Luteal Phase Support In Art - Dr. Abayomi Ajayi www.abayomiajayi.com.ng

1. LUTEAL PHASE
SUPPORT IN ART
By
DR. ABAYOMI AJAYI

2. OUTLINE
What is Luteal Phase
Why is LPS required
What are the options
When to start and when to stop
Estradiol
New challenges: GnRH - a triggering
Conclusion

3. LUTEAL PHASE
The 2nd half of the menstrual cycle after ovulation.
The corpus luteum is the principal actor secreting progesterone which prepares
the endometrium for implantation usually lasts for 14 days but 10-16 days is
considered normal.
Both fertilization and implantation may occur.

4. What is ART: Fertility treatment in which gametes and embryos
are handled. (not IUI)
1st baby through natural cycle (Luteal phase defect)
Georgeana and Howard Jones 1,2 pointed to the advantage of
COH – Elizabeth Carr (1981)
GnRH derivatives (agonist and antagonist) 1,3 were introduced
in the course of time to prevent spontaneous ovulation,
reducing cycle cancellation and improved pregnancy rates.

5. WHY IS LPS REQUIRED
Luteal phase in all stimulated IVF cycles are abnormal 4,5,6
Supraphysiological steroid levels
Effect of COH on endometrium
Down regulation - Agonist: pituitary suppression
- Antagonist: luteolysis
Triggering ovulation with HCG instead of LH

9. Main reason is the inhibition of LH secretion (LH pulse
frequency and amplitude) due to supraphysiological
steroid levels and distruption of the feedback
mechanisms of the Hypothalamo-pituitary-ovarian
axis.4,5,7,10

10. TYPES OF SUPPORT
Progesterone
HCG
GnRH agonist

13. THE ROLE OF PROGESTERONE
To obtain a secretory transformation of the endometrium
To facilitate implantation by promoting the immune system to produce
noninflammatory T-helper-2 cytokin (Druckmann et al. J.SBMB 2005)
To improve blood flow and oxygen to the endometrium by increasing nitric
oxide production (Simoncini et al. F&S 2006; Sladek et al. AJP1997)
To reduce the contractility of the myometrium at the time of implatation to
promote implatation (Hill et al. BJOG 1990)
Maintenance of the early pregnancy
- An insufficient progesterone
concentration at the time of
implantation or during early pregnancy
may cause early pregnancy loss.

14. ROUTES

16. When to Start

19. When to Stop

21. ESTRADIOL?

29. Prediction of the risk of OHSS was then used to classify patients into
a)Low risk
b)Moderate risk
c)High risk
Aljawoan et al 25 reported that patients having with an antagonist protocol triggered with
more than 18 follicles or an estradiol concentration > 5000pg|ml have a sensitivity of 83%
with a specificity of 84% for developing OHSS

30. Based on the low and high risk, the idea of personalized luteal support was introduced:
bid to optimize pregnancy rates and still prevent OHSS
i.Low risk : < 14
ii.Moderate risk : 15-25
iii.High risk : >25

31. i. Use of low dose HCG : 1500IU
a) OPU day
b) 5 days after OPU
c) Continue standard E+P
(2) Dual trigger; 1000/1500IU HCG + GnRHa simultaneously (Shapiro et
al 2011, Mahajan N. et al 2016, Griffin 2017)
ii. Modified intensive luteal support : injectables + vaginal
tablets/pessaries (Orivieto R. 2012)
iii. Cycle segmentation : freeze (Shapiro et al 2011)

33. CONCLUSION
The management of the luteal phase in ART has continued to undergo modification. The
introduction of GnRHa protocol to prevent spontaneous ovulation has made it possible
for the final oocyte maturation to be triggered with the use of GnRHa. This also has
thrown up a new challenge-luteal deficiency.

34. The search for the optimal LPS in patient using GnRHa for final trigger is still
on-going. However many options are available now that compare favourably
with HCG trigger