L.A. Kaye

Survey assessing obesity policies for assisted reproductive technology in the United States

OBJECTIVE To determine what assisted reproductive technologies (ART) policies, if any, have been instituted in response to an increasingly overweight and obese patient population. DESIGN Cross-sectional survey. SETTING University-affiliated IVF clinic. PATIENT(S) Women in the overweight and obese body mass index (BMI) categories seeking ART treatments. INTERVENTION(S) Anonymous survey sent to medical directors at 395 IVF centers listed in Society for Assisted Reproductive Technology database. MAIN OUTCOME MEASURE(S) Assessment of recommendations, policies, and restrictions for patients who are overweight/obese and who desire treatment for infertility, including in IVF, IUI, and donor egg cycles. RESULT(S) Seventy-seven anonymous responses were received (19.5% response rate): 64.9% of centers have a formal policy for obesity, and 84% of those have a maximum BMI at which they will perform IVF, while 38% of those have a maximum BMI for performing IUI; 64.6% of respondents reported anesthesia requirements/concerns as the primary criteria for patient exclusion. Other primary considerations included safety during ongoing pregnancy and ART outcomes. CONCLUSION(S) Centers that have policies regarding obesity and access to ART consider efficacy, procedural safety, safety in pregnancy, and overall health status. Policies vary widely. The patients autonomy must be balanced with nonmaleficence and the avoidance of interventions that may be unsafe both immediately and long term.

Frozen blastocyst transfer outcomes in immediate versus delayed subsequent cycles following GnRH agonist or hCG triggers

PurposeThe aim of this study is to analyze clinical pregnancy rates (CPR) and ongoing pregnancy rates (OPR) for frozen embryo transfers (FET) performed with blastocysts in the cycle immediately after GnRH agonist (GnRHa) versus human chorionic gonadotropin (hCG) triggers, with outcomes of delayed FET for comparison.MethodsRetrospective cohort study at a university-affiliated in vitro fertilization (IVF) clinic, including patients undergoing IVF between 2013-16 with a blastocyst FET performed within two menstrual cycles of a previous stimulation cycle and vaginal oocyte retrieval (VOR). FETs included programmed and natural endometrial preparation. Outcome measures were clinical and ongoing pregnancy rates.ResultsCPR and OPR for 344 FET cycles were similar when comparing immediate and delayed transfer overall (crude CPR 67.5 versus 76.5%, p = 0.11; OPR 57.5 versus 66.7%, p = 0.13), and after stratifying by cycles following hCG trigger (OPR 62.5 versus 66.3%, p = 0.61) and GnRHa trigger (OPR 55.6 versus 64.5%, p = 0.17). When considering a number of predictors for OPR, an adjusted odds ratio (OR) of 1.74 [95% CI 1.00–3.03] approached significance in favor of delayed FET.ConclusionsRegardless of trigger modality, patients can be reassured that pregnancy rates with FET are high in immediate and delayed cycles. However, our study suggests a potential benefit in delaying a cycle before proceeding with FET.

Does the Difference in Fascial Closure Technique Affect Postoperative Pain

STUDY OBJECTIVE To compare postoperative incisional pain on postoperative days (PODs) 1 and 14 when using a fascial closure device (FCD) versus a traditional fascial closure (TFC) of the 12-mm upper quadrant port during robotic surgery. Time required to close the incision was also compared. DESIGN Randomized controlled trial (Canadian Task Force classification I). SETTING Two academic affiliated hospitals, The Hospital of Central Connecticut and The University of Connecticut. PATIENTS Women undergoing robotic surgery for benign indications by minimally invasive gynecologists at our institutions between November 2012 and October 2014 were enrolled in the study at their preoperative visit. INTERVENTIONS Patients were randomized to either an FCD or TFC immediately before closure of the fascial incision. Pain score using a 10-point analog pain scale was recorded on POD 1 and POD 14. Time to close the fascial incision, length of surgery, and body mass index were also recorded. MEASUREMENTS AND MAIN RESULTS Sixty-seven patients were enrolled, and 65 were randomized at the time of the fascial closure, whereas 2 enrolled patients converted to laparotomy. Statistical analysis demonstrated that pain scores differed by fascial closure technique. Mean pain scores on POD 1 were 3.43 ± 2.48 and 2.06 ± 2.03 for the FCD and TFC, respectively (p = .028). On POD 14 the mean pain scores were 1.97 ± 2.48 and .83 ± 1.42 for the FCD and TFC, respectively (p = .102). Times to close fascia were 106.5 ± 102.28 seconds and 141.97 ± 102.85 seconds for the FCD and TFC, respectively (p = .138). CONCLUSION Our study demonstrates that at POD 1 the use of the fascia closure device results in higher pain scores without a significant difference in closure time.

Ultrashort Flare GnRH Agonist with GnRH Antagonist (MDA/Ant) Protocol Compared with Clomiphene Citrate/ Gonadotropins (CC/GND) for Poor Responder Patients

Background: The ultrashort flare GnRH agonist/ GnRH antagonist protocol (MDA/Ant) has recently been advocated as a useful option for poor ovarian response (POR). POR patients with repeated IVF failures were offered stimulation with MDA/Ant (Group 1) or clomiphene citrate/gonadotropins (CC/Gnd; Group 2). Objective: The aim of this study was to compare Group 1 versus Group 2 in a POR population, from January 1st, 2010 until October 1st, 2014. Design: Retrospective Cohort Analysis. Methods: A total of 116 IVF cycles were included in the study. Group 1 received 21 days of oral contraceptives (OCP’s), and were then treated with leuprolide acetate 40 mcg twice a day for the first 3 days, followed by high dose gonadotropins with a flexible start Gonadotropin Releasing Hormone (GnRH) antagonist. Group 2 received CC 100mg x 5 days, and on CC day 4 rec-FSH 600 IU was added. Results: No differences were found in age, body mass index (BMI), day 3 follicle stimulating hormone (FSH), or previous number of failed cycles. There were no differences noted in clinical pregnancy rate or live birth rate. Group 2 required a significantly lower amount of total gonadotropins, but Group 1 had a significantly lower rate of cycle cancellation. Conclusions: Although a higher dose of gonadotropins was required, the significantly lower cancellation rate when compared with Group 2 suggests that the MDA/Ant regimen may be a useful alternative protocol for poor responder patients.