Amniotic fluid rubidium concentration association with newborn birthweight: a maternal-neonatal pilot study

BACKGROUND

Although most biological systems, including human tissues, contain rubidium, its biogeochemical functions and possible role in neonatal birthweight are largely unknown. An animal study indicated a correlation between rubidium deficiency in the maternal diet and lower newborn birthweight.

OBJECTIVE

This pilot study measured rubidium concentrations in amniotic fluid during the second trimester of (low-risk) pregnancy and investigated potential correlations between rubidium levels and third-trimester newborn birthweight-small for gestational age, appropriate for gestational age, and large for gestational age-and between preterm birth and term birth in uncomplicated pregnancies.

STUDY DESIGN

This prospective, single-center study investigated a possible relationship between rubidium concentration in second-trimester amniotic fluid and third-trimester birthweight percentile. Amniotic fluid (at a median gestational age of 19 weeks) was sampled to determine rubidium concentration. Maternal and newborn characteristics were obtained from participant and delivery records.

RESULTS

After screening 173 pregnant women, 99 amniotic fluid samples were evaluated. Midpregnancy median rubidium concentrations were significantly lower among newborns that were classified as small for gestational age than among newborns that were classified as appropriate for gestational age (106 vs 136 μg/L; P<.01). Based on a logistic regression random forest model, amniotic fluid rubidium was identified as a significant contributing factor to appropriate-for-gestational-age birthweight with 54% of the total contribution.

CONCLUSION

Amniotic fluid rubidium concentration seems to be a strong predictor of appropriate-for-gestational-age birthweight and a potential marker for newborn birthweight classifications. In particular, low rubidium concentrations in amniotic fluid during midpregnancy are linked to third-trimester lower birthweight percentile. These findings could potentially serve as a valuable tool for early identification of pregnancy outcomes. Further investigation is necessary to fully explore the effect of rubidium on fetal development.

Fetal Inguinal Hernia: Case Report and Review of the Literature

Fetal inguinal hernia (FIH) is a rare event and only few cases were published in the medical literature. In the present study, we aimed to characterize the sonographic features, clinical presentation, management, outcomes, and differential diagnoses of FIH. Accordingly, we reviewed all 17 cases of FIH published in the medical literature, including one new case evaluated by our group. All 17 cases (100%) were male, and FIH is presented as a scrotal mass with a mean diameter of 38 ± 9.5 mm. The right side was dominant (62%). Peristalsis was reported in 80% of the cases, and blood flow was reported in two-thirds. Most cases were diagnosed in the third trimester (88%) at a mean gestational age (GA) of 33.1 ± 5.2 weeks. 60% of the cases had isolated FIH, and 40% had another sonographic or genetic abnormality. Three cases (18%) were syndromic with multiple malformations: trisomy 18, skeletal anomalies due to Jarcho-Levin syndrome, and undefined multiple joint contractures. Two cases (12%) had copathologies in the gastrointestinal tract: one had an echogenic bowel due to homozygosity for cystic fibrosis, and the other had low anorectal malformation. Bowel loop dilatation was observed prenatally in both cases and in another one isolated case (18%). GA at delivery was 38 ± 1.8 weeks, and the median time between diagnosis and delivery was 3 weeks. All three cases of neonatal death occurred in syndromic fetuses. All patients with nonsyndromic inguinal hernias underwent definitive surgical repair at a median of 13 days postpartum. No signs of strangulation and only one case of edematous bowel without necrosis have been reported. In conclusion, FIH should be suspected in male fetuses when an intrascrotal mass with peristalsis is diagnosed during the third trimester. Close follow-up until term in the absence of signs of bowel obstruction is reasonable, and in isolated FIH, the prognosis is favorable.

The relation between head circumference and mid pelvic circumference: A simple index for cephalo-pelvic disproportion evaluation

INTRODUCTION

Cephalo-pelvic-disproportion (CPD) is one of the most common obstetric complications. Since CPD is the disproportion between the fetal head and maternal bony pelvis, evaluation of the head-circumference (HC) relative to maternal bony pelvis may be a useful adjunct to pre-labor CPD evaluation. The aim of the present study was a proof-of-concept evaluation of the ratio between HC to pelvic circumference (PC) as a predictor of CPD.

METHODS

Of 11,822 deliveries, 104 cases that underwent an abdomino-pelvic CT for any medical indication and who underwent normal vaginal deliveries (NVD) (n=84) or cesarean deliveries (CD) due to CPD (n=20) were included retrospectively. Maternal pelvis dimensions were reconstructed and neonatal HC, as a proxy for fetal HC, were measured. The correlation between cases of CPD and Cephalo-Pelvic Circumference Index (CPCI), which represents the ratio between the HC and PC in percent (HC/PC *100) was evaluated.

RESULTS

The mid-pelvis cephalo-pelvic circumference index (MP-CPCI) was larger in CD groups as compared to the NVD group: 103±11 vs. 97±8% respectively (p=0.0003). In logistic regression analysis, the MP-CPCI was found to be independently associated with CD due to CPD: each 1% increase in MP-CPCI increased the likelihood of CD for CPD by 11% (aOR 1.11, CI 95% 1.03-1.19, p=0.004). The adjusted odds ratio for CD due to CPD increased incrementally as the MP-CPCI increased, from 3.56 (95%CI, 1.01-12.6) at MP-CPCI of 100, to 5.6 (95%CI, 1.63-19.45) at 105, 21.44 (95%CI, 3.05-150.84) at 110, and 28.88 (95%CI, 2.3-362.27) at MP-CPCI of 115 Conclusions: The MP-CPCI, representing the relative dimensions of the fetal HC and maternal PC, is a simple tool that can potentially distinguish between parturients at lower and higher risk of CPD. Prospective randomized studies are required to evaluate the feasibility of prenatal pelvimetry and MP-CPCI to predict the risk of CPD during labor.

First trimester expression of anorectal malformation: Case report and review of the literature

A 26-years-old woman, underwent an ultrasound examination at 13.4 weeks. A cystic structure was identified in the right lower abdomen. Gradually, the cystic mass was replaced by echogenic content and eventually attained the appearance of hyperechoic bowel. At 21.2 weeks, the anal sphincter could not be demonstrated which was consistent with the diagnosis of isolated anal agenesis. Amniocentesis revealed 46XY karyotype with normal comparative genomic hybridization. After termination of pregnancy at 23 weeks, an autopsy revealed an isolated high type anorectal malformation (ARM) without fistula. We reviewed all 14 cases reported in the literature of first trimester sonographic expression of ARM.

Does progesterone to oocyte index have a predictive value for IVF outcome? A retrospective cohort and review of the literature

The potential adverse effect of Serum progesterone (SP) elevation on the day of hCG administration is a matter of continued debate. Our study aimed to evaluate the relative value of progesterone to a number of aspirated oocytes ratio (POI) to predict clinical pregnancy (CP) and live birth (LB) in fresh IVF cycles and to review the relevant literature. A retrospective analysis of GnRH Antagonist IVF-ET cycles. POI was calculated by dividing the SP on the day of hCG by the number of aspirated mature oocytes. A multivariate logistic regression analysis was performed to evaluate the predictive value of POI for CP and LB. Cycle outcome parameters included clinical pregnancy, live-birth and miscarriage. A total of 2,693 IVF/ICSI cycles were analyzed. POI was inversely associated with CP adjusted OR 0.063 (95% CI 0.016-0.249, p < .001) and with LB adjusted OR 0.036 (95% CI 0.007-0.199, p < .001). For prediction of LB, the area under the curve (AUC) was 0.68 (95% CI 0.64-0.71, p < .001) for the POI model. POI above the 90th percentile with a value of 0.36 ng/mL/oocyte results in CP and LB rates of 8.0 and 5.9%, respectively. POI is a simple index for the prediction of IVF-ET cycle outcomes, it can advocate a limit above which embryo transfer should be reconsidered.

Should high BMI be a reason for IVF treatment denial?

Our aim was to examine the influence of BMI on the live-birth rate following IVF/ICSI and evaluate its specific contribution among other factors thus enabling accurate reproductive policy development. All patients that underwent IVF/ICSI at our center during January 2012-July 2015 were included in this retrospective study. A total of 1654 ICSI cycles were divided into four groups according to the patient's BMI (kg/m²): group I (normal weight): <25 (943 cycles); group II (overweight): 25-30 (403 cycles); group III (obese): 30-35 (212 cycles); group IV (morbid obesity): >35 (96 cycles). Comparing the four groups of BMI, mean age and number of previous ART cycles was significantly lower in group I compared to groups II, III and IV. Length of treatment was significantly shorter in group I compared to groups II, III and IV. Ovarian response to COH was comparable in terms of mean estradiol and progesterone levels on the day of hCG administration mean number of oocytes retrieved, fertilized and number of embryos transferred. Endometrial thickness was significantly lower in group IV. Outcome measures, such as implantation rate, clinical pregnancy rate (CPR) per cycle and per ET, as well as live-birth rates did not differ significantly between the groups, although in group IV LBR per cycle and per ET was lower. Multivariate logistic regression stepwise analysis found a significant correlation between age and BMI but did not find correlation between BMI and clinical pregnancy (p = 0.436) or LB (p = 0.206). The results of our relatively large retrospective study did not demonstrate a significant impact of BMI on the ART cycle outcome. Therefore, BMI should not be a basis for IVF treatment denial.

An upper limit of gonadotropin dose in patients undergoing ART should be advocated

AIM

As no upper limit of the daily dose of gonadotropins (DD GN) used for controlled ovarian hyperstimulation (COH) in patients undergoing assisted reproductive technology (ART) has been established, we aimed to evaluate the efficacy of using different DD GN in terms of live-birth achievement.

METHODS

Data of patients treated at a single university medical center during the same period was analyzed retrospectively. Four groups were analyzed according to the DD GN administered: group I ("high dose"):  >225- ≤ 375 IU; Group II ("Very high dose"): 376-450 IU; group III ("extremely high dose"): 451-600 IU. Normo-responders treated with DD GN ≤250 IU served as control (C). Variables included were DD GN, total GN dose/cycle, age, FSH, BMI, gravidity, parity, cycle number, IVF/ICSI, infertility diagnosis treatment protocol and outcome parameters.

RESULTS

The analysis of 1394 treatment cycles of 943 patients indicated that DD and total dose of GN correlated negatively with the number of oocytes, implantation, clinical pregnancy and live-birth rate (25.9%, 14.6%, 11.4% and 4.7% in groups C, I, II and III, respectively) The logistic regression analysis indicated that the adjusted odds ratios for LBR correlated inversely with the DD administered - independently from age, baseline FSH, BMI and previous failed cycles.

CONCLUSIONS

Increasing the daily dose of GN to doses higher than 450 IU or a total dose of 3000 IU/cycle is at least questionable if not harmful.

[CLINICAL ASPECTS OF INTRAUTERINE INSEMINATION]

Intrauterine insemination (IUI) is an intervention performed frequently in the treatment of couples suffering from subfertility and women treated using donor sperm. The factors predicting its success include female parameters such as age and ovarian function and male parameters such as sperm quality. However, many details regarding its clinical application such as the methodology of sperm preparation, timing of IUI, the number of inseminations in the same cycle, the recommended number of cycles to be performed and the minimal threshold values of the sperm sample profile required are controversial. The conclusion to be drawn from this literature survey is that there is still lack of sufficient good quality studies performed to allow evidence based recommendations for the performance of IUI.

The place of selective hysterosalpingography and tubal canalization among sub-fertile patients diagnosed with proximal tubal occlusion

OBJECTIVE

To evaluate the efficacy of selective salpingography and tubal canalization (TC) procedure among patients diagnosed with proximal tubal occlusion (PTO).

METHODS

We conducted a retrospective cohort study on 61 sub-fertile patients aged 32.6 ± 4.9 years that were referred between the years of 2011 and 2013 with the diagnosis of PTO by prior hysterosalpingography. Patients underwent TC and were classified as bilateral PTO or unilateral PTO. Information regarding the patient's reproductive outcome within the 12 months following the procedure was collected by a telephone survey.

RESULTS

During the study period, 58/61 (95 %) patients underwent TC, resulting in bilateral open tubes in 54 patients (93.1 %). 53/58 (91.3 %) patients answered our survey. There were 23/53 (43.4 %) patients with a successful procedure who conceived after spontaneous or COH + IUI resulting in 15/23 live births (65.2 %).

CONCLUSION

Tubal canalization is a safe and minimally invasive procedure that can be used effectively to restore patency in a proportion of cases of PTO thus avoiding the need for expensive and invasive procedures such as assisted reproductive techniques.

High rates of abnormalities in hysterosalpingography in couples with male factor infertility

The rate of anatomical abnormalities in infertile couples with obvious male factor is unknown. For this purpose the authors retrospectively analyzed 376 hysterosalpingographies (HSG) of couples with severe male factor. Patients were subdivided into four groups according to the woman's age, and primary or secondary infertility: A--less than 35-years-old, primary infertility, B--less than 35-years-old, secondary infertility, C--35-years-old or more, primary infertility, and D--35-years-old or more, secondary infertility. Overall, abnormalities in HSG were demonstrated in 25.5% of the patients, and in 18, 21, 52, and 40 percent of patients in groups A, B, C and D, respectively. Age was found to be a significant independent risk factor (p < 0.05) while primary or secondary infertility was not. The adjusted odds ratio for woman who were 35-years-old or more to have any abnormalities in HSG were 3.7-fold greater (95% CI 2.2- 6.23), than women who were less than 35-years-old. In conclusion, relatively high rates of female mechanical abnormalities may be found even in infertile couples with obvious male factor and are significantly more prevalent in older women.

The Fetal Larynx and Pharynx: Structure and Development Described by 2D and 3D Ultrasound Examination

Objectives:

Define the structure and function of the fetal pharynx and larynx. We describe for the first time the various components of these anatomical sites by 3D multiplanar and render modes during the late 1st and 2nd trimesters. Understanding these structures’ normal anatomy and function may contribute to our evaluation of pathologies.

Methods:

Gravidae with singleton fetuses were enrolled. Transabdominal 3DUS scan of the fetal neck was acquired. The pharynx width and height, upper, middle, and lower larynx width, and larynx height were measured. We developed a new approach based on 5 spatial planes: posterior and anterior coronal planes and high, mid, and low axial planes. Multiplanar reconstruction (MPR) in post-processing allowed adjustment of the volume to obtain the coronal plane of the area. Color Doppler was used to show fluid motion in the target area. 2DUS was also applied.

Results:

582 fetuses were examined during the late 1st and 2nd trimester of pregnancy. Components identified were the sphenoid bone, pterygoid processes, constrictor muscles, piriform sinus, uvula, epiglottis, aryepiglottic folds, arytenoid, cricoid, and thyroid cartilages, and the vocal cords. We defined the bilateral mode of movements of the constrictor muscles, aryepiglottic folds, and vocal folds, and bidirectional fluid jet flows through the larynx.

Conclusions:

The fetal larynx and pharynx can be visualized and measured with 3DUS in the late 1st and 2nd trimester. Knowledge of normal anatomy and biometry may prove useful in the evaluation of anatomic or functional pathologies involving the fetal upper respiratory tract.

The fetal larynx and pharynx: structure and development on two- and three-dimensional ultrasound

OBJECTIVES

To present a systematic approach for evaluating the fetal pharynx and larynx based on two- and three-dimensional ultrasound (2D-US and 3D-US) modalities, describing the sonographic appearance and function of the fetal upper respiratory tract and measuring the anatomical components of the pharynx and larynx.

METHODS

Gravidae presenting from the late first trimester to mid-gestation for routine booked examinations with structurally normal singleton fetuses of confirmed gestational age were enrolled. Transabdominal 2D-US was performed for anatomical and functional evaluation of the pharynx and larynx. Color Doppler was used to show fluid motion in the target area. 3D-US (Voluson® E6 with RAB-4-8-D transducer) scans of the fetal neck were acquired during fetal quiescence and in the absence of movements of the pharynx and larynx. Multiplanar reconstruction (MPR) in post-processing allowed adjustment of the volume to obtain the coronal plane. After a learning period to understand the sonographic anatomy of the target area, we measured the pharynx width and height, the upper, middle and lower larynx width and the larynx height. Render mode was applied for spatial evaluation of the target area. We developed a new methodological approach for structured evaluation of the fetal pharynx and larynx based on five spatial planes: posterior and anterior coronal planes and high, mid and low axial planes.

RESULTS

We examined 582 fetuses during the second trimester of pregnancy; target anatomy was imaged successfully in 218 patients at 11-24 gestational weeks. Acquisition added approximately 1 min to examination time. Rates of successful visualization and measurements increased significantly as pregnancy progressed, being 23% (46/194) at 11-13 weeks, 29% (69/240) at 14-16 weeks, 35% (18/51) at 17-19 weeks and 88% (85/97) at 20-24 weeks (P < 0.01). Pharynx components identified were: the sphenoid bone, pterygoid processes, constrictor muscles, piriform recesses and uvula. Larynx components identified were: the epiglottis, aryepiglottic folds, corniculate cartilages, arytenoid cartilages, cricoid cartilage, thyroid cartilage and vocal cords. MPR showed the biconcave shape of the uvula, which may explain the 'equals sign' observed on 2D-US. We observed the bilateral mode of movements of the constrictor muscles, aryepiglottic folds and vocal cords, and the bidirectional fluid jet flows through the larynx. Scatterplots of measured structures vs gestational age were created. Pharynx width ranged from 0.11 to 0.93 (mean ± SD, 0.48 ± 0.17) cm; pharynx height ranged from 0.23 to 2.01 (mean ± SD, 0.94 ± 0.34) cm; upper larynx width ranged from 0.04 to 0.37 (mean ± SD, 0.15 ± 0.07) cm; middle larynx width ranged from 0.08 to 0.77 (mean ± SD, 0.34 ± 0.16) cm; lower larynx width ranged from 0.05 to 0.64 (mean ± SD, 0.24 ± 0.11) cm; and larynx height ranged from 0.20 to 1.83 (mean ± SD, 0.71 ± 0.31) cm. All measurements were positively correlated with gestational age.

CONCLUSIONS

The fetal larynx and pharynx can be evaluated thoroughly using 2D- and 3D-US modalities. Knowledge of normal anatomy, function and biometry may prove useful in the evaluation of anatomical or functional pathology involving the fetal upper respiratory tract. Recognition of anatomical anomalies may enhance fetal intervention such as balloon placement in cases of diaphragmatic hernia.

GnRH-agonist ovulation trigger in patients undergoing controlled ovarian hyperstimulation for IVF with ultrashort flare GnRH-agonist combined with multidose GnRH-antagonist protocol

OBJECTIVE

To evaluate, whether Gonadotropin-releasing hormone-agonist (GnRH-agonist or GnRH-ag) trigger in patients undergoing the ultrashort GnRH-ag/GnRH-antagonist (GnRH-ant) protocol is as effective as in patients at high risk to develop severe ovarian hyperstimulation syndrome (OHSS), who undergo the multidose GnRH-ant protocol.

DESIGN

Cohort study.

SETTING

University hospital.

PATIENTS

All consecutive women aged ≤35 years admitted to our IVF unit from January 2011 to October 2011 who reached the ovum pick-up stage.

INTERVENTIONS

Triggering final oocytes maturation by GnRH-ag instead of hCG, in high-responder patients undergoing either the ultrashort GnRH-ag/GnRH-ant or the multidose GnRH-antagonist controlled ovarian hyperstimulation (COH) protocols.

MAIN OUTCOME MEASURES

Ovarian stimulation characteristics, percentage of mature oocytes, fertilization and pregnancy rates.

RESULTS

No inbetween groups differences were observed in ovarian-stimulation related variable, percentage of mature oocytes, fertilization or pregnancy rates. No case of moderate-severe OHSS was reported in the study, or the control groups.

CONCLUSIONS

Three consecutive doses of daily GnRH-ag administration at the beginning of ultrashort flare GnRH-ag/GnRH-ant COH protocol, did not interfere with the ability of the GnRH-ag to trigger final oocytes maturation at the end of the COH cycle.

Does day-3 LH/FSH ratio influence in vitro fertilization outcome in PCOS patients undergoing controlled ovarian hyperstimulation with different GnRH-analogue?

In an attempt to evaluate whether high basal day-3 luteinizing hormone/follicle-stimulating hormone (LH/FSH) ratio affects IVF cycle outcome in polycystic ovary syndrome (PCOS) patients undergoing ovarian stimulation with either GnRH-agonist (n = 47) or antagonist (n = 104), we studied 151 IVF cycles: 119 in patients with basal LH/FSH <2 and 32 in patients with LH/FSH ≥ 2. The PCOS with high LH/FSH ratio achieved a non-significantly higher pregnancy rate using the GnRH-agonist (50% vs 17.9%, p = 0.2; respectively), as compared to the GnRH-antagonist protocols, probably due to the ability of the long GnRH-agonist protocol to induce a prolong and sustained reduction of the high basal LH milieu and avert its detrimental effect on oocyte quality and implantation potential.

Human menopausal gonadotropin versus highly purified-hMG in controlled ovarian hyperstimulation for in-vitro fertilisation: does purity improve outcome?

OBJECTIVES

To examine and compare the effect of the two commercially available menotropins (highly purified-human menopausal gonadotropin (HP-hMG) and the traditional human menopausal gonadotropin (hMG)) on ovarian stimulation characteristics and in-vitro fertilisation (IVF) cycle outcome.

STUDY DESIGN

We studied 36 patients undergoing at least two controlled ovarian hyperstimulation cycles for IVF, with the same GnRH-analogue protocols, where one included HP-hMG and the other included hMG. Ovarian stimulation characteristics and outcome were compared between the two groups.

RESULTS

Patients in the HP-hMG group achieved significantly higher implantation (20.0% vs. 8.1%, p < 0.03; respectively) and pregnancy rates (47.2% vs. 19.4%, p < 0.009; respectively) compared to the hMG group. Although no in-between group difference was observed in the number of top-quality embryos per patient, the proportion of the total number of top-quality embryos per total number of generated embryos was significantly higher in the HP-hMG group (88/196 vs. 72/204, p < 0.049; respectively) as compared to the hMG group.

CONCLUSIONS

Patients undergoing controlled ovarian hyperstimulation for IVF that includes HP-hMG preparations produce significantly higher implantation and pregnancy rates, as compared to the traditional hMG.

Serum retinol-binding protein-4 levels in polycystic ovary syndrome patients undergoing controlled ovarian hyperstimulation for in-vitro fertilization cycle

AIMS

To determine serum retinol-binding rotein 4 (RBP-4) levels in polycystic ovary syndrome (PCOS) patients undergoing controlled ovarian hyperstimulation (COH) for an in vitro fertilization-embryo transfer (IVF-ET) cycle and the possible correlation to COH variables.

PATIENTS AND METHODS

11 consecutive PCOS patients undergoing our routine IVF flexible multidose gonadotropin-releasing hormone (GnRH)-antagonist protocol. Blood was drawn three times during the COH cycle: (1) day 1 or 2 of menstruation, and prior to gonadotropin administration (Day-S) (Day-S); (2) day of or prior to human chorionic gonadotropin (hCG) administration (Day-hCG); and (3) day of ovum pick-up (Day-OPU). Levels of estradiol and serum RBP-4 were compared among the three time points. Serum RBP-4 was measured with a commercial immunoassay.

RESULTS

Results showed significantly lower levels of serum RBP-4 on Day-OPU and Day-hCG than on Day-S. Though significant correlations were observed between serum RBP-4 and body mass index, fasting glucose or glucose to insulin ratio, no correlations were found between serum RBP-4 and IVF treatment variables or pregnancy rate.

CONCLUSION

While serum RBP-4 decreases during COH for IVF, there is apparently no correlation of serum RBP-4 levels with IVF treatment variables or outcome.

Relationships between FSH, inhibin B, anti-Mullerian hormone, and testosterone during long-term treatment with the GnRH-agonist histrelin in patients with prostate cancer

OBJECTIVES

Medical castration with long-acting GnRH-agonist (GnRHa) is a well-established treatment for metastatic prostate cancer. Our aim was to explore the relationships between FSH, inhibin B, anti-Mullerian hormone (AMH), and testosterone during treatment with an implant releasing GnRHa.

DESIGN

Analysis of hormone levels in frozen serum samples.

METHODS

Ten patients aged 77+/-7 (means+/-S.E.M.) years with prostate cancer were treated with the GnRHa histrelin for at least a year. Two weeks prior to insertion and for 3-4 months following removal the patients were treated with the antiandrogen flutamide. Serum inhibin B, FSH, testosterone, and AMH levels were measured retrospectively.

RESULTS

FSH, inhibin B, and testosterone increased during antiandrogen administration and levels fell after implant insertion. Four weeks post insertion, FSH gradually increased while inhibin B and testosterone remained fully suppressed. AMH levels did not change during antiandrogen treatment, but increased following implant insertion and remained elevated for the duration of implant use. Following removal, FSH and testosterone increased, inhibin B remained low, while AMH decreased.

CONCLUSIONS

The secondary increase in FSH following initial suppression with the implant is probably related to impaired inhibin B secretion. The lack of inhibin B response to the secondary increase in FSH suggests that long-term exposure of Sertoli-cells to GnRHa impairs their function. This effect appears to be selective since unlike inhibin B, AMH increased. In the absence of testosterone, FSH has a role in AMH regulation.

Ovarian hemorrhage after transvaginal ultrasonographically guided oocyte aspiration: a potentially catastrophic and not so rare complication among lean patients with polycystic ovary syndrome

OBJECTIVE

To report the first case series of ovarian hemorrhage after transvaginal ultrasonographically guided oocyte aspiration (TVOA).

DESIGN

Retrospective analysis.

SETTING

In vitro fertilization unit of a tertiary university hospital.

PATIENT(S)

Patients who underwent TVOA during a 6-year period.

INTERVENTION(S)

Surgical intervention due to active bleeding from the ovary.

MAIN OUTCOME MEASURE(S)

Prevalence and risk factors.

RESULT(S)

Among 3,241 patients undergoing TVOA, 7 were diagnosed as having ovarian hemorrhage afterward. All patients were thin, with a body mass index of 19-21 kg/m(2), and 4 had polycystic ovary syndrome (PCOS). The prevalence of ovarian bleeding among lean patients with PCOS was 4.5%. The odds ratio for bleeding in lean patients with PCOS vs. all other patients was 50 (95% confidence interval 11-250). The interval between the TVOA and surgical intervention ranged from 5 to 18 hours (mean +/- SD, 11.4 +/- 5 hours). The Delta decrease in hemoglobin levels was 3.2-9 g/dL (mean 6.1 +/- 1.8). In 6 of the 7 patients, laparoscopically guided electrocoagulation was sufficient to achieve hemorrhagic control.

CONCLUSION(S)

Although acute hemorrhage is a rare event after TVOA, lean patients with PCOS specifically are at much higher risk for this complication.

Peri-implantation pelvic inflammatory disease with normal pregnancy outcome

OBJECTIVE

To report on the presentation, diagnostic assessment, treatment, and outcome of a case of peri-implantation pelvic inflammatory disease.

DESIGN

Case report.

SETTING

Emergency department and gynecology ward of a tertiary university hospital.

PATIENT(S)

A 25-year-old multiparous woman in her 1st month of pregnancy.

INTERVENTION(S)

Diagnostic laparoscopy, antibiotic therapy, and pregnancy surveillance.

MAIN OUTCOME MEASURE(S)

Surveillance and outcome of pregnancy.

RESULT(S)

The patient presented with abdominal pain and fever 26 days after her last menstrual period. Examination revealed peritoneal irritation and cervical tenderness, with free fluid in the pelvis. Diagnostic laparoscopy was performed, with no evidence of ectopic pregnancy. A significant quantity of yellow purulent fluid was drained from the pelvis, which cultured for Escherichia coli. Antibiotic therapy yielded excellent response. The pregnancy continued, with no complications, to healthy term delivery.

CONCLUSION(S)

This rare diagnosis of peri-implantation pelvic inflammatory disease should be considered in the differential diagnosis of abdominal pain in early pregnancy. Timely, rational treatment, including early pelvic drainage and appropriate antibiotic therapy, may save the pregnancy.

Lidocaine–Prilocaine (EMLA) cream as analgesia for hysterosalpingography: a prospective, randomized, controlled, double blinded study

BACKGROUND

The aim of our study is to evaluate the efficacy of applying lidocaine 25 mg-prilocaine-25 mg/G cream (EMLA 5%) on the uterine cervix for pain relief when performing hysterosalpingography (HSG).

METHODS

Eighty-two patients undergoing HSG as part of infertility evaluation were randomized into groups receiving EMLA (42) or placebo cream (40) in a double-blinded prospective study from which four women were later excluded. The cream was applied to the uterine cervix by means of a cervical cup 30 min before the HSG. Pain perception related to the HSG procedure was scored by visual analogue scale (VAS) at five predefined steps: after speculum application, after cervical instrumentation of the tenaculum and cannula, at the end of uterine filling, at completion of tubal spillage, and immediately following instrument removal. In addition, the patients were asked to retrospectively rate the pain during the entire procedure in a telephone interview the following day.

RESULTS

Cervical instrumentation was found to be the most painful step of HSG (P < 0.001). When comparing the VAS pain scores, cervical instrumentation in the EMLA-treated patients was associated with significantly less pain than the control group: 3.3 +/- 2.9 versus 4.9 +/- 2.7, respectively (P = 0.02).

CONCLUSIONS

Topical application of EMLA 5% cream on the uterine cervix before performing HSG significantly reduced the pain during this procedure.