The impact of insurance mandates on donor oocyte utilization: an analysis of 39,338 donor oocyte cycles from the Society for Assisted Reproductive Technology registry.

BACKGROUND: A total of 19 states passed legislation mandating insurance coverage of assisted reproductive technology, and out-of-pocket costs associated with in vitro fertilization vary significantly depending on the region. Consequently, it has been observed that assisted reproductive technology utilization differs regionally and is associated with the presence of an insurance mandate. However, it is unknown whether regional differences exist among patients using donor oocytes. OBJECTIVE: This study aimed to determine the patient and cycle-specific parameters associated with the use of donor oocytes according to the insurance mandate status of the Society for Assisted Reproductive Technology clinic in which the assisted reproductive technology cycle was performed. STUDY DESIGN: This study was a retrospective cohort study using national data collected from the Society for Assisted Reproductive Technology registry for 39,338 donor oocyte cycles and 242,555 autologous oocyte cycles performed in the United States from January 1, 2014, to December 31, 2016. Cycles were stratified by insurance mandate of the state in which the assisted reproductive technology cycle was performed: comprehensive (coverage for at least 4 cycles of assisted reproductive technology), limited (coverage limited to 1-3 assisted reproductive technology cycles), offer (insurance mandates exist but exclude assisted reproductive technology treatment), and no mandate. The primary outcome was the number of previous autologous assisted reproductive technology cycles of the recipient. The secondary outcomes included age, serum follicle stimulating hormone level, frozen donor oocyte utilization, day of embryo transfer, number of embryos transferred, clinical pregnancy rate, and live birth rate. Analyses were adjusted for day of transfer, number of embryos transferred, and age of the recipient. RESULTS: Patients in no mandate states underwent fewer autologous assisted reproductive technology cycles (mean, 1.1; standard deviation, 1.6) before using donor oocytes than patients in offer (mean, 1.7; standard deviation, 2.5; P<.01), limited (mean, 1.5; standard deviation, 2.5; P<.01), and comprehensive (mean, 1.7; standard deviation, 2.0; P<.01) states. Patients in no mandate states were more likely to use frozen oocytes than patients in offer (relative risk, 0.54; 95% confidence interval, 0.52-0.57), limited (relative risk, 0.50; 95% confidence interval, 0.46-0.54), and comprehensive (relative risk, 0.94; 95% confidence interval, 0.89-0.99) states. Clinical pregnancy and live birth rates were similar among recipients of donor oocytes, regardless of insurance mandate. CONCLUSION: Despite similar ages and ovarian reserve parameters, patients without state-mandated insurance coverage of assisted reproductive technology were more likely to use frozen donor oocytes and undergo fewer autologous in vitro fertilization cycles than their counterparts in partial or comprehensive insurance coverage states. These differences in donor oocyte utilization highlight the financial barriers associated with pursuing assisted reproductive technology in uninsured states.

Fertility treatment for the transgender community: a public opinion study.

PURPOSE: The purposes of this study were to evaluate public opinion regarding fertility treatment and gamete cryopreservation for transgender individuals and identify how support varies by demographic characteristics. METHODS: This is a cross-sectional web-based survey study completed by a representative sample of 1111 US residents aged 18-75 years. Logistic regression was used to calculate odd ratios (ORs) and 95% confidence intervals (CIs) of support for/opposition to fertility treatments for transgender people by demographic characteristics, adjusting a priori for age, gender, race, and having a biological child. RESULTS: Of 1336 people recruited, 1111 (83.2%) agreed to participate, and 986 (88.7%) completed the survey. Most respondents (76.2%) agreed that "Doctors should be able to help transgender people have biological children." Atheists/agnostics were more likely to be in support (88.5%) than Christian-Protestants (72.4%; OR = 3.10, CI = 1.37-7.02), as were younger respondents, sexual minorities, those divorced/widowed, Democrats, and non-parents. Respondents who did not know a gay person (10.0%; OR = 0.20, CI = 0.09-0.42) or only knew a gay person without children (41.4%; OR = 0.29, CI = 0.17-0.50) were more often opposed than those who knew a gay parent (48.7%). No differences in gender, geography, education, or income were observed. A smaller majority of respondents supported doctors helping transgender minors preserve gametes before transitioning (60.6%) or helping transgender men carry pregnancies (60.1%). CONCLUSIONS: Most respondents who support assisted and third-party reproduction also support such interventions to help transgender people have children.

Serum progesterone concentration on day of embryo transfer in donor oocyte cycles.

PURPOSE: To evaluate the association between serum progesterone (P) levels on the day of embryo transfer (ET) and pregnancy rates in fresh donor IVF/ICSI cycles. METHODS: Fresh donor cycles with day 3 ET from 10/2007 to 8/2012 were included (n = 229). Most cycles (93 %) were programmed with a gonadotropin releasing hormone (GnRH) agonist; oral, vaginal or transdermal estradiol was used for endometrial priming, and intramuscular P was used for luteal support (50-100 mg/day). Recipient P levels were measured at ET, and P dose was increased by 50-100 % if <20 ng/mL per clinic practice. The main outcome measure was rate of live birth (> = 24 weeks gestational age). Generalized estimating equations were used to account for multiple cycles from the same recipient, adjusted a priori for recipient and donor age. RESULTS: Mean recipient serum P at ET was 25.5 ± 10.1 ng/mL. Recipients with P < 20 ng/mL at ET, despite P dose increases after ET, were less likely to achieve clinical pregnancy (RR = 0.75, 95 % CI = 0.60-0.94, p = 0.01) and live birth (RR = 0.77, 95 % CI = 0.60-0.98, p = 0.04), as compared to those with P ≥ 20 ng/mL. P dose increases were more often required in overweight and obese recipients. CONCLUSIONS: Serum P levels on the day of ET in fresh donor IVF/ICSI cycles were positively correlated with clinical pregnancy and live birth rates. An increase in P dose after ET was insufficient to rescue pregnancy rates. Overweight and obese recipients may require higher initial doses of P supplementation. Future research is needed to define optimal serum P at ET and the interventions to achieve this target.

Development of a Set of Lupus-Specific, Ambulatory Care-Sensitive, Potentially Preventable Adverse Conditions: A Delphi Consensus Study.

OBJECTIVE: Individuals with systemic lupus erythematosus (SLE) are at high risk for infections and SLE- and medication-related complications. The present study was undertaken to define a set of SLE-specific adverse outcomes that could be prevented, or their complications minimized, if timely, effective ambulatory care had been received. METHODS: We used a modified Delphi process beginning with a literature review and key informant interviews to select initial SLE-specific potentially preventable conditions. We assembled a panel of 16 nationally recognized US-based experts from 8 subspecialties. Guided by the RAND-UCLA Appropriateness Method, we held 2 survey rounds with controlled feedback and an interactive webinar to reach consensus regarding preventability and importance on a population level for a set of SLE-specific adverse conditions. In a final round, the panelists endorsed the potentially preventable conditions. RESULTS: Thirty-five potential conditions were initially proposed; 62 conditions were ultimately considered during the Delphi process. The response rate was 100% for both survey rounds, 88% for the webinar, and 94% for final approval. The 25 SLE-specific conditions meeting consensus as potentially preventable and important on a population level fell into 4 categories: vaccine-preventable illnesses (6 conditions), medication-related complications (8 conditions), reproductive health-related complications (6 conditions), and SLE-related complications (5 conditions). CONCLUSION: We reached consensus on a diverse set of adverse outcomes relevant to SLE patients that may be preventable if patients receive high-quality ambulatory care. This set of outcomes may be studied at the health system level to determine how to best allocate resources and improve quality to reduce avoidable outcomes and disparities among those at highest risk.

Combined Oocyte Retrieval and Robot-assisted Hysterectomy in a Super Morbidly Obese Patient with Endometrial Carcinoma.

AIM: To report on the unique, innovative management of a super morbidly obese patient presenting for fertility preservation in the setting of Grade 2 endometrioid endometrial adenocarcinoma. CASE REPORT: A back-to-back oocyte retrieval and robot-assisted total laparoscopic hysterectomy (RA-TLH) with bilateral salpingo-oophorectomy (BSO) was performed in a 37-year-old nulligravid woman with super morbid obesity (BMI 63 kg/m2) with endometrial cancer. MAIN OUTCOME MEASURE: the successful retrieval of oocytes for fertility preservation and oncologic intervention via RA-TLH with BSO in the same operative and anesthetic episode. RESULTS: This combined procedure strategy was successful in our case and is a feasible option for similar high-risk patients in the future. CONCLUSION: Identifying safe and effective approaches for oocyte retrieval in morbidly obese patients represents a pressing need as obesity rates rise among reproductive-aged women. Back-to-back oocyte retrieval and RA-TLH with BSO are not only feasible, but could also decrease significant anesthetic risks for morbidly obese patients.

The medical management of ectopic pregnancy: a meta-analysis comparing "single dose" and "multidose" regimens.

OBJECTIVE: Medical management of an unruptured ectopic pregnancy with intramuscular methotrexate is common and cost-effective. Two treatment protocols, the "single dose" and the "multidose," have been advocated and independently reported in the medical literature. This analysis systematically compares the success and prevalence of side effects of these two regimens. DATA SOURCES: Published data on women with an ectopic pregnancy medically managed were identified using a MEDLINE search from 1966 to 2001 using key words and review of the references of each manuscript. METHODS OF STUDY SELECTION: Studies were selected based on dosing regimen, number of subjects, and study quality. Data regarding outcome, number of doses administered, side effects, and baseline characteristics were extracted. Data were summarized, and the associations of failed management and the presence of side effects with treatment protocol were calculated. Baseline serum chorionic gonadotropin values and the presence of embryonic fetal actively were controlled for with multivariable logistic regression. TABULATION, INTEGRATION, AND RESULTS: The overall success rate for women treated with methotrexate for an ectopic pregnancy was 89% (1181 of 1327). The single dose was much more commonly used. The use of single dose was associated with a significantly greater chance of failed medical management than the use of the multidose in both crude (odds ratio [OR] 1.71; 1.04, 2.82) and adjusted analyses (OR 4.74; 1.77, 12.62). The single-dose regimen was associated with fewer side effects (OR 0.44; 0.31, 0.63). Women who experienced side effects were more likely to have successful treatment regardless of regimen. CONCLUSION: The multidose regimen is more effective than the single-dose regimen.

Embryo banking between induction and consolidation chemotherapy in women with leukemia.

OBJECTIVE: To report the results of controlled ovarian hyperstimulation (COH) after long-acting GnRH agonist (GnRH-a) and chemotherapy for the purposes of embryo cryopreservation. DESIGN: Case report. SETTING: University medical center. PATIENT(S): Two premenopausal women with acute myelogenous leukemia with recent treatment with GnRH-a and induction chemotherapy for hematopoietic cell transplantation (HCT). INTERVENTION(S): COH with embryo cryopreservation. MAIN OUTCOME MEASURE(S): Numbers of oocytes and embryos cryopreserved. RESULT(S): Both patients responded to gonadotropin stimulation and cryopreserved embryos. CONCLUSION(S): Women who have received recent long-acting GnRH-a and chemotherapy may respond to gonadotropin stimulation. The option of embryo banking can be offered to leukemia patients who are preparing for HCT.

Does emotional support during the luteal phase decrease the stress of in vitro fertilization?

OBJECTIVE: To determine if phone calls between ET and pregnancy test, decrease stress levels as determined by the Perceived Stress Scale (PSS). DESIGN: Randomized controlled trial. SETTING: Academic medical center. PATIENT(S): Women undergoing a first fresh cycle of assisted reproductive technology using autologous oocytes with a day 2 or 3 ET. INTERVENTION(S): Phone calls from specialized social workers or standard of care. MAIN OUTCOME MEASURE(S): Primary outcome was the change in PSS score from day of ET compared with 10 days after ET; secondary outcome was perceived patient benefit. RESULT(S): A total of 131 patients were randomized to the intervention (n = 66) or control (n = 65) group. No differences were seen in the final PSS score or the change in PSS score between groups. At the completion of the study, the intervention group was more likely to report that participating in this study was helpful (65.9% vs. 21.4%), as well as to recommend emotional support during an IVF cycle (95.4% vs. 78.6%). CONCLUSION(S): Although we observed no significant change in PSS score, first-cycle IVF patients felt that increased emotional support was needed during the waiting period between ET and pregnancy test. Additional research should be conducted to determine the best interventions for this time period.

Physical activity and semen quality among men attending an infertility clinic.

OBJECTIVE: To examine the association between regular physical activity and semen quality. DESIGN: Prospective cohort study. SETTING: Couples attending one of three IVF clinics in the greater Boston area during 1993-2003. At study entry, male participants completed a questionnaire about their general health, medical history, and physical activity. Odds ratios (ORs) and 95% confidence intervals (CIs) were derived using generalized estimating equations models, accounting for potential confounders and multiple samples per man. PATIENT(S): A total of 2,261 men contributing 4,565 fresh semen samples were enrolled before undergoing their first IVF cycles. INTERVENTION(S): None. MAIN OUTCOME MEASURE(S): Semen volume, sperm concentration, sperm motility, sperm morphology, and total motile sperm (TMS). RESULT(S): Overall, none of the semen parameters were materially associated with regular exercise. Compared with no regular exercise, bicycling ≥ 5 h/wk was associated with low sperm concentration (OR 1.92, 95% CI 1.03-3.56) and low TMS (OR 2.05, 95% CI 1.19-3.56). These associations did not vary appreciably by age, body mass index, or history of male factor infertility. CONCLUSION(S): Although the present study suggests no overall association between regular physical activity and semen quality, bicycling ≥ 5 h/wk was associated with lower sperm concentration and TMS.

Multivariate analysis of the association between oocyte donor characteristics, including basal follicle stimulating hormone (FSH) and age, and IVF cycle outcomes.

OBJECTIVE: To determine whether oocyte donor FSH and age are independently associated IVF cycle success. DESIGN: Retrospective cohort study. SETTING: University hospital-based IVF clinic. PATIENT(S): Three hundred twelve donor/recipient pairs undergoing oocyte donation IVF. MAIN OUTCOME MEASURE(S): Number of mature oocytes and embryos, clinical pregnancy, and live birth rates. RESULT(S): Donors' basal FSH levels were not associated with IVF cycle outcomes. However, for every year increase in donor age, the number of mature oocytes decreased by 0.39 and the number of embryos decreased by 0.25 resulting in 1 less embryo for each 4-year increase in age, even in young donors. For every 100 pg/mL increase in estradiol on the day of hCG administration, the number of mature oocytes increased by 0.49 and the number of embryos increased by 0.36. For each additional 75 IU of gonadotropin used during stimulation, the likelihood of pregnancy and live birth decreased by 3.5%. CONCLUSION(S): Donor oocyte IVF cycle outcomes were not associated with donor basal FSH. However, donor age and estradiol level on the day of hCG administration were significantly associated with numbers of mature oocytes and embryos obtained, and the amount of gonadotropin used in the stimulation was significantly associated with the likelihood of pregnancy and live birth.