Uterine Isthmus Agenesis with Inverted Uterine Body and Malrotated Kidney.

A 21-year-old with a history of cyclic abdominal pain beginning at age 13 years and a previous diagnosis of a complex müllerian anomaly presented with abdominal pain and a finding of a right distended hemiuterus, left hematosalpinx, and cervix separate from the uterine body. After laparoscopic decompression for symptomatic relief at that time, she presented to our center for definitive management. After a diagnostic vaginoscopy and laparoscopy confirmed the diagnosis of uterine isthmus agenesis, an abdominal approach to uterocervical anastomosis was planned and undertaken. At the postsurgical clinical follow-up, the patient reported normal menses and resolution of pain, and imaging confirmed maintenance of anastomotic patency. The diagnosis and classification system of müllerian anomalies are complex, and few reports detail the management of rare müllerian anomalies. In this case report, the successful anastomosis of the uterus and the cervix is reviewed as an approach that can restore normal menses successfully and safely and potentially allow for future fertility in patients with uterine isthmus agenesis.

Medical and mental health implications of gestational surrogacy.

Gestational surrogacy in the United States has quadrupled since 1999, but to date, only a few states explicitly permit compensated gestational surrogacy. Current legal prohibitions are often influenced by outdated and stereotyped understandings of surrogacy. It is increasingly important to understand the current literature about the medical and mental health impacts of surrogacy and how state legislatures have addressed compensated gestational surrogacy in recent years. Based on this review, we found no evidence of substantial adverse medical or psychological outcomes among women who are gestational carriers or among the children they give birth to. The literature suggests that gestational surrogacy is a safe and increasingly popular option for families as long as rigorous screening and medical, psychological, and social supports are equitably provided. As states move to responsibly legalize and regulate gestational surrogacy, there is a continued need for further longitudinal studies on the health and psychological outcomes of gestational surrogacy.

Optimal lead follicle size for human chorionic gonadotropin trigger in clomiphene citrate and intrauterine insemination cycles: an analysis of 1,676 treatment cycles.

OBJECTIVE: To identify the optimal lead follicle size for hCG trigger in clomiphene citrate (CC)-intrauterine insemination (IUI) cycles. DESIGN: Retrospective cohort study. SETTING: University-affiliated center. PATIENT(S): Patients <40 years of age with ovulatory dysfunction or unexplained infertility undergoing their first CC-IUI cycle. INTERVENTION(S): Ovulation induction, hCG trigger, and IUI. MAIN OUTCOME MEASURE(S): Clinical pregnancy rate (CPR) was the primary outcome and was plotted against lead follicle size in increments of 1 mm. Odds ratios with 95% confidence intervals for associations between lead follicle size and CPR were calculated from a multivariable logistic regression model. A receiver operating characteristic (ROC) curve was generated for CPR as a function of lead follicle size. RESULT(S): 1,676 cycles were included. The overall CPR was 13.8% (232/1,676). There was no difference in baseline demographics or ovulation induction parameters of patients who did or did not conceive. The odds of clinical pregnancy were 2.3 and 2.2 times higher with lead follicle sizes of 21.1-22.0 mm and >22.0 mm, respectively, compared with the referent category of 19.1-20.0 mm. Lead follicle size was an independent predictor of CPR, even after accounting for confounders. A lead follicle size of 22.1 mm corresponded to a sensitivity and specificity of 80.1% and 90.4% for clinical pregnancy, respectively, with an area under the ROC curve of 0.89. CONCLUSION(S): hCG administration at a lead follicle size of 21.1-22.0 mm is associated with higher odds of clinical pregnancy in patients undergoing their first CC-IUI cycles for ovulatory dysfunction or unexplained infertility.

Recurrent Ectopic Pregnancy: Current Perspectives.

Ectopic pregnancy represents a potentially life-threatening diagnosis. The risk factors for recurrent ectopic pregnancy have been enumerated but are not yet clearly defined. Understanding which risk factors are perhaps more common may allow providers to counsel and manage patients with a higher level of scrutiny.

Fresh or Frozen Embryo Transfer in In Vitro Fertilization: An Update.

The past decade has witnessed a rapid increase in the number of frozen-thawed embryo transfer (FET) cycles. Several factors have contributed to the increase in FET cycles, including improvement in culture media, vitrification, and an increase in preimplantation genetic testing of embryos. However, the accelerated trend in FET cycles also suggests that FET may be preferred over fresh embryo transfer. The current review explores the factors that have influenced this practice shift toward preferential FET and why this shift may be premature.

Early spontaneous multiple fetal pregnancy reduction is associated with adverse perinatal outcomes in in vitro fertilization cycles.

The primary objective of this study is to investigate whether early spontaneous multiple fetal pregnancy reduction, also known as vanishing twin syndrome, is associated with adverse perinatal outcomes in fresh in vitro fertilization cycles. This is a retrospective cohort study of women with live singleton births with and without an early vanishing twin after fresh in vitro fertilization. Characteristics compared included incidence of preterm birth, overall birth weight, overall low birth weight, overall very low birth weight, and term low birth weight. In all, 4049 patients with live singleton births were included-853 and 3196 with and without a vanishing twin, respectively. The vanishing twin group had a lower overall birth weight compared to those without (3279.5 ± 369.9 vs 3368.6 ± 567.5 g; p < 0.01). Early vanishing twin was also associated with an increased odds of overall low birth weight (odds ratio: 1.75; 95% confidence interval: 1.36-2.25; p < 0.01) and increased odds of term low birth weight (odds ratio: 3.44; 95% confidence interval: 2.14-5.53; p < 0.01). Our study suggests that early vanishing twin is associated with lower overall birth weight and higher odds of overall low birth weight and term low birth weight in live singleton births after fresh in vitro fertilization.

Comparison of perinatal outcomes following fresh and frozen-thawed blastocyst transfer.

OBJECTIVE: To investigate the effect of ovarian stimulation on endometrial receptivity by comparing singleton pregnancy and perinatal outcomes following fresh or frozen-thawed blastocyst transfers. METHODS: A retrospective cohort study enrolled patients undergoing fresh or frozen-thawed blastocyst transfers that resulted in live deliveries between January 1, 2010 and September 30, 2013 at a single academic center. Implantation, clinical pregnancy, spontaneous abortion, and live delivery rates were calculated. The incidence of term delivery, preterm delivery, low birth weight, term low birth weight, and very low birth weight were also recorded. To detect a 10% difference in the implantation rate, a minimum sample size of at least 415 transfer cycles in each group was estimated. RESULTS: The study included data from 918 fresh and 1273 frozen-thawed cycles. Patients in both groups were of similar age and there was no difference in the grading of blastocysts. No differences were observed in the implantation (37.3% vs 37.7%), clinical pregnancy (50.2% vs 49.4%), spontaneous abortion (7.3% vs 9.3%), and live delivery (42.9% vs 40.6%) rates of the two groups. A sub-analysis of all live singleton and twin deliveries revealed no difference in perinatal outcomes between the two techniques. CONCLUSIONS: The present study demonstrated equivalent singleton pregnancy and perinatal outcomes when comparing frozen-thawed and fresh blastocyst transfer procedures.

Is anti-Müllerian hormone associated with IVF outcomes in young patients with diminished ovarian reserve?

AIM: To investigate whether anti-Müllerian hormone (AMH) is associated with IVF cycle outcomes in young patients with diminished ovarian reserve. MATERIALS & METHODS: Retrospective study of patients <35 years of age undergoing fresh IVF who had at least two 8-cell, day-3 embryos transferred with grades 1, 1.5 or 2. Patients were subgrouped, a priori, based on serum AMH levels: <1 or >1 ng/ml and <0.5 or >0.5 ng/ml. RESULTS: In total, 1005 patients were included. Patients in the >1 ng/ml group required lesser gonadotropins compared with the <1 ng/ml and the <0.5 ng/ml group. More oocytes were retrieved from the same group compared with the latter two (p < 0.001). Despite these differences, the overall rates of clinical pregnancy, spontaneous abortion and live birth were comparable between the two groups. CONCLUSION: In patients with diminished ovarian reserve who have good quality embryos, AMH is not associated with clinical pregnancy, spontaneous miscarriage or live birth rates.

Pretreatment of normal responders in fresh in vitro fertilization cycles: A comparison of transdermal estradiol and oral contraceptive pills.

OBJECTIVE: The aim of this study was to investigate the impact of pretreatment with transdermal estradiol (E2) compared to oral contraceptive pills (OCPs) on controlled ovarian stimulation (COS) response in normal responders undergoing fresh in vitro fertilization (IVF)-embryo transfer (ET) cycles. METHODS: A retrospective cohort study was performed of normal responders undergoing fresh IVF-ET cycles who received pretreatment with transdermal E2 versus OCPs prior to fresh IVF-ET. The total days of ovarian stimulation, total dosage of gonadotropins, total number of oocytes, and mature oocytes retrieved were noted. Pregnancy outcomes after ET were also recorded. RESULTS: A total of 2,092 patients met the inclusion criteria: 1,057 and 1,035 patients in the transdermal E2 and OCP groups, respectively. Patients in the OCP group had a longer duration of COS (10.7±1.63 days, p<0.01) than the E2 group (9.92±1.94 days). Patients in the OCP group also required higher cumulative doses of gonadotropins (2,657.3±1,187.9 IU) than those in the E2 group (2,550.1±1,270.2 IU, p=0.002). No statistically significant differences were found in the total and mature oocytes retrieved or in the rates of biochemical pregnancy, clinical pregnancy, spontaneous miscarriage, and live birth between the groups. CONCLUSION: Our findings suggest that compared to OCPs, pretreatment with transdermal E2 is associated with a shorter duration of ovarian stimulation and lower gonadotropin utilization, without compromising the oocyte yield or pregnancy outcomes in normal-responder patients undergoing fresh IVF.

Perinatal Risks Associated with Early Vanishing Twin Syndrome following Transfer of Cleavage- or Blastocyst-Stage Embryos.

Objective. To investigate whether the perinatal risks associated with early vanishing twin (VT) syndrome differ between cleavage- or blastocyst-stage embryo transfers (ET) in fresh in vitro fertilization (IVF) cycles. Methods. Retrospective, single-center, cohort study of IVF cycles with fresh cleavage- or blastocyst-stage ETs resulting in a live singleton birth. The incidence of preterm birth (PTB), low birth weight (LBW), and very low birth weight (VLBW) was compared between cleavage- and blastocyst-stage ET cycles complicated by early VT. Results. 7241 patients had live singleton births. Early VT was observed in 709/6134 (11.6%) and 70/1107 (6.32%) patients undergoing cleavage-stage and blastocyst-stage ETs, respectively. Patients in the blastocyst-stage group were younger compared to the cleavage-stage group. The cleavage-stage group had a similar birth weight compared to the blastocyst-stage group. There was no difference in the incidence of PTB (9.87% versus 8.57%), LBW (11.1% versus 11.4%), or VLBW (1.13 versus 1.43%) when comparing the cleavage-stage early VT and blastocyst-stage early VT groups, even after adjustment with logistic regression. Conclusions. Our study highlights that the adverse perinatal risks of PTB, LBW, and VLBW associated with early VT syndrome are similar in patients undergoing cleavage-stage or blastocyst-stage ETs during fresh IVF cycles.

Surgical Management of Endometrial Polyps in Infertile Women: A Comprehensive Review.

Endometrial polyps are benign localized lesions of the endometrium, which are commonly seen in women of reproductive age. Observational studies have suggested a detrimental effect of endometrial polyps on fertility. The natural course of endometrial polyps remains unclear. Expectant management of small and asymptomatic polyps is reasonable in many cases. However, surgical resection of endometrial polyps is recommended in infertile patients prior to treatment in order to increase natural conception or assisted reproductive pregnancy rates. There is mixed evidence regarding the resection of newly diagnosed endometrial polyps during ovarian stimulation to improve the outcomes of fresh in vitro fertilization cycles. Hysteroscopy polypectomy remains the gold standard for surgical treatment. Evidence regarding the cost and efficacy of different methods for hysteroscopic resection of endometrial polyps in the office and outpatient surgical settings has begun to emerge.