Diagnostic accuracy of ultrasound and MRI in the prenatal diagnosis of placenta accreta.

OBJECTIVE: To analyze the value of ultrasound followed by magnetic resonance imaging (MRI) in doubtful cases for antenatal detection of placenta accreta. DESIGN: A prospective observational study. SETTING: Hospital in the southern region, Saudi Arabia. SAMPLE: Patients with a low-lying placenta or placenta previa. METHODS: The placentas of all included cases were scanned in a systematic fashion using both gray-scale and color Doppler (transabdominal and transvaginal). MAIN OUTCOME MEASURES: Explicit ultrasound criteria for placenta accreta were carefully applied, and any case with two or more criteria was labeled as highly suspicious. If only one criterion was detected, then the case was labeled as suspicious and MRI was applied. RESULTS: Five hundred and seventy seven women had a diagnosis of low-lying placenta or placenta previa. Of these, 42 had placenta accreta confirmed after delivery by pathological examination, and 39 of these were diagnosed prenatally. Ultrasound accurately predicted placenta accreta in 33 of 39 of women and correctly ruled out placenta accreta in 512 of 514 without placenta accreta (sensitivity 95.1% and specificity 95.5%). Twenty (20) women underwent MRI because of suspicion of placenta accreta by ultrasonography. MRI accurately predicted placenta accreta in six of 20 cases and correctly ruled out placenta accreta in 10 of 20 cases (sensitivity 85.7% and specificity 76.9%). CONCLUSION: Placenta accreta can be successfully detected prenatally using ultrasound. MRI can provide additional information in doubtful cases.

Effect of follicular diameter at the time of ovulation triggering on pregnancy outcomes during intrauterine insemination.

OBJECTIVE: To compare pregnancy outcomes when triggering ovulation at different follicle sizes during intrauterine insemination (IUI) cycles. METHODS: A prospective observational study was undertaken at two collaborative fertility centers in Saudi Arabia between January 2014 and May 2016. Women of any age were enrolled if they met inclusion criteria: primary, secondary, or unexplained infertility (≥1 year); day-2 follicle-stimulating hormone less than 12 IU/mL; normal prolactin, thyroid function, and uterine cavity; at least one patent tube; and a male partner with normal semen count and motility. IUI cycles were subdivided by size of dominant follicle (17 to <18 mm, 18 to <19 mm, 19 to <20 mm, and ≥20 mm), and pregnancy outcomes compared. RESULTS: Data from 516 IUI cycles were analyzed. Frequencies of clinical pregnancy, ongoing pregnancy, and live birth for a follicle size of 19-20 mm were 30.2% (39/129), 24.0% (31/129), and 24.0% (31/129), respectively; these rates were significantly higher than those in other groups (all P<0.05). Only endometrial thickness was found to also contribute to outcome: probability of pregnancy increased as thickness rose (odds ratio 1.148, 95% confidence interval 1.065-1.237; P<0.001). CONCLUSION: The optimal follicular diameter associated with increased pregnancy rates in gonadotropin-stimulated IUI cycles was between 19 and 20 mm.

A randomized trial of local endometrial injury during ovulation induction cycles.

OBJECTIVE: To investigate the effect of endometrial injury on pregnancy outcomes among infertile women taking clomifene citrate. METHODS: A prospective randomized trial was undertaken at an Egyptian hospital between January 26, 2015, and July 17, 2016. Eligible women (≥1 year primary/secondary/unexplained infertility, aged 20-35 years, day-2 follicle-stimulating hormone <12 IU/L, normal prolactin/thyroid function/uterine cavity, ≥1 patent tube, male partner with normal semen count and motility, 3 cycles of clomifene citrate without success) were randomly allocated (1:1) using computer-generated numbers into intervention (received endometrial injury on cycle day 15-24) or control groups (sham procedure). Women began ovulation induction on days 3-5 of the following cycle. Participants and investigators were not masked to group assignment. The primary outcomes were clinical pregnancy, spontaneous abortion, and multiple pregnancy rates. Women who completed follow-up were included in analyses. RESULTS: The intervention group included 52 women and the control group 53 women. The clinical pregnancy rate was significantly higher in the intervention group (37% [n=19]) than in the control group (13% [n=7]; P=0.006). No differences between the intervention and control groups were noted for spontaneous abortion rate (11% [2/19] vs 29% [2/7]; P=0.287) or multiple pregnancy rate (11% [2/19] vs 14% [1/7]; P=0.790). No adverse effects were reported. CONCLUSION: Endometrial injury before ovulation induction could improve chances of pregnancy and its outcomes. CLINICALTRIALS.GOV: NCT02345837.