High estradiol levels in fresh embryo transfer cycles are not associated with detrimental impact on birth outcomes.

PURPOSE: There is an unclear relationship between estradiol levels and fresh embryo transfer (ET) outcomes. We determined the relationship between estradiol on the day of trigger, in fresh ET cycles without premature progesterone elevation, and good birth outcomes (GBO). METHODS: We identified autologous fresh ET cycles from 2015 to 2021 at multiple clinics in the USA. Patients with recurrent pregnancy loss, uterine factor, and elevated progesterone on the day of trigger (progesterone > 2 ng/mL or 3-day area under the curve > 4.5 ng/mL) were excluded. The primary outcome was GBO (singleton, term, live birth with appropriate weight). Log-binomial generalized estimating equations determined the likelihood of outcomes. RESULTS: Of 17,608 fresh ET cycles, 5025 (29%) yielded GBO. Cycles with estradiol ≥ 4000 pg/mL had a greater likelihood of GBO compared to cycles < 1000 pg/mL (aRR = 1.32, 95% CI 1.13-1.54). Pairwise comparisons of estradiol between < 1000 pg/mL versus 1000-1999 pg/mL and 1000-1999 pg/mL versus 2000-2999 pg/mL revealed a higher likelihood of GBO with higher estradiol (aRR 0.83, 95% CI 0.73-0.95; aRR 0.91, 95% CI 0.85-0.97, respectively). Comparisons amongst more elevated estradiol levels revealed that the likelihood of GBO remained similar between groups (2000-2999 pg/mL versus 3000-3999 pg/mL, aRR 1.04, 95% CI 0.97-1.11; 3000-3999 pg/mL versus ≥ 4000 pg/mL, aRR 0.96, 95% CI 0.9-1.04). CONCLUSION: In fresh ET cycles, higher estradiol levels were associated with an increased prevalence of GBO until estradiol 2000-2999 pg/mL, thereafter plateauing. In fresh ET candidates, elevated estradiol levels should not preclude eligibility though premature progesterone rise, and risk of ovarian hyperstimulation syndrome must still be considered.

Fertility knowledge and views on egg freezing and family planning among surgical specialty trainees.

BACKGROUND: There are limited studies focusing on resident and fellow attitudes on family planning and egg freezing. Surgical training programs are often longer and more time consuming than other fields. It is important to understand how this training affects family planning decisions. OBJECTIVE: This study aimed to describe fertility knowledge and viewpoints on family planning among US residents or fellows. STUDY DESIGN: The Advocate Aurora Health Institutional Review Board approved this study on October 8, 2019 (IRB# AHC-7213-S5500413). A 32-question survey was emailed to trainees across US programs in a variety of specialties (obstetrics/gynecology; ophthalmology; otolaryngology; urology; and neurology, plastic, general, thoracic and orthopedic surgery) to assess fertility knowledge. Pearson chi square tests were conducted to investigate differences in fertility knowledge by groups of interest (trainee specialty, gender, trainee program type). Demographics and viewpoints on family planning and egg freezing are described. All analyses were performed using SAS, version 9.4. RESULTS: A total of 447 surveys were collected from October 2019 to January 2020. Participants included 309 residents, 94 fellows, and 44 with unknown status across the 9 specialties. Participants were mostly female (73%), aged 26 to 30 years (48%), White (69%), married (59%), and heterosexual (95%), with no children (72%). When asked at what age a woman's fertility slightly decreases, obstetrics/gynecology trainees had 39% less likelihood of answering correctly compared with non-obstetrics/gynecology respondents (P=.0207). Female respondents had 18% less likelihood of answering correctly relative to male respondents, and trainees in academic programs were 20% to 60% more likely to answer correctly relative to those in community programs, but these findings were not statistically significant. Interestingly, female respondents had 2.89 times increased odds of having 0 children (P<.0001), 0.42 times increased odds (ie, 58% decreased odds) of being married (P=.0003), and 1.33 times increased odds of postponing childbearing (P=.2438). CONCLUSION: This study found that despite their sex or focused training in reproductive endocrinology and infertility, female respondents and obstetrics/gynecology trainees were not more well-versed in basic female fertility knowledge than their counterparts. Furthermore, female respondents were less likely to have children or be married, and more likely to report postponing childbearing, highlighting differences in family planning by sex. Fertility-focused educational interventions for obstetrics/gynecology trainees are necessary. More research into barriers to family planning, particularly by sex, are also merited.

Endometrin as luteal phase support in assisted reproduction.

OBJECTIVE: To compare clinical pregnancy rate (PR) and live birth rate (LBR) between Endometrin monotherapy versus Endometrin and P in oil combination therapy in assisted reproductive technology (ART) cycles. DESIGN: Retrospective analysis. SETTING: Large private practice. PATIENT(S): Patients undergoing autologous fresh IVF cycles, autologous frozen ET cycles, and fresh oocyte donor cycles were included for analysis. INTERVENTION(S): Endometrin as a single agent for luteal support, Endometrin monotherapy or Endometrin with P in oil used at least once every 3 days for luteal support, Endometrin combination therapy. MAIN OUTCOME MEASURE(S): Clinical PR and LBR. RESULT(S): A total of 1,034 ART cycles were analyzed. Endometrin monotherapy was used in 694 of 1,034 (67%) cycles and Endometrin combination therapy was used in 340 of 1,034 (33%) cycles. In all fresh cycles, clinical PR was not significantly different (IVF autologous: Endometrin monotherapy 46.9% vs. Endometrin combination therapy 55.6%; donor oocyte endometrin monotherapy 45.2% vs. Endometrin combination therapy 52.0%). Frozen ET cycles had a significantly higher clinical PR and LBR with combination therapy group compared with monotherapy (clinical PR 47.9% vs. 23.5%; LBR 37.5% vs. 17.3%). CONCLUSION(S): Endometrin monotherapy was sufficient for the P component of luteal support and provided high PRs for fresh cycles in both autologous and donor oocyte cycles. Clinical PR and LBR in frozen ET cycles were significantly improved with the addition of IM P to Endometrin therapy. This may reflect the fact that lesser quality embryos are transferred in frozen ET cycles, and more intense P support is required for comparable PRs.

Adding human menopausal gonadotrophin to antagonist protocols - is there a benefit?

The objective of this retrospective analysis was to compare the clinical outcomes of recombinant FSH (r-FSH) with combination r-FSH plus human menopausal gonadotrophin (HMG) protocols in a large private practice using a single IVF laboratory, from 2001 to 2003. Patients underwent ovarian stimulation by standard gonadotrophin-releasing hormone (GnRH) antagonist protocol using r-FSH or combination r-FSH plus HMG. When two or more follicles had attained a minimum mean diameter of 20 mm, follicular triggering was achieved with either recombinant HCG (r-HCG; Ovidrel, 250 microg s.c.) or urinary HCG (u-HCG; 10,000 IU i.m.). The main outcome measures were number of oocytes retrieved and clinical pregnancy rate. There was a lower percentage of cancelled cycles and an increased number of oocytes retrieved, mature oocytes, oocytes that fertilized, embryo that cleaved and a tendency towards higher clinical pregnancy rates in patients treated with r-FSH alone compared with those treated with r-FSH plus HMG. Patients treated with r-FSH plus HMG had lower miscarriage rates and the live birth rate was similar in both treatment groups. In conclusion, irrespective of age, using a treatment regimen consisting of a combination of HMG plus r-FSH was not beneficial compared with r-FSH alone in patients using a GnRH antagonist protocol.

Laparoscopic appendectomy in an outpatient setting.

STUDY OBJECTIVE: To determine the ability to perform laparoscopic appendectomy on an outpatient basis. DESIGN: Prospective study (Canadian Task Force classification II-2). SETTING: University ambulatory surgery center. PATIENTS: Forty-two consecutive patients. INTERVENTION: Laparoscopic appendectomy. MEASUREMENTS AND MAIN RESULTS: After performing five laparoscopic appendectomies, three women required hospitalization. Thus a new multimodal protocol was implemented and admission and recovery times were monitored. After the new protocol was implemented, only 1 of 37 patients required hospitalization. Discharge times were similar to those for women undergoing gynecologic laparoscopy without appendectomy. CONCLUSION: With attention to surgical and anesthetic protocols, appendectomy can be performed at the time of gynecologic laparoscopy in an ambulatory setting without a significant delay in discharge.