Shlomi Sagi

Effect of paternal age on reproductive outcomes in oocyte donation model: a systematic review

OBJECTIVE To perform a meta-analysis of the literature examining the influence of paternal age on oocyte donation outcomes. DESIGN Systematic review of the literature with no language or time restrictions. SETTING Not applicable. PATIENT(S) None. INTERVENTION(S) None. MAIN OUTCOME MEASURE(S) Pregnancy and live-birth rates. RESULT(S) By independent screening of titles and abstracts, two investigators selected original studies examining the influence of paternal age on oocyte donation outcomes. Twelve articles were included, encompassing a total of 12,538 oocyte-donation cases. No statistically significant correlation was found by most studies between advanced paternal age and the rate of fertilization, cleavage embryo development, implantation, pregnancy, miscarriage, or live birth. A statistically significant decrease in blastocyst embryo formation was suggested in two articles. Except for volume and possibly motility, other sperm characteristics such as concentration and morphology did not alter with age. However, the overall quality of the evidence was rated as very low according to Grading of Recommendations Assessment, Development, and Evaluation criteria. CONCLUSION(S) The available evidence suggests that advancing paternal age is not associated with adverse oocyte donation outcomes, including pregnancy and live-birth rates. However, the suboptimal quality of the available evidence necessitates high-quality, well-adjusted prospective trials that are also aimed at evaluating additional outcomes such as congenital anomalies and various specific long-term disorders.

The role of episiotomy in prevention and management of shoulder dystocia: a systematic review

Importance Shoulder dystocia is an obstetric emergency with potential catastrophic outcomes. Objective To perform a systematic literature review examining the effectiveness of episiotomy in the prevention and management of shoulder dystocia during vaginal birth. Evidence Acquisition Search was conducted by a research librarian in MEDLINE, Web of Science, Cochrane Library, and SCOPUS databases using the terms “episiotomy” and “shoulder dystocia,” with no language or time restrictions. Two investigators independently selected original researches examining the effects of episiotomy on shoulder dystocia and its neonatal and maternal outcomes. Relevant articles were accessed in full text, including manual search of the references. We contacted authors of studies with insufficient or unclear data. Because of clinical and methodological diversity of the studies, meta-analysis was not performed. Results Fourteen articles met the inclusion criteria, encompassing a total of 9769 shoulder dystocia cases. Only 1 study effectively evaluated the role of episiotomy in shoulder dystocia prevention, yielding a nonsignificant result. Three articles assessed neonatal consequences of shoulder dystocia, one of them linking episiotomy to higher risk of neonatal injury. Two of the 3 studies evaluating maternal outcomes showed that episiotomy is related to increased risk of advanced perineal tears. Overall quality of evidence was rated as very low. Conclusions and Relevance Our systematic review found no evidence supporting the use of episiotomy in the prevention and management of shoulder dystocia. This observation carries major clinical and legal implications for the obstetricians. Higher-quality studies are needed to evaluate this important issue. Target Audience Obstetricians and gynecologists, family physicians Learning Objectives After completion of this educational activity, the reader will be better able to analyze the paucity of existing literature examining the role of episiotomy in the prevention and management of shoulder dystocia, discuss the crucial issues in exploring the subject including uniform definition of shoulder dystocia and the report of episiotomy timing, and assess the knowledge needed to determine whether to perform episiotomy in deliveries with increased risk of shoulder dystocia, such as in cases of macrosomic fetus.

CA 19-9 in evaluation of adnexal mass: retrospective cohort analysis and review of the literature

Objective The aim of this study was to estimate the diagnostic accuracy of serum marker CA 19-9 levels in the triage of adnexal masses. Methods This retrospective cohort study was carried out in patients referred to the Gynecology Department at Carmel Medical Center due to adnexal masses. All patients underwent preoperative measurements of serum CA 125 and CA 19-9 and surgery with histopathologically confirmed diagnosis. Results Between January 2005 and December 2012, 503 patients with adnexal masses were evaluated with serum tumor markers. Combination of CA 19-9 with CA 125, compared with CA 125 levels alone, suggested a nonsignificant effect on sensitivity (86.9% vs. 88.9%, respectively, p = 0.54) or specificity (79.5% vs. 73.5%, p = 0.1) in differentiating malignant from benign adnexal masses. CA 19-9 was not helpful in detecting mucinous histological types or borderline tumors. Mean CA 19-9 levels were higher in metastatic cases compared with primary ovarian malignancy (488.7 ± 1,457 vs. 46.3 ± 149.8 U/mL, respectively, p = 0.001). In mature cystic teratomas, mean CA 19-9 levels were higher and CA 125 levels were lower than in ovarian carcinoma (p = 0.049 and p = 0.0012, respectively). Conclusions The combination of the tumor markers CA 19-9 and CA 125 did not contribute significantly to the detection of malignant adnexal masses compared with CA 125 alone. As our results suggest that higher CA 19-9 levels could be helpful in differentiating metastatic tumors from primary ovarian malignancy; this issue should be investigated in large well-designed prospective cohort trials.

The Effect of Paternal Age on Oocyte Donation Outcomes.

Importance In recent decades, a trend toward delayed childbearing is noted in developed countries. Whereas the effects of maternal age on fertility, pregnancy complications, and postnatal outcomes have been thoroughly explored, consequences of advanced paternal age are less well known. Oocyte donation cycles can be used as an optimal model to analyze the association between male ageing and reproductive outcomes with minimal confounding. Objective The purpose of this work was to summarize the updated and relevant literature dealing with the effect of paternal age on oocyte donation outcomes. Results According to the available evidence from oocyte donation cycles, it seems that no significant association exists between advanced paternal age and fertility. However, this evidence is based on few studies, many of which are of low quality, yielding conflicting results. In addition, the emerging evidence clearly indicates an increased risk of adverse postnatal manifestations of pregnancies conceived by older fathers, including de novo autosomal dominant disorders, impaired neurocognitive development, and increased risk of malignancy. Conclusions and Relevance This review may be of aid to medical practitioners in counseling couples on the risks of delayed childbearing. Target Audience Obstetricians and gynecologists, family physicians Learning Objectives After completing this activity, the learner should be better able to analyze the paucity of existing literature examining the effect of paternal age on oocyte donation outcomes, understand the mechanisms underlying the increased risk for postnatal disorders associated with advanced male age, and counsel couples on the risks of delayed childbearing.

Risk for chromosomal aberrations in apparently isolated intrauterine growth restriction: A systematic review

To perform a systematic review examining the risk of chromosomal aberrations in apparently isolated intrauterine growth restriction (IUGR).

Response to the letter to the editor: the correct episiotomy—does it exist?

The concept of episiotomy was introduced in 1741. This procedure is still sparingly used in many countries, despite the surprising lack of evidence to support its benefits. According to several recent systematic reviews and meta-analyses, no solid evidence has been demonstrated in the professional literature to recommend episiotomy performance even in the most Bclassic^ scenarios, such as prevention and management of shoulder dystocia, vacuum delivery, and prevention of impending tear [1–3]. Furthermore, this procedure may be related to an increased risk of various obstetric complications, such as postpartum bleeding, pain, and a higher rate of advanced perineal lacerations [3]. Thus, in our opinion, episiotomy should be maximally restricted unless large randomized controlled trials are published supporting its use. Nevertheless, as episiotomy is still widely used worldwide, the obstetricians should try to minimize the potential complications of this procedure by optimizing the incision technique. As was previously described, no consensus definition has been formulated by national guidelines regarding the most appropriate episiotomy parameters, such as optimal angle and length of the incision. A novel piece of research by the European Project OASIS and Multicenter Study TASI focused on exploring the innervation of the external anal sphincter by using multichannel surface EMG [4, 5]. The investigators demonstrated a statistically significant reduction in innervation zones on the side of episiotomy. In addition, the authors reported very high intersubject variability in the distribution of the innervation zones, and suggested that preliminary evaluation of this distribution might guide the obstetrician to the preferred location for the episiotomy incision. Pre-deliverymultichannel surface EMG seems like a promising new method of minimizing episiotomy complications. The issue deserves stronger evidence, though, preferably using randomized controlled trials. The main point, still to be proven, is that the performance of selective episiotomy on the side with less innervation, compared with the traditional right-sided episiotomy, is indeed associated with a decreased risk for clinical manifestations of anal sphincter injury. In addition, we believe that it is crucial to perform a sufficiently large randomized controlled trial comparing selective episiotomy use with complete avoidance of episiotomy. Finally, uniform protocols and educational programs are needed to guide episiotomy practice.