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Short and long-term weight reduction interventions are considered in the preconception period for women and men with obesity and infertility as obesity is associated with poorer reproductive outcomes. Short-term weight loss achieved with diet, exercise, and medications does not improve per cycle conception or live birth rates in women undergoing ovulation induction, intrauterine insemination, or in vitro fertilization (IVF), but may increase the rate of natural conception. Long-term weight loss achieved through surgical interventions may increase spontaneous conceptions, particularly among women with polycystic ovary syndrome, and may increase the live birth rate from IVF, though these findings are limited by recent evidence. There is a clear need for additional treatment options and well-designed weight loss intervention trials that address the heterogeneous causes of obesity among women and men with infertility and include fertility outcomes and perinatal morbidity as outcome measures. [ABSTRACT FROM AUTHOR]

Objective: To determine if short-term weight change among women with unexplained infertility (UI) and polycystic ovary syndrome (PCOS) undergoing ovulation induction is associated with live birth.Design: Secondary analysis of randomized trials.Setting: Multicenter fertility trial sites.Patient(s): A total of 900 women with UI and 750 women with PCOS.Main Outcome Measure(s): Live birth.Intervention(s): Weight assessment at enrollment and start of up to 4-5 cycles of clomiphene, letrozole, or gonadotropins and intrauterine insemination for women with UI and clomiphene or letrozole with regular intercourse for women with PCOS.Result(s): Weight data were available for 856 women with UI and 697 women with PCOS. Mean weight change was -0.2 ± 0.3 kg among women with UI and +2.2 ± 0.2 kg among women with PCOS and did not differ based on treatment allocation. There were 115 women with PCOS (16.4%) who gained ≥3 kg. Increased body mass index and three or more cycles were associated with weight gain in women with PCOS. There was no difference in live birth rate among women with PCOS and ≥3 kg weight gain and women with PCOS who did not gain weight.Conclusion(s): Women with PCOS gained an average of 2.2 kg regardless of the medication received, whereas women with UI experienced no short-term weight change during ovulation induction. Weight gain in women with PCOS was not associated with live birth rate. [ABSTRACT FROM AUTHOR]

Chronic kidney disease (CKD) affects hypothalamic-pituitary-gonadal axis function, leading to menstrual abnormalities, sexual dysfunction, functional menopause, and loss of fertility. Pregnancy in a patient with CKD is associated with a higher risk of complications to both the mother and the fetus, highlighting the importance of contraceptive counseling at all stages of CKD. There has been limited research on the safety and efficacy of different contraceptive methods in the CKD population, and it is important to tailor the choice of contraception to the patient's lifestyle and comorbidity status. Cyclophosphamide is a commonly used immunosuppressive agent that impairs fertility in a dose-dependent fashion, with greater impact in older women of child-bearing age. Strategies to reduce the impact of cyclophosphamide on ovarian reserve as well as fertility preservation technologies are options to consider when treating immune-mediated CKD. A multidisciplinary approach in counseling the woman with CKD who wishes to contemplate or avoid pregnancy is necessary to optimize outcomes. Further research in this important area is required. [ABSTRACT FROM AUTHOR]

Polycystic ovary syndrome (PCOS) is a complex lifelong disorder with an etiology and pathophysiology that is not yet entirely understood. Women with PCOS have clinical presentations that may vary from adolescence to menopause, including menstrual irregularity/anovulation and symptoms of hyperandrogenism, such as acne and hirsutism. Over a lifetime, treatment needs and requirements can change. Unfortunately, there are no Food and Drug Administration–approved medications that are approved solely for the purpose of PCOS, but the symptoms and presentation of PCOS are often amenable to several approved agents, such as oral contraceptives for the indication of acne and clomiphene citrate for the indication of induction of ovulation. However, to meet the needs of women with PCOS, off-label use of medications has flourished. This review explores the data for those agents that do not carry an indication for PCOS but have been used for treating the signs and symptoms of PCOS. [ABSTRACT FROM AUTHOR]

Objective: To evaluate the laboratory and clinical outcomes of estrogen-suppressed in vitro maturation (ES-IVM), a novel IVM protocol that eliminates the need for FSH stimulation and cycle monitoring. Design: Case series. Setting: Academic infertility center. Patient(s): Eighteen infertile couples undergoing ES-IVM (n = 20). Eligible candidates included women ≤ 38 years old with eith polycystic ovarian syndrome, antral follicle count ≥ 15, and/or history of ovarian hyperstimulation syndrome. Intervention(s): ES-IVM. Main Outcomes Measure(s): 0ocyte yield, maturation, fertilization, embryo quality, implantation, clinical pregnancy, and live-birth rate were analyzed. Result(s): The average number of oocytes retrieved was 16.7 ± 5.9, with a 52.1% maturation rate and a 58% fertilization rate by intracytoplasmic sperm injection. The average number of embryos transferred was 2.85 4 ± 0.6. The implantation rate was 17.5%, the clinical pregnancy rate was 40%, and the live-birth rate was 40%. clinical pregnancy rate was 40%, and the live-birth rate was 40%. Conclusion(s): The efficiency of ES-IVM appears to be similar to natural cycle an low-stimulation 1VM protocols with respect to laboratory and clinical outcomes, while eliminating the need for FSH stimulation and cycle monitoring. [ABSTRACT FROM AUTHOR]

Abstract: Objective: To assess vaccine eligibility and factors associated with vaccine acceptance among ambulatory obstetric and gynecologic patients. Methods: An anonymous office-based survey was administered to women seeking ambulatory obstetric and gynecologic care at a large women''s hospital from December 2007 to July 2008. Information collected included: demographics, medical and vaccination history, interest in receiving vaccines and attitudes towards vaccine providers. Vaccine eligibility was based on age and/or self-reported risk factors in accord with the 2007–2008 Center for Disease Control and Prevention (CDC) adult immunization schedule. Vaccine eligibility was examined using descriptive statistics, and demographic characteristics were compared using chi-squared analysis. A multivariable logistic regression model was developed to assess factors associated with participants’ willingness to accept vaccines from their obstetrician–gynecologist. Results: A total of 1441 women completed the survey. The majority of participants (87%) would accept vaccines if recommended by their obstetrician–gynecologist. The primary factors associated with vaccine acceptance were having less than a high school education, being privately insured, currently being pregnant, reporting a history of vaccinations and previously receiving vaccinations from an obstetrician–gynecologist. A significant portion of participants were eligible for the hepatitis B, influenza and HPV vaccines (≥50% for each). The type of vaccine did not influence willingness to accept vaccines from an obstetrician–gynecologist. Conclusion: A majority of women appear eligible for, and will accept, vaccinations regardless of specific vaccine, if recommended by their obstetrician–gynecologist. These findings justify ongoing efforts to expand immunization services offered by obstetrician–gynecologists. [Copyright &y& Elsevier]

Objective: To compare leuprolide acetate to hCG as the trigger for final oocyte maturation in oocyte donor cycles. Design: Retrospective review. Setting: Academic IVF donor program. Patient(s): Thirty-two healthy oocyte donors aged 21–33 years with adequate ovarian reserve. Intervention(s): Donors were down-regulated with cetrorelix and received either leuprolide acetate (n = 12) or hCG (n = 20) for final oocyte maturation. Main Outcome Measure(s): Embryo number, embryo quality, fertilization, implantation, clinical pregnancy, and ovarian hyperstimulation syndrome rates. Result(s): The numbers of total oocytes (23 vs. 15), mature (metaphase II) oocytes (22 vs. 13), embryos (15 vs. 10), and cryopreserved embryos (12 vs. 6) per treatment cycle were significantly greater in the leuprolide arm than in the hCG arm. Fertilization rates (73% vs. 78%), implantation rates (30% vs. 29%), and clinical pregnancy rates (40% vs. 50%) were not statistically different between the arms. There were no cases of ovarian hyperstimulation syndrome. Conclusion(s): Leuprolide acetate–triggered oocyte donor cycles yielded similar fertilization, implantation, and clinical pregnancy rates to hCG-triggered cycles. [Copyright &y& Elsevier]

Background: Antimüllerian hormone is produced by small antral follicles and reflects ovarian reserve. Obesity is associated with lower serum antimüllerian hormone, but it is unclear whether lower levels of antimüllerian hormone in women with obesity reflect lower ovarian reserve.Objective: To determine whether lower antimüllerian hormone in women with obesity undergoing in vitro fertilization is associated with oocyte yield and live-birth rate.Materials and Methods: Retrospective cohort from the Society for Assisted Reproductive Technology Clinic Outcome Reporting System database of 13,316 women with obesity and 16,579 women with normal body mass index undergoing their first autologous in vitro fertilization with fresh transfers between 2012 and 2014. Normal body mass index was defined as body mass index 18.5-24.9 kg/m2, and obesity was defined as body mass index ≥30 kg/m2. Subjects with obesity were stratified as those with class 1 obesity (body mass index, 30.0-34.9 kg/m2), class 2 obesity (body mass index, 35.0-39.9 kg/m2), and class 3 obesity (body mass index, ≥40 kg/m2) based on the World Health Organization body mass index guidelines. Antimüllerian hormone levels were stratified as normal (>1.1 ng/mL), low (0.16-1-1 ng/mL), and undetectable (≤0.16 ng/mL). Multivariable modeling was used to assess oocyte yield using linear regression with a logarithmic transformation and odds of live birth using logistic regression.Results: Women with obesity were older (36.0 ± 4.8 vs 35.5 ± 4.8, P < .001), had lower antimüllerian hormone (1.8 ± 2.0 ng/mL vs 2.1 ± 2.0 ng/mL, P < .001), and had fewer oocytes retrieved (11.9 ± 7.3 vs 12.8 ± 7.7, P < .001) than women with normal body mass index. Lower oocyte yield was observed among women with obesity and normal antimüllerian hormone levels compared to women with normal body mass index and normal antimüllerian hormone levels (13.6 ± 7.3 vs 15.8 ± 8.1, P < .001). No difference in oocyte yield was observed among women with obesity and low antimüllerian hormone levels (P = .58) and undetectabl antimüllerian hormone (P = .11) compared to women with normal BMI and similar antimüllerian hormone levels. Among women with a body mass index ≥30 kg/m2, antimüllerian hormone levels were associated with the number of oocytes retrieved (β = 0.069; standard error, 0.005; P < .001) but not live-birth rate (odds ratio, 0.98; 95% confidence interval, 0.93-1.04, P = .57).Conclusion: Lower antimüllerian hormone in infertile women with obesity appears to reflect lower ovarian reserve, as antimüllerian hormone is associated with lower oocyte yield. Despite lower oocyte yield, lower antimüllerian hormone was not associated with lower live-birth rate among women with obesity. [ABSTRACT FROM AUTHOR]

The prevalence of obesity has doubled among reproductive-age adults in the US over the past 40 years and is projected to impact half of the population by 2030. Obesity is associated with a twofold to threefold increase in infertility, largely because of anovulation, and is associated with a lower rate of pregnancy with ovulation induction among anovulatory women. As a result of these trends and associations, in vitro fertilization (IVF) care will need to be adapted to provide safe, effective, and equitable access for patients with obesity. Research over the past 10 years has demonstrated safe sedation practices and effective procedure modifications for oocyte retrievals and embryo transfers in patients with obesity undergoing IVF treatment. We encourage IVF medical directors to revisit body mass index restrictions for IVF treatment in favor of individualized patient risk assessments to minimize weight bias and provide timely access to safe and effective IVF care for patients with obesity and infertility. [ABSTRACT FROM AUTHOR]

Background: Human epididymis protein 4 is a serum biomarker to aid in differentiating benign and malignant disease in women with a pelvic mass. Interpretation of human epididymis protein 4 results relies on robust normative data.Objective: The purpose of this study was to evaluate whether human epididymis protein 4 levels are variable in women during the normal menstrual cycle.Study Design: Healthy women, 18-45 years old, with regular menstrual cycles were recruited from community gynecologic practices in Rhode Island. Women consented to enroll and to participate by the donation of blood and urine samples at 5 specific times over the course of each cycle. Levels of reproductive hormones and human epididymis protein 4 were determined. Data were analyzed with the use of linear regression after log transformation.Results: Among 74 enrolled cycles, 53 women had confirmed ovulation during the menstrual cycle and completed all 5 sample collections. Levels of estradiol, progesterone, and luteinizing hormone displayed the expected menstrual cycle patterns. Levels of human epididymis protein 4 in serum were relatively stable across the menstrual cycle, except for a small ovulatory (median, 37.0 pM) increase. Levels of human epididymis protein 4 in urine, after correction for creatinine, displayed the same pattern of secretion observed in serum.Conclusion: Serum human epididymis protein 4 levels are relatively stable across the menstrual cycle of reproductive-aged women and can be determined on any day to evaluate risk of ovarian malignancy. A slight increase is expected at ovulation; but even with this higher human epididymis protein 4 level, results are well within the healthy reference range for women (<120 pM). Levels of human epididymis protein 4 in urine warrant further investigation for use in clinical practice as a simple and convenient sample. [ABSTRACT FROM AUTHOR]

Chronic pelvic pain can result from noncommunicating uterine cavities in patients with müllerian anomalies. Traditional management has been to resect the noncommunicating uterine horn. Two cases are described. One had a unicornuate uterus with noncommunicating left uterine horn (American Fertility Society [AFS] classification IIb) and the other had a normal external uterine contour with noncommunicating left uterine cavity that did not fit any category of the AFS classification of müllerian anomalies. Attempts at connecting the noncommunicating cavities hysteroscopically failed in both cases. Successful unification of the cavities was subsequently achieved in the first case using the classic Strassman metroplasty with the assistance of the robot. The unification of uterine cavities was achieved using a modified Strassman metroplasty in the second patient, as there was no uterine horn for landmark. Robot assistance was utilized in this case as well. Both patients are symptom free after surgery. We conclude that laparoscopic Strassman metroplasty, with or without robot assistance, is a viable alternative to resection of uterine horns in patients with hematometra, chronic pelvic pain, and noncommunicating uterine cavities. [ABSTRACT FROM AUTHOR]

Objective To determine whether concurrent use of GnRH agonists with chemotherapy preserves ovarian function in women with breast cancer who did not use tamoxifen. Design Systematic review and meta-analysis. Setting University-based hospitals. Patient(s) Premenopausal women with breast cancer treated with chemotherapy who did not receive tamoxifen. Intervention(s) Randomization to concurrent GnRH agonists with chemotherapy or chemotherapy alone. Main Outcome Measure(s) Odds ratio (OR) of resumption of menses 1 year or more after chemotherapy. Result(s) Searches were conducted in PubMed, Scopus, Cochrane Trials Register, and the National Research Register through March 2014, and all randomized trials that reported resumption of menses 1 year or more after GnRH agonist with chemotherapy or chemotherapy alone among women with breast cancer who did not receive tamoxifen were included. Four studies were analyzed in the meta-analysis and included 252 patients (GnRH agonist with chemotherapy, n = 131; chemotherapy alone, n = 121). There was no significant difference in the rate of return of menses between the two groups (OR, 1.47; 95% confidence interval [0.60–3.62]). Heterogeneity among the trials was not significant ( I 2 = 16.6%). Conclusion(s) Concurrent GnRH agonists with chemotherapy may not preserve ovarian function in women with breast cancer. Furthermore, randomized data are limited regarding fertility after concurrent use of GnRH agonists with chemotherapy. [ABSTRACT FROM AUTHOR]

Objective: To determine the cost-effectiveness of split IVF-intracytoplasmic sperm injection (ICSI) for the treatment of couples with unexplained infertility. Design: Adaptive decision model. Setting: Academic infertility clinic. Patient(s): A total of 154 couples undergoing a split IVF-ICSI cycle and a computer-simulated cohort of women <35 years old with unexplained infertility undergoing IVF. Intervention(s): Modeling insemination method in the first IVF cycle as all IVF, split IVF-ICSI, or all ICSI, and adapting treatment based on fertilization outcomes. Main Outcome Measure(s): Live birth rate, incremental cost-effectiveness ratio (ICER). Result(s): In a single cycle, all IVF is preferred as the ICER of split IVF-ICSI or all ICSI ($58,766) does not justify the increased live birth rate (3%). If two cycles are needed, split IVF/ICSI is preferred as the increased cumulative live birth rate (3.3%) is gained at an ICER of $29,666. Conclusion(s): In a single cycle, all IVF was preferred as the increased live birth rate with split IVF-ICSI and all ICSI was not justified by the increased cost per live birth. If two IVF cycles are needed, however, split IVF/ICSI becomes the preferred approach, as a result of the higher cumulative live birth rate compared with all IVF and the lesser cost per live birth compared with all ICSI. [Copyright &y& Elsevier]

Objective: To evaluate factors associated with elective single-embryo transfer (eSET) utilization and its effect on assisted reproductive technology outcomes in the United States.Design: Historical cohort.Setting: Not applicable.Patient(s): Fresh IVF cycles of women aged 18-37 years using autologous oocytes with either one (SET) or two (double-embryo transfer [DET]) embryos transferred and reported to the Society for Assisted Reproductive Technology Clinic Outcome Reporting System between 2004 and 2012. Cycles were categorized into four groups with ([+]) or without ([-]) supernumerary embryos cryopreserved. The SET group with embryos cryopreserved was designated as eSET.Intervention(s): None.Main Outcomes Measure(s): The likelihood of eSET utilization, live birth, and singleton non-low birth weight term live birth, modeled using logistic regression. Presented as adjusted odds ratios (aORs) and 95% confidence intervals (CIs).Result(s): The study included 263,375 cycles (21,917 SET[-]cryopreservation, 20,996 SET[+]cryopreservation, 103,371 DET[-]cryopreservation, and 117,091 DET[+]cryopreservation). The utilization of eSET (SET[+]cryopreservation) increased from 1.8% in 2004 to 14.9% in 2012 (aOR 7.66, 95% CI 6.87-8.53) and was more likely with assisted reproductive technology insurance coverage (aOR 1.60, 95% CI 1.54-1.66), Asian race (aOR 1.26, 95% CI 1.20-1.33), uterine factor diagnosis (aOR 1.48, 95% CI 1.37-1.59), retrieval of ≥16 oocytes (aOR 2.85, 95% CI 2.55-3.19), and the transfer of day 5-6 embryos (aOR 4.23, 95% CI 4.06-4.40); eSET was less likely in women aged 35-37 years (aOR 0.76, 95% CI 0.73-0.80). Compared with DET cycles, the likelihood of the ideal outcome, term non-low birth weight singleton live birth, was increased 45%-52% with eSET.Conclusion(s): Expanding insurance coverage for IVF would facilitate the broader use of eSET and may reduce the morbidity and healthcare costs associated with multiple pregnancies. [ABSTRACT FROM AUTHOR]

Objective: To investigate the association of non-cavity-distorting uterine fibroids and pregnancy outcomes after ovarian stimulation-intrauterine insemination (OS-IUI) in couples with unexplained infertility.Design: Secondary analysis from a prospective, randomized, multicenter clinical trial investigating fertility outcomes after OS-IUI.Setting: Reproductive Medicine Network clinical sites.Patient(s): Nine hundred couples with unexplained infertility who participated in the Assessment of Multiple Intrauterine Gestations from Ovarian Stimulation (AMIGOS) clinical trial.Intervention(s): Participants were randomized to one of three arms (clomiphene citrate, letrozole, or gonadotropins), and treatment was continued for up to four cycles or until pregnancy was achieved.Main Outcomes Measure(s): Conception (serum hCG increase), clinical pregnancy (fetal cardiac activity), and live birth rates.Result(s): A total of 102/900 participants (11.3%) had at least one documented fibroid and a normal uterine cavity. Women with fibroids were older, more likely to be African American, had a greater uterine volume, lower serum antimüllerian hormone levels, and fewer antral follicles than women without fibroids. In conception cycles, clinical pregnancy rates were significantly lower in participants with fibroids than in those without uterine fibroids. Pregnancy loss before 12 weeks was more likely in African American women with fibroids compared with non-African American women with fibroids. There was no difference in conception and live birth rates in subjects with and without fibroids.Conclusion(s): No differences were observed in conception and live birth rates in women with non-cavity-distorting fibroids and those without fibroids. These findings provide reassurance that pregnancy success is not impacted in couples with non-cavity-distorting fibroids undergoing OS-IUI for unexplained infertility.Clinical Trial Registration Number: NCT01044862. [ABSTRACT FROM AUTHOR]