P–233 The spatial arrangement of blastomeres and time of cavitation forming as predictors of blastocyst quality

Study question

Does the spatial arrangement of blastomeres and the start of blastulation affect blastocyst quality?

Summary answer

Better blastocyst quality is associated with the spatial arrangement of the embryo and the shorter time frame of blastulation (cavitation).

What is known already

The ability to select the human embryo with the highest implantation potential remains one of the greatest challenges in the management of In Vitro Fertilization patients. Several publications have proposed that additional morphological evaluations of blastomere arrangement and the dynamics of late-stage embryonic divisions might be a useful non-invasive way for embryo selection. In the last decade, the introduction of time-lapse technology enables continuous monitoring of embryo development, which leads to better outcomes than a selection based on the traditional morphology assessment.

Study design, size, duration

The spatial arrangement was defined as tetrahedrally if the cleavage planes were perpendicularly orientated, while embryos with rather parallelly orientated cleavage axes were considered as non-tetrahedral embryos. The injection time of ICSI was designated as “time zero” (t0), and EmbryoViewer software was used to calculate the time duration between injection and start of blastulation (cavitation). Obtained results were later correlated with the embryo’s capability to form a blastocyst as well as with blastocyst quality.

Participants/materials, setting, methods

A total of 195 oocytes from 40 patients undergoing the antagonist cycle for ICSI treatment were evaluated. All blastocysts were cultured in Embryoscope™ according to the manufacturer’s specifications (Vitrolife, Sweden). The Gardner and Schoolcraft scoring system was used to describe blastocyst quality. Statistical analyses were performed using IBM SPSS version 24. Data were reported as median and range. Differences between groups were tested using the Mann-Whitney U test. Statistical significance was defined as p < 0.05.

Main results and the role of chance

Obtained data showed that 83.6% (61/73) of embryos with tetrahedral arrangement formed blastocysts compared to 42.4% (50/116) of embryos with the non-tetrahedral arrangement (p < 0,001). Moreover, tetrahedral embryos more frequently formed good quality blastocyst compare to the non-tetrahedral [59% (36/61) vs 18 (9/50)% respectively; p < 0,001]. In addition, we found that good quality blastocyst had a significantly shorter time frame between injection and blastulation start, compared with blastocysts which did not reach good quality [95.00h (84–118) vs 102h (77–121) respectively; p = 0,006].

Limitations, reasons for caution

The limitation of the present study was that due to the double-embryo transfer correlation between those morphokinetic parameters and pregnancy rate can not be calculated. Further research should link these morphokinetic parameters with pregnancy rate and live birth rate as well.

Wider implications of the findings: The potential of our findings is considerable, especially for countries with strict Embryo Law Regulation. Obtained results might be highly useful for selecting embryos with high implantation potential. In addition, the present work illustrates the possibility of additional information that can potentially be incorporated into an embryo classification model.

Trial registration number

Not applicable

P–140 Zygote morphokinetics as a predictor of blastocyst quality

Study question

Does the total cytoplasmic volume (TCV) of the zygote and time of pronuclei disappearance (tPNf) affect blastocyst development potential and blastocyst quality?

Summary answer

The total cytoplasmic volume of zygote and the time of pronuclei disappearance strongly affect blastocyst development as well as blastocyst quality.

What is known already

Extended embryo culture with blastocyst transfer is considered a useful method for selecting embryos with a high implantation potential. One of the main concerns in the German Embryo Protection Act is that the choice of embryos that have a high potential for successful implantation must be made at the pronucleus stage. The introduction of time-lapse technology enabled comprehensive information regarding the morphology and kinetics of the embryo. Although for the past years, strong correlations between embryo morphokinetics and positive outcomes have been demonstrated, some disagreement concerning the wide application of these parameters into an early-stage embryo selection is still present.

Study design, size, duration

The injection time of ICSI was designated as “time zero”, and computer software was used to calculate the time frame between the injection and the moment of pronuclei disappearance (tPNf). The total cytoplasmic volume was calculated 16–18 h after injection based on manually drawn diameters of the zygotes, by the computer. Obtained measurements were later associated with the blastocyst formation potential as well as with blastocyst quality.

Participants/materials, setting, methods

A total of 187 oocytes from 34 patients undergoing the antagonist cycle for ICSI treatment were evaluated. All blastocysts were cultured in Embryoscope™ according to the manufacturer’s specifications (Vitrolife, Sweden). The Gardner and Schoolcraft scoring system was used to describe blastocyst quality. Statistical analyses were performed using IBM SPSS version 24. Data were reported as median and range. Differences between groups were tested using the Mann-Whitney U test. Statistical significance was defined as p < 0.05.

Main results and the role of chance

Obtained data showed that the total cytoplasmic volume values were significantly higher in zygotes that reached the blastocyst stage compared with those that did not [708376,268µm³ (560564,412µm³ - 838602,605µm³) vs 674349,917 (415749,353- 823640,638) respectively; p < 0.0001]. Furthermore, this parameter as well significantly affect blastocyst quality where zygotes which formed better blastocyst quality had smaller cytoplasmic volume [685568,079 µm³ (560564,412- 790112,397µm³) vs 745514,662 µm³ (616581,339- 838602,605) respectively; p < 0.0001]. Time of pronuclei disappearance (tPNf) was significantly different (p < 0.0001) in successfully formed blastocysts [22.00h (17–29 h)] versus arrested or non-blastulating embryos [23.00h (17–56 h)]. Zygotes who had a shorter time frame between injection and pronuclei disappearance showed better blastocyst quality values compared with those who had longer time frame [21.00h (17–28h) vs 23.00h (18–29h) respectively; p < 0.01].

Limitations, reasons for caution

The limitation of the presented study was that due to the double-embryo transfer correlation between morphokinetic parameters and pregnancy rate was not possible to be calculated. Further research should link these morphokinetic parameters with pregnancy rate and live birth rate as well.

Wider implications of the findings: The potential of the present findings is considerable, especially for countries with strict Embryo Law Regulation. Obtained results might be highly useful for selecting embryos with high implantation potential. In addition, the present work illustrates the possibility of additional information that can potentially be incorporated into an embryo classification model.

Trial registration number

Not applicable

Teaching breast ultrasound skills including core-needle biopsies on a phantom enhances undergraduate student's knowledge and learning satisfaction

Purpose

To investigate whether a training program on breast ultrasound skills including core-needle biopsies to undergraduate students can improve medical knowledge and learning satisfaction.

Methods

Medical students attending mandatory classes at the Medical School of the University of Saarland received a supplemental theoretical and hands-on training program on ultrasound (US) breast screening and on US-guided core-needle biopsy using an agar–agar phantom. Experienced breast specialists and ultrasound examiners served as trainers applying Peyton’s 4-step training approach. The students’ theoretical knowledge and hands-on skills were tested before and after the training program, using a multiple-choice questionnaire (MCQ), the Objective Structured Clinical Examination (OSCE) and a student curriculum evaluation.

Results

The MCQ results showed a significant increase of the student’s theoretical knowledge (50.2–75.2%, p < 0.001). After the course, the OSCE showed a mean total of 17.3/20 points (86.5%), confirming the practical implementation of the new skills. The student curriculum evaluation in general was very positive. A total of 16/20 questions were rated between 1.2 and 1.7 (very good) and 3 questions were rated as 2.1 (good).

Conclusion

Undergraduate student’s medical education can be enhanced by teaching breast US skills.

Survey of current practices and opinions of German Society of Gynecologic Endoscopy members regarding the treatment of ovarian neoplasia by robotic surgery

PURPOSE

As data on this topic are sparse and contradictory, we aimed to ascertain the opinions of the members of the German Society of Gynecologic Endoscopy (AGE) regarding the use of robotic surgery in the treatment of ovarian malignancies.

METHODS

In 2015, an anonymous questionnaire was sent to AGE members to assess their views on the treatment of ovarian malignancies by robotic surgery according to T stage and the current treatment practices in their facilities.

RESULTS

Of the 228 respondents, 132 (58%) were fellows or attending physicians and 156 (68%) worked at university hospitals or tertiary referral centers. Most [n = 218 (96%)] respondents reported treating < 10% of their patients using robotic surgery. Respondents felt that T1 and borderline ovarian tumors, but not T2 (51%) or T3/4 (76%) tumors, should and could be treated by robot surgery. 162 (71%) respondents considered the currently available data on this subject to be insufficient, and 42% indicated their willingness to participate in clinical studies on the applicability of robotic surgery to the treatment of T1/2 ovarian tumors.

CONCLUSION

The majority of AGE members surveyed considered robotic surgery to be an option for the treatment of T1 ovarian malignancies and borderline ovarian tumors. However, prospective randomized studies are needed to determine the relevance of robotic surgery in this context.

Teaching undergraduate students gynecological and obstetrical examination skills: the patient's opinion

Introduction

Our study assesses the patients’ opinion about gynecological examination performed by undergraduate students (UgSts). This assessment will be used in improving our undergraduate training program. A positive opinion would mean a lower chance of a patient refusing to be examined by a tutor or student, taking into account vaginal examination (VE).

Materials and methods

We performed a prospective cross-sectional survey on 1194 patients, consisting of outpatient and inpatient at the departments of obstetrics and gynecology from November 2015 to May 2016. The questionnaire consisted of 46 questions. Besides demographic data, we assessed the mindset of patients regarding the involvement of undergraduate student (UgSt) in gynecological and obstetrical examinations. We used SPSS version 23 for the statistical analysis. For reporting the data, we followed the STROBE statement of reporting observational studies.

Results

The median age was 38 years having a median of one child. 34% presented due to obstetrical problems, 38% due to gynecological complaints, and 19% due to known gynecological malignancies. Generally, we retrieved a positive opinion of patients towards the involvement of students in gynecological and obstetrical examination under supervision in 2/3 of the cases.

Conclusions

There is no reason to exclude medical UgSts from gynecological and obstetrical examinations after obtaining a written or oral consent.

Vaginal operative delivery in Germany: a national survey about experience and self-reported competency

Background: To determine German obstetricians' self-perceived experience with vacuum and forceps deliveries.Patients and methods: Using a web-based survey, German obstetricians were invited to participate in a survey. This survey was approved by the German society of obstetrics and gynecology.Results: Surveys of 635 obstetricians were received. All obstetricians reported performing significantly less forceps than vacuum deliveries. Almost all obstetricians want to perform more delivery, which indicates the willingness to learn both. More obstetricians felt confident to perform vacuum than forceps. In a similar obstetrical indication, most of the obstetricians would prefer to perform a vacuum assisted delivery. The majority of the obstetricians wished to receive more training in vaginal operative deliveries.Conclusion: Most of the German obstetricians prefer to use vacuum-assisted vaginal deliveries and feel less confident to perform forceps deliveries. Standardized training to improve the quality of care is recommended.

Impact of different intraoperative CO2 pressure levels (8 and 15 mmHg) during laparoscopic hysterectomy performed due to benign uterine pathologies on postoperative pain and arterial pCO2 : a prospective randomised controlled clinical trial

OBJECTIVE

To compare the effects of two different intraoperative CO₂ pressures (8 and 15 mmHg) during laparoscopic hysterectomy for benign uterine pathologies in terms of postoperative abdominal and shoulder pain, laparoscopy-mediated vegetative alterations, pain medication requirement, arterial CO₂ pressure (pCO₂ ), surgical parameters, and safety.

DESIGN

Prospective randomised controlled study.

SETTING

German university hospital.

POPULATION

Female patients undergoing laparoscopic hysterectomy for benign uterine pathologies.

METHODS

Patients were randomised to a standard pressure (SP; 15 mmHg, control) or low-pressure (LP; 8 mmHg, experimental) group.

MAIN OUTCOME MEASURES

Primary outcomes were postoperative abdominal and shoulder pain intensities, measured via numeric rating scale (NRS) and vegetative parameters (fatigue, nausea, vomiting, bloating) at 3, 24, and 48 hours postoperatively. Secondary outcomes were pain medication requirement (mg) and arterial pCO₂ (mmHg). Surgical parameters and intra- and postoperative complications were also recorded.

RESULTS

In total, 178 patients were included. Patients in the LP group (n = 91) showed significantly lower postoperative abdominal and shoulder pain scores, fewer vegetative alterations, lower pain medication requirements, a shorter postoperative hospitalization, and lower intra- and postoperative arterial pCO₂ values compared with the SP group (n = 87; P ≤ 0.01). No differences in intra- and postoperative complications were observed between groups.

CONCLUSIONS

Low-pressure laparoscopy seems to be an effective and safe technique for the reduction of postoperative pain and laparoscopy-induced metabolic and vegetative alterations following laparoscopic hysterectomy for benign indications.

TWEETABLE ABSTRACT

Low-pressure laparoscopy seems to be an effective and safe technique for reduction of pain following laparoscopic hysterectomy.

Pilot study: placental biomarker predictive capability (sFlt-1, PlGF and their ratio) of postpartum maternal outcome

BACKGROUND

Prenatal measurement of placental biomarkers was able to improve screening and diagnosis of preeclampsia. Little is known about the clinical role of placental biomarkers in the postpartum period.

METHODS

This study is a prospective monocentric trial that included a total of 30 women with preeclamptic pregnancies. Serum placental biomarkers including soluble fms-like tyrosine kinase 1 (sFlt-1) and placental growth factor (PlGF) were measured before and 2 h after delivery by Enzyme-Linked Immunosorbent Assay (ELISA) using commercially available kits according to manufacturer's instructions and correlated with the postpartum outcome.

RESULTS

Postpartum higher serum PlGF level was associated with postpartum elevation of the systolic blood pressure. Yet, the placental biomarkers were not able to predict general worsening of postpartum preeclampsia or other individual clinical or laboratory parameters.

CONCLUSION

Serum concentrations of sFlt-1 and PlGF or their ratio in our study cohort did not completely predict the occurrence of postpartum preeclampsia. Yet, postpartum higher serum PlGF level was associated with postpartum elevation of the systolic blood pressure.

Endoscopic surgery: talent or training?

PURPOSE

There are two groups of undergraduate students involved in endoscopic surgery with different degrees of experience: average and more experience. This study proves whether the subjective impression of the laparoscopic trainer is verifiable and which factors influence extreme talent.

METHODS

21 medical students of the eighth term of the University of Witten-Herdecke participated in the study. On their first course day, students got instructed in suturing and knot technique. They were then required to tie a maximum of five knots within 2 h. After a week, students repeated this procedure. Time used for tying knots was stopped.

RESULTS

Regarding the time students used for their first knots, great differences were provable (7-8 min, average 23 min). However, an adaption of the knotting time was noticed at the end of the first course day. This was confirmed during the second course day. Neither acquired factors (music, sport, etc.) nor individual factors (visual acuity, handedness, etc.) had any impact on the time used for knotting. Merely, one advantage was seen with the first knots with the factors of playing the guitar and having a more than 10-h surgical previous experience. Knotting times leveled off at 95% to less than 10 min, though.

DISCUSSION

Neither normally talented nor extremely talented junior surgeons could be noticed, and so could not the co-factors providing an advantage or disadvantage for surgery, respectively. All prospective surgeons can learn defined tasks (knots) by short interval training, and thus show similarly good results after a few repetitions.