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Anxiety and depression are negatively correlated with art success: prospective study using hospital anxiety and depression scale (HADS)
within the 10-90% percentile curve. However, the numbers of cases are still few, we need to consider further long-term follow up in the future.
P-154 Tuesday, October 18, 2011 ANXIETY AND DEPRESSION ARE NEGATIVELY CORRELATED WITH ART SUCCESS: PROSPECTIVE STUDY USING HOSPITAL ANXIETY AND DEPRESSION SCALE (HADS). H. Matsubayashi, T. Sakai, A. Tsukamoto, A. Satoh, Y. Takahashi, T. Tomiyama. Obstetrics and Gynecology, Osaka New ART Clinic, Osaka, Japan. OBJECTIVE: Many papers have suggested that psychological factors are implicated in the experience of infertility, however whether stress and infertility are linked as cause or consequence is still debatable. We have examined prospectively the pregnancy success on ART (IVF, intracytoplasmic sperm injection: ICSI or freeze-thaw embryo transfer: FET) along with Hospital Anxiety and Depression Scale (HADS). DESIGN: A prospective observational study. MATERIALS AND METHODS: IRB approved the current study. We measured HADS of 272 women with unexplained infertility at the beginning of the menstrual cycle performing ART attempt between June 2009 and February 2010. ART results were compared with HADS and other demographic factors by logistic regression analysis with SPSS for Windows (Ver. 14.0, SPSS Japan Inc., Tokyo, Japan). RESULTS: In 272 women, 76 became positive pregnancy test and 196 did not. Among positive test group, 37 miscarried including chemical pregnancy, 37 succeeded at least after 10 wk of gestation, 2 ended in ectopic pregnancy. Logistic regression analysis revealed that low HADS significantly related to pregnancy success (P¼0.03). Relative risk of pregnancy success (pregnant without miscarriage) in women with 13 or more HADS compared with less than 13 HADS was 0.309 (95% confidence interval: 0.113-0.844). Contrary, there was no association between pregnancy success and pregnancy histories (delivery of babies, P¼0.69; miscarriages, P¼0.83; artificial abortions, P¼0.76), previous number of ART failures (P¼0.16) or patient age (P¼0.05). FET showed significantly greater success rate than fresh IVF or ICSI (P¼0.02). CONCLUSION: Our finding suggests that elevated HADS in women with unexplained infertility is a risk factor for attaining pregnancy success. Psychological interventions to relieve or diminish these conditions might have significant therapeutic benefits for women prior to perform ART.
P-155 Tuesday, October 18, 2011 PSYCHOLOGICAL AND PHYSICAL SYMPTOMS IN WOMEN UNDERGOING SUPEROVULATION WITH CLOMIPHENE CITRATE: A DOUBLE-BLIND, PLACEBO-CONTROLLED, CROSSOVER STUDY. J. H. Pittman, A. Hammoud, W. R. Keye, S. E. Gurtcheff, L. Czajkowski, M. Gibson. Obstetrics and Gynecology, University of Utah, Salt Lake City, UT; Psychiatry, University of Utah, Salt Lake City, UT. OBJECTIVE: To identify psychological and physical symptoms experienced by women taking clomiphene citrate for superovulation in a prospective setting. DESIGN: Randomized, double-blind, placebo-controlled, crossover study. MATERIALS AND METHODS: After initial screening, twenty women with unexplained infertility seeking treatment with clomiphene citrate for superovulation participated in a two month double blind, placebo-controlled crossover study that included treatment with clomiphene citrate 50mg or placebo during menstrual cycle days 3-7, administered in a randomized order. Clinical care for infertility treatment in each cycle of the study conformed to standard care for women undergoing superovulation with clomiphene citrate and intrauterine insemination. If pregnancy did not occur in the initial study cycle, participants then crossed-over to the second cycle of the study. Symptoms were recorded daily using the Calendar of Premenstrual Experiences (COPE), a 22-item survey including 12 behavioral and 10 physical symptoms. Mean follicular and luteal phase scores were determined for each study phase and analyzed using a paired t-test. RESULTS: Of the twenty subjects enrolled, 16 women completed both cycles. Three women had positive pregnancy test results after cycle 1 and one woman was anovulatory. Symptoms most frequently reported during the follicular phase were headache and fatigue, while bloatedness and irritability were more commonly reported in the luteal phase.
FERTILITY & STERILITYÒ
CONCLUSION: Clomiphene citrate is well tolerated as treatment for superovulation, without significant increase in side effects compared to placebo. Supported by: Internal funding from the University of Utah Department of Obstetrics and Gynecology, Division of Reproductive Endocrinology and Infertility.
PRACTICE MANAGEMENT
P-156 Tuesday, October 18, 2011 PREDICTIVE VALUE OF INITIAL HUMAN CHORIONIC GONADOTROPIN (hCG) DECLINE IN PREGNANCIES OF UNKNOWN LOCATION (PULs). M. S. Greenman, W. S. Vitek, C. A. Raker, S. A. Carson. Department of Obstetrics and Gynecology, Women & Infants Hospital of Rhode Island, Providence, RI; Division of Reproductive Endocrinology and Infertility, Women & Infants Hospital of Rhode Island, Providence, RI; Women and Infants Division of Research, Women & Infants Hospital of Rhode Island, Providence, RI. OBJECTIVE: Multiple approaches to PULs exist with the goal of identifying and treating ectopic pregnancies, while minimizing unnecessary interventions. Spontaneously resolving PULs are defined as unlocated pregnancies where hCG resolution is observed without medical or surgical intervention. The ability to predict the time to hCG resolution in this population would inform patient counseling and reduce the number of serial hCG levels drawn to confirm resolution. The hypothesis of this study is that the slope of decline between the initial serial hCG levels will predict the time to hCG resolution in spontaneous resolving PULs. Secondary aims of this study were to identify characteristics associated with provider intervention in managing PULs. DESIGN: Retrospective cohort. MATERIALS AND METHODS: Of the 1178 women managed through the Women & Infants Hospital Emergency Room from 2008 -2010, 351 subjects had the initial diagnosis of PUL. Of these 351 subjects, 70 were classified as spontaneously resolving PULs given the following criteria: unlocated pregnancy upon initial evaluation, decline between the first and second hCG levels drawn within a 36-60 hour period from initial diagnosis, and spontaneous resolution of hCG to <5 mIU/ml without intervention. The correlation between the slope of initial hCG decline and time to hCG resolution was analyzed using spearman rank correlation. Characteristics associated with provider intervention were analyzed using Fisher’s exact test or T-test. RESULTS: The slope of initial hCG decline and the time to hCG resolution was not correlated given a rank correlation of -0.067 (P¼0.6). 16% underwent intervention such as uterine curettage or empiric methotrexate. A mean hCG decline of 22% was associated with an intervention. A mean decline of 60% was observed in subjects diagnosed with spontaneously resolving PULs (P<0.0001). CONCLUSION: Although the slope of initial hCG decline in PULs was not predictive of time to hCG resolution, it was predictive of provider decision to perform an intervention.
P-157 Tuesday, October 18, 2011 ESTABLISHING OF A PAY FOR PERFORMANCE PROGRAM FOR IN VITRO FERTILIZATION (IVF). E. M. Rosenbluth, A. E. T. Sparks, B. J. Van Voorhis. Obstetrics and Gynecology, University of Iowa Hospitals and Clinics, Iowa City, IA. OBJECTIVE: To establish a pay for performance program with Iowa’s largest insurer (Wellmark, 60% covered lives) that would reward good IVF outcomes. DESIGN: Retrospective analysis. MATERIALS AND METHODS: We determined Wellmark’s reimbursement for IVF, maternal, and neonatal care up to the day of discharge for live-birth deliveries for women who received their care at our center. Cost for all of our IVF patients were extrapolated from these data. We recalculated and compared estimated costs to Wellmark had our outcomes been equivalent to national averages by using 2006 CDC data for IVF pregnancy and multiple gestation rates. RESULTS: 38 insured women (31 singletons, 4 twins, and 3 triplets) who delivered at our center cost $42,893 for singletons, $209,716 for twins, and $268,274 for triplets. A total of 202 IVF live births: 164 (81%) singletons,
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P-154 Tuesday, October 18, 2011 ANXIETY AND DEPRESSION ARE NEGATIVELY CORRELATED WITH ART SUCCESS: PROSPECTIVE STUDY USING HOSPITAL ANXIETY AND DEPRESSION SCALE (HADS). H. Matsubayashi, T. Sakai, A. Tsukamoto, A. Satoh, Y. Takahashi, T. Tomiyama. Obstetrics and Gynecology, Osaka New ART Clinic, Osaka, Japan. OBJECTIVE: Many papers have suggested that psychological factors are implicated in the experience of infertility, however whether stress and infertility are linked as cause or consequence is still debatable. We have examined prospectively the pregnancy success on ART (IVF, intracytoplasmic sperm injection: ICSI or freeze-thaw embryo transfer: FET) along with Hospital Anxiety and Depression Scale (HADS). DESIGN: A prospective observational study. MATERIALS AND METHODS: IRB approved the current study. We measured HADS of 272 women with unexplained infertility at the beginning of the menstrual cycle performing ART attempt between June 2009 and February 2010. ART results were compared with HADS and other demographic factors by logistic regression analysis with SPSS for Windows (Ver. 14.0, SPSS Japan Inc., Tokyo, Japan). RESULTS: In 272 women, 76 became positive pregnancy test and 196 did not. Among positive test group, 37 miscarried including chemical pregnancy, 37 succeeded at least after 10 wk of gestation, 2 ended in ectopic pregnancy. Logistic regression analysis revealed that low HADS significantly related to pregnancy success (P¼0.03). Relative risk of pregnancy success (pregnant without miscarriage) in women with 13 or more HADS compared with less than 13 HADS was 0.309 (95% confidence interval: 0.113-0.844). Contrary, there was no association between pregnancy success and pregnancy histories (delivery of babies, P¼0.69; miscarriages, P¼0.83; artificial abortions, P¼0.76), previous number of ART failures (P¼0.16) or patient age (P¼0.05). FET showed significantly greater success rate than fresh IVF or ICSI (P¼0.02). CONCLUSION: Our finding suggests that elevated HADS in women with unexplained infertility is a risk factor for attaining pregnancy success. Psychological interventions to relieve or diminish these conditions might have significant therapeutic benefits for women prior to perform ART.
P-155 Tuesday, October 18, 2011 PSYCHOLOGICAL AND PHYSICAL SYMPTOMS IN WOMEN UNDERGOING SUPEROVULATION WITH CLOMIPHENE CITRATE: A DOUBLE-BLIND, PLACEBO-CONTROLLED, CROSSOVER STUDY. J. H. Pittman, A. Hammoud, W. R. Keye, S. E. Gurtcheff, L. Czajkowski, M. Gibson. Obstetrics and Gynecology, University of Utah, Salt Lake City, UT; Psychiatry, University of Utah, Salt Lake City, UT. OBJECTIVE: To identify psychological and physical symptoms experienced by women taking clomiphene citrate for superovulation in a prospective setting. DESIGN: Randomized, double-blind, placebo-controlled, crossover study. MATERIALS AND METHODS: After initial screening, twenty women with unexplained infertility seeking treatment with clomiphene citrate for superovulation participated in a two month double blind, placebo-controlled crossover study that included treatment with clomiphene citrate 50mg or placebo during menstrual cycle days 3-7, administered in a randomized order. Clinical care for infertility treatment in each cycle of the study conformed to standard care for women undergoing superovulation with clomiphene citrate and intrauterine insemination. If pregnancy did not occur in the initial study cycle, participants then crossed-over to the second cycle of the study. Symptoms were recorded daily using the Calendar of Premenstrual Experiences (COPE), a 22-item survey including 12 behavioral and 10 physical symptoms. Mean follicular and luteal phase scores were determined for each study phase and analyzed using a paired t-test. RESULTS: Of the twenty subjects enrolled, 16 women completed both cycles. Three women had positive pregnancy test results after cycle 1 and one woman was anovulatory. Symptoms most frequently reported during the follicular phase were headache and fatigue, while bloatedness and irritability were more commonly reported in the luteal phase.
FERTILITY & STERILITYÒ
CONCLUSION: Clomiphene citrate is well tolerated as treatment for superovulation, without significant increase in side effects compared to placebo. Supported by: Internal funding from the University of Utah Department of Obstetrics and Gynecology, Division of Reproductive Endocrinology and Infertility.
PRACTICE MANAGEMENT
P-156 Tuesday, October 18, 2011 PREDICTIVE VALUE OF INITIAL HUMAN CHORIONIC GONADOTROPIN (hCG) DECLINE IN PREGNANCIES OF UNKNOWN LOCATION (PULs). M. S. Greenman, W. S. Vitek, C. A. Raker, S. A. Carson. Department of Obstetrics and Gynecology, Women & Infants Hospital of Rhode Island, Providence, RI; Division of Reproductive Endocrinology and Infertility, Women & Infants Hospital of Rhode Island, Providence, RI; Women and Infants Division of Research, Women & Infants Hospital of Rhode Island, Providence, RI. OBJECTIVE: Multiple approaches to PULs exist with the goal of identifying and treating ectopic pregnancies, while minimizing unnecessary interventions. Spontaneously resolving PULs are defined as unlocated pregnancies where hCG resolution is observed without medical or surgical intervention. The ability to predict the time to hCG resolution in this population would inform patient counseling and reduce the number of serial hCG levels drawn to confirm resolution. The hypothesis of this study is that the slope of decline between the initial serial hCG levels will predict the time to hCG resolution in spontaneous resolving PULs. Secondary aims of this study were to identify characteristics associated with provider intervention in managing PULs. DESIGN: Retrospective cohort. MATERIALS AND METHODS: Of the 1178 women managed through the Women & Infants Hospital Emergency Room from 2008 -2010, 351 subjects had the initial diagnosis of PUL. Of these 351 subjects, 70 were classified as spontaneously resolving PULs given the following criteria: unlocated pregnancy upon initial evaluation, decline between the first and second hCG levels drawn within a 36-60 hour period from initial diagnosis, and spontaneous resolution of hCG to <5 mIU/ml without intervention. The correlation between the slope of initial hCG decline and time to hCG resolution was analyzed using spearman rank correlation. Characteristics associated with provider intervention were analyzed using Fisher’s exact test or T-test. RESULTS: The slope of initial hCG decline and the time to hCG resolution was not correlated given a rank correlation of -0.067 (P¼0.6). 16% underwent intervention such as uterine curettage or empiric methotrexate. A mean hCG decline of 22% was associated with an intervention. A mean decline of 60% was observed in subjects diagnosed with spontaneously resolving PULs (P<0.0001). CONCLUSION: Although the slope of initial hCG decline in PULs was not predictive of time to hCG resolution, it was predictive of provider decision to perform an intervention.
P-157 Tuesday, October 18, 2011 ESTABLISHING OF A PAY FOR PERFORMANCE PROGRAM FOR IN VITRO FERTILIZATION (IVF). E. M. Rosenbluth, A. E. T. Sparks, B. J. Van Voorhis. Obstetrics and Gynecology, University of Iowa Hospitals and Clinics, Iowa City, IA. OBJECTIVE: To establish a pay for performance program with Iowa’s largest insurer (Wellmark, 60% covered lives) that would reward good IVF outcomes. DESIGN: Retrospective analysis. MATERIALS AND METHODS: We determined Wellmark’s reimbursement for IVF, maternal, and neonatal care up to the day of discharge for live-birth deliveries for women who received their care at our center. Cost for all of our IVF patients were extrapolated from these data. We recalculated and compared estimated costs to Wellmark had our outcomes been equivalent to national averages by using 2006 CDC data for IVF pregnancy and multiple gestation rates. RESULTS: 38 insured women (31 singletons, 4 twins, and 3 triplets) who delivered at our center cost $42,893 for singletons, $209,716 for twins, and $268,274 for triplets. A total of 202 IVF live births: 164 (81%) singletons,
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