Fluoroscopic-guided hysteroscopic tubal cannulation results in high technical success and pregnancy rates comparable with the more traditional laparoscopically guided hysteroscopic tubal cannulation.

Objective: To compare women with proximal tubal obstruction (PTO) undergoing hysteroscopic tubal cannulation with fluoroscopic guidance vs. laparoscopic guidance. Design: Retrospective cohort study. Setting: All fluoroscopically-guided hysteroscopic tubal cannulations were performed in an ambulatory suite. All laparoscopically-guided hysteroscopic tubal cannulations were performed in a hospital operating room. Patients: Infertile women with unilateral or bilateral PTO on hysterosalpingography who failed selective salpingography in the radiology suite and had a planned laparoscopy or hysteroscopy in the operating room for defects seen on sonohysterography were studied. Intervention: All women had a Novy catheter system positioned hysteroscopically to cannulate the occluded fallopian tube(s). Women undergoing fluoroscopically guided hysteroscopic tubal cannulation (FHTC), which used contrast and C-arm pelvic imaging at an ambulatory center, were compared with those undergoing hospital-based laparoscopically guided hysteroscopic tubal cannulation (LHTC) with laparoscopic visualization. Main Outcome Measurements: Tubal cannulation success; bilateral cannulation success; tubal perforations; post-FHTC non-in vitro fertilization (non-IVF) intrauterine pregnancies; days from procedure to pregnancy for non-IVF intrauterine pregnancies; and time to non-IVF pregnancy hazards ratio. Results: A total of 76 infertile women undergoing either FHTC (34 women) or LHTC (42 women) between 2015 and 2019 were included. Demographic variables were similar among the 2 groups. A total of 31 (92%) of 34 of patients undergoing FHTC and 36 (86%) of 42 of patients undergoing LHTC had at least one tube successfully cannulated. In total, 30 (78%) of 34 of patients undergoing FHTC and 32 (79%) of 42 patients undergoing LHTC had all occluded tubes successfully cannulated. Tubal perforation occurred in 1 (3%) of 34 FHTC cases and 3 (7%) of 42 LHTC cases. A similar percentage of non-IVF treatment-induced intrauterine pregnancies were achieved in the FHTC and LHTC groups (10/34 [29%] vs. 12/42 [29%]). Among patients who conceived without IVF, time from procedure to pregnancy was lower in the FHTC group (101 ± 124.6 days) compared with the LHTC group (228 ± 216 days). There was a significant difference in time to pregnancy when only those who conceived were considered (hazard ratio, 9.39; 95% confidence interval, 2.42-36.51); however, there was no significant difference when all subjects regardless of pregnancy outcome were analyzed (hazard ratio, 1.48; 95% confidence interval, 0.64-3.446). Conclusion: Fluoroscopically guided hysteroscopic tubal cannulation is a safe, effective, incision free procedure that results in comparable rates of tubal patency and intrauterine pregnancies as LHTC. This technique should be considered in women undergoing treatment of PTO when operative laparoscopy is not otherwise indicated.

Premature Ovarian Insufficiency After Coronavirus Disease 2019 (COVID-19): Autoimmune Follicle-Stimulating Hormone (FSH) and FSH Receptor Blockade.

BACKGROUND: Since the onset of the coronavirus disease (COVID-19) pandemic, a variety of long-COVID-19 symptoms and autoimmune complications have been recognized. CASES: We report three cases of autoimmune premature poor ovarian response in patients aged 30-37 years after mild to asymptomatic COVID-19 before vaccination, with nucleotide antibody confirmation. Two patients failed to respond to maximum-dose gonadotropins for more than 4 weeks, despite a recent history of response before having COVID-19. After a month of prednisone 30 mg, these two patients had normal follicle-stimulating hormone (FSH) levels, high oocyte yield, and blastocyst formation in successful in vitro fertilization cycles. All three patients have above-average anti-müllerian hormone levels that persisted throughout their clinical ovarian insufficiency. Two patients had elevated FSH levels, perhaps resulting from FSH receptor blockade. One patient, with a history of high response to gonadotropins 75 international units per day and below-normal FSH levels, had no ovarian response to more than a month of gonadotropins (525 international units daily), suggesting autoimmune block of the FSH glycoprotein and possible FSH receptor blockade. CONCLUSION: Auto-antibody production in response to COVID-19 before vaccination may be a rare cause of autoimmune poor ovarian response. Although vaccination is likely protective, further study will be required to evaluate the effect of vaccination and duration of autoimmune FSH or FSH receptor blockade.

Fluoroscopically-Guided Hysteroscopic Tubal Cannulation: A Procedure for Proximal Tubal Obstruction.

Objectives: To evaluate the cannulation success rate, cumulative pregnancy, and time to intrauterine pregnancy rate following fluoroscopically-guided hysteroscopic tubal cannulation (FHTC) for infertile subjects with proximal tubal obstruction. Methods: This retrospective study evaluated subjects with unilateral or bilateral proximal tubal obstruction on hysterosalpingography, who failed concomitant selective salpingography and subsequently underwent FHTC at the time of a hysteroscopy performed for findings seen on sonohysterography. FHTC employed a Novy Catheter (CooperSurgical, Inc, Trumbull, CT.) with or without the 3 French inner catheter and guidewire, to cannulate the occluded fallopian tube(s), followed by the injection of HypaqueTM (Amersham Health, Inc, Princeton, NJ.) contrast under C-arm imaging. Technical success rates, complications, post-procedure pregnancies, and average time from surgery to pregnancy were evaluated. Results: Thirty-two women between January 1, 2017 and December 31, 2019 met the entry criteria and underwent FHTC. Of those women with bilateral obstruction, 6/6 (100%) of subjects achieved at least unilateral patency, while patency was achieved in 23/26 (88.5%) subjects with unilateral obstruction. Twenty-nine of 32 (90.6%) subjects had at least one tube successfully cannulated with 34/38 (89.5%) of proximally obstructed tubes opened. Asymptomatic tubal perforation occurred in 1/38 tubes (2.6%). Ten subjects (34.5%) achieved intrauterine pregnancies without in vitro fertilization in an average of 64.9 days from the procedure. There were no multiple pregnancies and one ectopic pregnancy. Conclusions: FHTC is a safe, effective, incision free procedure that results in 90% of tubes successfully cannulated, and an observed short time to intrauterine pregnancy.

Melanoma risk after in vitro fertilization: A review of the literature.

BACKGROUND: The role of female sex hormones in the pathogenesis of malignant melanoma (MM) remains controversial. Although melanocytes appear to be hormonally responsive, the effect of estrogen on MM cells is less clear. Available clinical data does not consistently demonstrate that increased endogenous hormones from pregnancy or increased exogenous hormones from oral contraceptive pills and hormone replacement affect MM prevalence and outcome. OBJECTIVE: We sought to examine potential associations between in vitro fertilization (IVF) and melanoma. METHODS: A literature review was conducted. Primary outcomes were reported as associations between IVF and melanoma risk compared with the general population. Secondary outcomes included associations stratified by type of IVF regimen and subgroup, such as parous versus nulliparous patients. RESULTS: Eleven studies met our inclusion criteria. Five studies found no increased risk for MM among IVF users compared with the general population. Two studies found an increase in MM in clomiphene users, and 4 studies found an increase in MM among patients who were gravid or parous either before or after IVF. CONCLUSION: The reviewed studies do not reveal consistent patterns of association between IVF and MM among all infertile women. However, the data indicates a potential increased risk for MM in ever-parous patients treated with IVF. High-quality studies including a large number of MM cases that control for well-established MM risk factors are needed to adequately assess the relationship between IVF and MM, particularly among ever-parous women.

Insulin Resistance and ß-cell Function Calculated by Homeostasis Model Assessment in Lean, Overweight, and Obese Women with Polycystic Ovary Syndrome.

OBJECTIVE: To evaluate the homeostasis model assessment (HOMA) measurement of insulin resistance (IR) and pancreatic ß-cell function (%ß) and compare those values between groups of healthy-weight, over-weight, and obese women with polycystic ovary syndrome (PCOS). STUDY DESIGN: Retrospective cohort study of women aged 24-48 with PCOS, diagnosed according to 2004 Rotterdam criteria. Participants were grouped by BMI. Quantitative variables were compared by one-way ANOVA and the Tukey method. Analysis for power to detect a difference between means was conducted. Pearson correlation was used to test differences in frequency distribution. RESULTS: By BMI category, 29 participants were of healthy weight, 11 were overweight, and 11 were obese. HOMA-IR was significantly higher in obese women as compared to overweight and healthy-weight patients (2.88 ± 2.09, 1.13 ± 0.73, 0.84 ± 0.49, respectively; p <0.0001). Moreover, HOMA-%ß was significantly increased in obese women as compared to overweight and healthy-weight patients (186.89 ± 131.62, 106.83 ± 46.77, 86.60 ± 40.91, respectively; p<0.0001). Adequate statistical power was not present to distinguish a difference between overweight and normal-weight participants. A positive linear correlation was found between log HOMA-IR and BMI, and between log HOMA-%ß and BMI. CONCLUSION: Obese PCOS patients have a higher risk of elevated insulin resistance and ß-cell function than do those with BMI <30.

Day 3 Biopsy and Blastulation Rates.

OBJECTIVE: To determine if blastomere biopsy affects the rate of blastulation as compared to intact embryos. STUDY DESIGN: Retrospective age-matched cohort study. RESULTS: Forty-one patients with 41 in vitro fertilization (IVF) cycles and 329 embryos who under- went cleavage-stage biopsy with preimplantation genet- ic screening using array com- parative genomic hybridiza- tion were compared to 41 IVF cycles with 352 embryos eligible for biopsy but who did not undergo biopsy January 2011-July 2013. The proportion of embryos that developed to the blastocyst stage was significantly lower in the case group than in the control group (46.5% vs. 59.9%; p=0.0134). This was most evident in the age group >35 years old (43.2% vs. 58.8%; p=0.035). No significant difference was detected in proportions that developed to fully expanded' or hatching blastulation between cases and controls (28.0% vs. 24.4%, p=0.56). There was a statistically .significant difference in the proportion of euploid embryos available for transfer when comparing day 3 vs. day 5 biopsy (20.9% vs. 13.1%, p=0.0003). CONCLUSION: Cleavage stage biopsy for genetic testing lowers the overall proportion of embryos that develop to the blastocyst stage by 25% (from 59.9% to 46.5%). When compared to trophectoderm biopsy, cleavage stage biopsy allows for a larger cohort of euploid embryos to be available for selection and transfer.

Sonohysterographic predictors of successful hysteroscopic myomectomies.

BACKGROUND AND OBJECTIVES: The purpose of this study is to assess the rate of persistent submucosal myomas and intrauterine scarring after hysteroscopic myomectomy, as well as to evaluate the preoperative and intraoperative sonohysterographic findings that will predict persistence of myomas, scarring, and the need for repeat surgery. METHODS: Charts from all hysteroscopic myomectomies performed by a single surgeon between 2003 and 2011 were reviewed for preoperative, intraoperative, and postoperative sonohysterographic findings. Predictors included myoma number, diameter and percent extension into the cavity of the largest fibroid, and percent surgically resected. These predictors were assessed with postoperative sonohysterography. Statistics included t test, logistic regression, χ(2) test, and Fisher exact test. RESULTS: Among the 79 cases with postoperative sonohysterograms, 17 (21.5%) had persistent submucosal myoma, and 9 (11.4%) had intrauterine scarring on postoperative sonohysterogram. Repeat hysteroscopic myomectomy was required in 11 (13.9%), but none required lysis of adhesions. The myoma number was not a significant predictor. A higher percentage of myoma within the cavity (63.35% vs 44.89%, P < .05) and smaller myoma size (2.22 cm vs 3.31 cm, P < .01) were significant predictors of a complete resection, a normal postoperative sonohysterogram, and avoidance of repeat surgery. On regression analysis, the percent of the myoma resected was the most significant outcome predictor (P < .001). CONCLUSION: Larger myomas with a lower percent found within the uterine cavity are less likely to be completely resected. Percent resection at the time of surgery is the most significant predictor of a normal postoperative sonohysterogram, as well as the best predictor of the need for repeat surgery.

Oocyte zona pellucida dysmorphology is associated with diminished in-vitro fertilization success.

BACKGROUND: Although irregularities in human zona pellucida (ZP) morphology are well described, there is scant literature on the clinical significance of ZP dysmorphology. We, therefore, designed a retrospective cohort trial of ZP dysmorphology to assess the clinical significance of ZP dysmorphology and its affect on IVF outcome. Over the same time period a random sample of 77 cycles of 77 subjects with all normal oocyte morphology were selected as controls. METHODS: Between July 2006 and December 2010, all fresh non-donor cases performed at a university hospital IVF center were assessed for ZP dysmorphology. ZP dysmorphology included extracytoplasmic abnormalities (dark ZP and large perivitelline space) and oocyte shape (oval or irregularly shaped ZP). 136 IVF cycles from 119 subjects were identified where a majority of oocytes displayed ZP dysmorphology. Over the same time period a random sample of 77 cycles of 77 subjects with all normal oocyte morphology were selected as controls. IVF prognostic and outcome parameters were compared between the patients with dysmorphic and normal oocytes. RESULTS: 136/1710 (8.0%) cycles of fresh non-donor IVF displayed predominant ZP dysmorphology. Dysmorphic and normal oocytes showed no difference in the oocyte quality predictors such as FSH (6.03+/-2.5 vs. 6.8+/-2.3 IU/L), or AMH (2.5+/-2.0 vs. 2.30+/-1.5 ng/ml levels). ZP dysmorphology was associated with markedly diminished clinical pregnancy rates (44% vs. 70%; RR:0.62 [0.48, 0.80]; p = 0.0002), implantation rates (.17 vs. .36; IRR: 0.48 [0.34, 0.68]; p < 0.0001) and live birth rates as compared to non dysmorphic oocytes (29% vs. 52%; RR:0.55 [0.39, 0.79]; p = 0.001). CONCLUSIONS: ZP dysmorphology is associated with markedly diminished pregnancy and implantation rates in IVF. The poorer outcome appears to be independent of the usual markers of ovarian reserve.

In vitro maturation and its role in clinical assisted reproductive technology.

IMPORTANCE: In vitro maturation (IVM) refers to maturation in culture of immature oocytes that may or may not have been exposed to short courses of gonadotropins. Approximately 5000 live births have occurred as a result of IVM since the 1970s. Currently, IVM is reserved for carefully selected patients at risk for ovarian hyperstimulation syndrome and for those with contraindications to hormone administration. The technology is still considered experimental. OBJECTIVE: The objective of this study was to identify a role for IVM and discuss clinical practices based on the current literature. EVIDENCE ACQUISITION: We conducted a literature review of all available and published data. Relevant studies were identified using PubMed and MEDLINE. Search parameters included "in vitro maturation or IVM" and "oocyte maturation." Multiple case-control studies were identified comparing reproductive outcomes between conventional in vitro fertilization (IVF) and IVM, but no randomized controlled trials have been reported to date comparing IVF and IVM. RESULTS: Results from retrospective and prospective observational studies have shown decreased live birth and implantation rates in comparison to conventional IVF/intracytoplasmic sperm injection for patients with various indications for IVM. However, rates of ovarian hyperstimulation syndrome were significantly reduced in studies with patients with polycystic ovary syndrome. CONCLUSIONS: Although the pregnancy rate is lower than conventional IVF, IVM is a safer and simpler alternative to conventional IVF. Future research needs to focus on improving implantation and live birth rates before universal implementation.

Blastulation rates decline in a linear fashion from euploid to aneuploid embryos with single versus multiple chromosomal errors.

OBJECTIVE: To test the hypothesis that the blastulation rate is higher in euploid embryos than in aneuploid embryos as assessed by cleavage-stage biopsy with array-comprehensive genomic hybridization (aCGH). DESIGN: Retrospective cohort study. SETTING: University-affiliated institution. PATIENT(S): Forty-one patients with 48 in vitro fertilization (IVF) cycles and 385 embryos that underwent cleavage-stage preimplantation genetic screening (PGS) with aCGH at the Continuum Reproductive Center between January 2010 and September 2013. INTERVENTION(S): None. MAIN OUTCOME MEASURE(S): Probability of blastocyst and/or fully expanded or hatching blastocyst (FEHB) progression depending on number of chromosomal abnormalities. RESULT(S): Euploid embryos are twice as likely to progress to blastocyst and three times as likely to progress to FEHB than aneuploid embryos: 76% versus 37% and 56% versus 18%, respectively. For every additional chromosomal abnormality, the likelihood of progressing to the blastocyst stage decreases by 22% and the likelihood of progressing to FEHB decreases by 33%. CONCLUSION(S): Euploid embryos are far more likely than aneuploid embryos to progress to the blastocyst and FEHB stages. There is a linear decrease in probability of blastulation with the increasing number of chromosomal abnormalities.

Positive Chlamydia trachomatis serology result in women seeking care for infertility is a negative prognosticator for intrauterine pregnancy.

BACKGROUND: There are no prior studies that assess the non-in vitro fertilization (IVF) pregnancy rates in chlamydia serology-positive versus serology-negative women. Therefore, we wanted to determine whether a positive Chlamydia trachomatis immunoglobulin G serology result predicts reduced clinical pregnancy rates without IVF. METHODS: A prospective observational study was performed at a university-affiliated reproductive center. A total of 1279 new infertility patients seen at the Continuum Reproductive Center between January 2007 and June 2009 underwent C. trachomatis immunoglobulin G screening. Charts were later reviewed for hysterosalpingography, laparoscopy, treatment cycles, and ultrasound evidence of an intrauterine pregnancy. The main outcome measure was non-IVF cumulative pregnancy rates. RESULTS: Seventy (5.5%) of 1279 of the participants were found to have a positive chlamydia serology result. Serology-positive participants had significantly more tubal block on hysterosalpingography (37.5% vs. 10.1%, P = 0.001) and laparoscopically confirmed tubal damage (85.7% vs. 48.9%, P = 0.002). The percent of all participants who achieved an ultrasound documented clinical pregnancy, at our center, without IVF was significantly lower among Chlamydia-positive participants (10.0% versus 21.7%) in seronegative participants (P < 0.02). The hazard rate of non-IVF clinical pregnancy among chlamydia antibody testing-positive patients was 57% less than the rate of pregnancy among chlamydia antibody testing-negative patients (hazard ratio, 0.43; 95% confidence interval, 0.20-0.92). Both the per-cycle and the cumulative IVF pregnancy rates were equivalent in seropositive and in seronegative participants. CONCLUSIONS: This is the first large study to report that a positive serology screening result is both predictive of tubal damage and a reduced cumulative pregnancy rate when excluding treatment with IVF.

Preimplantation genetic screening (PGS) with Comparative genomic hybridization (CGH) following day 3 single cell blastomere biopsy markedly improves IVF outcomes while lowering multiple pregnancies and miscarriages.

PURPOSE: To determine benefits of cleavage-stage preimplantation genetic screening (PGS) by array comparative genomic hybridization (CGH). METHODS: A retrospective case-control study was performed at a tertiary care university-affiliated medical center. Implantation rate was looked at as a primary outcome. Secondary outcomes included clinical and ongoing pregnancy rates, as well as multiple pregnancy and miscarriage rates. Thirty five patients underwent 39 fresh cycles with PGS by aCGH and 311 similar patients underwent 394 invitro fertilization cycles. RESULT(S): The implantation rate in the CGH group doubled when compared to the control group (52.63 % vs. 19.15 %, p = < 0.001), clinical pregnancy rate was higher (69.23 % vs. 43.91 %, p = 0.0002), ongoing pregnancy rate almost doubled (61.54 % vs. 32.49 %, p = < 0.0001), multiple pregnancy rate decreased (8.33 % vs. 34.38 %, p = 0.0082) and miscarriage rate trended lower (11.11 % vs. 26.01 %, p = 0.13). CONCLUSION: Cleavage stage PGS with CGH is a feasible and safe option for aneuploidy screening that shows excellent outcomes when used in fresh cycles. This is the first report of cleavage stage PGS by CGH showing improved ongoing pregnancy rates.

Elevated progesterone-to-estradiol ratio versus serum progesterone alone for predicting poor cycle outcome with in vitro fertilization.

OBJECTIVE: To determine whether a progesterone-to-estradiol (P/E2) ratio on day of human chorionic gonadotropin (hCG) administration would be a better predictor of in vitro fertilization (IVF) outcome than serum P alone. STUDY DESIGN: All 348 fresh IVF cycles performed in 2002 and 2003 at a university hospital center were reviewed for all cycle parameters as related to the peak P and peak P/E2 ration on day hCG administration. RESULTS: Out of the 348 cycles performed, 199 cycles resulted in clinical pregnancies. The mean P level (1.4 ng/mL) was equivalent in both conception and nonconception cycles. A P/E2 ratio > 1.0, however, was associated with a highly significant reduction in clinical pregnancy rate (38.2% vs. 62.6%, p< 0.01) and live birth rate (35.4% vs. 49.1%, p = 0.02). CONCLUSION: Cycles with elevated P/E2 ratios are associated with lower clinical pregnancy and live birth rates, which decrease further as the P/E2 ratio rises. P/E2 ratio improves the prediction of IVF outcome when compared to serum P levels alone.

Fresh MESA improved embryo fertilization, cleavage, blastula formation and implantation rates after failed TESA in couples with obstructive azoospermia.

PURPOSE: To determine whether our use of fresh MESA cycles improved outcomes in patients with obstructive azoospermia who had failed IVF with TESA. METHODS: A prospective observational trial of couples undergoing IVF for obstructive azoospermia was performed at an academic IVF center. RESULTS: When TESA resulted in poor embryo cleavage, implantation and ongoing pregnancy rates, subsequent fresh MESA cycles in these same couples, demonstrated dramatic improvement in cleavage, blastulation, implantation and live birth rates. CONCLUSIONS: In patients undergoing IVF-TESA-ICSI with obstructive azoospermia resulting in poor cleavage rates, blastulation rates and cycle failure, a repeat cycle with MESA may result in marked improvement in outcome.

Hysterosalpingography versus sonohysterography for intrauterine abnormalities.

OBJECTIVE: The hysterosalpingogram is commonly used to evaluate the uterine cavity and the fallopian tubes in the workup of infertile couples. The sonohysterogram is gaining popularity as part of this evaluation. This study compares hysterosalpingography to sonohysterography for the detection of polyps, cavitary fibroids, adhesions, and septae in infertile patients. METHODS: We conducted a retrospective chart review of 149 infertility patients seen at a University Hospital Center, divisions of Reproductive Endocrinology and Interventional Radiology. Patients underwent hysterosalpingography and sonohysterography as part of their infertility evaluation. The reports were reviewed and findings like polyps, fibroids, adhesions, and septae were compared to the findings obtained at the time of hysteroscopy. Sensitivity, specificity, and accuracy of radiologic tests were the main outcome measures. RESULTS: The sensitivity of hysterosalpingography and sonohysterography was 58.2% and 81.8%, respectively. The specificity for hysterosalpingography and sonohysterography was 25.6% and 93.8%. The differences in sensitivity and specificity were both statistically significant. Hysterosalpingography had a general accuracy of 50.3%, while sonohysterography had a significantly higher accuracy of 75.5%. CONCLUSION: Although hysterosalpingography is the standard screening test for the diagnosis of tubal infertility and can provide useful information about the uterine cavity, sonohysterography is more sensitive, specific, and accurate in the evaluation of the uterine cavity.

Defragmentation of low grade day 3 embryos resulted in sustained reduction in fragmentation, but did not improve compaction or blastulation rates.

In a prospective randomized fashion, this study evaluated embryo development in vitro after defragmentation versus assisted hatching alone of low grade day 3 embryos. Although a sustained decrease in day 5 fragmentation was observed in the defragmented group versus the assisted hatching only group, no difference in compaction rates or blastula formation rates were appreciated.

A comparison of gonadotropin-releasing hormone (GnRH) antagonist and GnRH agonist flare protocols for poor responders undergoing in vitro fertilization.

OBJECTIVE: To compare stimulation profiles, pregnancy, and live birth rates in poor responders during in vitro fertilization (IVF) cycles using either a gonadotropin-releasing hormone (GnRH) antagonist (cetrorelix) or a GnRH agonist flare protocol (leuprolide). DESIGN: Retrospective chart review. SETTING: A university-affiliated IVF program. PATIENT(S): Women designated as poor responders based on a prior stimulation cycle or baseline follicle-stimulating hormone (FSH) level of >10 mIU/mL, who needed at least 375 IU of starting daily gonadotropins in the study cycle. INTERVENTION(S): Administration of GnRH agonist flare or GnRH antagonist protocol. MAIN OUTCOME MEASURE(S): Clinical pregnancy rate, live birth rate. RESULT(S): For 68 GnRH antagonist and 45 GnRH agonist flare cycles, the groups were similar with respect to age (38.8 versus 38.6 years) and basal FSH concentration (8.33 versus 8.65 mIU/mL). No statistically significant differences between the protocol types were noted in peak estradiol levels, amount of gonadotropins used, number of oocytes obtained, or embryos transferred. The pregnancy rates (40% versus 45.2%) and live birth rates (27.7% versus 31.7%) in the GnRH antagonist and flare groups, respectively, were similar. CONCLUSION(S): We achieved excellent and comparable pregnancy and live birth rates in poor responders of advanced reproductive age with the use of either GnRH antagonist or flare protocol.

A 5-mm open-entry technique achieves safe, single-step, cosmetic laparoscopic entry.

BACKGROUND AND OBJECTIVE: The rare but serious complications of blind Veress needle insertion during laparoscopy include bowel and vascular injury. To reduce these risks, a novel method of open laparoscopy was introduced into our clinical practice, and its efficacy was evaluated. METHODS: This is a retrospective evaluation of a novel 5-mm-open laparoscopic technique in a university hospital-based endoscopy practice in 65 consecutive patients undergoing laparoscopy with a single surgeon. RESULT: A 71% success rate was achieved using the 5-mm open-entry laparoscopic technique. No complications occurred during any of the laparoscopic procedures, but 29% reverted to a standard 5-mm Veress needle technique. The success of the open-entry technique was independent of prior abdominal surgery, subject age, or body mass index (BMI). CONCLUSION: The 5-mm open-entry technique is safe, fast, and cosmetic. It is easily mastered and may be converted to a standard Veress needle technique if peritoneal entry is not achieved.

Comparison of FSH flare with and without pretreatment with oral contraceptive pills in poor responders undergoing in vitro fertilization.

OBJECTIVE: To compare FSH, LH, estrogen, and P flare response following 1 mg lupron injection in poor responders with or without pretreatment with oral contraceptive pills (OCPs). DESIGN: Prospective study. SETTING: University hospital. PATIENT(S): Poor responders undergoing IVF flare protocol from October 2002 to November 2003. INTERVENTION(S): Patients were divided into group A, who received OCPs before IVF cycle (n = 12), and group B, who did not (n = 7). One milligram Lupron was injected SC after measuring day 2 serum FSH, LH, estrogen, and P. After 24 hours, serum hormones were measured before lupron administration. MAIN OUTCOME MEASURE(S): Serum FSH, LH, estrogen, and P before and after 1 mg lupron RESULT(S): Basal FSH was similar in both groups (8.6 +/- 4.5 vs. 9.6 +/- 2.9 mIU/mL). Group A patients had significantly lower day 2 FSH (3.6 +/- 3.6 vs. 10.1 +/- 4.2 mIU/mL; P<.05). After lupron, although both groups had a significant rise in FSH and LH, mean LH rise in group B was 39.5 +/- 31 mIU/mL versus 11.3 +/- 4.6 mIU/mL in group A (P<.05). CONCLUSION(S): Pretreatment with OCPs in GnRH agonist flare protocol suppresses pre-Lupron FSH but does not blunt FSH flare. It blunts LH flare, which may be beneficial.

Successful pregnancy rates achieved with day 4 embryo transfers.

OBJECTIVE: To assess the success of day 4 embryo transfers (ETs) following IVF at one institution. DESIGN: Retrospective analysis. SETTING: A university hospital IVF program. PATIENT(S): Two hundred nondonor, fresh IVF cycles. INTERVENTION(S): None. MAIN OUTCOME MEASURE: Outcomes of IVF. Outcome assessments after day 4 ETs included rates of implantation, clinical pregnancy, and singleton and multiple live births. RESULT(S): The overall live-birth rate was 54.4%. Implantation rates were highest in younger age groups, and similar in patients 35-40 years of age. Pregnancy and live-birth rates were similar across all age groups up to age 40 years. Multiple gestations were highest in women < or =40 years of age. CONCLUSION: Acceptable pregnancy rates can be achieved with day 4 ETs.