Journal of Assisted Reproduction and Genetics, Vol. 9, No. 3, 1992
CLINICAL ASSISTED REPRODUCTION
Luteinizing Response to Human Chorionic Gonadotropin Does Not Predict Outcome in Gonadotropin Releasing Hormone Agonist-Suppressed/Human Menopausal Gonadotropin-Stimulated in Vitro Fertilization (IVF) Cycles 1 A L A N S. P E N Z I A S , 2'3 F A Y E K N. S H A M M A , 2 J A C Q U E L I N E N. G U T M A N N , 2 D A V I D B. S E I F E R , 2'4 A L A N H. D e C H E R N E Y , z'5 and G A D L A V Y 2
Submitted: December 16, 1991 Accepted: March 17, 1992
hCG administration between the pregnant and the nonpregnant groups. Both groups exhibited a significant rise in P level in response to hCG. There was no significant difference in E 2 levels on the day o f hCG between the two groups. The serum E 2 did not rise significantly in response to hCG in either group. Patients who became pregnant had significantly more oocytes retrieved, fertilized, cleaved, and transferred. Conclusions: Clinical response and outcome in GnRH-asuppressed/hMG-stimulated I V F cycles are not predicted by early luteinizing potential as indicated by the response o r E 2 or P to hCG.
Objective: The purpose o f this study was to determine if early luteinizing potential in gonadotropin releasing hormone agonist (GnRH-a)-suppressed/human menopausal gonadotropin (hMG)-stimulated I V F cycles is predictive o f cycle outcome. Design, Patients: The study was a prospective evaluation o f 41 women beginning a GnRH-a-suppressed/hMGstimulated I V F cycle. Setting: The in vitro fertilization program o f a tertiary care institution was the study setting. Main Outcome Measures: The main outcome measures were (I) estradiol (E2) and progesterone (P) levels on the day o f human chorionic gonadotropin (hCG) administration and the following day and (2) the ovarian response to ovulation induction and clinical outcome. Results: Ten of the 41 women achieved a clinical pregnancy (24.4%). There was no significant difference in progesterone (P) levels on the day of or the day following
WORDS: luteinizing response; human chorionic gonadotropin; gonadotropin releasing hormone agonist; human menopausal gonadotropin; periovulatory estradiol; periovulatory progesterone; in vitro fertilization. KEY
INTRODUCTION The evolution of controlled ovarian hyperstimulation for in vitro fertilization (IVF) has led to the widespread use of gonadotropin releasing h o r m o n e (GnRH) agonist (1). The addition of this medication has been reported to decrease the incidence of premature luteinization (2), change the efficiency of the e m b r y o (3), and widen the window of uterine implantation (4), among other effects. The patient's response to controlled ovarian hyperstimulation as indicated b y the pattern of estradiol (E 2) and progesterone (P) production in the follicular phase has been implicated in cycle o u t c o m e and patterns considered predictive of p o o r o u t c o m e
Presented at the 7th Annual World Congress of in Vitro Fertilization, Paris, France, June 30-July 3, 1991. 2 Yale University School of Medicine, Department of Obstetrics and Gynecology, Division of Reproductive Endocrinology, New Haven, Connecticut 06510. 3 To whom correspondence should be addressed at Yale University School of Medicine, Department of Obstetrics and Gynecology, 333 Cedar Street, P.O. Box 3333, New Haven, Connecticut 06510. 4 Present address: Women and Infants Hospital, Department of Obstetrics and Gynecology, Division of Gynecologic Endocrinology, Brown University School of Medicine, Providence, Rhode Island. Present address: Tufts University School of Medicine, New England Medical Center, Department of Obstetrics and Gynecology, Boston, Massachusetts. 1058-0468/92/0600-0244506.50/0© 1992 Plenum Publishing Corporation
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have been used to defer or cancel the cycle (5-7). Additional studies have attempted to identify or refute the association b e t w e e n E 2 and P levels throughout the cycle with outcome (8-12). Luteinization and the preovulatory production of P is an essential part of normal ovum maturation (13,14). Failure of this orderly sequence may impair ovum development. Similarly, premature luteinization of the follicle may result in an atretic oocyte. In either case, the oocyte obtained may have little or no reproductive potential. In this study we examine the ability of the preovulatory follicle to luteinize in response to human chorionic gonadotropin (hCG) as indicated by periovulatory changes in s e r u m E 2 and P and their ability to predict IVF cycle outcome.
days after the ovulatory dose of hCG. Clinical pregnancy was defined as the presence of fetal heart activity documented sonographically. Statistical analysis was performed using Systat (Systat Intelligent Software, Evanston, IL), Paired or unpaired Student's t tests were used where appropriate. Those parameters which differed significantly between patients achieving clinical pregnancy and those who did not were entered into a multivariate linear regression model with outcome as the dependent variable. Pearson correlation coefficients were calculated to measure the strength of association between related variables. Chi-square analysis was used to assess the impact of etiology of infertility on cycle outcome. Significance was assumed at P < 0.05.
MATERIALS AND METHODS
RESULTS
Forty-one patients treated in our IVF program between November 1990 and January 1991 were placed on a stimulation protocol which began with daily subcutaneous injections of leuprolide acetate (LA; Lupron, TAP Pharmaceuticals, Chicago, IL), 0.5 mg, on cycle day 1 and continued until suppression of the pituitary ovarian axis had been achieved as indicated by a n E 2 500 pg/ml. Transvaginal oocyte retrieval was performed 32 to 34 hr after hCG administration. Semen specimens were collected immediately following oocyte retrieval and the volume, concentration, and motility were determined after complete liquefaction. Embryo cleavage rates were determined and transfer was performed approximately 48 hr after oocyte retrieval. Luteal support consisted of 25 mg progesterone vaginal suppositories given three times daily beginning on the day of embryo transfer. Patients with peak s e r u m E 2 levels below 2000 pg/ml also received 5000 IU of hCG supplementation 5 and 10
All 41 patients underwent embryo transfer. Ten achieved a clinical pregnancy (24.4%) and one developed a preclinical pregnancy where an intrauterine gestation sac was seen without concomitant development of a fetal pole. This preclinical pregnancy was not included in the final data analysis. With one exception, the patient characteristics of the group which achieved clinical pregnancy were not significantly different from those of the group that did not achieve pregnancy. The pregnant group had a longer duration of infertility (5.5 vs 3.4 years; P = 0.018) (Table I). There was no statistically significant difference in the mean number of days of LA required to induce pituitary-ovarian suppression or the mean number of ampoules of hMG required. Semen parameters before and after preparation did not differ between groups. The s e r u m E 2 and P on the day of hCG administration, the m e a n E 2 change, the mean P change, and the progesterone-dependent endometrial protein did not differ between groups. Compared to those who did not become pregnant, the pregnant group had significantly more oocytes retrieved (P = 0.003), oocytes fertilized (P = 0.025), embryos cleaved (P < 0.0005), and embryos transferred (P = 0.013) (Table II). The hCG-induced luteinization was examined in each group. The E 2 did not change significantly in either group. The E 2 r o s e in 6 (60%) and fell in 4 (40%) of the 10 patients in the pregnant group, while it rose in 20 (64.5%) and fell in 11 (35.5%) of 31 patients in the nonpregnant group, a distribution
Journal of Assisted Reproduction and Genetics, Vol. 9, No. 3, 1992
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Table I. Patient Characteristics a as a Function of Cycle Outcome Parameter Age (mean; years) Age (range; years) Gravidity Parity Aborta Ectopics Etiology Tuboperitoneal Male factor Endometriosis Idiopathic Des exposure Semen Volume (ml) Conc. (million/ml) Motility (%) Duration of infertility (years)
Pregnant
Not pregnant
pb
Parameter
Day of h C G
1 day post h C G
pb
33.29 --- 0.83 29-38
34.92 - 0.80 24--42
NS
Pregnant Estradiol (pg/ml) Progesterone (ng/ml)
3023 +- 562 0.65 +-- 0.11
3750 --- 620 5.6 +-- 1.45
NS 0.007
Not pregnant Estradiol (pg/ml) Progesterone (ng/ml)
2138 -+ 235 0.65 -+ 0.10
2430 - 297 4.01 --- 0.54
NS 0.0005
1.5 0.40 0.60 0.50
-+ 0.5 - 0.30 -+ 0.22 -+ 0.34
4 (40%) 1 (10%) 1 (10%) 3 (30%) 1 (10%)
1.5 0.22 0.97 0.26 21 2 4 4 0
+-- 0.39 - 0.09 - 0.34 +- 0.11
(67.7%) (6.5%) (12.9%) (12.9%) (0)
NS NS NS NS NS c
3.92 -+ 0.63 75.4 --- 18.5 47.7 - 5.5
3.07 --- 0.28 92.0 -+ 10.9 49.8 -+ 3.2
NS NS NS
5.5 -+ 0.84
3.4 -+ 0.41
0.018
that was not significantly different. However, the P rose significantly in both groups (P = 0.007 and P < 0.0005, respectively, for pregnant and nonpregnant groups) (Table III). A Pearson correlation matrix was calculated to measure the strength of association between the related variables, number of o o c y t e s retrieved, oocytes fertilized, embryos cleaved, and embryos transferred. There was a strong, positive relationship noted between each of these variables (r > 0.71). The absolute number of oocytes retrieved was also strongly correlated with the peak serum E2 level (r = 0.713). Multivariate linear regression analysis was used to explore the relationship between cycle outcome Table II. Cycle Characteristics ~ as a Function of Cycle O u t c o m e
D a y s of L A until gonadal s u p p r e s s i o n Ampoules of hMG c Oocytes retrieved O o c y t e s fertilized E m b r y o s cleaved E m b r y o s transferred Luteal P E P a (U/ml)
a Values are e x p r e s s e d as m e a n +- SE. b Paired t test.
and E2 and P levels on the day of and after hCG administration, as well as the change in these levels. No relationship was identified.
DISCUSSION
a Values are e x p r e s s e d as m e a n + SE. b Unpaired t test. Significance a s s u m e d at P < 0.05. c Chi-square distribution of etiology v e r s u s outcome.
Parameter
Table III. R e s p o n s e to h C G a as a Function of Cycle O u t c o m e
Pregnant 16.1 30.3 14.5 10.2 8.0 5.0 131.6
--- 0.9 --- 2.2 ~- 2.3 --- 1.4 --- 1.0 +-- 0.2 - 25.4
N o t pregnant 17.6 33.0 8.2 6.4 4.6 3.9 85,5
-+ 1.2 -+ 1.2 --- 0.9 -+ 0.8 --- 0.4 +- 0.2 - 16.2
pb NS NS 0.003 0.025
CLINICAL ASSISTED REPRODUCTION
Luteinizing Response to Human Chorionic Gonadotropin Does Not Predict Outcome in Gonadotropin Releasing Hormone Agonist-Suppressed/Human Menopausal Gonadotropin-Stimulated in Vitro Fertilization (IVF) Cycles 1 A L A N S. P E N Z I A S , 2'3 F A Y E K N. S H A M M A , 2 J A C Q U E L I N E N. G U T M A N N , 2 D A V I D B. S E I F E R , 2'4 A L A N H. D e C H E R N E Y , z'5 and G A D L A V Y 2
Submitted: December 16, 1991 Accepted: March 17, 1992
hCG administration between the pregnant and the nonpregnant groups. Both groups exhibited a significant rise in P level in response to hCG. There was no significant difference in E 2 levels on the day o f hCG between the two groups. The serum E 2 did not rise significantly in response to hCG in either group. Patients who became pregnant had significantly more oocytes retrieved, fertilized, cleaved, and transferred. Conclusions: Clinical response and outcome in GnRH-asuppressed/hMG-stimulated I V F cycles are not predicted by early luteinizing potential as indicated by the response o r E 2 or P to hCG.
Objective: The purpose o f this study was to determine if early luteinizing potential in gonadotropin releasing hormone agonist (GnRH-a)-suppressed/human menopausal gonadotropin (hMG)-stimulated I V F cycles is predictive o f cycle outcome. Design, Patients: The study was a prospective evaluation o f 41 women beginning a GnRH-a-suppressed/hMGstimulated I V F cycle. Setting: The in vitro fertilization program o f a tertiary care institution was the study setting. Main Outcome Measures: The main outcome measures were (I) estradiol (E2) and progesterone (P) levels on the day o f human chorionic gonadotropin (hCG) administration and the following day and (2) the ovarian response to ovulation induction and clinical outcome. Results: Ten of the 41 women achieved a clinical pregnancy (24.4%). There was no significant difference in progesterone (P) levels on the day of or the day following
WORDS: luteinizing response; human chorionic gonadotropin; gonadotropin releasing hormone agonist; human menopausal gonadotropin; periovulatory estradiol; periovulatory progesterone; in vitro fertilization. KEY
INTRODUCTION The evolution of controlled ovarian hyperstimulation for in vitro fertilization (IVF) has led to the widespread use of gonadotropin releasing h o r m o n e (GnRH) agonist (1). The addition of this medication has been reported to decrease the incidence of premature luteinization (2), change the efficiency of the e m b r y o (3), and widen the window of uterine implantation (4), among other effects. The patient's response to controlled ovarian hyperstimulation as indicated b y the pattern of estradiol (E 2) and progesterone (P) production in the follicular phase has been implicated in cycle o u t c o m e and patterns considered predictive of p o o r o u t c o m e
Presented at the 7th Annual World Congress of in Vitro Fertilization, Paris, France, June 30-July 3, 1991. 2 Yale University School of Medicine, Department of Obstetrics and Gynecology, Division of Reproductive Endocrinology, New Haven, Connecticut 06510. 3 To whom correspondence should be addressed at Yale University School of Medicine, Department of Obstetrics and Gynecology, 333 Cedar Street, P.O. Box 3333, New Haven, Connecticut 06510. 4 Present address: Women and Infants Hospital, Department of Obstetrics and Gynecology, Division of Gynecologic Endocrinology, Brown University School of Medicine, Providence, Rhode Island. Present address: Tufts University School of Medicine, New England Medical Center, Department of Obstetrics and Gynecology, Boston, Massachusetts. 1058-0468/92/0600-0244506.50/0© 1992 Plenum Publishing Corporation
244
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have been used to defer or cancel the cycle (5-7). Additional studies have attempted to identify or refute the association b e t w e e n E 2 and P levels throughout the cycle with outcome (8-12). Luteinization and the preovulatory production of P is an essential part of normal ovum maturation (13,14). Failure of this orderly sequence may impair ovum development. Similarly, premature luteinization of the follicle may result in an atretic oocyte. In either case, the oocyte obtained may have little or no reproductive potential. In this study we examine the ability of the preovulatory follicle to luteinize in response to human chorionic gonadotropin (hCG) as indicated by periovulatory changes in s e r u m E 2 and P and their ability to predict IVF cycle outcome.
days after the ovulatory dose of hCG. Clinical pregnancy was defined as the presence of fetal heart activity documented sonographically. Statistical analysis was performed using Systat (Systat Intelligent Software, Evanston, IL), Paired or unpaired Student's t tests were used where appropriate. Those parameters which differed significantly between patients achieving clinical pregnancy and those who did not were entered into a multivariate linear regression model with outcome as the dependent variable. Pearson correlation coefficients were calculated to measure the strength of association between related variables. Chi-square analysis was used to assess the impact of etiology of infertility on cycle outcome. Significance was assumed at P < 0.05.
MATERIALS AND METHODS
RESULTS
Forty-one patients treated in our IVF program between November 1990 and January 1991 were placed on a stimulation protocol which began with daily subcutaneous injections of leuprolide acetate (LA; Lupron, TAP Pharmaceuticals, Chicago, IL), 0.5 mg, on cycle day 1 and continued until suppression of the pituitary ovarian axis had been achieved as indicated by a n E 2 500 pg/ml. Transvaginal oocyte retrieval was performed 32 to 34 hr after hCG administration. Semen specimens were collected immediately following oocyte retrieval and the volume, concentration, and motility were determined after complete liquefaction. Embryo cleavage rates were determined and transfer was performed approximately 48 hr after oocyte retrieval. Luteal support consisted of 25 mg progesterone vaginal suppositories given three times daily beginning on the day of embryo transfer. Patients with peak s e r u m E 2 levels below 2000 pg/ml also received 5000 IU of hCG supplementation 5 and 10
All 41 patients underwent embryo transfer. Ten achieved a clinical pregnancy (24.4%) and one developed a preclinical pregnancy where an intrauterine gestation sac was seen without concomitant development of a fetal pole. This preclinical pregnancy was not included in the final data analysis. With one exception, the patient characteristics of the group which achieved clinical pregnancy were not significantly different from those of the group that did not achieve pregnancy. The pregnant group had a longer duration of infertility (5.5 vs 3.4 years; P = 0.018) (Table I). There was no statistically significant difference in the mean number of days of LA required to induce pituitary-ovarian suppression or the mean number of ampoules of hMG required. Semen parameters before and after preparation did not differ between groups. The s e r u m E 2 and P on the day of hCG administration, the m e a n E 2 change, the mean P change, and the progesterone-dependent endometrial protein did not differ between groups. Compared to those who did not become pregnant, the pregnant group had significantly more oocytes retrieved (P = 0.003), oocytes fertilized (P = 0.025), embryos cleaved (P < 0.0005), and embryos transferred (P = 0.013) (Table II). The hCG-induced luteinization was examined in each group. The E 2 did not change significantly in either group. The E 2 r o s e in 6 (60%) and fell in 4 (40%) of the 10 patients in the pregnant group, while it rose in 20 (64.5%) and fell in 11 (35.5%) of 31 patients in the nonpregnant group, a distribution
Journal of Assisted Reproduction and Genetics, Vol. 9, No. 3, 1992
PENZIAS ET AL.
246
Table I. Patient Characteristics a as a Function of Cycle Outcome Parameter Age (mean; years) Age (range; years) Gravidity Parity Aborta Ectopics Etiology Tuboperitoneal Male factor Endometriosis Idiopathic Des exposure Semen Volume (ml) Conc. (million/ml) Motility (%) Duration of infertility (years)
Pregnant
Not pregnant
pb
Parameter
Day of h C G
1 day post h C G
pb
33.29 --- 0.83 29-38
34.92 - 0.80 24--42
NS
Pregnant Estradiol (pg/ml) Progesterone (ng/ml)
3023 +- 562 0.65 +-- 0.11
3750 --- 620 5.6 +-- 1.45
NS 0.007
Not pregnant Estradiol (pg/ml) Progesterone (ng/ml)
2138 -+ 235 0.65 -+ 0.10
2430 - 297 4.01 --- 0.54
NS 0.0005
1.5 0.40 0.60 0.50
-+ 0.5 - 0.30 -+ 0.22 -+ 0.34
4 (40%) 1 (10%) 1 (10%) 3 (30%) 1 (10%)
1.5 0.22 0.97 0.26 21 2 4 4 0
+-- 0.39 - 0.09 - 0.34 +- 0.11
(67.7%) (6.5%) (12.9%) (12.9%) (0)
NS NS NS NS NS c
3.92 -+ 0.63 75.4 --- 18.5 47.7 - 5.5
3.07 --- 0.28 92.0 -+ 10.9 49.8 -+ 3.2
NS NS NS
5.5 -+ 0.84
3.4 -+ 0.41
0.018
that was not significantly different. However, the P rose significantly in both groups (P = 0.007 and P < 0.0005, respectively, for pregnant and nonpregnant groups) (Table III). A Pearson correlation matrix was calculated to measure the strength of association between the related variables, number of o o c y t e s retrieved, oocytes fertilized, embryos cleaved, and embryos transferred. There was a strong, positive relationship noted between each of these variables (r > 0.71). The absolute number of oocytes retrieved was also strongly correlated with the peak serum E2 level (r = 0.713). Multivariate linear regression analysis was used to explore the relationship between cycle outcome Table II. Cycle Characteristics ~ as a Function of Cycle O u t c o m e
D a y s of L A until gonadal s u p p r e s s i o n Ampoules of hMG c Oocytes retrieved O o c y t e s fertilized E m b r y o s cleaved E m b r y o s transferred Luteal P E P a (U/ml)
a Values are e x p r e s s e d as m e a n +- SE. b Paired t test.
and E2 and P levels on the day of and after hCG administration, as well as the change in these levels. No relationship was identified.
DISCUSSION
a Values are e x p r e s s e d as m e a n + SE. b Unpaired t test. Significance a s s u m e d at P < 0.05. c Chi-square distribution of etiology v e r s u s outcome.
Parameter
Table III. R e s p o n s e to h C G a as a Function of Cycle O u t c o m e
Pregnant 16.1 30.3 14.5 10.2 8.0 5.0 131.6
--- 0.9 --- 2.2 ~- 2.3 --- 1.4 --- 1.0 +-- 0.2 - 25.4
N o t pregnant 17.6 33.0 8.2 6.4 4.6 3.9 85,5
-+ 1.2 -+ 1.2 --- 0.9 -+ 0.8 --- 0.4 +- 0.2 - 16.2
pb NS NS 0.003 0.025
