Scholarly article on topic 'Progesterone level significance in agonist versus antagonist protocols'

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Abstract of research paper on Health sciences, author of scientific article — Nayla Bushaqer, Wadha Mohawash, Fatima Alrakaf, Meshael Algaffli, Haya Rawah, et al.

Abstract Objective to evaluate the impact of serum progesterone level on the clinical outcome across agonist & antagonist protocols. Design retrospective cohort study. Setting IVF unit at Prince Sultan Military Medical City, Riyadh, KSA. Material & Methods A total of 943 cycles were included in the analysis, 605 long agonist protocol cycles, 227 antagonist protocol cycles & 101 short agonist protocol cycles reaching the stage of embryo transfer between November 2012 and March 2015. Main outcome clinical pregnancy and miscarriage rates. Results Number of retrieved, mature and fertilized oocytes, plus transferred embryos were lowest in the short protocol. Clinical pregnancy rate was the lowest in the short protocol and miscarriage rate was similar in all protocols. Setting progesterone cut off level of >1.5 nmol/L in the agonist cycles, high progesterone groups did not show difference in clinical pregnancy or miscarriage rates. In the short protocol, the group with high progesterone level had higher number of frozen embryos. In long protocol, high progesterone level group showed higher number of fertilized oocytes. A level of >2 nmol/L was set in the antagonist protocol. High progesterone group had lower clinical pregnancy rate and similar miscarriage rate, despite having higher number of fertilized oocytes and better quality of embryos. Conclusion high progesterone level did not affect clinical pregnancy or miscarriage rates in all protocols except in the antagonist protocol where it affected the clinical pregnancy rate adversely.

Similar topics of scientific paper in Health sciences , author of scholarly article — Nayla Bushaqer, Wadha Mohawash, Fatima Alrakaf, Meshael Algaffli, Haya Rawah, et al.

Academic research paper on topic "Progesterone level significance in agonist versus antagonist protocols"

Middle East Fertility Society Journal xxx (2017) xxx-xxx

Contents lists available at ScienceDirect

Middle East Fertility Society Journal

journal homepage: www.sciencedirect.com

Original Article

Progesterone level significance in agonist versus antagonist protocols

Nayla Bushaqera'*, Wadha Mohawasha, Fatima Alrakafa, Meshael Algafflia, Haya Rawaha Nawal Dayoub b, Hisham Ayoub a, Nouf Alasmaria

a IVF Unit, Prince Sultan Military Medical City (PSMMC), Riyadh, Saudi Arabia b Bahrain Military Hospital, Rifaa, Bahrain

ARTICLE INFO

Article history: Received 13 February 2017 Revised 23 September 2017 Accepted 26 September 2017 Available online xxxx

Keywords:

Intra cytoplasmic sperm injection (ICSI)

In vitro fertilization (IVF)

Protocols

Progesterone

Pregnancy rate

ABSTRACT

Objective: to evaluate the impact of serum progesterone level on the clinical outcome across agonist &

antagonist protocols.

Design: retrospective cohort study.

Setting: IVF unit at Prince Sultan Military Medical City, Riyadh, KSA.

Material & Methods: A total of 943 cycles were included in the analysis, 605 long agonist protocol cycles, 227 antagonist protocol cycles & 101 short agonist protocol cycles reaching the stage of embryo transfer between November 2012 and March 2015. Main outcome: clinical pregnancy and miscarriage rates.

Results: Number of retrieved, mature and fertilized oocytes, plus transferred embryos were lowest in the short protocol. Clinical pregnancy rate was the lowest in the short protocol and miscarriage rate was similar in all protocols. Setting progesterone cut off level of >1.5 nmol/L in the agonist cycles, high progesterone groups did not show difference in clinical pregnancy or miscarriage rates. In the short protocol, the group with high progesterone level had higher number of frozen embryos. In long protocol, high progesterone level group showed higher number of fertilized oocytes. A level of >2 nmol/L was set in the antagonist protocol. High progesterone group had lower clinical pregnancy rate and similar miscarriage rate, despite having higher number of fertilized oocytes and better quality of embryos. Conclusion: high progesterone level did not affect clinical pregnancy or miscarriage rates in all protocols except in the antagonist protocol where it affected the clinical pregnancy rate adversely. © 2017 Middle East Fertility Society. Production and hosting by Elsevier B.V. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

1. Introduction

Progesterone (P4) plays an important role in the menstrual cycle, particularly for pregnancy implantation and progression; however, its role in controlled ovarian stimulation cycles (COS) remains controversial [1-5].

Premature progesterone rise (PPR) is defined as P4 elevation on the day of human chorionic gonadotrophin (hCG) administration. Thus, authors reported that modest pre-ovulatory increase in serum P4 levels was associated adversely with pregnancy rates and had higher incidence of pregnancy loss. The pathogenesis and effects of PPR remain debatable [6-9]. Several studies have

Peer review under responsibility of Middle East Fertility Society.

* Corresponding author. E-mail addresses: dr.nayla.j.b@gmail.com (N. Bushaqer), drwadha@hotmail.com (W. Mohawash), fona.2007@hotmail.com (F. Alrakaf), mashael50@live.com (M. Algaffli), whiteroseaia@gmail.com (H. Rawah), nawaldaoub@doctors.org.uk (N. Dayoub), ayyoub52@hotmail.com (H. Ayoub), dr_al_asmari@hotmail.com (N. Alasmari).

evaluated the impact of PPR at the time of hCG trigger in COS, with conflicting results; while some investigators have reported that elevated P4 negatively impacts pregnancy rates, others have failed to do so [10-12].

PPR may have an adverse effect on endometrial receptivity explained by premature endometrial maturation leading to embryo-endometrium dys-synchrony and altered gene expression [1,3,9,13-15]. Patients who respond robustly to COS have higher E2 and P4 levels, impairing the receptivity of the endometrium due to PPR [1].

The PPR frequency in ovarian stimulated cycles varies. Although gonadotrophin releasing hormone (GnRH) agonists and antagonists prevent or decrease PPR frequency, yet it still occurred in some patients [8]. In patients treated with a GnRH agonist, it was estimated in a study to occur in up to 35% of cycles and up to 38% of GnRH antagonist cycles [10,13]. Moreover, some studies have found that it was affecting the clinical outcomes negatively in GnRH antagonist cycles but not in GnRH agonist cycles [2,10,16].

https://doi.org/10.1016/j.mefs.2017.09.010

1110-5690/® 2017 Middle East Fertility Society. Production and hosting by Elsevier B.V.

This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

Some studies showed a negative impact of PPR on the hCG day, in terms of embryo quality and cumulative live birth rate (LBR), regardless of the ovarian response [2,4,17]. Others linked the negative impact on clinical outcomes to cleavage embryo transfer but not to blastocyst or frozen-thawed embryo transfer [2,6,7,14].

Strategies proposed to overcome the PPR negative impact by some studies is to freeze all embryos and transfer in a frozen cycles [3,7,10,12,13,17]. Another suggested solution is to transfer day 5 blastocyst (D5-ET) to improve the clinical outcome [6,7,10,17].

The aim of our study is to evaluate the impact of serum P4 level on the day of triggering on the probability of pregnancy outcome across GnRH agonist & antagonist IVF protocols.

2. Materials and method

After obtaining approval from Prince Sultan Military Medical City Research Ethics Board, the files of all the patients who reached the stage of fresh embryo transfer were manually reviewed from November 2012 till March 2015. A total of 943 cycles were included in the analysis, 605 long GnRH agonist protocol cycles, 227 GnRH antagonist protocol cycles & 101 short GnRH agonist protocol cycles. The protocol and type of gonadotro-pins were decided by the treating physician before starting the stimulation, according to the department policy for age, follicle stimulating hormone (FSH), antral follicular count (AFC) & previous response.

COS was performed using rFSH (Gonal f or Puregon, Merck) or human menopausal gonadotrophin (HMG) (Menogon, Ferring). In the long protocol, GnRH agonist is started from cycle day 21 before stimulation (Decapeptyl 0.1 mg/day, IPSEN) while in the short protocol (Decapeptyl 0.05 mg/day) is started on the day of stimulation. Another protocol used was the fixed GnRH antagonist protocol (Cetrotide 0.25 mg/day, Merck) added on day 6 of stimulation. When two or more leading follicles reached a mean diameter > 1 8 mm or three or more reached > 17 mm, 5-10,000 1U hCG was injected. The oocytes were retrieved 36 h after the hCG injection (Pregnyl, Merck).

After 1VF or 1CS1, embryos were transferred 2-5 days after oocyte retrieval. Only 2 embryos were transferred, unless the patient was > 38 years, nulliparous, undergoing her 3rd ET or sperm were obtained by TESA; then 3 embryos will be transferred. Luteal phase support using either a twice daily dose of 400 mg of progesterone pessaries (Cyclogest, L.D.COLLINS & CO.) or 8% progesterone gel (Crinone, Merck), was started on the day of oocyte retrieval until the pregnancy test, or up to 12 weeks if the patient got pregnant. Pregnancy test was considered positive if the serum

hCG was > 10 ml lU/ml, 12 days after embryo transfer. Two weeks after a positive hCG, transvaginal ultrasonography was performed to confirm the presence of an intrauterine pregnancy and to identify the number of gestational sacs and the fetal viability.

Female age, number of stimulation cycle, BM1, parity, cause of infertility, AFC, basal FSH, male age, stimulation parameters including total dose of the gonadotropins used and duration of stimulation, were collected. On the hCG trigger day the following were collected: number of follicles > 14 mm, endometrial thickness and quality (grade 1 was the best and grade 3 was the worst), E2 and P4 levels. Grade 1 endometrium is when the endometrium shows a triple line pattern comprising a central hyper-echoic line surrounded by two hypo echoic layers, grade 2 is when the endo-metrium has an intermediate iso-echogenic pattern with the same reflectivity as the surrounding endometrium and poorly defined central echogenic line and grade 3 is when the endometrium is homogenous and hyper-echogenic.

Number of oocytes retrieved, mature and fertilized, day, number and grade of embryos transferred and frozen were collected.

The clinical pregnancy rate (CPR) was defined by visualizing fetal heart beat by ultrasonography. The miscarriage rate was defined as pregnancy loss before 20 weeks of gestation.

Data was analyzed using StatsDirect statistical package. Two-sided Mann-Whitney U test was used to compare medians between two groups, two-sided Unpaired t test was used to compare means between two groups, one way ANOVA was used to compare means between more than two groups, Kurskal-Wallis test was used to compare medians between more than two groups, Chi square test in crosstabs, Fisher- Freeman-Halton exact in cross-tabs when any cells have expectation of less than 5. P values of less than 0.05 were considered statistically significant.

3. Results

The patients were divided into 3 groups according to the type of protocol, (group 1) Short agonist protocol, (group 2) long agonist protocol and (group 3) fixed antagonist protocol. All groups had similar BM1, parity and male age. Female age and number of cycles were significantly highest in the short protocol (32.9 years old and 2.3 cycles) (p< .0001) and lowest in the long protocol (29.7 years old and 1.8 cycles done) (p < .0001). Among all protocols the most common cause of infertility was male followed by combined (p < . 0001). AFC was significantly highest in the antagonist protocol and lowest in the short protocol (24.1 vs 9.7 follicles) (p< .0001), FSH was lowest in the antagonist protocol and highest in the short protocol (6.1 vs 8.8 lU/l) (p< .0001) (Table 1).

Table 1

Demographic criteria of all stimulated patients.

Short (n = 111) Long (n = 605) Antagonists (n = 227) P value

Female age 32.9 ±4.11 29.7 ±4.26 30.2 ±4.25 <0.0001a

No. of cycles 2.33 ± 1.26 1.8 ±1.07 1.95 ±1.11 <0.0001b

BM1 (kg/m2) 26.5 ± 3.67 26.8 ± 3.2 26.8 ± 3.0 0.127b

Parity 0.35 ± 0.53 0.3 ± 0.6 0.29 ± 0.55 0.72b

AFC 9.7 ± 3.9 20.5 ± 9.57 24.1 ± 13.75 <0.0001b

Basal FSH (1U/L) 8.8 ± 3.9 6.2 ±1.9 6.1 ± 2.25 <0.0001b

Male age 36.4 ± 6.52 35.3 ± 6.5 34.9 ± 5.79 0.14a

1nfertility cause male = 69 male = 283 male = 88 <0.0001c

tubal = 8 tubal = 22 tubal = 12

ovarian = 4 ovarian = 54 ovarian = 28

endometriosis = 1 endometriosis = 10 endometriosis = 0

combined = 14 combined = 176 combined = 80

idiopathic = 15 idiopathic = 60 idiopathic = 19

a one way ANOVA. b Kurskal- Wallis test. c Fisher-Freeman-Halton exact.

The duration of stimulation median was similar in all protocols using rFSH, HMG, HMG/rFSH (p < .998). In the short protocol, it was 10.1, 10.2 and 11.2 days respectively. In the long protocol, it was 10.7,11.8, and 10.9 days respectively. In the antagonist protocol, it was 10.3,11.2, and 10.7 days respectively. P4 levels on day of HCG trigger were similar among all protocols using rFSH, HMG, HMG/rFSH (p < .98). In the short protocol, it was 2.1, 2.7, and 2.1 nmol/L respectively. In the long protocol, it was 2.1, 1.8, and 8.5 nmol/L respectively. In the antagonist protocol, it was 2.7, 2.4, and 2.5 nmol/L respectively. The total dose of all gonadotropins used was highest in the short protocol patients group (p < .0001). On the day of trigger the long protocol had the highest amount of follicles > 14 mm (8.5 ± 4.5 follicles) and the thickest endometrium (1.1 ±0.2 cm) (p<.0001). Endometrium quality grade 2 was the commonest among all protocols (p = .04). The E2 is the highest in the short protocol when using HMG or rFSH/HMG and in the antagonist protocol when using rFSH (p < .0001) (Table 2).

The number of oocytes retrieved was significantly highest in the long protocol (10.5 ± 5.4 follicles) and the lowest in the short protocol (6.3 ±3.3 follicles) (p<.0001). This was matched with a higher number of mature and fertilized oocytes in the long protocol and lower number in the short protocol. The majority of patients had 2-3 embryos transferred, unless only one embryo was available for transfer (p = .0005). Embryo transfer was done at an early embryonic stage in the short protocol as compared to the more advanced stage in the antagonist protocol (2.5 ± 0.85 Vs 2.9 ± 1) respectively (p = .0003), to avoid the risk of developmental

arrest. The quality of embryos transferred among all protocols were similar (p = .66). The antagonist protocol had the highest number of surplus embryos available for freezing (0.5 ± 1.4)(p = . 02). The short protocol had the lowest CPR (p = .005). CPR was 213/605 (35.2%), 80/227 (35.2%), and 22/111 (19.8%) in the long, antagonist and short protocols respectively. The miscarriage rate was similar in all protocols (p = .22). Although it was not significant, it was highest in the short protocol 7/22 (31.8%) and lowest in the long protocol 36/213 (16.9%) (Table 3).

In Table 4 and 5, a cut-off P4 level of 1.5 nmol/L (0.47 ng/ml) and 2 nmol/L (0.63 ng/ml) were set for both agonist and the antagonist protocols respectively, as these were the levels at which significant results started to appear, in which 1 ng/mL = 0.314465 nmol/L. The demographic, lab and cycle parameters were similar in the short protocol patients with different serum P4 levels. While in the long and antagonist protocol, the group with a higher P4 level had better prognostic parameters in terms on lower FSH, higher AFC, and higher E2 level.

In the short protocol both groups had similar number of fertilized oocytes, number and quality of embryos to be transferred. CPR was similar in low and high P4 level groups, 8/30 (26.7%) and 14/81 (17.3%) respectively (p = .4). Miscarriage rate was similar in both groups 1/8 (12.5%) and 6/14 (43%) respectively (p = .19). The group with the high P4 level had significantly more number of surplus embryos to be frozen (0.1 ± 0.5 vs 0.03 ± 0.2 embryos)(p < .0001).

In the long protocol both groups had similar stimulation outcome, except for the number of fertilized oocytes that was higher

Table 2

Stimulation parameters of all protocols.

Short (n = 111)

Long(n = 605)

Antagonist (n = 227)

P value

Total dose (IU)

Duration of stimulation

(days) E2 (pmol/L)

Progesterone (nmol/L) day of HCG trigger No. of follicles > 14 mm Endometrial thickness (cm)

Endometrial quality

rFSH 2751 ± 1047HMG 3139.2 ± 1331.2HMG/rFSH 1687.5 ± 689/915 rFSH 10.1 ± 1.9HMG 10.2 ± 2HMG/rFSH 11.2 ±1.8

rFSH 7808 ± 3407HMG 7021 ±

3575HMG/rFSH 5982 ± 2386

rFSH 2.1 ± 1.2HMG 2.7 ± 2.8HMG/rFSH

2.1 ± 1

5.3 ± 3

0.95 ± 0.2

rFSH 1639 ± 638HMG 2348.9 ± 909HMG/ rFSH 1170.2/1507 ±841.9/886 rFSH 10.7 ± 2HMG 11.8 ± 2.4HMG/rFSH 10.9 ±2.2

rFSH 8285 ± 3615HMG 6357.8 ± 2999.6HMG/rFSH 5613 ± 2993 rFSH 2.1 ± 1HMG 1.8 ± 0.9HMG/rFSH 1.7 ± 0.8 8.5 ± 4.5 1. 1 ±0.2

G1 266

rFSH 1766 ± 1035HMG 2243 ± 855HMG/rFSH 1659/2750 ± 912/1165 rFSH 10.3 ± 2.2HMG 11.2 ± 2.6HMG/ rFSH 10.7 ±2.8

rFSH 8340 ± 4069HMG 6176 ± 3678HMG/rFSH 5372 ± 3445 rFSH 2.7 ± 1.4HMG 2.4 ± 3.1HMG/rFSH 2.5 ± 1 8.1 ± 5.1 1 ± 0.2

G2 287

G2 102

<0.0001a

0.998a

<0.0001a

<0.0001a <0.0001a

Kurskal- Wallis test. Chi square test.

Table 3

Cycles and pregnancy outcome.

Short (n = 111) Long (n = 605) Antagonist (n = 227) P = value

Oocytes retrieved 6.3 ± 3.3 10.5 ±5.4 10.4 ±5.5 <0.0001a

Mature oocytes 5 ±2.8 7.7 ± 4 7.7 ± 4 <0.0001a

Fertilized Oocytes 3.2 ± 1.9 4.8 ± 2.8 4.9 ± 2.6 <0.0001a

No. of Frozen embryos 0.1 ± 0.4 0.4 ±1.4 0.5 ±1.4 0.02a

Day of embryo transfer 2.5 ± 0.85 2.8 ± 0.9 2.9 ± 1 0.0003a

No. Of embryos transferred N1 =21 N1 = 41 N1 =16 0.0005b

N2 = 64 N2 = 436 N2 = 161

N3 = 26 N3 = 128 N3 = 50

Grade of embryo transferred G1 =53 G1 = 304 G1 = 109 0.66b

G2 = 49 G2 = 248 G2 = 103

G3 = 6 G3 = 46 G3 = 13

G4 = 3 G4 = 7 G4 = 2

Clinical pregnancy rate (%) 22/111 (19.8%) 213/605 (35.2%) 80/227 (35.2%) 0.005b

Miscarriage rate (%) 7/22 (31.8%) 36/213 (16.9%) 16/80 (20%) 0.22b

a Kurskal- Wallis test. b Chi square test.

Table 4

Demographic characteristics of the groups in relation to Progesterone level.

Short GnRH protocol Long GnRH protocol Antagonist protocol

0.9a 0.001b 0.028b 0.0001b <0.0001c

0.144b

stimulation

(days)

a Unpaired T test. b Mann-Whitney. c Fisher-Freeman-Halton exact.

P < 1.5 N mol/L P > 1.5 N mol/L

P < 1.5 N mol/L P> 1.5 N mol/L

P < 2 N mol/ L P > 2 N mol/L

Age (years) AFC

FSH (1U/L) E2 level Gonadotropin type

Duration of

(n = 30) 33 ± 3.9

9.2 ± 3.9

9.3 ± 5.1 6137 ±2917 rFSH = 9 HMG = 18 HMG/rFSH = 3

10.8 ±2.9

(n = 81) 32.8 ± 4.2 9.9 ± 3.9 8.7 ± 3.4 7502 ± 3542 rFSH = 26HMG=45 HMG/rFSH = 10 ±1.87

0.87 0.48 0.43 0.62 0.95

(n = 252) 29.6 ± 4 18.6 ±9 6.5 ± 1.9 5546 ± 2499 rFSH = 62HMG=176 HMG/rFSH 11.2 ±2.4

(n = 353) 29.7 ± 4 21.9 ±9 6 ±1.9 7905 ± 3503 rFSH = 127 HMG = 210 HMG/rFSH = 16

11.3 ±2.3

0.0001b

0.0001b

0.0001b

0.019c

(n = 101) 30.2 ± 4.2 20.9 ±11 6.5 ± 2.4 5323 ± 2830 rFSH = 53 HMG = 47 HMG/rFSH = 1

10.9 ±2.5

(n = 126)

30.3 ± 4.3 26.7 ± 1 5.8 ± 2 9171 ±4166 rFSH = 92 HMG = 32 HMG/rFSH = 2

10.4 ±2.1

Table 5

Stimulation and pregnancy outcome in relation to progesterone levels in the study groups.

Short GnRH protocol Long GnRH protocol Antagonist protocol

P < 1.5 N mol/ P > 1.5 N mol/ P P < 1.5 N mol/ P> 1.5 Nmol/L P P < 2 N mol/ L P > 2 N mol/L P

L (n = 30) L(n = 81) L (n = 252) (n = 353) (n = 101) (n = 126)

N of fertilized 2.8 ± 1.6 3.3 ± 2 0.24a 4.2 ± 2.2 5.3 ± 3.1 0.0001a 4 ±2.3 5.6 ± 2.7 <0.0001a

oocytes

No of ET 1.9 ±0.7 2.1 ± 0.6 0.11a 2.1 ± 0.5 2.1 ± 0.5 0.136a 2.2 ± 0.5 2.2 ± 0.5 0.28a

N of frozen embryo 0.03 ± 0.2 0.1 ± 0.5 <0.0001a 0.3 ± 1 0.5 ±1.5 0.984a 0.3 ± 1 0.6 ±1.6 0.07a

Quality of best GI = 12 GI = 41 0.32b GI = 127 GI = 176 0.61b GI = 8GII = 74G GI = 55GII = 65G <0.037b

embryo Gil = 17 GII = 32 GII = 100 GII = 148 III = 19GIV=0 III = 6GIV=0

transferred

G III = 1 G III = 5 G III = 20 G III = 26

GIV = 0 GIV = 3 GIV = 5 GIV = 3

Clinical Pregnancy 8/30 (26.7%) 14/81(17.3%) 0.4c 80/252 (31.7%) 133/353 0.16c 44/101(43.6%) 36/126 (28.6%) 0.018c

rate% (37.7%)

Miscarriage rate% 1/8 (12.5%) 6/14 (43%) 0.19b 18/80(22.5%) 18/133(13.5%) 0.13c 7/44 (16%) 9/36 (25%) 0.47c

a Mann-Whitney. b Fisher-Freeman-Halton exact. c Chi square test.

in the high P4 group (5.3 ± 3.1 vs. 4.2 ± 2.2 oocytes) (P = .0001). CPR was similar in low and high P4 groups, 80/252 (31.7%) and 133/353 (37.7%) respectively (p = .16). Miscarriage rate was similar in both groups 18/80 (22.5%) and 18/133 (13.5%) respectively (p = .13).

1n the antagonist protocol the group with the high P4, had more number of fertilized oocytes (P < .0001) and more good quality embryos transferred (p < .037) with similar number of embryos transferred and frozen. CPR was significantly higher in the group with lower P4 level 44/101 (43.6%) and 36/126 (28.6%) respectively (p = .018). But the miscarriage rate was similar amongst low and high P4 groups 7/44 (16%) and 9/36 (25%) respectively (p = .47) (Table 5).

4. Discussion

In COS cycles, PPR was believed to have a variable effect on the pregnancy outcome. 1n the literature, the P4 cutoff level on the day of hCG was commonly ranging from 0.8 to 2 ng/ml (2.54-6.36 n mol/L) used with different protocols of COS [6].

4.1. Short GnRH agonist protocol

In the short GnRH agonist protocol, a PPR >1.5 nmol/L did not affect our clinical pregnancy or miscarriage rates. Our finding was similar to Marteniz et al. who used the short protocol like us in patients expected to be poor responders [18]. Although few studies used this protocol but most of their findings were different

from ours. The reason behind this could be our utilizing of this protocol mostly in patients expected to be poor responders, whereas others were utilizing it for all patients in general. A study by Yi-Ru Tsai et al., revealed that pregnancy rate and LBR were found to be significantly lower in the group of patients with a P4 level of >1.94 ng/ml (>6.17 nmol/L) [19]. Ze Wu et al., also reported that elevated P4 at the day of HCG would lower the pregnancy, implantation and LBR [20], while Rui Huang et al. reported a decrease in the LBR only [21]. However, most reports demonstrates a negative impact of an elevated P4 levels on the pregnancy outcome in such protocol, but did not elaborate on its correlation with miscarriage rate.

4.2. Long GnRH agonist protocol

1n the long agonist protocol, PPR had no impact on the clinical outcome of our study population. This finding is similar to other studies which had COS with long GnRH agonist protocol; and found that there were no association between high P4 level on day of HCG and pregnancy rate nor LBR [6,22]. Therefore, in agreement with et al., fresh embryo transfer is advised as there was no benefit from freezing them for a later transfer in a frozen cycle [16]. Moreover, others suggested to transfer day 5 blastocyst for patients with high P4 levels >1.5 ng/ml (4.77 nmol/L) [23], as some authors advised blastocysts transfer to overcome the PPR and allow the P4 level to drop after oocyte collection, in an attempt to increase the life birth rate [6].

N. Bushaqer et al./Middle East Fertility Society Journal xxx (2017) xxx-xxx

On the contrary, in the long protocol, a systematic review and meta-analysis of over 60,000 cycles done by venetis et al. concluded that PPR on the day of HCG was associated with a decreased probability of pregnancy in fresh cycles [24]. Moreover, studies concluded that the detrimental effect of PPR cannot be completely overcame by transferring blastocysts [17,24]. In addition, other studies reported PPR would impair the pregnancy and life birth rates [19-21].

A study done on PCOS patients using the long agonist protocol revealed that patients with PPR on the day of HCG were having higher chemical and clinical pregnancy rates; without reaching a statistically significant level. This could be due to the fact that premature luteinization with high P4 levels is a common event in PCOS patients due to their exaggerated response to COS [25]. Furthermore, others claimed that PPR may be a predictor of success in IVF and it seems that it does not adversely affect pregnancy rate as previously explained [26].

4.3. Fixed GnRH antagonist protocol

When using the fixed GnRH antagonist, we found that PPR was adversely related to CPR. Our result was inline with others authors who reported decreased CPR despite many oocytes retrieval [14,19]. While similarly, others reported decreased LBR with P4 l evel >1.5 ng/ml (4.77 nmol/L) [27]. Therefore, Raoul Orvieto et al. advised a ''freeze all" policy when the P4 level was >1.5 ng/ml (4.77 nmol/L) [16].

In antagonist cycles, the GnRH antagonist which has an average of 20 h when given to prevent the luteinizing hormone (LH) surge is stopped 36 h before oocyte retrieval which leads to a rapid recovery from pituitary suppression and thus endogenous LH surge may also occur, which, may raise P4 levels beyond what occurs with hCG trigger alone [10].

In the antagonist protocol, Papanikolau et al. reported that if blastocysts were transferred, PPR would have no effect on the pregnancy outcome [28]. But others reported that clinical pregnancy rate decreased with PPR in both cleavage and blastocyst stages of embryos [29], and that fresh blastocyst transfer does not completely overcome the detrimental effect of PPR [17]. This discrepancy may be attributed to different sample size, protocols used and P4 assays [28].

While some authors described no significant differences in LBR with increasing P4 levels [23], others stated that there was no P4 level on the HCG day that could be used to distinguish between good and poor cycle outcome [22].

This is the first paper published studying the effect of PPR on the day of HCG trigger, on the pregnancy outcome among the short GnRH agonist, long GnRH agonist, and fixed antagonist protocols. However, the drawbacks of our study were that our study was done with retrospective design, in addition to our low P4 cut off level as compared to other manuscripts.

One of the drawbacks of this analysis is that implantation was assessed at varied aged embryos. It is well known that implantation depends not only on the endometrium progesteronic hostility status but also on the embryonic stage. Day 2 to day 5 embryos have different endometrial receptivity which will undoubtedly affect the implantation and pregnancy rates. Other clinically modifiable factors associated with global placental methylation based on the transfer day, was also not been explored.

5. Conclusion

In the short and long GnRH agonist protocols, high progesterone level >1.5 nmol/l did not affect clinical pregnancy or miscarriage rates. In fixed GnRH antagonist protocol, high progesterone level

>2 nmol/l affected clinical pregnancy rate adversely, but did not affect miscarriage rate.

Conflict of interest

The authors declared that there is no conflict of interest.

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