|Year : 2018 | Volume
| Issue : 2 | Page : 82-87
Does Intrauterine Instillation of Human Chorionic Gonadotropin Hormone (hCG) Before Embryo Transfer (ET) Improve Pregnancy Outcomes in in-vitro Fertilization (IVF) Cycles?
Anjali Tempe, Priyanka Khandey, Devender Verma, Nilanchali Singh
Department of Obstetrics and Gynaecology, Maulana Azad Medical College, New Delhi, India
|Date of Web Publication||28-Aug-2018|
Dr. Priyanka Khandey
C/o Mr. Aswini Kakkar, D-19, Second Floor, Kotla, Vikram Nagar, New Delhi 110002
Source of Support: None, Conflict of Interest: None
Objective: To study the effect of intrauterine instillation of human chorionic gonadotropin hormone (hCG) before embryo transfer (ET) on pregnancy outcomes in women undergoing in-vitro fertilization (IVF) cycles. Materials and Methods: The study was an age and anti-mullerian hormone (AMH) level-matched case–control study. Total 80 women of age group 25 to 40 years were recruited who were undergoing IVF for mild male factor, tubal factor, or ovulatory dysfunction. Two groups were formed and age matched. Study group (n = 40) received 800 IU of hCG 5 min before ET, whereas control group (n = 40) underwent direct ET without prior instillation of hCG. The pregnancy outcomes were compared between the two groups. Result: Primary outcome was implantation rate (IR). IR was significantly higher in study (hCG) group as compared to control group (30.95% vs. 15.29%, P = 0.016). Secondary outcomes were clinical pregnancy rate and live birth rate. Study group had higher pregnancy rate as compared to control group, but the difference was not statistically significant (40% vs. 25%, P = 1.0). Live birth rate was higher in study group but not significant (35.5% vs. 22.5%, P = 0.35). Abortions were comparable in both the groups. Conclusion: Intrauterine hCG before ET significantly improves IR and resulted in better IVF outcomes.
Keywords: Human chorionic gonadotropin hormone (hCG), implantation, In vitro fertilization, intrauterine hCG
|How to cite this article:|
Tempe A, Khandey P, Verma D, Singh N. Does Intrauterine Instillation of Human Chorionic Gonadotropin Hormone (hCG) Before Embryo Transfer (ET) Improve Pregnancy Outcomes in in-vitro Fertilization (IVF) Cycles?. MAMC J Med Sci 2018;4:82-7
|How to cite this URL:|
Tempe A, Khandey P, Verma D, Singh N. Does Intrauterine Instillation of Human Chorionic Gonadotropin Hormone (hCG) Before Embryo Transfer (ET) Improve Pregnancy Outcomes in in-vitro Fertilization (IVF) Cycles?. MAMC J Med Sci [serial online] 2018 [cited 2018 Nov 21];4:82-7. Available from: http://www.mamcjms.in/text.asp?2018/4/2/82/239994
Infertility is defined as failure to conceive after 12 months or more of regular intercourse without contraception. Infertility is a common problem, affecting 10% to 15% couples of reproductive age group. Consequently one in 10 patients needs assisted reproductive technique.
In-vitro fertilization (IVF) is a highly complex technique that involves the use of standardized protocols for a controlled ovarian stimulation, oocyte retrieval under ultrasound guidance, fertilization of gametes in the laboratory, embryo culturing, and embryos transfer.
Major advances have occurred in clinical and laboratory IVF techniques in recent years; however, the pregnancy rate continues to remain around 30% per cycle. Successful implantation after IVF and embryo transfer (ET) depends on various factors, such as embryo quality, ET techniques, and the endometrial receptivity. It is estimated that about 50% to 75% of all pregnancies that are lost are due to failure of implantation.
Several approaches have been used to improve implantation by facilitating endometrial receptivity such as endometrial scratching, use of granulocyte colony stimulating factor, etc. One such attempt is the use of intrauterine instillation of human chorionic gonadotropin (hCG) hormone before ET in IVF cycles. hCG is easily available and less expensive.
The beneficial effects of hCG were described by various mechanisms which improve and facilitate implantation. A study by Licht et al. showed direct effect of intrauterine hCG on human endometrium. They postulated that intrauterine hCG provoked significant inhibition of intrauterine insulin-like growth factor binding protein 1 (IGFBP-1) and macrophage colony stimulating factor which help in implantation. hCG also stimulates secretion of leukemia inhibitory factor (LIF), vascular endothelial growth factor (VEGF), and matrix-metalloproteinase 9 (MMP-9), which facilitate implantation of embryo. Many studies showed that hCG stimulates angiogenesis via VEGF and insulin like growth factor II (IGF-II). hCG also regulates immune-tolerance of trophoblast by regulating the balance of TH1/TH2 and complement factors (C3 and C4). hCG causes progesterone secretion by maintenance of corpus luteum and also increases progesterone receptor expression.
Hence, the objective of our study was to evaluate the effect of intrauterine administration of hCG before ET in IVF cycles.
| Materials and Methods|| |
Population: The study was conducted at the IVF and reproductive biology center, Maulana Azad Medical College, Lok Nayak Hospital, New Delhi, during September 2014 to February 2016 after taking ethical clearance from the institutional ethical committee. A total of 80 women were recruited, who were planned for IVF cycles after taking informed consent. Exclusion criteria were donor oocyte or donor embryo cycle and frozen-thaw cycle.
This was an age and anti-Mullerian hormone (AMH)-matched case–control study. Complete history and general physical examination of patient was performed. Patients were investigated and planned for IVF as per the institutional protocol. Age and AMH-level-based matching was performed, and the patients were allocated as cases (Group A) or controls (Group B).
ET was performed on day 3/4 or day 5 under ultrasound guidance. On the day of transfer, 800 IU of hCG was instilled 5 min before the ET in the group A patients (cases), whereas direct ET was performed without prior hCG instillation in group B patients (controls).
Patient was put in dorsal lithotomy position and parts were cleaned and draped. Cusco’s speculum was introduced and cervix was visualized. An amount of 2000 IU of purified urinary hCG (Ovidac 2000 IU; Bayer Zydus Pharma, Thane, Maharashtra, India) was dissolved in 0.5 ml of Cook’s media and 0.2 ml of the media containing 800 IU of hCG was injected by soft outer catheter into the uterine cavity beyond the internal os under transabdominal ultrasound guidance. Catheter was withdrawn and reinserted after 5-min interval, and loaded embryos were transferred by standard technique. Direct ETs were conducted as usual by the soft tip catheter without prior instillation of hCG under ultrasound guidance in group B (controls).
All the procedures were performed by the same operator, experienced in transvaginal sonography (TVS) and IVF techniques. Serum beta hCG levels were evaluated 2 weeks after ET to confirm the pregnancy. A clinical pregnancy was defined as visualization of gestational sac at the first planned transvaginal ultrasound examination performed at 4 to 6 weeks of pregnancy. It was further confirmed by the presence of fetal cardiac activity at 7 to 8 weeks of gestation on trans vaginal sonography (TVS). Clinical pregnancy rates and spontaneous abortion rates were noted and compared between the two groups.
Outcomes: Primary outcome was implantation rate (IR) observed by rising hCG level in serum at 2 weeks of ET. IR was calculated as the total number of embryos implanted divided by the total number of embryos transferred. Secondary outcomes were clinical pregnancy rate, live birth rate, and abortion rate. Clinical pregnancy rate was defined as the presence of gestational sac with fetal echoes and cardiac activity performed after 2 to 3 weeks of positive pregnancy test. The abortion rate was calculated up to 14 weeks of gestation.
Statistical evaluation: Statistical analysis was performed using student t test, Mann–Whitney U test, and analysis of variance (ANOVA) for quantitative variables and Chi-square test and Fisher’s exact test for qualitative variables. Statistical significance is defined as P < 0.05. The data were analyzed using statistical package for the social sciences (SPSS) statistical software, version 21.
A total of 80 women were included in the study from September 2014 to February 2016. The baseline parameters were comparable in both the groups as shown in [Table 1]. Age and AMH were matched.
Both the groups had a mean patient age of 28 years. AMH level was 4.73 ng/ml in study group as compared to 4.20 ng/ml in control group. Both the groups were comparable in terms of duration of infertility, level of estradiol (E2) on the day of hCG trigger, and endometrial thickness on the day of ET. Total number of oocyte retrieved, fertilized, and fertilization rate were also comparable between the groups with no statistical difference as depicted in [Table 1].
ET was performed mostly on day 3 under ultrasound guidance. Majority of the patients received two embryos during ET in both the groups.
Implantation was defined as women tested urine pregnancy test (UPT) positive after 2 weeks of ET, also called biochemical pregnancy, if pregnancy later on did not develop into clinical pregnancy.
In Group A, out of 19 UPT-positive patients, 13 women had singleton pregnancy, five patients had twin gestation, and one patient had triplet pregnancy who underwent embryo reduction. In Group B, out of 12 UPT-positive patients, only one patient had twin pregnancy and remaining 11 pregnancies were singleton.
The IR was very high in group A as compared to group B (control), and this was statistically significant with the P value of 0.016 [Table 2]. The pregnancy rate was higher in group A as compared to group B (47.5% vs. 30% P value = 0.08) [Table 3].
In the present study, abortion rate were noted as loss of pregnancy up to 14 weeks of gestation. A total of three patients out of 19 pregnancies in group A (study) had missed abortion, and one patient aborted at 11 weeks of gestation. Three patients out of 12 pregnancies in group B (control) had abortion. The abortion rates in the two groups were comparable (10% vs. 7.5%) with no significant difference. One patient had preterm delivery at 26 weeks in group A (study).
Total 14 patients were delivered in group A, and nine patients were delivered in group B (control). Live birth rate was higher in group A (study) (35%) as compared to group B (control) (22.5%), but the difference was statistically not significant (P = 0.35) [Table 3].
In group A (study), six pregnancies were multifetal gestation as compared to single twin gestation in the controls (group B). Multifetal gestations were higher in group A (study) as compared to group B (control), but the difference was not statistically significant (37.5% vs. 10%, P value of 0.184).
Total live births were higher in group A, 20 babies (eight singletons and six twins) in study group. In group B (control), total babies delivered were 10 (eight singletons and one twin).
| Discussion|| |
In the present study, the authors found that instillation of 800 IU of hCG inside uterine cavity before ET significantly improved IR and pregnancy outcomes. The hypothesis that infertile women undergoing IVF might benefit from intrauterine instillation of hCG before embryos transfer was based on the results of previous studies showing that hCG is produced by the blastocyst before and after implantation. It is the first human embryo-derived signal through which the embryo mediates the immunologic tolerance and angiogenesis at the maternal–fetal interface. Several investigators described important paracrine roles of hCG in the process of implantation. hCG stimulates the secretion of LIF, VEGF, and MMP-9, which promotes implantation. Studies showed that hCG secreted from blastocyst could induce local trophinin expression in adjacent endometrial surface epithelia. Trophinin is a mediator of cell adhesion, causes hemophilic binding at the apical surfaces of endometrium and trophectoderm, and enhances implantation. The capacity for apical cell adhesion is enhanced in presence of hCG associated with interleukin Iβ. hCG plays an important role in the proliferation of myometrial smooth muscles cells. hCG also causes reduction of cell contractility via the regulation of gap junctions between smooth muscle cells and intracellular calcium. hCG causes progesterone secretion by maintenance of corpus luteum and also increases progesterone receptors. hCG level positively correlates with the level of trophoblast tolerance. hCG is a potent attractor of inflammatory cells such as neutrophils, monocytes, and lymphocytes. hCG regulates the development of local immune tolerance through cellular system apoptosis. Another most important mechanism by which hCG enhances implantation is by stimulating and enhancing angiogenesis. hCG enhances secretion of VEGF, which initiates neoangiogenesis, essential for implantation. hCG itself acts as a weak angiogenic factor. hCG mediates increased secretion of functional IGF-II by inhibition of IGFBP-1 concentration. IGF-II is another independent angiogenic factor.Till now a number of studies have been performed to see the effect of intrauterine hCG instillation on IVF outcomes with conflicting result. Mansour et al. studied the effect of intrauterine hCG before ET. They initially used 100 and 200 IU of hCG before ET but did not find improvement in pregnancy outcome. Then they instilled 500 IU of hCG inside uterine cavity before cleavage stage ET and found significant improvement in IR. Later on many authors used the similar methodology and demonstrated improvement in IR and pregnancy outcomes in IVF cycle as shown in [Table 4].,,
Zarei et al. used recombinant hCG 250 μg (6500 IU) before cleavage stage ET and concluded that hCG significantly improved the IR and IVF outcome. No study found any adverse effect of hCG on implantation and pregnancy outcome.
Few authors in their studies did not find intrauterine hCG beneficial for the implantation and IVF outcomes.,,, Wirleitner et al. studied the effect of intrauterine hCG before blastocyst transfer. They grouped the patients on the basis of morphological grading of blastocyst stage embryo into top grade and nontop blastocyst embryos. They did not find intrauterine hCG injection beneficial for implantation in both top blastocyst and nontop blastocyst transfer. Similar result was shown by Rebolloso et al.; they did not observe any improvement in clinical outcome after administration of hCG. The study included both cleavage stage and blastocyst stage ETs. Significantly, the authors reported a statistically significantly higher twin pregnancy rate in study group who received hCG injection before ET (66% vs. 8.3% in hCG vs. control). In our study, we also found higher number of multiple gestations in study (hCG) group (37.5%) as compared to control group (10%).
Human chorionic gonadotropin hormone used for intrauterine instillation in our study is not very expensive, easy to administer, apparently no adverse effect seen, and patient tolerance is good. So, combined with higher IR and live birth rate, observed as in our study, it may be used as an adjuvant to ET to improve pregnancy outcome in future. The difference of outcomes between the two groups in this study is small and nonsignificant. However, larger sample size my reveal significant beneficial effect.
| Conclusion|| |
The study concluded that administration of intrauterine hCG before ET improves IR, which is statistically significant. Clinical pregnancy rate, live birth rate, and multiple pregnancies are more in study (hCG) group, but the difference is not statistically significant. Abortion rate and ectopic pregnancy are comparable in both groups with no statistical significance. The study concluded that likelihood of multiple gestations is high with intrauterine hCG before ET due to improved implantation of embryos. However, randomized controlled trials with larger sample size are needed to further establish its benefits.
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Conflicts of interest
There are no conflicts of interest.
| References|| |
World Health Organisation. Manual for the standardised investigation and diagnosis of infertile couple. Cambridge, UK: Cambridge University Press 2000.
Mosher WD, Pratt WF. Fecundity and infertility in United States: Incidence and trends. Fertil Steril 1991;56:192.
Kably Ambe A, López Ortiz CS, Serviere Zaragoza C, Velázquez Cornejo G, Pérez Peña E, Santos Haliscack R et al.
Mexican national consensus on assisted reproduction treatment. Ginecol Obstet Mex 2012;80:581-624.
Mouzon J, Lancaster P, Nygren KG, Sullivan E, Zegers-Hochschild F, Mansour R et al.
International committee for monitoring assisted reproductive technology. World collaborative report on assisted reproductive technology 2002. Hum Reprod 2009;24:2310-20.
Koot YE, Teklenburg G, Salker MS, Brosens JJ, Macklon NS. Molecular aspects of implantation failure. Biochim Biophys Acta 2012;1822:1943-50.
Norwitz ER, Schust DJ, Fisher SJ. Implantation and the survival of early pregnancy. N Engl J Med 2001;345:1400-8.
Licht P, Losch A, Dittrich R, Neuwinger J, Siebzehnrubl E, Wildt L. Novel insights into human endometrial paracrinology and embryo-maternal communication by intrauterine microdialysis. Hum Reprod Update 1998;4:532-8.
Schumacher A, Brachwitz N, Sohr S, Engeland K, Langwisch S, Dolaptchieva M et al.
Human chorionic gonadotropin attracts regulatory T cells into the fetal-maternal interface during early human pregnancy. J Immunol 2009;182:5488-97.
Cole LA. HCG and hyperglycosylated hCG in the establishment and evolution of hemochorial placentation. J Reprod Immunol 2009;82:112-8.
Sugihara K, Kabir-Salmani M, Byrne J, Wolf DP, Lessey B, Iwashita M et al.
Induction of trophinin in human endometrial surface epithelia by CGbeta and IL-1beta. FEBS Lett 2008;582:197-202.
Berndt S, Blacher S, Munaut C, Detilleux J, Perrier d’Hauterive S, Huhtaniemi I et al.
Hyperglycosylated human chorionic gonadotropin stimulates angiogenesis through TGF-β receptor activation. FASEB J 2013;27:1309-21.
Mansour R, Tawab N, Kamal O, El-Faissal Y, Serour A, Aboulghar M et al.
Intrauterine injection of human chorionic gonadotropin before embryo transfer significantly improves the implantation and pregnancy rates in in vitro fertilization/ intracytoplasmic sperm injection: a A prospective randomized study. Fertil Steril 2011;96:1370-74.
Zarei A, Parsanezhad ME, Younesi M, Alborzi S, Zolghadri J, Samsami A et al.
Intrauterine administration of recombinant human chorionic gonadotropin before embryo transfer on outcome of in vitro fertilization/intracytoplasmic sperm injection: A randomized clinical trial. Iran J Reprod Med 2014;12:1-6.
Santibañez A, García J, Pashkova O, Colín O, Castellanos G, Sánchez AP et al.
Effect of intrauterine injection of human chorionic gonadotropin before embryo transfer on clinical pregnancy rates from in vitro fertilisation cycles: A prospective study. Reprod Biol Endocrinol 2014;12:9.
Aaleyasin A, Aghahosseini M, Rashidi M, Safdarian L, Sarvi F, Najmi Z et al.
In vitro fertilization outcome following embryo transfer with or without preinstillation of human chorionic gonadotropin into the uterine cavity: A randomized controlled trial. Gynecol Obstet Invest 2015;79:201-5.
Hong KH, Forman EJ, Werner MD, Upham KM, Gumeny CL, Winslow AD et al.
Endometrial infusion of human chorionic gonadotropin at the time of blastocyst embryo transfer does not impact clinical outcomes: A randomized double-blind, placebo-controlled trial. Fertil Steril 2014;102:1591-5.
Wirleitner B, Schuff M, Vanderzwalmen P, Stecher A, Okhowat J, Hradecky L et al.
Intrauterine administration of human chorionic gonadotropin does not improve pregnancy and live birth rates independently of blastocyst quality: A randomised prospective study. Reprod Biol Endocrinol 2015;13:70.
Rebolloso MM, Rosales De Leon JC, Galache Vega P, Santos-Haliscak R, Diaz-Spindola P, Gonzalez Vega O. Do intrauterine injection of human chorionic gonadotropin (hCG) before embryo transfer increases implantation and pregnancy rates in patients undergoing in vitro fertilization? Fertil Steril 2013;100(Suppl):S289.
Riboldi M, Barros B, Piccolomini M, Alegretti JR, Motta ELA, Serafini PC. Does the intrauterine administration of rhCG before vitrified blastocysts transfer improves the potential of pregnancies when using blastocysts of inferior morphological grading? Fertil Steril 2013;100(Suppl):S289.
[Table 1], [Table 2], [Table 3], [Table 4]