Background
In twin pregnancies, the rates of adverse perinatal outcome and subsequent long‐term morbidity are substantial, and mainly result from preterm birth (PTB).
Objectives
To assess the ...effectiveness of progestogen treatment in the prevention of neonatal morbidity or PTB in twin pregnancies using individual participant data meta‐analysis (IPDMA).
Search strategy
We searched international scientific databases, trial registration websites, and references of identified articles.
Selection criteria
Randomised clinical trials (RCTs) of 17–hydroxyprogesterone caproate (17Pc) or vaginally administered natural progesterone, compared with placebo or no treatment.
Data collection and analysis
Investigators of identified RCTs were asked to share their IPD. The primary outcome was a composite of perinatal mortality and severe neonatal morbidity. Prespecified subgroup analyses were performed for chorionicity, cervical length, and prior spontaneous PTB.
Main results
Thirteen trials included 3768 women and their 7536 babies. Neither 17Pc nor vaginal progesterone reduced the incidence of adverse perinatal outcome (17Pc relative risk, RR 1.1; 95% confidence interval, 95% CI 0.97–1.4, vaginal progesterone RR 0.97; 95% CI 0.77–1.2). In a subgroup of women with a cervical length of ≤25 mm, vaginal progesterone reduced adverse perinatal outcome when cervical length was measured at randomisation (15/56 versus 22/60; RR 0.57; 95% CI 0.47–0.70) or before 24 weeks of gestation (14/52 versus 21/56; RR 0.56; 95% CI 0.42–0.75).
Author's conclusions
In unselected women with an uncomplicated twin gestation, treatment with progestogens (intramuscular 17Pc or vaginal natural progesterone) does not improve perinatal outcome. Vaginal progesterone may be effective in the reduction of adverse perinatal outcome in women with a cervical length of ≤25 mm; however, further research is warranted to confirm this finding.
BACKGROUND: The objective of this systematic review was to assess the safety and efficacy of subcutaneous recombinant (r) HCG and high-dose rLH compared with intramuscular urinary (u) uHCG for ...inducing final oocyte maturation and triggering ovulation. METHODS: We searched the Cochrane Menstrual Disorders and Subfertility Group trials register (August 27, 2003), the Cochrane Central Register of Controlled Trials (CENTRAL on The Cochrane Library, issue 4, 2003), MEDLINE (1966 to February 2004) and EMBASE (1980 to February 2004). Searches were not limited by language. The bibliographies of included and excluded trials and abstracts of major meetings were searched for additional trials. Authors and pharmaceutical companies were contacted for missing and unpublished data. Only truly randomized controlled trials (RCTs) were included. Assessment of inclusion/exclusion, quality assessment and data extraction were performed independently by at least two reviewers. RESULTS: Seven RCTs were identified, four comparing rHCG and uHCG and three comparing rhLH and uHCG. There was no statistically significant difference between rHCG and uHCG regarding the ongoing pregnancy/live birth rate odds ratio (OR) 0.98; 95% confidence interval (CI) 0.69–1.39, clinical pregnancy rate, miscarriage rate or incidence of ovarian hyperstimulation syndrome (OHSS). There was no statistically significant difference between rhLH and uHCG regarding the ongoing pregnancy/live birth rate (OR 0.94; 95% CI 0.50–1.76), pregnancy rate, miscarriage rate or incidence of OHSS. rHCG was associated with a reduction in the incidence of local site reactions (OR 0.47; 95% CI 0.32–0.70). CONCLUSIONS: According to these data, there is no evidence of a difference in clinical outcomes between urinary and recombinant gonadotrophins used for induction of final follicular maturation. Additional factors should be considered when choosing gonadotrophin type, including safety, cost and drug availability.
The aim of this review was to summarize previously published classifications for ovarian hyperstimulation syndrome (OHSS), as well as to analyse the available methods for preventing OHSS. Withholding ...hCG and cycle cancellation—once the main methods of preventing OHSS—are now seldom used. There is a growing body of evidence to support the use of coasting to prevent OHSS, without cycle cancellation. However, most studies on coasting are retrospective, and well‐designed prospective randomized studies are lacking. There is no current consensus as to how coasting should be carried out. A serum estradiol level of 3000 pg/ml is generally considered optimum for administration of hCG. It appears that intravenous albumin or hydroxyethyl starch at the time of oocyte retrieval is beneficial in preventing OHSS, but does not offer complete protection. There is insufficient evidence to support routine cryopreservation of all embryos for the later transfer of frozen–thawed embryos in high‐risk patients. Several uncontrolled studies have reported the protective effect of GnRH agonist to trigger ovulation in preventing OHSS, though the method is applicable solely for gonadotrophin‐only or GnRH antagonist cycles. A single dose of recombinant LH to trigger ovulation significantly reduced OHSS as compared with hCG. The possible role of GnRH antagonist protocols in reducing the incidence of OHSS is debatable. The above measures to prevent OHSS were successful in reducing the incidence of the syndrome, but complete prevention is not as yet possible.
The technique of embryo transfer is very crucial and great attention and time should be given to this step. In order to optimize the embryo transfer technique, several precautions should be taken. ...The first and most important is to avoid the initiation of uterine contractility. This can be achieved by the use of soft catheters, gentle manipulation and by avoiding touching the fundus. Secondly, proper evaluation of the uterine cavity and utero–cervical angulation is very important, and can be achieved by performing dummy embryo transfer and by ultrasound evaluation of the utero–cervical angulation and uterine cavity length. Another important step is the removal of cervical mucus so that it does not stick to the catheter and inadvertently remove the embryo during catheter withdrawal. Finally, one has to be absolutely sure that the embryo transfer catheter has passed the internal cervical os and that the embryos are delivered gently inside the uterine cavity.
The management of hydrosalpinx is a difficult clinical problem. Surgical treatment includes fimbrioplasty for patients with fimbrial obstruction and salpingostomy to fashion a stoma in the distal ...Fallopian tube in patients with a damaged fimbrial end. Surgery is only suitable for a small thin-walled hydrosalpinx with healthy mucosa. These operations can be performed via laparoscopy or open microsurgery. The proper selection of patients for surgical treatment and of the type of surgical technique are essential to achieve good results. The results of open microsurgery and laparoscopic surgery are summarized. In general, the prognosis of surgery is poor; however, in well selected cases, good results can be achieved by an experienced surgeon. In-vitro fertilization (IVF) is the main line of treatment for infertility caused by hydrosalpinx. In 1991, our group was the first to report on fluid accumulation in the uterine cavity before embryo transfer as a possible hindrance for implantation. Later, several publications reported an associated between patients with hydrosalpinx and a reduced pregnancy rate when treated by IVF. The cause of a low pregnancy rate could be due to mechanical, chemical or toxic effects of the tubal fluid on the endometrium preventing implantation. All these mechanisms are reviewed in detail. The literature is controversial concerning the effect of transvaginal aspiration of hydrosalpinx on the outcome of IVF. Several reports suggest that surgical correction of the hydrosalpinx may improve the outcome of IVF. Further studies are required to verify this assumption and to find out the most suitable surgical procedure and if there is a sub-group of patients who could benefit most from salpingectomy. Keywords:fimbrioplasty/hydrosalpinx/pregnancy rate/salpingectomy/salpingostomy
BACKGROUND: The true impact of the embryo transfer catheter choice on an IVF programme has not been fully examined. We therefore decided to systematically review the evidence provided in the ...literature so that we may evaluate a single variable in relation to a successful transfer, the firmness of the embryo transfer catheter. METHODS: An extensive computerized search was conducted for all relevant articles published as full text, or abstracts, and critically appraised. In addition, a hand search was undertaken to locate any further trials. RESULTS: A total of 23 randomized controlled trials (RCT) evaluating the types of embryo transfer catheters were identified. Only ten of these trials, including 4141 embryo transfers, compared soft versus firm embryo catheters. Pooling of the results demonstrated a statistically significantly increased chance of clinical pregnancy following embryo transfer using the soft (643/2109) versus firm (488/2032) catheters P = 0.01; odds ratio (OR) = 1.39, 95% confidence interval (CI) = 1.08–1.79. When only the truly RCT were analysed, the results were again still in favour of using the soft embryo transfer catheters soft (432/1403) versus firm (330/1402), but with a greater significance (P < 0.00001; OR = 1.49, 95% CI = 1.26–1.77). CONCLUSION: Using soft embryo transfer catheters for embryo transfer results in a significantly higher pregnancy rate as compared to firm catheters.
Objective: This study was undertaken to evaluate the outcome of in vitro fertilization (IVF) in patients with advanced pelvic endometriosis and previous surgical treatment. Study design: A case ...controlled study was performed. Results: Patients with the diagnosis of stage IV endometriosis with previous surgical treatment were treated by IVF (group A = 85). An age-matched group of patients (group B = 177) with tubal factor infertility were treated with the same protocol of IVF. In group A, cycle cancellation because of poor response occurred in 29.7% compared with 1.1% in the control group (relative risk 26.03, 95% CI 6.02-112.45). There were 13 (15.3%) clinical pregnancies per stimulated cycle in group A compared with 93 (52.5%) clinical pregnancies in the control group, P < .0001 (odds ratio 0.29, 95% CI 0.15-0.55). Conclusion: The outcome of IVF in stage IV endometriosis with previous surgery was significantly lower compared with an age-matched group of tubal factor infertility. (Am J Obstet Gynecol 2003;188:371-5.)
A meta-analysis was conducted to investigate whether flexible gonadotrophin-releasing hormone (GnRH) antagonist administration according to follicular size would be more beneficial than starting on a ...fixed day. Only randomized controlled trials were included after a comprehensive search strategy. The data were combined for meta-analysis with RevMan software. Eleven trials were identified, but only four randomized controlled trials met the inclusion criteria. There was no statistically significant difference in pregnancy rate per woman randomized, although there was a trend towards a higher pregnancy rate with the fixed protocol, especially with delayed administration beyond day 8 odds ratio (OR) 0.7, 95% confidence interval (CI) 0.45−1.1. There was no premature LH surge in any participant in either protocol. However, there was a statistically significant reduction both in number of antagonist ampoules (OR −1.2 95%, CI −1.26 to −1.15) and amount of gonadotrophin (OR 95.5 IU, 95% CI 74.8−116.1) used in the flexible protocol. In conclusion, there was no statistically significant difference in pregnancy rate between flexible and fixed protocols. There was a statistically significant reduction in the amount of recombinant FSH with the flexible protocol.
The main perinatal complications of assisted reproduction include congenital malformation, chromosomal aberrations, multiple pregnancy, and prematurity. Earlier studies and in vitro fertilization ...(IVF) registries showed that there was no increased incidence of congenital malformations in children conceived by IVF/intracytoplasmic sperm injection (ICSI). However, a large Australian study has found that by one year of age, the incidence of congenital malformations in IVF/ICSI children is increased in comparison with those naturally conceived. Several investigators found a slight but increased risk of chromosomal aberrations in ICSI children. Multiple pregnancy is a major cause of increased perinatal mortality due to increased incidence of both prematurity and congenital malformations. Even in singleton pregnancies conceived by assisted reproductive technologies, the risk of prematurity and newborns small for gestational age is increased. In this article, recently published work on perinatal complications associated with assisted reproductive technologies is reviewed.
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