FIGO statement: Fertility preservation

Fertility preservation is a growing field in reproductive medicine that may raise ethical questions. Preservation of fertility must be discussed with the patient if gonadotoxic treatment is required, whether in the case of benign or malignant pathology, or in the management of transgender identity. As a result, surgery or chemotherapy that has fewer adverse impacts on fertility should be proposed if this does not alter the prognosis of the disease. If the risk of infertility persists, then fertility cryopreservation should be proposed for children and adults of reproductive age. Sperm, oocytes, and gonadal tissue can be cryopreserved for many years. FIGO wishes to emphasize the importance of fertility preservation in the medical and surgical management of patients, and the importance of a specialized, multidisciplinary approach.

The challenges of obesity for fertility: A FIGO literature review

Obesity has been linked to infertility through several mechanisms, including at a molecular level. Those living with obesity face additional barriers to accessing fertility treatments and achieving a successful pregnancy, which can contribute to their economic and psychosocial stressors. There is scope to further improve care for people living with obesity and infertility with empathy, via a multidisciplinary approach.

Ovulation induction: comparing success rates between anovulatory and ovulatory cycles using different treatment protocols

The management of patients with sub-fertility, particularly unexplained sub-fertility, is a sensitive and complex matter. This was a prospective observational study conducted from October 2016 to March 2017 in Galway, Ireland, the aim of which was to identify the clinical pregnancy rates (CPR) in women undergoing ovulation induction (OI) with timed sexual intercourse (TSI) or intrauterine insemination (IUI) and to compare them across two groups: (1) Anovulatory women and (2) ovulatory women with unexplained subfertility. Patients undergoing OI were recruited consecutively and OI regimens were prescribed as per local clinical protocol. The main observation was a higher CPR in the anovulatory group (18%) compared with the ovulatory group (CPR = 10%) (p < 0.05). No difference was observed in the CPR between the TSI and IUI groups. There are many studies to support the use of OI in the treatment of women with anovulatory subfertility, though the use of OI in ovulatory women is a more controversial issue. The treatment options offered to these patients need to be individualized to each couple and should consider their length of infertility, age, and financial means. Due to the lower cost and the less invasive nature of OI-treatment we conclude that a short treatment course could be offered as an acceptable alternative prior to IVF.

Applying the QUARTZ Trial Results in Clinical Practice: Development of a Prognostic Model Predicting Poor Outcomes for Non-small Cell Lung Cancers with Brain Metastases

AIMS

The role of whole brain radiotherapy (WBRT) in patients with brain metastases from non-small cell lung cancers (NSCLC) has been questioned. However, no reliable criteria exist to identify patients who do not benefit from WBRT. The objective of the current study was to develop a prognostic model to identify such patients whose survival matches that of the Quality of Life after Treatment for Brain Metastases (QUARTZ) study.

MATERIALS AND METHODS

Outcome data of patients with NSCLC with brain metastases undergoing WBRT enrolled in a prospective observational study in a tertiary cancer centre were used to develop a prognostic model. Baseline clinico-radiological factors were used for development of the model. The model was internally validated and calibration accuracy was checked for prediction of 70 day mortality. The generated prognostic model was presented as a nomogram.

RESULTS

The median overall survival of 140 patients enrolled in the study was 166 days (95% confidence interval 108-242 days). The prognostic model identified gender, Karnofsky performance status and epidermal growth factor receptor activating mutation status as significant factors influencing overall survival. The model showed a modest discriminative ability with an optimism-corrected C-index of 0.64. However, model calibration error did reveal a moderate degree of calibration error. The high-risk subgroup identified by the model had a median overall survival of 67 days (95% confidence interval 56-101 days), which was similar to that observed in the QUARTZ trial.

CONCLUSION

This prognostic model derived from traditional clinico-radiological features had a modest ability to identify patients with poor prognosis who may not benefit from WBRT. However, the high-risk subgroup identified using this prognostic model had a survival similar to that observed for patients in the QUARTZ trial.

Association between grade of referral smear and high-grade disease among women with biopsy samples showing cervical intraepithelial neoplasia grade 2

OBJECTIVE

To determine whether the grade of referral smear reflects the frequency of cervical intraepithelial neoplasia (CIN) grade 3 (CIN3) or worse lesions among patients with CIN2 on punch biopsy.

METHODS

In a retrospective study, data were reviewed from women with a punch biopsy sample showing CIN2 and a known referral smear who underwent large loop excision of the transformation zone (LLETZ) between January 1, 2013, and January 1, 2016, at Galway University Hospital, Ireland. Data were analyzed by patient age (≤30 and >30 years), referral smear (low and high grade), and LLETZ histology (≤CIN2 and ≥CIN3).

RESULTS

Overall, 264 women were included. LLETZ histology of CIN3 or worse was more common among women with high-grade referral smears (63/144 [43.8%]) than among those with low-grade smears (26/120 [21.7%]; relative risk 2.02, 95% confidence interval 1.37-2.96; P<0.001). Among patients younger than 30 years, underlying CIN3 and above was again more frequent among women with high-grade (44/95 [46.3%]) versus low-grade smears (12/56 [21.4%]; relative risk 2.16, 95% confidence interval 1.25-3.73; P=0.004). No difference was recorded in the older age group.

CONCLUSION

Although LLETZ can be performed for a CIN2 biopsy and high-grade smear, consideration should be given among young women (<30 years) with low-grade smears whose biopsy histology is incidentally CIN2.

Comparison of costs associated with substituting culture medium with saline solution for follicular flushing during oocyte retrieval

OBJECTIVES

To compare culture medium and saline solution for follicular flushing during oocyte retrieval with assisted reproductive technologies.

METHODS

The present retrospective study analyzed data collected at Galway Fertility Clinic, Galway, Ireland, between January 1, 2015 and August 31, 2016; all patients attending the clinic for in vitro fertilization/intracytoplasmic sperm injection during this period were included. Data were stratified by whether follicular flushing was performed with culture medium or saline, and the oocyte yield rate, fertilization rate, embryo utilization rate, and biochemical and clinical pregnancy rates were compared between the groups.

RESULTS

In total, 422 oocyte retrieval procedures with culture medium and 277 with normal saline were analyzed. The fertilization (P=0.676) and clinical pregnancy rates (P=0.593) did not differ between the groups. Using normal saline resulted in an approximately 41-fold per-patient cost saving compared with culture medium.

CONCLUSION

Switching from culture medium to normal saline for follicular flushing significantly reduced oocyte-retrieval costs without adversely affecting reproductive outcomes.

Optimizing treatment and analysis of prognostic factors for locally advanced nonsmall cell lung cancer in resource-limited population

BACKGROUND

Lung cancer most commonly presents in advanced stages in developing countries, where combined modality treatment using chemo-radiotherapy (CTRT) is the standard of care.

MATERIALS AND METHODS

A retrospective audit of patients of nonsmall cell lung cancer (NSCLC) treated at a single Institute from January 2008 to December 2012 was conducted. Various prognostic factors affecting disease-free survival (DFS) and overall survival (OS) were studied by univariate and multivariate analysis. All patients were meticulously followed-up clinically and telephonic contacts.

RESULTS

Overall 171 patients of NSCLC were treated with definitive CTRT using concurrent chemotherapy in 66% patients and sequential therapy in 28% patients. The actuarial 2 years DFS was 17.5% and 2 years OS was 61.5%. Complete response to treatment resulted in significantly better DFS and OS. Definitive CTRT was very well-tolerated in these patients with good compliance.

CONCLUSION

Definitive CTRT, sequence being individualized depending on performance status and disease stage at presentation, is a feasible and effective treatment modality for locally advanced NSCLC patients in the developing world. Response to treatment is an important prognostic factor for treatment outcomes.

The duration of gonadotropin stimulation does not alter the clinical pregnancy rate in IVF or ICSI cycles

BACKGROUND

Ovarian stimulation is an essential part of assisted reproduction treatments. Research on whether the duration of stimulation alters the success in assisted reproduction has not been conclusive.

AIM

The purpose of the study was to establish whether the duration of ovarian stimulation alters the success in assisted reproduction treatments.

METHODS

All fresh (non-donor) stimulation cycles performed in an academic tertiary referral ART centre over a period of 18 years, between 1st January 1997 and 31st December 2014, were identified. Data were prospectively and electronically collected. IVF and ICSI cycles were analysed independently. Each category was then subdivided into assisted reproduction cycles where the antagonist, long (down regulation) and flare protocol were used. Clinical pregnancy was the main outcome measured. A total of 10,478 stimulation cycles (6011 fresh IVF and 4467 fresh ICSI) reaching egg collection were included.

RESULTS

We showed no significant difference in CP rates in IVF cycles for the long (p = 0.082), antagonist (p = 0.217) or flare (p = 0.741) protocol cycles or in ICSI cycles with the long (p = 0.223), antagonist (p = 0.766) or the flare (p = 0.690) protocol with regards the duration of stimulation.

CONCLUSION

The duration of stimulation does not alter the CP rate in ICSI or IVF cycles using the long, antagonist or flare stimulation protocol.

Interleukin-15 is associated with disease severity in viral bronchiolitis

Disease severity in viral bronchiolitis in infancy is difficult to predict and has been linked to host innate immunity. The study aimed to investigate the innate cytokine interleukin-15 (IL-15) as a marker of disease severity.A prospective single-centre observational study was conducted in a university-affiliated paediatric teaching hospital, comparing children (0-18 months) hospitalised for viral bronchiolitis, those admitted to the paediatric intensive care unit with severe disease and healthy age-matched controls. IL-15-related parameters were compared between groups. PCR and microRNA (miRNA) sequencing was undertaken on natural killer (NK) cells collected from study participants.Samples from 88 children with viral bronchiolitis and 43 controls enrolled between 2009 and 2012 were analysed. Peripheral blood mononuclear cell (PBMC) IL-15 mRNA expression was significantly higher in those with moderate severity bronchiolitis compared with controls and those with severe disease. Serum IL-15 levels correlated with disease severity. The relative frequency of NK cells in peripheral blood was significantly reduced in participants with bronchiolitis. The NK cell miRNA transcriptome in bronchiolitis was distinct. Targets of de-regulated miRNA were differentially expressed in bronchiolitis, including JAK3, STAT5A and NFKB1 on the IL-15 signalling pathway.IL-15 is associated with disease severity in children hospitalised with viral bronchiolitis.

A rapidly enlarging cutaneous hemangioma in pregnancy

This is a case of a rapidly enlarging cutaneous pedunculated tumor on a patient’s thumb during her pregnancy. This was excised and identified as a hemangioma. A literature search identified a possible hormonal factor in causing an accelerated growth of this tumor.

Is it Time to Rejuvenate the Forceps?

The obstetric forceps was designed to assist extraction of the foetal head and thereby accomplish delivery of the foetus in the second stage of labour. More than 700 types of obstetric forceps have been described. An understanding of the anatomy of the birth canal and the foetal head is a prerequisite to becoming a skilled and safe user of forceps. Operative vaginal delivery rates have remained stable at between 10 and 13 %. The last few decades has seen a rise in caesarean section, along with the introduction and safe use of the vacuum extractor. This has resulted in a decline both in the use of the obstetric forceps as well as in the training for the same. The forceps is less likely to fail when used as the primary instrument thereby reducing the need for the sequential use of two instruments which increase the morbidity of the neonate. Perineal trauma is more likely to occur with the use of the forceps but the evidence is that the maternal concern is less when compared to the ventouse. Simulation training is an important part of obstetric training. Application of forceps blades in the simulation setting can improve the skill level of obstetricians. The use of the forceps should not be decreasing and more senior involvement in training is necessary so that juniors develop the proper skills to perform forceps delivery in a competent and safe manner. It is vital that the art of the forceps is not lost to future generations of obstetricians and the women they care for.

Paradoxical embolization: a potential cause of cerebral damage in Alzheimer's disease?

BACKGROUND

There are considerable overlaps between vascular dementia and Alzheimer's disease (AD), with a suggestion that cerebrovascular disease (CVD) contributes to the neurodegenerative pathology of AD. Paradoxical embolization of venous emboli into the systemic circulation through a venous to arterial circulation shunt (v-aCS), the most commonly a patent foramen ovale (PFO), is known to cause cryptogenic stroke in younger people. We reviewed the potential role of paradoxical embolization in AD.

METHODS

A review of the literature on paradoxical embolization in neurological disorders and techniques to detect v-aCS and PFO, supplemented by data from our own studies.

RESULTS

Before our research, the role of paradoxical embolism in dementia had not been studied. The potential role of embolization in cerebral damage was highlighted by studies in patients undergoing coronary artery bypass or carotid surgery. Paradoxical embolization was found to occur in patients with cryptogenic stroke, migraine, decompression sickles and during hip surgery. The methods for detecting v-aCS or PFO had not been standardized. We found 'significant' v-aCS (equivalent to PFO) in 32% of AD patients compared with 22% of controls, but the study was not sufficiently powered to test the statistic significance of this difference. In AD, there was evidence of an association between 'significant' v-aCS and the severity of white matter hyperintensities on magnetic resonance imaging (MRI).

CONCLUSION

Paradoxical embolization through a v-aCS may be a potentially preventable or treatable cause of CVD in AD.

Grieving after early pregnancy loss--a common reality

A miscarriage can be very traumatic for a couple and their immediate family. The aim of this study was to assess, using the Perinatal Grief Scale (PGS), whether the type of early pregnancy loss influences the severity of grief and whether the presence of living children influences the severity of grief. Over a period of 6 months in 2008, seventy five patients were recruited for the study, of which 7 (9.3%) had molar pregnancies, 20 (26.7%) had ectopic pregnancies, 43 (573%) had a miscarriage and 5 (6.7%) had recurrent miscarriages. In this study there was no significant difference in severity of grief, between women that had a miscarriage and ectopic pregnancy (p = 0.14) or, between women that had a miscarriage and a molar pregnancy (p = 0.85). Women who had experienced a ectopic pregnancy did not have a higher grief intensity than the women that had a molar pregnancy (p = 0.75). However, for women with a child, the grief intensity significantly increases with the number of miscarriages (p = 0.015). Women with no children with an ectopic pregnancy grieve significantly more than those with a child (p = 0.019). An appointment for the 'Miscarriage Clinic' should be offered to all of these women but special attention should be paid to those in the categories most at risk

Perinatal outcome after ultrasound diagnosis of anhydramnios at term

The aim was to assess the maternal and fetal outcome in women who had labour induced for anhydramnios after 37 completed weeks of gestation. A retrospective study was conducted at the Rotunda Hospital from 1 January 2003 to 31 December 2007. All women with anhydramnios at term were identified from a review of ViewPoint® (computer software for antenatal scans performed), hospital data and the labour ward register. All women with a history of previous lower segment caesarean section (LSCS), current significant medical illness such as diabetes, hypertension, pre-eclampsia or ruptured membranes were excluded because the aim of the study was to focus specifically on low risk pregnancies with an incidental diagnosis of anhydramnios after 37 weeks' gestation. The maternal and fetal outcome parameters reviewed included: maternal age, parity, gestation, method of induction, mode of delivery, Apgar score and the requirement for obstetric or neonatal intervention. This study showed that anhydramnios is associated with a 56.6% LSCS rate in primigravida and a 19.0% LSCS rate in multigravida. Our study did not show any significant neonatal morbidity and there were no cases of mortality.

Depressive symptom clusters are differentially associated with atherosclerotic disease

BACKGROUND

Depression increases the risk of subsequent vascular events in both cardiac and non-cardiac patients. Atherosclerosis, the underlying process leading to vascular events, has been associated with depression. This association, however, may be confounded by the somatic-affective symptoms being a consequence of cardiovascular disease. While taking into account the differentiation between somatic-affective and cognitive-affective symptoms of depression, we examined the association between depression and atherosclerosis in a community-based sample.

METHOD

In 1261 participants of the Nijmegen Biomedical Study (NBS), aged 50-70 years and free of stroke and dementia, we measured the intima-media thickness (IMT) of the carotid artery as a measure of atherosclerosis and we assessed depressive symptoms using the Beck Depression Inventory (BDI). Principal components analysis (PCA) of the BDI items yielded two factors, representing a cognitive-affective and a somatic-affective symptom cluster. While correcting for confounders, we used separate multiple regression analyses to test the BDI sum score and both depression symptom clusters.

RESULTS

We found a significant correlation between the BDI sum score and the IMT. Cognitive-affective, but not somatic-affective, symptoms were also associated with the IMT. When we stratified for coronary artery disease (CAD), the somatic-affective symptom cluster correlated significantly with depression in both patients with and patients without CAD.

CONCLUSIONS

The association between depressive symptoms and atherosclerosis is explained by the somatic-affective symptom cluster of depression. Subclinical vascular disease thus may inflate depressive symptom scores and may explain why treatment of depression in cardiac patients hardly affects vascular outcome.

Activational effects of sex hormones on cognition in men

BACKGROUND

Changing world demographic patterns, such as the increasing number of older people and the growing prevalence of cognitive impairment, present serious obstacles to preserving the quality of life and productivity of individuals. The severity of dementia varies from subclinical, mild cognitive impairment to neurodegenerative diseases such as Alzheimer's. In normally ageing men, these age-related cognitive declines are accompanied by gradual but marked decreases in androgen levels and changes in other hormone profiles. While developmental effects of sex hormones on cognition in the pre- and early postnatal period have been demonstrated, their activational effects in later life are still a focus of contemporary research. Although there is a plethora of published research on the topic, results have been inconsistent with different studies reporting positive, negative or no effects of sex hormones on various aspects of mental agility.

METHODS

This review summarizes the evidence supporting the biological plausibility of the activational effects of sex hormones upon cognition and describes the mechanisms of their actions. It offers a comprehensive summary of the studies of the effects of sex hormones on fluid intelligence in men utilizing elements from the Cochrane Collaboration Guidelines for Reviews. The results of both observational (cross-sectional and longitudinal) and interventional studies published to date are collated in table form and further discussed in the text. Factors contributing to the difficulties in understanding the effects of sex hormones on cognition are also examined.

CONCLUSIONS

Although there is convincing evidence that steroid sex hormones play an organizational role in brain development in men, the evidence for activational effects of sex hormones affecting cognition in healthy men throughout adult life remains inconsistent. To address this issue, a new multifactorial approach is proposed which takes into account the status of other elements of the sex hormones axis including receptors, enzymes and other hormones.

Biomarkers of cerebrovascular disease in dementia

There is increasing recognition that cerebrovascular disease contributes significantly to the development and progression of patients with dementia. The concepts of pure vascular and pure degenerative dementia have been replaced with a recognition that, in many patients, there is a spectrum of neurodegenerative and vascular processes. This is supported by preliminary studies showing response to vascular therapeutics and ventriculo-peritoneal shunting in patients with Alzheimer's disease. This article examines the imaging biomarkers that are available for the characterization of microvascular abnormality in the ageing brain, with particular reference to microvascular angiopathy, cerebral embolic disease, orthostatic hypotension and abnormalities of Monro-Kellie homeostasis.

Activities enjoyed by patients with dementia together with their spouses and psychological morbidity in carers

Caring for a spouse with dementia is stressful and respite care is sometimes used to reduce this burden. Spouses may find some aspects of caring rewarding but the literature on positive aspects of caring is limited. To describe activities enjoyed by patients with dementia together with their spouses, and examine their relationship with psychological morbidity in carers. A convenience sample of 46 patients with mild to moderate dementia (91% with Alzheimer's disease, AD) and their spouses were interviewed at home. Spouses completed the Pleasant Events Schedule (PES-AD) to identify activities enjoyed by patients and spouses on their own and together. Psychological morbidity in spouses was assessed using the General Health Questionnaire (GHQ-12). Cognitive functions, and non-cognitive symptoms were also assessed in patients. Multiple regression analysis using age, Mini-Mental State Examination, Cornell Scale for Depression in Dementia, Revised Memory and Behaviour Problems (RMBP) checklist frequency, and PES-AD- together scores as independent variables found PES-AD-together and RMBP-frequency to be independent predictors of GHQ-12 scores in spouses, but the model could explain only 28% of variance. Facilitating activities that are enjoyed by both patients with dementia and spouses may be an alternative intervention strategy to reduce carer burden.

18F-FDG uptakes in leptomeningeal metastases from carcinoma of the breast on a positron emission tomography/computerized tomography study

Leptomeningeal metastases (LM) are most commonly observed in hematological malignancies. With prolonged survival in solid tumors, an increased frequency of metastases is noted in these tumors too. Early diagnosis, when the patient has minimal neurological disability, is associated with prolonged survival and improved functional outcome although the therapy is palliative. The diagnosis of LM is difficult, and the demonstration of tumor cells in the cerebrospinal fluid remains the gold standard. This can also be done by definitive neuroimaging. MRI is routinely used in this aspect. We discuss here a case where 18F-FDG PET/CT (Fluoro-de-oxy glucose positron emission tomography/computerized tomography) study helped us in the diagnosis of LM. Whole-body PET/CT imaging could be a useful tool in identifying the possibility of metastases of breast carcinoma in the usual sites and the not-so-usual sites of metastases.