**Author details**

166 Enhancing Success of Assisted Reproduction

the time of a positive hCG test

**11. Chapter summary** 

support was returned from 21 leading centers worldwide [70]. Micronized vaginal progesterone was used in 16 centers, one center used oral micronized progesterone, three centers used 50 mg I.M. progesterone and one center used hCG. All centers started luteal phase support on day of oocyte retrieval or day of embryo transfer. Luteal phase support was stopped on the day of [beta] hCG (BhCG) in eight centers, 2 weeks after positive B hCG in four centers, 2–4 weeks after positive B hCG in five centers, at 9, 10 and 11 weeks of pregnancy in three centers and at 12 weeks in one center. Schmidt et al. [69] compared two groups of patients who used luteal phase support for 2 or 5 weeks. The ongoing pregnancy rate and the delivery rates were not significantly different. The same Danish group [71] conducted a prospective randomized study on 303 women who achieved pregnancy after IVF or ICSI. All were treated with the long protocol using GnRH agonist and given luteal support with 200 mg vaginal progesterone three times daily during 14 days from the day of transfer until the day of a positive hCG test. The study group (n = 150) withdrew vaginal progesterone from the day of positive hCG. The control group (n = 153) continued administration of vaginal progesterone during the next 3 weeks of pregnancy. The study showed that the number of miscarriages prior to and after week 7 of gestation was seven (4.6%) and 15 (10.0%) in the study group and five (3.3%) and 13 (8.5%) in the control group, respectively. The number of deliveries was 118 (78.7%) in the study group and 126 (82.4%) in the control group. The differences were not significant. This is the first randomized study to conclude that prolongation of progesterone supplementation in early pregnancy has no influence on the miscarriage rate, and thus no effect on the delivery rate and progesterone supplementation can safely be withdrawn at

In contemporary ART, luteal phase progesterone supplementation is common practice. Various routes of administration have been developed, but most have proved to have limitations and some side effects. The use of oral progesterone is clearly inferior to intramuscular or vaginal administration and is associated with an increased rate of side effects due to its metabolites. While intramuscular delivery of progesterone continues to remain an option, an increasing number of fertility specialists prefer the vaginal route of delivery. At present, there are insufficient data for a direct comparison between intramuscular and vaginal progesterone therapy; therefore, physicians should be guided by their own clinical experience. Progesterone by whatever route or form can be started on ovum pickup day or within 48 hours, without significant differences in cycle outcome.

Luteal phase support with hCG is not superior to luteal phase support with progesterone. Supplementary administration of hCG brings no advantage when progesterone is administered . Luteal phase support with hCG increases the risk of OHSS as compared with progesterone. As yet, the role of estrogen supplementation therapy during the luteal phase of IVF cycles lacks enough evidence to be employed in routine practice. Combined luteal support using progesterone and GnRh-a showed benefit from addition of GnRH- a to progesterone for the outcomes of live birth, clinical pregnancy and ongoing pregnancy.

Mohamad E. Ghanem\* and Laila A. Al-Boghdady *Mansoura Faculty of Medicine and Mansoura Integrated Fertility Center, Mansoura, Egypt* 
