Supplementation with human menopausal gonadotropin in the gonadotropin-releasing hormone antagonist cycles of women with high AMH: Pregnancy outcomes and serial hormone levels

ObjectiveTo evaluate the value of using both HMG and recombinant FSH (r-FSH) in the GnRH antagonist protocol for women with high AMH.Materials and methodsThis retrospective, single-center cohort study was conducted from January 2013 to December 2018. Of 277 GnRH antagonist IVF/ICSI cycles in women with anti-Mullerian hormone (AMH) ≥5 μg/L, 170 cycles receiving the combination of r-FSH and HMG (77 with HMG added at the beginning of the GnRH antagonist cycle and 93 with HMG added after GnRH antagonist administration) and 107 cycles receiving r-FSH alone were analyzed. The dynamic hormone profiles and embryonic and clinical outcomes of the patients were evaluated.ResultsWe observed significantly lower serum LH levels in the r-FSH + HMG groups during ovarian stimulation. The serum estradiol and progesterone levels were lower in the r-FSH + HMG groups on the trigger day. Nevertheless, there were no significant differences with respect to the number of oocytes retrieved, maturation, fertilization, blastocyst formation rate or ovarian hyperstimulation syndrome (OHSS). The implantation and live birth rates were increased in the r-FSH + HMG groups compared with the r-FSH alone group, with no statistical significance.ConclusionsHMG for LH supplementation in the GnRH antagonist protocol for patients with high AMH is not significantly superior to r-FSH alone in terms of ovarian response and pregnancy outcome. Nevertheless, HMG supplementation might be appropriate for women with an initially inadequate response to r-FSH or intracycle LH deficiency.     

Gonadotrophin-releasing hormone antagonists for assisted conception: a Cochrane review

Gonadotrophin-releasing hormone (GnRH) antagonists suppress gonadotrophin secretion resulting in dramatic reduction in treatment cycle duration. Assuming comparable clinical outcomes, these benefits may justify changing the standard long GnRH agonist protocol to GnRH antagonist regimens. To evaluate the evidence, databases (e.g. Cochrane Library, MEDLINE, EMBASE) were electronically searched, hand searches were performed, and manufacturers in the field were contacted. Twenty-seven randomized controlled trials (RCT) fulfilled inclusion criteria for comparison of GnRH antagonist with long GnRH agonist protocol. Clinical pregnancy rate and ongoing pregnancy/live-birth rate were significantly lower in the antagonist group (P = 0.009; OR = 0.83, 95% CI 0.72-0.95 and P = 0.02; OR = 0.82, 95% CI 0.68-0.97 respectively). Conversely, incidence of severe OHSS was significantly reduced with the antagonist protocol (P = 0.01; OR = 0.60, 95% CI 0.40-0.88), and interventions to prevent OHSS were administered more frequently in the agonist group (P = 0.03; OR = 0.43, 95% CI 0.20-0.92). Concluding, GnRH antagonist protocols are short, simple, with good clinical outcomes and significant reduction in severe OHSS incidence and gonadotrophin amount; however, the lower pregnancy rate compared with the GnRH agonist long protocol necessitates counselling subfertile couples before recommending change from GnRH agonist to antagonist.     

Adding human menopausal gonadotrophin to antagonist protocols – is there a benefit?

The objective of this retrospective analysis was to compare the clinical outcomes of recombinant FSH (r-FSH) with combination r-FSH plus human menopausal gonadotrophin (HMG) protocols in a large private practice using a single IVF laboratory, from 2001 to 2003. Patients underwent ovarian stimulation by standard gonadotrophin-releasing hormone (GnRH) antagonist protocol using r-FSH or combination r-FSH plus HMG. When two or more follicles had attained a minimum mean diameter of 20 mm, follicular triggering was achieved with either recombinant HCG (r-HCG; Ovidrel, 250 microg s.c.) or urinary HCG (u-HCG; 10,000 IU i.m.). The main outcome measures were number of oocytes retrieved and clinical pregnancy rate. There was a lower percentage of cancelled cycles and an increased number of oocytes retrieved, mature oocytes, oocytes that fertilized, embryo that cleaved and a tendency towards higher clinical pregnancy rates in patients treated with r-FSH alone compared with those treated with r-FSH plus HMG. Patients treated with r-FSH plus HMG had lower miscarriage rates and the live birth rate was similar in both treatment groups. In conclusion, irrespective of age, using a treatment regimen consisting of a combination of HMG plus r-FSH was not beneficial compared with r-FSH alone in patients using a GnRH antagonist protocol.     

Air fluid versus fluid-only models of embryo catheter loading: a systematic review and meta-analysis

The objective of this systematic review was to determine the beneficial or detrimental effect of using air bubbles to bracket the embryo-containing medium during embryo transfer. To test this theory, a meta-analysis of randomized trials comparing air fluid versus fluid-only methods was performed. The primary outcome measures were live birth, ongoing and clinical pregnancy rates. The secondary outcome measures were the rates of implantation, miscarriage, multiple and ectopic pregnancies and retained embryos. Electronic (e.g.PubMed, EMBASE, Cochrane Library) and hand searches of the literature revealed two included studies (298 women). Meta-analysis was conducted using the Mantel-Haenszel method (fixed-effect model). For the primary outcome measures, there were no significant differences between the two methods with regards to live birth (OR = 1.34; 95% CI = 0.59-3.07), ongoing pregnancy (OR = 1.34; 95% CI = 0.59-3.07) and clinical pregnancy (OR = 1.13; 95% CI = 0.70-1.83) rates. For the secondary outcomes, there were no significant differences between the two groups. In conclusion there is insufficient evidence to suggest that the fluid-only method is superior to the use of air brackets during embryo loading. There is a need for well-designed and powered randomized trials to determine any possible benefit to either method.     

Meta-analysis of GnRH antagonist protocols: do they reduce the risk of OHSS in PCOS?

This systematic review and meta-analysis investigated whether gonadotrophin-releasing hormone (GnRH) antagonist protocols reduce the risk of ovarian hyperstimulation syndrome (OHSS) in women with polycystic ovary syndrome undergoing IVF compared with the long agonist protocol. Searches were conducted on MEDLINE, EMBASE, Cochrane Library, National Research Register and ISI Conference Proceedings. Primary outcome was OHSS incidence. Secondary outcomes were total duration and dose of gonadotrophin, number of oocytes retrieved and clinical pregnancy and miscarriage rates. A total of 966 women were included in nine randomized controlled trials. There was inconsistency in definition, classification of severity and reporting of the OHSS rate. There was no difference in the incidence of severe OHSS in the antagonist group compared with the long agonist group (relative risk 0.61; 95% CI 0.23 to 1.64). However, when all moderate and severe OHSS cases were pooled, the antagonist protocol was associated with significantly lower risk of OHSS (relative risk 0.60; 95% CI 0.48-0.76; P<0.0001). A possible reduction in the incidence of severe OHSS with the GnRH antagonist protocol should be viewed with caution since the data is inconclusive. Larger randomized trials with adequate sample size and standardized definition, classification and diagnosis of OHSS remain necessary.     

Effect of passive uterine straightening during embryo transfer: a systematic review and meta-analysis

BACKGROUND: Part of the success of ultrasound-guided embryo transfer has been associated with the beneficial effect of uterine straightening by passive bladder distention. Even so, this has not been properly analysed in the literature. METHODS: This is a systematic review and meta-analysis of prospective, randomised, controlled trials, comparing embryo transfer with a full versus empty bladder. Electronic (e.g. PubMed, EMBASE, Cochrane Library) and hand searches were performed to locate trials. Primary outcomes were live-birth, ongoing and clinical pregnancy rates. Secondary outcomes were rates of implantation, miscarriage, multiple and ectopic pregnancies, and retained embryos. Also, the ease of transfer, need for instrumental assistance, and presence of blood on the catheter tip were evaluated. Four studies were identified, of which 1 study was excluded. Meta-analysis was conducted with the Mantel-Haenszel method, utilising the fixed-effect model. RESULTS: For the primary outcome measures, no data was available for the LBR rate. There was a significantly higher chance of an ongoing pregnancy [OR=1.44 (95% CI=1.04-2.04)] and clinical pregnancy [OR=1.55 (95% CI=1.16-2.08)] with a full bladder. For the secondary outcomes, there was a significantly greater incidence of difficulty, or need for instrumental assistance, with an empty bladder. Other outcome measures were not significantly different. CONCLUSION: There is evidence in the literature advising to fill the bladder prior to embryo transfer.     

Fertility outcomes of IVF/ICSI after Caesarean section: a cohort study

Research questionThe study objective was to evaluate the impact of a previous Caesarean section on fertility outcomes in women undergoing IVF/intracytoplasmic sperm injection (ICSI).DesignA retrospective cohort study was designed that included 1793 women undergoing IVF/ICSI who had had a previous delivery from January 2015 to December 2016. The primary outcome was live birth. Secondary outcomes were implantation, clinical pregnancy, miscarriage, ectopic pregnancy, multiple pregnancy and perinatal complications.ResultsOf the 1793 women included, 796 had had a previous Caesarean section and 997 a previous vaginal delivery. Propensity score matching in a 1:1 ratio resulted in 538 women per group. Compared with women with a previous vaginal delivery, women with a previous Caesarean section had a lower live birth rate (30.1% versus 38.1%, odds ratio [OR] 0.70, 95% confidence interval [CI] 0.54–0.90) and a higher miscarriage rate (25.9% versus 17.5%, OR 1.65, 95% CI 1.06–2.56). Among other secondary outcomes, implantation rates were 32.9% and 37.1% (OR 0.83, 95% CI 0.69–1.01), and clinical pregnancy rates were 42.4% and 46.8% (OR 0.84, 95% CI 0.66–1.06), in the Caesarean section group and vaginal delivery group, respectively. There were no statistically significant differences in terms of ectopic pregnancy, multiple pregnancy or perinatal outcomes between the groups. Further adjustment for confounders did not change the result of the primary outcome (OR 0.64, 95% CI 0.49–0.84).ConclusionsWomen undergoing IVF/ICSI who have had a previous Caesarean section have a lower live birth rate and a higher miscarriage rate than those with a previous vaginal delivery.     

The routine use of gonadotropin-releasing hormone agonists prior to in vitro fertilization and gamete intrafallopian transfer: a meta-analysis of randomized controlled trials.

OBJECTIVE: To assess the efficacy of gonadotropin-releasing hormone agonists (GnRH-a) used in ovulation induction for in vitro fertilization and embryo transfer (IVF-ET) and gamete intrafallopian transfer (GIFT). DESIGN: Meta-analysis of 10 trials comparing treatment cycle outcomes after GnRH-a (n = 914) with other ovulation induction protocols (n = 722) and 7 trials comparing outcomes after short flare-up (n = 368) with longer suppression (n = 476) GnRH-a protocols. MAIN OUTCOME MEASURES: The outcome of primary interest was clinical pregnancy rate (PR) per treatment cycle commenced. Data describing the amount of gonadotropin used, cycle cancellation rate, clinical pregnancy per ET, and multiple pregnancy and abortion rates were also analyzed. RESULTS: Clinical PR per cycle commenced was significantly improved after GnRH-a use for IVF (common odds ratio [OR] 1.80, 95% confidence interval [CI] 1.33 to 2.44) and GIFT (common OR 2.37, 95% CI 1.24 to 4.51). Clinical PR per embryo transfer was also significantly improved with GnRH-a use (common OR 1.40, 95% CI 1.01 to 1.95). Cycle cancellation was decreased (common OR 0.33, 95% CI 0.25 to 0.44), whereas spontaneous abortion rate was similar with and without GnRH-a use. Cycle cancellation and PRs after short flare-up and longer suppression protocols were similar between groups. CONCLUSIONS: This meta-analysis supports the routine use of GnRH-a for IVF and GIFT. Further research is needed, however, to assess the potential for increased rates of multiple pregnancy and ovarian hyperstimulation syndrome, which may be associated with this treatment.     

Use of GnRH antagonists in ovarian stimulation for assisted reproductive technologies compared to the long protocol

The use of GnRH antagonists has revolutionized ovarian stimulation for assisted reproduction. Two GnRH antagonists are clinically available, namely, cetrorelix and ganirelix. Several studies have directly compared these new stimulation protocols against the long GnRH agonist protocol. To evaluate whether there is a reduction in cases of ovarian hyperstimulation syndrome (OHSS) and/or a reduction in pregnancy rates, a meta-analysis was performed. There was a significant reduction of OHSS cases in the cetrorelix studies (odds ratio, OR, 0.23; 95% confidence interval, CI, 0.10-0.54), but no reduction for ganirelix (OR 1.13; 95% CI 0.24-5.31). The incidence of OHSS degree III cases was reduced in the cetrorelix protocols as compared to the long protocol to a nearly significant degree (OR 0.26; 95% CI 0.07-1.01). Ganirelix did not reduce the incidence of OHSS degree III at all (OR 1.08; 95% CI 0.27-4.38). The pregnancy rate per cycle was significantly lower in the ganirelix protocols than in the long protocol (OR 0.76; 95% CI 0.59-0.98). The studies using cetrorelix showed quite similar, not significantly different results for the antagonist and the long protocol groups for the pregnancy rate per cycle (OR 0.91; 95% Cl 0.68-1.22). From the data one can conclude that cetrorelix but not ganirelix will reduce the incidence of cases of OHSS and that cetrorelix but not ganirelix will result in the same pregnancy rates as the long protocol. Several possibilities to explain this phenomenon are discussed.     

Optimal lead follicle size in letrozole human menopausal gonadotrophin intrauterine insemination cycles with and without spontaneous LH surge

Research questionWhat is the optimal lead follicle size in letrozole, human menopausal gonadotrophin and intrauterine insemination (IUI) cycles with and without spontaneous LH surges?DesignThis retrospective cohort study included 3797 letrozole HMG IUI cycles between January 2010 and May 2021. All cycles were divided into two groups: the HCG trigger group (trigger day LH ≤15 mIU/ml) and the spontaneous LH surge group (trigger day LH >15 mIU/ml). These two groups were subdivided into smaller groups based on the diameter of the follicles. The primary outcome measure was clinical pregnancy rate. Logistic regression analysis was conducted to explore other risk factors.ResultsIn the HCG trigger group, the clinical pregnancy rate varied significantly, with rates of 20.8%, 14.9% and 11.8% for the 16.1–18.0, 18.1–20.0 and 20.1–22.0 mm groups, respectively (P = 0.005). In the spontaneous LH surge group, the pregnancy rate of follicles within 14.1–16.0 mm was significantly higher than that of follicles within 20.1–22.0 mm (adjusted OR 0.533, 95% CI 0.308 to 0.923, P = 0.025). Also, patients with two lead follicles were 2.569 times more likely to achieve a clinical pregnancy than those with only one lead follicle (adjusted OR 2.569, 95% CI 1.258 to 5.246, P = 0.010). The duration of infertility was also found to be a common influencing factor in both groups.ConclusionsThe optimal lead follicle size was between 16.1 and 18.0 mm in HCG-triggered letrozole HMG IUI cycles. If the lead follicle size is relatively small (14.1–18.0 mm) when a spontaneous LH surge occurs, there is no need to cancel the IUI cycle.     

氯米芬联合HMG在促排卵人工授精周期中防止过早内源性黄体生成素峰的有效性研究

目的:探讨氯米芬(CC)联合人绝经尿促性腺激素(HMG)在原因不明性不孕患者促排卵人工授精(COS/IUI)周期中防止过早内源性黄体生成素(LH)峰的有效性,为提高IUI妊娠率提供临床依据。方法:将2012年1月至2015年1月在我院生殖中心因原因不明性不孕行COS/IUI的144例患者随机分为观察组和对照组,每组72例。观察组给予CC+HMG方案促排卵,对照组单用HMG促排卵。观察两组的过早LH峰发生率、临床妊娠率、未破裂黄素化卵泡(LUF)发生率、周期取消率、卵巢过度刺激综合征(OHSS)发生率、多胎妊娠率,以及HCG注射日子宫内膜厚度、E2水平、成熟卵泡数。结果:观察组的过早LH峰发生率(5.8%)及LUF发生率(8.7%)显著低于对照组(17.9%、20.9%,P0.05),E2水平[(379.4±127.8)pg/ml]、成熟卵泡数(2.43±0.75)、临床妊娠率(21.7%)均高于对照组[(288.8±97.3)pg/ml,1.71±0.78,9.0%](P0.05);两组的周期取消率、子宫内膜厚度、OHSS发生率及多胎妊娠率比较,差异均无统计学意义。结论:原因不明性不孕患者COS/IUI过程中,CC+HMG促排卵方案可以有效防止过早内源性LH峰的发生,并提高IUI的临床妊娠率。     

<Emphasis Type="Italic">In vitro</Emphasis> fertilization outcome in severe ovarian hyperstimulation syndrome: An age-matched contemporaneous control study

Aim:   Ovarian hyperstimulation syndrome (OHSS) is a potentially life-threatening, iatrogenic complication of assisted reproduction and has been associated with poor in vitro fertilization outcome. The aim of the present study was to evaluate the pregnancy rate and outcome following severe OHSS, at a single center over a three-year period.
Methods:   The incidence of severe OHSS at the IVF Center, National University of Singapore, in Singapore, was 4% (48 cases over 1200 cycles) during the period of 1997–2000. The present retrospective study compared 48 cases of severe OHSS to 144 age-matched, contemporaneous controls without OHSS.
Results:   The total gonadotropin required for severe OHSS group was found to be lower than for that of controls (2664.06 ± 768.29 IU vs 3349.58 ± 2003.73 IU), although duration of stimulation was similar. The OHSS group was associated with a fivefold increase (OR 5.293, 95% CI: 2.116–13.238) in pregnancy rate compared to controls (87.5% vs 56.9%; P  < 0.05). Late OHSS was more common (38/48 cases) and had a pregnancy rate of 97% per embryo transfer. There was no significant difference in the multiple pregnancy (54% vs 48%; P  > 0.05) and miscarriage rates (14% vs 7.3%; P  > 0.05) between the groups.
Conclusion:   Severe OHSS at our center were mostly late onset. The pregnancy rate was significantly higher, but multiple pregnancy and miscarriage rates were not significantly increased when compared to the age-matched contemporaneous controls. (Reprod Med Biol 2005; 4 : 207–211)     

Ovulation induction in the new millennium: recombinant follicle-stimulating hormone versus human menopausal gonadotropin.

The renewed interest in luteinizing hormone (LH), together with limited and decreasing health resources, make essential the comparison of high-cost, recombinant follicle-stimulating hormone (rFSH) preparations (devoid of LH) and human menopausal gonadotropin (hMG) in terms of clinical efficacy. All published, randomized controlled trials (RCTs) comparing rFSH versus hMG under different protocols of stimulation were examined. Eight true RCTs were included in this meta-analysis, recruiting 2031 participants. Data for ongoing pregnancy/live birth rate, clinical pregnancy rate, miscarriage rate, multiple pregnancy rate and ovarian hyperstimulation syndrome (OHSS) were extracted, and odds ratios (ORs) and 95% confidence intervals (CIs) were calculated with the use of a fixed-effects model. Data for the meta-analysis were combined using RevMan software (using the Mantel-Haenszel method). Pooling the results of these RCTs showed no significant difference between rFSH and hMG regarding the different outcomes: ongoing pregnancy/live birth rate, OR 1.18 (95% CI 0.93-1.50); clinical pregnancy rate, OR 1.2 (95% CI 0.99-1.47), miscarriage rate, OR 1.2 (95% CI 0.70-2.16); multiple pregnancy rate, OR 1.35 (95% CI 0.96-1.90); incidence of moderate/severe OHSS, OR 1.79 (95% CI 0.74-4.33). However, there was significant reduction in the amount of gonadotropins in favor of hMG over rFSH. There was no significant heterogeneity of treatment effect across the trials. In conclusion, there is no clinically significant difference between hMG and rFSH in in vitro fertilization/intracytoplasmic sperm injection cycles. Decision-makers should establish their choice of one drug over the other based on the most up-to-date evidence available.     

Ovulation induction in the new millennium: Recombinant follicle-stimulating hormone versus human menopausal gonadotropin

The renewed interest in luteinizing hormone (LH), together with limited and decreasing health resources, make essential the comparison of high-cost, recombinant follicle-stimulating hormone (rFSH) preparations (devoid of LH) and human menopausal gonadotropin (hMG) in terms of clinical efficacy. All published, randomized controlled trials (RCTs) comparing rFSH versus hMG under different protocols of stimulation were examined. Eight true RCTs were included in this meta-analysis, recruiting 2031 participants. Data for ongoing pregnancy/live birth rate, clinical pregnancy rate, miscarriage rate, multiple pregnancy rate and ovarian hyperstimulation syndrome (OHSS) were extracted, and odds ratios (ORs) and 95% confidence intervals (CIs) were calculated with the use of a fixed-effects model. Data for the meta-analysis were combined using RevMan software (using the Mantel–Haenszel method). Pooling the results of these RCTs showed no significant difference between rFSH and hMG regarding the different outcomes: ongoing pregnancy/live birth rate, OR 1.18 (95% CI 0.93–1.50); clinical pregnancy rate, OR 1.2 (95% CI 0.99–1.47), miscarriage rate, OR 1.2 (95% CI 0.70–2.16); multiple pregnancy rate, OR 1.35 (95% CI 0.96–1.90); incidence of moderate/severe OHSS, OR 1.79 (95% CI 0.74–4.33). However, there was significant reduction in the amount of gonadotropins in favor of hMG over rFSH. There was no significant heterogeneity of treatment effect across the trials. In conclusion, there is no clinically significant difference between hMG and rFSH in in vitro fertilization/intracytoplasmic sperm injection cycles. Decision-makers should establish their choice of one drug over the other based on the most up-to-date evidence available.     

The recurrence risk of adverse outcome in the second pregnancy in women with rheumatic disease1

OBJECTIVE: To study recurrence risks of adverse pregnancy outcome in the second pregnancy in women with rheumatic disease. METHODS: In a national population-based cohort study, women with rheumatic disease recorded from 1967 to 1995 in the Medical Birth Registry of Norway were compared with mothers without such diagnoses with regard to recurrence risks of adverse pregnancy outcomes in the second pregnancy. The odds ratios (ORs) of all outcomes were adjusted for maternal age, those of cesarean delivery for time period, and those of preeclampsia for interpregnancy interval. RESULTS: Women with rheumatic disease an dadverse pregnancy outcome in the first pregnancy had a statistically significant higher recurrence risk of the same event in the second pregnancy than women without rheumatic disease (preeclampsia: OR 2.22; 95% confidence interval [CI] 1.18, 4.19) (cesarean delivery: OR 1.52; 95% CI 1.05, 2.21) (preterm birth: OR 1.86; 95% CI 1.12, 3.11). In women with rheumatic disease diagnosed between the first and second births, a significantly increased recurrence risk of low birth weight occurred. Women with rheumatic disease also had a higher occurrence of markers for placental dysfunction (preeclampsia, preterm birth, or small for gestational age) in the second birth after any of these outcomes in the first birth (OR 1.35; 95% CI 1.02, 1.78) (35.1% versus 29.2%). CONCLUSION: The recurrence risk of an adverse outcome in the second pregnancy is increased in any woman, but was even higher in women with a rheumatic disease. These patients should be counseled accordingly, be closely monitored during pregnancy, and have access to appropriate subspecialists.     

Multiple cryopreservation–warming cycles,coupled with blastocyst biopsy,negatively affect IVF outcomes

Research questionDo multiple cryopreservation–warming cycles, coupled with blastocyst biopsy, negatively affect IVF outcomes?DesignPatients undergoing IVF with homologous single embryo transfer, and who underwent trophectoderm biopsy for preimplantation genetic testing for aneuploidy (PGT-A) between 2013 and 2017, were divided into three groups based on degree of embryonic micromanipulation: once-biopsied, once-cryopreserved (group BC, n = 2603), once-biopsied, twice-cryopreserved (group CBC, n = 95) and twice-biopsied, twice-cryopreserved (group BCBC, n = 15). The primary outcome was live birth; secondary outcomes included positive serum pregnancy test, clinical pregnancy and miscarriage.ResultsGroup CBC had a significantly lower chance of live birth (adjusted RR 0.57, 95% CI 0.41 to 0.79) and clinical pregnancy (adjusted RR 0.67, 95% CI 0.53 to 0.85) compared with group BC. Miscarriage rates were similar between groups BC and CBC (adjusted RR 1.3, 95% CI 0.64 to 2.7).ConclusionsMultiple cryopreservation–warming cycles, coupled with blastocyst biopsy, negatively affect IVF outcomes. Although PGT-A is thought to improve reproductive outcomes on a per transfer basis, caution must be exercised in counselling patients on the possibility of diminishing returns owing to further embryonic micromanipulation after an embryo has been cryopreserved.     

Pregnancy outcome of patients with pruritic urticarial papules and plaques of pregnancy.

OBJECTIVE: The study was designed to investigate obstetric risk factors and pregnancy outcome of patients with pruritic urticarial papules and plaques of pregnancy (PUPPP). METHODS: A population-based study comparing all pregnancies of women with and without PUPPP was conducted. Deliveries occurred during the years 1988-2002 at the Soroka University Medical Center. A multivariable logistic regression model was constructed in order to find independent risk factors associated with PUPPP. RESULTS: During a 15-year period, 159 197 deliveries took place. PUPPP complicated 42 (0.03%) of all pregnancies. Using a multivariable analysis, the following conditions were significantly associated with PUPPP: multiple pregnancies (odds ratio (OR) = 4.9, 95% confidence interval (CI) 1.7-14.1), hypertensive disorders (OR = 2.2, 95% CI 1.1-4.7), and induction of labor (OR = 7.6, 95% CI 4.0-14.5). Higher rates of 5-minute Apgar scores lower than 7 (OR = 8.0, 95% CI 4.4-14.9) and of cesarean deliveries (OR = 2.9, 95% CI 1.5-5.6) were noted in the PUPPP as compared to the comparison group. While investigating other perinatal outcome parameters such as oligohydramnios, intrauterine growth restriction, meconium-stained amniotic fluid and perinatal mortality, no significant differences were observed between the groups. CONCLUSION: Pruritic urticarial papules and plaques of pregnancy is a condition significantly associated with multiple pregnancies, hypertensive disorders, and induction of labor. Perinatal outcome is comparable to pregnancies without PUPPP.     

Association between HLA-DQA1, HLA-DQB1 alleles and risk of early pregnancy loss

AIM: The aim of the study is to identify HLA-DQA1, HLA-DQB1 allele and to assess the risk of early pregnancy loss of women, couples with reproductive failure in the first trimester of pregnancy in comparison with fertile women, couples. The study group (B) enrolled 61 couples with reproductive failure and the control group (C) enrolled 20 fertile couples with at least 2 children. METHOD: HLA-DQA1 gene typing was performed using PCR-sequence-specific primer (SSP) on the high resolution level according to established procedure of labeling and using the detection kit (FASTYPE DQASSP Typing, FASTYPE DQA "High Resolution" Typing Sheet) purchased from Bio-Synthesis (USA). RESULTS: In female patient the highest risk quotient was associated with alleles HLA-DQA 01101/0105 OR 7.19 (95% CI 1.18-5.23; p=0.03) and HLA-DQB5 OR 3.67 (95% CI=1.11-12.0; p=0.037). The lowest but statistically significant risk of pregnancy failure in this group was related to allele HLA-DQB6 OR 0.48 (95% CI=0.22-1.04; p=0.087). In patient and control couples the significantly increased risk of pregnancy failure was related to the frequency of HLA-DQB5 allele OR 2.3 (95% CI 1.09-4.82; p=0,035). The lowest risk quotient in the patient couples was associated with HLA-DQ 0302/0303 allele OR 0.44 (95% CI 0.14-1.36; p=ns). SUMMARY: HLA-DQA and HLA-DQB allele might influence pregnancy outcome in the Polish population, but further studies are necessary in this regard.     

Coasting,embryo development and outcomes of blastocyst transfer: a case–control study

This study compared the effect on blastocyst development and clinical outcome of coasting in women at increased risk of moderate–severe ovarian hyperstimulation syndrome (OHSS; n = 389) with a control group matched for age and basal FSH that did not undergo coasting (n = 386) in IVF/intracytoplasmic sperm injection (ICSI) cycles. The main outcome measures were rate of blastocyst development and live birth. More cycles progressed to the blastocyst stage in the coasted group (n = 169) compared with the control group (n = 83; 43.4% versus 21.5%; P < 0.001). The biochemical pregnancy, clinical pregnancy and live birth rates were similar (46.5% versus 42.0%; 40.6% versus 37.8%; 31.6% versus 30.1%). The duration of coasting up to 4 days did not affect progression to blastocyst stage. The multivariate model showed that coasting (OR 1.73, P = 0.004) and the number of oocytes retrieved (OR 1.17, P = 0.001) were positively correlated with blastocyst formation. Coasting, a measure to reduce the risk of OHSS, does not impair blastocyst development or clinical outcome. Coasting should remain an effective measure to prevent OHSS.     

Comparison of the effect of caseload midwifery program and standard midwifery-led care on primiparous birth outcomes: A retrospective cohort matching study

BackgroundThe effectiveness of continuity of care during the perinatal period is well documented, but implementing continuity of care model to practice requires evaluation.AimTo evaluate the effect of a caseload midwifery program (CMP) on birth outcomes and rates of perinatal interventions at a metropolitan tertiary hospital in Australia, compared with standard midwifery-led care (SMC).MethodsThis was a retrospective, matched-cohort study. We extracted the data of 1000 nulliparous women from records of 19,001 women who gave birth at the hospital from 2011 to 2014. We used basic statistical tests to compare baseline demographic data, and logistic regression to calculate odds ratios, to evaluate maternal and neonatal outcomes.ResultsAdjusted regression analysis for the primary outcome showed that compared with women who received SMC, women who received care through CMP had an increased rate of normal vaginal birth (69% vs. 50%, OR = 1.79, 95%, CI = 1.38–2.32). Assessment of secondary outcomes showed that the women in CMP group had decreased rates of instrumental birth (15% vs. 26%, OR = 0.48, 95% CI = 0.35–0.66), episiotomy (23% vs. 40%, OR = 0.43, 95% CI = 0.33–0.57), epidural analgesia (33% vs. 43%, OR = 0.64, 95% CI = 0.50–0.83) and amniotomy (35% vs. 50%, OR = 0.56, 95% CI = 0.43–0.72). The CMP group also had greater rates of water immersion (54% vs. 22%, OR = 4.18, 95% CI = 3.17–5.5), physiological 3rd stage (7% vs. 1%, OR = 11.71, 95% CI = 3.56–38.43) and 2nd degree tear (34% vs. 24%, OR = 1.60, 95% CI = 1.21–2.11). There were no significant differences between the two groups for rates of other secondary outcomes including Caesarean section, cervical ripening procedures, third- and fourth-degree tears, postpartum haemorrhage and neonatal outcomes.ConclusionCMP care is associated with increased rate of normal vaginal birth which supports wider implementation of the model. In addition, using routinely collected data and a cohort matching design can be an effective approach to evaluate maternal and neonatal outcomes.