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Should All Infertile Patients Be Treated?
sterone sulfate (DHEAS), and SHBG levels, by ELISA and RIA. Statistical analysis was performed using KwikStat-4 Statistical Data Analysis Program (TexaSoft, Cedar Hill, TX). RESULTS: A total of 7 PCOS subjects completed the study. Mean age was 26.29 years. Mean body mass index (BMI) at basal conditions and end of treatment period were 24.35 and 24.29 kg/m2, respectively (p ⫽ 0.86). Ferriman-Gallwey score decreased during treatment period, but change did not reach significance (mean baseline and post-treatment values were 4.14 and 3.86; p ⫽ 0.36). Mean initial and after 12 weeks of treatment levels for TT, FT, DHEAS, and SHBG were 4.14 nmol/L (119 ng/dL) and 1.9 nmol/L (54.86 ng/dL); 0.01 nmol/L (0.28 ng/dL) and 0.004 nmol/L (0.11 ng/dL); 4.4 mol/L (164 g/dL) and 2.84 mol/L (105 g/dL); 59 nmol/L and 311 nmol/L, respectively. Following discontinuation of OCP androgen levels increased progressively, at 4 and 8 weeks. Levels of TT (3.72 nmol/L ⫽ 107.3 ng/dL) and DHEAS (3.81 mol/L ⫽ 140 g/dL) at week 4 were not significantly different from those measured at baseline. Alternatively, FT (0.008 nmol/L ⫽ 0.22 ng/dL) and SHBG (54.4 nmol/L) returned to levels not significantly different from baseline values, only at week 8 post discontinuation of OCP. CONCLUSION: In this population of PCOS women, discontinuation of an OCP containing drospirenone 3 mg and ethinyl estradiol 30 g was followed by return of TT and DHEAS to baseline levels in 4 weeks. On the other hand, levels of FT and SHBG returned to basal values only 8 weeks after discontinuation of OCP. These observations are pertinent when measuring androgens and SHBG in subjects suspected of having PCOS, who are currently taking OCP. Supported by: In part, by Schering de Venezuela, S.A.
P-757 Should All Infertile Patients Be Treated? J. Markovitz, H. Chung, J. Tsang, M. Lesser, A. Hershlag. North Shore University Hospital, Manhasset, NY. OBJECTIVE: Is infertility over-diagnosed and therefore over-treated? Current fertility practice relies on an arbitrary definition of 1 year of unprotected intercourse. While only a small minority of such patients suffer absolute infertility (no eggs, no sperm or both tubes blocked), all other patients may have only some or no compromise of fertility factors. The purpose of this study is to identify the incidence of treatment-independent pregnancies among infertile patients; define the profile of patients more likely to conceive without treatment; & provide guidelines for practitioners of when and when not to offer treatment. DESIGN: Retrospective cohort study. MATERIALS AND METHODS: We studied 988 consecutive couples who presented with primary or secondary infertility at the Center for Human Reproduction from January 1997. Couples were followed until their first pregnancy or for two years. Data collection included demographics, diagnosis, treatment and outcome. Statistical analysis assumed each cycle independent of any prior or future cycles. Cycles resulting in pregnancy were divided into three categories: treatment unrelated (⬎3 months from treatment or ⬎12 months from surgery), treatment-related (within the same treatment cycle or ⬍12 months from surgery), and indirectly-related (⬍3 months from treatment). Survival analysis accounted for censored subjects (i.e. lost to follow-up). Statistical analysis included product-limit method, logrank test, T-test, chi-square. RESULTS: Pregnancies occurred in 559 patients (56.5%). Approximately 25% (143/559) of these pregnancies were treatment-unrelated. Another 15 pregnancies were indirectly related to treatment, which left us with 401 patients where treatment was causally related with the pregnancy. The main impact of treatment was shortening time to conception. The median time to pregnancy directly resulting from treatment was six months, while in the non-treatment group it took sixteen months to conceive (p⬍0.001). In treatment-independent cycles, infertility was more often unexplained (p⬍0.007). In addition, this group had more cases where only minor abnormalities of questionable significance had been detected, (e.g. mild semen abnormalities, minimal to mild endometriosis, unilateral tubal obstruction) (p⬍0.007). The duration of infertility was significantly shorter in cases of spontaneous pregnancies, compared to the treatment group (median of 1 versus 2 years) (p⬍0.0004). The mean age of patients in the treatmentrelated group (32.2 years) was significantly lower than that of patients in the treatment-unrelated group (33.2 years) (p⬍0.02). Likewise, no differences
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were observed in the proportion of primary and secondary infertility (p⫽0.0788). CONCLUSION: About one quarter of pregnancies encountered in our infertility patients were treatment-unrelated. The profile of patients who conceived spontaneously includes a shorter duration of infertility and negative or minimal findings on fertility testing. This study confirms the notion that a significant proportion of patients presenting to fertility centers endure delayed conception or subfertility, rather than an absolute inability to conceive without treatment. Patients should be counseled that they have the option of no treatment, especially in cases of short duration infertility and no significant abnormalities. Surely, blanket treatment of all comers and the overzealous utilization of ART are unjustified. Supported by: None. P-758 Cardiopulmonary Comparisons in Healthy Normotensive Patients Undergoing Uncomplicated Transvaginal Oocyte Retrieval for IVF: Impact of Age and BMI. E. S. Sills, T. T. Vincent, M. Perloe, C. R. Kaplan, S. C. Conway, M. J. Tucker. Georgia Reproductive Specialists, Atlanta, GA. OBJECTIVE: To study selected cardiovascular parameters in non-obese normotensive women undergoing transvaginal oocyte retrieval. DESIGN: Prospective, descriptive analysis. MATERIALS AND METHODS: The following parameters were monitored in 135 consecutive IVF patients following uncomplicated transvaginal ultrasound-guided oocyte retrieval: systolic and diastolic blood pressure, pulse rate, and percent oxygen saturation (room air). Data were stratified according to age and BMI. RESULTS: In this group, mean⫾SD age and BMI were 33⫾4yrs and 26⫾3kg/m2, respectively. Post-retrieval systolic blood pressure among women with BMI⬍25 was 110⫾11mm Hg, which was significantly lower than that observed in women with BMI ⱖ25 (116⫾12mm Hg, p⫽0.01). Average diastolic blood pressure was similar in both groups after oocyte retrieval (BMI ⬍25, 68⫾10mm Hg vs. BMIⱖ25, 68⫾9mm Hg; p⫽0.7). Post-retrieval heart rate was somewhat lower among patients with BMI⬍25 (76⫾10/min) compared to those with BMIⱖ25 (79⫾12/min), p⫽0.1. Pulse oximetry showed similar %O2 saturations for both BMI groups after surgery (BMI ⬍25, 97⫾1% vs. BMIⱖ25, 96⫾1%,; p⫽0.2). Peak [terminal] serum E2 was comparable for both groups (BMI ⬍25, 2763⫾1246pg/ml vs. BMIⱖ25, 2870⫾1243pg/ml; p⫽0.6). Mean⫾SD post-retrieval systolic blood pressure among women age⬍33 was 113⫾11mm Hg, which was comparable to that observed in women ageⱖ33 (112⫾13mm Hg, p⫽0.62). Average diastolic blood pressure was also similar in both groups (age⬍33, 69⫾11mm Hg vs. ageⱖ33, 67⫾8mm Hg; p⫽0.44). Mean heart rate was not different among patients age⬍33 (78⫾12/min) compared to those ageⱖ33 (77⫾10/min), p⫽0.5. Similar mean %O2 saturations were recorded for both age groups (age⬍33, 96⫾13% vs. ageⱖ33, 97⫾0%,; p⫽0.3). CONCLUSION: These data confirm the safety of transvaginal oocyte retrieval performed under monitored i.v. anesthesia. In our population, post-operative cardiopulmonary function appears similar among healthy normotensive IVF patients irrespective of age or BMI. Significantly higher (although still normal) mean systolic blood pressure was observed in patients with BMIⱖ25. This difference was not related to cycle performance as estimated by pre-retrieval peak serum E2 measurements. Potential factors influencing systolic blood pressure in women with BMIⱖ25 are currently under investigation. Supported by: None. P-759 The Bioactivity of FSH Does Not Reflect Decreased Ovarian Reserve. G. S. Nakhuda, S. V. Pollak, J. Lustbader, M. Sauer, R. A. Lobo. Columbia University College of Physicians and Surgeons, New York, NY. OBJECTIVE: Postmenopausal women are known to have elevated bioactivity of FSH and an increased ratio of bioactive FSH to immunoreactive FSH (B: I). We hypothesized that an elevated FSH B: I ratio would be more reflective of decreased ovarian reserve than immunoreactive FSH (I-FSH) alone. To test this hypothesis, we compared FSH B: I ratios and Mullerian Inhibiting Substance (MIS) in premenopausal women with normal, borderline, or elevated I-FSH and in normal postmenopausal (PM) controls.
Vol. 84, Suppl 1, September 2005
P-757 Should All Infertile Patients Be Treated? J. Markovitz, H. Chung, J. Tsang, M. Lesser, A. Hershlag. North Shore University Hospital, Manhasset, NY. OBJECTIVE: Is infertility over-diagnosed and therefore over-treated? Current fertility practice relies on an arbitrary definition of 1 year of unprotected intercourse. While only a small minority of such patients suffer absolute infertility (no eggs, no sperm or both tubes blocked), all other patients may have only some or no compromise of fertility factors. The purpose of this study is to identify the incidence of treatment-independent pregnancies among infertile patients; define the profile of patients more likely to conceive without treatment; & provide guidelines for practitioners of when and when not to offer treatment. DESIGN: Retrospective cohort study. MATERIALS AND METHODS: We studied 988 consecutive couples who presented with primary or secondary infertility at the Center for Human Reproduction from January 1997. Couples were followed until their first pregnancy or for two years. Data collection included demographics, diagnosis, treatment and outcome. Statistical analysis assumed each cycle independent of any prior or future cycles. Cycles resulting in pregnancy were divided into three categories: treatment unrelated (⬎3 months from treatment or ⬎12 months from surgery), treatment-related (within the same treatment cycle or ⬍12 months from surgery), and indirectly-related (⬍3 months from treatment). Survival analysis accounted for censored subjects (i.e. lost to follow-up). Statistical analysis included product-limit method, logrank test, T-test, chi-square. RESULTS: Pregnancies occurred in 559 patients (56.5%). Approximately 25% (143/559) of these pregnancies were treatment-unrelated. Another 15 pregnancies were indirectly related to treatment, which left us with 401 patients where treatment was causally related with the pregnancy. The main impact of treatment was shortening time to conception. The median time to pregnancy directly resulting from treatment was six months, while in the non-treatment group it took sixteen months to conceive (p⬍0.001). In treatment-independent cycles, infertility was more often unexplained (p⬍0.007). In addition, this group had more cases where only minor abnormalities of questionable significance had been detected, (e.g. mild semen abnormalities, minimal to mild endometriosis, unilateral tubal obstruction) (p⬍0.007). The duration of infertility was significantly shorter in cases of spontaneous pregnancies, compared to the treatment group (median of 1 versus 2 years) (p⬍0.0004). The mean age of patients in the treatmentrelated group (32.2 years) was significantly lower than that of patients in the treatment-unrelated group (33.2 years) (p⬍0.02). Likewise, no differences
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were observed in the proportion of primary and secondary infertility (p⫽0.0788). CONCLUSION: About one quarter of pregnancies encountered in our infertility patients were treatment-unrelated. The profile of patients who conceived spontaneously includes a shorter duration of infertility and negative or minimal findings on fertility testing. This study confirms the notion that a significant proportion of patients presenting to fertility centers endure delayed conception or subfertility, rather than an absolute inability to conceive without treatment. Patients should be counseled that they have the option of no treatment, especially in cases of short duration infertility and no significant abnormalities. Surely, blanket treatment of all comers and the overzealous utilization of ART are unjustified. Supported by: None. P-758 Cardiopulmonary Comparisons in Healthy Normotensive Patients Undergoing Uncomplicated Transvaginal Oocyte Retrieval for IVF: Impact of Age and BMI. E. S. Sills, T. T. Vincent, M. Perloe, C. R. Kaplan, S. C. Conway, M. J. Tucker. Georgia Reproductive Specialists, Atlanta, GA. OBJECTIVE: To study selected cardiovascular parameters in non-obese normotensive women undergoing transvaginal oocyte retrieval. DESIGN: Prospective, descriptive analysis. MATERIALS AND METHODS: The following parameters were monitored in 135 consecutive IVF patients following uncomplicated transvaginal ultrasound-guided oocyte retrieval: systolic and diastolic blood pressure, pulse rate, and percent oxygen saturation (room air). Data were stratified according to age and BMI. RESULTS: In this group, mean⫾SD age and BMI were 33⫾4yrs and 26⫾3kg/m2, respectively. Post-retrieval systolic blood pressure among women with BMI⬍25 was 110⫾11mm Hg, which was significantly lower than that observed in women with BMI ⱖ25 (116⫾12mm Hg, p⫽0.01). Average diastolic blood pressure was similar in both groups after oocyte retrieval (BMI ⬍25, 68⫾10mm Hg vs. BMIⱖ25, 68⫾9mm Hg; p⫽0.7). Post-retrieval heart rate was somewhat lower among patients with BMI⬍25 (76⫾10/min) compared to those with BMIⱖ25 (79⫾12/min), p⫽0.1. Pulse oximetry showed similar %O2 saturations for both BMI groups after surgery (BMI ⬍25, 97⫾1% vs. BMIⱖ25, 96⫾1%,; p⫽0.2). Peak [terminal] serum E2 was comparable for both groups (BMI ⬍25, 2763⫾1246pg/ml vs. BMIⱖ25, 2870⫾1243pg/ml; p⫽0.6). Mean⫾SD post-retrieval systolic blood pressure among women age⬍33 was 113⫾11mm Hg, which was comparable to that observed in women ageⱖ33 (112⫾13mm Hg, p⫽0.62). Average diastolic blood pressure was also similar in both groups (age⬍33, 69⫾11mm Hg vs. ageⱖ33, 67⫾8mm Hg; p⫽0.44). Mean heart rate was not different among patients age⬍33 (78⫾12/min) compared to those ageⱖ33 (77⫾10/min), p⫽0.5. Similar mean %O2 saturations were recorded for both age groups (age⬍33, 96⫾13% vs. ageⱖ33, 97⫾0%,; p⫽0.3). CONCLUSION: These data confirm the safety of transvaginal oocyte retrieval performed under monitored i.v. anesthesia. In our population, post-operative cardiopulmonary function appears similar among healthy normotensive IVF patients irrespective of age or BMI. Significantly higher (although still normal) mean systolic blood pressure was observed in patients with BMIⱖ25. This difference was not related to cycle performance as estimated by pre-retrieval peak serum E2 measurements. Potential factors influencing systolic blood pressure in women with BMIⱖ25 are currently under investigation. Supported by: None. P-759 The Bioactivity of FSH Does Not Reflect Decreased Ovarian Reserve. G. S. Nakhuda, S. V. Pollak, J. Lustbader, M. Sauer, R. A. Lobo. Columbia University College of Physicians and Surgeons, New York, NY. OBJECTIVE: Postmenopausal women are known to have elevated bioactivity of FSH and an increased ratio of bioactive FSH to immunoreactive FSH (B: I). We hypothesized that an elevated FSH B: I ratio would be more reflective of decreased ovarian reserve than immunoreactive FSH (I-FSH) alone. To test this hypothesis, we compared FSH B: I ratios and Mullerian Inhibiting Substance (MIS) in premenopausal women with normal, borderline, or elevated I-FSH and in normal postmenopausal (PM) controls.
Vol. 84, Suppl 1, September 2005