Crinone 8%∗∗Crinone 8%, Wyeth-Ayerst Laboratories, Inc., Philadelphia, Pennsylvania. vaginal progesterone gel results in lower embryonic implantation efficiency after in vitro fertilization-embryo transfer

FERTILITY AND STERILITY威 VOL. 72, NO. 5, NOVEMBER 1999 Copyright ©1999 American Society for Reproductive Medicine Published by Elsevier Science Inc. Printed on acid-free paper in U.S.A.

Crinone 8%* vaginal progesterone gel results in lower embryonic implantation efficiency after in vitro fertilization-embryo transfer Mark A. Damario, M.D.,† Vasilios T. Goudas, M.D.,† Donna R. Session, M.D.,† Diane G. Hammitt, Ph.D.,†‡ and Daniel A. Dumesic, M.D.† Mayo Clinic, Rochester, Minnesota, and Mayo Clinic, Scottsdale, Arizona

Received November 19, 1998; revised and accepted May 3, 1999. Supported in part by a grant from Wyeth-Ayerst Laboratories, Inc., Philadelphia, Pennsylvania. Reprint requests: Mark A. Damario, M.D., Mayo Clinic, 200 First Street Southwest, Rochester, Minnesota 55905 (FAX: 507-284-1774). * Crinone 8%, WyethAyerst Laboratories, Inc., Philadelphia, Pennsylvania. † Division of Reproductive Endocrinology, Department of Obstetrics and Gynecology, Mayo Clinic, Rochester. ‡ Division of Reproductive Endocrinology, Department of Obstetrics and Gynecology, Mayo Clinic, Scottsdale. 0015-0282/99/$20.00 PII S0015-0282(99)00364-7

830

Objective: To evaluate the outcome of IVF-ET after the use of Crinone 8% (Wyeth-Ayerst Laboratories, Inc., Philadelphia, PA) vaginal progesterone gel and to compare these results with those seen in our program with the use of IM progesterone-in-oil. Design: Retrospective cohort study. Setting: A tertiary referral reproductive medicine unit. Patient(s): Patients ⬍40 years of age undergoing IVF-ET cycles. Intervention(s): Patients were treated with either Crinone 8% vaginal progesterone gel (90 mg) administered daily or IM progesterone-in-oil (50 mg) administered daily. Main Outcome Measure(s): Biochemical pregnancy rate, implantation rate, and clinical and ongoing pregnancy rates. Result(s): The use of Crinone 8% vaginal progesterone gel was associated with a lower implantation rate (16.6% versus 26.2%; odds ratio [OR] ⫽ 0.56; 95% confidence interval [CI], 0.35– 0.89) compared with the use of IM progesterone-in-oil. Biochemical pregnancies were more common after the use of Crinone 8% vaginal progesterone gel as defined by either biochemical pregnancies per transfer (15.9% versus 5.7%; OR ⫽ 3.11; 95% CI, 1.17– 8.32) or biochemical pregnancies as a proportion of positive serum hCG titers (29.2% versus 9.8%; OR ⫽ 3.80; 95% CI, 1.33–10.86). Clinical pregnancy rates also were lower with the use of Crinone 8% vaginal progesterone gel (36.4% versus 52.9%; OR ⫽ 0.51; 95% CI, 0.26 – 0.99). Conclusion(s): Implantation efficiency is reduced, as demonstrated by lower embryonic implantation rates and higher biochemical pregnancy rates, when Crinone 8% vaginal progesterone gel rather than IM progesterone-in-oil is used for luteal phase support after IVF-ET. (Fertil Steril威 1999;72:830 –36. ©1999 by American Society for Reproductive Medicine.) Key Words: Luteal phase support, progesterone, in vitro fertilization, implantation, biochemical pregnancy

Progesterone supplementation is used in many assisted reproductive technology (ART) procedures to improve endometrial receptivity. After controlled ovarian hyperstimulation for standard IVF-ET, there usually are large endogenous sources of E2 and progesterone as a result of multiple follicular development and corpora luteal function. There is concern, however, that either impaired corpora lutea from residual GnRH agonist effects or loss of granulosa cells during the process of oocyte retrieval may lead to relative progesterone deficiency and inadequate endometrial development for embryo implantation and pregnancy maintenance. A recent meta-analysis

supports the use of supplemental progesterone in the luteal phase after IVF-ET (1). The most common form of progesterone supplementation for ART in the United States has been IM progesterone-in-oil. Prolonged, repeated IM injections of progesterone-in-oil, however, may lead to severe inflammatory reactions, sterile abscesses, and/or significant patient discomfort. Unfortunately, there are few practical alternatives to IM progesterone-in-oil. Although plasma progesterone levels increase markedly in response to repeated injections of hCG, this approach appears to carry a significantly increased risk of severe ovarian

hyperstimulation syndrome (2). Moreover, orally administered progesterone is so intensely metabolized by the liver (⬍10% bioavailability) that the amounts of unaltered progesterone that reach the systemic circulation are insufficient to achieve consistently adequate secretory transformation of the endometrium, even after high doses (3). Oral progestins resist hepatic degradation but are unacceptable for use in ART procedures because of potential teratogenic effects on the fetus. Some investigators have reported favorable experience with Utrogestan (Laboratories Besins Isoresco, Paris, France), a micronized progesterone preparation designed for oral use, when administered vaginally (4). Crinone 8% (Wyeth-Ayerst Laboratories, Inc., Philadelphia, PA) is a vaginal progesterone gel designed to provide a controlled and sustained release of progesterone over a 48to 72-hour interval after a single vaginal application (5). The gel delivery system uses the bioadhesive properties of polycarbophil, a polymer known to attach to epithelial surfaces for extended periods (6). It is believed that prolonged contact time between the drug and the absorptive surface allows enhanced and continuous drug delivery. Dosages as low as 45 mg of Crinone 8% administered vaginally every other day have resulted in secretory transformation in postmenopausal women treated initially with estrogen (7). Another study in women with premature ovarian failure revealed that vaginal administration of 45, 90, or 180 mg of Crinone 8% every 2 days induced full secretory transformation of the endometrial stroma in all patients, despite plasma progesterone levels as low as 1–3.9 ng/mL (8). Because plasma progesterone levels in this range after IM injections of progesterone-in-oil consistently fail to induce normal secretory changes in the endometrial stroma (9), Crinone 8% administered vaginally appears to have a substantial local effect (“first uterine pass effect”) before it reaches the general circulation. Therefore, the administration of Crinone 8% vaginal progesterone gel may be a viable option for achieving endometrial receptivity for ART procedures, although there have been no comparative studies to date of Crinone 8% and IM progesterone-in-oil after standard IVF-ET.

MATERIALS AND METHODS Patient Population

Patients ⬍40 years of age undergoing standard IVF-ET cycles were invited to participate in a trial of Crinone 8% vaginal progesterone gel. This protocol was approved by the institutional review board. Patients undergoing donor oocyte recipient cycles, frozen ET cycles, or superovulation-IUI cycles were excluded. Active recruitment for the Crinone 8% vaginal progesterone gel study took place from August 15, 1997 to January 30, 1998. During this interval, most patients eligible to participate in the study chose to do so because of a preference to avoid parenteral medication therapy. All but one FERTILITY & STERILITY威

patient who received Crinone 8% vaginal progesterone gel had a stimulation cycle start date between August 29, 1997 and February 6, 1998. During this interval, there were only 11 patients ⬍40 years of age who initiated an IVF-ET cycle and subsequently were treated with IM progesterone-in-oil. To evaluate the clinical outcomes of treatment with IM progesterone-in-oil, we reviewed all standard IVF-ET cycles in patients ⬍40 years of age undertaken between January 1, 1996 and June 30, 1997 in our program. This strategy was implemented because of the small number of patients who elected to use progesterone-in-oil during the interval during which Crinone 8% was offered. All cycles from this previous period were reported except for those in 14 patients who refused to allow the use of their medical record for research in accordance with Minnesota law (MN Statute Section 144.335) and those in 5 patients who subsequently were in the Crinone 8% study group. As in the Crinone 8% study group, patients undergoing donor oocyte recipient cycles, frozen ET cycles, or superovulation-IUI cycles were excluded from the IM progesterone-in-oil study group.

Experimental Design Both groups of patients were treated in an identical manner. All patients underwent down-regulation with the GnRH agonist leuprolide acetate (Lupron; TAP Pharmaceuticals, Deerfield, IL) beginning on cycle day 21 of the preceding menstrual cycle. In some instances, oligo-ovulatory patients or high responder patients began leuprolide acetate therapy after initial treatment with either oral medroxyprogesterone acetate (Provera; Pharmacia & Upjohn Co., Kalamazoo, MI) or oral contraceptives (Ortho Novum 1/35; Ortho Pharmaceuticals, Raritan, NJ) (10). Leuprolide acetate initially was administered subcutaneously at a dosage of 1 mg daily. After withdrawal bleeding and confirmation of adequate ovarian down-regulation (no ovarian cysts of ⬎18 mm in diameter and E2 levels of ⬍35 pg/mL), the leuprolide acetate dosage was reduced to 0.5 mg daily. Gonadotropin therapy was begun using either purified FSH (Metrodin or Metrodin-HP; Serono Laboratories, Norwell, MA) or recombinant FSH (Gonal-F; Serono Laboratories, or Follistim; Organon Inc., West Orange, NJ). In general, 3 or 4 ampules containing 75 IU of gonadotropins were administered daily by either SC or IM injection. On occasion, a patient with a history of previous poor response was started on a higher initial dosage of gonadotropins (6 – 8 ampules containing 75 IU administered daily). The daily dosage usually was decreased in a step-down fashion once follicular recruitment was established. Daily monitoring of serum E2 levels and follicular growth was initiated on the fifth or sixth day of gonadotropin therapy. Follicular monitoring was undertaken with a Corometrics Aloka 650 realtime ultrasound device (Corometrics Medical Systems, Wallingford, CT) equipped with a 5.0-MHz transvaginal probe. The timing of hCG administration was based on several 831

parameters, including the mean lead follicular diameter, serum E2 level, rate of rise of serum E2, and oocyte or embryo quality in the patient’s previous cycle(s), if applicable. In general, hCG was administered at a dose of 10,000 IU given intramuscularly once the mean lead follicular diameter(s) exceeded 19 mm. Oocyte retrieval was scheduled for 36 hours after hCG administration. Leuprolide acetate therapy was discontinued on the day of hCG administration. All patients underwent transvaginal ultrasound-guided oocyte retrieval. Oocytes were inseminated with 0.25– 0.35 ⫻ 106 motile sperm per milliliter if no male factor was present or with 0.5 ⫻ 106 motile sperm per milliliter if a mild to moderate male factor was present. In cases of severe male factor infertility, intracytoplasmic sperm injection was undertaken to facilitate fertilization as previously reported (11). Human tubal fluid supplemented with 10% Synthetic Serum Substitute (Irvine Scientific, Santa Ana, CA) was used for oocyte culture, fertilization, and embryo culture. All normally fertilized zygotes in excess of the number selected by the patient for transfer were frozen at the pronuclear stage and the remaining embryos were cultured until transcervical ET was performed approximately 48 hours after oocyte retrieval. Embryos were evaluated for blastomere number and quality just before ET. Embryo quality was judged by a scoring system that ranged from 0 (best) to 3 (worst), based on criteria related to blastomere symmetry and cellular fragmentation (12). Assisted hatching and ET were performed approximately 72 hours after oocyte retrieval in a limited number of patients with a history of ⱖ3 failed prior cycles in our program (13). All patients received a short course of doxycycline (100 mg orally given twice daily for 5 days) starting the day before oocyte retrieval. Patients who required assisted hatching also received methylprednisolone (16 mg orally given daily for 4 days) starting on the day of oocyte retrieval. Therapy with either progesterone-in-oil (50 mg intramuscularly once daily) or Crinone 8% (90 mg vaginally once daily) was begun on the evening of oocyte retrieval and continued until either a serum pregnancy test result was negative or sonographically confirmed embryonic viability was noted. Data were gathered on body mass index, type of infertility (primary vs. secondary), infertility factor, number of prior assisted reproduction cycles (at other clinics), number of prior IVF-ET cycles (at Mayo Clinic), age, duration of gonadotropin stimulation, type of gonadotropin used, number of gonadotropin ampules (75 IU) administered, serum E2 level on the day of hCG administration, number of oocytes retrieved, number of oocytes normally fertilized (two pronuclei), number of embryos transferred, embryo quality, blastomere number, endometrial thickness, use of assisted hatching, number of ET attempts, and presence of blood either outside or inside the transfer catheter. Biochemical pregnancies were defined as those pregnan832

Damario et al.

Vaginal progesterone gel and IVF outcome

cies in which there was a transient elevation of the serum ␤-hCG level (⬎10 mIU/mL), as defined by the Third International Reference Preparation, in the absence of a detectable intrauterine gestational sac by transvaginal ultrasonography or a clinical ectopic pregnancy. The first quantitative serum ␤-hCG determination was always obtained ⱖ12 days after ET. Clinical pregnancies were exclusive of biochemical and ectopic pregnancies and required a detectable intrauterine gestational sac on ultrasound examination. Ongoing pregnancies were defined by the presence of intrauterine embryonic heart activity, as determined by transvaginal ultrasonography. The implantation rate was determined by dividing the number of sonographically visualized intrauterine gestational sacs by the total number of embryos transferred.

Hormonal Assays Estradiol was measured by an RIA using a commercial kit (Pantex, Santa Monica, CA) that used hexane-ethylacetate extraction. The E2 assay had an interassay coefficient of variation (CV) of 10% at a concentration of 40 pg/mL and an interassay CV of 8% at a concentration of 1,000 pg/mL. The hCG assay performed in our laboratory used an automated chemiluminescence assay on the ACS 180 instrument (Chiron Diagnostics, East Walpole, MA), standardized against the World Health Organization Third International Reference Preparation. The hCG assay had an interassay CV of 5.5% and an intra-assay CV of 3.7% at a concentration of 7.8 mIU/mL; it had an interassay CV of 3.8% and an intra-assay CV of 1.9% at a concentration of 63.9 mIU/mL. Approximately half the patients in each group had their serum hCG assay performed at an outside laboratory, although each of these outside assays also was standardized against the World Health Organization Third International Reference Preparation.

Statistical Analysis Characteristics of the patient groups that received Crinone 8% and progesterone-in-oil were analyzed by Wilcoxon’s rank sum test or Fisher’s exact test, as appropriate. Statistical significance was defined as P⬍.05. Analyses of outcome measures were undertaken with both univariate and multivariate methods. Because of the presence of some patients who underwent repeated cycles in the control group, each outcome parameter was assessed initially in a generalized estimating equations model to determine within-subject correlations (14). Working correlations of ⬍0.03 for each outcome parameter suggested minimal within-subject correlations and supported the inclusion of all treatment cycles in the control group. Univariate analysis included 2 ⫻ 2 tables with determination of odds ratios (ORs) and 95% confidence intervals (CIs) as well as P values. Multivariate analysis included a logistic regression model in which age, mean embryo quality, embryo transfer number, and type of progesterone agent used were included in a mandatory fashion for all outcome Vol. 72, No. 5, November 1999

parameters, except in the instance of implantation rate, for which embryo transfer number was not included. These models assume independence across repetitions. Other potential factors, including body mass index, primary infertility, previous IVF cycles, endometrial thickness, blood present on the transfer catheter, and number of transfer attempts, were placed into the model if the factor demonstrated a significant trend (P⬍.05) with regard to the particular outcome parameter. An additional multivariate analysis was performed using a generalized estimating equations model with an exchangeable correlation structure for implantation rate. This approach assumes that all embryos within a cohort might not exhibit independence.

RESULTS Fifty-three IVF-ET cycles were initiated with the intent of using Crinone 8% as the form of luteal phase support. There were 9 cycle cancellations (17%). Forty-four patients underwent 44 oocyte retrievals and 44 fresh ETs using Crinone 8%. No patients underwent more than one ET in this arm of the study. Two patients had undergone a previous ART cycle at another clinic (4.6%), and seven patients had undergone a previous IVF-ET cycle at our center (15.9%). Male factor infertility was the most common type of infertility in this patient group (50%), with tubal factor infertility (15.9%), endometriosis (11.4%), ovulatory factor infertility (6.8%), and other causes (15.9%) comprising the remainder (Table 1). From January 1, 1996 to June 30, 1997, 322 IVF-ET cycles were initiated in 258 patients ⬍40 years of age. Under Minnesota law, data in the medical records of 14 patients (15 treatment cycles) who had refused consent to the use of their medical record for research purposes were excluded. Five additional patients (5 treatment cycles) were excluded to conduct a proper statistical analysis because these patients also had a subsequent cycle in the Crinone 8% study group. After removal of these cycles, we analyzed 302 initiated cycles undertaken in 239 patients in the control group. There were 59 cycle cancellations (19.5%). Two hundred three patients underwent 243 oocyte retrievals, with a resultant 227 fresh ETs. Failure to progress to ET was due to either fertilization failure or significant risk for severe ovarian hyperstimulation, in which case all embryos were initially cryopreserved. All patients who underwent fresh ET during this interval received IM progesterone-in-oil for luteal phase support. Thirty-one patients had undergone a previous ART cycle at another clinic (15.3%), and 50 patients had undergone a previous IVF-ET cycle at our center (24.6%). Male factor infertility also was the most common type of infertility in this patient group (40.4%), with tubal factor infertility (31%), endometriosis (9.9%), ovulatory factor infertility (9.9%), and other causes (8.9%) comprising the remainder. FERTILITY & STERILITY威

TABLE 1 Comparison of patient-specific characteristics between patients who received Crinone 8% vaginal progesterone gel and IM progesterone-in-oil. Treatment group

Variable Mean (⫾SD) BMI (kg/m2) Primary infertility Infertility factor Male factor Tubal factor Endometriosis Ovulatory factor Other† Proportion with prior ART cycles‡ Proportion with prior IVF-ET cycles§

Crinone 8% (n ⫽ 44)

IM progesteronein-oil (n ⫽ 203)

P value*

24.09 ⫾ 4.55 59.1

25.09 ⫾ 5.14 53.0

.18 .51

50.0 15.9 11.4 6.8 15.9

40.4 31.0 9.9 9.9 8.9

.25 .04 .78 .78 .17

4.6

15.3

.08

15.9

24.6

.24

Note: ART ⫽ assisted reproductive technology; BMI ⫽ body mass index. Values are percentages unless otherwise noted. * Determined by Wilcoxon’s rank sum test or Fisher’s exact test as appropriate. † Includes uterine factor, cervical factor, immunologic factor, and unexplained infertility. ‡ Includes only cycles of ART undertaken at clinics other than Mayo Clinic-Rochester. § Includes only cycles of IVF-ET undertaken at Mayo Clinic-Rochester. Damario. Vaginal progesterone gel. Fertil Steril 1999.

Cycle-specific characteristics of the two patient groups are compared in Table 2. Age at the time of initiation of stimulation was similar between the IM progesterone-in-oil (mean age, 33.2 years) and vaginal Crinone 8% (mean age, 34.1 years) groups. The two patient groups had similar durations of gonadotropin stimulation, serum E2 levels on the day of hCG administration, numbers of oocytes retrieved and normally fertilized, and numbers of embryos transferred. Both patient groups had comparable overall embryo quality, as determined by mean embryo quality scores and mean blastomere numbers at ET, and endometrial thickness measurements. A comparably low percentage of patients in each group had assisted hatching, blood noted inside or outside the transfer catheter, and multiple transfer attempts. The only statistically significant difference noted in the cycle-specific outcome parameters was an increased number of gonadotropin ampules used in the Crinone 8% group (mean, 42.6) compared with the IM progesterone-in-oil group (mean, 32.9). An analysis of clinical outcomes (Table 3) revealed that the use of Crinone 8% vaginal progesterone gel was associated with an increased incidence of biochemical pregnancies, whether ascertained as an incidence rate per ET (OR ⫽ 3.11; 833

TABLE 2 Comparison of cycle-specific characteristics between patients who received Crinone 8% vaginal progesterone gel and IM progesterone-in-oil. Treatment group

Variable No. of transfer cycles Age (y) Duration of stimulation (days) No. of gonadotropin ampules (75 IU) Serum E2 level at hCG administration (pg/mL) No. of oocytes retrieved No. of oocytes fertilized (two pronuclei) No. of embryos transferred Mean embryo quality Mean blastomere number Endometrial thickness (mm)† Assisted hatching (%) Single transfer attempt (%) Blood noted inside ET catheter (%) Blood noted outside ET catheter (%)

Crinone 8% (n ⫽ 44)

IM progesteronein-oil (n ⫽ 203)

44 34.1 ⫾ 3.7

227 33.2 ⫾ 4.0

.23

10.0 ⫾ 1.3

9.7 ⫾ 1.4

.08

42.6 ⫾ 20.4

32.9 ⫾ 14.7

⬍.01

1,705 ⫾ 865 13.25 ⫾ 7.15

1,788 ⫾ 851 12.63 ⫾ 6.09

.47 .69

7.27 ⫾ 4.49 3.30 ⫾ 0.76 1.05 ⫾ 0.43 3.79 ⫾ 1.04 12.2 ⫾ 2.9 2.3 88.6

7.96 ⫾ 4.46 3.35 ⫾ 0.78 0.94 ⫾ 0.55 3.71 ⫾ 0.99 12.1 ⫾ 2.6 4.0 85.5

.28 .67 .09 .98 .93 1.00 .81

22.7

20.7

.84

2.3

2.6

1.00

P value*

Note: Values are means ⫾ SD unless otherwise indicated. * Determined by Wilcoxon’s rank sum test or Fisher’s exact test as appropriate. † Data were missing in five cycles in the IM progesterone group and one cycle in the Crinone 8% group. Damario. Vaginal progesterone gel. Fertil Steril 1999.

95% CI, 1.17– 8.32; P⫽.03) or as a proportion of all positive hCG titers (OR ⫽ 3.80; 95% CI, 1.33–10.86; P⫽.02). There was a significant decrease in the implantation rate associated with the use of Crinone 8% vaginal progesterone gel (OR ⫽ 0.56; 95% CI, 0.35– 0.89; P⫽.02). There also was a lower clinical pregnancy rate (OR ⫽ 0.51; 95% CI, 0.26 – 0.99; P⫽.049) and a trend toward a lower ongoing pregnancy rate (OR ⫽ 0.53; 95% CI, 0.27–1.04; P⫽.07) associated with the use of Crinone 8% vaginal progesterone gel. Multivariate methods were used to further define the interaction between the type of progesterone agent used and the clinical outcome. Logistic regression models included mandatory adjustments for age, mean embryo quality, embryo transfer number (except for implantation rate), and type of progesterone agent used, as well as any other identified significant factors. Using these models, Crinone 8% vaginal progesterone gel continued to be associated with an increased biochemical pregnancy rate, defined as either an incidence rate per ET (OR ⫽ 3.99; 95% CI, 1.39 –11.44; 834

Damario et al.

Vaginal progesterone gel and IVF outcome

P⫽.01) or a proportion of positive hCG titers (OR ⫽ 5.75; 95% CI, 1.78 –18.60; P⬍.01). The implantation rate also remained lower in the patients who received Crinone 8% vaginal progesterone gel (OR ⫽ 0.59; 95% CI, 0.36 – 0.94; P⫽.03). After adjusting for age, mean embryo quality, and mean embryo transfer number, there remained a trend toward lower clinical pregnancy rates in the patients who received Crinone 8% vaginal progesterone gel (OR ⫽ 0.56; 95% CI, 0.28 –1.12, P⫽.10), although this was not statistically significant. Using the generalized estimating equations model for implantation rate, a working correlation of 0.158 was estimated for embryos within a cohort. This demonstrated a moderate amount of positive correlation with regard to implantation. After adjusting for age, mean embryo quality, previous IVF cycles, and the correlation in this model, a similar odds ratio was obtained for implantation rate as with the logistic regression model (OR ⫽ 0.58). This model, however, demonstrated slightly wider confidence intervals (95% CI, 0.33–1.03; P⫽.06), which are accounted for by the slightly increased degree of uncertainty introduced by the assumptions of this method.

DISCUSSION Two previous studies were published regarding the use of Crinone 8% in assisted reproductive techniques. The first was a phase III clinical trial undertaken in seven European clinics that compared the effects of Crinone 8% with an oral form of progesterone (Utrogestan) for luteal phase support after IVF-ET (15). Crinone 8% (90 mg delivered per dose) was administered vaginally every day and Utrogestan was given at a dosage of 300 mg orally once daily. With 283 patients randomly allocated to either treatment, the preg-

TABLE 3 Clinical outcomes of patients who received Crinone 8% vaginal progesterone gel and IM progesterone-in-oil. Treatment group

Variable No. of transfer cycles Biochemical pregnancy rate (% of transfers) Biochemical pregnancy rate (% of positive hCG titers) Implantation rate (%) Clinical pregnancy rate (%) Ongoing pregnancy rate (%)

IM progesteroneCrinone 8% in-oil (n ⫽ 44) (n ⫽ 203) 44

OR (95% CI)

227

15.9

5.7

3.11 (1.17–8.32)

29.2 16.6 36.4 34.1

9.8 26.2 52.9 49.3

3.80 (1.33–10.86) 0.56 (0.35–0.89) 0.51 (0.26–0.99) 0.53 (0.27–1.04)

Note: OR ⫽ odds ratio; CI ⫽ confidence interval. Damario. Vaginal progesterone gel. Fertil Steril 1999.

Vol. 72, No. 5, November 1999

nancy rates per transfer were not significantly different between the Crinone 8% and Utrogestan groups at day 12 (Crinone 8% ⫽ 35.3%, Utrogestan ⫽ 29.9%; P⫽.55), day 30 (Crinone 8% ⫽ 28.8%; Utrogestan ⫽ 25%; P⫽.61), and day 90 (Crinone 8% ⫽ 25.9%, Utrogestan ⫽ 22.9%; P⫽ .69). The delivery rates per transfer (Crinone 8% ⫽ 23%, Utrogestan ⫽ 22.2%; P⫽.91) also were not significantly different. It is important to recognize, however, that the pregnancy rates per transfer in this trial do not reflect the relative efficiency of IM progesterone-in-oil for luteal phase support after IVF-ET. A second trial was undertaken in women with complete or partial ovarian failure who were undergoing oocyte donation (16). All subjects were treated with transdermal E2 patches according to a physiologic treatment regimen. Those individuals who had partial ovarian function initially had their remaining ovarian function suppressed with the GnRH agonist leuprolide acetate. Seventy-two patients completed both a mock cycle and a treatment cycle; 54 women received Crinone 8% vaginal progesterone gel (90 mg) twice daily and 18 women received 100 mg of IM progesterone-in-oil daily. All patients who received Crinone 8% had evaluable endometrial biopsy specimens during their “mock treatment” cycle and were noted to be “histologically in phase.” Twentynine (54%) of 54 patients who received Crinone 8% vaginal progesterone gel during their donor oocyte transfer cycle had a positive pregnancy test result. Seven (39%) of 18 patients who received IM progesterone-in-oil had a positive pregnancy test result. There were 17 (31%) and 4 (22%) ongoing pregnancies in the Crinone 8% and IM progesterone-in-oil groups, respectively. Although these results suggest that Crinone 8% may be an effective form of progesterone administration for women undergoing oocyte donation, the power in this study was only sufficient to ascertain a 50% difference in pregnancy rates. Moreover, the endometrial conditions after programmed hormonal replacement cycles for oocyte donation may be different from those that accompany the controlled ovarian superovulation regimens used for standard IVF-ET. The present study evaluated the clinical efficacy of Crinone 8% vaginal progesterone gel and compared its associated outcomes with those attained in our standard IVF program using IM progesterone-in-oil. Although significant limitations of a retrospective analysis exist, the patientspecific characteristics of the two groups in the present study were generally similar. The only statistically significant difference noted was an increased proportion of patients with tubal factor infertility in the IM progesterone-in-oil group. Current thinking suggests that, if anything, this may be a negative factor against the control group (17). Other factors, such as body mass index, the proportions of primary vs. secondary infertility, the types of infertility, and the proportions of patients who had undergone a previous ART cycle at FERTILITY & STERILITY威

another center or a previous IVF-ET cycle at our center were not statistically different between the two patient groups. Examination of cycle-specific characteristics revealed a statistically significant difference in the number of gonadotropin ampules administered. This difference may not represent inherent patient characteristics but rather the specific type of gonadotropins used. Because urinary FSH (Metrodin) was removed from the U.S. market in the spring of 1997, 80% of the patients who received Crinone 8%, but only 3% of the control patients, were treated with MetrodinHP. With the use of the latter gonadotropin, we routinely had increased our dosing protocols because our initial experience suggested that Metrodin-HP was less potent than Metrodin (which was used in 97% of the control cycles). This clinical suspicion was substantiated later as Metrodin-HP was shown to result in a significantly lower number of oocytes retrieved compared with a recombinant FSH product that previously had been shown to be clinically equivalent (in terms of mean total number of oocytes retrieved) to Metrodin (18, 19). The ultimate outcomes of stimulation in the treatment groups in this study were similar. The mean serum E2 levels at the time of hCG administration were 1,705 pg/mL and 1,788 pg/mL, the mean numbers of oocytes retrieved were 13.3 and 12.6, and the mean numbers of oocytes fertilized were 7.3 and 8 for the Crinone 8% and IM progesterone-inoil groups, respectively. The mean embryo quality and the mean numbers of blastomeres also were similar, as were the mean numbers of embryos transferred (3.30 in the Crinone 8% group and 3.35 in the IM progesterone-in-oil group). In addition, there did not appear to be any evidence from the literature that Metrodin-HP leads to occult poor oocyte and/or embryo quality, as the implantation rate reported by Bergh et al. (18) was 31% for Metrodin-HP (n ⫽ 89). Many aspects of our IVF laboratory, such as quality control reports and the individual performance of incubators, remained unchanged despite the decreased implantation rate and increased biochemical pregnancy rate seen with the use of Crinone 8%. The lack of quality control issues in our IVF laboratory is suggested further by our highly successful frozen ET program results during the same interval in which Crinone 8% was studied. From August 29, 1997 to February 6, 1998, a clinical pregnancy rate of 47.6% and an ongoing pregnancy rate per transfer of 38.1% were obtained in women ⬍40 years of age who underwent frozen-thawed ET cycles with programmed hormone replacement cycles and IM progesterone-in-oil (n ⫽ 42). There are two putative mechanisms by which Crinone 8% vaginal progesterone gel may have decreased embryonic implantation efficiency. First, Crinone 8% vaginal progesterone gel may have enhanced local effects on the endometrium compared with IM progesterone-in-oil. Miles et al. (20) reported that the use of intravaginal progesterone (micronized progesterone tablets, 200 mg four times per day) results in endometrial progesterone concentrations nearly 835

10-fold higher than those seen with IM progesterone-in-oil (50 mg two times per day). Therefore, a risk of premature endometrial advancement and early closure of the “window of implantation” exists with Crinone 8% vaginal progesterone gel; this is a problem of potentially greater significance in cycles that are performed after controlled ovarian hyperstimulation (21). Second, there may be a higher systemic E2-to-progesterone ratio as well as more fluctuations in the systemic E2-to-progesterone ratio after IVF-ET with luteal phase support provided by Crinone 8% vaginal progesterone gel. Although the significance of the serum E2-to-progesterone ratio is much debated, some investigators have reported decreased implantation efficiency in the setting of a higher systemic E2-to-progesterone ratio (22). In summary, the present study suggests that the use of Crinone 8% vaginal progesterone gel after IVF-ET is associated with a decreased embryonic implantation rate and a higher biochemical pregnancy rate compared with the use of IM progesterone-in-oil. If corroborated by other investigators, the potential adverse effects of Crinone 8% vaginal progesterone gel on clinical outcome may outweigh its benefit of easy administration. Our results suggest the need for a randomized, controlled trial comparing Crinone 8% vaginal progesterone gel and IM progesterone-in-oil for luteal phase support after IVF-ET.

Acknowledgments: The authors thank Timothy G. Lesnick, M.S., of the Department of Biostatistics, Mayo Clinic, Rochester, Minnesota, for assistance with the statistical analysis.

References 1. Soliman S, Daya S, Collins J, Hughes EG. The role of luteal phase support in infertility treatment: a meta-analysis of randomized trials. Fertil Steril 1994;61:1068 –76. 2. McClure N, Leya J, Radwanska E, Rawlins R, Haning RV Jr. Luteal phase support and severe ovarian hyperstimulation syndrome. Hum Reprod 1992;7:758 – 64. 3. Nahoul K, Dehennin L, Jondet M, Roger M. Profiles of plasma estrogens, progesterone, and their metabolites after oral or vaginal administration of estradiol or progesterone. Maturitas 1993;16:185–202. 4. Smitz J, Devroey P, Faguer B, Bourgain C, Camus M, Van Steirteghem AC. A prospective randomized comparison of intramuscular or intravaginal natural progesterone as a luteal phase and early pregnancy supplement. Hum Reprod 1992;7:168 –75.

836

Damario et al.

Vaginal progesterone gel and IVF outcome

5. Fanchin R, De Ziegler D, Bergeron C, Righini C, Torrisi C, Frydman R. Transvaginal administration of progesterone. Obstet Gynecol 1997; 90:396 – 401. 6. Anlar S, Capan U, Hincal AA. Physico-chemical and bioadhesive properties of polyacrylic acid polymers. Pharmazie 1993;48:285–7. 7. Casanas-Roux F, Nisolle M, Marbaix E, Smets M, Bassil S, Donnez J. Morphometric, immunohistological and three-dimensional evaluation of the endometrium of menopausal women treated by estrogen and Crinone, a new slow-release vaginal progesterone. Hum Reprod 1996; 11:357– 63. 8. Fanchin R, De Ziegler D, Bergeron C, Rorrisi C, Frydman R. Transvaginal administration of progesterone. Obstet Gynecol 1997;90:396 – 401. 9. De Ziegler D, Fanchin R, Massonneau M, Bergeron C, Frydman R, Bouchard P. Hormonal control of endometrial receptivity: the egg donation model and controlled ovarian hyperstimulation. Ann N Y Acad Sci 1994;734:209 –20. 10. Damario MA, Barmat L, Liu H-C, Davis OK, Rosenwaks Z. Dual suppression with oral contraceptives and gonadotropin-releasing hormone agonists improves in vitro fertilization outcome in high responder patients. Hum Reprod 1997;12:2359 – 65. 11. Palermo GD, Cohen J, Alikani M, Adler A, Rosenwaks Z. Intracytoplasmic sperm injection: a novel treatment for all forms of male factor infertility. Fertil Steril 1995;63:1231– 40. 12. Fishel S, Jackson P, Webster J, Faratian B. Endotoxins in culture medium for human in vitro fertilization. Fertil Steril 1988;49:108 –11. 13. Cohen J, Alikani M, Trowbridge J, Rosenwaks Z. Implantation enhancement by selective assisted hatching using zona drilling of embryos with poor prognosis. Hum Reprod 1992;7:685–91. 14. Zeger SL, Liang K-Y, Albert PS. Models for longitudinal data: a generalized estimating approach. Biometrics 1988;44:1049 – 60. 15. Pouly JC, Bassil S, Frydman R, Hedon B, Nicollet B, Prada Y, et al. Luteal support after in-vitro fertilization: Crinone 8%, a sustained release vaginal progesterone gel, versus Utrogestan, an oral micronized progesterone. Hum Reprod 1996;11:2085–9. 16. Gibbons WE, Toner JP, Hamacher P, Kolm P. Experience with a novel vaginal progesterone preparation in a donor oocyte program. Fertil Steril 1998;69:96 –101. 17. Zeyneloglu HB, Arici A, Olive DL. Adverse effects of hydrosalpinx on pregnancy rates after in vitro fertilization-embryo transfer. Fertil Steril 1998;70:492–9. 18. Bergh C, Howles CM, Borg K, Hamberger L, Josefsson B, Nilsson L, et al. Recombinant human follicle stimulating hormone (r-hFSH; Gonal-F) versus highly purified urinary FSH (Metrodin HP): results of a randomized comparative study in women undergoing assisted reproductive techniques. Hum Reprod 1997;12:2133–9. 19. Hedon D, Out HJ, Hugues JN, Camier B, Cohen J, Lopes P, et al. Efficacy and safety of recombinant follicle-stimulating hormone (Puregon) in infertile women pituitary-suppressed with triptorelin undergoing in vitro fertilization: a prospective, randomized, assessor-blind, multicentre trial. Hum Reprod 1995;10:3102– 6. 20. Miles RA, Paulson RJ, Lobo RA, Press MF, Dahmoush L, Sauer MV. Pharmacokinetics and endometrial tissue levels of progesterone after administration by intramuscular and vaginal routes: a comparative study. Fertil Steril 1994;62:485–90. 21. Kolb BA, Paulson RJ. The luteal phase of cycles utilizing controlled ovarian hyperstimulation and the possible impact of this hyperstimulation on embryo implantation. Am J Obstet Gynecol 1997;176: 1262–9. 22. Pellicer A, Valbuena D, Cano F, Remohi J, Simon C. Lower implantation rates in high responders: evidence for an altered endocrine milieu during the preimplantation period. Fertil Steril 1996;65:1190 –5.

Vol. 72, No. 5, November 1999