Fertility and sterility最新文献

Objective: To determine whether chronodisruption is associated with achieving pregnancy.

Design: Pilot prospective cohort study.

Subjects: One hundred eighty-three women desiring pregnancy were recruited from the local community of an academic medical center located in the Midwest and provided sleep information between February 1, 2015, and November 30, 2017.

Exposure: Sleep and activity data were obtained via actigraphy watches worn continuously for two weeks to assess measures of chronodisruption, including sleep period onset, offset, mid-time, and duration; as well as variability in each of these measures.

Main outcome measures: Time to becoming pregnant over one-year of follow-up.

Results: Of the 183 eligible women, 82 became pregnant over a median of 2.8 months of follow-up. Greater inter-daily variability in time of sleep onset and variability in sleep duration were associated with a longer time to achieving pregnancy after adjusting for age, body mass index, race, education, income, and smoking status (adjusted hazard ratio [aHR] 0.60, 95% CI 0.36 - 0.999 comparing participants with a standard deviation of >1.8 hours to <1.8 hours in daily time of sleep onset; and aHR 0.58, 95% CI 0.36-0.98 comparing participants with a standard deviation of > 2.3 hours to <2.3 hours in daily sleep duration). In adjusted analyses, no statistically significant associations were observed for average time of sleep onset and offset, mid-sleep time, and sleep duration; or for variability in time of sleep offset and mid-time.

Conclusion: Higher day-to-day variability in time of sleep onset and sleep duration - two measures of chronodisruption - were associated with a longer time to achieving pregnancy over one year of follow-up in women desiring pregnancy. If replicated in additional studies, these findings could point to lifestyle interventions to help women achieve a desired pregnancy.

Objective: To study and address the diagnostic, management, and classification challenges of unilocular myometrial cystic lesions adjacent to a normal uterine cavity.

Design: Describe 23 further cases, and undertake a systematic review using Medline, PubMed and Ovid for similar lesions.

Subjects: 23 cases of accessory uterine cavities presenting to pediatric and adolescent gynecologists in Australia and New Zealand.

Main outcome measures: 92 similar cases of cavitated myometrial masses were identified in the literature. The cases in our series and in the literature were examined for age at presentation, site of lesion, pathology, and presence of other anomalies.

Results: All patients in our series were aged ≤ 32 years. All presented with unilocular blood-filled myometrial lesions that did not communicate with the uterine cavity. All were located on the lateral aspect of the uterus in proximity to the round ligament. Of the 22 that have been resected, all were lined by endometrium and smooth muscle. These characteristics are mirrored in the previously described cases in the literature.

Conclusion: The frequency of these myometrial cystic masses is such that they can no longer be considered rare. Nevertheless, their etiology remains unclear. These lesions have often been given names suggesting that they are an early representation of adenomyosis. The alternative possibility of a Müllerian anomaly is supported by consistent anatomical location and young age of presentation in most reported cases. Yet the absence of documented associated anomalies raises concerns about this theory. To progress understanding of these lesions, consistent reporting of features including location and the presence or absence of other anomalies is required. In view of this ongoing uncertainty, we recommend the use of the term "accessory uterine cavity (AUC)." This terminology avoids the implication of either a pathological process or a congenital anomaly.

Importance: Patients with uterine factor infertility (UFI) have few options for family building. Uterus transplant is a feasible treatment for some patients; however, cost remains a significant concern.

Objective: To compare the cost effectiveness of treatment for patients with absolute uterine factor infertility to achieve 1-2 singleton births by gestational carrier or uterus transplant DESIGN: Decision analysis from the United States healthcare sector perspective, with time horizons to achieve one or two singleton births.

Intervention: Gestational carrier or uterus transplant MAIN OUTCOME MEASURES: Incremental cost-effectiveness ratios, comparing the costs (2020 U.S. Dollars) and effectiveness (quality-adjusted life years, QALYs, and live births) to achieve one or two births by gestational carrier and uterus transplant.

Results: In the base case of one singleton birth, the overall cost using a gestational carrier was $97,712.90 ($56,985.20-$153084.20) compared $116,137.20 ($67,142.88-$182,290.86) after uterus transplant. QALYs were higher in the gestational carrier arm (0.93) compared to uterus transplant (0.90) and overall rates of live birth were also higher in the gestational carrier arm (94%) compared to the uterus transplant arm (77%). Costs of the gestational carrier and uterus transplant recipient were the most significant cost variables in the model. Monte Carlo simulation showed that uterus transplant had a 37% chance of being the cost-effective strategy for a single live birth at a willingness to pay of $150,000/QALY. In the case of two singleton births, the cost using a gestational carrier was $186,278.56 ($103,597.81-$296,010.27) compared to $164,276.84 ($111,961.91-$229,394.43) after uterus transplant. QALYs were again higher in the gestational carrier arm (0.93) compared to uterus transplant (0.89). Overall rates of two live birth were also higher in the gestational carrier arm (86%) compared to the uterus transplant arm (66%). Monte Carlo simulation showed that uterine transplant has a 62% chance of being the cost-effective strategy for two live births at a willingness to pay of $150,000/QALY.

Conclusion: Treatment of uterine factor infertility with a gestational carrier is likely the most cost-effective approach for patients delivering a single child. However, the absolute costs associated uterus transplant were 14% less than a gestational carrier for those having two live singleton births.

ASRM develops evidence-based practice guidelines through a rigorous process of identifying clinically significant questions, conducting systematic literature reviews, and evaluating evidence quality. The evidence-based recommendations in ASRM practice guidelines provide reproductive healthcare professionals with standardized, scientifically grounded recommendations to enhance patient care.

Objective: To compare pregnancy outcomes and serum progesterone levels between women who took sublingual (SL) progesterone lozenges versus intramuscular (IM) progesterone-in-oil for endometrial preparation and luteal support in programmed frozen embryo transfer (pFET) cycles.

Design: Retrospective cohort study.

Subjects: All patients who underwent pFET of a single euploid good-quality blastocyst between January 2018 and April 2023 at a single fertility center.

Exposure: Patients received either compounded SL lozenges containing 200mg micronized progesterone three times per day or 50mg progesterone-in-oil daily. Both groups also took 100mg vaginal micronized progesterone three times per day.

Main outcome measures: Primary outcomes included clinical pregnancy (hCG ≥ 5 mIU/mL), ongoing pregnancy (pregnancy progressing past 8 weeks), live birth, and miscarriage. Secondary outcomes included progesterone levels at or one day prior to embryo transfer and at the time of the first pregnancy test.

Results: 1,951 pFET cycles were included, 1,030 (52.8%) who received IM progesterone and 921 (47.2%) who received SL progesterone. There were no significant differences between the IM and SL groups, respectively, in clinical pregnancy (69.5% vs. 74.4%, odds ratio (OR) 0.81, 95% confidence interval (CI) [0.61-1.09]), ongoing pregnancy (56.1% vs. 61.1%, OR 0.78, 95% CI [0.60-1.01]), live birth (50.1% vs. 57.0%, OR 0.85, 95% CI [0.64-1.14]), or miscarriage (25.1% vs. 24.1%, OR 1.24, 95% CI [0.87-1.79]) after controlling for age, race, estrogen preparation, endometrial thickness, physician performing the transfer, and number of prior embryo transfers (P>0.05, all). In the IM progesterone group, mean serum progesterone levels were significantly higher at the time of embryo transfer (41.6 ± 10.9 vs. 30.5 ± 15.7 ng/mL, P<0.01) and at first bhCG measurement (36.5 ± 11.5 vs. 29.4 ± 15.0 ng/mL, P<0.01) as compared to the SL group.

Conclusions: SL progesterone is a viable alternative to IM progesterone for pFET cycles that can minimize injection burden and likely improve patient satisfaction without compromising pregnancy outcomes. Progesterone levels, while slightly lower than the IM route, are in an acceptable range for luteal support.

Objective: To compare the cost-effectiveness of a gestational carrier to a uterine transplantation in the treatment of absolute uterine-factor infertility.

Design: We performed a cost-effectiveness analysis using a decision-tree mathematical model comparing a gestational carrier to a uterine transplantation.

Subjects: Published literature was used to derive costs for solid organ transplant, immunosuppression, gestational carrier obtainment, in vitro fertilization, preimplantation genetic testing, and frozen embryo transfer.

Exposure: Gestational modality: gestational carrier or uterine transplantation. We assumed graft failures occurred immediately and frozen embryo transfers at least six months after transplant.

Main outcome measure(s): The primary outcomes were costs per live birth, number of children born, and quality adjusted life years (QALYs) for each gestational modality.

Results: Uterine transplantation was more expensive than a gestational carrier by $1.4 million U.S. Dollars with a lower utility by 23.74 QALYs using the same average number of children born per two FETS. After 10,000 simulated iterations, the gestational carrier arm had two children born 42% of the time, compared to only 17% of the time in the uterine transplantation arm. No children were born 56% of the time in the uterine transplantation arm versus 16% for the gestational carrier arm. Deterministic and probabilistic sensitivity variance of all cost parameters by +/- 75% ($39,292-$275,044 for gestational carrier versus $390,761-$2,735,329 for uterine transplantation) and other input parameters by +/- 20%, including graft failure (21-31%) and live birth per embryo transfer (29-78%), produced the same outcomes in >99% of scenarios simulated, as did variation in immunosuppression time (2-18 months) between delivery and subsequent FET. UTX was no longer absolutely dominated if the probability of a live birth per transfer using UTX increased beyond 85%, startup cost for UTX decreased to less than $13,646.28, or GC costs increased to greater than $359,200.

Conclusions: Our model suggests gestational carrier use is currently more cost-effective than uterine transplantation for treating absolute uterine-factor infertility. However, the desire to carry one's own child is an intangible factor not captured in cost analyses, and improvements in uterine transplantation success rates or reduced costs may alter these results in the future.