Association between infertility and all-cause mortality: analysis of US claims data.

BACKGROUND: The consequences of an infertility diagnosis extend beyond the pursuit of family building, because women with infertility also face increased risks for severe maternal morbidity, cancer, and chronic disease. OBJECTIVE: This study aimed to examine the association between female infertility and all-cause mortality. STUDY DESIGN: This retrospective analysis compared 72,786 women with infertility, identified in the Optum Clinformatics Datamart from 2003 to 2019 by infertility diagnosis, testing, and treatment codes, with 3,845,790 women without infertility seeking routine gynecologic care. The baseline comorbidities were assessed using the presence of ≥1 metabolic syndrome diagnoses and the Charlson Comorbidity Index. The primary outcome, which was all-cause mortality, was identified by linkage to the Social Security Administration Death Master File outcomes and medical claims. The association between infertility and mortality was examined using a Cox proportional hazard regression by adjusting for age, hypertension, hyperlipidemia, type II diabetes, year of evaluation, smoking, number of visits per year, nulliparity, obesity, region of the country, and race. RESULTS: Among 16,473,458 person-years of follow-ups, 13,934 women died. Women with infertility had a 32% higher relative risk for death from any cause (0.42% vs 0.35%, adjusted hazard ratio, 1.32; 95% confidence interval, 1.18-1.48) than women without infertility. The mean follow-up time per patient was 4.0±3.7 years vs 4.2±3.8 years for women with and without infertility, respectively. When stratified by age of <35 or ≥35 years or baseline medical comorbidity, the association between infertility and mortality remained. Women with infertility who delivered a child during the follow-up period faced a similar increased risk for mortality than the overall infertile group. Finally, receiving fertility treatment was not associated with a higher risk for death than receiving an infertility diagnosis or testing alone. CONCLUSION: Although the absolute risk for death was low in both groups, women with infertility faced a higher relative risk for mortality than women without infertility. The association remained across all age, race and ethnicity groups, morbidities, and delivery strata. Importantly, infertility treatment was not associated with an increased risk for death. These findings reinforce the disease burden associated with infertility and its potential for long-term sequelae.

Direct Methotrexate Injection into the Gestational Sac for Nontubal Ectopic Pregnancy: A Review of Efficacy and Outcomes from a Single Institution.

STUDY OBJECTIVE: To evaluate the efficacy of nontubal ectopic pregnancy (NTEP) management with direct methotrexate (MTX) injection into the gestational sac. DESIGN: A retrospective chart review. SETTING: A tertiary academic and teaching hospital. PATIENTS: All cases of confirmed NTEP were retrospectively identified from 2012 to 2017. INTERVENTIONS: Ultrasound-guided direct injection of MTX into the fetal pole and surrounding gestational sac and a single dose of systemic MTX with or without fetal intracardiac injection of potassium chloride. MEASUREMENTS AND MAIN RESULTS: Treatment failure, complications from treatment, operating time, and days to negative serum human chorionic gonadotropin (hCG) after treatment were measured. Fourteen women (age 34 ± 5.2 years) with NTEP underwent direct MTX injection (cesarean scar, n = 4; interstitial, n = 6; cervical, n = 4). The mean estimated gestational age was 49 ± 11, CI (43, 56 days). One patient required laparoscopic intervention with a failure rate of 1 of 14 (a double interstitial, heterotopic pregnancy). There were no other major complications. The time in the operating room was similar for all NTEP types. The average time to negative serum hCG was not different for cesarean scar (84.5 ± 36 days), cervical pregnancies (70.5 ± 19 days), or interstitial pregnancies (45.3 ± 38 days, p = .15). CONCLUSION: Direct MTX injection into the gestational sac for NTEP treatment is safe and effective. The failure rate of 7% is considerably lower than what was previously reported for a failure of systemic MTX in similar cases (25%). Resolution of serum hCG after treatment can be quite prolonged even in uncomplicated cases.

Utility of Repeat Uterine Cavity Evaluation in the Infertility Workup.

Background: Uterine cavity abnormalities contribute to infertility. The purpose of this study was to evaluate the incidence, recurrence rates, and risk factors for uterine cavity abnormalities in women undergoing infertility workup and treatment, focusing on the utility of routinely repeated imaging. Methods: Retrospective cohort study at single academic medical center of 833 infertile women who had uterine cavity evaluations performed at least 9 months apart. Results: Of 833 eligible patients, 664 (79.7%) had normal initial imaging and 169 (20.3%) had abnormal initial imaging. Among the former, 10% had abnormal uterine cavity on repeat saline infusion sonohysterography (SIS); among the latter, 32% had abnormal repeat SIS [Chi-square p < 0.0001, risk ratio 2.30 (95% confidence interval 1.85-2.86)]. On average, 23.1 ± 13.6 months passed between studies. Regardless of initial imaging findings, women with abnormal repeat SIS were older than those with normal repeat SIS, with no difference in time elapsed between studies. There were no associations between repeat imaging outcomes and body mass index, uterine instrumentation, number of treatment cycles, or maximum peak estradiol levels in a single cycle between studies. There was no difference in live birth rate among cycles started within 1 year after repeat SIS across groups. Conclusions: Uterine cavity abnormalities were found in 10% of patients on repeat imaging despite initially normal testing. No risk factors for cavity abnormality on repeat imaging were identified besides age and prior abnormality. It would be prudent to continue performing routine repeat uterine cavity evaluation for women undergoing fertility treatment, particularly if corrective measures had been taken in the past.

Development and validation of a risk prediction index for severe maternal morbidity based on preconception comorbidities among infertile patients.

OBJECTIVE: To develop and validate a preconception risk prediction index for severe maternal morbidity (SMM), defined by the Centers for Disease Control and Prevention as indicators of a life-threatening complication, among infertile patients. DESIGN: Retrospective analysis of live births and stillbirths from 2007 to 2017 among infertile women. SETTING: National commercial claims database. PATIENT(S): Infertile women identified on the basis of diagnosis, testing, or treatment codes. INTERVENTION(S): None. MAIN OUTCOME MEASURE(S): The primary outcome was SMM, identified as any indicator from the Centers for Disease Control and Prevention Index except blood transfusion alone, which was found to overestimate cases. Twenty preconception comorbidities associated with a risk of SMM were selected from prior literature. Targeted ensemble learning methods were used to rank the importance of comorbidities as potential risk factors for SMM. The independent strength of the association between each comorbidity and SMM was then used to define each comorbidity's risk score. RESULT(S): Among 94,097 infertile women with a delivery, 2.3% (n = 2,181) experienced an SMM event. The highest risk of SMM was conferred by pulmonary hypertension, hematologic disorders, renal disease, and cardiac disease. Associated significant risks were lowest for substance abuse disorders, prior cesarean section, age ≥40 years, gastrointestinal disease, anemia, mental health disorders, and asthma. The receiver operating characteristic area under the curve for the developed comorbidity score was 0.66. Calibration plots showed good concordance between the predicted and actual risk of SMM. CONCLUSION(S): We developed and validated an index to predict the probability of SMM on the basis of preconception comorbidities in patients with infertility. This tool may inform preconception counseling of infertile women and support maternal health research initiatives.

Improving the fellowship interview experience for reproductive endocrinology and infertility candidates: a survey.

OBJECTIVE: To collect data on the current reproductive endocrinology and infertility (REI) fellowship interview process so that it may be improved in the future. DESIGN: Web-based cross-sectional survey. In addition, fellowship program directors and coordinators were contacted by e-mail. SETTING: Survey data were collected after completion of the 2018 REI fellowship interview season. PATIENTS: Not applicable. INTERVENTIONS: None. MAIN OUTCOME MEASURES: Number of days used for interviews, missed opportunities to interview, frequency of travel to the same city, average money spent, recommendations for how the interview process could be improved. RESULTS: There were 44 survey respondents. The mean number of interviews attended was 12.6 (range, 1-22). On average 13.4 (0-30) days off work were used to interview. About 68.1% (n = 30) missed an opportunity to interview at a program they were interested in. The most common reasons were the interview date was the same day as another interview, could not attend due to geographic location, and cost was too high. About 72% (n = 31) traveled to the same city more than once for an interview. The average cost per interview was $478 (range, $200-$1,000) and average cost per interview season was $5,660 (range, $900-$15,000). Fellowship program data were available from 43 of 48 programs contacted. The number of dates that had conflicting interviews scheduled were 26. CONCLUSIONS: These data highlight the need to coordinate the REI fellowship recruitment process between programs to reduce conflicting interview dates and mitigate costs to applicants. Based on these results, a concrete action plan is presented.

Balancing the professional and personal.

OBJECTIVE: To review the common roles that physicians pursue away from work and identify related challenges and potential solutions, so that individuals can develop a personalized plan for success in each of the areas. DESIGN: Literature review. SETTING: University-based and university-affiliated medical centers. PATIENT(S): No subjects were involved in this literature review. INTERVENTION(S): Literature searches in Entrez PubMed and the following Websites: http://www.apgo.org, http://www.psychiatrictimes.com, as well as other data sources. MAIN OUTCOME MEASURE(S): Results of physician surveys and summaries of strategies for achieving work-personal life balance. RESULT(S): According to surveys of physicians in various specialties, a majority of physicians have high levels of job, marital, and parental satisfaction. However, professional and personal challenges faced by physicians include struggle with time management, lack of mentorship, and difficulty maintaining intimate relationships. Multiple potentially effective strategies have been described in the literature, including exerting control over hours worked, taking a long view of life that acknowledges the need for changing priorities over time, developing communication skills, seeking counseling services if needed that focus on physician relationships, and simplifying home life whenever possible. CONCLUSION(S): Although there are unique challenges in being a physician, partner, and parent, many of the professional challenges faced by physicians are common to many adults in the United States. Self-assessment may help individuals to clarify priorities and develop strategies that can lead to improved personal satisfaction.

Economics may not explain Hispanic underutilization of assisted reproductive technology services.

In a lower cost, equal-access-to-care setting, Hispanic use of assisted reproductive technology was less than half of what would have been expected based on patient demographics. Despite this use disparity, there were no significant differences between Hispanic and Caucasian women with regard to infertility diagnoses, assisted reproductive technology cycle parameters, clinical pregnancy rates, live birth rates, spontaneous abortion rates, and implantation rates.

Assessment of resident competency in the performance of sonohysterography: does the level of training impact the accuracy?

OBJECTIVE: The objective of this study was to examine the true-positive rates by level of training of the operator and to determine whether the accuracy of the procedure differed by the level of education after formalized training. STUDY DESIGN: This was a retrospective analysis. The records of patients who underwent surgery for the indication of an abnormal saline sonohysterography were reviewed from January 2001 to April 2003 (n=73 patients). The nature of the saline sonohysterography abnormality, the intraoperative findings, and the level of training of the provider were recorded. Findings at saline sonohysterography were compared with findings at hysteroscopy or surgery. Statistical significance was determined by chi(2) test. RESULTS: The overall true-positive rate was 86.3% (63/73 patients). The true-positive rates for nurse practitioners, second- and fourth-year residents, and fellows were 84%, 80%, 90%, and 89%, respectively. There was no significant difference among providers (P=.96). CONCLUSION: The true-positive rates for saline hysterography were comparable among different provider levels.