Ina N. Cholst

The incidence of both serious and minor complications in young women undergoing oocyte donation

OBJECTIVE To investigate the incidence of serious and minor complications experienced by women undergoing controlled ovarian hyperstimulation and oocyte retrieval for oocyte donation. DESIGN Retrospective study. SETTING University-based IVF center. PATIENT(S) Five hundred eighty-seven donors underwent 973 cycles of controlled ovarian hyperstimulation and 886 oocyte retrievals for anonymous or directed oocyte donation. INTERVENTION(S) Controlled ovarian hyperstimulation; oocyte retrieval. MAIN OUTCOME MEASURE(S) Complications of the procedure. RESULT(S) The rate of serious complications, which included ovarian hyperstimulation syndrome, ovarian torsion, infection, and ruptured ovarian cyst, was 6 in 886 (0.7%) retrieval cycles. The rate of minor complications severe enough to prompt the donor to seek medical attention after retrieval was 8.5%. The cancellation rate after stimulation cycle initiation was approximately 9%, regardless of whether the donation was anonymous or directed. CONCLUSION(S) This study provides information on the incidence of serious complications experienced by oocyte donors after controlled ovarian hyperstimulation and oocyte retrieval. It provides evidence that with careful monitoring, and when a liberal cancellation policy is followed, oocyte donors experience lower rates of ovarian hyperstimulation syndrome, compared with infertile women undergoing IVF. Furthermore, the study provides the first set of data on the rate of symptomatic minor complications experienced by oocyte donors. This information will help clinicians administer appropriate informed consent to the young women who present themselves as potential oocyte donors.

Preimplantation genetic diagnosis for retinoblastoma: the first reported liveborn.

PURPOSE To develop an accurate mutation analysis procedure for retinoblastoma gene (RB1) mutation, which is sensitive at the single-cell level, and to use in vitro fertilization (IVF) and preimplantation genetic diagnosis (PGD) to achieve pregnancies without retinoblastoma. DESIGN Case report. METHODS Twelve day 3 embryos, obtained by IVF with intracytoplasmic sperm injection, underwent single-cell DNA testing via polymerase chain reaction and restriction enzyme analysis to detect the presence of a paternal RB1 mutation. Embryos were diagnosed as being unaffected and were transferred to the uterus on day 5. MAIN OUTCOME MEASURES Achieving a healthy pregnancy and delivery, assessed by clinical presentation, fundus photography, and RB1 molecular analysis. RESULTS A singleton pregnancy was achieved, and a child without retinoblastoma was born. The absence of the paternal RB1 mutation was confirmed on a sample of peripheral blood from the newborn. CONCLUSIONS We are first to report a successful human liveborn, delivered after IVF with preimplantation genetic diagnosis for retinoblastoma. The successful result indicates that preimplantation genetic diagnosis exists for this genetic disease and may represent a viable alternative to prenatal diagnosis with the subsequent option of terminating an affected pregnancy.

Families created through ovum donation: A preliminary investigation of obstetrical outcome and psychosocial adjustment

PurposeThis study attempted to obtain preliminary followup information regarding obstetrical outcomes and the psychosocial well-being of families created through ovum donation. There is presently very little known about this population with respect to obstetrical care, health status of offspring, family and marital relationships of recipient couples, or how couples feel about having chosen ovum donation as a family-building option.ResultsFifty-nine couples were initially surveyed and, ultimately, extensive information was obtained for 30 husbands, 31 wives, and 51 offspring. There was a very high percentage of cesarean section deliveries (81.6%), and although a few children experienced health problems at birth, they are all now in good health and developmental milestones are within normal limits. Information was also obtained about breast-feeding experiences, choice of donor (known) [sister] or anonymous), reasons for choosing ovum donation over other parenting options, and the impact of this choice on marital and family relationships. Demographic data were also obtained.ConclusionsFor many infertile couples, the long struggle to become parents culminated in a successful birth, and the experience of pregnancy seemed to meet a need to be both biological and psychosocial parents. In general, subjects were extremely cooperative with the investigation and they indicated a desire to learn as much as possible about the psychosocial status of families created through ovum donation. As the assisted reproductive technologies move rapidly into the 21st century, it now seems imperative that health and mental health professionals gain more knowledge about the impact of third party reproduction and the psychosocial adjustment and well-being of families created by this medical technology.

Risk factors for a suboptimal response to gonadotropin-releasing hormone agonist trigger during in vitro fertilization cycles

OBJECTIVE To identify risk factors for a suboptimal response to gonadotropin-releasing hormone (GnRH) agonist trigger in in vitro fertilization (IVF) cycles. DESIGN Retrospective cohort study. SETTING Academic medical center. PATIENT(S) All 424 patients undergoing fresh IVF cycles (n = 500) between August 2007 and June 2013 in whom a GnRH agonist was used as all or part of the ovulation trigger. INTERVENTION(S) GnRH-antagonist-based IVF cycles triggered with leuprolide acetate alone or in combination with low-dose human chorionic gonadotropin. MAIN OUTCOME MEASURE(S) Suboptimal response to GnRH-agonist trigger, as defined by a serum luteinizing hormone (LH) level <15 mIU/mL on the morning after trigger. RESULT(S) The rate of suboptimal response to the GnRH-agonist trigger was 5.2%. Patients with a suboptimal hormone response had lower follicle-stimulating hormone (<0.1 vs. 3.48) and LH (<0.1 vs. 2.51) levels on day 2 of the cycle start, lower LH (0.109 vs. 0.596) on the day of trigger, and required longer stimulation and more gonadotropins than those with an adequate response. Suboptimal responders were also more likely to have irregular menses and be on long-term oral contraception. Patients with an undetectable LH on the day of trigger had a 25% chance of a suboptimal LH surge. In our study cohort, limiting the use of the GnRH-agonist trigger alone to patients with a trigger day LH ≥0.5 would have reduced the rate of suboptimal response from 5.2% to 0.2%. CONCLUSION(S) Long-term hormonal contraception use is an independent risk factor for suboptimal response to GnRH-agonist trigger. Patients with very low endogenous serum LH levels on the day of LH trigger are at increased risk for a suboptimal GnRH-agonist trigger response. Understanding the at-risk phenotype and using trigger day LH as a marker for increased risk of suboptimal GnRH-agonist trigger response can be helpful for individualizing treatment and selecting a safe and efficacious trigger medication for patients undergoing IVF.

Incorporating Information Regarding Preimplantation Genetic Diagnosis Into Discussions Concerning Testing and Risk Management for BRCA1/2 Mutations A Qualitative Study of Patient Preferences

Studies have shown that BRCA1/2 mutation carriers are interested in learning about reproductive options such as preimplantation genetic diagnosis (PGD) to prevent passing their risk onto their children. However, attitudes vary widely, and the procedure raises complex ethical and psychosocial issues. This complexity, plus the highly technical nature of PGD, makes it difficult to integrate PGD information into genetic counseling sessions that already cover probabilistic, emotionally charged risk information.

Shared oocyte donation: society’s benefits

OBJECTIVE To assess the efficacy of oocyte donation when a cohort of oocytes is shared between two phenotypically matched recipients. DESIGN A retrospective analysis of a program using shared anonymous oocyte donation. SETTING Academic infertility center. PATIENT(S) Recipient women with partial or complete ovarian failure; oocyte donors who have been properly screened. INTERVENTION(S) Each oocyte donor was phenotypically matched with two potential recipients. The cohort of donated oocytes were divided between these two recipients if eight or more mature oocytes were obtained at retrieval. Recipients underwent hormone replacement therapy consisting of down-regulation with a GnRH agonist, transdermal estradiol, and intramuscular progesterone in a dose determined by a previous preparatory cycle. MAIN OUTCOME MEASURE(S) Pregnancy and delivery rates for all transfers originating from a cohort of oocytes obtained by retrieval of a single donor; pregnancy and delivery rates per recipient; rate of conversion of a shared donation cycle to a single recipient. RESULT(S) A total of 249 donor cycles permitted 241 retrievals. Each recipient received 8.3 +/- 3.5 oocytes per donation. There were 424 fresh ETs and 48 frozen ETs performed. For fresh ETs, clinical pregnancy and ongoing or delivery rates per recipient were 56.8% and 49.7%, respectively. For frozen ETs, these rates were 50% and 39.5%. Implantation rates were 31.8% and 26.1% for fresh and frozen ET, respectively. When analyzed per donor retrieval, clinical pregnancy and ongoing or delivery rates were 109.5% and 95.4%. These high pregnancy rates per donor reflect the numerous fresh and frozen ETs that can result from one donors retrieval. Conversion of a donation cycle from two recipients to one recipient occurred for 26 of 241 cycles (10.8%). CONCLUSION(S) Shared anonymous oocyte donation provides a very high pregnancy rate per donor retrieval that is not achievable with unshared donation. In addition, there is a diminished risk exposure of donors per total completed recipient transfers. We support shared oocyte donation as the most efficient use of the precious resource of human oocytes.

Prolactin response to breast stimulation in lactating women is not mediated by endogenous opioids

Several reports have shown that the prolactin response to suckling in rats can be blunted by administration of the opiate antagonist naloxone. In order to investigate whether the prolactin response to breast stimulation in women is similarly affected by naloxone, nine healthy lactating women participated in 10 studies. Each woman served as her own control and was studied on two occasions, receiving pretreatment with either saline solution or naloxone. Prolactin was measured in the baseline state and for 60 minutes after the onset of a 20-minute period of nipple stimulation by use of the Egnell mechanical breast pump. Neither baseline nor stimulated prolactin values were different by paired t test. Thus, in contrast to rats, an opioid pathway does not appear to be involved in the prolactin response to suckling in humans.

Oral contraceptives and dysmenorrhea.

This artical examines the risks and benefits associated with use of the oral contraceptive pill (OCP) by adolescents and the various alternatives and methods of prescribing OCPs. Any adolescent who is either sexually active or contemplating sexual activity should be offered a contraceptive method that is appropriate to her individual needs. The contraceptive needs to be highly effective, safe and within the means and desires of the adolescent. For the majority of teenagers, the contraceptive of choice will be the OCP. The IUD should almost never be prescribed to the adolescent. Most OCPs marketed today are combination pills containing both an estrogen and a progestin in each pill. A variety of contraceptive actions combines to create a contraceptive method that is 99.3-99.9% effective. OCPs provide some protection against the development of pelvic inflammatory disease (PID). Oral contraceptives also decrease the incidence of anemia by decreasing the amount and duration of menstrual flow. Ovarian cysts do not form in the ovaries of the OCP user. On the other hand, a serious risk of the use of OCPs is the increased danger of thromboembolic events including deep venous thrombosis, pulmonary embolus, and myocardial infarction. The increased risk of myocardial infarction in OCP users is additive with other risk factors including hypertension, hypercholesterolemia, cigarette smoking, obesity, diabetes mellitus, and age. OCP use seems to provide some protection against development of endometrial or ovarian cancer. Oral contraceptives are associated with the development of benign hepatocellular adenomas. A variety of metabolic and hormonal alterations also occur in pill users. Most appropriate for the adolescent is a formulation containing a low dose of estrogen because of the decreased risk of thromboembolic complications. Dysmenorrhea effects more than 1/2 of female adolescents, and can best be treated with ibuprofen.

Should all oocyte donors receive prophylactic antibiotics for retrieval

In a retrospective study comparing 526 oocyte donors who received prophylactic antibiotics for oocyte retrieval with a comparable group of 625 who did not, the incidence of infection after retrieval was reduced from 0.4% to 0 in the group receiving antibiotics. Donors take risks but have no medical indication for the procedures that they undergo; our data suggest that prophylactic antibiotics at retrieval should be considered to minimize the risk of infection.

WITHDRAWN: Initiation of the Society for Assisted Reproductive Technology Donor Egg Registry: a report from the Donor Egg Registry Task Force

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