Harms of third- and fourth-generation combined oral contraceptives in premenopausal women: A systematic review and meta-analysis.

We assessed the available evidence regarding adverse effects on surrogate and patient-important health outcomes of third- and fourth-generation combined oral contraceptives among premenopausal women. We performed a systematic review and meta-analysis including randomized controlled trials and observational studies comparing third- and fourth-generation combined oral contraceptives with other generation contraceptives or placebo. Studies that enrolled women aged 15 to 50 years, with at least three cycles of intervention and 6 months of follow-up were included. A total of 33 studies comprising 629,783 women were included. Low-density lipoprotein cholesterol levels were significantly lower in fourth-generation oral contraceptives (mean differences (MD): -0.24 mmol/L; [95% CI -0.39 to -0.08]), while total cholesterol was significantly increased in levonorgestrel users when compared to third-generation oral contraceptives (MD: 0.27 mmol/L; [95% CI 0.04 to 0.50]). A decreased arterial thrombosis incidence was shown in fourth-generation oral contraceptive users, as compared to levonorgestrel (incidence rate ratio (IRR): 0.41; [95% CI 0.19 to 0.86]). No difference was found in the occurrence of deep venous thrombosis between fourth-generation oral contraceptives and levonorgestrel users (IRR: 0.91; [95% CI 0.66 to 1.27]; p = 0.60; I2 = 0%). Regarding the remaining outcomes, data were heterogeneous and showed no clear difference. In premenopausal women, the use of third- and fourth-generation oral contraceptives is associated with an improved lipid profile and lower risk of arterial thrombosis. Data were inconclusive regarding the rest of outcomes assessed. This review was registered in PROSPERO with CRD42020211133.

The Effects of Preimplantation Genetic Testing for Aneuploidy (PGT-A) on Patient-Important Outcomes in Embryo Transfer Cases: A Meta-Analysis.

Background: The aim of this study was to evaluate the effect of preimplantation genetic testing for aneuploidy (PGT-A) on patient-important reproductive outcomes after in vitro fertilization (IVF). Methods: Randomized and non-randomized studies have been sought in Ovid, MEDLINE, EMBASE, Web of Science, Scopus, and Cochrane Central Register of Controlled Trials since each database's inception through May 2021. Main keywords used for the search strategy included "Embryo transfer", "In vitro fertilization", "DNA sequencing", and "Comparative genome hybridization". Studies were screened independently and in duplicate. Results: Ten studies were finally analyzed, representing a total of 2630 embryo transfers. The pooled OR for live birth rates were 1.45 (95%CI 0.24-8.78, I2 96%) and 1.66 (95%PI 0.15-18.01, 95%CI 0.98-2.83, I2 81%) derived from the NRSIs and the RCTs, respectively, in which the miscarriage rate were 1.25 (95%CI 0.19-8.33, I2 70%) and 0.57 (95%PI 0.06-5.34, 95%CI 0.27-1.21, I2 53%), and clinical pregnancy rates were 3.08 (95%CI 2.22-4.29, I2 0%) and 1.43 (95%PI 0.38-5.42, 95%CI 0.96-2.13, I2 68%). Influence analyses showed a greater treatment effect when excluding studies without patients at advanced maternal age. Conclusion: There seems to be no significant difference in reproductive outcomes when using PGT-A in the general population; however, the procedure seems advantageous for patients at advanced maternal age. Nevertheless, this warrants caution when recommending the procedure to all couples seeking ART, as the current possible benefits may not justify the additional costs for all groups of patients.

The Effect of Post warming Culture Period Between Thawing and Transfer of Cryopreserved Embryos on Reproductive Outcomes After In Vitro Fertilization (IVF): A Systematic Review and Meta-analysis.

BACKGROUND: The purpose of this study was to evaluate the effect of post warming culture period between thawing and transfer of cryopreserved embryos on reproductive outcomes after in vitro fertilization (IVF). METHODS: An extensive literature search was performed using PubMed, EmBase, and the Cochrane library from January 2000 to August 2019. A systematic review and meta-analysis of clinical trials was performed in this manuscript. The trials represented patients with embryo transfers of at least one previously cryopreserved good quality embryo. Main outcome measures of the study included clinical pregnancy rate, live birth rate, miscarriage rate, and ectopic pregnancy rate. RESULTS: A total of 5338 trial/abstracts were identified through a literature search. Totally, five studies were included in the systematic review, and three in the final meta-analysis. The studies included 1717 embryo transfers, 605 after short culture, and 1112 after long culture. The clinical pregnancy rate (CPR) was the most consistent outcome reported. The CPR was slightly better after short time culture with a RR of 1.09 (0.95-1.26, 95%CI) but this difference was not statistically significant. The great heterogenicity in the results reported in the included studies made it impossible to compare all planned outcomes. CONCLUSION: There are no differences in reproductive outcomes if cryopreserved embryos are transferred after overnight culture or after two hours of culture following thawing. Due to small number and the poor quality of trials reported on this topic, the results of this review should be treated with caution.

Association between thyroid autoimmunity and ovarian reserve in women with hypothyroidism.

BACKGROUND: The ovarian function and therefore the ovarian reserve may be compromised by the pathogenesis of autoimmune diseases of which, Hashimoto's thyroiditis (HT) is the most common in women of reproductive age. Furthermore, a prolonged reduction in thyroid hormone concentration results in a broad spectrum of reproductive alteration. Previous reports in the literature have been controversial regarding the impact of hypothyroidism and alterations in the ovarian reserve. Thus, this prospective and comparative study aimed to evaluate the association of hypothyroidism with low ovarian reserve. MATERIALS AND METHODS: A subset of 27 patients with primary autoimmune hypothyroidism were compared to healthy women. The ovarian reserve was assessed through the anti-Mullerian hormone (AMH) and the antral follicle count (AFC). RESULTS: Overall, the two groups did not display significant differences in length of their menstrual cycles neither in the AMH serum levels nor the AFC. CONCLUSIONS: No significant alteration was found in the ovarian reserve of women with HT.

Clinical Pregnancy After Elimination of Embryo Fragments Before Fresh Cleavage-stage Embryo Transfer.

Objective: To determine if the elimination of fragments in cleavage-stage embryos, before fresh transfer, improves pregnancy rates in in vitro fertilization cycles. Materials and methods: This is a Prospective observational case-control study carried out at a University Reproductive Center. We included Twenty-six infertile patients divided into two groups. Group one: 13 patients with embryos classified as grade B and C (embryos with fragments) according to the Hill classification, and Group two: 13 patients with grade A embryos (embryos with no fragments). Embryo Defragmentation was performed in embryos of group one 65 to 68 hours after conventional fertilization. Fresh embryo transfer was made after two hours post fragments removal. Reproductive results were evaluated and compared between both groups. Results: The total number of clinical pregnancies was nine. In group one there were 5 (38.5 %); in group two, there were 4 (30.8%). The difference was not statistically significant (p = 0.68). Two abortions were reported in the study, both in group one; were fragment elimination was performed. This represents an abortion rate of 40% in patients who got pregnant in this group. These patients had twice the probability of suffering an abortion (OR 2.1; 95% CI 1.4-3.37). Ongoing pregnancies were similar in both groups. Conclusion: Removal of fragments in freshly transferred day three embryos could be an alternative to increase clinical pregnancy and ongoing pregnancy rates in patients who have only poor-quality embryos. Despite the relationship with a higher abortion rate, this strategy could represent a real alternative for this type of patient.

The elimination of apoptotic sperm in IVF procedures and its effect on pregnancy rate.

OBJECTIVE: To identify the effect of apoptotic sperm elimination with MACS in patients that require IVF. METHODS: An experimental, cross-sectional, descriptive, prospective and non-blinded study of diagnostic tests performed in patients who required IVF and ICSI from July 2011 to July 2012. Ninety-two couples participated according to the treatment administered to the semen sample; in the control group: the samples were subjected only to density gradients before ICSI, in the study group: the same procedure was performed plus the addition of the MACS technique. Comparing the groups, we assessed the fertilization, division, viable embryos and clinical pregnancy rates in all cases. RESULTS: We found significant differences when using MACS technique in sperm parameters. We found no differences between the total samples of the control and study groups. When separating the own and donated eggs in each group, we found an improvement in the fertilization rates (p<0.001) of the own eggs. In both groups, the handling of donated eggs lead to a significant improvement in the immunological pregnancy test (IPT) and fetal heart rate (FHR) results. Only in the donated eggs group, where MACS was applied, could we see that all cases with positive IPT had a fetal heart rate, which shows a significant difference (p<0.002) when compared with the control group, where the percentage decreased abruptly. CONCLUSIONS: This study demonstrates the effectiveness of the use of annexins (MACS) in eliminating apoptotic sperm, and when the obtained sperm is applied to good-quality eggs.

Comparative study of the clinical features of patients with a tubo-ovarian abscess and patients with severe pelvic inflammatory disease.

OBJECTIVE: To determine the clinical characteristics that indicate the presence of tubo-ovarian abscess (TOA) among patients with severe pelvic inflammatory disease (PID). METHODS: An observational cohort study was performed from October 2011 to March 2013. The study included all patients with a diagnosis of TOA and PID admitted to a university hospital in Mexico. A complete medical history and physical examination were performed, and laboratory studies were reviewed. A logistic regression analysis was performed on variables with statistical significance. RESULTS: Overall, 26 patients with PID and TOA (TOA group) and 26 with PID without TOA (PID group) were included in the study. Significant differences between patients with TOA and PID were found with regard to the patients' age (39.3years vs 33.1years; P=0.04), educational level (only elementary, 13 [50%] vs 5 [19%]; P=0.14), presentation with fever (23 [88%] vs 16 [62%]; P=0.025), white blood cell count (21.8×10(9)/L vs 14.9×10(9)/L; P<0.001), number of deliveries (2.2 vs 1.1; P=0.01), and presence of diarrhea (16 [62%] vs 5 [19%]; P<0.001). The triad of fever, leukocytosis, and diarrhea was positively related to the presence of TOA. CONCLUSION: The triad of fever, leukocytosis, and diarrhea should alert clinicians to the possibility of TOA formation in patients with PID.

Randomized double-blind placebo-controlled trial of buccal misoprostol to reduce the need for additional uterotonic drugs during cesarean delivery.

OBJECTIVE: To determine whether buccal misoprostol during cesarean delivery in conjunction with active management of the third stage of labor reduces the need for additional uterotonic drugs. METHOD: A double-blind, randomized, placebo-controlled trial was performed in Monterrey, Mexico, between February 2008 and December 2013. Eligible women had risk factors for uterine atony and were to undergo cesarean delivery under epidural block. Using a computer-generated sequence and blocks of six, patients were randomly assigned to receive 400µg misoprostol or 800µg placebo buccally after cord clamping. Both groups received an intravenous oxytocin infusion. The primary outcome was the need for additional uterotonic drugs. Analyses were performed per protocol. Patients, investigators, and data analysts were masked to group assignment. RESULTS: A total of 120 women were included in analyses (60 in each group). At least one additional uterotonic drug was required in 24 (40%) women in the placebo group versus 6 (10%) women in the misoprostol group (relative risk 0.16; 95% confidence interval 0.06-0.44). No adverse effects due to misoprostol were recorded. CONCLUSION: Buccal misoprostol during cesarean delivery reduced the need for additional uterotonic drugs to treat uterine atony. ClinicalTrials.gov:NCT01733329.

Factors associated with the need for blood transfusion during hysterectomy.

OBJECTIVE: To identify the preoperative clinical conditions associated with the need to perform a blood transfusion among patients undergoing hysterectomy. METHODS: In a retrospective, comparative, case-control trial at the University Hospital, Nuevo León, Mexico, the records of patients who underwent elective hysterectomy between 2007 and 2009 were reviewed. Patients were grouped depending on whether or not they required blood transfusion. Clinical features were compared and statistical analysis was performed via the χ(2) test. RESULTS: Among 794 patients who underwent hysterectomy, 89 (11.2%) required transfusion. The factors significantly associated with transfusion were history of abnormal uterine bleeding (67.0% versus 52.1%), preoperative hemoglobin level (10.1g/dL versus 12.3g/dL), magnitude of intra-operative bleeding (410 mL versus 298 mL), and operative time (172 min versus 144 min); P<0.001. A significant number of patients who underwent transfusion had increased preoperative prothrombin levels; P=0.04. CONCLUSION: Hemoglobin level before surgery and a history of abnormal uterine bleeding can be identified preoperatively and might warn about the possibility of a need for transfusion among patients undergoing hysterectomy. For young patients, alterations in clotting mechanisms should be ruled out.