[Single dose of misoprostol for abortion until 9 weeks of gestation]

OBJECTIVES

The primary objective was to compare the efficacy of a single-dose misoprostol for abortion before 7 weeks of gestation and between 7 and 9 weeks of gestation. The secondary objectives were to compare the amount of misoprostol required for complete expulsion, the need for endo-uterine aspiration, and to assess pain and patient experience in these two groups.

METHODS

This was a single-centre prospective observational study conducted at the University Hospitals of Strasbourg from 1st October 2019 to 31st December 2020.

RESULTS

A total of 306 patients were included, 150 in the group before 7 weeks of gestation and 156 in the group between 7 and 9 weeks of gestation. There was no significant difference in the success rate of the single dose of misoprostol between the two groups with 34.7 and 37.8% respectively (P=0.63). After taking painkillers, there is no difference in terms of pain relief (EN ≤ 4 for 92 et 95% of patients P=0.37).

CONCLUSION

The single dose of misoprostol for in-hospital abortion is as effective between 7 and 9 weeks of gestation as it is before 7. By extension, therefore, we would suggest that there should be no difference in efficacy between home abortions before 7 weeks of gestation and between 7 and 9 weeks of gestation and therefore suggest that home abortions can be performed up to 9 weeks of gestation without fear of a decrease in the rate of complete expulsion and the efficacy of analgesia, with potentially less use of misoprostol compared with the hospital setting.

[Medical strategy for abortions between 14 and 16 weeks of gestation]

OBJECTIVE

To adapt the protocols for the management of voluntary termination of pregnancy following the new law extending the practice to 16 weeks of gestation.

MATERIAL AND METHOD

A systematic review of the literature in French and English concerning the management of patients requesting medically induced abortion was performed on PubMed, Cochrane Library and on the recommendations of international learned societies.

RESULTS

The efficacy of the medical method is greater than 95% when the protocols are adapted to the gestational age. The combination of mifepristone and misoprostol currently represents the "gold standard" of drug-based management. Mifepristone 200mg is sufficient, followed 24 to 48hours later by misoprostol 800μg administered sublingually or buccally. After the first dose, 400μg should be administered every 3hours buccally or sublingually until expulsion. Adverse effects (digestive and thermoregulatory disorders) during medical abortion are usually mild and short-lived. An anti-emetic treatment should be proposed as a prophylactic measure. For pain, ibuprofen is the analgesic treatment of choice, with the addition of level 2 analgesics if necessary.

CONCLUSION

Medical abortion is a safe and effective method up to 16 weeks of gestation, provided that the protocols, which differ according to gestational age, are respected. Women must be informed of the advantages and disadvantages of the methods according to the term and the side effects, which will allow them to choose the method that fits them best.

P–116 A 9-year monocentric retrospective analysis of glutaraldehyde-fixed and semithin section of testicular biopsies and TESE in azoospermic patients

Study question

What is the outcome of testicular sperm extraction (TESE) after microinjection of frozen–thawed sperm and the correlation with histological analysis in azoospermic patients?

Summary answer

In our cohort of 240 azoospermic patients, sperm could be retrieved in 167 patients (69.6%).

What is known already

Testicular biopsy is a crucial assessment in reproductive practice with diagnostic and prognostic importance for ICSI. Divers histological procedures are used throughout the centres. There is increasing need to accurately analyse histological biopsies in order to characterise different type of spermatogenic failure and allows data storage of value in clinical practice and research. Compared with Bouin’s and formalin, glutaraldehyde fixed and semithin section of testicular biopsies have the advantage of yielding not only good cellular morphology but also it allows the possibility of performing electron microscopy.

Study design, size, duration

This is a monocentric retrospective study of TESE practice in azoospermic patients in Strasbourg University Hospital from February 2011 to December 2019.

Participants/materials, setting, methods

A total of 240 azoospermic patients underwent TESE followed by sperm cryopreservation when sperm were present and data of histological analysis and clinical outcome of ICSI were analysed. The analysis include initial hormonal status, type of azoospermia, body max index, classification of histological findings, freezing rate and outcome of ICSI-IVF procedure.

Main results and the role of chance

The mean age of 240 patients was 34.5 years. Out of all patients, 42% were diagnosed with obstructive azoospermia (OA) and 58% patients with non-obstructive azoospermia (NOA). There was no correlation of sperm retrieval with the body mass index. Overall, sperm could be retrieved in 69.6% patients. Spermatozoa were always successfully recovered in patients with normal testicular histological findings, 41.7% patients (n 100). Histological analysis revealed a Sertoli cell-only (SCO) syndrome in 27.5% cases (n 66), hypospermatogenesis in 14.2% (n 34), germ cell arrest in 7.9 (n 19) and mixed pattern in 8.3% (n 20).

In patients with serum FSH concentrations >12 IU/l, 46% of patients (n 42) sperm were present at TESE. In patients with no sperm retrieval, 31.5% had normal FSH levels. Out of all men with elevated FSH, 63% had SCO pattern, 4% germ cell arrest, 21% hypospermatogenesis and 12% mixt patterns. In the group of patients with no sperm retrieved at TESE, histological analysis showed SCO in 69.9% cases, germ cell arrest in 15% and hypospermatogenesis in 9.6% of cases. Out of 167 patients with TESE and sperm cryopreservation, 126 patients undergone ICSI-IVF procedure and 80 babies were born.

Limitations, reasons for caution

This study is a retrospective analysis in a single centre. The cohort was not compared with groups of patients with different histological and fixation techniques.

Wider implications of the findings: Accurate histological diagnosis is a prerequisite for research and clinical data collection and open the possibilities to include patients with NOA in subsequent detailed genetic screen.

Trial registration number

NA

[Is there any relation between couple violence and repeated medical abortion?]

OBJECTIVES

Risk factors of repeated induced abortion remain unclear. One of them could be domestic violence. The aim of this study was to explore the association between repeated induced abortion and domestic violence, including violence during childhood.

MATERIALS AND METHODS

A cross-sectional questionnaire study was conducted in three hospitals in Alsace. All women between 18 and 50 years old were asked to complete an anonymous questionnaire during their hospitalization for induced abortion between 31th of November 2013 and 1st of December 2014. The questionnaire included questions about the current or past existence of domestic violence. They have also been questioned about the past existence of domestic violence between their parents and the fact that they had themselves been victims of violence and abuse during childhood.

RESULTS

Four hundred and eighty women answered to the questionnaire: 322 came for their first abortion while 158 were hospitalized for at least the second time for an induced abortion. The proportion of current or past violence was 53% in the "repeated induced abortions" group compared with 33% in the "first induced abortion" group (OR 2.1, CI 95% [1.4-3.1], P<0.01). Statistically significant differences were found between the two groups for all types of domestic violence.

CONCLUSION

In our sample of women, we found that experiencing domestic violence with current partner appeared to be a risk factor of repeated induced abortions.

[Intra-uterine insemination at either 24 or 48hours after ovulation induction: Pregnancy and birth rates]

OBJECTIVE

Comparing rates of pregnancy and childbirth between IUI at either 24 or 48hours after injection of HCG.

METHODS

This is a single-center retrospective study of couples who underwent intrauterine insemination between January 2013 and December 2014 at Medical-Surgical Obstetrical Centre of Schiltigheim. Stimulation of ovulation was done by FSH or HMG, and ovulation induction by 250μg of recombinant HCG. The insemination was performed after 2 days (group D2) or the day after (group D1).

RESULTS

Among the 1092 intrauterine insemination cycles included in our study, 62 were done the day after ovulation induction by HCG (D1), and 1030 the day after (D2). Our study showed no significant difference in the rate of biological pregnancy, defined by a rate of BHCG>15IU/L, between the group D1 (19.35%) and the group D2 (18.12%), P=0.94, and no difference in live birth rate: respectively 14,50% and 11.75%, P=0.18.

CONCLUSION

Our study reported similar rates of pregnancy and childbirth in the group who underwent IUI at D1 and D2 of ovulation induction, suggesting the possibility of IUI on day 1 when the organization of the service needs it, without loss of opportunity for pregnancy.

[Patient's experience of topical anesthesia by lidocaine vaginal gel for oocyte retrieval]

A recent adverse effect of a paracervical block (cardiac arrest) occurred during an oocyte retrieval (OR), forcing us to reconsider our pain management during OR. Since then, we decided to use intravaginal lidocaine gel as analgesia during OR.

OBJECTIVES

To evaluate the pain during OR after intravaginal lidocaine gel analgesia and to evaluate the motivations of women choosing this technique.

METHODS

A monocentric observational study was performed on 200 patients. Pain was measured using a numeric pain scale during and after oocyte retrieval. The tolerance of the procedure was evaluated through a patient questionnaire.

RESULTS

Median maximal pain was 5±2.3 (0-10) per-retrieval and 3±2.2 (0-10) post-retrieval. The procedure was considered bearable by 85.5% of the patients and 81.5% of them would choose this method in case of new oocyte retrieval. No adverse effect occurred during the study.

CONCLUSION

The use of intravaginal lidocaine gel seems an acceptable analgesia alternative during oocyte retrieval.

Antenatal diagnosis and treatment of fetal hydrops secondary to pulmonary extralobar sequestration

Bronchopulmonary sequestration with associated non-immune hydrops has been previously reported with generally poor prognosis for the neonate. The vast majority of sequestrations are discovered postnatally, and less than half are correctly identified as sequestration before birth.Until recently, treatment for pulmonary sequestration was limited to postnatal respiratory support and resection of the sequestered lung. But aggressive respiratory support does not succeed in salvaging infants with underlying pulmonary hypoplasia. In our report, we describe the antenatal treatment of pleural effusions complicated by hydrops fetalis secondary to a bronchopulmonary sequestration, successfully managed with a transthoracic catheter placement. This therapy resulted in the resolution of pleural effusion, polyhydramnios and hydrops, with a good fetal outcome.

Predictive value of transvaginal uterine Doppler assessment in an in vitro fertilization program

This study evaluates the prognostic value of uterine Doppler performed on the day of embryo transfer in an in vitro fertilization program. Patients were divided into two groups according to the type of ovarian stimulation. The Doppler investigation was carried out using vaginal sonography. The pulsatility index was used to evaluate the uterine blood flow pattern. The hormonal profile (estradiol, luteinizing hormone (LH) and progesterone) was correlated to Doppler results and to the pregnancy rate. The comparison between patients treated with analogs and those who were not shows a significant difference in their hormonal profile. In the first group, we found a higher estradiol and progesterone serum concentration. The LH level and the pulsatility index were statistically lower. The endometrium was thicker in patients treated with gonadotropin releasing hormone agonists. In the group of patients treated with analogs, the statistical analysis showed no significant difference in the mean pulsatility index value in women who achieved a pregnancy and in those who failed. In the group of patients who received no agonists, only one variable was significantly different: the mean age was lower in women who became pregnant. We observed no ongoing pregnancy in women who had a pulsatility index value higher than two standard deviations (pulsatility index = 3.55). We therefore suggest the use of this value as a threshold. Thus, if a patient has a high uterine artery impedance, cryopreservation should be used and embryo transfer should be postponed to a subsequent cycle, or embryo transfer delayed for a few days using co-culture. This study clearly shows the impact of hormonal response on the Doppler value and on the pregnancy rate. However, the use of a threshold value for uterine artery pulsatility index might have a clinical impact in the future management of patients attending an in vitro fertilization program.

Measurement of limb circumferences with three-dimensional ultrasound for fetal weight estimation

A large number of formulae have been published for fetal weight estimation. This study examines the possibility of using three-dimensional ultrasound to measure the limb circumference. This technology provides us with the opportunity to visualize two simultaneous, orthogonal planes, allowing the exact determination of the transverse plane at the mid-point of the limb. A total of 157 patients were scanned in the week prior to delivery. The following variables were measured in 154 fetuses: biparietal diameter, head circumference, transverse abdominal diameter, abdominal circumference, femur length, thigh circumference and arm circumference. The whole population was split into three subgroups according to the abdominal circumference centile (< 10th centile, 10-90th centile, and > 90th centile), because this single variable has the strongest correlation with neonatal weight (R = 0.901). With forward stepwise multiple regression analysis, four models were elaborated, one for the whole population and one for each subgroup. The small-for-dates fetuses need a targeted formula including only two variables, thigh circumference and femur length. Our data suggest that the thigh circumference measurement improves the estimation for growth-retarded fetuses and that the arm circumference improves the weight prediction for the others. The measurement of the two variables, made possible with three-dimensional ultrasound, has improved our results in fetal weight estimation.