Concurrent oxytocin with dinoprostone pessary versus dinoprostone pessary in labour induction of nulliparas with an unfavourable cervix: a randomised placebo-controlled trial.

OBJECTIVE: To compare concurrent oxytocin with dinoprostone pessary versus dinoprostone pessary in labour induction for nulliparas with an unfavourable cervix. DESIGN: A randomised double-blind study. SETTING: University Malaya Medical Centre, Malaysia. POPULATION: Nulliparas at term with intact membranes, Bishop score < or = 6 and admitted for labour induction. METHODS: All women received 3 mg dinoprostone pessary for labour induction. Those randomised to the oxytocin arm received oxytocin infusion started at 1 micro/minute and doubled every 30 minutes to a maximum 16 micro/minute. Women assigned to placebo received identical volume of saline infusion. After 6 hours, infusion was stopped and vaginal reassessment performed to guide further management. MAIN OUTCOME MEASURES: Primary outcome was vaginal delivery within 24 hours. RESULTS: Concurrent oxytocin infusion with dinoprostone pessary did not significantly increase vaginal delivery rate within 24 hours (48.6 versus 35.9%; P = 0.07, relative risk [RR] 1.4 [95% CI 1.0-1.9]). It reduced the requirement for repeat dinoprostone (37.1 versus 61.2%; P = 0.001, RR 0.61 [95% CI 0.45-0.81]) and improved maternal satisfaction with the birth process (median score of 3 versus 5 on a 10-point visual analogue scale, P = 0.007). Caesarean rates were not different (41.9 versus 44.7%, P = 0.52). CONCLUSIONS: Labour induction with concurrent oxytocin infusion and vaginal dinoprostone could be considered for nulliparas with an unfavourable cervix. Larger studies are needed.

The impact of luteal supplement on pregnancy outcome following stimulated IVF cycles.

This is a prospeve randomised study designed to clarify the impact of various luteal support regimes (HCG and progesterone) on progesterone profiles and pregnancy outcomes. This study involved subjects undergone down regulated. stimulated IVF cycles using various types of luteal support, namely: Cyclogest (n=35). Crinone gel (n=36), various doses of Utrogestan (n=55) and HCG (n=35). Various doses of Utrogestan (administered vaginally), Crinone gel (progesterone administered vaginally) and Cyclogest (progesterone administered rectally) supplementation induced similar end plasma progesterone concentrations ranging from 26 to 32 mmnl/l. These progesterone regimes produced no significant differences. Hence, the impact of exogenous proge,terone supplement was relatively trivial and did not 'stabilise' the sub-optimal luteal phase. In contrast, two small HCG injections during the early and mid-luteal phase possessed a much greater ability to 'stabilise' progesterone profiles. Despite this additional advantage, implantation and pregnancy rates with either HCG or progesterone supplements were similar. Although none of these forms of luteal support adequately 'normalised' luteal progesterone profiles, this did not appear to be detrimental to the process of implantation.

Progesterone Profiles in Pregnant, Non-Pregnant, Natural and Stimulated IVF Cycles with and Without Luteal Support.

OBJECTIVES: (1) To describe the progesterone profiles following pituitary down regulation in stimulated IVF cycles with the use of GnRH-a (2) To assess the impact of progesterone supplement and pregnancy on the subsequent luteal phase. STUDY DESIGN: A prospective observational study performed in a specialist infertility clinic based at a tertiary centre in the north of England. Subjects were divided into cohorts depending on their treatment (natural or stimulated IVF cycles), the type of luteal support (nil or Progesterone) and eventual outcome (successful pregnancy or failure to conceive). Saliva Progesterone concentrations were the only measuring outcome. RESULTS: Natural versus stimulated cycle (SIVF); As expected saliva progesterone concentrations were significantly higher in subjects undergoing SIVF than in the natural cycle from day 1 to day 6 of the cycle (P<0.001) but thereafter stimulated cycle concentrations declined prematurely to fall below those of the natural cycle group by day 7, becoming significantly lower than natural cycle concentrations by days 9 and 10 (P<0.01). With and without progesterone supplementation; Saliva progesterone concentrations in subjects undergoing NIVF and receiving progesterone supplement were 2.5-3 times greater than those concentrations seen in the unsupplementated natural cycle (P<0.001). Similarly in the SIVF-Progesterone supplemented group, saliva concentrations remained significantly higher (P<0.001) than in the unsupplemented cycle throughout luteal phase. Despite this, luteal supplementation did not prevent nor reverse the acute mid luteal (day 7) decline in progesterone seen in all stimulated cycles. CONCLUSION: Luteal phase following pituitary down regulation is grossly abnormal. The timing and degree of luteal support routinely provided following stimulated IVF is not effective in 'correcting' the progesterone profile.