Elagolix Represents a Less Invasive and Cheaper Option than Injectable GnRH Antagonist for Ovulation Suppression in IVF.

BACKGROUND: The injectable GnRH antagonists have traditionally been used for ovulation suppression during controlled ovarian hyperstimulation in IVF, leading to increased painful daily injections and cost. The use of the oral GnRH antagonist elagolix for ovulation suppression in IVF has not been studied. METHODS: A retrospective cohort study of patients undergoing IVF received either oral elagolix 50 mg every other day or ganirelix/cetrotide injection daily for ovulation suppression during controlled ovarian hyperstimulation. A total of 269 patients, 173 in the elagolix group and 96 in the ganirelix/cetrotide group, were included. The main outcome was the suppression of luteinizing hormone (LH) blood levels reflecting ovulation suppression. RESULTS: The age, body mass index, AMH levels, baseline FSH, antral follicles count, the dose of medications used, the number of days of ovarian stimulation, and peak estradiol (E2) levels were similar in both groups. When blood LH and E2 levels were measured before the intake and the day after intake of either elagolix or ganirelix/cetrotide, both groups had significant and similar drop in LH levels and increase in E2 levels. When comparing the IVF cycle outcomes in both groups, the number of oocytes retrieved, the number of mature oocytes, the fertilization rate, the blastocyst formation rate, the euploidy rate and the endometrial lining thickness at the time of the trigger were all similar. CONCLUSIONS: Oral GnRH antagonist, a much cheaper and less invasive medication that is used at a lower frequency, showed comparable ovulation suppression to the costly injectable GnRH antagonist. Further studies are required to evaluate the effect of oral GnRH antagonist on endometrial lining receptivity and pregnancy outcomes especially when using fresh embryo transfer IVF protocols.

Live Birth Following a Two-Way Transport In Vitro Fertilization Using a Portable Incubator: A Novel Protocol Executed During the COVID-19 Pandemic.

This case presents a live birth of a complete "two-way transport IVF" using a portable incubator during the COVID-19 pandemic, allowing the patient to undergo both oocyte collection and embryo transfer in a satellite office located 30 miles, 2-h drive, away from the central IVF laboratory. A 30-year-old patient who lives on Long Island NY, with a history of unexplained infertility and previously failed intra-uterine inseminations (IUI), had a telehealth consultation for IVF. Because of the high prevalence of the COVID-19 virus in Manhattan-NYC where the central IVF laboratory is located, the patient was consented to undergo a two-way transport IVF. She was initiated on a controlled ovarian superovulation protocol, after which follicular aspiration of 11 large follicles was performed in a regular examination room, under local vaginal anesthesia at the satellite office. The follicular fluid aspirates were collected in the usual tubes which were immediately sealed and placed inside a portable incubator. The sperm sample was also produced at the satellite location, washed, and placed in the same incubator. The aspirate tubes and the washed sperm were shipped immediately to the central laboratory. A total of ten oocytes were retrieved, out of which six were mature, leading to three good-quality blastocysts that were cryopreserved. The following month, the patient was prepared for a frozen embryo transfer (FET) cycle at the satellite location. On the day of the FET, two blastocysts were thawed and loaded in a transfer catheter in the central IVF laboratory. The catheter containing the embryos was shipped to the satellite location by an experienced embryologist using the portable incubator. The FET was performed in the same initial examination room. A singleton smooth pregnancy resulted from the FET, leading to the delivery of a healthy baby at term. This novel approach, learned during the pandemic, was able to alleviate the psychological, physical, and financial burdens on the patient, while also carrying the potential to reduce the costs of setting up an IVF laboratory, lowering prices and making IVF available to a larger portion of the population, especially when staffing IVF laboratories could be a major hurdle.

Intraovarian Platelet-rich Plasma Administration Induced Spontaneous Ovulation in an Anovulatory Woman With PCOS.

The use of platelet-rich plasma (PRP) has become popular as an adjunct to fertility treatment for women with infertility, particularly those with low ovarian reserve and premature ovarian insufficiency. Recent data in a polycystic ovary syndrome (PCOS) animal model demonstrated that intraovarian PRP administration improved folliculogenesis, ovarian antioxidant potential, and serum hormonal imbalance, suggesting that PRP could be considered a novel technique to alleviate PCOS-induced pathogenesis. With injection of PRP into the ovaries, it has been hypothesized that the infusion of cytokines and growth factors may exhibit a local effect that changes the expression of genes important in folliculogenesis and steroidogenesis, decreases inflammation, and partially restores normal ovarian function. This report is the first to present a case of a long-term amenorrheic woman with PCOS who has been trying to conceive, who resumed spontaneous ovulatory cycles, and had improvement in several aspects of her hormonal imbalance following intraovarian PRP administration. The purpose of this case report is to increase awareness regarding the possible benefits of intraovarian PRP injections for women with PCOS. There is a clear need for larger prospective studies to properly elucidate the effect of intraovarian PRP administration on both the reproductive and metabolic dysfunctions observed in women with PCOS.

Intraovarian platelet-rich plasma administration could improve blastocyst euploidy rates in women undergoing in vitro fertilization.

OBJECTIVE: Platelet-rich plasma (PRP) therapy has received a considerable attention as an adjunct to fertility treatments, especially in women with very low ovarian reserve and premature ovarian insufficiency. Although recent studies have demonstrated that PRP led to improvements in folliculogenesis and biomarkers of ovarian reserve, the effect of intraovarian PRP administration on embryo genetics has not been studied. METHODS: We report a pilot study of patients who had preimplantation genetic testing for aneuploidy (PGT-A) before and then within 3 months following PRP administration. Twelve infertile women with at least one prior failed in vitro fertilization (IVF) cycle underwent ovarian stimulation (cycle 1) with a gentle stimulation protocol and PGT-A performed at the blastocyst stage. Following cycle 1, autologous intraovarian PRP administration was performed. Within 3 months following PRP administration, the patients underwent cycle 2 and produced blastocysts for PGT-A. The percentage of euploid embryos between both cycles was compared. RESULTS: The mean age of all participants was 40.08±1.46 years, and their mean body mass index was 26.18±1.18 kg/m2. The number of good-quality embryos formed at the blastocyst stage was similar between cycle 1 and cycle 2 (3.08±0.88 vs. 2.17±0.49, respectively; p=0.11). Among all patients in cycle 1, 3 of 37 embryos were euploid (8.11%) while in cycle 2, 11 out of 28 embryos were euploid (39.28%, p=0.002). Three clinical pregnancies were noted among this patient group. CONCLUSION: This novel study is the first to present an improvement in the embryo euploidy rate following intraovarian PRP application in infertile women with prior failed IVF cycles. The growth factors present in PRP may exhibit a local paracrine effect that could improve meiotic aberrations in human oocytes and thus improve euploidy rates. Whether PRP improves live birth rates and lowers miscarriage rates remains to be determined in large trials.

Contribution of Advanced Glycation End Products to PCOS Key Elements: A Narrative Review.

In the last decade, data has suggested that dietary advanced glycation end products (AGEs) play an important role in both reproductive and metabolic dysfunctions associated with polycystic ovary syndrome (PCOS). AGEs are highly reactive molecules that are formed by the non-enzymatic glycation process between reducing sugars and proteins, lipids, or nucleic acids. They can be formed endogenously under normal metabolic conditions or under abnormal situations such as diabetes, renal disease, and other inflammatory disorders. Bodily AGEs can also accumulate from exogenous dietary sources particularly when ingested food is cooked and processed under high-temperature conditions, such as frying, baking, or grilling. Women with PCOS have elevated levels of serum AGEs that are associated with insulin resistance and obesity and that leads to a high deposition of AGEs in the ovarian tissue causing anovulation and hyperandrogenism. This review will describe new data relevant to the role of AGEs in several key elements of PCOS phenotype and pathophysiology. Those elements include ovarian dysfunction, hyperandrogenemia, insulin resistance, and obesity. The literature findings to date suggest that targeting AGEs and their cellular actions could represent a novel approach to treating PCOS symptoms.

A Case of Asthenozoospermia Following COVID-19 Infection.

PURPOSE: Studies pertaining to the effect of COVID-19 infection on male fertility are scarce. This case report describes a case of transient asthenozoospermia, absence of sperm motility, following a moderately severe COVID-19 infection. CASE: A couple presenting for infertility treatment due to low ovarian reserve presented for their second intrauterine insemination (IUI). Their first IUI was performed 1 month earlier when the semen parameters were normal. A couple of weeks before the second IUI, the unvaccinated 48-year-old male partner contracted COVID-19 and was admitted to the hospital for several days. He received IV Remdesivir and continuous oxygen by nasal cannula. His hospitalization did not require intubation or intensive care unit admission. He was discharged after 12 days of hospitalization without home oxygen treatment. On the day of the second IUI, the semen analysis showed a normal sperm count with 0% motility. Three months following his COVID-19 diagnosis, a repeat semen analysis showed restored normal parameters with more than 40% motility. CONCLUSION: This aim of this report is to increase awareness that moderate COVID-19 requiring hospitalization could affect, though temporarily, sperm motility and should be considered in the differential diagnosis when male infertility is encountered.

Impact of Dietary Advanced Glycation End Products on Female Reproduction: Review of Potential Mechanistic Pathways.

Advanced glycation end products (AGEs), a heterogenous group of products formed by the reaction between protein and reducing sugars, can form endogenously due to non-enzymatic reactions or by exogenous sources such as diet where considerable increase in AGEs is observed due to the modification of food mainly by thermal processing. Recent studies have suggested that AGEs could impact, via inducing inflammation and oxidative stress, the reproductive health and fertility in both males and females. This review presents a summary of recently published data pertaining to the pathogenesis of dietary AGEs and their receptors as well as their potential impact on female reproductive health. More specifically, it will present data pertaining to dietary AGEs' involvement in the mechanistic pathogenesis of polycystic ovary syndrome, ovarian dysfunction, as well as the AGEs' effect perinatally on the female offspring reproduction. Understanding the mechanistic impact of dietary AGEs on female reproduction can help contribute to the development of targeted pharmacological therapies that will help curb rising female infertility.

Ovarian response to intraovarian platelet-rich plasma (PRP) administration: hypotheses and potential mechanisms of action.

PURPOSE: Platelet-rich plasma (PRP) therapy has been used as an adjunct to fertility treatments in women with very low ovarian reserve and premature ovarian insufficiency. Recent literature in both humans and animals suggest that intraovarian PRP administration in the setting of poor ovarian reserve may help ovarian function and increase the chances of pregnancy. METHODS: A comprehensive literature search through PubMed, MEDLINE databases, and recent abstracts published at relevant society meetings was performed and resulted in 25 articles and 2 abstracts published that studied effect of PRP on the ovaries for the purpose of reproduction. RESULTS: This review article presents all the data published to date pertaining to intraovarian PRP injection and pregnancy, both naturally and after in vitro fertilization. It also presents the most recent data on the use of ovarian PRP in in vitro and animal model studies highlighting the possible mechanisms by which PRP could impact ovarian function. CONCLUSIONS: Even though recent commentaries questioned the use of PRP as an "add-on" therapy in fertility treatment because it has not been thoroughly studied, the recent basic science studies presented here could increase awareness for considering more serious research into the efficacy of PRP as an adjunct for women with poor ovarian reserve, premature ovarian insufficiency, and even early menopause who are trying to conceive using their own oocytes. Given its low-risk profile, the hypothetical benefit of PRP treatment needs to be studied with larger randomized controlled trials.

Intraovarian PRP Injection Improved Hot Flashes in a Woman With Very Low Ovarian Reserve.

PRP, rich in growth factors and cytokines, has been gaining considerable attention as an adjunct therapy to fertility treatment for women with very low ovarian reserve and premature ovarian insufficiency. To date, most prior studies have focused on the effect of PRP on ovarian response pertaining to oocyte production and pregnancy outcome following assisted reproductive technology. This report presents a patient with very low ovarian reserve, with medical problems that preclude her from taking hormone replacement therapy, who presented for fertility treatment with PRP and then accidentally reported significant improvement of menopausal symptoms including her hot flashes for 14 weeks following PRP intra-ovarian injection. The purpose of this case report is to increase awareness of clinicians about the use of PRP as a potential alternative therapy for hot flashes in women who have contraindications for hormone replacement therapy.

Use of Intra-uterine Injection of Platelet-rich Plasma (PRP) for Endometrial Receptivity and Thickness: a Literature Review of the Mechanisms of Action.

Endometrial receptivity and thickness play an important role in achieving a pregnancy. Intrauterine autologous platelet-rich plasma (PRP) infusion has been used in infertile women with recurrent implantation failure (RIF) and thin endometrial lining thickness (EMT). Literature search was performed in PubMed for studies including in vitro, animal, and human studies as well as in abstracts presented at national conferences. Animal studies demonstrated a decrease in the expression of inflammatory markers and fibrosis, and increased endometrial proliferation rate, increased expression of proliferative genes, and increased pregnancy rates. The in vitro studies showed that PRP was associated with increased stromal and mesenchymal cell proliferation, increased expression of regenerative enzymes, and enhancement in cell migration. In infertile women undergoing assisted reproductive technology, one randomized clinical trial showed that PRP intrauterine infusion improved EMT, implantation rate, and clinical pregnancy rate (CPR) in patients with thin EMT, while 3 other trials involving subjects with RIF showed conflicting results related to CPR. Case series and cohort studies showed conflicting results pertaining to CPR. Data to date suggest that PRP may be beneficial in improving endometrial thickness and endometrial receptivity. However, further large prospective and high-quality trials are needed to assert its effect and to identify the population of patients that would benefit the most.

Abdominal Fascia Closure Techniques During Laparoscopy.

Due to its decreased recovery time and increased patient satisfaction, laparoscopic surgery has witnessed an exponential rise in the last decade. In fact, the indications for laparoscopic surgery are currently numerous and involve multiple disciplines, including gastro-intestinal and gynecological surgery. With this boom, there is much focus on decreasing the rate of complications due to laparoscopy. This includes, but is not limited to, an increased interest in decreasing the risk of port-site herniation by ensuring proper closure of the abdominal wall at the site of port-insertion.

International authorship in leading world journals on incontinence and pelvic floor disorders: Is it truly international?

OBJECTIVE: The primary aim of this study is to compare the authorship in the Journal of Neurourology and Urodynamics (NAU) and the International Urogynecology Journal (IUJ) across two categories: country members of the Organization for Economic Co-operation and Development (OECD) and non-members of OECD (non-OECD). The secondary aim is to explore the obstacles in publishing in these two journals. STUDY DESIGN: NAU and IUJ articles between June 2014 and June 2018 were manually screened and divided into 2 categories depending on the country of affiliation of the corresponding author: OECD versus non-OECD. They were then divided into seven different types depending on the scope of the article. An online anonymous lime survey was then used to get the opinions of corresponding authors from non-OECD countries regarding obstacles to publishing. RESULTS: The OECD countries, representing 17.0% of the world population contributed to 85.4% of the 1885 articles evaluated, whereas only 14.6% originated from non-OECD countries. The distribution of the article types was comparable between the 2 groups. Out of 194 corresponding authors from non-OECD countries, 35 (18.7%) returned a completely filled survey that could be included in the analysis. Lack of funding, language barrier, and perceived bias were acknowledged as barriers to research and publishing. The majority of corresponding authors believed that international collaboration can improve the quality of research. CONCLUSIONS: The majority of NAU and IUJ articles originate from countries belonging to the OECD group. The uneven representation could be due to gaps in research activity, to obstacles in submission or both.

Unexplained First Trimester Intrahepatic Cholestasis of Pregnancy: A Case Report and Literature Review.

Intrahepatic cholestasis of pregnancy (ICP) is a condition that usually affects the 3rd trimester-pregnant women and is associated with adverse pregnancy outcomes. We present a 31-year-old G2P1 patient with symptoms of ICP as early as 10 weeks of gestation (WG). Her pruritis was initially attributed to eczema. Due to the intensity of her discomfort and failure of topical treatment, ICP was suspected, total bile acid salt levels were taken and ursodeoxycholic acid was subsequently started at 18 WG. The patient was followed closely during her pregnancy to adjust the dose of the medication accordingly. Induction of labor was performed at 37 WG without complications. This case demonstrated the importance of clinical suspicion in the setting of such symptomatology in order not to miss or delay treatment of threatening conditions such as ICP.