- Email: [email protected]
Is anti-mullerian hormone a predictor of embryo quality, fertilization, and cryopreservation in IVF cycles?
higher number of embryos were from CI (p¼0.037). Pure embryo transfers in 7 patients from only CI had clinical pregnancy and implantation rates of 57.1% and 56.3% (9/16). Pure transfers of ICSI embryos were performed in 10 patients, with clinical pregnancy and implantation rates of 40.0% and 30.4% (7/23), neither of which were different from CI.
# Oocytes (MII/Total) CI ICSI
418/455 364/525
2PN/MII
D3 embryos transferred
Blastocysts transferred
258/418 (61.7%) 291/364 (79.9%)
31 (50.8%)* 42 (66.7%)*
30 (49.2%)* 21 (33.3%)*
* p¼0.036. CONCLUSIONS: Appropriate counseling regarding method of fertilization can be challenging, particularly when ICSI has been performed in the past. This study demonstrates that the overall outcome is similar between the oocytes that were inseminated and injected, with no cases of failed fertilization in the CI split. Interestingly, CI embryos were selected more frequently for transfer at the blastocyst stage than ICSI embryos. A history of ICSI for non-male factor cases should not obligate the clinician to implement ICSI in subsequent cycles. Supported by: None.
P-370 PREDICTION OF PREGNANCY OUTCOME BY SERUM PROGESTERONE LEVEL AFTER ASSISTED REPRODUCTIVE TECHNOLOGY. H. F. Solomon, R. M. Sneeringer, A. S. Penzias. Obstetrics and Gynecology, Beth Israel Deaconess Medical Center, Boston, MA; Reproductive Endocrinology, Boston IVF, Beth Israel Deaconess Medical Center, Boston, MA. OBJECTIVE: To determine the predictive value of serum progesterone level in patients with a positive b-hCG after controlled ovarian hyperstimulation (COH) followed by intrauterine insemination (IUI) or in vitro fertilization (IVF). DESIGN: Retrospective chart review. MATERIALS AND METHODS: Using the Practice Highway EIVF Query research tool, all cycles for patients beginning treatment between January 1, 2004 and December 31, 2007 were examined. Patients who became pregnant and had luteal progesterone measured were selected for analysis. Pregnancy outcomes were compared with progesterone levels, and the sensitivity and specificity of progesterone level to predict ongoing pregnancy were determined. For all statistical analyses, p<0.05 was considered significant. RESULTS: Four hundred cycles met inclusion criteria. Pregnancy outcomes were as follows: 142 live births (35.5%), 97 ongoing clinical pregnancies (24.3 %), 81 spontaneous abortions (20.3%), 4 elective terminations (1.0%), 14 ectopic pregnancies (3.5%) and 61 biochemical pregnancies (15.3%). Of the 400 cycles, 284 (71.0%) were IVF and 116 (29%) were COH with IUI. Mean progesterone was significantly higher in IVF than IUI cycles (36.0 44.5 vs. 25.8 22.1 ng/mL, p<0.02). The most favorable outcomes (ongoing pregnancy and live birth) yielded a significantly higher mean progesterone level than pregnancy losses (41.5 46.7 vs. 20.6 20 ng/mL, p<0.0001). Additionally, for progesterone levels at or above the 3rd quartile (>24.2 ng/mL), more than 75% of patients had an ongoing pregnancy or delivery (Table 1).
CONCLUSIONS: Progesterone level is directly correlated with favorable pregnancy outcome among patients undergoing ART. Discriminatory progesterone value may vary by mode of conception. Our study represents the largest group of infertile patients analyzed for the predictive value of luteal progesterone on pregnancy outcome. Supported by: None.
P-371 ORIENTATION OF PRONUCLEI RELATIVE TO THE POLAR BODIES IS RELATED TO IVF OUTCOME: A 6 YEAR EXPERIENCE WITH HOMOLOGOUS EMBRYO TRANSFERS. Z. Khan, K. M. Barud, T. M. Galanitis, D. L. Walker, C. C. Coddington, D. E. Morbeck. OB/GYN, Reproductive Endocrinology and Infertility, Mayo Clinic, Rochester, MN; Mayo Clinic, Rochester, MN. OBJECTIVE: Previous studies have shown that the orientation of the polar bodies to each other and to the pronuclei is predictive of embryo quality. The most significant indicator of quality was the angle between the pronuclear axis and the farthest polar body (beta angle). The objective of this study was to determine if the beta angle affects implantation and clinical pregnancy rates in IVF cycles where zygotes with homologous beta angles were transferred. DESIGN: Retrospective cohort study. MATERIALS AND METHODS: All patients undergoing ART from 2001 – 2006 who gave IRB consent were considered for analysis. Embryo selection was performed at the time of fertilization check and the remaining embryos were cryopreserved as zygotes. Embryos kept in culture were assessed for polar body angles. Alpha: the angle between the pronuclear axis and the nearest polar body (PB), beta: the angle between the pronuclear axis and the farthest PB and gamma: the angle between the two PB’s were estimated and recorded. Clinical pregnancy rate (CP) and implantation rate (IR) for transfers where the beta angle was %45 degrees (grade a) or >45 degrees (grade b) for all embryos transferred were evaluated. Similar evaluation was performed for gamma angle for <5 degrees and 6-45 degrees. Data were analyzed with chi-square and ANOVA. RESULTS: A total of 143 homologous beta angle transfers were evaluated. Sixty percent (86/143) of transfers had a small beta angle (grade a). The implantation rate for grade (a) beta angles was significantly higher than for transfers with grade (b) beta angles (38.4% vs 24.0%; p < 0.05). Embryos with beta grade (a) had higher CP rate than beta grade (b) (59.3% vs. 43.8%: p< 0.07). There were no significant differences in the groups with regards to age and number of embryos transferred. Average patient age was 32.7 years and 32.2 years for grade (a) and (b) respectively, and the numbers of embryos transferred were 2.24 and 2.35 for grade (a) and (b) respectively. No difference was noted for CP rate and IR between the two gamma angle groups. CONCLUSIONS: Previous studies have shown a negative correlation between beta angle and embryo grade. However, the relationship between polar body angle and pregnancy outcomes has not been reported. We have shown that pronuclear embryos with small beta angles yield higher implantation and pregnancy rates. The degree of beta angle is an important variable to consider when selecting embryos based on pronuclear morphology. Supported by: None.
TABLE 1. Prediction of Favorable Pregnancy Outcome by Quartile of Progesterone Value
P-372
Progesterone Range Quartile (ng/mL) N (%) OPþLB N (%) Loss PPV
NPV
1 2 3 4
72.5% 62.5% 42.0% N/A
0 - 8.4 8.4 - 24.2 24.2 - 41.0 41.0 - 385
22 (27.5) 41 (46.6) 154 (74.8) 22 (84.6)
58 (72.5) 47 (53.4) 52 (25.2) 4 (15.4)
67.8% 75.9% 84.6% N/A
OPþLB ¼ Ongoing Pregnancy þ Live Birth; Loss ¼ Ectopic, SAB, Biochemical; Positive and Negative Predictive Value (PPV & NPV) refer to the prediction of OPþLB by the upper limit of each quartile; A statistically significant difference (p<0.01) is found between the proportion of OPþLB in all quartiles except 3 vs. 4 (p¼0.213).
FERTILITY & STERILITYÒ
IS ANTI-MULLERIAN HORMONE A PREDICTOR OF EMBRYO QUALITY, FERTILIZATION, AND CRYOPRESERVATION IN IVF CYCLES? E. Hobeika, R. Riggs, E. H. Duran, S. Oehninger, B. Leader, L. Stadtmauer. The Jones Institute for Rep. Medicine/OBGYN, Eastern Virginia Medical School, Norfolk, VA; Repromedix Corporation, Woburn, MA. OBJECTIVE: To evaluate basal menstrual cycle day three anti-Mullerian hormone (AMH) as a predictor of oocyte fertilization, embryo quality, and cryopreservation in IVF cycles. DESIGN: Retrospective evaluation of serum samples and IVF outcomes. MATERIALS AND METHODS: Menstrual cycle day three serum samples were retrospectively evaluated for AMH, inhibin B (IB), follicle
S231
stimulating hormone (FSH) and estradiol (E2) in 123 IVF cycles (93 infertility patients). An embryo score was calculated that incorporated the blastomere number and grading, with a larger number indicating superior embryo quality. Embryos not transferred with an embryo score > 4 were cryopreserved. This score corresponded to an embryo with at least 6 cells and a grade of 3 or better. Statistical testing was performed using correlation analysis and receiver operating characteristic (ROC) curves. RESULTS: Fertilization correlated with AMH (r¼0.553, P<0.01), age (r¼-0.456, P<0.01), and FSH (r¼-0.279, P<0.01). It did not correlate with IB (P¼0.172) or E2 (P¼0.133). Because only 3 cycles had no fertilization, receiver operating characteristic (ROC) curves were not constructed. Embryo score correlated with age (r¼-0.257, P<0.01), AMH (r¼0.223, P<0.01), and E2 (r¼-0.206, P<0.02) but not with FSH (P¼0.188) or IB (P¼0.306). For the prediction of an embryo score >4, ROC curve analysis demonstrated an area under the curve (AUC) for age (AUC¼0.739; P<0.001), AMH (AUC¼0.654; P¼<0.001), E2 (AUC¼0.637; P¼0.03), FSH (AUC¼0.556; P¼0.37), and IB (AUC¼0.515; P¼0.82). Number of cryopreserved embryos correlated with AMH (r¼0.364, P<0.01), age (r¼-0.273, P<0.01), E2 (r¼-0.271, P<0.01), FSH (r¼-0.201, P<0.02), but not with IB (-0.023, P¼0.811). ROC curve analysis demonstrated that cryopreservation was predicted by AMH (AUC¼0.682; P<0.001), age (AUC¼0.660; P<0.001), E2 (AUC¼0.646; P¼0.002), FSH (AUC¼0.605; P¼0.03), but not with IB (AUC¼0.516; P¼0.78). CONCLUSIONS: AMH correlated with embryo quality, fertilization, and the number of cryopreserved embryos. It was also highly predictive of superior embryo quality and the opportunity to cryopreserve embryos. Age was also consistently predictive of the outcomes analyzed. Supported by: Repromedix Corporation completed all AMH, FSH, and inhibin B assays for this study free of charge. The samples were deidentified and coded so that Repromedix Corporation and its employees were blinded. No specific de-identified study information or data, other than coded numerical assay results were available to Repromedix Corporation.
P-373 MEASURING SERUM HCG LEVELS BETWEEN HCG INJECTION AND EGG RETRIEVAL IS AN EFFECTIVE APPROACH TO AVOIDING ‘‘EMPTY FOLLICLE SYNDROME’’. J. G. Head, N. M. Giannios, S. J. Weil, J. H. Liu, W. W. Hurd. Obstetrics and Gynecology, Case Western Reserve University, Cleveland, OH; Obstetrics and Gynecology, University Hospitals Case Medical Center, Cleveland, OH. OBJECTIVE: Failure to retrieve eggs from apparently mature follicles (Empty Follicle Syndrome or EFS) has been reported in 0.6%-7% of in vitro fertilization (IVF) cycles. Most cases of EFS occur because sufficient serum hCG (human chorionic gonadotropin) levels are not attained due to patient or pharmaceutical errors. One method to prevent this occurrence is to document appropriate serum hCG values between the time of hCG injection and attempted egg retrieval. Our objective was to examine the efficacy of this approach and to determine the range of hCG levels consistent with appropriate ovulation triggering in IVF patients. DESIGN: Retrospective cohort. MATERIALS AND METHODS: We reviewed 272 fresh IVF cycles performed between June 2006 and April 2008. Women were treated with standard luteal leuprolide acetate (LA), microdose flare LA or ganirelix with the addition of FSH (follicle stimulating hormone) with or without LH (luteinizing hormone) prior to ovulation triggering with intramuscular urinary hCG (7,500-10,000 IU). Patients were excluded if their IVF cycle was incomplete or canceled. Serum hCG levels were measured 8-12 hours after hCG injection. Primary outcomes were oocyte number and number of mature oocytes per mature follicle (>14mm). Other outcomes included embryo number and implantation. Correlation coefficients and Chi-squared tests were used to analyze the relationship of hCG level and these outcomes. RESULTS: Of 272 fresh IVF cycles, 174 cycles (in 151 patients) met our criteria. Mean age was 34.44.5 years, and mean BMI was 25.35.6 kg/ M2. In one patient, hCG was undetectable 12 hours after injection. When questioned, she acknowledged confusion about mixing the injection. This patient received a second hCG injection, and 20 mature oocytes were retrieved 35 hours later. In the remaining patients, serum hCG levels 8-12 hrs after administration were 191108 IU/mL (range 47-647 IU/mL). The
S232
Abstracts
hCG concentration negatively correlated with BMI (R2¼-0.3, P<0.0001), but was unrelated to age (P¼0.087). There was no correlation of hCG values with number of mature oocytes retrieved, number of follicles >14mm, the ratio of mature oocytes to follicles >14 mm, number of embryos, or implantation rate. CONCLUSIONS: Routine measurement of hCG the day after triggering can avoid EFS due to incorrect hCG administration prior to egg retrieval. Levels of hCG as low as 47 IU/mL the day after IM injection appeared to indicate adequate ovulation triggering. Serum hCG levels at 8-12 hours did not correlate with treatment outcome. Supported by: None.
P-374 COMPARISON OF OUTCOMES BETWEEN CONTROLLED OVARIAN STIMULATION WITH GNRH-AGONIST VS GNRH-ANTAGONIST FOR IN VITRO FERTILIZATION CYCLES IN WOMEN WITH POLYCYSTIC OVARIAN SYNDROME. S. Segal, I. Glatstein, S. Pang, K. Go, R. Carson, R. Ezcurra. Reproductive Science Center, Lexington, MA; EMDSerono, Rockland, MA. OBJECTIVE: To determine if there is a difference in outcome in patients with PCOS who underwent COS with Gonadotropin/GnRH-agonist vs Gonadotropin/GnRH-antagonist protocols for IVF. DESIGN: Retrospective clinical case-series. MATERIALS AND METHODS: We evaluated the outcome of IVF in patients diagnosed with PCOS who underwent IVF with Gonadotropin/ GnRH-agonist protocol (n¼720), compared to Gonadotropin/GnRH-antagonist protocol (n¼48). Cycle data analyzed included patient age, infertility diagnosis, BMI, number of days of oral contraceptive pills, total dose of gonadotropin administered, number of stimulation days and number of follicles >12 mm. Data from the day of hCG administration included cycle day, estradiol (E2), luteinizing hormone (LH) and progesterone (P4) levels. Outcome data analyzed included number of oocytes, di-pronucleate (2PN) eggs, number of morphologically good embryos, number of embryos transferred, number of embryos frozen, cycle cancellation rate and clinical pregnancy rates. The outcomes were evaluated using ANOVA statistical analysis. P value <0.05 was considered statistically significant. RESULTS: Our data shows that PCOS patients who underwent COS with Gonadotropin/GnRH-antagonist had a lower E2 level, a higher number of 2PN eggs and a higher number of morphologically good embryos. CONCLUSIONS: Controlled ovarian stimulation with Gonadotropin/ GnRH-antagonist protocol in PCOS patients is associated with a higher number of 2PN eggs, a higher number of morphologically good embryos, and similar clinical pregnancy rates compared to a Gonadotropin/GnRH-agonist protocol. TABLE 1.
Cycles BMI OCP Days Total FSH Total hMG Stimulation Days Follicles >12 mm E2pg/mL P4 ng/mL LHmIU/mL # Oocytes 2PN Day 3 good embryos ET Embryos Cryo ancellation Cycles Pregnancy/Cycle Pregnancy/ET
GnRH-agonist
GnRH-antagonist
720 31.1 3.9 26.0 18.8 2796 1396 73 610 9.9 0.1 10.9 8.3 2115 1229 0.58 2.3 0.80 1.2 12.0 6.6 7.1 4.8 1.5 2.1 1.7 0.8 1.2 3.2 75/720 (10%) 34/720 (47%) 34/605 (56%
48 33.4 4.1 23.8 9.9 2557 1594 559 788 10.3 0.4 11.3 8.9 1521 175 0.75 0.6 0.951.1 13.8 9.8 8.6 5.9 2.3 3.1 1.8 0.9 2.0 3.1 8/48 (17%) 18/48 (37%) 18/40 (45%)
P value 0.5 0.2 0/2 0/0002 0.4 0.7 0.001 0.6 0.4 0.06 0.03 0.02 0.8 0.9 0.2 0.4
Supported by: None.
Vol. 90, Suppl 1, September 2008
# Oocytes (MII/Total) CI ICSI
418/455 364/525
2PN/MII
D3 embryos transferred
Blastocysts transferred
258/418 (61.7%) 291/364 (79.9%)
31 (50.8%)* 42 (66.7%)*
30 (49.2%)* 21 (33.3%)*
* p¼0.036. CONCLUSIONS: Appropriate counseling regarding method of fertilization can be challenging, particularly when ICSI has been performed in the past. This study demonstrates that the overall outcome is similar between the oocytes that were inseminated and injected, with no cases of failed fertilization in the CI split. Interestingly, CI embryos were selected more frequently for transfer at the blastocyst stage than ICSI embryos. A history of ICSI for non-male factor cases should not obligate the clinician to implement ICSI in subsequent cycles. Supported by: None.
P-370 PREDICTION OF PREGNANCY OUTCOME BY SERUM PROGESTERONE LEVEL AFTER ASSISTED REPRODUCTIVE TECHNOLOGY. H. F. Solomon, R. M. Sneeringer, A. S. Penzias. Obstetrics and Gynecology, Beth Israel Deaconess Medical Center, Boston, MA; Reproductive Endocrinology, Boston IVF, Beth Israel Deaconess Medical Center, Boston, MA. OBJECTIVE: To determine the predictive value of serum progesterone level in patients with a positive b-hCG after controlled ovarian hyperstimulation (COH) followed by intrauterine insemination (IUI) or in vitro fertilization (IVF). DESIGN: Retrospective chart review. MATERIALS AND METHODS: Using the Practice Highway EIVF Query research tool, all cycles for patients beginning treatment between January 1, 2004 and December 31, 2007 were examined. Patients who became pregnant and had luteal progesterone measured were selected for analysis. Pregnancy outcomes were compared with progesterone levels, and the sensitivity and specificity of progesterone level to predict ongoing pregnancy were determined. For all statistical analyses, p<0.05 was considered significant. RESULTS: Four hundred cycles met inclusion criteria. Pregnancy outcomes were as follows: 142 live births (35.5%), 97 ongoing clinical pregnancies (24.3 %), 81 spontaneous abortions (20.3%), 4 elective terminations (1.0%), 14 ectopic pregnancies (3.5%) and 61 biochemical pregnancies (15.3%). Of the 400 cycles, 284 (71.0%) were IVF and 116 (29%) were COH with IUI. Mean progesterone was significantly higher in IVF than IUI cycles (36.0 44.5 vs. 25.8 22.1 ng/mL, p<0.02). The most favorable outcomes (ongoing pregnancy and live birth) yielded a significantly higher mean progesterone level than pregnancy losses (41.5 46.7 vs. 20.6 20 ng/mL, p<0.0001). Additionally, for progesterone levels at or above the 3rd quartile (>24.2 ng/mL), more than 75% of patients had an ongoing pregnancy or delivery (Table 1).
CONCLUSIONS: Progesterone level is directly correlated with favorable pregnancy outcome among patients undergoing ART. Discriminatory progesterone value may vary by mode of conception. Our study represents the largest group of infertile patients analyzed for the predictive value of luteal progesterone on pregnancy outcome. Supported by: None.
P-371 ORIENTATION OF PRONUCLEI RELATIVE TO THE POLAR BODIES IS RELATED TO IVF OUTCOME: A 6 YEAR EXPERIENCE WITH HOMOLOGOUS EMBRYO TRANSFERS. Z. Khan, K. M. Barud, T. M. Galanitis, D. L. Walker, C. C. Coddington, D. E. Morbeck. OB/GYN, Reproductive Endocrinology and Infertility, Mayo Clinic, Rochester, MN; Mayo Clinic, Rochester, MN. OBJECTIVE: Previous studies have shown that the orientation of the polar bodies to each other and to the pronuclei is predictive of embryo quality. The most significant indicator of quality was the angle between the pronuclear axis and the farthest polar body (beta angle). The objective of this study was to determine if the beta angle affects implantation and clinical pregnancy rates in IVF cycles where zygotes with homologous beta angles were transferred. DESIGN: Retrospective cohort study. MATERIALS AND METHODS: All patients undergoing ART from 2001 – 2006 who gave IRB consent were considered for analysis. Embryo selection was performed at the time of fertilization check and the remaining embryos were cryopreserved as zygotes. Embryos kept in culture were assessed for polar body angles. Alpha: the angle between the pronuclear axis and the nearest polar body (PB), beta: the angle between the pronuclear axis and the farthest PB and gamma: the angle between the two PB’s were estimated and recorded. Clinical pregnancy rate (CP) and implantation rate (IR) for transfers where the beta angle was %45 degrees (grade a) or >45 degrees (grade b) for all embryos transferred were evaluated. Similar evaluation was performed for gamma angle for <5 degrees and 6-45 degrees. Data were analyzed with chi-square and ANOVA. RESULTS: A total of 143 homologous beta angle transfers were evaluated. Sixty percent (86/143) of transfers had a small beta angle (grade a). The implantation rate for grade (a) beta angles was significantly higher than for transfers with grade (b) beta angles (38.4% vs 24.0%; p < 0.05). Embryos with beta grade (a) had higher CP rate than beta grade (b) (59.3% vs. 43.8%: p< 0.07). There were no significant differences in the groups with regards to age and number of embryos transferred. Average patient age was 32.7 years and 32.2 years for grade (a) and (b) respectively, and the numbers of embryos transferred were 2.24 and 2.35 for grade (a) and (b) respectively. No difference was noted for CP rate and IR between the two gamma angle groups. CONCLUSIONS: Previous studies have shown a negative correlation between beta angle and embryo grade. However, the relationship between polar body angle and pregnancy outcomes has not been reported. We have shown that pronuclear embryos with small beta angles yield higher implantation and pregnancy rates. The degree of beta angle is an important variable to consider when selecting embryos based on pronuclear morphology. Supported by: None.
TABLE 1. Prediction of Favorable Pregnancy Outcome by Quartile of Progesterone Value
P-372
Progesterone Range Quartile (ng/mL) N (%) OPþLB N (%) Loss PPV
NPV
1 2 3 4
72.5% 62.5% 42.0% N/A
0 - 8.4 8.4 - 24.2 24.2 - 41.0 41.0 - 385
22 (27.5) 41 (46.6) 154 (74.8) 22 (84.6)
58 (72.5) 47 (53.4) 52 (25.2) 4 (15.4)
67.8% 75.9% 84.6% N/A
OPþLB ¼ Ongoing Pregnancy þ Live Birth; Loss ¼ Ectopic, SAB, Biochemical; Positive and Negative Predictive Value (PPV & NPV) refer to the prediction of OPþLB by the upper limit of each quartile; A statistically significant difference (p<0.01) is found between the proportion of OPþLB in all quartiles except 3 vs. 4 (p¼0.213).
FERTILITY & STERILITYÒ
IS ANTI-MULLERIAN HORMONE A PREDICTOR OF EMBRYO QUALITY, FERTILIZATION, AND CRYOPRESERVATION IN IVF CYCLES? E. Hobeika, R. Riggs, E. H. Duran, S. Oehninger, B. Leader, L. Stadtmauer. The Jones Institute for Rep. Medicine/OBGYN, Eastern Virginia Medical School, Norfolk, VA; Repromedix Corporation, Woburn, MA. OBJECTIVE: To evaluate basal menstrual cycle day three anti-Mullerian hormone (AMH) as a predictor of oocyte fertilization, embryo quality, and cryopreservation in IVF cycles. DESIGN: Retrospective evaluation of serum samples and IVF outcomes. MATERIALS AND METHODS: Menstrual cycle day three serum samples were retrospectively evaluated for AMH, inhibin B (IB), follicle
S231
stimulating hormone (FSH) and estradiol (E2) in 123 IVF cycles (93 infertility patients). An embryo score was calculated that incorporated the blastomere number and grading, with a larger number indicating superior embryo quality. Embryos not transferred with an embryo score > 4 were cryopreserved. This score corresponded to an embryo with at least 6 cells and a grade of 3 or better. Statistical testing was performed using correlation analysis and receiver operating characteristic (ROC) curves. RESULTS: Fertilization correlated with AMH (r¼0.553, P<0.01), age (r¼-0.456, P<0.01), and FSH (r¼-0.279, P<0.01). It did not correlate with IB (P¼0.172) or E2 (P¼0.133). Because only 3 cycles had no fertilization, receiver operating characteristic (ROC) curves were not constructed. Embryo score correlated with age (r¼-0.257, P<0.01), AMH (r¼0.223, P<0.01), and E2 (r¼-0.206, P<0.02) but not with FSH (P¼0.188) or IB (P¼0.306). For the prediction of an embryo score >4, ROC curve analysis demonstrated an area under the curve (AUC) for age (AUC¼0.739; P<0.001), AMH (AUC¼0.654; P¼<0.001), E2 (AUC¼0.637; P¼0.03), FSH (AUC¼0.556; P¼0.37), and IB (AUC¼0.515; P¼0.82). Number of cryopreserved embryos correlated with AMH (r¼0.364, P<0.01), age (r¼-0.273, P<0.01), E2 (r¼-0.271, P<0.01), FSH (r¼-0.201, P<0.02), but not with IB (-0.023, P¼0.811). ROC curve analysis demonstrated that cryopreservation was predicted by AMH (AUC¼0.682; P<0.001), age (AUC¼0.660; P<0.001), E2 (AUC¼0.646; P¼0.002), FSH (AUC¼0.605; P¼0.03), but not with IB (AUC¼0.516; P¼0.78). CONCLUSIONS: AMH correlated with embryo quality, fertilization, and the number of cryopreserved embryos. It was also highly predictive of superior embryo quality and the opportunity to cryopreserve embryos. Age was also consistently predictive of the outcomes analyzed. Supported by: Repromedix Corporation completed all AMH, FSH, and inhibin B assays for this study free of charge. The samples were deidentified and coded so that Repromedix Corporation and its employees were blinded. No specific de-identified study information or data, other than coded numerical assay results were available to Repromedix Corporation.
P-373 MEASURING SERUM HCG LEVELS BETWEEN HCG INJECTION AND EGG RETRIEVAL IS AN EFFECTIVE APPROACH TO AVOIDING ‘‘EMPTY FOLLICLE SYNDROME’’. J. G. Head, N. M. Giannios, S. J. Weil, J. H. Liu, W. W. Hurd. Obstetrics and Gynecology, Case Western Reserve University, Cleveland, OH; Obstetrics and Gynecology, University Hospitals Case Medical Center, Cleveland, OH. OBJECTIVE: Failure to retrieve eggs from apparently mature follicles (Empty Follicle Syndrome or EFS) has been reported in 0.6%-7% of in vitro fertilization (IVF) cycles. Most cases of EFS occur because sufficient serum hCG (human chorionic gonadotropin) levels are not attained due to patient or pharmaceutical errors. One method to prevent this occurrence is to document appropriate serum hCG values between the time of hCG injection and attempted egg retrieval. Our objective was to examine the efficacy of this approach and to determine the range of hCG levels consistent with appropriate ovulation triggering in IVF patients. DESIGN: Retrospective cohort. MATERIALS AND METHODS: We reviewed 272 fresh IVF cycles performed between June 2006 and April 2008. Women were treated with standard luteal leuprolide acetate (LA), microdose flare LA or ganirelix with the addition of FSH (follicle stimulating hormone) with or without LH (luteinizing hormone) prior to ovulation triggering with intramuscular urinary hCG (7,500-10,000 IU). Patients were excluded if their IVF cycle was incomplete or canceled. Serum hCG levels were measured 8-12 hours after hCG injection. Primary outcomes were oocyte number and number of mature oocytes per mature follicle (>14mm). Other outcomes included embryo number and implantation. Correlation coefficients and Chi-squared tests were used to analyze the relationship of hCG level and these outcomes. RESULTS: Of 272 fresh IVF cycles, 174 cycles (in 151 patients) met our criteria. Mean age was 34.44.5 years, and mean BMI was 25.35.6 kg/ M2. In one patient, hCG was undetectable 12 hours after injection. When questioned, she acknowledged confusion about mixing the injection. This patient received a second hCG injection, and 20 mature oocytes were retrieved 35 hours later. In the remaining patients, serum hCG levels 8-12 hrs after administration were 191108 IU/mL (range 47-647 IU/mL). The
S232
Abstracts
hCG concentration negatively correlated with BMI (R2¼-0.3, P<0.0001), but was unrelated to age (P¼0.087). There was no correlation of hCG values with number of mature oocytes retrieved, number of follicles >14mm, the ratio of mature oocytes to follicles >14 mm, number of embryos, or implantation rate. CONCLUSIONS: Routine measurement of hCG the day after triggering can avoid EFS due to incorrect hCG administration prior to egg retrieval. Levels of hCG as low as 47 IU/mL the day after IM injection appeared to indicate adequate ovulation triggering. Serum hCG levels at 8-12 hours did not correlate with treatment outcome. Supported by: None.
P-374 COMPARISON OF OUTCOMES BETWEEN CONTROLLED OVARIAN STIMULATION WITH GNRH-AGONIST VS GNRH-ANTAGONIST FOR IN VITRO FERTILIZATION CYCLES IN WOMEN WITH POLYCYSTIC OVARIAN SYNDROME. S. Segal, I. Glatstein, S. Pang, K. Go, R. Carson, R. Ezcurra. Reproductive Science Center, Lexington, MA; EMDSerono, Rockland, MA. OBJECTIVE: To determine if there is a difference in outcome in patients with PCOS who underwent COS with Gonadotropin/GnRH-agonist vs Gonadotropin/GnRH-antagonist protocols for IVF. DESIGN: Retrospective clinical case-series. MATERIALS AND METHODS: We evaluated the outcome of IVF in patients diagnosed with PCOS who underwent IVF with Gonadotropin/ GnRH-agonist protocol (n¼720), compared to Gonadotropin/GnRH-antagonist protocol (n¼48). Cycle data analyzed included patient age, infertility diagnosis, BMI, number of days of oral contraceptive pills, total dose of gonadotropin administered, number of stimulation days and number of follicles >12 mm. Data from the day of hCG administration included cycle day, estradiol (E2), luteinizing hormone (LH) and progesterone (P4) levels. Outcome data analyzed included number of oocytes, di-pronucleate (2PN) eggs, number of morphologically good embryos, number of embryos transferred, number of embryos frozen, cycle cancellation rate and clinical pregnancy rates. The outcomes were evaluated using ANOVA statistical analysis. P value <0.05 was considered statistically significant. RESULTS: Our data shows that PCOS patients who underwent COS with Gonadotropin/GnRH-antagonist had a lower E2 level, a higher number of 2PN eggs and a higher number of morphologically good embryos. CONCLUSIONS: Controlled ovarian stimulation with Gonadotropin/ GnRH-antagonist protocol in PCOS patients is associated with a higher number of 2PN eggs, a higher number of morphologically good embryos, and similar clinical pregnancy rates compared to a Gonadotropin/GnRH-agonist protocol. TABLE 1.
Cycles BMI OCP Days Total FSH Total hMG Stimulation Days Follicles >12 mm E2pg/mL P4 ng/mL LHmIU/mL # Oocytes 2PN Day 3 good embryos ET Embryos Cryo ancellation Cycles Pregnancy/Cycle Pregnancy/ET
GnRH-agonist
GnRH-antagonist
720 31.1 3.9 26.0 18.8 2796 1396 73 610 9.9 0.1 10.9 8.3 2115 1229 0.58 2.3 0.80 1.2 12.0 6.6 7.1 4.8 1.5 2.1 1.7 0.8 1.2 3.2 75/720 (10%) 34/720 (47%) 34/605 (56%
48 33.4 4.1 23.8 9.9 2557 1594 559 788 10.3 0.4 11.3 8.9 1521 175 0.75 0.6 0.951.1 13.8 9.8 8.6 5.9 2.3 3.1 1.8 0.9 2.0 3.1 8/48 (17%) 18/48 (37%) 18/40 (45%)
P value 0.5 0.2 0/2 0/0002 0.4 0.7 0.001 0.6 0.4 0.06 0.03 0.02 0.8 0.9 0.2 0.4
Supported by: None.
Vol. 90, Suppl 1, September 2008