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Increases in progesterone after human chorionic gonadotropin administration may predict cycle outcome in patients undergoing in vitro fertilization-embryo transfer*
:communications-in-brief Vol. 62, No.5, November 1994
FERTILITY AND STERILITY Copyright© 1994 The American Fertility Society
Printed on acid-free paper in U. S. A.
Increases in progesterone after human chorionic gonadotropin administration may predict cycle outcome in patients undergoing in vitro fertilization-embryo transfer*
Samuel D. Prien, Ph.D.t Melin S. Canez, M.D. Robert H. Messer, M.D. Department of Obstetrics and Gynecology, Texas Tech University Health Sciences Center, Lubbock, Texas
Previous researchers have debated the use of circulating P concentrations just before hCG administration as a predictor of IVF-ET cycle outcome. Some studies suggest P concentrations of>0.50 ng/ mL (conversion factor to SI unit, 3.180) on the day of hCG administration are associated with lower IVF-ET pregnancy rates (PRs) (1, 2). However, data from other studies dispute the usefulness of P as a predictor of cycle outcome (3, 4). Hsuing et al. (5) also demonstrated a relationship between P and cycle outcome, but used a different time reference point. In that study P was measured at 20 and 34 hours after hCG administration and the percent increase in P was compared with cycle outcome. An increased PR appeared to be associated with a threefold rise in P, again suggesting the predictive value of P in relation to IVF-ET outcome. The present study also examined the relationship between early P values and cycle outcome in IVF-ET patients using a new set of time reference points. To determine if the relationship described by Hsuing et al. (5) could be detected, circulating P concentrations were measured before and after hCG adminis-
Received January 25, 1994; revised and accepted June 10, 1994. * Presented in part at The Society for Gynecologic Investigation 39th Annual Meeting, San Antonio, Texas, March 18 to 20, 1992 and at the 48th Annual Meeting of the American Fertility Society, New Orleans, Louisiana, November 2 to 5, 1992. t Reprint requests: Samuel D. Prien, Ph.D., Department of Obstetrics and Gynecology, Texas Tech University Health Sciences Center, Lubbock, Texas 79430 (FAX: 806-743-3200)
1066
Prien et al.
Communications-in-brief
tration, and the increase in P was compared with cycle outcome.
MATERIALS AND METHODS
Patients undergoing IVF-ET at the Texas Tech University Health Sciences Center Reproductive Endocrinology and Infertility Clinic from January 1990 until April1993 (n = 324) were asked to participate in the study. A total of 119 agreed and completed the IVF-ET cycle with the three required blood draws. The patients had circulating P concentrations determined from blood drawn at approximately 12 hours before and 12 hours after the administration of 5,000 miU/mL of hCG (conversion factor to SI unit, 1.00) to trigger the onset of ovulation. The women had previously been stimulated with either clomiphene citrate or hMG with or without prior down regulation with GnRH agonist. Serum was isolated by centifugation of whole blood, and P concentrations were determined using a coated tube RIA (Diagnostic Products Inc., Los Angeles, CA). Sera from the first 29 patients were frozen and measured in a single assay. The remaining 90 patients' P concentrations were determined individually at the time of the patient's cycle. However, the data collected were not used to influence cycle outcome. To eliminate the interassay coefficient of variability of the RIA for samples from a given individual, both the pre-hCG and post-hCG serum from each patient were run together within a single assay. The interassay coefficient of variability of the 90 runs was 4.7%. Fertility and Sterility
Table 1 Stimulation-Protocol Effects on Circulating P Concentrations 12 hours Before and 12 hours after 5,000 miU/mL hCG Administration and Resulting Pregnancies in Women Undergoing IVF HCG induced increases in P <2-fold Stimulation protocol
Pre-hCG
Clomiphene n P (ng/mL)*
2- to 2.99-fold Post-hCG
Pre-hCG
0.97 (0.50 to 1.95)
0.53 (0.30 to 0.90)
7 0.74 (0.17 to 1.60)
+{J-hCGt HMG n P (ng/mL)*
0.62 (0.14 to 1.26)
0.74 (0.23 to 1.30)
11
0.96 (0.45 to 2.50)
0.82 (0.50 to 1.80)
55 1.97 (1.10 to 4.30)
0
3.95 (2.32 to 9.00) 5
7 1.44 (0.24 to 3.50)
3.46 (0.74 to 7.20) 6
1
10
Post-hCG
13
1.60 (0.32 to 3.20)
0
+{J-hCG
1.30 (0.80 to 2.60)
6 1.06 (0.26 to 2.85)
0.93 (0.17 to 1. 70)
Pre-hCG
1
4
+{J-hCG GnRH-a + hMG n P (ng/mL)*
Post-hCG
6
0 0.75 (0.17 to 1.75)
>3-fold
0.97 (0.10 to 1.80)
3
5.67 (0.40 to 14.00) 25
*Values are means with ranges in parentheses. Conversion factor to SI, 3.671.
t +{J-hCG determined as;;,: 25 miU on day 14 post-ET. The relationship between hCG-induced increases in P and resulting pregnancies appeared independent of stimulation-protocol. x2 = 0.198 (P = 0.91).
Increases in P were calculated by dividing the post-hCG P concentration by the pre-hCG P concentration. Data were also collected for cycle outcome, using a serum ,6-hCG titer of ~25 miU/mL, as determined by RIA (Diagnostic Products Inc.) on day 14 after ET, as positive. The data were then split into three groups on the basis of increases in P ( <2 fold, 2- to 2.99-fold, or ~3-fold) and analyzed for cycle outcome using x2 analysis. Additionally, data were compared with pregnancy outcome using Fisher's exact test.
RESULTS All 119 patients had an increased circulating P concentration after hCG administration. However, although the majority of the patients' P levels increased at least threefold (n = 79), fully one third (n = 40) of the patients demonstrated less than threefold increase after 12 hours, with 21 patients having a less than twofold increase in circulating P. Chi-square analysis of the number of pregnancies recorded within each of the three groups ofP increase
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Figure 1. Cycle outcome versus hCG-induced increases in P concentrations in 119 women undergoing IVF for the treatment of infertility. Positive, {J-hCG titer;;,: 25 miU /mL, 14 days postET. x2 = 15.92 (P < 0.001). Vol. 62, No.5, November 1994
<2
2 - 2.99
>3
hCGINDUCEDINCREASESIN CIRCULAnNG PROGESTERONE
Figure 2. Pregnancy outcome versus hCG-induced increases in P concentrations of 41 women conceiving from IVF for the treatment of infertility. Prien et al.
Communications-in-brief
1067
demonstrated the PR remained constant between the three stimulator-protocols (P = 0.91; Table 1). Therefore data from the three protocols were pooled for all subsequent analysis. Forty-one patients had a ,8-hCG titer;;:: 25 miU, on day 14 after ET. Thirty-six of the 41 positive ,8-hCG titers were from patients who had demonstrated a threefold or greater increase in circulating P from 12 hours before to 12 hours after hCG administration for a conception rate of 45.6% (36/79) in that group (Fig. 1). The remaining five positive titers were from patients with a 2- to 2.99-fold increase in circulating P (5/19; 26.3% ). No pregnancies were reported from patients with a less than twofold increase in P (n = 21) in the 24-hour period surrounding hCG administration. Analysis of these data by the x2 test showed an increased PR (P < 0.001) in patients with a threefold or greater increase in P when compared with the other two groups. Twenty-nine of the 41 patients (71%) with ,8-hCG titers;;:: 25 miU/mL delivered (Fig. 2). However, although 28 of 36 (78%) of the pregnancies from patients with a threefold or greater increase in circulating P after hCG administration have delivered, only 1 of 5 (20%) pregnancies from the group with a less than threefold increase in P went to term (P < 0.02).
DISCUSSION
The data suggest that a threefold or greater rise in P from 12 hours before hCG administration to 12 hours after is associated with an increased PR. Conversely, P increases ofless than twofold might possibly be useful as predictors of cycle failure. These data agree well with those reported earlier by Hsuing et al. (5) and suggest that it is the increase in P rather than an absolute P value that is important to subsequent pregnancy development. As these data were collected from patients under a number of different stimulation protocols, it appears the ratio of before to after hCG circulating P concentration (but not the absolute P concentration) is independent of stimulation used or the number of mature follicles developed. Increases in the P concentration (;;::3-fold) seen at the time of hCG administration may represent the overall capability of the ova-
1068
Prien et al.
Communications-in-brief
ries and uterus to both establish and maintain a viable pregnancy, whereas lesser increases are seen in those with an impaired chance of establishing and/ or maintaining a pregnancy. Further study will be necessary to delineate this relationship and how stimulation and follicle number are associated with this process. However, the data presented here do suggest a means of identifying and re-evaluating the treatment of those IVF-ET patients with potentially poor outcomes before oocyte retrieval, thus saving them the risks and expense of a procedure with very limited chances of success. SUMMARY
In this study, both IVF-ET cycle and pregnancy outcome were compared with increases seen in P concentration during the 24-hour period from 12 hours before to 12 hours after hCG administration. A significantly higher PR (P < 0.001) was seen in women who had at least a threefold increase in P during this time period. Further, no pregnancies were reported from women with a less than twofold increase in P. REFERENCES 1. Schoolcraft W, Sinton E, Schlenker T, Huynh D, Hamilton F, Meldrum DR. Lower pregnancy rate with premature lu· teinization during pituitary suppression with leuprolide acetate. Fertil Steril 1991; 55:563-6. 2. Silverberg KM, Burns WN, Olive DL, Riehl RM, Schenken RS. Serum P levels predict success of in vitro fertilization/ embryo transfer in patients stimulated with leuprolide acetate and human menopausal gonadotrophins. J Clin Endocrinol Metab 1991; 73:797-803. 3. Edelstein MC, Seltman HJ, Cox BJ, Robinson SM, Shaw RA, Muasher SJ. Progesterone levels on the day of human chorionic gonadotrophin administration in cycles with go· nadotrophin-releasing hormone agonist suppression are not predictive of pregnancy outcome. Fertil Steril1990;54:85370. 4. Hassiakos D, Toner JP, Muasher SJ, Jones HW. Implantation and pregnancy rates in relation to oestradiol and progesterone profiles in cycles with and without the use of gonadotrophin-releasing hormone agonist suppression. Hum Reprod 1990;5:1004-8. 5. Hsiung CH, Karow WG, Gentry WC, Pope AK, Lee TT. Tripling of serum progesterone (P4 ) and embryo morphological features in conception and nonconception cycles, after human in vitro fertilization. J In Vitro Fert Embryo Transfer 1988;5:161-6.
Fertility and Sterility
FERTILITY AND STERILITY Copyright© 1994 The American Fertility Society
Printed on acid-free paper in U. S. A.
Increases in progesterone after human chorionic gonadotropin administration may predict cycle outcome in patients undergoing in vitro fertilization-embryo transfer*
Samuel D. Prien, Ph.D.t Melin S. Canez, M.D. Robert H. Messer, M.D. Department of Obstetrics and Gynecology, Texas Tech University Health Sciences Center, Lubbock, Texas
Previous researchers have debated the use of circulating P concentrations just before hCG administration as a predictor of IVF-ET cycle outcome. Some studies suggest P concentrations of>0.50 ng/ mL (conversion factor to SI unit, 3.180) on the day of hCG administration are associated with lower IVF-ET pregnancy rates (PRs) (1, 2). However, data from other studies dispute the usefulness of P as a predictor of cycle outcome (3, 4). Hsuing et al. (5) also demonstrated a relationship between P and cycle outcome, but used a different time reference point. In that study P was measured at 20 and 34 hours after hCG administration and the percent increase in P was compared with cycle outcome. An increased PR appeared to be associated with a threefold rise in P, again suggesting the predictive value of P in relation to IVF-ET outcome. The present study also examined the relationship between early P values and cycle outcome in IVF-ET patients using a new set of time reference points. To determine if the relationship described by Hsuing et al. (5) could be detected, circulating P concentrations were measured before and after hCG adminis-
Received January 25, 1994; revised and accepted June 10, 1994. * Presented in part at The Society for Gynecologic Investigation 39th Annual Meeting, San Antonio, Texas, March 18 to 20, 1992 and at the 48th Annual Meeting of the American Fertility Society, New Orleans, Louisiana, November 2 to 5, 1992. t Reprint requests: Samuel D. Prien, Ph.D., Department of Obstetrics and Gynecology, Texas Tech University Health Sciences Center, Lubbock, Texas 79430 (FAX: 806-743-3200)
1066
Prien et al.
Communications-in-brief
tration, and the increase in P was compared with cycle outcome.
MATERIALS AND METHODS
Patients undergoing IVF-ET at the Texas Tech University Health Sciences Center Reproductive Endocrinology and Infertility Clinic from January 1990 until April1993 (n = 324) were asked to participate in the study. A total of 119 agreed and completed the IVF-ET cycle with the three required blood draws. The patients had circulating P concentrations determined from blood drawn at approximately 12 hours before and 12 hours after the administration of 5,000 miU/mL of hCG (conversion factor to SI unit, 1.00) to trigger the onset of ovulation. The women had previously been stimulated with either clomiphene citrate or hMG with or without prior down regulation with GnRH agonist. Serum was isolated by centifugation of whole blood, and P concentrations were determined using a coated tube RIA (Diagnostic Products Inc., Los Angeles, CA). Sera from the first 29 patients were frozen and measured in a single assay. The remaining 90 patients' P concentrations were determined individually at the time of the patient's cycle. However, the data collected were not used to influence cycle outcome. To eliminate the interassay coefficient of variability of the RIA for samples from a given individual, both the pre-hCG and post-hCG serum from each patient were run together within a single assay. The interassay coefficient of variability of the 90 runs was 4.7%. Fertility and Sterility
Table 1 Stimulation-Protocol Effects on Circulating P Concentrations 12 hours Before and 12 hours after 5,000 miU/mL hCG Administration and Resulting Pregnancies in Women Undergoing IVF HCG induced increases in P <2-fold Stimulation protocol
Pre-hCG
Clomiphene n P (ng/mL)*
2- to 2.99-fold Post-hCG
Pre-hCG
0.97 (0.50 to 1.95)
0.53 (0.30 to 0.90)
7 0.74 (0.17 to 1.60)
+{J-hCGt HMG n P (ng/mL)*
0.62 (0.14 to 1.26)
0.74 (0.23 to 1.30)
11
0.96 (0.45 to 2.50)
0.82 (0.50 to 1.80)
55 1.97 (1.10 to 4.30)
0
3.95 (2.32 to 9.00) 5
7 1.44 (0.24 to 3.50)
3.46 (0.74 to 7.20) 6
1
10
Post-hCG
13
1.60 (0.32 to 3.20)
0
+{J-hCG
1.30 (0.80 to 2.60)
6 1.06 (0.26 to 2.85)
0.93 (0.17 to 1. 70)
Pre-hCG
1
4
+{J-hCG GnRH-a + hMG n P (ng/mL)*
Post-hCG
6
0 0.75 (0.17 to 1.75)
>3-fold
0.97 (0.10 to 1.80)
3
5.67 (0.40 to 14.00) 25
*Values are means with ranges in parentheses. Conversion factor to SI, 3.671.
t +{J-hCG determined as;;,: 25 miU on day 14 post-ET. The relationship between hCG-induced increases in P and resulting pregnancies appeared independent of stimulation-protocol. x2 = 0.198 (P = 0.91).
Increases in P were calculated by dividing the post-hCG P concentration by the pre-hCG P concentration. Data were also collected for cycle outcome, using a serum ,6-hCG titer of ~25 miU/mL, as determined by RIA (Diagnostic Products Inc.) on day 14 after ET, as positive. The data were then split into three groups on the basis of increases in P ( <2 fold, 2- to 2.99-fold, or ~3-fold) and analyzed for cycle outcome using x2 analysis. Additionally, data were compared with pregnancy outcome using Fisher's exact test.
RESULTS All 119 patients had an increased circulating P concentration after hCG administration. However, although the majority of the patients' P levels increased at least threefold (n = 79), fully one third (n = 40) of the patients demonstrated less than threefold increase after 12 hours, with 21 patients having a less than twofold increase in circulating P. Chi-square analysis of the number of pregnancies recorded within each of the three groups ofP increase
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hCGINDUCEDINCREASESIN CIRCULATING PROGESTERONE
Figure 1. Cycle outcome versus hCG-induced increases in P concentrations in 119 women undergoing IVF for the treatment of infertility. Positive, {J-hCG titer;;,: 25 miU /mL, 14 days postET. x2 = 15.92 (P < 0.001). Vol. 62, No.5, November 1994
<2
2 - 2.99
>3
hCGINDUCEDINCREASESIN CIRCULAnNG PROGESTERONE
Figure 2. Pregnancy outcome versus hCG-induced increases in P concentrations of 41 women conceiving from IVF for the treatment of infertility. Prien et al.
Communications-in-brief
1067
demonstrated the PR remained constant between the three stimulator-protocols (P = 0.91; Table 1). Therefore data from the three protocols were pooled for all subsequent analysis. Forty-one patients had a ,8-hCG titer;;:: 25 miU, on day 14 after ET. Thirty-six of the 41 positive ,8-hCG titers were from patients who had demonstrated a threefold or greater increase in circulating P from 12 hours before to 12 hours after hCG administration for a conception rate of 45.6% (36/79) in that group (Fig. 1). The remaining five positive titers were from patients with a 2- to 2.99-fold increase in circulating P (5/19; 26.3% ). No pregnancies were reported from patients with a less than twofold increase in P (n = 21) in the 24-hour period surrounding hCG administration. Analysis of these data by the x2 test showed an increased PR (P < 0.001) in patients with a threefold or greater increase in P when compared with the other two groups. Twenty-nine of the 41 patients (71%) with ,8-hCG titers;;:: 25 miU/mL delivered (Fig. 2). However, although 28 of 36 (78%) of the pregnancies from patients with a threefold or greater increase in circulating P after hCG administration have delivered, only 1 of 5 (20%) pregnancies from the group with a less than threefold increase in P went to term (P < 0.02).
DISCUSSION
The data suggest that a threefold or greater rise in P from 12 hours before hCG administration to 12 hours after is associated with an increased PR. Conversely, P increases ofless than twofold might possibly be useful as predictors of cycle failure. These data agree well with those reported earlier by Hsuing et al. (5) and suggest that it is the increase in P rather than an absolute P value that is important to subsequent pregnancy development. As these data were collected from patients under a number of different stimulation protocols, it appears the ratio of before to after hCG circulating P concentration (but not the absolute P concentration) is independent of stimulation used or the number of mature follicles developed. Increases in the P concentration (;;::3-fold) seen at the time of hCG administration may represent the overall capability of the ova-
1068
Prien et al.
Communications-in-brief
ries and uterus to both establish and maintain a viable pregnancy, whereas lesser increases are seen in those with an impaired chance of establishing and/ or maintaining a pregnancy. Further study will be necessary to delineate this relationship and how stimulation and follicle number are associated with this process. However, the data presented here do suggest a means of identifying and re-evaluating the treatment of those IVF-ET patients with potentially poor outcomes before oocyte retrieval, thus saving them the risks and expense of a procedure with very limited chances of success. SUMMARY
In this study, both IVF-ET cycle and pregnancy outcome were compared with increases seen in P concentration during the 24-hour period from 12 hours before to 12 hours after hCG administration. A significantly higher PR (P < 0.001) was seen in women who had at least a threefold increase in P during this time period. Further, no pregnancies were reported from women with a less than twofold increase in P. REFERENCES 1. Schoolcraft W, Sinton E, Schlenker T, Huynh D, Hamilton F, Meldrum DR. Lower pregnancy rate with premature lu· teinization during pituitary suppression with leuprolide acetate. Fertil Steril 1991; 55:563-6. 2. Silverberg KM, Burns WN, Olive DL, Riehl RM, Schenken RS. Serum P levels predict success of in vitro fertilization/ embryo transfer in patients stimulated with leuprolide acetate and human menopausal gonadotrophins. J Clin Endocrinol Metab 1991; 73:797-803. 3. Edelstein MC, Seltman HJ, Cox BJ, Robinson SM, Shaw RA, Muasher SJ. Progesterone levels on the day of human chorionic gonadotrophin administration in cycles with go· nadotrophin-releasing hormone agonist suppression are not predictive of pregnancy outcome. Fertil Steril1990;54:85370. 4. Hassiakos D, Toner JP, Muasher SJ, Jones HW. Implantation and pregnancy rates in relation to oestradiol and progesterone profiles in cycles with and without the use of gonadotrophin-releasing hormone agonist suppression. Hum Reprod 1990;5:1004-8. 5. Hsiung CH, Karow WG, Gentry WC, Pope AK, Lee TT. Tripling of serum progesterone (P4 ) and embryo morphological features in conception and nonconception cycles, after human in vitro fertilization. J In Vitro Fert Embryo Transfer 1988;5:161-6.
Fertility and Sterility