Caesarean scar pregnancy in the UK: a national cohort study.

OBJECTIVE: To estimate the incidence of caesarean scar pregnancy (CSP) and to describe the management outcomes associated with this condition. DESIGN: A national cohort study using the UK Early Pregnancy Surveillance Service (UKEPSS). SETTING: 86 participating Early Pregnancy Units. POPULATION: All women diagnosed in the participating units with CSP between November 2013 and January 2015. METHODS: Cohort study of women identified through the UKEPSS monthly mailing system. MAIN OUTCOME MEASURES: Incidence, clinical outcomes and complications. RESULTS: 102 cases of CSP were reported, with an estimated incidence of 1.5 per 10 000 (95% CI 1.1-1.9) maternities. Full outcome data were available for 92 women. Management was expectant in 21/92 (23%), medical in 15/92 (16%) and surgical in 56/92 (61%). The success rates of expectant, medical and surgical management were 43% (9/21), 46% (7/15) and 96% (54/56), respectively. The complication rates were 15/21 (71%) with expectant, 9/15 (60%) with medical and 20/56 (36%) with surgical management. Discharge from care (median number of days) was 82 (range 37-174) with expectant, 21 (range 10-31) with medical and 11 (range 4-49) with surgical management. CONCLUSIONS: Surgical management appears to be associated with a high success rate, low complication rate and short post-treatment follow up. TWEETABLE ABSTRACT: Surgery for CSP appears to be successful, with low complication rates and short post-treatment follow up.

Methods employed to overcome difficult embryo transfer during assisted reproduction treatment.

PURPOSE: Multiple steps, at both scientific and clinical level, are involved in assisted reproduction technology (ART). Optimization of each of these steps contributes to maximize the success of ART. Embryo transfer is one of the vital steps in ART. An easy embryo transfer increases the success of ART. Adequate training is required to undertake embryo transfer, but anatomical difficulties in completing this procedure alter the success of treatment. Difficult embryo transfer is challenging for clinicians but has an overwhelming negative impact on patients. Difficult embryo transfer may cause cervical or endometrial trauma with uterine contractions which can lead to unsuccessful implantation and poor outcome after ART. METHODS: Literature review of published material looking at all interventions that were employed to overcome difficult embryo transfers during ART. RESULTS: We identified 5 methods (17 studies) were employed to overcome difficult embryo transfer which are: Hysteroscopic methods in 4 studies (2 case reports, 2 case series). Malecot catheters after hysteroscopic evaluation were used in 2 studies (1 case report, 1 case series). Dilators including hygroscopic dilators were used in 2 studies (1 case report, 1 case series) and mechanical dilators were used in 3 studies (2 case series, 1 RCT-patients 367). Intrafollopian transfer was reported in 1 case report. Transmyometrial embryo transfers were reported in 5 studies (2 case reports, 2 case series, 1 RCT). CONCLUSION: There were only two randomized controlled studies (RCTs) identified in the review. All other were either case series or case reports. We found that there was no uniform classification or grading of difficulty of embryo transfer in the literature. A grading system has been suggested in this review. We recommend that there should be a consensus guideline formulated for interventions to overcome difficult embryo transfer. A large multicenter randomized controlled study is required to compare different methods for women with difficult embryo transfer.

Assisted hatching on assisted conception (IVF & ICSI).

BACKGROUND: Failure of implantation and conception may result from an inability of the blastocyst to escape from its outer coat, know as the zona pellucida. In vitro culture conditions and/or advancing maternal age may alter the architecture of the zona pellucida and result in hatching difficulties. Artificial disruption of this coat is known as assisted hatching (AH) has been proposed as a method of improving the success of assisted conception. OBJECTIVES: To determine whether assisted hatching (AH) of embryos facilitates live births and clinical pregnancy and whether it impacts on negative outcomes (such as multiple pregnancy and miscarriage). SEARCH STRATEGY: We searched the Cochrane Menstrual Disorders and Subfertility Group trials register (1 June 2005), the Cochrane Controlled Trials Register (Cochrane Library Issue 2, 2005), MEDLINE (1996 to June 2003), EMBASE (1980 to June 2005) and reference lists of articles. Authors were contacted for missing and/or unpublished data. SELECTION CRITERIA: Trials were identified and independently screened by two reviewers. Randomised controlled trials of AH (mechanical, chemical or laser disruption of the zona pellucida prior to embryo replacement) versus no AH that reported live birth, clinical pregnancy or implantation rates were included. DATA COLLECTION AND ANALYSIS: Qualitative assessments and data extraction were performed independently by two reviewers. Outcomes were extracted as rates and combined using random effects meta-analysis, sensitivity analysis, sub grouping and meta-regression where appropriate. MAIN RESULTS: Twenty-three randomised controlled trials consisting of 2668 women reported on 849 pregnancy outcomes. There was no significant difference in the odds of live births in the AH compared with control groups (6 RCTs; OR 1.19 95% CI 0.81 to 1.73; 163 births from 516 women). Women undergoing assisted hatching were significantly more likely to achieve clinical pregnancy (23 RCTs, OR 1.33, 95% CI 1.12 to 1.57). Miscarriage rates per woman were similar in both groups (12 RCTs OR 1.23 (95% CI 0.73 to 2.05). Multiple pregnancy rates per woman was increased in women who were randomised to AH compared with control women (9 RCTs OR 1.83 (95% CI 1.19 to 2.83). The improvement in clinical pregnancy rate means for a clinic with a success rate of 25% could anticipate improving the CPR to between 28 and 39%, all things being equal. The trials provided insufficient data to investigate the impact of assisted hatching on several important outcomes, including monozygotic twinning, embryo damage, congenital and chromosomal abnormalities, and in vitro blastocyst development. AUTHORS' CONCLUSIONS: Despite significantly improved odds of clinical pregnancy, there is insufficient evidence to determine any effect of AH on live birth rates. The increased multiple pregnancy rate is of concern although it likely that with a policy of single embryo transfer this may be lowered. Currently, there is insufficient evidence to recommend assisted hatching.

Assisted hatching on assisted conception (IVF & ICSI).

BACKGROUND: Failure of implantation and conception may result from an inability of the blastocyst to escape from its outer coat, know as the zona pellucida. In vitro culture conditions and/or advancing maternal age may alter the architecture of the zona pellucida and result in hatching difficulties. Artificial disruption of this coat is known as assisted hatching (AH) has been proposed as a method of improving the success of assisted conception. OBJECTIVES: To determine whether assisted hatching (AH) of embryos facilitates live births and clinical pregnancy and whether it impacts on negative outcomes (such as multiple pregnancy and miscarriage). SEARCH STRATEGY: We searched the Cochrane Menstrual Disorders and Subfertility Group trials register (1 June 2005), the Cochrane Controlled Trials Register (Cochrane Library Issue 2, 2005), MEDLINE (1996 to June 2003), EMBASE (1980 to June 2005) and reference lists of articles. Authors were contacted for missing and/or unpublished data. SELECTION CRITERIA: Trials were identified and independently screened by two reviewers. Randomised controlled trials of AH (mechanical, chemical or laser disruption of the zona pellucida prior to embryo replacement) versus no AH that reported live birth, clinical pregnancy or implantation rates were included. DATA COLLECTION AND ANALYSIS: Qualitative assessments and data extraction were performed independently by two reviewers. Outcomes were extracted as rates and combined using random effects meta-analysis, sensitivity analysis, sub grouping and meta-regression where appropriate. MAIN RESULTS: Twenty-three randomised controlled trials consisting of 2668 women reported on 849 pregnancy outcomes. There was no significant difference in the odds of live births in the AH compared with control groups (6 RCTs; OR 1.19 95% CI 0.81 to 1.73; 163 births from 516 women). Women undergoing assisted hatching were significantly more likely to achieve clinical pregnancy (23 RCTs, OR 1.33, 95% CI 1.12 to 1.57). Miscarriage rates per woman were similar in both groups (12 RCTs OR 1.23 (95% CI 0.73 to 2.05). Multiple pregnancy rates per woman was increased in women who were randomised to AH compared with control women (9 RCTs OR 1.83 (95% CI 1.19 to 2.83). The improvement in clinical pregnancy rate means for a clinic with a success rate of 25% could anticipate improving the CPR to between 28 and 39%, all things being equal. The trials provided insufficient data to investigate the impact of assisted hatching on several important outcomes, including monozygotic twinning, embryo damage, congenital and chromosomal abnormalities, and in vitro blastocyst development. AUTHORS' CONCLUSIONS: Despite significantly improved odds of clinical pregnancy, there is insufficient evidence to determine any effect of AH on live birth rates. The increased multiple pregnancy rate is of concern although it likely that with a policy of single embryo transfer this may be lowered. Currently, there is insufficient evidence to recommend assisted hatching.

Munchausen's syndrome in obstetrics and gynecology: a review.

Nineteen review articles and case reports were identified and reviewed through August 1996 in Index Medicus, MEDLINE (English and foreign language), conference abstracts, and bibliographies from major articles, textbooks and reviews, to review Munchausen's syndrome in obstetrics and gynecology. In these 19 articles, 30 reported cases of the syndrome were identified in obstetric and gynecological patients. This survey found that the presentation varied, diagnosis was difficult, treatment was unclear, and the economic burden was enormous. Increasingly, this syndrome is becoming an important clinical entity in the specialty, and requires a high index of suspicion to improve detection and optimize treatment.

Effect(s) of assisted hatching on assisted conception (IVF & ICSI).

BACKGROUND: Failure of implantation and thus conception might result from inability of the blastocyst to escape from its zona pellucida. Artificial disruption of this coat has been proposed as a method of improving the success of assisted conception. OBJECTIVES: To determine whether assisted hatching of embryos facilitates live births, clinical pregnancy and implantation and whether it impacts on negative outcomes (such as miscarriage). SEARCH STRATEGY: We searched the Cochrane Menstrual Disorders and Subfertility Group trials register (26 November 2002), the Cochrane Controlled Trials Register (Cochrane Library Issue 2, 2002), MEDLINE (1996 to February 2003), EMBASE (1980 to February 2003) and reference lists of articles. Authors were contacted for missing and/or unpublished data. SELECTION CRITERIA: Trials were identified and independently screened by two reviewers. Randomised controlled trials of AH (mechanical, chemical or laser disruption of the zona pellucida prior to embryo replacement) versus no AH that reported live birth, clinical pregnancy or implantation rates were included. DATA COLLECTION AND ANALYSIS: Qualitative assessments and data extraction were performed independently by two reviewers. Outcomes were extracted as rates and combined using random effects meta-analysis, sensitivity analysis, subgrouping and meta-regression where appropriate. MAIN RESULTS: Twenty-three randomised controlled trials (2572 women) were included. There was no significant difference in the odds of live births in the AH compared with control groups (6 RCTs; OR 1.21, 95% CI 0.82 to 1.78; 161 births from 523 women). Women undergoing assisted hatching were significantly more likely to achieve clinical pregnancy (722 clinical pregnancies in 2175 women, OR 1.63, 95% CI 1.27 to 2.09), however the studies were heterogeneous. Implantation data were difficult to analyse due to the practice of replacing multiple embryos in individual women. The trials provided insufficient data to investigate the impact of assisted hatching on several important outcomes, including monozygotic twinning, embryo damage, congenital and chromosomal abnormalities, and in vitro blastocyst development. REVIEWER'S CONCLUSIONS: There is insufficient evidence to determine any effect of AH on the 'take-home-baby rate' of assisted conception. There are also very few data regarding miscarriage rates and other adverse events. This prevents us from extrapolating the impact of AH on live births from our finding of improved odds of clinical pregnancy.

First trimester threatened miscarriage treatment with human chorionic gonadotrophins: a randomised controlled trial.

OBJECTIVE: To determine whether administration of exogenous human chorionic gonadotrophin (hCG) treatment improve the pregnancy outcome in first trimester threatened miscarriages. DESIGN: A prospective, double blind, randomised, placebo-controlled trial. SETTING: The Early Pregnancy Assessment Unit, Royal Bolton Hospital, Bolton, United Kingdom. POPULATION: One hundred and eighty-three women with vaginal bleeding and a viable fetus seen on ultrasound scan (USS) in the first 12 weeks of pregnancy. METHODS: The patients were randomised to receive either hCG or placebo treatment until 14 weeks of gestation. MAIN OUTCOME MEASURES: The primary objective of the trial was to determine the miscarriage rate in the hCG arm compared from the placebo arm. RESULTS: Of the 183 cases, 87 were randomised to treatment with hCG while 96 were randomised to receive a placebo. Forty-seven (25%) did not comply with the study protocol. The mean [SD] gestational age at presentation was 7 [1.33] weeks. The mean [SD] age of women in study was 27 [5] years in the placebo and 28 [5] in the hCG group. The mean body mass index (kg/m(2)) was 25 [5] in the study. The number of patients actively bleeding per vaginum at presentation was 85 (93%) in placebo group and 79 (96%) in the hCG group. The median number of hCG or placebo injections for both groups was 7. Ten women (11%) in the placebo group proceeded to have a complete miscarriage, as did 10 women (12%) in the hCG group, relative risk (RR) [95% confidence interval (CI)] of 1.1 (0.63-1.6). CONCLUSION: Our study showed no evidence of a difference in the outcome of threatened miscarriages when treated with hCG in the first trimester, this may be because our study sample size was small and follow up was suboptimal. A large, randomised, multicentre trial is still needed to establish the usefulness of hCG treatment in cases of threatened miscarriage.

Achieving pregnancy against the odds: successful implantation of frozen-thawed embryos generated by ICSI using spermatozoa banked prior to chemo/radiotherapy for Hodgkin's disease and acute leukaemia.

Two cases are reported of successful pregnancies following long-term semen banking prior to chemotherapy and radiotherapy for malignancy. With the first case, the patient banked semen at the age of 20 years prior to chemotherapy for Hodgkin's disease; 11 years later the thawed semen was used for IVF with intracytoplasmic sperm injection (ICSI), resulting in twins being born following the transfer of frozen-thawed embryos. In the second case, the patient banked semen at the age of 17 years prior to chemotherapy and radiotherapy for acute myeloid leukaemia; 8 years later it was used for ICSI, resulting in triplets being born following the transfer of frozen-thawed embryos. These cases support long-term semen banking for men whose future fertility may be compromised by suppression of spermatogenesis secondary to administration of chemo/radiotherapy treatment. The advent of successful ICSI combined with embryo cryopreservation has increased the chance of thawed cryopreserved semen achieving fertilization. Banking of a single ejaculate prior to commencement of chemotherapy/radiotherapy treatment may preserve potential fertility without compromising the oncology treatment.

Uterine exteriorisation at caesarean section: influence on maternal morbidity.

OBJECTIVE: To compare the influence on caesarean section morbidity of uterine exteriorisation or in situ repair. DESIGN: Randomised controlled trial. SETTING: Princess Anne Maternity Unit of the Royal Bolton Hospital, UK. POPULATION: One hundred and ninety-four women undergoing delivery by caesarean section. METHODS: Two intra-operative readings of arterial pulse rate, mean arterial blood pressure, and arterial haemoglobin oxygen saturation were obtained. Pre-operative and day-3 haemoglobin concentrations were determined. Intra- and post-operative complications, puerperal pain scores, and febrile and infectious morbidity were assessed. A postal questionnaire was used to assess morbidity six weeks after delivery. MAIN OUTCOME MEASURES: Intra-operative changes in pulse rate, mean arterial blood pressure and oxygen saturation; peri-operative changes in haemoglobin concentration; incidence of intraoperative vomiting, pain, intra- and post-operative complications, and febrile and infectious morbidity; immediate and late puerperal pain scores; satisfaction with the operation. RESULTS: No clinically significant differences between uterine exteriorisation and in situ repair were found in pulse rate, mean arterial pressure, oxygen saturation and haemoglobin changes. Likewise, the incidence of vomiting and pain was similar. Vomiting occurred in 10% of all the women, and 57% of all pain complaints occurred at the initial skin incision. There was a trend towards higher immediate and late pain scores in the exteriorisation group, reaching statistical significance on day 3. Overall, pain scores averaged 6/10 on day 1 despite patient-controlled analgesia, and three-quarters of all women reported persisting pain on day 42. Intra- and post-operative complications, febrile and infectious morbidity, and duration of hospital stay were similar in both groups. CONCLUSIONS: We have demonstrated that uterine exteriorisation and in situ repair have similar effects on peri-operative caesarean section morbidity. Intra-operative pain reflected adequacy of anaesthesia, while vomiting reflected adequacy of pre-operative preparation of patients. Exteriorising the uterus at caesarean section is a valid option.