Kaylen M. Silverberg

Effect of prolonged gonadotropin-releasing hormone agonist therapy on the outcome of in vitro fertilization- embryo transfer in patients with endometriosis

OBJECTIVE To evaluate the effect of a 3-month course of GnRH agonist administered immediately before IVF-ET in infertile patients with endometriosis. DESIGN Prospective, randomized trial. SETTING Three tertiary care assisted reproductive technology programs. PATIENT(S) IVF-ET candidates with surgically confirmed endometriosis. INTERVENTION(S) Twenty-five patients received three courses of a long-acting GnRH agonist, 3.75 mg i.m. every 28 days, followed by standard controlled ovarian hyperstimulation. Twenty-six patients received standard controlled ovarian hyperstimulation with mid-luteal phase GnRH agonist down-regulation or microdose flare regimens. MAIN OUTCOME MEASURE(S) Response to controlled ovarian hyperstimulation, ongoing pregnancy rates per cycle, group implantation rates, and implantation rate per embryo transfer procedure. RESULT(S) The extent of surgically confirmed endometriosis was greater in patients who received the long-acting GnRH regimen for 3 months before IVF-ET. The groups did not differ significantly in terms of dose or duration of gonadotropin stimulation, number of oocytes retrieved, fertilization rate, or number of embryos transferred. Patients who received the long-acting GnRH regimen had significantly higher ongoing pregnancy rates (80% vs. 53.85%) and a trend toward higher implantation rates (42.68% vs. 30.38%). CONCLUSION(S) Prolonged use of GnRH agonist before IVF-ET in patients with endometriosis resulted in significantly higher ongoing pregnancy rates than did standard controlled ovarian hyperstimulation regimens. No deleterious effect on ovarian response was observed.

Success Rate with Repeated Cycles of In Vitro Fertilization–Embryo Transfer

OBJECTIVE To analyze data from a large multicenter study to determine whether pregnancy and delivery rates decrease with repeated IVF-ET cycles. DESIGN Multicenter retrospective study. SETTING Participating centers from the Society of Assisted Reproductive Technology. PATIENT(S) Fifty-four centers contributed 4,043 cycles of oocyte retrieval for uterine transfer. INTERVENTION(S) Oocyte retrieval for uterine transfer. MAIN OUTCOME MEASURE(S) Pregnancy and delivery rates, analyzed according to age, program success rate, and whether the program was doing assisted hatching. RESULT(S) Pregnancy and delivery rates for cycles 1, 2, 3, 4, and >4 were 33.7% and 27.0%, 33.9% and 27.4%, 28.9% and 23.4%. 25.9% and 16.1%, and 21.0% and 15.4%, respectively. The pregnancy rate decreased significantly for >4 cycle; delivery rate decreased significantly for cycles 4 and >4. Assisted hatching was strongly related to better odds of pregnancy (OR, 1.50) and delivery (OR, 1.44) in women under age 40, and for pregnancy (1.64) in women age 40-42 years. CONCLUSION(S) Success rates do not decrease markedly with repeated IVF attempts, and the decrease did not change with program success rate, suggesting the IVF population is not markedly heterogeneous. Uncontrolled studies of new treatments for cycle repeaters cannot assume that success rate is poor without a treatment change.

Establishment of TEST-yolk buffer enhanced sperm penetration assay limits for fertile males

TEST-yolk buffer has been shown to enhance sperm penetration of zona-free hamster eggs. Review of sperm penetration assay (SPA) data from a fertile population was undertaken to determine a normal range for SPA with TEST-yolk buffer enhancement. Thirty-eight intrauterine insemination patients and 4 artificial insemination donors who had successfully initiated a pregnancy within 18 months of SPA analysis were examined. All 42 enhanced SPAs demonstrated penetration of greater than 10%, and 37 of these (88%) yielded SPA values of greater than or equal to 20%. Thirty-three percent (14/42) of these individuals achieved 0% penetration in the SPA without TEST-yolk buffer. The SPA performed with the TEST-yolk modification has fewer false negatives than the assay done with the original methodology.

Vaginal (Crinone 8%) gel vs. intramuscular progesterone in oil for luteal phase support in in vitro fertilization: a large prospective trial

OBJECTIVE To compare the efficacy of intravaginal and IMP for luteal phase support in IVF cycles. DESIGN Prospective trial. SETTING Tertiary care private practice. PATIENT(S) Women 25-44 years old with infertility necessitating treatment with IVF. From April 1, 2008-April 1, 2009, 511 consecutive patients were enrolled; 474 completed participation, and 37 were excluded for no autologous ET (freeze all, donor recipients, failed fertilization/cleavage). There were no demographic differences between the two treatment groups. INTERVENTION(S) Luteal phase support using either Crinone or P in oil starting 2 days following oocyte retrieval. MAIN OUTCOME MEASURE(S) Pregnancy and delivery rates stratified by patient age. RESULT(S) Overall, patients who received vaginal P had higher pregnancy (70.9% vs. 64.2%) and delivery (51.7% vs. 45.4%) rates than did patients who received IMP. Patients <35 who received vaginal P had significantly higher delivery rates (65.7% vs. 51.1%) than did patients who received IMP. There were no differences, regardless of age, in the rates of biochemical pregnancy, miscarriage, or ectopics. CONCLUSION(S) In younger patients undergoing IVF, support of the luteal phase with Crinone produces significantly higher pregnancy rates than does IMP. Crinone and IMP appear to be equally efficacious in the older patient.

Gynecologic use of Sepraspray Adhesion Barrier for reduction of adhesion development after laparoscopic myomectomy: a pilot study

OBJECTIVE To assess the safety and efficacy of Sepraspray Adhesion Barrier (a modified hyaluronic acid and carboxymethylcellulose powder) after laparoscopic surgery, in view of both the high efficacy of Seprafilm Adhesion Barrier in reducing postoperative adhesions after open surgical procedures and the difficulty with laparoscopic delivery. DESIGN Multicenter, randomized, reviewer-blinded trial. SETTING Reproductive endocrinology and infertility clinics. PATIENT(S) Women undergoing laparoscopic myomectomy for indications including infertility. INTERVENTION(S) Randomization to treatment with (n = 21) or without (n = 20) Sepraspray Adhesion Barrier. MAIN OUTCOME MEASURE(S) Postoperative adhesions development was assessed at early second-look laparoscopy. Adhesions were scored using the modified American Fertility Society scoring system. RESULT(S) Surgical procedure duration length was 99 versus 102 minutes in the control versus Sepraspray Adhesion Barrier groups, respectively, with the median number of fibroids removed being two in each group and corresponding fibroid weights of 134 ± 103 versus 113 ± 161 g, respectively. Adhesions scores increased in both the control and Sepraspray Adhesion Barrier groups, with larger although nonstatistically significant increases noted in control subjects when evaluating for the anterior uterus, the posterior uterus, and the entire uterus. CONCLUSION(S) Laparoscopic application of Sepraspray Adhesion Barrier after myomectomy in this pilot study was associated with a trend toward a reduction in postoperative adhesion development, as well as an encouraging safety profile. Further evaluation is warranted. CLINICAL TRIAL NUMBER Sepraspray Adhesion Barrier #NCT00624930.

Recurrence of ovarian torsion in a multiple pregnancy: conservative management via transabdominal ultrasound-guided ovarian cyst aspiration

OBJECTIVE To report a case of recurrent ovarian torsion during a multiple-gestation pregnancy and successful treatment via transabdominal ultrasound-guided ovarian cyst aspiration. DESIGN Case report and literature review. SETTING Tertiary care fertility center. PATIENT(S) A 33-year-old gravida 2, para 1 woman with a history of ovarian torsion in a previous pregnancy, who presented with recurrent ovarian torsion in the 13th week of a multiple pregnancy. INTERVENTION(S) Ultrasound-guided transabdominal ovarian cyst aspiration and body repositioning to allow for spontaneous detorsion. MAIN OUTCOME MEASURE(S) Resolution of the ovarian torsion, as well as preservation of the pregnancy without surgical intervention. RESULT(S) After transabdominal ultrasound-guided cyst aspiration, ovarian detorsion was observed, accompanied by resolution of the patients acute pain. The remainder of the patients pregnancy was uncomplicated, culminating in the delivery of healthy infants. CONCLUSION(S) Conservative treatment of ovarian torsion via ultrasound-guided transabdominal cyst aspiration and body repositioning represents a reasonable alternative to surgical intervention in the pregnant patient.

An employer's experience with infertility coverage: a case study

A case study of Southwest Airlines, a Fortune 500 company, demonstrates that a well-designed infertility coverage plan can control resource use. This successful model could be used by employers who wish to ensure that their employees have access to high-quality, cost-effective infertility services in a managed-care environment.

The effect of prolonged GnRH agonist (GnRHa) therapy on in vitro fertilization-embryo transfer (IVF-ET) cycle outcome in endometriosis (ENDO) patients: a multicenter randomized trial.

group, the mean numbers of vessels with endoglin expression in stages ¥° and ¥6 were not different from stages ¥ 2 and ¥. Conclusions: This study shows the expression of endoglin in the eutopic endometrium of women with endometriosis is significantly increased and the increase is observed only in the late secretory phase. It is suggested from these findings that activation of angiogenesis in the eutopic endometrium might be a key factor in the pathogenesis of endometriosis.

The Intercycle Variability in Patients Treated With Repeated Cycles of Gonadotropins Is Due to Intrinsic Factors and Is Not Eliminated by Recombinant Gonadotropins

2.4 6 1.9 2.1 6 2.7 2.7 6 2.6 1.6 6 1.3 ,0.05 1.6 6 1.0 1.3 6 0.5 1.9 6 1.1 1.6 6 0.7 ,0.05 25 6 83 0 610 31 6 84 2 615 ,0.05 23 6 32 17 6 29 29 6 51 8 6 12 N.S.