Adenomyosis and ART (ADENOFERT)

July 6, 2023 updated by: Fabio Facchinetti, Azienda Ospedaliero-Universitaria di Modena

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

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.

Study Overview

Status

Recruiting

Conditions

Intervention / Treatment

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 Type

Interventional

Enrollment (Estimated)

500

Phase

  • Phase 4

Contacts and Locations

This section provides the contact details for those conducting the study, and information on where this study is being conducted.

Study Contact

Study Contact Backup

Study Locations

Participation Criteria

Researchers look for people who fit a certain description, called eligibility criteria. Some examples of these criteria are a person's general health condition or prior treatments.

Eligibility Criteria

Ages Eligible for Study

  • Adult

Accepts Healthy Volunteers

Yes

Description

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.

Study Plan

This section provides details of the study plan, including how the study is designed and what the study is measuring.

How is the study designed?

Design Details

  • Primary Purpose: Treatment
  • Allocation: Randomized
  • Interventional Model: Parallel Assignment
  • Masking: None (Open Label)

Arms and Interventions

Participant Group / 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.
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 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: Enantone
administration of depot leuprorelin 3.75 mg on day 21 of the previous luteal phase of the stimulation cycle.
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).
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
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
administration of depot leuprorelin 3.75 mg on day 21 of the previous luteal phase of the stimulation cycle.
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.

What is the study measuring?

Primary Outcome Measures

Outcome Measure
Measure Description
Time Frame
live birth after ART
Time Frame: 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.
Through study completion, an average of 2 year

Secondary Outcome Measures

Outcome Measure
Measure Description
Time Frame
Other ART and pregnancy outcomes
Time Frame: Through study completion, an average of 2 year
Uterine volume reduction between TV-US measurements at baseline and at time of COH onset
Through study completion, an average of 2 year
Other ART and pregnancy outcomes
Time Frame: Through study completion, an average of 2 year
Occurrence of poor responders
Through study completion, an average of 2 year
Other ART and pregnancy outcomes
Time Frame: Through study completion, an average of 2 year
Implantation rate
Through study completion, an average of 2 year
Other ART and pregnancy outcomes
Time Frame: Through study completion, an average of 2 year
Number of participants with ongoing pregnancy
Through study completion, an average of 2 year
Other ART and pregnancy outcomes
Time Frame: Immediately after the childbirth
Preterm delivery rate
Immediately after the childbirth
Other ART and pregnancy outcomes
Time Frame: Immediately after the childbirth
Pre-eclampsia occurrence
Immediately after the childbirth
Other ART and pregnancy outcomes
Time Frame: Immediately after the childbirth
Caesarean section rate
Immediately after the childbirth
Other ART and pregnancy outcomes
Time Frame: Immediately after the childbirth
Fetal malpresentation rate
Immediately after the childbirth
Other ART and pregnancy outcomes
Time Frame: Immediately after the childbirth
Small for gestational age rate
Immediately after the childbirth
Other ART and pregnancy outcomes
Time Frame: Immediately after the childbirth
Low birth weight (<5 centile) rate
Immediately after the childbirth
Other ART and pregnancy outcomes
Time Frame: Immediately after the childbirth
Postpartum hemorrhage(>500 ml) rate
Immediately after the childbirth

Collaborators and Investigators

This is where you will find people and organizations involved with this study.

Sponsor

Azienda Ospedaliero-Universitaria di Modena

Collaborators

University of Modena and Reggio Emilia
Ministero della Salute, Italy

Publications and helpful links

The person responsible for entering information about the study voluntarily provides these publications. These may be about anything related to the study.

General Publications

Study record dates

These dates track the progress of study record and summary results submissions to ClinicalTrials.gov. Study records and reported results are reviewed by the National Library of Medicine (NLM) to make sure they meet specific quality control standards before being posted on the public website.

Study Major Dates

Study Start (Actual)

March 27, 2023

Primary Completion (Estimated)

March 1, 2025

Study Completion (Estimated)

March 1, 2025

Study Registration Dates

First Submitted

June 13, 2023

First Submitted That Met QC Criteria

July 6, 2023

First Posted (Actual)

July 10, 2023

Study Record Updates

Last Update Posted (Actual)

July 10, 2023

Last Update Submitted That Met QC Criteria

July 6, 2023

Last Verified

July 1, 2023

More Information

Terms related to this study

Keywords

Additional Relevant MeSH Terms

Other Study ID Numbers

  • ENDO-2021-12371935

Plan for Individual participant data (IPD)

Plan to Share Individual Participant Data (IPD)?

NO

Drug and device information, study documents

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

This information was retrieved directly from the website clinicaltrials.gov without any changes. If you have any requests to change, remove or update your study details, please contact register@clinicaltrials.gov. As soon as a change is implemented on clinicaltrials.gov, this will be updated automatically on our website as well.

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