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ASRM 2015SCIENTIFIC ABSTRACTS to be presented at the 71st Annual Meetingof the American Society for Reproductive Medicine, October 17-21,2015, Baltimore, Maryland.

(e2) ORAL SESSION(e106) POSTER SESSION(e362) AUTHOR INDEX(e378) TOPIC INDEX(e380) AUTHOR AND SPOUSE/PARTNER DISCLOSURES INDEX

October 17-21, 2015Baltimore, Maryland

These abstracts of research studies, printed as submitted by the authors, are presentedin the ASRM 2015 meeting sessions and are published in the order of theirpresentation. Abstracts of plenary lectures, symposia and interactive sessions arenot included.

Copyright 2015 American Society for Reproductive Medicine,1209 Montgomery Highway, Birmingham, Alabama 35216-2809

The first six papers are candidates for the ASRM Scientific ProgramPrize Paper Awards. Six additional candidates will be presented duringthe Prize Paper Candidates session on Tuesday.

SCIENTIFIC PROGRAM PRIZE PAPER SESSION 1

O-1 Monday, October 19, 2015 11:15 AM

DIETARY PROTEIN INTAKE AND REPRODUCTIVE HORMONESAND OVULATION: THE BIOCYCLE STUDY. S. L. Mumford,a

A. Alohali,b J. Wactawski-Wende.c aNICHD, NIH, Rockville, MD; bGeorgeMason University, Arlington, VA; cUniversity at Buffalo, Buffalo, NY.

OBJECTIVE: Protein intake has been associated with changes in steroido-genesis in women with polycystic ovary syndrome, likely through reducinghyperinsulinemia. However, the associations among premenopausal womenwithout a history of infertility or polycystic ovary syndrome are not wellcharacterized. The objective of this study was to evaluate the association be-tween protein intake and reproductive hormone concentrations and ovulationin a healthy population.

DESIGN: Prospective cohort study of 259 healthy premenopausal womenfollowed for up to two menstrual cycles.

MATERIALS ANDMETHODS: Estradiol, progesterone, luteinizing hor-mone, follicle-stimulating hormone, and testosterone were measured up toeight times per cycle for up to two cycles, with visits scheduled using fertilitymonitors to coincide with menstrual cycle phases. Percent energy from totalprotein, animal protein, and vegetable protein were assessed by 24-hourrecall up to four times per cycle. Linear mixed models and generalized linearmixed models were used to evaluate the association between protein intakeand reproductive hormone levels, and with ovulatory status (peak progester-one%5ng/mL with no LH peak on the mid or late luteal phase visit), respec-tively. All models were adjusted for total energy intake, age, body massindex, race, fat intake, and physical activity.

RESULTS: Dietary protein consumption, specifically animal protein, wasfound to be inversely associated with testosterone concentrations. In partic-ular, the highest tertile of percent energy from total protein intake was asso-ciated with lower testosterone concentrations (beta -0.05, 95% CI -0.01,-0.005) compared to the lowest tertile of intake. The highest tertile of percentenergy from animal protein intake was also associated with lower testos-terone (beta -0.02, 95% CI -0.04, -0.0001). No associations were observedbetween protein intake and other hormones, including estradiol, progester-one, luteinizing hormone, or follicle stimulating hormone levels, nor wasthere an association between protein intake and ovulation.

CONCLUSIONS: These findings suggest that a diet high in protein, partic-ularly animal protein, is significantly associated with reduced testosteronelevels among healthy women. These results highlight the importance ofdiet on reproductive function and the potential role of protein intake inandrogen synthesis.

Supported by: Intramural Research Program, DIPHR, NICHD, NIH.


ROCKINGTHEDOGMAOFSEMINALROUNDCELLS. Q. V. Neri,T. Cozzubbo, Z. Rosenwaks, G. D. Palermo. Reproductive Medicine, WeillCornell Medical College, New York, NY.

OBJECTIVE: To revisit the origin and significance of the sporadic pres-ence of round cells in the ejaculates of men screened for male infertility.

DESIGN: In a prospective fashion, a total of 4,051 men undergoing maleinfertility screening in a period of 24 months were included in the study. RCcells were characterized for WBC components versus exfoliated germ cellsby testing for multiple markers of ploidy as well as protamine assays. Casesdisplaying R2 million RC were screened for bacteria. The effect of RC onclinical outcome was assessed in specimens used for ART.

MATERIALS AND METHODS: Raw specimens containing RC wereprocessed by peroxidase and other leukocyte assays, specific stains for prot-amines were used to identify spermiogenic stage, aneuploidy (9 chromosomeFISH) assessment was carried out, and the presence of various Sertoli-cellcytoplasmic remnants was analyzed to identify and characterize immaturegerm cells (IGC).

RESULTS: A total of 4,810 ejaculated samples were processed for semenanalysis. The average age of the men involved was 39.2 7yrs. Semen sam-ples had a mean concentration of 40.7 31 million, motility of 42.6 35%,and morphology of 2.3 2%. Round cells were identified in 261 of the spec-imens evaluated, representing a proportion of 5.4%. Men presenting with

round cell had comparable age but lower sperm concentration andmorphology than the control (P < 0.0001). Aneuploidy was detected in 91specimens, of which 30.8% (28/91) presented with round cells. The aneu-ploidy rate of 4.3%, remarkably higher than the control (2.3%; P < 0.001).Sperm aneuploidy rate positively correlate with the amount of RC (P 0.0001).In 44 men, 17 of them in 18 cycles had up to 1.9 million RC withoutaffecting fertilization and clinical pregnancy rates when compared to control(n365 cycles). In 27 men with 33 ICSI cycles with over R2 million roundcells, the fertilization rate trended lower and the miscarriage rate was signif-icantly increased (P 0.05).The absence of any correlation between RC andbacteriological growth as well as the results of marker testing indicates thatseminal RC are mostly immature germ cells that stain for vimentin andinhibin B. Moreover, their modest protamine content and their haploid statusconfirm that they are post-meiotic. Sequential observation in the same manshowed that the RC episode was followed by an amelioration of the semenparameters and that the presence of RC corresponds to flu season peaks.CONCLUSIONS: Seminal round cell presence is not a marker of infec-

tiousness but rather a transient indicator of spermatogenic insult that possiblyoccurs in most men following a mild and transient ailment such as the flu.Supported by: WCMC.


THE SUPEROVULATED ENVIRONMENT, INDEPENDENT OFEMBRYO VITRIFICATION, RESULTS IN LOW BIRTHWEIGHTFOLLOWING EMBRYO TRANSFER IN A MOUSEMODEL. R. S. Weinerman, T. S. Ord, C. Coutifaris, M. A. Mainigi. Di-vision of Reproductive Endocrinology and Infertility, University of Pennsyl-vania, Philadelphia, PA.

OBJECTIVE: Babies born following fresh embryo transfer are of lowerbirthweight than babies born following frozen embryo transfer. The objectiveof this study was to determine, in a mouse model, if this difference is due tothe superovulated (SO) peri-implantation environment or embryo vitrifica-tion (VIT).DESIGN: Laboratory research.MATERIALS AND METHODS: Female CF1 mice were superovulated

with gonadotropins and mated to male mice heterozygous for green-fluores-cent protein (GFP). 2-pronuclear embryos were collected and cultured to theblastocyst stage and a subset of embryos were vitrified. For each transferexperiment, 10 blastocysts, 5 fresh and 5 vitrified/thawed, were transferredinto a host mouse, using GFP to tag the embryos as fresh or frozen. Transferswere performed into pseudopregnant females created through either naturalmating to vasectomized males (n30) or superovulation followed by matingto vasectomized males (n45). This resulted in 4 experimental groups: 1)Natural environment, fresh embryos (Nat-Fresh) 2) Natural environment,frozen embryos (Nat-VIT) 3) Superovulated environment, fresh embryos(SO-Fresh) 4) Superovulated environment, frozen embryos (SO-VIT). Preg-nant mice were sacrificed near term (E18.5) for assessment of fetal andplacental weights and GFP status. An a-priori power calculation determinedthat 17 fetuses per group would provide 80% power to detect a 15% differ-ence in fetal weight with an alpha of 0.05.RESULTS: There was no difference in litter size between natural (n15

litters) and SO (n13 litters) hosts. Although there was no difference inplacental weight, therewas a highly significant difference (p

O-4 Monday, October 19, 2015 12:00 PM

THE SYNCHRONIZATION OF THE LEIOMYOMAEXTRACELLULAR MATRIX SIGNALING PATHWAYS OFSURGICAL SPECIMENS IN RESPONSE TO ULIPRISTALACETATE. M. Malik,a J. Cox,b J. Britten,a A. Patel,c L. K. Nieman,d

W. H. Catherino.a aObstetrics and Gynecology, Uniformed Services Univer-sity of the Health Sciences, Bethesda, MD; bProgram in Reproductive andAdult Endocrinology, Eunice Kennedy Shriver National Institute of ChildHealth and Human Development, Bethesda, MD; cHenry Jackson Founda-tion, Bethesda, MD; dReproductive Biology and Medicine Branch, EuniceKennedy Shriver National Institute of Child Health and Human Develop-ment, Bethesda, MD.

OBJECTIVE: To elucidate the pathways that may be involved in the actionof Ulipristal acetate, a selective progesterone receptor modulator, on leio-myoma extracellular matrix (ECM) production and breakdown.

DESIGN: Uterine leiomyomas are characterized by increased stiffness as aresult of excessive and disordered ECMwhich contributes to the total bulk ofthe tumor. Ulipristal acetate reduced leiomyoma size in several randomizedplacebo-controlled studies. We have previously demonstrated that Ulipristalacetate reduces the total ECM that forms the bulk of the tumor in over 60% ofpatients studied. Clinical tissue was sent for RNASeq analysis to identifypathways that may be involved in leiomyoma ECMbreakdown. In-vitro anal-ysis was carried out to analyze the effect of the medroxyprogesterone acetate(MPA) and Ulipristal acetate.

MATERIALS AND METHODS: RNA isolated from clinically collectedfibroid and myometrial tissue from patients treated with Ulipristal acetatein a placebo-controlled, randomized trial, underwent RNASeq analysis(Beckman Coulter Genomics Inc). To further evaluate the impact of Ulipris-tal acetate, 3-dimensional leiomyoma cultures were treated with MPA, Uli-pristal acetate, and combinations. The expressions of ECM genes as wellas Wnt/b-catenin pathway genes were analyzed. Proteins were analyzed us-ing Western Blot.

RESULTS: Both TGFb3 and TGFb1 transcripts were reduced in tumors ofwomen treated with Ulipristal acetate. The reduction was also observed atprotein levels. Multiple components of the TGFb signaling pathway demon-strated an overall reduction. Reduced transcript and protein expressions wereobserved in matrix metalloproteinases (MMPs), such as MMP-9 (2.38-fold)and MMP-13 (1.97-fold). Decreased WNT5a protein indicated an involve-ment of the WNT/b-catenin pathway that was Supported by changes inexpression of Frizzled gene transcripts such as FZD6. In addition, therewas increased expression of aquaporins and other osmotic stress regulatorssuch as NFAT5, which are known to be regulated by WNT pathway.Leiomyoma cells in 3D culture, in response to MPA, demonstrated a3.23+/-0.15-fold increase in b-catenin expression. Ulipristal acetate aloneand in combination with MPA decreased b-catenin expression below thatof untreated leiomyoma cells.

CONCLUSIONS: TGFb signaling pathway in association with bothcanonical and non-canonical WNT pathway may participate in Ulipristalacetate clinical activity by reducing the total amount of ECM proteins pro-duced, and by decreasing osmotic stress. Ulipristal acetate may also reducethe progesterone-mediated fibrosis.

Supported by: This research was Supported by Intramural grant from Uni-formed Services University of the Health Sciences, QP85GF13 andRO85298815. The research was also Supported, in part, by the intramuralresearch Program in Reproductive and Adult Endocrinology, NIH; NIHR21 and EMD Serono.


ELECTIVE SINGLE EMBRYO TRANSFERS (ESET) AS COMPAREDTO COMPREHENSIVE CHROMOSOME SCREENING(CCS). A. R. Anderson, D. Taylor, K. C. Chiles, U. Balthazar,A. S. Browne. Reproductive Medicine Associates of Texas, San Antonio, TX.

OBJECTIVE: To investigate the association with eSET with optimal em-bryo development and CCS testing for embryo selection.

DESIGN: A prospective cohort study.MATERIALS AND METHODS: CCS aneuploidy testing was performed

on 297 embryo transfers. Alternately, 172 eSET blastocyst transfers werecompleted based on at least two high quality day 5 embryos available fortransfer where one is transferred and at least one selected for cryopreservationon day 5. In the CCS subgroup, 5 to 7 cells were biopsied fromday 5 and day 6blastocysts in a HEPES buffered Medium. Biopsied cells were placed inseparate PCR tubes and analyzed for 24 chromosomes at an outside reference

laboratory. All embryos in the CCS subgroup were subjected to vitrificationfor a delayed embryo transfer in a subsequent frozen embryo cycle.RESULTS: There was no significant difference in ongoing pregnancy,

average age, embryos transferred, or miscarriage rates when eSET criterionor CCS was utilized for embryo selection. In the eSET group there were 172transfers with 126 (73%) positive pregnancies, 25 (20%) losses, and 101(59%) ongoing pregnancies. From 297 CCS embryo transfers there were209 (70%) positive pregnancies, 47 (22%) losses, and 162 (54%) ongoingpregnancies respectively with no significant difference between these twosubgroups. However, there was a significant (P

expression of AMH, FSHR, Inhibina and Inhibinb in growing follicles ingroup 3 versus group 2.Tracking studies demonstrated the human MSCsevenly infiltrating and repopulating growing follicles in treated ovaries.Finally, breeding data showed significant increase in both the number ofpregnancies and total number of pups per litter in group 3 compared to group2 (P 0.02).

CONCLUSIONS: Our study shows that intra-ovarian injected humanBMSCs were able to restore ovarian hormone production, reactivate follicu-logenesis in chemotherapy-damaged ovaries and reverse infertility in thispreclinical model. This approach carries high promise towomenwith chemo-therapy-induced, and potentially other types of, premature ovarian failure.

MENOPAUSE


DRUG METABOLIZING ENZME POLYMORPHISMS AREASSOCIATEDWITHCHEMOTHERAPYRELATEDAMENORRHEAIN YOUNG BREAST CANCER SURVIVORS. L. M. Charo,a

M. V. Homer,a L. Natarajan,a C. Haunschild,b A. DeMichele,c I. Su.aaUC San Diego, San Diego, CA; bStanford University, Stanford, CA;cUniversity of Pennsylvania, Philadelphia, PA.

OBJECTIVE: To test if candidate single nucleotide polymorphisms(SNPs) in enzymes involved in cyclophosphamide activation or detoxifica-tion are associated with time to ovarian failure after chemotherapy in youngbreast cancer survivors.

DESIGN: Prospective cohort study.MATERIALS AND METHODS: Premenopausal breast cancer survivors

(n 116) with Stages 0 to III disease and planned cyclophosphamide-basedchemotherapy were enrolled at diagnosis from three academic breast pro-grams and followed longitudinally for menstrual pattern. Participants weregenotyped for SNPs in genes involved in cyclophosphamide activation(CYP3A4 [rs1067910] and CYP2C19 [rs42244285]) and detoxification(GSTP1 [rs1695] and GSTA1 [rs4715332]). The primary endpoint wastime to chemotherapy-related amenorrhea (CRA), defined as >12 monthsof amenorrhea after the end of chemotherapy. Using the time-to-eventmethod, the association between SNPs and CRA were assessed using Coxproportional hazard regressionmodels. A priori sample size calculations esti-mated 80% power to detect relative risks of 1.7-2.6.

RESULTS: The cohort had a median age of 39.7 years (range 20.8-46.1) atend of chemotherapy and median follow up of 594.5 days (range 23-2119).28% experienced CRA. Survivors with at least one major allele of GSTA1had significantly lower hazards of developing CRA compared to survivorswho were homozygous for the minor allele (HR 0.22 [95% CI 0.61-0.91],p0.04). Survivors with at least one major allele of CYP2C19 had signifi-cantly higher hazards of developing CRA compared to survivors who werehomozygous for the minor allele (HR 4.56 [95% CI 1.54-13.57], p0.01).CYP3A4 and GSTP1 SNPs were not related to CRA. Increased age wasalso associated with CRA. In separate multivariable models adjusting forage and BMI, GSTA1 remained significantly associated with CRA (HR0.23 [95% CI 0.06-0.96], p0.04) while CYP2C19 was attenuated (HR2.75 [0.89-8.49], p0.08).

CONCLUSIONS: In younger breast cancer patients undergoing cyclo-phosphamide-based chemotherapy, the presence of one or more major allelesof GSTA1 was found to have lower risk of developing CRA. Inter-individualvariation in enzymes involved in chemotherapymetabolism is related to post-treatment ovarian function.

Supported by: MRSG-08-110-01-CCE, HD058799, T32 HD007203.


PRESCRIBING OF COMPOUNDED AND COMMERCIALLYAVAILABLE MENOPAUSAL HORMONE THERAPY BYOBSTETRICIAN-GYNECOLOGISTS AND FAMILY MEDICINEPHYSICIANS. J. P. Dubaut, F. Dong, B. L. Tjaden, D. A. Grainger,J. Duong, L. L. Tatpati. University of Kansas School of Medicine -Wichita, Wichita, KS.

OBJECTIVE: Compounded bioidentical hormone use has risen in theUnited States (1). The American College of Obstetricians and Gynecologists(ACOG) released a committee opinion on this topic, including guidelines forits members (2).We explored factors that may influence prescribing practicesof compounded and bioidentical menopausal hormonal therapy (MHT) and

level of agreement with relevant ACOG statements among obstetrician-gyne-cologists (OB/GYNs) and family medicine physicians (FPs).DESIGN: Cross-sectional physician survey.MATERIALS AND METHODS: After Institutional Review Board

approval, investigators created an online anonymous survey. The surveylink was emailed to Kansas OB/GYN and FP physicians. The initial andreminder emails were sent 4 weeks apart; the survey was available for 3months. Survey constructs included: demographics, MHT knowledge,MHT prescribing practices, and opinions on statements published in theACOG Committee Opinion 532. Chi-square analyses were conducted toidentify associations between specialties, practices and opinions on ACOGstatements.RESULTS: Overall response rate was 11.1% (150 of 1349). The response

rate of OB/GYNs (27%) exceeded that of FPs (7.2%). Of 150 respondents,53.3% were FPs. The majority of respondents identified as female (64%),were under 50 years old (57.4%), and worked in cities with populationsover 100,000 (70.5%). In the past year, 84.5% prescribed conventionalMHT, 83% prescribed commercial bioidentical MHT, and 58.9% pre-scribed compounded bioidentical MHT. OB/GYNs prescribed more thanFPs in each category; the difference in prescribing commercial bioidenticalMHT was statistically significant (p0.03). Hormone levels were moni-tored in at least some patients by 40% of physicians. When asked whethercompounded MHT was regulated by the Food and Drug Administration(FDA), 76.7% answered no, 4% answered yes, and 19.3% werenot sure or declined to answer. Most respondents stated efficacy, risks,tolerability, cost, patient preference, and experience of previous patientswere important factors influencing their MHT prescribing practices. FDAregulation was not important to 15.3%, while customization was importantto 62% of physicians. The majority of respondents agreed with 10 ACOGstatements regarding MHT (range 53-97%), but at least 15% showeddisagreement with 7 of 10 statements. More OB/GYNs than FPs agreedsaliva levels are not biologically meaningful (p

RESULTS: Ethnic distribution did not differ in each reproductive cate-gory: 39 premenopausal South Asians and 34 Europeans; 10 perimenopausalSouth Asians and 14 Europeans; and 42 postmenoapusal South Asians and 39Europeans. Body fatness variables increased with reproductive ageing to analmost similar degree in both ethnic groups (p for trend greater than 0.05 forall associations) without ethnicity modifying the gradient of the associationsbetween menopausal state and body fatness (p for interaction with ethnicitygreater than 0.05 for all associations). Moderate to vigorous physical activityand VO2max decreased in a similar fashion across the reproductive stages inboth ethnic groups whereas energy intake remained unchanged. Bodyfatness, physical activity and fitness did not differ among the ethnic groupsfor each reproductive stage either. Metabolic biomarkers (insulin, totalcholesterol, triglycerides and blood pressure) deteriorated with reproductiveageing in both ethnic groups in a similar degree. Notably, HbA1c levelsincreased to a much greater degree with reproductive ageing in the SouthAsians than in the Europeans (p0.02 for interaction with ethnicity).

CONCLUSIONS: The increase in HbA1c levels in healthy womenwithout overt T2DM during menopausal transition was much greater in theSouth Asians than in their White counterparts and this discrepancy was notexplained by a greater deterioration in body composition or physical activityvariables along with reproductive ageing.


ASSOCIATION BETWEEN POLYCYSTIC OVARY SYNDROMEAND HOT FLASH PRESENTATION DURING THEMENOPAUSE TRANSITION. O. Yin,a H. A. Zacur,b J. A. Flaws,c

M. S. Christianson.a aJohns Hopkins University School of Medicine,Lutherville, MD; bReproductive Endocrinologist, Lutherville, MD;cUniversity of Illinois, Urbana, IL.

OBJECTIVE: While polycystic ovary syndrome (PCOS) is the most com-mon endocrinopathy in reproductive-age women, most research has focusedon young women and the impact of PCOS on the menopause transition re-mains poorly understood. This study aims to determine the influence ofPCOS on hot flash presentation in midlife women.

DESIGN: Retrospective cohort study.MATERIALS AND METHODS: Subjects were recruited from an ongoing

cohort study involving 748 midlife women aged 45-54 from an urbanmetropolitan area. Subjects completed detailed questionnaires that includedhot flash symptom and demographic information. Between June 2014 andMarch 2015, 656 patients were contacted by telephone. Those who agreed toparticipate were screened for history of PCOS using the Rotterdam criteria.Chi square analysis andWilcoxon rank sum testwere used as needed to comparesubjects with a history of PCOSwith other midlifewomen.Multivariate logisticregression was performed to identify factors associated with hot flashes atmidlife; odds ratios (OR) with 95% confidence intervals (CI) were calculated.

RESULTS: A total of 453 women (69%) responded to the telephone inter-view and 9.3% (n42) met diagnostic criteria for PCOS. The remaining 411were included as controls. Mean PCOS subject age was 48.0 and body massindex (BMI) was 27.3. The majority of subjects were Caucasian (73%) with asmaller proportion African American (21%) and other ethnicities (2%).PCOS and control groups were not statistically different with respect toage, BMI, race, income, smoking, drinking, physical activity, number of pe-riods in the last year, and testosterone, progesterone, or estradiol levels.Multivariate logistic regression analysis demonstrated that PCOS was notassociated with increased odds of hot flash prevalence, frequency, duration,or severity. Smokingwas the only variable that demonstrated an increased as-sociation with experiencing hot flashes (OR 2.0, 95% CI 1.05-3.98).

CONCLUSIONS: A history of PCOS was not associated with increasedhot flashes during the menopause transition in this study. These data suggestthat women with PCOS have similar hot flash presentations in midlife ascompared to the general population. Additional research should continueto investigate the health and quality of life implications associated with ahistory of PCOS in the aging population.

Supported by: 2R01AG018400 - 05A2.


ORAL TIBOLONE (2.5 MG) VERSUS TRANSDERMAL ESTRA-DIOL GEL (0.06%, 2.5 GM) - EFFECTS ON SERUM CALCIUMAND 25-HYDROXY VITAMIN D3 LEVELS AFTER SURGICALMENOPAUSE. S.M. Bhattacharyaa A. Jha.b aObstetrics and Gynecology,KPC Medical College, Kolkata, India; bResearch Associate, West Virginia,WV.

OBJECTIVE: To compare the effects of oral Tibolone (2.5 mg) and Trans-dermal Estradiol gel (0.06%; 2.5g) on serum Calcium and 25-hydroxyVitamin D3 levels in surgically postmenopausal women after 6 months oftreatment.DESIGN: Open label randomized controlled study.MATERIALS AND METHODS: 144 women (40-52 years of age) with

surgical menopause (duration 3-18 months and done for benign gynecolog-ical causes and having distressing menopausal symptoms) with preset in-clusion and exclusion criteria were randomized in 1:1 ratio, between01.03 2013 and 30.06.2014 into 2 groups. Prior ethical approval andinformed written consents (from all participants) were obtained. Group Areceived Tibolone (2.5mg, daily) orally and Group B received TransdermalEstradiol gel (0.06%; 2.5 g, daily). The primary outcomes were comparisonof the absolute changes in serum Calcium and 25- hydroxy Vitamin D3levels following 6 months of treatment between the two groups. Bodymass index (BMI) and blood pressure (systolic, SBP: diastolic, DBP)were recorded. Serum calcium and 25- hydroxyl vitamin D3 levels weremeasured. All parameters were studied at baseline and after 6 months oftreatment. Sample size was calculated based on a pilot study where 6months treatment with Tibolone increased vitamin D3 level by 4.91ng/ml (SD 6.54) and Transdermal estradiol gel increased vitamin D3level by 2.08 ng/ml (SD 3.99). It was calculated that a sample size of58 patients per group would have 80% power and 95% confidence levelwith 2-sided test of significance to detect this mean difference betweenthe two groups. 6 cases in the Group A and 9 cases in the Group B werelost to follow up after 6 months of treatment.RESULTS: Intent-to-treat analysis showed that after 6 months of treat-

ment, effects of the two treatment interventions were identical in the studiedpopulation. In both intervention arms, patients recorded increase in serumCalcium and Vitamin D3 levels, but the mean differences were not statisti-cally significant.CONCLUSIONS: There were no differences in therapeutic effects of oral

Tibolone and Transdermal Estradiol gel on BMI, blood pressure, serum Cal-cium and Vitamin D3 levels in surgically postmenopausal women after 6months of treatment. Effects of the changes in serum Calcium and VitaminD3 levels, by either mode of treatment, on bone remodelling in menopausalwomen would need more studies.Support: None.CTRI registration no. - CTRI/2013/02/003341.


LONG TERM HORMONE REPLACEMENT THERAPY (HT)DOES NOT AFFECT POST-MENOPAUSAL TOTAL BODYCOMPOSITION. A. H. Bayer,a K. N. Goldman,b R. Mauricio,a

M. J. Nachtigall,b F. Naftolin,b L. E. Nachtigall.b aNYU School ofMedicine,New York, NY; bDepartment of Obstetrics & Gynecology, NYU School ofMedicine, New York, NY.

OBJECTIVE: The impact of HT on menopause-related changes in bodycomposition is not resolved. We sought to evaluate differences in totalbody composition in post-menopausal women who had taken HT for anaverage of 14 years.DESIGN: Retrospective cohort study.MATERIALSANDMETHODS: Post-menopausal women (40-100 years)

on HT for a minimum of 6 years in a university-affiliated menopause clinicunderwent annual Dual Energy X-ray Absorptiometry (DXA) from August2004 to October 2014. Annual DXA scans from untreated post-menopausalwomen seen in the same clinic during the same time period were evaluated ascontrols. Exclusion criteria included the diagnosis of primary ovarian insuf-ficiency, DXA data unavailable or incomplete, and DXA scan not performedwhile on HT (for HT group). Primary outcomes were percent (%) total bodyfat and % total lean body mass. Secondary outcomes included body mass in-dex (BMI) and relevant co-morbidities. Data were analyzed using Studentst-test and Fishers exact test where appropriate (p

differences in medical co-morbidities in women on HT compared to controls,including but not limited to osteoporosis, diabetes, hypertension, hyperlipid-emia, coronary artery disease, fibrocystic breast disease, endometrial polyps,colonic polyps, endometrial cancer, ovarian cancer, mammogram BIRADS(breast imaging-reporting data system) 3, 4, or 5, or breast cancer.

CONCLUSIONS: Evaluation by DXA of post-menopausal womenreceiving HT for up to 25 years demonstrates that long-term HT has no sig-nificant impact on body composition. It is notable that there was no increasedprevalence of medical co-morbidities between the treated and control groups.These findings may inform the risk-benefit ratio when considering long-termHT for post-menopausal women.

Supported by: Pfizer Corporation.

REPRODUCTIVE ENDOCRINOLOGY: RESEARCH 1


ELEVATED SERUM ANTI-MULLERIAN HORMONE (AMH)STALLS OVARIAN FOLLICLE DEVELOPMENT BYDOWNREGULATING FSH- AND LH-RECEPTORS ANDINHIBIN-B PRODUCTION. L. Detti,a L. J. Williams,a

S. E. Osborne,a N. M. Fletcher,b G. M. Saed.b aObstetrics and Gynecology,University of Tennessee, Memphis, Memphis, TN; bWayne State Univer-sity, Detroit, MI.

OBJECTIVE: In granulosa cell cultures AMH inhibits the FSH-dependentfollicular growth and the cyclic selection for dominance [1-3]. Women withpolycystic ovary syndrome (PCOS) have high serum AMH levels fromincreased production [4] which are correlated to the follicle number andAMH levels [5]. We tested the hypothesis that administration of recombinantAMH to ovarian cortex fragments would inhibit follicular development bydownregulating hormone receptors expression.

DESIGN: Pilot experimental study with ovarian cortex obtained from 3patients.

MATERIALS AND METHODS: Immediately after explant the ovariancortex specimens were divided into 5 equal fragments. One fragment wasflash-frozen (untreated) and four were incubated for 48 hours 37C in apH-adjusted gamete buffer media with increasing AMH concentrations of0-5-25-50 ng/ml. After incubation, all specimens were rinsed and flash-frozen for PCR analyses, which were executed in triplicates. We utilizedreal time RT-PCR to determine mRNA levels for FSH-R, LH-R andInhibin-B in ovarian cortex tissue. We performed ANOVAwith Tukey posthoc tests to evaluate changes in mRNA levels among the five different frag-ments. A p

were collected. We used microanalytical assays to measure the levels of ATPand citrate in single oocytes. To evaluate spindle and chromosome alignment,mice were injected with PMSG and hCG, sacrificed and ovulated meiosis II(MII) oocytes were collected. Mature oocytes were stained with tubulin andDAPI. Imaging was performed on a Leica confocal microscope and analysisperformed blindly with ImageJ software. ANOVA, students t-tests, and chi-square analysis were used in the statistical analysis as appropriate.

RESULTS: HF mice weighed significantly more than mice on the controldiet (28g vs 21.7g, p

Supported by: Expanding the Boundaries Research Grant, Brigham &Womens Hospital, Harvard Medical School NIH Grant RO1 HD053112,R21 HD061259.


SELECTIVE PROGESTERONE RECEPTOR MODULATOR(SPRM), CDB-4142 INHIBITS DECIDUALIZATION OF HUMANANDMOUSEENDOMETRIAL STROMALCELLSANDPREVENTSEMBRYO IMPLANTATION IN THE MOUSEUTERUS. S. Kuokkanen,a L. Zhu,b B. McAvey,c J. Pollard.d aObstetrics& Gynecology, Albert Einstein College of Medicine, Bronx, NY; bDepart-ment of Molecular Biology, Albert Einstein College of Medicine, Bronx,NY; cObstetrics & Gynecology, Icahn School of Medicine, Mt. Sinai andRMA of NY, New York, NY; dCollege of Medicine and Veterinary Medicine,University of Edinburgh, Edinburg, United Kingdom.

OBJECTIVE: SPRMs with selective effects on hormone responsive tis-sues hold promise for long-term medical management of fibroids and endo-metriosis. Telapristone acetate (CDB-4124) is a derivative form of ulipristalacetate, a reliable emergency contraceptive (Ella). Here, we examined theimpact of CDB-4124 on in vivo decidualization and embryo implantation inthe mouse uterus and in vitro decidualization of human endometrial stromalcells (hESC).

DESIGN: Controlled laboratory study.MATERIALS AND METHODS: Endometrial tissue was collected by bi-

opsy from healthy volunteers. After isolation, stromal cells were seeded in 6-well plates in DMEM-F12 with 2% charcoal/dextran-treated FBS. The de-cidualization media was supplemented with 1uM progesterone (P), 30 nMestradiol (E) and CDB or 0.1% EtoH vehicle control. hESC decidualizationwas monitored by morphology and prolactin (PRL) and IGFBP1 mRNA byqrtPCR. Decidualization of the mouse uterus was induced in ovariectomized,E/P or E/P/CDB treated mice by intraluminal injection of peanut oil or PBS(control) and decidual response was assessed by uterine horn weight andmorphology. For implantation study, copulation of wild type CD1 micewas monitored with daily vaginal plugs and CDB was administered on preg-nancy d 3-6. The mice were euthanized on pregnancy d7 and implantationsites were quantified.

RESULTS: After 9 days of incubation, hESC in the decid. media trans-formed from fibroblast-like cells to round decidual cells and producedincreased levels of the decidualization markers compared to the control cells(PRL FC41, p0.0003; IGFBP1 FC76, p0.01). hESC decidualized inthe decid. media with CDB 0.1uM (PRL FC8.5, p0.0006; IGFBP1FC10, p0.03). In contrast, hESC cultured in the decid. media withCDB at 1, 3 or 9 uM remained spindle-shaped and PRL and IGFBP1mRNAwere at the level of the control cells. CDB inhibited decidual responsein the mouse uterus and the weight ratio of the oil stimulated to the controlmouse horn was approximately 3 in E/P treated mice (0.1095 mg 0.034mg vs. 0.034 mg 0.0072, p0.01), but only 1.03 in E/P/CDB treatedmice (0.042 mg 0.011 mg vs. 0.041 mg 0.011, p0.25). Implantationsites were absent in the CDB treated uteri after copulation compare to anaverage of 12 sites in the control mice.

CONCLUSIONS: CDB-4124 acts as progesterone receptor antagonist inhuman and mouse endometrial stromal cells, completely inhibiting stromaldecidualization and inhibiting embryo implantation in the mouse uterus.These findings describe a novel mechanism as to how SPRM can be effica-cious in treating sex-steroid dependent conditions and, as post-coital contra-ceptive, delay endometrial maturation and extend contraceptive efficacybeyond the time of ovulation.

Supported by: U54 HD058155, ABOG/AAOGF Bridge Funding (S.K).

MALE REPRODUCTION AND UROLOGY:TRAVELING SCHOLARS


COMPARISON OF THREE METHODS OF PENILE VIBRATORYSTIMULATION (PVS) IN MEN WITH SPINAL CORD INJURY(SCI). W. Chong,a E. Ibrahim,b T. Aballa,b C. Lynne,a N. L. Brackett.baUniversity of Miami/Jackson Memorial Hospital, Miami, FL; bThe MiamiProject to Cure Paralysis, Miami, FL.

OBJECTIVE: PVS is recommended as the first line of therapy for semenretrieval in anejaculatory men with SCI. This study compared ejaculatory

success rates and patient preference for three methods of PVS within thesame group of men with SCI.DESIGN: Prospective, three-way crossover design.MATERIALS AND METHODS: Subjects were 15 men with SCI whose

level of injury was T10 or rostral. Each subject received the following threemethods of PVS, with an interval of 2-4 weeks between each method.Method 1 (M1): applying one FertiCare Personal (Multicept, Denmark)device to the dorsum or frenulum of the glans penis; Method 2 (M2): sand-wiching the glans penis between two FertiCare devices; Method 3 (M3):sandwiching the glans penis between the two vibrating surfaces of the Viber-ect X3 (Reflexonic, Frederick, MD) device. To control for sequencing ef-fects, 5 subjects received PVS in the following sequence: M1, M2, M3; 5received the sequence M2, M3, M1; and 5 received the sequence M3, M2,M1. For trials with M1 and M2, FertiCare device(s) were set at 2.5 mmamplitude and 100 Hz. For trials with M3, stimulation parameters of the Vi-berect X3 were preset by the manufacturer and were not adjustable. For allmethods, PVS was delivered in 2 minute increments with inspection of thepenile skin between increments. PVS was stopped if ejaculation occurredor after 10 minutes of PVS with no ejaculation. Following each PVS trial,subjects were asked to rate their experience on a questionnaire with scaledresponses.RESULTS: Please see Table 1. Ejaculation success rates were high for

each method, however, ejaculation latency was significantly longer withM3 compared with M1 or M2. When analyzing subject responses to surveyquestions, there were no significant differences in ratings of M1 compared toM2. In contrast,M3was rated lower thanM1 andM2 for all survey questions.These differences were significant for survey questions 1, 2 and 4. Semencollection was more problematic withM3 versusM1 orM2 due to the config-uration of the Viberect X3 device, which hampered proximity of the spec-imen cup to the urethral meatus.CONCLUSIONS: Based on these findings, our recommended algorithm is

to attempt PVS with one FertiCare device. If that fails, use two FertiCare de-vices. Although the Viberect X3 was preferred less by patients, it is a lowercost alternative that may be suitable for home use by some patients.

SEM standard error of the meanUnless indicated by a superscripted letter, comparisons between groups

were not significant.aSignificantly different from M1 (p 0.0006) and M2 (p 0.001)bSignificantly different from M1 (p 0.01) and M2 (p 0.03)cSignificantly different from M1 (p 0.03) and M2 (p 0.03)dSignificantly different from M1 (p 0.02)

Table 1

One FertiCareDevice (M1)

Two FerticareDevices (M2)

Viberect X3Device (M3)

Success rate (% of menejaculating)

87 100 87

Ejaculation latency inseconds (mean SEM)

29.6 5.0 32.2 4.4 56.8 5.0a

Survey Questions:(Values representmeans SEM)

1. How much did thismethod meet yourexpectations?

0 Did not meetexpectations

100 Met expectations

74.9 6.1 77.2 6.1 52.8 5.9b

2. How comfortabledid you feel duringstimulation?

0 Not comfortable100 Very comfortable

82.2 5.7 82.2 5.7 64.3 5.5c

3. How comfortable doyou feel about usingthis method at homeeither by yourself orwith a partner?

0 Not comfortable100 Very comfortable

79.1 6.5 71.5 6.5 67.5 6.2

4. Would you recommendthis method to othermen with spinalcord injury?

0 Would not recommend100 Would recommend

91.7 7.0 83.6 7.0 68.4 6.7d

e8 ASRM Abstracts Vol. 104, No. 3, Supplement, September 2015


REDEFINING AND CLARIFYING THE RELATIONSHIPBETWEEN TOTAL MOTILE SPERM COUNTS (TMSC) ANDINTRAUTERINE INSEMINATION (IUI) PREGNANCYRATES. R. S. Rubin,a K. S. Richter,b F. Naeemi,b S. Shipley,b

P. R. Shin,c J. E. OBrien.b aUrology, Medstar Georgetown UniversityHospital, Washington, DC; bShady Grove Fertility Reproductive ScienceCenter, Rockville, MD; cShady Grove Fertility Center, Washington, DC.

OBJECTIVE: The value of post-wash TMSC for predicting IUI outcomesis not well defined. Limitations of previous reports include small samplesizes and attempts to identify clinically meaningful thresholds as opposedto gradual trends across a continuum of TMSC. To clarify the relationship be-tween post-wash TMSC and IUI outcomes we evaluated a large single insti-tution sample.

DESIGN: Retrospective reviewMATERIALS ANDMETHODS: All stimulated clomiphene citrate, letro-

zole, and/or injectable gonadotropin IUI cycles performed at a single institu-tion from 2004 to 2014 were reviewed, excluding double insemination.Generalized estimating equations (GEE) analysis was used to account formultiple cycles by individual patients and to adjust for age, BMI, infertilitydiagnoses, stimulation protocol, and pre-insemination endometrial thickness,serum estradiol, and numbers of follicles R14 mm.

RESULTS: 47,553 insemination cycles were available to evaluate the rela-tionship between TMSC and clinical pregnancy (defined as ultrasoundconfirmation of an intrauterine gestational sac). Pregnancy rates were highestwith a clear threshold noted atR9 million TMSC. Pregnancy rates declinedgradually as TMSC decreased.

Complete data for the adjusted GEE analysis were available for 40,655 cy-cles. Adjusted GEE analysis among cycles with R9 million TMSCconfirmed that TMSC in this range was unrelated to pregnancy (p0.47).Conversely, TMSC was highly predictive of pregnancy (Wald c2120) inadjusted GEE analysis among cycles with

(not gender specific). Among all cancer centers, only 60% include informa-tion on fertility preservation specifically directed toward men, such as spermcryopreservation. Survivorship information on family building after cancerwas available on 32% of cancer center web sites. State population densityhad no significant effect on whether a web site included risks of treatmenton fertility (p0.90) or information on fertility preservation (p0.29).

CONCLUSIONS: Forty percent of NCI designated cancer center web sitesdo not discuss options for male fertility preservation, and over one-thirdmake no mention of the ramifications of cancer treatment on male fertility.Given the increasing recognition of the importance of oncofertility in cancersurvivorship, more education should be available about options for fertilitypreservation, particularly among men.

References: [1] There are 68 NCI designated cancer centers, of which 61engage in clinical activity. Cleveland Clinic Taussig Cancer Institute wasincluded as a separate data point although it is also a member of the CaseComprehensive Cancer Center, for final n62.


BLOCKADE OF PHOSPHATIDYLSERINE ON MURINE SPERMINHIBITS IN VITRO FERTILIZATION. L. Smith-Harrison,a

K. Wheeler,b C. Barberry,a W. Xu,b R. Smith,c J. Lysiak.b aUrology,University of Virginia, Charlottesville, VA; bUniversity of Virginia, Charlot-tesville, VA; cUVA Urology, Charlottesville, VA.

OBJECTIVE: Phosphatidylserine (PtdSer) expression is not only a markerfor apoptotic cells but also a ligand for engulfment receptors essential for therecognition and efficient removal of these dead cells. The engulfment of thedead/apoptotic cells by phagocytes or neighboring cells is actually the finalstep of apoptotic cell death. Our lab has recently shown that efficient clear-ance of apoptotic germ cells is essential for normal spermatogenesis. Studiesin the boar, ram, mouse, rat, and human have found mature sperm positive forthe expression of PtdSer. PtdSer positive sperm were found to be functionaland may even positively correlate with embryo formation in humans. In thiscurrent study we test the novel hypothesis that egg-sperm interactions duringfertilization may hijack the machinery normally used for engulfing apoptoticcells, with the spermmimicking an apoptotic cell and the oocyte a phagocyte.

DESIGN: In vitro fertilization (IVF) experiments were performed usingoocytes from super-ovulated mice and sperm isolated from the murine caudaepididymis.

MATERIALS ANDMETHODS: Expression of PtdSer on sperm was per-formed with fluorescenctly tagged Annexin V (AnV). Blockade of PtdSer onsperm was accomplished with unlabeled AnV.

RESULTS: The percentage of fertilized embryos after PtdSer blockadewith AnV was 57.6% versus 87.2% in controls (p < 0.001). Sperm motilitywas not affected by AnV. Additionally, immunofluorescence identifiedPtdSer on the midpiece and acrosome regions of sperm from the cauda butnot caput epididymis.

CONCLUSIONS: The exact mechanisms involved in sperm entry into theoocyte remain elusive. These results suggest that PtdSer on sperm play animportant role in fertilization and supports our hypothesis that ligands andreceptors involved in apoptotic cell engulfment may be used during spermoocyte interactions. Whether oocytes have receptors for PtdSer, or whetherPtdSer interacts with cumulus cells or the zona pellucida remains to be eluci-dated. The results of this study will have potential impacts on in vitro fertil-ization and contraceptive technologies.


PROTEOMIC PATHWAY IN SEMINAL PLASMA OF MEN WITHSPINAL CORD INJURY (SCI) BEFORE AND AFTER ORALADMINISTRATION OF PROBENECID. M. Camargo,a E. Ibrahim,b

T. C. Aballa,b V. Carvalho,c K. Cardozo,c C. M. Lynne,b,d R. Bertolla,a

N. Brackett.b,d aDepartment of Surgery, Division of Urology, Human Repro-duction Section, Sao Paulo Federal University, Sao Paulo, Brazil; bMiamiProject To Cure Paralysis, University of Miami, Miami, FL; cFleury Group,Sao Paulo, Brazil; dUrology, University of Miami, Miller School of Medi-cine, Miami, FL.

OBJECTIVE: Previous results demonstrate that oral administration ofprobenecid increases sperm motility in men with SCI (J Urol 193(4S)e344-e345). Our objective was to evaluate the proteome of seminal plasmain SCI patients before and after treatment with oral probenecid in order todemonstrate changes in associated pathways.

DESIGN: Prospective Study.

MATERIALS AND METHODS: This study included 10 men with SCIwho ejaculated regularly by penile vibratory stimulation or electroejacula-tion. Probenecid tablets (Watson Pharma Inc., Corona, CA) were adminis-tered in two phases. In Phase 1, subjects received 250 mg orally twice aday for 1 week. In Phase 2, subjects who completed Phase 1 with no compli-cations or side effects were administered 500 mg orally twice a day for 3weeks. Semen analyses were performed at two time points: Pre-treatment(Pre-Rx group, 1-2 days before Phase 1) and Post-treatment (Post-Rx group,within 4 weeks after completion of Phase 2). Seminal plasma proteomics wasperformed by a label-free quantitative approach, in which 50 mg of total pro-teins were pooled, digested into tryptic peptides and analyzed by liquid chro-matography followed by tandem mass spectrometry (LC-MS/MS). Eachsample was run in triplicate. Significant proteins (Students t-test) wereused for functional enrichment analysis performed using the Cytoscape plat-form.RESULTS: In total, 806 proteins were identified, of which 695 were not

significantly changed in both groups. Thirteen proteins were down-regulatedand 65 other proteins were exclusive to the Pre-Rx group. Five proteins wereup-regulated and 28 other proteins were exclusive to the Post-Rx group. ThePre-Rx group expressed increased immunologic functions, such as antigenprocessing and preservation of peptide antigen via MHC class I. Catabolicactivities such as amino acid degradation, lysosome organization, as wellas the pentose-phosphate shunt oxidative functions were also observed inthe Pre-Rx group. The Post-Rx group expressed enriched energy productionpathways (glycine-tRNA ligase activity) as well as 4-hydroxyproline cata-bolic processes.CONCLUSIONS: Oxidative and immune functions, as well as catabolic

processes were enhanced in patients with SCI. Treatment with oral proben-ecid enhanced the energy-production pathways that play an important rolein the biological process of improving sperm motility in men with SCI.Supported by: Craig H. Neilsen Foundation #224598.

MALE REPRODUCTION AND UROLOGY: CLINICAL 1


SEMINAL VESICLE SPERM ASPIRATION FROM WOUNDEDWARRIORS: A CASE SERIES. M. W. Healy,a B. Yauger,a

A. N. James,b R. Dean.c aDepartment of Obstetrics and Gynecology, Divi-sion of Reproductive Endocrinology and Infertility, Walter Reed NationalMilitary Medical Center, Bethesda, MD; bART Institute of Washington,Inc, Bethesda, MD; cDepartment of Urology, Division of Andrology, WalterReed National Military Medical Center, Bethesda, MD.

OBJECTIVE: There has been an increase in blast injuries from dis-mounted Improvised Explosive Devices (IEDs) encountered on the battle-field (i.e. ambulatory soldiers not within the protection of a vehicle).Associated injuries involve the lower extremities, pelvis, and perineum.Thus, options to retrieve sperm may be limited due to type and extent ofinjury. An alternative technique to the standard Testicular Sperm Extractionor Microsurgical Epididymal Sperm Aspiration is seminal vesicle spermaspiration (SVSA), described in cases of ejaculatory duct obstructions or pri-mary anorgasmy. Given the type of pelvic injuries seen in these woundedwarriors, we assessed SVSA as an option to retrieve sperm with the goalof cryopreservation for future use in In Vitro Fertilization (IVF) with intra-cytoplasmic sperm injection (ICSI).DESIGN: Retrospective case series.MATERIALS AND METHODS: Wounded warriors who underwent

SVSA at Walter Reed National Military Medical Center between 2012-2014 were included. Patient age, type and date of injury, date of SVSA, spec-imen fluid analysis, post-thaw analysis, fertilization rates during IVF/ICSI,pregnancy rates, and live birth outcomes were evaluated.RESULTS: Six patients who presented with lower extremity, pelvic, and

perineal injuries resulting from dismounted IEDs underwent SVSA within5-12 days of the initial injury. Sperm retrieved were analyzed (volume:0.4mL to 1.8mL, concentration: 40K to 2,200K, motility: 0% to 5%). Spermwas washed and cryopreserved. In two cases, IVF/ICSI cycles were per-formed using the frozen samples. Sperm retrieval for these cases occurred5 and 9 days after the initial injuries. In one couple, 13 mature oocytes under-went ICSI with morphologically normal sperm that responded to the touchtest with a fertilization rate of 38%. One grade V embryo was transferredon day 4 with a negative pregnancy test. The second couple underwenttwo IVF/ICSI cycles. In the first cycle, 9 mature oocytes underwent ICSIwith 4 sperm that responded to Pentoxifylline and 5 sperm that responded


to touch test notable for a 44% fertilization rate. On day 5, one expanded blas-tocyst, B/B, was transferred with a negative pregnancy test. In the second cy-cle, 17 mature oocytes underwent ICSI with sperm that responded toPentoxifylline, with a 47% fertilization rate. Two B/B expanded blastocystswere cryopreserved due to concern for ovarian hyperstimulation in the fe-male partner. Among all three cycles, fertilization rate was 43.5%.

CONCLUSIONS: SVSA is a reasonable option to retrieve sperm inwounded warriors or trauma patients with pelvic or perineal injuries.

Supported by: This research was Supported, in part, by the Program inReproductive and Adult Endocrinology, NICHD, NIH.


EVALUATION OF REPRODUCTIVE SYSTEM ANATOMY ANDGONADAL FUNCTION IN PATIENTS WITH PRUNE-BELLYSYNDROME. M. Cocuzza,a B. C. Tiseo,a R. Park,a G. P. Padovani,a

R. H. Baroni,b A. Tavares,a F. T. Denes,a M. Srougi.a aDivision of Urology,Hospital das Clinicas, University of Sao Paulo Medical School, Sao Paulo,Brazil; bRadiology Institute, Hospital das Clinicas, University of Sao PauloMedical School, Sao Paulo, Brazil.

OBJECTIVE: To report the first series of Prune-belly syndrome (PBS) pa-tients that were submitted to surgical treatment during early childhoodfocusing in the evaluation of reproductive system anatomy and gonadal func-tion. To date, PBS patients were diagnosed as infertile and fertility was oftengiven lowest priority. Their infertility is multifactorial and is probably relatedto the undescended testes, prostatic hypoplasia and retrograde ejaculation.There are no documented cases of unassisted paternity; few successful preg-nancies have been reported through assisted reproduction, but all usingepididymal or testicular sperm extraction.

DESIGN: Series of case analysis.MATERIALSANDMETHODS:We accessed 30 patients with PBS from

our service that were submitted to any surgical procedure during theirchildhood and now are at least 14 years old. Patient records were accessedto identify age at orchidopexy. All patients were submitted to pelvic MRI inorder to evaluate anatomical findings of reproductive system, includingprostate size, characteristics of seminal vesicles and vas deferentia. Serumlevels of LH, FSH, testosterone and also creatinine were evaluated. Spermanalysis was conducted and analysis of the urine after masturbation whenneeded.

RESULTS: We contacted 18 patients. Of those, 15 had reliable data frompatient records including physical examination and hormone profile. Theaverage of age of this group at evaluation is 18.2 years. The average age atorchidopexy was 17 months and an average follow-up was 17.4 years. Allhad normal physical development and stable anatomy and function of the re-constructed urinary tract with an average creatinine of 1.64 mg/dL. Fourteenpatients had both testes in scrotum, and the testicular volume varied from2.1cc to 9.4cc, averaging 6.9cc. Eight patients collected semen with a spermcount of 5.07 million/mL, whereas motile sperm was found in 62.5%including three in the ejaculate and two in urine after masturbation. Averagehormones levels were LH: 5.3 mg/dL, FSH: 6.9 mg/dL, total testosterone:531.2 mg/dL and free testosterone: 450.6 mg/dL. MRI revealed prostates hy-poplastic in 55.6% and absent in 22.3%, while 55.6% had absence of at leastone of the seminal vesicles. There was no vasal abnormality.

CONCLUSIONS: Our data enlightens findings in patients with PBS thatwere not described yet. A high prevalence of hypoplastic or absent prostateand seminal vesicle abnormalities was observed in our patients; those find-ings may represent their main cause of infertility. Probably, early orchido-pexy increases testicular function salvage preserving their fertilitypotential patients leading to the finding of motile sperm in the ejaculate orin urine after masturbation. The next step is to provide a better understandingof their fertility potential improving quality of life.


THE EFFECTS OF TRANSVERSE AND LONGITUDINALINCISION OF TUNICA ALBUGINEA IN MICRODISSECTIONTESTICULAR SPERM EXTRACTION. T. Ishikawa, K. Yamaguchi,R. Nishiyama, Y. Takaya, K. Kitaya, H.Matsubayashi. Reproduction ClinicOsaka, Osaka, Japan.

OBJECTIVE: The optimal technique of sperm extraction would beminimally invasive and avoid destruction of testicular function without

compromising the chance of retrieval adequate numbers of spermatozoa toperform ICSI. In general, the tunica albuginea should be opened on an equa-torial plane because antimesenteric incision increases the risk of testiculardevascularization and may adversely affect access to the seminiferous tu-bules. To demonstrate the differences of sperm retrieval rate (SRR) and post-operative complication between transverse or longitudinal incision of tunicaalbuginea in microdissection testicular sperm extraction (micro TESE).DESIGN: A retrospective study.MATERIALS AND METHODS: A total of 1080 patients (including 970

46XY males with NOA and 110 Klinefelter syndrome (KS) patients) under-went micro TESE were subjected to sperm retrieval procedures. All opera-tions were performed by one surgeon (TI). Karyotyping test wasperformed on a sample of blood to all patients. SRR and postoperativecomplication were analyzed in the 960 patients with transverse incision(group T) and the 120 patients with longitudinal incision (group L). Ninetyand 20 non-mosaic KS cases each were included in group T and group L,respectively.RESULTS: Testicular sperm were successfully retrieved by micro-TESE

in 415 of 960 (43.2%) NOA (including 47 of 90 KS: 52.2%) and 56 of 120(46.7%) NOA (including 10 of 20 KS: 50%) patients with group Tand groupL incision in micro TESE, respectively. There was no significant differenceof sperm retrieval rate with either approach. No patients had postoperativecomplications such as major hematoma or leakage of seminiferous tubulesthrough this series. The hospital stay was all the same in both groups(a-day-surgery). For the 46XY males with NOA patients, after micro-TESE, the testosterone level did not drop significantly in both group T andgroup L. In addition, there were no significant differences in the levels oftestosterone between group T and group L for the 46XY males with NOApatients. Of the KS patients who underwent micro TESE, the mean serumtestosterone level showed an average decline of 30-35% from baselinewhen assessed at 1, 3, and 6 months after micro-TESE, but no significant dif-ferences were also shown in the levels of testosterone between group T andgroup L.CONCLUSIONS: There were no significant differences between trans-

verse or longitudinal incision for SRR and postoperative complication inmicro TESE. We should take care of the hypogonadism in KS patients aftereven microdissection procedure by either transverse or longitudinal inci-sion.


COMPARISON OF SEMEN QUALITY BETWEEN UNIVERSITYAND PRIVATE CLINIC LABORATORIES. O. Khan,a C. F. Jensen,b

J. Sonksen,b M. Fode,b T. Shah,c D. A. Ohl.a aUrology, University of Mich-igan, Ann Arbor, MI; bUrology, Herlev University Hospital, Herlev,Denmark; cObstetrics and Gynecology, University of Michigan, Ann Arbor,MI.

OBJECTIVE: Obtaining an ejaculate and performing a semen analysis(SA) is an essential first step in evaluating the infertile man. Based on theSA the physician determines the nature of further evaluation and treatment.Multiple treatment options are available and range from simple counseling tothe more complicated and expensive assisted reproduction techniques(ART). The objective of this study was to investigate inter-laboratory varia-tion in semen quality between private ART laboratories and university-basedART laboratories respectively.DESIGN: Clinical retrospective study.MATERIALS AND METHODS: IRB approval was obtained to retro-

spectively evaluate patients who had undergone a SA at both the Universityof Michigan Center For Reproductive Medicine and private practice IVFclinics. When more than one SA was available from both clinics the SAwith the highest total motile sperm was selected for analysis. Major semenparameters from both SAs were compared using Wilcoxon signed-ranktest.RESULTS: A total of 20 men aged 35 6 (mean SD) years were

included in the study. Table 1 shows comparisons of the major semen param-eters obtained at the two laboratories. Morphology was reported significantlylower at the private clinics.CONCLUSIONS: In this small series, morphologywas significantly lower

in semen analyses performed at private IVF clinics. Since spermmorphologyunder 5% is commonly used to recommend IVF with ISCI, underestimationof sperm morphology at private clinics may lead to over-utilization of highlevel assisted reproductive techniques at these sites.

FERTILITY & STERILITY e11


CLOMIDHASGOTABRIGHTSIDEANDADARKSIDE.WHATDOWEREALLYKNOWAFTERALLTHESEYEARS? EVIDENCEFORTOXICITY. R. Wiehle G. K. Fontenot. Research and Development,Repros Therapeutics Inc, The Woodlands, TX.

OBJECTIVE: Clomid has been approved in women with PCOS/ovulationinduction. In men it is used off-label to increase testosterone or to relievesymptoms of androgen abuse. Clomid is a mixture of two isomers: zuclomi-phene and enclomiphene. The former is a weak estrogen agonist and the latteris a strong estrogen antagonist. Repros Therapeutics is developing enclomi-phene for elevating endogenous testosterone in men with secondary hypogo-nadism.

DESIGN: We have administered each isomer of clomid to mice, bothchronically and acutely, in an attempt to determine the relative differences.

MATERIALS AND METHODS: Enclomiphene and zuclomiphene wereseparated from clomiphene as pure mono-isomers. Mice were administeredeach isomer chronically (90 days) then tissues were examined histologic.In a mouse ADME, pigmented mice were acutely administered each of the14C-labelled isomers. Tissue and fluid distribution were followed up to 45days.

RESULTS: In animals chronically administered each isomer, zuclomi-phene had pernicious effects on the male reproductive tract (testes, epidid-ymis, and seminal vesicles) and the kidney. Significant reduction in size oftestes with testicular degeneration was seen, including Leydig cell losswith absence of sperm in the seminiferous tubules and reduction in size ofthe epididymis, seminal vesicles and kidneys. In the ADME study, for 47 tis-sues assessed, 97.5% of the 14C-enclomiphene seen at 4 hours was lost by 24hours. In contrast, only 40.8% of the 14C-zuclomiphene seen at 4 hours waslost. Zuclomiphene was retained selectively. Among those that accumulatedzuclomiphene that seen in the blood were the pigmented portions of the eye,the brain, adrenal gland, the kidneys and the testes.

CONCLUSIONS: We infer that zuclomiphene accumulates in excess overenclomiphene. Human studies have suggested this as well. We concede thatthe antagonist effects of enclomiphene can overwhelm effects of zuclomi-phene when used chronically, however the extreme high build-up of theagonist isomer may have lasting effects. These results justify the case for amonoisomeric preparation and the development of Enclomiphene citrate,for clinical use in men with secondary hypogonadism to increase testos-terone. It is interesting to speculate whether clomiphene citrate would havebeen granted FDA approval given the differences between its constitutiveisomers.

Supported by: Repros Therapeutics Inc.


THE EFFECT OF CLOMIPHENE CITRATE IN THE TREATMENTOF SUBFERTILE MALES WITH BODY MASS INDEX (BMI) 25KG/M2. B. Patel,a T. Shah,a D. Shin.b aUrology, Rutgers New JerseyMedical School, Newark, NJ; bUrology, Hackensack University MedicalCenter, Hackensack, NJ.

OBJECTIVE: Elevated BMI has been shown to have a negative impact onmale fertility. Clomiphene citrate (CC), a selective estrogen receptor modu-lator, is often used in the empiric treatment of subfertile males to increasetestosterone levels and improve spermatogenesis. The objective of this studywas to assess the effect of CC in the treatment of subfertile males withelevated BMI R 25 kg/m2.

DESIGN: Retrospective cohort study.

MATERIALS AND METHODS: Fifty-six subfertile males with BMIR 25 kg/m2 were treated with CC between 2009 and 2014. Semen analysiswas conducted on all 56 patients at baseline and at minimum, 3 monthsfollow-up. Fifty of the 56 patients had baseline and 5 month follow-up mea-surements of follicle-stimulating hormone (FSH), luteinizing hormone (LH),total testosterone (TT), bioavailable testosterone (BT) and estradiol (E)levels. Pregnancy status was obtained when possible. Paired t-test wasused to compare baseline and follow-up hormonal profiles and semen ana-lyses.RESULTS: Significant increase in sperm concentration, from 19.0 2.7

M to 28.2 4.0M (p

MATERIALS AND METHODS: Patients with normal ovarian reserve% 42 years of agewere recruited. Following routine IVF care, trophectodermbiopsy was performed. Embryos were subsequently selected for transfer perroutine. No NGS CCS analysis was done prior to transfer. A novel targetedamplification method of NGS based CCS which does not require wholegenome amplification was then performed. The outcome for each transferredembryo was compared to the NGS screening result to determine thepredictive value of that result. In the case of a two embryo transfer, DNAfingerprinting was utilized to ensure that the embryo responsible for the preg-nancy was identified correctly. Implantation rates were compared betweenembryos designated euploid, aneuploid, and for the population as a whole.

RESULTS: 117 patients had 187 blastocysts transferred. Of the 41 em-bryos assigned an aneuploid karyotype, none sustained implantation yieldinga predictive value of an aneuploid result of 100%. 97 of 146 embryos desig-nated as euploid implanted and progressed to delivery yielding a predictivevalue for a euploid result of 66.0%. No embryo designated as euploid subse-quently developed into an aneuploid gestation. Euploid embryos had a highersustained implantation rate than the population as a whole (50.8%,p0.05).CONCLUSIONS: While NGS screening has been recently introduced to

assist IVF patients, this is the first randomized clinical study on the efficiencyof NGS for single embryo transfer in comparison to aCGH. With theobserved high accuracy of 24-chromosome screening and the resultinghigh clinical pregnancy and ongoing pregnancy rates, NGS has demonstratedan efficient, robust high-throughput technology for selection of single em-bryo for transfer.


BLASTOCYSTS NEEDED TO TRANSFER AT LEAST ONEEUPLOID EMBRYO: DATA FROM 10,852 PRE-IMPLANTATIONGENETIC SCREENING (PGS) CYCLES. S. Munne,a L. Ribustello,a

B. Kolb,b G. Haddad,c J. A. Grifo,d B. Acacio,e Z. Nagy,f J. Zhang,g

J. Hesla,h R. J. Kiltz.i aReprogenetics, Livingston, NJ; bMedical Director-HRC Fertility, Pasadena, CA; cHouston Fertility Institute, Tomball, TX;dNYU Langone Medical Center, New York, NY; eAcacio Fertility Centers,Laguna Niguel, CA; fReproductive Biology Associates, Sandy Springs,GA; gNew Hope Fertility Center, New York, NY; hOregon ReproductiveMedicine, Portland, OR; iCNY Fertility Center, Syracuse, NY.

Cycle Characteristics and Birth Outcomes

CCS (n139) Non-CCS (n308) P value

Cycle age (y) 37.4 3.9 35.5 4.0

OBJECTIVE: The objective of this study was twofold; first we wanted todetermine the number of blastocysts needed at a certain age to produce atleast one euploid blastocyst (>95%) through PGS using whole comprehen-sive chromosome screening. Secondly, we evaluated the chance of obtaininga euploid embryo in the next cycle after obtaining all aneuploid embryos.

DESIGN: Retrospective cohort study.MATERIALS AND METHODS: 10,852 cycles of PGS were performed

using blastocyst biopsy and analyzed by array Comparative GenomicHybridization (aCGH). A total of 58,798 embryos were analyzed. IVFcycles were performed at multiple fertility centers and biopsies sent to areference laboratory for analysis. Some poor prognosis patients accumu-lated embryos from several cycles and then performed PGS (embryobanking).

RESULTS: There was no correlation between cohort size of blastocystanalyzed and euploidy rates, but there were significant differences betweeneuploidy rates and maternal age (p< 0.001). Euploidy rates 65%, 56%,46%, 33%, 19% and 13% for egg donors were observed for ages 42 yearsold, respectively.The cumulative number of blastocyst needed to produceat least one euploid blastocyst with 95% or higher chance was calculatedfrom single cycles or embryo banking cycles from the same patient and isshown in the below table.

Of patients that underwent two or more cycles, 50% (113/225) and71% (84/118) of patients 41-42 and > 42 years old, respectively, pro-duced no euploid embryos in the first cycle. Of those with no euploid em-bryos in the first cycle, 38% (41-42 years old) and 25% (> 42 yeas old)of those that produced 17 embryos produced euploid embryos in succes-sive cycles.

CONCLUSIONS: This is the largest study so far on the relationship be-tween aneuploidy and maternal age and cohort size. In women, 35 andolder more than 50% of embryos are chromosomally abnormal, with those41 and older needing 18 or more embryos to secure one euploid one. How-ever, a cycle with no euploid embryos does not preclude finding euploidones in the next cycle(s) provided those cycles are not far apart andenough embryos are generated. This data will help couples assess theirodds at producing a viable pregnancy and how many cycles and embryosit might involve.


WHY DO ARRAY-CGH (ACGH) EUPLOID EMBRYOS MISCARRY?REANALYSIS BY NGS REVEALS UNDETECTED ABNORMALITIESWHICH WOULD HAVE PREVENTED 56% OF THEMISCARRIAGES. J. Grifo,a P. Colls,b L. Ribustello,b T. Escudero,b

E. Liu,b S. Munne.b aNYU Langone Medical Center, NY, NY; bReprogenetics,Livingston, NJ.

OBJECTIVE: aCGH, qPCR and SNP arrays have been extensively usedfor preimplantation genetic screening (PGS) but a more robust and sensitivetechnique, Next Generation Sequencing (NGS) can detect mosaicism andpolyploidy more effectively. The objective of this study was to determineif miscarriages occurring after PGS were due to abnormalities not detectedby aCGH.

DESIGN: Retrospective Analysis with prospective sample re-analysis byaCGH and NGS

MATERIALS AND METHODS: A total of 43 miscarriages were re-ported upon follow up of spontaneous pregnancy loss resulting from2442 cycles with euploid blastocysts obtained from PGS by blastocyst bi-opsy and array CGH. Karyotype analysis of products of conception (POC)in 18 samples revealed aneuploidy (full aneuploidy, mosaic aneuploidyand partial aneuploidy) which was inconsistent with the aCGH analysisfrom the blastocyst biopsy and went undetected prior to embryo transfer.In the remaining 25 samples no POC data was available. Saved amplified

DNA samples from these 43 blastocyst biopsies previously diagnosed aseuploid by aCGH were re-analyzed by aCGH yielding the same result.A third aliquot of the same amplified DNA was then analyzed by NGS todetermine if abnormalities not detectable by aCGH were present.RESULTS: The DNA from the embryos replaced that resulted in preg-

nancy and miscarriage were reanalyzed by NGS and the results are shownin the table below:

NGS Reanalysis of TE Biopsy Specimen

Normal Triploid

MosaicWhole

Aneuploidy

MosaicPartial

AneuploidyFull

TrisomyNo

Diagnosis

POC NotAnalyzed

N25

11 (44%) 2 (8%) 3 (12%) 7 (28%) 0 2 (8%)

POCAneuploid

N18

6 (33%) 0 9 (50%) 1 (6%) 0 2 (11%)

TotalN43

17 (40%) 2 (5%) 12 (28%) 8 (19%) 0 4 (9%)

CONCLUSIONS: NGS is known to be able to detect mosaicism as well astriploidy, which is also well-known cause of spontaneous pregnancy loss.Whole and partial mosaicism could also play a role in spontaneous pregnancyloss depending on the chromosomes involved as well as the percentage ofabnormal cells in the embryo. Of 16 embryos diagnosed euploid by aCGHthat resulted in an aneuploid loss 10 (62%) were diagnosed as abnormal byNGS (2 not analyzable). Similarly, of the 23 embryos diagnosed euploidby aCGH that resulted in loss but not diagnosed by POC analysis, 12(52%) were abnormal by NGS (2 not analyzable). The use of NGS wouldhave avoided 56%(22/39) of the pregnancy losses resulting from aCGHtested embryos. Likely, mosaicism and triploidy accounted for most of theselosses and NGS is more sensitive at detecting them. These data support thenotion that NGS is the most powerful technique for PGS analysis in predict-ing euploid outcome but will not predict all euploid losses. It reduces themiscarriage rate bymore than 50% over aCGH andwill significantly improveoutcomes.


GENETIC CARRIER SCREENING IN AN EGG DONORPROGRAM. A. Quinteiro Retamar,a C. M. Borghi,a G. Fiszbajn,a

S. Papier,a S. Munne,b J. Hamer,a C. Alvarez Sedo.a aCEGYR (Reproduc-tive Medicine and Genetics), Buenos Aires, Argentina; bReprogenetics, Liv-ingston, NJ.

OBJECTIVE:With the emergence of genomics platforms and the possibil-ity of studying multiple diseases in only one study and the lack of local up-dated data, raised the necessity to establish the prevalence of genetic carriers(250 diseases) in our egg donor population, in order to improve our egg dona-tion program.DESIGN: Retrospective prevalence study.MATERIALS AND METHODS: Three hundred two oocyte donors were

included (21-33 y/o), fromDecember 2013-March 2015. All donor signed aninformed consent to participate in this study. Donors were included in thisstudy after fulfilling the egg donation program inclusion criteria (antral fol-licle count >16, negative serology, psychological counseling, genetic coun-seling, and normal karyotype). All patients were evaluated by a clinicalgeneticist, in order to detect relevant family history, before and after thestudy.A blood sample was taken, and DNA was extracted in our molecularbiology laboratory. Dried DNAwas sent to Recombine Laboratory (Living-ston, NJ, USA). A genomics platformwas used to detect more than 1700 mu-tations that correspond to 250 autosomal recessive diseases by microarraySNPs array technique.RESULTS: Considering the 250 tested autosomal recessive diseases, our

donors have mutations for 35 (14%), 74.3% (26) of the latter have a highimpact over life expectancy and quality of life, and 25.7% (9) have a moder-ate impact.Among the high impact diseases, 61.54% (16) may be subject tomedical treatment, but the 38.46% (10) do not. Cystic Fibrosis (1:19), thenonsyndromic hearing loss and deafness: GJB2-Related (1:50) and Bio-tinidase Deficiency (1:50) were the most prevalent high impact diseaseswith medical treatment. Spinal Muscular Atrophy: SMN1 Linked (1:23)was the most prevalent disease in the group without treatment.Moderate

% of patients with normal blastocysts

# ofembryos

eggdonors

42 years

1-3 83% 80% 71% 57% 36% 22%4-6 97% 95% 92% 82% 59% 43%7-10 99% 98% 96% 89% 74% 50%10-17 100% 99% 99% 97% 88% banked 64% banked>17 100% 100% 100% 99% 97% banked 87% banked


impact diseases were the least present. Within this group, 44.4%(4) have nottreatment and 55.6%(5) have a possible treatment. The 21-Hydroxylase-Deficient Congenital Nonclassical Adrenal Hyperplasia (1:9), Familial Med-iterranean Fever (1:100) and Pseudocholinesterase Deficiency (1:50) werethe most prevalent detected diseases.

CONCLUSIONS: It is clear that the screening of genetic diseasesfor oocyte donors is part of the necessary studies to reduce the risk of childrenborn from this kind of treatment. We can infer that the genetic screening ofrecessive mutations in people who donate their gametes will further reducethe risk of certain genetic diseases transmission.

OUTCOME PREDICTORS - CLINICAL: ART 1


MATERNAL PREGNANCY AND BIRTH COMPLICATIONS BYFERTILITYSTATUS: THEMASSACHUSETTSOUTCOMESSTUDYOF ASSISTED REPRODUCTIVE TECHNOLOGIES. B. Luke,a

D. Gopal,b J. E. Stern,c E. Declercq,b L. Hoang,b M. Kotelchuck,d

H. Diop.e aObstetrics, Gynecology, and Reproductive Biology, MichiganState University, East Lansing, MI; bCommunity Health Sciences, BostonUniversity, Boston,MA; cGeisel School ofMedicine at Dartmouth, Lebanon,NH; dMGHCenter for Child &Adolscent Health Research and Policy, Mass-General Hospital for Children, Boston, MA; eBureau of Family Health andNutrition, Massachusetts Department of Public Health, Boston, MA.

OBJECTIVE: To evaluate the effect of maternal fertility status on the riskof pregnancy and birth complications.

DESIGN: Longitudinal cohort study, linking cycles from the SARTCORS, hospital discharge, and vital records from 2004-2010 in Massachu-setts.

MATERIALS AND METHODS: The study included three fertilitygroups: women without ART or other infertility treatment (fertile); womenwith indicators of subfertility but no ART treatment (subfertile), and womenwith ART treatment. The risks of seven adverse outcomes were modeled us-ing logistic regression, adjusted for parental ages, race/ethnicity, education,payor status, maternal pre-existing conditions (diabetes and chronic hyper-tension), and plurality, and reported as adjusted odds ratios (AORs) and95% confidence intervals.

RESULTS: The study population included 470,258 pregnancies: 447,583fertile, 8,858 subfertile, and 13,817 ART; and 459,623 singletons, 10,352twins, and 283 triplets and higher-order multiple pregnancies. The risks ofadverse outcomes by fertility status are shown below.

CONCLUSIONS: Both subfertile and ART-treated women experiencesignificantly more perinatal complications than their fertile counterparts,even after adjustment for plurality and other important covariates.


HOW COMPLIANT ARE MEMBER CLINICS IN FOLLOWINGASRM/SART BLASTOCYST STAGE TRANSFER GUIDELINES?:AN ANALYSIS OF 34,140 FRESH FIRST AUTOLOGOUS CYCLESFROM THE SART REGISTRY. S. Keyhan,a K. S. Acharya,a

C. R. Acharya,a J. S. Yeh,a M. Provost,a J. M. Goldfarb,b S. J. Muasher.aaDuke University Medical Center, Durham, NC; bUniversity HospitalsFertility Center, Beachwood, OH.

OBJECTIVE: ASRM and SART regularly update guidelines on themaximum number of embryos to transfer per cycle in various age groups.Providers/patients, however, often elect to transfer more than the recommen-ded number of embryos, which can lead to an unnecessary increase in thenumber of multiple pregnancies. The objective of this study was to determinethe prevalence of blastocyst transfer cycles that do not conform to currentrecommended embryo transfer (ET) limits and assess the impact of noncom-pliance on multiple pregnancy rate (MPR) in first IVF cycles with a favorableprognosis.DESIGN: Retrospective cohort study.MATERIALS AND METHODS: 34,140 first fresh autologous IVF cycles

in women under 43 undergoing blastocyst stage (day 5 and 6) ET from the2011-2012 SART registry were stratified into cohorts based on ASRM definedage bins. Cycles were classified as compliant (C) or noncompliant (NC) basedon their adherence to published 2009/2013 guidelines based on first IVF cycleswith a favorable prognosis. Main outcomes were the percentage of C and NCcycles in each age group as well as the MPR (R2 fetal heart beats on ultra-sound) in each of these groups. Secondary outcomes included clinical preg-nancy rate (CPR), live birth rate (LBR), and singletons. Data were analyzedusing two-sidedWelchs t-test for each age category and the Benjamini-Hoch-berg procedure was used to control the false discovery rate.

RESULTS: The vast majority of cycles performed in women 35, NC cycles demonstrated lowerLBR but significantly higher MPR (Table). In a sub-analysis of C cyclesamong patients 35-37 and 38-40 years, transferring two embryos resultedin a higher LBR than transferring one embryo (50.4% vs. 40.9%,p


ELECTIVE SINGLEEMBRYOTRANSFER (ESET) IS ASSOCIATEDWITH NON-LOW BIRTHWEIGHT TERM SINGLETONOUTCOMES: AN ANALYSIS OF 263,375 CYCLES. A. K. Styer,a

W. Vitek,b M. S. Christianson,c V. Baker,d A. Armstrong,e N. Santoro,f

B. Luke,g A. J. Polotsky.f aMassachusetts General Hospital/HarvardMedicalSchool, Boston, MA; bUniversity of Rochester School of Medicine, Roches-ter, NY; cJohns Hopkins University School of Medicine, Lutherville, MD;dStanford University, Palo Alto, CA; eNICHD, Bethesda, MD; fUniversityof Colorado, Aurora, CO; gResearch, Ann Arbor, MI.

OBJECTIVE:Multiple gestation and its concomitant risk of prematurity isthe major complication of ART. The adoption of good perinatal outcomeas a more relevant measure of term live birth with a normal birth weightneonate has been recently advocated. The objective of this study is to eval-uate the likelihood of non-low birth weight (NLBW) term singleton live birthoutcomes with single (SET) and double embryo transfer (DET) in the UnitedStates.

DESIGN: Historical cohort study from the Society for Assisted Reproduc-tive Technology Clinic Online Reporting System between 2004 and 2012.

MATERIALS AND METHODS: Fresh autologous IVF cycles amongwomen ages 18-37 years using partners semen with either SET or DETwere assessed and categorized into groups with or without cryopreserved(cryo) supernumerary embryos. SET (cryo) was designated as eSET. SET(no cryo) were non elective SET due to limited embryo cohort. Gestationalcarrier, preimplantation genetic screening or diagnosis, and research cycleswere excluded. Logistic regression (adjusted for age, race/ethnicity, infer-tility diagnosis, year of cycle, number of oocytes retrieved, day of transfer)was used to determine the likelihood of NLBW term singleton live birthoutcome (birthweight R2,500 g and gestation R259 days). Results are re-ported as adjusted odds ratios (AORs) and 95% confidence intervals.

RESULTS: 263,375 cycles were analyzed. Compared to eSET, the likeli-hood of clinical pregnancy and live birth was significantly increased for DET(cryo). The odds of NLBW term singleton live birth was significantly lowerin all groups compared to eSET [Table].

Pregnancy Outcomes Following SET and DET

Group

Clinical Pregnancy Live Birth NLBW Term Singleton

% AOR (95% CI) % AOR (95% CI) % AOR (95% CI)

SET(cryo)[eSET]n20,996

57.6 Reference 49.3 Reference 39.1 Reference

DET(cryo)n117,091

62.5 1.38 (1.34, 1.42) 55.0 1.40 (1.36, 1.44) 25.8 0.55 (0.53, 0.57)

SET(no cryo)n21,917

26.6 0.39 (0.37, 0.41) 21.7 0.41 (0.39, 0.43) 17.3 0.36 (0.34, 0.38)

DET(no cryo)n103,371

47.8 0.86 (0.83, 0.89) 40.9 0.89 (0.86, 0.91) 23.0 0.48 (0.46, 0.49)

CONCLUSIONS: Elective SET increases the likelihood of NLBW by 45-52% as compared to DET. The use of NLBW term singleton live birth as ameasure of ART success may be useful for the development of clinical stra-tegies which optimize good perinatal birth outcomes.

Supported by: Clinical Research Scientist Training Program/NICHD,R25HD075737.


THE IMPACTOF INSURANCEMANDATES ONMULTIPLE BIRTHRATES FOLLOWING IN VITRO FERTILIZATION. M. P. Provost,a

J. S. Yeh,a S. M. Thomas,b W. W. Hurd,a J. L. Eaton.a aDivision of Repro-ductive Endocrinology & Infertility, Duke University Medical Center,Durham, NC; bDepartment of Biostatistics & Bioinformatics, Duke Univer-sity Medical Center, Durham, NC.

OBJECTIVE: To examine the relationship between state-mandated insur-ance coverage for in vitro fertilization (IVF) and multiple birth rate.DESIGN: Retrospective cohort study.MATERIALS AND METHODS: We utilized the Society for Assisted

Reproductive Technologies-Clinical Outcomes Reporting System (SART-CORS) database to identify fresh, autologous IVF cycles performed between2007 and 2011 in women aged 20-42 years. Only first IVF cycles performedin each womans state of residencewere included in the analysis. Cycles wereexcluded if the indication for IVF was non-infertile or preimplantationgenetic diagnosis, if they were performed in a state with only one reportingclinic, or if embryo transfer occurred on days other than 3 or 5. Among the 40states with more than one clinic, 6 have legislation requiring insurancecoverage for at least one IVF cycle and were designated mandated: CT,HI, IL, MA, MD, and NJ. The remaining 34 states were designated non-mandated. Students t-test and the X2 test were used to analyze continuousand categorical variables, respectively. P < 0.00019 was considered statisti-cally significant after Bonferroni adjustment for multiple comparisons. Lo-gistic regression was performed to model IVF outcomes while controllingfor potential confounders.RESULTS: Of the 173,968 cycles included in the analysis, 45,011 (26%)

were performed in mandated states and 128,957 (74%) were performed innon-mandated states. The multiple birth rate per live birth was significantlylower in mandated vs. non-mandated states (29% vs. 33%, P < 0.00001).This association remained significant after adjusting for potential con-founders (OR 0.87, 95%CI 0.83-0.91). After stratification by SARTage cate-gory and day of transfer, the relationship between mandate status andmultiple birth rate remained statistically significant only inwomen

OBJECTIVE: ASRM and SART regularly update guidelines on themaximum number of embryos to transfer per cycle. Providers/patients, how-ever, often elect to transfer more than the recommended number of embryoswhich can lead to an unnecessary increase in the number of multiple pregnan-cies. The objective of this study was to determine the prevalence of cleavagetransfer cycles that do not conform to current recommended embryo transfer(ET) limits and assess the impact of noncompliance on multiple pregnancyrate (MPR) in first IVF cycles with a favorable prognosis.

DESIGN: Retrospective cohort study.MATERIALS ANDMETHODS: 30,567 first fresh autologous IVF cycles

in women under 43 undergoing cleavage stage embryo transfer (ET) from the2011-2012 SART registry were stratified into cohorts based on ASRMdefined age bins. Cycles were classified as compliant (C) versus noncompli-ant (NC) based on their adherence to the published 2009/2013 guidelines forfirst IVF cycles with a favorable prognosis. Main outcomes measured werepercentage of C and NC cycles in each age group as well as the MPR (R2fetal heart beats on ultrasound) in each of these groups. Secondary outcomesincluded clinical pregnancy rate (CPR), live birth rate (LBR), and singletons(1 fetal heart beat on ultrasound). Data were analyzed using two-sidedWelchs t-test for each age category and the Benjamini-Hochberg procedurewas used to control the false discovery rate.

RESULTS: The percentage of NC cycles ranged from 2 to 27.4% indifferent age groups. Compared to C cycles, noncompliance resulted inhigher MPR in every age group, but statistical significance was reachedonly in the two youngest age bins (p

CONCLUSIONS: There is no significant difference of epigenetic profilingbetween PBs and corresponding female nuclear genome in the ooplasm atspecific stage from mouse to human, suggesting PB1 and PB2 could be theoptimum candidate of oocyte genome replacement for preventing the trans-mission of inherited mitochondrial diseases.

References:1. Wakayama T, Hayashi Y, Ogura A. Participation of the female pronu-

cleus derived from the second polar body in full embryonic develop-ment of mice. J Reprod Fertil. 1997, 110(2): 263-266.

2. Tachibana M, Sparman M, Sritanaudomchai H, Ma H, Clepper L,Woodward J, Li Y, Ramsey C, Kolotushkina O and Mitalipov S. Mito-chondrial gene replacement in primate offspring and embryonic stemcells. Nature. 2009, 461(7262): 367-372.

3. Wang T, Sha H, Ji D, Zhang HL, Chen D, Cao Y, Zhu J. Polar bodygenome transfer for preventing the transmission of inherited mitochon-drial diseases. Cell. 2014, 157(7):1591-1604.

4. Bartholomeusz R. Review of the longevity of the second polar body inthe mouse. Zygote. 2003, 11(1): 23-34.

5. Hino T, Kusakabe, H and Tateno H. Chromosomal stability of secondpolar bodies in mouse embryos. J Assist Reprod Genet. 2013, 30(1):91-98.

6. Fabian D, Cikos S, Rehak P, Koppel J. Do embryonic polar bodiescommit suicide? Zygote. 2012, 22(1): 10-17.

7. Montag M, Koster M, Strowitzki T, Toth B. Polar body biopsy. Fertilsertil; 2013, 100(3):603-607.

8. HouY, FanW, Yan L, Li R, Lian Y, Huang J, Li J, Xu L, Tang F, Xie XS,Qiao J. Genome analyses of single human oocytes. Cell. 2013, 155(7):1492-1506.

Supported by: This study was Supported by grants from National BasicResearch Program of China (2014CB 81471512 to H.S.,2014CB 81370691to C.Y.).


ANEUPLOIDYAND RECOMBINATION IN IN VITRO FERTILIZEDEMBYROS (BLASTOCYSTS) UNDERGOING PREIMPLANTATIONGENETIC DIAGNOSIS (PGD). K. Ravichandran,a Z. K. Gunes,b

B. Bankowski,c A. M. Rosen,d S. H. Chen,e A. Hershlag,f B. Sandler,g

J. Grifo,h D. Wells,i M. Konstantinidis.a aReprogenetics, Livingston, NJ;bReprogenetics UK, Oxford, United Kingdom; cOregon Reproductive Med-icine, Portland, OR; dMercy Hospital and Medical Center, Chicago, IL;eIRMS at Saint Barnabas, Livingston, NJ; fNorth Shore LIJ Health System,Cold Spring Harbor, NY; gObstetrics, Gynecology and Reproductive Sci-ence, Icahn School of Medicine at Mount Sinai, New York City, NY;hNYU Langone Medical Center, NY, NY; iUniversity of Oxford.

OBJECTIVE: To investigate aneuploidy and recombination in human pre-implantation embryos in an effort to advance knowledge regarding the occur-rence of these events during reproduction.

DESIGN: Single nucleotide polymorphism (SNP) arrays and arraycomparative genomic hybridization (aCGH) were used in parallel to screenblastocysts undergoing PGD.

MATERIALSANDMETHODS: The InfiniumKaryomapping assay (Illu-mina, USA) wa

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