RESUMO
Objectives We aimed to examine the extent to which health plan expenditures for infertility services differed by whether women resided in states with mandates requiring coverage of such services and by whether coverage was provided through a self-insured plan subject to state mandates versus fully-insured health plans subject only to federal regulation. Methods This retrospective cohort study used individual-level, de-identified health insurance claims data. We included women 19-45 years of age who were continuously enrolled during 2011 and classified them into three mutually exclusive groups based on highest treatment intensity: in vitro fertilization (IVF), intrauterine insemination (IUI), or ovulation-inducing (OI) medications. Using generalized linear models, we estimated adjusted annual mean, aggregate, and per member per month (PMPM) expenditures among women in states with an infertility insurance mandate and those in states without a mandate, stratified by enrollment in a fully-insured or self-insured health plan. Results Of the 6,006,017 women continuously enrolled during 2011, 9199 (0.15%) had claims for IVF, 10,112 (0.17%) had claims for IUI, and 23,739 (0.40%) had claims for OI medications. Among women enrolled in fully insured plans, PMPM expenditures for infertility treatment were 3.1 times higher for those living in states with a mandate compared with states without a mandate. Among women enrolled in self-insured plans, PMPM infertility treatment expenditures were 1.2 times higher for mandate versus non-mandate states. Conclusions for Practice Recorded infertility treatment expenditures were higher in states with insurance reimbursement mandates versus those without mandates, with most of the difference in expenditures incurred by fully-insured plans.
Assuntos
Fármacos para a Fertilidade/economia , Programas Governamentais/economia , Adulto , Feminino , Programas Governamentais/métodos , Programas Governamentais/estatística & dados numéricos , Gastos em Saúde/tendências , Implementação de Plano de Saúde/economia , Implementação de Plano de Saúde/métodos , Humanos , Infertilidade/tratamento farmacológico , Infertilidade/economia , Cobertura do Seguro/normas , Pessoa de Meia-Idade , Estudos Retrospectivos , Governo Estadual , Estados UnidosRESUMO
Objective: To describe the relationship between severe diminished ovarian reserve (DOR) and assisted reproductive technology outcomes. Study Design: Retrospective cohort including all United States' fertility centers reporting to the CDC National ART Surveillance System, 20042012. Among women aged <41 (504,266 fresh autologous IVF cycles), we calculated cancellation rate/cycle and pregnancy rate/transfer, stratified by age, by maximum follicle-stimulating hormone (FSH). Cancellation rate per cycle and pregnancy, live birth, and miscarriage rates per transfer were compared among women with and without DOR. We used multivariable log binomial regression, stratified by age, to calculate adjusted relative risk (aRR) for the association between DOR and these outcomes and, within DOR groups, between stimulation type and outcomes. Results: Cancellation rate/cycle increased with increasing FSH and with DOR severity. For women aged <35 who underwent transfer, aRR for pregnancy and live birth indicated slightly reduced likelihood of these outcomes (severe vs. no DOR); confidence intervals approached the null. Among women with severe DOR, stimulation type was not associated with likelihood of pregnancy or live birth per transfer in any group except women ages 3840. Conclusion: Women with severe DOR are at significantly increased risk of cancellation; however, those who undergo transfer have pregnancy and live birth chances similar to those of women without DOR after controlling for cycle characteristics.
Assuntos
Infertilidade Feminina/terapia , Reserva Ovariana , Taxa de Gravidez , Técnicas de Reprodução Assistida/estatística & dados numéricos , Adulto , Bases de Dados Factuais , Feminino , Fertilidade , Humanos , Infertilidade Feminina/epidemiologia , Nascido Vivo , Gravidez , Resultado da Gravidez/epidemiologia , Estudos Retrospectivos , Estados UnidosRESUMO
Retinoids are essential for ovarian steroid production and oocyte maturation in mammals. Oocyte competency is known to positively correlate with efficient gap junction intercellular communication (GJIC) among granulosa cells in the cumulus-oocyte complex. Connexin 43 (C x 43) is the main subunit of gap junction channels in human cumulus granulosa cells (CGC) and is regulated by all-trans retinoic acid (ATRA) in other hormone responsive cell types. The objectives of this study were to quantify retinoid levels in human CGC obtained during IVF oocyte retrievals, to investigate the potential relationship between CGC ATRA levels and successful oocyte fertilization, and to determine the effects of ATRA on C x 43 protein expression in CGC. Results showed that CGC cultures actively metabolize retinol to produce ATRA. Grouped according to fertilization rate tertiles, mean ATRA levels were 2-fold higher in pooled CGC from women in the highest versus the lowest tertile (P < 0.05). ATRA induced a rapid dephosphorylation of C x 43 in CGC and granulosa cell line (KGN) cultures resulting in a >2-fold increase in the expression of the functional non-phosphorylated (P0) species (P < 0.02). Similar enhancement of P0 by ATRA was shown in CGC and KGN cultures co-treated with LH or hCG which, by themselves, enhanced the protein levels of C x 43 without altering its phosphorylation profile. Correspondingly, the combination of ATRA+hCG treatment of KGN caused a significant increase in GJIC compared with single agent treatments (P < 0.025) and a doubling of GJIC from that seen in untreated cells (P < 0.01). These findings indicate that CGC are a primary site of retinoid uptake and ATRA biosynthesis. Regulation of C x 43 by ATRA may serve an important role in folliculogenesis, development of oocyte competency, and successful fertilization by increasing GJIC in CGC.
Assuntos
Conexina 43/metabolismo , Fertilização , Retinoides/fisiologia , Tretinoína/fisiologia , Células do Cúmulo/metabolismo , Feminino , Células da Granulosa/metabolismo , Humanos , Oócitos , Folículo Ovariano/crescimento & desenvolvimento , Folículo Ovariano/metabolismo , Retinoides/metabolismo , Tretinoína/metabolismoRESUMO
IMPORTANCE: The prevalence of oocyte donation for in vitro fertilization (IVF) has increased in the United States, but little information is available regarding maternal or infant outcomes to improve counseling and clinical decision making. OBJECTIVES: To quantify trends in donor oocyte cycles in the United States and to determine predictors of a good perinatal outcome among IVF cycles using fresh (noncryopreserved) embryos derived from donor oocytes. DESIGN, SETTING, AND PARTICIPANTS: Analysis of data from the Centers for Disease Control and Prevention's National ART Surveillance System, to which fertility centers are mandated to report and which includes data on more than 95% of all IVF cycles performed in the United States. Data from 2000 to 2010 described trends. Data from 2010 determined predictors. MAIN OUTCOMES AND MEASURES: Good perinatal outcome, defined as a singleton live-born infant delivered at 37 weeks or later and weighing 2500 g or more. RESULTS: From 2000 to 2010, data from 443 clinics (93% of all US fertility centers) were included. The annual number of donor oocyte cycles significantly increased, from 10,801 to 18,306. Among all donor oocyte cycles, an increasing trend was observed from 2000 to 2010 in the proportion of cycles using frozen (vs fresh) embryos (26.7% [95% CI, 25.8%-27.5%] to 40.3% [95% CI, 39.6%-41.1%]) and elective single-embryo transfers (vs transfer of multiple embryos) (0.8% [95% CI, 0.7%-1.0%] to 14.5% [95% CI, 14.0%-15.1%]). Good perinatal outcomes increased from 18.5% (95% CI, 17.7%-19.3%) to 24.4% (95% CI, 23.8%-25.1%) (P < .001 for all listed trends). Mean donor and recipient ages remained stable at 28 (SD, 2.8) years and 41 (SD, 5.3) years, respectively. In 2010, 396 clinics contributed data. For donor oocyte cycles using fresh embryos (n = 9865), 27.5% (95% CI, 26.6%-28.4%) resulted in good perinatal outcome. Transfer of an embryo at day 5 (adjusted odds ratio [OR], 1.17 [95% CI, 1.04-1.32]) and elective single-embryo transfers (adjusted OR, 2.32 [95% CI, 1.92-2.80]) were positively associated with good perinatal outcome; tubal (adjusted OR, 0.72 [95% CI, 0.60-0.86]) or uterine (adjusted OR, 0.74 [95% CI, 0.58-0.94]) factor infertility and non-Hispanic black recipient race/ethnicity (adjusted OR, 0.48 [95% CI, 0.35-0.67]) were associated with decreased odds of good outcome. Recipient age was not associated with likelihood of good perinatal outcome. CONCLUSIONS AND RELEVANCE: In the United States from 2000 to 2010, there was an increase in number of donor oocyte cycles, accompanied by an increase in good outcomes. Further studies are needed to understand the mechanisms underlying the factors associated with less successful outcomes.
Assuntos
Fertilização in vitro/estatística & dados numéricos , Doação de Oócitos/estatística & dados numéricos , Transferência de Embrião Único/estatística & dados numéricos , Adulto , Peso ao Nascer , Aconselhamento , Tomada de Decisões , Feminino , Humanos , Recém-Nascido , Pessoa de Meia-Idade , Doação de Oócitos/tendências , Gravidez , Resultado da Gravidez , Estudos Retrospectivos , Estados UnidosRESUMO
BACKGROUND: Administration of recombinant luteinizing hormone (rLH) in controlled ovarian hyperstimulation may benefit a subpopulation of patients. However, late follicular phase administration of high doses of rLH may also reduce the size of the follicular cohort and promote monofollicular development. METHODS: To determine if rLH in late follicular development had a negative impact on follicular growth and oocyte yield, IVF patients in our practice who received rFSH and rLH for the entire stimulation were retrospectively compared with those that had the rLH discontinued at least two days prior to hCG trigger. RESULTS: The two groups had similar baseline characteristics before stimulation with respect to age, FSH level and antral follicle count. However, the group which had the rLH discontinued at least two days prior to their hCG shot, had a significantly higher number of oocytes retrieved, including a higher number of MII oocytes and number of 2PN embryos. CONCLUSIONS: When using rLH for controlled ovarian hyperstimulation, administering it from the start of stimulation and stopping it in the late follicular phase, at least two days prior to hCG trigger, may increase oocyte and embryo yield.
Assuntos
Gonadotropina Coriônica/administração & dosagem , Fertilização in vitro , Hormônio Luteinizante/administração & dosagem , Recuperação de Oócitos , Oócitos/citologia , Indução da Ovulação/métodos , Adulto , Estudos de Casos e Controles , Esquema de Medicação , Feminino , Fertilização in vitro/métodos , Humanos , Recuperação de Oócitos/métodos , Oócitos/efeitos dos fármacos , Gravidez , Taxa de Gravidez , Proteínas Recombinantes/administração & dosagem , Estudos Retrospectivos , Resultado do Tratamento , Suspensão de TratamentoAssuntos
Hemorragia/etiologia , Infecções/etiologia , Síndrome de Hiperestimulação Ovariana/etiologia , Técnicas de Reprodução Assistida/efeitos adversos , Adulto , Feminino , Hemorragia/epidemiologia , Hospitalização/estatística & dados numéricos , Humanos , Infecções/epidemiologia , Mortalidade Materna , Síndrome de Hiperestimulação Ovariana/epidemiologia , Vigilância da População , Risco , Estados Unidos/epidemiologiaRESUMO
OBJECTIVE: To analyze cost-effectiveness studies in regard to the costs of in vitro fertilization (IVF) and discuss specific economic trends that may affect the future utilization of IVF in the United States. STUDY DESIGN: Health economics. A Pub Med literature review and the Centers for Disease Control's (CDC) Fertility Clinic Success Rate registry served to access cost analyses and trends, respectively. RESULTS: The average cost of an IVF cycle in the U.S. is $9,226. Among policies that provide IVF services, the increase in premium per month ranges from $0.67 to $14. CONCLUSION: When IVF is provided as a health benefit, the cost increases can be variable. As utilization increases, contemporary cost analyses and outcomes research will aid providers, third-party payers and policymakers in better understanding the economic impact of lVF.
Assuntos
Fertilização in vitro/economia , Custos de Cuidados de Saúde , Cobertura do Seguro/economia , Análise Custo-Benefício/economia , Feminino , Humanos , Infertilidade Feminina/economia , Estados UnidosRESUMO
Anti-Müllerian hormone (AMH) has potential local effects on ovarian function and endometrial tissue, including endometriosis, but its presence in peritoneal fluid is not fully understood. This is a cross-sectional study evaluating AMH in peritoneal fluid and plasma from women with endometriosis (N = 61) and from control women without endometriosis (N = 36). There was a significant correlation between AMH in plasma and peritoneal fluid from both patients with endometriosis (r(2) = .767 [P < .001]) and control participants (r(2) = .647 [P < .001]) less than 45 years of age. Anti-Müllerian hormone declined with women's increasing age in both plasma and peritoneal fluid in women with and without endometriosis. There were no differences in the plasma or peritoneal fluid AMH in women with endometriosis versus control women. The strong relationship between plasma and peritoneal fluid may allow plasma AMH to be a marker for peritoneal AMH in studies evaluating the local effects of AMH.
Assuntos
Hormônio Antimülleriano/sangue , Líquido Ascítico/química , Endometriose/sangue , Adulto , Fatores Etários , Biomarcadores/sangue , Estudos de Casos e Controles , Estudos Transversais , Regulação para Baixo , Endometriose/diagnóstico , Feminino , Humanos , Pessoa de Meia-IdadeRESUMO
OBJECTIVE: To assess endometriosis-associated infertility trends among assisted reproductive technology (ART) cycles, and to compare cancellation and hyperstimulation risks and pregnancy and live birth rates among women using ART for endometriosis-associated vs. male factor infertility. DESIGN: Descriptive and multivariable analyses of Centers for Disease Control and Prevention (CDC) National ART Surveillance System data. SETTING: Fertility centers. PATIENT(S): All reported fresh autologous ART cycles in the United States between 2000 and 2011 (n = 1,589,079). INTERVENTION(S): None. MAIN OUTCOME MEASURE(S): Oocyte yield, hyperstimulation, cancellation, implantation, pregnancy, live birth. RESULT(S): The absolute number of ART cycles with an endometriosis diagnosis fell in recent years, from 16,751 (2000) to 15,311 (2011); the percentage fell over time, from 17.0% (2000) to 9.6% (2011) of all cycles. Compared with male factor (n = 375,557), endometriosis-associated cycles (n = 112,475) yielded fewer oocytes (50.5% vs. 42.5% of cycles with only 0-10 oocytes retrieved), lower risk of hyperstimulation (1.1% vs. 1.3%, adjusted risk ratio [aRR] 0.82, 95% confidence interval [CI] 0.74-0.91), and an increased risk of cancellation (12.9% vs. 10.1%, aRR 1.30, 95% CI 1.25-1.35). Endometriosis was associated with a statistically decreased but likely clinically insignificant difference in the following outcomes: chance of pregnancy per transfer (43.7% vs. 44.8%, aRR 0.96, 95% CI 0.95-0.98) among couples who did not also have tubal factor infertility and live birth per transfer (37.2% vs. 37.6%, aRR 0.96, 95% CI 0.94-0.98). CONCLUSION(S): The percentage of endometriosis-associated ART cycles has decreased over time. As compared with male factor infertility, endometriosis is associated with increased cancellation and decreased hyperstimulation risks. Despite decreased oocyte yield and higher medication dose, the difference in pregnancy and live birth rates may be of limited clinical significance, suggesting comparable pregnancy outcomes per transfer.
Assuntos
Endometriose/epidemiologia , Infertilidade Feminina/terapia , Infertilidade Masculina/epidemiologia , Infertilidade Masculina/terapia , Nascido Vivo/epidemiologia , Técnicas de Reprodução Assistida/tendências , Adulto , Distribuição por Idade , Causalidade , Comorbidade , Endometriose/diagnóstico , Feminino , Humanos , Infertilidade Feminina/diagnóstico , Infertilidade Feminina/epidemiologia , Infertilidade Masculina/diagnóstico , Masculino , Pessoa de Meia-Idade , Gravidez , Fatores de Risco , Estados Unidos/epidemiologia , Adulto JovemRESUMO
Insulin action is mediated by two insulin receptor (IR) isoforms, differing in mitogenic and metabolic function. IR isoform expression might occur in human granulosa cells and could be altered in polycystic ovary syndrome (PCOS) from hyperinsulinemia. To determine the relationship between granulosa cell IR isoform expression and follicular fluid insulin concentration in individual follicles, 18 normal women and seven PCOS patients receiving gonadotropins for in vitro fertilization were studied. Glucose tolerance testing was performed before pituitary desensitization, and fasting serum insulin was measured at oocyte retrieval. Granulosa cells and fluid aspirated from the first follicle were used to determine IR isoform mRNA expression and insulin concentration, respectively. IR isoform A mRNA expression was greater than that of IR isoform B expression in normal mural granulosa and cumulus cells, without a cell type effect. Intrafollicular insulin levels increased with adiposity and serum insulin levels at oocyte-retrieval but did not predict IR mRNA expression. Total IR mRNA expression, but not intrafollicular insulin levels, was elevated in PCOS patients, whereas intrafollicular insulin levels were increased in women with impaired glucose tolerance. Granulosa cell IR heterogeneity, together with adiposity-dependent intrafollicular insulin availability, introduces a novel mechanism by which insulin may affect granulosa cell function within the follicle.
Assuntos
Insulina/metabolismo , Folículo Ovariano/metabolismo , Síndrome do Ovário Policístico/metabolismo , Receptor de Insulina/metabolismo , Adulto , Estudos de Casos e Controles , Células Cultivadas , Feminino , Intolerância à Glucose , Células da Granulosa/metabolismo , Hirsutismo , Humanos , Ovulação , Síndrome do Ovário Policístico/patologia , Receptor de Insulina/genéticaRESUMO
OBJECTIVE: To estimate cumulative chance for first live birth after elective pronuclear stage cryopreservation of all embryos due to ovarian hyperresponsiveness. DESIGN: Retrospective analysis with longitudinal follow-up. SETTING: Academic hospital. PATIENT(S): Thirty subjects with elective cryopreservation of all embryos due to ovarian hyperresponsiveness. INTERVENTION(S): Elective cryopreservation of all embryos at the pronuclear stage (n = 30) and subsequent cryopreserved-thawed ET (n = 51). MAIN OUTCOME MEASURE(S): Cumulative chance for first live birth. RESULT(S): Cumulative chance for first live birth was 77% when analyzed by intention to treat and 82% by treatment with ET. Nearly 40% of live births were multiple. CONCLUSION(S): Cumulative first live birth increased with repetitive ET after elective pronuclear stage cryopreservation of all embryos due to ovarian hyperresponsiveness. Multiple births, however, were frequent. In the context of initial ET attempts in young women, transfer of no more than two cryopreserved-thawed embryos is advised.
Assuntos
Criopreservação/métodos , Embrião de Mamíferos , Fertilização in vitro/métodos , Síndrome de Hiperestimulação Ovariana/fisiopatologia , Resultado da Gravidez , Adulto , Gonadotropina Coriônica/sangue , Transferência Embrionária , Estradiol/sangue , Feminino , Seguimentos , Humanos , Recém-Nascido , Estudos Longitudinais , Oócitos/citologia , Gravidez , Estudos Retrospectivos , Fatores de TempoRESUMO
BACKGROUND: The benefits of ultrasound-guided hysteroscopic metroplasty have been well described in the management of the partial septate uterus. The use of ultrasonography at the time of hysteroscopy provides visualization of the intrauterine instruments within the uterine cavity. This report describes a case where ultrasound-guidance was used to enter a noncommunicating uterine cavity hysteroscopically. METHODS: A 22-year-old female after her third miscarriage experienced worsening dysmenorrhea. The patient underwent a laparoscopy and hysteroscopy to further evaluate the cause of pelvic pain and to treat the Müllerian anomaly. Under ultrasound-guidance, the 2 uterine cavities were unified by hysteroscopic metroplasty. RESULTS: Postoperative sonohysterography demonstrated unification of the 2 cavities. CONCLUSIONS: This unique application of ultrasound-guidance in hysteroscopic surgery may aid the surgeon in entering a noncommunicating uterine cavity.
Assuntos
Histeroscopia , Útero/anormalidades , Útero/cirurgia , Aborto Habitual , Adulto , Feminino , Humanos , Ductos Paramesonéfricos/anormalidades , Gravidez , Ultrassonografia , Útero/diagnóstico por imagemRESUMO
OBJECTIVE: To assess trends and outcomes of assisted hatching among assisted reproductive technology (ART) cycles. DESIGN: Retrospective cohort analysis using National ART Surveillance System (NASS) data. SETTING: U.S. fertility centers reporting to NASS. PATIENT(S): Fresh autologous noncanceled ART cycles conducted from 2000-2010. INTERVENTION(S): None. MAIN OUTCOME MEASURE(S): Implantation, clinical pregnancy, live-birth, miscarriage, multiple gestation. RESULT(S): Assisted hatching use statistically significantly increased in absolute number (from 25,724 to 35,518 cycles), percentages of day-3 (from 50.7% to 56.3%) and day-5 transfers (from 15.9% to 22.8%), and percentage of transfers among women ≥38 years (from 17.8% to 21.8%) or women with ≥2 prior ART cycles and no live birth(s) (from 4.3% to 7.4%). Both day-3 and day-5 cycles involving assisted hatching were associated with lower odds of implantation (adjusted odds ratios [aOR] 0.7 and 0.6, respectively), clinical pregnancy (aOR 0.8 and 0.7, respectively), live birth (aOR 0.8 and 0.7, respectively), and increased odds of miscarriage (aOR 1.4 and 1.4, respectively), as compared with cycles without assisted hatching. Assisted hatching was associated with lower odds of multiple gestation in day-5 cycles (aOR 0.8). In cycles for women with a "poor prognosis," the association of assisted hatching with pregnancy outcomes was not statistically significant. CONCLUSION(S): Assisted hatching use had an increasing trend but was not associated with improved pregnancy outcomes, even in poor-prognosis patients. Prospective studies are needed to identify the patients who may benefit from assisted hatching.
Assuntos
Resultado da Gravidez/epidemiologia , Técnicas de Reprodução Assistida/estatística & dados numéricos , Técnicas de Reprodução Assistida/tendências , Adulto , Técnicas de Cultura Embrionária/estatística & dados numéricos , Transferência Embrionária/estatística & dados numéricos , Feminino , Fertilização in vitro/estatística & dados numéricos , Humanos , Gravidez , Taxa de Gravidez , Estados Unidos/epidemiologia , Adulto JovemRESUMO
OBJECTIVE: To assess trends of tubal factor infertility and to evaluate risk of miscarriage and delivery of preterm or low birth weight (LBW) neonates among women with tubal factor infertility using assisted reproductive technology (ART). METHODS: We assessed trends of tubal factor infertility among all fresh and frozen, donor, and nondonor ART cycles performed annually in the United States between 2000 and 2010 (N=1,418,774) using the National ART Surveillance System. The data set was then limited to fresh, nondonor in vitro fertilization cycles resulting in pregnancy to compare perinatal outcomes for cycles associated with tubal compared with male factor infertility. We performed bivariate and multivariable analyses controlling for maternal characteristics and calculated adjusted risk ratios (RRs) and 95% confidence intervals (CI). RESULTS: The percentage of ART cycles associated with tubal factor infertility diagnoses decreased from 2000 to 2010 (26.02-14.81%). Compared with male factor infertility, tubal factor portended an increased risk of miscarriage (14.0% compared with 12.7%, adjusted RR 1.08, 95% CI 1.04-1.12); risk was increased for both early and late miscarriage. Singleton neonates born to women with tubal factor infertility had an increased risk of preterm birth (15.8% compared with 11.6%, adjusted RR 1.27, 95% CI 1.20-1.34) and LBW (10.9% compared with 8.5%, adjusted RR 1.28, 95% CI 1.20-1.36). Significant increases in risk persisted for early and late preterm delivery and very low and moderately LBW delivery. A significantly elevated risk was also detected for twin, but not triplet, pregnancies. CONCLUSION: Tubal factor infertility, which is decreasing in prevalence in the United States, is associated with an increased risk of miscarriage, preterm birth, and LBW delivery as compared with couples with male factor infertility using ART.
Assuntos
Doenças das Tubas Uterinas/complicações , Fertilização in vitro/estatística & dados numéricos , Recém-Nascido de Baixo Peso , Infertilidade Feminina/complicações , Nascimento Prematuro/etiologia , Aborto Espontâneo/epidemiologia , Aborto Espontâneo/etiologia , Adulto , Doenças das Tubas Uterinas/epidemiologia , Feminino , Humanos , Recém-Nascido , Infertilidade Feminina/epidemiologia , Infertilidade Masculina/complicações , Masculino , Gravidez , Nascimento Prematuro/epidemiologia , Medição de Risco , Estados Unidos/epidemiologiaRESUMO
Retinol (ROL) and its biologically active metabolite, all-trans retinoic acid (ATRA), are essential for a number of reproductive processes. However, there is a paucity of information regarding their roles in ovarian folliculogenesis, oocyte maturation, and early embryogenesis. The objectives of this study were to quantify and compare peripheral plasma (PP) and follicular fluid (FF) retinoid levels, including ATRA in women undergoing in vitro fertilization (IVF) and to investigate the relationship between retinoid levels and embryo quality. Retinoid levels were evaluated in PP and FF from 79 women undergoing IVF at the time of oocyte retrieval and corresponding embryo quality assessed on a daily basis after retrieval for 3 days until uterine transfer. Analysis compared the retinoid levels with day 3 embryo grades and between endometriosis versus control patients. Results demonstrated distinctive levels of retinoid metabolites and isomers in FF versus PP. There was a significantly larger percentage of high-quality grade I embryos derived from the largest versus smallest follicles. An increase in follicle size also correlated with a >50% increase in FF ROL and ATRA concentrations. Independent of follicle size, FF yielding grade I versus nongrade I embryos showed higher mean levels of ATRA but not ROL. In a nested case-control analysis, control participants had 50% higher mean levels of ATRA in their FF and PP than women with endometriosis. These findings strongly support the proposition that ATRA plays a fundamental role in oocyte development and quality, and that reduced ATRA synthesis may contribute to decreased fecundity of participants with endometriosis.
Assuntos
Endometriose/complicações , Fertilização in vitro , Líquido Folicular/metabolismo , Infertilidade Feminina/terapia , Retinoides/metabolismo , Adulto , Estudos de Casos e Controles , Regulação para Baixo , Técnicas de Cultura Embrionária , Transferência Embrionária , Embrião de Mamíferos/metabolismo , Embrião de Mamíferos/patologia , Endometriose/metabolismo , Endometriose/fisiopatologia , Feminino , Fertilidade , Humanos , Infertilidade Feminina/etiologia , Infertilidade Feminina/metabolismo , Infertilidade Feminina/fisiopatologia , Modelos Logísticos , Pessoa de Meia-Idade , Análise Multivariada , Razão de Chances , Gravidez , Estudos Prospectivos , Retinoides/sangueRESUMO
OBJECTIVE: To estimate trends in good perinatal outcomes (singleton live births at term with birthweight more than 2,500 g) among live births after assisted reproductive technology in the United States from 2000 to 2008, and associated factors among singletons in 2008. METHODS: Using retrospective cohort data from the National Assisted Reproductive Technology Surveillance System from 2000 to 2008, we calculated relative change and χ tests for trend in the proportion of good perinatal outcomes among assisted reproductive technology live births (n=444,909) and liveborn singletons (n=222,500). We conducted univariable analyses followed by multiple logistic regression to estimate the effects of various characteristics on the outcome among singletons born in 2008 after fresh, nondonor assisted reproductive technology cycles (n=20,780). RESULTS: The proportion of good perinatal outcomes among all liveborn neonates increased from 38.6% in 2000 to 42.5% in 2008, whereas it declined marginally among singletons from 83.6% to 83.4%. One previous birth, transfer of fewer than three embryos, and the presence of fewer than three fetal hearts on 6-week ultrasound examination were associated with good perinatal outcome among singletons. Non-Hispanic black race, tubal factor infertility, uterine factor infertility, ovulatory disorder, and 5-day embryo culture were associated with reduced odds for a good outcome. The strongest association was the presence of one fetal heart compared with more than two (adjusted odds ratio 2.43, 95% confidence interval 1.73-3.42). CONCLUSION: From 2000 to 2008, good perinatal outcomes increased among assisted reproductive technology live births. Among singleton live births, odds for good outcome were greatest with the presence of a single fetal heart and lowest in women of non-Hispanic black race. LEVEL OF EVIDENCE: II.
Assuntos
Peso ao Nascer , Nascido Vivo/epidemiologia , Técnicas de Reprodução Assistida , Nascimento a Termo , Negro ou Afro-Americano , Estudos de Coortes , Feminino , Humanos , Recém-Nascido , Nascido Vivo/etnologia , Modelos Logísticos , Vigilância da População , Gravidez , Gravidez Múltipla , Estudos Retrospectivos , Nascimento a Termo/etnologia , Estados Unidos/epidemiologiaRESUMO
OBJECTIVE: To present a case in which the use of a titanium/nickel microinsert in the management of unilateral hydrosalpinx contributed to a spontaneous intrauterine pregnancy. DESIGN: Case report. SETTING: University hospital. PATIENT(S): A 37-year-old nulligravid female with dense pelvic adhesive disease and unilateral hydrosalpinx. INTERVENTION(S): Unilateral proximal occlusion of left fallopian tube with titanium/nickel microinsert. MAIN OUTCOME MEASURE(S): Pregnancy. RESULT(S): Spontaneous intrauterine pregnancy after confirmation via hysterosalpingogram of left tubal occlusion and right tubal patency. CONCLUSION(S): Transcervical proximal tubal occlusion using titanium/nickel microinserts provides an alternative in the management of hydrosalpinx in the setting of tubal factor infertility. Additionally, in the setting of a unilateral hydrosalpinx, unilateral occlusion can contribute to spontaneous intrauterine pregnancy.
Assuntos
Doenças das Tubas Uterinas/cirurgia , Esterilização Tubária/efeitos adversos , Adulto , Transferência Embrionária , Doenças das Tubas Uterinas/complicações , Tubas Uterinas/cirurgia , Feminino , Fertilização in vitro , Humanos , Recém-Nascido , Níquel/efeitos adversos , Gravidez , Resultado da Gravidez , Esterilização Tubária/métodos , Titânio/efeitos adversosRESUMO
Ovulation induction using a minimal stimulation protocol with clomiphene citrate and highly purified hMG was associated with a 20% reduction in the number of follicles recruited compared with clomiphene citrate and recombinant FSH. This reduction may reduce the risk of multiple gestation without reducing the pregnancy rate.
Assuntos
Hormônio Foliculoestimulante/farmacologia , Menotropinas/farmacologia , Folículo Ovariano/efeitos dos fármacos , Indução da Ovulação/métodos , Adulto , Clomifeno/farmacologia , Feminino , Fármacos para a Fertilidade Feminina/farmacologia , Humanos , Hormônio Luteinizante/metabolismo , Análise Multivariada , Gravidez , Taxa de Gravidez , Gravidez Múltipla , Estudos RetrospectivosRESUMO
Assisted reproductive technologies are important tools in the clinical armamentarium used to treat both female and male infertility disorders. Pre-implantation genetic diagnosis offers couples at risk of having children with inheritable disorders the ability to analyze the genetic make-up of embryos before transfer. For patients undergoing treatment of cancer with chemotherapy or radiation therapy, these technologies offer the potential for the preservation of future fertility. As technology evolves, it is likely the clinical applications of assisted reproduction will continue to develop and expand in the future to enhance fertility.
Assuntos
Infertilidade/terapia , Técnicas de Reprodução Assistida , Contraindicações , Análise Citogenética , Técnicas de Cultura Embrionária , Transferência Embrionária , Feminino , Fertilização in vitro/métodos , Testes Genéticos , Humanos , Infertilidade/etiologia , Masculino , Recuperação de Oócitos , Indução da Ovulação , Gravidez , Técnicas de Reprodução Assistida/efeitos adversosRESUMO
OBJECTIVE: To report a case in which uterine torsion in a nulligravid female adolescent was noted upon surgical management of complete cervical and partial vaginal agenesis. DESIGN: Case report. SETTING: University hospital. PATIENT(S): A 13-year-old nulligravid adolescent female. INTERVENTION(S): Ultrasound-guided vaginal exploration, diagnostic laparoscopy, and hysterectomy. MAIN OUTCOME MEASURE(S): Uterine torsion as complication of cervical agenesis and its management. RESULT(S): Complete cervical agenesis, hematometra, and resultant 180-degree horizontal uterine torsion and sacral entrapment. CONCLUSION(S): Cervical agenesis can be a risk factor for uterine torsion. Hysterectomy is a common treatment due to resultant hematometra, pelvic pain, and severe endometriosis, although rare case reports show success with uterovaginal recanalization in cases with cervical dysgenesis.