Category Archives: Human Reproduction

BACKGROUND

High-quality healthcare should be effective, safe and patient-centred. How important patient-centredness is in relation to effectiveness of fertility care has never been investigated. This study aimed to determine and compare the importance of patient-centredness, relative to pregnancy rates, to patients and physicians.

METHODS

A discrete choice experiment (DCE) was designed. Participants had to choose between hypothetical fertility clinics differing in following attributes: travel time; pregnancy rate (effectiveness); physicians' attitude; information on treatment; and continuity of physicians (the latter three represent patient-centredness). A total of 1378 patients and 268 physicians from eight Dutch and Belgian fertility clinics received the DCE-questionnaire. The attributes' relative importance was analysed using multinomial logistic regression. Additionally, patients' actual choice behaviour was investigated.

RESULTS

In total, 925 patients and 227 physicians participated. Pregnancy rates were relatively more important to physicians. Patients assigned more value to patient-centredness (P< 0.001) and were willing to trade-off a higher pregnancy rate for patient-centredness than physicians recommended them to do (P< 0.05). For example, patients considered pregnancy rates 1.5 times as important as an interested physician's attitude, whereas physicians considered this 2.4 times as important (P< 0.001). The willingness to trade-off pregnancy rate for this attitude was 9.8% for patients and 6.3% for physicians (P< 0.001). A lack of patient-centredness was the most cited non-medical reason for changing fertility clinics.

CONCLUSIONS

Patients and physicians put considerable value on pregnancy rates. However, physicians significantly undervalue the importance of patient-centredness to patients. Clinics aiming to optimize the quality of their services should be aware of the substantial importance their patients assign to patient-centredness.

BACKGROUND

Controlled ovarian hyperstimulation with intrauterine insemination (COH/IUI) is an established tool in medically assisted conception for many infertility factors. However, the proper timing of IUI after hCG trigger and the frequency of IUI are still debated. We aimed to examine the association between the cycle pregnancy rate (CPR) and: (i) single IUI timed at 36 ± 2 h post-hCG (pre- or post-ovulation) (ii) the number of IUI (single or double) for pre-ovulatory cases both aims in male, anovulatory and unexplained infertility.

METHODS

The study included a total 1146 first-stimulated cycles in infertile couples due to male factor, anovulation or unexplained infertility. Cycles were stimulated by clomiphine citrate (CC) or sequential CC–hMG or hMG and monitored by transvaginal ultrasound. When the leading follicle reached ≥18 mm mean diameter, 10000 IU hCG was given to trigger ovulation and IUI was timed for 36 ± 2 h later. Semen was processed and ovulation was checked at the time of IUI. Post-ovulatory cases received single IUI, while pre-ovulatory cases were sequentially randomized to receive either single or double IUI. The end-point of the cycle was CPR.

RESULTS

Overall CPR in the whole cohort was 10.1%. When ovulation was present before IUI, CPR was 11.7% compared with 6.7% when ovulation was absent [OR (95% CI): 1.85 (1.12–3.06), P = 0.015]. When this OR was computed according to infertility etiology, it was 1.26 (0.52–2.95) (P =0.82) for male factor infertility and 2.24 (1.23–4.08) (P = 0.007) for non-male factor infertility. Comparing the CPR for double versus single IUI in pre-ovulatory cases, the OR for all cycles was 1.9 (0.76–4.7) (P = 0.22), but according to etiology, it was 4.667 (0.9–24.13) (P = 0.06) in male factor and 1.2 (0.43–3.33) (P = 0.779) for non-male factors.

CONCLUSIONS

Single IUI timed post-ovulation gives a better CPR when compared with single pre-ovulation IUI for non-male infertility, whereas for male factors, pre-ovulation, double IUI gives a better CPR when compared with single IUI.

BACKGROUND

IVF treatments carry a high risk of twin pregnancy which confers a higher risk to the mother and child than singletons. Increased use of elective single embryo transfer (eSET) can reduce this twin rate. We aimed to utilize a previously published data set and statistical model based on routinely collected clinical data to predict the outcomes of policies that increase the proportion of eSET.

METHODS

The models allow simultaneous prediction of outcomes from double embryo transfer (DET) and SET. These models were used to predict outcomes for different scenarios using SET in both the initial (fresh) transfer and over a complete cycle (transfer of all embryos created, with cryopreservation). A total of 16 096 cycles (12 487 fresh and 3609 frozen) from 9040 couples treated between 2000 and 2005 were included in the final analyses.

RESULTS

For any transfer, SET has about a one-third lower live birth rate relative to DET: this can be partially mitigated by appropriate patient and treatment cycle selection, with several realistic policies performing similarly. However, if we consider complete cycles with embryo cryopreservation, it is possible for repeat SET to produce more live births per egg retrieval than repeat DET.

CONCLUSIONS

All patients receiving SET would have a higher chance of successful treatment in that cycle if they received DET. The selection of appropriate patients for SET can partially ameliorate the overall loss. For complete cycles, repeat SET could produce more live births per egg retrieval than repeat DET. All treatments involving SET will increase the number of treatments required to achieve a successful outcome and this extra treatment burden will be a significant barrier to the implementation of such treatments.

BACKGROUND

Torsion of the ovary is a rare but serious cause of gynecologic surgical emergency. Specific laboratory markers that support the preoperative diagnosis of ovarian torsion are not currently available in the clinical routine. The aim of this study was to investigate the diagnostic value of plasma D-dimer level as an early indicator of ovarian torsion in an experimental rat ovarian torsion model.

METHODS

Sixteen female adult Sprague–Dawley rats were used for this controlled experimental study. Eight rats in the sham operation group (Group I) underwent a surgical procedure similar to Group II but the ovary was not occluded. In Group II (eight rats), a torsion model was created by using atraumatic vascular clips just above and below the right ovary for a 2-h period of ischemia. Right ovaries were surgically removed at the end of the procedure in each group. Blood was sampled before and after operation to assess plasma D-dimer levels. The main outcome measure was ovarian histopathologic findings scores and plasma D-dimer levels.

RESULTS

There was no significant difference in pre-operative plasma D-dimer levels (0.5963 ± 0.2047 mg/l in Group I, 0.6344 ± 0.1348 mg/l in Group II, P = 0.815, Mann–Whitney U-test). However, mean plasma D-dimer value for Group II was significantly higher than that in the control group (1.2267 ± 0.3099 versus 0.6213 ± 0.2346 mg/l, respectively, Mann–Whitney U-test, P < 0.001), following 2 h of ovarian torsion. Ovarian tissue damage scores were also statistically significantly different among groups.

CONCLUSIONS

If the observations made in a rat model are extended to humans, plasma D-dimer measurement may be a valuable parameter in the early diagnosis of ovarian torsion.

BACKGROUND

Myolysis is one of the procedures that is claimed to provide significant improvement in myoma status without hysterectomy. Myolysis procedures have been generally performed via laparoscopy, and there are limited data on transvaginal radiofrequency (RF) myolysis. This study investigated the feasibility, efficacy and safety of transvaginal ultrasound-guided RF myolysis.

METHODS

Transvaginal ultrasound-guided RF myolysis was performed on 69 premenopausal women with symptomatic uterine myomas as an outpatient procedure. Outcomes were assessed 1, 3, 6 and 12 months after RF myolysis. Myoma volumes were measured by ulrasonography. Menorrhagia was evaluated by the number of soaked normal-sized sanitary products used per menstrual period and overall symptoms were evaluated using the symptom severity subscale of the uterine fibroids symptom questionnaire.

RESULTS

Mean (± SD) age of patients was 39.8 ± 6.5 years. Mean baseline volume of the dominant myomas was 304.6 ± 229.1 cm³ and its volume at 3 months following RF myolysis decreased compared with the previous examination (P = 0.002). An improvement of menorrhagia occurred 1, 3, 6 and 12 months after operation (all P < 0.001 versus baseline). Overall symptoms at 1, 3, 6 and 12 months after RF myolysis also improved (all P < 0.001 versus baseline). No major complications were observed or reported. After 12 months, three patients had successfully conceived and delivered and there were no complications during labor or delivery.

CONCLUSIONS

Transvaginal ultrasound-guided RF myolysis might be a safe, effective and minimally invasive outpatient procedure for uterine myoma in terms of size reduction, symptom improvement and safety.

BACKGROUND

Uterus transplantation (UTx) research aims towards the introduction of UTx as a treatment for uterine factor infertility. The rat model is the principal rodent model used and this study aims to assess the potential for pregnancy and to assess effects on pregnancy outcome.

METHODS

Female Lewis rats underwent hysterectomy and received syngeneic uterine transplants (with one horn removed) by end-to-side anastomosis between the common iliac vessels of the recipient and the graft. The graft was placed in an orthotopic position with anastomosis to the upper part of the native uterine horn and vagina to allow for pregnancy by mating. Controls had only one uterine horn removed. Mating and pregnancy frequencies, successful deliveries and pup weight trajectory were compared.

RESULTS

Pregnancy was achieved in rats after UTx with the pregnancy rate, number of pups and growth trajectory of pups being similar to controls. However, numbers of resorbed pregnancies and arrested parturitions were more common in the UTx group.

CONCLUSIONS

A model for orthotopic UTx was developed and pregnancies with live offspring were for the first time demonstrated in the rat model of UTx. The model will be useful in future studies of fertility after UTx.