V. Leitão

Cabergoline for the prevention of ovarian hyperstimulation syndrome: systematic review and meta-analysis of randomized controlled trials

OBJECTIVEnTo evaluate the efficacy and safety of using cabergoline for reducing the risk of ovarian hyperstimulation syndrome (OHSS).nnnDESIGNnSystematic review and meta-analysis of randomized clinical trials (RCTs).nnnPATIENTSnWomen submitted to controlled ovarian stimulation (COS) for assisted reproduction.nnnINTERVENTIONSnCabergoline.nnnSETTINGnFertility centers.nnnMAIN OUTCOME MEASURESnModerate-severe OHSS, live birth, clinical pregnancy, number of retrieved oocytes, miscarriage, congenital abnormalities. Comparisons were performed with the use of risk ratios (RRs) or mean differences (MDs) and their respective 95% confidence intervals (CIs).nnnRESULT(S)nEight RCTs were considered to be eligible; data from seven studies could be extracted and included in the meta-analysis. Cabergoline reduces the risk of moderate-severe OHSS (RR 0.38, 95% CI 0.29-0.51, 7 studies, 858 women) and probably has no clinically relevant negative impact on clinical pregnancy (RR 1.02, 95% CI 0.78-1.34, 4 studies, 561 women) or on the number of retrieved oocytes (MD 1.15, 95% CI -0.76 to 3.07, 5 studies, 628 women). However, our estimates were imprecise for distinguishing between substantial harm, no effect, and substantial benefit considering live birth (RR 1.03, 95% CI 0.71-1.48, 1 study, 200 women), and miscarriage (RR 0.69, 95% CI 0.27 to 1.76, 3 studies, 194 pregnant women). No studies reported congenital abnormalities.nnnCONCLUSION(S)nCabergoline reduces the occurrence of moderate-severe OHSS. Cabergoline is unlikely to have a clinically relevant negative impact on clinical pregnancy or on the number of retrieved oocytes. However, we are still uncertain of its impact on live birth, miscarriage, and congenital abnormalities.

Ovarian hyperstimulation syndrome: pathophysiology, staging, prediction and prevention.

To identify, appraise and summarize the current evidence regarding the pathophysiology, staging, prediction and prevention of ovarian hyperstimulation syndrome (OHSS).

Melatonin supplementation during controlled ovarian stimulation for women undergoing assisted reproductive technology: systematic review and meta-analysis of randomized controlled trials.

OBJECTIVEnTo examine the best evidence available regarding the effect of melatonin supplementation during controlled ovarian stimulation (COS) on the main assisted reproductive technology (ART) outcomes.nnnDESIGNnSystematic review and meta-analysis of randomized clinical trials (RCT).nnnSETTINGnNot applicable.nnnPATIENT(S)nWomen undergoing COS for ART.nnnINTERVENTION(S)nMelatonin supplementation during COS for women undergoing ART.nnnMAIN OUTCOME MEASURE(S)nLive birth rate, clinical pregnancy rate, number of retrieved oocytes, miscarriage rate, ovarian hyperstimulation syndrome (OHSS) rate, and number of congenital abnormalities. Comparisons were performed using risk ratio (RR) or mean difference (MD).nnnRESULT(S)nFive RCTs were considered eligible, and their data were extracted and included in a meta-analysis. No studies reported live-birth or congenital abnormalities. Our estimates were imprecise for distinguishing between no effect and benefit considering clinical pregnancy (RR, 1.21; 95% confidence interval [CI], 0.98-1.50, five studies, 680 women, low quality-evidence) and the number of oocytes retrieved (MD, 0.6; 95% CI, -0.2-2.2, five studies, 680 women, low quality-evidence). Our estimates were imprecise for distinguishing among harm, no effect, and benefit considering miscarriage (RR, 1.07; 95% CI, 0.43-2.68, two studies, 143 clinical pregnancies, low quality-evidence) and interventions to reduce the risk of OHSS (RR,1.01; 95% CI, 0.33-3.08, one study, 358 women, low quality-evidence).nnnCONCLUSION(S)nMore studies investigating the role of melatonin supplementation are still needed before recommending its use in clinical practice.

Congenital Uterine Malformation by Experts (CUME): better criteria for distinguishing between normal/arcuate and septate uterus?

To assess the level of agreement between experts in distinguishing between septate and normal/arcuate uterus using their subjective judgment when reviewing the coronal view of the uterus from three‐dimensional ultrasound. Another aim was to determine the interobserver reliability and diagnostic test accuracy of three measurements suggested by recent guidelines, using as reference standard the decision made most often by experts (Congenital Uterine Malformation by Experts (CUME)).

Eco-epidemiologic study of emerging fungi related to the work of babaçu coconut breakers in the State of Maranhão, Brazil

INTRODUCTIONnThere are more than 300,000 extractors using the babaçu coconut as a source of income in the States of Maranhão, Pará, Tocantins and Piauí, and this activity is associated with fungal infections. The objective of this study was to examine the occurrence of emergent fungi in the conjunctiva, nails and surface and subcutaneous injuries of female coconut breakers in Esperantinópolis, Maranhão. Additionally, soil samples and palm structures were collected.nnnMETHODSnThe obtained samples were cultured in Petri dishes containing potato-dextrose-agar and chloramphenicol. The etiological agent was confirmed by a direct mycological exam and growth in culture.nnnRESULTSnIn total, 150 domiciles were visited, and samples were collected from 80 patients. From the ground, the most frequently isolated fungus was Aspergillus niger (53. 8%). the most frequently detected fungus in babaçu coconut was Aspergillus niger (66.7%). Conjunctival fungal growth occurred in 76.3% of the women. The ocular fungal microbiota consisted of filamentous fungi (80.6%), and yeasts were present in 19.4% of cases. Onychomycosis was diagnosed in 44% (11/25) of the women.nnnCONCLUSIONSnThe identification of the genera Neosartorya, Rhizopus and Curvularia in onychomycoses shows that emergent filamentous fungi can be isolated. Aspergillus sp., Penicillium sp. and Scedosporium sp. were the predominant genera found in the babaçu coconut. From ocular conjunctiva, Candida spp. were the most prevalent species isolated, and Fusarium sp. was present only in one woman. The nearly permanent exposure of coconut breakers to the external environment and to the soil is most likely the reason for the existence of a mycotic flora and fungal infections, varying according to the individuals practices and occupation.

EP27.11: Normal/arcuate vs septate uterus: interobserver reliability/agreement of currently used measurements

withdrawn EP27.11 Normal/arcuate vs septate uterus: interobserver reliability/agreement of currently used measurements A. Ludwin2,9, W.P. Martins5,4, C.O. Nastri4,5, I. Ludwin2,9, M.A. Coelho Neto4, V. Leitão4, M. Acién10, J. Alcazar8, B.R. Benacerraf3, G. Condous1, R.L. De Wilde17, M.H. Emanuel6, W.E. Gibbons11, S. Guerriero7, W.W. Hurd12, D. Levine13, S. Lindheim14, A. Pellicer15, F. Petraglia15, E. Saridogan16 1Obstetrics and Gynecology, Acute Gynecology, Early Pregnancy and Advanced Endosurgery Unit, Nepean Hospital, Sydney Medical School Nepean, University of Sydney, Sydney, NSW, Australia; 2Department of Gynecology and Oncology, Chair of Gynecology and Obstetrics of Jagiellonian University, Krakow, Poland; 3Harvard Medical School, Brookline, MA, USA; 4Department of Obstetrics and Gynecology, Ribeirao Preto Medical School, University of São Paulo, Ribeirao Preto, Brazil; 5Reproductive Medicine, SEMEAR fertilidade, Ribeirao Preto, São Paulo, Brazil; 6Obstetrics and Gynecology, Spaarne Hospital, Hoofddorp, Netherlands; 7Department of Obstetrics and Gynecology, University of Cagliari, Cagliari, Italy; 8Obstetrics and Gynecology, University of Navarra, Pamplona, Spain; 9Ludwin and Ludwin Gynecology, Krakow, Poland; 10San Juan University Hospital/Miguel Hernández University, Alicante, Spain; 11Baylor College of Medicine, Houston, TX, USA; 12Division of Reproductive Endocrinology and Infertility Department of Obstetrics and Gynecology, Duke University Medical Centre, Durham, NC, USA; 13Beth Israel Deaconess Medical Centre, Boston, MA, USA; 14Department of Obstetrics and Gynecology, Wright State University, Boonshoft School of Medicine, Dayton, OH, USA; 15Instituto Valenciano de Infertilidad, Krakow, Spain; 16University College London Hospital, London, United Kingdom; 17Carl-von-Ossietzky-University Oldenburg, Oldenburg, Germany Objectives: To evaluate the inter-observer reliability/agreement of currently used measurements to distinguish between normal/arcuate and septate uterus. Methods: We included 100 women evaluated between Jun-2016 and Jul-2016 with suspected uterine anomaly, using a single 3D data-set of each uterus. Two observers using the same initial data-set, independently manipulated the uterus to obtain the coronal plane and performed the following measurements blinded to each other results: indentation depth, indentation angle, and uterine fundal wall thickness; the latter was used to calculated the indentation to wall thickness (I:WT) ratio. Inter-observer reliability and agreement of indentation depth, angle and I: WT ratio were assessed by concordance correlation coefficient (CCC) and limits of agreement (LoA). Results: The inter-rater reliability of indentation depth (CCC=0.99, 95%CI=0.98-0.99) was significantly better than both indentation angle (CCC=0.96, 95%CI=0.94-0.97) and I:WT ratio (CCC=0.92, 95%CI=0.90-0.94). The LoA were: indentation depth = -1.7mm to +2.1mm; indentation angle = -17◦ to +16◦; and I:WT ratio = -75% to + 96%. Conclusions: Among the three measurements frequently used to distinguish between normal/arcuate and septate uterus, the indentation depth was the most reliable; differences up to ± 2mm are expected if the measurement is repeated by another observer. EP27.12 Abstract withdrawn EP28: BLEEDING, ENDOMETRIAL AND MYOMETRIAL PATHOLOGY EP28.01 Uterine artery pseudoaneurysm with coexisting artrovenous malformation F. Buonomo1, R. Federico1, R. De Leo2, M. Mirandola1, T. Stampalija1, G. Ricci1 1Institute of Maternal and Child Health IRCCS Burlo Garofolo, Trieste, Italy; 2Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Catholic University of the Sacred Heart, Rome, Italy A 33-year old woman with a massive uterine bleeding occurred after a LPS treated uterine rupture due to a miomectomy scar pregnancy. US revealed an anechoic intramiometrial lesion surrounded by multiple tubular anechoic lesions distributed in the myometrium. 2D US and Colour Doppler sonography revealed a central arterial-like turbulent, low impedance blood flow inside the lesion. The hypothesis was of a uterine artery pseudoaneusysm and coexisting AV malformation. A 3DTVUS was performed to evaluate the exact position of the lesion and its angioarchitecture. The HD-flow 3D reconstruction of the resulting image revealed a large right pseudoaneurysm vascularised by an ecstatic vessel originated by the right uterine artery. Right artery embolisation was performed. 3D HD flow Doppler evaluation four days later showed persistent blood flow deriving from a collateral left uterine artery vessel. The patient was led to left uterine artery embolisation as well. 3D reconstruction of colour/Power Doppler sonographic images can enable us to understand the spatial relationship of vessels in areas where complex structures are present. 3D-US can provide additional information useful to clinicians such as identification of the vascular connections including its feeding and draining vessel. The present case emphasises the importance of ultrasound investigation, in the management of vascular pathologies, initially with 2D grey and subsequently with Colour Doppler and 3D, both in terms of diagnostic approach of vascular defects as well as of follow up in order to assess the persistence of a turbulent flow after invasive procedures such as artery embolisation. Supporting information can be found in the online version of this abstract

P26.10: Normal/arcuate vs septate uterus: agreement among experts' subjective impression evaluating the coronal plane of the uterus on 3D ultrasound

using HDlive. The four images for each uterus were combined in a single image, and the 100 combined images (one for each uterus) were anonymised and submitted to 15 experts (5 clinicians, 5 surgeons and 5 sonologists). These experts were asked to judge the image quality of each imaging technique using an 11-point numeric scale (0-10), providing only one vote for each imaging technique. Results were summarised as median and interquartile range (IQR), and comparison across groups performed with Friedman test. Results: Considering the opinion of all fifteen experts, only MP was considered as providing significantly worse imaging quality: MP=7(6-9), VCI=8(8-10), Omniview=8(8-9), and HDlive=9(8-10); p=0.002. Considering only the five clinicians the results were: MP=7(5-9.5), VCI=8(7.5-9.5), Omniview=8(7.5-9.5), and HDlive=8(8-9.5; p=0.39). Considering only the five surgeons, the results were: MP=7(5-9.5), VCI=8(7.5-9.5), Omniview=8(7.5-9.5), and HDlive=8(8-9.5). Considering only the five sonologists, the results were: MP=7(6-8.5), VCI=8(7.5-10), Omniview=9(8.5-9.5), and HDlive=10(9-10). Conclusions: Experts showed a preference for rendered imaging techniques when assessing the coronal plane of the uterus.

P26.09: Image quality of the coronal plane of the uterus by 3D ultrasound: comparison of four techniques based on the opinion of several experts

female offspring of PCOS women already show higher androgen levels compared to the female offspring of non-PCOS women. Methods: Androgen levels were determined in maternal serum and umbilical cord blood from PCOS and non-PCOS women and the respective offspring at the Medical University of Graz, Austria, between 2012 and 2015. Results: A total of 79 PCOS and 354 non-PCOS women were recruited. The main results are shown in table 1. Conclusions: The comparison revealed that androgen levels in female offspring of PCOS and non-PCOS women do not differ although maternal hormone levels differ significantly.

EP27.04: Normal/arcuate vs septate uterus: agreement between currently recommended cut-off values for measurements and experts' opinion

EP27.04 Normal/arcuate vs septate uterus: agreement between currently recommended cut-off values for measurements and experts’ opinion A. Ludwin2,9, W.P. Martins5,4, C.O. Nastri4,5, I. Ludwin2,9, M.A. Coelho Neto4, V. Leitão4, M. Acién8, J. Alcazar8, B.R. Benacerraf3, G. Condous1, R.L. De Wilde10, M.H. Emanuel6, W.E. Gibbons11, S. Guerriero7, W.W. Hurd12, D. Levine13, S. Lindheim14, A. Pellicer15, F. Petraglia16, E. Saridogan17 1Obstetrics and Gynecology, Acute Gynecology, Early Pregnancy and Advanced Endosurgery Unit, Nepean Hospital, Sydney Medical School Nepean, University of Sydney, Sydney, NSW, Australia; 2Department of Gynecology and Oncology, Chair of Gynecology and Obstetrics of Jagiellonian University, Krakow, Poland; 3Harvard Medical School, Brookline, MA, USA; 4Department of Obstetrics and Gynecology, Ribeirao Preto Medical School, University of São Paulo, Ribeirao Preto, São Paulo, Brazil; 5Reproductive Medicine, SEMEAR Fertilidade, Ribeirao Preto, São Paulo, Brazil; 6Obstetrics and Gynecology, Spaarne Hospital, Hoofddorp, Netherlands; 7Department of Obstetrics and Gynecology, University of Cagliari, Cagliari, Italy; 8Obstetrics and Gynecology, University of Navarra, Pamplona, Spain; 9Ludwin and Ludwin Gynecology, Krakow, Poland; 10Carl-von-Ossietzky-University Oldenburg, Oldenburg, Germany; 11Baylor College of Medicine, Huston, TX, USA; 12Division of Reproductive Endocrinology and Infertility Department of Obstetrics and Gynecology, Duke University Medical Centre, Durham, NC, USA; 13Beth Israel Deaconess Medical Centre, Boston, MA, USA; 14Department of Obstetrics and Gynecology, Wright State University, Boonshoft School of Medicine, Dayton, OH, USA; 15Instituto Valenciano de Infertilidad, Valencia, Spain; 16University of Florence, Florence, Italy; 17University College London Hospital, London, United Kingdom

DIVERSITY AND INFECTIVITY POTENTIAL OF EMERGING FUNGI IN AN AREA OF BABAÇU TREES IN THE STATE OF MARANHÃO, BRAZIL

We studied human mycoses in conjunctiva, nails (onycholytic lesions) and skin lesions in 100 babaçu coconut breakers of Esperantinópolis, Maranhão (Fig. 1), and studied the ground near the babaçu palms, coconut shells and palm leaves (Fig. 2), for taxonomic classification of fungi by direct mycological and microscopic examination. We also performed direct examination with KOH for human mycoses. After the growth of colonies, these were analyzed by light microscopy using blue lactophenol dye. Colonies of interest were subcultured in tubes of 16 x 150, containing Sabouraud agar medium and subsequently was prepared microcultivation for taxonomic identification. The study was approved by the Ethics Committee in Research of the University Hospital of UFMA. Of the 20 samples taken from the soil, we obtained 13 isolates of fungi, whose macro and micromorphological characteristics of the colonies allowed the diagnosis of Aspergillus niger, Penicillium sp., and Scedosporium sp., besides others, Fusarium sp. not being found. In coconut shells Aspergillus niger and Penicillium sp. were found; in almond coconut, Aspergillus niger, A. versicolor, A. flavus, and Penicillium sp. were obtained. On palm leaves we identified Aspergillus niger and Penicillium sp. (Table 1). Twenty-five nail samples that showed suggestive alterations of onycholytic lesions (Fig. 3) were harvested; eleven positive cultures for yeast, Neosartorya spinosa, and Trichophyton sp. Rhizopus sp. and Curvularia sp. (Fig. 4) were isolated. Seventy-two fungal isolates were obtained from the conjunctiva, the most common were filamentous fungi from 58 (80.57%) breakers and 14 samples (19.43%) were found corresponding to Candida sp., and the Fusarium spp. occurred in only one sample (Fig. 5 and Table 2).