L. Sekhon

Effect of oocyte donation on pregnancy outcomes in in vitro fertilization twin gestations

OBJECTIVE To estimate the effect of oocyte donation on pregnancy outcomes in patients with twin pregnancies conceived via IVF. DESIGN Retrospective cohort study. SETTING Patients with IVF twin pregnancies delivered by one maternal-fetal medicine practice from 2005 to 2013. PATIENT(S) Fifty-six patients with IVF twin pregnancies who had oocyte donation and 56 age-matched controls with IVF twin pregnancies who used autologous oocytes. We excluded women aged >50 years because there were no age-matched controls aged >50 years using autologous oocytes. INTERVENTION(S) None. MAIN OUTCOME MEASURE(S) Gestational hypertension, pre-eclampsia. RESULT(S) The baseline characteristics were similar between the groups, including maternal age, race, parity, chorionicity, and comorbidities. The mean (±SD) age was 43.0 ± 6.0 vs. 41.9 ± 1.7 years. There were no differences in outcomes between the groups in regard to preterm birth, birth weight, or gestational diabetes. There was a greater incidence of gestational hypertension (32.1% vs. 13.0%) and pre-eclampsia (28.3% vs. 13.0%) in the group that underwent IVF with donor oocytes. CONCLUSION(S) In patients who conceive twin pregnancies using IVF, oocyte donation increases the risk of gestational hypertension and pre-eclampsia. However, this did not translate into increased rates of preterm birth or low birth weight. Patients who require oocyte donation should be carefully counseled regarding the increased risk for pre-eclampsia and gestational hypertension but should be reassured that oocyte donation does not seem to lead to other adverse outcomes.

In-vitro maturation of germinal vesicle and metaphase I eggs prior to cryopreservation optimizes reproductive potential in patients undergoing fertility preservation.

Purpose of review To evaluate current and previous findings related to a timely implementation of in-vitro maturation (IVM) of germinal vesicle, metaphase I and metaphase II oocytes with an optimal cryopreservation to determine whether IVM should be attempted prior to (fresh IVM) or IVM after cryopreservation (postthaw IVM). Mitochondrion, chromatin and spindle formation in both groups were interpreted from referenced studies to establish best management of all oocytes. Recent findings The postthaw survival of germinal vesicle, metaphase I, fresh IVM-metaphase II and control metaphase II oocytes did not differ significantly [83.3% (n = 9), 86.7% (n = 12), 83% (n = 57) and 86% (n = 68), respectively]. Overall, combined survival and maturation were significantly higher (P < 0.05) in the fresh IVM group at 63.8% (44 of 69) compared with the postthaw IVM group at 33.3% (nine of 27). Summary Conservation of retrieved immature oocytes after vaginal oocyte retrieval has become a major concern for patients, as they strive to maximize the reproductive viability of all oocytes obtained during treatment. Oocyte cryopreservation is important for patients at risk of ovarian cancer, elective fertility preservation and potentially for ovum donation. The superior maturation rate of germinal vesicle and metaphase I oocytes in the fresh IVM vs. postthaw groups provides strong impetus to mature oocytes to the metaphase II stage prior to cryopreservation.

The Menopause and Oxidative Stress

Reproductive aging resulting in menopause is characterized by the permanent cessation of ovarian follicular activity. The signs and symptoms resulting from estrogen withdrawal can significantly disrupt a woman’s activities of daily living and sense of well being, while predisposing them to osteoporosis and heart disease. Current medical therapies are targeted at symptomatic relief or alleviating the hormonal deficiency itself to prevent its harmful sequelae. The progressive loss of estrogen and its protective effects, combined with deficient endogenous antioxidant, results in oxidative stress—which is implicated in the pathogenesis of vasomotor disturbances, loss of bone mass, and heart disease in menopause. The link between oxidative stress and estrogen deficiency has been demonstrated by numerous studies. Based on this, hormonal replacement therapy, antioxidant supplementation, and lifestyle modification have been investigated for their efficacy and safety in the treatment and prevention of menopause-related symptoms and chronic disease processes.

Endometriosis and Oxidative Stress

Endometriosis is a chronic gynecologic disease process with multifactorial etiology. Increased oxidative stress, a result of increased production of free radicals or depletion of the body’s endogenous antioxidant defense, has been implicated in its pathogenesis. Oxidative stress is thought to promote angiogenesis and the growth and proliferation of endometriotic implants. Oxidative stress in the reproductive tract microenvironment is known to negatively affect sperm count and quality and may also arrest fertilized egg division leading to embryo death. Increased DNA damage in sperm, oocytes, and resultant embryos may account for the increase in miscarriages and fertilization and implantation failures seen in patients with endometriosis. The evidence linking endometriosis and infertility to endogenous pro-oxidant imbalance provides a rationale for the empiric use of antioxidant therapy. Vitamin C and E deficiency has been demonstrated in women with endometriosis. Observational and randomized controlled studies have shown vitamin C and E combination therapy to decrease markers of oxidative stress.

Oxidative Stress and the Use of Antioxidants for Idiopathic OATs

Aim: To examine the effects of ROS and OS on male fertility and to evaluate the use of antioxidants as a means of treatment to improve fertilization rates in subfertile males suffering from idiopathic oligoasthenoteratozoospermia (iOAT). Methods: Review of PubMed database. Results: Current research notes ROS-associated male factor infertility to be the most common potential etiology of impaired sperm quality. The various effects of these oxidants may be neutralized by antioxidants. Although antioxidant therapy has shown to potentially treat iOAT by improving semen parameters, its success remains limited. Our review calls for a deeper look and understanding of the type(s), dosage, and duration of antioxidant treatment used in order to apply its use in a clinical setting.

Blastocyst vitrification, cryostorage and warming does not affect live birth rate, infant birth weight or timing of delivery

RESEARCH QUESTION Does vitrification and warming affect live birth rate, infant birth weight and timing of delivery? DESIGN Retrospective, cohort study comparing outcomes of donor oocyte recipient fresh (n = 25) versus vitrified (n = 86) euploid blastocyst transfers; donor oocyte recipient singleton live births from fresh (n = 100) versus vitrified (n = 102) single embryo transfers (SET); and autologous vitrified euploid SET (n = 1760) (cryostored 21-1671 days). RESULTS Group 1: fresh and vitrified-warmed blastocysts had similar live birth (OR 1.7; 95% CI 0.5 to 5.9), implantation (OR 0.9; 95% CI 0.2 to 3.9), clinical pregnancy (OR 3.4; 95% CI 0.9 to 13.0) and pregnancy loss (OR 1.2; 95% CI 0.98 to 1.4); group 2: low birth weight (OR 0.44; 95% CI 0.1 to 1.6) and preterm delivery (0.99; 95% CI 0.4 to 2.3) rates were similar in fresh and vitrified-warmed blastocyst transfers; group 3: cryostorage duration did not affect live birth (OR 1.0; 95% CI 1.0 to 1.0), implantation (OR 1.0; 95% CI 0.99 to 1.01), clinical pregnancy (OR 1.0; 95% CI 1.0 to 1.0]), pregnancy loss (OR 0.99; 95% CI 1.0 to 1.0), birth weight (β = -15.7) or gestational age at delivery (β = -0.996). CONCLUSIONS Vitrification and cryostorage (up to 4 years) are safe and effective practices that do not significantly affect clinical outcome after embryo transfer.

PD07-07 IS SPERM MORPHOLOGY ASSESSMENT OF PATIENTS UTLIZING IN VITRO FERTILIZATION USEFUL IN PREDICTING ANEUPLOIDY?

INTRODUCTION AND OBJECTIVES: It is generally accepted that semen quality, as judged by the volume, motility, and morphology of spermatozoa, predicts both in vitro and in vivo fertilization. Kruger et al. demonstrated that microscopic assessment of sperm morphology plays an integral role in evaluating the male. This study aims to determine whether there is a correlation between specimens with extremely low percentages of structurally normal sperm and embryonic aneuploidy in couples that pursue IVF with Comprehensive Chromosomal Screening (CCS). METHODS: Couples who underwent IVF and utilized aneuploidy screening (preimplantation genetic screening (PGS)) from July 2010 e October 2015 were included. At least 100 sperm in four different areas of the slide were evaluated according to Kruger’s strict criteria (Kruger et al: 1⁄44%: normal; >4%: abnormal). Female and male partner ages were binned (A: 1⁄435; B: (35-38]; C: (38-41]; D: (41-43]; and E: >43). Male age group E was subbinned (a: 1⁄443; b: (43-50]; c: (50-55]; d: (55-60]; and e: >60). Aneuploidy rate for each female age group was calculated, with 95% confidence intervals calculated by Clopper-Pearson method. Chi-square and ANOVA were used to test significance, established at p 4% was similar between all five male age groups (A: 61.7%, B: 66.2%, C: 59.7%, D: 75.2%, E: 59.7%). When male age group E was subdivided, the proportion of patients with an abnormal morphology count increased with age (a: 36.2%, b: 44.1%, c: 70.4%, d: n/a, e: 100%). Aneuploidy rate was similar between normal and abnormal sperm morphology groups in all five age female groups (Table 1). Additionally, PR, clinical PR and early pregnancy loss rate were similar between groups in each female age group (Table 1). CONCLUSIONS: No correlation was identified between teratozoospermic specimens and increased incidence of embryonic aneuploidy. Male partners with specimens found to have abnormal Kruger morphology should be reassured that they do not have an increased incidence of producing chromosomally abnormal embryos.

What Is the Ideal Interval for Re-Testing Anti-Mullerian Hormone (AMH) Levels in an Infertility Population? [25G]

INTRODUCTION: Although not traditionally recommended, repeated tests of ovarian reserve via AMH testing is often performed. After controlling for oocyte age and first AMH level reading, we sought to discern the prognostic ability and treatment outcome of patients who had a repeat AMH level assessed during infertility treatment. METHODS: Patients from July 2007–March 2015 with 2 AMH readings separated by >30 days and obtained 12 months prior to a fresh in vitro fertilization (IVF) cycle start were included. AMH levels greater than 5 ng/mL were excluded. Basal (day 3) follicle stimulating hormone (FSH), basal antral follicle count (BAFC) and vaginal oocyte retrieval (VOR) count were measured. VOR was modeled by Poisson regression against age and first AMH level. Improvements to the model were assessed by second AMH level using chi-square of ANOVA. Additional improvements of VOR predictions were recomputed based on time intervals between AMH measurement readings. RESULTS: Study couples (n=110) underwent 131 fresh IVF cycles. First and second AMH measurements (1.16±0.96 ng/mL and 1.22±1.00 ng/mL, respectively) were strongly correlated (R2=0.73, P<.001). The improvement from a second AMH was significant if performed ≥78 days after the first AMH measurement (14% of total variability in VOR, P<.001). More frequent testing (<78 days) did not significantly improve ovarian reserve assessment. CONCLUSION: Despite modest fluctuations in AMH levels, evaluation of repeat testing of AMH improved prognostic value in predicting a successful VOR. Quarterly AMH level assessment (⩽1 per 3 months) may convey additional diagnostic and prognostic benefits for infertile patient seeking infertility treatment therapy.

Aromatase Inhibitors in the Treatment of Unexplained Female Infertility

When considering treatment options for couples with unexplained infertility the initial approach often involves intrauterine insemination (IUI) combined with ovulation induction. Aromatase inhibition is a newer method of ovulation induction that has been used and studied as an alternative to clomiphene citrate (CC) to treat patients with unexplained infertility. Letrozole has been studied for its use as an adjunct to assisted reproductive technologies in an attempt to minimize the dose of costly gonadotropins needed and to overcome the adverse peripheral effects of clomiphene on the endometrium. Use of letrozole may eventually supersede that of clomiphene if the results of ongoing multicenter trials provide definitive evidence that letrozole has similar efficacy to gonadotropins or CC with a favorable side-effect profile and reduced cost.

Evaluation of Symptom Resolution in Patients With a Small Number of Myomas Following Robotic-Assisted Laparoscopic Myomectomy

Study Objective: The purpose of this study is to compare the differences between robotic pelvic lymph node dissection (PLND) using the singleport approach to the multi-port approach, with respect to patient and tumor characteristics. Design: Retrospective chart review. Setting: Tertiary health care center. Patients: The charts of patients with endometrial pathology who underwent robotic pelvic lymph node dissection in the period from February 2014 to February 2015 were reviewed. Other gynecologic malignancies were excluded from the analysis because the single-port approach for pelvic lymph node dissection was not used in the event that cervical or ovarian cancer were suspected. Intervention: All cases of pelvic lymph node dissection were done at the same time as the total laparoscopic hysterectomy (TLH) and/or bilateral salpingo-oophrectomy (BSO) together with other procedures deemed necessary by the surgeon for staging purposes. All surgeries were performed by one highly trained gynecologic oncologist at a single institution. Measurements and Main Results: Variables of interest were the age of the patient, body mass index (BMI), operative time (defined as the time noted in anesthesia records between procedure start and finish, and the number of lymph nodes removed on the right pelvic side and the left pelvic side as described in the pathology report. During the study period, 41 patients underwent PLND via the multi-port approach and 10 patients via the