O-058 Obstetric outcomes of twin gestation after In-Vitro Fertilization and Embryo Transfer (IVT-ET) treatment in patients who underwent hysteroscopic septoplasty for subseptate uterus

Study question

Is there an associated increased risk of preterm birth (PTB) in patients who underwent hysteroscopic septoplasty for subseptate uterus (SSU) with twin gestation through IVF-ET?

Summary answer

This study suggests an increased risk of PTB in patients, who underwent hysteroscopic septoplasty for SSU, and subsequently conceived twins after IVF-ET treatment.

What is known already

In general, the incidence of PTB is higher after IVF-ET treatment. In addition, Müllerian uterine anomalies, such as unicornuate uterus, are considered risk factors for PTB, even with singleton pregnancy. Furthermore, historical data suggest that some patients with uterine anomaly may have cervical incompetence. Twin gestation is associated with PTB in approximately 50% of cases. It is assumed that the obstetric outcome of twin gestation after successful septoplasty should be no different from those with normal uterine cavity. The impact of previous septoplasty for SSU on the obstetric outcomes of twin gestation after IVF-ET treatment has not been adequately studied.

Study design, size, duration

This retrospective cohort study included 377 fertility patients who received treatment between 2006-2019. The study group included 162 patients who underwent hysteroscopic septoplasty for SSU and subsequently conceived dichorionic-diamniotic (DI-DI) twins after IVF-ET treatment (Group 1). The control group included 215 patients who had normal endometrial cavity on hysteroscopy (#109) or Transvaginal 3D ultrasound scan with saline sonohysterogram (#106) and subsequently conceived DI-DI twins after IVF-ET treatment (Group 2).

Participants/materials, setting, methods

This study was conducted at an infertility clinic affiliated with an academic hospital. Demographic, clinical, and obstetric outcome data were collected for both groups and compared using appropriate statistical methods. PTB, severe PTB, extreme PTB, and peri-viable birth were defined as < 37 weeks, <32 weeks, <28 weeks and between 20 weeks-25 weeks 6 days gestation respectively.

Main results and the role of chance

There was no significant difference in mean age, BMI and infertility duration or in the incidence of smoking, primary infertility, tubal factors and unexplained infertility between the two groups. There was significantly lower mean baseline FSH levels (p < 0.01), lower incidence of male infertility (p < 0.001) and higher incidence of ovulatory disorders (p < 0.001) and endometriosis (p < 0.05) in Group 1 compared to Group 2. As expected, there was past history of lower parity rate (p < 0.01) and higher miscarriage rate (p < 0.001) in Group 1 compared to Group 2 prior to septum division. There was significantly higher incidence of PTB (72.8% vs 56.3%, p < 0.01), severe PTB (20.3% vs 8.2%, p < 0.01), extreme PTB (8.3% vs 3.9%, p < 0.05), and peri-viable birth (6.3% vs 1.9%, p < 0.05) in Group 1 compared to Group 2. There was no significant difference in cesarean section rate (82.8% vs 87.5%, p = 0.349) between Group1 and Group 2 respectively. There was significantly lower gestational age at birth in weeks (34.0 + 4.0 vs 35.6 + 3.0, p < 0.001), birth weight of the first newborn (2180.5 + 717.9 vs 2436.4 + 606.6, p < 0.001), and the second newborn (2235.2 + 674.2 vs 2398.0 + 537.9, p < 0.05) in grams in Group 1 compared to Group 2.

Limitations, reasons for caution

Our study has limitations being retrospective in nature. Data on cervical length measurements via ultrasound, if performed, was not available. However, recall bias was prevented by retrieving data from that submitted to the Society of Assisted Reproductive Technology. Additionally, procedural variation was reduced as this was a single-center study.

Wider implications of the findings

Our study suggests that twin gestation after IVF-ET in patients who underwent successful hysteroscopic septoplasty for SSU may increase the likelihood of PTB. Such patients may require increased surveillance with ultrasound cervical length and signs for preterm labor. Future research should focus on measures to reduce PTB in such patients.

Trial registration number

Not Applicable

PVP1-The People's Ventilator Project: A fully open, low-cost, pressure-controlled ventilator research platform compatible with adult and pediatric uses

Mechanical ventilators are safety-critical devices that help patients breathe, commonly found in hospital intensive care units (ICUs)-yet, the high costs and proprietary nature of commercial ventilators inhibit their use as an educational and research platform. We present a fully open ventilator device-The People's Ventilator: PVP1-with complete hardware and software documentation including detailed build instructions and a DIY cost of $1,700 USD. We validate PVP1 against both key performance criteria specified in the U.S. Food and Drug Administration's Emergency Use Authorization for Ventilators, and in a pediatric context against a state-of-the-art commercial ventilator. Notably, PVP1 performs well over a wide range of test conditions and performance stability is demonstrated for a minimum of 75,000 breath cycles over three days with an adult mechanical test lung. As an open project, PVP1 can enable future educational, academic, and clinical developments in the ventilator space.

Learning the rules of collective cell migration using deep attention networks

Collective, coordinated cellular motions underpin key processes in all multicellular organisms, yet it has been difficult to simultaneously express the ‘rules’ behind these motions in clear, interpretable forms that effectively capture high-dimensional cell-cell interaction dynamics in a manner that is intuitive to the researcher. Here we apply deep attention networks to analyze several canonical living tissues systems and present the underlying collective migration rules for each tissue type using only cell migration trajectory data. We use these networks to learn the behaviors of key tissue types with distinct collective behaviors—epithelial, endothelial, and metastatic breast cancer cells—and show how the results complement traditional biophysical approaches. In particular, we present attention maps indicating the relative influence of neighboring cells to the learned turning decisions of a ‘focal cell’–the primary cell of interest in a collective setting. Colloquially, we refer to this learned relative influence as ‘attention’, as it serves as a proxy for the physical parameters modifying the focal cell’s future motion as a function of each neighbor cell. These attention networks reveal distinct patterns of influence and attention unique to each model tissue. Endothelial cells exhibit tightly focused attention on their immediate forward-most neighbors, while cells in more expansile epithelial tissues are more broadly influenced by neighbors in a relatively large forward sector. Attention maps of ensembles of more mesenchymal, metastatic cells reveal completely symmetric attention patterns, indicating the lack of any particular coordination or direction of interest. Moreover, we show how attention networks are capable of detecting and learning how these rules change based on biophysical context, such as location within the tissue and cellular crowding. That these results require only cellular trajectories and no modeling assumptions highlights the potential of attention networks for providing further biological insights into complex cellular systems.

Collective behaviors are crucial to the function of multicellular life, with large-scale, coordinated cell migration enabling processes spanning organ formation to coordinated skin healing. However, we lack effective tools to discover and cleanly express collective rules at the level of an individual cell. Here, we employ a carefully structured neural network to extract collective information directly from cell trajectory data. The network is trained on data from various systems, including canonical collective cell systems (HUVEC and MDCK cells) which display visually distinct forms of collective motion, and metastatic cancer cells (MDA-MB-231) which are highly uncoordinated. Using these trained networks, we can produce attention maps for each system, which indicate how a cell within a tissue takes in information from its surrounding neighbors, as a function of weights assigned to those neighbors. Thus for a cell type in which cells tend to follow the path of the cell in front, the attention maps will display high weights for cells spatially forward of the focal cell. We present results in terms of additional metrics, such as accuracy plots and number of interacting cells, and encourage future development of improved metrics.

Practical fluorescence reconstruction microscopy for large samples and low-magnification imaging

Fluorescence reconstruction microscopy (FRM) describes a class of techniques where transmitted light images are passed into a convolutional neural network that then outputs predicted epifluorescence images. This approach enables many benefits including reduced phototoxicity, freeing up of fluorescence channels, simplified sample preparation, and the ability to re-process legacy data for new insights. However, FRM can be complex to implement, and current FRM benchmarks are abstractions that are difficult to relate to how valuable or trustworthy a reconstruction is. Here, we relate the conventional benchmarks and demonstrations to practical and familiar cell biology analyses to demonstrate that FRM should be judged in context. We further demonstrate that it performs remarkably well even with lower-magnification microscopy data, as are often collected in screening and high content imaging. Specifically, we present promising results for nuclei, cell-cell junctions, and fine feature reconstruction; provide data-driven experimental design guidelines; and provide researcher-friendly code, complete sample data, and a researcher manual to enable more widespread adoption of FRM.

Correction to: The role of diagnostic hysteroscopy in diagnosis of incomplete uterine septum/significant arcuate uterine anomaly in infertile patients in the era of transvaginal 3D ultrasound scan

An amendment to this paper has been published and can be accessed via the original article.

The role of diagnostic hysteroscopy in diagnosis of incomplete uterine septum/significant arcuate uterine anomaly in infertile patients in the era of transvaginal 3D ultrasound scan

Background

To determine the accuracy of measurement of internal indentation length on transvaginal 3D ultrasound scan (TV 3D US) in detecting patients with an incomplete uterine septum (IUS) or a significant arcuate uterine anomaly (AUA) based on the actual length as measured on diagnostic hysteroscopy. We compared the mean internal indentation length on TV 3D US and on diagnostic hysteroscopy in patients with IUS or a significant AUA.

Results

This is a retrospective study of 546 patients who were found to have IUS (134) or significant AUA (412) on diagnostic hysteroscopy and who had TV 3D US prior to surgery. The mean internal indentation length measured in millimeter on hysteroscopy was significantly higher than the mean internal indentation length measured on TV 3D US in patients with IUS (16.7 + 5.5 vs 5.5 + 4.2; P < 0.001), in patients with significant AUA (12.9 + 2.8 vs 3.9 + 4.6; P < 0.001), and in the overall population (13.8 + 4.0 vs 4.3 + 4.5; P < 0.001). The same findings were obtained when the comparison was limited to patients who had moderate significant internal indentation length (10–14 mm) and those with significant internal indentation length (15–25 mm).

Conclusion

Data in this study suggests that the mean internal indentation length in patients with IUS or AUA can be underestimated on TV 3D US. A diagnostic hysteroscopy is the only gold standard to make the correct diagnosis in these patients.

The utility of PEG3350 without electrolytes for 2-day colonoscopy preparation in children

OBJECTIVES

Successful colonoscopy preparation requires a method which is easy to administer. Simplifying this technique would be useful for adult and pediatric gastroenterologists. Most cleanout agents are not well tolerated by children. Polyethylene glycol without electrolytes (PEG3350 without electrolytes) has been used for constipation and bowel cleanout, but has not been studied as 2-day preparation for colonoscopy in children. This study evaluates the dosing, effectiveness and satisfaction with PEG3350 without electrolytes as a 2-day cleanout for colonoscopy preparation in children.

METHODS

Parents of patients aged 5 years or older undergoing colonoscopies were approached for participation. All caretakers received standard instructions with a suggested food handout and a diary to track the doses of PEG3350 administered and to document other adjunct measures (suppository, enema). On the procedure day, parents and children completed appropriate satisfaction questionnaires. Post procedure, the physician rated the visualization of the mucosa. A pediatric gastroenterologist investigator and a second blinded pediatric gastroenterologist assessed the effectiveness using standard procedure photos.

RESULTS

30 patients aged 5-16 years were recruited (15 males, 15 females). The majority of parents and children reported being “very satisfied” or “satisfied” with the preparation. The preparation was rated by the principal investigator and independent pediatric gastroenterologist as effective in all cases. The mean number of doses was 4.7 on Day 1 and 4.9 on Day 2. The average dose given was 1.90 g/kg/day.

CONCLUSION

PEG3350 without electrolytes appears to be safe, effective, and well tolerated as a 2-day clean out for colonoscopy preparation in children with an average dose of 1.90 g/kg/day.