ObjectiveTo present a case of abnormally trending hCG levels due to ovarian hyperstimulation syndrome (OHSS) and to portray the obscurities of this commonly used method for tracking early pregnancies.DesignCase report.SettingOutpatient ART facility.PatientA patient who received controlled ovarian hyperstimulation in an ART cycle.InterventionSupportive care.Main outcome measurehCG level.ResultThe hCG levels in this patient with OHSS trended in an abnormal fashion, suggesting a failing or ectopic pregnancy, but the patient had a normal intrauterine fetus.ConclusionhCG levels may be falsely low in pregnancies complicated by OHSS.
In programmed FET cycles, there does not appear to be a difference in clinical pregnancy rates, miscarriage rates, or live birth rates when comparing method of estrogen delivery (oral vs oral and vaginal) and length of estrogen exposure within a narrowly defined window.IMPACT STATEMENT: Although programmed frozen embryo transfers have been associated with increased risk of poor obstetric outcomes, it is reassuring that despite the presumed differences in estrogen levels in patients taking oral vs oral and vaginal estrogen, no clinically significant differences in reproductive success were observed. In addition, differences in duration of estrogen exposure within a narrow window does not seem to impact reproductive success.
OBJECTIVE: To identify the potential cause of the partial oocyte maturation arrest syndrome in a patient that presented to our clinic over a time span of 10 years.MATERIALS AND METHODS: Here-described patient underwent 7 IVF cycles under several ovarian stimulation protocols at different gonadotropin dosages in attempts to recruit mature eggs. She in 2009 (aged 29 y.o.) conceived in her 2nd IVF cycle and delivered in 2010 uneventfully a healthy female. In 2014, she conceived spontaneously and delivered a healthy boy. Her son, however, unfortunately expired at age 5 from an accidental aspiration. Since then, the couple has been attempting another pregnancy through IVF in 5 unsuccessful cycles, characterized by, remarkably, however, all but one egg arresting in each cycle at prophase. RESULTS: The female demonstrated abnormally high functional ovarian reserve for age (in 2019, AMH 5.9 ng/mL). Among a mean of 10.6 oocytes/cycle, all but one was immature and the in vitro maturation rate for the GV oocytes was 28%. Resultant M2 oocytes in addition also demonstrated morphological abnormalities, such as giant polar bodies. M2s, in contrast, in vivo were always morphologically unremarkable, and their fertilization rate was 85%. Embryo morphology deteriorated appreciatively with advancing patient age. Sanger sequencing for TUBB8 and PATL2 genes, known to identify oocyte maturation failure, was unremarkable. Whole genome sequencing of her and her sister (who had no fertility problems) revealed a heterozygous deleterious mutation of a gene belonging to the integrin family (ITGB3, mutation c.1198T>G) which currently appears suspect of being the determinant in the observed maturation arrest.CONCLUSIONS: This case report presents a likely new point mutation leading to female infertility, which appears to increase in efficiency with advancing age. It is characterized by almost complete maturation arrest which, however, intermittently, for still unclear reasons allows for incidental pregnancies, though likely with decreasing frequency with advancing age.IMPACT STATEMENT: Though a relatively rare phenomenon in embryology, repeated maturation arrest is a highly frustrating clinical presentation in IVF labs. Isolation of underlying mutations offers the potential of early diagnosis. Here observed functional progression with advancing female age appears of interest. Further insights may allow a better understanding into checkpoints required for the transition from prophase to metaphase in human oocytes.
Study question How does here presented case offer further evidence for existence of a functional hormonal adrenal-ovarian axis? Summary answer This is the first case of iatrogenic Cushing syndrome leading to severe adrenal and ovarian insufficiency, as evidenced by undetectable estrogen and low androgen levels. What is known already Animal models and human data have convincingly demonstrated that hypo-androgenism affects follicle recruitment and growth, especially at small growing follicle stages, in most severe cases even mimicking primary ovarian insufficiency (POI). In milder forms, hypoandrogenism reduces follicle number, egg numbers as well as egg quality, unless reconstituted in timely fashion before IVF cycle start. Study design, size, duration We here report a 34-year-old G1P1, who presented for a second opinion with a diagnosis of secondary “unexplained” infertility after two IVF cycles at another fertility center. Participants/materials, setting, methods Since our center considers a diagnosis of “unexplained” infertility as subjective, the patient underwent a thorough diagnostic evaluation. She was using oral contraceptive pills for one week at the time her laboratory results were drawn. Main results and the role of chance: Her free (FT) and total testosterone (TT) (0.4 pg/ml and 5.0 ng/dL, respectively), DHEA and DHEAS (103.0 ng/dL and 92.0 µg/dL, respectively) were low and her estradiol was undetectable (<25 pg/mL), reflecting significant adrenal as well as ovarian suppression. Morning ACTH was undetectable at < 5 pg/mL but cortisol was abnormally elevated (17.7mcg/dL), leading to diagnoses of secondary adrenal insufficiency as well as secondary ovarian insufficiency (SOI) due to adrenal hypo-androgenism from lack of ACTH production. She, in addition, revealed a positive ANA titer (1:160). Because of eczema, she for over a year had been on a super-potent topical steroid ointment. Upon termination of this steroid, adrenal as well as ovarian function, as evidenced by her hormonal values, normalized. Limitations, reasons for caution This is the first case in the literature where iatrogenic-induced insufficiency of adrenal androgen production resulted in secondary ovarian insufficiency (SOI), characterized by undetectable estradiol, reversible by withdrawal of topical steroid treatment. Wider implications of the findings: This case offers further evidence that the traditional hypothalamic-pituitary-ovarian axis (HPAA) extends downstream to ovaries (HPAOA), reaffirming the ability of adrenals to control ovarian function. Trial registration number n/a
INTRODUCTION: Abnormal vaginal bleeding is a common side effect seen in the majority of patients in the first six months after LNG-IUS placement. Some women may desire its removal because of this effect. The objective of this study was to assess the ability of medroxyprogesterone (MP) to reduce this initial bleeding transition period. METHODS: We prescribed a tapering regimen of medroxyprogesterone (MP) overlapping the first 35 days with the LNG-IUS. Four women who desired amenorrhea adhered to this regimen: on day three of their menses, they began a 14-day course of MP 10 mg daily; on day four, the LNG-IUS was inserted; on day 17, the MP was reduced to 5 mg daily for ten days; on day 27, the MP was reduced to 2.5 mg daily for ten days. The women were given a diary to record their bleeding pattern. RESULTS: All four women (100%) became amenorrheic within seven days of LNG-IUS insertion and remained so for the duration of use with the LNG-IUS (>1 year). Three out of four (75%) recorded 3-5 days of spotting for the first 1-4 months with the LNG-IUS. CONCLUSION: Our tapering regimen of MP overlapping the first 35 days with an LNG-IUS is sufficient to eliminate the initial period of abnormal bleeding. Iatrogenic amenorrhea may alleviate many patients' feelings of anxiety as well as other menstrual symptoms, and this may affect a patient's decision to continue using the LNG-IUS. More research is required to validate this study.
Never investigated before in poor prognosis patients, we here determined how in vitro fertilization (IVF) outcomes after fresh embryo transfers compare to frozen-thawed transfers after embryo banking. Using data from our center’s anonymized electronic research data bank, we in a retrospective controlled observational study investigated IVF cycle outcomes of poor-prognosis infertility patients, utilizing autologous eggs, while utilizing donor-egg recipient cycles as controls for covariables. To accomplish statistically valid comparisons, 4 different pairings of 1st IVF cycles were utilized: (i) 127 fresh vs. 193 frozen donor recipient cycles; (ii) 741 autologous fresh unselected non-donor IVF cycles vs. 217 autologous frozen non-donor IVF cycles; (iii) 143 favorably selected autologous non-donor IVF cycles vs. the same 217 frozen autologous cycles non-donor; and (iv) 598 selected average and poor-prognosis autologous non-donor cycles vs. the same 217 frozen autologous non-donor cycles. Main outcome measures were pregnancies and live births. Even within poor-prognosis patients, patient selection to significant degrees impacted how fresh and frozen-thawed IVF cycles compared. Though embryo banking with delayed embryo transfer in best-prognosis patients marginally improved IVF outcomes, in unselected patients it had no effect on outcomes, while in poor-prognosis patients it adversely affected IVF outcomes. Unexpectedly, the study also discovered a previously unreported effect of recipient-age on miscarriage risk in donor-egg recipient cycles, which apparently is independent of age-associated increases in chromosomal abnormalities and, therefore, must have other causes. This study suggests that in poor-prognosis patient banking cycles should be considered contraindicated, in intermediate-prognosis patients they do not appear to change outcomes and, therefore, do not warrant additional costs from thaw cycles, leaving only good-prognosis patients as potential candidates for such a strategy.
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