Ninety-five orthotopic transplantations in 74 women of ovarian tissue after cytotoxic treatment in a fertility preservation network: tissue activity, pregnancy and delivery rates

STUDY QUESTION

What is the success rate in terms of ovarian activity (menstrual cycles) as well as pregnancy and delivery rates 1 year after orthotopic ovarian transplantations conducted in a three-country network?

SUMMARY ANSWER

In 49 women with a follow-up >1 year after transplantation, the ovaries were active in 67% of cases and the pregnancy and delivery rates were 33 and 25%, respectively.

WHAT IS KNOWN ALREADY

Cryopreservation of ovarian tissue in advance of cytotoxic therapies and later transplantation of the tissue is being performed increasingly often, and the total success rates in terms of pregnancy and delivery have been described in case series. However, published case series have not allowed either a more detailed analysis of patients with premature ovarian insufficiency (POI) or calculation of success rates based on the parameter 'tissue activity'.

STUDY DESIGN, SIZE, DURATION

Retrospective analysis of 95 orthotopic transplantations in 74 patients who had been treated for cancer, performed in the FertiPROTEKT network from 2008 to June 2015. Of those 95 transplantations, a first subgroup (Subgroup 1) was defined for further analysis, including 49 women with a follow-up period >1 year after transplantation. Of those 49 women, a second subgroup (Subgroup 5) was further analysed, including 40 women who were transplanted for the first time and who were diagnosed with POI before transplantation.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Transplantation was performed in 16 centres and data were transferred to the FertiPROTEKT registry. The transplantations were carried out after oncological treatment had been completed and after a remission period of at least 2 years. Tissue was transplanted orthotopically, either into or onto the residual ovaries or into a pelvic peritoneal pocket. The success rates were defined as tissue activity (menstrual cycles) after 1 year (primary outcome) and as pregnancies and deliveries achieved.

MAIN RESULTS AND THE ROLE OF CHANCE

The average age of all transplanted 74 women was 31 ± 5.9 years at the time of cryopreservation and 35 ± 5.2 at the time of transplantation. Twenty-one pregnancies and 17 deliveries were recorded. In Subgroup 1, tissue was cryopreserved at the age of 30 ± 5.6 and transplanted at 34 ± 4.9 years. Ovaries remained active 1 year after transplantation in 67% of cases (n = 33/49), the pregnancy rate was 33% (n = 16/49) and the delivery rate was 25% (n = 12/49). In Subgroup 5, tissue was cryopreserved at the age 30 ± 5.9 years and transplanted at 34 ± 5.2 years. Ovaries remained active 1 year after transplantation in 63% of cases (n = 25/40), the pregnancy rate was 28% (n = 11/40) and the delivery rate was 23% (n = 9/40). The success rates were age dependant with higher success in women who cryopreserved at a younger age. In Subgroup 5, tissue was exclusively transplanted into the ovary in 10% (n = 4/40) of women and into a peritoneal pocket in 75% (n = 30/40), resulting in spontaneous conceptions in 91% of patients (n = 10/11).

LIMITATIONS, REASONS FOR CAUTION

The data were drawn from a retrospective analysis. The cryopreservation and transplantation techniques used have changed during the study period. The tissue was stored in many tissue banks and many surgeons were involved, leading to heterogeneity of the procedures. However, this does reflect the realistic situation in many countries. Although patients with POI were evaluated before transplantation to allow specific analysis of the transplanted tissue itself, the possibility cannot be excluded that residual ovarian tissue was also reactivated.

WIDER IMPLICATIONS OF THE FINDINGS

This is the largest case series worldwide to date and it confirms that cryopreservation and transplantation of ovarian tissue can be a successful option for preserving fertility. Persistent tissue activity 12 months after transplantation suggests that the pregnancy and delivery rates may increase further in the future. As transplantation into the peritoneum results in a high success rate, this approach may be an alternative to transplantation into the ovary. However, in order to establish the best transplantation site, a randomized study is required.

STUDY FUNDING/COMPETING INTEREST

This study was in part funded from the Deutsche Forschungsgemeinschaft (# DI 1525) and the Wilhelm Sander Foundation (2012.127.1) and did not receive any funding from a commercial company. No competing interests.

TRIAL REGISTRATION NUMBER

None.

Research on the thermal decomposition of Mongolian Baganuur lignite and Naryn sukhait bituminous coal

The technical characteristics, elemental composition of the organic and mineral matters, ash melting behaviors and carbonization and gasification reactivities of coals from Baganuur and Naryn sukhait deposits were investigated. The results of proximate and ultimate analysis confirmed that the coal from Baganuur deposit can be graded as a low rank lignite B2 mark coal and Naryn sukhait coal is a bituminous G mark one. The carbonization and gasification experiments were performed using TGA apparatus and fixed bed quartz reactor. The data obtained with two experimental reactors showed that Baganuur lignite had lower thermal stability and much higher CO2 gasification reactivity at 950°C as compared to those for Naryn sukhait bituminous coal.Mongolian Journal of Chemistry 16 (42), 2015, 22-29

Induction of labor using prostaglandin vaginal gel: cost analysis comparing early amniotomy with repeat prostaglandin gel

BACKGROUND

In a randomized controlled trial of two policies for induction of labor (IOL) using Prostaglandin E2 (PGE2) vaginal gel, women who had an earlier amniotomy experienced a shorter IOL-to-birth time.

OBJECTIVE

To report the cost analysis of this trial and determine if there are differences in healthcare costs when an early amniotomy is performed as opposed to giving more PGE2 vaginal gel, for women undergoing IOL at term.

STUDY DESIGN

Following an evening dose of PGE2 vaginal gel, 245 women with live singleton pregnancies, ≥37+0 weeks, were randomized into an amniotomy or repeat-PGE2 group. Healthcare costs were a secondary outcome measure, sourced from hospital finance systems and included staff costs, equipment and consumables, pharmacy, pathology, hotel services and business overheads. A decision analytic model, specifically a Markov chain, was developed to further investigate costs, and a Monte Carlo simulation was performed to confirm the robustness of these findings. Mean and median costs and cost differences between the two groups are reported, from the hospital perspective.

RESULTS

The healthcare costs associated with IOL were available for all 245 trial participants. A 1000-patient cohort simulation demonstrated that performing an early amniotomy was associated with a cost-saving of $AUD289 ($AUD7094 vs $AUD7338) per woman induced, compared with administering more PGE2. Propagating the uncertainty through the model 10,000 times, early amniotomy was associated with a median cost savings of $AUD487 (IQR -$AUD573, +$AUD1498).

CONCLUSIONS

After an initial dose of PGE2 vaginal gel, a policy of administering more PGE2 when the Modified Bishop's score is <7 was associated with increased healthcare costs compared with a policy of performing an amniotomy, if technically possible. Length of stay was the main driver of healthcare costs.

Service-wide management of healthy gestational weight gain following an implementation science approach

The aim of health guidelines is to ensure consistency in the delivery of care to minimise health-related complications. However, even when good evidence is available, professionals do not necessarily implement it. Following a 2011 survey (Time 1) of staff in a tertiary maternity hospital, a number of service changes were implemented to facilitate best practice delivery of care to pregnant women regarding gestational weight gain (GWG). A (second) staff survey was then undertaken to re-assess staff knowledge, attitudes and behaviours around the management of GWG in our hospital. This cross-sectional, prospective online survey was distributed to staff in antenatal clinic. The survey assessed staff awareness of pregnancy-related weight complications, knowledge and application of specific guidelines, and a guideline adherence score was calculated. Sixty-nine staff (44.8% response rate) completed the 2014 (Time 2) survey. Just over half (51.9%) stated they were familiar with clinical guidelines regarding weight management in pregnancy. Guideline adherence ranged from 3.7 ± 1.9 to 11.3 ± 1.0 /15 across different professional groups; significant improvements with adherence by dietitians were noted over time. Despite minimal change over time in the overall adherence score, compliance with individual elements of the guideline recommendations comprising the adherence score differed. Improvements in staff practices and attitudes are apparent since the first survey. However, further improvements in guideline awareness and guideline elements are still required to improve the delivery of best practice antenatal GWG care.

Harmonizing Biodiversity Conservation and Productivity in the Context of Increasing Demands on Landscapes

Biodiversity conservation and agricultural production are often seen as mutually exclusive objectives. Strategies for reconciling them are intensely debated. We argue that harmonization between biodiversity conservation and crop production can be improved by increasing our understanding of the underlying relationships between them. We provide a general conceptual framework that links biodiversity and agricultural production through the separate relationships between land use and biodiversity and between land use and production. Hypothesized relationships are derived by synthesizing existing empirical and theoretical ecological knowledge. The framework suggests nonlinear relationships caused by the multifaceted impacts of land use (composition, configuration, and intensity). We propose solutions for overcoming the apparently dichotomous aims of maximizing either biodiversity conservation or agricultural production and suggest new hypotheses that emerge from our proposed framework.

Optimisation of water-cannon cleaning for deposit removal on water walls inside waste incinerators

Deposits in municipal waste incinerators are very inhomogeneous in structure and constitution. They cause corrosion and reduce the efficiency, so they need to be removed frequently. Among other systems, operators use water cannons for the deposit removal. Two different removal mechanisms of water-cannon cleaning are suggested: A direct shattering of the deposit by the impact of the water jet, as well as the cracking caused by thermal stresses where droplets cool the deposits. As the contribution of each of the aforementioned mechanisms to the overall cleaning efficiency is unknown, we performed empirical investigations to determine the dominating effect. In a first experimental setup focusing on thermal stress, cold droplets were applied onto hot deposits taken from a waste incinerator. Results showed that the cleaning effect strongly depends on the deposit thickness and structure, so that the deposits could be categorised in three different groups. A second measurement campaign focused on the influence of deposit material, deposit temperature and water jet momentum. It could be shown that both deposit material and temperature have a significant effect on the cleaning efficiency, whereas an increase in water jet momentum only led to modest improvements. The combination of these two parameter studies implies that the influence of the thermal stress outweighs that of the momentum. This knowledge is applicable to the cleaning setup by increasing the temperature gradient.

Prostaglandin vaginal gel induction of labor comparing amniotomy with repeat prostaglandin gel

OBJECTIVE

The purpose of this study was to compare 2 inductions of labor protocols.

STUDY DESIGN

Women with live singleton pregnancies at ≥37 + 0 weeks gestation who were booked for prostaglandins 2 (PGE2) vaginal gel induction with a modified Bishop's score of <7 were eligible for inclusion. After an evening dose of PGE2 vaginal gel, women were assigned randomly the next morning into the amniotomy or repeat-PGE2 group. The amniotomy group underwent artificial rupture of membranes (ARM), regardless of modified Bishop's score, and received further PGE2 doses only if ARM was not technically possible. The repeat-PGE2 group received further PGE2 (to a maximum of 3 doses) until a modified Bishop's score ≥7 occurred, when an ARM was performed. In both groups, Syntocinon was commenced once membranes were ruptured. The primary outcome measure was time from commencement of induction until birth.

RESULTS

Two hundred forty-five women were assigned randomly into either the amniotomy (n = 121) or repeat-PGE2 group (n = 124). The time for induction of labor-to-birth was >5 hours shorter in the amniotomy group (24.8 vs 30.0 hours; mean difference, 5.2 h; 95% confidence interval, -2.5 to -7.8). Fewer women in the amniotomy group remained undelivered after 24 hours (47.1% vs 67.7%; P < .01). However, the likelihood of an in-hours birth and the length of hospital stay were no different between the groups. There was no difference in the mode of birth or any of the secondary outcomes.

CONCLUSION

After an initial dose of PGE2 vaginal gel, an amniotomy (once technically possible) is associated with a shorter induction of labor-to-birth time compared with the use of repeat doses of PGE2. Administering more PGE2 with the aim of starting contractions or making the cervix "more favorable," appears to have no clinical advantage.

[Documentation Time and Effort and Associated Resources for Patients with Primary Breast Cancer from Diagnosis to End of Follow-Up - Results of a Multicentre Validation]

INTRODUCTION

Tumour documentation is essential for quality assurance of oncological therapies and as a source of reliable information about the in- and outpatient care. The documentation effort and the associated resource consumption were analysed for the example of breast cancer.

MATERIAL AND METHODS

The different steps in the care of patients with primary breast cancer in a standardised disease situation were defined from initial diagnosis to the end of the follow-up. After the pilot phase, a multicentre validation (n=7 centres) was performed with the support of the Federal Ministry of Health. The documentation time points were horizontally collected and analysed with regard to amount, duration and personnel expenses.

RESULTS

57% of the documentation costs are caused by the physicians. Regarding the different centres, documentation costs were calculated between € 352.82 and € 1 084.08 per patient from diagnosis to completion of aftercare. Non-certified centres had a reduced documentation effort and thus lower costs.

CONCLUSIONS

The results demonstrate the need for a reduction of the documentation effort - particularly for physicians - the most expensive profession in the health system. A quality improvement is expected from the certification with its special requirements. In this context, there is a justified demand for an adequate remuneration of the documentation effort for certified centres. Furthermore, it is necessary to reduce the number of variables for quality assurance and to define them centrally. A comprehensive multi-disciplinary documentation should be achieved. Investments in a single data set and interface enhancements of existing documentation systems should be realised.

Introducing a laparoscopic simulation training and credentialing program in gynaecology: an observational study

BACKGROUND

Simulation training in laparoscopic surgery has been shown to improve surgical performance.

AIMS

To describe the implementation of a laparoscopic simulation training and credentialing program for gynaecology registrars.

MATERIALS AND METHODS

A pilot program consisting of protected, supervised laparoscopic simulation time, a tailored curriculum and a credentialing process, was developed and implemented. Quantitative measures assessing simulated surgical performance were measured over the simulation training period. Laparoscopic procedures requiring credentialing were assessed for both the frequency of a registrar being the primary operator and the duration of surgery and compared to a presimulation cohort. Qualitative measures regarding quality of surgical training were assessed pre- and postsimulation.

RESULTS

Improvements were seen in simulated surgical performance in efficiency domains. Operative time for procedures requiring credentialing was reduced by 12%. Primary operator status in the operating theatre for registrars was unchanged. Registrar assessment of training quality improved.

CONCLUSIONS

The introduction of a laparoscopic simulation training and credentialing program resulted in improvements in simulated performance, reduced operative time and improved registrar assessment of the quality of training.