P–001 Effect of mild α -chymotrypsin treatment of highly viscous semen samples on fertilization rates

Study question

The main objective of this study was to examine the influence of mild α -chymotrypsin treatment of highly viscous semen samples on the fertilisation rate after artificial reproductive treatment (ART).

Summary answer

The use of mild α -chymotrypsin treatment of semen samples in case of hyperviscosity does not appear to impact negatively on the fertilization rates after ART.

What is known already

Highly viscous semen reduces sperm motility significantly and can contribute to infertility. When processing semen samples, few techniques exist to induce liquefaction in case of seminal hyperviscosity such as different washing steps and mechanical treatment. The use of α -chymotrypsin seems controversial due to possible negative effects on fertilisation rates after IVF.

Study design, size, duration

All patients were recruited at the Department of Gynecological Endocrinology and Reproductive Medicine, University Hospital of Bonn, Germany from July first 2018 till June first 2019. Anonymized data on age, number of previous pregnancies and deliveries were retrospectively collected. The study group consisted of a cohort of 52 couples meeting the inclusion criteria of highly viscous semen and were compared to a cohort control group of 88 couples.

Participants/materials, setting, methods: The fertilization rate of 52 ART cycles was examined following IVF using a low dose of α -chymotrypsin to induce liquefaction of highly viscous semen and was compared to a control group of 88 ART cycles. Data was analyzed using SPSS version 25. A Mann Whitney U test was used to compare continuous parameters between groups.

Main results and the role of chance

The study group consisted of a cohort of 52 couples meeting the inclusion criteria of highly viscous semen and were compared to a cohort control group of 88 couples. The Fertilization rate between the two groups was not significant (p < 0.146, Mann-Whitney U test), with a rate of 57.95 in the study group compared to 57.53 in the control group. Our analysis showed no significant differences in male and female age, male abstinence period, semen volume, sperm concentration, total sperm count, and total progressive sperm count between the two groups. We observed a significant difference [p = 0.025] in the progressive motility and a borderline significance in the total progressive sperm count [p = 0.052] between α -chymotrypsin treated samples and the non α -chymotrypsin treated samples. Analyzing the clinical and biochemical pregnancy parameters of the study group (n = 41) and the control group (n = 66) per fresh embryo transfer procedures (n = 107) we found no significant differences. Freeze all cycles were excluded from the study. No significant differences concerning previous pregnancies and childbirth were detected.

Limitations, reasons for caution

The study is a pilot study as the majority of the studies using α -chymotrypsin was conducted up to three decades ago, comparison of data must be interpreted in the light of the fact that since then, IVF has seen a rapid evolution of technology and culture techniques.

Wider implications of the findings

The use of mild α -chymotrypsin treatment of semen samples in case of hyperviscosity does not appear to impact negatively on the fertilization rates after ART and could be regarded as an additional method to induce liquefaction of highly viscous semen samples in IVF...

Trial registration number

not applicable

Anti-adhesion Gel versus No gel following Operative Hysteroscopy prior to Subsequent fertility Treatment or timed InterCourse (AGNOHSTIC), a randomised controlled trial: protocol

STUDY QUESTIONS

Does the application of anti-adhesion gel, compared to no gel, following operative hysteroscopy to treat intrauterine pathology in women wishing to conceive increase the chance of conception leading to live birth?

WHAT IS KNOWN ALREADY

Intrauterine adhesions (IUAs) following operative hysteroscopy may impair reproductive success in women of reproductive age. Anti-adhesion barrier gels may decrease the occurrence of IUAs, but the evidence on their effectiveness to improve reproductive outcomes is sparse and of low quality.

STUDY DESIGN SIZE DURATION

This multicentre, parallel group, superiority, blinded and pragmatic randomised controlled trial is being carried out in seven participating centres in Belgium. Recruitment started in April 2019. Women will be randomly allocated to treatment with anti-adhesion gel (intervention group) or no gel (control group). Sterile ultrasound gel will be applied into the vagina as a mock-procedure in both treatment arms. The patient, fertility physician and gynaecologist performing the second-look hysteroscopy are unaware of the allocated treatment. Power analysis, based on a target improvement of 15% in conception leading to live birth using anti-adhesion gel, a power of 85%, a significance level of 5%, and a drop-out rate of 10%, yielded a number of 444 patients to be randomised. The baseline rate of conception leading to live birth in the control group is expected to be 45%.

PARTICIPANTS/MATERIALS SETTING METHODS

Women of reproductive age (18-47 years), wishing to conceive (spontaneously or by fertility treatment) and scheduled for operative hysteroscopy to treat intrauterine pathology (endometrial polyps, myomas with uterine cavity deformation, uterine septa, IUAs or retained products of conception) are eligible for recruitment. Women may try to conceive from 3 to 6 weeks after receiving allocated treatment with follow-up ending at 30 weeks after treatment. If the woman fails to conceive within this timeframe, a second-look hysteroscopy will be scheduled within 2-6 weeks to check for IUAs. The primary endpoint is conception leading to live birth, measured at 30 weeks after randomisation. The secondary endpoints are time to conception, clinical pregnancy, miscarriage and ectopic pregnancy rates, measured at 30 weeks after receiving allocated treatment. The long-term follow-up starts when the patient is pregnant and she will be contacted every trimester.

STUDY FUNDING/COMPETING INTERESTS

This work is funded by the Belgian Healthcare Knowledge Centre (KCE). The anti-adhesion gel is supplied at no cost by Nordic Pharma and without conditions. Dr. Tomassetti reports grants and non-financial support from Merck SA, non-financial support from Ferring SA, personal fees and non-financial support from Gedeon-Richter, outside the submitted work. None of the other authors have a conflict of interest.

The rationale of opportunistic bilateral salpingectomies (OBS) during benign gynaecological and obstetric surgery: a consensus text of the Flemish Society of Obstetrics and Gynaecology (VVOG)

Ovarian cancer (OC), is a disease difficult to diagnose in an early stage implicating a poor prognosis. The 5-year overall survival in Belgium has not changed in the last 18 years and remains 44 %. There is no effective screening method (secondary prevention) to detect ovarian cancer at an early stage. Primary prevention of ovarian cancer came in the picture through the paradigm shift that the fallopian tube is often the origin of ovarian cancer and not the ovary itself. Opportunistic bilateral salpingectomy (OBS) during benign gynaecological and obstetric surgery might have the potential to reduce the risk of ovarian cancer by as much as 65 %. Bilateral risk-reducing salpingectomy during a benign procedure is feasible, safe, appears to have no impact on the ovarian function and seems to be cost effective. The key question is whether we should wait for a RCT or implement OBS directly in our daily practice. Guidelines regarding OBS within our societies are therefore urgently needed. Our recommendation is to inform all women without a child wish, undergoing a benign gynaecological or obstetrical surgical procedure about the pro's and the con's of OBS and advise a bilateral salpingectomy. Furthermore, there is an urgent need for a prospective registry of OBS. The present article is the consensus text of the Flemish Society of Obstetrics and Gynaecology (VVOG) regarding OBS.

Recommendations for a standardised educational program in robot assisted gynaecological surgery: Consensus from the Society of European Robotic Gynaecological Surgery (SERGS)

BACKGROUND

The Society of European Robotic Gynaecological Surgery (SERGS) aims at developing a European consensus on core components of a curriculum for training and assessment in robot assisted gynaecological surgery.

METHODS

A Delphi process was initiated among a panel of 12 experts in robot assisted surgery invited through the SERGS. An online questionnaire survey was based on a literature search for standards in education in gynaecological robot assisted surgery. The survey was performed in three consecutive rounds to reach optimal consensus. The results of this survey were discussed by the panel and led to consensus recommendations on 39 issues, adhering to general principles of medical education.

RESULTS

On review there appeared to be no accredited training programs in Europe, and few in the USA. Recommendations for requirements of training centres, educational tools and assessment of proficiency varied widely. Stepwise and structured training together with validated assessment based on competencies rather than on volume emerged as prerequisites for adequate and safe learning. An appropriate educational environment and tools for training were defined. Although certification should be competence based, the panel recommended additional volume based criteria for both accreditation of training centres and certification of individual surgeons.

CONCLUSIONS

Consensus was reached on minimum criteria for training in robot assisted gynaecological surgery. To transfer results into clinical practice, experts recommended a curriculum and guidelines that have now been endorsed by SERGS to be used to establish training programmes for robot assisted surgery.

Influence of contraceptive choice on vaginal bacterial and fungal microflora

The influence of contraception on vaginal microflora can have a major impact on the risk of developing acute or recurrent vaginal infections, but also may influence the risk of acquiring sexually transmissible infections (STI) such as HIV. A cohort of 248 women presenting for levonorgestrel-releasing intrauterine system (LNG-IUS) insertion or reinsertion were stratified according to their current contraceptive method. Information concerning their menstrual pattern and data about the medical history were collected. The composition of their vaginal microflora was studied by detailed phase contrast microscopy of fresh vaginal fluid, and aerobic cultures were taken to detect enteric bacterial growth and fungal colonisation. LNG-IUS and progesterone-only-pill (POP) users had significantly lower blood loss (p < 0.001) than other women. Regardless of the type of contraception used, all women reported similar rates of symptomatic lower genital tract infection during the preceding year. Women using combined oral contraception (COC) and long-term LNG-IUS had the same bacterial composition of vaginal microflora as non-contraceptive users, even when infections were combined. Both hormonal and non-hormonal intrauterine device users had an increased tendency to have more vaginal colonisation with Candida. Women on POPs or subcutaneous implants had a tendency towards increased vaginal atrophy, but had a lower Candida carriage rate compared to IUCD users (LNG-IUS and Copper-IUCD, p = 0.037). Women with an increased risk of acquiring STIs or recurrent BV could benefit from LNG-IUS or COC due to a well-preserved vaginal bacterial flora. Women with a susceptibility for RVVC should prefer POPs, and avoid intrauterine contraception.

[The use of intrauterine device in nulliparous over 18 years: a Belgian consensus]

Under the presidency of prof. H. Depypere (UZ Ghent) and Prof. P. Simon (ULB Erasme) a Belgian panel of thirteen experts (gynecologists, representatives of universities and scientific associations for gynecology-obstetrics) reached a consensus on the use of intrauterine systems, both copper IUDs as hormone IUDs, in nultiparous women.

Normative data for uterine size according to age and gravidity and possible role of the classical golden ratio

OBJECTIVES

To document normal measurements (length, width, anteroposterior (AP) diameter) and proportions of the non-pregnant uterus according to age and gravidity. We hypothesized that uterine proportions conform to the classical 'golden ratio' (1.618).

METHODS

This was a retrospective study of ultrasonographic measurements of the length, width and AP diameter of non-pregnant uteri recorded in our database between 1 January 2000 and 31 July 2012. All patients for whom abnormal findings were reported were excluded and only the first set of measurements for each patient was retained for analysis. Loess (local regression) analysis was performed using age and gravidity as explanatory variables.

RESULTS

Measurements of 5466 non-pregnant uteri were retrieved for analysis. The mean length was found to increase to 72 mm at the age of 40 and decrease to 42 mm at the age of 80 years. Gravidity was associated with greater uterine length, width and AP diameter. Mean length/width ratio was found to be 1.857 at birth, decreasing to 1.452 at the age of 91 years. At the age of 21 years, the mean ratio was found to be 1.618, i.e. equal to the golden ratio. Increasing gravidity was associated with lower mean length/width ratio.

CONCLUSIONS

Uterine size in non-pregnant women varies in relation to age and gravidity. Mean length/width ratio conformed to the golden ratio at the age of 21, coinciding with peak fertility.

Accuracy of peritoneal fluid measurements by transvaginal ultrasonography

OBJECTIVE

To assess the accuracy of the assessment of peritoneal fluid volumes of up to 1 L by transvaginal ultrasonography and to re-evaluate the formula used to calculate total volume from the dimensions of the largest pocket.

METHODS

Patients (n = 13) enrolled for a minor laparoscopic procedure were prospectively recruited. At the end of the procedure, with the patient in the 30 degrees anti-Trendelenburg position, Ringer's lactate was instilled into the abdomen in discrete steps up to 1 L. Following equilibration the diameters of the single pocket of fluid were measured by transvaginal ultrasonography in order to calculate the volume, and regression models were used to determine the relationship between this and the instilled volume. The body mass index (BMI) of the patient was evaluated as a parameter for predicting the instilled volume more accurately.

RESULTS

The intra-abdominal fluid volume could be calculated from the measured volume using a quadratic regression equation with an overall coefficient of variation of 19%. In individual patients, changes in volume could be assessed with a coefficient of variation of 7.3%. BMI was not found to be a significant parameter in relating the measured to the instilled volume.

CONCLUSION

Transvaginal ultrasound in a standardized setting can accurately estimate the volume of peritoneal fluid, with the accuracy consistent for small and large volumes. Changes in peritoneal fluid volume over time in the same individual can be measured more accurately than the total volume present.

Pain experienced during transvaginal ultrasound, saline contrast sonohysterography, hysteroscopy and office sampling: a comparative study

OBJECTIVE

To evaluate and compare the pain experienced by women during transvaginal ultrasound, saline contrast sonohysterography (SCSH), diagnostic hysteroscopy and office sampling.

METHODS

This was a descriptive study of 402 consecutive patients presenting at a 'one-stop' Bleeding Clinic between October 2004 and November 2006. Thirty-nine percent of the patients were postmenopausal. The patients underwent the following examinations transvaginally: first ultrasound with color Doppler, second SCSH, third diagnostic hysteroscopy and fourth endometrial biopsy. After completion of the examinations the patients were asked to complete a questionnaire including a visual analog scale (VAS) about their subjective appreciation of all four examinations. Two-hundred and ninety-three (72%) patients returned the questionnaire.

RESULTS

The median (range) VAS scores for transvaginal ultrasound, SCSH, diagnostic hysteroscopy and endometrial sampling were 1.0 (0-8.1), 2.2 (0-10), 2.7 (0-10) and 5.1 (0-10), respectively (P < 0.0001). The patients' answers to the other questions about the pain experienced, including comparison with other minor procedures such as venous blood sampling, were all concordant with the VAS scores.

CONCLUSIONS

Transvaginal ultrasound was the procedure best accepted, followed by SCSH, hysteroscopy and endometrial sampling. These results suggest that patients would prefer SCSH over hysteroscopy as an initial diagnostic approach in the evaluation of abnormal uterine bleeding.

HPV induced ovarian squamous cell carcinoma: case report and review of the literature

BACKGROUND

Ovarian squamous cell carcinoma is usually derived from a teratoma, a Brenner tumour or endometriosis. Association with an HPV infection is rare.

CASE

A fourth case of ovarian squamous cell cancer associated with HR-HPV is presented. Debulking for stage IIIc ovarian squamous cell cancer was performed and she received adjuvant combination chemotherapy. She developed bone metastases and received radiotherapy. The Progression of these metastases and the newly developed metastases did not respond to an oral tyrosine kinase inhibitor (gefitinib).

CONCLUSION

The development of bone metastases in association with an ovarian squamous cell carcinoma is a rare finding, and it did not respond to treatment with a tyrosine kinase. A review of literature is presented.

Prediction of recurrence after treatment for high-grade cervical intraepithelial neoplasia: the role of human papillomavirus testing and age at conisation

OBJECTIVES

The aim of this study was to examine the accuracy of the presence of high-risk human papillomavirus (HR-HPV) DNA (HR-HPV DNA test) postconisation as prediction of recurrent or residual cervical intraepithelial neoplasia (CIN) after treatment of high-grade cervical intraepithelial lesions (CIN2+) in a prospective study and to compare this with follow-up cytology and the marginal status of the excised tissue.

DESIGN

Prospective follow-up study.

SETTING

Unselected women presenting at colposcopy clinic of University Hospital Gasthuisberg, Leuven.

POPULATION

Seventy-two women treated with conisation for CIN2 or CIN3.

METHODS

Women were followed by HR-HPV DNA test (Hybrid Capture II test of Digene) every 3 to 6 months. The same vial was used for cytology and the HR-HPV DNA test (SurePath). All women were further followed by colposcopy and cytology for 24 months at 6-month intervals. The outcome of the study was presence of >CIN2, proven with colposcopy-directed biopsy occurring within 24 months after treatment. HR-HPV status was correlated with recurrent or residual CIN2+.

MAIN OUTCOME MEASURES

Sensitivity, specificity, predictive values and diagnostic odds ratios to predict treatment failure or cure were computed for HR-HPV testing, marginal status and follow-up cytology. HR-HPV status was also correlated with section margins postconisation and with the first cervical smear.

RESULTS

In 6 of the 72 treated women (8%), residual or recurrent CIN occurred. Women with recurrence were significantly older than women without a recurrence (51.5 +/- 9.6 versus 39.8 +/- 12.2 years, P= 0.007). All six women with recurrence were HR-HPV positive, four had a positive follow-up smear (>or=atypical squamous cells of uncertain significance = ASCUS+) and only two had involved section margins. Among the 66 cured women, 15 were HR-HPV positive, 6 had an abnormal smear and 12 had positive section margins. Sensitivity of cytology, positive section margins and HR-HPV DNA positivity was 66.7, 33.3 and 100% to predict treatment failure. Specificity of the three tests was, respectively, 90.9, 81.8 and 77.3%. Women with HR-HPV DNA at 3 to 6 months showed recurrent or residual CIN in 15% (2/13) if they had normal follow-up Pap smears and in 50% (4/8) if they had abnormal Pap smears. Margin status was not statistically significantly associated with human papillomavirus status.

CONCLUSION

Persistence or clearance of HR-HPV DNA is an early valid prognostic marker of failure or cure after treatment for CIN2+ and is more accurate than cytology or section margin status at the time of conisation. The absence of HR-HPV DNA has a 100% negative predictive value. Higher age at conisation may be a previously unrecognised risk factor for recurrence.

The pedicle artery sign based on sonography with color Doppler imaging can replace second-stage tests in women with abnormal vaginal bleeding

OBJECTIVE

Unenhanced transvaginal sonography is not accurate in the detection of endometrial polyps. Currently, second-stage tests such as saline contrast sonohysterography and office hysteroscopy are used to diagnose endometrial lesions, but both have limitations and side effects. We proposed visualization of the pedicle artery on color Doppler imaging as a sign of polyps.

METHODS

This was a prospective observational study involving 3099 consecutive patients referred for assessment of the endometrium and myometrium. The uterus was assessed in sagittal and coronal planes using color Doppler sonography. Patients with suspected endometrial pathology on sonography were noted and the volume of the focal lesion was calculated. Patients with a clearly visible pedicle artery reaching the central part of the endometrium were regarded as test-positive. The gold standard was defined as the presence or absence of an endometrial polyp at hysterectomy, hysteroscopy and/or endometrial histology on dilatation and curettage within 1 year of sonography.

RESULTS

Of the 3099 women, no gold standard was available in 2230. Only 28 of the 199 patients who were test-positive did not have a gold standard. In the 869 patients in whom a gold standard was available, 182 had one or more endometrial polyps. The pedicle artery test had an apparent sensitivity for detection of endometrial polyps of 76.4%, specificity of 95.3%, positive predictive value (PPV) of 81.3%, and negative predictive value of 93.8%. When extending the test to the prediction of any focal intracavitary pathology the PPV was 94.2%.

CONCLUSIONS

The pedicle artery test has a very high PPV for intracavitary pathology. We expect that in the majority of patients with an endometrial polyp this test may replace more invasive established second-stage tests, such as saline contrast sonohysterography and office hysteroscopy.