A.N. Beltsos

Body mass index: impact on IVF success appears age-related †

BACKGROUNDnThe objective of this study was to examine the effect of BMI on IVF outcomes.nnnMETHODSnThis was a retrospective analysis of all patients undergoing IVF from 1st January 2005 to 1st March 2006 in a large private practice using a single IVF laboratory. The patients underwent standard protocols for controlled ovarian hyperstimulation and embryology parameters. The main outcome measure was clinical pregnancy rate.nnnRESULTSnA total of 2167 fresh, non-donor IVF cycles were queried, but to minimize bias, only the first treatment cycle for each patient was analyzed (n = 1273). The data were examined by multiple regression models that included BMI and Age as main effects plus a BMI x Age interaction. When examined as a main effect, BMI did not appear to have a major effect on IVF outcome, but there was a significant BMI x Age interaction. At younger ages, a high BMI had a pronounced negative influence on fertility, but this effect diminished as the patient age increased. Clinical pregnancy rates decreased with increasing BMI and increasing Age.nnnCONCLUSIONSnIn younger patients undergoing IVF, BMI has a significant negative impact on fertility that diminishes as patients reach their mid thirties. After Age 36, BMI has a minimal impact on fertility.

Embryo transfer practices in the United States: a survey of clinics registered with the Society for Assisted Reproductive Technology

OBJECTIVEnTo gain a better understanding of factors influencing clinicians embryo transfer practices.nnnDESIGNnCross-sectional survey.nnnSETTINGnWeb-based survey conducted in December 2008 of individuals practicing IVF in centers registered with the Society for Assisted Reproductive Technology (SART).nnnPATIENT(S)nNone.nnnINTERVENTION(S)nNone.nnnMAIN OUTCOME MEASURE(S)nPrevalence of clinicians reporting following embryo transfer guidelines recommended by the American Society for Reproductive Medicine (ASRM), prevalence among these clinicians to deviate from ASRM guidelines in commonly encountered clinical scenarios, and practice patterns related to single embryo transfer.nnnRESULT(S)nSix percent of respondents reported following their own, independent guidelines for the number of embryos to transfer after IVF. Of the 94% of respondents who reported routinely following ASRM embryo transfer guidelines, 52% would deviate from these guidelines for patient request, 51% for cycles involving the transfer of frozen embryos, and 70% for patients with previously failed IVF cycles. All respondents reported routinely discussing the risks of multiple gestations associated with standard embryo transfer practices, whereas only 34% reported routinely discussing single embryo transfer with all patients.nnnCONCLUSION(S)nAlthough the majority of clinicians responding to our survey reported following ASRM embryo transfer guidelines, at least half would deviate from these guidelines in a number of different situations.

Adding human menopausal gonadotrophin to antagonist protocols - : is there a benefit?

The objective of this retrospective analysis was to compare the clinical outcomes of recombinant FSH (r-FSH) with combination r-FSH plus human menopausal gonadotrophin (HMG) protocols in a large private practice using a single IVF laboratory, from 2001 to 2003. Patients underwent ovarian stimulation by standard gonadotrophin-releasing hormone (GnRH) antagonist protocol using r-FSH or combination r-FSH plus HMG. When two or more follicles had attained a minimum mean diameter of 20 mm, follicular triggering was achieved with either recombinant HCG (r-HCG; Ovidrel, 250 microg s.c.) or urinary HCG (u-HCG; 10,000 IU i.m.). The main outcome measures were number of oocytes retrieved and clinical pregnancy rate. There was a lower percentage of cancelled cycles and an increased number of oocytes retrieved, mature oocytes, oocytes that fertilized, embryo that cleaved and a tendency towards higher clinical pregnancy rates in patients treated with r-FSH alone compared with those treated with r-FSH plus HMG. Patients treated with r-FSH plus HMG had lower miscarriage rates and the live birth rate was similar in both treatment groups. In conclusion, irrespective of age, using a treatment regimen consisting of a combination of HMG plus r-FSH was not beneficial compared with r-FSH alone in patients using a GnRH antagonist protocol.

Endometrin as luteal phase support in assisted reproduction

OBJECTIVEnTo compare clinical pregnancy rate (PR) and live birth rate (LBR) between Endometrin monotherapy versus Endometrin and P in oil combination therapy in assisted reproductive technology (ART) cycles.nnnDESIGNnRetrospective analysis.nnnSETTINGnLarge private practice.nnnPATIENT(S)nPatients undergoing autologous fresh IVF cycles, autologous frozen ET cycles, and fresh oocyte donor cycles were included for analysis.nnnINTERVENTION(S)nEndometrin as a single agent for luteal support, Endometrin monotherapy or Endometrin with P in oil used at least once every 3 days for luteal support, Endometrin combination therapy.nnnMAIN OUTCOME MEASURE(S)nClinical PR and LBR.nnnRESULT(S)nA total of 1,034 ART cycles were analyzed. Endometrin monotherapy was used in 694 of 1,034 (67%) cycles and Endometrin combination therapy was used in 340 of 1,034 (33%) cycles. In all fresh cycles, clinical PR was not significantly different (IVF autologous: Endometrin monotherapy 46.9% vs. Endometrin combination therapy 55.6%; donor oocyte endometrin monotherapy 45.2% vs. Endometrin combination therapy 52.0%). Frozen ET cycles had a significantly higher clinical PR and LBR with combination therapy group compared with monotherapy (clinical PR 47.9% vs. 23.5%; LBR 37.5% vs. 17.3%).nnnCONCLUSION(S)nEndometrin monotherapy was sufficient for the P component of luteal support and provided high PRs for fresh cycles in both autologous and donor oocyte cycles. Clinical PR and LBR in frozen ET cycles were significantly improved with the addition of IM P to Endometrin therapy. This may reflect the fact that lesser quality embryos are transferred in frozen ET cycles, and more intense P support is required for comparable PRs.

How members of the Society for Reproductive Endocrinology and Infertility and Society of Reproductive Surgeons evaluate, define, and manage hydrosalpinges

OBJECTIVEnTo describe the management of hydrosalpinges among Society for Reproduction Endocrinology and Infertility (SREI)/Society of Reproductive Surgeons (SRS) members.nnnDESIGNnCross-sectional survey of SREI/SRS members.nnnSETTINGnAcademic and private practice-based reproductive medicine physicians.nnnPARTICIPANT(S)nA total of 442 SREI and/or SRS members.nnnINTERVENTION(S)nInternet-based survey.nnnMAIN OUTCOME MEASURE(S)nTo understand how respondents evaluate, define, and manage hydrosalpinges.nnnRESULT(S)nOf 1,070 SREI and SRS members surveyed, 442 responded to all items, for a 41% response rate. Respondents represented both academic and private practice settings, and differences existed in the evaluation and management of hydrosalpinges. More than one-half (57%) perform their own hysterosalpingograms (HSGs), and 54.5% involve radiologists in their interpretation of tubal disease. Most respondents thought that a clinically significant hydrosalpinx on HSG is one that is distally occluded (80.4%) or visible on ultrasound (60%). Approximately one in four respondents remove a unilateral hydrosalpinx before controlled ovarian hyperstimulation (COH)/intrauterine insemination (IUI) and clomiphene citrate (CC)/IUI (29.3% and 22.8%, respectively), and physicians in private practice were more likely to intervene (COH: risk ratio [RR] 1.81, 95% confidence interval [CI] 1.31-2.51; CC: RR 1.98, 95% CI 1.33-2.95). Although laparoscopic salpingectomy was the preferred method of surgical management, nearly one-half responded that hysteroscopic tubal occlusion should have a role as a primary method of intervention.nnnCONCLUSION(S)nSREI/SRS members define a clinically significant hydrosalpinx consistently, and actual practice among members reflects American Society for Reproductive Medicine/SRS recommendations, with variation attributed to individual patient needs. Additionally, one in four members intervene before other infertility treatments when there is a unilateral hydrosalpinx present.

Age-matched comparison of recombinant and urinary HCG for final follicular maturation

This age-matched retrospective analysis compared the clinical outcomes of recombinant human chorionic gonadotrophin (rHCG) and urinary HCG (uHCG) in patients undergoing fresh, nondonor IVF cycles. The patients underwent ovarian stimulation by standard gonadotrophin-releasing hormone (GnRH) agonist down-regulation or a GnRH antagonist protocol using recombinant FSH (rFSH) alone or in combination with human menopausal gonadotrophin. When two or more follicles had attained a mean diameter of 20 mm, follicular triggering was achieved with either Ovidrel (rHCG) 250 mug SC or uHCG 10,000 IU IM. Patients receiving rHCG were considered subjects, and they were age-matched in a 1:2 ratio to patients receiving uHCG, who were designated as controls. The main outcome measures were number of oocytes retrieved, number of mature oocytes obtained, number of oocytes fertilized and clinical pregnancy rates. A total of 273 subjects were age-matched and compared with 546 controls. Recombinant HCG had a minimal effect on the number of oocytes retrieved (13.4 versus 13.2), mature oocytes (10.5 versus 10.3) and oocytes fertilized (8.2 versus 7.8) compared with uHCG. Pregnancy (46.0 versus 45.2%) and clinical pregnancy rates (38.1 versus 36.8%) were similar for rHCG and uHCG. Recombinant HCG was as effective as uHCG for final follicular maturation in IVF cycles.

State-mandated insurance coverage is associated with the approach to hydrosalpinges before IVF ☆

The aim of this study was to determine whether practice in states with infertility insurance mandates is associated with physician-reported practice patterns regarding hydrosalpinx management in assisted reproduction clinics. A cross-sectional, internet-based survey of 442 members of Society for Reproductive Endocrinology and Infertility or Society of Reproductive Surgeons was performed. Physicians practising in states without infertility insurance mandates were more likely to report performing diagnostic surgery after an inconclusive hysterosalpingogram than physicians practising in states with mandates (RR 1.2, 95% CI 1.1-1.3, P < 0.01). Additionally, respondents in states without mandates were more likely to report that, due to lack of infertility insurance coverage, they did not perform salpingectomy (SPX) or proximal tubal occlusion (PTO) before assisted reproduction treatment (RR 1.4, 95% CI 1.1-1.8, P = 0.01). Finally, respondents in states without mandates were less likely to report that the presence of assisted reproduction treatment coverage determined the urgency with which they pursued SPX or PTO before treatment (RR 0.7, 95% CI 0.5-1.0, NS). These results persisted after controlling for physician years in practice, age and clinic volume. In conclusion, self-reported physician practice interventions for hydrosalpinges before assisted reproduction treatment may be associated with state-mandated infertility insurance. Fallopian tube dysfunction is a known cause of infertility and severe dysfunction is manifested by dilation and occlusion, known as hydrosalpinx. Outcomes with assisted reproductive techniques (ART) are lower when hydrosalpinges are present and while there are several theories for this, reproductive specialist recommend neutralizing the tube either by occlusion or removal in order to enhance pregnancy rates. In the United States, coverage for infertility services is not uniform with only 15 states having some legislation requiring infertility benefits. Some states where ART is covered liberally, physicians might have different practice patterns related to the neutralization of hydrosalpinges compared to those who are in non -mandated states. We utilized a survey of over 400 providers in the United States to examine their practice patterns as it relates to hydrosalpinges based on which state they practice in and whether or not that state has mandated coverage of not.

High Intercycle Variability of Day 3 FSH Levels is Useful for Predicting Ovarian Responses But Not Pregnancy Outcomes in IVF

OBJECTIVE: To determine if intercycle variability in day 3 FSH (D3FSH) levels is useful in predicting IVF outcomes. DESIGN: Retrospective analysis of patients undergoing IVF from January 2004 to March 2005 in a large private practice setting. MATERIALS AND METHODS: A total of 2504 fresh, nondonor IVF cycles were available for analysis. This group encompassed a broad spectrum of patients representing typical infertility patients presenting for assisted reproduction. The patients ranged in age from 21-44 and underwent controlled ovarian hyperstimulation by standard midluteal phase GnRH agonist down regulation or GnRH antagonist protocol using recombinant FSH or FSH in combination with HMG. Adjustments were made based on individual responses, and when two or more follicles had attained a minimum mean diameter of 19-20mm, follicular triggering was achieved with hCG and oocyte retrieval was performed 36 hours later. Standard laboratory protocols were followed, including intracytoplasmic sperm injection, assisted hatching for cleavage embryos and extended culture for blastocyst transfer, as clinically appropriate. Ultrasound guided embryo transfer was performed, and all patients received luteal progesterone support. Serum hCG levels were measured 15 days after retrieval, and a clinical pregnancy was defined as the presence of a gestational sac on ultrasound. An estimate of normal intercycle D3FSH variability was derived by regressing standard deviations of replicate measurements against mean FSH in patients 35 years old with D3FSH 10. Patients were placed in the high variability category when their calculated standard deviation was significantly higher than normal. Comparisons were made between patients with normal and high D3FSH variability as well as patients with a single treatment cycle. Continuous and categorical data were analyzed by ANOVA and Chi Square tests, respectively. A value of P 0.05 was considered to be statistically significant. Results are expressed as mean SD. RESULTS: Patients with replicate cycles were older. Relative to patients with normal variability, patients with high D3FSH variability had significantly diminished ovarian responses, with fewer retrieved and mature oocytes but similar fertilization, pregnancy and clinical pregnancy rates. All patients with replicate cycles had significantly lower pregnancy outcomes than patients with single cycles.