Oncologic, fertility, and obstetric outcomes with MPA therapy in women with endometrial cancer and atypical endometrial hyperplasia

AIM

Medroxyprogesterone acetate (MPA) is one of the treatments of atypical endometrial hyperplasia (AEH) and endometrial cancer (EC) to preserve the fertility. Efficacy of MPA therapy and fertility and obstetric outcomes after remission were evaluated in EC or AEH patients.

METHODS

Among patients diagnosed with EC or AEH at Tokushima University Hospital between January 2002 and October 2020, we retrospectively analyzed patients, ages range from 26 to 40, who underwent conservative management using MPA (400-600 mg/day).

RESULTS

In total, 19 patients underwent MPA therapy. The 18 (94%) patients achieved complete response (CR), and 1 (5%) patient achieved partial response (PR). Relapse occurred in 6 (32%) patients who had achieved CR. Of the patients who relapsed, 4 patients resumed MPA therapy and were in remission. Among 19 patients, 13 patients attempted pregnancy after CR. All of them underwent ovulation induction or assisted reproductive technology. As a result, 20 pregnancies in 10 (77%) patients and 12 live births in 9 (69%) patients were achieved. Rate of spontaneous abortion was 35% (7/20).

CONCLUSIONS

MPA therapy can produce a high remission rate, and be considered an effective treatment for patients who wish fertility preservation. Around 70% patients who attempt to pregnancy can have at least one baby by infertility treatments. Because recurrence rate after MPA therapy is high, it may be desirable to aim for early pregnancy by active intervention.

Applying a simplified economic evaluation approach to evaluate infertility treatments in clinical practice

IVF is the backbone of infertility treatment, but due to its costs, it is not affordable for everyone. The cost of IVF is further escalated by interventions added to the routine treatment, which are claimed to boost pregnancy rates, so-called add-ons. Consequently, it is critical to offset the increased costs of an intervention against a potentially higher benefit. Here, we propose using a simplified framework considering the cost of a standard IVF procedure to create one live-born baby as a benchmark for the cost-effectiveness of other fertility treatments, add-ons inclusive. This framework is a simplified approach to a formal economic evaluation, enabling a rapid assessment of cost effectiveness in clinical settings. For a 30-year-old woman, assuming a 44.6% cumulative live birth rate and a cost of $12 000 per complete cycle, the cost to create one live-born baby would be ∼$27 000 (i.e. willingness to pay). Under this concept, the decision whether to accept or reject a new treatment depends from an economic perspective on the incremental cost per additional live birth from the new treatment/add-on, with the $27 000 per live-born baby as a reference threshold. This threshold can vary with women's age, and other factors such as the economic perspective and risk of side effects can play a role. If a new add-on or treatment costs >$27 000 per live birth, it might be more rational to invest in a new IVF cycle rather than spending on the add-on. With the increasing number of novel technologies in IVF and the lack of a rapid approach to evaluate their cost-effectiveness, this simplified framework will help with a more objective assessment of the cost-effectiveness of infertility treatments, including add-ons.

Investigations and treatment offered to women presenting for infertility care in Harare, Zimbabwe: a cross sectional study

Introduction

clinical infertility is failure to conceive within a year of regular sexual intercourse by a non contracepting couple. Infertility care is costly and result in investigations being incomplete and inconclusive. It is therefore important to streamline investigations offered to infertile couples such that only the most cost effective tests are done. This paper explores the adequacy of investigations and treatments offered to women presenting for infertility care.

Methods

the data used in this analysis was obtained from a cross sectional sample of 216 women who presented with infertility in public and private gynaecological clinics in Harare, Zimbabwe. Information on investigations and treatment offered to women presenting for care was extracted from hospital cards, case notes, laboratory and radiological reports. Data was analysed using STATA SE/15.

Results

of the 178 (82.4%) who had ultrasound scan evaluation (USS) 50 (28.1%) had fibroids and 22 (12.4%) had polycystic ovaries. Tubal patency tests were done in 118 participants using (hystero-salpingogram) HSG alone in 62.7%, laparoscope and dye alone in 21.2% and both in 16.1% of them. Of the 97 (44.9%) men who had semen analysis 61 (62.9%) had abnormal parameters.

Conclusion

this study reveals that evaluation for tubal patency and USS to rule out reproductive organ pathology are not being offered to all women with a diagnosis of infertility. Likewise, male partner semen evaluation is not being done in all male partners. There is a high prevalence of abnormal semen parameters. Studies should be done to understand why some male partners are not forthcoming in providing semen for analysis. It is important for protocols to be produced by professional bodies which prescribe the minimum basic investigations in couples with infertility.

Fertility treatments and offspring pediatric infectious morbidities: results of a population-based cohort with a median follow-up of 10 years

OBJECTIVE

To study the association between mode of conception and offspring infectious morbidity risk.

DESIGN

Population-based cohort study.

SETTING

Regional university medical center.

PATIENT(S)

All singleton infants born between the years 1991 and 2014 and discharged alive from the hospital.

INTERVENTION(S)

Follow-up time in the study was calculated from birth to an event, defined as the first offspring hospitalization with any infectious morbidity. All infectious diagnoses were compared between the study groups, and a multivariable survival model was created to study the association between mode of conception and offspring pediatric hospitalization with infectious morbidity, and adjusting for confounding or clinically significant variables.

MAIN OUTCOME MEASURE(S)

First offspring pediatric hospitalization with infectious morbidity.

RESULT(S)

During the study period, 242,187 newborns met the inclusion criteria: 2,603 (1.1%) of which were conceived after undergoing IVF, 1,172 (0.7%) after ovulation induction (OI), and 237,863 (98.3%) were conceived spontaneously. Mothers receiving fertility treatments were older and with higher rates of preterm births and low birthweights. The hospitalizations rates per 1,000 person years of follow-up were 16.34/1,000 person years, 11.61/1,000 person years, and 10.19/1,000 person years, among the IVF, OI, and spontaneously conceived offspring, respectively. The adjusted hazard ratios were 1.26 (95% confidence interval 1.13-1.42) and 1.14 (95% confidence interval 1.00-1.38), for the IVF and OI compared with the spontaneously conceived offspring, respectively. The model adjusted for preterm delivery, birthweight, maternal age, hypertension, diabetes, and cesarean section.

CONCLUSION(S)

Higher risk for infectious morbidity was found among offspring conceived after fertility treatments compared with spontaneously conceived offspring.

PCOS and pregnancy: a review of available therapies to improve the outcome of pregnancy in women with polycystic ovary syndrome

INTRODUCTION

Polycystic ovary syndrome (PCOS) is a common cause of female infertility affecting multiple aspects of a women's health.

AREAS COVERED

The aim of this review is to summarize the existing evidence on the treatment of PCOS patients and to examine the actual available therapies to overcome the problem of infertility and improve the outcome of pregnancy. We analyse different treatment strategies such as lifestyle modification, bariatric surgery, insulin sensitizing agents, inositol, clomiphene citrate (CC), aromatase inhibitors, gonadotrophins, laparoscopic ovarian drilling, and assisted reproductive techniques (ART).

EXPERT COMMENTARY

Lifestyle modification is the best initial management for obese PCOS patients seeking pregnancy and insulin sensitizing agents seem to have an important role in treating insulin resistance. Up to now, CC maintains a central role in the induction of ovulation and it has been confirmed as the first-line treatment; the use of gonadotrophins is considered the second-line in CC resistant patients; laparoscopic ovarian drilling is an alternative to gonadotrophins in patients who need laparoscopy for another reason. However, in anovulatory patients, ART represents the only possible alternative to obtain pregnancy. Larger and well-designed studies are needed to clarify the best way to improve the outcome of pregnancy in PCOS women.

Birth Outcomes by Infertility Treatment: Analyses of the Population-Based Cohort: Massachusetts Outcomes Study of Assisted Reproductive Technologies (MOSART)

OBJECTIVE

To evaluate pregnancy and birth outcomes by type of infertility treatment received.

STUDY DESIGN

Assisted reproductive technology (ART) data on women who were both treated and gave birth in Massachusetts were linked to vital records and hospital data. Singleton and twin live births were categorized by ART treatment parameters. Risks for adverse outcomes (pregnancy-induced hypertension [PIH], gestational diabetes [GDM, primary cesarean [CS], prematurity [PTB], low birthweight [LBW], small for gestational age [SGA], large for gestational age [LGA], and birth defects [BD]) were modeled using logistic regression (adjusted odds ratios and 95% confidence intervals), adjusted for parental and treatment factors. GDM and PIH were additionally modeled as adverse outcomes.

RESULTS

Among the 8,948 pregnancies, risks were significantly higher among twins (PIH 2.58, GDM 1.30, CS 5.83, PTB 11.84, LBW 10.68, SGA 2.17, BD 2.54), donor oocytes (PIH 1.87, CS 1.43, PTB 1.43), ICSI (SGA 1.20), and the presence of > 1 fetal heartbeat at 6 weeks' gestation (2 fetal heartbeats: PTB 1.49, LBW 1.57; 3 fetal heartbeats: PTB 2.07, LBW 2.30, SGA 2.04). Thawed embryos were associated with a higher risk for PIH (1.30) but lower risks for LBW (0.79) and SGA (0.38). GDM was associated with increased risks for CS (1.22), LGA (1.40), and BD (1.50); PIH was associated with risks for CS (1.86), PTB (2.70), and LBW (1.83).

CONCLUSION

Plurality is the predominant ART treatment risk factor associated with substantial excess morbidity for both mother and infants.

The "graying" of infertility services: an impending revolution nobody is ready for

BACKGROUND

As demand for infertility services by older women continues to grow, because achievable in vitro fertilization (IVF) outcomes are widely underestimated, most fertility centers do not offer maximal treatment options with use of autologous oocytes. Limited data suggest that clinical IVF outcomes in excess of what the American Society for Reproductive Medicine (ASRM) considers "futile" can, likely, be achieved up to at least age 45 years.

METHODS

In an attempt to point out an evolving demographic trend in IVF, we here report our center's IVF data for 2010-2012 and national U.S. data for 1997-2010. Though our center's data are representative of only one IVF center's patients, they, likely, are unique since they probably represent the most adversely selected IVF patient population ever reported and, thus, are predictive of future demographic trends. In addition we performed a systematic review of the literature on the subject based on PubMed, Medline and Google Scholar searches till year-end 2013. The literature search was performed using key words and phrases relevant to fertility treatments in older women.

RESULTS

As demonstrated by our center's patient demographics and national U.S. data, IVF centers are destined to treat increasingly adversely selected patients. Despite our center's already extremely adversely selected patient population, age-specific IVF cycle outcomes in women above age 40 years, nevertheless, exceeded criteria for "futility" by the ASRM and widely quoted outcome expectations in the literature for patient ages. Age 43 discriminates between better and poorer clinical pregnancy and live birth rates.

CONCLUSIONS

"Graying" of the infertility populations in the developed world, a problem with potentially far-reaching medical and societal consequences, has so far been only insufficiently addressed in the literature. As women's postmenopausal life spans already exceed postmenarcheal life spans at the start of the 20th century, the "graying" of infertility services can be expected to further accelerate, no longer as in recent decades bringing only women in their 40s into maternity wards but also women in their 50s and 60s. Medicine and society better get ready for this revolution.

Barriers to infertility treatment: an integrated study

BACKGROUND

Infertility is one of the most important events in life. Despite the negative impact of infertility, a significant number of women struggling to conceive do not consult a physician and do not fallow up infertility treatment. This integrated study aimed to investigate a large amount of factors which influenced discontinuation of infertility treatment.

METHODS

This integrated study (qualitative - quantitative study) was done on infertile women who had referred to infertility center in Jahrom University of medical sciences using purposive sampling. In the first study, data were collected from a valid questionnaire with 22 questions in a 5-point likert scale about barriers to infertility treatments and in the second study, as a phenomenology approach, data collection was done using deep unstructured interviews and focused groups were aimed to identify deep individual experiences about it.

RESULTS

major barriers to infertility treatments included the probability of treatment failure (52.5%), couple's age and possibility of high risk pregnancy (51.5%), Painfulness of some treatment methods such as laparoscopy (50.5%). Qualitative results led to the identification of three main themes: Nature of treatment, negative thinking, social and cultural factors.

CONCLUSION

As a result, we suggest family education and enrichment of cultural context in the field of infertility; infertile people would be willing to pursue infertility treatments.