Effect of Preoperative Anxiety on Depth of Anaesthesia and In Vitro Fertilization Success.

Objective: Infertility anxiety may have a harmful effect on embryo quality and fertilization during in vitro fertilization (IVF). Monitoring brain function gives real-time information about the depth of anaesthesia of a patient. This study examined the effect of preoperative anxiety on the depth of anaesthesia and IVF success. Methods: One hundred thirty-one patients who had undergone oocyte retrieval were divided into two groups according to the Beck Anxiety Inventory (BAI): the low-anxious Group L (n = 71) and high-anxious Group H (n = 60). Hemodynamic stability, intraoperative total propofol and fentanyl consumption, good quality embryo (GQE) rate, and fertilization rate were recorded. Results: Fertilization and GQE rates were not significant between groups L and H. Total propofol consumption was significantly higher in group H than in group L. Heart rate (HR) preoperatively and postoperatively and systolic arterial pressure (SAP) preoperatively and diastolic arterial pressure (DAP) postoperatively were significantly increased in group H than in group L. The time for the modified Aldrete score to reach 9 (MAS 9) in group H was significantly higher than that in group L. The effect of variables that were found significantly in the univariate analysis (Propofol, HRpreop, HRpostop, SAPpreop, DAPpostop, and MAS 9) on BAI score. Conclusion: Total propofol consumption was higher in patients with high anxiety levels, but it did not have a negative effect on IVF success.

Effect of telephone-supported ergonomic education on pregnancy-related low back pain.

This study investigated the effect of telephone-supported ergonomic education on pregnancy-related low back pain. This study was performed at Trakya University Hospital in Edirne, Turkey between December 15, 2016 and April 4, 2017. One hundred ten pregnant women were included in the study and randomly assigned to one of two groups. Sixty pregnant women received one face-to-face session of ergonomic education followed by three weekly sessions of telephone-supported ergonomic education (intervention group). Fifty pregnant women received only one session of standard face-to-face ergonomic education. Before and after the intervention, low back pain was evaluated using the Visual Analog Scale. Pain-related disability was evaluated with the Oswestry Disability Index, and health-related quality of life was evaluated with the SF-36. Telephone-supported ergonomic education was more effective than standard ergonomic education and can be used as an effective solution for pregnancy-related low back pain.

The attitudes of fertile and infertile women to Oocyte donation in a Muslim and Secular population.

OBJECTIVE: To determine general attitudes of fertile and infertile women to oocyte donation in a Muslim and secular population. METHODS: The participants consisted of fertile women (n=133) who had at least one healthy living child spontaneously conceived without any fertility treatment and infertile women (n=133) who were diagnosed with primary infertility. Both groups were evaluated with charts comprised of 34 questions addressing demographic characteristics and the social aspects of oocyte and sperm donation. RESULTS: Although the age of fertile women was significantly greater than infertile women, there was no significant difference in terms of duration of marriage, education level, or employment status between the two groups. Most of the women in each group reported that they did not have enough knowledge about oocyte donation to make a decision. Only 12% of fertile women and 18% of infertile women declared that they would have oocytes from another woman if they did not have or could not have a child (p=0.004). Only 9.0% of fertile women and 18.8% of infertile women declared that they would donate oocytes to anyone who is infertile (p=0.021). CONCLUSION: Despite improvement in health care, most fertile and infertile women are still against oocyte donation. This situation may be related to the conservative leanings of Turkish society in recent decades.

Surgical treatment before assisted reproductive technologies.

Advances in technology have transformed surgery from a major approach into an art of science capable of treating many diseases and conditions in a less risky way. This advance let physicians perform surgery commonly in their practice. Today, surgery in reproductive medicine has become so customary that evidence has not been questioned commonly. Therefore, this review will help reproductive endocrinologists to read the most recent evidence for surgery to improve in vitro fertilization outcome. This will also help them to inform their patients with the most recent evidence.

Serum Oestradiol Pattern during Coasting is Different in Antagonist Cycles Compared with Long Agonist Cycles in In Vitro Fertilisation.

BACKGROUND: GnRH agonists and antagonists have different mechanism of action, and therefore serum estradiol levels might differ during coasting in IVF. AIMS: To compare the change in serum oestradiol levels after withholding the gonadotropins for coasting between long agonist and antagonist cycles. STUDY DESIGN: Retrospective study. METHODS: Antagonist and long agonist cycles, in which coasting was performed, were analysed in this retrospective analysis. Antagonist cycles (n=50) were compared with long agonist cycles (n=52) with respect to daily serum oestradiol levels following withholding of gonadotropins. RESULTS: The pattern of change in serum oestradiol was different between groups; it increased on the first day by 11.2% and decreased thereafter on the second and third days in the agonist group. However, it began to decrease from the first day in the antagonist group. Therefore, peak serum oestradiol levels were significantly higher in the agonist group than in the antagonist group (mean±standard deviation; 5798±1748 vs 5104±1351 pg/mL). The duration of coasting was shorter in the antagonist group compared with that in the agonist group (mean±standard deviation; 2.60±1.40 vs 1.96±0.88 days). CONCLUSION: Serum oestradiol pattern during coasting is different in antagonist cycles compared with long agonist cycles in in vitro fertilisation.

Successful medical management of post-hysteroscopic metroplasty bleeding with intravenous estrogen therapy: a report of two cases and review of the literature.

Complications from hysteroscopy are rare, but some are potentially life-threatening. Hemorrhage is one of the most common complications of hysteroscopy. In this study, we report 2 cases of post-hysteroscopic bleeding successfully treated with intravenous conjugated equine estrogen (CEE). In our case report, 2 women who were evaluated for infertility were diagnosed with intrauterine septum. After surgical resection of the septum, significant late post-hysteroscopic bleeding was seen in the fourth and eighteenth day of surgery, respectively. Both patients were successfully treated with intravenous CEE 25mg in normal saline solution 50 mL given over 20 minutes every 6 hours. These 2 cases illustrate that intravenous CEE therapy as a short-term treatment is relatively safe and can be considered as an alternative in the treatment of severe post-hysteroscopy bleeding in selected patients without risk factors. In patients with risk factors, such as previous thromboembolic disease, alternative modalities of treatment should be considered.

Use of porcine small intestinal submucosa to reconstruct an ovarian defect.

OBJECTIVE: To investigate the feasibility of using porcine small intestinal submucosa (SIS) as a scaffold for repairing ovarian defects. METHOD: Fourteen female New Zealand rabbits undergoing ovarian resection were randomly allocated to 2 equal groups. The unilateral ovarian defects were repaired with SIS in group 1 animals and without SIS in group 2 animals (control). The volumes of the ovaries were calculated and the severity of adhesions was assessed in 1 animal from each group each month. The ovaries were removed and examined under a microscope. RESULTS: The volumes of the SIS-grafted ovaries were larger than those of the operated ovaries of the control animals (P<0.05). The SIS-grafted ovaries had a lower adhesion score than the operated ovaries of the control group (P<0.001). SIS grafts showed hemorrhage and leukocyte infiltration until the 4th week after surgery, but the ovarian tissue appeared to be well organized from the 12th to the 16th week. At the 28th week, primordial follicles were scattered in the SIS graft. CONCLUSION: SIS graft could be used for repairing the ovary after surgery.

Combating endometriosis by blocking proteasome and nuclear factor-kappaB pathways.

BACKGROUND: The objective of this study is to investigate the effect of pyrrolidine dithiocarbamate [PDTC; a nuclear factor-kappaB (NF-kappaB) inhibitor] and bortezomib (Velcade; a proteasome inhibitor) on the development of experimental endometriotic implants in rats. METHODS: Endometriosis was surgically induced in 30 rats using the method of Vernon and Wilson. Three weeks later the viability and volume of the implants were recorded and classified. Afterwards, rats were put into three groups with equal numbers. The groups were labelled as the control, the PDTC and the bortezomib groups. Seven days after treatment, a third laparotomy was done and the volume of implants was measured again. The animals were then sacrificed, and the implants were stained with Ki67, proliferating cell nuclear antigen (PCNA), CD34, CD31 and Masson's trichrome histochemical staining. RESULTS: In 80% of the implanted rats, vesicles at the suture region were observed, and the rats graded according to average vesicle diameter (D) as: Grade 1 (no vesicle, 20% of rats), Grade 2 (D < 2 mm, 33.3% of rats), Grade 3 (2 mm 4.5 mm, 26.7% of rats) and Grade 4 (D > 4.5 mm, 20% of rats). After treatment with PDTC or bortezomib, these percentages were decreased for Grades 3 and 4, and increased in Grade 1. The post-treatment implant volumes were decreased in the PDTC and bortezomib groups (P < 0.002 and P < 0.001), and slightly increased in the control group (P = 0.279). In the PDTC and bortezomib groups, CD34, CD31, PCNA and Ki67 expression levels were similar but were significantly reduced compared with the control group. CONCLUSIONS: PDTC and bortezomib may represent a novel therapeutic strategy for treatment of endometriosis.

Novel noninvasive detection method for endometriosis: research and development of scintigraphic survey on endometrial implants in rats.

In this experimental study on endometriosis, the majority of the implants were successfully detected with technetium-(99mTc) labeled red blood cell scintigraphy.

Assessment of myoelectrical signal parameters in estrogen, progesterone, and human chorionic gonadotropin administered in nonpregnant rat myometrium after ovariectomy.

OBJECTIVE: To investigate the correlation of myoelectrical signals with spontaneous contractile events and physiological states in the nonisolated uterine horn of rats. DESIGN: In vivo uterine myoelectrical activity recording study. SETTING: Animal and pharmacology laboratory at Inonu University. ANIMAL(S): Thirty-six female Wistar albino rats. INTERVENTION(S): Six animals were not castrated and served as a sham-operated control group; the other 30 were ovariectomized (OVX) and put into groups: unbiased OVX subjects, estrogen (E)-biased OVX subjects, P-biased OVX subjects, E-plus-P-biased OVX subjects, and hCG-biased OVX subjects. An MP100 A-CE was used for data acquisition, and a personal computer was used for processing. MAIN OUTCOME MEASURE(S): Besides the temporal, spectral, and joint time-frequency (spectrotemporal) analysis, some quantitative measures such as standard deviation and mark to space power ratios of myoelectrical signals were measured. RESULT(S): Progesterone, E, and hCG administration down-regulated the power and contraction frequency of the uterine electrical signal. The spectral concentrations that occurred around the 0.9, 0.35, and 0.7 Hz frequency ranges may be distinguishing characteristics for P, E, and hCG, respectively. CONCLUSION(S): Based on the obtained results, uterine contractions change with ovariectomy and administration of hormones. Progesterone, E, and hCG particularly prolong the quiescent periods of the uterus by reducing the frequency of uterine contractions as well as the power of the myoelectrical activity. Individual or combined use of P, E, or hCG might favor quiescence of the uterine muscle and the maintenance of pregnancy.

Spectrotemporal changes in electrical activity of myometrium due to recombinant follicle-stimulating hormone preparations follitropin alfa and beta.

OBJECTIVE: To investigate the effects of follitropin alfa and beta on the myoelectrical activity of rat myometrium using signal-processing techniques. DESIGN: Prospective, placebo-controlled study. SETTING: Animal and pharmacology laboratory at Inonu University. ANIMAL(S): Forty-five female Wistar albino rats. INTERVENTION(S): Thirty of 45 animals involved in the experiment were registered as the superovulation group. After two successive normal estrous cycles, these animals were put into three equal subgroups. Group 1 was the control; animals were given 0.9% saline. Groups 2 and 3 were treated with follitropin alfa (Gonal-f) and follitropin beta (Puregon), respectively. The other 15 animals were ovariectomized (OVX) and subjected to the same protocol. The uterine myoelectrical signals were recorded and analyzed using a Matlab environment. MAIN OUTCOME MEASURE(S): Power/second, variance, and the effects of recombinant human follicle-stimulating hormone (FSH) on myoelectrical signals were assessed through temporal, spectral, and joint time-frequency analysis. The uterine endometrium and ovarian morphology were also assessed concerning primary follicles, antral follicles, and corpora lutea. RESULT(S): The power and some characteristic spectral components of myoelectrical signal were reduced with the administration of follitropin alfa and beta. No statistically significant difference was detected between endometrial and ovarian histology of the rats treated with these follitropins. CONCLUSION(S): Uterine myoelectrical signals change with administration of recombinant human FSH preparations. Follitropin beta and, more precisely, follitropin alfa suppress the spectral components and power of the myoelectrical signals, which provides uterine quiescence.

The impact of cesarean birth on subsequent fertility.

PURPOSE OF REVIEW: Recently, the rate of cesarean delivery has increased to 25-30% of all births, the highest rate ever reported in the USA. Primary cesarean deliveries, especially elective procedures, mainly contribute to this increase. Currently, controversy concerning elective cesarean delivery is an area of growing debate. Women should be well informed about the benefits and risks of on-demand cesarean delivery. This may be problematic, however, due to the limited current scientific data on the benefits and risks. One of the issues causing debate is the association between cesarean section and subsequent infertility. In the present review, we aim to analyze the evidence for the impact of cesarean delivery on subsequent fertility. RECENT FINDINGS: Cesarean section has been reported to be associated with decreased subsequent fertility. Recent studies, which have tried to explain this association, suggest that this is most probably voluntary or due to some other biases, or possible confounding factors, which are due to organic or psychosocial effects of an emergency cesarean section or labor preceding the cesarean delivery. SUMMARY: Elective cesarean section does not appear to cause infertility. What we need now, however, are more qualitative studies to determine the contribution of cesarean section per se on fecundity.

The efficacy of first-trimester PAPP-A and free beta hCG levels for predicting adverse pregnancy outcome.

OBJECTIVE: To determine whether first-trimester measurements of maternal serum PAPP-A and free beta hCG levels were associated with adverse pregnancy outcomes. STUDY DESIGN: First trimester maternal serum free beta hCG and PAPP-A were measured in 490 singleton pregnancies. Pregnancies were followed by the fetal-maternal unit, and predictive efficacy of these markers for small for gestational age (SGA) babies, gestational diabetes mellitus and hypertensive disorders were analyzed by cut-off values determined by using a ROC analysis, and also, by using the fifth percentile as the cut-off value. RESULTS: The sensitivities for PAPP-A in predicting pregnancies with a SGA baby and those complicated by a hypertensive disorder were 49% and 73%, respectively, when optimal cut-off values were used. Specificities were 76% and 65%, respectively. Serum free beta hCG had no predictive value for individual pregnancy outcomes. CONCLUSION: Efficacy of first trimester maternal serum markers in predicting adverse pregnancy outcome is low. Even after optimization of cut-off values, these markers do not appear to be clinically acceptable as an effective tool for screening for adverse pregnancy outcomes.

Predictive power of maternal serum and amniotic fluid CRP and PAPP-A concentrations at the time of genetic amniocentesis for the preterm delivery.

OBJECTIVE: To investigate whether maternal serum and amniotic fluid CRP and PAPP-A concentrations at the time of genetic amniocentesis are markers of preterm delivery. STUDY DESIGN: One hundred and forty-one pregnant women were included in this prospective study. Amniotic fluid and maternal serum CRP and PAPP-A concentrations were determined by using commercially available kits. Receiver-operating characteristic (ROC) analysis was performed to determine the efficacy of maternal serum and amniotic fluid CRP and PAPP-A levels in predicting women with preterm delivery. RESULTS: The prevalence of spontaneous preterm delivery before 37 weeks of gestation was 9.9%. ROC analysis revealed that amniotic fluid CRP level was the only parameter, which had a significant power in the prediction of preterm delivery. The optimum cut-off level was 0.65 mg/L. The sensitivity and specificity were 92.9% and 78.7%, respectively. CONCLUSION: The amniotic fluid CRP level has a high sensitivity and specificity in the prediction of preterm delivery and this may be helpful in predicting preterm delivery during genetic amniocentesis.

Screening for pre-eclampsia by using maternal serum inhibin A, activin A, human chorionic gonadotropin, unconjugated estriol, and alpha-fetoprotein levels and uterine artery Doppler in the second trimester of pregnancy.

AIMS: To analyse the predictive power of maternal serum inhibin A, activin A, human chorionic gonadotropin (hCG), unconjugated estriol (uE(3)), alpha-fetoprotein (AFP) levels and uterine artery Doppler in the second trimester of pregnancy in screening for pre-eclampsia. METHODS: Maternal serum inhibin A, activin A, hCG, uE(3), and AFP levels and uterine artery Doppler were determined in 178 healthy, pregnant women in the second trimester of pregnancy. Serum samples were collected between the 16th and 18th weeks of gestation, and Doppler investigation was performed between the 24th and 26th weeks of gestation. Receiver operating characteristic curves were created to analyse the predictive powers of the above parameters in screening for pre-eclampsia. Different combinations also were analysed. RESULTS: The rate of pre-eclampsia was 7.9% (14/178). Maternal serum inhibin A, activin A, hCG, AFP levels, the rate of presence of the prediastolic notch and uterine artery resistance index (RI) values in pre-eclamptic pregnancies were significantly higher than those in healthy pregnancies. Presence of the prediastolic notch, uterine artery RI, maternal serum activin A and inhibin A levels had high predictive efficacy, and each had a sensitivity between 70 and 93% and a specificity between 87% and 98%. The addition of inhibin A or activin A measurement to the Doppler velocimetry improved the specificity to 99-100%. CONCLUSIONS: Maternal serum inhibin A and activin A levels and uterine artery Doppler appear to be useful screening tests during the second trimester for pre-eclampsia. However, addition of these hormonal markers to Doppler velocimetry only slightly improves the predictive efficacy, which appears clinically insignificant.

Intercycle variabilities of basal antral follicle count and ovarian volume in subfertile women and their relationship to reproductive aging: a prospective study.

BACKGROUND: Reproducibility is an important issue when using tests for estimating ovarian reserve and counseling patients. However, little is known about the intercycle variabilities of basal antral follicle count and ovarian volume. In this prospective study, we analysed the intercycle variabilities of the antral follicle count and ovarian volume, and compared them with those of other basal ovarian reserve tests in subfertile patients. METHOD: Fifty-two ovulatory and infertile women were followed for two consecutive spontaneous cycles. The antral follicle count, ovarian volume, serum follicle stimulating hormone and estradiol levels were determined on day 3 of both cycles. Limits of agreement between two measurements were determined. RESULTS: Limits of agreement were -6.9 and 6.5 for the antral follicle count, and -8.3 and 8.6 for the ovarian volume. These degrees of variation corresponded to a range of 1.30 and 1.45 times their means for the ovarian volume and antral follicle count, respectively. The variability in the antral follicle count was greater in women who were younger than 24.5 years than in those who were older. CONCLUSIONS: Intercycle variabilities of the antral follicle count and ovarian volume were clinically significant. More variation was observed in the antral follicle count of young infertile patients. Therefore, a low antral follicle count in young, infertile, but ovulatory women should be cautiously interpreted. This may not reflect a low ovarian reserve, and these women may have a high antral follicle count in the next cycle.

Antral follicle assessment after down-regulation may be a useful tool for predicting pregnancy loss in in vitro fertilization pregnancies.

Women with diminished ovarian reserve (OR) have a high rate of pregnancy loss. The relationship between hormonal OR tests and pregnancy loss has been studied previously, but, to our knowledge, that between the antral follicle count (AFC) and pregnancy loss has not. Therefore, we aimed to determine whether OR tests, including the AFC, can predict pregnancy loss in women achieving pregnancy by means of in vitro fertilization (IVF), and also to compare their predictive value. All women underwent a fresh cycle of intracytoplasmic sperm injection with a long protocol with mid-luteal start of the gonadotropin-releasing hormone analog, and antral follicles were counted on cycle day 3 following down-regulation. Pregnancy losses up to 12 gestational weeks (n=28) were compared with apparently healthy deliveries (n=34) in this retrospective analysis. Receiver operating characteristic analysis of consecutive pregnancies (n=71) was performed to analyze the optimum cut-off value for the significantly different OR tests. Women with a pregnancy loss had a lower AFC than those with healthy deliveries. Age and hormonal OR tests were comparable between groups. The optimum cut-off value for the AFC to predict pregnancy loss was 7.5. AFC may be a useful tool for predicting pregnancy loss in IVF pregnancies.

Exposure to low outdoor temperature in the midtrimester is associated with low birth weight.

BACKGROUND: Although seasonal variation of birth weight has been reported previously, contributing factors such as the meteorological factor and its specific period of exposure remain unclear. AIM: To investigate the effect of season on birth weight and to determine the meteorological factor and its specific period of exposure which can contribute to any seasonal variation in birth weight. METHODS: Retrospective analysis of 3333 singleton live births after 36 completed weeks of pregnancy. Maternal age, parity, route of delivery, sex and individual meteorological variables for the first, second, and third trimesters of each pregnancy were analysed using multiple regression analysis with the birth weight as the dependent variable. RESULTS: A seasonal pattern was observed with lowest birth weights in women who had their last menstrual periods in summer and autumn. Upon multiple regression analysis, sex, parity, mode of delivery, and the temperature which the mother was exposed to in the second trimester were the independent determinants of birth weight. CONCLUSION: Exposure to low outdoor ambient temperature in the midtrimester can be associated with low birth weight.

Combining cycle day 7 follicle count with the basal antral follicle count improves the prediction of ovarian response.

OBJECTIVE: To analyze the predictive value of cycle day 7 follicle count (CD7-FC) for poor ovarian response during IVF in women down-regulated with a luteal start of GnRH analogue (long protocol). DESIGN: A retrospective analysis. SETTING: University hospital. PATIENT(S): Ninety-one consecutive IVF cycles of 82 subjects. INTERVENTION(S): Basal levels of FSH and E2 were determined in the spontaneous cycle before the IVF cycle. During the IVF cycle, the number of basal and CD7 follicles and CD7 endometrial thickness were determined by ultrasound, and CD7 serum E2 levels were measured. MAIN OUTCOME MEASURE(S): Ovarian response determined according to the number of mature oocytes retrieved. RESULT(S): On receiver operating characteristic analysis, CD7-FC had the highest combination of sensitivity and specificity to detect women with poor ovarian response when compared with the basal ovarian reserve tests. When a combined basal antral FC and CD7-FC evaluation was used with the optimum cutoff values of 6.5 and 7.5, respectively, sensitivity and specificity improved to 85% and 90%, respectively. CONCLUSION(S): Cycle day 7 follicle count during a long IVF protocol is helpful in predicting ovarian response in combination with the antral FC. This combination has high positive and negative predictive values. This may help clinicians and women to cancel cycles earlier and decrease the psychological, financial, and medical burden of a later cancellation.