W. Vitek

Gonadotropin-releasing hormone agonists for the preservation of ovarian function among women with breast cancer who did not use tamoxifen after chemotherapy: a systematic review and meta-analysis

OBJECTIVE To determine whether concurrent use of GnRH agonists with chemotherapy preserves ovarian function in women with breast cancer who did not use tamoxifen. DESIGN Systematic review and meta-analysis. SETTING University-based hospitals. PATIENT(S) Premenopausal women with breast cancer treated with chemotherapy who did not receive tamoxifen. INTERVENTION(S) Randomization to concurrent GnRH agonists with chemotherapy or chemotherapy alone. MAIN OUTCOME MEASURE(S) Odds ratio (OR) of resumption of menses 1 year or more after chemotherapy. RESULT(S) Searches were conducted in PubMed, Scopus, Cochrane Trials Register, and the National Research Register through March 2014, and all randomized trials that reported resumption of menses 1 year or more after GnRH agonist with chemotherapy or chemotherapy alone among women with breast cancer who did not receive tamoxifen were included. Four studies were analyzed in the meta-analysis and included 252 patients (GnRH agonist with chemotherapy, n=131; chemotherapy alone, n=121). There was no significant difference in the rate of return of menses between the two groups (OR, 1.47; 95% confidence interval [0.60-3.62]). Heterogeneity among the trials was not significant (I2=16.6%). CONCLUSION(S) Concurrent GnRH agonists with chemotherapy may not preserve ovarian function in women with breast cancer. Furthermore, randomized data are limited regarding fertility after concurrent use of GnRH agonists with chemotherapy.

Gonadotropin-releasing hormone agonist or human chorionic gonadotropin for final oocyte maturation in an oocyte donor program

OBJECTIVE To compare leuprolide acetate to hCG as the trigger for final oocyte maturation in oocyte donor cycles. DESIGN Retrospective review. SETTING Academic IVF donor program. PATIENT(S) Thirty-two healthy oocyte donors aged 21-33 years with adequate ovarian reserve. INTERVENTION(S) Donors were down-regulated with cetrorelix and received either leuprolide acetate (n = 12) or hCG (n = 20) for final oocyte maturation. MAIN OUTCOME MEASURE(S) Embryo number, embryo quality, fertilization, implantation, clinical pregnancy, and ovarian hyperstimulation syndrome rates. RESULT(S) The numbers of total oocytes (23 vs. 15), mature (metaphase II) oocytes (22 vs. 13), embryos (15 vs. 10), and cryopreserved embryos (12 vs. 6) per treatment cycle were significantly greater in the leuprolide arm than in the hCG arm. Fertilization rates (73% vs. 78%), implantation rates (30% vs. 29%), and clinical pregnancy rates (40% vs. 50%) were not statistically different between the arms. There were no cases of ovarian hyperstimulation syndrome. CONCLUSION(S) Leuprolide acetate-triggered oocyte donor cycles yielded similar fertilization, implantation, and clinical pregnancy rates to hCG-triggered cycles.

Management of the first in vitro fertilization cycle for unexplained infertility: a cost-effectiveness analysis of split in vitro fertilization-intracytoplasmic sperm injection

OBJECTIVE To determine the cost-effectiveness of split IVF-intracytoplasmic sperm injection (ICSI) for the treatment of couples with unexplained infertility. DESIGN Adaptive decision model. SETTING Academic infertility clinic. PATIENT(S) A total of 154 couples undergoing a split IVF-ICSI cycle and a computer-simulated cohort of women <35 years old with unexplained infertility undergoing IVF. INTERVENTION(S) Modeling insemination method in the first IVF cycle as all IVF, split IVF-ICSI, or all ICSI, and adapting treatment based on fertilization outcomes. MAIN OUTCOME MEASURE(S) Live birth rate, incremental cost-effectiveness ratio (ICER). RESULT(S) In a single cycle, all IVF is preferred as the ICER of split IVF-ICSI or all ICSI (

Treatment of polycystic ovary syndrome in adolescence.

58,766) does not justify the increased live birth rate (3%). If two cycles are needed, split IVF/ICSI is preferred as the increased cumulative live birth rate (3.3%) is gained at an ICER of

Metformin and Other Insulin Sensitizers in Polycystic Ovary Syndrome

29,666. CONCLUSION(S) In a single cycle, all IVF was preferred as the increased live birth rate with split IVF-ICSI and all ICSI was not justified by the increased cost per live birth. If two IVF cycles are needed, however, split IVF/ICSI becomes the preferred approach, as a result of the higher cumulative live birth rate compared with all IVF and the lesser cost per live birth compared with all ICSI.

Off-label drug use in the treatment of polycystic ovary syndrome

Adolescence is a time of rapidly changing reproductive hormones and menstrual patterns making diagnosis of polycystic ovary syndrome (PCOS) challenging in this population. Nonetheless, there is significant concern that the metabolic and reproductive abnormalities that emerge at adolescence associated with a diagnosis of PCOS have lifelong implications for the individual. There are limited data available on the best treatments for the adolescent with PCOS. The focus of treatment is often best served by attention to the individual abnormalities such as menstrual dysfunction, symptoms of androgen excess such as hirsutism and acne, possible metabolic dysfunction primarily seen with concurrent obesity, and concerns related to self-image and mood disorders.

In vitro maturation

Polycystic ovary syndrome (PCOS) is a complex disorder affecting a substantial group of women from adolescent to menopausal age groups. A substantial subgroup of these women exhibits increased insulin resistance. Insulin resistance is difficult to establish in clinical practice and many surrogate tests are available, although their value in the clinical setting is uncertain. The QUICKI method is an inexpensive and easy test to administer and is probably the best test to be used in PCOS patients, preferably in a clinical trial context. There is considerable evidence that insulin-sensitizing agents are not contributory to infertility management in the majority of women with PCOS. Currently, there is no evidence that cardiovascular morbidity is decreased by long-term use of insulin sensitizers in PCOS women.

Metroplasty to treat chronic pelvic pain resulting from outflow tract müllerian anomalies

Polycystic ovary syndrome (PCOS) is a complex lifelong disorder with an etiology and pathophysiology that is not yet entirely understood. Women with PCOS have clinical presentations that may vary from adolescence to menopause, including menstrual irregularity/anovulation and symptoms of hyperandrogenism, such as acne and hirsutism. Over a lifetime, treatment needs and requirements can change. Unfortunately, there are no Food and Drug Administration-approved medications that are approved solely for the purpose of PCOS, but the symptoms and presentation of PCOS are often amenable to several approved agents, such as oral contraceptives for the indication of acne and clomiphene citrate for the indication of induction of ovulation. However, to meet the needs of women with PCOS, off-label use of medications has flourished. This review explores the data for those agents that do not carry an indication for PCOS but have been used for treating the signs and symptoms of PCOS.

Fertility, Contraception, and Novel Reproductive Technologies in Chronic Kidney Disease

In vitro maturation is an alternative to in vitro fertilisation for young women with polycystic ovary syndrome and young ovulatory women. In vitro maturation accomplishes the maturation of immature oocytes in the laboratory, thus minimising or avoiding gonadotrophin stimulation and the associated cost, side‐effects and risks. Pregnancy rates are lower with in vitro maturation than with in vitro fertilisation.

Allostatic load, a measure of chronic physiological stress, is associated with pregnancy outcomes, but not fertility, among women with unexplained infertility

Chronic pelvic pain can result from noncommunicating uterine cavities in patients with müllerian anomalies. Traditional management has been to resect the noncommunicating uterine horn. Two cases are described. One had a unicornuate uterus with noncommunicating left uterine horn (American Fertility Society [AFS] classification IIb) and the other had a normal external uterine contour with noncommunicating left uterine cavity that did not fit any category of the AFS classification of müllerian anomalies. Attempts at connecting the noncommunicating cavities hysteroscopically failed in both cases. Successful unification of the cavities was subsequently achieved in the first case using the classic Strassman metroplasty with the assistance of the robot. The unification of uterine cavities was achieved using a modified Strassman metroplasty in the second patient, as there was no uterine horn for landmark. Robot assistance was utilized in this case as well. Both patients are symptom free after surgery. We conclude that laparoscopic Strassman metroplasty, with or without robot assistance, is a viable alternative to resection of uterine horns in patients with hematometra, chronic pelvic pain, and noncommunicating uterine cavities.