Cervical mucus removal prior to intrauterine insemination: a randomized trial

OBJECTIVE

To detect if removing the cervical mucus before performing intrauterine insemination (IUI) could improve pregnancy outcomes in patients with unexplained infertility.

DESIGN

Prospective randomized study.

SETTING

An Egyptian University Hospital.

POPULATION

Seven hundred and fourteen couples with unexplained infertility who underwent intrauterine insemination (IUI) with or without cervical mucus removal.

METHODS

Using computer-generated numbers, patients were randomly allocated to cervical-mucus-removal (removed from both internal and external os) or non-mucus-removal groups. Only participants were blinded as to group assignment.

MAIN OUTCOME MEASURES

The clinical pregnancy rate.

RESULTS

Of 714 IUI patients between November 2014 and March 2017, 361 were in the mucus removal group, and 353 in the non-mucus-removal group. Difficult catheterization was encountered in 17 cases out of 666 (2.6%) 12 in the cervical-mucus-removal group and five in the non-mucus-removal group). A total of 666 IUI cycles were completed while 48 were either cancelled or lost in their follow-up. The clinical pregnancy rate was significantly higher in the mucus-removal group [31.0% (n = 112)] than in the non-mucus-removal group [21.8% (n = 77); P = 0.005]. Ovarian hyperstimulation developed in 33 (4.6%) cases: 18 cervical mucus-removal and 15 non-mucus-removal. All except one were mild and managed with outpatient care.

CONCLUSIONS

Cervical mucus removal before IUI could improve pregnancy outcomes in women with unexplained infertility.

TWEETABLE ABSTRACT

Cervical mucus removal before IUI can improve pregnancy outcomes.

Early pregnancy screening for hypertensive disorders in women without a-priori high risk

OBJECTIVES

To evaluate the performance of mean arterial pressure, uterine artery pulsatility index and soluble endoglin level alone or in combination in screening for hypertensive disorders in pregnant women without a-priori high risk.

METHODS

This was a nested case-control study of women with singleton pregnancies without a-priori high risk who developed pregnancy-induced hypertensive complications. Women were enrolled into the study at 11-14 weeks' gestation, when mean arterial pressure and uterine artery pulsatility index were recorded and a blood sample was taken for measurement of soluble endoglin. Women were followed up in the clinic to detect development of any hypertensive disorder. Each affected case was matched with two normotensive control women with uncomplicated pregnancies that resulted in phenotypically normal infants. Mean values for each variable were compared between cases and controls. Sensitivities, positive predictive values and negative predictive values at fixed specificity were derived from receiver-operating characteristics (ROC) curves.

RESULTS

During the study period, 2120 patients were examined. Of these, 170 (8.02%) were excluded because they were lost to follow-up and in 52 (2.45%) there was fetal death or miscarriage before 24 weeks' gestation. Thus, 1898 cases formed the cohort population. Of these, 89 (4.69%) patients developed complications (study group), including 16 (0.84%) cases with early pre-eclampsia (PE), 60 (3.16%) with late PE and 13 (0.68%) with gestational hypertension (GH). There were 49 (2.58%) cases of spontaneous preterm delivery before 34 weeks. The rest of the cohort population (1760 (92.73%) patients, the base cohort) were not affected by PE or GH. The control group comprised 178 patients. The best model for the prediction of any of the types of hypertensive disorders was one that combined mean arterial pressure with soluble endoglin (area under the ROC curve (AUC), 0.83). The predictive value of the three combined markers was highest for screening for early and late PE (AUC, 0.86 and 0.83, respectively). When each marker was considered alone, the highest prediction of any type of hypertensive disorder was achieved by mean arterial pressure (AUC, 0.73). Sensitivity was lowest for detection of GH when screening both by individual and by combined markers.

CONCLUSION

First-trimester screening can be useful in predicting women at high risk of developing hypertensive disorders of pregnancy but more prospective longitudinal studies are needed.