Embryonic karyotype as a prognostic indicator in women with unexplained recurrent pregnancy loss

MATERIALS AND METHODS: Women with molar pregnancies were identified using ICD codes. The medical record was reviewed to confirm the diagnosis which required histopathology. Women were included in the study if they had confirmed molar pregnancy diagnosis and were less than 14 weeks gestation. Procedure location was determined from the operative note and appointment schedule. Charts were reviewed for complications including: need to stop procedure due to pain, conversion to general anesthesia, postabortal syndrome, estimated blood loss greater than 300ccs, blood transfusion, hospital admission, uterine perforation, endometritis, retained products of conception, and visit to the emergency department within 2 weeks. Additionally, the incidence of recurrent gestational neoplastic disease, metastases and need for chemotherapy was recorded. Risk factors for complications including uterine size, gestational age, mean sac diameter by ultrasound, suspicion for mole preoperatively and maximum b-hcg values were also examined. RESULTS: We identified 136 women with histopathology confirmed molar pregnancy of which 49 underwent office MVA. Patients undergoing office based procedures had slightly smaller gestational ages (53.0 vs 63.7 days for OR group, p 0.03). B-hcg values were also lower for office based procedures (56,203 vs. 161,478, p<0.001). Patients undergoing evacuation in the clinic were less likely to have blood loss greater than 300ccs (4.1% vs. 42.5% in the OR group, p <0.001). There were no other significant differences in complication rates. CONCLUSION: Based on this small series of patients, complication rates were not increased if treated in the office as compared to in the operating room. P-534 Wednesday, October 16, 2013 EMBRYONIC KARYOTYPE AS A PROGNOSTIC INDICATOR IN WOMEN WITH UNEXPLAINED RECURRENT PREGNANCY LOSS. J. A. M. Massiea R. B. Lathi.b aReproductive Endocrinology and Infertility, San Antonio Military Medical Center, Fort Sam Houston, TX; b Reproductive Endocrinology and Infertility, Stanford University Medical Center, Palo Alto, CA. OBJECTIVE: To ascertain if women with unexplained recurrent pregnancy loss (RPL) who experience euploid miscarriages have a similar prognosis for live birth as women with aneuploid miscarriages. DESIGN: Cohort study. MATERIALS AND METHODS: Women with unexplained RPL who had chromosomal analysis of a miscarriage specimen and subsequently conceived a clinical pregnancy were included. RPL was defined as R2 clinical pregnancy losses, <20 weeks. Patients were excluded if they had an identifiable cause of RPL, such as uterine cavity abnormality, parental chromosome abnormality, or Antiphospholipid Antibody Syndrome. Those that utilized PGS, donor oocytes or gestational carrier were also excluded. Live birth rate (LBR) in the first subsequent pregnancy was compared between patients with euploid and aneuploid miscarriages. Statistical analysis utilized Student’s t-test or X2 tests, with logistic-regression to adjust for potential confounders. RESULTS: 391 women with a history of RPL between April 1998 and November 2011 were identified. Of these, 95 satisfied all inclusion and exclusion criteria. Demographic characteristics are shown in Table 1. There was a non-significant trend toward a lower LBR after a euploid loss compared to aneuploid loss (52% vs 67%). TABLE 1.

Euploid (n¼40)

Aneuploid (n¼55)

Age (time of intake loss) 35.9 36.7 (range 26-43) (range 25-42) # SABs 2 21 (52.5%) 26 (47.3%) 3 11 (27.5%) 21 (38.2%) R4 8 (20.0%) 8 (14.5%) Method of Conception Spontaneous 22 (55%) 25 (45%) IUI 7 (18%) 14 (25%) IVF 11 (27%) 16 (29%) BMI <25 27 (67.5%) 36 (65.5%) R25 13 (32.5%) 19 (34.5%) Primary RPL 26 (65.0%) 37 (67.3%)

FERTILITY & STERILITYÒ

p-value 0.15

CONCLUSION: Counseling patients with unexplained RPL is based largely on age and previous number of losses. Embryonic karyotype may offer an additional prognostic marker in women with unexplained RPL. Further research is needed into the etiology of euploid losses in patients with RPL, as the prognosis seems to be worse for these patients. P-535 Wednesday, October 16, 2013 HUMAN CHORIONIC GONADOTROPIN (hCG) TRENDS IN THE MEDICAL MANAGEMENT OF ECTOPIC PREGNANCY WITH SINGLE-DOSE (SD) AND TWO-DOSE (2D) METHOTREXATE PROTOCOLS: A DIFFERENCE OF RISK. M. C. Mergenthal,a S. Senapati,b J. Zee,c L. Allen-Taylor,d M. D. Sammel,c K. T. Barnhart.b a Department of Obstetrics and Gynecology, University of Pennsylvania, Philadelphia, PA; bDepartment of Obstetrics and Gynecology, Reproductive Endocrinology and Infertility, University of Pennsylvania, Philadelphia, PA; c Department of Biostatistics and Epidemiology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA; dCenter for Clinical Epidemiology and Biostatistics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA. OBJECTIVE: To evaluate the association between methotrexate (MTX) protocol, hCG trends, and time to resolution of ectopic pregnancy (EP). DESIGN: Retrospective multicenter cohort study. MATERIALS AND METHODS: Women diagnosed with EP in 20072009 who underwent management with either SD or 2D MTX protocol were included. Data on center, age, race, ethnicity, parity, body mass index, gestational age, ultrasound findings, hCG levels on days 0, 4, and 7, and treatment outcome were collected. Successful resolution was hCG<5 mIU/mL while failure was need for surgical management after MTX. A propensity score analysis was used to address confounding by indication. Linear regression models were used to assess hCG change from day 0 to 7 and day 4 to 7 by protocol while Cox proportional hazards models were used to assess time to success. RESULTS: 162 women were included; 114 received SD and 48 received 2D. Protocol differed by center, race, and ethnicity (p<0.001, p¼0.011, and p<0.001, respectively). hCG levels declined faster in the SD compared to 2D group from day 0 to 4 (-10.8% vs. +5.14%, p¼0.03); however, the change from day 4 to 7 was no different between groups (p¼0.11). Success rates were comparable between the two groups (83% vs. 79%, p¼0.53). There was no difference in time to success (HR 0.67, p¼0.44). CONCLUSION: We hypothesized that 2D protocol would have a greater effect on hCG decline and would result in a faster time to resolution. However, outcomes were similar due to confounding by indication in clinical practice. SD protocol was given to patients with better prognosis as demonstrated by the larger hCG drop from day 0 to 4, when MTX exposure is the same between the two protocols. Ultimately, there was no difference in success rates or time to success between the two groups, suggesting that the 2D protocol may be attenuating the expected poor prognosis and subsequent risk of failure. Randomized trials are needed to elucidate differences between protocols. Supported by: T32HD007440 (SS), K24HD060687 (KB). P-536 Wednesday, October 16, 2013 HOW LOW CAN YOU GO? INTERPRETING LOW BETA HUMAN CHORIONIC GONADOTROPIN (hCG) LEVELS FOLLOWING IN VITRO FERTILIZATION (IVF) AND FROZEN EMBRYO TRANSFER (FET). J. Buldo-Licciardi,a K. N. Goldman,a D. McCulloh,a F. Licciardi,a J. Goldfarb,b J. A. Grifo.a aObstetrics and Gynecology, Reproductive Endocrinology and Infertility, New York University Langone Medical Center, New York, NY; bUniversity Hospitals of Cleveland Fertility Center, Beachwood, OH.

0.76

0.57

0.42 0.41

OBJECTIVE: To assess outcomes in patients with low (<50mIU/ml) initial hCG levels on cycle day 28 following IVF and FET. DESIGN: Retrospective cohort study. MATERIALS AND METHODS: From October 2010 through March 2013, 368 women were identified who underwent IVF (n¼269) and FET (n¼99) at our center and presented with a cycle day 28 hCG level R5 and <50mIU/ml. We sought to determine the incidence of biochemical pregnancy, spontaneous abortion or anembryonic gestation, ectopic pregnancy, and ongoing pregnancy(OP)/live birth in patients presenting with low initial hCG following frozen versus fresh cycles. Data were analyzed using Fisher’s Exact and Student’s T-test.

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