Craig H. Syrop

Obstetric outcomes after in vitro fertilization in obese and morbidly obese women.

OBJECTIVE: In addition to numerous health detriments caused by obesity, fertility and pregnancy success may also be compromised. The aims of this study were to compare the effects of obesity and morbid obesity on in vitro fertilization (IVF) outcomes. We also investigated the effects of obesity on obstetric outcomes after IVF treatment. METHODS: Retrospective study of women less than 38 years of age during their first fresh IVF cycle (January 1995 to April 2005). RESULTS: A total of 1,293 women were included in the study, with 236 obese women (body mass index [BMI] = 30–39.9) and 79 morbidly obese women (BMI ≥ 40). The morbidly obese group had a 25.3% IVF cycle cancellation rate compared with 10.9% in normal-weight women (odds ratio 2.73, 95% confidence interval 1.49–5.0), P < .001). Morbidly obese women without polycystic ovarian syndrome had an even higher cancellation rate (33%). Women with higher BMI required significantly more days of gonadotropin stimulation but had lower peak estradiol levels (P < .001). There were no significant differences in clinical pregnancy or delivery rates between the four BMI groups. Of the women who delivered, there was a significant linear trend for risk of preeclampsia, gestational diabetes, and cesarean delivery with increasing BMI (P < .03). CONCLUSION: We report a significantly higher risk for IVF cycle cancellation in morbidly obese patients with no effect of BMI on clinical pregnancy or delivery rate. However, obese and morbidly obese subjects had a significantly higher risk for obstetric complications. This target population should be aggressively counseled regarding their increased obstetric risk and offered treatment options for weight reduction before the initiation of fertility therapy. LEVEL OF EVIDENCE: II-2

Effect of the total motile sperm count on the efficacy and cost-effectiveness of intrauterine insemination and in vitro fertilization

OBJECTIVE To determine prognostic factors for achieving a pregnancy with intrauterine insemination (IUI) and IVF. To compare the effectiveness and cost-effectiveness of IUI and IVF based on semen analysis results. DESIGN Retrospective cohort study. SETTING Academic university hospital-based infertility center. PATIENT(S) One thousand thirty-nine infertile couples undergoing 3,479 IUI cycles. Four hundred twenty-four infertile couples undergoing 551 IVF cycles. INTERVENTION(S) IUI and IVF treatment. MAIN OUTCOME MEASURE(S) Multiple logistic regression analysis was used to assess the significance of prognostic factors including a womans age, gravidity, duration of infertility, diagnoses, use of ovulation induction, and sperm parameters for predicting the outcomes of clinical pregnancy and live birth rate after the first cycle of IUI and IVF. The relative effectiveness and cost-effectiveness of these treatments were then determined based on sperm count results. RESULT(S) Female age, gravidity, and use of ovulation induction were all independent factors in predicting pregnancy after IUI. The average total motile sperm count in the ejaculate was also an important factor, with a threshold value of 10 million. For IVF, only female age was an important predictor for both clinical and ongoing pregnancy. When the average total motile sperm count was under 10 million, IVF with ICSI was more cost-effective than IUI in our clinic. CONCLUSION(S) An average total motile sperm count of 10 million may be a useful threshold value for decisions about treating a couple with IUI or IVF.

Natural history of uterine polyps and leiomyomata

OBJECTIVE To estimate the incidence and regression rates of uterine leiomyomata and polyps in a cohort of asymptomatic, premenopausal women. METHODS Saline infusion sonography was performed twice, 2.5 years apart, in a cohort of 64 initially asymptomatic women. Subjects completed a questionnaire that assessed the development of abnormal uterine bleeding. RESULTS The mean age of women (at second ultrasound) was 44 years. In four of seven women with polyps at the original ultrasound, their polyps regressed. Polyps that regressed tended to be smaller than polyps that persisted. Ten women had endometrial polyps at the second ultrasound for a point prevalence of 16% and a cumulative incidence rate of 12% per 2.5 years. A higher percentage of women with uterine polyps had complaints of abnormal uterine bleeding than women with no uterine abnormalities (70% versus 33%, P = .04). Six leiomyomata in four women were no longer detected in the second ultrasound. Leiomyomata that regressed were in older premenopausal women and were smaller than leiomyomata that persisted. The point prevalence and incidence rates of leiomyomata were 27% and 13% per 2.5 years, respectively. Leiomyomata grew an average of 1.2 cm per 2.5 years, but great variation in growth rates were noted. CONCLUSION Small uterine polyps frequently regressed spontaneously, whereas larger polyps were more likely to persist and were associated with the development of abnormal bleeding. Smaller leiomyomata in older premenopausal women also regressed whereas larger leiomyomata tended to grow while often remaining asymptomatic.

Increased risk of monochorionic twinning associated with assisted reproduction.

OBJECTIVE To determine the incidence of monochorionic twinning in pregnancies resulting from assisted reproduction technologies (ARTs). METHODS We reviewed our experience with 218 ART pregnancies achieved over 3 years. All patients underwent transvaginal ultrasound 26 and 36 days after oocyte retrieval. The presence of two yolk sacs or two fetal poles within one sac suggested monochorionicity, and was confirmed by follow-up ultrasound and placental pathology. The various ARTs were compared to determine if any method had an increased incidence of monochorionicity compared to any other method. Statistical analysis was performed employing Chi Square analysis. RESULTS The incidence of monochorionicity in all gestations was 3.2% (8 times background rate); among multiple gestations it was 9.8%. The rates of monochorionicity for each ART appeared similar. CONCLUSION The incidence of monochorionic twinning is increased in pregnancies resulting from ART. Careful ultrasound evaluation of such pregnancies for monochorionicity is strongly recommended, both for planning of prenatal care and when considering a multifetal pregnancy reduction procedure.

Sonohysterography in premenopausal women with and without abnormal bleeding

OBJECTIVE To estimate the prevalence of abnormalities detected by sonohysterography in premenopausal women who were asymptomatic or had abnormal uterine bleeding. METHODS Standard sonohysterography was done in 100 asymptomatic premenopausal women age 30 and older. The prevalence of uterine abnormalities was recorded and compared with findings in 80 premenopausal women evaluated in our unit for abnormal uterine bleeding. RESULTS Compared with asymptomatic women, premenopausal women with abnormal uterine bleeding had a higher prevalence of polyps (33 versus 10%), intracavitary myomas (21 versus 1%), and intramural myomas (58 versus 13%). Ten percent of asymptomatic women had polyps, but these polyps tended to be smaller than the polyps found in women with abnormal bleeding (8.5 versus 13.9 mm, P = .064). Polyps were associated significantly with myomas, and both were more common in older premenopausal women. CONCLUSION Intracavitary lesions and intramural myomas are more prevalent in women with abnormal uterine bleeding than in asymptomatic women, suggesting a causative relationship. However, small endometrial polyps are common and frequently asymptomatic.

Ovarian volume : a novel outcome predictor for assisted reproduction

OBJECTIVE To determine the potential of ovarian volume as a predictor of assisted reproduction outcomes. DESIGN Retrospective chart review. SETTING University-based assisted reproduction program. PATIENTS One hundred eighty-eight women initiating their first cycle of assisted reproduction. INTERVENTIONS None. MAIN OUTCOME MEASURES Pretreatment transvaginal ultrasound ovarian measurements were compared with subsequent ovulation induction parameters (peak E2, numbers of oocytes, and embryos) and cycle outcome (cancellation and pregnancy). RESULT Total ovarian volume and volume of the smallest ovary were significant variables predicting peak E2 and numbers of oocytes and embryos. Total ovarian volume was a predictor of cycle cancellation and volume of the smallest ovary a predictor of clinical pregnancy. Large ovarian volumes are associated with good assisted reproductive technology outcomes whereas small ovarian volumes are associated with poor outcomes. CONCLUSION Beyond maternal age, total ovarian volume, and volume of the smallest ovary are significant predictors of the success of assisted reproductive techniques.

The Effects of Smoking on Ovarian Function and Fertility During Assisted Reproduction Cycles

Objective To investigate the effects of cigarette smoking on ovarian function and fertility in women undergoing assisted reproduction cycles. Methods We assessed the effects of smoking on ovarian function and fertility in a cohort of 499 women. Questionnaires were designed to quantify past smoking exposure and to determine whether the woman was smoking during the treatment cycle. Ovarian function characteristics and pregnancy rates were compared among current smokers, past smokers, and nonsmokers. Results Compared with nonsmokers, both current and past smokers have reduced gonadotropin-stimulated ovarian function. A history of increasing tobacco exposure was associated with decreasing serum estradiol concentrations, numbers of retrieved oocytes, and numbers of embryos. On average, for every 10 pack-years of cigarette smoking, 2.5 fewer mature oocytes and 2.0 fewer embryos were obtained. Women who smoked during their treatment cycle had approximately a 50% reduction in implantation rate and ongoing pregnancy rate compared with women who had never smoked. Women who quit smoking before their treatment cycle had the same pregnancy rate as nonsmokers. Conclusion Cigarette smoking is associated with a prolonged and dose-dependent adverse effect on ovarian function. Smoking appears to have a more transient toxic effect on fertility, because current smokers, but not past smokers, had a markedly reduced pregnancy rate after treatment cycles compared with nonsmokers. Women should quit smoking before assisted reproduction cycles.

Detection of cesarean scars by transvaginal ultrasound

OBJECTIVE: To assess the ability of transvaginal ultrasound to detect cesarean scars and their defects in the nonpregnant state. METHODS: Asymptomatic, parous volunteers underwent transvaginal ultrasound of the cervix, uterus, and adnexa. Uterine measurements, the presence or absence of a cesarean scar, and the presence of a scar defect, defined as fluid within the scar, were recorded. All subjects completed a self‐report questionnaire regarding obstetric history. Sonographers and investigators were blinded to subject history. RESULTS: A total of 70 subjects were enrolled. Of these, 38 women had a prior vaginal delivery and 32 women a prior cesarean delivery. One woman with a bicornuate uterus and three cesarean deliveries was excluded from data analysis. Real‐time transvaginal ultrasound proved 100% sensitive (exact 95% confidence interval [CI] 88.8, 100) and 100% specific (exact 95% CI 90.7, 100). Stored image review had a sensitivity of 87% (exact 95% CI 70.2, 96.4) and a specificity of 100% (exact 95% CI 90.7, 100). Fluid was visualized within the scars of 13 of 31 subjects (42%) with a prior cesarean delivery. All 13 were found among the 23 subjects (56%) who had labored prior to cesarean delivery. Moreover, women with cesarean scar defects had a greater number of cesarean deliveries (P < .04) than women without scar defects. CONCLUSION: Transvaginal ultrasound is highly accurate in detecting cesarean hysterotomy scars. Cesarean scar defect, defined by the presence of fluid within the incision site, was more common when labor preceded cesarean delivery and with multiple cesarean deliveries. (Obstet Gynecol 2003; 101:61‐5.

Role, epidemiology, and natural history of benign uterine mass lesions.

IntroductionBoth major tissue types of the uterine corpus-the endometrium and the myometrium-can develop nonmalignant mass lesions, especially during a womans fertile years. Endometrial polyps, consisting of endometrial glands, fibrotic stroma, and central thick-walled vascular channels, protru

Cost-effectiveness of infertility treatments: a cohort study

OBJECTIVE To determine the cost-effectiveness of infertility treatments. DESIGN Retrospective cohort study. SETTING Academic medical center infertility practice. PATIENT(S) All patients treated for infertility in a 1-year time span. INTERVENTION(S) Intrauterine inseminations, clomiphene citrate and IUI (CC-IUI), hMG and IUI (hMG-IUI), assisted reproductive techniques (ART), and neosalpingostomy by laparotomy. MAIN OUTCOME MEASURE(S) All medical charges and pregnancy outcomes associated with the treatments were obtained. Cost-effectiveness ratios defined as cost per delivery were determined for each procedure. The effects of a womans age and the number of spermatozoa inseminated on cost-effectiveness of the procedures was also determined. RESULT(S) Intrauterine inseminations, CC-IUI, and hMG-IUI have a similar cost per delivery of between