- Email: [email protected]
All Clear or So We Thought: A Novel Approach to the Diagnosis of Clear Vesicular Endometriosis
RESULT(S): Among the 4,200 samples evaluated, we routinely detected common mutations among 14 disorders utilizing the NGS technology platform. In addition, and as expected, we also detected numerous rare mutations that would not be detected by traditional screening assays routinely used in IVF centers. Among these were mutations in cystic fibrosis (e.g., S1455X/ c.4364C>G; P67L/c.200C>T; Q1476X/c.4426C>T), Canavan disease (e.g., G27R /c.79G>A), and Bloom’s syndrome (e.g., Q548X/ c.1642C>T). Had traditional carrier screening assays been used, these carriers would have been missed, putting the reproductive partners at increased risk of having a child with a genetic disorder. CONCLUSION(S): NGS has significant advantages over traditional carrier screening assays. Due to the vast number of pathogenic mutations detectable for each gene assessed, NGS enables comprehensive examination of carrier status, and is, therefore, expected to yield higher detection rates, irrespective of patient ethnicity, resulting in fewer missed carriers. FINANCIAL SUPPORT: Good Start Genetics,Ò Inc. (Cambridge, MA, USA). P-66 Carrier Screening for Cystic Fibrosis among IVF Patients Utilizing Next Generation DNA Sequencing Detects Common, Rare, and Otherwise Undetectable Mutations. Stephanie Hallam, Benjamin Breton, Nicole Faulkner, Caleb Kennedy, Dana Neitzel, Marcia Nizzari, Greg Porreca, Patrick Saunders, Mark Umbarger, Robert Rochelle, Valerie Greger. Good Start GeneticsÒ, Inc., Cambridge, MA, USA. BACKGROUND: Carrier screening for cystic fibrosis (CF) is recommended by the American College of Medical Genetics, the American Congress of Obstetricians and Gynecologists and societies representing the Ashkenazi Jewish population. Due to cost considerations and restrictive technologies, traditional CF carrier screening assays are designed to look for only the most common CF mutations. Next generation DNA sequencing (NGS) allows for comprehensive determination of CF carrier status through its ability to detect a much larger set of mutations, thereby increasing detection of CF mutations in Caucasians, as well as in patients of other or mixed ethnicities. OBJECTIVE(S): NGS is expected to increase the sensitivity of preconception screening for CF carriers over traditional assays by increasing dramatically the number of CF mutations detected (R550 vs. 100). Our objective was to evaluate the clinical effectiveness of NGS for detecting not only common but also rare CF mutations that would go undetected using traditional carrier screening assays. MATERIALS AND METHOD(S): A high-throughput and proprietary methodology (comprised of multiplex gene capture, NGS and computational analysis), which looks for over 550 known pathogenic CF mutations, was applied to over 4,000 patient DNA samples, as of this writing. Clinical reports were issued on the presence or absence of disease-causing CF mutations. RESULT(S): Among 4,000 patients screened for CF utilizing NGS, we were able to detect 114 carriers, a frequency consistent with that reported in the literature given the ethnic mix tested. Several of these mutations – including S1455X (c.4364C>G), P67L (c.200C>T), Q1476X (c.4426C>T) were not detected by traditional screening assays. Had traditional screening assays been used, these carriers would have been missed, thereby increasing the risk of having a child with CF. Additionally, during test validation, a DNA sample from a CF patient was found to have not only a known mutation (R334/c.100C>T) from one parent, but also a previously uncharacterized mutation (c.3368-2A>T) from the other parent. If the parent carrying c.3368-2A>T had been tested with a traditional, more limited carrier screening assay, this at-risk couple would have been missed. CONCLUSION(S): NGS has significant advantages over traditional carrier screening assays. Due to the vast number of pathogenic mutations detectable, NGS enables comprehensive examination of carrier status for CF in persons of all ethnicities, and is, therefore, expected to yield higher detection rates, resulting in fewer missed carriers. FINANCIAL SUPPORT: Good Start Genetics,Ò Inc. (Cambridge, MA, USA).
P-67 The Effect of Soy Isoflavones on Menopausal Vasomotor Flushing. S. J. Mucowski,a D. Shoupe,a H. Dang,b V. Henderson,c N. Kono,b,d H. N. Hodis,b,d W. J. Mack.b,d aDivision of Reproductive Endocrinology and Infertility, Keck School of Medicine of the University of Southern Califor-
FERTILITY & STERILITYÒ
nia, 2020 Zonal Avenue, Los Angeles, CA 90033; bDepartment of Preventive Medicine, Keck School of Medicine of the University of Southern California, 1975 Zonal Avenue, Los Angeles, CA 90033; cDepartment of Neurology & Neurological Sciences and Division of Epidemiology, Stanford University, 300 Pasteur Drive, Stanford, CA 94305; dAtherosclerosis Research Unit, Keck School of Medicine of the University of Southern California, 1975 Zonal Avenue, Los Angeles, CA 90033. BACKGROUND: The use of over the counter soy products and soy-rich diets has become popular among women in an attempt to control vasomotor flushing associated with menopause as an alternative to estrogen-based hormonal therapies. Soy isoflavones are structurally similar to 17b-estradiol and possess selective estrogen receptor modulator (SERM)-like activity. It has been suggested that hot flushes can be reduced in women whose diets incorporate soy products, but trials testing this hypothesis have been inconsistent. OBJECTIVE(S): To determine the effect of long-term use of isoflavone soy protein supplementation on frequency and intensity of hot flushes. MATERIALS AND METHOD(S): The Women’s Isoflavone Soy Health (WISH) trial was a randomized placebo-controlled trial designed to determine the impact of isoflavone soy protein (ISP) supplementation on health outcomes (including atherosclerosis, osteoporosis, cognition and breast density) in a healthy population of postmenopausal women. 350 healthy postmenopausal women were randomized 1;1 to 2.5 yrs of ISP supplementation or placebo. Participants completed daily flushing diaries prior to randomization and throughout intervention; numbers of mild, moderate and severe flushes were recorded. This is a secondary analysis of the WISH trial, focusing on 110 women who reported at least seven weekly hot flushes of any level at baseline. Flushing intensity level was assigned a score of 1, 2, or 3 corresponding to mild, moderate, or severe flushing, respectively. The frequency of each level was multiplied by the corresponding intensity score and summed to create a composite flushing score. Data were analyzed using linear mixed effects models, with the repeatedly measured flushing composite score as the dependent outcome variable. An unstructured variance-covariance matrix was used, assuming a common covariance structure for placebo and ISP groups, to determine if the average linear change in composite flushing score over the trial differed between treatment groups. RESULT(S): Flushing scores did not differ by treatment group at baseline or at any post-randomization period. The treatment-by-time interaction was not statistically significant (p¼0.40), indicating no difference in the longitudinal change in the composite flushing score between treatment groups. CONCLUSION(S): The use of dietary isoflavone soy protein supplementation has no significant impact on either frequency or intensity of hot flushes. FINANCIAL SUPPORT: NIH U01AT-001653. Solae LLC provided study products gratis.
P-68 All Clear or So We Thought: A Novel Approach to the Diagnosis of Clear Vesicular Endometriosis. Tiffany D. Justice, M.D., Steven T. Nakajima, M.D. Division of Reproductive Endocrinology and Infertility, Department of Obstetrics, Gynecology and Women’s Health, University of Louisville School of Medicine, 550 S. Jackson Street, Louisville, KY 40202. BACKGROUND: Chronic pelvic pain and primary infertility are common indications for diagnostic laparoscopy. Endometriosis is known to affect 7 to 10% of all reproductive aged women in the United States and nearly 50% of women with primary infertility. Endometriosis can take on many different appearances: from blue-black, red, white or clear. The degree of pelvic pain is often out of proportion to the extent of visible active endometriosis at laparoscopy. Clear vesicular lesions are thought to be recent, active lesions leading to inflammation and pain. OBJECTIVE(S): To describe a novel surgical technique to better visualize clear vesicular endometriosis at the time of laparoscopy. METHOD(S): After placing an intrauterine catheter, the fallopian tube is easily draped over the specific area of interest on the ovary. Upon chromopertubation, one can more readily resolve the areas of clear endometriosis that are present once the ovary has been stained with indigo carmine, allowing for proper diagnosis. In cases where the fallopian tube is not mobile, occluded or absent, indigo carmine could be introduced into the pelvis with a 22-gauge spinal needle placed through the abdominal wall. Placement of tip of the spinal needle could be directed using laparoscopic instruments
S35
and indigo carmine allowed to wash over the surface of the ovary or other area of interest. RESULT(S): Figure 1. Clear vesicular endometriosis present on the ovarian surface prior to chromopertubation.
Figure 2. Chromopertubation with indigo carmine allows for better detection of clear vesicular endometriosis for biopsy or ablation.
intercourse. Ovulatory dysfunction is estimated to be the cause in approximately 20% of infertile couples. In most anovulatory women, ovulation will occur with the use of clomiphene or letrozole single agent therapy. However, there is a subset of women, nearly 22%, who do not respond to either medication. OBJECTIVE(S): To describe the response of two patients with clomiphene and letrozole resistant polycystic ovarian syndrome to combined simultaneous therapy with clomiphene citrate 150mg and letrozole 5 mg daily cycle day 3-7. METHODS/RESULT(S): Patient One: 26 yo G0 with polycystic ovarian syndrome who had failed to ovulate after three cycles of clomiphene citrate therapy (maximum dose 150mg for five days) and one cycle of letrozole 7.5 mg daily for five days. She was started on simultaneous clomiphene citrate 150mg and letrozole 5 mg daily on cycle day 3-7. Ultrasound monitoring on cycle day 14 showed a single dominant follicle 14.5 mm in diameter. Ovulation was triggered with purified human chorionic gonadotropin on cycle day 17 with timed intercourse. The patient conceived during her first combined cycle and currently has a singleton gestation in the third trimester. Patient Two: 27 yo G0 with polycystic ovarian syndrome who failed to ovulate/spontaneously menstruate after six unmonitored cycles of clomiphene citrate up to 150 mg for 5 days and one cycle of letrozole 5 mg daily for 5 days. She was started on combined clomiphene citrate 100 mg and letrozole 5 mg daily on cycle day 3-7. Ultrasound monitoring on cycle day 21 showed a single dominant follicle 24 mm in size. Ovulation was triggered with purified human chorionic gonadotropin followed by timed intercourse. Spontaneous menses occurred 14 days post ovulation. CONCLUSION(S): Combined simultaneous clomiphene citrate and letrozole therapy can be considered for ovulation induction women who are resistant to single agent therapy prior to proceeding to therapy with gonadotropins. Further study in this patient population is underway. FINANCIAL SUPPORT: None.
P-70 Number of Embryos Transferred and Multiple Pregnancy Rates in a Randomized Study of Progesterone Vaginal Ring Versus Gel for Luteal Support following In Vitro Fertilization. V. Schnell, B. Howard, H. Weiss. Teva Women’s Health, Webster, TX, USA.
CONCLUSION(S): Chromopertubation with indigo carmine (2 ampules [10 mL] diluted in 100 ml saline) is used to confirm tubal patency. With proper positioning of the fimbriae, one can utilize the indigo carmine solution to examine the surface of the ovary and better perceive the clear vesicular lesions characteristic of atypical endometriosis. SUPPORT: No financial support was received.
P-69 Simultaneous Clomiphene Citrate and Letrozole Therapy for Ovulation Induction in Clomiphene-resistant Polycystic Ovarian Syndrome. Tiffany D. Justice, M.D., Steven T. Nakajima, M.D., Henry C. L. Bohler, Jr., M.D. University of Louisville, Department of Obstetrics, Gynecology and Women’s Health, Division of Reproductive Endocrinology and Infertility, Louisville, KY, USA. BACKGROUND: Infertility is known to affect approximately 15% of all couples. It is defined as the inability to conceive after one year of unprotected
S36
PCRS Abstracts
BACKGROUND: A large phase 3, single-blind, randomized study (ClinicalTrials.gov Identifier: NCT00615251) compared the safety and efficacy of luteal phase support (LPS) during in vitro fertilization (IVF) using a novel once-weekly progesterone vaginal ring (PVR) or daily progesterone vaginal gel (PVG). This trial demonstrated therapeutic equivalence of PVR compared with PVG for LPS. OBJECTIVE(S): To report the number of embryos transferred and multiple pregnancy rate with PVR versus PVG when used for LPS in IVF. MATERIALS AND METHOD(S): Women were randomized to onceweekly PVR or daily 8% PVG (90 mg/day) the day after egg retrieval (ER). Embryo transfer (ET) occurred 3-5 days post-ER. Those determined to be pregnant 2 weeks post-ER by a serum pregnancy test continued dosing with progesterone for up to a total of 10 weeks (through pregnancy Week 12). Clinical pregnancy and multiple gestation rates were determined via ultrasound 6 and 10 weeks post-ER (pregnancy Weeks 8 and 12). Also recorded were the number of embryos transferred/woman, rates of multiple gestation, and the rates of multiple live births. RESULT(S): Of the 1297 women randomized, 1271 had an ET (631 in the PVR group; 640 in the PVG group). Overall, the mean number of embryos transferred was 2.13 for both treatment groups. The majority of women in both treatment groups had one or two embryos transferred (81.8% in the PVR group; 80.8% in the PVG group). Approximately 1% overall had four embryos transferred (1.4% in the PVR group; 0.6% in the PVG group) and no woman had more than five embryos transferred. The overall multiple pregnancy rate (twins and triplets) at Week 8 was 41.3% in the PVR group compared with 39.7% in the PVG group. At Week 12, overall multiple pregnancy rates were 39.3% and 37.8% for PVR and PVG, respectively. No higher order multiple gestations beyond triplets were recorded. The overall multiple live birth rates (twins and triplets) were 38.7% and 36.2% for the PVR and PVG treatment groups, respectively. Rates of ectopic pregnancy and spontaneous abortion were similar between treatment groups, regardless of whether the pregnancy involved singleton or multiple gestations. CONCLUSION(S): This large phase 3 study demonstrated comparable overall pregnancy rates and overall multiple gestation rates with
Vol. 99, No. 3, Supplement, March 1, 2013
P-67 The Effect of Soy Isoflavones on Menopausal Vasomotor Flushing. S. J. Mucowski,a D. Shoupe,a H. Dang,b V. Henderson,c N. Kono,b,d H. N. Hodis,b,d W. J. Mack.b,d aDivision of Reproductive Endocrinology and Infertility, Keck School of Medicine of the University of Southern Califor-
FERTILITY & STERILITYÒ
nia, 2020 Zonal Avenue, Los Angeles, CA 90033; bDepartment of Preventive Medicine, Keck School of Medicine of the University of Southern California, 1975 Zonal Avenue, Los Angeles, CA 90033; cDepartment of Neurology & Neurological Sciences and Division of Epidemiology, Stanford University, 300 Pasteur Drive, Stanford, CA 94305; dAtherosclerosis Research Unit, Keck School of Medicine of the University of Southern California, 1975 Zonal Avenue, Los Angeles, CA 90033. BACKGROUND: The use of over the counter soy products and soy-rich diets has become popular among women in an attempt to control vasomotor flushing associated with menopause as an alternative to estrogen-based hormonal therapies. Soy isoflavones are structurally similar to 17b-estradiol and possess selective estrogen receptor modulator (SERM)-like activity. It has been suggested that hot flushes can be reduced in women whose diets incorporate soy products, but trials testing this hypothesis have been inconsistent. OBJECTIVE(S): To determine the effect of long-term use of isoflavone soy protein supplementation on frequency and intensity of hot flushes. MATERIALS AND METHOD(S): The Women’s Isoflavone Soy Health (WISH) trial was a randomized placebo-controlled trial designed to determine the impact of isoflavone soy protein (ISP) supplementation on health outcomes (including atherosclerosis, osteoporosis, cognition and breast density) in a healthy population of postmenopausal women. 350 healthy postmenopausal women were randomized 1;1 to 2.5 yrs of ISP supplementation or placebo. Participants completed daily flushing diaries prior to randomization and throughout intervention; numbers of mild, moderate and severe flushes were recorded. This is a secondary analysis of the WISH trial, focusing on 110 women who reported at least seven weekly hot flushes of any level at baseline. Flushing intensity level was assigned a score of 1, 2, or 3 corresponding to mild, moderate, or severe flushing, respectively. The frequency of each level was multiplied by the corresponding intensity score and summed to create a composite flushing score. Data were analyzed using linear mixed effects models, with the repeatedly measured flushing composite score as the dependent outcome variable. An unstructured variance-covariance matrix was used, assuming a common covariance structure for placebo and ISP groups, to determine if the average linear change in composite flushing score over the trial differed between treatment groups. RESULT(S): Flushing scores did not differ by treatment group at baseline or at any post-randomization period. The treatment-by-time interaction was not statistically significant (p¼0.40), indicating no difference in the longitudinal change in the composite flushing score between treatment groups. CONCLUSION(S): The use of dietary isoflavone soy protein supplementation has no significant impact on either frequency or intensity of hot flushes. FINANCIAL SUPPORT: NIH U01AT-001653. Solae LLC provided study products gratis.
P-68 All Clear or So We Thought: A Novel Approach to the Diagnosis of Clear Vesicular Endometriosis. Tiffany D. Justice, M.D., Steven T. Nakajima, M.D. Division of Reproductive Endocrinology and Infertility, Department of Obstetrics, Gynecology and Women’s Health, University of Louisville School of Medicine, 550 S. Jackson Street, Louisville, KY 40202. BACKGROUND: Chronic pelvic pain and primary infertility are common indications for diagnostic laparoscopy. Endometriosis is known to affect 7 to 10% of all reproductive aged women in the United States and nearly 50% of women with primary infertility. Endometriosis can take on many different appearances: from blue-black, red, white or clear. The degree of pelvic pain is often out of proportion to the extent of visible active endometriosis at laparoscopy. Clear vesicular lesions are thought to be recent, active lesions leading to inflammation and pain. OBJECTIVE(S): To describe a novel surgical technique to better visualize clear vesicular endometriosis at the time of laparoscopy. METHOD(S): After placing an intrauterine catheter, the fallopian tube is easily draped over the specific area of interest on the ovary. Upon chromopertubation, one can more readily resolve the areas of clear endometriosis that are present once the ovary has been stained with indigo carmine, allowing for proper diagnosis. In cases where the fallopian tube is not mobile, occluded or absent, indigo carmine could be introduced into the pelvis with a 22-gauge spinal needle placed through the abdominal wall. Placement of tip of the spinal needle could be directed using laparoscopic instruments
S35
and indigo carmine allowed to wash over the surface of the ovary or other area of interest. RESULT(S): Figure 1. Clear vesicular endometriosis present on the ovarian surface prior to chromopertubation.
Figure 2. Chromopertubation with indigo carmine allows for better detection of clear vesicular endometriosis for biopsy or ablation.
intercourse. Ovulatory dysfunction is estimated to be the cause in approximately 20% of infertile couples. In most anovulatory women, ovulation will occur with the use of clomiphene or letrozole single agent therapy. However, there is a subset of women, nearly 22%, who do not respond to either medication. OBJECTIVE(S): To describe the response of two patients with clomiphene and letrozole resistant polycystic ovarian syndrome to combined simultaneous therapy with clomiphene citrate 150mg and letrozole 5 mg daily cycle day 3-7. METHODS/RESULT(S): Patient One: 26 yo G0 with polycystic ovarian syndrome who had failed to ovulate after three cycles of clomiphene citrate therapy (maximum dose 150mg for five days) and one cycle of letrozole 7.5 mg daily for five days. She was started on simultaneous clomiphene citrate 150mg and letrozole 5 mg daily on cycle day 3-7. Ultrasound monitoring on cycle day 14 showed a single dominant follicle 14.5 mm in diameter. Ovulation was triggered with purified human chorionic gonadotropin on cycle day 17 with timed intercourse. The patient conceived during her first combined cycle and currently has a singleton gestation in the third trimester. Patient Two: 27 yo G0 with polycystic ovarian syndrome who failed to ovulate/spontaneously menstruate after six unmonitored cycles of clomiphene citrate up to 150 mg for 5 days and one cycle of letrozole 5 mg daily for 5 days. She was started on combined clomiphene citrate 100 mg and letrozole 5 mg daily on cycle day 3-7. Ultrasound monitoring on cycle day 21 showed a single dominant follicle 24 mm in size. Ovulation was triggered with purified human chorionic gonadotropin followed by timed intercourse. Spontaneous menses occurred 14 days post ovulation. CONCLUSION(S): Combined simultaneous clomiphene citrate and letrozole therapy can be considered for ovulation induction women who are resistant to single agent therapy prior to proceeding to therapy with gonadotropins. Further study in this patient population is underway. FINANCIAL SUPPORT: None.
P-70 Number of Embryos Transferred and Multiple Pregnancy Rates in a Randomized Study of Progesterone Vaginal Ring Versus Gel for Luteal Support following In Vitro Fertilization. V. Schnell, B. Howard, H. Weiss. Teva Women’s Health, Webster, TX, USA.
CONCLUSION(S): Chromopertubation with indigo carmine (2 ampules [10 mL] diluted in 100 ml saline) is used to confirm tubal patency. With proper positioning of the fimbriae, one can utilize the indigo carmine solution to examine the surface of the ovary and better perceive the clear vesicular lesions characteristic of atypical endometriosis. SUPPORT: No financial support was received.
P-69 Simultaneous Clomiphene Citrate and Letrozole Therapy for Ovulation Induction in Clomiphene-resistant Polycystic Ovarian Syndrome. Tiffany D. Justice, M.D., Steven T. Nakajima, M.D., Henry C. L. Bohler, Jr., M.D. University of Louisville, Department of Obstetrics, Gynecology and Women’s Health, Division of Reproductive Endocrinology and Infertility, Louisville, KY, USA. BACKGROUND: Infertility is known to affect approximately 15% of all couples. It is defined as the inability to conceive after one year of unprotected
S36
PCRS Abstracts
BACKGROUND: A large phase 3, single-blind, randomized study (ClinicalTrials.gov Identifier: NCT00615251) compared the safety and efficacy of luteal phase support (LPS) during in vitro fertilization (IVF) using a novel once-weekly progesterone vaginal ring (PVR) or daily progesterone vaginal gel (PVG). This trial demonstrated therapeutic equivalence of PVR compared with PVG for LPS. OBJECTIVE(S): To report the number of embryos transferred and multiple pregnancy rate with PVR versus PVG when used for LPS in IVF. MATERIALS AND METHOD(S): Women were randomized to onceweekly PVR or daily 8% PVG (90 mg/day) the day after egg retrieval (ER). Embryo transfer (ET) occurred 3-5 days post-ER. Those determined to be pregnant 2 weeks post-ER by a serum pregnancy test continued dosing with progesterone for up to a total of 10 weeks (through pregnancy Week 12). Clinical pregnancy and multiple gestation rates were determined via ultrasound 6 and 10 weeks post-ER (pregnancy Weeks 8 and 12). Also recorded were the number of embryos transferred/woman, rates of multiple gestation, and the rates of multiple live births. RESULT(S): Of the 1297 women randomized, 1271 had an ET (631 in the PVR group; 640 in the PVG group). Overall, the mean number of embryos transferred was 2.13 for both treatment groups. The majority of women in both treatment groups had one or two embryos transferred (81.8% in the PVR group; 80.8% in the PVG group). Approximately 1% overall had four embryos transferred (1.4% in the PVR group; 0.6% in the PVG group) and no woman had more than five embryos transferred. The overall multiple pregnancy rate (twins and triplets) at Week 8 was 41.3% in the PVR group compared with 39.7% in the PVG group. At Week 12, overall multiple pregnancy rates were 39.3% and 37.8% for PVR and PVG, respectively. No higher order multiple gestations beyond triplets were recorded. The overall multiple live birth rates (twins and triplets) were 38.7% and 36.2% for the PVR and PVG treatment groups, respectively. Rates of ectopic pregnancy and spontaneous abortion were similar between treatment groups, regardless of whether the pregnancy involved singleton or multiple gestations. CONCLUSION(S): This large phase 3 study demonstrated comparable overall pregnancy rates and overall multiple gestation rates with
Vol. 99, No. 3, Supplement, March 1, 2013