Jeff G. Wang

Providing fertility care to men seropositive for human immunodeficiency virus: reviewing 10 years of experience and 420 consecutive cycles of in vitro fertilization and intracytoplasmic sperm injection

OBJECTIVE To review 10 years of experience providing fertility care to men seropositive for human immunodeficiency virus (HIV) using sperm washing and in vitro fertilization with intracytoplasmic sperm injection (IVF-ICSI). DESIGN Retrospective study. SETTING University-based practice. PATIENT(S) HIV-seropositive men with HIV-seronegative partners. INTERVENTION(S) IVF-ICSI, HIV testing of females and infants. MAIN OUTCOME MEASURE(S) IVF performance, pregnancy rates, obstetrical outcomes, infection rates. RESULT(S) We initiated 420 cycles (355 fresh and 65 frozen cycles) in 181 couples. Due to poor ovarian response, 16% of stimulations were canceled. The number of oocytes collected per retrieval was 15.0 +/- 0.5, providing 12.1 +/- 0.5 mature oocytes suitable for ICSI, yielding 9.0 +/- 0.3 embryos per couple. The overall clinical pregnancy rate/embryo transfer was 45%; ongoing/delivered pregnancy rate/embryo transfer was 37%. The most frequent obstetric complication was multiple gestation (41%), with 5% experiencing high order multiple birth. An attendant high rate of preterm delivery was noted, as 43% of infants were born premature. No maternal or neonatal HIV infections or deaths occurred. CONCLUSION(S) We have found IVF-ICSI to be an expeditious and safe means for HIV-serodiscordant couples to achieve pregnancy with minimal risk of viral infection. Risks and liabilities of IVF-ICSI relate to multiple gestations and will occur in a significant number of participants.

The association between anti-Müllerian hormone and IVF pregnancy outcomes is influenced by age.

The conflicting results from studies on the predictive capabilities of serum anti-Müllerian hormone (AMH) for IVF pregnancy outcomes may be attributed to small sample sizes and disparities in the age of the study populations. The relationship between AMH and IVF pregnancy outcomes was clarified with retrospective cross-tabulation analyses (n=1558) stratified by age to control for its confounding effects. Serum AMH concentrations were divided into tertiles (≤ 0.29, 0.30-1.20, ≥ 1.21 ng/ml) and ages into four groups (<34, 34-37, 38-41, ≥ 42 years). For women <34, having serum AMH in the lowest tertile did not reduce the chance of IVF pregnancy/live birth compared with those with higher AMH concentrations. For women 34-41, a significant positive relationship existed between serum AMH and pregnancy rates. For women ≥ 42, serum AMH concentrations ≤ 0.29 ng/ml were associated with a 3% chance of pregnancy, and women with AMH ≥ 1.21 ng/ml had the same pregnancy rate as women with concentrations 0.30-1.20 ng/ml. In conclusion, AMH has limited predictive value for IVF outcomes in the two extremes of female reproductive age; however, for women between 34 and 41, higher serum AMH concentrations are associated with significantly greater chances of pregnancy (P<0.01).

Müllerian inhibiting substance is an accurate marker of ovarian response in women of advanced reproductive age undergoing IVF

While multiple investigators have demonstrated that Müllerian inhibiting substance (MIS) concentration is an accurate marker of ovarian reserve, all previous reports have focused on patients aged 36 and younger. It remains to be seen if MIS concentration is a useful marker in patients with the highest prevalence of diminished ovarian reserve: those aged 37 and over. Day 2 MIS concentrations in patients aged 37 and over undergoing IVF were examined, and the predictive value of MIS concentration was compared to that of FSH and oestradiol concentration. Three groups of patients were studied: (i) patients who experienced cycle cancellation; (ii) patients who underwent oocyte retrieval; (iii) patients who were precluded from IVF due to elevated FSH concentrations. While FSH and oestradiol concentrations were statistically similar in groups 1 and 2, MIS concentrations were significantly lower in group 1. In group 2, MIS concentration positively correlated with the number of oocytes retrieved. In group 3, 91% had low or undetectable MIS concentrations. The results indicate that MIS concentration accurately predicts cycle cancellation that is belied by normal FSH and oestradiol measurements, and has a better correlation with the number of oocytes retrieved than FSH and oestradiol measurements.

Posthumous assisted reproduction: a survey of attitudes of couples seeking fertility treatment and the degree of agreement between intimate partners

OBJECTIVE To study attitudes about posthumous assisted reproduction (PAR) in individuals presenting for assisted reproduction, to examine the degree of concordance of attitudes within couples, and to determine whether individuals can accurately predict the attitudes of their intimate partners. DESIGN Cross sectional survey. SETTING University-based fertility center. PATIENT(S) One hundred six couples presenting for an initial fertility evaluation. INTERVENTION(S) Anonymous survey completed independently by each partner. MAIN OUTCOME MEASURE(S) 1) individual attitudes about PAR, 2) the rate of concordance in attitudes within couples, and 3) the ability of individuals to predict their partners attitudes. RESULT(S) Approximately 78% of individuals stated they would permit PAR. Couples expressed concordant attitudes about 75% of the time. Statistically, women and men were equivalent in correctly predicting their partners attitudes (79% vs. 71%). CONCLUSION(S) Although most individuals presenting for fertility treatment would agree to PAR, there was also a notable portion that stated that they would not consent with the process. Although most couples had concordant attitudes, discordance was also prevalent. Individuals often, but not always, were able to predict their partners attitudes about PAR.

The Complex Relationship between Hypothalamic Amenorrhea and Polycystic Ovary Syndrome

BACKGROUND Polycystic ovarian morphology (PCOM) is occasionally observed in women with hypothalamic amenorrhea (HA). Although these women with HA/PCOM meet two of the Rotterdam criteria, they are excluded from the diagnosis of polycystic ovary syndrome (PCOS) by having HA. We explored the coexistence of these two disorders in women with HA/PCOM by analyzing their androgen response to gonadotropins and by following their clinical characteristics over time. METHODS Baseline and dynamic endocrine profiles during controlled ovarian hyperstimulation for women with HA/PCOM [n = 6, median (interquartile range) age 30 yr (28-31), body mass index (BMI) 19.2 kg/m(2) (18.0-19.2)] were retrospectively compared with those of women with PCOS [n = 10, age 33 (31-34), BMI 24.8 (23.2-27.6)] and normoovulatory controls [n = 20, age 33 (31-35), BMI 21.5(20.3-23.1)]. Long-term outcomes for five women with HA/PCOM were followed during their spontaneous recovery from HA. RESULTS With the exception of decreased LH [0.7 (0.3-0.8) vs. 6.0 IU/liter (4.8-7.4); P = 0.003], FSH [3.9 (2.5-5.7) vs. 7.5 IU/liter (5.3-9.5); P < 0.025], and estradiol [20 (14-24) vs. 32 pg/ml (20-39); P < 0.027], baseline endocrine profiles of women with HA/PCOM did not differ significantly from those of normoovulatory controls in terms of 17alpha-hydroxyprogesterone, dehydroepiandrosterone, dehydroepiandrosterone-sulfate, androstenedione, and total testosterone. However, controlled ovarian hyperstimulation with similar doses of gonadotropins resulted in an excess of androgen production compared with the controls [Deltaandrostenedione per dominant follicle 0.30 (0.23-0.37) vs. 0.10 ng/ml (0.05-0.18), P = 0.005; Deltatestosterone per dominant follicle 16 (7-24) vs. 6 ng/dl (2-12), P = 0.04], and these levels were comparable to those of women with PCOS. Recovery from HA/PCOM in some patients was associated with the development of oligomenorrhea and symptoms of androgen excess. CONCLUSIONS Women with HA/PCOM may have inherently hyperandrogenic ovaries but are quiescent due to low gonadotropins from the hypothalamic inactivity. The exaggerated ovarian androgen response to low-dose gonadotropin stimulation in these women is consistent with the clinical observation that hyperandrogenism emerges in association with weight gain and the recovery of hypothalamic function. Over time, these patients may fluctuate between symptoms of HA and PCOS, depending on the current status of hypothalamic activity. The fluidity of this transition in HA/PCOM challenges the simple dichotomous definition of PCOS using the Rotterdam criteria, which categorizes the two conditions as being mutually exclusive.

A systematic, multidisciplinary approach to address the reproductive needs of HIV- seropositive women

Nearly 130,000 American women are human immunodeficiency virus (HIV) seropositive. The present study sought to establish a comprehensive programme to address their fertility needs in order to minimize infectious, medical and reproductive risks to prospective patients. Forty women, aged 27-42 years, were evaluated. HIV was diagnosed 7.2 +/- 0.7 years prior to their seeking care, and most women (n = 38) were on highly active antiretroviral therapy. Their prenatal CD4 counts were 712.2 +/- 56 cells/mm(3) (range 327-1881) and HIV-1 concentrations were undetectable in all cases prior to initiating treatment. HIV-seropositive women were statistically identical to their age-matched HIV-seronegative counterparts with respect to the IVF clinical outcome parameters measured. Throughout the pregnancies, maternal HIV-1 RNA concentrations remained undetectable and CD4 counts were stable. All infants, tested at birth and at 3 and 6 months of age, remained HIV negative. This is the first report of an institutional paradigm in the USA dedicated to evaluate and treat HIV-seropositive women. Using a multidisciplinary approach to care, HIV-seropositive women may be successfully managed in a programme of assisted reproduction.

Bilateral megaureters may masquerade as hydrosalpinges on ultrasound

Gynaecologists are familiar with occluded Fallopian tubes presenting as pelvic masses on ultrasound. However, it is important to also consider anomalies of the urinary collecting system when presented with a pelvic mass, some of which do not necessitate surgical therapy. This report describes the case of a woman with unknown and asymptomatic bilateral megaureters who presented for evaluation of infertility. Initially, it was presumed that she had tubal disease and the possibility of a laparoscopy to remove her hydrosalpinges was entertained.

Optimization of IVF pregnancy outcomes with donor spermatozoa

PurposeTo identify risk factors for suboptimal IVF outcomes using insemination with donor spermatozoa and to define a lower threshold that may signal a conversion to fertilization by ICSI rather than insemination.MethodRetrospective, age-matched, case-control study of women undergoing non-donor oocyte IVF cycles using either freshly ejaculated (N = 138) or cryopreserved donor spermatozoa (N = 69). Associations between method of fertilization, semen sample parameters, and pregnancy rates were analyzed.ResultsIn vitro fertilization of oocytes with donor spermatozoa by insemination results in equivalent fertilization and pregnancy rates compared to those of freshly ejaculated spermatozoa from men with normal semen analyses when the post-processing motility is greater than or equal to 88%. IVF by insemination with donor spermatozoa when the post-processing motility is less than 88% is associated with a 5-fold reduction in pregnancy rates when compared to those of donor spermatozoa above this motility threshold. When the post-processing donor spermatozoa motility is low, fertilization by ICSI is associated with significantly higher pregnancy rates compared to those of insemination.ConclusionWhile ICSI does not need to be categorically instituted when using donor spermatozoa in IVF, patients should be counseled that conversion from insemination to ICSI may be recommended based on low post-processing motility.