Progesterone levels on the human chorionic gonadotropin trigger day affect the pregnancy rates for embryos transferred at different stages of development in both general and selected IVF/ICSI populations

Abstract

Background: Two meta-analyses have shown that pregnancy and birth rates are significantly higher after blastocyst transfer than after cleaved embryo transfer. Other studies have revealed that a serum progesterone level > 1.5 ng/ml on the trigger day is responsible for premature luteinization and is associated with a low pregnancy rate. The objectives of this retrospective study were to determine whether blastocyst transfer gave higher pregnancy rates than cleaved embryo transfer at day 3 in both the general and selected IVF/ICSI populations, and whether the serum progesterone level influenced the pregnancy rate.

Method: We studied IVF/ICSI cycles with GnRH antagonist - FSH/hMG protocols in a general population (n = 1210) and a selected "top cycle" population (n = 677), after blastocyst transfer on day 5 or cleaved embryo transfer on day 3. The selected couples had to meet the following criteria: female age < 35, first or second cycle, and one or two embryos transferred. We recorded predictive factors for pregnancy and calculated the progesterone to oocyte index (POI), the progesterone:estradiol ratio (P:E2 ratio), and the progesterone to follicle (> 14 mm) index (PFI).

Results: In the general population, the clinical pregnancy rate was significantly higher after blastocyst transfer (33.3%) than after cleaved embryo transfer (25.3%; p < 0.01); the same was true for the birth rate (32.1 and 22.8%, respectively, p < 0.01). The differences between blastocyst and embryo transfer groups were not significant in the selected population (respectively 35.7% vs. 35.8% for the clinical pregnancy rate, and 33.9 and 34.9% for the birth rate). The serum progesterone levels on the eve of the trigger day and on the day itself were significantly lower in the pregnant women (p < 0.01). We found a serum progesterone threshold of 0.9 ng/ml, as also reported by other researchers. The POI and the PFI appear to have predictive value for cleaved embryos transfers.

Conclusions: Blastocyst transfers were associated with higher clinical pregnancy and birth rates than cleaved embryo transfers in a general population but not in a selected population. The serum progesterone levels on the eve of the trigger day and on the day itself predicted the likelihood of pregnancy.

Keywords: Blastocyst; Cleaved embryo; IVF/ICSI; Pregnancy; Progesterone.

Fig. 1

Study flow chart for the general population (above the dotted line) and the selected population (below the dotted line). E: embryo; t: transfer; culture failures: includes fertilization and embryo culture failures, and poor embryo quality. Statistical analysis: Difference between blastocyst and cleaved embryo transfers: ^a-b: p < 0.001; ^c-d: p < 0.01; ^e-f: p < 0.05

Fig. 2

Clinical pregnancy rates above and below the progesterone threshold (≤ 0.9 and > 0.9 ng/ml), after blastocyst or cleaved embryo transfers in general (all cycles) and selected (top cycles) populations. CPR: clinical pregnancy rate. Statistical analysis: ^a-b: p < 0.02; ^c-d: p < 0.05

Fig. 3

Clinical pregnancy rates as a function of the progesterone range (ng/ml) after blastocyst transfers (a) and cleaved embryo transfers (b), in general (all cycles) and selected (top cycles) populations. CPR: clinical pregnancy rate