Pathways to fatherhood: evaluating the priorities of self-identified gay and bisexual men pursuing family building options.

Objective: To assess the priorities and decisions of gay and bisexual men pursuing fatherhood. Design: Cross-sectional study. Setting: Internet-based survey. Patients: Gay and bisexual men who were interested in pursuing or had previously pursued family building options. Interventions: None. Main Outcome Measures: This study aimed to assess the attitudes of respondents regarding the following: mode of achieving parenthood and the relative importance of a genetic link to offspring; the relative importance of factors considered when selecting an oocyte donor (OD); and the relative importance of factors associated with selecting a gestational carrier (GC). Access to care and financial considerations were also analyzed. Results: Of the 110 respondents, most (68.2%) desired parenthood via an OD and GC. This was consistent with 53.2% of respondents reporting that a genetic link to a child was "extremely important" or "important." Most couples (86.6%) desired to use sperm from both partners. In addition, 40.5% of respondents reported that a twin gestation would be the most ideal pregnancy outcome. Medical history was considered the most important factor when selecting an OD (83.5%), whereas pregnancy history was considered the most important selection criterion for a GC (86.2%). Furthermore, 89.1% of respondents reported that the fertility services they desired were available to them, although 33.0% reported they would have to travel to another state for care. Conclusions: Understanding the circumstances of gay and bisexual men pursuing fatherhood allows for individualized care. Since several respondents desired twin pregnancies, it is important to counsel patients regarding the risks of multiple gestation and determine the motivations for this preference.

Male Infertility and the Future of In Vitro Fertilization.

The male contribution to infertility has traditionally been overlooked, or at best oversimplified. In recent years efforts have been made to optimize diagnostic and therapeutic techniques to maximize fertility outcomes. A renewed focus on the male partner has resulted in an increased understanding of both genetic and epigenetic changes within the male germline. Furthermore, single-nucleotide polymorphisms, copy-number variants, DNA damage, sperm cryopreservation, obesity, and paternal age have recently been recognized as important factors that play a role in male fertility. Developing a deeper knowledge of these issues could potentially lead to improved success with assisted reproductive technology.

Double intrauterine insemination (IUI) of no benefit over single IUI among lesbian and single women seeking to conceive.

PURPOSE: To explore clinical benefit of performing two intrauterine inseminations (IUI) 24 h apart-a double IUI vs. a single IUI among lesbian and single women. METHODS: Retrospective cohort study using electronic medical record review during a 17-year period (11/1999-3/2017). A total of 11,396 patients at a single academic-affiliated private practice were included in this study. All cycles with a single or double IUI were included. A sub-analysis of first cycles only (n = 10,413) was also performed. Canceled IVF cycles converted to IUI were excluded. T tests and Wilcoxon rank-sum tests were used for continuous data, and chi-square for categorical data. Multivariable logistic regression controlled for patient age, day 3 follicle-stimulating hormone (D3 FSH), body mass index (BMI), peak estradiol (E2), and post-wash total motile sperm counts to model the association between IUI number and ongoing pregnancy rate (OPR) according to sperm source (autologous vs. donor). Generalized estimating equations and mixed effect models accounted for multiple cycles from the same woman. Adjusted odds ratio (AOR) with 95% CI was determined. Sub-analyses of sexual orientation and partner status were performed to compare heterosexual couples with proven infertility to women with lesbian and single women. RESULTS: During the study period, 22,452 cycles met inclusion criteria (single IUI 1283 vs. double IUI 21,169). Mean patient age and BMI were similar between groups. For couples using autologous sperm, OPR was significantly higher with double IUI (12.0% vs. 14.1%; p = 0.0380). A similar increase was observed for donor sperm OPR among heterosexual couples (14.4% vs. 16.2%), though this did not reach statistical significance (p = 0.395). A sub-analysis restricted to donor sperm demonstrates a clinical benefit of second IUI in heterosexual couples, 8.5% vs. 17.6% OPR (AOR 2.94; CI 1.00-10.99; p = 0.0496). When lesbian and single patients were evaluated, there was no difference (17.2% vs. 15.2%; AOR 0.99; CI 0.59-1.70; p = 0.0958). CONCLUSIONS: Double IUI is associated with a significantly higher OPR for heterosexual couples using an autologous or donor sperm source. The benefit of a second IUI is less clear in patients with undocumented fertility status using donor sperm, such as single and lesbian women.

Randomized controlled trial of low (5%) versus ultralow (2%) oxygen for extended culture using bipronucleate and tripronucleate human preimplantation embryos.

OBJECTIVE: To determine whether [1] exposure of embryos to 5% oxygen (O2) from day 1 (D1) to D3, and then to 2% O2 from D3 to D5, improves total blastocyst yield, as compared with continuous exposure to 5% O2; and [2] extended culture in 2% O2 alters key metabolic processes and O2-regulated gene expression in human preimplantation embryos. DESIGN: Randomized controlled trial. SETTING: Academic medical center. PATIENT(S): Bipronucleate and tripronucleate embryos donated for research. INTERVENTION(S): On D1, sibling zygotes were randomized to culture in 5% O2 from D1 to D5 (n = 102; "5% group") or 5% O2 from D1 to D3, then 2% O2 from D3 to D5 (n = 101, "2% group"). MAIN OUTCOME MEASURE(S): Developmental stage and grade; D5 total cell counts; mass spectrometry of spent media; quantitative polymerase chain reaction of 21 genes in inner cell mass and trophectoderm. RESULT(S): Among cleaved embryos (n = 176, 87%), those in the 2% group were less likely to arrest at the cleavage stage on D5 (34 of 87, 39.1%) compared with the 5% group (52 of 89, 58.4%) (adjusted odds ratio 0.38, 95% confidence interval 0.18-0.80). Those in the 2% group were more likely to blastulate (35 of 87, 40.2%) than those in the 5% group (20 of 89, 22.5%) (adjusted odds ratio 2.55, 95% confidence interval 1.27-5.12). Culture in 2% O2 was associated with significantly fewer cells in early and advanced blastocysts, alteration in relative abundances of anabolic amino acids and metabolites involved in redox homeostasis, and differential expression of MUC1 in trophectoderm. CONCLUSION(S): These findings provide foundational evidence for future investigation of 2% O2 as the preferred O2 tension for extended culture of human embryos.

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

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.

The dilemma of aneuploidy screening on low responders.

PURPOSE OF REVIEW: Preimplantation genetic testing for aneuploidy (PGT-A) has been demonstrated to improve implantation and pregnancy rates and decrease miscarriage rates over standard morphology-based embryo selection. However, there are limited data on its efficacy in patients with diminished ovarian reserve or a poor response to stimulation who may have fewer embryos to select amongst. RECENT FINDINGS: Early findings demonstrate that PGT-A reduces the miscarriage rate and decreases the time to delivery in poor responders. These studies highlight the importance of designing trials that compare outcomes over multiple cycles as the benefit of PGT-A in this patient population lies in eliminating the time lost to futile transfers of aneuploid embryos. Furthermore, recent studies have demonstrated that a catch-all category of 'poor responder' may need to be reevaluated as different subpopulations of patients with low response exhibit different clinical characteristics. SUMMARY: More information is needed on characterizing the physiology of ovarian aging across multiple phenotypes of diminished ovarian reserve and establishing the predictive value of aneuploid results across multiple PGT-A platforms. However, initial data suggests benefit of PGT-A in poor responders.

The Status of Genetic Screening in Recurrent Pregnancy Loss.

Recurrent pregnancy loss is often idiopathic, but numerical and structural chromosomal abnormalities constitute an important cause. Numerical chromosomal abnormalities in the conceptus are primarily due to meiotic nondisjunction; the rate and complexity of embryonic aneuploidy are driven by female age. Structural chromosomal abnormalities (balanced translocations or inversions) can lead to unbalanced gametes depending on specific recombination and segregation patterns during meiosis. The attendant reproductive risk depends on the type of rearrangement and its parental origin. Current methods for analysis of products of conception include cytogenetics, array comparative genomic hybridization, and single nucleotide polymorphism microarray; each platform has advantages and disadvantages.

Characterization of reproductive endocrinology and infertility (REI) fellowship applicants: guiding our mentees toward success.

BACKGROUND: Advanced subspecialty training in reproductive endocrinology and infertility (REI) entails a competitive application process with many data points considered. It is not known what components weigh more heavily for applicants. Thus, we sought to study the REI fellow applicant and compare 1) those who apply but do not receive an interview, 2) those who receive an interview but do not match, and 3) those who successfully match. METHODS: This retrospective cohort study was conducted at a single REI fellowship program from 2013 to 2017. Academic variables assessed included standardized test scores and total number of publications listed on their curriculum vitae. Logistic regression models were constructed to determine variables that were predictive of being offered an interview in our program and of matching in any program. RESULTS: There were 270 applicants, of which 102 were offered interviews. Interviewed applicants had significantly higher mean USMLE 1 and CREOG scores, as well as total publications and total abstracts. There was no difference in Step 2 and Step 3 scores or in number of book chapters. Of those interviewed, USMLE scores remained predictive of matching in any program; however, publications and scientific abstracts were no longer predictive. CONCLUSIONS: The decision to offer applicants interviews appears to be influenced by objective standardized test scores, as well as a threshold of academic productivity. These items are less predictive of matching once the interview process begins, indicating that other factors, such as performance during the interview day, may be more heavily weighted.

Fertility treatment for the transgender community: a public opinion study.

PURPOSE: The purposes of this study were to evaluate public opinion regarding fertility treatment and gamete cryopreservation for transgender individuals and identify how support varies by demographic characteristics. METHODS: This is a cross-sectional web-based survey study completed by a representative sample of 1111 US residents aged 18-75 years. Logistic regression was used to calculate odd ratios (ORs) and 95% confidence intervals (CIs) of support for/opposition to fertility treatments for transgender people by demographic characteristics, adjusting a priori for age, gender, race, and having a biological child. RESULTS: Of 1336 people recruited, 1111 (83.2%) agreed to participate, and 986 (88.7%) completed the survey. Most respondents (76.2%) agreed that "Doctors should be able to help transgender people have biological children." Atheists/agnostics were more likely to be in support (88.5%) than Christian-Protestants (72.4%; OR = 3.10, CI = 1.37-7.02), as were younger respondents, sexual minorities, those divorced/widowed, Democrats, and non-parents. Respondents who did not know a gay person (10.0%; OR = 0.20, CI = 0.09-0.42) or only knew a gay person without children (41.4%; OR = 0.29, CI = 0.17-0.50) were more often opposed than those who knew a gay parent (48.7%). No differences in gender, geography, education, or income were observed. A smaller majority of respondents supported doctors helping transgender minors preserve gametes before transitioning (60.6%) or helping transgender men carry pregnancies (60.1%). CONCLUSIONS: Most respondents who support assisted and third-party reproduction also support such interventions to help transgender people have children.

Prospective study of automated versus manual annotation of early time-lapse markers in the human preimplantation embryo.

STUDY QUESTION: How does automated time-lapse annotation (Eeva™) compare to manual annotation of the same video images performed by embryologists certified in measuring durations of the 2-cell (P2; time to the 3-cell minus time to the 2-cell, or t3-t2) and 3-cell (P3; time to 4-cell minus time to the 3-cell, or t4-t3) stages? SUMMARY ANSWER: Manual annotation was superior to the automated annotation provided by Eeva™ version 2.2, because manual annotation assigned a rating to a higher proportion of embryos and yielded a greater sensitivity for blastocyst prediction than automated annotation. WHAT IS KNOWN ALREADY: While use of the Eeva™ test has been shown to improve an embryologist's ability to predict blastocyst formation compared to Day 3 morphology alone, the accuracy of the automated image analysis employed by the Eeva™ system has never been compared to manual annotation of the same time-lapse markers by a trained embryologist. STUDY DESIGN, SIZE, DURATION: We conducted a prospective cohort study of embryos (n = 1477) cultured in the Eeva™ system (n = 8 microscopes) at our institution from August 2014 to February 2016. PARTICIPANTS/MATERIALS, SETTING, METHODS: Embryos were assigned a blastocyst prediction rating of High (H), Medium (M), Low (L), or Not Rated (NR) by Eeva™ version 2.2 according to P2 and P3. An embryologist from a team of 10, then manually annotated each embryo and if the automated and manual ratings differed, a second embryologist independently annotated the embryo. If both embryologists disagreed with the automated Eeva™ rating, then the rating was classified as discordant. If the second embryologist agreed with the automated Eeva™ score, the rating was not considered discordant. Spearman's correlation (ρ), weighted kappa statistics and the intra-class correlation (ICC) coefficients with 95% confidence intervals (CI) between Eeva™ and manual annotation were calculated, as were the proportions of discordant embryos, and the sensitivity, specificity, positive predictive value (PPV) and NPV of each method for blastocyst prediction. MAIN RESULTS AND THE ROLE OF CHANCE: The distribution of H, M and L ratings differed by annotation method (P < 0.0001). The correlation between Eeva™ and manual annotation was higher for P2 (ρ = 0.75; ICC = 0.82; 95% CI 0.82-0.83) than for P3 (ρ = 0.39; ICC = 0.20; 95% CI 0.16-0.26). Eeva™ was more likely than an embryologist to rate an embryo as NR (11.1% vs. 3.0%, P < 0.0001). Discordance occurred in 30.0% (443/1477) of all embryos and was not associated with factors such as Day 3 cell number, fragmentation, symmetry or presence of abnormal cleavage. Rather, discordance was associated with direct cleavage (P2 ≤ 5 h) and short P3 (≤0.25 h), and also factors intrinsic to the Eeva™ system, such as the automated rating (proportion of discordant embryos by rating: H: 9.3%; M: 18.1%; L: 41.3%; NR: 31.4%; P < 0.0001), microwell location (peripheral: 31.2%; central: 23.8%; P = 0.02) and Eeva™ microscope (n = 8; range 22.9-42.6%; P < 0.0001). Manual annotation upgraded 82.6% of all discordant embryos from a lower to a higher rating, and improved the sensitivity for predicting blastocyst formation. LIMITATIONS, REASONS FOR CAUTION: One team of embryologists performed the manual annotations; however, the study staff was trained and certified by the company sponsor. Only two time-lapse markers were evaluated, so the results are not generalizable to other parameters; likewise, the results are not generalizable to future versions of Eeva™ or other automated image analysis systems. WIDER IMPLICATIONS OF THE FINDINGS: Based on the proportion of discordance and the improved performance of manual annotation, clinics using the Eeva™ system should consider manual annotation of P2 and P3 to confirm the automated ratings generated by Eeva™. STUDY FUNDING/COMPETING INTEREST(S): These data were acquired in a study funded by Progyny, Inc. There are no competing interests. TRIAL REGISTRATION NUMBER: N/A.

A pilot randomized controlled trial of Day 3 single embryo transfer with adjunctive time-lapse selection versus Day 5 single embryo transfer with or without adjunctive time-lapse selection.

STUDY QUESTION: Compared to D5 selection with conventional morphology (CM), does adjunctive use of the Eeva™ test on D3 or D5 improve the clinical pregnancy rate (CPR) per transfer? SUMMARY ANSWER: The evidence is insufficient to conclude that adjunctive use of the Eeva™ test on D3 or D5 improves CPR per transfer as compared to D5 selection with CM. WHAT IS KNOWN ALREADY: Time-lapse imaging is increasingly used for embryo selection, despite there being no class I data to support its clinical application. STUDY DESIGN, SIZE, DURATION: Pilot randomized controlled trial included 163 patients from August 2014 to February 2016. PARTICIPANTS/MATERIALS, SETTING, METHODS: Patients up to age 41 years with a planned fresh autologous single embryo transfer (SET), less than four prior oocyte retrievals, and four or more zygotes were blocked according to age (<35, 35-37, 38-40 years) and randomized to one of three study arms: (1) D3 SET + EevaTM, (2) D5 SET + Eeva™ or (3) D5 SET with CM alone. All embryos were cultured in the same time-lapse system under identical conditions. Intention-to-treat (ITT) and as-treated analyses of the primary endpoint (CPR at 7 weeks) and secondary endpoint (ongoing pregnancy rate at 12 weeks) were performed. Multivariate regression analyses adjusted for patient age and ICSI. MAIN RESULTS AND THE ROLE OF CHANCE: Of 478 eligible patients, 217 consented and 163 were randomized. Demographic characteristics were similar among the three study arms. There were no statistically significant differences in the clinical pregnancy rate or the ongoing pregnancy rate between the study arms for either the ITT or as-treated analyses (CPR ITT: D3 + Eeva™: 41.1% vs. D5 + Eeva™: 38.9% vs. D5 CM: 49.1%). LIMITATIONS, REASONS FOR CAUTION: This study was designed as a pilot randomized controlled trial and was not powered to detect a statistically significant difference at α < 0.05. Importantly, the study was terminated prematurely by the sponsor due to a change in funding priorities, so the sample size is limited and the results should be interpreted with caution due to the role of chance. Furthermore, these findings may not be generalizable to other time-lapse systems. WIDER IMPLICATIONS OF THE FINDINGS: Our findings do not support the clinical application of these time-lapse markers. STUDY FUNDING/COMPETING INTEREST(S): This study was funded by Progyny, Inc. There are no competing interests. TRIAL REGISTRATION NUMBER: clinicaltrials.gov: NCT02218255. TRIAL REGISTRATION DATE: 14 August 2014. DATE OF FIRST PATIENT'S ENROLLMENT: 3 September 2014.

On developing a thesis for Reproductive Endocrinology and Infertility fellowship: a case study of ultra-low (2%) oxygen tension for extended culture of human embryos.

Fellows in Reproductive Endocrinology and Infertility training are expected to complete 18 months of clinical, basic, or epidemiological research. The goal of this research is not only to provide the basis for the thesis section of the oral board exam but also to spark interest in reproductive medicine research and to provide the next generation of physician-scientists with a foundational experience in research design and implementation. Incoming fellows often have varying degrees of training in research methodology and, likewise, different career goals. Ideally, selection of a thesis topic and mentor should be geared toward defining an "answerable" question and building a practical skill set for future investigation. This contribution to the JARG Young Investigator's Forum revisits the steps of the scientific method through the lens of one recently graduated fellow and his project aimed to test the hypothesis that "sequential oxygen exposure (5% from days 1 to 3, then 2% from days 3 to 5) improves blastocyst yield and quality compared to continuous exposure to 5% oxygen among human preimplantation embryos."

Oocyte, embryo and blastocyst cryopreservation in ART: systematic review and meta-analysis comparing slow-freezing versus vitrification to produce evidence for the development of global guidance.

BACKGROUND: Successful cryopreservation of oocytes and embryos is essential not only to maximize the safety and efficacy of ovarian stimulation cycles in an IVF treatment, but also to enable fertility preservation. Two cryopreservation methods are routinely used: slow-freezing or vitrification. Slow-freezing allows for freezing to occur at a sufficiently slow rate to permit adequate cellular dehydration while minimizing intracellular ice formation. Vitrification allows the solidification of the cell(s) and of the extracellular milieu into a glass-like state without the formation of ice. OBJECTIVE AND RATIONALE: The objective of our study was to provide a systematic review and meta-analysis of clinical outcomes following slow-freezing/thawing versus vitrification/warming of oocytes and embryos and to inform the development of World Health Organization guidance on the most effective cryopreservation method. SEARCH METHODS: A Medline search was performed from 1966 to 1 August 2016 using the following search terms: (Oocyte(s) [tiab] OR (Pronuclear[tiab] OR Embryo[tiab] OR Blastocyst[tiab]) AND (vitrification[tiab] OR freezing[tiab] OR freeze[tiab]) AND (pregnancy[tiab] OR birth[tiab] OR clinical[tiab]). Queries were limited to those involving humans. RCTs and cohort studies that were published in full-length were considered eligible. Each reference was reviewed for relevance and only primary evidence and relevant articles from the bibliographies of included articles were considered. References were included if they reported cryosurvival rate, clinical pregnancy rate (CPR), live-birth rate (LBR) or delivery rate for slow-frozen or vitrified human oocytes or embryos. A meta-analysis was performed using a random effects model to calculate relative risk ratios (RR) and 95% CI. OUTCOMES: One RCT study comparing slow-freezing versus vitrification of oocytes was included. Vitrification was associated with increased ongoing CPR per cycle (RR = 2.81, 95% CI: 1.05-7.51; P = 0.039; 48 and 30 cycles, respectively, per transfer (RR = 1.81, 95% CI 0.71-4.67; P = 0.214; 47 and 19 transfers) and per warmed/thawed oocyte (RR = 1.14, 95% CI: 1.02-1.28; P = 0.018; 260 and 238 oocytes). One RCT comparing vitrification versus fresh oocytes was analysed. In vitrification and fresh cycles, respectively, no evidence for a difference in ongoing CPR per randomized woman (RR = 1.03, 95% CI: 0.87-1.21; P = 0.744, 300 women in each group), per cycle (RR = 1.01, 95% CI: 0.86-1.18; P = 0.934; 267 versus 259 cycles) and per oocyte utilized (RR = 1.02, 95% CI: 0.82-1.26; P = 0.873; 3286 versus 3185 oocytes) was reported. Findings were consistent with relevant cohort studies. Of the seven RCTs on embryo cryopreservation identified, three met the inclusion criteria (638 warming/thawing cycles at cleavage and blastocyst stage), none of which involved pronuclear-stage embryos. A higher CPR per cycle was noted with embryo vitrification compared with slow-freezing, though this was of borderline statistical significance (RR = 1.89, 95% CI: 1.00-3.59; P = 0.051; three RCTs; I2 = 71.9%). LBR per cycle was reported by one RCT performed with cleavage-stage embryos and was higher for vitrification (RR = 2.28; 95% CI: 1.17-4.44; P =  0.016; 216 cycles; one RCT). A secondary analysis was performed focusing on embryo cryosurvival rate. Pooled data from seven RCTs (3615 embryos) revealed a significant improvement in embryo cryosurvival following vitrification as compared with slow-freezing (RR = 1.59, 95% CI: 1.30-1.93; P < 0.001; I2 = 93%). WIDER IMPLICATIONS: Data from available RCTs suggest that vitrification/warming is superior to slow-freezing/thawing with regard to clinical outcomes (low quality of the evidence) and cryosurvival rates (moderate quality of the evidence) for oocytes, cleavage-stage embryos and blastocysts. The results were confirmed by cohort studies. The improvements obtained with the introduction of vitrification have several important clinical implications in ART. Based on this evidence, in particular regarding cryosurvival rates, laboratories that continue to use slow-freezing should consider transitioning to the use of vitrification for cryopreservation.

Robotic single-site myomectomy: a step-by-step tutorial.

OBJECTIVE: To provide a step-by-step description of our published technique of single-site robot-assisted laparoscopic myomectomy with the goal of promoting its safe adoption. DESIGN: Surgical video tutorial. SETTING: University medical center. PATIENT(S): Ten women undergoing single-site robot-assisted laparoscopic myomectomy between November 2014 and March 2015. INTERVENTION(S): A 2.5-cm vertical incision is made within the umbilicus, through which a multilumen single-site port (da Vinci Single-Site; Intuitive Surgical) is seated. An 8.5-mm 0-degree laparoscope is introduced, and the teleoperator (da Vinci Si Surgical Platform; Intuitive Surgical) is docked, allowing subsequent placement of two curved 5-mm instrument cannulae. Two wristed, semirigid needle drivers are loaded onto robotic arms 1 and 2. An 8-mm assistant cannula is also placed through the multilumen single-site port; a flexible 2-mm CO2 laser fiber and all conventional 5-mm laparoscopic instruments are introduced through this cannula as needed. Intramyometrial dilute vasopressin is injected, and fibroid enucleation is performed. The hysterotomy is repaired in layers with unidirectional barbed suture (Stratafix; Ethicon). The teleoperator is undocked. The single-site port is exchanged for a self-retaining wound retractor with gel-sealed cap. An endoscopic pouch is placed in the abdomen, and the specimen is placed within the pouch. The edges of the pouch are exteriorized. Extracorporeal tissue extraction is performed with a scalpel. A running mass closure of the fascia and peritoneum is performed, followed by a subcuticular closure of the skin. MAIN OUTCOME MEASURE(S): Median number and size of fibroids removed, specimen weight, operative time, estimated blood loss, and perioperative complications. RESULT(S): The technique described in our video was successfully employed in our first 10 patients. The median number of fibroids removed was 2.5 (range: 1-8); the median size of the largest myoma was 6 cm (range: 4-8 cm); the median specimen weight was 70 g (range: 26-154 g); the median operating time was 202 minutes (range: 141-254 minutes); the median blood loss was 87.5 mL (range: 10-300 mL). No conversions to multiport robotic or open myomectomy occurred. No major complications occurred, and no patients required blood transfusion. CONCLUSION(S): Robot-assisted laparoscopic single-site myomectomy employing a multilumen port and wristed, semirigid needle drivers is a safe and reproducible technique. Our technique allows surgeons to offer myomectomy and contained, extracorporeal tissue extraction via a single 2.5-cm umbilical incision in select patients with low tumor burden.

Cryopreserved embryo transfer is an independent risk factor for placenta accreta.

OBJECTIVE: To explore the association between cryopreserved embryo transfer (CET) and risk of placenta accreta among patients utilizing in vitro fertilization (IVF) and/or intracytoplasmic sperm injection (ICSI). DESIGN: Case-control study. SETTING: Academic medical center. PATIENT(S): All patients using IVF and/or ICSI, with autologous or donor oocytes, undergoing fresh or cryopreserved transfer, who delivered a live-born fetus at ≥24 weeks of gestation at our center, from 2005 to 2011 (n = 1,571), were reviewed for placenta accreta at delivery. INTERVENTION(S): Cases of accreta (n = 50) were matched by age and prior cesarean section to controls (1:3) without accreta. The association between CET and accreta was modeled using conditional logistic regression, controlling a priori for age and placenta previa. Receiver operating characteristic curves were used to determine thresholds of endometrial thickness and peak serum E2 levels related to accreta. MAIN OUTCOME MEASURE(S): Placenta accreta. RESULT(S): Univariate predictors of accreta were non-Caucasian race (odds ratio [OR] 2.85, 95% confidence interval [CI] 1.25-6.47); uterine factor infertility (OR 5.80, 95% CI 2.49-13.50); prior abdominal or laparoscopic myomectomy (OR 7.24, 95% CI 1.92-27.28); and persistent or resolved placenta previa (OR 4.25, 95% CI 1.94-9.33). In multivariate analysis, we observed a significant association between CET and accreta (adjusted OR 3.20, 95% CI 1.14-9.02), which remained when analyses were restricted to cases of accreta with morbid complications (adjusted OR 3.87, 95% CI 1.08-13.81). Endometrial thickness and peak serum E2 level were each significantly lower in CET cycles and those with accreta. CONCLUSION(S): Cryopreserved ET is a strong independent risk factor for accreta among patients using IVF and/or ICSI. A threshold endometrial thickness and a "safety window" of optimal peak E2 level are proposed for external validation.

Techniques for contained morcellation in gynecologic surgery.

OBJECTIVE: To demonstrate 2 step-by-step techniques for contained morcellation of uterine tissue. DESIGN: Instructional video showing laparoscopic electromechanical morcellation within an endoscopic pouch, and alternatively, tissue extraction via ultra-minilaparotomy. SETTING: Academic medical center. PATIENT(S): Women undergoing laparoscopic myomectomy or hysterectomy. INTERVENTION(S): For contained electromechanical morcellation, the specimen is placed within an endoscopic pouch, the edges of which are exteriorized through a 15-mm cannula. The cannula is repositioned inside the pouch for insufflation. A bladed fixation trocar enters the pouch through an assistant port and is secured by its retention disk and balloon tip. Gas inflow is changed to this assistant port, through which the laparoscope is inserted. A power morcellator is introduced via the 15-mm port site, and morcellation thus proceeds within the containment system. Residual fragments of tissue are collectively retrieved by withdrawing the endoscopic pouch. For tissue extraction via ultra-minilaparotomy, the specimen is placed within a pouch that is drawn up through a flexible, self-retaining retractor seated in a 2 to 3-cm incision. The specimen is cored out sharply with a scalpel. MAIN OUTCOME MEASURE(S): None. RESULT(S): Contained morcellation is technically feasible, efficient (mean additional operative time is approximately 30 minutes), and prevents intraperitoneal dispersion of tissue fragments. Our group has safely performed >100 such procedures and removed specimens weighing nearly 1,500 grams. Potential complications include viscous injury upon insertion of the bladed trocar, and pouch failure. CONCLUSION(S): These techniques allow surgeons to adopt the new standard of contained morcellation and permit removal of extensive pathology with a minimally invasive approach.

When is clomiphene or gonadotropin intrauterine insemination futile? Results of the Fast Track and Standard Treatment Trial and the Forty and Over Treatment Trial, two prospective randomized controlled trials.

OBJECTIVE: To determine whether day 3 FSH and E2 levels at the upper limits of normal affect live-birth rates and treatment trajectory in a conventional versus "fast track" treatment program for IVF. DESIGN: Secondary analysis of two randomized controlled trials, FASTT and FORT-T. SETTING: Not applicable. PATIENT(S): Infertile women ages 21-42 years randomized to conventional or accelerated treatment with controlled ovarian hyperstimulation (COH)-IUI and/or IVF (n=603 patients contributing 2,717 total cycles). INTERVENTION(S): Patients were stratified according to basal FSH and E2: FSH<10 mIU/mL and E2<40 pg/mL (group 1A), FSH<10 mIU/mL and E2≥40 pg/mL (group 1B), FSH, 10-15 mIU/mL and E2<40 pg/mL (group 2A), and FSH, 10-15 mIU/mL and E2≥40 pg/mL (group 2B). MAIN OUTCOME MEASURE(S): Number of cancelled cycles, disenrollment for poor response, and cumulative live-birth rates per couple. RESULT(S): Women in groups 2A and 2B were more likely to have cancelled cycles and be disenrolled for poor response. While no live births occurred in group 2B during COH-IUI (0/19 couples, 0/58 cycles), IVF still afforded these patients a reasonable chance of success (6/18 couples, 6/40 cycles, 33.3% live-birth rate per couple). The specificity and positive predictive value of basal FSH of 10-15 mIU/mL and E2≥40 pg/mL for no live birth during COH-IUI treatment were both 100%. CONCLUSION(S): Women who initiated infertility treatment with FSH of 10-15 mIU/mL and E2≥40 pg/mL on day 3 testing were unlikely to achieve live birth after COH-IUI treatment.