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::Objectives: Serial measurements of sonographic fetal abdominal circumference (AC) are useful for monitoring fetal growth during pregnancy and are essential for predicting macrosomia. The study was aiming to compare the AC profiles of infants born to mothers with or without hyperglycemia in Chinese population.Subjects and methods: The "GDM Prevalence Study (GPS)" was a large study conducted in 22 hospitals in three large cities in China, which included 34,085 NGT (normal glucose tolerant) women, 8272 GDM (gestational diabetes mellitus) women and 729 DM (diabetes mellitus) women. A total of 116,740 scans and 103,377 valid AC measurements were performed for the NGT, GDM and DM groups at different gestational age. AC profiles and fetal growth rates at different stages of pregnancy were compared between different groups.Results: The overall AC growth rate (β) was higher in the macrosomia group than in the no macrosomia group in NGT (β =10.250 versus 9.541, p < .001), GDM (β = 10.572 versus 9.705, p < .001) and DM (β = 11.363 versus 9.924, p < .001) pregnancies. Significant differences were observed between NGT-macrosomia, GDM-macrosomia and DM-macrosomia. Significant differences were also noted between NGT-no macrosomia, GDM-no macrosomia and DM-no macrosomia women. Participants in NGT-macrosomia group exhibited larger AC values than NGT-no macrosomia group beginning at 21 gestational weeks, and GDM-macrosomia group exhibited larger AC values than GDM-no macrosomia group beginning at 22 gestational weeks. AC growth rate was higher in NGT-macrosomia and GDM-macrosomia groups than in the corresponding no macrosomia groups between 22 and 30 gestational weeks.Conclusions: The overall AC growth rates are higher in macrosomia group compared to the no macrosomia group in NGT, GDM as well as DM participants. The significant difference of AC growth rates in NGT-macrosomia and GDM-macrosomia indicate the possible differential underlying mechanisms in developing macrosomia with or without hyperglycemia exposure. Our study demonstrate that larger fetal AC measurements around 21-22 weeks are associated with subsequent diagnosis of macrosomia, suggesting that macrosomia management should be initiated much earlier than we thought.
METHODS::Background: Pregnancy outcomes are affected by many different factors. One of the influential factors on pregnancy outcomes is the male partner as an important person to mother's wellbeing.Objective: The aim of the present study was to investigate the effects of male partner's role including socioeconomic support, emotional support, accompanying pregnant women during prenatal care visits (PNC) and labor, and the level of pregnant women's satisfaction from their partners' support and involvement during pregnancy on pregnancy outcomes.Method: Two hundred first gravid pregnant women with mean age of 23.2 ± 4.3 were studied. Primary outcomes were total maternal and neonatal adverse outcome (TMNAO), total maternal adverse end result (TMAE), and total neonatal adverse outcome (TNAO), regardless of the type of outcomes. Preterm labor and delivery; premature rupture of membrane (PROM) and preterm premature rupture of membrane (PPROM); preeclampsia and eclampsia; placental abruption; chorioamnionitis; stillbirth; meconium passage; maternal death; postpartum hemorrhage; poor progression labor; abnormal vaginal bleeding in third trimester of pregnancy; low birth weight and neonatal need for CPR or intubation, neonatal anomaly, NICU admission, and neonatal mortality were also analyzed as subgroup outcomes.Results: One hundred twenty-seven (63.5%) participants showed a kind of total maternal and neonatal adverse outcome (TMNAO), 72 (36%) deliveries resulted in a kind of neonatal adverse outcome (TNAO), and 104 (52%) of participants had a kind of maternal adverse end result (TMAE). Iranian fathers showed a significantly higher rate of TMNAO than Afghan fathers did (82 versus 69%, odds ratio: 2.9, 95% CI 1.0-7.8, p: .01). Mother's nationality showed the same result (82 versus 64%, odds ratio: 2.6, 95% CI 0.9-6.8, p: .03). Iranian fathers showed a significantly higher rate of TMAE than Afghan fathers did (79 versus 58%, odds ratio: 2.7, 95% CI 1.1-6.3, p: .01). Mother's nationality showed the same result (78 versus 60%, odds ratio: 2.4, 95% CI 1.0-5.6, p: 0.02). Neonates with Iranian fathers showed significantly more TNAO than those with Afghan fathers (50 versus 31%, odds ratio: 2.21, 95% CI 0.9-5.5, p: .04). The same trend was observed among Iranian mothers in comparison to Afghan mothers (50 versus 32%, odds ratio: 2.11, 95% CI 0.9-4.6, p: .06). Of mother's age, mother's BMI, father's age, father's BMI, and mother's nationality, only father's BMI contributed significantly to the binary logistic regression model (n = 116, R2: 9%, p: .028). It was found that for each decreased unit in BMI, the risk of TNAO was increased by 16%, p: .03. Moreover, Father's family history of preeclampsia resulted in a higher prevalence of total neonatal adverse outcome (TNAO) in comparison with lack of such family history (87 versus 43%, odds ratio: 8.9, 95% CI 1.1-74.5, p: .02). Besides, mothers' participation in prenatal care (PNC) visits, assessed by caregivers, was significantly more satisfactory in neonates without any adverse outcome than those with neonatal adverse outcomes (median (IQR) = 2 (1-2) versus 2 (2-3), p: .04). PROM, pre-eclampsia, NICU admission, neonatal intubation, low Apgar score minute 0, and low Apgar score minute 5 were significantly more prevalent in participants revealing positive father's family history of pre-eclampsia. Regarding psychosocial exposures, placental abruption was more prevalent in mothers with exposure to verbal aggression versus non-exposed ones (9 versus 2%, odds ratio: 4.0, 95% CI 0.9-24.6, p: .04). Moreover, a weak positive association between neonatal gestational age at birth and quality of mother's participation in PNC visits (r: +0.3, p: .01) as well as mother's satisfaction from father's commitment to PNC visits was found (r: +0.1, p: .03).Conclusion: Male partners may play a key role in pregnant women and fetus's heath.
METHODS::Objective: To compare maternal and neonatal outcomes by forceps vaginal delivery versus cesarean delivery during the second stage of labor.Methods: We conducted a retrospective cohort study in a large tertiary maternity center in Shanghai, China through 2007-2016. A total of 7046 women carrying a singleton term nonanomalous fetus with vertex presentation who underwent forceps vaginal delivery, or cesarean delivery from a low station in the second stage of labor were included.Results: Of the 7046 women, 6265 underwent forceps and 781 underwent second stage cesarean delivery. Forceps were associated with lower frequency of maternal infection (2.2 versus 4.7%), but higher incidence of mild postpartum hemorrhage (PPH) (4.3 versus 0.6%). When the procedures were performed for fetal indication, forceps were associated with lower frequency of the composite of perinatal mortality and/or hypoxic ischemic encephalopathy (HIE) (0.5 versus 1.9%; adjusted odds ratio (aOR), 0.24; 95% CI: 0.08-0.75), and also shorter decision to delivery interval (12.3 ± 3.5 versus 19.1 ± 5.0 min). The neonatal infection rate was higher in the forceps group (3.9 versus 2.0%). There were no differences in other neonatal outcomes including birth trauma.Conclusions: In women who had a need for intervention during the second stage with a station of +2 or below, forceps were associated with a lower frequency of maternal infection but a higher rate of PPH. Deliveries performed for nonreassuring status were accomplished faster by forceps and were associated with a lower frequency of the composite of perinatal mortality and HIE.