M. Abuzeid

Vaginal micronized progesterone versus intramuscular progesterone for luteal support in women undergoing in vitro fertilization-embryo transfer

OBJECTIVE To study the outcome of IVF-ET in women who used vaginal P (vaginal P(4)) versus those who used P in oil via IM injection (IM-P(4)) for luteal support. DESIGN Retrospective cohort. SETTING Tertiary referral infertility center. PATIENT(S) A cohort of 544 women. INTERVENTION(S) In 145 women, vaginal P(4) was used, while in 399 women, IM-P(4) was used for luteal support. MAIN OUTCOME MEASURE(S) The primary outcome was ongoing pregnancy rate. Secondary outcomes included other IVF-ET outcomes: rates of clinical pregnancy and pregnancy loss (chemical and miscarriage) and serum P levels during the luteal phase and early pregnancy. RESULT(S) Women who used vaginal P(4) for luteal support had ongoing pregnancy rates (odds ratio [OR], 1.0675; 95% confidence interval [CI], 0.7587-1.5020) and rates of total pregnancy loss (OR, 1.0775; 95% CI, 0.7383-1.5727) that were not statistically different from those who used IM-P(4). During the luteal phase, women who used vaginal P(4) had mean serum P levels that were not statistically different from those who used IM-P(4). However, during early pregnancy, mean P levels in pregnant women who used vaginal P(4) were statistically significantly higher. CONCLUSION(S) In women undergoing IVF-ET according to the GnRH agonist long protocol, luteal support with vaginal P(4) was associated with treatment outcomes that were no different from those associated with IM-P(4) luteal support.

Safety and Efficacy of Two Techniques of Temporary Ovarian Suspension to the Anterior Abdominal Wall after Operative Laparoscopy

Background This retrospective study compares the safety and efficacy of temporary ovarian suspension (TOS) to the anterior abdominal wall using absorbable versus non-absorbable suture after operative laparoscopy to elevate the ovaries away from the ovarian fossa to reduce postoperative adhesion development. Methods Patients (n=152) underwent TOS to the anterior abdominal wall at the conclusion of surgery between 1998 and 2017. One hundred forty-two patients underwent operative laparoscopy for advanced stages of endometriosis (93.4%) and 10 patients for other indications (6.6%). In 78 patients the ovaries were suspended to the fascia using absorbable 3-0 plain catgut sutures (Group 1). In 74 earlier patients non-absorbable 3-0 mono-lamentous nylon was used to suspend the ovaries to the anterior abdominal (Group 2). Results In both groups there was no reported incidence of any major intra-operative complications such as bleeding, or late complications such as infection, hematoma or bowel herniation through the suture loop and its sequalae (bowel obstruction or strangulation). In all patients in both groups the ovaries were present in its anatomical location on transvaginal ultrasound scan, one week after surgery following absorption or removal of the TOS suture. There was no significant difference in clinical pregnancy (34.3% vs 44.2%) and delivery (31.3% vs 36.5%) rates in patients who conceived with non-IVF methods between Group 1 and Group 2 respectively. Conclusions TOS to the anterior abdominal wall, using absorbable or non-absorbable sutures, in an attempt to reduce postoperative adhesion development between the ovary and ovarian fossa, is simple, safe, easy to learn, and has potential effectiveness.

Modified natural cycle for embryo transfer using frozen-thawed blastocysts: A satisfactory option

OBJECTIVE To describe pregnancy outcomes of frozen-thawed blastocysts cycles using modified natural cycle frozen embryo transfers (NC-FET) and down-regulated hormonally controlled frozen embryo transfers (HC-FET) protocols. STUDY DESIGN This retrospective cohort study included all patients undergoing either modified NC-FET or down-regulated HC-FET using frozen-thawed day 5 embryos. Cycles with donor blastocysts were excluded. Four hundred twenty eight patients underwent a total of 493 FET cycles. Patients with regular menses and evidence of ovulation underwent modified NC-FET. These patients were given hCG 10,000 IU IM on the day of LH-surge. Vaginal progesterone (P4) was started two days later and blastocyst transfer was planned seven days after detecting the LH surge. Anovulatory patients and some ovulatory patients underwent down-regulated HC-FET. These patients were placed on medroxy-progesterone acetate (10mg) for 10days to bring on menses and were also given a half-dose of GnRH-agonist (GnRH-a) on the third day of medroxy-progesterone acetate. Exogenous estradiol was initiated on the third day of menses. Once serum E2 levels reached >500pg/mL and endometrial lining reached >8mm, intramuscular (IM) P4 in oil was administered. Blastocyst FET was planned 6days after initiating P4. The primary outcomes included clinical pregnancy and delivery rates. RESULTS There were 197 patients in the modified NC-FET protocol and 181 in the down-regulated HC-FET protocol. Mean age (years), day-3 FSH levels (mIU/mL) and percentage of patients with male factor infertility were significantly higher and mean BMI (kg/m2) was significantly lower in modified NC-FET compared to HC-FET, respectively. Analysis of the first cycle pregnancy outcomes revealed no significant differences in clinical pregnancy rate (54.3% vs. 52.5%) and delivery rate (47.2% vs. 43.6%) between modified NC-FET and HC-FET. Logistic regression analysis showed age (OR=0.939, 95% CI 0.894-0.989, p=0.011), number of blastocysts transferred (OR=1.414, 95% CI 1.046-1.909, p=0.024), and the year of FET (OR=1.127, 95% CI 1.029-1.234, p=0.010) were significant factors impacting clinical pregnancy. An age analysis within three age groups (≤35, 36-39, ≥40) was performed, but no significant difference in clinical pregnancy was observed. CONCLUSION Our data suggests that modified NC-FET protocol has comparable pregnancy outcomes to down-regulated HC-FET when utilizing frozen-thawed day 5 embryos.

Ultrasonography in Reproductive Medicine and Infertility: Ultrasonography-guided embryo transfer: clinical experience

The classic candidate for a transrectal ultrasonography (TRUS) evaluation has semen analysis findings consistent with complete distal ejaculatory obstruction, including low ejaculate volume (usually less than 1.5 ml), azoospermia, low pH (less than7), and absence of fructose. In most cases, TRUS can be performed as an outpatient procedure without the need for anesthesia. In order to understand the normal and pathological appearance of the ejaculatory structures on TRUS, it is important to appreciate their anatomic relationships and embryological origins. Traditionally, vasography after vasopuncture was used to evaluate the patency of the ejaculatory ducts. The types of pathologies found on a TRUS evaluation include agenesis or hypoplasia of urogenital structures, cysts, dilatations, calcifications, and stones. Distal ejaculatory duct obstruction (EDO) is strongly suspected in case of azoospermia in which TRUS reveals dilated seminal vesicles with an anteroposterior length greater than 15 mm, or ejaculatory ducts with diameter greater than 2.3 mm.