M. Barbosa

Dydrogesterone vs progesterone for luteal‐phase support: systematic review and meta‐analysis of randomized controlled trials

To compare the effects of dydrogesterone and progesterone for luteal‐phase support (LPS) in women undergoing assisted reproductive techniques (ART).

High miscarriage rate in women treated with Essure® for hydrosalpinx before embryo transfer: a systematic review and meta‐analysis

Essure® has been tested as an alternative treatment for hydrosalpinx before embryo transfer (ET) in women undergoing assisted reproduction techniques. However, the persistence of a foreign body inside the uterine cavity might have a negative impact on the outcome of pregnancy. The present systematic review aimed at identifying, appraising and summarizing the available evidence regarding the effectiveness and safety of using Essure prior to ET for women with hydrosalpinx.

Low versus atmospheric oxygen tension for embryo culture in assisted reproduction: a systematic review and meta-analysis

OBJECTIVE To appraise the available evidence comparing low oxygen (LowO2) and atmospheric oxygen tension (AtmO2) for embryo culture. DESIGN Systematic review and meta-analysis. SETTING Not applicable. PATIENT(S) Women undergoing assisted reproduction using embryo culture. INTERVENTION(S) Embryo culture using LowO2 versus AtmO2. MAIN OUTCOME MEASURE(S) Reproductive, laboratory, and pregnancy outcomes. RESULT(S) A total of 21 studies were included in this review. All used O2 concentration between 5% and 6% in the LowO2 group. Considering the studies that randomized women/couples, we observed very low quality evidence that LowO2 is better for live birth/ongoing pregnancy (relative risk [RR] = 1.1, 95% confidence interval [CI] 1.0-1.3) and clinical pregnancy (RR = 1.1, 95% CI 1.0-1.2). Considering the studies that randomized oocytes/embryos, we observed low quality evidence of no difference of fertilization (RR = 1.0, 95% CI 1.0-1.0) and cleavage rate (RR = 1.0, 95% CI 1.0-1.1), and low quality evidence that LowO2 is better for high/top morphology at the cleavage stage (RR = 1.2, 95% CI 1.1-1.3). No studies comparing pregnancy outcomes were identified. Several studies used different incubators in the groups-a new model for the LowO2 group and an old model for the AtmO2 group. The risk of detection bias for the laboratory outcomes was high as embryologists were not blinded. CONCLUSION(S) Although we observed a small improvement (∼5%) in live birth/ongoing pregnancy and clinical pregnancy rates (PRs), the evidence is of very low quality and the best interpretation is that we are still very uncertain about differences in this comparison. The clinical equipoise remains and more large well-conducted randomized controlled trials are needed. They should use the same incubators in both groups and the embryologists should be blinded at least when evaluating laboratory outcomes.

Oocyte retrieval using the lateral recumbent position.

A 33-year-old nulliparous woman who had been trying to conceive for 3 years attended our center for in-vitro fertilization (IVF). She had a regular menstrual cycle, but with severe dysmenorrhea on the first day. Her body mass index was 17.9 kg/m2 and her antral follicle count was nine. She had been diagnosed with Camurati–Engelmann disease at 17 years old, a genetic disease characterized by hyperostosis of the long bones and skull, proximal muscle weakness, severe limb pain and joint contractures1. She had undergone previously diagnostic laparoscopy, which revealed endometriosis Grade I, with patency of both Fallopian tubes. Besides endometriosis as a potential cause for infertility, we also identified mild male factor infertility in her partner (total sperm motility of 25%). Controlled ovarian stimulation using menotropin 225 IU/day (Menopur, Ferring GmbH, Kiel, Germany) combined with ganirelix 0.25 mg/day (Vetter Pharma-Fertigung GmbH & Co, Ravensburg, Germany) was started on day 2 of the menstrual cycle, when a follicle of ≥ 14 mm was identified. Although somewhat difficult, and requiring some effort from the patient because of her condition, we were able to perform a transvaginal ultrasound examination in the standard gynecological position to monitor the controlled ovarian stimulation. Final oocyte maturation was triggered by a 0.25-mg dose of recombinant human chorionic gonadotropin (Ovidrel, Merck, Kenilworth, NJ, USA) on the day on which three follicles of ≥ 17 mm were observed. Oocyte retrieval was scheduled for 36 h later. On the day of oocyte retrieval, just after sedation of the patient with propofol and fentanyl, she presented intense muscle contracture at any attempt of thigh abduction and we feared she would not be able to undergo oocyte retrieval in the standard lithotomy position using stirrups. Therefore, we decided to place the patient in the lateral recumbent (or Sims’) position2 (Figure 1). This is considered a good position for performing gynecological Figure 1 Artistic representation of oocyte retrieval using the lateral recumbent position.

Oral dydrogesterone vs. vaginal progesterone capsules for luteal-phase support in women undergoing embryo transfer: a systematic review and meta-analysis

Objective To identify, appraise, and summarize the evidence from randomized controlled trials (RCTs) comparing oral dydrogesterone to vaginal progesterone capsules for luteal-phase support (LPS) in women offered fresh or frozen embryo transfers following in vitro fertilization. Methods Two independent authors screened the literature for papers based on titles and abstracts, then selected the studies, extracted data, and assessed the risk of bias. Dydrogesterone and progesterone were compared based on risk ratios (RR) and the precision of the estimates was assessed through the 95% confidence interval (CI). Results An electronic search performed on June 7, 2017 retrieved 376 records, nine of which were papers deemed eligible and included in this systematic review and quantitative analysis. Good quality evidence indicates that oral dydrogesterone provided at least similar results than vaginal progesterone capsules on live birth/ongoing pregnancy (RR=1.08, 95%CI=0.92-1.26, I2=29%, 8 RCTs, 3,386 women) and clinical pregnancy rates (RR 1.10, 95% CI 0.95 to 1.27; I2=43%; 9 RCTs; 4,061 women). Additionally, moderate quality evidence suggests there is no relevant difference on miscarriage rates (RR=0.92, 95%CI=0.68-1.26, I2=6%, 8 RCTs, 988 clinical pregnancies; the quality of the evidence was downgraded because of imprecision). Conclusions Good quality evidence from RCTs suggest that oral dydrogesterone provides at least similar reproductive outcomes than vaginal progesterone capsules when used for LPS in women undergoing embryo transfers. Dydrogesterone is a reasonable option and the choice of either of the medications should be based on cost and side effects.

EP27.02: Ultra-high magnification (IMSI) vs standard sperm selection (ICSI) for assisted reproduction

The development of Mullerian duct anomalies can be explained by two theories: the classical unidirectional caudal to cranial fusion theory and the alternative bidirectional theory suggesting that fusion proceeds simultaneously in both caudal and cranial directions. In the literature case reports inconsistent with the traditional unidirectional theory can be found. We present an uncommon case which supports the alternative theory. A 38-year-old nulligravida presented in our centre for assisted reproductive treatment because of infertility. Considering her personal history, she underwent laparoscopy with hysteroscopy in 2002 where uterus didelphys was suspected and longitudinal vaginal septum was resected. However, another laparoscopy in 2014 revealed the uterus of a normal shape. We decided to perform hysterosalpingo-foam sonography (HyFoSy) with contrast ExEmFoam®. After acquiring a 3D volume of the uterus, two catheters were placed into both external cervical canals and ExEmFoam® was continuously administered first into the left cervical canal and subsequently into the right one. The progress through uterine cavities and tubes was observed in real-time with ultrasound. Finally, a 3D volume of the uterus with contrast foam was acquired. Frontal views of the uterine cavity from 3D volume were rendered. We observed both tubes patent. As for the uterus, we found normal uterine fundus without indentation with symmetrical corns. The cavity was separated with wide septum starting from the fundus and going downwards between the cervices with the lower half of the septum relatively thin. Interestingly, the distinctive oval communication of size 5.5 x 7 mm between both uterine cavities was observed at the level of an upper and middle third of the septum. The final diagnosis of complete septate uterus with double cervix and communication between both cavities is inconsistent with the traditional embryonic theory and suggests the bidirectional theory is more probable.

Ultrasound for Embryo Transfer

Embryo transfer (ET) is the final procedure during assisted reproductive treatments (ART). Despite all the efforts on improving ART results, ET has changed little overtime [1]. Although embryo implantation is still not fully understood, some evidences suggest the impact of ET technique on the implantation process [2], impacting the reproductive outcomes [1, 3]. Several factors have recently been associated with better results of ET procedure: the ease of transfer [1], physician’s experience [4], type of catheter, and the use of ultrasound (US) guidance [3]. Moreover, even though ET is an important process, its technique is rarely described in clinical trials [5], reducing the possibility of standardization and compromising the reproducibility of studies.

EP32.03: Uterine cavity volume estimation by different techniques: a feasibility, reliability and agreement study

Objectives: This study aimed to compare levator ani muscle (LAM) injury among nulligravid, primiparous and multiparous women. Methods: This is a prospective cross sectional observational study conducted from October 2014 to June 2015 to nulliparous, primigravid and multiparous women with 129 participants to determine association of parity with LAM injury to women who had normal spontaneous delivery. Transperineal 3D ultrasound was used to asess and evaluate with women in dorsal lithotomy position. Data gathered included the presence of levator ani muscle injury, location scored using Weinstein scoring, average thickness of LAM, length of injury and depth assessed using Multiple Slice View (MSV). Results: Total of 129 women were included, equally divided as nulligravid, primiparous and multiparous with 43 (33.3%) for each group, age ranged 18 to 49 years with 57 (44.2%) (95% CI: 35.56% 52.84%) of them had LAM injury with significant difference p value of <0.000001. Proportion with injury increases with increasing parity with highest proportion among multiparous women 32 (74.4%) compared to 3 (7.0%) and 22 (51.2%) of nulliparous and primiparous. Majority of injury were located unilaterally 45 (78.9%) while 12 (21.1%) had bilateral. Score also increases with parity (p value <0.000001). Significant difference was noted in the levator thickness with p value of 0.03. It increases with increasing parity with highest thickness for multiparous with mean thickness of 11.89 mm. Mean length and depth of injury also increases with parity (10.37 +/− 3.66 and 4.75 +/− 0.87) however, these are insignificant. Relationship noted between age and parity may also attribute, in that as age increases, parity also increases, seen among our subjects (r = 0.448; p < 0.001). Age of women with LAM injury was significantly higher than those without with mean of 34.96 ± 8.64 and 31.68 ± 7.72. Conclusions: Therefore, it can be concluded that levator muscle injury increases with increasing parity. EP32: INNOVATIONS IN IMAGING