Vaginal Progesterone Supplementation in Women With PCOS Undergoing Ovulation Induction With Letrozole

Study Overview
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Brief Summary
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Aromatase inhibitors such as letrozole are hypothesized to maintain normal hypothalamic/ pituitary feedback mechanisms and in the case of OI (ovulation induction) in women with PCOS, may act to increase follicular sensitivity to FSH by increasing intrafollicular androgen levels. Letrozole also may act to increase midluteal P levels presumably by induction of follicles and corpora lutea. The investigators are asking the question whether P supplementation with Crinone (8%) may have an additive beneficial effect on endometrial development in those women taking letrozole. Progesterone levels in the endometrium (tissue levels) have been documented to be significantly higher than serum levels after vaginal administration which may lead to higher pregnancy rates. In addition P has been shown to decrease LH pulse frequency which is elevated in PCOS and has been shown to down regulate endometrial androgen receptors. There have been retrospective studies showing progesterone supplementation seems to benefit both CC and letrozole treatment groups. In fact, this study showed the only pregnancies in the letrozole group were those in women who took P supplementation. However the number of cycles studied was small. There is a place for a randomized controlled trial (RCT) to determine if luteal phase P supplementation with Crinone should be used in all women using letrozole for Ovulation Induction (OI) in combination with Intrauterine Insemination (IUI) or Timed Intercourse (TI). This is currently not done in all clinical practices.

Detailed Description
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Approval of the study was obtained from the local IRB. Prospective volunteers had had an infertility workup including blood hormone levels (FSH, LH, E2, Progesterone, Prolactin, and Thyroid), partner's semen analysis, HSG, laparoscopy or hydrosonogram, plus a baseline evaluation including ultrasound of ovaries and uterus performed as standard of care. If the results of these tests and the remaining Inclusion/Exclusion criteria were met, the study consent was reviewed with participants and signatures were obtained. Participants contacted the clinic at the start of their menses (spontaneous or progesterone-induced) to start the treatment cycle. Eligibility criteria was reviewed, and Letrozole 2.5-7.5 mg day 3-7 was initiated based on BMI and prior response. An ultrasound was performed on cycle day 11 or 12 and repeated if needed to determine response until at least 1 follicle with mean diameter > 17mm in size was observed. When the appropriate follicle size was reached, participants were randomized into one of the two treatment groups as determined by a randomization table, and Ovidrel (250mcg) was administered. If there was no response identified by follicle growth on day 21, the participant was considered a letrozole failure, the cycle was stopped, and the participant was dropped from the study and was not included in subsequent cycles. IUI/TI was performed at 24-48 hours after the Ovidrel (hCG) injection. If the participant was randomized to progesterone (Crinone), the luteal phase was supplemented once daily with vaginal progesterone (Crinone 8%) starting the second day after the IUI or TI and continued for 14 days. A urine or serum pregnancy test was performed as standard of care 16 days after the IUI/TI. If the test was positive, a confirmatory blood level (βhCG) was performed as standard of care X2 (1 week apart) and an ultrasound on post-hCG day 35-42 was done. Any pregnancies occurring in either treatment group were followed for delivery outcomes. Information regarding the delivery (induced, vaginal, cesarean section), date of birth, infant measurements (weight and length) and other important information regarding the infant's condition was obtained. Participants were allowed to undergo up to 3 cycles of letrozole as the pregnancy rates for the first 3 cycles have been shown to be similar. The participants were re-randomized each cycle. If the participant was pregnant, Crinone (8%) was continued until 10 weeks gestation in both groups. Each participant was able to proceed with up to 3 cycles (consecutively, if desired) of OI over the next 6 months and was re-randomized each cycle.

Official Title
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Supplementation of the Luteal Phase With Vaginal Progesterone (Crinone 8%) in Women With Polycystic Ovary Syndrome Undergoing Ovulation Induction With Letrozole: A Prospective and Randomized Controlled Trial

Conditions
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Polycystic Ovary Syndrome

Intervention / Treatment
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* Drug: Progesterone Vaginal Gel 8%
* Drug: Letrozole Oral Tablet
* Diagnostic Test: pelvic ultrasound
* Drug: Ovidrel 250 MCG Per 0.5 ML Prefilled Syringe
* Other: Intrauterine insemination or timed intercourse


Participation Criteria
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Eligibility Criteria
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Inclusion Criteria: Women who have anovulatory or oligoovulatory infertility who are undergoing ovulation induction for infertility with TI or IUI , with or without regular cycles defined as cycle length > 35 days, < 26 days or amenorrhea (no cycles in the past six months), and who meet 2 out of 3 of the Rotterdam Criteria (1. Chronic anovulation or irregular cycles, 2. Clinical or biochemical hyperandrogenism, 3. Polycystic appearing ovaries on ultrasound.) Day 3 FSH(Follicle stimulating hormone)< 10 (obtained within 2 years prior to screening Documented infertility for at least 1 year or documented anovulation Willing to participate in up to 3 cycles of OI with letrozole and IUI or TI Partner's or donor's SA> 5 million motile sperm within 2 years of screening Patients may have received clomiphene citrate or letrozole treatment in the past. Exclusion Criteria: Untreated thyroid or prolactin abnormalities Pregnancy in the last 3 months BMI< 18 or >40kg/m2 Abnormal uterine bleeding of undetermined origin Contraindications to pregnancy Progesterone sensitivity Uterine anomalies seen on ultrasound (performed within 6 months prior to screening) that can affect pregnancy chances such as submucosal uterine fibroids or polyps Three or more previous consecutive pregnancy losses Blocked fallopian tubes X2 (documented by HSG, laparoscopy, or hydrosonogram completed within past 3 years) More than 3 failed monitored letrozole cycles prior to enrolling

Ages Eligible for Study
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Minimum Age: 20 Years
Maximum Age: 40 Years

Sexes Eligible for Study
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Female

Accepts Healthy Volunteers
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No

Study Plan
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How is the study designed?
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Design Details

Primary Purpose: Other
Allocation: Randomized
Intervention Model: Parallel Assignment
Interventional Model Description: Participants who met criteria were randomized to either Crinone vaginal therapy versus no therapy in the luteal phase of an ovulation induction cycle. Participants who did not achieve a pregnancy were able to participate in up to 3 cycles, and were re-randomized with each cycle.
Masking: Single


Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| Other: # 1- no progesterone therapy<br>Letrrozole 2.5 to 5 mg oral tablet cycle day 3-7.Pelvic ultrasound at cycle day 11 or 12 and repeat if needed until leading follicle is >17 mm. Ovidrel 250 mcg injected sq. Timed intercourse or intrauterine insemination. No supplemental progesterone therapy in luteal phase | Drug: Letrozole Oral Tablet<br>* letrozole oral tablet 2.5 mg or 5 mg administered cycle day 3-7 for ovulation induction<br>Diagnostic Test: pelvic ultrasound<br>* pelvic ultrasound performed at cycle day 11 or 12 and repeated as necessary until leading follicle size is >17 mm in diameter<br>Drug: Ovidrel 250 MCG Per 0.5 ML Prefilled Syringe<br>* ovidrel 250 mcg given when leading follicle size is > 17 mm in diameter<br>* Other names: recombinant hCG 250 mcg;Other: Intrauterine insemination or timed intercourse<br>* Intrauterine insemination or timed intercourse (depending on semen parameters) performed 36-40 hours after Ovidrel<br>|
| Active Comparator: # 2 - Progesterone Vaginal Gel 8%<br>Letrrozole 2.5 to 5 mg oral tablet cycle day 3-7. Pelvic ultrasound at cycle day 11 or 12 and repeat if needed until leading follicle is >17 mm. Ovidrel 250 mcg injected sq. Timed intercourse or intrauterine insemination.Crinone 8% (progesterone) vaginal therapy was provided in luteal phase for 14 days .Administration was started the second day after intrauterine insemination or timed intercourse. | Drug: Progesterone Vaginal Gel 8%<br>* progesterone supplementation for luteal phase support administered with vaginal applicators and used instead of progesterone intramuscular injections or progesterone vaginal suppositories.<br>* Other names: Crinone 8% vaginal gel;Drug: Letrozole Oral Tablet<br>* letrozole oral tablet 2.5 mg or 5 mg administered cycle day 3-7 for ovulation induction<br>Diagnostic Test: pelvic ultrasound<br>* pelvic ultrasound performed at cycle day 11 or 12 and repeated as necessary until leading follicle size is >17 mm in diameter<br>Drug: Ovidrel 250 MCG Per 0.5 ML Prefilled Syringe<br>* ovidrel 250 mcg given when leading follicle size is > 17 mm in diameter<br>* Other names: recombinant hCG 250 mcg;Other: Intrauterine insemination or timed intercourse<br>* Intrauterine insemination or timed intercourse (depending on semen parameters) performed 36-40 hours after Ovidrel<br>|

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Clinical pregnancy rates | The primary endpoint of the trial is the Clinical Pregnancy Rate per cycle initiated | Per initiated cycle of treatment. At the end of Cycle 1, 2, and 3 (each cycle is 28 days) and if pregnant up to 8 weeks after completion of cycle | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Live birth rates | The secondary endpoint is the Live Birth Rate per cycle initiated (each cycle is 28 days) | Up to 1 year or until delivery | 

 Terms related to the study
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Keywords Provided by Centre Hospitalier Valida
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PCOS, crinone, vaginal progesterone, ovulation induction