Search

The measurement of ovarian volume has been recently shown to predict follicular response in in-vitro fertilization (IVF), specifically a lower number of retrieved oocytes with decreasing ovarian volume. This test appears to be better than basal follicle-stimulating hormone (FSH) as a prognostic measure of ovarian reserve. However, the effect of pituitary desensitization on ovarian volume has not been previously investigated. We prospectively evaluated 38 women undergoing IVF using a long luteal leuprolide acetate (LA) protocol. All women had their ovarian volume measurements performed on day 21, the day of LA start, and again on the day of gonadotrophin start. The mean age was 30.6 ± 3.9 years (range 23-37). Basal FSH was 5.4 ± 1.9 IU/l (range 1.2-10.2). The mean preLA ovarian volume was 7.0 ± 3.6 cm3 (left ovary 6.8 ± 3.9, right ovary 7.1 ± 3.8), compared to 6.3 ± 4.2 cm3 postLA (left ovary 6.0 ± 4.9, right ovary 6.5 ± 4.8) (not significant). The mean number of small antral follicles noted in both ovaries was also unchanged after pituitary desensitization. Pituitary desensitization using LA had no effect on overall ovarian volume measurements. The total number of retrieved oocytes decreased with increasing age and decreasing ovarian volume. [ABSTRACT FROM PUBLISHER]

Research Question: How do capacitation ability, measured by Cap-Score™, and traditional semen analysis measures (volume, concentration, motility) change with age in men questioning their fertility (MQF)?, Design: Cap-Score and semen analysis measures were obtained from MQF (n = 2652; multicentric design: 35 reproductive endocrinologist prescribers, n = 16 clinics). Morphology was not included due to differences among clinics. A Mann-Whitney test was used to compare Cap-Scores between MQF and men with known recent paternity (n = 76). The following age groups were constructed for MQF: 20-24, 25-29, 30-34, 35-39, 40-44, 45-49 and 50+. Associations between semen analysis, Cap-Score and age groups were evaluated using mixed-model analysis of variance to identify possible influence of Cap-Score collection kit type (n = 763 collected at home; n = 1889 collected at clinics)., Results: MQF had reduced capacitation ability (mean ± SE; 29.25 ± 0.15 versus 35.34 ± 0.88; P < 0.001). No change in Cap-Score (P = 0.916) or concentration (P = 0.926) was detected with age group. In contrast, both volume (P = 0.008) and % motility (P < 0.001) declined with age., Conclusions: Men presenting because of difficulties in generating pregnancy showed equivalent reductions in capacitation ability regardless of age. In contrast, motility and volume declined with age. These data suggest that capacitation ability is a more sensitive indicator of male fertility across age groups than traditional semen analysis and should not be reserved for older men. Importantly, these data do not address whether sperm fertilizing ability declines in the general population as men age. Instead, they indicate that if men are having difficulty conceiving, no matter what their age, then defects in sperm fertilizing ability are equally likely to be the cause., (Copyright © 2022 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Purpose: The use of platelet-rich plasma is being investigated in reproductive medicine and clinically promoted as a fertility treatment for menopause. We aimed to review the literature on the impact of PRP on fertility in menopause., Methods: A literature search was performed using the PubMed and MEDLINE search engines. The search was limited to the English language. Articles studying PRP use in menopause were selected for the purpose of this review., Results: Limited case reports and case series studied fertility outcomes of PRP in menopause. Randomized controlled trials are lacking. Furthermore, no studies have been conducted to evaluate the effect of different PRP concentrations, injection techniques, or side effects on reproductive outcomes in menopausal women., Conclusion: There is a dearth of data to support the routine implementation of intraovarian PRP injections for fertility restoration in menopausal women. Patients considering such therapy need to be well aware of the lack of adequate data for PRP use in menopause and should be counseled accordingly., (© 2022. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

We propose the Disparities in ART (DART) hypothesis which identifies underlining causes that contribute to racial disparities in access and outcomes of ART treatment in the USA. Reasons for disparities in access and outcomes of ART treatment for infertility are derived from some relative contribution of four identified causes. They are simply stated as delays in obtaining treatment, higher dropout during and following unsuccessful ART treatment, provider factors, and differences in patient biological factors. Each of these causes has a subset of 4-6 factors that contribute to each of the 4 broad categorical causes that are discussed. This hypothesis may serve as a platform for better understanding the scope of the challenges and potential research inquiries that may lead to narrowing of racial/ethnic disparities in access and outcomes in ART., (© 2022. Society for Reproductive Investigation.)

Purpose: Adenomyosis is a poorly understood entity with no unified treatment protocol. It has been thought to only affect the quality of life of older women, but growing evidence is highlighting the increased frequency of adenomyosis in younger patients and its possible effects on fertility outcomes. This can have a great impact on how clinicians screen, diagnose, and treat this condition. The aim of this review is to explore the relationship between adenomyosis and infertility., Methods: A literature search of the keywords "adenomyosis", "infertility", "pregnancy" and "fertility" was conducted using the PubMed and Medline search engines. The articles selected were observational, systematic reviews, meta-analyses, and randomized controlled trials. The search was limited to English, abstracts were screened, and articles were selected., Results: The literature reports lower clinical pregnancy rates, lower live birth rates, higher miscarriage rates, and higher odds of adverse obstetric outcomes in patients with adenomyosis. Treatment seems to be associated with higher pregnancy rates and live births rates., Conclusion: An association between adenomyosis and infertility seems to exist, and treatment could lead to improved fertility outcomes., (© 2022. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Controlled ovarian stimulation has been an integral part of in vitro fertilisation (IVF) treatment cycles. Availability of different gonadotropins for ovarian stimulation and gonadotropin releasing hormone (GnRH) analogues for prevention of premature rise of leutinising hormone during follicular phase offer an opportunity to utilise them for a successful outcome in women with different subsets of ovarian response. Further, use of GnRH agonist as an alternative for human chorionic gonadotropin improves safety of ovarian stimulation in hyper-responders. Mild ovarian stimulation protocols have emerged as an alternative to conventional protocols in the recent years. Individualisation plays an important role in improving safety of IVF in hyper-responders while efforts continue to improve efficacy in poor responders. Some of the follicular and peri-ovulatory phase interventions may be associated with negative impact on the luteal phase and segmentalisation of the treatment with frozen embryo transfer may be an effective strategy in such a clinical scenario. This narrative review looks at the available evidence on various aspects of ovarian stimulation strategies and their consequences. In addition, it provides a concise summary of the evidence that has emerged from India on various aspects of ovarian stimulation., Competing Interests: Ferring organised a meeting of all authors and facilitated discussion and provided the assistance of a medical writing team whose role was limited to aiding the search strategy and creating the flow chart for search strategy. PRJ: Is the current Editor-in-Chief of the Journal of Human Reproductive Sciences. She has not received any monetary compensation for the article. She has been a faculty for symposiums organised by Ferring in the past. She has not had any role in the peer review/editorial process/decision making about the manuscript. NM: Has not received any monetary compensation for the article. She has received honorarium as a faculty from Ferring in the past. JS: He has not received any monetary support from Ferring for the writing up of this manuscript. MMP: Has been a part of Ferring C-Create programs and was invited to speak for Abbott scientific sessions. She has not received any monetary support from Ferring for the writing up of this manuscript. RG: Has been compensated by Ferring India, Merck and Abott India in the last year for various speaker/KOL assignments. He has not received any monetary support from Ferring for the writing up of this manuscript. VSR: She has received honorarium from Ferring Pharmaceutical Pvt Ltd as an expert in Embryology towards preparing/updating & being a member of Virtual ‘C-CREATE Scientific Committee meeting, but not received any funds for this particular project. MG: Never received any monetary support or honorarium from Ferring for writing up this Manuscript. Has been part of Ferring's C-Create teaching programs and part of invited faculty in educational programs conducted by Abbott, Astra Zeneca and Shield Pharma companies. FIS: Has received compensation from Ferring (but not for this article) as part of Ferring Speaker Bureau and investigator., (Copyright: © 2022 Journal of Human Reproductive Sciences.)

Purpose: Endometriomas are a common cause of infertility necessitating assisted reproductive technology (ART). It had been previously thought that surgical removal of the endometriomas prior to ART would improve reproductive outcomes, but recent data suggests that surgical cystectomy might affect the ovarian reserve, decreasing the chances of ART success. The aim of this article is to review the literature on the effects of endometrioma surgery on ART outcomes providing an overview of the current evidence and assessing the need for further studies., Methods: A literature search was performed using PubMed and MEDLINE databases to identify studies that discuss endometriomas and assisted reproductive technology before versus after surgery., Results: In women with an endometrioma requiring ART, growing evidence suggests that surgery might result in damage to the ovarian reserve and further decrease chances of fertility. However, pregnancy rates, implantation rates, fertilization rates, and live birth rates seemed to be consistently similar across both groups., Conclusion: The current evidence is inconclusive on whether endometriomas should be surgically removed prior to ART. Further large randomized controlled trials are needed for a definite answer, and until then, management should be individualized., (© 2022. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

(1) Background: Adenomyosis is a poorly understood entity which makes it difficult to standardize treatment. In this paper we review and compare the currently approved medical and surgical treatments of adenomyosis and present the evidence behind them. (2) Methods: A PubMed search was conducted to identify papers related to the different treatments of adenomyosis. The search was limited to the English language. Articles were divided into medical and surgical treatments. (3) Results: Several treatment options have been studied and were found to be effective in the treatment of adenomyosis. (4) Conclusions: Further randomized controlled trials are needed to compare treatment modalities and establish a uniform treatment algorithm for adenomyosis.

Research Question: The economic and reproductive medicine response to the coronavirus disease 2019 (COVID-19) pandemic in the USA has reduced the affordability and accessibility of fertility care. What is the impact of the 2008 financial recession and the COVID-19 recession on fertility treatments and cumulative live births?, Design: The study examined annual US natality, Centers for Disease Control and Prevention IVF cycle activity and live birth data from 1999 to 2018 encompassing 3,286,349 treatment cycles, to estimate the age-stratified reduction in IVF cycles undertaken after the 2008 financial recession, with forward quantitative modelling of IVF cycle activity and cumulative live births for 2020 to 2023., Results: The financial recession of 2008 caused a 4-year plateau in fertility treatments with a predicted 53,026 (95% confidence interval [CI] 49,581 to 56,471) fewer IVF cycles and 16,872 (95% CI 16,713 to 17,031) fewer live births. A similar scale of economic recession would cause 67,386 (95% CI 61,686 to 73,086) fewer IVF cycles between 2020 and 2023, with women younger than 35 years overall undertaking 22,504 (95% CI 14,320 to 30,690) fewer cycles, compared with 4445 (95% CI 3144 to 5749) fewer cycles in women over the age of 40 years. This equates to overall 25,143 (95% CI 22,408 to 27,877) fewer predicted live births from IVF, of which only 490 (95% CI 381 to 601) are anticipated to occur in women over the age of 40 years., Conclusions: The COVID-19 recession could have a profound impact on US IVF live birth rates in young women, further aggravating pre-existing declines in total fertility rates., (Copyright © 2021 Reproductive Healthcare Ltd. Published by Elsevier Ltd. All rights reserved.)

Purpose: Platelet-rich plasma (PRP) has become a novel treatment in various aspects of medicine including orthopedics, cardiothoracic surgery, plastic surgery, dermatology, dentistry, and diabetic wound healing. PRP is now starting to become an area of interest in reproductive medicine more specifically focusing on infertility. Poor ovarian reserve, menopause, premature ovarian failure, and thin endometrium have been the main areas of research. The aim of this article is to review the existing literature on the effects of autologous PRP in reproductive medicine providing a summation of the current studies and assessing the need for additional research., Methods: A literature search is performed using PubMed, MEDLINE, and CINAHL Plus to identify studies focusing on the use of PRP therapy in reproductive medicine. Articles were divided into 3 categories: PRP in thin lining, PRP in poor ovarian reserve, and PRP in recurrent implantation failure., Results: In women with thin endometrium, the literature shows an increase in endometrial thickness and increase in chemical and clinical pregnancy rates following autologous PRP therapy. In women with poor ovarian reserve, autologous intraovarian PRP therapy increased anti-Mullerian hormone (AMH) levels and decreased follicle-stimulating hormone (FSH), with a trend toward increasing clinical and live birth rates. This trend was also noted in women with recurrent implantation failure., Conclusions: Limited literature shows promise in increasing endometrial thickness, increasing AMH, and decreasing FSH levels, as well as increasing chemical and clinical pregnancy rates. The lack of standardization of PRP preparation along with the lack of large randomized controlled trials needs to be addressed in future studies. Until definitive large RCTs are available, PRP use should be considered experimental.

There have been over 8 million babies born through in vitro fertilization (IVF) and this number continues to grow. There is a global trend to perform elective single embryo transfers, avoiding risks associated with multiple pregnancies. It is therefore important to understand where current research of noninvasive testing for embryos stands, and what are the most promising techniques currently used. Furthermore, it is important to identify the potential to translate research and development into clinically applicable methods that ultimately improve live birth and reduce time to pregnancy. The current focus in the field of human reproductive medicine is to develop a more rapid, quantitative, and noninvasive test. Some of the most promising fields of research for noninvasive assays comprise cell-free DNA analysis, microscopy techniques coupled with artificial intelligence (AI) and omics analysis of the spent blastocyst media. High-throughput proteomics and metabolomics technologies are valuable tools for noninvasive embryo analysis. The biggest advantages of such technology are that it can differentiate between the embryos that appear morphologically identical and has the potential to identify the ploidy status noninvasively prior to transfer in a fresh cycle or before vitrification for a later frozen embryo transfer.

Objective: To study the impact of an educational program on the knowledge base of reproductive endocrinology nurses on embryology and genetics topics to determine both improvement in knowledge and confidence in the nurses' ability to counsel patients on such topics., Design: Interventional study., Setting: Clinics., Patient(s): None; subjects were reproductive endocrinology nurses., Intervention(s): Preintervention knowledge self-efficacy test, educational exposure, and 2-week follow-up testing., Main Outcome Measure(s): Knowledge test scores, self-efficacy scores., Result(s): Nurses, regardless of educational attainment, demonstrated statistically significant increases in knowledge of both embryology and genetics, which was retained at least 2 weeks after the educational intervention. Furthermore, nurse self-efficacy increased after intervention, and qualitative data support the desire for increased educational opportunities., Conclusion(s): Nurses benefit from focused educational efforts, resulting in improved knowledge in embryology and genetics. This improved knowledge base resulted in improved nurse confidence in patient education., (Published by Elsevier Inc.)

Purpose: Selecting an embryo at the transfer stage with the best chance of a successful pregnancy is still largely dependent on preceding subjective evaluation of morphokinetics. Expensive prenatal genomic profiling has been so far proved ineffective. Proteomics and metabolomics are promising new approaches to assess embryo viability, but methodologies are often complex and do not lend themselves to rapid analysis in the critical time between blastocyst formation and embryo transfer. Here, we used matrix-assisted laser desorption ionization time-of-flight (MALDI ToF) mass spectrometry to assess the secretome of blastocysts in the minutes prior to embryo transfer and correlated spectral features with pregnancy outcome., Methods: Four hundred one samples of spent blastocyst culture media were collected from embryo cultures at the time of embryo transfer, of which 136 were used to construct the predictive model. The media samples were frozen at - 20 °C and stored for analysis. Sample analysis was conducted in batches using 1 μl of spent embryo in direct MALDI ToF mass spectral analysis. Quantitative characteristics within this mass range (2000-17,000 m/z) were used to generate a score for selected mass regions (bins) in order to predict pregnancy outcome for each sample., Results: With a simple algorithm based on nine mass bins within the 2000-10,000 m/z region, it was possible to identify samples with the best chance of becoming an ongoing pregnancy (positive predictive value of 82.9%, p = 0.0018)., Conclusion: A simple, direct and rapid analysis of spent culture fluid from blastocysts at the point of embryo transfer can quickly identify optimal embryos with the best chance of achieving ongoing pregnancy. Methods like this, which take less than 20 min to perform, could dramatically improve the approach to embryo selection and live births.

Purpose: The aim of the systematic review is to describe the obstetrical complications associated with pregnancies in the context of a thin endometrial lining., Methods: Systematic review of the literature., Results: Patients who conceive in the setting of a thin endometrium have a significantly increased risk of early pregnancy loss, namely miscarriage and ectopic pregnancy. These patients also have a twofold increase in low birth weight and preterm delivery, as well as a significantly higher risk of intrauterine growth restriction and composite adverse perinatal outcomes., Conclusions: In addition to the lower probability of conception, a thin endometrium in assisted reproductive technologies appears to be associated with both early and late pregnancy complications. These pregnancies thus warrant special attention and close follow-up from obstetricians.

Objective: We sought to determine whether administering the daily gonadotropin dose in the morning (AM) or in the evening (PM) affects cycle outcome in patients undergoing IVF., Design: This is a prospective randomized study., Setting: The study is performed in a private assisted reproductive technology (ART) clinic., Patient(s): The study included one hundred and twenty-seven women undergoing IVF., Intervention(s): Morning (AM) and evening (PM) administration of gonadotropins (uFSH and hMG) was compared., Main Outcome Measure(s): Live birth rate was the main outcome measured. Secondary outcomes including total IU use, days of stimulation, peak E 2 , peak P 4 , endometrial thickness, number of oocytes retrieved, MII oocytes, fertilization rates, #ET, IR, and clinical PR were all assessed., Results: A total of 127 cycles were included, 61 in the AM group and 67 in the PM group. Baseline and stimulation characteristics were similar in both groups. There was a trend for a higher implantation rate in the AM group vs. the PM group (60.3 vs. 47.2%, P = 0.066). The AM group had a higher chemical pregnancy rate compared to the PM group (81.7 vs. 65.6%, P = 0.024) and a higher clinical pregnancy rate (78.3 vs. 62.1%, P = 0.048), but the delivery rates were similar (68.3 vs. 56.1%, P = 0.16). The study was unfortunately prematurely terminated when uFSH (Bravelle©) was pulled out of the US market., Conclusions: AM administration of gonadotropins may be associated with a better ART outcome compared to PM administration. Larger studies are needed to confirm our findings.

Purpose: The Cap-Score™ was developed to assess the capacitation status of men, thereby enabling personalized management of unexplained infertility by choosing timed intrauterine insemination (IUI), versus immediate in vitro fertilization (IVF) or intracytoplasmic sperm injection (ICSI) in individuals with a low Cap-Score™. The objective of this study was to estimate the differences in outcomes and costs comparing the use of the Cap-Score™ with timed IUI (CS-TI) and the standard of care (SOC), which was assumed to be three IUI cycles followed by three IVF-ICSI cycles., Methods: We developed and parameterized a decision-analytic model of management of unexplained infertility for women based on data from the published literature. We calculated the clinical pregnancy rates, live birth rates, and medical costs comparing CS-TI and SOC. We used Monte Carlo simulation to quantify uncertainty in projected estimates and performed univariate sensitivity analysis., Results: Compared to SOC, CS-TI was projected to increase the pregnancy rate by 1-26%, marginally reduce live birth rates by 1-3% in couples with women below 40 years, increase live birth rates by 3-7% in couples with women over 40 years, reduce mean medical costs by $4000-$19,200, reduce IUI costs by $600-$1370, and reduce IVF costs by $3400-$17,800, depending on the woman's age., Conclusion: The Cap-Score™ is a potentially valuable clinical tool for management of unexplained infertility because it is projected to improve clinical pregnancy rates, save money, and, depending on the price of the test, increase access to treatment for infertility.

Purpose: The study aims to describe two promising therapeutic options for resistant "thin" endometrium in fertility treatment: granulocyte colony-stimulating factor (G-CSF) and stem cell therapy., Methods: A review of the scientific literature related to patients with thin endometrium undergoing fertility treatment., Results: Sufficient endometrial growth is fundamental for embryo implantation. Whether idiopathic or resulting from an underlying pathology, a thin endometrium of <7 mm is associated with lower probability of pregnancy; however, no specific thickness excludes the occurrence of pregnancy. We specifically reviewed two relatively new treatment options for resistant thin lining: intrauterine G-CSF and stem cell therapy. The majority of the reviewed trials showed a significant benefit for intrauterine G-CSF infusion in improving endometrial thickness and pregnancy rates. Early results of stem cell therapy trials seem promising., Conclusions: EMT <7 mm is linked to lower probability of pregnancy in assisted reproductive technology. Intrauterine G-CSF infusion appears to be a potentially successful treatment option for resistant cases, while stem cell therapy seems to be a promising new treatment modality in severely refractory cases.

Purpose: The objective of this study is to determine if IVF outcome disparities exist among MENA women in the USA in comparison to a control group of Caucasian women., Methods: A retrospective cohort study comparing MENA (N = 190) and Caucasian (N = 200) women undergoing their first IVF cycle between 5/2006 and 5/2014 was carried out at an academically affiliated fertility practice. All MENA cycles during that time period undergoing IVF/ICSI using autologous embryos and blastocyst transfers were compared to a control group of Caucasian women., Results: MENA women were significantly younger (32.9 vs 34.5, P < 0.005) and had a lower BMI (25.2 vs 27.1, P < 0.001). Male factor infertility was higher among partners of MENA women (62 vs 50%, P < 0.05). MENA women experienced decreased live birth rates per blastocyst transfer compared to Caucasian women after controlling for age and BMI (OR 0.55, 95% CI 0.35-0.85 P = 0.007). The odds of a miscarriage were also significantly higher among MENA women (OR 2.55, 95% CI 1.04-6.27 P = 0.036)., Conclusion: Middle Eastern/North African women have worse IVF outcomes with decreased live birth rates per blastocyst transfer and increased miscarriage rates compared to Caucasian women.

Background: The transfer of multiple embryos after in vitro fertilization (IVF) increases the risk of twins and higher-order births. Multiple births are associated with significant health risks and maternal and neonatal complications, as well as physical, emotional, and financial stresses that can strain families and increase the incidence of depression and anxiety disorders in parents. Elective single embryo transfer (eSET) is among the most effective methods to reduce the risk of multiple births with IVF., Main Body: Current societal guidelines recommend eSET for patients <35 years of age with a good prognosis, yet even this approach is not widely applied. Many patients and clinicians have been reluctant to adopt eSET due to studies reporting higher live birth rates with the transfer of two or more embryos rather than eSET. Additional barriers to eSET include risk of treatment dropout after embryo transfer failure, patient preference for twins, a lack of knowledge about the risks and complications associated with multiple births, and the high costs of multiple IVF cycles. This review provides a comprehensive summary of strategies to increase the rate of eSET, including personalized counseling, access to educational information regarding the risks of multiple pregnancies and births, financial incentives, and tools to help predict the chances of IVF success. The use of comprehensive chromosomal screening to improve embryo selection has been shown to improve eSET outcomes and may increase acceptance of eSET., Conclusions: eSET is an effective method for reducing multiple pregnancies resulting from IVF. Although several factors may impede the adoption of eSET, there are a number of strategies and tools that may encourage the more widespread adoption of eSET in clinical practice.

Purpose: Poor ovarian reserve and poor ovarian response presents a challenge to IVF centers. Dehydroepiandrosterone (DHEA) supplementation is increasingly being used by many IVF centers around the world in poor responders despite the lack of convincing data. We therefore examined the rationale for the use of DHEA in poor responders, address the relevant studies, present new data, and address its potential mechanisms of action., Methods: All published articles on the role of DHEA in infertile women from 1990 to April 2013 were reviewed., Results: Several studies have suggested an improvement in pregnancy rates with the use of DHEA. Potential mechanisms include improved follicular steroidogenesis, increased IGF-1, acting as a pre-hormone for follicular testosterone, reducing aneuploidy, and increasing AMH and antral follicle count. While the role of DHEA is intriguing, evidence-based recommendations are lacking., Conclusions: While nearly 25 % of IVF programs use DHEA currently, large randomized prospective trials are sorely needed. Until (and if) such trials are conducted, DHEA may be of benefit in suitable, well informed, and consented women with diminished ovarian reserve.

Our health care system has been facing significant changes over the past 20 years with the introduction of health maintenance organizations plus the seismic changes associated with the introduction of the Patient Protection and Affordable Health Care Act and accountable care organizations. Lower reimbursements by health plans and the need for significant infrastructure investments in information technology such as electronic medical records have also put major financial and organizational strains on solo practices. Although it is unknown how these changes will have an impact on reproductive endocrinologists, consolidation and mergers seem to be on the rise in anticipation of the coming tsunami. Many solo physicians have cherished the freedom and opportunity of small practices, but it appears that the delivery system of the future will be dramatically different., (Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.)

Objective: Despite the lack of any scientific data, many ART programs split the daily gonadotropin dose during ovarian stimulation, while others give the entire dose during a single administration, usually at night., Design: Prospective randomized., Patient(s): 213 women undergoing IVF/ICSI cycles at a single private ART center., Intervention(s): Gonadotropin administration once daily compared to twice daily., Main Outcome Measure(s): Gonadotropin usage, clinical and ongoing PR RESULTS: There were 110 women in the once daily compared to 103 in the twice daily arm. All cycles were blastocyst transfers. There was a significantly lower FSH use in the once daily arm compared to the twice daily arm (1507.5 ± 517.5 IU vs. 1702.5 ± 622.5, P = 0.015), and a trend towards lower hMG use in the once daily arm (1342.5 ± 562.5 IU vs. 1462.5 ± 645.0, P = 0.15), without compromising clinical pregnancy rate (PR) (71.8% vs. 70.9%, P = NS) or delivery/ongoing PR (58.2% vs. 62.1%, P = NS). There were no differences in age, body mass index (BMI), peak estradiol, peak progesterone, retrieved oocytes, fertilized oocytes, number of ET, or PR., Conclusions: Once daily administration is associated with lower gonadotropin usage without compromising success rates.

Objective: To study the incidence of monozygotic twins (MZT) in blastocyst and cleavage stage ET., Design: Retrospective review., Patient(s): Four hundred ninety-six women undergoing IVF/intracytoplasmic sperm injection cycles at a private assisted reproductive technology (ART) center., Intervention(s): Patients undergoing ART were divided according to the stage of ET into blastocyst transfer (BT) and cleavage stage (CS) ET., Main Outcome Measure(s): Incidence of MZT as noted on vaginal ultrasound at 6 to 8 weeks., Result(s): There were 374 (75.4%) BT cycles, and 122 (24.6%) CS cycles. Women in the BT group were significantly younger, had more oocytes retrieved, and had less embryos transferred compared with the CS group. The clinical pregnancy rate was significantly higher in the BT group at 67.9% (254 of 374), compared with 37.7% (46 of 122) among the CS group. There was a significantly higher incidence of multiple gestation in the BT group compared with CS group (37.4% compared with 19.6%). The overall incidence of MZT was 1.3%, but differed with the stage of ET: the incidence of MZT was 1.57% (4 of 254) in the BT group, and 0 (0 of 46) in the CS group., Conclusion(s): Contrary to the older published literature on MZT in BT cycles, the incidence of MZT is low. Women undergoing ART therefore should not be discouraged to undergo BT for fear of MZT, especially in light of the higher pregnancy rate and lower number of transferred embryos noted in those cycles compared with cleavage stage transfers., (Copyright 2010 American Society for Reproductive Medicine. Published by Elsevier Inc. All rights reserved.)

Objective: To report successful pregnancies in the setting of exaggerated endometrial thickness., Design: Case report., Setting: Two infertility practices., Patient(s): Two IVF patients., Intervention(s): IVF and ET., Main Outcome Measure(s): Endometrial thickness on the days of hCG injection, oocyte retrieval, and ET., Result(s): Two successful twin pregnancies, each after the transfer of two embryos, in the setting of an endometrial thickness of 16 mm in one case and 20 mm in the other., Conclusion(s): This report illustrates the possibility for a successful outcome in the setting of an exaggerated endometrial thickness, including for the first time a value of 20 mm on the day of egg retrieval.

Multiple endocrine, ultrasound-based and dynamic tests have been proposed for the assessment of ovarian reserve. Lately, ovarian biopsy has been proposed as a more representative functional test of ovarian reserve, and has been recommended as an early step in the investigation of infertility. Central to this hypothesis is the idea that a random biopsy of the ovarian cortex is reflective of the actual ovarian follicular pool. Recent studies have shown a wide variation in the number and distribution of ovarian follicles even from the same ovary and in the same patient. Coupled with the invasiveness of performing the biopsy and the risk of adhesion formation, we believe that there should not be a role for ovarian biopsy in ovarian reserve testing.

Purpose: Few studies have addressed the effect of weight on IVF outcome, with some showing a decrease in IVF success and some showing no change in overweight women (BMI > 25 kg/m2) compared to women with normal weight (BMI < 25 kg/m2)., Methods: One hundred thirty-nine women < 40 years old undergoing 180 IVF cycles with fresh embryo transfers were retrospectively evaluated between January 1997 and March 1999, stratified by body mass index (BMI) (cutoff of 25)., Results: In the group with BMI > 25 kg/m2, basal FSH, implantation rates (IR), and pregnancy rates (PR) were significantly lower, while the duration of stimulation, gonadotropin requirements, and spontaneous miscarriages were slightly higher, compared to the BMI < or = 25 group., Conclusions: Excess weight defined as BMI > 25 kg/m2 has a negative impact on IVF outcome. Future prospective studies evaluating oocyte and/or embryo quality, and androgen and insulin levels, between overweight women and those with normal weight are needed.

Ovarian volume measurements have been recently shown to be predictive of response to ovarian stimulation. Women with small ovarian volumes, i.e. <3 cm(3), have a higher incidence of cycle cancellation, together with a lower peak oestradiol concentration, lower number of retrieved oocytes, and lower pregnancy rates, compared with women with larger ovarian volumes. We prospectively investigated whether a higher dose, microdose flare gonadotrophin-releasing hormone (GnRH) agonist protocol, can improve IVF outcome in women with a small ovarian volume. Only the first IVF cycle was reviewed. In total, 109 women aged <40 years undergoing 109 cycles were prospectively evaluated. Women with an ovarian volume of < or =3 cm(3) noted on the day of luteal GnRH agonist administration had their stimulation regimen changed to a more aggressive microdose flare GnRH agonist protocol. In all, 30 women (27.5%) with an ovarian volume of <3 cm(3), and 79 women (72.5%) with an ovarian volume of >3 cm(3) were compared. Women with an ovarian volume of <3 cm(3) had a significantly higher incidence of unexplained infertility as their presenting aetiology, compared with women with a larger ovarian volume (33 and 8.6%, P = 0.0036). There was a significant negative correlation between age and ovarian volume, and between day 3 FSH concentration and ovarian volume. We also report a significant positive correlation between body mass index and ovarian volume. There was also a significant positive correlation between ovarian volume and the number of oocytes retrieved. Despite a trend towards higher day 3 FSH concentrations, a significantly longer duration of stimulation, higher gonadotrophin requirements, and lower oocyte yield, the implantation and pregnancy rates were comparable between the two groups. Women with a small ovarian volume noted at baseline ultrasound can have comparable implantation and pregnancy rates to those with larger ovarian volumes with the use of a higher dose gonadotrophin, microdose GnRH agonist stimulation.

In conclusion, several studies indicate that there is an association between cigarette smoking and adverse reproductive outcomes in women as well as men. Some studies indicate that alcohol consumption impairs the reproductive capacity of women. Exposures to PCE in the dry cleaning industry, toluene in the printing business, ethylene oxide and mixed solvents have been associated with decreased fecundity. Abnormalities in sperm production have been found in men exposed to radiant heat or heavy metals. Environmental exposure to chlorinated hydrocarbons (e.g., DDT, PCB, pentachlorophenol, hexachlorocyclohexane) has been associated with an increase in rates of miscarriage and endometriosis. Clinicians should counsel patients who are trying to achieve a successful pregnancy to stop smoking and limit alcohol intake. Clinicians can additionally counsel patients who are in contact with potentially harmful occupational and environmental toxicants to limit their exposure. It is important to recognize, however, that many of the studies to date are limited by small sample size, poor exposure assessment, poor outcome measurements, recruitment bias, or recall bias. Additional studies will be necessary to clarify the magnitude of risk associated with these factors.

Objective: To determine if basal E(2) screening increases the diagnostic accuracy of basal FSH screening and to determine whether basal E(2) levels correlate with outcome in ART cycles., Design: Retrospective., Setting: Tertiary care center., Patient(s): Two thousand six hundred thirty-four infertility patients., Intervention(s): Cycle outcome was evaluated after grouping patients by basal E(2) levels beginning at <20 pg/mL and extending to >100 pg/mL at 10 pg/mL increments., Main Outcome Measure(s): Retrieved oocytes, pregnancy rate, and cancellation rate., Result(s): Cancellation rates were significantly increased in patients with basal E(2) levels of <20 pg/mL or >/=80 pg/mL. Basal E(2) levels neither predicted pregnancy outcome nor correlated with ovarian response in those patients not canceled., Conclusion(s): Patients with basal E(2) levels of <20 pg/mL or >/=80 pg/mL had an increased risk for cancellation. Basal E(2) was predictive of stimulation parameters in patients 40 years or older. For those patients who proceeded to retrieval, there were no differences in pregnancy or delivery rates relative to basal E(2) levels. This suggests that irrespective of basal E(2) levels patients who produce more than three maturing follicles in response to stimulation have adequate ovarian reserve as evidenced by their pregnancy rates.

Objective: To compare IVF outcomes between white and black women in an inner-city, university-based IVF program., Design: Retrospective study., Setting: University-based IVF program., Patient(s): Ninety-five white women undergoing 121 cycles and 37 black women undergoing 47 cycles., Intervention(s): None., Main Outcome Measure(s): Implantation rate and pregnancy rate (PR)., Result(s): Black women constituted 28. 0% of the population and underwent 28.0% of the total cycles. There were no statistically significant differences in age, basal FSH, number of ampules, duration of stimulation, endometrial thickness, P on the day of hCG, cancellation rate, number of oocytes, or embryos transferred. However, the duration of infertility, body mass index (BMI), incidence of tubal-factor infertility, and peak E(2) levels were significantly higher in black women. In addition, a larger proportion of black women required aggressive stimulation than white women (70.2% and 43.0%). Both implantation rates and clinical PRs were significantly lower in black women than in white women (9.8% and 19.2% compared with 23.4% and 42.2%, respectively)., Conclusion(s): Black women have poorer IVF outcomes than white women. These differences can be partly explained by higher BMI, longer duration of infertility, higher incidence of tubal-factor infertility, and higher peak E(2).

Objective: To report a case of secondary amenorrhea and infertility caused by an inhibin-B-producing ovarian fibrothecoma., Design: Case report., Setting: Academic medical center., Patient: A 37-year-old woman with a 2-year history of secondary amenorrhea and infertility., Intervention(s): Operative removal of a 5-cm ovarian fibrothecoma., Main Outcome Measure(s): Luteinizing hormone, FSH, E2, inhibin-B, TSH, and prolactin measured preoperatively and postoperatively. Immunostaining of tumor cells for inhibin and LH., Result(s): Preoperative hormone levels were as follows: FSH, 1.7 mIU/mL; LH, 23.4 mIU/mL; E2, 31 pg/mL; and inhibin B, 1,154 pg/mL. Three weeks postoperatively, the FSH was 1.5 mIU/mL, LH decreased to 7.1 mIU/mL, E2 increased to 276 pg/mL, and inhibin-B decreased to 17 pg/mL. The fibrothecoma did not stain for LH but was strongly positive for inhibin. Regular menstrual cycles resumed 28 days postoperatively., Conclusion(s): Inhibin-B produced by an ovarian tumor profoundly suppressed FSH levels and resulted in secondary amenorrhea and infertility. Use of sensitive and specific immunoassays for inhibin-A and -B may aid in the differential diagnosis of hormonally active ovarian tumors.

Purpose: Multiple studies have confirmed a lower implantation (IR) and pregnancy rate (PR) in women who exhibit a homogeneous pattern (pattern II) of the endometrium compared to a triple-line pattern (pattern I) on the day of hCG administration. However, no data are available to evaluate if patients alter their endometrial thickness and pattern between the day of hCG administration (DhCG) and the day of oocyte retrieval (DRET) and whether these changes adversely affect endometrial receptivity., Methods: We prospectively evaluated 86 women (mean age, 32.9 +/- 3.8 years; range, 24-40 years) undergoing 103 IVF/ET cycles., Results: Pattern II was noted in 7 cycles (6.8%) on DhCG, compared to 96 cycles with pattern I (93.2%). However, 20 cycles (19.4%) had pattern II on DRET. The ongoing IR was 13.0% (3/23) in the pattern II group compared to 20.8% (76/365) in the pattern I group on DhCG (P = NS). However, a significant decrease in the ongoing IR, to 9.9% (7/71), was noted in pattern II, compared to 23.3% (71/305) in pattern I, on DRET (P = 0.019). There was no difference in age, basal FSH, peak E2, P4 on the day of hCG, number of oocytes, number of ET, or endometrial thickness between pregnant and nonpregnant patients, or between patients with pattern I and those with pattern II. A trend toward higher progesterone levels on DhCG was noted in women with pattern II (P = 0.078)., Conclusions: Endometrial pattern, rather than thickness, on the day of oocyte retrieval appears to be an important prognosticator of endometrial receptivity.

The role of luteal oestradiol for successful implantation in humans seems to be permissive rather than obligatory. Few studies have attempted to clarify the role of early luteal oestradiol in in-vitro fertilization (IVF) outcome, whether peri-implantation oestradiol is predictive of successful IVF outcome. We retrospectively analysed 106 women undergoing 106 IVF/embryo transfer cycles. Only the first treatment cycle per patient was analysed. Peak oestradiol denoted the concentration on the day of human chorionic gonadotrophin (HCG) administration. Mid-luteal oestradiol was obtained 3 days after embryo transfer (8 days after HCG administration). A total of 44 pregnancies were noted (41.51%). There were no differences in age, cycle day 3 follicle stimulating hormone (FSH), peak oestradiol, number of retrieved oocytes, number of embryo transfers, and mid-luteal oestradiol between pregnant and non-pregnant women. However, the ratio of day of HCG oestradiol to mid-luteal oestradiol was highly predictive of successful outcome: the ongoing pregnancy rate and implantation rate (sacs with fetal heart beat/embryo transfer) were 15.8 and 5.7% respectively if the above ratio exceeded 5.0 (n = 19), compared to 42.1 and 16.3%, and 53.3 and 26. 5% if the ratio was between 0.4 and 2.5 (n = 57), and between 2.5 and 5.0 (n = 30) respectively. Our study suggests that the magnitude of decline in oestradiol concentrations after oocyte retrieval may be important in predicting IVF success. We postulate that endometrial integrity may become compromised when a dramatic drop in oestradiol occurs by the mid-luteal period. Whether these women benefit from oestradiol supplementation after oocyte retrieval remains to be investigated.

Objective: To evaluate the impact of elevated peak E2 levels and a high number of retrieved oocytes on implantation in patients undergoing assisted reproductive techniques., Design: Retrospective study., Setting: University-based IVF program., Patient(s): One hundred six patients undergoing 106 IVF cycles. High responders were defined as those who had peak E2 levels of >3,000 pg/mL on the day of hCG administration (n = 38) or >15 retrieved oocytes (n = 48). Their IVF outcomes were compared with those of patients whose peak E2 levels were < or =3,000 pg/mL (n = 68) or who had < or =15 retrieved oocytes (n = 58)., Intervention(s): None., Main Outcome Measure(s): Implantation and pregnancy rates., Result(s): There were no statistically significant differences in age, basal FSH level, basal E2 level, number of ampules of gonadotropins required, fertilization rate, number of ETs, implantation rate, or pregnancy rate between normal and high responders or between women who did and did not become pregnant. In addition, no differences were detected when outcome was analyzed according to the stimulation regimen used., Conclusion(s): Elevated peak E2 levels and high oocyte yield are not detrimental to IVF outcome. More studies are needed to characterize the threshold E2 levels above which implantation rates are reduced.

Objective: To test the hypothesis that aging is associated with a decrease in ovarian volume, and that the FSH level and volume are correlated inversely., Methods: One hundred nine women who had 73 in vitro fertilization cycles and 36 ovulation induction cycles were analyzed. Basal FSH and estradiol (E2) levels were measured on cycle day 3, and ovarian volume was measured and antral follicles were counted on the day of starting gonadotropin., Results: The mean age (+/- standard deviation) was 32.6+/-4.7 years. The mean FSH was 6.9+/-2.4 IU/L. The mean ovarian volume was 6.0+/-4.7 cm3. There were no significant differences between the median volumes of the left and right ovaries in individual subjects (4.6 and 4.8 cm3, respectively; interquartile range 3.0-7.3 and 3.1-7.9; P = .79). There was a significant positive correlation between age and FSH level (R = .372, P<.001), but not between age and ovarian volume (R = .039, P = .69). A significant relation was noted between FSH and the number of follicles (H = 20.8, P<.001), but not between FSH and volume (R = .102, P = .29). There was a significant decrease in the number of follicles and a higher cycle cancellation rate in women with volume smaller than 3 cm3 compared with those with volume greater than 3 cm3., Conclusion: Women with small ovarian volumes, low number of antral follicles, and normal basal FSH and E2 levels may have diminished ovarian reserve.

Objective: To analyze the impact of elevated Chlamydia IgG antibody (Ab) titers on the outcome of gamete intrafallopian transfer (GIFT) cycles., Study Design: We retrospectively evaluated all the GIFT cycles in a five-year period performed at our center. One hundred one women under 40 years of age undergoing a total of 112 consecutive GIFT cycles were included., Results: Twenty-six cycles (23.2%) were in women with elevated serum Chlamydia IgG Ab, and 86 (76.8%) were in women with negative titers. There were no significant differences in mean age, number of mature oocytes obtained or number of oocytes transferred between the two groups. Patients with elevated IgG Ab had clinical and ongoing pregnancy rates (PR) of 34.6% and 23.1%, respectively, and an implantation rate (IR) of 7.1% (13/184) as compared to a clinical and ongoing PR of 47.7% and 40.7%, respectively, and an IR of 16.5% (61/369) in the negative Ab group, respectively (P = NS for clinical and ongoing PR, P = .003 for IR). No ectopic pregnancies were noted in either group. The incidence of early pregnancy loss was 33.3% (3/9) and 14.6% (6/41) in the positive and negative Ab groups, respectively (P = .40)., Conclusion: The presence of elevated serum Chlamydia IgG Ab was associated with a significantly lower implantation rate, a trend toward a lower PR and a trend toward a higher early pregnancy loss rate as compared to women with negative Ab titers. This group may represent a subset of assisted reproductive technology patients who are less likely to benefit from GIFT.

Background: The presence of endometrial fluid collections' developing during ovarian-stimulation was previously reported to occur in women with hydrosalpinx. We report on the occurrence of endometrial fluid collections in four women with polycystic ovary syndrome (PCOS) undergoing ovarian stimulation for in vitro fertilization., Cases: Four women developed endometrial fluid collections during ovarian stimulation. These fluid collections were noted as early as day 5 of stimulation. The reproductive outcome when fluid collections were noted on the day of human chorionic gonadotropin (hCG) or of embryo transfer (ET) was poor. One of three women with fluid collection on the day of hCG conceived but had a missed abortion. One patient with fluid on the day of ET failed to conceive. Three of four patients who underwent repeat cycles conceived when no fluid collections were seen on day of hCG or ET., Conclusion: Abnormal endometrial milieu could be an underlying defect in some women with PCOS and chronic anovulation who fail to conceive with ovulation-induction agents. This is the first report of endometrial fluid collections in patients with PCOS in the absence of hydrosalpinx. Continuous monitoring of the endometrial lining during ovulation induction is mandatory to rule out any abnormality in endometrial development. Cryopreserving all embryos may be considering in cycles with fluid collections noted on the day hCG or ET.

Background: The incidence of congenital uterine anomalies in the general population is estimated at 0.001-10%. Müllerian defects are associated with an increased incidence of urinary anomalies, an increased risk of infertility, early pregnancy loss, premature rupture of membranes, preterm labor and malpresentation., Case: A 34-year-old, infertile woman with a presumed diagnosis of uterine didelphys and a longitudinal vaginal septum was noted to have a thin, communicating membrane separating the uterine horns on magnetic resonance imaging (MRI). A communication between these two horns was noted on hysterosalpingography (HSG). The diagnosis of complete uterine septum was therefore established. Uterine leiomyomata and a complete duplication of the right renal collecting system were also noted., Conclusion: Cases of complete uterine and vaginal septum can be easily confused with uterine didelphys. Management of these two müllerian anomalies is different, with surgical correction usually needed in cases of complete uterine septum. The use of pelvic ultrasound, MRI and HSG aided in correctly diagnosing this unusual form of müllerian anomaly.