Vaginal micronized progesterone on preventing luteinizing hormone untimely surge in ART cycles: A prospective proof-of-concept study.

OBJECTIVE: A new approach to evaluate whether Progestin-Primed Ovarian Stimulation with micronized vaginal progesterone was as effective as using dydrogesterone in suppress LH pulse surge in young women under stimulation in an oocyte donor programme. METHODS: This prospective study included 21 patients aged 19 to 32 years-old stimulated with Elonva® 150, associated or not with Menopur® or Merional® (75 or 150IU) since the beginning of the cycle, plus HMG 150-225IU after the 8th day or just HMG 150-300IU per day. Patients were placed in a PPOS protocol with micronized vaginal progesterone (MVP) 200 mg (Gynpro® Exeltis or Junno Farmoquimica) every 12 hours or dydrogesterone (Duphaston® Abbott) 10 mg every 8 hours from the start of stimulation until the day after the GnRH trigger with Triptorelin 0.2 mg (Gonapeptyl daily®). The primary endpoint was the prevention of untimely LH surge, and secondarily the number of 16 mm follicles, retrieved oocytes and metafase II. RESULTS: Fourteen oocyte donor patients were prescribed MVP while seven others received dydrogesterone (DYG).The gonadotropin protocols included 04 with Corifollitropin alfa 150 plus HMG since the beginning and complemented after the 7th day, and 17 times of just HMG. There was no diferences in the number of follicles >10≤15mm, ≥16mm or number of metafase II oocytes. There was no untimely LH surge on both groups and no OHSS was developed after the agonist trigger. CONCLUSIONS: Progestin-Primed Ovarian Stimulation with micronized vaginal progesterone seems to be a compelling choice for preventing premature ovulation without compromising oocyte quality in women undergoing ovarian stimulation.

Switching from cetrorelix to dydrogesterone in an IVF cycle - a new strategy for unexpected freeze-all cycles.

Preventing a luteinizing hormone (LH) surge is a major concern in controlled ovarian stimulation (COS). Several strategies have been developed over the years, including protocols with Gonadotrophin Releasing Hormone agonists and antagonists. More recently Progestin Primmed Ovarian Stimulation (PPOS) has shown to be equally effective in pituitary suppression, with comparable clinical and laboratorial outcomes. This is the case of a 34 year old female, with a previous diagnosis of primary infertility due to tubal factor and high ovarian reserve markers. The initial plan was to perform IVF/ICSI. followed by fresh blastocyst transfer. The chosen COS strategy was to use Alfacorifolitropin 150mg (Elonva®) and Cetrorelix acetate 0,25mg (Cetrotide®) in a flexible pituitary suppression protocol. However, because of elevated risk for Ovarian Hyper-stimulation Syndrome (OHSS) detected during ultrasound and hormonal monitoring, in order to diminish financial burden and to have a more patient friendly protocol, we switched cetrorelix acetate to oral dydrogesterone. COS was successful and resulted in 24 retrieved oocytes (16 metaphase 2 oocytes) without any premature LH peak. No OHSS symptoms occurred. Our main goal with this case report is to reinforce the feasibility and efficacy of this innovative approach, especially in patients aiming for a fresh embryo transfer, who present alert sings of OHSS during the stimulation. Developing friendlier and cheaper protocols in assisted reproduction makes the treatment more accessible and affordable.

Herlyn-Werner-Wunderlich syndrome: A fertility-sparing approach to a rare mullerian anomaly.

The Herlyn-Werner-Wunderlich syndrome (HWWS) is characterized by the triad of uterus didelphys, obstructed hemivagina, and renal agenesis. The typical clinical presentation involves chronic pelvic pain, dysmenorrhea, and palpable abdominal mass, related to hematocolpos/hematometra. It is a rare disease, with a challenging clinical and radiological diagnosis. Surgery is the definitive treatment. Complications such as endometriosis, infertility and chronic pelvic pain occur more frequently and severely when diagnosis and treatment are delayed. This is a case report of a twelve-year-old patient admitted to the Gynecology Department of the Federal University of Rio de Janeiro's General Hospital (HUCFF/UFRJ), in March 2021, with progressive symptoms of dysmenorrhea and abdominal distention due to palpable abdominal mass. She had a previous history of congenital solitary kidney. Magnetic Resonance Imaging (MRI) showed a double uterus with hematometra and hematocolpos on the left side, pelvic endometriosis and left renal agenesis. Conservative clinical treatment with inhibition of the hypothalamic-pituitary-ovarian (H-P-O) axis was initiated while a definitive surgical approach was being defined. In June 2022, the patient underwent left hemi-hysterectomy and salpingectomy, achieving full remission of symptoms. Given the rarity of this syndrome and its potential complications, our report aims to familiarize clinicians with it, mostly those who work with children and adolescents, so that more patients have access to early diagnosis and adequate treatment. Consequently, future fertility can be effectively preserved.

Evaluation of the Effects of Platelet-Rich Plasma on Follicular and Endometrial Growth: A Literature Review.

Platelet-rich plasma (PRP) has been used in several areas of medicine due to its ability to promote tissue regeneration by growth factors and cytokines. This review addresses the use of PRP to rejuvenate ovarian follicles and increase the thickness of the endometrium to receive an embryo. PRP is obtained from the patient's own blood (autologous blood) - a fact that determines a lower chance of rejection reactions. Alpha granules of platelets provide and release supra physiological amounts of growth factors and cytokines, which provide a regenerative stimulus in tissues with low healing potential. In the ovary, PRP and its growth factors stimulate vascularization and recruitment of available primordial follicles that could no longer be otherwise stimulated. The rejuvenation of the ovary by PRP infusion aims to obtain new oocytes in ovaries with low numbers of follicles or low follicular reserve markers. In the preparation of the endometrium, PRP is used for its several growth factors that allow tissue proliferation and endometrial thickening, especially in cases of endometria that are difficult to prepare or that fail to reach an adequate minimum thickness (>7mm). To date, there are few studies of greater expression in the literature that support the use of PRP with the two purposes described above. Thus, although promising, the technique must still be validated by larger clinical trials.

Evaluation of follicular flushing with double lumen needle in patients undergoing assisted reproductive technology treatments.

OBJECTIVE: The purpose of this study was to investigate the possible impact of follicular flushing on the number of oocytes retrieved and oocytes in metaphase II in patients with poor ovarian response (POR) compared to direct aspiration. METHODS: This prospective, comparative, randomized single center study included 208 punctures of patients with POR, submitted to assisted reproduction technology (ART) treatments. Two groups were compared; one in which double lumen needles were used (Wallace DNS1733) for follicular flushing (n=105), and one in which single lumen needles were used (Wallace ONS1733) for direct aspiration (n=103), upon the observation of ≤ 5 follicles between 15-17 mm, ≤ 4 follicles with sizes greater than 18 mm on hCG day, and ≤ 7 recovered oocytes. RESULTS: There were no differences in age (39.07±3.88 vs. 38.11±3.43); weight (61.73±17.53 vs. 65.96±15.44); AMH (0.63±0.59 vs. 0.94±0.97); stimulation days (9.57±1.87 vs. 10.29±2.82); estradiol levels (788.94±670.82 vs. 940.16±694.69); progesterone (617.29±319.76 vs. 561.18±486.78); or number of follicles with sizes ≥18 mm (1.84±0.95 vs. 2.07±1.09). Although gonadotropin totals (1678.28±798.52 vs. 2080.45±852.36; p=0.0008), number of aspirated oocytes (3.00±2.11 vs. 3.69±2.20; p=0.02), and number of metaphase II oocytes (2.20±1.64 vs. 2.99±1.88; p=0.02) were significantly different, oocyte / follicle ratio ≥15 mm (0.93 vs. 0.98) and metaphase II oocytes / follicles ≥15 mm (0.68 vs. 0.79) were similar in both groups. The failure to capture was 16% vs. 9.8%. CONCLUSIONS: Considering that there was no difference in the oocyte per follicle ratio, follicular flushing did not increase the number of oocytes recovered from poor responders.

Maternal obesity influences the endocrine cord blood profile of their offspring.

Objective To compare the endocrine cord blood characteristics of offspring from obese mothers with those of offspring from healthy controls. Methods Cross-sectional case control study. SETTING: University medical centers. PATIENT(S): Offspring from obese mothers (n = 41) and healthy controls (n = 31). INTERVENTION(S): Cord blood withdrawal from neonates. MAIN OUTCOME MEASURE(S): Cord blood total cholesterol (TC), triglycerides (TGs), high-density lipoprotein-cholesterol (HDL-C), low-density lipoprotein-cholesterol (LDL-C), blood glucose (GL) and insulin (Ins). Result(s) Fetal GL and TGs were reduced in the offspring of obese women when compared to those in the offspring of the controls. The mean cord blood GL level was 47.8 mg/dL standard deviation (SD 33.1) in the offspring of the obese group vs. 57.9 mg/dL (SD 12.5) in the offspring of the control group, and the mean cord blood TG level was 26.5 (SD 33.6) in the offspring of the obese group vs. 34.6 (SD 12.3) in the offspring of the control group. Maternal obesity was also associated with reduced levels of TC and HDL-C in the pregnant women. Conclusion The observed results suggest that GL and TGs in the cord blood of the offspring of obese mothers were significantly lower than those in the offspring of the control group.

Psychological Intervention in the Oocyte Pick-up Room and Recovery Room in Assisted Reproduction: new listening accounts.

OBJECTIVE: This study seeks to identify the role and possible participation of a psychologist/psychoanalyst inside an Oocyte Pick-up Room and Recovery Room (OPR-RR) in an Assisted Reproduction clinic and its implications on patients and team. METHODS: Prospective study of psychological support during the procedures from September 2014 to December 2018. Most visits took place during oocyte retrievals, for either IVF/ICSI or gamete freezing. RESULTS: Of the 2,343 cases, the psychologist was present in 965 of them (41%), during oocyte retrievals, with available professionals in 59% of the times (722 cases). The embryo transfers (1,011) had psychological assistance in 20% of the time (218 cases). The intrauterine insemination cases were excluded for not happening in a surgical environment. The recovery room was identified as one of the spaces for welcoming and listening to anxieties, desires, projects, worries, fears, frustrations, joys and expectations for those who come to the clinic seeking the desire to gestate. The patients' talks, collected in observations transcribed from what was heard, with dates and types of procedures, were discussed with either the team or the assistant physician. The team stands positively in the presence of a psychologist/psychoanalyst, who brings new perceptions and the development of the whole art of listening, for all involved. CONCLUSION: The presence of a psychologist/psychoanalyst in the Oocyte Pick-up Room and the Recovery Room in an Assisted Reproduction clinic means an opportunity to listen to patients' emotions, providing well-being to patients and echoing in the teamwork relationships.

Bladder hematoma: a complication from an oocyte retrieval procedure.

INTRODUCTION: More than one million fertilization cycles are performed every year. The incidence of serious complications associated with transvaginal oocyte pick-up is low, but the procedure is not risk-free. Risks are inherent to procedures in which thin needles and sharp instruments are introduced into the vaginal wall and ovarian capsule to access the ovaries. CASE DESCRIPTION: A 45-year-old patient reported urinary discomfort and difficulty urinating after her second cycle, 12 hours after oocyte pick-up. She had visible hematuria with small blood clots. Transvaginal ultrasound examination performed 24 hours after pick-up showed a heterogeneous intravesical image suggestive of a clot; her bladder measured 23x19mm. She was afebrile and in good condition. The patient was managed conservatively and offered fluids. The clot was expelled within a matter of hours. This case of a bladder hematoma was the first in the 21 years of a clinic where all procedures are guided by ultrasonography with clear visualization of the tip of the needle throughout the 15-20 minutes of the procedure. Patients submitted to ultrasound-guided transvaginal oocyte pick-up procedures in IVF protocols must be informed of this rare potential complication.

Live Births after Fertility-saving Surgery in Ovarian Borderline Tumor and Oocyte Donation: Case Report.

A left borderline serous ovarian tumor stage I (FIGO) was discovered and treated in a 26-year-old black nulliparous woman, by conservative approach (laparotomy, salpingo- oophorectomy). In a six months interval she had a 7.5 x 7.1 x 5.7cm multilocular contralateral tumor with septa and vegetative areas and in a year interval a CT showed a 8.4 x 7.4 x 7.0 lesion that precluded a follicular aspiration. The authors discuss the multidisciplinary strategy and the approach with the couple: the best option considered would be the resection of the tumor remaining attached to a new study pelvic. If possible uterine conservation should be held for further procedure of oocyte donation. Two years from the first surgery she had the second laparotomy and six months later she had an ICSI with oocyte donation. She became pregnant and delivered two 34 week-pregnancy boys through C-section due to hypertension plus preeclampsia. There happened a post- operative intestinal obstruction that required a new surgical approach to adhesions lysis. There was no report of tumor lesions then. Seven months later, mother and children are doing well. Comments are made about borderline ovarian tumors and fertility-sparing approaches.