- Email: [email protected]
Incidence of Chronic Endometritis and Subsequent Pregnancy Outcomes in Patients with Recurrent Pregnancy Loss
had such a prediction based on age alone. Compared with age-based controls, PredictIVF-D showed 75% improved predictive power, ability to discriminate cases with differential prognoses (10% improvement in area-underthe-curve in a receiver operating characteristic analysis), while extending the dynamic range from four discrete, age-based probabilities to a continuous spectrum ranging from 7 to 60%. Table 1 shows the population distribution and error for five different prognostics groups. CONCLUSION(S): Using a validated, multi-center IVF prediction model, we showed that a large portion of patients with prior IVF would receive a significantly different predicted probability compared with agebased counseling, at improved predictive power and discrimination, and reliable accuracy.
Cycle demographics and outcomes
TABLE 1. PredictIVF-D error rate for each prognostic group Probability of live birth by predictIVF-D
Population distribution (Percentage of cycles)
PredictIVF error
8% 26% 27% 23% 17%
0.9% 1.9% 0.6% 1.4% 1.2%
>50% 40-50% 30-40% 20-30% 0-20%
SUPPORT: Each institution funded its research expenses and personnel.
P-9 Motherhood after Malignancy: Embracing Oocyte Banking (OB) as a Means to Preserve Fertility between Diagnosis and Cure. Brooke Hodes-Wertz,a J. M. Knopman,b K. Melzer,a S. Druckenmiller,a N. Noyes.a a New York University School of Medicine, New York NY; bMt. Sinai School of Medicine, New York, NY. BACKGROUND: No longer carrying an experimental designation, OB can now serve as a viable fertility preservation (FP) option for cancer survivors. OBJECTIVE(S): Reporting of FP cycles performed for malignancy. MATERIALS AND METHOD(S): All cancer patients (n¼166) referred to one clinician were counseled. Treatment protocols were tailored to cancer diagnoses. FP choices included: no treatment, OB-only, OB+2-pronuclear zygote banking (ZB), or ZB-only. RESULT(S): See Table. Fourteen patients declined treatment; 152 (92%) completed R1 FP cycle; 10 women cycled twice; 2,878 oocytes [2,195 mature (MII)] were collected. Oocyte yield was age but not diagnosis-dependent, even with full tumor load; only prior ovarian surgery negatively impacted outcome. To minimize OHSS, GnRH-agonist was substituted as the ovulation trigger in 68 (42%) cases. Oocyte yield (mean: 2214) and percent MII (mean: 1712; total:1155/1516¼76%) were not compromised when compared with cycles using hCG. Two unexpected complications occurred in HL patients. A 17yo had no oocytes retrieved, received an hCG trigger that day, followed by harvest of 27 oocytes and subsequent OHSS; a 29yo with peak-E2 of 3087 pg/ml and robust ultrasound cohort had only 3 oocytes harvested. One other 15yo HL patient underwent successful stimulation and retrieval despite being premenarchal. In 45/58 (78%) breast-cancer cycles, an aromatase inhibitor was added to the stimulation regimen resulting in lower peak E2 (833497 pg/ml) with 1711 oocytes retrieved (129 MII)/cycle. In 22 of these cycles, GnRHagonist served as the ovulation trigger; oocyte yield (2213) and maturity (330/479¼69%) were not significantly impacted, suggesting that this combination is an acceptable alternative for patients with hormone-sensitive tumors. In urgent situations where patients weren’t near menstrual day-2 (n¼26), the administration of GnRH-antagonist oral contraceptives for 4-6 days (‘‘quick-start’’) decreased time from REI consult-to-retrieval resulting in peak E2 of 14651226 pg/ml, 102 stimulation days and 168 retrieved (137 MII) oocytes. Fourteen oocyte/embryo thaws have been performed in 9 cancer survivors; 3 patients used a gestational carrier. For ZB, 19 zygotes were thawed in 7 cycles; mean:3/cycle. For OB, 32 oocytes were thawed in 5 cycles;
FERTILITY & STERILITYÒ
mean:6/cycle. Three of nine (33%) ZB and 1/5 (20%) OB cycles resulted in an ongoing/live birth. The OB success was age 40.5yo at freeze, representing the oldest oocytes thawed resulting in pregnancy for a cancer survivor. CONCLUSION(S): OBZB appear acceptable FP options for cancer patients. OB enhances reproductive autonomy and minimizes ethical and personal dilemmas. Unique considerations/complications may arise when treating this patient population. Continued advances/research may help to improve outcomes.
Cancer diagnosis All (n¼152 pts; 162 cycles) Breast All (n¼54 pts) Letrozole (n¼45 pts) No Letrozole (n¼9 pts) Gynecologic All (n¼52 pts, including 4 ‘‘other’’) Ovary (n¼24 pts) Cervix (n¼15 pts) Endometrial (n¼9) Hematologic (lymphoma, leukemia) (n¼30 pts) Other (genitourinary, gastrointestinal, CNS, thymic, thyroid, sarcoma) (n¼16 pts) Timing From request to REI consult From REI consult to retrieval if urgent (n¼74) Duration of ovarian stimulation Partnership status at diagnosis and FP choice Not Partnered Chose OB-only Chose OB+ZB Chose ZB-only Partnered Chose OB-only Chose OB+ZB Chose ZB-only
Age (y) (mean)
E2 Day of ov trigger (pg/ml)
Total no. retrieved eggs
Total no. MII eggs
31
1785
18
14
35 35 37
987 833 1518
17 16 19
12 12 14
30
2376
16
12
28 31 28 25
1837 2600 3526 2250
12 18 23 21
9 15 17 17
29
1700
19
15
Days 2 17 10 n
%
81 78 1 2 71 28 20 23
53% 96% 1% 3% 47% 40% 28% 32%
FINANCIAL SUPPORT: None.
P-10 Incidence of Chronic Endometritis and Subsequent Pregnancy Outcomes in Patients with Recurrent Pregnancy Loss. C. O. Perfetto,a F. K. Hazard,b R. B. Lathi.a aDept of Ob/Gyn; bDept of Pathology, Stanford University Medical Center, Palo Alto, CA. BACKGOUND: Over half of the patients diagnosed with recurrent pregnancy loss (RPL) have no explanation for their losses after a standard evaluation. In an effort to identify treatable factors associated with RPL, endometrial pathology has become an area of emerging research. Early literature reports a prevalence of chronic endometritis (CE) of 0.2-46%, but more recent studies suggest a rate of 2.8% and 9.3% in patients with infertility and RPL, respectively (1, 2). Pregnancy outcomes after treatment are largely unknown. OBJECTIVE(S): To report the incidence and subsequent pregnancy outcomes in women with RPL and CE.
S11
MATERIALS AND METHOD(S): This is a prospective study on patients seen in an RPL clinic during 2010-2012. Only patients with 2 or more clinical pregnancy losses were included. All patients underwent a standard RPL work-up, including uterine evaluation, anti-phospholipid antibody testing, and parental chromosome analysis. Additionally, an endometrial biopsy (EMB) was obtained and the specimens were evaluated for CE by the Department of Pathology. Chronic endometritis was diagnosed by histopathologic review of endometrial biopsy specimens and categorized as positive (>1 plasma cell/hpf) and negative (<1 plasma cell/hpf). Patients diagnosed with CE were treated with Doxycycline for 3 weeks and had a repeat EMB after treatment prior to attempting pregnancy. RESULT(S): Of the 116 RPL patients who had an EMB, 10 (8.6%) had biopsy-proven CE. Patient age and body mass index was similar between the groups. There was a trend toward a higher rate of secondary RPL (70% vs. 35%) in those women with CE. There was also a trend toward a lower pregnancy rate after a diagnosis of CE, compared with those with a normal biopsy, but no apparent difference in subsequent miscarriage rate.
EMB positive for CE
EMB negative for CE
All patients (116) 10 (8.6%) 106 (91.4%) Ages 36.4yr 36.6yr Unexplained RPL** 9 (90%) 86 (80%) Mean number of prior losses 3.5 (range, 2-7) 3 (range, 2-7) Primary RPL 3/10 (30%) 69/116 (65%) Secondary RPL 7/10 (70%) 37/116 (35%) Underweight (BMI <18.5) 2 (20%) 2 (2%) Normal weight (BMI 18.6-24.9) 4 (40%) 68 (66%) Overweight (BMI 25-29.9) 3 (30%) 22 (21%) Obese (BMI >30) 1 (10%) 11 (10%) Pregnant after EMB 3 (30%) 58 (55%) Clinical pregnancy loss 1 (33%) 11 (21%) Ongoing or live birth 2 (67%) 45 (80%) Not pregnant after EMB 7 (70%) 47 (45%) ** Unexplained RPL if uterine cavity, parental karyotypes, and anti-phospholipid antibody testing was normal.
CONCLUSION(S): Overall, we found an 8.6% incidence of CE in this population of RPL patients, which is similar to prior literature. There was no difference in age, BMI, or number of prior losses in patients with CE. A trend toward higher rates of secondary RPL and lower pregnancy rates in patients diagnosed with CE was noted. Given the small num-
Female diagnosis
Male diagnosis
bers of patients with CE in this pilot study, further research is ongoing to counsel patients with chronic endometritis about future pregnancy rates and outcomes. FINANCIAL SUPPORT: Nothing to disclose. References 1. Kasius JC, Fatemi HM, et al. The impact of chronic endometritis on reproductive outcome. Fert & Steril 2011;96(6). 2. Kitaya K. Prevalence of chronic endometritis in recurrent miscarriages. Fert & Steril. 2011;95(3).
P-11 Use of Confocal Laser and Three-dimensional Imaging Techniques to Study Failed Fertilization after ICSI: A Pilot Study. Chandra Shenoy, Jeffrey M. Goldberg, Stephanie Ploskonka, Nina Desai. Obstetrics and Gynecology/Women’s Health Institute, Cleveland Clinic, 16900 Cedar Rd. Beachwood, OH, United States, 44122. BACKGROUND: While many observations have been made of the sperm and oocyte after intracytoplasmic sperm injection (ICSI) failure via conventional microscopy and FISH, confocal laser microscopy has the potential to provide greater details to help elucidate the cause of ICSI fertilization failure. OBJECTIVE(S): This study looks at oocytes that failed to fertilize after ICSI using confocal laser microscopy with three-dimensional image analysis. MATERIALS AND METHOD(S): After ICSI, oocytes were noted to be unfertilized, fertilized, or abnormally fertilized (1PN/3PN). The unfertilized oocytes were fixed in formaldehyde and stained with alpha- and beta-tubulin and propidium iodide to identify DNA of the oocyte, polar bodies, and the sperm using confocal microscopy. Confocal sections were assembled to make interactive three-dimensional models. Photographs could be taken from all sides and angles. Videos of rotating oocytes were captured. Patient’s infertility diagnoses and IVF cycle outcomes were recorded. RESULT(S): Seventeen oocytes from 9 couples were stained, mounted, imaged, and analyzed. The use of confocal laser sectioning and three-dimensional modeling greatly enhanced our ability to study fertilization failure. Early events in meiotic arrest were able to be visualized. Types of defects seen were: unactivated oocytes, fragmented pronuclear formation, failure of the sperm decondensation, premature sperm chromatin condensation (PCC), extruded sperm, and sperm injected in close proximity to meiotic spindles that may have cause disruption. CONCLUSION(S): Confocal laser microscopy with three-dimensional imaging served to better define the causes of ICSI fertilization failure. While some degree of fertilization failure is expected, complete or near total fertilization failure is a clinical problem. Helping to delineate the cause of these fertilization failures as a primary sperm defect, oocyte defect, or
Fertilization rate
# Mature eggs
Oocyte
Sperm
Fragmented pronucleus Unactivated Disorganized spindle Unactivated Unactivated Unactivated Activated Unactivated Activated Disrupted spindle Disrupted spindle Unactivated Unactivated Unactivated Unactivated Activated Unactivated
Decondensed Nondecondensed Nondecondensed PCC Extruded sperm PCC Decondensed Nondecondensed Decondensed Decondensed Nondecondensed Partially decondensed Partially decondensed Partially decondensed Extruded sperm Decondensed Extruded sperm
Couple 1 Couple 2 Couple 3 Couple 4
Endometriosis Tubal Donor Tubal
Mild teratospermia Normal SA Normal SA Normal SA
86% 50% 71% 66%
21 6 7 12
Couple 5
Normal
CAVD/PESA
72%
11
Couple 6
Normal
Asthenoteratospermia
73%
11
Couple 7 Couple 8
Unexplained PCOS
Mild asthenospermia Quadriplegia/PESA
71% 50%
7 14
Couple 9
Unexplained
Normal SA
46%
13
S12
PCRS Abstracts
Vol. 99, No. 3, Supplement, March 1, 2013
Cycle demographics and outcomes
TABLE 1. PredictIVF-D error rate for each prognostic group Probability of live birth by predictIVF-D
Population distribution (Percentage of cycles)
PredictIVF error
8% 26% 27% 23% 17%
0.9% 1.9% 0.6% 1.4% 1.2%
>50% 40-50% 30-40% 20-30% 0-20%
SUPPORT: Each institution funded its research expenses and personnel.
P-9 Motherhood after Malignancy: Embracing Oocyte Banking (OB) as a Means to Preserve Fertility between Diagnosis and Cure. Brooke Hodes-Wertz,a J. M. Knopman,b K. Melzer,a S. Druckenmiller,a N. Noyes.a a New York University School of Medicine, New York NY; bMt. Sinai School of Medicine, New York, NY. BACKGROUND: No longer carrying an experimental designation, OB can now serve as a viable fertility preservation (FP) option for cancer survivors. OBJECTIVE(S): Reporting of FP cycles performed for malignancy. MATERIALS AND METHOD(S): All cancer patients (n¼166) referred to one clinician were counseled. Treatment protocols were tailored to cancer diagnoses. FP choices included: no treatment, OB-only, OB+2-pronuclear zygote banking (ZB), or ZB-only. RESULT(S): See Table. Fourteen patients declined treatment; 152 (92%) completed R1 FP cycle; 10 women cycled twice; 2,878 oocytes [2,195 mature (MII)] were collected. Oocyte yield was age but not diagnosis-dependent, even with full tumor load; only prior ovarian surgery negatively impacted outcome. To minimize OHSS, GnRH-agonist was substituted as the ovulation trigger in 68 (42%) cases. Oocyte yield (mean: 2214) and percent MII (mean: 1712; total:1155/1516¼76%) were not compromised when compared with cycles using hCG. Two unexpected complications occurred in HL patients. A 17yo had no oocytes retrieved, received an hCG trigger that day, followed by harvest of 27 oocytes and subsequent OHSS; a 29yo with peak-E2 of 3087 pg/ml and robust ultrasound cohort had only 3 oocytes harvested. One other 15yo HL patient underwent successful stimulation and retrieval despite being premenarchal. In 45/58 (78%) breast-cancer cycles, an aromatase inhibitor was added to the stimulation regimen resulting in lower peak E2 (833497 pg/ml) with 1711 oocytes retrieved (129 MII)/cycle. In 22 of these cycles, GnRHagonist served as the ovulation trigger; oocyte yield (2213) and maturity (330/479¼69%) were not significantly impacted, suggesting that this combination is an acceptable alternative for patients with hormone-sensitive tumors. In urgent situations where patients weren’t near menstrual day-2 (n¼26), the administration of GnRH-antagonist oral contraceptives for 4-6 days (‘‘quick-start’’) decreased time from REI consult-to-retrieval resulting in peak E2 of 14651226 pg/ml, 102 stimulation days and 168 retrieved (137 MII) oocytes. Fourteen oocyte/embryo thaws have been performed in 9 cancer survivors; 3 patients used a gestational carrier. For ZB, 19 zygotes were thawed in 7 cycles; mean:3/cycle. For OB, 32 oocytes were thawed in 5 cycles;
FERTILITY & STERILITYÒ
mean:6/cycle. Three of nine (33%) ZB and 1/5 (20%) OB cycles resulted in an ongoing/live birth. The OB success was age 40.5yo at freeze, representing the oldest oocytes thawed resulting in pregnancy for a cancer survivor. CONCLUSION(S): OBZB appear acceptable FP options for cancer patients. OB enhances reproductive autonomy and minimizes ethical and personal dilemmas. Unique considerations/complications may arise when treating this patient population. Continued advances/research may help to improve outcomes.
Cancer diagnosis All (n¼152 pts; 162 cycles) Breast All (n¼54 pts) Letrozole (n¼45 pts) No Letrozole (n¼9 pts) Gynecologic All (n¼52 pts, including 4 ‘‘other’’) Ovary (n¼24 pts) Cervix (n¼15 pts) Endometrial (n¼9) Hematologic (lymphoma, leukemia) (n¼30 pts) Other (genitourinary, gastrointestinal, CNS, thymic, thyroid, sarcoma) (n¼16 pts) Timing From request to REI consult From REI consult to retrieval if urgent (n¼74) Duration of ovarian stimulation Partnership status at diagnosis and FP choice Not Partnered Chose OB-only Chose OB+ZB Chose ZB-only Partnered Chose OB-only Chose OB+ZB Chose ZB-only
Age (y) (mean)
E2 Day of ov trigger (pg/ml)
Total no. retrieved eggs
Total no. MII eggs
31
1785
18
14
35 35 37
987 833 1518
17 16 19
12 12 14
30
2376
16
12
28 31 28 25
1837 2600 3526 2250
12 18 23 21
9 15 17 17
29
1700
19
15
Days 2 17 10 n
%
81 78 1 2 71 28 20 23
53% 96% 1% 3% 47% 40% 28% 32%
FINANCIAL SUPPORT: None.
P-10 Incidence of Chronic Endometritis and Subsequent Pregnancy Outcomes in Patients with Recurrent Pregnancy Loss. C. O. Perfetto,a F. K. Hazard,b R. B. Lathi.a aDept of Ob/Gyn; bDept of Pathology, Stanford University Medical Center, Palo Alto, CA. BACKGOUND: Over half of the patients diagnosed with recurrent pregnancy loss (RPL) have no explanation for their losses after a standard evaluation. In an effort to identify treatable factors associated with RPL, endometrial pathology has become an area of emerging research. Early literature reports a prevalence of chronic endometritis (CE) of 0.2-46%, but more recent studies suggest a rate of 2.8% and 9.3% in patients with infertility and RPL, respectively (1, 2). Pregnancy outcomes after treatment are largely unknown. OBJECTIVE(S): To report the incidence and subsequent pregnancy outcomes in women with RPL and CE.
S11
MATERIALS AND METHOD(S): This is a prospective study on patients seen in an RPL clinic during 2010-2012. Only patients with 2 or more clinical pregnancy losses were included. All patients underwent a standard RPL work-up, including uterine evaluation, anti-phospholipid antibody testing, and parental chromosome analysis. Additionally, an endometrial biopsy (EMB) was obtained and the specimens were evaluated for CE by the Department of Pathology. Chronic endometritis was diagnosed by histopathologic review of endometrial biopsy specimens and categorized as positive (>1 plasma cell/hpf) and negative (<1 plasma cell/hpf). Patients diagnosed with CE were treated with Doxycycline for 3 weeks and had a repeat EMB after treatment prior to attempting pregnancy. RESULT(S): Of the 116 RPL patients who had an EMB, 10 (8.6%) had biopsy-proven CE. Patient age and body mass index was similar between the groups. There was a trend toward a higher rate of secondary RPL (70% vs. 35%) in those women with CE. There was also a trend toward a lower pregnancy rate after a diagnosis of CE, compared with those with a normal biopsy, but no apparent difference in subsequent miscarriage rate.
EMB positive for CE
EMB negative for CE
All patients (116) 10 (8.6%) 106 (91.4%) Ages 36.4yr 36.6yr Unexplained RPL** 9 (90%) 86 (80%) Mean number of prior losses 3.5 (range, 2-7) 3 (range, 2-7) Primary RPL 3/10 (30%) 69/116 (65%) Secondary RPL 7/10 (70%) 37/116 (35%) Underweight (BMI <18.5) 2 (20%) 2 (2%) Normal weight (BMI 18.6-24.9) 4 (40%) 68 (66%) Overweight (BMI 25-29.9) 3 (30%) 22 (21%) Obese (BMI >30) 1 (10%) 11 (10%) Pregnant after EMB 3 (30%) 58 (55%) Clinical pregnancy loss 1 (33%) 11 (21%) Ongoing or live birth 2 (67%) 45 (80%) Not pregnant after EMB 7 (70%) 47 (45%) ** Unexplained RPL if uterine cavity, parental karyotypes, and anti-phospholipid antibody testing was normal.
CONCLUSION(S): Overall, we found an 8.6% incidence of CE in this population of RPL patients, which is similar to prior literature. There was no difference in age, BMI, or number of prior losses in patients with CE. A trend toward higher rates of secondary RPL and lower pregnancy rates in patients diagnosed with CE was noted. Given the small num-
Female diagnosis
Male diagnosis
bers of patients with CE in this pilot study, further research is ongoing to counsel patients with chronic endometritis about future pregnancy rates and outcomes. FINANCIAL SUPPORT: Nothing to disclose. References 1. Kasius JC, Fatemi HM, et al. The impact of chronic endometritis on reproductive outcome. Fert & Steril 2011;96(6). 2. Kitaya K. Prevalence of chronic endometritis in recurrent miscarriages. Fert & Steril. 2011;95(3).
P-11 Use of Confocal Laser and Three-dimensional Imaging Techniques to Study Failed Fertilization after ICSI: A Pilot Study. Chandra Shenoy, Jeffrey M. Goldberg, Stephanie Ploskonka, Nina Desai. Obstetrics and Gynecology/Women’s Health Institute, Cleveland Clinic, 16900 Cedar Rd. Beachwood, OH, United States, 44122. BACKGROUND: While many observations have been made of the sperm and oocyte after intracytoplasmic sperm injection (ICSI) failure via conventional microscopy and FISH, confocal laser microscopy has the potential to provide greater details to help elucidate the cause of ICSI fertilization failure. OBJECTIVE(S): This study looks at oocytes that failed to fertilize after ICSI using confocal laser microscopy with three-dimensional image analysis. MATERIALS AND METHOD(S): After ICSI, oocytes were noted to be unfertilized, fertilized, or abnormally fertilized (1PN/3PN). The unfertilized oocytes were fixed in formaldehyde and stained with alpha- and beta-tubulin and propidium iodide to identify DNA of the oocyte, polar bodies, and the sperm using confocal microscopy. Confocal sections were assembled to make interactive three-dimensional models. Photographs could be taken from all sides and angles. Videos of rotating oocytes were captured. Patient’s infertility diagnoses and IVF cycle outcomes were recorded. RESULT(S): Seventeen oocytes from 9 couples were stained, mounted, imaged, and analyzed. The use of confocal laser sectioning and three-dimensional modeling greatly enhanced our ability to study fertilization failure. Early events in meiotic arrest were able to be visualized. Types of defects seen were: unactivated oocytes, fragmented pronuclear formation, failure of the sperm decondensation, premature sperm chromatin condensation (PCC), extruded sperm, and sperm injected in close proximity to meiotic spindles that may have cause disruption. CONCLUSION(S): Confocal laser microscopy with three-dimensional imaging served to better define the causes of ICSI fertilization failure. While some degree of fertilization failure is expected, complete or near total fertilization failure is a clinical problem. Helping to delineate the cause of these fertilization failures as a primary sperm defect, oocyte defect, or
Fertilization rate
# Mature eggs
Oocyte
Sperm
Fragmented pronucleus Unactivated Disorganized spindle Unactivated Unactivated Unactivated Activated Unactivated Activated Disrupted spindle Disrupted spindle Unactivated Unactivated Unactivated Unactivated Activated Unactivated
Decondensed Nondecondensed Nondecondensed PCC Extruded sperm PCC Decondensed Nondecondensed Decondensed Decondensed Nondecondensed Partially decondensed Partially decondensed Partially decondensed Extruded sperm Decondensed Extruded sperm
Couple 1 Couple 2 Couple 3 Couple 4
Endometriosis Tubal Donor Tubal
Mild teratospermia Normal SA Normal SA Normal SA
86% 50% 71% 66%
21 6 7 12
Couple 5
Normal
CAVD/PESA
72%
11
Couple 6
Normal
Asthenoteratospermia
73%
11
Couple 7 Couple 8
Unexplained PCOS
Mild asthenospermia Quadriplegia/PESA
71% 50%
7 14
Couple 9
Unexplained
Normal SA
46%
13
S12
PCRS Abstracts
Vol. 99, No. 3, Supplement, March 1, 2013