B. McAvey

How many eggs are needed to produce an assisted reproductive technology baby: is more always better?

OBJECTIVE To evaluate the association between the number of mature (metaphase II [MII]) oocytes per assisted reproductive technology (ART) cycle and the likelihood of live birth. DESIGN Retrospective study. SETTING Academic infertility practice. PATIENT(S) Seven hundred thirty-seven infertile women undergoing their initial fresh embryo, nondonor IVF or intracytoplasmic sperm injection cycle at Montefiores Institute for Reproductive Medicine and Health between January 2002 and December 2008. INTERVENTION(S) None. MAIN OUTCOME MEASURE(S) Live birth. RESULT(S) Two hundred twenty-four cycles resulted in a live birth (30.4%). Live birth cycles had significantly more MII oocytes obtained per cycle as compared with their unsuccessful counterparts (11.0 ± 5.9 vs. 9.7 ± 6.2, respectively). Multivariate logistic regression was done to determine the minimum number of MII oocytes per cycle as a predictor of live birth after adjustment for age and historical maximum FSH values. Cycles that included the average number of MII in this cohort were used as a reference group. For cycles with five or fewer MII oocytes obtained, there was a statistically significant decrease in the likelihood of a live birth as compared with the reference group (odds ratio 0.61, 95% confidence interval 0.38-0.99). However, cycles with six or fewer obtained MII oocytes were not less likely to result in a live birth when compared with the reference group (odds ratio 0.69, 95% confidence interval 0.45-1.08). CONCLUSION(S) In our cohort, there was an advantage to obtaining six or more MII oocytes during the fresh oocyte retrieval compared with five or fewer oocytes. There was not an advantage, however, to obtaining 10 or more or 15 or more oocytes as compared with obtaining 6-9 oocytes. The strategy of aiming for a greater number of oocytes in an ART cycle should be revisited.

Aromatase Inhibition Causes Increased Amplitude, but not Frequency, of Hypothalamic-Pituitary Output in Normal Women

OBJECTIVE To better understand the site and mode of action of aromatase inhibitors. DESIGN Prospective study. SETTING Academic research environment. PATIENT(S) Five eumenorrheic (without polycystic ovary syndrome), early follicular phase women with a normal body mass index (mean: 20.47±0.68 kg/m2), and 12 normal weight, midreproductive aged, early follicular phase women with a normal body mass index (mean: 20.8±1.7 kg/m2) as historical controls. INTERVENTION(S) 2.5 mg letrozole daily for 7 days, with daily urine collection (first morning void), thrice weekly blood sampling, and 4 hours of blood sampling every 10 minutes. MAIN OUTCOME MEASURE(S) Serum luteinizing hormone (LH) measured by a well-characterized immunofluorometric assay with LH pulse characteristics compared between treated and control groups using t tests. RESULT(S) Mean LH and LH pulse amplitude more than doubled in the women who had taken letrozole compared with the controls, but the LH pulse frequency did not differ between the women taking letrozole and the controls. CONCLUSION(S) These results indicate that the release of negative feedback inhibition of estradiol on the hypothalamic-pituitary axis in normal women by aromatase inhibitors creates an amplitude-related increase in endogenous hypothalamic-pituitary drive. The finding that the mean LH and LH pulse amplitude, but not the frequency, increased after letrozole suggests a possible pituitary site of action.

Gaps in Fertility Knowledge Among Female Medical Trainees [357]

INTRODUCTION: Reproductive decision-making is complicated by a preponderance of fertility misconceptions. Because physicians often delay childbearing until completing training, we sought to validate a novel fertility knowledge instrument assessing the basis for these decisions. METHODS: A web-based survey on fertility knowledge and treatment was constructed and validated. The pilot survey was distributed to female students and obstetrics and gynecology housestaff at two academic hospitals. Relevant demographics were collected. The study was institutional review board-exempt. RESULTS: A total of 127 (99 students, 28 housestaff) participated. The mean score was 18.8 out of 29 (64.9%). Respondents underestimated the miscarriage rate (34.6%) and effect of alcohol (30.7%) and lubricants (36.2%). Fourteen percent believed a safely conducted pregnancy termination decreases fertility. All respondents recognized the definition of in vitro fertilization (IVF), 92.1% understood intrauterine insemination, and 97.6% oocyte cryopreservation. There was greater inaccuracy in estimating IVF success and complications (23.6–33.9% correct). The majority overestimated success in delayed childbearing scenarios relating to maternal age (73.2%) and oocyte cryopreservation (97.6%). Scores positively correlated with training year (r=0.40, P<.001). Housestaff knew more about natural fertility (P<.001), but not about assisted reproductive technologies (P=.49). In bivariate analyses, being older (P<.001) or married (P<.01), plan for obstetrics and gynecology specialization (P=.02), and training year (P<.001) predicted increasing score. In multivariate linear regression, training year remained the only independent predictor. CONCLUSION: Similar to the general public, students and housestaff demonstrate gaps in fertility knowledge, raising concern about the counseling they can provide to patients and themselves. Greater educational efforts must be undertaken.