FERTILITY AND STERILITY VOL. 76, NO.

2, AUGUST 2001
Copyright 2001 American Society for Reproductive Medicine Published by Elsevier Science Inc. Printed on acid-free paper in U.S.A.

A prospective randomized study comparing intramuscular progesterone and 17hydroxyprogesterone caproate in patients undergoing in vitro fertilization embryo transfer cycles
Loredana Costabile, M.D.,a Sandro Gerli, M.D.,b Claudio Manna, M.D.,a Dario Rossetti, M.D.,b Gian Carlo Di Renzo, M.D.,b and Vittorio Unfer, M.D.a
GENESIS Center for Reproductive Medicine and Infertility Therapy, Rome, and University of Perugia, Perugia, Italy

Objective: To compare the effectiveness of i.m. P and 17-hydroxyprogesterone caproate (17-HPC) for luteal phase support, in patients undergoing IVF-ET cycles. Design: Prospective, randomized study. Setting: Patients undergoing IVF-ET in our Centers. Patient(s): The inclusion criteria were the use of GnRH down-regulation and aged 40 years. Intervention(s): A total of 300 cycles were randomly treated with either 17-HPC (341 mg every 3 days) or P (50 mg daily). Main Outcome Measure(s): The outcomes of IVF in both study groups were evaluated for biochemical pregnancy, miscarriage, clinical pregnancy, and ongoing pregnancy. Result(s): No difference was found in the main outcome parameters considered. Conclusion(s): Although the results of the study encourage the use of 17-HPC for luteal phase support in patients undergoing IVF-ET program, more studies are necessary to support the hypothesis that it can replace i.m. P-in-oil. (Fertil Steril 2001;76:394 6. 2001 by American Society for Reproductive Medicine.) Key Words: 17-HPC, progesterone, IVF-ET cycles

Establishment of a successful pregnancy requires a complex preparation of the endometrium, starting with the proliferative phase and throughout the luteal phase.
Received November 14, 2000; revised and accepted February 2, 2001. Reprint requests: Loredana Costabile, M.D., Via C. Massini, 43/D, 00155 Rome, Italy (FAX: 39/06/ 3241284; E-mail: cdigerl@ box2.tin.it). a GENESIS Center for Reproductive Medicine and Infertility Therapy. b Department of Obstetrics and Gynecology, University of Perugia.
0015-0282/01/$20.00 PII S0015-0282(01)01901-X

preparation has not aroused great enthusiasm in most patients and it is often associated with painful injection and rash. Unfortunately, there are few practical alternatives to i.m. P-in-oil: indeed, although P can be also administered orally or vaginally, the former route is associated with a signicantly lower implantation rate per embryo transferred (1) and the latter does not give encouraging results when used in IVF programs (2). 17-Hydroxyprogesterone caproate (17-HPC) is a P derivative. Esterication of 17 OH P with caproic acid gives a much greater and prolonged progestational activity after i.m. injection. As soon as 17-HCP became available in 1954, its effectiveness in controlling pregnancy complications was suggested by four characteristics of this steroid ester: 1) the high

Endometrial development in the follicular phase of IVF cycles is driven by E2 (secreted by the ovaries) and is clinically followed up by the thickness and echogenicity of the endometrium, which are markers of its receptivity. Luteal phase support is routinely used in IVF-ET cycles. This approach is based on the observation that P supplementation increases pregnancy rates in IVF cycles using a downregulation protocol. Particularly in these cycles, P supplementation is given as i.m. injection of natural P-inoil. This route of administration of an oily

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potency of the compound; 2) the prolonged action; 3) the marked solubility in oil that allows high dosage; and 4) the minimal local irritation after injection. In 1963 it was used to decrease repeated abortion rate (3). In 1975 Johnson et al. (4) made the rst double-blind study on prevention of premature labor with 17-HPC. Possible teratogenic effects of 17-HPC have been investigated and ruled out (5). The purpose of this prospective, randomized study was to compare the outcome of IVF-ET cycles during which either i.m. P or 17-HPC were used.

ET cycles) had i.m. administration of 341 mg of 17-HPC every 3 days. Group B (n 157 ET cycles) had i.m. administration of 50 mg daily of P-in-oil. Treatment was continued until either a serum pregnancy test result was negative or embryonic heart beat was conrmed sonographically. Concentrations of hCG, P, and 17-E2 were measured by commercially available methods (RSL-E2 and RSL-P4 radioimmunoassays, ICN Biomedical; Tandem hCG, Hybritech, Costa Mesa, CA). Interassay and intra-assay coefcients of variation never exceeded 5% and 8%, respectively.

Determination of Pregnancy States

A biochemical pregnancy was dened as a small and transitory increase in -hCG levels. Miscarriage was classied as clinical loss of an intrauterine pregnancy between the seventh and twelfth weeks of gestation. A clinical pregnancy was dened by the visualization of an embryo with cardiac activity at 6 7 weeks of pregnancy. Ongoing pregnancies were considered those reaching 20 weeks of gestation.

MATERIALS AND METHODS Patients

All patients treated in our IVF units between September 1997 and September 1999 were asked to participate in the study. The inclusion criteria were the use of GnRH analog down-regulation and age 40 years. Patients were assigned to receive either i.m. P or 17-HPC supplementation according to a randomization table. The institutional review board approved the protocol, and all patients gave informed consent before entering the study. Patients were prescribed either P-in-oil (50 mg i.m. daily) or 17-HPC (341 mg twice a week) starting in the evening of oocyte retrieval.

Statistical Analysis
Statistical analysis of the results was carried out using Students t test and 2 analyses. Results with P.05 were considered signicant.

RESULTS
During the study period, 220 patients conforming to the inclusion criteria were prospectively randomized. Group A (17-HPC) consisted of 143 cycles and group B (P) consisted of 157 cycles. As a conrmation of appropriate randomization no difference was found between groups in mean age, cause and duration of infertility, or presence of primary/ secondary infertility. Progesterone and 17-E2 levels were measured throughout the luteal phase. The E2 levels were similar in both groups, whereas the serum P concentrations were signicantly higher (P.0015) in group B (84.8 7.8 ng/mL) than in the group A (10.7 3.4 ng/mL). The discrepancy between the two groups in the P levels is related to the fact that 17-HPC is not detected by the P assay. No difference was found in the mean number of oocytes retrieved, the mean number of oocytes fertilized, or the mean number and quality of embryos transferred (data not shown). The outcome of IVF in both study groups was evaluated for biochemical, clinical, and ongoing pregnancy rates (Table 1); no statistical signicant difference was found for this parameters in the two groups.

Controlled Ovarian Hyperstimulation

All patients underwent pituitary desensitization by the s.c. administration of 400 g of GnRH-a s.c. b.i.d. starting on day 20 of the previous menstrual cycle until the i.m. injection of 10,000 IU of hCG. Then, controlled ovarian hyperstimulation was performed in all patients by administration of urinary FSH. Patients were monitored by measuring plasma concentration of 17-E2 and size of follicles on 5, 7, and 12 stimulation days. The amount of gonadotropins given was adjusted according to the individual response. Human chorionic gonadotropin (10,000 IU) was injected i.m. in all patients when serum 17-E2 exceeded 200 pg/follicle and at least three follicles with a minimum diameter of 18 mm were recognized.

In Vitro Procedure
Oocytes were retrieved 34 36 hours after hCG administration by transvaginal echoguided aspiration. The IVF medium (Medi-Cult A/S, Innogenetics, Jyllinge, Denmark) was used as culture medium. Spermatozoa were prepared using the swim-up technique. All patients underwent conventional IVF technique with gametes and embryos cultured under oil. The ET was performed at the two- to four-cell stage, 40 44 hours after insemination. No more than three embryos were transferred.

DISCUSSION
The high incidence of luteal defects in patients undergoing a down-regulation protocol for IVF program is possibly related to the heterogeneous population of follicles at the time of ovulation induction. Under these conditions the P 395

Luteal Phase
Starting in the evening of oocytes retrieval, all patients were randomly allocated in two groups. Group A (n 143
FERTILITY & STERILITY

TABLE 1 Pregnancy outcome of patients who received 17-HPC and P-in-oil.

17-HPC Group A (n 143) 14 (9.7) 5 (3.5) 64 (44.7) 60 (42) Progesterone-in-oil Group B (n 157) 16 (10.2) 7 (4.4) 68 (43.3) 63 (40.1)

Variable Biochemical pregnancy (%) Miscarriage (%) Clinical pregnancies (%) Ongoing pregnancy (%)

who received i.m. P-in-oil. The 17-HPC was not detected by the assay of natural P, but it could be revealed by high pressure liquid chromatography, which was not used in this clinical study. The determination of radioactivity in the blood plasma after the administration of 17-HPC labeled with carbon-14 demonstrated its slow increase in plasma until the fth day, which was caused by a retarded absorption from the injection site; urinary and fecal metabolites of 17-HPC differ considerably from those observed in P 17hydroxyprogesterone, but they are not metabolized in pregnandiol. The fact that 17-HPC is not detected by the P assays helped us monitor corpus luteum function in the treated group and this can be considered an advantage. In the present study we found no statistically signicant difference in positive -hCG and ongoing pregnancy rates in women who received luteal phase support with 17-HPC or i.m. P-in-oil. We should also consider the benets associated with patient compliance. Indeed, an effective drug supplementation is important not only during the actual cycle of IVF-ET. Acceptance or repeated cycles in case of failure depends on previous complaints, experiences such as discomfort of i.m. P injections, which lasted sometimes for a long time after the administration was discontinued. Although the results of the study encourage the use of 17-HPC during the luteal phase in patients undergoing IVF-ET program, more studies are necessary to support the hypothesis that it might replace i.m. P-in-oil. References
1. Licciardi FL, Kwiatkowski A, Noyes NL, Berkeley AS, Krey LL, Grifo JA. Oral versus intramuscular progesterone for in vitro fertilization: a prospective randomized study. Fertil Steril 1999;71:614 8. 2. Damario MA, Goudas VT, Session DR, Hammitt DG, Dumesic DA. Crinone 8%* vaginal progesterone gel results in lower embryonic implantation efciency after in vitro fertilization embryo transfer. Fertil Steril 1999;72:830 6. 3. Shearman R, Garret W. Double-blind study of effect of 17-hydroxyprogesterone caproate on abortion rate. Br Med J 1963;2:2925. 4. Johnson J, Austin K, Jones G, Davis G, King TM. Efcacy of 17alphahydroxyprogesterone caproate in the prevention of premature labor. N Engl J Med 1975;293:675 80. 5. Hendrickx A, Korte R, Leushener B, Neumann BW, Poggel A, Blinkerd P, et al. Embryotoxicity of sex steroidal hormones in nonhuman primates: II. Hydroxyprogesterone caproate, estradiol valerate. Teratology 1987;35: 129 36.

Costabile. IM P vs. 17-HPC in IVF-ET patients. Fertil Steril 2001.

synthesized by the smaller follicles is probably much less than that synthesized by follicles 18 mm in diameter. Smaller follicles that had not yet reached full maturity at the time of the hCG injection may become luteinized at an immature stage with the possible consequence of an early and unavoidable demise of the corpora lutea thus induced. That might lead to a relative decline in P levels and the progesterone/E2 ratio at some time between implantation and the luteoplacental shift, and cause premature resumption of uterine activity and result in loss of the pregnancy. According to the above-mentioned hypothesis, P supplementation of the luteal phase is prescribed routinely for women undergoing IVF. The most common form of P supplementation in Italy is daily i.m. P-in-oil administration. This may lead to severe inammatory reactions, sterile abscesses, and signicant patient discomfort. Unfortunately, there are few practical alternatives to i.m. P-in-oil. When progesterone is given orally a reduced implantation rate per embryo (1) is observed. The vaginal route has also resulted in lower embryonic implantation rates (2). The 17-HPC is a slowly released, long-acting progestative and represents a valid alternative to reduce patient discomfort. In the present trial, we found that midluteal P levels obtained 6 7 days after oocyte retrieval were markedly lower in patients who received 17-HPC than in patients

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Costabile et al.

IM P vs. 17-HPC in IVF-ET patients

Vol. 76, No. 2, August 2001