Embarazo múltiple posterior a la transferencia de embrión único: serie de casos y revisión de la literatura / Multiple pregnancies after single embryo transfer: case report and literature review

El embarazo gemelar es la complicación más frecuente tras técnicas de reproducción asistida (TRA). En un esfuerzo por disminuir su incidencia, cada vez más centros adoptan la medida de transferencia de embrión único. Sin embargo, a pesar de estas medidas, se ha observado que existe un riesgo elevado de duplicación embrionaria inherente a las TRA cuyo mecanismo permanece desconocido. En el presente trabajo presentamos una serie de casos y una revisión de la literatura acerca de los posibles mecanismos y teorías involucradas en dichos acontecimientos (AU)

Twin pregnancy is the most frequent complication for the assisted reproduction techniques. A strategy for reducing its incidence, many IVF centres have adopted a policy of single embryo transfer. However, despite these efforts, a risk of multiple pregnancies is still present and the mechanisms for its occurrence are unknown. We present a number of cases and a literature review discussing the theories and possible mechanisms involved (AU)

Comparación de resultados perinatales entre gestaciones gemelares espontáneas y las provenientes de técnicas de reproducción asistida / Comparison between spontaneous twin pregnancy and ivf twin pregnancy perinatal outcomes

OBJETIVO: Evaluar si las técnicas de reproducción asistida influyen sobre los resultados perinatales del embarazo gemelar. Sujetos y métodos: Estudio de revisión de resultados perinatales en embarazos gemelares en una clínica privada en el que se incluyen todos los embarazos gemelares espontáneos y por técnicas de reproducción asistida (TRA) que acuden a su atención obstétrica excluyendo aquellas mujeres con enfermedades preexistentes que supongan un resultado perinatal adverso. Se analizan 95 casos. RESULTADOS: No hubo diferencia estadística en términos de diabetes gestacional, presencia de preeclampsia, práctica de cesárea, peso promedio del recién nacido e ingreso a unidad de cuidados intensivos neonatales. Hubo diferencia estadística en los casos de anemia gestacional (61,29 % del grupo de gemelar espontáneo versus un 31,25 % del gemelar por TRA, p= 0,0075) y en el grupo de semanas de edad gestacional al momento del parto: 32-36,6 semanas (32,25 % para gemelar espontáneo y 65,62 % para gemelar por TRA, p = 0,0039) y en el de >37 semanas de gestación (58,08 % para gemelar espontáneo y 26,57 % para gemelar por TRA, p = 0,0059). CONCLUSIONES: Las técnicas de reproducción asistida se asocian con una mayor prevalencia de parto pretérmino

OBJECTIVE: To evaluate if assisted reproductive techniques affect perinatal outcomes of twin pregnancies. Subject and method: This is a review of perinatal outcomes of twin pregnancies in a private institution. All twin pregnancies detected were included and classified in two groups: spontaneous pregnancy and assisted reproduction (AR) pregnancy. Those women who had a preexistent condition that could represent an adverse outcome were excluded. 95 cases were included. RESULTS: There was no statistical difference in terms of gestational diabetes, preeclampsia, c-section, newborn weight and in those who required neonatal intensive care. There was statistical difference in gestational anemia (61.29 % vs 31.25 % for spontaneous twin pregnancy and assisted reproduction twin pregnancy respectively, p = 0.0075) and in two groups according to gestational weeks at delivery: 32-36.6 weeks (32.25 % for spontaneous twin pregnancy and 65.62 % for AR twin pregnancy, p = 0.0039) and >37 weeks at delivery (58.08 % for spontaneous twin pregnancy and 26.57 % for AR twin pregnancy, p = 0.0059). CONCLUSION: Assisted reproductive techniques associate with a higher prevalence of preterm labor

Reproducción Asistida: ¿Debemos solo transferir un embrión? / Assisted Reproduction: Should be transferred only one embryo?

OBJETIVO: Comparar resultados obstétricos y perinatales de embarazos únicos espontáneos con los obtenidos por reproducción asistida, tanto únicos como gemelares. MATERIAL Y MÉTODO: Estudio descriptivo observacional retrospectivo. Se analizan un total de 1 096 embarazos de pacientes que acuden a control obstétrico en una clínica privada y se clasifican en tres grupos según el modo de concepción y número de fetos: Grupo 1, embarazo único espontáneo; Grupo 2, embarazo único por técnica de reproducción asistida (TRA) y, Grupo 3, embarazo gemelar por reproducción asistida. Se analizan los resultados obstétricos y perinatales entre los tres grupos. Se considera que hay diferencia estadística con un valor menor a <0.01 utilizando la prueba de chi cuadrado. RESULTADOS: La tasa de diabetes gestacional fue mayor en el grupo de embarazo único por TRA (23,78%) comparada a la de embarazo único espontáneo (6,66%) y gemelar por TRA (0%), presentando diferencia estadísticamente significativa. Hubo mayor presencia de anemia gestacional en el grupo de embarazo único espontáneo (76,66%) que en los grupos de TRA (19,51% y 31,25% para único y gemelar respectivamente) con diferencia estadística. Se presenta diferencia significativamente estadística a favor del grupo de embarazo gemelar por TRA en cuanto a un mayor número de casos de amenaza de parto pretérmino (25 %), una mayor ganancia de peso materno a final del embarazo (12,33 ± 3,2 Kg), un mayor número de nacimientos por cesárea (81,25%), menor edad en semanas de gestación al parto (35,28 ± 3,6), menor peso del recién nacido (2 388,69 ± 378 g) y un mayor número de casos que requieren ingreso a unidad de cuidados intensivos neonatales (18,75%). CONCLUSIONES: El embarazo gemelar tiene un peor pronóstico perinatal que el embarazo único sea espontáneo o por TRA

OBJETIVE: To determine the correlation between the semen parameters (concentration, motility, morphology and vitality) and sperm DNA integrity, using the test Halosperm. Material And METHODS: Prospective study conducted at the Laboratory of Andrology of Assisted Reproduction Laboratory FERTILAB, Lima - Peru, from August 2012 to March 2013. 282 patients were analyzed. We have established the DNA fragmentation index (IFA) from patients with semen sample normozoospermic and patients with semen sample altered in some parameters. We used two types of threshold (18% and 30%) and were correlated with semen parameters. In the total population was determined the Spearman correlation between sperm parameters and the IFA. RESULTS: It was determined that the value of the median the IFA of the patients with semen sample normozoospermic was significantly lower than that patients with semen sample altered in some parameters (12.8% vs 19.0, P=0.000). Using threshold of 18% was determined the there significant difference between the median of the two groups (Group 1: ≤ 18% y Group 2: > 18%) in age (37 years vs 40 years, P = .002), sperm concentration (82.30 X 106/ml vs 58.00 X 106/ml, P = 0.046), progressive motility (45.80% vs 27.40, P = 0.000), normal morphology (12.50% vs 9.00%, P = 0.000) and sperm vitality (89.0% vs 78.0%, P = 0.000). Using the threshold of 30 % was found significant difference between the median of the two groups (Group 1: ≤ 30% y Group 2:> 30%) in age (39 years vs 44 years, P=0.000), sperm concentration ( 78.00 X 106/ml vs. 36.75  X 106/ml, P = 0.015 ), motility progressive (40.85% vs 22.38 %, P=0.000 ), normal morphology (12.0 % vs 6.0 %, P=0.004) and sperm vitality (85.0 % vs 72.5%, P=0.000). Also identified an inverse correlation between the IFA and concentration (r=- 0.219 P=0.000), progressive motility (r=-0.452 P=0.000), normal morphology (r=-0.322 P=0.000) and vitality (r = -0.452 P = 0.000) in the total population. We determined a significant positive correlation between age and the IFA (r=0.267 P = 0.000). CONCLUSIONS: The results indicate that the level of DNA damage in sperm patients with semen sample altered in some parameters is significantly higher than in patients with semen sample normozoospermic. It has been shown that the semen parameters (concentration, motility, morphology and vitality) are highly negatively correlated with sperm DNA fragmentation index. It showed a positive correlation between age and the IFA

Síndrome de Ovario Poliquístico: Donde estamos y hacia donde dirigirnos / Polycystic Ovary Syndrome: Where we are and where to go

OBJETIVO: Sintetizar la información con mayor relevancia sobre los criterios diagnósticos del SOP y revisar los principales estudios de prevalencia. Material Y método: Estudio de revisión de la literatura. Se realiza una búsqueda avanzada en MEDLINE con las siguientes palabras clave: PCOS AND diagnostico criteria, PCOS AND prevalence. RESULTADOS: Se obtienen más de 3000 artículos seleccionando 27 de ellos en base a su relevancia, autores, factor impacto de la revista y fecha de publicación. CONCLUSIONES: El SOP puede clasificarse en 4 fenotipos según la presencia de tres criterios diagnósticos: SOP clásico (oligo/anovulación + hiperandrogenismo + ovarios poliquísticos (OP)), SOP clásico sin OP (oligo/anovulación + hiperandrogenismo), SOP ovulatorio hiperandrogenismo + OP), SOP sin hiperandrogenismo (oligo/anovulación + OP). Consideramos que lo más importante y determinante será el establecer La morbilidad (problemas reproductivos, síndrome metabólico, enfermedad cardiovascular, riesgo de cáncer) para cada fenotipo o presentación del síndrome

OBJECTIVE: To analyze and discuss the latest in the literature about PCOS diagnostic criteria and to review today prevalence. MATERIAL AND METHOD: Review of the literature. A search in MEDLINE was performed with the following keywords: PCOS AND diagnostic criteria, PCOS and prevalence. RESULTS: There was over 3000 articles as a result and we selected 27 based on the relevance, authors, journal impact factor and date of publication. CONCLUSIONS: PCOS can be classified into four phenotypes according to the presence or not of three diagnostic criteria: Classic PCOS: (oligo/anovulation + hyperandrogenism + polycystic ovaries (PO)), Classic PCOS w/out PO (oligo/anovulation + hyperandrogenism), Ovulatory PCOS (hyperandrogenism + PO), PCOS w/out hyperandrogenism (oligo/anovulation + PO). We think that the most important step will be to establish each phenotype morbidity (in terms of reproductive problems, metabolic syndrome, ardiovascular disease risk, cancer risk)

[Proteomics and PCOS: Is it here the missing link? Literature review]. / Proteómica y síndrome de ovario poliquístico: ¿encontraremos aquí el eslabón perdido? Revisión de la bibliografía.

Polycystic ovary syndrome (PCOS) is known as a common gynecologic and endocrinology disease with multiple short and long-term consequences. It is one of the most common causes for hyperandrogenism and anovulation, increases the risk for metabolic syndrome, type 2 diabetes and cardiovascular disease. Its etiology remains unclear. PCOS is thought to be the result of the interaction between predisposing genetic variants with environmental factors and strongly depends on ethnicity. Proteomics allows the study of several hundreds or thousands of proteins in order to reveal physiological state of a tissue or an organ at the molecular level and to identify disease-specific biomarkers. Its use on PCOS patients will permit us to identify molecules that are involved in the PCOS pathology so we can develop specific diagnostic and management approaches.

Tumoración anexial gigante en paciente con obesidad mórbida: abordaje multidisciplinario / Giant adnexal mass in a morbidly obese patient: multidisciplinary approach

Objetivo: Describir el manejo clínico y terapéutico de las masas anexiales gigantes en pacientes con alto riesgo operatorio debido a obesidad mórbida. Sujetos y métodos: Se presenta una paciente con un índice de masa corporal > 60, afectada de un fibroma ovárico de 13 kg que ocupa toda la cavidad abdominal. Resultados: La imposibilidad de utilizar técnicas de imagen accesorias llevó a realizar un abordaje laparoscópico para descartar malignidad. Se procedió una histerectomía con doble anexectomía laparotomía por un equipo quirúrgico multidisciplinario sin complicaciones. Conclusiones: El manejo de las pacientes con obesidad mórbida y patología anexial gigante por un equipo multidisciplinar es seguro y eficaz (AU)

Objective: To describe the clinical and therapeutic management of giant adnexal masses in morbidly obese patients at high surgical risk. Subjects and methods: We report the case of a patient with a body mass index of over 60 and a 13-kg ovarian fibroma occupying the entire abdominal cavity. Results: Due to the impossibility of using accessory imaging techniques, we employed a laparoscopic approach to exclude malignancy. Hysterectomy with bilateral salpingo-oophorectomy was performed by a multidisciplinary team without complications. Conclusions: Morbidly obese patients with giant adnexal masses can be safely and effectively managed by a multidisciplinary team (AU)

Agenesia congénita de endometrio. Una etiologia inusual de amenorrea primaria / Congenital absence of the endometrium: an unusual cause of primary amenorrhea

Se describe el caso de una paciente de 25 años que presenta amenorrea primaria y esterilidad como consecuencia de la agenesia congénita de endometrio, sin otro tipo de alteraciones fenotípicas, cromosómicas o endocrinológicas asociadas. Se discuten aspectos de la fisiopatología, el diagnóstico y las posibilidades terapéuticas en la actualidad (AU)

We report a case of primary amenorrhea and infertility due to congenital absence of the endometrium in a 25 year-old woman. There were no other malformations or endocrinological or chromosomal alterations. The physiopathological features, diagnosis and current therapeutic options in this malformation are discussed (AU)

Miastenia gravis y diabetes mellitus tipo 1. Evolución durante el embarazo / Myasthenia gravis and type 1 diabetes mellitus. Clinical course during pregnancy

Objetivo: Revisar la evolución de 2 gestaciones consecutivas, en la misma paciente, en las que se asocian miastenia gravis y diabetes mellitus pregestacional. Resultados: Durante la primera gestación, se produjeron 2 recaídas miasténicas, tratadas con piridostigmina e inmunoglobulina. La evolución de la HbA1c fue satisfactoria. Finalizó la gestación en la semana 39 mediante cesárea por pérdida del bienestar fetal, con 8 cm de dilatación. La lactancia fue artificial. En la segunda gestación, el control de la miastenia fue mejor, pero con cifras de HbA1c algo más elevadas. Finalizó mediante cesárea electiva en la semana 39. Conclusiones: Las etapas de mayor riesgo de exacerbación miasténica son el primer trimestre y el posparto. El parto de una paciente miasténica puede evolucionar normalmente, aunque se recomienda acortar el expulsivo. La timectomía no supone un riesgo para el embarazo, para el parto ni para el recién nacido. En relación con la diabetes, HbA1c menores del 6% se asocian con una menor morbilidad y mortalidad materna y fetal

Objective: To review and analyze the clinical course of myasthenia gravis and diabetes mellitus associated in the same patient during two consecutive pregnancies. Results: During the first pregnancy, the patient had two myasthenic relapses, which were treated with pyridostigmine and immunoglobulin. HbA1c levels were satisfactorily controlled. Labor started spontaneously at week 39 and dilatation reached 8 cm but a cesarian section was performed because of fetal distress. Lactation was artificial. In the second pregnancy, the patient was under a better myasthenic control, and HbA1c levels were higher. Elective cesarean section was performed at week 39. Conclusions: The risk of myasthenic recurrence is higher during the first trimester and the postpartum. Vaginal delivery is feasible in patients with myasthenia but shortening of the expulsion period is recommended. Thymectomy does not represent a risk for pregnancy, delivery or the neonate. HbA1c of less than 6% is associated with lower maternal and fetal mortality and morbidity

Ovulation induction with a starting dose of 50 IU of recombinant follicle stimulating hormone in WHO group II anovulatory women: the IO-50 study, a prospective, observational, multicentre, open trial.

OBJECTIVE: To assess the efficacy and safety in clinical practice of a low dose regimen of 50 IU of recombinant follicle stimulating hormone in induction of ovulation. DESIGN: Prospective, observational, non-comparative, open, multicentre study. SETTING: Eighty-eight infertility clinics and teaching hospital fertility units throughout Spain. POPULATION: Women with normogonadotrophic chronic anovulation (WHO group II) with or without echographic diagnosis of polycystic ovary syndrome. METHODS: Low dose step-up protocol of recombinant follicle stimulating hormone administration (follitropin beta, Puregon) with a starting dose of 50 IU and weekly increments according to follicular response monitored prospectively by transvaginal ultrasonography. Patients were followed for a minimum of one cycle and a maximum of six. MAIN OUTCOME MEASURES: Rate and size of follicular growth, cumulative ovulation rate, follicle stimulating hormone doses and duration of treatment, pregnancy and cycle cancellation rate, ovarian hyperstimulation syndrome and multiple pregnancy. RESULTS: A total of 945 treatment cycles were evaluated. In 817 cycles, ovulation was induced with human chorionic gonadotrophin (hCG) and in 501 (61.3%) unifollicular development (a follicle of > or =18 mm) was achieved. A total of 128 cycles (13.5%) were cancelled because of ovarian hyper-responsiveness or spontaneous ovulation. The cumulative ovulation rate (confirmed by mid-luteal serum progesterone concentrations) after six treatment cycles was 84%. There were 136 clinical pregnancies (14.4% pregnancies per cycle). The cumulative pregnancy rate after six treatment cycles was 53.1%. Eight twin pregnancies occurred. Thirteen women miscarried and there were two cases of ectopic pregnancies. The median of average daily doses of follitropin beta in all cycles was 50 IU. Between 68% and 86% of patients received treatment with follitropin beta for a maximum of 14 days. Ovarian hyperstimulation syndrome occurred in 64 (6.8%) cases but no case of severe ovarian hyperstimulation developed. CONCLUSIONS: Low dose regimen of 50 IU of recombinant follicle stimulating hormone (Puregon) is efficient, safe and well tolerated for inducing follicular development in WHO group II anovulatory women.