Factors beyond insurance coverage that are associated with in vitro fertilization dropout

treatment beliefs based on age, sexuality, parity or being pregnant at time of survey completion. There was no correlation between the fertility knowledge score and negative or positive treatment beliefs. CONCLUSIONS: Despite being disproportionately affected by infertility2, African American women have a significantly low level of infertility knowledge. Overall, our subjects had a neutral response to negative fertility treatment beliefs and disagreed with positive treatment beliefs. It is likely that these findings contribute to the delayed pursuit of infertility care commonly found in the African American population. Patient education in fertility awareness should occur in routine visits with Women’s health providers. Further research is needed to decipher how these differences in knowledge and beliefs translate to infertility care decision-making and future childbearing. References: 1. Bunting L, Tsibulsky I, Boivin J. Fertility Knowledge and Beliefs About Fertility Treatment: Findings from the International Fertility Decision-making Study. Human Reproduction. 2012. 28: 385-397. 2. Wellons MF, Lewis CE, Schwartz SM, et al. Racial Differences in SelfReported Infertility and Risk Factors for Infertility in a Cohort of Black and White Women: The CARDIA Women’s Study. Fertility and sterility. 2008;90(5):1640-1648. O-99 Tuesday, October 31, 2017 11:30 AM SERUM BDNF AND IGF-1 LEVELS PREDICT IVF OUTCOME IN CAUCASIAN BUT NOT AFRICAN M. Irani,a AMERICAN WOMEN. S. Elder,a D. Nasioudis,b S. S. Witkin,b S. D. Spandorfer.a aThe Ronald O. Perelman and Claudia Cohen Center for Reproductive Medicine, Weill Cornell Medicine, New York, NY; bDepartment of Obstetrics and Gynecology, Weill Cornell Medicine, New York, NY. OBJECTIVE: Accumulating evidence indicates that some growth factors and cytokines play an important role in embryo development and implantation. Brain-derived neurotrophic factor (BDNF), insulin-like growth factor 1 (IGF-1), and insulin-like growth factor 2 (IGF-2) have been shown to be implicated in this process and correlate with pregnancy outcomes. However, most patients included in prior studies were Caucasian. Here we investigated whether there are differences in serum levels of IGF-1, IGF-2, and BDNF and their predictive values of IVF outcomes between Caucasian (C) and African American (AA) women. DESIGN: Retrospective case-control study including age-matched 129 C and 88 AA women undergoing fresh IVF-ET cycles. MATERIALS AND METHODS: Serum levels of IGF-1, IGF-2, and BDNF on cycle day 3 (CD3) before starting ovarian stimulation and CD28 (14 days after oocyte retrieval) were compared between those who achieved live birth and those who had pregnancy loss among AA and C women. Serum IGF-1, IGF-2, and BDNF levels were measured by ELISA assay. Values were expressed as mean
SEM. t-test was used as appropriate. RESULTS: C women had significantly higher serum IGF-1 (21.9
0.8 vs. 17.0
0.9 ng/mL, P<0.001) and lower BDNF (5078.9
0.5 vs. 77019.1
4.3 pg/mL, P<0.001) levels on CD3 compared to AA women. AA women had a significantly higher body mass index (BMI) compared to C women (28.6
0.7 vs. 23.8
0.4 Kg/m2, respectively; P<0.001). There were no differences between AA and C women in gravidity, parity, peak endometrial thickness, or age at retrieval (37.4
0.4 vs. 37.3
0.3 years, respectively; P¼0.2). C women who conceived had a significantly higher serum IGF-1 levels on CD3 compared to those who did not (23.5
0.9 vs. 17.7
1.2 ng/mL; P¼0.001). Among C women who conceived, those who had pregnancy loss had lower serum IGF-1 (21.7
1.0 vs. 27.0
1.6 ng/mL; P¼0.006) levels on CD3, lower IGF-2 (634.1
36.1 vs. 846.9
29.3 ng/mL; P<0.001) and BDNF (749.0
31.4 vs. 996.8
52.3 pg/mL; P<0.001) levels on CD28 compared to those who did not. However, there were no differences in any of the measured cytokines or growth factors between groups of AA women. CONCLUSIONS: AA women have significantly different serum cytokine levels compared to C women. In this preliminary study, serum levels of IGF-1, IGF-2, and BDNF appear to predict IVF outcome in C but not AA women. Although prior studies have shown that these cytokines may correlate with IVF outcome, they may not be applicable for AA women. Our findings could be partially related to the difference in BMI but may also reflect the racial differences in the expression of cytokines and growth factors implicated in embryo growth and implantation. A large prospective study is currently underway to investigate the racial differences in patients undergoing IVF in terms of cytokines and growth factors.

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ASRM Abstracts

O-100 Tuesday, October 31, 2017 11:45 AM EARLY HCG TRENDS IN IVF SINGLETONS VARY BY ETHNICITY: A COMPARISON OF ASIAN AND CAUCASIAN WOMEN UNDERGOING FRESH IVF-ET. K. Hancock,a A. G. Kelly,b N. Pereira,c J. Lekovich,c P. Chung,c Z. Rosenwaks.c aObstetrics and Gynecology, Weill Cornell Medicine, New York, NY; bWeill Cornell Medical College, New York, NY; cThe Ronald O. Perelman and Claudia Cohen Center for Reproductive Medicine, New York, NY. OBJECTIVE: Serial measurements of hCG are routinely used to assess the early viability of IVF conceptions. Recent data have indicated that early hCG trends may vary by race and ethnicity. The primary objective of the current study is to investigate whether the trends in early hCG levels differ in Asian and Caucasian women with IVF singletons. DESIGN: Cross-sectional study. MATERIALS AND METHODS: Women <40 years undergoing IVF with fresh embryo transfer (ET) at our center between 2008 and 2014 resulting in live singleton births were included. Vanishing twins and multiple gestations were excluded, as well as those undergoing genetic testing of embryos or IVF with donor oocytes. All women in the included cohort underwent serial measurements of hCG on cycle day (CD) 24, 26, 28 and 30. hCG levels on the aforementioned cycle days were compared between Asian women and Caucasian women. The early rise of hCG levels over CD 24, 26, 28 and 30 were converted into linear slopes and compared by ethnicity. hCG measurements were performed using the IMMULITE 2000 Immunoassay System (Siemens, Berlin, Germany). RESULTS: 1152 women with IVF singletons were included, of which 224 (19.4%) and 928 (80.6%) were Asian and Caucasian, respectively. There was no difference in the mean age; however, Asian women had lower BMIs (22.6
3.8 vs. 23.4
4.8 kg/m2; P¼0.01) when compared to Caucasians. Although there was no difference in mean hCG levels on CD 24 (10.6 vs. 10.2 mIU/mL), mean hCG levels on CD 26 (58.1 vs. 53.4 mIU/mL), CD 28 (223.4 vs. 188.1 mIU/mL), and CD 30 (1327.2 vs. 859.9 mIU/mL) were higher in Asians compared to Caucasians. The differences in CD 28 and CD 30 hCG levels persisted even when women with normal BMIs were compared. The overall slope of early hCG rise was higher in Asian women (+205.8) when compared to Caucasian women (+134.2). Multivariate regression showed that every 1 mIU/mL increase in hCG in Caucasian women was associated with a 6.4 mIU/mL increase in hCG on CD 28 and 19.2 mIU/mL increase in hCG on CD 30 in Asian women. CONCLUSIONS: hCG levels on CD 26, 28 and 30 are significantly higher in Asians women when compared to Caucasian women with IVF singletons. Furthermore, the slope of early rise in hCG levels over CD 24, 26, 28 and 30 is also higher in Asians.

Comparison of mean early hCG levels of the study cohort (n¼1152)

Parameter

Asian (n¼224) Caucasian (n¼928)

CD 24 hCG (mIU/mL) CD 26 hCG (mIU/mL) CD 28 hCG (mIU/mL) CD 30 hCG (mIU/mL) CD 24 to CD30 hCG rise (slope)

10.6 58.1 223.4 1327.2 +205.8

10.2 53.4 188.1 859.9 +134.2

P NS 0.02 <0.001 <0.001 N/A

O-101 Tuesday, October 31, 2017 12:00 PM FACTORS BEYOND INSURANCE COVERAGE THAT ARE ASSOCIATED WITH IN VITRO FERTILIZATION DROPOUT. D. E. Broughton, A. Eskew, M. Schulte, K. Omurtag, E. Jungheim. Obstetrics and Gynecology, Washington University in St. Louis, St. Louis, MO. OBJECTIVE: Lack of insurance coverage for in vitro fertilization (IVF) is associated with dropout after a failed cycle. However, some women with IVF insurance dropout of care, and the reasons for this are less clear. Our objective was to determine factors associated with dropout after a failed cycle in women with IVF insurance coverage. DESIGN: Retrospective cohort study. MATERIALS AND METHODS: In our tertiary care IVF center, we queried an insurance database and included all women with IVF coverage

Vol. 108, No. 3, Supplement, September 2017

who underwent a first cycle of IVF in our center between 2001 and 2010. On average about half of our patients have an infertility benefit. Women who conceived during their first cycle and women using gestational carriers or donor oocytes were excluded. This yielded a total of 408 women with IVF coverage that did not conceive with an initial fresh cycle. Of this cohort, 41% had IVF insurance coverage through an Illinois mandate, and 59% had employer-sponsored IVF insurance coverage. Demographic data included age, BMI, race, antral follicle count, obstetrical history, and distance from the clinic. Initial IVF cycle data included total gonadotropin used, peak estradiol, number of oocytes retrieved, and whether excess embryos were cryopreserved. Standard univariate statistics were used to determine differences in baseline characteristics between women with and without IVF coverage. Probabilities of returning for an additional IVF cycle were calculated with Students t-test and chi-square analysis. Logistic regression was used to control for potential confounders. Statistical analyses were performed in SPSS. RESULTS: There was a trend toward higher dropout in women with a prior live birth, but this did not reach statistical significance (RR 0.88, CI 0.761.00, p¼0.06). Black women were significantly less likely to return for another cycle than women who were not black, with a RR of 0.71 (CI 0.51-0.99, p¼0.04). Women who froze excess embryos were more likely to return for another cycle, with a RR of 1.21 (CI 1.08-1.35, p¼0.0008). Black race and cryopreservation of embryos remained significant after controlling for prior live birth, total gonadotropin dose, and number of oocytes retrieved (RR 0.4, CI 0.14-0.97; RR 2.5, CI 1.3-5.1, respectively). CONCLUSIONS: In a cohort of women with insurance coverage for IVF, black women and women without cryopreserved embryos were more likely to dropout of care after an initial failed cycle. For women who did not freeze embryos, the prognosis for future IVF cycles may have been poor or they may have been unwilling to undergo another invasive and time consuming fresh cycle despite having coverage. It is unclear from our data why black patients dropout of care more frequently, but there are likely disparities in access to care that go beyond insurance coverage and should be investigated in future studies. O-102 Tuesday, October 31, 2017 12:15 PM ASIAN ETHNICITY IS AN INDEPENDENT DETERMINANT OF OVARIAN RESERVE AND RESPONSE IN WOMEN UNDERGOING FRESH IVF-ET CYCLES. A. G. Kelly,a K. Hancock,b N. Pereira,c J. Lekovich,c P. Chung,c Z. Rosenwaks.c aWeill Cornell Medical College, New York, NY; bDepartment of Obstetrics and Gynecology, Weill Cornell Medical College, New York, NY; cThe Ronald O. Perelman and Claudia Cohen Center for Reproductive Medicine, New York, NY. OBJECTIVE: Studies have shown that ethnicity can be an independent determinant of ovarian reserve and response in IVF-embryo transfer (ET) cycles. In this context, we investigate if ovarian reserve and response parameters differ among Asian and Caucasian women. DESIGN: Cross-sectional study. MATERIALS AND METHODS: Women <37 years, with baseline follicle stimulating hormone (FSH) <12 mIU/mL, AMH >1 ng/mL and antral follicle count (AFC) >5 undergoing fresh IVF-ET for unexplained infertility during a 5-year period were assessed for inclusion. Women with poor ovarian reserve (defined as AMH<1, FSH >12, or AFC<5), PCOS, or a history of oophorectomy were excluded. Of those included, ovarian reserve and response parameters were compared between Asians and Caucasians. Ovarian reserve was assessed by day 3 FSH, AMH, and AFC. Ovarian response was determined by stimulation duration, total gonadotropins and number of oocytes retrieved, with the primary outcome being the number of mature oocytes retrieved. A multivariate regression model was constructed for the primary outcome to account for potential confounders. RESULTS: 1378 women were included, of which 390 (28.3%) and 988 (71.7%) were Asian and Caucasian, respectively. Asians were slightly older (33.7
2.7 vs. 33.3
2.9 years; P¼0.02) with lower BMIs (22.1
4.3 vs. 22.9
5.5 kg/m2; P¼0.01). Asians had lower AFCs than Caucasians (13.9
4.4 vs. 14.7
4.3; P¼0.01). While still within normal range, Asians had higher day 3 FSH levels (5.5
2.8 vs. 4.8
2.8 mIU/mL; P<0.001). There was no difference in AMH levels between the groups. Despite a comparable stimulation duration and gonadotropin dosage, the total oocyte yield (13.6
6.2 vs. 14.8
7.0; P¼0.003) and mature oocyte yield (10.1
6.1 vs. 12.0
5.6; P<0.001) was lower in Asians. Overall, the number of oocytes per unit of AMH was lower in Asians compared to Caucasians (4.3
3.4 vs. 5.3
3.4; P<0.001). Multivariate regression suggested that Asian women

FERTILITY & STERILITYÒ

yield approximately 3 fewer mature oocytes than Caucasians (co-efficient +2.8; 95% CI 1.68-3.67; P¼0.003; R2 0.63). Despite these differences, the live birth rate in Asians (42.6%) was comparable to Caucasians (48.6%). CONCLUSIONS: Despite similar ages, AMH levels, ovarian stimulation duration and gonadotropin doses, Asian women have decreased AFCs and a lower yield of total and mature oocytes compared to their Caucasian counterparts. These results suggest a decreased ovarian response in Asian women undergoing IVF-ET. Comparison of baseline demographics, ovarian reserve and ovarian response parameters (n¼1378)

Parameter

Asian (n¼390)

Caucasian (n¼988)

Age (years) 33.7 (
2.7) 33.3 (
2.9) BMI (kg/m2) 22.1 (
4.3) 22.9 (
5.5) Baseline FSH 5.5 (
2.8) 4.8 (
2.8) (mIU/mL) Baseline AMH (ng/mL) 3.2 (
2.6) 3.2 (
2.9) Baseline AFC 13.9 (
4.4) 14.7 (
4.3) Total stimulation days 9.3 (
1.7) 9.5 (
1.8) Total gonadotropins 2460.9 (
1287.6) 2358.1 (
1157.4) (IU) Total oocytes retrieved 13.6 (
6.2) 14.8 (
7.0) Mature oocytes 10.1 (
6.1) 12.0 (
5.6) retrieved % Mature oocytes 74.9 (
27.2) 82.0 (
15.8 Mature oocyte 4.3 (
3.4) 5.3 (
3.4) retrieved: AMH

P 0.02 0.01 <0.001 NS 0.002 NS NS 0.003 <0.001 <0.001 <0.001

References: 1. Huddleston HG, Cedars MI, Sohn SH, Giudice LC, Fujimoto VY. Racial and ethnic disparities in reproductive endocrinology and infertility. Am J Obstet Gynecol 2010;202(5):413-9. 2. Iglesias C, Banker M, Mahajan N, Herrero L, Meseguer M, Garcia-velasco JA. Ethnicity as a determinant of ovarian reserve: differences in ovarian aging between Spanish and Indian women. Fertil Steril 2014;102(1):244-9.

ENDOMETRIOSIS 1 O-103 Tuesday, October 31, 2017 11:00 AM ENDOMETRIOSIS ALTERS ANXIETY, DEPRESSION AND PAIN PERCEPTION AS WELL AS BRAIN ELECTROPHYSIOLOGY AND GENE EXPRESSION IN MICE. R. Mamillapalli, X. Gao, H. S. Taylor. Obstretics, Gynecology and Reproductive Sciences, Yale University School of Medicine, New Haven, CT. OBJECTIVE: Although various psychological and behavioral symptoms are observed in endometriosis patients, the underlying changes in the brain remain unknown. Identifying specific molecular mechanisms associated with pain, depression and anxiety in endometriosis patients is necessary to develop targeted treatment strategies for women who are undergoing these symptoms. This study aim to determine if endometriosis could cause central pain sensitization, anxiety and depression in a mouse model and the molecular changes in the brain that are mechanistically responsible. DESIGN: Endometriosis was induced in experimental mice to identify changes in pain perception, brain electrophysiology and differential gene expression that were induced by endometriosis by performing behavioral tests, qRT-PCR and patch-clamp testing. MATERIALS AND METHODS: Experimental endometriosis was created in 9 weeks old female C57BL/6 mice by suturing uterine tissue into the peritoneal cavity while controls underwent sham surgery (N¼ 5). Behavioral tests including hot plate, open field and tail suspension were performed at serial time point. Mice were sacrificed after 12 weeks of surgery and brain was collected (insula, amygdala, hippocampus and cerebral cortex) by microdissection. Differential gene expression was detected by affymetrix array followed by qRT-PCR validation. Protein expression was detected by immunohistochemical staining. Electrophysiology studies were carried out by whole-cell patch clamp (at -60 mV) in

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