assessed by hysterosalpingography or laparoscopy with chromosalpingography and optimal ovarian reserve: day 3 serum FSH510 mIU/mL and estradiol (E2)575 pg/mL, at the initiation of the stimulation. Only stimulated cycles using gonadotropins were included. GnRH analogs were not used in any of the cycles. Ovarian stimulation was started between 2nd and 3rd day of the cycle. Before starting ovulation induction, all women underwent TVUSG on day 2–3 of the menstrual cycle in order to exclude any ovarian pathology. Ovarian response was monitored by TVUSG starting from the 5th stimulation day. When one to three dominant follicles reached 17 mm, ovulation was triggered by 6500 IU rhCG (OvitrelleÕ , Serono, Italy). Semen samples were collected by masturbation in sterile containers. Liquefaction of semen was performed at 37 C, and then the concentration, volume and motility of sperm were evaluated according to World Health Organization criteria [11]. The method for semen preparation was the density gradient centrifugation. The liquefied semen sample was overlaid on 90 and 40% density gradients made from a 100% stock solution (Sperm Grad, Vitrolife, Gothenburg, Sweden). After centrifugation at 1400g for 10 min the supernatant was discarded. Then the pellet was re-suspended in 3 mL medium (sperm rinse, Vitrolife, Sweden). After one more centrifugation at 1400g for 10 min and discarding the supernatant, total sperm number was evaluated and the final pellet was used for IUI. IUI was performed 36 h after rhCG administration with a disposable cannula (Insemi-CathÕ , Cook Medical Technologies, Bloomington, IN). In the supported cycles, vaginal micronized progesterone capsules 200 mg three times daily (ProgestanÕ , Koc¸ak Farma, Istanbul, Turkey) or vaginal progesterone gel (Crinone 8%, 90 mg vaginal gel, MerckSerono, Bedford, UK) were administered beginning two days after insemination until pregnancy testing. Patients in the unsupported group did not receive any luteal phase support. Pregnancy testing was performed at 14th day after the IUI, and all patients with positive pregnancy test results underwent TVUSG at 6–7 weeks of gestation, and detect the number of sacs and embryonic viability. Luteal phase support was continued through the 12th week of pregnancy if the patient conceived. A clinical pregnancy was defined as the presence of the gestational sac on TVUSG or by histologic examination of products of conception in patients who were aborted. Live birth rate was defined as having a child who was living at 1 week after birth. Data analysis was performed by using SPSS for Windows, version 18 (SPSS Inc., Chicago, IL). Whether the metric discrete and continuous variables were normally distributed or not were determined by using the Kolmogorov–Smirnov test. Metric discrete and continuous variables were shown as mean ± standard deviation or median (min–max), where applicable. While, the mean differences between groups were compared by Student’s t-test, otherwise, Mann–Whitney U-test was applied for comparisons of the median values. Nominal data were analyzed by Pearson’s Chi-square test. A p value less than 0.05 was considered statistically significant.
Results A total of 579 cycles from 2010 to 2013 were evaluated. All patients received IUI. 451 cycles were supported by receiving
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Table 1. Demographic, baseline characteristics and stimulation data of the groups.
Characteristics
Unsupported (n ¼ 128)
Female age 28.2 ± 4.6 Male age 31.4 ± 4.4 Female BMI (kg/m2) 24.5 ± 3.7 Infertility duration (months) 36 (12–98) Infertility diagnosis Unexplained 112 (87.5%) Mild male factor 16 (12.5%) Capacitated sperm (106/mL) 56 (9–220) Capacitated sperm 78 (13–98) (motility%) Dominant follicles 1 85 (66.4%) 2 38 (29.7%) 3 5 (3.9%) Drugs used for OI rFSH 72 (56.3%) hMG 56 (43.7%) Total dose (units) 750 (250–1800) FSH (mIU/mL) 5 (3–9.6) LH (mIU/mL) 4.7 (2.8–9.8) Estradiol (pg/mL) 39.5 (22–74) Prolactin (mIU/mL) 16 (4.3–27) TSH (mIU/mL) 1.4 (0.2–4.7) Free testosterone (pg/mL) 0.9 (0.2–4.5) DHEA-SO4 (mg/dL) 188.5 (71–520) 17-OH-P (ng/mL) 1.2 (0.2–3.9) Endometrial thickness 9 (6–14) on hCG day (mm)
Supported (n ¼ 451) 28.6 ± 5.0 31.2 ± 5.2 23.9 ± 2.9 36 (12–98) 400 51 50 80
(88.7%) (11.3%) (6–280) (18–98)
p 0.462 0.591 0.119 0.227 0.710 0.663 0.078 0.797
288 (63.8%) 140 (31.1%) 23 (5.1%) 0.699 245 206 750 4.8 5 39 14 1.5 1.1 180 1.1 9
(54.3%) (45.7%) (300–3300) (2.6–9.9) (2.7–9.9) (21–72) (3.8–29) (0.1–5.3) (0.1–4.9) (37–615) (0.1–3.4) (6–15)
0.120 0.321 0.290 0.554 0.147 0.651 0.418 0.327 0.233 0.644
BMI: body mass index, OI: ovulation induction, rFSH: recombinant follicle stimulating hormone, hMG: human menopausal gonadotropin, FSH: follicle stimulating hormone, LH: luteinizing hormone, TSH: thyroid stimulating hormone, DHEA-SO4: dehydroepiandrosterone sulphate, 17-OH-P: 17hydroxiprogesterone.
Table 2. Pregnancy outcomes of supported and unsupported cycles.
Pregnancy outcome Clinical pregnancy rate Live birth rate Early miscarriage rate Multiple pregnancy rate
Unsupported (n ¼ 128) 12 9 3 2
(9.4%) (7.0%) (2.3%) (1.5%)
Supported (n ¼ 451) 93 63 30 5
(20.6%) (14.0%) (6.6%) (1.1%)
p 0.004 0.036 0.064 0.678
vaginal micronized progesterone capsules (142 cycles) or vaginal progesterone gel (309 cycles), whereas 128 cycles were not supported. Demographic, baseline characteristics and stimulation data of the patients are shown in Table 1. Data were similar among the supported and unsupported groups in female and male age, female BMI, duration of infertility, concentration and motility of capacitated sperm, and baseline hormones at day 3. The infertility diagnosis, number of dominant follicles and drugs used for ovarian stimulation in each group were also comparable. Pregnancy outcomes are shown in Table 2 and Figure 1. Of the 579 cycles, a total of 105 clinical pregnancies occurred. There were 93 pregnancies in the group with luteal phase support and 12 pregnancies in the unsupported group. 63 live births occurred in the supported group whereas nine live births occurred in the group without luteal phase support. Clinical pregnancy (20.6 versus 9.4%; p ¼ 0.004) and live birth rates (14 versus 7%; p ¼ 0.036) were higher for the supported group than for the
Luteal phase support in intrauterine insemination
DOI: 10.3109/09513590.2014.947567
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Figure 1. Pregnancy outcomes for IUI cycles.
Table 3. Clinical pregnancy and live birth rates regarding subgroups. Micronized Unsupported progesterone Progesterone (n ¼ 142) gel (n ¼ 309) Pregnancy outcome (n ¼ 128) Clinical pregnancy rate Live birth rate
12 (9.4%)*,y 9 (7%)z
p
27 (19%)*
66 (21.4%)y
0.012
19 (13.4%)
44 (14.2%)z
0.107
*Significant difference between the unsupported group and the micronized progesterone group (p ¼ 0.024). ySignificant difference between the unsupported group and the progesterone gel group (p ¼ 0.003). zSignificant difference between the unsupported group and the progesterone gel group (p ¼ 0.036).
unsupported group. Progesterone gel and micronized progesterone subgroups achieved similar clinical pregnancy and live birth rates (21.4 versus 19%, p ¼ 0.567 and 14.2 versus 13.4%, p ¼ 0.807; respectively). When the progesterone gel subgroup was compared with the unsupported group, both clinical pregnancy and live birth rates were higher in the supported group (21.4 versus 9.4% and p ¼ 0.003; 14.2 versus 7%, p ¼ 0.036; respectively). However, despite micronized progesterone subgroup achieved both higher clinical pregnancy and live birth rates than unsupported group (19 versus 9.4%, p ¼ 0.024 and 13.4 versus 7%, p ¼ 0.088; respectively) live birth rates did not reach statistical significance (Table 3). An early miscarriage rate of 6.6% was observed in the supported cycles and 2.3% in the unsupported cycles, with no significant differences between groups (p ¼ 0.064). Twin pregnancy rates were also similar between groups, with five (1.1%) twin pregnancies in the supported and two (1.5%) twin pregnancies in the unsupported cycles (p ¼ 0.678).
Discussion The data of the present study suggested that in patients with unexplained and mild male factor infertility treated with ovulation induction with gonadotropins and IUI, luteal phase support with vaginal progesterone improved the pregnancy outcomes as compared with patients with no luteal phase support. It is well established that luteal phase support is an essential aspect of assisted reproduction techniques. Initially, the removal of large quantities of granulosa cells during oocyte retrieval in IVF cycles was thought to cause a decrease in progesterone secretion by the corpora lutea, resulting in a luteal phase defect. However, this hypothesis is disproven; as it is indicated that in natural IVF cycles aspiration of pre-ovulatory follicle do
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not cause a decrease in steroid secretion or shorten the luteal phase [12]. Both in GnRH agonist and antagonist IVF cycles, defective luteal phase have been detected due to low LH levels [2,3]. In IVF cycles, the use of GnRH analogs causes suppression of pituitary LH secretion even after the last dosage, and without a sufficient LH signal the corpus luteum is compromised, resulting in an iatrogenic luteal phase defect [13]. In GnRH antagonist cycles, there is also premature luteolysis causing a reduction in the length of luteal phase and reducing the chance of pregnancy [14]. Recently, it has been observed that the primary cause of luteal phase defect in IVF cycles is the supraphysiological levels of steroids secreted by the high number of corpora lutea during the early luteal phase directly inhibiting LH release through negative feedback effects at the level of hypothalamic–pituitary axis [3,15]. Although the necessity of luteal phase support is well established in IVF cycles, there is still debate in IUI cycles. The queries about the quality of luteal phase and the necessity of luteal phase support in IUI cycles, whose aim is to produce a small number of follicles (one to three), thereby lesser number of corpora lutea, with mild ovarian stimulation, still remain unresolved. Two previous studies reported shortened luteal phase and luteal phase deficiency in 20 and 11.9% of cycles mildly stimulated with hMG or rFSH and with hMG alone, respectively [9,16]. Up until this time, six prospective randomized studies evaluated the effect of luteal phase support in IUI cycles. Kyrou et al. [1] stated that routine supplementation of the luteal phase with vaginal micronized progesterone does not seem to improve pregnancy rates in normo-ovulatory women stimulated with clomiphene citrate (CC) for IUI. Similarly, Ebrahimi et al. [17] evaluated the effect of luteal phase progesterone supplementation in IUI cycles with CC plus hMG. They demonstrated that luteal phase support has no beneficial effect on pregnancy rates. In contrast, the data of the two previous prospective studies [3,18] suggested that both clinical pregnancy and live birth rates were higher in the supported cycles with vaginal progesterone gel, when rFSH was used for ovulation induction, similar to our findings. Another study by Agha-Hosseini et al. [19] also reported that the use of vaginal progesterone suppositores as luteal phase support significantly improved clinical pregnancy rates in controlled ovarian stimulation and IUI in patients with unexplained or mild male factor infertility. However, in their study population, ovulation induction was yielded by CC and/or letrozole with or without hMG. Recently a meta-analysis by Hill et al. [20] was published reviewing the data of the aforementioned prospective studies [1,3,17–19]. They concluded that progesterone luteal phase support may be of benefit to patients undergoing ovulation induction with gonadotropins in IUI cycles, whereas it was not beneficial in patients undergoing ovulation induction with CC, suggesting a potential difference in endogenous luteal phase function depending on the method of ovulation induction. However, there is a lack of homogeneity between these studies and they reach different conclusions. Lastly, Romero Nieto et al. [7] conducted a prospective study including 893 cycles and stated that in infertile patients treated with mildly ovarian stimulation with gonadotropins and IUI, luteal phase support with vaginal micronized progesterone is not associated with higher live birth rate or clinical pregnancy rate compared with unsupported patients. Discrepant results may be attributed to the design and sample size and the demographic and genetic characteristics of the different populations as well as the different methods used for ovulation induction and luteal phase support. In this study, we also compared the two different methods for luteal phase support with either vaginal progesterone gel or vaginal micronized progesterone capsulas. Currently, vaginal
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progesterone is considered as the first-line therapy for luteal phase support with the least side effects in IVF cycles. Bergh et al. [21] reported in their multicenter study that there is no substantial difference in ongoing pregnancy rate between vaginal progesterone gel and vaginal micronized progesterone tablets. Their results also showed that progesterone gel is considered more convenient for the patient. For IVF cycles, Cochrane review [5] showed a significant effect in favor of progesterone for luteal phase support, favoring synthetic progesterone over micronized progesterone. To the best of our knowledge, the present study is the first in which vaginal progesterone gel or micronized progesterone capsulas are compared in IUI cycles. Our data suggested that the use of vaginal progesterone gel or micronized progesterone significantly improved clinical pregnancy rates. However; despite micronized progesterone subgroup achieved both higher clinical pregnancy and live birth rates than the unsupported group, live birth rates did not reach statistical significance. Progesterone gel and micronized progesterone subgroups achieved similar clinical pregnancy and live birth rates. Taken together, the data of the present study revealed that luteal phase support improved the success of IUI cycles affecting both clinical pregnancy and live birth rates when gonadotropins were used for ovulation induction. Additionally, this study is the first one comparing the two different methods for luteal phase support with either vaginal progesterone gel or micronized progesterone capsules. The retrospective design may be a limitation whereas the large sample size may provide advantages. It now appears that stimulated IVF cycles need luteal phase support. For IUI cycles, further randomized trials with different subgroups are needed to establish which patients and stimulation protocols may benefit from luteal phase support as well as to determine the dose and duration for progesterone administration.
Declaration of interest The authors report no declaration of interest.
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