Outcomes and cost analysis of single-embryo transfer versus double-embryo transfer.

BACKGROUND: Studies had compared single-embryo transfer to double-embryo transfer with cleavage stage embryos and found that while single-embryo transfer was less costly, it was also associated with a lower live birth rate than double-embryo transfer. A single blastocyst transfer has been shown to improve the live birth rate per cycle compared to single-embryo transfer at cleavage stage. OBJECTIVES: To compare live birth rates and real costs of elective single-embryo transfer to double-embryo transfer and to determine the incremental cost-effectiveness ratio of these two strategies in an unselected pool of women in a single center. DESIGN: Retrospective study. METHODS: We analyzed data of 4232 women who underwent their first fresh in vitro fertilization/intra-cytoplasmic sperm injection cycles with at least two embryos available for transfer in KK Women's and Children's Hospital from 2010 to 2017. RESULTS: Five hundred and sixty-four women underwent elective single-embryo transfer and 3668 women underwent double-embryo transfer. One hundred and fifty-six women who failed to achieve a live birth in their fresh elective single-embryo transfer cycle underwent a sequential thaw single-embryo transfer cycle. Live birth rate of fresh elective single-embryo transfer was significantly higher at 41.3% than that of double-embryo transfer at 32.6%. Cumulative live birth rate for sequential elective single-embryo transfer (fresh elective single-embryo transfer + thaw single-embryo transfer) was 47.9%. After accounting for variables which may affect live birth rates such as age and stage of embryo transfer, the odds of achieving a live birth from double-embryo transfer was 24% lower than that from sequential single-embryo transfer, although not statistically significant. For every live birth gained from an elective single-embryo transfer compared to double-embryo transfer, cost savings were S$20,172 per woman. If a woman had to have a sequential single-embryo transfer after a failed single-embryo transfer in her fresh cycle, cost savings were reduced to S$1476 per woman. CONCLUSION: Single-embryo transfer is a dominant strategy in an unselected population and adopting it in assisted reproductive treatments (ART) can produce cost savings without compromising on live birth rates.

Abdominal heterotopic pregnancy post-IVF double embryo transfer.

Uterosacral ligament (USL) is an uncommon site of implantation for abdominal ectopic pregnancies. This is the first case of USL heterotopic pregnancy post invitro fertilisation (IVF). The patient presented 6 weeks after a double embryo transfer with acute onset abdominal pain and was diagnosed with a suspected live tubal ectopic pregnancy with a viable intrauterine pregnancy on ultrasound. A diagnostic laparoscopy revealed an ectopic pregnancy implanted on the left USL which was resected and confirmed on histology. The patient was discharged well on postoperative day 2 with a viable intrauterine pregnancy. This case highlights the importance of considering non-tubal heterotopic pregnancies in the context of risk factors including IVF with double embryo transfer presenting with abdominal pain.

Discovery and validation of peritoneal endometriosis biomarkers in peritoneal fluid and serum.

RESEARCH QUESTION: What are the potential biomarkers for peritoneal endometriosis in peritoneal fluid and serum? DESIGN: Case-control studies composed of independent discovery and validation sets were conducted. In the discovery set, untargeted liquid chromatography-mass spectrometry (LC-MS/MS) metabolomics, multivariable and univariable analyses were conducted to generate global metabolomic profiles of peritoneal fluid for endometriosis and to identify potential metabolites that could distinguish peritoneal endometriosis (n = 10) from controls (n = 31). The identified metabolites from the discovery set were validated in independent peritoneal fluid (n =19 peritoneal endometriosis and n = 20 controls) and serum samples (n = 16 peritoneal endometriosis and n = 19 controls) using targeted metabolomics. The area under the receiver-operating characteristics curve (AUC) analysis was used to evaluate the diagnostic performance of peritoneal endometriosis metabolites. RESULTS: In the discovery set, peritoneal fluid phosphatidylcholine (34:3) and phenylalanyl-isoleucine were significantly increased in peritoneal endometriosis groups compared with control groups, with AUC 0.77 (95% CI 0.61 to 0.92; P = 0.018) and AUC 0.98 (95% CI 0.95 to 1.02; P < 0.001), respectively. In the validation set, phenylalanyl-isoleucine retained discriminatory performance to distinguish peritoneal endometriosis from controls in both peritoneal fluid (AUC 0.77, 95% CI 0.61 to 0.92; P = 0.006) and serum samples (AUC 0.81, 95% CI 0.64 to 0.99; P = 0.004), with notably stronger discrimination between peritoneal endometriosis and controls in proliferative phase. CONCLUSION: Our preliminary results propose phenylalanyl-isoleucine as a potential biomarker of peritoneal endometriosis, which may be used as a minimally invasive diagnostic biomarker of peritoneal endometriosis.

Rare Surgical Complication of In Vitro Fertilisation Treatment: Bladder Injury During Oocyte Retrieval.

Current literature suggests that surgical complications from oocyte retrievals (ORs) are uncommon. Here, we present a rare case of bladder injury during OR and its subsequent management. A 37-year-old nulliparous woman underwent assisted reproductive therapy (ART) for primary infertility secondary to anovulatory cycle. During OR, there was an inadvertent puncture of the bladder, with active intra-bladder bleeding seen on transvaginal ultrasound. Bladder washout followed by continuous drainage was instituted with antibiotic coverage over several days. Bladder integrity ascertained through computer tomography urogram and cystoscopy were unremarkable. She was discharged well and continued with her fertility treatment. Transvaginal OR is associated with few complications. Bladder injury, albeit rare, can present with massive hematuria and hemodynamic instability. Early identification of the injury is key to management with insertion of the indwelling urinary catheter, hemodynamic resuscitation and bladder irrigation. With a urological multi-disciplinary approach, most bladder injuries can be resolved non-invasively.

Resolution of severe fetal distress following treatment of maternal diabetic ketoacidosis.

Diabetic ketoacidosis (DKA) during pregnancy is a serious metabolic complication of diabetes with high mortality and morbidity if not detected and treated immediately. We report a case of a woman with type 1 diabetes mellitus who had poorly controlled diabetes in the first half of pregnancy and developed DKA at 29 weeks gestation. At presentation, she had a pathological fetal heart tracing but delivery was delayed for maternal stabilisation and reversal of acidosis. Once hyperglycaemia, acidosis and maternal stabilisation were achieved, fetal compromise resolved and delivery was no longer indicated. The patient was subsequently discharged home. She delivered vaginally a 2400 g baby at 34 weeks gestation after presenting with spontaneous rupture of membranes.

Determining optimal gestational weight gain in a multiethnic Asian population.

AIM: To define the optimal gestational weight gain (GWG) for the multiethnic Singaporean population. METHODS: Data from 1529 live singleton deliveries was analyzed. A multinomial logistic regression analysis, with GWG as the predictor, was conducted to determine the lowest aggregated risk of a composite perinatal outcome, stratified by Asia-specific body mass index (BMI) categories. The composite perinatal outcome, based on a combination of delivery type (cesarean section [CS], vaginal delivery [VD]) and size for gestational age (small [SGA], appropriate [AGA], large [LGA]), had six categories: (i) VD with LGA; (ii) VD with SGA; (iii) CS with AGA; (iv) CS with SGA; (v) CS with LGA; (vi) and VD with AGA. The last was considered as the 'normal' reference category. In each BMI category, the GWG value corresponding to the lowest aggregated risk was defined as the optimal GWG, and the GWG values at which the aggregated risk did not exceed a 5% increase from the lowest aggregated risk were defined as the margins of the optimal GWG range. RESULTS: The optimal GWG by pre-pregnancy BMI category, was 19.5 kg (range, 12.9 to 23.9) for underweight, 13.7 kg (7.7 to 18.8) for normal weight, 7.9 kg (2.6 to 14.0) for overweight and 1.8 kg (-5.0 to 7.0) for obese. CONCLUSION: The results of this study, the first to determine optimal GWG in the multiethnic Singaporean population, concur with the Institute of Medicine (IOM) guidelines in that GWG among Asian women who are heavier prior to pregnancy, especially those who are obese, should be lower. However, the optimal GWG for underweight and obese women was outside the IOM recommended range.

Predictors and adverse outcomes of inadequate or excessive gestational weight gain in an Asian population.

AIM: The aim of this study was to assess maternal characteristics as predictors of inadequate or excessive gestational weight gain (GWG) and to characterize maternal and neonatal outcomes associated with inadequate or excessive GWG in Asian women. MATERIAL AND METHODS: A study was conducted among 1166 Chinese, Malay, and Indian women who delivered a live singleton infant at KK Women's and Children's Hospital, Singapore. Logistic regression analysis was used to determine predictors and maternal and neonatal outcomes of inadequate or excessive GWG, relative to adequate (recommended) GWG. RESULTS: While maternal age less than 20 years, Malay ethnicity and underweight pre-pregnancy body mass index increased the risk of inadequate GWG, overweight pre-pregnancy body mass index decreased this risk. Tall stature and Malay ethnicity were associated with an increased risk of excessive GWG, while maternal age greater than 30 years was associated with a decreased risk. Inadequate GWG increased the risk of preterm birth and decreased the risk of delivery by cesarean section and postpartum weight retention at 6 months. Excessive GWG increased the risk of delivery by cesarean section, postpartum weight retention at 6, 12 and 24 months and having a high-birthweight baby. CONCLUSION: Maternal predictors and perinatal outcomes of GWG among Asian women are similar to those identified previously among Caucasian, African-American and Hispanic women.