Amniocentesis-related adverse outcomes according to placental location and risk factors for fetal loss after midtrimester amniocentesis

PURPOSE OF INVESTIGATION

Amniocentesis-related adverse outcomes in singleton pregnancies and possible risk factors for fetal loss after mid-trimester amniocentesis performed in a single institution were investigated.

METHODS

Amniocentesis-related adverse outcomes such as insufficient aspiration of amniotic fluid (AF), repeated puncture, and aspiration of hemorrhagic AF after mid-trimester amniocentesis were reviewed, while special consideration was given according to the placental location. Fetal loss rate up to 24 weeks of gestation and risk factors related to fetal losses were also investigated.

RESULTS

5,948 cases with the inclusion criteria were analyzed. Advanced maternal age was the most common indication (53%) for amniocentesis. A need for repeated puncture was overall 2.1% (n = 128) and was associated with a fundal placental location. Aspiration of hemorrhagic amniotic fluid was observed in 3.7% (n = 222) and was significantly associated with an anterior or fundal placental position. Fetal loss rate was 0.3% and there was no relationship with advanced maternal age (> or = 35 years), gestational age at amniocentesis > 18 weeks, repeated procedure, aspiration of hemorrhagic AF or placental location.

CONCLUSION

Anterior or fundal placental position is a risk factor for amniocentesis-related adverse outcomes, however without significant contribution to the fetal losses. Placental location, advanced maternal age, amniocentesis gestational age > 18 weeks, and the procedure's adverse outcomes seem to have no impact on fetal loss rate.

Intravaginal misoprostol reduces intraoperative blood loss in minimally invasive myomectomy: a randomized clinical trial

PURPOSE OF INVESTIGATION

We performed a randomized clinical trial to estimate whether preoperative use of misoprostol may reduce intraoperative blood loss of patients treated by minimally invasive surgery (MIS), such as laparoscopic (LM) or laparoscopically assisted myomectomy (LAM).

METHODS

Sixty-seven menstruating patients with three or less myomas of a maximum diameter of 90 mm, scheduled for MIS, were randomly allocated to receive a preoperative single dose of intravaginal misoprostol or placebo. Sixty-four patients remained in the final analysis: 30 in the misoprostol (I) and 34 in the placebo group (II). Estimated blood loss (EBL), decline of postoperative hemoglobin (Hb) and side-effects of administered agent were the outcomes of main interest.

RESULTS

The EBL was significantly higher in the placebo versus misoprostol group (217 +/- 74 vs 126 +/- 41, respectively). Similarly, the decline of postoperative Hb was significantly higher in group II (1.6 +/- 0.43) compared to group I (1 +/- 0.33). The operative time was comparable in both groups, while the rate of side-effects was similar between groups.

CONCLUSION

The preoperative use of misoprostol in patients with uterine fibroids managed by minimally invasive surgery significantly reduces intraoperative blood loss. Misoprostol might be useful for the prevention of postoperative anemia in more extended minimal invasive interventions, such as myomectomy of large fibroids or laparoscopic hysterectomy.

[Closed carrier device: a reality to vitrify oocytes and embryos in aseptic conditions]

Vitrification with the use of "Open" carrier devices (Cryoloop, cryotop, cryoleaf, Vitriplug) which allowed the contact with liquid nitrogen has become a more popular way to achieve cooling rate superior to 20,000 °C/min. Even though the question of contamination with liquid nitrogen during ultra-rapid cooling and storage remain debatable with the use of "open" devices, it is important to revise the carrier system in a way, which minimizes the risk of contamination. According to the EU tissues and cells directive, it is advisable that the cooling and storage should be carried out in embryo carrier devices ensuring complete separation of the embryos from liquid nitrogen in a way, which minimizes the risk of contamination. The consequence of a reduction in the cooling rate resulting from the heat-insulating barrier of aseptic devices has to be counteracted by gradually increasing intracellular concentrations of cryoprotectants without inducing a toxic effect. We developed an aseptic vitrification method of vitrification for MII oocytes and embryos at different stage of development using the "VitriSafe" as "closed" carrier device.

Previous cesarean section increases the risk for breech presentation at term pregnancy

PURPOSE OF INVESTIGATION

The aim of the present study was to estimate the risk for breech presentation in women with singleton pregnancies at-term who had had at least one previous cesarean section (CS) versus at least one previous vaginal delivery.

METHODS

Out of 4269 singleton pregnancies during the study period, 2008 met the inclusion criteria. The history, the number of previous CSs, as well as maternal age, parity, birth weight, gestational age, neonatal sex and placenta previa were used to estimate the risk for breech at term.

RESULTS

The overall incidence of breech presentation was 3.2%, while 20% of the women had a history of at least one previous CS. The rate of breech presentation at term in singleton pregnancies after CS increased two-fold (5.3%) when compared to those with at least one previous vaginal delivery (2.6%), (p = 0.01) [OR 2.08 (95% CI, 1.23-3.52)], while the number of the previous CSs did not correlate with breech presentation (p = NS) [OR 0.86 (95% CI, 0.31-2.4)].

CONCLUSION

According to the present study, women with a history of at least one cesarean delivery have an increased risk for breech presentation in the subsequent singleton pregnancy at-term.

GnRH agonist versus GnRH antagonist in oocyte donation cycles: a prospective randomized study

BACKGROUND

The specific role of LH in folliculogenesis and oocyte maturation is unclear. GnRH antagonists, when administered in the late follicular phase, induce a sharp decrease in serum LH which may be detrimental for IVF outcome. This study was performed to evaluate whether the replacement of GnRH agonist (triptorelin) by a GnRH antagonist (ganirelix; NV Organon) in oocyte donation cycles has any impact on pregnancy and implantation rates.

METHODS

A total of 148 donor IVF cycles was randomly assigned to use either a GnRH antagonist daily administered from the 8th day of stimulation (group I) or a GnRH agonist long protocol (group II) for the ovarian stimulation of their donors. The primary endpoints were the pregnancy and the implantation rates.

RESULTS

The clinical pregnancy rate per transfer (39.72%, 29/73 versus 41.33%, 31/75) based on transvaginal scan findings at 7 weeks of gestation, the implantation rate (23.9 versus 25.4%) and the first trimester abortion rate (10.34 versus 12.90%) were similar in the two groups.

CONCLUSION

In oocyte donation cycles the replacement of GnRH agonist by a GnRH antagonist appears to have no impact on the pregnancy and implantation rates when its administration starts on day 8 of stimulation.

Cervical dilatation has a positive impact on the outcome of IVF in randomly assigned cases having two previous difficult embryo transfers

BACKGROUND

The difficulty of embryo transfer has been reported to affect success rates in some centres, but not in others. Cervical dilatation has been proposed as a means to overcome difficult embryo transfer, but consistent criteria for patient selection are lacking. In a prospective randomized study, we examined the influence of cervical dilatation 1-3 months before embryo transfer on the outcome of IVF in cases having difficult embryo transfer in two previously failed IVF cycles.

METHODS

Two alternative methods of embryo transfer preparation were evaluated in 283 randomly assigned women having difficult embryo transfers in two previously failed IVF attempts. Randomization was made using a computer-generated random number table. Cervical dilatation before starting any IVF treatment was used in 145 cases, and no dilatation was performed in 138 cases.

RESULTS

The cervical dilatation group yielded a significantly higher pregnancy rate than the non-dilated group (40% versus 24%; P < 0.01). Likewise, the implantation rate (24.1% versus 14.9%; P < 0.01) and the live birth rate (34.48% versus 19.56%; P < 0.01) were significantly higher in the dilatation group than in the non-dilated group.

CONCLUSIONS

In patients with prior difficult embryo transfer, cervical dilatation 1-3 months before embryo transfer lead to an improved pregnancy rate.

Ultrasound-guided embryo transfer maximizes the IVF results on day 3 and day 4 embryo transfer but has no impact on day 5

BACKGROUND

The use of ultrasound-guided embryo transfer has been reported to affect success rates in some centres but not others. In a prospective study, we examined the influence of ultrasound guidance in embryo transfer performed on different days after oocyte retrieval.

METHODS

Two different methods of embryo transfer were evaluated in 1069 consecutive transfers. The ultrasound-guided embryo transfer was used in 433 cases, whereas 636 embryo transfers were performed with the tactile assessment ('clinical feel') method.

RESULTS

Ultrasound-guided embryo transfer yielded a higher overall pregnancy rate than the 'clinical feel' approach, 47 versus 36% (P < 0.001). This difference was statistically significant where embryos were transferred after 3 or 4 days of culture, 45.9 versus 37.1% (P = 0.001) and 42.3 versus 27% (P = 0.035) respectively but not significant (P = 0.112) on day 5 embryo transfer (56.3 versus 45.7%). Likewise, the implantation rate was significantly different between the two groups on day 3 and 4 embryo transfer, 23.3 versus 15.8% (P < 0.01) and 21.6 versus 15.7% (P < 0.05%) respectively but no statistical difference was noted on day 5 embryo transfer, 26.7 versus 23.6%.

CONCLUSION

Ultrasound assistance in embryo transfer on day 3 and 4 significantly improved pregnancy rates in IVF but had no impact on day 5.

Effect of treatment with GnRH agonists on new markers of bone metabolism

To assess the utility of new markers in monitoring bone turnover during treatment with GnRH agonists, alkaline phosphatase (total and bone specific) and urinary N-telopeptides were measured. 16 women undergoing treatment with GnRH agonists for endometriosis or leiomyomas were studied before and 3 months after the onset of treatment. N-telopeptide levels increased significantly (44% of baseline, p < 0.05). Bone specific alkaline phosphatase (BALP), measured with a new ELISA assay, was more elevated (40% of baseline, p = 0.001) than total ALP (15% of baseline, p < 0.001). In conclusion, in estrogen deficiency states, urinary N-telopeptide measurements provide a quantitative measure of bone resoption. In the assessment of bone formation, BALP determination is move sensitive than total ALP and this may be clinically useful.

Congenital malformations after intracytoplasmic injection of spermatids

Spermatid microinjection into oocytes was applied in cases of intracytoplasmic sperm injection (ICSI)/testicular sperm extraction (TESE) where no spermatozoa could be found in numerous testicular samples. Although several pregnancies were obtained with this procedure, serious concerns remain regarding its safety. Although the relevance of the injection of spermatids is by no means certain, we wish to report that from four pregnancies obtained after injection of elongated spermatids, two cases of major malformation resulted.

Is there a future for spermatid injections?

Microinjection of spermatids into oocytes has proven to be a successful assisted reproduction procedure in the animal model. In the human, low fertilization and cleavage to the 4-cell stage were reported after intracytoplasmic sperm injection (ICSI) with round spermatids. In comparison with a conventional ICSI-testicular sperm extraction (TESE) programme, the implantation rate after round spermatid injection is dramatically low. Different problems have been encountered during the development of the spermatid injection technique and they could be partially responsible for the lower outcome when using round spermatids. Compared with the round spermatid cells, spermatids in the elongation phase are easy to isolate and identify from other round cells present in a wet preparation. The morphological identification does not reveal anything about the viability or the genetic normality of the round spermatids. Severe testicular dysfunction may have consequences on the quality of the few spermatogenic cells present. Others factors, such as the pathology of the patient, play an important role in the successful treatment. Even if the results are extremely low, spermatid injection seems more favourable for men who have already proven their capacity to produce some spermatozoa. A spermatogenic block at the round spermatid level has led to early abortions, increasing the suspicion of the role of a genetic factor. In order for this technique to be safe for use in clinics, more intensive work is needed to improve the selection and handling of cells and to ascertain the genomic imprinting and gene expression necessary for embryonic development. Hence, when using immature cells for conception, the screening of the patient and the follow-up of the pregnancies and babies should be mandatory.

The window for embryo transfer in oocyte donation cycles depends on the duration of progesterone therapy

In 192 oocyte donation cycles performed between January 1993 and July 1996, we examined the width of 'the window for embryo transfer' using standard hormonal replacement methods. All transfers were performed within 48 h of insemination. We varied the day of embryo transfer with regard to the initiation of progesterone therapy and, thus, the duration of endometrial exposure to progesterone and analysed the resulting pregnancy rates. Patients were divided into five groups (I-V) and embryo transfers were performed 2, 3, 4, 5 or 6 days following initiation of progesterone therapy. The number of pregnancies per transfer cycle achieved in groups I-V were 0 (0%), 3 (12%), 16 (40%), 29 (48.3%), and 10 (20.4%) respectively. The increased pregnancy rate in group III in comparison to group II is statistically significant (P < 0.03). Furthermore, the pregnancy rate in group IV (5 days of progesterone administration before embryo transfer) was significantly higher than in group V (6 days of progesterone administration before embryo transfer; P < 0.005). We also noted that, when embryos were transferred 4 or 5 days after initiation of progesterone therapy, the pregnancy rates were not significantly different between menopausal and cycling recipients (50% vs 43.7%). Our results indicate that the window for embryo transfer is dependent on duration of treatment with progesterone; it begins approximately 48 h after starting progesterone administration and lasts for approximately 4 days. The optimum period for transferring embryos at the 4- to 8-cell stage corresponds to cycle days 18 and 19. Transfers performed on the 17th and 20th days of the cycle can result in successful implantation, although the rates of implantation are highest when transfers are done on days 18 and 19.

The echoguide embryo transfer maximizes the IVF results

The performance of two different methods of embryo transfer for IVF has been evaluated in 132 consecutive embryo transfers. Thirty Eight pregnancies were achieved, corresponding to a pregnancy rate of 28.7% of all embryos transfers. The embryo transfer under ultrasound control was used in 61 cases of our study whereas 71 cases were performed with the "clinical feel" method without ultrasound control. The echoguide embryo transfer procedure yielded a significantly higher pregnancy rate than the blind method (36.06% versus 22.6%). The mean number of embryos transferred per attempt was similar in the two groups (3.1 +/- 0.1 and 3.0 +/- 0.1) as was the quality. The randomized comparative study will continue in order to get more data.

Laparoscopic tubal surgery. A retrospective comparative study of open microsurgery versus laparoscopic surgery

The aim of this study is to compare retrospectively the outcome of patients that underwent tubal surgery by laparotomy or laparoscopy by the same surgeon Thirty two women that presented with distal tubal obstruction were treated by laparoscopic tubal surgery and 38 by laparotomy and microsurgery. Patients were equally matched for age, duration of infertility and severity of disease. In all cases there were no injuries to adjacent groups and no additional surgery was needed. The duration of surgery was 35-60 min for laparoscopy and 70-120 min for laparotomy and mean duration of hospital stay was 2 and 7 days respectively. Of the 32 cases that underwent laparoscopic surgery 10 had intrauterine pregnancies (31.25%) and 2 ectopic (6.2%). Conversely 11 (28.9%) of the 38 cases with tubal microsurgery resulted in intrauterine pregnancy and 4 (10.5%) in ectopic. Our results suggest that laparoscopic tubal surgery is the method of choice for the treatment of distal tubal obstruction.

Ovarian hyperstimulation syndrome and heterotopic pregnancy after IVF

We report a case of Severe OHSS combined with Heterotopic pregnancy. During the treatment of OHSS the patient underwent transvaginal paracentesis for the ascites but no sign of blood was noticed into the fluid. The ultrasound control in the 8th week had shown a normal intrauterine pregnancy without any suspicion for heterotopic pregnancy. The diagnosis for heterotopic pregnancy became possible at 10 Weeks of gestation by Ultrasound. Laparotomy with partial tubal resection was performed. The intrauterine pregnancy is still ongoing without complications.

Term pregnancy after vaginal transplantation in a case of vaginal agenesis with a functional uterus

This is a report of a successful pregnancy on a patient that had congenital vaginal aplasia with a functioning uterus. Continuity of the reproductive tract was restored at 12 years of age with transplantation of vaginal wall from the mother. The patient had no problems after initiating intercourse 7 years later and conceived without treatment after 5 years of primary infertility. She was delivered by cesarean section at term.