Comparison of the duration of estradiol administration and the effect on pregnancy outcome of day 3 vitrified-warmed embryo transfer cycle: a randomized controlled trial.

Based on the fact that the follicular phase in the menstrual cycle has length variation, it has been assumed that the duration of oestrogen (E2) administration could also be variable; therefore, for the first time, this randomized clinical trial study was conducted to investigate and compare the duration of estradiol administration and the effect on pregnancy outcomes in the cleavage-stage frozen embryo transfer (FET) cycle. We included women aged 20-40 with a normal uterus on hysteroscopy between September and December 2022 and who were divided randomly into three groups: group A [n = 79; 8-11 days of oestrogen before progesterone (P4) supplementation], group B (n = 78; 12-14 days of oestrogen before P4 supplementation), and group C (n = 76; 15-18 days of estrogen before P4 supplementation). Serum levels for E2 on the initial progesterone day and P4 on the transfer day were measured. The effect of the duration of E2 administration on clinical pregnancy and pregnancy loss was investigated. We found no significant differences between the three groups in the clinical pregnancy rate (P = 0.696) and clinical abortion rate (P = 0.925) according to the duration of the E2. There was no significant difference in the E2, P4 levels, and endometrial thickness in pregnant vs. non-pregnant women. The mean of the E2 and P4 levels was 300.03 ± 22.21 and 25.36 ± 5.78, respectively. Our findings suggest that variation in the length of E2 administration (8-18 days) before progesterone initiation in day 3 FET cycles does not affect pregnancy outcome and transfer time can be flexibly arranged.

Effect of piroxicam administration on outcome of frozen-thawed embryo transfer: A randomized, double-blinded, placebo-controlled trial.

AIM: This study aimed to evaluate the effect of piroxicam adjuvant therapy on the clinical and biochemical pregnancy rate in patients undergoing in vitro fertilization (IVF) and frozen-thawed embryo transfer (ET) cycles. METHODS: In a randomized, double-blinded, placebo-controlled clinical trial, 178 patients eligible for IVF-ET received either single dose of piroxicam 1-2 h before frozen-thawed ET or a placebo at the same time. Study participants were then followed and compared regarding the primary outcome of the study, which was biochemical (positive ß-human chorionic gonadotrophin test) and clinical pregnancy (detected fetal heart beat in ultrasound) rate. RESULTS: The results of this study indicated that there is no significant association between the piroxicam administration before frozen-thawed ET and the clinical or biochemical pregnancy rate (P = 0.208 and P = 0.699, respectively). CONCLUSION: The findings of the current study suggest that piroxicam administration before ET has no beneficial effects on pregnancy rate among women undergoing IVF and frozen-thawed ET. However, further studies with larger sample sizes and longer follow-ups are recommended.

Effect of a novel herbal vaginal suppository containing myrtle and oak gall in the treatment of vaginitis: a randomized clinical trial.

BACKGROUND: Uncomplicated infections such as candidiasis, bacterial vaginosis (BV), or trichomoniasis are easy to diagnose and treat. However, about 8% of patients will have a more complicated course with failure to respond to treatment or rapid recurrence of symptoms. There are many suggestions in Traditional Persian Medicine like myrtle (Myrtus communis L.) and oak gall (Quercus infectoria G.Olivier) for treatment of vaginitis. OBJECTIVES: A clinical trial was designed to assess the efficacy of a novel herbal suppository, containing myrtle and oak gall (MOGS) in treatment of vaginitis. METHODS: In a parallel randomized clinical trial, 120 women with vaginitis were randomly assigned to MOGS, metronidazole, or placebo. Formulation was simulated from traditional Persian manuscripts and MGOS was prepared after pharmaceutical optimization processing as well as quantification of gallic acid by HPLC. The study was double-blind for MOGS and placebo and single-blind for metronidazole group. RESULTS: MOGS effectively improved vaginal discharge (p = 0.024 for BV and 0.018 for trichomoniasis) and pH (compared to placebo (p = 0.013) and metronidazole (p = 0.001)). Both MOGS and metronidazole could reverse whiff test. Metronidazole was the best medication for making Nugent score negative (p = 0.005) as well as the best therapy according to laboratory findings to treat BV in comparison with placebo (p = 0.021). While for trichomoniasis, MOGS could improve the disease more successfully (p = 0.001). Both MOGS and metronidazole treated mixed vaginitis (p = 0.002). CONCLUSION: MOGS would be a chance for developing new treatment for trichomoniasis.

Determining an optimal cut-off value for follicle-stimulating hormone to predict microsurgical testicular sperm extraction outcome in patients with non-obstructive azoospermia.

Objective To determine the optimal cut-off value for follicle stimulating hormone (FSH) to predict the outcome of microsurgical testicular sperm extraction (micro-TESE) in patients with nonobstructive azoospermia (NOA). Subjects and methods We included a total number of 180 patients with NOA. The serum level of FSH was determined and all the subjects underwent micro-TESE. We determined the optimal cut-off value for FSH and assessed whether the test could be effectively used as a successful predictor of sperm retrieval by calculating the Receiver Operating Characteristic (ROC) area under the curve. Results Overall we included a total number of 171 patients with mean age of 34.3 ± 8.6 years. The micro-TESE was considered to be successful in 79 (43.8%) while it failed in 92 (56.2%) patients. We found that the mean level of serum FSH was significantly higher in group those with failed micro-TEST compared to successful group (p < 0.001). The cut-off value for FSH was calculated to be 14.6 mIU/mL to predictive the outcome of micro-TESE with a sensitivity of 83.5% [73.5%-90.9%] and a specificity of 80.3% [69.5%-88.5%]. At this value, the other parameters were calculated to be PPV, 81.5%; NPV, 82.4; LR+, 4.23; and LR-, 0.21. Conclusions The results of the current study indicate that FSH plasma levels above 14.6 mIU/mL can be considered to be the failure predictor of the micro-TESE in NOA patients.

Determining an optimal cut-off value for follicle-stimulating hormone to predict microsurgical testicular sperm extraction outcome in patients with non-obstructive azoospermia

ABSTRACT Objective To determine the optimal cut-off value for follicle stimulating hormone (FSH) to predict the outcome of microsurgical testicular sperm extraction (micro-TESE) in patients with nonobstructive azoospermia (NOA). Subjects and methods We included a total number of 180 patients with NOA. The serum level of FSH was determined and all the subjects underwent micro-TESE. We determined the optimal cut-off value for FSH and assessed whether the test could be effectively used as a successful predictor of sperm retrieval by calculating the Receiver Operating Characteristic (ROC) area under the curve. Results Overall we included a total number of 171 patients with mean age of 34.3 ± 8.6 years. The micro-TESE was considered to be successful in 79 (43.8%) while it failed in 92 (56.2%) patients. We found that the mean level of serum FSH was significantly higher in group those with failed micro-TEST compared to successful group (p < 0.001). The cut-off value for FSH was calculated to be 14.6 mIU/mL to predictive the outcome of micro-TESE with a sensitivity of 83.5% [73.5%-90.9%] and a specificity of 80.3% [69.5%-88.5%]. At this value, the other parameters were calculated to be PPV, 81.5%; NPV, 82.4; LR+, 4.23; and LR-, 0.21. Conclusions The results of the current study indicate that FSH plasma levels above 14.6 mIU/mL can be considered to be the failure predictor of the micro-TESE in NOA patients.

Delayed Start Protocol with Gonadotropin-releasing Hormone Antagonist in Poor Responders Undergoing In Vitro Fertilization: A Randomized, Double-blinded, Clinical Trial.

OBJECTIVES: We sought to determine the effects of the delayed start protocol with gonadotropin-releasing hormone (GnRH) antagonists in poor responders undergoing in vitro fertilization (IVF). METHODS: This randomized clinical trial was conducted during a 15-month period from April 2014 to July 2015 in clinics in Shiraz, Iran. A total of 42 poor responders with primary infertility were randomly assigned to the controlled ovarian stimulation group utilizing the delayed start protocol (n = 21) or the traditional group (n = 21) using GnRH antagonist, Cetrotide. The primary endpoint was the number of patients undergoing oocyte pick-up, implantation, and the rate of pregnancy. RESULTS: The baseline characteristics of the two study groups were comparable including age, infertility duration, and body mass index. The number of follicles measuring > 13 mm in diameter (p = 0.057), retrieved oocytes (p = 0.564), mature metaphase II oocytes (p = 0.366), embryos (p = 0.709), and transferred embryos (p = 0.060) were comparable between the two groups. The number of patients undergoing oocyte pick-up (p = 0.311), the rates of implantation (p = 0.407), and pregnancy (p = 0.596) were also comparable between the two groups. CONCLUSIONS: The delayed start protocol was not associated with better conception results or cycle outcomes in poor responders with primary infertility undergoing IVF cycles.

Effects of clomiphene citrate for prevention of premature luteinizing hormone surge in those undergoing intrauterine insemination outcome: A randomized, double-blind, placebo-controlled trial.

The objective of the study is to determine the effects of clomiphene citrate (CC) on preventing premature luteinizing hormone (LH) surge in infertile patients with polycystic ovary syndrome (PCOS) undergoing intrauterine insemination (IUI). This was a randomized clinical trial being performed at Shiraz Mother and Child Hospital. We included 162 women with PCOS selected for IUI cycles. Patients were randomly allocated to receive 150 mg/day CC from the 8th of the cycle though the day of human chorionic gonadotropin (hCG) injection (n = 81) or nothing in the same period (n = 81). Main outcomes included the incidence of premature LH surge, pregnancy rate, abortion and ongoing pregnancy rates, number of maturing follicles, and endometrial thickness. The incidence of premature LH surge was significantly lower in those who received CC (3.0% vs. 14.9%; P = 0.021). The pregnancy rate was 10 (15.1%) and 6 (8.9%) in CC and control groups, respectively (P = 0.342). The ongoing pregnancy rate found to be comparable between two study groups (12.1% vs. 5.9%; P = 0.068). Serum level of estradiol (E2) level at the time of hCG administration was significantly higher in those who were treated with CC when compared to control (1153.5 ± 326.4 vs. 943.2 ± 215.3; P < 0.001). Patients who received CC also had higher number of mature follicles >18 mm when compared to controls (3.85 ± 1.3 vs. 2.94 ± 1.01; P < 0.001). Administration of CC from the 8th day of the cycle to the day of hCG injection in combination with Gonal-f in infertile patients with CC-resistant PCOS undergoing IUI cycles is associated with decreased incidence of premature LH surge, higher E2levels, and higher number of mature ovarian follicles. This protocol is safe and simple and could be considered to be cost-effective.

Assessment of oxytocin level, glucose metabolism components and cutoff values for oxytocin and anti-mullerian hormone in infertile PCOS women.

OBJECTIVE: Comparing oxytocin level and some other parameters between infertile women with or without polycystic Ovary Syndrome (PCOS), to evaluate the correlation between oxytocin with anti-mullerian hormone (AMH), Body Mass Index (BMI) and insulin resistance (IR). MATERIALS AND METHODS: This cross-sectional study was performed on 80 PCOS and 81 non-PCOS women as the control group. Oxytocin, various hormones, Oral glucose tolerance test (OGTT) and Homeostatic model assessment of insulin resistance (HOMA-IR) were compared between two groups. Correlations between parameters were assessed by the spearman's rank correlation coefficient. Cutoff values for oxytocin and AMH in PCOS were calculated by the ROC-Curve and DeLong method. RESULTS: The mean oxytocin level was statistically lower in the case group (p ≤ 0.001). The mean BMI, AMH, HOMA-IR, fasting insulin and insulin 2-h after 75-g glucose were significantly higher in the PCOS group. Oxytocin was negatively correlated to AMH when evaluated for all participants or only among controls. Moreover oxytocin was negatively correlated to HOMA-IR among all participants. However the relationship between oxytocin and BMI was not statistically significant. The calculated cutoff value for oxytocin was 125 ng/L and for AMH was 3.6 ng/mL in the PCOS group. CONCLUSION: The mean oxytocin level in the PCOS infertile women was lower than non-PCOS women. Oxytocin showed a significant reverse correlation with AMH and HOMA-IR.

Comparison of four protocols for luteal phase support in frozen-thawed Embryo transfer cycles: a randomized clinical trial.

PURPOSE: To compare the pregnancy outcomes between four regimens of luteal phase support (LPS), including vaginal progesterone, oral dydrogesterone, combination of oral dydrogesterone and gonadotropin releasing hormone analog (GnRH-α), and combination of oral dydrogesterone and human chorionic gonadotrophin (hCG), in Frozen-thawed Embryo Transfer (FET) cycles. METHODS: This randomized clinical trial was performed during a 6-month period, including candidates for FET. Patients were randomly assigned to four groups for LPS: 400 mg vaginal progesterone suppository twice daily, 10 mg oral dydrogesterone twice daily, 10 mg oral dydrogesterone twice daily combined with injection of 0.1 mg GnRH-α, and 10 mg oral dydrogesterone twice daily combined with injection of 1500 IU hCG. Primary endpoint included clinical pregnancy rate, ongoing pregnancy rate (OPR), and miscarriage rate (MR). RESULTS: A total of 400 FET cycles were analyzed. CPR was significantly lower in dydrogesterone group (9 %) when compared to vaginal progesterone (20 %), dydrogesterone and GnRH-α (25 %), and dydrogesterone and hCG (17 %). Logistic regression showed that only dydrogesterone group had significantly lower CPR in comparison with vaginal progesterone (OR = 0.39; p = 0.03), while it was comparable between other three groups. There were no significant difference between four groups regarding to OPR and MR. CONCLUSION: Vaginal progesterone provides appropriate LPS. Yet, combination of oral dydrogesterone and GnRH-α or hCG can be more suitable option compared to vaginal progesterone for LPS in women with vaginal irritation or discharge at a lower cost.

The effects of endometrial injury on intrauterine insemination outcome: A randomized clinical trial.

BACKGROUND: Implantation is considered as the rate-limiting step in success of assisted reproduction techniques, and intrauterine insemination cycles. It might be affected by ovarian superovulation and endometrial local scratching. OBJECTIVE: This study aims to investigate the effect of local endometrial injury on the outcome of IUI cycles. MATERIALS AND METHODS: In this randomized clinical trial 144 women with unexplained infertility, mild male factor, and mild endometriosis randomly divided into two study groups through block randomization. The patients were randomly assigned to undergo endometrial biopsy between days 6-8 of the previous menstrual cycle before IUI (n=72, IUI cycles =126) or receive no interventions (n=72, IUI cycles=105). RESULTS: The pregnancy rate per patient was 17 (23.6%) and 14 (19.4%) in endometrial biopsy and control groups, respectively (p=0.686). The pregnancy rate per cycle was 17/126 (13.5%) and 14/105 (13.3%) in endometrial biopsy and control groups, respectively (p=0.389). The abortion rate was comparable between the two groups (6.9% vs. 9.7%; p=0.764). The ongoing pregnancy rate was found to be comparable between the two study groups, as well (16.7% vs. 9.7%; p=0.325). Endometrial thickness (p=0.609) was comparable between the groups; however E2 was significantly lower in the endometrial biopsy group (p<0.001). CONCLUSION: Application of local endometrial injury in the cycle before the IUI cycles is not associated with increased pregnancy rate per patient and per cycle, decreased abortion, and increased endometrial thickness.

Thalidomide affects experimental endometriosis: a randomized controlled study in the rat.

AIM: This study aimed to assess the efficacy of thalidomide for treatment of experimental endometriosis. METHODS: This study was a parallel-group, double-blind, stratified, randomized controlled animal trial with 1:1 allocation ratio. Endometriosis was induced experimentally in 23 mature, nulligravid, female Sprague-Dawley rats, weighing approximately 200 g and aged 2 months. A checkpoint surgery was performed 6 weeks later. Then, the rats were randomly allocated into the thalidomide (22 mg/day p.o.) and control (0.5 mL saline 0.9%/day p.o.) groups of nine. After 6 weeks, they were killed. Before each laparotomy, blood for leukocyte and lymphocyte counts and during them, implants for histopathology and peritoneal fluid for interleukin (IL)-6, tumor necrosis factor-α and vascular endothelial growth factor (VEGF)-A concentrations (by enzyme-linked immunoassay) were collected. Allocation and stratified randomization were done using a computer, based on the obtained histopathology scores of the implants of the checkpoint surgery. RESULTS: The histopathology scores (the main outcome measure) were 2.00 ± 1.55 versus 0.44 ± 1.01 (P = 0.035). The comparisons of after-treatment counts of leukocytes, lymphocytes, VEGF-A and IL-6 between the two groups were statistically significant. CONCLUSION: The results of this study are in favor of therapeutic implication of thalidomide in experimental endometriosis in rats. This is the first time thalidomide has been evaluated on endometriosis in an animal model.

Intrauterine administration of recombinant human chorionic gonadotropin before embryo transfer on outcome of in vitro fertilization/ intracytoplasmic sperm injection: A randomized clinical trial.

BACKGROUND: The direct effect of hCG on the human endometrium was studied several times. OBJECTIVE: The objectives of this study were to evaluate the effectiveness of intrauterine injection of recombinant human chorionic gonadotropin (rhCG) before embryo transfer (ET). MATERIALS AND METHODS: In this randomized placebo-controlled clinical trial, a total number of 182 infertile patients undergoing their first in vitro fertilization/ intracytoplasmic sperm injection (IVF-ICSI) cycles were randomly assigned to receive 250µg intrauterine rhCG (n=84) or placebo (n=98) before ET. The implantation and pregnancy rates were compared between groups. RESULTS: Patients who received intrauterine rhCG before ET had significantly higher implantation (36.9% vs. 22.4%; p=0.035), clinical pregnancy rates (34.5% vs. 20.4%; p=0.044) and ongoing pregnancy rate (32.1% vs. 18.4%; p=0.032) when compared to those who received placebo. The abortion (2.4% vs. 2.0%; p=0.929) and ectopic pregnancy rates (1.2% vs. 1.0%; p=0.976) were comparable between groups of rhCG and placebo, respectively. CONCLUSION: Intrauterine injection of 250µg of rhCG before ET significantly improves the implantation and pregnancy rates in IVF/ICSI cycles. REGISTRATION ID IN IRCT: IRCT2012121711790N1 This article extracted from fellowship course thesis. (Masoumeh Younesi).

The effects of levamisole on experimental endometriosis: a randomized controlled trial in a rat model.

PURPOSE: To assess the effects of levamisole on experimental endometriosis in rats through the histopathology of the implants, the blood leukocyte and lymphocyte counts and the concentrations of interleukin-6, vascular endothelial growth factor-A and tumor necrosis factor-alpha in the peritoneal environment at the three healthy, endometriotic and post-treatment milestones. METHODS: Twenty-two 8-week-old Sprague-Dawley rats with normal estrus cycles were recruited in a prospective, parallel-group, placebo-controlled, double-blind, stratified-randomized animal trial with the equal allocation ratio of 1:1 challenging the efficacy of levamisole. Endometriosis was induced. After 6 weeks, laparotomy was performed to randomly excise one implant for histopathology assessment. Based on the results, they were stratified randomized and allocated (by software) to two groups of nine: levamisole (5 mg/rat/day) or placebo. After 6 weeks, necropsy was done. Two days before each laparotomy, blood samples and during the procedure, peritoneal wash were collected for ELISA. RESULTS: Seven rats showed success in treatment in the levamisole group, while three did in the other group. The histopathology results descriptively revealed a drop in the levamisole group, which was not meaningful statistically (0.66 ± 1.32 vs. 2.00 ± 1.50, p = 0.065). The comparisons of the post-treatment leukocytes and lymphocytes in the groups showed significant differences (11088.88 ± 5869.50 vs. 4677.77 ± 3476.98, p = 0.008, and 8588.88 ± 5721.32 vs. 3511.11 ± 2835.24, p = 0.014, respectively). The results of the cytokines were mostly, but not completely, in favor of the efficacy of levamisole. CONCLUSION: This study indicates a possible successful role for levamisole in the treatment of experimental endometriosis. Further studies to assess the effects of high dose levamisole on endometriosis are recommended.

Hypothalamic Expression of KiSS1 and RFamide-related Peptide-3 mRNAs during The Estrous Cycle of Rats.

Kisspeptin and RFamide-related peptide-3 (RFRP-3) are known to affect GnRH/luteinizing hormone (LH) in several species, including the rat. It has been hypothesized that GnRH/LH changes during the rat estrous cycle may result from changes in the expression of KiSS1 and RFRP-3 genes. Therefore, the present study investigates KiSS1 and RFRP-3 gene expression at the transcriptional level in the rat hypothalamus during the estrous cycle. In the present experimental study, 36 adult female Sprague-Dawley rats (3-4 months old) were used to study the expression of KiSS1 and RFRP-3 mRNA in the hypothalamus during the estrous cycle. Four rats were ovariectomized, whereas the remainder were allotted to four different phases of the estrous cycle (n=8 per estrus phase). Rats were decapitated, and the hypothalami were immediately dissected and frozen in liquid nitrogen. Expressions of KiSS1 and RFRP-3 mRNAs were analyzed by real-time PCR. The expression of KiSS1 mRNA during estrus was lower than other phases of the cycle (p<0.01). Expression of KiSS1 mRNA during the metestrus phase was lower than the proestrus phase (p<0.01). The expression of RFRP-3 mRNA during proestrus was lower than the diestrus phase (p<0.01). Results of the present study showed the role of coordinated expression of KiSS1 and RFRP-3 mRNA in the hypothalamus in the control of the rat estrous cycle.

Effects of ovarian puncture for in vitro maturation on subsequent in vitro fertilization cycle in women with polycystic ovaries.

We conducted a case-control study and compared the results of IVF treatment in two groups of women with polycystic ovaries. The first group consisted of 42 women who were previously treated unsuccessfully with in vitro maturation (IVM), and the second group, 48 others with no previous IVM (control group). We included the first IVF cycle only. Our preliminary result shows that previous ovarian puncture for IVM is associated with improved number of mature oocytes retrieved and total number of embryos produced. However, it is not associated with a better pregnancy rate. A larger study is needed.

Changing practice from laparoscopic supracervical hysterectomy to total hysterectomy.

OBJECTIVE: To compare morbidity and mortality related to laparoscopic supracervical hysterectomy (LASH) and laparoscopic total hysterectomy (LTH). METHODS: We reviewed the medical records of 227 patients who underwent laparoscopic hysterectomy for benign gynaecological diseases between January 2004 and March 2008. Before January 2006, we performed mainly LASH (n: 122), and from January 2006 we performed LTH (n: 105). We reviewed and compared operating times, requirement for narcotics, duration of hospital stay, and complications of the two procedures. RESULTS: The mean age of the patients in the LASH group was 45.7+/-0.6 years, and in the LTH group was 45.9+/-0.7 years. Patients in each group were comparable in mean body mass index and preoperative hemoglobin concentration. There were no differences in the duration of hospital stay or mean postoperative hemoglobin concentration. Patients in the LASH group had a shorter mean operating time than the LTH group (111.0+/-2.9 vs. 136+/-3.6 minutes; 95% CI 16-33, P<0.001), but the patients in the LASH group required a greater mean dose of narcotic than those in the LTH group (28.0+/-2.9 mg of morphine or morphine equivalent vs. 37.5+/-3.4 mg; 95% CI 1.5-10.5, P=0.02). There was no difference between the two groups in the incidence of major and minor complications. However, five patients in the LASH group required a repeat operation, but none of the LTH group did. CONCLUSION: Laparoscopic total hysterectomy is associated with a longer operating time than laparoscopic supracervical hysterectomy, but with less need for postoperative narcotics.

Tubal surgery.

Today, reproductive surgery has a limited place. In selected cases such as young women with a history of pelvic inflammatory disease, pelvic adhesions, and endometriosis, surgery could be considered. Most operations can be performed by laparoscopy; these include tubal anastomosis that yields a high pregnancy rate. On the other hand, women over the age of 37 with a long history of infertility or those who require a laparotomy are better treated with in-vitro fertilization. For women with hydrosalpinx undergoing IVF, salpingectomy is the best treatment option. It increases the chance of pregnancy and live birth rates and decreases the miscarriage rate.

Adhesion development and morbidity after repeat cesarean delivery.

OBJECTIVE: The purpose of this study was to evaluate the development and implications of intraabdominal adhesions after repeat cesarean section delivery (CS). STUDY DESIGN: We reviewed the charts of 1283 women who underwent repeat CS and 203 other women who underwent primary CS. Primary outcome measures were incidence and extent of adhesions, incision-to-delivery interval, and operating time. RESULTS: No adhesions were found in primary CS. Compared with those women with a second CS (24.4%), significantly more women had adhesions after 3 CSs (42.8%; 95% confidence interval [CI], 0.84-0.99). Compared with a first CS (7.7 +/- 0.3 minutes), the delivery time was significantly longer at subsequent CSs (second CS, 9.4 +/- 0.1 minutes; 95% CI, 1-2; third CS, 10.6 +/- 0.3 minutes; 95% CI, 2-4; >or= 4 CSs, 10.4 +/- 0.1 minutes; 95% CI, 1-2). However, complication rates in those women with >or= 2 CSs were comparable with primary CS. CONCLUSION: Increased adhesion development and a longer time to delivery were found with each subsequent CS.

Management of ovarian endometrioma.

The optimal conservative treatment for endometriotic cysts is unclear, particularly when treated laparoscopically. We performed a systematic analysis of the published literature on ovarian endometrioma especially focused on comparing laparoscopic cystectomy with laparoscopic drainage and coagulation of the cyst with regard to evaluating advantage and disadvantage of each method. We observed that cystectomy was superior in terms of risk of recurrent symptoms, cyst, reoperation, pregnancy: this was true in both prospective and retrospective studies previously published. Given the evidence available, excision of cyst wall in endometrioma is strongly recommended especially in infertile patients.