Use of gonadotropins in ovarian stimulation in Spain: Delphi consensus.

Two-round Delphi study carried out in Spain. Three theme-based blocks were set out: 1) Patient profiles: therapeutic goal and parameters to be analysed according to POSEIDON patient profiles; 2) Ovarian stimulation protocols with antagonists: monotherapy (FSH) vs combined therapy (FSH + LH/HMG); 3) Safety and effectiveness of the devices. The antral follicle count and the anti-Müllerian hormone level were considered indicators that can be used to predict ovarian response. More than 80% of the participants agreed that FSH monotherapy is the recommended regimen in normal/hyper-responsive patients of < 35 years of age; that 150-300 IU is the dose to be used in ovarian stimulation in monotherapy depending on clinical parameters; and that FSH monotherapy improves patients' comfort compared to two combined drugs. It was unanimously considered that the type of device used by the patient influences the comfort of the treatment.IMPACT STATEMENTWhat is already known on this subject? There is currently no consensus on the optimal treatment for controlled ovarian stimulation for patients undergoing IVF which leads to highly variable clinical practices.What the results of this study add? This study's strong point is that, since it is a consensus, it has been possible to include more topics than would normally be dealt with in a systematic review or guidelines, which are generally based on a strict method that restricts the scope of the research. Experts have reached a consensus on most of the statements and based on these they have issued consensus statements that will enable the optimal use of gonadotropins in IVF.What the implications are of these findings for clinical practice and/or further research? This Delphi consensus provides a real-life clinical perspective on gonadotropin usage in IVF.

Preservación de la fertilidad en cáncer de mama: caso clínico / Preservation of fertility in breast cancer: a clinical case

El cáncer de mama es la neoplasia más frecuente en la mujer. Actualmente estas pacientes tienen altas tasas de supervivencia, aunque derivado del tratamiento quimioterápico sufren riesgo de fallo ovárico prematuro y/o pérdida de reserva folicular. La preservación de la fertilidad debe ser ofertada a las pacientes oncológicas jóvenes con deseos genésicos. La técnica de elección es la vitrificación de ovocitos, ya que se trata de una técnica consolidada y se evita la generación de embriones con un futuro incierto (AU)

Breast cancer is the most frequent tumor in women; nowadays these patients have high survival rates, although due to chemotherapy they are at risk of premature ovary failure. Preservation of fertility should be offered to young oncological patients who desire to have children. The elective technique is the oocyte vitrification, since it is considered an established technique and it avoids the creation of embryos with unknown future (AU)

Iodine is associated to semen quality in men who undergo consultations for infertility.

The role that adequate iodine intake could have on the male reproductive function is not entirely known. The aim of this study is to determine whether there is a relation between male infertility and urinary and semen iodine levels in 96 couples who underwent consultation for infertility. The median of semen iodine was higher in men who consumed iodized salt than in those who consumed non-iodized salt (p=0.019). Men with a higher semen iodine level had more morphological alterations in spermatozoa (p=0.032). Men with a higher urinary iodine level had a lower motile sperm count according to the "direct swim-up" technique (p=0.044). Men >3years without successfully achieving pregnancy had a higher urinary iodine level than those with ≤ 3years (p=0.035). In conclusion, iodine may play a role in the quality of semen: an increase in semen iodine levels is associated with different variables related to male infertility.

Pobre respuesta ovárica / Poor ovarian response

Uno de los retos no resueltos en reproducción asistida es el manejo de las pacientes con pobre respuesta ovárica. Múltiples definiciones y diagnósticos diversos han contribuido a dificultar el grupo definido como pobre respuesta de forma que las diversas terapias aplicadas no han resuelto cuál es el tratamiento más adecuado para estas pacientes. En 2011 se ha realizado un documento de consenso que puede permitir armonizar criterios y realizar estudios científicos más objetivos. Con respecto a su manejo, se publican casi a diario estudios con resultados contradictorios en la mayoría de los casos. Se presenta una revisión del tema

One of the unsolved challenges in assisted reproduction is the management of patients with poor ovarian response. Multiple definitions and various diagnoses have contributed to hinder the group defined as poor responders, so that the various therapies applied have not determined what is the most appropriate treatment for these patients. A consensus document was performed in 2011, which may allow further harmonize criteria and objective scientific studies. Regarding handling, are published almost daily studies with conflicting results in most cases. We present a review of the topic

Pelvic abscess after oocyte retrieval in women with endometriosis: A case series.

BACKGROUND: Pelvic inflammatory disease with progression to pelvic abscess is a rare complication after oocyte retrieval during in vitro fertilization cycles. However, in patients with endometriosis the risk appears to be increased. Many authors agree on the need for antibiotic prophylaxis during the oocyte retrieval in these patients, but there is no consensus regarding the best antibiotic. CASE: We discuss 3 clinical cases of tubo-ovarian abscess in women with endometriosis after oocyte retrieval despite antibiotic prophylaxis between 2004 and 2011 at our center, and discuss our experience in the context of earlier reports. CONCLUSION: It is unclear whether antibiotic prophylaxis is necessary in these women, and which antibiotic is best. Only douching with povidone-iodine appears to decrease the rate of pelvic infection.

Epidemiología del aborto de repetición / Epidemiology of recurrent miscarriage

Objetivo. Conocer las posibles causas de aborto de repetición en nuestro medio y la tasa de embarazo en estas parejas. Material y métodos. Estudio observacional retrospectivo de 172 mujeres que consultaron en nuestra Unidad durante los años 2002 a 2008 por dos o más abortos de repetición. Resultados. El 80,2% de las mujeres quedaron gestantes, 81,2% de ellos a término. El estudio de abortabilidad fue normal en el 70,9%. Las alteraciones halladas fueron: uterinas 48%, genéticas 2% y alteraciones de la coagulación 44%, apareciendo asociadas en el 6% de las pacientes. Conclusiones. La mayoría de las parejas que consultan por abortos de repetición se van a quedar sin un diagnóstico etiológico tras el estudio de abortabilidad. El pronóstico reproductivo empeora conforme aumenta el número de abortos a la consulta. Sin embargo hasta el 80,2% vuelven a quedar gestantes, llegando a tener un hijo sano en casa el 81,1% de las embarazadas (AU)

Objective. To determine the possible causes of recurrent miscarriage in our environment and the pregnancy rate in these couples. Material and methods. An observational retrospective study was carried out in 172 women who attended our unit for two or more recurrent miscarriages between 2002 and 2008. Results. A total of 80.2% of the women became pregnant. Of these, 81.2% carried the fetus to term. The results of clinical study were normal in 70.9%. The alterations found were uterine in 48%, genetic in 2% and coagulation alterations in 44%. These alterations were associated in 6% of the patients. Conclusions. Most of the couples consulting for recurrent miscarriage will not receive an etiologic diagnosis after clinical study. Reproductive prognosis worsens as the number of miscarriages increases. However, up to 80.2% of these women become pregnant again, of whom 81.1% will deliver a healthy neonate (AU)

Could the addition of hp-hMG and GnRH antagonists modulate the response in IVF-ICSI cycles?

OBJECTIVE: To assess if the luteinizing hormone/human chorionic gonadotropin present in some gonadotropin formulations may be of benefit in protocols with GnRH antagonists. METHODS: Open, quasi-experimental, multicenter, prospective, parallel-controlled study compared 136 women undergoing in vitro fertilization--intracytoplasmic sperm injection after stimulation with highly purified human menopausal gonadotropin (hp-hMG) (n = 44), recombinant-follicle stimulating hormone (r-FSH) (n = 46), or a combination of both (r FSH + hp-hMG) (n = 46) following an antagonist protocol. Blood determinations were made on day 6 of stimulation and on the day of ovulation induction, with centralized analysis. RESULTS: No differences were found in the ongoing pregnancy rates between groups [37.0% versus 29.5% (hp-hMG) and 23.9% (r-FSH); p = 0.688]. However, the ratio top-quality embryos/retrieved oocytes (TQE/RO) was higher in the combined therapy group (19.6%)--reaching significance versus the r-FSH group (6.5%) (p = 0.008), but not versus hp-hMG (12.3%) (p = 0.137). CONCLUSIONS: An improved TQE/RO ratio was obtained together with a greater percentage of frozen embryos in the patients that incorporated hp-hMG to their stimulation protocol. Despite good results of adding hp-hMG, non statistical differences were found in terms of ongoing pregnancy rate.

Tratamiento conservador del cáncer de endometrio en una pareja estéril / Conservative treatment of endometrial cancer in an infertile couple

El tratamiento conservador del cáncer deendometrio (estadio I) es una opción terapéuticapara aquellas mujeres jóvenes que aún no hancumplido sus deseos genésicos. Aunque los datospublicados sobre los resultados de las técnicas dereproducción asistida (TRA) tras el manejoconservador del cáncer de endometrio son escasos,el pronóstico no parece empeorar con el uso deestas. A continuación, se describe el caso de unapaciente de 29 años, con esterilidad primaria,diagnosticada de cáncer de endometrio en estadioIA, tratada con altas dosis de progesterona oral, ytras el cual quedó embarazada mediante TRA (AU)

Successful conservative management for early-stagelow-grade endometrial cancer in young womenwishing to preserve fertility has been reported insmall series. Although few data are available on assisted reproductive technology (ART) outcomesafter conservative management of endometrialcarcinoma, ART does not seem to worsenprognosis. We report the case of a 29-year-oldwoman with a history of primary infertility, whowas diagnosed with a well-differentiatedendometrial adenocarcinoma (stage Ia), which wastreated with high doses of oral progesterone. Asuccessful pregnancy was achieved after ART (AU)

Inseminación artificial intrauterina en mujeres con síndrome de ovario poliquístico resistentes al citrato de clomifeno / Intrauterine insemination in women with polycystic ovary syndrome and clomiphene citrate resistance

Objetivo: Evaluar los resultados del tratamiento mediante inducción de la ovulación con gonadotropinas e inseminación artificial intrauterina (IAC-IU) realizados en mujeres con síndrome de ovario poliquístico (SOP) resistentes al citrato de clomifeno (CC). Material y métodos: Estudio observacional retrospectivo de 462 ciclos de inducción de la ovulación con IAC-IU en mujeres diagnosticadas de SOP resistentes al tratamiento con CC. Resultados. La tasa de embarazo clínico fue del 11,9% por ciclo iniciado y del 14,74% por inseminación, finalizando en aborto el 45,45% de los embarazos. El porcentaje acumulativo efectivo de embarazo a término por ciclo iniciado fue del 8% al primer ciclo y del 10,23% por inseminación, manteniéndose en el 26,15% a partir del quinto ciclo y en 32,24% a partir de la quinta inseminación. Se canceló el 19,26% de los ciclos. Conclusiones: La IAC-IU es un método útil en mujeres con SOP resistentes al CC, con resultados similares a los obtenidos con otras indicaciones. Estas pacientes presentan altas tasas de aborto del primer trimestre y de cancelación de ciclo. Esta elevada tasa de aborto debe dar lugar al desarrollo de una línea de investigación que logre encontrar la pauta que disminuya la pérdida reproductiva (AU)

Objective: To evaluate the results of ovulation induction cycles with gonadotropins and intrauterine insemination (IUI) carried out in women with polycystic ovary syndrome (POS) resistant to clomiphene citrate. Material and methods: We performed an observational retrospective study of 462 ovulation induction cycles with IUI in women with SOP and clomiphene citrate resistance. Results: The clinical pregnancy rate was 11.9% per cycle initiated and 14.74% per insemination and 45.45% of the pregnancies terminated in abortion. The effective accumulative percentage of term pregnancies per cycle initiated was 8% for the 82 first cycle and 10.23% for insemination, increasing to 26.15% from the fifth cycle and to 32.24% from the fifth insemination. A total of 19.26% of the cycles was cancelled. Conclusions: IUI is a useful method in women with SOP who are resistant to clomiphene citrate, with similar results to those obtained with other indications. These patients have high abortion and cycle cancellation rates. The high abortion rate should prompt research into ways of reducing reproductive loss (AU)

[Cost of assisted reproduction technology in a public hospital]. / Coste de las técnicas de reproducción asistida en un hospital público.

OBJECTIVES: Most studies on the costs of assisted reproductive technologies (ART) identify the total cost of the procedure with the direct cost, without considering important items such as overhead or intermediate costs. The objective of this study was to determine the cost per ART procedure in a public hospital in 2003 and to compare the results with those in the same hospital in 1998. METHODS: Data from the Human Reproduction Unit of the Virgen de las Nieves University Hospital in Granada (Spain) from 1998 and 2003 were analyzed. Since the total costs of the unit were known, the cost of the distinct ART procedures performed in the hospital was calculated by means of a methodology for cost distribution. RESULTS: Between 1998 and 2003, the activity and costs of the Human Reproduction Unit analyzed evolved differently. Analysis of activity showed that some techniques, such as intracytoplasmic sperm injection, were consolidated while others, such as stimulation without assisted reproduction or intracervical insemination were abandoned. In all procedures, unit costs per cycle and per delivery decreased in the period analyzed. CONCLUSIONS: Important changes took place in the structure of costs of ART in the Human Reproduction Unit of the Virgen de las Nieves University Hospital between 1998 and 2003. Some techniques were discontinued, while others gained importance. Technological advances and structural innovations, together with a "learning effect," modified the structure of ART-related costs.

Coste de las técnicas de reproducción asistida en un hospital público / Cost of assisted reproduction technology in a public hospital

Objetivos: La mayoría de trabajos sobre costes de las técnicas de reproducción asistida (TRA) identifican el coste directo del procedimiento, sin considerar elementos como los costes estructurales o intermedios, de gran importancia. El objetivo de este trabajo es calcular el coste por proceso de las TRA realizadas en un hospital público en 2003 y compararlo con los resultados de 1998 en el mismo centro. Métodos: El estudio se realiza en la Unidad de Reproducción Humana (URH) del Hospital Universitario Virgen de las Nieves de Granada en 1998 y 2003. Partiendo de los costes totales de dicha unidad, y mediante una metodología de distribución de costes basada en la estructura de costes, calculamos el coste por proceso de las TRA realizadas en este centro, considerando los costes completos. Resultados: Entre 1998 y 2003, la actividad y los costes de la URH analizada evolucionan de forma distinta. El análisis de la actividad muestra la consolidación de técnicas, como la microinyección espermática (ICSI) y la desaparición de otras (ciclo sin reproducción asistida e inseminación artificial conyugal intracervical). En todos los procesos, los costes unitarios por ciclo y por embarazo disminuyen en el período analizado. Conclusiones: Se han producido importantes cambios en la estructura de costes de las TRA de la URH-HUVN entre 1998-2003. Mientras algunos procesos desaparecen, otros se consolidan con una elevada actividad. Los avances técnicos y las innovaciones organizativas, junto con un «efecto aprendizaje», han alterado la estructura de costes de las TRA

Objectives: Most studies on the costs of assisted reproductive technologies (ART) identify the total cost of the procedure with the direct cost, without considering important items such as overhead or intermediate costs. The objective of this study was to determine the cost per ART procedure in a public hospital in 2003 and to compare the results with those in the same hospital in 1998. Methods: Data from the Human Reproduction Unit of the Virgen de las Nieves University Hospital in Granada (Spain) from 1998 and 2003 were analyzed. Since the total costs of the unit were known, the cost of the distinct ART procedures performed in the hospital was calculated by means of a methodology for cost distribution. Results: Between 1998 and 2003, the activity and costs of the Human Reproduction Unit analyzed evolved differently. Analysis of activity showed that some techniques, such as intracytoplasmic sperm injection, were consolidated while others, such as stimulation without assisted reproduction or intracervical insemination were abandoned. In all procedures, unit costs per cycle and per delivery decreased in the period analyzed. Conclusions: Important changes took place in the structure of costs of ART in the Human Reproduction Unit of the Virgen de las Nieves University Hospital between 1998 and 2003. Some techniques were discontinued, while others gained importance. Technological advances and structural innovations, together with a «learning effect», modified the structure of ART-related costs