Establishing transducers-dependent sensorineural acuity level normative data among young Malaysian adults

INTRODUCTION

The sensorineural acuity level (SAL) test was developed as an alternative assessment to estimate bone conduction (BC) thresholds in cases where masking problems occur in pure tone audiometry (PTA). Nevertheless, prior to its clinical application, the respective SAL normative data must be made available. As such, the present study was carried out to establish SAL normative data using an insert earphone and two different commercially available bone transducers. Additionally, to determine the effect of earphone type on SAL test results, it was also of interest to compare the present study's findings with those of a previous study (that used a headphone to derive SAL normative data).

MATERIALS AND METHODS

In this repeated-measures study, 40 Malaysian adults (aged 19-26 years) with normal hearing bilaterally (based on PTA results) were enrolled. They then underwent the SAL test based on the recommended protocol by Jerger and Tillman (1960). The SAL normative data for each ear were obtained by calculating the differences between air conduction (AC) thresholds in quiet and AC thresholds in noise by means of insert earphone, B71 and B81 bone vibrators.

RESULTS

The SAL normative values were comparable between the ears (p > 0.05), and the data were pooled for subsequent analyses (n = 80 ears). Relative to B81 bone transducer, B71 bone vibrator produced statistically higher SAL normative data at all frequencies (p < 0.05). The SAL normative values established by the present study were statistically lower than those of the previous study (that utilised headphones) at most of frequencies tested (p < 0.05).

CONCLUSIONS

The SAL normative data produced by the two bone vibrators were significantly different. The SAL normative values were also affected by the type of earphone used. While conducting the SAL test on Malaysian patients, the information provided by this study can be useful to guide the respective clinicians in choosing the appropriate normative data.

Endocrine Responses to Triptorelin in Healthy Women, Women With Polycystic Ovary Syndrome, and Women With Hypothalamic Amenorrhea

CONTEXT

Limited data exist regarding whether the endocrine response to the gonadotropin-releasing hormone receptor agonist (GnRHa) triptorelin differs in women with polycystic ovary syndrome (PCOS) compared with healthy women or those with hypothalamic amenorrhea (HA).

OBJECTIVE

We compared the gonadotropin response to triptorelin in healthy women, women with PCOS, or those with HA without ovarian stimulation, and in women with or without polycystic ovaries undergoing oocyte donation cycles after ovarian stimulation.

METHODS

The change in serum gonadotropin levels was determined in (1) a prospective single-blinded placebo-controlled study to determine the endocrine profile of triptorelin (0.2 mg) or saline-placebo in healthy women, women with PCOS, and those with HA, without ovarian stimulation; and (2) a retrospective analysis from a dose-finding randomized controlled trial of triptorelin (0.2-0.4 mg) in oocyte donation cycles after ovarian stimulation.

RESULTS

In Study 1, triptorelin induced an increase in serum luteinizing hormone (LH) of similar amplitude in all women (mean peak LH: healthy, 52.3; PCOS, 46.2; HA, 41.3 IU/L). The AUC of change in serum follicle-stimulating hormone (FSH) was attenuated in women with PCOS compared with healthy women and women with HA (median AUC of change in serum FSH: PCOS, 127.2; healthy, 253.8; HA, 326.7 IU.h/L; P = 0.0005). In Study 2, FSH levels 4 hours after triptorelin were reduced in women with at least one polycystic morphology ovary (n = 60) vs normal morphology ovaries (n = 91) (34.0 vs 42.3 IU/L; P = 0.0003). Serum anti-Müllerian hormone (AMH) was negatively associated with the increase in FSH after triptorelin, both with and without ovarian stimulation.

CONCLUSION

FSH response to triptorelin was attenuated in women with polycystic ovaries, both with and without ovarian stimulation, and was negatively related to AMH levels.

Dosimetry assessment of theranostic Auger-emitting radionuclides in a micron-sized multicellular cluster model: A Monte Carlo study using Geant4-DNA simulations

The present work is aimed at improving the multicellular dosimetry of several Auger radionuclides of interest for targeted cancer therapy, including ^99mTc, ¹¹¹In, ¹²³I, ¹²⁵I, and ²⁰¹Tl. For this purpose, using the Geant4-DNA Monte Carlo code, a cluster of 13 similar spherical cells with a hexagonal packed arrangement was modeled, and the mean absorbed doses per unit cumulated activity (S-values) were calculated by considering two target←source configurations, cell←cell and nucleus←nucleus. The obtained ratios of cross-dose to self-dose S-value in terms of the distance between the source and target regions were evaluated and also compared to those estimated by the Medical Internal Radiation Dose (MIRD) method. Besides, the contribution of the Coster-Kronig, Auger and internal conversion electrons to the S-values was provided for each radionuclide. According to the results, it can be concluded that in contrast to self-absorption, the cross-absorption due to the Auger-emitters has not a significant role in the total energy deposition within a cell in the cluster.

P-402 The association between embryo morphology and first trimester miscarriage after single blastocyst transfer

Study question

Can standard morphological assessment of blastocyst quality accurately predict first trimester miscarriage?

Summary answer

Decreasing trophectoderm and inner cell mass grade equally predicted first trimester miscarriage independently. After adjusting for confounders, poor embryo quality was not associated with miscarriage.

What is known already

Embryo quality determined by morphological assessment is a well-established predictor of successful implantation and live birth with in vitro fertilization treatment. Chromosomal abnormalities account for over half of first trimester miscarriages, and links between ploidy status and embryo morphology have been demonstrated. However, the association between blastocyst morphology and first trimester miscarriage is still poorly understood with consensus opinion yet to be established.

Study design, size, duration

This single centre retrospective cohort study included 2020 fresh and frozen single embryo transfers between October 2010 and October 2020. Blastocyst degree of expansion, inner cell mass (ICM) grade, and trophectoderm (TE) grade were compared for 354 pregnancies ending in first trimester miscarriage and 1666 pregnancies that surpassed 12 weeks of gestation. The association between blastocyst morphology and miscarriage was examined by logistic regression analysis.

Participants/materials, setting, methods

All single blastocyst transfers over a 10-year period resulting in first trimester miscarriage or pregnancy beyond 12 weeks of gestation were included in our analysis. Cycles involving donor oocytes, preimplantation genetic testing, resulting in biochemical pregnancy, or ectopic pregnancy were excluded. Differences between groups were analysed with chi-square and logistic regression analysis. Odds ratios (aOR) for miscarriage versus ongoing pregnancy were adjusted for maternal age, cycle type, blastocyst expansion, ICM grade, and TE grade.

Main results and the role of chance

Out of 2020 single embryo transfer cycles, a total of 354 resulted in first trimester miscarriage (17.5%). Independently, miscarriage rates increased with decreasing ICM grade (A to C; 14.6%, 18.9%, and 26.5%, p = 0.003) and TE grade (A to C; 14.6%, 17.7%, and 26.6%, p = 0.004). Univariate logistic regression showed higher risks of miscarriage with ICM grade C compared to ICM grade A (OR 2.241, 95%CI 1.292-3.886, p = 0.004), TE grade C compared to TE grade A (OR 2.116, 95%CI 1.360 – 3.292, p = 0.001), and expansion grades of 1 and 2 compared to expansion of 5 and 6 (OR 2.514, 95%CI 1.477 – 4.278, p = 0.001). After multivariable logistic regression adjusting for maternal age at embryo transfer, cycle type, and all morphological parameters (degree of expansion, ICM, and TE), only expansion grade of 1 and 2 showed a statistically significant association with first trimester miscarriage.

Limitations, reasons for caution

The main limitation of this study is the retrospective design of the analysis, and subjective nature of embryo morphological assessment. There may also be residual confounding by unknown or unmeasured confounders such as paternal age or maternal BMI.

Wider implications of the findings

Embryo selection for transfer should continue to be guided by standard morphological assessment. Decreasing grade of ICM and TE are both positively associated with an increased miscarriage risk, while poorly expanded blastocysts are most predictive of first trimester miscarriage. Patients undergoing embryo transfer should be adequately counselled about these risks.

Trial registration number

Not applicable

P-282 Blastocyst transfer in advanced maternal age: Single versus double embryo transfer

Study question

Is there a role for elective single blastocyst transfer (eSBT) in advanced maternal age?

Summary answer

Double blastocyst transfer (DBT) versus eSBT resulted in higher live birth rates except for those undergoing their first cycle.

What is known already

Women with advanced maternal age are generally considered poorer prognosis patients with lower live birth rates compared to their younger counterparts. This often results in a higher likelihood of double embryo transfer in this group. This is not without risk as multiple pregnancy is associated with significant maternal and neonatal morbidity especially with advancing maternal age. In older women with blastocysts available for transfer, it is unclear who should be recommended double versus elective single transfer. The concept of the “good-prognosis” older woman remains elusive.

Study design, size, duration

This was a retrospective observational study looking at 511 IVF/ICSI cycles between January 2010 and January 2020. Treatment cycle details and clinical outcomes were entered prospectively into a dedicated clinic database. Data was retrieved and analysed using SPSS V25.

Participants/materials, setting, methods

The study was conducted in a large London IVF centre. Data was collected on women aged 40 or above undergoing an IVF/ICSI cycle with eSBT (Group 1, n = 79) or DBT (Group 2, n = 430). Women with more than three previous IVF attempts were excluded. eSBT was defined as a single blastocyst transfer with at least one further blastocyst available for cryopreservation. Subgroup analysis was performed for those undergoing their first cycle.

Main results and the role of chance

Data from 511 cycles was analysed. The mean age was 40.6±1.2years. The live birth rate was 27%. Group 1 was marginally younger (40.2±0.6 v 40.8±1.2, p &lt; 0.005) and was more likely to be undergoing their first IVF cycle (84% v 68%, p = 0.003). Those in Group 1 had more eggs collected (13.6±7.3 v 11.3±5.5, p = 0.009), more zygotes (8.9±4.7 v 7.3±3.6) formed and more blastocysts frozen (3.4±2.6 v 1.1±1.7, p &lt; 0005). More women in Group 1 had a top quality blastocyst (expansion of &gt; 2 and inner cell mass and trophectoderm of AA, AB, BA or BB) transfer (91% v 71%, p &lt; 0.005).

After logistic regression controlling for maternal age, number of previous IVF cycles and blastocyst quality, Group 1 had a lower likelihood of livebirth (aOR 0.550, 95%CI 0.306-0.988) but with a significantly lower multiple pregnancy rate (0% v 24%, p = 0.024).

Importantly, for those undergoing their first IVF cycle (n = 359), there was no difference in live birth rate in the two groups (aOR 0.617, 95%CI 0.329-1.156) after controlling for age and blastocyst quality but Group 2 had a higher multiple pregnancy rate (24% v 0%, p = 0.020).

Limitations, reasons for caution

This study is limited by its retrospective nature putting it at risk of information bias as it relied on accurate documentation of studied variables into the patient database. The study did not examine cumulative birth rates of fresh and subsequent frozen cycles in Group 1.

Wider implications of the findings

Women should have individualised counseling about number of blastocysts to transfer taking into account their circumstances. Those undergoing their first IVF attempt and with a blastocyst available for transfer, should be counselled that DBT is associated with a higher multiple pregnancy rate with no increase in overall live birth rate.

Trial registration number

Not Applicable

Decreased inferior vena cava diameter as an early marker in postpartum hemorrhage

OBJECTIVES

To examine the association between inferior vena cava (IVC) diameter and postpartum blood loss and assess whether IVC diameter is a useful marker in the evaluation of intravascular volume status in women with postpartum hemorrhage (PPH).

METHODS

This was a prospective case-control study conducted in a university medical teaching center in Afula, Israel, between November 2018 and March 2020. The study cohort consisted of women with a singleton pregnancy who delivered vaginally at term. The PPH group included women diagnosed with PPH based on visually estimated blood loss of 1000 mL or more at the time of enrolment. Hemodynamically unstable women or women with major bleeding at the time of diagnosis were not included. The control group consisted of women with an uneventful fourth stage of labor. IVC diameter was measured using transabdominal ultrasonography during inspiration (IVCi diameter) and expiration (IVCe diameter), and the collapsibility index was calculated ((IVCe - IVCi)/IVCe × 100). The primary outcome was the percentage difference in IVC diameter and collapsibility index between the PPH group and controls. The performance of the IVC collapsibility index in the prediction of the need for blood transfusion in women with PPH was assessed. In order to demonstrate a difference of 20% with a power of 80% and alpha of 0.05, 108 women, at a ratio of 1:2 in the study and control groups, respectively, were needed.

RESULTS

Overall, 36 and 72 women were included in the final analysis in the PPH and control groups, respectively. IVCi and IVCe diameters were significantly smaller in the PPH group (0.93 ± 0.30 cm and 1.26 ± 0.32 cm, respectively) than in controls (1.42 ± 0.31 cm and 1.75 ± 0.28 cm, respectively) (P = 0.001 for both). The percentage reductions in IVCi and IVCe diameters in the PPH group compared with controls were 35.0% and 28.0%, respectively. IVC collapsibility index was increased significantly, by 42.9% (26.04 ± 8.67% vs 18.15 ± 5.07%; P = 0.001) in the PPH group compared with controls. IVC collapsibility index was a significant predictor of the need for blood transfusion and correctly predicted 81% of cases. Logistic regression analysis demonstrated that IVC collapsibility index was also a significant predictor of a drop in hemoglobin level of ≥ 2 g/dL (P = 0.001).

CONCLUSIONS

IVC diameter changes in response to postpartum blood loss. Measurement of IVC diameter using transabdominal ultrasonography is an objective and useful non-invasive method for the early evaluation of intravascular volume status in women with PPH and for the prediction of cases that might require blood transfusion. © 2021 International Society of Ultrasound in Obstetrics and Gynecology.

Thiophene derivatives as corrosion inhibitors for 2024-T3 aluminum alloy in hydrochloric acid medium

Thiophene derivatives, namely (E)-thiophene-2-carbaldehyde oxime (OXM) and (E)-5-(thiophen-2-yl)-1H-tetrazole (TET), were synthesized and characterized via¹H and ¹³C NMR. Furthermore, their inhibitory property for AA2024-T3 in 1 M HCl solution was investigated via electrochemical impedance spectroscopy and potentiodynamic polarization at 293 K, together with DFT/B3LYP-based calculations. Numerous global and local descriptors of reactivity such as EHOMO, ELUMO, energy gap, electronegativity (χ), hardness (η), and frontier molecular orbital repartitions were investigated to describe the reactivity of each molecule. Alternatively, Monte Carlo simulations were performed under the solvation condition on the Al (111) surface to understand the adsorption behavior of the as-studied inhibitors deeply. The inhibition efficiency increased with an increase in the inhibitor concentration, achieving maximum values of 94.0% and 96% at 10⁻³ M, respectively. The polarization curves showed that the examined compounds act as mixed-type inhibitors. In addition, the adsorption of these compounds obeyed the Al Awady, Flory-Huggins and Temkin isotherms. The surface characterization analysis via SEM/EDX confirmed the presence of a barrier layer covering the aluminum surface. The experimental inhibition efficiencies were correlated with global descriptors, which confirmed that this theoretical study is useful for the protection of aluminum alloy metal in an acidic medium.

Thiophene derivatives: thiophene-2-carbaldehyde oxime (OXM) and 5-(thiophen-2-yl)-1H-tetrazole (TET), were synthesized and characterized. Furthermore, their inhibitory property for AA2024-T3 in 1 M HCl solution was investigated via electrochemical and with theoretical study.

Correction: Thiophene derivatives as corrosion inhibitors for 2024-T3 aluminum alloy in hydrochloric acid medium

Correction for ‘Thiophene derivatives as corrosion inhibitors for 2024-T3 aluminum alloy in hydrochloric acid medium’ by N. Arrousse et al., RSC Adv., 2022, 12, 10321–10335, https://doi.org/10.1039/D2RA00185C.

B Cell Subset Analysis and Gene Expression Characterization in Mid-Luteal Endometrium

The human endometrium is the innermost mucosal membrane of the uterus and is the first point of contact for an implanting blastocyst. A wide variety of immune cells are found amongst the endometrial epithelial layers and stromal cells which both provide host immune responses against pathogens and also assist with placentation and pregnancy establishment, however, B cells have not been characterized, despite being a vital player in both adaptive and mucosal immunity. Through analysis of mid-luteal endometrial biopsies, we find 1–5% of endometrial immune cells are B cells, the majority were naïve or memory B cells, with few plasma cells. Compared with circulating B cells, endometrial B cells had an activated phenotype, with increased expression of CD69, HLA-DR, CD74, and CD83, and IL-10 production capacities. PD1⁺CXCR5⁺ICOS⁺ T follicular helper-like cells and FAS⁺IgD^–BCL6⁺ germinal center B cells were also present in the endometrium, which may indicate that endometrial B cells are playing an active role through germinal center reactions in the human endometrial environment.

P–635 Standard versus mild ovarian stimulation in women with polycystic ovaries (PCO): Impact on outcomes in subsequent frozen embryo treatment cycles (FET)

Study question

Does mild ovarian stimulation in women with PCO result in higher live birth rates during subsequent FET cycles?

Summary answer

Mild ovarian stimulation with FSH doses &lt;150IU did not result in higher clinical pregnancy or livebirth rates in subsequent FET.

What is known already

Ovarian stimulation during IVF in women with PCO is associated with an exaggerated response, ovarian hyperstimulation syndrome, poor egg to follicle ratio, low fertilisation rates and poor blastocyst conversion. Mild ovarian stimulation, often referred to as protocols with FSH doses under 150IU, is often employed to overcome these challenges. One of the perceived benefits of this approach is improved oocyte and embryo quality reflected in lower aneuploidy rates.

Study design, size, duration

This was a retrospective observational study looking at 99 FET between January 2011 and Jan 2021 that followed a fresh cycle in women with a pre-treatment antral follicle count of 12 + 12 or greater. Patients were identified through the antral follicle count at the pre-treatment investigation ultrasound scan. Ultrasound findings, treatment cycle details and clinical outcomes were entered prospectively into a dedicated clinic database. Data was retrieved and analysed using SPSS V25.

Participants/materials, setting, methods

The study was conducted in a large IVF centre. Data on women with an AFC of 12 + 12 or above, undergoing an autologous FET cycle following a fresh cycle were collected. Women were split into those receiving &lt;150IU of FSH (Group1, n = 51) and those receiving FSH ³150 IU (Group 2, n = 48). Binary logistic regression analysis was performed to control for confounders. Live birth was the primary outcome, with biochemical and clinical pregnancy being secondary outcomes.

Main results and the role of chance

Women in Group 1 were younger (30.8±3.6 v 33.8±3.65, p &lt; 0.005) but had a similar antral follicle count (38.2±11.7 v 34.2±9.1, p = 0.07). The total number of eggs collected (24.1±13.8 v 25.9±8.8, p = 0.45) and fertilisation rate (0.59±0.2 v 0.58±0.18, p = 0.77) during their fresh cycle were comparable. Women in Group 2 had a larger number of embryos suitable for cryopreservation (7.36±4.2 v 4.8±3.5, p = 0.001)

In the subsequent frozen embryo replacement cycle, there was no difference in the number or quality of embryos transferred with most women having a single embryo transfer (63% v 48%, p = 0.14) and at least one top quality embryo transferred (68.6% v 81%, p = 0.15). There was a higher biochemical pregnancy rate in Group 1 (84% v 66%, p = 0.035) but with no difference in clinical pregnancy rate (53% v 44%, p = 0.37) or live birth rate (49% v 42%, p = 0.76). Live birth rates remained comparable even after controlling for age, and number and quality of embryos transferred (OR: 1.21 (95% CI 0.50–2.94).

Limitations, reasons for caution

This was a retrospective analysis raising the risk of allocation bias. This study was also at risk of information bias as it relied on accurate documentation of the AFC at the pre-treatment scan.

Wider implications of the findings: Patients can be reassured that both stimulation protocols result in similar live birth rates in subsequent frozen embryo replacement cycles.

Prospective trials using PGT-A are required to assess whether aneuploidy could account for the discrepancy in biochemical pregnancy rates in the two groups considering the subsequent comparable clinical pregnancy rates.

Trial registration number

Not applicable

Kisspeptin receptor agonist has therapeutic potential for female reproductive disorders

BACKGROUNDKisspeptin is a key regulator of hypothalamic gonadotropin-releasing hormone (GnRH) neurons and is essential for reproductive health. A specific kisspeptin receptor (KISS1R) agonist could significantly expand the potential clinical utility of therapeutics targeting the kisspeptin pathway. Herein, we investigate the effects of a KISS1R agonist, MVT-602, in healthy women and in women with reproductive disorders.METHODSWe conducted in vivo and in vitro studies to characterize the action of MVT-602 in comparison with native kisspeptin-54 (KP54). We determined the pharmacokinetic and pharmacodynamic properties of MVT-602 (doses 0.01 and 0.03 nmol/kg) versus KP54 (9.6 nmol/kg) in the follicular phase of healthy women (n = 9), and in women with polycystic ovary syndrome (PCOS; n = 6) or hypothalamic amenorrhea (HA; n = 6). Further, we investigated their effects on KISS1R-mediated inositol monophosphate (IP1) and Ca2+ signaling in cell lines and on action potential firing of GnRH neurons in brain slices.RESULTSIn healthy women, the amplitude of luteinizing hormone (LH) rise was similar to that after KP54, but peaked later (21.4 vs. 4.7 hours; P = 0.0002), with correspondingly increased AUC of LH exposure (169.0 vs. 38.5 IU∙h/L; P = 0.0058). LH increases following MVT-602 were similar in PCOS and healthy women, but advanced in HA (P = 0.004). In keeping with the clinical data, MVT-602 induced more potent signaling of KISS1R-mediated IP1 accumulation and a longer duration of GnRH neuron firing than KP54 (115 vs. 55 minutes; P = 0.0012).CONCLUSIONTaken together, these clinical and mechanistic data identify MVT-602 as having considerable therapeutic potential for the treatment of female reproductive disorders.TRIAL REGISTRATIONInternational Standard Randomised Controlled Trial Number (ISRCTN) Registry, ISRCTN21681316.FUNDINGNational Institute for Health Research and NIH.

Novel triazole derivatives as ecological corrosion inhibitors for mild steel in 1.0 M HCl: experimental & theoretical approach

The present paper illustrates the investigation of two novel ecological triazole derivative corrosion inhibitors, namely ethyl 2-(4-phenyl-1H-1,2,3-triazol-1-yl) acetate [Tria-CO₂Et], and 2-(4-phenyl-1H-1,2,3-triazol-1-yl) acetohydrazide [Tria-CONHNH₂].

Endocrine Requirements for Oocyte Maturation Following hCG, GnRH Agonist, and Kisspeptin During IVF Treatment

OBJECTIVE

The maturation of oocytes to acquire competence for fertilization is critical to the success of in vitro fertilization (IVF) treatment. It requires LH-like exposure, provided by either human chorionic gonadotropin (hCG), or gonadotropin releasing hormone agonist (GnRHa). More recently, the hypothalamic stimulator, kisspeptin, was used to mature oocytes. Herein, we examine the relationship between the endocrine changes following these agents and oocyte maturation.

DESIGN

Retrospective cohort study.

METHODS

Prospectively collected hormonal data from 499 research IVF cycles triggered with either hCG, GnRHa, or kisspeptin were evaluated.

RESULTS

HCG-levels (121 iU/L) peaked at 24 h following hCG, whereas LH-levels peaked at ~4 h following GnRHa (140 iU/L), or kisspeptin (41 iU/L). HCG-levels were negatively associated with body-weight, whereas LH rises following GnRHa and kisspeptin were positively predicted by pre-trigger LH values. The odds of achieving the median mature oocyte yield for each trigger were increased by hCG/LH level. Progesterone rise during oocyte maturation occurred precipitously following each trigger and strongly predicted the number of mature oocytes retrieved. Progesterone rise was positively associated with the hCG-level following hCG trigger, but negatively with LH rise following all three triggers. The rise in progesterone per mature oocyte at 12 h was greater following GnRHa than following hCG or kisspeptin triggers.

CONCLUSION

The endocrine response during oocyte maturation significantly differed by each trigger. Counter-intuitively, progesterone rise during oocyte maturation was negatively associated with LH rise, even when accounting for the number of mature oocytes retrieved. These data expand our understanding of the endocrine changes during oocyte maturation and inform the design of future precision-triggering protocols.

The impact of cross-border IVF on maternal and neonatal outcomes in multiple pregnancies: Experience from a UK fetal medicine service

OBJECTIVES

To determine whether women seeking NHS care for IVF multiple pregnancies were more likely to have sought IVF treatment overseas and whether this was associated with different maternal and neonatal outcomes.

STUDY DESIGN

A single large tertiary centre, for perinatal care in northwest London. Sixty-five women were referred to our fetal medicine centre, between 2012-2016, with IVF conceived multiple pregnancies.

INCLUSION CRITERIA

In Vitro fertilisation and conception of twins/ triplets/quadruplets.

EXCLUSION CRITERIA

Intra-uterine insemination, ovulation induction, Clomid-conception and singleton pregnancies. The primary outcome measure was the Country where IVF treatment was performed. The secondary outcomes measures included the specifics of IVF treatment (e.g. number of embryos transferred), subsequent pregnancy outcomes (e.g. live-births and prematurity) and neonatal outcomes (e.g. length and cost of care).

RESULTS AND CONCLUSION

Thirty-eight women had IVF overseas; they were older and had more pre-existing medical conditions. Eleven pregnancies used donor embryos, of which ten were from overseas treatment. 75% of women treated overseas conceived a triplet or higher order pregnancy compared to fewer than 10% of women who conceived in the UK. Almost half of all women treated overseas had more than two embryos transferred. Overseas IVF pregnancies had poorer obstetric and neonatal outcomes: 24% of live born babies died in the neonatal period compared to 0% in the UK group. The average neonatal costs per baby born from overseas IVF were £20, 600: two-and-a-half times higher than for those whose mothers conceived in the UK. Higher order multiple pregnancies are greatly over-represented by those undergoing IVF in overseas clinics. These are associated with poorer obstetric and neonatal outcomes. Perhaps paradoxically, improving NHS provision of fertility services might improve outcomes for the mother and babies while reducing the long-term burden to both fertility patients and the NHS.

SAT-211 Gonadotrophin Rise Following Kisspeptin Analogue (MVT-602) Is Increased In Women With Hypothalamic Amenorrhoea Compared To Healthy Women

Background Hypothalamic amenorrhoea (HA) is a condition characterised by reduced GnRH pulsatility as a result of low body weight, excessive exercise, or psychological stress. HA leads to anovulatory infertility and osteoporosis. Kisspeptin is a neuropeptide that is known to be a key regulator of hypothalamic GnRH function. Hypothalamic kisspeptin expression is reduced, and kisspeptin receptor expression increased, in a rodent model of HA. We have previously demonstrated that a continuous infusion of the native form of kisspeptin (kisspeptin-54; KP54) can restore GnRH pulsatility in women with HA, but excessive doses cause tachyphylaxis. Kisspeptin analogue (MVT-602) is a modified form of kisspeptin with a longer half-life compared to native kisspeptin-54 (1.5-2.2h vs 0.5h). Importantly, the more prolonged gonadotrophin profile induced by MVT-602 could enable restoration of physiological hormonal secretion with less frequent administration than by KP54, and thus mitigate against the risk of tachyphylaxis. We therefore investigated the hormonal response to MVT-602 in women with HA to evaluate its potential future utility in the treatment of anovulatory infertility. Methods A previous dose-finding study during the follicular phase of healthy women determined that no further increase in gonadotrophin rise was observed at doses of MVT-602 higher than 0.03nmol/kg. We therefore compared the gonadotrophin rise following a subcutaneous bolus of MVT-602 at a dose of 0.03nmol/kg in 6 women with HA compared to 9 healthy women studied during the follicular phase of their menstrual cycle (day 1-4). Serum gonadotrophin and oestradiol levels were monitored every 30mins for 24hrs. Groups were compared by unpaired t test. Results The maximal rise in LH following MVT-602, was over two-fold greater in women with HA compared to healthy women in the follicular phase (mean±SD of maximal change in LH: HA 18.3±11.0iU/L, follicular phase 7.4±2.7iU/L; P=0.01). The time to peak LH was expedited in women with HA (time to first peak: HA 380±53mins, follicular phase 1067±415mins; P=0.002). Serum FSH rise was also augmented by over four-fold in women with HA (mean±SD of maximal change in FSH: HA 10.0±4.4iU/L, follicular phase 2.2±1.6iU/L; P=0.0003). Maximal rise in oestradiol was higher in women with HA (700pmol/L) when compared with healthy women (297pmol/L; P=0.03). Conclusion In women with HA, the rise in gonadotrophins following MVT-602 is more pronounced and occurs sooner than in healthy women during the follicular phase. The augmented and sustained rise in oestradiol highlights the potential for MVT-602 to be used as an ovulation induction agent in women with anovulatory HA. Therefore, further research is indicated to evaluate repeated administration of MVT-602 as a novel therapeutic approach to restore fertility in HA.

Anti-Müllerian hormone (AMH) in the Diagnosis of Menstrual Disturbance Due to Polycystic Ovarian Syndrome

Introduction: Polycystic ovarian syndrome (PCOS) is a leading cause of female subfertility worldwide, however due to the heterogeneity of the disorder, the criteria for diagnosis remains subject to conjecture. In the present study, we evaluate the utility of serum Anti-Müllerian hormone (AMH) in the diagnosis of menstrual disturbance due to PCOS. Method: Menstrual cycle length, serum AMH, gonadotropin and sex-hormone levels, total antral follicle count (AFC), body mass index (BMI) and ovarian morphology on ultrasound were analyzed in a cohort of 187 non-obese women, aged 18-35 years, screened for participation in a clinical trial of fertility treatment between 2013 and 2016 at a tertiary reproductive endocrine center. Results: Serum AMH was higher in women with menstrual disturbance when compared to those with regular cycles (65.6 vs. 34.8 pmol/L; P < 0.0001). The odds of menstrual disturbance was increased 28.5-fold (95% CI 3.6-227.3) in women with serum AMH >60 pmol/L, in comparison to those with an AMH < 15 pmol/L. AMH better discriminated women with menstrual disturbance (area under ROC 0.77) from those with regular menstrual cycles than AFC (area under ROC 0.67), however the combination of the two markers increased discrimination than either measure alone (0.83; 95% CI 0.77-0.89). Serum AMH was higher in women with all three cardinal features of PCOS (menstrual disturbance, hyperandrogenism, polycystic ovarian morphology) when compared to women with none of these features (65.6 vs. 14.6 pmol/L; P < 0.0001). The odds of menstrual disturbance were increased by 10.7-fold (95% CI 2.4-47.1) in women with bilateral polycystic morphology ovaries than those with normal ovarian morphology. BMI was a stronger predictor of free androgen index (FAI) than either AMH or AFC. Conclusion: Serum AMH could serve as a useful biomarker to indicate the risk of menstrual disturbance due to PCOS. Women with higher AMH levels had increased rates of menstrual disturbance and an increased number of features of PCOS.

FSH Requirements for Follicle Growth During Controlled Ovarian Stimulation

Introduction: Ovarian follicle growth is a key step in the success of assisted reproductive treatment, but limited data exists to directly relate follicle growth to recombinant FSH (rFSH) dose. In this study, we aim to evaluate FSH requirements for follicular growth during controlled ovarian stimulation. Method: Single center retrospective cohort study of 1,034 IVF cycles conducted between January 2012-January 2016 at Hammersmith Hospital IVF unit, London, UK. Median follicle size after 5 days of stimulation with rFSH and the proportion of antral follicles recruited were analyzed in women treated with rFSH alone to induce follicular growth during IVF treatment. Results: Starting rFSH dose adjusted for body weight (iU/kg) predicted serum FSH level after 5 days of rFSH (r ² = 0.352, p < 0.0001), median follicle size after 5 days of rFSH, and the proportion of antral follicles recruited by the end of stimulation. Day 5 median follicle size predicted median follicle size on subsequent ultrasound scans (r ² = 0.58-0.62; p < 0.0001), and hence time to oocyte maturation trigger (r ² = 0.22, P < 0.0001). Insufficient rFSH starting dose that required >5% dose-increase was associated with increased variability in follicle size on the day of oocyte maturation trigger, and negatively impacted the number of mature oocytes retrieved. Conclusion: Weight-adjusted rFSH dose correlates with follicular growth during ovarian stimulation. Early recruitment of follicles using a sufficient dose of rFSH from the start of stimulation was associated with reduced variability in follicle size at time of oocyte maturation trigger and an increased number of mature oocytes retrieved.

Sudden sensorineural hearing loss: A missed opportunity for treatment

Sudden sensorineural hearing loss (SSNHL) is an otology emergency and carries significant morbidity if the diagnosis is missed. It can present to any specialty but in our local setting the patient usually presents to primary care as it is easily accessible. We present a case of SSNHL that was initially presented to a primary care centre and the patient was reassured without any investigation being carried out. SSNHL has many causes thus making diagnosis difficult. However, with knowledge of its possible, a diagnosis can be made and appropriate management can be advocated to the patient. Hence, we discuss the three main causes of SSNHL, while emphasizing the immune system-mediated mechanism as the main cause in this case.

Metallic hair pin aspiration into the left tertiary bronchus

Foreign body aspiration is commonly described in infants and children. However, recently, a new high-risk group was identified among young women, especially those from the Muslim population who wear the traditional hair scarf. This is due to the habit of holding the scarf pin in between the lips to free hands to adjust the scarf more easily. Talking, laughing, or coughing while fixing the scarf may result in inadvertent inhalation of the pin into the tracheobronchial tree. We present a case of scarf pin inhalation and the challenges encountered in managing this patient during the successful removal of the pin via flexible bronchoscopy under fluoroscopy guidance. This particular case was technically challenging for us as the sharp tip of the needle was pointing upward and piercing the bronchial mucosa.

Clinical parameters of ovarian hyperstimulation syndrome following different hormonal triggers of oocyte maturation in IVF treatment

OBJECTIVE

Ovarian hyperstimulation syndrome (OHSS) is a serious iatrogenic condition, predominantly related to the hormone used to induce oocyte maturation during IVF treatment. Kisspeptin is a hypothalamic neuropeptide that has recently been demonstrated to safely trigger final oocyte maturation during IVF treatment even in women at high risk of OHSS. However, to date, the safety of kisspeptin has not been compared to current hormonal triggers of oocyte maturation.

DESIGN

We conducted a retrospective single-centre cohort study investigating symptoms and clinical parameters of early OHSS in women at high risk of OHSS (antral follicle count or total number of follicles on day of trigger ≥23) triggered with human chorionic gonadotrophin (hCG) (n = 40), GnRH agonist (GnRHa; n = 99) or kisspeptin (n = 122) at Hammersmith Hospital IVF unit, London, UK (2013-2016).

RESULTS

Clinical Parameters of OHSS: Median ovarian volume was larger following hCG (138 ml) than GnRHa (73 ml; P < .0001), and in turn kisspeptin (44 ml; P < .0001). Median ovarian volume remained enlarged 20-fold following hCG, 8-fold following GnRHa and 5-fold following kisspeptin compared to prestimulation ovarian volumes. Mean (±SD) ascitic volumes were lesser following GnRHa (9 ± 44 ml) and kisspeptin (5 ± 8 ml) than hCG (62 ± 84 ml; P < .0001). Symptoms of OHSS were most frequent following hCG and least frequent following kisspeptin. Diagnosis of OHSS: The odds ratio for OHSS diagnosis was 33.6 (CI 12.6-89.5) following hCG and 3.6 (CI 1.8-7.1) following GnRHa, when compared to kisspeptin.

CONCLUSION

Triggering oocyte maturation by inducing endogenous gonadotrophin release is preferable to the use of exogenous hCG in women at high risk of OHSS.

A food bolus obstructing the oesophagus in a patient with infantile cerebral palsy

INTRODUCTION

A foreign body (FB) in the upper aerodigestive tract is a fairly common encounter. Fish bones are the commonest FB seen in adults. The commonest presentation is odynophagia. Usually, the patient will point at the level of FB on the neck to indicate the location.

METHODS

Clinical report.

RESULTS

This case report describes a large FB in an adult with underlying infantile cerebral palsy. Besides dysphagia, it was associated with drooling of saliva and pain in the throat region.

CONCLUSION

FB ingestion with complete obstruction of the oesophagus is an emergency. It may cause total dysphagia as the passage of food is completely blocked.

Follicle Size on Day of Trigger Most Likely to Yield a Mature Oocyte

OBJECTIVE

To identify follicle sizes on the day of trigger most likely to yield a mature oocyte following hCG, GnRH agonist (GnRHa), or kisspeptin during IVF treatment.

DESIGN

Retrospective analysis to determine the size of follicles on day of trigger contributing most to the number of mature oocytes retrieved using generalized linear regression and random forest models applied to data from IVF cycles (2014-2017) in which either hCG, GnRHa, or kisspeptin trigger was used.

SETTING

HCG and GnRHa data were collected at My Duc Hospital, Ho Chi Minh City, Vietnam, and kisspeptin data were collected at Hammersmith Hospital, London, UK.

PATIENTS

Four hundred and forty nine women aged 18-38 years with antral follicle counts 4-87 were triggered with hCG (n = 161), GnRHa (n = 165), or kisspeptin (n = 173).

MAIN OUTCOME MEASURE

Follicle sizes on the day of trigger most likely to yield a mature oocyte.

RESULTS

Follicles 12-19 mm on the day of trigger contributed the most to the number of oocytes and mature oocytes retrieved. Comparing the tertile of patients with the highest proportion of follicles on the day of trigger 12-19 mm, with the tertile of patients with the lowest proportion within this size range, revealed increases of 4.7 mature oocytes for hCG (P < 0.0001) and 4.9 mature oocytes for GnRHa triggering (P < 0.01). Using simulated follicle size profiles of patients with 20 follicles on the day of trigger, our model predicts that the number of oocytes retrieved would increase from a mean 9.8 (95% prediction limit 9.3-10.3) to 14.8 (95% prediction limit 13.3-16.3) oocytes due to the difference in follicle size profile alone.

CONCLUSION

Follicles 12-19 mm on the morning of trigger administration were most likely to yield a mature oocyte following hCG, GnRHa, or kisspeptin.

A second dose of kisspeptin-54 improves oocyte maturation in women at high risk of ovarian hyperstimulation syndrome: a Phase 2 randomized controlled trial

STUDY QUESTION

Can increasing the duration of LH-exposure with a second dose of kisspeptin-54 improve oocyte maturation in women at high risk of ovarian hyperstimulation syndrome (OHSS)?

SUMMARY ANSWER

A second dose of kisspeptin-54 at 10 h following the first improves oocyte yield in women at high risk of OHSS.

WHAT IS KNOWN ALREADY

Kisspeptin acts at the hypothalamus to stimulate the release of an endogenous pool of GnRH from the hypothalamus. We have previously reported that a single dose of kisspeptin-54 results in an LH-surge of ~12-14 h duration, which safely triggers oocyte maturation in women at high risk of OHSS.

STUDY DESIGN, SIZE, DURATION

Phase-2 randomized placebo-controlled trial of 62 women at high risk of OHSS recruited between August 2015 and May 2016. Following controlled ovarian stimulation, all patients (n = 62) received a subcutaneous injection of kisspeptin-54 (9.6 nmol/kg) 36 h prior to oocyte retrieval. Patients were randomized 1:1 to receive either a second dose of kisspeptin-54 (D; Double, n = 31), or saline (S; Single, n = 31) 10 h thereafter. Patients, embryologists, and IVF clinicians remained blinded to the dosing allocation.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Study participants: Sixty-two women aged 18-34 years at high risk of OHSS (antral follicle count ≥23 or anti-Mullerian hormone level ≥40 pmol/L). Setting: Single centre study carried out at Hammersmith Hospital IVF unit, London, UK. Primary outcome: Proportion of patients achieving an oocyte yield (percentage of mature oocytes retrieved from follicles ≥14 mm on morning of first kisspeptin-54 trigger administration) of at least 60%. Secondary outcomes: Reproductive hormone levels, implantation rate and OHSS occurrence.

MAIN RESULTS AND THE ROLE OF CHANCE

A second dose of kisspeptin-54 at 10 h following the first induced further LH-secretion at 4 h after administration. A higher proportion of patients achieved an oocyte yield ≥60% following a second dose of kisspeptin-54 (Single: 14/31, 45%, Double: 21/31, 71%; absolute difference +26%, CI 2-50%, P = 0.042). Patients receiving two doses of kisspeptin-54 had a variable LH-response following the second kisspeptin dose, which appeared to be dependent on the LH-response following the first kisspeptin injection. Patients who had a lower LH-rise following the first dose of kisspeptin had a more substantial 'rescue' LH-response following the second dose of kisspeptin. The variable LH-response following the second dose of kisspeptin resulted in a greater proportion of patients achieving an oocyte yield ≥60%, but without also increasing the frequency of ovarian over-response and moderate OHSS (Single: 1/31, 3.2%, Double: 0/31, 0%).

LIMITATIONS, REASONS FOR CAUTION

Further studies are warranted to directly compare kisspeptin-54 to more established triggers of oocyte maturation.

WIDER IMPLICATIONS OF THE FINDINGS

Triggering final oocyte maturation with kisspeptin is a novel therapeutic option to enable the use of fresh embryo transfer even in the woman at high risk of OHSS.

STUDY FUNDING/COMPETING INTEREST(S)

The study was designed, conducted, analysed and reported entirely by the authors. The Medical Research Council (MRC), Wellcome Trust & National Institute of Health Research (NIHR) provided research funding to carry out the studies. There are no competing interests to declare.

TRIAL REGISTRATION NUMBER

Clinicaltrial.gov identifier NCT01667406.

TRIAL REGISTRATION DATE

8 August 2012.

DATE OF FIRST PATIENT'S ENROLMENT

10 August 2015.

The risk reduction of recurrent periodontal pathogens of local application minocycline HCl 2% gel, used as an adjunct to scaling and root planing for chronic periodontitis treatment

Background

The aim of this study was to evaluate the clinical and microbiological effects of local application minocycline HCl 2% gel, used as an adjunct to scaling and root planing (SRP) for treatment of chronic periodontitis (CP). CP is an inflammation of periodontal tissue that is caused mainly by bacterial infection, where periodontal destruction such as loss of attachment and bone destruction occurred.

Methods

A total of 81 subjects with moderate to severe periodontitis whose baseline clinical attachment loss (CAL) was ≥4 mm were randomly assigned to receive SRP alone (control group, N=39) or SRP followed by four times of local application of minocycline HCl gel (Periocline) once a week (test group, N=42). Pocket depth, CAL, and papilla bleeding index were examined at baseline, 21 days, 2, 3, and 6 months. Subgingival plaque samples were collected with sterile curettes and were analyzed by real-time polymerase chain reaction for the presence of three periodontal pathogens (Porphyromonas gingivalis [P.g.], Tannerella forsythia [T.f.], and Treponema denticola [T.d.]) at baseline, 2, 3, and 6 months.

Results

The number of bacteria was reduced in both groups at 2 months after baseline (SRP treatment). The changes (2–6 months) in T.d. and T.f. counts in the test group were significantly lower than those in the control group. In the control group, a significant regrowth of P.g., T.f., and T.d. was observed from 2 to 6 months and of P.g. and T.f. from 3 to 6 months. On the other hand, in the test group, the number of the three bacteria did not significantly increase during the 6-month period.

Conclusion

The results showed that local application of minocycline, used as an adjunct to SRP, was effective for suppressing regrowth of periodontal pathogens, suggesting its risk reduction of recurrent periodontal pathogens in CP.

Fixed time interval compared with on-demand oral analgesia protocols for post-caesarean pain: a randomised controlled trial

OBJECTIVES

To compare the efficacy, safety and satisfaction from two modes of oral analgesia administration for the treatment of post-caesarean pain in the first 48 h following surgery: on-demand versus fixed time interval administration.

DESIGN

Open label parallel-group, randomised-controlled trial from February to December 2013.

SETTING

University-affiliated hospital in Israel.

POPULATION

Two-hundred women who underwent caesarean delivery with regional anaesthesia.

METHODS

Patients were randomly assigned to receive predetermined combinations of tramadol, paracetamol and diclofenac either following patient demand or at predetermined 6-h intervals for the first 48 h. If the patient requested additional analgesia, Percocet (oxycodone and paracetamol) was given as a rescue treatment.

MAIN OUTCOME MEASURES

Pain intensity and satisfaction were self-evaluated with visual analogue scale of 0 (no pain/least satisfaction) to 10 (worst pain/highest satisfaction). Breastfeeding, need for supplemental formula, and maternal and neonatal adverse effects were also evaluated.

RESULTS

The 'fixed time interval' group, compared with the 'on-demand' group, had lower mean pain score (2.8 ± 0.84 versus 4.1 ± 0.48, respectively; P < 0.0001), higher satisfaction rate (9.1 ± 1.2 versus 8.3 ± 1.5, respectively; P < 0.0001), more breastfeeds (23.7 ± 6.5 versus 19.2 ± 6.2, respectively; P < 0.0001) and less use of supplemental formulas (8.2 ± 5.2 versus 11.9 ± 6.5, respectively; P < 0.0001). The number of times that drugs were given was slightly higher in the 'fixed time interval' group without an increase in maternal adverse effects, which were mild. No adverse effects were reported for the neonates.

CONCLUSION

Administration of oral analgesia in fixed time intervals is superior to drug administration following patient demand without increasing maternal or neonatal adverse outcomes.

TWEETABLE ABSTRACT

Oral analgesia in fixed time intervals is superior to analgesia following demand.

Fibroids that do not distort the uterine cavity and IVF success rates: an observational study using extensive matching criteria

OBJECTIVE

To assess the impact of non-cavity-distorting fibroids on in vitro fertilisation (IVF) pregnancy outcomes.

DESIGN

A retrospective, matched, single-centre, cohort study was performed.

SETTING

The IVF unit of a tertiary, university hospital.

POPULATION

We analysed all women with non-cavity-distorting uterine fibroids undergoing IVF/intracytoplasmic sperm injection (ICSI) cycles from 1 January 2011 to 1 May 2015.

METHODS

Each woman was matched with two separate controls of the same age (±6 months), stimulation protocol (gonadotropin-releasing hormone agonist or antagonist), starting dose of follicle-stimulating hormone (FSH), number of embryos transferred (one or two), day of transfer (day 3 or day 5), and no uterine fibroids identified by transvaginal ultrasound.

MAIN OUTCOME MEASURES

Clinical pregnancy and live birth rates.

RESULTS

Our study demonstrates that the presence of non-cavity-distorting fibroids appears to negatively affect clinical pregnancy (odds ratio, OR 0.62; 95% confidence interval, 95% CI 0.41-0.94) and live birth rates (OR 0.58; 95% CI 0.48-0.78) in patients undergoing their first IVF/ICSI cycle, when matched with controls of the same age, starting dose of FSH, stimulation protocol, number of embryos, and day of embryo transfer. The deleterious effect of fibroids on live birth rates was significant in women with two or more fibroids (OR 0.47; 95% CI 0.26-0.83) and in women with fibroids of ≥30 mm in diameter (OR 0.41; 95% CI 0.19-0.89). The negative impact of non-cavity-distorting fibroids was also present in women with an embryo transfer on day 5 (OR 0.58; 95% CI 0.35-0.94). Conversely, in women with single fibroids of <30 mm in diameter, no difference in pregnancy outcomes was identified.

CONCLUSIONS

A well-designed, adequately powered, randomised controlled trial is required to address the role of medical or surgical interventions in patients with intramural and subserosal fibroids before undergoing fertility treatment.

TWEETABLE ABSTRACT

Non-cavity-distorting fibroids negatively affect pregnancy rates after IVF.

Cervical ripening with the balloon catheter and the risk of subsequent preterm birth

OBJECTIVE

To examine the risk of subsequent preterm birth after cervical ripening using a balloon catheter.

STUDY DESIGN

A retrospective study was held at a university teaching hospital between January 2007 and June 2013. The study group included women who underwent cervical ripening using a balloon (single or double) catheter in the previous pregnancy followed by a subsequent singleton delivery (balloon catheter group). Two control groups were included. The first was similar to the study group except that ripening was achieved in the previous pregnancy with vaginal prostaglandin E2 (PGE2 group). The second control group had a previous pregnancy that resulted in spontaneous onset of labor at term (unexposed group). The primary outcome was the incidence of spontaneous preterm birth (before 37 weeks) in the index pregnancy.

RESULT

Overall, 558 women were included; each group consisted of 186 women. The incidence of spontaneous preterm birth in the index pregnancy did not differ between the groups (0.5, 1.6 and 2.7% in the balloon catheter, PGE2 and in the unexposed groups, respectively, P=0.31). Among the balloon catheter group, 58 (31.2%) women had the ripening performed with a single-balloon catheter and 128 (68.8%) women with a double-balloon catheter. The rate of the spontaneous preterm birth in the index pregnancy did not differ between the two groups (P=1.0).

CONCLUSION

Cervical ripening with a balloon catheter does not increase the rate of subsequent spontaneous preterm birth.

Efficacy of Kisspeptin-54 to Trigger Oocyte Maturation in Women at High Risk of Ovarian Hyperstimulation Syndrome (OHSS) During In Vitro Fertilization (IVF) Therapy

CONTEXT

In vitro fertilization (IVF) treatment is an effective therapy for infertility, but can result in the potentially life-threatening complication, ovarian hyperstimulation syndrome (OHSS).

OBJECTIVE

This study aimed to investigate whether kisspeptin-54 can be used to effectively and safely trigger oocyte maturation in women undergoing IVF treatment at high risk of developing OHSS.

SETTING AND DESIGN

This was a phase 2, multi-dose, open-label, randomized clinical trial of 60 women at high risk of developing OHSS carried out during 2013-2014 at Hammersmith Hospital IVF unit, London, United Kingdom.

INTERVENTION

Following a standard recombinant FSH/GnRH antagonist protocol, patients were randomly assigned to receive a single injection of kisspeptin-54 to trigger oocyte maturation using an adaptive design for dose allocation (3.2 nmol/kg, n = 5; 6.4 nmol/kg, n = 20; 9.6 nmol/kg, n = 15; 12.8 nmol/kg, n = 20). Oocytes were retrieved 36 h after kisspeptin-54 administration, assessed for maturation, and fertilized by intracytoplasmic sperm injection with subsequent transfer of one or two embryos. Women were routinely screened for the development of OHSS.

MAIN OUTCOME MEASURE

Oocyte maturation was measured by oocyte yield (percentage of mature oocytes retrieved from follicles ≥ 14 mm on ultrasound). Secondary outcomes include rates of OHSS and pregnancy.

RESULTS

Oocyte maturation occurred in 95% of women. Highest oocyte yield (121%) was observed following 12.8 nmol/kg kisspeptin-54, which was +69% (confidence interval, -16-153%) greater than following 3.2 nmol/kg. At all doses of kisspeptin-54, biochemical pregnancy, clinical pregnancy, and live birth rates per transfer (n = 51) were 63, 53, and 45%, respectively. Highest pregnancy rates were observed following 9.6 nmol/kg kisspeptin-54 (85, 77, and 62%, respectively). No woman developed moderate, severe, or critical OHSS.

CONCLUSION

Kisspeptin-54 is a promising approach to effectively and safely trigger oocyte maturation in women undergoing IVF treatment at high risk of developing OHSS.

Efficiency of removal of cadmium from aqueous solutions by plant leaves and the effects of interaction of combinations of leaves on their removal efficiency

Removal of cadmium from aqueous solutions using 20 species of plant leaves and combinations of these leaves have been studied. Several factors affecting the removal efficiency have been studied. The most efficient types of plant leaves for the removal of cadmium are those of styrax, plum, pomegranate and walnut. The interaction effect of the combined leaf samples on the efficiency of removal of cadmium has been found to be additive in combinations involving styrax plant leaves but seems to be antagonistic in all other combinations. The optimum experimental conditions for removal of cadmium have been found to be at pH 4.1, using high concentrations of naturally dried plant leaves, using ground leaves and to remove cadmium from agitated aqueous solutions. The percentage of metal removed at an initial cadmium concentration of 10mg/l by the most efficient types of leaves have been found to be 85% for styrax leaves, 85% for plum leaves, 80% for pomegranate leaves, 78% for walnut leaves and 77% for meddler leaves. The presence of foreign ions or complexing agents has been found to reduce the efficiency of removal of cadmium by plant leaves. About 80-85% of the cadmium in charged plant leaves has been released under the influence of changing the pH of the solution, addition of competing ions and the addition of EDTA. The results of removal of cadmium by plant leaves have been found to follow the Freundlich adsorption isotherm, first-order reaction with respect to cadmium and to have intra-pore diffusion as the rate-limiting step.