Progestin suppression for endometriosis before IVF

Progestin is a good alternative to GnRH agonist suppression before IVF

Key Points

Highlights:

• Progestins can be recommended as a pretreatment suppressive agent to improve in vitro fertilization outcomes in women having endometriosis. 

Importance:

• Pituitary down-regulation before ovarian stimulation to promote surrogate parameters of oocyte quality, pregnancy rate, and quality of life is possible with GnRH agonists or progestins.

What’s done here?

• This is an open-label randomized controlled study conducted in laparoscopically confirmed endometriosis patients attending for in vitro fertilization (IVF).
• Participants were randomized either GnRHa (group A, n=67) or Dienogest (group B, n=67) suppression before ovarian stimulation.
• Short-acting GnRHa was started and Dienogest was stopped in the last 3 weeks of the pretreatment period in Group B patients.  
• Ovarian stimulation by human menopausal gonadotropin was modified bsed on age, ovarian reserve tests, polycystic ovary status, and previous ovarian response.
• Overall satisfaction and quality of life was assessed by FertiQoL questionnaire.
• Ovarian responsiveness regarding the number of retrieved oocytes was the primary outcome. The fertilization rate, the number of transferrable embryos, cost, pregnancy rate-clinical pregnancy rate per cycle, miscarriage rate, patient’s quality of life, and the side effects were secondary outcome measures.

Key results:

• There was no significant difference between the two groups regarding baseline characteristics, severity of endometriosis, ovarian stimulation and response parameters, and pregnancy outcomes.
• The mean combined cost of pretreatment with GnRHa and ovarian stimulation was found to be significantly higher compared with the cost of Dienogest pretreatment and ovarian stimulation.
• Patients receiving Dienogest therapy had a higher quality of life and lower side effects profile than those receiving GnRHa therapy significantly.

Limitations

• The absence of significant differences between the groups in terms of pregnancy rates could be accepted as the main limitation of this study.

Lay Summary

“Dienogest is a suitable and safe substitute for GnRHa pretreatment in endometriosis patients”, according to the Khalifa et al., from Egypt.

Endometriosis is one of the leading reasons for infertility due to decreased oocyte/embryo quality, fertilizability, tubal function, and aberrant endometrial receptivity.

In vitro fertilization (IVF) overcomes some mechanisms that lead to infertility in endometriosis patients including removal of oocytes from the toxic peritoneal environment, bypassing tubal factor, and improvement of endometrial receptivity.

There are several IVF protocols that are preferred depending on the patients’ characteristics: Long-term suppression therapy before ovarian stimulation is most frequently performed in endometriosis patients to provide synchronization and suppress endometriotic lesions.

A recent study published in the journal "BMC Pregnancy and Childbirth" entitled “Role of suppression of endometriosis with progestins before IVF-ET: a non-inferiority randomized controlled trial” aimed to compare the effectiveness of progestin and gonadotropin-releasing hormone agonists (GnRHa) pretreatment for suppression in endometriosis patients attending for IVF. The number of retrieved oocytes was evaluated as primary outcome while fertilization rate, the number of transferrable embryos, cost of the treatment, pregnancy rate and clinical pregnancy rate per cycle, miscarriage rate, patient’s quality of life during the pretreatment period, and side effects were investigated as secondary outcome measures.

Participants did not have any significant difference regarding the severity of endometriosis, ovarian stimulation and response parameters, and pregnancy outcomes. However, the mean combined cost of pretreatment with GnRHa and ovarian stimulation was found to be significantly higher compared with the cost of Dienogest pretreatment and ovarian stimulation. Additionally, patients receiving Dienogest therapy had a higher quality of life and lower side effects profile than those receiving GnRHa therapy significantly.

Research Source: https://pubmed.ncbi.nlm.nih.gov/33784989/