Louis N. Weckstein

Low-dose aspirin for oocyte donation recipients with a thin endometrium: prospective, randomized study

OBJECTIVE To evaluate the effect of low-dose aspirin use in oocyte donation recipients with an endometrial thickness of < 8 mm. DESIGN A prospective, randomized study. SETTING An oocyte donation program in a private infertility practice. PATIENT(S) Twenty-eight recipients undergoing oocyte donation who failed to develop an endometrial thickness of at least 8 mm in a previous evaluation cycle. INTERVENTION(S) Fifteen recipients received low-dose aspirin (81 mg/d) in addition to standard hormone replacement for an oocyte donation cycle. The remaining 13 recipients did not receive aspirin. MAIN OUTCOME MEASURE(S) Clinical pregnancy rates, delivery rates, implantation rates, and change in endometrial thickness were compared in the aspirin and nonaspirin groups. RESULT(S) There was no demonstrable increase in endometrial thickness in the aspirin-treated group. However, there was a statistically significant increase in implantation rates in the aspirin-treated group (24% versus 9%) and in implantation rates and clinical pregnancy rates in the aspirin-treated group when the final endometrial thickness was < 8 mm. CONCLUSION(S) Low-dose aspirin therapy improves implantation rates in oocyte donation recipients with a thin endometrium.

Successful treatment of immunologic abortion with low-dose intravenous immunoglobulin

OBJECTIVE To evaluate the efficacy of low-dose intravenous immunoglobulin (IVIG) treatment in older women with immunologic abnormalities and recurrent spontaneous abortion (RSA), a condition referred to as immunologic abortion. DESIGN Prospective clinical trial. SETTING Outpatient referral practice. PATIENT(S) Forty-seven women were enrolled in the study. The mean age of the women was 37 years (range, 28-45 years), and the mean number of prior miscarriages was 3.7. Immunologic abnormalities included antiphospholipid antibodies (32%), antithyroid antibodies (53%), antinuclear antibodies (28%), antiovarian antibodies (2%), increased natural killer cells (40%), increased immunoglobulin (Ig)M level (28%), and increased CD4/CD8 T-cell ratio (15%). One patient had IgA deficiency, and three women had endometriosis. Thirty-one of the 47 patients (66%) had more than one immunologic abnormality. INTERVENTION(S) Treatment with IVIG at a dose of 0.2 g/kg within 2 weeks of attempted conception. Once conception was achieved, IVIG treatment was continued on a monthly basis at the same dose through 26-30 weeks of gestation. MAIN OUTCOME MEASURE(S) Successful pregnancy or recurrent abortion. RESULT(S) Of the 47 women, 36 received initial IVIG treatment, and 24 subsequently became pregnant. Of these women, 20 continued IVIG treatment through 26-30 weeks of gestation, and 19 (95%) had a successful term pregnancy. Four women discontinued IVIG therapy after 10-12 weeks of gestation, and 3 (75%) had a successful pregnancy outcome. Of the 11 women who refused IVIG therapy, 7 became pregnant, and all 7 miscarried. The difference in pregnancy success rate between the IVIG-treated and untreated groups was significant (P=.001). Three women had adverse reactions during the low-dose IVIG infusion, and these reactions resolved when the IVIG brand was changed. Fetal abnormalities were not observed. CONCLUSION(S) Low-dose IVIG therapy is beneficial for older women with immunologic abortion. The optimum duration of IVIG treatment in these women requires further study.

Reduction of cannula-related laparoscopic complications using a radially expanding access device

STUDY OBJECTIVE To determine the safety of a new radially expanding access device compared with complication rates associated with sharp laparoscopic cannulas. DESIGN Prospective, multicenter study (Canadian Task Force classification II-1). SETTING Free-standing and hospital-based ambulatory surgery centers. PATIENTS Two hundred twelve women undergoing various laparoscopic procedures and followed over 44 months. INTERVENTION Five hundred forty-one radially dilating access devices were used exclusively for laparoscopic abdominal wall access. MEASUREMENTS AND MAIN RESULTS No major vascular injury, abdominal wall bleeding, intestinal injury, bladder or ureteral injury, liver trauma, or postoperative incisional hernia occurred. One patient developed a postoperative mesenteric hematoma probably caused by a venous injury from the Veress needle. Of the 541 radially expanding access cannulas placed, only 6 (1%) slipped, despite absence of fascial anchoring devices. CONCLUSION Radially dilating abdominal access devices may reduce laparoscopic complications, lessen a surgeons exposure to liability, and improve patient outcomes while reducing facility costs. (J Am Assoc Gynecol Laparosc 6(1):79-84, 1999)

Outpatient laparoscopic-assisted vaginal hysterectomy

STUDY OBJECTIVE To compare laparoscopic-assisted hysterectomy (LAVH) with conventional abdominal hysterectomy. DESIGN First 50 consecutive LAVH procedures. SETTING An outpatient facility at a major medical center (35 procedures) and a nonhospital free-standing surgicenter (15). PATIENTS Sequential sample of 50 women requiring hysterectomy. INTERVENTIONS LAVH in 46 women, converted to open laparotomy in 4. MEASUREMENTS AND MAIN RESULTS Outpatient LAVH was performed successfully in the majority of women. Most patients had significant uterine enlargement, pelvic adhesions, or endometriosis. Only six required replacement of autologous blood postoperatively. Other complications were cystotomy and postoperative pelvic hematoma in one patient each. CONCLUSIONS LAVH can be performed safely in free-standing surgicenters. It offers several advantages to patients, and is considered cost effective by third-party payers.

Improvement of pregnancy rates with oocyte donation in older recipients with the addition of progesterone vaginal suppositories

Pregnancy rates and implantation rates with oocyte donation in recipients 40 years of age and older were significantly lower than those obtained in recipients under the age of 40. This difference was eliminated when P vaginal suppositories were added to the luteal regimen in older recipients. Our experience suggests that uterine aging may play a role in the successful initiation of a pregnancy, but this may be overcome with the preparation of the uterus with P vaginal suppositories.

Ultrasound: a technique useful in determining the side of ovulation *

It is often assumed that ovulation commonly occurs from alternating sides each month, but it is unknown whether it can occur repeatedly from the same side. In an effort to answer this question, we selected 39 women from our infertility clinic who had six consecutive courses of ultrasound (US) to monitor ovulation and in whom the side of ovulation was recorded. Nine patients (23.1%) ovulated from the same side for six consecutive cycles, whereas no patient alternated side of ovulation in the same period of time. Stimulation with clomiphene citrate and/or human menopausal gonadotropin that results in single ovulation did not affect this pattern. The data were analyzed statistically with the use of a Markov Chain Model and the chi-square goodness-of-fit; the occurrence of persistent same-side ovulation was significant to P less than or equal to 0.001.

Argon beam coagulation rescue to correct bleeding during pelviscopy

A new technique of unipolar laparoscopic coagulation is particularly useful for the treatment of pelvic or abdominal bleeding during laparoscopic procedures. Blood present at the coagulation site is blown clear with a stream of argon gas prior to tissue coagulation. Of particular importance is the virtual absence of smoke, and because the procedure involves a nontouch technique, eschar is not removed inadvertently. The speed of tissue coagulation is faster than that of conventional bipolar and unipolar techniques.

High gonadotropin dosage does not affect euploidy and pregnancy rates in IVF PGS cycles with single embryo transfer

STUDY QUESTION Does high gonadotropin dosage affect euploidy and pregnancy rates in PGS cycles with single embryo transfer? SUMMARY ANSWER High gonadotropin dosage does NOT affect euploidy and pregnancy rates in PGS cycles with single embryo transfer. WHAT IS KNOWN ALREADY PGS has been proven to be the most effective and reliable method for embryo selection in IVF cycles. Euploidy and blastulation rates decrease significantly with advancing maternal age. In order to recruit an adequate number of follicles, the average dosage of gonadotropins administered during controlled ovarian stimulation in IVF cycles often increases significantly with advancing maternal age. STUDY DESIGN, SIZE, AND DURATION A retrospective study of SNP (Single Nucleotide Polymorphism) PGS outcome data from blastocysts biopsied on day 5 or day 6 was conducted to identify differences in euploidy and clinical pregnancy rates. Seven hundred and ninety four cycles of IVF treatment with PGS between January 2013 and January 2017 followed by 651 frozen embryo transfers were included in the study (506 patients, maternal age (y.o.) - 37.2 ± 4.31). PARTICIPANTS/MATERIALS, SETTING, METHODS A total of 4034 embryos were analyzed (5.1 ± 3.76 per case) for euploidy status. All embryos were vitrified after biopsy, and selected embryos were subsequently thawed for a hormone replacement frozen embryo transfer cycle. All cycles were analyzed by total gonadotropin dosage (<3000 IU, 3000-5000 IU and >5000 IU), by number of eggs retrieved (1-5, 5-10, 10-15 and >15 eggs) and patients age (<35, 35-37, 38-40 and ≥41 y.o.). Clinical pregnancy rate was defined by the presence of a fetal heartbeat at 6-7 weeks of gestation. MAIN RESULTS AND THE ROLE OF CHANCE Euploidy rates within the same age group were not statistically different regardless of the total dosage of gonadotropins used or the number of eggs retrieved. In the youngest group of patients (<35 y.o. - 187 IVF cycles) euploidy rates ranged from 62.3% (<3000 IU were used in the IVF cycle) to 67.5% (>5000 IU were used in the IVF cycle) (OR = 0.862, 95% CI 0.687-1.082, P = 0.2) and from 69.5% (1-5 eggs retrieved) to 60.0% (>15 eggs retrieved) (OR = 0.658, 95% CI 0.405-1.071, P = 0.09). Similar data were obtained in the oldest group of patients (≥41 y.o. - 189 IVF cycles): euploidy rates ranged from 30.7 to 26.4% (OR = 0.811, 95% CI 0.452-1.454, P = 0.481) when analyzed by total dosage of gonadotropins used in the IVF cycle and from 40.0 to 30.7% (OR = 0.531, 95% CI 0.204-1.384, P = 0.19), when assessed by the total number of eggs retrieved. Ongoing pregnancy rates were similar, not only within particular age groups, but also between different age groups regardless of the total dosage of gonadotropins used: ranging from to 63.6% (<3000 IU, < 35 y.o.) to 54.8% (>5000 IU, ≥41 y.o) (OR = 0.696, 95% CI 0.310-1.565, P = 0.38). LIMITATIONS, REASONS FOR CAUTION Retrospective study and heterogeneity of patients included. WIDER IMPLICATIONS OF THE FINDINGS These data are reassuring for the common practice of increasing gonadotropin dosages in PGS cycles, particularly in older woman. STUDY FUNDING/COMPETING INTEREST(S) No formal funding has been received for this study. TRIAL REGISTRATION NUMBER N/A.

Clinical Pregnancy Rates after Elective versus Non-Elective Single Embryo Transfer in PGS Cycles

Objective: The objective of this study was to evaluate ongoing clinical pregnancy rates after elective single embryo transfer (eSET) versus non-elective single embryo transfer (non-elective SET) and compare them to ongoing pregnancy rates after double embryo transfer (DET) in IVF cycles with preimplantation genetic screening (PGS). Design: A retrospective study of SNP PGS outcome data from blastocysts biopsied on day 5 or day 6 was conducted to identify differences in ongoing clinical pregnancy rates between study groups. Settings: Large private IVF practice. Materials and methods: 676 cycles of IVF treatment (591 patients) with PGS between January 2013 and July 2016 followed by 658 FETs were included in the study (569 SETs and 89 double embryo transfers). 4102 embryos were vitrified after the trophectoderm biopsy, and selected embryos were subsequently thawed for a hormone replacement frozen embryo transfer (FET) cycle. 415 SETs were elective (two or more euploid embryos were available) and 154 SETs were non-elective (only one euploid embryo was available). Cumulative live birth rates were assessed by Kaplan-Meier function. Results: Our data demonstrated no statistically significant difference in clinical outcomes between the study groups: the ongoing pregnancy rate after an elective SET was 61.0% (253/415) and 53.3% (82/154) after a nonelective SET. Moreover, the ongoing pregnancy rates in a group of patients who had elective SET were not statistically different among different age groups (ongoing PR ranged from 42.3% to 56.1%). Similar results were obtained in a group of patients with non-elective SET (ongoing PR ranged from 56.1% to 66.1%). An increase in the total number of available euploid embryos from 2 to ≥ 5 embryos did not affect ongoing pregnancy rates after SET: 58.2% (53/91), 68.4% (67/98), 52.9% (36/68) and 61.4% (97/158), respectively, χ2=2.087, p=0.1486. Cumulative live birth rate after two consecutive SETs is equivalent to live birth rate after DET: 74.3% and 72.9%, respectively. Conclusion: Analysis of the data proved the effectiveness of single embryo transfers in IVF PGS cycles regardless of maternal age or total number of euploid embryos available for transfer. In order to maintain high ongoing pregnancy rates and reduce multiple gestation rates, single embryo transfer should be imperative in PGS cycles.