Comparison of urodynamic volume measurements using room and body temperature saline: a double-blinded randomized crossover study design.

INTRODUCTION: Urodynamic studies, routinely performed in women with lower urinary tract symptoms, have a large impact on clinical decision making. Unfortunately, these studies are insensitive in reproducing idiopathic detrusor overactivity (IDO). We set out to examine whether serial cystometry with different distending fluid temperatures could better reproduce symptoms. METHODS: Eighty-six women were enrolled in a double-blinded, randomized, crossover study. Two cystometries were performed in series, starting with either body temperature fluid (BTF) or room temperature fluid (RTF) and then repeating cystometry with the other temperature fluid. Primary outcomes included first sensation, first urge, and maximum cystometric capacity. Secondary outcomes included subjective sensation of bladder discomfort and the incidence of IDO. RESULTS: In aggregate, the temperature of the fluid did not affect volumes of bladder sensation. There were no differences in self-reported bladder irritation or IDO between the different temperature fluids. There was a significant carryover effect with BTF. BTF administered first reached sensory thresholds at lower volumes than when it was administered second after RTF. Room temperature fluid cystometry showed no statistical difference in volume between first fill and second fill. Idiopathic detrusor overactivity contractions were seen in 9% of studies and were not affected by period or temperature. CONCLUSIONS: These data suggest that BTF and RTF independently do not affect bladder sensory thresholds. The periodicity in combination with varying fluid temperature is of greater impact. This study documents that changes in temperature of the distending fluid from BTF to RTF or vice versa likely do not provoke IDO contractions.

A luteal estradiol protocol for anticipated poor-responder patients may improve delivery rates.

OBJECTIVE: To compare IVF data and outcomes between a standard protocol and a luteal phase E(2) protocol. DESIGN: Retrospective cohort analysis. SETTING(S): Large academic assisted reproduction technologies center. PATIENT(S): Fifty-seven infertile patients with a history of poor response to IVF stimulation and 228 matched control patients. INTERVENTION(S): IVF with a standard protocol or a luteal phase E(2) protocol. MAIN OUTCOME MEASURE(S): Live-birth rates. RESULT(S): Patients in the luteal E(2) protocol required more days of stimulation and total gonadotropins and had higher peak E(2) levels when compared with the control group. The luteal E(2) protocol showed a greater percentage of embryos with >or=7 cells on day 3. A trend toward improved delivery rates was seen in the luteal E(2) protocol (28.1% vs. 22.4%; relative risk, 1.25, 0.78-2.03). CONCLUSION(S): A luteal E(2) protocol results in improved day 3 embryo development as demonstrated by the percent of embryos at the >or=7-cell stage. Likewise, the luteal E(2) protocol may ultimately improve pregnancy outcomes for patients with poor response to IVF stimulation.

The effect of membrane sweeping on prelabor rupture of membranes: a randomized controlled trial.

OBJECTIVE: To estimate if membrane sweeping increases the rate of prelabor rupture of membranes. METHODS: This randomized trial of term, uncomplicated pregnancies included 300 patients. Patients were randomly assigned into sweep or no-sweep groups, with patients and delivering providers blinded to group allocation. Only the examining provider in the clinic was unblinded to group allocation. Membranes were then swept or not swept at each weekly visit from 38 weeks of gestation onward, depending on the randomization. Data collected included parity, cervix examination at each visit, estimated gestational age at delivery, rupture of membranes, and maternal or fetal complications. RESULTS: A total of 162 patients were randomly assigned to the membrane sweep group and 138 to the no-sweep group. There was no difference in baseline characteristics or obstetric and neonatal outcomes between the groups. The average gestational age at delivery and induction rate were not different. The overall prelabor rupture of membranes rate was not significantly higher in the membrane sweep group (12% compared with 7%) (P=.19); however, patients with a cervix more than 1 cm dilated at time of membrane sweeping were more likely to have prelabor rupture of membranes if they were in the membrane sweep group (9.1% compared with 0%; relative risk 1.10, 95% confidence interval 1.03-1.18). CONCLUSION: No benefit in gestational age at delivery or reduction of postmaturity occurred from membrane sweeping. Although the overall prelabor rupture of membranes rates were similar, patients with membrane sweeping occurring at more than 1 cm cervical dilation may be at increased risk of prelabor rupture of membranes. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov, www.clinicaltrials.gov, NCT00294242. LEVEL OF EVIDENCE: I.

Gynecologic emergencies.

Gynecologic emergencies are relatively common and include ectopic pregnancies, adnexal torsion, tubo-ovarian abscess, hemorrhagic ovarian cysts, gynecologic hemorrhage, and vulvovaginal trauma. The purpose of this article is to provide a concise review of these emergencies, focusing on the evaluation and treatment options for the patient. In many cases, other causes of an acute abdomen are in the differential diagnosis. Understanding the tenets of diagnosis helps the surgeon narrow the etiology and guide appropriate treatment.

A luteal estradiol protocol for expected poor-responders improves embryo number and quality.

OBJECTIVE: To compare embryo and oocyte data between a standard protocol and a luteal phase estradiol protocol. DESIGN: Retrospective paired cohort analysis. SETTING: Private in vitro fertilization (IVF) center. PATIENT(S): 60 poor-responder patients undergoing 120 IVF cycles. INTERVENTION(S): Addition of luteal estradiol to the standard IVF protocol. MAIN OUTCOME MEASURE(S): Number of embryos with > or = 7 cells on day 3 of development. RESULT(S): The luteal phase estradiol protocol showed a statistically significantly greater number of embryos with > or = 7 cells, oocytes retrieved, mature oocytes, and embryos than did the standard protocol. There was no difference between the two protocols with respect to basal antral follicle count, days of stimulation, number of follicles > or = 14 mm on day of surge, or endometrial thickness on day of surge. A trend toward improved pregnancy outcomes was found with the luteal estradiol protocol. CONCLUSION(S): Giving estradiol in the luteal phase preceding IVF hyperstimulation increases the number and the quality of embryos achieved in patients deemed to have a poor response to IVF. Ultimately, this may translate into improved pregnancy outcomes in these patients.

Low-dose aspirin use does not improve in vitro fertilization outcomes in poor responders.

OBJECTIVE: To assess if aspirin improves pregnancy outcome in patients undergoing in vitro fertilization (IVF) with a diagnosis of poor response. DESIGN: Retrospective cohort analysis. SETTING: Academic private practice. PATIENT(S): 1250 poor-responder patients undergoing IVF. INTERVENTION(S): Low-dose (81 mg) aspirin before and during an IVF cycle. MAIN OUTCOME MEASURE(S): Live-birth rate. RESULT(S): Patients taking 81 mg of aspirin had statistically significantly higher basal antral follicle counts, more days of stimulation, more ampules of gonadotropins used, higher peak estradiol levels, and more follicles that were > or = 14 mm in diameter on the day of human chorionic gonadotropin administration. There was a decrease in the overall fertilization rate for the patients taking aspirin. There was no difference in IVF outcome rates (implantation, pregnancy, loss, or live birth). CONCLUSION(S): Patients with a diagnosis of poor response who were taking a regimen of 81 of mg aspirin showed an increase in many IVF stimulation parameters and a decrease in fertilization rates. No improvement secondary to 81-mg aspirin intake was found in IVF outcome rates.

Changes in measured endometrial thickness predict in vitro fertilization success.

OBJECTIVE: To assess the predictive ability of endometrial thickness and changes in endometrial thickness on pregnancy outcomes in patients undergoing IVF. DESIGN: Retrospective cohort analysis. SETTING: Academic IVF center. PATIENT(S): Infertile patients undergoing 132 fresh autologous IVF cycles. INTERVENTION(S): Transvaginal ultrasound to assess endometrial thickness at three defined points during IVF (after pituitary suppression, on the sixth day of gonadotropin stimulation, and on the day of hCG administration). MAIN OUTCOME MEASURE(S): Primary outcome variables included endometrial lining thickness at baseline, on day 6 of gonadotropins, the day of hCG administration, and the change in endometrial thickness during gonadotropin stimulation. RESULT(S): Patients attaining pregnancy had significantly greater endometrial thickness on day 6 and endometrial thickness on day of hCG administration. Pregnant patients had a greater change in endometrial thickness from the baseline to day 6 when compared to nonpregnant patients. Threshold analysis and receiver-operator characteristic curves noted significant endometrial thickness levels for implantation and pregnancy rates. CONCLUSION(S): Endometrial responsiveness and thickness during the early IVF stimulation seem to be better prognostic predictors of success than endometrial thickness at the start or the end of the IVF cycle.

Surgical competence of obstetrics and gynecology residents performing microsurgical tubal anastamoses.

OBJECTIVE: To assess tubal patency rates after microsurgical tubal anastamosis in a residency program. STUDY DESIGN: Retrospective cohort analysis. Primary outcome measurement was tubal patency rates. RESULTS: Twenty-seven of the forty-nine patients (55.1%) had bilateral tubal patency and twenty-one of the forty-nine (42.9%) had only one tube open after surgery. No statistical difference in tubal patency rate was noted between the REI staff (85.7%) and the resident (71.4%) (p=0.09). No statistical difference was noted when comparing the patency rate of the residents' first procedure (68.6%) to subsequent procedures (72.8%) (p=0.99). CONCLUSIONS: These data suggest that with appropriate guidance, residents without prior experience are able to perform microsurgical procedures under direct supervision. Residents completed the procedure with patency rates similar to the REI staff. Additionally, tubal patency rates were not significant different in comparing the residents' first or subsequent procedures.