Progestogens for preterm birth prevention: a systematic review and meta-analysis by drug route

Purpose

Progestogen has been investigated as a preventive intervention among women with increased preterm birth risk. Our objective was to systematically review the effectiveness of intramuscular (IM), vaginal, and oral progestogens for preterm birth and neonatal death prevention.

Methods

We included articles published from January 1966 to January 2013 and found 27 randomized trials with data for Bayesian meta-analysis.

Results

Across all studies, only vaginal and oral routes were effective at reducing preterm births (IM risk ratio [RR] 0.95, 95 % Bayesian credible interval [BCI]: 0.88–1.03; vaginal RR 0.87, 95 % BCI: 0.80–0.94; oral RR 0.64, 95 % BCI: 0.49–0.85). However, when analyses were limited to only single births all routes were effective at reducing preterm birth (IM RR 0.77, 95 % BCI: 0.69–0.87; vaginal RR 0.80, 95 % BCI: 0.69–0.91; oral RR 0.66, 95 % BCI: 0.47–0.84). Only IM progestogen was effective at reducing neonatal deaths (IM RR 0.78, 95 % BCI: 0.56–0.99; vaginal RR 0.75, 95 % BCI: 0.45–1.09; oral RR 0.72, 95 % BCI: 0.09–1.74). Vaginal progestogen was effective in reducing neonatal deaths when limited to singletons births.

Conclusions

All progestogen routes reduce preterm births but not neonatal deaths. Future studies are needed that directly compare progestogen delivery routes.     

Effect of metformin on ovulation and reproductive outcomes in women with polycystic ovary syndrome: a meta-analysis of randomized controlled trials

Purpose

To evaluate the effect of MET on ovulation and reproductive outcomes in patients with polycystic ovary syndrome.

Methods

Meta-analysis of available data from randomized controlled trials that examined the ovulation, pregnancy and live birth rate after the administration of clomiphene citrate (CC) or MET alone or combined.

Results

The ovulation rate was found to be higher in the group treated with MET combined with clomiphene citrate (CC) than only with CC, odds ratio (OR): 1.27, 95 % confidence interval (95 % CI) (1.03–1.56), while the pregnancy and live birth rate showed no significant difference between the two groups, OR: 1.19, 95 % CI (0.99–1.42) and OR: 0.99, 95 % CI (0.84–1.17), respectively. The MET + CC group produced a higher ovulation and pregnancy rate than MET group, OR: 2.10, 95 % CI (1.89–2.34) and OR: 2.08, 95 % CI (1.55–2.80), respectively, while between two groups the live birth rate showed no significant difference, OR: 1.50, 95 % CI (0.75–3.00). The ovulation rate was lower in MET than in CC group, OR: 0.65, 95 % CI (0.43–0.995), while between the two groups the pregnancy and live birth rate showed no significant difference, OR: 0.86, 95 % CI (0.42–1.74) and OR: 0.89, 95 % CI (0.71–1.13).

Conclusion

The current study indicated that combination of MET and CC could gain advantage over a single administration in the ovulation induction and pregnancy rate.     

Vitamin D improves endometrial thickness in PCOS women who need intrauterine insemination: a randomized double-blind placebo-controlled trial

Purpose

To determine whether administration of vitamin D affects the success rates of intra uterine insemination (IUI) in infertile polycystic ovarian syndrome (PCOS) women and their endometrial thickness.

Methods

This randomized, double-blind, placebo-controlled trial was conducted in an infertility clinic of Women’s Hospital, and 110 infertile PCOS patients undergoing IUI were randomly divided to receive vitamin D or placebo. Endometrial thickness, IUI results, number of dominant follicles, duration of IUI cycle, and dose of HMG used in IUI were determined.

Results

The endometrial thickness was significantly different in the group treated with vitamin D versus the placebo group (p = 0.003). There was no statistical difference in pregnancy out come between the two groups (RR = 1.167, CI 95 % 0.70–1.93). No statistical difference was found in number of dominant follicles (p = 0.96), duration of IUI cycles (p = 0.70) and dose of HMG used for IUI (p = 0.95).

Conclusions

It seems that administration of vitamin D induces endometrial proliferation in PCOS women during IUI cycle.     

Effect of luteal phase support after ovulation induction and intrauterine insemination

Objective: This study aimed to evaluate the effect of luteal phase support on clinical pregnancy and live birth rates after ovulation induction and intrauterine insemination (IUI).

Methods: 579 cycles from 2010 to 2013 were retrospectively evaluated. Ovarian stimulation was performed with gonadotropins, and rHCG was used for ovulation triggering. All patients received IUI. 451 cycles were supported by receiving vaginal micronized progesterone capsules (142 cycles) or vaginal progesterone gel (309 cycles) whereas 128 cycles were not supported.

Results: Clinical pregnancy (20.6 versus 9.4%; p?=?0.004) and live birth rates (14 versus 7%; p?=?0.036) were higher for supported group than for unsupported group. Progesterone gel and micronized progesterone subgroups achieved similar clinical pregnancy and live birth rates (21.4 versus 19%, p?=?0.567 and 14.2 versus 13.4%, p?=?0.807; respectively).

Conclusions: Luteal phase support improved the success of IUI cycles affecting both clinical pregnancy and live birth rates when gonadotropins were used for ovulation induction. The use of vaginal progesterone gel or micronized progesterone significantly improves clinical pregnancy rates. The live birth rates were higher in the progesterone gel group, but were similar in the micronized progesterone group compared to the unsupported group.     

Route of progesterone administration for luteal phase support may affect outcome of controlled ovarian hyperstimulation for IVF with ICSI using GnRH antagonist

Purpose

This study evaluated the impact of route of progesterone administration as luteal phase support on the outcome of assisted conception cycles.

Methods

Intramuscular progesterone in oil (IMP) at 100 mg daily was administered to 903 women following oocyte retrieval whereas vaginal progesterone gel (VMP) at 90 mg was administered twice daily to 1,110 women. Retrospective analysis was performed according to the type of GnRH analogue used. Implantation (IR), clinical pregnancy (CPR) and biochemical pregnancy rates (BPR) were main outcomes.

Results

In GnRH agonist cycles, neither IR, CPR or BPR differed according to the route of progesterone. However, in GnRH antagonist cycles, IR and CPR were significantly lower in VMP group compared to IMP group. BPR also was significantly higher in VMP group compared to IMP group.

Conclusion

Our results suggest that route of progesterone administration for luteal phase support can be an important prognostic factor according to the type of GnRH analogue used for controlled ovarian hyperstimulation.     

Ovarian stimulation in the luteal phase: systematic review and meta-analysis

Purpose

The purpose of this study was to evaluate whether outcomes are different if controlled ovarian stimulation (COS) is started in the luteal phase rather than the follicular phase.

Methods

A systematic review and meta-analysis was performed. Sixteen studies were included in the qualitative analysis, and eight studies with a total of 338 women were included in the quantitative analysis.

Results

Cycles initiated in the luteal phase were slightly longer (WMD 1.1 days, 95 % CI 0.39–1.9) and utilized more total gonadotropins (WMD 817 IU, 95 % CI 489–1144). However, no differences were noted in peak estradiol levels (WMD ?411 pg/ml, 95 % CI ?906–84.7) or in the total number of oocytes retrieved (WMD 0.52 oocytes, 95 % CI ?0.74–1.7). There were slightly more mature oocytes retrieved in the luteal phase (WMD 0.77 oocytes, 95 % CI 0.21–1.3), and fertilization rates were significantly higher (WMD 10 %, 95 % CI 0.03–0.18). While only three studies reported pregnancy outcomes, no difference was noted in the FET pregnancy rates after COS in the luteal versus follicular phase (RR 0.95, 95 % CI 0.56–1.7).A post hoc power analysis revealed that a sample of this size was sufficient to detect a clinically meaningful difference of 2 oocytes retrieved with 93 % power.

Conclusion

Although initiating COS in the luteal phase requires a longer stimulation and a higher dose of total gonadotropin, these differences are not clinically significant. Furthermore, COS initiated in the luteal phase does not compromise the quantity or quality of oocytes retrieved compared to outcomes of traditional stimulation in the follicular phase.

     

Sperm selection using magnetic activated cell sorting (MACS) in assisted reproduction: a systematic review and meta-analysis

Purpose

To determine whether the use of Magnetic Activated Cell Sorting (MACS) as a sperm selection technique improves ART success rates in couples undergoing assisted reproduction treatment.

Methods

Systematic review and meta-analysis of prospective randomized trials. Two reviewers conducted study selection and data extraction independently.

Results

Five studies (prospective randomized trials) that comprised 499 patients were included. Sperm selection using MACS resulted in statistically significant differences in pregnancy rates when compared with density gradient centrifugation and swim-up techniques (RR?=?1.50, 95 % CI 1.14–1.98). No differences were found between the groups according to the implantation (RR?=?1.03, 95 % CI 0.80–1.31) and miscarriage (RR?=?2.00, 95 % CI 0.19–20.90) rates.

Conclusions

MACS appears to be a safe and efficient method to select functional sperm with consistently good results. This technique may improve pregnancy rates when used to complement standard sperm selection methods in ART.     

Pregnancy outcome following loop electrosurgical excision procedure (LEEP) a systematic review and meta-analysis

Objective

This study aimed at assessing the association of the relative risk (RR) of adverse pregnancy outcomes with previous treatment of loop electrosurgical excision procedure (LEEP) for the management of cervical intraepithelial neoplasia (CIN).

Methods

Data sources were from MEDLINE, EMBASE, and SCI citation tracking. Selection criteria: The eligible studies had data on pregnancy outcomes of women with or without previous treatment for CIN. Considered outcomes were severe preterm delivery (<34/32 weeks), extreme preterm delivery (<28 weeks), low birth weight (<2,500 g), stillbirth, preterm spontaneous rupture of membranes, perinatal mortality, and neonatal mortality and induction.

Results

36,954 cases and 1,794,174 controls in 4 prospective cohort and 22 retrospective studies were included in this meta-analysis. LEEP was associated with a higher risk of severe preterm delivery (<32 weeks, relative risk 1.98, 95 % CI [1.31, 2.98] 159/11,337 vs. 7,830/860,883), extreme preterm delivery (<28 weeks, RR, 2.33, 95 % CI [1.84, 2.94] 97/9,611 vs. 1,559/618,332), preterm premature rupture of the membranes (RR, 1.88, 95 % CI [1.54, 2.29] 126/2,837 vs. 7,899/313,094), and low birth weight (<2,500 g, RR, 2.48, 95 % CI [1.75, 3.51] 110/1,451 vs. 55/1,742). A cervical length of less than 3 cm was significantly increased in LEEP as compared with that of control group (RR, 4.88, 95 % CI [1.56, 15.25]), but increasing LEEP volume or depth was not associated with an increased rate of preterm birth <37 weeks. And LEEP was not associated with a significantly increased risk of perinatal mortality, cesarean section, stillbirth mortality, neonatal mortality, induction, and neonatal intensive care unit admission.

Conclusions

LEEP is associated with an increased risk of subsequent preterm delivery (<32/34, <28 weeks) and other serious pregnancy outcomes. But increasing LEEP volume or depth is not associated with an increased rate of preterm birth.     

Basal progesterone level as the main determinant of progesterone elevation on the day of hCG triggering in controlled ovarian stimulation cycles

Purpose

Modest increases of serum progesterone at human chorionic gonadotrophin (hCG) administration in controlled ovarian hyperstimulation (COH) cycles have been shown to have a negative impact on pregnancy outcomes. The aim of this study was to identify early predictors of progesterone elevation at hCG.

Design

Pregnancy outcome of 303 consecutive patients undergoing COH and fresh day-3 embryo transfer was analysed. Considering the non-linear relationship between progesterone at hCG triggering and pregnancy outcomes, partial area under the curve (pAUC) analysis was used to implement marker identification potential of receiver operating characteristic (ROC) curve analysis. Multivariate logistic analysis was then performed to identify predictors of progesterone rise.

Results

Pregnancy outcomes could be predicted by pAUC analysis (pAUC = 0.58, 95 % CI 0.51–0.66, p = 0.02) and a significant detrimental cut-off could be calculated (progesterone at hCG > 1.35 ng/ml). Total dose of rFSH administered, E₂ level at hCG but mostly basal progesterone level (OR = 12.21, 95 % CI 1.82–81.70) were predictors of progesterone rise above the cut-off.

Conclusion

Basal progesterone is shown to be the main prognostic factor for progesterone elevation. This observation should be taken into consideration in the clinical management of IVF/ICSI cycles to improve pregnancy outcomes.     

Dehydroepiandrosterone treatment in women with poor ovarian response undergoing IVF or ICSI: a systematic review and meta-analysis

Purpose

We reviewed the influence of dehydroepiandrosterone (DHEA) supplementation in patients with poor ovarian response (POR) undergoing in vitro fertilization or intracytoplasmic sperm injection (IVF/ICSI).

Methods

We searched Embase, MEDLINE, PubMed, and the Cochrane Library (1980–2015) for relevant papers and used the Newcastle–Ottawa Scale scoring system to evaluate study quality. Dichotomous data were expressed as pooled relative risk (RR) estimates with fixed or random effect models. Continuous variables were expressed as the weighted mean difference (WMD). All data were analyzed using Revman Software v. 5 and are shown with 95 % confidence intervals (CI).

Results

Twenty-one studies met the inclusion criteria. DHEA pretreatment increased the clinical pregnancy rate (RR 1.53, 95 % CI 1.25–1.86), live birth rate (RR 1.87, 95 % CI 1.22–2.88), implantation rate (RR 1.56, 95 % CI 1.20–2.01), and antral follicle count (WMD 0.4, 95 % CI 0.14 to 0.66) while reducing miscarriages (RR 0.50, 95 % CI 0.27–0.90). After subgroup analysis, oocyte numbers and anti-Müllerian hormone levels were also enhanced after DHEA treatment. However, the endometrial thickness and estradiol levels on the day of injecting hCG to induce ovulation were similar between the DHEA supplementation groups and controls.

Conclusions

Based on the limited available evidence, DHEA supplementation seems to improve ovarian reserves and IVF/ICSI outcome in patients with POR. Further research is required to clarify the effect of DHEA exposure in assisted reproduction technology.

     

Elevated progesterone and its impact on birth weight after fresh embryo transfers

Purpose

The purpose of the study was to examine the association between serum progesterone levels on the day of hCG administration and birth weight among singleton live births after fresh embryo transfer.

Methods

This study was conducted as a retrospective cohort database analysis on patients who underwent IVF treatment cycles from January 2004 to April 2012. The study was performed at a University affiliated private infertility practice. All cycles that had achieved a singleton live birth after fresh embryo transfer and for which progesterone was measured on the day of hCG administration were examined. Generalized linear models were used to calculate mean birth weight and z-scores.

Results

We analyzed 817 fresh IVF embryo transfers in which birth weight, gestational age, and progesterone (ng/mL) level on day of hCG administration were documented. While there was a decrease in birth weight as progesterone quartile [≤0.54; >0.54 to ≤0.81; >0.81 to ≤1.17; >1.17 ng/mL] increased, the difference in mean birth weights among the four quartiles was not statistically significant (p = 0.11) after adjusting for maternal age and peak estradiol levels. When dichotomizing based on a serum progesterone considered clinically elevated, cycles with progesterone >2.0 ng/mL had a significantly lower mean singleton birth weight (2860 g (95% CI 2642 g, 3079 g)) compared to cycles with progesterone ≤2.0 ng/mL (3167 g (95% CI 3122 g, 3211 g) p = 0.007)) after adjusting for maternal age and estradiol.

Conclusion

We demonstrated that caution should be exercised when performing fresh embryo transfers with elevated progesterone levels and in particular with levels (>2.0 ng/mL) as this may lead to lower birth weight.

     

Puerperal morbidity following repeat cesarean delivery in twin pregnancies

Objective

To evaluate the puerperal complications following twin deliveries.

Study design

We conducted a population-based analysis of puerperal delivery-related complications of twins born in Slovenia for comparing three groups of births (vaginal, elective and emergent cesarean).

Results

A total of 1,001 elective, 1,109 emergent cesarean sections, and 2,204 vaginal twin births were evaluated. No differences were found between the complications after emergent and elective cesareans. Uterine atony was more frequent after vaginal births (OR 1.8–2.0, 95 % CI 1.1–1.2, 2.9–3.3). Vaginal births had a higher frequency of endometritis compared with elective cesarean (OR 4.1, 95 % CI 1.2, 13.6). Conversely, vaginal deliveries were less frequently associated with anemia, hematoma formation, and need for blood transfusion as compared to both modes of cesarean deliveries.

Conclusion

No solid data exist to show a clear advantage or disadvantage in terms of puerperal complications of an elective cesarean over vaginal birth for twins.     

Ring and Gellhorn pessaries used in patients with pelvic organ prolapse: a retrospective study of 8 years

Background

Membrane sweeping (MS) could increase the likelihood of spontaneous labor within 48 h. However, the rationale for performing routinely an intervention with the potential to induce labor in women with an uneventful pregnancy at 38 weeks of gestation is, at least, questionable. We conducted a meta-analysis of randomized controlled trial (RCT) studies to assess evaluated the effect of MS added to formal induction method on the spontaneous vaginal delivery, compared with formal induction alone.

Methods

PubMed, Embase, Cochrane Library databases, Web of Science, and Clinical Trials were searched from their inception to March 8, 2017. We estimate summarized relative risk (RR) and 95% confidence intervals (CIs) for dichotomous outcomes. The primary outcome was vaginal delivery, and second outcomes (side effects of MS) included meconium-stained liquor, admission to the neonatal unit, instrumental delivery.

Results

Four RCTs with a total of 1377 participants were identified. The summary RR in the overall group was 1.12 (95% CI 1.05–1.18), with moderate heterogeneity (P = 0.22, I² = 33%). The summary RR in the nulliparas’ subgroup was 1.32 (95% CI 1.18–1.48), with no heterogeneity (P = 0.79, I² = 0%). MS did not increase the risk of side effects.

Conclusions

MS added to formal induction significantly increased vaginal delivery rates, especially in nulliparas compared with formal induction alone. Notably, there are no obvious side effects of MS. Meanwhile, more RCTs studies are needed to investigate the side effects of MS on instrumental delivery, postpartum hemorrhage, and cervical laceration.

     

The success rate of pregnancy in IUI cycles following endometrial sampling. A randomized controlled study

Objective

The aim of this work was to compare the pregnancy rates during IUI cycles with or without endometrial sampling.

Study design

A prospective, randomized study.

Patients and methods

150 patients were recruited. They were classified into three groups. Each comprised 50 patients. Group 1 was considered the control group and underwent IUI with no endometrial sampling. Group 2 underwent Tao Brush endometrial sampling on day 8–9 of the uterine cycle that preceded the stimulation cycle, and finally, Group 3 underwent Tao Brush endometrial sampling on day 8–9 of the same IUI cycle

Outcome of the study

A positive pregnancy test.

Results

Pregnancy percentages were 18, 38, and 36 % for group 1, group 2, and group 3, respectively. The paired t test was used to compare each two individual group means. The results show a highly significant value for the paired t test of the control group and group 2 of the patients (p = 0.001), as well as a highly significant results (p = 0.002) for the group 3 and the control group. No significant value was present between the group 2 and 3 of patients (p = 0.322).

Conclusion

Endometrial sampling significantly increases pregnancy rates in IUI procedures when it is done in the proliferative phase of the IUI cycle, or the cycle prior to IUI, than pregnancy rates with IUI alone.     

Validity and efficacy of office hysteroscopy before in vitro fertilization treatment

Introduction

Office hysteroscopy (OH) allows assessment of the uterine cavity. The aim of this study is to investigate uterine cavity of infertile patients with OH, to treat pathologies and to measure the impact of OH on live birth rates and IVF treatment costs.

Materials and methods

498 IVF patients were selected for this study. Control group (398 patients) underwent IVF without OH evaluation. OH group (100 patients) was assessed prior to IVF and detected intrauterine pathologies were treated. OH group was divided into two subgroups: patients with normal uterine cavity (59 patients) and patients who had intrauterine pathologies (41 patients). Number needed to treat (NNT) was also measured.

Results

When live birth rates of the control and OH groups were compared, OH group’s rate was significantly higher (18.3 vs. 26 %; p > 0.05). 41 % of the patients in the OH group had intrauterine pathologies. When live birth rates of control group and the subgroups were compared, it was significantly higher in the subgroups (p < 0.05). When live birth rates of the subgroups were compared, there was a statistically significant difference in intrauterine pathology subgroup (p < 0.05). NNT measures showed that 13 OH interventions were needed to achieve one additional pregnancy [NNT 13.05; relative risk (RR) 1.418], while five pathologies had to be found and treated with OH to achieve one additional pregnancy (NNT 5; RR 1.962).

Conclusion

Usage of OH can play an important role in detecting intrauterine pathologies in IVF patients. Therefore, it may have a positive impact on pregnancy outcome and treatment costs.     

Influence of ultrasound-guided artificial insemination on pregnancy rates: a randomized study

Purpose

To evaluate the influence of ultrasound guidance during intrauterine insemination (IUI) on pregnancy rates (PRs). The impacts of two different groups of providers were also investigated.

Methods

Study population consisted of 387 gonadotropin stimulated IUI cycles performed for unexplained infertility. The patients were randomized into two groups as ultrasound-guided IUI (n = 180) and classical IUI (n = 207). Pregnancy rates were compared. Two groups were further analyzed based on the experience of the provider (senior versus junior subgroups) who performed IUI.

Results

Pregnancy rates were higher in the ultrasound-guided IUI group (17.2 %) compared to the classical IUI (10.1 %) (p = 0.042). In further analysis based on the experience of the provider; in the classical IUI group, PRs were similar for both subgroups, however, in the ultrasound-guided group it was higher when IUI was performed by a senior physician (21.7 versus 9.2 %, p = 0.033). Logistic regression revealed that the experience of the provider was the independent variable for improved PRs.

Conclusions

Ultrasound guidance improves PRs only when a senior provider performs the IUI procedure. It seems that the experience of the provider physician is one of the determinants of IUI success.     

The outcome of different post-thawed culture period in frozen-thawed embryo transfer cycle

Purpose

To study the influence of post-thawed culture (2–4 h and 20–24 h) on the outcome of frozen-thawed embryo transfer (FET) cycle.

Methods

In this retrospective study, a total of 1,353 patients were undergoing the FET treatment at the reproductive medical center between June 2010 and July 2012. 3,398 frozen-thawed embryos were divided in two study groups, depending on their post-thawed culture period: short culture (2–4 h) group and long culture (20–24 h) group. Groups were compared including clinical pregnancy rate, implantation rate, spontaneous abortion rate, ectopic pregnancy rate, multiple pregnancy rate, live birth rate and birth weight.

Results

When embryos including at least one grade I embryo after thawed transferred, the clinical pregnancy rate, implantation rate, multiple pregnancy rate, abortion rate, ectopic pregnancy rate, live birth rate and birth weight were similar in the short culture group compared with these in the long culture group.

Conclusions

The outcomes of the two approaches (short culture and long culture) are no different in FET cycles.     

Antenatal counseling in maternal and newborn care: use of job aids to improve health worker performance and maternal understanding in Benin

Background

Most women use some method of pain relief during labour. There is extensive research evidence available of pharmacological pain relief during labour; however this evidence is not readily available to pregnant women. Decision aids are tools that present evidence based information and allow preference elicitation.

Methods

We developed a labour analgesia decision aid. Using a RCT design women either received a decision aid or a pamphlet. Eligible women were primiparous, ≥ 37 weeks, planning a vaginal birth of a single infant and had sufficient English to complete the trial materials. We used a combination of affective (anxiety, satisfaction and participation in decision-making) and behavioural outcomes (intention and analgesia use) to assess the impact of the decision aid, which were assessed before labour.

Results

596 women were randomised (395 decision aid group, 201 pamphlet group). There were significant differences in knowledge scores between the decision aid group and the pamphlet group (mean difference 8.6, 95% CI 3.70, 13.40). There were no differences between decisional conflict scores (mean difference -0.99 (95% CI -3.07, 1.07), or anxiety (mean difference 0.3, 95% CI -2.15, 1.50). The decision aid group were significantly more likely to consider their care providers opinion (RR 1.28 95%CI 0.64, 0.95). There were no differences in analgesia use and poor follow through between antenatal analgesia intentions and use.

Conclusions

This decision aid improves women's labour analgesia knowledge without increasing anxiety. Significantly, the decision aid group were more informed of labour analgesia options, and considered the opinion of their care providers more often when making their analgesia decisions, thus improving informed decision making.

Trial Registration

Trial registration no: ISRCTN52287533     

Risk factors for emergency caesarean section in planned vaginal breech delivery

Purpose

To identify risk factors for emergency caesarean section in women attempting a vaginal breech delivery at term.

Methods

Data from 1092 breech deliveries performed between 1998 and 2013 at a Swiss cantonal hospital were extracted from an electronic database. Of the 866 women with a singleton, full term pregnancy, 464 planned a vaginal breech delivery. Fifty-seven percent (265/464) were successful in delivering vaginally. Multivariate regression analyses of risk factors were performed, and neonatal and maternal complications were compared.

Results

Risk factors for failed vaginal delivery were peridural anaesthesia (OR 2.05; 95 % CI 1.09–3.84; p = 0.025), nulliparity (OR 2.82; 95 % CI 1.87–4.25; p < 0.001), high birth weight (OR 1.17; 95 % CI 1.04–1.30; p = 0.006) and induction of labour (OR 1.56; 95 % CI 1.003–2.44; p = 0.048). Maternal age, height and weight; gestational age; or newborn length and head circumference were not associated with an unplanned caesarean section. The rate of successful vaginal delivery in the low risk sub-group (multiparous women without induction of labour) was 58–83 %, depending on birth weight category. The likelihood of success for the high risk sub-group (nulliparous women with induction of labour) fell below a third at neonatal birth weights >3250 g. Complication rates were low in the cohort.

Conclusions

Use of peridural anaesthesia, nulliparity, high birth weight and induction of labour were risk factors for unsuccessful vaginal breech delivery requiring an unplanned caesarean section. Awareness of these risk factors is useful when counselling women who are considering a vaginal breech delivery.

     

Replacing single frozen-thawed euploid embryos in a natural cycle in ovulatory women may increase live birth rates compared to medicated cycles in anovulatory women

Purpose

The goal of this study was to compare pregnancy outcomes between natural frozen embryo transfer (FET) cycles in ovulatory women and programmed FET cycles in anovulatory women after undergoing in vitro fertilization with preimplantation genetic screening (IVF-PGS).

Methods

This was a retrospective cohort study performed at an academic medical center. Patients undergoing single FET IVF-PGS cycles between October 2011 and December 2014 were included. Patients were stratified by type of endometrial replacement: programmed cycles with estrogen/progesterone replacement and natural cycles. IVF-PGS with 24-chromosome screening was performed on all included patients. Those patients with euploid embryos had single embryo transfer in a subsequent FET. The primary study outcome was live birth/ongoing pregnancy rate. Secondary outcomes included implantation, biochemical pregnancy, and miscarriage rates.

Results

One hundred thirteen cycles met inclusion criteria: 65 natural cycles and 48 programmed cycles. The programmed FET group was younger (35.9 ± 4.5 vs. 37.5 ± 3.7, P = 0.03) and had a higher AMH (3.95 ± 4.2 vs. 2.37 ± 2.4, P = 0.045). The groups were similar for BMI, gravidity, parity, history of uterine surgery, and incidence of Asherman’s syndrome. There was also no difference in embryo grade at biopsy or transfer, and proportion of day 5 and day 6 transfers. Implantation rates were higher in the natural FET group (0.66 ± 0.48 vs. 0.44 ± 0.50, P = 0.02). There was no difference in the rates of biochemical pregnancy or miscarriage. After controlling for age, live birth/ongoing pregnancy rate was higher in natural FETs with an adjusted odds ratio of 2.68 (95% CI 1.22–5.87).

Conclusions

Natural FET in ovulatory women after IVF-PGS is associated with increased implantation and live birth rates compared to programmed FET in anovulatory women. Further investigation is needed to determine whether these findings hold true in other patient cohorts.