Effectiveness of modified downregulation for women with moderate and severe adenomyosis of the uterus prior to frozen thawed embryo transfer (MODA) study protocol: a pragmatic randomised-controlled trial

Abstract

Introduction: Adenomyosis can adversely reduce chances of pregnancy in couples undergoing assisted conception. We aim to evaluate the effect of two different downregulation protocols on the reproductive outcomes in women with moderate and severe adenomyosis undergoing frozen-thawed embryo transfer (FTET).

Methods and analysis: We will conduct a two-armed pragmatic randomised clinical trial comparing modified downregulation with gonadotrophin-releasing hormone (GnRH) analogue for 6 weeks to standard downregulation with GnRH analogue for 1 week prior to FTET. Our primary outcome is clinical pregnancy, defined as a viable intrauterine pregnancy confirmed by ultrasound at greater than 6 weeks gestation, with other secondary reproductive, neonatal and safety outcomes. We aim to randomise 162 patients over 3 years to achieve 80% power for detecting a 20% difference in the primary outcome at 5% significance.

Ethics and dissemination: To date there is no consensus on the optimal protocol for management of subfertile women with adenomyosis. Modified downregulation could improve the clinical pregnancy rate by reducing the endometrial inflammatory reaction and/or myometrial contractility and their impact on uterine receptivity in women with moderate and severe adenomyosis of the uterus undergoing FTET. The MODA trial is designed to offer pragmatic, real-life evaluation of the optimal protocol for downregulation for this population during assisted conception treatments. Our findings will be published in peer-reviewed journals and presented at national and international scientific meetings and congresses. Ethical approval was granted by the NHS Research Ethics Committees (19/LO/1567).

Trial registration number: NCT03946722.

Keywords: reproductive medicine; subfertility.

Figure 1

MODA trial study design. AFC, antral follicle count; AMH, anti-müllerian hormone; BMI, body mass index; FIGO, The International Federation of Gynecology and Obstetrics; FSH, follicle stimulating hormone; GnRH, gonadotrophin-releasing hormone; ICSI, intracytoplasmic sperm injection; IVF, in vitro fertilisation.

Figure 2

Standard and modified downregulation protocol overview. ET, embryo transfer; USS, ultrasound scan.

Figure 3

Standard and modified downregulation protocol daily schedule. ET, embryo transfer; USS, ultrasound scan.