Delay in IVF treatment up to 180 days does not affect pregnancy outcomes in women with diminished ovarian reserve.
- 作者列表："Romanski PA","Bortoletto P","Rosenwaks Z","Schattman GL
STUDY QUESTION:Will a delay in initiating IVF treatment affect pregnancy outcomes in infertile women with diminished ovarian reserve? SUMMARY ANSWER:A delay in IVF treatment up to 180 days does not affect the live birth rate for women with diminished ovarian reserve when compared to women who initiate IVF treatment within 90 days of presentation. WHAT IS KNOWN ALREADY:In clinical practice, treatment delays can occur due to medical, logistical or financial reasons. Over a period of years, a gradual decline in ovarian reserve occurs which can result in declining outcomes in response to IVF treatment over time. There is disagreement among reproductive endocrinologists about whether delaying IVF treatment for a few months can negatively affect patient outcomes. STUDY DESIGN, SIZE, DURATION:A retrospective cohort study of infertile patients in an academic hospital setting with diminished ovarian reserve who started an IVF cycle within 180 days of their initial consultation and underwent an oocyte retrieval with planned fresh embryo transfer between 1 January 2012 and 31 December 2018. PARTICIPANTS/MATERIALS, SETTING, METHODS:Diminished ovarian reserve was defined as an anti-Müllerian hormone (AMH) <1.1 ng/ml. In total, 1790 patients met inclusion criteria (1115 immediate and 675 delayed treatment). Each patient had one included cycle and no subsequent data from additional frozen embryo transfer cycles were included. Since all cycle outcomes evaluated were from fresh embryo transfers, no genetically tested embryos were included. Patients were grouped by whether their cycle started 1-90 days after presentation (immediate) or 91-180 days (delayed). The primary outcome was live birth (≥24 weeks of gestation). A subgroup analysis of more severe forms of diminished ovarian reserve was performed to evaluate outcomes for patients with an AMH <0.5 and for patients >40 years old with an AMH <1.1 ng/ml (Bologna criteria for diminished ovarian reserve). Logistic regression analysis, adjusted a priori for patient age, was used to estimate the odds ratio (OR) with a 95% CI. All pregnancy outcomes were additionally adjusted for the number of embryos transferred. MAIN RESULTS AND THE ROLE OF CHANCE:The mean ± SD number of days from presentation to IVF start was 50.5 ± 21.9 (immediate) and 128.8 ± 25.9 (delayed). After embryo transfer, the live birth rate was similar between groups (immediate: 23.9%; delayed: 25.6%; OR 1.08, 95% CI 0.85-1.38). Additionally, a similar live birth rate was observed in a subgroup analysis of patients with an AMH <0.5 ng/ml (immediate: 18.8%; delayed: 19.1%; OR 0.99, 95% CI 0.65-1.51) and in patients >40 years old with an AMH <1.1 ng/ml (immediate: 12.3%; delayed: 14.7%; OR 1.21, 95% CI 0.77-1.91). LIMITATIONS, REASONS FOR CAUTION:There is the potential for selection bias with regard to the patients who started their IVF cycle within 90 days compared to 91-180 days after initial consultation. In addition, we did not include patients who were seen for initial evaluation but did not progress to IVF treatment with oocyte retrieval; therefore, our results should only be applied to patients with diminished ovarian reserve who complete an IVF cycle. Finally, since we excluded patients who started their IVF cycle greater than 180 days from their first visit, it is not known how such a delay in treatment affects pregnancy outcomes in IVF cycles. WIDER IMPLICATIONS OF THE FINDINGS:A delay in initiating IVF treatment in patients with diminished ovarian reserve up to 180 days from the initial visit does not affect pregnancy outcomes. This observation remains true for patients who are in the high-risk categories for poor response to ovarian stimulation. Providers and patients should be reassured that when a short-term treatment delay is deemed necessary for medical, logistic or financial reasons, treatment outcomes will not be affected. STUDY FUNDING/COMPETING INTEREST(S):No financial support, funding or services were obtained for this study. The authors do not report any potential conflicts of interest. TRIAL REGISTRATION NUMBER:Not applicable.
研究问题: 延迟开始IVF治疗会影响卵巢储备减少的不孕妇女的妊娠结局吗？ 摘要答案: 与在90天内开始IVF治疗的女性相比，IVF治疗延迟180天不会影响卵巢储备减少的女性的活产率。 已知的是: 在临床实践中，由于医疗、后勤或经济原因，可能发生治疗延迟。经过几年的时间，卵巢储备逐渐下降，这可能导致随着时间的推移，IVF治疗的结果下降。生殖内分泌学家对于延迟几个月的IVF治疗是否会对患者的结局产生负面影响存在分歧。 研究设计、规模、持续时间: 一项回顾性队列研究，研究对象是在2012年1月1日至20 18年12月31日期间，在学术医院中卵巢储备功能下降的不孕患者，这些患者在初次就诊后180天内开始IVF周期，并接受了计划新鲜胚胎移植的卵母细胞提取。 参与者/材料，背景，方法: 卵巢储备功能下降被定义为抗苗勒管激素 (AMH) <1.1 ng/ml。总共有1790例患者符合纳入标准 (1115立即治疗和675延迟治疗)。每个患者有一个包括的周期，没有包括来自额外的冷冻胚胎移植周期的后续数据。由于评价的所有周期结果均来自新鲜胚胎移植，因此不包括遗传测试胚胎。根据他们的周期是在出现后1-90天 (立即) 还是91-180天 (延迟) 开始对患者进行分组。主要结局为活产 (≥ 24周妊娠).进行了更严重形式的卵巢储备减少的亚组分析，以评估AMH <0.5的患者和AMH <1.1 ng/ml的> 40岁患者的结局 (Bologna卵巢储备减少的标准)。采用Logistic回归分析，根据患者年龄进行先验调整，以95% CI估计比值比 (OR)。所有妊娠结局均额外调整了移植胚胎的数量。 主要结果和机会的作用: 从就诊到IVF开始的平均 ± SD天数为50.5 ± 21.9 (立即) 和128.8 ± 25.9 (延迟)。胚胎移植后，两组的活产率相似 (即刻: 23.9%; 延迟: 25.6%; OR 1.08，95% CI 0.85-1.38)。此外，在对AMH <0.5 ng/ml的患者 (立即: 18.8%; 延迟: 19.1%; OR 0.99，95% CI 0.65-1.51) 和AMH <1.1 ng/ml的> 40岁患者 (立即: 12.3%; 延迟: 14.7%; 或1.21，95% CI 0.77-1.91)。 限制，谨慎的原因: 对于在90天内开始IVF周期的患者，与最初咨询后91-180天相比，存在选择偏倚的可能性。此外，我们没有纳入接受初始评估但未进行IVF治疗并取卵的患者; 因此，我们的结果应仅适用于完成IVF周期的卵巢储备功能下降的患者.最后，由于我们排除了从第一次就诊开始IVF周期超过180天的患者，因此不知道这种治疗延迟如何影响IVF周期中的妊娠结局。 研究结果的更广泛含义: 卵巢储备减少患者开始IVF治疗延迟至初次就诊180天不影响妊娠结局。这一观察结果仍然适用于对卵巢刺激反应不良的高风险类别的患者。提供者和患者应该放心，当由于医疗、后勤或经济原因而认为短期治疗延迟是必要的时，治疗结果不会受到影响。 研究资金/竞争利益: 本研究没有获得财政支持、资金或服务。作者没有报告任何潜在的利益冲突。 试用注册号: 不适用。
METHODS:INTRODUCTION:Cytoreductive surgery (CRS) and intraperitoneal chemotherapy (IPC) is an effective treatment option for selected patients with peritoneal metastases (PM), but national utilization patterns are poorly understood. The objectives of this study were to (1) describe population-based trends in national utilization of CRS/IPC; (2) define the most common indications for the procedure; and (3) characterize the types of hospitals performing the procedure. METHODS:The National Inpatient Sample (NIS) was used to identify patients from 2006 to 2015 who underwent CRS/IPC, and to calculate national estimates of procedural frequency and oncologic indication. Hospitals performing CRS/IPC were classified based on size and teaching status. RESULTS:The estimated annual number of CRS/IPC cases increased significantly from 189 to 1540 (p < 0.001). Overall, appendiceal cancer was the most common indication (25.7%), followed by ovarian cancer (23.3%), colorectal cancer (22.5%), and unspecified PM (15.0%). Remaining cases (13.5%) were performed for other indications. Most cases were performed in large teaching hospitals (65.9%), compared with smaller teaching hospitals (25.1%), large non-teaching hospitals (5.3%), or small non-teaching hospitals (3.2%). Patients were more likely to undergo CRS/IPC without a diagnosis based on level I evidence (appendiceal, ovarian, or colorectal) at large non-academic hospitals (odds ratio 2.00, 95% confidence interval 1.18-3.38, p = 0.010) compared with large academic hospitals. CONCLUSIONS:Utilization of CRS/IPC is increasing steadily in the US, is performed at many types of facilities, and often for a variety of indications that are not supported by high-level evidence. Given associated morbidity of CRS/IPC, a national registry dedicated to cases of IPC is necessary to further evaluate use and outcomes.
METHODS::Results of epidemiologic studies of physical activity and ovarian cancer risk are inconsistent. Few have attempted to measure physical activity over the lifetime or in specific age windows, which may better capture etiologically relevant exposures. We examined participation in moderate-to-vigorous recreational physical activity (MVPA) in relation to ovarian cancer risk. In a population-based case-control study conducted in Montreal, Canada from 2011 to 2016 (485 cases and 887 controls), information was collected on lifetime participation in various recreational physical activities, which was used to estimate MVPA for each participant. MVPA was represented as average energy expenditure over the lifetime and in specific age-periods in units of metabolic equivalents (METs)-hours per week. Odds ratios (OR) and 95% confidence intervals (CI) for the relation between average MVPA and ovarian cancer risk were estimated using multivariable logistic regression models. Confounding was assessed using directed acyclic graphs combined with a change-in-estimate approach. The adjusted OR (95% CI) for each 28.5 MET-hr/week increment of lifetime recreational MVPA was 1.11 (0.99-1.24) for ovarian cancer overall. ORs for individual age-periods were weaker. When examined by menopausal status, the OR (95% CI) for lifetime MVPA was 1.21 (1.00-1.45) for those diagnosed before menopause and 1.04 (0.89-1.21) for those diagnosed postmenopausally. The suggestive positive associations were stronger for invasive ovarian cancers and more specifically for high-grade serous carcinomas. These results do not support a reduced ovarian cancer risk associated with MVPA.
METHODS::The aim of our study was to evaluate whether cardiovascular disease risks seen in adults with polycystic ovary syndrome (PCOS) develop in adolescents with PCOS using conventional Doppler echocardiography (CDE) and tissue Doppler echocardiography (TDE) or not. The other aim was to investigate the association of paraoxonase-1 (PON-1) level with cardiovascular parameters. 30 PCOS patients and 30 control patients were included in the study. All patients were evaluated with TDE and CDE. Paraoxonase-1 levels of both groups were studied. In CDE study, myocardial performance index (MPI) was higher in the PCOS group than in the control group (0.54 ± 0.11, 0.50 ± 0.12, p = .049, respectively). In the TDE study, early diastolic myocardial velocity (E)'/late diastolic myocardial velocity (A') was lower in PCOS group than in the control group (2.07 ± 0.08, 2.44 ± 0.10, p = .008, respectively). PON-1 was higher in PCOS group than in the control group (26.81 ± 3.05, 18.68 ± 1.18, p = .011, respectively). Cardiovascular disease risks, which are among the long-term complications of PCOS, seem to begin from the early stage of PCOS. The high PON-1 level was thought to increase in response to increased oxidative stress in PCOS.Impact statementWhat is already known on this subject? Polycystic ovary syndrome (PCOS) is one of the most commonly seen endocrinopathy in the adolescent age group. PCOS has detrimental effects on the cardiovascular system in the adult population which is reported in many studies.What the results of this study add? The result of this study showed that cardiovascular effects, which are among the long-term complications of PCOS, seem to begin from the early stage of PCOS. And also, serum paraoxonase-1 level increases in response to the oxidative stress in the adolescent with PCOS.What are the implications of these findings for clinical practice and/or further research? The cardiovascular system evaluation should be started in early phases of PCOS development in the adolescent age group. The potential role of oxidative effect of Paraoxonase-1 on the PCOS needs to be elucidated in further studies.