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Biomedical subjects

N Gleicher

Publications and source records attributed to N Gleicher.

At least 19 recordsLinked to original sources
PubMed2000

Reducing the risk of high-order multiple pregnancy after ovarian stimulation with gonadotropins.

BACKGROUND: The incidence of multiple gestation after therapy for infertility is especially high among women in whom ovulation is induced with gonadotropins. Whether the number of high-order multiple pregnancies (those with three or more fetuses) can be reduced is not known. METHODS: We analyzed data on 3347 consecutive treatment cycles in 1494 infertile women, 441 of which resulted in pregnancy. The data collected included the peak serum estradiol concentration, the number of follicles 16 mm or larger in diameter, and the total number of follicles on the day of induction of ovulation with human chorionic gonadotropin. Receiver-operating-characteristic curves and ordinal logistic-regression analyses were used to identify values that predicted multiple conceptions. RESULTS: Among the 441 pregnancies, 314 resulted from the conception of singletons, 88 of twins, 22 of triplets, 10 of quadruplets, 5 of quintuplets, and 2 of sextuplets. Neither the number of follicles 16 mm or larger nor peak serum estradiol concentrations greater than 2000 or 2500 pg per milliliter (7342 or 9178 pmol per liter) (the cutoff values currently in wide use) were significantly associated with the incidence of high-order multiple pregnancy. However, increasing total numbers of follicles and increasing peak serum estradiol concentrations correlated significantly with an increasing risk of high-order multiple pregnancy (P<0.001), as did younger age (P=0.008). The risk of high-order multiple pregnancy was significantly increased in women with a peak serum estradiol concentration of 1385 pg per milliliter (5084 pmol per liter) or higher (multivariate odds ratio, 1.9; 95 percent confidence interval, 1.3 to 2.8) or with seven or more follicles (multivariate odds ratio, 2.1; 95 percent confidence interval, 1.2 to 3.9) on the day of induction of ovulation. CONCLUSIONS: Gonadotropin stimulation that is less intensive than is currently customary may reduce the incidence of high-order multiple pregnancy in infertile women, though only to a limited extent and at the expense of overall pregnancy rates.

Adult↗
PubMed1999

Octreotide is not useful for clomiphene citrate resistance in patients with polycystic ovary syndrome but may reduce the likelihood of ovarian hyperstimulation syndrome.

OBJECTIVE: To determine whether octreotide is effective for ovulation induction in patients with polycystic ovary syndrome (PCOS) and clomiphene citrate resistance or for reduction of the risk of ovarian hyperstimulation syndrome (OHSS) with gonadotropin therapy. DESIGN: Prospective, double-blind, placebo-controlled, crossover trial. SETTING: Private infertility practice. PATIENT(S): Twelve patients with PCOS undergoing therapy for infertility. INTERVENTION(S): The patients were assigned randomly to receive either octreotide or placebo. Those with clomiphene citrate-resistant PCOS received clomiphene citrate, 150 mg. Patients at risk for the development of OHSS received urinary FSH for ovulation induction. MAIN OUTCOME MEASURE(S): Ovulation, pregnancy, the development of OHSS, and levels of fasting insulin, insulin-like growth factor 1, insulin-like growth factor binding proteins 1 and 3, testosterone, androstenedione, DHEAS, E2, LH, and FSH. RESULT(S): Octreotide significantly reduced levels of fasting insulin, insulin-like growth factor 1, and LH in both clomiphene citrate- and urinary FSH-stimulated cycles. Levels of insulin-like growth factor binding protein 3 were increased. Two of six clomiphene citrate-stimulated cycles reached ovulation with the use of either octreotide or placebo. In urinary FSH-stimulated cycles, patients who received octreotide had significantly lower E2 levels at the time of hCG administration and fewer mature follicles. No cases of OHSS occurred in either group. One pregnancy occurred in each group. CONCLUSION(S): Octreotide was no more effective than placebo for clomiphene citrate resistance in patients with PCOS, but it did reduce E2 levels and follicle numbers when combined with urinary FSH. Thus, octreotide may reduce the incidence of OHSS in patients with PCOS.

Adult↗
PubMed1999

Prospective randomized trial comparing the outcome and cost of in vitro fertilization with that of a traditional treatment algorithm as first-line therapy for couples with infertility.

OBJECTIVE: To determine whether IVF or a standard infertility treatment algorithm results in better outcome and/or lower cost when used as first-line therapy for couples with infertility. DESIGN: Prospective, randomized clinical study. SETTING: University-affiliated infertility clinic. PATIENT(S): Couples with newly diagnosed infertility and no prior treatment. INTERVENTION(S): Couples were randomized to undergo either IVF (group 1, n = 46) or a standard infertility treatment algorithm (group 2, n = 50) as initial therapy for infertility. MAIN OUTCOME MEASURE(S): Pregnancy rates and costs per couple, per month of treatment, and per pregnancy. RESULT(S): Pregnancy rates were higher in group 2 than in group 1. Costs per couple were not statistically different, although a trend toward higher costs was apparent in group 1, reflected by a higher median cost per clinical pregnancy established and a higher cost per month of treatment. Whereas cost differences between the groups diminished over time, pregnancy rates remained the same. CONCLUSION(S): In vitro fertilization currently does not represent an appropriate first-line treatment option for couples with infertility. The use of a standard infertility treatment algorithm results in a higher pregnancy rate and lower cost and therefore should be the preferred treatment approach.

Adult↗
PubMed1999

Impact of the "physician factor" on pregnancy rates in a large assisted reproductive technology program: do too many cooks spoil the broth?

OBJECTIVE: To determine whether in one program with unified treatment protocols, patients can expect varying treatment outcomes with different physicians. DESIGN: Retrospective data analysis. SETTING: University-affiliated infertility center with 14 physicians. PATIENT(S): One thousand eight hundred fifty IVF cycles performed consecutively between August 1995 and June 1997. INTERVENTION(S): The pregnancy rate and implantation rate per ET were evaluated for individual physicians between August 1995 and June 1996 (phase I). Physicians with lower success rates underwent strict supervision from July 1996 to June 1997 (phase II). MAIN OUTCOME MEASURE(S): Variations in success rates between physicians. RESULT(S): The pregnancy rate varied among the physicians from 13.2%-37.4%, and the implantation rate varied from 4.4%-14%. Some physicians' outcomes improved between phase I and phase II of the study, whereas others' did not. The pregnancy and implantation rates varied significantly for some physicians, depending on whether they were responsible for the choice of stimulation protocol, supervision of cycle monitoring, or ET in their own or other physicians' patients. CONCLUSION(S): Outcomes of IVF vary depending on the treating physician. Lower than expected pregnancy and implantation rates usually are not caused by poor ET techniques alone, but appear to be disproportionately the consequences of poor cycle stimulation.

Embryo Implantation↗
PubMed1999

Resection of uterine septum using gynaecoradiological techniques.

This paper presents further refinements in our technique for the resection of uterine septum. Fourteen patients [infertility (n = 9) and recurrent miscarriages (n = 5)] underwent in-office resection of a uterine septum under fluoroscopic control. The main outcome measure was complete resection of uterine septum. Resections were carried out using either hysteroscopic scissors in combination with a specially designed uterine balloon catheter, or microlaparoscopy scissors in conjunction with a cervical cannula. In all patients the septum was successfully resected without any intra-operative complications. We conclude that ambulatory gynaecoradiological resection of uterine septa is a safe and simple procedure. It avoids utilization of expensive operating room time, general anaesthesia, and some complications associated with hysteroscopic resection, such as fluid retention and electrolyte imbalance.

Abortion, Habitual↗
PubMed1998

Strategies to improve insurance coverage for infertility services.

Various studies repeatedly have demonstrated that in the United States, only a minority of couples with infertility receive medical treatment and even fewer receive such treatment from specialists. Primarily couples of higher socioeconomic status receive such treatment. It is therefore obvious that a lack of insurance coverage greatly contributes to this country's disproportionately low utilization of fertility services compared with other developed nations. Such low utilization raises significant ethical and economic issues. For example, if the treatment of infertility is to be perceived as the treatment of a disease stage (a notion widely supported in our professional community), then how can we defend the fact that services are principally available only to the affluent? Moreover, by having access to only a fraction of the potential national market for infertility services, the national overhead for these services is distributed over only a fraction of potential buyers, greatly increasing unit costs. In short, obtaining a larger market for our services through better insurance coverage would solve ethical quandaries and, at the same time, reduce fertility costs on a unit level. How, then, can such improved insurance coverage be achieved? A number of possible strategies come to mind.

Ethics, Medical↗
PubMed1998

Cost considerations with infertility therapy: outcome and cost comparison between health maintenance organization and preferred provider organization care based on physician and facility cost.

Of 98 retrospectively selected patient couples insured under one scheme (group I) who, based on performance of a hysterosalpingogram (HSG), were assumed to be under active infertility care, 96 were confirmed as infertile. These were matched by date, patient age and time of HSG to 96 patients under infertility care (group II). Both patient populations were then prospectively evaluated for outcome and cost of treatment. Total physician charges for groups I and II were similar. However, charges per achieved clinical pregnancy were higher in group I than group II since group I patients demonstrated a lower pregnancy rate (28/96, 29%) than group II patients (41/96, 43%) (P=0.05). Within group I, pregnancy rates were identical, whether treatment was provided by generalists or subspecialists. In group II, all care was provided by specialists. The number of days of treatment did not vary between groups I and H, though generalists in group I provided significantly fewer treatment days than specialists in either group I (P=0.003) or in group II (P=0.021). This was primarily due to a significantly higher patient drop-out rate in group I patients, and especially amongst those who received care from generalists (P < 0.0019). Group I patients also encountered significantly more surgical procedures than group H patients (P=0.0016). If physician charges are discounted and customary surgical facility costs are added, the actual cost structure for fertility care in group I patients was dramatically higher than in group II patients. The most cost-effective format to provide infertility care of high quality appears to be a managed care setting in which subspecialists provide a majority of care and in which patient choice is restricted to those subspecialists.

Female↗
PubMed1997

Lysis of intrauterine adhesions using gynecoradiologic techniques.

OBJECTIVE: To present further experience with in-office lysis of intrauterine adhesions under fluoroscopic control using a specially designed catheter. DESIGN: Prospective study. SETTING: Medical school-affiliated infertility center. PATIENT(S): Seventeen infertile patients undergoing routine gynecoradiologic investigation as part of an initial infertility workup. INTERVENTION(S): The initial hysterosalpinography was performed with a commercially available uterine catheter that seals off the uterine cavity before injection of contrast. If intrauterine adhesions were diagnosed, an immediate attempt at lysis was made using the catheter's balloon tip or hysteroscopic scissors, which were inserted through the main port of the catheter. The procedures were carried out using a paracervical block or IV analgesia. MAIN OUTCOME MEASURE(S): Normal uterine cavity after lysis of intrauterine adhesions. RESULT(S): Seventeen patients underwent lysis of intrauterine adhesions. In 13 patients (9 mild, 3 moderate, and 1 severe), the adhesions were lysed successfully (81.2%). Among those, nine procedures were performed with the balloon and four with scissors. In 4 cases (2 moderate and 2 severe), lysis of adhesions was only partially successful. These procedures had to be abandoned prematurely because of patient discomfort before attempting the use of scissors (n = 1), extravasation of dye into the myometrium making visualization difficult (n = 1), and thick, fibrotic adhesions that were resistant to scissors (n = 2). CONCLUSION(S): In-office lysis of intrauterine adhesions under gynecoradiologic control can be carried out safely in the majority of patients, using minimally invasive techniques. The potential cost savings in comparison with endoscopic procedures, which require utilization of expensive operating room time, are especially relevant in today's cost-conscious managed care environment. Only failures of in-office procedures would reach the operating room under the algorithm proposed here.

Catheterization↗
PubMed1997

Limited success using the "flare" protocol in poor responders in cycles with low basal follicle-stimulating hormone levels during in vitro fertilization.

OBJECTIVE: To assess an alternate protocol for stimulating poor responders. DESIGN: Prospective clinical study. SETTING: University-affiliated infertility clinic. PATIENT(S): Eighty poor responders. INTERVENTION(S): Stimulation was withheld until patients fulfilled the following criteria: basal FSH < or = 12 mIU/mL (conversion factor to SI unit, 1.00) with concurrent E2 level < or = 100 pg/mL (conversion factor to SI unit, 3.671), and P level < or = 1.0 ng/mL (conversion factor to SI unit, 3.467). They then started leuprolide acetate on cycle day 2 and a high dose of gonadotropins on cycle day 3. MAIN OUTCOME MEASURE(S): Stimulation response and pregnancy rates (PRs). RESULT(S): Nineteen cycles (23.8%) were canceled because of poor ovarian response. The mean E2 level on day of hCG was 2,578 +/- 1,339 pg/mL (9,464 +/- 4,915 pmol/L) (range, 789 to 5934 pg/mL [2,896 to 21,784 pmol/L]). The number of oocytes retrieved was 10 +/- 6.6 (range, 1 to 37). Nine patients did not have ET (failed fertilization [n = 5], no cleavage of preembryos [n = 3], freeze all [n = 1]). The number of pre-embryos transferred was 3.9 +/- 1.6 (range, 1 to 8). The clinical pregnancy rate was 7 of 61 (11.5%) per retrieval, and 7 of 52 (13.4%) per transfer with an implantation rate of 7 of 201 (3.5%). Three patients miscarried with an ongoing PR of 4 of 61 (6.5%) per retrieval and 4 of 52 (7.6%) per transfer. CONCLUSION(S): Poor responders undergoing controlled ovarian hyperstimulation with the "flare" protocol in cycles with low basal FSH will often show adequate ovarian response and reach oocyte retrieval and ET. The PRs, however, remain low.

Adult↗