Unintended pregnancies among women serving in the Israeli military.

OBJECTIVE: The objective was to identify the prevalence of and variables associated with unintended pregnancy among young, unmarried women serving in the Israeli military. STUDY DESIGN: We performed a retrospective cohort study of unmarried women drafted by the Israeli military between 2013 and 2015 at the age of 18 years. We used multivariable logistic regression to examine associations between unintended pregnancy and women's education, IQ, immigration status, country of origin, neighborhood socioeconomic status and history of psychiatric illness. RESULTS: Most women (n=127,262) did not become pregnant while serving in the Israeli military. Unintended pregnancy was reported by 2365, with an additional 6 women reporting pregnancy resulting from sexual assault and 5 an intended pregnancy. Annual rates of unintended pregnancy among young women serving in the Israeli military declined from 1.69% in 2013 to 1.56% in 2014 and 1.33% in 2015. In multivariable models, unintended pregnancy was more common among women soldiers who had not graduated from high school (adjusted relative risk [RR], 5.3; 95% confidence interval [CI], 4.69-6.04) and those who were first-generation immigrants (adjusted RR, 2.1; 95% CI, 1.90-2.35). CONCLUSION: Unintended pregnancy is rare among women serving into the Israeli military. IMPLICATIONS: Increasing contraceptive use among women who have not graduated from high school may further reduce rates of unintended pregnancy among women serving in the Israeli military.

Modifying the luteal phase support in natural cycle frozen-thawed embryo transfer improves cycle outcome.

With the recent trend toward single embryo transfer (ET), cryopreservation of extraneous embryos is becoming increasingly prevalent. Several replacement protocols for frozen-thawed ET (FET) exist, with no advantage of one protocol over the others. All consecutive patients undergoing natural cycle Day-3 FET cycles between May 2012 and March 2015 in our IVF unit were evaluated. While following spontaneous ovulation, all patients received progesterone luteal support. Since June 2014, patients underwent the same aforementioned natural cycle FET cycles, with two additional injections, one of recombinant hCG (250 mcg) and the other of GnRH-agonist (triptorelin 0.1 mg), on the day of transfer and 4 d later, respectively. While the patients' clinical characteristics, the prevalence of embryos that survived the thawing process and the number of embryos transferred were comparable between the earlier as compared with the later period, implantation rate, positive ß-hCG, clinical, and ongoing pregnancy rates were significantly higher during the later period. We, therefore, suggest that when natural cycle FET is offered, the addition of two injections of recombinant hCG and GnRH-agonist, on the day of transfer and 4 d later, respectively, might increase clinical pregancy rates. Further large prospective studies are needed to elucidate the aforementioned recommendation prior to its routine implementation.

[Do poor-responder patients benefit from increasing the daily gonadotropin dose from 300 to 450 IU during controlled ovarian hyperstimulation for IVF?].

OBJECTIVE: We aim to evaluate the IVF-ET outcome in patients receiving a high daily dose (300 IU) of gonadotropins during controlled ovarian hyperstimulation (COH) for IVF and to assess the role of increasing the daily dose to 450 IU on improving outcome. PATIENTS AND METHODS: All consecutive women admitted to our IVF unit during an 11 year period who underwent COH consisting of daily gonadotropin dose of 300 IU were included in the study. The ovarian stimulation characteristics, number of oocytes retrieved, number of embryo transferred and pregnancy rate were assessed. We also evaluated the subsequent cycle, using daily gonadotropin doses of 450 IU, among those patients who did not conceive using the 300 IU daily gonadotropin dose. RESULTS: Nine hundred and forty-nine consecutive IVF cycles were evaluated. Patients who conceived using the daily gonadotropin dose of 300 IU (n = 133, 14% pregnancy rate) had significantly longer stimulation, yielded higher numbers of oocytes retrieved, fertilization rate and number of embryos transferred, compared to those who did not conceive. Moreover, while comparing IVF cycles using daily gonadotropin doses of 300 IU to 450 IU (n = 117), no in-between group differences were observed, except for significantly higher yields of oocytes retrieved. Moreover, cycles using daily gonadotropin doses of 450 IU resulted in a 7.7 live-birth rate. CONCLUSIONS: In poor responders undergoing COH with a daily gonadotropin dose of 300 IU, increasing the dose to 450 IU resulted in significantly higher oocyte yields and a reasonable live birth rate.

Assisted reproduction involving gestational surrogacy: an analysis of the medical, psychosocial and legal issues: experience from a large surrogacy program.

STUDY QUESTION: What are the medical, psychosocial and legal aspects of gestational surrogacy (GS), including pregnancy outcomes and complications, in a large series? SUMMARY ANSWER: Meticulous multidisciplinary teamwork, involving medical, legal and psychosocial input for both the intended parent(s) (IP) and the gestational carrier (GC), is critical to achieve a successful GS program. WHAT IS KNOWN ALREADY: Small case series have described pregnancy rates of 17-50% for GS. There are no large case series and the medical, legal and psychological aspects of GS have not been addressed in most of these studies. To our knowledge, this is the largest reported GS case series. STUDY DESIGN, SIZE AND DURATION: A retrospective cohort study was performed. Data were collected from 333 consecutive GC cycles between 1998 and 2012. PARTICIPANTS/MATERIALS, SETTING, METHODS: There were 178 pregnancies achieved out of 333 stimulation cycles, including fresh and frozen transfers. The indications for a GC were divided into two groups. Those who have 'failed to carry', included women with recurrent implantation failure (RIF), recurrent pregnancy loss (RPL) and previous poor pregnancy outcome (n = 96; 132 cycles, pregnancy rate 50.0%). The second group consisted of those who 'cannot carry' including those with severe Asherman's syndrome, uterine malformations/uterine agenesis and maternal medical diseases (n = 108, 139 cycles, pregnancy rate 54.0%). A third group, of same-sex male couples and single men, were analyzed separately (n = 52, 62 cycles, pregnancy rate 59.7%). In 49.2% of cycles, autologous oocytes were used and 50.8% of cycles involved donor oocytes. MAIN RESULTS AND THE ROLE OF CHANCE: The 'failed to carry' group consisted of 96 patients who underwent 132 cycles at a mean age of 40.3 years. There were 66 pregnancies (50.0%) with 17 miscarriages (25.8%) and 46 confirmed births (34.8%). The 'cannot carry pregnancy' group consisted of 108 patients who underwent 139 cycles at a mean age of 35.9 years. There were 75 pregnancies (54.0%) with 15 miscarriages (20.0%) and 56 confirmed births (40.3%). The pregnancy, miscarriage and live birth rates between the two groups were not significantly different (P = 0.54; 0.43; 0.38, respectively). Of the 178 pregnancies, 142 pregnancies were ongoing (surpassed 20 weeks) or had ended with a live birth and the other 36 pregnancies resulted in miscarriage (25.4%). Maternal (GS) complication rates were low, occurring in only 9.8% of pregnancies. Fetal anomalies occurred in only 1.8% of the babies born. LIMITATIONS, REASONS FOR CAUTION: Although it is a large series, the data are retrospective and conclusions must be drawn accordingly while considering bias, confounding and power. Due to the retrospective nature of this study, follow-up data on 6.3% of birth outcomes were incomplete. In addition, long-term follow-up data on GCs and IPs were not available to us at the time of publication. WIDER IMPLICATIONS OF THE FINDINGS: To our knowledge, this is the largest GS series published. We have included many details regarding not only the medical protocol but also the counseling and legal considerations, which are an inseparable part of the process. Data from this study can be included in discussions with future intended parents and gestational carriers regarding success rates and complications of GS.

Co-administration of GnRH-agonist and hCG, for final oocyte maturation (double trigger), in patients with low proportion of mature oocytes.

OBJECTIVE: Human chorionic gonadotropin (hCG) is usually used at the end of controlled ovarian hyperstimulation (COH), as a surrogate LH surge, to induce final oocyte maturation and resumption of meiosis. Recently, the co-administration of GnRH agonist and hCG for final oocyte maturation - 40 and 34 h prior to OPU, respectively (double trigger) was suggested to improve IVF outcome in patient with genuine empty follicle syndrome. In the present study, we aim to evaluate whether the double trigger might improve the proportions of metaphase-II (MII) oocytes in patients with low proportion of mature oocytes (<66%) per number oocytes retrieved. PATIENTS AND METHODS: We compared the stimulation characteristics of 12 IVF cycles, which include the cycle with the double trigger to the same patients' previous IVF attempt, triggered with hCG-only. RESULTS: Patients who received the double trigger (study group) had a significantly higher number of mature oocytes - MII (6.5 versus 3.6 p < 0.008), number of embryos transferred (2.4 versus 1.1 p < 0.03), a significantly higher proportions of MII oocytes per number of oocytes retrieved (69.7% versus 47.1% p < 0.03) and a higher number of top quality embryos (3.1 versus 1 p < 0.02), as compared to their previous control cycles (hCG-only trigger). Six pregnancies were recorded in the study group and none in the control group. CONCLUSIONS: Co-administration of GnRH-agonist and hCG for final oocyte maturation, 40 and 34 h prior to OPU, respectively (double trigger) improves IVF outcome in patients with high proportion of immature oocytes.

Co-administration of GnRH-agonist and hCG for final oocyte maturation (double trigger) in patients with low number of oocytes retrieved per number of preovulatory follicles--a preliminary report.

BACKGROUND: Recently, the co-administration of GnRH agonist and hCG for final oocyte maturation- 40 and 34 hours prior to OPU, respectively (double trigger) was suggested as the treatment of genuine empty follicle syndrome. In the present study, we aim to evaluate whether the double trigger improves the number of oocytes retrieved in patients with low (<50%) number of oocytes retrieved per number of preovulatory follicles. METHODS: In this proof of concept cohort historical study, we compared the stimulation characteristics of 8 IVF cycles, which include the double trigger to the patients' previous IVF attempt, triggered with hCG-only. RESULTS: Patients who received the double trigger (study group) had a significantly higher number of oocytes retrieved, number of 2PN, number of embryos transferred and significantly higher proportions of the number of oocytes retrieved to the number of follicles >10 mm and >14 mm in diameter on day of hCG administration, with a tendency toward a higher number of TQE, as compared to their previous cycles (hCG-only trigger). Three ongoing clinical pregnancies were recorded in the study group and none in the hCG-only trigger group. CONCLUSIONS: Co-administration of GnRH-agonist and hCG for final oocyte maturation, 40 and 34 hours prior to OPU, respectively (double trigger), is suggested as a valuable new tool in the armamentarium for treating patients with low/poor oocytes yield despite an apparently normal follicular development and E2 levels and in the presence of optimal hCG levels on the day of OPU.

HCG (1500IU) administration on day 3 after oocytes retrieval, following GnRH-agonist trigger for final follicular maturation, results in high sufficient mid luteal progesterone levels - a proof of concept.

BACKGROUND: Controlled ovarian hyperstimulation (COH) which combining GnRH antagonist co-treatment and GnRH agonist trigger with an additional 1500 IU hCG luteal rescue on day of oocytes retrieval, has become a common tool aiming to reduce severe ovarian hyperstimulation syndrome (OHSS). In the present, proof of concept study, we evaluate whether by deferring the hCG rescue bolus for 3 days, we are still able to rescue the luteal phase. METHODS: Patients undergoing the GnRH-antagonist protocol, who were considered at high risk for developing severe OHSS and received GnRH-agonist for final oocyte maturation, were included. For luteal phase support, all patients received an "intense" luteal support. Those who had no signs of early moderate OHSS on day 3 after oocytes retrieval were instructed to inject 1500 IU of HCG bolus (hCG group). Ovarian stimulation characteristics and mid luteal progesterone levels were compared between those who received the HCG bolus and those who did not. RESULTS: Eleven IVF cycles were evaluated, 5 in the hCG group and 6 in the intense luteal support only group. While no in-between group differences were observed in ovarian stimulation characteristics, significantly higher mid luteal progesterone levels (>127 nmol/L vs 42.1 ± 14.5 nmol/L, respectively) and a non-significant increase in pregnancy rate (40% vs 16.6%, respectively), were observed in those who receive the hCG bolus compared to those who did not. CONCLUSIONS: hCG luteal rescue should be offered 3 days after oocytes retrieval only to those patients with no signs of early moderate OHSS. Further studies are required to elucidate the appropriate regimen of luteal HCG administration in patients undergoing final follicular maturation with GnRH-agonist.

Comparison of IVF Outcomes between Minimal Stimulation and High-Dose Stimulation for Patients with Poor Ovarian Reserve.

We examined whether treatment with minimum-dose stimulation (MS) protocol enhances clinical pregnancy rates compared to high-dose stimulation (HS) protocol. A retrospective cohort study was performed comparing IVF and pregnancy outcomes between MS and HS gonadotropin-antagonist protocol for patients with poor ovarian reserve (POR). Inclusion criteria included patients with an anti-Müllerian hormone (AMH) ≤8 pmol/L and/or antral follicle count (AFC) ≤5 on days 2-3 of the cycle. Patients from 2008 exclusively had a HS protocol treatment, while patients in 2010 had treatment with a MS protocol exclusively. The MS protocol involved letrozole at 2.5 mg over 5 days, starting from day 2, overlapping with gonadotropins, starting from the third day of letrozole at 150 units daily. GnRH antagonist was introduced once one or more follicles reached 14 mm or larger. The HS group received gonadotropins (≥300 IU/day) throughout their antagonist cycle. Clinical pregnancy rate was significantly higher in the MS protocol compared to the HS protocol (P = 0.007). Furthermore, the live birth rate was significantly higher in the MS group compare to the HS group (P = 0.034). In conclusion, the MS IVF protocol is less expensive (lower gonadotropin dosage) and resulted in a higher clinical pregnancy rate and live birth rate than a HS protocol for poor responders.

Lessons learned from an obstetrics and gynecology field hospital response to natural disasters.

Field hospitals were deployed by the Israel Defense Forces as part of the international relief efforts after major seismic events, one in Haiti (2010) and one in Japan (2011). The teams treated a total of 44 pregnant and 24 nonpregnant women and performed 16 deliveries and three cesarean deliveries under extreme conditions. Half of all deliveries were complicated by preeclampsia and 31% were preterm (at 30-32 weeks of gestation). It is imperative that obstetrician-gynecologists be included among humanitarian aid delegations sent to sites of natural disasters. The complicated cases we encountered required highly skilled obstetricians and led to a shortage of specific medications for these women. Cases that would have been considered routine under normal conditions created unanticipated ethical and practical issues in the face of very limited resources. The aim of this commentary is to share the experiences and lessons learned by our field hospital obstetrics and gynecology teams after the major earthquakes in Haiti and Japan. We present what we consider to be the 10 most important lessons learned and propose that they serve as guidelines in preparing for essential needs in other natural disaster settings.

In vitro fertilization-intracytoplasmic sperm injection outcome in patients with a markedly high DNA fragmentation index (>50%).

OBJECTIVE: To investigate differences in fertilization, clinical pregnancy, and miscarriage rates between men with a markedly high sperm DNA fragmentation index (DFI) (>50%) and those with low DFI (≤ 15%) in couples matched by female partner age and ovarian reserve as determined by antimüllerian hormone (AMH) level. DESIGN: Retrospective cohort study. SETTING: University-affiliated fertility center. PATIENT(S): Men undergoing intracytoplasmic sperm injection (ICSI) cycles who had low (n = 114) or markedly high (n = 36) DNA damage. INTERVENTION(S): None. MAIN OUTCOME MEASURE(S): Sperm DNA damage evaluated by acridine orange flow cytometry and expressed as the DFI, with the potential confounders of ovarian reserve and age controlled for by multivariable logistic regression analysis. RESULT(S): The fertilization and clinical pregnancy rates were not different between the two groups. We observed a trend toward a higher miscarriage rate with the high DFI group, but it did not reach statistical significance. CONCLUSION(S): Intracytoplasmic sperm injection in men with a high DFI with sperm selected by movement and morphology characteristics resulted in a similar pregnancy rate compared with the controls with a normal DFI. However, the trend observed of an increase in miscarriages suggests that any potential negative impact may appear later in development. Future studies involving a larger cohort may determine if the miscarriage trend reaches statistical significance.

Do we need routine complete blood count following vaginal delivery?

Routine post partum complete blood count examination (CBC) is customary in many medical centers. The rationale behind drawing a routine CBC is to estimate blood loss during delivery and to identify patients who will need blood transfusions. The present study was aimed to determine the necessity of routine post-partum CBC following vaginal delivery. A retrospective cohort study was performed including all patients who received blood transfusions following vaginal delivery between January 2003 and November 2004. Data were collected from birth files. The indications for administration of blood transfusions were noted. Of 20,694 vaginal deliveries, 0.7% (n = 138) received blood transfusions. All patients had at least one obstetric risk factor of postpartum hemorrhage or symptomatic anemia. None received the blood transfusion based upon postpartum CBC hemoglobin level alone. Routine postpartum CBC is not warranted for the purpose of identifying the patient in need of blood transfusions. Postpartum CBC should be performed when indicated according to risk factors for excessive blood loss or patients' complaints.