Perioperative complications in women undergoing thermal balloon endometrial ablation after one or more cesarean deliveries.

OBJECTIVE: To determine whether thermal ballon endometrial ablation can be safely performed after one or more cesarean sections. STUDY DESIGN: Retrospective cohort study including all women who underwent thermal balloon endometrial ablation at the Kepler University Hospital, Austria, between November 2017 and December 2022. For the analysis of the study endpoints, the dataset was divided into two groups: women with at least one cesarean section, and women without a history of cesarean section. Complications were classified according to the Clavien-Dindo classification. Association was tested using Fisher's exact test. RESULTS: Of the 361 women included, 29.3 % (n = 105) had at least one previous cesarean section. The association between intraoperative uterine rupture and previous cesarean section was not statistically significant (0 % vs. 1 %; p = 0.292). Only one uterine rupture was observed in the cesarean section group, which was located at the uterine fundus after a preoperatively unknown previous uterine perforation during IUD insertion. Secondary endpoints (overall complication rate, postoperative endometritis, vesicouterine fistula, different grades of Clavien-Dindo-classification) showed no significant associations either, even when considering the number of previous cesarean sections. The readmission rate to the clinic for bleeding disorders was 11.4 % in both groups (p = 1.00). CONCLUSION: Women who have had one or more prior cesarean sections with transverse isthmocervical hysterotomy do not appear to have an increased risk of complications in a subsequent thermal balloon endometrial ablation.

Can Classifications Adequately Represent Genital Malformations?: EVA Study ( E SHRE/ESGE | V CUAM | A FS) - A Prospective Multicenter Study to Evaluate the Current Female Genital Malformation Classifications.

Introduction Genital malformations are a common clinical occurrence that can be represented using different classifications. Reproducibility is an essential quality characteristic for a classification, and it plays an important role, especially in consultations and the treatment of infertile patients and in obstetric management. The aim of this study is to demonstrate the reproducibility and clinical practicality of three commonly used classifications: the ESHRE/ESGE (European Society of Human Reproduction and Embryology/ European Society for Gynecological Endoscopy), VCUAM (Vagina Cervix Uterus Adnex-associated Malformation), and AFS (American Fertility Society) classifications. Materials and Methods Sixty-five patients with female genital malformations were included in this prospective, multicenter, exploratory, observational study. All participants underwent a clinical examination and a medical interview. The investigators were instructed to classify the presenting malformations according to the ESHRE/ESGE, VCUAM, and AFS classifications using a structured questionnaire. Investigators were asked whether the malformation could be reproducibly classified (yes/no) and about the grade (grade 1-5 from "very good" to "deficient") they would assign to each classification. Classification assessment was queried for vagina, cervix, uterus, adnexa, and associated malformations and was scored from 1 to 5. Results Reproducibility was rated as 80% (n = 52/65), 92.3% (n = 60/65), and 56.9% (n = 37/65) for the ESHRE/ESGE, VCUAM, and AFS classification, respectively. ESHRE/ESGE, VCUAM and AFS were rated as "very good" or "good" for 83.3%, 89.2%, and 10.8% of vaginal malformations; for 75.8%, 87.5%, and 24.2% of cervical malformations; and for 89.7%, 89.5%, and 86.2% of uterine malformations, respectively. VCUAM was rated as "very good" or "good" for 77.8% and 69.6% of adnexal malformations and associated malformations, respectively. ESHRE/ESGE and AFS were rated as "sufficient" or "deficient" for 100% and 75% of adnexal malformations and for 77.3% and 69.6% of associated malformations, respectively. Conclusion The prospective multicenter EVA ( E SHRE/ESGE | V CUAM | A FS) study revealed that the organ-based ESHRE/ESGE and VCUAM classifications of female genital malformations perform better in terms of reproducibility as well as in the assessment of individual compartments than the non-organ-based AFS classification.

Antibody Response and Maternofetal Antibody Transfer in SARS-CoV-2-Positive Pregnant Women: A Multicenter Observational Study.

Introduction Awareness of SARS-CoV-2 infection in pregnant women and the potential risk for infection of their neonates is increasing. The aim of this study was to examine the immune status of affected women and evaluate the dynamics of placental antibody transfer. Materials and Methods The study included 176 women with SARS-CoV-2 infection during pregnancy who delivered between April 2020 and December 2021 at eight obstetric maternity sites. Demographic data, maternal and neonatal characteristics were summarized. Antibody testing for IgA and IgG in maternal blood sera and umbilical cord samples was evaluated and IgG transfer ratios were calculated. Values were related to the time of infection during pregnancy and birth. Results The percentage of IgG positive women increased from 29.0% (95% CI 23.8 - 37.8) at presentation with a positive PCR test result to 75.7% (95% CI 71.6 - 79.8), the percentage of IgG positive umbilical cord blood samples increased from 17.1% (95% CI 13.0 - 21.3) to 76.4% (95% CI 72.2 - 80.7) at more than six weeks after infection. Regression lines differed significantly between maternal and fetal IgG responses (p < 0.0001). Newborns react with a latency of about one week; umbilical cord blood antibody concentrations are highly correlated with maternal concentration levels (ρ = 0.8042; p < 0.0001). IgG transplacental transfer ratios were dependent on infection-to-birth interval. Two of the umbilical cord blood samples tested positive for IgA. Conclusions These findings confirm vertical SARS-CoV-2 transmission is rare; however, antibodies are transferred to the fetus soon after infection during pregnancy. Since transplacental antibody transfer might have a protective value for neonatal immunization this information may be helpful when counseling affected women.

Double ionophore application in cases with previous failed/low fertilization or poor embryo development.

RESEARCH QUESTION: Does a double ionophore application improve the outcome of cycles in which single ionophore application was unsuccessful? DESIGN: This retrospective intervention study (duration 4.5 years) included 79 patients with suspected chronic failed oocyte activation (<30% fertilizations) and/or poor embryo development (developmental arrest, 24 h developmental delay, blastulation rate <15%) in both preceding cycles, the first without ionophore and the second with single ionophore treatment. Within the study period, all patients with failed ionophore treatments (single applications of ready-to-use calcimycin for 15 min) were offered an adapted protocol in the subsequent cycle (study cycle) in which the same ionophore was applied twice (separated by 30 min). Tests for paired data (control and study cycle) were used to reduce the effect of confounders. RESULTS: The overall fertilization rate did not differ between the study and control cycles. Cleavage (P = 0.020) and blastocyst formation (P = 0.018) rates improved significantly in the study cycles. Implantation (P = 0.001), biochemical (P < 0.001) and clinical pregnancy (P < 0.001) rates were also significantly higher in the study cycles. The study cycles resulted in 29 live births and all 32 babies born were healthy. CONCLUSIONS: This study suggests that double ionophore application may improve blastocyst formation and clinical pregnancy rates in cases of failed single ionophore treatment, irrespective of whether the ionophore was used to overcome fertilization failure or poor embryo development. Fertilization rate was only increased in cases with a history of fertilization failure. Because single ionophore treatment was used in only one previous cycle it cannot be ruled out that some improvement in clinical outcomes would also have been achieved by using single instead of double ionophore treatment again in the subsequent attempt.

Bleeding pattern after medical management of early pregnancy loss with mifepristone-misoprostol and its prognostic value: a prospective observational cohort study.

PURPOSE: To improve counseling of women by reporting bleeding characteristics at home after medical management of an early pregnancy loss (EPL) with mifepristone and misoprostol, and to evaluate occurring bleeding patterns as a prognostic tool. METHODS: This prospective two-center observational cohort study enrolled 197 women who presented with an EPL (embryonic or anembryonic miscarriage) from December 2017 to April 2019 and chose a home-based medical management with 200 mg mifepristone and 800 mcg misoprostol. From the day of mifepristone intake, the strength of vaginal bleeding was recorded daily for 2 weeks by the patient herself using a diary sheet. Treatment success was defined as no histologically confirmed retained products of conception (RPOC) within 3 months. After considering all drop-out criteria, 154 women were included in the analysis. RESULTS: 40.0% of patients (95% CI 30.4-49.6) already reported bleeding onset in the time period between the intake of mifepristone and misoprostol. The median duration of vaginal bleeding including spotting was 13 days. The chance of RPOC was about sixfold (OR 6.06, 95% CI 2.15-17.10) in the group of persistent bleeding after 2 weeks compared to the group with a terminated bleeding at that time. Exploratory regression analysis indicated association of higher serum levels of leukocytes at treatment start with RPOC (p = 0.013). CONCLUSIONS: Terminated bleeding after 2 weeks is a useful indicator for successful medical induction of EPL. Women undergoing medical treatment with mifepristone must be informed about the high frequency of bleeding onset before misoprostol intake. CLINICAL TRIAL REGISTRATION: DRKS-German Clinical Trials Register, ID: DRKS00013515, registration date 05.12.2017. http://www.drks.de/DRKS00013515 .

Ionophore application for artificial oocyte activation and its potential effect on morphokinetics: a sibling oocyte study.

PURPOSE: To evaluate whether ionophore application at the oocyte stage changes the morphokinetics of the associated embryos in cases of artificial oocyte activation. METHODS: In a prospective sibling oocyte approach, 78 ICSI patients with suspected fertilization problems had half of their MII-oocytes treated with a ready-to-use ionophore (calcimycin) immediately following ICSI (study group). Untreated ICSI eggs served as the control group. Primary analyses focused on morphokinetic behavior and the presence of irregular cleavages. The rates of fertilization, utilization, pregnancy, and live birth rate were also evaluated. RESULTS: Ionophore-treated oocytes showed a significantly earlier formation of pronuclei (t2PNa) and a better synchronized third cell cycle (s3) (P < .05). The rate of irregular cleavage was unaffected (P > .05). Ionophore treatment significantly improved the overall rates of fertilization (P < .01) and blastocyst utilization (P < .05). CONCLUSION: Ionophore application does not negatively affect cleavage timing nor is it associated with irregular cleavage.

Retrospective evaluation of attempted vaginal deliveries in dichorionic twin pregnancies.

PURPOSE: Numbers of planned cesarean deliveries are increasing in twin pregnancies, despite the lack of evidence for this approach, and the second twin is thought to be at risk for a poorer outcome. The aim of this study was to examine whether twins have a poorer outcome if an attempted vaginal delivery is changed to a cesarean section or combined delivery. METHODS: This retrospective data analysis included all women with dichorionic twin pregnancies attempting vaginal delivery over a 10-year period. Outcome parameters for the first and second twins relative to their mode of birth were compared. A correlation model between the interdelivery time interval and Apgar scores was calculated. Subgroup analyses assessing the birth mode of the first and second twins were conducted. RESULTS: A total of 248 women were enrolled in the study. The second twins had significantly lower values for outcome parameters, such as umbilical artery cord pH and Apgar scores in comparison with the first twins (P < 0.01). The subgroup analysis of birth modes in first and second twins showed a significantly poorer outcome in the cesarean section and combined delivery group (P < 0.05). The interdelivery time interval was significantly longer in the second twin cesarean section group (P < 0.01). There was no significant correlation between the interdelivery time intervals and Apgar scores (P > 0.05). CONCLUSION: Although outcome parameters were significantly lower in second twins and twins born via secondary cesarean section, the clinical relevance of this appears to be negligible.