A clinical predictive model for live birth in women of advanced age undergoing PGT cycles.

PURPOSE: The trend of delaying childbirth has resulted in a growing number of advanced-aged women who are opting for preimplantation genetic testing (PGT) to screen for monogenic diseases or structural chromosomal rearrangements (PGT-M and PGT-SR). This increase in demand necessitates the development of a clinical predictive model for live birth outcomes in these women. Therefore, the objective of this study is to construct a comprehensive predictive model that assesses the likelihood of achieving a successful live birth in advanced-aged women undergoing PGT-M and PGT-SR treatments. METHODS: A retrospective cohort study of 37-45-year-old women undergoing preimplantation genetic testing for monogenic disease or structural chromosomal rearrangement cycles from 2010 to 2021 was conducted at a university hospital reproductive centre. The purpose was to develop a clinical predictive model for live birth in these women. The main outcome studied was the cumulative live birth rate in the first or subsequent cycles. Developing a decision tree enabled a comprehensive study of clinical parameters and expected outcomes. RESULTS: The analysis included 158 women undergoing 753 preimplantation genetic testing cycles. The cumulative live birth rate was 37.342% (59/158). Decision tree analysis revealed that women aged ≤ 40.1 or women > 40.1 with one or more top-quality transferable embryos in their first cycle had the best chance for a live baby (56% and 41%, respectively). Those older than 40.1 without top-quality embryos and seven or fewer dominant follicles had no live births. A Kaplan-Meier curve showed that for autosomal dominant diseases, there was a negligible increase in live birth rate after three cycles, compared to six cycles in autosomal recessive inheritance. CONCLUSION: In older women, the chance of delivering after repeated cycles is higher in those with at least one top-quality unaffected embryo in their first preimplantation genetic testing cycle. Additional preimplantation genetic testing cycles after three in carriers of an autosomal dominant disorder and six in those with an autosomal recessive disorder should be considered prudently.

A decision tree analysis applied to women aged 43-45: who should be referred for ovum donation?

RESEARCH QUESTION: In women at the advanced age of 43-45 years undergoing repeated IVF cycles with autologous oocytes, who has the highest chance for birth and who should be referred early to receive donor oocytes? DESIGN: A retrospective cohort study was conducted at a university hospital reproductive centre. The computerized database of 394 women aged 43-45 years undergoing 1528 non-donor IVF or intracytoplasmic sperm injection cycles between 2010 and 2019 was analysed. A decision tree was developed, enabling a comprehensive study of a set of clinical parameters and the expected outcomes. RESULTS: The cumulative clinical pregnancy rate was 15.0% (59/394) and the cumulative live birth rate was 8.4% (33/394). The decision tree developed to predict women who should be offered egg donation included age, poor ovarian response to stimulation, the number of top-quality embryos, dominant follicles, previous pregnancy or live birth, fertilized oocytes and body mass index. The model showed that a good ovarian response in the first cycle was the best predictor for live birth (13.3% gave birth). However, among women with poor responses, 7.1% of those who were younger than 43.5 years gave birth, and none of the women who were older than 43.5 years did. CONCLUSIONS: Women over 43.5 years old with fewer than four oocytes collected in their first IVF cycle should be offered ovum donation, since their live birth rate in subsequent cycles is negligible.

The impact of fragile X premutation carrier status on embryo morphokinetic development.

RESEARCH QUESTION: Does inheritance of the fragile X mental retardation 1 (FMR1) premutation allele affect embryo morphokinetic development? DESIGN: A retrospective cohort analysis of 529 embryos from 126 IVF cycles of 39 FMR1 premutation female carriers undergoing preimplantation genetic testing for monogenic/single gene defects (PGT-M). Morphological and morphokinetic parameters obtained using a time-lapse monitoring system were compared between embryos that inherited the FMR1 premutation allele (FMR1 group, n = 271) and those who received the normal allele (normal group, n = 258). The following embryo outcome measures were compared: morphokinetic parameters up to day 3, start of blastulation time (tSB) for day 5 embryos and the rate of top-quality embryos on days 3 and 5. RESULTS: No differences were found in morphokinetic parameters between the groups from the time of intracytoplasmic sperm injection (ICSI) until a biopsy on day 3. The blastulation rate in the two groups was comparable. However, the start of blastulation was delayed in FMR1 embryos compared to that in the genetically normal embryos (median tSB: 104.2 h [99.3-110.3] versus 101.6 h [94.5-106.7], P = 0.01). In addition, the rate of top-quality FMR1 embryos was lower than that of genetically normal embryos (25.6% versus 38.8%, P = 0.04). CONCLUSION: Embryos that inherit the FMR1 premutation allele are of lower quality at the blastocyst stage compared with those that do not inherit the mutated allele.

A decision tree model for predicting live birth in FMR1 premutation carriers undergoing preimplantation genetic testing for monogenic/single gene defects.

RESEARCH QUESTION: Can patient selection for successful preimplantation genetic testing for women who are fragile X (FMR1) premutation carriers be optimized using a decision tree analysis? This decision support tool enables a comprehensive study of a set of clinical parameters and the expected outcomes. DESIGN: A retrospective case-control study analysing the results of 264 fresh and 21 frozen preimplantation genetic testing for monogenic disorders/single gene defects (PGT-M) cycles in 64 FMR1 premutation carriers. Primary outcome was live birth per cycle start. Live birth rate was calculated for the start of the ovarian stimulation cycle. Fresh and frozen embryo transfers from the same cycle were included. RESULTS: The decision tree model showed that the number of cytosine guanine (CGG) repeats was only a moderate predictor for live birth, whereas an age younger than 36 years was the best predictor for live birth, followed by a collection of 14 or more oocytes. These findings were supported by the results of the logistic regression, which found that only age and oocyte number were significantly associated with live birth (P = 0.005 and 0.017, respectively). CONCLUSIONS: The number of CGG repeats is a relatively poor predictor for live birth in PGT-M cycles. FMR1 premutation carriers are no different from non-carriers. Age is the best identifier of live birth, followed by the number of retrieved oocytes.

Effects of letrozole or tamoxifen coadministered with a standard stimulation protocol on fertility preservation among breast cancer patients.

PURPOSE: To assess the effects of letrozole or tamoxifen coadministration on fertility preservation treatment outcomes. METHODS: Retrospective cohort study of 118 breast cancer patients undergoing fertility preservation treatment between 2008 and 2018. Patients who received letrozole (n = 36) or tamoxifen (n = 30) were compared to controls (n = 52) who underwent standard ovarian stimulation protocols. The primary outcome measures included the number of retrieved oocytes, mature oocytes (MII), fertilization, and top-quality embryo rates. The secondary outcome measures included duration of stimulation, gonadotropin dose and peak estradiol level. RESULTS: The number of oocytes retrieved, MII oocytes, fertilization rate, duration of stimulation, or gonadotropin dose were similar in the letrozole and tamoxifen groups, compared to controls. Top-quality embryo rate was lower in the tamoxifen group compared to controls (25% vs 39.4%, respectively, P = 0.034). The abnormal fertilization rate was higher in the letrozole group compared to controls (7.8% vs 3.60%, respectively, P = 0.015). A stepwise logistic regression analysis revealed that letrozole and peak estradiol were significantly associated with abnormal fertilization (OR 11.94; 95% CI 2.35-60.4, P = 0.003 for letrozole and OR 1.075; 95% CI 1.024-1.12, P = 0.004 per 100 unit change in estradiol). CONCLUSIONS: There may be a negative effect of letrozole or tamoxifen on fertilization and embryo quality, in fertility preservation cycles. Further studies are needed to confirm these findings.

Complicated Clinical Course and Poor Reproductive Outcomes of Women with Tubo-Ovarian Abscess after Fertility Treatments.

STUDY OBJECTIVE: To assess the clinical course and surgical and fertility outcomes of patients diagnosed with tubo-ovarian abscess (TOA) after fertility treatment. DESIGN: Parallel case series over 10 consecutive years (Canadian Task Force classification II-2). SETTING: Tel Aviv Sourasky Medical Center, a tertiary university-affiliated hospital. PATIENTS: Thirty-seven women who were diagnosed with TOA after fertility treatments (in vitro fertilization and intrauterine insemination) were compared with 313 women who were diagnosed with TOA not associated with fertility treatments during the same time period. INTERVENTION: Medical records search, chart review, and phone survey were used to assess clinical course and surgical and reproductive outcomes. MEASUREMENTS AND MAIN RESULTS: Women with TOA after fertility treatments had significantly higher inflammatory markers upon admission compared with the nonfertility treatment group (mean white blood cell count, 16.1 × 1000/mm3 [standard deviation [SD], ±4.3] vs 13.8 × 1000/mm3 [SD, ±6.3], p = .001, respectively; and mean C-reactive protein, 149 mg/L [SD, ±78.3] vs 78.2 mg/L [SD, ±68.5], p = .001, respectively). In addition, TOA after fertility treatments was associated with a significantly higher surgical intervention rate and a more complicated clinical course, as evidenced by a shorter time interval from admission to surgery (2.1 days vs 3.2 days, p = .01), higher rates of antibiotic failure, higher conversion rate from laparoscopy to laparotomy (14.2% vs 3.2%, p = .005), increased perioperative complications rate (25.0% vs 3.8%, p = .0001), and a longer hospitalization stay (7.2 days vs 4.8 days, p = .01). Clinical pregnancy rate per cycle in women with TOA after fertility treatments was 9%, and 1 case of live birth was recorded. CONCLUSIONS: Our data indicate that TOA after fertility treatment has a substantial effect on the clinical course and surgical outcome. Prophylactic antibiotic treatment before ovum retrieval and deferral of embryo transfer should be considered in patients at risk of infection.

Surgical Intervention in Patients with Tubo-Ovarian Abscess: Clinical Predictors and a Simple Risk Score.

STUDY OBJECTIVE: To identify the clinical characteristics associated with surgical intervention in patients with tubo-ovarian abscess (TOA). DESIGN: Retrospective cohort study (Canadian Task Force classification II-2). SETTING: Tertiary university-affiliated hospital. PATIENTS: Three hundred thirty-five patients were diagnosed with TOA based on sonographic and clinical criteria. Patients who underwent surgical intervention were compared with patients managed conservatively. INTERVENTION: Electronic medical records were used to identify patients who were diagnosed with TOA between 2007 and 2015. All patients received the same antibiotic regimen upon admission. The data extracted included microbial and pathologic reports. Clinical characteristics such as disease severity and outcomes were compared. The clinical predictors available on patient admission for surgical intervention were identified retrospectively. A logistic regression was used to determine the independent predictors of treatment failure. A risk score was created by giving a nominal weight to each predictor. The score was validated by a random bootstrap analysis. An additional validation cohort that consisted of patients diagnosed with TOA during the 2 years after the original study period was applied to the final score. MEASUREMENTS AND MAIN RESULTS: The following variables of patients who underwent surgical intervention in comparison with those successfully treated and were enrolled into the score analysis differed significantly: age at admission (odds ratio [OR], 2.1; 95% confidence interval [CI], 1.3-3.5), mean leukocytosis at admission (OR, 2.2; 95% CI, 1.3-3.6), ultrasonographic measurement of abscess diameter (OR, 3.6 95% CI, 2.0-6.3), and the presence of bilateral abscess (OR, 2.2; 95% CI, 1.3-3.9). Risk groups A, B, C, and D were positively correlated with the need for surgical intervention. Those in the highest risk group D had an antibiotic failure rate of 92%, as compared with those with the lowest risk group, in which there was a 20% risk of antibiotic failure. CONCLUSIONS: Antibiotic treatment failure for TOA can be predicted on patient admission using a novel risk assessment score.

Hydrosalpinx Sclerotherapy Before In Vitro Fertilization: Systematic Review and Meta-analysis.

The presence of a hydrosalpinx has been shown to impair the outcome of in vitro fertilization (IVF) treatment. This outcome can be improved by removing the hydrosalpinx; however, there are some concerns regarding its feasibility and safety, especially in women with previous surgeries and dense adhesions. The purpose of our meta-analysis was to evaluate the efficacy of hydrosalpinx aspiration with or without sclerotherapy on the risk of recurrence and the IVF outcome compared with salpingectomy or no intervention. We performed an electronic-based search using PubMed, Embase, Ovid MEDLINE, Google Scholar, ClinicalTrials.gov, and the Cochrane Central Register of Controlled Trials. Our main outcome measures were the recurrence rate, fertility outcome, and adverse events. Ten studies were included in our review. The overall recurrence rates of hydrosalpinx aspiration with or without sclerotherapy were 21.7% to 30.5% and 21.8% to 32.5%, respectively. There was no difference in the clinical pregnancy or miscarriage rate between hydrosalpinx sclerotherapy and salpingectomy. When compared with salpingectomy, hydrosalpinx aspiration only was associated with a significantly lower clinical pregnancy rate and higher miscarriage rate. Compared with no intervention, hydrosalpinx aspiration resulted in significantly higher clinical pregnancies rates but a similar miscarriage rate. We conclude that hydrosalpinx sclerotherapy before IVF improves the fertility outcome and can be used as an alternative to salpingectomy.

The ovarian response in fragile X patients and premutation carriers undergoing IVF-PGD: reappraisal.

STUDY QUESTION: What is the association between the ovarian response and the number of CGG repeats among full mutation and premutation carriers of fragile X (FMR1), undergoing controlled ovarian hyperstimulation (COH) for PGD? SUMMARY ANSWER: Ovarian response was normal in full mutation patients but decreased in premutation carriers, although the number of repeats was not statistically significantly associated with the number of oocytes retrieved. WHAT IS KNOWN ALREADY: There is inconsistent data in the literature regarding ovarian response in FMR1 carriers. Studies exploring the ovarian response of full mutation patients are lacking. STUDY DESIGN, SIZE, DURATION: Retrospective study, a university affiliated tertiary hospital, IVF unit, PGD referral center. PARTICIPANTS/MATERIALS, SETTING, METHODS: We examined the medical records of all women undergoing fresh IVF-PGD cycles due to fragile X. Data recorded included demography, duration of stimulation, amount of gonadotropins administered, number of dominant follicles, maximal E2 levels and number of oocytes retrieved. Data were analyzed using univariate and multivariate mixed models. P-values <0.05 were considered significant. Data were collected from the medical records of 21 patients with a full mutation on the FMR1 gene and 51 premutation carriers. Overall 309 fresh cycles were analyzed. MAIN RESULTS AND THE ROLE OF CHANCE: Premutation carriers displayed reduced ovarian response, as demonstrated by fewer oocytes retrieved. In contrast, full mutation patients had a normal response. Comparison of premutation carriers and full mutation patients showed: mean oocytes retrieved per cycle (8.4 ± 1.1 versus 14.1 ± 1.7, P = 0.005), lower levels of estradiol (E2; 1756 ± 177, versus 2928 ± 263, P = 0.0004), respectively. There was no significant difference between premutation carriers and full mutation patients in regard to fertilization rate, cleavage rate or biopsy rate. No correlation was found between the number of repeats in the premutation carriers and the number of oocytes retrieved or E2 levels. Age and the type of protocol were the only factors found to be in correlation with the number of the oocyte retrieved (P = 0.037, and P = 0.003, respectively) among the premutation carriers. Similarly, no association was found between the number of repeats and the fertilization rate, cleavage rate or biopsy rate among premutation carriers. LIMITATIONS, REASONS FOR CAUTION: We had a relatively low number of premutation carriers with >100 repeats, which made it challenging to draw a firm conclusions from this group. WIDER IMPLICATIONS OF THE FINDINGS: Physicians must address the increased risk for reduced ovarian response and  primary ovarian insufficiency (POI) among carriers and consider surveillance of ovarian reserve markers. The last, might expedite family plans completion or fertility preservation. STUDY FUNDING/COMPETING INTEREST(S): None.

The effect of endometrial injury on implantation and clinical pregnancy rates.

AIM: To assess the effect of endometrial scratching (ES) on in vitro fertilization-embryo transfer outcome (IVF-ET) Materials and methods: Retrospective matched case control study including all fresh IVF cycles performed between January 2006 and December 2012 at an academic IVF center. ES with an endometrial biopsy catheter was performed in the cycle preceding the index IVF cycle. Patients (n = 238) were pair matched with controls according to age, number of previous failed IVF cycles and number of embryos transferred. RESULTS: Demographic and cycle characteristics were comparable in all of the following: age, number of previous cycles, number of collected oocyte, number of embryos transferred and quality of transferred embryos. Implantation, clinical and ongoing pregnancy rates were comparable in both groups (28%, 34% and 18.4% vs 30%, 40.3% and 29%, in ES group and controls, respectively). Logistic regression analysis found no significant association between ES and pregnancy rate. CONCLUSIONS: Mechanical endometrial stimulation did not improve implantation and pregnancy rates. Furthermore, no factors that may predict which patients could benefit from ES were identified. Further prospective studies are warranted to evaluate possible benefits in different subsets of patients such as patients with recurrent implantation failures.

Adnexal Torsion in Postmenopausal Women: Clinical Presentation and Risk of Ovarian Malignancy.

STUDY OBJECTIVE: To investigate the clinical presentation, operative outcome, and incidence of malignancy in postmenopausal women who were diagnosed with adnexal torsion. DESIGN: Retrospective cohort study (Canadian Task Force classification II-2). SETTING: Tertiary university-affiliated hospital. PATIENTS: Postmenopausal women diagnosed with adnexal torsion between 1995 and 2014 (study group) were reviewed and compared with 220 premenopausal patients diagnosed with adnexal torsion during the same time period. INTERVENTION: Demographic data, clinical signs and symptoms, and intra- and postoperative characteristics were compared between the 2 groups. MEASUREMENTS AND MAIN RESULTS: During the study period 44 postmenopausal women were diagnosed with adnexal torsion. Continuous dull pain was the most common presenting symptom in the postmenopausal group (57%), whereas acute-onset sharp pain was the predominant symptom in the premenopausal group (86%). The time interval from admission to surgery was significantly longer in the postmenopausal group (24 vs 6 hours, p < .001). Laparoscopic surgery was performed in 84.5% of the cases in the premenopausal group, whereas it was carried out in only 50% of cases in the postmenopausal group (p < .001). Four women in the postmenopausal group were diagnosed with malignancy, whereas only 1 case of malignancy was found in the premenopausal group (9% vs .4%, respectively; p = .003). CONCLUSIONS: Adnexal torsion in postmenopausal women is an uncommon event with a unique presentation. Because ovarian malignancy is not an uncommon finding in this group of patients, preparation for more extensive surgery should be contemplated.

Methotrexate success rates in progressing ectopic pregnancies: a reappraisal.

OBJECTIVE: The purpose of this study was to determine the success rates of methotrexate in progressing ectopic pregnancies and to correlate them with beta-human chorionic gonadotropin (ß-hCG) levels. STUDY DESIGN: This retrospective cohort study that was carried out in a tertiary university-affiliated medical center included women who had been diagnosed with ectopic pregnancies between January 2001 and June 2013. Daily ß-hCG follow-up examinations were performed to determine the progression of the ectopic pregnancy. Women with hemodynamically stable progressing ectopic pregnancies received methotrexate (50 mg/m(2) of body surface). We measured the success and failure rates for methotrexate treatment in correlation to ß-hCG level. RESULTS: One thousand eighty-three women were candidates for "watchful waiting" (ß-hCG follow up). Spontaneous resolution and decline of ß-hCG levels occurred in 674 patients (39.5%); 409 women (24.0%) had stable or increasing ß-hCG levels and were treated with methotrexate. In 356 women (87.0%), the treatment was successful; 53 women (13.0%) required laparoscopic salpingectomy. Compared with prompt administration of methotrexate, our protocol resulted in lower overall success rates for all levels of ß-hCG in women with progressing ectopic pregnancies: 75% in women with ß-hCG levels of 2500-3500 mIU/mL, and 65% in women with ß-hCG levels >4500 mIU/mL. A mathematic model was found describing the failure rates for methotrexate in correlation with ß-hCG levels. CONCLUSION: The success rates for methotrexate treatment in progressing ectopic pregnancies after daily follow-up evaluation of ß-hCG levels are lower than previously reported. This reflects redundant administration of methotrexate in cases in which the ectopic pregnancy eventually will resolve spontaneously.

Embryo quality in controlled ovarian stimulation for in vitro fertilization in young poor responders.

This retrospective matched case control study was conducted to evaluate the effects of poor ovarian response in a group of young women (20-30 years) on embryos quality in controlled ovarian hyperstimulation (COH) for in vitro fertilization. Thirty-nine young patients with poor ovarian response (≤5 oocytes on retrieval) were enrolled and compared to age- and date-matched controls. Maximal Estradiol levels, number of oocytes aspirated, number of M2 oocytes and number of fertilized oocytes were significantly lower in the study group compared to controls. Implantation rate and rate of good quality embryos transferred of the study group and control were comparable (15.3 versus 16.3% and 62 versus 67.2%, respectively). Additionally, clinical pregnancy rate per transfer and delivery rate per transfer were also comparable (26.6 versus 35.8% and 23.3 versus 30.7%, respectively). The rate of cycles with no transfer, however, was 23.07% in the study group compared to zero cycles with no transfer in the control group. We conclude that young poor responders may still have reasonable proportion of good quality embryos when compared to controls. This results in comparable implantation rate and clinical pregnancy rate. Cycle transfer cancelation, however, represents a true barrier for achieving pregnancy.

Total fertilization failure in intra-cytoplasmic sperm injection cycles--classification and management.

In this retrospective cohort study we intended to propose a classification and preliminary management strategy for couples exhibiting total fertilization failure (TFF) in intra-cytoplasmic sperm injection (ICSI) cycles. Sixteen couples with a total of 27 cycles exhibiting TFF, age <40 and/or more than four M2 oocytes aspirated were enrolled. While TFF occurred in 4.3% of all 3723 ICSI cycles, in women younger than 40 with at least 5 M2 oocytes the TFF rate was 0.7%. Indications for ICSI were severe male factor and unexplained infertility. Of the 16 couples with TFF, 4 demonstrated a single episode of TFF, with either subsequent or former normal fertilizations, thus implying possible sporadic faulty laboratory conditions. Ten couples demonstrated repeated total or very low fertilization rates, hinting at a gamete defect not overcome by ICSI. Two couples experienced TFF in the first and only cycle performed at our unit. We conclude that initial and repeated TFF hints at severe gamete defects for which only donor gametes may prove successful while sporadic TFF events could simply imply a technical modifiable condition.

The value of diagnostic hysteroscopy before operative hysteroscopy for suspected abnormal intrauterine findings.

STUDY OBJECTIVE: To evaluate the accuracy of diagnostic office hysteroscopy in the detection of abnormal uterine findings in symptomatic and asymptomatic patients and compare it with the accuracy of operative hysteroscopy. DESIGN: A retrospective analysis of all women after operative hysteroscopy between 2010 and 2012 in our institution (Canadian Task Force classification II-2). SETTING: The department of gynecology in a tertiary referral medical center. PATIENTS: One hundred thirty-two patients with a mean age of 48 years after diagnostic office hysteroscopy and subsequent operative hysteroscopy. INTERVENTIONS: Operative hysteroscopy. MEASUREMENTS AND MAIN RESULTS: We collected demographic and clinical data from patients' charts. The indications as well as findings of the previous diagnostic modality (transvaginal ultrasound [TVUS] and diagnostic hysteroscopy) were gathered and compared with the final tissue diagnosis obtained via operative hysteroscopy. Positive predictive values in diagnostic hysteroscopy were calculated for common pathological intrauterine findings. Forty-eight patients (37%) were menopausal, and 84 (63%) were premenopausal. The indications for hysteroscopy were abnormal uterine bleeding in 46% of patients and suspected uterine finding in 44%. A TVUS preceded the diagnostic hysteroscopy in 105 women (80%). Older female age, menopausal status, and abnormal intrauterine findings larger than 15 mm were associated with significantly greater true-positive rates on diagnostic hysteroscopy (i.e., the suspected findings on diagnostic hysteroscopy were verified by final pathology). Uterine bleeding during the interval between procedures was marginally significant and associated with greater false-positive results. Bleeding as opposed to routine evaluation of uterine cavity, interval between procedures, location of intrauterine finding, and hormone replacement therapy were not associated with greater true-positive values. CONCLUSION: Although diagnostic hysteroscopy is superior to TVUS in the assessment of polyps, it contributes little to TVUS when myomas and endometrial hyperplasia are suspected. Therefore, it should not be used routinely as an interface between TVUS and operative hysteroscopy when such findings such are suspected. Furthermore, in premenopausal patients with abnormal uterine bleeding between diagnostic and operative procedures and when small (<15 mm) polyps are suspected, it might be worthwhile to repeat a diagnostic procedure before operative hysteroscopy.

Risk factors, symptoms, and treatment of ovarian torsion in children: the twelve-year experience of one center.

OBJECTIVE: To assess risk factors, clinical findings and mode of diagnosis and treatment in premenarchal children with surgically verified ovarian torsion (OT). STUDY DESIGN: A retrospective case review (Canadian Task Force Classification II-2). SETTING: Teaching and research hospital, a tertiary center. PATIENTS: Premenarchal children with surgically verified OT. INTERVENTIONS: Patients underwent either laparoscopy or laparotomy. RESULTS: Twenty-two cases of OT in 20 premenarchal girls (median age 12 years) were identified. Three cases involved recurrent torsion after detorsion without cystectomy. The main presenting symptoms were sudden pain and vomiting. Six patients underwent Doppler examinations, and all demonstrated an abnormal flow. Seventeen interventions were by laparoscopy. Conservative management, mainly detorsion with additional cyst drainage or cystectomy, was performed in 19 cases (86.4%). Oophoropexy was performed in 3 cases (13.6%). Pathologic examination demonstrated 5 simple cysts and 1 dermoid cyst. CONCLUSIONS: Ovarian torsion in premenarchal girls usually presents with intermittent abdominal pain and abdominal tenderness. Other signs and symptoms are nonspecific. When performed, Doppler imaging may assist in diagnosing ovarian torsion in children. Detorsion followed by cystectomy may prevent recurrence.

Outcomes of mid-trimester emergency cerclage in twin pregnancies.

INTRODUCTION: Placement of emergency cerclage at mid-trimester is controversial. At present, clinical trials comparing outcomes of mid-trimester cerclage to bed rest in twin pregnancies are lacking. Our aim was to examine the efficacy, safety and outcomes of mid-trimester cerclage in patients carrying twin gestations. MATERIAL AND METHODS: We retrospectively studied the outcomes of 14 patients carrying twin gestations with significant cervical dynamics who underwent cerclage. Outcomes of patients with cervical effacement only and patients with bulging membranes through the external os were examined. The interval between cerclage and delivery and the complication rates were calculated. RESULTS: The average time interval between cerclage placement and delivery was 71.1 days overall. Patients with cervical shortening or effacement only (n = 10) gave birth an average of 80.2 days after the procedure, while 4 patients with bulging membranes gave birth an average of 48.5 days after cerclage placement. The overall procedure failure rate, defined as delivery before 28 completed weeks, was 14.2%. DISCUSSION: Patients carrying twin gestations with advanced cervical changes might benefit from therapeutic cerclage. Further studies are required to demonstrate whether there is a difference compared to bed rest alone.

Morbidity with total laparoscopic and laparoscopically assisted vaginal hysterectomy.

We evaluated the operative and postoperative morbidity among 103 women who underwent total laparoscopic hysterectomy and 107 others who underwent laparoscopically assisted vaginal hysterectomy. Blood loss was significantly greater in the assisted vaginal hysterectomy group (178.0 ± 12.1 ml) than in the total hysterectomy group (130.2 ± 10.7 ml) (p < 0.001). Despite higher uterine weight in the total hysterectomy group, the operative time of both techniques was similar. The complications of both hysterectomies were also comparable. The results from our study suggest that the complication rates of laparoscopically assisted vaginal hysterectomy and total hysterectomy are similar. However, laparoscopically assisted vaginal hysterectomy is associated with increased blood loss.

Saline instillation sonohysterography test after normal baseline transvaginal sonography results in infertility patients. Is it justified?

PURPOSE: To investigate whether there is additional value for saline instillation sonohysterography (SIS) as a routine screening tool when baseline transvaginal sonography (TVS) is normal. METHODS: Two-hundred ninety four infertility patients underwent baseline TVS and were categorised according to the results. TVS findings were negative in study group (n = 124) and positive (any abnormalities) in control group (n = 170). All the patients were further investigated by SIS. Hysteroscopy was performed whenever SIS results were suspicious. Our main outcome measure was accuracy of SIS in detecting intracavitary lesions using pathology reports as gold standard. RESULTS: In the study group, out of 124 SIS tests, 13 (10.4%) showed positive findings and were further investigated by hysteroscopy. Three out of the 13 (23.0%) had subsequent positive hysteroscopy findings, however, no (0.0%) abnormality was found on pathologic examination. In the control group, out of 170 SIS tests, 62 (36.4%) showed positive findings, and were further investigated by hysteroscopy. Forty-two cases out of the 62 (67.7%) had subsequent positive hysteroscopic findings. Pathological examination was positive in 35 out of the 42 (83.3%) positive hysteroscopies. CONCLUSION: Routine SIS for patients with normal TVS did not contribute additional findings. However, in patients with any suspicious findings on TVS (including extracavitary lesions), SIS was beneficial.