High prevalence of low prognosis by the POSEIDON criteria in women undergoing planned oocyte cryopreservation.

OBJECTIVE: Planned oocyte cryopreservation (OC) is being increasingly utilized worldwide. However, some women cannot accumulate sufficient oocytes because of poor response to stimulation. The POSEIDON classification is a novel system to classify patients with 'expected' or 'unexpected' inappropriate ovarian response to exogenous gonadotropins. Our study aimed to examine the prevalence of POSEIDON patients among women undergoing planned OC. STUDY DESIGN: We retrospectively reviewed the first cycles of 160 consecutive patients undergoing planned OC. Patients were classified into the four POSEIDON groups or as 'non-POSEIDON' based on age, AMH level and the number of oocytes retrieved. The primary outcome measure was the prevalence of POSEIDON patients. RESULTS: Overall, 63 patients (39.4 %) were classified as POSEIDON patients, 12 in group 1, 12 in group 2, 8 in group 3, and 31 in group 4. Compared to non-POSEIDON patients, POSEIDON patients had increased basal FSH levels and reduced serum AMH levels and antral follicle counts, required higher FSH starting doses and increased gonadotropin requirements and reached lower peak serum estradiol levels. Additionally, POSEIDON patients had a lower number of oocytes retrieved (7.6 ± 3.1 vs.20.2 ± 9.9, p < 0.001) and vitrified (5.8 ± 2.9 vs.14.7 ± 6.8, p < 0.001) than non-POSEIDON counterparts, respectively. CONCLUSION: We found a high prevalence of patients being classified as low prognosis according to the POSEIDON criteria among patients seeking planned OC. POSEIDON patients had increased gonadotropin requirements and a significantly lower number of oocytes retrieved and vitrified. This novel, unexpected finding adds clinically relevant information for counselling and management of patients undergoing planned OC.

The effect of SARS-CoV-2 mRNA vaccination on AMH concentrations in infertile women.

RESEARCH QUESTION: Does SARS-CoV-2 mRNA vaccination affect the ovarian reserve of infertile women undergoing IVF? DESIGN: This was a prospective observational study at a single university-affiliated IVF unit that included infertile women aged 18-44 years who were undergoing IVF/intracytoplasmic sperm injection between November 2020 and September 2021, had received two doses of SARS-CoV-2 mRNA vaccination and had undergone measurement of baseline anti-Müllerian hormone (AMH) concentration within the 12 months preceding their recruitment. AMH concentrations before and after vaccination were evaluated and compared. RESULTS: Overall, 31 women were included in the study. The median AMH concentrations before and after COVID-19 vaccine were comparable (1.7 versus 1.6 g/ml, respectively, P = 0.96). No correlation was found between the participant's anti-COVID-19 antibody titre and the change in AMH concentration. CONCLUSIONS: SARS-CoV-2 mRNA vaccination does not adversely affect ovarian reserve, as shown by comparing serum AMH concentrations before and after vaccination. These findings may serve as a counselling tool for clinicians to reassure women undergoing fertility treatment that SARS-CoV-2 mRNA vaccination is safe.

A randomized controlled trial of vaginal progesterone for luteal phase support in modified natural cycle - frozen embryo transfer.

OBJECTIVE: Our aim was to study whether luteal phase support (LPS) increases the live-birth rate (LBR) in women undergoing modified natural cycle (mNC) frozen-thawed embryo transfer (FET). METHODS: In a randomized controlled trial, conducted at a university-affiliated tertiary medical center, a total of 59 patients aged 18-45 years, underwent mNC-FET. FET was performed in mNC following ovulation triggering by hCG. Patients were randomized into two groups; The No-LPS Group included 28 women who did not receive LPS, and the LPS Group included 31 women who received vaginal progesterone for LPS. The main outcome measure was LBR. RESULTS: Baseline demographic and clinical characteristics were comparable between the study groups. The no-LPS group and the LPS group did not differ with regard to clinical pregnancy rate (21.4% vs. 32.3%; respectively, p = .35), LBR (17.9% vs. 19.4%; respectively, p = .88), or spontaneous miscarriage rate (3.6% vs. 12.9%; respectively, p = .35). On multivariate logistic regression analysis, LPS was not associated with LBR after controlling for confounders. CONCLUSION: The results of our study suggest that LPS after mNC-FET does not improve the reproductive outcome, and therefore, might not be necessary.C linicaltrials.gov identifier: NCT01483365.

Modified natural-cycle cryopreserved embryo transfer: is a washout period needed after a failed fresh cycle?

RESEARCH QUESTION: Are the characteristics of the natural cycle or modified natural cycle (mNC), or live birth rates (LBR), affected by delaying frozen embryo transfer (FET) after a failed fresh IVF cycle? DESIGN: In a retrospective study, conducted at a university-affiliated tertiary centre, 198 women aged 18-45 years undergoing their first FET cycle after a failed fresh embryo transfer attempt using an mNC were evaluated. Cycles were divided according to the time interval between oocyte retrieval and the start of the FET cycle into the immediate FET group (<22 days) and the delayed FET group (≥22 days). The main outcome measures were ovulation day and LBR. RESULTS: The mean interval between oocyte retrieval and the start of the FET cycle was 15.6 ± 3.2 days in the immediate FET group and 84.8 ± 73.7 days in the delayed FET group (P < 0.001). Ovulation day was significantly delayed in the immediate FET group (day 17.1 ± 4.4 versus day 15.4 ± 3.7; P = 0.004). There was no difference between the immediate and delayed FET groups in terms of clinical pregnancy rate (CPR) (25.4% and 25.0%, respectively) or LBR (21.2% and 20.0%, respectively). CONCLUSIONS: Natural-cycle characteristics are similar in immediate and delayed cycles, except for a slight delay in ovulation day. Deferring mNC-FET after a failed fresh IVF cycle does not improve the reproductive outcome. These results should encourage patients and clinicians who want to proceed with FET immediately after failure of fresh IVF.

Comparison of Emergent and Elective Surgeries of Endometriomas: Is Adnexal Torsion a Concern?

BACKGROUND: When a woman with an endometrioma presents with acute abdominal pain, it is unclear whether ovarian torsion should be suspected. OBJECTIVES: To compare patient characteristics, imaging results, and surgical management of endometriomas in elective versus emergent surgeries. METHODS: This retrospective cohort study included women treated at our institution during the period 1990-2015 who presented with histologically verified endometrioma and who underwent either planned surgery or emergent surgery due to suspected adnexal torsion. RESULTS: Of 225 surgeries performed, 174 were elective and 51 emergent. Patients in the emergent group were significantly younger (33.9 ± 11.1 vs. 39.01 ± 10.9 years, P = 0.004). Abdominal pain was the main complaint of all the emergent surgery patients and the leading complaint in 21% of the elective surgery patients (P < 0.001), with right-sided predominance in both groups. Sonographic parameters were similar in both groups. Bilateral ovarian cysts were noted in 11.7% and 11.0% of emergent and elective patients, respectively (P = 0.87). Laboratory evaluation was notable for a higher white blood cell count and CA125 levels among emergent patients. All patients in the emergent group and 93% of patients in the elective group were managed laparoscopically. No cases of torsion were noted. The rate of intra-pelvic adhesions was similar in both groups (56.8% vs. 66.6%, P = 0.19). CONCLUSIONS: Endometrioma may present with acute abdominal pain. However, adnexal torsion in these patients is rare. These cases can be managed using a minimally invasive approach, assuming an optimal surgical setting.

Screening for blood born viruses in assisted reproduction: is annual testing necessary?

PURPOSE: Screening for blood born viruses is routinely performed before fertility treatment in assisted reproduction technology (ART) clinics worldwide. It involves testing for human immunodeficiency virus (HIV), hepatitis B virus (HBV), and hepatitis C virus (HCV), among others. Identifying patients with positive viral screening allows to refer them and their partners for appropriate counseling and treatment. The need for repeat viral screening and its required frequency have never been clearly established. In Israel, viral screening is mandatory and is repeated annually. Our aim was to determine the prevalence of HBV, HCV, and HIV seroconversion in patients with negative screening upon initiation of ART treatment. METHODS: A retrospective analysis of viral screening tests of all fertility patients in a single assisted conception unit between 1997 and 2015. RESULTS: During the study period, 2844 patients were treated at our clinic, out of whom 1945 patients met the inclusion criteria. The average length of treatment was 1.61 ± 0.81 years, during which female patients underwent screening tests 2.6 ± 0.9 times, and male patients 2.3 ± 1.2 times. No case of seroconversion to any of the three viruses was noted during the entire study period, resulting a seroconversion rate of 0%. CONCLUSIONS: Primary infection with HBV, HCV, or HIV is an extremely rare event among Israeli infertile patients, and the risk for seroconversion in this population is practically nil. Annual screening of both partners leads to substantial costs and appears to be futile. Our results question the current practice and support increasing the interval between screening tests in low-risk populations.

Cumulative pregnancy and live birth rates through assisted reproduction in women 44-45 years of age: is there any hope?

PURPOSE: The purpose of the study is to calculate the cumulative pregnancy rate and cumulative live birth rate in women undergoing in vitro fertilization (IVF) at ages 44-45. METHODS: The study calculated cumulative live pregnancy rate and cumulative live birth rate of 124 women aged 44 to 45 years old who commenced IVF treatment. MAIN OUTCOME MEASURES: The main outcome measures are cumulative live pregnancy rate and cumulative live birth rate. RESULTS: Cumulative live pregnancy rates following 1, 2, 3, and 4 cycles were 5.6, 11, 17, and 20%, respectively, with no additional pregnancies in further cycles. Cumulative live birth rates following 1, 2, and 3 cycles were 1.6, 3, and 7%, respectively, with no additional live births in further cycles. CONCLUSIONS: The cumulative pregnancy rate rises during the first 4 cycles and cumulative live birth rate rises during the first 3 cycles, with no additional rise in pregnancies or deliveries thereafter, suggesting that it is futile to offer more than 3 cycles of treatment to 44-45-year-old women.

The changing indications and rates of cesarean section in one academic center over a 16-year period (1997-2012).

OBJECTIVE: To compare trends and rates of cesarean section delivery by indication in one academic center. MATERIALS AND METHODS: A retrospective analysis of the indications of all cesarean sections performed in Edith Wolfson Medical Center, Holon, Israel, a tertiary healthcare university facility, during 1997-2012 was done. Each delivery was assigned to the primary indication noted for that pregnancy, regardless of other indications reported. Whenever more than one indication was present, the principle indication chosen by the attending obstetrician was chosen for the analysis. RESULTS: The cesarean section rate gradually rose from 15.29% in 1997 to 21.10% in 2012, with an overall cesarean section rate of 20.66%. The cesarean section rate between 1997 and 2000 was 17.52%, between 2001 and 2004 was 18.5%, between 2005 and 2009 was 22.86%, and between 2009 and 2012 was 22.07% (p < 0.001). The five leading primary indications across the years were previous cesarean section (26.0%), non-reassuring fetal heart rate pattern (18.1%), malpresentation (16.9%), labor dystocia (8.8%), and suspected macrosomia (7.2%). CONCLUSION: Previous cesarean section persistently increased and was the leading indication throughout the years. Any attempt to reverse this trend must be based on reduction of the primary cesarean section rate.

Clinical characteristics of adnexal torsion in premenarchal patients.

PURPOSE: To compare clinical characteristics of adnexal torsion in premenarchal patients as compared to postmenarchal ones. METHODS: A retrospective 22-year cohort of all cases of surgically verified adnexal torsion in premenarchal and postmenarchal patients (excluding postmenopausal and pregnant patients). Data collected included symptoms, signs and imaging at presentation, surgical mode, and procedure and histology. RESULTS: 16 cases of adnexal torsion among premenarchal patients were compared to 302 cases among postmenarchal ones. Clinical presentation was similar, notable only for more nausea and vomiting among the premenarchal group. Ovarian cysts were more commonly demonstrated among postmenarchal patients (82.4 and 30.8%, p < 0.001), as opposed to a normal adnexal appearance on ultrasound, which was more common in premenarchal patients (69.3 vs. 17.2%, p < 0.001). Absent Doppler flow, when preformed, did not differ statistically between the groups. Laparoscopic detorsion only was more commonly performed in premenarchal patients (56.2 vs. 19.8%, p = 0.001), with a trend for detorsion and cystectomy/fenestration, which were more common in postmenarchal surgeries (25 vs. 50.6%, p = 0.06). Histology was similar among both groups, with no cases of malignancy in premenarchal patients. CONCLUSION: Adnexal torsion in premenarchal patients is rare, presents similarly to older patients, but involves a normal adnexa in 69% of cases, therefore requiring a high index of suspicion in any premenarchal patient with acute onset abdominal pain.

Clinical characteristics and the risk for malignancy in postmenopausal women with adnexal torsion.

OBJECTIVE: To compare clinical characteristics and management of adnexal torsion in postmenopausal patients as compared to premenopausal ones. METHODS: A retrospective 22 year cohort of all cases of surgically verified adnexal torsion in postmenopausal and premenopausal patients, comparing presentation, imaging, surgical procedure and histology. RESULTS: Thirty five cases of adnexal torsion among postmenopausal patients were compared to 302 cases among premenopausal ones. Complex ovarian masses and larger ovarian diameter were more common among postmenopausal patients (7.8 vs. 6.8 cm, p=0.003). The admission to surgical interval differed substantially between the groups (75.5h in postmenopausal patients vs. 24.4 in the premenopausal ones, p<0.001). The main surgical indication for postmenopausal patients was pelvic mass investigation (54.3% vs 11.6%, p<0.001), and more premenopausal patients underwent surgery with a clinical suspicion of adnexal torsion (77.1% vs. 40%, p<0.001). Extensive surgery including bilateral salpingo-oophorectomy with or without total abdominal hysterectomy was more commonly performed in postmenopausal patients, as opposed to conservative surgery, including detorsion and cystectomy/fenestration or detorsion only, in premenopausal surgeries. Cancer was diagnosed in 3% of postmenopausal patients with adnexal torsion. CONCLUSION: Adnexal torsion in postmenopausal women is rare, but presents similarly, results in more delayed and extensive surgery and involves malignancy in 3%.

Differences between adnexal torsion in pregnant and nonpregnant women.

STUDY OBJECTIVE: To compare the clinical manifestation, management, and outcome of adnexal torsion in pregnant and nonpregnant women. DESIGN: Retrospective case-control study (Canadian Task Force classification II-3). SETTING: Tertiary care university hospital. PATIENTS: Sixty-four pregnant women and 198 nonpregnant women with episodes of adnexal torsion. INTERVENTIONS: Surgery to treat proved adnexal torsion. MEASUREMENTS AND MAIN RESULTS: The mean (SD) gestational age in the pregnant group was 11.5 (7.7) weeks. Thirty six episodes of adnexal torsion in the pregnant group (56%) developed after treatment for infertility, compared with only 14 such episodes (7%) in the nonpregnant group (p < .001). A repeated episode of torsion occurred more frequently in the pregnant group (14% vs 4%; p = .03). Sonographic demonstration of multicystic ovaries was more common in pregnant women with recurrent torsion than in women with a single episode of torsion (86% vs 31%; p = .009). Tissue preservation was achieved more frequently in pregnant than in nonpregnant patients (95% vs 77%; p < .001), and the duration of surgery was 15 minutes shorter in the pregnant women (p < .001). CONCLUSION: Pregnancy after treatment for infertility is a risk factor for adnexal torsion. Recurrence of ovarian torsion occurs more frequently in pregnant patients, and in particular in enlarged multicystic ovaries.

Personality, fear of childbirth and cesarean delivery on demand.

OBJECTIVES: To investigate both the psychological traits and the demographic factors associated with cesarean section on maternal demand. DESIGN: Cross-sectional questionnaire study. SETTING: Delivery ward, Edith Wolfson Medical Center, Holon, Israel. SAMPLE: Fifty-nine healthy primigravida with a singleton pregnancy were recruited during 2009, of whom 28 requested and were delivered by cesarean section without obstetrical indication, whereas 31 opted for spontaneous vaginal delivery. METHODS: All questionnaires were administered to the two groups at term. Various psychological (fear of childbirth questionnaire, Millon Clinical Multiaxial Inventory III, Anxiety Sensitivity Index, State-Trait Anxiety Index and social support scale) as well as demographic variables were measured before labor and compared. A priori power calculation yielded a power of 95%. MAIN OUTCOME MEASURES: Fear of childbirth, various personality disorders and psychiatric clinical syndromes (29 Millon Clinical Multiaxial Inventory III scales), Anxiety Sensitivity, State Anxiety Index, social support and demographic variables. RESULTS: Differences in age and method of conceiving (p<0.001) were found between the groups. The study group reported a higher level of fear of childbirth (p<0.001), but no differences were found in all other personality characteristics measured (29 Millon Clinical Multiaxial Inventory III scales, State-Trait Anxiety, Anxiety Sensitivity and social support scale). The origin of the difference regarding the fear of childbirth was located to two specific questions: 'Have you always been afraid of giving birth?' and 'Have you sometimes thought of the delivery as something unnatural?' CONCLUSIONS: The only psychological variable associated with the choice for cesarean section on maternal request was the fear of childbirth.

Operative hysteroscopy to remove retained products of conception: novel treatment of an old problem.

STUDY OBJECTIVE: To assess the efficacy and reproductive outcome of hysteroscopic removal of retained products of conception. DESIGN: Retrospective analysis (Canadian Task Force classification II-3). SETTING: Tertiary care university hospital. PATIENTS: One hundred fifty-nine patients were consecutively admitted to our department from July 2001 through August 2007 with a diagnosis of retained products of conception after medical abortion, dilation and evacuation, or delivery. INTERVENTIONS: Hysteroscopic removal of retained products of conception without the use of electrical energy. MEASUREMENTS AND MAIN RESULTS: Complete evacuation of the uterus was achieved in all patients. Trophoblastic tissue was histologically confirmed in 88%. All of the women regained normal menstrual bleeding. Complications occurred in 3 patients during or immediately after the procedure: pulmonary edema, sepsis and diffuse intravascular coagulopathy, and excessive bleeding, respectively. Of the 28 women who expressed a desire to become pregnant, 23 conceived. The conception rate was 82% (23 of 28), with a live-birth rate of 75% (21 of 28). Second-look hysteroscopy performed in 21 patients revealed no adhesions. CONCLUSION: Hysteroscopic removal of retained products of conception is a simple and safe, and most probably the preferred procedure. It should be considered an alternative to conventional blind evacuation by curettage. It seems that this procedure preserves the integrity of the uterine cavity while averting additional trauma, and retains reproductive capacity. Further studies, including randomized controlled trials, may be necessary to confirm these results.

[Creative work of painters with Alzheimer's disease].

Alzheimer's disease is characterized by progressive cognitive and functional decline. Recently, there have been reports in the medical literature on artists who continued to paint while suffering from Alzheimer's. This article describes the changes that occurred in the work of three artists who suffered from Alzheimer's: William Utermohlen, Carolus Horn and Willem de Kooning. In the case of William Utermohlen (1935-2007), Alzheimer's disease was diagnosed at the age of 61. A series of 15 self-portraits that he painted during the years he suffered from Alzheimer's disease provide a rare opportunity to look into the world of an Alzheimer's patient, and testifies to sustained motivation to create, despite severe cognitive impairment. Although Utermohlen's portraits show distortions in proportion and defects in spatial organization that became more evident as the disease progressed, the portraits are characterized by an extraordinary ability to express emotion, as well as by originality: each is a new piece of work, not an attempt to copy a previous painting. Carolus Horn (1921-1992) was diagnosed with Alzheimer's disease at the age of 58. In Horn's paintings, from the time he was diagnosed, there is evidence of distortion in perspective, "primitive" style, lack of individual characteristics in depicting his subjects, more schematic drawing, and a preference for using reds and yellows. In the most advanced stage of the disease Horn was only able to scribble. Despite his cognitive and functional limitations, Horn continued to draw daily, even in the advanced stages of his illness, until shortly before his death. Willem de Kooning's (1904-1997) Alzheimer's was diagnosed in his late eighties. During the following years, he painted more than 300 abstract paintings, which art critics assess as among the finest and most sensitive artistic achievements in contemporary painting. Despite cognitive limitations, de Kooning was able to muster the concentration to continue painting. Common to these three painters was the continuous urge to create, despite considerable cognitive impairment. Their art enables us to have a close look into the world of Alzheimer's sufferers. Analysis of their artwork can help us to understand the type of cognitive impairment caused by ALzheimer's, as well as some neurological aspects of art creation.