Ultrasound is the optimal choice for guidance in difficult hysteroscopy.

OBJECTIVES: To compare costs and complications associated with ultrasound-guided hysteroscopy vs laparoscopy-guided hysteroscopy vs hysteroscopy alone for the surgical repair of intrauterine septa and synechiae. METHODS: This was a retrospective cohort study. Charts of all patients undergoing reparative surgery for intrauterine synechiae or uterine septa at our academic institution between 2000 and 2008 were reviewed. A total of 159 procedures were included in the study, categorized into concurrent laparoscopic guidance (n = 69), ultrasound guidance (n = 52) or no guidance (n = 38). Data regarding billing, surgical case logs and complications were collected for these procedures. Using these data, complication rates and inflation-adjusted charges were compared between the groups. Statistical analysis was performed using Fisher's exact test and Student's t-test, as appropriate. RESULTS: A uterine perforation rate of 8.7% was observed with laparoscopic guidance vs 1.9% with ultrasound guidance (P = 0.12) and 5.3% with no guidance (P = 0.41). Analysis of billing data showed that average total costs were significantly less for ultrasound guidance than for laparoscopic guidance ($9124 vs $11 895, P < 0.001). Ultrasound guidance did not increase costs over hysteroscopy alone ($9124 vs $8242, P = 0.54). CONCLUSION: Real-time transabdominal ultrasound guidance during the resection of intrauterine synechiae or septa resulted in a trend towards reduced uterine perforation. Moreover, ultrasound guidance is less costly than laparoscopic guidance and adds no additional cost over hysteroscopy alone. Taken together, transabdominal ultrasound guidance is the optimal means of intraoperative guidance for the resection of uterine synechiae and septa.

Effect of the total motile sperm count on the efficacy and cost-effectiveness of intrauterine insemination and in vitro fertilization.

OBJECTIVE: To determine prognostic factors for achieving a pregnancy with intrauterine insemination (IUI) and IVF. To compare the effectiveness and cost-effectiveness of IUI and IVF based on semen analysis results. DESIGN: Retrospective cohort study. SETTING: Academic university hospital-based infertility center. PATIENT(S): One thousand thirty-nine infertile couples undergoing 3,479 IUI cycles. Four hundred twenty-four infertile couples undergoing 551 IVF cycles. INTERVENTION(S): IUI and IVF treatment. MAIN OUTCOME MEASURE(S): Multiple logistic regression analysis was used to assess the significance of prognostic factors including a woman's age, gravidity, duration of infertility, diagnoses, use of ovulation induction, and sperm parameters for predicting the outcomes of clinical pregnancy and live birth rate after the first cycle of IUI and IVF. The relative effectiveness and cost-effectiveness of these treatments were then determined based on sperm count results. RESULT(S): Female age, gravidity, and use of ovulation induction were all independent factors in predicting pregnancy after IUI. The average total motile sperm count in the ejaculate was also an important factor, with a threshold value of 10 million. For IVF, only female age was an important predictor for both clinical and ongoing pregnancy. When the average total motile sperm count was under 10 million, IVF with ICSI was more cost-effective than IUI in our clinic. CONCLUSION(S): An average total motile sperm count of 10 million may be a useful threshold value for decisions about treating a couple with IUI or IVF.

Bilateral undescended ovaries: association with infertility and treatment with IVF.

OBJECTIVE: To describe the clinical findings in a patient with bilateral undescended ovaries and infertility who was successfully treated by IVF. DESIGN: Case report. SETTING: University hospital. PATIENT(S): A 35-year-old woman with bilateral undescended ovaries. INTERVENTION(S): Hysterosalpingography, laparoscopy, and an IVF cycle. MAIN OUTCOME MEASURE(S): Anatomic description and pregnancy test. RESULT(S): This patient conceived and delivered a twin gestation after laparoscopic retrieval of oocytes and transfer of two blastocysts. CONCLUSION(S): Bilateral undescended ovaries is a rare condition that can be associated with infertility but can be successfully treated by IVF.

Cost-effective treatment for the couple with infertility.

Although the evaluation of cost-effective approaches to infertility treatment remains in its infancy, several important principles have emerged from the initial studies in this field. Currently, in treating couples with infertility without tubal disease or severe male-factor infertility, the most cost-effective approach is to start with IUI or superovulation-IUI treatments before resorting to IVF procedures. The woman's age and number of sperm present for insemination are significant factors influencing cost-effectiveness. The influence of certain diagnoses on the cost-effectiveness of infertility treatments requires further study. Even when accounting for the costs associated with multiple gestations and premature deliveries, the cost of IVF decreases within the range of other cost-effective medical procedures and decreases to less than the willingness to pay for these procedures. Indeed, for patients with severe tubal disease, IVF has been found to be more cost-effective than surgical repair. The cost-effectiveness of IVF will likely improve as success rates show continued improvements over the course of time. In addition, usefulness of embryo selection and practices to reduce the likelihood of high-order multiple pregnancies, without reductions in pregnancy rates, will significantly impact cost-effectiveness. The exclusion of infertility treatments from insurance plans is unfortunate and accentuates the importance of physicians understanding the economics of infertility treatment with costs that are often passed directly to the patient. The erroneous economic policies and judgments that have led to inequities in access to infertility health care should not be tolerated.

The cost of infertility evaluation and therapy: findings of a self-insured university healthcare plan.

OBJECTIVE: To assess the total costs of infertility coverage, determine the proportion of healthcare costs related to infertility, compare infertility costs to those of other diseases, and calculate a per member per month cost of an infertility benefit. DESIGN: Historical prospective analysis. SETTING: A university-based, self-insured, fee-for-service healthcare plan. PATIENT(S): Healthcare policy members from January 1993 through December 1995. INTERVENTION(S): General and infertility-specific healthcare that included diagnostic tests for infertility, induction of ovulation, artificial insemination, donor gametes, in vitro fertilization, gamete intrafallopian transfer, zygote intrafallopian transfer, microsurgical epididymal sperm aspiration, embryo cryopreservation, and frozen embryo transfer. MAIN OUTCOME MEASURE(S): Healthcare costs, as calculated from the International Classification of Diseases, Volume 9 codes. RESULT(S): Total healthcare and infertility-specific costs of the university healthcare plan over a 3-year period were $86,445,642 and $680,921, respectively. Therefore, infertility accounted for 0.79% of the total university healthcare costs. The mean total and infertility-specific per member per month healthcare costs were $86.15 and $0.67, respectively. CONCLUSION(S): These data reveal that infertility costs account for only a small fraction of the total healthcare costs and can be attained at a nominal monthly fee.

Sonohysterography in premenopausal women with and without abnormal bleeding.

OBJECTIVE: To estimate the prevalence of abnormalities detected by sonohysterography in premenopausal women who were asymptomatic or had abnormal uterine bleeding. METHODS: Standard sonohysterography was done in 100 asymptomatic premenopausal women age 30 and older. The prevalence of uterine abnormalities was recorded and compared with findings in 80 premenopausal women evaluated in our unit for abnormal uterine bleeding. RESULTS: Compared with asymptomatic women, premenopausal women with abnormal uterine bleeding had a higher prevalence of polyps (33 versus 10%), intracavitary myomas (21 versus 1%), and intramural myomas (58 versus 13%). Ten percent of asymptomatic women had polyps, but these polyps tended to be smaller than the polyps found in women with abnormal bleeding (8.5 versus 13.9 mm, P = .064). Polyps were associated significantly with myomas, and both were more common in older premenopausal women. CONCLUSION: Intracavitary lesions and intramural myomas are more prevalent in women with abnormal uterine bleeding than in asymptomatic women, suggesting a causative relationship. However, small endometrial polyps are common and frequently asymptomatic.

Ovarian volume may predict assisted reproductive outcomes better than follicle stimulating hormone concentration on day 3.

This study was undertaken to compare ovarian volume with other factors which are important for the success of assisted reproduction. The first treatment cycle for 261 patients meeting all entry criteria between September 1993 and June 1995 was considered. All cycles employed the same stimulation protocol and no interventions were based upon pre-treatment indicators. Pre-treatment ovarian volumes, cycle day 3 follicle stimulating hormone (FSH) and oestradiol concentrations, smoking status and age were compared to subsequent peak oestradiol concentrations, numbers of oocytes retrieved, cycle cancellation and occurrence of clinical pregnancy. Statistical evaluation was performed using simple and multiple logistic regression analysis to determine odds ratios. The resultant odds ratios suggest that age and small ovarian volume may predict retrieval of fewer mature oocytes, while the failure to achieve clinical pregnancy was predicted by current smoking and small ovarian volume. Day 3 FSH values failed to be a significant predictor when maternal age, smoking status and ovarian volume were known. It can be concluded that, like maternal age and smoking status, ovarian volume may be a clinically important predictor of reproductive success, being superior to cycle day 3 FSH or oestradiol concentrations as an assessment of ovarian reserve.

Cost-effective treatment of the infertile couple.

OBJECTIVE: To review the published literature on the cost-effective approach to infertility treatment. DESIGN: The literature on the economics and cost-effectiveness of infertility treatments was reviewed. Studies related to this topic were identified through MEDLINE. RESULT(S): Few cost-effectiveness studies about infertility treatment have been published. In the absence of tubal blockage and severe male factor, use of IUI and hMG-IUI is more cost-effective than IVF. In vitro fertilization is at least as cost-effective as tubal surgery. Although IVF costs are high, they fall well within the range of other accepted medical treatments and are below the general public's willingness to pay for these treatments. CONCLUSION(S): Cost-effectiveness analysis is an important means of improving quality of care while controlling costs. Further work regarding cost-effectiveness of treatments among different diagnostic groups is needed.

Selective early elimination of luteal support in assisted reproduction cycles using a gonadotropin-releasing hormone agonist during ovarian stimulation.

OBJECTIVE: To determine if women undergoing GnRH agonist-hMG stimulated IVF cycles can undergo successful discontinuation of luteal phase support. DESIGN: A protocol for selective discontinuation of luteal phase support was evaluated prospectively in women undergoing assisted reproduction cycles. SETTING: A tertiary care institutional-based assisted reproduction program. PATIENT(S): One hundred eighty-eight women who conceived after an IVF or zygote intrafallopian transfer cycle including a GnRH agonist between January 1994 and June 1997. INTERVENTION(S): Women with serum progesterone levels of > or = 60 ng/mL at 4 weeks' gestation were selected for discontinuation of their luteal phase support. MAIN OUTCOME MEASURE(S): Delivery rate. RESULT(S): Sixty-three women (62.4%) met the criteria for discontinuation of luteal phase support. There were no differences in the mean age, peak E2 levels, number of follicles, number of embryos transferred, or delivery rates (85.7% versus 78.9%) between the women who did and those who did not have discontinuation of their progesterone supplementation. CONCLUSION(S): These data reveal that luteal phase support can be discontinued successfully for selective women undergoing IVF who are receiving a GnRH agonist.

Ultrasound-guided aspiration of hydrosalpinges is associated with improved pregnancy and implantation rates after in-vitro fertilization cycles.

Previous reports have shown that the presence of hydrosalpinges may have a detrimental effect on in-vitro fertilization (IVF) outcomes and salpingectomy has been recommended by some authors as a means of improving IVF pregnancy rates. Our first objective was to determine the effect of hydrosalpinges diagnosed by ultrasound on IVF outcomes in our clinic. Our second objective was to examine the effects of aspiration of hydrosalpinges at the time of oocyte retrieval on IVF outcomes. Women with hydrosalpinges (n=34) were compared with women who had tubal disease but no hydrosalpinges (n=124) and were found to have a reduced clinical pregnancy rate (18 % versus 37%, P=0.053), a reduced ongoing pregnancy rate (15 versus 34%, P=0.051), and a reduced implantation rate (7 versus 18%, P=0.003) after IVF procedures. Among women with hydrosalpinges present, 16 had their hydrosalpinges aspirated at the time of oocyte retrieval and 18 did not. Aspiration of hydrosalpinges was associated with a higher clinical pregnancy rate (31 versus 5%, P=0.07), a higher ongoing pregnancy rate (31 versus 0%, P=0.015), and a higher implantation rate (14 versus 1%, P=0.015). This study confirms the association between the presence of hydrosalpinges and poor IVF outcomes. We find that aspiration of hydrosalpinges at the time of oocyte retrieval leads to improved pregnancy rates and may be an acceptable alternative to salpingectomy for treatment of these patients.

Uterine leiomyomas reduce the efficacy of assisted reproduction cycles: results of a matched follow-up study.

A matched follow-up study design was used to test the hypothesis that pregnancy rates following assisted reproduction procedures do not differ between women with or without intramural or sub-serosal uterine leiomyomas. Women undergoing their first in-vitro fertilization (IVF)-embryo transfer or zygote intra-Fallopian transfer (ZIFT) cycle between January 1993 and June 1995 were included. Cases (women with leiomyomas) were matched 1:1 with the next consecutive control (women without leiomyomas) according to age, number of embryos transferred, embryo grade, and the route of embryo transfer (uterine or Fallopian). Assisted reproduction cycles were performed in an identical manner, independent of the presence or absence of uterine leiomyomas. The main outcomes measured were clinical pregnancy and delivery rates. A total of 182 cycles was evaluated. Of the 91 assisted reproduction cycles performed in the leiomyoma group, there were 34 clinical pregnancies (37%) and 30 deliveries (33%). Of the 91 assisted reproduction cycles in the control group, there were 48 clinical pregnancies (53%) and 44 deliveries (48%). The Mantel-Haenszel estimate of relative risk indicated that the presence of a uterine leiomyoma significantly reduced the chance for a clinical pregnancy or delivery. These findings suggest that leiomyomas are associated with a reduction in the efficacy of assisted reproduction cycles.

Cost-effectiveness of infertility treatments: a cohort study.

OBJECTIVE: To determine the cost-effectiveness of infertility treatments. DESIGN: Retrospective cohort study. SETTING: Academic medical center infertility practice. PATIENT(S): All patients treated for infertility in a 1-year time span. INTERVENTION(S): Intrauterine inseminations, clomiphene citrate and IUI (CC-IUI), hMG and IUI (hMG-IUI), assisted reproductive techniques (ART), and neosalpingostomy by laparotomy. MAIN OUTCOME MEASURE(S): All medical charges and pregnancy outcomes associated with the treatments were obtained. Cost-effectiveness ratios defined as cost per delivery were determined for each procedure. The effects of a woman's age and the number of spermatozoa inseminated on cost-effectiveness of the procedures was also determined. RESULT(S): Intrauterine inseminations, CC-IUI, and hMG-IUI have a similar cost per delivery of between $7,800 and $10,300. All of these were more cost-effective than ART, which had a cost per delivery of $37,000. Assisted reproductive techniques in women with blocked fallopian tubes was more cost-effective than tubal surgery performed by laparotomy, which had a cost per delivery of $76,000. Increasing age in women and lower numbers of spermatozoa inseminated were factors leading to higher costs per delivery for IUI, CC-IUI, hMG-IUI, and ART. Use of donor oocytes reduced the cost per delivery of older women to the range seen in younger women with ART. CONCLUSION(S): Our analysis supports, in general, the use of IUI, CC-IUI, and hMG-IUI before ART in women with open fallopian tubes. For women with blocked fallopian tubes, IVF-ET appears to be the best treatment from a cost-effectiveness standpoint.

The effects of smoking on ovarian function and fertility during assisted reproduction cycles.

OBJECTIVE: To investigate the effects of cigarette smoking on ovarian function and fertility in women undergoing assisted reproduction cycles. METHODS: We assessed the effects of smoking on ovarian function and fertility in a cohort of 499 women. Questionnaires were designed to quantify past smoking exposure and to determine whether the woman was smoking during the treatment cycle. Ovarian function characteristics and pregnancy rates were compared among current smokers, past smokers, and nonsmokers. RESULTS: Compared with nonsmokers, both current and past smokers have reduced gonadotropin-stimulated ovarian function. A history of increasing tobacco exposure was associated with decreasing serum estradiol concentrations, numbers of retrieved oocytes, and numbers of embryos. On average, for every 10 pack-years of cigarette smoking, 2.5 fewer mature oocytes and 2.0 fewer embryos were obtained. Women who smoked during their treatment cycle had approximately a 50% reduction in implantation rate and ongoing pregnancy rate compared with women who had never smoked. Women who quit smoking before their treatment cycle had the same pregnancy rate as nonsmokers. CONCLUSION: Cigarette smoking is associated with a prolonged and dose-dependent adverse effect on ovarian function. Smoking appears to have a more transient toxic effect on fertility, because current smokers, but not past smokers, had a markedly reduced pregnancy rate after treatment cycles compared with nonsmokers. Women should quit smoking before assisted reproduction cycles.

The effectiveness of sublingual progesterone administration during cryopreserved embryo transfer cycles: results of a matched follow-up study.

OBJECTIVE: To compare cryopreserved ET pregnancy rates in subjects receiving either sublingual parenteral P. DESIGN: Matched follow-up study. SETTING: University-based assisted reproduction program. PATIENTS: Women undergoing cryopreserved ET between January 1993, and December 1994. Cases received a hormone replacement protocol containing oral E2 and sublingual P and controls received a hormone replacement protocol containing oral E2 and parenteral P. Cases and controls were matched one-to-one according to age, number of embryos transferred, embryo grade, and route of ET. INTERVENTIONS: Cryopreserved embryos were thawed and transferred in all patients in an identical manner independent of the route of P administration. MAIN OUTCOME MEASURES: Clinical and ongoing pregnancy rates. RESULTS: Of 61 ET cycles performed in the sublingual P group, there were 16 clinical pregnancies (26.2%) and 12 ongoing pregnancies (19.7%). Of the 61 ET cycles in the parenteral P group, there were 14 clinical pregnancies (23.0%) and 11 ongoing pregnancies (18.0%). A chi 2 test revealed no significant differences in either clinical or ongoing pregnancy rates according to the route of P administration. CONCLUSIONS: This data suggests that sublingual P administration is an effective alternative to parenteral P administration in preparing the endometrium for the implantation of cryopreserved embryos.

Ovarian volume: a novel outcome predictor for assisted reproduction.

OBJECTIVE: To determine the potential of ovarian volume as a predictor of assisted reproduction outcomes. DESIGN: Retrospective chart review. SETTING: University-based assisted reproduction program. PATIENTS: One hundred eighty-eight women initiating their first cycle of assisted reproduction. INTERVENTIONS: None. MAIN OUTCOME MEASURES: Pretreatment transvaginal ultrasound ovarian measurements were compared with subsequent ovulation induction parameters (peak E2, numbers of oocytes, and embryos) and cycle outcome (cancellation and pregnancy). RESULT: Total ovarian volume and volume of the smallest ovary were significant variables predicting peak E2 and numbers of oocytes and embryos. Total ovarian volume was a predictor of cycle cancellation and volume of the smallest ovary a predictor of clinical pregnancy. Large ovarian volumes are associated with good assisted reproductive technology outcomes whereas small ovarian volumes are associated with poor outcomes. CONCLUSION: Beyond maternal age, total ovarian volume, and volume of the smallest ovary are significant predictors of the success of assisted reproductive techniques.

The efficacy and cost effectiveness of embryo cryopreservation compared with other assisted reproductive techniques.

OBJECTIVE: To evaluate the efficacy and cost effectiveness of embryo cryopreservation compared with other assisted reproductive techniques (ARTs). DESIGN: Retrospective review of medical records and health care costs. SETTING: Tertiary care academic medical school ART program. PATIENTS: For determination of the efficacy of cryopreserved ET, we analyzed 610 patients undergoing the first 1,000 oocyte retrievals in our program. For determination of cost effectiveness, we analyzed the costs associated with 334 initiated ART cycles in 1992. MAIN OUTCOME MEASURES: The ongoing pregnancy rate (PR) per initiated cycle and per oocyte retrieval. The medical costs associated with each procedure. RESULTS: The transfer of cryopreserved embryos increased the ongoing PR per oocyte retrieval by 6.6%. Transfer of cryopreserved embryos was cost effective compared with other ARTs. The cost per delivery for cryopreserved ETs was between 25% and 45% that of a fresh cycle. CONCLUSIONS: Including embryo cryopreservation in an ART program can improve PRs and lower the ultimate cost per delivery.

Tubal versus uterine transfer of cryopreserved embryos: a prospective randomized trial.

OBJECTIVE: To compare pregnancy rates after fallopian tubal and uterine transfer of cryopreserved embryos. DESIGN: Prospective randomized trial with assignment to treatment groups by a random number table. SETTING: University of Iowa Hospitals and Clinics, a tertiary care academic institution. PATIENTS: Forty patients with patent fallopian tubes and at least three cryopreserved embryos. INTERVENTIONS: Cryopreserved embryos were thawed and transferred to the fallopian tube by laparoscopy or to the uterus by a transcervical catheter. MAIN OUTCOME MEASURES: Clinical and ongoing pregnancy rates. RESULTS: Tubal transfer of cryopreserved embryos resulted in statistically higher clinical (68% versus 24%) and ongoing pregnancy rates (58% versus 19%) when compared with uterine transfer. CONCLUSIONS: Tubal transfer of cryopreserved embryos is highly effective and offers an improved pregnancy rate when compared with uterine transfer of embryos. This method of transfer should be considered in patients with patent fallopian tubes and at least three cryopreserved embryos.

An evaluation of the effect of anesthetic technique on reproductive success after laparoscopic pronuclear stage transfer. Propofol/nitrous oxide versus isoflurane/nitrous oxide.

BACKGROUND: Laparoscopic pronuclear stage transfer (PROST) is the preferred method of embryo transfer after in vitro fertilization in many infertility programs. There are scant data to recommend the use or avoidance of any particular anesthetic agent for use in women undergoing this procedure. The authors hypothesized that propofol would be an ideal anesthetic for laparoscopic PROST because of its characteristic favorable recovery profile that includes minimal sedation and a low incidence of postoperative nausea and vomiting. The purpose of the study was to compare propofol and isoflurance with respect to postanesthetic recovery and pregnancy outcomes after laparoscopic PROST. METHODS: One hundred twelve women scheduled for laparoscopic PROST were randomized to receive either propofol/nitrous oxide or isoflurane/nitrous oxide for maintenance of anesthesia. RESULTS: Visual analog scale scores for sedation were lower in the propofol group than in the isoflurance group at all measurements between 30 min and 3 h after surgery. More women experienced emesis and were given an antiemetic during recovery in the isoflurance group than in the propofol group. However, the percentage of pregnancies with evidence of fetal cardiac activity was 54% in the isoflurane group compared with only 30% in the propofol group (P = 0.023). Also, the ongoing pregnancy rate was greater in the isoflurane group than in the propofol group (54% vs. 29%, P = 0.014). CONCLUSIONS: Propofol/nitrous oxide anesthesia was associated with lower clinical and ongoing pregnancy rates compared with isoflurane/nitrous oxide anesthesia.

Primary hypothyroidism associated with multicystic ovaries and ovarian torsion in an adult.

BACKGROUND: Primary hypothyroidism is known to be associated with multicystic ovaries in juvenile females, but this association has been reported only once previously in an adult. This report describes an unusual case of bilateral multicystic ovaries occurring in an adult patient with profound hypothyroidism. CASE: A 26-year-old woman presented with an acute abdomen and bilateral adnexal masses. An emergency exploratory laparotomy revealed bilateral enlarged multicystic ovaries with torsion of the right ovary. Because this ovary was necrotic, it was removed; pathology revealed multiple hemorrhagic follicular cysts. Laboratory studies to evaluate the cause of the multicystic ovaries revealed negative serum beta-hCG, LH 0.7 IU/L, FSH 15.7 IU/L, and estradiol 80 pg/mL. The TSH value was greater than 50 IU/L and serum thyroxine was undetectable, demonstrating profound hypothyroidism. Subsequent thyroid hormone replacement was associated with resolution of the cysts in the remaining ovary. CONCLUSION: Profound hypothyroidism can cause multicystic ovaries in an adult. In the absence of ovarian torsion, surgery can be avoided, as thyroid hormone replacement leads to clinical resolution of the cysts within 3 months.

Increased risk of monochorionic twinning associated with assisted reproduction.

OBJECTIVE: To determine the incidence of monochorionic twinning in pregnancies resulting from assisted reproduction technologies (ARTs). METHODS: We reviewed our experience with 218 ART pregnancies achieved over 3 years. All patients underwent transvaginal ultrasound 26 and 36 days after oocyte retrieval. The presence of two yolk sacs or two fetal poles within one sac suggested monochorionicity, and was confirmed by follow-up ultrasound and placental pathology. The various ARTs were compared to determine if any method had an increased incidence of monochorionicity compared to any other method. Statistical analysis was performed employing Chi Square analysis. RESULTS: The incidence of monochorionicity in all gestations was 3.2% (8 times background rate); among multiple gestations it was 9.8%. The rates of monochorionicity for each ART appeared similar. CONCLUSION: The incidence of monochorionic twinning is increased in pregnancies resulting from ART. Careful ultrasound evaluation of such pregnancies for monochorionicity is strongly recommended, both for planning of prenatal care and when considering a multifetal pregnancy reduction procedure.