|Year : 2020 | Volume
| Issue : 2 | Page : 511-515
Predictive value of C-reactive protein level and pregnancy rate in intracytoplasmic sperm injection cycle
Alaa E. F. A. Elhalaby1, Abd E. E. Shaheen1, Doha G. M. Hashish2, Nabih I El-Khouly1
1 Department of Obstetrics and Gynecology, Faculty of Medicine, Menoufia University, Menoufia, Egypt
2 Department of Obstetrics and Gynecology, Shebin El Kom Teaching Hospital, Menoufia, Egypt
|Date of Submission||03-Dec-2019|
|Date of Decision||08-Jan-2020|
|Date of Acceptance||11-Jan-2020|
|Date of Web Publication||27-Jun-2020|
Nabih I El-Khouly
Gamal Abd El Nasr Street, Shebin El Kom, Menoufia
Source of Support: None, Conflict of Interest: None
The aim was to determine the possible relation between the maternal serum C-reactive protein (CRP) level and outcome of controlled ovarian stimulation and pregnancy rate in patients undergoing in-vitro fertilization (IVF) or intracytoplasmic sperm injection.
Controlled ovarian hyperstimulation is apparently a key factor in the success of IVF embryo transfer. CRP is a sensitive marker in the inflammatory process rises following hormonal stimulation and does not have diurnal alterations but administration of exogenous estrogen increases its level.
Materials and methods
This prospective cohort study was conducted at the outpatient clinic in a Private Infertility Unit, Menoufia, Egypt, from November 2018 to August 2019. This study included 100 infertile patients who were candidates for IVF/intracytoplasmic sperm injection and fulfilled the inclusion and exclusion criteria. Full history was taken. Participants underwent CRP measuring at three times, at the day of beginning of ovarian stimulation, ovum pickup, and the day of transfer. Two groups were identified for those who get pregnant and those who did not get pregnant.
Patients whose CRP level decreased on transfer day (19 cases) 14 got pregnant (73.7%), whereas only five failed to get pregnant (26.3%). Patients whose CRP level increased on transfer day (81 cases) 52 got pregnant (64%), whereas 29 failed to get pregnant (36%).
Ovulation induction is an inflammatory process leading to increased levels of CRP but with different patterns. These patterns of changes failed to be used as markers of successful outcome of IVF treatment.
Keywords: C-reactive protein, intracytoplasmic sperm injection, predictive, pregnancy
|How to cite this article:|
Elhalaby AE, Shaheen AE, Hashish DG, El-Khouly NI. Predictive value of C-reactive protein level and pregnancy rate in intracytoplasmic sperm injection cycle. Menoufia Med J 2020;33:511-5
|How to cite this URL:|
Elhalaby AE, Shaheen AE, Hashish DG, El-Khouly NI. Predictive value of C-reactive protein level and pregnancy rate in intracytoplasmic sperm injection cycle. Menoufia Med J [serial online] 2020 [cited 2020 Oct 28];33:511-5. Available from: http://www.mmj.eg.net/text.asp?2020/33/2/511/287792
| Introduction|| |
C-reactive protein (CRP) is an acute inflammatory protein that increases up to 1000-fold at sites of infection or inflammation. CRP is produced as a homopentameric protein, termed native CRP (nCRP), which can irreversibly dissociate at sites of inflammation and infection into five separate monomers, termed monomeric CRP (mCRP). CRP is synthesized primarily in liver hepatocytes but also by smooth muscle cells, macrophages, endothelial cells, lymphocytes, and adipocytes. Evidence suggests that estrogen in the form of hormone replacement therapy influences CRP levels in the elderly. CRP protein enforces innate immunity and protection against tissue damage from damaged, dead, or dying organisms. Therefore, CRP by increasing the renovation speed of damaged tissues results in healing of these tissues; also, it has been shown that psychological stress causes a rise in inflammatory proteins such as CRP, which can result in poor prognosis and pregnancy complications. This protein as a sensitive marker in inflammatory process rises following hormonal stimulation and does not have diurnal alterations, but administration of exogenous estrogen increases its level,,. Controlled ovarian hyperstimulation is apparently a key factor in the success of in-vitro fertilization (IVF)-embryo transfer; ovarian stimulation is defined as pharmacological treatment with the intention of inducing the development of ovarian follicles. Controlled hyperstimulation of the ovary and specially puncture of the ovaries in IVF or intracytoplasmic sperm injection (ICSI) cycles is probably associated with some degrees of tissue damage and therefore changes in CRP concentrations. These changes may affect the success rate of IVF/ICSI, implantation, and pregnancy,. The aim of this study was to determine the possible relation between the maternal serum CRP level and outcome of controlled ovarian stimulation and pregnancy rate in patients undergoing IVF or ICSI.
| Materials and Methods|| |
This prospective cohort study was conducted at the outpatient clinic in a Private Infertility Unit, Menoufia, Egypt from November 2018 to August 2019, after obtaining an approval from Hospital Local Medical Ethics Committee and informed consent was obtained from all study participants after explanation of the nature and scope of the study. The study was conducted on 100 infertile patients who were candidates for IVF/ICSI; the selected cases were fulfilled the following the inclusion criteria: age from 20 to 35 years who were candidates for IVF/ICSI due to primary infertility or secondary infertility, with normal uterus and fallopian tubes on HSG and/or hysteroscopy. Exclusion criteria: Those with positive CRP level at the day of beginning of induction protocol; those who had endometriosis or myoma at the beginning of induction protocol; and those who had any medical problems were excluded from this study. All participants were subjected to full medical and surgical history, general clinical examination, and routine laboratory investigations. We documented infertility duration, number of oocytes retrieved, grading of oocytes, number of embryos transferred, grading and quality of embryos, and comment on transfer procedure. Patients underwent treatment by pituitary desensitization using the gonadotrophin-releasing hormone (GnRH) agonist (Superfact, Aventis Pharma, Germany) from day 21 of the cycle proceeding the stimulation cycle. Then from the second to the third day of the menstrual cycle, the patients received human menopausal gonadotrophin (HMG) injection (Merional, IBSA, Switzerland), 150–300 units daily. When at least three follicles had a diameter exceeding 16–18 mm and estradiol concentration was appropriate 10 000 IU of HCG was administered. At 34–36 h after HCG injection transvaginal ultrasound-guided ovum pickup was done. Then only metaphase II oocytes identified by the presence of the first polar body were chosen for fertilization. ICSI was performed 3–6 h after oocyte recovery and 48–72 h afterwards; fetuses from ICSI were transferred with Labotect embryo transfer catheter. After fulfillment of the above criteria and prerequisites, all the eligible patients underwent serum sampling of CRP in different times as follows: The day of ovarian stimulation start (day-S), ovum pick-up (day-OPU), and day of transfer (day-transfer). All samples were centrifuged for 10 min at 1000 g and were stored at −20°C until the final assay. The gathered samples were evaluated by comparative the enzyme-linked immunosorbent assay method. Pregnancy tests were done 14 days; after embryo transfer two groups were identified those who get pregnant and those who did not get pregnant. The sample size was calculated using PASS, version 11 (NCSS LLC, Kaysville, Utah, USA), according to Soheila et al. at an α error of 0.05 and study power of 80%. A total sample size of 100 participants were assures to fulfil the aim of this study.
Results were collected, tabulated, and statistically analyzed by an IBM-compatible personal computer with SPSS statistical package version 20 (SPSS Inc. released 2011. IBM SPSS statistics for Windows, version 20.0; IBM Corp., Armonk, New York, USA). Quantitative data were expressed as mean ± SD while qualitative data were expressed as numbers and percentages. χ2 was used to test the significance of difference for qualitative variables which were less than five, Mann–Whitney test (U) is a test of significance used to test parameters. A probability value P less than 0.05 was considered statistically significant. Data were analyzed and are appropriately presented in tables and figures.
| Results|| |
This study included 100 infertile patients who were candidates for ICSI and who fulfill the inclusion and exclusion criteria. Pregnancy tests were done 14 days after embryo transfer: two groups were identified, those who get pregnant (N = 66) and those who did not get pregnant (N = 34). The mean age of the studied participants was 26.42 ± 4.03 years; the mean of duration of infertility was 4.41 ± 2.38 years. Among those, 63 women had primary infertility and 37 women has secondary infertility and the mean number of ova retrieved was 14.12 ± 6.31. The mean of embryo transferred was 2.95 ± 0.62 and 66 women got pregnant [Table 1]. There was no significant statistical difference between women who got pregnant or not according to the level of CRP at the beginning (1.53 ± 1.67 vs 1.71 ± 1.54, respectively) and at day of embryo transfer (22.21 ± 23.61 vs 19.82 ± 23.28, respectively), but there was significant statistical difference as regards CRP at ova pickup (11.18 ± 12.49 vs 6.47 ± 5.83, respectively) (P = 0.04) ([Table 2] and [Figure 1]). According to the number of oocyte retrieved and the number of embryo transferred, there was no significant statistical difference between women who got pregnant or not (P > 0.05) [Table 3]. Patients whose CRP level decreased on transfer day (19 cases) 14 got pregnant (73.7%), whereas only five failed to get pregnant (26.3%). Of those patients whose CRP level increased on transfer day (81 cases) 52 got pregnant (64%), whereas 29 failed to get pregnant (36%) [Table 4]. Sensitivity of CRP level testing for predicting pregnancy was 78.79%, while specificity was 14.71% [Table 5]. Positive predictive value was 48.02%, while negative predictive value was 40.94% [Table 5].
|Table 2: Comparison of serum C-reactive protein levels between pregnant and notpregnant groups|
Click here to view
|Figure 1: Comparison of serum C-reactive protein levels between pregnant and nonpregnant groups.|
Click here to view
|Table 3: Number of ova retrieved and number of embryo transferred among study participants|
Click here to view
|Table 4: Percentage of C-reactive protein change among the studied cases in relation to occurrence of pregnancy|
Click here to view
|Table 5: Sensitivity, specificity, positive predictive value, and negative predictive value of increased C-reactive protein level at the day of embryo transfer to predict pregnancy|
Click here to view
| Discussion|| |
CRP is a sensitive marker in inflammatory reaction. The level of this protein has known to be changed with gender and increase with age. Women at the time of pregnancy have elevated levels of CRP compared with those who are not pregnant. However, the concentration of CRP does not differ between infertile and fertile individuals. Controlled hyperstimulation of the ovary, and especially puncture of the ovaries, in IVF or ICSI cycles is probably associated with some degrees of tissue damage and therefore changes in CRP concentrations,. To the best of our knowledge, there were many studies conducted to determine the possible relationship between the serum CRP level and outcome of controlled ovarian stimulation, and pregnancy rate in patients undergoing IVF or ICSI. Mohamed et al. have conducted a prospective, cross-sectional study on 50 infertile patients who were candidates for IVF/ICSI. The recruited cases in their study was relatively older than our cases. The mean age of cases was 30.5 ± 4.1 years versus 26.42 ± 4.03 years in our study. Soheila et al. conducted a prospective, cross-sectional study in Avicenna Infertility Clinic on 70 infertile patients who were candidates for IVF/ICSI. The participant was relatively older than ours; the mean age was 30.96 ± 3.39 vs 26.42 ± 4.03 years in our present study. Orvieto et al. have conducted a prospective, cross-sectional study in Avicenna Infertility Clinic on consecutive infertile patients who were older; the mean age was 35 ± 5.2 years versus 26.42 ± 4.03 years in our study. The duration of infertility in the study by Soheila et al. was longer than ours; the mean was 8.61 ± 2.87 years versus 4.68 ± 2.01 years. But the mean duration of infertility was near in the Mohamed et al. study and in our present study it was 4.68 ± 2.01 and 4.41 ± 2.38 years, respectively. All of us used a standard, long protocol for controlled ovarian hyperstimulation. All of these studies,, showed that there were no significant differences in age, duration of infertility, and number of oocytes and number of transferred embryo between these two groups (who got pregnant or not) and this agrees with our results. The mean of CRP level on the day of ovum pickup in the study byMohamed et al. was 8.08 ± 3.93 vs 9.58 ± 10.90 mg/dl in the present study, but our patients have a higher mean of CRP level on the day of embryo transfer 21.39 ± 23.41 vs 9.93 ± 7.15 mg/dl. The CRP level increased in 68% of cases and decreased in 32% of cases. In our present study, the CRP level increased in 81% and decreased in 19%. Mohamed et al. concluded that the patients whose CRP level decreased on transfer day (11 cases), had a lower chance of pregnancy, whereas patients whose CRP level elevated on embryo transfer day had a higher chance of pregnancy (24 cases) and this disagrees with the results of this study. This may be due to the fact that a high level of CRP in the blood is a marker of inflammation. It can be caused by a wide variety of conditions, from infection to cancer not only due to ovarian stimulation and puncture during ovum pickup, but also there are many factors that affect the rate of IVF success such as egg/embryo quality, stimulation protocol and timing of ovulation, receptivity of the endometrium (implantation), embryo transfer and sperm factors. The Soheila et al. study results showed in 82.2% of cases that the serum CRP level was higher on the day of ovum pickup than on the first day of stimulation. The ratio of CRP level on the day of transfer to the day of ovum pickup was significantly higher (ratio ≥ 1.23) in patients who became pregnant after ICSI. All patients with a ratio less than this ratio have not been pregnant and this disagrees with our results as the sensitivity of CRP level testing for predicting pregnancy was 78.79% while specificity was 14.71%. Positive predictive value was 48.02%, while the negative predictive value was 40.94%. The Orvieto et al. study results showed that the serum CRP levels were significantly higher on day-OPU and day-HCG than on day-S. This agrees with our results as CRP at the beginning was 1.60 ± 1.60 mg/dl. The mean of CRP at the day of ova pickup was 9.58 ± 10.90 mg/dl with highly significant statistical differences compared with the day of beginning stimulation. The Orvieto et al. results also showed that the CRP level was significantly higher on day-OPU than on day-HCG, but we did not measure the CRP level at the day of HCG administration. Orvieto et al. have concluded that there were no significant correlations between serum CRP level and patient's age, cause of infertility, number of oocytes retrieved, or fertilization or pregnancy rates and this agrees with our results. Controlled hyperstimulation of the ovary and specially puncture of the ovaries in IVF or ICSI cycles is probably associated with some degrees of tissue damage and therefore changes in CRP concentrations. According to our results, the CRP level failed to serve as a predictor of success in patients undergoing IVF/ICSI, as a high level of CRP in the blood can be caused by a wide variety of conditions from infection to cancer not only due to ovarian stimulation and puncture during ovum pickup, but also there are many factors that affect the rate of IVF success such as egg/embryo quality, stimulation protocol and timing of ovulation, receptivity of the endometrium (implantation), embryo transfer, and sperm factors.
| Conclusion|| |
Ovulation induction is an inflammatory process leading to increased levels of CRP but with different patterns. These patterns of changes failed to be used as markers of a successful outcome of IVF/ICSI treatment.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Sproston NR, Ashworth JJ. Role of C-reactive protein at sites of inflammation and infection. Front Immunol 2018; 9
Coussons-Read ME, Okun ML, Nettles CD. Psychosocial stress increases inflammatory markers and alters cytokine production across pregnancy. Brain Behav Immun 2007; 21
De Maat MP, Madsen JS, Langdahl B, Bladbjerg EM, Tofteng CL, Abrahamsen B, et al
. Genetic variation in estrogen receptor, C-reactive protein and fibrinogen does not predict the plasma levels of inflammation markers after long term hormone replacement therapy. Thromb Haemost 2007; 97
Meier Ewert HK, Ridker PM, Rifaei M, Price N, Dinges DF, Mullington JM. Absence of diurnal variation of C-rective protein level in healthy human subjects. Clin Chem 2001; 47
Störk S, Bots ML, Grobbee DE, van der Schouw YT. Endogenous sex hormones and C-reactive protein in healthy postmenopausal women. J Intern Med 2008; 264
Zegers-Hochschild F, Adamson GD, Dyer S, Racowsky C, de Mouzon J, Sokol R, et al
. The international glossary on infertility and fertility care. Hum Reprod 2017; 32
Korhonen KV, Savolainen-Peltonen HM, Mikkola TS, Tiitinen AE, Unkila-Kallio LS. C-reactive protein response is higher in early than in late ovarian hyperstimulation syndrome. Eur J Obstet Gynecol Reproduct Biol 2016; 207
Orvieto R, Chen R, Ashkenazi J, Ben-Harush A, Bar J, Fisch B. C- Reactive protein level in patients undergoing controlled ovarian hyperstimulation for IVF cycle. Human Reprod 2004; 19
Soheila A, Babashams MD, Poneh P, Lima S, Hojjat Z. C-reactive protein level and pregnancy rate in patients undergoing IVF/ICSI. Iran J Reprod Med 2010; 8
Assunção LG, Eloi-Santos SM, Peixoto SV. High sensitivity C-reactive protein distribution in the elderly: The Bambuí Cohort Study, Brazil. Brazil J Med Biol Res 2012; 45
Yagati AK, Pyun JC, Min J, Cho S. Label-free and direct detection of C-reactive protein using reduced graphene oxide-nanoparticle hybrid impedimetric sensor. Bioelectrochemistry 2016; 107
Mohamed MF, Zakria AEM, El- Sayed WM. Serum CRP level in day of ovum pickup and embryo transfer as a predictor for success in patients undergoing IVF/ICSI. Int J Reprod Contracept Obstet Gynecol 2019; 8
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]