2014 Update on Fertility

National standards for vaccination have been established by the Advisory Committee on Immunization Practices (ACIP) of the Centers for Disease Control and Prevention (CDC). This yearly updated vaccination schedule is available at the CDC’s Web site (http://www.cdc.gov/vaccines/schedules/hcp/adult.html).⁷ Ideally, a woman’s immunization status should be evaluated and made complete prior to pregnancy. Some vaccines are safe and appropriate for administration during pregnancy, provided the benefits clearly outweigh the risks. The recommended vaccines during pregnancy include inactivated influenza (seasonal and H1N1) and the combined tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis (Tdap).

Related Article: CDC urges flu vaccination for all, especially pregnant women (News for Your Practice, October 2013)

Many physicians avoid giving vaccinations during pregnancy because of the concern that a spontaneous abortion or congenital anomaly might be incorrectly attributed to vaccine administration, but few vaccines are contradicted during pregnancy. Those that are contraindicated are those containing live virus, including measles, mumps, and rubella (MMR); varicella; and herpes zoster. Concerns also have been raised regarding the safety of administering influenza vaccines containing the mercury-based preservative thimerosol. However, no scientific evidence has conclusively linked adverse effects on offspring with thimerosol-containing vaccines administered during pregnancy.

Immunizations recommended for women of reproductive age
Measles, mumps, rubella (MMR). This vaccine is recommended for all women lacking confirmed immunity to rubella. The vaccine contains live, attenuated virus and is given as a single dose. Women should avoid pregnancy for 1 month after vaccination.

Varicella. This vaccine is for all women lacking confirmed immunity to varicella. It also contains a live, attenuated virus. It is administered in two doses, 1 month apart, and women should avoid pregnancy for 1 month after vaccination.

Influenza. The flu vaccine is recommended annually for individuals 6 months of age and older. The injectable vaccine contains inactivated virus and may be administered during pregnancy—at any time but optimally in October or November because the flu season occurs January through March. (The intranasal influenza vaccine contains live, attenuated virus and should be avoided in pregnancy.) Either method is administered as a single dose.

Thimerosal is a mercury-based preservative used in vaccines, including the influenza vaccine, and is appropriate for use in pregnant women; studies have not shown an association between vaccines containing thimerosal and adverse effects in pregnant women or their offspring.

Tetanus-diptheria-pertussis (Tdap) and tetanus-diphtheria (Td). Tdap or Td is recommended for adults aged 19 to 64 years who have or anticipate having close contact with an infant less than 12 months of age. Due to the recent increase in pertussis infection, Tdap should be given to all women who have not previously received the vaccine and who are pregnant or might become pregnant. It can be given anytime during pregnancy, but optimal administration is during the third trimester or late second trimester (after 20 weeks’ gestation) to confer the greatest amount of fetal protection.

If the vaccine is not being administered during pregnancy, it should be given in the immediate postpartum period to ensure pertussis immunity and to reduce transmission to the newborn. Tdap is administered as a single dose of tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis.

Non-routine vaccines include pneumococcus, hepatitis A, hepatitis B, and meningococcus (TABLE). These vaccines should be administered as indicated in high-risk patients.

Health-care providers caring for women with infertility are urged to assess patients’ immunization status prior to attempting pregnancy, to counsel patients about the importance of protecting them and their potential offspring from preventable disease, and to facilitate vaccination prior to conception attempts.

WHAT THIS EVIDENCE MEANS FOR PRACTICE
Vaccination is a very important aspect of pre-pregnancy care but is especially important for infertile women who desire pregnancy. Planning of infertility treatment should include assessment of the patient’s vaccination status and completion of appropriate vaccinations before infertility treatment is initiated.

DO CURRENT OPTIONS EFFECTIVELY PREVENT POSTSURGICAL ADHESIONS?

Practice Committee of American Society for Reproductive Medicine in collaboration with Society of Reproductive Surgeons. Pathogenesis, consequences, and control of peritoneal adhesions in gynecologic surgery: A committee opinion. Fertil Steril. 2013;99(6):1550–1555.

Postoperative adhesions are a natural consequence of surgery and a major problem in gynecology. They may cause postsurgical infertility, abdominal/pelvic pain, or bowel obstruction as well as complicate subsequent surgeries by increasing operative times and the risk of bowel injury. The American Society for Reproductive Medicine (ASRM) and the Society of Reproductive Surgeons (SRS) recently evaluated the epidemiology, pathogenesis, and clinical consequences of adhesion formation and the evidence behind strategies for reducing adhesion formation.

In their joint Committee Opinion, they noted that open and laparoscopic approaches to surgery carry comparable levels of risk for adhesion-related hospital readmission. Ovarian surgery has the highest risk for adhesion-related readmission, at 7.5 per 100 initial operations, and the incidence of small bowel obstruction after hysterectomy was found to be 1.6 per 100 procedures. Adhesion-related US health-care costs are estimated at approximately $1 billion annually.