P-634 Safety of ART cycles with extremely high estradiol levels - A retrospective cohort study

Study question

Are IVF treatments with extremely high peak estradiol levels during ovarian hyperstimulation associated with higher complication rates?

Summary answer

Extremely high estradiol levels were not associated with higher major complication rates, but patients were more likely to seek medical care following retrieval.

What is known already

The freeze-all policy and the increasing popularity of social oocyte freezing, have led to an increase in gonadotropin doses and number of oocytes retrieved and, as a direct effect, higher estradiol levels. Studies reporting major ART complications (OHSS, bleeding, infection, torsion, thromboembolic events) are based on heterogeneous patient populations without stratification by oocyte number or estradiol levels, except for a single study reporting an association between peak estradiol levels and the risk of ovarian torsion. Extreme estradiol levels, are associated with larger ovaries, repeated ovarian punctures, and possibly a thrombogenic effect. Therefore, higher complication rates can be expected.

Study design, size, duration

A retrospective cohort study including patients from two large medical centers treated between 2019-2021.

Participants/materials, setting, methods

A study group (239 patients) with extremely high peak estradiol levels (>20,000 pmol/L on the day of ovulation induction, or > 15,000 pmol/L on the previous day) and a control group (208 patients) with normal range estradiol levels (3000-12000pmol/L), treated at two large units were included. Patients were surveyed about complaints and medical care related to ovum pick up (OPU), and medical files were reviewed. Complication rates and the need for medical assistance were compared.

Main results and the role of chance

Several differences between the study and control group were observed as a consequence of the study design: Mean age was 33.01±5.14 vs. 34.57±4.52 (p = 0.01), Mean peak estradiol levels was 26645.34±8592.56 vs.7229.750±2329.20 (p < 0.001), mean number of oocytes were 27.55±13.46 vs. 11.63±5.77 (p < 0.001) for the study and control group respectivly. More patients in the control group underwent fertility preservation. Mean FSH levels and total gonadotropin dosage were higher in the control group. Major complications [3 (1.25%) in the study group vs. 1 (0.96%) in the control group] were similar between groups (p = 0.62). In the study group Two patients were diagnosed with ovarian torsion (0.83%), and one (0.41%) with early severe OHSS as a result of a positive BhCG related to an undiagnosed pregnancy prior to OPU. All three were admitted (1.25%). In the control group one patient was diagnosed with PID requiring inpatient IV antibiotic treatment (0.48%). One more patient was admitted with severe abdominal pain following OPU, for a total of 2 admissions (0.96%) (p = 1). 33 patients (13.8%) in the study group and 10 (4.8%) in the control group sought medical care after OPU, mostly due to abdominal pain, without further workup or hospitalization (p = 0.001).

Limitations, reasons for caution

A retrospective study with possible recall bias. Major adverse events are rare in IVF and may not be fully captured in the study population.

Wider implications of the findings

Based on our results, extremely high estradiol levels during ovarian hyperstimulation were not associated with thromboembolic events, higher major complication or hospitalization rates, thus may be considered safe. Nevertheless, patients may be informed of possible higher rates of discomfort, mostly abdominal pain. Larger studies are warranted to confirm our results.

Trial registration number

0090-21-ASF

P-710 COVID-19 Vaccination and Infertility Treatment Outcomes

Study question

Is there an influence of mRNA COVID-19 vaccine on ovarian response and in vitro fertilization (IVF) treatment outcomes?

Summary answer

COVID-19 mRNA vaccine did not affect the ovarian response nor pregnancy rates in IVF treatment

What is known already

Studies demonstrated that infection with COVID-19 during pregnancy increased the risk of the development of severe disease and pregnancy complications.

A recent meta-analysis of international data showed a declining tendency to be vaccinated, possibly influenced by public concerns over safety of the vaccines. Specifically, concerns were raised about a possible detrimental effect on fertility and pregnancy outcomes due to similarity between syncytin-1, a human placental fusion protein, and the SARS-CoV-2 spike protein expressed after administration of the COVID-19 vaccine.

To date, only one retrospective analysis on 36 infertility patients has assessed the influence of COVID-19 vaccination on IVF treatment outcomes.

Study design, size, duration

A retrospective cohort study . The study included a total of 400 patients, 200 vaccinated women and 200 age matched non-vaccinated women, undergoing IVF treatments during January-April 2021.

Participants/materials, setting, methods

All vaccinated women aged 20-42 that underwent IVF treatment cycles between January 1, 2021 and April 31 2021 were included. All participants completed two doses of the BNT162b2 (Pfizer-BioNTech) vaccine at least two weeks before starting ovarian stimulation. The study group was matched by age to non-vaccinated patients that underwent IVF treatments during the same period. Patients with a positive COVID 19 test in the past were excluded.

Main results and the role of chance

Two hundred patients underwent oocyte retrieval 14-68 days after receiving COVID-19 vaccination. No difference was found between vaccinated and non-vaccinated patients in mean number of oocytes retrieved per cycle (10.63 vs 10.72, p = 0.93). Among 128 vaccinated patients and 133 non-vaccinated patients that underwent fresh embryos transfers, no difference was demonstrated in clinical pregnancy rates (32.8% vs. 33.1%, p-value=0.96), 42 and 44 pregnancies respectively. The fertilization rates and mean number of cryopreserved embryos were similar between the two groups in freeze all cycles (55.43% vs. 54.29%, p-value=0.73), (3.59 vs. 3.28, p-value=0.80). Among vaccinated patients and non-vaccinated patients that underwent fresh embryos transfers, no difference was demonstrated in the fertilization rate (64.81% vs. 61.98%, p = 0.51), and transferred embryos quality. Regression models applied demonstrated no effect of the vaccine on oocyte yields and pregnancy rates.

Limitations, reasons for caution

Limitations include retrospective nature and different treatment protocols.

Additional limitation is the lack of information about vaccination status of the partners. One would assume that if unbalanced, the proportion of vaccinated males would be higher in the study group as partners tend to choose similarly in regard to vaccine administration.

Wider implications of the findings

Women should consider vaccination prior to their attempts to conceive via IVF treatments.

Trial registration number

ASF-0094-21

Effect of seminal plasma application to the vaginal vault in in vitro fertilization or intracytoplasmic sperm injection treatment cycles-a double-blind, placebo-controlled, randomized study

PURPOSE

To study whether intravaginal application of seminal plasma after follicle aspiration has the potential to increase implantation and clinical pregnancy rates after IVF-ET.

METHODS

We conducted a prospective, double-blind, placebo-controlled randomized study of 230 patients undergoing IVF-ET cycles. 500 μL of Fresh seminal plasma from the patient's partner or culture medium (placebo) were injected in the vaginal vault just after follicle aspiration. The main outcome measured was ongoing clinical-pregnancy rate.

RESULTS

After ET cancellation in ten patients due to lack of fertilization or embryo cleavage, 220 embryo transfers (103 and 117 in the study and control groups) resulted in a clinical pregnancy rate of 36.9 % and 29.1 % for the study and control groups, corresponding to a relative increase of 26.8 %. After an early pregnancy loss of 13.1 % (5/38) and 23.5 % (8/34) in the study and control groups respectively an ongoing pregnancy rate of 32.0 % (33/103) and 22.2 % (26/117) was achieved corresponding to a relative increase of 44.1 %. Multivariate logistic regression analysis adjusted for study group, age, infertility, and cycle characteristics did not demonstrate any parameter that could predict occurrence of clinical pregnancy rates after IVF-ET.

CONCLUSIONS

Patients who underwent SP intravaginal insemination after oocyte pick-up reached higher implantation and clinical pregnancy rates following ET compared to controls, although the difference did not reach statistical significance. More studies and variable methodologies may clarify the potential clinical effect of SP in improving live birth rates after ART.

A unique biological in-vivo model to evaluate follicular development during in-vitro maturation treatment

The aim of this study was to identify the size in which the dominant follicle acquires the ability to produce a functional corpus luteum. This observational study includes 15 women with ovulatory cycles who underwent human chorionic gonadotrophin (HCG)-primed in-vitro maturation (IVM) treatments without embryo transfer. All patients received subcutaneous injection of HCG 10,000 IU 38 h prior to oocyte retrieval. Five to seven days following retrieval, serum concentrations of progesterone and oestradiol were measured along with ultrasound scan measuring the antral follicle count. Using receiver operating characteristic curves and the Youden index (J), this study clearly shows that the diameter of the dominant follicle at the time of the LH surge is a good predictor for its ability to form a progesterone-producing corpus luteum (area under the curve 0.94). These findings revealed that the dominant follicle develops the competence to form a corpus luteum, signified by the production of more than 10 nmol/l serum progesterone at 5-7 days from oocyte retrieval, as soon as it acquires a diameter of 10.5-12.0mm. In addition, a new cohort of viable antral follicles can be identified as early as 5-7 days following IVM oocyte retrieval.

Postpartum chills phenomenon: is it a feto-maternal transfusion reaction?

OBJECTIVE

To examine the theory that the postpartum shivering phenomenon is related to feto-maternal bleed during the third stage of labor.

METHODS

One hundred laboring low-risk women who had a normal vaginal delivery were observed for the presence of postpartum chills. The duration of the first and second stages of labor changes in body temperature, maternal and fetal blood types and the use of epidural anesthesia were recorded. Following the delivery maternal blood was examined for the presence of fetal red blood cells using the Kleihauer-Betke stain.

RESULTS

Complete data was available in 97 patients. Post-partum chills occurred in 31 of them (32%). Women with and without chills were similar in their maternal and gestational age, the use of epidural anesthesia, and length of second stage of labor. Women with chills delivered smaller babies but the difference did not reach significance. Maternal-fetal blood group incompatibility was significantly more common among shivering than non-shivering women (48% vs. 20% respectively, p=0.006). Kleihauer-Betke test was positive in 11 women. The only two women in this group who experienced chills had maternal-fetal blood group incompatibility.

CONCLUSION

Post-partum chills are a common phenomenon. It may be the clinical presentation of feto-maternal transfusion reaction. The small number of positive Kleihauer-Betke tests may reflect its low sensitivity in the detection of small feto-maternal bleeds.