Timothy N. Hickman

Incidence of symptom recurrence after hysterectomy for endometriosis

OBJECTIVES To determine the relative risk of symptom recurrence and/or reoperation after hysterectomy with ovarian preservation for the treatment of endometriosis. DESIGN Historical prospective study of patients with endometriosis who underwent hysterectomy with or without ovarian preservation. PATIENTS One hundred thirty-eight women who underwent hysterectomy with the diagnosis of endometriosis. METHODS A computer search identified 138 women who underwent hysterectomy with the diagnosis of endometriosis at Johns Hopkins Hospital from 1979 to 1991. Follow-up information was obtained from medical records, outpatient charts, and telephone surveys. RESULTS Twenty-nine women had hysterectomy with some ovarian tissue preserved; 109 had all ovarian tissue removed. Of those with ovarian preservation, 18 of 29 (62%) had recurrent pain and 9 of 29 (31%) required reoperation. Of those who had no ovarian preservation, 11 of 109 (10%) had recurrent symptoms and 4 of 109 (3.7%) required reoperation. Ovarian conservation was associated with a relative risk for pain recurrence of 6.1 (95% confidence interval [CI] 2.5 to 14.6) compared with patients with oophorectomy in a Cox proportional hazards model. The relative risk for reoperation in patients with ovarian conservation was 8.1 (95% CI 2.1 to 31.3). CONCLUSION Compared with women who had oophorectomy for endometriosis, patients who underwent hysterectomy with ovarian conservation had 6.1 times greater risk of developing recurrent pain and 8.1 times greater risk of reoperation.

DEVELOPMENT OF BRIEF STRESS MANAGEMENT SUPPORT GROUPS FOR COUPLES UNDERGOING IN VITRO FERTILIZATION TREATMENT

OBJECTIVE To develop and assess the efficacy of couples stress management groups offered concurrently with IVF treatment. DESIGN Couples in IVF treatment were given the option of participating in a biweekly stress management group. SETTING The IVF treatment clinic at Wilford Hall Medical Center, San Antonio, Texas. PATIENT(S) One or both members of 17 couples participated in the program in one of four group cycles. INTERVENTION(S) A cognitive behavioral treatment model was used to help couples process their feelings and cognitions about the impact of infertility on their life and explore their expectations about their future options for becoming parents. MAIN OUTCOME MEASURE(S) Couples were asked to anonymously evaluate the efficacy of the group after they had completed their IVF cycle. RESULT(S) Participants reported that the group helped them deal with the stress of infertility and that they valued the social bonds they formed with other group members. CONCLUSION(S) These data suggest that brief focused group therapy, offered while couples are undergoing IVF, is an effective way to help people deal with the stress of infertility treatment.

Day 4 estradiol levels predict pregnancy success in women undergoing controlled ovarian hyperstimulation for IVF.

OBJECTIVE To evaluate the usefulness of serum estradiol levels obtained on the fourth day of gonadotropin stimulation in predicting the likelihood of pregnancy during controlled ovarian hyperstimulation (COH) using luteal phase leuprolide acetate (LA). DESIGN A 4-year retrospective analysis of day 4 estradiol levels and subsequent clinical pregnancy and delivery rates. SETTING A university hospital tertiary referral center. PATIENT(S) Couples undergoing IVF treatment. MAIN OUTCOME MEASURE(S) Primary outcome measures included clinical pregnancy and delivery rates. Secondary outcome measures included the number of oocytes retrieved and the number of embryos available for transfer per COH cycle. RESULT(S) The clinical pregnancy and delivery rates for cycles with day 4 estradiol levels of >75 pg/mL were 42.3% (30/71) and 32.4% (23/71), respectively. These rates differed significantly from those for cycles with day 4 estradiol levels of < or = 75 pg/mL, which were only 9.1% (4/44) and 6.8% (3/44), respectively. The number of oocytes retrieved and the number of embryos available for transfer for cycles with day 4 estradiol levels of >75 pg/mL also differed significantly from those for cycles with day 4 estradiol levels of < or = 75 pg/mL (11.4 and 7.8 versus 6.8 and 4.3, respectively). CONCLUSION(S) Estradiol levels obtained on the fourth day of gonadotropin therapy are highly predictive of successful ovulation induction and pregnancy outcome in cycles using luteal phase LA.

Clinically recognizable error rate after the transfer of comprehensive chromosomal screened euploid embryos is low

OBJECTIVE To determine the clinically recognizable error rate with the use of quantitative polymerase chain reaction (qPCR)-based comprehensive chromosomal screening (CCS). DESIGN Retrospective study. SETTING Multiple fertility centers. PATIENT(S) All patients receiving euploid designated embryos. INTERVENTION(S) Trophectoderm biopsy for CCS. MAIN OUTCOME MEASURE(S) Evaluation of the pregnancy outcomes following the transfer of qPCR-designated euploid embryos. Calculation of the clinically recognizable error rate. RESULT(S) A total of 3,168 transfers led to 2,354 pregnancies (74.3%). Of 4,794 CCS euploid embryos transferred, 2,976 gestational sacs developed, reflecting a clinical implantation rate of 62.1%. In the cases where a miscarriage occurred and products of conception were available for analysis, ten were ultimately found to be aneuploid. Seven were identified in the products of conception following clinical losses and three in ongoing pregnancies. The clinically recognizable error rate per embryo designated as euploid was 0.21% (95% confidence interval [CI] 0.10-0.37). The clinically recognizable error rate per transfer was 0.32% (95% CI 0.16-0.56). The clinically recognizable error rate per ongoing pregnancy was 0.13% (95% CI 0.03-0.37). Three products of conception from aneuploid losses were available to the molecular laboratory for detailed examination, and all of them demonstrated fetal mosaicism. CONCLUSION(S) The clinically recognizable error rate with qPCR-based CCS is real but quite low. Although evaluated in only a limited number of specimens, mosaicism appears to play a prominent role in misdiagnoses. Mosaic errors present a genuine limit to the effectiveness of aneuploidy screening, because they are not attributable to technical issues in the embryology or analytic laboratories.

Can the Society for Assisted Reproductive Technology Clinic Outcome Reporting System (SART CORS) be used to accurately report clinic total reproductive potential (TRP)

OBJECTIVE To assess whether total reproductive potential (TRP), the chance of a live birth from each fresh cycle (fresh cycle plus frozen transfers), could be calculated from the national Society for Assisted Reproductive Technology Clinic Outcome Reporting System (SART CORS) database and whether information not available in SART CORS resulted in significant changes to the TRP calculation. DESIGN Retrospective study using SART CORS and clinic data. SETTING Three assisted reproductive technology clinics. PATIENT(S) Women undergoing ART. INTERVENTION(S) None. MAIN OUTCOME MEASURE(S) Two- and three-year TRPs for 2005 and 2006 were calculated according to patient age at cycle start by linking fresh to frozen cycles up to first live birth. Clinic records were used to adjust for (remove) frozen cycles that used more than one fresh cycle as a source of embryos and for any embryos donated to other patients or research or shipped to another facility before a live birth. RESULT(S) TRP was higher than fresh per-cycle rates for most ages at all clinics, although accuracy was compromised when there were fewer than 20 cycles per category. Two- and 3-year TRPs differed in only 2 of 24 calculations. Adjusted TRPs differed less than three percentage points from unadjusted TRPs when volume was sufficient. CONCLUSION(S) Clinic TRP can be calculated from SART CORS. Data suggest that calculations of clinic TRP from the national dataset would be meaningful.

Decreased progesterone receptor expression in the intermediate trophoblastic cells of spontaneous abortions

OBJECTIVE To determine whether there are differences in the expression of progesterone receptor (PR) in intermediate trophoblastic cells of pregnancies ending in either spontaneous abortion (SAB) or elective abortion. DESIGN Immunohistochemical identification of PR in intermediate trophoblastic cells. SETTING Academic medical center. PATIENT(S) Subjects were 86 patients who either underwent first trimester SAB or elective abortion. INTERVENTION(S) All SAB and elective abortion specimens were serially sectioned and immunohistochemically stained for PR and for melanoma cell adhesion molecule. Melanoma cell adhesion molecule immunohistochemical staining was used as a sensitive and specific marker to identify intermediate trophoblastic cells on the adjacent tissue section. MAIN OUTCOME MEASURE(S) The PR staining of intermediate trophoblastic cells by semiquantitative immunostaining score. RESULT(S) The PR expression in intermediate trophoblastic cells was significantly greater in elective abortion specimens than in SAB specimens. When controlling for estimated gestational age, the difference in PR expression was even greater. CONCLUSION(S) The quantity of PR in intermediate trophoblastic cells is significantly less in SAB when compared to elective abortion pregnancies. Although it is unknown whether this is a primary or secondary event, this information may be an important finding in attempting to characterize both the molecular etiology of implantation and the molecular pathophysiology of SAB.