الفهرس 
INTRODUCTIONOnly 14 pages are availabe for public view
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Abstract
Premature luteinization (PL) remains one of the most controversial topics in reproductive endocrinology. PL is usually defined as subtle premature increases in serum Progesterone (P) concentrations on or before the day of hCG administration. Gonadotrophin-releasing hormone agonists (GnRH a) and antagonists have been used for pituitary down-regulation during controlled ovarian stimulation (COS) to prevent a premature luteinizing hormone (LH) surge. Despite the use of GnRH analogues, a subtle pre-ovulatory rise in the serum progesterone (P) concentration before the administration of hCG for final oocyte maturation still occurred in 5–30% of COS cycles, this phenomenon has been called premature luteinization (PL).Several hypotheses have been proposed to explain the possible pathophysiology of PL, such as precocious elevation of follicular LH levels, serum accumulation of hCG or LH from hMG, and increased sensitivity of granulosa cell LH receptors to gonadotrophin. It has been proposed that the term PL is inappropriate because premature serum P rise occurs when the serum LH concentration is low. Therefore, excess serum progesterone is unlikely produced by the luteinization process and is more probably due to accumulation from a large number of follicles.
As early as 1991, concerns were raised that in ovarian stimulation for IVF a preovulatory modest increase in serum P levels is associated with lower pregnancy rates and higher pregnancy loss. Two mechanisms have been proposed: either a poor oocyte quality plus a reduction in their fertilizability or a detrimental effect on endometrial receptivity
The aim of this study was to determine the incidence of premature progesterone rise in long agonist ICSI cases and to determine the detrimental cutoff value of progesterone and P:E2 ratio and to evaluate the impact of premature progesterone rise on cleavage stage and blastocyst stage embryos in cases of intra cytoplasmic sperm injection and the effect of high serum progesterone on embryos quality and blastocyst formation, and its effect on clinical pregnancy rate.
This study was carried out on 200 infertile females who were candidate for intra- cytoplasmic sperm injection (ICSI) who were good responders and have ≥ 5 grade A embryos. Women were recruited from the outpatient clinic at El Shatby Maternity University-Hospital, All cases had an age < 37 years old, antral Follicular count ≥ 8, Basal FSH < 9 IU/ml and Basal E2 < 50 pg/ml. The Used drugs were A GnRH agonist for pituitary down regulation, Gonadotrophins for follicular growth and Human chorionic gonadotrophins for follicular maturation. Cases were randomly allocated into 2 equal groups 100 female each, according to the day of embryo transfer (ET); 100 females were subjected to embryo transfer on day 3 (groupΙ),and 100 females were subjected to embryo transfer on day 5 (group ΙΙ). Serum progesterone (P) and estradiol (E2) levels were measured on day of hCG administration, follow up of cases was performed by biochemical pregnancy rate and clinical pregnancy rate.
The results of the study have showed that by using ROC curve in group Ι there was a reduction in clinical pregnancy rate in cases with premature progesterone rise with P cutoff > 1.5ng/ml and P: E2 ratio> 0.6 but there was no effect of high serum progesterone on clinical pregnancy rate in group ΙΙ and there was no detrimental cutoff point neither for P nor P: E2 ratio. The Clinical pregnancy rate in patients of day 3 ET (group Ι) with normal p level was 36(46.8%) cases and in p raised patients was 5(21.7%) cases, while the clinical pregnancy rate in patients of day 5 ET(group ΙΙ) with normal p level was 39(54.9%) cases and in patients with raised p level was 15(44.8%). The clinical pregnancy rate was statistically higher in patients of day 3 ET with normal p level than patients with raised p level with (P < 0.05) while there was no statistical significant difference at day 5 (P > 0.05).
Finally we recommended that in cases of high progesterone, estradiol and or P/E2 ratio at the end of the ovarian stimulation, targeting ET on day 5 could be a good strategy for better synchronization with an endometrium already affected by COS, rather than prematurely exposing the embryo to such environment. This actually might explain one of scenarios responsible for higher pregnancy of blastocyst in comparison to cleavage stage ET. Another option is freezing embryos to another cycle.