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ADENOFERT: Adenomyosis and ART

Sponsor
Azienda Ospedaliero-Universitaria di Modena (Other)
Overall Status
Recruiting
CT.gov ID
NCT05937490
Collaborator
University of Modena and Reggio Emilia (Other), Ministero della Salute, Italy (Other)
500
Enrollment
1
Location
4
Arms
23.2
Anticipated Duration (Months)
21.6
Patients Per Site Per Month

Study Details

Study Description

Brief Summary

The goal of this clinical trial is to:

  • Prospectively investigate the association of Adenomyosis with fertility outcomes in relation to COH protocols for ART (long or ultra- long protocol) with a preventive high-dose anti-inflammatory progestin such as DNG and to assess their association with pregnancy and neonatal outcomes (preterm delivery,pre-eclampsia,Caesarean section,fetal malpresentation,small for gestational age,low birth weight and postpartum hemorrhage).

  • Understand how the endometrial interface by studying the response of progesterone and DNG stimulated decidualization markers, correlating them with the success of ART protocol stimulation and to pregnancy specific outcomes

  • Evaluate the immune changes during the implantation period and in the different trimesters of the pregnancies after ART conception.

Condition or Disease Intervention/Treatment Phase
Phase 4

Detailed Description

Adenomyosis (internal endometriosis) may negatively influence fertility and perinatal outcomes. Inflammation, immune modulation, oxidative stress, extracellular matrix remodelling, aberrant angiogenesis have been implicated in altered oocyte development, uterine receptivity, implantation, successful maintenance of pregnancy. An improvement for infertile women could be a longer GnRH(gonadotropin-releasing hormone) agonist protocol with the addition of a preventive high-dose progestin treatment during controlled ovarian hyperstimulation (COH) Infertile women with transvaginal ultrasound (TV-US) based diagnosis of adenomyosis treated will be randomized into 3 different protocols of COH. Study group 1: Long COH, Study group 2: Long COH + high-dose dienogest (DNG), Study Group 3: Ultra-long COH. COH in controls without adenomyosis will be performed using a long GnRH agonist protocol as previous described or using a flexible GnRH antagonist protocol, according to clinical practice. Our aim is to include a total of n=250 women with adenomyosis and n=250 healthy women of a similar age and basal features at the first ART attempt. The primary outcome will be the number of live birth defined as delivery of one or more live-born infant at > 22 weeks of gestation. Many secondary outcomes will be evaluated as well.

Subsequent eventual ongoing pregnancies will be followed as in normal clinical practice, in particular for the risk of preterm delivery, pre-eclampsia, Caesarean section, fetal malpresentation,small for gestational age, low birth weight and postpartum hemorrhage. In a subgroup of randomized women, the role of endometrial decidualization and its mechanisms will be evaluated in endometrial cells in vitro looking at the response to progesterone and DNG stimulated decidualization markers (in particular osteopontin and prolactin). The different responses will be related to the outcome of ARt and pregnancy related outcomes (preterm delivery, pre-eclampsia, Caesarean section, fetal malpresentation, small for gestational age, low birth weight and postpartum hemorrhage).

Another in vitro study will evaluate the immune system contribution in the implantation period and its changes in the different trimesters of pregnancies after ART conception in women with and without adenomyosis. Blood samples will be obtained - Baseline: prior to ovarian stimulation - Post ovarian stimulation (day of HCG, human chorionic gonadotropin, administration) - Post implantation (2 weeks after embryo transfer, the day of first beta HCG measurement -Second (18-24 gestational weeks) and -Third trimester (28-32 gestational week) of eventual subsequent pregnancies).

The aim of this study will be to identify immunological markers such as cellular component and related cytokines in healthy women and women with adenomyosis that undergo ART. In particular the immune system cells population and relative cytokines, the frequency of immune system cells, the interleukins profile, T cells activity and of specific receptors of pregnancy hormone involved in T cell activity will be studied. These results will be linked with estradiol, progesterone and nitric oxide in vivo levels: this will be very important in order to prevent birth losses and to propose new therapies and targets to improve early stages of blastocyst implantation in women with adenomyosis. Forty women with adenomyosis vs. 40 healthy controls will be included in this last part of the study.

Study Design

Study Type:
Interventional
Anticipated Enrollment :
500 participants
Allocation:
Randomized
Intervention Model:
Parallel Assignment
Masking:
None (Open Label)
Primary Purpose:
Treatment
Official Title:
Assisted Reproductive Technology (ART) and Pregnancy Outcomes in Women With Adenomyosis (Internal Endometriosis) According to Stimulation Protocol in Relation to Immunological and Endometrial Features: a Prospective, Randomized Study
Actual Study Start Date :
Mar 27, 2023
Anticipated Primary Completion Date :
Mar 1, 2025
Anticipated Study Completion Date :
Mar 1, 2025

Arms and Interventions

Arm Intervention/Treatment
Experimental: Group 1 (Long)

COH will be performed using a long GnRH agonist protocol(administration of depot leuprorelin 3.75 mg on day 21 of the previous luteal phase of the stimulation cycle). COH will be commenced when pituitary desensitization was achieved(~14 days after the initiation of GnRH agonists) as evidenced by the absence of ovarian follicles >10 mm and endometrial thickness <4 mm on TV-US examination.

Drug: Enantone
administration of depot leuprorelin 3.75 mg on day 21 of the previous luteal phase of the stimulation cycle.
Experimental: Group 2 (Long + high dose DNG)

Before COH, patients will be treated with DNG at high dose (2 mg+2 mg/day) for 28 days, from the first day of previous menstrual cycle. COH will be performed using a long GnRH agonist protocol (administration of depot leuprorelin 3.75 mg on day 21 of the previous luteal phase of the stimulation cycle). COH will be commenced when pituitary desensitization was achieved (~14 days after the initiation of GnRH agonists), as defined above.

Drug: Dienogest 2 MG (milligram)
Before COH, patients will be treated with DNG at high dose (2 mg+2 mg/day) for 28 days, from the first day of previous menstrual cycle. COH will be performed using a long GnRH agonist protocol (administration of depot leuprorelin 3.75 mg on day 21 of the previous luteal phase of the stimulation cycle).
Other Names:
  • Enantone

    • Drug: Enantone
    COH will be performed using a ultra-long GnRH agonist protocol (administration of the first depot leuprorelin 3.75 mg on day 21 of menstrual cycle, repeated after 28 days for other two times).
    Experimental: Group 3 (ultra-long):

    COH will be performed using a ultra-long GnRH agonist protocol (administration of the first depot leuprorelin 3.75 mg on day 21 of menstrual cycle, repeated after 28 days for other two times). COH will be commenced when pituitary desensitization was achieved (~14 days after the initiation of GnRH agonists), as described above.

    Drug: Enantone
    COH will be performed using a ultra-long GnRH agonist protocol (administration of the first depot leuprorelin 3.75 mg on day 21 of menstrual cycle, repeated after 28 days for other two times).
    Other: Control group (without adenomyosis)

    COH will be performed by using a long GnRH agonist protocol as previous described or using a flexible GnRH antagonist protocol. During TV-US monitoring, when at least one follicle reached 14 mm in diameter, to achieve LH (luteinizing hormone) suppression avoiding spontaneous ovulation, GnRH antagonist 0.25 mg/day will be added subcutaneously until the day of HCG administration.

    Drug: long GnRH agonist or flexible GnRH antagonist protocol.
    During TV-US monitoring, when at least one follicle reached 14 mm in diameter, to achieve LH suppression avoiding spontaneous ovulation, GnRH antagonist 0.25 mg/day will be added subcutaneously until the day of HCG administration.

    Outcome Measures

    Primary Outcome Measures

    1. live birth after ART [Through study completion, an average of 2 year]

      Primary Outcome:Number of live birth after ART attempt defined as delivery of one or more live-born infant at >22 weeks of gestation.

    Secondary Outcome Measures

    1. Other ART and pregnancy outcomes [Through study completion, an average of 2 year]

      Uterine volume reduction between TV-US measurements at baseline and at time of COH onset

    2. Other ART and pregnancy outcomes [Through study completion, an average of 2 year]

      Occurrence of poor responders

    3. Other ART and pregnancy outcomes [Through study completion, an average of 2 year]

      Implantation rate

    4. Other ART and pregnancy outcomes [Through study completion, an average of 2 year]

      Number of participants with ongoing pregnancy

    5. Other ART and pregnancy outcomes [Immediately after the childbirth]

      Preterm delivery rate

    6. Other ART and pregnancy outcomes [Immediately after the childbirth]

      Pre-eclampsia occurrence

    7. Other ART and pregnancy outcomes [Immediately after the childbirth]

      Caesarean section rate

    8. Other ART and pregnancy outcomes [Immediately after the childbirth]

      Fetal malpresentation rate

    9. Other ART and pregnancy outcomes [Immediately after the childbirth]

      Small for gestational age rate

    10. Other ART and pregnancy outcomes [Immediately after the childbirth]

      Low birth weight (<5 centile) rate

    11. Other ART and pregnancy outcomes [Immediately after the childbirth]

      Postpartum hemorrhage(>500 ml) rate

    Eligibility Criteria

    Criteria

    Ages Eligible for Study:
    18 Years to 42 Years
    Sexes Eligible for Study:
    Female
    Accepts Healthy Volunteers:
    Yes
    Inclusion Criteria:

    • Adenomyosis of the uterus defined with at least one of the following features: (1) heterogeneous myometrium; (2) hypoechoic striation in the myometrium; (3) myometrial anechoic lacunae or cysts; (4) asymmetrical myometrial thickening of the uterine walls.

    • Couples who are undergoing a cycle of IVF/ICSI, where a cycle is defined as egg collection following ovarian stimulation.

    • First or second IVF or ICSI attempt.

    • Absence of severe premature ovarian insufficiency defined by antral follicle count < 8 and AMH (anti-mullerian hormone) < 1ng/ml

    • Meet the criteria from the Italian law to be included in a ART program.

    • The female partner is ≥18 and < 42 years of age.

    • The female partner has a BMI <30.

    • Both partners are willing and able to provide written informed consent.

    Exclusion Criteria:

    • Concurrent and/or recent involvement in other research that is likely to interfere with the intervention within the previous 3 months of study enrolment.

    • Other potential causes of implantation failure: in situ leiomyoma, hydrosalpinx, malformed uterus (unicornis, bicornis, septate, duplex), antiphospholipid syndrome

    • Uterine fibroids (untreated FIGO, International Federation of Gynecology and Obstetrics, Type 0-I-II and type III-IV fibroids > 3 cm)

    • Use of GnRH analogues within previous 3 months.

    • Extremely severe male factor infertility (sperm count < 1x 10 6 /ml, use o surgically retrieved spermatozoa)

    • Positive plasma viral load for human immunodeficiency virus(HIV), hepatitis C virus (HCV) or hepatitis B virus (HBV) for one (or both) in the couple during the year before inclusion

    • Couples unable to give fully informed consent to the study.

    Contacts and Locations

    Locations

    Site City State Country Postal Code
    1 Azienda Ospedaliero-Universitaria di Modena Modena Italy 41124

    Sponsors and Collaborators

    • Azienda Ospedaliero-Universitaria di Modena
    • University of Modena and Reggio Emilia
    • Ministero della Salute, Italy

    Investigators

    None specified.

    Study Documents (Full-Text)

    None provided.

    More Information

    Publications

    Responsible Party:
    Fabio Facchinetti, Head of Obstetrics and Gynecology at the University Hospital unimore, Azienda Ospedaliero-Universitaria di Modena
    ClinicalTrials.gov Identifier:
    NCT05937490
    Other Study ID Numbers:
    • ENDO-2021-12371935
    First Posted:
    Jul 10, 2023
    Last Update Posted:
    Jul 10, 2023
    Last Verified:
    Jul 1, 2023
    Individual Participant Data (IPD) Sharing Statement:
    No
    Plan to Share IPD:
    No
    Studies a U.S. FDA-regulated Drug Product:
    No
    Studies a U.S. FDA-regulated Device Product:
    No
    Product Manufactured in and Exported from the U.S.:
    No
    Keywords provided by Fabio Facchinetti, Head of Obstetrics and Gynecology at the University Hospital unimore, Azienda Ospedaliero-Universitaria di Modena
    Adenomyosis
    Assisted reproductive technology
    ART
    Additional relevant MeSH terms:
    Adenomyosis
    Leuprolide
    Dienogest

    Study Results

    No Results Posted as of Jul 10, 2023