Long-Term Outcomes of the Restoration of Uterovaginal Continuity and Vaginoplasty-Utero-Colo-Neovaginoplasty-in Cervicovaginal Agenesis Using the Sigmoid Colon.

INTRODUCTION AND HYPOTHESIS: Congenital cervicovaginal agenesis in the presence of a functional endometrium is a rare Müllerian anomaly. The management ranges from hysterectomy historically to various reconstructive procedures more recently. We report our experience with utero-colo-vaginoplasty in the management of this anomaly and its long-term follow-up. METHODS: The case records of all the patients with vaginal or cervicovaginal agenesis in our hospital from January 2002 to December 2019 were reviewed retrospectively. The patients were then called for an outpatient visit and examined in detail. The anatomical variations, surgical procedures and outcomes were recorded and analysed. RESULTS: Sixteen patients aged 14 to 26 years were included during the study period. They presented with cyclical painful cryptomenorrhea. Magnetic resonance imaging (MRI) confirmed cervicovaginal or distal vaginal agenesis. All the patients underwent utero-colo-vaginoplasty. Intraoperative rectal injury led to post-operative faecal leak from the perineal wound in one patient in the post-operative period. Restoration of painless menstrual flow was possible in all 16 cases. Long-term complications were seen in 4 patients. These were stenosis of the perineal neovaginal orifice in 2 patients, obstruction at colo-uterine anastomosis in 1 patient and mucosal prolapse at the neovagina in 1 patient. Three of these patients needed secondary surgical procedures. Five were sexually active and reported consummation of penetrative intercourse. None of them had conceived. CONCLUSION: In our experience, utero-colo-vaginoplasty allows for regular painless menstruation and coitus with minimal long-term complications. The sole disadvantage is the failure to conceive.

Identification of biochemical differences between different forms of male infertility by nuclear magnetic resonance (NMR) spectroscopy.

PURPOSE: The aim of this study was to analyze the seminal plasma of patients with idiopathic/male factor infertility and healthy controls with proven fertility by NMR spectroscopy, with a hope of establishing difference in biomarker profiles, if any, between the groups. METHODS: A total of 103 subjects visiting the infertility clinic of Manipal University with normozoospermic parameters, oligozoospermia, asthenozoospermia, azoospermia and teratozoospermia were included. Semen characteristics were analysed by standard criteria. Seminal plasma was subjected to NMR spectroscopy at a 700 MHz (1)H frequency. The resultant data was analyzed by appropriate software. RESULTS: The analysis revealed significant differences between the fertile control group and other forms of male infertility. Interestingly, seminal plasma profile of the idiopathic infertility group showed distinct segregation from the control population as well as other infertile groups. The difference in biomarker profiles between the idiopathic infertility and the rest of the groups combined could originate from either the up-regulation or down regulation of a several compounds, including lysine, arginine, tyrosine, citrate, proline and fructose. CONCLUSION: Our data suggests the presence of a metabolic reason behind the origin of idiopathic infertility. (1)H NMR based metabonomic profiling based on concentration of biomarker lysine has the potential to aid in the detection and diagnosis of idiopathic infertility in an efficient manner.

A clinical alert: Oral glucose tolerance test triggering diabetic ketoacidosis in pregnancy.

Gestational diabetes mellitus is a common medical disorder of pregnancy. Diabetic ketoacidosis is a complication that may affect both maternal and perinatal wellbeing adversely. It is rare, most often involving women with type 1 or type 2 diabetes, but occasionally can be seen in gestational diabetes mellitus. Here are two cases of ketoacidosis seemingly triggered by glucose ingestion for the oral glucose tolerance test in previously normoglycemic women, posing a diagnostic and therapeutic challenge. Prevention of such complications must be considered when treating high-risk pregnant women> 40 years of age, pregnant as a result of assisted reproductive techniques. Fasting blood glucose checked before ingestion of the glucose in a selected group of women may be one way of avoiding this complication. This suggestion may put women at risk of prolonged fasting and stretching services. Glucose tolerance test is a diagnostic test, and these cases demonstrate a rare complication.

Sperm processing by swim-up and density gradient is effective in elimination of sperm with DNA damage.

PURPOSE: DNA damage may occur during sperm processing, thereby negatively influencing fertilizing ability of the sperm. The present study was designed to compare the effectiveness of gradient and swim-up, either alone or in combination, to eliminate sperm with DNA damage. METHODS: A total of 51 subjects visiting the University infertility clinic with normozoospermic parameters, oligozoospermia and teratozoospermia were included. Semen characteristics were analysed by standard criteria; Terminal deoxy nucelotidyl transferase mediated dUTP nick end labeling assay was employed for DNA damage assessment. RESULTS: The percentage of TUNEL positive sperm after sperm processing was significantly lower in normozoospermic (P < 0.05), oligozoospermic (P < 0.001) and teratozoospermic samples (P < 0.01). No difference was observed in the incidence of TUNEL positive sperm between the various techniques, suggesting that they are comparable. CONCLUSIONS: Sperm preparation has been found to result in enrichment of sperm with intact chromatin, which is likely to improve the chances of achieving a viable pregnancy.

Clinical utility of aortic isthmus Doppler in the prediction of perinatal outcomes.

BACKGROUND: Doppler studies of uteroplacental-fetal circulation have been proven useful in diagnosing fetal growth restriction, appropriately timing delivery, and improving perinatal morbidity and mortality. There has been an extensive search for the ideal means to identify fetuses between the compensatory and acidemic phase (ie, the "preacidemic phase"), and the aortic isthmus Doppler seems to show promise. OBJECTIVE: This study aimed to investigate: (1) the prevalence of abnormal aortic isthmus Dopplers in a cohort of small-for-gestational-age fetuses and their correlation with other conventional Doppler abnormalities, and (2) the predictive ability of abnormal aortic isthmus Dopplers with regard to short-term adverse neonatal outcomes. STUDY DESIGN: Fetuses diagnosed as small-for-gestational-age at ≥24 weeks' gestation were included. Management was as per the standard protocol. Aortic isthmus Doppler was performed within a week of delivery with other conventional Dopplers. The adverse perinatal outcomes studied were: requirement of neonatal resuscitation at birth, Apgar score at 5 minutes <7, cord blood pH <7, presence of bronchopulmonary dysplasia, hypoxic-ischemic encephalopathy, grade III/IV intraventricular hemorrhage, necrotizing enterocolitis, sepsis, neonatal intensive care unit stay longer than 14 days, and stillbirth or neonatal death. RESULTS: Among 121 small-for-gestational-age fetuses, 67 showed Doppler abnormalities in ≥1 vessels. The prevalence of abnormal aortic isthmus Doppler was 14.87%. Analysis was between group 1 with 103 normal aortic isthmus and group 2 with 18 abnormal aortic isthmus fetuses; 41 cases had some form of adverse perinatal outcome, the frequency of which was comparable between the groups. Abnormal aortic isthmus Doppler had a significant correlation with low cerebroplacental ratio, absent or reversed end-diastolic flow in the umbilical artery, and high pulsatility index in the ductus venosus. The positive likelihood ratio for predicting composite adverse perinatal outcome was 10.2 for absent or reversed end-diastolic flow in the umbilical artery, 9.6 for low cerebroplacental ratio, 2.28 for absent or retrograde flow in the aortic isthmus, and 2 for abnormal ductus venosus. CONCLUSION: Predelivery abnormal aortic isthmus Dopplers performed worse than other conventional Dopplers in predicting abnormal perinatal outcomes.

Evaluation of fetal echocardiography as a routine antenatal screening tool for detection of congenital heart disease.

BACKGROUND: Fetal echocardiography plays a pivotal role in identifying the congenital heart defects (CHDs) in utero. Though foetal echocardiography is mostly reserved for high risk pregnant women, its role as a routine prenatal screening tool still needs to be defined. Performing foetal echocardiography based on only these indications can lead to a significant numbers of CHD cases going undetected who will be deprived of further management leading to increased early neonatal mortalities. The aim of this study is to assess the incidence of CHDs by fetal echocardiography in an unselected population of pregnant women in comparison with pregnant women with conventional high risk factors for CHD. METHODS: This study enrolled consecutive pregnant women who attended antenatal clinic between 2008 and 2012 in a tertiary care hospital. These pregnant women were categorized into two groups: high risk group included pregnant women with traditional risk factors for CHD as laid down by Pediatric Council of the American Society of Echocardiography and low risk group. Detailed fetal 2 D echocardiography was done. RESULTS: A total of 1,280 pregnant women were included in study. The 118 women were categorized as the high risk group while remaining 1,162 were included in the low risk group. Twenty six cases of CHDs were detected based on abnormal foetal echocardiography (20.3 per 1,000). Two of the 26 cases of CHD occurred in high risk group whereas the remaining 24 occurred in low risk pregnancy. The difference in the incidence of CHDs between the two groups was not significant statistically (P=0.76). CONCLUSIONS: Our study shows no difference in incidence of CHDs between pregnancies associated with high risk factors compared to low risk pregnancies. So we advocate foetal echocardiography should be included as a part of routine antenatal screening and all pregnant women irrespective of risk factors for CHDs.

Oocyte retrieval at 140-mmHg negative aspiration pressure: A promising alternative to flushing and aspiration in assisted reproduction in women with low ovarian reserve.

BACKGROUND: Oocyte retrieval in women with low ovarian reserve is challenging and often results in poor pregnancy outcomes. AIM: The aim was to compare outcomes of oocyte retrieval using three aspiration methods in women with normal and low antral follicle counts (AFCs). STUDY DESIGN: Retrospective cohort study. SETTING: Tertiary care hospital. MATERIALS AND METHODS: Data from 172 women who underwent in-vitro fertilization/intracytoplasmic sperm injection over 3 years was studied after dividing into three groups: Group A (96) - normal AFC (≥10), direct oocyte retrieval at 120 mmHg, Group B (41) - low AFC (<10), direct retrieval at 140-mmHg, Group C (35) - low AFC, follicular flushing, and aspiration at 120-mmHg. In each group, oocyte yield, embryo quality, and pregnancy out comes were assessed. RESULTS: The oocyte and embryo yield in Groups A and B were comparable (P > 0.05) but were significantly less in Group C (P < 0.05). The pregnancy rates in Groups A and B were similar (35.4%, 39%) but were significantly less (17.1%) in Group C (P < 0.05). The live birth rate was 76% in Group A, 69% in Group B, and 50% in Group C. The miscarriage rates in the three groups were 21%, 31%, and 50%, respectively. CONCLUSION: Direct oocyte retrieval with 140-mmHg showed significantly better oocyte yield and pregnancy outcomes compared to flushing and aspiration in women with low AFC.