Administration of high-dose estradiol and progesterone in hormone replacement therapy improves results of frozen-thawed embryo transfer in a patient with 21-hydroxylase deficiency and persistently high serum progesterone levels: a case report

doi:10.21203/rs.3.rs-2562651/v1

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Administration of high-dose estradiol and progesterone in hormone replacement therapy improves results of frozen-thawed embryo transfer in a patient with 21-hydroxylase deficiency and persistently high serum progesterone levels: a case report

https://doi.org/10.21203/rs.3.rs-2562651/v1

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Background

Women with 21-hydroxylase deficiency have reduced fertility because of excessive production of adrenal androgen and progesterone, which can inhibit folliculogenesis, disturb the normal gonadotropin secretion pattern and development of the endometrium, and affect endometrial receptivity. The use of high doses of estradiol and progesterone in frozen-thawed embryo transfer with hormone replacement therapy may improve the results of fertility treatment in women with 21-hydroxylase deficiency and high progesterone.

Case presentation:

A 40-year-old woman with 21-hydroxylase deficiency and persistently high progesterone levels who was receiving steroid treatment visited our institution because she wanted to have a second child. Previously, she had had difficulties with frozen-thawed embryo transfer because of a gradual increase in progesterone levels. After reduction of progesterone levels with steroid hormone treatment, she had succeeded having a healthy baby after frozen-thawed embryo transfer with hormone replacement therapy. She hoped to have a second child with the same method, but steroid hormone treatment did not decrease her progesterone level. Frozen-thawed embryo transfer with hormone replacement therapy was attempted despite the high progesterone level, but the patient had two miscarriages. In the third attempt, the patient was given a high dose of estradiol and progesterone medication, which led to a better result than with the first two attempts.

Conclusions

Administering a high dose of estradiol and progesterone medication during frozen-thawed embryo transfer with hormone replacement therapy might achieve better results in women with 21-hydroxylase deficiency and persistently high progesterone levels.

endometrium receptivity

estradiol

frozen-thawed embryo transfer

hormone replacement therapy

progesterone

window of implantation

21-hydroxylase deficiency

The most common form of congenital adrenal hyperplasia is 21-hydroxylase deficiency (21OHD), an inherited autosomal recessive disorder of adrenal steroidogenesis. Women with 21OHD have reduced fertility because of excessive production of androgen and progesterone (P), which causes inhibition of follicular growth, inadequate development of the endometrium, and lack of endometrial receptivity [1, 2].

Previously, we reported on a woman with 21OHD who initially had normal P levels and spontaneous ovulation with steroid treatment but who had repeated failures of embryo transfer (ET) because of the P level gradually increased. After adjustment of the P level with steroid hormone treatment, the woman gave birth to a healthy baby [3]. Here, we report on this patient’s attempt to have another child despite persistently high P levels that did not respond to increased steroid hormone treatment. The patient succeeded in becoming pregnant with high doses of estradiol (E) and P medication during hormone replacement therapy (HRT), but the pregnancy resulted in early miscarriage due to 16-trisomy.

Two years after giving birth to her first child, a 40-year-old woman (height, 150 cm; weight, 46.8 kg; body mass index, 20.7 kg/m², blood pressure, 120/70; pulse, 75/min) who had been diagnosed with 21OHD classic-salt wasting type at age 3 years old visited our institution because she wished to have a second child. Her menstrual cycle had been irregular, and on day 3 of menstruation, her hormone levels were as follows: estrogen, 110 pg/mL; P, 9.6 ng/mL; follicle-stimulating hormone, 16.3 mIU/mL; and luteinizing hormone, 5.1 mIU/mL. On the same day, we found a cystic lesion with a diameter of 11 mm on the right ovary. While trying to become pregnant with her first child, the patient had had difficulties because of a gradual increase in P levels during frozen-thawed ET (FET) treatment, and we had asked her endocrinologist to reduce her P level. Subsequently, the patient had succeeded in having her first child by FET. After the delivery, the patient had been treated by her endocrinologist with hydrocortisone (16 mg/day) and fludrocortisone acetate (0.05 mg/day).

At the recent visit, we attempted to treat the patient by in vitro fertilization and FET, i.e., in the same way she had successfully become pregnant with her first child. We administered the aromatase inhibitor (letrozole F, 2.5 mg; Fuji Pharma Co., Ltd, Toyama, Japan) at a dose of one tablet per day from day 3 of menstruation for five days, human menopausal gonadotrophin injection (150 IU/day; Ferring Pharmaceuticals Co., Ltd., Saint-Prex, Switzerland) for two days, and gonadotropin releasing hormone agonist (GnRHA) nasal spray (busererin nasal solution 0.15% F 600 µg; Fuji Pharma Co., Ltd, Toyama, Japan) as a trigger at 36 hours before oocyte retrieval. We obtained three oocytes on day 17, and three embryos were formed by intracytoplasmic sperm injection. Three blastocysts formed (4AA in the Gardner classification) [4]. Five days after oocyte retrieval, the three blastocysts were frozen with vitrification.

Because of the elevated P level, we consulted the patient’s endocrinologist and waited until the P level decreased to at least 1.3 ng/mL in the early proliferative phase because this was the P level at which the patient was able to become pregnant with her first child, as described in our previous report [3]. We administered GnRHA by injection (leuprorelin acetate, 1.88 mg; Asuka Pharmaceutical., Ltd.) every 4 weeks to inhibit P production by the ovary. After we had consulted the endocrinologist, they increased the dexamethasone dose to 0.5 to 1.0 mg/day; however, the P level did not decrease. The endocrinologist told the patient that her 21OHD had been controlled well enough;, 17-hydroxyprogesterone (17-HOP), 0.3 ng/mL, [reference range (RR), 2-4.5 ng/mL]; adrenocorticotropic hormone (ACTH), < 1.5 pg/mL [RR, 7.2–63.3 pg/mL]; aldosterone, 19.1 ng/dL [RR, 10.8–56.9 ng/dL]; and dehydroepiandrosterone sulfate, 53 ug/dL [RR, 23–266 ug/dL]), that it would be difficult to further reduce the high P level, 4.4–5.9 ng/mL [RR in the proliferative phase, < 1.5 ng/mL; RR in the secretory phase, 10–20 ng/mL], and that administering a higher dose of steroid hormones would increase the risk of complications such as diabetes. For these reasons, we tried to manage the patient’s FET-HRT treatment despite the high P level. To investigate the status of endometrium receptivity, we performed both endometrial receptivity analysis (ERA: ERA® Endometrial Receptivity Analysis, Igenomix) and endometrial dating [5]. On day 15 of HRT, the patient’s P level was 4.4 ng/mL, E was 877 pg/mL, and endometrial thickness was 8.4 mm.

For HRT, from day 2 to 30 we used three transdermal E patches (Estraderm M; Kissei Pharmaceutical Co., Ltd, Matsumoto, Nagano, Japan) every 2 days and oral E (Progynova, Estradiol valerate, 2 mg; Bayer Ltd., Leverkeusen, Germany) at a dose of two tablets per day. From day 15 to 30, nine vaginal P suppositories (Progestan; Kocak Farma Pharmaceutical and Chemical Industry Co., Ltd., Istanbul, Turkey) and three oral P (dydrogesterone) tablets (Duphaston 5 mg tablets; Mylan IRE Healthcare Ltd., Dublin, Ireland) were administered per day. At 113 hours after the first P administration, we performed a biopsy of the endometrium by using an endometrial suction curette (Pipet Curet; Fuji Medical Corporation, Tokyo, Japan). Subsequent ERA showed that the endometrium was post receptive, and the best timing of ET was recommended to be 89 ± 3 hours after the first administration of P. Endometrial dating indicated the late secretory phase and showed prominent spiral arteries because of the beginning of predecidualization of periarterial stromal cells (Fig. 1).

After another month of GnRHA treatment, the P level had decreased to 2.3 ng/mL (a level that was still high for the proliferative phase) and the E level was 566 pg/mL on day 15 of the first FET-HRT treatment. According to the ERA result, we transferred one blastocyst 89 hours after the first P administration. On day 30, the serum human chorionic gonadotropin (hCG) level was 22.5 mIU/ml, E2 was 491 pg/mL, and P was 7.7ng/mL, and the patient had a miscarriage; no gestational sack (GS) was seen in the uterus.

To improve the implantation rate in the second FET-HRT treatment, we performed endometrial scratching before ET [6]. Also, from day 15 onwards, we administered one 125-mg hydroxyprogesterone caproate injection per week intramuscularly (Proge Depor intramuscular injection; Mochida Pharmaceutical Co., Ltd., Tokyo, Japan) to increase the P concentration [7, 8]. One blastocyst transfer was performed 87 hours after the first administration of vaginal and intramuscular P. On day 30, the serum hCG level was low (13.8 mIU/mL), P was 7.6 ng/mL, and E2 was 757 pg/mL, and the patient had a miscarriage, again without a visible GS.

More than 6 months after the second miscarriage, we started administering GnRHA treatment again, and 5 months later, we performed the second ERA. In the second ERA, we added a daily intramuscular injection of 25-mg progesterone Dex, a single-dose intramuscular injection formulation (Progestan; 50 mg Kocak Farma Pharmaceutical and Chemical Industry Co., Ltd., Istanbul, Turkey) from day 15 to increase the P concentration [7, 8]. We attempted to perform an endometrial biopsy 75 hours after the first P administration, but the second ERA indicated that the endometrium was pre-receptive. Consequently, and because of the results of the first and second ERAs, the Igenomix analysis showed that the recommended time to perform FET was 94 hours after the first P intake. We assumed that the window of implantation would be between the times identified by the first and second ERAs.

Although the discrepancy between these two ERA results was confusing, we decided to try the following method. For the third FET-HRT, to increase the E administration, we increased oral E medication from two to four tables for priming. On day 15, the P level was 3.14 ng/mL, E was 721pg/mL, and endometrium was 7.2 mm. We performed endometrial scratching and started administering P vaginally and orally. To increase P administration more than before two FET-HRTs, we added a single-dose 25-mg P intramuscular injection every day from day 15. We performed one blastocyst ET 94 hours after the first P intake. On day 30, the hCG level was 260.6 mIU/mL, which was higher than in the previous two HRT-ET attempts (first attempt, 22.5 mIU/mL; second attempt, 13.8 mIU/mL), P was 20.78 ng/mL, and E2 was 1040 pg/mL. At gestational week 5, we saw a small GS inside the uterus, and the hCG level had risen to 3058 mIU/mL. At gestational week 6, we observed the yolk sack. Unfortunately, we could not detect a fetal heat beat even at gestational week 7, and the patient subsequently had a miscarriage. Chromosomal analysis of miscarriage tissue showed the presence of trisomy 16.

Our case suggests that the receptivity of the endometrium, which is decreased embryo receptivity because of a persistently high P level in 21OHD, improves with a high dose of E and P medication in HRT treatment.

In women with 21OHD, 17-OHP is not converted to 11-deoxycortisol, and cortisol production is decreased; this negative feedback loop leads to increased ACTH secretion. Consequently, excessive 17-OHP and P are produced. Persistently high P inhibits endometrial receptivity, resulting in ET failure [1, 2]. Although, many successful live births have been reported in women with 21OHD in whom P levels can be reduced with steroid hormone treatment, another study found that P levels are difficult to decrease in some cases [9].

Usually, estrogen acts via the estrogen receptor (ER) during the proliferative phase to cause priming and proliferation of the endometrium, and the endometrium responds to estrogen and P stimulation by differentiating in a distinctive fashion. In a spontaneous ovulation cycle, the primary trophic hormone for the uterus is estrogen, the concentrations of which are highest during the proliferative phase and decline after ovulation in response to rising P [10].

P antagonizes the actions of estrogen in the endometrium and promotes glandular and stromal differentiation via the P receptor (PR). At the time of ovulation, endometrial PRs peak in response to estrogen and localize to both epithelial and stromal cells; then, they decline when P levels increase in the luteal phase after ovulation and P downregulates its own receptor [11, 12, 13].

Studies on HRT have shown that sequential administration of E and P are essential for normal endometrial maturation and adequate embryo implantation and receptivity [14]. We assume that in the present patient, who had continuously high P levels, also in the proliferative phase, endometrial maturation and/or adequate embryo implantation and receptivity were diminished because P had an antagonizing effect on E.

Previously, many studies have reported that in fresh ET, the premature elevation of P levels before administration of hCG in the stimulation cycle results in a lower rate of implantation or pregnancy than in cases without elevated P [15]. In women undergoing fresh ET, endometrial receptivity for embryos is hypothesized to be lower in case of prematurely elevated P. The direct effect of elevated P on endometrial receptivity before hCG administration has been analyzed by means of its gene expression profile and in clinical studies [16–19], and the results indicate that the above-mentioned hypothesis is biologically plausible (because prematurely elevated P affects the endometrium) and consistent with the known accelerated maturation of the endometrium described in stimulated cycles.

In the present case, the P level was consistently high, which is different from the cases of prematurely elevated P in the stimulation cycle. Nevertheless, one could hypothesize that high P during the period of E2 priming of the endometrium (i.e., the proliferative phase) had some effects on the changes required for intimal receptivity of embryos and that the mechanism was similar to that of prematurely elevated P. Furthermore, the first ERA in our patient showed that the endometrium was post receptive, indicating accelerated maturation. In usual HRT methods, patients are given E, so the number of ERs increases gradually to prime the endometrium despite the lack of spontaneous ovulation. Gradually, the thickness of the endometrium increases, and the endometrium becomes receptive for implantation. In contrast, we assume that the persistently high P level in our case affected endometrial receptivity in that it antagonized the action of E, for example, so ER expression was insufficient for embryo receptivity and persistence of pregnancy. Therefore, increasing the amount of E administration for priming might have increased the expression of ER. Moreover, administering additional P subsequent to E might have caused an increase also in PRs, similar to the normal reaction in the endometrium; this hypothesis would explain why the result of the third FET attempt was better than that of the previous two attempts, which used the usual doses of medication.

This case report has some limitations. The ERA results were unreliable because ERA-based recommendations are only applicable if the level of endogenous P measured before the first P intake is less than 1 ng/mL; nevertheless, the ERA led us to assume that P concentrations are associated with the window of implantation because the results were different when different amounts of P were administered. Also, the embryos were not genetically screened, so we cannot rule out that the embryos in the first two FETs might have had characteristics that resulted in early miscarriage. However, the three embryos we transferred were all good quality (4AA according to the Gardner classification).

In conclusion, on the basis of our case we suggest that in women with uncontrollable 21OHD, it may be possible to improve endometrial receptivity, which is diminished because of persistently high P levels, by administering high doses of E and P in HRT treatment. This method may be suitable for use in similar cases of adrenal dysfunction. However, some studies found that administration of high P doses is not always beneficial for pregnancy [20, 21]. Consequently, careful consideration and observation are required because the miscarriage in our patient may have been due to the P level being too high P, either because of endogenous P from the adrenal gland or exogenous P administered during HRT.

ACTH

adrenocorticotropic hormone

estradiol

embryo transfer

estrogen receptor

ERA

endometrial receptivity analysis

FET

frozen-thawed embryo transfer

gestational sack

GnRHA

gonadotropin releasing hormone agonist

HRT

hormone replacement therapy

hCG

human chorionic gonadotropin

progesterone

progesterone receptor

reference range

17-HOP

17-hydroxyprogesterone

21OHD

21-hydroxylase deficiency

Ethics declarations

Ethics approval and consent to participate

This case report was approved by the Hanabusa Women’s Clinic ethics committee (reference number 2023-01) on January 13, 2023, and treatment was performed according to the ethical principles that have their origin in the Declaration of Helsinki.

Consent for publication

Written informed consent was obtained from the patient to be included in this case report.

Availability of data and materials

The datasets generated during and/or analyzed in this case study are not publicly available because of information that may be personally identifiable; however, they are available from the corresponding author on reasonable request.

Competing interests

Yuri Mizusawa, Yihsien Enatsu, Eri Okamoto, Toshiro Iwasaki, Shoji Kokeguchi, and Masahide Shiotani declare that they have no competing interests.

Funding

Not applicable

Authors' contributions

Yuri Mizusawa made substantial contributions to the conception and design of this work and drafted the original manuscript. Yihsien Enatsu and Toshiro Iwasaki made a significant contribution to interpretation of the data, mainly the analysis of pathology specimens. The other authors substantially contributed to the revision of the manuscript drafts. All authors approved the submitted version of the manuscript and agree to be accountable for any part of the work.

Acknowledgements

The authors are grateful to Professor Hiroaki Shibahara, Professor Naoki Koji, Dr. Masanori Ono, and other colleagues for helpful discussions and contributions.

Authors' information (optional)

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No competing interests reported.

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Administration of high-dose estradiol and progesterone in hormone replacement therapy improves results of frozen-thawed embryo transfer in a patient with 21-hydroxylase deficiency and persistently high serum progesterone levels: a case report

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Background

Case presentation:

Conclusions

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Background

Case Presentation

Discussion And Conclusions

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References

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