Intrauterine Gestation Research Articles

Ruptured heterotopic pregnancy: a case report

Heterotopic pregnancy is a rare condition when at least two pregnancies are present simultaneously at different implantation sites and only one is located in the uterine cavity. The majority of cases are diagnosed in the first trimester. Heterotopic gestation is very rare in natural conception. A high index of suspicion is required for timely diagnosis and appropriate intervention. We report a case of heterotopic pregnancy in a 26-year-old woman presented with hemoperitoneum from ruptured tubal pregnancy with live intrauterine gestation at 8 weeks of amenorrhea, diagnosed on ultrasound examination. She underwent exploratory laparotomy with right salpingectomy and post-operative period was uneventful.

Fresh vs. frozen embryo transfer: new approach to minimize the limitations of using national surveillance data for clinical research

To assess the benefit of frozen vs. fresh elective single embryo transfer using traditional and novel methods of controlling for confounding. Retrospective cohort study using data from the National Assisted Reproductive Technology Surveillance System. Not applicable. A total of 44,750 women aged 20-35 years undergoing their first lifetime oocyte retrieval and embryo transfer in 2016-2017, who had ≥4 embryos cryopreserved. Fresh elective single embryo transfer and frozen elective single embryo transfer. The primary outcome was a singleton live birth. Secondary outcomes included rates of total live birth (singleton plus multiple gestations), twin live birth, clinical intrauterine gestation, total pregnancy loss, biochemical pregnancy, and ectopic pregnancy. Outcomes for infants included gestational age at delivery, birth weight, and being small for gestational age. The eligibility criteria were met by 6,324 fresh and 2,318 frozen cycles. Patients undergoing fresh and frozen transfer had comparable mean age (30.69 [standard deviation {SD} 0.08] years vs. 31.06 [SD 0.08] years) and body mass index (24.76 [SD 0.20] vs. 25.65 [SD 0.15]); however, women in the frozen cohort created more embryos (8.1 [SD 0.12] vs. 6.8 [SD 0.08]). Singleton live birth rates in the fresh vs. frozen groups were 51.4% vs. 48.8% (risk ratio 1.05; 95% confidence interval [CI], 1.00-1.10). After adjustment with a log-linear regression model and propensity score analysis, the difference in singleton live birth rates remained nonsignificant (adjusted risk ratio, 1.05; 95% CI, 0.97-1.14 and 1.02; 95% CI, 0.96-1.08, respectively). A novel dynamical model confirmed inherent fertility (probability of ever achieving a pregnancy) was balanced between groups (odds ratio, 1.23; 95% CI 0.78-1.95]). The per-cycle probability of singleton live birth was not different between groups (odds ratio 1.11 [95% CI 0.94-1.3]). In this retrospective cohort study of fresh vs. frozen elective single embryo transfer, there was no statistically significant difference in singleton live birth rate after adjustment using log-linear models and propensity score analysis. The successful application of a novel dynamical model, which incorporates multiple assisted reproductive technology cycles from the same woman as a surrogate for inherent fertility, offers a novel and complementary perspective for assessing interventions using national surveillance data.

A rare case of triplet heterotopic pregnancy - A case report

Triplet heterotopic pregnancy refers to the presence of specifically 3 concurrent gestations with at least 1 being abnormally implanted. Heterotopic pregnancy is rare and estimated to occur in about 1 per 30,000 spontaneous pregnancies while a higher prevalence may occur in assisted reproduction techniques that may reach up to 1 case per 100 in some literatures. The triplet heterotopic pregnancies are often in association with risk factors, as tubal factor infertility, pelvic infections, in vitro fertilization, more embryos transfer, and use of pharmacologic ovulation induction. A 22-year-old primigravida with history of undergoing ovulation induction treatment with 2 & ½ months of amenorrhea was brought to the Emergency Department with complaints of pain abdomen, vomiting and generalized weakness since one day. Transvaginal ultrasound revealed a single live intrauterine gestation at 9 weeks 3 days with fetal cardiac activity alongwith a well defined round to oval anechoic lesion likely gestation sac within the left fallopian tube with moderate to gross hemoperitoneum leading to the diagnosis of a heterotopic pregnancy with left ruptured ectopic pregnancy. She underwent an Exploratory Laparotomy under general anesthesia and was found to have a left sided ruptured tubal ectopic at the isthmo-ampullary junction measuring about 4 x 5 cms for which salpingectomy was done along with an incidental finding of a right sided unruptured ectopic pregnancy in the ampullary region which was in the process of tubal abortion for which right salpingotomy was done. Hemoperitoneum of 900 ml was present. Serial USG monitoring and regular antenatal check ups were done for intrauterine pregnancy and patient was followed up till term. She was admitted at 38 weeks gestation and delivered a healthy, term male baby of birth weight 2.86 kgs through caesarean section.

Probability of Pregnancy With Mono vs Multiple Folliculogenesis in Women With Unexplained Infertility.

Ovarian stimulation (OS) increases pregnancy rates but can cause multiple folliculogenesis and multiple pregnancy. To determine whether the probability of pregnancy differs in OS cycles with mono- vs multifolliculogenesis in women with unexplained infertility (UI). Secondary analysis of a multicenter, randomized controlled trial: Assessment of Multiple Intrauterine Gestations from Ovarian Stimulation with 3 treatment arms: gonadotropins, clomiphene, or letrozole, combined with intrauterine insemination. Women were categorized as having either 1 or ≥ 2 mature follicles (≥ 16 mm). Relative risk (RR) and 95% CIs for clinical pregnancy and live birth by number of follicles were estimated using generalized linear models adjusted for age, body mass index, years of infertility, and history of prior live birth. 12 US-based clinical sites. Normally cycling women aged 18 to 40 years with a normal uterine cavity and at least 1 patent fallopian tube. Male partners with ≥ 5 million total motile sperm. Gonadotropins, clomiphene, or letrozole with insemination. Clinical pregnancy rates (CPR) and live birth rates (LBR). A single mature follicle > 16 mm resulted in lower CPR (RR, 0.70; 95% CI, 0.54-0.90) and LBR (RR, 0.67; 95% CI, 0.51-0.89) compared with ≥ 2 mature follicles. When stratified by treatment modality, no association of follicle number with CPR or LBR was observed for letrozole or clomiphene, but women using gonadotropins had lower CPR and LBR with monofolliculogenesis. In couples undergoing gonadotropin treatment for UI, monofolliculogenesis following OS is related to a lower rate of live birth.

Eighteen-Year-Old Nulliparous Woman with Massive Mucinous Cystadenoma in Pregnancy: Case Report

Background: Ovarian mucinous cystadenoma is rare in adolescents. We report the diagnosis and management of a massive ovarian mucinous cystadenoma in a pregnant adolescent. Case Presentation: An 18-year-old G1PO was referred by a midwife to the Komfo Anokye Teaching Hospital on account of excessive abdominal distension at 25 weeks’ gestation and an ultrasound scan finding of a large non-septate cystic adnexal mass. She, however,reported to the hospital 6 weeks later with a complaint of worsening abdominal distension and discomfort. A transabdominal ultrasound scan revealed single intrauterine gestation and a large non-septate cystic adnexal lesion measuring more than 19 cm in its widest plane. She had a conservative in-patients management followed by emergency caesarean delivery, exploratory laparotomy and unilateral salpingo-ophorectomy at 33 weeks 1 day. The outcome of the delivery was a 1.8 kg female infant with Apgar score of 4 and 6 at 1 and 5 minutes respectively. A 6.8 kg cystic ovarian mass measuring about 40 cm at its widest diameter was removed.Conclusion: Although pregnancy-associated adnexal masses are not uncommon, significant socio-economic challenges may render the diagnosis and treatment of extremely large pelvic masses in pregnant adolescents difficult. The decision to optimize maternal and fetal outcomes is essential in managing rare conditions in marginalized obstetric populations.

Ruptured Spontaneous Heterotopic Pregnancy Presenting with Hemoperitoneum: a case report

Heterotopic pregnancy (HP) is the coexistence of intrauterine (IU) and extrauterine (EU) gestation. It is rare and potentially fatal condition if not correctly treated or diagnosed. In this case report, we present a 33-year-old woman with a 16-week topical pregnancy with spontaneous rupture of an ectopic pregnancy (EP) in the uterine tube. At first, the patient had diffused abdominal pain, specifically in the lower abdominal level and tachycardia. The evaluation of the fetus showed no signs of distress. Abdominal and transvaginal ultrasound (US) show free intraperitoneal fluid, a normal-looking IU gestation with a positive fetal heart rate consistent with a fetal age of approximately 16 weeks, signs of parenchymal vascular hypoflux of the spleen on the color doppler study, associated with a splenic vein with low vascular amplitude flow. General surgery team were requested and to rule out aneurysm of splenic vessels as a source of bleeding she had an abdominal angiotomography that showed a moderate amount of free fluid, ectasia of gonadal and uterine vessels, with no signals of active bleeding and no spleen changes. No signs of EP were identified in this exam. The patient had hemodynamic deterioration with maintenance of abdominal girth. An emergency exploratory laparotomy was performed under general anesthesia through a supra and subumbilical incision, leading to a finding of a ruptured EP. There was a 3 cm right tubal ruptured ectopic pregnancy. A total right salpingectomy was performed with removal of the hemoperitoneum and peritoneal lavage. The patient recovered uneventfully and was discharged from the hospital within 5 days.

A new method to rescue embryos contaminated by bacteria

ObjectiveTo report a case of successful pregnancy involving embryos that wereaffected by bacterial contamination.DesignA case report.SettingAcademic assisted reproductive center.Patient(s)A 31-year–old infertile patient with obstructed fallopian tubes facing bacterial contamination in her embryos during in vitro fertilization.Intervention(s)The zona pellucida (ZP) of the embryos that was contaminated by bacteria was removed by acidic Tyrode’s solution. The ZP-free embryos were then cultured in a time-lapse culture dish with 1 zygote per well until day 5 when a single ZP-free blastocyst was selected for transfer.Main Outcome Measure(s)The rate of obtaining embryos without recurrence of bacterial contamination and the developmental potential of the embryos.Result(s)Twenty oocytes were retrieved and were coincubated with sperm in vitro overnight. A total of 9 zygotes with 2 pronuclei and 3 zygotes with 1 pronucleus were obtained. Unfortunately, all zygotes were contaminated by the Klebsiella pneumoniae bacteria. The ZP of 7 zygotes were removed using acidic Tyrode’s solution (ZP-free group), whereas the remaining 5 zygotes and 3 metaphase II (MII) stage oocytes were washed with G-1 PLUS medium multiple times (washing treatment group). In the washing treatment group, all embryos experienced recontamination on day 2 and were dead by day 3. In the ZP-free group, 2 embryos were found to be recontaminated on day 2. The remaining 5 embryos that stayed uncontaminated were selected for blastocyst culture. On day 5, 2 of the cultured embryos developed into blastocysts. One blastocyst was transferred during the fresh cycle, and the other was vitrified. A single intrauterine gestation was confirmed 4 weeks after the transfer. At the time of writing this article, the patient was 30 weeks pregnant without any occurrence of intrauterine infection during pregnancy.Conclusion(s)Zona pellucida removal is a safe and effective method to rescue embryos contaminated with bacteria.

Intrauterine Twin Gestation with Tubal Ectopic: A Rare Spontaneous Heterotopic Pregnancy

Intrauterine Twin Gestation with Tubal Ectopic: A Rare Spontaneous Heterotopic Pregnancy

Case report: Heterotopic pregnancy - A very unlikely cause of haemoperitoneum in trauma setting.

Heterotopic pregnancy is a rare occurrence whereby a concurrent intrauterine and extrauterine pregnancy exists. It is a difficult diagnosis to make early, and often associated with significant morbidity and mortality from complications if diagnosed late. In this report, we present a rare case of heterotopic pregnancy in a 25-year-old woman who presented with abdominal pain following blunt abdominal trauma, and ultrasound showing haemoperitoneum and a viable intrauterine 10-week gestation. CT scan was non diagnostic and significance of left parametrial contrast was not considered. She was admitted under the general surgical team and underwent laparoscopy showing a ruptured left tubal ectopic pregnancy and partial salpingectomy was performed. She recovered well post operatively and has continued to carry the intrauterine pregnancy without complications. Surgeons and emergency physicians should be aware of this condition and to consider it in female patients presenting with acute abdomen or trauma even in the presence of an intrauterine pregnancy.

Preconception ovarian reserve and placenta-mediated pregnancy complications among infertile women.

Are preconception ovarian reserve markers, such as Anti-Mullerian hormone and antral follicle count, associated with preeclampsia and placenta mediated pregnancy complications among women with unexplained infertility who conceive with superovulation? This is a secondary analysis of women with unexplained infertility who had a singleton live birth after enrollment in the Analysis of Multiple Intrauterine Gestations after Ovarian Stimulation (AMIGOS) trial that randomized couples to superovulation with letrozole, clomiphene, or gonadotropins with insemination for up to 4 cycles. Compared to controls (N=156), women who developed preeclampsia (N=17) had lower Anti-Mullerian hormone levels (2.24±1.20 vs. 2.89±2.32, p=0.07) and lower antral follicle count (18±7.67 vs. 21±11.43, p=0.16); though these differences were not statistically significant. There was no relationship between Anti-Mullerian hormone (OR: 1.00, 95% CI: 0.76-1.25) or antral follicle count (OR: 0.98, 95% CI 0.93-1.04) with preeclampsia and between Anti-Mullerian hormone (OR: 1.00, 95% CI: 0.83-1.17) and antral follicle count (OR: 1.00, 95% CI: 0.97-1.04) with placenta medicated pregnancy complications after adjusting for age, BMI and race. Preconception ovarian reserve markers are not associated with preeclampsia and placenta mediated pregnancy complications among women with unexplained infertility who conceive with superovulation with insemination.

Proteome-defined changes in cellular pathways for decidua and trophoblast tissues associated with location and viability of early-stage pregnancy

BackgroundIn early pregnancy, differentiating between a normal intrauterine pregnancy (IUP) and abnormal gestations including early pregnancy loss (EPL) or ectopic pregnancy (EP) is a major clinical challenge when ultrasound is not yet diagnostic. Clinical treatments for these outcomes are drastically different making early, accurate diagnosis imperative. Hence, a greater understanding of the biological mechanisms involved in these early pregnancy complications could lead to new molecular diagnostics.MethodsTrophoblast and endometrial tissue was collected from consenting women having an IUP (n = 4), EPL (n = 4), or EP (n = 2). Samples were analyzed by LC–MS/MS followed by a label-free proteomics analysis in an exploratory study. For each tissue type, pairwise comparisons of different pregnancy outcomes (EPL vs. IUP and EP vs. IUP) were performed, and protein changes having a fold change ≥ 3 and a Student’s t-test p-value ≤ 0.05 were defined as significant. Pathway and network classification tools were used to group significantly changing proteins based on their functional similarities.ResultsA total of 4792 and 4757 proteins were identified in decidua and trophoblast proteomes. For decidua, 125 protein levels (2.6% of the proteome) were significantly different between EP and IUP, whereas EPL and IUP decidua were more similar with only 68 (1.4%) differences. For trophoblasts, there were 66 (1.4%) differences between EPL and IUP. However, the largest group of 344 differences (7.2%) was observed between EP and IUP trophoblasts. In both tissues, proteins associated with ECM remodeling, cell adhesion and metabolic pathways showed decreases in EP specimens compared with IUP and EPL. In trophoblasts, EP showed elevation of inflammatory and immune response pathways.ConclusionsOverall, differences between an EP and IUP are greater than the changes observed when comparing ongoing IUP and nonviable intrauterine pregnancies (EPL) in both decidua and trophoblast proteomes. Furthermore, differences between EP and IUP were much higher in the trophoblast than in the decidua. This observation is true for the total number of protein changes as well as the extent of changes in upstream regulators and related pathways. This suggests that biomarkers and mechanisms of trophoblast function may be the best predictors of early pregnancy location and viability.

A personalized medicine approach to ovulation induction/ovarian stimulation: development of a predictive model and online calculator from level-I evidence

To estimate the probability of clinical or multiple pregnancy during ovulation induction (OI)/ovarian stimulation (OS). Secondary analysis of two multicenter randomized clinical trials (combined). Multicenter. A total of 750 women with polycystic ovary syndrome and 900 women with unexplained infertility. Ovulation induction/OS with either timed intercourse (polycystic ovary syndrome) or intrauterine insemination. Clinical and multiple pregnancy rates/cycle, cumulative pregnancy rates. Age, body mass index, parity, diagnosis, medication, markers of ovarian reserve, and ovarian response were considered in multivariable regression models for clinical, multiple, and cumulative pregnancy rates. Receiver operating characteristic curves were created for clinical and multiple pregnancy rates. Younger patient and partner age, treatment type, lower body mass index, and medication dose were all associated with clinical pregnancy. Variables associated with multiple pregnancy included the abovementioned variables (except age), in addition to diagnosis, parity, higher antral follicle count, antimüllerian hormone levels, and ovarian response. Gonadotropin use was associated with multiple pregnancy, with progressively increasing odds ratios (cycles 1-4). Receiver operating characteristic curves indicated the model's predictive power to be fair for clinical pregnancy (areas under the curve [95% confidence interval {CI}]: 0.78 [0.75-0.81] for cycle 1 and 0.70 [0.64-0.75] for cycle 4) and good-to-excellent for multiple pregnancy (areas under the curve [95% CI]: 0.78 [0.72-0.84] for cycle 1 and 0.86 [0.78-0.93] for cycle 4). Partner age, lower medication dose, parity, antimüllerian hormone levels, and diagnosis were associated with cumulative pregnancy rates. Using the majority of the factors known to predict the outcome of OI/OS cycles, we constructed an easy-to-use formula that may predict individualized chances of clinical and multiple pregnancy for commonly used fertility treatments (https://pregnancyprediction.medicine.yale.edu/CalDirect.html). Assessing Multiple Intrauterine Gestations after Ovulation Stimulation NCT01044862; PPCOSII NCT00719186.

History of cancer and fertility treatment outcomes: a registry linkage study in Massachusetts.

To investigate assisted reproductive technology (ART) outcomes among adolescent and young-adult female cancer survivors. The Society for Assisted Reproductive Technology Clinic Outcome Reporting System (SART CORS) data were linked to the Massachusetts Cancer Registry for 90,928 ART cycles in Massachusetts to women ≥ 18years old from 2004 to 2013. To estimate relative risks (RR) and 95% confidence intervals (CI), we used generalized estimating equations with a log link that accounted for multiple cycles per woman and a priori adjusted for maternal age and cycle year. The main outcomes of interest were ART treatment patterns; number of autologous oocytes retrieved, fertilized, and transferred; and rates of implantation, clinical intrauterine gestation (CIG), live birth, and pregnancy loss. We saw no difference in number of oocytes retrieved (aRR: 0.95 (0.89-1.02)) or proportion of autologous oocytes fertilized (aRR: 0.99 (0.95-1.03)) between autologous cycles with and without a history of cancer; however, cancer survivors required a higher total FSH administered (aRR: 1.12 (1.06-1.19)). Among autologous cycle starts, cycles in women with a history of cancer were less likely to result in CIG compared to no history of cancer (aRR: 0.73 (0.65-0.83)); this relationship was absent from donor cycles (aRR: 1.01 (0.85-1.20)). Once achieving CIG, donor cycles for women with a history of cancer were two times more likely to result in pregnancy loss (aRR: 1.99 (1.26-3.16)). Our analysis suggests that cancer may influence ovarian stimulation response, requiring more FSH and resulting in lower CIG among cycle starts.

High-sensitivity C-reactive protein levels and pregnancy outcomes in women with unexplained infertility after ovarian stimulation with intrauterine insemination in a multicenter trial

ObjectiveTo determine if chronic inflammation, assessed by basal high-sensitivity C-reactive protein (hs-CRP) levels, is associated with pregnancy outcomes in women with unexplained infertility undergoing ovarian stimulation with intrauterine insemination.DesignProspective cohort analysis of the Reproductive Medicine Network’s Assessment of Multiple Intrauterine Gestations from Ovarian Stimulation (AMIGOS) randomized controlled trial.SettingMulticenter university-based randomized controlled trial.Patient(s)A total of 781 couples with unexplained infertility.Intervention(s)Secondary analysis.Main Outcome Measure(s)Adjusted risk ratios of live birth, clinical pregnancy, and pregnancy loss rates by hs-CRP levels.Result(s)Associations between hs-CRP levels and clinical pregnancy rates were not observed after adjustment for baseline body mass index. There were fewer live births among women with higher hs-CRP levels, although confidence intervals crossed 1.0. The risk of pregnancy loss was greater in women with increased hs-CRP levels (1–3 mg/L: risk ratio [RR], 1.67; 95% confidence interval [CI], 1.00–2.79; >3–10 mg/L: RR, 1.84; 95% CI, 1.06–3.20; and >10 mg/L: RR, 2.14; 95% CI, 1.05–4.36 compared to women with hs-CRP <1 mg/L).Conclusion(s)This investigation suggests that chronic inflammation may increase the risk of pregnancy loss but not impact the clinical pregnancy rate in women with unexplained infertility undergoing ovarian stimulation with intrauterine insemination. Associations between inflammation and pregnancy outcomes in women with infertility merit further investigation.Clinical Trial Registration Numberclinicaltrials.gov NCT01044862.

Heterotopic pregnancy in natural conception – A case report

Introduction: Heterotopic pregnancy is the coexistence of living or dead intrauterine pregnancy, single or multiple, and extra-uterine pregnancy located in the oviduct, ovary, uterine cornua, cervix or peritoneal cavity. Heterotopic gestation, although common with assisted reproductive techniques, is very rare in natural conception. A high index of suspicion can help in timely diagnosis and appropriate intervention.Case report: A 37- year-old primigravida lady with spontaneous pregnancy presented with amenorrhoea of 5 weeks, sudden and increasing lower abdominal pains of 5 days, dizziness of 2 days and vaginal bleeding of 4hours. Transabdominal and Transvaginal ultrasound scan was performed and revealed a non-viable intrauterine gestation at 6 weeks and 3 days, associated with a heterogenous complex right adnexal mass. Laparotomy was done, it revealed a ruptured right fallopian tube with remnant products of conception and hemoperitoneum; and right salpingectomy was done. The specimen was sent for histopathology. The patient tolerated the procedure well, though was resuscitated with normal saline and blood transfusion; she was taken to the recovery room in stable condition. The histopathological report confirmed the diagnosis of ectopic pregnancy.Conclusion: Despite the rarity of heterotopic pregnancy it should be suspected in patients with hemoperitoneum and an adnexal mass, even in the absence of risk factors, and should be included in the differential diagnosis of acute abdomen in the first trimester. The patient should be thoroughly investigated using abdominal and transvaginal ultrasound to exclude this rare diagnosis and allow on-time proper management.

Term Pregnancy with Septate Uterus and Longitudinal Vaginal Septum – A Case Report

Herein a case of 22-year-old primigravida women has been reported who was diagnosed with septate uterus along with longitudinal vaginal septum. Her antenatal period was uneventful, routine ultrasound scan during antenatal period detected no abnormalities. On per abdomen examination uterus was term size, heart rate of fetus was 144 beats per minute. Examination of vagina showed longitudinal vaginal septum of 0.5 cm thick, and cervical dilatation of 4 cm. Intraoperative findings recorded were; (i) Gravid uterus harbouring singleton intrauterine gestation in longitudinal lie & cephalic presentation. (ii) Dimple at the uterine fundus, uterine septum that extends to cervix from fundus, enlarged left horn containing the present pregnancy & the other is smaller. Women underwent emergency ceasarean section mode of delivery on account of longitudinal vaginal septum. The case described here is the unique case report wherein 22-year-old primigravida women detected with a complaint of septate uterus along with longitudinal vaginal septum was successfully delivered live male baby weighing 2.70 Kg following emergency ceasarean section. Keywords: Septate uterus; Longitudinal vaginal septum; Caesarean section

CHARACTERISTICS AND OUTCOMES OF PATIENTS UNDERGOING ENDOMETRIAL RECEPTIVITY ANALYSIS (ERA) IN A PRIVATE NYC FERTILITY CLINIC

Implantation failure is a major reason for infertility in women. Successful embryo implantation requires both a receptive uterus and a competent blastocyst. Recently, Endometrial Receptivity Analysis (ERA) tests have increased in popularity to determine each patient’s personalized window of implantation (WOI). This study aims to closely examine the characteristics of patients who underwent an ERA and compare success rates of patients who transferred a PGT-A euploid embryo with an adjusted WOI and with a standard WOI. Patients who underwent an ERA at a private fertility clinic in NYC during 2019 and 2020 were included. The outcome of the first programmed FET cycle following the ERA with PGT-A euploid embryo(s) was evaluated for patients with Receptive ERA vs. those with an adjusted WOI due to a non-receptive ERA. Exclusion criteria were untested embryos and natural FET cycles. Continuous variables were measured as mean and standard deviation and compared with a two-sample t-test. Categorical variables were compared with a Fisher test. A p-value of <0.05 was considered statistically significant. A total of 46 PGT-A euploid transfers following an ERA were included. Out of the 46 patients, 23 patients received receptive results, while the other 23 patients were classified as non-receptive (including pre-, early, or post-receptive). The distribution of infertility diagnoses was similar between both groups. A PGT-A euploid FET in the receptive group resulted in a 70% implantation rate and 39% rate of ongoing clinical intrauterine gestation. In the non-receptive group, the rates were respectively 65% and 35% and statistically similar. Adjusted timing of FET for non-receptive ERA patients produced similar pregnancy rates as patients with a receptive ERA.

OBESITY IS ASSOCIATED WITH REDUCED PEAK SERUM ESTRADIOL CONCENTRATION IN PROGRAMMED HORMONE REPLACEMENT FROZEN EMBRYO TRANSFER CYCLES

In addition to the assessment of endometrial lining thickness, serum estradiol concentration is often measured during programmed hormone replacement endometrial preparation cycles prior to frozen embryo transfer (FET) as a measure of adequate response. We investigated whether peak estradiol levels vary in overweight or obese women compared to normal and underweight women. A retrospective cohort study of patients who underwent a programmed hormone replacement endometrial preparation protocol prior to FET at Shady Grove Fertility centers was performed from January 1, 2017 to July 31, 2020. Patients were stratified by BMI according to the WHO BMI Classification system. Peak estradiol level was measured on the day the patient passed their endometrial lining check, which was defined as an endometrial thickness ≥8 mm on ultrasound. Exclusion criteria were natural cycle FET, uterine factor infertility, or initial endometrial preparation protocol that included Letrozole, injectable gonadotropin (Gonal-F), or a Phosphodiesterase inhibitor. Data were compared by students t-test and chi square as appropriate. 1009 cycles met inclusion criteria. Cycles were categorized as normal weight and underweight (BMI <24.9 kg/m2, n=475), overweight (BMI ≥ 25- 29.9 kg/m2, n=303), or obese (BMI ≥ 30 kg/m2, n=231). There was a statistically significant difference in peak estradiol level following estradiol treatment in preparation for FET based on BMI (normal and underweight 660.7 pg/ml, overweight 549.75 pg/ml, and obese 485.41 pg/ml, p=0.004). Despite the decrease in serum estradiol concentration with increasing BMI, the mean endometrial thickness prior to embryo transfer was not significantly different between the 3 respective groups (9.71 mm, 10.01 mm and 9.87 mm, p=0.288). The route of estradiol administration was not significantly different based on BMI, and the majority of patients in all BMI groups were on oral estradiol (71.8%, 68% and 74%). Additionally, the differences in estradiol level did not result in a difference in cycle outcome. The percentage of cycles resulting in clinical intrauterine gestations were 64.4%, 63.7% and 60.2% respectively. When adjusting for BMI, there remained no difference in clinical intrauterine gestations based on maximum E2 level (p=0.26). Increasing BMI was associated with a decreased peak estradiol level in FET cycles that utilized programmed hormone replacement endometrial preparation protocols, however this did not impact endometrial thickness or cycle outcome.

Heterotopic Pregnancy in Natural Conception – A Case Report

Heterotopic gestation is very rare in natural conception but can be common with assisted reproductive techniques; a high index of suspicion can help in timely diagnosis and appropriate intervention. We report a case of heterotopic pregnancy in a 32-year-old woman presented with hemoperitoneum from ruptured right sided tubal pregnancy with live intrauterine gestation at 12 weeks of amenorrhea, diagnosed on clinical and ultrasound examination.

Quantifying Heterogeneity of Testicular Histopathology in Men with Nonobstructive Azoospermia.

We sought to determine if testicular histopathological heterogeneity is associated with sperm retrieval rates (SRRs) in men with nonobstructive azoospermia (NOA) who are undergoing microdissection testicular sperm extraction (mTESE). All patients undergoing mTESE by a single, high-volume surgeon at a tertiary infertility referral center between 2010 and 2020 were evaluated. Pathology reports from testis biopsy at the time of mTESE reported by fellowship-trained genitourinary pathologists were reviewed. Testicular heterogeneity was correlated to absolute SRRs. Logistic regression was used to determine if heterogeneity was associated with sperm retrieval. A total of 918 men with mTESE were included. Of these, 391 men (43%) had 1 pathology, 388 men (42%) had 2, 108 (12%) had 3, and 31 (3.4%) had 4. Overall, the most common histopathology was Sertoli-cell only, followed by maturation arrest. The overall SRR was 42% with a clinical intrauterine gestation rate of 30%. Increasing histopathological variety was associated with higher SRRs (p <0.01); a SRR of 33% was observed when one histopathological subtype was present vs 94% with 4 subtypes. Furthermore, men with any foci of spermatogenesis had higher SRRs. In men with NOA, increasing testicular histopathological heterogeneity is correlated with higher SRRs driven by the identification of focal areas of spermatogenesis. This is an important, although predictable, observation. While diagnostic biopsy is not routinely required, these findings emphasize the value of having histology to perhaps predict the chance of sperm retrieval for future mTESE procedures.