First birth following natural IVF/ICSI treatment in Ireland.

The first reported delivery following a natural cycle ICSI in Ireland is described. This technique has the potential to provide successful treatment for a selected group of patients.

The thickness and volume of LLETZ specimens can predict the relative risk of pregnancy-related morbidity.

OBJECTIVE: The aim of this study was to determine if the individual physical characteristics of the extirpated transformation zone after large loop excision of the transformation zone (LLETZ) might predict the relative risk of adverse obstetric outcome, specifically preterm labour (PTL). DESIGN: A retrospective observational study. SETTING: University teaching hospital in Dublin (Coombe Women & Infants University Hospital, CWIUH). POPULATION: Women who had LLETZ treatment for cervical intraepithelial neoplasia (CIN) in the colposcopy service between 1999 and 2002, and who subsequently had a pregnancy at the CWIUH. METHODS: Case records and histology reports for eligible women were examined. Age, parity, smoking history, pregnancy complications and CIN grade were recorded. Exclusion criteria were age >42 years, previous treatment for CIN, previous premature labour or twin pregnancies. The Student's t-test, Mann-Whitney U-test, analysis of variants (ANOVA) and logistic regression were employed to analyse the data. MAIN OUTCOME MEASURES: Gestational age at birth, PTL (i.e. <37 weeks of gestation) and miscarriage rate (<24 weeks of gestation). RESULTS: Out of 1808 women who underwent LLETZ treatment, a total of 353 women were identified who subsequently had a pregnancy at the CWIUH, with 321 being eligible for inclusion in the study. Of these, 76.3% delivered at term, 9.1% delivered at <37 weeks of gestation and 14.6% miscarried at <24 weeks of gestation. There was a three-fold increase in the risk of PTL if the excision volume exceeded 6 cm(3) (RR = 3.00; 95% CI 1.45-5.92), or when the thickness of the excised tissue was greater than 12 mm (RR = 2.98; 95% CI 1.27-7.01). The time interval between LLETZ and pregnancy did not appear to have an effect on PTL rates. We found no association between the grade of CIN and the risk of PTL. CONCLUSIONS: This study reveals that the thickness and the total volume of the excised transformation zone are associated with an increased risk of PTL. Excisions thicker than 1.2 cm and larger than 6 cm(3) carry a three times greater risk for PTL.

The efficacy of fibrinogen concentrate compared with cryoprecipitate in major obstetric haemorrhage--an observational study.

BACKGROUND: Fibrinogen replacement is critical in major obstetric haemorrhage (MOH). Purified, pasteurised fibrinogen concentrate appears to have benefit over cryoprecipitate in ease of administration and safety but is unlicensed in pregnancy. In July 2009, the Irish Blood Transfusion Service replaced cryoprecipitate with fibrinogen. OBJECTIVES: To examine the impact of this externally imposed change on blood product use and clinical outcomes in MOH. METHODS: Women with MOH requiring fibrinogen between 1 January 2009 and 30 June 2011 were identified from an MOH database. Aetiology of MOH, medical treatments, blood product use and clinical outcomes were compared between the cryoprecipitate and fibrinogen groups. RESULTS: Of 21 614 deliveries, 77 cases of MOH were identified. Of the 77 cases, 34 (44%) received cryoprecipitate (n = 14) or fibrinogen concentrate (n = 20). The mean (± SEM) dose utilised was 2.21 ± 0.35 pools of cryoprecipitate and 4 ± 0.8 g of fibrinogen. There was a stronger correlation between the increase in fibrinogen level and dose of fibrinogen (Pearson co-efficient 0.5; P = 0.03) than dose of cryoprecipitate (Pearson co-efficient 0.32; P = 0.3). Mean (± SEM) estimated blood loss (EBL), red cell concentrate (RCC) and Octaplas transfused were greater (but not significantly) in the cryoprecipitate group compared with the fibrinogen group; EBL = 5.2 ± 1.1 vs 3.3 ± 0.5 L (P = 0.1); RCC = 7.2 ± 1.2 vs 5.9 ± 1.0 U (P = 0.4); Octaplas = 4.1 ± 0.7 vs 3.2 ± 0.7 U (P = 0.36), respectively. Haemostasis was secured, and there were no adverse reactions or thrombotic complications. CONCLUSION: Purified virally inactivated fibrinogen concentrate is as efficacious as cryoprecipitate in correcting hypofibrinogenaemia in MOH.

A Rare Coincidence-a Second Trimester Ectopic Pregnancy Following Early Medical Abortion: a Case Report.

We describe a case of a woman in her mid-30s who presented to a tertiary level maternity hospital 17 days following early medical abortion with a positive pregnancy test. On the ultrasound examination, it was discovered that she had a second trimester ectopic pregnancy which was treated surgically with a unilateral salpingectomy. We discuss in depth factors related to this woman's care, such as appropriate assessment and evaluation of early medical abortion cases, the diagnostic challenges of early pregnancy scanning as well as the implications of the COVID-19 pandemic on the provision of care in these scenarios, and how this affected this woman's care.

The duration of gonadotropin stimulation does not alter the clinical pregnancy rate in IVF or ICSI cycles.

BACKGROUND: Ovarian stimulation is an essential part of assisted reproduction treatments. Research on whether the duration of stimulation alters the success in assisted reproduction has not been conclusive. AIM: The purpose of the study was to establish whether the duration of ovarian stimulation alters the success in assisted reproduction treatments. METHODS: All fresh (non-donor) stimulation cycles performed in an academic tertiary referral ART centre over a period of 18 years, between 1st January 1997 and 31st December 2014, were identified. Data were prospectively and electronically collected. IVF and ICSI cycles were analysed independently. Each category was then subdivided into assisted reproduction cycles where the antagonist, long (down regulation) and flare protocol were used. Clinical pregnancy was the main outcome measured. A total of 10,478 stimulation cycles (6011 fresh IVF and 4467 fresh ICSI) reaching egg collection were included. RESULTS: We showed no significant difference in CP rates in IVF cycles for the long (p = 0.082), antagonist (p = 0.217) or flare (p = 0.741) protocol cycles or in ICSI cycles with the long (p = 0.223), antagonist (p = 0.766) or the flare (p = 0.690) protocol with regards the duration of stimulation. CONCLUSION: The duration of stimulation does not alter the CP rate in ICSI or IVF cycles using the long, antagonist or flare stimulation protocol.

Anti-Mullerian hormone normogram in an Irish subfertile population.

BACKGROUND: There has been much interest in the use of anti-Mullerian hormone (AMH) as a biomarker in the assessment of ovarian reserve, and debate on its use as a predictor of assisted reproductive technology (ART) outcomes. Normal levels have not been well defined, and age-based reference ranges may have a role in counselling patients. AIMS: To determine AMH levels in females attending with subfertility, identify age-specific centiles and the age-related decline, to create population normograms to be used in patient counselling prior to ART. METHODS: Retrospective study in a tertiary academic Assisted Conception Centre analysing AMH levels in female patients attending for investigation of subfertility between January 2009 and December 2011 (n = 3,058). RESULTS: Few patients have AMH levels within external laboratory pre-defined "normal fertility potential" ranges. Only 8.1 % had "optimal fertility" and 18.6 % "satisfactory", with 54.6 % "low" fertility and 15.9 % in the "very low/undetectable" group. By age 32, over 50 % of women have AMH levels categorised as "low fertility" (AMH ≤19.5 pmol/L), increasing to 75 % by age 39. Based on a regression model a decrease in mean AMH of 1.72 pmol/L/year was measured. CONCLUSIONS: We recommend that each ART centre defines their "own" normograms for accurate advice for and treatment of their patients. External laboratory-defined "normal" and "abnormal" AMH levels should be filtered and adapted to the reality of each population. These findings need to be considered when counselling patients and planning treatments as age-specific population normograms can provide a tailored approach.