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Bilateral tubal ectopic pregnancies (BTP) are the rarest form of ectopic pregnancy. They are difficult to diagnose preoperatively, and an evidence-based guideline for management does not exist. In this report, we discuss a 35-year-old patient who presented with suspected right tubal ectopic pregnancy. BTP was diagnosed intraoperatively, and a laparoscopic bilateral salpingectomy was performed without complication. The diagnosis was subsequently confirmed by pathology. This case highlights the importance of patient counseling and comprehensive preoperative planning. Due to the poor presurgical diagnosis of BTP, patient counseling should include the possibility of BTP, appropriate options for management, and potential loss of fertility following treatment. In addition, all cases of suspected ectopic pregnancy necessitate a thorough preoperative investigation of bilateral adnexa and intraoperative inspection of the pelvis.

Objective To present a case of abnormally trending hCG levels due to ovarian hyperstimulation syndrome (OHSS) and to portray the obscurities of this commonly used method for tracking early pregnancies. Design Case report. Setting Outpatient ART facility. Patient A patient who received controlled ovarian hyperstimulation in an ART cycle. Intervention Supportive care. Main outcome measure hCG level. Result The hCG levels in this patient with OHSS trended in an abnormal fashion, suggesting a failing or ectopic pregnancy, but the patient had a normal intrauterine fetus. Conclusion hCG levels may be falsely low in pregnancies complicated by OHSS., Highlights • Levels of human chorionic gonadotropin are affected by the fluid dynamics in ovarian hyperstimulation syndrome. • In ovarian hyperstimulation syndrome, human chorionic gonadotropin values do not follow normal trends. • Caution is warranted before diagnosing an abnormal early pregnancy in patients with ovarian hyperstimulation syndrome.

There is an abnormal increase in TGF-β1 bioavailability in women with polycystic ovary syndrome (PCOS), which might play a role in the pathophysiology of this syndrome. Vitamin D (VD) supplementation improves various clinical manifestations of PCOS and decreases TGF-β1 levels in several diseases including myelofibrosis.The objective of the study was to determine the effect of VD supplementation on TGF-β1 bioavailability in VD-deficient women with PCOS and assess whether changes in TGF-β1/soluble endoglin (sENG) levels correlate with an improvement in PCOS clinical manifestations.This was a prospective, randomized, placebo-controlled trial.The study was conducted at an academic-affiliated medical center.Sixty-eight VD-deficient women with PCOS who were not pregnant or taking any exogenous hormones were recruited between October 2013 and January 2015.Forty-five women received 50 000 IU of oral vitamin D3 and 23 women received oral placebo once weekly for 8 weeks.Serum TGF-β1, sENG, lipid profile, testosterone, dehydroepiandrosterone sulfate, and insulin resistance were measured. The clinical parameters were evaluated before and 2 months after treatment.The VD level significantly increased and normalized after VD supplementation (16.3 ± 0.9 [SEM] to 43.2 ± 2.4 ng/mL; P.01), whereas it did not significantly change after placebo. After the VD supplementation, there was a significant decrease in the following: the interval between menstrual periods (80 ± 9 to 60 ± 6 d; P = .04), Ferriman-Gallwey score (9.8 ± 1.5 to 8.1 ± 1.5; P.01), triglycerides (138 ± 22 to 117 ± 20 mg/dL; P = .03), and TGF-β1 to sENG ratio (6.7 ± 0.4 to 5.9 ± 0.4; P = .04). In addition, the ΔTGF-β1 to sENG ratio was positively correlated with Δtriglycerides (r = 0.59; P = .03).VD supplementation in VD-deficient women with PCOS significantly decreases the bioavailability of TGF-β1, which correlates with an improvement in some abnormal clinical parameters associated with PCOS. This is a novel mechanism that could explain the beneficial effects of VD supplementation in women with PCOS. These findings may support new treatment modalities for PCOS, such as the development of anti-TGF-β drugs.

The pro-inflammatory advanced glycation end products (AGEs) and their anti-inflammatory soluble receptors, sRAGE, play a role in the pathogenesis of PCOS. There is a correlation between vitamin D (vit D) and sRAGE in the serum, whereby vit D replacement increases serum sRAGE levels in women with PCOS, thus incurring a protective anti-inflammatory role. This study aims to compare levels of sRAGE, N-carboxymethyl-lysine (CML; one of the AGEs), and 25-hydroxy-vit D in the follicular fluid (FF) of women with or without PCOS, and to evaluate the correlation between sRAGE and 25-hydroxy-vit D in the FF. Women with (n = 12) or without (n = 13) PCOS who underwent IVF were prospectively enrolled. Women with PCOS had significantly higher anti-Mullerian hormone levels, higher number of total retrieved and mature oocytes, and higher number of day 3 and day 5 embryos formed. Compared to women without PCOS, women with PCOS had significantly lower FF sRAGE levels. In women with PCOS, in women without PCOS, and in all participants together, there was a significant positive correlation between sRAGE and 25-hydroxy-vit D. sRAGE positively correlated with CML in women without PCOS but not in women with PCOS. In women with PCOS, the low ovarian levels of the anti-inflammatory sRAGE suggest that sRAGE could represent a biomarker and a potential therapeutic target for ovarian dysfunction in PCOS. Whether there is a direct causal relationship between sRAGE and vit D in the ovaries remains to be determined.

Vascular endothelial growth factor (VEGF) has been suggested to play a role in the pathophysiology of polycystic ovary syndrome (PCOS) and may contribute to increased risk of ovarian hyperstimulation syndrome (OHSS) in affected individuals. Vitamin D (VitD) supplementation improves multiple clinical parameters in VitD-deficient women with PCOS and decreases VEGF levels in several other pathologic conditions. Unveiling the basic mechanisms underlying the beneficial effects of vitamin D on PCOS may enhance our understanding of the pathophysiology of this syndrome. It may also suggest a new treatment for PCOS that can improve it through the same mechanism as vitamin D and can be given regardless of vitamin D levels. Therefore, we aimed to explore the effect of VitD supplementation on serum VEGF levels and assess whether changes in VEGF correlate with an improvement in characteristic clinical abnormalities of PCOS. This is a randomized placebo-controlled trial conducted between October 2013 and March 2015. Sixty-eight VitD-deficient women with PCOS were recruited. Women received either 50,000 IU of oral VitD3 or placebo once weekly for 8 weeks. There was a significant decrease in serum VEGF levels (1106.4 ± 36.5 to 965.3 ± 42.7 pg·mL–1; p < 0.001) in the VitD group. Previously reported findings of this trial demonstrated a significant decrease in the intermenstrual intervals, Ferriman-Gallwey hirsutism score, and triglycerides following VitD supplementation. Interestingly, ∆VEGF was positively correlated with ∆triglycerides (R2 = 0.22; p = 0.02) following VitD supplementation. In conclusion, VitD replacement significantly decreases serum VEGF levels correlating with a decrease in triglycerides in women with PCOS. This is a novel molecular explanation for the beneficial effects of VitD treatment. It also suggests the need to investigate a potential role of VitD treatment in reducing the incidence or severity of OHSS in VitD-deficient women with PCOS.

Introduction Like other countries, Poland relies on the altruism of potential kidney donors but has an insufficient number of organs available to meet the growing need for organ transplantation. Aim We investigate the ethics of non-altruistic kidney donations from the perspective of Jewish Medical Ethics, and consider how that ethic might work to alleviate the shortage in donations currently experienced by Poland and other countries. Discussion Jewish medical ethics outlines a nuanced response to this shortage, suggesting that the requirement for organs to be donated without any commercial consideration may be modified to allow compensating an organ donor for his or her time, discomfort, inconvenience and recovery. Compensating an organ donor is fully consistent with traditional Judaism's moral code and does not detract from the ethical quality of the donation. Conclusions While non-altruistic sale of kidneys might be theoretically acceptable, it requires creating a state system to insure that potential donors are properly informed and not exploited; that medical screening and support of the donors to insure that their health is not permanently endangered is provided; that vulnerable potential donors are protected; and that payments are regulated so that they reasonably reflect compensation for pain and suffering.

This study evaluated anti-Mullerian hormone (AMH) as a possible predictor of twin pregnancy in women undergoing fresh cycles who had more than one embryo transferred. A retrospective study was performed of 139 patients undergoing fresh non-donor cycles which resulted in either singleton or twin pregnancy between 2009 and 2010 in this fertility clinic. Random serum AMH and other clinically relevant variables were compared. For further analysis, the population was stratified by age (

Objective To investigate the association between elevated body mass index (BMI) and ovarian reserve. Design Cross-sectional study. Setting Academic institutions. Patient(s) Two hundred ninety women with infertility. Diminished ovarian reserve (DOR) was defined as day 3 FSH >10 IU/L. Intervention(s) None. Main Outcome Measure(s) Random serum antimullerian hormone (AMH) levels and number of oocytes retrieved during assisted reproductive technology cycle. Result(s) Increasing BMI was associated with lower random serum AMH levels in infertile women with DOR but not in women with normal ovarian reserve (NOR). Among women with DOR, mean random serum AMH levels were 33% lower in overweight and obese women compared with women with normal weight. The same association was not true for women with NOR. Out of 290 women evaluated for infertility, 109 women underwent a controlled ovarian hyperstimulation (COH)–IVF cycle. Women with elevated BMI and DOR had lower number of oocytes retrieved compared with women with normal BMI and DOR (6.4 ± 4.3 vs. 9.4 ± 6), an association that was not observed among women with NOR. Conclusion(s) Overweight and obese women with DOR as defined by high day 3 serum FSH levels have lower serum AMH levels and number of oocytes retrieved compared with nonobese women with DOR.

Infertility counseling is a specialized field that will continue to grow in coming years as the impact of infertility and its treatment is documented more and more in terms of emotional, physical, social and life consequences. Counselors should anticipate issues that may arise in the future and assist couples in their efforts to address them. We report here on recordkeeping issues of possible future concern that should be addressed when Orthodox Jewish couples make use of donor eggs. Good medical practice values the importance of understanding the patient's individual concerns and values, including the complex psychological, sociological and cultural context in which they experience their infertility. Good counseling anticipates and addresses future problems about which patients might not currently be aware.

We report here on recent developments in Israel on the issue of sex selection for nonmedical reasons by preimplantation genetic diagnosis (PGD). Sex selection for medical reasons (such as in cases of sex-linked genetic diseases) is generally viewed as uncontroversial and legal in European and American law. Its use for nonmedical reasons (like “balancing” the gender ratio in a family) is generally illegal in European countries. In the United States, it is not illegal, although in the opinion of the Ethics Committee of the American Society for Reproductive Medicine (ASRM), it is problematic. This position is undergoing reconsideration, albeit in a limited way.

There is a spectrum of attitudes within the Orthodox Jewish community towards genetic testing and PGD. Increased understanding of the belief systems of the Orthodox Jewish population will enhance the genetic counselors’ ability to better serve this unique group of patients. By improving cultural competence, genetic counselors can help patients choose the testing options that they deem appropriate, while simultaneously respecting the patient’s belief system.

Infertility counseling is a specialized field that will continue to grow in coming years as the impact of infertility and its treatment is documented more in terms of emotional, physical, social and life consequences. We report here on more recent developments in halakha (Jewish law and ethics) that are of importance to Orthodox Jewish infertile couple considering donor gametes or surrogacy. Counselors should anticipate issues that may arise in the future and assist couples in their efforts to address them. Good medical practice values the importance of understanding the patient’s individual concerns and values, including the complex psychological, sociological and cultural context in which they experience their infertility. Good counseling anticipates and addresses future problems about which patients might not currently be aware, and requires up-to-date authoritative information.

Ovarian stimulation increases the risk of ovarian torsion. During an in vitro fertilization (IVF) cycle, the effects of ovarian torsion on retrieved oocytes and subsequent pregnancy chances are not clear. Moreover, no cases of ovarian torsion occurring following oocyte retrieval but prior to same-cycle embryo transfer have been reported. Such cases present a clinical dilemma with respect to optimal timing of embryo transfer. We report two cases of a 41-year-old and a 32-year-old infertility patients undergoing IVF who were diagnosed with ovarian torsion within several days following oocyte retrieval. Both patients were treated by early laparoscopic evaluation and detorsion followed by day five embryo transfer, resulting in successful pregnancies. Therefore, after prompt laparoscopic ovarian untwisting of a torsed ovary following egg retrieval, embryo transfer may be performed as originally scheduled during the concurrent cycle leading to favorable pregnancy outcomes.

BACKGROUND Peritoneal mesothelioma is regarded as a fatal disease that presents with progressive ascites in a relatively late stage of its natural history. To the authors' knowledge, prior published articles have not described the early manifestations of this cancer. METHODS A 30-year-old asymptomatic woman underwent laparoscopy for an infertility workup. Nodules noted in the pelvis were biopsied and determined to be mesothelioma. Standard immunohistochemical studies were performed. Cytoreductive surgery and heated intraoperative intraperitoneal chemotherapy were used for treatment. RESULTS Multiple (approximately 30) tumor nodules up to 2 mm in dimension and limited to the pelvis were observed and resected. No primary tumor focus was evident. These tumor nodules stained positive for Calretinin and negative for carcinoembryonic antigen immunohistochemically. CONCLUSIONS In this patient, no incidence for transcoelomic dissemination of mesothelioma from a single primary site was observed. Rather, this patient's clinical presentation suggested that mesothelioma may be multifocal in origin within a limited region of the peritoneal cavity. This hypothesis may support a rationale for aggressive local-regional management of selected patients in whom peritoneal mesothelioma is of limited distribution and mass. Cancer 2000;89:1279–84. © 2000 American Cancer Society.

Objective: To determine the incidence of early-pregnancy bleeding and spontaneous abortion (SAB) after various treatments for infertility and to assess whether bleeding is predictive of SAB. Design: An historic cohort study of women who conceived after various treatments. Setting: Hospital-based private practice. Patient(s): We studied 418 patients in whom 500 consecutive clinical pregnancies occurred. Intervention(s): Patients were grouped according to the method of conception: ovulation induction, IVF, and other. The latter category included interventions not requiring ovulation induction, such as surgery and insemination. A fourth group of subjects who conceived independently of treatment was used as the control. Main Outcome Measure(s): Bleeding and pregnancy outcome (SAB, ectopic pregnancy, or ongoing pregnancy). Result(s): Rates of SAB did not differ among the treatment groups. SAB occurred significantly more often after bleeding than when bleeding did not occur (30.8% versus 19.8%, respectively). Bleeding was predictive of SAB only in patients Conclusion(s): Infertile women who conceive after reproductive therapy are not at increased risk for SAB compared with women who conceive naturally. There appears to be no association between previous diagnosis or treatment and the occurrence of SAB in previously infertile women. Bleeding is associated with a twofold relative risk of SAB.

Serum Antimüllerian hormone (AMH) levels are elevated in polycystic ovarian syndrome and have been shown to be useful in its diagnosis. However, the clinical significance of extremely high AMH levels is understudied. We aimed to characterize a population of women with elevated AMH (5 ng/mL).This was a retrospective cohort study of 134 women presenting to our fertility clinic for infertility evaluation and treatment who were found to have random serum AMH over 5 ng/mL. Women were divided into 3 groups according to AMH: 5-10 ng/mL,10-14 ng/mL, and14 ng/mL. Endocrine characteristics, polycystic ovarian syndrome (PCOS) phenotypes, fertilization rate, implantation rate, clinical pregnancy, and multiple pregnancy rates were compared between groups.AMH ranged between 5 to 48 ng/mL. Greater than 97% of women with ultrahigh AMH (10 ng/mL) had PCOS. In addition, women with AMH10 ng/mL had greater prevalence of polycystic ovarian morphology and oligoamenorrhea than women with AMH 5-10 ng/mL. Moreover, serum AMH correlated positively with luteinizing hormone, total testosterone, and dehydroepiandrosterone sulfate. Furthermore, AMH showed strong predictive ability for the presence of amenorrhea (area under the curve, 0.87; 95% confidence interval, 0.80-0.92; P.0001). Despite similar age and mean number of transferred embryos, women with AMH10 ng/mL showed higher rates of ovarian hyperstimulation syndrome and clinical pregnancy rates compared with women with AMH 5-10 ng/mL.These data characterize a population of women with elevated AMH levels, demonstrating that the vast majority of women with AMH10 ng/mL have PCOS. Increased AMH levels correlated with PCOS severity and are associated with greater ovarian stimulation and higher clinical pregnancy rates following assisted reproductive technology.

Objective To evaluate the relationship between transforming growth factor (TGF)-β1 and its receptor, soluble endoglin (sENG), in the serum and follicular fluid of women with polycystic ovarian syndrome (PCOS) compared with that of non-PCOS normal ovulating women during controlled ovarian stimulation (COS). Design Prospective case-control study. Setting Academic-affiliated assisted reproductive technology unit. Patient(s) Fourteen PCOS and 14 matched non-PCOS control women undergoing COS. Intervention(s) Serum was collected on day 3 (baseline), day of hCG, and day of retrieval. Follicular fluid (FF) was collected on day of oocyte retrieval. ELISA was performed to determine TGF-β1 and sENG protein levels. Main Outcome Measure(s) Serum and FF levels of TGF-β1 and sENG. Result(s) Serum TGF-β1 did not change significantly during COS but was increased in PCOS compared with non-PCOS women on day 3 and days of hCG administration and oocyte retrieval. Serum sENG increased after hCG administration only in the non-PCOS control group. In addition, serum sENG was decreased in PCOS compared with non-PCOS control women on the days of hCG and retrieval. Accordingly, the bioavailability of TGF-β1 (TGF-β1/sENG ratio) was increased in women with PCOS compared with non-PCOS controls at all three time points. No differences in either factor were noted in FF between groups. Conclusion(s) The increased TGF-β1 bioavailability in PCOS is not only due to increased TGF-β1 levels but also to decreased levels of its receptor, sENG. These data suggest that increased TGF-β1 bioavailability may contribute to the pathogenesis of PCOS and its increased risk for ovarian hyperstimulation.

This article recapitulates and extends a discussion of the position of halakhic Judaism (traditional Jewish law and ethics) on various issues that relate to assisted reproduction, including genetic and legal relationships, disposal of untransplanted embryos, embryo tissue research, multifetal pregnancy reduction, preimplantation genetic screening and sex selection and donor gametes.

We report here on the cultural reasons motivating some idiosyncratic requests from married Orthodox Jewish women to delay ovulation. Understanding and respecting the patient's individual concerns and religious values, including the complex psychological, sociological and cultural factors that they involve, is part of good medical practice.

Objective To investigate the utility of random anti-Mullerian hormone (AMH) in assessing ovarian response among women with diminished ovarian reserve (DOR) diagnosed by elevated early follicular-phase FSH levels. Design Retrospective study. Setting Academic and academically affiliated assisted reproductive technology (ART) programs. Patient(s) Seventy-three women undergoing ART with elevated early follicular FSH levels. Intervention(s) None. Main Outcome Measure(s) Number of oocytes retrieved during ART cycle, number of day 3 embryos, and cycle cancellation and clinical pregnancy rates. Result(s) Random AMH levels were strongly correlated with the number of oocytes retrieved during an ART cycle among women with elevated FSH (r = 0.55). Women with elevated FSH who had a random serum AMH level of 0.6 ng/mL or higher had twice the number of oocytes retrieved (11 ± 1.3 vs. 5.6 ± 0.6), a greater number of day 3 embryos (5.7 ± 0.9 vs. 3 ± 0.5), and approximately a third of the cycle cancellation rate (14% vs. 41%) compared with women with a random serum AMH below 0.6 ng/mL. The clinical pregnancy rate was also higher among women with a random serum AMH ≥0.6 ng/mL (28% vs. 14%), however, the difference was not statistically significant. Conclusion(s) A random serum AMH level is useful in setting expectations for ART prognosis in women with elevated early follicular-phase serum FSH levels.

Recent responsa (rabbinical rulings) on multifetal pregnancy reduction and disposal of untransplanted embryos indicate that the position of contemporary Jewish law and ethics on these specific issues differs strongly from the Instruction of the Roman Catholic Church and is closer to the view adopted by the Ethics Committee of the American Fertility Society.

We report here on ethical considerations addressing the idiosyncratic needs of two Orthodox Jewish couples requesting sex selection through PGD. The patients’ considerations stem from generally healthy concerns, are not based on any gender biases and have little chance of having any major societal impact, given the idiosyncratic nature of the situation. Halakhah, the legal and ethical system of rabbinic Orthodox Judaism, generally opposes sex selection through PGD for nonmedical reasons, but would approve the procedure in these cases. Meeting these needs within the context of the doctor-patient relationship necessitates reconsidering to some extent the ASRM Ethics Committee guidelines.

The Israel Health Ministry is preparing legislation that would allow a person to receive monetary compensation in exchange for donating a kidney for a lifesaving transplant. Such a bill would be the first of its kind, and would seem to establish a policy that is in contrast with both existing international professional ethics and major Christian and Islamic religious ethics. In an attempt to investigate the extent to which such a bill would be consistent with traditional Jewish ethics, we reviewed the opinions of major traditional Jewish ethicists/halakhists, with emphasis on contemporary opinions, and found that compensating an organ donor for his or her time, discomfort, inconvenience, and recovery is fully consistent with traditional Jewish law and ethics. While non-altruistic sale of kidneys might be theoretically ethical from a Jewish perspective, ultimately its ethical status is inextricably connected to solving a series of pragmatic issues, such as creating a system that insures that potential vendors/donors are properly informed and not exploited, controlling and supervising medical screening and support of the donors to insure that their health is not permanently endangered, protecting minors and incompetents, and regulating payments so that they reasonably reflect compensation for pain and suffering.

BACKGROUND In 2000, the Consensus Statement on the Live Organ Donor reported that "direct financial compensation for an organ from a living donor remains controversial and illegal in the United States" and took note of the position of the Transplantation Society that "Organs and tissue should be given without commercial consideration or commercial profit." Christian authorities insist that organ donors must not accrue economic advantage, and "selling" organs deprives the donation of its ethical quality. METHODS The writings of major contemporary authorities of Jewish law and ethics whose halakhic positions on bioethical issues are regularly considered by Orthodox, Conservative, and Reform ethicists were reviewed. Their positions on this issue were contrasted with those of various contemporary secular and religious authorities. RESULTS These Jewish authorities reject the notion that generosity and charity, rather than monetary gain and greed, must serve as the exclusive basis for donation of functioning organs. CONCLUSION Although nonaltruistic sale of kidneys may be theoretically ethical, ultimately its ethical status in Jewish ethics and law is inextricably connected to solving a series of pragmatic programs, such as creating a system that ensures that potential vendors and donors are properly informed and not exploited. Lacking such arrangements, ethical nonaltruistic kidney donations remain but a theoretical possibility.

by endometrial thickness for any group. Adjusting for lead follicle diameter, women in the unexplained group who became pregnant tended to have thinner endometrial measurements than non-pregnant women from the other groups (p

Background Polycystic ovarian syndrome (PCOS) is characterized by increased ovarian angiogenesis and vascularity. Accumulating evidence indicates that vascular endothelial growth factor (VEGF) is increased in PCOS and may play an important role in these vascular changes and the pathogenesis of this disease. Placental growth factor (PlGF), a VEGF family member, has not been previously characterized in PCOS women. We investigated levels and temporal expression patterns of PlGF and its soluble receptor sFlt-1 (soluble Fms-like tyrosine kinase) in serum and follicular fluid (FF) of women with PCOS during controlled ovarian stimulation. Methods This was a prospective cohort study of 14 PCOS women (Rotterdam criteria) and 14 matched controls undergoing controlled ovarian stimulation. Serum was collected on day 3, day of hCG and day of oocyte retrieval. FF was collected on retrieval day. PlGF, sFlt-1 and anti-mullerian hormone (AMH) protein concentrations were measured using ELISA. Since sFlt-1 binds free PlGF, preventing its signal transduction, we calculated PlGF bioavailability as PlGF/sFlt-1 ratio. Results Serum PlGF and sFlt-1 levels were constant throughout controlled ovarian stimulation, and no significant differences were observed in either factor in PCOS women compared with non-PCOS controls at all three measured time points. However, FF PlGF levels were increased 1.5-fold in PCOS women compared with controls (p

WITHDRAWN O-422 Wednesday, October 16, 2013 05:15 PM LETROZOLEVERSUSCLOMIPHENECITRATEINANOVULATORY PCOSWOMEN:ACOST-EFFECTIVENESSANALYSIS. NIH/NICHD Reproductive Medicine NetworkNIH/NICHD Reproductive Medicine Network, Bethesda, MD. OBJECTIVE: To compare the cost effectiveness of Letrozole to Clomiphene for treatment of anovulatory infertility related to the Polycystic Ovary Syndrome. DESIGN: A randomized controlled trial was conducted as part of the Reproductive Medicine Network with randomization to either Letrozole or Clomiphene citrate. This cost-effectiveness analysis was based on the results of that study. MATERIALS AND METHODS: Differences in conception, pregnancy and live birth rates were calculated from the trial data. These were supplemented with hospital charge data from Healthcare Cost and Utilization ProjS128 ASRM Abstracts ect, which were converted to costs using national Medicare charge to cost ratios. Results were corrected for differences in cesarean rates and pregnancy complications. Medication and monitoring costs constituted the costs per treatment cycle. The outcome was cost per live birth. The study adopted the societal perspective. RESULTS: The rates of conception, pregnancy and live birth were statistically significantly higher among patients treated with Letrozole versus Clomiphene. 25.2% of treated women in the Letrozole arm had a live birth versus 16.8% for Clomiphene (p1⁄40.036). Rates of pregnancy complications were insignificantly different (p1⁄4 .81) as were the cesarean rates. The cost per event was higher for the Clomiphene arm, driven both by the comparable medication and monitoring treatment costs and lower rates of birth. The cost per live birth was equal to a weighted average of $6660.55. Given that inputs were comparable in all other areas, the higher pregnancy rate for Letrozole dominated Clomiphene citrate. CONCLUSION: Comparable treatment costs for Letrozole and Clomiphene citrate are largely offset by its higher effectiveness, yielding lower cost per live birth. Given the lack of downstream cost increases due to similar rates of cesarean section and pregnancy complications, Letrozole is the more cost effective alternative. Supported by: The content is solely the responsibility of the authors and does not represent the official views of the NICHD or NIH. O-423 Wednesday, October 16, 2013 05:30 PM IMPAIRED FLUX VIA THE PENTOSE PHOSPHATE PATHWAY CORRELATES WITH ABNORMAL ENDOMETRIAL RECEPTIVITY IN PCOS PATIENTS. M. M. B. Schulte, J.-H. Tsai, K. Moley. Obstetrics & Gynecology, Washington University in St. Louis, St. Louis, MO. OBJECTIVE: Markers of uterine receptivity are decreased in PCOS patients. Recent work from our laboratory suggests that elevated DHEA levels in vitro inhibit the pentose phosphate pathway resulting in inhibition of endometrial decidualization. Glucose-6-phosphate dehydrogenase (G6PD) is the rate-limiting enzyme in this pathway. As DHEA levels are elevated in 50% of PCOS patients, alterations in the pentose phosphate pathway may contribute to impaired endometrial function and thus subfertility. DESIGN: Basic Science. MATERIALS AND METHODS: Controls are normo-ovulatory women with proven fertility while cases have primary infertility and PCOS (Rotterdam). All patients underwent an endometrial biopsy, blood draw for DHEA and Testosterone and completed a survey. ESC decidualization was induced and the mRNA expression levels of prolactin, IGFBP1, and interleukin-15, and G6PD expression were measured by quantitative RT-PCR. The fold change in gene expression between non-decidualized and decidualized samples was calculated. Enzymatic assays investigating G6PD activity in each tissue sample are currently underway. RESULTS: The fold changes in gene expression of decidual markers exhibit a decrease in PCOS patients. Additionally, they have a decrease in G6PD expression suggesting that the pentose phosphate pathway is inhibited by elevated DHEA levels thus inhibiting proper decidualization and leading to subfertility. Further correlation with DHEA laboratory values and endometrial receptivity markers are pending. Fold Change in Gene Expression PCOS vs Control Fold change PRL IGFBP1 IL-15 G6PDH Vol. 100 , No. 3, Suppleme nt, Septem PCOS (N1⁄420) 615.0 620.6 57587.4 97426.3 7.9 3.2 2.2 0.5 Control (N1⁄420) 3740.8 11217.3 190860.9 341586.0 10.2 4.1 2.3 0.8 Values are a mean SEM. CONCLUSION: By controlling the in vitro hormonal environment, measuring markers of endometrial decidualization and G6PD expression we found that women with PCOS have ESCs that demonstrate decreased pentose phosphate enzyme expression and reduced ability to undergo normal decidualization. Supported by: ACOG/Merck.

Due to the risk of asepatic peritonitis associated with intraoperative rupture of dermoid cysts, many surgeons are reluctant to remove the lesions laparoscopically. In our series, 12 dermoid cysts were removed laparoscopically. Intraoperative spillage occurred in all cases and was managed with copious lavage. None of the patients experienced postoperative morbidity associated with peritonitis, indicating that intraoperative spillage of dermoid cysts is not associated with morbidity as long as vigorous lavage is performed.

Objective: The study was undertaken to ascertain whether body mass index (BMI) affects first-trimester pregnancy outcome in patients with infertility. Study Design: Records of 494 patients with a singleton gestation after treatment for infertility at a single academic center were retrospectively reviewed. Patients were classified with regard to BMI and treatment protocol. Outcomes were defined as ongoing pregnancy, spontaneous abortion, or ectopic pregnancy. Results: The average rate of spontaneous abortion was 21.5% and of ongoing pregnancy 75.1%. This did not differ significantly in any of the BMI groups. When patients were further subdivided according to diagnosis or fertility treatment, the spontaneous abortion rate remained the same. Conclusion: The likelihood of a spontaneous abortion, ongoing pregnancy, or ectopic pregnancy in singleton gestations in the first trimester, after treatment for infertility, was not affected by BMI. (Am J Obstet Gynecol 2003;188:1169-70.)

Objective Luteal phase abnormalities are known to complicate ovulation induction with gonadotropins. This study was performed to test the effect of a modified human chorionic gonadotropin (hCG) regimen on the luteal phase during gonadotropin treatment. Design Fifteen women from a private practice setting volunteered to be studied during each of two nonconception, gonadotropin-stimulated cycles. After ovarian stimulation with human menopausal gonadotropins (hMG), hCG was administered either as a single dose of 10,000 IU (single dose) or in two divided doses of 5,000 IU given 1 week apart (split dose). Main Outcome Measures Early, midluteal, and late luteal estradiol (E 2 ) and progesterone (P) levels and luteal phase lengths were measured, and their median values and intraquartile ranges (IQR) compared using nonparametric analysis. Results Early and midluteal E 2 and P levels were similar regardless of which hCG regimen was administered. The median late luteal E 2 level was 1,146.0 pg/mL (the IQR ranged from 633 to 1,650, IQR=1,017) with the split-dose regimen and 240.0 pg/mL (the IQR ranged from 150 to 460, IQR=310) with the single-dose regimen. The median late luteal P level was 108.0 ng/mL (the IQR ranged from 58.5 to 129, IQR=70.5) with the split-dose regimen and 4.2 ng/mL (the IQR ranged from 1.9 to 11.7, IQR=9.8) with the single-dose regimen. Median luteal phase lengths were 16 days (the IQR ranged from 15 to 17, IQR=2) for the split-dose regimen and 11 days (the IQR ranged from 10 to 12, IQR=2) for the single-dose regimen. Conclusion In hMG-stimulated cycles, a second dose of hCG given during the midluteal phase significantly increases late luteal E 2 and P levels and consistently lengthens the luteal phase.

Poor cervical mucus (CM) may be caused by a number of factors, including premature luteinization, local cervical effects, and inadequate folliculogenesis. In an attempt to distinguish between these causes of poor CM, we obtained progesterone (P) levels at the time of postcoital tests (PCTs) in infertile women during spontaneous or clomiphene citrate (CC)-stimulated cycles. The amount of CM, viscosity, ferning, spinnbarkeit, and cellularity were each scored from 0 to 3 points on the day after detection of the urinary luteinizing hormone surge (luteal day 1). The charts of 46 such patients were retrospectively reviewed. Eleven control patients with good CM scores (greater than 10) had low P levels (less than 2.5 ng/mL). Of the remaining 35 cycles, 19 were marked by low P levels, and 16 were accompanied by P levels of greater than 2.5 ng/mL. Overall, 94.4% of CC-stimulated cycles versus 64.3% of spontaneous cycles had abnormal CM scores (less than 9). On the basis of these inappropriately elevated P levels, premature luteinization can be cited as the cause of poor mucus quality. In fact, premature luteinization may be responsible for some of the purported antiestrogenic effects of CC. Therefore, it is appropriate to draw a P level at the time of a poor PCT, particularly in cycles stimulated by CC.