Estimating Ejection Fraction from the 12 Lead ECG among Patients with Acute Heart Failure.

Background: Identifying patients with low left ventricular ejection fraction (LVEF) in the emergency department using an electrocardiogram (ECG) may optimize acute heart failure (AHF) management. We aimed to assess the efficacy of 527 automated 12-lead ECG features for estimating LVEF among patients with AHF. Method: Medical records of patients >18 years old and AHF-related ICD codes, demographics, LVEF %, comorbidities, and medication were analyzed. Least Absolute Shrinkage and Selection Operator (LASSO) identified important ECG features and evaluated performance. Results: Among 851 patients, the mean age was 74 years (IQR:11), male 56% (n=478), and the median body mass index was 29 kg/m2 (IQR:1.8). A total of 914 echocardiograms and ECGs were matched; the time between ECG-Echocardiogram was 9 hours (IQR of 9 hours); ≤30% LVEF (16.45%, n=140). Lasso demonstrated 42 ECG features important for estimating LVEF ≤30%. The predictive model of LVEF ≤30% demonstrated an area under the curve (AUC) of 0.86, a 95% confidence interval (CI) of 0.83 to 0.89, a specificity of 54% (50% to 57%), and a sensitivity of 91 (95% CI: 88% to 96%), accuracy 60% (95% CI:60 % to 63%) and, negative predictive value of 95%. Conclusions: An explainable machine learning model with physiologically feasible predictors may be useful in screening patients with low LVEF in AHF.

Sperm DNA fragmentation negatively influences the cumulative live birth rate in the intracytoplasmic sperm injection cycles of couples with unexplained infertility.

OBJECTIVE: This study aimed to determine the effect of sperm DNA fragmentation (SDF) on the cumulative live birth rate (CLBR) in intracytoplasmic sperm injection (ICSI) cycles in couples with unexplained infertility. METHODS: We conducted a prospective study of 145 couples who underwent ICSI cycles for unexplained infertility. Based on the SDF rate, patients were categorized into a low SDF group (SDF ≤30%, n=97) and a high SDF group (SDF >30%, n=48). SDF was assessed using the acridine orange test on density gradient centrifugation prepared samples. The CLBR was calculated as the first live birth event per woman per egg collection over 2 years. RESULTS: The high SDF group (SDF >30%) showed a significantly lower CLBR (p<0.05) and a significantly higher miscarriage rate (p<0.05) than the low SDF group (SDF ≤30%). No significant difference was observed in the implantation and cumulative pregnancy rates between the two SDF groups. The total number of embryo transfers was stratified further into fresh and frozen embryo transfers. In the fresh embryo transfers, there were significant differences in the implantation rates, clinical pregnancy rates, and live birth rates (p<0.05) between the low SDF and high SDF groups. However, in the frozen embryo transfers, there were no significant differences in clinical outcomes between the two groups. In the multivariable logistic regression analysis, SDF was a predictor of CLBR (p<0.05) when adjusted for possible confounding factors. CONCLUSION: High SDF was associated with a lower CLBR and a higher miscarriage rate in the ICSI cycles of couples with unexplained infertility.

Role of Female Age in Regulating the Effect of Sperm DNA Fragmentation on the Live Birth Rates in Intracytoplasmic Sperm Injection Cycles with Own and Donor Oocytes.

Background: Sperm DNA integrity assessment has been progressively used as an unfettered measure of sperm as it proffers more prognostic and diagnostic information than routine semen analysis. The contentious effect of sperm DNA fragmentation (SDF) on clinical outcomes can be attributed to female factors such as age, oocyte quality and ovarian reserve. Aims: The study is mainly aimed to know the influence of SDF on the live birth rates in intracytoplasmic sperm injection (ICSI) cycles with own and donor oocytes. Second, to know the role of female age in regulating the effect of SDF on the live birth rates in ICSI cycles with own and donor oocytes. Setting and Design: A prospective cohort study was done at our tertiary care centre attached to the reproductive medicine unit in medical college. Materials and Methods: The study included 356 patients who underwent first ICSI cycles either with own or donor-oocytes along with day 5 fresh embryo transfers only. The main outcome measures were live birth rates and miscarriage rates. Statistical Analysis Used: Chi-squared test was used to compare the categorical variables between the groups. The receiver operating characteristic curve was developed to correlate the female age with the live birth rate. Results: A significant decrease in the live birth rates (42.85% vs. 26.15%, P = 0.023) and an increase in the miscarriage rates (12.30% vs. 34.61%, P = 0.013) were observed in the high-SDF group ICSI cycles of own-oocyte patients. However, there was no significant difference in the live birth rates and miscarriage rates in the low- and high-SDF groups of donor oocyte ICSI cycle patients (P > 0.05). The own-oocyte ICSI cycle patients were further stratified based on the female age. In the female age group ≤30 years there was no significant difference in the live birth and miscarriage rates (P > 0.05) similar to donor oocyte ICSI cycles. Whereas, there was a significant difference in the live birth rates in the females of age >30 years (13.79% vs. 34.37%, P = 0.040). Conclusion: In conclusion, high-SDF has a negative influence on the live birth rates and a positive influence on the miscarriage rates in patients with own-oocyte ICSI cycles. A similar influence was not observed in patients with donor-oocyte ICSI cycles and in young female patients (age ≤30 years) with own-oocyte ICSI cycles.

Effect of Body Mass Index on the Efficacy of Paracervical Block for Ultrasound-Guided Transvaginal Oocyte Retrieval as assessed by Requirement of Rescue Propofol.

BACKGROUND AND AIMS: Oocyte retrieval is the only vital aspect of in vitro fertilization requiring anesthesia. Previous studies have shown the inconclusive role of paracervical block (PCB) in transvaginal oocyte retrieval (TVOR) under ultrasound guidance. This study was planned to observe the role and efficacy of PCB as measured by the amount of propofol used as rescue in patients undergoing TVOR and grading it on the basis of body mass index (BMI). METHODS: This prospective, comparative study, conducted over 1 year, recruited 140 American Society of Anesthesiologists I and II patients and divided into two groups as follows: Group A received PCB with 20 ml of 1% lignocaine and Group B received no PCB. Total propofol consumed, BMI, time taken, oocytes retrieved, postprocedure visual analog scale score, and complications were noted. In both the groups, patients were then divided into underweight, normal, overweight, and obese according to BMI. Statistical analysis was done using Statistical Package Mini Tab Version 17.0. The primary objective was to study the efficacy of PCB as estimated by amount of propofol required during the procedure. The secondary aim was to assess the effect of BMI on the efficacy of PCB. RESULTS: Propofol requirement was found to be significantly more (P < 0.05) in Group B patients (172.14 ± 64.15) in comparison to Group A (132.14 ± 66.11). Amount of propofol required in normal BMI and overweight patients was significantly higher in Group B. No significant difference was observed in underweight, and obese patients in both the groups. CONCLUSION: PCB reduces the consumption of propofol in normal BMI patients. Underweight and obese population do not benefit from PCB.

Efficacy of Low-dose Ketamine as Sole Analgesic Agent in Maintaining Analgesia and Intraoperative Hemodynamics During Laparoscopic Gynecological Surgeries.

BACKGROUND: Ketamine, in low doses, is known to possess intense analgesic properties. The available literature shows wide variation regarding the time and dose of administration of ketamine during surgery. AIM: The aim of this study was to evaluate the effect of intraoperative administration of ketamine when used as sole analgesic in low doses, on hemodynamics and postoperative analgesia in patients undergoing laparoscopic gynecological surgery and compared on the basis of duration of surgery. SETTINGS AND DESIGN: This prospective, observational study was conducted from July to December 2015, over a period of 6 months in a tertiary care medical college and hospital. MATERIALS AND METHODS: Seventy patients between 23 and 55 years planned for laparoscopic gynecological surgery were recruited. Ketamine was given in a dose of 0.5 mg/kg preoperatively and then repeated every ½ hourly in a dose of 0.25 mg/kg throughout the surgery. Hemodynamic parameters, time to the first rescue analgesia and complications were recorded for the first 8 h. Statistical evaluation was done and result expressed as percentage. Paired t-test was employed for the comparison of numerical variables within the group. RESULTS: Seventy percent of the patients did not require any postoperative rescue analgesia during the first 8 h after surgery. None of the patients complained of pain immediately after extubation, and 16% of the patients had minor postoperative complications. The intraoperative hemodynamic profile was significantly altered. Duration of surgery and dose of ketamine required did not affect the duration of analgesia. CONCLUSION: Ketamine in low dose proved to be an efficacious analgesic even in the long duration laparoscopic gynecological surgeries. It stabilizes intraoperative hemodynamics thereby reducing the requirement of other anesthetic and antihypertensive agents.

Relationship of Number of Embryos Transferred with Perinatal Outcome of Singleton Pregnancy.

BACKGROUND: Singleton pregnancy with a live birth beyond 37 weeks of gestation is the ultimate goal of any assisted reproductive technology. However, singletons conceived after ART are found to have a poor perinatal outcome in comparison to naturally conceived singletons. It was hypothesized that the outcome of singleton conceived after transfer of two or more embryos may be dependent on the sharing of uterine space with other embryos. METHODS: Patients who had single gestational sac visualized at 6 weeks after transfer of 4, 3 or 2 embryos were considered for the study. 195 singleton pregnancies were selected for final evaluation such that as per implantation rates of 25%, 33%, and 50%, they were divided into 3 groups of 50, 82 and 63 cases, respectively. The basic characteristics of pregnancy (gestational age, birth weight) were compared using analysis of variance (continuous variables), and categorical variables were evaluated with chi-squared test. The p<0.05 was considered statistically significant. RESULTS: Among the various variables including maternal age, conception, type of infertility, type of abortion, total live birth, gestational age in live birth, birth weight, kind of embryo transfer and gestational age, there was not significant statistical differences between groups except gestational age that it was higher in group with 50% (p<0.04) implantation rate. Therefore, higher number of initial embryos may affect the perinatal outcome of singleton conceived subsequently. CONCLUSION: There is higher chance of missed abortion in patients with singleton pregnancies conceived after multiple embryo transfer. Gestational age at delivery and birth weight were correlated with number of embryo transfered.

Effect of Endometrial Cavity Fluid On Pregnancy Rate of Fresh Versus Frozen In Vitro Fertilization Cycle.

OBJECTIVE: This study aims to study the difference in etiology and outcome in terms of implantation rate and abortion rate in fresh (self-stimulated) versus frozen (oocyte donation cycle) in vitro fertilization (IVF) and in transient versus persistent fluid. MATERIAL AND METHODS: This retrospective study was conducted in the Department of Reproductive Medicine of tertiary care center from January 2012 to November 2015. Data were collected retrospectively from the departmental files. Twenty-four patients from fresh IVF-stimulated cycles and 24 from frozen oocyte donation cycle with their endometrium prepared by hormone replacement treatment were included in the study. All patients selected in the study had grade-A embryo transfer of day 3-4 with maximum three embryo transferred. Pregnancy was defined by rising serum beta-human chorionic gonadotrophin levels performed after 14 days of embryo transfer and further confirmed by ultrasonographic visualization of gestational sac at 6 weeks. All biochemical pregnancies were included in implantation failure. All pregnant patients were followed till the termination of pregnancy and further noted as live birth or abortion. RESULTS: Clinical pregnancy rate was seen more in self-stimulated cycle (62.5%) with live birth rate of 50% than hormone replacement treatment cycle, in which clinical pregnancy rate was 45.83% with live birth rate of 33.33%. Clinical pregnancy rate was highest in group with very less fluid in cavity (1-2 mm) 63% and with live birth of 52.63%. Clinical pregnancy was seen only in two patients of group B with anterior and posterior (AP) diameter of fluid in cavity of 2-3 mm with live birth of only one, whereas in group C, with AP diameter of 3-5 mm, none of the patient conceived. This difference was statistically significant. Clinical pregnancy rate was 65.62% in transient fluid accumulation with live birth rate of 53.25%, which was significantly higher than persistent fluid accumulation (P value - 0.0337 for pregnancy rate and 0.0312 for live birth rate). CONCLUSION: Fluid accumulation seen in fresh cycles are generally associated with better outcome because it may be associated with good prognostic factors - small AP diameter of fluid, with transient fluid accumulation and more with poly cystic ovarian syndrome as an etiological factor; however, in frozen cycle, it can be associated with poor outcome.

Perinatal Outcome in Assisted Reproductive Pregnancies: Comparative Analysis of Reduced versus Unreduced Gestation.

Objectives. This study aims to evaluate perinatal outcomes such as gestational age at delivery and live birth rate in singleton and twin gestation with or without fetal reduction. Method. A retrospective analysis was done on patients which were divided into reduced and unreduced groups on the basis of order of reduction of one or more fetuses between 6 and 13 weeks of gestation. Patients records were studied to note gestational age at delivery/abortion, birth weight, and neonatal outcome. Result. The cohort included a total of 292 patients: 102 singletons and 190 twins. 52 pregnancies were reduced in singleton cohort and 68 were reduced in twin cohort. No statistical difference was observed in live birth rate, gestational age at delivery, and birth weight and significant higher incidence of IUGR was observed in reduced and unreduced twin gestation. In singleton pregnancies however preterm delivery rate increased with fetal reduction. Conclusion. Although reduction does not reduce the live birth rate, it does reduce gestation age of delivery and birth weight of newborn. This effect is more apparent when multiple gestation is reduced to singleton.

Use of clomiphene-based stimulation protocol in oocyte donors: A comparative study.

INTRODUCTION: This study was undertaken to compare between clomiphene citrate (CC) and gonadotropin-releasing hormone antagonist-based protocols in donor-recipient cycles in terms of parameters of ovarian stimulation and obstetric outcome. MATERIALS AND METHODS: Two hundred and three fertile oocyte donors were stimulated using two different protocols: Clomiphene based (n = 103) and antagonist based (n = 100). Donors in the one group were stimulated from day 1 or 2 of spontaneous or withdrawal bleeds with CC (50 mg/day) and recombinant follicle-stimulating hormone (FSH) till the day of trigger while donors in the other group were stimulated using recombinant FSH from day 1 or 2, and the antagonist was added as per flexible antagonist protocol. When >3 follicles were >17 mm in diameter, trigger was given with 2 mg leuprolide intramuscular. Transvaginal oocyte retrieval was done after 34 h of trigger. RESULTS: There was no significant difference in between the two groups in terms of age, antral follicle count, starting dose of gonadotropins, total dose required, duration of stimulation, number of follicles retrieved, mature follicles, and fertilization rate. The serum estradiol levels were significantly raised in the clomiphene group (P < 0.001). Pregnancy rate was similar in both the groups. The clinical pregnancy rate was 65.94% in the clomiphene group and 57.46% in the antagonist group. The live birth rate per cycle started was 47.8% in the clomiphene group and 39.55% in the antagonist group. There was one case of ectopic pregnancy in the antagonist group. CONCLUSION: Controlled ovarian stimulation using clomiphene and gonadotropin is a viable option for donor oocyte cycles. The cost and number of injections used per cycle can be reduced by using the clomiphene-based protocols.

Comparative analysis of perinatal outcome of spontaneous pregnancy reduction and multifetal pregnancy reduction in triplet pregnancies conceived after assisted reproductive technique.

INTRODUCTION: With the advent of assisted reproductive treatment options, the incidence of multiple pregnancies has increased. Although the need for elective single embryo transfer is emphasized time and again, its uniform applicability in practice is yet a distant goal. In view of the fact that triplet and higher order pregnancies are associated with significant fetomaternal complications, the fetal reduction is a commonly used option in such cases. This retrospective study aims to compare the perinatal outcome in patients with triplet gestation who have undergone spontaneous fetal reduction (SFR) as against those in whom multifetal pregnancy reduction (MFPR) was done. MATERIALS AND METHODS: In the present study, eighty patients with triplet gestation at 6 weeks were considered. The patients underwent SFR or MFPR at or before 12-13 weeks and were divided into two groups (34 and 46), respectively. RESULTS: Our study found no statistical difference in perinatal outcome between the SFR and MFPR groups in terms of average gestational age at delivery, abortion rate, preterm delivery rate, and birth weight. The study shows that the risk of aborting all fetuses after SFR is three times (odds ratio [OR] = 3.600, 95% confidence interval [CI] = 0.2794-46.388) that of MFPR in subsequent 2 weeks. There were more chances of loss of extra fetus in SFR (23.5%) group than MFPR group (8.7%) (OR = 3.889, 95% CI = 1.030-14.680). As neither group offers any significant benefit from preterm delivery, multiple pregnancies continue to be responsible for preterm delivery despite fetal reduction. CONCLUSION: There appears to be some advantages of MFPR in perinatal outcome when compared to SFR, especially if the latter happens at advanced gestation. Therefore, although it is advisable to wait for SFR to occur, in patients with triplet gestation at 11-12 weeks, MFPR is a viable option to be considered.

Pregnancy Predictors after Intrauterine Insemination in Cases of Unexplained Infertility: A Prospective Study.

Introduction. Aim of the study was to find the effect of various prognostic factors in cases of unexplained infertility undergoing controlled ovarian stimulation (COS) with intrauterine insemination (IUI). Methods. 146 cases of unexplained infertility were included. A maximum of 3 cycles of IUI were done with clomiphene citrate/HMG. Ovulation trigger was given when the largest follicle diameter was >18 mm, and IUI was planned 36 hours later. Luteal phase support was given for 15 days, urine pregnancy test was done on day 15, ultrasonography was done at 7 weeks, and pregnancy was followed up till delivery. Results. A total of 146 couples have undergone 239 cycles of IUI out of which 27 had UPT positive after 15 days. 14.8% had 1st-trimester abortion while 3.7% were ectopic. 86.3% were singleton pregnancies and 13.6% were twins. CPR was 11.29% per cycle and 18.4% per couple; LBR was 9.2% per cycle. Apart from duration of stimulation (p = 0.037) and number of treatment cycles (p = 0.045), no other factors had significant prognostic value. Conclusion. For unexplained infertility, IUI can be done to provide patients with the time that they need before moving on to IVF while providing a respectable chance of pregnancy.

Effect of myomectomy on endometrial cavity: A prospective study of 51 cases.

CONTEXT: Fibroids are the most common tumors of the uterine cavity. Most of them are diagnosed during the reproductive age when the fertility is an important concern for the female. However, complications can occur after removal of fibroid (myomectomy) too for future pregnancy. Though myomectomy has been sighted as a cause of intrauterine adhesions data regarding the effect of myomectomy on endometrial cavity is lacking. AIMS: Evaluate the incidence of intrauterine adhesion formation after myomectomy and to identify the associated factors. MATERIALS AND METHODS: In this prospective observational study, hysteroscopy was done in 51 infertile patients who had undergone myomectomy 3 months before in a tertiary care center from 2012 to 2015. The presence of intrauterine adhesions noted on hysteroscopy was investigated on the basis of size, number, location and type of fibroid removed, along with intraoperative breach of the uterine cavity. STATISTICAL ANALYSIS: Chi-square test was used for the calculating significant difference in frequency of discrete variables in two groups. P < 0.05 was considered significant. RESULTS: Intrauterine adhesions were seen in 11 out of 51 (21.57%) cases. No significant relationship between intrauterine adhesions and type, size or number of fibroid was observed. No statistical difference in the rate of adhesion formation was seen irrespective of breach of the uterine cavity during myomectomy. CONCLUSION: Intrauterine adhesion formation after myomectomy is not related to the type of surgery or the nature of fibroid. However, in all cases desiring fertility postoperative hysteroscopy is highly recommended to diagnose and treat these adhesions early.

Chlamydia antibody testing helps in identifying females with possible tubal factor infertility.

INTRODUCTION: Chlamydia is an important cause of sexually transmitted diseases leading to tubal factor infertility. BACKGROUND: This study aims to define the role of chlamydial antibody detection in predicting presence, nature and type of tubal pathology in laparoscopy. MATERIALS AND METHODS: A prospective study was conducted on 200 consecutive patients undergoing laparoscopy as a part of infertility work-up. Preoperatively, serological determination of Immunoglobulin G (IgG) specific antibodies against Chlamydia Trachomatis was done by Enzyme linked immunosorbant assay (ELISA). Findings of laparoscopy were evaluated against presence or absence of chlamydial antibodies in serum. RESULTS: Out of 200 patients,10 patients tested positive for chlamydial antibody. Chlamydial antibody was found positive in 20% and 22.7% of patients with tubal pathology and peri-hepatic adhesions of patients, respectively. The sensitivity of chlamydial antibody for diagnosing tubal pathology was found to be 20%, while specificity was 100%. The positive chlamydial antibody test was not statistically associated with involvement of one or both tubes and site of tubal block. CONCLUSION: Chlamydia antibody test does not appear to be good screening test for tubal pathology especially in Indian subcontinent. In view of its high specificity, this test can be used to identify patients with higher chances of tubal pathology requiring operative intervention.

Effect of sleeve gastrectomy bariatric surgery-induced weight loss on serum AMH levels in reproductive aged women.

OBJECTIVE: This study aims to evaluate the change in serum anti-Mullerian hormone (AMH) levels in patients with morbid obesity undergoing bariatric surgery for weight loss. MATERIAL AND METHODS: In this prospective observational study, 75 patients of reproductive age (20-35 years) undergoing bariatric surgery for morbid obesity were followed up after six months to determine the changes in weight, Body Mass Index (BMI), menstrual pattern and serum AMH. The results were further studied on basis of pre operative classification of patients in polycystic ovary syndrome (PCOS) and non-PCOS group. RESULT: The serum AMH levels were statistically higher in patients of PCOS group pre operatively and at the end of six months in comparison to non-PCOS patients. The AMH values reduced post operatively in both groups significantly so much in the values though not significant statistically. Non-PCOS patients had lower AMH values pre operatively and showed a trend towards reducing ovarian reserve after six months. The overall change in AMH values in both groups was statistically significant as was the normalization of menstrual irregularity. CONCLUSION: Morbidly obese patients with PCOS appear to benefit from bariatric surgery both in terms of regularization of menstrual function and normalization of serum AMH values.

Comparison Between Banded and Nonbanded Roux-En-Y Gastric Bypass with 2-Year Follow-Up: a Preliminary Retrospective Analysis.

BACKGROUND: Roux-en-Y gastric bypass (RYGB) is one of the most widely used bariatric surgeries for treatment of moderate and severe obesity. Placing a band around the pouch to band the gastric bypass operation has been reported to increase the restriction resulting in better weight loss and weight loss maintenance. A retrospective comparative study of banded versus nonbanded gastric bypass was done to see if banding the pouch made a difference in the weight loss and quality of life outcome in the patients. METHODS: Data from all patients who had a gastric bypass in the year 2012 at our centre were reviewed. They were divided into two groups the banded and the nonbanded groups. Patients with complete 2-year follow-up were analysed in terms of weight loss, weight regain and quality of life changes. RESULTS: Two hundred ten patients had gastric bypass in 2012; 165 had complete 2-year follow-up; 64 were banded and 101 nonbanded. The preoperative patient profile in terms of weight, gender and comorbid conditions was similar in both groups except the body mass index (BMI) was significantly higher in the banded group. The perioperative and postoperative complication rates were similar. The weight, BMI and percentage excess weight loss (PEWL) at 2 years were 80.93 kg, 29.45 kg/m2 and 60.76 % in the nonbanded group and 77.06 kg, 27.66 kg/m2 and 71.45 % in the banded group, respectively. Resolution of comorbid conditions was the same in both groups. The overall Gastrointestinal Quality of Life Index went from 88.98 preoperatively to 109.33 postoperatively in the nonbanded group and 92.5 to 112.81 in the banded group, respectively. CONCLUSIONS: The patients with banded gastric bypass had significantly better results in terms of weight loss, weight stability and Gastrointestinal Quality of Life Index scores at 2 years.

Reproductive Outcome of Patients with Asherman's Syndrome: A SAIMS Experience.

BACKGROUND: The purpose of the study was to evaluate menstrual and reproductive outcome in patients diagnosed with Asherman's syndrome on hysteroscopy and to assess the role of hysteroscopic adhesiolysis. METHODS: A prospective study was performed for patients having intrauterine adhesion at a tertiary care teaching hospital, Indore, India for a period of 2 years. Findings at hysteroscopy, details of adhesiolysis, changes in menstrual pattern following adhesiolysis, need for repeat procedure and fertility outcome were prospectively collected. Data was analysed using SPSS software. A p-value of <0.05 was considered significant. RESULTS: A total of 60 patients with a mean age of 30.1±5.5 years with Asherman's syndrome were included. In 53.3% of them, no factors like post-partum curettage, uterine surgery or history of tuberculosis could be found in which the present intrauterine adhesions could be attributed to. Hypomenorrhoea was the most common (53.3%) menstrual pattern in patients diagnosed with Asherman's syndrome. Thirty eight out of 60 (63.33%) required second look hysteroscopy. There was a significant change in endometrial lining and echo pattern after adhesiolysis (p<0.05). 45% of patients started having normal menstrual flow after adhesiolysis which was statistically significant. A total of 16 conceptions and 10 live births were reported in the present cohort. Pregnancy rate was higher in patients having mild Asherman's syndrome (53.3%) as compared to moderate (26.9%) or severe type (9.5%), (p=0.0049). It was also higher in patients having normal endometrial pattern after adhesiolysis (p=0.0005). CONCLUSION: Women who underwent hysteroscopic adhesiolysis showed significant improvement in the menstrual pattern. Pregnancy rates were improved after hysteroscopic adhesiolysis.

Body Mass Index and Its Role in Total Laparoscopic Hysterectomy.

Objective. To evaluate operative and perioperative outcomes in patients undergoing total laparoscopic hysterectomy according to their body mass index. Method. A retrospective study was performed for patients undergoing total laparoscopic hysterectomy at a tertiary care center for a period of 4 years. Patients were divided into two groups: obese (BMI > 30 Kg/m(2)) and nonobese (BMI < 30 Kg/m(2)). Duration of surgery, intraoperative blood loss, successful laparoscopic completion, and intraoperative complications were compared in two groups. Result. A total of 253 patients underwent total laparoscopic hysterectomy from January 2010 to December 2013. Out of them, 105 women (41.5%) had a BMI of more than 30 kg/m(2). Overall, the mean blood loss was 85.79 ± 54.17 mL; the operative time was 54.17 ± 19.83 min. The surgery was completed laparoscopically in 244 (96.4%) women while laparotomy was done in 4 cases and vaginal suturing and closure of vault were done in 5 cases. Risk of vaginal assistance was higher in obese patients whereas out of the 4 conversions to laparotomy 3 had BMI < 30 kg/m(2). The operative time was increased as the BMI of patient increased. Conclusions. Total laparoscopic hysterectomy is a safe and effective procedure for obese patients and can be performed with an efficacy similar to that in nonobese patients.

Laparoendoscopic single-site surgery in gynecology: LESS is actually how much less?

Gynecological surgery is evolving continuously. Laparoendoscopic single-site surgery (LESS) is the recent addition in this field that stands to benefit almost 40% of women in midlife who will eventually undergo adnexal surgery or hysterectomy. Carried out through a single umbilical incision, the potential benefit of single site surgery is improvement in operative morbidity and cosmesis. The safety, feasibility and efficacy of laparoendoscopic single site procedures have been established in studies over the last few years. In this article, we will review the nomenclature, instruments, and the evidence around the commonly performed gynecologic surgeries using the LESS procedure.

Hysteroscopic diagnosis and successful management of an acquired uterine arteriovenous malformation by percutaneous embolotherapy.

Arteriovenous malformations are a rare but important cause of abnormal uterine bleeding in the midlife. Acquired uterine arteriovenous malformations are being increasingly diagnosed by transvaginal ultrasound, color Doppler and magnetic resonance angiography. We present a case where the suspected diagnosis was placental polyp or retained products of conception and hysteroscopy showed typical findings of uterine arteriovenous malformation, which was later, confirmed by magnetic resonance angiography. The patient underwent arterial embolization and recovered satisfactorily with resolution of hemorrhage and resumption of normal menstrual cycles. Abnormal bleeding due to arteriovenous malformations is worsened by curettage and hence its recognition is important in the management of abnormal uterine bleeding in the midlife.

Does centrifugation and semen processing with swim up at 37°C yield sperm with better DNA integrity compared to centrifugation and processing at room temperature?

AIM: To evaluate whether semen processing at 37°C yield sperm with better DNA integrity compared to centrifugation and processing at room temperature (RT) by swim-up method. SETTINGS: This study was done at tertiary care center attached to Reproductive Medicine Unit and Medical College. DESIGN: Prospective pilot study. PATIENTS: Normozoospermic men (n = 50) undergoing diagnostic semen analysis. MATERIALS AND METHODS: Normozoospermic samples (World Health Organization, 2010 criteria) after analysis was divided into two aliquots (0.5 mL each); one was processed at 37°C and the other at RT by swim-up method. DNA fragmentation of both samples post wash was calculated by acridine orange method. STATISTICAL ANALYSIS USED: The values of sperm DNA fragmentation were represented as mean and standard error (mean ± SEM) of the mean. Paired t-test was used for calculating the sperm DNA integrity difference between post wash at RT and 37°C. RESULTS: Statistically significant difference was not observed in post wash sperm DNA fragmentation values at 37°C compared to RT. CONCLUSION: Our data represents that there was no significant difference in sperm DNA fragmentation values of samples processed at 37°C and at RT. Hence, sperm processing at 37°C does not yield sperm with better DNA integrity compared to centrifugation and processing at RT.