Department of Reproductive Medicine and Gynecological Endocrinology, University Hospital of Schleswig-Holstein, Campus Luebeck, Luebeck, Germany.
Institut für Medizinische Biometrie und Statistik, Universität zu Lübeck, Universitätsklinikum Schleswig-Holstein, Campus Lübeck, Lübeck, Germany.
Hum Reprod. 2022 May 30;37(6):1183-1193. doi: 10.1093/humrep/deac045.
What are the plasma concentrations of dydrogesterone (DYD) and its metabolite, 20α-dihydrodydrogesterone (DHD), measured on day of embryo transfer (ET) in programmed anovulatory frozen embryo transfer (FET) cycles using 10 mg per os ter-in-die (tid) oral DYD, and what is the association of DYD and DHD levels with ongoing pregnancy rate?
DYD and DHD plasma levels reach steady state by Day 3 of intake, are strongly correlated and vary considerably between and within individual subjects, women in the lowest quarter of DYD or DHD levels on day of FET have a reduced chance of an ongoing pregnancy.
DYD is an oral, systemic alternative to vaginal progesterone for luteal phase support. The DYD and DHD level necessary to sustain implantation, when no endogenous progesterone is present, remains unknown. While DYD is widely used in fresh IVF cycles, circulating concentrations of DYD and DHD and inter- and intraindividual variation of plasma levels versus successful treatment have never been explored as measurement of DYD and DHD is currently only feasible by high-sensitivity chromatographic techniques such as liquid chromatography/tandem mass spectroscopy (LC-MS/MS).
STUDY DESIGN, SIZE, DURATION: Prospective, clinical cohort study (May 2018-November 2020) (NCT03507673); university IVF-center; women (n = 217) undergoing a programmed FET cycle with 2 mg oral estradiol (tid) and, for luteal support, 10 mg oral DYD (tid); main inclusion criteria: absence of ovulatory follicle and low serum progesterone on Days 12-15 of estradiol intake; serum and plasma samples were taken on day of FET and stored at -80°C for later analysis by LC-MS/MS; in 56 patients, two or more FET cycles in the same protocol were performed.
PARTICIPANTS/MATERIALS, SETTING, METHODS: Women undergoing FET on Day 2 or Day 3 (D2, D3, cleavage) or Day 5 (D5, blastocyst) of embryonic development had blood sampling on the 3rd, 4th or 6th day of 10 mg (tid) DYD oral intake, respectively. The patient population was stratified by DYD and DHD plasma levels by percentiles (≤25th versus >25th) separately by day of ET. Ongoing pregnancy rates (a viable pregnancy at >10th gestational week) were compared between ≤25th percentile versus >25th percentile for DYD and DHD levels (adjusted for day of ET). Known predictors of outcome were screened for their effects in addition to DYD, while DYD was considered as log-concentration or dichotomized at the lower quartile. Repeated cycles were analyzed assuming some correlation between them for a given individual, namely by generalized estimating equations for prediction and generalized mixed models for an estimate of the variance component.
After exclusion of patients with 'escape ovulation' (n = 14, 6%), detected by the presence of progesterone in serum on day of ET, and patients with no results from LC-MS/MS analysis (n = 5), n = 41 observations for cleavage stage ETs and n = 157 for blastocyst transfers were analyzed. Median (quartiles) of plasma levels of DYD and DHD were 1.36 ng/ml (0.738 to 2.17 ng/ml) and 34.0 ng/ml (19.85 to 51.65 ng/ml) on Day 2 or 3 and 1.04 ng/ml (0.707 to 1.62 ng/ml) and 30.0 ng/ml (20.8 to 43.3 ng/ml) on Day 5, respectively, suggesting that steady-state is reached already on Day 3 of intake. DHD plasma levels very weakly associated with body weight and BMI (R2 < 0.05), DYD levels with body weight, but not BMI. Levels of DYD and DHD were strongly correlated (correlation coefficients 0.936 for D2/3 and 0.892 for D5, respectively). The 25th percentile of DYD and DHD levels were 0.71 ng/ml and 20.675 ng/ml on day of ET. The ongoing pregnancy rate was significantly reduced in patients in the lower quarter of DYD or DHD levels: ≤25th percentile DYD or DHD 3/49 (6%) and 4/49 (8%) versus >25th percentile DYD or DHD 42/149 (28%) and 41/149 (27%) (unadjusted difference -22% (CI: -31% to -10%) and -19% (CI: -29% to -7%), adjusted difference -22%, 95% CI: -32 to -12, P < 0.0001).
LIMITATIONS, REASONS FOR CAUTION: Some inter- and intraindividual variations in DYD levels could be attributed to differences in time between last 10 mg DYD intake and blood sampling, as well as concomitant food intake, neither of which were registered in this study. Ninety percent of subjects were European-Caucasian and DYD/DHD blood concentrations should be replicated in other and larger populations.
Daily 10 mg DYD (tid) in an artificial FET cycle is potentially a suboptimal dose for a proportion of the population. Measurement of DYD or DHD levels could be used interchangeably for future studies. The pharmacokinetics of oral DYD and associated reproductive pharmacodynamics need further study.
STUDY FUNDING/COMPETING INTEREST(S): The trial was financed by university funds, except for the cost for plasma and serum sample handling, storage and shipment, as well as the liquid chromatography-mass spectrometry (LC-MS/MS) analysis of DYD, DHD and progesterone, which was financially supported by Abbott Products Operations AG (Allschwil, Switzerland). Abbott Products Operations AG had no influence on the study protocol, study conduct, data analysis or data interpretation. K.N. has received honoraria and/or non-financial support (e.g. travel cost compensation) from Ferring, Gedeon-Richter, Merck and MSD. A.M. has no competing interests. R.V. has no competing interests. M.D. has received honoraria and/or non-financial support from Ferring and Merck. A.S.-M. has no competing interests. T.K.E. has received honoraria and/or non-financial support from Roche, Novartis, Pfizer, Aristo Pharma, Merck. G.G. has received honoraria and/or non-financial support (e.g. travel cost compensation) from Abbott, Ferring, Gedeon Richter, Guerbet, Merck, Organon, MSD, ObsEva, PregLem, ReprodWissen GmbH, Vifor and Cooper.
ClinicalTrials.gov NCT03507673.
在使用 10 毫克口服每日三次（tid）地屈孕酮（DYD）的程序化无排卵冻融胚胎移植（FET）周期中，在胚胎移植日（ET）当天测量的 DYD 和其代谢物 20α-二氢地屈孕酮（DHD）的血浆浓度是多少，以及 DYD 和 DHD 水平与持续妊娠率有何关联？
DYD 和 DHD 血浆水平在摄入第 3 天达到稳定状态，两者之间以及个体内之间具有很强的相关性，DYD 或 DHD 水平在 FET 日处于最低四分位数的女性持续妊娠的机会降低。
DYD 是一种替代阴道孕酮的口服、全身制剂，用于黄体期支持。在没有内源性孕酮的情况下，维持着床所需的 DYD 和 DHD 水平仍然未知。虽然 DYD 广泛应用于新鲜 IVF 周期，但 DYD 和 DHD 的循环浓度以及与成功治疗相关的个体内和个体间变化从未被探索过，因为目前仅通过液相色谱/串联质谱（LC-MS/MS）等高灵敏度色谱技术才能测量 DYD 和 DHD。
研究设计、大小、持续时间：前瞻性、临床队列研究（2018 年 5 月至 2020 年 11 月）（NCT03507673）；大学 IVF 中心；接受程序化 FET 周期的女性（n=217），使用 2 毫克口服雌二醇（tid）和 10 毫克口服 DYD（tid）进行黄体支持；主要纳入标准：在雌二醇摄入的第 12-15 天没有排卵卵泡和低血清孕酮；在 FET 当天采集血清和血浆样本，并在-80°C 下储存，以便以后通过 LC-MS/MS 进行分析；在 56 名患者中，同一方案中进行了两次或更多次 FET 周期。
参与者/材料、设置、方法：在胚胎发育的第 2 天或第 3 天（D2、D3、卵裂）或第 5 天（D5、囊胚）进行 FET 的女性在分别在口服 10 毫克（tid）DYD 摄入的第 3、4 或 6 天进行血液采样。根据 DYD 和 DHD 血浆水平的百分位数（<25 与>25）分别按 ET 日对患者人群进行分层。持续妊娠率（>10 孕周的存活妊娠）在 DYD 和 DHD 水平的<25 与>25 百分位之间进行比较（调整 ET 日）。除 DYD 外，还筛选了已知的结局预测因素及其对治疗的影响，而 DYD 则被视为对数浓度或在下四分位数处二分。对于给定个体，假设重复周期之间存在某种相关性，即通过广义估计方程进行预测，并通过广义混合模型进行方差分量的估计。
排除了因血清孕激素存在而出现“逃逸排卵”（n=14，6%）的患者和未进行 LC-MS/MS 分析的患者（n=5）后，分析了 41 例卵裂期 ET 观察和 157 例囊胚转移的患者。DYD 和 DHD 的血浆水平中位数（四分位数）分别为 1.36ng/ml（0.738 至 2.17ng/ml）和 34.0ng/ml（19.85 至 51.65ng/ml）在第 2 或 3 天和 1.04ng/ml（0.707 至 1.62ng/ml）和 30.0ng/ml（20.8 至 43.3ng/ml）在第 5 天，提示在摄入第 3 天已经达到稳定状态。DHD 血浆水平与体重和 BMI 非常弱相关（R2<0.05），DYD 水平与体重相关，但与 BMI 无关。DYD 和 DHD 水平之间存在很强的相关性（D2/3 的相关系数为 0.936，D5 的相关系数为 0.892）。ET 日 DYD 和 DHD 的 25 百分位数分别为 0.71ng/ml 和 20.675ng/ml。DYD 或 DHD 水平较低的患者持续妊娠率显著降低：DYD 或 DHD 的<25 百分位数为 3/49（6%）和 4/49（8%），而 DYD 或 DHD 的>25 百分位数为 42/149（28%）和 41/149（27%）（未调整差异-22%（CI：-31% 至-10%）和-19%（CI：-29% 至-7%），调整差异-22%，95%CI：-32 至-12，P<0.0001）。
局限性、谨慎的原因：DYD 水平的个体内和个体间差异可能归因于最后 10mg DYD 摄入与血液采样之间的时间差异以及同时摄入的食物，这些都没有在本研究中记录。90%的受试者为欧洲白种人，DYD/DHD 血药浓度应在其他更大的人群中得到复制。
在人工 FET 周期中，每天 10 毫克 DYD（tid）可能对一部分人群来说剂量不足。DYD 或 DHD 水平的测量可在未来的研究中互换使用。口服 DYD 的药代动力学及其相关生殖药效学需要进一步研究。
研究资金/利益冲突：该试验由大学资金资助，除了血浆和血清样本处理、储存和运输的费用以及 DYD、DHD 和孕酮的液相色谱-质谱（LC-MS/MS）分析的费用外，雅培产品运营公司（Allschwil，瑞士）也提供了部分资金支持。雅培产品运营公司对研究方案、研究实施、数据分析或数据解释没有影响。K.N. 收到了 Ferring、Gedeon-Richter、Merck 和 MSD 的酬金和/或非财务支持（例如旅行费用补偿）。A.M. 没有竞争利益。R.V. 没有竞争利益。M.D. 收到了 Ferring 和 Merck 的酬金和/或非财务支持。A.S.-M. 没有竞争利益。T.K.E. 收到了 Roche、Novartis、Pfizer、Aristo Pharma、Merck、Organon、MSD、ObsEva、PregLem、ReprodWissen GmbH、Vifor 和 Cooper 的酬金和/或非财务支持。
ClinicalTrials.gov NCT03507673。
