Verbal analgesia is as good as oral tramadol prior to intrauterine device (IUD) insertion, among nulliparous women: A randomized controlled trial.

OBJECTIVE: To compare two pain management strategies: oral tramadol or a verbal analgesia technique during insertion of an intrauterine device (IUD) among nulliparous women. STUDY DESIGN: In this randomized, controlled trial, 54 nulliparous women undergoing insertion of a levonorgestrel-releasing intrauterine device (IUD), from December 2015 to December 2018 were randomized to receive oral tramadol for analgesia or verbal analgesia prior to IUD insertion. Demographic data, clinical symptoms, visual analogue scale (VAS) and complications were reviewed from patient records. RESULTS: There was no difference between the two groups regarding gravidity, age, smoking or body mass index. No significant differences were detected between the groups regarding the procedure, including ease of insertion (p = .415), number of insertion attempts (p = .514) and complications during the insertion (p = .150). Mean pain level by VAS was 4.5 ± 1.6 (range 2-8) for the tramadol group and 4.8 ± 2.4 (0-10) for the verbal analgesia group (p = .610). There was no spontaneous ejection of the IUD in either group, and no endometritis or discomfort that resulted in IUD removal. CONCLUSION: There was no benefit in using oral tramadol for analgesia prior to IUD insertion among nulliparous women. Verbal analgesia can be a suitable technique for this process and clinicians should become more familiar with its use.

Monochorionic diamniotic in vitro fertilization twins have a decreased incidence of twin-to-twin transfusion syndrome.

OBJECTIVE: To compare the incidence of twin-to-twin transfusion syndrome (TTTS) in spontaneous versus IVF-conceived twin pregnancies. DESIGN: Retrospective multicenter study. SETTING: University-affiliated tertiary medical centers. PATIENT(S): Women admitted for 11-14 week's scan between January 1997 and July 2013 who were diagnosed with monochorionic (MC) diamniotic twin pregnancies. INTERVENTION(S): None. MAIN OUTCOME MEASURE(S): Mode of conception, TTTS. RESULT(S): The study cohort included 327 pregnant women with live MC diamniotic twins. Of them, 284 (86.9%) and 43 (13.1%) were spontaneous and IVF conceived, respectively. The mean maternal age was significantly higher in IVF compared with in spontaneously conceived pregnancies (33.8 ± 5.5 vs. 31.6 ± 5.4, respectively). Thirty-seven twins (11.3%) had TTTS, of whom 36/284 (12.7%) versus 1/43 (2.3%) were spontaneously and IVF conceived, respectively. The mean week of delivery was significantly lower in MC twins diagnosed with TTTS compared with those without TTTS (32.7 ± 3.3 vs. 35.5 ± 2.5, respectively). Furthermore, there was a significantly higher birthweight discordancy in twins diagnosed with TTTS compared with those without (20.6% vs. 11%, respectively). CONCLUSION(S): The significantly lower proportion of TTTS found in IVF-conceived twins may suggest a different embryological process that lies at the core of IVF conception of monozygotic twinning.

The association of crown-rump length discrepancy with birthweight discordance in spontaneous versus IVF monochorionic twins: a multicenter study.

OBJECTIVE: The objective of this study was to compare the associations of crown-rump length (CRL) discrepancy with birthweight discordance in spontaneous versus in vitro fertilization (IVF) monochorionic (MC) twin pregnancies. METHOD: This is a multicenter retrospective study on women with twin pregnancies assessed for nuchal translucency between January 1997 and July 2013. The study group was subdivided into MC twins conceived spontaneously and after IVF. Pregnancies with later fetal death or twin transfusion syndrome were excluded. A large-weight discordance was defined as a difference of birthweights of >15%. RESULTS: The study group included 171 pregnancies; of them, 142 (83%) were spontaneous and 29 (17%) were IVF conceived. In the entire cohort, we found a significant correlation between birthweight discordance and CRL discrepancy (r = 0.173, P < 0.05). While a significant correlation was found between CRL discrepancy and birthweight discordance in spontaneous-conceived pregnancies (n = 142, r = 0.24, P = 0.005), such correlation was not present in IVF pregnancies (n = 29, r = -0.7, P = 0.724). A logistic regression analysis found significant odds of larger-weight discordance for each increase of 1% in CRL discrepancy among spontaneously conceived pregnancies (odds ratio = 1.1, confidence interval = 1.03-1.2, P = 0.005). A receiver operating characteristic (ROC) for large-weight discordance in the spontaneously conceived pregnancies demonstrated an area under the ROC curve of 0.613 (P = 0.039). CONCLUSION: The significant correlation between CRL discrepancy and birthweight discordance in spontaneous versus IVF MC twin pregnancies might suggest differential monozygotic twinning process.