The biochemical pregnancy loss rate remains stable up irrespective of age and differs in pattern from clinical miscarriages

INTRODUCTION

As women age, the increasing rate of aneuploidy lead to an augmentation in the incidence of clinical miscarriages. It was anticipated that biochemical pregnancy rates would also rise with maternal age. However, no study has previously evaluated the effect of maternal age on biochemical pregnancy rates.

MATERIAL AND METHODS

A retrospective cohort study of 2177 subjects who underwent single embryo transfer (SET) as part of a fresh or thawed IVF cycle were recruited from 2008 through 2012, resulting in 952 pregnancies. Data was stratified for age and compared using analysis of variance (continuous data) and chi-squared tests (categorical data).

RESULTS

The likelihood of a clinical miscarriage increased with age (p < .001). Surprisingly, advancing age had no effect on the biochemical pregnancy loss rate (p = .72) (Age 21-30 y: 10.7%, Age 31-35 y:9.8%, Age 36-40y:11.5%, Age 41-42 y:13.6%).

CONCLUSIONS

Biochemical pregnancy loss rate did not increase as a function of age in women 21 to 42 years of age.

Blastocyst morphology has no relationship with serum β-hCG levels and live birth rates once pregnant

OBJECTIVE

What is the role of blastocyst morphology on day16 β-hCG serum levels and pregnancy outcomes among patients who conceived through IVF cycles with single fresh Gardner's scored blastocyst transfers.

STUDY DESIGN

A retrospective cohort study conducted at a single academic fertility center between January 2013 and December 2017. A total of 643 pregnancies were included in the study.

RESULTS

The patients were divided into 5 groups according to Gardner's blastocysts grade of the ICM and the TE (grade), and into 4 groups according to blastocyst Gardner's degree of blastocoel expansion (stage). No significant differences were found between the different morphologic groups and day16 β-hCG serum levels, clinical pregnancy rates and live births. A weak significant correlation was observed between Gardner's blastocysts grade and day 16 β-hCG (Correlation Coefficient r= -0.098, p = .014) this correlation remained significant after controlling for confounders. (r= -0.099 p = . 013). A weak significant correlation was observed between Gardner's stage and day 16 β-hCG (Correlation Coefficient r = 0.086, p = 0.029) this correlation lost significance after controlling for confounders. (r = 0.055, p = 0.340). When evaluating predictors of live birth using multivariate logistic regression, blastocyst grade (p = 0.33) and stage (p = 0.65), at transfer, were not associated with live births, when controlling for confounding effects.

CONCLUSION

Once the patient conceives after IVF with single blastocyst, none of the morphological parameters have a strong impact on the day16 serum level of β-hCG. Among women who conceived, blastocyst grade and stage were not associated with live births.

Can in vitro maturation overcome cycles with repeated oocyte maturation arrest? A classification system for maturation arrest and a cohort study

OBJECTIVE

To investigate the role of gonadotropin-stimulated and human chorionic gonadotropin (hCG) -primed in vitro oocyte maturation (IVM) in cases of repeated in vitro fertilization (IVF) failure due to various forms of oocyte maturation arrest (OMA).

METHODS

Retrospective cohort study.

RESULTS

In all, 63 women with IVF failure due to OMA were evaluated in this study. According to the Hatirnaz & Dahan classification, 11 (17.5%) women were OMA type 1, 22 (34.9%) were OMA type 2, 0 were OMA type 3, 11 (17.5%) were OMA type 4, and 19 women were OMA type 5 (30.1%). Fewer oocytes were retrieved in the IVM than in the IVF cycles. No embryos were produced from oocytes collected in the IVM cycles of women with OMA types 1, 2, and 4. In the OMA type 5 group, 9 (47.4%) day 2 embryos and 6 (31.6%) day 3 embryos were obtained. The difference between the groups was statistically significant (P = 0.001, P = 0.002, respectively). Single day 3 embryo transfer was performed for the six patients with OMA type 5 but no clinical pregnancies occurred.

CONCLUSIONS

Follicle-stimulating hormone-stimulated and hCG-primed IVM does not improve oocyte maturation, developmental potential, or pregnancy rates of women with OMA. Future studies directed to re-establishing normal cytoskeletal architecture and machinery, and resumption of meiosis may be beneficial for obtaining mature oocytes.

What Are the Live Birth and Multiple Pregnancy Rates When 1 Versus 2 Low-Quality Blastocysts Are Transferred in a Cryopreserved Cycle? a Retrospective Cohort Study, Stratified for Age, Embryo Quality, and Oocyte Donor Cycles

Outcomes among women who transferred only Gardner's grade BB or lower quality frozen embryos transferred (FET) are not well known. Our objective is to study whether transferring 2 versus 1 frozen low-quality blastocysts will increase the live birth rate (LBR) and the multiple pregnancy rate (MPR). This is a retrospective cohort study including 1104 FET cycles. Only day 5-6 blastocysts of grade BB or lower quality were included. Clinical pregnancy rate (CPR), MPR, and LBR per cycle were compared between single embryo transfer (SET) (n = 969) and double embryo transfer (DET) (n = 135). CPR and MPR were compared between SET and DET in grade BB, BC, CB, and CC individually. Among SET, BB blastocysts had higher CPR 34% (P = 0.0001) and a sub-significant increase in LBR 19% (P = 0.059) in comparison to other grade SET. Among all BB, MPR was significantly higher when transferring two versus one (5.9 vs. 1.9, P = 0.009). If age at egg collection ≥ 40 years (n = 97), no difference was found in CPR (11.1 vs. 11.7, P = 0.9), MPR (0 vs. 0), and LBR (6.3 vs. 0,P = 0.13) when SET or DET was performed. If age was < 40 years (n = 818), the MPR was significantly higher in DET than SET (6.7 vs. 1.63, P = 0.004). In egg donor cycles (n = 189), there was no difference in CPR, MPR, and LBR between SET and DET. Single embryo transfer should be offered even in women ≥ 40 years of age or transferring lower quality embryos since transferring more did not increase outcomes in this group, and SET is likely the safest path.

Is intrauterine insemination a viable treatment option for women over 43 years old? An analysis by ovarian stimulation protocol and sperm source

PURPOSE

The aim of this study was to determine how female age at the end of the reproductive spectrum effects success of natural cycle intrauterine insemination (IUI) or IUI in combination with ovarian stimulation.

METHODS

We performed a retrospective cohort study of women 43 years of age and older at the time of IUI in a single academic fertility center between January 2011 and March 2018. Primary outcomes were both pregnancies and live births per cycle of IUI. Data are presented as percentage or mean ± SD. Fisher exact and chi-squared analyses were performed.

RESULTS

There were 9334 IUI cycles conducted during the study period. Of these cycles, 325 IUIs (3.5%) were for women aged 43 years and over at the time of insemination (43.6 ± 0.8, range 43 to 47 years). Analysis of these 325 IUI cycles revealed 5 biochemical pregnancies (1.5%) and only 1 live birth (0.3%). The pregnancy rate did not differ between IUIs using donor sperm (N = 1/49, 2.0%) compared to IUIs with partner sperm (N = 4/276, 1.4%). The pregnancy rate did not differ between IUIs with gonadotropins (N = 2/211, 0.9%), clomiphene or letrozole (N = 2/78, 2.6%), or natural cycle (N = 1/36, 2.8%).

CONCLUSIONS

The use of intrauterine inseminations in women 43 years of age and older is an ineffective treatment strategy. This is irrespective of the use of ovarian stimulation or donor sperm. Costly gonadotropin injections did not increase the chance of pregnancy nor did oral medication when compared to natural cycle IUIs.

Believing that transferring more embryos will result in increased pregnancy rates: a flawed concept: a SWOT analysis

A belief exists that transferring multiple embryos can improve pregnancy rates. However, this concept is flawed. Multiple factors affect outcomes when transferring embryos, endometrial receptivity, and rates of aneuploidy among them. In this article, we will discuss how factors can affect outcomes at IVF that are independent of the number of embryos transferred. It is important to understand the role of accessory factors on pregnancy rates to be able to counsel patients as per the number of embryos that should be transferred. An understanding of this concept will also lead to a realistic understanding of how multiple embryo transfers may result in better cumulative pregnancy rates than a single transfer of multiple embryos. Finally, we will present a SWOT analysis diagram to help guide clinical decision-making.

An age-based sperm nomogram: the McGill reference guide

STUDY QUESTION

How does age affect various semen parameters?

SUMMARY ANSWER

For most semen parameters, the nomogram of the entire population was biphasic, peaking around the fourth decade of life.

WHAT IS KNOWN ALREADY

In clinical practice, semen quality is examined by using the WHO 2010 reference limits but these limits do not account for male age. A percentile-based, large-scale nomogram describing how different semen parameters change throughout reproductive life has been lacking.

STUDY DESIGN, SIZE, DURATION

A retrospective study was conducted with 12 188 sperm samples, obtained from individuals who attended the McGill University Health Centre reproductive clinic between 2009 and 2018.

PARTICIPANTS/MATERIALS, SETTING, METHODS

One sample from each individual who attended the clinic during the study period was analysed by using computer-assisted sperm analysis (CASA). The analysed parameters were human-verified and included sperm concentration, motility, progressive motility, total count, morphology and semen volume. Based on this analysis, the entire dataset (n = 12 188) was further divided into two groups of samples: samples that surpassed the WHO 2010 lower reference limits (‘above reference limits’ group, ARL; n = 6305), and samples that did not (‘below reference limit’ group, BRL; n = 5883). Regression quantiles were fitted as a function of age to generate age-dependent nomograms, and these quantiles were divided into 5th, 25th, 50th, 75th and 95th percentiles.

MAIN RESULTS AND THE ROLE OF CHANCE

In the entire dataset, age had a significant influence (P &lt; 0.001) on all parameters (except morphology) which demonstrated a biphasic trend peaking in the fourth decade of life. In the ARL group, age had a significant influence (P &lt; 0.01) on all semen parameters except sperm concentration and morphology. However, unlike in the entire dataset, only semen volume demonstrated a biphasic trend in the ARL group (peaking in the fourth decade of life), whereas other parameters either remained unchanged (concentration and morphology) or consistently declined with age (sperm motility, progressive motility and total sperm count). Percentile-based nomograms were generated for individuals between the ages of 20 and 60 years in the entire dataset and in the ARL group.

LIMITATIONS, REASONS FOR CAUTION

First, the semen samples were obtained from individuals who were referred to a fertility clinic, such that the entire dataset does not necessarily represent the general population. Second, the cross-sectional sampling design increases variance, and the nomograms are less accurate in the 5th and 95th percentiles and at the extremes of the age distributions. Third, the observed age-dependent changes in semen parameters do not necessarily indicate changes in fertility, as not all factors that affect male fertility were analysed. Fourth, some of our semen analyses employed CASA, which can have variability issues. Finally, our models did not incorporate possible secular trends.

WIDER IMPLICATIONS OF THE FINDINGS

We provide the first nomogram that correlates age with semen quality parameters in different population percentiles, thus complementing the current reference limits set by the WHO in 2010. Most examined semen parameters in our study changed non-linearly with age; therefore, age should be regularly employed as a factor in the clinical analysis of semen samples.

STUDY FUNDING/COMPETING INTEREST(S)

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

TRIAL REGISTRATION NUMBER

N/A.

Pregnancy, delivery and neonatal outcomes among women with congenital adrenal hyperplasia: a study of a large US database

RESEARCH QUESTION

What is the association between congenital adrenal hyperplasia (CAH) and pregnancy, delivery and neonatal outcomes, using a population database cohort.

DESIGN

Retrospective study using the Health Care Cost and Utilization Project-Nationwide Inpatient Sample database from 2004-2014. ICD-9 code 255.2 was used to extract the cases of CAH. Pregnancies complicated with CAH were compared with the other pregnancies. All confounding variables were adjusted using multivariate logistic regression, based on any significant differences between the two groups.

RESULTS

A total of 9,096,788 deliveries occurred during the study period. Two hundred and ninety-nine pregnant women had CAH. Chorioamnionitis was higher in CAH compared with controls after controlling for risk factors (adjusted OR 2.67, 95% CI 1.17 to 6.06). The rates of caesarean section and maternal infection were also higher in CAH than controls (adjusted OR 2.10, 95% CI 1.44 to 3.07 and adjusted OR 2.63, 95% CI 1.22 to 5.63, respectively). Risk of gestational diabetes and pregnancy-induced hypertension rates were not significantly different in CAH (adjusted OR 1.53, 95% CI 0.91 to 2.58 and adjusted OR 0.87, 95% CI 0.49 to 1.56, respectively). At birth, 8% and 2.2% of the neonates were found to be small for gestational age in the CAH and the control groups, respectively (adjusted OR 3.37, 95% CI 1.86 to 6.11). Congenital anomalies were encountered in 2.7% and 0.4% in the CAH and control groups, respectively (adjusted OR 5.24, 95% CI 2.31 to 11.90).

CONCLUSIONS

Women with CAH were at risk of complications and fetal anomalies. Expected increases in rates of hypertension and gestational diabetes were not encountered. These patients will benefit from surveillance to decrease morbidity.

Effect of uterine dimensions on live birth rates after single embryo transfer in infertile women

RESEARCH QUESTION

Do uterine size parameters measured by baseline transvaginal ultrasound predict live birth after single embryo transfer (SET) of a high-quality blastocyst?

DESIGN

Retrospective cohort study including women undergoing their first SET between August 2010 and March 2014 at a large university hospital reproductive centre. The effects of baseline uterine dimensions on live birth rate (LBR) were analysed while controlling for confounding effects.

RESULTS

A total of 437 nulliparous and 70 parous women were included. The nulliparous group had lower body mass index (BMI) (24.4 ± 5.1 versus 25.9 ± 4.5 kg/m²; P = 0.015) and a higher number of fibroids (0.4 ± 1.0 versus 0.2 ± 0.5; P = 0.005) than the parous group. While controlling for confounding effects, none of the uterine parameters appeared to be a significant predictor of LBR among nulliparous and parous women (P > 0.05 in all cases). A subsequent analysis of endometrial length was done, whereby the endometrial lengths were divided into quartiles (20.0-32.2 mm; 32.3-36.5 mm; 36.6-40.0 mm; 40.1-54.0 mm). After controlling for confounders, the shortest quartile in the nulliparous group had a significantly lower LBR (P = 0.02) than the other groups. Receiver operating characteristic curves suggested that endometrial cavity length and cervical length did not aid clinically.

CONCLUSION

Uterine parameters do not have a clinically useful impact on LBR after SET of a blastocyst in infertile women. The use of baseline endometrial length to predict live birth is no better than chance, while cervical length only predicts failure to live birth.

Effect of newborn gender on placental histopathology and perinatal outcome in singleton live births following IVF

RESEARCH QUESTION

Does newborn gender affect placental histopathology pattern and perinatal outcome in singleton live births following IVF treatment?

DESIGN

Retrospective cohort study evaluating data of all live births from one academic tertiary hospital following IVF treatment during 2009-2017. All patients had placentas sent for pathological evaluation irrelevant of maternal and fetal complications status. Exclusion criteria were abnormal uterine cavity findings, previous uterine surgery, in-vitro maturation cycles, gestational carrier cycles, oocyte recipient cycles, preimplantation genetic diagnosis cycles and multiple pregnancies. The primary outcomes included anatomical, inflammation, vascular malperfusion and villous maturation placental features. The secondary outcomes included fetal, maternal, perinatal and delivery complications. A multivariate analysis was conducted to adjust the results for factors potentially associated with placental pathology features.

RESULTS

A total of 1057 live births were included in the final analysis and were allocated to the study groups according to fetal gender: males (n = 527) and females (n = 530). After adjustment for potential confounding factors, male gender was significantly associated with villous agglutination (odds ratio [OR] 9.8; 95% confidence interval [CI] 1.4-78.2), avascular villi (OR 4.1; 95% CI 1.3-12.6) and maternal vascular malperfusion (OR 1.8; 95% CI 1.2-2.7). Female gender was significantly associated with bilobed placenta (OR 0.2; 95% CI 0.06-0.8) and subchorionic thrombi (OR 0.5; 95% CI 0.3-0.9). The prevalence of adverse fetal, maternal and delivery outcomes was similar between the groups.

CONCLUSIONS

Newborn gender has a significant impact on the placental histopathology pattern, which can contribute to the development of adverse perinatal outcomes.

Pretreatment with a gonadotropin-releasing hormone agonist and an aromatase inhibitor may improve outcomes in in vitro fertilization cycles of women with stage I-II endometriosis

OBJECTIVE

To determine whether 2 months of pretreatment with 5 mg of letrozole daily plus leuprolide acetate at 3.75 mg monthly in women with laparoscopically confirmed American Society of Reproductive Medicine stage I-II endometriosis improves in vitro fertilization (IVF) outcomes.

DESIGN

Prospective cohort study.

SETTING

University-affiliated tertiary hospital.

PATIENT(S)

Women with laparoscopically confirmed endometriosis treated in the period from 2012 to 2016.

INTERVENTION(S)

None.

MAIN OUTCOME MEASURE(S)

Primary outcomes: clinical pregnancy and live-birth rate; secondary outcomes: stimulation parameters and pregnancy.

RESULT(S)

A total of 68 patients were included in the final analysis. Thirty-six women received a gonadotropin-releasing hormone (GnRH) agonist and an aromatase inhibitor (AI), and 32 women received a GnRH agonist alone. The women did not differ in mean age, antral follicle count, basal serum level of follicle-stimulating hormone, or previous pregnancies. The stimulation parameters were similar between both groups: gonadotropin dose, number of collected oocytes, number of blastocysts. All women underwent a single blastocyst transfer. The grade of embryos transferred did not differ. Clinical pregnancy (24 [66.7%] vs. 13 [40.6%]) and live-birth (22 [61.1%] vs 10 [31.3%]) rates improved with aromatase inhibitor added to the GnRH agonist treatment versus a GnRH agonist alone.

CONCLUSION(S)

In this study, we present the first comparison in the medical literature comparing IVF outcomes in women with minimal and mild endometriosis pretreated with a GnRH agonist with or without an AI. This prospective cohort study suggests that combining these two treatment modalities which work at different sites may improve pregnancy outcomes with IVF treatment.

Effect of embryo stage at transfer on placental histopathology features in singleton live births resulting from fresh embryo transfers

OBJECTIVE

To evaluate the effect of embryo stage at transfer on placental histopathology and perinatal outcome in singleton live births resulting from fresh embryo transfers (ETs).

DESIGN

Retrospective cohort study.

SETTING

Not applicable.

PATIENT(S)

The study population included all live births after fresh ETs during the period from 2009 to 2017.

INTERVENTION(S)

None.

MAIN OUTCOME MEASURE(S)

Primary outcomes included anatomic, inflammatory, vascular malperfusion, and villous maturation placental features. Secondary outcomes included fetal, maternal, and perinatal complications.

RESULT(S)

A total of 677 live births were included in the final analysis and were allocated to the cleavage-stage (n = 252) and blastocyst (n = 425) ET groups. After the adjustment for confounding factors, the blastocyst group was found to be associated with a higher incidence of circummarginate membranes insertion (odds ratio [OR] 1.9, 95% confidence interval [CI] 1.2-3.4), delayed villous maturation (OR 8.5, 95% CI 1.2-69.3), chorangiosis (OR 2.0, 95% CI 1.2-3.8), parenchymal calcifications (OR 10.6, 95% CI 1.4-80.2), and intrapartum nonreassuring fetal heart rate tracing (OR 2.4, 95% CI 1.3-4.5). Compared with cleavage-stage ETs, live births resulting from the blastocysts were associated with a lower incidence of velamentous cord insertion (OR 0.5, 95% CI 0.3-0.9), retroplacental hematoma (OR 0.3, 95% CI 0.1-0.8), subchorionic thrombi (OR 0.3, 95% CI 0.1-0.8), and avascular villi (OR 0.2, 95% CI 0.03-0.7).

CONCLUSION(S)

Live births resulting from fresh cleavage-stage and blastocyst ETs have different placental histopathology features, with a higher rate of intrapartum nonreassuring fetal heart rate tracing in the blastocyst group.

A comparison of IVF outcomes transferring a single ideal blastocyst in women with polycystic ovary syndrome and normal ovulatory controls

PURPOSE

To assess the effects PCOS on live birth rates when transferring a single fresh ideal blastocyst.

METHODS

A retrospective cohort study performed at the university-affiliated reproductive center. Women with PCOS and a control group of normal ovulatory women who underwent their first fresh embryo transfer with single ideal grade blastocyst were included in the study. Demographic, stimulation information and pregnancy outcomes were collected and analysed. The primary outcome was live birth rates, and secondary outcomes included pregnancy and clinical pregnancy rates.

RESULTS

71 Women with PCOS and 272 normal ovulatory controls underwent their first embryo transfer and met the inclusion and exclusion criteria. PCOS patient were younger (31.0 ± 3.7 vs. 33.1 ± 3.2, p = 0.0001), with higher AFC (40.0 ± 9.3 vs. 13.3 ± 4.6, p = 0.0001), required lower dose of gonadotropins to stimulate (1198 ± 786 vs. 1891 ± 1224, p = 0.0001), and had higher serum testosterone levels (2.3 ± 0.7 vs. 1.1 ± 0.3, p = 0.0001). No significant difference was found between the two groups regarding the number of previous pregnancies, the number of previous full-term pregnancies, the level of basal serum FSH, estradiol level at triggering and the BMI. When compared by Chi squared testing pregnancy rates, clinical pregnancy rates and live birth rates did not differ. However, when controlling (with multivariate stepwise logistic regression) for confounders, live birth rates were lower among the women with PCOS (p = 0.035, CI: 0.18-0.92).

CONCLUSION

After controlling for confounders, when transferring a fresh single ideal blastocyst, live birth rates were lower among the women with PCOS than normal ovulatory controls.

Trends in ovarian hyperstimulation syndrome hospitalization rates in the USA: an ongoing concern

Ovarian hyperstimulation syndrome (OHSS) is a serious, almost exclusively, iatrogenic complication of ovarian stimulation. Many techniques have been developed over the past 25 years to decrease OHSS risks, and most have been in common use for 15-20 years. In view of these techniques, it could be hypothesized that severe OHSS rates would decrease or almost disappear. According to the US National ART Surveillance System, rates did not change significantly between 2000 and 2009, at 106 OHSS cases per 10,000 IVF cycles annually. In the present study, OHSS-related hospital admissions were evaluated to establish whether a decline has occurred in OHSS admissions since the development of preventative strategies. A retrospective-population-based study was conducted using data from the Health-Care Cost and Utilization Project-Nationwide-Inpatient-Sample database between 2004 and 2014 inclusively. Between 2004 and 2008, admissions of OHSS decreased in absolute numbers and rates; however, these statistics plateaued, remaining stable between 2008 and 2014. Despite this, OHSS remains a concern and is clearly not a disease of the past. The financial burden of OHSS hospitalizations likely persists. Although techniques have resulted in a decrease in OHSS admissions since 2004, this change has plateaued, and therefore efforts to further reduce OHSS must continue.

COVID-19 and assisted reproductive technology services: repercussions for patients and proposal for individualized clinical management

The prolonged lockdown of health services providing high-complexity fertility treatments -as currently recommended by many reproductive medicine entities- is detrimental for society as a whole, and infertility patients in particular. Globally, approximately 0.3% of all infants born every year are conceived using assisted reproductive technology (ART) treatments. By contrast, the total number of COVID-19 deaths reported so far represents approximately 1.0% of the total deaths expected to occur worldwide over the first three months of the current year. It seems, therefore, that the number of infants expected to be conceived and born -but who will not be so due to the lockdown of infertility services- might be as significant as the total number of deaths attributed to the COVID-19 pandemic. We herein propose remedies that include a prognostic-stratification of more vulnerable infertility cases in order to plan a progressive restart of worldwide fertility treatments. At a time when preventing complications and limiting burdens for national health systems represent relevant issues, our viewpoint might help competent authorities and health care providers to identify patients who should be prioritized for the continuation of fertility care in a safe environment.

A review of the use of hormonal contraception in women with cardiovascular disease complications and risk factors. A systematic review

INTRODUCTION

The Centers for Disease Control and Prevention (CDC) developed a point form guideline for the use of oral contraceptives in women with coexisting medical conditions. Although this acts as a guide, it leaves the clinician without an understanding of why they are doing what they are doing.

EVIDENCE ACQUISITION

In this article, which is one of two articles addressing coexisting medical condition and oral contraceptive use, an update of the scientific knowledge is provided.

EVIDENCE SYNTHESIS

The explanation of the guidelines are to be used as a supplement for those who desire more information than is found in the CDC guidelines and in general a review for clinicians dealing with women desiring hormonal contraception.

CONCLUSIONS

The development of lower dose contraceptive pills as well as the increased incidence of comorbid conditions, such as metabolic syndrome, in younger women seeking contraception has brought along new research and new evidence to guide clinicians in the prescription of these medications.

A review of the use of hormonal contraception in women with non-cardiovascular coexisting medical conditions. A comprehensive review

INTRODUCTION

Previously, the American College of Obstetrics and Gynecology (ACOG) had published an excellent practice bulletin addressing the use of hormone contraception in women with pre-existing medical conditions. This practice bulletin became out of date. The Centers for Disease Control and prevention (CDC) of the USA subsequently developed a point form guideline for the use of oral contraceptives in women with coexisting medical conditions.

EVIDENCE ACQUISITION

Although this acts as a guide, it leaves the clinician without an understanding of why they are doing what they are doing. This article is one of two related to women with coexisting medical conditions.

EVIDENCE SYNTHESIS

In this article we will provide an update of the scientific knowledge since the publication of the ACOG guideline (2006). It is to be used as a supplement for those who desire more information than that found in the CDC guidelines.

CONCLUSIONS

Although some recommendations have remained unchanged over the years, the development of lower dose contraceptive pills as well as the increased incidence of comorbid conditions, such as metabolic syndrome, in younger women seeking contraception has brought along new research and new evidence to guide clinicians in the prescription of these medications.

Fertility care in the era of commercial direct-to-consumer home DNA kits: issues to ponder

Recently, we have witnessed a shift in the nature of genetic testing. What was once solely in the hands of the scientific community is now easily accessible to anyone. Commercial companies such as Veritas Genetics, Ancestry, and 23andMe offer cheap direct-to-consumer home DNA kits that are branded as a "health and ancestry service." These tests are gaining in popularity, and it is estimated that since their marketing, over 30 million people worldwide have provided their DNA samples. The implications of this new genetic era are diverse, ranging from the individuals personal health assessment, to family genealogy and ancestry, and the complexity of establishing an enormous population-based genetic database. Unique implications of commercial DNA tests on fertility patients and heath care providers, such as in the case of gamete donation, are important to acknowledge and have implications for reproductive care.

Supplements to Conventional Treatment After Hysteroscopic Lysis of Intrauterine Adhesions: A Systematic Review

Intrauterine adhesions (IUAs) are a result of trauma to the basalis layer of the endometrium and may lead to clinical sequelae such as miscarriage, infertility, and menstrual irregularities. Hysteroscopy is recognized as the gold standard in diagnosis and management, although the optimal treatment after surgical intervention remains unclear. This review aimed to provide an update on the treatment options available after hysteroscopic adhesiolysis and to facilitate clinical management of patients with IUAs. To avoid duplicating previous work, the review focused on studies that compared various adjunctive postoperative treatments in patients receiving hormone therapy. Of 548 studies, 15 papers fit our criteria that compared post-resection treatment options in women with IUAs. Meta-analysis of the use of Foley catheter or amnion graft as an adjunctive therapy after adhesiolysis failed to show a statistical difference (odds ratio 1.55; 95% confidence interval 0.60-3.99). Meta-analysis could not be done for the 13 remaining studies as a result of extensive heterogeneity, bias, or non-comparable end points. The lack of a universal classification system for IUAs and the use of variable outcomes to measure the success of adjunctive treatment pose challenges in generating standard treatment recommendations. This review calls for the development of a universal classification system and studies with consistent parameters and end points to allow for the generation of standard treatment guidelines. On the basis of the available evidence, recommendation of specific adjunctive treatments after hysteroscopic adhesiolysis is unjustified.

When to do intracytoplasmic sperm injection: a prospective comparison

PURPOSE

The purpose of the study was to assess the fertilization rate and embryo development in sibling human oocytes after split insemination in patients with and without isolated teratozoospermia.

METHODS

A prospective cohort study at a university affiliated reproduction center was performed. Hundred and three patients during the time periods 01-2013 to 12-2015 had split insemination ordered for their first IVF cycle. The primary outcome measured was fertilization rate. Secondary outcomes were the number and quality of embryos.

RESULTS

Mature oocytes at the time of collection were assigned as follows: 558 to IVF and 556 to ICSI. An additional 48 immature oocytes matured while awaiting spontaneous fertilization with IVF for a total of 606 in that group. The study group of normal strict sperm morphology ≤ 4 included 61 patients, and the control group included 42 patients with normal strict sperm morphology > 4. ICSI was statistically favored over IVF only in cases with normal strict sperm morphology ≤ 4%. There was a higher fertilization rate in ICSI compared to IVF (74.4% vs. 38%, p < 0.0001), a higher number of day 2 (4 ± 3.4 vs. 2.4 ± 2.7, p < 0.0001), day 3 (4 ± 3.4 vs. 2.2 ± 2.7, p < 0.0001) and day 5 embryos (2.2 ± 2.6 vs. 1.2 ± 2, p = 0.001), and they were of better quality; however, it did not reach significance (p = 0.062). A similar advantage for ICSI was seen in a subgroup of unexplained infertility with normal strict sperm morphology > 4%.

CONCLUSIONS

In conclusion, in couples with normal strict sperm morphology ≤ 4%, there is an advantage of ICSI over IVF in terms of fertilization rate, quantity and quality of cleavage stage embryos and blastocysts. Based on the results, ICSI seems reasonable as a first-line treatment in patients with normal strict sperm morphology ≤ 4%, as well as in patients with unexplained infertility.

Revisiting serum β-hCG cut-off levels and pregnancy outcomes using single embryo transfer

PURPOSE

The objective of this study is to identify the pregnancy outcomes based on day-16 β-hCG level assessed with modern assays, in fresh single embryo transfers.

METHODS

A retrospective cohort study at a single academic center between 2013 and 2017. A total of 1076 pregnancies were included.

RESULTS

Pregnancies were divided into 10% groupings of 107-108 patients each. The 10 groups did not differ for baseline characteristics. There was no difference on outcomes based on cleavage or blastocyst transfer. At a serum β-hCG level of 103 ± 13 (range 74-135), 50% had a biochemical loss. Biochemical pregnancy losses remained 21% at serum β-hCG range (136-197). It was only once serum β-hCG level reached 199-252 that the probability of a biochemical pregnancy loss was 12%. Interestingly, if a clinical pregnancy is present even at low day-16 serum β-hCG levels, the likelihood of live birth is approximately 50%. This maximizes to 75% when the serum β-hCG level was at least 253 IU/L. The relationship between serum day-16 β-hCG levels and clinical pregnancy or live birth is quite strong with correlation coefficients above 0.8 which accounted for more than 75% of the variability in outcomes in both cases. Receiver operator curves determined that the cut-off for a clinical pregnancy was 190 and for live birth, it was 213 IU/L.

CONCLUSION

An increase in the serum β-hCG levels at which to expect a reassuring outcome is required based on modern assays, as compared with the old cut-off levels.

Relationship between surrogate estimates and direct measurement of insulin resistance in women with polycystic ovary syndrome

PURPOSE

To evaluate the relationship between surrogate estimates of insulin resistance and a direct measurement of insulin-mediated glucose uptake women with and without PCOS.

METHODS

Retrospective cohort study of 75 PCOS and 118 controls. Fasting plasma glucose and insulin concentrations, insulin resistance as determined by the insulin suppression test, calculation of multiple surrogate estimates of insulin resistance, total and free testosterone concentrations, and correlations between the direct measure and surrogate estimates of insulin resistance were evaluated.

RESULT(S)

Surrogate markers of insulin resistance were correlated to a variable, but statistically significant degree with the direct measure of insulin resistance in control population and the women with PCOS. There was no correlation between the surrogate estimates of insulin resistance and total or free plasma testosterone concentrations.

CONCLUSION(S)

The surrogate estimates of insulin resistance evaluated were significantly related to a direct measure of insulin resistance, and this was true of both the control population and women with PCOS. The magnitude of the relationship between the surrogate estimates and the direct measurement was comparable and not significantly altered by androgen levels. Fasting plasma insulin concentration seems to be at least as accurate as any other surrogate estimate, and is by far the simplest.

Amount of Progesterone Consumed Based on Varying Fat Concentrations, Dietary Recommendations, and Estimated Safe Levels in Commercial Cow Origin Liquid Dairy Products

Federal guidelines recommend that food with hormone content fall below 1% of endogenous production in the subset of the population with the lowest daily production. The majority of dairy products are obtained from pregnant cows, which increase the level of hormones present. The purpose of this article was to perform theoretical evaluation of the quantity of progesterone in cow's milk based on fat percentages and to assess whether this was within the recommended range. Daily recommended dairy product intake from various countries worldwide was researched. This was compared to the concentration of progesterone previously identified in varying fat contents of cow origin milk to assess the amount of progesterone (mg/day) that would be consumed if the guidelines were followed. The maximum daily progesterone consumption suggested will be met by ingestion of 2.7 L, 1.42 L, 1.13 L, 940 mL, 810 mL, 650 mL of 0% (skim), 1%, 2%, 3.25%, 10% (cream), and 35% (whipping cream) fat liquid cow origin dairy product, respectively. Therefore, ingestion of the highest amount of recommended daily dairy intake fell below 1% of the daily endogenous quantity produced, except in the unlikely case of consumption of 650 mL of 35% fat. Studies demonstrating an effect of cow's liquid dairy product intake may need to be revisited, since levels of progesterone consumption remain within the recommended levels. However, it should be considered that ingestion of cow's milk might have a potential effect on the hormonal profile in patients; however, this seems unlikely.

Relationship among obesity, insulin resistance, and hyperinsulinemia in the polycystic ovary syndrome

PURPOSE

To evaluate the relationship between obesity and insulin resistance among women with polycystic ovary syndrome (PCOS) using a gold standard test.

METHODS

A retrospective database analysis of 75 women with PCOS and 118 normal controls who underwent a modification of the insulin suppression test. The relationships between body mass index (BMI) and steady-state plasma glucose (SSPG) levels were investigated.

RESULTS

Mean SSPG score for PCOS subjects was statistically similar than that of the controls at all BMI groupings. Only when PCOS subjects reached a BMI of ≥30 kg/m² that the PCOS subjects had higher mean SSPG score than the control subjects, although not significantly so (p = 0.07). The distribution of PCOS and control subjects in each SSPG quartile grouping was investigated. When comparing all PCOS and control subjects, PCOS subjects were more likely to be in the higher quartiles of SSPG score (p = 0.0001). However, when comparing the PCOS and control subjects, at each BMI grouping (<25, 25-29.9, and ≥30 kg/m²), there was no difference in the likelihood that a larger percent of subjects fell into a different quartile (p = 0.12, 0.69, 0.32, respectively).

CONCLUSIONS

PCOS subjects have increased magnitudes of insulin resistance when compared to ovulatory controls, when controlling for age, BMI, fasting glucose, and insulin levels. However, the magnitude of this insulin resistance in lean subjects is mild. Quantity of excess body fat, particularly subjects with a BMI of at least 30 kg/m² is the primary predictor of insulin resistance of sufficient magnitude to put PCOS subjects at increased risk for metabolic abnormalities.

Effect of GnRH agonist and letrozole treatment in women with recurrent implantation failure

OBJECTIVE

To compare the influence of dual suppression with the use of GnRH agonist plus aromatase inhibitor compared with suppression with the use of GnRH agonist alone or no suppression at all in patients with idiopathic recurrent implantation failure (RIF).

DESIGN

Retrospective cohort study.

SETTING

University-affiliated reproductive center.

PATIENT(S)

A total of 523 infertile women who failed two blastocyst transfers underwent a third frozen blastocyst transfer. Women with known endometriosis were excluded.

INTERVENTION(S)

A total of 204 subjects were not pretreated, 143 received 2 months of GnRH agonist (3.75 mg intramuscular leuprolide acetate monthly) only, and 176 received GnRH agonist and aromatase inhibitor (5 mg oral letrozole daily for 60 days). Demographic and stimulation information was collected and cycle outcomes reported.

MAIN OUTCOME MEASURE(S)

Clinical pregnancy rates.

RESULT(S)

Age, antral follicle count, basal FSH levels, duration of infertility, previous pregnancies, and full-term deliveries were similar (P>.05). Clinical pregnancy rates were higher among women who received GnRH agonist plus letrozole compared with women who received GnRH agonist only or women without pretreatment (63%, 42%, and 40%, respectively; P<.0001). Live birth rates were higher among women who received GnRH agonist plus letrozole compared with the other groups (56%, 36%, and 34%; P<.0001). No differences in pregnancy outcomes were noted between patients who did not receive pretreatment and those in the GnRH agonist only group.

CONCLUSION(S)

In patients with RIF, treatment with a GnRH agonist plus letrozole may improve live birth rates in subsequent cycles. We hypothesize that this improvement is due to alterations in the endometrium receptivity or treatment of undiagnosed endometriosis.

Decrease in American birth rates makes it imperative for the United States to implement state mandated fertility coverage

In recent years, the prevalence of infertility has increased due to delayed childbearing and an increase in the rate of male infertility. Given the high cost of fertility treatment, this option is not valid for families with a low income, and those who can afford it usually choose to have multiple embryo transfer, which has led to an increase in multiple birth rates and an increase in the cost of perinatal care. Due to the expected increase in infertility and decrease in the national live birth rate, the US should set a plan to fund infertility treatment and lead a policy for single embryo transfer. This will offset the decrease in the national birth rates and decrease expenditure on perinatal and neonatal complications resulting from multiple births.

Management of recurrent implantation failure by gonadotropin-releasing hormone agonist and aromatase inhibitor suppression, in women without evidence of endometriosis

Endometriosis is common among those with infertility, although many cases go undiagnosed. This study was performed to determine whether empiric treatment with two months of depo-leuprolide 3.75 mg monthly (dep-GnRH-ag) and letrozole 5 mg daily improves pregnancy outcomes in patients with at least two unexplained failed embryo transfers (ETs) but without a previous diagnosis of endometriosis. A retrospective cohort study was performed with subjects who failed at least two good quality ET. The study excluded women with a known history of endometriosis or ovarian cysts (possible endometriomas). Subjects (N = 38) were treated with dep-GnRH-ag and letrozole pre-cycle. Matched women (N = 37) who did not receive either pretreatment served as a control group. Data were compared by non-paired T-tests and multivariate logistic regression to control for confounding effects. Demographic data, hormonal profiles, and ovarian reserve parameters were similar between the two groups. The treated group had failed more embryo transfers (3.5 ± 1.7 vs. 2.0 ± 1.3, p = .01) than the controls. When adjusting for the number of MII oocytes collected, number of blastocysts developed and number of blastocysts transferred, there were more pregnancies (24/38 vs. 11/37, p = .02) and ongoing pregnancies (18/38 vs. 9/37, p = .03) in the treated group. Patients with multiple unexplained failed ET may have undiagnosed endometriosis and may benefit from pretreatment with dep-GnRH-ag and letrozole. These results would benefit from being subjected to a randomized prospective study.

Vaginal ultrasound-guided ovarian needle puncture compared to laparoscopic ovarian drilling in women with polycystic ovary syndrome

STUDY OBJECTIVE

To compare pregnancy outcomes in PCOS women undergoing transvaginal ovarian injury (TVOI) and laparoscopic ovarian drilling (LOD) DESIGN: 126 infertile patients with PCOS were included in this prospective cohort study CANADIAN TASK FORCE CLASSIFICATION OF LEVEL OF EVIDENCE: IIA.

SETTING

University-affiliated fertility center.

PATIENTS

Sixty-seven infertile patients with the history of failed in vitro maturation underwent follow-up as the TVOI group. Fifty-nine infertile women who underwent LOD acted as controls. All subjects had PCOS with menstrual irregularity and were anovulatory by repetitive serum progesterone levels.

INTERVENTIONS

The LOD group underwent six cauterizations of a single ovary with 30W for 4-6 s. Failed IVM subjects with 20-30 needle punctures per ovary acted as the TVOI group. Subjects were followed for six months.

MEASUREMENTS AND MAIN RESULTS

There was not a significant difference between the groups when the cases were evaluated in terms of spontaneous pregnancy or miscarriage rates. BMI levels decreased in both the TVOI and the LOD groups in a similar fashion. However, serum AMH and AFC decreased greater after LOD than they did with TVOI over the six-month duration of the study (p < 0.001 in both cases).

CONCLUSIONS

Preliminary data suggest that TVOI likely represents a safer, less costly and equally effective manner of surgical ovulation induction in anovulatory PCOS women when compared to LOD.

Outcomes of random start versus clomiphene citrate and gonadotropin cycles in occult premature ovarian insufficiency patients, refusing oocyte donation: a retrospective cohort study

The aim of this study is to present the clinical outcomes of a random start, a spontaneous folliculogenesis protocol versus Clomiphene Citrate and Gonadotropin treatment in women with occult premature ovarian insufficiency. Women underwent treatment between 1 February 2009, and 30 May 2016. 41 women were treated with the random start protocol while 48 cases received ovarian stimulation with clomiphene and gonadotropins. All included cases met the criteria of 4 months of oligo-ovulation, follicular-stimulating hormone levels over 30 IU/L and anti-Mullerian hormone levels below 0.30 ng/mL. The random start protocol involved following the subjects for up to 6 months until spontaneous folliculogenesis occurred. The mean number of oocytes collected, mature oocytes, fertilized oocytes, and grade II embryos were significantly higher in the random start protocol (p < .05). The doses of gonadotropin administration and hCG were significantly lower in the random start protocol (p < .05). The clinical pregnancy and live birth rates were significantly higher in the random start protocol (p < .05). Likely stimulation is of little benefit in women with occult premature ovarian insufficiency. Observation while waiting for spontaneous folliculogenesis results in better outcomes, and less oocyte collections.

Do pregnancy rates differ with intra-uterine insemination when different combinations of semen analysis parameters are abnormal?

OBJECTIVE

To evaluate the relationship of one or a combination of semen analysis parameter results on insemination outcomes.

MATERIAL AND METHODS

A retrospective analysis was performed to evaluate the effect on pregnancy rates in relation to one or more abnormal semen analysis parameters based on the 2010 World Health Organization semen analysis guidelines.

RESULTS

Nine hundred eighty-one couples underwent 2231 intrauterine insemination cycles at the Stanford Fertility and Reproductive Medicine Center. In our study, the pregnancy rates ranged from 11-25% when an individual or combined semen analysis parameters were analyzed. Similar pregnancy rates were found when one, two, and in most cases three parameters were abnormal. When a single parameter was abnormal among volume, concentration, and motility, pregnancy rates were mainly unaffected. There was the exception of total sperm count where pregnancy rates were diminished when counts were below 39 million (p=0.04).

CONCLUSIONS

Clearly, total sperm in the specimen and not the concentration of sperm per milliliter was the critical factor for predicting pregnancy. Therefore, a reorganization of semen analysis reports should be done emphasizing the total amount of sperm present and de-emphasizing concentration of sperm.

Combined modalities for the prevention of ovarian hyperstimulation syndrome following an excessive response to stimulation

Although the classification and management of ovarian hyperstimulation syndrome (OHSS) are well described in the literature, little attention has been given to modalities that aim to prevent its occurrence. In this retrospective study, we sought to investigate whether a combination of modalities in addition to GnRH agonist triggering in GnRH antagonist cycles could result in better prevention of OHSS. The study included 170 hyperresponder patients who were stimulated with GnRH antagonist protocol and were triggered with GnRH agonist for final oocyte maturation. Freeze all embryos was performed in all patients. The intervention group included treatment with dopamine agonist and restarting the GnRH antagonist. Of the 170 patients included, 63 were included in the intervention group. Compared to no intervention, women in the intervention group were more likely to have: menses within 7 days of the oocyte retrieval, smaller ovarian diameter, the absence of free pelvic fluid, less hemoconcentration and higher serum sodium levels. It can be concluded that combining other modalities in addition to triggering with GnRH agonist in GnRH antagonist cycles, results in targeting several pathways that lead to OHSS and result in rapid resolution of signs of ovarian hyperstimulation.

A protocol for ovulation delay in women who cannot use estrogen, including Jewish women with Niddah issues and a pilot study

Orthodox Jewish women abstain from sexual intercourse from the commencement of menstruation until seven days after the end of menstrual bleeding at which point they can immerse themselves in a ritual bath and recommence relations. For women who ovulate prior to commencing intercourse this results in religious infertility. The traditional treatment for religious infertility is oral estrogens in the early follicular phase to delay ovulation. However, certain groups of women have contraindications to oral estrogens. In this group, no treatment options have existed until now. In this study we proposed a treatment protocol substituting the use of gonadotropin releasing hormone-antagonists in the early follicular phase for the oral estrogens. In a small pilot study, we demonstrate that these two protocols have similar outcomes in terms of ovulation delay (p = 1.0) and likelihood of ongoing pregnancy (p = 1.0). This protocol for ovulation delay also has applications in non-Jewish women who need to delay ovulation due to life constraints.