Obstetric and neonatal outcomes after natural versus artificial cycle frozen embryo transfer and the role of luteal phase support: a systematic review and meta-analysis

Abstract

BACKGROUND The number of frozen embryo transfers (FET) has increased dramatically over the past decade. Based on current evidence, there is no difference in pregnancy rates when natural cycle FET (NC-FET) is compared to artificial cycle FET (AC-FET) in subfertile women. However, NC-FET seems to be associated with lower risk of adverse obstetric and neonatal outcomes compared with AC-FET cycles. Currently, there is no consensus about whether NC-FET needs to be combined with luteal phase support (LPS) or not. The question of how to prepare the endometrium for FET has now gained even more importance and taken the dimension of safety into account as it should not simply be reduced to the basic question of effectiveness. OBJECTIVE AND RATIONALE The objective of this project was to determine whether NC-FET, with or without LPS, decreases the risk of adverse obstetric and neonatal outcomes compared with AC-FET. SEARCH METHODS A systematic review and meta-analysis was carried out. A literature search was performed using the following databases: CINAHL, EMBASE, and MEDLINE from inception to 10 October 2022. Observational studies, including cohort studies, and registries comparing obstetric and neonatal outcomes between singleton pregnancies after NC-FET and those after AC-FET were sought. Risk of bias was assessed using the ROBINS-I tool. The quality of evidence was evaluated using the Grading of Recommendations Assessment, Development and Evaluation approach. We calculated pooled odds ratios (ORs), pooled risk differences (RDs), pooled adjusted ORs, and prevalence estimates with 95% CI using a random effect model, while heterogeneity was assessed by the I2. OUTCOMES The conducted search identified 2436 studies, 890 duplicates were removed and 1546 studies were screened. Thirty studies (NC-FET n = 56 445; AC-FET n = 57 231) were included, 19 of which used LPS in NC-FET. Birthweight was lower following NC-FET versus AC-FET (mean difference 26.35 g; 95% CI 11.61–41.08, I2 = 63%). Furthermore NC-FET compared to AC-FET resulted in a lower risk of large for gestational age (OR 0.88, 95% 0.83–0.94, I2 = 54%), macrosomia (OR 0.81; 95% CI 0.71–0.93, I2 = 68%), low birthweight (OR 0.81, 95% CI 0.77–0.85, I2 = 41%), early pregnancy loss (OR 0.73; 95% CI 0.61–0.86, I2 = 70%), preterm birth (OR 0.80; 95% CI 0.75–0.85, I2 = 20%), very preterm birth (OR 0.66, 95% CI 0.53–0.84, I2 = 0%), hypertensive disorders of pregnancy (OR 0.60, 95% CI 0.50–0.65, I2 = 61%), pre-eclampsia (OR 0.50; 95% CI 0.42–0.60, I2 = 44%), placenta previa (OR 0.84, 95% CI 0.73–0.97, I2 = 0%), and postpartum hemorrhage (OR 0.43; 95% CI 0.38–0.48, I2 = 53%). Stratified analyses on LPS use in NC-FET suggested that, compared to AC-FET, NC-FET with LPS decreased preterm birth risk, while NC-FET without LPS did not (OR 0.75, 95% CI 0.70–0.81). LPS use did not modify the other outcomes. Heterogeneity varied from low to high, while quality of the evidence was very low to moderate. WIDER IMPLICATIONS This study confirms that NC-FET decreases the risk of adverse obstetric and neonatal outcomes compared with AC-FET. We estimate that for each adverse outcome, use of NC-FET may prevent 4 to 22 cases per 1000 women. Consequently, NC-FET should be the preferred treatment in women with ovulatory cycles undergoing FET. Based on very low quality of evidence, the risk of preterm birth be decreased when LPS is used in NC-FET compared to AC-FET. However, because of many uncertainties—the major being the debate about efficacy of the use of LPS—future research is needed on efficacy and safety of LPS and no recommendation can be made about the use of LPS.

Vitrification of human blastocysts for couples undergoing assisted reproduction: an updated review

“…Along those lines, no difference in birthweight was seen by Shi and co-authors when embryos were transferred in a natural cycle, leading one to consider that endometrial preparation might play a crucial relevant role in that regard (Shi et al, 2018). Similar results were also found in a systematic review and meta-analysis performed by Zaat and colleagues (Zaat et al, 2023) including 1,546 studies in which FETs were compared between natural cycles (n = 56,445) and artificial cycles (n = 57,231). The authors reported a decreased risk of adverse obstetric and neonatal outcomes when a natural cycle was adopted compared with artificial treatments.…”

The optimal timing of frozen-thawed embryo transfer: delayed or not delayed? A systematic review and meta-analysis

“…Nevertheless, some studies have evaluated the clinical efficacy of long-acting GnRH agonists in general populations, and have identified a variety of proteins that facilitate embryo implantation in the endometrium, suggesting that long-acting agonists may enhance endometrial receptivity ( 30 ). In addition, another study showed that increased levels of GnRH-a directly modulate the expression of enzymes and cytokines and increase the expression of endometrial tolerance markers such as integrin b3 and leukaemia inhibitory factor, improving endometrial tolerance and clinical outcome in patients with intermediate and very thin endometrium ( 31 ). Xu’s et al ( 23 ) study used clomiphene citrate (CC) + human menopausal gonadotrophin (HMG) protocol for COS.…”

Finding of the optimal preparation and timing of endometrium in frozen-thawed embryo transfer: a literature review of clinical evidence

“…The results showed that AC FET protocol had a higher early pregnancy loss rate than true-NC FET (54.7% versus 33%, P<0.0001) ( 120 ). Similarly, a meta-analysis comparing the obstetric outcomes after NC versus AC FET showed that patients using AC FET protocol had a higher early pregnancy rate ( 121 ). A total of 26 RCTs and 113 cohort studies were included in a network meta-analysis, which compared 7 different FET protocols: true- NC; modified-NC; AC with GnRH agonist suppression; AC without GnRH agonist suppression; aromatase inhibitor (letrozole); clomiphene citrate; and exogenous gonadotropin ( 122 ) ( Figure 1 ).…”