Protocol change improves live birth and recurrent cycle cancellation rates after a previous IVF cycle cancellation: an analysis of 13 000 autologous cycles reported to SART CORS

STUDY QUESTION

After an IVF cycle cancellation, does changing the stimulation protocol affect the odds of live birth and recurrent cancellation in the subsequent cycle?

SUMMARY ANSWER

After IVF cycle cancellation, compared to those who repeated the same stimulation protocol, those who changed their protocol had higher odds of live birth and lower odds of recurrent cycle cancellation.

WHAT IS KNOWN ALREADY

There is limited data addressing the effect of changing the stimulation protocol after an IVF cycle is cancelled during initial stimulation. The odds of live birth outcomes are not known so far in studies addressing the effect of changing the protocol.

STUDY DESIGN, SIZE, DURATION

Retrospective Cohort Study using the 2014-2017 Society for Assisted Reproductive Technology Clinic Outcome Reporting System (SART CORS) database.

PARTICIPANTS/MATERIALS, SETTING, METHODS

The data included 13 135 patients with a first autologous IVF cycle that resulted in a cycle cancellation and was followed by a second autologous cycle within the study period. We excluded fertility preservation cycles, supernumerary cycle attempts after the second IVF cycle attempt, and cycles with more than one stimulation protocol documented per cycle start. Patients who received the same protocol for both cycles (n = 6434) were compared to those who changed their protocol in the second cycle (n = 6701). Multivariable logistic regression analyses were performed to estimate the adjusted odds of live birth and recurrent cancellation.

MAIN RESULTS AND THE ROLE OF CHANCE

Changing the protocol in the second cycle resulted 14% lower odds of recurrent cycle cancellation (P = 0.01) and 17% higher odds of live birth after fresh transfers (P = 0.04). When stratifying the data by specific combinations of protocol change (agonist flare, agonist suppression, antagonist), there was an increase in live birth when switching from antagonist to agonist suppression (odds ratio (OR) = 1.36, P = 0.03) and from agonist suppression to antagonist (OR = 1.73, P = 0.01) compared to those who repeated their same stimulation protocol. Specifically in poor responders, outcomes were worse when using the agonist flare protocol and significantly improved with the agonist suppression protocol.

LIMITATIONS, REASONS FOR CAUTION

Comparison of response to stimulation between first and second cycles cannot be made in this study because the index IVF cycle was cancelled during ovarian stimulation, and thus there is no reportable outcome data for that cycle. Additionally, SART only tracks the three stimulation protocols addressed in this study and does not have data on more contemporary protocols that are used in poor responders thus limiting the generalizability of our findings.

WIDER IMPLICATIONS OF THE FINDINGS

Using the SART CORS database, which includes >90% of all reported IVF cycles in the USA, provides generalizability to the demographically diverse IVF populations found here. In agreement with prior studies assessing change in IVF protocols, the agonist flare protocol seems to result in worse IVF outcomes, and based on our results, we believe that there is no role for the agonist flare protocol in patients with a prior poor response to stimulation.

STUDY FUNDING/COMPETING INTEREST(S)

None declared.

TRIAL REGISTRATION NUMBER

N/A.

Validity Assessment of an Automated Brain Morphometry Tool for Patients with De Novo Memory Symptoms

BACKGROUND AND PURPOSE

Automated volumetric analysis of structural MR imaging allows quantitative assessment of brain atrophy in neurodegenerative disorders. We compared the brain segmentation performance of the AI-Rad Companion brain MR imaging software against an in-house FreeSurfer 7.1.1/Individual Longitudinal Participant pipeline.

MATERIALS AND METHODS

T1-weighted images of 45 participants with de novo memory symptoms were selected from the OASIS-4 database and analyzed through the AI-Rad Companion brain MR imaging tool and the FreeSurfer 7.1.1/Individual Longitudinal Participant pipeline. Correlation, agreement, and consistency between the 2 tools were compared among the absolute, normalized, and standardized volumes. Final reports generated by each tool were used to compare the rates of detection of abnormality and the compatibility of radiologic impressions made using each tool, compared with the clinical diagnoses.

RESULTS

We observed strong correlation, moderate consistency, and poor agreement between absolute volumes of the main cortical lobes and subcortical structures measured by the AI-Rad Companion brain MR imaging tool compared with FreeSurfer. The strength of the correlations increased after normalizing the measurements to the total intracranial volume. Standardized measurements differed significantly between the 2 tools, likely owing to differences in the normative data sets used to calibrate each tool. When considering the FreeSurfer 7.1.1/Individual Longitudinal Participant pipeline as a reference standard, the AI-Rad Companion brain MR imaging tool had a specificity of 90.6%-100% and a sensitivity of 64.3%-100% in detecting volumetric abnormalities. There was no difference between the rate of compatibility of radiologic and clinical impressions when using the 2 tools.

CONCLUSIONS

The AI-Rad Companion brain MR imaging tool reliably detects atrophy in cortical and subcortical regions implicated in the differential diagnosis of dementia.

Design improvement and experimental study on shell and tube condenser for bio-oil recovery from fast pyrolysis of wheat straw biomass

In this study, the design improvement was done in a shell and tube condenser for improved heat transfer and condensation of bio-oil vapour. The developed condenser has split shell and segmental baffles, which divide the shell in various zones and condensate collection points. The fast pyrolysis of wheat straw was done and the bio-oil vapour condensate collected from various outlets located at bottom of condenser shell. From experimental results it was found that production of bio-oil increased from 10.2 to 20.8% with increase in cooling water flow rate from 1000 to 2500 L/h; but, further increasing it beyond 2500 L/h provide marginal effects on production of bio-oil. The production of bio-oil increased from 15.2 to 20.7% as sweep gas flow rate was increased from 20 to 40 L/min at 2500 L/h of cooling water flow rate. But, further increase in sweep gas flow rate beyond 40 L/min resulted in to decrease in production of bio-oil. The novelty of this work is development of improved condenser with segmental baffles, which help in fractional condensation of bio-oil vapour, split shell for cleaning of outer surface of the cooling water tubes and compact design of condenser for optimal condensation of bio-oil.

INFRASTRUCTURE, RESOURCES, SERVICES EVALUATION AND GAP ANALYSIS OF INTEGRATED MATERNAL AND CHILD DEVELOPMENT SERVICES IN INDIA

Background. Integrated Child Development Services (ICDS) is an Indian community-centric government program organized under Anganwadi centres catering to supplementary nutrition, health and preschool education, primary healthcare, growth monitoring and counselling the children under six years old along with their mothers. It is the world’s largest outreach program in a developing country covering a population of 1.35 billion; the variations in service delivery were analysed involving cross-sectional rural and urban Anganwadi centers in New Delhi. Methods. Data were collected by assessment of children and mothers, interview of Anganwadi workers and observation of service delivery parameters and conduction of activities. Infrastructural, beneficiaries, services and content were evaluated by a suitable pre-tested questionnaire based on the National Institute of Public Cooperation and Child Development (NIPCCD) evaluation proforma. The data was analysed by a descriptive statistics. Results. Gaps were found in respect of infrastructure, resources, health and nutrition facilities especially at rural Anganwadi centre which was inadequate in terms of implementation of nutrition and health program, supplementary nutrition, preschool education and nutrition rehabilitation centre for existing beneficiaries. Both Anganwadi centres were not catering for new WHO growth standards and adolescent health. Conclusions. Gaps found in respect of infrastructure, resources, health and nutrition facilities can affect performance of ICDS program and the services delivered by Anganwadi centres, which need a boost. Both urban and rural centres have a direct opportunity towards delivering adolescent health program focusing on nutrition and education of girls prior to their pregnancy, and adoption of new WHO growth standards.

Bilateral Asymmetrical Fracture Dislocation of Shoulder with Rare Combination of Injuries after Epileptic Seizure: A Case Report

The incidence of bilateral gleno-humeral joint dislocation is rare, is almost always posterior and is usually caused by sports injuries, epileptic seizures, electrical shock, or electroconvulsive therapy. Bilateral fracture-dislocation is even rarer, with a few cases reported in the literature. We report an unusual case with dislocation of the both glenohumeral joints in opposite direction after a seizure episode, with fracture of greater tuberosity on one side and of the lesser tuberosity on the contralateral side. Although there have been a few reports of bilateral asymmetric fracture dislocations of the shoulder in the past, an injury pattern resembling our case has, to the best of our knowledge, not been described in the literature so far. This report includes a detailed discussion regarding the mechanism of injury in a case of asymmetrical dislocation following a seizure episode. At final follow-up, the patient had healed fractures, painless near normal range of motion with no redislocations.

Perception of Simulation-based Learning among Medical Students in South India

Background:

Traditional methods of educating medical students are no longer sufficient in the current era largely influenced by multimedia. Simulation-based techniques may play a pivotal role in bridging this educational gap.

Aim:

This study was conducted to explore the perception of medical students towards simulation based learning (SBL).

Subjects and Methods:

This cross-sectional study was conducted in May 2013 in a private medical college in Mangalore, Karnataka, India. A total of 247 participants from fourth, sixth, eighth semester and internship were chosen by convenience sampling method. Attitudinal data on perception towards SBL were collected using a self-administered questionnaire with responses in a 5-point Likert's scale.

Results:

The mean age of students was 21.3 (standard deviation 1.9) years, and males constituted 55.5% (137/247). Most participants 72.5% (179/247) had favorable perceptions of SBL, with scores of92–118 out of a possible 118 points. Favorable perception towards SBL was seen significantly more among female students (P = 0.04) and senior MBBS students of sixth and eighth semesters (P = 0.05). Nearly, all students (90.7%; 224/247) agreed that simulation supports the development of clinical skills. As many as 29.6% (73/247) agreed that real patients might be replaced with simulated patients in practical examinations.

Conclusion:

SBL was perceived as favorable by a large number of participants in this study indicating a bright prospect for its implementation in the medical curriculum.

Mullerian Anomaly Presenting as Chronic Pelvic Pain

DOI: http://dx.doi.org/10.3126/njog.v9i1.11198 NJOG 2014 Jan-Jun; 2(1):87-88

Squamous Cell Carcinoma Arising in Mature Cystic Teratoma of the Ovary

Malignant transformation of mature germ cell teratoma is rare and has been reported sporadically. Any of the constituent tissue of a teratoma has the potential to undergo malignant transformation. Squamous cell carcinoma is the most common transformation and is derived from the metaplastic squamous epithelium of teratoma. We are reporting a case of 65 years old postmenopausal women with squamous cell carcinoma arising in mature cystic cell teratoma of the ovary. DOI: http://dx.doi.org/10.3126/njog.v9i1.11191 NJOG 2014 Jan-Jun; 2(1):61-63

Abstract P1-05-01: Characterization of human postpartum breast involution: Implications for young women’s breast cancer

Introduction: Women diagnosed with breast cancer within 5 years postpartum have poor outcomes. In rodents, postpartum mammary gland involution promotes tumor progression and metastasis, implicating breast involution in the poor prognosis of breast cancers diagnosed in postpartum women. Rodent mammary gland involution is characterized by wound healing programs that include epithelial cell death, immune cell infiltrate, and fibrillar collagen deposition; all attributes associated with breast cancer progression. Thus, the gland remodeling of postpartum involution may provide a plausible explanation for how postpartum breast involution promotes breast cancer. Here, we characterize human breast tissue across pregnancy, lactation, and the postpartum time-period to determine if remodeling of the secretory competent breast to a quiescent state involves loss of secretory lobules, and whether involution is mediated by wound healing-like programs.

Methods: Adjacent normal breast tissues from pre-menopausal women (n = 140), aged 20-45 years, were grouped by reproductive categories of never-been-pregnant (NBP), pregnant, lactating, and by time since last delivery, and evaluated histologically and by special stain for epithelial area, lobular subtype composition, apoptosis, immune cell infiltration, and collagen deposition, using computer assisted quantitative methods. Statistical comparisons between multiple categories were done using one way ANOVA.

Results: Dramatic increases in breast epithelial area and lobule differentiation were observed, with 5-8 fold increases for pregnancy and 10-13 fold for lactation, over nulliparous controls. By 12 months postpartum, epithelial content and lobular differentiation were indistinguishable from nulliparous controls, consistent with complete regression of the lobular structures developed in preparation for lactation. Analyses of apoptosis, immune cell infiltration, and collagen deposition confirmed human postpartum breast involution is characterized by wound healing-like, tissue remodeling programs.

Conclusion: Human postpartum breast involution is a dominant tissue-remodeling process that returns the gland to a morphological state largely indistinguishable from the never-been-pregnant gland. Further, involution occurs within a defined window of time. Our data implicate postpartum breast involution as window of risk for breast cancer progression and suggest a rational window for intervention.

Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr P1-05-01.

Effect of sesamol on the pathophysiological changes induced by surgical menopause in rodents

OBJECTIVE

Estrogen deprivation after menopause is associated with increased oxidative stress. The present study was designed to study the role of sesamol (3,4-methylenedioxyphenol), a phenolic antioxidant and anti-inflammatory molecule, in oxidative stress-induced changes in three major affected organ systems, the central nervous system, the cardiovascular system and the skeletal system in ovariectomized rats, a widely used animal model of menopause.

DESIGN

Animals were divided into eight different groups (n = 6-8). Five groups underwent ovariectomy; starting from the 2nd day of ovariectomy, three of these groups received sesamol (2, 4, 8 mg/kg) and the fourth group was administered α-tocopherol (100 mg/kg) orally for 7 weeks. The fifth ovariectomized group did not receive any drug treatment. Rats in the naïve (non-operated) and sham-operated groups did not receive any drug treatment, while the eighth group consisted of naïve animals which were treated for 7 weeks with only sesamol 8 mg/kg orally daily. After 7 weeks, animals were subjected to testing of behavioral paradigms (elevated plus maze and Morris water maze for assessment of anxiety and memory, respectively) 24 h after the last dose. After behavioral studies, animals were sacrificed for various biochemical estimations.

RESULT

Administration of sesamol (2, 4, 8 mg/kg orally) to ovariectomized rats for 7 weeks significantly and dose-dependently improved memory, attenuated anxiety, decreased oxidative stress in brain, improved the serum lipid profile and reduced serum tumor necrosis factor-α levels when compared with ovariectomized control rats. Similar protective effects were observed in the case of the skeletal system studies. Sesamol increased the bone ash content and the mechanical stress parameters in treated groups.

CONCLUSION

The results emphasize the involvement of oxidative stress and inflammation in the development of ovariectomy-induced pathophysiological changes and point towards the therapeutic potential of sesamol in menopausal pathologies.

Tubercular abdominal cocoon- a rare cause of intestinal obstruction

Termed as a rare entity so far “abdominal cocoon” which is an encasing of the small bowel within the fibrous membrane is usually of unknown origin, although at times, it may be seen secondary to a variety of conditions. Though described in literature as a rare entity we report a case of tubercular abdominal cocoon in 15 year old boy. This case report emphasizes the importance of this surgical condition in a tuberculosis endemic region.

Female genital tuberculosis: early diagnosis by laparoscopy and endometrial polymerase chain reaction

OBJECTIVE

To evaluate the efficacy of laparoscopic visual inspection vs. endometrial tuberculosis (TB) polymerase chain reaction (PCR) for an early diagnosis and management of female genital TB (GTB) in India.

DESIGN

Observational case study.

RESULTS

Both laparoscopy and endometrial (endo) TB-PCR were performed on 162 infertile women: 52 endo TB-PCR-positive patients were diagnosed as definite GTB, of whom 44 (84.6%) also showed laparoscopic findings suspicious of TB (Type I). Subgroup analysis showed a similar PCR positivity of 54.5% (24/44) in the strongly suspicious and 54.1% (20/37) in the mildly suspicious patients. Using the Bayesian approach, the maximum likelihood estimates of the sensitivity and specificity of laparoscopy in diagnosing GTB were 0.96 and 0.93 and those of a positive PCR were respectively 0.59 and 0.92. Of the 52 women who were TB-PCR positive, 16 (30.8%) conceived following treatment.

CONCLUSIONS

Endo TB-PCR had high specificity to diagnose GTB, as did laparoscopy. Laparoscopy may therefore be avoided in TB-PCR-positive patients for diagnosis but may still be required to rule out GTB in PCR-negative cases.

Evaluation of Testosterone Supplementation during Anastrozole Therapy in a Breast Explant Model

Background: Aromatase inhibitors (AI) are currently used as first line adjuvant therapy for postmenopausal women with estrogen receptor (ER) positive breast cancer. Side effects of AI therapy, such as arthralgia, can cause significant patient discomfort leading to compliance issues. This may be exacerbated by low tissue testosterone (T), which is naturally lower post-menopause and may be decreased further following chemotherapy. T supplementation has emerged as a potential means to treat AI-associated arthralgia and has generated favourable results in a phase II clinical trial (NCT00497458). However, T replacement in breast cancer had been contraindicated until the advent of powerful 3rd generation AIs such as anastrozole. AIs are highly efficacious in blocking conversion of T to estrogen, thereby increasing the potential for 5α-reduction of T to its more active tissue form, 5α-dihydrotestosterone (DHT), which counterbalances estrogen induced proliferative effects in hormonally sensitive breast tumors1. Our objective was to test the effects of T supplementation during AI administration on tumor growth in a human breast explant system.Materials and Methods: Fresh breast tumor samples collected from 17 post-menopausal women were cut into 3 mm3 pieces, cultured for 24h on gelatine sponges submersed in culture media with 10% steroid depleted fetal calf serum and treated with vehicle (control), T (5nM) and/or AI (25ng/ml). Tissues were stained with antibodies for ER, progesterone receptor (PR), androgen receptor (AR), and Ki67, a marker of cell proliferation that has been used to predict the outcome of therapy with anastrozole2. Tissue sections were scanned using a high resolution image scanner (NanoZoomer) and the percent Ki67 positive cells was determined by counting at least 2000 cells per slide.Results: All tumor tissues were positive (>30%) for ER, AR and PR, with the exception of 1 tumor that lacked PR. As expected for primary tissues, percent Ki67 positivity (mean; range) in the control was highly variable (6.45; 1-43.2). Tissue responses to T (7.9; 0.1-46), AI (6.06; 1.4-35.3), and T+AI (4.97; 0.7-26.1) were not significantly different from control (Wilcoxon signed rank test). However, the combination of T+AI showed a trend towards reduced Ki67 positivity compared to AI alone (p=0.07). In two patients T significantly increased Ki67 positivity by 2-4 fold, and in both instances this stimulatory effect of T was reduced to or below control values by treatment with AI.Discussion: Our results suggest that T supplementation during adjuvant AI therapy does not compromise AI-mediated inhibition of breast tumor growth. Indeed, combined therapy with T and AI may further enhance tumor suppression through elevation of DHT levels in the breast. This finding supports the clinical potential of T supplementation in post-menopausal women on adjuvant AI therapy to prevent or relieve AI-associated side effects.1. Peters A et al Cancer Res (In Press)2. Dowsett M et al JNCI 2007

Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 4089.

166. MATERNAL OBESITY IS ASSOCIATED WITH AN INCREASED INCIDENCE OF PROSTATE ABNORMALITIES IN ADULT RAT OFFSPRING

The World Health Organization has stated that 75% of adults worldwide are overweight, and in Australia nearly 25% of men are obese. Obesity is associated with an increased risk of cardiovascular disease, type 2 diabetes and cancer, with 30 to 40% of the latter possibly preventable by maintaining a healthy weight (The International Association for the Study of Obesity). Prostate cancer is the most commonly diagnosed cancer in men and there is increasing evidence that obesity increases the risk of prostate cancer mortality. High birth weight, an indication of excess nutrition during foetal development, has been associated with an increased risk of childhood and adult obesity, and for cancer. Using an animal model, we investigated whether obese mothers are more likely to have obese sons who are at an increased risk of developing prostate abnormalities and thus prostate cancer, in adulthood. Female rats were fed with either a control diet (4g fat/kg) or high fat diet (100g fat/kg) from before mating and throughout pregnancy. Prostate tissues were collected from the male offspring at 90 days (post-puberty) and 180 days (young adult). Histological analysis of the day 90 prostates identified hyperplasia in 100% of the ventral lobes (VL) and 64% of the dorsolateral lobes (DLP) in offspring of the maternal high fat group compared to 0% in each respectively, in those of the maternal control diet group. The VL is the most hormone sensitive prostate lobe of the rat, while the DLP is considered the equivalent of the human peripheral zone, the region from which the majority of human prostate cancers arise. These results suggest for the first time that maternal high fat diet may induce prostate abnormalities in male offspring that may in turn, predispose to an increased risk of prostate cancer in later life.

Hemifacial microsomia: a case report

Hemifacial microsomia is a congenital malformation in which there is a deficiency in the amount of hard and soft tissue on one side of the face. It is primarily a syndrome of the first branchial arch, involving underdevelopment of the temporomandibular joint, mandibular ramus, masticatory muscles and the ear. The affected ear may have an external soft-tissue malformation in addition to being lower set than on the contra lateral side. Hearing loss may result from underdevelopment of the osseous components of the auditory system and a diminished or absent external auditory meatus. Occasionally, second branchial arch defects involving the facial nerve and facial muscles coexist with Hemifacial microsomia. Radiographic examination in case of Hemifacial microsomia is of limited value because of superimposition of normal and abnormal bony structures. The skeletal and soft-tissue findings of a patient with Hemifacial microsomia who underwent three-dimensional computerized tomography is presented here to improve our knowledge and diagnostic skill of this uncommon entity.

415. Increased expression of an androgen receptor regulated gene, kit ligand, in polycystic ovaries

Polycystic ovaries (PCO) are induced by pathological or pharmacological female androgen excess, but the role of the androgen receptor (AR) in the pathogenesis of PCO is unknown. We therefore tested the hypothesis that PCO have increased expression of AR or kit ligand (KITL), a cytokine that was recently identified as a candidate AR-regulated gene in the ovary (1). Immunohistochemical analysis of AR and KITL expression was performed on archival paraffin-embedded sections of 8 morphologically normal and 8 polycystic ovaries from women under the age of 40 years. Stained sections were scanned with a NanoZoomer Digital Pathology System and immunoreactivity was qualitatively assessed using a 0-3+ scale, where 3+ represents the most intense staining. Electronic images of follicles at different stages of folliculogenesis were assessed by two independent observers who were blinded to the morphology of the source ovary. Each individual ovary contributed a minimum of 1 follicle per size class and a minimum of 10 follicles per size class were analysed. AR immunoreactivity was present in granulosa cells at all stages of folliculogenesis, in thecal cells of large antral follicles, and in the ovarian stroma. Staining intensity for AR did not differ between normal and polycystic ovaries. KITL expression, summarised in Table 1, was found to be significantly elevated in the oocytes of primordial and primary follicles and in the granulosa cells of follicles at all stages of folliculogenesis. These results show that AR expression is normal in PCO but expression of an AR-regulated gene is increased, potentially due to an excess of androgen hormone that is characteristic of women with PCO. Based on the roles of KITL established by murine studies, increased expression of KITL could explain many of the features of PCO including follicle excess, hyperthecosis and abnormal androgen secretion.