University of California, Los Angeles (UCLA): Annual In Vitro Fertilization and Embryo Transfer

SANTA BARBARA, CALIF. – Lower-than-average clinical pregnancy rates among obese women undergoing assisted reproductive techniques may be less relevant clinically than they seem at first blush, according to Dr. Marcelle I. Cedars.

A third of American women today are overweight or obese, she pointed out, and excess weight can translate into pregnancy complications and risks to the fetus.

But actual differences in ART outcomes may not warrant drastic steps, such as denying in vitro fertilization (IVF) treatment for women who are overweight, she argued.

©dblight/iStockphoto.com

"If you look at the abstracts of all these papers, they list these huge significance factors, but if you’re looking at tens of thousands of cycles, a very small reduction in pregnancy rate is highly, highly significant," said Dr. Cedars, professor of obstetrics, gynecology, and reproductive sciences and director of the division of reproductive endocrinology and infertility at the University of California, San Francisco.

For example, she referenced a national study based on Society for Assisted Reproductive Technology data that documented significantly more cancelled treatment cycles because of a low response rate and increased odds of treatment failure among heavier ART patients (Fertil. Steril. 2011;96:820-5). In that study, the greatest decrements in ART success were among women with BMIs of 50 kg/m² or higher.

At that BMI (translating into a woman about 5 feet 5 inches tall who weighs more than 300 pounds), pregnancy rates in the SART database averaged 36%, compared with 43% for those with a BMI of 18.5 kg/m² (about 5 foot 5 and 110 pounds).

For women with BMIs between 30 and 35 kg/m² (5 foot 5 and 180-210 pounds), the pregnancy rate was 41%, Dr. Cedars reported at a conference on IVF and embryo transfer, sponsored by the University of California, Los Angeles.

This study and others like it have prompted some IVF programs to refuse treatment to women with BMIs of 30 kg/m² and above, according to Dr. Cedars.

But the disparity in pregnancy rates between women with BMIs of 30 vs. 18.5 is, in fact, about the same as the disparity between Asian women compared with white women following ART, she noted.

"Are you going to refuse to treat Asians because their success rate is lower?" she asked rhetorically.

Obesity factors related to ART success take on less significance in older patients, she noted, "because obviously the strongest driver in your older patients is age.

"Age trumps everything, so if your plan is going to make these women lose weight, the time that might take them if they’re older is going to be way more significant than any potential benefit in terms of weight loss," she said.

Based on small studies, acute weight loss appears to reduce fertilization rates rather than improve the odds of ART success, said Dr. Cedars.

She reported no relevant financial relationships.

SANTA BARBARA, CALIF. – Lower-than-average clinical pregnancy rates among obese women undergoing assisted reproductive techniques may be less relevant clinically than they seem at first blush, according to Dr. Marcelle I. Cedars.

A third of American women today are overweight or obese, she pointed out, and excess weight can translate into pregnancy complications and risks to the fetus.

But actual differences in ART outcomes may not warrant drastic steps, such as denying in vitro fertilization (IVF) treatment for women who are overweight, she argued.

©dblight/iStockphoto.com

"If you look at the abstracts of all these papers, they list these huge significance factors, but if you’re looking at tens of thousands of cycles, a very small reduction in pregnancy rate is highly, highly significant," said Dr. Cedars, professor of obstetrics, gynecology, and reproductive sciences and director of the division of reproductive endocrinology and infertility at the University of California, San Francisco.

For example, she referenced a national study based on Society for Assisted Reproductive Technology data that documented significantly more cancelled treatment cycles because of a low response rate and increased odds of treatment failure among heavier ART patients (Fertil. Steril. 2011;96:820-5). In that study, the greatest decrements in ART success were among women with BMIs of 50 kg/m² or higher.

At that BMI (translating into a woman about 5 feet 5 inches tall who weighs more than 300 pounds), pregnancy rates in the SART database averaged 36%, compared with 43% for those with a BMI of 18.5 kg/m² (about 5 foot 5 and 110 pounds).

For women with BMIs between 30 and 35 kg/m² (5 foot 5 and 180-210 pounds), the pregnancy rate was 41%, Dr. Cedars reported at a conference on IVF and embryo transfer, sponsored by the University of California, Los Angeles.

This study and others like it have prompted some IVF programs to refuse treatment to women with BMIs of 30 kg/m² and above, according to Dr. Cedars.

But the disparity in pregnancy rates between women with BMIs of 30 vs. 18.5 is, in fact, about the same as the disparity between Asian women compared with white women following ART, she noted.

"Are you going to refuse to treat Asians because their success rate is lower?" she asked rhetorically.

Obesity factors related to ART success take on less significance in older patients, she noted, "because obviously the strongest driver in your older patients is age.

"Age trumps everything, so if your plan is going to make these women lose weight, the time that might take them if they’re older is going to be way more significant than any potential benefit in terms of weight loss," she said.

Based on small studies, acute weight loss appears to reduce fertilization rates rather than improve the odds of ART success, said Dr. Cedars.

She reported no relevant financial relationships.

SANTA BARBARA, CALIF. – Lower-than-average clinical pregnancy rates among obese women undergoing assisted reproductive techniques may be less relevant clinically than they seem at first blush, according to Dr. Marcelle I. Cedars.

A third of American women today are overweight or obese, she pointed out, and excess weight can translate into pregnancy complications and risks to the fetus.

But actual differences in ART outcomes may not warrant drastic steps, such as denying in vitro fertilization (IVF) treatment for women who are overweight, she argued.

©dblight/iStockphoto.com

"If you look at the abstracts of all these papers, they list these huge significance factors, but if you’re looking at tens of thousands of cycles, a very small reduction in pregnancy rate is highly, highly significant," said Dr. Cedars, professor of obstetrics, gynecology, and reproductive sciences and director of the division of reproductive endocrinology and infertility at the University of California, San Francisco.

For example, she referenced a national study based on Society for Assisted Reproductive Technology data that documented significantly more cancelled treatment cycles because of a low response rate and increased odds of treatment failure among heavier ART patients (Fertil. Steril. 2011;96:820-5). In that study, the greatest decrements in ART success were among women with BMIs of 50 kg/m² or higher.

At that BMI (translating into a woman about 5 feet 5 inches tall who weighs more than 300 pounds), pregnancy rates in the SART database averaged 36%, compared with 43% for those with a BMI of 18.5 kg/m² (about 5 foot 5 and 110 pounds).

For women with BMIs between 30 and 35 kg/m² (5 foot 5 and 180-210 pounds), the pregnancy rate was 41%, Dr. Cedars reported at a conference on IVF and embryo transfer, sponsored by the University of California, Los Angeles.

This study and others like it have prompted some IVF programs to refuse treatment to women with BMIs of 30 kg/m² and above, according to Dr. Cedars.

But the disparity in pregnancy rates between women with BMIs of 30 vs. 18.5 is, in fact, about the same as the disparity between Asian women compared with white women following ART, she noted.

"Are you going to refuse to treat Asians because their success rate is lower?" she asked rhetorically.

Obesity factors related to ART success take on less significance in older patients, she noted, "because obviously the strongest driver in your older patients is age.

"Age trumps everything, so if your plan is going to make these women lose weight, the time that might take them if they’re older is going to be way more significant than any potential benefit in terms of weight loss," she said.

Based on small studies, acute weight loss appears to reduce fertilization rates rather than improve the odds of ART success, said Dr. Cedars.

She reported no relevant financial relationships.

SANTA BARBARA, CALIF.  – Although there are hints, researchers remain largely baffled about why ethnic minority patients have lower pregnancy and live birth rates than do whites when they undergo in vitro fertilization, especially as natural conception rates do not appear to be disparate.

Many potential explanations have been hypothesized, including differences in obesity rates, leiomyomata prevalence, inflammatory processes, and estrogen metabolism, Dr. Marcelle I. Cedars said at a meeting on in vitro fertilization and embryo transfer, which was sponsored by the University of California, Los Angeles.

Photo credit: ©oneclearvision/iStockphoto.com

None seem to fully account for diminished IVF outcomes in Asian Americans, blacks, and Hispanics. Pregnancy loss rates associated with assisted reproductive techniques also are higher for blacks and Hispanics, she noted.

Economic disparities and unequal access to IVF have been suggested as playing a role, but military studies, in which all patients have equal access to care, confirm reduced outcomes numerically – although the numbers did not quite reach statistical significance.

Dr. Cedars’ group at the University of California, San Francisco (UCSF), has focused on IVF outcomes in Asian Americans, who represent approximately a third of their patient population. Differences came under scrutiny beginning about 6 years ago.

"If we looked at live birth rate overall in any age group, we saw a significantly decreased rate in the Asian population," said Dr. Cedars, director of the in vitro fertilization program and director of the division of reproductive endocrinology and infertility at UCSF.

The clinical pregnancy rate among Asian patients also was lower than among white patients in their clinic, but the number of eggs, number of embryos, and number of high-quality embryos were similar.

"We don’t think there is something intrinsically different in terms of their ovarian reserve," she said.

Further investigation revealed higher estradiol levels during stimulation in Asian patients, even among those on a strictly controlled regimen, when "everyone gets the same dose," she noted.

Asian oocyte donors, like IVF patients, had peak serum estradiol rates 23% higher than those of white donors, but their implantation, clinical pregnancy, and live birth rates were not statistically different.

Environmental or lifestyle factors, such as higher rates of mercury exposure through fish consumption, have been hypothesized as contributing to poorer IVF outcomes, said Dr. Cedars, who also is a professor of obstetrics, gynecology, and reproductive sciences at UCSF.

But such a factor would influence spontaneous conception and pregnancy as well as IVF.

"When we looked at spontaneous pregnancies and time to pregnancy, there were absolutely no decrements in the Asian population," she said.

Indeed, Dr. Cedars believes more attention should be focused on possible differences in the way patients metabolize drugs used during ovarian stimulation. "I think we really need to think about our stimulation protocols, which were not developed with [proportional representation] of these minorities."

In the meantime, "much still remains to be explained, and this is an active area for investigation," she concluded.

Dr. Cedars reported no financial relationships relevant to her talk.

SANTA BARBARA, CALIF.  – Although there are hints, researchers remain largely baffled about why ethnic minority patients have lower pregnancy and live birth rates than do whites when they undergo in vitro fertilization, especially as natural conception rates do not appear to be disparate.

Many potential explanations have been hypothesized, including differences in obesity rates, leiomyomata prevalence, inflammatory processes, and estrogen metabolism, Dr. Marcelle I. Cedars said at a meeting on in vitro fertilization and embryo transfer, which was sponsored by the University of California, Los Angeles.

Photo credit: ©oneclearvision/iStockphoto.com

None seem to fully account for diminished IVF outcomes in Asian Americans, blacks, and Hispanics. Pregnancy loss rates associated with assisted reproductive techniques also are higher for blacks and Hispanics, she noted.

Economic disparities and unequal access to IVF have been suggested as playing a role, but military studies, in which all patients have equal access to care, confirm reduced outcomes numerically – although the numbers did not quite reach statistical significance.

Dr. Cedars’ group at the University of California, San Francisco (UCSF), has focused on IVF outcomes in Asian Americans, who represent approximately a third of their patient population. Differences came under scrutiny beginning about 6 years ago.

"If we looked at live birth rate overall in any age group, we saw a significantly decreased rate in the Asian population," said Dr. Cedars, director of the in vitro fertilization program and director of the division of reproductive endocrinology and infertility at UCSF.

The clinical pregnancy rate among Asian patients also was lower than among white patients in their clinic, but the number of eggs, number of embryos, and number of high-quality embryos were similar.

"We don’t think there is something intrinsically different in terms of their ovarian reserve," she said.

Further investigation revealed higher estradiol levels during stimulation in Asian patients, even among those on a strictly controlled regimen, when "everyone gets the same dose," she noted.

Asian oocyte donors, like IVF patients, had peak serum estradiol rates 23% higher than those of white donors, but their implantation, clinical pregnancy, and live birth rates were not statistically different.

Environmental or lifestyle factors, such as higher rates of mercury exposure through fish consumption, have been hypothesized as contributing to poorer IVF outcomes, said Dr. Cedars, who also is a professor of obstetrics, gynecology, and reproductive sciences at UCSF.

But such a factor would influence spontaneous conception and pregnancy as well as IVF.

"When we looked at spontaneous pregnancies and time to pregnancy, there were absolutely no decrements in the Asian population," she said.

Indeed, Dr. Cedars believes more attention should be focused on possible differences in the way patients metabolize drugs used during ovarian stimulation. "I think we really need to think about our stimulation protocols, which were not developed with [proportional representation] of these minorities."

In the meantime, "much still remains to be explained, and this is an active area for investigation," she concluded.

Dr. Cedars reported no financial relationships relevant to her talk.

SANTA BARBARA, CALIF.  – Although there are hints, researchers remain largely baffled about why ethnic minority patients have lower pregnancy and live birth rates than do whites when they undergo in vitro fertilization, especially as natural conception rates do not appear to be disparate.

Many potential explanations have been hypothesized, including differences in obesity rates, leiomyomata prevalence, inflammatory processes, and estrogen metabolism, Dr. Marcelle I. Cedars said at a meeting on in vitro fertilization and embryo transfer, which was sponsored by the University of California, Los Angeles.

Photo credit: ©oneclearvision/iStockphoto.com

None seem to fully account for diminished IVF outcomes in Asian Americans, blacks, and Hispanics. Pregnancy loss rates associated with assisted reproductive techniques also are higher for blacks and Hispanics, she noted.

Economic disparities and unequal access to IVF have been suggested as playing a role, but military studies, in which all patients have equal access to care, confirm reduced outcomes numerically – although the numbers did not quite reach statistical significance.

Dr. Cedars’ group at the University of California, San Francisco (UCSF), has focused on IVF outcomes in Asian Americans, who represent approximately a third of their patient population. Differences came under scrutiny beginning about 6 years ago.

"If we looked at live birth rate overall in any age group, we saw a significantly decreased rate in the Asian population," said Dr. Cedars, director of the in vitro fertilization program and director of the division of reproductive endocrinology and infertility at UCSF.

The clinical pregnancy rate among Asian patients also was lower than among white patients in their clinic, but the number of eggs, number of embryos, and number of high-quality embryos were similar.

"We don’t think there is something intrinsically different in terms of their ovarian reserve," she said.

Further investigation revealed higher estradiol levels during stimulation in Asian patients, even among those on a strictly controlled regimen, when "everyone gets the same dose," she noted.

Asian oocyte donors, like IVF patients, had peak serum estradiol rates 23% higher than those of white donors, but their implantation, clinical pregnancy, and live birth rates were not statistically different.

Environmental or lifestyle factors, such as higher rates of mercury exposure through fish consumption, have been hypothesized as contributing to poorer IVF outcomes, said Dr. Cedars, who also is a professor of obstetrics, gynecology, and reproductive sciences at UCSF.

But such a factor would influence spontaneous conception and pregnancy as well as IVF.

"When we looked at spontaneous pregnancies and time to pregnancy, there were absolutely no decrements in the Asian population," she said.

Indeed, Dr. Cedars believes more attention should be focused on possible differences in the way patients metabolize drugs used during ovarian stimulation. "I think we really need to think about our stimulation protocols, which were not developed with [proportional representation] of these minorities."

In the meantime, "much still remains to be explained, and this is an active area for investigation," she concluded.

Dr. Cedars reported no financial relationships relevant to her talk.

SANTA BARBARA, CALIF. – Ovarian cortex orthotransplantation has resulted in the live births of at least 21 babies to cancer survivors in Europe, where the technique was pioneered and is being refined, Dr. Antonio Pellicer reported at a meeting on in vitro fertilization and embryo transfer.

Unlike the freezing of oocytes or embryos to preserve potential fertility, which requires ovarian stimulation, the ovarian cortex can be harvested from a cancer patient without delay, permitting immediate initiation of chemotherapy and/or radiation therapy. The tissue is cryopreserved until the patient is in remission.

If cancer treatment results in premature ovarian failure and the patient wishes to become pregnant, her autologous ovarian cortex can then be reintroduced.

©tirc83/iStockphoto.com

Ovarian function generally resumes within 3-4 months, said Dr. Pellicer, professor of obstetrics and gynecology and dean of the medical school at the University of Valencia (Spain). Follicle stimulating hormone rates do not reach normal levels, but are sufficient in many cases for resumption of menses and pregnancy, either naturally or through assisted reproductive techniques.

The technique is currently believed to be safe for breast cancer patients and those with Hodgkin’s and non-Hodgkin’s lymphoma, based on histologic and immunologic evaluations of harvested ovarian tissue, Dr. Pellicer said at the meeting, which was sponsored by the University of California, Los Angeles.

It is considered unsafe for patients with leukemia, as metastatic cells might well circulate through the bloodstream to the ovaries. Because of its highly metastatic potential, Ewing’s sarcoma is also considered a contraindication for the procedure, according to Dr. Pellicer.

The technique offers hope, potentially, for prepubertal girls and adolescents with other types of cancer, as well as adult cancer patients, although much remains unknown about the viability and usefulness of the treatment, explained Dr. Pellicer.

At the Valencia Program of Fertility Preservation, more than 600 cancer patients from across Spain have undergone removal of the ovarian cortex around the time of diagnosis, said Dr. Pellicer.

He reported on results in 583 of those patients who were treated since 2005, 55% of whom had been diagnosed with breast cancer.

Regular menses and fertility were restored in some patients who received ovarian autografts, said Dr. Pellicer. In all, 16 pregnancies and 3 live births have occurred, some following in vitro fertilization and some following natural conception.

Those results, along with published studies from programs in France, Germany, Denmark, Belgium, and other countries, indicate that at least 21 and perhaps 23 or more live births have resulted from the technique.

The problem, as Dr. Pellicer sees it, is a lack of cohesive follow-up or evidence that would put those births into perspective.

"We don’t know the number of failed attempts," he said. "There are no registries. There are no real data. Are we doing something which is really helpful? Or are the unsuccessful cases more [typical] than the successful cases?"

"This is a concern to me," he said.

Responding to a question from an audience member, Dr. Pellicer acknowledged that the removal of one ovarian cortex prior to cancer treatment might diminish fertility potential rather than enhance it, because some cancer patients conceive naturally following remission.

Dr. Pellicer reported that he had no relevant financial relationships to disclose.

SANTA BARBARA, CALIF. – Ovarian cortex orthotransplantation has resulted in the live births of at least 21 babies to cancer survivors in Europe, where the technique was pioneered and is being refined, Dr. Antonio Pellicer reported at a meeting on in vitro fertilization and embryo transfer.

Unlike the freezing of oocytes or embryos to preserve potential fertility, which requires ovarian stimulation, the ovarian cortex can be harvested from a cancer patient without delay, permitting immediate initiation of chemotherapy and/or radiation therapy. The tissue is cryopreserved until the patient is in remission.

If cancer treatment results in premature ovarian failure and the patient wishes to become pregnant, her autologous ovarian cortex can then be reintroduced.

©tirc83/iStockphoto.com

Ovarian function generally resumes within 3-4 months, said Dr. Pellicer, professor of obstetrics and gynecology and dean of the medical school at the University of Valencia (Spain). Follicle stimulating hormone rates do not reach normal levels, but are sufficient in many cases for resumption of menses and pregnancy, either naturally or through assisted reproductive techniques.

The technique is currently believed to be safe for breast cancer patients and those with Hodgkin’s and non-Hodgkin’s lymphoma, based on histologic and immunologic evaluations of harvested ovarian tissue, Dr. Pellicer said at the meeting, which was sponsored by the University of California, Los Angeles.

It is considered unsafe for patients with leukemia, as metastatic cells might well circulate through the bloodstream to the ovaries. Because of its highly metastatic potential, Ewing’s sarcoma is also considered a contraindication for the procedure, according to Dr. Pellicer.

The technique offers hope, potentially, for prepubertal girls and adolescents with other types of cancer, as well as adult cancer patients, although much remains unknown about the viability and usefulness of the treatment, explained Dr. Pellicer.

At the Valencia Program of Fertility Preservation, more than 600 cancer patients from across Spain have undergone removal of the ovarian cortex around the time of diagnosis, said Dr. Pellicer.

He reported on results in 583 of those patients who were treated since 2005, 55% of whom had been diagnosed with breast cancer.

Regular menses and fertility were restored in some patients who received ovarian autografts, said Dr. Pellicer. In all, 16 pregnancies and 3 live births have occurred, some following in vitro fertilization and some following natural conception.

Those results, along with published studies from programs in France, Germany, Denmark, Belgium, and other countries, indicate that at least 21 and perhaps 23 or more live births have resulted from the technique.

The problem, as Dr. Pellicer sees it, is a lack of cohesive follow-up or evidence that would put those births into perspective.

"We don’t know the number of failed attempts," he said. "There are no registries. There are no real data. Are we doing something which is really helpful? Or are the unsuccessful cases more [typical] than the successful cases?"

"This is a concern to me," he said.

Responding to a question from an audience member, Dr. Pellicer acknowledged that the removal of one ovarian cortex prior to cancer treatment might diminish fertility potential rather than enhance it, because some cancer patients conceive naturally following remission.

Dr. Pellicer reported that he had no relevant financial relationships to disclose.

SANTA BARBARA, CALIF. – Ovarian cortex orthotransplantation has resulted in the live births of at least 21 babies to cancer survivors in Europe, where the technique was pioneered and is being refined, Dr. Antonio Pellicer reported at a meeting on in vitro fertilization and embryo transfer.

Unlike the freezing of oocytes or embryos to preserve potential fertility, which requires ovarian stimulation, the ovarian cortex can be harvested from a cancer patient without delay, permitting immediate initiation of chemotherapy and/or radiation therapy. The tissue is cryopreserved until the patient is in remission.

If cancer treatment results in premature ovarian failure and the patient wishes to become pregnant, her autologous ovarian cortex can then be reintroduced.

©tirc83/iStockphoto.com

Ovarian function generally resumes within 3-4 months, said Dr. Pellicer, professor of obstetrics and gynecology and dean of the medical school at the University of Valencia (Spain). Follicle stimulating hormone rates do not reach normal levels, but are sufficient in many cases for resumption of menses and pregnancy, either naturally or through assisted reproductive techniques.

The technique is currently believed to be safe for breast cancer patients and those with Hodgkin’s and non-Hodgkin’s lymphoma, based on histologic and immunologic evaluations of harvested ovarian tissue, Dr. Pellicer said at the meeting, which was sponsored by the University of California, Los Angeles.

It is considered unsafe for patients with leukemia, as metastatic cells might well circulate through the bloodstream to the ovaries. Because of its highly metastatic potential, Ewing’s sarcoma is also considered a contraindication for the procedure, according to Dr. Pellicer.

The technique offers hope, potentially, for prepubertal girls and adolescents with other types of cancer, as well as adult cancer patients, although much remains unknown about the viability and usefulness of the treatment, explained Dr. Pellicer.

At the Valencia Program of Fertility Preservation, more than 600 cancer patients from across Spain have undergone removal of the ovarian cortex around the time of diagnosis, said Dr. Pellicer.

He reported on results in 583 of those patients who were treated since 2005, 55% of whom had been diagnosed with breast cancer.

Regular menses and fertility were restored in some patients who received ovarian autografts, said Dr. Pellicer. In all, 16 pregnancies and 3 live births have occurred, some following in vitro fertilization and some following natural conception.

Those results, along with published studies from programs in France, Germany, Denmark, Belgium, and other countries, indicate that at least 21 and perhaps 23 or more live births have resulted from the technique.

The problem, as Dr. Pellicer sees it, is a lack of cohesive follow-up or evidence that would put those births into perspective.

"We don’t know the number of failed attempts," he said. "There are no registries. There are no real data. Are we doing something which is really helpful? Or are the unsuccessful cases more [typical] than the successful cases?"

"This is a concern to me," he said.

Responding to a question from an audience member, Dr. Pellicer acknowledged that the removal of one ovarian cortex prior to cancer treatment might diminish fertility potential rather than enhance it, because some cancer patients conceive naturally following remission.

Dr. Pellicer reported that he had no relevant financial relationships to disclose.

SANTA BARBARA, CALIF. – A third of the audience attending a specialty conference on in vitro fertilization reported hospitalizing a patient for pelvic infection following transvaginal follicle aspiration, and the same percentage reported performing a laparoscopy or laparotomy for bleeding following the procedure.

Bowel and ureteral injuries and retroperitoneal hematomas also were reported, but at far lower rates, Dr. David R. Meldrum said at a conference on in vitro fertilization and embryo transfer sponsored by the University of California, Los Angeles.

While the instant survey was unscientific and represented complications only among specialists who perform many transvaginal procedures, the high rate of serious complications was noteworthy, said Dr. Meldrum, scientific director of Reproductive Partners Medical Group in Redondo Beach, Calif., and director of the annual course on in vitro fertilization and embryo transfer.

"I’ve talked to several people who feel that complications of this procedure are underreported," he said.

"The last thing you want to be is complacent," Dr. Meldrum continued. "As a pilot, I know ... if you ever get complacent about something you should be paying maximal attention to," it will "bite you in the bottom."

Dr. Meldrum noted that transvaginal oocyte retrieval is highly efficacious and generally well tolerated under intravenous sedation. It is not, however, a risk-free procedure.

To reduce the potential for complications, he recommended using a 16- or 17-gauge needle with a very sharp tip and rinsing both the needles and collection tubing before use.

The ovary should be positioned very close to the transducer. Use "firm, constant pressure" of the probe, abdominal pressure, and a tenaculum, he suggested.

During the procedure, the needle should be rotated during movement to avoid bending the needle in any direction.

The ovary should be entered high, away from lower structures. "Don’t have a hint of anything between the ovary and the posterior pelvic wall," he said. In case of positioning difficulties, "keep in mind you can come across from the other side."

"Keep the needle tip well visualized and within the ovary," he said.

Dr. Meldrum reminded the audience that retroperitoneal bleeding can usually be managed by pressure from above when it is recognized during a procedure, but that symptoms may develop hours after the procedure. Abscesses may present up to 6 weeks following a transvaginal follicle aspiration.

Even during normal, successful aspirations, severe pain may occur during the procedure and for several days afterward, in a small percentage of patients.

Dr. Meldrum noted that Tylenol with codeine, a commonly prescribed analgesic, will be ineffective in approximately 1 of 10 patients who don’t metabolize codeine.

He reported that he had no relevant conflicts of interest.

SANTA BARBARA, CALIF. – A third of the audience attending a specialty conference on in vitro fertilization reported hospitalizing a patient for pelvic infection following transvaginal follicle aspiration, and the same percentage reported performing a laparoscopy or laparotomy for bleeding following the procedure.

Bowel and ureteral injuries and retroperitoneal hematomas also were reported, but at far lower rates, Dr. David R. Meldrum said at a conference on in vitro fertilization and embryo transfer sponsored by the University of California, Los Angeles.

While the instant survey was unscientific and represented complications only among specialists who perform many transvaginal procedures, the high rate of serious complications was noteworthy, said Dr. Meldrum, scientific director of Reproductive Partners Medical Group in Redondo Beach, Calif., and director of the annual course on in vitro fertilization and embryo transfer.

"I’ve talked to several people who feel that complications of this procedure are underreported," he said.

"The last thing you want to be is complacent," Dr. Meldrum continued. "As a pilot, I know ... if you ever get complacent about something you should be paying maximal attention to," it will "bite you in the bottom."

Dr. Meldrum noted that transvaginal oocyte retrieval is highly efficacious and generally well tolerated under intravenous sedation. It is not, however, a risk-free procedure.

To reduce the potential for complications, he recommended using a 16- or 17-gauge needle with a very sharp tip and rinsing both the needles and collection tubing before use.

The ovary should be positioned very close to the transducer. Use "firm, constant pressure" of the probe, abdominal pressure, and a tenaculum, he suggested.

During the procedure, the needle should be rotated during movement to avoid bending the needle in any direction.

The ovary should be entered high, away from lower structures. "Don’t have a hint of anything between the ovary and the posterior pelvic wall," he said. In case of positioning difficulties, "keep in mind you can come across from the other side."

"Keep the needle tip well visualized and within the ovary," he said.

Dr. Meldrum reminded the audience that retroperitoneal bleeding can usually be managed by pressure from above when it is recognized during a procedure, but that symptoms may develop hours after the procedure. Abscesses may present up to 6 weeks following a transvaginal follicle aspiration.

Even during normal, successful aspirations, severe pain may occur during the procedure and for several days afterward, in a small percentage of patients.

Dr. Meldrum noted that Tylenol with codeine, a commonly prescribed analgesic, will be ineffective in approximately 1 of 10 patients who don’t metabolize codeine.

He reported that he had no relevant conflicts of interest.

SANTA BARBARA, CALIF. – A third of the audience attending a specialty conference on in vitro fertilization reported hospitalizing a patient for pelvic infection following transvaginal follicle aspiration, and the same percentage reported performing a laparoscopy or laparotomy for bleeding following the procedure.

Bowel and ureteral injuries and retroperitoneal hematomas also were reported, but at far lower rates, Dr. David R. Meldrum said at a conference on in vitro fertilization and embryo transfer sponsored by the University of California, Los Angeles.

While the instant survey was unscientific and represented complications only among specialists who perform many transvaginal procedures, the high rate of serious complications was noteworthy, said Dr. Meldrum, scientific director of Reproductive Partners Medical Group in Redondo Beach, Calif., and director of the annual course on in vitro fertilization and embryo transfer.

"I’ve talked to several people who feel that complications of this procedure are underreported," he said.

"The last thing you want to be is complacent," Dr. Meldrum continued. "As a pilot, I know ... if you ever get complacent about something you should be paying maximal attention to," it will "bite you in the bottom."

Dr. Meldrum noted that transvaginal oocyte retrieval is highly efficacious and generally well tolerated under intravenous sedation. It is not, however, a risk-free procedure.

To reduce the potential for complications, he recommended using a 16- or 17-gauge needle with a very sharp tip and rinsing both the needles and collection tubing before use.

The ovary should be positioned very close to the transducer. Use "firm, constant pressure" of the probe, abdominal pressure, and a tenaculum, he suggested.

During the procedure, the needle should be rotated during movement to avoid bending the needle in any direction.

The ovary should be entered high, away from lower structures. "Don’t have a hint of anything between the ovary and the posterior pelvic wall," he said. In case of positioning difficulties, "keep in mind you can come across from the other side."

"Keep the needle tip well visualized and within the ovary," he said.

Dr. Meldrum reminded the audience that retroperitoneal bleeding can usually be managed by pressure from above when it is recognized during a procedure, but that symptoms may develop hours after the procedure. Abscesses may present up to 6 weeks following a transvaginal follicle aspiration.

Even during normal, successful aspirations, severe pain may occur during the procedure and for several days afterward, in a small percentage of patients.

Dr. Meldrum noted that Tylenol with codeine, a commonly prescribed analgesic, will be ineffective in approximately 1 of 10 patients who don’t metabolize codeine.

He reported that he had no relevant conflicts of interest.

SANTA BARBARA, CALIF. – Routine comprehensive chromosomal screening so improves implantation rates that it makes single embryo transfer a realistic and highly cost-efficient procedure for couples undergoing in vitro fertilization, according to Dr. Richard T. Scott Jr.

In a randomized clinical trial, comprehensive chromosome screening led to successful implantation in 54 of 71 cycles (a 76.1% implantation rate), compared with 42 of 81 cycles (51.8%) in those treated in a standard fashion at Reproductive Medicine Associates of New Jersey, Morristown, the clinical center serving the division of reproductive endocrinology at the Robert Wood Johnson Medical School. Dr. Scott serves as professor and director of the division, and as clinical and scientific director of the medical group.

A 4-hour polymerase chain reaction (PCR) screening assay chromosome screen resulted in a delivery rate of 87.2% (34 of 39 patients), compared with a control rate of 68.3% (28 of 41) in a randomized trial conducted at his center, reported Dr. Scott at the conference on in vitro fertilization and embryo transfer, which was sponsored by the University of California, Los Angeles.

By upping the odds of a successful implantation and delivery, routine chromosome screening may one day outpace aneuploidy screening as the method of choice for selecting prime candidates for transfer, Dr. Scott predicted.

Indeed, his group has challenged the accuracy of aneuploidy screening, suggesting that it results in a high rate of false aneuploid results, thus lowering the transfer rate of embryos that might result in healthy infants. Along the way, the temptation builds to implant more than one embryo, despite the risks inherent in twin or higher-order multiple pregnancies, he said.

"It’s mathematically impossible for one to be as good as two," he said. "The gain approaches 25%. The bottom line is, it’s always tempting."

Dr. Scott said that the results from using comprehensive chromosomal screening for embryo selection are so superior that they might override that temptation, resulting in healthier singleton pregnancies at a reasonable cost to patients.

"I think it’s safe to say one screened embryo does as well or better than two unscreened embryos," he said. "The question is, is it cost effective?"

Answering his own question, Dr. Scott asserted, "It’s overwhelmingly and amazingly cost effective."

The cost of a singleton pregnancy, delivery, and newborn care following comprehensive chromosomal screening and IVF vs. aneuploidy screening and IVF followed by a twin pregnancy saves $1.8 million per 100 patients, or $18,700 per patient, he estimated.

The cost of infertility treatment in such an equation basically costs out at zero for couples who decide to transfer only one chromosomally selected embryo, said Dr. Scott.

The chance of abnormal gestations following comprehensive chromosomal screening is "not zero, but awfully low," he reported.

Specifically, Dr. Scott’s clinic’s clinical error rate was 0.2% in over 3,500 screened euploid embryos transferred, in more than 2,400 clinical implantations.

When products of conception were subjected to DNA fingerprinting to establish embryo origins, five abnormal gestations were traced to the procedure, including one diagnostic error (a tetraploid embryo), one trisomy 13, one Turner’s syndrome, one trisomy 21, and one healthy baby born with the opposite gender than what was predicted, through a lab error.

Dr. Scott reported that he receives grant research support and is on the speakers bureau and the scientific advisory board for EMD Serono and Ferring Pharmaceuticals. He also receives grant research support and is on the speakers bureau for Merck.

SANTA BARBARA, CALIF. – Routine comprehensive chromosomal screening so improves implantation rates that it makes single embryo transfer a realistic and highly cost-efficient procedure for couples undergoing in vitro fertilization, according to Dr. Richard T. Scott Jr.

In a randomized clinical trial, comprehensive chromosome screening led to successful implantation in 54 of 71 cycles (a 76.1% implantation rate), compared with 42 of 81 cycles (51.8%) in those treated in a standard fashion at Reproductive Medicine Associates of New Jersey, Morristown, the clinical center serving the division of reproductive endocrinology at the Robert Wood Johnson Medical School. Dr. Scott serves as professor and director of the division, and as clinical and scientific director of the medical group.

A 4-hour polymerase chain reaction (PCR) screening assay chromosome screen resulted in a delivery rate of 87.2% (34 of 39 patients), compared with a control rate of 68.3% (28 of 41) in a randomized trial conducted at his center, reported Dr. Scott at the conference on in vitro fertilization and embryo transfer, which was sponsored by the University of California, Los Angeles.

By upping the odds of a successful implantation and delivery, routine chromosome screening may one day outpace aneuploidy screening as the method of choice for selecting prime candidates for transfer, Dr. Scott predicted.

Indeed, his group has challenged the accuracy of aneuploidy screening, suggesting that it results in a high rate of false aneuploid results, thus lowering the transfer rate of embryos that might result in healthy infants. Along the way, the temptation builds to implant more than one embryo, despite the risks inherent in twin or higher-order multiple pregnancies, he said.

"It’s mathematically impossible for one to be as good as two," he said. "The gain approaches 25%. The bottom line is, it’s always tempting."

Dr. Scott said that the results from using comprehensive chromosomal screening for embryo selection are so superior that they might override that temptation, resulting in healthier singleton pregnancies at a reasonable cost to patients.

"I think it’s safe to say one screened embryo does as well or better than two unscreened embryos," he said. "The question is, is it cost effective?"

Answering his own question, Dr. Scott asserted, "It’s overwhelmingly and amazingly cost effective."

The cost of a singleton pregnancy, delivery, and newborn care following comprehensive chromosomal screening and IVF vs. aneuploidy screening and IVF followed by a twin pregnancy saves $1.8 million per 100 patients, or $18,700 per patient, he estimated.

The cost of infertility treatment in such an equation basically costs out at zero for couples who decide to transfer only one chromosomally selected embryo, said Dr. Scott.

The chance of abnormal gestations following comprehensive chromosomal screening is "not zero, but awfully low," he reported.

Specifically, Dr. Scott’s clinic’s clinical error rate was 0.2% in over 3,500 screened euploid embryos transferred, in more than 2,400 clinical implantations.

When products of conception were subjected to DNA fingerprinting to establish embryo origins, five abnormal gestations were traced to the procedure, including one diagnostic error (a tetraploid embryo), one trisomy 13, one Turner’s syndrome, one trisomy 21, and one healthy baby born with the opposite gender than what was predicted, through a lab error.

Dr. Scott reported that he receives grant research support and is on the speakers bureau and the scientific advisory board for EMD Serono and Ferring Pharmaceuticals. He also receives grant research support and is on the speakers bureau for Merck.

SANTA BARBARA, CALIF. – Routine comprehensive chromosomal screening so improves implantation rates that it makes single embryo transfer a realistic and highly cost-efficient procedure for couples undergoing in vitro fertilization, according to Dr. Richard T. Scott Jr.

In a randomized clinical trial, comprehensive chromosome screening led to successful implantation in 54 of 71 cycles (a 76.1% implantation rate), compared with 42 of 81 cycles (51.8%) in those treated in a standard fashion at Reproductive Medicine Associates of New Jersey, Morristown, the clinical center serving the division of reproductive endocrinology at the Robert Wood Johnson Medical School. Dr. Scott serves as professor and director of the division, and as clinical and scientific director of the medical group.

A 4-hour polymerase chain reaction (PCR) screening assay chromosome screen resulted in a delivery rate of 87.2% (34 of 39 patients), compared with a control rate of 68.3% (28 of 41) in a randomized trial conducted at his center, reported Dr. Scott at the conference on in vitro fertilization and embryo transfer, which was sponsored by the University of California, Los Angeles.

By upping the odds of a successful implantation and delivery, routine chromosome screening may one day outpace aneuploidy screening as the method of choice for selecting prime candidates for transfer, Dr. Scott predicted.

Indeed, his group has challenged the accuracy of aneuploidy screening, suggesting that it results in a high rate of false aneuploid results, thus lowering the transfer rate of embryos that might result in healthy infants. Along the way, the temptation builds to implant more than one embryo, despite the risks inherent in twin or higher-order multiple pregnancies, he said.

"It’s mathematically impossible for one to be as good as two," he said. "The gain approaches 25%. The bottom line is, it’s always tempting."

Dr. Scott said that the results from using comprehensive chromosomal screening for embryo selection are so superior that they might override that temptation, resulting in healthier singleton pregnancies at a reasonable cost to patients.

"I think it’s safe to say one screened embryo does as well or better than two unscreened embryos," he said. "The question is, is it cost effective?"

Answering his own question, Dr. Scott asserted, "It’s overwhelmingly and amazingly cost effective."

The cost of a singleton pregnancy, delivery, and newborn care following comprehensive chromosomal screening and IVF vs. aneuploidy screening and IVF followed by a twin pregnancy saves $1.8 million per 100 patients, or $18,700 per patient, he estimated.

The cost of infertility treatment in such an equation basically costs out at zero for couples who decide to transfer only one chromosomally selected embryo, said Dr. Scott.

The chance of abnormal gestations following comprehensive chromosomal screening is "not zero, but awfully low," he reported.

Specifically, Dr. Scott’s clinic’s clinical error rate was 0.2% in over 3,500 screened euploid embryos transferred, in more than 2,400 clinical implantations.

When products of conception were subjected to DNA fingerprinting to establish embryo origins, five abnormal gestations were traced to the procedure, including one diagnostic error (a tetraploid embryo), one trisomy 13, one Turner’s syndrome, one trisomy 21, and one healthy baby born with the opposite gender than what was predicted, through a lab error.

Dr. Scott reported that he receives grant research support and is on the speakers bureau and the scientific advisory board for EMD Serono and Ferring Pharmaceuticals. He also receives grant research support and is on the speakers bureau for Merck.

SANTA BARBARA, CALIF. – To err on the side of caution, couples who are concerned about the risks to mother and baby from in vitro fertilization might be advised to avoid intracytoplasmic sperm injection, to transfer frozen embryos rather than fresh, and to ask their fertility specialists to restrict the estrogen level during stimulation to less than 3,450 pg/mL on the day of HCG administration, according to Dr. Joseph C. Gambone.

The problem is, none of those guidelines is clear-cut, he said at a conference on in vitro fertilization and embryo transfer, sponsored by the University of California, Los Angeles.

Flaws in scientific methodology permeate studies that hint at elevated risks of maternal and childhood cancer, perinatal complications, and birth defects, making it difficult to advise patients about which risks are truly elevated because of assisted reproductive technology (ART).

"It’s just so enticing to get into these big databases and start fishing," said Dr. Gambone, who is in private practice in Durango, Colo. "There certainly are people who violate [valid scientific method] more than others."

Common scientific errors include inappropriate data mining, the failure to include subfertile women as controls, and the failure to consider the potential contribution of male infertility or advanced paternal age to genetic abnormalities.

Pointing to one example, Dr. Gambone reviewed a recent report from an autism conference implying an increased rate of autism among infants born through ART. However, fertile women in the general population were used as the control group, rather than subfertile women who did not undergo ART treatment prior to becoming pregnant.

Other studies failed to control for maternal age, although in vitro fertilization (IVF) mothers are generally far older than women who become pregnant on their own, and would be at higher risk for some negative outcomes based on their age alone.

That said, Dr. Gambone updated the audience on the new studies – albeit with limitations – that might give providers and prospective parents some perspective on the following IVF risks:

• Birth defects. A study based on a large Australian registry found significant differences in the rate of birth defects in ART babies, compared with the rate in babies of a control group comprising fertile and subfertile women (8.3% vs. 5.8%); the highest rate of birth defects (9.9%) was in babies conceived via intracytoplasmic sperm injection (N. Engl. J. Med. 2012;366:1803-13). No increase in risk was seen when frozen embryo transfer was employed, noted Dr. Gambone.

Accumulating data suggest that frozen embryo transfer "may be the way for us to head with this technology," he said.

• Maternal breast cancer. No overall increase in breast cancer risk was seen in women who underwent IVF in a large, population-based cohort study that was also drawn from Australian hospital and registry data. However, a 59% increase in risk was seen among younger women, defined in this study as those who started IVF at age 24 years (Fertil. Steril. 2012;98:334-40).

• Preeclampsia and SGA risks. Like many studies, a new report from the Massachusetts General Hospital in Boston found an increased risk of small-for-gestational-age infants in singleton pregnancies among women who underwent IVF (Fertil. Steril. 2012;97:1374-9). Preeclampsia rates were also higher in pregnancies associated with elevated peak serum estradiol levels during controlled ovarian hyperstimulation, but "this was interesting, and actually gave us a threshold," said Dr. Gambone. "It’s a novel and interesting way of looking at it."

Higher risk for both events was associated with elevated peak serum estradiol levels (greater than 3,450 pg/mL) on the day of HCG administration.

Dr. Gambone reported that he has no relevant financial disclosures.

SANTA BARBARA, CALIF. – To err on the side of caution, couples who are concerned about the risks to mother and baby from in vitro fertilization might be advised to avoid intracytoplasmic sperm injection, to transfer frozen embryos rather than fresh, and to ask their fertility specialists to restrict the estrogen level during stimulation to less than 3,450 pg/mL on the day of HCG administration, according to Dr. Joseph C. Gambone.

The problem is, none of those guidelines is clear-cut, he said at a conference on in vitro fertilization and embryo transfer, sponsored by the University of California, Los Angeles.

Flaws in scientific methodology permeate studies that hint at elevated risks of maternal and childhood cancer, perinatal complications, and birth defects, making it difficult to advise patients about which risks are truly elevated because of assisted reproductive technology (ART).

"It’s just so enticing to get into these big databases and start fishing," said Dr. Gambone, who is in private practice in Durango, Colo. "There certainly are people who violate [valid scientific method] more than others."

Common scientific errors include inappropriate data mining, the failure to include subfertile women as controls, and the failure to consider the potential contribution of male infertility or advanced paternal age to genetic abnormalities.

Pointing to one example, Dr. Gambone reviewed a recent report from an autism conference implying an increased rate of autism among infants born through ART. However, fertile women in the general population were used as the control group, rather than subfertile women who did not undergo ART treatment prior to becoming pregnant.

Other studies failed to control for maternal age, although in vitro fertilization (IVF) mothers are generally far older than women who become pregnant on their own, and would be at higher risk for some negative outcomes based on their age alone.

That said, Dr. Gambone updated the audience on the new studies – albeit with limitations – that might give providers and prospective parents some perspective on the following IVF risks:

• Birth defects. A study based on a large Australian registry found significant differences in the rate of birth defects in ART babies, compared with the rate in babies of a control group comprising fertile and subfertile women (8.3% vs. 5.8%); the highest rate of birth defects (9.9%) was in babies conceived via intracytoplasmic sperm injection (N. Engl. J. Med. 2012;366:1803-13). No increase in risk was seen when frozen embryo transfer was employed, noted Dr. Gambone.

Accumulating data suggest that frozen embryo transfer "may be the way for us to head with this technology," he said.

• Maternal breast cancer. No overall increase in breast cancer risk was seen in women who underwent IVF in a large, population-based cohort study that was also drawn from Australian hospital and registry data. However, a 59% increase in risk was seen among younger women, defined in this study as those who started IVF at age 24 years (Fertil. Steril. 2012;98:334-40).

• Preeclampsia and SGA risks. Like many studies, a new report from the Massachusetts General Hospital in Boston found an increased risk of small-for-gestational-age infants in singleton pregnancies among women who underwent IVF (Fertil. Steril. 2012;97:1374-9). Preeclampsia rates were also higher in pregnancies associated with elevated peak serum estradiol levels during controlled ovarian hyperstimulation, but "this was interesting, and actually gave us a threshold," said Dr. Gambone. "It’s a novel and interesting way of looking at it."

Higher risk for both events was associated with elevated peak serum estradiol levels (greater than 3,450 pg/mL) on the day of HCG administration.

Dr. Gambone reported that he has no relevant financial disclosures.

SANTA BARBARA, CALIF. – To err on the side of caution, couples who are concerned about the risks to mother and baby from in vitro fertilization might be advised to avoid intracytoplasmic sperm injection, to transfer frozen embryos rather than fresh, and to ask their fertility specialists to restrict the estrogen level during stimulation to less than 3,450 pg/mL on the day of HCG administration, according to Dr. Joseph C. Gambone.

The problem is, none of those guidelines is clear-cut, he said at a conference on in vitro fertilization and embryo transfer, sponsored by the University of California, Los Angeles.

Flaws in scientific methodology permeate studies that hint at elevated risks of maternal and childhood cancer, perinatal complications, and birth defects, making it difficult to advise patients about which risks are truly elevated because of assisted reproductive technology (ART).

"It’s just so enticing to get into these big databases and start fishing," said Dr. Gambone, who is in private practice in Durango, Colo. "There certainly are people who violate [valid scientific method] more than others."

Common scientific errors include inappropriate data mining, the failure to include subfertile women as controls, and the failure to consider the potential contribution of male infertility or advanced paternal age to genetic abnormalities.

Pointing to one example, Dr. Gambone reviewed a recent report from an autism conference implying an increased rate of autism among infants born through ART. However, fertile women in the general population were used as the control group, rather than subfertile women who did not undergo ART treatment prior to becoming pregnant.

Other studies failed to control for maternal age, although in vitro fertilization (IVF) mothers are generally far older than women who become pregnant on their own, and would be at higher risk for some negative outcomes based on their age alone.

That said, Dr. Gambone updated the audience on the new studies – albeit with limitations – that might give providers and prospective parents some perspective on the following IVF risks:

• Birth defects. A study based on a large Australian registry found significant differences in the rate of birth defects in ART babies, compared with the rate in babies of a control group comprising fertile and subfertile women (8.3% vs. 5.8%); the highest rate of birth defects (9.9%) was in babies conceived via intracytoplasmic sperm injection (N. Engl. J. Med. 2012;366:1803-13). No increase in risk was seen when frozen embryo transfer was employed, noted Dr. Gambone.

Accumulating data suggest that frozen embryo transfer "may be the way for us to head with this technology," he said.

• Maternal breast cancer. No overall increase in breast cancer risk was seen in women who underwent IVF in a large, population-based cohort study that was also drawn from Australian hospital and registry data. However, a 59% increase in risk was seen among younger women, defined in this study as those who started IVF at age 24 years (Fertil. Steril. 2012;98:334-40).

• Preeclampsia and SGA risks. Like many studies, a new report from the Massachusetts General Hospital in Boston found an increased risk of small-for-gestational-age infants in singleton pregnancies among women who underwent IVF (Fertil. Steril. 2012;97:1374-9). Preeclampsia rates were also higher in pregnancies associated with elevated peak serum estradiol levels during controlled ovarian hyperstimulation, but "this was interesting, and actually gave us a threshold," said Dr. Gambone. "It’s a novel and interesting way of looking at it."

Higher risk for both events was associated with elevated peak serum estradiol levels (greater than 3,450 pg/mL) on the day of HCG administration.

Dr. Gambone reported that he has no relevant financial disclosures.

SANTA BARBARA, CALIF. – Given the state of the economy, lower cost alternatives to in vitro fertilization appear to be gaining favor, spurring a look back into history at the potential for superovulation and intrauterine insemination to achieve pregnancy in infertile couples.

At a conference on in vitro fertilization and embryo transfer, an audience response survey found that 58% of the audience of more than 100 specialists reported that they currently performed more superovulation/intrauterine insemination (IUI) cycles than IVF cycles.

"Last year, it was a third" of the audience, said Dr. Bill Yee, medical director of Reproductive Partners Medical Group in Westminster, Calif., and a presenter at the meeting, which was sponsored by the University of California, Los Angeles.

Dr. Yee reviewed early papers on superovulation/IUI, including a series documenting a pregnancy rate of 16%/cycle in 85 patients (Fertil. Steril. 1987;48:441-5).

"That was damned good in the mid-’80s," and rivaled the results of early IVF, said Dr. Yee.

A renewed interest in the technique led Dr. Yee to investigate recent results using gonadotropin/IUI in more than 7,000 cycles among participants in IntegraMed America’s group of fertility centers that includes Dr. Yee’s offices.

In 2009, the group’s overall success rate averaged 10%/cycle in patients aged 41-42 years; 13.6% in those aged 38-40 years; 15.5% in 35- to 37-year-olds, and 20.3% in those younger than 35. Dr. Yee’s own practice’s results during 2009 and 2010 were 7.8%, 10.7%, 13.5%, and 24.3% in the same age categories, respectively.

"The overall success rate per cycle is not too bad," he concluded, noting that each cycle costs far less than an IVF cycle.

The use of clomiphene followed by IUI was less successful in Dr. Yee’s practice, achieving pregnancy rates of 6%-9% per cycle in patients younger than 40, and no pregnancies in the group older than 40.

Higher-order pregnancy – a risk of hyperstimulation and IUI – was the result in 2%-3% of pregnancies in the large IntegraMed series.

As Dr. Yee was collecting the data, a pertinent overview appeared "just by chance" on the occasion of the quarter-centennial of the technique’s use in treating infertility (Fertil. Steril. 2012;97:802-9). The overview authors compared higher-order multiple rates in 10 studies that employed high doses (150 IU or more) of gonadotropins vs. 7 studies using 75 IU or less and determined that the risk of triplets or above was "practically zero," when the lower dose was used.

Indeed, although twins resulted from as many as 29% of successful inseminations in the low-dose studies, no higher-order multiples were reported in 1,123 cycles. When higher doses of gonadotropins were used, as many as 9.3% of pregnancies involved higher-order multiples.

"Maybe the take-home message is that despite the fact the patient is 45 [years old,] maybe we should stick to 75 IU or less just to prevent the risk of higher-order pregnancies," said Dr. Yee.

Dr. Yee also discussed natural or "minimal" stimulation using clomiphene during IVF and noted that the approach can achieve a 10% pregnancy rate/cycle in so-called "poor responders" as a final alternative to using donor eggs.

"You have to individualize," he said, but such an approach would cost a couple approximately $5,000/cycle vs. $16,000-$17,000, primarily by reducing visits, procedures, and medications.

Dr. Yee made the following general recommendations for budget-conscious patients:

• In patients younger than 40 years with unexplained infertility or mild "male factor" infertility, try one cycle of clomiphene/IUI followed by one cycle of low-dose FSH/IUI.

• In poor responders who require IVF, try natural or minimal stimulation IVF with clomiphene alone as a "viable alternative" to standard IVF.

• For clomiphene IVF cycles, freezing embryos with subsequent frozen embryo transfer appears to lead to higher success rates.

Dr. Yee reported no financial disclosures relevant to his talk.

SANTA BARBARA, CALIF. – Given the state of the economy, lower cost alternatives to in vitro fertilization appear to be gaining favor, spurring a look back into history at the potential for superovulation and intrauterine insemination to achieve pregnancy in infertile couples.

At a conference on in vitro fertilization and embryo transfer, an audience response survey found that 58% of the audience of more than 100 specialists reported that they currently performed more superovulation/intrauterine insemination (IUI) cycles than IVF cycles.

"Last year, it was a third" of the audience, said Dr. Bill Yee, medical director of Reproductive Partners Medical Group in Westminster, Calif., and a presenter at the meeting, which was sponsored by the University of California, Los Angeles.

Dr. Yee reviewed early papers on superovulation/IUI, including a series documenting a pregnancy rate of 16%/cycle in 85 patients (Fertil. Steril. 1987;48:441-5).

"That was damned good in the mid-’80s," and rivaled the results of early IVF, said Dr. Yee.

A renewed interest in the technique led Dr. Yee to investigate recent results using gonadotropin/IUI in more than 7,000 cycles among participants in IntegraMed America’s group of fertility centers that includes Dr. Yee’s offices.

In 2009, the group’s overall success rate averaged 10%/cycle in patients aged 41-42 years; 13.6% in those aged 38-40 years; 15.5% in 35- to 37-year-olds, and 20.3% in those younger than 35. Dr. Yee’s own practice’s results during 2009 and 2010 were 7.8%, 10.7%, 13.5%, and 24.3% in the same age categories, respectively.

"The overall success rate per cycle is not too bad," he concluded, noting that each cycle costs far less than an IVF cycle.

The use of clomiphene followed by IUI was less successful in Dr. Yee’s practice, achieving pregnancy rates of 6%-9% per cycle in patients younger than 40, and no pregnancies in the group older than 40.

Higher-order pregnancy – a risk of hyperstimulation and IUI – was the result in 2%-3% of pregnancies in the large IntegraMed series.

As Dr. Yee was collecting the data, a pertinent overview appeared "just by chance" on the occasion of the quarter-centennial of the technique’s use in treating infertility (Fertil. Steril. 2012;97:802-9). The overview authors compared higher-order multiple rates in 10 studies that employed high doses (150 IU or more) of gonadotropins vs. 7 studies using 75 IU or less and determined that the risk of triplets or above was "practically zero," when the lower dose was used.

Indeed, although twins resulted from as many as 29% of successful inseminations in the low-dose studies, no higher-order multiples were reported in 1,123 cycles. When higher doses of gonadotropins were used, as many as 9.3% of pregnancies involved higher-order multiples.

"Maybe the take-home message is that despite the fact the patient is 45 [years old,] maybe we should stick to 75 IU or less just to prevent the risk of higher-order pregnancies," said Dr. Yee.

Dr. Yee also discussed natural or "minimal" stimulation using clomiphene during IVF and noted that the approach can achieve a 10% pregnancy rate/cycle in so-called "poor responders" as a final alternative to using donor eggs.

"You have to individualize," he said, but such an approach would cost a couple approximately $5,000/cycle vs. $16,000-$17,000, primarily by reducing visits, procedures, and medications.

Dr. Yee made the following general recommendations for budget-conscious patients:

• In patients younger than 40 years with unexplained infertility or mild "male factor" infertility, try one cycle of clomiphene/IUI followed by one cycle of low-dose FSH/IUI.

• In poor responders who require IVF, try natural or minimal stimulation IVF with clomiphene alone as a "viable alternative" to standard IVF.

• For clomiphene IVF cycles, freezing embryos with subsequent frozen embryo transfer appears to lead to higher success rates.

Dr. Yee reported no financial disclosures relevant to his talk.

SANTA BARBARA, CALIF. – Given the state of the economy, lower cost alternatives to in vitro fertilization appear to be gaining favor, spurring a look back into history at the potential for superovulation and intrauterine insemination to achieve pregnancy in infertile couples.

At a conference on in vitro fertilization and embryo transfer, an audience response survey found that 58% of the audience of more than 100 specialists reported that they currently performed more superovulation/intrauterine insemination (IUI) cycles than IVF cycles.

"Last year, it was a third" of the audience, said Dr. Bill Yee, medical director of Reproductive Partners Medical Group in Westminster, Calif., and a presenter at the meeting, which was sponsored by the University of California, Los Angeles.

Dr. Yee reviewed early papers on superovulation/IUI, including a series documenting a pregnancy rate of 16%/cycle in 85 patients (Fertil. Steril. 1987;48:441-5).

"That was damned good in the mid-’80s," and rivaled the results of early IVF, said Dr. Yee.

A renewed interest in the technique led Dr. Yee to investigate recent results using gonadotropin/IUI in more than 7,000 cycles among participants in IntegraMed America’s group of fertility centers that includes Dr. Yee’s offices.

In 2009, the group’s overall success rate averaged 10%/cycle in patients aged 41-42 years; 13.6% in those aged 38-40 years; 15.5% in 35- to 37-year-olds, and 20.3% in those younger than 35. Dr. Yee’s own practice’s results during 2009 and 2010 were 7.8%, 10.7%, 13.5%, and 24.3% in the same age categories, respectively.

"The overall success rate per cycle is not too bad," he concluded, noting that each cycle costs far less than an IVF cycle.

The use of clomiphene followed by IUI was less successful in Dr. Yee’s practice, achieving pregnancy rates of 6%-9% per cycle in patients younger than 40, and no pregnancies in the group older than 40.

Higher-order pregnancy – a risk of hyperstimulation and IUI – was the result in 2%-3% of pregnancies in the large IntegraMed series.

As Dr. Yee was collecting the data, a pertinent overview appeared "just by chance" on the occasion of the quarter-centennial of the technique’s use in treating infertility (Fertil. Steril. 2012;97:802-9). The overview authors compared higher-order multiple rates in 10 studies that employed high doses (150 IU or more) of gonadotropins vs. 7 studies using 75 IU or less and determined that the risk of triplets or above was "practically zero," when the lower dose was used.

Indeed, although twins resulted from as many as 29% of successful inseminations in the low-dose studies, no higher-order multiples were reported in 1,123 cycles. When higher doses of gonadotropins were used, as many as 9.3% of pregnancies involved higher-order multiples.

"Maybe the take-home message is that despite the fact the patient is 45 [years old,] maybe we should stick to 75 IU or less just to prevent the risk of higher-order pregnancies," said Dr. Yee.

Dr. Yee also discussed natural or "minimal" stimulation using clomiphene during IVF and noted that the approach can achieve a 10% pregnancy rate/cycle in so-called "poor responders" as a final alternative to using donor eggs.

"You have to individualize," he said, but such an approach would cost a couple approximately $5,000/cycle vs. $16,000-$17,000, primarily by reducing visits, procedures, and medications.

Dr. Yee made the following general recommendations for budget-conscious patients:

• In patients younger than 40 years with unexplained infertility or mild "male factor" infertility, try one cycle of clomiphene/IUI followed by one cycle of low-dose FSH/IUI.

• In poor responders who require IVF, try natural or minimal stimulation IVF with clomiphene alone as a "viable alternative" to standard IVF.

• For clomiphene IVF cycles, freezing embryos with subsequent frozen embryo transfer appears to lead to higher success rates.

Dr. Yee reported no financial disclosures relevant to his talk.

SANTA BARBARA, CALIF. – Unique protein signatures in the media surrounding embryos may soon provide a noninvasive means of identifying viability and aneuploidy, Dr. William B. Schoolcraft predicted at a conference on in vitro fertilization and embryo transfer sponsored by the University of California, Los Angeles.

Biopsies performed during preimplantation genetic diagnosis or comprehensive chromosome screening are "very invasive procedures" that are comparable to surgery or a forceps delivery, said Dr. Schoolcraft.

Removal of the embryo from an incubator, exposure to the heat of a laser, and traumatic manipulation may cause subtle harm, resulting in short- or long-term complications, he added.

But fascinating developments in the laboratory have confirmed dynamic, day-by-day evolutions in the pattern of proteins that are taken up – and secreted – by embryos in culture, providing evidence of distinctive signatures indicating viability, gene expression, and prospects for implantation, Dr. Schoolcraft noted.

To date, his group has identified more than 250 proteins in spent media from embryos, 74 of which are uniquely expressed in that environment.

"Some are excreted only by early embryos, some by embryos throughout preimplantation development, and most interestingly, some proteins are just excreted by embryos on day 3 to day 5, suggesting they might be markers for viability," said Dr. Schoolcraft, medical director of the Colorado Center for Reproductive Medicine, Lone Tree.

Indeed, 14 biomarkers are differentially expressed in culture on day 5, which holds great promise for selection of the embryos that are most likely to be successfully implanted.

Nine specific proteins have been identified as candidate biomarkers, including lipocalin-1, which has proved to demonstrate increased expression in aneuploid blastocyst secretome, the material secreted from the embryo.

Significant differences in pregnancy rates have also been found based on reactive oxygen species in the spent media of day 3 embryos, highlighting "another potential marker" for embryo viability and health, said Dr. Schoolcraft.

"The concept would be that in addition to morphology – certainly not in place of morphology – we would be able to look at spent media and identify proteins" that suggest high viability, and select only those embryos that "don’t possess a signature of aneuploidy," he said.

Dr. Schoolcraft reported that he had no relevant financial disclosures.

SANTA BARBARA, CALIF. – Unique protein signatures in the media surrounding embryos may soon provide a noninvasive means of identifying viability and aneuploidy, Dr. William B. Schoolcraft predicted at a conference on in vitro fertilization and embryo transfer sponsored by the University of California, Los Angeles.

Biopsies performed during preimplantation genetic diagnosis or comprehensive chromosome screening are "very invasive procedures" that are comparable to surgery or a forceps delivery, said Dr. Schoolcraft.

Removal of the embryo from an incubator, exposure to the heat of a laser, and traumatic manipulation may cause subtle harm, resulting in short- or long-term complications, he added.

But fascinating developments in the laboratory have confirmed dynamic, day-by-day evolutions in the pattern of proteins that are taken up – and secreted – by embryos in culture, providing evidence of distinctive signatures indicating viability, gene expression, and prospects for implantation, Dr. Schoolcraft noted.

To date, his group has identified more than 250 proteins in spent media from embryos, 74 of which are uniquely expressed in that environment.

"Some are excreted only by early embryos, some by embryos throughout preimplantation development, and most interestingly, some proteins are just excreted by embryos on day 3 to day 5, suggesting they might be markers for viability," said Dr. Schoolcraft, medical director of the Colorado Center for Reproductive Medicine, Lone Tree.

Indeed, 14 biomarkers are differentially expressed in culture on day 5, which holds great promise for selection of the embryos that are most likely to be successfully implanted.

Nine specific proteins have been identified as candidate biomarkers, including lipocalin-1, which has proved to demonstrate increased expression in aneuploid blastocyst secretome, the material secreted from the embryo.

Significant differences in pregnancy rates have also been found based on reactive oxygen species in the spent media of day 3 embryos, highlighting "another potential marker" for embryo viability and health, said Dr. Schoolcraft.

"The concept would be that in addition to morphology – certainly not in place of morphology – we would be able to look at spent media and identify proteins" that suggest high viability, and select only those embryos that "don’t possess a signature of aneuploidy," he said.

Dr. Schoolcraft reported that he had no relevant financial disclosures.

SANTA BARBARA, CALIF. – Unique protein signatures in the media surrounding embryos may soon provide a noninvasive means of identifying viability and aneuploidy, Dr. William B. Schoolcraft predicted at a conference on in vitro fertilization and embryo transfer sponsored by the University of California, Los Angeles.

Biopsies performed during preimplantation genetic diagnosis or comprehensive chromosome screening are "very invasive procedures" that are comparable to surgery or a forceps delivery, said Dr. Schoolcraft.

Removal of the embryo from an incubator, exposure to the heat of a laser, and traumatic manipulation may cause subtle harm, resulting in short- or long-term complications, he added.

But fascinating developments in the laboratory have confirmed dynamic, day-by-day evolutions in the pattern of proteins that are taken up – and secreted – by embryos in culture, providing evidence of distinctive signatures indicating viability, gene expression, and prospects for implantation, Dr. Schoolcraft noted.

To date, his group has identified more than 250 proteins in spent media from embryos, 74 of which are uniquely expressed in that environment.

"Some are excreted only by early embryos, some by embryos throughout preimplantation development, and most interestingly, some proteins are just excreted by embryos on day 3 to day 5, suggesting they might be markers for viability," said Dr. Schoolcraft, medical director of the Colorado Center for Reproductive Medicine, Lone Tree.

Indeed, 14 biomarkers are differentially expressed in culture on day 5, which holds great promise for selection of the embryos that are most likely to be successfully implanted.

Nine specific proteins have been identified as candidate biomarkers, including lipocalin-1, which has proved to demonstrate increased expression in aneuploid blastocyst secretome, the material secreted from the embryo.

Significant differences in pregnancy rates have also been found based on reactive oxygen species in the spent media of day 3 embryos, highlighting "another potential marker" for embryo viability and health, said Dr. Schoolcraft.

"The concept would be that in addition to morphology – certainly not in place of morphology – we would be able to look at spent media and identify proteins" that suggest high viability, and select only those embryos that "don’t possess a signature of aneuploidy," he said.

Dr. Schoolcraft reported that he had no relevant financial disclosures.

SANTA BARBARA, CALIF. – Surgical hysteroscopy may be the most efficient way to restore fertility in women with cesarean-induced isthmoceles, but no randomized trials exist to guide clinicians concerning what may loom as a notable contributor to secondary infertility.

Reservoirlike pouch defects develop on the anterior wall of the uterine isthmus at the site of a cesarean section scar in an unknown percentage of women, explained Dr. Mousa Shamonki at an annual conference on in vitro fertilization and embryo transfer sponsored by the University of California, Los Angeles.

"This may be a cause of fluid accumulation in the uterine cavity, or be associated with abnormal uterine bleeding," said Dr. Shamonki, director of in vitro fertilization and assisted reproduction at the university.

Surgical correction, he added, "may correct bleeding and fluid accumulation, and potentially restore fertility."

"You’ll notice I’m being very careful in my verbiage here," he emphasized, noting that the lack of epidemiologic data or randomized trials makes the scope of the problem and its treatment unclear.

With cesarean deliveries’ constituting nearly a third of live births in the United States, any common complication is likely to powerfully impact gynecologic and obstetrical practice.

In a recent review, Dr. Pasquale Florio and his associates at the University of Siena (Italy) suggested that cesarean section–induced isthmoceles may interfere with passage of menstrual blood through the cervix, and the accumulated fluid may lead to suprapubic pelvic pain and postmenstrual abnormal uterine bleeding (Curr. Opin. Obstet. Gynecol. 2012;24:180-6).

"Moreover," the authors wrote, "persistence of the menstrual blood after menstruation in the cervix may negatively influence the mucus quality and sperm quality, obstruct sperm transport through the cervical canal, [and] interfere with embryo implantation, leading to secondary infertility."

The diagnosis of cesarean-induced isthmocele can be reliably made by transvaginal ultrasound, they stated.

In the largest treatment series to date, the same group reported in 2011 on 41 consecutive patients in whom other causes of infertility had been ruled out, and whose cesarean-induced isthmoceles were hysteroscopically excised (J. Minim. Invasive Gynecol. 2011;18:234-7).

"Believe it or not, all patients spontaneously conceived 12-24 months after isthmoplasty," said Dr. Shamonki.

Also, isthmoplasty resolved the postmenstrual abnormal uterine bleeding and suprapubic pelvic pain in all patients.

"It appears promising," he acknowledged. "But again, this is not a randomized trial. It’s very important that we get more information."

The talk generated considerable interest at the meeting, which draws reproductive medicine specialists from around the world.

In an interview, Dr. Ivan Valencia from Quito, Ecuador, estimated that in his reproductive endocrinology practice, 60%-70% of infertile patients with a history of cesarean section have evidence of an isthmocele. Deep suturing or an exaggerated healing response is likely to blame, he noted.

In such patients, he creates a small hole through the stenotic tissue on hysteroscopy that is performed without anesthesia during patients’ initial office visit. "Many patients get pregnant the next month and you don’t have to do IVF."

In others, the procedure eases the embryo transfer procedure, said Dr. Valencia.

Dr. Valencia hypothesized that isthmocele is very common following cesarean deliveries. "In some cases, this scar is not affecting them," he surmised. "They don’t come to see a specialist."

Dr. Shamonki reported that he had no relevant financial disclosures.

SANTA BARBARA, CALIF. – Surgical hysteroscopy may be the most efficient way to restore fertility in women with cesarean-induced isthmoceles, but no randomized trials exist to guide clinicians concerning what may loom as a notable contributor to secondary infertility.

Reservoirlike pouch defects develop on the anterior wall of the uterine isthmus at the site of a cesarean section scar in an unknown percentage of women, explained Dr. Mousa Shamonki at an annual conference on in vitro fertilization and embryo transfer sponsored by the University of California, Los Angeles.

"This may be a cause of fluid accumulation in the uterine cavity, or be associated with abnormal uterine bleeding," said Dr. Shamonki, director of in vitro fertilization and assisted reproduction at the university.

Surgical correction, he added, "may correct bleeding and fluid accumulation, and potentially restore fertility."

"You’ll notice I’m being very careful in my verbiage here," he emphasized, noting that the lack of epidemiologic data or randomized trials makes the scope of the problem and its treatment unclear.

With cesarean deliveries’ constituting nearly a third of live births in the United States, any common complication is likely to powerfully impact gynecologic and obstetrical practice.

In a recent review, Dr. Pasquale Florio and his associates at the University of Siena (Italy) suggested that cesarean section–induced isthmoceles may interfere with passage of menstrual blood through the cervix, and the accumulated fluid may lead to suprapubic pelvic pain and postmenstrual abnormal uterine bleeding (Curr. Opin. Obstet. Gynecol. 2012;24:180-6).

"Moreover," the authors wrote, "persistence of the menstrual blood after menstruation in the cervix may negatively influence the mucus quality and sperm quality, obstruct sperm transport through the cervical canal, [and] interfere with embryo implantation, leading to secondary infertility."

The diagnosis of cesarean-induced isthmocele can be reliably made by transvaginal ultrasound, they stated.

In the largest treatment series to date, the same group reported in 2011 on 41 consecutive patients in whom other causes of infertility had been ruled out, and whose cesarean-induced isthmoceles were hysteroscopically excised (J. Minim. Invasive Gynecol. 2011;18:234-7).

"Believe it or not, all patients spontaneously conceived 12-24 months after isthmoplasty," said Dr. Shamonki.

Also, isthmoplasty resolved the postmenstrual abnormal uterine bleeding and suprapubic pelvic pain in all patients.

"It appears promising," he acknowledged. "But again, this is not a randomized trial. It’s very important that we get more information."

The talk generated considerable interest at the meeting, which draws reproductive medicine specialists from around the world.

In an interview, Dr. Ivan Valencia from Quito, Ecuador, estimated that in his reproductive endocrinology practice, 60%-70% of infertile patients with a history of cesarean section have evidence of an isthmocele. Deep suturing or an exaggerated healing response is likely to blame, he noted.

In such patients, he creates a small hole through the stenotic tissue on hysteroscopy that is performed without anesthesia during patients’ initial office visit. "Many patients get pregnant the next month and you don’t have to do IVF."

In others, the procedure eases the embryo transfer procedure, said Dr. Valencia.

Dr. Valencia hypothesized that isthmocele is very common following cesarean deliveries. "In some cases, this scar is not affecting them," he surmised. "They don’t come to see a specialist."

Dr. Shamonki reported that he had no relevant financial disclosures.

SANTA BARBARA, CALIF. – Surgical hysteroscopy may be the most efficient way to restore fertility in women with cesarean-induced isthmoceles, but no randomized trials exist to guide clinicians concerning what may loom as a notable contributor to secondary infertility.

Reservoirlike pouch defects develop on the anterior wall of the uterine isthmus at the site of a cesarean section scar in an unknown percentage of women, explained Dr. Mousa Shamonki at an annual conference on in vitro fertilization and embryo transfer sponsored by the University of California, Los Angeles.

"This may be a cause of fluid accumulation in the uterine cavity, or be associated with abnormal uterine bleeding," said Dr. Shamonki, director of in vitro fertilization and assisted reproduction at the university.

Surgical correction, he added, "may correct bleeding and fluid accumulation, and potentially restore fertility."

"You’ll notice I’m being very careful in my verbiage here," he emphasized, noting that the lack of epidemiologic data or randomized trials makes the scope of the problem and its treatment unclear.

With cesarean deliveries’ constituting nearly a third of live births in the United States, any common complication is likely to powerfully impact gynecologic and obstetrical practice.

In a recent review, Dr. Pasquale Florio and his associates at the University of Siena (Italy) suggested that cesarean section–induced isthmoceles may interfere with passage of menstrual blood through the cervix, and the accumulated fluid may lead to suprapubic pelvic pain and postmenstrual abnormal uterine bleeding (Curr. Opin. Obstet. Gynecol. 2012;24:180-6).

"Moreover," the authors wrote, "persistence of the menstrual blood after menstruation in the cervix may negatively influence the mucus quality and sperm quality, obstruct sperm transport through the cervical canal, [and] interfere with embryo implantation, leading to secondary infertility."

The diagnosis of cesarean-induced isthmocele can be reliably made by transvaginal ultrasound, they stated.

In the largest treatment series to date, the same group reported in 2011 on 41 consecutive patients in whom other causes of infertility had been ruled out, and whose cesarean-induced isthmoceles were hysteroscopically excised (J. Minim. Invasive Gynecol. 2011;18:234-7).

"Believe it or not, all patients spontaneously conceived 12-24 months after isthmoplasty," said Dr. Shamonki.

Also, isthmoplasty resolved the postmenstrual abnormal uterine bleeding and suprapubic pelvic pain in all patients.

"It appears promising," he acknowledged. "But again, this is not a randomized trial. It’s very important that we get more information."

The talk generated considerable interest at the meeting, which draws reproductive medicine specialists from around the world.

In an interview, Dr. Ivan Valencia from Quito, Ecuador, estimated that in his reproductive endocrinology practice, 60%-70% of infertile patients with a history of cesarean section have evidence of an isthmocele. Deep suturing or an exaggerated healing response is likely to blame, he noted.

In such patients, he creates a small hole through the stenotic tissue on hysteroscopy that is performed without anesthesia during patients’ initial office visit. "Many patients get pregnant the next month and you don’t have to do IVF."

In others, the procedure eases the embryo transfer procedure, said Dr. Valencia.

Dr. Valencia hypothesized that isthmocele is very common following cesarean deliveries. "In some cases, this scar is not affecting them," he surmised. "They don’t come to see a specialist."

Dr. Shamonki reported that he had no relevant financial disclosures.