Sexual dimorphism of the fetal brain biometry: an MRI-based study.

PURPOSE: Fetal growth assessment is a key component of prenatal care. Sex-specific fetal brain nomograms on ultrasound are available and are clinically used. In recent years, the use of fetal MRI has been increasing; however, there are no sex-specific fetal CNS nomograms on MRI. The study aimed to assess the differences in fetal brain biometry and growth trajectories and to create population-based standards of the fetal brain on MRI. METHODS: In this cross-sectional study, brain structures of singleton fetuses with normal brain MRI scans were analyzed: biparietal diameter, occipitofrontal diameter, trans-cerebellar diameter, and the corpus callosum were measured and converted into centiles. Sex-specific nomograms were created. RESULTS: A total of 3848 MRI scans were performed in one tertiary medical center between 2011 and 2019; of them, 598 fetuses met the inclusion criteria, 300 males and 298 females between 28- and 37-weeks' gestation. Males had significantly larger occipitofrontal diameter than females (median 75%, IQR 54-88%; median 61%, IQR 40-77%) and biparietal diameter (median 63%, IQR 42-82%; median 50%, IQR 25-73%), respectively (p < 0.001). The cerebellum had the greatest growth rate, with a 1.5-fold increase in diameter between 28 and 37 weeks' gestation, with no measurement difference between the sexes (p = 0.239). No significant difference was found in the corpus callosum (p = 0.074). CONCLUSION: Measuring both sexes on the same nomograms may result in over-estimation of male fetuses and under-estimation of females. We provide fetal sex-specific nomograms on two-dimensional MRI.

Predictive value of new onset versus primary meconium-stained amniotic fluid.

BACKGROUND: Transition of clear amniotic fluid to meconium-stained fluid is a relatively common occurrence during labor. However, data regarding the clinical significance and the prognostic value of the presence of meconium-stained amnionic fluid (MSAF) are scarce. This study aimed to investigate delivery and neonatal outcomes according to the presence of MSAF and the timing of the meconium passage. METHODS: We used an historical cohort study at a single tertiary medical center in Israel between the years 2011 and 2018. Women were divided into two groups according to timing of meconium passage: primary MSAF (MSAF present at membrane rupture) and secondary MSAF (clear amnionic fluid that transitioned to MSAF during labor). Neonatal complication rates were compared between groups. Composite adverse neonatal outcome was defined as arterial cord blood pH <7.1, 5 min Apgar score ≤7, and/or neonatal intensive care unit admission. RESULTS: The study cohort included 56 863 singleton term births. Of these, 9043 (15.9%) were to women who had primary MSAF, and 1484 (2.6%) to those with secondary MSAF. Secondary MSAF compared with primary MSAF increased the risks of cesarean birth and operative vaginal delivery, increased the risks of low one- and five-minute Apgar scores and low arterial cord blood pH, and increased hospital stay duration. Multivariate analysis revealed that secondary MSAF was independently associated with an increased risk of composite adverse neonatal outcome (OR1.68, 95% CI 1.25-2.24, p < 0.001) compared with primary MSAF. CONCLUSIONS: In this sample, secondary MSAF was associated with more adverse neonatal outcomes than primary MSAF. Closer monitoring of fetal well-being may be prudent in these cases.

Isolated Fallopian Tube Torsion: An Underdiagnosed Entity with Debatable Management.

STUDY OBJECTIVE: To study features of isolated fallopian tube torsion (IFTT) to promote early diagnosis of this entity and describe options for management. DESIGN: Retrospective cohort study from October 2017 through October 2020. SETTING: Tertiary care hospital. PATIENTS: All patients with surgically confirmed adnexal torsion or IFTT during the study period. INTERVENTIONS: All of the patients underwent gynecological examination, imaging, and laparoscopy. MEASUREMENTS AND MAIN RESULTS: During this 3-year period, 64 patients underwent laparoscopy owing to confirmed torsion, of which 55 had adnexal torsion, and 9 had IFTT. Patients with IFTT tended to be younger (21.2 years ± 8.2 vs 29.1 years ± 11.9, p = .06) and had more fever on admission (p = .007). On ultrasound examination, isolated hydrosalpinx was demonstrated only in patients with IFTT (p <.001). During surgery, more para-ovarian cysts were observed in patients with IFTT (44.4% vs 10.9%, p = .01), whereas patients with adnexal torsion had more ovarian cysts (52.7% vs 0%, p = .003). The most common procedure was detorsion in both groups. Most patients that underwent detorsion of the tube had a normal ultrasound scan on follow-up examination. CONCLUSION: IFTT is probably underdiagnosed. Its clinical presentation is more equivocal than adnexal torsion, and ovaries are usually of normal size on ultrasonography. Hydrosalpinx or para-ovarian cysts should raise suspicion toward IFTT. Detorsion of the tube is probably a valid management option, although further research with long-term follow-up analyzing tubal patency is necessary to define the optimal management for this condition.

Feasibility of Fetal Proximal Lateral Cerebral Ventricle Measurement.

OBJECTIVES: Measuring the posterior horn of the lateral ventricle in the fetus during ultrasound scans may be challenging. We aimed to examine this measurement feasibility, in relation to gestational age. METHODS: A cross-sectional study was conducted, including nonanomalous fetuses, in which both lateral ventricles measured less than 10 mm during anomaly scans. The measurements were performed according to the International Society of Ultrasound in Obstetrics and Gynecology guidelines. Success rate of measuring both ventricles was assessed at different gestational ages. Association between lateral ventricle width with contralateral ventricle width, gender, gestational age, and fetal head position were assessed. RESULTS: A total of 156 cases were recruited. The lateral ventricle distal to the probe was measured in all cases. In 10 cases proximal lateral ventricle could not be adequately measured (failed proximal ventricle measurement group). In 146 scans both ventricle measurements were available. All 10 cases of failed proximal ventricle measurement were in third trimester (30-38 weeks). Success rate of measurement of both ventricles was 100%, 96.2%, 71.4%, and 37.5% for gestational week 14-29, 30-32, 33-35, and 36-38, respectively (P <.001). Proximal lateral ventricle width was strongly associated with the distal ventricle width (B = 0.422, 95% confidence interval 0.29, 0.555, P <.001), but not with head position, fetal gender, or gestational age. CONCLUSIONS: Measurement of the proximal lateral ventricle is feasible in most cases, even during late third trimester scans. Efforts should be made to visualize both ventricles in every evaluation of the fetal brain.

Association of the Cerebro-Placental Ratio With Adverse Outcomes in Pregnancies Affected by Gestational Diabetes Mellitus.

OBJECTIVES: Cerebro-placental ratio (CPR) is a doppler tool contributes to clinical decision-making in pregnancies affected by small for gestational age weight (SGA). Pregnancies affected by gestational diabetes mellitus (GDM) tend to have higher newborn weight, but greater risk of adverse perinatal outcomes. We hypothesized that in GDM-complicated-pregnancies CPR will be associated with adverse perinatal outcomes even in the absence of SGA. METHODS: This prospective single-center cohort study included non-anomalous singleton pregnancies in women with GDM. Those with pre-pregnancy diabetes mellitus, hypertensive disorder or suspected SGA were excluded. Routine fetal sonographic assessment included CPR-defined as middle cerebral artery pulsatilty index/umbilical artery pulsatilty index. Masked CPR measurement closest to birth was used, classified as >10th (normal) or ≤10th centile (low). Primary outcome was a composite, consisting of stillbirth, Caesarean birth due to abnormal fetal heart rate pattern, 5-minute Apgar <7, cord arterial pH < 7.0, hypoxic ischemic encephalopathy, or NICU admission >24 hours. RESULTS: Of 281 participants, 24 (8.5%) had low CPR, at a mean gestational age of 36.3 weeks (IQR 34.0-37.4). Birthweight percentile was significantly lower among the low CPR group (35th [IQR 16-31] versus 60th [IQR 31-82]; P = .002). There was no statistically difference in the primary composite outcome between the groups (8.3% versus 7.0%, P = .68). Low CPR was significantly associated with a higher risk of neonatal hypoglycemia (adjusted odds ratio 3.2, 95% CI 1.2-8.3). CONCLUSION: In pregnancies affected by GDM, CPR ≤10th percentile was not associated with adverse perinatal outcome but was associated with neonatal hypoglycemia.

"One-stop shop" for the evaluation of the infertile patient: hystero-salpingo foam sonography combined with two and three dimensional ultrasound and sonohysterography.

Hysterosalpingo-foam sonography (HyFoSy) is considered an acceptable alternative for hysterosalpingography (HSG). By combining HyFoSy with two and three-dimensional (2D and 3D) ultrasound and hysterosonography, a complete fertility work-up can be done. We aimed to evaluate the value of a combined ultrasound examination for fertility work-up. During the study period 113 women were examined. Five of 113 (4.4%) examinations were abandoned due to intra-uterine adhesions that were detected by hysterosonography, and five (4.4%) were abandoned due to technical difficulties. Of 103 women who had completed the examination, 2D ultrasound revealed six patients with hydrosalpinx (5.8%) and sonographic signs of adenomyosis in 13 (12.6%) patients. By combining 2D ultrasound with hysterosonography, two (1.9%) fibroids that were penetrating the uterine cavity and seven (6.8%) endometrial polyps were detected. HyFoSy showed bilateral patent tubes in 58 patients (56.3%), unilateral tubal occlusion in 29 (28.1%) and bilateral tubal occlusion in 16 (15.5%). This study shows that the 'one-stop shop' examination is feasible. The combined examination had detected 16 pathological findings that would have not been detected by HyFoSy alone. Hence, it should be offered to couples undergoing routine infertility work-up.IMPACT STATEMENTWhat is already known on this subject? The accuracy of the HyFoSy alone has been evaluated in different studies, but this presented ultrasound scan is integrating 4 different modalities in one exam (2D scanning of the pelvis, 3D scanning of the uterus, hysterosonography and HyFoSy) and we were able to evaluate the female pelvic organs, including the uterine cavity, the tubes and the ovaries, in order to expand the range of diagnosed pathologies.What do the results of this study add? The concept of 'one-stop shop' for the evaluation of female pelvis in couples suffering from infertility is feasible, has comparable accuracy as HSG for tubal occlusion, and higher detection rate for uterine malformations.What are the implications of these findings for clinical practice and/or further research? We suggest to incorporate this examination in routine fertility work-up.

The association between level of physical activity and pregnancy rate after embryo transfer: a prospective study.

RESEARCH QUESTION: Is physical activity after embryo transfer, as assessed by a smart band activity tracker, associated with decreased pregnancy rates? DESIGN: Prospective observational cohort study comprising infertile women aged < 38 years, who had undergone fewer than three previous embryo transfers, achieved a good ovarian response and were undergoing frozen-thawed embryo transfer in a tertiary-referral centre. A validated smart band activity tracker was used to assess physical activity level immediately after the embryo transfer and until the pregnancy test. No specific recommendations were given to participants on level or intensity of physical activity. Physicians and patients were blinded to the data stored in the pedometer. Primary outcome was ongoing pregnancy rate. RESULTS: Fifty women met the inclusion criteria. Ongoing pregnancy rate was 30%. In a pooled analysis, participants walked significantly fewer steps per day on the day of embryo transfer compared with the first 2 days after embryo transfer (4075, interquatile range [IQR] 2932-5592 versus 5204, IQR4203-8584, P = 0.01). No significant difference was observed between pregnant women and non-pregnant women in the median steps per day after embryo transfer until serum beta-HCG was measured (7569, IQR 6008-10884 versus 6572.5, IQR 5299-8786, P = 0.43). No significant difference was observed in the median number of steps on the day of embryo transfer or the first 2 days after embryo transfer between pregnant and non-pregnant women. CONCLUSIONS: A quantitative objective assessment of the association between physical activity and pregnancy rates after frozen-thawed embryo transfer was conducted. Ambulation after embryo transfer has no adverse effect on pregnancy rates and, therefore, women should resume regular activity immediately after embryo transfer.

Twin discordance: a study of volumetric fetal brain MRI and neurodevelopmental outcome.

OBJECTIVE: This study employed magnetic resonance imaging (MRI) to compare brain volumes of discordant twins and examined their neurodevelopment after birth by using a validated exam. STUDY DESIGN: A prospective historical cohort study of discordant dichorionic diamniotic (DCDA) or monochorionic diamniotic (MCDA) twin fetuses, who undergone an MRI scan to evaluate growth restriction in the discordant twin (weight < 10th centile) during 6 years period, at a single tertiary center. Twenty-seven twin pairs were included in the volumetric study and 17 pairs were included in the neurodevelopmental outcome examination. The volumes of the supratentorial brain region, both hemispheres, eyes, and the cerebellum were measured by 3D MRI semi-automated volume measurements. Volumes were plotted on normal growth curves and discordance was compared between weight at birth and brain structure volumes. Neurodevelopmental outcome was evaluated using the VABS-II questionnaire at a mean age of 4.9 years. RESULTS: The volume of major brain structures was significantly larger in the appropriate-for-gestational-age twins (AGA) compared to the small-for-gestational-age (SGA) co-twins (p < 0.001). The birth weight discordance was 32.3% (24.9-48.6) and was significantly greater (p < 0.001) than the discordance of the prenatal supratentorial brain (13.6% [5.6-18]), cerebellum volume (21.7% [9.5-30.8]). Further neurodevelopmental outcome evaluation found no significant difference between the AGA twin and the SGA twin. CONCLUSION: In discordant twins, the smaller twin showed a "brain-preserving effect," which in our study was not associated with a worse neurodevelopmental outcome. The use of MRI in such cases may aid in decision-making and parental consultation. KEY POINTS: • Weight discordance at birth was significantly greater compared to intrauterine brain volume discordance measured by 3D MRI. • Small-for-gestational-age (SGA) fetuses preserve brain development. • In highly discordant twins, there was no long-term difference in neurodevelopmental outcome at a mean age of 4.9 years.

Development and validation of a machine learning-based postpartum depression prediction model: A nationwide cohort study.

BACKGROUND: Currently, postpartum depression (PPD) screening is mainly based on self-report symptom-based assessment, with lack of an objective, integrative tool which identifies women at increased risk, before the emergent of PPD. We developed and validated a machine learning-based PPD prediction model utilizing electronic health record (EHR) data, and identified novel PPD predictors. METHODS: A nationwide longitudinal cohort that included 214,359 births between January 2008 and December 2015, divided into model training and validation sets, was constructed utilizing Israel largest health maintenance organization's EHR-database. PPD was defined as new diagnosis of a depressive episode or antidepressant prescription within the first year postpartum. A gradient-boosted decision tree algorithm was applied to EHR-derived sociodemographic, clinical, and obstetric features. RESULTS: Among the birth cohort, 1.9% (n = 4104) met the case definition of new-onset PPD. In the validation set, the prediction model achieved an area under the curve (AUC) of 0.712 (95% confidence interval, 0.690-0.733), with a sensitivity of 0.349 and a specificity of 0.905 at the 90th percentile risk threshold, identifying PPDs at a rate more than three times higher than the overall set (positive and negative predictive values were 0.074 and 0.985, respectively). The model's strongest predictors included both well-recognized (e.g., past depression) and less-recognized (differing patterns of blood tests) PPD risk factors. CONCLUSIONS: Machine learning-based models incorporating EHR-derived predictors, could augment symptom-based screening practice by identifying the high-risk population at greatest need for preventive intervention, before development of PPD.

Addition of Lidocaine to the Distension Medium in Hysteroscopy Decreases Pain during the Procedure-A Randomized Double-blind, Placebo-controlled Trial.

STUDY OBJECTIVE: To evaluate the effect of adding a local anesthetic to the distension medium in office diagnostic hysteroscopy using the vaginoscopic approach on pain during the procedure. Secondary aims included documenting side effects, patient satisfaction, and the time needed to complete the procedure. DESIGN: Randomized double-blind placebo-controlled study. SETTING: University-affiliated hospital; office hysteroscopy clinic. PATIENTS: Total of 100 patients who underwent office hysteroscopies divided in half with 50 in the intervention group and 50 in the control group. INTERVENTIONS: Ten mL of lidocaine 2% added to 1000 mL of saline solution that was used as the distension medium for hysteroscopy in the study group vs 1000 mL of saline alone in the control group. MEASUREMENTS AND MAIN RESULTS: A significant difference was found in the increment of pain as measured by visual analog scale after the hysteroscopy between the 2 groups. Patients receiving lidocaine had an average rise of 1.9 in the visual analog scale score after the procedure compared with 2.9 in the control group (p = .033). There was also a nonsignificant trend for shorter duration of hysteroscopy in the intervention group compared with the control group (180.1 vs 222.1 seconds, p = .08). Patients' satisfaction was high in both groups (98% for the study group and 92% for the control group). Success rates were also similar between the 2 groups at approximately 95%. No side effects were recorded in either group. CONCLUSION: The addition of local anesthetic to the distension medium in office hysteroscopy produces significant reduction in pain during the procedure without adding time to the procedure and without side effects.

The Significance of Fetal Brain Ventricular Asymmetry Without Dilation.

OBJECTIVES: Fetal brain non-dilated ventricular asymmetry (NDVA) is a common finding on prenatal ultrasound exams. However, the optimal prenatal management in these cases remains unknown. We aimed to evaluate the benefit of prenatal genetic and magnetic resonance imaging (MRI) exams performed in cases of fetal NDVA detected on ultrasound. METHODS: A historical cohort study from a tertiary medical center. Singleton pregnancies with fetal brain NDVA diagnosed on ultrasound were included. We defined ventricular asymmetry as a difference of ≥2.0 mm between the lateral ventricles and ventricular dilation as ventricular width of >10.0 mm. Outcomes were evaluated with genetic exams (karyotype and chromosomal microarray analysis [CMA]) and fetal brain MRI. RESULTS: During the study period, there were 145 cases diagnosed with NDVA on ultrasound that comprised the cohort study. The rate of abnormal karyotype was 1.8% (1/56) and of abnormal CMA was 10% (3/30). The rate of minor additional CNS findings did not differ between ultrasound and MRI (3.4 versus 2.8%, respectively, p = .74). No major additional fetal brain findings were detected on MRI performed after ultrasound. CONCLUSIONS: In cases diagnosed with NDVA on ultrasound, no significant additional anomalies were detected on fetal brain MRI. The rate of abnormal genetic tests was relatively high and warrants further studies.

Cleavage vs blastocyst stage embryos: how are they interrelating?

PURPOSE: To assess the variables that may predict which cleavage-stage embryo may develop into a blastocyst, and vice versa, to determine whether the cleavage-stage embryo morphology should be taken into consideration when transferring the embryo at the blastocyst stage. METHODS: A single center, retrospective cohort study. The study cohort included 3072 patients undergoing 3607 retrieval cycles and 23,124 embryos at the cleavage stage. We assessed the blastulation rate and evaluated which variables impact the ongoing pregnancy rate. RESULTS: High blastulation rate correlates with higher embryos' grading (I > II > III > IV > V) and higher number of blastomeres (8 > 7 > 6 > 5 > 4). 949 patients had fresh single blastocyst transfers. The ongoing pregnancy rate was 28.9% per transfer. Patients with ongoing pregnancies were significantly younger (34.3 vs. 36 years, p < 0.001), had higher number of oocyte yield (9.8 vs. 9, p = 0.02), and an increased rate of good-quality embryos transferred (70.7% vs. 47.7%, p = 0.001). When evaluating embryos progression, we found that whenever embryo developed to a good-quality blastocyst, its appearance at the cleavage stage did not affect ongoing pregnancy rate. CONCLUSION: Higher the number of blastomeres and better embryo grading were found to correlate with a higher blastulation rate. Nevertheless, if the embryo has already developed to a top-quality blastocyst, its morphology at the cleavage stage did not impact ongoing pregnancy rate.

Relaparotomy post-cesarean delivery: characteristics and risk factors.

PURPOSE: Relaparotomy following cesarean delivery (CD) is performed at a rate of 0.2-1% of CD. The objective of the present study was to identify risk factors for relaparotomy following CD, and to examine whether there is a difference in the risk of relaparotomy between CD performed during different hours of the day. METHODS: A retrospective study on all CD over 10 years compared pregnancies that underwent laparotomy within 1 week following CD to those that did not. RESULTS: Sixty-four patients underwent relaparotomy out of 24,239 CDs (0.26%). In univariate analysis, relaparotomy was significantly associated with pregnancies following assisted-reproductive-technologies odds ratio (OR) 95% confidence interval (CI) 3.15 (1.90-5.22), hypertensive disorders of pregnancy OR 3.05 (1.62-5.72), twin pregnancies OR 95% CI 3.78 (2.21-6.48), preterm deliveries OR 95% CI 2.44 (1.46-4.10), placenta previa OR 95% CI 6.41(2.55-16.09) and urgent CD 1.74 (1.06-2.86), especially during the second-stage of labor OR 95% CI 2.73 (1.34-5.54). The time of day of CD did not influence the rate of relaparotomy. In a multivariable-regression analysis, the adjusted odds ratio for relaparotomy was 10.24 in CD due to placenta previa, and 5.28 in CD performed at the second-stage of delivery. At relaparotomy, active bleeding was found in 50 patients (78.1%), nearly half received packed cells, 12.5% developed consumptive coagulopathy, and 17.2% needed hospitalization in the intensive care unit. 6.3% underwent a second relaparotomy, mainly due to bleeding. CONCLUSION: Placenta previa, and urgent CDs mainly those performed at the second stage of labor are risk factors for relaparotomy after CD.

Pregnancy outcome after multifetal pregnancy reduction of triplets to twins versus reduction to singletons.

RESEARCH QUESTION: Does fetal reduction of triplet pregnancies to singleton result in superior obstetric and neonatal outcomes compared with triplets reduced to twins? DESIGN: A historical cohort study including 285 trichorionic and dichorionic triplet pregnancies that underwent abdominal fetal reduction at 11-14 weeks in a single tertiary referral centre. The study population comprised two groups: reduction to twins (n = 223) and singletons (n = 62). Main outcome measures were rates of pregnancy complications, preterm delivery and neonatal outcomes. Non-parametric statistical methods were employed. RESULTS: Triplet pregnancies reduced to twins delivered earlier (36 versus 39 weeks, P < 0.001) with higher prevalence of Caesarean section (71.1% versus 32.2%, P < 0.001) compared with triplets reduced to singletons. Preterm delivery rates were significantly higher in twins compared with singletons prior to 37 weeks (56.9% versus 13.6%, P < 0.001), 34 weeks (20.2% versus 3.4%, P = 0.002) and 32 weeks (9.6% versus 0%, P = 0.01). No significant difference was found in the rate of pregnancy loss before 24 weeks (1.3% in twins versus 4.8% in singletons, P = 0.12) or in the rate of intrauterine fetal death after 24 weeks (0.4% versus 0%, P = 1.0). Both groups had comparable obstetrical complications and neonatal outcomes, except for higher rates of neonatal intensive care unit admission in twins (31.9% versus 6.8%, P < 0.001). CONCLUSIONS: Reduction of triplets to singletons rather than twins resulted in superior obstetric outcomes without increasing the procedure-related complications. However, because the rate of extreme prematurity in pregnancies reduced to twins was low, the overall outcome of those pregnancies was favourable. Therefore, the option of reduction to singletons should be considered in cases where the risk of prematurity seems exceptionally high.

What is the optimal timing of embryo transfer when there are only one or two embryos at cleavage stage?

Today, most IVF programs have moved to blastocyst transfer but there is still uncertainty regarding when to transfer if there are only one or two embryos at the cleavage stage. The aim of this study was to compare the pregnancy rate of day 3 transfers vs. blastocyst stage transfers in patients who had only one or two embryos on day 3. We conducted a retrospective study of 102 patients with one or two cleavage stage embryos that had their embryos transferred on day 3 and 429 patients had their embryos cultured to day 5 for transfer. The number of mature oocytes (4.0 vs 4.6, p = NS) and number of cleavage stage embryos on day 3 was similar in the two groups (1.3 vs. 1.5, p = NS). The clinical pregnancy rate per retrieval (22% vs. 24.6%, p= NS) and the ongoing pregnancy rate per retrieval (20% vs. 20.2%, p = NS) was comparable between the groups. Fifty seven (13.2%) of the patients had cleavage embryo arrest and did not have an embryo to transfer on day 5. We conclude that the cumulative pregnancy rate is the same for patients with 1-2 cleavage stage embryos regardless of whether the embryo is transferred on day 3 or day 5.

Sub-endometrial contractility or computer-enhanced 3-D modeling scoring of the endometrium before embryo transfer: are they better than measuring endometrial thickness?

PURPOSE: Recent studies have focused on transvaginal ultrasound measurement (TVUS) of sub-endometrial contractility and computer-enhanced 3-D modeling scoring of the endometrium prior to embryo transfer (ET).The aim of this study was to compare pregnancy outcome of patients who performed the 3-D scoring or the sub-endometrial measurement prior to the ET with patients that did not perform those procedures. METHODS: A single center retrospective cohort study of 635 freeze/thaw cycles of blastocysts vitrified on day 5 and transferred between January 2016 and August 2016. RESULTS: We compared the patients who performed 3-D scoring with the control group and found comparable patients' characteristics, clinical pregnancy rates (42% vs. 44.3, p = NS, respectively), and ongoing pregnancy rates (31.7% vs. 33.9%, p = NS).We then compared the patients who performed the sub-endometrial wave measurements with the control group and found similar findings. The clinical pregnancy rate (38.2% vs. 44.3, p = NS, respectively) and the ongoing pregnancy rate (30.8% vs. 33.9%) were comparable between the two groups. We performed a regression analysis to examine the independent contribution of different variables to the ongoing pregnancy rates. Both the 3-D and the wave count procedures were not found to have any influence on the ongoing pregnancy rates. CONCLUSIONS: Although new ultrasonic methods of evaluating the endometrium have been proposed during the last years, these methods have not been shown to improve the pregnancy rates compared to the original method of assessing the endometrium by measuring the endometrial thickness.

Prolonged culture of blastocysts after thawing as a tool for improving prediction of success.

PURPOSE: A few years ago, we started to use a new freeze-thaw protocol for the frozen embryo transfer cycles. Instead of thawing the embryos 2-4 h prior to the transfer, we started thawing the embryos 20-22 h prior to the transfer. The aim of this study was to compare the pregnancy rate in cases of embryos that continued to develop in the post-thawing culture to that of embryos that did not. METHODS: A retrospective cohort study of blastocyst freeze/thaw cycles vitrified on day 5, thawed and transferred after 20-22 h in the culture, between January 2012 and December 2016. RESULTS: A total of 375 patients were included in the analysis. Two hundred twenty-eight embryos graded as good, 87 graded as fair, and 60 graded as poor embryos were transferred. The clinical pregnancy rate (50% vs. 19.5% vs 3.3% p < 0.01) and the ongoing pregnancy rate (38.5% vs. 13.6% vs 1.7% p < 0.01) were higher in cases of good embryo quality compared with fair and poor-quality embryos, respectively. For good embryos, progressing to a better grade during the culture did not change the clinical pregnancy rate (51.3% vs. 46.2% p = NS) or the ongoing pregnancy rate (38.5% vs. 37.5% p = NS). For fair embryos, progressing to a better grade during the culture resulted in a higher clinical pregnancy rate (25.4% vs 9% p = 0.05). CONCLUSIONS: The development of the fair embryos in the culture has a highly positive impact on the pregnancy rate and this factor should be taken into consideration before deciding how many embryos to transfer.

Does the endometrial receptivity array really provide personalized embryo transfer?

PURPOSE: The aim of the present study was to determine the percentage of infertility patients who are diagnosed with a non-receptive endometrium according to the endometrial receptivity array (ERA) test and to examine whether adjusting the embryo transfer day according to the proposed shift in the window of implantation improves the pregnancy rate compared to non-ERA-tested patients. METHODS: A single-center retrospective cohort study, including 53 consecutive good prognosis patients (0-2 previous frozen embryo transfers) admitted to our IVF unit for a mock cycle prior to their frozen day-5 embryo (blastocyst) transfer cycle. The mock cycle included an endometrial biopsy for both the ERA test and histological assessment by the Noyes criteria (study group). The next cycle frozen embryo transfer (FET) in the study group was adjusted according to the ERA results. The control group consisted of patients who underwent FET cycles at our clinic during the same period, without performing the endometrial biopsy and ERA testing. RESULTS: During the study period, 503 patients (control group) underwent FET cycles without performing the ERA testing and 41 patients had FET following an ERA test. There were no between-group differences in patients' age, number of previous transfers, endometrial thickness, number of transferred embryos, and ongoing pregnancy rates (35.2 vs. 39%, respectively, p = NS). Out of the 53 patients who performed the ERA test before their first or second FET, five endometrial samples (9.4%) were found to be post-receptive, 29 (54.7%) pre-receptive, and only 19 samples (35.8%) were receptive. Women in the study group with pre- or post-receptive endometrium on ERA testing, the appropriate adjustment in timing of FET according to the ERA test resulted in a 33.3% pregnancy rate, which is comparable to the 35.2% background ongoing pregnancy rate of the control group. CONCLUSIONS: Performing the ERA test in a mock cycle prior to a FET does not seem to improve the ongoing pregnancy rate in good prognosis patients. Further large prospective studies are needed to elucidate the role of ERA testing in both good prognosis patients and in patients with recurrent implantation failure.

Does daily co-administration of letrozole and gonadotropins during ovarian stimulation improve IVF outcome?

BACKGROUND: For the last year we have been treating normal responders with gonadotropins and letrozole during the whole stimulation in order to improve response to FSH by increasing the intrafollicular androgen concentration, and to reduce circulating estrogen concentrations. The aim of this study was to compare the IVF outcome of normal responders treated with letrozole and gonadotropins during ovarian stimulation with patients treated with gonadotropins only. METHODS: A single centre retrospective cohort study of 174 patients (87 in each group). RESULTS: The age of the patients was comparable between the groups. Estradiol levels were significantly higher in the control group (6760 pmol/L vs. 2420 pmol/L respectively, p < 0.01), and the number of follicles ≥15 mm at the trigger day was significantly lower in the control group (7.9 vs. 10, p = 0.02). The number of retrieved oocytes (10 vs. 14.5, p < 0.01), MII oocytes (7.9 vs. 11.2, p < 0.01) and blastocysts (2.7 vs. 4.0, p = 0.02) was significantly higher in the study group. We found no significant differences in the cumulative pregnancy outcome between the two groups (65.2% vs 58.3% p = NS). CONCLUSIONS: We conclude that co-treatment with letrozole improves the IVF outcome in normal responders in terms of increased number of blastocysts obtained without increasing the pregnancy rate or the risk of OHSS.

Multifetal reduction of triplets to twins compared with non-reduced twins: a meta-analysis.

The current systematic review and meta-analysis evaluates the perinatal outcomes in twin pregnancies following multifetal pregnancy reduction (MPR) compared with non-reduced twins. We considered all studies comparing perinatal outcomes of twin pregnancies following MPR to non-reduced twin pregnancies. Our search yielded 639 publications, of which 91 were assessed for eligibility. A total of 22 studies met our inclusion criteria. Overall, fetal reduction of triplets to twins resulted in comparable perinatal outcomes to non-reduced twins with regards to gestational age and birthweight at delivery, pregnancy loss prior to 24 weeks, as well as the development of gestational diabetes and hypertensive disorders of pregnancy. Of all outcomes, only the Caesarean section rate was significantly higher in the MPR group compared with the non-reduced twins group with an odds ratio of 1.95 (95% confidence interval 1.33-2.87). This meta-analysis suggests that MPR of triplet pregnancies to twins is associated with comparable perinatal outcomes to that of non-reduced twins. This information can further help in guiding, and probably reassuring, clinician and patient decision-making when faced with high-order multifetal pregnancies.