GnRH antagonist administered twice the day before hCG trigger combined with a step-down protocol may prevent OHSS in IVF/ICSI antagonist cycles at risk for OHSS without affecting the reproductive outcomes: a prospective randomized control trial

Purpose

The purpose this study is to investigate whether a double antagonist dose (0.25 mg/12 h) administered the day before hCG trigger is effective in preventing ovarian hyperstimulation syndrome (OHSS) in GnRH antagonist IVF/intracytoplasmic sperm injection (ICSI) cycles at risk for OHSS.

Methods

This is a prospective randomized control study, conducted from November 2012 to January 2016. A total of 194 patients undergoing a IVF/ICSI GnRH antagonist cycle that were at risk of OHSS and chose to proceed with embryo transfer and avoid cycle cancellation or embryo cryopreservation were allocated into two groups. The inclusion criteria consisted of a rapid rise of oestradiol ≥ 3500 pg/ml combined with ≥ 18 follicles > 11 mm in diameter without any mature follicle > 16 mm, in any day of stimulation. Overall, 97 patients (intervention group A) received a double dose of GnRH antagonist (0.25 mg/12 h) the day before hCG while 97 patients (control group B) did not. Recombinant FSH administration was tapered to 100 IU/24 h the day of the allocation in both groups.

Results

Incidence of early-onset moderate/severe OHSS was significantly lower in intervention group A compared to control group B (0 vs 12.37%, P < 0.001). Clinical pregnancy rate per cycle (50.52 vs 42.27%, P = 0.249) was not significantly different between the two groups. Oestradiol (3263.471 ± 1271.53 vs 5233 ± 1425.17, P < 0.001), progesterone (0.93 ± 0.12 vs 1.29 ± 0.14, P < 0.001) and luteinizing hormone (1.42 ± 0.31 vs 1.91 ± 0.33, P < 0.001) were significantly lower in group A the day of the hCG triggering.

Conclusion

The administration of a rescue double GnRH antagonist dose the day before hCG trigger may represent a safe alternative preventive strategy for early OHSS without affecting the reproductive outcomes.

Trial registration number

ISRCTN02750360

     

Laparoscopically assisted myomectomy versus abdominal myomectomy in short-term outcomes: a prospective study

Purpose  

Comparison between laparoscopically assisted myomectomy (LAM) and abdominal myomectomy (laparotomy), used in the management of women with intramural or subserous uterine fibroids up to 90 mm of maximum diameter.     

Acute clinical benefits of chest wall-stretching exercise on expired tidal volume, dyspnea and chest expansion in a patient with chronic obstructive pulmonary disease: A single case study

Chest physical therapy (CPT) has an important role in a medical team to assist in resolving the critical problems deriving from chronic lung disease.These critical problems include increased secretion volume, difficult breathing or dyspnea, ineffective coughing, inability to be weaned off a ventilator, and physical deterioration resulting from low aerobic capacity and endurance after prolonged bed rest. The inability to be weaned off a ventilator does not only result from secretion production or muscle weakness, but other conditions including chest stiffness or immobility. The procedure to increase chest mobility includes specific chest stretching and mobilization. Chest wall-stretching exercises were composed of thoracic rotation and anterior compression with stretching in sitting position, trunk extension and rib torsion in supine lying, and lateral stretching in side lying. These exercises were given to the patient as a regular daily program along with postural drainage, percussion, breathing exercise and limb exercises. The expired tidal volume, dyspnea level, and chest expansion were evaluated and clinical efficiency was analyzed during CPT, compared to Pre-CPT and Post-CPT with Bloom table. The results showed a significant clinical improvement of expired tidal volume, reduction in dyspnea level, and increase in chest expansion.     

HIV Prevalence, Risk, and Partner Serodiscordance Among Pregnant Women in Bangkok

Context.— Most prior studies of the human immunodeficiency virus (HIV) epidemic in Thailand have focused on commercial sex encounters; however, because the epidemic increasingly concerns stable heterosexual relationships, determining risk factors for this form of transmission is warranted. Objectives.— To determine temporal trends in HIV prevalence, risk factors for HIV seropositivity, and rates of partner serodiscordance for pregnant women in Bangkok, Thailand. Design.— Retrospective review of hospital antenatal clinic HIV test results from 1991 through 1996. Baseline demographic and behavioral risk factors for HIV were assessed for subjects enrolled from November 1992 through March 1994. Setting.— Two Bangkok hospitals with routine antenatal clinic HIV counseling and testing. Participants.— The HIV-positive pregnant women enrolled in a perinatal HIV transmission study and their partners and HIV-negative pregnant controls. Results.— From 1991 through 1996, antenatal clinic HIV seroprevalence increased from 1.0% to 2.3%. On multivariate analysis of data from 342 HIV-positive and 344 HIV-negative pregnant women, more than 1 lifetime sex partner, history of a sexually transmitted disease, and a high-risk sex partner were the most important factors for seropositivity (all P<.001). Twenty-six percent of partners of HIV-positive women were HIV negative. Women reporting more than 1 lifetime sex partner were more likely to have an HIV-negative partner than women reporting only 1 (45% vs 8%; relative risk, 5.5; 95% confidence interval, 3.2-9.5; P<.001); women reporting no high-risk behaviors were less likely to have an HIV-negative partner (10% vs 44%; relative risk, 0.2; 95% confidence interval, 0.1-0.4; P <.001). Conclusions.— Prevalence of HIV in pregnant women has increased steadily in Bangkok from 1991 through 1996. Sex with current partners was the only identified risk exposure for about half (52%) of the HIV-positive women. Although few HIV-positive pregnant women reported high-risk behaviors, more than 1 lifetime partner and a partner with high-risk behavior were strong risk factors for seropositivity. Together with the unexpected finding that one fourth of partners of seropositive pregnant women were seronegative, these data emphasize that women in the general population are at risk for HIV because of the risk behavior of both current and previous partners.      

Low-dose human chorionic gonadotropin during the proliferative phase may adversely affect endometrial receptivity in oocyte recipients

The effect of low-dose human chorionic gonadotropin (hCG) administration in the proliferative phase of oocyte recipients was investigated in a prospective randomized trial. Sibling oocytes from the same donor were shared at random among two different recipients. In group I oocyte recipients received 750 IU of hCG every three days concomitant to endometrial preparation with estradiol until hCG injection to the donor, whereas in group II recipients received no hCG during endometrial priming with estradiol. Endometrial thickness was significantly lower in group I compared with group II, although similar endometrial thickness was detected during the mock cycle. Pregnancy rates were significantly lower in group I than in group II (13.6% vs. 45.4%, p<0.05). Implantation rates were also significantly lower in group I (1.7% vs. 22.4%, p<0.01). The study was discontinued prematurely for ethical reasons when 22 cycles were completed, as pregnancy rates were very low in group I. In conclusion, hCG administration in the proliferative phase might directly affect endometrial proliferation and receptivity.     

Immigrants Present Improved Obstetric and Neonatal Outcomes Compared to Native Women. A Northern Greek Population Analysis

To compare the incidence of obstetric and neonatal outcomes between native and immigrant women. A retrospective cohort of singleton pregnancies was conducted concerning the period 2003–2009. Women were divided in group 1, including natives and group 2, including immigrants. Epidemiological characteristics, obstetric outcomes and neonatal morbidity parameters were studied. Out of 7033 singleton pregnancies delivered during this period, 6980 with complete information were finally included. Immigrants consisted 47.59 % of all gravidas (group 2, n = 3322), presenting significantly lower rates of emergency caesarean section, preeclampsia, preterm delivery, placenta praevia and fetal distress. Furthermore, all parameters of neonatal morbidity, including Mean Apgar score in the 1st and 5th minute as well as rates of NICU admission and emergency intubation were significantly improved in the group of immigrants. According to our results, pregnancies of immigrant women are less likely to be complicated by severe obstetric and neonatal outcomes.     

Amniocentesis-related adverse outcomes in diamniotic twins: is there a difference compared to singleton pregnancies?

Objective

To investigate whether diamniotic twin gestations are at increased risk of amniocentesis-related adverse outcomes compared to singleton pregnancies.

Study design

This was a retrospective study of mid-trimester amniocenteses performed during the period 1993-2009. Cases were divided in two groups, one including singleton (Group 1) and the other diamniotic twin pregnancies (Group 2). All amniocentesis-related adverse outcomes were reviewed, including aspiration of insufficient amniotic fluid, aspiration of hemorrhagic amniotic fluid, repeated puncture and miscarriage. The incidence of these adverse outcomes was compared between the two groups.

Results

In total, 6270 cases were included in the study (Group 1, n = 6150 and Group 2, n = 120). Advanced maternal age was the main indication for amniocentesis in both singleton and twin pregnancies. There was no difference in the incidence of insufficient sample aspiration (0.2% in singletons vs. 0.0% in twins, P = NS), in the incidence of blood-stained amniotic fluid (3.7% in singletons vs. 4.6% in twins, P = NS), in the rate of need for second attempt (2.1% in singletons vs. 1.7% in twins, P = NS) or in the miscarriage rate (0.24% in singletons vs. 0% in twins).

Conclusion

In our experience, the incidence of amniocentesis-related adverse outcomes is not increased in diamniotic twins compared to singleton pregnancies.     

Left ventricular surgical remodeling 2.0

Left ventricular surgical remodeling has been, for a long time, the procedure applied for large dyskinetic, or akinetic, areas as a consequence of a myocardial infarction, mainly located in the left anterior descending area. Many surgical techniques were developed, aimed to a pure reduction of the volume of the left ventricular (LV) cavity or to add to volume reduction a more physiologic conical shape. The expansion of interventional procedures invaded most of the fields before treated only by cardiac surgeons. In this issue, Pillay describes a hybrid technique, involving both interventional cardiologists and cardiac surgeons, aimed to LV volume reduction after an anterior myocardial infarction. A series of internal (right ventricular septum) and external (anterior wall) anchors are implanted to approximate the LV free wall to the anterior septum, consequently excluding the scarred myocardium. Although some limitations of this study, the authors have to be commended for having revitalized a procedure almost eliminated from the surgical scenario.     

Healing pattern of bone defects covered by different membrane types--a histologic study in the porcine mandible

Few investigations on guided bone regeneration (GBR) focus on the behaviour of tissues adjacent to barrier membranes. This study was conducted to (1) evaluate the barrier function potential of different resorbable and nonresorbable membranes for GBR, (2) investigate their structural changes after different intervals, and (3) characterize tissue composition and reaction adjacent to the barrier by qualitative histologic evaluation. Seven barriers for GBR were used per animal (made of dense or expanded polytetrafluoroethylene (d/ePTFE), titanium, polyetherurethane, collagen and two polylactide-polyglycolide-/-trimethylenecarbonate-co-polymers (PLPG, LPGTC) in standardized defects not exceeding the critical size) without using bone substitution material or autogenous bone at the right inferior margin of the mandibles of six domestic pigs. Samples of the defect areas with membranes were harvested after 2 days (one animal), 4 and 8 (two animals, each) and 12 weeks (one animal), respectively. The healing of bone defects was completed in all animals after 12 weeks. Nonresorbable barriers prevented the soft tissue in-growth into standardized defects. Thinner layers of fibrous tissue were seen underneath the dense and rigid barriers (dPTFE, titanium) when compared with collagen and PLPG/LPGTC, in which soft-tissue plugs occupied the crestal defect portion. PLPG-/LPGTC-barriers underwent structural changes after 4 weeks and revealed blistered central layers, whereas structural changes were not evident in nonresorbable barriers. The degradation of PLPG-/LPGTC-membranes was present with in-growth of fibres, vessels, and cells. Using collagen or synthetic polymer barriers for GBR, the application of bone or bone substitutes to prevent membrane prolapse into the defect is suggested.