Effects of two different types of luteal support on pregnancy outcomes following antagonist fresh embryo transfer

doi:10.21203/rs.3.rs-2453259/v1

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Effects of two different types of luteal support on pregnancy outcomes following antagonist fresh embryo transfer

https://doi.org/10.21203/rs.3.rs-2453259/v1

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published 04 May, 2023

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Background: There are few reports on the use of progesterone vaginal gel in combination with dydrogesterone in the antagonist protocol for fresh embryo transfer. This study compared the effects of differing luteal support on the pregnancy outcomes following the antagonist protocol for fresh embryo transfer.

Methods: A retrospective analysis of clinical data from infertile patients who underwent fresh embryo transfer via the antagonist protocol (2785 cycles) from February to July 2019 and from February to July 2021 at the Peking University Third Hospital Reproductive Medicine Centre was performed. The groups were divided according to their luteal support into a progesterone vaginal gel group (single medication group; 1170 cycles) and progesterone vaginal gel plus dydrogesterone group (combination medication; 1615 cycles). After propensity score matching, the clinical pregnancy, ongoing pregnancy, early miscarriage, and ectopic pregnancy rates were compared between the two groups.

Results: A total of 1057 pairs of cycles were successfully propensity score matched. The clinical and ongoing pregnancy rates in the combination medication group were significantly higher than those in the single medication group (P < 0.05), whereas the differences in early miscarriage and ectopic pregnancy rates between the two groups were not significant (both P > 0.05).

Conclusions: Combined luteal support after the antagonist protocol is preferred for patients undergoing fresh cycle embryo transfer.

in vitro fertilization-embryo transfer

antagonists

luteal support

pregnancy outcome

propensity score matching

Normal luteal function is an important factor in maintaining pregnancy; luteal insufficiency decreases the rate of embryo implantation and pregnancy and increases the rate of early miscarriage. The prevalence of luteal insufficiency in the ovulation-promoting cycle population is 12–20% [1], while that in the natural cycle population is only 3–10% [2]. Therefore, luteal support is an essential component of in vitro fertilization-embryo transfer (IVF-ET). Several meta-analyses [3–5] have confirmed that enhancing luteal support can significantly improve the pregnancy outcomes of IVF-ET. The guidelines used for the maintenance of pregnancy with luteal support and progestogen [6] also note that luteal support in the early luteal phase of human-assisted reproductive technology (ART) can improve pregnancy outcomes. While several protocols exist, there is no commonly accepted protocol for optimal luteal support after IVF-ET, and there is controversy regarding whether drugs should be administered alone or in combination. There are very few reports on the use of progesterone vaginal gel in combination with dydrogesterone in the antagonist protocol for fresh embryo transfer. Therefore, the effects of these two luteal supports on pregnancy outcomes after IVF-ET were compared with the antagonist protocol to clarify a rational protocol of luteal support.

Study participants

Clinical data were obtained on infertile patients who underwent fresh embryo transfer with the antagonist protocol at the Peking University Third Hospital Reproductive Medicine Centre from February to July 2019 and from February to July 2021. Patients with the following criteria were screened for study inclusion: 1) being 18–45 years old, 2) having primary or secondary infertility due to tubal factors, endometriosis causes, male factors, or unknown causes, 3) having undergone the gonadotropin-releasing hormone (GnRH)-antagonist (GnRH-ant) protocol, 4) having received fresh embryo transfer, and 5) having human chorionic gonadotropin (hCG) or hCG + gonadotropin-releasing hormone- agonist (GnRH-a) double trigger modes. Patients with 1) an abnormal uterine environment: uterine adhesions, submucosal fibroids, adenomyosis, or congenital uterine abnormalities; 2) repeated implantation failure; 3) recurrent miscarriage; 4) tubal effusion; 5) chromosomal and genetic abnormalities in either spouse subjected to pre-implantation genetic testing; 6) immune abnormalities, such as systemic lupus erythematosus and antiphospholipid syndrome; 7) ≥ 3 cycles of transfer or failure of ovulation promotion; 8) intrauterine pregnancy combined with ectopic pregnancy or molar pregnancy; and 9) a trigger mode reduced to double trigger or GnRH - a single trigger - were excluded. A total of 2785 cycles meeting the criteria were included and divided into two groups according to the luteal support: the progesterone vaginal gel group (VP group; 1170 cycles) and progesterone vaginal gel plus dydrogesterone group (DYD + VP group; 1615 cycles) (Fig. 1).

[Figure 1 near here]

Ovulation promotion and embryo transfer

All patients were treated with the antagonist protocol. Gonadotropin (Gn) was injected on the second day of the menstrual cycle, and transvaginal ultrasound was performed to detect follicle growth from the fourth day after the Gn injection. On the seventh to eighth day of the menstrual cycle or when the follicle diameter was ≥ 14 mm until the day of trigger, patients received an injection of 0.25 mg GnRH-ant. The Gn starting dose was 75 to 450 IU, which was adjusted according to ultrasound monitoring of follicles and serum estradiol levels. Triggers were administered when at least two of the dominant follicles were ≥ 18 mm in diameter, and an hCG trigger or hCG + GnRH-a double trigger - was administered according to the E2 level on the trigger day. After 34–36 h, oocytes were retrieved under vaginal ultrasound guidance for conventional IVF or intracytoplasmic sperm injection, and 1–2 embryos at the cleavage stage or one embryo at the blastocyst stage were transferred.

Embryo and blastocyst evaluation criteria

The quality of D3 embryos was evaluated using Peter’s cleavage-stage embryo scoring system, in which embryos with ≥ 8 cells that scored grades I–II were considered high-quality embryos. Gardner’s grading standard was used to score blastocysts; blastocysts that scored stage ≥ 4 were considered high-quality blastocysts.

Luteal support

The combination medication group received a combination of progesterone vaginal gel (90 mg daily dose) and dydrogesterone oral capsules (10 mg twice a day) from the day of oocyte retrieval. If pregnancy was confirmed, luteal support was continued for 30 days after embryo transfer. For intrauterine pregnancy confirmed by vaginal ultrasound, luteal support was continued until approximately 7–8 weeks of intrauterine pregnancy, at which time the progesterone vaginal gel was discontinued. The dydrogesterone tablets were continued, with the dosage gradually reduced until 8–10 weeks of pregnancy when luteal support was discontinued. In the single medication group, 90 mg of progesterone vaginal gel was administered daily. Luteal support for confirmed pregnancies was continued for 30 days after embryo transfer, while that for confirmed intrauterine pregnancies was continued until 8–10 weeks of pregnancy.

Determination of pregnancy outcome

Two weeks after embryo transfer, serum was drawn to assess the β-hCG level, and an hCG level of ≥ 5 mIU/mL was considered positive. miscarriage, ectopic pregnancy, simultaneous pregnancy at multiple sites inside and outside the uterus, and pathological examination of chorionic villi were considered clinical pregnancies when observed on vaginal ultrasound at 30 days following the transfer. The presence of embryonic arrest or spontaneous miscarriage was regarded as miscarriage.

Observation indicators

The basic data of the patients in both groups were analyzed, including age, body mass index (BMI), years of infertility, type of infertility, and days of Gn medication. Pregnancy outcome indicators were clinical pregnancy, ongoing pregnancy, miscarriage, and ectopic pregnancy rates.

Statistical methods

Statistical analyses were performed using SPSS 26.0 and R4.03 statistical software. The MatchIt package was used to match the two groups of patients by the propensity score matching method, with the grouping situation as the dependent variable and age, basal follicle-stimulating hormone (FSH), anti-Müllerian hormone (AMH), endometrial thickness on the trigger day, number of embryos transferred, type of embryos transferred, trigger mode, and number of oocytes obtained as covariates. The propensity score values were calculated by logistic regression, and the 1:1 nearest neighbor matching method was used, with the caliper value set at 0.2 to ensure excellent matching results. Covariate equilibrium tests were performed on the matched samples between the groups. Statistical analyses were performed using newly matched samples. Measurement data for the normal distribution variables are expressed as mean ± standard deviation, and comparisons between the two groups were conducted using an independent-samples t‑test. The variables in line with non‑normal distribution are expressed as the median (p25, p75) and were compared using the rank-sum test. The numerical data are expressed as n (%) and were compared using the Chi‑square test. The difference was considered statistically significant at P < 0.05 (two‑sided).

Propensity score matching

There were significant differences in age, basal FSH and AMH levels, number of oocytes obtained, and trigger mode between the two groups, which were not comparable. Thus, the 1:1 nearest neighbor matching method was used to effectively improve the balance of variables between non-randomized data groups to eliminate selection bias and reduce the effects of bias and confounding variables. The single and combination medication groups with complete data before matching comprised 1170 and 1615 cycles, respectively, and 1057 pairs of cycles were successfully matched between the two groups. After matching, all unbalanced covariates between the two groups reached equilibrium and were comparable (Table 1).

Table 1

Comparison of general information before and after data matching between the two groups
Parameter		Before matching	P-value		After matching	P-value
	VP n = 1170	DYD + VP n = 1615	P-value	VP n = 1057	DYD + VP n = 1057	P-value
Age (years)	32.75 ± 4.54	33.10 ± 4.36	0.042	32.83 ± 4.59	32.83 ± 4.44	0.985
FSH (IU/L)	7.42 ± 2.76	6.57 ± 2.30	༜0.001	7.16 ± 2.53	6.99 ± 2.54	0.133
AMH	2.96 ± 2.64	2.65 ± 2.43	0.002	2.89 ± 2.63	2.78 ± 2.67	0.333
Endometrial thickness (mm)	10.67 ± 1.59	10.64 ± 1.66	0.74	10.67 ± 1.59	10.65 ± 1.63	0.863
Number of embryos transferred			0.532			0.819
1	201 (17.2%)	263 (16.3%)		184 (17.4%)	188 (17.8%)
2	969 (82.8%)	1352 (83.7%)		873 (82.6%)	869 (82.2%)
Number of oocytes obtained	9.60 ± 4.40	8.65 ± 3.99	༜0.001	9.36 ± 4.33	9.07 ± 4.17	0.118
Type of embryos transferred			0.051			0.483
D3	1126 (96.2%)	1575 (97.5%)		1016 (96.1%)	1022 (96.7%)
D5	44 (3.8%)	40 (2.5%)		41 (3.9%)	35 (3.3%)
Trigger mode			༜0.001			0.113
Single trigger	601 (51.4%)	1137 (70.4%)		592 (56%)	628 (59.4%)
Double trigger	569 (48.6%)	478 (29.6%)		465 (44%)	429 (40.6%)
FSH: follicle-stimulating hormone; AMH: anti-Müllerian hormone; D3: day 3 embryo; D5: day 5 embryo; VP: vaginal progesterone gel group (single medication group); DYD + VP: dydrogesterone plus vaginal progesterone gel group (combination medication)

[Table 1 near here]

Comparison of general information after data matching between the two groups

After matching, the differences between the two groups were not significant when comparing age, type of infertility, years of infertility (all P > 0.05), BMI, or days of Gn medication, which were significant (P < 0.05) (Table 2).

Table 2

Comparison of general information between the two groups after propensity score matching
Parameter	VP n = 1057	DYD + VP n = 1057	P-value
Age, in years			0.056
20–30	349 (33.02%)	323 (30.56%)
31–35	414 (39.17%)	472 (44.65%)
36–39	202 (19.11%)	170 (16.08%)
≥ 40	92 (8.70%)	92 (8.71%)
Type of infertility			0.189
Primary infertility	660 (62.44%)	689 (65.18%)
Secondary infertility	397 (37.56%)	368 (34.82%)
Years of infertility			0.499
< 5 years	867 (82.02%)	886 (83.82%)
5–10 years	162 (15.33%)	143 (13.53%)
≥ 10 years	28 (2.65%)	28 (2.65%)
BMI	22.31 (20.43, 24.97)	22.03 (20.05, 24.47)	0.03
Days of Gn medication	10 (9, 11)	10 (9, 11)	0.016
BMI: body mass index; Gn: gonadotropin; VP: vaginal progesterone gel group (single medication group); DYD + VP: dydrogesterone plus vaginal progesterone gel group (combination medication)

Pregnancy outcomes

The clinical and ongoing pregnancy rates were significantly different between the combination and single medication groups (42.29% [n = 447] vs. 36.8% [n = 389]; P = 0.01 and 35.57% [n = 376] vs. 31.22% [n = 330]; P = 0.034, respectively). There were no significant differences in the early abortion or ectopic pregnancy rates between the combination and single medication groups (13.2% [n = 59] vs. 10.54% [n = 41] and 2.68% [n = 12] vs. 4.63% [n = 18], respectively; all P > 0.05) Table 3.

Table 3

Comparison of pregnancy outcomes between the groups
Parameter	DYD + VP n = 1057	VP n = 1057	P-value
CPR	42.29% (447)	36.8% (389)	0.01
OPR	35.57% (376)	31.22% (330)	0.034
EMR	13.20% (59)	10.54% (41)	0.237
EPR	2.68% (12)	4.63% (18)	0.132
CPR: clinical pregnancy rate, OPR: ongoing pregnancy rate, EMR: early miscarriage rate, EPR: ectopic pregnancy rate; VP: vaginal progesterone gel group (single medication group); DYD + VP: dydrogesterone plus vaginal progesterone gel group (combination medication)

Progesterone is the primary drug prescribed for luteal support. There are currently various modes of administration and combinations of luteal support protocols in ART, such as intramuscular injection; oral, vaginal, or combination medication; intramuscular injection combined with oral and others. Although the efficacy of intramuscular progestogen injection has been proven, it is gradually being replaced by oral and vaginal progesterone due to its serious adverse effects.

The clinical and ongoing pregnancy rates in this study were significantly higher in the combination medication group than in the single medication group. Patki et al. compared the effect of 600 mg of micronized progesterone combined with 20 mg of dydrogesterone with 600 mg of micronized progesterone alone as a luteal support for clinical pregnancy in a long protocol and found a higher clinical pregnancy rate in the combination medication group than that in the single medication group [7]. Devine et al. showed that while the single medication group had the same embryo implantation rate as the combination medication group, the combination medication group had a higher ongoing pregnancy rate than the single medication group. They concluded that high local progesterone levels are sufficient to maintain embryo implantation and that higher and more stable serum progesterone levels are required for ongoing pregnancies [8]. This suggests the feasibility of using a combination medication as luteal support.

Dydrogesterone is an orally administered reverse progesterone with an average bioavailability of 28%–10 to 20 times higher than that of micronized progesterone capsules [9, 10]–that does not alter the serum progesterone levels at its effective dosage of 10–20 mg/day. The advantages of dydrogesterone include its easy absorption, reduced hepatic load, convenience, good tolerability, high bioavailability, few side effects, and good compliance.

Progesterone vaginal gel is a new microfibrillated natural progesterone drug formulation with no hepatic first-pass effect that targets the uterus and causes a “local high concentration effect” in the endometrium. Due to the low absorption rate into the blood, its concentration in the blood is significantly lower, which effectively reduces the risk of systemic side effects. In addition, it can evoke a sedation effect on the uterus, increase the production of cervical mucus (thereby driving the formation of the cervical mucus plug), improve the Th1/Th2 balance, relax the uterine smooth muscle, significantly reduce the propagation of electrical signals in the myometrium, effectively reduce the frequency of uterine contractions [11], and reduce uterine arterial resistance [12], thus increasing the pregnancy rate. A meta-analysis [13] comparing the efficacy of progesterone vaginal gel with that of intramuscular progesterone for luteal support in assisted reproduction techniques suggested that both had good efficacy; however, the incidence of side effects associated with progesterone vaginal gel was lower than with intramuscular progesterone, and the patients reported higher satisfaction with the progesterone vaginal gel than with intramuscular progesterone. It was also noted that the high incidence of early bleeding during the use of progesterone vaginal gel did not affect pregnancy outcomes [14, 15], possibly because low serum progesterone levels do not effectively prevent short-term endometrial breakdown [16]. Therefore, a dynamic equilibrium between serum and local endometrial progesterone levels may be necessary to achieve good pregnancy outcomes, and topical vaginal medications combined with oral or intramuscular luteal support may be an important way to maintain this equilibrium.

Tomic et al. compared the effect of 100 mg of micronized progesterone administered orally three times a day in combination with 90 mg of progesterone vaginal gel applied daily with that of 90 mg of progesterone vaginal gel applied daily on the pregnancy outcome of GnRH-a long protocol ovulatory fresh embryo transfer cycles and found that the combination group had a higher ongoing pregnancy rate and lower miscarriage rate [17], which is consistent with the findings from this study. In a previous study comparing progesterone vaginal gel with progesterone injection for luteal support in fresh embryo transfers on antagonist protocols, it was found that the application of progesterone vaginal gel resulted in better clinical outcomes than the progesterone injection [14]. Moreover, this study found that a combination luteal support after an antagonist protocol resulted in higher clinical and ongoing pregnancy rates than those with a single luteal support, suggesting that enhanced luteal support may be required for patients undergoing IVF-ET with the GnRH-ant protocol.

There are limitations in this study that should be acknowledged. This was a single-center retrospective study with differences in baseline data between the two groups of patients. However, propensity score matching analysis was used to effectively improve the balance of covariates between groups and to eliminate selection bias between groups, such that the study results are realistic.

Progesterone vaginal gel combined with dydrogesterone luteal support provided better clinical outcomes than progesterone vaginal gel alone in antagonist protocol fresh cycle embryo transfer. Therefore, combined luteal support may be preferred for patients undergoing antagonist-protocol fresh embryo transfer.

CPR: clinical pregnancy rate; OPR: ongoing pregnancy rate; EMR: early miscarriage rate; EPR: ectopic pregnancy rate; IVF-ET: In vitro fertilization-Embryo transfer; ART: assisted reproductive technology; GnRH-ant: Gonadotropin-releasing hormone- antagonist; GnRH-a: Gonadotropin-releasing hormone- agonist; hCG: human chorionic gonadotropin; Gn: Gonadotropin; BMI: body mass index; FSH: follicle-stimulating hormone; AMH: anti-Müllerian hormone.

Ethics approval and consent to participate: This study was approved by the Institutional Ethics Committee of the Peking University Third Hospital [Ethics No. (2022) 381-02]. The authors confirm that all experiments were performed in accordance with the principles of Declaration of Helsinki. As this was a retrospective study, the need for informed consent was waived, by the Institutional Ethics Committee of the Peking University Third Hospital

Consent for publication: Not applicable.

Availability of data and materials: The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.

Competing interests: The authors declare that they have no competing interests.

Funding: This study was supported by the National Natural Science Foundation of China [grant number 82171626] and the Start-up Fund for Excellent Returnee of Peking University Third Hospital [grant number BYSYLXHG2019003]. They don’t have any role in design of the study and collection, analysis, and interpretation of data and in writing the manuscript.

Authors’ contributions: H.C. and R.L. were responsible for designing and coordinating the study. M.D., L.C., and R.Y. were responsible for data collection and data interpretation. L.Z., M.D., and Y.W were responsible for the statistical analysis and data analysis. M.D. was responsible for writing the manuscript. All authors read and approved the final manuscript.

Acknowledgements: We would like to thank Dr. Lin Zeng for her contribution to data statistics in writing this article.

Duffy DA, Manzi D, Benadiva C, Maier D, Saunders M, Nulsen J. Impact of leuprolide acetate on luteal phase function in women undergoing controlled ovarian hyperstimulation and intrauterine insemination. Fertil Steril. 2006;85:407–11. https://doi.org/10.1016/j.fertnstert.2005.07.1330.
Mesen TB, Young SL. Progesterone and the luteal phase: a requisite to reproduction. Obstet Gynecol Clin North Am. 2015;42. https://doi.org/10.1016/j.ogc.2014.10.003. :135 – 51.
Daya S, Gunby JL. Luteal phase support in assisted reproduction cycles. Cochrane Database Syst Rev. 2004;3:CD004830. https://doi.org/10.1002/14651858.CD004830.
Nosarka S, Kruger T, Siebert I, Grové D. Luteal phase support in in vitro fertilization: meta-analysis of randomized trials. Gynecol Obstet Investig. 2005;60:67–74. https://doi.org/10.1159/000084546.
van der Linden M, Buckingham K, Farquhar C, Kremer JA, Metwally M. Luteal phase support for assisted reproduction cycles. Cochrane Database Syst Rev. 2015;2015:CD009154. https://doi.org/10.1002/14651858.CD009154.pub3.
Qiao J. Clinical practice guidelines for progesterone in pregnancy maintenance and luteal phase support. Chin J Reprod Contracept. 2021;41:95–105.
Patki A, Pawar VC. Modulating fertility outcome in assisted reproductive technologies by the use of dydrogesterone. Gynecol Endocrinol. 2007;23:68–72. https://doi.org/10.1080/09513590701584857.
Devine K, Richter KS, Widra EA, McKeeby JL. Vitrified blastocyst transfer cycles with the use of only vaginal progesterone replacement with Endometrin have inferior ongoing pregnancy rates: results from the planned interim analysis of a three-arm randomized controlled noninferiority trial. Fertil Steril. 2018;109:266–75. https://doi.org/10.1016/j.fertnstert.2017.11.004.
Stanczyk FZ, Hapgood JP, Winer S, Mishell DR. Progestogens used in postmenopausal hormone therapy: differences in their pharmacological properties, intracellular actions, and clinical effects. Endocr Rev. 2013;34:171–208. https://doi.org/10.1210/er.2012-1008.
Sun Y, Liu P, Ye H, Li R, Qiao J, Wu QF, et al. Consensus on luteal support and progesterone supplementation. Reprod Contracept. 2015;35:1–8.
Lucovnik M, Trojner Bregar A, Bombac L, Gersak K, Garfield RE. Effects of vaginal progesterone for maintenance tocolysis on uterine electrical activity. J Obstet Gynaecol Res. 2018;44:408–16. https://doi.org/10.1111/jog.13545.
Jamal A, Moshfeghi M, Molaei B, Moradi Y, Hashemi N. The effect of vaginal progesterone on Doppler findings in increased uterine artery resistance. J Matern Fetal Neonatal Med. 2021;34:2630–3. https://doi.org/10.1080/14767058.2019.1670794.
Cao YuM, Du EQ, Zhang Y, Zhang YZ. Evaluation of effect of luteal support by different administration routes in the assisted reproductive process. J Reprod Med. 2018;27:327–34.
Chi HB, Liu NN, Li R, Tao LY, Chen LX, Qiao J. Comparison of vaginal gel and intramuscular progesterone for in vitro fertilization and embryo transfer with gonadotropin-releasing hormone antagonist protocol. Chin Med J (Engl). 2018;131:1557–61. https://doi.org/10.4103/0366-6999.235106.
Chi H, Li R, Qiao J, Chen X, Wang X, Hao G, et al. Vaginal progesterone gel is non-inferior to intramuscular progesterone in efficacy with acceptable tolerability for luteal phase support: a prospective, randomized, multicenter study in China. Eur J Obstet Gynecol Reprod Biol. 2019;237:100–5. https://doi.org/10.1016/j.ejogrb.2019.04.012.
Romàn E, Aytoz A, Smitz JE, Faguer B, Camus M, Van Steirteghem AC, et al. Analysis of the bleeding pattern in assisted reproduction cycles with luteal phase supplementation using vaginal micronized progesterone. Hum Reprod. 2000;15:1435–9. https://doi.org/10.1093/humrep/15.7.1435.
Tomic V, Tomic J, Klaic DZ. Oral micronized progesterone combined with vaginal progesterone gel for luteal support. Gynecol Endocrinol. 2011;27:1010–3. https://doi.org/10.3109/09513590.2011.569791.

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You are reading this latest preprint version

Effects of two different types of luteal support on pregnancy outcomes following antagonist fresh embryo transfer

Status:

Journal Publication

Version 1

Abstract

Figures

Background

Methods

Study participants

Ovulation promotion and embryo transfer

Embryo and blastocyst evaluation criteria

Luteal support

Determination of pregnancy outcome

Observation indicators

Statistical methods

Results

Propensity score matching

Comparison of general information after data matching between the two groups

Pregnancy outcomes

Discussion

Conclusions

Abbreviations

Declarations

References

Additional Declarations

Status:

Journal Publication

Version 1