Publications by authors named "Phillip A Romanski"

26 Publications

  • Page 1 of 1

Incidence of first trimester pregnancy loss in the infertile population during the first wave of the coronavirus disease 2019 pandemic in New York City.

F S Rep 2021 Jun 28;2(2):209-214. Epub 2021 Apr 28.

Ronald O. Perelman and Claudia Cohen Center for Reproductive Medicine, Weill Cornell Medical College, New York, New York.

Objective: To describe the incidence of first trimester clinical pregnancy loss in the infertile population during the first wave of the COVID-19 pandemic in New York City.

Design: Web-based cross-sectional survey.

Setting: New York City-based academic reproductive medicine practice.

Patients: A total of 305 infertile patients with a confirmed intrauterine pregnancy in their first trimester between December 1, 2019, and April 1, 2020, were matched by age and treatment type to pregnant patients from the year prior.

Interventions: None.

Main Outcome Measures: First trimester clinical pregnancy loss rate.

Results: In total, the first trimester pregnancy loss rate was lower in the COVID-19 era cohort compared with that in the pre-COVID-19 era cohort (11.9% vs. 20.1%). There was no difference between cohorts in the pregnancy loss rate of women conceiving via fresh embryo transfer (19.6% vs. 24.4%) or via frozen embryo transfer with preimplantation genetic testing (5.4% vs. 9.5%,). In women conceiving via frozen embryo transfer without preimplantation genetic testing, the pregnancy loss rate was statistically lower in the COVID-19 group (12.5% vs. 24.5%). There was no difference in the pregnancy loss rate by treatment type when stratifying by COVID-19 testing or symptom status. Of the 40 (13.1%) patients with a pregnancy loss, there was no difference in self-reported COVID-19 symptoms or symptom type compared with results in those who did not experience a pregnancy loss.

Conclusion: Despite patients expressing significant worry about COVID-19 and pregnancy, our data provides reassuring information that the first trimester pregnancy loss rate is not elevated for women conceiving via assisted reproductive technology during the global COVID-19 pandemic.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.xfre.2021.04.005DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8267398PMC
June 2021

Outcomes in, and characteristics of, patients who undergo intrauterine insemination immediately after failed oocyte retrieval.

F S Rep 2020 Dec 13;1(3):239-242. Epub 2020 Oct 13.

The Ronald O. Perelman and Claudia Cohen Center for Reproductive Medicine, Weill Cornell Medical College, New York, New York.

Objective: To describe the patient and cycle characteristics of women who undergo intrauterine insemination (IUI) immediately after an unsuccessful oocyte retrieval.

Design: Retrospective case series.

Setting: University-affiliated center.

Patients: Women who underwent an oocyte retrieval procedure in which no oocytes were retrieved followed by an IUI on the same morning.

Interventions: None.

Main Outcome Measures: Live birth rate, subsequent live birth rate.

Results: From 2011 to 2019, 63 cycles in 57 patients were identified. The mean (SD) age was 39.6 (4.6) years, and diminished ovarian reserve (94.7%) was the most common diagnosis. The median (IQR) number of previous IVF cycles in this cohort was 3 (1-7), with 56.1% having had at least one previous canceled IVF cycle. The majority of patients had undergone either controlled ovarian hyperstimulation (COH) (64.9%) or modified natural cycles (21.1%). The mean (SD) number of follicles >14 mm at the time of trigger was 1.9 (1.4), with 38.9% of patients manifesting a drop in their estradiol levels after the trigger. One pregnancy resulting in a live birth was identified (1.8%). For patients who underwent subsequent IVF cycles, 60.7% had at least one subsequent cancelled cycle. Three patients went on to achieve a live birth using autologous oocytes (6.5%).

Conclusions: Same-day IUI for patients who have no oocytes retrieved is associated with a <2% chance of achieving a live birth. Of patients who attempt subsequent IVF cycles, nearly two thirds will go on to have at least one subsequent cancelled cycle. In this poor-prognosis cohort, fewer than 10% will ultimately achieve a live birth by the use of autologous oocytes.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.xfre.2020.10.002DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8244274PMC
December 2020

Determining the optimal follicle size at trigger in patients undergoing ovarian stimulation with a clomiphene citrate plus gonadotropin and GnRH antagonist protocol for in vitro fertilization.

Minerva Obstet Gynecol 2021 Jun 28. Epub 2021 Jun 28.

The Ronald O. Perelman and Claudia Cohen Center for Reproductive Medicine, Weill Cornell Medical Center, New York, NY, USA.

Objective: Determine the optimal follicle size at trigger in clomiphene citrate-based IVF protocols.

Study Design: This is a retrospective cohort study performed in at a single academic institution that included first IVF cycles with clomiphene citrate-based protocols at our center between 01/01/2013-03/31/2019. Patients were dichotomized by whether they had ≥2 follicles >20 mm on trigger day. Group A consisted of patients with <2 follicles >20 mm on trigger day and Group B consisted of patients with ≥2 follicles >20 mm on trigger day. The primary outcome was the number of mature oocytes retrieved. Secondary outcomes included pregnancy and live birth rates.

Results: A total of 635 patients were included: (Group A = 399 patients and Group B = 236 patients). The median (IQR) diameter of the largest follicle was 20.0 mm (19.0-21.0) in Group A and 22.7 mm (21.8-24.0) in Group B (p < 0.001). Among the entire cohort, mean number of oocytes retrieved was significantly higher in Group B (9.9 ± 6.5; RR 1.08 (95% CI 1.03-1.14)) compared to Group A (9.2 ± 6.3). In a subgroup analysis of patients in the upper quartile for age (≥41.7 years), Group B had significantly more oocytes retrieved (8.1 ± 5.9 vs. 6.7 ± 4.5; RR 1.23 (95% CI 1.10-1.38)), more mature oocytes retrieved (6.0 ± 4.0 vs. 5.2 ± 3.4; RR 1.16 (95% CI 1.02-1.33)), and more zygotes (4.7 ± 3.5 vs. 3.6 ± 2.8; RR 1.32 (95% CI 1.13-1.55)). In the secondary analysis, pregnancy and live birth rates after fresh transfer were similar between groups.

Conclusions: In clomiphene citrate-based IVF protocols, administering the ovulatory trigger at larger follicle sizes yielded more total oocytes retrieved without a significant difference in mature oocyte number. In older patients, larger follicle sizes at trigger yielded more mature oocytes and zygotes per retrieval. Based on these results, in older patients it may be advantageous to administer the ovulatory trigger in clomiphene-based IVF cycles when two or more follicles measures >20 mm. However, this benefit was not observed when assessed among all ages combined.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.23736/S2724-606X.21.04837-5DOI Listing
June 2021

Length of estradiol exposure >100 pg/ml in the follicular phase affects pregnancy outcomes in natural frozen embryo transfer cycles.

Hum Reprod 2021 06;36(7):1932-1940

The Ronald O. Perelman and Claudia Cohen Center for Reproductive Medicine, Weill Cornell Medical College, New York, NY, USA.

Study Question: Do the length of follicular phase estradiol exposure and the total length of the follicular phase affect pregnancy and live birth outcomes in natural frozen embryo transfer (FET) cycles?

Summary Answer: An estradiol level >100 pg/ml for ≤4 days including the LH surge day is associated with worse pregnancy and live birth outcomes; however, the total length of the follicular phase is not associated with pregnancy and live birth outcomes.

What Is Known Already: An estradiol level that increases above 100 pg/ml and continues to increase is indicative of the selection and development of a dominant follicle. In programmed FET cycles, a limited duration of follicular phase estradiol of <9 days results in worse pregnancy rates, but a prolonged exposure to follicular phase estradiol for up to 4 weeks does not affect pregnancy outcomes. It is unknown how follicular phase characteristics affect pregnancy outcomes in natural FET cycles.

Study Design, Size, Duration: This retrospective cohort study included infertile patients in an academic hospital setting who underwent their first natural frozen autologous Day-5 embryo transfer cycle in our IVF clinic between 01 January 2013 and 31 December 2018. Donor oocyte and gestational carrier cycles were excluded.

Participants/materials, Setting, Methods: The primary outcomes of this study were pregnancy and live birth rates. Patients were stratified into two groups based on the cohorts' median number of days from the estradiol level of >100 pg/ml before the LH surge: Group 1 (≤4 days; n = 1052 patients) and Group 2 (>4 days; n = 839 patients). Additionally, patients were stratified into two groups based on the cohorts' median cycle day of LH surge: Group 1 (follicular length ≤15 days; n = 1287 patients) and Group 2 (follicular length >15 days; n = 1071 patients). A subgroup analysis of preimplantation genetic testing for aneuploidies (PGT-A) embryo transfer cycles was performed. Logistic regression analysis, adjusted a priori for patient age, number of embryos transferred, and use of PGT-A, was used to estimate the odds ratio (OR) with a 95% CI.

Main Results And The Role Of Chance: In the length of elevated estradiol analysis, the pregnancy rate per embryo transfer was statistically significantly lower in patients with an elevated estradiol to surge of ≤4 days (65.6%) compared to patients with an elevated estradiol to surge of >4 days (70.9%; OR 1.30 (95% CI 1.06-1.58)). The live birth rate per embryo transfer was also statistically significantly lower in patients with an elevated estradiol to surge of ≤4 days (46.6%) compared to patients with an elevated estradiol to surge of >4 days (52.0%; OR 1.23 (95% CI 1.02-1.48)). In the follicular phase length analysis, the pregnancy rate per embryo transfer was similar between patients with a follicular length of ≤15 days (65.4%) and patients with a follicular length of >15 days (69.0%; OR 1.12 (95% CI 0.94-1.33)): the live birth rate was also similar between groups (45.5% vs 51.5%, respectively; OR 1.14 (95% CI 0.97-1.35)). In all analyses, once a pregnancy was achieved, the length of the follicular phase or the length of elevated oestradiol >100 pg/ml no longer affected the pregnancy outcomes.

Limitations, Reasons For Caution: The retrospective design of this study is subject to possible selection bias in regard to which patients at our clinic were recommended to undergo a natural FET compared to a fresh embryo transfer or programmed FET. To decrease the heterogeneity of our study population, we only included patients who had blastocyst embryo transfers; therefore, it is unknown whether similar results would be observed in patients with cleavage-stage embryo transfers. The retrospective nature of the study design did not allow randomized to a specific ovarian stimulation or ovulation trigger protocol. However, all patients were managed with the standardized protocols at a single center, which strengthens the external validity of our results when compared to a study that only evaluates one specific stimulation protocol.

Wider Implications Of The Findings: Our observations provide cycle-level characteristics that can be applied during a natural FET cycle to help optimize embryo transfer success rates. Physicians should consider the parameter of number of days that oestradiol is >100 pg/ml prior to the LH surge when determining whether to proceed with embryo transfer in a natural cycle. This cycle-specific characteristic may also help to provide an explanation for some failed transfer cycles. Importantly, our findings should not be used to determine whether to recommend a natural or a programmed FET cycle for a patient, but rather, to identify natural FET cycles that are not optimal to proceed with embryo transfer.

Study Funding/competing Interest(s): No financial support, funding, or services were obtained for this study. The authors do not report any potential conflicts of interest.

Trial Registration Number: N/A.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1093/humrep/deab111DOI Listing
June 2021

Psychosocial response of infertile patients to COVID-19-related delays in care at the epicenter of the global pandemic.

Minerva Obstet Gynecol 2021 May 28. Epub 2021 May 28.

The Ronald O. Perelman and Claudia Cohen Center for Reproductive Medicine, Weill Cornell Medical College, New York, NY, USA.

Background: To describe the psychosocial response of the infertile population whose care was curtailed due to the COVID-19 pandemic.

Methods: A web-based cross-sectional survey was administered to 117 infertile patients at our center who had their infertility treatment delayed due to suspension of care at our hospital during the COVID-19 pandemic. The survey consisted of 52-question multiple-choice questions including the Life Orientation Test-Revised (LOT-R) and the Hospital Anxiety and Depression Scale (HADS) instruments. Characteristics of respondents who "agreed" (strongly agree and agree) that "delaying treatment has permanently impacted my chances at future conception" were compared with participants who "disagreed" (neutral, disagree, and strongly disagree) using Fischer's exact test.

Results: In total, 79.5% agreed that delaying treatment has permanently impacted their chances at future conception. There were no discernible demographic differences between patients who "agreed" versus "disagreed" with the above statement. The mean LOT-R score was 14.1 (5.1) with an optimism score of 6.8 (2.6) and a pessimism score of 7.3 (2.9). The mean HADS depression score was 5.4 (3.4) with 28.2% reporting scores in the borderline-abnormal to abnormal range. The mean HADS anxiety score was 9.0 (3.9) with 64.6% reporting scores in the borderline-abnormal to abnormal range. Nearly one third of respondents (36.8%) reported wanting to "expedite/be more aggressive with treatment," whereas only 5.1% wanted to postpone treatment.

Conclusions: Women undergoing ART during the COVID-19 pandemic express significant concern and signs of distress about how delays in care affect their future reproductive potential.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.23736/S2724-606X.21.04852-1DOI Listing
May 2021

Unilateral Obstructed Müllerian Anomalies: A Series of Unusual Variants of Known Anomalies.

J Pediatr Adolesc Gynecol 2021 Apr 25. Epub 2021 Apr 25.

The Ronald O. Perelman and Claudia Cohen Center for Reproductive Medicine, Weill Cornell Medical College, New York, New York.

Background: Obstructed Müllerian anomalies in adolescents can be grouped into complete outflow obstruction or unilateral outflow obstruction. The challenge with unilateral obstructions is that diagnosis can be delayed for weeks to years, as menstruation occurs normally through the patent side and thus obstruction is often not initially considered in the differential diagnosis.

Cases: In this case series, we present 3 unusual and challenging cases of unilateral Müllerian obstructions in adolescent female patients, along with strategies for diagnosis and management. Each case involves a unique variation of a recognized Müllerian anomaly that was initially misdiagnosed, leading to a significant delay in definitive diagnosis and treatment.

Summary And Conclusion: These cases highlight that even among the well-described Müllerian anomalies, there can be unusual variations. Patients who do not respond to initial management or who develop new symptoms should be further evaluated to confirm the correct diagnosis Tools that may be helpful in making the correct diagnosis include imaging studies that use contrast dye to better delineate cavities and their connections, magnetic resonance imaging with a radiologist experienced in Müllerian anomalies, and an examination under anesthesia. A definitive diagnosis is critical to the successful management of these conditions, and individualized management plans are required for each patient depending on their specific anomaly and their preferences for treatment.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.jpag.2021.04.005DOI Listing
April 2021

Postwash total motile sperm count and intrauterine insemination pregnancy rate: how low can you go?

Fertil Steril 2021 Jun 15;115(6):1424-1425. Epub 2021 Apr 15.

The Ronald O. Perelman and Claudia Cohen Center for Reproductive Medicine, Weill Cornell Medical Center, New York, New York.

View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.fertnstert.2021.03.013DOI Listing
June 2021

Body mass index is not associated with embryo ploidy in patients undergoing in vitro fertilization with preimplantation genetic testing.

Fertil Steril 2021 Apr 4. Epub 2021 Apr 4.

The Ronald O. Perelman and Claudia Cohen Center for Reproductive Medicine, Weill Cornell Medical Center, New York, New York.

Objective: To assess the association between body mass index (BMI) and embryo aneuploidy and mosaicism in a cohort of patients undergoing in vitro fertilization (IVF) with trophectoderm biopsy for preimplantation genetic testing for aneuploidy (PGT-A) using next-generation sequencing technology.

Design: Retrospective cohort study.

Setting: Academic center.

Patients: Patients undergoing their first IVF cycle with trophectoderm biopsy and PGT-A at our center between January 1, 2017, and August 31, 2020. Patients classified as underweight on the basis of BMI (BMI <18.5 kg/m) and patients who underwent fresh embryo transfers were excluded.

Intervention: None.

Main Outcome Measures: Number and proportion of aneuploid, mosaic, and euploid embryos.

Results: The patients were stratified according to the World Health Organization's BMI classification: normal weight (18.5-24.9 kg/m, n = 1,254), overweight (25-29.9 kg/m, n = 351), and obese (≥30 kg/m, n = 145). Age-adjusted regression models showed no relationship between BMI classification and the number or proportion of aneuploid embryos. There were no statistically significant associations between BMI classifications and the number or proportion of mosaic or euploid embryos. A subgroup analysis of patients classified into age groups of <35, 35-40, and >40 years similarly showed no relationships between BMI and embryo ploidy outcomes.

Conclusion: Body mass index was not associated with the number or proportion of aneuploid, mosaic, or euploid embryos in this large cohort of patients undergoing IVF with PGT-A, suggesting that the negative effect of excess weight on reproductive outcomes was independent of the ploidy status of the embryo cohort.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.fertnstert.2021.02.029DOI Listing
April 2021

For the next 40 years of in vitro fertilization-let's sharpen our focus on iatrogenic harm reduction.

Fertil Steril 2021 Apr 6;115(4):897. Epub 2021 Mar 6.

Department of Reproductive Medicine, The Ronald O. Perelman and Claudia Cohen Center for Reproductive Medicine, Weill Cornell Medical College, New York, New York.

View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.fertnstert.2021.01.032DOI Listing
April 2021

Chronic endometritis in women with suspected retained products of conception and their reproductive outcomes.

Am J Reprod Immunol 2021 Aug 13;86(2):e13410. Epub 2021 Mar 13.

The Ronald O. Perelman and Claudia Cohen Center for Reproductive Medicine, Weill Cornell Medicine, New York, NY, USA.

Objective: To determine whether women who underwent operative hysteroscopy for suspected retained products of conception (rPOC) have histopathologic evidence of chronic endometritis (CE).

Design: Retrospective cohort.

Setting: Academic center.

Patient(s): One hundred and eleven women who underwent operative hysteroscopy for suspected rPOC between 2016 and 2018.

Intervention(s): None.

Main Outcome Measure(s): Evidence of CE on histopathology and subsequent reproductive outcomes.

Result(s): One hundred and eleven women with retained products of conception were included in our study of which 26 (23.4%) were diagnosed with CE. Women without CE had a higher median gravidity (1 vs. 2, p = .021) and a higher median number of prior pregnancy losses (1 vs. 2 prior losses, p = .005) compared to those with CE. Subsequent pregnancy data were available for 63 women. There was no difference in the subsequent pregnancy rate (61.5 vs. 54%, p = .626) between those with and without CE. Once pregnant, miscarriage (37.5 vs. 25.9%, p = .524) and live birth rates (50 vs. 44.4%, p = .782) were similar between the groups. Women with CE received antibiotics 57.7% of the time, the most common of which was doxycycline (46.6%). Of the women with CE who received antibiotics (n = 10), 8 became pregnant, and 4 of whom went on to have a live birth.

Conclusion(s): Nearly 1 in 4 women undergoing hysteroscopy for rPOC was incidentally diagnosed with CE. It is not clear whether CE is a causative agent for retained products or a response to the pregnancy loss. In this cohort, a diagnosis of CE did not negatively impact subsequent reproductive outcomes.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1111/aji.13410DOI Listing
August 2021

Time from oocyte retrieval to frozen embryo transfer in the natural cycle does not impact reproductive or neonatal outcomes.

Fertil Steril 2021 May 12;115(5):1232-1238. Epub 2021 Feb 12.

The Ronald O. Perelman and Claudia Cohen Center for Reproductive Medicine, Weill Cornell Medical College, New York, New York. Electronic address:

Objective: To determine if the time from oocyte retrieval to frozen embryo transfer (FET) in the natural cycle affects reproductive or neonatal outcomes.

Design: Retrospective cohort.

Setting: Not applicable.

Patient(s): Five hundred and seventy-six consecutive freeze-all cycles from January 2011 to December 2018 followed by natural cycle FET of a single blastocyst.

Intervention(s): None.

Main Outcome Measure(s): Primary outcome of live birth; secondary outcomes of preterm delivery (24-37 weeks) and small for gestational age (SGA) with a multivariable logistic regression performed with adjustment for age, infertility diagnosis, ovulatory trigger type, and preimplantation genetic testing (PGT).

Result(s): Before adjustment for confounding, we found a statistically significantly different live-birth rate (57.7% vs. 48.6%) for natural cycle FET occurring in the first versus second menstrual cycle, respectively. In a multivariate analysis, performing a natural cycle FET of a single blastocyst in the second compared with the first menstrual cycle did not statistically significantly impact the odds of live-birth rate. After adjustment for age, diagnosis, and ovulatory trigger type, only PGT was associated with statistically significantly increased odds of live birth compared with no PGT. There were no differences in the incidence of SGA (male, 6.6% vs. 2.3%; female, 9.8% vs. 11.1%) or preterm delivery (1.6% vs. 5.6%) between both groups.

Conclusion(s): Performing a natural cycle FET of a single blastocyst in the second compared with the first menstrual cycle after ovarian stimulation did not statistically significantly impact the odds of live birth or neonatal outcomes.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.fertnstert.2020.11.011DOI Listing
May 2021

Lessons from the tortoise and the hare.

Fertil Steril 2021 Mar 25;115(3):588-589. Epub 2021 Jan 25.

The Ronald O. Perelman and Claudia Cohen Center for Reproductive Medicine, Weill Cornell Medical College, New York, New York.

View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.fertnstert.2020.12.026DOI Listing
March 2021

Creation of a novel inflatable vaginal stent for McIndoe vaginoplasty.

Fertil Steril 2021 Mar 4;115(3):804-806. Epub 2020 Dec 4.

Ronald O. Perelman and Claudia Cohen Center for Reproductive Medicine, Weill Cornell Medical College, New York, New York.

Objective: To describe how to create an inflatable vaginal stent for use in McIndoe vaginoplasty that can be constructed using standard operating room supplies.

Design: Step-by-step video instructions that demonstrate how to construct and use an inflatable vaginal stent. (This video article was exempt from institutional review board approval.) SETTING: Academic hospital.

Patient(s): A woman presenting with vaginal agenesis requiring a McIndoe vaginoplasty for the creation of a neovagina.

Intervention(s): A novel inflatable vaginal stent compliant with operating room procedures that is radio-opaque, functional, and can be used for patients with or without a functional uterus. The device is modeled after the effective inflatable vaginal stent that was previously commercially available but is no longer produced. Although a vaginal stent may be created in the operating room by placing surgical sponges inside a sterilized condom, many operating rooms have restrictions on equipment that can be brought into the operating room and special criteria for how to sterilize this equipment, and there are also restrictions against leaving non-radio-opaque objects "inside" the patient. The novel inflatable vaginal stent we have developed has multiple advantages compared with a rigid dilator: it is deflatable, so it does not cause trauma or interrupt the delicate tissue graft during insertion, removal, or repositioning; it is firm enough to conform and circumferentially press the tissue graft against the dissected vaginal space but is soft enough to decrease the risk of pressure necrosis or damage to the urethra; and it has a drainage port to prevent the buildup of a fluid pocket that could interfere with graft adherence. Our stent incorporates all these unique properties and can be easily constructed using sterile operating room supplies. The construction of this device requires a silicone Foley catheter, sterile foam sponges from a vaginal prep kit, a sterile radio-opaque sponge, a sterile vaginal ultrasound probe cover, a long Kelly, a 60-cc catheter tip syringe, a ruler, scissors, 0-vicryl suture, and sterile gloves.

Main Outcome Measure(s): Effectiveness of a self-made inflatable vaginal stent using standard operating room supplies that meets operating room protocol standards.

Result(s): A standard dose of prophylactic antibiotics should be administered preoperatively to prevent surgical site infection. After placement of the tissue graft in the dissected neovagina cavity, the vaginal stent is placed and slowly inflated to circumferentially apply the tissue graft against the dissected vaginal space. The stent remains in place for 7 days and then should be removed in the operating room to allow for an examination under anesthesia, which provides the ideal setting to best evaluate the initial graft adherence. After careful inspection of the neovagina and tissue graft, a standard silicone vaginal mold is placed to maintain vaginal patency and prevent stricture of the tissue graft. The silicone mold should remain in place continuously until complete graft adherence occurs (approximately 4 to 6 weeks), and then it can be worn nightly until the patient is regularly sexually active. If at any point the patient discontinues nightly use of the silicone mold before regular sexual activity, vaginal stricture and a decrease in vaginal caliber will occur.

Conclusion(s): Our novel inflatable vaginal stent is useful to surgeons performing a McIndoe vaginoplasty for vaginal agenesis with or without a uterus. It is compliant with operating room protocols and restrictions, as it is constructed from operating room supplies and is radio-opaque. Moreover, it is adjustable in size and effective in applying circumferential pressure for graft adherence. When used for segmental vaginal agenesis, the Foley catheter may be advanced through the cervix, then the balloon can be inflated, to stabilize the position of the stent during the first week postoperatively. The main limitation of this device is that it must be constructed by the surgeon, but the advantage of self-constructing the stent is that the size and shape can be tailored to conform to each individual patient. We prefer this inflatable vaginal stent to a rigid vaginal dilator in the first week of tissue healing to allow for easy insertion and removal of the stent without disrupting the tissue graft, to help prevent tissue necrosis, and to provide a fluid drainage port during graft adherence. We recommend this device as an ideal option for surgeons to consider when performing a McIndoe vaginoplasty.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.fertnstert.2020.09.030DOI Listing
March 2021

Reproductive and obstetric outcomes in mildly and significantly underweight women undergoing IVF.

Reprod Biomed Online 2021 Feb 24;42(2):366-374. Epub 2020 Oct 24.

The Ronald O. Perelman and Claudia Cohen Center for Reproductive Medicine, Weill Cornell Medical Center, New York NY, USA. Electronic address:

Research Question: What is the impact of low body mass index (BMI) on live birth rates and obstetric outcomes in infertile women treated with IVF and fresh embryo transfer?

Design: This was a retrospective cohort study of infertile patients in an academic hospital setting who underwent their first oocyte retrieval with planned autologous fresh embryo transfer between 1 January 2012 and 31 December 2018. The primary study outcome was live birth rate. Secondary outcomes were IVF treatment and delivery outcomes. Underweight patients were stratified into a significantly underweight group (body mass index [BMI] <17.5 kg/m) and a mildly underweight group (BMI 17.5-18.49 kg/m), and were compared with a normal-weight group (BMI 18.5-24.9 kg/m).

Results: A total of 5229 patients were included (significantly underweight, 76; mildly underweight, 231; normal weight, 4922), resulting in 4798 embryo transfers. After oocyte retrieval, there were no significant differences between groups for total oocytes, mature oocyte yield and number of supernumerary blastocysts cryopreserved. Among women who had an embryo transfer, there were no significant differences in the live birth rates in significantly (31.0%, odds ratio [OR] 0.67, confidence interval [0.95, CI] 0.40-1.13) and mildly (37.7%, OR 0.95, CI 0.73-1.33) underweight patients compared with normal-weight patients (35.9%). Additionally, there were no statistically significant increased risks of preterm delivery, Caesarean delivery or a low birthweight (<2500 g) neonate.

Conclusions: Mildly and significantly underweight infertile women have similar pregnancy and live birth rates to normal-weight patients after IVF treatment. In addition, underweight patients do not have an increased risk of preterm delivery (<37 weeks), Caesarean delivery or a low birthweight neonate.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.rbmo.2020.10.011DOI Listing
February 2021

Live birth outcomes in infertile patients with class III and class IV obesity following fresh embryo transfer.

J Assist Reprod Genet 2021 Feb 16;38(2):347-355. Epub 2020 Nov 16.

The Ronald O. Perelman and Claudia Cohen Center for Reproductive Medicine, Weill Cornell Medical Center, 1305 York Avenue, New York, NY, 10021, USA.

Objective: Assess the effect of class III (body mass index [BMI, kg/m] 40-49.9) and class IV obesity (≥ 50) on clinical pregnancy and live birth outcomes after first oocyte retrieval and fresh embryo transfer cycle.

Design: Cohort study SETTING: Academic center PATIENTS: Patients undergoing their first oocyte retrieval with planned fresh embryo transfer in our clinic between 01/01/2012 and 12/31/2018. Patients were stratified by BMI: 18.5-24.9 (n = 4913), 25-29.9 (n = 1566) 30-34.9 (n = 559), 35-39.9 (n = 218), and ≥ 40 (n = 114).

Intervention: None MAIN OUTCOME MEASURE: Live birth rate RESULTS: Following embryo transfer, there were no differences in pregnancy rates across all BMI groups (p value, linear trend = 0.86). However among pregnant patients, as BMI increased, a significant trend of a decreased live birth rate was observed (p value, test for linear trend = 0.004). Additionally, as BMI increased, a significant trend of an increased miscarriage rate was observed (p value, linear trend = < 0.001). Compared to the normal-weight cohort, women with a BMI ≥ 40 had a significantly higher rate of cancelled fresh transfers after retrieval (18.4% vs. 8.2%, OR 2.51; 95%CI 1.55-4.08). Among singleton deliveries, a significant trend of an increased c-section rate was identified as the BMI increased (p value, linear trend = <0.001).

Conclusion: Overall, patients with a BMI > 40 have worse IVF treatment outcomes compared to normal-weight patients. After embryo transfer, their pregnancy rate is comparable to normal-weight women; however, their miscarriage rate is higher, leading to a lower live birth rate for pregnant women in this population. Patients with a BMI > 40 have a c-section rate that is 50% higher than normal-weight patients.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1007/s10815-020-02011-1DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7884488PMC
February 2021

Gynecological Cancers Caused by Deficient Mismatch Repair and Microsatellite Instability.

Cancers (Basel) 2020 Nov 10;12(11). Epub 2020 Nov 10.

The Ronald O. Perelman and Claudia Cohen Center for Reproductive Medicine, Weill Cornell Medicine, New York, NY 10021, USA.

Mutations in mismatch repair genes leading to mismatch repair (MMR) deficiency (dMMR) and microsatellite instability (MSI) have been implicated in multiple types of gynecologic malignancies. Endometrial carcinoma represents the largest group, with approximately 30% of these cancers caused by dMMR/MSI. Thus, testing for dMMR is now routine for endometrial cancer. Somatic mutations leading to dMMR account for approximately 90% of these cancers. However, in 5-10% of cases, MMR protein deficiency is due to a germline mutation in the mismatch repair genes , , , , or . These germline mutations, known as Lynch syndrome, are associated with an increased risk of both endometrial and ovarian cancer, in addition to colorectal, gastric, urinary tract, and brain malignancies. So far, gynecological cancers with dMMR/MSI are not well characterized and markers for detection of MSI in gynecological cancers are not well defined. In addition, currently advanced endometrial cancers have a poor prognosis and are treated without regard to MSI status. Elucidation of the mechanism causing dMMR/MSI gynecological cancers would aid in diagnosis and therapeutic intervention. Recently, a new immunotherapy was approved for the treatment of solid tumors with MSI that have recurred or progressed after failing traditional treatment strategies. In this review, we summarize the MMR defects and MSI observed in gynecological cancers, their prognostic value, and advances in therapeutic strategies to treat these cancers.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.3390/cancers12113319DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7697596PMC
November 2020

Electronic whiteboard implementation as a quality management tool optimizes IVF laboratory standardization and improves clinical outcomes.

J Assist Reprod Genet 2021 Jan 11;38(1):203-210. Epub 2020 Nov 11.

Department of Obstetrics, Gynecology and Reproductive Biology, Brigham & Women's Hospital and Harvard Medical School, 75 Francis Street, Boston, MA, 02115, USA.

Purpose: To test whether an electronic whiteboard in the IVF laboratory increases the likelihood that critical evaluation procedures are performed within optimum pre-set time ranges.

Methods: A retrospective cohort study of oocyte retrievals in our IVF clinic between 06/01/2012 and 05/31/2018 was included. The electronic whiteboard was introduced on 04/06/2014. Prior to implementation, embryologists strived to adhere to the set evaluation times without a formal guide. The primary outcomes were the proportion of embryologist evaluations performed in optimum time ranges and the proportion of usable embryos per patient.

Results: A total of 4645 retrievals met inclusion criteria. Implementation of the whiteboard was associated with (1) an increase in the proportion of fertilization checks performed within the optimum time range for ICSI cycles (+ 5.1%, RR = 1.06, CI = 1.02-1.10); (2) an increase in the proportion of day 3 evaluations performed within the optimum time range, whether assisted hatching was performed (+ 23.6%, RR = 1.48, CI = 1.36-1.60) or not (+ 13.8%, RR = 1.23, CI = 1.12-1.35); and (3) an increase in the proportion of day 5 evaluations within the optimum time range (+ 15.5%, RR = 1.23, CI = 1.12-1.35). Additionally, the mean number of usable embryos per patient increased from 2.8 to 4.5 after the whiteboard was implemented (RR = 1.25, CI = 1.19-1.31).

Conclusion: The use of an electronic whiteboard that posts optimum times for performing critical procedures significantly increases the proportion of evaluations that occur within these ranges. Such improved standardization led to positive downstream effects on the number of usable embryos per patient. We suggest that electronic whiteboard implementation driven by real-time data collection should be considered in all IVF laboratories.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1007/s10815-020-02007-xDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7822993PMC
January 2021

Tubal Ectopic Pregnancy with Undetectable Initial Serum β-Human Chorionic Gonadotropin Level.

J Minim Invasive Gynecol 2021 01 26;28(1):142-145. Epub 2020 Jun 26.

The Ronald O. Perelman and Claudia Cohen Center for Reproductive Medicine (Drs. Pereira, Romanski, Kligman, Rosenwaks, and Ms. Wright), Weill Cornell Medicine, New York, New York.

We present a case of a tubal ectopic pregnancy (EP) in a patient with an initially undetectable serum β-human chorionic gonadotropin (β-hCG) level. A 33-year-old woman in a same-sex relationship underwent timed donor intrauterine insemination. Her serum β-hCG level was <5 mIU/mL 14 days after the intrauterine insemination. She reported menstrual bleeding 3 days after her negative pregnancy test and returned to the office 10 days later to begin a new treatment cycle. Her serum levels of estradiol, progesterone, and β-hCG were 119 pg/mL, 6.1 ng/mL and 1157 mIU/mL, respectively. Transvaginal ultrasonography did not show an intrauterine pregnancy. Her β-hCG level increased to 1420 mIU/mL the next day. She was diagnosed with a pregnancy of unknown location and treated with methotrexate. Her β-hCG levels continued to increase despite 3 methotrexate doses, necessitating laparoscopy. The diagnostic laparoscopy demonstrated approximately 100 mL of hemoperitoneum in the posterior cul-de-sac with an intact right fallopian tube that was dilated at its distal end by the EP. A total right salpingectomy was performed. Her β-hCG level was <5 mIU/mL 3 weeks later. The current case supports that although rare, an undetectable serum β-hCG level does not completely rule out the diagnosis of an EP.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.jmig.2020.06.015DOI Listing
January 2021

Delay in IVF treatment up to 180 days does not affect pregnancy outcomes in women with diminished ovarian reserve.

Hum Reprod 2020 07;35(7):1630-1636

Ronald O. Perelman and Claudia Cohen Center for Reproductive Medicine, Weill Cornell Medical College, New York, NY, USA.

Study Question: Will a delay in initiating IVF treatment affect pregnancy outcomes in infertile women with diminished ovarian reserve?

Summary Answer: A delay in IVF treatment up to 180 days does not affect the live birth rate for women with diminished ovarian reserve when compared to women who initiate IVF treatment within 90 days of presentation.

What Is Known Already: In clinical practice, treatment delays can occur due to medical, logistical or financial reasons. Over a period of years, a gradual decline in ovarian reserve occurs which can result in declining outcomes in response to IVF treatment over time. There is disagreement among reproductive endocrinologists about whether delaying IVF treatment for a few months can negatively affect patient outcomes.

Study Design, Size, Duration: A retrospective cohort study of infertile patients in an academic hospital setting with diminished ovarian reserve who started an IVF cycle within 180 days of their initial consultation and underwent an oocyte retrieval with planned fresh embryo transfer between 1 January 2012 and 31 December 2018.

Participants/materials, Setting, Methods: Diminished ovarian reserve was defined as an anti-Müllerian hormone (AMH) <1.1 ng/ml. In total, 1790 patients met inclusion criteria (1115 immediate and 675 delayed treatment). Each patient had one included cycle and no subsequent data from additional frozen embryo transfer cycles were included. Since all cycle outcomes evaluated were from fresh embryo transfers, no genetically tested embryos were included. Patients were grouped by whether their cycle started 1-90 days after presentation (immediate) or 91-180 days (delayed). The primary outcome was live birth (≥24 weeks of gestation). A subgroup analysis of more severe forms of diminished ovarian reserve was performed to evaluate outcomes for patients with an AMH <0.5 and for patients >40 years old with an AMH <1.1 ng/ml (Bologna criteria for diminished ovarian reserve). Logistic regression analysis, adjusted a priori for patient age, was used to estimate the odds ratio (OR) with a 95% CI. All pregnancy outcomes were additionally adjusted for the number of embryos transferred.

Main Results And The Role Of Chance: The mean ± SD number of days from presentation to IVF start was 50.5 ± 21.9 (immediate) and 128.8 ± 25.9 (delayed). After embryo transfer, the live birth rate was similar between groups (immediate: 23.9%; delayed: 25.6%; OR 1.08, 95% CI 0.85-1.38). Additionally, a similar live birth rate was observed in a subgroup analysis of patients with an AMH <0.5 ng/ml (immediate: 18.8%; delayed: 19.1%; OR 0.99, 95% CI 0.65-1.51) and in patients >40 years old with an AMH <1.1 ng/ml (immediate: 12.3%; delayed: 14.7%; OR 1.21, 95% CI 0.77-1.91).

Limitations, Reasons For Caution: There is the potential for selection bias with regard to the patients who started their IVF cycle within 90 days compared to 91-180 days after initial consultation. In addition, we did not include patients who were seen for initial evaluation but did not progress to IVF treatment with oocyte retrieval; therefore, our results should only be applied to patients with diminished ovarian reserve who complete an IVF cycle. Finally, since we excluded patients who started their IVF cycle greater than 180 days from their first visit, it is not known how such a delay in treatment affects pregnancy outcomes in IVF cycles.

Wider Implications Of The Findings: A delay in initiating IVF treatment in patients with diminished ovarian reserve up to 180 days from the initial visit does not affect pregnancy outcomes. This observation remains true for patients who are in the high-risk categories for poor response to ovarian stimulation. Providers and patients should be reassured that when a short-term treatment delay is deemed necessary for medical, logistic or financial reasons, treatment outcomes will not be affected.

Study Funding/competing Interest(s): No financial support, funding or services were obtained for this study. The authors do not report any potential conflicts of interest.

Trial Registration Number: Not applicable.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1093/humrep/deaa137DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7337822PMC
July 2020

The "Invisible Student": Neglect as a Form of Medical Student Mistreatment, a Call to Action.

J Surg Educ 2020 Nov - Dec;77(6):1327-1330. Epub 2020 Jun 2.

Department of Obstetrics, Gynecology and Reproductive Biology, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts.

The mistreatment of trainees is known to lead to burnout, loss of empathy, and career changes. Medical students in particular are vulnerable to mistreatment due to their lack of seniority and frequent transitions to new teams. Traditionally, initiatives to eliminate medical student mistreatment have focused on preventing their victimization surrounding verbal, physical, and sexual misconduct. While initiatives to eliminate these types of behaviors are exceedingly important, the most common form of mistreatment that is reported by medical students is not these active forms of abuse. Instead, students on their clinical rotations more frequently report the covert "obstruction of learning" or "exclusion from the medical team" as the most common form of mistreatment experienced. Though the passive neglect of a medical student is not seemingly as serious an offense as active abuse, it can certainly have an impactful, lasting negative effect on student development, morale, and career choice. In this perspective, we recognize the importance of observational learning as a component of medical education, but state that the neglect or exclusion of a medical student should not be considered acceptable and should be labeled what it is-a form of mistreatment. We additionally provide examples for how to prevent medical student neglect by establishing a supportive and inclusive teaching environment.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.jsurg.2020.05.013DOI Listing
June 2021

Women's health providers' perspectives on preimplantation genetic testing.

Reprod Biomed Online 2019 Sep 11;39(3):530-537. Epub 2019 May 11.

Department of Obstetrics and Gynecology, Division of Reproductive Endocrinology and Infertility, Massachusetts General Hospital and Harvard Medical School, Boston MA, USA.

Research Question: What are the perspectives of women's health providers on the use of preimplantation genetic testing (PGT) for common medical disorders?

Design: A cross-sectional 15-question online anonymous survey was conducted of women's health providers specializing in general obstetrics/gynaecology, gynaecologic oncology and infertility at a tertiary care academic institution in Massachusetts, USA. Respondents could answer 'yes', 'no' or 'unsure' to each thematic question.

Results: The survey was sent to 1060 providers and 240 providers responded (response rate 22.6%). Overall, 93% of respondents supported the use of PGT for the identification of genetic mutations which lead to childhood-onset disease, 83% supported the use of PGT for chromosomal aneuploidy screening, and 76% supported the use of PGT for cancer-related genetic disorders. Only 1.7% of respondents supported the use of PGT for non-disease-related indications, including sex selection and physical traits. Compared with general obstetrics/gynaecology providers, infertility specialists were more supportive of PGT. In total, 22.5% of respondents reported no prior knowledge of PGT.

Conclusions: In a sample of women's health providers across multiple different obstetrics/gynaecology specialties, there was overall support for the use of PGT for a variety of common indications. Infertility specialists were the most supportive, which may reflect the familiarity that these providers have with this procedure. There was an overwhelmingly non-supportive response for the use of PGT for non-disease-related indications. The percentage of medical professionals working in women's health without prior knowledge of PGT (22.5%) was higher than expected, identifying the need for more education regarding the availability and potential indications for this procedure.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.rbmo.2019.05.005DOI Listing
September 2019

The effect of endometriosis on the antimüllerian hormone level in the infertile population.

J Assist Reprod Genet 2019 Jun 16;36(6):1179-1184. Epub 2019 Apr 16.

Department of Obstetrics, Gynecology and Reproductive Biology, Brigham and Women's Hospital and Harvard Medical School, 75 Francis St., Boston, MA, 02115, USA.

Purpose: To determine whether the presence of endometriosis in infertile women without prior ovarian surgery influences markers of ovarian reserve, AMH and FSH.

Methods: A retrospective cohort study included three groups of women who presented for IVF treatment at our tertiary care center from 04/27/2015 to 05/31/2017: women with endometriosis and prior ovarian surgery (EnSx), women with endometriosis without prior ovarian surgery (En), and women with a primary diagnosis of male factor infertility (MF; reference group).

Results: There were 671 patients that met inclusion criteria (78 EnSx, 60 En, and 533 MF). Compared to the MF group (3.6 ± 3.0), a lower mean AMH level (ng/mL) was observed in the EnSx group (2.5 ± 2.5; aβ - 1.21; 95% CI [- 1.79, -0.62]) and in the En group (2.5 ± 2.2; aβ - 1.11; 95% CI [- 1.68, - 0.54]). Both endometriosis groups had a statistically significantly higher proportion of patients with an AMH < 1 (EnSx, 24.4%; OR, 2.39 [95% CI, 1.31, 4.36]; En, 28.3%; OR, 2.67 [95% CI, 1.41, 5.08]) compared to the MF group (13.9%). The mean baseline FSH level (lU/L) was statistically significantly higher in both endometriosis groups (EnSx, 8.6 ± 4.3; β, 1.37 [95% CI, 0.39, 2.34]; En, 8.4 ± 3.7; β, 0.96 [95% CI, 0.04, 1.87]) compared to the MF group (7.3 ± 2.2).

Conclusions: Among infertility patients with endometriosis, with and without a history of ovarian surgery, ovarian reserve markers were worse (lower AMH and higher FSH) and a higher proportion had decreased ovarian reserve as measured by AMH compared to women with MF.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1007/s10815-019-01450-9DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6603105PMC
June 2019

Effect of class III and class IV obesity on oocyte retrieval complications and outcomes.

Fertil Steril 2019 02;111(2):294-301.e1

Department of Obstetrics, Gynecology and Reproductive Biology, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts.

Objective: To assess the effect of class III (body mass index [BMI] 40-49.9 kg/m) and class IV obesity (BMI ≥ 50 kg/m) on oocyte retrieval complications and outcomes.

Design: Cohort study.

Setting: Academic center.

Patient(s): Women who underwent an oocyte retrieval from January 1, 2012 to May 31, 2017. Women with BMI ≥ 40 kg/m (n = 144) were age-matched to women with BMI <25, 25-29.9, 30-34.9, and 35-39.9 kg/m (n = 1,016).

Intervention(s): None.

Main Outcome Measure(s): Anesthetic and procedural outcomes during oocyte retrieval.

Result(s): Overall, 1,924 of 1,947 oocyte retrievals (98.8%) were performed under total intravenous anesthesia. No patients with BMI ≥ 40 kg/m required intraoperative conversion to endotracheal intubation or hospital admission. Two patients (0.8%) with BMI ≥ 40 kg/m required a laryngeal mask airway intraoperatively owing to oxygen desaturation. An oral/nasal airway was used to resolve oxygen desaturation in 16 patients (6.25%) with BMI ≥ 40 kg/m, compared with in 17 patients (1.0%) with BMI < 40 kg/m. As BMI increased, a statistically significant increase in propofol dose, fentanyl dose, and procedure time was observed. Eighteen patients (7.0%) with BMI ≥ 40 kg/m underwent a transabdominal retrieval, compared with 15 (0.9%) with BMI < 40 kg/m.

Conclusion(s): Serious intraoperative and postoperative complications were uncommon across all BMI groups, though minor complications were more common with class III and class IV obesity. These patients were also more likely to require higher doses of propofol and fentanyl, have longer oocyte retrievals, and require a transabdominal retrieval. Overall, oocyte retrieval can be safely performed as an outpatient procedure in women with class III and class IV obesity.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.fertnstert.2018.10.015DOI Listing
February 2019

The association between quality of supernumerary embryos in a cohort and implantation potential of the transferred blastocyst.

J Assist Reprod Genet 2018 Sep 5;35(9):1651-1656. Epub 2018 Jul 5.

Department of Obstetrics, Gynecology and Reproductive Biology, Brigham and Women's Hospital and Harvard Medical School, 75 Francis St., Boston, MA, 02115, USA.

Purpose: Despite studies focused on the association between embryo morphology and implantation potential, it is unknown how the collective quality of the supernumerary embryos in a cohort is associated with the implantation rate (IR) of the transferred embryo. This study tested the hypothesis that a relationship exists between the quality of the supernumerary cohort and IR.

Methods: A retrospective cohort study of first fresh autologous IVF cycles from 05/2012 to 09/2016, with ≥ 3 blastocysts, resulting in a single blastocyst transfer (n = 819) was performed. Cohorts were grouped in two ways: by mean priority score (PS; 1 being best) of supernumerary embryos and by percent supernumerary embryos with low implantation potential. The relationship between cohort quality and IR was assessed using logistic regression.

Results: As mean cohort PS increased, IR of the transferred embryo decreased (test for linear trend, p = 0.05). When ≥ 75% of the supernumerary cohort was predicted to have low implantation potential, IR of the transferred embryo was significantly lower compared to when < 75% of the cohort was predicted to have low implantation potential (OR 0.71; 95% CI (0.53-0.94)). All associations were attenuated when adjusting for PS of the transferred embryo.

Conclusions: Our findings suggest that quality of supernumerary embryos is associated with IR of the transferred embryo, among patients with ≥ 3 blastocysts available on day 5. As cohort quality declines and the proportion of low implantation potential embryos increases, the IR of the transferred embryo declines. These associations are attenuated when controlling for quality of the transferred embryo, suggesting that the relationship between embryo cohort quality and implantation is not independent of the transferred embryo quality.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1007/s10815-018-1254-xDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6133805PMC
September 2018

Perinatal and Peripartum Outcomes in Vanishing Twin Pregnancies Achieved by In Vitro Fertilization.

Obstet Gynecol 2018 06;131(6):1011-1020

Department of Obstetrics, Gynecology and Reproductive Biology, Brigham and Women's Hospital and Harvard Medical School, and the Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, Massachusetts; the Department of Obstetrics, Gynecology, and Reproductive Biology, College of Human Medicine, Michigan State University, Grand Rapids, Michigan; and Reproductive Medicine Associates of New Jersey, Basking Ridge, New Jersey.

Objective: To compare perinatal and peripartum outcomes of vanishing twin gestations with singleton and dichorionic twin gestations in pregnancies conceived by in vitro fertilization.

Methods: We conducted a retrospective cohort study of vanishing twin pregnancies after fresh and cryopreserved autologous in vitro fertilization cycles performed at our institution from 2007 to 2015. Singleton, dichorionic twin, and dichorionic twin pregnancies with spontaneous reduction to one by 14 weeks of gestation (vanishing twins) were included. Analysis was restricted to patients with a live birth delivery at our institution at or beyond 24 weeks of gestation. The primary outcomes were gestational age and birth weight at delivery; secondary outcomes included peripartum morbidities. A subanalysis further differentiated the vanishing twin pregnancies between those in which demise of the twin occurred before compared with after identification of fetal cardiac activity. Logistic regression models were used to estimate the adjusted odds ratio (OR) with a 95% CI of outcomes.

Results: There were 1,189 pregnancies that met inclusion criteria (798 singleton, 291 twin, and 100 vanishing twin). The mean gestational age at birth and birth weights were 38.6±2.3 weeks of gestation and 3,207±644 g in singleton pregnancies, 35.5±2.7 weeks of gestation and 2,539±610 g in twin pregnancies, and 38.5±1.8 weeks of gestation and 3,175±599 g in vanishing twin pregnancies. When compared with twins, those with a vanishing twin had lower odds of preterm delivery (OR 0.13, 95% CI 0.07-0.23; adjusted OR 0.12, 95% CI 0.07-0.22) and small-for-gestational-age birth weight (OR 0.24, 95% CI 0.13-0.45; adjusted OR 0.14, 95% CI 0.07-0.28).

Conclusion: In pregnancies conceived by in vitro fertilization that progress to at least 24 weeks of gestation, vanishing twin and singleton pregnancies had similar perinatal and peripartum outcomes. Both were significantly better than twin pregnancies.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1097/AOG.0000000000002595DOI Listing
June 2018

Association between peak estradiol levels and ovarian torsion among symptomatic patients receiving gonadotropin treatment.

J Assist Reprod Genet 2017 May 15;34(5):627-631. Epub 2017 Mar 15.

Center for Infertility and Reproductive Surgery, Department of Ob/Gyn, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA.

Purpose: Ovarian torsion is a surgical emergency that can be clinically challenging to diagnose. Patients who have received assisted reproductive technologies (ART) are a subset of women with an increased risk for torsion. As the ART population continues to increase, there is a need to delineate risk factors for the development of ovarian torsion in this unique population. A pilot study was performed to determine the proportion of patients with suspected ovarian torsion who have received ART and to identify possible diagnostic biomarkers for ovarian torsion among these patients.

Methods: A single institution retrospective cohort study of patients taken to surgery for suspected ovarian torsion over a 5-year period.

Results: During the study period, 171 patients were taken to surgery for suspected ovarian torsion. Patients receiving ART constituted 19 (11%) of these patients. Among the 19 fertility treatment patients, 16 had received treatment with gonadotropins, 10 of which had surgically confirmed ovarian torsion. These ten patients had higher preoperative peak estradiol levels (3122 versus 1875 pg/mL, p = 0.05) and a larger ovarian diameter (9.7 versus 7.6 cm, p = 0.05) than the six patients receiving gonadotropins found to not have ovarian torsion.

Conclusions: These results suggest infertility treatment using gonadotropins for ovarian hyperstimulation may be an independent risk factor for ovarian torsion as suggested by the disproportionate number of such individuals represented in the study population (9% of all patients, 84% of fertility patients). Additionally, among women taking gonadotropins, an association exists between peak estradiol levels, ovarian diameter, and risk for ovarian torsion.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1007/s10815-017-0901-yDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5427652PMC
May 2017
-->