The relationship between fat and progesterone, estradiol, and chorionic gonadotropin levels in Quebec cow's milk

PURPOSE

The majority of milk in industrialized countries is obtained from pregnant cows, which contains increased levels of estrogen and progesterone compared to non-pregnant cows. The aim of this study was to quantify the amount of hormones present in milk with different fat content because previous studies on humans have shown potential effects of increased milk consumption on serum and urine hormone levels as well as on sperm parameters. However, it is unclear whether consumption of milk at the currently recommended levels would lead to systemic effects.

METHODS

Samples of cow's milk of varying fat concentrations (0, 1, 2, 3.25, 10, and 35%) were analyzed via competitive ELISA assays.

RESULTS

Progesterone concentrations were significantly correlated to increasing fat content of milk (r = 0.8251, p = 0.04).

CONCLUSIONS

Research on conditions in which additional progesterone may have an effect on human health should consider inclusion of limitation of milk intake and its effects. Further studies are needed to determine the concentration of progesterone in milk of different fat content in other regions and countries and to quantify the potential pathophysiologic role.

A Comparison of Outcomes from In Vitro Fertilization Cycles Stimulated with Follicle Stimulating Hormone Plus either Recombinant Luteinizing Hormone or Human Menopausal Gonadotropins in Subjects Treated with Long Gonadotropin Releasing Hormone Agonist Protocols

BACKGROUND

This study compared rates of pregnancy and in vitro fertilization (IVF) parameters in subjects stimulated with follicle stimulating hormone (FSH) plus either recombinant human luteinizing hormone (r-LH) or human menopausal gonadotropin (hMG) in a long gonadotropin releasing hormone (GnRH) agonist IVF protocol.

MATERIALS AND METHODS

This cohort study enrolled patients who underwent IVF stimu- lation with a long GnRH agonist protocol and received FSH plus r-LH or hMG. Outcomes measured included: FSH and LH doses, number of oocytes and embryos obtained, pregnancy rate per cycle, and clinical pregnancy rate per cycle. Stepwise logistic regression was performed on continuous and categorical variables to control for confounding effects between all variables analyzed.

RESULTS

There were 122 patients who underwent 122 IVF cycles with long GnRH agonist protocols. Similar baseline parameters existed between groups. Patients that received r-LH required a lower FSH dose (3207 ± 1300 IU) for stimulation compared to the group that received hMG (4213 ± 1576 IU, P=0.0001). The LH dose was also lower in these patients (1332 ± 587 IU) compared to the patients who received hMG (1938 ± 1110 IU, P=0.0001). The number of days of stimulation did not differ between groups (P=1.0). The group that received r-LH also had statistically higher numbers of oocytes (14.4 ± 6.3) and embryos (7.9 ± 4.8) compared to the hMG group with 11.0 ± 5.3 oocytes and 6.0 ± 3.7 embryos. Pregnancy rates per cycle start were higher for patients in the r-LH group (49%) compared to the hMG group (27%, P=0.025). Patients that received r-LH had higher implantation rates (62%) compared to the hMG group (33%, P=0.001). The r-LH group had a higher trend toward clinical pregnancy rates per cycle start (39%) compared to the hMG group (25%, P=0.065).

CONCLUSION

r-LH may offer benefits compared to hMG when combined with FSH for ovarian stimulation in long GnRH agonist protocols in good responders. Prospective studies should be undertaken to confirm these results.

Relationship between pre-ICSI meiotic spindle angle, ovarian reserve, gonadotropin stimulation, and pregnancy outcomes

PURPOSE

The goals of this study are to analyze the clinical pregnancy rate as a function of the pre-intracytoplasmic sperm injection (ICSI) oocyte spindle angle and determine factors which can be associated with different spindle angles, if clinically relevant.

METHODS

Fifty-eight patients, who underwent their first ICSI cycle from January to December 2013, were included. Eight hundred thirty oocytes were collected, and 648 were metaphase II (MII) on retrieval day. Spindles were characterized in terms of visibility and position in relation to the first polar body (PB). Oocytes were separated into four groups based on angle: (group 1, n = 297) 0°-29°; (group 2 n = 212) 30°-89°; (group 3, n = 72) ≥90°; and those with no visible spindle (group 4, n = 67).

RESULTS

The rate of blastocyst development was associated with the spindle angle (p = 0.002). The rate of good quality blastocysts were as follows: group 1 (42%), group 2 (30%), group 3 (35%), and group 4 (19%) (p = 0.02). Pregnancy and live birth rates were also affected (p = 0.007 and p = 0.046, respectively). Antral follicle count (AFC) (p = 0.001), total FSH stimulating dose (p = 0.0001), and peak serum estradiol level (p = 0.0001) were associated with spindle angle grouping. Miscarriage rates trended different (p = 0.07). On the other hand, day 3 follicle-stimulating hormone (FSH) levels and female and male age were not associated with spindle angle grouping.

CONCLUSIONS

Embryos resulting from oocytes with pre-ICSI spindle angles between 0° and 29° were associated with better blastocyst, pregnancy, live birth, and miscarriage rates when compared to oocytes that had no visible spindle. Low ovarian reserve and excessive stimulation were also associated with lack of spindle and therefore lower pregnancy outcomes.

Morbid obesity and pregnancy outcomes after single blastocyst transfer: a retrospective, North American study

PURPOSE

Maternal obesity has been shown to affect reproductive function and pregnancy outcomes following in vitro fertilization. More recently, studies have demonstrated lower live birth rates after single blastocyst transfer (SBT) in patients who are overweight or obese. However, the impact of morbid obesity on pregnancy outcomes after SBT has not been well elucidated. The present study aimed to determine whether morbid obesity has a detrimental impact on pregnancy outcomes after SBT in a North American population.

METHODS

A retrospective, cohort study including 520 nulliparous and multiparous women undergoing top-quality SBT between August 2010 and March 2014 at a University Health Centre in North America was conducted. Primary outcomes included: miscarriage rate, clinical pregnancy rate, and live birth rate. Subjects were divided into different BMI categories (kg/m²), including <20, 20-24.9, 25.0-29.9, 30-40, and 40 or more.

RESULTS

The miscarriage rate per pregnancy for each group, respectively, was 36, 64, 59, 61, and 50% (p = 0.16); the clinical pregnancy (per patient) rate per group was 36, 52, 38, 26, and 10% (p = 0.009); and the live birth rate (per patient) per group was 35, 50, 38, 26 and 10% (p = 0.03).

CONCLUSION

Morbid obesity is a strong and independent predictor of poor pregnancy outcomes in patients undergoing top-quality SBT.

The benefits of other treatments than in vitro fertilization to aid conception in minimal and mild endometriosis

The treatment of minimal or mild endometriosis prior to non-in-vitro fertilization (IVF) assisted reproduction to improve pregnancy outcomes is controversial. Ovulation suppression may be offered to women who do not wish to conceive to suppress advancement of the disease. There is little evidence to suggest improvements in fertility associated ovarian suppression prior to non-IVF infertility treatments. The use of intrauterine insemination without ovulation induction offers little benefit, with low pregnancy rates in most studies. Surgical ablation seems to improve outcomes when other care will not be delivered. Although controversial, surgical ablation before ovulation induction may offer benefit but further studies would be helpful. Ovulation induction seems to increase pregnancy rates and either letrozole or clomiphene citrate should be considered as first line options. If pregnancy does not occur with three months of ovulation induction, based on dropping success rates with further cycles of ovarian stimulation, IVF should be offered.

Control-matched surgical evaluation of endometriosis progression after IVF: a retrospective cohort study

BACKGROUND

The aim of this study was to examine the surgical findings at repeated surgeries for endometriosis and to compare disease progression in patients after IVF to those without interval fertility treatments.

METHODS

A retrospective case-control study set at the referral center for gynecologic endoscopy at Stanford University. Women who had two surgeries for treatment of symptomatic endometriosis since 1997 were searched in the database. Twenty-one women were identified who underwent IVF treatment between the two procedures (IVF group), and compared to 36 women who did not receive any fertility treatment (controls). The main outcomes were time to recurrence and surgical findings including rASRM score. The presence and size of endometrioma, rectovaginal and para-rectal spaces location of endometriosis were also compared between the two surgical procedures.

RESULTS

Demographics in the two groups were similar. The change in rASRM score between surgeries was not significantly different (P=0.80) between the two groups. There was no difference between the two groups in the size and number of pathology proven endometriomas as well as no difference in the presence of rectovaginal and pararectal endometriosis.

CONCLUSIONS

No significant difference was found in the two groups, suggesting that IVF treatment does not lead to an accelerated progression of endometriosis in patients with recurrence.

Is elective single-embryo transfer a viable treatment policy in in vitro maturation cycles?

OBJECTIVE

To compare the clinical outcome of single-embryo transfer (SET) with double-embryo transfer (DET) in in vitro maturation (IVM) cycles performed in patients with polycystic ovary syndrome (PCOS), and to determine which factors predict those outcomes.

DESIGN

A retrospective analysis.

SETTING

Private assisted reproduction center.

PATIENT(S)

One hundred and fifty-nine women with PCOS.

INTERVENTION(S)

In vitro maturation with elective SET or DET conducted between September 2007 and May 2014.

MAIN OUTCOME MEASURE(S)

Live-birth rates.

RESULT(S)

Single-embryo transfer was performed in 83 patients (52.2%), and DET was performed in 76 patients (47.7%). When compared with the patients who had DET, the patients who had SET were statistically significantly younger (32.4 ± 3.5 vs. 24.1 ± 4.2 years) and had a shorter infertility duration (9.2 ± 4.5 vs. 4.4 ± 2.1 years), fewer previous ART cycles (<2 prior attempts, 39.5% vs. 6%; ≥2 prior attempts, 60.5% vs. 0), fewer collected oocytes (15.1 ± 4.6 vs. 12.6 ± 3.8), fewer metaphase II oocytes (9.0 ± 4.1 vs. 5.7 ± 2.9), fewer fertilized oocytes (8.2 ± 3.7 vs. 3.6 ± 2.3), and a higher implantation rate (27% vs. 47%). The SET and DET groups had similar embryo quality and similar clinical pregnancy (44.6% vs. 44.7%) and live-birth rates (34.9% vs. 34.2%). Twin pregnancy rates were statistically significantly higher in the DET compared with the SET groups (9.2% vs. 2.4%).

CONCLUSION(S)

In vitro maturation is a successful assisted reproduction technique that can be an alternative to conventional in vitro fertilization in women presenting with PCOS-related infertility. Our observations suggest that SET is a feasible option to prevent multiple pregnancies while maintaining the live-birth rate.

Transvaginal Ultrasonographic Rates of Folliculogenesis Among Oligomenorrheic Women with Polycystic Ovary Syndrome

OBJECTIVE

To probe the rate of folliculogenesis among women with polycystic ovary syndrome (PCOS) who are oligomenorrheic, and to compare parameters among the group that de- veloped follicles with those who did not to determine how the 2 groups differed.

STUDY DESIGN

A pro- spective cohort study per- formed on women with PCOS who gave a history of regular menstrual cycles less frequent than every 35 days. Transvaginal ultra- sound and urinary luteinizing hormone kits (ovulation predictor) were used to determine the development of a dominant follicle.

RESULTS

A total of 55% of patients developed an ovulatory follicle with menstrual cycle lengths less frequent than every 35 days. The calculated cycle length for this group was 36-45 days.

CONCLUSION

Among women with PCOS and oligo- menorrhea, rates of ovulation seem to be consistent with -the one study in the literature and lower than the other.

A comparison between r-LH and urinary supplements containing LH activity in patients undergoing the microdose GnRH agonist flare protocol for in-vitro fertilization: a pilot study

BACKGROUND

The aim of this study was to compare pregnancy rates and stimulation parameters in patients with diminished ovarian reserve, who were treated with recombinant human luteinizing hormone (r-LH) or menopausal gonadotropins (hMG), as part of a microdose flare protocol.

METHODS

A retrospective cohort study was performed. Comparisons between the group that was stimulated with r-LH plus follicle stimulating hormone (FSH) to those treated with hMG and FSH, were performed. Measurements included: medication doses, number of oocyte collected, number of embryos obtained, pregnancy and clinical pregnancy rates.

RESULTS

Patients in the r-LH group (N.=40) had significant higher clinical pregnancy rates (33% vs. 14%; P=0.04) and used lower dose of LH (1938 IU vs. 2807 IU; P=0.02) compared to patients that were stimulated with hMG (N.=39).

CONCLUSIONS

r-LH may offer advantages for the treatment of diminished ovarian reserve when performing a microdose flare protocol when compared to hMG. Both larger and prospective studies should be carried out to confirm these findings.

A primer on pituitary injury for the obstetrician gynecologist: Simmond's disease, Sheehan's Syndrome, traumatic injury, Dahan's Syndrome, pituitary apoplexy and lymphocytic hypophysitis

The pituitary gland plays a critical role in reproduction. In response to the hypothalamus the anterior pituitary secretes prolactin, thyroid-stimulating hormone, adreno-corticotropic hormone, follicle-stimulating hormone, luteinizing hormone and growth hormone. Dysregulation in these hormones often lead to reproductive failure. Multiple mechanisms of pituitary injury exist. Simmond's disease is atrophy or destruction of the anterior lobe of the pituitary gland resulting in hypopituitarism. Sheehan's syndrome is post-partum pituitary injury due to massive hemorrhage. Traumatic injury resulting in hemorrhage in a non-pregnancy state can also cause partial or complete pituitary failure. Dahan's syndrome is pituitary injury due to severe vasospasm, without significant hemorrhage. Pituitary apoplexy is infarction of a pituitary adenoma and intra-mass hemorrhage with result injury to hormone production by the gland. Lymphocytic infiltration is the most common cause of hypophysitis and the mechanism is often unknown, although it may be autoimmune-related. The mechanism and treatments of each of these pathologies will be discussed in a context of reproduction.

Pregnancy rates unaffected by sperm count in intrauterine insemination: a retrospective cohort study

BACKGROUND

The aim of this study was to elucidate the impact of both pre and postprocessing total motile sperm count (TMSC) on pregnancy rates in a subfertile population undergoing intrauterine insemination (IUI).

METHODS

Subfertile couples presenting to the Stanford University Fertility Center during a two-year period were retrospectively enrolled. Eligible couples consisted of women with good ovarian reserve, proven tubal patency, normal anatomy and inducible ovulation. Ovulation induction was administered per standard protocols. IUI was performed using only fresh semen; samples were analyzed pre and post-processing. Pregnancy was established using β-HCG assays performed 15-17 days after IUI. Pregnancy rates for subgroups of pre and postprocessing TMSC were compared.

RESULTS

A total of 981 couples underwent 2231 IUI cycles. Overall, the pregnancy rate was 20.2%. Pregnancy rates did not differ and remained rather stable for the pre (P=0.12) and post (P=0.66) processing semen analysis when stratified for TMSC.

CONCLUSIONS

In the absence of teratospermia, TMSC does not appear to impact pregnancy rates in subfertile couples undergoing IUI.

Should we diagnose and treat minimal and mild endometriosis before medically assisted reproduction?

The treatment of minimal or mild endometriosis prior to assisted reproduction (ranging from intrauterine insemination to in vitro fertilization [IVF]) to improve the likelihood of success is controversial. Ovulation suppression is commonly used in endometriosis to decrease pain, however, there is little evidence to suggest improvements in fertility associated with this technique. Moreover, current evidence is sparse and does not support ovarian suppression prior to intrauterine insemination with or without ovulation induction, while there is some evidence favoring ovarian suppression with gonadotropin releasing hormone agonists prior to IVF to improve pregnancy rates. However, the majority of studies were performed in women with moderate to severe endometriosis. There is currently conflicting evidence regarding surgical ablation or removal of endometriomas prior to IVF, and its outcome on pregnancy rates. This review highlights the paucity of data in the management of endometriosis prior to assisted reproductive technologies and suggests that further studies are needed.

Public health implications of a North American publicly funded in vitro fertilization program; lessons to learn

PURPOSE

A retrospective study was conducted to determine trends in practice and outcomes that occurred since the implementation of the publicly funded in vitro fertilization (IVF) and single embryo transfer (SET) program in Quebec, in August, 2010.

METHODS

Data presented was extracted from an advisory report by the Health and Welfare Commissioner, and from a report by the Ministry of Health and Social Services published in June 2014 and October 2013, respectively. This data is publicly available, and was collected from all six private and three public-assisted reproduction centers in Quebec providing IVF services. Data pertains to all IVF cycles performed from the 2009-2010 to 2012-2013 fiscal years.

RESULTS

SET was performed in 71 % of cycles in 2012. The number of children born from IVF was 1057 in 2009-2010 and 1723 in 2012-2013 (p < 0.0001). Multiple birth rates from IVF were 24 % in 2009-2010 (before the program began) and 9.45 % in 2012-2013 (p < 0.0001). The proportions of IVF babies that were premature, that were the result of multiple births, or that required neonatal intensive care unit admission (NICU) all decreased by 35.5 % (p < 0.0001), 55 % (p < 0.0001), and 37 % (p < 0.0001), respectively, from 2009-2010 to 2012-2013. The cost per NICU admission for an IVF baby increased from $19,990 to $28,418 from 2009-2010 to 2011-2012.

CONCLUSION

This first North American publicly funded IVF program with a SET policy shows that such a program contributes substantially to number of births. It has also succeeded in increasing access to treatment and decreasing perinatal morbidity by decreasing multiple birth rates from IVF. A substantial increase in global public health care costs occurred as well.

Pituitary injury and persistent hypofunction resulting from a peripartum non-hemorrhagic, vaso-occlusive event

Cerebral vascular accidents are caused by vasospasm when induced by preeclampsia or by dopamine agonists. However, six arteries nourish the pituitary and prevent against vasospasm-induced damage, which up until now has not been thought to occur. Bromocriptine was used to arrest lactation in a 31-year-old with secondary amenorrhea following preeclampsia and fetal demise at 28 weeks gestation. Tests and history revealed panhypopituitarism not associated with hemorrhage or mass infarction but instead caused by vasospasm. The present study is the first report of pituitary damage from a non-hemorrhagic, vaso-occlusive event in the literature. In keeping with Sheehan's and Simon's syndromes, we have named pituitary damage resulting from vaso-occlusion as Dahan's syndrome, and a literature review suggests that it may be a common and previously overlooked disorder.

Collection of 125 oocytes in an in vitro maturation cycle using a new oocyte collection technique: a case report

BACKGROUND

We have developed a new oocyte collection technique applicable to use in women with "string-of-pearls" polycystic ovaries undergoing in vitro maturation (IVM) of oocytes for in vitro fertilization.

CASE

A 34-year-old woman with polycystic ovary syndrome and infertility underwent IVM. Her ovaries had the string-of-pearls appearance on ultrasound, and antral follicle counts were consistently less than 60. An IVM cycle was performed using a new "rapid-pass" oocyte collection technique. We retrieved 125 germinal vesicle oocytes. A total of 44 oocytes reached the metaphase II stage after 48 hours in culture. After fertilization, four embryos were transferred to the uterus, resulting in a live birth.

CONCLUSION

We believe this to be the largest number of oocytes retrieved from a single individual at one time. This was done using a newly developed aspiration technique.

Predicting pregnancy in women undergoing in-vitro fertilization with basal serum follicle stimulating hormone levels between 10.0 and 11.9 IU/L

OBJECTIVE

To evaluate the results of the in vitro fertilization (IVF) cycle outcomes in women whose borderline basal follicle stimulating hormone (FSH) levels were between 10.0 and 11.9 IU/L and to analyze the predictors of pregnancy in this population.

MATERIAL AND METHODS

A prospective cohort study was performed at an academic teaching hospital; participants were infertile couples in which the women were undergoing IVF treatment and had borderline basal highest FSH levels between 10.0 and 11.9 IU/L. Statistical modeling was performed to determine risk factors for pregnancy and clinical pregnancy.

RESULTS

A clinical pregnancy rate of 26.5% per cycle and 35% per patient was found in the study population. Among all subjects and non-intracytoplasmic sperm injection (ICSI) subjects, younger age, higher gravidity, higher number of mature follicles on day of Human Chorionic gonadotrophin (hCG) triggering, higher number of oocytes retrieved, and number of embryos produced were significant discriminators between individuals who conceived and those who did not. However, only the number of embryos predicted those who had a clinical pregnancy when compared with those who did not. Higher gravidity, and basal estradiol (E2) levels, and lower maximum basal FSH levels predicted clinical pregnancy in non-ICSI patients. Among ICSI patients, the only predictor of pregnancy was a thicker endometrium. A trend towards higher pregnancy rates was noted in ICSI patients.

CONCLUSION

We showed that pregnancy rates per cycle and per patient in this population were not significantly different than those in patients with a basal FSH level below 10.0 IU/L. Preliminary evidence suggests that ICSI is the fertilization method of choice in these patients.

A comparison of biochemical pregnancy rates between women who underwent IVF and fertile controls who conceived spontaneously†

STUDY QUESTION

Does IVF affect the biochemical pregnancy rate?

SUMMARY ANSWER

The likelihood of an early pregnancy loss may be lower and is certainly not higher in IVF cycles when compared with published rates of biochemical pregnancy in fertile women ≤42 years old.

WHAT IS KNOWN ALREADY

The use of gonadotrophins to stimulate multi-folliculogenesis alters endometrial expression of genes and proteins, compared with unstimulated cycles. Exogenous estrogen and progesterone taken for endometrial preparation in frozen embryo transfer cycles, also cause changes in endometrial gene and protein expression .These endometrial alterations may compromise the ability of embryos to develop once implanted, possibly increasing the biochemical pregnancy rate.

STUDY DESIGN, SIZE, DURATION

This is a retrospective study, involving 1636 fresh and 188 frozen, single embryo transfer (SET) IVF cycles performed between August 2008 and December 2012. The biochemical pregnancy rate of the 1824 combined IVF and frozen cycles were compared with fertile controls, derived from the three prospective studies in the medical literature that evaluate this rate.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Subjects ≤42-years old, who underwent a SET, as part of a fresh or thawed IVF cycle were considered for inclusion. Each subject is represented only once. The biochemical pregnancy rates were compared with those of historical standard, fertile populations with spontaneous conceptions.

MAIN RESULTS AND THE ROLE OF CHANCE

The pregnancy rates per transfer for fresh and frozen IVF cycles were similar at 39 and 40%, respectively. There was also no significant difference in the likelihood of pregnancy outcomes (clinical, biochemical and ectopic pregnancy) between fresh IVF and frozen cycles (85.4 versus 85.6%, 13.8 versus 14.8%, 0.5 versus 0%, P = 0.82). However, pregnancy rates decreased in older patients when compared with younger ones P < 0.0001. The biochemical pregnancy rate for fresh and frozen IVF cycles combined was 13.8% of all pregnancies. IVF and frozen cycles were combined as the IVF group treated with hormones for further comparison with the fertile control group. The biochemical pregnancy rate (14%) in the IVF group was lower than the rate based on the total fertile group (18%), P = 0.01 and differed significantly from the rate in two out of the three studies used to establish the normative rate. The age ranges of the IVF and fertile controls were 21-42 years. The mean age in the IVF population was 34.8 years, as compared with 29 years, 29, 4 years and 30.6 years (Zinaman) in the three published studies (mean: 29.4 years).

LIMITATIONS, REASONS FOR CAUTION

This is a retrospective study and it was impossible to recruit an in-house biochemical pregnancy control population.

WIDER IMPLICATIONS OF THE FINDINGS

Lower early pregnancy wastage after IVF may be due to the opportunity to select the embryo for transfer. This finding should be confirmed in further studies but supports the idea that embryo selection is an important step.

STUDY FUNDING/COMPETING INTERESTS

None.

Pregnancy rates with intrauterine insemination: comparing 1999 and 2010 World Health Organization semen analysis norms

Over the past 30 years, The World Health Organization has serially measured norms for human sperm. In this study, 1999 and 2010 semen analysis norms as predictors of pregnancy were compared during intrauterine insemination (IUI). A retrospective cohort study was conducted using data collected from the Stanford Fertility Center, between 2005 and 2007, with 981 couples undergoing 2231 IUI cycles. Collected semen was categorized according to total motile sperm counts (TMSC): 'normal (N.) 1999 TMSC', 'abnormal (AbN.) 1999/N. 2010 TMSC', or 'AbN. 2010 TMSC'. Sample comparison was also based on individual semen parameters: 'N. 1999 WHO', 'AbN. 1999/N. 2010 WHO', or 'AbN. 2010 WHO'. Pregnancy (defined by beta-HCG concentration) rates were calculated. Data were compared using correlation coefficients, t-tests and chi-squared tests, with and without adjusting for confounders. Pregnancy rate comparison based on TMSC ('N. 1999 TMSC', 'AbN. 1999/N. 2010 TMSC' and 'AbN. 2010 TMSC') showed a negative correlation (r = -0.41, P = 0.05). Pregnancy rate did not differ when comparisons were based on the presence of abnormal parameters, even when controlling for confounders. Therefore, TMSC based on the 1999 parameters shows best correlation with pregnancy rate for IUI; updating these norms in 2010 has little clinical implication in infertile populations.

Should IVF be used as first-line treatment or as a last resort? A debate presented at the 2013 Canadian Fertility and Andrology Society meeting

Infertility outcomes can be influenced by many factors. Although a number of treatments are offered, deciding which one to use first is a controversial topic. Although IVF may have superior efficacy in achieving a live birth with a reasonable safety profile, the availability of cheaper and less invasive treatments preclude its absolute use. For this reason, certain patient groups with 'good-prognosis' infertility are traditionally treated with less invasive treatments first. 'Good-prognosis' infertility may include unexplained infertility, mild male factor infertility, stage I or II endometriosis, unilateral tubal blockage and diminished ovarian reserve. Here, evidence behind the use of IVF as a first-line treatment is compared with its use as a last-resort option in women with 'good-prognosis' infertility.

Pituitary mass and subsequent involution causing fluctuations of serum follicle-stimulating hormone levels in a Turner syndrome patient with premature ovarian failure: a case report

BACKGROUND

Premature ovarian failure (POF) is described as estrogen deficiency, amenorrhea, and hypergonadotropinemia in a woman < 40 years old. In a proportion of patients diagnosed with POF, intermittent and unpredictable return of ovarian function can be observed, causing fluctuations of follicle-stimulating hormone (FSH). However, these patients also have return of menstrual cycles. When cycles do not resume, other causes could explain the changes in FSH levels.

CASE

A 43-year-old woman with known premature ovarian failure since age 23 and high serum FSH levels was referred for normalization of FSH levels. She did not have any resumption of menstrual cycles. Karyotype revealed a mosaicism consistent with Turner syndrome. Computed tomography of the head detected a pituitary macroadenoma which is believed to have caused a decrease in FSH production by compression of the pituitary stalk. Spontaneous involution of the mass ensued, and the patient's serum FSH returned to menopausal level accompanied by an empty sella syndrome.

CONCLUSION

In menopausal patients with low FSH and no return of menstrual cycles, further investigations should be pursued in order to exclude a possible pituitary mass.

The evaluation of pre and post processing semen analysis parameters at the time of intrauterine insemination in couples diagnosed with male factor infertility and pregnancy rates based on stimulation agent. A retrospective cohort study

OBJECTIVE

To identify pre or post processing semen analysis parameters that may be predictive of successful pregnancy in couples with male factor infertility undergoing intra uterine insemination (IUI). To evaluate the pregnancy rate based on ovulation inducing agent in couples with male factor infertility per the 2010 world health organization criteria treated with IUI.

STUDY DESIGN

This retrospective study was performed at Stanford University medical center. All couples with male factor infertility fitting inclusion criteria were included over a 2 year period of time. 147 couples with male factor infertility were included and 356 IUIs were analyzed. All subjects in this study had Kruger strict analysis >4% normal forms. Logistic regression analysis was used to control for confounding effects and multiplicity.

RESULTS

The overall pregnancy rate was 5.3%. No parameter in either the pre or post analysis predicted pregnancy. Furthermore, it was found that natural cycle and letrazole treatment had similar pregnancy rates (3% and 3%) p=ns. Similar outcomes were also observed between clomiphene citrate and gonadotropin stimulated cycles (7.5% and 6.0%) p=ns.

CONCLUSIONS

Total motile sperm count which has been found to be a predictor of pregnancy when evaluated in isolation, may be due to a confounding effect. These low pregnancy rates should be considered when deciding whether to suggest IUI and when selecting a protocol for ovulation induction for couples with male factor infertility.

Comparison of complication rates and pain scores after transvaginal ultrasound-guided oocyte pickup procedures for in vitro maturation and in vitro fertilization cycles

OBJECTIVE

To compare complication rates and pain scores after oocyte pickup (OPU) in in vitro maturation (IVM) and IVF cycles.

DESIGN

Retrospective cohort study.

SETTING

University-affiliated ART center.

PATIENT(S)

One hundred eighty-eight IVM and 188 IVF OPUs.

INTERVENTION(S)

IVM OPUs were done using a 19-gauge single-lumen needle, and IVF OPUs were done using a 17-gauge single- or 16-gauge double-lumen needles.

MAIN OUTCOME MEASURE(S)

Duration of OPU, complication rates, and pain scores during the OPU procedure.

RESULT(S)

IVM OPU took significantly more time than IVF OPU (22 vs. 15 minutes). Two women in the IVM and four in the IVF group experienced bleeding from the vaginal wall or ovary. None of them required hospitalization, transfusion, or an operative intervention. One patient in each group had pelvic infection. Severe post-OPU abdominal pain occurred in one patient in the IVM group and five patients in the IVF group. No differences were found between pain scores in the IVF and IVM groups (3.4 vs. 3.8).

CONCLUSION(S)

Although IVM OPU requires more punctures per ovary, it is well tolerated and does not seem to be associated with a higher complication rate than IVF OPU.

Twice-daily dosing of gonadotropins does not improve embryo quality during in vitro fertilization cycles in women with polycystic ovary syndrome, when compared to once-daily dosing: a pilot study

PURPOSE

To determine whether overexpression of the FSH receptor in polycystic ovary syndrome (PCOS) results in a relative deficiency of gonadotropins and poor oocyte and embryo quality during in vitro fertilization (IVF) cycles. Whether twice-daily dosing of gonadotropins could therefore result in improved embryo quality, by fixing this hypothesized relative deficiency of gonadotropins.

METHOD

Embryos generated at a university-based fertility center in women with PCOS were compared from twice-daily dosing to once-daily dosing of gonadotropins during IVF cycles. Oocyte and embryo quality was compared. A single patient's embryos were included in the analysis from only one IVF cycle and all embryos from that cycle were included. 254 embryos were compared.

RESULTS

Twice-daily vs. once-daily dosing of gonadotropins does not improve embryo or oocyte quality in women with PCOS.

CONCLUSIONS

The defect in response to gonadotropins in PCOS is most likely due to an inherent defect in the ovary and not a relative deficiency of gonadotropins due to overexpression of the FSH receptors. More studies are needed to confirm this finding.

A comparison of outcomes from in vitro fertilization cycles stimulated with either recombinant luteinizing hormone (LH) or human chorionic gonadotropin acting as an LH analogue delivered as human menopausal gonadotropins, in subjects with good or poor ovarian reserve: a retrospective analysis

OBJECTIVES

To compare rates of pregnancy and IVF parameters in subjects who were stimulated with FSH plus recombinant human luteinizing hormone or menopausal gonadotropins. To determine whether responses to type of LH differ in poor or good responders.

STUDY DESIGN

Retrospective analysis at a university-based fertility center. Subjects were women with good and poor ovarian reserve, who underwent in vitro fertilization during a 2 year period, as part of a long agonist (N=122), or microdose flair (N=79) protocol. Measurements included FSH and LH dose, number of oocytes collected, number of embryos obtained, and pregnancy and clinical pregnancy rates.

RESULTS

Patients treated with r-hLH (n=105) had higher numbers of eggs retrieved and of embryos while using less FSH than their hMG-treated (n=96) counterparts. Pregnancy and clinical pregnancy rates were significantly higher with r-hLH than with hMG protocols (p=0.008 and 0.009, respectively). If patients had a baseline serum FSH level ≥10IU/L, clinical pregnancy rates were higher when r-hLH was used. When the antral follicle count was below 6 no significant differences in stimulation parameters or outcomes were detected between the groups.

CONCLUSION

r-hLH may be beneficial when compared to hMG and used for in-vitro fertilization, except in subjects with baseline follicle counts less than 6. Further data should be obtained.

Severe early ovarian hyperstimulation syndrome following GnRH agonist trigger with the addition of 1500 IU hCG

STUDY QUESTION

Is severe early ovarian hyperstimulation syndrome (OHSS) completely prevented with the GnRH agonist trigger and 1500 IU hCG luteal rescue protocol?

SUMMARY ANSWER

Severe early OHSS can occur even after the GnRH agonist trigger and 1500 IU hCG luteal rescue protocol.

WHAT IS KNOWN ALREADY

Prior studies including over 200 women who received the GnRH agonist trigger and 1500 hCG luteal rescue protocol have reported complete prevention of severe early OHSS. Only a few late OHSS cases have been reported and it has been suggested that this protocol can be safely applied to any women under risk.

STUDY DESIGN, SIZE, DURATION

This retrospective cohort study included all women who were at high risk of OHSS and were given the GnRH agonist trigger plus hCG luteal rescue protocol between December 2008 and August 2012 in the two participating centers.

PARTICIPANTS/MATERIALS, SETTING, METHODS

There were 23 women with a mean estradiol level of 4891 ± 2214 pg/ml and a mean number of >12 mm follicles of 20 ± 6 on the day of ovulation triggering. OHSS was categorized according to the Golan criteria.

MAIN RESULTS AND THE ROLE OF CHANCE

Overall 6 of the 23 (26%) women developed severe OHSS. Five women had severe early OHSS requiring ascites drainage and hospitalization and three of these women did not undergo embryo transfer. The number of follicles measuring 10-14 mm on the day of triggering was significantly different between women who developed severe early OHSS and those who did not.

LIMITATIONS, REASONS FOR CAUTION

The small number of women with severe early OHSS may have prevented identification of other significant risk factors.

WIDER IMPLICATIONS OF THE FINDINGS

Although the GnRH agonist plus 1500 IU hCG luteal rescue protocol significantly decreases the risk of severe OHSS, this life threatening complication can still occur in high-risk patients. It would be prudent to avoid hCG luteal rescue and freeze all embryos for future transfer in such women particularly when there are ≥18 follicles with 10-14 mm diameters even with few larger follicles.

Transvaginal ligation of the cervical branches of the uterine artery and injection of vasopressin in a cervical pregnancy as an initial step to controlling hemorrhage: a case report

BACKGROUND

Hemorrhage from a cervical pregnancy is a time-sensitive matter. Effective temporization measures for the initial management of this hemorrhage have not previously been reported in the literature.

CASE

A 43-year-old woman, gravida 0, underwent in vitro fertilization and embryo transfer. She subsequently presented to the office with sudden onset of vaginal hemorrhage due to a cervical pregnancy. Cervical artery sutures were placed, and a cervical vasoconstricting agent was injected, at which point the patient's bleeding stopped. She then underwent successful treatment with dilation and curettage.

CONCLUSION

Conservative measures to manage hemorrhage due to cervical pregnancy can be initiated, with possible rapid establishment of hemostasis until definitive treatment can be achieved.

A comparison of letrozole to gonadotropins for ovulation induction in subjects with advanced maternal age: a retrospective pilot study

This retrospective study was performed to compare the success of ovulation induction using letrozole versus gonadotropins in women at least 38 years of age, with normal ovarian reserve. Pregnancy and clinical pregnancy rates (PR) were statistically higher with gonadotropin than with letrozole stimulation.

Circulating and cellular adiponectin in polycystic ovary syndrome: relationship to glucose tolerance and insulin action

OBJECTIVE

To evaluate serum adiponectin levels and organization into multimers in women with polycystic ovary syndrome (PCOS) and assess relationships between adiponectin, glucose tolerance, and insulin resistance.

DESIGN

In vivo and in vitro study.

SETTING

Outpatient clinic at university and Veterans hospitals in the United States and university laboratory.

PATIENT(S)

Thirty-one obese women with PCOS and six age- and body mass index (BMI)-matched normal cycling control subjects.

INTERVENTION(S)

All subjects studied in the fasting state.

MAIN OUTCOME MEASURE(S)

A 75-g oral glucose tolerance test (OGTT), hyperinsulinemic/euglycemic clamp, circulating adiponectin levels, adipocyte adiponectin content, and organization of adiponectin into multimeric forms.

RESULT(S)

Whole body insulin action (glucose disposal rate, 5.61 +/- 2.90 vs. 8.79 +/- 0.81 mg/kg/min, PCOS and control) and adiponectin levels (9.5 +/- 0.7 7 vs. 17.4 +/- 1 microg/mL, PCOS vs. control) were significantly reduced in the subjects with PCOS. There were significant correlations between glucose tolerance, insulin action, and circulating adiponectin levels in all subjects. The content of adiponectin protein was reduced in subcutaneous adipocytes from subjects with PCOS (252 +/- 31 vs. 388 +/- 58 arbitrary units/10 microg protein). Subjects with PCOS had less of their circulating adiponectin organized into high molecular weight (HMW) multimeric complexes. Glucose-intolerant subjects with PCOS also had less intracellular HMW adiponectin.

CONCLUSION(S)

Both circulating adiponectin levels and the portion present as the most active HMW form are reduced in PCOS, with differences related to the degree of glucose intolerance and insulin resistance.

The effect of infertility medication on thyroid function in hypothyroid women who conceive

OBJECTIVE

To determine whether infertility medications alter thyroid status in patients with treated hypothyroidism, and whether resulting pregnancies require additional thyroid supplementation compared with those conceived spontaneously.

DESIGN

Prospective observational study of 18 infertility patients with treated hypothyroidism who conceived between July 2005 and July 2006 with or without infertility medications. Thyroid studies were performed prior to conception, at the time of pregnancy diagnosis, and approximately 6 weeks after an increase in thyroid replacement dose.

MAIN OUTCOME

Orally medicated conceptions were similar to spontaneous conceptions on all thyroid related variables, and therefore the two groups were combined for analysis. Although there was a nonsignificant difference in thyrotropin (TSH) levels postconception (3.8 mIU/L vs. 2.2 mIU/L, p = 0.30), there was no difference in TSH levels after increase in thyroid replacement dose (1.7 mIU/L vs. 1.1 mIU/L, p = 0.30) between patients who conceived after gonadotropin stimulation compared with those who conceived spontaneously or with oral medications. The mean percent dose increases for the nongonadotropin and gonadotropin pregnancy groups were 30.6% and 32.4%, respectively.

CONCLUSIONS

Hypothyroid patients who conceive after gonadotropin stimulation or with oral medications for ovulation induction do not need additional thyroid supplementation compared with those who conceive spontaneously.

Serum total testosterone levels in a patient with late onset 21-hydroxylase deficiency and a twin gestation

OBJECTIVE

To present serum androgen levels during pregnancy in a twin gestation complicated by maternal late onset 21-hydroxylase deficiency.

DESIGN

Case report.

SETTING

University teaching hospital reproductive endocrinology and infertility practice.

PATIENT(S)

A 27-year-old with nonclassic 21-hydroxylase deficiency and infertility, twin female fetuses, and elevated androgens.

INTERVENTION(S)

Steroid replacement.

MAIN OUTCOME MEASURE(S)

Serum T and 17-hydroxyprogesterone (17-OHP) levels.

RESULT(S)

Elevated androgen levels persisted throughout pregnancy in spite of aggressive steroid replacement. However, twin girls were born without any evidence of virilization.

CONCLUSION(S)

The changes associated with a twin gestation may result in excessive stimulation of androgens in mothers with nonclassic 21-hydroxylase deficiency. However, the increased placental aromatase provides protection.

A randomized, prospective study comparing laser-assisted hatching and assisted hatching using acidified medium

OBJECTIVE

To compare the clinical outcomes of patients whose transferred embryos underwent either laser-assisted hatching or hatching with acidified medium.

DESIGN

Randomized, prospective, double-blinded study.

SETTING

University-based IVF center.

PATIENT(S)

Clinical outcomes following IVF were compared in 159 patient cycles who randomly had all transferred embryos undergo laser-assisted hatching (Laser; n = 57) or hatching with acidified medium (Acid; n = 54). Patients whose embryos had zonae thickness <13 mum were not hatched (Thin; n = 8) and patients with > or =4 embryos at the 7- to 8-cell stage or higher on Day 3 were transferred on Day 5 (Day 5; n = 40).

MAIN OUTCOME MEASURE(S)

Implantation rates, clinical pregnancy rates, ongoing pregnancy rates, multiple pregnancy rates.

RESULT(S)

No significant differences were noted in clinical, ongoing, or multiple pregnancy rates between the four groups. The implantation rate for Day 5 transfers was significantly greater than both the Laser and Acid treatment groups.

CONCLUSION

The use of a 1.48-micron infrared diode laser beam provides a safe and rapid method for performing assisted hatching and did not have a negative impact on patient care when compared to outcomes achieved using acidified medium.

Serum sex hormone-binding globulin levels show too much variability to be used effectively as a screening marker for insulin resistance in women with polycystic ovary syndrome

OBJECTIVE

To evaluate the relationship between serum sex hormone-binding globulin (SHBG) and parameters of insulin sensitivity in women with polycystic ovary syndrome (PCOS) and controls, and determine the feasibility of using SHBG levels to predict insulin resistance.

DESIGN

Evaluation of a prospectively collected database.

SETTING

University reproductive center.

PATIENT(S)

A total of 21 women with PCOS and 17 controls.

INTERVENTION(S)

Oral glucose tolerance test.

MAIN OUTCOME MEASURE(S)

Correlations of serum SHBG and parameters of insulin sensitivity.

RESULT(S)

[1] Among all participants, SHBG levels indicated a correlation between the fasting glucose-to-insulin (GI) ratio and the quantitative insulin sensitivity check index (QUICKI). Participants with PCOS demonstrated significant correlations of SHBG and fasting GI ratio, 1-hour postglucola insulin levels, and random 17-hydroxyprogesterone (17ohP4) levels. Among controls, SHBG and fasting serum glucose and 2-hour postglucola serum glucose levels were associated. [2] Participants with PCOS and lean controls exhibited different glucose and insulin responses to 75 g of glucose at 1 and 2 hours postchallenge, resulting in paradoxically similar GI ratios.

CONCLUSION(S)

[1] Although certain parameters of insulin status and serum SHBG demonstrated statistically significant correlation coefficients, these relationships are weak and SHBG cannot be used as a predictor of insulin resistance. [2] The post-glucose load GI ratio cannot be used to determine the magnitude of insulin resistance.

Congenital interruption of the ampullary portion of the fallopian tube

We present a rare case of a congenital isolated missing segment of the fallopian tube, including hysterosalpingographic and laparoscopic images. We conclude that when this occurs without concomitant müllerian anomalies, the mechanism of development would not be expected to be associated with an increase in renal abnormalities.

Risk of surgery after use of potassium chloride for treatment of tubal heterotopic pregnancy

BACKGROUND

Spontaneous heterotopic pregnancies are rare, but with assisted reproductive techniques the incidence may approach 1:100. With the widespread use of transvaginal ultrasonography, physicians have attempted treatment of heterotopic pregnancies with minimally invasive procedures such as transvaginal guided potassium chloride (KCl) injection. However, there are few data on the success of this treatment.

CASE

A 30-year-old primigravida presented with a desired pregnancy and was found to have a tubal pregnancy in addition to an intrauterine pregnancy. Ultrasound-guided KCl injection into the heterotopic pregnancy was complicated by abdominal pain, surgical abdomen, and hemoperitoneum requiring salpingectomy.

CONCLUSION

A review of the literature revealed that 55% of tubal heterotopic pregnancies treated by KCl injection required subsequent salpingectomy. This raises concerns about the advisability of this treatment.

Radiologic and surgical demonstration of uterine polyposis

We describe a rare case of uterine polyposis that was visualized by sonohysterogram, hysterosalpingogram, and hysteroscopy.

Fetal weight, maternal age and height are poor predictors of the need for caesarean section for arrest of labor

Retrospective data on 228 patients was analyzed in order to develop a predictive model of operative delivery, caesarean section for arrest of labor. The ANOVA, discriminant analysis and the Fisher discriminant function of SPSS were used. Birth weight, maternal age and maternal height were statistically significant risk factors, but only 10.9% of caesarean sections could be predicted with these variables. Seven percent of patients who delivered vaginally were predicted as needing a caesarean section for arrest of labor.

Programming Ovulation Using Estrogens for Patients to Time Intercourse

BACKGROUND

A woman wishing to conceive may be separated from her spouse at the time of ovulation. Moreover, some orthodox Jewish women have a unique problem when they are unable to initiate intercourse before ovulation. They are prohibited from participating in sexual relations from the start of menstruation until 7 days after the end of flow when they go to the ritual bath (mikveh).

CASES

Two orthodox Jewish women who ovulated before restarting intercourse were treated with oral estrogens to delay ovulation.

CONCLUSION

Women separated from their husbands at the time of ovulation and Jewish women who ovulate before ritual cleansing can effectively use oral estrogens to program ovulation.