Ultrasonographic assessment of metoclopramide effect on gastric volume in parturients females undergoing Caesarean section: a randomized double blind study.

BACKGROUND: The prokinetic effect of metoclopramide promotes gastric emptying and decreases stomach capacity. The aim of the present study was to assess the efficacy of metoclopramide in reducing gastric contents and volume using gastric point-of-care ultrasonography (PoCUS) in parturients females prepared for elective Cesarean section under general anesthesia. METHODS: A total of 111 parturient females were randomly allocated to one of two groups. The intervention group (Group M; N.=56) received 10 mg metoclopramide diluted in 10 mL 0.9% normal saline. The control group (Group C; N.=55): received 10 mL 0.9% normal saline. The cross-sectional area and volume of stomach contents were measured using ultrasound before and one hour after the administration of metoclopramide or saline. RESULTS: Statistically significant differences in mean antral cross-sectional area and gastric volume were observed between the two groups (P<0.001). Group M had significantly lower rates of nausea and vomiting compared to the control group. CONCLUSIONS: Metoclopramide decreases gastric volume, reduces postoperative nausea and vomiting, and may lower the risk of aspiration when used as premedication before obstetric surgery. Preoperative gastric PoCUS has utility in objectively assessing stomach volume and contents.

Intrauterine injection of HCG before embryo transfer: a parallel, double-blind randomized trial.

RESEARCH QUESTION: Does intrauterine administration of HCG before embryo transfer improve live birth rate during IVF cycles? DESIGN: A parallel, randomized controlled trial conducted between July 2018 and February 2020. Infertile women (n = 181) scheduled for fresh or vitrified-warmed embryo transfer after IVF carried out for any indication were randomized in a 1:1 ratio to receive either HCG (500 IU in 0.1 ml of tissue culture media) or culture media (0.1 ml of tissue culture media) via intrauterine injection 4 min before embryo transfer. In both groups, an intrauterine insemination catheter was used for administering the medication. Primary outcome was live birth, with ongoing pregnancy and clinical pregnancy as secondary outcomes. Analysis was based on intention-to-treat principle. RESULTS: Baseline and cycle characteristics were comparable between the two groups. In the control group, one woman with a confirmed clinical pregnancy was lost to follow-up. Live birth rates were 24% (22/90) in the HCG group versus 19% (17/90) in the control group (RR 1.29, 95% CI 0.74 to 2.27). Clinical pregnancy and ongoing pregnancy rates were 34% versus 26% (RR 1.31, 95% CI 0.84 to 2.04) and 24% versus 19% (RR 1.29, 95% CI 0.74 to 2.27) in the HCG and the control groups, respectively. CONCLUSION: Intrauterine injection of HCG before embryo transfer did not improve live birth rates in women undergoing IVF. As the study was designed to detect a 20% difference between groups, a smaller, clinically important difference could not be ruled out. Treatment outcomes were lower than expected in the control group.

Progesterone/Oestradiol ratio can Better Predict Intracytoplasmic Sperm Injection Outcomes than Absolute Progesterone Level.

BACKGROUND: Several parameters were proposed to predict the impact of premature luteinization on intracytoplasmic sperm injection (ICSI) outcomes such as isolated progesterone (P) level, progesterone to oocyte ratio, and progesterone/estradiol ratio (P/E2). AIM: The aim of this study is to compare the predictive value of P/E2 ratio and isolated P level on the ovulation triggering day for pregnancy outcomes in fresh GnRH antagonist ICSI cycles. SETTINGS AND DESIGN: A retrospective cohort study conducted in a university-affiliated in vitro fertilization center between January 2017 and April 2019. METHODS: The study included women who underwent their first- or second-ranked GnRH antagonist ICSI cycles with day-3 embryo transfer. P/E2 ratio was calculated as (P [ng/mL] × 1000)/E2 (pg/mL). Cutoff values of ≥1.5 ng/ml for high P (HP) and ≥0.55 for HP/E2 ratio were chosen based on the literature. STATISTICAL ANALYSIS: A receiver operating curve was performed to detect the predictability of serum P/E2 and P for the ongoing pregnancy rate. First, patients were divided according to either P level (low P < 1.5 ng/mL and HP ≥1.5 ng/mL) or P/E2 ratio (low P/E2 <0.55 and HP/E2 ≥ 0.55). Patients were further divided into four subgroups: (Group A: HP and HP/E2 ratio, Group B: low P and low P/E2 ratio, Group C: HP only, and Group D: HP/E2 only). A multivariate regression analysis models were used to account for the effect of the cycle confounders on the likelihood of pregnancy. RESULTS: A total of 402 ICSI cycles were analyzed. The area under the curve was 0.67 and 0.59 for P/E2 and P, respectively. P/E2 showed a significant association with ongoing pregnancy (adjusted odds ratios [aOR]: 0.409, 95% confidence interval [CI] 0.222-0.753, P = 0.004) while HP revealed no significant predictive value (aOR: 0.542, 95% CI 0.284-1.036, P = 0.064) after the multivariate analysis. CONCLUSIONS: P elevation may not present as an independent predictor for cycle outcomes. P/E2 ratio has a better prognostic value than P alone in predicting pregnancy of GnRH antagonist cycles.

Effect of Metformin on Premature Luteinization and Pregnancy Outcomes in Intracytoplasmic Sperm Injection-Fresh Embryo Transfer Cycles: A Randomized Double-Blind Controlled Trial.

BACKGROUND: Premature luteinization (PL) is not unusual in in vitro fertilization (IVF) and could not be wholly avoided by using either gonadotropin-releasing hormone (GnRH) agonists or GnRH antagonist regimens. The study aims to evaluate metformin's efficacy in preventing PL in fresh GnRH antagonist intracytoplasmic sperm injection (ICSI) cycles with cleavage-stage embryo transfer. MATERIALS AND METHODS: This randomized, double-blind, placebo-controlled trial was conducted in a tertiary university IVF center. We recruited infertile women who were scheduled to perform their first or second ICSI trial. Eligible women were recruited and randomized in a 1:1 ratio into two groups. Metformin was administered in a dose of 1500 mg per day since the start of contraceptive pills in the cycle antecedent to stimulation cycle until the day of ovulation triggering, while women in the placebo group received a placebo for the same regimen and duration. The primary outcome was the incidence of PL, defined as serum progesterone (P) on the triggering day ≥1.5 ng/mL. Secondary outcomes comprised the live birth, ongoing pregnancy, implantation, and good-quality embryos rates. RESULTS: The trial involved 320 eligible participants (n=160 in each group). Both groups had comparable stimulation days, endometrial thickness, peak estradiol levels, number of oocytes retrieved, and number of mature oocytes. Metformin group experienced lower level of serum P (P<0.001) and incidence of PL (10 vs. 23.6%, P=0.001). Moreover, lower progesterone/estradiol (P/E) ratio and progesterone to mature oocyte index (PMOI) (P=0.002 and P=0.002, respectively) were demonstrated in women receiving metformin. Metformin group generated a better rate of goodquality embryos (P=0.005) and ongoing pregnancy (43.8 vs. 31.8%, P=0.026). A similar trend, though of borderline significance, was observed in the live birth rate in favor of metformin administration (38.15 vs. 27.5%, P=0.04). CONCLUSION: Metformin could be used in patients with potential PL to improve fresh cycle outcomes by preventing PL (Registration number: NCT03088631).

Dual trigger using recombinant HCG and gonadotropin-releasing hormone agonist improve oocyte maturity and embryo grading for normal responders in GnRH antagonist cycles: Randomized controlled trial.

OBJECTIVES: To evaluate the effectiveness of dual trigger using gonadotropin-releasing hormone (GnRH) agonist and recombinant human chorionic gonadotropin (rHCG) versus rHCG alone for normal responders in GnRH antagonist intracytoplasmic sperm injection (ICSI) cycles. PATIENTS AND METHODS: The current study was a registered open-labeled randomized controlled trial (clinical trial.gov: NCT02916173) conducted in the ART Unit of a tertiary University hospital between October 2016 and October 2018. The study participants were randomized to either group I (HCG group) or group II (dual trigger group). The primary outcome was the number of mature (MII) oocytes in both groups. RESULTS: Both groups were similar regarding the baseline demographic and clinical characteristics. Women in the dual trigger group had a statistically significant higher number of retrieved oocytes (p = 0.001), MII oocytes (p = 0.01) and the number of grade one embryos (p = 0.04). Both groups were similar regarding the fertilization, implantation, clinical pregnancy and live birth rates in a fresh cycle. Dual trigger group was significantly higher in the clinical pregnancy rate and live birth rate after frozen embryo transfer (p = 0.04, 0.03, respectively). CONCLUSION: Dual trigger by GnRH agonist and rHCG improve the oocyte maturity and embryo grading for normal responders in GnRH antagonist ICSI cycles.

Revisiting debates of premature luteinization and its effect on assisted reproductive technology outcome.

The impact of the prematurely elevated serum progesterone on the late follicular phase, commonly known as premature luteinization (PL), is a matter of continuing debate. Available evidence supports that serum progesterone ≥ 1.5 ng/ml on the day of ovulation triggering could reduce the pregnancy potential in fresh in vitro fertilization (IVF) cycles by jeopardizing endometrial receptivity. Causes of PL during ovarian stimulation are unclear. Recent studies point toward the daily follicle-stimulating hormone dosage, duration of controlled ovarian stimulation, number of oocytes retrieved, and peak estradiol level as factors affecting the incidence of PL. Emerging data show additional influence on embryo quality. The prevention of PL has been challenging. The key elements in preventing PL include individualization of ovarian stimulation according to patient's ovarian reserve, proper ovulation trigger timing, and use of medications such as corticosteroids and metformin. Embryo cryopreservation with deferred embryo transfer is the established strategy to overcome PL, yet it is an extra burden to the IVF laboratory and increased cost for patients. Herein, we review the up-to-date knowledge of this frequent IVF problem including causes, proposed diagnostic criteria, and its impact on endometrial receptivity, embryo quality, and pregnancy outcomes. The preventive measures and rescue strategies are also discussed.

Impact of Metformin on IVF Outcomes in Overweight and Obese Women With Polycystic Ovary Syndrome: A Randomized Double-Blind Controlled Trial.

OBJECTIVES: To evaluate the impact of metformin on in vitro fertilization (IVF) outcomes in overweight and obese women with polycystic ovary syndrome (PCOS). METHODS: This was a randomized double-blind placebo-controlled study ( ClinicalTrials.gov : NCT02910817) carried out in a University IVF Center. The study included 102 overweight and obese women (body mass index [BMI] >24 kg/m2) with PCOS who underwent their first fresh autologous IVF-embryo transfer cycle and agreed to participate in the study. The study participants were randomized into 2 groups: metformin group received metformin (1000 mg per day) at the start of controlled ovarian stimulation (COH) until the day of the pregnancy check, and placebo group received placebo tablets in the same duration. The primary outcome measure was the total number of retrieved oocytes. RESULTS: Both groups were homogenous in baseline demographic characteristics. Metformin group versus the placebo group demonstrated decrease in the mean number of the retrieved oocytes (9.06 ± 4.23 vs 16.86 ± 8.3, P < .01) and similar live birth rate (LBR; 25.5% vs 17.6%, P = .34). The number of fertilized oocytes was lower in the metformin group (5.65 ± 2.66 vs 9 ± 4.55, P < .01). However, the fertilization rate was similar in both groups (62.3% vs 53.4%, P = .10). There was no difference in the implantation rate (15.7% vs 11.8%, P = .32), multiple pregnancy rate (13.4% vs 3.9%, P = .08), or miscarriage rate (23.5% vs 35.7%, P = .46). No cases of ovarian hyperstimulation syndrome (OHSS) were observed in both groups. CONCLUSION: Short-term administration of metformin to overweight or obese women with PCOS undergoing IVF decreased number of the retrieved oocytes but did not improve the LBR. SYNOPSIS: Metformin use could decrease the number of retrieved oocytes in overweight and obese women with polycystic ovary syndrome undergoing IVF.

The Effect of Age and Body Mass Index on the Surgical Anatomy of Supraumbilical Port Insertion: Implications for Laparoscopic and Robotic Surgery.

BACKGROUND: Minimally invasive surgery is the preferred approach for performing many gynecologic procedures. Occasionally, supraumbilical port placement may be preferable to optimize visibility and maneuverability although the risks of complications are less well characterized compared to umbilical entry. METHODS: We conducted a retrospective review of computed tomograms from 92 patients to evaluate the anatomic considerations for umbilical and supraumbilical port entry based on patient age, body mass index (BMI), parity, abdominal wall thickness, and distance to the great vessels. RESULTS: Supraumbilical entry was not associated with differences in distance to the great vessels compared to the umbilicus. However, supraumbilical location and BMI were associated with greater abdominal wall thickness. Age and BMI were associated with greater distance to the great vessels, while age was associated with thinner abdominal wall. Multiple linear regression confirmed independent effects of age and BMI. No association between parity and distance to retroperitoneal vessels was observed. CONCLUSION: Younger patients may be at increased risk for great vessel injury and pre-peritoneal insufflation. Obese patients may be at risk for pre-peritoneal insufflation, while patients with BMI < 30, particularly with a skin-to-aorta distance < 7 cm, may be at an increased risk for great vessel injury. Surgeons should consider these factors when considering supraumbilical port entry.

The effect of follicullar fluid pesticides and polychlorinated biphenyls concentrations on intracytoplasmic sperm injection (ICSI) embryological and clinical outcome.

OBJECTIVES: The present study evaluated the correlation between the concentrations of polychlorinated biphenyls (PCBs) and pesticides in the follicular fluid (FF) obtained during intracytoplasmic sperm injection (ICSI) with the ovarian response, endometrial thickness, and embryological and clinical outcomes. DESIGN: Cross-sectional observational study. MATERIALS AND METHODS: Women aged 20 to 38 years (300 infertile couples) presenting to a university-affiliated fertility center were approached to participate in the study. Only 150 couples that underwent ICSI for male factor infertility agreed to participate, and 94 of them had retrieved enough FF samples suitable for laboratory testing. The FF sample was obtained, centrifuged, and stored in liquid nitrogen. Two organochlorine pesticides (OCPs), Lindane and DDT;three organophosphates (OPs);chlorpyrifos;Diazinon; malathion; one Chloroacetanilide (Pretilachlor);two pyrethroids(Bioallethrin and ß-cyfluthrin); and the concentrations of four PCBs, 28, 52, 138, 180, were estimated in the obtained FF samples by using gas chromatography/mass spectrometry. SPSS statistical analysis program (version 17) was used for analysis. Multiple regression analysis was used to correlate the PCBs and pesticides with ICSI outcomes. RESULTS: There were significant negative correlations between FF concentrations of the eight examined pesticides and the four PCBs on the endometrial thickness. However, Pretilachlor, chlorpyrifos, ß-cyfluthrin, and Diazinon were the only toxic agents that negatively correlated with the number of the oocytes retrieved. Fertilization and early embryo cleavage rates were negatively correlated with Pretilachlor and ß-cyfluthrin. Moreover, high concentrations of Lindane,DDT, Diazinon,and chlorpyrifos were significantly associated lower implantation rate. PCB 28 and 180 concentration in the FF was associated with a lower number of retrieved oocytes and fertilization rate, respectively. The number of implanted embryos was negatively correlated with PCB 52 FF concentration. However, the clinical pregnancy rate did not reach the level of significance. CONCLUSION: Higher concentrations of any studied PCBs and pesticides are associated with thinner endometrial thickness. The higher the level of Pretilachlor, ß-cyfluthrin, PCB 28 and 180, the lower the retrieval, fertilization, and embryo cleavage rates. High PCB and pesticide concentrations in the FF adversely affected embryological ICSI outcomes. However, more data are needed to evaluate their effect on the clinical outcome.

Laparoendoscopic single-site surgery for management of ovarian endometriomas.

BACKGROUND AND OBJECTIVES: To compare our initial experience in laparoscopic surgery for ovarian endometriomas performed through an umbilical incision using a single 3-channel port and flexible laparoscopic instrumentation versus traditional laparoscopy. METHODS: This study was conducted in 3 tertiary care referral centers. Since September 2009, we have performed laparoendoscopic single-site surgery in 24 patients diagnosed with ovarian endometriomas. A control group of patients with similar diagnoses who underwent traditional operative laparoscopy during the same period was included (n = 28). In the laparoendoscopic single-site surgery group, a multichannel port was inserted into the peritoneum through a 1.5- to 2.0-cm umbilical incision. RESULTS: Patients in the laparoendoscopic single-site surgery group were significantly older (P = .04) and had a higher body mass index (P = .005). Both groups were comparable regarding history of abdominal surgery, lateral pelvic side wall involvement, and cul-de-sac involvement. After we controlled for age and body mass index, the size of the resected endometriomas, duration of surgery, and amount of operative blood loss were comparable in both groups. When required, an additional 5-mm port was inserted in the right or left lower quadrant in the laparoendoscopic single-site surgery group to allow the use of a third instrument for additional tissue retraction or manipulation (10 of 24 patients, 41.6%). However, adhesiolysis was performed more frequently in the conventional laparoscopy group. The duration of hospital stay was <24 hours in both groups. No intraoperative complications were encountered. All incisions healed and were cosmetically satisfactory. CONCLUSION: The laparoendoscopic single-site surgery technique is a reasonable initial approach for the treatment of endometriomas. In our experience, an additional side port is usually needed to treat pelvic side wall and cul-de-sac endometriosis that often accompanies endometriomas.

The impact of training residents on the outcome of robotic-assisted sacrocolpopexy.

Objective. To evaluate the surgical outcomes of robotic-assisted sacrocolpopexy (RASCP) before and after the incorporation of hands-on training for urology and gynecology residents. Study Design. Forty-one patients underwent RASCP between December 2008 and March 2010 with one surgeon. RASCP was performed in the context of surgical repair of complex pelvic organ prolapse and/or stress urinary incontinence. The first 20 cases (group I) were performed exclusively by the attending surgeon. In the last 21 cases (group II), the urology resident performed a 50% or more of the RASCP while the gynecology resident performed the supracervical hysterectomy. The primary outcome measure was vaginal vault support at 24 weeks postoperatively based on pelvic organ prolapse quantification (POP-Q). Results. Mean ± SD operative time for the entire surgery including RASCP was 282.3 ± 51.3 min and median EBL was 83.1 ± 50.4 mL. Patient demographics and stage of disease did not differ between groups. Procedure time, PACU time, blood loss, and intraoperative complications were similar between groups. Follow-up POP-Q evaluations demonstrated significant correction of all points on vaginal examination for both groups (P < 0.001). Conclusions. Incorporation of resident training during RASCP allows teaching of robotic surgery techniques in an effective manner without prolonging operative time or affecting the overall surgical outcome.

Bilateral uterine artery ligation plus B-Lynch procedure for atonic postpartum hemorrhage with placenta accreta.

OBJECTIVE: To assess the effectiveness of bilateral uterine artery ligation followed by B-Lynch compression suturing in women with atonic postpartum hemorrhage and placental site bleeding due to adherent placenta accreta. METHOD: This protocol was followed in 26 women undergoing cesarean delivery for placenta accreta. RESULTS: Two women died from disseminated intravascular coagulopathy. In the remaining 24 women, placental remnants completely disappeared within 8 months and ovulation resumed after a mean+/-SD of 51.6+/-3.2 days. Moreover, 18 women (75%) became pregnant within 12 months. CONCLUSION: Atonic postpartum hemorrhage and placental site bleeding due to adherent placenta accreta can be safely controlled by bilateral uterine artery ligation followed by B-Lynch compression suturing in women who desire to remain fertile.