Effect of intraovarian platelet-rich plasma injection on IVF outcomes in women with poor ovarian response: the PROVA randomized controlled trial.

STUDY QUESTION: Does intraovarian platelet-rich plasma (PRP) injection increase the number of mature oocytes obtained after controlled ovarian stimulation (COS) in young women with poor ovarian response (POR) undergoing IVF? SUMMARY ANSWER: Intraovarian PRP injection procedure does not improve mature oocyte yield after COS in women less than 38 years old with an established IVF history of POR. WHAT IS KNOWN ALREADY: POR is frequently encountered among the infertile population and the number of women seeking infertility treatment related to POR is increasing. Effective treatment options for this patient population to conceive with autologous oocytes are lacking. Case series and cohort studies suggest that intraovarian PRP injection may improve follicular recruitment in women with premature ovarian insufficiency (POI) and POR, yet robust randomized studies have not been performed to date to determine the clinical utility of this intervention. STUDY DESIGN, SIZE, DURATION: This was a multi-center randomized controlled trial (RCT) conducted at university-affiliated reproductive centers in the USA and Turkey, between January 2020 and November 2022. PARTICIPANTS/MATERIALS, SETTING, METHODS: Patients who met inclusion criteria (<38 years old, two or more prior cycles with <3 oocytes retrieved; and without single gene disorders, prior ovarian surgery, endometriomas, BMI >35 kg/m2, or severe male factor infertility) were randomized to either the PRP or control group. Patients in both groups subsequently underwent COS, oocyte retrieval, ICSI, preimplantation genetic testing for aneuploidy (PGT-A), and single euploid embryo transfer. Number of metaphase II (MII) oocytes obtained was the primary outcome. Secondary outcomes included ovarian reserve tests (antral follicle count [AFC] and anti-Müllerian hormone [AMH]), blastocyst and euploid blastocyst yields, and sustained implantation. The study was powered to detect a difference of one mature oocyte obtained at oocyte retrieval. MAIN RESULTS AND THE ROLE OF CHANCE: In total, 83 patients met inclusion criteria and were randomized to receive autologous intraovarian PRP injection (n = 41) or to no intervention (n = 42). No significant differences were observed in number of MII oocytes retrieved per cycle (2.8 ± 2.4 vs 3.1 ± 3.3 in PRP vs control, respectively; P = 0.9), blastocysts (1.0 ± 1.3 vs 1.3 ± 2.1, P = 0.8), or euploid blastocysts (0.8 ± 1.1 vs 0.9 ± 1.6; P = 0.5). Similarly, no differences were observed in the likelihood of obtaining at least one euploid blastocyst (45% vs 37%, P = 0.4; relative risk [RR], 95% CI = 0.9, 0.6-1.2) or the rate of sustained implantation (31% vs 29%, P = 0.9; RR 1.0, 0.7-1.3). Posttreatment AFC (7.9 ± 4.5 vs 6.8 ± 4.8, P = 0.3) and AMH (0.99 ± 0.98 vs 0.7 ± 0.6, P = 0.2) were also not different between the groups. LIMITATIONS, REASONS FOR CAUTION: Results from this RCT may not be generalizable to other PRP preparations owing to heterogeneity and lack of standardization. The control groups did not undergo a sham ovarian injection, which would have been relevant had the results shown benefit of PRP injection. Only patients with POR were included in this study, and these results may not be generalizable to more severe diminution of ovarian reserve, as seen with POI. WIDER IMPLICATIONS OF THE FINDINGS: The intraovarian PRP injection procedure does not improve mature oocyte yield or other parameters of IVF outcome in women less than 38 years old with an established IVF history of POR. The results from this study do not support the use of intraovarian PRP injection in this population. STUDY FUNDING/COMPETING INTEREST(S): Departmental funds were used and no external funding was requested for this study. ES is a consultant for and receives grant funding from the Foundation for Embryonic Competence. All other authors have no conflict of interest to declare. TRIAL REGISTRATION NUMBER: Clinicaltrials.gov Registry Identifier: NCT04163640. TRIAL REGISTRATION DATE: 15 November 2019. DATE OF FIRST PATIENT'S ENROLMENT: 24 February 2020.

Thyroid hormones and ovarian reserve: a comprehensive study of women seeking infertility care.

BACKGROUND: Ovarian reserve is the number of oocytes remaining in the ovary and is one of the most important aspects of a woman's reproductive potential. Research on the association between thyroid dysfunction and ovarian reserve has yielded controversial results. In our study, we aimed to investigate the relationship between thyroid-stimulating hormone (TSH) levels and ovarian reserve markers. METHODS: From 1443 women seeking infertility care, the data of 1396 women aged between 20-45 years old who had a body mass index between 18-30 kg/m2 were recruited for this retrospective study. The anti-Müllerian hormone (AMH) and TSH relationship was analyzed with generalized linear and polynomial regression. RESULTS: Median age, follicle-stimulating hormone (FSH), AMH, and TSH levels were 36.79 years, 9.55 IU/L, 3.57 pmol/L, and 1.80 mIU/L, respectively. Differences between TSH groups were statistically significant in terms of AMH level, antral follicle count (AFC), and age (p = 0.007 and p = 0.038, respectively). A generalized linear regression model could not explain age-matched TSH levels concerning AMH levels (p > 0.05). TSH levels were utilized in polynomial regression models of AMH, and the 2nd degree was found to have the best fit. The inflection point of the model was 2.88 mIU/L. CONCLUSIONS: Our study shows a correlation between TSH and AMH values in a population of infertile women. Our results are as follows: a TSH value of 2.88 mIU/L yields the highest AMH result. It was also found that AMH and AFC were positively correlated, while AMH and FSH were negatively correlated.

Effects of Non-Cavity-Distorting Intramural Fibroids on IVF Outcomes in Patients with Recurrent IVF Failure: Does Myomectomy Change IVF Outcomes ?

Background: Uterine fibroids are the most common benign smooth muscle tumors of the uterus. However, there is no consensus on whether myomectomy improves IVF success in women with non-cavity-distorting intramural fibroids. The aim of this study was to compare the IVF and pregnancy outcomes of women who had non-cavity-distorting intramural fibroids and underwent myomectomy vs women who had intramural fibroids, but did not undergo myomectomy. Methods: A retrospective cohort study at Acibadem Maslak Hospital, IVF Center, between 2019 and 2020. Data of 128 women aged between 25 and 43 years who have at least 2 intramural non-cavity-distorting fibroids of 2-6 cm in size were used. All patients had at least two IVF failure. The intervention group comprised women who decided to proceed to myomectomy before IVF (Group 1, n = 56). The control group was established women with intramural fibroids who reject myomectomy (Group 2, n = 71). Results: In regard to IVF result parameters and perinatal outcomes, there was no statistically significant difference between the two groups. Between study groups, there were no statistically significant differences in the perinatal outcomes. Myomectomy surgery did not increase miscarriage and biochemical pregnancy rate (odds ratio (OR) 0.9; 95% confidence interval (CI) 2.8-3.7). Conclusion: Myomectomy does not impact on pregnancy or live birth rates substantially, according to the results of this study.

Does dual trigger improve euploidy rate in normoresponder? A cross-sectional study.

Background: With the introduction of the dual triggering-gonadotropin-releasing hormone (GnRH) analog and recombinant human chorionic gonadotropin (hCG) combination, women with a history of low mature oocyte proportion and empty follicle syndrome were shown to benefit from the dual trigger. Objective: To investigate whether dual triggering of oocyte maturation with a GnRH agonist (GnRHa) combined with hCG can affect the euploidy rate and improve in vitro fertilization outcomes for normoresponder women. Materials and Methods: In this cross-sectional study, 494 women who underwent controlled ovarian stimulation with hCG (n = 274) or dual triggering (hCG+GnRHa, n = 220) at Acibadem Maslak hospital, Assisted Reproductive Unit, from January 2019-2022 were enrolled in this study. Preimplantation genetic testing for aneuploidy was performed on all participants. Results: Both groups had similar baseline and clinical characteristics. Of the 881 embryos biopsied, 312 (35.4%) were reported as euploid in the hCG trigger group; in the dual trigger group, 186 (29.8%) of 623 screening embryos were reported as euploid. The hCG group had a higher euploidy rate per biopsied embryo, although the difference was not statistically significant (31.4 ± 26.5 vs. 26.5 ± 33.3, p > 0.05). Conclusion: In normoresponders, adding GnRHa for final follicular maturation to hCG did not improve the euploidy rate.

Treatment options for endometrial hypoproliferation.

PURPOSE OF REVIEW: Endometrial hypoproliferation refers to the failure of the endometrium to reach optimal thickness during fresh or frozen embryo transfer cycles in women undergoing infertility treatment with in-vitro fertilization (IVF). This review discusses the treatment options for endometrial hypoproliferation. RECENT FINDINGS: Apart from factors related to the embryo quality, ultrasonographic findings associated with the endometrium, such as endometrial thickness, endometrial pattern and subendometrial blood flow, are considered key factors associated with the outcome of assisted reproductive treatment. To date, a consensus has not been reached regarding the definition of thin endometrium, while thresholds of 6, 7 or 8 mm have been used in the literature. Strategies to increase endometrial thickness can be reviewed in three groups: endocrine approaches, vitamins & supplements, and new experimental therapeutic interventions. Some of the recently introduced experimental therapeutic interventions such as platelet-rich plasma injection, stem cell treatment and tissue bioengineering are exciting potential therapies that need to be further studied. SUMMARY: Despite a large number of publications on the topic, diagnosing and treating endometrial hypoproliferation remains a challenge. Well designed studies are needed to establish a widely accepted endometrial thickness cut-off value below which endometrial hypoproliferation is diagnosed and to generate meaningful data that would allow an evidence-based discussion of available therapeutic options with patients.

Distress response in granulosa cells of women affected by PCOS with or without insulin resistance.

PURPOSE: In this study, we investigated whether metabolic dysfunction in women with Polycystic ovarian syndrome (PCOS) induces granulosa cell (GC) stress and activates in the endoplamatic reticulum and the mitochondria (UPRer and UPRmt, respectively). METHODS: Women who were diagnosed with PCOS (based on the Rotterdam criteria), were divided into two groups, PCOS with insulin resistance (PCOS-IR; n = 20) and PCOS with no insulin resistance (PCOS-nIR; n = 20), and compared to healthy oocyte donors (CONT; n = 20). Insulin resistance (IR) was assessed on the results of homeostasis model assessment (HOMA) that determines IR using the concentration of fasting plasma glucose and fasting insuline. Expression of UPRer genes (i.e., IRE1, ATF4, ATF6, XBP1, BIP, and CHOP), and UPRmt genes (i.e., HSP60, HSP10, CLPP, and HSP40) was assessed in cumulus GCs by qRT-PCR. RESULTS: We found that several genes involved in UPRer and UPRmt were overexpressed in the GCs of PCOS-IR and PCOS-nIR compared to CONT. IRE1, ATF4 and XBP1, that are activated by ER stress, were significantly overexpressed in PCOS-IR compared to CONT. BIP and CHOP were overexpressed in PCOS groups compared to CONT. HSP10 and HSP40 were upregulated in PCOS-IR and PCOS-nIR groups compared to the CONT. HSP60 and CLPP showed no statistical different expression in PCOS-IR and PCOS-nIR compared to CONT group. CONCLUSION: Our findings suggest that the GCs of women with PCOS (with or without IR) are metabolically distressed and upregulate UPRer and UPRmt genes. Our study contributes to the understanding of the molecular mechanisms underlying the pathological changes that occur in the follicular microenvironment of women with PCOS.

What should be the strategy in case of a big follicle at the start of the cycle? Shall we start the stimulation or postpone it to the next cycle?

Objective: This study facilitates decision-making when an antral follicle diameter >15 mm is detected at the beginning of the menstrual cycle in poor responder (POR) patients. Materials and Methods: Eighty-three POR patients with at least one leading follicle with a diameter of 15 to 24 mm on the 2nd-4th days of the menstrual cycle were assessed. Results: The mean age of females was 40.1±4.8 (26-45), and the mean partners' age was 42.1±7.8 (26-65). Fifty-one (61.4%) women underwent an oocyte pick-up procedure 36 h after the first ultrasonographic examination on the 2nd-4th days of the menstrual cycle. Gonadotrophin stimulation was initiated in 32 (38.6%) patients. Among women in whom oocyte retrieval was performed, an oocyte was obtained in 49 (59.75%) patients. In 13 of 49 patients (26.5%), no mature oocytes were obtained. Fertilized 2pn embryos were obtained in 18 of 33 patients (54.5%). Among the fertilized embryos, 12 were good, six were moderate, and two were of poor quality. Following the frozen embryo transfer procedure, one of the two patients experienced a clinical pregnancy. Conclusion: Patients with POR are still difficult to manage both clinically and therapeutically. Since every oocyte is valuable and important, patients should be carefully followed up. Our research will be directed by the need to rule out a physiological ovarian cyst when large antral follicles appear at the beginning of the cycle. The clinician should give them a chance.

Ovarian reserve parameters and IVF outcomes in 510 women with poor ovarian response (POR) treated with intraovarian injection of autologous platelet rich plasma (PRP).

The aim of the current study was to characterize ovarian reserve parameters and IVF outcomes in women with a history of poor ovarian response (POR) treated with intraovarian injection of autologous platelet rich plasma (PRP). Reproductive age women (N=510; age range 30-45yo) diagnosed with POR based on Poseidon criteria were included in the study. PRP treatment resulted in higher AFC, higher serum AMH, lower serum FSH, and a higher number of mature oocytes and cleavage and blastocyst stage embryos. After PRP injection, 22 women (4.3%) conceived spontaneously, 14 (2.7%) were lost to follow up, and 474 (92.9%) attempted IVF. Among women who attempted IVF, 312 (65.8%) generated embryos and underwent embryo transfer, 83 (17.5%) achieved a pregnancy, and 54 (11.4%) achieved sustained implantation/live birth (SI/LB). In total, of the 510 women with POR and mean age of 40.3, PRP resulted in improvement of ovarian reserve parameters, a pregnancy rate of 20.5% and SI/LB rate of 12.9%. Our findings suggest that PRP treatment may be considered in women with POR. For wider clinical application, its clinical efficacy will need to be demonstrated in prospective randomized clinical trials.

Effects of intraovarian injection of autologous platelet rich plasma on ovarian reserve and IVF outcome parameters in women with primary ovarian insufficiency.

We aimed to determine whether intraovarian injection of autologous platelet rich plasma (PRP) improves response to ovarian stimulation and in vitro fertilization (IVF) outcome in women with primary ovarian insufficiency (POI). Women (N=311; age 24-40) diagnosed with POI based on ESHRE criteria underwent intraovarian PRP injection. Markers of ovarian reserve, and IVF outcome parameters were followed. PRP treatment resulted in increased antral follicle count (AFC) and serum antimullerian hormone (AMH), while serum follicle stimulating hormone (FSH) did not change significantly. After PRP injection, 23 women (7.4%) conceived spontaneously, 201 (64.8%) developed antral follicle(s) and attempted IVF, and 87 (27.8%) had no antral follicles and therefore did not receive additional treatment. Among the 201 women who attempted IVF, 82 (26.4% of total) developed embryos; 25 of these women preferred to cryopreserve embryos for transfer at a later stage, while 57 underwent embryo transfer resulting in 13 pregnancies (22.8% per transfer, 4% of total). In total, of the 311 women treated with PRP, 25 (8.0%) achieved livebirth/sustained implantation (spontaneously or after IVF), while another 25 (8.0%) cryopreserved embryos. Our findings suggest that in women with POI, intraovarian injection of autologous PRP might be considered as an alternative experimental treatment option.

Determining diagnostic criteria and cause of recurrent implantation failure.

PURPOSE OF REVIEW: Recurrent implantation failure (RIF) refers to the absence of implantation after repeated transfer of good embryos into a normal uterus. This review discusses the diagnostic criteria and cause of RIF. RECENT FINDINGS: Regardless of the advancements in IVF practice, RIF is still a challenge that has to be solved. Exact definition of RIF is lacking today. For the initial evaluation, a rigorous algorithmic evaluation should be compromised with an individualized principle. Factors that might affect the number and quality of the oocyte and sperm cells should be investigated in order to obtain a good-quality embryo. Embryo assessment should be performed under ideal laboratory circumstances. The uterine environment should be carefully evaluated and the embryo should be transferred into the uterus at the most receptive time. Some of the newly introduced diseases and empirical treatment strategies, such as chronic endometritis, vaginal microbiota, immunologic profile and immunomodulator treatments, can be discussed with the couple under the light of adequate evidence-based information. SUMMARY: New diagnostic and treatment modalities are needed to be introduced, which would be safe, efficient and efficacious after well-designed randomized controlled trials.

Branch retinal artery occlusion in a patient undergoing Methotrexate therapy for ectopic pregnancy: A case report.

Methotrexate is a commonly used agent in the treatment of an un-ruptured ectopic pregnancy. Thromboembolic events are rarely seen side effects of such a medicine. We report the case of the 22-year-old woman who underwent Methotrexate therapy for an un-ruptured ectopic pregnancy without any history of thromboembolic risk factors. A second dose (50 mg/m2) was administered to the patient showing a nondecreasing pattern of ß-HCG levels after an initial standard dosage of Methotrexate (50 mg/m2). On the 12th day of the treatment, a sudden onset of painless vision loss was seen in the right eye. Fundal imaging and fluorescein angiography revealed an occlusion of the superior temporal branch of the right retinal artery. After a month of hyperbaric oxygen therapy, complete recovery without loss of vision was achieved.

HOXA-10 gene expression in ectopic and eutopic endometrium tissues: Does it differ between fertile and infertile women with endometriosis?

OBJECTIVE: To compare HOXA-10 gene expression in eutopic endometrium samples, between fertile and infertile endometriosis patients and the fertile control cases, and in endometrium and endometrioma specimens, between severe and moderate endometriosis cases. STUDY DESIGN: Prospective clinical study included women without infertility and endometriosis (Group 1); women without infertility but with endometrioma (Group 2); and infertile women with endometrioma (Group 3). In addition, the Group 2 and 3 cohort were assessed based on the findings obtained during laparoscopy, based on the (rAFS) scoring, as women with a rAFS score of 16-40 were evaluated in Group A, whereas those with rAFS score above 40 were considered in Group B. HOXA-10 gene expression was evaluated in both secretory endometrium tissue and endometrioma specimens. RESULTS: Eutopic endometrium samples from group 2 (reference gene = 0,680 vs. target gene = 0,362) and group 3 (reference gene = 0,641 vs. target gene = 0,183) patients revealed a 1,871-fold and 3,509-fold decrease in HOXA-10 gene expression, respectively, as compared to group 1. Endometrial HOXA-10 gene expression was 1,778-fold down-regulated in group 3 women (reference gene = 1,510 vs. target gene = 0,850), when compared to group 2. Both eutopic endometrium and endometrioma tissue samples from severe endometriosis patients revealed 1,259-fold (reference gene = 1,523 vs. target gene = 1,210) and 1,338-fold (reference gene = 1,274 vs. target gene = 0,952), down-regulation in HOXA-10 gene expressions, respectively, as compared to moderate cases. CONCLUSION: Endometrial HOXA-10 gene expression in women with endometriosis is significantly down-regulated than in those without endometriosis. Endometriosis patients with infertility have significantly lower levels of endometrial HOXA-10 gene expression than endometriosis without infertility; thus decreased expression of this gene may, directly or indirectly, be related with the endometriosis-associated infertility. Severe endometriosis cases express, in their both endometrium and endometrioma tissues, significantly lower levels of HOXA-10 gene than moderate endometriosis cases.

The Timing of Embryo Transfer Catheter Removal: Should It be Delayed or Done Immediately? A Prospective Randomized Trial.

BACKGROUND/AIMS: Data on the timing of catheter removal technique following embryo transfer (ET) are quite limited. We aimed to compare the reproductive outcomes of intracytoplasmic sperm injection (ICSI)/ET cycles in which the transfer catheter was removed immediately with those in which the catheter was removed after a delay period and hereby to evaluate the impact that the time interval before removal of the catheter following embryo deposit may have on the fertility outcomes. METHODS: A prospective randomized study was designed. ICSI/ET patients <40 years were randomly assigned to either of the group from which catheter was withdrawn immediately within the first 5 s (Group A) or after a 30 s delay (Group B) following ET. RESULTS: Groups A and B consisted of 147 and 148 patients, respectively. Patient demographics and stimulation characteristics were comparable between the groups. Pregnancy rate was 32.2% (95 of 295) and clinical pregnancy rate was 28.8% (85 of 295), whereas ongoing pregnancy was 24.4% (72 of 295) and implantation rate was 29.6% (100 of 338). The comparison of reproductive outcomes revealed no significant differences in pregnancy (p = 0.933), clinical pregnancy (p = 0.673), ongoing pregnancy (p = 0.590), multiple pregnancy (p = 0.801), and implantation rates (p = 0.979) between the groups. CONCLUSION: No significant difference was observed in the reproductive outcomes between the groups; thus, there appears no requirement to delay the withdrawal of the catheter to improve the outcomes in ICSI cycles.

Impact of insulin resistance and obesity on intracytoplasmic sperm injection outcomes in young women with polycystic ovary syndrome.

OBJECTIVE: To examine effects of body mass index (BMI) and insulin resistance (IR) on the in vitro fertilization (IVF) outcomes in women with polycystic ovary syndrome (PCOS). METHODS: A total of 106 women with PCOS who underwent intracytoplasmic sperm injection were investigated. The patients were stratified into groups according to their BMI [healthy weight: BMI <25 kg/m2 (n=51), overweight: ≤25-29.9 kg/m2 (n=27), and obese: ≥30 kg/m2 (n=28)]. Secondly, the patients were classified based on the presence of IR (IR was considered to be present if homeostatic model assessment-IR was >2.5). The main outcome measures were reproductive and IVF outcomes with respect to BMI and IR. RESULTS: The basal hormonal evaluations, such as follicle-stimulating hormone (FSH), luteinizing hormone (LH), LH/FSH, estradiol, testosterone, DHEAS, AMH, and antral follicle counts, were similar between the groups of BMI and IR. The number of retrieved oocytes, MII oocytes, embryo counts, and fertilization and pregnancy rates were similar between lean and overweight/obese PCOS with and without IR. Even though pregnancy and delivery rates per started cycle and embryo transfer were higher in healthy-weight women with PCOS than in overweight/obese patients, it did not reach statistical significance. CONCLUSION: Reproductive outcomes in women with PCOS according to BMI and IR were similar. Neither BMI nor IR had an independent effect on ovarian response and IVF success in young women with PCOS.

Application of a Mixed Material Graft to Posterior Intravaginal Slingoplasty Procedure: Preliminary Pilot Series.

Good anatomic outcomes have been achieved with transvaginal synthetic materials in pelvic organ prolapse, but mesh-related complications are a major health concern. Therefore, developing new synthetic or biological materials with increased tissue strength and decreased complications are major challenges. This paper presents preliminary pilot series of Posterior Intravaginal Slingoplasty (PIVS) procedure performed with mixed material graft containing both autologous tissue and a synthetic material. Six women with symptomatic Utero-Vaginal Prolapse (UVP) ≥ stage 2 underwent the PIVS procedure. Pelvic floor symptoms were assessed with the Pelvic Organ Prolapse Quantification (POP-Q) system, Pelvic Floor Distress Inventory (PFDI), and the Pelvic Floor Impact Questionnaire (PFIQ) both before the procedure and 36 months after the surgery. There were no mesh-related complications or recurrence and all the patients had good functional and anatomic outcomes. These preliminary results are promising, but further long-term studies with a larger series are needed.

Evaluation of endometrial natural killer cell expression of CD4, CD103, and CD16 cells in women with unexplained infertility.

OBJECTIVE: To determine whether natural killer cell (NK) concentrations in the mid-secretory endometrial tissue of women with unexplained infertility differ from those in the mid-secretory endometrial tissue of fertile women. METHODS: This study was conducted with 22 patients with unexplained infertility caused by unsuccessful ovulation induced with gonadotrophins and 12 healthy fertile women, who formed a control group. Mid-secretory endometrial tissue samples were obtained with a Pipelle catheter, and the endometrial NK cell phenotypes were determined by flow cytometry. RESULTS: The median number of CD4+ cells in the endometrium was significantly lower in women with unexplained infertility compared with in the fertile controls (3.31 vs. 5.81; p=0.02). The CD4(+)/CD8(+) cell ratio in the unexplained-infertility group was significantly lower than that in the control group (0.42 vs. 0.76, p=0.01). The median number of CD103(+) cells in the endometrium of the infertile group was significantly lower than that in the endometrium of the control group (4.40 vs. 6.73, p=0.02). The median number of CD16(+) cells was significantly higher in infertile women than in control women (0.12 vs. 0.001, p=0.01). CONCLUSIONS: Significant reductions in the numbers of CD4(+) and CD103(+) cells as well as in the CD4(+)/CD8(+) ratio but an increased number of CD16(+) cells in the endometrium of infertile women suggest that disordered NK cell activity may be a contributor to the etiology of unexplained infertility.

Perifollicular blood flow and its relationship with endometrial vascularity, follicular fluid EG-VEGF, IGF-1, and inhibin-a levels and IVF outcomes.

PURPOSE: The aim of this study is to investigate the association of perifollicular blood flow (PFBF) with follicular fluid EG-VEGF, inhibin-a, and insulin-like growth factor-1 (IGF-1) concentrations, endometrial vascularity, and IVF outcomes. METHODS: Forty women with tubal factor infertility were included in a prospective cohort study. Each woman underwent IVF/ICSI procedure. Individual follicles of ≥16 mm (n = 156) were evaluated by power Doppler analysis and categorized as well-vascularized follicles (WVFs) or poorly vascularized follicles (PVFs). WVFs referred to those with perifollicular vascularity of 51-100 %. Each follicular fluid (FF) was individually aspirated and FF/serum EG-VEGF, inhibin-a, and FF IGF-1 levels were evaluated. Zones III-IV endometrial vascularity was classified as a well-vascularized endometrium (WVE). The presence of a WVE and mature oocytes, in addition to the embryo quality and clinical pregnancy rate (CPR), were recorded for each follicle. The main outcome measures were FF serum EG-VEGF, inhibin-a, IGF-1 levels, and WVE and IVF outcome per PFBF. RESULTS: For WVFs, the level of FF EG-VEGF (p = 0.008), oocyte quality (p = 0.001), embryo quality (p = 0.002), a WVE (p = 0.001), and CPR (p = 0.04) increased significantly. The pregnant group was characterized by increased numbers of WVFs (p = 0.044), a WVE (p = 0.022), and increased levels of FF IGF-1 (p = 0.001) and serum EG-VEGF (p = 0.03). FF IGF-1 >50 ng/mL (AUC 0.72) had 75 % sensitivity and 64 % specificity for predicting CPR. CONCLUSIONS: WVFs yield high-quality oocytes and embryos, a WVE, increased FF EG-VEGF levels, and increased CPRs.

The Effect of Combined Antenatal and Postnatal Counselling on Postpartum Modern Contraceptive Use: Prospective Case-Control Study in Kocaeli, Turkey.

INTRODUCTION: The integration of family planning education into obstetric care has been suggested to increase postpartum contraception use. However, ideal time and type of counseling is controversial. There is no prospective study about combining prenatal and postnatal education on the postpartum modern contraceptive use (PPMC). AIM: This study was aimed to explore the effects of the addition of postpartum contraceptive counselling to antenatal education on PPMC. MATERIALS AND METHODS: Family planning counselling was given to all participating patients throughout antenatal care (ANC) via brief communications. After delivery, the women were categorised into two age-matched groups with a 1:1 allocation ratio in the order of the birth date. No further intervention was performed for Group I (n: 98). Women in Group II (n: 102) received further contraceptive education at six weeks after hospital discharge. Six months after delivery, PPMC was compared between the two groups. RESULTS: PPMC was similar between Group I and II (p>0.05). Previous contraceptive experiences, obstetric care service intensity and partner's support were the factors related to postnatal contraceptive use. Logistic regression analysis showed that PPMC was independent of confounding factors in each group. CONCLUSION: The addition of postnatal counseling to antenatal one did not further increase PPMC. The results of this study suggested that family planning counseling should be provided antenatally.

Exogenous cesarean scar pregnancies managed by suction curettage alone or in combination with other therapeutic procedures: A series of 33 cases and analysis of complication profile.

AIM: The aim of this study was to review our exogenous cesarean scar pregnancy (CSP) cases that were managed through transabdominal ultrasound (TAUS)-guided suction curettage either alone or with a concomitant additional therapeutic modality. The study was carried out over a 6-year period and we compared clinical outcomes, success rates and complication profiles between the two therapeutic approaches. METHODS: A total of 33 exogenous CSP patients who were managed by suction curettage were extracted from the medical records. The patients were analyzed according to the intervention applied in the two groups as: TAUS-guided suction curettage alone (Group 1); and additional therapeutic tools, such as systemic or intracavitary administration of methotrexate and intracavitary ethanol instillation, in combination with suction curettage (Group 2). Basic demographic and clinical characteristics of women experiencing hemorrhagic complications and those who did not after the treatment were also compared. RESULTS: There were no cases of uterine perforation, hysterectomy or unresponsiveness to treatment in our analyzed CSP cases. Four patients, two in each group, required blood transfusion. Our success rate in the overall patient population was 87.8% (29/33). Fourteen out of 16 patients who were treated with TAUS-guided suction curettage alone, and 15 out of 17 patients who received other interventional treatment modalities preceding suction curettage revealed successful resolution of the CSP without any complication (P = 0.948). Clinical and demographic characteristics of women who experienced any hemorrhagic complication did not significantly differ from those who did not. CONCLUSION: In appropriate CSP cases, TAUS-guided suction curettage appears to be a reliable treatment option with acceptable success rates and similar complication profile to other therapeutic options.

The predictive value of lactate peak detected by the magnetic resonance spectroscopy in the brain of growth-restricted fetuses for adverse perinatal outcomes.

OBJECTIVE: To compare perinatal outcomes between patients with and without abnormal Doppler findings and lactate peak in the fetal brain detected by magnetic resonance spectroscopy ((1)HMRS) and to assess the feasibility of fetal brain lactate in the prediction of adverse obstetric outcomes in growth-restricted fetuses. METHODS: Pregnancies with FGR fetuses underwent Doppler ultrasonography and 3 Tesla (1)HMRS for the presence of lactate peak prior to the delivery. Patients were assigned into the following groups; normal Doppler, no lactate peak (Group 1), normal Doppler, lactate peak (+) (Group II), abnormal Doppler, no lactate peak (Group III), abnormal Doppler, lactate peak (+) (Group IV). RESULTS: Five perinatal deaths, all in Group IV, were encountered (p < 0.001). Perinatal death rate was higher in patients with Doppler flow abnormality ((5/12 (41.7%)) than in patients without Doppler abnormality (0/23) (p < 0.001) and was significantly higher in the presence (5/18 (27.8%)) than in the absence of lactate peak (0/17) (p = 0.019). CONCLUSIONS: Fetuses with brain lactate peak detected by (1)HMRS in addition to altered Doppler findings are more likely to develop short-term morbidities and perinatal death. Fetal brain lactate detected by (1)HMRS may represent a clinical marker of altered brain metabolism and further perinatal complications.