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Objective To evaluate the association between different ovarian hyperstimulation protocols and ectopic pregnancy (EP) in in vitro fertilization (IVF) cycles in fresh autologous embryo transfer cycles in the United States between 2008 and 2011 as reported to the Society of Assisted Reproductive Technology (SART). Design Historical cohort study. Setting Not applicable. Patient(s) None. Intervention(s) None. Main Outcome Measure(s) All autologous cycles that resulted in a clinical pregnancy after a fresh, intrauterine embryo transfer and described characteristics of cycles according to protocol were included: luteal GnRH agonist, GnRH agonist flare, or GnRH antagonist. Multivariate logistic regression was conducted to investigate the association between type of protocol and EP. Result(s) Among 136,605 clinical pregnancies, 2,645 (1.94%) were EP. Ectopic pregnancy was more frequent with GnRH antagonist (2.4%) cycles than with GnRH agonist flare (2.1%) or luteal GnRH agonist (1.6%) cycles. After adjusting for maternal and treatment characteristics, the GnRH antagonist and the GnRH agonist flare protocols were associated with increased odds of EP (adjusted odds ratio [aOR] 1.52; 95% confidence interval [CI], 1.39–1.65; and aOR 1.25; 95% CI, 1.09–1.44, respectively) compared with luteal GnRH agonist. Analysis of differences in the factors related to EP in luteal GnRH agonist versus GnRH antagonist protocols indicated that diminished ovarian reserve was associated with an increased risk of EP in luteal GnRH agonist but not in GnRH antagonist cycles. Conclusion(s) The type of protocol used during ovarian hyperstimulation in fresh autologous cycles was associated with EP. This finding suggests a role for extrapituitary GnRH on the tubal and uterine environment during ovarian hyperstimulation treatment for IVF.

The congenital aplasia or severe hypoplasia of mullerian structures is infrequent. However, the features of normal female endocrine function paired with the absence of a functional uterus and vagina makes it a fascinating entity. The diagnosis and work-up in these patients has become very efficient, thanks to the use of imaging, and there are multiple successful procedures for the creation of a neovagina. In recent years, infertility treatment options through in vitro fertilization have also become available as part of the long-term care of these patients.

Objective To evaluate whether the uterine environment is associated with the risk of ectopic implantation by comparing outcomes of fresh and frozen-thawed embryo transfers. Design Retrospective historical cohort. Setting Not applicable. Patient(s) We used the Society for Assisted Reproductive Technologies (SART) database to identify pregnancies that resulted from fresh and frozen blastocyst transfers from 2008 to 2011. Intervention(s) None. Main Outcome Measure(s) We determined the proportion of ectopic (EP) versus intrauterine-only pregnancies resulting from fresh or frozen embryo transfers in autologous and donor-oocyte cycles. Generalized estimation equation regression models were used to adjust for maternal and treatment characteristics. Result(s) Among 103,070 cycles that resulted in a clinical pregnancy, 1.38% were ectopic. The odds of EP were 65% lower in women who had a frozen compared with a fresh transfer in autologous cycles. Donor-oocyte transfers had lower odds of EP compared with autologous cycles, with no difference between fresh and frozen donor transfers. Women who had both a fresh and a frozen transfer with autologous oocytes had a higher risk of EP in their fresh cycles compared with their frozen cycles. Conclusion(s) Embryo transfers in cycles without ovarian hyperstimulation, such as frozen or donor cycles, were associated with lower rates of EP compared with fresh autologous cycles, suggesting that a difference in the tubal-uterine environment contributes to abnormal implantation after IVF.

Since inception, the use of assisted reproductive technologies (ART) has been accompanied by ethical, legal, and societal controversies. Guidelines have been developed to address many of these concerns; however, the rapid evolution of ART requires their frequent re-evaluation. We review the literature on ethical and legal aspects of ART, highlighting some of the most visible and challenging topics. Of specific interest are: reporting of ART procedures and outcomes; accessibility to ART procedures; issues related to fertility preservation, preimplantation genetic testing, gamete and embryo donation, and reproductive outcomes after embryo transfer. Improvements in ART reporting are needed nationally and worldwide. Reporting should include outcomes that enable patients to make informed decisions. Improving access to ART and optimizing long-term reproductive outcomes, while taking into account the legal and ethical consequences, are challenges that need to be addressed by the entire community of individuals involved in ART with the assistance of bioethicists, legal counselors, and members of society in general.

Objective To determine whether intrapartum mean platelet volume (MPV) can predict new-onset delayed postpartum pre-eclampsia. Methods In a retrospective study, data were obtained for women with delayed postpartum pre-eclampsia (≥ 48 hours after delivery) who attended the Detroit Medical Center, Detroit, MI, USA, between January 2002 and July 2010. Patients were divided into two subgroups: new-onset delayed postpartum pre-eclampsia (no history of hypertensive disorder before 48 hours after delivery) and other late-onset/delayed postpartum pre-eclampsia (history of hypertensive disorders). Cases with no hypertensive disorders paired by delivery date were selected as controls. Receiver operating characteristic (ROC) curves were used to determine whether MPV could distinguish between cases and controls. Results Data for 130 cases of new-onset delayed postpartum pre-eclampsia, 71 cases of other late-onset/delayed postpartum pre-eclampsia, and 405 controls were collected. MPV was significantly different between the pre-eclampsia subgroups (P = 0.007). ROC curves showed that MPV significantly distinguished new-onset delayed postpartum pre-eclampsia cases (area under the curve 0.6, 95% confidence interval 0.5–0.6; P = 0.02), with a sensitivity and specificity of 58.1% and 55.4%, respectively. Conclusion Although MPV was significantly lower in women who went on to develop new-onset delayed postpartum pre-eclampsia than among controls, it is not a useful predictor. The low MPV suggests a different mechanism for the development of new-onset delayed postpartum pre-eclampsia.

Precis. The postoperative course of a neovagina creation procedure in a young woman with Meyer-Rokitansky-Kuster-Hauser syndrome was complicated, despite prophylaxis, by extensive pelvic deep venous thrombosis secondary to unsuspected severe inferior vena cava stenosis.Background. Mayer-Rokitansky-Kuster-Hauser (MRKH) syndrome is characterized by congenital vaginal agenesis and an absent or rudimentary uterus in genotypical females. Malformations of the inferior vena cava (IVC) are not commonly associated with MRKH syndrome. We report a case of a patient with MRKH syndrome with severe IVC stenosis that was diagnosed when the patient presented with extensive pelvic deep venous thrombosis (DVT) during the postoperative course of a neovagina creation.Case. A 19-year-old female underwent a McIndoe procedure. Despite DVT prophylaxis, extensive pelvic DVT of the femoral vein was diagnosed on postoperative day 7. Therapeutic anticoagulation was initiated, and pharmacological and mechanical thrombolysis were performed. During these procedures, a hypoplastic IVC was noted.Conclusion. MRKH syndrome can be associated with IVC malformations, which constitute an anatomical risk factor for postoperative DVT.

Objective To analyze the use of Spanish language translation on the websites of reproductive endocrinology and infertility (REI) practices in the context of evidence of underuse of infertility services by minority populations. Design Cross-sectional survey of websites from REI practices. Setting Not applicable. Patient(s) None. Intervention(s) None. Main Outcome Measure(s) Assessment of the relationship between having a Spanish-translated website and REI practice characteristics. Variables included concurrent use of social media, size of the practice, Spanish-speaking practitioner in the practice, being a private or a university-based practice, being in a mandated insurance state, and being in an area with different levels of percentage of Hispanic population, adjusted for annual income levels of the population. Result(s) Of the 376 REI practice websites analyzed, 101 (27%) offered at least some information in Spanish. We identified 97 Spanish-speaking practitioners at 71 REI practices. Having a Spanish-translated website was significantly associated with the practice's use of social media, having an international/out-of-town web page, and having a Spanish-speaking physician in the practice. The size of the practice, as measured in number of cycles reported per year, was not associated with having a translated website. In practices located in the top 60 metropolitan areas by Hispanic population, the odds of having a Spanish-translated website were only related to the percentage of Hispanic population after adjusting for state-mandated insurance and average annual income level of the Hispanic population. Sixty-six of the websites with Spanish-translated content had been automatically translated. An additional eight websites were partially translated automatically. Conclusion(s) REI practices in metropolitan areas with a higher percentage of Hispanics were more likely to reach out to this minority population by translating their website content into Spanish. These practices were also more likely to use social media. Future studies are needed to determine whether the availability of Spanish language content on REI websites is associated with increased use of reproductive services by this minority population.