Quality of life of immigrant and non-immigrant infertile patients in a publicly funded in vitro fertilisation program: a cross-sectional study.

OBJECTIVE: To investigate whether there are differences in fertility quality of life (FertiQoL) and socio-demographic characteristics between immigrants and non-immigrant patients attending a government-funded fertility program. DESIGN: Cross-sectional study. SETTING: McGill University Reproductive Center in Montreal, Canada, at a time when governmental funding for in vitro fertilisation (IVF) was provided to all residents. POPULATION: All infertile patients, males and females, attending the center between March and July 2015. METHODS: Patients were invited to complete anonymous questionnaires which included socio-demographic items and the validated FertiQoL questionnaire. MAIN OUTCOME MEASURES: Socio-demographic characteristics (age, gender, marital state, infertility type & duration, previous IVF attempts; education, employment, income, ethnicity, spoken languages) and FertiQoL scores. RESULTS: In all, 1020 patients completed the questionnaires; of these, 752 (77.7%) non-immigrant Canadian citizens and 215 (22.3%) resident immigrants were included in the analysis. Median duration in Canada for immigrants was 4 years. Immigrants were more likely to have university/graduate degrees (75% versus 64%), to be unemployed (37% versus 13.1%) and to have lower annual household incomes (72.8% versus 39.5%, all P < 0.05). They also reported poorer QoL and achieved significantly lower scores in the emotional, mind/body, social, treatment and total FertiQoL domains. Multivariate analysis showed male gender, lower education level and Caucasian/European ethnicity to be significantly associated with higher QoL. CONCLUSIONS: Despite governmental funding of IVF, immigrants experience reduced fertility QoL, implying cost is not the only barrier to IVF use. The reduced QoL may stem from cross-cultural differences in infertility perception. This population may be at greater risk for depression and anxiety and should be flagged accordingly. TWEETABLE ABSTRACT: Immigrants' fertility QoL is lower despite publicly funded IVF implying cost is not the only barrier to IVF use.

Quebec public funding facilitates fertility preservation for male cancer patients.

BACKGROUND: Sperm cryopreservation remains the only clinically feasible option to preserve male fertility. The quality of counselling provided by the treating physicians and the cost of sperm cryopreservation can both influence a patient's decision about whether to preserve sperm. On 5 August 2010, the Quebec government introduced provincial coverage of assisted reproductive technologies, with sperm cryopreservation included as a covered service. The aim of the present study was to evaluate whether and how such a program affects the behaviour of cancer patients with respect to sperm cryopreservation. METHODS: We analyzed the database derived from male patients undergoing sperm cryopreservation from August 2008 to August 2012 at our centre. The retrieved data included patient age, male infertility or oncologic diagnosis, sperm quality parameters, and details about the number of visits for sperm cryopreservation. RESULTS: The number of cancer patients who cryopreserved sperm before and after the policy change did not differ significantly, but a marked increase in the number of non-cancer patients was observed. Further analysis revealed that, after implementation of the public funding program, the total number of sperm cryopreservation sessions per patient increased significantly in cancer patients but not in non-cancer patients. CONCLUSIONS: It appears that cancer patients who are willing to freeze sperm are keen to return for more sessions of sperm banking when no fees are associated with the service. Those findings suggest that cost reduction is an important factor for improving delivery of fertility preservation services to male cancer patients.

Cryopreservation of ovarian tissue and in vitro matured oocytes in a female with mosaic Turner syndrome: Case Report.

We report a novel approach of fertility preservation in a young woman with mosaic Turner syndrome. A 16-year-old female with 20% 45XO and 80% 46XX karyotype underwent laparoscopic ovarian wedge resection. Before performing ovarian tissue cryopreservation, all visible follicles on the ovarian surface were aspirated. We recovered 11 immature germinal vesicle stage oocytes, which were subjected to in vitro maturation (IVM). Eight oocytes that matured (73% maturation rate) were cryopreserved by vitrification. The combination of ovarian tissue cryobanking and immature oocyte collection from the tissue followed by IVM and vitrification of matured oocytes represent a promising approach of fertility preservation for young women with mosaic Turner syndrome.

Pregnancy outcomes in women with osteogenesis imperfecta: a retrospective cohort study.

OBJECTIVE: Osteogenesis imperfecta (OI) is a rare genetic disorder characterized by defects in type I collagen that can pose serious complications during pregnancy. The aim was to evaluate maternal and fetal outcomes in pregnant women with OI. STUDY DESIGN: This was a retrospective cohort study, using the Healthcare Cost and Utilization Project Nationwide Inpatient Sample. We examined the records of pregnant women with OI during the period 2003 to 2011. We evaluated antenatal complications and method of delivery among 295 women with OI, using unconditional logistic regression. RESULTS: Of the total 7 287 994 births in our cohort, we encountered 295 deliveries among women with OI. The prevalence was 4 per 1 00 000 deliveries per year over the study period. Births to women with OI were more likely to be complicated by antepartum hemorrhage (odds ratio (OR) 2.01, 95% confidence interval (CI) 1.04 to 3.91), placenta abruption (OR 2.50, 95% CI 1.24 to 5.03), intrauterine growth restriction and small-for-gestational-age infants (OR 2.42, 95% CI 1.42 to 4.14), congenital malformation (OR 7.33, 95% CI 4.20 to 12.78) and preterm birth (OR 2.24, 95% CI 1.63 to 3.06). Seventy-five percent of women with OI delivered by cesarean section, and they had an increased rate of tubal sterilization at delivery (OR 1.67, 95% CI 1.18 to 2.36). No differences in rates of stress fracture and maternal death were found. CONCLUSION: These findings suggest that there are increased risks to both mother and fetus in pregnancies complicated by OI.

Effect of estrogen on the growth hormone response to the alpha-adrenergic agonist clonidine in women with menopausal flushing.

The serum GH response to the alpha 2-adrenergic receptor agonist clonidine (0.15 mg, iv) was measured in 8 postmenopausal women with hot flushes before and during treatment with the conjugated estrogen premarin (1.25 mg, orally daily for 4 weeks), 9 normal premenopausal women, and 12 normal men. The men had a significantly greater GH response than did the age-matched premenopausal women (P less than 0.05). The mean individual peak GH response was significantly higher in the premenopausal compared with the postmenopausal women (P less than 0.05). Premarin decreased the number of hot flushes (P less than 0.01), but had no effect on the GH response to clonidine. These results suggest that estrogens do not enhance alpha 2-adrenergic mechanisms that regulate GH secretion and that improvement in menopausal flushing after estrogen therapy is not mediated by an effect on central alpha 2-adrenergic function.

"Add-back" estrogen reverses cognitive deficits induced by a gonadotropin-releasing hormone agonist in women with leiomyomata uteri.

Treatment of women with uterine myomas with GnRH agonists results in symptoms of hypoestrogenism which can be prevented by concurrent "add-back" estrogen administration. We took advantage of these induced endocrine changes to investigate their effects on cognitive functioning in young women with myomas. Nineteen women with uterine myomas were tested before treatment. They all received the GnRH agonist, leuprolide acetate depot (LAD), every 4 weeks for 12 weeks and were then randomized to receive LAD plus estrogen or LAD plus placebo every 4 weeks for 8 additional weeks. Levels of all sex hormones decreased after 12 weeks of LAD treatment (P < 0.01), and only estradiol (E2) levels increased (P < 0.01) following 8 weeks of subsequent treatment in the group that received LAD plus E2. Scores on neuropsychological tests of verbal memory decreased from pretreatment to 12 weeks posttreatment with LAD (P < 0.05). These memory deficits were reversed in the group that received LAD plus E2 for 8 weeks coincident with an increase in plasma E2, whereas memory scores remained depressed in the group that received LAD plus placebo. These findings are consistent with those from studies on surgically menopausal women and strongly suggest that estrogen serves to maintain verbal memory in women. These results provide support for the efficacy of add-back estrogen regimens in women treated with GnRH agonists and also imply that estrogen may be important for maintaining memory in the postmenopause.

Adhesion formation and reproductive outcome after myomectomy and second-look laparoscopy.

OBJECTIVES: To evaluate adhesion formation after myomectomy and the reproductive outcome of infertile women with a large leiomyomatous uterus after myomectomy and second-look laparoscopy. METHODS: Twenty-six infertile women with a large leiomyomatous uterus underwent second-look laparoscopy 6 weeks after a myomectomy. At laparoscopy, the degree of adhesions was scored using the American Fertility Society classification of adnexal adhesions, and the adhesions were lysed. The pregnancy rates of these women were evaluated by life table analysis. RESULTS: A myomectomy incision on the posterior wall of the uterus was associated with more adnexal adhesions than that on the fundus or anterior uterine wall (93.7 versus 55.5%; P = .04). The degree of adnexal adhesions was also higher among women who underwent myomectomy with a posterior uterine incision (22.2 +/- 2.3 points) than in those with a fundal or anterior uterine incision (2.7 +/- 1.2 points) (P < .000001). The cumulative pregnancy rate was 33.4% at 6 months and 66.7% at 12 months after the procedures. CONCLUSIONS: Myomectomy incisions on the posterior uterine wall are associated with more and a higher degree of adnexal adhesions than those on the fundus and anterior wall. Conception occurs in the majority of infertile women with a large myomatous uterus who undergo myomectomy and second-look laparoscopy.

Laparoscopic treatment of interstitial pregnancy.

The conventional treatment of interstitial pregnancy has been cornual resection of hysterectomy by laparotomy. We have used a laparoscopic approach to treatment of interstitial pregnancy, consisting of cornual excision in four patients and salpingotomy incision via the myometrium in another. In all five cases, the procedure was associated with minimal bleeding and no complications.

Diabetes insipidus: a postpartum complication.

Sheehan's syndrome and diabetes insipidus were diagnosed in a 31-year-old woman seven months after postpartum bleeding with a short duration of hypotension. The diagnosis of diabetes insipidus was established by the inability to concentrate urine during water deprivation and the marked increase in urinary osmolality after administration of 1-Desamino-8-D-arginine-vasopressin (DDAVP). Obstetricians should be aware of diabetes insipidus as a postpartum complication.

Peritoneal fluid inhibin during the menstrual cycle.

Serum and peritoneal fluid inhibin levels were measured by radioimmunoassay throughout the menstrual cycle in 14 women with endometriosis and in 16 controls. In controls, serum values (+/- standard error of the mean) increased from the early follicular phase (49.8 +/- 6.5 microLEq/mL) to the late follicular phase (178 +/- 37.8 microLEq/mL) and the luteal phase (346 +/- 98.3 microLEq/mL). Peritoneal fluid inhibin levels were several-fold higher than those in serum and reached a maximum value during the late follicular phase (early follicular: 2404 +/- 85 microLEq/mL, late follicular: 22,922 +/- 7145 microLEq/mL, luteal: 5195 +/- 1959 microLEq/mL). There was no difference in peritoneal fluid or serum inhibin concentrations between patients with and without endometriosis. These findings suggest that human gametes in the fallopian tube may be exposed to a very high concentration of inhibin. The lack of difference in inhibin concentrations between patients with and without endometriosis suggests that this hormone does not play a role in endometriosis-related infertility.

A study of nerve fibers and histopathology of postsurgical, postinfectious, and endometriosis-related adhesions.

OBJECTIVE: To evaluate the presence of nerve fibers and histopathology of endometriosis-related adhesions, postsurgical adhesions, and postinfectious adhesions in women with and without pelvic pain. METHODS: We evaluated the presence of nerve fibers and histopathology of endometriosis-related adhesions, postsurgical adhesions, and postinfectious adhesions in 50 women. The nerve fibers were identified by immunocytochemistry staining with an antibody to neurofilament. RESULTS: Nerve fibers were found in the intraabdominal adhesions in 39 of the total 50 patients with such adhesions (78%). There was no significant difference in the proportion and the mean nerve score in adhesions due to previous intra-abdominal infection, endometriosis, and previous uninfected intra-abdominal surgery. The degree of lymphocytes and edema in endometriosis-related adhesions was significantly higher than in postsurgical adhesions and postinfectious adhesions (P < .05). No difference was found in the amount of nerve fibers and the mean nerve score in adhesions from women with pelvic pain and from those without pelvic pain. CONCLUSION: Nerve fibers are found commonly in intraabdominal adhesions, and their presence are not related to the underlying pathology or pelvic pain. Endometriosis-related adhesions contain more inflammatory cells and tissue edema than postsurgical or postinfectious adhesions.

Pseudocyesis: pituitary function before and after resolution of symptoms.

Pseudocyesis was clinically established in a 39-year-old woman. Pituitary function was assessed with the use of hypothalamic peptides and dopamine receptor agonists. Basal serum concentrations of anterior pituitary and ovarian hormones were normal. An exaggerated rise in luteinizing hormone (LH) and prolactin levels was seen following the administration of luteinizing hormone-release hormone and thyrotropin-releasing hormone (TRH), respectively. A paradoxic rise in growth hormone (GH) levels followed TRH administration, whereas the response to dopamine receptor agonists was normal. Pituitary hormone secretion after deflation remained similar to that before deflation, although a normal response of GH to apomorphine was reestablished. These data indicate that the amenorrhea of pseudocyesis is associated with normoprolactinemia and a readily releasable pituitary LH pool, which suggests a suprahypophyseal etiology of the amenorrhea. The abnormalities in GH secretion may also support this contention.

Treatment of ectopic pregnancy by transvaginal intratubal methotrexate administration.

Twelve women with tubal pregnancies were treated with intratubal transvaginal methotrexate injection (1 mg/kg body weight). Serum beta-hCG levels decreased in all patients, and the resolution time from injection to undetectable beta-hCG levels was 14-120 days. In spite of declining serum beta-hCG and unruptured tubal pregnancy, two patients subsequently requested definitive treatment for their ectopic pregnancies and underwent surgery. Four of six women found to have a living embryo in their gestational sacs required a repeat methotrexate injection; one of these also required a local potassium chloride injection. The tubal pregnancies resolved in nine patients treated with methotrexate alone. During resolution, we noted a gradually increasing resistance index of the blood flow in the region of the gestation, but the tube became distended to 4.4 +/- 0.4 cm before gradually decreasing in size. No complications or side effects were encountered. These findings suggest that intratubal transvaginal methotrexate administration can provide a safe alternative to surgical treatment for patients with early unruptured tubal ectopic pregnancy. However, the presence of a living embryo makes the ectopic pregnancy more resistant to methotrexate treatment.

Ovarian stimulation and in vitro fertilization in women with mature cystic teratomas.

OBJECTIVE: To report the results of ovulation induction and in vitro fertilization-embryo transfer (IVF-ET) in patients with ovarian cystic teratomas. METHODS: Six women with ultrasonographically diagnosed ovarian cystic teratomas (mean diameter 2.4 cm) who presented with infertility underwent IVF-ET (n = 4) or ovulation induction (n = 2). Serial ultrasound examinations were used to determine the size of the cystic teratomas during therapy and throughout pregnancy. RESULTS: Ovarian stimulation was successful, as evidenced by the serum estradiol concentration on the day of hCG administration (mean in IVF-ET patients, 3558+/-1319 pg/mL) and the number of oocytes retrieved (10+/-4.24). Three patients having IVF-ET and both patients having ovulation induction conceived, and six healthy infants were born. Cyst sizes remained unchanged throughout treatment and pregnancy. There were no cyst-related complications during ovulation induction or IVF-ET, or during the entire course of pregnancy, labor, and delivery. CONCLUSION: The presence of ovarian cystic teratoma should not be considered a contraindication for therapy in women undergoing ovulation induction and IVF-ET.

A study of ruptured tubal ectopic pregnancy.

OBJECTIVE: Ectopic pregnancy continues to be a leading cause of maternal morbidity and of reduced childbearing potential among women of reproductive age. Because of tubal rupture it is still the main cause of pregnancy-related death during the first trimester. The purpose of our study was to evaluate factors that may predispose a woman to rupture of a tubal ectopic pregnancy. METHODS: In this retrospective study of 693 ectopic pregnancies from three McGill University teaching hospitals, we compared risk factors, preoperative ultrasound, and serum hCG levels between cases with ruptured and unruptured tubal ectopic pregnancy. RESULTS: The age and the number of pregnancies among the two groups of women were similar. The gestational age of women with an unruptured tube was 6.9 +/- 1.9 weeks, and of those with a ruptured tube, the gestational age was 7.2 +/- 2.2 weeks. Tubal rupture was encountered more often in women with at least one child than in childless women. History of ectopic pregnancy was found in 35% of women with an unruptured tubal pregnancy and in 26% of those with a ruptured tube. Serum hCG levels at the time of treatment were not significantly different among the two groups of women. Eleven percent of women with a ruptured tube had serum beta-hCG levels of less that 100 IU/L. CONCLUSION: Tubal rupture is encountered more often in women with no history of ectopic pregnancy and in those with at least one child. This suggests that ectopic pregnancy is less suspected in these women. Tubal rupture is encountered less often in ampullary pregnancy and in small ectopic pregnancies. There is no correlation between serum beta-hCG levels and tubal rupture, and rupture can occur even when serum beta-hCG levels are very low.

Adhesion reformation after reproductive surgery with and without the carbon dioxide laser.

The degree of adhesion reformation and tubal patency after salpingostomy with the use of CO2 laser and with microdiathermy needle was evaluated by second-look laparoscopy. The results indicate that there is no difference in adhesion reformation and tubal patency after laser surgery and after electrosurgery.

Effects of fibrin sealant on tubal anastomosis and adhesion formation.

The results of the present study suggest that there is no difference in adhesion formation and PR after tubal anastomosis using sutures or fibrin sealant. It appears that the use of fibrin sealant is associated with decreased incidence of ectopic pregnancy.

Reproductive performance of women after two tubal ectopic pregnancies.

Twenty-four women who had undergone total salpingectomy due to ectopic pregnancy and who subsequently underwent a laparotomy for a second ectopic pregnancy in their opposite tube were treated by the author. Treatment consisted of linear salpingostomy (n = 20) and partial salpingectomy (n = 4). The intrauterine pregnancy rate after linear salpingostomy in women who attempted to conceive was 50%, and the incidence of a third ectopic pregnancy was 27.8%. These findings suggest that linear salpingostomy should be considered in the management of a second tubal pregnancy in women with a single tube. The high incidence of a third ectopic pregnancy, however, is concerning.