Treatment with piroxicam before embryo transfer increases the pregnancy rate after in vitro fertilization and embryo transfer

Transcription

1 FERTILITY AND STERILITY VOL. 82, NO. 4, OCTOBER 2004 Copyright 2004 American Society for Reproductive Medicine Published by Elsevier Inc. Printed on acid-free paper in U.S.A. Treatment with piroxicam before embryo transfer increases the pregnancy rate after in vitro fertilization and embryo transfer Hwa Sook Moon, M.D., Ph.D., Sea Hee Park, M.S., Ju Ok Lee, B.S., Kyung Seo Kim, M.D., and Bo Sun Joo, Ph.D. Center for Reproductive Medicine and Infertility, Department of Obstetrics and Gynecology, Good Moon-Hwa Hospital, Busan, Korea Objective: To examine the effect of -cyclodextrin piroxicam treatment for priming of the uterus on the pregnancy outcome of IVF embryo transfer (ET) programs. Design: Prospective, randomized, double-blinded placebo-controlled clinical study. Setting: Large urban medical center. Patient(s): One hundred eighty-eight consecutive cycles of fresh IVF ET and 78 cycles of frozen thawed ET. The patients underwent IVF because of tubal, male infertility, unexplained, or endometriosis factors. They were randomly divided into treatment and control groups. Intervention(s): In the treatment group, 94 cycles in fresh ET and 39 cycles in frozen thawed ET the patients received an oral dose of 10 mg of piroxicam. In the control group, the same number cycles corresponding to the treatment group were treated with placebo. Both groups started piroxicam or placebo treatment 1 2 hours before ET. Patients and staff were blinded to the treatment. Main Outcome Measure(s): Implantation rate (IR) and pregnancy rate (PR). Result(s): Piroxicam increased significantly IR (18.7%) and PR (46.8%) compared to the control group (8.6% and 27.6%, respectively) in fresh cycles. With the exception of an unexplained factor, patients with the tubal, male infertility, or endometriosis factor had significantly higher PR in the treatment group compared to the control group. The beneficial effect of piroxicam was found in patients less than 40 years old, but was not found in patients more than 40 years. In frozen thawed cycles, there were statistically significant differences between the treatment group and the control group in IR (9.4% vs. 2.3%) and PR (25.6% vs. 7.7%), respectively. Conclusion(s): Our study showed that piroxicam increases IR and PR after IVF ET in both fresh and frozen thawed ET cycles. The beneficial effect seems to be more remarkable in patients less than 40 years old with tubal, male infertility, or endometriosis factors. These results suggest that piroxicam treatment before ET is very effective in the priming of a uterus suitable for embryo implantation. This is the first study to investigate the possible consequence of piroxicam for improving the PR after IVF ET. (Fertil Steril 2004; 82: by American Society for Reproductive Medicine.) Key Words: -Cyclodextrin piroxicam, pregnancy outcome, uterine contractility Received April 17, 2003; revised and accepted February 17, Reprint requests: Bo Sun Joo, Ph.D., Center for Reproductive Medicine and Infertility, Good Moon-Hwa Hospital, Bum-il Dong, Busan , Korea (FAX: ; bosunjoo@ hotmail.com) /04/$30.00 doi: /j.fertnstert During the past 20 years numerous studies have been made to improve the implantation process. Most of their attempts have been focused on the induction and selection of the best quality embryos and the improvement of uterus receptivity. Several developments in controlled ovarian hyperstimulation (COH), fertilization, and embryo culture techniques have contributed to the improvement of the quality of embryos available for ET. In contrast, little development has increased the uterus receptivity. Practical limitations in the evaluation and improvement of uterine receptivity may be influenced by several factors. First, no one factor was considered to play a critical determining role in the establishment of uterus receptivity for implantation because the events of implantation are regulated by a complex morphological and biochemical change of the endometrium (1). Thus all of these factors should be investigated simultaneously to clearly assess the receptivity status of the endometrium. Second, tissue sampling for the direct assessment 816

2 of markers of uterine receptivity is inherently impossible in the actual ET cycles. Recently many researchers have focused on noninvasive prognostic factors of uterine receptivity with the advent of high resolution ultrasound probes, which permitted the direct visualization of the uterine contractile activity (2, 3). The uterus has typically three patterns of contractility throughout the menstrual cycle that influence embryo implantation (4 7). Uterine contraction at the time of ET alters pregnancy rates (PRs) after IVF (8). These results suggest that uterine contractility can be an important factor in determining endometrial receptivity as well as an alternative noninvasive prognostic factor (9). In this respect, treatment of adjuvants, such as uterine relaxants, should be considered to prime of a uterus suitable for embryo implantation. Prostaglandin, which is synthesized from arachidonic acid by cyclooxygenase (COX), stimulates uterine contraction. Nonsteroidal anti-inflammatory drugs (NSAIDs) block the action of COX and inhibit the production of prostaglandin (10). This result indicates that NSAIDs may cause the reduction of uterine contractility. To date, no reports have evaluated NSAIDs with the purpose of improving a pregnancy outcome after IVF ET. Piroxicam is the most effective of all NSAIDs in the clinical relief of dysmenorrhea (10). The aim of this study was to examine the effect of piroxicam treatment for the priming of the uterus on the pregnancy outcome in IVF ET programs. MATERIALS AND METHODS This study was performed on 188 consecutive cycles of fresh IVF ET and 78 cycles of frozen thawed ET from March 1998 to February 2000 at the Center for Reproductive Medicine of Good Moon-Hwa Hospital. The study included women who underwent IVF because of tubal, male infertility, unexplained, or endometriosis factor. Written informed consent was obtained from all patients. This study was approved by the Institutional Review Board of the Human Investigation Committee of Good Moon-Hwa Hospital. led Ovarian Hyperstimulation and IVF Procedures led ovarian hyperstimulation (COH) was performed by a long standard protocol with GnRH agonist (GnRH-a; Lucrin, Johannesburg Abbott, France), hmg (IVF-M; LG Inc., Iksan, Korea), and highly purified FSH (hpfsh; Follimon, LG Inc.). In brief, GnRH-a was given daily at a dose of 1 mg until a serum E 2 level was obtained to assess whether adequate suppression had been achieved. When ovarian suppression was observed by serum E 2 and FSH levels on the third day of the menstrual cycle, GnRH-a was given daily at a dose of 0.5 mg in the morning and one or two ampules of 75 IU of hmg and hpfsh were given IM in the evening, depending on the follicular development. Follicular development was assessed by transvaginal ultrasonography. When at least two dominant follicles were 18 mm or larger, the serum E 2 level was measured and 10,000 IU of hcg (IVF-C, LG Inc.) was administered. Oocyte retrieval by transvaginal ultrasonographic guidance was performed approximately 36 hours after the hcg administration. Follicular aspirates were transferred into 60-mm tissue culture dishes (Falcon 3002; Becton Dickinson, Lincoln Park, NJ). Oocyte cumulus cell complexes were isolated under a dissecting microscope (SZH, Olympus, Tokyo, Japan). The maturity and quality of each oocyte cumulus cell complex was graded under inverted phase contrast microscope (Olympus IX 70, Olympus) by spreading each oocyte cumulus cell complex on one line of the surface of 60-mm culture dishes. Oocytes with first polar body and extensive cumulus cells were regarded as mature. Four or five oocytes were placed into each organ culture dish (Falcon 3037; Becton Dickinson) containing 0.9 ml of glucose-free mhtf medium supplemented with 10% follicular fluid (FF). Highly motile spermatozoa were collected by a discontinuous three-layered percoll gradient (100% 90% 50%) and suspended in glucose-containing HTF medium with 10% FF. Then they were inseminated 4 12 hours after oocyte retrieval, depending on the oocyte maturity. Fertilization was confirmed hours after insemination by visualization of two pronuclei. Fertilized oocytes were transferred to fresh mhtf medium with 20% FF, and then cultured for 24 hours or more, followed by co-culture with autologous cumulus cells in glucose-containing HTF with 20% FF. After co-culture, embryos were graded based on the size of the blastomere and the presence of fragmentation, using Bolton sdefinition (11), just before ET. The ET was performed with Embryon transfer catheter (Rocket medical, Waterford, United Kingdom) 3 days after oocyte recovery in fresh cycles and 3 days after ovulation in frozen thawed cycles. Piroxicam Treatment The 188 fresh IVF ET cycles and 78 frozen thawed ET cycles were randomly divided into treatment and control groups. In the fresh ET cycles, the treatment group (94 cycles) received an oral dose of 10 mg of piroxicam (Brexin; Kolon Inc., Daejeon, Korea), and the control group (94 cycles) received a placebo. In the frozen thawed ET cycles, 39 cycles received 10 mg of piroxicam orally (treatment group) and 39 cycles were treated with placebo (control group). Both groups started piroxicam or placebo treatment 1 2 hours before ET. Patients and staff were blinded to the treatment. Statistical Analysis All data were presented as mean SD. Statistical analysis was carried out using the unpaired Student s t-test and 2 -test. A P value.05 was considered statistically significant. 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3 TABLE 1 Patient characteristics in the control and piroxicam treatment groups. TABLE 3 Comparison of pregnancy rates according to the infertility causes. Piroxicam treatment Infertility causes Piroxicam treatment No. of cases Age (y) Parity Basal FSH (miu/ml) LH (miu/ml) E 2 (pg/ml) E 2 (pg/ml) on the hcg 2,937 1,678 3,726 1,834 administration No. of oocytes retrieved No. of embryos transferred No. of grade A embryo a a Grade A embryo is the best quality embryo with even-sized blastomere and no fragmentation. RESULTS The mean age ( SD) of patients was 32.7 ( 4.3) years in the control group and 33.0 ( 4.8) years in the piroxicam treatment group. The mean number of retrieved oocytes was 10 in the control group and 11 in the piroxicam treatment group. The mean number of embryos transferred was four in both groups. The woman s age, parity, ovarian reserve, or E 2 level on the day of hcg administration was not significantly different in both groups. The number of oocytes retrieved, number of embryos transferred, and the quality of embryo transferred also showed no significant differences (Table 1). The implantation rate and the clinical pregnancy rate (PR) were 8.6% and 27.6% in the control group, and 18.7% and 46.8% in the piroxicam treatment group. The implantation rate and PR were significantly higher in the piroxicam treatment group compared with the control group (P.05; Table 2). When the PRs were compared according to the causes of infertility, piroxicam treatment increased about twice as much in patients with tubal, male infertility, or endometriosis factors compared to the control group (P.05). However, Male 4/17 (23.5%) 7/16 (43.8%) a Tubal 15/57 (26.3%) 24/50 (48.0%) a Endometriosis 2/7 (28.5%) 5/10 (50.0%) a Unexplained 5/13 (38.5%) 8/18 (44.4%) no beneficial effect of piroxicam was found in unexplained infertile patients (Table 3). Piroxicam treatment resulted in a significant increase in PR in patients less than 40 years old (P.05), but not in patients more than 40 years (Table 4). Of 78 cycles of frozen thawed ET, 39 cycles were treated with piroxicam. The number and quality of embryos transferred was similar in both groups. The implantation rate and clinical PR were 9.4% and 25.6% in the piroxicam-treated group, which were significantly higher than in the control group (2.3% and 7.7%, respectively) (P.05; Table 5). DISCUSSION This study shows higher rates of implantation and pregnancy with piroxicam treatment before ET. This is the first study to date that focused on the use of piroxicam for priming the uterus to improve the pregnancy rate after IVF ET. Piroxicam is a NSAID and is a risk factor C in pregnancy. The use of NSAIDs during pregnancy has not been associated with congenital malformations, preterm delivery, or low birth weight, but two reports showed adverse effects of NSAIDs during pregnancy. One states that NSAIDs block blastocyst implantation by inhibiting blastocyst hatching (10, 12). The other reports that the use of NSAIDs might be associated with spontaneous abortion (13). However, there are no reports concerning any adverse effects from one dose TABLE 2 IVF ET outcomes in the control and piroxicam treatment groups. Piroxicam treatment Implantation rate 8.6% 18.7% a Clinical pregnancy rate 27.6% (26/94) 46.8% (44/94) a TABLE 4 Comparison of pregnancy rate with the age of patients. Age Piroxicam treatment 30 9/28 (32.1%) 19/36 (52.8%) a /48 (29.2%) 19/41 (46.3%) a /8 (25.0%) 5/11 (45.5%) a 40 1/10 (10.0%) 1/6 (16.6%) 818 Moon et al. Piroxicam increases pregnancy rate of IVF Vol. 82, No. 4, October 2004

4 TABLE 5 Pregnancy outcomes in frozen thawed ET cycles. Piroxicam treatment No. of cases No. of embryos transferred No. of grade A embryo a Implantation rate 2.3% 9.4% b Clinical pregnancy rate 7.7% (3 cases) 25.6% (10 cases) b a Grade A embryo is the best quality embryo with even sized blastomere and no fragmentation. b P.05 (vs. control group). (10 mg) of piroxicam during the preimplantation period. Our present study does not show any increase in spontaneous abortion as well as malformation after piroxicam treatment compared to the control group in IVF ET. The cause for this beneficial effect of piroxicam may be postulated in two aspects. First, piroxicam treatment may reduce uterine contractility. IJland et al. (5) found that conceptional cycles had less endometrial wavelike activity compared with nonconception cycles in spontaneous cycles. High frequency contractions of uterus at the time of ET are associated with poorer implantation (8) and poorer IVF ET outcome (14). These results mean that uterine contractility influences embryo implantation. Uterine contractility is stimulated by prostaglandins (PGs) synthesized by COX (10). The NSAIDs block the action of COX and inhibit the production of PGs (15), probably resulting in the decrease of uterine contractility. In this respect, the one time oral treatment with piroxicam on the day of ET seems to increase the implantation of human blastocyst by calming uterine contraction rather than inhibiting embryo development and blastocyst hatching. Second is the increase of uterine blood flow with piroxicam treatment. A few studies used aspirin, another inhibitor of PG, to improve the pregnancy outcome of IVF ET. They concluded that low-dose aspirin improved implantation rates and PRs in IVF patients (16 18). Rubinstein et al. (18) explained that the effect of aspirin is attributable to an increase in uterine blood flow. Studies similar to ours were conducted by Fanchin (19) and Ayoubi (20) and their colleagues. Uterine contractions are increased by rising E 2 levels during the follicular phase (21 23) and are reduced by P exerted during the luteal phase (21, 24, 25). These researchers administered vaginal P starting on the day of oocyte retrieval to relax uterine contractility at the time of ET. As a result, they found a decrease in uterine contraction frequency on the day of ET, suggesting that a uterine relaxation effect by P administration before ET is likely to improve IVF ET outcome. Uterine contractility follows three characteristic patterns according to the phase of the menstrual cycle. Uterine contractility during the early follicular phase (menses, antegrade: fundus-to-cervix) increases progressively to a maximum activity at midcycle (retrograde: cervix-to-fundus), and declines gradually throughout the luteal phase (quiescence) (4, 25 27). Dyskinetic alterations in this process may be responsible for infertility, especially with endometriosis (28, 29). The uterine contraction amplitude is three times higher in women with endometriosis than in women without endometriosis (30). The finding that endometriosis is intimately associated with dyskinetic alteration on uterine contractility is looked at in our present study, which shows that the PR in women with endometriosis who had the piroxicam treatment increased about twice as much as in control women. We hypothesize that this increased PR may be a result of the normalization of uterine contractility by piroxicam treatment. However, our present study did not show the significant improvement of PR by piroxicam treatment in the patient group with an unexplained infertility factor. One explanation of this unexpected finding is an unknown factor of unexplained infertility may surpass the calming effect of piroxicam on the uterine contractility. Therefore, further study to seek the effect of NSAIDs on the uterine contractility and PR is necessary. Also, in the present study, the beneficial effect of piroxicam was not expressed in older women, notably patients more than 40 years. This result implies that the calming effect of piroxicam does not seem to overcome the age-related fertility declines. In conclusion, this study is the first to investigate the possible consequence of piroxicam to improve the pregnancy outcome of IVF ET, and shows that the treatment with piroxicam increases the implantation rate and PR after IVF ET in both fresh and frozen thawed cycles. These results suggest that administration of piroxicam just before ET is very effective in the priming of the uterus to be suitable for embryo implantation. However, our study did not evaluate whether piroxicam calms the uterus by reducing uterine contractions or if it increases uterine blood flow. 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