Anthony M. Propst

Complications of hysteroscopic surgery: predicting patients at risk.

Objective To determine the frequency of operative complications and whether they can be predicted by specific patient characteristics or type of hysteroscopic procedure. Methods We collected demographic and medical history information on 925 women who had hysteroscopies from 1995 through 1996. We compared differences in rates of operative complications of specific hysteroscopic procedures. Operative complications were defined as uterine perforation, excessive glycine absorption (1 L or more), hyponatremia, hemorrhage (500 mL or more), bowel or bladder injury, inability to dilate the cervix, and procedure-related hospital admissions. Results Operative complications occurred in 25 (2.7%) of 925 hysteroscopies. Excessive fluid absorption was the most frequent complication. Hysteroscopic myomectomy and resection of uterine septum were associated with greater odds of complications (odds ratio [OR] 7.4, 95% confidence interval [CI] 3.3, 16.6 and OR 4.0, 95% CI 0.9, 19.6, respectively). Hysteroscopic polypectomy and endometrial ablation were associated with lower odds of complications (OR 0.1, 95% CI 0.0, 0.7 and OR 0.4, 95% CI 0.1, 3.3, respectively). Hysteroscopies done by reproductive endocrinologists and preoperative GnRH agonist therapy were associated with 4–7 times higher odds for operative complications. Conclusion Complications during hysteroscopic surgery are rare. Among hysteroscopic procedures, myomectomies and resections of uterine septa have significantly higher rates of complications, especially excessive fluid absorption. Meticulous fluid management might limit the number of serious complications of these higher-risk procedures.

A randomized study comparing Crinone 8% and intramuscular progesterone supplementation in in vitro fertilization-embryo transfer cycles

OBJECTIVE To compare the efficacy of Crinone 8% intravaginal progesterone gel vs. IM progesterone for luteal phase and early pregnancy support after IVF-ET. DESIGN Randomized, open-label study. SETTING Academic medical center. PATIENT(S) Two hundred and one women undergoing IVF-ET. INTERVENTION(S) Women were randomized to supplementation with Crinone 8% (90 mg once daily) or IM progesterone (50 mg once daily) beginning the day after oocyte retrieval. MAIN OUTCOME MEASURE(S) Pregnancy, embryo implantation, and live birth rates. RESULT(S) The women randomized to luteal phase supplementation with IM progesterone had significantly higher clinical pregnancy (48.5% vs. 30.4%; odds ratio [OR], 2.16; 95% confidence interval [CI], 1.21, 3.87), embryo implantation (24.1% vs. 17.5%; OR, 1.89; 95% CI, 1.08, 3.30), and live birth rates (39.4% vs. 24.5%; OR, 2.00; 95% CI, 1.10, 3.70) than women randomized to Crinone 8%. CONCLUSION(S) In women undergoing IVF-ET, once-a-day progesterone supplementation with Crinone 8%, beginning the day after oocyte retrieval, resulted in significantly lower embryo implantation, clinical pregnancy, and live birth rates compared with women supplemented with IM progesterone.

Baby budgeting: oocyte cryopreservation in women delaying reproduction can reduce cost per live birth.

OBJECTIVE To determine whether oocyte cryopreservation for deferred reproduction is cost effective per live birth using a model constructed from observed clinical practice. DESIGN Decision-tree mathematical model with sensitivity analyses. SETTING Not applicable. PATIENT(S) A simulated cohort of women wishing to delay childbearing until age 40 years. INTERVENTION(S) Not applicable. MAIN OUTCOME MEASURE(S) Cost per live birth. RESULT(S) Our primary model predicted that oocyte cryopreservation at age 35 years by women planning to defer pregnancy attempts until age 40 years would decrease cost per live birth from

Diminished ovarian reserve in the United States assisted reproductive technology population: diagnostic trends among 181,536 cycles from the Society for Assisted Reproductive Technology Clinic Outcomes Reporting System

55,060 to

Lateral cervical displacement is associated with endometriosis

39,946 (and increase the odds of live birth from 42% to 62% by the end of the model), indicating that oocyte cryopreservation is a cost-effective strategy relative to forgoing it. If fresh autologous assisted reproductive technology (ART) was added at age 40 years, before thawing oocytes, 74% obtained a live birth, and cost per live birth increased to

Timing luteal support in assisted reproductive technology: a systematic review.

61,887. Separate sensitivity analyses demonstrated that oocyte cryopreservation remained cost effective as long as performed before age 38 years, and more than 49% of those women not obtaining a spontaneously conceived live birth returned to thaw oocytes. CONCLUSION(S) In women who plan to delay childbearing until age 40 years, oocyte cryopreservation before 38 years of age reduces the cost to obtain a live birth.

Impact of day 3 or day 5 embryo transfer on pregnancy rates and multiple gestations

OBJECTIVE To evaluate trends in diminished ovarian reserve (DOR) assignment in the Society for Assisted Reproductive Technology (SART) Clinic Outcomes Reporting System database and to evaluate its accuracy in predicting poor ovarian response (POR) as defined in European Society of Human Reproduction and Embryologys Bologna criteria (2011). DESIGN Retrospective cohort study. SETTING Not applicable. PATIENT(S) A total of 181,536 fresh, autologous ART cycles reported to SART by U.S. clinics in 2004 and 2011 (earliest and most recent available reporting years). INTERVENTION(S) None. MAIN OUTCOME MEASURE(S) DOR assignment was the primary exposure. POR, defined as cycle cancellation for poor response or less than 4 oocytes retrieved after conventional gonadotropin stimulation (>149 IU FSH daily), was the primary outcome. Secondary outcomes were live birth and number of oocytes retrieved. DOR prevalence, power of DOR and FSH (</≥12 mIU/mL) to predict POR, and live birth in POR cycles were also calculated. RESULT(S) DOR prevalence increased from 19% to 26% from 2004 to 2011. Among cycles clinically assigned as DOR, incidence of POR decreased from 32% to 30%, and live birth improved from 15% to 17%. Comparing basal FSH ≥12 versus clinical assignment of DOR, basal FSH had a higher specificity (92.2% vs. 81.6%) and positive predictive value (38.3% vs. 30.9%) for predicting POR. Live birth among POR cycles was 4%. CONCLUSION(S) DOR diagnosis is increasing, and accuracy remains poor, despite the availability of additional diagnostic parameters such as antral follicle count and antimüllerian hormone. POR entailed poor outcomes, but the majority of patients clinically assigned as DOR did not experience POR. Development and use of more accurate predictors of POR are needed to minimize patient distress resulting from overdiagnosis.

Establishing Institutional Critical Values of Follicle-Stimulating Hormone Levels to Predict In Vitro Fertilization Success

OBJECTIVE To report on a series of cases of lateral cervical displacement and uterosacral ligament scarring associated with endometriosis. DESIGN Case series. SETTING Academic medical center. PATIENT(S) Three nulliparous women with chronic pelvic pain, lateral cervical displacement, and uterosacral nodularity. INTERVENTION(S) Physical examination to evaluate for lateral cervical displacement. Laparoscopic surgery to evaluate for endometriosis and uterosacral ligament involvement. MAIN OUTCOME MEASURE(S) Displacement of the entire cervix lateral to the midline of the vagina. Presence of endometriosis on the affected uterosacral ligament. RESULT(S) All three patients had lateral cervical displacement and implants of endometriosis and scarring on the uterosacral ligament ipsilateral to the displaced cervix. CONCLUSION(S) In women with pelvic pain, lateral cervical displacement due to uterosacral scarring may be a physical finding associated with endometriosis.

The Use of rLH, HMG and hCG in Controlled Ovarian Stimulation for Assisted Reproductive Technologies

OBJECTIVE To summarize the available published randomized controlled trial data regarding timing of P supplementation during the luteal phase of patients undergoing assisted reproductive technology (ART). DESIGN A systematic review. SETTING Not applicable. PATIENT(S) Undergoing IVF. INTERVENTION(S) Different starting times of P for luteal support. MAIN OUTCOME MEASURE(S) Clinical pregnancy (PR) and live birth rates. RESULT(S) Five randomized controlled trials were identified that met inclusion criteria with a total of 872 patients. A planned meta-analysis was not performed because of a high degree of clinical heterogeneity with regard to the timing, dose, and route of P. Two studies compared P initiated before oocyte retrieval versus the day of oocyte retrieval and PRs were 5%-12% higher when starting P on the day of oocyte retrieval. One study compared starting P on day 6 after retrieval versus day 3, reporting a 16% decrease in pregnancy in the day 6 group. Trials comparing P start times on the day of oocyte retrieval versus 2 or 3 days after retrieval showed no significant differences in pregnancy. CONCLUSION(S) There appears to be a window for P start time between the evening of oocyte retrieval and day 3 after oocyte retrieval. Although some studies have suggested a potential benefit in delaying vaginal P start time to 2 days after oocyte retrieval, this review could not find randomized controlled trials to adequately assess this. Further randomized clinical trials are needed to better define P start time for luteal support after ART.

Anatomic factors associated with recurrent pregnancy loss.

OBJECTIVE To test the hypothesis that day 5 ET (D5ET) is superior to day 3 ET (D3ET) in pregnancy outcome and that it also reduces multiple gestations. DESIGN Retrospective cohort study. SETTING Assisted reproductive technologies program at Wilford Hall Medical Center. PATIENT(S) Patients electing for either D3ET or D5ET. INTERVENTION(S) Participants meeting inclusion criteria for D5ET elected either D3ET or D5ET. MAIN OUTCOME MEASURE(S) Cycles were compared by day of transfer and further stratified by patient age (<35 years and 35-40 years). The number of oocytes retrieved, embryos on day 3, embryos transferred, pregnancy rate, implantation rate, and twin and high order multiples (>or=triplets) rates were compared. RESULT(S) Of the 274 patients who met our inclusion criteria, 153 underwent a D3ET and 121 underwent a D5ET. The D5ET group had a significantly lower mean age and number of embryos transferred and a higher implantation rate (56% vs. 42%) than the D3ET group. Patients who were 35-40 years old had a significantly higher live-birth rate (68% vs. 40%). Although not statistically significant, the D5ET groups had higher clinical pregnancy (73% vs. 65%) and twin pregnancy (33% vs. 25%) rates. CONCLUSION(S) Blastocyst transfer resulted in fewer embryos transferred, with a trend toward improved clinical pregnancy and higher twin pregnancy rates. Live-birth rates were improved in patients 35-40 years of age. Younger patients opting for D5ET should do so with a commitment toward single ET.