Factors Associated with the Success of In Vitro Fertilization in Women with Inflammatory Bowel Disease.

BACKGROUND: It is unknown whether certain factors are associated with the success of in vitro fertilization (IVF) in women with inflammatory bowel disease (IBD). AIM: This study assessed whether certain characteristics are associated with greater success of live birth following IVF. METHODS: In a cohort study of 8684 women with IBD seen at two tertiary care centers, we identified 121 women with IBD who underwent IVF. We assessed the effect of numerous factors on likelihood of achieving live birth after IVF. RESULTS: Seventy-one patients with ulcerative colitis (UC) and 49 patients with Crohn's disease (CD) were analyzed. Patients with UC who achieved a live birth were younger (p = 0.03), had a shorter duration of disease (p = 0.01), and were more likely to be in remission (p = 0.03) versus those who did not achieve live birth. Patients with CD who achieved live birth were younger (p < 0.001), had lower body mass index (BMI) (p = 0.02), and had lower cycle day 3 follicle-stimulating hormone levels (p = 0.02). There was no difference in likelihood of achieving live birth among patients in remission and those with mild or unknown disease status (p = 0.69), though most CD patients (79.5 %) were in remission. Prior surgery was not associated with live birth in patients with UC (p = 0.31) or CD (p = 0.62). CONCLUSIONS: As in the general infertility population, younger patients and those with lower BMI were more likely to achieve live birth. History of surgery was not associated with live birth among IBD patients. This is important information for practitioners counseling IBD patients.

In Vitro Fertilization in Women With Inflammatory Bowel Disease Is as Successful as in Women From the General Infertility Population.

BACKGROUND & AIMS: Inflammatory bowel disease (IBD) affects women of reproductive age, so there are concerns about its effects on fertility. We investigated the success of in vitro fertilization (IVF) in patients with IBD compared with the general (non-IBD) IVF population. METHODS: We conducted a matched retrospective cohort study of female patients with IBD who underwent IVF from 1998 through 2011 at 2 tertiary care centers. Patients were matched 4:1 to those without IBD (controls). The primary outcome was the cumulative rate of live births after up to 6 cycles of IVF. Secondary outcomes included the proportion of patients who became pregnant and the rate of live births for each cycle. RESULTS: Forty-nine patients with Crohn's disease (CD), 71 patients with ulcerative colitis (UC), 1 patient with IBD-unclassified, and 470 controls underwent IVF during the study period. The cumulative rate of live births was 53% for controls, 69% for patients with UC (P = .08 compared with controls), and 57% for patients with CD (P = .87 compared with controls). The incidence of pregnancy after the first cycle of IVF was similar among controls (40.9%), patients with UC (49.3%; P = .18), and patients with CD (42.9%; P = .79). Similarly, the incidence of live births after the first cycle of IVF was similar among controls (30.2%), patients with UC (33.8%; P = .54), and patients with CD (30.6%; P = .95). CONCLUSIONS: Based on a matched cohort study, infertile women with IBD achieve a rate of live births after IVF that is comparable with those of infertile women without IBD.

In Vitro Fertilization Is Successful in Women With Ulcerative Colitis and Ileal Pouch Anal Anastomosis.

BACKGROUND: Women with ulcerative colitis (UC), who require ileal pouch anal anastomosis (IPAA), have up to a threefold increased incidence of infertility. To better counsel patients who require colectomy, we examined the success rates of in vitro fertilization (IVF) among women who have undergone IPAA. METHODS: This was a retrospective cohort study conducted at the Brigham and Women's Hospital and Beth Israel Deaconess Medical Center. Female patients with UC were identified via ICD-9 codes and cross-referenced with those presenting for IVF from 1998 through 2011. UC patients with IPAA were compared with the following two unexposed groups that underwent IVF: (1) patients with UC, who had not undergone IPAA, and (2) patients without inflammatory bowel disease (IBD). The primary outcome was the cumulative live birth rate. Secondary outcomes included number of oocytes retrieved, proportion of patients who underwent embryo transfer, pregnancy rate, and live birth rate at first cycle. RESULTS: There were 22 patients with UC and IPAA, 49 patients with UC and without IPAA, and 470 patients without IBD. The cumulative live birth rate after six cycles in the UC and IPAA groups was 64% (95% confidence interval (CI): 44-83%). This rate did not differ from the cumulative live birth rate in the UC without IPAA group (71%, 95% CI: 59-83%; P=0.63) or the group without IBD (53%, 95% CI: 48-57%; P=0.57). CONCLUSIONS: This study demonstrates that in our cohort, women who undergo IPAA achieve live births following IVF at comparable rates to women with UC without IPAA and to women without IBD.

The impact of length of second stage of labor on shoulder dystocia outcomes: a retrospective cohort study.

OBJECTIVE: To compare obstetrical and neonatal outcomes of vaginal deliveries complicated by shoulder dystocia, according to the length of second stage of labor. METHODS: We conducted a retrospective cohort study of 177 shoulder dystocia cases that were divided into three categories according to second stage duration (1-20, 21-59, 60-180 min, respectively). The three categories were compared in terms of obstetric characteristics and neonatal outcomes. Statistical analysis utilized the χ2-test and analysis of variance where appropriate. The odds ratios of brachial plexus injury and having a 5-min APGAR score <7 across the second stage duration categories were calculated using logistic regression models that adjusted for potential confounders. RESULTS: The incidence of brachial plexus injury was 5.4% (1st category), 4.4% (2nd category) and 26.9% (3rd category); P<0.01. The higher incidence of brachial plexus injury in the group where second stage lasted >1 h was confirmed by logistic regression, with and without adjusting for confounders. CONCLUSIONS: The incidence of brachial plexus injury increases with the length of second stage, even after controlling for confounders.

Improved overall delivery documentation following implementation of a standardized shoulder dystocia delivery form.

OBJECTIVE: Our objective was to evaluate whether using a standardized shoulder dystocia delivery form improved documentation. A standardized delivery form was added to our institution's obstetrical record in August 2003. METHODS: A retrospective cohort study was conducted comparing 100 vaginal deliveries complicated by shoulder dystocia before, and 81 after implementation of the standardized delivery form. The two groups were compared in terms of obstetric characteristics, neonatal outcomes and documentation components. RESULTS: Charts that included the standardized delivery form were more likely to contain documentation of estimated fetal weight (82.7% vs. 39.0% without the form, P<0.001) and head-to-shoulder delivery interval (76.5% vs. 15.0% without the form, P<0.001). Both groups were statistically similar in terms of documenting estimated blood loss and fetal weight, umbilical cord pH, type and order of maneuvers utilized to relieve the shoulder dystocia, and second stage duration. CONCLUSIONS: Inclusion of a standardized form in the delivery record improves the rate of documentation of both shoulder dystocia-specific and general delivery components.

Risk factors associated with retained placenta after cesarean delivery.

OBJECTIVES: Retained placenta after cesarean delivery (RPAC) is a rare phenomenon that has not been previously studied in detail. The objective of our study was to identify potential risk factors that predispose to the development of this obstetrical complication. METHODS: We performed a retrospective case-control study comparing 20 cases of RPAC with 40 matched controls, using logistic regression models to test likely risk factors. RESULTS: RPAC occurred in 0.16% of cesarean deliveries in our population. The crude odds ratio (OR) of RPAC was increased in patients who had preterm delivery (PTD) (OR=9.06, 95% CI: 2.04-40.29), conceived with artificial reproductive technology (ART) (OR=5.03, 95% CI: 1.24-20.40), and carried multiples (OR=18.89, 95% CI: 2.29-151.23). Conversely, for each week of gestation the odds of RPAC decreased by 0.57 (95% CI: 0.40-0.82). CONCLUSIONS: Earlier gestational age, PTD, use of ART and multiples are associated with increased OR of RPAC.

Cumulative live-birth rates after assisted reproductive technology.

PURPOSE OF REVIEW: Despite the promising success rates of IVF, many couples have to undergo several cycles before achieving live birth. In counseling patients faced with subfertility, it is important to provide cumulative live-birth rates. This review evaluates the current knowledge on cumulative rates, summarizing recently published evidence. RECENT FINDINGS: Existing data have been mostly presented in the form of live-birth rates per IVF cycle as a function of maternal age or reason for subfertility. Recent publications have been reporting IVF success rates in terms of cumulative live-birth rate (CLBR) per woman, thus providing a more realistic estimate that becomes applicable to individual couples. In general, CLBR following IVF has been reported between 45 and 55%. Maternal age has been shown to significantly reduce these rates, as has preimplantation genetic diagnosis. On the contrary, techniques mostly used to decrease the chance of multiple births, such as elective single embryo transfer and natural cycle IVF, do not affect CLBR while achieving a significant reduction in the rates of multiples. SUMMARY: Couples should be counseled that CLBR following IVF lies mostly around 50% and that maternal age as well as genetics of transferred embryos remain factors that influence success.

Thicker endometrial linings are associated with better IVF outcomes: a cohort of 6331 women.

Our objective was to determine if a correlation exists between endometrial thickness measured on the day of ovulation trigger during an in vitro fertilization (IVF) cycle and pregnancy outcomes among non-cancelled cycles. We performed a retrospective cohort study looking at 6331 women undergoing their first, fresh autologous IVF cycle from 1 May 2004 to 31 December 2012 at Boston IVF (Waltham, MA). Our primary outcome was the risk ratio (RR) of live birth and positive ß-hCG. We found that thicker endometrial linings were associated with positive ß-hCG and live birth rates. For each additional millimetre of endometrial thickness, we found a statistically significant increased risk of positive ß-hCG (adjusted RR: 1.14; 95% CI: 1.09-1.18) and live birth (RR: 1.08; 95% CI: 1.05-1.11). There was no association between endometrial thickness and miscarriage (RR: 0.99; 95% CI: 0.91-1.07). Similar results were seen when categorizing endometrial thickness. Compared with an endometrial thickness >7 to <11 mm, the likelihood of a live birth was significantly higher for an endometrial thickness ≥11 mm (adjusted RR: 1.23; 95% CI: 1.11-1.37) and significantly lower for the ≤7 mm group (adjusted RR: 0.64; 95% CI: 0.45-0.90). In conclusion, thicker endometrial linings were associated with increased pregnancy and live birth rates.

Profound hypothyroidism-induced acute menorrhagia resulting in life-threatening anemia.

BACKGROUND: Menorrhagia is a very common gynecologic entity with a broad differential diagnosis which includes both hypothyroidism and hyperthyroidism. CASE: We present the case of a 31-year-old patient with acute menorrhagia causing life-threatening anemia that resulted from profound hypothyroidism. Despite timely institution of thyroid replacement, the patient required emergent embolization of a uterine arteriovenous malformation after dilatation and curettage failed to control her bleeding. She was stabilized and discharged to home on the sixth hospital day. Three years later, she successfully conceived and delivered a healthy infant. CONCLUSION: Our case demonstrates the importance of thyroid evaluation in the patient who presents with menorrhagia. Timely management with medical treatment as well as conservative surgical or radiological interventions can facilitate resolution of symptoms and preserve the patient's fertility potential.

The effect of body mass index on the outcomes of first assisted reproductive technology cycles.

OBJECTIVE: To provide assisted reproductive technology (ART) outcome rates per body mass index (BMI) category after controlling for potential confounders. DESIGN: Retrospective cohort study. SETTING: Large university-affiliated infertility practice. PATIENT(S): Women undergoing ART. INTERVENTION(S): None. MAIN OUTCOME MEASURE(S): The primary outcome was live birth. Analyses were stratified according to BMI category and adjusted for potential confounders, including maternal and paternal age, baseline serum FSH, duration of gonadotropin stimulation, mean daily gonadotropin dose, peak serum E(2), number of oocytes retrieved, use of intracytoplasmic sperm injection, embryo quality and number, transfer day, and number of embryos transferred. RESULT(S): We analyzed the first autologous fresh IVF or IVF-ICSI cycle of 4,609 patients. There were no differences in the rates of cycle cancellation, spontaneous abortion, biochemical and ectopic pregnancies, or multiple births. After adjusting for potential confounders, patients with BMI ≥ 30.0 kg/m(2) had significantly decreased odds of implantation, clinical pregnancy, and live birth. The adjusted odds ratio (95% confidence interval [CI]) of live birth were 0.63 (0.47-0.85) for BMI 30.00-34.99, 0.39 (0.25-0.61) for BMI 35.00-39.99, and 0.32 (0.16-0.64) for BMI ≥ 40.0 compared with normal-weight cohorts. CONCLUSION(S): Obesity has a significant negative effect on ART outcomes. Patients with BMI > 30 kg/m(2) have up to 68% lower odds of having a live birth following their first ART cycle compared with women with BMI < 30.

Management of a cervical heterotopic pregnancy presenting with first-trimester bleeding: case report and review of the literature.

OBJECTIVE: To report a rare case of a cervical heterotopic pregnancy resulting from intrauterine insemination (IUI) that presented with first-trimester bleeding. DESIGN: Case report and literature review. SETTING: Large university-affiliated infertility practice. PATIENT(S): A 40-year-old gravida 2 para 1 Asian woman at 7-3/7 weeks gestational age following clomiphene citrate/IUI for the treatment of secondary infertility presented with heavy vaginal bleeding for several days. INTERVENTION(S): Transvaginal ultrasound on admission revealed a single live intrauterine pregnancy and a cervical gestational sac containing a nonviable embryo. The patient continued to have vaginal bleeding and 2 days later underwent removal of the cervical ectopic pregnancy tissue with ring forceps, as well as an ultrasound-guided intracervical Foley balloon and cerclage placement. The bleeding subsided, and 48 hours later the Foley and cerclage were removed. MAIN OUTCOME MEASURE(S): Pregnancy outcome. RESULT(S): The remainder of the pregnancy was uncomplicated and the patient had a full-term cesarean delivery for footling breech of a healthy male infant. CONCLUSION(S): Cervical heterotopic pregnancy is a very rare event that almost universally results from infertility treatment. We present a case where we were able to remove the cervical ectopic and tamponade the bleeding, thus preserving the intrauterine pregnancy for this subfertile couple, and we review the existing literature.

Effect of steroid and antibiotic treatment during assisted hatching on IVF outcomes.

There are limited data on the use of steroids and antibiotics in assisted reproductive technology (ART). Our aim was to evaluate the impact of these treatments on the outcome of IVF cycles in which Assisted Hatching (AH) was performed. We studied a retrospective cohort in a large university-affiliated infertility centre. Data from 1126 AH cycles performed between 2007 and 2009 were reviewed. Cycles were categorized as "treatment" (n = 640) and "no treatment" (n = 486), depending on whether they received steroids and antibiotics. The primary outcome was live birth. Secondary outcomes included implantation, spontaneous abortion, biochemical, clinical and ectopic pregnancy. Logistic regression was used to calculate odds ratios (OR) and 95% confidence intervals (CI). OR were adjusted (AOR) for age, BMI, baseline FSH, peak estradiol, cycle number, number of oocytes retrieved, number of embryos that underwent AH, number of high-implantation potential embryos, number of embryos transferred and physician in charge. The AOR (95% CI) of live birth was 1.91 (1.08-3.38), of clinical pregnancy, 1.75 (1.08-2.83) and of biochemical pregnancy, 0.24 (0.07-0.85). Our study suggests that treatment with steroids and antibiotics during AH cycles significantly increases the odds of live birth.

Short-term energy deprivation alters activin a and follistatin but not inhibin B levels of lean healthy women in a leptin-independent manner.

CONTEXT: Leptin is a potent modulator of the hypothalamic-pituitary-gonadal axis mediating the effect of energy deprivation on several hypothalamic-pituitary-peripheral axes. Activin A, inhibin B, and follistatin (FST) also regulate the hypothalamic-pituitary-gonadal axis in humans. It remains unknown whether energy deprivation affects these hormone levels in a leptin-dependent or -independent manner. OBJECTIVE: We investigated 1) day-night variability patterns of activin, inhibin, and FST in the fed state, 2) whether their levels are affected by fasting, and 3) whether such an effect is mediated by leptin in physiological replacement or pharmacological doses. DESIGN: We conducted two studies in healthy, eumenorrheic females, each comprising three separate admissions. In study 1, six women were maintained for 72 h 1) on isocaloric diet, 2) fasting while receiving placebo, or 3) fasting while receiving metreleptin in physiological replacement doses. In study 2, five women were administered physiological or pharmacological metreleptin doses (0.01, 0.1, or 0.3 mg/kg i.v. four times daily). RESULTS: Neither activin A nor FST had a pulsatile or day-night variability pattern. Inhibin B levels were also nonpulsatile, but a trend toward a day-night pattern was noted. When compared with the fed state, inhibin B levels remained unchanged, whereas FST levels increased (P = 0.01) and activin A decreased (P = 0.01) in the fasting state. These changes were not corrected with metreleptin administered in replacement or pharmacological doses. CONCLUSIONS: Short-term energy deprivation alters levels of activin A and FST, but these effects are not mediated by leptin.

Outcomes of day-1, day-3, and blastocyst cryopreserved embryo transfers.

The optimal developmental stage for cryopreserving embryos in IVF-ET remains controversial. Our study demonstrates that besides an improvement in postthaw survival rate for day-1 and blastocyst cryopreserved ET over day-3, all three groups attained statistically similar implantation, clinical pregnancy, multiple, twinning, and male gender rates.

Effect of macroscopic or microscopic blood and mucus on the success rates of embryo transfers.

OBJECTIVE: To assess the effect of microscopic and macroscopic contamination of embryo transfer (ET) catheters with blood or mucus on in vitro fertilization (IVF)-ET success rates. DESIGN: Retrospective cohort study. SETTING: Infertility practice in teaching community hospital. PATIENT(S): Four hundred seventy patients undergoing IVF-ET. INTERVENTION(S): Controlled ovarian hyperstimulation and IVF-ET. MAIN OUTCOME MEASURE(S): Implantation rate (IR) and clinical pregnancy rate (CPR). RESULT(S): The IR and CPR of IVF-ETs were comparable regardless of the presence (26.59% and 48.78%, respectively) or absence (23.49% and 44.44%, respectively) of any type of contamination. Even when analyzing specific contamination categories (i.e., macroscopic blood, microscopic blood on the outer catheter, microscopic blood on the inner catheter, blood anywhere without mucus, mucus only, or blood and mucus combined), there was no statistical significance in IR (range: 21.17% to 26.69%) or CPR (range: 32.69% to 49.5%). CONCLUSION(S): In general, IR and CPR appear to be unaffected by ET catheter contamination, whether it is macroscopic or microscopic presence of blood or mucus.

Follicular fluid-specific distribution of vascular endothelial growth factor isoforms and sFlt-1 in patients undergoing IVF and their correlation with treatment outcomes.

OBJECTIVE: To investigate the distribution of vascular endothelial growth factor (VEGF) isoforms and soluble form of VEGF receptor 1 (sFlt-1) in the follicular fluid (FF) of in vitro fertilization (IVF) patients in relationship to age, body mass index (BMI), diagnosis of polycystic ovary syndrome (PCOS), and their correlation with IVF outcomes. DESIGN: Prospective study. MAIN OUTCOME MEASURES: VEGF( 121) and VEGF(165) isoforms were detected using Western blotting and pixel density analysis. The concentration of sFlt-1 was determined by enzyme-linked immunosorbent assay (ELISA). In vitro fertilization outcomes measured included number of oocytes retrieved, fertilization rate, and clinical pregnancy. Statistical analysis used the Kruskal-Wallis and Mann-Whitney U test where appropriate. RESULTS: There was a statistically significant association between higher VEGF(165) levels and the diagnosis of PCOS, BMI ≥ 30, and age ≥40 years. In vitro fertilization cycles resulting in pregnancy were linked to statistically lower VEGF(165) levels in the FF. No statistically significant trend was identified in levels of VEGF(121) or sFlt-1 relative to patient characteristics or IVF outcomes. CONCLUSION: Our results suggest that elevated VEGF(165) levels are associated with less favorable patient characteristics and clinical IVF outcomes.