Dr Sujoy Dasgupta was invited to deliver a lecture in the CME organized by Walter Bushnell in November 2019 at Kolkata

1. Sujoy Dasgupta
MBBS (Gold Medalist, Hons)
MS (OBGY- Gold Medalist)
DNB (New Delhi)
MRCOG (London)
Advanced ART Course for Clinicians (NUHS, Singapore)
Consultant: Reproductive Medicine, Genome Fertility Centre, Kolkata
• Managing Committee Member, Bengal Obstetric & Gynaecological Society
(BOGS)- 2019-20
• Secretary, Subfertility and Reproductive Endocrinology Committee, BOGS-
2019-20
• Winner, Prof Geoffrey Chamberlain Award, RCOG World Congress,
London, 2019
Estradiol Valerate in Fertility
Care : New Vistas

2. IVF Success Rate- 40%

3. Implantation
• 1/3 of the top quality embryo transferred
finally implants *
• 2/3 of the failure → Endometrial Factors *
• Only 15-20% of embryos transferred after
IVF/ICSI lead to the birth of a healthy baby *
*Ghazal et al, 2017

4. Window of Implantation (WOI)
• Is the window of time when the uterine environment is
conducive to blastocyst acceptance
• Maximal endometrial receptivity is seen between 20th –
24th day (LH+6 to LH+10) of a 28 day cycle
• After sufficient estrogen hormone exposure, initiation
of progesterone hormone starts a "clock" - and the
uterine lining passes through a receptive "window" of
time when implantation can occur. Before, or after this
window - implantation can not occur*
*G Nie et al, 2019

5. Reproductive Biology and Endocrinology 2005 3:56

6. Embryo-Maternal Communication
=
embryo
hCG
hCG
receptor
Endometrium
EGF, LIF
other cytokines
hCG
Implantation Good embryo Good Endometriumx
E2
P4

7. Shifting of WOI
• Implantation failure
• In IVF → supraphysiological number of developing
follicles → supraphysiological level of E2 and P4
hormones → endometrial histology is advanced by 1-2
days → correlates with premature P4 elevation*
*Bartels CB et al, 2019; Shapiro et al, 2008
• Same situation can arise by non-targeted use of
progesterone in ovulation induction cycle (CC,
Letrozole)

8. Estradiol in Ovulation
Induction/ IUI Cycle

9. CC cycle- case scenario
D1 D2 D10 D12 D15
CC 50-100 mg
Serial TVS
DF 12/1 DF 15/1 DF collapsed
ET 5 mm ET 6 mm ET 7.5 mm
POD Fluid +

10. CC cycle- case scenario
D1 D2 D10 D12 D15
CC 50-100 mg
Serial TVS
DF 12/1 DF 15/1 DF collapsed
ET 5 mm ET 6 mm ET 7.5 mm
POD Fluid +

11. CC cycle- case scenario
D1 D2 D10 D12 D15
CC 50-100 mg
Serial TVS
DF 12/1 DF 15/1 DF collapsed
ET 5 mm ET 6 mm ET 7.5 mm
POD Fluid +

12. Physiology of Endometrial growth
• Endometrium grows at the rate of 0.5mm /day in
Proliferative phase and 0.1 mm/day in the luteal phase
• Periovulatory E2 surge causes the optimum endometrial
growth

14. Counter the antiestrogenic effect of CC
J. Obstet. Gynaecol. Res 2014

15. • We retrieved 1718 articles of which 33 RCTs
• In women with WHO group II ovulatory disorders, ovulation
induction with CC might result in lower EMT than other
ovulation induction regimens. Whether the lower EMT caused the
lower pregnancy and live birth rates remains to be elucidated.
Letrozole seems to be beneficial for these women. However, our
findings should be interpreted with caution as the quality of
evidence was very low.

16. • Sildenafil-estrogen combination has a potent
effect on improving the endometrium
(thickness and pattern) in patients undergoing
induction of ovulation by clomiphene citrate.
This improvement in endometrial
development has a weak positive feedback
on pregnancy rate.

17. Do NOT use CC further
• Periovulatory ET <7 mm
• Hypomenorrhoea in next cycle

18. • There was a statistically significant difference in
endometrial thickness between the two groups, (p
value < 0.00) as, the mean of endometrial thickness/was
8.28 ± 1.7 in group A (cc + E2) and 9.2 ± 1.8 in group B
(Letrozole) respectively. Pregnancy rate was higher in
Letrozole (group B) compared to CC (group A) (16.2% &
12.7%) respectively without statistically significant
difference

19. Letrozole cycle
• This study showed that the pregnancy rate
achieved with letrozole/estradiol valerate
combination was significantly higher than with
letrozole alone. This was attributed to the
improvement of endometrial thickness by
estradiol valerate.

21. Estradiol in Endometrial
Preparation in IVF

22. Fresh Embryo Transfer- Problems
Increased risk of
• Ectopic Pregnancy
• Preeclampsia
• Low birth weight
• Fetal growth restriction
• Placenta praevia
• Placental abruption
• Perinatal death
• Premature delivery
K Van Heertum et al, 2018; Grady et al, 2012; Shapio et al, 2012;
Rombauts et al, 2015; Acharya et al, 2015

23. Frozen Embryo Transfer (FET)
• Significantly decreases the risk associated with
fresh ET
• Cycle Segmentation
• Good freezing programme by the IVF
Laboratory- Vitrification

24. FET- Indications
• Premature progesterone rise at the time of hCG
trigger
• OHSS
• Thin Endometrium
• Preimplantation genetic test (PGT)
• Fertility preservation- Cancer patients,
Endometriosis surgery, Social freezing

25. Endometrial
Preparation in
FET
Natural Cycle (NC)
Pure natural cycle
Modified Natural
Cycle (MNC)
Hormone
Replacement Cycle
(HRT)
HRT without DR
Down-regulated HRT
(DR-HRT)
Stimulated Cycle

26. Hormone Replacement Cycle
(Artificial Cycle)
• Exogenous supply of Estrogen & Progesterone that equals the
effects of ovarian hormones on the endometrial tissue is
required Gupta SA et al, 2018
1. Estrogen priming- needed for endometrial profileration and
development of P4 receptors
2. Time-related progesterone induced secretory changes in the
endometrium

27. Most widely used
Estradiol valerate is structurally similar to main female sex
hormone, estrogen
Estradiol Valerate
Estradiol valerate Natural estrogen

28. Diffuses across the cell membrane
↓
Binds to oestrogen-receptor protein forming hormone-receptor complex
↓
Complex interacts with DNA
↓
ER-DNA complex interacts with co-activator proteins in target genes
↓
Transcription of mRNA and hormone-regulated genes
↓
protein synthesis in the cytoplasm and results in cellular activity
Estradiol Valerate – Mechanism of Action

29. • Prodrug- cleaved into estradiol
• Rapidly metabolised in the liver to estriol and
estrone
• When given orally in doses of 2-4 mg,
I. peak levels are observed 3-6 hours after ingestion
II. Normal output by ovary= 0.05-0.5 mg/ 24 hours
III. Reproduces the serum level and peripheral effects
as seen in normal menstrual cycle
IV. Clearly contrasts the route of administration of
progesterone (daily production >25 mg/ 24 hours)-
despite the same first-pass hepatic metabolism
Estradiol Valerate – Pharmacokinetics

30. Benefits of micronization
Better dissolution
Better absorption
Markedly increased bioavailability
Desired clinical efficacy
- The preferred medicament

31. Micronized vs Non micronized Estradiol valerate
40
80
40
30
60
10
0
10
20
30
40
50
60
70
80
90
1st day 21st day 28th day
DAYS
serumconcentration
Micronized EV (pg/ml)
Plain EV (pg/ml)
Benefits of Micronization
“Serum Concentration are significantly higher with micronized estradiol valerate as
compared with plain estradiol valerate”**
Zentralbl Gynakol. 2001 Sep;123(9):505-12.

32. Other routes for estradiol
administration
• Vaginal
• Sublingual
• Transdermal- Patch, gel

33. Superiority of Esradiol valerate over
other estrogens
Ethinyl Estradiol ↑ Triglyceride
↑PRA → Hypertension
↑ Factor VII → ↑ Coagulation
Conjugated Estrogen Inter-batch variability
Allergic reaction
↑PRA → Hypertension
↑ Factor VII → ↑ Coagulation
Estriol 1/6 estrogenic activity
↑ LDL
Estradiol Transdermal Patch Inconsistency between products
Skin reaction
Problem in humid atmosphere
Estradiol Transdermal Gel ↓Bioavailability
Skin reaction

34. Conversion
1 mg of Estradiol Valerate (oral/ vaginal) =
0.75 mg of 17-β-Estradiol (oral) =
1.25 g of 17-β-Estradiol Gel (transdermal)

35. Dose and duration
D1 D2 D11 D12
E2 4 mg/day
(2 mg BD)
E2 8 mg/day
(4 mg BD)
E2 12 mg/day
(6 mg BD)
E2 6-12 mg/day
TVS
ET 7-14 mm
Adjust E2 dose
tOR
P4 gel/ injectable
D3 D5
ET ET

36. When to start progesterone
• From the day of theoretical oocyte retrieval
(tOR)
• Day of P4 start = P+0 = Day0
• Day3 (Cleavage stage) embryo transfer on P+3
day
• Day5 (Blastocyst) embryo transfer on P+5 day

37. Monitoring
• Maximum distance between
the Echogenic Interfaces of
the Myometrium and the
Endometrium in the
midsagital plane
• Thickness ranging from 9-14
mm has higher implantation
and pregnancy rates as
compared with an endometrial
thickness of 7-8mm *
*Fertil Steril, 2008

38. An endometrial thickness of 9-14 mm is associated with higher
implantation & pregnancy rates as compared to endometrial thickening
of < 7mm
12%
18%
16%
14%
19%
27%
25%
30%
0%
5%
10%
15%
20%
25%
30%
35%
Implantation rate Clinical pregnancy
rate
Ongoing
pregnancy rate
Live birth rates
ET (<7mm) ET (9-14 mm)
Fertil Steril, 2008
Importance of endometrial thickness and endometrial
receptivity in implantation

40. Duration of Estrogen Therapy
• Endometrial receptivity (ER) is tolerant to a wide
duration of E2 treatment
• Uterine preparation consisting of 6 mg EV can be
extended as long as 5 weeks with no significant
decrease in ER
Journal of Assisted Reproduction & genetics ,vol 18 ,No 4,april 2001
Fertil steril 1995 jun ;63(6):1284-6
• Long duration of E2 therapy is not deleterious
• Decreasing the length of E2 therapy is beneficial in
terms of cost and time to pregnancy

42. Estradiol dose in luteal phase

43. Estradiol dose in luteal phase

44. How long to continue HRT in FET
• 8-10 weeks until the placenta becomes
autonomous

45. Side Effects of Estrogen Replacement
 Nausea, vomiting, bloating
 Impaired liver function
 Cardiovascular risk
 Deranged coagulation parameters
 Fluid retention
 Uterine bleeding
 Mastodynia

46. Down-Regulation (GnRHa) with HRT
D21 of previous cycle D1 D2 D11 D1
2
Inj Leuprolide SC 0.5 mg/day Inj Leuprolide 0.2 mg/ day
Inj Leuprolide Depot 3.75 mg IM
DR is confirmed
(LH <5 mU/ml,
E2 <50 pg/ml
Follicle <10
mm)
E2 4 mg/day
(2 mg BD)
E2 8 mg/day
(4 mg BD)
E2 12 mg/day
(6 mg BD)
E2 6-12 mg/day
TVS
ET 7-14 mm
Adjust E2 dose
tOR
P4 gel/ injectable
D3 D5
ET ET

47. Is DR needed?
• If E2 (6-12 mg/day) is started from day1/2/3 or
even before the period starts, it’s enough to
suppress the FSH and follicular recruitment
• Obviates the need of GnRHa

49. DR vs no DR?
DR with GnRHa-
• Cost ↑
• Side effects ↑
• ↓Cyst formation
• ↓ chance of escape luteinization
• Better suppression of the follicular recruitment
• Low cancellation rate

50. DR is beneficial in endometriosis

51. Natural cycle Endometrial
preparation
D1 D2 D10 D12
Serial TVS
DF >14
mm
Serial Blood/ Urine LH
LH >180%- a day before
ovulation
Ovulation
tOR
P4 Optional
D3 D5
ET ET
Benefit-
•No exogenous hormonal exposure
Drawback-
•Needs frequent monitoring and visits
•High cancellation rate
•Fallacies in LH testing
•No flexibility
•Only in ovulatory women

52. Modified Natural cycle Endometrial
preparation
D1 D2 D10 D12
Serial TVS
DF 16-17
mm
hCG Trigger
Ovulation
(after 36-38 hour)
tOR
P4 Optional
D3 D5
ET ET
Benefit-
•No exogenous hormonal exposure
•Increased chance of ovulation
Drawback-
•Needs frequent monitoring and visits
•High cancellation rate
•Fallacies in LH testing
•No flexibility
•Difficult in PCOS

53. Stimulated cycle Endometrial
preparation
D1 D2 D10 D12
CC 50-100 mg
Letrozole 2.5-5 mg
FSH 75 IU
Serial TVS
DF 16-17 mm
hCG Trigger
Ovulation
(after 36-38 hour)
tOR
P4 Optional
D3 D5
ET ET
Benefit-
•Increased chance of ovulation
•Uses endogenous hormones
Drawback-
•Frequent monitoring
•No flexibility

54. Which Endometrial Preparation is the best?
• The number of high quality randomized controlled
trials (RCTs) is scarce and, hence, the evidence for the
best protocol for FET is poor.
• In terms of embryo transfer timing, we propose to start
progesterone intake on the theoretical day of oocyte
retrieval in HRT and to perform blastocyst transfer at
hCG + 7 or LH + 6 in modified or true NC, respectively.

55. When HRT is particularly beneficial
• POF- Donor Cycle
• PCOS- Anovulation
• Thin endometrium during IVF stimulation
• Programming is desirable
• Can be used in all women

56. Thin Endometrium despite use of
Estradiol
1. Find out the cause and treat
• Hydrosalpinx
• Endometritis
• Endometriosis
• Intrauterine adhesions
2. Increase the dose of Estradiol
3. Change the preparation protocol

57. How thin is the “thin endometrium”?

58. • In fresh IVF-embryo transfer cycles, patients
should be counselled that endometrial thickness
<8 mm may have a negative impact on
pregnancy and live birth rates
• In frozen IVF-embryo transfer cycles, patients
should be counselled that endometrial thickness
<7 mm may have a negative impact on
pregnancy and live birth rates.

59. Use of Adjuvants
• Sildenafil- oral/ vaginal
• Aspirin
• L-Arginine
• Vitamin E
• Pentoxiphylline
• G-CSF
• Platelet rich plasma (PRP)
• Stem cells

60. Canadian Fertility and Andrology
Society Guideline, 2019
• In patients with thin endometrium undergoing
embryo transfer cycles, we suggest
AGAINST the use of aspirin, vaginal
sildenafil, G-CSF, pentoxifylline, HCG,
gonadotropin-releasing hormone agonists,
platelet-rich plasma or stem cells to
improve pregnancy rates
• Quality of evidence- weak

61. • Large, well-designed, randomized trials must
be conducted to evaluate the effectiveness and
safety of these interventions.

62. Donor Cycle

63. Freeze all for all ?
• Inadequate evidence to suggest improved
pregnancy rate than fresh transfer
• Increased cost, treatment time, patient
dissatisfaction
• May increase the risk of macrosomia (?)
• Long term effects ?
Blocked C et al, 2016

64. Luteal Phase Support in Fresh ET
1. Disruption of granulosa cells (?)
2. Supraphysiological E+P → suppresses LH →
Lack of stimulation for corpus luteum to
secrete E and P
Progesterone supplementation significantly
improves pregnancy rate and live birth
rate

65. Addition of luteal estrogen supplementation in stimulated cycles improves the pregnancy
rates & hence improves IVF embryo transfer rates **
** Fertil Steril. 2005 May;83(5):1372-6
0.00% 10.00% 20.00% 30.00% 40.00% 50.00% 60.00%
P4
P4+2mg E2
P4+6mg E2
Estradiol in Fresh ET as LPS

66. • Progesterone vs progesterone with oestrogen
• 16 RCTs, 2577 women
• There was no evidence of a difference between the
groups in rates of live birth or ongoing pregnancy (OR
1.12, 95% CI 0.91 to 1.38, nine RCTs, 1651 women, I2
= 0%, low-quality evidence) or OHSS (OR 0.56, 95%
CI 0.2 to 1.63, two RCTs, 461 women, I2 = 0%, low-
quality evidence)

67. Pregnancyrates,%
Significantly higher IR and PR were found in patients who received
low dose E2 (2 mg) compared with no E2, but the best outcomes
were found significantly in the group with high dose E2 (6 mg)
supplementation.
Lukaszuk et al, 2005
Estrogen in Agonist Cycle

68. • Any benefit of oestradiol supplementation for
luteal phase support appears to correlate with the
serum oestradiol level on the day of hCG trigger.
• Oestradiol supplementation is beneficial for
improving live birth rate in cycles with oestradiol
levels less than 5000 pmol/L, but is not
recommended in cycles with oestradiol levels
over 10 000 pmol/L.

69. Estradiol in Fresh ET- the Debate
continues
1. GnRH Agonist trigger- needs intensive LPS (high
dose of E and P both)- freeze all better
2. Thin ET
• In fresh IVF-embryo transfer cycles, patients with thin
endometrium can be offered elective cryopreservation
of embryos and transfer in a subsequent cycle.*
• In patients with thin endometrium undergoing fresh
IVF-embryo transfer cycles, we suggest against the
use of luteal oestradiol to improve pregnancy rates. *
*Canadian fertility and Andrology Society Guideline, 2019

70. Estradiol in poor responder

71. Poor Responder
• Donor- easy solution
• <40 years- different strategies should be
adopted before offering egg-donation
• Emotion vs Finance

72. Luteal FSH suppression
• E2 pretreatment
1. prevents intercycle FSH rise
2. reduces the pace of growth of the
follicles (synchronous growth)
3. increases the number of follicles
reaching maturation at once
4. more physiological alternative to
GnRH agonist or OCP pre-treatment
Fanchin R et al, 2003; Reynolds KA et al, 2013

73. Estradiol Pretreatment

75. Cycle control in ART
• Use of estrogen in the luteal phase of the preceding cycle has
definitely shown benefits with regard to better control of cycle
as well as synchronization of follicles available for stimulation

76. Take home Message
• Estradiol valerate in micronized form is close to the
physiological estradiol
• Orally administered, well tolerated, few side effects
• Very much useful in endometrial preparation in frozen
embryo transfer
• The role in fresh embryo transfer is questionable
• Can be used for cycle regulation and in poor responders
before IVF stimulation
• Effectiveness in thin endometrium after CC/ Letrozole
cycle- needs further studies