Outcomes of BRCA pre-implantation genetic testing according to the parental mutation origin: a cohort study

BACKGROUND

The process of gamete formation and early embryonic development involves rapid DNA replication, chromosome segregation and cell division. These processes may be affected by mutations in the BRCA1/2 genes. The aim of this study was to evaluate BRCA mutation inheritance and its effect on early embryonic development according to the parental origin of the mutation. The study question was approached by analyzing in vitro fertilization cycles (IVF) that included pre-implantation testing (PGT-M) for a BRCA gene mutation.

METHODS

This retrospective cohort study compared cycles of pre-implantation genetic testing for mutations (PGT-M) between male and female patients diagnosed with BRCA 1/2 mutations (cases), to a control group of two other mutations with dominant inheritance (myotonic dystrophy (MD) and polycystic kidney disease (PKD)). Results were compared according to mutation type and through a generalized linear model analysis.

RESULTS

The cohort included 88 PGT-M cycles (47 BRCA and 41 non-BRCA) among 50 patients. Maternal and paternal ages at oocyte retrieval were comparable between groups. When tested per cycle, FSH dose, maximum estradiol level, oocytes retrieved, number of zygotes, and number of embryos available for biopsy and affected embryos, were not significantly different among mutation types. All together 444 embryos were biopsied: the rate of affected embryos was comparable between groups. Among BRCA patients, the proportion of affected embryos was similar between maternal and paternal mutation origin (p = 0.24). In a generalized linear model analysis, the relative oocyte yield in maternal BRCA patients was significantly lower (0.7, as related to the non BRCA group)(p < 0.001). Zygote formation and blastulation were not affected by the BRCA gene among paternal cases (P = 0.176 and P = 0.293 respectively), nor by paternal versus maternal BRCA carriage (P = 0.904 and P = 0.149, respectively).

CONCLUSIONS

BRCA PGT-M cycles performed similarly compared to non-BRCA cycles. Inheritance rate and cycle parameters were not affected by the parental origin of the mutation.

You are not in the army now! A field study on the impact of a Preparation for Civilian Life program on young soldiers

Recent years have seen the implementation of educational programs aimed at developing future orientation and better employability skills, mostly for people new to or returning to the job market. In a field study, we investigated the impact of a 5-day program on reintegration to civilian life on young Israeli combat soldiers' time preferences, gratitude, patriotism, and perceptions of their combat experience. Questionnaires administered before and after the program revealed a positive effect on future orientation but a negative effect on gratitude and perceptions of the combat experience. Although the positive effect on future orientation is in line with the program design, the negative effects found should be taken into consideration when planning or improving similar educational programs.

Clinical pregnancy rates among anovulatory and oligoovulatory women after letrozole versus hormone replacement therapy in frozen-thawed embryo transfer cycles

This cohort study investigated whether letrozole versus hormone replacement therapy (HRT) results in higher live birth rate among anovulatory and oligoovulatory women in frozen-thawed embryo transfer (FET) cycles. It was conducted from 1st February 2018 to 31st January 2019 and included 261 anovulatory and oligoovulatory women. Since letrozole has become an effective alternative to HRT cycles, 121 patients received letrozole in 121 cycles from 1st February 2018 to 31st January 2019 and were compared to 140 HRT FET cycles among 140 women from 1st February 2017 to 31st January 2018. The primary outcome was live birth rate. Secondary outcomes were clinical pregnancy, multiple pregnancy and miscarriage rates. Clinical pregnancy and live birth rates of transferred cleavage embryos were higher in the letrozole compared to the HRT group (36/65 (55.3%) vs. 20/110 (18.1%), p < 0.001) and (25/65 (38.4%) vs. 17/110 (15.4%), p < 0.001) respectively, whilst these rates were similar for transferred blastocyst embryos. Miscarriage and multiple pregnancy rates were similar between groups. The letrozole group was older than the HRT group (31.8 ± 5.1 vs. 29.9 ± 5.1 years, p = 0.002) and more smoked cigarettes (p = 0.035). Groups were similar regarding BMI, male versus non-male indication for fertility treatment, peak oestradiol levels, and numbers of oocytes retrieved, blastocysts, frozen and transferred embryos. Letrozole compared to HRT might improve live birth and clinical pregnancy rates among anovulatory and oligoovulatory women undergoing FET cycles.

Gonadotropin releasing hormone agonist triggering for in vitro maturation cycles

The objective was to evaluate the outcomes of in vitro maturation (IVM) cycles using gonadotropin releasing hormone agonist (GnRH-ag) triggering. A retrospective cohort of IVM cycles from January 2015 to December 2019 in a single university-affiliated centre was examined. Main outcome measures were: (i) IVM maturation rate; and (ii) IVM maturation result. Secondary outcome measures were: (i) metaphase II (MII) rate on the day of egg retrieval; (ii) final MII maturation rate; and (iii) pregnancy rates. A total of 98 IVM cycles were performed during the study period: 50 (51%) were triggered with GnRH-ag (17 received FSH priming and 33 did not) and 48 cycles (49%) were triggered by hCG (37 with FSH priming and 11 without). A significant (p = 0.01) difference was noticed in maturation rate on egg retrieval day, in favour of the GnRH-ag group, although not in the final maturation rate achieved. Pregnancy rates were comparable between treatment sub-groups. GnRH-ag triggering in IVM cycles is an optional triggering mode and can be considered an acceptable option, especially when fertility preservation is a concern. GnRH agonists resulted in higher maturation rate on day of oocyte retrieval, but no difference in the total maturation rate.

Does fresh single embryo transfer outcome predict the result of a subsequent vitrified-warmed blastocyst of the same cohort?

Reflecting the current trends, the utilization of frozen-thawed transfer cycles has been steadily increasing worldwide; outcome predictors of these cycles are therefore a major research goal. Our aim was to investigate whether the outcome of a fresh single blastocyst transfer (SBT) can serve as a prognostic factor for the subsequent vitrified-warmed SBT originating from the same cohort. A retrospective cohort study was performed at a single unit. Non-donor fresh cycles were analyzed as predictors of the following vitrified-warmed cycle. Only SBTs were included. Cycles designated to a freeze-all policy and cycles involving pre-implantation genetic analysis were excluded. A total of 1127 vitrified-warmed single blastocyst cycles were included. The indications for artificial reproductive technologies were comparable across the study groups. Vitrified-warmed cycles following a live birth outcome in the fresh cycle were more likely to result in a clinical pregnancy than those following a fresh cycle, which failed to reach a live birth. The same trend was observed for live birth rate following vitrified-warmed transfer in the fresh cycle. After correcting for possible confounders, age and embryo quality were significantly correlated with the chance for a live birth, but the previous fresh cycle did not affect the results. We therefore conclude that after adjustment for age, embryo quality and number of previous oocyte retrieval cycles, the fresh cycle outcome was not a significant influential factor for the following vitrified-warmed cycle.

Neutrophils to lymphocytes ratio and platelets to lymphocytes ratio in pregnancy: A population study

BACKGROUND

Neutrophils to lymphocytes ratio (NLR) and platelets to lymphocytes ratio (PLR) are both inflammatory ratios that can be easily calculated from a simple blood count. They are frequently reported and tested as prognostic factors in several medical disciplines. Pregnancy involves special reference values for laboratory assays.

OBJECTIVE

The aim of this study was to define pregnancy-related reference values for NLR and PLR according to trimester, background morbidity and according to the patient's age.

STUDY DESIGN

A retrospective analysis of a large cohort undergoing community-based pregnancy surveillance between the years 2011-2016. Data were analyzed according to high-risk patient versus normal-risk patient.

RESULTS

A total of 11,415 patients were included. Mean PLR and NLR values were 136.3±44.3, 2.6±1, respectively during the first trimester, 144.6±47.1, 4.0±1.4 respectively during the second trimester and 118.1±42.0, 3.5±1.2 respectively during the third trimester. No difference was detected between the high-risk and the normal population (P-values 0.3, 0.5 and 0.4 for PLR in each trimester respectively and 0.3, 0.4, 0.6 for NLR in each trimester, respectively). No differences were detected among parity categories. The correlation between patient's age and either PLR and NLR was a weak positive correlation (though statistically significant). Both PLR and NLR reached a maximum value during the second trimester. The differences between mean NLR and PLR between trimesters were significant (P <0.01 for all differences tested). PLR rises in the presence of anemia, reaching statistical significance (P-value for PLR in each trimester was <0.01). NLR showed an opposite trend (P-values for NLR were 0.4, 0.005 and 0.06 in each trimester, respectively).

CONCLUSIONS

In our cohort, there were generally no differences between the high-risk and the normal population, excluding patients with a fibroid uterus or inflammatory bowel disease who presented a significantly elevated PLR through all trimesters. Both PLR and NLR reached a maximum value during the second trimester and were positively correlated with age. We anticipate that the population-based data will assist in providing accurate reference values for future research testing NLR and PLR measures during pregnancy.

Cumulative live birth rate following elective single blastocyst transfer compared with double blastocyst transfer in women aged 40 years and over

This retrospective cohort study aimed to identify predictive factors for live birth following blastocyst transfer in women aged 40-43, and to compare the cumulative live birth rate (LBR) following elective single blastocyst (eSBT) and double blastocyst (DBT) transfer. The study included 411 women who had fresh blastocyst transfers on day 5. In stepwise logistic regression, independent predictive factors for live birth were: transferring fully expanded blastocysts (Gardner stage ≥3) (odds ratio [OR] 3.5, 95% confidence interval [CI] 1.59-9.71) and transferring two blastocysts compared with a single blastocyst (OR 1.7, 95% CI 1.08-2.9). Maternal age was not found to be significant (OR 0.78, 95% CI 0.62-1.1). When comparing eSBT (n = 150) with DBT (n = 151), the DBT group achieved higher LBRs (26.5 versus 19.3%, P = 0.017) and higher multiple births (0 versus 17.5%, P = 0.02). However, the cumulative LBR was similar (28.0 versus 31.1%), with significantly lower multiple births in the eSBT group (0 versus 14.9%, P = 0.03). These results indicate that in women aged 40-43, when fully expanded blastocysts are achieved, maternal age is not a predictor for live birth, and eSBT can be performed without compromising cumulative LBRs.

Can we alter pregnancy outcome by adjusting progesterone treatment at mid-luteal phase: a randomized controlled trial

Our study aimed to determine whether mid-luteal serum P concentrations can serve as a predictive factor for in vitro fertilization (IVF) outcomes and whether increasing P dosage for patients with low levels at mid-luteal phase may improve pregnancy rates. It was a prospective, randomized controlled study. A total of 146 patients undergoing IVF treatment were prospectively enrolled and received routine luteal phase support (LPS) regimen of Endometrin® (progesterone) 200 mg/day. Serum P levels were measured 7 days after embryo transfer (ET). Considering a cutoff level of 15 ng/ml on this day, patients with higher levels continued the same dosage until pregnancy test (control group). Patients with lower levels were randomly allocated to continue Endometrin® 200 mg/day (Group A) or to increase Endometrin® dosage to 300 mg/day (Group B). The Main Outcome Measures were pregnancy rates. Both biochemical and clinical pregnancy and live birth rates were comparable between all groups regardless of P level on day 7 of luteal phase and regardless of dose adjustment. ROC analysis determined that mid-luteal P levels of 17 ng/ml can be a better predictor of cycle outcome. In conclusion raising the P dose at mid-luteal phase to 300 mg daily did not improve cycle outcomes.

What we learned from extended culture of 'rejected' day-3 cleavage stage embryos: a prospective cohort study

Background

To test whether poor quality day-3 embryos can undergo successful blastulation and implantation.

Methods

A prospective cohort study was conducted. Whether or not a good quality embryo was transferred on day-3, poor quality (rejected) embryos were further cultured and followed. The clinical outcome of each embryo was assessed.

Results

A total of 694 rejected embryos (from 205 patients) were included, with a blastulation rate of 21.2% (147 embryos) compared to 64.2% general blastulation rate reported by our laboratory (P < 0.01). In a multivariate logistic regression model, only their grade on day-3 significantly affected blastulation (P = 0.01). A total of 97 embryos attained eligibility for fresh transfer or cryopreservation, only 6 of which resulted from a day-3 embryo scored < 2. Of these, 52 were transferred, resulting in 21 pregnancies (16 clinical and 5 chemical). In summary, 694 cultured embryos yielded 16 clinical pregnancies; a 2.3% clinical pregnancy rate.

Conclusions

Low score day-3 embryos can result in successful blastulation and clinical pregnancies. However, the normal blastulation rate is poor.

Reproductive outcomes after a single dose of gonadotropin-releasing hormone agonist compared with human chorionic gonadotropin for the induction of final oocyte maturation in hyper-responder women aged 35-40 years

OBJECTIVE

To investigate the reproductive outcomes after the use of GnRH agonist (GnRHa) compared with hCG for the induction of final oocyte maturation in GnRH antagonist cycles performed in hyper-responder women aged 35-40 years.

DESIGN

Retrospective study.

SETTING

Academic fertility center.

PATIENT(S)

Two hundred seventy-two hyper-responder women aged 35-40 years who underwent controlled ovarian stimulation under GnRH antagonist suppression were included. Final oocyte maturation was performed with GnRHa (n = 168) or hCG (n = 104). Embryos were cryopreserved at the blastocyst stage and transferred in subsequent warming cycles (n = 542). Subjects were included in the analysis until live birth was achieved, after which they were excluded from further analysis.

INTERVENTION(S)

None.

MAIN OUTCOME MEASURE(S)

Cumulative live birth rate.

RESULT(S)

Subjects in the GnRHa group achieved a higher number of oocytes (22 vs. 21) and a higher number of mature oocytes (16 vs. 14). The number of cryopreserved blastocysts (median of five blastocysts in both groups) was similar. Women in the hCG group needed a lower number of warming cycles to achieve live birth (1.32 vs. 2.12), had higher embryo implantation rates (48% vs. 39%), and the proportion of embryos transferred until live birth was lower (33% vs. 57%). The cumulative live birth rate was similar between the groups (48.15% vs. 48%).

CONCLUSION(S)

Although the cumulative live birth rate is similar, a single dose of GnRHa possibly results in suboptimal oocyte and embryo competence, as manifested by decreased embryo implantation rates and increased time needed to achieve live birth.

Vitrified-warmed single-embryo transfers may be associated with increased maternal complications compared with fresh single-embryo transfers

Cryopreservation of embryos allows single-embryo transfer and storage of supernumerary embryos, maximizing cumulative pregnancy rates. The purpose of this retrospective cohort study was to compare pregnancy outcome in singletons born after fresh or vitrified-warmed single blastocyst transfer (SBT). Singleton live births resulting from SBT of fresh or vitrified-warmed embryos were compared. Primary outcomes were perinatal outcomes including small for gestational age (SGA), low birthweight, preterm deliveries (PTD), large for gestational age (LGA) and congenital malformations. Maternal complications included pre-eclampsia, placenta previa, placental abruption, gestational diabetes mellitus (GDM) and chorioamnionitis. Adjustment for confounding factors was performed. Of 1886 fresh SBTs and 1200 vitrified-warmed SBTs during the study period, vitrified-warmed SBTs compared with fresh SBTs resulted in significantly lower clinical pregnancy rate (P < 0.0001). Live birth and miscarriage rates calculated only for pregnancy with known outcome revealed lower live birth rates and higher miscarriage rates for the vitrified-warmed group. Perinatal complications were calculated for clinical pregnancies with known outcomes (12.9% catchment failure was excluded from analysis). The vitrified-warmed group showed a trend toward higher rates of pre-eclampsia, GDM, Caesarean delivery and LGA neonates. Rates of PTD and SGA were comparable. In conclusion, vitrified-warmed SBT might be associated with increased feto-maternal complications.

¿Vale la pena el riesgo? Miedo inducido por el terrorismo a volar

We conducted two bi-national experiments regarding emotional and behavioral responses to a terrorist plot against commercial flights, examining both feelings and projected action. The studies employed hypothetical scenarios in which terrorists attacked airplanes with shoulder-fired missiles as they were landing or taking off from an international airport. The scenarios were built around two factorially crossed manipulated variables, each with three levels: (1) government announcements or actions (2) social norm, expressed as variation in airline ticket sales. Each respondent read a questionnaire containing only one of the nine scenarios. Experiment 1 was conducted in Spain and California (n = 360, 50% female), Experiment 2 in Israel and California (n = 504, 50% female). In both studies, fear and flight plans were not differentially affected by governmental response or social norm. Women expressed more fear than men. Experiment 1 examined the purpose of the trip. Most respondents would not change a planned flight to attend a close friend’s wedding or important job interview, but a substantial number would postpone a vacation or drive to a different location. Experiment 2 featured escalating attacks. These yielded increased fear and more canceled trips. Within both studies, responses were similar across countries despite national differences in direct experience with terrorism.

Timing embryo biopsy for PGD - before or after cryopreservation?

OBJECTIVE

Pre-implantation genetic diagnosis (PGD) is required in order to screen and diagnose embryos of patients at risk of having a genetically affected offspring. A biopsy to diagnose the genetic profile of the embryo may be performed either before or after cryopreservation. The aim of this study was to determine which biopsy timing yields higher embryo survival rates.

STUDY DESIGN

Retrospective cohort study of all PGD patients in a public IVF unit between 2010 and 2013. Inclusion criteria were patients with good-quality embryos available for cryopreservation by the slow freezing method. Embryos were divided into two groups: biopsy before and biopsy after cryopreservation. The primary outcome was embryo survival rates post thawing.

RESULTS

Sixty-five patients met inclusion criteria. 145 embryos were biopsied before cryopreservation and 228 embryos were cryopreserved and biopsied after thawing. Embryo survival was significantly greater in the latter group (77% vs. 68%, p < 0.0001).

CONCLUSION

Cryopreservation preceding biopsy results in better embryo survival compared to biopsy before cryopreservation.

A comparison between r-LH and urinary supplements containing LH activity in patients undergoing the microdose GnRH agonist flare protocol for in-vitro fertilization: a pilot study

BACKGROUND

The aim of this study was to compare pregnancy rates and stimulation parameters in patients with diminished ovarian reserve, who were treated with recombinant human luteinizing hormone (r-LH) or menopausal gonadotropins (hMG), as part of a microdose flare protocol.

METHODS

A retrospective cohort study was performed. Comparisons between the group that was stimulated with r-LH plus follicle stimulating hormone (FSH) to those treated with hMG and FSH, were performed. Measurements included: medication doses, number of oocyte collected, number of embryos obtained, pregnancy and clinical pregnancy rates.

RESULTS

Patients in the r-LH group (N.=40) had significant higher clinical pregnancy rates (33% vs. 14%; P=0.04) and used lower dose of LH (1938 IU vs. 2807 IU; P=0.02) compared to patients that were stimulated with hMG (N.=39).

CONCLUSIONS

r-LH may offer advantages for the treatment of diminished ovarian reserve when performing a microdose flare protocol when compared to hMG. Both larger and prospective studies should be carried out to confirm these findings.

Comparison between stimulation with highly purified hMG or recombinant FSH in patients undergoing IVF with GnRH antagonist protocol

PURPOSE

Highly purified Human Menopausal Gonadotropins (hp-hMG) and recombinant FSH (rFSH) are widely used in assisted reproductive technology (ART). The aim of this study was to compare ART results of the two preparations in GnRH antagonist cycles.

METHODS

In this retrospective cohort study, IVF antagonist cycles performed from 2011 through 2013 were reviewed. There were 508 antagonist cycles: 320 stimulated with rFSH and 188 with hp-hMG. For every hp-hMG, two rFSH were matched for patient's age and infertility diagnosis. Subgroup analysis of patients younger and older than 35 was done as well.

RESULTS

Both treatments were resulted in comparable pregnancy and live birth rates. However, cumulative pregnancy rates were higher for the rFSH group. In the matching analysis, the rFSH group had more mature oocytes and more embryos while using lower doses of gonadotropins. Pregnancy, cumulative pregnancy rates, and live birth rates were comparable. In the subgroup analysis, young patients in the rFSH group had better cycle outcomes compared with those in the hp-hMG group.

CONCLUSION

In antagonist protocol, different gonadotropin products are equally effective. The choice of one or the other should depend on the availability, convenience of use, and cost.

Is there time discounting for risk premium?

Individuals with a higher subjective discount rate concentrate more on the present and delay is more significant for them. However, when a risky asset is delayed, not only is the outcome delayed but also the risk. In this paper, we suggest a new, two-stage experimental method with real monetary incentives that allows us to distinguish between the effect of the risk and the effect of the time when pricing a risky asset. We show that when individuals have greater preference for the present, their risk aversion for a risky asset realized in the future decreases. We argue that the effect of the risk for future asset is lower for individuals with higher time preference because they discount not only the outcome but also the risks.

Can intra cytoplasmatic morphologically selected sperm injection (IMSI) technique improve outcome in patients with repeated IVF-ICSI failure? a comparative study

OBJECTIVE

Spermatozoal morphology was reported to effect fertilization, embryo quality and pregnancy results in spontaneous conception and ART. Intracytoplasmic morphologically selected sperm injection (IMSI) is an innovative, not invasive technique, which examines the sperm with no harm at a magnification of 6000 × in order to obtain optimal sperm to perform IVF-ICSI. We evaluated the efficiency of IMSI technique in patients with repeated IVF-ICSI failure of at least three cycles with no viable pregnancy and/or very poor sperm quality.

STUDY DESIGN AND METHODS

All couples who performed IMSI between the years 2009 to 2012 were enrolled retrospectively to the study. Couples with male infertility who were treated with IMSI were included in the study. All their treatments were evaluated and divided into two subgroups: conventional IVF-ICSI treatment and their subsequent IMSI treatment. Demographic data, clinical parameters and outcome were recorded. The IMSI treatments were compared to previous non-IMSI treatments in terms of fertilization rates, cleavage rates, number of embryos and their quality, number of embryos transferred and pregnancy outcome.

MAIN RESULTS

Forty-two couples were reviewed. Basic characteristics of the groups were comparable. Fertilization and cleavage rates of the two groups were comparable. The embryos quality demonstrated a trend toward superior quality (grade 1-2) embryos in the IMSI versus ICSI (60% versus 47%; p = 0.07 and 53% versus 40%; p = 0.07), respectively. Implantation and clinical pregnancy rates were significantly superior in IMSI group (19.2% versus 7.8%; p = 0.042 and 41.3% versus 10.5%; p = 0.02, respectively). Miscarriage rate was significantly higher in conventional IVF-ICSI group (100% versus 15.8%; p = 0.04), and live birth rate was significantly higher in IMSI group (0 in conventional IVF-ICSI and 34.7% per transfer in IMSI group; p = 0.003).

CONCLUSION

IVF outcome of IMSI resulted in a higher implantation rate, pregnancy rate and most importantly delivery rate compare to non IMSI treated cycles.

Sweet sixteen: changing time preferences in the transition from middle school to high school, for different scenarios

Teenagers earn, save and spend large amounts of money. Therefore, understanding teenagers' time preference and how it affects their economic behavior is very important. The current study investigates time preferences of high school and middle school students, and the effect of different intertemporal choice scenarios on teenagers' subjective discount rate. One scenario used a standard intertemporal choice question while the other was a wage scenario. We found higher future orientation (lower subjective discount rate) among high school students than among middle school students when using a standard scenario but found no difference between groups in the wage scenario. For both groups, we found the subjective discount rates increased when the teenagers are asked to delay receipt of wages they earned by working (wage scenario). Other variables, like participation in sports and an allowance given by parents, were found to affect teenagers' time preferences.

IVM results are comparable and may have advantages over standard IVF

Retrieval of immature oocytes from unstimulated ovaries, followed by in vitro maturation (IVM) was originally proposed in order to avoid side effects of gonadotropin administration. The target is to eliminate or significantly reduce the risk of ovarian hyperstimulation syndrome (OHSS) in patients with polycystic ovary syndrome (PCOS), drug cost and burden on patients. This technology was also suggested in treatment of normo-ovulatory women, fertility preservation or infrequent conditions such as failure of oocytes to mature or repeated development of poor quality embryos. In this study we intended to examine the possibility that IVM results may be comparable to standard IVF. A PubMed database search from 1999-2013 was carried out for publications concerning the indications of IVM and study the possibility that IVM results may be comparable to standard IVF. In vitro maturation of the oocytes procedures obtained up to 35% clinical pregnancy rate in young women, comparable with in vitro fertilization (IVF) in many programs. The obstetric and perinatal outcomes of IVM cycles are comparable with IVF/ICSI cycles. In conclusion IVM may gradually replace IVF in certain cases, as the technique continues to develop and pregnancy rates continue to increase, being a promising and simple alternative approach to standard IVF in various indications.

Unusual case of recurrent heterotopic pregnancy after bilateral salpingectomy and literature review

Heterotopic pregnancy occurs in up to 1% of pregnancies after IVF and embryo transfer. A case of a 35-year-old woman undergoing IVF treatment who had had previous laparoscopic bilateral salpingectomy due to hydrosalpinges is presented. She had had two heterotopic pregnancies in both tubal stumps in consecutive pregnancies achieved by IVF. The intrauterine pregnancies ended in spontaneous abortions. The possibility of a heterotopic pregnancy needs to be considered when more than one embryo has been transferred in a cycle, especially when an inappropriately high serum β-human chorionic gonadotrophin concentration is associated with an ultrasound finding of singleton intrauterine pregnancy.

Is it necessary to induce labor in cases of intrauterine growth restriction at term?

OBJECTIVES

Infants with intrauterine growth restriction (IUGR) have increased morbidity and mortality. The decision whether to induce labor at term or to expectantly manage these pregnancies is controversial. The aim of this study was to assess the outcomes of these two management strategies in term pregnancies.

STUDY DESIGN

This retrospective cohort study compared neonatal and maternal morbidity and mortality of IUGR fetuses (estimated fetal weight below the 10th percentile) between induced and spontaneous labors.

RESULTS

Records of 669 IUGR newborns were reviewed; 499 were delivered through spontaneous labor and 170 were delivered through induced labor. Epidemiology and early perinatal outcomes between the two groups were similar. The cesarean section rate was significantly higher (P<0.005) in the induced group.

CONCLUSIONS

Expectant management for term IUGR pregnancies seems to be safe, with lower rates of cesarean deliveries. A large, prospective, randomized controlled trial with long-term neonatal follow-up is indicated.

Proangiogenic immature myeloid cells populate the human placenta and their presence correlates with placental and birthweight

OBJECTIVE

To determine whether proangiogenic immature myeloid cells are present in human placentas.

STUDY DESIGN

Biopsies were obtained from 61 placentas of term pregnancies. Percentage of CD45(+)CD33(+)LIN2(-)HLADR(-) immature myeloid cells of total CD45(+) hematopoietic cells was determined by flow cytometry. Location of immature myeloid cells in the placenta was identified using confocal microscopy. The proangiogenic potential of immature myeloid cells was analyzed by endothelial tube formation.

RESULTS

Immature myeloid cells comprise ∼25% of human placental CD45(+) hematopoietic cells and infiltrate placentas in proximity of blood vessels. The percentage of immature myeloid cells correlated positively with placental weight (r(2) = 0.108, P = .01) and birthweight (r(2) = 0.087, P = .02). Endothelial tube formation was increased in the presence of immature myeloid cells as compared with the presence of CD45(+)LIN2(+) control cells.

CONCLUSION

Human placentas are populated by immature myeloid cells in the proximity of blood vessels. Consistent with their involvement in angiogenesis, immature myeloid cells accelerated endothelial tube formation. The presence of immature myeloid cells in pathologic pregnancies warrants further studies.

Monitoring stimulated cycles during in vitro fertilization treatment with ultrasound only--preliminary results

OBJECTIVE

To evaluate if monitoring patients by ultrasound (US) only during in vitro fertilization (IVF) treatment is safe.

DESIGN

Randomized prospective study.

INTERVENTION

Patients undergoing their first IVF treatment were randomized into two groups. The ultrasound only group (study group) was monitored by US for follicle size and endometrial thickness without blood tests. In this group, only one blood test was taken before human chorionic gonadotropin (hCG) injection, to ensure a safe level of estradiol (E(2)) regarding ovarian hyperstimulation syndrome (OHSS) risk. The control group was monitored by ultrasound plus serum estradiol and progesterone concentration at each visit.

MAIN OUTCOME MEASURE

Clinical pregnancy rate.

RESULTS

No differences were found between the groups in the parameters of IVF treatment, induction days, number of ampoules, E(2) level of hCG, as well as embryo quality. The clinical pregnancy rate was not statistically different between the groups, 57.5% vs. 40.0%, respectively (p = 0.25). No OHSS cases were found among the study or control groups.

CONCLUSION

Ultrasound as a single monitoring tool for IVF cycles is reliable, safe, patient friendly, and reduces treatment expenses. In an era of cost effectiveness awareness, this regimen should be considered for routine management in IVF programs.

Successful response to docetaxel treatment in recurrent ovarian granulosa cell tumor: a case report

BACKGROUND

Ovarian granulosa cell tumor (GCT) is primarily treated surgically. Treatment for advanced or recurrent disease includes primary or adjuvant chemotherapy. Data about the efficacy of treatment with paclitaxel are limited, without data about the role of docetaxel in treating recurrent GCT.

CASE

A 68-year-old patient with Stage IA ovarian GCT diagnosed ten years earlier, presented with a third episode of recurrent disease. Following the first event of recurrent disease, she underwent a second laparotomy followed by BEP chemotherapy. Because of new liver masses, she was treated with paclitaxel, with complete response. Following diagnosis of new liver lesions, third-line chemotherapy with docetaxel was initiated, resulting in stable disease and a PFI of 24 months.

CONCLUSION

Docetaxel might be a good alternative for treating recurrent GCT.