The use of follicle flushing during oocyte retrieval in assisted reproductive technologies: a systematic review and meta-analysis.

STUDY QUESTION: Does follicular flushing during assisted reproductive technologies (ART) improve the number of oocytes retrieved? SUMMARY ANSWER: Follicular flushing during ART does not result in a greater number of oocytes in normal responders. WHAT IS KNOWN ALREADY: Despite limited evidence supporting the use of follicular flushing, it continues to be a common procedure in many ART clinics. Prior studies have provided conflicting results regarding the routine use of flushing during oocyte retrieval. STUDY DESIGN, SIZE, DURATION: Systematic review and meta-analysis of 518 patients who participated in 6 randomized trials over 20 years. PARTICIPANTS/MATERIALS, SETTING, METHODS: Literature searches were conducted to retrieve randomized controlled trials on follicle or ovarian flushing in ART. Databases searched included PubMed, EMBASE, Web of Science and the Cochrane Database of Clinical Trials (CENTRAL). Six trials that included 518 subjects matched the inclusion criteria. Studies included were limited to trials that were published, randomized trials comparing oocyte retrieval with a single-lumen pick-up needle versus follicle flushing after direct aspiration with a multi-channel oocyte pick-up needle in ART patients. MAIN RESULTS AND THE ROLE OF CHANCE: In each of the trials, measures of the oocyte yield (oocytes retrieved divided by follicles aspirated), total oocytes retrieved, fertilization or pregnancy were not different when comparing direct aspiration with follicle flushing. Four trials reported a higher operative time with follicle flushing. Results of the meta-analysis indicated no significant differences in the oocytes retrieved [weighted mean difference: 0.07, 95% confidence interval (CI): -0.13 to 0.29] or the oocyte yield (odds ratio: 1.06, 95% CI: 0.95-1.18) between the non-flushing and flushing groups. LIMITATIONS, REASONS FOR CAUTION: All trials featured an open label design and the majority of patients in this meta-analysis were normal responders. The applications of these results to poor responders, patients undergoing natural cycle ART or minimal stimulation ART should be made with caution. WIDER IMPLICATIONS OF THE FINDINGS: Follicle flushing does not improve ART outcomes in normal-responding patients and should not be performed. This meta-analysis should solidify this recommendation as it includes the largest trial published on the subject and is consistent with a recently published Cochrane review. STUDY FUNDING/COMPETING INTEREST(S): This work was supported, in part, by the Program in Reproductive and Adult Endocrinology, NICHD, NIH, Bethesda, MD. The authors have no competing interests to declare. TRIAL REGISTRATION NUMBER: N/A.

The use of recombinant luteinizing hormone in patients undergoing assisted reproductive techniques with advanced reproductive age: a systematic review and meta-analysis.

OBJECTIVE: To evaluate the effect of recombinant LH in assisted reproduction technology (ART) cycles in patients of advanced reproductive age. DESIGN: A systematic review and meta-analysis. SETTING: Published randomized controlled clinical trials comparing recombinant LH plus recombinant FSH versus recombinant FSH only in patients of advanced reproductive age. PATIENT(S): Patients 35 years and older undergoing assisted reproduction. INTERVENTION(S): Recombinant LH plus recombinant FSH controlled ovarian hyperstimulation (COH) versus recombinant FSH stimulation only in assisted reproduction cycles. MAIN OUTCOME MEASURE(S): Implantation and clinical pregnancy. RESULT(S): Seven trials were identified that met inclusion criteria and comprised 902 assisted reproduction technology cycles. No differences in serum E(2) on the day of hCG administration were reported in any trials. Two trials reported lower oocyte yield and one trial reported lower metaphase II oocyte yield in the recombinant LH-supplemented group. One trial reported higher fertilization rates in the recombinant LH-supplemented group. In a fixed effect model, implantation was higher in the recombinant LH-supplemented group (odds ratio 1.36, 95% confidence interval 1.05-1.78). Similarly, clinical pregnancy was increased in the recombinant LH-supplemented group (odds ratio 1.37, 95% confidence interval 1.03-1.83). CONCLUSION(S): The addition of recombinant LH to ART cycles may improve implantation and clinical pregnancy in patients of advanced reproductive age.

Acupuncture for symptom management in patients with hyper-IgE (Job's) syndrome.

OBJECTIVES: The objective of this study was to investigate the effects of acupuncture treatment for symptom management in patients with hyper-immunoglobulin E (IgE) syndrome (HIES). DESIGN: This was a retrospective case series. SETTING/LOCATION: The study was conducted at the The Clinical Research Center of the National Institutes of Health. SUBJECTS: There were 8 adult patients with HIES ages 23-56 with varying symptoms in the study. INTERVENTION: Acupuncture treatments were given from May 29, 2001 to February 17, 2009. OUTCOME MEASURES: Acupuncture treatment efficacy was measured and evaluated using a 0-10 assessment instrument pre- and post-treatment. RESULTS: The 8 patients with HIES suffered from a wide variety of symptoms related to the disease. Acupuncture treatments uniformly decreased the self-reported severity of symptoms. CONCLUSIONS: This case series demonstrates that acupuncture is a clinically useful and safe therapy for symptom management in patients with HIES.

The time is now for a new approach to primary ovarian insufficiency.

OBJECTIVE: To articulate the need for a new approach to primary ovarian insufficiency. The condition, also known as premature menopause or premature ovarian failure, is defined by the presence of menopausal-level serum gonadotropins in association with irregular menses in adolescent girls or women younger than 40 years. It can be iatrogenic as related to cancer therapy or may arise spontaneously, either alone or as part of a host of ultrarare syndromes. In a large percentage of spontaneous cases no pathogenic mechanism can be identified. DESIGN: Literature review and consensus building at a multidisciplinary scientific workshop. CONCLUSION(S): There are major gaps in knowledge regarding the etiologic mechanisms, psychosocial effects, natural history, and medical and psychosocial management of primary ovarian insufficiency. An international research consortium and disease registry formed under the guidance of an umbrella organization would provide a pathway to comprehensively increase basic and clinical knowledge about the condition. Such a consortium and patient registry also would provide clinical samples and clinical data with a goal toward defining the specific pathogenic mechanisms. An international collaborative approach that combines the structure of a patient registry with the principles of integrative care and community-based participatory research is needed to advance the field of primary ovarian insufficiency.

Acupuncture treatment for persistent hiccups in patients with cancer.

OBJECTIVE: The objective of this study was to investigate the effects of acupuncture treatment for persistent hiccups in cancer patients. DESIGN: The study design was a retrospective case series. SETTINGS/LOCATION: The study setting was the Clinical Research Center of the National Institutes of Health. SUBJECTS: The subjects were 16 adult male patients ages 27-71 with cancer, with persistent hiccups. INTERVENTIONS: There were one to three acupuncture sessions over a 1-7-day period. OUTCOME MEASURES: Treatment efficacy was measured using a hiccup assessment instrument pre- and post-treatment. The effects of acupuncture on common symptoms reported by all patients were also evaluated. RESULTS: Thirteen (13) patients experienced complete remission of persistent hiccups (p < 0.0001); 3 patients experienced decreased hiccups severity. Significant improvement was observed in discomfort (p < 0.0001), distress (p < 0.0001), and fatigue (p = 0.0078). CONCLUSIONS: This case series demonstrates that acupuncture may be a clinically useful, safe, and low-cost therapy for persistent hiccups in patients with cancer.

The psychosocial transition associated with spontaneous 46,XX primary ovarian insufficiency: illness uncertainty, stigma, goal flexibility, and purpose in life as factors in emotional health.

OBJECTIVE: To examine factors associated with emotional well-being in women with spontaneous primary ovarian insufficiency. DESIGN: Cross-sectional and case-control study. SETTING: Clinical research center, national U.S. health research facility. PATIENT(S): Women diagnosed with spontaneous 46,XX primary ovarian insufficiency (n = 100) at a mean age of 32.4 years and healthy control women of similar age (n = 60). INTERVENTION(S): Administration of validated self-reporting instruments. MAIN OUTCOME MEASURE(S): Illness uncertainty, stigma, goal disengagement/re-engagement, purpose in life, Positive and Negative Affect Schedule, Center of Epidemiologic Studies Depression Scale, State-Trait Anxiety Inventory. RESULT(S): Compared with controls, women with spontaneous primary ovarian insufficiency scored adversely on all measures of affect. Illness uncertainty and purpose in life were significant independent factors associated with anxiety (R(2) = 0.47), stigma and purpose in life were the significant independent factors associated with depression (R(2) = 0.51), and goal re-engagement and purpose in life were significantly and independently associated with positive affect (R(2) = 0.43). CONCLUSION(S): This evidence supports the need for prospective studies. Our findings are consistent with the hypothesis that clinicians could improve the emotional well-being of their patients with primary ovarian insufficiency by [1] informing them better about their condition, [2] helping them to feel less stigmatized by the disorder, and [3] assisting them in developing alternative goals with regard to family planning as well as other goals.

Inquiring Informationists: A Qualitative Exploration of Our Role.

OBJECTIVE: The goal of this study is to explore the impact of an informationist program at the National Institutes of Health (NIH) Library and to provide a basis for further program assessment. In 2001 the NIH Library began its informationist program, where librarians with training in both biomedicine and information science work alongside researchers. The goal of the program is to facilitate researchers' access to and usage of information resources. METHODS: The researchers used qualitative interviews with key informants to characterize the current informationist services of user groups. Subjects were selected to capture a variety of activities that would show patterns of how the program assists the researchers of various NIH groups. Following the interviews, the authors extracted recurring and significant themes from the subjects' comments. RESULTS: Interview subjects provided their views on the informationists' skills, impact, and team participation. Research results documented that informationists helped find resources, provided instruction, and worked as part of the research team. The NIH groups currently using this service value their informationists' knowledge of library resources and their ability to access information needs quickly. The informationists' skills in finding information save the researchers time, increase the efficiency of the research team, and complement the contributions of other team members. Training by informationists was found useful. Informationist services led to increased self-reported library use, albeit in some cases this use was entirely via the informationist. CONCLUSIONS: Informationists saved researchers time by obtaining requested information, finding esoteric or unfamiliar resources, and providing related training. These activities appeared to be facilitated by the acceptance of the informationist as part of the research team. This exploratory study provides background that should be useful in future, more extensive evaluations.