Estradiol Valerate in Fertility Care: New Vistas

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 20 th – 24 th 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 Endometrium x 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

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

14. 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.

15. 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.

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

17. 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

18. 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 .

19. Estradiol in Endometrial Preparation in IVF

20. 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

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

22. 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

23. 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 Estrogen priming- needed for endometrial profileration and development of P4 receptors Time-related progesterone induced secretory changes in the endometrium

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

25. 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

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

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

28. 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.

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

30. 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

31. 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 )

32. 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

33. 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

34. 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

35. An endometrial thickness of 9-14 mm is associated with higher implantation & pregnancy rates as compared to endometrial thickening of < 7mm Fertil Steril , 2008 Importance of endometrial thickness and endometrial receptivity in implantation

36. 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

37. Estradiol dose in luteal phase

38. Estradiol dose in luteal phase

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

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

41. Down-Regulation ( GnRHa ) with HRT D21 of previous cycle D1 D2 D11 D12 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

42. 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

43. 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

44. DR is beneficial in endometriosis

45. 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

46. 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

47. 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

48. 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.

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

50. 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

51. How thin is the “thin endometrium ”?

52. 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.

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

54. 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

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

56. Donor Cycle

57. 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

58. Luteal Phase Support in Fresh ET Disruption of granulosa cells (?) 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

59. 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 Estradiol in Fresh ET as LPS

60. 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 )

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

62. 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.

63. Estradiol in Fresh ET- the Debate continues GnRH Agonist trigge r- needs intensive LPS (high dose of E and P both)- freeze all better 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

64. Estradiol in poor responder

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

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

67. Estradiol Pretreatment

68. 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

69. 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

70. Thank you