Abstract


OBJECTIVE: To determine if a protocol of measuring serum estradiol and progesterone, and modifying the dose the day prior to frozen embryo transfer (FET), improves the likelihood of clinical intrauterine gestation (CIG).
DESIGN: Retrospective cohort study at an academic institution of all autologous blastocyst FETs from January 2013-February 2017 in women who underwent endometrial preparation with estradiol and progesterone supplementation for a programmed FET. view more

OBJECTIVE: To determine if a protocol of measuring serum estradiol and progesterone, and modifying the dose the day prior to frozen embryo transfer (FET), improves the likelihood of clinical intrauterine gestation (CIG).
DESIGN: Retrospective cohort study at an academic institution of all autologous blastocyst FETs from January 2013-February 2017 in women who underwent endometrial preparation with estradiol and progesterone supplementation for a programmed FET.
MATERIALS AND METHODS: Medical records of all programmed FETs were reviewed. A protocol of checking serum estradiol and progesterone one day prior to FET was instituted at Penn Fertility Care in June 2015. There were no other changes in the performance of FET at this center during the study period. Progesterone dosage was increased from 50mg/mL to 75mg/mL if serum progesterone was below 15ng/mL, and estradiol dosage was increased by 2mg oral estradiol and/or the addition of vaginal estradiol if serum estradiol was below 150pg/mL. Multivariable logistic regression was used to compare the likelihood of CIG after institution of the flexible dose protocol based on pre-FET blood serum levels compared to the likelihood before implementation of the protocol. Adjustment for potential confounders included age, BMI, diagnosis, number of embryos transferred and preimplantation genetic testing.
RESULTS: A total of 389 FET cycles were performed before institution of pre-FET serum evaluation with potential modification of dose and 528 were performed after. During the time period when the flexible dose protocol was implemented, progesterone dosage was increased in 135 cycles (25.6%) and estradiol dosage was increased in 56 (10.6%). Those whose dose was modified were less likely to achieve a CIG compared to those whose dose did not need modification (54.3% vs. 65.1%) (OR 0.64 95%CI [0.44, 0.92]; aOR 0.62; 95%CI[0.42, 0.91]). In addition, compared to normal weight individuals, obese individuals had lower progesterone hormone levels, thus requiring dose adjustment (OR 3.6 95%CI [2.0, 6.3]). However, overall those managed with pre-FET serum evaluation were significantly more likely to achieve CIG compared to those managed before the protocol was implemented (61.5% vs. 50.4%) (OR 1.6 95%CI[1.21, 2.05]; aOR 1.8; 95%CI [1.3, 2.3]).
CONCLUSIONS: Overall, cycles in which pre-FET labs were measured and used to adjust hormone supplementation were more likely to result in CIG, despite a lower pregnancy rate in those who needed hormonal adjustment. This suggests that patients requiring adjustment may represent a poor prognosis group, such as obese individuals, and when identified may have benefited from improved hormonal preparation prior to FET.

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