A Prospective Randomised Comparative Clinical Trial Study of Luteal PhaseLetrozole versus Ganirelix Acetate Administration to Prevent Severity of Early Onset OHSS in ARTs.

BACKGROUND: Ovarian hyperstimulation syndrome (OHSS) is the most notable complication in ovulation induction for assisted reproductive techniques (ARTs) like in vitro fertilization (IVF) and intracytoplasmic sperm injection (ICSI). Hence, we decided to evaluate the effect of the aromatase inhibitor, letrozole, versus gonadotrophin-releasing hormone (GnRH)-antagonist (ganirelix acetate) on prevention of severity of OHSS and reduction in serum estradiol (E2) levels when administered during the luteal phase after oocyte retrieval in IVF/ICSI cycles. MATERIALS AND METHODS: In this prospective single-centred, randomized, parallel-arm study, 122 patients were randomized to receive oral letrozole (n=61, 2.5 mg twice daily) or ganirelix acetate (n=61, 0.25 mg subcutaneously daily) from the day of egg retrieval for the next 7 days. Incidence and severity of early OHSS were the primary endpoints assessed by the signs, symptoms, and laboratory findings of OHSS (e.g., serum E2 levels). The secondary endpoints were patient satisfaction and the additional cost of therapy to prevent the severity of OHSS. RESULTS: Letrozole group had lower incidence of OHSS (13.1%) compared to 19.6% in ganirelix acetate group (P=0.32). Serum E2 levels on post-pick up days 5 and 7 were significantly lower in the letrozole group when compared to the ganirelix acetate group (P=0.001). The majority of the patients in both groups had no major complications. No significant difference was found between the study groups with respect to the incidence of OHSS (P=0.33). The additional cost per IVF cycle for prevention of severity of early-onset OHSS in the letrozole group was 5.32 USD compared to 267.26 USD in the ganirelix acetate group, which was almost fifty times costlier. CONCLUSION: Letrozole and ganirelix acetate have the same efficiency for the overall prevention of OHSS, whereas letrozole was more effective in preventing moderate OHSS. Letrozole had better patient satisfaction and is cheaper compared to GnRH antagonists (Registration number: CTRI/2020/10/028674).

Joint IFS-ISAR-ACE Recommendations on Resuming/Opening up Assisted Reproductive Technology Services.

COVID-19 - A Global challenge on a scale not previously seen. Reproductive care is essential for the well-being of society and therefore the treatment needs to be completely re-thought and individualised. Infectivity and mortality rates are higher than previous pandemics and the disease is present in almost every country. Propagation and containment have varied widely by location and, at present, the timeline to complete resolution is unknown. With successful mitigation strategies in some areas and emergence of additional data, the societies have sanctioned gradual and judicious resumption of delivery of full reproductive care. When we resume, monitor local conditions, including prevalence of disease, status of government or state regulations, and availability of resource. It is important to implement proactive risk assessment within their practices prior to restarting services. One needs to develop clear and modified plans to ensure the ability to provide care while maximizing the safety of their patients and staff. One should also remain informed and stay current regarding new medical findings. These recommendations provide resources for restarting ART practice again.

Sildenafil Citrate: Novel Therapy in the Management of Ovarian Torsion.

Ovarian torsion is defined as partial or complete rotation of ovarian vascular pedicle, leading to the obstruction of venous outflow and arterial inflow. It is an emergency condition with an incidence of 2%-15% in patients with adnexal masses. The main risk in ovarian torsion is an ovarian mass or an enlarged ovary with a long pedicle. Due to the rotation of ovarian tissue axis on its vascular pedicle, there is compression of vessels followed by stromal edema, hemorrhagic infarction, and necrosis of adnexa. Expedient diagnosis poses a difficult challenge because clinical presentation is a variable and often misleading. We report a case of right ovarian torsion after oocyte retrieval for in vitro fertilization, where vaginal sildenafil citrate was successfully used to reduce ovarian edema by improving venous drainage. It also helped in maintaining ovarian tissue perfusion and preventing reperfusion injury and spontaneous detorsion of the ovary without any surgical intervention.

Ureteric Injury During Transvaginal Oocyte Retrieval (TVOR) and Review of Literature.

We report a case of ureteric injury during transvaginal oocyte retrieval (TVOR), which was identified immediately (on the operation table) and managed successfully in the same sitting. A 28-year-old woman with primary infertility underwent in-vitro fertilisation (IVF) in a private centre. Because of the policy of doing an ultrasonography post-procedure, she was diagnosed immediately with vaginal vault haematoma and ureteric injury. A double-J catheter was inserted under cystoscopic guidance. A major complication was averted by the timely diagnosis of ureteric injury and its appropriate management. To conclude, given the elective nature of TVOR and IVF, patients should be informed about all potential complications, including ureteric injury. Early diagnosis of complications (by knowing and anticipating potential risks of procedure) leads to efficient management by timely intervention.

Sildenafil citrate for the management of fetal growth restriction and oligohydramnios.

Fetal growth restriction (FGR) and preeclampsia are the major causes of neonatal morbidity and mortality, which affect up to 8% of all pregnancies. The pathogenesis in FGR is an abnormal trophoblastic invasion leading to compromised uteroplacental circulation. However, in spite of this understanding and identification of high-risk patients, the management options are limited. There are some new studies which have demonstrated the role of sildenafil citrate in improving vasodilatation of small myometrial vessels and therefore improvement in amniotic fluid index, fetal weight, and even uterine and umbilical artery Doppler patterns. We report here the case of a 31-year-old female with infertility and preconceptional thin endometrium responding well to sildenafil citrate, followed by conception. However, she presented with an early-onset FGR at 26 weeks of gestation, and again after treatment with sildenafil citrate, showed improvement in amniotic fluid index and fetal weight, finally resulting in delivery of a full-term healthy baby with uneventful neonatal course.