Repeated doses of GnRH antagonist at midcycle in artificial frozen embryo transfer cycles may not affect pregnancy outcomes.

No significant differences in outcomes have been found between protocols of endometrial preparation for frozen embryo transfer (FET), though gonadotropin releasing hormone (GnRH) antagonists may have detrimental effects on the endometrium. We conducted a retrospective cohort noninferiority study at a single academic center of women receiving multiple doses of mid-cycle GnRH antagonist (GAnt) to those receiving GnRH agonist (GAg) to determine if there are detrimental effects of GnRH antagonists. 1047 FET cycles were identified, detailed data was available in 840 cycles: 610 GAg and 230 GAnt cycles. Patients undergoing GAnt cycles were older (40 ± 6.6 versus 37 ± 5.1 years, p < 0.0001), more often used donor oocyte (36% versus 18.6%, p < 0.0001), and more often exhibited diminished ovarian reserve (49.1% versus 36.2%, p = 0.0009). Clinical pregnancy rates (CPRs) per transfer and implantation rates (IRs) were similar for GAnt and GAg cycles. There was a trend for higher pregnancy and IRs with GAg cycles in younger women (CPR 38.8% versus 26.7%, p = 0.16; IR 36% versus 23.3%, p = 0.07). Stratifying by diagnosis, CPR and IR were similar in GAnt and GAg cycles. A GAnt protocol of endometrial preparation for FET is not inferior to a GAg protocol regardless of patient age, use of donor oocyte, or infertility diagnosis.

Survey of HIV care providers on management of HIV serodiscordant couples - assessment of attitudes, knowledge, and practices.

Human immunodeficiency virus (HIV) serodiscordant couples are at risk of sexual transmission of HIV between the infected and uninfected partner. We assessed New York area care providers for people living with HIV regarding attitudes, knowledge, and practice patterns toward fertility and conception in serodiscordant couples. Data were collected via a survey distributed in October 2013. Seventeen percent of respondents reported prescribing antiretroviral preexposure prophylaxis (PrEP) for a woman in a serodiscordant couple, and 38% percent of respondents reported having counseled serodiscordant couples on timed, unprotected intercourse without PrEP. Respondents who reported being "very" familiar with the data on HIV transmission in serodiscordant couples were more likely to report counseling their patients in timed, unprotected intercourse compared with those who reported less familiarity with the data (41% vs. 8%, p = 0.001). Although only 20% reported being "very" or "somewhat" familiar with the data on the safety of sperm washing with intrauterine insemination, those who did were more likely to have reported referring a patient for assisted reproductive technology (61% vs. 32%, p = 0.006). Effective patient counseling and referral for appropriate reproductive options were associated with knowledge of the literature pertaining to these options. This emphasizes the need for further provider education on reproductive options and appropriate counseling for serodiscordant couples.

Hyperreactio luteinalis in pregnancy and hyperandrogenism: a case report.

BACKGROUND: Hyperreactio luteinalis in pregnancy is associated with theca lutein cysts (TLCs) and androgenization. CASE: A 24-year-old, primigravid woman was referred at 35 weeks' gestation for bilateral enlarged cystic ovaries. She showed signs of androgenization. On ultrasonogram the ovaries bore a spoke-wheel appearance. A nonvirilized female infant was subsequently delivered by cesarean section because of obstruction of the birth canal by a large impacted ovarian cyst. There was an initial delay in lactogenesis; however, it was well-established after regression of the TLC, by postpartum week 6. Signs ofandrogenization resolved and testosterone levels returned to normal by 3 months postpartum. CONCLUSION: Hyperreactio luteinalis is associated with TLC and maternal androgenization in the antepartum period and persists into the postpartum period with subsequent resolution. Aromatization of testosterone in hyperreactio luteinalis prevents fetal virilization, unlike that seen with masculinizing ovarian tumors. There is some evidence of genetic predisposition and a possibility for recurrence in future pregnancies.

Utility of Ovarian Reserve Screening with Anti-Müllerian Hormone for Reproductive Age Women Deferring Pregnancy.

BACKGROUND: Ovarian reserve (OR) testing with serum anti-Müllerian hormone (AMH) can provide information about a woman's fertility potential. The aim of this study was to assess interest and knowledge about OR testing and investigate the utility of measuring AMH in women of reproductive age deferring pregnancy. METHODS: Women ages 27-37 years currently delaying childbearing were invited to take a survey regarding attitudes and knowledge about OR testing before and after an AMH measurement with explanation of their results. RESULTS: Of 121 women who took the pre-test survey, 96% believed OR testing was beneficial. The median AMH of the 97 women who underwent testing was 3.3 ng/mL (IQR 1.9-5.4 ng/mL). Nineteen percent of women had AMH <10th percentile for age and 3% had an undetectable AMH. Although 83% of these women were using hormonal contraception, none had known risk factors for diminished ovarian reserve. Seventy-eight percent of women with low AMH levels for age planned to seek fertility preservation or pregnancy, while those with AMH levels within established age normograms were reassured. On the post-test survey, 100% reported benefit in knowing their AMH level. Follow-up testing, 6-8 months after the initial measurement, showed stable AMH levels for most participants. CONCLUSIONS: Women are interested in OR testing. Most women will be reassured by knowing their AMH level, whereas those with a lower AMH can be counseled on fertility preservation options or may attempt pregnancy earlier.

Use of anti-Müllerian hormone testing during ovarian reserve screening to identify women at risk of polycystic ovary syndrome.

OBJECTIVE: To assess the applicability of anti-Müllerian hormone (AMH) testing in the identification of women at risk for polycystic ovary syndrome (PCOS) when AMH is used in ovarian reserve screening in the general population. METHODS: A secondary analysis was undertaken of a large cross-sectional study. Women aged 27-37years, presently delaying childbearing but interested in future fertility, completed an online questionnaire to assess knowledge and attitudes about ovarian reserve testing, and underwent serum AMH testing between October 2014 and April 2015 in New York, NY, USA. For the secondary analysis, women considered to have elevated AMH levels (≥4.7ng/mL) were invited for physical examination and transvaginal ultrasonography. RESULTS: Among 97 women who underwent AMH testing, 32 (33.0%) had elevated AMH levels. Hyperandrogenism was reported by 8 (25.0%) women with elevated AMH and none with AMH concentrations lower than 4.7ng/mL (P<0.001). Irregular menstrual cycles before hormonal contraceptive use were reported by 16 (24.6%) of 65 women with AMH concentrations lower than 4.7ng/mL and 11 (34.4%) with elevated AMH (P=0.34). Of the 20 women with elevated AMH who returned for further evaluation, 16 (80.0%) had polycystic ovaries and 13 (65.0%) were diagnosed with PCOS (Rotterdam criteria). CONCLUSION: When AMH levels are used as a screening test for fertility, elevated concentrations can identify women at risk for PCOS.

Reproductive outcomes of HIV seropositive women treated by assisted reproduction.

BACKGROUND: Over one million Americans are infected with HIV, and approximately 300,000 are women. Overall health in HIV infected persons has improved, and many seropositive women desire children. This study describes the reproductive outcomes of HIV seropositive women treated by assisted reproduction at our center and compares their clinical results with age-matched HIV seronegative controls. METHODS: From January 1, 1998 to December 31, 2011, 36 HIV seropositive women received treatment with in vitro fertilization (IVF) at a single center. The mean age at start of fertility treatment was 37.7±4.8 years. At presentation, 92% of seropositive women were using antiretrovirals and all had undetectable viral loads at time of cycle initiation. Clinical outcomes of seropositive women were compared in a one-to-one ratio to those of randomly selected age-matched seronegative controls undergoing treatment for male factor infertility during the same time period. Comparisons were stratified by age--women less than 35 and greater than 35 years of age. RESULTS: Fifteen treatment cycles resulted in live births (21 infants born without HIV infection). HIV seropositive and seronegative women < 35 years of age had nearly identical IVF clinical outcome parameters, including clinical pregnancy rates and live birth rates. For women 35 years of age or older, baseline serum estradiol levels and live birth rates were significantly lower in HIV seropositive women. CONCLUSIONS: This study demonstrates that the presence of well-controlled HIV infection does not impair fertility treatment in women undergoing IVF. Virally infected women should be encouraged to seek treatment in appropriate cases.

The pathophysiology of ovarian hyperstimulation syndrome: an unrecognized compartment syndrome.

OBJECTIVE: To compare and contrast the pathophysiology of ovarian hyperstimualtion syndrome (OHSS) with known syndromes of increased intraabdominal pressure (IAP), and to explore the relationship of increased IAP with symptom severity in OHSS. DESIGN: Literature review. MAIN OUTCOME MEASURE(S): Correlation of OHSS symptoms with IAP; effects of paracentesis on IAP in patients with OHSS. SETTING: Academic Research Institution. INTERVENTION(S): None. RESULT(S): OHSS involves a rapid accumulation of volume (from 1.5-17 liters) in the peritoneal cavity that can lead to organ dysfunction, including respiratory impairment and oliguria. In published reports of 20 moderate-to-severe OHSS patients in whom IAP was measured, IAP was found to be elevated to a pathologic range. The increased IAP indicates that OHSS may be considered a compartment syndrome and meets criteria for abdominal compartment syndrome in advanced cases. For this reason, management of OHSS should include reduction of pressure by paracentesis to avoid morbidity and syndrome progression. In addition, measurement of IAP may help to classify the stage of OHSS. CONCLUSION(S): IAP was found to be elevated in the few cases of OHSS in which it was measured, substantiating the conclusion that OHSS may be considered a compartment syndrome. An understanding of the pathophysiology of increased intrabdominal pressure is useful in the management of OHSS.