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The optimal endometrial preparation for frozen-thawed single embryo transfer in a natural cycle: a retrospective analysis
LUTEAL PHASE SUPPORT P-290 Tuesday, October 21, 2014 EFFICACY OF A SINGLE INJECTION OF HUMAN CHORIONIC GONADOTROPIN AT PEAK FOLLICULAR MATURATION IN NATURAL CYCLES ON PREGNANCY RATE AND MID-LUTEAL HORMONAL AND SONOGRAPHIC PARAMETERS. J. H. Check, J. R. Liss, G. DiAntonio. Cooper Medical School of Rowan University, Camden, NJ. OBJECTIVE: To determine if the addition of human chorionic gonadotropin (hCG) single injection at the time of peak follicular improves pregnancy rates in women being treated with progesterone (P) in the luteal phase in natural cycles and if so is it related to higher serum estradiol (E2) or P levels in mid-luteal phase or increased mid-luteal endometrial thickness or higher percentage of the homogeneous hyperechogenic (HH) echo pattern? DESIGN: Prospective controlled study. MATERIALS AND METHODS: Two age groups were studied - <39.9 and 40-45. Micronized P gel 90mg (CrinoneÒ) twice daily was used from the early luteal phase once follicular collapse was demonstrated. A woman was eliminated and a replacement recruited if the dominant follicle did not attain an average diameter of 18mm and a serum E2 >200pg/mL. Clinical pregnancy rates were obtained for the first 3 cycles. Mid-luteal hormonal and ultrasound parameters were only obtained in the first treatment cycle. Both age groups were assigned to either receive 10,000 units hCG at peak follicular maturation or not. Chi-square analysis, Fisher’s exact test or student T-test was used where appropriate. RESULTS: Women aged <39.9 – pregnancies (3 months) – 3 with hCG – 3/17 (25.0%) vs. without hCG 4/17 (23.5%) – no miscarriages (p¼NS, Chisquare analysis). Women aged 40-45 – with hCG – 1/12 (8.3%) with 1 miscarriage vs. 0/12 (0%) without hCG (p¼NS). For 39.9 with hCG the mid-luteal E2 and P were 175.4pg/mL and 22.4ng/mL, respectively vs. 125.7pg/mL and 16.9ng/mL without hCG (p< .05 for E2 and P, Student ttest). One woman in each group had blood tests but failed to do ultrasound. An HH pattern was found in 11/16 (68.7%) taking hCG vs. 10/16 (62.5%) without hCG (p¼NS, chi-square). For women 40-45 HH was present in 6/ 12 (50%) with hCG vs. 5/12 (41.6%) without hCG (p¼NS). Endometrial thickness age <39.9 10.2mm with hCG and 13.0mm without hCG and 9.3 vs. 9.9mm in women 40-45 (p¼NS). CONCLUSION: The addition of hCG for luteal phase support in natural cycles of infertile women does not seem to offer any improvement in pregnancy rates in women being treated with luteal phase P despite an increased mid-luteal serum E2 and P.
P-291 Tuesday, October 21, 2014 THE OPTIMAL ENDOMETRIAL PREPARATION FOR FROZENTHAWED SINGLE EMBRYO TRANSFER IN A NATURAL CYCLE: A RETROSPECTIVE ANALYSIS. A. Chikawa, K. Iwahashi, H. Hamai, M. Shigeta. Advanced Fertility Center of Fuchu Nozomi, Izumi, Osaka, Japan. OBJECTIVE: Single embryo transfer (SET) is the best method for preventing multiple births. The purpose of this study is to evaluate pregnancy outcomes with or without luteal phase support (LPS) of frozen-thawed single blastocyst transfer (SBT) treatment performed in natural cycles. DESIGN: The study retrospectively analyzed 966 frozen-thawed SBT in natural cycles with or without LPS performed between the periods January 2010 to April 2013. MATERIALS AND METHODS: Oral chlomadinone acetate (LutoralÒ) was given daily during the luteal phase. The outcomes of frozen-thawed SBT treatment including demographic data, clinical pregnancy rates and miscarriage rates, were compared with or without LPS. Ovulation was determined by the LH surge, progesterone (P4) levels and ultrasonography. And all patients underwent ovarian stimulation with human chorionic gonadotrophin (hCG). In order to determine whether the P4 levels after ovulation are associated with clinical pregnancy rate or miscarriage rate, we analyzed P4 levels 2 days after ovulation in 383 cycles out of 966cycles with or without LPS. Post ovulation P4 levels were divided into four groups (with (+), without (-) LPS): Low (L+, L-), 1.4-4.4ng/ml; Middle Low (ML+, ML-), 4.5-5.5ng/ml; Middle High P4 (MH+, MH-), 5.6-7.5ng/ml and High (H+, H-), 7.6-14.8ng/ml.
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ASRM Abstracts
RESULTS: There were no significant differences in the patients’ demographic data (age, basal FSH and embryo quality), clinical pregnancy rate (42.5% vs. 38.0%, p¼0.150) and miscarriage rate (24.7% vs. 20.3%, P¼0.296), between the groups. On the second comparison (383 cycles), a strong tendency of increased clinical pregnancy rates were observed in the high P4 levels group compared to the low P4 levels group (51.1% (H-) vs. 31.9%(L-), p ¼ 0.059) and (42.1% (H+) vs. 28.0%(L+), p¼0.131), but no difference in the miscarriage rates were noted (26.7% (H-) vs. 25.0% (L-), p¼0.908) and (37.5% (H+) vs. 23.8% (L+), p¼0.367). CONCLUSION: The pregnancy outcomes of natural cycle frozen-thawed SBT were similar regardless of LPS. Our results suggest that LPS with oral chlomadinone acetate may not improve the clinical pregnancy nor decrease miscarriage rate. Patients with low levels of P4 might need additional interventions in order to achieve higher pregnancy rates. Our findings suggest that 2-day post ovulation levels R 7.6 ng/ml of P4 provide an optimal endometrial environment. However, we need further studies to determine the optimal treatment for patients with low P4 levels to undergo frozen thawed SBT in a natural cycle.
P-292 Tuesday, October 21, 2014 COMPARING ROUTES OF PROGESTERONE (P) FOR LUTEAL SUPPORT IN DONOR-OOCYTE RECIPIENTS (DER) FOLLOWING FRESH EMBRYO TRANSFER (ET). R. B. Makhijani, K. N. Goldman, J. Buldo-Licciardi, D. H. McCulloh, J. A. Grifo, F. Licciardi. New York University Langone Medical Center, New York, NY. OBJECTIVE: To compare pregnancy outcomes with varying routes of P administration for luteal support in DER in vitro fertilization (IVF) cycles. DESIGN: Retrospective cohort study. MATERIALS AND METHODS: From 1/2007-11/2011, 508 DER IVF cycles (270 exclusive, 238 shared) followed by fresh ET. Intramuscular (IM) P in oil1, vaginal (VG) P2 oral (PO) P3 or both IM and VG P, were administered for luteal support. The primary outcomes measured were implantation rate (IR), clinical pregnancy rate (CPR), live birth rate (LBR) and spontaneous abortion rate (SABR). Data were analyzed using Student’s T-test and Fisher’s exact test (p<0.05). RESULTS: IM P was used in 445, VG P in 14, VG + PO P in 13 and IM + VG P in 36. There were no significant differences in IR, CPR, LBR or SABR (p>0.05). There was a significant difference in recipient age in the IM P vs VG P + PO groups (42.74.2 vs 45.85.6, p<0.05), day 19 serum P level in the IM P vs VG P+PO groups (24.7 17.9 vs 47.650.0, p<0.05) and day 28 serum P levels between IM, vaginal P+PO and VG P groups (28.9 15.7 vs 47.254.7 vs 179.6, p<0.05). There was no significant difference in oocyte donor age, endometrial (EM) thickness prior to start of P, day of embryo transfer, number of embryos transferred, donor oocytes assigned per recipient, mature oocytes, 2 pronuclear (PN) embryos, day 3 or day 5 embryos (p>0.05) (table 1). Cycle Characteristics and Outcomes IM P
VG P
IM + VG P
No. of cycles DER age (yrs) Oocyte donor age (yrs) EM thickness (mm) Day 19 P Day 28 P
445 42.7 4.2* 26 3.81 9.4 2.03 24.7 17.9* 28.9 15.7*
+PO 13 45.8 5.6* 27.8 3.0 8.9 1.2 47.6 50* 47.2 54.7*
-PO 14 43.9 2.6 27.4 2.1 8.9 2.10 24.7 28.8 17.0 9.6*
36 42.8 5.1 27.2 2.9 9.5 2.10 20.3 9.6 27.0 17.7
Day of embryo transfer No. embryos transferred No. donor oocytes assigned No. mature oocytes assigned No. 2 PN embryos No. day 3 embryos
5.0 0.6 1.9 0.4 15.5 9.1 12.3 7.5 10.4 6.3 10.4 6.5
4.8 0.6 1.8 0.5 14.2 6.7 10.5 5.4 8.6 5.5 8.6 5.4
5.0 0.0 1.9 0.5 14.5 6.4 12.3 5.2 10.3 4.4 10.7 4.9
4.9 0.5 1.9 0.3 17.3 9.6 14.6 7.8 11.8 6.7 11.9 7.5
3.3 2.7 51.3 68.3 61.3 5.8
2.3 2.1 61.5 61.5 46.2 15.4
2.7 1.3 71.4 71.4 64.3 7.7
3.4 3.3 80.6 80.6 72.2 8.3
No. blastocysts IR (%) CPR (%) LBR (%) SABR (%)
Data expressed as mean S.D. or percentage; *¼p<0.05
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Vol. 102, No. 3, Supplement, September 2014
P-291 Tuesday, October 21, 2014 THE OPTIMAL ENDOMETRIAL PREPARATION FOR FROZENTHAWED SINGLE EMBRYO TRANSFER IN A NATURAL CYCLE: A RETROSPECTIVE ANALYSIS. A. Chikawa, K. Iwahashi, H. Hamai, M. Shigeta. Advanced Fertility Center of Fuchu Nozomi, Izumi, Osaka, Japan. OBJECTIVE: Single embryo transfer (SET) is the best method for preventing multiple births. The purpose of this study is to evaluate pregnancy outcomes with or without luteal phase support (LPS) of frozen-thawed single blastocyst transfer (SBT) treatment performed in natural cycles. DESIGN: The study retrospectively analyzed 966 frozen-thawed SBT in natural cycles with or without LPS performed between the periods January 2010 to April 2013. MATERIALS AND METHODS: Oral chlomadinone acetate (LutoralÒ) was given daily during the luteal phase. The outcomes of frozen-thawed SBT treatment including demographic data, clinical pregnancy rates and miscarriage rates, were compared with or without LPS. Ovulation was determined by the LH surge, progesterone (P4) levels and ultrasonography. And all patients underwent ovarian stimulation with human chorionic gonadotrophin (hCG). In order to determine whether the P4 levels after ovulation are associated with clinical pregnancy rate or miscarriage rate, we analyzed P4 levels 2 days after ovulation in 383 cycles out of 966cycles with or without LPS. Post ovulation P4 levels were divided into four groups (with (+), without (-) LPS): Low (L+, L-), 1.4-4.4ng/ml; Middle Low (ML+, ML-), 4.5-5.5ng/ml; Middle High P4 (MH+, MH-), 5.6-7.5ng/ml and High (H+, H-), 7.6-14.8ng/ml.
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ASRM Abstracts
RESULTS: There were no significant differences in the patients’ demographic data (age, basal FSH and embryo quality), clinical pregnancy rate (42.5% vs. 38.0%, p¼0.150) and miscarriage rate (24.7% vs. 20.3%, P¼0.296), between the groups. On the second comparison (383 cycles), a strong tendency of increased clinical pregnancy rates were observed in the high P4 levels group compared to the low P4 levels group (51.1% (H-) vs. 31.9%(L-), p ¼ 0.059) and (42.1% (H+) vs. 28.0%(L+), p¼0.131), but no difference in the miscarriage rates were noted (26.7% (H-) vs. 25.0% (L-), p¼0.908) and (37.5% (H+) vs. 23.8% (L+), p¼0.367). CONCLUSION: The pregnancy outcomes of natural cycle frozen-thawed SBT were similar regardless of LPS. Our results suggest that LPS with oral chlomadinone acetate may not improve the clinical pregnancy nor decrease miscarriage rate. Patients with low levels of P4 might need additional interventions in order to achieve higher pregnancy rates. Our findings suggest that 2-day post ovulation levels R 7.6 ng/ml of P4 provide an optimal endometrial environment. However, we need further studies to determine the optimal treatment for patients with low P4 levels to undergo frozen thawed SBT in a natural cycle.
P-292 Tuesday, October 21, 2014 COMPARING ROUTES OF PROGESTERONE (P) FOR LUTEAL SUPPORT IN DONOR-OOCYTE RECIPIENTS (DER) FOLLOWING FRESH EMBRYO TRANSFER (ET). R. B. Makhijani, K. N. Goldman, J. Buldo-Licciardi, D. H. McCulloh, J. A. Grifo, F. Licciardi. New York University Langone Medical Center, New York, NY. OBJECTIVE: To compare pregnancy outcomes with varying routes of P administration for luteal support in DER in vitro fertilization (IVF) cycles. DESIGN: Retrospective cohort study. MATERIALS AND METHODS: From 1/2007-11/2011, 508 DER IVF cycles (270 exclusive, 238 shared) followed by fresh ET. Intramuscular (IM) P in oil1, vaginal (VG) P2 oral (PO) P3 or both IM and VG P, were administered for luteal support. The primary outcomes measured were implantation rate (IR), clinical pregnancy rate (CPR), live birth rate (LBR) and spontaneous abortion rate (SABR). Data were analyzed using Student’s T-test and Fisher’s exact test (p<0.05). RESULTS: IM P was used in 445, VG P in 14, VG + PO P in 13 and IM + VG P in 36. There were no significant differences in IR, CPR, LBR or SABR (p>0.05). There was a significant difference in recipient age in the IM P vs VG P + PO groups (42.74.2 vs 45.85.6, p<0.05), day 19 serum P level in the IM P vs VG P+PO groups (24.7 17.9 vs 47.650.0, p<0.05) and day 28 serum P levels between IM, vaginal P+PO and VG P groups (28.9 15.7 vs 47.254.7 vs 179.6, p<0.05). There was no significant difference in oocyte donor age, endometrial (EM) thickness prior to start of P, day of embryo transfer, number of embryos transferred, donor oocytes assigned per recipient, mature oocytes, 2 pronuclear (PN) embryos, day 3 or day 5 embryos (p>0.05) (table 1). Cycle Characteristics and Outcomes IM P
VG P
IM + VG P
No. of cycles DER age (yrs) Oocyte donor age (yrs) EM thickness (mm) Day 19 P Day 28 P
445 42.7 4.2* 26 3.81 9.4 2.03 24.7 17.9* 28.9 15.7*
+PO 13 45.8 5.6* 27.8 3.0 8.9 1.2 47.6 50* 47.2 54.7*
-PO 14 43.9 2.6 27.4 2.1 8.9 2.10 24.7 28.8 17.0 9.6*
36 42.8 5.1 27.2 2.9 9.5 2.10 20.3 9.6 27.0 17.7
Day of embryo transfer No. embryos transferred No. donor oocytes assigned No. mature oocytes assigned No. 2 PN embryos No. day 3 embryos
5.0 0.6 1.9 0.4 15.5 9.1 12.3 7.5 10.4 6.3 10.4 6.5
4.8 0.6 1.8 0.5 14.2 6.7 10.5 5.4 8.6 5.5 8.6 5.4
5.0 0.0 1.9 0.5 14.5 6.4 12.3 5.2 10.3 4.4 10.7 4.9
4.9 0.5 1.9 0.3 17.3 9.6 14.6 7.8 11.8 6.7 11.9 7.5
3.3 2.7 51.3 68.3 61.3 5.8
2.3 2.1 61.5 61.5 46.2 15.4
2.7 1.3 71.4 71.4 64.3 7.7
3.4 3.3 80.6 80.6 72.2 8.3
No. blastocysts IR (%) CPR (%) LBR (%) SABR (%)
Data expressed as mean S.D. or percentage; *¼p<0.05
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Vol. 102, No. 3, Supplement, September 2014