OBJECTIVE: To assess the impact of elevated peak serum E₂ levels (EPE₂; defined as levels >90th percentile) on the day of hCG administration during controlled ovarian hyperstimulation (COH) for IVF ...on the likelihood for small for gestational age (SGA), preeclampsia (PreE), and preterm delivery (PTD) in singleton pregnancies. DESIGN: Retrospective cohort study. SETTING: Tertiary-care academic medical center. PATIENT(S): Singleton live-birth pregnancies conceived after fresh IVF-ET. INTERVENTION(S): None. MAIN OUTCOME MEASURE(S): The delivery rate of SGA infants and the development of PreE and PTD in patients with and without EPE₂. RESULT(S): Patients with EPE₂ during COH were more likely to deliver SGA infants (7 26.9% vs. 10 3.8%; odds ratio OR, 95% confidence interval CI {9.40, 3.22–27.46}) and develop PreE (5 18.5% vs. 12 4.5%; adjusted OR, 95% CI {4.79, 1.55–14.84}). No association was found between EPE₂ and the likelihood for delivery before 37 weeks, 35 weeks, or 32 weeks of gestation. Receiver operating characteristic analysis revealed that EPE₂ level predicted adverse obstetrical outcome (SGA + PreE) with 38.5% and 91.7% sensitivity and specificity, respectively. Using a serum peak E₂ cutoff value of 3,450 pg/mL (>90th percentile level), the positive predictive value was 37%, while the negative predictive value was 92%. CONCLUSION(S): EPE₂ level (>3,450 pg/mL) on the day of hCG administration during COH is associated with greater odds of developing PreE and delivery of an SGA infant in singleton pregnancies resulting from IVF cycles.
To evaluate the predictive value of sperm morphology, specifically teratospermia, seen during initial semen analysis on the success of intrauterine insemination (IUI) cycles and pregnancy outcomes.
A ...retrospective cohort analysis on patients undergoing IUI at a large US fertility network. Baseline demographic characteristics, primary infertility diagnoses, and pregnancy outcomes were recorded. A total of 27,925 IUI cycles in 16,169 unique patients were analyzed. IUI cycles were grouped by a sperm morphology of 1% (n=3,799), 2% (n=5,506), 3% (n=4,857), or 4% or greater (n=13,763). The outcome measures were pregnancy rate (positive pregnancy test), clinical pregnancy rate (ultrasound confirmation of a gestational sac with a yolk sac around 5-6 weeks), live birth rate, and miscarriage rate.
Sperm morphology is a significant predictor of pregnancy rate (p= <0.001), clinical pregnancy rate (p=0.011), and live birth rate (p=0.026) following IUI. In each of these outcome measures, patients with 1% normal forms had the lowest percentage of success, and patients with 4% or greater normal forms had the most success. Relative outcome percentages, however, were similar in each group. Live birth rates in the 1%, 2%, 3% and > 4% group were 12.3%, 13.1%, 12.7% and 13.9%, respectively. Sperm morphology is not a significant predictor of miscarriage rate per clinical pregnancy post IUI (p=0.054).
Sperm morphology was a statistically significant predictor of pregnancy, clinical pregnancy, and live birth but not miscarriage rate after an IUI cycle. Higher morphology percentages were associated with increasingly favorable outcomes. However, the small observed differences did not demonstrate clinical significance.
Objective We sought to investigate the most recent national trends of bilateral salpingectomy (BS) and bilateral salpingo-oophorectomy (BSO) at the time of hysterectomy performed for benign ...indications. Study Design We conducted a national cross-sectional analysis of all inpatient discharges for women aged ≥18 years who underwent a hysterectomy for benign indications from 1998 through 2011 using the largest publicly available all-payer inpatient database in the United States. We scanned International Classification of Diseases, Ninth Revision codes for an indication of specific bilateral adnexal surgeries, including BSO and BS. Joinpoint regression was used to characterize and estimate 14-year national trends in performing BSO and BS at the time of hysterectomy for benign indications, overall and in population subgroups. Results During the study period, there were approximately 428,523 inpatient hysterectomy procedures performed annually for benign indications. Of these, >53% had no adnexal surgery performed during the same hospitalization, whereas 43.7% and 1.3% of those discharges had BSO and BS procedures, respectively. The rate of BSO was directly correlated with increasing age for patients <65 years. Conversely, we observed an inverse relationship between BS and patient age, with the BS rate among women aged <25 years twice that of women aged ≥45 years. From 1998 through 2001, there was a 2.2% increase in the rate of BSO per year (95% confidence interval, 0.4–4.0); however, this was followed by a consistent 3.6% (95% confidence interval, –4.0 to –3.3) annual decline in the BSO rate, from 49.7% in 2001 to 33.4% in 2011. National rates of BS among women undergoing hysterectomy for benign indications increased significantly throughout the study period, with an estimated 8% annual increase from 1998 through 2008, followed by a sharp 24% increase annually during the last 4 years of the study period. The BS rate nearly quadrupled in 14 years. Conclusion The type of adnexal surgery performed concomitantly with hysterectomy for benign indications has undergone a significant shift since 2001. Significantly more BS and less BSO procedures are being performed among gynecologic surgeons in the United States.
To identify whether the serum estradiol (E2) level on the day of human chorionic gonadotropin (hCG) trigger or luteinizing hormone (LH) surge (hCG-LH) was associated with the live birth rate (LBR) ...during ovulation induction (OI) or controlled ovarian hyperstimulation with letrozole followed by intrauterine insemination (IUI).
Retrospective cohort study.
Large, multicenter private practice.
A total of 2,368 OI-IUI cycles in patients treated with letrozole followed by IUI were evaluated from January 1, 2014, to July 31, 2019.
Ovulation induction with letrozole, followed by autologous IUI.
The primary outcome measure was the LBR as a function of the serum E2 level at the time of hCG administration or LH surge, adjusting for age, body mass index, the largest follicle diameter, and the number of follicles ≥14 mm in diameter. The clinical pregnancy rate as a function of the E2 level, pregnancy rate as a function of the lead follicle diameter, and pregnancy loss rates were the secondary outcome variables.
A total of 2,368 cycles met the inclusion criteria. Outcomes were evaluated at the 25th (E2 level, 110 pg/mL), 50th (157 pg/mL), 75th (225 pg/mL), and 90th (319 pg/mL) percentiles. The LBRs ranged from 9.4% to 11.1% in the lower E2 cohorts and from 12.5% to 13.5% in the higher E2 cohorts. The LBR was significantly greater in the cohort of women with higher E2 levels in all percentile comparisons except for the 90th percentile. The mean periovulatory follicle diameter of ≥20 or <20 mm was not independently associated with the LBR or clinical pregnancy rate, despite a significantly higher mean E2 level in the larger follicle group.
In letrozole OI cycles followed by IUI, lower LBRs and clinical pregnancy rates were found in women with lower E2 levels than in those with higher E2 levels at the 25th, 50th, and 75th percentile E2 level quartiles. Where possible, delaying hCG trigger until the E2 level increases after aromatase inhibition and approaches the physiologic periovulatory level may improve the pregnancy rates with letrozole followed by IUI.
Endometriosis is one of the most common gynecologic conditions that women face throughout their lives. Despite advances in technology, diagnosis and treatment of this relapsing and remitting ...condition is still challenging for many women. This review focuses on literature pertaining to minimal/mild (stage I/II) endometriosis and its impact on fertility. The effectiveness of medical interventions to improve infertility and obstetric outcomes in both natural and assisted reproductive technologies cycles remains debated. The recent ESHRE guidelines suggests that operative laparoscopy could be considered for rASRM stage I/II endometriosis as it improves ongoing pregnancy rates.
Perform gene expression profiling of adult mouse ovary-derived oogonial stem cells (OSCs).
Experimental animal study.
Research laboratory.
Adult C57BL/6 female mice.
None.
Gene expression profiles ...were compared between freshly isolated and cultured OSCs, as well as between OSCs and embryonic stem cells (ESCs), fetal primordial germ cells (PGCs), and spermatogonial stem cells (SSCs); OSC yield from ovaries versus meiotic gene activation during the estrous cycle was determined.
Freshly isolated OSCs, PGCs, and SSCs exhibited distinct gene expression profiles. Cultured OSCs maintained their germline gene expression pattern but gained expression of pluripotency markers found in PGCs and ESCs. Cultured OSCs also expressed the meiotic marker, stimulated by retinoic acid gene 8 (Stra8). In vivo, OSC yield was higher from luteal versus follicular phase ovaries, and this was inversely related to Stra8 expression.
Freshly isolated OSCs exhibit a germline gene expression profile that overlaps with, but is distinct from, that of PGCs and SSCs. After in vitro expansion, OSCs activate expression of pluripotency genes found in freshly isolated PGCs. In vivo, OSC numbers in the ovaries fluctuate during the estrous cycle, with the highest numbers noted during the luteal phase. This is followed by activation of Stra8 expression during the follicular phase, which may signify a wave of neo-oogenesis to partially offset follicular loss through atresia and ovulation in the prior cycle.
Ovarian cancer is the leading cause of Gynecological cancer related mortality in the USA. Due to the absence of an effective screening method, concomitant adnexal management during hysterectomy or ...other pelvic surgeries is a prime consideration. Bilateral salpingo-oophorectomy (BSO) offers the benefit of eliminating the risk of ovarian cancer however it leads to surgical menopause with unfavourable overall health outcomes. With the latest verification that serous tubal intraepithelial carcinoma detected in the distal fimbriated end of the fallopian tube being the precursor of Type 2 ovarian cancers, there is an increased trend of performing bilateral salpingectomy (BS) as a risk reduction strategy for ovarian cancer. Women with a high risk for ovarian cancer due to familial or genetic mutations and those diagnosed with endometriosis need particular attention while planning adnexal management during hysterectomy. Physician and patient's shared decision-making regarding adnexal management during benign hysterectomy taking into consideration the route of hysterectomy is an important portion of pre-operative planning. The objective of this article is to understand the current trends of BSO and BS during benign hysterectomy and appreciate the pros and cons to aid in pre-operative counselling of patients.
OBJECTIVE: To test the hypothesis that patients who undergo elective cryopreservation of all embryos, due to risk of ovarian hyperstimulation syndrome and elevated peak serum estradiol (E₂), ...previously defined as level >3,450 pg/mL (90th percentile) during in vitro fertilization (IVF), will be less likely to have small for gestational age (SGA) infants and preeclampsia as compared with patients with elevated peak serum E₂ who undergo fresh embryo transfer (ET). DESIGN: Cohort study. SETTING: Tertiary care academic medical center. PATIENT(S): Twenty women who underwent elective cryopreservation of all embryos with subsequent cryothaw ET and 32 similar women with elevated peak E₂ during controlled ovarian hyperstimulation for IVF who underwent a fresh ET. INTERVENTION(S): None. MAIN OUTCOME MEASURE(S): Prevalence of SGA infants and development of preeclampsia in patients with cryothaw ET or fresh ET in the setting of elevated peak E₂. RESULT(S): After adjusting for confounders (body mass index, antral follicle count, peak serum E₂ level) using forward stepwise logistic regression, the patients who elected cryopreservation of all embryos and subsequent cryothaw ET were statistically significantly less likely to deliver SGA infants as compared with the patients who had fresh ET in the setting of elevated peak E₂. In the entire cohort, a total of seven women had preeclampsia, all of whom had had fresh ET in the setting of elevated peak serum E₂: 7 (21.9%) in the fresh ET group versus 0 women in the elective cryopreservation group. CONCLUSION(S): This preliminary study suggests that elective cryopreservation of all embryos in patients with elevated peak serum E₂ for subsequent cryothaw ET in cycles with a better physiologic hormonal milieu may reduce the odds of SGA and preeclampsia in IVF singleton deliveries.
PDF
