Preimplantation genetic testing for aneuploidy versus morphology as selection criteria for single frozen-thawed embryo transfer in good-prognosis patients: a multicenter randomized clinical trial.

OBJECTIVE: To evaluate the benefit of next-generation sequencing (NGS)-based preimplantation genetic testing for aneuploidy (PGT-A) for embryo selection in frozen-thawed embryo transfer. DESIGN: Randomized controlled trial. SETTING: Not applicable. PATIENT(S): Women aged 25-40 years undergoing IVF with at least two blastocysts that could be biopsied. INTERVENTION(S): Randomization for single frozen-thawed embryo transfer with embryo selection based on PGT-A euploid status versus morphology. MAIN OUTCOME MEASURE(S): Ongoing pregnancy rate (OPR) at 20 weeks' gestation per embryo transfer. RESULT(S): A total of 661 women (average age 33.7 ± 3.6 years) were randomized to PGT-A (n = 330) or morphology alone (n = 331). The OPR was equivalent between the two arms, with no significant difference per embryo transfer (50% [137/274] vs. 46% [143/313]) or per intention to treat (ITT) at randomization (41.8% [138/330] vs. 43.5% [144/331]). Post hoc analysis of women aged 35-40 years showed a significant increase in OPR per embryo transfer (51% [62/122] vs. 37% [54/145]) but not per ITT. CONCLUSION(S): PGT-A did not improve overall pregnancy outcomes in all women, as analyzed per embryo transfer or per ITT. There was a significant increase in OPR per embryo transfer with the use of PGT-A in the subgroup of women aged 35-40 years who had two or more embryos that could be biopsied, but this was not significant when analyzed by ITT. CLINICAL TRIAL REGISTRATION NUMBER: NCT02268786.

Assessing ovarian response: antral follicle count versus anti-Müllerian hormone.

Oocyte number and quality decline with age; however, fertility varies significantly even among women of the same age. Various measures have been developed to predict response to ovarian stimulation and reproductive potential. Evaluation of ovarian reserve can identify patients who may experience poor response or hyper-response to exogenous gonadotrophins and can aid in the personalization of treatment to achieve good response and minimize risks. In recent years, two key methods, antral follicle count (AFC), an ultrasound biomarker of follicle number, and the concentration of serum anti-Müllerian hormone (AMH), a hormone biomarker of follicle number, have emerged as preferred methods for assessing ovarian reserve. In this review, a live debate held at the American Society for Reproductive Medicine 2013 Annual Meeting is expanded upon to compare the predictive values, merits, and disadvantages of AFC and AMH level. An ovarian reserve measure without limitations has not yet been discovered, although both AFC and AMH have good predictive value. Published evidence, however, as well as the objectivity and potential standardization of AMH level and the convenience of testing any time throughout the menstrual cycle, leans towards AMH level becoming the gold-standard biomarker to evaluate ovarian reserve and predict ovarian response to stimulation.

Clinical impact of LH rises prior to and during ganirelix treatment started on day 5 or on day 6 of ovarian stimulation.

BACKGROUND: We sought to evaluate the incidence and clinical impact of luteinizing hormone (LH) rises prior to and during gonadotropin-releasing hormone (GnRH) antagonist treatment started on day 5 or 6 of ovarian stimulation with recombinant follicle-stimulating hormone (rFSH). METHODS: Pooled data from three trials with the GnRH antagonist ganirelix started on day 5 (n = 961) and from five trials with ganirelix started on day 6 (n = 1135) of ovarian stimulation with rFSH were retrospectively analyzed. RESULTS: The incidence of LH rises (LH ≥ 10.0 IU/L) prior to ganirelix treatment was 2.3% and 6.6% on ganirelix start days 5 and 6, respectively (P < 0.01). During ganirelix treatment this incidence was 1.2% and 2.3%, respectively (P = 0.06). Women with LH rise on day 5 or 6 had a higher ovarian response with more oocytes recovered, mean ± SD, 12.9 ± 8.5 versus no LH rise, 10.2 ± 6.4 (P < 0.01). In women with and without LH rise prior to ganirelix treatment the ongoing pregnancy rates were similar (26.0% vs 29.9%; odds ratio [OR], 0.89; 95% confidence interval [CI], 0.55-1.44). Women with LH rise during ganirelix treatment had a lower ovarian response with 7.5 ± 6.7 oocytes recovered versus no LH rise, 10.2 ± 6.4 (P = 0.02) and a tendancy for a lower chance of ongoing pregnancy (16.7% vs 29.9%; OR, 0.52; 95% CI, 0.21-1.26). CONCLUSIONS: The incidence of early and late LH rises was low but may be further reduced by initiating ganirelix on stimulation day 5 rather than on day 6. In contrast to women with an early LH rise, women with a late LH rise may have a reduced chance of ongoing pregnancy.

Body mass index impacts in vitro fertilization stimulation.

The objective of the study was to prospectively determine if body mass index (BMI) is predictive of live birth rates in patients undergoing IVF. The prospective study enrolled 117 infertility patients with the primary outcome measure being IVF success rates. Mean BMI did not differ between patients with successful outcomes and those without successful outcomes. There was a significant positive correlation between BMI and the number of stimulated follicles (r = 0.19, P < .05). A significant negative correlation between BMI and ampules of gonadotropins used (r = -0.25, P < .01) and between BMI and days of stimulation (r = -0.19, P < .05) was noted. These data demonstrate that women with an elevated BMI produce more follicles, stimulate quicker, and require less gonadotropins during IVF. However, BMI did not have a significant effect on pregnancy outcome rates.

The relationship between pulsatile GnRH secretion and cAMP production in immortalized GnRH neurons.

In perifused immortalized GnRH neurons (GT1-7), simultaneous measurements of GnRH and cAMP revealed that the secretory profiles for both GnRH and cAMP are pulsatile. An analysis of GnRH and cAMP pulses in 16 independent experiments revealed that 25% of pulses coincide. Inversion of the peak and nadir levels was found in 33% and random relationship between GnRH and cAMP found in 42% of analyzed pulses. The random relation between GnRH and cAMP pulse resets to synchronous after an inverse relation between pulses occurred during the major GnRH release, indicating that GnRH acts as a switching mechanism to synchronize cAMP and GnRH release in perifused GT1-7 neurons. Activation of GnRH receptors with increasing agonist concentrations caused a biphasic change in cAMP levels. Low nanomolar concentrations increased cAMP production, but at high concentrations the initial increase was followed by a rapid decline to below the basal level. Blockade of the GnRH receptors by peptide and nonpeptide antagonists generated monotonic nonpulsatile increases in both GnRH and cAMP production. These findings indicate that cAMP positively regulates GnRH secretion but does not participate in the mechanism of pulsatile GnRH release.

Multivariate analysis of factors affecting probability of pregnancy and live birth with in vitro fertilization: an analysis of the Society for Assisted Reproductive Technology Clinic Outcomes Reporting System.

OBJECTIVE: To evaluate factors predictive of clinical pregnancy and of pregnancy loss from assisted reproductive technology (ART) using data from the Society for Assisted Reproductive Technology database for 2004-2006. DESIGN: Retrospective cohort. SETTING: Clinic-based data. PATIENT(S): The study population included 225,889 fresh embryo transfer cycles using autologous oocytes and partner semen. INTERVENTION(S): None. MAIN OUTCOME MEASURE(S): Clinical intrauterine gestation (presence of gestational sac) and live birth (>or=22 weeks gestation and >or=300 g birth weight). RESULT(S): Increasing maternal age was significantly associated with a reduced odds of conception and increased fetal loss until 19 weeks gestation, but not with later pregnancy loss. Intracytoplasmic sperm injection (ICSI), assisted hatching, and increasing number of embryos transferred had significant positive effects on the odds of conception and pregnancy continuation through the first trimester, but did not affect the risk of later loss. Blacks, Asians, and Hispanics had significantly lower odds of clinical pregnancy compared with whites. Also compared with whites, Hispanics and Asians had a significantly greater risk of pregnancy loss in the second and third trimesters, and blacks had a significantly greater risk of pregnancy loss in all trimesters. CONCLUSION(S): Certain demographic and ART treatment parameters influenced chance of conception and early pregnancy loss, whereas black race and Hispanic ethnicity were also significantly associated with late pregnancy loss in ART-conceived pregnancies.

A GnRH agonist and exogenous hormone stimulation protocol has a higher live-birth rate than a natural endogenous hormone protocol for frozen-thawed blastocyst-stage embryo transfer cycles: an analysis of 1391 cycles.

OBJECTIVE: To compare embryo and birth data in cryopreserved-thawed blastocyst-stage ET cycles between natural endogenous hormone cycles and exogenous hormone stimulation cycles. DESIGN: Retrospective cohort analysis. SETTING: Large academic assisted reproductive technology center. PATIENT(S): One thousand three hundred ninety-one patient cycles undergoing frozen-thawed blastocyst-stage ET cycles. MAIN OUTCOME MEASURE(S): Live-birth rate. INTERVENTION(S): The synthetic protocol used GnRH agonist followed by estrogen and P. The natural protocol used monitoring and post-transfer P. RESULT(S): The patients in the two protocols had similar baseline characteristics. Multiple linear regression showed the synthetic protocol to have a higher live-birth rate (odds ratio [OR], 1.46; 95% confidence interval [CI], 1.02-2.09). In patients having two embryos transferred, the synthetic stimulation protocol resulted in a higher live-birth rate per cycle start (32.3% vs. 20.4%; relative risk [RR], 1.58; 95% CI, 1.22-2.06). Similarly, patients with one or two embryos transferred who had additional cryopreserved blastocysts available also had a higher live-birth rate per cycle start (36.1% vs. 12.1; RR, 2.98; 95% CI, 1.16-7.63). CONCLUSION(S): The synthetic hormone protocol was associated with a higher live-birth rate when compared with a natural cycle protocol for frozen-thawed blastocyst-stage ET cycles. This improvement persisted when analysis was controlled for cycle cancellation. The synthetic stimulation protocol for frozen-thawed embryo cycles offers improved outcome results for patients.

Aneuploidy in abortuses following IVF and ICSI.

PURPOSE: To compare aneuploidy rates in first trimester pregnancy losses following IVF+/-ICSI. METHODS: A retrospective cohort analysis of karyotypes of abortuses following conventional IVF (n=159) and ICSI (n=196). RESULTS: 50.1% of losses were found to be cytogenetically abnormal among all patients undergoing IVF+/-ICSI. A significant increase in fetal aneuploidy rate was noted with increasing maternal age (<30 years=26.1% vs. 31 to 34 years.=38.2% vs. 35 to 39 years.=51.3% vs. >39 years.=65.9%). Aneuploidy rates were similar in the ICSI vs. conventional IVF groups (52.6% vs. 47.2% [p 0.31, RR 1.11, 95% CI 0.90, 1.38]). More sex chromosome anomalies were noted in the ICSI group. CONCLUSIONS: The aneuploidy rate in first trimester abortuses significantly increases with increasing maternal age. ICSI was not shown to significantly increase the aneuploidy rate. However, more sex chromosome anomalies were found among pregnancies resulting from ICSI.

Live birth sex ratios are not influenced by blastocyst-stage embryo transfer.

OBJECTIVE: To analyze the sex ratio of infants born after blastocyst-stage transfer of embryos with normal preimplantation FISH genetic screening. DESIGN: Retrospective cohort analysis. SETTING: Large academic assisted reproductive technology center. PATIENT(S): Two hundred twenty-eight patients undergoing fresh IVF cycle with blastocyst transfer. INTERVENTION(S): Preimplantation genetic screening for sex complement. MAIN OUTCOME MEASURE(S): Sex ratio in liveborn infants following blastocyst transfer. RESULT(S): One thousand thirteen embryos were normal by preimplantation genetic screening of chromosomes 13, 15, 16, 17, 18, 21, 22, X, and Y. Four hundred ninety-eight normal embryos were transferred to 228 patients with an overall live birth rate of 41.7%. Transferred blastocysts were selected based upon morphologic assessment. When controlling for the sex of the blastocyst embryo, there was no difference in the male-to-female delivery rate per embryo transferred (27.3% vs. 21.4%) (relative risk =1.28, confidence interval 0.93-1.74). Of the live births 51.7% were male and 48.3% were female (P=.61). Subanalysis revealed no difference in male-to-female delivery rates in groups with a 1:1 ratio of male:female embryos transferred, a non 1:1 ratio transferred, or single-sex transfers. CONCLUSION(S): Blastocyst-stage embryo transfer does not influence the live birth sex ratio of embryos with normal preimplantation FISH genetic screening.

The p53 codon 72 single nucleotide polymorphism lacks a significant effect on implantation rate in fresh in vitro fertilization cycles: an analysis of 1,056 patients.

OBJECTIVE: To determine whether the p53 codon 72 single nucleotide polymorphism, a change of the amino acid arginine (Arg) to proline (Pro) resulting from a single nucleotide mutation of guanine (G) to cytosine (C), has a clinically significant effect on implantation rate in fresh IVF cycles. DESIGN: Prospective cohort analysis. SETTING: University-affiliated private IVF center. PATIENT(S): One thousand fifty-six female patients undergoing fresh nondonor IVF cycles. MAIN OUTCOME MEASURE(S): Embryo implantation rate. RESULT(S): Of the 1,056 patients (2,600 total embryos transferred) undergoing their first IVF cycle, 289 had no implantation events and attempted a second cycle. Of the 289 patients in their second cycle, 72 had no implantation events and attempted a third cycle. The p53 codon 72 single nucleotide polymorphism frequencies in the first cycle (homozygous major allele Arg/Arg [G_G] = 45%, heterozygous allele Arg/Pro [G_C] = 44%, and homozygous minor allele Pro/Pro [C_C] = 11%) did not differ significantly across subsequent IVF cycles. There was no statistically significant difference in embryo implantation rate with respect to the single nucleotide polymorphism. CONCLUSION(S): The p53 codon 72 single nucleotide polymorphism lacks a clinically significant effect on embryo implantation rate in patients undergoing fresh nondonor IVF cycles.

A luteal estradiol protocol for anticipated poor-responder patients may improve delivery rates.

OBJECTIVE: To compare IVF data and outcomes between a standard protocol and a luteal phase E(2) protocol. DESIGN: Retrospective cohort analysis. SETTING(S): Large academic assisted reproduction technologies center. PATIENT(S): Fifty-seven infertile patients with a history of poor response to IVF stimulation and 228 matched control patients. INTERVENTION(S): IVF with a standard protocol or a luteal phase E(2) protocol. MAIN OUTCOME MEASURE(S): Live-birth rates. RESULT(S): Patients in the luteal E(2) protocol required more days of stimulation and total gonadotropins and had higher peak E(2) levels when compared with the control group. The luteal E(2) protocol showed a greater percentage of embryos with >or=7 cells on day 3. A trend toward improved delivery rates was seen in the luteal E(2) protocol (28.1% vs. 22.4%; relative risk, 1.25, 0.78-2.03). CONCLUSION(S): A luteal E(2) protocol results in improved day 3 embryo development as demonstrated by the percent of embryos at the >or=7-cell stage. Likewise, the luteal E(2) protocol may ultimately improve pregnancy outcomes for patients with poor response to IVF stimulation.

Logarithmic curves depicting initial level and rise of serum beta human chorionic gonadotropin and live delivery outcomes with in vitro fertilization: an analysis of 6021 pregnancies.

OBJECTIVE: To correlate the live delivery rate with the initial level and rise of serum beta-hCG. DESIGN: Retrospective cohort analysis. SETTING: Large private academic center for assisted reproductive technologies and infertility. PATIENT(S): Records of all patients from 1999 to 2005 undergoing IVF with detectable early serum beta-hCG after ET. INTERVENTION(S): None. MAIN OUTCOME MEASURE(S): Live delivery rate. RESULT(S): Data from 6021 pregnancies were analyzed. Initial beta-hCG was predictive for delivery rate for all patients and for each age group. After controlling for the first beta-hCG, there were higher loss rates as age increased. Percent rise in second beta-hCG drawn 2 days later added predictive value. A decline in beta-hCG almost always resulted in a failure to deliver. There was a progressive increase in delivery rate as the percent rise in beta-hCG went from 0 to 100%; however, there was no further enhancement in delivery rates beyond the 100% rise point. While a better rise in beta-hCG was a good prognostic factor in all age groups, the differences in outcomes for the different age groups remained, even after controlling for first beta-hCG and percent rise. CONCLUSION(S): Initial level and rise in beta-hCG predicts live delivery rate, with oocyte age providing additional predictive value. The established logarithmic curves should provide convenient reference tools for tracking outcomes and counseling patients.

A luteal estradiol protocol for expected poor-responders improves embryo number and quality.

OBJECTIVE: To compare embryo and oocyte data between a standard protocol and a luteal phase estradiol protocol. DESIGN: Retrospective paired cohort analysis. SETTING: Private in vitro fertilization (IVF) center. PATIENT(S): 60 poor-responder patients undergoing 120 IVF cycles. INTERVENTION(S): Addition of luteal estradiol to the standard IVF protocol. MAIN OUTCOME MEASURE(S): Number of embryos with > or = 7 cells on day 3 of development. RESULT(S): The luteal phase estradiol protocol showed a statistically significantly greater number of embryos with > or = 7 cells, oocytes retrieved, mature oocytes, and embryos than did the standard protocol. There was no difference between the two protocols with respect to basal antral follicle count, days of stimulation, number of follicles > or = 14 mm on day of surge, or endometrial thickness on day of surge. A trend toward improved pregnancy outcomes was found with the luteal estradiol protocol. CONCLUSION(S): Giving estradiol in the luteal phase preceding IVF hyperstimulation increases the number and the quality of embryos achieved in patients deemed to have a poor response to IVF. Ultimately, this may translate into improved pregnancy outcomes in these patients.

The predictive value for in vitro fertility delivery rates is greatly impacted by the method used to select the threshold between normal and elevated basal follicle-stimulating hormone.

OBJECTIVE: To evaluate the predictive accuracy of different methodologies for selecting a basal FSH threshold level that prognosticates live birth after IVF. DESIGN: Retrospective. SETTING: Academic private practice. PATIENT(S): Eight thousand nineteen patients who had their basal FSH levels determined by the program's endocrinology laboratory. INTERVENTION(S): Thresholds between normal and elevated basal FSH levels were calculated by using six different methodologies. MAIN OUTCOME MEASURE(S): Live birth rate per initiated IVF cycle. RESULT(S): The thresholds selected by using the manufacturer's normal range or using 95% confidence intervals of a fertile population, the infertile population, or distinct age groups within the infertile population all proved unsatisfactory. The live birth rates for patients in whom there had been a previously elevated FSH level were

Low-dose aspirin use does not improve in vitro fertilization outcomes in poor responders.

OBJECTIVE: To assess if aspirin improves pregnancy outcome in patients undergoing in vitro fertilization (IVF) with a diagnosis of poor response. DESIGN: Retrospective cohort analysis. SETTING: Academic private practice. PATIENT(S): 1250 poor-responder patients undergoing IVF. INTERVENTION(S): Low-dose (81 mg) aspirin before and during an IVF cycle. MAIN OUTCOME MEASURE(S): Live-birth rate. RESULT(S): Patients taking 81 mg of aspirin had statistically significantly higher basal antral follicle counts, more days of stimulation, more ampules of gonadotropins used, higher peak estradiol levels, and more follicles that were > or = 14 mm in diameter on the day of human chorionic gonadotropin administration. There was a decrease in the overall fertilization rate for the patients taking aspirin. There was no difference in IVF outcome rates (implantation, pregnancy, loss, or live birth). CONCLUSION(S): Patients with a diagnosis of poor response who were taking a regimen of 81 of mg aspirin showed an increase in many IVF stimulation parameters and a decrease in fertilization rates. No improvement secondary to 81-mg aspirin intake was found in IVF outcome rates.

Male age negatively impacts embryo development and reproductive outcome in donor oocyte assisted reproductive technology cycles.

OBJECTIVE: To determine whether male age influences embryo development and reproductive potential in assisted reproductive technology cycles. DESIGN: Retrospective cohort analysis. SETTING: Private IVF center. PATIENT(S): One thousand twenty-three male partners participating in anonymous oocyte donation cycles. INTERVENTION(S): Infertile couples undergoing 1,023 anonymous oocyte donation cycles. MAIN OUTCOME MEASURE(S): Live birth rate. RESULT(S): A significant increase in pregnancy loss, decrease in live birth rate, and decrease in blastocyst formation rate were noted in men >50 years of age. There was no significant difference in implantation rate, pregnancy rate, or early embryo development through the cleavage stage (demonstrated by fertilization rate, embryo cleavage rate, percentage of nonfertilized or polyspermic embryos, rate of embryo arrest, or seven or more cell embryo development on day 3). Men < or =45 years of age had significantly more semen volume and more motile sperm than men >45 years of age. There was no significant change in sperm morphology or concentration. CONCLUSION(S): After controlling for female age with use of the donor oocyte model, male age >50 years significantly affected pregnancy outcomes and blastocyst formation rates. Semen volume and total motility decreased with increasing male age. Initial embryo morphology through the cleavage stage was not affected.

The utility of serum leptin and follicular fluid leptin, estradiol, and progesterone levels during an in vitro fertilization cycle.

PURPOSE: To prospectively evaluate serum and follicular fluid leptin, estradiol, and progesterone levels during in vitro fertilization. METHODS: Prospective observational study measuring serum levels at six points during the IVF cycle and follicular fluid at the time of retrieval. RESULTS: Serum leptin and estradiol levels both significantly increased for the individual patients during the IVF stimulation process. None of the leptin levels differed based on pregnancy outcome. BMI significantly correlated with all leptin levels. Follicular fluid estradiol correlated with serum estradiol only in pregnant patients (r = 0.97, p<0.01) and was unrelated in non-pregnant patients (r=-0.15, p=0.81). CONCLUSION: Serum and follicular leptin levels are highly correlated. Leptin levels increase during the IVF cycle and vary between patients based on maternal BMI, but do not correlate with other serum hormone levels or pregnancy outcome. Pregnancy outcome success was reflected in the relationship between follicular fluid and serum levels of estradiol, independent of leptin levels.

The pre-cycle blind mock embryo transfer is an inaccurate predictor of anticipated embryo transfer depth.

PURPOSE: To assess if the uterine cavity depth measured by a blind pre-cycle mock transfer changes after gonadotropin stimulation. METHODS: This is a retrospective cohort study at an academic IVF program involving 128 infertility patients. The main outcome measures were uterine cavity depth measured at the blind pre-stimulation mock transfer and the ultrasound-guided embryo transfer. RESULTS: A >or= 1 cm increase in uterine cavity depth was found in 57.9% of the patients. The mean pre-cycle blind mock transfer uterine depth significantly differed from the mean uterine depth measured at embryo transfer. Based on the mock transfer, the anticipated embryo transfer depth was significantly less than the actual ultrasound-guided embryo transfer depth. CONCLUSION: Uterine depth significantly differed between the blind pre-cycle mock transfer measurement and the ultrasound-guided embryo transfer measurement. The mock transfer may predict a difficult embryo transfer but it is an inaccurate predictor of the final embryo transfer depth.

Changes in measured endometrial thickness predict in vitro fertilization success.

OBJECTIVE: To assess the predictive ability of endometrial thickness and changes in endometrial thickness on pregnancy outcomes in patients undergoing IVF. DESIGN: Retrospective cohort analysis. SETTING: Academic IVF center. PATIENT(S): Infertile patients undergoing 132 fresh autologous IVF cycles. INTERVENTION(S): Transvaginal ultrasound to assess endometrial thickness at three defined points during IVF (after pituitary suppression, on the sixth day of gonadotropin stimulation, and on the day of hCG administration). MAIN OUTCOME MEASURE(S): Primary outcome variables included endometrial lining thickness at baseline, on day 6 of gonadotropins, the day of hCG administration, and the change in endometrial thickness during gonadotropin stimulation. RESULT(S): Patients attaining pregnancy had significantly greater endometrial thickness on day 6 and endometrial thickness on day of hCG administration. Pregnant patients had a greater change in endometrial thickness from the baseline to day 6 when compared to nonpregnant patients. Threshold analysis and receiver-operator characteristic curves noted significant endometrial thickness levels for implantation and pregnancy rates. CONCLUSION(S): Endometrial responsiveness and thickness during the early IVF stimulation seem to be better prognostic predictors of success than endometrial thickness at the start or the end of the IVF cycle.

Surgical competence of obstetrics and gynecology residents performing microsurgical tubal anastamoses.

OBJECTIVE: To assess tubal patency rates after microsurgical tubal anastamosis in a residency program. STUDY DESIGN: Retrospective cohort analysis. Primary outcome measurement was tubal patency rates. RESULTS: Twenty-seven of the forty-nine patients (55.1%) had bilateral tubal patency and twenty-one of the forty-nine (42.9%) had only one tube open after surgery. No statistical difference in tubal patency rate was noted between the REI staff (85.7%) and the resident (71.4%) (p=0.09). No statistical difference was noted when comparing the patency rate of the residents' first procedure (68.6%) to subsequent procedures (72.8%) (p=0.99). CONCLUSIONS: These data suggest that with appropriate guidance, residents without prior experience are able to perform microsurgical procedures under direct supervision. Residents completed the procedure with patency rates similar to the REI staff. Additionally, tubal patency rates were not significant different in comparing the residents' first or subsequent procedures.