Methotrexate or expectant management in women with ectopic pregnancy or PUL and low serum hCG concentrations? A randomized controlled trial

ORAL SESSION The following six papers are candidates for the ASRM Scientific Program Prize Paper Awards. Six additional candidates will be presented during the Prize Paper Candidates’ Session on Tuesday morning. SCIENTIFIC PROGRAM PRIZE PAPER ORAL ABSTRACT PRESENTATIONS I O-1 Monday, October 22, 2012 11:15 AM COMPREHENSIVE CHROMOSOME SCREENING (CCS) WITH VITRIFICATION RESULTS IN IMPROVED CLINICAL OUTCOME IN WOMEN >35 YEARS: A RANDOMIZED CONTROL TRIAL. W. B. Schoolcraft,a E. Surrey,a D. Minjarez,a R. L. Gustofson,a R. T. Scott, Jr.,b M. G. Katz-Jaffe.a aColorado Center for Reproductive Medicine, Lone Tree, CO; bReproductive Medicine Associates of New Jersey, Morristown, NJ. OBJECTIVE: Chromosome aneuploidy accounts for >70% of first trimester pregnancy loss, with maternal aging being the most significant risk factor. If demonstrated to be effective, the goal of ART should include the transfer of euploid embryos to maximize the potential for a healthy live birth. The objective of this study was to evaluate the clinical efficacy of blastocyst CCS with trophectoderm (TE) biopsy and vitrification in ART candidates of advanced maternal age (AMA). DESIGN: IRB approved randomized control trial. MATERIALS AND METHODS: Infertile patients of maternal age >35 years were computer randomized at oocyte retrieval into either: Group A ¼ Fresh blastocyst transfer with embryos selected by morphology alone (n¼30) or Group B ¼ Frozen blastocyst transfer with only euploid embryos tested by CCS (n¼30). CCS was performed on TE biopsies using SNP microarray and all biopsied blastocysts were vitrified. RESULTS: There were no significant differences between the groups for maternal age (A¼39.72.2, B¼39.21.7 years), D3 FSH (A¼7.32.1, B¼6.82.1mIU/ml), AMH (A¼2.51.8, B¼2.72.1ng/ml) or AFC (A¼16.37.2, B¼20.910.1). 100% survival was observed following vitrification in Group B. Viable implantation rates (positive cardiac activity) (A¼40.9%, B¼60.8%; P<0.05) and the number of blastocysts transferred (A¼2.20.8, B¼1.70.5; P<0.01) were significantly different between the groups. In addition, significantly higher first trimester pregnancy losses were observed in Group A (A¼20%, B¼0%; P<0.05). CONCLUSION: Infertile AMA patients have higher ongoing implantation rates and fewer first trimester pregnancy losses, following a frozen blastocyst transfer with euploid embryos tested by CCS, when compared to routine fresh blastocyst transfer based on embryo morphology alone. Blastocyst CCS significantly increases the likelihood of ART success for AMA patients, which could allow for the realization of routine single blastocyst transfer, typically only recommended for younger good prognosis patients. Supported by: Ferring Pharmaceuticals. O-2 Monday, October 22, 2012 11:30 AM USE OF DEPOT GnRH ANTAGONIST (DEGARELIX) IN THE OVARIAN STIMULATION IN WOMEN WITH PCOS UNDERGOING IVF. A CONTROLLED TRIAL. M. Sbracia F. Scarpellini. CERM, Hungaria IVF, Rome, Italy. OBJECTIVE: In this study we reported the data of a controlled trial comparing in PCOS women depot GnRH antagonist administered the first day of menstrual cycle versus flexible daily GnRH antagonist protocol. DESIGN: Controlled randomized trial. MATERIALS AND METHODS: We selected 40 women with PCOS (according to Rotterdam criteria). The study was reviewed and approved by the Ethical Committee of the Institution. The patients eligible for the study were informed and they signed an informed consents before undergoing to randomization for treatment.. Patients were randomized by a computer generated number sequence. The women of experimental group underwent at the first day of menstrual cycle to a dose of 20mg of Degarelix (Firmagon 80mg, Ferring Denmark), a depot GnRH antagonist. They underwent controlled ovarian hyperstimulation with recFSH 225IU daily (Gonal-f 900, Merck Serono, Italy) from the second through the sixth day of menstrual cycle and after that adjusted according to patients response. The control group underwent to 225IU of recFSH daily (Gonal-f 900, Merck Serono, Italy) for five days and after adjusted according to patient response;

FERTILITY & STERILITYÒ

when estradiol was higher than 300pg(L or the leading follicle R14mm Cetrorelix 0.25mg/die (Cetrotide Merck Serono, Italy)was started. Patients underwent daily ultrasound scan and plasma levels of Estradiol, Progesterone, Androstenedione, Testosterone assessment. When the leading follicle was R 18mm the ovulation was induced by hCG 10.000IU (Gonasi, IBSA) administration. RESULTS: The pregnancy rate in the experimental group was of 65% whereas in the controls 30% (P<0.05). The number of mature oocytes was statistically significant higher in the experimental group (P<0.01), as well as the number of embryos obtained (P<0.05). The frequency of OHSS was lower in the experimental group than in the controls (5% vs 20%; P<0.05). CONCLUSION: The use of a depot GnRH antagonist in patients with PCOS gave interesting and promising results. These findings should be confirmed in larger studies. O-3 Monday, October 22, 2012 11:45 AM GLUT3 AND CASPR5 – NOVEL GENETIC FACTORS IN MALE INFERTILITY. A. W. Pastuszak, C. J. Jorgez, L. I. Lipshultz, D. J. Lamb. Scott Department of Urology, Center for Reproductive Medicine, Baylor College of Medicine, Houston, TX. OBJECTIVE: Many unrecognized genetic causes of male infertility likely exist. Here, we implicate glucose transporter GLUT3 and contactin-associated protein CASPR5 in male fertility. DESIGN: Genetic study comparing infertile and fertile men. MATERIALS AND METHODS: Genomic DNA from 22 men with nonobstructive azoospermia (NOA) and normal Y-chromosome microdeletion and karyotype assays, as well as 4 fertile men, was used for array comparative genomic hybridization (aCGH) to assess copy number variations (CNVs). Candidate fertility genes were selected using CNV frequency and magnitude, as well as gene expression data. CNVs were validated using qPCR and candidate genes sequenced. Immunohistochemical staining of testis sections used available antibodies and standard protocols. RESULTS: Copy number gains on aCGH were identified in GLUT3 in 2/22 and in CASPR5 in 1/22 NOA men and in no controls, and confirmed using qPCR copy number assays (CNAs). CNAs of DNA from 43 infertile men yielded 5 more men with GLUT3 gains, and no men with CASPR5 losses. The frequency of GLUT3 CNVs in the general population is approximately 5%, whereas our gain frequency is 16%. CNVs in CASPR5 occur in 0.002% of the general population and in 2% of our cohort. Sequencing of GLUT3 yielded benign SNPs in exons 2, 6, and 10; no damaging SNPs were identified in CASPR5. Staining of testis from a male with 3 GLUT3 copies and hypospermatogenesis showed cytoplasmic Leydig cell and spermatocyte staining. CONCLUSION: CNVs in GLUT3 and CASPR5 were identified in infertile males. Future work assessing the impact of both genes on fertility-related cellular pathways, as well as animal model studies, will elucidate the roles of these genes in male fertility. Supported by: AUA Foundation Russell Scott, Jr., MD, Resident Research Award (AWP), NIH grants K12 DK0083014 (CJJ, DJL), the Multidisciplinary K12 Urologic Research (KURe) Career Development Program (CJJ, DJL), and P01HD36289 from the Eunice Kennedy Shriver National Institute for Child Health and Human Development, NIH (DJL).

O-4 Monday, October 22, 2012 12:00 PM METHOTREXATE OR EXPECTANT MANAGEMENT IN WOMEN WITH ECTOPIC PREGNANCY OR PUL AND LOW SERUM hCG CONCENTRATIONS? A RANDOMIZED CONTROLLED TRIAL. N. M. van Mello, On behalf of the METEX Study Group. Department of Obstetrics and Gynaecology, Academic Medical Centre, University of Amsterdam, Amsterdam, Noord-Holland, Netherlands. OBJECTIVE: To determine whether expectant management is effective compared to treatment with systemic methotrexate (MTX) in women with an ectopic pregnancy (EP) or pregnancy of unknown location (PUL) with low but plateauing serum hCG concentrations. DESIGN: Multicentre randomized controlled trial. MATERIALS AND METHODS: We included women with an EP and a plateauing serum hCG <1,500 IU/L and women with a PUL and a plateauing serum hCG <2,000 IU/L. Randomization to single dose systemic MTX or expectant management. Women were monitored weekly, in case of an inadequate decline (<15%) of serum hCG after one week systemic MTX was continued or installed. In case of signs of tubal rupture surgery was performed. The

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primary outcome measure was an uneventful decline of serum hCG. Secondary outcomes were additional MTX injections, surgical treatment and complications. Analysis by intention to treat. RESULTS: We included 73 women, 41 were allocated single dose MTX and 32 expectant management. There was no difference in primary treatment success of single dose MTX and expectant management, 31/41 (76%) and 19/ 32 (59%), respectively (RR 1.3 95% CI 0.9 to 1.8). In nine women (22%) additional MTX injections were needed after initial MTX treatment, compared to nine women (28%) in whom systemic MTX was installed after initial expectant management (RR 0.8 95%CI 0.4 to 1.7). One woman (2%) from the MTX group underwent surgery compared to four women (13%) in the expectant management group (RR 0.2 95%CI 0.02 to 1.7), all because of abdominal pain within the first week of follow up. No serious adverse events were reported. CONCLUSION: In women with an EP or PUL and low but plateauing serum hCG concentrations, expectant management is a safe alternative to single dose systemic MTX. Sixty percent of these women had steadily declining serum hCG levels without any intervention, this finding implicates that MTX, a potentially harmful drug, can be withheld in these women. Supported by: Netherlands Organization for Health Research and Development (grant 90700154). O-5 Monday, October 22, 2012 12:15 PM MACAQUE OVARIAN TISSUE VITRIFIED IN A CLOSED SYSTEM YIELDS FUNCTIONAL SECONDARY FOLLICLES. A. Y. Ting, R. R. Yeoman, J. R. Campos, M. S. Lawson, M. B. Zelinski. Division of Reproductive and Developmental Sciences, Oregon National Primate Research Center, Beaverton, OR. OBJECTIVE: Clinical practice for ovarian tissue cryopreservation uses an open system that allows cross contamination between specimens. We examined the function of secondary follicles isolated from macaque ovarian tissue vitrified in a closed system in vitro. DESIGN: Nonhuman primate model, randomized, controlled study. MATERIALS AND METHODS: Macaque (N¼4) ovarian cortical pieces (3x3x0.5mm3; N¼28/animal) were equilibrated in vitrification solution containing 27% glycerol and 27% ethylene glycol (w/v) with 0.8% polymers (X1000, polyvinylpyrrolidone, Z-1000), loaded into heat sealable straws and cooled in LN2 vapor. Tissues were warmed and transferred to decreasing sucrose concentrations. Secondary follicles (n¼24/treatment/animal) were isolated from fresh and vitrified tissues, individually encapsulated in alginate and cultured for 6 weeks (wks). Follicle health, diameter and steroid (progesterone [P], androstenedione [A], estradiol [E2]) production were analyzed weekly. RESULTS: Both vitrified (522%) and fresh (7012%) follicles showed similar survival rates. Antrum formation rates were lower (P<0.05) for vitrified (376%) relative to fresh (648%) follicles. For both groups, initial follicle diameter was similar and increased by wk3, but diameters in vitrified follicles were decreased (P<0.05) by wk6 (56627um) compared to fresh (75726um). P production was reduced (P<0.05) in vitrified follicles at wk4 (441 ng/ml) and wk6 (7115) compared to fresh follicles (1146 and 13717, respectively). However, similar levels of E2 and A were produced throughout culture. CONCLUSION: Functional secondary follicles were derived, for the first time, from primate ovarian tissue vitrified in a closed system. While diminished antrum formation and slower growth in vitro reflect residual cyrodamage, closed system vitrification can offer a significant technical advancement as a safe and efficient method of fertility preservation. Supported by: NIH UL1RR024926, R01AHD058293, PL1EB008542, U54 HD018185, 8P51OD011092-53. O-6 Monday, October 22, 2012 12:30 PM STATIN THERAPY IMPAIRS INSULIN SENSITIVITY IN WOMEN WITH POLYCYSTIC OVARY SYNDROME (PCOS): A PROSPECTIVE, RANDOMIZED, DOUBLE-BLINDED, PLACEBO-CONTROLLED STUDY. J. Puurunen,a,b T. Piltonen,a,b,c A. Ruokonen,d M. J. Savolainen,e L. Morin-Papunen,a J. S. Tapanainen.a,b,f aDepartment of Obstetrics and Gynecology, Oulu University Hospital, Oulu, Finland; bDepartment of Obstetrics and Gynecology, Clinical Research Center, Oulu University Hospital, Oulu, Finland; cDepartment of Obstetrics, Gynecology and Reproductive Sciences, The University of California, San Francisco, San Francisco, CA; dDepartment of Clinical Chemistry, Institute of Diagnostics,

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ASRM Abstracts

Oulu University Hospital, Oulu, Finland; eDepartment of Internal Medicine, Institute of Clinical Medicine, University of Oulu, Oulu, Finland; fDepartment of Obstetrics and Gynecology, University of Helsinki and Helsinki University Central Hospital, Helsinki, Finland. OBJECTIVE: Previous studies have suggested that women with PCOS may benefit from statin therapy as it has shown to decrease serum testosterone levels especially in subjects with hyperandrogenism. However, the data concerning the effects of statin therapy on glucose tolerance in PCOS have been controversial. The purpose of the present study was to explore the effects of atorvastatin therapy on glucose metabolism, androgens, lipid profile and chronic inflammation in women with PCOS. DESIGN: A randomized, double-blinded, placebo-controlled 6-month follow-up study. MATERIALS AND METHODS: The diagnosis of PCOS was based on Rotterdam criteria. Twenty-eight of 38 women with PCOS completed the study; atorvastatin 20 mg/day (n¼15) or placebo (n¼13) for 6 months. Fasting serum samples were collected at baseline and thereafter at 3 and 6 months of treatment. Oral glucose tolerance tests (OGTTs) and intravenous glucose tolerance tests (IVGTTs) were performed at 0 and 6 months. Repeated measures ANOVA, Friedman’s test and One-Way ANOVA were used for statistical analyses. RESULTS: Fasting insulin levels and area under the curve (during OGTT) increased and whole-body insulin sensitivity decreased significantly in the atorvastatin group. However, insulin sensitivity measured by IVGTT did not change in either group. Serum levels of dehydroepiandrosterone sulphate decreased in the atorvastatin group, whereas no change was observed in testosterone levels. Serum levels of C-reactive protein decreased significantly and lipid profile improved during statin therapy. CONCLUSION: Atorvastatin therapy improves lipid profile and chronic inflammation but impairs insulin sensitivity in women with PCOS. Since these women present with high risk of type 2 diabetes, the results suggest that statin therapy should be initiated based on generally accepted criteria and individual risk assessment of cardiovascular disease, and not only due to the diagnosis of PCOS. Supported by: Supported by grants from the Academy of Finland and the Sigrid Juselius Foundation. CLINICAL FEMALE INFERTILITY AND GYNECOLOGY O-7 Monday, October 22, 2012 04:15 PM HOW GENES INFLUENCE A WOMAN’S REPRODUCTIVE LIFESPAN: THE IMPACT OF THE FMR1 GENE ON AGE AT MENARCHE. A. Weghofera,b A. Kim.a aCenter for Human Reproduction (CHR), New York, NY; bObstetrics & Gynecology, Medical University Vienna, Vienna, Austria. OBJECTIVE: Recent evidence suggests that genetic factors determine the length of reproduction in women. Amongst implicated genes, abnormal CGGn on the FMR1 gene are, for instance, associated with a tenfold increased risk towards premature ovarian failure. Abnormal CGGn have also been associated with premature ovarian aging. Whether the FMR1 gene in its various genotypes and sub-genotypes is also associated with menarcheal age is, however, unknown, and was subject of this investigation. DESIGN: Cohort study. MATERIALS AND METHODS: We evaluated 222 infertility patients and oocyte donors, correlating their CGGn with their menarcheal ages. Women with chromosomal abnormalities and with CGG n¼55-200 (premutation range genotype) were excluded. Ovarian genotypes of the FMR1 gene, based on a normal range of CGG n¼26-34, were determined as previously reported (PLoS ONE 2010; 5: e 15303; PLoS ONE 2011; 6: e18781). We then assessed whether menarcheal age differed based on CGG n%34 vs. CGG n>34. RESULTS: Mean age of the cohort at study was 30.912.1 years; mean age at menarche was 12.91.5 years. There was a significant relationship between CGG repeat number (%34 vs. >34) and age at menarche (<13 years vs. R13 years) [c2 (1, N¼222) ¼4.10, P¼0.043]. Specifically, women with at least one high FMR1 allele (CGG n>34) were more likely to reach menarche later (age R13 years) than women with low or normal (norm) alleles (75.0% vs. 58.4%). This association between CGG repeat length and age at menarche remained significant when adjusted for race (P¼0.02). CONCLUSION: Our preliminary results suggest that CGGnR34, representing high sub-genotypes of the FMR1 gene, is associated with later

Vol. 98, No. 3, Supplement, September 2012