Progesterone level on the day of triggering and pregnancy outcome in long GnRH agonist protocol

Middle East Fertility Society Journal xxx (2017) xxx–xxx

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Original Article

Progesterone level on the day of triggering and pregnancy outcome in long GnRH agonist protocol Wadha Mohawash a,⇑, Nayla Bushaqer a, Fatemah Alrakaf a, Meshael Algaffli a, Haya Rawah a, Nawal Dayoub b, Hisham Ayoub a, Nouf Alasmari a a b

IVF Reproductive Medicine Unit, Prince Sultan Military Medical City, Riyadh, Saudi Arabia Bahrain Military Hospital, Rifaa, Bahrain

1. Introduction Even with the introduction of gonadotropin-releasing hormone analogues during in vitro fertilization (IVF) cycles premature luteinizing hormone (LH) surge can still occur with an incidence between 5 and 35%. This variable incidence was due to discrepancies in the definition of premature LH surge, variable population characteristics and/or IVF treatment protocols [1–3]. The term premature luteinization (PL) refers to a rise in serum progesterone (P4) level on the day of human chorionic gonadotrophin (HCG) administration. This excessive amount of P4 is produced by granulosa cells that have started the process of luteinization. Recently, it was suggested that the term ‘PL’ is not appropriate in the presence of normal LH level. However, despite being misnomer it is still used. Premature progesterone rise (PPR) is a more precise term defined as serum P4 level 1.0 ng/ mL (3.2 nmol/L) or P4/estradiol (E2) ratio 1 on HCG day [3]. Most studies used an absolute P4 level on the day of triggering as an indicator of PPR, with variable cutoff level between 0.4 and 3 ng/ mL = (1.27–9.54 nmol/L) [2,4,5]. The pathogenesis of PPR in IVF/ICSI cycles is not well understood. Multiple follicular development producing certain amount of P4 was suggested to be the cause. Others thought that it could be due to the effect of exogenous gonadotropin on granulosa cells promoting the conversion of cholesterol to P4. LH rise in late follicular phase and increased LH sensitivity were also hypothesized to be the cause for this phenomena [1,6,7]. The effect of PPR on IVF/ICSI cycles outcome is also unclear. Some studies demonstrated an adverse effect on the endometrial receptivity, while others thought that poor oocyte quality and low fertilization rate could be the cause [1,6–10]. Other authors have failed to find an association between PPR and pregnancy

out comes [3,4,11–13], while some demonstrated either a negative or beneficial effect [5,7,14–17]. At present there is no consensus on the effect of PPR in IVF/ICSI cycle outcome or the P4 level at which this effect may appear. [6,9,10,18]. These discrepancies highlighted the necessity to reevaluate the effect of PPR on pregnancy outcomes. Our objective of this study was to investigate the relationship between P4 level and the pregnancy outcomes in patients undergoing IVF/ICSI cycles stimulated with long gonadotropin-releasing hormone agonist (GnRH-a) protocol, and to establish a cutoff level above which P4 might have an effect. 2. Materials and methods After obtaining approval form the research ethics committee at Prince Sultan Medical Military city (Reg. #HAP-01-R-015), this retrospective study was conducted. The medical records of all patients who underwent long GnRH-a IVF/ICSI protocol ending up with fresh embryo transfer (ET) (606 patients), from November 2012 to March 2015 were manually reviewed. Our IVF clinic patients acceptance criteria is: age  40 years, parity  1, body mass index (BMI)  30 kg/m2 and baseline follicular stimulating hormone (FSH)  13 IU/L. 2.1. Inclusion criteria All Patients who met our clinic acceptance criteria and underwent long GnRH-a IVF/ICSI cycles reaching the stage of fresh ET were included in the study. These Patients were 40 years old, BMI is 30 kg/m2, parity 1 and their baseline FSH level 13 IU/L. 2.2. Exclusion criteria

Peer review under responsibility of Middle East Fertility Society. ⇑ Corresponding author. E-mail addresses: [email protected] (W. Mohawash), dr.nayla.j.b@gmail. com (N. Bushaqer), [email protected] (F. Alrakaf), [email protected] (M. Algaffli), [email protected] (H. Rawah), [email protected] (N. Dayoub), [email protected] (H. Ayoub), [email protected] (N. Alasmari).

Patients who underwent IVF/ICSI stimulation with other protocols, age >40 years, BMI >30 kg/m2, parity 2, base line FSH >13 IU/L or if P4 level was not measured on the HCG day were all excluded. The cycles which didn’t reach the stage of embryo transfer were excluded as well.

http://dx.doi.org/10.1016/j.mefs.2017.08.002 1110-5690/Ó 2017 Middle East Fertility Society. Production and hosting by Elsevier B.V. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

Please cite this article in press as: W. Mohawash et al., Progesterone level on the day of triggering and pregnancy outcome in long GnRH agonist protocol, Middle East Fertil Soc J (2017), http://dx.doi.org/10.1016/j.mefs.2017.08.002

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W. Mohawash et al. / Middle East Fertility Society Journal xxx (2017) xxx–xxx

2.3. Data collected 2.3.1. Patients demographics Female age, BMI (kg/m2), parity, number of IVF/ICSI attempts, cause of infertility, FSH level (IU/L), E2 level (pmol/L) and antral follicle count (AFC) were obtained on day (D) 2–3 of cycle; as well as the husband age and his smoking history. 2.3.2. Ovarian stimulation parameters: On the day of triggering the type, total dose of gonadotropin and duration of stimulation were all checked. In addition to that, FSH, E2 and P4 levels were measured, as well as the number of follicles 14 mm, endometrial thickness and endometrial quality. Endometrial thickness is defined as the maximum distance between echogenic interface between endometrium and myometrium in the plane of the central longitudinal axis of the uterus at the fundus in cm on transvaginal scan [19]. The quality of the endometrium was categorized as grade (G) I if endometrial appearance looks homogenous with clear triple-line; G III if heterogeneous cavity with no definite layers seen or G II if it is in between. 2.3.3. Stimulation outcome The number of collected, mature and fertilized oocytes as well as the number and the quality of the developing embryos, the day of embryos transferred and the number of surplus frozen embryos were all collected. Embryo quality was classified according to the number of blastomere, their symmetry and degree of their compaction as well as the percentage of fragmentation and the presence of multinucleated blastomere according to our standard laboratory grading system. Grade (G) I is a top quality embryo in which (4–5 cells on D 2 or 7 cells on D 3) with equal size non multinucleated blastomeres and 20% fragmentation. G IV is the worst. 2.4. Controlled ovarian stimulation protocol Pituitary down regulation was achieved using triptorelin acetate (Decapeptyl; Fering) 0.1 mg subcutaneous (S.C.) daily, starting from D 21 of the preceding cycle, for a minimum duration of 14 days. Once pituitary suppression was achieved, the dose was reduced to 0.05 mg daily from the day of gonadotropin stimulation till the day of triggering. Pituitary downregulation was confirmed by low E2 level <150 pmol/L, endometrial thickness 4 mm and absence of ovarian cyst [20]. Either recombinant FSH (r-FSH) (Gonal-F; Serono or Puregon; Organon), human menopausal gonadotropin (hMG) (Menogon; Fering) or combination of both were used to achieve adequate stimulation. Gonadotropin doses (150–450 IU/day) were calculated according to patient age, BMI, baseline FSH level, AFC and response in previous cycle. Patients were evaluated by USS, FSH and E2 levels after 1 week of gonadotropin stimulation and every 1–2 days thereafter to monitor their response. When at least 2 follicles reached a mean diameter of 18 mm or 3 follicles 17 mm, HCG (Pregnyle; Serono) 5000–10,000 IU was given for final oocytes maturation. Blood sample for P4 measurement was collected on the day of HCG administration at 7–8 am. Serum P4 level was analyzed using electrochemiluminescence immunoassay ‘‘ECLIA” technology performed on the COBAS 8000 system with a sensitivity of 0.095 nmol/l or 0.03 ng/ml (range of measurement was 0.095–191 nmol/l or 0.03–60 ng/ml) according to our laboratory standards. Oocytes retrieval was performed trans-vaginally (TV) under USS guidance 36 h after HCG trigger using automatic aspiration system with single or double lumen needle according to the number of follicles. Denudation was done with repeated pipetting in hyaluroni-

dase 1 h post oocytes retrieval. The oocytes were inseminated by the conventional IVF method or by ICSI according to the quality of sperm, number of oocytes and fertilization rate in previous cycles. Semen preparation was done by density gradient centrifugation. Embryos were cultured in sequential media and fertilization was evaluated 16–18 h after IVF/ICSI procedure. Embryo(s) were transferred under USS guidance between D 2–5 after oocyte retrieval according to the number of embryos available for transfer, their grade and the outcome of previous cycles. Two best quality embryos were transferred unless there was only one embryo available for transfer. If the patient age was 35 years, had previous two implantation failures or her husband underwent testicular procedure for sperm retrieval, then three embryos were transferred. Surplus good quality embryos (G1 and II) were frozen after obtaining couple consent. Luteal phase support was achieved using vaginal progesterone ((cyclogest; Actavis) 400 mg suppository or (crinone; Serono) 8% gel) twice daily. P4 administration was started from the day of oocyte retrieval until the pregnancy test and up to 12 weeks of gestation if the patient was pregnant. Pregnancy test was done 12–14 days post ET using serum quantitative beta-HCG. Patients with positive pregnancy test underwent TVS two weeks after positive beta-HCG result to confirm the presence of an intrauterine pregnancy. 2.5. Outcome variables Primary outcome was the relationship between P4 level and the pregnancy rate (PR). Secondary outcomes were the relationship between P4 level and the embryo quality, implantation, miscarriage, and ectopic pregnancy rates. Pregnancy was defined as positive serum beta-HCG 12–14 days post ET [1]. Implantation rate was defined as the number of intrauterine gestational sacs seen by USS divided by the total number of embryos transferred [6]. Miscarriage rate defined as pregnancy loss before 20 weeks of gestation. Ectopic pregnancy rate is defined as the implantation of the fertilized oocyte in site other than uterine cavity. Normal fertilization is defined as zygotes with two pronuclei (2 PN) 16–18 h post insemination [3]. 2.6. Statistical analysis Data was analyzed using StatsDirect statistical package. Twosided Mann-Whitney U test was used to compare medians between two groups, two-sided unpaired t test was used to compare means between two groups, Chi square test in crosstabs, Fisher-Freeman-Halton exact in crosstabs when any cells have expectation of less than 5. P values of less than 0.05 were considered statistically significant. 3. Results Total patients included in the study were 606 patients. Pregnancy achieved in 293 patients giving PR of 48.3%. There were 35 miscarriages giving a miscarriage rate of 12%. There were 3 cases of ectopic pregnancy giving an ectopic pregnancy rate of 1%. 3.1. Demographic characteristics The population was divided into 2 groups (non-pregnant, n = 313) and (pregnant, n = 293). Both groups had comparable demographics. The two analyzed groups were statistically similar in female/male age, parity, FSH/AFC, number of IVF attempts,

Please cite this article in press as: W. Mohawash et al., Progesterone level on the day of triggering and pregnancy outcome in long GnRH agonist protocol, Middle East Fertil Soc J (2017), http://dx.doi.org/10.1016/j.mefs.2017.08.002

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W. Mohawash et al. / Middle East Fertility Society Journal xxx (2017) xxx–xxx Table 1 Demographic characteristics in the non-pregnant and pregnant groups. Non pregnant (313) Female age (years) Parity # of IVF attempts FSH (IU/L) AFC BMI (kg/m2) Male age (years) Smoking

Cause of infertility

* ** *** ****

29.7 ± 4.6 0.3 ± 0.6 1.8 ± 1.1 6.2 ± 1.8 20 ± 9 28 ± 3.4 35.2 ± 7.3 Smoker = 79 Nonsmoker = 66 Ex-smoker = 10 Nonsmoker = 158 Male = 145 Combined = 94 Idiopathic = 31 PCO = 27 Tubal factor = 13 Endometriosis = 3

Pregnant (293) 29.8 ± 3.9 0.4 ± 0.6 1.7 ± 1 6.2 ± 2 21.2 ± 10 27 ± 3.2 35.4 ± 6.7 Smoker = 65 Nonsmoker = 57 Ex-smoker = 7 Nonsmoker = 164 Male = 138 Combined = 85 Idiopathic = 26 PCO = 27 Tubal factor = 9 Endometriosis = 6 Uterine =1

Table 3 Stimulation outcome in the non-pregnant and pregnant groups.

P value *

P = 0.83 P = 0.12** P = 0.32** P = 0.85* P = 0.12* P = 0.026** P = 0.82* P = 0.57***

# Oocytes collected # Mature oocytes # Fertilized oocytes # Embryos transferred Grade of best embryos transferred

P = 0.8****

Unpaired t test. Mann-Whitney U test. Chi-square. Fisher-Freeman-Halton exact.

smoking and causes of infertility. However, heavier patients were less likely to achieve pregnancy (P = 0.026). Male factor was the main cause of infertility, followed by combined factors (i.e. male and female factors) in both groups [Table 1].

Day of embryo transfer # Frozen embryos * ** ****

Non pregnant 313

Pregnant 293

P value

10.3 ± 5.3 7.5 ± 4.1 4.5 ± 2.8 2 ± 0.6 Grade1 = 113 Grade11 = 150 Grade 111 = 43 Grade 1 V = 6 NA = 1 2 ± 0.8 0.3 ± 1.2

10.9 ± 5.5 8 ± 3.7 5.3 ± 2.8 2 ± 0.4 Grade1 = 185 Grade11 = 99 Grade 111 = 5 Grade 1 V = 2 NA = 2 3±1 0.6 ± 1.5

P = 0.19* P = 0.1* P = 0.0005* P = 0.94** P < 0.0001****

P = 0.01** P = 0.006**

Unpaired t test. Mann-Whitney U test. Fisher-Freeman-Halton exact.

of fertilized oocytes was significantly higher in the pregnant group (P = 0.0005). The number of embryos transferred in each group was similar but obviously better quality embryos observed in the pregnant group (P < 0.0001). Pregnant group had their embryo transferred on day 3 ± 1 compared to day 2 ± 0.8 in the non-pregnant group (p = 0.01). There was significantly more frozen embryos in the pregnant group (P = 0.006) [Table 3]. 3.4. Demographics and cycle parameters among the different P4 level groups

3.2. Stimulation parameters Analysis of cycle characteristics confirm no difference in the type and duration of gonadotropin stimulation or the dose of recombinant FSH in pregnant and non-pregnant groups but significantly higher doses of HMG were required in the pregnant group (p = 0.01). There was no difference in the number of follicles above or equal to 14 mm and endometrial quality in these groups. Endometrial thickness, however, was significantly thicker in the pregnant group (p = 0.04). Though estradiol level was higher in the pregnant group (P = 0.01), the progesterone level was similar in the two groups [Table 2]. 3.3. Stimulation outcome There was no difference in the number of collected or mature oocytes between pregnant and non-pregnant groups. The number

The whole population was divided into two groups according to the P4 level on the HCG day. We choose a P4 cut off level of 1.5 nmol/l as this was the median in the majority of our population. There were 251 patients with progesterone level equal or less than 1.5 nmol/L with 355 patients over that cut off point. The two groups were analyzed according to female age, FSH, AFC, cycle number, E2 level and stimulation requirements. There was no difference in patient age, cycle number, duration of stimulation and r-FSH dose. FSH level was significantly higher in the low progesterone level group (P = 0.0001). Accordingly the AFC was significantly lower in the same group (P < 0.0001) with less estradiol level (P < 0.0001). The same group require significantly higher dose of mixed HMG and recombinant FSH (P = 0.01). The group with higher progesterone level stimulated more often with r FSH (P = 0.01) [Table 4].

Table 2 Stimulation parameters in the non-pregnant and pregnant groups.

Type of gonadotropin

Dose of gonadotropin (IU)

Duration of stimulation (days)

# of follicles 14 mm Endometrial thickness (cm) Endometrial quality

E2 (pmol/L) Progesterone (nmol/L) * ** ***

Non pregnant 313

Pregnant 293

P value

r-FSH = 98 HMG = 200 HMG/r-FSH = 15 r-FSH = 1669 ± 723 HMG = 2226 ± 972 HMG/r-FSH = 1010 ± 592/1512 ± 968 r-FSH = 10.5 ± 2 HMG = 11.8 ± 2.5 HMG/r-FSH = 12 ± 2.1 8.3 ± 4.6 1.08 ± 0.2 Grade1 = 138 Grade 11 = 145 Grade 111 = 30 6614 ± 3082 1.9 ± 0.9

r-FSH = 91 HMG = 188 HMG/r-FSH = 14 r-FSH = 1593 ± 538 HMG = 2458 ± 818 HMG/r-FSH = 1091 ± 592/1441 ± 968 r-FSH = 12 ± 2 HMG = 11.8 ± 2.3 HMG/r-FSH = 12 ± 2 8.8 ± 4.4 1.1 ± 0.2 Grade1 = 128 Grade 11 = 143 Grade 111 = 22 7283 ± 3551 1.9 ± 0.9

P = 0.99***

P = 0.42* P = 0.01* P = 0.75* P = 0.32** P = 0.59** P = 0.43** P = 0.17* P = 0.04* P = 0.62***

P = 0.01* P = 0.92*

Unpaired t test. Mann-Whitney U test. Chi-square.

Please cite this article in press as: W. Mohawash et al., Progesterone level on the day of triggering and pregnancy outcome in long GnRH agonist protocol, Middle East Fertil Soc J (2017), http://dx.doi.org/10.1016/j.mefs.2017.08.002

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W. Mohawash et al. / Middle East Fertility Society Journal xxx (2017) xxx–xxx

Table 4 Demographics and cycle parameters among the different P4 level groups.

Female age in (Years) FSH (IU/L) Cycle no AFC Gonadotropin type Gonadotropin dose (IU)

Duration of stimulation (days) Peak E2 level

P  1.5 nmol/L N = 251

P > 1.5 nmol/L N = 355

P value

29.6 ± 3.7

29.8 ± 4

P = 0.61*

6.6 ± 1.9 1.8 ± 1.1 18.7 ± 9.1 r-FSH = 62 HMG = 177 HMG/r-FSH = 12 r-FSH 1745 ± 563 HMG 2410 ± 977 HMG/r-FSH 1362 ± 929/ 1671.8 ± 1137 r-FSH = 10.9 ± 2.1 HMG = 11.8 ± 2.5 HMG/rFSH = 11.1 ± 2.2 5553.8 ± 2523.7

6 ± 1.9 1.7 ± 1 21.9 ± 9.7 r-FSH = 127 HMG = 211 HMG/r-FSH = 17 r-FSH 1583 ± 673 HMG 2295 ± 845 HMG/r-FSH 827 ± 260/ 1341 ± 632 r-FSH = 10.6 ± 1.9 HMG = 11.8 ± 2.2 HMG/rFSH = 10.6 ± 2.1 7913.2 ± 3495.2

P = 0.0001* P = 0.28** P < 0.0001* P = 0.01**

P = 0.11** P = 0.35** P = 0.01**

P = 0.37**

P < 0.0001*

***

Chi-square. * Unpaired t test. Mann-Whitney U test.

**

Table 5 Cycle and pregnancy outcome according to P4 level.

Retrieved oocytes Mature oocytes Fertilized oocytes Transferred embryos Quality of best embryo transferred

Frozen embryos Pregnancy rate % Implantation rate % Miscarriage rate % Ectopic pregnancy rate % * ** *** ****

P  1.5 nmol/L N = 251

P > 1.5 nmol/L N = 355

P value

9 ± 4.3 6.7 ± 3.3 4.3 ± 2.2 2.1 ± 0.5 Grade1 = 125 Grade11 = 101 Grade111 = 20 Grade1 V = 3 NA = 2 0.3 ± 1 45.8% 24% 15.7% 0%

11.7 ± 5.8 8.5 ± 4.2 5.3 ± 3.1 2.2 ± 0.5 Grade1 = 173 Grade11 = 148 Grade111 = 28 Grade1 V = 5 NA = 1 0.5 ± 1.6 50.1% 27% 9.6% 1.7%

P < 0.0001* P < 0.0001* P < 0.0001* P = 0.07* P = 0.93****

P = 0.4** P = 0.29*** P = 0.36* P = 0.11*** P = 0.28****

Unpaired t test. Mann-Whitney U test. Chi-square. Fisher-Freeman-Halton exact.

3.5. Cycle and pregnancy outcome according to P4 level The group with higher P4 value had significantly higher number of retrieved and mature oocytes which resulted in higher fertilization than the lower P4 group11.7 ± 5.8 vs 9 ± 4.3, 8.5 ± 4.2 vs. 6.7 ± 3.3 and 5.3 ± 3.1vs. 4.3 ± 2.2 respectively (P < 0.0001). Consequently, there were more transferred, frozen, and better quality embryos in the group with high P4 levels but these findings were not significant. Pregnancy outcome in the form of pregnancy and implantation rates were higher in the group with high Progesterone levels but again not reach significant level. We also noted lower miscarriage rate and higher ectopic pregnancy rate in the same group but again it was not statistically significant [Table 5]. 4. Discussion Although patients who underwent long GnRh-a cycles and had a high P4 level on the day of triggering were found to be better

responders, yet their pregnancy outcome was similar to the patients who had a low P4 level. This coincides with the findings of Venetis et al., when they first conducted a systematic review and meta-analysis in 2007 and found no association between high P4 level on the day of HCG administration and the probability of clinical pregnancy in women undergoing IVF cycles with GnRH analogues [11]. In line with our study Martinez et al., in 2016 found no relation between high P4 level and PR despite higher number of oocyte retrieved and high E2 level [21]. Similarly high serum P4 did not improve the implantation rate [3]. Saharkhiz et al., found that P4 elevation did not adversely affect the biochemical pregnancy, clinical pregnancy or implantation rates nor increase the miscarriage rate [9]. On the contrary, Venetis et al., conducted another systematic review and meta-analysis in 2013 with over 60,000 cycles and state that high P4 level had an adverse effect on the probability of pregnancy [5]. Xu et al., analyzed more than 10,000 cycles and found that high P4 level was associated with high E2 level and higher number of retrieved oocytes in high responders but the PR was adversely affected regardless ovarian response in long GnRH-a protocol [22]. Another study by Bosch et al., showed a similar adverse effect on ongoing PR in high P4 group [7]. On the other hand, a study on PCOS patients contradict the above studies and demonstrated a better PR in the high P4 group with an increase in the miscarriage rate [23]. In terms of embryo quality and on agreement with our findings, Haiyan et al. and Ubaldi et al., observed that high P4 level didn’t affect the embryo quality [12,24]. Bu et al., found an adverse association between high P4 level, the number of good quality embryos and cumulative LBR [25]. Huang et al. in 2015 suggest that lower clinical PR was found in high P4 group in GnRH-a IVF/ICSI protocol regardless the stage of ET [26]. While a study on the effect of PPR showed that blastocyst transfer is associated with higher LBR than cleavage stage embryo transfer [27]. In theory, abnormally accelerated endometrial maturation during the prereceptive secretory phase and not during the implantation window might affect the success of transferring cleavage stage embryo with no effect on blastocyst [8]. The mechanism through which PPR might adversely affect pregnancy outcome is unclear. Some related it to the disturbance in endometrial receptivity causing embryo endometrial dys-synchrony, while others think it is related to abnormality in the endometrial gene expression affecting implantation [28]. On the contrary others believe it could be related to the oocyte or embryo quality [25]. Therefore, in cases of PPR some authors recommend to freeze all embryos and replace them in later cycles, [6] while others suggested a blastocyst transfer believing that P4 level might be lower at that stage [27]. All these might have a negative impact on the patient psychological status and will increase the cost of IVF cycles. Our study support that P4 level on the triggering day could be a poor predictor of the cycle outcome. Factors like female age, AFC, endometrial thickness, number of retrieved oocyte and number and quality of embryos, in fresh cycles could be better predictors of pregnancy [21,29]. In the literature most authors have agreed that a rise in the P4 level coincides with the rise in the E2 level in good responders with high oocyte yield. Shufaro et al., suggested that the increased P4 production is per follicle, and not due to additional follicular recruitment, better correlate with adverse outcome. To differentiate between these two conditions, P4 to follicular index (PFI) should be measured (P4 level divided by the number of follicle 14 mm). Lower PFI was correlated better with the clinical pregnancy rate than the P4 level [30]. The discrepancies between these results and our result were owed to diversities in the definition of PPR, P4 cut off level, P4 assay methods, population studied, stimulation protocols and tim-

Please cite this article in press as: W. Mohawash et al., Progesterone level on the day of triggering and pregnancy outcome in long GnRH agonist protocol, Middle East Fertil Soc J (2017), http://dx.doi.org/10.1016/j.mefs.2017.08.002

W. Mohawash et al. / Middle East Fertility Society Journal xxx (2017) xxx–xxx

ing of P4 testing. Therefore, a consensus on the definition of PPR and the set of P4 cutoff level is needed with further large randomized controlled trials to reach an optimal P4 level or index to dictate fresh ET. Meanwhile, each institute should determine their P4 cutoff level in their protocols and implement the best strategy to overcome its possible adverse effects. The limitation of our study was its retrospective design and the relatively low P4 cut off level as compared to most of the studies. In view of the absence of a proven negative effect of the elevated P4 level on the day of triggering in long protocol cycles, P4 testing may not be recommended, advocating a fresh embryo transfer even with an elevated P4 level. 5. Conclusion In conclusion, the present results suggest that in long GnRh-a protocol patients achieving statistically good laboratory and stimulation parameters had a higher P4 level on the day of HCG trigger. Whereas, the improvement in the pregnancy outcome was not significant.

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Please cite this article in press as: W. Mohawash et al., Progesterone level on the day of triggering and pregnancy outcome in long GnRH agonist protocol, Middle East Fertil Soc J (2017), http://dx.doi.org/10.1016/j.mefs.2017.08.002