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Elevated serum progesterone-to-estradiol ratio during gonadotropin stimulation for intrauterine insemination or in vitro fertilization is not associated with diminished ovarian reserve
FERTILITY AND STERILITY威 VOL. 78, NO. 1, JULY 2002 Copyright ©2002 American Society for Reproductive Medicine Published by Elsevier Science Inc. Printed on acid-free paper in U.S.A.
Elevated serum progesterone-to-estradiol ratio during gonadotropin stimulation for intrauterine insemination or in vitro fertilization is not associated with diminished ovarian reserve Glen E. Hofmann, M.D., Ph.D.,a Jane Khoury, M.S.,b and Chad Michener, M.D.a Bethesda Hospital, Cincinnati, Ohio
Received September 10, 2001; revised and accepted January 2, 2002. Presented in part at the 55th Annual Meeting of the American Society for Reproductive Medicine, Toronto, Ontario, Canada, September 25–30, 1999. Reprint requests: Glen E. Hofmann, M.D., Ph.D., Bethesda Center for Reproductive Health and Fertility, Bethesda Hospital, 619 Oak Street, Cincinnati, Ohio 45206 (FAX: 513-7451676; E-mail: hofmanng@ aol.com). a Department of Obstetrics and Gynecology, Bethesda Center for Reproductive Health and Fertility, Bethesda Hospital. b Department of Environmental Health, Division of Biostatistics and Epidemiology, University of Cincinnati, Cincinnati, Ohio, 0015-0282/02/$22.00 PII S0015-0282(02)03162-X
Objective: To determine whether an elevated serum P:E2 ratio on the day of hCG administration during gonadotropin stimulation for intrauterine insemination (IUI) or IVF is associated with diminished ovarian reserve. Design: Retrospective chart review. Setting: Tertiary fertility center. Patient(s): Two hundred eighty-six women undergoing a fertility evaluation. Intervention(s): Clomiphene citrate challenge test (CCCT). Main Outcome Measure(s): E2 and P concentrations on the day of hCG administration. Result(s): For the IUI group (n ⫽ 98), 74 women had a normal CCCT, while 24 had an abnormal CCCT. For women undergoing IVF (n ⫽ 188), 171 had a normal CCCT and 17 had an abnormal CCCT. For women undergoing IUI with a normal CCCT, 33 (44%) had a [(P/E2) ⫻ 1000] ratio ⬍1 on the day of hCG, while 12 (50%) (abnormal CCCT) had a [(P/E2) ⫻ 1000] ratio ⬍1. Similarly, for women doing IVF with a normal CCCT, 96 (56%) had a [(P/E2) ⫻ 1000] ratio ⬍1 on the day of hCG, and 9 (44%) (abnormal CCCT) had a [(P/E2) ⫻ 1000] ratio ⬍1 on the day of hCG. The frequencies were similar for all comparable groups. For both groups, there was no association between serum (P/E2) ⫻ 1000 on the day of hCG administration and day 3 or 10 FSH during the CCCT. For women with a normal CCCT, there were no differences in delivery rates based on the (P/E2) ⫻ 1000 ratio. Conclusion(s): In women stimulated with hMG for IUI or IVF, the serum P:E2 ratio on the day of hCG administration is not associated with diminished ovarian reserve, as demonstrated by the CCCT, or pregnancy outcome. (Fertil Steril威 2002;78:47–50. ©2002 by American Society for Reproductive Medicine.) Key Words: P:E2 ratio, diminished ovarian reserve, clomiphene citrate challenge test, pregnancy outcome
For many years, clinicians treating couples for infertility by using complex ovulation induction or IVF with hMG have sought to prospectively evaluate women for diminished ovarian reserve, in an attempt to predict the chance of live birth with the patient’s own oocytes. Typically, elevated FSH concentrations on menstrual day 3 or during a clomiphene citrate challenge test (CCCT) reveal diminished ovarian reserve, which predicts a poor response to gonadotropins and poor follicular recruitment (1–7). Elevated day 3 FSH concentrations or an abnormal CCCT have been associated with a significantly decreased
chance for live birth with a woman’s own oocytes, both in the general population with infertility and women undergoing ovulation induction for IUI or IVF (1–5). Recently, Younis et al. (8) suggested that for women with unexplained infertility undergoing ovulation induction with hMG or IVF with a luteal GnRH agonist (9), an elevated [(P:E2) ⫻ 1000) ratio ⬎ 1 on the day of hCG administration might also reflect diminished ovarian reserve. This was hypothesized because of the known relationship between diminished ovarian reserve and an elevated serum P level (⬎1.1 ng/mL) on cycle day 10 of a CCCT (10) 47
and because published literature suggested that a serum P level ⱖ 1.1 ng/mL on the day of hCG administration predicted a poor live birth rate with IVF (11). Younis et al.’s retrospective definition of diminished ovarian reserve was based solely on an elevated [(P/E2) ⫻ 1000] ratio (ⱖ1.1). The patients with an elevated [(P/E2) ⫻ 1000] ratio were found to have higher basal FSH and E2 concentrations, lower peak E2 concentrations, higher peak P concentrations, and fewer recruited follicles, findings consistent with those of other studies on diminished ovarian reserve. The choice of the ratio was made to decrease the chance that women with a high P concentration resulting from multiple small follicles would not be considered to have diminished ovarian reserve compared with women with an elevated P level in whom few follicles are recruited. We sought to further evaluate the above preliminary results (8, 9) in a larger sample of women with well-characterized ovarian reserve based on a CCCT. Women undergoing complex ovulation induction for IUI and IVF were included. These women were evaluated for the relationship of the serum P:E2 ratio on the day of hCG administration. This ratio was correlated with the results of a CCCT, hormonal and follicular variables associated with ovulation induction and IVF, and pregnancy outcome.
MATERIALS AND METHODS Two hundred eighty-four women had a CCCT as part of their infertility work-up according to the criteria of age ⱖ 35 years; any age but with a diagnosis of unexplained infertility, one ovary, or a history of significant ovarian surgery; or a previous poor response to hMG administration (12). Because the CCCT is a routine part of any fertility evaluation in our center for women with the above criteria, institutional review board approval for the study was not sought. The CCCT was performed by obtaining serum on menstrual day 3 for FSH and E2 concentrations, administering 100 mg of clomiphene citrate on days 5–9, and obtaining serum on menstrual day 10 to measure FSH concentrations. Hormone assays were performed as described elsewhere, with correction of the FSH levels for the nonisotopic assay used in our laboratory (Imx; Abbott Laboratories, Abbott Park, IL) (10). An abnormal result was a serum FSH concentration ⱖ 25 mIU/mL (based on the radio immunoassay, or ⱖ14.5 mIU/mL for the IMx assay) on either day 3 or 10. All women later underwent ovarian hyperstimulation with hMG for IUI (n⫽98) or IVF (n⫽188) after luteal suppression with a GnRH agonist. Women undergoing IUI had unexplained infertility, minimal to mild endometriosis, mild male factor, ovulatory dysfunction, or a combination of these diagnoses, and women undergoing IVF had tubal disease, male factor, endometriosis, unexplained infertility, or ovulatory dysfunction. 48
Hofmann et al.
P:E2 ratio and diminished ovarian reserve
Chart review was performed to obtain peak E2 and P concentrations on the day of hCG administration, from which the P:E2 ratio was calculated. From the charts, we also obtained the number of ampules of hMG required for stimulation, the number of mature follicles (ⱖ16 mm) or eggs retrieved, day 3 FSH and day 10 FSH concentrations from the CCCT, patient age, and pregnancy outcome. Comparisons were made between the P:E2 ratio on the day of hCG administration and results of the CCCT (normal or abnormal), day 3 and day 10 FSH concentrations, patient age, number of ampules of hMG required for stimulation, peak E2 concentrations, the number of mature follicles or eggs observed after ovarian stimulation, and pregnancy outcome. Pregnancy was defined as a live birth. Bivariate comparisons were made by using the 2 or Fisher exact test, as appropriate. Day of hCG administration, serum P concentrations on day 10 CCCT and day of hCG administration, day 3 and day 10 FSH concentrations, peak E2level, P:E2 ratio, and number of follicles were log transformed because they were non-normally distributed. Values for these variables are expressed as the geometric mean and 95% CI. Univariate analysis was done by performing a t-test, and multiple variate analysis was done by using regression analysis. For variables that did not requiring transformation, values are expressed as the mean (⫾SD). Using an abnormal result on the CCCT as the outcome variable, the 2 test or Fisher exact test was used for univariate comparisons, and multiple logistic regression analysis was used for multivariate analysis. P⬍.05 was considered statistically significant. A power analysis was performed to determine the adequacy of the sample size, anticipating a 20% difference between groups (␣⫽0.05, ⫽0.8). Power analysis indicated that 229 and 513 patients would be required in the IUI and IVF groups respectively, to detect an existing difference.
RESULTS Ninety-eight women underwent ovulation induction with hMG. Seventy-four women (75.5%) had a normal CCCT. Of those women, 41 (55.4%) had a [(P/E2) ⫻ 1000] ratio ⬍1.0 and 33 (44.5%) had a ratio ⱖ 1.1 (abnormal/normal ratio, 44.5%). Of the 24 women (24.5%) with an abnormal CCCT, 12 (50%) had a [(P/E2) ⫻ 1000] ratio ⬍ 1.0 and 12 (50%) had a ratio ⱖ 1.1 (abnormal/normal ratio, 50%) (P⫽.5 [CI, ⫺0.8 to 1.33]). The P concentration on the day of hCG administration was 0.8⫾0.5 ng/mL in women with a normal CCCT and 0.97⫾.6 ng/mL in those with an abnormal CCCT (P⫽.38 [CI, 0.6 to 2.4]) (Table 1). One hundred eighty-eight women underwent IVF. One hundred seventy-one of these women (90.9%) had a normal CCCT. Of those, 96 (56.1%) had a [(P/E2) ⫻ 1000] ratio ⬍ 1.0 and 75 (43.9%) had a ratio ⱖ 1.1 (abnormal/normal ratio, 56%). Of the 17 women (9.1%) with an abnormal CCCT, 8 Vol. 78, No. 1, July 2002
TABLE 1 Comparison of P/E2 ratio and serum P concentration on the day of hCG administration in women undergoing IUI or IVF, based on the results of the CCCT. IUI group
Clomiphene citrate challenge test Normal Abnormal
IVF group
P/E2 ratio⬍1
P/E2 ratioⱖ1.1
Patients (%)a
P level on day of hCGb administration (ng/mL)
41/74 12/24
33/74 12/24
44 50
0.8 ⫾ 0.5 0.9 ⫾ 0.6
P/E2 ratio⬍1
P/E2 ratioⱖ1.1
Patients (%)a
P level on day of hCGb administration (ng/mL)
96/171 8/17
75/171 9/17
56 44
1.05 ⫾ 0.3 1.03 ⫾ 1.1
P⫽.5 (CI, ⫺0.8 to 1.33) for normal versus abnormal CCCT in IUI group; P⫽.47 (CI, 0.4 –3.4) for normal versus abnormal CCCT in IVF group. P⫽.38 (CI, 0.6 –2.4) for normal versus abnormal CCCT in IVF group; P⫽.5 (CI, 0.6 to 1.7) for normal versus abnormal CCCT in IVF group. Conversion factor for progesterone to SI unit, 3.18.
a
b
Hofmann. PE2 ratio and diminished ovarian reserve. Fertil Steril 2002.
(47%) had a [(P/E2) ⫻ 1000] ratio ⬍1.0 and 9 (53%) had a ratio ⱖ 1.1 (abnormal/normal ratio, 44%) (P⫽.47 [CI, 0.4 to 3.4]). The P concentration on the day of hCG administration was 1.05⫾.3 ng/mL in women with a normal CCCT and 1.03⫾1.13 ng/mL in women with an abnormal CCCT (P⫽.5 [CI, 0.6 to 1.7]) (Table 1). For women undergoing IUI, independent of the CCCT results, the P:E2 ratio was not correlated with the day 3 or 10 FSH concentrations during the CCCT, peak E2 concentration, number of ampules of hMG required for stimulation, number of mature follicles, or patient age (P⬎.05 for all comparisons, by linear regression). For women undergoing IVF, the P:E2 ratio was not correlated with day 3 or 10 FSH concentrations during the CCCT but a strong positive correlation with peak E2 concentration (P⬍.01, by linear regression), number of ampules of hMG required for ovarian hyperstimulation (P⬍.05, by linear regression), and number of oocytes retrieved was observed (P⬍.01, by linear regression). Among women undergoing IUI or IVF, those with an abnormal challenge test result required more ampules of hMG to achieve lower peak E2 concentrations and had fewer mature follicles compared with women with a normal result (data not shown).
initiating ovulation induction for IUI or IVF. Basal FSH concentrations and abnormal results on the CCCT have been shown to predict diminished ovarian reserve and a poor chance of live birth with a woman’s own oocytes (1–7, 10, 11). We examined the role of the [(P/E2) ⫻ 1000] ratio at the time of hCG administration in detecting diminished ovarian reserve in women undergoing ovulation induction for IUI or IVF. Our data suggest that this ratio is not a marker for diminished ovarian reserve when the CCCT is used as the gold standard (Table 1). No difference in the P:E2 ratio was noted for the IUI or IVF group, independent of the results of the CCCT. However, these data are limited by type II error. The sample size for either group was inadequate to detect a 20% difference in
FIGURE 1 Pregnancy rates in the IUI and IVF groups as a function of the P/E2 ratio. Pregnancy rates did not differ between groups on the basis of the ratio.
Pregnancy outcome was considered only for women with a normal CCCT. Among women undergoing IUI, 18 of 41 (43.9%) with a [(P/E2) ⫻ 1000] ratio ⬍1.0 and 14 of 33 (42.4%) with a ratio ⱖ 1.1 delivered (odds ratio, 1.01 [95% CI, 0.78 –1.30] P⫽.89). Among women undergoing IVF, 35 of 75 (46.6%) with a [(P/E2) ⫻ 1000] ratio ⬍1.0 and 48 of 96 (50%) with a ratio ⱖ 1.1 delivered (odds ratio, 1.05 [CI, 0.82–1.16]; P⫽.51) (Fig. 1).
DISCUSSION Clinicians are constantly seeking newer, more sensitive, and more specific prospective testing to evaluate a couple’s chance of a successful live birth with self oocytes before FERTILITY & STERILITY威
Hofmann. PE2 ratio and diminished ovarian reserve. Fertil Steril 2002.
49
the proportion of patients with a ratio or serum P concentration ⱕ 1. Using the ratio, 229 patients would have been required for the IUI group and 513 patients for the IVF group. However, even with larger numbers, the results would probaly not affect clinical decisions substantially enough to warrant using either of these hormonal markers when counseling patients about their likelihood of successful birth from ovulation induction for IUI or IVF. The [(P/E2) ⫻ 1000] ratio did not correlate with the number of ampules of hMG required for hyperstimulation, the peak E2 level, or the number of mature (⬎16 mm) follicles on the day of hCG administration for patients undergoing IUI. This finding contrasts with that of Younis et al. (8). However, for patients undergoing IVF, the ratio correlated strongly with the number of ampules of hMG required for hyperstimulation, the peak E2 level, and the number of mature oocytes retrieved. The reasons for the differences between our findings and those of Younis et al. (8, 9) are unknown. Their study examined only patients with unexplained infertility in the IUI group; in contrast, we did not restrict patient selection to those with unexplained infertility or limit patient selection to those requiring IUI for their care. Our sample included women with documented diminished ovarian reserve. Studies have documented that many women with unexplained infertility have diminished ovarian reserve (6, 11). Thus, our sample differed considerably from that of the IUI group in the study by Younis et al. (8). The IVF groups in our study and that of Younis et al. included similar patients by infertility diagnosis, but our IVF patients included women with known diminished ovarian reserve. Furthermore, and perhaps more significantly, the samples in both our IUI and IVF groups were significantly larger than those in the studies by Younis et al. (8, 9). The ultimate outcome variable for infertility treatment is live birth. In our study, live birth rates in either study group
50
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P:E2 ratio and diminished ovarian reserve
did not differ by the P:E2 ratio. Women with diminished ovarian reserve were not included in this part of the analysis because they have known poor reproductive outcome. Thus, the P:E2 ratio did not predict live birth with self oocytes. In summary, in a retrospective analysis, the [(P/E2) ⫻ 1000] ratio did not correlate with the results of a CCCT or predict live birth with self oocytes. Thus, this ratio should not be used in place of the prospective CCCT, whose ability to predict pregnancy outcome is well documented. References 1. Scott RT, Toner JP, Muasher SJ, Oehninger S, Robinson S, Rosenwaks Z. Follicle-stimulating hormone levels on cycle day 3 are predictive of in vitro fertilization outcome. Fertil Steril 1989;51:651– 4. 2. Toner JP. Philput CB, Jones GS, Muasher SJ. Basal follicle-stimulating hormone levels is a better predictor of in vitro fertilization performance than age. Fertil Steril 1991;55:784 –91. 3. Navot D, Margolith EJ, Rosenwaks Z. Prognostic assessment of female fecundity. Lancet 1987;2:645–7. 4. Tambo T, Dale PO, Lunde O, Norman N, Abyholm T. Prediction of response to controlled ovarian hyperstimulation: a comparison of basal and clomiphene citrate-stimulated follicle-stimulating hormone levels. Fertil Steril 1992;57:819 –24. 5. Burwinkle T, Buster JE, Scoggan JL, Carson SA. Basal follicle-stimulating hormone (FSH) predicts response to controlled ovarian hyperstimulation (COH)-intrauterine insemination (IUI) therapy. J Assist Reprod Genet 1994;11:24 –7. 6. Scott RT, Leonardi MR, Hofmann GE, Illions EH, Neal GS, Navot D. A prospective evaluation of CCCT screening of the general infertility population. Obstet Gynecol 1993;82:539 – 44. 7. Scott RT Jr, Hofmann GE. Prognostic assessment of ovarian reserve. Fertil Steril 1997;63:1–11. 8. Younis JS, Haddad S, Matilsky M, Ben-Ami, M. Premature luteinization: could it be an early manifestation of low ovarian reserve? Fertil Steril 1998;69:461–5. 9. Younis JS, Matilsky M, Radin O, Ben-Ami M. Increase progesterone/ estradiol ratio in the late follicular phase could be related to low ovarian reserve in in vitro fertilization-embryo transfer cycles with a long gonadotropin-releasing hormone agonist protocol. Fertil Steril 2001;76: 294 –9. 10. Hofmann GE, Scott RT Jr, Horowitz GM, Thie J, Navot D. Evaluation of the reproductive performance of women with elevated day 10 progesterone during ovarian reserve screening. Fertil Steril 1995;63:979 – 83. 11. Hofmann GE, Khoury J, Johnson CA, Thie J, Scott RT Jr. Premature luteinization during controlled ovarian hyperstimulation for in vitro fertilization-embryo transfer has no impact on pregnancy outcome. Fertil Steril 1996;66:980 – 6. 12. Hofmann GE, Sosnowski J, Scott RT Jr, Thie J. Efficacy for selection criteria for ovarian reserve screening using the CCCT in a tertiary fertility center. Fertil Steril 1996;66:49 –53.
Vol. 78, No. 1, July 2002
Elevated serum progesterone-to-estradiol ratio during gonadotropin stimulation for intrauterine insemination or in vitro fertilization is not associated with diminished ovarian reserve Glen E. Hofmann, M.D., Ph.D.,a Jane Khoury, M.S.,b and Chad Michener, M.D.a Bethesda Hospital, Cincinnati, Ohio
Received September 10, 2001; revised and accepted January 2, 2002. Presented in part at the 55th Annual Meeting of the American Society for Reproductive Medicine, Toronto, Ontario, Canada, September 25–30, 1999. Reprint requests: Glen E. Hofmann, M.D., Ph.D., Bethesda Center for Reproductive Health and Fertility, Bethesda Hospital, 619 Oak Street, Cincinnati, Ohio 45206 (FAX: 513-7451676; E-mail: hofmanng@ aol.com). a Department of Obstetrics and Gynecology, Bethesda Center for Reproductive Health and Fertility, Bethesda Hospital. b Department of Environmental Health, Division of Biostatistics and Epidemiology, University of Cincinnati, Cincinnati, Ohio, 0015-0282/02/$22.00 PII S0015-0282(02)03162-X
Objective: To determine whether an elevated serum P:E2 ratio on the day of hCG administration during gonadotropin stimulation for intrauterine insemination (IUI) or IVF is associated with diminished ovarian reserve. Design: Retrospective chart review. Setting: Tertiary fertility center. Patient(s): Two hundred eighty-six women undergoing a fertility evaluation. Intervention(s): Clomiphene citrate challenge test (CCCT). Main Outcome Measure(s): E2 and P concentrations on the day of hCG administration. Result(s): For the IUI group (n ⫽ 98), 74 women had a normal CCCT, while 24 had an abnormal CCCT. For women undergoing IVF (n ⫽ 188), 171 had a normal CCCT and 17 had an abnormal CCCT. For women undergoing IUI with a normal CCCT, 33 (44%) had a [(P/E2) ⫻ 1000] ratio ⬍1 on the day of hCG, while 12 (50%) (abnormal CCCT) had a [(P/E2) ⫻ 1000] ratio ⬍1. Similarly, for women doing IVF with a normal CCCT, 96 (56%) had a [(P/E2) ⫻ 1000] ratio ⬍1 on the day of hCG, and 9 (44%) (abnormal CCCT) had a [(P/E2) ⫻ 1000] ratio ⬍1 on the day of hCG. The frequencies were similar for all comparable groups. For both groups, there was no association between serum (P/E2) ⫻ 1000 on the day of hCG administration and day 3 or 10 FSH during the CCCT. For women with a normal CCCT, there were no differences in delivery rates based on the (P/E2) ⫻ 1000 ratio. Conclusion(s): In women stimulated with hMG for IUI or IVF, the serum P:E2 ratio on the day of hCG administration is not associated with diminished ovarian reserve, as demonstrated by the CCCT, or pregnancy outcome. (Fertil Steril威 2002;78:47–50. ©2002 by American Society for Reproductive Medicine.) Key Words: P:E2 ratio, diminished ovarian reserve, clomiphene citrate challenge test, pregnancy outcome
For many years, clinicians treating couples for infertility by using complex ovulation induction or IVF with hMG have sought to prospectively evaluate women for diminished ovarian reserve, in an attempt to predict the chance of live birth with the patient’s own oocytes. Typically, elevated FSH concentrations on menstrual day 3 or during a clomiphene citrate challenge test (CCCT) reveal diminished ovarian reserve, which predicts a poor response to gonadotropins and poor follicular recruitment (1–7). Elevated day 3 FSH concentrations or an abnormal CCCT have been associated with a significantly decreased
chance for live birth with a woman’s own oocytes, both in the general population with infertility and women undergoing ovulation induction for IUI or IVF (1–5). Recently, Younis et al. (8) suggested that for women with unexplained infertility undergoing ovulation induction with hMG or IVF with a luteal GnRH agonist (9), an elevated [(P:E2) ⫻ 1000) ratio ⬎ 1 on the day of hCG administration might also reflect diminished ovarian reserve. This was hypothesized because of the known relationship between diminished ovarian reserve and an elevated serum P level (⬎1.1 ng/mL) on cycle day 10 of a CCCT (10) 47
and because published literature suggested that a serum P level ⱖ 1.1 ng/mL on the day of hCG administration predicted a poor live birth rate with IVF (11). Younis et al.’s retrospective definition of diminished ovarian reserve was based solely on an elevated [(P/E2) ⫻ 1000] ratio (ⱖ1.1). The patients with an elevated [(P/E2) ⫻ 1000] ratio were found to have higher basal FSH and E2 concentrations, lower peak E2 concentrations, higher peak P concentrations, and fewer recruited follicles, findings consistent with those of other studies on diminished ovarian reserve. The choice of the ratio was made to decrease the chance that women with a high P concentration resulting from multiple small follicles would not be considered to have diminished ovarian reserve compared with women with an elevated P level in whom few follicles are recruited. We sought to further evaluate the above preliminary results (8, 9) in a larger sample of women with well-characterized ovarian reserve based on a CCCT. Women undergoing complex ovulation induction for IUI and IVF were included. These women were evaluated for the relationship of the serum P:E2 ratio on the day of hCG administration. This ratio was correlated with the results of a CCCT, hormonal and follicular variables associated with ovulation induction and IVF, and pregnancy outcome.
MATERIALS AND METHODS Two hundred eighty-four women had a CCCT as part of their infertility work-up according to the criteria of age ⱖ 35 years; any age but with a diagnosis of unexplained infertility, one ovary, or a history of significant ovarian surgery; or a previous poor response to hMG administration (12). Because the CCCT is a routine part of any fertility evaluation in our center for women with the above criteria, institutional review board approval for the study was not sought. The CCCT was performed by obtaining serum on menstrual day 3 for FSH and E2 concentrations, administering 100 mg of clomiphene citrate on days 5–9, and obtaining serum on menstrual day 10 to measure FSH concentrations. Hormone assays were performed as described elsewhere, with correction of the FSH levels for the nonisotopic assay used in our laboratory (Imx; Abbott Laboratories, Abbott Park, IL) (10). An abnormal result was a serum FSH concentration ⱖ 25 mIU/mL (based on the radio immunoassay, or ⱖ14.5 mIU/mL for the IMx assay) on either day 3 or 10. All women later underwent ovarian hyperstimulation with hMG for IUI (n⫽98) or IVF (n⫽188) after luteal suppression with a GnRH agonist. Women undergoing IUI had unexplained infertility, minimal to mild endometriosis, mild male factor, ovulatory dysfunction, or a combination of these diagnoses, and women undergoing IVF had tubal disease, male factor, endometriosis, unexplained infertility, or ovulatory dysfunction. 48
Hofmann et al.
P:E2 ratio and diminished ovarian reserve
Chart review was performed to obtain peak E2 and P concentrations on the day of hCG administration, from which the P:E2 ratio was calculated. From the charts, we also obtained the number of ampules of hMG required for stimulation, the number of mature follicles (ⱖ16 mm) or eggs retrieved, day 3 FSH and day 10 FSH concentrations from the CCCT, patient age, and pregnancy outcome. Comparisons were made between the P:E2 ratio on the day of hCG administration and results of the CCCT (normal or abnormal), day 3 and day 10 FSH concentrations, patient age, number of ampules of hMG required for stimulation, peak E2 concentrations, the number of mature follicles or eggs observed after ovarian stimulation, and pregnancy outcome. Pregnancy was defined as a live birth. Bivariate comparisons were made by using the 2 or Fisher exact test, as appropriate. Day of hCG administration, serum P concentrations on day 10 CCCT and day of hCG administration, day 3 and day 10 FSH concentrations, peak E2level, P:E2 ratio, and number of follicles were log transformed because they were non-normally distributed. Values for these variables are expressed as the geometric mean and 95% CI. Univariate analysis was done by performing a t-test, and multiple variate analysis was done by using regression analysis. For variables that did not requiring transformation, values are expressed as the mean (⫾SD). Using an abnormal result on the CCCT as the outcome variable, the 2 test or Fisher exact test was used for univariate comparisons, and multiple logistic regression analysis was used for multivariate analysis. P⬍.05 was considered statistically significant. A power analysis was performed to determine the adequacy of the sample size, anticipating a 20% difference between groups (␣⫽0.05, ⫽0.8). Power analysis indicated that 229 and 513 patients would be required in the IUI and IVF groups respectively, to detect an existing difference.
RESULTS Ninety-eight women underwent ovulation induction with hMG. Seventy-four women (75.5%) had a normal CCCT. Of those women, 41 (55.4%) had a [(P/E2) ⫻ 1000] ratio ⬍1.0 and 33 (44.5%) had a ratio ⱖ 1.1 (abnormal/normal ratio, 44.5%). Of the 24 women (24.5%) with an abnormal CCCT, 12 (50%) had a [(P/E2) ⫻ 1000] ratio ⬍ 1.0 and 12 (50%) had a ratio ⱖ 1.1 (abnormal/normal ratio, 50%) (P⫽.5 [CI, ⫺0.8 to 1.33]). The P concentration on the day of hCG administration was 0.8⫾0.5 ng/mL in women with a normal CCCT and 0.97⫾.6 ng/mL in those with an abnormal CCCT (P⫽.38 [CI, 0.6 to 2.4]) (Table 1). One hundred eighty-eight women underwent IVF. One hundred seventy-one of these women (90.9%) had a normal CCCT. Of those, 96 (56.1%) had a [(P/E2) ⫻ 1000] ratio ⬍ 1.0 and 75 (43.9%) had a ratio ⱖ 1.1 (abnormal/normal ratio, 56%). Of the 17 women (9.1%) with an abnormal CCCT, 8 Vol. 78, No. 1, July 2002
TABLE 1 Comparison of P/E2 ratio and serum P concentration on the day of hCG administration in women undergoing IUI or IVF, based on the results of the CCCT. IUI group
Clomiphene citrate challenge test Normal Abnormal
IVF group
P/E2 ratio⬍1
P/E2 ratioⱖ1.1
Patients (%)a
P level on day of hCGb administration (ng/mL)
41/74 12/24
33/74 12/24
44 50
0.8 ⫾ 0.5 0.9 ⫾ 0.6
P/E2 ratio⬍1
P/E2 ratioⱖ1.1
Patients (%)a
P level on day of hCGb administration (ng/mL)
96/171 8/17
75/171 9/17
56 44
1.05 ⫾ 0.3 1.03 ⫾ 1.1
P⫽.5 (CI, ⫺0.8 to 1.33) for normal versus abnormal CCCT in IUI group; P⫽.47 (CI, 0.4 –3.4) for normal versus abnormal CCCT in IVF group. P⫽.38 (CI, 0.6 –2.4) for normal versus abnormal CCCT in IVF group; P⫽.5 (CI, 0.6 to 1.7) for normal versus abnormal CCCT in IVF group. Conversion factor for progesterone to SI unit, 3.18.
a
b
Hofmann. PE2 ratio and diminished ovarian reserve. Fertil Steril 2002.
(47%) had a [(P/E2) ⫻ 1000] ratio ⬍1.0 and 9 (53%) had a ratio ⱖ 1.1 (abnormal/normal ratio, 44%) (P⫽.47 [CI, 0.4 to 3.4]). The P concentration on the day of hCG administration was 1.05⫾.3 ng/mL in women with a normal CCCT and 1.03⫾1.13 ng/mL in women with an abnormal CCCT (P⫽.5 [CI, 0.6 to 1.7]) (Table 1). For women undergoing IUI, independent of the CCCT results, the P:E2 ratio was not correlated with the day 3 or 10 FSH concentrations during the CCCT, peak E2 concentration, number of ampules of hMG required for stimulation, number of mature follicles, or patient age (P⬎.05 for all comparisons, by linear regression). For women undergoing IVF, the P:E2 ratio was not correlated with day 3 or 10 FSH concentrations during the CCCT but a strong positive correlation with peak E2 concentration (P⬍.01, by linear regression), number of ampules of hMG required for ovarian hyperstimulation (P⬍.05, by linear regression), and number of oocytes retrieved was observed (P⬍.01, by linear regression). Among women undergoing IUI or IVF, those with an abnormal challenge test result required more ampules of hMG to achieve lower peak E2 concentrations and had fewer mature follicles compared with women with a normal result (data not shown).
initiating ovulation induction for IUI or IVF. Basal FSH concentrations and abnormal results on the CCCT have been shown to predict diminished ovarian reserve and a poor chance of live birth with a woman’s own oocytes (1–7, 10, 11). We examined the role of the [(P/E2) ⫻ 1000] ratio at the time of hCG administration in detecting diminished ovarian reserve in women undergoing ovulation induction for IUI or IVF. Our data suggest that this ratio is not a marker for diminished ovarian reserve when the CCCT is used as the gold standard (Table 1). No difference in the P:E2 ratio was noted for the IUI or IVF group, independent of the results of the CCCT. However, these data are limited by type II error. The sample size for either group was inadequate to detect a 20% difference in
FIGURE 1 Pregnancy rates in the IUI and IVF groups as a function of the P/E2 ratio. Pregnancy rates did not differ between groups on the basis of the ratio.
Pregnancy outcome was considered only for women with a normal CCCT. Among women undergoing IUI, 18 of 41 (43.9%) with a [(P/E2) ⫻ 1000] ratio ⬍1.0 and 14 of 33 (42.4%) with a ratio ⱖ 1.1 delivered (odds ratio, 1.01 [95% CI, 0.78 –1.30] P⫽.89). Among women undergoing IVF, 35 of 75 (46.6%) with a [(P/E2) ⫻ 1000] ratio ⬍1.0 and 48 of 96 (50%) with a ratio ⱖ 1.1 delivered (odds ratio, 1.05 [CI, 0.82–1.16]; P⫽.51) (Fig. 1).
DISCUSSION Clinicians are constantly seeking newer, more sensitive, and more specific prospective testing to evaluate a couple’s chance of a successful live birth with self oocytes before FERTILITY & STERILITY威
Hofmann. PE2 ratio and diminished ovarian reserve. Fertil Steril 2002.
49
the proportion of patients with a ratio or serum P concentration ⱕ 1. Using the ratio, 229 patients would have been required for the IUI group and 513 patients for the IVF group. However, even with larger numbers, the results would probaly not affect clinical decisions substantially enough to warrant using either of these hormonal markers when counseling patients about their likelihood of successful birth from ovulation induction for IUI or IVF. The [(P/E2) ⫻ 1000] ratio did not correlate with the number of ampules of hMG required for hyperstimulation, the peak E2 level, or the number of mature (⬎16 mm) follicles on the day of hCG administration for patients undergoing IUI. This finding contrasts with that of Younis et al. (8). However, for patients undergoing IVF, the ratio correlated strongly with the number of ampules of hMG required for hyperstimulation, the peak E2 level, and the number of mature oocytes retrieved. The reasons for the differences between our findings and those of Younis et al. (8, 9) are unknown. Their study examined only patients with unexplained infertility in the IUI group; in contrast, we did not restrict patient selection to those with unexplained infertility or limit patient selection to those requiring IUI for their care. Our sample included women with documented diminished ovarian reserve. Studies have documented that many women with unexplained infertility have diminished ovarian reserve (6, 11). Thus, our sample differed considerably from that of the IUI group in the study by Younis et al. (8). The IVF groups in our study and that of Younis et al. included similar patients by infertility diagnosis, but our IVF patients included women with known diminished ovarian reserve. Furthermore, and perhaps more significantly, the samples in both our IUI and IVF groups were significantly larger than those in the studies by Younis et al. (8, 9). The ultimate outcome variable for infertility treatment is live birth. In our study, live birth rates in either study group
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P:E2 ratio and diminished ovarian reserve
did not differ by the P:E2 ratio. Women with diminished ovarian reserve were not included in this part of the analysis because they have known poor reproductive outcome. Thus, the P:E2 ratio did not predict live birth with self oocytes. In summary, in a retrospective analysis, the [(P/E2) ⫻ 1000] ratio did not correlate with the results of a CCCT or predict live birth with self oocytes. Thus, this ratio should not be used in place of the prospective CCCT, whose ability to predict pregnancy outcome is well documented. References 1. Scott RT, Toner JP, Muasher SJ, Oehninger S, Robinson S, Rosenwaks Z. Follicle-stimulating hormone levels on cycle day 3 are predictive of in vitro fertilization outcome. Fertil Steril 1989;51:651– 4. 2. Toner JP. Philput CB, Jones GS, Muasher SJ. Basal follicle-stimulating hormone levels is a better predictor of in vitro fertilization performance than age. Fertil Steril 1991;55:784 –91. 3. Navot D, Margolith EJ, Rosenwaks Z. Prognostic assessment of female fecundity. Lancet 1987;2:645–7. 4. Tambo T, Dale PO, Lunde O, Norman N, Abyholm T. Prediction of response to controlled ovarian hyperstimulation: a comparison of basal and clomiphene citrate-stimulated follicle-stimulating hormone levels. Fertil Steril 1992;57:819 –24. 5. Burwinkle T, Buster JE, Scoggan JL, Carson SA. Basal follicle-stimulating hormone (FSH) predicts response to controlled ovarian hyperstimulation (COH)-intrauterine insemination (IUI) therapy. J Assist Reprod Genet 1994;11:24 –7. 6. Scott RT, Leonardi MR, Hofmann GE, Illions EH, Neal GS, Navot D. A prospective evaluation of CCCT screening of the general infertility population. Obstet Gynecol 1993;82:539 – 44. 7. Scott RT Jr, Hofmann GE. Prognostic assessment of ovarian reserve. Fertil Steril 1997;63:1–11. 8. Younis JS, Haddad S, Matilsky M, Ben-Ami, M. Premature luteinization: could it be an early manifestation of low ovarian reserve? Fertil Steril 1998;69:461–5. 9. Younis JS, Matilsky M, Radin O, Ben-Ami M. Increase progesterone/ estradiol ratio in the late follicular phase could be related to low ovarian reserve in in vitro fertilization-embryo transfer cycles with a long gonadotropin-releasing hormone agonist protocol. Fertil Steril 2001;76: 294 –9. 10. Hofmann GE, Scott RT Jr, Horowitz GM, Thie J, Navot D. Evaluation of the reproductive performance of women with elevated day 10 progesterone during ovarian reserve screening. Fertil Steril 1995;63:979 – 83. 11. Hofmann GE, Khoury J, Johnson CA, Thie J, Scott RT Jr. Premature luteinization during controlled ovarian hyperstimulation for in vitro fertilization-embryo transfer has no impact on pregnancy outcome. Fertil Steril 1996;66:980 – 6. 12. Hofmann GE, Sosnowski J, Scott RT Jr, Thie J. Efficacy for selection criteria for ovarian reserve screening using the CCCT in a tertiary fertility center. Fertil Steril 1996;66:49 –53.
Vol. 78, No. 1, July 2002