Subsequent Reproductive Outcomes Research Articles

O-244 AMH levels in infertile women in APAC region - prospective study in multiple countries, ethnicities and centres

Abstract Secretary General, Asia Pacific Initiative on Reproductive (ASPIRE) President, Taiwan Endometriosis Society Founder & CEO, Taipei Fertility Center AMH is produced by granulosa cells of small growing follicles in the ovary and serum AMH levels strongly correlate with the number of growing follicles, AMH has been used clinically as a marker for ovarian reserve. Despite being of similar ages, with similar AMH levels, durations of ovarian stimulation, and gonadotropin doses, Asian women have been documented as having decreased AFCs and lower yields of total and mature oocytes after ovarian stimulation compared to their Caucasian counter- parts. These earlier data suggested that the effect of ethnicity was as an independent marker of ovarian reserve and potentially subsequent reproductive outcomes. We conducted the first multi-nation, multi-centre, and multi-ethnicity prospective cohort study from January 2020 to May 2021 to investigate serum AMH profiles among infertile Asian women. A total of 4613 women who visited fertility clinics at 12 IVF centres in 11 regions throughout Asia were recruited from Taiwan, China, Hong Kong SAR, India, Indonesia, Japan, Korea, Malaysia (2 centres), Thailand, Vietnam, and Singapore. The inclusion criteria were female partners aged 20–43years and naive to any ovarian stimulation cycle. The AMH measurement was performed using an AMH automated assay on a clinically validated platform. Among the 12 centres that joined the study, most demonstrated racial homogeneity except for Singapore and Malaysia which presented a highly diverse ethnic profile, while others were supposedly monoethnic communities. Unexplained or male infertility is the most common infertility cause in most countries, except for China with a notably high incidence of tubal disease. Age, ethnicity, obesity, and PCOS are significantly associated with ovarian reserve. The highest rates of PCOS were found in Indians (18.6%), Malays (18.9%), and Vietnamese (17.7%), yet remarkably lean with lower obesity rate was found in Vietnamese. Serum AMH levels are not affected by smoking or GnRHa and OCPs pretreatment but are affected by endometrioma surgery. Moreover, the assay can be conveniently conducted on any day of the menstrual cycle and is not influenced by the use of fresh or frozen samples. The rate of decline in ovarian reserve increases with age in Asian women, at 0.13ng/ml/year at 25–33years old and 0.31ng/ ml/year at 33–43 years old. We also found that a cut-off at 4.0 ng/ml could be considered for PCOS diagnosis in the Asian region. Despite limitations, the results can help guide clinicians for personalized infertility treatment, and call for further investigation into the effects of genetic, environmental and lifestyle factors on ovarian reserve.

The Analysis of in vitro Fertilization Outcomes after Fertility-Preserving Therapy for Endometrial Hyperplasia or Carcinoma.

This study aimed to evaluate the clinical efficacy of fertility-preserving therapy through in vitro fertilization (IVF) procedures in women who were pathologically diagnosed with endometrial hyperplasia or carcinoma. A retrospective cohort study on fertility-preserving therapy was conducted. Participants/Materials, Setting: A total of 82 women were enrolled who had simple endometrial hyperplasia (SH), complex hyperplasia (CH), complex atypical hyperplasia (CAH), and endometrioid endometrial carcinoma stage IA (EC IA) and underwent IVF at Gangnam CHA fertility center between January 2008 and December 2020. The primary endpoints were oncologic outcomes and subsequent reproductive outcomes of patients who underwent fertility-preserving treatments analyzed by χ2 test or Fisher's exact test. Of the 82 patients, 33 had a cumulative clinical pregnancy (40.2%), and 25 had a cumulative live birth (30.5%) through IVF procedures following pathologic confirmation of complete remission or non-progressive status. The cumulative clinical pregnancy rates and live birth rates for SH were 50.0% and 30.0%, for CH were 37.8% and 28.9%, for CAH were 25.0% and 25.0%, and for EC were 38.5% and 38.5%, respectively. There were no significant differences in cumulative clinical pregnancy rates or live birth rates when comparing the four groups. There was a difference in endometrial thickness between medroxyprogesterone acetate (MPA) treatment group and intrauterine device (IUD) group (p = 0.036); however, there were no significant differences in clinical pregnancy rates among MPA, IUD, and MPA+IUD groups. Because of the retrospective nature of the study, many factors relevant to the treatment decision were not strictly controlled. All endometrial hyperplasia and carcinoma groups had competent cumulative live birth rates by IVF procedures. There may be differences in endometrial thickness depending on the treatment methods, but this does not affect clinical pregnancy rates. Therefore, the fertility-preserving treatment for endometrial hyperplasia and carcinoma is a safe and feasible method that results in good IVF outcomes.

Reproductive factors and subsequent pregnancy outcomes in patients with prior pregnancy loss

BackgroundAt present, individualized interventions can be given to patients with a clear etiology of pregnancy loss to improve the subsequent pregnancy outcomes, but the current reproductive status of the patient cannot be changed. The aim of this study was to investigate the association between female reproductive status and subsequence pregnancy outcome in patients with prior pregnancy loss (PL).MethodsA prospective, dynamic population cohort study was carried out at the Second Hospital of Lanzhou University. From September 2019 to February 2022, a total of 1955 women with at least one previous PL were enrolled. Maternal reproductive status and subsequent reproductive outcomes were recorded through an electronic medical record system and follow-up. Logistic regression was used to evaluate the association between reproductive status and the risk of subsequent reproductive outcomes.ResultsAmong all patients, the rates of subsequent infertility, early PL, late PL, and live birth were 20.82%, 24.33%, 1.69% and 50.77% respectively. In logistic regression, we found that age (OR 1.08, 95% CI 1.04–1.13) and previous cesarean delivery history (OR 2.46, 95% CI 1.27–4.76) were risk factors for subsequent infertility in patients with PL. Age (OR 1.06, 95% CI 1.03–1.10), age at first pregnancy (OR 1.06, 95% CI 1.03–1.10), BMI (OR 1.06, 95% CI 1.02–1.11), previous PL numbers (OR 1.18, 95% CI 1.04–1.57) and without pre-pregnancy intervention (OR 1.77, 95% CI 1.35–2.24) were risk factors for non-live birth. Age (OR 1.06, 95% CI 1.03–1.09), age at first pregnancy (OR 1.06, 95% CI 1.02–1.09), BMI (OR 1.07, 95% CI 1.02–1.11), previous PL numbers (OR 1.15, 95% CI 1.02–1.31) and without pre-pregnancy intervention (OR 2.16, 95% CI 1.65–2.84) were risk factors for PL.ConclusionsThe reproductive status of people with PL is strongly correlated with the outcome of subsequent pregnancies. Active pre-pregnancy intervention can improve the subsequent pregnancy outcome.Trial registrationThis study was registered in the Chinese Clinical Trial Registry with the registration number of ChiCTR2000039414 (27/10/2020).

Severe Perineal Lacerations in First Delivery: Association with Subsequent Reproductive Outcomes.

Background: Severe perineal lacerations (SPLs), common worldwide, are associated with short- and long-term complications: pelvic floor disorders, fecal incontinence, fistula, and profound psychological impacts. Limited research suggests that experiencing SPL may influence future reproductive intentions, but research on outcomes is lacking. Methods: We analyzed the effect of experiencing SPL during a first delivery among a large cohort of Swedish births between 1992 and 2013. We used linear and multinomial logistic regression to estimate the associations between SPL and four reproductive outcomes: subsequent total birth number, probability of a second birth, interpregnancy interval (IPI), and subsequent scheduled cesarean birth. Results: Among 947,035 singleton live-born first-births, we found that experiencing SPL was associated with slightly fewer overall births in fully adjusted models (a decrease of -0.020 births; 95% confidence interval [CI]: -0.028 to -0.012), but no difference in the probability of a second birth (risk ratio [RR]: 1.00; 95% CI: 0.99 to 1.00) or IPI. Scheduled cesarean was increased in births after SPL (adjusted RR: 4.57; 95% CI: 4.42 to 4.73). A secondary comparison of SPL to severe postpartum hemorrhage suggests that some of these observed differences may be related to experiencing any severe outcome, and some specifically to perineum disruption. Conclusion: This study provides a deeper understanding of the long-term impacts of SPL, which may be useful in informing best clinical practices for supporting women who have experienced SPL.

Exposure to Di-(2-Ethylhexyl) phthalate drives ovarian dysfunction by inducing granulosa cell pyroptosis via the SLC39A5/NF-κB/NLRP3 axis

Endocrine-disrupting chemicals (EDCs) have been reported to affect populations by disrupting the human endocrine system. Di-(2-ethylhexyl) phthalate (DEHP) is an EDC that is present in various consumer products. Exposure to DEHP could contribute to reproductive system dysfunction, with subsequent adverse female reproductive outcomes. Granulosa cells (GCs) play essential roles in ovarian function and fertility. To further reveal the underlying mechanism by which DEHP impairs female fertility and affects the normal function of GCs, in vivo and in vitro experiments were performed. Transcript sequencing was used to identify genes that were differentially expressed in GCs after DEHP treatment. SLC39A5 was shown to be overexpressed in the DEHP group compared to the normal control group. DEHP treatment and overexpression of SLC39A5 activated NF-κB-related factors, followed by an increase in the transcript expression level of NLRP3. NLRP3 inflammasomes play crucial roles in pyroptosis by acting as sensors. Pyroptosis is a type of inflammation-related cell death associated with various diseases, including ovarian cancer and polycystic ovary syndrome. Activation of NF-κB contributed to the upregulation of pyroptosis in GCs, while pyroptosis factors were downregulated after the inhibition of NF-κB with JSH-23. The same phenomenon was also observed in a mouse model in which DEHP-treated mice had higher expression levels of NF-κB and pyroptosis markers in GCs. Moreover, this phenomenon could be partially reversed by the NF-κB inhibitor JSH-23. DEHP treatment also disrupted the normal expression of ovarian function-related genes and inhibited the proliferation of GCs. Reproductive system impairment was observed in mice exposed to DEHP. DEHP-treated mice had a lower body weight, smaller reproductive organs, fewer healthy follicles, and diminished ovarian reserve. Thus, DEHP contributes to ovarian dysfunction by inducing pyroptosis via the SLC39A5/NF-κB/NLRP3 axis in GCs.

Meta-analysis of the relevance between sperm parameters and serum vitamin D levels in infertile men

To systematically estimate the relevance between sperm parameters and serum vitamin D levels and the subsequent reproductive outcomes in men. PubMed, Web of Science and other databases were searched for studies that examined a possible correlation between serum vitamin D levels and sperm parameters and reproductive outcomes. The documents were screened according to the corresponding inclusion and exclusion criteria. Selection criteria included all published randomised and controlled trials and non-randomised studies that focus on vitamin D and the reproductive function of men The patients were classified into observation/intervention and control groups, the intervention group was given vitamin D supplementation and the control group was not. The meta-analysis was conducted using Stata 16.0 software. A meta-analysis of 11 clinical studies that enrolled a total of 1356 patients, revealed that the clinical pregnancy rate in the observation group was no statistically different in the control group. A meta-analysis of 8 studies demonstrated that there was no statistically difference in sperm concentration between the experimental group and the control group. A meta-analysis of 8 studies found that sperm progressive motility in the experimental group was greater than that in the control group by using a random-effects model. The mean concentration of vitamin D was significantly lower in the control group. Appropriate vitamin D supplement intervention in infertile men improves sperm progressive motility. Interpretation of these results should be done with caution due to the significant heterogeneity of the included studies. Furthermore, Well-conducted prospective cohort studies are needed to better explain the relationship between vitamin D and sperm parameters in infertile men.

Does hysteroscopy surgery enhance subsequent reproductive outcomes in women with unexplained infertility?

Introduction and Aim: Embryo implantation and a healthy placenta depend on the uterine cavity and endometrium, thus any reproductive surgery for unexplained infertility must evaluate these. Hysteroscopy cures intrauterine adhesions, submucous fibroids, endometrial polyps, and endometriosis and directly visualizes the uterus cavity. This study investigated whether hysteroscopy could diagnose uterine disorders in women with recurrent, unexplained miscarriages and improve reproductive outcomes.
 
 Methods: This observational retrospective study included 58 patients who had recurrent pregnancy loss and were hospitalized in the Kamal AL-Samarrai Hospital's reproduction unit / Physiopathology section in Baghdad, Iraq between January 2021 and February 2022. The participants were divided into two groups based on whether they had received hysteroscopic surgery. IVF was performed on patients who underwent hysteroscopy surgery. A comparative analysis was made for clinical factors and uterine pathology among the two groups. Data were subjected to statistical analysis.
 
 Results: The patients in this study ranged in age from 20 to 42 years, with an average of 3265 years, and a BMI ranging from (20-39) with an average of 29.270.48 kg/m2. Out of the 58 women analyzed, 31 (53.4%), 13 (22.4%), and 48 (82.7%) had a previous cesarean, laparoscopy, and HSG procedures, respectively. 28 patients (48.2%) who underwent hysteroscopic surgery were detected with uterine disorders; IUA (28%), fibroids (25%), submucosal polyps (21.4%), endometrial hyperplasia (17.8%), and endometriosis (7.1%). No significant difference was seen for the duration of infertility, type of infertility, or previous IVF attempt failure between the hysteroscopic and control groups (p>0.05). In women who underwent IVF procedures after hysteroscopic surgery, the clinical pregnancy rate was lower as compared to women without surgery.
 Conclusion: Hysteroscopy can diagnose some intrauterine diseases early enough for surgery. Undiagnosed infertility in women with RPL suggests a hysteroscopic examination before in vitro fertilization.

Prevalence of Human Papillomavirus Infection in the Female Partner of Infertile Couples Undergoing IVF/ICSI-ET and Subsequent Reproductive Outcomes.

We investigated the prevalence of human papillomavirus (HPV) infection in the female partner of infertile couples and the reproductive outcomes after in vitro fertilization/intracytoplasmic sperm injection-embryo transfer (IVF/ICSI-ET). We conducted a retrospective analysis on 8117 women from infertile couples who underwent IVF/ICSI treatment and evaluated the prevalence of HPV infection in these women. The prevalence of HPV infection in the female partner of infertile couples was 9.2% (747/8117). These HPV-infected female patients undergoing ART were divided into high-risk HPV (hrHPV) (n = 130) and low-risk HPV (lrHPV) groups (n = 94), and non-infected women patients formed the negative group (n = 126). Of the 747 cases infected with HPV, 529 showed hrHPV infection (70.82%; primarily genotypes 16, 52, 53, 58, and 59); 175 exhibited lrHPV infection (23.43%; primarily genotypes 6, 43, 44, 55, 61, and 81); and 43 cases were co-infected with hrHPV and lrHPV (5.76%). Except for the Day-3 high-quality embryo rate, there were no differences in ovum maturation, fertilization, implantation, clinical pregnancy, live birth, or miscarriage rates between women infected with HPV and non-infected women (p > 0.05); however, we noted an increased miscarriage rate after logistic regression analyses (OR, 0.16; 95% CI, 0.03−0.84; p = 0.041). For single-male-factor-induced infertility in couples (smHPV), although we likewise observed no differences in ovum maturation, fertilization, or implantation rates (p > 0.05) between the smHPV group and the negative group, we discerned diminutions in the Day-3 high-quality embryo rate (46.01% vs. 70.04%, p = 0.013), clinical pregnancy rate (46.67% vs. 57.94%, p = 0.003), and live birth rate (33.33% vs. 46.83%, p = 0.027) as well as an augmented miscarriage rate (11.11% vs. 4.76%, p = 0.003), respectively. Logistic regression analyses indicated that smHPV was a risk factor for decreased clinical pregnancy rate (OR, 4.17; 95% CI, 2.31−7.53; p < 0.001) and live birth rate (OR, 1.83; 95% CI, 0.81−2.14; p = 0.045) and elevated miscarriage rate (OR, 6.83; 95% CI, 2.22−21.00; p = 0.001). HPV infection in women was associated with increased miscarriage rate, and single-male-factor infertility influenced reproductive outcomes in couples undergoing IVF/ICSI treatment. Both were potentially due to HPV infection in the couple.

A systematic review of the reproductive and oncologic outcomes of fertility-sparing surgery for early-stage cervical cancer

In this review, we aim to evaluate the current literature on reproductive and oncologic outcomes after fertility-sparing surgery for early-stage cervical cancer (stage IA1-IB1). This is a systematic review of the existing literature using the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) checklist to report on fertility-sparing surgery and its outcomes in early-stage cervical cancer. Outcomes of interest were subsequent clinical pregnancy rate, reproductive outcomes, and cancer recurrence outcomes. Included in this systematic review were 68 studies encompassing 3,592 patients who underwent fertility-sparing surgery. Of these, reproductive outcomes were reported in 1096 pregnancies. The mean clinical pregnancy rate was 53.2%. Those who underwent vaginal radical trachelectomy had the highest clinical pregnancy rate (67.5%). The mean live birth rate was 67.8% in our study. Twenty-one percent of pregnancies after fertility-sparing surgery required assisted reproductive technology. The mean cancer recurrence rate was 3.2%, and the cancer death rate was 0.6% after a median follow-up period of 40.1 months with no statistically significant difference across surgical approaches. Offering fertility-sparing surgery in early-stage cervical cancer is reasonable. Highest clinical pregnancy rate is associated with vaginal radical trachelectomy. Moreover oncologic outcomes of minimally invasive approaches were comparable with abdominal approaches. We encourage detailed preoperative counseling and multidisciplinary approach to achieve best outcomes.

Reproductive outcomes following recurrent first-trimester miscarriage: a retrospective cohort study.

What are the subsequent reproductive outcomes (livebirths, miscarriages or other adverse pregnancy outcomes or no further pregnancy) of women with recurrent miscarriage (RM) attending a dedicated clinic? Of women with RM, 77% had a subsequent pregnancy, and among these pregnancies, the livebirth rate was 63%. RM affects ∼1-3% of women of reproductive age. RM has known associations with advanced maternal age, obesity, diabetes, inherited thrombophilias, thyroid dysfunction, endometriosis and parental balanced translocations. However, ∼ 50% of women or couples will be left without an explanation for their pregnancy loss, even after completing investigations. RM is also associated with secondary infertility and adverse pregnancy outcomes including preterm birth and perinatal death. We undertook a retrospective cohort study to identify subsequent pregnancy outcomes in women with RM, defined as three consecutive first-trimester miscarriages. Women attending the RM clinic at a tertiary university hospital in the Republic of Ireland over 12 years (2008-2020) with a confirmed diagnosis of primary or secondary first-trimester RM were eligible for inclusion. In total, 923 charts were identified for review against the eligibility criteria. Women with non-consecutive first-trimester miscarriages or ectopic pregnancy were excluded. Epidemiological and clinical information regarding medical history, investigation and management was gathered from paper and electronic medical records. Data were analysed using SPSS (Version 27). Associations between maternal characteristics and outcomes were explored using the χ2 test, with significance set at P < 0.05. Multinomial regression analysis was performed using a stepwise approach. There were 748 women who were included; 332 (44%) had primary RM and 416 (56%) had secondary RM. The median age was 36 years (range 19-47). Foetal aneuploidy was the most common investigative finding (15%; n = 111/748); 60% had unexplained RM. In addition to supportive care, most women were prescribed aspirin (96%) and folic acid (75%). Of the 748 women, 573 had a subsequent pregnancy (77%) and 359 (48% of all women; 63% of pregnancies) had a livebirth, while 208 had a further pregnancy loss (28% of all women; 36% of pregnancies) and 6 were still pregnant at the end of the study. Women aged 35-39 years were more likely to have a livebirth than no further pregnancy (relative risk ratio (RRR): 2.29 (95% CI: 1.51-5.30)). Women aged 30-34 years were more likely to have a livebirth (RRR: 3.74 (95% CI: 1.80-7.79)) or a miscarriage (RRR: 2.32 (95% CI: 1.07-4.96)) than no further pregnancy. Smokers were less likely to have a livebirth (RRR: 0.37 (95% CI: 0.20-0.69)) or a miscarriage (RRR: 0.45 (95% CI: 0.22-0.90)) than no further pregnancy. Couples with an abnormal parental karyotype were less likely to have a miscarriage than no further pregnancy (RRR: 0.09 (95% CI: 0.01-0.79)). Including successive pregnancies conceived over the study period, the overall livebirth rate was 63% (n = 466/742), but this was reduced to 44% in women aged ≥40 years and 54% in women with infertility. This work covers 13 years; however, those included in the later years have a shorter follow-up time. Although electronic health records have improved data availability, data collection in this cohort remains hampered by the absence of a formal booking visit for women presenting with miscarriage and a national miscarriage database or register. Our findings are largely reassuring as most women with RM and hoping to conceive achieved a livebirth. In addition to older age, smoking and parental balanced translocations were associated with a reduced likelihood of further pregnancy. No investigation or treatment was associated with pregnancy outcome, reiterating the importance of the supportive aspects of care for women and their partners after RM and counselling regarding individual risk factors. This contributes to the limited international data on the investigative findings and treatment of women with RM. The high rate of prescribed medications merits greater scrutiny, in conjunction with other pregnancy outcomes, and reiterates the need for a national guideline on RM. L.A.L. is a PhD scholar funded through the Pregnancy Loss Research Group, Department of Obstetrics and Gynaecology, University College Cork. M.H. and C.F. are Postdoctoral Researchers on a project funded by the Health Research Board Ireland [ILP-HSR-2019-011] and led by K.O.D., titled: 'Study of the impact of dedicated recurrent miscarriage clinics in the Republic of Ireland'. The funders had no role in study design, data collection and analysis, decision to publish or preparation of the manuscript. The authors have no conflicts of interests to declare. N/A.

Tubal ectopic pregnancy: a retrospective cohort study on clinical characteristics, treatment options and reproductive outcomes within 5years.

To investigate the association between different treatments of tubal ectopic pregnancy (EP) -expectant management, methotrexate (MTX), selected or recommended laparoscopic surgery-and the subsequent reproductive outcomes. We conducted a retrospective cohort study including 228 EPs. The patients were divided into four treatment groups: 28 (12.3%) with expectant management successfully, 60 (26.3%) with MTX successfully, 140 patients with laparoscopic salpingectomy, of which 47 (20.6%) were assigned to selected surgery group because they opted for surgical treatment versus MTX, 93 (40.8%) were assigned to recommended surgery group as recommended by the attending physician. The recommended surgery group had the lowest rate of intrauterine pregnancy (IUP) (77.42%) and live birth (LB) (72.04%), while the incidence of recurrent EP (REP) (20.43%) was the highest, but the statistical differences were not significant. We did not observe significant differences of the EP-IUP time interval, rates of LB and miscarriage (MIS) between the four groups. Compared to the MTX group, recommended surgery was negatively associated with IUP (adjusted OR, 95%CI: 0.34, 0.11-1.03) and LB (0.35, 0.14-0.92), while it had higher risk for REP (3.48, 1.03-11.74) in the subsequent pregnancy. Further, compared to selective surgery group, recommended surgery was negatively associated with IUP (0.15, 0.03-0.68) and LB (0.23, 0.07-0.74), while it had higher risk for REP (6.83, 1.43-32.67) in the subsequent pregnancy. Expectant treatment was negatively associated with assisted reproductive technology (ART) (0.08, 0.02-0.40) compared with MTX. Of the185 patients who had LBs, all adverse outcomes were not statistically different between the four groups. Patients with recommended laparoscopic salpingectomy had worse reproductive outcomes than the other treatment groups. The disease status of EP may play an important role in the association rather than the surgery alone.

Reproductive outcomes of cesarean scar pregnancies treated with uterine artery embolization combined with curettage

ObjectiveThe aim of this study was to review the reproductive outcomes of women with a cesarean scar pregnancy (CSP) treated with dilation and curettage (D&C) after uterine artery embolization (UAE). Materials and methodsThis was a retrospective study to review women who received UAE followed by D&C for CSP between January 2010 and December 2019 at the Changhua Christian Hospital, Changhua in Taiwan. Data were collected from both electronic and paper medical records. Patients were contact via phone call to follow up reproductive outcomes between January 2021 and March 2021. These subsequent reproductive outcomes (including pregnancy rate, secondary infertility rate, miscarriage rate, live birth rate, and recurrent CSP rate) were recorded and analyzed. ResultsA total of 53 cases of women who received UAE followed by D&C for CSP were identified. The women's average age was 34.8 ± 5.1 years. The mean gestational age at diagnosis was 6.2 ± 1.1 weeks. The mean level for human chorionic gonadotropin was 23,407.7 ± 29,105.5 mIU/ml. The average of blood loss during D&C was 19.2 ± 43.6 ml. The average hospitalization time after D&C was 3.5 ± 1.1 days. Of the 53 cases, 10 patients were lost to follow-up and 43 patients agreed to follow-up on reproductive outcomes in 2021. Twenty-three patients who desired to conceive were analyzed. Nineteen out of these 23 women (82.6%) succeeded in conceiving again and gave birth to 15 healthy babies (78.9%). Only one woman (1/19, 5.3%) experienced recurrence of CSP. The average time interval between previous CSP treatment and subsequent conception was 10.4 ± 6.7 months. ConclusionUAE combined with curettage treatment in CSP patients results in a positive rate of subsequent pregnancy outcomes. This minimally invasive procedure may be considered as one of the treatment options for CSP, as it enables preservation of fertility after treatment.

Reproductive tract disease in Irish grazing dairy cows: Retrospective observational study examining its association with reproductive performance and accuracy of 2 diagnostic tests

The detection of reproductive tract disease (RTD) 3 wk postpartum is important because of its effect on subsequent reproductive outcomes. Numerous methods for the diagnosis of RTD are described, some of which are more practical and instantaneous in terms of diagnosis. Two of these methods involve identification of purulent vaginal discharge (PVD) and evidence of ultrasonographic uterine changes indicative of endometritis (UE). The objectives of our retrospective observational study were (1) to assess the association of PVD or UE score at the prebreeding examination (PBE) with the hazard of pregnancy within the subsequent breeding season; (2) to determine the test sensitivity (Se) and specificity (Sp) at the point of sampling of both tests using a Bayesian latent class model; and (3) to determine the effect of varying positivity thresholds on test accuracy. To achieve these objectives, we analyzed an initial data set of 5,049 PBE from 2,460 spring-calved cows in 8 herds between 2014 and 2018. Each PBE was conducted once between 25 and 86 d in milk. At each PBE, vaginal discharge was obtained with a Metricheck device (Simcro) whereas uterine contents were assessed using transrectal ultrasonography. Purulent vaginal discharge was scored on a scale of 0 to 3 depending on discharge character, and UE was scored on a scale of 0 to 4 depending on the presence and consistency of intraluminal fluid. Cows with scores of ≥2 in either test had received treatment. Fertility data were available from 4,756 PBE after data exclusion. The association between PVD or UE score at the PBE and subsequent hazard of pregnancy was analyzed using a Cox proportional hazards model. Cows with a PVD score of 2 or 3 were less likely to conceive than cows with a PVD score 0 [score 2 hazard ratio (HR) = 0.74; 95% confidence interval (CI): 0.59-0.94; score 3 HR = 0.65; 95% CI: 0.51-0.84]. Cows with a UE score of 1, 2, 3, or 4 were less likely to conceive than cows with a UE score of 0 (score 1 HR = 0.82; 95% CI: 0.73-0.93; score 2 HR = 0.79; 95% CI: 0.62-1.00; score 3 HR = 0.43; 95% CI: 0.43-0.90; score 4 HR = 0.39; 95% CI: 0.26-0.58). To determine the Se and Sp of PVD or UE score for diagnosis of RTD at the time of PBE, a Bayesian latent class model was fitted on 2,460 individual cow PBE. Flat priors were used for the Se and Sp of UE, whereas informative priors were used for PVD Se (mode = 65%, 5th percentile = 45%) and Sp (mode = 90%, 5th percentile = 80%) and RTD prevalence (mode = 20%, 5th percentile = 10%). Posterior estimates (median and 95% Bayesian probability intervals; BPI) were obtained using 'rjags' (R Studio). The optimal test thresholds (PVD and UE score ≥1) were selected by assessing the effect of different thresholds on test estimates and using a misclassification cost analysis. Based on these, median (95% BPI) Se for PVD and UE score ≥1 were 44% (29-60%) and 67% (33-100%), respectively. Median Sp for PVD and UE score ≥1 were 90% (86-93%) and 91% (86-93%), respectively. Higher scores in both tests were associated with impaired fertility, and UE scoring with a threshold of ≥1 had the highest test Se and Sp estimates although test Se was conditional on days in milk when the PBE occurred.

Effects of Septum Resection for Secondary Infertility on Subsequent Reproductive Outcomes of in vitro Fertilization-Intracytoplasmic Sperm Injection.

ObjectiveTo assess the effect of uterine septum resection on reproductive outcomes of in vitro fertilization (IVF) / intracytoplasmic sperm injection (ICSI) in patients with secondary infertility complicated with uterine septum.MethodsA retrospective cohort study included 269 patients. Surgical group included 169 patients with secondary infertility complicated with uterine septum, who underwent 252 embryo-transfer (ET) cycles following septum resection. Control group consisted of 100 patients with secondary infertility and uterine septum, who underwent 178 ET cycles. Cumulative pregnancy rate and cumulative live birth rate after one complete assisted reproductive technology (ART) cycle were the primary outcomes.ResultsThe results showed that the cumulative pregnancy rate was higher in the surgery group, and statistically significant difference was observed in the cumulative pregnancy rate between the two groups (71.0 vs. 59%, P = 0.044). In fresh ET cycle, no statistically significant difference between the two groups was evident (54.9 vs. 40.6%, P = 0.061). Statistical analysis of other results of the fresh ET cycle did not differ significantly between the two groups. In terms of frozen embryo transfer (FET) cycle outcomes, the clinical pregnancy rate and delivery rate in surgery group were 52.7 and 38.2%, respectively, which were significantly higher than those in the control group (38.2 and 22.5%, respectively) (P = 0.028 and P = 0.011).ConclusionThe reproductive outcomes of IVF/ICSI after septum resection in patients with secondary infertility were better than that in the untreated group, suggesting that uterine septum resection can be performed in patients with uterine septum combined with infertility to improve their reproductive outcomes.

Hysteroscopic treatment and reproductive outcomes in cesarean scar pregnancy: experience at a single institution

To study the risk factors leading to type II/III cesarean scar pregnancy and evaluate the efficacy of hysteroscopic treatment and subsequent reproductive outcomes. Retrospective study from 2013 to2018. Inpatient samples. A total of 439 patients with cesarean scar pregnancy received hysteroscopic treatment. They were grouped according to the type of surgery as hysteroscopy combined with dilation and curettage, systemic methotrexate followed by hysteroscopy combined with dilation and curettage, and uterine artery embolization or laparoscopic ligation of bilateral uterine arteries followed by hysteroscopy combined with dilation and curettage. Cesarean scar pregnancy was classified as types I, II, and III on the basis of the relationship between the gestational sac and myometrial thickness by ultrasound. Not applicable. Risk factors leading to type II/III cesarean scar pregnancy. The success of hysteroscopic treatment as well as favorable reproductive outcomes. The significant variables were multiple parity, prior cesarean section (CS), hysteroscopic therapy, and dilation and curettage after the last CS between type I and type II/III. There were significant differences among the three groups in symptoms, largest diameter of the gestational sac, presence of fetal heartbeat, myometrial thickness, type of cesarean scar pregnancy, blood loss, length of hospital stay, and expense. The rates of complications and success were 8.2% and 93.6%, respectively. Thirty-seven women conceived again, and 22 women completed a term pregnancy with no uterine rupture. The recurrence rate of cesarean scar pregnancy was 10.8%. The type of cesarean scar pregnancy is related to the rates of multiple parity, cesarean deliveries, and dilation and curettage procedures after the last CS. Hysteroscopic therapy is a safe and effective surgical approach with a low risk of subsequent ectopic pregnancy.

Postabortion Medicaid Enrollment and the Affordable Care Act Medicaid Expansion in Oregon

Background: The Affordable Care Act Medicaid expansion had the potential to increase continuity of insurance coverage and remove barriers to accessing health services following an abortion in states where Medicaid pays for abortion. We examined the association of Medicaid expansion with postabortion Medicaid enrollment and described postabortion preventive reproductive services among Medicaid-enrolled women in Oregon. Methods: We used Medicaid claims and enrollment data to identify abortions to women ages 20-44 in 2009-2017 (N = 30,786), classified into a treatment group-those likely to be affected by Medicaid expansion-and a comparison group. Outcomes included Medicaid enrollment (number of months enrolled and any lapse in enrollment) in the 6 and 12 months postabortion. Difference-in-differences analyses were used to compare outcomes preexpansion (2009-2012) and postexpansion (2014-2017) for treatment and comparison groups. Linear regression models were adjusted for age, race/ethnicity, rurality, and month. We described receipt of preventive reproductive services in 0-2 months and in 3-12 months postabortion. Results: Medicaid expansion was associated with enrollment increases of 2.0 and 4.7 months and with declines in any enrollment lapse of 54 and 48 percentage-points over 6 and 12 months postabortion, respectively (p < 0.001). Many who remained enrolled through postabortion received preventive care including contraceptive services (41%) and screening for sexually transmitted infections (23%). Conclusions: Medicaid expansion may increase continuity of insurance coverage for those receiving abortions, and in turn promote access to preventive services that can improve subsequent reproductive health outcomes.

Reproductive success diminished following mate loss for females but not males in a monogamous rodent

The strictly monogamous California mouse (Peromyscus californicus) forms life-long pair bonds and mates exclusively with a single partner. While studies in the wild indicate that individuals may re-pair with a new partner following mate loss, the preponderance of this behavior and subsequent reproductive outcomes following re-pairing are understudied. To examine reproductive outcomes following re-pairing and to look for sex-specific differences following mate loss, birth records of 584 California mouse pairs from our laboratory were analyzed. Of these pairs, 59 pairs were identified as re-pairs and used for further descriptive analysis. We found that 50/59 (84.7 %) of re-paired animals gave birth, indicating that reproduction with a new mate is not only possible, but perhaps more common than previously described for this species. Additionally, we found that when re-paired, females took significantly longer to birth a subsequent litter as compared to original breeding pairs. Overall findings from the current study provide evidence for sex differences in reproductive outcomes following repairing and for greater flexibility in mating strategy for a species described as strictly monogamous.

CHRONIC ENDOMETRITIS IN WOMEN WITH SUSPECTED RETAINED PRODUCTS OF CONCEPTION AND THEIR REPRODUCTIVE OUTCOMES

Objective To determine whether women who underwent operative hysteroscopy for suspected retained products of conception (rPOC) have histopathologic evidence of chronic endometritis (CE). Design Retrospective cohort. Setting Academic center. Patient(s) One hundred and eleven women who underwent operative hysteroscopy for suspected rPOC between 2016 and 2018. Intervention(s) None. Main outcome measure(s) Evidence of CE on histopathology and subsequent reproductive outcomes. Result(s) One hundred and eleven women with retained products of conception were included in our study of which 26 (23.4%) were diagnosed with CE. Women without CE had a higher median gravidity (1 vs. 2, p = .021) and a higher median number of prior pregnancy losses (1 vs. 2 prior losses, p = .005) compared to those with CE. Subsequent pregnancy data were available for 63 women. There was no difference in the subsequent pregnancy rate (61.5 vs. 54%, p = .626) between those with and without CE. Once pregnant, miscarriage (37.5 vs. 25.9%, p = .524) and live birth rates (50 vs. 44.4%, p = .782) were similar between the groups. Women with CE received antibiotics 57.7% of the time, the most common of which was doxycycline (46.6%). Of the women with CE who received antibiotics (n = 10), 8 became pregnant, and 4 of whom went on to have a live birth. Conclusion(s) Nearly 1 in 4 women undergoing hysteroscopy for rPOC was incidentally diagnosed with CE. It is not clear whether CE is a causative agent for retained products or a response to the pregnancy loss. In this cohort, a diagnosis of CE did not negatively impact subsequent reproductive outcomes.

Parent, partner and individual contexts of very early first sex experiences among young men and their links to subsequent reproductive health outcomes

Research indicates that upwards to 30% of US urban Black male adolescents report first sex younger than age 13; however, there is limited literature on the sexual and reproductive health outcomes and contexts of these early first sex experiences. This exploratory study described sexual and reproductive health histories and explored personal, partner and parent contextual factors associated with first sex experiences occurring at 13 years or younger among a sample of US urban young men aged 15–24. Participants were assessed on their demographics and sexual health histories and a subset of young men were assessed on the contextual factors related to their first sex experience. Pearson chi-squared tests examined factors associated with early first sex and Fisher’s exact tests examined associated contextual factors. First sex at 13 years or younger was reported by 29% of young men. A higher proportion of young men who had first sex at 13 or younger than those who had sex onset at 14 or older reported having got someone pregnant, having a “much older” first partner, and relationship satisfaction with their mother (16%) and father (12%). Study findings highlight the need to better understand urban young men’s early first sex experiences, including the support needed to promote their healthy sexual development.

Limited Availability of Deceased Uterus Donors: A UK Perspective.

We read with interest the article by Kristek et al1 that summarizes the limitations of donor availability for uterine transplantation (UTx) using deceased donors. We applaud the authors’ international assessment of deceased donor availability and agree it may limit the future clinical applicability of UTx. Our team has recently commenced a UTx research program in the United Kingdom using donors after brain death (DBD), The INvestigational Study Into Transplantation of the Uterus (INSITU). In the United Kingdom between 2018 and 2019, out of 6991 potential deceased donors, 17% (n = 1176) were excluded because of an absolute medical contraindication to solid organ donation.2 Of those 5815 potential donors, 1600 eventually proceeded with organ donation, just 962 were DBD, with the remaining 638 donating after circulatory death (DCD).2 In the context of UTx, a fertility restoring, quality of life-improving procedure, the selection criteria are understandably more stringent. For INSITU, we have imposed similar selection criteria to those proposed by Kristek et al1 as standard donor criteria, including the necessity for donors to be premenopausal, albeit up to the age of 50, have a body mass index <30, and be multiparous. Of the 962 DBD organ donations last year, just 487 were women.2 Moreover, only 38% of donors were aged between 17 and 49 and 75% had a body mass index <30 kg/m2,2 resulting in an estimated donor availability of <150 annually before the implementation of further criteria that determine uterine functionality and suitability including parity, cervical smear history, and reproductive and obstetric outcomes. Although the use of selection criteria facilitates the minimalization of confounding variables and aims to optimize outcomes following UTx, they will undoubtedly concurrently impact donor availability, highlighting the need for careful consideration. We, therefore, support the authors’ proposal of extended donor criteria, particularly the alleviation of only using multiparous donors. The vast majority (93%) of UTx procedures undertaken so far have been using multiparous donors.3 This trend undoubtedly followed the first DBD UTx performed globally, which was undertaken in Turkey using a nulliparous donor.4 The recipient subsequently suffered repeated in vitro fertilization failure and recurrent miscarriages. Despite being largely attributed to the nulliparity of the donor, it is more likely a dysbiotic vaginal microbiome from the intestinal neovagina in the recipient negatively impacted reproductive outcomes.5 Although the only way to truly determine the reproductive potential of a uterus is following conception, pregnancy, and childbirth, the probability of a macroscopically and ultrasonographically normal uterus having undiagnosed uterine factor infertility is remote. In addition, the inclusion of ‘no miscarriages’ as a standard donor criterion may be overly exclusive, given the vast majority of miscarriages are sporadic in nature because of reasons unrelated to the uterus, such as embryonic aneuploidy. As around a quarter of women have sporadic miscarriages, this may exclude a significant proportion of otherwise suitable donors. Moreover, the decision to not consider donors with previous Caesarean sections may exclude another quarter of potential donors. For INSITU, we will consider donors who have had a previous Caesarean section, as well as those with 1–2 previous miscarriages, although donors with recurrent miscarriages (≥3) will not be considered.6 We further concur that the use of DCD is currently ill-advised owing to the unpredictable impact of prolonged warm ischemia on subsequent uterine functionality and reproductive outcomes. However, in the context of the numbers presented herein, it would increase the number of potential donors greatly, highlighting the potential benefit for further consideration and research in this area.