Relationship between the follicular distribution pattern of polycystic ovaries and the degree of menstrual disturbance and serum sex steroid levels

Objective:

This study aimed to examine the associations between follicular distribution pattern (FDP) in polycystic ovaries and menstrual disturbances in women with infertility.

Materials and Methods:

A retrospective review of patients was performed (n=73). Ultrasound images from cycle day 2-5 of a spontaneous or progestin induced menstrual cycle were reviewed. Ovaries were classified as polycystic ovarian morphology (PCOM) if they contained ≥12-follicles measuring 2-9 mm in diameter. Images of PCOM ovaries were classified as having a peripheral cystic pattern (PCP) with follicles arranged at the periphery of the ovary, or general cystic pattern (GCP) if follicles were dispersed heterogeneously throughout the ovarian stroma. Menstrual disturbance was assessed by questionnaire, and oligomenorrhea was defined as cycles >35 days in length.

Results:

PCP was more strongly associated with menstrual irregularity that GCP. 94% of subjects with bilateral PCP-experienced oligomenorrhea compared with 65% of women with a unilateral PCP ovary [odds ratio (OR) 9; p<0.05]. 29% of women with bilateral GCP ovaries experienced menstrual disturbances, less than bilateral PCP (OR 36; p=0.002), but similar to unilateral PCP (OR 3; p=0.07). Serum testosterone and luteinizing hormone (LH) levels were significantly correlated with the ovarian FDP.

Conclusion:

There is a relationship between menstrual irregularity or certain types of serum steroids and ovarian morphology. It remains unknown if morphology, testosterone or LH causes the menstrual disturbance or if they are co-initiated by an intervening factor.

Associations between hyperthyroidism and adverse obstetric and neonatal outcomes: A study of a population database including almost 17,000 women with hyperthyroidism

OBJECTIVE

Large population-based studies on maternal hyperthyroidism's effect on antepartum, intrapartum, and neonatal complications are few. Most of these studies were small or did not evaluate a broad scope of possible complications. Therefore, a large population-based cohort study was conducted to study the associations between maternal hyperthyroidism and pregnancy and perinatal complications.

DESIGN

This is a retrospective population-based cohort study utilizing data from the Healthcare Cost and Utilization Project-Nationwide Inpatient Sample over 11 years from 2004 to 2014.

PATIENTS

16,984 deliveries to women with hyperthyroidism and 9,079,804 deliveries to mothers who did not suffer of hyperthyroidism.

METHODS

A cohort of all deliveries between 2004 and 2014 inclusively was created. Within this group, all deliveries to women with hyperthyroidism were the study group (n = 16,984) and the remaining deliveries were categorized as nonhyperthyroidism births and comprised the reference group (n = 9,079,804). The main outcome measures were pregnancy and perinatal complications.

RESULTS

Maternal hyperthyroidism was associated with several pregnancy and perinatal complications, including increased risks of gestational hypertension (adjusted odds ratio [aOR]: 1.236, 95% confidence interval [CI]: 1.045-1.462, p = .013) and preeclampsia (aOR: 1.190, 95% CI: 1.006-1.408, p = .042). These patients are more likely to experience preterm premature rupture of membranes (aOR: 1.322, 95% CI: 1.007-1.735, p = .044), preterm delivery (aOR: 1.287 95% CI: 1.132-1.465, p < .001), placental previa (aOR: 1.527, 95% CI: 1.082-2.155, p = .016), and suffer from venous thromboembolism (aOR: 2.894, 95% CI: 1.293-6.475, p = .010). As for neonatal outcomes, small for gestational age and stillbirth were more likely to occur in the offspring of women with hyperthyroidism (aOR: 1.688, 95% CI: 1.437-1.984, p < .001 and aOR: 1.647, 95% CI: 1.109-2.447, p = .013, respectively).

CONCLUSIONS

Women with hyperthyroidism are more likely to experience pregnancy, delivery, and neonatal complications. We found an association between hyperthyroidism and hypertensive disorders, preterm delivery, and intrauterine fetal death.

Geographic variation in semen parameters from data used for the World Health Organization semen analysis reference ranges

OBJECTIVE

To study geographic variations in sperm parameters using data from the trials that defined the reference ranges of the World Health Organization 2021 manual.

DESIGN

Retrospective evaluation of the data used to define the World Health Organization reference ranges.

SETTING

Not applicable.

PATIENT(S)

Data from 11 studies, including 3,484 participants across 5 continents.

INTERVENTION(S)

The data were divided according to geographic locations.

MAIN OUTCOME MEASURE(S)

Differences in sperm parameters.

RESULT(S)

The semen volume was significantly lower in samples from Asia and Africa than in other regions. The sperm concentration was the lowest in Africa and highest in Australia. The total motile sperm count (TMSC) and total motile progressive sperm count (TMPS) were significantly lower in Africa than in other regions. The TMSC and TMPS in Asia and the United States were significantly lower than in Europe and Australia. The 5th percentile of the sperm concentration was lowest in the United States (12.5 × 10⁶/mL). The 5th percentile for the normal sperm morphology was lowest in the United States (3%) and highest in Asia (5%). The 5th percentile for the TMSC and TMPS were lowest in Africa (TMSC, 15.08 million; TMPS, 12.06 million) and the United States (TMSC, 18.05 million; TMPS, 16.86 million) and highest in Australia (TMSC, 29.61 million; TMPS, 25.80 million).

CONCLUSION(S)

Significant geographic differences in sperm parameters exist, and regional fertility societies should consider adding their own reference ranges on the basis of local experience and treatment outcomes.

Gonadotropin releasing hormone (GnRH) antagonist administration to decrease the risk of ovarian hyperstimulation syndrome in GNRH agonist cycles triggered with human chorionic gonadotropin

PURPOSE

In Gonadotropin releasing hormone(GnRH) agonist IVF, after administration of human chorionic gonadotropin(HCG) triggering, there is a risk of ovarian hyperstimulation syndrome(OHSS). Few methods exist to prevent OHSS in these cases. Therefore, we investigated the use of a GnRH antagonist to decrease the risk of OHSS, due to its ability to decrease VEGF production and function.

METHOD

A retrospective cohort study of 171-IVF patients at risk for developing OHSS after a GnRH agonist cycle with HCG trigger was performed from 2011 to 2019. The patient population consisted of women with an unexpected exuberant response to stimulation based on ovarian reserve testing and were triggered with hCG. Women were converted to a freeze-all cycle and received either cabergoline 0.5 mg orally alone for 7 days from the collection(Group 1, n = 123) or received cabergoline 0.5 mg orally and ganirelix, 250 mcg SC for 7-10 days(Group 2, n = 48).

RESULTS

Group 1 had more cases of moderate and severe OHSS than group 2-(25% vs. 10% p = 0.03, and 52% vs. 25% p = 0.001 respectively). Group 1 reported more abdominal discomfort and bloating than group 2(91% vs. 65% p < 0.001) and the presence of free fluid was more frequent in group 1 than group 2(74% vs. 35% p < 0.001). Hemoconcentration and electrolyte disturbances were less severe in group 2 than in group 1 (p < 0.001 all cases).

CONCLUSION

In patients at high risk for developing OHSS after hCG trigger in a GnRH agonist cycle, the addition of GnRH antagonists in the luteal phase may reduce the risk of developing moderate and severe OHSS. The GnRH antagonist likely leads to more rapid luteolysis and down regulation of VEGF production and receptor response, thereby decreasing the hallmark increased vascular permeability.

The impact of embryo vitrification on placental histopathology features and perinatal outcome in singleton live births

STUDY QUESTION

Does embryo vitrification affect placental histopathology pattern and perinatal outcome in singleton live births?

SUMMARY ANSWER

Embryo vitrification has a significant effect on the placental histopathology pattern and is associated with a higher prevalence of dysfunctional labor.

WHAT IS KNOWN ALREADY

Obstetrical and perinatal outcomes differ between live births resulting from fresh and frozen embryo transfers. The effect of embryo vitrification on the placental histopathology features associated with the development of perinatal complications remains unclear.

STUDY DESIGN, SIZE, DURATION

Retrospective cohort study evaluating data of all live births from one academic tertiary hospital resulting from IVF treatment with autologous oocytes during the period from 2009 to 2017.

PARTICIPANTS/MATERIALS, SETTING, METHODS

All patients had placentas sent for pathological evaluation irrelevant of maternal or fetal complications status. Placental, obstetric and perinatal outcomes of pregnancies resulting from hormone replacement vitrified embryo transfers were compared with those after fresh embryo transfers. A multivariate analysis was conducted to adjust the results for determinants potentially associated with the development of placental histopathology abnormalities.

MAIN RESULTS AND THE ROLE OF CHANCE

A total of 1014 singleton live births were included in the final analysis and were allocated to the group of pregnancies resulting from fresh (n = 660) and hormone replacement frozen (n = 354) embryo transfers. After the adjustment for confounding factors the frozen embryo transfers were found to be significantly associated with chorioamnionitis with maternal (odds ratio (OR) 2.0; 95% CI 1.2-3.3) and fetal response (OR 2.6; 95% CI 1.2-5.7), fetal vascular malperfusion (OR 3.9; 95% CI 1.4-9.2), furcate cord insertion (OR 2.3 95% CI 1.2-5.3), villitis of unknown etiology (OR 2.1; 95% CI 1.1-4.2), intervillous thrombi (OR 2.1; 95% CI 1.3-3.7), subchorionic thrombi (OR 3.4; 95% CI 1.6-7.0), as well as with failure of labor progress (OR 2.5; 95% CI 1.5-4.2).

LIMITATIONS, REASONS FOR CAUTION

Since the live births resulted from frozen-thawed embryos included treatment cycles with previously failed embryo transfers, the factors over embryo vitrification may affect implantation and placental histopathology.

WIDER IMPLICATIONS OF THE FINDINGS

The study results contribute to the understanding of the perinatal future of fresh and vitrified embryos. Our findings may have an implication for the clinical decision to perform fresh or frozen-thawed embryo transfer.

STUDY FUNDING/COMPETING INTEREST(S)

Authors have not received any funding to support this study. There are no conflicts of interest to declare.

TRIAL REGISTRATION NUMBER

N/A.

Pregnancy complications and placental histology following embryo transfer with a thinner endometrium

STUDY QUESTION

Are deliveries following IVF with a thinner endometrium associated with adverse perinatal outcomes and placental findings?

SUMMARY ANSWER

Live births following IVF with a thinner endometrium are associated with an increased rate of placental-mediated obstetric complications and lower birthweight, while the placentas are notable for gross anatomical and histological malperfusion lesions.

WHAT IS KNOWN ALREADY

Past studies have noted a higher rate of adverse outcomes on deliveries following IVF with a thinner endometrium, mainly placental-associated complications. However, no study to date has investigated placental histopathology in such cases.

STUDY DESIGN, SIZE, DURATION

This was a retrospective cohort study of 1057 deliveries following IVF, between 2009 and 2017. All placentas were sent to pathology irrelevant of pregnancy complication status, per protocol at our institution.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Live singleton births from a tertiary university hospital after IVF were compared between patients for whom embryo transfer was performed with an endometrium <9 mm (thinner endometrium group) and patients with an endometrium ≥9 mm (control group). Placental pathologic findings were categorized according to the Amsterdam Placental Workshop Group Consensus. Outcomes were placental findings, including anatomic, inflammatory, vascular malperfusion and villous maturation lesions, as well as obstetric and perinatal outcomes. Continuous and categorical variables were compared as appropriate, and multivariate regression and linear analyses were employed to control for confounders.

MAIN RESULTS AND THE ROLE OF CHANCE

A total 292 cases in the thinner endometrium group, and 765 in the control group were compared. Maternal demographics were non-significant between the groups, except for main fertility indication was more commonly diminished reserve in patients with a thinner endometrium and less commonly male factor, P = 0.003. Higher rates of fresh transfers were noted in the control group, while the thinner endometrium group was notable for higher rates of blastocyte transfers. After adjustment for confounders, deliveries in the thinner endometrium group were associated with an overall higher rate of main placental-mediated complications, 22.9% versus 15.2%, P = 0.003, and significantly lower birthweight, β -100.76 g (-184.4-(-17.0)). Placentas in the thinner endometrium group were notable for reduced thickness and a higher rate of bilobated placentas. Placental histology in the thinner endometrium group demonstrated a higher rate of maternal malperfusion lesions.

LIMITATIONS, REASONS FOR CAUTION

The study was limited by its retrospective design and lack of data regarding prior uterine surgery. In addition, sample size was limited for detection of differences in outcomes of rarer occurrence and for analysis as per a stricter definition of thin endometrium.

WIDER IMPLICATIONS OF THE FINDINGS

Excess obstetric risks should be taken into consideration while planning an embryo transfer with a thinner endometrium. Further studies are needed to assess the yield of cycle cancellation and the effect of potential preventive measures such as Micropirin treatment.

STUDY FUNDING/COMPETING INTEREST(S)

No funding was used and the authors report no conflicting interests.

TRIAL REGISTRATION NUMBER

N/A.

Pregnancy, delivery, and neonatal outcomes among women with psoriatic arthritis, a population based study

OBJECTIVES

Many autoimmune diseases negatively affect pregnancies. Studies report conflicting data about the effects of psoriatic arthritis (PsA) in pregnancy. We sought to evaluate the pregnancy, delivery, and neonatal outcomes among women with PsA.

METHODS

We conducted a retrospective population-based study using data from the Healthcare Cost and Utilization Project-Nationwide Inpatient Sample (HCUP-HIS). Cases of PsA were identified using the ICD code 696.0. Pregnancies complicated with PsA were compared with the other pregnancies. A multivariate logistic regression was used to adjust for confounding variables.

RESULTS

A total of 9,096,369 control births and 419 with PsA occurred during the study period. Women with PsA were more likely to be older, Caucasian, obese, have a higher income, and private insurance (p-value <0.0001 all). Also, they were more likely to start their pregnancy with chronic hypertension, pregestational diabetes, thyroid disorders, inflammatory bowel disease, and depression. Rates of pregnancy induced hypertension (PIH) (aOR 1.58, 95% CI 1.13-2.21) and small for gestational age (SGA) (aOR 2.42, 95% CI 1.49-3.93) were higher in PsA. There were no differences in the rates of most outcomes including: preeclampsia, gestational diabetes, preterm delivery, preterm premature rupture of membranes (PPROM), placenta previa, abruption, modes of delivery, hemorrhage, deep vein thrombosis (DVT), pulmonary embolism (PE), chorioamnionitis, intrauterine fetal death, or congenital anomalies (p>0.05 all).

CONCLUSIONS

Women with PsA should be reassured about their pregnancy outcomes as only PIH and SGA were more common. Healthcare providers should take appropriate surveillance and preventive methods to mitigate the effect of these two complications in pregnancies complicated with PsA.

Placental histology following assisted hatching in fresh transfer cycles

PURPOSE

To assess placental histological findings following assisted hatching in fresh transfer in vitro fertilization cycles.

METHODS

Evaluation of a historic cohort of live singleton deliveries after fresh embryo transfer (ET) at a single university medical center between 2009 and 2017. We compared perinatal outcomes and placental histology in cases where assisted hatching was performed prior to ET (AH group) and cases with no AH (no AH group).

RESULTS

Overall, 166 deliveries following AH were compared to 494 deliveries with no AH. Patients' demographics were similar between the groups. Median antral follicle count was significantly lower in the AH group, median 11 (range 1-50) vs. 16 (range 1-80), p < 0.001, and the primary indication for infertility treatment significantly more often diminished ovarian reserve (p < 0.001). Cycle characteristics in the AH group included a higher gonadotropin dose employed, and a lower rate of single and blastocyte transfer. Pregnancies following AH were associated with less low-lying placentas, 0.6% vs. 6.2%, p = 0.001, and comparable for other perinatal outcomes. After adjusting for confounders, the rate of bilobated placentas was higher following AH, aOR 7.10, 95% CI 1.50-33.51. The rate of perivillous depositions was higher with AH, aOR, 95% CI 3.18, 1.46-6.93, and the rate of chorangiosis lower in this group, aOR, 95% CI 0.32, 0.11-0.93. The overall rate of vascular lesions was similar between the groups.

CONCLUSION

Pregnancies following AH are notable for a lower rate of placenta previa, yet a higher rate of bilobated placentas and perivillous depositions and less chorangiosis, warranting further investigation.

Can endometrial thickness at baseline or maximum stimulated levels during IVF predict the presence of endometrial polyps in women with two failed embryo transfers?

PURPOSE

To evaluate whether different measurements of endometrial thickness pre-IVF cycle and during the IVF cycles as measured by transvaginal ultrasound are associated with the absence or presence of endometrial polyps.

DESIGN

A retrospective cohort study was conducted in a university-affiliated fertility center. Patients were women who underwent two embryo transfer cycles and failed to conceive.

INTERVENTIONS

hysteroscopic evaluation and resection of any masses.

RESULTS

There was no difference on comparing the groups with and without polyps in the mean endometrial thicknesses at baseline scans pre-treatment or during IVF cycle. For women who failed two embryo transfer cycles, at any given endometrial thickness the probability of the presence of a polyp was 30-40%. ROC curves failed to detect an actionable relationship with different endometrial thicknesses and the relationship with an endometrial polyp, with most areas under the curve being just above 0.5. However, once the maximum stimulated endometrial thickness was ≥ 13 mm, there was a 70% chance of a polyp being noted at hysteroscopy. This was a statistical difference in the probability of a polyp being present as compared to the lesser thicknesses (p = 0.05).

CONCLUSION

Baseline or maximum stimulated endometrial thickness at IVF fails to predict with accuracy the presence of a polyp. However, if the maximum stimulated thickness was at least 13 mm, there was a higher probability of a uterine polyp being present. Such a cutoff would nevertheless miss most polyps. At any baseline thickness on CD 2-5, a polyp has a 30-40% probability of being present in women who failed two embryo transfers. ROC curves suggest that at baseline, or maximum stimulated endometrial thickness, the ability to predict a polyp is no better than flipping a coin. As such, endometrial cavity evaluation for polyps is legitimate in women with two embryo transfers irrelevant of the baseline or stimulated thickness.

How long can oocytes be frozen with vitrification and still produce competent embryos? A series of six cases

Cryopreservation of oocytes is a relatively new and valuable option for fertility preservation. The duration since vitrification of embryos may be associated with a lower likelihood of success. We do not know how long the oocytes can be vitrified to produce viable pregnancies. We present six cases in which oocytes were vitrified for >10 years for social freezing or cancer. Two patients returned after 11 years, one after 12 years, and one returned after 13 years to use their vitrified oocytes for pregnancy. Four singleton live births were recorded. The two remaining patients returned after 13 years and again after 14 and 15 years, respectively, and failed to conceive. This has raised the burden of the literature on oocyte vitrification for more than 10 years. Oocyte vitrification is an effective option for long-term fertility preservation in women.

Should pregnant women with diabetes be counseled differently if nephropathy was detected? a population database study

INTRODUCTION

The prevalence of diabetes mellitus has increased tremendously in the last two decades among women of reproductive age and this is mainly due to the pandemic of obesity. Diabetes mellitus is a well-known cause of maternal and neonatal complications in pregnancy. Diabetic nephropathy is a marker of severe diabetes and results in organ damage. However, only a small number of studies have evaluated the implications of diabetic nephropathy on pregnancy complications, with most having 50 to 100 nephropathy subjects. Our study aims to compare pregnant women with diabetes mellitus complicated by nephropathy or not and evaluate the relationship with obstetrical and perinatal morbidity and mortality, on a larger population.

METHODS

This was a population-based study using data from the Healthcare Cost and Utilization Project-Nationwide Inpatient Sample (HCUP-NIS) including women who delivered between 2004 and 2014. Multivariate logistic regression was used to control for confounding effects.

RESULTS

Among 86,615 pregnancies that were complicated by diabetes mellitus, 1,241 (1.4%) had diabetic nephropathy. Diabetic nephropathy was strongly associated with preeclampsia (aOR 2.3, 95% CI 1.90-2.68), as well as chronic hypertension with superimposed preeclampsia or eclampsia (aOR 4.2, 95% CI 3.53-5.01), preterm birth (aOR 1.8, 95% CI 1.59-2.1), and blood transfusion (aOR 3.6 95% CI 2.82-4.46). Both groups were similar in age and income.

CONCLUSION

Diabetic nephropathy is associated with increased obstetrical and perinatal morbidity compared to diabetes mellitus alone. These patients may benefit from a high dose of folic acid, more vigilant antenatal surveillance, delivery in a tertiary care center, and more rigorous screening and prevention methods for pregnancy-induced hypertension diseases at antenatal care visits.

The relation between cigarette smoking with delivery outcomes. An evaluation of a database of more than nine million deliveries

OBJECTIVES

Smoking in pregnancy is associated with an increased risk of preterm birth (PTB), intrauterine growth restriction, placental abruption and perinatal death. The association between smoking and other delivery outcomes, such as chorioamnionitis, mode of delivery or postpartum hemorrhage (PPH), however, is insufficient as only few studies addressed these issues. The aim of the study was to evaluate the association between prenatal smoking and delivery outcomes in a large database, while controlling for confounding effects.

METHODS

A retrospective population-based study using data from the Healthcare Cost and Utilization Project-Nationwide Inpatient Sample (HCUP-NIS). A dataset of all deliveries between 2004 and 2014 (inclusively) was created. Our control group included all pregnant women who did not smoke during pregnancy, which was compared to pregnant women who smoked. A multivariate logistic analysis was conducted, adjusting for any statistically significant confounding effects.

RESULTS

Our study identified 9,096,788 births between 2004 and 2014. Of which, 443,590 (4.8%) had a documented diagnosis of smoking. A significantly higher risk was found for PTB (odds ratio 1.39, CI 1.35-1.43), preterm premature rupture of membranes (odds ratio 1.52, CI 1.43-1.62) and small for gestational age (SGA) neonates (odds ratio 2.27, CI 2.19-2.35). The risks of preeclampsia (odds ratio 0.82, CI 0.78-0.85), chorioamnionitis (odds ratio 0.88, CI 0.83-0.4), PPH (odds ratio 0.94 CI 0.9-0.98) and operative vaginal delivery (odds ratio 0.9, CI 0.87-0.94) were lower among smokers.

CONCLUSIONS

This large database confirms the findings of previous smaller studies, according to which smoking decreases the risk of preeclampsia while increasing the risk of PTB and SGA neonates. The current study also revealed a decreased risk for PPH as well as for chorioamnionitis among pregnant smokers.

Predıctıve value of pregnancy of follıcular fluıd fetuın-A and -B levels ın infertıle women after intra-cytoplasmic sperm injection

AIM

We aimed to investigate the value of follicular fluid fetuins-A and -B to predict successful IVF and pregnancy outcomes in infertile women with poor, normal, and high ovarian reserve.

METHODS

The follicular fluid of 96 infertile women who underwent intra-cytoplasmic sperm injection (ICSI) procedure was analyzed. Fetuins-A and -B levels were examined and compared in those who could achieve pregnancy and those who could not. Receiver operating characteristic curve analyzes were used to determine cut-off and statistically significant associations for fetuins-A and -B.

RESULTS

Follicular fluid fetuin-A levels were higher in cases with weak ovarian reserve (OR) (p < 0.05) and higher in patients who did not achieve clinical pregnancy (p < 0.05). Conversely, the follicular fluid fetuin-B levels were lower in cases with poor OR (p < 0.05) and were lower in patients who did not achieve a clinical pregnancy (p < 0.05). A follicular fluid fetuin-A concentration ≤ 19.12 ng/mL had a sensitivity and specificity of 94.74% and 93.1%, respectively, at predicting clinical pregnancy. While the follicular fluid fetuin-B concentration >24.7 ng/mL had sensitivity and specificity of 71.1% and 51.7%, respectively, for clinical pregnancy prediction.

CONCLUSION

Overall, high levels of follicular fluid fetuin-A may be independently associated with unsuccessful IVF irrespective of OR grouping. A low level of follicular fetuin-B was also associated with failed IVF. The sensitivity and specificity were found to be higher for fetuin-A in predicting clinical pregnancy. Therefore, the follicular fluid fetuin-A may be more predictive for successful IVF and clinical pregnancy outcomes than follicular fluid fetuin-B.

An evaluation of changes over time in the semen parameters data used for the World Health Organization semen analysis reference ranges

BACKGROUND

Previous meta-analyses concluded that there is a decline in sperm parameters over time. This conclusion might be incorrect due to inherent biases or focusing only on a single parameter - sperm concentration.

OBJECTIVE

To study trends in sperm parameters over the past twenty years using data from the trials that defined the reference ranges of the World Health Organization manual.

MATERIALS AND METHODS

Retrospective evaluation of the data used to define the World Health Organization reference ranges. The data from 11 studies, including 3589 participants between 1996-2016, were divided into three period groups based on the decade of study. Differences in semen parameters' distribution were presented in boxplot. P-values were calculated by the Kruskal Wallis rank-sum test followed by Dunn post-hoc test. Analyses were conducted using the R programming language.

RESULTS

A small decrease was noted in mean sperm concentrations (88.1 million/ml, 87.6 million/ml and 77.2 million/ml for the first second and third decades respectively) (p<0.01). However, the 5^th percentile of sperm concentration for the third decade was higher than the first or second decades (18 million/ml vs. 14.9 million/ml and 15 million/ml respectively). No significant differences were noted in progressive motility over the years (p = 0.32). The percent of morphologically normal sperm decreased between the first (24.2%) and the second (12.6%) periods of the study (p<0.001) and then increased in the third decade (14.2%) (p<0.01). While TMC declined between the second and third decades (189 million and 153.9 million respectively, p<0.001), at levels unlikely to decrease fertility. However, the 5^th percentile of the TMC remained stable at 24.9, 20.8 and 20.6 million, for the first, second and third decades respectively (p = 0.36).

DISCUSSION AND CONCLUSION AND RELEVANCE

Trends in sperm parameters over the last three decades do not seem to be clinically significant. This article is protected by copyright. All rights reserved.

Pregnancy outcomes in women with panhypopituitarism: a population-based study

RESEARCH QUESTION

What are the consequences of panhypopituitarism on pregnancy outcomes?

DESIGN

Retrospective population-based study using data from the Healthcare Cost and Utilization Project - Nationwide Inpatient Sample (HCUP-NIS). A dataset was created of all deliveries between 2004 and 2014 inclusive. Within this group, all deliveries to women who had a diagnosis of panhypopituitarism during pregnancy were identified as part of the study group (n = 120), and the remaining deliveries comprised the reference group (n = 8,732,641). A multivariate logistic regression analysis, controlling for confounding effects, was conducted to explore associations between panhypopituitarism and pregnancy complications, delivery and neonatal outcomes.

RESULTS

No significant differences were found in the risk of developing gestational hypertension, gestational diabetes mellitus, placental abruption, or preterm delivery delivering a small for gestational age neonate, or in the mode of delivery. There was a higher risk of developing maternal infection (odds ratio [OR] 3.14, 95% confidence interval [CI] 1.46-6.74) and congenital anomalies (OR 6.97, 95% CI 2.57-18.95); however, due to the small number of cases these results should be interpreted with caution.

CONCLUSIONS

Pregnancy outcomes of women with panhypopituitarism are comparable to those of the general population. Further studies are needed to assess the risk of congenital anomalies and maternal infection in pregnant women with panhypopituitarism.

The effect of Cushing's syndrome on pregnancy complication rates: analysis of more than 9 million deliveries

PURPOSE

The purpose of this study to evaluate the risk of Cushing's syndrome (CS) and maternal and fetal complications using the American Nationwide Inpatient Sample database.

MATERIALS AND METHODS

This is a retrospective study using the Health Care Cost and Utilization Project-Nationwide Inpatient Sample database from 2004 to 2014. We compared pregnancies with CS versus non-CS regarding pregnancy, delivery, and neonatal outcomes using multivariate logistic regression.

RESULTS

We identified 9,096,788 pregnancies during the study period. Cushing's syndrome complicated 135 pregnancies at a rate of 1-2 cases per 100,000 births. Cushing's syndrome subjects were more likely to be older, obese, have private insurance, chronic hypertension, and pre-gestational diabetes (p<.001). The maternal mortality rate was 0.7 and 0.007% in Cushing's syndrome and control groups, respectively, although due to small numbers of cases, this should be interpreted with caution. Preeclampsia was higher in CS compared to controls after controlling for confounding variables, aOR 2.20. Operative vaginal delivery and blood transfusion rates were higher in CS patients than controls after controlling for confounding factors, aOR 6.49 and 3.09, respectively. The rates of preterm delivery (8.9 versus 7.2%) and gestational diabetes (8.1 versus 5.8%) were not statistically different between CS and control groups.

CONCLUSION

Cushing's syndrome patients begin pregnancies often with maladies making them more at risk for complications including, preeclampsia, blood transfusion, and operative vaginal delivery. These patients might benefit from prevention methods for preeclampsia, and increased surveillance to decrease maternal morbidity and mortality. However, the nature of the database and its limitations, including the lack of information about CS activity and treatments received by patients, warrant careful interpretation of these results.

O-164 Associations between hypothyroidism and adverse obstetric and neonatal outcomes: a population study of 9.1 million births

Study question

Does hypothyroidism confer an independent risk for adverse delivery and neonatal outcomes, based on analysis of the Healthcare Cost and Utilization Project-Nationwide Inpatient Sample database?

Summary answer

After controlling for confounders, women with hypothyroidism are at an increased risk of hypertensive disorders of pregnancy, preterm delivery, placental abruption, hemorrhage and caesarean section.

What is known already

Surprisingly, studies in the literature on maternal and neonatal complications of hypothyroidism in pregnancy are relatively small. The largest study to date included 184,611 pregnancies overall, with 7140 with hypothyroidism. Maternal hypothyroidism has been associated with multiple adverse pregnancy outcomes. These findings have not been confirmed in a large population database study.

Study design, size, duration

This is a retrospective study utilizing data from the Healthcare Cost and Utilization Project-Nationwide Inpatient Sample (HCUP-NIS). A cohort of all deliveries between 2004 and 2014 inclusively was created. Within this group, all deliveries to women with hypothyroidism formed the study group (n = 185,073), and the remaining deliveries were categorized as non- hypothyroidism births and comprised the reference group (n = 8,911,715). The main outcome measures were pregnancy and perinatal complications. Patients were included once per pregnancy.

Participants/materials, setting, methods

The HCUP-NIS is the largest inpatient sample database in the USA. It provides information relating to seven million inpatient stays per year, includes ∼20% of hospital admissions, and represents over 96% of the American population. Multivariate logistic regression analysis, controlling for confounding effects, was conducted to explore associations between hypothyroidism and delivery and neonatal outcomes. According to Tri-Council Policy statement (2018), IRB approval was not required, given data was anonymous and publicly available.

Main results and the role of chance

Women with hypothyroidism were more likely to be older than 25 years, Caucasian, have higher household incomes, private insurance and deliver in an urban teaching hospital, as compared with the non-hypothyroidism obstetrical population (p &lt; 0.0001, all cases). After adjustment for all statistically significant confounders, women with hypothyroidism were more likely to suffer from gestational diabetes mellitus (aOR 1.43, 95%CI 1.38-1.47), hypertensive disorders of pregnancy: gestational hypertension (aOR 1.17, 95%CI 1.11-1.22) and preeclampsia (aOR 1.21, 95%CI 1.16-1.27) (all P &lt; 0.001)). They were more likely to experience PPROM (aOR 1.19, 95%CI 1.09-1.29) and preterm delivery (aOR 1.12 95%CI 1.08-1.17), and deliver by caesarean section (aOR 1.21, 95% CI 1.18-1.24 (all P &lt; 0.001)). Women with hypothyroidism more often developed chorioamnionitis (aOR 1.09, 95%CI 1.01-1.17, P = 0.019), maternal infections (aOR 1.08, 95% CI 1.01-1.16, P = 0.017), post-partum hemorrhage (aOR 1.07, 95%CI 1.01-1.13, P = 0.012), disseminated intravascular coagulation (aOR 1.20, 95%CI 1.00-1.43, P = 0.047), require blood transfusions (aOR 1.12, 95%CI 1.03-1.22, P = 0.009), and hysterectomy (aOR 1.42, 95% CI 1.13-1.80, P = 0.012) compared to the control group. [HB1] As for neonatal outcomes, small for gestational age and congenital anomalies were more likely to occur in the offspring of women with hypothyroidism (aOR 1.20, 95% CI 1.14-1.27 and aOR 1.34, 95% CI 1.22–1.48, both P &lt; 0.001).

Limitations, reasons for caution

This is a retrospective analysis utilizing an administrative database that relies on data coding accuracy and consistency.

Wider implications of the findings

Women with hypothyroidism were more likely to experience pregnancy, delivery and neonatal complications. We found an association between hypothyroidism and; hypertensive disorders, post-partum hemorrhage, transfusions, infections, preterm deliveries and hysterectomy, among other problems. This data from a population sized database confirmed the findings of the smaller studies in the literature.

Trial registration number

not applicable

P–695 Establishing predictors of the mode of conception in fertility patients presenting with a clinical pregnancy

Study question

What are the predictors for pregnancies conceived spontaneously (SC), by ovulation induction+/-insemination (OI±IUI) or via In-Vitro Fertilization(IVF), and what proportion of pregnancies were conceived with each method?

Summary answer

Pregnancies were conceived by SC(27.7%), OI±IUI(33%) or IVF(39.2%).Unexplained infertility positively-predicted SC and OI±IUI-conceptions. Male factor-infertility demonstrated the opposite trend, positively predicting IVF. Endometriosis negatively-predicted SC.

What is known already

Spontaneous conception (SC) occurs regularly among infertility patients. Most studies have evaluated predictors of pregnancy among women with infertility who were trying to conceive. Few studies have addressed the role of different factors on the mode of conception in infertility patients who were pregnant. Factors found in some studies to be related with a SC were younger female age, shorter duration of infertility, fewer failed IVF cycles, and diagnosis of unexplained-infertility.

Study design, size, duration

We conducted a retrospective cohort study at a University fertility-center over a six-month period in 2019 and 2020. We reviewed viability scans of 285-patients. Mode of conception was recorded as Spontaneous, OI±IUI, or IVF. Patients’ demographics, obstetric and fertility diagnosis as well as base-line hormones and ovarian reserve testing were extracted to calculate predictors for the mode of conception. Pregnancy was defined as an intra-uterine fetal sac on a transvaginal ultrasound in the 1st-trimester.

Participants/materials, setting, methods

Parametric analysis was done using ANOVA and Tukey’s post-hoc test. Nonparametric analysis was performed using the chi-square test. Predictors of the mode of conception were calculated by multivariate regression analysis using the variables not in the equation model including the following parameters: male and female age, gravidity, parity, ectopic-pregnancies, infertility diagnosis, baseline serum: FSH, estradiol, TSH, AMH, and AFC. Data is presented as mean ±SD or percentage. P &lt; 0.05 was significant. IRB approval was obtained.

Main results and the role of chance

79 (27.7%) of pregnancies were SC, 94 (33%) resulted from OI±IUI, and 112 (39.2%) from IVF. Demographics didn’t differ between the groups including: female age(p = 0.06), male age(p = 0.79), gravidity (p = 0.47), parity(p = 0.7), ectopic-pregnancies(p = 0.07), baseline serum FSH(p = 0.29), estradiol(p = 0.65), TSH(p = 0.56), AMH(p = 0.42), and AFC(p = 0.06). Infertility diagnoses differed when comparing SC, OI±IUI and IVF conceptions respectively: Unexplained (22.7%, 22.3%, 15.1%, p = 0.03), Male-Factor(MF) (25%, 27.6%, 42.8%, p = 0.042), Tubal-factor (2.5%, 2.1%, 13.4, p = 0.002) and Ovulation-disorders/PCOS (24%, 32%, 12.5% p = 0.002). Endometriosis trended higher in women with IVF (p = 0.09).

A positive predictor for SC was unexplained infertility(p = 0.0001). A negative predictor was endometriosis(p = 0.005). SC was sub-significantly less likely in the presence of MF (p = 0.057). Unexplained-infertility was a positive predictor for OI±IUI pregnancies(p = 0.047), whereas MF was a negative predictor(p = 0.0001). As for IVF-conceptions, MF was a positive predictor(p = 0.008), while unexplained-infertility negatively predicted conception by IVF(p = 0.018). Ovulation-disorders/PCOS trended lower in women with IVF (p = 0.052). While baseline serum estradiol levels were similar between groups (means 194–218pmol/L), multivariate regression showed it to be a predictor for OI±IUI and IVF conceptions. The clinical significance of this finding is not clear. Interestingly, female age and ovarian reserve were not found to predict one type of conception over another. Other possible predictors in the model were not significant.

Limitations, reasons for caution

This retrospective cohort may hide underlying bias. Clinical pregnancies were evaluated and not live birth. Our cohort represents patients that conceived and do not offer information about the entire sub-fertile population that is treated in our center, which is also a strength as it’s a novel way of evaluating predictors.

Wider implications of the findings: Among patients that conceived spontaneously, advanced age and ovarian reserve did not play a negative role. Predictors of pregnancy were confirmed as expected with the majority of unexplained infertility conceptions occurring spontaneously or with OI+/-IUI, patients with Male factor infertility often conceived by IVF, and ovulation disorders by OI+/-IUI.

Trial registration number

NA

P–393 The relationship of cigarette smoking with gestational diabetes. An evaluation of a database of more than nine million deliveries

Study question

Given the common pathophysiology between type 2 DM (risk of which is increased by smoking) and GDM we sought to assess whether an association between smoking and GDM exists?

Summary answer

After controlling for confounding effects, women who smoke during pregnancy are at an increased risk of developing GDM.

What is known already

Smoking is well associated with type 2 diabetes mellitus (DM) in multiple studies. It has remained unclear whether there is also an association between smoking and GDM as publications report conflicting results. In a meta-analysis of 1,364,468 pregnancies (22,811 smokers) there was no association between cigarette smoking and the risk of GDM. While a study from the Pregnancy Risk Assessment Monitoring System, on 222,408 patients (54,114 smoked during pregnancy) found a higher risk for GDM among smokers.

Study design, size, duration

A retrospective population-based study utilizing data from the Healthcare Cost and Utilization Project—Nationwide Inpatient Sample (HCUP-NIS). A dataset of all deliveries between 2004 and 2014 inclusively, was created. Within this group, all deliveries to women who smoked during pregnancy were identified as part of the study group (n = 443,590), and the remaining deliveries were categorized as non smoker births and comprised the reference group (n = 8,653,198).

Participants/materials, setting, methods

The HCUP-NIS is the largest inpatient sample database in the USA, and it is comprised of hospitalizations throughout the country. It provides information relating to 20% of US admissions and represents over 96% of the American population. Multivariate logistic regression analysis, controlling for confounding effects, was conducted to explore associations between smoking and delivery and neonatal outcomes. According to Tri-Council Policy statement (2018), IRB approval was not required, given data was anonymous and publicly available.

Main results and the role of chance

Our study identified 9,096,788 births between 2004–2014, of which 443,590 (4.8%) had a documented diagnosis of maternal smoking. Smokers were more likely to be young (53% vs 37.2% under the age of 35), white (78% vs 51.1%), of lower income (39.1% vs 26.6%), delivered in a rural hospital (28.7% vs 13.2%), suffer from obesity (6.4% vs 3.4%), have pregestational diabetes (1.2% vs 0.9%) and chronic hypertension (2.5% vs 1.8%) and to have undergone a previous caesarean section (17.7% vs 5.9%) (all p value &lt;0.0001, all were controlled for in the logistic regression analysis). An increased risk for GDM among smokers was detected with an adjusted odds ratio (aOR) of 1.10 (95%CI:1.07–1.14 p &lt; 0.0001), when controlling for the factors above. A significant higher risk of preterm delivery (aOR1.39, 95%CI:1.35–1.43, p &lt; 0.0001), PPROM (aOR 1.52 ,95%CI:1.43–1.62, p &lt; 0.0001), wound complications (aOR1.24,95%CI:1.09–1.41, p &lt; 0.0001), and the need for hysterectomy (aOR1.32,95%CI:1.0–1.64,p&lt; 0.0001) among the smokers was found as well.

Limitations, reasons for caution

The limitations of our study are its retrospective nature and the fact that it relies on an administrative database.

Wider implications of the findings: The public health implications of confirming smoking as a risk for GDM are many. This can lead to earlier screening in pregnancy of smokers for GDM. The earlier initiation of interventions could decrease fetal complications and possibly have impact on the life and long-term health of that offspring.

Trial registration number

Not applicable

Is controlled ovarian stimulation and insemination an effective treatment in older women with male partners with decreased total motile sperm counts?

OBJECTIVE

To assess the effect of the total motile sperm counts (TMSC) on the success of controlled ovarian stimulation (COH) and intra-uterine insemination (IUI) in women 38-42 years of age.

STUDY DESIGN

A database of all women aged 38-42 years who underwent IUI with stimulation at a University Reproductive Centre between 2009 and 2018 inclusive was developed. Including stimulation with clomiphene citrate, letrozole or gonadotropins and divided into TMSC 5.00-10.0 mil and < 5.00 mil. Statistics were compared with multivariate logistic regression, t tests or Chi-squared tests.

RESULTS

A total of 397 cycles of IUI in 397 patients were included, of which, 190 cycles with TMSC 5.00-10.0 and 207 cycles with TMSC < 5.00. There were no statistical differences in the baseline characteristics between the two groups including: age (P = 0.2), gravidity (P = 0.7), parity (P = 0.6), basal FSH (P = 0.2), basal E2 (P = 0.4), antral follicular count (P = 0.5) and the number of mature follicles stimulated (P = 0.2). As expected, TMSC was 7.6 ± 1.5 mil in the first group and 2.4 ± 1.6 mil in the second group (P < 0.0001). The clinical pregnancy rate per cycle in the 5.01-10.00 TMSC group was 9.5 vs. 3.4% when TMSC < 5.00 (P = 0.01). When evaluating only women 40-42 years of age (99 women in the 5.00-10.00 TMSC group and 95 in the group of TMSC < 5.00); the pregnancy rates were not statistically different between the two groups (7 vs. 7.3%, P = 1), nor was the clinical pregnancy rate (5 vs. 6.3%, P = 0.7).

CONCLUSIONS

Women 38-39 years of age have poorer outcomes at COH/IUI when TMSC < 5 million than if it is 5-10 million. Once a woman is 40 years of age, this effect is lost. With TMSC 5-10 million, women 38-39 years of age have respectable outcomes at COH/IUI. Clinical pregnancy rates are very low in women 40 years of age with TMSC ≤ 10 million or 38-39 years old with TMSC < 5 million and other treatments should be offered.

Influence of Maternal Age and Ovarian Reserve on the Decision to Continue or to Cancel IVF Cycles in Patients with One or Two Large Follicles: a Dual Effect

This study aimed to study whether IVF stimulation that results in one or two mature follicles should proceed to oocyte retrieval. This is a retrospective cohort study conducted at McGill University Health Center on 459 patients who underwent IVF treatment between 2011 and 2014, undergoing hormonal stimulation and monitoring of their ovarian response. The primary outcomes were pregnancy and live birth rates. Statistical modeling was used to determine individual roles of patient age and ovarian reserve on outcomes, while controlling for the other factors. Of the 459 cycles included in the study, 360 cycles (78.4%) ended in embryo transfer. Live birth rates per cycle were 15.6%, for the ≤ 34-year-olds; 6.5%, for the 35-39-year-olds; and 2.7%, for the ≥ 40-year-olds (p < 0.01). Twenty-five percent of the cycles in the ≥ 40-year-old group were canceled versus 17% and 15% in the 35-39-year-old and ≤ 34-year-old groups, respectively (p < 0.05). Testing likelihood of live birth as a function of age and antral follicular count (AFC) revealed that a 1-year increase in age reduces the likelihood of live birth by 11% (p < 0.05) and one-unit increase in AFC count leads to a 9% increase in the odds of a live birth (p < 0.05). For the youngest age group, the AFC had a most significant effect, and those with AFC > 11 had 56% live birth rate, while those with AFC ≤ 11 had only 6% of live birth rate. This study supports a shift in reasoning from age being the predictor of outcomes in women with a low response at IVF to both age and ovarian reserve needing to be taken into consideration.

Effect of double embryo transfer derived from autologous frozen oocytes on multiple pregnancy rates and presentation of success rates stratified by age at retrieval

Objective:

To compare outcomes transferring one or two embryos in autologous frozen oocyte cycles.

Material and Methods:

A retrospective cohort study conducted at an academic fertility center between January 2012 and December 2018. One-hundred and fourteen patients underwent frozen oocyte transfers; 67 single embryo transfer (SET) and 47 double embryo transfer (DET). No subjects had more than two embryos transferred. Data were analyzed using t-test and chi-squared testing. Multivariate logistic regression was used to control for confounding effects. Power analysis suggested an 82% power with alpha of 5% and effect size of 27%.

Results:

Regarding the embryo stage, 72% were cleavage embryos and 28% were blastocyst embryos. Among those who had cleavage stage embryos, 48.8% underwent SET and 51.2% underwent DET. In the blastocyst embryos group these proportions were 84.4% and 15.6%, respectively. There were no difference in pregnancy rate for SET (40.3%) vs DET (36.2%) (p=0.78). Additionally, the live birth rate did not differ between SET and DET (28.4 vs 19.1%, respectively, p=0.26). The multivariate multilevel analysis provided adjusted odds ratios (95% confidence interval) of: 1.85 (0.46-7.44) for pregnancy; 0.497 (0.05-4.86) for clinical pregnancy; and 0.82 (0.11-6.29) for live birth when comparing SET and DET. Multiple pregnancy rates were significantly lower in the SET (0%), compared with DET group (44.4%) (p<0.002).

Conclusion:

SET results in excellent live birth outcomes in autologous frozen oocyte cycles. However DET results in significantly increased rates of multiple pregnancies. This suggests that SET is a viable option in autologous frozen oocyte cycles.

The impact of timing for estrogen supplementation in polycystic ovary syndrome patients undergoing primed in vitro maturation

OBJECTIVE

This study aims to determine the effects of early and late onset estrogen supplementation on the immature oocyte retrieval, fertilization and clinical pregnancy rates in follicle stimulating hormone (FSH) and human chorionic hormone (hCG) primed in vitro maturation (IVM) cycles of the patients with polycystic ovary syndrome (PCOS).

METHODS

This is a retrospective analysis of 161 patients with PCOS who underwent FSH and hCG primed IVM. Group 1 included 120 patients who received early onset estrogen supplementation while group 2 consisted of 41 patients who had late onset estrogen supplementation in primed IVM cycles. Immature oocyte (germinal vesicle and/or metaphase I) retrieval and fertilization rates were the primary outcomes, whereas clinical pregnancy and live rates were the secondary outcomes.

RESULTS

Group 1 patients had significantly higher body mass index and more previous IVF attempts (p = 0.001 and p = 0.008, respectively). All of the retrieved oocytes from the PCOS patients were either germinal vesicle or metaphase I oocytes and there were no metaphase II oocytes among the retrieved oocytes. Both groups had statistically similar numbers of metaphase I and fertilized oocytes (p > 0.05 for both). However, group 1 patients had significantly lower number of germinal vesicle oocytes but significantly higher number of metaphase II oocytes (p = 0.001 for both). Both groups had statistically similar fertilization (85.0% vs 78.0%), clinical pregnancy (49.2% vs 43.9%) and live birth (37.5% vs 39.0%) rates (p > 0.05 for all).

CONCLUSION

Early onset estrogen supplementation appears to improve the quality of retrieved immature oocytes and contribute to the maturation of oocytes in stimulated IVM cycles.

Polycystic ovary syndrome as an independent risk factor for gestational diabetes and hypertensive disorders of pregnancy: a population-based study on 9.1 million pregnancies

STUDY QUESTION

Does polycystic ovary syndrome (PCOS) confer an independent risk for the development of gestational diabetes mellitus (GDM), gestational hypertension (GHTN) and preeclampsia (PEC) based on analysis of the Healthcare Cost and Utilization Project Nationwide Inpatient Sample (HCUP-NIS) database.

SUMMARY ANSWER

After controlling for all potential confounding effects, women with PCOS are at a 2-fold higher risk of developing GDM, a 50% increased risk for the development of GHTN and a 30% increased risk of developing PEC than women without PCOS.

WHAT IS KNOWN ALREADY

Currently, there is evidence of an increased prevalence of maternal pregnancy complications in women with PCOS. However, there remain significant gaps in understanding how PCOS affects the development of GDM, GHTN and PEC. This is most likely due to the complex, multifactorial etiology of PCOS, its range of potential confounders for pregnancy complications and the variable methodology of studies that have been conducted. To date, the largest meta-analysis on this subject includes 11 565 women with PCOS analyzed for their risk of GDM and 5896 patients analyzed for their risk of PEC.

STUDY DESIGN, SIZE, DURATION

This is a retrospective population-based study utilizing data from the HCUP-NIS over 11 years from 2004 to 2014. A dataset of all deliveries between 2004 and 2014 inclusively was created. Within this group, all deliveries to women with PCOS were identified as part of the study group (n = 14 882), and the remaining deliveries were categorized as non-PCOS births and comprised the reference group (n = 9 081 906).

PARTICIPANTS/MATERIALS, SETTING, METHODS

The HCUP-NIS is the largest inpatient sample database in the USA and is comprised of hospital inpatient stays submitted by hospitals throughout the entire country. Each year, the database provides information relating to 7 million inpatient stays, including patient characteristics, diagnosis and procedures. The data are representative of ∼20% of admissions to US hospitals across 48 states and the District of Columbia.

MAIN RESULTS AND THE ROLE OF CHANCE

At baseline, more pregnant women with PCOS were obese (22.3% vs. 3.5%, P < 0.001), had chronic hypertension (HTN) (8.4% vs. 1.8%, P < 0.001), had pregestational diabetes (4.1% vs. 0.9%, P < 0.001) and had treated thyroid disease (12.6% vs. 2.4%, P < 0.001). Women with PCOS were also more likely to have undergone IVF treatment (2.4% vs. 0.1%, P < 0.001), have multi-gestation pregnancies (5.9% vs. 1.5%, P < 0.001), and more multiple gestations (MGs) in the PCOS group were the result of IVF treatment than the non-PCOS groups (12.3% vs. 2.3%, P < 0.001). In all pregnancies, women with PCOS were more likely to develop gestational diabetes (adjusted odds ratio (aOR) 2.19, 95% CI 2.02-2.37), pregnancy associated HTN (aOR 1.38, 95% CI 1.27-1.50, P < 0.001), GHTN (aOR 1.47, 95% CI 1.31-1.64), PEC (aOR 1.29, 95% CI 1.14-1.45) and superimposed PEC (aOR 1.29, 95% CI 1.04-1.59) after controlling for confounding effects (age, race, income level, insurance type, obesity, IVF use, previous cesarean section, chronic HTN, pregestational diabetes, thyroid disease, MG, smoking and recreational drug use). Odds ratios were comparable between all pregnancies and singleton pregnancies only. In women pregnant with multiple fetuses, PCOS only conferred a statistically significant increased risk of developing GDM (aOR 2.33, 95% CI 1.92-2.83, P < 0.001). However, there was a trend toward an increased risk for developing pregnancy associated HTN (aOR 1.92, 95% CI 0.99-1.42, P = 0.058).

LIMITATIONS, REASONS FOR CAUTION

This is a retrospective analysis utilizing an administrative database which relies on the accuracy and consistency of the individuals coding the data. There are known limitations in how accurately hospital coding is able to capture perinatal conditions and complications, making it difficult to know with certainty that such events are accurate.

WIDER IMPLICATIONS OF THE FINDINGS

Pregnant women with PCOS are at increased risk of adverse complications in pregnancy even when they do not present with other coexisting metabolic conditions. Furthermore, it is important to also consider the risk of all other coexisting metabolic conditions frequently encountered in PCOS women, as these risks are additive and place women with PCOS at significantly increased risk for adverse complications in pregnancy.

STUDY FUNDING/COMPETING INTEREST(S)

None.

Associations between polycystic ovary syndrome and adverse obstetric and neonatal outcomes: a population study of 9.1 million births

STUDY QUESTION

Does polycystic ovary syndrome (PCOS) confer an independent risk for adverse delivery and neonatal outcomes, based on analysis of the Healthcare Cost and Utilization Project-Nationwide Inpatient Sample (HCUP-NIS) database?

SUMMARY ANSWER

After controlling for all potential confounding effects, women with PCOS are at an increased risk of experiencing preterm pre-labour rupture of membranes (PPROM), pre-term delivery (PTD), placental abruption, caesarean section (C/S) delivery, chorioamnionitis and post-partum maternal infections.

WHAT IS KNOWN ALREADY

PCOS may be associated with an increased risk of adverse perinatal outcomes. However, there remain significant gaps in understanding the correlation between PCOS and important delivery and neonatal complications.

STUDY DESIGN, SIZE, DURATION

This is a retrospective population-based cohort study utilising data from the HCUP-NIS over 11 years from 2004 to 2014. A cohort of all deliveries between 2004 and 2014 inclusively was created. Within this group, all deliveries to women with PCOS were identified as part of the study group (n = 14 882), and the remaining deliveries were categorised as non-PCOS births and comprised the reference group (n = 9 081 906).

PARTICIPANTS/MATERIALS, SETTING, METHODS

The HCUP-NIS is the largest inpatient sample database in the USA and it is comprised of hospital inpatient stays throughout the entire country. It provides information relating to 7 million inpatient stays per year, includes ∼20% of admissions, and represents over 96% of the American population.

MAIN RESULTS AND THE ROLE OF CHANCE

After adjustment for all potential confounders, women with PCOS were more likely to experience PPROM (aOR 1.48, 95% CI 1.20-1.83), PTD (aOR 1.37 95% CI 1.24-1.53) and placental abruption (aOR 1.63, 95% CI 1.30-2.05) and were more likely to deliver by C/S (aOR 1.50, 95% CI 1.40-1.61 (all P < 0.001). Women with PCOS more often developed chorioamnionitis (aOR 1.58, 95% CI 1.34-1.86, P < 0.001) and maternal infections (aOR 1.58, 95% CI 1.36-1.84 (both P < 0.001)). With the exception of multiple gestations (aOR 1.27, 95% CI 1.01-1.62, P = 0.04), there was no difference in the number of women who gave birth to small for gestational age (SGA) infants (aOR 0.97, 95% CI 0.82-1.15, P = 0.72) between the women with PCOS and the reference group. Intrauterine foetal deaths (IUFDs) were also comparable between the two groups (aOR 1.03, 95% CI 0.68-1.59, P = 0.88). However, congenital anomalies were more likely to occur in the offspring of women with PCOS (aOR 1.89, 95% CI 1.51-2.38, P < 0.001).

LIMITATIONS, REASONS FOR CAUTION

This is a retrospective analysis utilising an administrative database which relies on the accuracy and consistency of the individuals coding the data. There are known limitations in how accurately hospital coding is able to capture perinatal conditions and complications, making it difficult to know with certainty that such events are accurate.

WIDER IMPLICATIONS OF THE FINDINGS

Women with PCOS are more likely to experience adverse delivery and neonatal outcomes. It is important to additionally consider the risk of all other co-existing conditions frequently encountered in PCOS women, as these risks are additive and place women with PCOS at significantly increased risk of adverse pregnancy outcomes.

STUDY FUNDING/COMPETING INTEREST(S)

No specific funding was obtained for this study. The authors have no conflicts of interest to disclose.

Pregnancy, delivery, and neonatal outcomes among women with irritable bowel syndrome (IBS) an evaluation of over 9 million deliveries

OBJECTIVE

Evaluate the associations between irritable bowel syndrome (IBS) and pregnancy, delivery, and neonatal outcomes, using a population database cohort.

METHODS

We conducted a retrospective analysis utilizing the Health Care Cost and Utilization Project-Nationwide Inpatient Sample database over 11 years from 2004 to 2014. A delivery cohort was created using ICD-9 codes. ICD-9 code 564.1 was used to extract the cases of IBS. Pregnant women with IBS (study group) were compared to pregnant women without IBS (control). A multivariate logistic regression model was used to adjust for statistically significant variables (p value <.05).

RESULTS

There were a total of 9,096,788 deliveries during the study period. Of those, 8962 pregnant women were found to have IBS. The prevalence of IBS increased from 47.96 to 172.68 per 100,000 women during the study period. Compared to the control group, women with IBS were more likely to be Caucasian, older, have higher incomes and private insurance plans (p < .0001, in all cases). In addition, they were more likely to be obese, smokers, hypertensive, IVF pregnancies, have multiple gestations, thyroid disorders, chronic interstitial cystitis, fibromyalgia and have psychiatric disorders (p < .0001 in all cases). Women with IBS were more likely to experience pregnancy-induced hypertension (aOR 1.11, 95% CI 1.02-1.21), preeclampsia (aOR 1.23, 95% CI 1.09-1.38), deep venous thrombosis (aOR 2.26, 95% CI 1.12-4.57), and gestational diabetes (aOR 1.1, 95% CI 1.002-1.22) compared to the non-IBS group. Congenital anomalies were encountered in 1.7% of the IBS group compared to 0.4% in the control group (aOR 2.57, 95% CI 2.13-3.09).

CONCLUSION

When controlling for confounding effects, IBS is associated with an increased risk for preeclampsia, DVT and increased risk for congenital malformation.

Outcomes of donor versus partner sperm in intrauterine insemination in women aged 38 years and older

OBJECTIVE

To compare pregnancy rates of donor versus partner sperm in intrauterine insemination (IUI) cycles in women aged 38 years and above.

METHODS

A retrospective cohort study was performed using data from 944 women aged 38-43 years old who underwent a combined 1596 IUI cycles at an academic fertility clinic in Montreal, Canada between February 2009 to April 2018.

RESULTS

Partner sperm was used in 1421 cycles (89.0%), and donor sperm was inseminated in 175 cycles (11.0%). Mean ages of the women were 39.8 (±1.5) and 40.2 (±1.6) years in the partner and donor insemination groups, respectively (P < 0.001). Positive serum (β human chorionic gonadotropin) pregnancy rate in the partner sperm group was 9.0% (n = 128) whereas that in the donor insemination group was 9.7% (n = 17) (P = 0.759). Clinical pregnancy rates were 5.8% (n = 83) and 8.0% (n = 14) in the respective groups (P = 0.260). There were five multiple gestation (twin) pregnancies in the cohort, three in those undergoing IUI with partner sperm and two in those undergoing IUI with donor sperm.

CONCLUSION

In women aged 38-43 years undergoing IUI with controlled ovarian stimulation, using donor sperm, compared with partner sperm, did not increase rate of pregnancy.

Comparison of in vitro fertilization cycles stimulated with 20 mg letrozole daily versus high-dose gonadotropins in Rotterdam Consensus ultra-poor responders: A proof of concept

OBJECTIVE

To evaluate if high-dose letrozole can be used successfully to stimulate poor responders for in vitro fertilization (IVF).

METHODS

This was a retrospective study conducted at a university hospital reproductive center. The analysis included women who were up to 42 years of age and were Rotterdam Consensus poor responders. A total of 247 patients received gonadotropins (300-450 IU daily) and 62 patients were stimulated with letrozole (20 mg daily) as part of an antagonist IVF protocol.

RESULTS

The use of 20 mg of letrozole decreased the total dose of gonadotropins used (645 ± 175 IU vs. 5360 ± 1028 IU, P = 0.001) and resulted in lower costs of stimulation medications ($ 555.56 ± $ 150 vs. $ 4616 ± $ 885 Canadian Dollars; P = 0.001). Pregnancy per cycle (14.5%) and per transfer (16%) rates were legitimate for this low prognosis group and may have been better than or similar to those with high-dose gonadotropins. The rate of cycle cancellation may have been reduced in the letrozole versus gonadotropin group (11% vs. 38%; P = 0.001).

CONCLUSION

Letrozole (20 mg daily) may be used to reduce the cost of ovarian stimulation in ultra-poor responders, significantly reducing the cost of the IVF cycle with probably at least similar outcomes to high-dose gonadotropins.

A comparison of oral versus injectable ovarian stimulation in IUI in women ≥38 years of age with decreased ovarian reserve

PURPOSE

To compare pregnancy rates of oral ovarian hyperstimulation agents (clomiphene citrate (CC) and letrozole) versus injectable agents (gonadotropins) in intrauterine insemination (IUI) in the older reproductive age group with diminished ovarian reserve.

METHODS

A retrospective cohort study was performed among 210 women 38-43 years of age undergoing IUI with controlled ovarian hyperstimulation (COH) at a single academic institution between 2009 and 2018.

RESULTS

A total of 335 IUI cycles met inclusion criteria. Gonadotropins were the most frequently used ovarian hyperstimulation agent (n = 264), followed by CC (n = 38) and letrozole (n = 33). Mean age of the cohort was 40.5 (±1.6) years (range 38-43) did not differ significantly among groups (p = 0.41). Mean AFC and number of mature follicles on day of ovulation trigger also did not differ among groups (p = 0.98, p = 0.10). Overall clinical pregnancy rate was 7.5% per cycle, and rates for CC, letrozole, and gonadotropins respectively were 5.3%, 9.1%, 7.5% per cycle (p = 0.347). There was one multiple gestation pregnancy (twins), which was in a patient stimulated with gonadotropins.

CONCLUSION

This is the first study to compare CC, letrozole, and gonadotropins in older reproductive age women with decreased ovarian reserve. The findings reveal that COH/IUI in older women with decreased ovarian reserve is a viable option (clinical pregnancy rate of 7.5% per cycle), and suggest that oral stimulation agents may be the first-line option, with letrozole having conferred the highest clinical pregnancy rate, 9.1%, which is notable given the typical poor fecundability of this population. However, larger population studies are needed to support this.

Three hour abstinence as a treatment for high sperm DNA fragmentation: a prospective cohort study

PURPOSE

This study sought to compare sperm DNA fragmentation (SDF) in semen specimens after 3 days and then after 3 h of abstinence in men presenting for initial infertility evaluation.

METHODS

A prospective cohort study of 112 men undergoing their first semen analysis as part of an infertility work-up was conducted. All participants presented with 3 days of abstinence for a semen analysis and DNA-fragmentation test. Both tests were repeated on a second sample collected 3 h after the first ejaculation. DNA-fragmentation was evaluated with the halo test by one of two technicians blinded to duration of abstinence. Variables analyzed include ejaculate volume, sperm concentration and motility, smoking status, cannabis use, initial specimen DNA fragmentation, and use of sperm-directed anti-oxidant formulations.

RESULTS

Among all subjects, DNA fragmentation improved in the 3-h abstinence specimen (34.6 ± 19.4% vs. 23.7 ± 16.0%, p = 0.0001). Among subjects with high DNA fragmentation (> 35%) on the initial specimen, 55% improved into the normal range. Semen volume and sperm concentration decreased (3.1 ± 3.3 ml vs. 1.9 ± 0.8 ml, p < 0.01 and 41 ± 39 vs. 32 ± 31 (millions/ml), p = 0.01), while progressive motility tended to increase. Fifty-eight subjects demonstrated ≥ 30% improvement in SDF in the second specimen as compared to the first. Factors found to correlate with > 30% improvement in DNA fragmentation in the 3-h abstinence specimen compared to 3 days were younger age and use of anti-oxidants.

CONCLUSION

High SDF can often be managed with a second ejaculation 3 h after the first in infertile couples, including in males with abnormal semen analyses per the 2010 WHO guide. Apart from SDF levels, changes in sperm quality were not clinically significant in the second specimen and did not increase rates of ICSI. However, a second ejaculation after 3 h probably may reduce the necessity of costly and/or invasive ART strategies.