Proposal for Diagnostic Criteria of Y-Shaped Dysmorphic Uterus Based on 3-Dimensional Transvaginal Ultrasound Measurements.

STUDY OBJECTIVE: To define objective and readily applied diagnostic criteria for Y-shaped uteri using 3-dimensional transvaginal ultrasound (3D-TVUS) volume recordings. DESIGN: A retrospective case-control diagnostic measurements study. SETTING: A tertiary university hospital's reproductive health and research center. PATIENTS: Two hundred thirteen patients who presented with infertility between January 2020 and December 2022. INTERVENTIONS: Two blinded physicians re-evaluated the 3D-TVUS images of all patients for the presence of a uterine abnormality. The images of patients with a Y-shaped uterus were re-evaluated, and descriptive measurements were done. MEASUREMENTS AND MAIN RESULTS: The most common uterine abnormality in this cohort was the Y-shaped uterus with a prevalence of 12.2%, followed by the arcuate, T-shaped, and septate uteri, respectively. Reviewers identified 26 and 28 Y-shaped uteri, respectively, and came to a consensus on 25 images. Diagnostic criteria for the Y-shaped uterus based on 3D-TVUS findings have been specified as: lateral indentation depths between 4 and 7 mm, fundal indentation depth between 5 and 9 mm, lateral indentation angles between 121° and 149°, fundal indentation angle between 121° and 145°, and Y-angles 25° to 46°. CONCLUSION: Some subtypes of dysmorphic uteri, such as the Y-shaped uterus, whose clinical significance is unknown and may be variants of the normal, may actually be more common than thought. Determining objective diagnostic criteria with 3D-TVUS will allow standard research on these anomalies and their clinical significance.

Evaluation of the Impact of Letrozole in Combination with the GnRH Antagonist Ovarian Stimulation Protocol in Patients Expected to Have a Poor Ovarian Response (POSEIDON Groups 3 and 4).

Background and Objectives: The objective of this study was to evaluate the impact of adjuvant letrozole administration during ovarian stimulation using the gonadotropin-releasing hormone (GnRH) antagonist protocol on treatment outcomes in women categorized into POSEIDON groups 3 and 4. Materials and Methods: This retrospective cohort study analyzed data from patients classified into POSEIDON groups 3 and 4 who underwent fresh embryo transfer subsequent to intracytoplasmic sperm injection following a GnRH antagonist stimulation protocol between January 2017 and December 2021. Patients were divided into two groups: the GnRH-LZ group, who received letrozole at a dosage of 5 mg/day for five consecutive days, and the GnRH-ant group, who did not receive adjuvant letrozole. The primary outcome measure of the study was a comparative analysis of live birth rates between the two groups. Results: A total of 449 patients were deemed suitable for final analysis and were allocated into two groups: 281 patients in the GnRH-ant group and 168 patients in the GnRH-LZ group. Live birth rates were found to be comparable in both groups (11% vs. 9%, p = 0.497). Letrozole administration significantly reduced the total amount of gonadotropins required (2606.2 ± 1284.5 vs. 3097.8 ± 1073.3, p < 0.001), the duration of ovarian stimulation (11.2 ± 3.9 vs. 10.2 ± 3, p = 0.005), and the serum peak estradiol concentration (901.4 ± 599.6 vs. 463.8 ± 312.3, p < 0.001). Conclusions: Adjuvant letrozole administration did not demonstrate a significant impact on live birth rates among women categorized into POSEIDON groups 3 and 4. However, this approach may offer potential cost reductions by diminishing the necessity for exogenous gonadotropins and shortening the duration of ovarian stimulation.

Intrauterine insemination with ovarian stimulation is a successful step prior to assisted reproductive technology for couples with unexplained infertility.

The present retrospective cohort study analysed data of couples with unexplained infertility who underwent two to three intrauterine insemination (IUI) cycles. The inclusion criteria were age 20-40 years, failure to conceive for at least two years of unprotected intercourse, ovulation, normal semen analysis, and tubal patency. Total of 578 IUI cycles of 286 couples with unexplained infertility were included in the final analyses. The mean age and duration of infertility of the study population were 28.8 ± 5.1 and 5.2 ± 3.4 years, respectively. The clinical pregnancy rate (CPR) and live birth rate (LBR) per cycle were 16.6 and 13.1%, respectively. The cumulative CPR following two to three IUI cycles was 33.5% and the cumulative LBR was 26.5% for the entire cohort. The duration of infertility was significantly shorter in women whose IUI attempt were successful (p = .036). Up to three cycles of IUI with ovarian stimulation seems as an effective first-line treatment modality in unexplained infertility.IMPACT STATEMENTWhat is already known on this subject? Cont rolled ovarian stimulation combined with intrauterine insemination (IUI) is a common infertility treatment as a low-cost, less-invasive alternative to in vitro fertilisation (IVF) and was approved as a first line treatment option for unexplained infertility However, the UK National Institute for Health and Care Excellence (NICE) guideline states that IUI is not recommended to couples with unexplained infertility, male factor and mild endometriosis, unless the couples have religious, cultural or social objections to proceed with IVF.What do the results of this study add? Up to three IUI cycles with ovarian stimulation can be considered as an effective treatment modality in unexplained infertility even in couples who could not achieve pregnancy by expectant management for two years.What are the implications of these findings for clinical practice and/or further research? The clinicians should reconsider the NICE recommendation of IVF in the light of recent studies including ours which recommend IUI together when dealing couples with unexplained infertility.

Longitudinal change in serum inflammatory markers in women with tubo-ovarian abscess after successful surgical treatment: a retrospective study.

High levels of serum inflammatory markers are related to extended hospitalisation and more severe disease in the case of tubo-ovarian abscess (TOA). There is scarce information on the serial measurement of inflammatory markers during the postoperative follow-up period of surgically treated TOA. The present study aimed to assess the postoperative longitudinal changes in serum inflammatory markers following surgery for TOA. In this retrospective cohort study, patients who underwent surgery for TOA between January 2010 and March 2020 were reviewed. All inflammatory markers peaked within 48 hours after surgical intervention and then declined with time. The predicted mean of white blood cell count (WBC) to return to normal was 2.5 days (95% CI: 1.0-4.3), which was followed by neutrophil to lymphocyte ratio (NLR) (7.1 days, 95% CI: 4.7-10.8) and C-reactive protein (CRP) (+14 days). In conclusion, serum inflammatory markers increase in the very early post-operative period. While the normalisation period is very slow, it may not be appropriate to use CRP for evaluating the treatment success of TOA surgery. However, WBC and NLR measurements might be useful for follow-up and predicting the need for medical or surgical intervention.Impact statementWhat is already known on this subject? Serum inflammatory markers such as C-reactive protein, white blood cell count, and neutrophil to lymphocyte ratio are usually elevated in women with tubo-ovairan abscess, and high levels of these markers are associated with extended hospitalisation and more severe disease.What do the results of this study add? Our results indicate that the serum inflammatory markers increase and peak within the first 48 hours after surgery for tubo-ovarian abscess. Normalisation of white blood cell count is the fastest in successfully treated patients. However, normalisation of C-reactive protein is slowest, reaching 14 days and might not be as feasible as white blood cell count and neutrophil to lymphocyte ratio in postoperative patient follow-up.What are the implications of these findings for clinical practice and further research? The serum inflammatory markers should be interpreted with caution within 48 hours after surgical treatment for tubo-ovarian abscess. Instead of C-reactive protein white blood cell count, and neutrophil to lymphocyte ratio measurements can be preferred in post-operative follow-up to predict the need for further medical or surgical intervention.

The association between operative hysteroscopy prior to assisted reproductive technology and cervical insufficiency in second trimester.

PURPOSE: To assess the association between operative hysteroscopy prior to assisted reproductive technology (ART) cycle and cervical insufficiency (CI) in the second trimester of pregnancy. METHODS: A retrospective cohort study was conducted. The charts of all women who got pregnant following an ART cycle between January 2015 and June 2018 were reviewed. The study group consisted of pregnant women who underwent operative hysteroscopy within 6 months before conception. The control group consisted of pregnant women who did not undergo hysteroscopy or any type of cervical surgical procedure before conception. The primary outcome measure was CI during the second trimester (13-27 weeks of gestation). RESULTS: A total of 363 pregnancies achieved by ART cycles were assessed. After the exclusion of multiple pregnancies (n = 19), previous surgical procedures (n = 4) and first-trimester pregnancy losses (n = 80), there were 29 women in the study group and 231 women in the control group. The mean ages of the study and control groups were 31.2 ± 4.06 and 29.82 ± 4.71 years, respectively (P = 0.13). The indications for operative hysteroscopy were uterine septum (n = 19), T-shaped uterus (n = 4), endometrial polyp (n = 4), and submucosal fibroids (n = 2). The rates of CI in the study and control groups were 13.7% (4/29) and 3.4% (8/231), respectively (P = 0.012). The term delivery rates in the study and control groups were 79.3 and 91.8%, respectively (P = 0.044). CONCLUSIONS: Operative hysteroscopy prior to ART cycles is significantly associated with CI between 13 and 27 weeks of gestation. Further investigation with larger cohorts is urgently needed to clarify this issue.

Endometrioma surgery is associated with increased risk of subsequent assisted reproductive technology cycle cancellation; a retrospective cohort study.

The aim of this study was to assess the effect of laparoscopic removal of endometrioma on assisted reproductive technology (ART) outcome. A retrospective cohort study was conducted at a university hospital between January 2014 and December 2017. The ART group consisted of 26 women who underwent 44 ART cycles in the presence of ovarian endometrioma and the surgery group consisted of 53 women who underwent 58 ART cycles after laparoscopic removal of ovarian endometrioma/s. There were no statistically significant differences between the groups regarding demographic parameters and background features including cycle parameters. The live birth rates in the ART and Surgery groups per embryo transfer were 23.7 and 26.1%, respectively (p = .800). The rate of cycle cancellation due to poor response and/or failed oocyte retrieval was significantly higher in the Surgery group than ART group (13.7 vs. 0%, respectively; p = .018). In conclusion, cystectomy significantly increases the risk of cycle cancellation due to poor ovarian response, which might be catastrophic individually. However, it does not seem to affect the live birth rates.IMPACT STATEMENTWhat is already known on this subject? Both the presence of an endometrioma or surgical removal may have deleterious effects on fertility potential.What do the results of this study add? Our results confirm that although cystectomy has no benefit on the number of oocytes collected and live birth rate, it increases the risk of cycle cancellation significantly in assisted reproductive technology cycles following endometrioma surgery.What are the implications of these findings for clinical practice and/or further research? Postponing cystectomy until a freeze-all cycle may be the best option to maximise the number of oocytes retrieved and to maximise the ovarian response.

Final oocyte maturation with two different GnRH agonists in antagonist co-treated cycles at risk of ovarian hyperstimulation syndrome.

Triptorelin 0.2 mg and leuprolide 1 mg subcutaneous injections for triggering final follicular maturation were compared in patients with a high risk for ovarian hyperstimulation syndrome (OHSS). Infertile patients treated with GnRH antagonist protocol between January 2014 and March 2016 were recruited. Patients with high serum oestradiol levels on HCG day (>3000 pg/ml) indicating a risk of OHSS consisted of the study groups (A and B). Patients with serum oestradiol levels less than 3000 pg/ml consisted of the control group (C). A single injection of 0.2 mg triptorelin, 1 mg leuprolide and 10000 IU HCG were administered for final oocyte triggering in groups A (n = 63), B (n = 74) and C (n = 131), respectively. Demographic parameters were comparable between the groups. No cases of severe or moderate OHSS occurred in any group. The clinical pregnancy rates were 31.7%, 37.8% and 32.8% in groups A, B and C, respectively. Both injections had comparable efficacy in clinical outcome and OHSS risk. Regardless of preferred drug, GnRH agonist trigger for final oocyte maturation seems to be safe for patients with high OHSS risk, and can be safely used in fresh embryo transfer cycles.

Does adding endometrial scratching to diagnostic hysteroscopy improve pregnancy rates in women with recurrent in-vitro fertilization failure?

OBJECTIVE: To investigate the effect of additional endometrial scratching procedure during hysteroscopy on assisted reproductive technology (ART) cycle outcomes in repeated implantation failure (RIF) patients without endometrial or uterine abnormalities on hysteroscopic evaluation. MATERIALS AND METHODS: Three hundred and forty-five RIF patients who underwent ART at a university-based infertility clinic between January 2011 and June 2015 were recruited in this retrospective cohort study. Uterine cavities of all included patients were evaluated by diagnostic hysteroscopy 7-14 days prior to the subsequent ART cycle. Women without endometrial abnormalities were allocated into two groups; the scratching group was consisted of patients who underwent endometrial scratching by using monopolar electric energy with needle forceps during hysteroscopy, and the control group was consisted of patients who underwent only diagnostic hysteroscopy. RESULTS: The implantation rate was significantly higher in the scratching group than the control group (37.7% versus 24.5%; p = 0.04). Clinical and ongoing pregnancy rates were also found to be significantly higher in the scratching group than the control group (37.7% versus 27.6%; p = 0.03; and 33.3% versus 23%; p = 0.03, respectively). CONCLUSION: Endometrial scratching during diagnostic hysteroscopy seems to enhance implantation and as well pregnancy rates in comparison to diagnostic hysteroscopy alone.

Follicular fluid norepinephrine and dopamine concentrations are higher in polycystic ovary syndrome.

The aim of the present study was to compare follicular fluid (FF) levels of norepinephrine (NE) and dopamine (DA) in polycystic ovary syndrome (PCOS) and non-PCOS patients who underwent in vitro fertilization (IVF). Forty-seven PCOS patients (study group) and 61 patients with male factor infertility (control group) who underwent IVF using GnRH agonist protocol were recruited. Concentrations of NE and DA were measured in FF specimens of all patients. Demographic characteristics were comparable between the groups. Significantly higher levels of NE were measured in FF of PCOS patients (median: 61.05 nmol/l) compared to those with male infertility (median: 49.82 nmol/l). Similarly, significantly higher levels of DA were measured in FF of PCOS patients (median: 23.70 nmol/l) compared to those with male infertility (median: 18.28 nmol/l). In conclusion, the FF concentrations of both catecholamine are increased in PCOS patients when compared to non-PCOS patients.

Infertility work-up: To what degree does laparoscopy change the management strategy based on hysterosalpingography findings?

AIM: The aim of this study was to assess the diagnostic accuracy of hysterosalpingography (HSG) on tubal patency (TP) and to determine whether performing laparoscopy (LS) can change the original management strategy based on HSG findings. MATERIAL AND METHODS: Records of all infertile couples (n = 1298) treated at a university-based infertility clinic between January 2002 and June 2010 were reviewed. All patients who had both HSG and LS testing (n = 264) were included in the study. HSG was performed in an attempt to rule out tubal and/or uterine pathologies. All patients included in the study were evaluated with LS not more than 12 months after HSG. RESULTS: The validity of HSG screening for TP was calculated as 84.1%. The positive and negative predictive values of HSG were 54.6% and 98.3%, respectively. The sensitivity of HSG was higher in patients with distal tubal occlusion than in patients with proximal tubal occlusion (69.8% [44/63] vs 46.7% [28/60], respectively; P = 0.011). The rates of management plan change in patients with bilateral TP, unilateral tubal occlusion and bilateral tubal occlusion were 2.8%, 12.2% and 32.4%, respectively (P = 0.000). CONCLUSIONS: Patients with both unilateral tubal occlusion and bilateral tubal occlusion on HSG should be reevaluated with LS to determine the appropriate management strategy.

Comparison of two oral contraceptive forms containing cyproterone acetate and drospirenone in the treatment of patients with polycystic ovary syndrome: a randomized clinical trial.

PURPOSE: To compare the effects of combined oral contraceptives (OCs) containing cyproterone acetate and drospirenone in the treatment of polycystic ovary syndrome (PCOS). METHODS: Fifty-two patients with PCOS were randomized in two groups: group A (n = 26) received 0.035 mg ethinyl estradiol + 2 mg cyproterone acetate and group B (n = 26) received 0.03 mg ethinyl estradiol + 3 mg drospirenone-containing OCs for 12 months. Baseline clinical features including body mass index, waist to hip ratio (WHR), and modified Ferriman-Gallwey (mFG) score were noted. Baseline biochemical parameters included androgen profile, carbohydrate metabolism, lipid profile, and oxidative stress. The percentages of changes for all parameters were compared. RESULTS: The groups were comparable regarding the baseline characteristics. WHR decreased significantly from baseline (-4 % [-31 to 35]) in group B when compared to group A (0 % [-11 to 14]) (P = 0.033). The total mFG score decreased significantly from baseline (-35 % [-71 to 10]) in group A when compared to group B (-18 % [-72 to 30]) (P = 0.035). Changes in androgen hormone profile were comparable except DHEA-SO4 (-32 % [-53 to 15] in group B vs. -10 % [-49 to 63] in group A; P = 0.046). The effects of the drugs were similar regarding carbohydrate metabolism, lipid profile, and oxidative stress parameters. CONCLUSIONS: Cyproterone acetate containing OCs seem to be more effective to treat clinical hirsutism in patients with PCOS after 12 months of treatment.

Can ovarian damage be reduced using hemostatic matrix during laparoscopic endometrioma surgery? A prospective, randomized study.

PURPOSE: To compare the effect of hemostatic matrix (HM) and electrosurgical bipolar coagulation (EBC) on ovarian reserve in patients undergoing endometrioma surgery. METHODS: Thirty patients with single ovarian endometrioma ≥4 cm were randomized to two groups. Ovarian reserve after laparoscopic excision of endometrioma was assessed by serum anti-Müllerian hormone (AMH); preoperatively and in postoperative months 1 and 3. RESULTS: The preoperative AMH levels were similar between the groups. Intra-group comparisons: the AMH levels were significantly lower in the first and third postoperative months as compared to basal levels in both groups. In each group, AMH levels were significantly higher in the third postoperative month as compared to first postoperative month. Inter-group comparisons: AMH levels were significantly lower in the EBC as compared to the HM at 1st postoperative month (1.64 ± 0.93 vs. 2.72 ± 1.49 ng/mL). However, the AMH levels were increased and became similar at 3rd postoperative month. CONCLUSIONS: Although acute ovarian damage was more in EBC group, ovarian reserve was compensated at 3rd month. Further studies with long-term follow-up will clarify the importance of these findings.

Endometrial compaction is associated with the increased live birth rate in artificial frozen-thawed embryo transfer cycles.

We aimed to assess the effect of endometrial compaction on the live birth rate in frozen-thawed embryo transfer (FET) cycles and to investigate the parameters associated with compaction. FET cycles performed in a tertiary care infertility centre between May 2013 and October 2019 were reviewed retrospectively. The decremental change of endometrial thickness between the end of oestrogen phase and ET day was defined as endometrial compaction. The primary outcome measure was endometrial compaction, and the secondary outcome was the live birth rate. Among all, 89 had endometrial compaction and 194 did not. The live birth rate was significantly higher in the compaction group (23.6 vs. 13.4%, respectively; p = 0.039). Multivariate logistic regression analysis revealed that in FET cycles with artificial endometrial preparation, the chance for live birth was significantly higher in cycles with endometrial compaction [OR: 3.133, 95% confidence interval (CI) 1.104-8.892; p = 0.032] when adjusted for age, stage of the embryo, and endometrial thickness at the end of the oestrogen phase. According to receiver operating characteristic (ROC) curve analysis the sensitivity and specificity of 9.25 mm endometrial thickness at the end of oestrogen phase were 76.4 and 58.8%, respectively (area under the curve: 0.701, 95% CI 0.640-0.763; p < 0.001) to predict endometrial compaction.

Impact of an estrogen replacement regimen on live birth rate in frozen-thawed good-quality embryo transfer.

OBJECTIVE: To assess the impact of an estrogen replacement regimen on frozen embryo transfer (FET) cycle outcome. METHODS: In the present retrospective cohort study, data of infertile women undergoing FET with good-quality embryos were reviewed. The first group received 2 mg of estradiol hemihydrate (EH) once daily for 6 to 7 days, then twice daily for 4 to 5 days, and then three times a day until embryo transfer. The second group received EH twice daily for 7 to 8 days, then three times a day. The third group received EH three times a day constantly. The main outcome measure was live birth rate. RESULTS: In total, 394 FET cycles were included. The fixed 6-mg group required the highest estradiol hemihydrate dose. The duration of estrogen treatment was significantly longer in the first group. Maximal endometrial thickness was highest in the second group (10.2 ± 1.3 mm vs. 9.6 ± 1.4 mm vs. 8.6 ± 0.9 mm, respectively; P < 0.001). The clinical pregnancy rates in the groups were 41.1%, 55.2%, and 42.2%, respectively (P = 0.035). Live birth rates were 40.8%, 50.9%, and 48.1%, respectively (P = 0.320). CONCLUSION: In FET cycles with hormone replacement therapy, a step-up 4-mg regimen provides thicker endometrium with optimal-dose estrogen in an adequate time frame. The tendency for increased clinical pregnancy and live birth rates is remarkable.

The size, number and bilaterality of endometriomas do not affect spontaneous conception chance following surgical removal.

OBJECTIVE: Endometrioma surgery is associated with a reduction in ovarian reserve. However, removal of an endometrioma may increase the likelihood of a spontaneous conception. The objective of this study was to assess the pre-operative and operative variables affecting spontaneous conception following endometrioma surgery. METHODS: Data from 211 women ≤40 years of age who underwent an endometrioma surgery at a university-based infertility clinic between January 2005 and June 2020 were reviewed retrospectively. The main outcome measure was spontaneous clinical pregnancy. We had 84 women with and 127 women without a successful spontaneous conception making up the case and control groups. RESULTS: The median ages of the cases and controls were 27 and 32 years, respectively (p<0.001). The rate of recurrence was significantly lower in the spontaneous conception group when compared to controls (29.8% vs. 52.8%, respectively; p=0.001). Our results showed no differences in the number, size, or side of the endometriomas in both groups. Multivariate logistic regression analysis showed significant independent effects of age (B: -.166, OR {odds ratio}: 0.847, 95% CI {confidence interval}: 0.791-0.907, p<0.001), recurrence (B: -1.030, OR: 0.357, 95% CI: 0.188-0.678, p=0.002), and laparoscopic surgery rather than laparotomy (B: 1.585, OR: 4.879, 95% CI: 1.029-23.133, p=0.046) for spontaneous conception. CONCLUSIONS: The size, number and bilaterality of the endometrioma did not affect the spontaneous conception likelihood following surgical removal. However, increasing age and recurrence are negatively associated with the likelihood of spontaneous conception. Laparoscopic surgery may increase the chance of spontaneous conception when compared to laparotomy.

Laparoscopy versus open surgery for the surgical management of tubo-ovarian abscess (TOA). Is there a beneficial impact of early endoscopic intervention in terms of fertility rates?

OBJECTIVES: To compare success rates and complications in women undergoing laparoscopic versus open surgical management of tubo-ovarian abscess. We further examined whether early laparoscopic intervention has any impact on pregnancy rates in a subgroup of infertile patients following frozen-thawed embryo transfer. MATERIAL AND METHODS: Hospital records of 48 patients diagnosed with TOA between January 2015 and December 2020, who underwent surgical intervention or received only medical treatment were analyzed. All patients were hospitalized, and parenteral antibiotics were commenced on admission initially. Laparoscopic or open surgery was performed within 48 hours course of intravenous antibiotherapy (early intervention) or later according to the clinical findings and antibiotherapy response. RESULTS: Of 48 patients with TOA, 18 (37.5%) underwent laparoscopic and 30 (62.5%) underwent open surgical intervention. The median postoperative hospital stay was shorter (4.5 days vs 7.5 days, respectively; p = 0.035), and postoperative opioid analgesic requirement was lesser in the laparoscopy group compared to open surgery group (22% vs 53%, respectively; p = 0.034). Intra- and post-operative complication rates were similar between the groups. Of these 48 patients, seven were diagnosed to have TOA following oocyte retrieval, and four of these conceived with frozen thawed embryo transfer all of whom underwent laparoscopic surgery within 48 hours of diagnosis. CONCLUSIONS: Minimal invasive surgery should be preferred even in the presence of severely adhesive and inflammatory TOA in order to improve postoperative outcomes. Moreover, early laparoscopic intervention may be considered in infertile patients with an aim to optimize pregnancy rates in a subsequent frozen-thawed embryo transfer.

Presence of Endometrioma Does Not Impair Embryo Quality and Assisted Reproductive Technology (ART) Cycle Outcome in Diminished Ovarian Reserve (DOR) Patients.

This study aims to assess the impact of endometrioma on embryo quality and cycle outcome in patients who undergo assisted reproductive technology (ART) treatment due to diminished ovarian reserve (DOR). Retrospective case-control study was conducted in women ≤ 40 years of age who underwent ART treatment caused by DOR, defined according to POSEIDON criteria, at a university-based infertility clinic between January 2015 and December 2020. Three groups of patients were selected: group A included patients with an idiopathic DOR, group B included patients with endometrioma(s) who underwent ovarian cystectomy, and group C included patients with endometrioma(s) without surgical treatment. A total of 351 women with DOR were included in the final analysis. Demographic characteristics, including age and AMH, were similar between the groups. Significant differences were observed among groups on mean number of MII oocytes retrieved (1.88 ± 1.59 vs. 2.84 ± 2.89 vs. 2.78 ± 2.41, respectively; p < 0.001) and mean number of embryos (1.04 ± 1.18 vs. 1.87 ± 2.01 vs. 1.66 ± 1.81, respectively; p < 0.001). However, the mean number of top-quality embryos, cycle cancellation, and live birth rates were similar between the groups. Clinical pregnancy (35 (26.5%) vs. 8 (18.2%) vs. 18 (42.9%), respectively; p = 0.038) and miscarriage rates (12 (9.1%) vs. 0 vs. 8 (19.0%), respectively; p = 0.009) were higher in endometrioma group without surgery. Women with DOR appear to have similar ART cycle outcomes regardless of the etiology, in terms of live birth rates. Infertility of endometrioma patients might be related to altered endometrium rather than to decreased oocyte quality. Cystectomy for endometrioma before IVF did not seem to affect the LBR.

Diagnostic laparoscopy prior to IVF cycle improves outcome in patients with unilateral distal tubal occlusion.

OBJECTIVE: To assess the impact of laparoscopy before in vitro fertilization (IVF) treatment on live birth rates in patients with distal unilateral tubal obstruction (UTO). METHODS: Retrospective cohort study which was conducted in tertiary ART center in Ankara University Hospital between January 2008- January 2019. Inclusion criteria were distal UTO at HSG, patients who were 18-40 years age and baseline serum FSH levels between 3 and 15 IU/ml. Exclusion criteria were patients who had previous tubal surgery and, hormonal dysfunction such as hyperprolactinemia or hypothyroidism at the time of the IVF cycle. RESULTS: 49 patients who underwent 117 IVF treatment cycles were included in the final analysis. Among those 17 patients (34 IVF cycles) in the study group who underwent laparoscopy prior to IVF cycles, and 32 patients (83 IVF cycles) in the control group who directly underwent IVF cycle with no prior laparoscopy. Eleven pathologies (64.7%) were detected and treated at laparoscopies of 17 patients with distal UTO. Both the clinical pregnancy and the live birth rates were also significantly higher in the study group when compared to the control group (29.4% vs. 12%, P=.031; 26.5% vs. 9.6%, respectively; P=.039). CONCLUSIONS: Patients with distal UTO generally have a pelvic pathology and laparoscopy prior to IVF cycles can improve the treatment outcome.

Recombinant FSH versus clomiphene citrate for ovarian stimulation in couples with unexplained infertility and male subfertility undergoing intrauterine insemination: a randomized trial.

PURPOSE: To compare the efficacy of clomiphene citrate (CC) and recombinant FSH (rFSH) protocols in ovarian stimulation (OS)/intrauterine insemination (IUI) cycles for couples with unexplained infertility or male subfertility. METHODS: One hundred and eighty-nine patients with unexplained or male subfertility were randomized to treatment with 100 mg/day CC for 5 days (93 patients) or rFSH with starting dose of 75-100 IU daily (96 patients). The main outcome measurement was ongoing pregnancy rate (OPR). RESULTS: The number of preovulatory (≥ 17 mm) follicles on the day of hCG administration was significantly greater in the rFSH group than in the CC group (1.7 vs. 1.4, P = .01). Multifollicular growth was observed in 35.1% in the CC group and 54.8% in the FSH group (P = .01). The OPR per cycle was 9.6 and 15.6% for CC and rFSH groups, respectively (P = .31). CONCLUSIONS: Recombinant FSH is superior to CC for enabling multifollicular development in OS/IUI cycles of unexplained and male subfertile couples. Although this finding did not lead to a statistically significant superiority of rFSH in terms of clinical outcomes, the presence of relative increase by 62.5% in OPR with rFSH may be regarded as a clinically significant trend.

A Feasible Option before Cycle Cancellation for Poor Responders; STOP-START Protocol.

Despite the advances in controlled ovarian stimulation (COS), management of a subgroup of poor ovarian responder patients may still be challenging. We describe a feasible and simplified protocol, namely the STOP-START protocol, for poor responders defined as Patient-Oriented Strategies Encompassing Individualize D Oocyte Number (POSEIDON) groups 3 and 4, who are unresponsive to COS with maximum dose gonadotrophins. Data of 11 women unresponsive to COS were reviewed. Mean age of the patients was 36.5 ± 6.0 years. Unresponsiveness was defined as no follicular growth >9 mm and/or estradiol level less than 40 pg/ml after a week of recombinant follicle stimulating hormone (rFSH, 225-300 IU) administration. In that case, COS was stopped and each woman underwent weekly ultrasound assessment to catch a secondary follicular growth. All women showed at least one follicular growth within five to 20 days. Six women (54.5%) had spontaneous follicular growth and the other five required ovarian stimulation. At least one oocyte was retrieved from each one of seven patients (63.6%). The mean number of oocytes retrieved was 1.6 ± 1.4 and five women (45.5%) had at least one grade A embryo. Among all, two women became pregnant successfully and both gave live births (18.2%). In conclusion, STOP-START protocol may potentially be an effective, feasible, and time-saving management option for POSEIDON group 3/4 poor responders who are unresponsive to standard COS treatment with maximum dose gonadotrophins.