- Email: [email protected]
outcomes of minimal ovarian stimulation protocol before intrauterine insemination
O-463 Wednesday, October 16, 2013 05:30 PM
Obstetrical Outcomes in D3 vs. Blast Transfers
THE EFFECT OF EMBRYO STATE AND EMBRYO SOURCE ON PREDICTING LIVE BIRTH AFTER ASSISTED REPRODUCTIVE TECHNOLOGY (ART). B. Luke,a M. B. Brown,b E. Wantman,c E. A. Widra,d W. E. Gibbons,e G. D. Ball.f aObstetrics, Gynecology, and Reproductive Biology, Michigan State University, East Lansing, MI; bBiostatistics, University of Michigan, Ann Arbor, MI; cRedshift Technologies, New York, NY; dShady Grove Fertility Center, Washington, DC; eObstetrics and Gynecology, Baylor College of Medicine, Houston, TX; fSeattle Reproductive Medicine, Seattle, WA. OBJECTIVE: To model factors in the Society for Assisted Reproductive Technology Clinic Outcomes Reporting System predictive of a live birth after ART by embryo source and embryo state. DESIGN: Longitudinal cohort. MATERIALS AND METHODS: Live birth rates were modeled by demographic, medical history, and treatment factors using backward-stepping logistic regression for each embryo source/state combination for cycles reported between 2007 and 2010. Model results are presented as odds ratios (<1 signifies poorer outcome) and 95% confidence intervals. RESULTS: The most significant factors were woman’s age, cryopreservation of embryos (fresh cycles only), number of embryos transferred, use of assisted hatching, BMI, and diagnoses of tubal factors and uterine factors; partial results are shown below.
Embryo State/Source
Fresh, Thawed, Autologous Autologous
Fresh, Donor
Thawed, Donor
Cycles Age 30-34 vs <30 35-39 vs <30 40-44 vs <30 R45 vs <30
306,943 AOR (95% CI) 0.94 (0.92, 0.96) 0.67 (0.66, 0.69) 0.33 (0.32, 0.34) 0.07 (0.06, 0.08)
86,297 AOR (95% CI) 0.99 (0.94, 1.03) 0.79 (0.75, 0.82) 0.50 (0.47, 0.54) 0.26 (0.21, 0.31)
35,203 AOR (95% CI) 1.26 (1.07, 1.48) 1.19 (1.03, 1.39) 1.15 (0.99, 1.33) 0.96 (0.83, 1.11)
20,165 AOR (95% CI) 1.06 (0.85, 1.31) 0.97 (0.79, 1.19) 0.92 (0.76, 1.12) 0.89 (0.73, 1.08)
BMI 25-29 vs <25 BMI R30 vs <25
0.94 (0.92, 0.96) 0.81 (0.78, 0.84)
0.93 (0.90, 0.96) 0.79 (0.75, 0.83)
0.96 (0.91, 1.00) 0.82 (0.75, 0.89)
—— ——
Tubal factor Uterine factor
0.85 (0.83, 0.87) 0.78 (0.75, 0.82)
0.88 (0.85, 0.92) 0.77 (0.71, 0.82)
0.76 (0.70, 0.82) 0.74 (0.67, 0.82)
0.87 (0.78, 0.97) ——
No embryos cryopreserved Assisted hatching
0.58 (0.57, 0.59)
——
0.56 (0.54, 0.59)
——
0.81 (0.79, 0.82)
1.03 (1.00, 1.07)
0.75 (0.71, 0.80)
1.14 (1.07, 1.21)
1.83 (1.78, 1.87)
1.76 (1.69, 1.83)
1.49 (1.40, 1.60)
1.84 (1.70, 2.01)
1.86 (1.80, 1.91)
1.78 (1.70, 1.86)
1.18 (1.08, 1.29)
1.75 (1.59, 1.93)
Embryos transferred 2 vs 1 Embryos transferred R3 vs 1
CONCLUSION: Components of the prediction model for live birth include demographics, medical presentation, and measures of embryo quality. Supported by: SART. O-464 Wednesday, October 16, 2013 05:45 PM EXTENDED EMBRYO CULTURE (BLAST): SUPERIOR LIVE BIRTH RATES (LBR) WITH SMALL INCREASED RISK OF ADVERSE OBSTETRICAL OUTCOMES AS COMPARED TO J. Kim,b CLEAVAGE STAGE TRANSFERS. M. D. Werner,a,b E. J. Forman,a,b K. H. Hong,a,b T. A. Molinaro,a,b R. T. Scott, Jr.a,b aReproductive Endocrinology and Infertility, Robert Wood Johnson Medical School, Basking Ridge, NJ; bReproductive Medicine Associates of NJ, Basking Ridge, NJ. OBJECTIVE: Deciding the developmental stage to transfer embryos is complex. Class I data show higher implantation rates with blast transfer, but delivery data show increased low birth weight (LBW) risk. This study combines these endpoints and assesses outcomes from the clinical vantage point where decisions are made – on day 3 (D3) when embryos are available for transfer or to place into extended culture. DESIGN: Retrospective Cohort.
FERTILITY & STERILITYÒ
N D3 723 Blast 2735 p value
Pre-term Full-term Failure VLBW LBW NBW Delivery Delivery to Deliver% % % % % % 57 43.5 0.0001
2.9 4.0 0.229
8.8 31.3 14.5 38.0 0.0003 0.0008
10.1 16.1 0.00002
32.2 39.5 0.0003
MATERIALS AND METHODS: The first IVF cycle for patients with FSH< 18 and R2 embryos from 2008-12 were studied. D3 was compared to blast ETs regarding: failure to deliver; very low birth weight (VLBW, %1500g), low birth weight (LBW, 1500-2500g), normal birth weight (NBW, 2500-4000g). Gestational age at delivery was also compared. RESULTS: 3458 patients were included for analysis. The live births rates were 13.5% higher in blast than D3 (56.5 vs 43.0%, P¼0.0001; RR¼ 1.3; 95%CI 1.2-1.4). Extended culture resulted in more NBW (35.5 vs 28.9%, P¼0.001) and full term deliveries (39.5% vs 32.2%; p¼0.0003). Blasts did have a small increase in LBW rates. No difference was detected in the twins (D3 35.2% vs blast 39.6%). Even when controlling for age, blast transfer continued to yield higher odds of full term delivery (OR: 1.2; 95% CI: 1.0-1.5). CONCLUSION: Evaluating outcomes from the point of clinical management, blast transfer provides a 32.0% relative increase in the probability of a live birth including an absolute 6.7% increase in NBW children. This gain is balanced by a small increase in LBW risk. Going forward, use of chromosomal screening which allows effective single embryo transfer may lead to the near elimination of multiples. This question will certainly need to be reevaluated in that context as it will likely heavily favor extended culture for all endpoints. CLINICAL FEMALE INFERTILITY AND GYNECOLOGY II O-465 Wednesday, October 16, 2013 04:00 PM OUTCOMES OF MINIMAL OVARIAN STIMULATION PROTOCOL BEFORE INTRAUTERINE INSEMINATION. Y. Mouhayar,a D. Christie,a,b M. Barrionuevo,a,b D. Hoffman,a,b W. Maxson,a,b S. Ory.a,b aDepartment of Obstetrics and Gynecology, University of Miami-Jackson Memorial Hospital, Miami, FL; bIVF Florida Reproductive Associates, Margate, FL. OBJECTIVE: To compare the clinical and multiple pregnancy rates in patients undergoing minimal-stimulation (mini-stim) with clomiphene citrate (CC) followed by a single injection of gonadotropin, to those receiving either CC or gonadotropin alone prior to intrauterine insemination (IUI). DESIGN: Retrospective chart review of 1,692 infertile couples that underwent ovulation induction between 2008 and 2011 in a single fertility clinic. MATERIALS AND METHODS: Included were all women undergoing infertility treatment with ovarian stimulation followed by IUI. Ovarian stimulation protocols included daily 100 mg of CC alone, 100 mg of CC for 5 days followed by one 150 IU of gonadotropins (mini-stim), or daily gonadotropin injections. Couples were limited to a single treatment arm, and underwent between one and three cycles. Clinical and multiple pregnancies were defined by sonographic evidence of fetal cardiac activity. Pearson’s ChiSquared was used to test for association between treatment protocols and outcome. RESULTS: The distribution of patients undergoing one, two, or three IUI cycles was similar irrespective of the treatment type. In patients younger than 35, the pregnancy rates for CC, mini-stim, and gonadotropins were 18.1%, 27.6%, and 31.7%, respectively (X2(2)¼13.9, P¼.0009). Patients aged 3537 had pregnancy rates of 15.1%, 19.8%, and 15.0% (X2(2)¼1.22, P¼.5425). Patients between 38-40 of age had pregnancy rates of 8.7%, 17.6%, and 17.0% (X2(2)¼2.63, P¼.2677). Those older than 40 had pregnancy rates of 6.6%, 8.5%, and 5.3% (X2(2)¼0.99, P¼.6). Moreover, gonadotropins protocol had a significantly higher multiple pregnancy rate (25.6%) than both mini-stim (15.0%) and CC (11.7%), (X2(2)¼7.29, P¼.026). CONCLUSION: A mini-stim protocol with IUI achieves pregnancy rates similar to gonadotropins with IUI. In addition, mini-stim with IUI and CC
S141
with IUI protocols, had significantly lower multiple pregnancy rates than that of gonadotropins with IUI, in patients undergoing infertility treatments. O-466 Wednesday, October 16, 2013 04:15 PM CLINICAL PREGNANCY FOLLOWING UTERUS TRANSPLANTATION. M. Erman Akar,a O. Ozkan,b B. A. Uraz,c K. Dirican,c M. Cincik,d I. Mendilcioglu.a aObstetrics and Gynecology, Akdeniz University, Antalya, Turkey; bPlastic Surgery, Akdeniz University, Antalya, Turkey; c Obstetrics and Gynecology, Memorial Antalya Hospital, Antalya, Turkey; d Obstetrics and Gynecology, Acibadem Hospital, Istanbul, Turkey. OBJECTIVE: Our goal is to present the first clinical pregnancy following uterus transplantation. DESIGN: Case report. MATERIALS AND METHODS: In 2011,uterus allotransplantation was performed in a patient with complete mullerian agenesis from a deceased donor.Eight embryos were vitrified before the transplantation procedure. Embryo transfer was planned following confirmation of graft stability and safe serum immunosuppressive levels. RESULTS: Immunosuppressive and infection prophylaxis therapies were started. Bilateral uterine artery doppler ultrasonography, cervical and endometrial biopsies demontrated no signs of thromboses or rejection. Starting from first month, the patient had menstrual bleeding with almost every cycle. Eighteen months after uterus allotransplantation and confirmation of the graft stability, one thawed embryo was transferred to the allotransplanted uterus. Serum human chorionic gonadotrophin levels and transvaginal ultrasonography confirmed a viable intrauterine pregnancy. CONCLUSION: Experimental animal and human research are promising to show allo uterus transplantation might be an alternative for fertility restoration.
O-467 Wednesday, October 16, 2013 04:30 PM THE OUTCOMES AND BENEFITS OF HYSTEROSCOPIC PROCEDURES IN WOMEN WITH RECURRENT IMPLANTATION FAILURE (RIF) AFTER IN VITRO FERTILIZATION (IVF). M. M. Chawla, M. Fakih, A. Shunnar, J. Diwakaran. FakihIVF, Abu Dhabi, United Arab Emirates. OBJECTIVE: Evaluation of hysteroscopic procedures in achieving a pregnancy in women with a history of RIF in IVF. DESIGN: A retrospective case control study in a private assisted conception unit. MATERIALS AND METHODS: 145 subjects with history of RIF were included. All had a transvaginal scan (TVS) and hysterosalpingogram (HSG) performed. In case of abnormal findings in the uterine cavity, they were consented for hysteroscopy for evaluation and treatment. In case of no abnormality being detected, they were offered a hysteroscopy for unsuspected findings and correction. Clinical pregnancy rates (CPR) were calculated. Statistical significance was calculated using chi square. RESULTS: 92 /145 (63.4%) patients of RIF underwent hysteroscopy. 60/ 92 (65.21%) of these had no abnormalities on prior investigations (Group 1). 32/92 (34.78%) patients had abnormal findings on TVS /HSG. 24/32 (75%) of patients had their abnormalities confirmed and were treated. (Group 2). 53 / 145 (36.5%) patients who had normal HSG /TVS opted to go ahead with subsequent IVF without any hysteroscopy. (Group 3) In Group 1, 39/60 patients (65%) had abnormalities found on hysteroscopy which were rectified at the same time. The most common abnormality was Endometrial polyp 41/92 (44.56%) followed by partial septum (8.69%). The others were submucous fibroids, intrauterine adhesions, endometritis, septate uterus . CPR in Group 1 after correction of abnormalities was found to be 66.6%. The CPR in group 2 and Group 3 was calculated as 46.8 % and 33.96% respectively. The difference between group 1 and 2 versus 3 was found to be statistically significant p<0.01. CONCLUSION: Hysteroscopy is beneficial in women in RIF with a high possibility for unsuspected abnormalities in such cases despite normal cavitary assessments. It significantly improves the clinical pregnancy rates compared to the control group. It may serve as a universal tool in this group of women to improve implantation rates.
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ASRM Abstracts
O-468 Wednesday, October 16, 2013 04:45 PM A PILOT CASE CONTROL STUDY OF THE USE OF MELATONIN IN PATIENTS WITH MULTIPLE FAILED IVF CYCLES. N. L. Pritchard,a K. L. Sorby,b T. Osianlis,b B. J. Vollenhoven.a,b,c aMonash University, Clayton, VIC, Australia; bMonash IVF, Clayton, Vic, Australia; cMonash Health, Clayton, Vic, Australia. OBJECTIVE: Egg quality and therefore embryo quality is a limiting factor in IVF. Mitochondria supply ATP to cells, and higher levels are associated with better quality eggs. Excessive reactive oxygen species (ROS) are implicated in mitochondrial damage. Melatonin regulates reproductive physiology via gonadotropin release, but is also a powerful free radical scavenger and antioxidant. Our study examined the use of melatonin in IVF patients with multiple unsuccessful cycles. DESIGN: Retrospective case control study. MATERIALS AND METHODS: !?A3B2 tlsb=0.06pt?>From June 2012April 2013, 13 women from Monash IVF Australia who had undergone at least two unsuccessful IVF cycles were given 4mg melatonin daily from the first day of follicle stimulating hormone. Two controls per case were matched for age, cycle number, stimulation type and dose; with consideration for BMI, infertility aetiology and andrology. Primary outcomes were oocyte quantity, oocyte maturity and utilization rates. Secondary outcomes included duration of FSH, peak oestrodial levels, number of follicles >11mm and clinical and biochemical pregnancies. T-tests were used to analyse continuous data and Fisher’s exact test for categorical data; p<0.05 considered significant. RESULTS: When the melatonin cases were compared to the matched controls, there were no statistically significant differences in any of the primary or secondary outcomes assessed. Interestingly, when melatonin cases were compared with their own previous cycle, oocyte number showed a trend towards increased value (5.1 vs 7.1, p¼0.1744). Of clinical relevance, increase in mature oocyte numbers compared to previous cycles approached statistical significance (3.4 vs 4.9, p¼0.0515). Duration of FSH, max E2, follicle number and utilization rate showed no significant changes. CONCLUSION: In patients with multiple unsuccessful IVF cycles, melatonin may improve oocyte quantity and increase development to mature oocytes. The trends in this small group of patients warrants further study. O-469 Wednesday, October 16, 2013 05:00 PM ETIOLOGY OF INFERTILITY IN RURAL AFRICA. J. Mugisha,b R. Kudesia,a C. Hickmon,a P. C. Klatsky.a aDepartment of Obstetrics, Gynecology & Women’s Health, Albert Einstein College of Medicine, Bronx, NY; bSt. Francis Hospital Mutolere, Kisoro, Uganda. OBJECTIVE: We examine causes of infertility in patients presenting to a infertility consultation clinic in rural Uganda. DESIGN: Descriptive case series. MATERIALS AND METHODS: A radio announcement preceded a twoweek infertility consultation clinic provided by the Albert Einstein College of Medicine and St. Francis Mutolere Mission Hospital in Kisoro, Uganda. Evaluation included assessment of male factor via semen analysis (SA) assessed by 2011 World Health Organization (WHO) criteria, ovulatory status as determined by menstrual calendars, and tubal and uterine factors as evaluated by hysterosalpingogram. RESULTS: 110 women were evaluated, with a mean age of 29.3 6.3 years. SAs were available for 73 men, and were abnormal in 23 cases (33%), 8 revealing azoopermia. Most couples, 66%, had primary infertility. Evaluation revealed a roughly identical prevalence of tubal infertility and ovulatory dysfunction, 26% and 25%, respectively.
Current Study Etiology Primary Infertility Tubal Diagnosis Anovulation Male Factor
Cates et al, 1985
Kisoro, Uganda (%)
Africa (%)
Developed Countries (%)
66 26 25 25
48 49 7 8
71 11 16 22
Vol. 100, No. 3, Supplement, September 2013
Obstetrical Outcomes in D3 vs. Blast Transfers
THE EFFECT OF EMBRYO STATE AND EMBRYO SOURCE ON PREDICTING LIVE BIRTH AFTER ASSISTED REPRODUCTIVE TECHNOLOGY (ART). B. Luke,a M. B. Brown,b E. Wantman,c E. A. Widra,d W. E. Gibbons,e G. D. Ball.f aObstetrics, Gynecology, and Reproductive Biology, Michigan State University, East Lansing, MI; bBiostatistics, University of Michigan, Ann Arbor, MI; cRedshift Technologies, New York, NY; dShady Grove Fertility Center, Washington, DC; eObstetrics and Gynecology, Baylor College of Medicine, Houston, TX; fSeattle Reproductive Medicine, Seattle, WA. OBJECTIVE: To model factors in the Society for Assisted Reproductive Technology Clinic Outcomes Reporting System predictive of a live birth after ART by embryo source and embryo state. DESIGN: Longitudinal cohort. MATERIALS AND METHODS: Live birth rates were modeled by demographic, medical history, and treatment factors using backward-stepping logistic regression for each embryo source/state combination for cycles reported between 2007 and 2010. Model results are presented as odds ratios (<1 signifies poorer outcome) and 95% confidence intervals. RESULTS: The most significant factors were woman’s age, cryopreservation of embryos (fresh cycles only), number of embryos transferred, use of assisted hatching, BMI, and diagnoses of tubal factors and uterine factors; partial results are shown below.
Embryo State/Source
Fresh, Thawed, Autologous Autologous
Fresh, Donor
Thawed, Donor
Cycles Age 30-34 vs <30 35-39 vs <30 40-44 vs <30 R45 vs <30
306,943 AOR (95% CI) 0.94 (0.92, 0.96) 0.67 (0.66, 0.69) 0.33 (0.32, 0.34) 0.07 (0.06, 0.08)
86,297 AOR (95% CI) 0.99 (0.94, 1.03) 0.79 (0.75, 0.82) 0.50 (0.47, 0.54) 0.26 (0.21, 0.31)
35,203 AOR (95% CI) 1.26 (1.07, 1.48) 1.19 (1.03, 1.39) 1.15 (0.99, 1.33) 0.96 (0.83, 1.11)
20,165 AOR (95% CI) 1.06 (0.85, 1.31) 0.97 (0.79, 1.19) 0.92 (0.76, 1.12) 0.89 (0.73, 1.08)
BMI 25-29 vs <25 BMI R30 vs <25
0.94 (0.92, 0.96) 0.81 (0.78, 0.84)
0.93 (0.90, 0.96) 0.79 (0.75, 0.83)
0.96 (0.91, 1.00) 0.82 (0.75, 0.89)
—— ——
Tubal factor Uterine factor
0.85 (0.83, 0.87) 0.78 (0.75, 0.82)
0.88 (0.85, 0.92) 0.77 (0.71, 0.82)
0.76 (0.70, 0.82) 0.74 (0.67, 0.82)
0.87 (0.78, 0.97) ——
No embryos cryopreserved Assisted hatching
0.58 (0.57, 0.59)
——
0.56 (0.54, 0.59)
——
0.81 (0.79, 0.82)
1.03 (1.00, 1.07)
0.75 (0.71, 0.80)
1.14 (1.07, 1.21)
1.83 (1.78, 1.87)
1.76 (1.69, 1.83)
1.49 (1.40, 1.60)
1.84 (1.70, 2.01)
1.86 (1.80, 1.91)
1.78 (1.70, 1.86)
1.18 (1.08, 1.29)
1.75 (1.59, 1.93)
Embryos transferred 2 vs 1 Embryos transferred R3 vs 1
CONCLUSION: Components of the prediction model for live birth include demographics, medical presentation, and measures of embryo quality. Supported by: SART. O-464 Wednesday, October 16, 2013 05:45 PM EXTENDED EMBRYO CULTURE (BLAST): SUPERIOR LIVE BIRTH RATES (LBR) WITH SMALL INCREASED RISK OF ADVERSE OBSTETRICAL OUTCOMES AS COMPARED TO J. Kim,b CLEAVAGE STAGE TRANSFERS. M. D. Werner,a,b E. J. Forman,a,b K. H. Hong,a,b T. A. Molinaro,a,b R. T. Scott, Jr.a,b aReproductive Endocrinology and Infertility, Robert Wood Johnson Medical School, Basking Ridge, NJ; bReproductive Medicine Associates of NJ, Basking Ridge, NJ. OBJECTIVE: Deciding the developmental stage to transfer embryos is complex. Class I data show higher implantation rates with blast transfer, but delivery data show increased low birth weight (LBW) risk. This study combines these endpoints and assesses outcomes from the clinical vantage point where decisions are made – on day 3 (D3) when embryos are available for transfer or to place into extended culture. DESIGN: Retrospective Cohort.
FERTILITY & STERILITYÒ
N D3 723 Blast 2735 p value
Pre-term Full-term Failure VLBW LBW NBW Delivery Delivery to Deliver% % % % % % 57 43.5 0.0001
2.9 4.0 0.229
8.8 31.3 14.5 38.0 0.0003 0.0008
10.1 16.1 0.00002
32.2 39.5 0.0003
MATERIALS AND METHODS: The first IVF cycle for patients with FSH< 18 and R2 embryos from 2008-12 were studied. D3 was compared to blast ETs regarding: failure to deliver; very low birth weight (VLBW, %1500g), low birth weight (LBW, 1500-2500g), normal birth weight (NBW, 2500-4000g). Gestational age at delivery was also compared. RESULTS: 3458 patients were included for analysis. The live births rates were 13.5% higher in blast than D3 (56.5 vs 43.0%, P¼0.0001; RR¼ 1.3; 95%CI 1.2-1.4). Extended culture resulted in more NBW (35.5 vs 28.9%, P¼0.001) and full term deliveries (39.5% vs 32.2%; p¼0.0003). Blasts did have a small increase in LBW rates. No difference was detected in the twins (D3 35.2% vs blast 39.6%). Even when controlling for age, blast transfer continued to yield higher odds of full term delivery (OR: 1.2; 95% CI: 1.0-1.5). CONCLUSION: Evaluating outcomes from the point of clinical management, blast transfer provides a 32.0% relative increase in the probability of a live birth including an absolute 6.7% increase in NBW children. This gain is balanced by a small increase in LBW risk. Going forward, use of chromosomal screening which allows effective single embryo transfer may lead to the near elimination of multiples. This question will certainly need to be reevaluated in that context as it will likely heavily favor extended culture for all endpoints. CLINICAL FEMALE INFERTILITY AND GYNECOLOGY II O-465 Wednesday, October 16, 2013 04:00 PM OUTCOMES OF MINIMAL OVARIAN STIMULATION PROTOCOL BEFORE INTRAUTERINE INSEMINATION. Y. Mouhayar,a D. Christie,a,b M. Barrionuevo,a,b D. Hoffman,a,b W. Maxson,a,b S. Ory.a,b aDepartment of Obstetrics and Gynecology, University of Miami-Jackson Memorial Hospital, Miami, FL; bIVF Florida Reproductive Associates, Margate, FL. OBJECTIVE: To compare the clinical and multiple pregnancy rates in patients undergoing minimal-stimulation (mini-stim) with clomiphene citrate (CC) followed by a single injection of gonadotropin, to those receiving either CC or gonadotropin alone prior to intrauterine insemination (IUI). DESIGN: Retrospective chart review of 1,692 infertile couples that underwent ovulation induction between 2008 and 2011 in a single fertility clinic. MATERIALS AND METHODS: Included were all women undergoing infertility treatment with ovarian stimulation followed by IUI. Ovarian stimulation protocols included daily 100 mg of CC alone, 100 mg of CC for 5 days followed by one 150 IU of gonadotropins (mini-stim), or daily gonadotropin injections. Couples were limited to a single treatment arm, and underwent between one and three cycles. Clinical and multiple pregnancies were defined by sonographic evidence of fetal cardiac activity. Pearson’s ChiSquared was used to test for association between treatment protocols and outcome. RESULTS: The distribution of patients undergoing one, two, or three IUI cycles was similar irrespective of the treatment type. In patients younger than 35, the pregnancy rates for CC, mini-stim, and gonadotropins were 18.1%, 27.6%, and 31.7%, respectively (X2(2)¼13.9, P¼.0009). Patients aged 3537 had pregnancy rates of 15.1%, 19.8%, and 15.0% (X2(2)¼1.22, P¼.5425). Patients between 38-40 of age had pregnancy rates of 8.7%, 17.6%, and 17.0% (X2(2)¼2.63, P¼.2677). Those older than 40 had pregnancy rates of 6.6%, 8.5%, and 5.3% (X2(2)¼0.99, P¼.6). Moreover, gonadotropins protocol had a significantly higher multiple pregnancy rate (25.6%) than both mini-stim (15.0%) and CC (11.7%), (X2(2)¼7.29, P¼.026). CONCLUSION: A mini-stim protocol with IUI achieves pregnancy rates similar to gonadotropins with IUI. In addition, mini-stim with IUI and CC
S141
with IUI protocols, had significantly lower multiple pregnancy rates than that of gonadotropins with IUI, in patients undergoing infertility treatments. O-466 Wednesday, October 16, 2013 04:15 PM CLINICAL PREGNANCY FOLLOWING UTERUS TRANSPLANTATION. M. Erman Akar,a O. Ozkan,b B. A. Uraz,c K. Dirican,c M. Cincik,d I. Mendilcioglu.a aObstetrics and Gynecology, Akdeniz University, Antalya, Turkey; bPlastic Surgery, Akdeniz University, Antalya, Turkey; c Obstetrics and Gynecology, Memorial Antalya Hospital, Antalya, Turkey; d Obstetrics and Gynecology, Acibadem Hospital, Istanbul, Turkey. OBJECTIVE: Our goal is to present the first clinical pregnancy following uterus transplantation. DESIGN: Case report. MATERIALS AND METHODS: In 2011,uterus allotransplantation was performed in a patient with complete mullerian agenesis from a deceased donor.Eight embryos were vitrified before the transplantation procedure. Embryo transfer was planned following confirmation of graft stability and safe serum immunosuppressive levels. RESULTS: Immunosuppressive and infection prophylaxis therapies were started. Bilateral uterine artery doppler ultrasonography, cervical and endometrial biopsies demontrated no signs of thromboses or rejection. Starting from first month, the patient had menstrual bleeding with almost every cycle. Eighteen months after uterus allotransplantation and confirmation of the graft stability, one thawed embryo was transferred to the allotransplanted uterus. Serum human chorionic gonadotrophin levels and transvaginal ultrasonography confirmed a viable intrauterine pregnancy. CONCLUSION: Experimental animal and human research are promising to show allo uterus transplantation might be an alternative for fertility restoration.
O-467 Wednesday, October 16, 2013 04:30 PM THE OUTCOMES AND BENEFITS OF HYSTEROSCOPIC PROCEDURES IN WOMEN WITH RECURRENT IMPLANTATION FAILURE (RIF) AFTER IN VITRO FERTILIZATION (IVF). M. M. Chawla, M. Fakih, A. Shunnar, J. Diwakaran. FakihIVF, Abu Dhabi, United Arab Emirates. OBJECTIVE: Evaluation of hysteroscopic procedures in achieving a pregnancy in women with a history of RIF in IVF. DESIGN: A retrospective case control study in a private assisted conception unit. MATERIALS AND METHODS: 145 subjects with history of RIF were included. All had a transvaginal scan (TVS) and hysterosalpingogram (HSG) performed. In case of abnormal findings in the uterine cavity, they were consented for hysteroscopy for evaluation and treatment. In case of no abnormality being detected, they were offered a hysteroscopy for unsuspected findings and correction. Clinical pregnancy rates (CPR) were calculated. Statistical significance was calculated using chi square. RESULTS: 92 /145 (63.4%) patients of RIF underwent hysteroscopy. 60/ 92 (65.21%) of these had no abnormalities on prior investigations (Group 1). 32/92 (34.78%) patients had abnormal findings on TVS /HSG. 24/32 (75%) of patients had their abnormalities confirmed and were treated. (Group 2). 53 / 145 (36.5%) patients who had normal HSG /TVS opted to go ahead with subsequent IVF without any hysteroscopy. (Group 3) In Group 1, 39/60 patients (65%) had abnormalities found on hysteroscopy which were rectified at the same time. The most common abnormality was Endometrial polyp 41/92 (44.56%) followed by partial septum (8.69%). The others were submucous fibroids, intrauterine adhesions, endometritis, septate uterus . CPR in Group 1 after correction of abnormalities was found to be 66.6%. The CPR in group 2 and Group 3 was calculated as 46.8 % and 33.96% respectively. The difference between group 1 and 2 versus 3 was found to be statistically significant p<0.01. CONCLUSION: Hysteroscopy is beneficial in women in RIF with a high possibility for unsuspected abnormalities in such cases despite normal cavitary assessments. It significantly improves the clinical pregnancy rates compared to the control group. It may serve as a universal tool in this group of women to improve implantation rates.
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ASRM Abstracts
O-468 Wednesday, October 16, 2013 04:45 PM A PILOT CASE CONTROL STUDY OF THE USE OF MELATONIN IN PATIENTS WITH MULTIPLE FAILED IVF CYCLES. N. L. Pritchard,a K. L. Sorby,b T. Osianlis,b B. J. Vollenhoven.a,b,c aMonash University, Clayton, VIC, Australia; bMonash IVF, Clayton, Vic, Australia; cMonash Health, Clayton, Vic, Australia. OBJECTIVE: Egg quality and therefore embryo quality is a limiting factor in IVF. Mitochondria supply ATP to cells, and higher levels are associated with better quality eggs. Excessive reactive oxygen species (ROS) are implicated in mitochondrial damage. Melatonin regulates reproductive physiology via gonadotropin release, but is also a powerful free radical scavenger and antioxidant. Our study examined the use of melatonin in IVF patients with multiple unsuccessful cycles. DESIGN: Retrospective case control study. MATERIALS AND METHODS: !?A3B2 tlsb=0.06pt?>From June 2012April 2013, 13 women from Monash IVF Australia who had undergone at least two unsuccessful IVF cycles were given 4mg melatonin daily from the first day of follicle stimulating hormone. Two controls per case were matched for age, cycle number, stimulation type and dose; with consideration for BMI, infertility aetiology and andrology. Primary outcomes were oocyte quantity, oocyte maturity and utilization rates. Secondary outcomes included duration of FSH, peak oestrodial levels, number of follicles >11mm and clinical and biochemical pregnancies. T-tests were used to analyse continuous data and Fisher’s exact test for categorical data; p<0.05 considered significant. RESULTS: When the melatonin cases were compared to the matched controls, there were no statistically significant differences in any of the primary or secondary outcomes assessed. Interestingly, when melatonin cases were compared with their own previous cycle, oocyte number showed a trend towards increased value (5.1 vs 7.1, p¼0.1744). Of clinical relevance, increase in mature oocyte numbers compared to previous cycles approached statistical significance (3.4 vs 4.9, p¼0.0515). Duration of FSH, max E2, follicle number and utilization rate showed no significant changes. CONCLUSION: In patients with multiple unsuccessful IVF cycles, melatonin may improve oocyte quantity and increase development to mature oocytes. The trends in this small group of patients warrants further study. O-469 Wednesday, October 16, 2013 05:00 PM ETIOLOGY OF INFERTILITY IN RURAL AFRICA. J. Mugisha,b R. Kudesia,a C. Hickmon,a P. C. Klatsky.a aDepartment of Obstetrics, Gynecology & Women’s Health, Albert Einstein College of Medicine, Bronx, NY; bSt. Francis Hospital Mutolere, Kisoro, Uganda. OBJECTIVE: We examine causes of infertility in patients presenting to a infertility consultation clinic in rural Uganda. DESIGN: Descriptive case series. MATERIALS AND METHODS: A radio announcement preceded a twoweek infertility consultation clinic provided by the Albert Einstein College of Medicine and St. Francis Mutolere Mission Hospital in Kisoro, Uganda. Evaluation included assessment of male factor via semen analysis (SA) assessed by 2011 World Health Organization (WHO) criteria, ovulatory status as determined by menstrual calendars, and tubal and uterine factors as evaluated by hysterosalpingogram. RESULTS: 110 women were evaluated, with a mean age of 29.3 6.3 years. SAs were available for 73 men, and were abnormal in 23 cases (33%), 8 revealing azoopermia. Most couples, 66%, had primary infertility. Evaluation revealed a roughly identical prevalence of tubal infertility and ovulatory dysfunction, 26% and 25%, respectively.
Current Study Etiology Primary Infertility Tubal Diagnosis Anovulation Male Factor
Cates et al, 1985
Kisoro, Uganda (%)
Africa (%)
Developed Countries (%)
66 26 25 25
48 49 7 8
71 11 16 22
Vol. 100, No. 3, Supplement, September 2013