Trophectoderm grade as a predictor of beta human-chorionic gonadotropin rise in early pregnancy.

PURPOSE: To evaluate the association, if any, between the grade of the trophectoderm (TE) and the rate at which ß-human-chorionic gonadotropin (ß-HCG) rises in early pregnancy. METHODS: This is a retrospective cohort study including 1116 singleton clinical pregnancies resulting from in vitro fertilization with single day 5 blastocyst transfer at an academic fertility center. TE quality was assessed by trained embryologists employing standard criteria. Three groups were formed based on the TE grade: grade A (n = 358), grade B (n = 628), and grade C (n = 130). Main outcome measure was the rise (%) in serum levels of ß-HCG (days 12 to 14 post embryo transfer), using the following formula [(ß-HCG D14 - ß-HCG D12) * 100/ß-HCG D12]. RESULTS: Fresh embryo transfers accounted for 64.1% of the population. Overall, in adjusted models there were no significant differences in the ß-HCG% rise when comparing the TE grade C group to TE grade A [adjß (95%CI): 10.09 (- 0.05, 20.22)] or when comparing TE grade Β group to TE grade A [4.46 (- 2.97, 11.88)]. When the analysis was restricted to fresh embryo transfers, significant differences were observed in the % rise of ß-HCG when comparing the TE grade C group to TE grade A [adjß (95%CI): 21.71 (5.67, 37.74)], but not when comparing the TE grade B group to TE grade A [2.68 (- 5.59, 10.95)]. In frozen transfers, there were no significant differences. CONCLUSION: TE grade appears to impact early pregnancy serum ß-HCG levels in the setting of a fresh day 5 embryo transfer, even after adjusting for potential confounders.

IVF outcomes following ICSI cycles using testicular sperm in obstructive (OA) vs. non-obstructive azoospermia (NOA) and the impact of maternal and paternal age: a SART CORS data registry.

PURPOSE: To assess the differences in IVF outcomes between couples with obstructive azoospermia (OA), non-obstructive azoospermia (NOA), and male factor (MF). METHODS: Using the SART CORS data from 2016 to 2017, we included all initial autologous cycles with a diagnosis of male factor with ejaculated and surgically obtained sperm. We analyzed 71,121 cycles, including 3467 with a diagnosis of azoospermia and 67,654 with other non-azoospermic MF. Using a multivariate binomial regression, we estimated adjusted risk ratios comparing outcomes for ICSI cycles using surgically acquired (OA and NOA) versus ejaculated sperm (MF). Outcomes reported per initial cycle included clinical pregnancy, live birth, biochemical pregnancy, and miscarriage. Outcomes reported per singleton pregnancy included full-term delivery (≥ 37 weeks), normal birth weight (≥ 2500 g), and delivery method. RESULTS: After frozen embryo transfers (FET), patients with NOA had 7% higher odds of live birth compared to MF (aOR 1.23 (0.94-1.74)), and those with OA had 2.6% lower chance of live birth compared to MF (aOR 0.73 (95%CI 0.5-1.05)). After fresh ET, patients with NOA had 5% higher chance of live birth (aOR 1.11 (0.9-1.36)), and those with OA had a 2.5% higher chance of live birth (aOR 1.10 (95%CI 0.89-1.34)) compared to MF. All three subgroups had lower fresh live birth rates (LBR) compared to FETs. CONCLUSION: Couples with either NOA or OA have overall comparable ART and perinatal outcomes to couples with MF, and their success is primarily dependent on both patient's and partner's age.

Ovarian response to intraovarian platelet-rich plasma (PRP) administration: hypotheses and potential mechanisms of action.

PURPOSE: Platelet-rich plasma (PRP) therapy has been used as an adjunct to fertility treatments in women with very low ovarian reserve and premature ovarian insufficiency. Recent literature in both humans and animals suggest that intraovarian PRP administration in the setting of poor ovarian reserve may help ovarian function and increase the chances of pregnancy. METHODS: A comprehensive literature search through PubMed, MEDLINE databases, and recent abstracts published at relevant society meetings was performed and resulted in 25 articles and 2 abstracts published that studied effect of PRP on the ovaries for the purpose of reproduction. RESULTS: This review article presents all the data published to date pertaining to intraovarian PRP injection and pregnancy, both naturally and after in vitro fertilization. It also presents the most recent data on the use of ovarian PRP in in vitro and animal model studies highlighting the possible mechanisms by which PRP could impact ovarian function. CONCLUSIONS: Even though recent commentaries questioned the use of PRP as an "add-on" therapy in fertility treatment because it has not been thoroughly studied, the recent basic science studies presented here could increase awareness for considering more serious research into the efficacy of PRP as an adjunct for women with poor ovarian reserve, premature ovarian insufficiency, and even early menopause who are trying to conceive using their own oocytes. Given its low-risk profile, the hypothetical benefit of PRP treatment needs to be studied with larger randomized controlled trials.

Assessment of uterine receptivity by endometrial and sub-endometrial blood flow using SlowflowHD in hormone prepared frozen embryo transfer cycles: a pilot study.

PURPOSE: Utilizing SlowflowHD as a measurement of endometrial and sub-endometrial blood flow in women with infertility undergoing frozen embryo transfer (FET) cycles and correlation with pregnancy outcomes. METHODS: A prospective pilot study of 99 women undergoing hormone replacement FET cycles. Ultrasounds were performed with Voluson E8 at 3-time points: day 15, day of transfer, and 11 days post transfer (T + 11). SlowflowHD Doppler blood flow indices in the endometrium and sub-endometrium were compared in women who achieved pregnancy with those who did not. RESULTS: Using SlowflowHD, both pregnant and non-pregnant women had similar trends with decreased endometrial blood flow day of transfer compared with day 15. However, there was a borderline significantly lower mean percentage decrease of endometrial blood flow in women achieving a pregnancy (28.3% vs 42.9%). Significantly higher numbers of pregnant women had a 20% or less decrease in blood flow (21 vs 9) with increases in mean percentage blood flow on T + 11 (pregnant 39.59% vs non-pregnant 25.20%). The RI and S/D ratio in the spiral arteries was also significantly higher on transfer day in women who had a live birth RI (0.68 vs 0.65) and S/D (3.91 vs 3.17). CONCLUSION: There are blood flow changes both in pregnant and non-pregnant patients with decreases in blood flow after progesterone replacement. Pregnancy and live births were associated with a lower mean percentage drop in blood flow from day 15 to the day of transfer and elevated RI and S/D ratio on transfer day.

To curette or not to curette; efficiency of oocyte retrieval technique.

PURPOSE: Follicular curetting is the gentle and rapidly rotating movement of the aspiration needle in a clockwise and counterclockwise fashion. The aim of our study is to assess this retrieval technique comparing cycle and pregnancy outcomes between curetting and non-curetting. METHODS: This was a retrospective review of 817 patients that underwent oocyte retrieval at our fertility center from January 1st, 2016 until August 31st, 2019. All patients enrolled in the study underwent standard ovarian stimulation protocols. Three physicians routinely utilized follicle curetting during oocyte retrieval, while a fourth physician did not curette. Retrievals and embryo transfers were performed based on a rotating physician schedule. RESULTS: Retrievals that were performed using a curetting technique had a significantly higher number of total oocytes retrieved 12.4 ± 8.1 vs 10.7 ± 7.5 (p = 0.01), and number of M2 oocytes retrieved 8.1 ± 6.4 vs 6.9 ± 6.0 (p = 0.03), resulting in an increased M2 oocyte yield 63.7% ± 41.3 vs 50.9% ± 30.6 (p = 0.0001). These patients also had a significant increase in clinical pregnancy rate per retrieval 55 vs 41% (p = 0.0016), live birth rate per retrieval 42 vs 34% (p = 0.04) and with no significant difference in multiple gestations or OHSS. CONCLUSIONS: A significant improvement in clinical pregnancy rates and live birth per retrieval was detected in patients undergoing curetting. These patients had more embryos frozen, leading to more transfers and more successful pregnancies.

A Case of Asthenozoospermia Following COVID-19 Infection.

PURPOSE: Studies pertaining to the effect of COVID-19 infection on male fertility are scarce. This case report describes a case of transient asthenozoospermia, absence of sperm motility, following a moderately severe COVID-19 infection. CASE: A couple presenting for infertility treatment due to low ovarian reserve presented for their second intrauterine insemination (IUI). Their first IUI was performed 1 month earlier when the semen parameters were normal. A couple of weeks before the second IUI, the unvaccinated 48-year-old male partner contracted COVID-19 and was admitted to the hospital for several days. He received IV Remdesivir and continuous oxygen by nasal cannula. His hospitalization did not require intubation or intensive care unit admission. He was discharged after 12 days of hospitalization without home oxygen treatment. On the day of the second IUI, the semen analysis showed a normal sperm count with 0% motility. Three months following his COVID-19 diagnosis, a repeat semen analysis showed restored normal parameters with more than 40% motility. CONCLUSION: This aim of this report is to increase awareness that moderate COVID-19 requiring hospitalization could affect, though temporarily, sperm motility and should be considered in the differential diagnosis when male infertility is encountered.

Cryopreservation Does Not Affect the Clinical Pregnancy Rate of Blastocysts Derived from Vitrified Oocytes.

Vitrified, or "frozen", donor eggs can either be fertilized and cultured for fresh transfer (group 1), or fertilized and cryopreserved for transfer in a "frozen embryo transfer" cycle (group 2). This study compared the pregnancy rates between the two groups. Frozen donor egg cycles (N = 1213) were analyzed at the World Egg Bank. The outcome studied was clinical pregnancy rate. Cycles included only single embryo transfers (ET) without preimplantation genetic testing (PGT). A total of 600 cycles met the inclusion criteria. Group 1 included 409 cycles and group 2 had 191 cycles. There was no statistical significance in clinical pregnancy rate between the two groups (38.63% vs 32.46%, p = 0.14). Mean embryo age was higher in group 2 (5.1 vs. 5.4 days, p < 0.01). The compounding effect of vitrification when applied to two distinct stages (oocyte and embryo), has not been studied. When comparing the two groups, we found no difference in pregnancy rate. However, there was a trend towards fewer pregnancies in group 2. A larger study should be done to determine the validity of this result (Ramadan et al. in Fertil Steril, 2020).

Knowledge and attitudes regarding elective oocyte cryopreservation in undergraduate and medical students.

BACKGROUND: To assess knowledge and attitudes regarding elective oocyte cryopreservation among female undergraduate students (UG) and medical students (MS) in Eastern Virginia. METHODS: An anonymous cross-sectional study surveying female UG at a local university and MS at our academic medical center in May of 2017. The survey contained questions on demographic information, interest in fertility preservation, and knowledge about age related changes in fertility. RESULTS: There were 74 of 102 female UG and 95 of 117 female MS who responded, for a response rate of 73 and 81% respectively. UG were significantly younger than MS (21.4 vs 26.8, p < 0.001). Further, UG generally planned on conceiving at a younger age than MS (age 26-30 vs 31-35), and favored younger ages to consider oocyte cryopreservation (age 26-30 vs 31-35). Only a minority of both UG and MS were willing to undergo egg freezing at the current price of approximately $10,000 (15% vs 26% respectively, p = 0.044). Moreover, 73% of students overall responded that they would be more likely to freeze oocytes if their employer paid. Notably, both UG and MS underestimated age of fertility decline. CONCLUSION: Both UG and MS revealed a need for education on age-related changes in fertility. Most UG and MS would not undergo elective oocyte cryopreservation at the present cost but would consider it at a lower cost.

Accuracy of Pelvic Ultrasound in Diagnosing Adnexal Torsion.

Ovarian/adnexal torsion is a rather frequent occurrence in women of reproductive age group worldwide. Etiologies are quite diverse with ovarian lesions and corpus luteal cysts being the most two common. Pelvic or intravaginal ultrasound remains the first-line imaging modality used for diagnosis and evaluation of suspected ovarian/adnexal torsion. In this study, we have adopted a case-based statistical analysis to identify important sonographic markers and further evaluated their contribution in identifying ovarian torsion. Our study successfully determined the important sonographic markers. Our observation and analysis suggest that ovarian enlargement is the most sensitive marker. Ovarian edema was found to be the most specific marker to identify the ovarian torsion with higher level of accuracy and confidence. This pioneer study will provide valuable information and direction to the medical practitioners and radiologists for better diagnosis. Further studies with large sample size will help in establishing our findings universally.

Angiogenic Factor Estimation as a Warning Sign of Preeclampsia-Related Peripartum Morbidity Among Hospitalized Patients.

Preeclampsia-related morbidity and mortality is rising predominantly because of delayed identification of patients at risk for preeclampsia with severe features and associated complications. This study explored the association between angiogenic markers (sFlt1 [soluble fms-like tyrosine kinase-1]) and PlGF [placental growth factor]) and preeclampsia-related peripartum complications. Normotensive women or those with hypertensive disorders of pregnancy were enrolled. Blood samples were collected within 96 hours before delivery, and angiogenic markers were measured on an automated platform. Our study included 681 women, 375 of which had hypertensive disorders. Of these, 127 (33.9%) had severe preeclampsia, and 71.4% were black. Compared with normotensive women, women with severe preeclampsia had higher levels of sFlt1 (9372.5 versus 2857.0 pg/mL; P<0.0001), lower PlGF (51.0 versus 212.0 pg/mL; P<0.0001), and a high sFlt1/PlGF (212.0 versus 14.0; all P<0.0001). A similar trend in sFlt1, PlGF, and sFlt1/PlGF was found in those women with complications secondary to preeclampsia (all P<0.001). The highest tertile of sFlt1/PlGF was strongly associated with severe preeclampsia in a multivariable analysis. Among patients with a hypertensive disorder of pregnancy, 340 (90.7%) developed postpartum hypertension, of which 50.4% had mild, and 40.3% had severe postpartum hypertension. The sFlt1/PlGF ratio was significantly higher for severe and mild postpartum hypertension compared with women with normal postpartum blood pressures (73.5, 46.0, and 13.0, respectively; P values<0.0001). Furthermore, the highest tertile of antepartum sFlt1/PlGF was associated with postpartum hypertension ( P=0.004). This study demonstrates a significant association between an abnormal angiogenic profile before delivery and severe preeclampsia and peripartum complications.

Activin A and Late Postpartum Cardiac Dysfunction Among Women With Hypertensive Disorders of Pregnancy.

Women with hypertensive disorders of pregnancy have an increased risk of subsequent heart failure and cardiovascular disease when compared with women with normotensive pregnancies. Although the mechanisms underlying these findings are unclear, elevated levels of the biomarker activin A are associated with myocardial dysfunction and may have predictive value. We hypothesized that elevated levels of antepartum activin A levels would correlate with postpartum cardiac dysfunction in women with hypertensive disorders of pregnancy. We prospectively studied 85 women to determine whether increased antepartum activin A levels were associated with cardiac dysfunction at 1 year postpartum as measured by global longitudinal strain. Thirty-two patients were diagnosed with preeclampsia, 28 were diagnosed with gestational or chronic hypertension, and the remainder were nonhypertensive controls. Activin A levels were measured with ELISA both in the third antepartum trimester and at 1 year postpartum. Comprehensive echocardiograms including measurement of global longitudinal strain were also performed at enrollment and at 1 year postpartum. Antepartum activin A levels correlated with worsening antepartum global longitudinal strain (r=0.70; P=0.0001). Across the entire cohort, elevated antepartum activin A levels were associated with the development of abnormal global longitudinal strain at 1 year (C statistic 0.74; P=0.004). This association remained significant after multivariable adjustment for clinically relevant confounders (C statistic 0.93; P=0.01). Postpartum activin A levels also correlated with increasing left ventricular mass index (P=0.02), increasing mean arterial pressures (P=0.02), and decreasing E' values (P=0.01). Activin A may be a useful tool for identifying and monitoring patients at risk for postpartum development of cardiovascular disease.

Prevalence, risk factors and associated complications of postpartum hypertension in rural Haiti.

BACKGROUND: The prevalence of hypertensive disorders during pregnancy is high in developing countries such as Haiti, however little is known about postpartum hypertension (PPHTN). METHODS: This is a prospective study done at Hospital Albert Schweitzer in rural Haiti among pregnant women age 18 or older who were admitted for labor. Blood pressures were collected before and after delivery and medical charts were reviewed to gather delivery characteristics and fetal/neonatal outcomes. Differences between groups are presented based on postpartum blood pressures (BP) as mild PPHTN (systolic BP≥140 or diastolic BP≥90) and severe PPHTN (systolic BP≥160 or diastolic BP≥110). RESULTS: Of 175 women, the prevalence of PPHTN during the two-month study period was 57.1% (97/172) and included 56 parturients with mild and 41 with severe PPHTN. Severe PPHTN was associated with a higher proportion of complications including abruption (14.6%), fetal (14.6%) and neonatal death (7.3%). Thirty-nine (69.6%) patients with mild PPHTN and 9 (21.9%) patients with severe PPHTN did not receive any antihypertensive medications postpartum. Patients with severe PPHTN had prolonged hospitalization compared to the normal group (3.5 vs. 2.0days, p=0.0003). There was a strong correlation between antepartum and postpartum systolic and diastolic BP's (r=0.62 and 0.54, p<0.0001, respectively). CONCLUSION: In this study, we identified a high prevalence of PPHTN in rural Haiti. Severe PPHTN was associated with adverse outcomes and treatment is not universal. This data is a starting point to develop region-specific protocols to treat and control PPHTN.

Abnormal mid-trimester cardiac strain in women with chronic hypertension predates superimposed preeclampsia.

BACKGROUND: Chronic hypertension (cHTN) affects 7% of all pregnancies. We hypothesized that cHTN during pregnancy would be associated with abnormal myocardial strain patterns and adverse perinatal outcomes. METHODS: This was a retrospective cohort study of patients seen in a high-risk obstetrics clinic with cHTN. Parturients with a singleton pregnancy who had undergone an echocardiogram as part of routine clinical care were eligible. Clinical and demographic information was collected from medical records. Global peak longitudinal strain (GLS) was measured using automated software from stored echocardiographic images. RESULTS: 60 patients were included in this analysis, of which 48 (80.0%) were African American. The median BMI was 40.6, age was 34 years, and the gestational age was 20.4 weeks at the time of the echo and 37.9 weeks at delivery. Thirty-four patients (56.7%) demonstrated abnormal strain, defined as a GLS <= -19%. Patients with abnormal strain were similar in age and BMI to patients with normal cardiac function. When compared to women with normal strain, those with abnormal strain had lower stroke volume (69.0 ml vs 81.5 ml; p = .001) and ejection fraction (49.6% vs 57.5%; p < .0001). Rates of superimposed preeclampsia were higher (38.2% vs 11.5%, p-value = .02) and a higher proportion of patients in the abnormal strain group delivered before 37 weeks (44.1% vs 19.2%; p = .04). CONCLUSION: In a population of parturients with cHTN, we found that more than one-half demonstrated subclinical abnormal cardiac function. The presence of abnormal cardiac strain predates superimposed preeclampsia and preterm delivery. Further studies are needed to validate these findings.

Myocardial performance index in hypertensive disorders of pregnancy: The relationship between blood pressures and angiogenic factors.

OBJECTIVE: To study the association between cardiac function measured by myocardial performance index (MPI), blood pressures and angiogenic factors measured at the time of echocardiography in patients with and without hypertensive disorders of pregnancy (HDP). METHODS: We prospectively studied 189 pregnant women and evaluated whether changes in cardiac function observed on echocardiography were correlated with higher blood pressures and whether higher blood pressures were associated with antiangiogenic proteins (soluble fms-like tyrosine kinase, sFlt1; soluble endoglin, sEng). Comprehensive echocardiograms, including measurement of MPI, were performed on all patients. sFlt1 and sEng levels were measured using enzyme-linked immunosorbent assay. RESULTS: Overall, 189 patients were divided into tertiles based on mean arterial pressure (MAP). The MPI was worst in tertile 3 (0.50 ± 0.15) compared to tertile 1 (0.42 ± 0.10), p = 0.0004. sFlt1 (pg/ml) and sEng (ng/ml) were highest in tertile 3 compared to tertile 1: 15055.37 vs. 1623.01 and 33.06 vs. 8.15, respectively, with p-value <0.001. In crude multivariate regression analysis, MAP was positively correlated with MPI (r = 0.32, p < 0.001), GLS (r = 0.54, p < 0.001), sFlt1 (r = 0.60, p < 0.001) and sEng (r = 0.61, p < 0.001). After adjustment for confounders, these relationships persisted between MAP and MPI (r = 0.31, p = 0.0003), GLS (r = 0.46, p < 0.001), sFlt1 (r = 0.56, p < 0.001) and sEng (r = 0.58, p < 0.001). CONCLUSION: Mean arterial pressure correlates with worsening cardiac function as measured by MPI and serum levels of angiogenic factors. Further studies are needed to evaluate whether a reduction in blood pressure will reverse changes in MPI or reduce levels of angiogenic proteins seen among women with HDP.

Cardiogenic shock in pregnancy: Analysis from the National Inpatient Sample.

OBJECTIVE: Cardiogenic shock (CS) may occur during pregnancy and dramatically worsen peripartum outcomes. METHODS: We analyzed the National Inpatient Sample from 2002 to 2013 to describe the incidence of, risk factors for and outcomes of CS during pregnancy. RESULTS: Of the 53,794,192 hospitalizations analyzed, 2044 were complicated by CS. The mortality rate in peripartum women with CS was 18.81% versus 0.02% without. It occurs more often during postpartum (58.83%) as compared with delivery (23.47%) or antepartum (17.70%) hospitalizations. Factors associated with CS -related death included cardiac arrest, renal failure, and sepsis. CONCLUSIONS: CS during pregnancy occurs more commonly in the postpartum period and is associated with a high mortality.