The HERA (Hyper-response Risk Assessment) Delphi consensus for the management of hyper-responders in in vitro fertilization

PURPOSE

To provide agreed-upon guidelines on the management of a hyper-responsive patient undergoing ovarian stimulation (OS) METHODS: A literature search was performed regarding the management of hyper-response to OS for assisted reproductive technology. A scientific committee consisting of 4 experts discussed, amended, and selected the final statements. A priori, it was decided that consensus would be reached when ≥66% of the participants agreed, and ≤3 rounds would be used to obtain this consensus. A total of 28/31 experts responded (selected for global coverage), anonymous to each other.

RESULTS

A total of 26/28 statements reached consensus. The most relevant are summarized here. The target number of oocytes to be collected in a stimulation cycle for IVF in an anticipated hyper-responder is 15-19 (89.3% consensus). For a potential hyper-responder, it is preferable to achieve a hyper-response and freeze all than aim for a fresh transfer (71.4% consensus). GnRH agonists should be avoided for pituitary suppression in anticipated hyper-responders performing IVF (96.4% consensus). The preferred starting dose in the first IVF stimulation cycle of an anticipated hyper-responder of average weight is 150 IU/day (82.1% consensus). ICoasting in order to decrease the risk of OHSS should not be used (89.7% consensus). Metformin should be added before/during ovarian stimulation to anticipated hyper-responders only if the patient has PCOS and is insulin resistant (82.1% consensus). In the case of a hyper-response, a dopaminergic agent should be used only if hCG will be used as a trigger (including dual/double trigger) with or without a fresh transfer (67.9% consensus). After using a GnRH agonist trigger due to a perceived risk of OHSS, luteal phase rescue with hCG and an attempt of a fresh transfer is discouraged regardless of the number of oocytes collected (72.4% consensus). The choice of the FET protocol is not influenced by the fact that the patient is a hyper-responder (82.8% consensus). In the cases of freeze all due to OHSS risk, a FET cycle can be performed in the immediate first menstrual cycle (92.9% consensus).

CONCLUSION

These guidelines for the management of hyper-response can be useful for tailoring patient care and for harmonizing future research.

The HERA (Hyper-response Risk Assessment) Delphi consensus definition of hyper-responders for in-vitro fertilization

PURPOSE

To provide an agreed upon definition of hyper-response for women undergoing ovarian stimulation (OS)?

METHODS

A literature search was performed regarding hyper-response to ovarian stimulation for assisted reproductive technology. A scientific committee consisting of 5 experts discussed, amended, and selected the final statements in the questionnaire for the first round of the Delphi consensus. The questionnaire was distributed to 31 experts, 22 of whom responded (with representation selected for global coverage), each anonymous to the others. A priori, it was decided that consensus would be reached when ≥ 66% of the participants agreed and ≤ 3 rounds would be used to obtain this consensus.

RESULTS

17/18 statements reached consensus. The most relevant are summarized here. (I) Definition of a hyper-response: Collection of ≥ 15 oocytes is characterized as a hyper-response (72.7% agreement). OHSS is not relevant for the definition of hyper-response if the number of collected oocytes is above a threshold (≥ 15) (77.3% agreement). The most important factor in defining a hyper-response during stimulation is the number of follicles ≥ 10 mm in mean diameter (86.4% agreement). (II) Risk factors for hyper-response: AMH values (95.5% agreement), AFC (95.5% agreement), patient's age (77.3% agreement) but not ovarian volume (72.7% agreement). In a patient without previous ovarian stimulation, the most important risk factor for a hyper-response is the antral follicular count (AFC) (68.2% agreement). In a patient without previous ovarian stimulation, when AMH and AFC are discordant, one suggesting a hyper-response and the other not, AFC is the more reliable marker (68.2% agreement). The lowest serum AMH value that would place one at risk for a hyper-response is ≥ 2 ng/ml (14.3 pmol/L) (72.7% agreement). The lowest AFC that would place one at risk for a hyper-response is ≥ 18 (81.8% agreement). Women with polycystic ovarian syndrome (PCOS) as per Rotterdam criteria are at a higher risk of hyper-response than women without PCOS with equivalent follicle counts and gonadotropin doses during ovarian stimulation for IVF (86.4% agreement). No consensus was reached regarding the number of growing follicles ≥ 10 mm that would define a hyper-response.

CONCLUSION

The definition of hyper-response and its risk factors can be useful for harmonizing research, improving understanding of the subject, and tailoring patient care.

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

STUDY QUESTION

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

SUMMARY ANSWER

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

WHAT IS KNOWN ALREADY

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

STUDY DESIGN, SIZE, DURATION

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

PARTICIPANTS/MATERIALS, SETTING, METHODS

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

MAIN RESULTS AND THE ROLE OF CHANCE

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

LIMITATIONS, REASONS FOR CAUTION

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

WIDER IMPLICATIONS OF THE FINDINGS

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

STUDY FUNDING/COMPETING INTEREST(S)

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

TRIAL REGISTRATION NUMBER

N/A.

P-753 Pregnancy complications and placental histology following embryo transfer with a thinner endometrium

Study question

Our objective was to assess perinatal outcomes and placental findings following in vitro fertilization (IVF) with a thinner endometrium.

Summary answer

Live births following IVF with a thinner endometrium were associated with placental mediated obstetric complications and lower birthweight, yet with no differences in placental histology.

What is known already

A lower average birth weight and higher rate of small for gestational age infants have been demonstrated in both fresh transfer and frozen transfer cycles with thinner endometrial thicknesses. Additional adverse outcomes associated with thin endometrium included hypertensive disorders of pregnancy, placenta previa, cesarean section and overall obstetric complications. Yet, no study has explored placental histology in such cases.

Study design, size, duration

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

Participants/materials, setting, methods

Data was from a university-affiliated tertiary hospital. Included were live singleton births after IVF, compared according to maximum endometrial thickness prior to transfer: thinner endometrium group, defined as < 9-millimeters, as compared to controls, defined as ≥ 9-millimeters. Outcomes were placental findings, including anatomic, inflammatory, vascular malperfusion and villous maturation lesions and obstetric and perinatal outcomes. Continuous and categorial variables were compared as appropriate, and logistic and linear regression analyses employed.to control for confounders.

Main results and the role of chance

A total 292 deliveries in the thinner endometrium group, and 765 in the control (thicker) group were compared. Maternal demographics were similar between the groups, except for main treatment indication, which was more commonly diminished reserve in patients with a thinner endometrium – 17.8% vs. 9.4%, and less commonly male factor – 27.0% vs. 35.6%, p = 0.003. Live births following fresh transfer were more common in the control group, while the thinner endometrium group was notable for a higher rate of single blastocyst transfers. When controlling for confounding effects, thinner endometrium was associated with an increased rate of obstetric complications (preterm delivery, preeclampsia, low birth weight or placental abruption) - 26.0% vs. 17.5%, p = 0.001, while placental histological examination demonstrated no differences in anatomical, inflammatory or vascular lesions. In a linear regression analysis, after adjustment for confounders, thinner endometrium was associated with lower birthweights – β -101.3 grams, 95% CI (-185.0 to -17.6 grams), p = 0.01.

Limitations, reasons for caution

The study was limited by sample size. Missing historical information included obstetric complications in previous deliveries, which would increase the risk of reoccurrence in subsequent pregnancies and data regarding endometrial trauma (curettage for example).

Wider implications of the findings

Transfer with a thinner endometrium was associated with placental mediated complications and lower birthweights, despite similar placental histology. This may result from functional placental changes throughout implantation and placentation. Preventive measures for adverse obstetric outcomes, such as Micropirin, in cases in which endometrial thicknesses are suboptimal are to be determined.

Trial registration number

Not applicable

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

RESEARCH QUESTION

What are the consequences of panhypopituitarism on pregnancy outcomes?

DESIGN

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

RESULTS

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

CONCLUSIONS

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

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

Study question

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

Summary answer

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

What is known already

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

Study design, size, duration

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

Participants/materials, setting, methods

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

Main results and the role of chance

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

Limitations, reasons for caution

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

Wider implications of the findings

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

Trial registration number

not applicable

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

Study question

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

Summary answer

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

What is known already

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

Study design, size, duration

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

Participants/materials, setting, methods

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

Main results and the role of chance

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

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

Limitations, reasons for caution

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

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

Trial registration number

NA

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

Study question

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

Summary answer

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

What is known already

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

Study design, size, duration

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

Participants/materials, setting, methods

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

Main results and the role of chance

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

Limitations, reasons for caution

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

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

Trial registration number

Not applicable

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.

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.

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.

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.