A randomised controlled trial to assess the clinical effectiveness and safety of the endometrial scratch procedure prior to first-time IVF, with or without ICSI.

STUDY QUESTION: What is the clinical-effectiveness and safety of the endometrial scratch (ES) procedure compared to no ES, prior to usual first time in vitro fertilisation (IVF) treatment? SUMMARY ANSWER: ES was safe but did not improve pregnancy outcomes when performed in the mid-luteal phase prior to the first IVF cycle, with or without intracytoplasmic sperm injection (ICSI). WHAT IS KNOWN ALREADY: ES is an 'add-on' treatment that is available to women undergoing a first cycle of IVF, with or without ICSI, despite a lack of evidence to support its use. STUDY DESIGN, SIZE, DURATION: This pragmatic, superiority, open-label, multi-centre, parallel-group randomised controlled trial involving 1048 women assessed the clinical effectiveness and safety of the ES procedure prior to first time IVF, with or without ICSI, between July 2016 and October 2019. PARTICIPANTS/MATERIALS, SETTING, METHODS: Participants aged 18-37 years undergoing their first cycle of IVF, with or without ICSI, were recruited from 16 UK fertility clinics and randomised (1:1) by a web-based system with restricted access rights that concealed allocation. Stratified block randomisation was used to allocate participants to TAU or ES in the mid-luteal phase followed by usual IVF with or without ICSI treatment. The primary outcome was live birth after completing 24 weeks gestation within 10.5 months of egg collection. MAIN RESULTS AND THE ROLE OF CHANCE: In total, 1048 women randomised to TAU (n = 525) and ES (n = 523) were available for intention to treat analysis. In the ES group, 453 (86.6%) received the ES procedure. IVF, with or without ICSI, was received in 494 (94.1%) and 497 (95.0%) of ES and TAU participants respectively. Live birth rate was 37.1% (195/525) in the TAU and 38.6% (202/523) in the ES: an unadjusted absolute difference of 1.5% (95% CI -4.4% to 7.4%, P = 0.621). There were no statistical differences in secondary outcomes. Adverse events were comparable across groups. LIMITATIONS, REASONS FOR CAUTION: A sham ES procedure was not undertaken in the control group, however, we do not believe this would have influenced the results as objective fertility outcomes were used. WIDER IMPLICATIONS OF THE FINDINGS: This is the largest trial that is adequately powered to assess the impact of ES on women undergoing their first cycle of IVF. ES was safe, but did not significantly improve pregnancy outcomes when performed in the mid-luteal phase prior to the first IVF or ICSI cycle. We recommend that ES is not undertaken in this population. STUDY FUNDING/COMPETING INTEREST(S): Funded by the National Institute of Health Research. Stephen Walters is an National Institute for Health Research (NIHR) Senior Investigator (2018 to present) and was a member of the following during the project: National Institute for Health Research (NIHR) Health Technology Assessment (HTA) Clinical Trials and Evaluation Committee (2011-2017), NIHR HTA Commissioning Strategy Group (2012 to 2017); NIHR Programme Grants for Applied Research Committee (2020 to present); NIHR Pre doctoral Fellowship Committee (2019 to present). Dr. Martins da Silva reports grants from AstraZeneca, during the conduct of the study; and is Associate editor of Human Reproduction and Editorial Board member of Reproduction and Fertility. Dr. Bhide reports grants from Bart's Charity and grants and non-financial support from Pharmasure Pharmaceuticals outside the submitted work. TRIAL REGISTRATION NUMBER: ISRCTN number: ISRCTN23800982. TRIAL REGISTRATION DATE: 31 May 2016. DATE OF FIRST PATIENT'S ENROLMENT: 04 July 2016.

Erratum: Anti-Müllerian hormone concentrations in women with chronic kidney disease.

[This corrects the article DOI: 10.1093/ckj/sfz164.][This corrects the article DOI: 10.1093/ckj/sfz164.].

Anti-Müllerian hormone concentrations in women with chronic kidney disease.

BACKGROUND: Serum anti-Müllerian hormone (AMH) is a biomarker of ovarian reserve. There are limited data to guide the clinical interpretation of AMH in women with chronic kidney disease (CKD). The purpose of this study was to examine AMH concentrations in women with CKD compared with women without CKD. METHODS: We conducted a prospective cohort study of serum AMH concentrations in 163 non-pregnant women with CKD. Serum AMH concentrations were compared with age-specific AMH centiles from 887 healthy female controls. RESULTS: Participants included 30 women with Stage 1 CKD, 37 women with Stage 2 CKD, 26 women with Stage 3a CKD, 31 women with Stage 3b CKD and 39 women with Stages 4 and 5 CKD. The median estimated glomerular filtration rate (eGFR) was 51 (interquartile range 31-80) mL/min/1.73 m2. Serum AMH concentrations were lower in all CKD stages compared with women without CKD. Women ages 20-24 years with CKD had comparable serum AMH concentrations (median 1.959 ng/mL) to women ages 35-39 years without CKD (median 1.995 ng/mL). There was no evidence that eGFR was an independent modifier of serum AMH concentrations. More than half of women with CKD (58%) were predicted to have a low response to gonadotrophin stimulation. CONCLUSIONS: Women with CKD have a lower ovarian reserve and are predicted to have a lower ovarian response to gonadotrophin stimulation compared with women without CKD of a similar age. Women with CKD who fail to conceive within 6 months of regular unprotected intercourse should be considered for fertility assessment and intervention.

Reduction of the multiple pregnancy rate in a preimplantation genetic diagnosis programme after introduction of single blastocyst transfer and cryopreservation of blastocysts biopsied on day 3.

BACKGROUND: An elective single-embryo transfer (SET) policy has not been applied to preimplantation genetic diagnosis (PGD) for inherited genetic disorders because of concerns regarding post-thaw survival of biopsied embryos. Our objective was to evaluate the survival and pregnancy potential of embryos biopsied for PGD at the cleavage stage and cryopreserved at the blastocyst stage and its contribution to the overall success of an elective SET policy in a PGD programme. METHODS: From January 2006, all couples who had two or more transferable PGD blastocysts biopsied on Day 3 of culture were offered single-blastocyst transfer (SBT) and cryopreservation of surplus blastocyst(s) using a slow-freezing technique. We compared the outcome of 32 cryo-thawed PGD cycles with that of 191 cryo-thawed conventional in vitro fertilization (IVF)/intracytoplasmic sperm injection (ICSI) cycles performed between January 2006 and July 2008. We also compared the outcome of all fresh PGD cycles performed before and after January 2006. RESULTS: The cryo-thawed blastocyst survival rate was similar between the PGD and IVF/ICSI groups (87% versus 88%, P = 0.94). There was no significant difference in the implantation and clinical pregnancy rates between the two groups (35% versus 29%, P = 0.45 and 34% versus 36%, P = 0.77, respectively). During the same period, the multiple pregnancy rate in the fresh PGD programme dropped from 36% to 10% (OR = 0.20, 95% CI 0.08-0.48, P < 0.001) with no reduction in pregnancy rates. CONCLUSIONS: The survival and implantation potential of biopsied PGD embryos cryopreserved at the blastocyst stage is comparable to that of non-biopsied IVF/ICSI cryopreserved blastocysts. Elective SBT and cryopreservation of surplus blastocysts for later use should extend to include PGD for inherited genetic disorders.

Outpatient hysteroscopy and subsequent IVF cycle outcome: a systematic review and meta-analysis.

A systematic review of studies evaluating the influence of outpatient (office) hysteroscopy on the outcome of the subsequent IVF cycle was conducted. MEDLINE, EMBASE, the Cochrane Library, National Research Register, ISI Conference Proceedings, ISRCTN Register and Meta-register were searched for randomized controlled trials (up to July 2007). All trials comparing the outcome of IVF treatment performed in patients who had outpatient hysteroscopy in the cycle preceding their IVF treatment with a control group in which hysteroscopy was not performed were included. Study selection, quality appraisal and data extraction were performed independently and in duplicate. Study authors were contacted for additional information. The main outcome measure was pregnancy rate. In total, 1691 participants were included in two randomized (n = 941) and three non-randomized controlled studies (n = 750). The quality of the studies was variable. Meta-analyses of the results of five studies showed evidence of benefit from outpatient hysteroscopy in improving the pregnancy rate in the subsequent IVF cycle (pooled relative risk = 1.75, 95% CI 1.51-2.03). The evidence from randomized trials was consistent with that from non-randomized controlled studies. Future robust randomized trials comparing outpatient hysteroscopy or mini-hysteroscopy with no intervention before IVF treatment would be a useful addition to further guide clinical practice.

Bilateral ureteric obstruction during in vitro fertilisation therapy in a patient with complex surgically managed Crohn's disease.

A 37-year-old woman receiving in vitro fertilisation (IVF) treatment presented with lethargy, fevers and anuria. Her background included complex surgically managed Crohn's disease and mild right-sided hydronephrosis (with no evidence of obstruction on MAG3 renogram). On examination, she had a distended abdomen with generalised tenderness. Blood tests revealed an acute kidney injury and confirmed sepsis. She was found to have bilateral ureteric obstruction with worsening of the right-sided hydronephrosis and new-onset left-sided hydronephrosis secondary to bilateral ovarian masses, diagnosed as mild ovarian hyperstimulation syndrome (OHSS). She was initially managed with fluid resuscitation, bilateral nephrostomies, antibiotics and supportive management of mild OHSS. She made a good recovery and was discharged after placement of antegrade stents and removal of nephrostomies. On follow-up, following resolution of ovarian hyperstimulation, she has been diagnosed with a right-sided distal ureteric stricture and is awaiting reconstruction. Her left ureteric stent has been removed.

Regulation of attention and response to therapy in dementia by butyrylcholinesterase.

OBJECTIVES: To determine the response of patients with different butyrylcholinesterase genotypes to therapy, and the influence of butyrylcholinesterase on cognition. Acetylcholine plays a key role in attention and memory and reduced cortical acetylcholine is associated with the severity of dementia. Inhibitors of the enzyme acetylcholinesterase are an effective dementia treatment, though the role of the related enzyme butyrylcholinesterase is less well understood. METHODS: We examined the response of a cohort of dementia patients enrolled in a trial of a cholinesterase inhibitor who had been genotyped at the butyrylcholinesterase locus. Additionally a prospectively assessed cohort of dementia patients was genotyped and rate of cognitive decline examined, along with baseline cognitive performance in a group of elderly non-demented individuals. We identified that the presence of reduced-activity butyrylcholinesterase variants correlates with preserved attentional performance and reduced rate of cognitive decline. During cholinesterase inhibitor therapy, patients with normal butyrylcholinesterase show improved attention, though patients carrying reduced-activity enzyme do not, possibly due to being at ceiling performance. Butyrylcholinesterase did not however affect attentional performance in non-demented individuals with mild cognitive impairment. CONCLUSIONS: These findings indicate that the butyrylcholinesterase enzyme is a major regulator of attention especially in cholinergic deficiency states through its ability to hydrolyse acetylcholine. Pharmacologic manipulation of this enzyme may be a viable strategy in dementia treatment and, with butyrylcholinesterase genotyping, may provide pharmacogenomic treatment of dementia.

A clinical dilemma: the potential use of egg freezing to preserve fertility in a young patient at risk of developing premature ovarian failure.

Following diagnosis of premature ovarian failure (POF), few women become pregnant spontaneously and the only fertility treatment that can be offered is oocyte donation. With advances in fertility technology, timely preservation of female fertility in the form of egg freezing is a topical area, and one of which patients are increasingly aware. Women with a family history of POF may be especially concerned about future fertility. We describe a case where a consultation was sought in the POF clinic for this issue.