Evaluation of costs associated with fertility treatment leading to a live birth after one fresh transfer: A global perspective

Considerable costs are associated with infertility treatment, but little evidence is available on the main drivers of treatment costs. This cost analysis investigated key costs for treatment with assisted reproductive technology (ART) and the proportion of costs attributed to the acquisition of recombinant human follicle-stimulating hormone (r-hFSH) alfa originator for one fresh embryo transfer (ET) leading to a live birth in Spain, Norway, the UK, Germany, Denmark, South Korea, Australia, and New Zealand. The total costs for one ART cycle with a fresh ET leading to a live birth varied between countries (€4108-€12,314). Costs for pregnancy and live birth were the major contributors in European countries, and the costs of oocyte retrieval, monitoring during ovarian stimulation, pregnancy, and live birth were the top contributors in the Asia-Pacific countries, included in this analysis. Acquisition costs for r-hFSH alfa originator contributed to only 5%-17% of the total costs of one ART cycle with one fresh ET leading to a live birth.

Pathogens identified in the internal tissues and placentas of stillbirths: results from the prospective, observational PURPOSe study

OBJECTIVE

To examine internal organ tissues and placentas of stillbirths for various pathogens.

DESIGN

Prospective, observational study.

SETTINGS

Three study hospitals in India and a large maternity hospital in Pakistan.

POPULATION

Stillborn infants delivered in a study hospital.

METHODS

A prospective observational study.

MAIN OUTCOME MEASURES

Organisms identified by pathogen polymerase chain reaction (PCR) in internal organs and placental tissues of stillbirths.

RESULTS

Of 2437 stillbirth internal tissues, 8.3% (95% CI 7.2-9.4) were positive. Organisms were most commonly detected in brain (12.3%), cerebrospinal fluid (CSF) (9.5%) and whole blood (8.4%). Ureaplasma urealyticum/parvum was the organism most frequently detected in at least one internal organ (6.4% of stillbirths and 2% of all tissues). Escherichia coli/Shigella was the next most common (4.1% one or more internal organ tissue sample and 1.3% of tissue samples), followed by Staphylococcus aureus in at least one internal organ tissue (1.9% and 0.9% of all tissues). None of the other organisms was found in more than 1.4% of the tissue samples in stillbirths or more than 0.6% of the internal tissues examined. In the placenta tissue, membrane or cord blood combined, 42.8% (95% CI 40.2-45.3) had at least one organism identified, with U. urealyticum/parvum representing the most commonly identified (27.8%).

CONCLUSIONS

In about 8% of stillbirths, there was evidence of a pathogen in an internal organ. Ureaplasma urealyticum/parvum was the most common organism found in the placenta and in the internal tissues, especially in the fetal brain.

COVID-19 pandemic underscores role of green space in urban carbon dynamics

For Detroit Michigan the arrival of COVID-19 led to intensive measures to prevent further spread of the virus resulting in consequent changes in traffic and energy use. We take advantage of these different emission scenarios to explore CO₂ dynamics in a postindustrial city with a declining population and increasing green space. We present atmospheric CO₂ concentration and net urban ecosystem exchange of CO₂ (NUE) from a typical eddy covariance system and canopy greenness from a field camera on the Wayne State University campus in midtown Detroit. We categorized our study period (January 18, 2020-July 31, 2020) into three subperiods associated with the state-wide shelter-in-place order. Our results support that the city was a net carbon source throughout the period, particularly during the shelter-in-place period, although reduced traffic lowered CO₂ concentrations and NUE. However, during the post-order period when traffic was highest, atmospheric CO₂ concentrations and NUE were lowest, suggesting that the greening of urban vegetation may have greater carbon mitigation potential than lowering anthropogenic carbon emissions through traffic reductions.

Genomic testing for copy number and single nucleotide variants in spermatogenic failure

PURPOSE

To identify clinically significant genomic copy number (CNV) and single nucleotide variants (SNV) in males with unexplained spermatogenic failure (SPGF).

MATERIALS AND METHODS

Peripheral blood DNA from 97/102 study participants diagnosed with oligozoospermia, severe oligozoospermia, or non-obstructive azoospermia (NOA) was analyzed for CNVs via array comparative genomic hybridization (aCGH) and SNVs using whole-exome sequencing (WES).

RESULTS

Of the 2544 CNVs identified in individuals with SPGF, > 90% were small, ranging from 0.6 to 75 kb. Thirty, clinically relevant genomic aberrations, were detected in 28 patients (~ 29%). These included likely diagnostic CNVs in 3/41 NOA patients (~ 7%): 1 hemizygous, intragenic TEX11 deletion, 1 hemizygous DDX53 full gene deletion, and 1 homozygous, intragenic STK11 deletion. High-level mosaicism for X chromosome disomy (~ 10% 46,XY and ~ 90% 47,XXY) was also identified in 3 of 41 NOA patients who previously tested normal with conventional karyotyping. The remaining 24 CNVs detected were heterozygous, autosomal recessive carrier variants. Follow-up WES analysis confirmed 8 of 27 (30%) CNVs (X chromosome disomy excluded). WES analysis additionally identified 13 significant SNVs and/or indels in 9 patients (~ 9%) including X-linked AR, KAL1, and NR0B1 variants.

CONCLUSION

Using a combined genome-wide aCGH/WES approach, we identified pathogenic and likely pathogenic SNVs and CNVs in 15 patients (15%) with unexplained SPGF. This value equals the detection rate of conventional testing for aneuploidies and is considerably higher than the prevalence of Y chromosome microdeletions. Our results underscore the importance of comprehensive genomic analysis in emerging diagnostic testing of complex conditions like male infertility.

Regional and annual patterns in respiratory virus co-infection etiologies and antibiotic prescriptions for pediatric mycoplasma pneumoniae pneumonia

OBJECTIVE

Mycoplasma pneumoniae (M. pneumoniae) pneumonia is the second-most common cause of community-acquired pneumonia (CAP). This study aimed at investigating into the prevalence of macrolide-resistant M. pneumoniae (MRMP) with respiratory virus co-infection and the antibiotic prescriptions in children with CAP in four provinces in Korea, and to assess the variations in the findings across regions and throughout the year.

PATIENTS AND METHODS

This prospective study was conducted in 29 hospitals in Korea between July 2018 and June 2020. Among the enrolled 1,063 children with CAP, all 451 patients with M. pneumoniae underwent PCR assays of M. pneumoniae and respiratory viruses, and the presence of point mutations of residues 2063 and 2064 was evaluated.

RESULTS

Gwangju-Honam (88.6%) showed the highest prevalence of MRMP pneumonia, while Daejeon-Chungcheong (71.3%) showed the lowest, although the differences in prevalence were not significant (p=0.074). Co-infection of M. pneumoniae pneumonia and respiratory virus was observed in 206 patients (45.4%), and rhinovirus co-infection (101 children; 22.2%) was the most frequent. The prevalence of MRMP pneumonia with respiratory virus co-infection and the antibiotic prescriptions differed significantly among the four provinces (p < 0.05). The monthly rate of MRMP pneumonia cases among all cases of M. pneumoniae pneumonia and tetracycline or quinolone prescriptions did not differ significantly among the four regions (trend p > 0.05) during the study period.

CONCLUSIONS

The prevalence of M. pneumoniae pneumonia with virus co-infection and antibiotic prescriptions could differ according to region, although the MRMP pneumonia rate showed no difference within Korea.

Preventable stillbirths in India and Pakistan: a prospective, observational study

OBJECTIVE

Stillbirths occur 10-20 times more frequently in low-income settings compared with high-income settings. We created a methodology to define the proportion of stillbirths that are potentially preventable in low-income settings and applied it to stillbirths in sites in India and Pakistan.

DESIGN

Prospective observational study.

SETTING

Three maternity hospitals in Davangere, India and a large public hospital in Karachi, Pakistan.

POPULATION

All cases of stillbirth at ≥20 weeks of gestation occurring from July 2018 to February 2020 were screened for participation; 872 stillbirths were included in this analysis.

METHODS

We prospectively defined the conditions and gestational ages that defined the stillbirth cases considered potentially preventable. Informed consent was sought from the parent(s) once the stillbirth was identified, either before or soon after delivery. All information available, including obstetric and medical history, clinical course, fetal heart sounds on admission, the presence of maceration as well as examination of the stillbirth after delivery, histology, and polymerase chain reaction for infectious pathogens of the placenta and various fetal tissues, was used to assess whether a stillbirth was potentially preventable.

MAIN OUTCOME MEASURES

Whether a stillbirth was determined to be potentially preventable and the criteria for assignment to those categories.

RESULTS

Of 984 enrolled, 872 stillbirths at ≥20 weeks of gestation met the inclusion criteria and were included; of these, 55.5% were deemed to be potentially preventable. Of the 649 stillbirths at ≥28 weeks of gestation and ≥1000 g birthweight, 73.5% were considered potentially preventable. The most common conditions associated with a potentially preventable stillbirth at ≥28 weeks of gestation and ≥1000 g birthweight were small for gestational age (SGA) (52.8%), maternal hypertension (50.2%), antepartum haemorrhage (31.4%) and death that occurred after hospital admission (15.7%).

CONCLUSIONS

Most stillbirths in these sites were deemed preventable and were often associated with maternal hypertension, antepartum haemorrhage, SGA and intrapartum demise.

TWEETABLE ABSTRACT

Most stillbirths are preventable by better care for women with hypertension, growth restriction and antepartum haemorrhage.

Investigation of a Novel Decision Support Metric for Head and Neck Adaptive Radiation Therapy Using a Real-Time In Vivo Portal Dosimetry System

In adaptive radiation therapy of head and neck cancer, any significant anatomical changes observed are used to adapt the treatment plan to maintain target coverage without elevating the risk of xerostomia. However, the additional resources required for adaptive radiation therapy pose a challenge for broad-based implementation. It is hypothesized that a change in transit fluence is associated with volumetric change in the vicinity of the target and therefore can be used as a decision support metric for adaptive radiation therapy. This was evaluated by comparing the fluence with volumetric changes in 12 patients. Transit fluence was measured by an in vivo portal dosimetry system. Weekly cone beam computed tomography was used to determine volume change in the rectangular region of interest from condyloid process to C6. The integrated transit fluence through the region of interest on the day of the cone beam computed tomography scan was calculated with the first treatment as the baseline. The correlation between fluence change and volume change was determined. A logistic regression model was also used to associate the 5% region of interest volume reduction replanning trigger point and the fluence change. The model was assessed by a chi-square test. The area under the receiver-operating characteristic curve was also determined. A total of 46 pairs of measurements were obtained. The correlation between fluence and volumetric changes was found to be -0.776 (P value <.001). The negative correlation is attributed to the increase in the photon fluence transport resulting from the volume reduction. The chi-square of the logistic regression was found to be 17.4 (P value <.001). The area under the receiver-operating characteristic curve was found to be 0.88. Results indicate the change in transit fluence, which can be measured without consuming clinical resources or requiring additional time in the treatment room, can be used as a decision support metric for adaptive therapy.

P14.104 The outcomes of conservatively observed asymptomatic nonfunctioning pituitary adenomas with optic nerve compression

BACKGROUND

We investigated the natural history of asymptomatic nonfunctioning pituitary adenomas (NFPAs) abutting on optic nerve.

MATERIAL AND METHODS

Eighty-three patients with asymptomatic NFPAs with documented optic nerve compression on magnetic resonance imaging (MRI) at the time of detection between 2000 and 2016 were included in this study. Patients were evaluated with a hormone test, visual acuity test, visual field test and MRI at the time of diagnosis, and then, yearly, without any treatment (including surgery and radiation).

RESULTS

The mean age was 57.7±13.6 (range, 15 - 81) years. The mean follow-up duration was 66.6±39.0 (range, 12 - 184) months. Tumor volume growth ≥ 20% was observed in 64 (77.1%) patients. Ten (12.2%) patients experienced any kind of hormonal dysfunction, and gonadotropin deficiency was the most common type of hormonal deficiency [n=9 (10.8%)]. Visual deterioration quantified by Visual Impairment Scale was seen 27 (32.5%) patients. There was no statistically significant factor for tumor growth or visual aggravation. Fourteen (16.9%) patients eventually underwent tumor resection. From multivariate analysis, the significant predictors for eventual surgical intervention were cavernous sinus invasion (OR=20.95; 95% CI, 2.754–159.3; p=0.003) and last follow-up visual field defect score (OR=1.170; 95% CI, 1.049–1.305; p=0.005). All patients who underwent surgery did not experience any neurologic or endocrinological deficits postoperatively.

CONCLUSION

The clinical outcomes of conservatively observed NFPAs with optic nerve compression can be acceptable. The decision for surgical intervention should be made by balancing the risk and benefits.

High-quality human and rat spermatozoal RNA isolation for functional genomic studies

Sperm RNA is a sensitive monitoring endpoint for male reproductive toxicants, and a potential biomarker to assess male infertility and sperm quality. However, isolation of sperm RNA is a challenging procedure due to the heterogeneous population of cells present in the ejaculate, the low yield of RNA per spermatozoon, and the absence of 18S and 28S ribosomal RNA subunits. The unique biology of spermatozoa has created some uncertainty in the field about RNA isolation methods, indicating the need for rigorous quality control checks to ensure reproducibility of data generated from sperm RNA. Therefore, we developed a reliable and effective protocol for RNA isolation from rat and human spermatozoa that delivers highly purified and intact RNA, verified using RNA-specific electrophoretic chips and molecular biology approaches such as RT-PCR and Western blot analysis. The sperm RNA isolation technique was optimized using rat spermatozoa and then adapted to human spermatozoa. Three steps in the sperm isolation procedure, epididymal fluid collection, sperm purification, and spermatozoon RNA extraction, were evaluated and assessed. The sperm RNA extraction methodology consists of collection of rat epididymal fluid with repeated needle punctures of the epididymis, somatic cell elimination using detergent-based somatic cell lysis buffer (SCLB) and the use of RNA isolation Kit. Rat sperm heads are more resistant to disruption than human spermatozoa, necessitating the addition of mechanical lysis with microbeads and heat in the rat protocol, whereas the human sperm protocol only required lysis buffer. In conclusion, this methodology results in reliable and consistent isolation of high-quality sperm RNA. Using this technique will aid in translation of data collected from animal models, and reproducibility of clinical assessment of male factor fertility using RNA molecular biomarkers.

The Impact of Maternal Body Mass Index and Gestational Age on the Detection of Uterine Contractions by Tocodynamometry: A Retrospective Study

OBJECTIVE

To examine the impact of maternal body mass index (BMI) and gestational age (GA) on uterine contraction detection by tocodynamometry.

METHODS

Gravidas with preterm labor (PTL) complaints who were evaluated by tocodynamometry, discharged from Labor and Delivery triage, and subsequently readmitted for preterm delivery were studied. Forty-six patients in whom contractions were detected (group 1) were compared to 49 women in whom contractions were not detected (group 2) with respect to BMI and GA at both evaluation and delivery. Multivariable logistic regression was used to adjust for confounders.

RESULTS

Group 2 had a higher mean BMI (31.7 vs 26.1, P < .001), were more likely to be obese (57.1% vs 19.6%, P < .001), and were more likely to have been evaluated in the mid-trimester (36.7% vs 17.4%, P = .04) compared to group 1. Independent risk factors for the inability of the tocodynamometer to detect contractions were obesity (odds ratio [OR] 0.18, 95% confidence interval [CI] 0.07-0.46) and evaluation in the mid-trimester (OR 0.33, 95% CI 0.13-0.84).

CONCLUSION

Our study provides evidence that the effectiveness of tocodynamometry diminishes with increasing maternal BMI. Efficacy of tocodynamometry is also decreased at earlier GA, most pronounced below 25 weeks. To evaluate women with PTL symptoms in the mid-trimester or symptomatic obese women at any GA, a modality other than tocodynamometry could be valuable to more accurately assess uterine activity.

Intra- and inter-individual differences in human sperm DNA methylation

There is growing evidence that sperm DNA methylation is important in maintaining proper sperm health and function. Previous studies have associated sperm DNA methylation levels with sperm quality and function, however, little is known regarding the intra- and inter-individual variability in sperm methylation levels. This study characterizes this variation. Sperm epigenetic differences between successive semen samples from 12 patients were examined to identify the intra- and inter-individual differences globally across the genome, and in specifically defined genomic regions using the Illumina Infinium HumanMethylation450 BeadChips. Methylation analysis identified a bimodal distribution in the methylation levels that were non-uniformly distributed across the different genomic regions. The methylation levels were highly correlated in both the intra- and inter-individual comparisons. The intra-individual methylation levels were more highly correlated than the inter-individual comparison both globally and across the defined genomic regions, demonstrating that sperm DNA methylation levels are relatively stable between semen sample collections.

Estimation of the 6-digit level allele and haplotype frequencies of HLA-A, -B, and -C in Koreans using ambiguity-solving DNA typing

Because Korean society is fast becoming multi-ethnic, the determination of ambiguous human leukocyte antigen (HLA) types using HLA allele frequencies is becoming less applicable. In this study, we focused on the development of new technical methods to directly resolve the ambiguities arising from HLA genotyping. One hundred and fifty unrelated healthy Korean adults were included in this study. All alleles from each HLA locus were first divided into 2-4 groups, with each group amplified in a single PCR tube (multi-group-specific amplification, MGSA). To resolve phase ambiguities, some allele groups were also amplified separately in small group-specific amplification (SGSA) tubes. In order to then resolve incomplete sequence ambiguities, primers for MGSA and SGSA were initially designed to cover additional exons. If needed, a heterozygous ambiguity resolving primer (HARP) or sequence specific primer (SSP) was also used. When MGSA and SGSA methods were applied, the rate of phase ambiguity was greatly reduced to an average of 6% (1.3% in HLA-A, 15.7% in -B, and 2.0% in -C). Additional HARP and SSP methods could resolve all the phase ambiguities. Using our proposed method, we also detected three alleles that have not been previously reported in Korea, C*04:82, C*07:18, and C*08:22, and report 6-digit level HLA allele and haplotype frequencies among Koreans. In conclusion, the use of MGSA/SGSA for the initial amplification step is a cost-effective method facilitating timely and accurate reporting, given the continuing increase in the ethnic diversity of the Korean population. The MGSA described here can be applicable to various populations and thus could be shared by the majority of HLA typing laboratories. However, efforts to solve HLA ambiguity should continue, because SGSA, HARPs and SSPs would be specific to a particular population.

WE-G-217A-06: Spatial Accuracy Quantification of an MR System

PURPOSE

To develop a phantom and measurement protocol for quantifying spatial accuracy of an MR imaging system over its entire imaging volume.

METHODS

The measurement protocol is comprised of a phantom, a set of MR sequence parameters for imaging the phantom, and analysis software for calculating spatial errors in the acquired phantom images. The phantom covers the entire imaging volume of the scanner above the patient table. It consists of layers of tooling foam which does not produce any detectable signal on conventional MR images, embedded with a matrix of oil capsules to serve as markers. To account for possible spatial errors in the construction of the phantom, the phantom was imaged with CT to create a gold standard data set. On MR scanners, the phantom is acquired with a 3D FGRE sequence that covers an extended FOV of 61.44 mm and with bandwidth = ±62.5 kHz. Error measurements are performed by detecting markers in the image sets and identifying them based on their known locations on the phantom. The spatial error of a marker is defined as the difference between its locations on the MR and CT image sets.

RESULTS

The phantom was constructed and the measurement protocol was executed on two different MR scanners. Some markers were located in areas of severe field inhomogeneity or gradient nonlinearity, and could not be adequately detected for analysis. Maximum errors over concentric spherical regions were observed by plotting the error of each marker as a function of their distance from isocenter.

CONCLUSION

The proposed phantom and protocol can be an effective tool for verifying the spatial accuracy of an MR system, which in turn can improve the accuracy and confidence of MR guided therapies. Data from this protocol may also be used in the development of advanced distortion correction algorithms. Employed by General Electric Healthcare.

WE-G-217A-07: Increased MR Spatial Accuracy with Improved Gradient Nonlinearity and Magnet Inhomogeneity Correction

PURPOSE

To develop improved distortion correction of MR images based on higher degree spherical harmonic models of the gradient system and the main magnetic field.

METHODS

The induced field gradient along all three axes can be modeled by first order spherical harmonics. These models provide a true encoding of the physical location of a spin to the frequency at which it is detected. Currently on many commercial systems, only the lower 5 degrees of the model are used for gradient nonlinearity correction. While this provides sufficient accuracy for diagnostic imaging, the gradient nonlinearity correction was extended to include all first order harmonics up to the 9th degree to improve the spatial accuracy of the images. Using zeroth degree spherical harmonics up to the 20th order, a model of the main magnetic field was also incorporated into the correction algorithm. Shifts caused by field inhomogeneity were calculated using knowledge of the receiver bandwidth, frequency encode direction, and the magnetic field at any given point. These corrections were applied to images of a 50 cm diameter phantom, acquired with an extended FOV 3D FGRE sequence. Any improvements in spatial accuracy were measured in the resulting images.

RESULTS

Visual improvements in spatial accuracy were observed with both corrections. With standard gradient nonlinearity correction, edges of the phantom were distorted in a wave-like fashion. With accurate models, almost all of the errors at the edges of the phantom were corrected when both gradient and field homogeneity corrections were applied.

CONCLUSION

With accurate models of the gradient and magnetic field, the two greatest system-induced spatial errors can be corrected. This improved spatial accuracy enables the use of widebore MR scanners for therapy planning on large FOV images and guidance of percutaneous devices. Further applications include extended FOV imaging for combined PET-MR systems. All authors are employed by General Electric Healthcare.