Reproductive outcomes of patients with T-Shaped and septate uterus following metroplasty: an observational study.

INTRODUCTION: Uterine malformations are common and may contribute to infertility and adverse pregnancy outcomes. After an accurate diagnosis, correcting the abnormal uterine morphology is the main goal to optimize reproductive outcomes. The principal objective of this study was to assess the impact of metroplasty for T-shaped (U1a) and septate uteri (U2) on live birth rates in infertile patients. METHODS: This was a prospective observational study of infertile women with either U1a or U2 uterine anomaly. Patients with unexplained infertility and repeated (IVF/ICSI) failure were included. Hysteroscopic metroplasty was performed by a single experienced surgeon. Fertility outcomes of all cases were evaluated prospectively evaluated. The main outcome parameter was a live birth rate either achieved spontaneously or with assisted conception. RESULTS: A total of 48 patients were included in U1a group and bilateral longitudinal uterine-lateral wall incision was carried out. A total of 63 patients were included in the U2 group and septum incision was carried out, 60 out of these 63 patients with U2 uterine anomaly required further lateral wall incision during septoplasty. During the first 12 months following surgery, nearly half of the patients in both groups achieved spontaneous pregnancy; 45% in the U1a group and 39% in the U2 group delivered at term. CONCLUSIONS: Hysteroscopic metroplasty offers promising reproductive outcomes in the presence of U1a and U2 uterine anomalies for those with unexplained infertility and repeated IVF/ICSI failures. In addition, uterine septum cases should be carefully evaluated intra-operatively to detect and repair concurrent lateral uterine wall anomalies.

Testicular versus ejaculated spermatozoa in ICSI cycles of normozoospermic men with high sperm DNA fragmentation and previous ART failures.

As a part of male assessment, conventional sperm parameters including morphologic features have been dedicated as major factors influencing fertilisation and pregnancy rates in assisted reproductive technology (ART). Genomic integrity of spermatozoa has also been found to influence fertility prognosis, and hence, sperm DNA fragmentation index (DFI) has been adopted by many centres to document this entity. Despite several suggested approaches, there is lack of universal consensus on optimising fertility outcomes in males with high sperm DFI. In this context, the results from cycles using testicular spermatozoa (TESA) obtained by aspiration were compared with those of ejaculated spermatozoa (EJ) in normozoospermic subjects with high sperm DFI and previous ART failures. Clinical (41.9% versus 20%) and ongoing pregnancy rates (38.7% versus 15%) were significantly better and miscarriages were lower in TESA group when compared to EJ group. Sperm DFI should be a part of male partner's evaluation following unsuccessful ART attempts. When high DFI is detected (>30%), ICSI using testicular spermatozoa obtained by TESA seems an effective option particularly for those with repeated ART failures in terms of clinical, ongoing pregnancies and miscarriages even though conventional sperm parameters are within normal range.

Combined progesterone (IM + V) versus vaginal progesterone for luteal support in cleavage-stage embryo transfer cycles of good prognosis patients.

Many reports led to the consensus on the use of progesterone (P) for luteal-phase support. Vaginal P application is the method of choice due to its simplicity and high patient convenience but is hampered by application difficulties and personal or cultural aversions. Inappropriate vaginal P use may alter successful implantation, leading physicians to consider alternate P application routes. A worldwide survey revealed that intramuscular plus vaginal P (combined P) is the method used in nearly one-third of in vitro fertilization (IVF) cycles, particularly in Asia and North America; unfortunately, the outcomes of this approach have not been clearly elucidated. In the current analysis, we evaluated any additional benefit of short course parenteral P in addition to vaginal P capsules during a specific period in terms of implantation, pregnancy rates, miscarriages and ectopic pregnancies in cleavage stage embryo transfer (ET) cycles of good-prognosis patients. Despite significantly higher implantation rates in the combined arm, clinical and ongoing pregnancies were comparable in both groups, whereas a trend toward increased pregnancy rates was observed with combined support. The available data are too limited to draw conclusions.

Uncommon but devastating event: total fertilisation failure following intracytoplasmic sperm injection.

Fertilisation with intracytoplasmic sperm injection (ICSI) is a consequence of complex molecular interactions between spermatozoon and oocyte. Disruption of the process obviously prompts a frustrating event called total fertilisation failure (TFF). Up to 3% of ICSI cycles may result in TFF, and brief counselling for subsequent cycle management is indispensable. Within this perspective, ICSI cycles of a centre over a 10-year period were analysed to document TFF cases. Initial TFF after ICSI and subsequent ICSI cycle of the same cases were documented to clarify predictive factors of successful outcomes after initial TFF. In subsequent cycles, assisted oocyte activation (AOA) with calcium ionophore and Hypo-osmotic swelling test (HOST)/pentoxifilline for sperm selection was used. In the current analysis, successful fertilisation was achieved in 85% of the cases with previous TFF. The significant contributing factors for successful fertilisation in the latter cycle were: improved oocyte quantity and better sperm morphology. In conclusion, sporadic TFF event in the first and only cycle is usually a technically modifiable condition, but repeated TFF could indicate possible gamete defects, which might not be overcomed in the next modified ICSI cycle.

The value of placental protein 13, ß-human chorionic gonadotropin and progesterone in the prediction of miscarriages in threatened miscarriage patients.

The aim of this paper was to investigate the levels of maternal serum placental protein13 (PP13), beta human chorionic gonadotropin (ß-hCG) and progesterone in the prediction of miscarriages in threatened miscarriages. A total of 110 patients with a gestational age < 14 weeks were included in the study. A total of 42 patients were allocated as the study group (threatened miscarriage) and 68 patients were allocated as controls. A total of six miscarriages were observed in the study group. ß-hCG levels were significantly lower in the group with threatened miscarriage when compared with controls (p = 0.018). There was no statistically significant difference in regard to progesterone and PP13 levels occurred between two groups (p = 0.653 and p = 0.062, respectively). Following receiver operating characteristic (ROC) analysis, the ß-hCG parameter was found useful in differentiating miscarriages from the threatened miscarriage group (p = 0.031). PP13 and progesterone parameters in predicting miscarriages were not found as statistically significant (p = 0.084 and p = 0.914, respectively). This study suggests that ß-hCG measurements could be useful in predicting spontaneous miscarriage in women presenting with threatened miscarriage. Even though PP13 seems unfeasible to be used as a predictive marker for miscarriage, factors affecting PP13 levels should be considered along with the need for comprehensive studies including larger patient populations.

Diagnostic performance of p16 staining in atypical squamous cells 'cannot exclude high-grade squamous epithelial lesion' in predicting high-grade cervical pathology.

Atypical squamous cells 'cannot exclude high-grade squamous epithelial lesion' (ASC-H) cytology represents clear risk and has been a controversial issue in clinical practice. The objective of this study is to investigate the diagnostic performance of p16(INK4A) immunohistochemistry (IHC) among ASC-H Pap smears in predicting high-grade cervical intraepithelial lesions. Decolourisation and staining process with p16(INK4A) is applied to 27 ASC-H diagnosed conventional Pap smears, which were all managed with colposcopy-directed cervical biopsy priorly. Staining characteristics of ASC-H Pap smears were compared with histopathological data and sensitivity-specificity values of p16 triage to detect CIN2 + histopathology were determined. The sensitivity and specificity of positive p16(INK4A) immune staining to detect CIN2 + histopathology were as 87.5% and 68%, respectively. The positive predictive value of p16 triage is found as 53.8% and negative predictive value was as 92.8%. p16(INK4A) IHC seems applicable for conventional Pap smears and may provide an alternative triage option in ASC-H category.

The role of ultrasound and symptom-based triage for detection of pathological endometrial changes in patients undergoing tamoxifen therapy for breast cancer.

PURPOSE OF INVESTIGATION: To estimate the value of ultrasonographic screening and symptom-based triage for the detection of endometrial pathologies in breast cancer patients using tamoxifen. METHOD(S): A total of 292 breast cancer patients using tamoxifen were analyzed retrospectively. A total of 115 endometrial biopsies were performed on the basis of ultrasonographic examination and symptomatic status of both premenopausal and postmenopausal patients. Endometrial thickness and symptomatic status were then correlated with histopathologic data to figure out the clinical implications of ultrasonographic screening and symptom-based triage. RESULT(S): The cut-off value of endometrial thickness was 8 mm for asymptomatic postmenopausal patients and the positive predictive value of transvaginal ultrasound for endometrial pathologies was 59%. The positive predictive values of symptom-based triage alone for premenopausal and postmenopausal patients were 37.5% and 48.2%, respectively. CONCLUSION: Transvaginal ultrasound may be a useful method for the detection of pathological endometrial changes in asymptomatic postmenopausal breast cancer patients administered adjuvant tamoxifen. In premenopausal patients, symptom-based triage alone does not seem to be an effective diagnostic tool for endometrial pathologies.