Endometrial scratch injury for women with one or more previous failed embryo transfers: a systematic review and meta-analysis of randomized controlled trials

OBJECTIVE: To investigate endometrial scratch injury (ESI) as an intervention to improve IVF outcome in women with a history of ET failure. DESIGN: Systematic review and meta-analysis. SETTING: Not applicable. PATIENT(S): Infertile women undergoing IVF after one or more failed ET. INTERVENTION(S): We included all randomized controlled trials of women undergoing IVF after one or more failed ET, where the intervention group received ESI and controls received placebo or no intervention. Pooled results were expressed as relative risk (RR) with a 95% confidence interval (95% CI). The review protocol was registered in PROSPERO before starting the data extraction (CRD42017082777). MAIN OUTCOME MEASURE(S): Live birth rate (LBR), clinical pregnancy rate (PR), multiple PR, miscarriage rate, ectopic pregnancy (EP) PR. RESULT(S): Ten studies were included (1,468 participants). The intervention group showed higher LBR (RR 1.38, 95% CI 1.05-1.80) and clinical PR (RR 1.34, 95% CI 1.07-1.67) in comparison to controls, without difference in terms of multiple PR, miscarriage rate, and EP PR. Double luteal ESI with pipelle was associated with the greatest effect on LBR (RR 1.54, 95% CI 1.10-2.16) and clinical PR (RR 1.30, 95% CI 1.03-1.65). The ESI was beneficial for patients with two or more previous ET failure, but not for women with a single previous failed ET. No effect was found in women undergoing frozen-thawed ET cycles. CONCLUSION(S): The ESI may improve IVF success in patients with two or more previous ET failures undergoing fresh ET. The ESI timing and technique seem to play a crucial role in determining its effect on embryo implantatio

EDUCATION AND ASSESSMENT THROUGH THE COURSE OF TRAINING PROGRAMME IN GYNAECOLOGY AND OBSTETRICS

Abstract. The article presents an insight in the residency training programme of Obstetrics and Gynaecology in Slovenia and presents the assessment system of Obstetrics and Gynecology residents. Authors' personal view of possible improvement of both is presented. The residency training programme of Obstetrics and Gynaecology together with assesment system are relatively well based. Minor changes together with consistent implementation of theory and bringing the theory to praxis are crucial

ANAL INCONTINENCE AFTER UNRECOGNISED ANAL SPHINCTER TEAR AT VAGINAL DELIVERY

Background: Anal sphincter tears during vaginal delivery may result in serious sequel. Anal sphincter tears occur in approximately 2–19 % of all vaginal deliveries and are the most common precursor for faecal incontinence,1 however »occult« anal sphincter injury has been defined in 33 % of primiparous women following vaginal delivery.2 Methods: 31-year old primiparous woman received transfusion due to atony after delivery. Episiotomy, second degree perineal tear and vaginal tear were surgically corrected immediately after delivery. In the following days inability to control passing of liquid stools and flatulence together with stress urinary incontinence appeared. The complaint persisted. Ultrasound and EMG examination confirmed rupture of the external anal sphincter, which had been missed at delivery. Over a year after delivery the patient had a posterior colporraphy with surgical correction of external anal sphincter, which did not result in any clinical improve- ment. On follow-up ultrasound examination a hypoechoegenic area between the external sphincter and vaginal wall was detected. The patient was referred to The University Hos- pital in Graz, where the tear will be treated with autologous myoblast transplantation in a clinical trial. Conclusions: Treatment of a missed anal sphincter tear is complicated, expensive and unpleasant for the patient. Early detection with immediate appropriate surgical correction after delivery is most efficient, but it takes experience

Office hysteroscopy in removing retained products of conception – a highly successful approach with minimal complications

Data of 101 patients with retained products of conception (RPOC), treated with office hysteroscopy (OH) from 2012 to 2015 at the University Medical Centre Ljubljana were analysed. Patients with >30 mm RPOC thickness or strong vascularisation on ultrasound (US) were excluded. Procedures were successfully completed in 94/101 (93%). Mean duration was 18 min (4–60), patient pain estimation with VAS was 2.3 (0–8). No intraoperative complications > Grade II according to Clavien-Dindo classification occurred. Uncompleted cases were safely referred to procedures in general anaesthesia. Follow-up after one month was performed in 78/101 (77%) patients with OH (69) or US (9). Only three patients reported endometritis, three cases of intrauterine adhesions were related to curettage or pre-existing adhesions. We compared preoperative findings of completed and uncompleted cases. Larger size of RPOC and the presence of irregular tissue-myometrial border on US was statistically significantly higher in uncompleted OH (p<.05); mild vascularisation and β-hCG levels up to 80 U/L did not affect the outcome.Impact statement What is already known on this subject? In the last three decades research has focussed on comparing hysteroscopic resection (HR) to traditional dilation and curettage in removing retained products of conception (RPOC). Office hysteroscopy (OH) without hospitalisation or general anaesthesia enables women to return to their daily routine immediately (especially desired by breastfeeding mothers) and is used where available, yet there is little published data to evaluate its role in the management of RPOC. What do the results of this study add? To the best of our knowledge, this article is unique in addressing success, safety and possible limiting factors of OH in removing placental polyps. According to our findings, OH is highly successful (93%), safe, and well tolerated in removing RPOC up to 30 mm in thickness and with no or minimal vascularisation on ultrasound. Thorough follow-up (68% with OH, 9% with US after 1 month) adds to strength of data. What are the implications of these findings for clinical practice and/or further research? Removing large and vascularised RPOC can be a very demanding procedure, yet a majority of patients might benefit from an outpatient approach. Prospective studies on limiting factors and more data on long term reproductive outcomes are needed to fully compare OH to other methods of removal

Laparoskopická sakrocolpopexie jako hlavní článek pro studii signifikantního apikálního prolapsu pánevních orgánů

Primárním cílem této studie bylo pousouzení klinické proveditelnosti nové strategie, kde laparoskopická sacrocolpopexie je hlavní metoda pro řízení signifikantního apikálního prolapsu pánevních orgánů. Sekundárním cílem bylo vyhodnocení LSC výstupů ve vztahu k předoperačnímu lékařskému posudku žen s pomocí kategorizace Ameriské Společnosti Anesteziologů (ASA-PS).The primary aim of this study was to assess the clinical feasibility of a policy where laparoscopic sacrocolpopexy (LSC) is the default procedure for the management of a significant apical pelvic organ prolapse (a-POP). As a secondary aim, we wanted to evaluate LSC outcomes in relation to women’s preoperative assessment of their surgical fitness using the American Society of Anesthesiologists physical status (ASA-PS) categorization

Biomechanical Properties of the Pelvic Floor and its Relation to Pelvic Floor Disorders

Pelvic organ prolapse and stress urinary incontinence remain a clinical challenge as they have unclear pathophysiology and suboptimal treatments. These common pelvic floor disorders (PFD) are characterized by the weakening of the pelvic floor supportive tissues that are directly related to their biomechanical properties. Characterizing the biomechanical properties of the pelvic floor tissues has been the focus of recent studies and researchers are using tools that are not always well understood by clinicians. Therefore, the aim of this review is to provide an overview of the most used methods to test the passive biomechanical properties of the human pelvic floor tissues. We also summarize recent findings from studies looking into the passive properties of the pelvic floor in pelvic floor disorders using the ex vivo tensile test and emerging in vivo techniques. Together, these studies provide valuable quantitative information about the different biomechanical properties of the supportive tissues of the pelvic floor under normal and pathological conditions. Results from ex vivo tests provide valuable data that needs to be correlated to the in vivo data and the clinical manifestations of the symptoms of the PFD. As more research is conducted we will obtain an enhanced understanding of the effect of age, PFD, and treatments on the biomechanical properties of the pelvic floor. This information can contribute to better identify individuals at risk, improve clinical diagnosis, and develop new treatments to advance clinical practice. Pelvic floor disorders are characterized by the weakening of the pelvic floor tissues that is directly related to their biomechanical properties. Such properties change with age, disease, and treatments. This review provides the physician with an overview of the most used methods to investigate the passive biomechanical properties of the human pelvic floor tissues in the context of pelvic floor disorders

Sling Surgery for Female Incontinence

The pelvic floor is at an increased risk of damage during the lifespan of women. Pregnancy, vaginal delivery, aging, menopause, previous pelvic surgery, and lifestyle factors have a negative influence on the connective tissue and muscular components of the pelvic floor leading to urinary incontinence (UI). Pregnancy and vaginal delivery have been identified as the most important risk factors for incontinence. Cystocele, rectocele, uterine, vault prolapse, and/or incontinence can occur due to lacerations of the connective tissue support at different levels. Moreover, muscular damage of the levator complex can lead to widening of the levator hiatus, giving way to the descent of pelvic organs resulting in UI. Although some genetic abnormalities have been identified, their clinical implications remain unclear. Diagnostic evaluations should be performed in accordance with established evidence-based guidelines. Although short-term results of single-incision midurethral slings indicate similar efficacy to conventional midurethral slings, their long-term outcome is still not determined. Scientists continue to investigate the exact causes of stress UI as well as the optimum substitute material using the best surgical reconstructive approach. The recent European Association of Urology consensus statement underlines an imperative requirement for an optimal solution using minimal amount of material related to the indication and higher competence of surgeons for this surgery. High-quality trials with a longer follow-up are currently an unmet need.status: publishe