Comparison of clinical outcomes following CuT-380A insertion in postplacental period with interval insertion

Background: Postplacental intra-uterine device has many benefits like providing contraception immediately after childbirth, non-interference with lactation and high efficacy. However, concerns about its safety have led to decreased use of this method of contraception. Hence, this study aims to compare the complication rates following insertion of immediate postplacental IUCD (PPIUCD) with interval insertion.Methods: This is a prospective study conducted under the Department of Obstetrics and Gynaecology in PGIMER, Chandigarh. 196 women were included in the study. Women were divided in two groups, those who were inserted with immediate postplacental IUCD versus those who had IUCD insertion in interval period. The two groups were followed up for a period of 6 months and complications were recorded. The PPIUCD group was further subdivided into 2 subgroups based on mode of delivery, vaginal delivery and caesarean section. These PPIUCD subgroups were also compared.Results: There was no statistically significant difference in the incidence of pelvic pain, infection, abnormal uterine bleeding and expulsion between the PPIUCD and interval group. However, when the PPIUCD subgroups were compared, it was seen that no woman in caesarean section subgroup had expulsion of IUCD whereas 9.8% women had expulsion in the vaginal delivery PPIUCD subgroup.Conclusions: Postplacental and interval IUCD seem to be comparable for the incidence of various complications. However, intra-caesarean PPIUCD insertion seems to have a much lower expulsion rate as compared to vaginal delivery PPIUCD insertion

Outcome of pregnancy following IVF/IUI complicated by ovarian torsion: case reports

Ovarian torsion though uncommon after in vitro fertilization (IVF)/ intrauterine insemination (IUI), but if not diagnosed early can lead to ischemic necrosis of the ovary. The reported incidence of ovarian torsion after IVF/IUI is 0.025-0.2% and is primarily attributed to controlled ovarian stimulation (COS). Here we present three case reports of ovarian torsion after IVF/IUI reported in a government hospital, India. The first case was referred to our institute after IVF with acute onset abdominal pain. Diagnosis of ovarian torsion was made. In this patient, ovaries could be salvaged by early diagnosis and intervention and she even delivered a 2.95 kg girl baby in the same pregnancy. The second case also followed IVF done in our institute and by early diagnosis and intervention, we could salvage the ovary. The third case followed IUI, but due to delayed presentation, the patient had to undergo ipsilateral salpingo-oopherectomy.  A total of 1562 IUI and 98 IVF were done at our institute last year, of which only one case each of IUI and IVF landed up in ovarian torsion. The significance of this article is to discuss the diagnosis and management of ovarian torsion and to reiterate the importance of early diagnosis and management

Effect of GnRH antagonist on follicular development and uterine biophysical profile in controlled ovarian stimulation

Background: Objective of current study was to assess the effect of GnRH antagonist on follicular development, premature luteinization, uterine biophysical profile and pregnancy rate in controlled ovarian stimulation with clomiphene and gonadotropins for intrauterine insemination in women with unexplained infertility.Methods: Randomised controlled trial. Minimal stimulation protocol with or without GnRH antagonist was compared. Setting: Infertility clinic, PGIMER, Chandigarh. Patients: Couples with unexplained infertility, age of female partner between 20-39 years. Intervention: GnRH antagonist 0.25 mg since follicle size 14 mm till hCG administration. Main outcome measures: Follicle characteristics, premature luteinisation, uterine biophysical profile and pregnancy rate.  Results: The mean number of follicles recruited in group A was 2.32 ± 1.01 while that in group B (receiving GnRH antagonist) it was 4.10 ± 1.69. Statistically significant increase in total biophysical profile score was observed in periovulatory phase in the antagonist group. 40% women in group A had premature luteinization whereas only 4% women in group B suffered from premature luteinization. 20% women who received GnRH antagonist conceived against only 6% in group A, this difference however was not statistically significantConclusions: GnRH antagonist has a role in increasing the number of follicles recruited. Furthermore, GnRH antagonist can improve the total uterine biophysical profile score by improving the endometrial thickness, endometrial pattern, blood flow and decreasing the impedance to the blood flow in uterine artery. The drug can potentially help in improving pregnancy rates by decreasing the rate of premature luteinisation. 

Assessment of outcome of trial of labour after caesarean in a tertiary hospital based setting: prospective observational study

Background: Aim of this study was to determine the success rate of vaginal birth after caesarean (VBAC) in Indian women, identify the factors that predict its success, and assess the maternal and neonatal outcomes following a trial of labour after caesarean (TOLAC). Methods: A prospective observational study involving women with one  previous lower segment caesarean section (LSCS) who were admitted for TOLAC between January 2019 and June 2020 at Department of Obstetrics and Gynaecology, Post Graduate Institute of Medical Education and Research, Chandigarh, India. There were 124 women with previous LSCS who opted for TOLAC. Results: During the study period, 124 women with previous LSCS who opted for TOLAC were included, of whom 68 (54.8%) had successful VBAC and 56 (45.2%) had failed TOLAC. The induction of labour (IOL) rate in the study was 69.4%, and 30.6% of women had spontaneous onset of labor. VBAC rates were significantly higher in women who went into labour spontaneously (84.2% vs. 15.8%). Maternal complication rates were comparable, whereas the neonatal complication rate was significantly higher in neonates born by CS (51.7% vs. 30.8%), with a greater incidence of low birthweight (LBW) and transient tachypnea in the newborn (TTNB). Conclusions: TOLAC can be considered a safe option for women with a previous caesarean when combined with vigilant and stringent labour monitoring, despite the use of IOL agents

Clinical significance of ovarian stromal blood flow in assessment of ovarian response in stimulated cycle for in vitro fertilization

Background: Several ultrasound parameters have been examined to predict the ovarian response to gonadotropins. The only parameter that has been conclusively proven to predict ovarian response is the antral follicle count. It has been suggested that ovarian blood flow may play a crucial role in the development of ovarian follicles. The present study was planned to prospectively analyse the effect of ovarian stromal blood flow on ovarian responsiveness in terms of number of oocytes retrieved in stimulated cycle for IVF.Methods: Fifty subjects between 22 to 37 years of age with male factor, tubal factor or unexplained infertility underwent controlled ovarian stimulation by the standard “Long protocol”. Ovarian stromal blood flow was recorded on baseline transvaginal sonography on day 2 or 3 of cycle and was correlated with number of oocytes retrieved in IVF cycle.Results: The ovarian stromal blood flow was found to be negatively correlated with age. The number of follicles formed in a subject after stimulation with gonadotropins was negatively correlated with ovarian stromal resistance index and pulsatility index.Conclusions: Ovarian blood flow predicts ovarian responsiveness and hence provides a non-invasive and cost effective prognostic factor of IVF outcome

Endometrial hyperplasia and tubal ectopic: a correlation

Anovulation due to polycystic ovarian syndrome (PCOS) is one of the causes of endometrial hyperplasia in infertile women. Tubal ectopic apart from tubal factors can also be the result of hampered endometrial receptivity in these women which could be due to disturbed hormonal mileu, endometrial hyperplasia at cornua thereby interfering with transport of embryo from fallopian tube to uterus, or could be because of mechanical damage caused while taking endometrial biopsy. We are presenting case series of eight women of PCOS who presented to infertility clinic within two years with history of ectopic pregnancy or had subsequent ectopic pregnancy (after taking endometrial biopsy) with histopathology report of endometrial hyperplasia with or without atypia were enrolled. Out of 1200 PCOS women presenting to infertility clinic, eight women had coexistence of both endometrial hyperplasias and ectopic pregnancy. It is rare to find endometrial hyperplasias causing ectopic pregnancy. The causative factor in these cases could be the faulty endometrium by not being receptive thereby causing the embryo to implant in the fallopian tube or the tubes due to subtle infection secondary to repeated endometrial evaluation

A novel approach in non-surgical management of tubal ectopic: combination of minimally invasive technique under ultrasound guidance with systemic methotrexate based on initial beta-HCG levels

Background: Single dose methotrexate is the most preferred method of non-surgical management of unruptured tubal ectopic. A 2-dose regimen is suggested to treat tubal ectopic with higher trophoblastic cell load. Minimally invasive technique of ultrasound guided intracardiac KCL instillation along with systemic methotrexate has been in use even for live ectopic pregnancy. Objective of the study was to evaluate the success rate of single dose regimen of MTX (Methotrexate), 2-dose regimen of MTX and ultrasound guided instillation of intracardiac KCl in three different cohort of unruptured tubal ectopic pregnancy with an attempt to increase success of non-surgical management.Methods: Fifty-eight women with unruptured tubal ectopic pregnancy were assigned to treatment protocols according to the initial β-HCG levels and presence/absence of FCA (fetal cardiac activity). Group 1: presence of FCA in the tubal ectopic; Group 2: initial β-HCG ≤5000 IU/ml; Group 3:  initial β-HCG ≥5000 IU/ml without FCA. Women in group 1 were treated with ultrasound guided instillation of intracardiac KCl combined with systemic MTX. While women in group 2 were administered single dose regimen of MTX and group 3 received 2-dose regimen of MTX.Results: Overall success rate of non-surgical management was 89.3% across all groups. Success rate in Group 1 was 78.6%. Success rate was 93.1% in group 2 while 92.3% in group 3. Rupture rate was 1.7% in the present study.Conclusions: For non-surgical management categorizing and treating is an option with good result. Women with presence of cardiac activity can opt for non-surgical option with likely resolution in 78% cases

Disseminated peritoneal leiomyomatosis: a rare entity with diagnostic conundrum

Disseminated peritoneal leiomyomatosis (DPL) is a rare, usually benign disease primarily affecting premenopausal women. It is signalized by multiple smooth muscle nodules which grossly or radiologically may simulate peritoneal carcinomatosis or disseminated intraabdominal malignancies. A case study of 45 year female who presented with DPL after 8 years of hysterectomy is reported here

Update on management of polycystic ovarian syndrome for dermatologists

Polycystic ovarian syndrome (PCOS) is the commonest endocrine disorder in women having wide range of clinical manifestation. These women may present with reproductive, dermatological, metabolic, psychological, or neoplastic implications from adolescence to menopause. The common dermatological manifestations include hirsutism, acne, alopecia, or acanthosis nigricans. Women presenting with these dermatological manifestations must be evaluated for PCOS. A multidisciplinary team approach involving a reproductive endocrinologist, dermatologist, psychologist/psychiatrist, dietician, and sometimes a bariatric surgeon should be undertaken for long-term management of these patients. Unless metabolic and underlying endocrinal disturbances arecorrected and simultaneous life-style modification is adopted, cosmetic treatment would give only temporary relief