Effect of vitamin D in addition to letrozole on the ovulation rate of women with polycystic ovary syndrome: protocol of a multicentre randomised double-blind controlled trial

INTRODUCTION

Low vitamin D status is prevalent among women with polycystic ovary syndrome (PCOS). The objective of the study is to assess the effect of vitamin D supplementation on (1) the ovulation rate to letrozole and (2) other reproductive, endocrine and metabolic outcomes after 1 year of supplementation in women with PCOS.

METHODS AND ANALYSIS

This is a multicentre, randomised, double-blind, controlled clinical trial. A total of 220 anovulatory women with PCOS diagnosed by the Rotterdam criteria will be recruited. They will be randomly assigned to either the (1) vitamin D supplementation group or (2) placebo group. Those in the vitamin D group will take oral Vitamin D3 50 000 IU/week for 4 weeks, followed by 50 000 IU once every 2 weeks for 52 weeks. Those who remain anovulatory after 6 months will be treated with a 6-month course of letrozole (2.5 mg to 7.5 mg for 5 days per cycle titrated according to response) for ovulation induction. The primary outcome is the ovulation rate. All statistical analyses will be performed using intention-to-treat and per protocol analyses.

ETHICS AND DISSEMINATION

Ethics approval was sought from the Institutional Review Board of the participating units. All participants will provide written informed consent before joining the study. The results of the study will be submitted to scientific conferences and peer-reviewed journals.

TRIAL REGISTRATION NUMBER

NCT04650880.

Optimizing non-invasive preimplantation genetic testing: investigating culture conditions, sample collection, and IVF treatment for improved non-invasive PGT-A results

PURPOSE

This study aimed to optimize the non-invasive preimplantation genetic testing for aneuploidy (niPGT-A) in the laboratory by comparing two collection timing of the spent culture medium (SCM), two embryo rinsing protocols, and the use of conventional insemination instead of intracytoplasmic sperm injection (ICSI).

METHODS

Results of two embryo rinsing methods (one-step vs sequential) and SCM collected on day 5 vs day 6 after retrieval were compared against trophectoderm (TE) biopsies as reference. Results from day 6 SCM in cycles fertilized by conventional insemination were compared with PGT-A using ICSI.

RESULTS

The rate of concordance was higher in day 6 samples than in day 5 samples when the sequential method was used, in terms of total concordance (TC; day 6 vs day 5: 85.0% vs 60.0%, p = 0.0228), total concordance with same sex (TCS, 82.5% vs 28,0%, p < 0.0001), and full concordance with same sex (FCS, 62.5% vs 24.0%, p = 0.0025). The sequential method significantly out-performed the one-step method when SCM were collected on day 6 (sequential vs one-step, TC: 85.0% vs 64.5%, p = 0.0449; TCS: 82.5% vs 54.8%, p = 0.0113; FCS: 62.5% vs 25.8%, p = 0.0021). There was no significant difference in niPGT-A results between cycles fertilized by the conventional insemination and ICSI.

CONCLUSION

We have shown a higher concordance rate when SCM was collected on day 6 and the embryos were rinsed in a sequential manner. Comparable results of niPGT-A when oocytes were fertilized by conventional insemination or ICSI. These optimization steps are important prior to commencement of a randomized trial in niPGT-A.

Randomised double-blind controlled trial of non-invasive preimplantation genetic testing for aneuploidy in in vitro fertilisation: a protocol paper

INTRODUCTION

The success rate of in vitro fertilisation (IVF) treatment for couples with infertility remains low due to lack of a reliable tool in selecting euploid embryos for transfer. This study aims to compare the efficacy in embryo selection based on morphology alone compared with non-invasive preimplantation genetic testing for aneuploidy (niPGT-A) and morphology in infertile women undergoing IVF.

METHODS AND ANALYSIS

This is a randomised double-blind controlled trial conducted in two tertiary assisted reproduction centres. A total of 500 infertile women will be recruited and undergo IVF as indicated. They will be randomly assigned on day 6 after oocyte retrieval into two groups: the intervention group using morphology and niPGT-A and the control group based on morphology alone. In the control group, blastocysts with the best quality morphology will be replaced first. In the intervention group, blastocysts with the best morphology and euploid result of spent culture medium will be replaced first. The primary outcome is a live birth per the first embryo transfer. The statistical analysis will be performed with the intention to treat and per protocol.

ETHICS AND DISSEMINATION

Ethics approval was sought from the institutional review board of the two participating units. All participants will provide written informed consent before joining the study. The results of the study will be submitted to scientific conferences and peer-reviewed journals.

TRIAL REGISTRATION NUMBER

NCT04474522.

Use of oral progestogen in women with threatened miscarriage in the first trimester: a randomized double-blind controlled trial

STUDY QUESTION

Will use of oral progestogen in women with threatened miscarriage in the first trimester reduce the miscarriage rate when compared with placebo?

SUMMARY ANSWER

Use of oral progestogen in women with threatened miscarriage in the first trimester did not reduce miscarriage before 20 weeks when compared with placebo.

WHAT IS KNOWN ALREADY

Miscarriage is a common complication of pregnancy and occurs in 15-20% of clinically recognized pregnancies. Use of vaginal progestogens is not effective in reducing miscarriage but there is still no good evidence to support use of oral progestogen for the treatment of threatened miscarriage.

STUDY DESIGN, SIZE, DURATION

This was a randomized double-blind controlled trial. A total of 406 women presenting with threatened miscarriage in the first trimester were recruited from 30 March 2016 to May 2018.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Women attending Early Pregnancy Assessment Clinics because of vaginal bleeding during the first trimester were recruited and randomly assigned to use dydrogesterone 40 mg orally, followed by 10 mg orally three times a day or placebo until 12 completed weeks of gestation or 1 week after the bleeding stopped, whichever was later. The primary outcome was the miscarriage rate before 20 weeks of gestation.

MAIN RESULTS AND THE ROLE OF CHANCE

The two groups of women had comparable age, BMI, number of previous miscarriages, gestation and ultrasound findings at presentation. The miscarriage rate before 20 weeks of gestation was similar in both groups, being 12.8% (26/203) in the progestogen group and 14.3% (29/203) in the placebo group (relative risk 0.897, 95% CI 0.548-1.467; P = 0.772). The live birth rate was 81.3% in the progestogen group versus 83.3% in the placebo group (P = 0.697). No significant differences were found between the two groups in terms of obstetric outcomes and side effects.

LIMITATIONS, REASONS FOR CAUTION

The primary outcome was the miscarriage rate, rather than the live birth rate. Women were recruited from Early Pregnancy Assessment Clinics and those with heavy vaginal bleeding might be admitted into wards directly instead of attending Early Pregnancy Assessment Clinic. The severity of vaginal bleeding was subjectively graded by women themselves. The sample size was not adequate to demonstrate a smaller difference in the miscarriage rate between the progestogen and placebo groups. We did not exclude women with multiple pregnancy, which increased the risk of miscarriage although there was only one set of twin pregnancy in the placebo group.

WIDER IMPLICATIONS OF THE FINDINGS

Use of oral progestogen is not recommended in women with threatened miscarriage in the first trimester.

STUDY FUNDING/COMPETING INTEREST(S)

This study was funded by the Health and Medical Research Fund, HKSAR (reference number 12132341). All authors declared no conflict of interest.

TRIAL REGISTRATION NUMBER

ClinicalTrials.gov with an identifier NCT02128685.

TRIAL REGISTRATION DATE

1 May 2014.

DATE OF FIRST PATIENT'S ENROLMENT

30 March 2016.

Hyaluronic acid-enriched transfer medium for frozen embryo transfer: a randomized, double-blind, controlled trial

OBJECTIVE

To compare the effects of hyaluronic acid (HA)-enriched transfer medium versus standard medium on live birth rate after frozen embryo transfer (FET).

DESIGN

Randomized, double-blind, controlled trial.

SETTING

Two tertiary fertility centers.

PATIENT(S)

Infertile women aged <43 years at the time of in vitro fertilization undergoing FET.

INTERVENTION(S)

The women were randomly assigned to 2 groups in a 1:1 ratio. The HA group used EmbryoGlue (Vitrolife, Gothenburg, Sweden) with an HA concentration of 0.5 mg/mL, while the control group used supplemented G-2 (Vitrolife) medium with an HA concentration of 0.125 mg/mL.

MAIN OUTCOME MEASURE(S)

Live birth rate.

RESULT(S)

Five hundred fifty women were recruited from April 2016 to April 2018 and included in the intention-to-treat analysis. Eight women in the HA group and 5 women in the control group did not undergo FET because the embryos did not survive on thawing. One woman in the HA group cancelled FET because of fever. One woman in the HA group withdrew and received conventional medium. The 2 groups were similar in demographic characteristics. The live birth rates in the HA group and the control group were comparable (25.5% vs. 25.8%; relative risk 0.99; 95% confidence interval 0.74-1.31). The other clinical outcomes were also similar between the 2 groups. Logistic regression showed that the type of transfer medium was not associated with live birth.

CONCLUSION(S)

The use of HA-enriched transfer medium does not improve the live birth rate of FET compared with standard medium.

TRIAL REGISTRATION NUMBER

NCT02725827 (ClinicalTrials.gov).

A questionnaire survey on patients' willingness to pay with reference to the waiting time of public in-vitro fertilization treatment in Hong Kong

OBJECTIVE

To evaluate patients' willingness to pay (WTP) with reference to the waiting time of public in-vitro fertilisation (IVF) treatment in order to improve the public IVF service in Hong Kong.

STUDY DESIGN

A prospective multi-centred questionnaire survey. Infertile women attending infertility clinics of nine public hospitals in Hong Kong between October 2017 and August 2018 were asked to complete a questionnaire in their first clinic visit.

RESULTS

Out of 1092 respondents, 10.4 % had private IVF cycles prior to their first visit at public hospitals. In general, patients were willing to pay more for a shorter waiting time for public IVF service. The proportion of respondents who were willing to pay more than HK$10,000 (US$1282) for one IVF cycle increased from 54.6% to 80.7% if the waiting time for public IVF service were hypothetically shortened from four years to one year. Likewise, 22.5 % versus 45.5 % were willing to pay more than HK$ 25,000 (US$3205) with a waiting time of four versus one year respectively. Assuming the cost per IVF cycle was HK$ 25,000 (US$3205), 23.4 % of respondents could afford one IVF cycle, 40.0 % of them could afford two IVF cycles and 31.5 % could afford three IVF cycles. A multivariate regression model demonstrated that only family income and presence of existing child(ren) were significant independent determinants of the maximum amount that an individual was willing to pay for IVF (p < 0.05). Those with family monthly income below HK$100,000 ($12,820) were less than half as likely, and those without existing child(ren) were more than double as likely, to be willing to pay higher for IVF.

CONCLUSION

Patients were willing to pay more for a shorter waiting time for public IVF service. Those with family income below HK$100,000 (US$ 12,820) were less than half as likely, and those without existing children were more than double as likely, to be willing to pay higher for IVF.

Cross-border reproductive care use by women with infertility in Hong Kong: cross-sectional survey

OBJECTIVES

Cross-border reproductive care (CBRC) is an increasingly common global phenomenon, but there is a lack of information regarding its frequency among residents of Hong Kong. This study aimed to evaluate the use of CBRC and the factors affecting its use among residents of Hong Kong.

METHODS

This cross-sectional questionnaire study collected data from 1204 women with infertility who attended Hong Kong Hospital Authority and Family Planning Association infertility clinics.

RESULTS

In total, 178 women (14.8% of all respondents) had used CBRC. Among respondents who had not used CBRC, 36.3% planned to use or would consider it. The main factors influencing the likelihood of using CBRC among women with infertility in Hong Kong use were long waiting times in the public sector and high cost in the private sector. Taiwan was the most preferred destination for CBRC (69.6% of respondents). Most information concerning CBRC was accessed via the internet. More than two thirds of respondents believed that the government in Hong Kong should formulate some regulations or guidance regarding CBRC.

CONCLUSION

Nearly one in six women with infertility in Hong Kong had used CBRC. Among women who had not used CBRC, more than one third planned to use or would consider it. The main factors influencing the likelihood of CBRC use were long waiting times in the public sector and high cost in the private sector. These results will help clinicians to more effectively counsel patients considering CBRC and facilitate infertility services planning by authorities in Hong Kong.

A randomized double-blinded non-inferiority trial comparing fentanyl and midazolam with pethidine and diazepam for pain relief during oocyte retrieval

RESEARCH QUESTION

Is fentanyl and midazolam non-inferior to pethidine and diazepam in pain relief during oocyte retrieval under conscious sedation?

DESIGN

A randomized double-blinded non-inferiority trial of 170 infertile women undergoing oocyte retrieval under conscious sedation in an assisted reproduction centre. The women were randomized to receive intravenously either 0.1 mg fentanyl and 5 mg midazolam or 25 mg pethidine and 5 mg diazepam, plus paracervical block with 10 ml 1% lignocaine. The primary outcome was abdominal pain level during retrieval assessed by linear visual analogue scale from 0-10. Secondary outcomes included vaginal pain levels during and after retrieval and postoperative abdominal pain levels and side-effects, satisfaction level, clinical pregnancy and ongoing pregnancy rates. A pre-defined non-inferiority margin of 1 for the difference in pain levels between two groups was set.

RESULTS

Vaginal and abdominal pain levels during retrieval were significantly lower in the fentanyl and midazolam group compared with the pethidine and diazepam group (per-protocol analysis, vaginal pain: 1.6 versus 4.3; mean difference: -2.7, 95% CI -3.7, -1.8; P < 0.001; abdominal pain: 2.9 versus 5.2; mean difference: -2.3, 95% CI -3.3 to -1.3; P < 0.001 for non-inferiority). No differences were observed in these pain levels after retrieval. Most women experienced no postoperative side-effects. The fentanyl and midazolam group had better sedation level, satisfaction level on pain relief and satisfaction on the overall retrieval procedure than the pethidine and diazepam group. No significant differences were found in clinical pregnancy and ongoing pregnancy rates between the two groups.

CONCLUSION

The fentanyl and midazolam group had significantly lower vaginal and abdominal pain levels during oocyte retrieval than the pethidine and diazepam group.

Effect of paternal age on semen parameters and live birth rate of in-vitro fertilisation treatment: a retrospective analysis

OBJECTIVE

To determine the effect of paternal age on semen parameters and the live birth rate from in-vitro fertilisation (IVF) treatment.

METHODS

We performed a retrospective cohort study of couples undergoing a first IVF cycle between 2004 and 2014 in a tertiary assisted reproduction centre in Hong Kong.

RESULTS

We analysed 3549 cases. Paternal age ≥40 years was negatively correlated with semen volume, progressive motility, total motility and total normal motile count (P<0.005) and positively correlated with sperm concentration (P<0.001). There was no correlation with sperm count, normal morphology, or total motile count. Subgroup analyses in Chinese men only and in men with normal versus abnormal semen parameters showed the same correlations. Paternal age was positively associated with maternal age (P<0.001) and miscarriage (P=0.006), and negatively associated with ongoing pregnancy and live birth (P<0.001). Logistic regression showed that maternal age, total number of oocytes retrieved, and number of embryos transferred were significant factors which independently predicted the likelihood of live birth from IVF (all P<0.001).

CONCLUSION

Paternal age was negatively correlated with some semen parameters, which showed a significant decline after age 40 years. However, paternal age is not predictive of the live birth from IVF treatment.

Randomized, controlled, double-blind trial of topical lidocaine gel and intrauterine lidocaine infusion for pain relief during saline contrast sonohysterography

OBJECTIVES

To evaluate the efficacy of topical lidocaine gel and intrauterine lidocaine infusion administered prior to saline contrast sonohysterography (SCSH) in reducing pain level during the procedure.

METHODS

This was a randomized, double-blind, placebo controlled trial. We recruited 120 women scheduled to undergo SCSH and randomized them into one of three groups according to administration of gel and intrauterine infusion immediately prior to the procedure: (1) the 'lidocaine gel' group received 3 mL 2% lidocaine gel applied to the cervix and intrauterine infusion, using an infant feeding tube without balloon, of 5 mL normal saline; (2) the 'lidocaine infusion' group received 3 mL gel lubricant applied to the cervix and intrauterine infusion of 5 mL 2% lidocaine; (3) the placebo group received 3 mL gel lubricant applied to the cervix and intrauterine infusion of 5 mL normal saline. The tube was left in place for the SCSH procedure. The primary outcome measure was the overall pain level (on a scale of 0-100) reported by the women during the SCSH procedure. Women also rated their pain levels at various other time points and an observer assessed visible signs of the women's discomfort during the procedure, producing a distress score.

RESULTS

There were no significant differences among the three groups in baseline characteristics, volume of saline solution infused, tenaculum use and duration and difficulty level of the SCSH procedure. The median (range) pain scores during normal saline infusion for the SCSH procedure were 0 (0-65) in the placebo group, 2.5 (0-80) in the lidocaine gel group, and 0 (0-70) in the lidocaine infusion group. The pain scores at other time points, the overall pain score and the distress score were also comparable for the three groups. No significant adverse events were reported.

CONCLUSIONS

SCSH performed with an infant feeding tube without balloon is associated with very low pain levels. Topical lidocaine gel application and intrauterine lidocaine infusion do not further reduce pain levels during SCSH.

Factors influencing the mode of delivery and associated pregnancy outcomes for twins: a retrospective cohort study in a public hospital

OBJECTIVES

To determine current trends for different modes of delivery in twin pregnancies, factors affecting the mode of delivery, and associated outcomes.

DESIGN

Retrospective cohort study.

SETTING

A public hospital in Hong Kong.

PARTICIPANTS

All twin pregnancies booked at Kwong Wah Hospital during a 3-year period from 1 April 2006 to 31 March 2009.

RESULTS

Of 197 sets of twins, 35 (18%) were delivered vaginally and 162 (82%) by caesarean section (47% were emergencies and 53% elective). In all, 32 (37%) of the elective and 21 (28%) of the emergency caesarean sections were in response to maternal requests. Vaginal delivery was more common in mothers with a history of vaginal delivery and monochorionic diamniotic twins. Women who conceived by assisted reproduction or those who had a tertiary education were more likely to deliver by caesarean section. The type of conception and the presentation of the second twin were statistically significant factors affecting maternal choice on the mode of delivery. Maternal age did not affect the choice of delivery mode. Except for the higher frequency of sepsis and cord blood acidosis in second twins delivered vaginally, there were no significant differences in neonatal morbidity between the groups that attempted vaginal delivery or requested caesarean sections. All the women who had compression sutures or hysterectomy to control massive postpartum haemorrhage were delivered by caesarean section.

CONCLUSION

A high caesarean section rate observed in our cohort was associated with maternal requests for this mode of delivery. The type of conception and the presentation of the second twin were statistically significant factors affecting maternal choice on mode of delivery. Women's requests for caesarean delivery out of the concern for their babies are not supported by current evidence. In response to a woman with a twin pregnancy requesting caesarean delivery, the pros and cons of vaginal deliveries and caesarean sections should be fully explained before the woman's autonomy is respected.

Evaluation of an intestinalLactobacillus reuteristrain expressing rumen fungal xylanase as a probiotic for broiler chickens fed on a wheat-based diet

1. This study was conducted to evaluate the feasibility of using a transformed Lactobacillus reuteri Pg4 strain harbouring a rumen fungal xylanase gene as a probiotic supplement in a wheat-based poultry diet. 2. A total of 400 broiler chicks was allocated to two treatment groups with or without supplementation with 10(6) colony forming units (cfu)/g of transformed L. reuteri Pg4 in a wheat-based regimen to investigate the performance, intestinal microflora populations, digesta viscosity and excreta ammonia concentrations in these broiler chickens. 3. Supplementation of the wheat-based diet with transformed L. reuteri Pg4 decreased intestinal viscosity, caecal coliform population, and increased body weight gain and ileal villus height and crypt depth from 0 to 21 d of age. It also decreased excreta ammonia concentrations, and increased the caecal total volatile fatty acid (VFA) and lactic acid concentrations from 0 to 21 d and 22 to 37 d of age. 4. Further, it was demonstrated that 40% of the Lactobacillus cells randomly isolated from the digesta of the ileum and caecum of the supplemented group possessed xylanase secretion capability. 5. It appears reasonable to assume, therefore, that the derived benefit is a result of the organism surviving, and the associated performance of some function in the intestinal tract which benefits gut health.

Uterine perforation during elective first trimester abortions: a 13-year review

OBJECTIVE

The purpose of this study was to determine the incidence, presentation, management and outcome of uterine perforation during elective first trimester abortions.

METHODS

We conducted a retrospective study of 40 patients, including 2 transferred patients, who sustained uterine perforation during elective abortions from January 1980 to December 1992.

RESULTS

The incidence of uterine perforation was 0.8 per 1,000 procedures (0.08%). There were 8 (20%) nulliparae and 3 (7.5%) grand multigravidae. 82.5% of the cases occurred when the abortion was performed by medical officers or junior registrars under training. The commonest perforating instrument was the suction cannula (25%) followed by the uterine sound (22.5%) and the dilator (20%). Three (7.5%) cases were treated conservatively, 33 (82.5%) cases underwent emergency operation, 2 (5%) cases were discovered during subsequent sterilisation, and 2 (5%) cases suffered undiagnosed perforation and were re-admitted for emergency surgery. Morbidity included post operative fever (12.5%), bowel injury (7.5%), retained conceptus (5%) and wound breakdown (2.5%). There was no mortality.

CONCLUSION

A careful assessment of the uterine size and position, vigilance in the use of uterine sound and dilators, greater care in the use of suction cannula, and experience in vacuum aspiration will decrease the incidence of uterine perforation during elective abortions. A high degree of suspicion, early diagnosis and treatment will prevent the potential complications that may arise from uterine perforation.

Primary ovarian pregnancy: current diagnosis and management

We reviewed five cases of ovarian pregnancy that were diagnosed at the Kandang Kerbau Hospital Histopathology Laboratory over three years. The clinical presentation, diagnosis and management of these patients are discussed in detail. This condition usually occurs in parous fertile women as evidenced by three of the five patients studied. It is probably an accidental event with no predisposing features as compared to the tubal pregnancy patient. The diagnosis has been aided by the recent advances in human chorionic gonadotrophin determination and ultrasound. Ultrasound, especially transvaginal ultrasound scanning has proven to be an invaluable tool in the diagnosis of this condition. Fertility after conservative surgical procedures does not appear to be affected and ovarian wedge resection or ovarian cystectomy is the treatment of choice.

Primary unruptured ovarian pregnancy--a case report

A rare case of an unruptured ovarian ectopic pregnancy is reported. This patient had a dilatation and curettage for an incomplete abortion and no products of conception were revealed in the histology specimen. A repeat ultrasound scan detected an ectopic pregnancy. Laparotomy confirmed the diagnosis of an unruptured ovarian pregnancy. The problems with the diagnosis and the management of this case are discussed.

Benign teratoma of the fallopian tube: a case report

A benign teratoma of the fallopian tube in a 33-year-old woman with primary subfertility is reported. This is the first case reported in Singapore. The features of benign teratoma of the fallopian tube is discussed.

Delivery after a lower segment caesarean section

A retrospective study on the outcome of 130 consecutive patients with a previous lower segment Caesarean section who delivered in Kandang Kerbau Hospital, Singapore from January to June 1989 was performed. Seventy-six percent of these patients were selected for a trial of labour and 24% of the patients had a repeat (elective) Caesarean section. Vaginal delivery was achieved in 65% of patients chosen to undergo a trial of labour. A trial of labour was found to be relatively safe with only a 0.7% incidence of uterine dehiscence and a perinatal mortality of 10.1 per 1,000 births with no maternal mortality. Cephalopelvic disproportion in the previous pregnancy and cervical dilatation during the previous Caesarean section were not important prognostic factor for the subsequent pregnancy outcome. A previous vaginal delivery in patients who had a previous Caesarean section was a good prognostic factor for a subsequent successful vaginal delivery (p < 0.05) in the trial of labour. More vaginal deliveries (p < 0.05) were achieved when oxytocic infusion was used in selected cases during the trial of labour. Maternal morbidities were higher in patients who had a failed trial of labour (57%) and repeat elective Caesarean section (20%) than those who had a successful trial of labout (10%). Management of patients with a previous lower segment Caesarean section may present a dilemma, but if properly conducted, the outcome can be favourable.