Efficacy and safety of IVF/ICSI in patients with severe endometriosis after long-term pituitary down-regulation

Long-term pituitary down-regulation with a gonadotrophin-releasing hormone (GnRH) agonist for 3-6 months prior to IVF/intracytoplasmic sperm injection (ICSI) improves clinical pregnancy rates in endometriosis patients. However, some discussion about this treatment strategy still exists. This retrospective study from a tertiary-care university hospital examined the efficacy and safety of IVF/ICSI with and without long-term pituitary down-regulation in severe endometriosis patients (surgically confirmed American Society for Reproductive Medicine stages III and IV). All first IVF/ICSI treatment cycles between January 2009 and January 2012 were analysed. In patients treated with (n = 68) and without (n = 45) long-term pituitary down-regulation, 13 (19.1%) versus nine (20.0%) ongoing pregnancies after fresh embryo transfer (adjusted OR 0.58, 95% CI 0.18-1.86,) and 24 (35.3%) versus 10 (22.2%) ongoing pregnancies after fresh and cryopreserved embryo transfers (adjusted OR 1.62, 95% CI 0.60-4.38) were accomplished, respectively. Three complications (2.7%) and three recurrences (2.7%) were reported, only in patients treated with long-term pituitary down-regulation. The 1-year cumulative endometriosis recurrence rate was 7.3%. IVF/ICSI in patients with severe endometriosis is safe with low complication and recurrence rates. A favourable effect, albeit non-significant, of long-term pituitary down-regulation in achieving an ongoing pregnancy was observed only after including cryopreserved embryo transfers. Long-term pituitary down-regulation with a GnRH agonist for 3-6 months prior to IVF or intracytoplasmic sperm injection (ICSI) improves pregnancy rates in endometriosis patients. However, some discussion about this treatment strategy still exists. This retrospective study examined the efficacy and safety of IVF/ICSI with and without long-term pituitary down-regulation in severe endometriosis patients. All first IVF/ICSI treatment cycles between January 2009 and January 2012 were analysed. In patients treated with long-term pituitary down-regulation (n = 68) 13 (19.1%) ongoing pregnancies were accomplished after fresh embryo transfer and 24 (35.3%) after fresh including frozen embryo transfers. In patients treated without long-term pituitary down-regulation (n = 45), nine (20%) ongoing pregnancies were accomplished after fresh embryo transfer and 10 (22.2%) after fresh including frozen embryo transfers. Three complications (2.7%) and three recurrences (2.7%) were reported, only in patients treated with long-term pituitary down-regulation. This study showed that IVF/ICSI in patients with severe endometriosis is a safe procedure with low complication and recurrence rates. Long-term pituitary down-regulation with a GnRH agonist is more beneficial in achieving an ongoing pregnancy after including frozen embryo transfer cycles

Efficacy and safety of intrauterine insemination in patients with moderate-to-severe endometriosis

Performing intrauterine insemination (IUI) in moderate-to-severe endometriosis patients is not implemented in international guidelines, as only limited data exist on treatment efficacy and safety. This retrospective study examined the efficacy and safety of two IUI treatment strategies performed between January 2007 and July 2012 in moderate-to-severe endometriosis patients. Eight (40.0%) versus seven (15.6%) ongoing pregnancies were accomplished in patients undergoing IUI with ovarian stimulation (n = 20, 61 cycles) versus IUI without ovarian stimulation in the first three cycles followed by IUI with ovarian stimulation (IUI with natural/ovarian stimulation; n = 45, 184 cycles). Preceding long-term pituitary down-regulation tended to result in a higher ongoing pregnancy rate (adjusted HR 1.8) and a higher chance of endometriosis recurrence (adjusted HR 2.3). Eight (40.0%) versus 16 (35.6%) recurrences of endometriosis complaints were reported in patients receiving IUI with ovarian stimulation versus IUI with natural/ovarian stimulation. IUI might be a valuable treatment in moderate-to-severe endometriosis patients and IUI with ovarian stimulation should be offered over IUI with natural/ovarian stimulation. Preceding long-term pituitary down-regulation might positively influence the ongoing pregnancy rate and can be considered. Whether this treatment strategy can be structurally offered prior to IVF must be investigated in a randomized controlled trial. Performing intrauterine insemination (IUI) in moderate-to-severe endometriosis patients is not implemented in international guidelines, as only limited data exist on treatment efficacy and safety. This retrospective study examined the efficacy and safety of IUI performed between January 2007 and July 2012 in moderate-to-severe endometriosis patients (ASRM III-IV). Two treatment strategies were compared: IUI with ovarian stimulation (20 patients, 61 cycles and IUI without ovarian stimulation in the first three cycles followed by IUI with ovarian stimulation (45 patients, 184 cycles, IUI with natural/ovarian stimulation). Also, the additional effect of preceding long-term pituitary down-regulation was investigated. Eight (40.0%) and seven (15.6%) ongoing pregnancies were accomplished in patients undergoing IUI with ovarian stimulation and IUI with natural/ovarian stimulation (P = 0.05). Preceding long-term pituitary down-regulation with a gonadotrophin-releasing hormone (GnRH) agonist tended to result in a higher ongoing pregnancy rate (adjusted HR 1.8). Eight (40.0%) and 16 (35.6%) recurrences of endometriosis complaints were reported in patients undergoing IUI with ovarian stimulation and IUI with natural/ovarian stimulation. Preceding long-term pituitary down-regulation with a GnRH agonist tended to result in a higher chance of endometriosis recurrence (adjusted HR 2.3). Although IUI is not implemented in the current guidelines, IUI with ovarian stimulation could be a valuable treatment in moderate-to-severe endometriosis patients. Long-term pituitary down-regulation with a GnRH agonist prior to the first IUI treatment cycle might positively influence the ongoing pregnancy rate and can be considered. Whether this treatment strategy can be structurally offered prior to IVF must be investigated in a randomized controlled trial. © 2014 Reproductive Healthcare Ltd. Published by Elsevier Ltd. All rights reserved

Towards more patient-centred endometriosis care: a cross-sectional survey using the ENDOCARE questionnaire

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Spontaneous haemoperitoneum in pregnancy: nationwide surveillance and Delphi audit system

Objective: To evaluate the incidence, diagnostic management strategies and clinical outcomes of women with spontaneous haemoperitoneum in pregnancy (SHiP) and reassess the definition of SHiP.Design: A population-based cohort study using the Netherlands Obstetric Surveillance System (NethOSS).Setting: Nationwide, the Netherlands.Population: All pregnant women between April 2016 and April 2018.Methods: This is a case study of SHiP using the monthly registry reports of NethOSS. Complete anonymised case files were obtained. A newly introduced online Delphi audit system (DAS) was used to evaluate each case, to make recommendations on improving the management of SHiP and to propose a new definition of SHiP.Main outcome measures: Incidence and outcomes, lessons learned about clinical management and the critical appraisal of the current definition of SHiP.Results: In total, 24 cases were reported. After a Delphi procedure, 14 cases were classified as SHiP. The nationwide incidence was 4.9 per 100 000 births. Endometriosis and conceiving after artificial reproductive techniques were identified as risk factors. No maternal and three perinatal deaths occurred. Based on the DAS, adequate imaging of free intra-abdominal fluid, and identifying and treating women with signs of hypovolemic shock could improve the early detection and management of SHiP. A revised definition of SHiP was proposed, excluding the need for surgical or radiological intervention.Conclusions: SHiP is a rare and easily misdiagnosed condition that is associated with high perinatal mortality. To improve care, better awareness among healthcare workers is needed. The DAS is a sufficient tool to audit maternal morbidity and mortality.Research into fetal development and medicin

Botulinum toxin A injections do not improve surface EMG patterns during gait in children with cerebral palsy-A randomized controlled study

AbstractChildren with cerebral palsy who walk with knee flexion during midstance are treated with intramuscular injections of botulinum toxin A (BTX-A) to prevent them from potential deterioration and to improve their mobility. The present study evaluates the effect of this treatment on the muscle activation patterns of the rectus femoris, medial hamstrings and gastrocnemius medialis during gait. Twenty-two children (aged 4–11 years) with cerebral palsy, who walked with knee flexion, were randomly assigned to an intervention group (multilevel BTX-A injections combined with comprehensive rehabilitation) or a control group (usual care). Sagittal and frontal video recordings were made of gait, together with simultaneous surface electromyography recordings of the rectus femoris, medial hamstring and gastrocnemius medialis muscles, before and six weeks after treatment. Abnormal muscle activation patterns were quantified, after gain-normalisation, according to the root mean square difference (RMSD), which is the difference relative to normal patterns. Six weeks after the treatment the RMSD of the gastrocnemius medialis muscles in the intervention group changed significantly, showing a deterioration (p<0.05). This study demonstrated that BTX-A injections do not result in an improvement in lower limb muscle activation patterns during gait. In spite of this lack of direct effect on muscle activation patterns, the combination of BTX-A injections and comprehensive rehabilitation was effective in improving gait kinematics