Second cycle: to hatch or not to hatch?

The objective of this study was to assess the impact of assisted hatching (AH) on pregnancy rate (PR), clinical pregnancy rate (CPR), and implantation rate (IR) after a single failed, fresh, nondonor IVF cycle. Accordingly, we report that patients with one prior implantation failure benefit from AH with improved PR, CPR, and IR in a subsequent cycle.     

Celiac disease during pregnancy: to screen or not to screen?

Permanent intolerance to gluten, known as celiac disease, affects both fertility and pregnancy outcomes when left untreated. Recent research on celiac disease and reproduction urge increased screening for celiac disease. While this may be beneficial for couples facing idiopathic infertility or those from particular risk groups, screening involves its own risks and expenses, and has not been consistently proven effective for the general population while pregnant. The present editorial discusses the potential advantages and disadvantages of screening during pregnancy and examines when screening may be helpful.     

Polycystic Ovarian Syndrome: Is It Time to Rename PCOS to HA-PODS?

The term polycystic ovarian syndrome (PCOS) came into existence 80 years ago. Pathophysiology of PCOS remains ill understood despite extensive research in this field. It is now accepted that the manifestations of PCOS are not confined to the reproductive dysfunction, and there are endocrine–metabolic implications to PCOS with several consequences to female health. PCOS is a misnomer as ovaries do not contain epithelial cysts, but they are actually antral follicles. Moreover, the name PCOS neither reflects the hyperandrogenism which is essential for diagnosis nor the metabolic derangements. While various authors have expressed the need for change of the name, a suitable new option has not yet been established. This review aims to analyse the current understanding of pathophysiology of PCOS and addresses to the controversies associated with its diagnosis and nomenclature. The name “Hyperandrogenic Persistent Ovulatory Dysfunction Syndrome or HA-PODS” is proposed here to overcome diagnostic pitfalls of previous nomenclature. This new name will help formulate appropriate treatment and promote consistency in research as well. Further categorizations of HA-PODS are also discussed in the article.     

Is letrozole superior to clomiphene for ovarian stimulation prior to intrauterine insemination?

Objective

To compare the efficacy of letrozole with clomiphene citrate for ovarian stimulation prior to intrauterine insemination.

Methods

A total of 272 patients underwent 362 cycles of stimulation prior to IUI from January 2009 to May 2011. One hundred and twenty-six patients (170 cycles) received letrozole 5 mg and 146 patients (192 cycles) received clomiphene citrate 100 mg for 5 days starting on day 3 of the cycle. Intrauterine insemination was done 36 ± 4 h after hCG injection in 99 patients (131 cycles) in the letrozole group and 115 patients (136 cycles) in the clomiphene group. The number of mature follicles and serum E2 levels was monitored on the day of hCG. Endometrial thickness was noted on the day of hCG and IUI as well. The pregnancy rate, the miscarriage rate, and other parameters were evaluated only for patients who underwent IUI.

Results

The mean number of mature follicles was significantly more in the clomiphene group (1.66 ± 1.69 vs. 1.41 ± 1.53) than in the letrozole group. No significant difference in endometrial thickness on the day of hCG administration was found; however, endometrial thickness was statistically significantly higher in the clomiphene group on the day of IUI (9.28 ± 1.43 vs. 8.77 ± 1.34). Serum E₂ levels on the day of hCG were statistically significantly higher in the clomiphene group (501.09 ± 2.45 vs. 214.79 ± 2.43 pg/ml). Pregnancy rate was 9.2 %/cycle and 12.12 %/patient in the letrozole group, and 8.1 %/cycle and 9.5 %/cycle in the clomiphene group; these differences were not statistically significant.

Conclusion

This study found no superiority of letrozole over clomiphene when used for ovarian stimulation and IUI.     

Essure® hydrosalpinx occlusion prior to IVF-ET as an alternative to laparoscopic salpingectomy

Objective

To investigate the success rate of proximal tubal occlusion with Essure^® devices in subfertile women with unilateral or bilateral hydrosalpinx and to observe the results of subsequent treatment with IVF-ET and/or frozen embryo transfer.

Study design

Prospective, single-arm, clinical study in 20 women with unilateral or bilateral hydrosalpinges (all visible on transvaginal ultrasound) due to undergo IVF-ET and/or frozen embryo transfer. In all patients, laparoscopy was considered to be contraindicated due to extensive pelvic adhesions.

Result(s)

In all patients the Essure^® devices were placed in an ambulant setting without any complications. Proximal tubal occlusion was confirmed by hysterosalpingography in 19 out of 20 patients (95%) and in 26 of 27 treated tubes (96%). After 45 embryo transfer procedures in 19 patients, 18 pregnancies with 12 live births, 6 miscarriages and 1 immature delivery (probably related to cervical insufficiency leading to chorioamnionitis and subsequent rupture of the membranes) were observed.

Conclusion(s)

Essure^® devices are effective in inducing proximal tubal occlusion in subfertile patients with hydrosalpinges. After artificial reproductive treatments a cumulative live birth rate per patient of 63% and a cumulative live birth rate per transfer of 27% were achieved. The latter was related to the large proportion of patients with severe endometriosis.     

How to date pregnancy?

Accurate gestational assessment is essential for adequate growth assessment, appropriate aneuploidy screening and correct management of term. Based on expert opinion and beside ART pregnancies, it is recommended to use crown-rump length (CRL) to determine date of conception whenever there is an appropriate measurement taken at 11-14 weeks. This allows accurate dating at approximately 5 days in 95% of cases.     

Prior cerclage: to repeat or not to repeat? That is the question

Our objective was to compare obstetrical outcomes of women with a prior cerclage for nontraditional indications who in the subsequent pregnancy either received a history-indicated cerclage or were followed by transvaginal ultrasound (TVU) cervical length (CL). All women with a history- or ultrasound- indicated cerclage in a prior pregnancy and who had a subsequent pregnancy were retrospectively identified from a preexisting database of women at risk for preterm birth between 1995 and 2002. Only women who reached >or= 12 weeks of gestation were included for analysis. Women with a diagnosis other than classic cervical insufficiency were managed in the subsequent pregnancy either by history-indicated cerclage or by serial TVU CL. The primary outcome was spontaneous preterm birth < 35 weeks. We identified 56 women with a prior cerclage for nontraditional indications. In the subsequent pregnancy, 28 women were followed with TVU and 28 matched controls received history-indicated cerclage. The groups were matched for demographics and risk factors. There were no differences between the two groups in the incidence of preterm labor < 35 weeks (21% versus 11%; P = 0.5), preterm premature rupture membranes < 35 weeks (7% versus 11%; P = 1.0), spontaneous preterm birth < 35 weeks (11% versus 11%; P = 1.0), or the gestational age at delivery (36.3 +/- 6.6 versus 36.5 +/- 5.6; P = 0.5). We concluded that in women with prior cerclage for indications other than classic cervical insufficiency, repeat history-indicated cerclage may not improve outcome compared with management with TVU CL follow-up.