Vaginal cuff dehiscence following transvaginal oocyte retrieval: a case report.

BACKGROUND: Vaginal cuff dehiscence (VCD) is a rare but potentially serious complication following hysterectomy with an estimated incidence of 0.14-1.4%. There is a wide range of risk factors thought to contribute to VCD, but due to its rare occurrence, much still remains to be learned about the true impact of risk factors leading to dehiscence. We present here the second known report of VCD to occur in a patient undergoing transvaginal oocyte retrieval during her fertility treatment. This case highlights what may become a more common clinical scenario as more premenopausal women are diagnosed with reproductive tract cancers and access assisted reproductive therapies to preserve fertility. CASE PRESENTATION: Our patient is a 35-year-old G1 P0 A1 who had undergone ovary-sparing total laparoscopic hysterectomy (TLH) following diagnosis of endometrial adenocarcinoma. She underwent two in-vitro fertilization (IVF) cycles after TLH to bank frozen blastocysts, the first vaginal oocyte retrieval (VOR) taking place 12 weeks following hysterectomy. She experienced VCD during her second VOR that occurred 17 weeks after TLH, the second case of VCD to be reported in the literature during fertility preservation treatment following hysterectomy. The patient underwent an emergent and uncomplicated repair of the defect vaginally the same day. CONCLUSIONS: Currently there are no guidelines in place for women who have undergone hysterectomy with regard to when they can begin fertility treatment in the post-operative period. Based on now two case reports, it is worth considering extension of the typical 6-week timeline of avoidance of vaginal procedures to allow for full cuff healing. Infertility providers should also be mindful of limiting transvaginal ultrasounds where possible to reduce force along the cuff.

Ovarian reserve status in young women is associated with altered gene expression in membrana granulosa cells.

Diminished ovarian reserve (DOR) is a challenging diagnosis of infertility, as there are currently no tests to predict who may become affected with this condition, or at what age. We designed the present study to compare the gene expression profile of membrana granulosa cells from young women affected with DOR with those from egg donors of similar age and to determine if distinct genetic patterns could be identified to provide insight into the etiology of DOR. Young women with DOR were identified based on FSH level in conjunction with poor follicular development during an IVF cycle (n = 13). Egg donors with normal ovarian reserve (NOR) comprised the control group (n = 13). Granulosa cells were collected following retrieval, RNA was extracted and microarray analysis was conducted to evaluate genetic differences between the groups. Confirmatory studies were undertaken with quantitative RT-PCR (qRT-PCR). Multiple significant differences in gene expression were observed between the DOR patients and egg donors. Two genes linked with ovarian function, anti-Mullerian hormone (AMH) and luteinizing hormone receptor (LHCGR), were further analyzed with qRT-PCR in all patients. The average expression of AMH was significantly higher in egg donors (adjusted P-value = 0.01), and the average expression of LHCGR was significantly higher in DOR patients (adjusted P-value = 0.005). Expression levels for four additional genes, progesterone receptor membrane component 2 (PGRMC2), prostaglandin E receptor 3 (subtype EP3) (PTGER3), steroidogenic acute regulatory protein (StAR), and StAR-related lipid transfer domain containing 4 (StarD4), were validated in a group consisting of five NOR and five DOR patients. We conclude that gene expression analysis has substantial potential to determine which young women may be affected with DOR. More importantly, our analysis suggests that DOR patients fall into two distinct subgroups based on gene expression profiles, indicating that different mechanisms may be involved during development of this pathology.

Does emotional support during the luteal phase decrease the stress of in vitro fertilization?

OBJECTIVE: To determine if phone calls between ET and pregnancy test, decrease stress levels as determined by the Perceived Stress Scale (PSS). DESIGN: Randomized controlled trial. SETTING: Academic medical center. PATIENT(S): Women undergoing a first fresh cycle of assisted reproductive technology using autologous oocytes with a day 2 or 3 ET. INTERVENTION(S): Phone calls from specialized social workers or standard of care. MAIN OUTCOME MEASURE(S): Primary outcome was the change in PSS score from day of ET compared with 10 days after ET; secondary outcome was perceived patient benefit. RESULT(S): A total of 131 patients were randomized to the intervention (n = 66) or control (n = 65) group. No differences were seen in the final PSS score or the change in PSS score between groups. At the completion of the study, the intervention group was more likely to report that participating in this study was helpful (65.9% vs. 21.4%), as well as to recommend emotional support during an IVF cycle (95.4% vs. 78.6%). CONCLUSION(S): Although we observed no significant change in PSS score, first-cycle IVF patients felt that increased emotional support was needed during the waiting period between ET and pregnancy test. Additional research should be conducted to determine the best interventions for this time period.

Spontaneous reduction before 12 weeks' gestation and selective reduction similarly extend time to delivery in in vitro fertilization of trichorionic-triamniotic triplets.

OBJECTIVE: To determine the prevalence and the relative benefits conferred by selective and spontaneous reduction of one or more fetuses in trichorionic triamniotic triplet pregnancies on time to delivery. DESIGN: Retrospective cohort study. SETTING: Academic medical center. PATIENT(S): IVF patients with trichorionic triamniotic triplets between January 1998 and December 2007. INTERVENTION(S): None. MAIN OUTCOME MEASURE(S): Gestational length at time of delivery. RESULT(S): Selective reduction to twins was used in 87 of the 153 (56.9%) triplet pregnancies that did not spontaneously reduce prior to <12 weeks, and was associated with longer gestation (13.9 days) with a fourfold greater likelihood of delivery at ≥ 34 weeks' gestation (odds ratio [OR], 4.3; 95% confidence interval [CI] = 2.2-8.6), compared with pregnancies not undergoing selective reduction. Compared with ongoing triplets, spontaneous reduction at <12 weeks' gestation (28 cases) was associated with longer gestation (13.7 days) and significantly greater likelihood delivering at or after 34 weeks' gestation (OR, 3.7; 95% CI, 1.4-9.9). CONCLUSION(S): Selective reduction of one fetus was used in 56.9% of patients in this population. Early spontaneous reduction (<12 weeks) and selective reduction to twins each conferred similar benefits by extending time to delivery and increasing the likelihood of delivery at or after 34 weeks' gestation.

Impact of selective reduction of the monochorionic pair in in vitro fertilization triplet pregnancies on gestational length.

In this retrospective cohort of IVF-conceived triplets complicated by a monochorionic pair (n = 21), selective reduction of the pair to a singleton pregnancy was associated with a significantly greater likelihood of delivery at ≥34 weeks. On average, reduction of the pair was associated with 52 days longer gestation.

Risk factors associated with pregnancies containing a monochorionic pair following assisted reproductive technologies.

BACKGROUND: Although several factors have been identified to predispose to an increased incidence of monozygotic twinning in assisted reproductive technologies (ART), the relative risks associated with each have yet to be fully established. Moreover, the focus has been predominantly on monozygosity, which, in the absence of monochorionicity, does not increase perinatal risk. The present objective was to undertake an analysis of the relative risks of factors associated with monochorionic pairs resulting from ART. METHODS: Study cycles included the last cycle, of each patient undergoing ART at Brigham and Women's Hospital from January 1998 to December 2004, that resulted either in a pregnancy with a monochorionic pair (n = 41) or a pregnancy without a monochorionic pair at 12 weeks (n = 2460). We used multivariable logistic regression to estimate odds ratios (OR) and 95% confidence intervals (CI) to identify factors significantly associated with a monochorionic pair. RESULTS: Independent predictors of a monochorionic pair were assisted hatching (OR 2.23, 95% CI 1.06-4.67), ICSI (OR 2.42, 95% CI 1.22-4.83) and Day 5 embryo transfer (OR 2.48, 95% CI 1.62-3.80). The effects of ICSI and Day 5 transfer were amplified when cycles involved both interventions. CONCLUSIONS: ICSI and Day 5 embryo transfer synergistically increase the risk of monochorionic placentation. Patients undergoing these procedures should be counselled regarding these increased risks.

Early compaction on day 3 may be associated with increased implantation potential.

OBJECTIVE: To determine whether day 3 embryos exhibiting early compaction have an improved implantation potential compared to embryos without compaction. DESIGN: A retrospective cohort study. SETTING: Hospital-based academic medical center. PATIENT(S): Women <38 years of age undergoing IVF cycles between November 2001 and December 2004 having a day 3 transfer of one or two embryos with >8 cells. INTERVENTION(S): Standard IVF protocol. MAIN OUTCOME MEASURE(S): Compaction grading and implantation rates of 1,047 embryos as related to fragmentation of >or= 8-cell embryos in patients with either 0% or 100% implantation. RESULT(S): Compaction grading was strongly associated with implantation potential; however, the direction of this effect depended on the degree of fragmentation. In embryos with <10% fragmentation, implantation rates increased with the degree of compaction (grade 1, 25%; grade 2, 33%; and grade 3, 47%); in embryos with >or=10% fragmentation, the effect was reversed (grade 1, 38%; grade 2, 20%; and grade 3, 9%). CONCLUSION(S): Assessing the degree of compaction can be a valuable addition to traditional morphologic assessment in identifying optimal embryos for transfer on day 3.

The manchester-fothergill procedure as a fertility sparing alternative for pelvic organ prolapse in young women.

Although reproductive organ prolapse typically affects older, parous women, a certain population of children and adolescents, primarily adolescents with congenital spinal defects, are also at risk. The Manchester-Fothergill procedure was first performed in 1888 by Dr. Archibald Donald of Manchester, England. Although this is a well-described procedure in historic texts, the practical application is not often employed, and modern surgical texts rarely describe how to perform this surgery. It is crucial to educate younger physicians about the technical aspects of this procedure so as not to lose this operation as an alternative surgical approach. We present a case of recurrent uterine prolapse after a prior laparoscopic uterine suspension procedure. In order to address recurrent prolapse, which was accompanied by cervical elongation, this young woman elected to have additional surgical management with the Manchester-Fothergill procedure. We describe the procedure in detail, accompanied by photographs taken during the operation to fully illustrate the extent of this patient's condition and to document the surgical technique. The Manchester Fothergill procedure is an additional fertility-sparing surgical approach to treatment of pelvic organ prolapse.