P–745 The efficacy of Buscopan® in reducing pain during ultrasound-guided manual vacuum aspiration (USG-MVA): A double-blind randomised placebo-controlled trial

Study question

Does Buscopan® reduce abdominal pain experienced by women undergoing ultrasound-guided manual vacuum aspiration (USG-MVA)?

Summary answer

The addition of 20mg Buscopan® intravenous injection was not associated with a statistical reduction in pain score but leads to a higher patient satisfaction score.

What is known already

Ultrasound-guided Manual Vacuum aspiration is a feasible and effective out-patient treatment option for treating early pregnancy loss. However, it is associated with a moderate amount of pain due to uterine contraction.

Study design, size, duration

This randomised, double-blinded, placebo-controlled trial was conducted in a university-affiliated tertiary hospital. The study assessed whether 1 ml of 20mg Buscopan® intravenous injection 5 minutes before the USG-MVA will reduce the abdominal pain experienced by the women immediately and 2 hours after the procedure. Participants were randomised between June 2018 to January 2020 using a computer-generated number series in a 1:1 ratio.

Participants/materials, setting, methods

Women aged 18 years or older with first-trimester miscarriage undergoing the USG-MVA procedure were eligible. In total, 122 participants out of 128 eligible were included. Of whom, 111 underwent the USG-MVA procedure, 60 randomised to the Buscopan® group, and 62 to the placebo group.

Main results and the role of chance

The median abdominal pain scores in the Buscopan® group were 16.0% and 21.2% lower than the placebo group immediately post-procedure and 2 hours after the procedure in the Buscopan® group. Repeated measures ANOVA indicated that the both vaginal and abdominal pain scores improved significantly with the time (Vaginal F(1,108)=180.1,p<0.0001; Abdominal: F(1,108)=83.41,p<0.001) but not with group. No difference was noted in the complications and side effects profile. The physiological stress measured by Log10 sAA levels reduced significantly with time (F(2.8,286.1)= 6.3, p < 0.001) but not with group (F = 0.1, p = 0.96). Women randomised to Buscopan® had a significantly higher (p = 0.032) mean VAS satisfaction scores compared to those receiving placebo (79.0±17.3 vs 73.4±24.1).

Limitations, reasons for caution

This study was a single-centre study, thus one should be cautious in the overall generalisability of the results.

Wider implications of the findings: Few studies have evaluated the use of anti-spasmodic agents to minimise uterine contraction pain in women undergoing outpatient uterine evacuation. We consider Buscopan® a useful adjunct in the pain control of USG-MVA to specifically reduce uterine cramps. Further larger studies are required to evaluate its efficacy.

Trial registration number

ChiCTR1800014590

P–134 Zygote morphokinetic parameters (ZMP) differs between fertilized and non-fertilized (in vitro maturation) oocytes

Study question

Is there any difference on the ZMP between the fertilized and the non-fertilized oocytes in an IVM cohort?

Summary answer

The zona pellucida (zp_g) , cytoplasm greyscale（cm_g),the cytoplasm size (cm_size), radius (cm_r) and deviation (cm_d) showed different patterns from the two groups.

What is known already

We developed a convolutional neural network (CNN) based algorithm that provides instant and bias-free analytical outcomes of oocyte morphological segmentation. The mature but not-fertilized oocytes tend to be static while the fertilized oocytes are more dynamic for preparing its following biological events.

Study design, size, duration

This was a case-control study on oocytes including 631 normal fertilized oocytes and 100 IVM oocytes from 01/08/2017 to 31/12/2019 conducted in the Prince of Wales Hospital, The Chinese University of Hong Kong.

Participants/materials, setting, methods

We used the convolutional neural network (CNN) algorithm to segment the ZMPs of the cytoplasm and zona pellucida of the oocytes. The ZMPs include cm_g, cm_size, cm_r, cm_d, zp_g, thickness of zona pellucida and the area of perivitelline space. For the ZMPs that did not change with time, we used t-test to test the significance and for the parameters changed with time we used dynamic warp timing and similarity test to find the difference.

Main results and the role of chance

The IVM group had a higher intensity of zp_g of 142.03 (128.52–158.70) compared with the fertilized group of 137.04 (121.69–154.37). The cm_g of IVM group was higher than fertilized group [122.55 (114.87–137.62) vs 119.37(108.88–132.87)]. The cm_size, cm_r and cm_d as parameters changed with time and showed a different pattern in two groups. The IVM group decreased the cm_size faster than the fertilized group but the fertilized group had a more dynamic change in the shape of cytoplasm (cm_d) during the development. The cm_r changed with the same pattern of cm_size provided evidence supporting the finding above.

Limitations, reasons for caution

The ZMPs in the IVM group was captured for 21 hours from the first polar body extrusion. Though the duration was similar to the one from fertilized to the first cleavage. The morphology change during that period may not represent the holistic one of IVM oocytes.

Wider implications of the findings: The IVM oocytes have different morphokinetic performance from fertilized oocytes. We used a novel method based on CNN to confirm the differences between the two groups showing that our algorithm was able to describe the morphokinetic changes in a quantitative way and corresponded with embryologist’s experience.

Trial registration number

The Hong Kong Obstetrical & Gynaecological Trust Fund

Potential effects of COVID-19 on reproductive systems and fertility; assisted reproductive technology guidelines and considerations: a review

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) employs the angiotensin-converting enzyme 2 (ACE2) receptor in the renin-angiotensin system for viral entry. The ACE2 receptor is present in both female and male reproductive systems, and reports of multi-organ involvement have led to uncertainty regarding its effects on the reproductive system and fertility. We review the existing literature regarding the function of ACE2 and the renin-angiotensin system in the female and male reproductive systems to postulate the possible implications of SARS-CoV-2 regarding fertility. Because of the presence of ACE2 in the ovaries, SARS-CoV-2 infection may disrupt ovarian function and hence oocyte quality. Higher expression of ACE2 in the endometrium with age and during the secretory phase raises concern about increased susceptibility to infection during periods of high ACE2 expression. The possibility of vertical transmission and the presence of ACE2 in the placenta and during pregnancy are also discussed. The presence of SARS-CoV-2 RNA in semen is controversial, but impaired semen quality has been found in men with moderate coronavirus disease 2019 infection. Evidence of orchitis and hormonal changes seen in male coronavirus disease 2019 infection may lead to infertility. The implications of these effects on assisted reproductive technology (ART) outcomes are also explored. The ART guidelines from different fertility societies for the management of patients treated with ART are provided. The importance of prioritising 'time-sensitive' patients for ART, counselling patients about the uncertainty and risks of ART, and pregnancy during the pandemic is discussed. Recommendations are also provided for infection control and safe regulation of ART centres and laboratories.

Expanded carrier screening using next-generation sequencing of 123 Hong Kong Chinese families: a pilot study

INTRODUCTION

To determine the carrier frequency and common mutations of Mendelian variants in Chinese couples using next-generation sequencing (NGS).

METHODS

Preconception expanded carrier testing using NGS was offered to women who attended the subfertility clinic. The test was then offered to the partners of women who had positive screening results. Carrier frequency was calculated, and the results of the NGS panel were compared with those of a target panel.

RESULTS

One hundred twenty-three women and 20 of their partners were screened. Overall, 84 (58.7%) individuals were identified to be carriers of at least one disease, and 68 (47.6%) were carriers after excluding thalassaemias. The most common diseases found were GJB2-related DFNB1 nonsyndromic hearing loss and deafness (1 in 4), alpha-thalassaemia (1 in 7), beta-thalassaemia (1 in 14), 21-hydroxylase deficient congenital adrenal hyperplasia (1 in 13), Pendred's syndrome (1 in 36), Krabbe's disease (1 in 48), and spinal muscular atrophy (1 in 48). Of the 43 identified variants, 29 (67.4%) were not included in the American College of Medical Genetics and Genomics or American College of Obstetrics and Gynecology guidelines. Excluding three couples with alpha-thalassaemia, six at-risk couples were identified.

CONCLUSION

The carrier frequency of the investigated members of the Chinese population was 58.7% overall and 47.6% after excluding thalassaemias. This frequency is higher than previously reported. Expanded carrier screening using NGS should be provided to Chinese people to improve the detection rate of carrier status and allow optimal pregnancy planning.

Incidence and predictors of postoperative ischaemic stroke after coronary artery bypass grafting in the United States

Background

Postoperative acute ischemic stroke (AIS) is a catastrophic complication of coronary artery bypass grafting (CABG). There is limited data on the incidence and outcomes of AIS complicating CABG in the contemporary era, and whether these have changed over the years.

Purpose

To study the incidence and outcomes of postoperative AIS in a nationally representative cohort of CABG procedures over a 12-year period and examine predictors of AIS in patients undergoing CABG.

Methods

The National Inpatient Sample was used to identify all adult patients (>18 years old) who underwent CABG in the United States between January 2004 and September 2015. Multivariable logistic regression was performed to examine the associations between postoperative AIS and in-hospital mortality and identify predictors of AIS after CABG, expressed as odds ratios (OR) with corresponding 95% confidence intervals (CI).

Results

A total of 2,569,597 CABG operations were analysed. The incidence of postoperative AIS was 1.8% (n=47,279) in the overall cohort increasing from 1.2% in 2004 to 2.3% in 2015 (p<0.001). Significantly higher rates of AIS were observed amongst patients with atrial fibrillation (AF) and those undergoing non-elective or concomitant valve operations over the study period (see Figure). Patient risk profiles increased over time in both AIS and no-AIS cohorts, with higher Charlson comorbidity scores observed amongst AIS patients. AIS was independently associated with increased odds of in-hospital mortality (OR 3.03, 95% CI 2.93, 3.13) and prolonged hospital stay (∼6 more days) and a higher hospitalisation cost (∼$80,000 more) (p<0.001 for all). Several factors were predictors of AIS including age>60 years (61–70 years: OR 1.33, 95% CI 1.29, 1.37; 71–80 years: OR 1.49, 95% CI 1.44, 1.54; >80 years: OR 1.42, 95% CI 1.37, 1.48), female sex (OR 1.33, 95% CI 1.31, 1.36) and AF (OR 1.14 95% CI 1.12, 1.16) (p<0.001 for all). In contrast, on-pump CABG was not an independent predictor of stroke (OR 1.01, 95% CI 0.94, 1.09) (p=0.784).

Conclusion

In this nationally representative study, we have shown that the rates of postoperative stroke following CABG have increased over time in line with complexity of patient risk profiles. The present findings emphasise the need for further work on strategies to reduce the risk of postoperative stroke after CABG.

Trends of postoperative AIS (2004-2015)

Funding Acknowledgement

Type of funding source: None

Current locoregional therapies and treatment strategies in hepatocellular carcinoma

Locoregional therapies (lrts) play an important role in the treatment of hepatocellular carcinoma (hcc), with the aim of increasing overall survival while preserving liver function. Various forms of lrt are available, and choosing the best one depends on technical aspects, liver morphology, tumour biology, and the patient's symptoms. The purpose of the present review article is to provide an overview of the current evidence relating to the use of percutaneous ablation, transarterial chemoembolization, and transarterial radioembolization for the curative or palliative treatment of hcc. Special situations are also reviewed, including the combined use of systemic therapy and lrt, indications and techniques for bridging to transplant and downstaging, and the use of lrt to treat patients with hcc and macrovascular invasion.

Treatment of patients with Mayer-Rokitansky- Küster-Hauser syndrome in a tertiary hospital

INTRODUCTION

Mayer-Rokitansky-Küster-Hauser (MRKH) syndrome is an uncommon congenital malformation characterised by agenesis or hypoplasia of the vagina and uterus. Here, we describe the treatment of patients with MRKH syndrome in a tertiary hospital.

METHODS

This retrospective study included patients with MRKH syndrome attending the Paediatric and Adolescent Gynaecology Clinic in a tertiary hospital. Their clinical manifestations, examinations, and methods for neovagina creation were recorded. Among patients who underwent vaginal dilation (VD), therapy duration, vaginal width and length at baseline and after VD, complications, and sexual activity and dyspareunia outcomes were evaluated.

RESULTS

Forty nine patients with MRKH syndrome were identified. Their mean age at presentation was 17.9 years; 69.4% and 24.5% of patients presented for primary amenorrhoea treatment and vaginoplasty, respectively. Forty eight patients had normal renal imaging findings and 46 XX karyotypes. Seventeen (34.7%) patients underwent VD as first-line therapy; three did not complete the therapy. Two had surgical vaginoplasty, whereas five achieved adequate vaginal length by sexual intercourse alone; 25 had not yet requested VD. The mean duration of VD was 16±10.2 (range, 4-35) weeks. The widths and lengths of the vagina at baseline and after VD were 1.1±0.28 cm and 1.3±0.7 cm, and 3.1±0.5 cm and 6.9±0.9 cm, respectively. The overall success rate of VD was 92.3%. Vaginal spotting was the most common complication (21%); only one patient reported dyspareunia.

CONCLUSIONS

Mayer-Rokitansky-Küster-Hauser syndrome is an uncommon condition that requires multidisciplinary specialist care. Vaginal dilation is an effective first-line approach for neovagina creation.

Awareness of fertility preservation among Chinese medical students

INTRODUCTION

The fertility preservation (FP) services offered in Hong Kong are underutilised. There have been no previous studies on Chinese medical students to investigate the underlying reasons for this underutilisation in terms of awareness, knowledge, and attitudes towards FP and age-related fertility.

METHODS

This was a cross-sectional survey among Chinese medical students in Hong Kong.

RESULTS

The majority of participants (77.8%) were not familiar with any clinics or specialists who provide FP services. The vast majority (88.1%) underestimated female infertility at age 45 years, and 89.8% overestimated the age of male fertility decline. The students' FP knowledge was mainly acquired from electronic media (58.4%) and medical school (57.6%). Medical students showed overwhelming support towards FP for medical reasons (97.9%) but had mixed responses about FP for elective reasons related to career development in women (58.8%). Of the participants, 80.2% agreed that the government should subsidise FP services for patients with medical reasons.

CONCLUSION

This study highlights the limited awareness and knowledge of FP among Chinese medical students. There is a strong worldwide need to increase education about and exposure to FP in the medical curriculum and improve medical students' knowledge.

Preservation of fertility in premenopausal patients with breast cancer

INTRODUCTION

Cancer survivorship is increasingly important with advances in cancer therapeutics. Minimisation of treatment-related morbidity is an area that requires attention. This situation is most pressing in premenopausal patients with breast cancer, in whom advances in hormonal and targeted therapies have improved mortality rates. However, treatment-related infertility is still poorly addressed, and in East Asia, there is limited discussion regarding management of treatment-related infertility.

METHODS

A search of the literature was conducted using PubMed, Google Scholar, and Science Direct using the terms "breast cancer", "fertility preservation", "oocyte and embryonic cryopreservation", "GnRH-a co-administration", "ovarian tissue cryopreservation and transplantation", "Japan", "China", "Korea", and 'Singapore". Only studies published in English from 1980-2019 were included. The focus of the review was on identifying the current fertility preservation methods available to premenopausal women with breast cancer and the barriers that impede access.

RESULTS

Fertility preservation options include GnRH-a co-administration to minimise treatment-associated infertility, oocyte and embryonic cryopreservation, and emerging treatments such as ovarian tissue cryopreservation and transplantation. In East Asia, the uptake of fertility preservation options has been limited despite it being a major patient concern. A lack of awareness of fertility preservation treatments hinders discussion between patients and clinicians about fertility preservation.

CONCLUSION

Despite progress in fertility preservation technologies, their impact for patients will be minimal if there is a lack of awareness/use of the technology. This review aims to raise awareness of such technologies among clinicians, enabling discussion between patients and clinicians about fertility preservation options.