Serum progesterone on the day of human chorionic gonadotropin (hCG) trigger as a predictor of in-vitro fertilization (IVF) outcome - a retrospective analysis of seven years.

OBJECTIVE: To investigate the relationship between progesterone (P4) levels on the day of hCG trigger and IVF outcomes. METHODS: This is a retrospective analysis of IVF cycles from January-2013 to December-2019 from a single center. Women (21-39 years) submitted to IVF treatment for various infertility factors were included, while donor oocyte cycles and cancelled cycles were excluded from the study. The primary outcome measure was live birth rate. RESULTS: A total of 2149 cycles were analyzed. Of these, 223 (10.38%) were in the low P4 group (<0.5 ng/ml), 1163 (54.12%) in the normal P4 group (0.5-1.5 ng/ml), and 763 (35.50%) in the high P4 group (>1.5ng/ml). The groups were comparable with respect to age, factor of infertility and baseline AMH. The antagonist protocol was significantly more prescribed to the high P4 group (p<0.001). Live birth rates were 14.4%, 21.6%, and 21% (p<0.001), respectively, in three groups. Univariate analysis found that total cetrotide dose, total number of retrieved and fertilized oocytes, total number of embryos formed, transferred, and vitrified, and P4 on the day of hCG (p<0.001) were statistically significant after adjusting for age and BMI. In multivariate logistic regression after adjusting for age and BMI, only high P4 (aOR:0.60; p<0.001), total cetrotide dose (aOR: 0.82; p<0.001), and total utilizable embryos (aOR:1.11; p=0.029) were statistically significant. CONCLUSIONS: Having an elevated serum progesterone level on the day of hCG trigger was associated with lower pregnancy rates, but this is still not a robust marker to predict live births. More good quality evidence is needed.

Successful Management of Caesarean Scar Ectopic Pregnancies: A Report of Five Cases.

BACKGROUND: Cesarean section scar ectopic pregnancy (CSEP) is a rare and potentially life-threatening condition. A standardized management protocol is yet to be established owing to limited data available. CASE PRESENTATION: In this paper, five cases of CSEP over a period of 18 months at a tertiary referral hospital, managed medically with methotrexate administered both systemically and into the gestational sac at the time of feticide with potassium chloride (KCL) are presented. Surgical management was the second line therapy when medical treatment failed. CONCLUSION: With rising trends in cesarean deliveries, CSEP may be a challenge which requires close investigation regarding its diagnosis and treatment on the merits of case studies and available healthcare facilities.

Extraperitoneal Laparoscopy in Severe Intra-abdominal Adhesions: A Safe Alternative to Laparotomy.

Surgery in a frozen abdomen can be difficult and dangerous with a significant risk of visceral injuries. We report a case of a 26-year-old lady with chronic pelvic pain diagnosed to have large bilateral adnexal cysts on magnetic resonance imaging with normal tumor markers. She had previous two laparotomies for benign conditions. Laparoscopy was planned, but pneumoperitoneum could not be created due to dense intraperitoneal adhesions. Direct entry was done into the preperitoneal space followed by insufflation of gas in this space. Blunt and sharp dissection of this space was done without breaching the peritoneum to reach the adnexa. The adnexal cyst was found to be encysted collection due to adhesions from previous surgeries. Deroofing was done followed by the visualization of pelvic structures intraperitoneally. Extraperitoneal laparoscopy may be used as a safe alternative to laparotomy in patients with dense intra-abdominal adhesions with the advantage of faster postoperative recovery.

Gynecological laparoscopic surgeries in the era of COVID-19 pandemic: a prospective study.

OBJECTIVE: The novel coronavirus pandemic led to the suspension of elective surgeries and the diversion of resources and manpower towards pandemic control. However, gynecological emergencies and malignancies must be addressed despite the restricted resources and the need for protective measures against COVID-19. This study aimed to determine the types of gynecological surgeries performed, difficulties encountered, and their outcomes in the setting of the pandemic. METHODS: We performed a prospective cohort study over 6 months at a single tertiary center, including 60 women with gynecological complaints, categorized as emergencies and semi-emergencies, who underwent further surgery. Their surgical outcomes were measured through various parameters. RESULTS: We found that 68.3% were emergency cases, while the rest were classified as semi-emergencies. Fibroid and adenomyosis with failed medical management (48.3%), followed by cervical intraepithelial neoplasia (10%), and malignancies (10%) accounted for the semi-emergency cases, while ruptured ectopic pregnancies (13.3%) and torsion and ovarian cysts (18.4%) comprised the emergency cases. The decision to incision time between emergency and semi-emergency cases varied widely due to the safety prerequisites during the pandemic, ranging from 1 hour in emergency cases to 48 hours in semi-emergency cases. In addition, we studied the ease of preoperative preparation, patient satisfaction, and the average number of personnel available to run the operation theaters at these times. No serious perioperative adverse events were observed in the present study. CONCLUSION: In conclusion, gynecological surgeries could continue to be safely performed with all precautions in place against COVID-19 infection and related morbidities.

Role of para-cervical block in reducing immediate postoperative pain after total laparoscopic hysterectomy: a prospective randomized placebo-controlled trial.

OBJECTIVE: To study the efficacy and safety of 0.5% bupivacaine in paracervical block to reduce immediate postoperative pain after total laparoscopic hysterectomy. METHODS: A prospective, randomized, double-blind, placebo-controlled study was conducted at a tertiary referral center involving thirty women each in the treatment and placebo groups. Paracervical block with 10 mL of 0.5% bupivacaine (treatment group) or 0.9% saline (placebo group) was administered following general anesthesia and prior to proceeding with total laparoscopic hysterectomy. Visual analogue scale (VAS) scores at 30 and 60 minutes post extubation and mean VAS score (average VAS score at 30 and 60 minutes) were compared. Adequate pain control was defined as mean VAS score ≤5. Additional postoperative opioid requirement, hospital stay, and readmissions were also compared. RESULTS: Baseline variables such as age, previous history of cesarean section, operating time, and weight of the specimen were comparable in both groups. VAS scores at 30 (5.0±2.8 vs. 7.0±1.4) and 60 minutes (5.2±2.8 vs. 7.0±0.8) and the mean VAS score (5.1±2.7 vs. 6.8±0.9) were significantly lower in the treatment group. Adequate pain control (mean VAS score ≤5) was 57% higher and additional opioid consumption was 47% lower in the treatment group. No significant difference was found in the duration of hospital stay and readmission rate. CONCLUSION: Paracervical block with bupivacaine was useful in reducing immediate postoperative pain with a 25% reduction in mean VAS score and a 47% reduction in opioid consumption in the first hour after total laparoscopic hysterectomy.

Laparoscopic gynecological surgery in COVID-19 pandemic.

The major concern that has confronted surgeons during the COVID-19 pandemic is the risk of infection during surgery. So far, no studies have found SARS-CoV-2 in surgical smoke, and if it was found, whether it was infectious or not is unknown. To date, no evidence shows that respiratory viruses can be transmitted through a surgical plume or an aerosolized gas. There are various advantages of laparoscopy over laparotomy that must be kept in mind in the COVID-19 era, such as early recovery and shorter hospital stay, which can greatly help to conserve valuable hospital resources, and reduced risk of spillage of blood and body fluids, which can help to reduce transmission risk; most importantly, the distance between surgeons and between surgeons and patient is greater. Certain precautionary measures can be taken to reduce SARS-CoV-2 transmission during laparoscopy. Whenever possible, it should be the surgical option of choice.

Neurological manifestation in severe hypothyroidism in pregnancy.

Neurological manifestations of hypothyroidism include peripheral neuropathy and pituitary hyperplasia. However, these associations are rarely encountered during pregnancy. We report a case of a known hypothyroid with very high thyroid stimulating hormone (TSH) values (512 µIU/mL) in the second trimester. At 24 weeks she developed facial palsy and pituitary hyperplasia which responded to a combination of steroids and thyroxine. She had caesarean delivery at 35 weeks and 3 days gestation in view of pre-eclampsia with severe features and was discharged on oral antihypertensives and thyroxine. On follow-up at 5 months, TSH normalised and pituitary hyperplasia showed a greater than 50% reduction in size. To our knowledge, this is the first reported case of facial palsy and pituitary hyperplasia associated with hypothyroidism during pregnancy.

Three-Dimensional Automated Volume Calculation (Sonography-Based Automated Volume Count) versus Two-Dimensional Manual Ultrasonography for Follicular Tracking and Oocyte Retrieval in Women Undergoing in vitro Fertilization-Embryo Transfer: A Randomized Controlled Trial.

AIM: To compare the oocyte yield using three-dimensional (3D) automated and two-dimensional (2D) ultrasound-based follicle tracking in women undergoing in vitro fertilization-embryo transfer (IVF-ET). SETTINGS AND DESIGN: A randomized controlled trial was conducted in the Reproductive Medicine Unit of a teaching medical institute from January 2017 to December 2018. MATERIALS AND METHODS: A total of 130 patients undergoing IVF-ET were enrolled and randomized into two groups (65 patients in each group). In Group A, follicular tracking during controlled ovarian stimulation (COS) was done using 3D Sonography- based Automated Volume Count (SonoAVC), whereas in Group B, follicular tracking was done by manual ultrasonography (2D USG). The primary outcome measures were the number of oocytes retrieved (the total number and the number of mature oocytes). Secondary outcomes were fertilization rate, cleavage rate, total number of embryos and time taken to perform scans. Other outcome measures were clinical pregnancy rate, miscarriage rate and live birth rate (LBR). STATISTICAL ANALYSIS USED: Chi-square test, Student's t-test, Z-test, Wilcoxon rank-sum test, Bland-Altman's plot. RESULTS: The two groups were comparable with regard to assisted reproductive technology (ART) outcomes. Group B required more time for performing the scan (P < 0.01). CONCLUSION: Automated SonoAVC ultrasound can be used interchangeably with manual 2D USG for follicle tracking during COS giving comparable ART outcomes with the added advantage of saving time. Our study implies the promising results of applying artificial intelligence in follicular tracking during COS.