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English K, Frise C, Trinder J, Cauldwell M, Simpson M, Adamson D, Elton C, Burns G, Choudhary M, Nathanson M, Robert L, Moore J, O'Brien P, Pundir J. Best practice recommendations for medically assisted reproduction in patients with known cardiovascular disease or at high risk of cardiovascular disease. HUM FERTIL 2024; 27:2278295. [PMID: 38196173 DOI: 10.1080/14647273.2023.2278295] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2023] [Accepted: 10/02/2023] [Indexed: 01/11/2024]
Abstract
Increasing numbers of people are seeking assisted conception. In people with known cardiac disease or risk factors for cardiac disease, assisted conception may carry increased risks during treatment and any subsequent pregnancy. These risks should be assessed, considered and minimized prior to treatment.
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Affiliation(s)
- Kate English
- Department of Congenital Cardiology, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Charlotte Frise
- Department of Obstetrics, Queen Charlotte's and Chelsea Hospital, London, UK
| | | | | | | | - Dawn Adamson
- Department of Cardiology, University Hospitals Coventry and Warwickshire NHS Trust, Coventry, UK
| | - Chris Elton
- Department of Anaesthesia, Leicester Royal Infirmary, Leicester, UK
| | | | - Meenakshi Choudhary
- Newcastle Fertility Centre at Life, Newcastle Upon Tyne Hospitals NHS Foundation Trust, Newcastle Upon Tyne, UK
| | - Mike Nathanson
- Department of Anaesthesia, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Leema Robert
- Department of Clinical Genetics, Guys and St Thomas' NHS Foundation Trust, London, UK
| | - Jim Moore
- Department of Primary Care, NHS Gloucestershire Clinical Commissioning Group, Brockworth, UK
| | - Pat O'Brien
- Department of Obstetrics, University College London, London, UK
| | - Jyotsna Pundir
- Reproductive Medicine, St Bartholomew's Hospital, London, UK
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Pundir J, Dimitriou E, Thangaratinam S. P-612 Current understanding of polycystic ovary syndrome (PCOS) and potential interest in future trial to evaluate role of myo-inositol as ovulation induction agent – Stakeholder’s surveys. Hum Reprod 2022. [DOI: 10.1093/humrep/deac107.562] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Abstract
Study question
To assess awareness amongst consumers and gynaecologists on various aspects of PCOS and to explore the willingness to participate in a future trial of myo-inositol as an ovulation induction agent.
Summary answer
Significant lack of awareness on various aspect of PCOS amongst consumers is concerning. Gynaecologists and consumers are keen on trial exploring myo-inositol in anovulatory PCOS.
What is known already
Initial studies have reported that Myo-inositol can increase the frequency of menstruation and ovulation along with benefit with androgenic and glycaemic parameters in women with PCOS. There is a need for large, well designed and powered randomised controlled trial to evaluate the role of Myo-inositol as a fertility enhancing agent on its own and as an adjunct to clomiphene/letrozole in women with anovulatory PCOS. There has been a growing interest in patient and public involvement in setting research priorities to reduce the risk of discrepancy between what stakeholder’s experience as important unanswered questions and those which are actually researched.
Study design, size, duration
The surveys were hosted using on-line survey tool (www.surveymonkey.com) between Dec 2020 and April 2021, in the UK. Bespoke questionnaires were designed for the survey of gynaecologists (comprising of 27 questions) and the women with PCOS (comprising of 20 questions). These were peer reviewed and included, multiple choice questions, questions with a Likert scale response and open format questions. Ethical approval was provided by Queen Mary University of London (QMUL) ethics committee (Ref: QMERC2014/76).
Participants/materials, setting, methods
The online clinician survey was a cross sectional study of gynaecologists who look after women with PCOS, and the consumer survey was a cross sectional study of the members of PCOS support organisation “Verity”. The data was collected using on-line survey tool and was summarised descriptively using numbers and percentages. For the descriptive statistics, we used absolute and relative frequencies, and we also used the median and the IQR to detect the most common answers.
Main results and the role of chance
There were 244 responses; 104 gynaecologists and 140 consumers.
Majority of the consumers were aware that, women with PCOS struggle with irregular cycles (94%); to loss/maintain weight (83%); and to conceive (85%). 81% were aware of risk of subfertility, however, only half were aware of risks associated with irregular menstrual cycles (51%), gestational diabetes (57%) and long-term risks such as diabetes (62%). 96% felt subfertility was an important issue, however, only 2/5th were aware of treatment options, a third were aware of need for USS monitoring whilst taking clomid tablets and that clomid tablets can only be used for 6-12 cycles.
The clinician survey showed that 70% of the gynaecologists chose life-style measurements for the first line option and the second line options were 35% for clomiphene, 29% for clomiphene + metformin, followed by 21% for letrozole. 79% use USS to confirm ovulation and 60% by measuring serum progesterone; 37% monitor all cycles of ovulation induction whereas 41% monitor index cycle.
Two thirds of the gynaecologists (72%) and majority of consumers (88%) agreed on the need to research myo-inositol for ovulation induction in PCOS and were willing to participate in such a study. Barriers for recruitment and retention were also explored.
Limitations, reasons for caution
Clinician survey was unable to get the views of general practitioners and endocrinologists, who might have a different perspective particularly on non-reproductive outcomes. Consumer survey was online survey in English which can result in a selection bias and the views of women from other socio-economic and cultural backgrounds may differ.
Wider implications of the findings
These surveys provide vital information in planning a definitive RCT on the role of myo-inositol in women with anovulatory PCOS trying to conceive. Further research tools need to be explored to provide better information and education to the women with PCOS particularly on the long-term risks associated with PCOS.
Trial registration number
NA
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Affiliation(s)
- J Pundir
- St Bartholomew's Hospital, Centre of Reproductive Medicine , London, United Kingdom
| | - E Dimitriou
- National and Kapodistrian University of Athens-, Department of Mathematics & Medical School- , Athens-, Greece
| | - S Thangaratinam
- Institute of Metabolism and Systems Research University of Birmingham, University of Birmingham- Edgbaston- Birmingham , Birmingham, United Kingdom
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Maheshwari A, Bari V, Bell JL, Bhattacharya S, Bhide P, Bowler U, Brison D, Child T, Chong HY, Cheong Y, Cole C, Coomarasamy A, Cutting R, Goodgame F, Hardy P, Hamoda H, Juszczak E, Khalaf Y, King A, Kurinczuk JJ, Lavery S, Lewis-Jones C, Linsell L, Macklon N, Mathur R, Murray D, Pundir J, Raine-Fenning N, Rajkohwa M, Robinson L, Scotland G, Stanbury K, Troup S. Transfer of thawed frozen embryo versus fresh embryo to improve the healthy baby rate in women undergoing IVF: the E-Freeze RCT. Health Technol Assess 2022; 26:1-142. [PMID: 35603917 PMCID: PMC9376799 DOI: 10.3310/aefu1104] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Freezing all embryos, followed by thawing and transferring them into the uterine cavity at a later stage (freeze-all), instead of fresh-embryo transfer may lead to improved pregnancy rates and fewer complications during in vitro fertilisation and pregnancies resulting from it. OBJECTIVE We aimed to evaluate if a policy of freeze-all results in a higher healthy baby rate than the current policy of transferring fresh embryos. DESIGN This was a pragmatic, multicentre, two-arm, parallel-group, non-blinded, randomised controlled trial. SETTING Eighteen in vitro fertilisation clinics across the UK participated from February 2016 to April 2019. PARTICIPANTS Couples undergoing their first, second or third cycle of in vitro fertilisation treatment in which the female partner was aged < 42 years. INTERVENTIONS If at least three good-quality embryos were present on day 3 of embryo development, couples were randomly allocated to either freeze-all (intervention) or fresh-embryo transfer (control). OUTCOMES The primary outcome was a healthy baby, defined as a live, singleton baby born at term, with an appropriate weight for their gestation. Secondary outcomes included ovarian hyperstimulation, live birth and clinical pregnancy rates, complications of pregnancy and childbirth, health economic outcome, and State-Trait Anxiety Inventory scores. RESULTS A total of 1578 couples were consented and 619 couples were randomised. Most non-randomisations were because of the non-availability of at least three good-quality embryos (n = 476). Of the couples randomised, 117 (19%) did not adhere to the allocated intervention. The rate of non-adherence was higher in the freeze-all arm, with the leading reason being patient choice. The intention-to-treat analysis showed a healthy baby rate of 20.3% in the freeze-all arm and 24.4% in the fresh-embryo transfer arm (risk ratio 0.84, 95% confidence interval 0.62 to 1.15). Similar results were obtained using complier-average causal effect analysis (risk ratio 0.77, 95% confidence interval 0.44 to 1.10), per-protocol analysis (risk ratio 0.87, 95% confidence interval 0.59 to 1.26) and as-treated analysis (risk ratio 0.91, 95% confidence interval 0.64 to 1.29). The risk of ovarian hyperstimulation was 3.6% in the freeze-all arm and 8.1% in the fresh-embryo transfer arm (risk ratio 0.44, 99% confidence interval 0.15 to 1.30). There were no statistically significant differences between the freeze-all and the fresh-embryo transfer arms in the live birth rates (28.3% vs. 34.3%; risk ratio 0.83, 99% confidence interval 0.65 to 1.06) and clinical pregnancy rates (33.9% vs. 40.1%; risk ratio 0.85, 99% confidence interval 0.65 to 1.11). There was no statistically significant difference in anxiety scores for male participants (mean difference 0.1, 99% confidence interval -2.4 to 2.6) and female participants (mean difference 0.0, 99% confidence interval -2.2 to 2.2) between the arms. The economic analysis showed that freeze-all had a low probability of being cost-effective in terms of the incremental cost per healthy baby and incremental cost per live birth. LIMITATIONS We were unable to reach the original planned sample size of 1086 and the rate of non-adherence to the allocated intervention was much higher than expected. CONCLUSION When efficacy, safety and costs are considered, freeze-all is not better than fresh-embryo transfer. TRIAL REGISTRATION This trial is registered as ISRCTN61225414. FUNDING This project was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 26, No. 25. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Abha Maheshwari
- Aberdeen Fertility Centre, NHS Grampian and University of Aberdeen, Aberdeen, UK
| | - Vasha Bari
- Clinical Trials Unit National Perinatal Epidemiology Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Jennifer L Bell
- Clinical Trials Unit National Perinatal Epidemiology Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | | | - Priya Bhide
- Assisted Conception Unit, Homerton University Hospital NHS Foundation Trust and Queen Mary University of London, London, UK
| | - Ursula Bowler
- Clinical Trials Unit National Perinatal Epidemiology Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Daniel Brison
- Assisted Conception Unit, Manchester University NHS Foundation Trust, Manchester, UK
| | - Tim Child
- Oxford Fertility, The Fertility Partnership, University of Oxford, Oxford, UK
| | - Huey Yi Chong
- Aberdeen Fertility Centre, NHS Grampian and University of Aberdeen, Aberdeen, UK
| | - Ying Cheong
- Complete Fertility Centre, University of Southampton, Southampton, UK
| | - Christina Cole
- Clinical Trials Unit National Perinatal Epidemiology Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Arri Coomarasamy
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Rachel Cutting
- Human Fertilisation and Embryology Authority, London, UK
| | - Fiona Goodgame
- Clinical Trials Unit National Perinatal Epidemiology Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Pollyanna Hardy
- Clinical Trials Unit National Perinatal Epidemiology Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Haitham Hamoda
- Assisted Conception Unit, King's College Hospital, London, UK
| | - Edmund Juszczak
- Clinical Trials Unit National Perinatal Epidemiology Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK.,Nottingham Clinical Trials Unit, University of Nottingham, Nottingham, UK
| | - Yacoub Khalaf
- Assisted Conception Unit and Centre for Pre-implantation Genetic Diagnosis, Guy's and St Thomas' Hospital and King's College London, London, UK
| | - Andrew King
- Clinical Trials Unit National Perinatal Epidemiology Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Jennifer J Kurinczuk
- Clinical Trials Unit National Perinatal Epidemiology Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Stuart Lavery
- Assisted Conception Unit, Imperial College London, London, UK
| | | | - Louise Linsell
- Clinical Trials Unit National Perinatal Epidemiology Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Nick Macklon
- London Women's Clinic, London, UK.,Gynaecology, University of Copenhagen, Copenhagen, Denmark
| | - Raj Mathur
- Assisted Conception Unit, St Mary's Hospital, Manchester, UK
| | - David Murray
- Clinical Trials Unit National Perinatal Epidemiology Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Jyotsna Pundir
- Assisted Conception Unit, St Bartholomew's Hospital, London, UK
| | | | | | - Lynne Robinson
- Gyanecology and Assisted Conception, Birmingham Women's and Children's NHS Foundation Trust, Birmingham, UK
| | - Graham Scotland
- Aberdeen Fertility Centre, NHS Grampian and University of Aberdeen, Aberdeen, UK
| | - Kayleigh Stanbury
- Clinical Trials Unit National Perinatal Epidemiology Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
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Maheshwari A, Bell JL, Bhide P, Brison D, Child T, Chong HY, Cheong Y, Cole C, Coomarasamy A, Cutting R, Hardy P, Hamoda H, Juszczak E, Khalaf Y, Kurinczuk JJ, Lavery S, Linsell L, Macklon N, Mathur R, Pundir J, Raine-Fenning N, Rajkohwa M, Scotland G, Stanbury K, Troup S, Bhattacharya S. Elective freezing of embryos versus fresh embryo transfer in IVF: a multicentre randomized controlled trial in the UK (E-Freeze). Hum Reprod 2022; 37:476-487. [PMID: 34999830 PMCID: PMC9206534 DOI: 10.1093/humrep/deab279] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2021] [Revised: 11/24/2021] [Indexed: 11/30/2022] Open
Abstract
STUDY QUESTION Does a policy of elective freezing of embryos, followed by frozen embryo transfer result in a higher healthy baby rate, after first embryo transfer, when compared with the current policy of transferring fresh embryos? SUMMARY ANSWER This study, although limited by sample size, provides no evidence to support the adoption of a routine policy of elective freeze in preference to fresh embryo transfer in order to improve IVF effectiveness in obtaining a healthy baby. WHAT IS KNOWN ALREADY The policy of freezing all embryos followed by frozen embryo transfer is associated with a higher live birth rate for high responders but a similar/lower live birth after first embryo transfer and cumulative live birth rate for normal responders. Frozen embryo transfer is associated with a lower risk of ovarian hyperstimulation syndrome (OHSS), preterm delivery and low birthweight babies but a higher risk of large babies and pre-eclampsia. There is also uncertainty about long-term outcomes, hence shifting to a policy of elective freezing for all remains controversial given the delay in treatment and extra costs involved in freezing all embryos. STUDY DESIGN, SIZE, DURATION A pragmatic two-arm parallel randomized controlled trial (E-Freeze) was conducted across 18 clinics in the UK from 2016 to 2019. A total of 619 couples were randomized (309 to elective freeze/310 to fresh). The primary outcome was a healthy baby after first embryo transfer (term, singleton live birth with appropriate weight for gestation); secondary outcomes included OHSS, live birth, clinical pregnancy, pregnancy complications and cost-effectiveness. PARTICIPANTS/MATERIALS, SETTING, METHODS Couples undergoing their first, second or third cycle of IVF/ICSI treatment, with at least three good quality embryos on Day 3 where the female partner was ≥18 and <42 years of age were eligible. Those using donor gametes, undergoing preimplantation genetic testing or planning to freeze all their embryos were excluded. IVF/ICSI treatment was carried out according to local protocols. Women were followed up for pregnancy outcome after first embryo transfer following randomization. MAIN RESULTS AND THE ROLE OF CHANCE Of the 619 couples randomized, 307 and 309 couples in the elective freeze and fresh transfer arms, respectively, were included in the primary analysis. There was no evidence of a statistically significant difference in outcomes in the elective freeze group compared to the fresh embryo transfer group: healthy baby rate {20.3% (62/307) versus 24.4% (75/309); risk ratio (RR), 95% CI: 0.84, 0.62 to 1.15}; OHSS (3.6% versus 8.1%; RR, 99% CI: 0.44, 0.15 to 1.30); live birth rate (28.3% versus 34.3%; RR, 99% CI 0.83, 0.65 to 1.06); and miscarriage (14.3% versus 12.9%; RR, 99% CI: 1.09, 0.72 to 1.66). Adherence to allocation was poor in the elective freeze group. The elective freeze approach was more costly and was unlikely to be cost-effective in a UK National Health Service context. LIMITATIONS, REASONS FOR CAUTION We have only reported on first embryo transfer after randomization; data on the cumulative live birth rate requires further follow-up. Planned target sample size was not obtained and the non-adherence to allocation rate was high among couples in the elective freeze arm owing to patient preference for fresh embryo transfer, but an analysis which took non-adherence into account showed similar results. WIDER IMPLICATIONS OF THE FINDINGS Results from the E-Freeze trial do not lend support to the policy of electively freezing all for everyone, taking both efficacy, safety and costs considerations into account. This method should only be adopted if there is a definite clinical indication. STUDY FUNDING/COMPETING INTEREST(S) NIHR Health Technology Assessment programme (13/115/82). This research was funded by the National Institute for Health Research (NIHR) (NIHR unique award identifier) using UK aid from the UK Government to support global health research. The views expressed in this publication are those of the author(s) and not necessarily those of the NIHR or the UK Department of Health and Social Care. J.L.B., C.C., E.J., P.H., J.J.K., L.L. and G.S. report receipt of funding from NIHR, during the conduct of the study. J.L.B., E.J., P.H., K.S. and L.L. report receipt of funding from NIHR, during the conduct of the study and outside the submitted work. A.M. reports grants from NIHR personal fees from Merck Serono, personal fees for lectures from Merck Serono, Ferring and Cooks outside the submitted work; travel/meeting support from Ferring and Pharmasure and participation in a Ferring advisory board. S.B. reports receipt of royalties and licenses from Cambridge University Press, a board membership role for NHS Grampian and other financial or non-financial interests related to his roles as Editor-in-Chief of Human Reproduction Open and Editor and Contributing Author of Reproductive Medicine for the MRCOG, Cambridge University Press. D.B. reports grants from NIHR, during the conduct of the study; grants from European Commission, grants from Diabetes UK, grants from NIHR, grants from ESHRE, grants from MRC, outside the submitted work. Y.C. reports speaker fees from Merck Serono, and advisory board role for Merck Serono and shares in Complete Fertility. P.H. reports membership of the HTA Commissioning Committee. E.J. reports membership of the NHS England and NIHR Partnership Programme, membership of five Data Monitoring Committees (Chair of two), membership of six Trial Steering Committees (Chair of four), membership of the Northern Ireland Clinical Trials Unit Advisory Group and Chair of the board of Oxford Brain Health Clinical Trials Unit. R.M. reports consulting fees from Gedeon Richter, honorarium from Merck, support fees for attendance at educational events and conferences for Merck, Ferring, Bessins and Gedeon Richter, payments for participation on a Merck Safety or Advisory Board, Chair of the British Fertility Society and payments for an advisory role to the Human Fertilisation and Embryology Authority. G.S. reports travel and accommodation fees for attendance at a health economic advisory board from Merck KGaA, Darmstadt, Germany. N.R.-F. reports shares in Nurture Fertility. Other authors' competing interests: none declared. TRIAL REGISTRATION NUMBER ISRCTN: 61225414. TRIAL REGISTRATION DATE 29 December 2015. DATE OF FIRST PATIENT’S ENROLMENT 16 February 2016.
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Affiliation(s)
- Abha Maheshwari
- Aberdeen Fertility Centre, NHS Grampian and University of Aberdeen, Aberdeen, UK
| | - Jennifer L Bell
- National Perinatal Epidemiology Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Priya Bhide
- Assisted Conception Unit, Homerton University Hospital NHS Foundation Trust and Queen Mary University of London, London, UK
| | - Daniel Brison
- Assisted Conception Unit, Manchester University NHS Foundation Trust, Manchester, UK
| | - Tim Child
- Oxford Fertility, TFP, University of Oxford, UK
| | - Huey Yi Chong
- Health Economics Research Unit, University of Aberdeen, Aberdeen, UK
| | - Ying Cheong
- Complete Fertility, University of Southampton, Southampton, UK
| | - Christina Cole
- National Perinatal Epidemiology Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Arri Coomarasamy
- Department of Metabolomics, University of Birmingham, Birmingham, UK
| | | | - Pollyanna Hardy
- National Perinatal Epidemiology Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Haitham Hamoda
- Assisted Conception Unit, King's College Hospital, London, UK
| | - Edmund Juszczak
- National Perinatal Epidemiology Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK.,Nottingham Clinical Trials Unit, University of Nottingham, Nottingham, UK
| | - Yacoub Khalaf
- Assisted Conception Unit and Centre for Pre-implantation Genetic Diagnosis, Guy's and St Thomas' Hospital and King's College London, London, UK
| | - Jennifer J Kurinczuk
- National Perinatal Epidemiology Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | | | - Louise Linsell
- National Perinatal Epidemiology Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Nick Macklon
- London Women's Clinic, London, UK.,University of Copenhagen, Denmark
| | - Raj Mathur
- Assisted Conception Unit, St. Mary's Hospital, Manchester, UK
| | - Jyotsna Pundir
- Assisted Conception Unit, St. Bartholomew's Hospital and Queen Mary University of London, London, UK
| | | | | | - Graham Scotland
- Health Economics Research Unit, University of Aberdeen, Aberdeen, UK
| | - Kayleigh Stanbury
- National Perinatal Epidemiology Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
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Manchanda R, Gaba F, Talaulikar V, Pundir J, Gessler S, Davies M, Menon U. Risk-Reducing Salpingo-Oophorectomy and the Use of Hormone Replacement Therapy Below the Age of Natural Menopause: Scientific Impact Paper No. 66 October 2021: Scientific Impact Paper No. 66. BJOG 2022; 129:e16-e34. [PMID: 34672090 PMCID: PMC7614764 DOI: 10.1111/1471-0528.16896] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
This paper deals with the use of hormone replacement therapy (HRT) after the removal of fallopian tubes and ovaries to prevent ovarian cancer in premenopausal high risk women. Some women have an alteration in their genetic code, which makes them more likely to develop ovarian cancer. Two well-known genes which can carry an alteration are the BRCA1 and BRCA2 genes. Examples of other genes associated with an increased risk of ovarian cancer include RAD51C, RAD51D, BRIP1, PALB2 and Lynch syndrome genes. Women with a strong family history of ovarian cancer and/or breast cancer, may also be at increased risk of developing ovarian cancer. Women at increased risk can choose to have an operation to remove the fallopian tubes and ovaries, which is the most effective way to prevent ovarian cancer. This is done after a woman has completed her family. However, removal of ovaries causes early menopause and leads to hot flushes, sweats, mood changes and bone thinning. It can also cause memory problems and increases the risk of heart disease. It may reduce libido or impair sexual function. Guidance on how to care for women following preventative surgery who are experiencing early menopause is needed. HRT is usually advisable for women up to 51 years of age (average age of menopause for women in the UK) who are undergoing early menopause and have not had breast cancer, to minimise the health risks linked to early menopause. For women with a womb, HRT should include estrogen coupled with progestogen to protect against thickening of the lining of the womb (called endometrial hyperplasia). For women without a womb, only estrogen is given. Research suggests that, unlike in older women, HRT for women in early menopause does not increase breast cancer risk, including in those who are BRCA1 and BRCA2 carriers and have preventative surgery. For women with a history of receptor-negative breast cancer, the gynaecologist will liaise with an oncology doctor on a case-by-case basis to help to decide if HRT is safe to use. Women with a history of estrogen receptor-positive breast cancer are not normally offered HRT. A range of other therapies can be used if a woman is unable to take HRT. These include behavioural therapy and non-hormonal medicines. However, these are less effective than HRT. Regular exercise, healthy lifestyle and avoiding symptom triggers are also advised. Whether to undergo surgery to reduce risk or not and its timing can be a complex decision-making process. Women need to be carefully counselled on the pros and cons of both preventative surgery and HRT use so they can make informed decisions and choices.
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Pundir J, Achilli C, Bhide P, Sabatini L, Legro RS, Rombauts L, Teede H, Coomarasamy A, Zamora J, Thangaratinam S. Risk of foetal harm with letrozole use in fertility treatment: a systematic review and meta-analysis. Hum Reprod Update 2020; 27:474-485. [PMID: 33374012 DOI: 10.1093/humupd/dmaa055] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2020] [Revised: 09/06/2020] [Indexed: 01/22/2023] Open
Abstract
BACKGROUND The aromatase inhibitor letrozole is increasingly recommended for ovulation induction, as it is more effective with fewer side-effects than other agents. But many clinicians are reluctant to use the drug for fertility treatment due to a strong-label warning against its use, which warns about congenital malformation risk to the foetus in women seeking pregnancy. OBJECTIVE AND RATIONALE The aim of this study was to determine the risks of congenital malformations and pregnancy loss with letrozole compared with clomiphene primarily, and with other fertility drugs and natural conception. SEARCH METHODS A systematic review and meta-analysis using PRISMA harms guidelines. We searched MEDLINE, EMBASE and other sources from inception until January 2020, with the MeSH words for 'letrozole' and pregnancy OR foetal/neonatal outcome. We included studies reported on congenital malformations in foetuses born to mothers conceived after fertility treatment, with letrozole versus clomiphene, placebo, gonadotrophins, metformin, natural conception or other agents, from randomised trials, comparative cohort studies and non-comparative observational cohorts. Quality of the studies was assessed using Cochrane risk of bias tool and Newcastle Ottawa Scale. The McMaster tool was used to assess the quality of reported harm for foetal congenital malformations in the studies. We compared the absolute risk of events using risk difference measures and pooled the findings using a fixed-effect model. We evaluated the statistical heterogeneity using forest plots and the I2 statistic and funnel plot to assess publication bias. We assessed the strength of evidence for congenital malformation and pregnancy loss as per the GRADE recommendations and with the Fragility index. OUTCOMES We included 46 studies (18 randomised trials; 21 comparative cohorts; 7 non-comparative cohorts). Overall 2.15% (101/4697; 95% CI 1.7 to 2.5) of babies conceived on letrozole for fertility treatment had congenital foetal malformations. We did not observe a significant increase in congenital malformations with letrozole versus clomiphene in the randomised trials (risk difference (RD) 0.01, 95% CI -0.02, 0.03; I2 = 0%; 14 studies) and found a significant reduction in the cohort studies (RD -0.02, 95% CI -0.04, -0.01; I2 = 0%, 11 studies). The fragility index was 44% (7/16) (either an increase in the intervention arm or a decrease in control arm was needed to alter the results). The risks of pregnancy loss were not increased with letrozole versus clomiphene in the 14 randomised trials (RD -0.01, 95% CI -0.06, 0.04; I2 = 0%), and the risks were reduced in the six cohort studies (RD -0.09, 95% CI -0.17, -0.00; I2 = 68%). The GRADE quality of evidence was low to moderate for congenital malformations and pregnancy loss. We did not find any increased congenital malformation risk with letrozole versus gonadotrophins, natural conception or natural cycle ART, but the number of studies was small. WIDER IMPLICATIONS There is no evidence that letrozole increases the risk of congenital foetal malformation or pregnancy loss compared with clomiphene, natural conception or other fertility agents, to warrant warning against its use. Given its therapeutic benefits and lack of evidence of harm to the foetus, clinicians should consider letrozole as first-line agent for ovulation induction.
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Affiliation(s)
- Jyotsna Pundir
- Queen Mary University, London E1 4NS, UK.,Centre for Reproductive Medicine, St. Bartholomew's Hospital, London EC1A 7BE, UK
| | - Chiara Achilli
- Hewitt Fertility Centre, Liverpool Women's Hospital, Liverpool L8 7SS, UK
| | - Priya Bhide
- Centre for Women's Health, Queen Mary University of London, E1 2AB, UK.,Homerton University Hospital, London E9 6SR, UK
| | - Luca Sabatini
- Centre for Reproductive Medicine, St. Bartholomew's Hospital, London EC1A 7BE, UK
| | - Richard S Legro
- Department of Obstetrics and Gynecology, Penn State University College of Medicine, USA
| | | | - Helena Teede
- Monash Centre for Health Research and Implementation, Monash University, Clayton, VIC 3800, Australia
| | - Arri Coomarasamy
- Tommy's National Centre for Miscarriage Research, Institute of Metabolism and Systems Research, University of Birmingham, Edgbaston, Birmingham B15 2TT, UK.,Birmingham Women's and Children's NHS Foundation Trust, Birmingham, UK
| | - Javier Zamora
- CIBER Epidemiology and Public Health, Clinical Biostatistics Unit, Hospital Ramon y Cajal Ctra, Madrid 28034, Spain.,Women's Health Research Unit, Queen Mary University of London
| | - Shakila Thangaratinam
- Birmingham Women's and Children's NHS Foundation Trust, Birmingham, UK.,Institute of Metabolism and Systems Research, University of Birmingham, Edgbaston, Birmingham B15 2TT UK
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7
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Pundir J, Charles D, Sabatini L, Hiam D, Jitpiriyaroj S, Teede H, Coomarasamy A, Moran L, Thangaratinam S. Overview of systematic reviews of non-pharmacological interventions in women with polycystic ovary syndrome. Hum Reprod Update 2020; 25:243-256. [PMID: 30608609 DOI: 10.1093/humupd/dmy045] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2018] [Revised: 10/21/2018] [Accepted: 11/28/2018] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND Polycystic ovary syndrome (PCOS) is a major contributor to subfertility, diabetes and cardiovascular disease in women. The role of non-pharmacological interventions to prevent these outcomes has been reported in many systematic reviews, but robust conclusions have not been made due to variations in the scope, quality and findings of these reviews. OBJECTIVE AND RATIONALE Our aim was to provide an overview of existing evidence on the effects of non-pharmacological interventions in women with PCOS on fertility and non-fertility outcomes by a review of existing systematic reviews. SEARCH METHODS We reviewed systematic reviews of randomized trials that have evaluated the effects of non-pharmacological interventions, such as lifestyle interventions, nutritional supplements or alternative medicine therapies in women with PCOS on fertility, endocrine, glycaemic and weight-related outcomes. We assessed the quality of systematic reviews with the AMSTAR tool, and reported the outcomes with regard to: fertility (live birth, clinical pregnancy, ovulation and menstrual cycle regularization); endocrine outcomes (Ferriman-Gallwey score, free androgen index, free testosterone and total testosterone levels); and glycaemic (fasting blood insulin, fasting blood glucose, homoeostatic model assessment) and weight-related (BMI) outcomes. We assessed the strength of evidence for significant outcomes as per the grading of recommendations assessment, development and evaluation (GRADE) system. OUTCOMES We found twelve eligible systematic reviews which included between three (143 women) and 27 randomized trials (2093 women). Four reviews assessed the effects of lifestyle interventions (diet, physical activity and/or behavioural interventions); four evaluated nutritional supplements (one each on n-acetylcysteine, omega-3 fatty acids, inositol and vitamin D); and four studied alternative medical therapies (Chinese herbal medicine and acupuncture). All of the included reviews were of high quality and scored between 8 and 11 with the AMSTAR tool (with a maximum score of 11).Randomized evidence is lacking for live birth rate. N-acetylcysteine, inositol and the addition of alternative medicine to ovulation induction agents show preliminary potential to improve fertility (odds ratios (OR) for clinical pregnancy rate range from 1.99 to 4.83). Lifestyle interventions show benefits in improving hirsutism (mean difference (MD): -1.01 to -1.19). Lifestyle interventions (MD: -1.10 to -2.02), inositol (MD: -2.1) and acupuncture (MD: -1.90 to -3.43) all show some evidence of improvement in glycaemic outcomes and there is some evidence of reduced BMI with lifestyle interventions (MD: -0.15 to -1.12). All of these outcomes scored either low or very low quality of evidence on the GRADE score. WIDER IMPLICATIONS Lifestyle interventions in women with PCOS appear to improve glycaemic results, androgenic symptoms and anthropometric outcomes. The role of inositol and N-acetylcysteine in women with PCOS needs further evaluation. Large primary trials on all interventions are needed for an agreed set of core outcomes.
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Affiliation(s)
- Jyotsna Pundir
- Centre for Reproductive Medicine, St. Bartholomew's Hospital, London, UK
| | - David Charles
- Barts and the London School of Medicine, Queen Mary University of London, London, UK
| | - Luca Sabatini
- Centre for Reproductive Medicine, St. Bartholomew's Hospital, London, UK
| | - Danielle Hiam
- Institute of Health and Sport, Victoria University, Footscray, Australia
| | - Sonia Jitpiriyaroj
- Monash Centre for Health Research and Implementation, Monash University, Clayton, Australia
| | - Helena Teede
- Monash Centre for Health Research and Implementation, Monash University, Clayton, Australia
| | - Arri Coomarasamy
- Tommy's National Centre for Miscarriage Research, University of Birmingham, Birmingham, UK
| | - Lisa Moran
- Monash Centre for Health Research and Implementation, Monash University, Clayton, Australia
| | - Shakila Thangaratinam
- Women's Health Research Unit, The Blizard Institute, Queen Mary University of London, London, UK
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8
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Gadalla MA, Norman RJ, Tay CT, Hiam DS, Melder A, Pundir J, Thangaratinam S, Teede HJ, Mol BWJ, Moran LJ. Medical and Surgical Treatment of Reproductive Outcomes in Polycystic Ovary Syndrome: An Overview of Systematic Reviews. Int J Fertil Steril 2019; 13:257-270. [PMID: 31710185 PMCID: PMC6875858 DOI: 10.22074/ijfs.2020.5608] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/01/2018] [Accepted: 03/10/2019] [Indexed: 12/28/2022]
Abstract
Polycystic ovary syndrome (PCOS) is a common, complex condition that affects up to 18% of reproductive-
aged women, causing reproductive, metabolic and psychological dysfunctions. We performed an overview
and appraisal of methodological quality of systematic reviews that assessed medical and surgical treatments
for reproductive outcomes in women with PCOS. Databases (MEDLINE, EMBASE, CINAHL PLUS and
PROSPERO) were searched on the 15th of September 2017. We included any systematic review that assessed
the effect of medical or surgical management of PCOS on reproductive, pregnancy and neonatal outcomes.
Eligibility assessment, data extraction and quality assessment by the Assessing the Methodological Quality
of Systematic Reviews (AMSTAR) tool were performed in duplicate. We identified 53 reviews comprising
44 reviews included in this overview; the majority were moderate to high quality. In unselected women with
PCOS, letrozole was associated with a higher live birth rate than clomiphene citrate (CC), while CC was better
than metformin or placebo. In women with CC-resistant PCOS, gonadotrophins were associated with a higher
live birth rate than CC plus metformin, which was better than laparoscopic ovarian drilling (LOD). LOD was
associated with lower multiple pregnancy rates than other medical treatments. In women with PCOS undergo-
ing in vitro fertilization/intracytoplasmic sperm injection (IVF/ICSI), the addition of metformin to gonadotro-
phins resulted in less ovarian hyperstimulation syndrome (OHSS), and higher pregnancy and live birth rates
than gonadotrophins alone. Gonadotrophin releasing hormone (GnRH) antagonist was associated with less
OHSS, gonadotrophin units and shorter stimulation length than GnRH agonist. Letrozole appears to be a good
first line treatment and gonadotrophins, as a second line treatment, for anovulatory women with PCOS. LOD
results in lower multiple pregnancy rates. However, due to the heterogeneous nature of the included popula-
tions of women with PCOS, further larger scale trials are needed with more precise assessment of treatments
according to heterogeneous variants of PCOS.
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Affiliation(s)
- Moustafa A Gadalla
- Women's Health Hospital, Department of Obstetrics and Gynaecology, Assiut University, Assiut, Egypt.Elevtronic Address:.,Robinson Research Institute, Discipline of Obstetrics and Gynaecology, University of Adelaide, Adelaide, Australia
| | - Robert J Norman
- Monash Centre for Health Research and Implementation, School of Public Health and Preventive Medicine, Victoria, Melbourne, Australia.,Monash Diabetes and Endocrinology Units, Monash Health, Victoria, Melbourne, Australia
| | | | - Danielle S Hiam
- Institute of Sport, Exercise and Active Living, Victoria University, Melbourne, Australia
| | - Angela Melder
- Monash Centre for Health Research and Implementation, School of Public Health and Preventive Medicine, Victoria, Melbourne, Australia
| | - Jyotsna Pundir
- Centre of Reproductive Medicine, St Bartholomew's Hospital, London, United Kingdom
| | - Shakila Thangaratinam
- Women's Health Research Unit, Barts and the London School of Medicine and Dentistry, Queen Mary University London, London, United Kingdom
| | - Helena J Teede
- Monash Centre for Health Research and Implementation, School of Public Health and Preventive Medicine, Victoria, Melbourne, Australia.,Monash Diabetes and Endocrinology Units, Monash Health, Victoria, Melbourne, Australia
| | - Ben W J Mol
- Robinson Research Institute, Discipline of Obstetrics and Gynaecology, University of Adelaide, Adelaide, Australia.,Department of Obstetrics and Gynaecology, Monash University, Clayton, Victoria, Melbourne, Australia
| | - Lisa J Moran
- Robinson Research Institute, Discipline of Obstetrics and Gynaecology, University of Adelaide, Adelaide, Australia.,Monash Centre for Health Research and Implementation, School of Public Health and Preventive Medicine, Victoria, Melbourne, Australia
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Teo UL, Kopeika J, Pundir J, El-Toukhy T. Peri-operative morbidity and fertility outcome after repeat abdominal myomectomy for large fibroid uterus. J OBSTET GYNAECOL 2019; 40:673-677. [DOI: 10.1080/01443615.2019.1647520] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Affiliation(s)
- Ung Lim Teo
- Department of Obstetrics and Gynaecology, Guys’ and St. Thomas’ Hospital NHS Foundation Trust, London, UK
| | - Julia Kopeika
- Department of Obstetrics and Gynaecology, Guys’ and St. Thomas’ Hospital NHS Foundation Trust, London, UK
| | - Jyotsna Pundir
- Department of Obstetrics and Gynaecology, Guys’ and St. Thomas’ Hospital NHS Foundation Trust, London, UK
| | - Tarek El-Toukhy
- Department of Obstetrics and Gynaecology, Guys’ and St. Thomas’ Hospital NHS Foundation Trust, London, UK
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10
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Bhide P, Pundir J, Gudi A, Shah A, Homburg R, Acharya G. The effect of myo-inositol/di-chiro-inositol on markers of ovarian reserve in women with PCOS undergoing IVF/ICSI: A systematic review and meta-analysis. Acta Obstet Gynecol Scand 2019; 98:1235-1244. [PMID: 30993683 DOI: 10.1111/aogs.13625] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2019] [Revised: 03/27/2019] [Accepted: 04/08/2019] [Indexed: 12/25/2022]
Abstract
INTRODUCTION High levels of anti-Mullerian hormone and a high antral follicle count in women with polycystic ovary syndrome, reflecting increased ovarian antral follicles, predisposes them to have a high number of retrieved oocytes with in vitro fertilization (IVF)/intracytoplasmic sperm injection (ICSI) and an increased risk of ovarian hyperstimulation syndrome. Inositols, which act as insulin sensitizers, have the potential to alter folliculogenesis and the functional ovarian reserve, with subsequent benefits to reproductive outcomes following IVF/ICSI treatment. Published literature is, however, unable to provide definitive evidence of its efficacy. The objective of our review was to evaluate the effect of inositols on anti-Mullerian hormone, antral follicle count and reproductive outcomes in women with polycystic ovary syndrome undergoing IVF/ICSI. MATERIAL AND METHODS We performed a literature search using standard methodology recommended by Cochrane. Randomized controlled trials and non-randomized studies comparing inositols with no treatment, placebo or other treatment were included in the review. Using standard methodology recommended by Cochrane we pooled results using the random effects model; our findings were reported as relative risk or mean differences. PROSPERO registration: CRD42017082275. RESULTS We included 18 trials. The primary outcome was a change in anti-Mullerian hormone and antral follicle count before and after treatment, for which data were unsuitable for meta-analysis. A narrative review showed no consistent direction or size of effect. A meta-analysis for the secondary outcomes showed no evidence of a significant difference between inositol and control groups for any outcome: number of oocytes (mean difference -0.39, 95% confidence interval [CI] -1.11 to 0.33), number of metaphase II oocytes (mean difference 0.29, 95% CI -0.83 to 1.40), number of top grade embryos (risk ratio [RR] 1.02, 95% CI 0.93-1.12), clinical pregnancy rate (RR 1.16, 95% CI 0.87-1.53), and risk of ovarian hyperstimulation syndrome (RR 0.73, 95% CI 0.39-1.37). The quality of evidence was assessed as very low. CONCLUSIONS There is insufficient evidence for an effect of inositols on ovarian reserve markers and to support their use as pretreatment before IVF/ICSI in women with polycystic ovary syndrome.
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Affiliation(s)
- Priya Bhide
- Women's Health and Perinatology Research Group, Department of Clinical Medicine, UiT - The Arctic University of Norway, Tromsø, Norway.,Homerton Fertility Center, Homerton University Hospital, London, UK
| | - Jyotsna Pundir
- Center for Reproductive Medicine, St Bartholomew's Hospital, London, UK
| | - Anil Gudi
- Homerton Fertility Center, Homerton University Hospital, London, UK
| | - Amit Shah
- Homerton Fertility Center, Homerton University Hospital, London, UK
| | - Roy Homburg
- Homerton Fertility Center, Homerton University Hospital, London, UK
| | - Ganesh Acharya
- Women's Health and Perinatology Research Group, Department of Clinical Medicine, UiT - The Arctic University of Norway, Tromsø, Norway.,Division of Obstetrics and Gynecology, Department of Clinical Science, Intervention and Technology, Karolinska Institutet and Center for Fetal Medicine, Karolinska University Hospital, Stockholm, Sweden
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11
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Bhide P, Pundir J, Homburg R, Acharya G. Biomarkers of ovarian reserve in childhood and adolescence: A systematic review. Acta Obstet Gynecol Scand 2019; 98:563-572. [PMID: 30758847 DOI: 10.1111/aogs.13574] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2018] [Accepted: 02/06/2019] [Indexed: 12/11/2022]
Abstract
INTRODUCTION Certain medical disorders as well as their management may affect gonadal function. Recent advances in the management of these conditions accompanied by the availability and success of methods of fertility preservation has highlighted the need for assessment of ovarian reserve in childhood and adolescence. Serum anti-Mullerian hormone (AMH) and antral follicle count are well established markers of ovarian reserve and serum inhibin has also been used. However, literature on reference ranges for ovarian reserve markers in this age-group is relatively scarce. Thus, our aim was to evaluate published data to estimate reference values of ovarian reserve makers in childhood and adolescence. MATERIAL AND METHODS We performed a systematic review of the literature reporting ovarian reserve markers in childhood and adolescence. We included only those studies examining markers of ovarian reserve in the normal healthy population between the ages of 0 and 19 years. PROSPERO registration: CRD42018119064. RESULTS Serum AMH emerged as the most common biomarker assessed. Serum AMH was detectable at birth and, after a transient increase in infancy, increased steadily in childhood. Following a slight decrease at puberty, levels were constant throughout adolescence with a peak in adolescence or early adulthood. The mean serum AMH values during infancy, childhood and adolescence were 10.55, 22.32 and 31.84 pmol/L, respectively. The corresponding median values were 9.85, 24.49 and 26.32 pmol/L. It was not possible to construct age-specific reference intervals because of methodological heterogeneity, variations in the assay used to measure AMH and differing interval width for age used in included studies. Serum inhibin showed an increase from childhood to adolescence, with median serum inhibin values of 53.86 pg/mL in adolescence. Antral follicle count showed a significant positive correlation with serum AMH and a median value of 30.52 in adolescence. CONCLUSIONS We summarize the trends and levels of biomarkers of ovarian reserve from birth until young adulthood. Peak levels of serum AMH are reported in adolescence or early adulthood. We have reported median/mean values for serum AMH in different age-groups based on data pooled from several studies, which may be used as a reference when evaluating ovarian reserve in childhood and adolescence especially when considering fertility preservation.
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Affiliation(s)
- Priya Bhide
- Women's Health and Perinatology Research Group, Department of Clinical Medicine, UiT-The Arctic University of Norway, Tromsø, Norway.,Homerton Fertility Center, Homerton University Hospital, London, UK
| | - Jyotsna Pundir
- Center for Reproductive Medicine, St. Bartholomew's Hospital, London, UK
| | - Roy Homburg
- Homerton Fertility Center, Homerton University Hospital, London, UK
| | - Ganesh Acharya
- Women's Health and Perinatology Research Group, Department of Clinical Medicine, UiT-The Arctic University of Norway, Tromsø, Norway.,Division of Obstetrics and Gynecology, Department of Clinical Science, Intervention and Technology, Karolinska Institutet and Center for Fetal Medicine, Karolinska University Hospital, Stockholm, Sweden
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12
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Tay CT, Joham AE, Hiam DS, Gadalla MA, Pundir J, Thangaratinam S, Teede HJ, Moran LJ. Pharmacological and surgical treatment of nonreproductive outcomes in polycystic ovary syndrome: An overview of systematic reviews. Clin Endocrinol (Oxf) 2018; 89:535-553. [PMID: 29846959 DOI: 10.1111/cen.13753] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2018] [Revised: 05/25/2018] [Accepted: 05/28/2018] [Indexed: 12/20/2022]
Abstract
BACKGROUND Polycystic ovary syndrome (PCOS) affects up to 13% women and is associated with significant complications. The quality of evidence supporting the recommendations on treatment of nonreproductive outcomes in PCOS is unknown. OBJECTIVE To summarize and appraise the methodological quality of systematic reviews and meta-analyses evaluating pharmacological and surgical treatments for nonreproductive outcomes in PCOS. METHODS A literature search from MEDLINE, EMBASE, CINAHL PLUS and PROSPERO was performed from inception until 15th of September 2017. Article selection, data extraction and quality appraisal of included reviews were performed in duplicate. A narrative synthesis of the findings was conducted. RESULTS This overview included 31 reviews. The quality was low for 7 (23%), moderate for sixteen (52%) and high for 8 reviews (26%). Two reviews assessed psychological outcomes. Metformin improved anthropometric (7 of 10 reviews), metabolic (4 of 14 reviews) and endocrine outcomes (3 of twelve reviews). Thiazolidinediones improved metabolic (2 of 5 reviews) and endocrine outcomes (one of 5 reviews) but worsened weight gain (5 of 5 reviews). Combined oral contraceptive pill (COCP) improved clinical hyperandrogenism (2 of 2 reviews). Statins improved lipid profile (3 of 3 reviews) and testosterone level (2 of 3 reviews). There was no conclusive evidence from included systematic reviews regarding the use of other interventions. CONCLUSIONS There is reliable evidence regarding the use of metformin for anthropometric outcomes and COCPs for hyperandrogenism in women with PCOS but not for other interventions. There is significant gap in knowledge regarding the management of psychological outcomes in women with PCOS which needs further evaluation.
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Affiliation(s)
- Chau T Tay
- Monash Centre for Health Research and Implementation, School of Public Health and Preventive Medicine, Monash University, Melbourne, Vic., Australia
- Department of Diabetes and Vascular Medicine, Monash Health, Melbourne, Vic., Australia
| | - Anju E Joham
- Monash Centre for Health Research and Implementation, School of Public Health and Preventive Medicine, Monash University, Melbourne, Vic., Australia
- Department of Diabetes and Vascular Medicine, Monash Health, Melbourne, Vic., Australia
| | - Danielle S Hiam
- Institute of Health, Exercise and Sport, Victoria University, Melbourne, Vic., Australia
| | - Moustafa A Gadalla
- Robinson Research Institute, Discipline of Obstetrics and Gynaecology, University of Adelaide, Adelaide, SA, Australia
- Department of Obstetrics and Gynaecology, Women's Health Hospital, Assiut University, Assiut, Egypt
| | - Jyotsna Pundir
- Centre of Reproductive Medicine, St Bartholomew's Hospital, London, UK
- Barts Research Centre for Women's Health (BARC), Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Shakila Thangaratinam
- Barts Research Centre for Women's Health (BARC), Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Helena J Teede
- Monash Centre for Health Research and Implementation, School of Public Health and Preventive Medicine, Monash University, Melbourne, Vic., Australia
- Department of Diabetes and Vascular Medicine, Monash Health, Melbourne, Vic., Australia
| | - Lisa J Moran
- Monash Centre for Health Research and Implementation, School of Public Health and Preventive Medicine, Monash University, Melbourne, Vic., Australia
- Robinson Research Institute, Discipline of Obstetrics and Gynaecology, University of Adelaide, Adelaide, SA, Australia
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13
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Maheshwari A, Bhide P, Pundir J, Bhattacharya S. Routine serum thyroid-stimulating hormone testing-optimizing pre-conception health or generating toxic knowledge? Hum Reprod 2018; 32:1779-1785. [PMID: 28854714 DOI: 10.1093/humrep/dex240] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2017] [Accepted: 06/16/2017] [Indexed: 12/15/2022] Open
Abstract
Monitoring subclinical hypothyroidism (SCH) in women is believed to be important in terms of preventing overt hypothyroidism and optimizing the health and cognitive development of their children. Current systematic reviews have suggested an association between maternal SCH and adverse obstetric and neonatal outcomes. However, initiating the administration of thyroxine during pregnancy has failed to demonstrate appreciable health benefits. Hence there are calls by professional endocrine societies for optimizing serum thyroid-stimulating hormone (TSH) levels pre-conception. The strategy of ensuring that serum TSH levels are below 2.5 mIU/l during the pre-conception period has generated considerable uncertainty partly because the recommended level of <2.5 mIU/l is lower than those previously used to define the condition and partly due to uncertainty about the best screening programme clinicians can use in this context. Recalibrating the expected normal peri-conceptional range of serum TSH (<2.5 mIU/l), will have a significant impact on clinical services due to an inevitable increase in numbers of women diagnosed with SCH who will need to be investigated, treated and monitored. Serum TSH fulfils the criteria for a screening test and oral thyroxine is an inexpensive drug. Therefore, there is no reason to believe that screening cannot be undertaken in all women planning to conceive. Yet this approach will miss women whose pregnancies are unplanned and generate anxiety, further tests and many more prescriptions for thyroxine, coupled with the need for lifelong monitoring in affected women. A number of existing and ongoing randomized trials have evaluated the use of thyroxine in women with infertility or miscarriage with detectable thyroid auto-antibodies. These are unlikely to answer the question whether routine pre-conception testing for SCH in asymptomatic women is beneficial. Routine screening of women at risk of pregnancy and optimization of their thyroid status could result in significant health benefits for their offspring. Alternatively this approach could prove to be an expensive way of generating toxic knowledge resulting in anxiety, increased drug use and potential harm. Only large, appropriately designed studies can reveal the answer.
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Affiliation(s)
- Abha Maheshwari
- Aberdeen Fertility Centre, NHS Grampian Foresterhill, Aberdeen, AB25 2ZL, UK
| | - Priya Bhide
- Fertility and Assisted Reproduction, Homerton University Hospital, Homerton Row, Hackney, E9 6SR, London
| | - Jyotsna Pundir
- Centre for Reproductive Medicine, St Bartholomew's Hospital, London W Smithfield, EC1A 7BE, London
| | - Siladitya Bhattacharya
- School of Medicine and Dentistry, University of Aberdeen, Foresterhill, Aberdeen, AB25 2ZD, UK
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14
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Pundir J, Psaroudakis D, Savnur P, Bhide P, Sabatini L, Teede H, Coomarasamy A, Thangaratinam S. Authors' reply re: Inositol treatment of anovulation in women with polycystic ovary syndrome: a meta-analysis of randomised trials. BJOG 2017; 125:509-510. [PMID: 29226510 DOI: 10.1111/1471-0528.14996] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/17/2017] [Indexed: 11/29/2022]
Affiliation(s)
- Jyotsna Pundir
- Centre for Reproductive Medicine, St. Bartholomew's Hospital, London, UK
| | | | - Prakash Savnur
- Centre for Reproductive Medicine, St. Bartholomew's Hospital, London, UK
| | - Priya Bhide
- Fertility and Assisted Reproduction, Homerton University Hospital, Queen Mary University of London, London, UK
| | - Luca Sabatini
- Centre for Reproductive Medicine, St. Bartholomew's Hospital, London, UK
| | - Helena Teede
- Monash Centre for Health Research and Implementation, Monash University, Clayton, Vic., Australia
| | - Arri Coomarasamy
- Tommy's National Centre for Miscarriage Research, University of Birmingham, Birmingham, UK
| | - Shakila Thangaratinam
- Women's Health Research Unit, The Blizard Institute, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK
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15
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Affiliation(s)
- Jyotsna Pundir
- Centre for Reproductive Medicine, St. Bartholomew's Hospital, West Smithfield, London, UK
| | - Elias Kovoor
- Maidstone and Tunbridge Wells NHS Trust, Kent, UK
| | - Gillian Lancaster
- Professor of Medical Statistics, Institute of Primary Care and Health Sciences, Keele University, Keele, Newcastle, UK
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16
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El-Toukhy T, Kopeika JY, Beebeejaun Y, El Tokhy O, Pundir J, Khalaf Y. Impact of the outcome of fresh blastocyst transfer on the subsequent frozen-thawed blastocyst transfer cycle. Reprod Biomed Online 2017; 35:536-541. [DOI: 10.1016/j.rbmo.2017.06.024] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2016] [Revised: 06/28/2017] [Accepted: 06/29/2017] [Indexed: 10/19/2022]
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17
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Pundir J, Psaroudakis D, Savnur P, Bhide P, Sabatini L, Teede H, Coomarasamy A, Thangaratinam S. Authors' reply re: Inositol treatment of anovulation in women with polycystic ovary syndrome: a meta-analysis of randomised trials. BJOG 2017; 125:385-386. [PMID: 28815914 DOI: 10.1111/1471-0528.14811] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/03/2017] [Indexed: 11/30/2022]
Affiliation(s)
- Jyotsna Pundir
- Centre for Reproductive Medicine, St. Bartholomew's Hospital, London, UK
| | | | - Prakash Savnur
- Centre for Reproductive Medicine, St. Bartholomew's Hospital, London, UK
| | - Priya Bhide
- Fertility and Assisted Reproduction, Homerton University Hospital, Queen Mary University of London, London, UK
| | - Luca Sabatini
- Centre for Reproductive Medicine, St. Bartholomew's Hospital, London, UK
| | - Helena Teede
- Monash Centre for Health Research and Implementation, Monash University, Clayton, Vic., Australia
| | - Arri Coomarasamy
- Tommy's National Centre for Miscarriage Research, University of Birmingham, Birmingham, UK
| | - Shakila Thangaratinam
- Women's Health Research Unit, The Blizard Institute, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK
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Pundir J, Psaroudakis D, Savnur P, Bhide P, Sabatini L, Teede H, Coomarasamy A, Thangaratinam S. Inositol treatment of anovulation in women with polycystic ovary syndrome: a meta-analysis of randomised trials. BJOG 2017; 125:299-308. [DOI: 10.1111/1471-0528.14754] [Citation(s) in RCA: 67] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/17/2017] [Indexed: 02/07/2023]
Affiliation(s)
- J Pundir
- Centre for Reproductive Medicine; St. Bartholomew's Hospital; London UK
| | - D Psaroudakis
- Centre for Reproductive Medicine; St. Bartholomew's Hospital; London UK
| | - P Savnur
- Centre for Reproductive Medicine; St. Bartholomew's Hospital; London UK
| | - P Bhide
- Fertility and Assisted Reproduction; Homerton University Hospital; Queen Mary University of London; London UK
| | - L Sabatini
- Centre for Reproductive Medicine; St. Bartholomew's Hospital; London UK
| | - H Teede
- Monash Centre for Health Research and Implementation; Monash University; Clayton Vic. Australia
| | - A Coomarasamy
- Tommy's National Centre for Miscarriage Research; University of Birmingham; Birmingham UK
| | - S Thangaratinam
- Women's Health Research Unit; The Blizard Institute; Barts and the London School of Medicine and Dentistry; Queen Mary University of London; London UK
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Pundir J, Omanwa K, Kovoor E, Pundir V, Lancaster G, Barton-Smith P. Laparoscopic Excision Versus Ablation for Endometriosis-associated Pain: An Updated Systematic Review and Meta-analysis. J Minim Invasive Gynecol 2017; 24:747-756. [PMID: 28456617 DOI: 10.1016/j.jmig.2017.04.008] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2016] [Revised: 04/18/2017] [Accepted: 04/19/2017] [Indexed: 10/19/2022]
Abstract
The aim of this study was to update the evidence on the surgical management of endometriosis-associated pain. Does laparoscopic excision offer any benefits over laparoscopic ablation? This is a systematic review and meta-analysis in which we searched MEDLINE, Embase, Institute for Scientific Information conference proceedings, the International Standard Randomised Controlled Trial Number registry, the Register and Meta-register for randomized controlled trials, the World Health Organization trials search portal, the Cochrane Library, and the British Library of electronic theses. Three randomized controlled trials were included, which enrolled 335 participants with a sample size per study ranging from 24 to 178 participants. Of these 3 studies, data from 2 could be pooled for meta-analysis. The primary outcome measure was the reduction in the visual analog scale score for dysmenorrhea. The secondary outcome measures included the reduction in the visual analog scale score for dyspareunia, dyschezia, and chronic pelvic pain and the reduction in Endometriosis Health Profile-30 core pain scores. The meta-analysis showed that the excision group had a significantly greater reduction in symptoms of dysmenorrhea (mean difference [MD] = 0.99; 95% confidence interval [CI], -0.02 to 2.00; p = .05) and dyschezia (MD = 1.31; 95% CI, 0.33-2.29; p = .009) compared with ablation. The symptoms of dyspareunia showed a nonsignificant benefit with excision (MD = 0.96; 95% CI, -0.07 to 1.99; p = .07). Data from 1 study showed a significant reduction in chronic pelvic pain (MD = 2.57; 95% CI, 1.27-3.87; p = .0001) and Endometriosis Health Profile-30 core pain scores (MD = 13.20; 95% CI, 3.70-22.70; p = .006) with the excision group compared with the ablation group. The limited available evidence shows that at 12 months postsurgery, symptoms of dysmenorrhea, dyschezia, and chronic pelvic pain secondary to endometriosis showed a significantly greater improvement with laparoscopic excision compared with ablation.
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Affiliation(s)
- Jyotsna Pundir
- Centre for Reproductive Medicine, St Bartholomew's Hospital, West Smithfield, London, United Kingdom.
| | - Kireki Omanwa
- Department of Obsterics and Gynaecology, University of Nairobi, Nairobi, Kenya
| | - Elias Kovoor
- Maidstone and Tunbridge Wells NHS Trust, Kent, United Kingdom
| | - Vishal Pundir
- Maidstone and Tunbridge Wells NHS Trust, Kent, United Kingdom
| | - Gillian Lancaster
- Institute of Primary Care and Health Sciences, Keele University, Newcastle, United Kingdom
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Pundir V, Pundir J, Lancaster G, Kirkland P, Cornet M, Lourijsen E, Georgalas C, Fokkens W. Role of corticosteroids in Functional Endoscopic Sinus Surgery - a systematic review and meta-analysis. Rhinology 2016. [DOI: 10.4193/rhin15.079] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Kayani SI, Pundir J, Omanwa K. Quality of life after total laparoscopic hysterectomy: a one-year follow-up study. Minerva Ginecol 2016; 68:412-417. [PMID: 26018242] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
BACKGROUND A small prospective observational cohort study with the aim to evaluate postoperative health-related quality of life (HRQOL) at one-year follow-up after total laparoscopic hysterectomy for benign gynecological conditions and to assess postoperative functions in terms of return to work, sexual activity and driving was conducted. METHODS Sixty out of 65 women with a mean age of 45.7±5.4 responded to the questionnaire. Change in HRQOL was assessed by comparing the preoperative and postoperative QOL on scale of 1-5 grades. RESULTS HRQOL improved significantly at 12 months postoperatively. Multiple logistic regression analysis showed that the presence of irregular periods (P=0.048) and dyspareunia (P=0.017) were significant predictors of overall postoperative improvement in QOL by 3 or more grades. Women with ovarian preservation were more likely to report overall improvement in HRQOL by 3 or more grades compared to those who had bilateral salpingo-oophrectomy (P=0.04). There was statistically significant improvement in QOL postoperatively as compared to preoperatively (P<0.0001). CONCLUSIONS In our study we found that women presenting with dyspareunia were more likely to report higher improvement in postoperative QOL. This highlights that dyspareunia is a symptom which is a marker for chronic pelvic pain conditions like endometriosis, adenomyosis, fibroids and adhesions.
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Pundir J, Magdalani L, El-Toukhy T. Outcome of preimplantation genetic diagnosis using FISH analysis for recurrent miscarriage in low-risk reciprocal translocation carriers. Eur J Obstet Gynecol Reprod Biol 2016; 203:214-9. [PMID: 27343738 DOI: 10.1016/j.ejogrb.2016.05.053] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2016] [Revised: 05/16/2016] [Accepted: 05/31/2016] [Indexed: 11/17/2022]
Abstract
OBJECTIVE To assess PGD outcome using FISH analysis in couples with a history of recurrent miscarriage associated with a parental carrier of reciprocal translocation. STUDY DESIGN Couples in whom one partner was a carrier of a reciprocal translocation and had a history of two or more miscarriages and a low risk of a live born offspring with an unbalanced chromosomal rearrangement, underwent PGD treatment between 2000 and 2012. RESULTS 91 couples started 171 fresh and 11 frozen PGD cycles. Of the fresh cycles, 162 (95%) reached oocyte retrieval and 107 (63%) had embryo transfer. In 14 cycles (8%), surplus embryos were cryopreserved. Pregnancy was achieved in 52 fresh PGD cycles, leading to 20 miscarriages and 32 live births. Eleven frozen embryo transfer cycles resulted in two miscarriages and three live births. The overall live birth rate was 19% per fresh and frozen PGD cycle started (35/182) and miscarriage rate was 39% per pregnancy (22/57). The cumulative live birth rate was 32% per couple (29/91). CONCLUSION After PGD for recurrent miscarriage in low-risk reciprocal translocation carriers, the miscarriage risk remains high and chance of live birth is low. For those translocation carriers, natural conception may be a better option.
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Affiliation(s)
- Jyotsna Pundir
- Centre of Preimplantation Genetic Diagnosis and Assisted Conception Unit, Guy's and St. Thomas' Hospital NHS Foundation Trust, London, UK.
| | - Laurice Magdalani
- Centre of Preimplantation Genetic Diagnosis and Assisted Conception Unit, Guy's and St. Thomas' Hospital NHS Foundation Trust, London, UK
| | - Tarek El-Toukhy
- Centre of Preimplantation Genetic Diagnosis and Assisted Conception Unit, Guy's and St. Thomas' Hospital NHS Foundation Trust, London, UK
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Osman A, Pundir J, Elsherbini M, Dave S, El-Toukhy T, Khalaf Y. The effect of intrauterine HCG injection on IVF outcome: a systematic review and meta-analysis. Reprod Biomed Online 2016; 33:350-9. [PMID: 27317131 DOI: 10.1016/j.rbmo.2016.05.010] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2015] [Revised: 05/25/2016] [Accepted: 05/26/2016] [Indexed: 12/23/2022]
Abstract
In this systematic review and meta-analysis, the effect of intrauterine HCG infusion before embryo transfer on IVF outcomes (live birth rate, clinical pregnancy rate and spontaneous aboretion rate) was investigated. Searches were conducted on MEDLINE, EMBASE and The Cochrane Library. Randomized studies in women undergoing IVF and intracytoplasmic sperm injection comparing intrauterine HCG administration at embryo transfer compared with no intrauterine HCG were eligible for inclusion. Eight randomized controlled trials were eligible for inclusion in the meta-analysis. A total of 3087 women undergoing IVF and intracytoplasmic sperm injection cycles were enrolled (intrauterine HCG group: n = 1614; control group: n = 1473). No significant difference was found in the live birth rate (RR 1.13; 95% CI 0.84 to 1.53) and spontaneous abortion rate (RR 1.00, 95% CI 0.74 to 1.34) between women who received intrauterine HCG and those who did not receive HCG. Although this review was extensive and included randomized controlled trials, no significant heterogeneity was found, and the overall included numbers are relatively small. In conclusion the current evidence does not support the use of intrauterine HCG administration before embryo transfer. Well-designed multicentre trials are needed to provide robust evidence.
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Affiliation(s)
- A Osman
- Assisted Conception Unit, Guys Hospital, Great Maze Pond SE1 9RT, UK; Faculty of Medicine, Cairo University, Al-Saray Street, El Manial Cairo 11956, Egypt.
| | - J Pundir
- Centre of reproductive medicine, St Bartholomew's Hospital, Bart's Health, London EC1A 7BE, UK
| | - M Elsherbini
- Faculty of Medicine, Cairo University, Al-Saray Street, El Manial Cairo 11956, Egypt
| | - S Dave
- Centre of reproductive medicine, St Bartholomew's Hospital, Bart's Health, London EC1A 7BE, UK
| | - T El-Toukhy
- Assisted Conception Unit, Guys Hospital, Great Maze Pond SE1 9RT, UK
| | - Y Khalaf
- Assisted Conception Unit, Guys Hospital, Great Maze Pond SE1 9RT, UK
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Pundir V, Pundir J, Lancaster G, Baer S, Kirkland P, Cornet M, Lourijsen ES, Georgalas C, Fokkens WJ. Role of corticosteroids in Functional Endoscopic Sinus Surgery--a systematic review and meta-analysis. Rhinology 2016; 54:3-19. [PMID: 26970247 DOI: 10.4193/rhino15.079] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND The aim of our study is to systematically review the existing evidence on the role of corticosteroids in patients undergoing functional endoscopic sinus surgery (FESS). METHODOLOGY Systematic search of MEDLINE (1950- 2014), EMBASE (1980-2014), metaRegister, Cochrane Library and ISI conference proceedings was carried out. RESULTS Eighteen randomised controlled trials with 1309 patients were included. Use of local and/or systemic corticosteroids with FESS was reported in four categories; operative, anaesthesia related, post-operative outcomes and risk of recurrence. Meta-analysis for operative outcomes demonstrated that, mean operative time (MD -10.70 minutes; 95% CI -15.86, -5.55; P <0.0001) and mean estimated blood loss (MD -28.32 mls; 95% CI -40.93, -15.72; P <0.0001) was significantly lower; and surgical field quality (MD -0.81; 95% CI -1.32, -0.30; P = 0.002) was significantly better in corticosteroid group. Meta-analysis showed that post-operative endoscopic scores (SMD -0.39; 95% CI -0.60, -0.17; P = 0.0004) were significantly better in corticosteroid group compared to no corticosteroid group. There was no increase in risk of sinusitis (RR 0.64; 95% CI 0.32, 1.30; P = 0.22) between use of corticosteroids and no corticosteroids; There was no significant difference in recurrence risk of chronic rhinosinusitis (CRS) in mixed population studies (RR 0.77; 95% CI 0.35, 1.70; P = 0.52) between the two groups but analysis of studies reporting on chronic rhinosinusitis with nasal polyps (CRSwNP) (RR 0.64;95% CI 0.45,0.91;P=0.01) showed significant difference in favour of the corticosteroid group. CONCLUSION Pre-operative use of local and/or systemic corticosteroids in FESS, results in significantly reduced blood loss, shorter operative time and improved surgical field quality. Studies are limited on the intra-operative use of corticosteroids to reduce postoperative pain. Postoperative corticosteroids improve postoperative endoscopic scores in CRS and recurrence rates in cases of CRSwNP.
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Affiliation(s)
- Vishal Pundir
- Ear Nose and Throat Department, Academic Medical Centre, Amsterdam, the Netherlands
| | - Jyotsna Pundir
- Department of Obstetrics and Gynaecology, Barts Health NHS Trust, United Kingdom
| | - Gillian Lancaster
- Department of Mathematics and Statistics, Fylde College, Lancaster University, Lancaster, United Kingdom
| | - Simon Baer
- Department of Otorhinolaryngology, East Sussex Healthcare NHS Trust, Conquest Hospital, United Kingdom
| | - Paul Kirkland
- Department of Otorhinolaryngology, East Sussex Healthcare NHS Trust, Conquest Hospital, United Kingdom
| | - Marjolein Cornet
- Ear Nose and Throat Department, Academic Medical Centre, Amsterdam, the Netherlands
| | - E S Lourijsen
- Ear Nose and Throat Department, Academic Medical Centre, Amsterdam, the Netherlands
| | - Christos Georgalas
- Ear Nose and Throat Department, Academic Medical Centre, Amsterdam, the Netherlands
| | - W J Fokkens
- Ear Nose and Throat Department, Academic Medical Centre, Amsterdam, the Netherlands
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Pundir J, Kopeika J, Harris L, Krishnan N, Uwins C, Siozos A, Khalaf Y, El-Toukhy T. Reproductive outcome following abdominal myomectomy for a very large fibroid uterus. J OBSTET GYNAECOL 2014; 35:37-41. [DOI: 10.3109/01443615.2014.930097] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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El-Toukhy T, Pundir J. Response: hysteroscopy prior to a first IVF treatment cycle: the need for well-performed RCT. Reprod Biomed Online 2014; 29:143. [PMID: 24857195 DOI: 10.1016/j.rbmo.2014.03.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2014] [Accepted: 03/24/2014] [Indexed: 11/30/2022]
Affiliation(s)
- T El-Toukhy
- Assisted Conception Unit, 11th Floor, Tower Wing, Guy's and St Thomas NHS Trust, London, UK.
| | - Jyotsna Pundir
- Assisted Conception Unit, 11th Floor, Tower Wing, Guy's and St Thomas NHS Trust, London, UK
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Pundir V, Pundir J, Georgalas C, Fokkens WJ. Role of tranexamic acid in endoscopic sinus surgery - a systematic review and meta-analysis. Rhinology 2014; 51:291-7. [PMID: 24260760 DOI: 10.4193/rhino13.042] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND The role of tranexamic acid in patients undergoing endoscopic sinus surgery (ESS) is not clearly defined. The aim of our study is to systematically review the existing evidence on the role of tranexamic acid in patients undergoing ESS. METHODOLOGY Systematic search of MEDLINE (1950 - 2013), EMBASE (1980 - 2013), metaRegister, Cochrane Library and ISI conference proceedings was carried out. RESULTS Five randomised controlled trials with 192 patients receiving tranexamic acid and 196 controls were included. Meta-analysis demonstrated that mean estimated blood loss was significantly lower, and surgical field quality was significantly better in tranexamic acid group. There was no significant difference in mean operative time between the two groups. No significant adverse effects were noted in either of the groups. CONCLUSION Intra-operative use of local and systemic tranexamic acid in ESS, results in significantly reduced estimated blood loss and improved surgical field quality. There is no statistically significant difference seen in operative time and incidence of side effects. Well-conducted larger RCTs using validated objective outcome measures and reporting on minor and major complications are required.
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Pundir J, Walawalkar R, Seshadri S, Khalaf Y, El-Toukhy T. Perioperative morbidity associated with abdominal myomectomy compared with total abdominal hysterectomy for uterine fibroids. J OBSTET GYNAECOL 2013; 33:655-62. [DOI: 10.3109/01443615.2013.816661] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Saad H, Khalil E, Bora SA, Parikh J, Abdalla H, Thum MY, Bina V, Roopa P, Shyamala S, Anupama A, Tournaye H, Polyzos NP, Guzman L, Nelson SM, Lourenco B, Sousa AP, Almeida-Santos T, Ramalho-Santos J, Okhowat J, Wirleitner B, Neyer T, Bach M, Murtinger M, Zech NH, Polyzos NP, Nwoye M, Corona R, Blockeel C, Stoop D, Camus M, Tournaye H, Rajikin MH, Kamsani YS, Chatterjee A, Nor-Ashikin MNK, Nuraliza AS, Scaravelli G, D'Aloja P, Bolli S, De Luca R, Spoletini R, Fiaccavento S, Speziale L, Vigiliano V, Farquhar C, Brown J, Arroll N, Gupta D, Boothroyd C, Al Bassam M, Moir J, Johnson N, Pantasri T, Robker RL, Wu LL, Norman RJ, Buzaglo K, Velez M, Shaulov T, Sylvestre C, Kadoch IJ, Krog M, Prior M, Carlsen E, Loft A, Pinborg A, Andersen AN, Dolleman M, Verschuren WMM, Eijkemans MJC, Dolle MET, Jansen EHJM, Broekmans FJM, Van der Schouw YT, Fainaru O, Pencovich N, Hantisteanu S, Barzilay I, Ellenbogen A, Hallak M, Cavagna M, Baruffi RLR, Petersen CG, Mauri AL, Massaro FC, Ricci J, Nascimento AM, Vagnini LD, Pontes A, Oliveira JBA, Franco JG, Canas MCT, Vagnini LD, Nascimento AM, Petersen CG, Mauri AL, Massaro FC, Nicoletti A, Martins AMVC, Cavagna M, Oliveira JBA, Baruffi RLR, Franco JG, Lichtblau I, Olivennes F, Aubriot FA, Junca AM, Belloc S, Cohen-Bacrie M, Cohen-Bacrie P, de Mouzon J, Nandy T, Caragia A, Balestrini S, Zosmer A, Sabatini L, Al-Shawaf T, Seshadri S, Khalaf Y, Sunkara SK, Joy J, Lambe M, Lutton D, Nicopoullos J, Bora SA, Parikh J, Faris R, Abdalla H, Thum MY, Behre HM, Howles CM, Longobardi S, Chimote N, Mehta B, Nath N, Chimote NM, Mehta B, Nath N, Chimote N, Chimote NM, Mine K, Yoshida A, Yonezawa M, Ono S, Abe T, Ichikawa T, Tomiyama R, Nishi Y, Kuwabara Y, Akira S, Takeshita T, Shin H, Song HS, Lim HJ, Hauzman E, Kohls G, Barrio A, Martinez-Salazar J, Iglesias C, Velasco JAG, Tejada MI, Maortua H, Mendoza R, Prieto B, Martinez-Bouzas C, Diez-Zapirain M, Martinez-Zilloniz N, Matorras R, Amaro A, Bianco B, Christofolini J, Mafra FA, Barbosa CP, Christofolini DM, Pesce R, Gogorza S, Ochoa C, Gil S, Saavedra A, Ciarmatori S, Perman G, Pagliardini L, Papaleo E, Corti L, Vanni VS, Ottolina J, de Michele F, Marca AL, Vigano P, Candiani M, Li L, Yin Q, Huang L, Huang J, He Z, Yang D, Parikh J, Bora SA, Abdalla H, Thum MY, Tiplady S, Ledger W, Godbert S, Hart S, Johnson S, Wong AWY, Kong GWS, Haines CJ, Franik S, Nelen W, Kremer J, Farquhar C, Gillett WR, Lamont JM, Peek JC, Herbison GP, Sung NY, Hwang YI, Choi MH, Song IO, Kang IS, Koong MK, Lee JS, Yang KM, Celtemen MB, Telli P, Karakaya C, Bozkurt N, Gursoy RH, Younis JS, Ben-Ami M, Pundir J, Pundir V, Omanwa K, Khalaf Y, El-Toukhy T. Female (in)fertility. Hum Reprod 2013. [DOI: 10.1093/humrep/det213] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Pundir J, Krishnan N, Siozos A, Uwins C, Kopeika J, Khalaf Y, El-Toukhy T. Peri-operative morbidity associated with abdominal myomectomy for very large fibroid uteri. Eur J Obstet Gynecol Reprod Biol 2013; 167:219-24. [PMID: 23290249 DOI: 10.1016/j.ejogrb.2012.12.010] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2011] [Revised: 07/12/2012] [Accepted: 12/10/2012] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To evaluate the safety of abdominal myomectomy for very large fibroid uteri, and to assess the effect of relevant confounding variables on the occurrence of major peri-operative complications. STUDY DESIGN A cohort study of 200 abdominal myomectomies for fibroid uteri of 16 gestational weeks or greater. Logistic regression analysis was used to examine the influence of important clinical variables on the risk of complications. A systematic literature search was conducted for evidence related to peri-operative morbidity associated with abdominal myomectomy for very large fibroid uteri. RESULTS The mean (±standard deviation) uterine size was 21±5 weeks. The overall rate of major complications was 30%. Peri-operative bleeding necessitating blood transfusion occurred in 49 (24.5%) cases. During surgery, two patients had bowel injury, two had bladder injury, seven women returned to theatre and two (1%) had hysterectomy. Four patients were re-admitted within 14 days of surgery. Multivariable logistic regression analysis showed that the risk of major complications was significantly higher in cases with a uterine size of 20 gestational weeks or more [odds ratio (OR) 3.4, 95% confidence interval (CI) 1.1-10.2; p=0.03], where 10 or more fibroids were removed (OR 3.5, 95% CI 1.1-10.8; p=0.05) and where midline skin incision was required (OR 6.1, 95% CI 1.7-22.3; p=0.006). On comparison of primary vs repeat abdominal myomectomy, there was significantly higher blood loss (mean 1023±1112 ml vs 579±787 ml; p=0.02) and risk of major complications in the repeat myomectomy group (40% vs 5%; p<0.001). The systematic review identified only one study that reported a comparable risk of major complications related to abdominal myomectomy for very large fibroid uteri. CONCLUSION The risk of organ injury, hysterectomy, re-operation or hospital re-admission after abdominal myomectomy for very large fibroid uteri is low, but the procedure is associated with a significant risk of bleeding necessitating blood transfusion. This risk is increased after repeat myomectomy, and in patients with a uterine size of 20 gestational weeks or larger, requiring removal of 10 or more fibroids, and requiring a midline skin incision.
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Affiliation(s)
- J Pundir
- Assisted Conception Unit, Guy's and St. Thomas' NHS Trust, London, UK.
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Pundir V, Pundir J, Georgalas C, Fokkens W. Role of tranexamic acid in endoscopic sinus surgery - A systematic review and meta-analysis. Rhinology 2013. [DOI: 10.4193/rhin13.042] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Pundir J, Chandraharan E, Chui D. Profuse and persistent vaginal discharge following fibroid embolisation. J OBSTET GYNAECOL 2012; 32:404-5. [PMID: 22519499 DOI: 10.3109/01443615.2012.658890] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Affiliation(s)
- J Pundir
- Department of Obstetrics and Gynaecology, Conquest Hospital, St Leonards-on-Sea, UK.
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Pundir J, Sunkara SK, El-Toukhy T, Khalaf Y. Meta-analysis of GnRH antagonist protocols: do they reduce the risk of OHSS in PCOS? Reprod Biomed Online 2012; 24:6-22. [DOI: 10.1016/j.rbmo.2011.09.017] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2011] [Revised: 09/29/2011] [Accepted: 09/29/2011] [Indexed: 10/16/2022]
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Pundir J, Krishnan N, Siozos T, Uwins C, Khalaf Y, El-Toukhy T. Morbidity and long term reproductive outcome after abdominal myomectomy for very large fibroid uteri of 16 weeks or more. Fertil Steril 2011. [DOI: 10.1016/j.fertnstert.2011.07.132] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
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Sunkara SK, Pundir J, Khalaf Y. Effect of androgen supplementation or modulation on ovarian stimulation outcome in poor responders: a meta-analysis. Reprod Biomed Online 2011; 22:545-55. [PMID: 21493151 DOI: 10.1016/j.rbmo.2011.01.015] [Citation(s) in RCA: 44] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2010] [Revised: 01/24/2011] [Accepted: 01/26/2011] [Indexed: 11/15/2022]
Abstract
Many trials have evaluated the use of androgen supplements and androgen-modulating agents to improve outcome of poor responders undergoing IVF treatment. This study conducted a systematic review and meta-analysis of controlled trials of androgen adjuvants (testosterone, dehydroepiandrostereone) and the androgen-modulating agent (letrozole) in poor responders undergoing IVF treatment. Searches were conducted on MEDLINE, EMBASE, Cochrane Library, ISRCTN Register and ISI proceedings. All randomized and non-randomized controlled trials were included. Study selection, quality appraisal and data extraction were performed independently and in duplicate. The main outcome measure was clinical pregnancy rate. The secondary outcome measures were dose and duration of gonadotrophin use, cycles cancelled before oocyte retrieval, oocytes retrieved and ongoing pregnancy rates. A total of 2481 cycles in women considered as poor responders undergoing IVF/intracytoplasmic sperm injection (ICSI) treatment were included in nine controlled trials. Meta-analyses of these studies did not show any significant difference in the number of oocytes retrieved and ongoing pregnancy/live-birth rates with androgen supplementation or modulation compared with the control groups. There is currently insufficient evidence from the few randomized controlled trials to support the use of androgen supplementation or modulation to improve live birth outcome in poor responders undergoing IVF/ICSI treatment.
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Affiliation(s)
- Sesh Kamal Sunkara
- Assisted Conception Unit, Guy's Hospital, St. Thomas Street, London, UK.
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Abstract
Approximately 15% of couples are affected with subfertility, of which up to 20% remain unexplained. Uterine cavity abnormalities can be a contributing cause of subfertility and recurrent implantation failure. Uterine cavity assessment has been suggested as a routine investigation in the evaluation of subfertile women. Traditionally, hysterosalpingography has been the most commonly used technique in the evaluation of infertility. Transvaginal ultrasound scan allows visualization of the endometrial lining and cavity, and has been used as a screening test for the assessment of uterine cavity. Abnormal uterine findings on a baseline scan can be further evaluated with saline hysterosonography, which is highly sensitive and specific in identifying intrauterine abnormalities. Hysteroscopy is considered as the definitive diagnostic tool to evaluate any abnormality suspected on hysterosalpingography, transvaginal ultrasound scan or saline hysterosonography during routine investigation of infertile patients. Minimally invasive hysteroscopes have minimized the pain experienced by patients during the procedure and made it feasible to use hysteroscopy as a routine outpatient examination. Following recurrent IVF failure there is some evidence of benefit from hysteroscopy in increasing the chance of pregnancy in the subsequent IVF cycle, both in those with abnormal and normal hysteroscopic findings. Various possible mechanisms have been proposed for this beneficial effect, but more randomized controlled trials are needed before its routine use in the general subfertile population can be recommended.
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Pundir J, Sunkara S, Khalaf Y, Braude P. 113 ASSESSMENT OF IMPACT OF ANDROGEN SUPPLEMENTATION OR MODULATION DURING OVARIAN STIMULATION IN POOR RESPONDERS UNDERGOING IVF TREATMENT: A SYSTEMATIC REVIEW AND META-ANALYSIS. Reprod Biomed Online 2010. [DOI: 10.1016/s1472-6483(10)62531-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Abstract
Fetal macrosomia represents a continuing challenge in obstetrics, as it has risk of shoulder dystocia leading to transient or permanent fetal, maternal injury and medicolegal liability. The overall incidence of macrosomia has been rising. Non-diabetic macrosomia is still an obstetric dilemma, as there is no clear consensus regarding its ante-partum prediction and management, as accurate diagnosis is only made retrospectively. The risk of shoulder dystocia rises from 1.4% for all vaginal deliveries to 9.2-24% for birth weights more than 4,500 g. Unfortunately, 50% of all cases of shoulder dystocia occur at birth weights of less than 4,000 g. Brachial plexus injury occurs in 1:1,000 births and permanent damage in 1:10,000 deliveries (12% of all) leading to litigation 1:45,000 deliveries. The prenatal diagnosis of macrosomia remains imprecise. Pre-pregnancy and ante-partum risk factors and ultrasound have poor predictive value. Induction of labour and prophylactic caesarean delivery has not been shown to alter the incidence of shoulder dystocia among nondiabetic patients. Caesarean section and induction of labour are associated with increased risk of operative morbidity and mortality with added cost implications.
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Affiliation(s)
- J Pundir
- Conquest Hospital, St Leonard's on Sea, UK
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Abstract
Bartholin's abscess and cyst account for 2% of all gynaecological visits per annum. This article reviews the anatomy, epidemiology and pathophysiology of the Bartholin's gland. The management of Bartholin's abscess including antibiotic use in the early stage of the condition together with options for surgical intervention are discussed and in so doing the variation of clinical practice in other countries is considered. The use of the word catheter, carbon dioxide laser are compared with traditional surgical techniques of incision and drainage and marsupialisation. The outcomes of treatment particularly the high recurrence rate (2-25%) and the associated morbidity are reviewed. Finally the issue of cancerous pathology as an aetiology is highlighted in the postmenopausal age group.
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Affiliation(s)
- J Pundir
- Conquest Hospital, St Leonard's on Sea, East Sussex, UK
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