Limitations of imaging screening tests in the detection of incomplete uterine septum or arcuate uterine anomaly.

OBJECTIVES: To determine the detection rates of hysterosalpingogram (HSG), transvaginal 2D ultrasound (TV 2D US), transvaginal 3D ultrasound (TV 3D US) in diagnosing of incomplete uterine septum (IUS) and significant arcuate uterine anomaly (AUA). METHODS: This retrospective cohort study included patients with infertility or recurrent pregnancy loss (516) that were found to have IUS (317) or significant AUA (199) on diagnostic hysteroscopy (DHS). We compared the detection rate of the various radiological tests in all patients with documented IUS or AUA on DHS. RESULTS: The diagnosis of IUS and AUA was made in 49.7% on HSG, 54.2% on TV 2D US and 69.5% on TV 3D US. When both HSG and TV 2D US or HSG and TV3D US were used, the diagnosis was correct in 67.7% and 82.6% of patients, respectively. CONCLUSION: Although HSG, TV 2D US, TV 3D US are useful in the screening for IUS/AUA, none of these imaging tests alone or in combination are accurate enough to rule out the diagnosis of such congenital uterine anomalies. In patients with a history of infertility or RPL and negative radiologic tests, DHS is the only reliable method to rule out IUS or significant AUA.

Perfecting hysterosalpingography: Limitations to the use of disposable balloon catheter and its solution.

OBJECTIVE: To revive the use of the Kahn Uterine Trigger Cannula to overcome limitations associated with technical difficulties during hysterosalpingography (HSG) using the disposable balloon HSG catheter. METHOD: A case series was conducted of 17 patients who encountered technically difficult or incomplete HSG study while using a disposable HSG balloon catheter, also leading to false-positive findings. Nine patients underwent a repeat HSG using a Kahn Uterine Trigger Cannula (Group 1). Eight patients underwent diagnostic laparoscopy and tubal perfusion testing using a Kahn Uterine Trigger Cannula (Group 2). The findings for each group in comparison to their initial HSG results using the disposable balloon HSG catheter are described. RESULTS: All patients were noted to have patent fallopian tubes using a Kahn Uterine Trigger Cannula on repeat HSG or tubal perfusion testing during laparoscopy. CONCLUSION: Providers who perform HSG studies should be familiar with the value of a Kahn Uterine Trigger Cannula when the traditional use of disposable HSG balloon catheter fails due to technical difficulty or incomplete study. The use of the Kahn Uterine Trigger Cannula in such situations can prevent inaccurate assessment and unnecessary interventions.

A Modified Technique of Temporary Suspension of the Ovary to the Anterior Abdominal Wall.

STUDY OBJECTIVE: To demonstrate a modified technique of temporary suspension of the ovary to the fascia of the anterior abdominal wall after operative laparoscopy for advanced stage-endometriosis to reduce postoperative adhesion formation. DESIGN: Video illustrating this modified technique of ovarian suspension (Canadian Task Force classification III). SETTING: A previous study described a technique of temporary suspension of the ovary to the abdominal wall using nylon suture [1]. Here we demonstrate a modification of this technique involving underwent temporary suspension of the right ovary, using dissolvable 3-0 plain catgut suture, after operative laparoscopy for advanced-stage endometriosis (American Society for Reproductive Medicine stage III classification). INTERVENTIONS: This patient underwent right ovariolysis for stage III endometriosis. A CO2 laser was used to evaporate spots of endometriosis on the surface of the ovary, ovarian fossa, and the wall of a small endometrioma. A 3-0 plain catgut suture was placed in the right ovarian ligament, and the needle was cut and removed from the peritoneal cavity. The ends of the sutures were brought out of the peritoneal cavity through a 3-mm skin incision using an Endo Close device (Medtronic, Minneapolis, Minnesota). The suture was tied over the fascia while allowing CO2 gas out of the peritoneal cavity, to ensure that the suture remained under tension and the ovary was well suspended without touching the abdominal wall. The suture was used to elevate the ovary away from the ovarian fossa, to avoid recurrence of adhesions between it and the ovary. Postoperatively the patient did well and was discharged home on oral pain medication on the same day of surgery. No postoperative complications related to the suspension procedure were reported. The patient had an uneventful recovery. CONCLUSION: This modified approach of temporary ovarian suspension to the fascia of the anterior abdominal wall appears to be simple, safe, and easy to learn.

Safety and efficacy of two techniques of temporary ovarian suspension to the anterior abdominal wall after operative laparoscopy.

BACKGROUND: This retrospective study compares the safety and efficacy of temporary ovarian suspension (TOS) to the anterior abdominal wall using absorbable versus non-absorbable suture after operative laparoscopy to elevate the ovaries away from the ovarian fossa to reduce postoperative adhesion development. METHODS: Patients (n=152) underwent TOS to the anterior abdominal wall at the conclusion of surgery between 1998 and 2017. One hundred forty-two patients underwent operative laparoscopy for advanced stages of endometriosis (93.4%) and 10 patients for other indications (6.6%). In 78 patients the ovaries were suspended to the fascia using absorbable 3-0 plain catgut sutures (Group 1). In 74 earlier patients non-absorbable 3-0 mono-lamentous nylon was used to suspend the ovaries to the anterior abdominal (Group 2). RESULTS: In both groups there was no reported incidence of any major intra-operative complications such as bleeding, or late complications such as infection, hematoma or bowel herniation through the suture loop and its sequalae (bowel obstruction or strangulation). In all patients in both groups the ovaries were present in its anatomical location on transvaginal ultrasound scan, one week after surgery following absorption or removal of the TOS suture. There was no significant difference in clinical pregnancy (34.3% vs 44.2%) and delivery (31.3% vs 36.5%) rates in patients who conceived with non-IVF methods between Group 1 and Group 2 respectively. CONCLUSIONS: TOS to the anterior abdominal wall, using absorbable or non-absorbable sutures, in an attempt to reduce postoperative adhesion development between the ovary and ovarian fossa, is simple, safe, easy to learn, and has potential effectiveness.

Pediatric Foley Catheter Placement After Operative Hysteroscopy Does Not Cause Ascending Infection.

STUDY OBJECTIVE: To determine the incidence of postoperative ascending infection without antibiotics with the use of a pediatric Foley catheter (PFC) after operative hysteroscopy for intrauterine pathology. DESIGN: Retrospective case series (Canadian Task Force classification III). SETTING: University-affiliated outpatient medical center. PATIENTS: Patients who underwent operative hysteroscopy for uterine septum, arcuate uterine anomaly, or multiple submucosal myomas between 1992 and 2015. INTERVENTIONS: In all patients, a PFC was placed in the endometrial cavity at the conclusion of operative hysteroscopy and left in place for 7 days to reduce intrauterine adhesion formation. MEASUREMENTS AND MAIN RESULTS: A total of 1010 patients who underwent operative hysteroscopy for uterine septum (n = 479), arcuate uterine anomaly (n = 483), or multiple submucosal myomas (n = 48) were studied. All patients presented with infertility, recurrent pregnancy loss, or excessive uterine bleeding (in patients with submucous myomas). In all patients, a PFC was placed at the conclusion of the procedure and left in place for 7 days. An 8Fr PFC was used after hysteroscopic division of uterine septum or arcuate uterine anomaly, and a 10Fr PFC was used after hysteroscopic myomectomy. Patients with a history of pelvic inflammatory disease were excluded. Following PFC placement, patients were prescribed estrogen for 6 weeks and progestogen for the last 10 days of the estrogen course. No prophylactic antibiotic therapy was provided. All patients were discharged to home on the same day. Postoperative pain was well controlled with oral pain medication in 98.5% of the patients. There were no reported postoperative infections, and all patients had an uneventful recovery. CONCLUSION: In 1010 consecutive operative hysteroscopies followed by temporary (7-day) PFC placement, no clinically significant uterine infection was observed.

The place for prophylactic cerclage in the infertile patient with established cervical incompetence who conceived twins after septum reduction.

INTRODUCTION: It is well known that cervical incompetence and associated preterm birth confers greater morbidity and mortality on birth outcomes, with an additional increased risk of cervical incompetence in higher order gestations. While the pathophysiology of cervical incompetence has yet to be elucidated, research has identified risk factors and assessed outcomes of numerous interventions. Cervical cerclage has been shown, in certain situations involving singleton pregnancies, to improve outcomes. Conversely, rescue cerclage increases the risk of preterm birth in twin gestations. However, these studies did not consider the unique situation of infertile patients, with known cervical incompetence, who have utilized assisted reproductive technologies to attain pregnancy. This study aims to describe the outcomes of infertile patients with known cervical incompetence, carrying twin gestation, who have undergone cervical cerclage. METHODS: This case series includes eight infertile patients who have cervical incompetence resulting in fetal loss between 20-24 weeks after in vitro fertilization embryo transfer (IVF-ET). These patients continued with IVF treatments and subsequently conceived twins. All patients underwent prophylactic cervical cerclage placement before 12 weeks. The outcomes of these pregnancies are reviewed. RESULTS: All pregnancies resulted in the delivery of viable twins. Six of the eight pregnancies (75%) were carried beyond 34 weeks. One pregnancy delivered at 31 weeks and one pregnancy delivered at 25 weeks after placental abruption. CONCLUSIONS: This data suggest that the use of prophylactic cervical cerclage may be beneficial in improving reproductive outcomes in infertile patients with known cervical incompetence that subsequently conceived twin gestations via IVF-ET treatment.

Modified natural cycle for embryo transfer using frozen-thawed blastocysts: A satisfactory option.

OBJECTIVE: To describe pregnancy outcomes of frozen-thawed blastocysts cycles using modified natural cycle frozen embryo transfers (NC-FET) and down-regulated hormonally controlled frozen embryo transfers (HC-FET) protocols. STUDY DESIGN: This retrospective cohort study included all patients undergoing either modified NC-FET or down-regulated HC-FET using frozen-thawed day 5 embryos. Cycles with donor blastocysts were excluded. Four hundred twenty eight patients underwent a total of 493 FET cycles. Patients with regular menses and evidence of ovulation underwent modified NC-FET. These patients were given hCG 10,000 IU IM on the day of LH-surge. Vaginal progesterone (P4) was started two days later and blastocyst transfer was planned seven days after detecting the LH surge. Anovulatory patients and some ovulatory patients underwent down-regulated HC-FET. These patients were placed on medroxy-progesterone acetate (10mg) for 10days to bring on menses and were also given a half-dose of GnRH-agonist (GnRH-a) on the third day of medroxy-progesterone acetate. Exogenous estradiol was initiated on the third day of menses. Once serum E2 levels reached >500pg/mL and endometrial lining reached >8mm, intramuscular (IM) P4 in oil was administered. Blastocyst FET was planned 6days after initiating P4. The primary outcomes included clinical pregnancy and delivery rates. RESULTS: There were 197 patients in the modified NC-FET protocol and 181 in the down-regulated HC-FET protocol. Mean age (years), day-3 FSH levels (mIU/mL) and percentage of patients with male factor infertility were significantly higher and mean BMI (kg/m2) was significantly lower in modified NC-FET compared to HC-FET, respectively. Analysis of the first cycle pregnancy outcomes revealed no significant differences in clinical pregnancy rate (54.3% vs. 52.5%) and delivery rate (47.2% vs. 43.6%) between modified NC-FET and HC-FET. Logistic regression analysis showed age (OR=0.939, 95% CI 0.894-0.989, p=0.011), number of blastocysts transferred (OR=1.414, 95% CI 1.046-1.909, p=0.024), and the year of FET (OR=1.127, 95% CI 1.029-1.234, p=0.010) were significant factors impacting clinical pregnancy. An age analysis within three age groups (≤35, 36-39, ≥40) was performed, but no significant difference in clinical pregnancy was observed. CONCLUSION: Our data suggests that modified NC-FET protocol has comparable pregnancy outcomes to down-regulated HC-FET when utilizing frozen-thawed day 5 embryos.

Interstitial ectopic pregnancy: conservative surgical management.

INTRODUCTION: Interstitial pregnancy is a rare and life-threatening condition. Diagnosis and appropriate management are critical in preventing morbidity and death. CASE DESCRIPTION: Four cases of interstitial pregnancy are presented. Diagnostic laparoscopy followed by laparotomy and cornuostomy with removal of products of conception was performed in 1 case. Laparoscopic cornuostomy and removal of products of conception were performed in the subsequent 3 cases with some modifications of the technique. Subsequent successful reproductive outcomes are also presented. DISCUSSION: Progressively conservative surgical measures are being used to treat interstitial pregnancy successfully, with no negative impact on subsequent pregnancies.

Short follicular phase of stimulation following corifollitropin alfa or daily recombinant FSH treatment does not compromise clinical outcome: a retrospective analysis of the Engage trial.

To evaluate whether a short follicular phase of ovarian stimulation compromises the chance of pregnancy, subjects from a double-blind, randomized trial treated with a single dose of corifollitropin alfa (n=756) or daily recombinant FSH (n=750) were categorized as early responders if three follicles ≥17 mm were reached and human chorionic gonadotrophin (HCG) was administered prior to or on stimulation day 8, and as normal responders if three follicles ≥17 mm were reached and HCG was administered after stimulation day 8. In the corifollitropin alfa and recombinant FSH groups, 23.2% and 29.1%, respectively, were early responders (P=0.01). Regardless of the treatment group, the initial ovarian response was higher in early responders, but with two extra days of stimulation, the number and size of follicles on the day of HCG in the normal responders was similar to those of the early responders. The number of oocytes was similar in both response groups following corifollitropin alfa treatment (13.6 versus 14.5) and recombinant FSH treatment (12.8, both groups). The ongoing pregnancy rates were comparable for early and normal responders regardless of the treatment group, supporting successful outcome following a stimulation period of only 1 week.

Early initiation of gonadotropin-releasing hormone antagonist in polycystic ovarian syndrome patients undergoing assisted reproduction: randomized controlled trial ISRCTN69937179.

PURPOSE: To compare the implantation rates in two groups of women with Polycystic Ovary Syndrome (PCOS) after embryo transfer based on the initiation time of GnRH antagonist. Secondary outcome measures included clinical pregnancy, delivery and miscarriage rates. METHODS: This is a prospective, randomized trial in which 140 PCOS patients underwent ICSI, with 122 having ET performed. GnRH-antagonist was started on day 1 of stimulation in 69 patients (Group 1) or day 5 in 71 patients (Group 2). RESULTS: The overall implantation rate in Group 1 (46.2 %) was clinically higher than Group 2 (35.5 %), although not statistically significant (p = 0.075). For blastocysts transfer, the implantation rate in Group 1 was 55.1 %, compared to 40.4 % in Group 2 (p = 0.051). There was a clinically, but not statistically, higher clinical pregnancy rate (68.3 % vs. 56.5 %) and delivery rate (60.0 % vs. 53.2 %) per transfer in Group 1 compared to Group 2, respectively. There was a statistically significant lower biochemical pregnancy rate in Group 1 (2.4 %) compared to Group 2 (18.6 %) [p = 0.015]. There was no difference in miscarriage rates between the two groups. CONCLUSION: Our data suggest that early initiation of GnRH antagonist on day 1 of ovarian stimulation in PCOS patients undergoing ICSI-ET may improve implantation rates, especially after blastocyst transfer.

Vaginal micronized progesterone versus intramuscular progesterone for luteal support in women undergoing in vitro fertilization-embryo transfer.

OBJECTIVE: To study the outcome of IVF-ET in women who used vaginal P (vaginal P(4)) versus those who used P in oil via IM injection (IM-P(4)) for luteal support. DESIGN: Retrospective cohort. SETTING: Tertiary referral infertility center. PATIENT(S): A cohort of 544 women. INTERVENTION(S): In 145 women, vaginal P(4) was used, while in 399 women, IM-P(4) was used for luteal support. MAIN OUTCOME MEASURE(S): The primary outcome was ongoing pregnancy rate. Secondary outcomes included other IVF-ET outcomes: rates of clinical pregnancy and pregnancy loss (chemical and miscarriage) and serum P levels during the luteal phase and early pregnancy. RESULT(S): Women who used vaginal P(4) for luteal support had ongoing pregnancy rates (odds ratio [OR], 1.0675; 95% confidence interval [CI], 0.7587-1.5020) and rates of total pregnancy loss (OR, 1.0775; 95% CI, 0.7383-1.5727) that were not statistically different from those who used IM-P(4). During the luteal phase, women who used vaginal P(4) had mean serum P levels that were not statistically different from those who used IM-P(4). However, during early pregnancy, mean P levels in pregnant women who used vaginal P(4) were statistically significantly higher. CONCLUSION(S): In women undergoing IVF-ET according to the GnRH agonist long protocol, luteal support with vaginal P(4) was associated with treatment outcomes that were no different from those associated with IM-P(4) luteal support.

Comparison of urinary and recombinant human chorionic gonadotropin during ovulation induction in intrauterine insemination cycles: a prospective randomized clinical trial.

OBJECTIVES: To compare the in vivo effectiveness of recombinant (r) hCG with urinary (u) hCG during controlled ovarian hyperstimulation and intrauterine insemination (COH-IUI) cycles. DESIGN: Prospective controlled clinical study. SETTING: Private IVF center. PATIENT(S): Two hundred eighty-four subjects undergoing COH-IUI cycles. INTERVENTIONS(S): Women were randomized into receiving r-hCG or u-hCG for final maturation and induction of ovulation. MAIN OUTCOME MEASURE(S): Clinical pregnancy rate and outcome of pregnancy. RESULT(S): Background characteristics were similar in the two groups studied except for a slight difference in the mean duration of infertility (3.0 vs. 2.3). There was no significant difference in the number of follicles > or =16 mm, mean peak E(2), or mean 1-week P levels between the two groups. The clinical pregnancy rate was 27.1% in the recombinant group compared with 28.5% in the urinary group. The outcome of pregnancy was similar in both groups. CONCLUSION(S): Recombinant hCG was found to be as effective as u-hCG in achieving pregnancy during COH-IUI cycles. This is in agreement with earlier studies on the effectiveness of r-hCG in IVF cycles.

The prevalence of fimbrial pathology in patients with early stages of endometriosis.

STUDY OBJECTIVE: The presence of fimbrial pathology in advanced endometriosis is clearly understood. However, little is known about the prevalence of fimbrial pathology in early stages of endometriosis. The purpose of this study is to determine the prevalence of fimbrial pathology in patients with infertility with early stages of endometriosis. DESIGN: Historical cohort study (Canadian Task Force classification II/III). SETTING: Tertiary referral center. PATIENTS: The study group (Group 1) consisted of 315 infertile women who were found to have stage I or stage II endometriosis, and the control group (Group 2) consisted of 152 infertile women without endometriosis (Group 2). INTERVENTION: Laparoscopic evaluation for the presence and type of fimbrial pathology. MEASUREMENTS AND MAIN RESULTS: The prevalence of fimbrial pathology was significantly higher in infertile patients with early stages of endometriosis (50.2%) compared with infertile patients with no endometriosis (17.8%, p <.0001). CONCLUSION: These preliminary data suggest the presence of fimbrial pathology in many patients with early stages of endometriosis. Such pathology may act as a mechanical factor interfering with the ovum pick-up mechanism.

Gestational sac aspiration: a novel alternative to dilation and evacuation for management of early pregnancy failure.

STUDY OBJECTIVE: To explore the effectiveness (success, safety, and complications) of a novel technique of gestational sac aspiration in the management of early pregnancy failure as an alternative to dilation and evacuation (D&E) and conservative management. DESIGN: Prospective historical cohort study comparing effectiveness of gestational sac aspiration (study group) to conservative management (control group) with follow-up until negative quantitative beta human chorionic gonadotropin testing is achieved (Canadian Task Force classification II-1). SETTING: An infertility treatment center. PATIENTS: Among 60 women with failed early pregnancies that were achieved by in vitro fertilization or intrauterine insemination, 20 underwent gestational sac aspiration, whereas 40 chose conservative management. INTERVENTIONS: Gestational sac aspiration was done by transvaginal ultrasound-guided needle aspiration under conscious sedation. Aspirated tissue was sent for karyotyping. Both study and control (conservative management) groups received close follow-up with ultrasound and serial beta human chorionic gonadotropin measurements. MEASUREMENTS AND MAIN RESULTS: There was no significant difference in age, infertility factor, or treatment between study and control groups. Mean gestational age was 8 versus 6 weeks in study and control groups, respectively (p < .05). One and 11 patients required D&E in the study and control groups, respectively (p < .05). Karyotyping was successful in all except one patient in the study group. Chromosomal abnormalities were found in 36% of products of conception. No significant complications occurred CONCLUSION: Gestational sac aspiration is a simple and safe outpatient technique that is more effective than conservative management of early pregnancy failure and less invasive than D&E. Moreover, the technique provides a high probability of obtaining a noncontaminated adequate gestation tissue sample for chromosomal study.

Infertility and ventriculoperitoneal shunt.

Two women with a ventriculoperitoneal shunt had primary infertility. At laparoscopy they both had extensive peritoneal adhesions that made evaluation of pelvic organs impossible and increased the risk of bowel injury. History of ventriculoperitoneal shunt should be considered a contraindication of laparoscopy.

Temporary ovarian suspension at laparoscopy for prevention of adhesions.

We performed an innovative technique of temporary ovarian suspension after operative laparoscopy for stage 3 and 4 endometriosis and evaluated the results in a retrospective study. Subjects were 20 women who underwent operative laparoscopy for infertility. Temporary ovarian suspension to the anterior abdominal wall was performed as the last step in the surgical procedure. It was done in an attempt to separate adhesiogenic surfaces during the initial phase of tissue healing (5-7 days). No complications occurred. After excluding patients who had additional infertility factors and/or were of advanced reproductive age, nine women tried to conceive spontaneously. Of these, five conceived (55%): three delivered, one pregnancy continues (80%), and one woman had an ectopic pregnancy (20%). Of the remaining 15 patients who failed to conceive spontaneously, 5 had a second-look laparoscopy. In four patients (80%), we found no evidence of recurrent adhesions. The remaining 20% had minimal adhesions. Temporary ovarian suspension appears to be simple and safe, and may be effective in preventing postoperative adhesions near the ovaries after operative laparoscopy for advanced endometriosis.