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Modified Downregulation for Women With Adenomyosis of the Uterus Prior to Frozen-thawed Embryo Transfer. (MODA)

Primary Purpose

Adenomyosis

Status
Recruiting
Phase
Phase 4
Locations
United Kingdom
Study Type
Interventional
Intervention
GnRH analogue downregulation
Participant questionnaire
Sponsored by
University College, London
About
Eligibility
Locations
Arms
Outcomes
Full info

About this trial

This is an interventional treatment trial for Adenomyosis focused on measuring In vitro fertilisation, Assisted conception, Randomised controlled trial, Down-regulation

Eligibility Criteria

18 Years - 42 Years (Adult)FemaleDoes not accept healthy volunteers

Inclusion Criteria:

  1. Couples who are undergoing a cycle of IVF/ICSI, where a cycle is defined as egg collection following ovarian stimulation.
  2. The female partner is ≥18 and < 42 years of age.
  3. The female partner has a BMI <30.
  4. Two out of three of the following criteria are met: AMH >5.4, FSH <8.9, antral follicle count >4.
  5. Moderate or severe adenomyosis of the uterus diagnosed on ultrasound scan.
  6. Both partners are willing and able to provide written informed consent.

Exclusion Criteria:

  1. Concurrent and/or recent involvement in other research that is likely to interfere with the intervention within the previous 3 months of study enrolment.
  2. Previous open or laparoscopic myomectomy
  3. Uterine fibroids (untreated FIGO Type 0-I-II and type III-IV fibroids > 3 cm)
  4. Use of GnRH analogues within previous 3 months.
  5. Severe male factor infertility (sperm count < 2 x 106/ml, use of surgically retrieved spermatozoa)
  6. Couples who in the opinion of the researcher by virtue of language or learning impairment would be unable to give fully informed consent to the study.

Sites / Locations

  • University College London HospitalRecruiting

Arms of the Study

Arm 1

Arm 2

Arm Type

Other

Experimental

Arm Label

Standard downregulation with GnRH analogue

Prolonged downregulation with GnRH analogue

Arm Description

Participants in this arm will be assigned to the routine IVF protocol currently being used in the investigators' IVF unit, as outlined below, with one week of downregulation. Downregulation is the suppression of the ovaries during an IVF cycle in order to perform controlled ovarian stimulation and prevent premature ovulation. Start progesterone (Norethisterone 5mg twice daily orally) on day 14 of downregulation cycle and continue for 11 days. Start GnRH analogue (Buserelin 0.5ml subcutaneously once daily) on day 21 of downregulation cycle and reduce to 0.2ml on day 1 of bleed. Baseline scan on day 1 - 5 of bleed and start oestrogen (Progynova 2mg three times daily orally). Serial scanning from day 10 until endometrial thickness more than 8mm. Once endometrial thickness more than 8mm start progesterone (Cyclogest 400mg twice daily vaginally/rectally and Lubion 25mg twice daily subcutaneously) and proceed to embryo transfer on appropriate day for embryo age.

Participants in this arm will be exposed to an additional five weeks of downregulation using a GnRH analogue. Downregulation is the suppression of the ovaries during an IVF cycle in order to perform controlled ovarian stimulation and prevent premature ovulation. Baseline scan on day 1-5 of bleed and administer GnRH analogue (Leuprorelin acetate 3.75 mg subcutaneously single injection). 28 days later administer second dose of GnRH analogue (Leuprorelin acetate 1.875 mg subcutaneously), and 21 days later start oestrogen (Progynova 2 mg three times daily orally). Serial scanning from day 10 of oestrogen until endometrial thickness more than 8mm. Once endometrial thickness more than 8mm start progesterone (Cyclogest 400mg twice daily vaginally/rectally and Lubion 25mg twice daily subcutaneously) and proceed to embryo transfer on appropriate day for embryo age.

Outcomes

Primary Outcome Measures

Clinical pregnancy rate
Clinical pregnancy is defined as an intrauterine pregnancy with a visible heart beat older than 6 weeks gestation.

Secondary Outcome Measures

Livebirth
Pregnancy greater than 24 weeks
Pregnancy loss
Includes biochemical pregnancy, miscarriage, ectopic pregnancy, stillbirth, termination of pregnancy
Gestational age at delivery
Number of weeks at which infant is delivered
Birthweight at delivery
Weight at time of delivery
Neonatal mortality
The death of a baby before or during birth after 24 weeks of gestation
Major cogenital anomaly
Major cogenital anomaly
Serious medication reaction
Serious medication reaction
Number of frozen embryos available for transfer
Number of frozen embryos available for transfer
Number of days to achieve optimal endometrial thickness
Number of days to achieve optimal endometrial thickness
Presence and severity of adenmyosis-related symptoms
Menorrhagia, dysmenorrhoea

Full Information

First Posted
May 7, 2019
Last Updated
February 11, 2021
Sponsor
University College, London
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1. Study Identification

Unique Protocol Identification Number
NCT03946722
Brief Title
Modified Downregulation for Women With Adenomyosis of the Uterus Prior to Frozen-thawed Embryo Transfer.
Acronym
MODA
Official Title
Modified Downregulation for Women With Adenomyosis of the Uterus Prior to Frozen-thawed Embryo Transfer.
Study Type
Interventional

2. Study Status

Record Verification Date
February 2021
Overall Recruitment Status
Recruiting
Study Start Date
August 17, 2020 (Actual)
Primary Completion Date
August 17, 2023 (Anticipated)
Study Completion Date
May 17, 2024 (Anticipated)

3. Sponsor/Collaborators

Responsible Party, by Official Title
Sponsor
Name of the Sponsor
University College, London

4. Oversight

Studies a U.S. FDA-regulated Drug Product
No
Studies a U.S. FDA-regulated Device Product
No
Data Monitoring Committee
Yes

5. Study Description

Brief Summary
1 in 7 couples experience difficulty in conceiving. Many will require in vitro fertilization (IVF). IVF involves an initial period of downregulation to suppress the ovaries and prevent premature ovulation. Hormone injections are then used to stimulate a woman's ovaries to produce eggs which are removed by a minor operation. The harvested eggs are mixed with sperm to create embryos in the laboratory. These embryos are replaced in the womb a few days after they are created (fresh embryo transfer). Any remaining embryos are frozen such that they can be thawed and transferred at a later date (frozen thawed embryo transfer, FTET). The investigators have previously shown that the presence of moderate or severe adenomyosis significantly reduces the chance of clinical pregnancy after embryo transfer. The purpose of this study is to examine whether it is possible to improve the chance of clinical pregnancy in these women by modifying the IVF protocol they undergo for FTET. The hypothesis is that a prolonged downregulation regimen for women with adenomyosis would reduce the inflammatory reaction in the endometrium of these women and thus improve the chance of implantation after embryo transfer. Consenting patients will be offered FTET. Those proceeding will be randomized to one of two protocols (A - standard protocol vs. B - prolonged downregulation protocol). Women will also be offered a questionnaire before and after IVF treatment to assess their adenomyosis symptoms . The primary outcome of the study is clinical pregnancy defined as an intrauterine pregnancy with a visible heart beat older than 6 weeks gestation. Secondary outcomes include livebirth, pregnancy loss (biochemical pregnancy, miscarriage, ectopic pregnancy, stillbirth, termination of pregnancy), gestational age at delivery, birth weight, neonatal mortality, major congenital anomaly, serious medication reaction, number of frozen embryos available for transfer, number of days to achieve optimal endometrial thickness.
Detailed Description
Objectives: The primary objective is to determine whether modified downregulation before embryo transfer improves the chance of clinical pregnancy after embryo transfer in women with moderate/severe adenomyosis of the uterus. A secondary objective is to evaluate the impact of IVF on adenomyosis-related symptom presence, severity and progression. Type of trial: A randomised, controlled, multi-site trial in women with moderate/severe adenomyosis of the uterus undergoing frozen-thawed embryo transfer. Trial design and methods: This will be a prospective, randomised controlled study of patients undergoing assisted conception. Prior to assisted conception all patients are referred for a diagnostic scan. The scan is done in a systematic fashion starting from the uterus in longitudinal plane and measurement of the endometrial thickness. The probe is then rotated to the transverse plane and the uterus scanned from the cervix to the fundus with any uterine pathologies noted and measured in 3 orthogonal planes. A 3D ultrasound volume is then be obtained and saved starting with the uterus in longitudinal view making sure to include all uterine tissue in the 3D volume sweep. Any congenital or acquired uterine anomalies are diagnosed according to published diagnostic criteria. Adenomyosis is diagnosed according to the diagnostic criteria outlined by Exacoustos et al and Naftalin et al and graded for severity according to the number of adenomyosis features present (assign a score of 1 for each of: i) asymmetrical myometrial thickening, ii) parallel shadowing, iii) myometrial cysts, iv) disrupted endometrial myometrial junction, v) endometrial striae, vi) endometrial islands, vii) adenomyoma). The operator then sweeps to the adnexae, starting from the left, identifies and measures the ovaries in 3 orthogonal planes and documents the antral follicle count. Each ovary is examined for the presence of cysts as well as for mobility and tenderness by gentle pressure with the ultrasound probe. Once the ovaries have been assessed the operator examines the pouch of Douglas for the presence of free fluid as well as any evidence of endometriosis such as obliteration and/or endometriotic nodules as previously described by Holland et al. Videosonography for a period of 5 mins will be performed. Once the ultrasound scan is concluded all information is added to the clinical database. Patients found to have moderate or severe adenomyosis (4 or more features of adenomyosis as defined by Mavrelos et al) on this scan will be approached by a member of the research team. The researcher will describe the project and provide a copy of the patient information leaflet. Patients will then be invited to return to the unit at a designated time for a scan by a member of the research team. On return to the unit the researcher will repeat the scan to confirm eligibility. After the scan and once eligibility is confirmed patients will be asked to confirm if they want to participate in the trial. If they agree they will be asked to sign a consent form. Participating patients will then be followed through the process of assisted conception. Consenting patients will be randomized to one of two protocols (A vs. B) for frozen thawed embryo transfer. Protocol A (standard) - start Norethisterone on day 14 of downregulation cycle and continue for 11 days. Start Buserelin 0.5ml on day 21 of downregulation cycle and reduce to 0.2ml on day 1 of bleed. Baseline scan on day 1 - 5 of bleed and start Progynova 2mg TDS PO. Serial scanning from day 10 until endometrial thickness more than 8mm. Once endometrial thickness more than 8mm start cyclogest 400mg BD PV/PR and lubion 25mg BD and proceed to embryo transfer on appropriate day for embryo age. Protocol B (modified) - Baseline scan on day 1-5 of bleed and administer Triptorelin acetate 3.75 mg. 28 days later administer 1.875 mg Triptorelin acetate and 21 days later start Progynova 2 mg TDS PO. Serial scanning from day 10 of Progynova until endometrial thickness more than 8mm. Once endometrial thickness more than 8mm start Cyclogest 400mg BD PV/PR and Lubion 25mg BD and proceed to embryo transfer on appropriate day for embryo age. Patients will be offered the opportunity to complete an adenomyosis symptom assessment questionnaire at the start of their treatment, and again two months after completion of treatment. Trial duration per participant: 8-12 weeks Estimated total duration: 3 years. Planned trial sites: Multi-site. Total number of participants planned: 162. Sample size estimation: The investigators recently reported that the clinical pregnancy rate in women with moderate to severe adenomyosis is 22.9% vs. 42.7% in women with mild disease. They speculate that the modified protocol will improve the chance of clinical pregnancy to be equivalent to those with mild disease. 162 patients are required to have an 80% chance of detecting an increase in the clinical pregnancy rate from 22.9% in the control group to 42.7% in the experimental group, as significant at the 5% level (α = 0.05, β = 0.20). The trial is powered at 80%. Statistical methodology and analysis: The investigators will first perform univariate analysis to explore significant differences in the demographic characteristics (age, duration of subfertility), and clinical factors known to impact the outcome of assisted conception (number of oocytes retrieved, number and quality of embryos transferred) between women randomized to standard and modified FTET protocol. In the second stage analysis the investigators will perform univariate analysis to compare the primary outcome (clinical pregnancy rate after FTET) between woman randomized to the standard and modified clinical protocol. The investigators will perform univariate analysis to compare secondary outcomes (livebirth, pregnancy loss (biochemical pregnancy, miscarriage, ectopic pregnancy, stillbirth, termination of pregnancy), gestational age at delivery, birth weight, neonatal mortality, major congenital anomaly, serious medication reaction, number of frozen embryos available for transfer, number of days to achieve optimal endometrial thickness). They will perform a sub-analysis for women with co-existing endometriosis. All models will be estimated in the Stat 12 statistical software.

6. Conditions and Keywords

Primary Disease or Condition Being Studied in the Trial, or the Focus of the Study
Adenomyosis
Keywords
In vitro fertilisation, Assisted conception, Randomised controlled trial, Down-regulation

7. Study Design

Primary Purpose
Treatment
Study Phase
Phase 4
Interventional Study Model
Parallel Assignment
Model Description
This is a prospective, randomised controlled trial with two parallel arms. Frozen thawed embryo transfer takes approximately 6 weeks in a standard protocol, including a one week period of downregulation. Downregulation will be extended by five weeks in the modified protocol compared to the standard protocol. Participants will be followed up until the pregnancy outcome is determined, maximum 9 months after embryo transfer.
Masking
None (Open Label)
Masking Description
It will not be possible to perform blinding due to the difference in frequency of administration of medication between the two protocols, therefore an open label method will be used.
Allocation
Randomized
Enrollment
162 (Anticipated)

8. Arms, Groups, and Interventions

Arm Title
Standard downregulation with GnRH analogue
Arm Type
Other
Arm Description
Participants in this arm will be assigned to the routine IVF protocol currently being used in the investigators' IVF unit, as outlined below, with one week of downregulation. Downregulation is the suppression of the ovaries during an IVF cycle in order to perform controlled ovarian stimulation and prevent premature ovulation. Start progesterone (Norethisterone 5mg twice daily orally) on day 14 of downregulation cycle and continue for 11 days. Start GnRH analogue (Buserelin 0.5ml subcutaneously once daily) on day 21 of downregulation cycle and reduce to 0.2ml on day 1 of bleed. Baseline scan on day 1 - 5 of bleed and start oestrogen (Progynova 2mg three times daily orally). Serial scanning from day 10 until endometrial thickness more than 8mm. Once endometrial thickness more than 8mm start progesterone (Cyclogest 400mg twice daily vaginally/rectally and Lubion 25mg twice daily subcutaneously) and proceed to embryo transfer on appropriate day for embryo age.
Arm Title
Prolonged downregulation with GnRH analogue
Arm Type
Experimental
Arm Description
Participants in this arm will be exposed to an additional five weeks of downregulation using a GnRH analogue. Downregulation is the suppression of the ovaries during an IVF cycle in order to perform controlled ovarian stimulation and prevent premature ovulation. Baseline scan on day 1-5 of bleed and administer GnRH analogue (Leuprorelin acetate 3.75 mg subcutaneously single injection). 28 days later administer second dose of GnRH analogue (Leuprorelin acetate 1.875 mg subcutaneously), and 21 days later start oestrogen (Progynova 2 mg three times daily orally). Serial scanning from day 10 of oestrogen until endometrial thickness more than 8mm. Once endometrial thickness more than 8mm start progesterone (Cyclogest 400mg twice daily vaginally/rectally and Lubion 25mg twice daily subcutaneously) and proceed to embryo transfer on appropriate day for embryo age.
Intervention Type
Drug
Intervention Name(s)
GnRH analogue downregulation
Intervention Description
Downregulation is the suppression of the ovaries during an IVF cycle in order to perform controlled ovarian stimulation and prevent premature ovulation. Participants will be exposed to one week of downregulation using a GnRH analogue in the standard downregulation arm and 6 weeks of downregulation using a GnRH analogue in the modified downregulation arm.
Intervention Type
Other
Intervention Name(s)
Participant questionnaire
Intervention Description
Participant will be offered the opportunity to complete an adenomyosis symptom assessment questionnaire at the start of their treatment, and again two months after completion of treatment.
Primary Outcome Measure Information:
Title
Clinical pregnancy rate
Description
Clinical pregnancy is defined as an intrauterine pregnancy with a visible heart beat older than 6 weeks gestation.
Time Frame
6 weeks after embryo transfer
Secondary Outcome Measure Information:
Title
Livebirth
Description
Pregnancy greater than 24 weeks
Time Frame
9 months after embryo transfer
Title
Pregnancy loss
Description
Includes biochemical pregnancy, miscarriage, ectopic pregnancy, stillbirth, termination of pregnancy
Time Frame
9 months after embryo transfer
Title
Gestational age at delivery
Description
Number of weeks at which infant is delivered
Time Frame
9 months after embryo transfer
Title
Birthweight at delivery
Description
Weight at time of delivery
Time Frame
9 months after embryo transfer
Title
Neonatal mortality
Description
The death of a baby before or during birth after 24 weeks of gestation
Time Frame
9 months after embryo transfer
Title
Major cogenital anomaly
Description
Major cogenital anomaly
Time Frame
9 months after embryos transfer
Title
Serious medication reaction
Description
Serious medication reaction
Time Frame
9 months after embryo transfer
Title
Number of frozen embryos available for transfer
Description
Number of frozen embryos available for transfer
Time Frame
Day of embryo transfer
Title
Number of days to achieve optimal endometrial thickness
Description
Number of days to achieve optimal endometrial thickness
Time Frame
Start of endometrial preparation until day of embryo transfer
Title
Presence and severity of adenmyosis-related symptoms
Description
Menorrhagia, dysmenorrhoea
Time Frame
2 months after embryo transfer

10. Eligibility

Sex
Female
Gender Based
Yes
Gender Eligibility Description
Adenomyosis of the uterus is a condition which affects women only.
Minimum Age & Unit of Time
18 Years
Maximum Age & Unit of Time
42 Years
Accepts Healthy Volunteers
No
Eligibility Criteria
Inclusion Criteria: Couples who are undergoing a cycle of IVF/ICSI, where a cycle is defined as egg collection following ovarian stimulation. The female partner is ≥18 and < 42 years of age. The female partner has a BMI <30. Two out of three of the following criteria are met: AMH >5.4, FSH <8.9, antral follicle count >4. Moderate or severe adenomyosis of the uterus diagnosed on ultrasound scan. 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. Previous open or laparoscopic myomectomy Uterine fibroids (untreated FIGO Type 0-I-II and type III-IV fibroids > 3 cm) Use of GnRH analogues within previous 3 months. Severe male factor infertility (sperm count < 2 x 106/ml, use of surgically retrieved spermatozoa) Couples who in the opinion of the researcher by virtue of language or learning impairment would be unable to give fully informed consent to the study.
Central Contact Person:
First Name & Middle Initial & Last Name or Official Title & Degree
Dimitrios Mavrelos, MRCOG MD
Phone
02034476550
Email
dimitrios.mavrelos@nhs.net
First Name & Middle Initial & Last Name or Official Title & Degree
Sania Latif, MRCOG
Email
sanialatif@nhs.net
Facility Information:
Facility Name
University College London Hospital
City
London
ZIP/Postal Code
NW1 2BU
Country
United Kingdom
Individual Site Status
Recruiting
Facility Contact:
First Name & Middle Initial & Last Name & Degree
Dimitrios Mavrelos, MRCOG MD
Email
dimitrios.mavrelos@nhs.net
First Name & Middle Initial & Last Name & Degree
Sania Latif, MRCOG
Email
sanialatif@nhs.net

12. IPD Sharing Statement

Plan to Share IPD
No
IPD Sharing Plan Description
Individual participant data will not be shared outside of the research group.
Citations:
PubMed Identifier
34716161
Citation
Latif S, Wattar BHA, Balachandren N, Lukaszewski T, Saridogan E, Yasmin E, Serhal P, Mavrelos D. Effectiveness of modified downregulation for women with moderate and severe adenomyosis of the uterus prior to frozen thawed embryo transfer (MODA) study protocol: a pragmatic randomised-controlled trial. BMJ Open. 2021 Oct 29;11(10):e050248. doi: 10.1136/bmjopen-2021-050248.
Results Reference
derived

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Modified Downregulation for Women With Adenomyosis of the Uterus Prior to Frozen-thawed Embryo Transfer.

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