Routine monitoring of liver function tests after single or double dose methotrexate treatment for ectopic pregnancies

P-705 Wednesday, October 21, 2015 PRECONCEPTION LOW DOSE ASPIRIN TREATMENT IMPROVES CLINICAL PREGNANCY AND LIVE BIRTH IN WOMEN WITH HIGHER SYSTEMIC INFLAMMATION. L. Sjaarda,a E. Mitchell,a S. L. Mumford,a R. Radin,a N. J. Perkins,a N. Galai,b R. M. Silver,c E. Schisterman.a aNICHD, NIH, Rockville, MD; bHaifa University, Haifa, Israel; cUnversiy of Utah, Salt Lake City, UT. OBJECTIVE: While some studies of low dose aspirin (LDA) to improve reproductive outcomes have found a beneficial effect, others have found none. Recently, we reported that preconception LDA (81mg) increased fecundability and live birth rates relative to placebo in a subset of women with a history of one recent (prior 12 months) pregnancy loss in the EAGeR trial. Here we aimed to evaluate the effect of LDA, a known anti-inflammatory agent, according to inflammatory status to explore possible mechanisms and best identify women who may benefit from treatment. DESIGN: Multicenter, block-randomized, double-blind, placebocontrolled trial of 1228 women to evaluate the effect of preconception-initiated daily LDA on clinical pregnancy and live birth in women with a history of pregnancy loss. MATERIALS AND METHODS: We assessed high-sensitivity C-reactive protein (CRP), a marker of systemic inflammatory status, at baseline. Women were stratified into tertiles of baseline CRP concentration: lower (<0.72 mg/L), medium (0.72 to <2.1), and higher (R2.1). Log-binomial models with robust variance assessed the effect of LDA vs. placebo, stratified by CRP tertile, on both ultrasound-confirmed pregnancy and live birth, excluding participants who withdrew or were missing CRP. RESULTS: Compared to placebo, clinical pregnancy was more frequent among LDA-treated women in the higher (67 vs. 57%; RR: 1.19; 95%CI: 1.01, 1.41), but not lower (69 vs. 68%; RR: 1.01; CI: 0.88, 1.17) or medium (73 vs. 67%; RR: 1.09; CI: 0.95, 1.25) CRP level at baseline. Likewise, a similar trend was noted for live birth which was somewhat higher in the LDA group among women with higher (55 vs. 46%; RR: 1.21; CI: 0.98, 1.49), but not lower (57 vs. 55%; RR: 1.04; CI: 0.86, 1.26) or medium (60 vs. 58%; RR: 1.03; CI: 0.86, 1.23) CRP. CONCLUSIONS: Higher systemic inflammation may reduce fecundability, but the anti-inflammatory effect of LDA could be a mechanism by which it improves pregnancy rates in certain women. Indeed, this study observed somewhat lower pregnancy and live birth rates among women with higher compared with lower baseline CRP, and these reduced rates were restored by LDA treatment. Supported by: Intramural Research Program, DIPHR, NICHD, NIH. P-706 Wednesday, October 21, 2015 PREDICTORS AND OUTCOMES OF SHORT INTERPREGNANCY INTERVAL IN PATIENTS UNDERGOING IN VITRO FERTILIZATION. C. Roeca,a D. J. Kaser,a J. H. Fox,b C. Racowsky,c D. A. Carusi.d aBrigham & Women’s Hospital, Harvard Medical School, Boston, MA; bOBGYN, Brigham & Women’s Hospital, Harvard Medical School, Boston, MA; cBrigham and Women’s Hospital ART Center, Boston, MA; dOB/GYN, Brigham & Women’s Hospital, Harvard Medical School, Boston, MA.

OBJECTIVE: In vitro fertilization (IVF) patients may desire a delivery-tocycle interval (DCI) shorter than the 18-month interpregnancy interval recommended by the World Health Organization. This study was performed to identify predictors of a short DCI among IVF patients and evaluated cycle outcomes according to length of DCI. DESIGN: Retrospective cohort study of all IVF patients, excluding gestational carriers, who delivered at our center and had a subsequent IVF cycle from 2012-2014. MATERIALS AND METHODS: IVF DCI was calculated as the time from index delivery to start date of the next IVF cycle. Length of DCI was defined as very short (<12 months), short (12-18 months) or recommended (>18 months). Predictors of DCI length and subsequent IVF cycle outcomes were modeled using Wilcoxon and chi-squared analyses, and multivariable logistic regression. RESULTS: 118 patients delivered and returned for a subsequent IVF cycle. Of these, 48 (41%) had a very short DCI, 33 (28%) had a short DCI, and 37 (31%) had a recommended DCI. Median maternal age (years) was 37.9, 35.9 and 35.4, respectively (P¼.12). Predictors of very short DCI included women >40 years (P<.01), overweight BMI (P¼0.02), uterine factor or unexplained infertility (P¼.03), no breastfeeding postpartum (P<.01), shorter breastfeeding duration (P<0.001) and use of donor eggs in the upcoming cycle (p¼ .02). Women ages 35-40 were more likely to have the recommended DCI (P<0.01). Gravidity, parity, race, medical or psychiatric comorbidities, previous myomectomy, mode of delivery, postpartum morbidity, gestational age at delivery, index cycle type (fresh vs frozen), presence and quantity of cryopreserved embryos, other infertility diagnoses, and number of previous cycles were not predictive of DCI. Among frozen embryo cycles (n¼75), ongoing pregnancy rates were higher for those with a very short DCI (OR 3.56 (CI 1.06-11.96), P¼.03), and this remained significant after adjusting for confounders. Fresh cycle outcomes (n¼40) were not significantly affected by DCI. CONCLUSIONS: Maternal factors predicting very short DCI included age >40 years, overweight BMI, uterine or unexplained infertility, and short duration or no breastfeeding. The only significant cycle factor was use of donor eggs. It remains to be determined why patients undergoing frozen embryo transfer with a very short DCI have higher pregnancy rates than those with the recommended DCI.

P-707 Wednesday, October 21, 2015 ROUTINE MONITORING OF LIVER FUNCTION TESTS AFTER SINGLE OR DOUBLE DOSE METHOTREXATE TREATMENT J. Bender,b FOR ECTOPIC PREGNANCIES. N. Pereira,a K. Hancock,b J. Lekovich,c R. Elias,b I. Kligman,b Z. Rosenwaks.b aThe Ronald O. Perelman and Claudia Cohen Center for Reproductive Medicine, Weill Cornell Medical College, New York, NY; bWeill Cornell Medical College, New York, NY; cRonald O. Perelman and Claudia Cohen Center for Re, New York, NY. OBJECTIVE: To investigate the changes in liver function tests (LFTs) between day 1 and day 7 after single or double dose methotrexate (MTX) treatment for sonographically confirmed ectopic pregnancies. DESIGN: Retrospective chart review. MATERIALS AND METHODS: All patients with a sonographically confirmed ectopic pregnancy after fresh in vitro fertilization (IVF) - embryo

LFTs on Day 1 and Day 7 after Single and Double dose MTX therapy.

Parameter ALT (U/L) AST (U/L) Albumin (g/dL) Albumin (g/dL)

Day 1 15.2 (4.41) 21.3 (5.42) 4.25 (0.28) 0.72 (0.16)

ALT (U/L) AST (U/L) Albumin (g/dL) Albumin (g/dL)

15.2 (4.35) 21.7 (4.47) 4.25 (0.23) 0.73 (0.13)

Single MTX (n¼89) Day 7 16.3 (4.68) 21.8 (6.37) 4.28 (0.31) 0.76 (0.17) Double MTX (n¼18) 16.4 (4.68) 22.3 (6.01) 4.29 (0.24) 0.78 (0.17)

P 0.12 0.57 0.50 0.11

D Day 1 vs. Day 7 +1.1 +0.5 +0.03 +0.04

0.42 0.74 0.61 0.12

+1.2 +0.6 +0.04 +0.05

transfer (ET) cycles between January 2004 and June 2013 treated with MTX

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were included in this study. Exclusion criteria included donor oocyte cycles, frozen-thawed embryo cycles, pregnancies of unknown location, and treatment with salpingectomy. LFTs, specifically alanine aminotransferase (ALT), aspartate aminotransferase (AST), albumin and total bilirubin levels were measured on day of MTX administration (day 1) and 7 days later (day 7). The change in LFTs (D) between day 1 and day 7 was calculated for both single and double dose MTX protocols. Furthermore, the change in LFTs (D) for single dose and double dose MTX protocols was compared. Continuous variables were checked for normality and expressed as mean  standard deviation. Paired student’s t-tests were utilized. Statistical significance was set at P<0.05. Statistical analyses were performed using STATA version 13 (College Station, TX: StataCorp LP). RESULTS: 107 patients met inclusion criteria: 89 patients received single dose MTX and 18 patients received double dose MTX. Baseline demographic and IVF characteristics were comparable between the 2 groups. Our data is summarized in the table below. There was no difference in the change in LFTs (D) when comparing single dose to double dose MTX protocols. CONCLUSIONS: Our study suggests that repeating LFTs on day 7 after single or double dose methotrexate (MTX) treatment for sonographically confirmed ectopic pregnancies may not be necessary in patients with normal baseline LFTs on day 1. P-708 Wednesday, October 21, 2015 MATERNAL EXPOSURE TO BISPHENOL-A (BPA) DURING EARLY IMPLANTATION DISRUPTS FETAL GROWTH, A MOUSE MODEL. I. Robertshaw, J. M. Sroga, M. A. Thomas. University of Cincinnati, West Chester, OH. OBJECTIVE: To determine the effects of maternal BPA exposure on epigenetic regulation at the implantation site during pregnancy progression from decidualization. DESIGN: Basic research animal study. MATERIALS AND METHODS: In this IACUC approved animal study, pregnant female CD-1 mice were exposed to subcutenous injections of either sesame oil control or BPA on day (D) 4 of gestation. The BPA experimental group was divided into 4 groups injected with 10mg/kg/day BPA, 1mg kg/day, BPA 0.1mg /kg/day BPA or 0.01mg /kg/day BPA. Injections were administered as a series of four 0.1mL injections given at 9:00, 11:30, 14:00, and 16:30 in order to maintain a steady dose exposure during decidualization. The mice were weighed on gestational D5, D9, D11, D13, D15, D17, and D19. Litter size, pup weight and neonatal anomalies were documented once delivered. RESULTS: 22 litters were delivered resulting in 297 pups. Twenty-one litters delivered on D19, while one litter, in the 10mg/kg/d BPA group, delivered on D20. No pup anomalies were noted in any group. The control group (n¼79) demonstrated a mean litter size of 13.2  1.17and mean pup weight of 1.71  0.06 grams. The 10mg/kg/d BPA group (n¼81), 1mg/kg/d BPA group (n¼39), 0.1mg/kg/d BPA group (n¼73), and 0.01mg/kg/d BPA group (n¼25) had a mean litter size of 13.5  2.51, 13  2.0, 14.6  1.52 and 12.5  2.12, respectively. But these differences were not statistically significant. However, mean pup weight for each BPA group was statistically significant at 1.50  0.06 grams (p<0.001), 1.53  0.08 grams (p<0.001), 1.64  0.05 grams (p<0.001) and 1.67  0.06 grams (p<0.01), respectively. CONCLUSIONS: Our preliminary results demonstrate BPA exposure disrupts decidualization causing poor embryonic growth. The perturbation is most detrimental if experienced during the implantation window and it is dose dependent. A greater impact on pup weight was observed in mice with a higher dose of BPA exposure. These effects can be attributed to BPA; however, further studies are needed to investigate decidual progression and fetal growth through histological, molecular analysis and gene expression at the implantation site. Supported by: NIEH Grant. P-709 Wednesday, October 21, 2015 A SIMPLE AND FAST APPROACH TO CONFIRM THE PRESENCE OF AN INTRAUTERINE PREGNANCY. A. Mor,a R. Tal,b M. Irani,a D. Garg,a S. Haberman,a S. McCalla,a J. Perlman,c R. Grazi,a H. Minkoff.a a Obstetrics and Gynecology and Genesis Fertility and Reproductive Medicine, Maimonides Medical Center, Brooklyn, NY; bObstetrics and Gynecology and Reproductive Sciences, Yale University School of Medicine, New Haven, CT; cOb/Gyn, Maimonides Medical Center, Brooklyn, NY.

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ASRM Abstracts

OBJECTIVE: Oftentimes sonographic findings in early pregnancy are inconclusive, and differentiating between intrauterine and extrauterine pregnancies (IUP and EUP) is challenging. In the first trimester, alpha-fetoprotein (AFP) concentration in fetal serum is at least 1000 fold higher than in maternal serum. The goal of this study was to determine whether measurement of AFP concentration in material evacuated from the uterus can assist with confirmation of an IUP. DESIGN: A prospective cohort study. MATERIALS AND METHODS: Eighteen pregnant women scheduled for dilation and curettage (D&C) were enrolled. As negative controls, endometrial sampling specimens were obtained from 2 women with a laparoscopically confirmed EUP. For each individual participant AFP concentration was measured in the serum and compared to its concentration in the liquid component of the specimen evacuated from the uterus. All specimens underwent histopathological analysis. IUP was confirmed or ruled out by the final pathology report. Values were expressed as mean  SEM. Paired t-test was used. RESULTS: The mean gestational age of the 20 participants was 9 weeks (range 5-14 weeks). Among the 18 women scheduled for D&C, the mean AFP concentrations in the maternal serum and the evacuated specimen were 53  41 ng/mL and 31,829  12,868 ng/mL, respectively (p ¼ 0.024). AFP concentrations in the evacuated specimen were 8 to 11,104 fold higher than in the corresponding maternal serum. Pathology reports confirmed IUP in all 18 specimens. In the 2 women with confirmed EUP, AFP concentration in the endometrial specimen did not differ from the concentration in the maternal serum. CONCLUSIONS: A relatively higher AFP concentration in the evacuated contents of the uterus than in maternal serum may confirm the presence of an IUP. AFP concentration levels can be obtained within 30 minutes, whereas a final pathology report is not usually available until 2-3 days thereafter. Therefore, the determination of whether a pregnancy is intrauterine vs. extrauterine can be expedited by comparing AFP levels as described above. Future studies are needed to investigate the utility of AFP measurement in the evaluation of first trimester bleeding. Supported by: This research was Supported by the Maimonides Medical Center Research Foundation.

P-710 Wednesday, October 21, 2015 ACTIVE NOTCH SIGNALING IN THE MOUSE DECIDUA AND H. I. Levin,a DEVELOPING PLACENTA. C. S. Sullivan-Pyke,a J. Deng,b J. Kitajewski,a C. Shawber,a N. C. Douglas.a aColumbia University Medical Center, New York, NY; bColumbia University, New York, NY. OBJECTIVE: Abnormal endothelial cell (EC)/trophoblast (TB) interactions are associated with improper implantation, early pregnancy failure and poor placentation. Notch signaling is a key regulator of angiogenesis. Our goal was to define the cell types with Notch activity and correlate this with Notch protein and ligand expression during uterine decidualization and placentation. DESIGN: Prospective animal laboratory. MATERIALS AND METHODS: The Notch reporter mouse, CBF:H2BVenus, was used to identify active Notch signaling. Implantation sites from pregnant females at embryonic day (E) 8.5 and placentas at E12.5 were analyzed. Double staining immunofluorescence was used to determine Notch activity in CD31+ endothelial cells (ECs), cytokeratin+ trophoblasts (TBs) and Tpbpa+ spongiotrophoblasts (spongio-TBs). Data was correlated to specific receptor (Notch1-4) and ligand (Delta-like (Dll) 4, Jagged (Jag) 1, Jag2) expression. Images were captured by confocal microscopy. RESULTS: Notch activity was detected in ECs of maternal decidual capillaries and spiral arterioles and in TBs and fetal ECs in the placenta (Table 1). Dll4 was co-expressed with Notch1 in ECs of decidual capillaries at E8.5, while both Dll4 and Jag1 were co-expressed with Notch1 in ECs of decidual capillaries at E12.5. At E8.5, Notch2, Notch4 and Dll4 overlap with Notch activity in TBs. In the E12.5 placental labyrinth, Notch activity was detected in fetal vessels that expressed Dll4 and Notch1 and in trophoblast giant cells (TGCs) that expressed Jag2, Notch2 and Notch4. Notch2 and Notch4 were also expressed in syncytiotrophoblasts (syncytio-TBs) surrounding fetal vessels. CONCLUSIONS: Notch signaling is active in decidual ECs and placental TBs, which overlaps with distinct Notch protein and ligand expression. Our data suggest that Dll4 and Jag1 activate Notch1 in maternal decidual

Vol. 104, No. 3, Supplement, September 2015