Vaccination in pregnancy.

The evidence indicates that pregnancy is associated with increased severity of some infectious diseases. Given the high maternal morbidity associated with influenza in pregnancy and the high neonatal morbidity and mortality associated with pertussis, the traditionally two recommended vaccines during pregnancy were those against influenza and Tdap (tetanus toxoid, reduced diphtheria toxoid and acellular pertussis) vaccines. The recent COVID-19 pandemic introduced a third vaccine that after much debate is now recommended for all pregnant women. Other vaccines can be offered based for high-risk pregnant women, and only when the benefits of receiving them outweigh the risks. The soon expected vaccines against group B streptococcus infection and respiratory syncytial virus infection will be a breakthrough in reducing perinatal mortality. In this paper, the recommendations for administration of each vaccine during pregnancy are discussed.

Postpartum Depression and Anxiety among Lebanese Women: Correlates and Scales Psychometric Properties.

Background: We found that it was important to fill a gap in the literature and check the psychometric properties of the Edinburgh Postnatal Depression Scale (EPDS) and Perinatal Anxiety Screening Scale (PASS) in the Arabic language and delineate factors associated with postnatal depression (PPD) and anxiety (PPA) among Lebanese women 4−6 weeks after delivery. Methods: This cross-sectional study carried out between July 2018 and March 2019 enrolled 295 participants who came for a postnatal checkup at four clinics. Results: The EPDS and PASS scales' items converged over two- and four-factor solutions, explaining 62.51% and 53.33% of the variance, respectively (KMO EPDS = 0.816, αCronbach EPDS = 0.826; KMO PASS = 0.878, αCronbach PASS = 0.920; Bartlett's test of sphericity p < 0.001). Higher postpartum anxiety (Beta = 0.256), higher postpartum insomnia (Beta = 0.079), having hypotension during pregnancy (Beta = 2.760), and having a second (Beta = 1.663) or a third baby or more (Beta = 2.470) compared with the first one were significantly associated with higher postpartum depression. Higher postpartum depression (Beta = 1.33) was significantly associated with higher postpartum anxiety, whereas having a baby through a planned pregnancy (Beta = −4.365) and having a baby who ate regularly (Beta = −3.639) were significantly associated with lower postpartum anxiety. Conclusion: Depression and anxiety prevalence rates in the Lebanese population were higher compared with other countries, which may be due in part to the differences in regional, social and environmental culture.

Effect of Sustained Uterine Compression versus Uterine Massage on Blood Loss after Vaginal Delivery: A Randomized Controlled Trial.

OBJECTIVE: This study aimed to compare the effectiveness of sustained uterine compression versus uterine massage in reducing blood loos after a vaginal delivery. STUDY DESIGN: This was a prospective randomized trial conducted at the American University of Beirut Medical Center (AUBMC) between October 2015 and October 2017. Inclusion criteria were women with a singleton pregnancy at ≥36 weeks of gestation, with less than three previous deliveries, who were candidates for vaginal delivery. Participants were randomized into two groups, a sustained uterine compression group (group 1) and a uterine massage group (group 2). Incidence of postpartum hemorrhage (blood loss of ≥500 mL) was the primary outcome. We assumed that the incidence of postpartum hemorrhage at our institution is similar to previously published studies. A total of 545 women were required in each arm to detect a reduction from 9.6 to 4.8% in the primary outcome (50% reduction) with a one-sided α of 0.05 and a power of 80%. Factoring in a 10% dropout rate. Secondary outcomes were admission to intensive care unit (ICU), postpartum complications, drop in hemoglobin, duration of hospital stay, maternal pain, use of uterotonics, or of surgical procedure for postpartum hemorrhage. RESULTS: A total of 550 pregnant women were recruited, 273 in group 1 and 277 in group 2. There was no statistically significant difference in baseline characteristics between the two groups. Type of anesthesia, rate of episiotomy, lacerations, and mean birth weight were also equal between the groups. Incidence of the primary outcome was not different between the two groups (group 1: 15.5%, group 2: 15.4%; p = 0.98). There was no statistically significant difference in any of the secondary outcomes between the two groups, including drop in hemoglobin (p = 0.79). CONCLUSION: There was no difference in blood loss between sustained uterine compression and uterine massage after vaginal delivery. KEY POINTS: · Transabdominal uterine compression and uterine massage are appropriate to prevent postpartum hemorrhage.. · No significant difference in blood loss or maternal discomfort observed between the two techniques.. · Both methods are equally effective and either one can be used based on provider preference..

Appropriateness of hysterectomies at the time of surgical removal of presumed benign adnexal masses.

OBJECTIVE: To evaluate factors that affect a gynecologist's decision to remove an asymptomatic uterus at the time of removal of a presumed benign adnexal mass. METHODS: Retrospective chart review of hysterectomies conducted when removing presumed benign adnexal masses at a tertiary-care academic center. Primary outcome was the final pathology of the adnexal mass to determine whether the hysterectomy was medically indicated. Secondary outcomes included the rate of postoperative complications. RESULTS: We included 185 out of 1415 charts. Most hysterectomies were performed by gynecologic oncologists (68.8%); 113 (61%) had a frozen section and of those, 76 (67.3%) were benign. Final adnexal pathology was benign in 135 (73%) cases. Using a bivariate analysis, menopausal status (P = 0.019), parity (P = 0.047), sonographic appearance of the mass (P = 0.049), and the physician's preoperative suspicion for malignancy (P < 0.001) were significantly associated with the final adnexal pathology. At the multivariate level, only the physician's suspicion for malignancy was significantly associated with the final adnexal pathology (P < 0.0001) with an odds ratio of 7.28 (95% confidence interval 3.11-17.02). CONCLUSION: Despite gynecologists' capacity to predict the malignant nature of an adnexal mass, 135 of 185 (73%) hysterectomies were performed without a clear medical indication, at the time of removal of benign adnexal masses.

Practice patterns of obstetric care in twin gestations: the value of MFM consultation.

OBJECTIVES: To evaluate the practice patterns among Lebanese obstetricians regarding obstetric care of twins and to compare selected practice patterns between general obstetricians and maternal fetal medicine physicians. METHODS: Questionnaires distributed during the annual meeting of the Lebanese Society of Obstetrics and Gynecology. RESULTS: Questionnaires were returned by 69.2% of the 296 physicians approached. Ten percent had fellowship training in Maternal Fetal Medicine (MFM). Thirty-nine percent perform cervical length measurement at 20-24 weeks of gestation and 34% recommend vaginal progesterone in case of a short cervix. When comparing selected practice patterns between MFM & general obstetricians, MFM specialists were less likely to perform cervical cerclage in the first trimester (5.9% versus 49%, p = .001), more likely to offer prenatal screening for aneuploidy (66.6% vs 46.4%, p = .03), less likely to use vaginal progesterone in the second trimester in the case of a short cervix (42.1% vs 61.8%, p = .04), less likely to perform serial ultrasound exam in the third trimester to assess fetal growth (50% vs 78%, p = .005) and more likely to deliver monoamniotic twins at 32-34 weeks of gestation (55% vs 37%, p = .05). CONCLUSION: Because of the different background of the Lebanese physicians, MFM specialists are more likely to follow obstetric care guidelines in twin gestation.

Human Mesenchymal Stem Cell Therapy and Other Novel Treatment Approaches for Premature Ovarian Insufficiency.

Premature ovarian insufficiency (POI) is a condition characterized by amenorrhea, hypergonadotropic hypogonadism, estrogen deficiency, and reduced follicle counts leading to infertility under the age of 40. POI occurs in approximately 1-3% of women in the general population. Evaluation is warranted when the diagnosis of POI is made to rule out underlying etiologies, which could be multifactorial. This review serves to cover the novel treatment approaches reported in the literature.

Human BM-MSC secretome enhances human granulosa cell proliferation and steroidogenesis and restores ovarian function in primary ovarian insufficiency mouse model.

Primary ovarian insufficiency (POI) is defined as the loss of ovarian function before 40 years of age. It clinically manifests as amenorrhea, infertility, and signs of estrogen insufficiency. POI is frequently induced by chemotherapy. Gonadotoxic chemotherapy reagents damage granulosa cells, which are essential for follicular function and development. Our recently published studies demonstrated that intraovarian transplantation of human mesenchymal stem cells (hMSCs) can restore fertility in a chemotherapy-induced POI mouse model. However, the regenerative mechanism underlying the hMSC effect in POI mice is not fully understood. Here, we report that the hMSC secretome increased the proliferation of human granulosa cells (HGrC1). We showed by FACS analysis that treatment of HGrC1 cells with hMSC-conditioned media (hMSC CM) stimulates cellular proliferation. We also demonstrated that the expression of steroidogenic enzymes involved in the production of estrogen, CYP19A1 and StAR, are significantly elevated in hMSC CM-treated HGrC1 cells. Our data suggest that hMSC CM stimulates granulosa cell proliferation and function, which may explain the therapeutic effect of hMSCs in our chemotherapy-induced POI animal model. Our findings indicate that the hMSC secretome may be a novel treatment approach for restoring granulosa cell and ovarian function in patients with POI.

Mesenchymal Stem Cells as a Bio Organ for Treatment of Female Infertility.

Female infertility is a global medical condition that can be caused by various disorders of the reproductive system, including premature ovarian failure (POF), polycystic ovary syndrome (PCOS), endometriosis, Asherman syndrome, and preeclampsia. It affects the quality of life of both patients and couples. Mesenchymal stem cells (MSCs) have received increasing attention as a potential cell-based therapy, with several advantages over other cell sources, including greater abundance, fewer ethical considerations, and high capacity for self-renewal and differentiation. Clinical researchers have examined the therapeutic use of MSCs in female infertility. In this review, we discuss recent studies on the use of MSCs in various reproductive disorders that lead to infertility. We also describe the role of microRNAs (miRNAs) and exosomal miRNAs in controlling MSC gene expression and driving MSC therapeutic outcomes. The clinical application of MSCs holds great promise for the treatment of infertility or ovarian insufficiency, and to improve reproductive health for a significant number of women worldwide.

Salt-inducible Kinases Are Critical Determinants of Female Fertility.

Follicle development is the most crucial step toward female fertility and is controlled mainly by follicle-stimulating hormone (FSH). In ovarian granulosa cells (GCs), FSH activates protein kinase A by increasing 3',5'-cyclic adenosine 5'-monophosphate (cAMP). Since cAMP signaling is impinged in part by salt-inducible kinases (SIKs), we examined the role of SIKs on the regulation of FSH actions. Here, we report that SIKs are essential for normal ovarian function and female fertility. All SIK isoforms are expressed in human and rodent GCs at different levels (SIK3>SIK2>SIK1). Pharmacological inhibition of SIK activity potentiated the stimulatory effect of FSH on markers of GC differentiation in mouse, rat, and human GCs and estradiol production in rat GCs. In humans, SIK inhibition strongly enhanced FSH actions in GCs of patients with normal or abnormal ovarian function. The knockdown of SIK2, but not SIK1 or SIK3, synergized with FSH on the induction of markers of GC differentiation. SIK inhibition boosted gonadotropin-induced GC differentiation in vivo, while the genomic knockout of SIK2 led to a significant increase in the number of ovulated oocytes. Conversely, SIK3 knockout females were infertile, FSH insensitive, and had abnormal folliculogenesis. These findings reveal novel roles for SIKs in the regulation of GC differentiation and female fertility, and contribute to our understanding of the mechanisms regulated by FSH. Furthermore, these data suggest that specific pharmacological modulation of SIK2 activity could be of benefit to treat ovulatory defects in humans and to increase the propagation of endangered species and farm mammals.

Regulation of Insulin-Like Growth Factor 2 by Oocyte-Secreted Factors in Primary Human Granulosa Cells.

CONTEXT: Human granulosa cells (hGCs) produce and respond to insulin-like growth factor 2 (IGF2) but whether the oocyte participates in IGF2 regulation in humans is unknown. OBJECTIVE: To determine the role of oocyte-secreted factors (OSFs) such as growth differentiation factor 9 (GDF9) and bone morphogenetic protein 15 (BMP15) in IGF2 production by hGCs. DESIGN: Primary human cumulus GCs in culture. SETTING: University infertility center. PATIENTS OR OTHER PARTICIPANTS: GCs of women undergoing in vitro fertilization. INTERVENTION(S): Cells treated with GDF9 and BMP15 in the presence of vehicle, follicle-stimulating hormone (FSH), dibutyryl cyclic-AMP (dbcAMP), or mothers against decapentaplegic homolog (SMAD) inhibitors. MAIN OUTCOME MEASURE(S): Quantification of mRNA, protein, promoter activity, and DNA methylation. RESULTS: FSH stimulation of IGF2 (protein and mRNA) was significantly potentiated by the GDF9 and BMP15 (G+B) combination (P < 0.0001) in a concentration-dependent manner showing a maximal effect at 5 ng/mL each. However, GDF9 or BMP15 alone or in combination (G+B) have no effect on IGF2 in the absence of FSH. FSH stimulated IGF2 promoter 3 activity, but G+B had no effect on promoter activity. G+B potentiated IGF2 stimulation by cAMP. SMAD3 inhibitors inhibited G+B enhancement of IGF2 stimulation by FSH (P < 0.05) but had no effect on FSH induction. Moreover, inhibition of insulin-like growth factor receptor partially blocked G+B potentiation of FSH actions (P < 0.009). CONCLUSIONS: For the first time, we show that the oocyte actively participates in the regulation of IGF2 expression in hGCs, an effect that is mediated by the specific combination of G+B via SMAD2/3, which in turn target mechanisms downstream of the FSH receptor.

A 2019 reproductive update from the Midwest Reproductive Symposium International.

"Mystery, Medicine, and the Magnificent Mile," the theme for the annual Midwest Reproductive Symposium International (MRSi) in Chicago, IL, captured the attention of reproductive professionals all over the world. Each year, the conference agenda encompasses emerging technologies in assisted reproduction, updates in the management of reproductive diseases, and common challenges encountered in clinical practice. The structure of the meeting, offering a mixture of lectures, panel discussions, and interactive workshops, creates a collaborative environment for physicians, geneticists, embryologists, nurses, mental health professionals, basic scientists, business administrative professionals, reproductive endocrinology and infertility fellows, and obstetrics and gynecology residents. The goal of the MRSi meeting is to provide all reproductive professionals the opportunity to exchange ideas, foster relationships, and deliver quality patient care. As the field continues to evolve, MRSi provides an exciting venue to uncover the mysteries of reproductive medicine with enthusiasm and collaboration.

Pregnancy rates after pre-implantation genetic screening for aneuploidy are only superior when trophectoderm biopsy is performed on hatching embryos.

PURPOSE: In vitro fertilization with trophectoderm embryo biopsy and pre-implantation genetic screening with comprehensive chromosomal screening (PGS-CCS) for aneuploidy is becoming increasingly more popular. Embryos are cryopreserved and implanted in a subsequent frozen thawed embryo transfer cycle (FET). No studies have investigated differences in pregnancy outcomes by timing of trophectoderm biopsy relative to stages of blastocyst development. METHODS: Retrospective study of all patients (n = 363) at a single IVF center between January 1, 2013 and December 31, 2016 undergoing single embryo transfer with PGS-CCS where embryos were cryopreserved with subsequent FET. Embryo expansion and grading was assessed both at the time of biopsy and transfer. Pregnancy rates were analyzed by embryo expansion and embryo grading. RESULTS: Implantation, clinical pregnancy, and live birth rates improved significantly with increased embryo expansion at the time of embryo biopsy (P < 0.001). Pregnancy loss decreased with increases in embryo expansion prior to biopsy (P < 0.001). Superior live birth rates with PGS-CCS were seen when embryos were hatching at the time of biopsy (p < 0.001). For fresh and frozen embryo transfers without PGS-CCS, embryo expansion did not affect pregnancy outcomes. CONCLUSIONS: PGS-CCS significantly increases implantation and live birth rates only if embryos are hatching at the time of biopsy. The embryo biopsy itself on a non-hatching embryo significantly damages the embryo in ways which are not reflected in future embryo expansion. IVF labs should wait until embryos hatch before performing trophectoderm biopsy.

Oocyte-Secreted Factors Synergize With FSH to Promote Aromatase Expression in Primary Human Cumulus Cells.

CONTEXT: The role of growth differentiation factor 9 (GDF9) and bone morphogenetic protein 15 (BMP15) on aromatase regulation is poorly understood in humans. OBJECTIVE: Determine GDF9 and BMP15 effects on FSH stimulation of estradiol production in primary human cumulus granulosa cells (GCs). We hypothesized that the combination of GDF9 and BMP15 potentiates FSH-induced aromatase expression. DESIGN: Primary human cumulus GCs in culture. SETTING: University infertility center. PATIENTS OR OTHER PARTICIPANTS: GCs of 60 women undergoing in vitro fertilization were collected. INTERVENTIONS: Cells were treated with GDF9 and/or BMP15 (GB) in the presence or absence of FSH, dibutyryl cAMP, or SMAD inhibitors. MAIN OUTCOME MEASURES: Promoter activity, mRNA, protein, and estradiol levels were quantified. RESULTS: FSH and GB treatment increased CYP19A1 promoter activity, mRNA, and protein levels as well as estradiol when compared with cells treated with FSH only. GB treatment potentiated cAMP stimulation of aromatase and IGF2 stimulation by FSH. GB effects were inhibited by SMAD3 inhibitors and IGF1 receptor inhibitors. GB, but not FSH, stimulates SMAD3 phosphorylation. CONCLUSION: The combination of GDF9 and BMP15 potently stimulates the effect of FSH and cAMP on CYP19a1 promoter activity and mRNA/protein levels. These effects translate into an increase in estradiol production. This potentiation seems to occur through activation of the SMAD2/3 and SMAD3 signaling pathway and involves, at least in part, the effect of the IGF system.

The Role of Gene Therapy in Premature Ovarian Insufficiency Management.

Premature ovarian insufficiency (POI) is a highly prevalent disorder, characterized by the development of menopause before the age of 40. Most cases are idiopathic; however, in some women the cause of this condition (e.g.; anticancer treatment, genetic disorders, and enzymatic defects) could be identified. Although hormone-replacement therapy, the principal therapeutic approach for POI, helps alleviate the related symptoms, this does not effectively solve the issue of fertility. Assisted reproductive techniques also lack efficacy in these women. Thus, an effective approach to manage patients with POI is highly warranted. Several mechanisms associated with POI have been identified, including the lack of function of the follicle-stimulating hormone (FSH) receptor, alterations in apoptosis control, mutations in Sal-like 4 genes, and thymulin or basonuclin-1 deficiency. The above mentioned may be good targets for gene therapy in order to correct defects leading to POI. The goal of this review is to summarize current experiences on POI studies that employed gene therapy, and to discuss possible future directions in this field.

Practice and attitudes towards immunization among Lebanese obstetricians and gynecologists.

We designed our study to evaluate the knowledge and immunization practices among Lebanese obstetricians and gynecologists (OBGYN) for women of different age groups. Anonymous questionnaires were used to assess the knowledge and immunization practices among OBGYN. The survey was conducted at the annual meeting of the Lebanese Society of Obstetrics and Gynecology on November 13-15, 2014. Data collected included demographics, type of practice, academic background and familiarity with vaccine guidelines. Descriptive statistical methods were used to evaluate the responses. The response rate was 54.8% (114/208). Only 62.3% (71/114) recommend vaccination(s) to pregnant women with only 25.9% of those who recommend the Tdap vaccine for pregnant women giving it during the recommended third trimester. In addition, 52.6% are unaware of the CDC/ACIP immunization schedule for women in general. However, 83.0% (93/112) of respondents are willing to integrate vaccination in their practice. Our study highlights several gaps in the knowledge of Lebanese OBGYN regarding vaccination in addition to practices that are not in full accordance with common guidelines. Measures should be taken to spread proper awareness of the proper guidelines among Lebanese practitioners.

Initial maternal serum human chorionic gonadotropin levels in pregnancies achieved after assisted reproductive technology are higher after preimplantation genetic screening and after frozen embryo transfer: a retrospective cohort.

PURPOSE: Few published articles have compared initial hCG values across all different types of ART cycles, including cycles with fresh or frozen embryo transfer. No articles have compared initial hCG values in cycles utilizing preimplantation genetic screening (PGS). The purpose of this study is to compare initial hCG values after fresh embryo transfer, frozen embryo transfer, and after PGS. METHODS: This was a single-center retrospective cohort study at an academically affiliated private IVF center. All fresh and frozen embryo transfers between January 2013 and December 31, 2015 were included. We compared mean initial serum hCG values 14 days after oocyte retrieval for fresh cycles and 9 days after frozen embryo transfer. We examined cycles of single embryo transfer (SET) and double embryo transfer (DET). RESULTS: Two hundred elven IVF (fresh embryo transfer), 128 FET (frozen embryo transfer cycles, no PGS), and 111 PGS cycles (ovarian stimulation with embryo cryopreservation, PGS, and frozen transfer in a subsequent estrogen-primed cycle) with initial positive hCG values were analyzed. In patients achieving a positive hCG after SET, initial hCG values were higher after PGS compared to FET (182.4 versus 124.0 mIU/mL, p = 0.02) and IVF (182.4 versus 87.1 mIU/mL, p < 0.001) as well as FET compared to IVF (124.0 versus 87.1 mIU/mL, p < 0.01). After DET, initial hCG values were higher after PGS (222.8 mIU/mL) compared to FET (182.1 mIU/mL, p = 0.02) and IVF (131.1 mIU/mL, p = 0.001). CONCLUSIONS: Our study suggests that initial serum hCG values are higher after using PGS and higher after the transfer of a frozen embryo compared to a fresh embryo. This suggests that initial hCG values relate to the chromosomal status of embryos. Initial hCG values may help determine intervention and monitoring later in pregnancy.

Use of Concomitant FSH with hCG at the Time of Trigger May Improve Success Rates of Couples with Poor Ovarian Response Undergoing Gonadotropin Therapy with IUI.

OBJECTIVE: To investigate if administration of an additional dose of gonadotropins concomitantly to human chorionic gonadotropin (hCG) trigger increases pregnancy rates in patients undergoing intrauterine insemination (IUI) with controlled ovarian hyperstimulation (COH). STUDY DESIGN: This is a retrospective cohort study of all gonadotropin-IUI cycles performed by a single physician in a private practice between January 2012 and September 2013. Control cycles were those in which follicle-stimulating hormone (FSH) was discontinued prior to the day of hCG trigger shot, and study cycles received continuous FSH including the day of hCG trigger shot. A total of 423 cycles from 239 patients were included; 275 (65.5%) were control cycles (137 patients), and 146 (34.7%) were study cycles (102 patients). RESULTS: Pregnancy rates were comparable in both control and study groups (15.27% vs. 15.07%, respectively, p=0.956). There was a 42% increase in multiple gestations in the study group; however, the difference was not statistically significant (p=0.155). Upon multivariate logistic regression, male factor infertility was the only variable that was associated with pregnancy outcomes. CONCLUSION: Continuous administration of FSH including the day of hCG trigger in patients undergoing COH with IUI does not seem to increase pregnancy rates. Our suggested protocol might be beneficial in patients with poor ovarian response.

Antibiotic Prophylaxis for Gynecologic Procedures prior to and during the Utilization of Assisted Reproductive Technologies: A Systematic Review.

The use of assisted reproductive technologies (ART) has increased steadily. There has been a corresponding increase in the number of ART-related procedures such as hysterosalpingography (HSG), saline infusion sonography (SIS), hysteroscopy, laparoscopy, oocyte retrieval, and embryo transfer (ET). While performing these procedures, the abdomen, upper vagina, and endocervix are breached, leading to the possibility of seeding pelvic structures with microorganisms. Antibiotic prophylaxis is therefore important to prevent or treat any procedure-related infections. After careful review of the published literature, it is evident that routine antibiotic prophylaxis is generally not recommended for the majority of ART-related procedures. For transcervical procedures such as HSG, SIS, hysteroscopy, ET, and chromotubation, patients at risk for pelvic infections should be screened and treated prior to the procedure. Patients with a history of pelvic inflammatory disease (PID) or dilated fallopian tubes are at high risk for postprocedural infections and should be given antibiotic prophylaxis during procedures such as HSG, SIS, or chromotubation. Antibiotic prophylaxis is recommended prior to oocyte retrieval in patients with a history of endometriosis, PID, ruptured appendicitis, or multiple prior pelvic surgeries.

Cyst aspiration or GnRH antagonist administration for ovarian cysts detected at the start of fresh in vitro fertilization cycles.

The primary objective of this study is to investigate the effect of transvaginal ultrasonogram (TVUS)-guided cyst aspiration or gonadotropin releasing hormone antagonist (GnRH-ant) administration for the management of solitary ovarian cysts detected at the start of in vitro fertilization (IVF) cycles on the outcomes of the same cycles. This is a single-center, retrospective, cohort study of patients who had TVUS-guided cyst aspiration or GnRH-ant treatment for ovarian cysts detected at the start of IVF during a 5-year period. Four hundred and three patients met inclusion criteria: 41 (10.2%) underwent cyst aspiration and 362 (89.2%) were treated with GnRH-ant. There was no difference in the demographics or baseline IVF cycle characteristics of the two groups. Patients treated with GnRH-ant had a longer duration of ovarian stimulation (10.8 ± 3.45 days versus 9.05 ± 4.06 days, p = 0.003) and required higher gonadotropin doses (3887.7 ± 1097.8 IU versus 3293.7 ± 990.5 IU; p = 0.01) compared with the cyst aspiration group. There was no difference in the clinical pregnancy (43.9% versus 41.4%), spontaneous miscarriage (9.76% versus 8.01%) and live birth (34.1% versus 33.4%) rates between the groups. Our findings suggest that cyst aspiration is comparable to GnRH-ant administration for the management of solitary ovarian cysts detected at the start of IVF cycles.

Maternal mortality ratio in Lebanon in 2008: a hospital-based reproductive age mortality study (RAMOS).

INTRODUCTION AND OBJECTIVES: International agencies have recently assigned Lebanon to the group H of countries with "no national data on maternal mortality," and estimated a corresponding maternal mortality ratio (MMR) of 150 per 100,000 live births. The Ministry of Public Health addressed the discrepancy perceived between the reality of the maternal mortality ratio experience in Lebanon and the international report by facilitating a hospital-based reproductive age mortality study, sponsored by the World Health Organization Representative Office in Lebanon, aiming at providing an accurate estimate of a maternal mortality ratio for 2008. The survey allowed a detailed analysis of maternal causes of deaths. METHODS: Reproductive age deaths (15-49 years) were initially identified through hospital records. A trained MD traveled to each hospital to ascertain whether recorded deaths were in fact maternal deaths or not. ICD10 codes were provided by the medical controller for each confirmed maternal deaths. RESULTS: There were 384 RA death cases, of which 13 were confirmed maternal deaths (339%) (numerator). In 2008, there were 84823 live births in Lebanon (denominator). The MMR in Lebanon in 2008 was thus officially estimated at 23/100,000 live births, with an "uncertainty range" from 153 to 30.6. Hemorrhage was the leading cause of death, with double the frequency of all other causes (pregnancy-induced hypertension, eclampsia, infection, and embolism). CONCLUSION: This specific enquiry responded to a punctual need to correct a clearly inadequate report, and it should be relayed by an on-going valid surveillance system. Results indicate that special attention has to be devoted to the management of peri-partum hemorrhage cases. KEYWORDS: Arab, postpartum hemorrhage, development, pregnancy management, verbal autopsy