Limitations and barriers in access to care for male factor infertility

The primary challenge to identifying and addressing barriers in access to care for male factor infertility is accurate measurement of the prevalence of male infertility. Current estimates are based on couples pursuing assisted reproduction, and likely underestimate the problem. These estimates also fail to account for the number of patients facing infertility due to cancer or cancer treatment. Lack of health insurance coverage for the diagnosis and treatment of infertility presents a major barrier for couples struggling with infertility. However, it is not the only barrier. Education level, household income, cultural norms, religious beliefs, geographic location, and the availability of specialty-trained reproductive urologists are all important factors in determining the ease with which patients access and obtain infertility care. Addressing each of these obstacles directly is imperative to improving reproductive care and outcomes for infertile couples in the United States.

Factors associated with the use of elective single-embryo transfer and pregnancy outcomes in the United States, 2004-2012

OBJECTIVE

To evaluate factors associated with elective single-embryo transfer (eSET) utilization and its effect on assisted reproductive technology outcomes in the United States.

DESIGN

Historical cohort.

SETTING

Not applicable.

PATIENT(S)

Fresh IVF cycles of women aged 18-37 years using autologous oocytes with either one (SET) or two (double-embryo transfer [DET]) embryos transferred and reported to the Society for Assisted Reproductive Technology Clinic Outcome Reporting System between 2004 and 2012. Cycles were categorized into four groups with ([+]) or without ([-]) supernumerary embryos cryopreserved. The SET group with embryos cryopreserved was designated as eSET.

INTERVENTION(S)

None.

MAIN OUTCOMES MEASURE(S)

The likelihood of eSET utilization, live birth, and singleton non-low birth weight term live birth, modeled using logistic regression. Presented as adjusted odds ratios (aORs) and 95% confidence intervals (CIs).

RESULT(S)

The study included 263,375 cycles (21,917 SET[-]cryopreservation, 20,996 SET[+]cryopreservation, 103,371 DET[-]cryopreservation, and 117,091 DET[+]cryopreservation). The utilization of eSET (SET[+]cryopreservation) increased from 1.8% in 2004 to 14.9% in 2012 (aOR 7.66, 95% CI 6.87-8.53) and was more likely with assisted reproductive technology insurance coverage (aOR 1.60, 95% CI 1.54-1.66), Asian race (aOR 1.26, 95% CI 1.20-1.33), uterine factor diagnosis (aOR 1.48, 95% CI 1.37-1.59), retrieval of ≥16 oocytes (aOR 2.85, 95% CI 2.55-3.19), and the transfer of day 5-6 embryos (aOR 4.23, 95% CI 4.06-4.40); eSET was less likely in women aged 35-37 years (aOR 0.76, 95% CI 0.73-0.80). Compared with DET cycles, the likelihood of the ideal outcome, term non-low birth weight singleton live birth, was increased 45%-52% with eSET.

CONCLUSION(S)

Expanding insurance coverage for IVF would facilitate the broader use of eSET and may reduce the morbidity and healthcare costs associated with multiple pregnancies.

Age-Related Normogram for Ovarian Antral Follicle Count in Women with Polycystic Ovary Syndrome and Comparison with Age Matched Controls Using Magnetic Resonance Imaging

INTRODUCTION

Antral Follicle count (AFC) is a reliable marker for ovarian reserve. Previous studies have used transvaginal ultrasound for estimation of AFC, however we used magnetic resonance imaging (MRI) for estimation of AFC and for creating an age-related normogram in patients with polycystic ovary syndrome (PCOS) and compared it with normal patients.

AIM

The aim of this study is to create an age related normogram for AFC in women with PCOS and to compare that with women without polycystic ovarian syndrome using MRI.

MATERIALS AND METHODS

A total of 1500 women were examined, out of which 400 fitted the criteria for PCOS. They all underwent MRI study and similar age matched women without PCOS also underwent MRI examination. Normogram for AFC were obtained using LMS software and a percentile chart was obtained.

RESULTS

Normogram for AFC in PCOS women showed decline in number of AFC as the age progresses and the decline was linear. The normogram for AFC was compared with equal number of patients without PCOS and they also showed decline in AFC as the age progresses, however the decline was exponential and faster.

CONCLUSION

Age related normogram for AFC is widely used and considered as best clinical predictor for ovarian response in assisted reproductive technology. Knowledge of ovarian reserve is important in PCOS and non-PCOS females as PCOS patients are at risk for ovarian hyperstimulation syndrome during gonadotrophin theraphy. MRI is an equally effective and in some times better alternative to transvaginal ultrasound as it has got its own advantages.

Lack of transmission of murine norovirus to mice via in vitro fertilization, intracytoplasmic sperm injection, and ovary transplantation

Since its discovery in 2003, murine norovirus (MNV) is still endemic in many rodent animal facilities. Our aim was to determine the risk of transmission of MNV (91% homology to MNV3) to embryo recipients and pups via assisted reproductive technologies, especially those which compromise the integrity of the zona pellucida. In vitro fertilization (IVF), assisted in vitro fertilization (AIVF) with reduced glutathione, intracytoplasmic sperm injection, and ovary transplantation were performed. Murine norovirus was detected by qualitative and quantitative reverse transcription polymerase chain reaction. After natural infection of immunocompetent C57BL/6NTacCnrm and immunodeficient athymic nude mice with MNV, the mesenteric lymph nodes, small intestine, spleen, liver, lung, brain, ovary, and testis were infected at specific intervals for more than a 1-year period. At Week 12, the number of viral genomes per milligram of gonad from both strains was 20 to 50. Murine norovirus strictly adhered to spermatozoa collected from infected mice because three washes did not remove MNV from the sperm. After using MNV-positive sperm for IVF, AIVF, and intracytoplasmic sperm injection, 27 to 30 genomes were detected in IVF (n = 100) and AIVF (n = 100) embryos from both mouse strains. Approximately 87% of MNV detected in these embryos was found in the zona pellucida. However, all embryo transfer recipients, pups, and ovary recipients were MNV-negative. The results indicate that manipulation of the germplasm through assisted reproductive technologies did not lead to transmission of MNV to mice. This may be because of the absence of an infectious dose or failure of the MNV strain to replicate effectively in developing embryos and the reproductive tract.

History of Assisted Reproductive Technology and Chlamydia Trachomatis Infection in Pregnancy

Background and Methods

To identify whether or not a history of assisted reproductive technology (ART) is associated with the low incidence of Chlamydia trachomatis (CT) infection in pregnant women, we reviewed the obstetric records of the Japanese women aged 35 - 42 years.

Results

The prevalence of CT in the pregnancies without ART was 1.1% (28/2,632) using nucleic acid amplification tests, while it was zero in the pregnancies conceived by ART (0/364, P = 0.049 by the X² test).

Conclusions

A history of ART seemed to be a negative risk factor for CT infection in pregnant women.

Comparing blastocyst quality and live birth rates of intravaginal culture using INVOcell™ to traditional in vitro incubation in a randomized open-label prospective controlled trial

PURPOSE

The purpose of this study is to to compare the efficacy of intravaginal culture (IVC) of embryos in INVOcell™ (INVO Bioscience, MA, USA) to traditional in vitro fertilization (IVF) incubators in a laboratory setting using a mild pre-determined stimulation regimen based solely on anti-mullerian hormone (AMH) and body weight with minimal ultrasound monitoring. The primary endpoint examined was total quality blastocysts expressed as a percentage of total oocytes placed in incubation. Secondary endpoints included percentage of quality blastocysts transferred, pregnancy, and live birth rates.

METHODS

In this prospective randomized open-label controlled single-center study, 40 women aged <38 years of age with a body mass index (BMI) of <36 and an AMH of 1-3 ng/mL were randomized prior to trigger to receive either IVC or IVF. Controlled ovarian stimulation was administered with human menopausal gonadotropin (hMG) in a fixed gonadotropin-releasing hormone (GnRH) agonist cycle based solely on AMH and body weight. A single ultrasound-monitoring visit was performed on the 10th day of stimulation. One or two embryos were transferred following 5 days of culture.

RESULTS

IVF produced a greater percentage of total quality embryos as compared to IVC (50.6 vs. 30.7 %, p = 0.0007, respectively). There was no significant difference between in IVF and IVC in the percentage of quality blastocysts transferred (97.5 vs. 84.9 %, p = 0.09) or live birth rate (60 % IVF, 55 % IVC).

CONCLUSIONS

IVF was shown to be superior to IVC in creating quality blastocysts. However, both IVF and IVC produced identical blastocysts for transfer resulting in similar live birth rates. IVC using INVOcell™ is effective and may broaden access to fertility care in selected patient populations by ameliorating the need for a traditional IVF laboratory setting. Further studies will help elucidate the potential physiological, psychological, geographic, and financial impact of IVC on the delivery of fertility care.

Increased incidence of gestational hypertension and preeclampsia after assisted reproductive technology treatment

OBJECTIVE

To determine the association between assisted reproductive technology (ART) treatment and the rate of combined gestational hypertension (GH), preeclampsia (PE).

DESIGN

Retrospective population study.

SETTING

Not applicable.

PATIENT(S)

A total of 596,520 mothers (3.6% ART mothers) who gave birth between 2007 and 2011.

INTERVENTION(S)

Not applicable.

MAIN OUTCOME MEASURE(S)

Comparison of the rate of GH/PE for ART and non-ART mothers, with odds ratio (OR), adjusted odds ratio (AOR), and 95% confidence interval (CI) used to assess the association between ART and GH/PE.

RESULT(S)

The overall rate of GH/PE was 4.3%, with 6.4% for ART mothers and 4.3% for non-ART mothers. The rate of GH/PE was higher for mothers of twins than singletons (12.4% vs. 5.7% for ART mothers; 8.6% vs. 4.2% for non-ART mothers). The ART mothers had a 17% increased odds of GH/PE compared with the non-ART mothers (AOR 1.17; 95% CI, 1.10-1.24). After stratification by plurality, the difference in GH/PE rates between ART and non-ART mothers was not statistically significant, with AOR 1.05 (95% CI, 0.98-1.12) for mothers of singletons and AOR 1.10 (95% CI, 0.94-1.30) for mothers of twins.

CONCLUSION(S)

The changes in AOR after stratification indicated that multiple pregnancies after ART are the single most likely explanation for the increased rate of GH/PE among ART mothers. The lower rate of GH/PE among mothers of singletons compared with mothers of twins suggests that a policy to minimize multiple pregnancies after ART may reduce the excess risk of GH/PE due to ART treatment.

Comparison between follicular stimulation and luteal stimulation protocols with clomiphene and HMG in women with poor ovarian response

This retrospective study is to compare the follicular mild stimulation and luteal simulation protocols for poor responders undergoing in vitro fertilization (IVF). A total of 131 women were diagnosed as poor responders. Thirty-three women started ovarian stimulation in early-luteal phase and 98 women started in early follicular phase with 100 mg/d clomiphene citrate and 75-150 IU/d HMG. There were more oocytes retrieved (2.8 ± 2.0 versus 2.0 ± 1.2, p < 0.05), more available embryos (1.8 ± 1.4 versus 1.3 ± 1.1, p < 0.05) and top-quality embryos (0.9 ± 0.9 versus 0.4 ± 0.6, p < 0.05), and reduced cycle cancellation rate (12.1% versus 30.6%, p < 0.05) in luteal group than in follicular group. The clinical pregnancy (17.7%, 20.0% and 41.2%) and live-birth rates (10.78%, 20.0% and 29.4%) after transferring embryos obtained from luteal, follicular and mixed stages were comparable (p > 0.05). For poor responders, luteal phase stimulation could be an option because of increasing the chance to obtain competent embryos and reducing the cycle cancellation rate.

Homocysteine in embryo culture media as a predictor of pregnancy outcome in assisted reproductive technology

The aim of this study was to determine whether homocysteine (hcy) concentrations in embryo culture media correlate with pregnancy outcome in assisted reproductive technology (ART) cycles. Forty patients who underwent single embryo transfer at the infertility clinic of a tertiary care center were recruited for this case-control study. Spent embryo culture media from all patients were collected after single embryo transfer on day 3 (n = 40). Hcy concentrations in embryo culture media were analyzed by enzyme cycling method. Patients were grouped according to the diagnosis of a clinical pregnancy. Sixteen patients were pregnant while 24 patients failed to achieve conception. Mean Hcy levels in the culture media were significantly different between the groups (p < 0.003), as 4.58 ± 1.31 μmol/l in the non-pregnant group and 3.37 ± 0.92 μmol/l in the pregnant group. Receiver operator curve analysis for determining the diagnostic potential of Hcy for pregnancy revealed an area under the curve of 0.792 (confidence interval: 0.65-0.94; p < 0.05). A cut-off value of 3.53 μmol/l was determined with a sensitivity of 83.3%, and a specificity of 68.8%. Lower hcy levels were associated with a better chance of pregnancy and better embryo grades. Hcy may be introduced as an individual metabolomic profiling marker for embryos.

[Assisted reproductive technologies and the embryo status]

The status of the human embryo has always be a subject of philosophical and theological thoughts with major social consequences, but, until the 19th century, it has been mainly an abstraction. The arrival of the human embryo in vitro, materialized by Louise Brown's birth in 1978 and above all by the supernumerary embryos produced by the Australian team of Trounson and Wood following the introduction of ovarian stimulation, will turn theoretical thoughts into a reality. Nobody may ignore the hidden intentions behind the debate, as to recognise a status to a few days old embryo will immediately have a major impact on the status of a few weeks old foetus and therefore on the abortion rights. We will see that the embryo status, essentially based as well on a vision on the good and evil as on social order, cannot be based on a scientific analysis of the reproduction process but comes from a society's choice, by essence " arbitrary " and always disputable. This does not preclude the collectivity right and legitimacy to give a precise status and it is remarkable to observe the law is careful not to specify which status to give to the human embryo. It is more thru handling procedures and functioning rules that the law designed the embryo position, neither with a status of a person, nor of a thing. It nevertheless remains true that there is a constant risk that the legislation gives the embryo a status that would call into question it's unique characteristic of early reproductive stage, jeopardizing at once the hard-won reproductive freedom (reproductive choice) as well as freedom of research on embryonic stem cells, one of the most promising field of medical research.

Essure a novel option for the treatment of hydrosalpinx: a case series and literature review

OBJECTIVE

The aim of this study is to evaluate the use of hysteroscopic Essure device placement for the treatment of hydrosalpinx (HS)-related infertility in patients with laparoscopic contraindications and compared their pregnancy outcomes following IVF-ICSI treatment with those patients having had laparoscopic tubal occlusion (LTO).

PATIENTS

From 2008 to 2014 a total of 50 patients were diagnosed with unilateral or bilateral hydrosalpinges: 29 patients had laparoscopic contraindications and were treated hysteroscopically and 21 patients were treated with laparoscopical salpingectomy.

RESULTS

Of the 29 patients who underwent treatment with Essure(®), 21 began a cycle of in vitro fertilization (IVF), and 13 finished in embryo transfer that resulted in seven clinical pregnancies. Furthermore, in the group of women treated with salpingectomy, 17 started an IVF cycle that resulted in 12 clinical pregnancies. The clinical pregnancy rate per patient with an IVF cycle started was 33.3% and 70.6%, the live-birth rate per patient was 14.3% and 52.9%, the miscarriage rate was 57.1% and 18.2%, and the implantation rate was 16.3% and 34.1% for hysteroscopy and laparoscopy, respectively.

CONCLUSION

Essure(®) placement is an alternative method for occlusion of hydrosalpinges before IVF. Monitoring the live-birth rate confirms that this option may be considered when laparoscopy is impossible or contraindicated.

Dydrogesterone use in early pregnancy

Successful oocyte implantation and a favorable pregnancy outcome rely on optimal progesterone levels. Therefore, progesterone deficiencies associated with infertility and miscarriage have commonly been treated with progestogens that mimic the activity of progesterone. Among those is dydrogesterone, an oral retrosteroid with a structure closely related to that of progesterone yet with a greater bioavailability and higher selectivity for the progesterone receptor. This review describes the efficacy of dydrogesterone for the treatment of threatened and recurrent miscarriage, and infertility due to luteal phase insufficiency. Data from clinical trials evaluating dydrogesterone in assisted reproductive technology are also discussed. Prospective clinical trials, systematic reviews and meta-analyses have demonstrated that dydrogesterone significantly improves pregnancy outcomes in women with threatened miscarriage or with a history of miscarriage. Although this is not yet a registered indication, dydrogesterone was as effective as vaginal micronized progesterone for luteal phase support in the setting of assisted reproductive technology. The safety and tolerability of dydrogesterone treatment in pregnant women are also briefly addressed and the data support a well-established and favorable benefit-risk profile.

Is the wrong question being asked in infertility research?

A persistent finding is that assisted reproductive technology (ART) is associated with compromised birth outcomes, including higher risks for prematurity, low birthweight, and congenital malformations, even among singletons. Over the past decade, our research group, the Massachusetts Outcome Study of Assisted Reproductive Technology (MOSART), has evaluated pregnancy and birth outcomes among three groups of women, those women treated with ART, those with indicators of subfertility but without ART treatment, and fertile women. We have also explored the influence of infertility-related diagnoses on outcomes for women and infants. Over the course of our research, we have changed our perspective from an original focus on ART treatment parameters as the primary cause of excess morbidity to one centered instead on the underlying infertility-related diagnoses. This paper summarizes the research findings from our group that support this change in focus for infertility-based research from a primary emphasis on ART treatment to greater attention to the contribution of preexisting pathology underlying the infertility and suggests directions for future analyses.

Impact of endometrial cavity fluid on assisted reproductive technology outcomes

BACKGROUND

The impact of endometrial cavity fluid (ECF) on assisted reproductive technology (ART) outcomes has not been evaluated in a meta-analysis.

OBJECTIVES

To evaluate the impact of ECF on the outcome of ART cycles.

SEARCH STRATEGY

PubMed, China Academic Journals Full-text Database, and China Doctoral/Masters Dissertations Full-text Databases were searched for reports published in any language before January 1, 2015, using relevant keywords.

SELECTION CRITERIA

Studies were included if they compared the outcome of ART in women with and without ECF.

DATA COLLECTION AND ANALYSIS

Background information, participants' characteristics, and study outcomes were recorded. Odds ratios (ORs) with 95% confidence intervals (CIs) were calculated using the Mantel-Haenszel method.

MAIN RESULTS

Six studies evaluating 5928 ART cycles were included. The pregnancy rate was significantly lower in the group with ECF than in the group without ECF (OR 0.74, 95% CI 0.55-0.98; P=0.03). The same association was observed if the analysis included only patients with hydrosalpinx (OR 0.36, 95% CI 0.15-0.86; P=0.02).

CONCLUSIONS

The clinical pregnancy rate after ART is significantly lower among patients with ECF than among those without ECF. In addition, if ECF is found in patients with hydrosalpinx, ART cycles should be cancelled after oocyte retrieval.

Effects of in vitro fertilization and maternal characteristics on perinatal outcomes: a population-based study using siblings

OBJECTIVE

To study birthweight in consecutively born sibling singletons conceived with and without in vitro fertilization (IVF) to disentangle the effects of maternal characteristics from those of the IVF treatment itself.

DESIGN

Population-based study.

SETTING

Not applicable.

PATIENT(S)

Firstborn and secondborn children from a 9-year birth cohort (1999-2007) comprising of 272,551 women who conceived two siblings.

INTERVENTION(S)

No intervention; children were conceived naturally or through IVF.

MAIN OUTCOME MEASURE(S)

Birthweight.

RESULT(S)

The study included 545,102 children born by natural conception (NC) or IVF with the data set obtained from the population-based Netherlands Perinatal Registry (PRN) containing information on pregnancies, deliveries, and neonatal outcomes. We used two approaches: [1] the intersibling approach and [2] the sibling-ship approach. In the first approach we included children born to four groups of mothers who conceived in the following order (numbers indicate birth order): NC1-NC2 (reference, n = 254,721), IVF1-NC2 (n = 1342), NC1-IVF2 (n = 471), and IVF1-IVF2 (n = 687). Several comparisons were made to interpret the effects of IVF and maternal characteristics separately. In the second approach, perinatal outcomes of IVF children (n = 1,813) were compared with those of their NC siblings (n = 1,813). The intersibling analyses suggested an association between maternal characteristics and a lower birthweight, with estimates of the maternal effect ranging from -7 g (95% CI, -40; 26) to -101 g (95% CI, -170; -32). Neither the intersibling analyses nor the sibling-ship analyses indicated an additional adverse effect of IVF treatment itself.

CONCLUSION(S)

Maternal characteristics of subfertile women are associated with a lower birthweight. In vitro fertilization treatment itself does not additionally contribute to a lower birthweight in the offspring.

Estrous cycle staging before mating led to increased efficiency in the production of pseudopregnant recipients without negatively affecting embryo transfer in mice

The goal was to increase pseudopregnant mice production by estrous cycle staging by visual examination before pairing and to determine the effect of such pseudopregnant recipients on embryo transfer. To compare methods of estrous cycle staging over 14 days, groups consisted of 10 females in proestrus-estrus and 10 vasectomized males; group 1: only daily visual observation; group 2: daily visual observation and cytological examination on day 1; group 3: daily visual observation and daily cytological examination. The average time to first vaginal plug was 1.8 days in group 1, 2.7 days in group 2, and 3.2 days in group 3, whereas the average time between consecutive vaginal plugs was 9.2 days (group 1), 10 days (group 2), and 9.25 days (group 3). The average time between consecutive estrous cycles was 9.7 days (group 1), 11.8 days (group 2), and 9.4 days (group 3). The congruence between visual and cytological examination in determining proestrus-estrus in group 2 was 100% and that for the four stages in group 3 was 79% with a range of 44% to 100%. From 162 plug-positive females originally selected in proestrus-estrus, 49%, 30%, 19%, and 2% were plug-positive on Day 1, Day 2, Day 3, and Day 4, respectively, showing that pseudopregnant mice production was significantly increased on the first 2 days. From 192 plug-positive females originally selected randomly, these values were 31%, 21%, 35%, 10%, and 3% on d1, d2, d3, d4, and d5, respectively. No significant differences were observed between groups with respect to embryo transfers with fresh or cryopreserved embryos although the number of pups born per litter was higher in group A with fresh (7.57 vs. 6.39) and cryopreserved-thawed embryos (5.0 vs. 4.38). Furthermore, the sex ratio and the genotype of the pups were not significantly affected.

Is there an association between assisted reproductive technologies and time and complications of the third stage of labor?

PURPOSE

To determine if vaginal deliveries exposed to assisted reproductive technologies (ART) are associated with an increased time between delivery of the neonate and placenta and select complications.

METHODS

A retrospective cohort of patients enrolled in an infertility practice who had term, singleton, vaginal deliveries at two academic hospitals from 2008 to 2013 was analyzed. Controls were patients with spontaneous conceptions after infertility consultations. The exposure groups were patients with controlled ovarian hyper-stimulation (COH) with in vivo fertilization, COH with in vitro fertilization and fresh embryo transfer (COH/IVF), and frozen embryo transfer or oocyte donation recipients without COH (non-COH ET). Multiple gestations and stillbirths were excluded. Median time of third stage was compared using the Mann-Whitney U test. Secondary outcomes of retained placenta, manual placental extraction, and post-partum hemorrhage (PPH) were compared using Chi-square or Fisher's exact analyses.

RESULTS

A total of 769 patients met criteria and were analyzed. While there were no differences in time of third stage of labor, retained placenta, or PPH, manual extraction was significantly more common among non-COH ET [age-adjusted OR 5.6 (95 % CI 2.2-13.8); p < 0.001].

CONCLUSIONS

Patients who conceived after non-COH ET were at increased risk for manual placental extraction. This association was not influenced by age differences between groups. Further research must be done to determine which elements of the ART process are responsible for these differences.

Cancer in women after assisted reproductive technology

OBJECTIVE

To evaluate the risk of cancer after assisted reproductive technology (ART) therapy.

DESIGN

Longitudinal cohort study.

SETTING

Not applicable.

PATIENT(S)

New York, Texas, and Illinois residents between 2004 and 2009, treated with ART, comprising cycles of 113,226 women, including 53,859 women without prior ART treatment, who were linked to their respective state cancer registries and whose cycles were reported to the Society for Assisted Reproductive Technology Clinic Outcomes Reporting System (SART CORS).

INTERVENTION(S)

None.

MAIN OUTCOME MEASURE(S)

Diagnosis of cancer, as reported to the state cancer registry; standardized incidence ratios (SIR) and their 95% confidence intervals, comparing the observed to expected cancer cases based on age-specific cancer rates in the general population of each state.

RESULT(S)

Among the cohort of women without prior ART therapy, hazard ratios (HR) and 95% confidence intervals (CI) were calculated for treatment parameters and reproductive history factors. The mean follow-up period was 4.87 years; among women without prior ART, 450 women developed 460 cancers. Women treated with ART had a statistically significantly lower risk for all cancers (for all women: SIR 0.78; CI, 0.73-0.83; women without prior ART: SIR 0.75; CI, 0.68-0.82), breast cancer, and all female genital cancers; a non-statistically-significant lower risk for endocrine and uterine cancer; and a non-statistically-significant higher risk for melanoma and ovarian cancer. Among women without prior ART, we found no statistically significant increased HR by parity, number of cycles, cumulative follicle-stimulating hormone dosage, or cycle outcome.

CONCLUSION(S)

Women initiating ART treatment have no greater risk for developing cancer after nearly 5 years of follow-up compared with the general population and with other women treated with ART.

Impact of single embryo transfer policy on perinatal outcomes in fresh and frozen cycles-analysis of the Japanese Assisted Reproduction Technology registry between 2007 and 2012

OBJECTIVE

To investigate whether the introduction of single embryo transfer (SET) policy in Japan has improved perinatal outcomes.

DESIGN

A retrospective cohort study.

SETTING

Not applicable.

PATIENT(S)

A total of 140,718 live births and 510 stillbirths (after 22 weeks of gestation) conceived by assisted reproductive technology in Japan between 2007 and 2012 were reviewed.

INTERVENTION(S)

None.

MAIN OUTCOME MEASURE(S)

Preterm birth (PTB), low birth weight (LBW), very low birth weight (VLBW), small for gestational age (SGA), large for gestational age (LGA), perinatal mortality, and other pregnancy complications.

RESULT(S)

The rate of SET increased significantly from 52.2% in 2007 to 82.6% in 2012, while the rate of multiple pregnancy decreased significantly from 10.7% to 4.1% over the same period. The rates of PTB, LBW, and SGA decreased significantly, while that of LGA increased. Perinatal mortality decreased from 0.70% to 0.40% in fresh cycles, while that of frozen cycles did not change. Double ET or more was associated with a significantly increased risk for multiple pregnancy, placenta accreta, preterm premature rupture of membrane, cesarean section (CS), PTB, LBW, SGA, and early neonatal death compared with SET. Compared with before the SET policy was launched, the risks of multiple pregnancy, CS, early PTB before 32 weeks, LBW, VLBW, and SGA were significantly decreased after the policy was launched, with significant interactions of fresh/frozen status.

CONCLUSION(S)

The results suggest that the SET policy improved perinatal outcomes in Japan. The impact of SET policy was different in fresh and frozen cycles for several perinatal outcomes.

Can anti-Mullerian hormone (AMH) predict the outcome of intrauterine insemination with controlled ovarian stimulation?

OBJECTIVE

To assess whether the levels of anti-Mullerian hormone (AMH) are related to outcome of intrauterine insemination (IUI) in patients treated with gonadotropins.

INTERVENTION(S)

A total of 195 patients underwent controlled ovarian stimulation (COS) with recombinant follicle stimulating hormone (rFSH) (50-150 IU/d). All patients were submitted upto three cycles of IUI.

OUTCOME

Primary outcome was the ability of AMH levels to predict clinical pregnancy at first attempt and the cumulative clinical pregnancy probability of upto three IUI cycles. Secondary outcomes were the relation of AMH, LH, FSH, BMI, age, parity and basic estradiol levels with each other and the outcome of IUI.

RESULTS

The area under the receiver operating characteristic (ROC) curve in predicting clinical pregnancy for AMH at first attempt was 0.53 and for cumulative clinical pregnancy was 0.76. AMH levels were positively correlated with clinical pregnancy rate at first attempt and with cumulative clinical pregnancy rate, but negatively correlated with patient's age and FSH levels. Patient's FSH, LH levels were negatively correlated with cumulative clinical pregnancy rate.

CONCLUSIONS

AMH levels seem to have a positive correlation and patient's age and LH levels had a negative correlation with the outcome of IUI and COS with gonadotropins. AMH concentration was significantly higher and LH was significantly lower in patients with a clinical pregnancy after three cycles of IUI treatment compared with those who did not achieve pregnancy.

Placental development during early pregnancy in sheep: estrogen and progesterone receptor messenger RNA expression in pregnancies derived from in vivo-produced and in vitro-produced embryos

Sex steroids are important regulators of angiogenesis and growth in reproductive tissues, including the placenta. In experiment (exp.) 1, to examine the expression of a suite of sex steroid receptors throughout early pregnancy, maternal (caruncular [CAR]) and fetal (fetal membranes [FM]) placental tissues were collected on days 14 to 30 after mating and on day 10 after estrus (nonpregnant controls). In exp. 2, to examine the hypothesis that assisted reproductive technology would affect the expression of the same suite of sex steroid receptors, pregnancies were achieved through natural mating (NAT) or transfer of embryos from natural mating (NAT-ET), in vitro fertilization (IVF), or in vitro activation (IVA), and CAR and FM were collected on day 22. In exp. 1, for CAR messenger RNA (mRNA) expression of estrogen receptors (ESR) 1 and 2, nuclear (n) progesterone receptors (PGR) and membrane (m) PGRα, β, and γ were affected (P < 0.02) by pregnancy stage, as were ESR1, nPGR, and mPGRα, β, and γ for FM (P < 0.03). In exp. 2, for CAR, mRNA expression of ESR1 and nPGR was decreased (P < 0.001) in NAT-ET, IVF, and IVA groups compared with NAT. For FM, mRNA expression of ESR1 tended to be greater (P = 0.10) in the IVA group compared with NAT and NAT-ET, and GPER1 was greater (P < 0.05) in NAT-ET and IVF compared with NAT. These data establish the normal pattern of sex steroid receptor mRNA expression in maternal and fetal placenta during early pregnancy in sheep, and in addition, suggest that altered expression of placental sex steroid receptors may be an early event leading to poor placental vascularization and growth after assisted reproductive technology.

Comprehensive carrier genetic test using next-generation deoxyribonucleic acid sequencing in infertile couples wishing to conceive through assisted reproductive technology

OBJECTIVE

To develop an expanded pan-ethnic preconception carrier genetic screening test for use in assisted reproductive technology (ART) patients and donors.

DESIGN

Retrospective analysis of results obtained from 2,570 analyses.

SETTING

Reproductive genetic laboratory.

PATIENT(S)

The 2,570 samples comprised 1,170 individuals from the gamete donor programs; 1,124 individuals corresponding to the partner of the patient receiving the donated gamete; and 276 individuals from 138 couples seeking ART using their own gametes.

INTERVENTION(S)

None.

MAIN OUTCOME MEASURE(S)

Next-generation sequencing of 549 recessive and X-linked genes involved in severe childhood phenotypes reinforced with five complementary tests covering high prevalent mutations not detected by next-generation sequencing.

RESULT(S)

Preclinical validation included 48 DNA samples carrying known mutations for 27 genes, resulting in a sensitivity of 99%. In the clinical dataset, 2,161 samples (84%) tested positive, with an average carrier burden of 2.3 per sample. Five percent of the couples using their own gametes were found to have pathogenic variants conferring high risk for six different diseases. These high-risk couples and patients received genetic counseling and recommendations for preimplantation genetic diagnosis. For patients receiving gamete donation, we applied a genetic testing and blinded matching system to avoid high-risk combinations regardless of their carrier burden. For female donors, 1.94% were positive for X-linked conditions; they received genetic counselling and were discarded.

CONCLUSION(S)

We have developed a comprehensive carrier genetic screening test that, combined with our matching system and genetic counseling, constitutes a powerful tool to avoid more than 600 mendelian diseases in the offspring of patients undergoing ART.

Restricting Access to ART on the Basis of Criminal Record : An Ethical Analysis of a State-Enforced "Presumption Against Treatment" With Regard to Assisted Reproductive Technologies

As assisted reproductive technologies (ART) become increasingly popular, debate has intensified over the ethical justification for restricting access to ART based on various medical and non-medical factors. In 2010, the Australian state of Victoria enacted world-first legislation that denies access to ART for all patients with certain criminal or child protection histories. Patients and their partners are identified via a compulsory police and child protection check prior to commencing ART and, if found to have a previous relevant conviction or child protection order, are given a "presumption against treatment." This article reviews the legislation and identifies arguments that may be used to justify restricting access to ART for various reasons. The arguments reviewed include limitations of reproductive rights, inheriting undesirable genetic traits, distributive justice, and the welfare of the future child. We show that none of these arguments justifies restricting access to ART in the context of past criminal history. We show that a "presumption against treatment" is an unjustified infringement on reproductive freedom and that it creates various inconsistencies in current social, medical, and legal policy. We argue that a state-enforced policy of restricting access to ART based on the non-medical factor of past criminal history is an example of unjust discrimination and cannot be ethically justified, with one important exception: in cases where ART treatment may be considered futile on the basis that the parents are not expected to raise the resulting child.

Altered gene expression of H19 and IGF2 in placentas from ART pregnancies

INTRODUCTION

The aim of this study is to determine whether the gene expression and associated DNA methylation regulation of H19 and IGF2 are altered in placentas conceived by assisted reproductive technologies (ART) compared to natural conceptions.

METHODS

113 pregnancies were recruited resulting in 119 placentas (83 singletons and 36 twins), where 56 were conceived via in vitro fertilization (IVF), 41 via intracytoplasmic sperm injection (ICSI), and 22 naturally. Regulation of imprinting of H19 and IGF2 was determined by the DNA methylation status at three CpG sites within the H19 imprinting control region 1 (ICR1) using bisulphite pyrosequencing. Expression of H19 and IGF2 in 45 of these placentas (17 IVF, 14 ICSI, and 14 NC) was measured by determining the relative mRNA transcript levels using RT-qPCR in placental villi.

RESULTS

Placental weight and birth weight were not significantly different between groups. H19 expression was significantly increased in both IVF and ICSI placentas when compared to controls (1.8 and 1.9 fold higher, respectively). Conversely, IGF2 was significantly decreased in both ART groups (0.8 and 0.7 fold lower, respectively). Mean DNA methylation at ICR1 was found to be similar between all groups. No correlation was found between DNA methylation at ICR1 and expression of either gene. However, a significant inverse relationship was found between H19 and IGF2 expression.

CONCLUSION

We provide evidence of altered H19 and IGF2 expression in ART placentas. The altered expression pattern may suggest a loss of imprinting on the paternal allele. Furthermore, these alterations may not be entirely associated with DNA methylation at ICR1. We show further indirect evidence of the H19-IGF2 inverse expression pattern.

[Circulating nucleic acids and infertility]

Circulating nucleic acids (cell-free DNA and microRNAs) have for particularity to be easily detectable in the biological fluids of the body. Therefore, they constitute biomarkers of interest in female and male infertility care. Indeed, in female, they can be used to detect ovarian reserve disorders (polycystic ovary syndrome and low functional ovarian reserve) as well as to assess follicular microenvironment quality. Moreover, in men, their expression levels can vary in case of spermatogenesis abnormalities. Finally, circulating nucleic acids have also the ability to predict successfully the quality of in vitro embryo development. Their multiple contributions during assisted reproductive technology (ART) make of them biomarkers of interest, for the development of new diagnostic and/or prognostic tests, applied to our specialty. Circulating nucleic acids would so offer the possibility of personalized medical care for infertile couples in ART.

The relationship between the changes in the level of progesterone and the outcome of in vitro fertilization-embryo transfer

We observed the effects of changes in progesterone (P) during late follicular phases on the treatment outcome of in vitro fertilization-embryo transfer (IVF-ET) and intracytoplasmic sperm injection (ICSI) in patients with different ovarian responses. The data of 8,575 cycles of patients receiving gonadotropin-releasing hormone (GnRH) agonist using the long protocol were retrospectively analyzed. According to the number of oocytes retrieved, the cycles were divided into poor ovarian response group (oocyte retrieval <5), intermediate ovarian response group (5≤ oocyte retrieval ≤15), and high ovarian response group (oocyte retrieval ≥16). We found that in the poor ovarian response group, the clinical pregnancy rate was not significantly associated with both the level of P or the day of human chorionic gonadotrophin (hCG) and the duration of pre-hCG P elevation (p = 0.66 and p = 0.1874). In intermediate and high ovarian response groups, the clinical pregnancy rate was inversely related to both the level of P on the day of hCG administration and the duration of pre-hCG P elevation (all p < 0.0001). The cut-off values of serum P level on the day of hCG administration were 1 ng/ml and 1.75 ng/ml in intermediate and high ovarian response groups, respectively. The cut-off values of pre-hCG P elevation duration were obtained on day 1 in the intermediate ovarian response group, and days 1 or 3 in the high ovarian response group. After correcting for other confounding factors, multivariate logistic regression analysis indicated that P level on the day of hCG administration was not associated with clinical pregnancy rates, but pre-hCG P elevation duration was negatively associated with clinical pregnancy rate in the intermediate and high ovarian response groups. P level is associated with clinical pregnancy rate only in the patients with intermediate or high ovarian response. The longer the duration of pre-hCG P 1 ng/ml, the lower the clinical pregnancy rate.

Risk of preterm birth after blastocyst embryo transfer: a large population study using contemporary registry data from Australia and New Zealand

OBJECTIVE

To investigate whether there is an increased risk of preterm birth with blastocyst transfer compared with cleavage-stage embryo transfer (ET) after assisted reproductive technology (ART).

DESIGN

A retrospective, population-based study.

SETTING

Not applicable.

PATIENT(S)

A total of 50,788 infants conceived after ART treatment performed from 2009 to 2012.

INTERVENTION(S)

None.

MAIN OUTCOME MEASURE(S)

The rates of preterm birth, low birth weight (LBW), and small for gestational age (SGA) for 43,952 singleton and 3,418 twin deliveries after transfers of blastocyst or cleavage-stage embryos.

RESULT(S)

Among singletons, there was no significant difference in the odds of preterm birth between blastocyst and cleavage-stage ET (9.1% compared with 9.3%, respectively, adjusted odds ratio 1.00, 95% confidence interval 0.94-1.08). Among twins, the crude rates of preterm birth were similar after blastocyst and cleavage-stage ETs (61.5% and 64.4%, respectively). However, after adjusting for potential confounders, blastocyst transfer was associated with a lower odds of preterm birth among twins (adjusted odds ratio 0.80, 95% confidence interval 0.70-0.93). There was no difference in risks of LBW and SGA between blastocyst and cleavage-stage ETs for both singletons and twins after adjusting for potential confounders.

CONCLUSION(S)

In contrast with the findings from a number of other studies, blastocyst culture in Australian and New Zealand is not associated with an increased risk of preterm, LBW, and SGA for singletons. Further studies are needed to assess longer-term outcomes of children born after ART treatment and possible biological or treatment factors related to adverse outcomes.

A systematic review and meta-analysis of metformin among patients with polycystic ovary syndrome undergoing assisted reproductive technology procedures

BACKGROUND

Metformin is used among patients with polycystic ovary syndrome (PCOS), but findings for its effects on outcomes of assisted reproductive technology (ART) have been conflicting.

OBJECTIVES

To compare ART outcomes among women with PCOS who were and were not given metformin.

SEARCH STRATEGY

Databases were searched for reports published in English between 2002 and 2013, using combinations of the terms "polycystic ovary syndrome," "PCOS," "insulin-sensitizing," and "metformin."

SELECTION CRITERIA

Randomized controlled trials of metformin versus placebo among women with PCOS undergoing ART were included if they assessed rates of pregnancy, live birth, spontaneous abortion, multiple pregnancy, and/or ovarian hyperstimulation syndrome (OHSS).

DATA COLLECTION AND ANALYSIS

Data were extracted from included studies. The Mantel-Haenzel random-effects model was used for meta-analyses.

MAIN RESULTS

Twelve studies (1516 participants) were included. No significant differences were recorded between metformin and placebo groups for rates of pregnancy (risk ratio [RR] 1.11, 95% CI 0.92-1.33), live birth (RR 1.12, 0.92-1.36), spontaneous abortion (RR 1.00, 0.60-1.67), or multiple pregnancy (RR 0.96, 0.47-1.96). However, OHSS rate was significantly lower among patients who received metformin than among those who received placebo (RR 0.44, 0.26-0.77).

CONCLUSIONS

Metformin does not improve ART outcomes among patients with PCOS, but does significantly reduce their risk of OHSS.

Effect of endometrial biopsy on intrauterine insemination outcome in controlled ovarian stimulation cycle

OBJECTIVE

The objective was to evaluate the effect of endometrial biopsy (EB) on intrauterine insemination (IUI) outcome in controlled ovarian stimulation (COS) cycle.

DESIGN

Prospective randomized control study.

SETTING

Tertiary care center.

MATERIALS AND METHODS

A total of 251 subjects were enrolled in the study. Subjects undergoing COS with IUI were randomly allocated into three groups. Group A: EB was taken between D19 and 24 of the spontaneous menstrual cycles that precedes the fertility treatment and IUI, which was done in next cycle (n = 86). Group B: EB was taken before D6 of the menstrual cycle, and fertility treatment and IUI was done in the same cycle (n = 90). Group C: (control group) no EB in previous 3 cycle (n = 75).

MAIN OUTCOME MEASURE

Clinical pregnancy rate (CPR).

RESULTS

Clinical pregnancy rate was 19.77%, 31.11%, and 9.3% for Group A, Group B, and Group C, respectively. The results show a highly significant value for the paired t-test of intervention Group B and control Group C of the cases (P = 0.000957). CPR was maximum after first cycle of ovulation induction and IUI following EB scratch in both Groups A and in Group B (P < 0.001).

CONCLUSIONS

Endometrial biopsy done in early follicular phase in the same cycle of stimulation with IUI gives better CPR as compared with EB done in the luteal phase of the previous cycle.

Adverse pregnancy outcomes after in vitro fertilization: effect of number of embryos transferred and plurality at conception

OBJECTIVE

To evaluate risks for adverse pregnancy outcomes by number of embryos transferred (ET) and fetal heartbeats (FHB) in assisted reproductive technology-conceived singleton live births.

DESIGN

Longitudinal cohort using cycles reported to the Society for Assisted Reproductive Technology Clinic Outcomes Reporting System between 2004 and 2008 among women who were treated and gave birth in Massachusetts.

SETTING

Not applicable.

PATIENT(S)

Assisted reproductive technology data on 6,073 births between 2004 and 2008 were linked to vital records and hospital data. Likelihood of ET ≥3 vs. 1-2, FHB >1 vs. 1, and risks of preterm birth (PTB, <37 weeks' gestation), low birth weight (LBW, <2,500 g), and small-for-gestational-age birth weight (SGA, <10th percentile) with FHB >1 were modeled with binary logistic regression using a backward-stepping algorithm, and presented as adjusted odds ratios (95% confidence intervals).

INTERVENTION(S)

None.

MAIN OUTCOME MEASURE(S)

ET ≥3, FHB >1, PTB, LBW, and SGA.

RESULT(S)

Higher ET was significantly more likely with older maternal age, intracytoplasmic sperm injection, assisted hatching, cleavage-stage embryos, and thawed embryos. The likelihood of FHB >1 with ≥3 ET vs. 1-2 ET was 2.04 (1.68-2.48). Risks of PTB and LBW with FHB >1 were 1.63 (1.27-2.09) and 1.81 (1.36-2.39), respectively; the risk of SGA was not significant. Nulliparity was associated with higher risks of PTB (1.34 [1.12-1.59]), LBW (1.48 [1.20-1.83]), and SGA (2.17 [1.69-2.78]).

CONCLUSION(S)

Number of embryos transferred was strongly associated with FHBs, with twice the risk of FHB >1 with ≥3 ET vs. 1-2 ET. Increasing FHBs were associated with significantly greater risks for PTB and LBW outcomes.

Role of the mental health professional in education and support of the medical staff

This review argues that mental health professionals are underutilized in the reproductive health care system. Counselors in the field of reproductive medicine could broaden their care from a strictly one-on-one patient care perspective to a more integrated and collaborative approach that also involves education, training, and support of the fertility clinic staff. The literature has shed light on reasons for patient discontinuation, but little is known about staff burnout in reproductive health care, and even less has been done to address work-related stress, job dissatisfaction, and poor emotional and physical health among fertility clinic staff. Specific educational strategies and training techniques are addressed to help reduce staff stress, prevent burnout, and improve overall patient care.

Embryo transfer practices and perinatal outcomes by insurance mandate status

OBJECTIVE

To use linked assisted reproductive technology (ART) surveillance and birth certificate data to compare ET practices and perinatal outcomes for a state with a comprehensive mandate requiring coverage of IVF services versus states without a mandate.

DESIGN

Retrospective cohort study.

SETTING

Not applicable.

PATIENT(S)

Live-birth deliveries ascertained from linked 2007-2009 National ART Surveillance System and birth certificate data for a state with an insurance mandate (Massachusetts) and two states without a mandate (Florida and Michigan).

INTERVENTION(S)

None.

MAIN OUTCOME MEASURE(S)

Number of embryos transferred, multiple births, low birth weight, preterm delivery.

RESULT(S)

Of the 230,038 deliveries in the mandate state and 1,026,804 deliveries in the nonmandate states, 6,651 (2.9%) and 8,417 (0.8%), respectively, were conceived by ART. Transfer of three or more embryos was more common in nonmandate states, although the effect was attenuated for women 35 years or older (33.6% vs. 39.7%; adjusted relative risk [RR], 1.46; 95% confidence interval [CI], 1.17-1.81) versus women younger than 35 (7.0% vs. 26.9%; adjusted RR, 4.18; 95% CI, 2.74-6.36). Lack of an insurance mandate was positively associated with triplet/higher order deliveries (1.0% vs. 2.3%; adjusted RR, 2.44; 95% CI, 1.81-3.28), preterm delivery (22.6% vs. 30.7%; adjusted RR, 1.31; 95% CI, 1.20-1.42), and low birth weight (22.3% vs. 29.5%; adjusted RR, 1.28; 95% CI, 1.17-1.40).

CONCLUSION(S)

Compared with nonmandate states, the mandate state had higher overall rates of ART use. Among ART births, lack of an infertility insurance mandate was associated with increased risk for adverse perinatal outcomes.

Pregnancy following breast cancer using assisted reproduction and its effect on long-term outcome

INTRODUCTION AND AIMS

We have previously shown that pregnancy is safe following breast cancer, even in endocrine sensitive disease. Yet infertility remains common following systemic treatment. To date, no study has evaluated the safety of assisted reproductive technology (ART) after breast cancer treatment. In this study, we evaluated the impact of ART on pregnancy and long-term outcomes of young breast cancer survivors.

METHODS

This is a multi-centre retrospective study in which women who were diagnosed with breast cancer between 2000 and 2009, and had a pregnancy following breast cancer diagnosis were eligible. Patients were divided into two groups according to whether ART following primary systemic therapy was performed to achieve pregnancy. We evaluated the association between ART use and clinic-pathological characteristics, pregnancy outcome and long-term breast cancer outcome.

RESULTS

A total of 198 patients were evaluated; of whom 25 underwent ART. No significant differences in tumour characteristics were observed between both groups, except for histological grade 3 tumours, which were fewer in the ART group (36% versus 59%, p=0.033). Around 90% of patients received primary adjuvant chemotherapy and more than 50% had an endocrine sensitive disease. Patients in the ART group were older at diagnosis (31.4 versus 33.7 years, p=0.009), at conception (38 versus 35 years, p<0.001), and experienced more miscarriages (23.5 versus 12.6%, p=0.082). Full term pregnancies were achieved in 77% and 76% of the spontaneous and ART groups, respectively. Mean follow-up between conception and last follow-up was 63 and 50 months in the spontaneous and ART groups, respectively with no difference in breast cancer outcome observed between the two groups (p=0.54).

CONCLUSION

Pregnancy using ART in women with history of breast cancer is feasible and does not seem to be detrimental to cancer outcome. Larger studies are needed to further confirm this observation.

Effects of assisted reproductive technology and of women's quality of life on depressive symptoms in the early postpartum period: a prospective case-control study

This study explored the influence of both assisted reproductive technology (ART) and reduced quality of life (QoL) during pregnancy on postpartum blues (PPB). Sixty-three sub-fertile patients who conceived through ART and 72 women who naturally conceived were enrolled in this prospective study. At 22nd and 32nd gestational weeks, women completed the Edinburgh Postnatal Depression Scale (EPDS) and the Short-Form 36 (SF-36), to investigate depressive symptoms and QoL, respectively; EPDS was again used at 15 days after birth to assess PPB. At both time points, higher EPDS scores and lower mental well-being scores (SF-36) significantly predicted PPB. The number of previous ART cycles emerged as the strongest predictor, whereas no significant effect was observed for the conceiving method. The results suggest the usefulness of assessing QoL during pregnancy and considering previous ART failures in preventing PPB.

Obstetrical and neonatal outcomes of triplet births - spontaneous versus assisted reproductive technology conception

OBJECTIVE

To determine the average gestational age at birth and to compare obstetrical and neonatal outcomes of triplet births conceived spontaneously versus via assisted reproductive technology (ART).

METHODS

A retrospective chart review of triplet pregnancies that resulted in three live babies was conducted at Mount Sinai Hospital (Toronto, Canada) from January 2000 to June 2013.

RESULTS

A total of 230 women and 690 fetuses were identified. The mean gestational age at birth was 32.0 ± 3.8 weeks. Obstetrical outcomes included preterm premature rupture of the membranes in 29%, preterm labor in 26%, preeclampsia or HELLP syndrome in 19% and gestational diabetes in 10%. The mean birth weight of infants born after 24 weeks was 1655 ± 550 g and the rate of small for gestational age was 28%. The neonatal mortality rate prior to discharge was 7%. Aside from respiratory distress syndrome (30.6 versus 46.6%; p = 0.02), there were no differences in gestational age at birth, obstetrical or neonatal outcomes between spontaneous versus ART triplet conception. Monochorionicity carried a higher risk of small for gestational age, congenital anomalies and neonatal mortality compared to trichorionicity.

CONCLUSION

Rates of preterm birth and related complications remain high in triplet gestation. However, obstetrical and neonatal outcomes were similar for triplets conceived spontaneously versus via ART.

Comparison of the effect of different media on the clinical outcomes of the density-gradient centrifugation/swim-up and swim-up methods

Objective

Sperm must be properly prepared in in vitro fertilization (IVF)-embryo transfer (ET) programs in order to control the fertilization rate and ensure that embryos are of high quality and have appropriate developmental abilities. The objective of this study was to determine the most optimal sperm preparation method for IVF.

Methods

Patients less than 40 years of age who participated in a fresh IVF-ET cycle from November 2012 to March 2013 were included in this study. Poor responders with less than three mature oocytes were excluded. Ham's F-10 medium or sperm-washing medium (SWM) was used in combination with the density-gradient centrifugation/swim-up (DGC-SUP) or SUP methods for sperm preparation. A total of 429 fresh IVF-ET cycles were grouped according to the media and methods used for sperm preparation and retrospectively analyzed (DGC-SUP/Ham's F-10, n=82; DGC-SUP/SWM, n=43; SUP/Ham's F-10, n=181; SUP/SWM, n=123).

Results

There were no significant differences among these four groups with respect to the mean age of the female partners, duration of infertility, number of previous IVF cycles, and retrieved oocytes. We determined that both the DGC-SUP and SUP methods for sperm preparation from whole semen, using either Ham's F-10 or SWM media, result in comparable clinical outcomes, including fertilization and pregnancy rates.

Conclusion

We suggest that both media and both methods for sperm preparation can be used for selecting high-quality sperm for assistive reproductive technology programs.

Current status of assisted reproductive technology in Korea, 2010

Objective

Great advances have been made in the field of assisted reproductive technology (ART) since the first in vitro fertilization (IVF) baby was born in Korea. This study was designed to report on the current status of ART therapy in South Korea between January 1 and December 31 of 2010.

Methods

A revised survey, originally developed by the International Committee Monitoring Assisted Reproductive Technologies, was sent to all available ART centers via email in 2013. Fresh embryo transfer (FET) cases were categorized into standard IVF or intracytoplasmic sperm injections. These cases, the thawing embryo transfer (TET) cases, and other related procedures were surveyed.

Results

Data from 30,785 ART procedures were provided by 78 clinics. Of the 28,200 cycles in which oocytes were retrieved, 92.2% of these cycles were completely transferred. In addition, 8,075 cycles were confirmed to be clinical pregnancies in the FET cycles, which represent a pregnancy rate of 28.6% per oocyte pick-up and 31.1% per embryo transfer. The most common number of embryos transferred in the FET was three embryos (37.3%) followed by two embryos (36.3%) and one embryo (14.0%). Of the 6,648 TET cycles transferred, 2,356 clinical pregnancies were confirmed by ultrasonography. The most common number of embryos in the TET group was two embryos (43.4%) followed by three embryos (25.4%) and one embryo (18.9%).

Conclusion

The clinical pregnancy rate per transfer in the FET cycles was similar in 2009 and 2010. Among the FET cycles where one or two embryos were transferred, the clinical pregnancy rate per transfer slightly increased from 2009 (28.7%) to 2010 (32.9%).

Effects of female increased body mass index on in vitro fertilization cycles outcome

BACKGROUND

As being overweight can impair female spontaneous fertility or after assisted reproductive technology (ART) cycles, the aim of this study was to compare in vitro fertilization (IVF) outcome according to women's body mass index (BMI).

METHODS

Retrospective study conducted from 2006 to 2009 in the IVF unit of Nantes University Hospital, France. 582 patients undergoing standard infertility workup and controlled ovarian stimulation were categorized according to BMI into two groups: group 1: normal weight (20-24.9 kg/m(2); n=409) and group 2: overweight and obese (≥25 kg/m(2); n=149). Basal hormonal status, smoking habitus, infertility duration, IVF cycle parameters and outcome were recorded.

RESULTS

Basal LH, FSH and estradiol levels were higher in group 1 than group 2, but ovarian reserve markers were comparable across the two BMI groups. Higher doses of gonadotropins were required in group 2 to obtain equivalent ovarian response than in group 1. No difference was observed on ovarian response and embryonic parameters. Cycle outcome were not significantly different between both groups, but we found a strong trend towards increasing transfer cancellation and miscarriage rates in group 2.

CONCLUSION

Although overweight and obesity do not compromise ovarian stimulation results whenever adaptation of recombinant FSH doses is made, our data suggest an increased risk of cancellation transfer and miscarriage rate, leading to poorer IVF outcome.

Male factors in ART outcome prediction

Paternal influences on reproduction are significant causing about half of the infertile couples to turn to assisted reproductive techniques. Due to the increasing proportion of infertile couples adopting to conceive by in vitro fertilisation (IVF), predicting outcomes is of ever increasing importance. Since pregnancy rates following IVF are still quite low, prognostic information is very helpful in clinical decisions. Although significant research has been done on the maternal influence, male factor infertility is relatively understudied. To date, potential predictors include: method of fertilisation, age, reactive oxygen species, sperm quality parameters and DNA fragmentation. Predictors under investigation which show promising signs, even though there is no clear cut consensus on the predictive value to date include: folate and homocysteine, anti müllerian hormone measurement, environmental factors, body mass index, smoking, male age, stress, some subsets of antisperm antibodies and epigenetic features.

[Impact of thyroid function on fertility]

Until recently, anovulation or recurrent miscarriages were the only situations for screening a thyroid dysfunction in an infertile patient. Recent U.S. guidelines published in 2011 identify infertile women as being at risk for thyroid dysfunction. This paper proposes, on the occasion of the new recommendations, a review of the literature data on the known impact of thyroid dysfunction on fertility, on the first trimester of pregnancy and on the way to treat them.

Can serum estradiol levels on the fourth day of IVF/ICSI cycle predict outcome in poor responder women?

We aimed to investigate the value of fourth day serum estradiol levels in predicting cycle outcome in poor responders. The medical records of 426 patients with low oocyte yield following controlled ovarian hyperstimulation (COH) treatment for a procedure in our institution's center for ART between 2008 and 2013 were evaluated. Eighty-eight patients exhibiting poor ovarian response (POR) were included in the study. The clinical outcomes of IVF/ICSI were compared based on the basal hormone profile, clinical, and laboratory parameters. Cycle day 4 E2 levels below 110 pg/ml had an odds ratio of 6.05 (95% CI 2.33-15.7; p < 0.001) for embryo transfer. The early follicular response to ovarian stimulation can be anticipated with the cycle day 4 estradiol levels during COH. When a low day 4 serum estradiol level is encountered, abandoning the current COH and proceeding with agents that increase ovarian response to ovarian stimulation before the next treatment cycle can be a realistic approach.

Gonadotrophins: The future

The role of the IVF clinician is to make the ART treatment safe, patient-friendly, cost effective and at the same time offer good and high quality treatment. IVF protocols are a burden for women and are one of the potential reasons why women don’t return for subsequent cycles. Frequent injections may increase stress and also result in high error rates. Simple short treatment regimen with optimal recovery of good quality oocytes results in development of good quality embryos followed by SET in treatment and cryopreservation cycles are a less burden and result in related lesser discontinuation, side effects, treatment cycles in time and are more cost-effective.

Development of FSH analogues with longer terminal t1/2 and slower absorption to peak serum levels will increase the efficiency, decrease the side effects and also is easy to administer. This makes it convenient for the patients increasing the compliance. A certain minimum LH concentration is necessary for adequate thecal cell function and subsequent oestradiol synthesis in the granulosa cells. Adjuvant r-HLH gives clinician's precise control over the dose of LH bioactivity administered to target the therapeutic window. New parenteral, transdermal, inhaled and oral fertility drugs and regimens are currently under research and development with the objective to further simplify treatment for ART.

Assisted reproductive technology and somatic morbidity in childhood: a systematic review

OBJECTIVE

To assess whether children conceived by assisted reproductive technology are at increased risk of somatic morbidity in childhood compared with spontaneously conceived children.

DESIGN

Systematic review.

SETTING

None.

PATIENT(S)

Children conceived by assisted reproductive technology and reference groups of spontaneously conceived children or children from the background population.

INTERVENTION(S)

Medline/Pubmed, Embase, and the Cochrane Library were searched as well as reference lists of the retrieved relevant studies. Only cohort studies and case-control studies were included. All studies were scored using the Newcastle-Ottawa scale to assess study quality and the risk of bias in the individual studies.

MAIN OUTCOME MEASURE(S)

Postneonatal somatic diseases, health care use, chronic illnesses (unspecified), surgery, use of medication, and mortality.

RESULT(S)

Thirty-eight studies were included. Results indicated that children conceived by assisted reproductive technology may be at increased risk of unspecified infectious and parasitic diseases, asthma, genitourinary diseases, epilepsy or convulsions, and longer hospitalizations. However, several results in individual studies were not statistically significant and some inconsistency existed between study results. No differences between groups were found regarding hospital admission, outpatient visits, or use of medication. Results regarding mortality, unspecified cancer, pneumonia, allergy, respiratory, and gastrointestinal diseases were contradictory. When considering only the 13 studies allocated the highest score on the Newcastle-Ottawa scale, similar results were found.

CONCLUSION(S)

Children conceived by assisted reproductive technology may be at increased risk of somatic morbidity in childhood compared with spontaneously conceived children, although some inconsistency exists between study results.

A healthy delivery of twins by assisted reproduction followed by preimplantation genetic screening in a woman with X-linked dominant incontinentia pigmenti

The purpose of this study is to report a successful twin pregnancy and delivery in a female patient with X-linked dominant incontinentia pigmenti (IP) who underwent assisted reproductive technology followed by preimplantation genetic screening (PGS). A 29-year-old female with IP had a previous history of recurrent spontaneous abortion. A molecular analysis revealed the patient had a de novo mutation, 1308_1309insCCCCTTG(p.Ala438ProfsTer26), in the inhibitor of the kappa B kinase gamma gene located in the Xq28 region. IVF/ICSI and PGS was performed, in which male embryos were sexed using array-based comparative genomic hybridization (aCGH). After IVF/ICSI and PGS using aCGH on seven embryos, two euploid male blastocysts were transferred with a 50% probability of a viable male pregnancy. The dizygotic twin pregnancy was confirmed and the amniocentesis results of each twin were normal with regard to the mutation found in the mother. The patient delivered healthy twin babies during the 37th week of gestation. This case shows the beneficial role of PGS in achieving a successful pregnancy through euploid male embryo gender selection in a woman with X-linked dominant IP with a history of multiple male miscarriages.

Focusing on surgery results in infertile patients with deep endometriosis

Infertility is a common problem in patients with endometriosis and the involved mechanisms are still not completely known. The management of infertility in endometriosis patients includes surgery as well as assisted reproductive technology. Laparoscopic surgery has shown better results in infertility patients with endometriosis in comparison to laparotomy procedures. Laparoscopic surgery has proposed benefits in both minimal to moderate diseases. However, while there may be some benefits with severe diseases, there is still not enough evidence to recommend laparoscopic surgery as the recommended surgery when the main goal is to obtain fertility. We performed a MEDLINE search for articles on fertility in women with deep infiltrating endometriosis (DIE) published between 1990 and April 2015 using the following keywords: "endometriosis", "deep infiltrative endometriosis", "infertility", "fertility after surgery", "laparoscopy surgery", "laparotomy", "pregnancy", "fertility outcome", "bladder endometriosis", and "ureteral endometriosis". The aim of this review was to analyze the results of available clinical studies (randomized controlled or not controlled studies; retrospective cohort studies; or case-control and prospective studies) and guidelines on surgical treatment of infertile endometriosis patients, and pregnancy outcomes after surgery.

Surgery for endometriosis-associated infertility: do we exaggerate the magnitude of effect?

OBJECTIVE

Surgery remains the mainstay in the diagnosis and management of endometriosis. The number of surgeries performed for endometriosis worldwide is ever increasing, however do we have evidence for improvement of infertility after the surgery and do we exaggerate the magnitude of effect of surgery when we counsel our patients? The management of patients who failed the surgery could be by repeat surgery or assisted reproduction. What evidence do we have for patients who fail assisted reproduction and what is their best chance for achieving pregnancy?

MATERIAL AND METHODS

In this study we reviewed the evidence-based practice pertaining to the outcome of surgery assisted infertility associated with endometriosis. Manuscripts published in PubMed and Science Direct as well as the bibliography cited in these articles were reviewed. Patients with peritoneal endometriosis with mild and severe disease were addressed separately. Patients who failed the primary surgery and managed by repeat or assisted reproduction technology were also evaluated. Patients who failed assisted reproduction and managed by surgery were also studied to determine of the best course of action.

RESULTS

In patients with minimal and mild pelvic endometriosis, excision or ablation of the peritoneal endometriosis increases the pregnancy rate. In women with severe endometriosis, controlled trials suggested an improvement of pregnancy rate. In women with ovarian endometrioma 4 cm or larger ovarian cystectomy increases the pregnancy rate, decreases the recurrence rate, but is associated with decrease in ovarian reserve. In patients who have failed the primary surgery, assisted reproduction appears to be significantly more effective than repeat surgery. In patients who failed assisted reproduction, the management remains to be extremely controversial. Surgery in expert hands might result in significant improvement in pregnancy rate.

CONCLUSION

In women with minimal and mild endometriosis, surgical excision or ablation of endometriosis is recommended as first line with doubling the pregnancy rate. In patients with moderate and severe endometriosis surgical excision also is recommended as first line. In patients who failed to conceive spontaneously after surgery, assisted reproduction is more effective than repeat surgery. Following surgery, the ovarian reserve may be reduced as determined by Anti Mullerian Hormone. The antral follicle count is not significantly reduced. In women with large endometriomas > 4 cm the ovarian endometrioma should be removed. In women who have failed assisted reproduction, further management remains controversial in the present time.

Experiences of Infertile Women Seeking Assisted Pregnancy in Iran: A Qualitative Study

BACKGROUND

Assisted reproductive technologies (ARTs) are complicated and stressful techniques and the social and cultural norms are major obstacles against their use. Many qualitative studies have been done in the field of women's experiences of infertility, but less is known about the experiences of infertile women seeking assisted pregnancy. The aim of this study was to understand and describe the experience of women who have used assisted reproductive technologies for their current pregnancy.

METHODS

This qualitative study was conducted based on a content analysis approach. With purposive sampling, 12 pregnant women who were using ART were recruited from Avicenna Fertility Center in Tehran. Women were selected purposefully and with maximum variation. Interviews were performed after a positive test of pregnancy and women were introduced to researchers in their first visit of pregnancy in the prenatal clinic. Interviews were recorded, transcribed verbatim and analyzed concurrently. Semi-structured interviews were coded, categorized and the themes were also identified.

RESULTS

Four main themes were uncovered which included struggle to achieve pregnancy, fear and uncertainty, escape from stigma and the pursuit to achieve husband satisfaction.

CONCLUSION

It is essential for these women to be counseled and prepared by their health care providers after the use of ARTs. Distress can be reduced for infertile women seeking assisted pregnancy when they are prepared for possible failures, empowered to deal with stigma, and have their partners' involvement in counseling sessions.

Joint reproductive autonomy: does Evans v Amicus Healthcare Ltd provide for a gender-neutral approach to assisted reproductive rights?

Assisted reproductive technology encompasses methods of achieving pregnancy by artificial or partially artificial means. Whilst these methods are more commonly used by couples suffering from problems of infertility, some forms of assistance are employed by fertile couples, for example pre-implantation genetic diagnosis. The overall regulatory framework in the UK is predominantly found in the Human Fertilisation and Embryology Act 1990. The usual rules relating to consent and autonomy apply and were discussed in depth in Evans v Amicus Healthcare Ltd and later in Evans v United Kingdom. This paper considers whether the Evans litigation envisages the possibility of further encouraging joint autonomy in the use of zygotes and whether there is a continuing right to autonomy by the party not bearing the pregnancy.

The possible association between exposure to air pollution and the risk for congenital malformations

BACKGROUND

Over the last decade, there is growing evidence that exposure to air pollution may be associated with increased risk for congenital malformations.

OBJECTIVES

To evaluate the possible association between exposures to air pollution during pregnancy and congenital malformations among infants born following spontaneously conceived (SC) pregnancies and assisted reproductive technology (ART) pregnancies.

METHODS

This is an historical cohort study comprising 216,730 infants: 207,825 SC infants and 8905 ART conceived infants, during the periods 1997-2004. Air pollution data including sulfur dioxide (SO2), particulate matter <10 µm (PM10), nitrogen oxides (NOx) and ozone (O3) were obtained from air monitoring stations database for the study period. Using a geographic information system (GIS) and the Kriging procedure, exposure to air pollution during the first trimester and the entire pregnancy was assessed for each woman according to her residential location. Logistic regression models with generalized estimating equation (GEE) approach were used to evaluate the adjusted risk for congenital malformations.

RESULTS

In the study cohort increased concentrations of PM10 and NOx pollutants in the entire pregnancy were associated with slightly increased risk for congenital malformations: OR 1.06(95% CI, 1.01-1.11) for 10 µg/m(3) increase in PM10 and OR 1.03(95% CI, 1.01-1.04) for 10 ppb increase in NOx. Specific malformations were evident in the circulatory system (for PM10 and NOx exposure) and genital organs (for NOx exposure). SO2 and O3 pollutants were not significantly associated with increased risk for congenital malformations. In the ART group higher concentrations of SO2 and O3 in entire pregnancy were associated (although not significantly) with an increased risk for congenital malformations: OR 1.06(95% CI, 0.96-1.17) for 1 ppb increase in SO2 and OR 1.15(95% CI, 0.69-1.91) for 10 ppb increase in O3.

CONCLUSIONS

Exposure to higher levels of PM10 and NOx during pregnancy was associated with an increased risk for congenital malformations. Specific malformations were evident in the circulatory system and genital organs. Among ART pregnancies possible adverse association of SO2 and O3 exposure was also observed. Further studies are warranted, including more accurate exposure assessment and a larger sample size for ART pregnancies, in order to confirm these findings.

Does weight loss in overweight or obese women improve fertility treatment outcomes? A systematic review

This systematic review assessed the effect of weight loss in overweight and/or obese women undergoing assisted reproductive technology (ART) on their subsequent pregnancy outcome. Weight losses achieved by diet and lifestyle changes, very-low-energy diets, non-surgical medical interventions and bariatric surgery translated into significantly increased pregnancy rates and/or live birth in overweight and/or obese women undergoing ART in 8 of the 11 studies reviewed. In addition, regularization of the menstrual pattern, a decrease in cancellation rates, an increase in the number of embryos available for transfer, a reduction in the number of ART cycles required to achieve pregnancy and a decrease in miscarriage rates were reported. There were also a number of natural conceptions in five of the six studies that reported this outcome. Non-surgical medical weight loss procedures and bariatric surgery induced the greatest weight losses, but their use, as well as that of very-low-energy diets, for weight loss prior to ART requires careful consideration. While the overall quality of the studies included in this review was poor, these results support the clinical recommendation of advising overweight and/or obese women to lose weight prior to ART. Prospective randomized controlled trials are required to establish efficacious evidence-based guidelines for weight loss interventions in overweight and/or obese women prior to ART treatment.