Transcervical uterine flushing and embryo transfer in sheep: Morphophysiological basis for approaches currently used, major challenges, potential improvements, and new directions (alas, including some old ideas).

At present, the success of non-surgical embryo recovery (NSER) and transfer (NSET) hinges upon the cervical passage of catheters, but penetration of the uterine cervix in ewes is problematic due to its anatomical structure (i.e., long and narrow cervical lumen with misaligned folds and rings). It is a major obstacle limiting the widespread application of NSER and NSET in sheep. While initial attempts to traverse the uterine cervix focused on adapting or re-designing insemination catheters, more recent studies demonstrated that cervical relaxation protocols were instrumental for transcervical penetration in the ewe. An application of such protocols more than tripled cervical penetration rates (currently at 90-95 %) in sheep of different breeds (e.g., Dorper, Lacaune, Santa Inês, crossbred, and indigenous Brazilian breeds) and ages/parity. There is now sufficient evidence to suggest that even repeatedly performed cervical passages do not adversely affect overall health and reproductive function of ewes. Despite these improvements, appropriate selection of donors and recipients remains one of the most important requirements for maintaining high success rates of NSER and NSET, respectively. Non-surgical ovine embryo recovery has gradually become a commercially viable method as even though the procedure still cannot be performed by untrained individuals, it is inexpensive, yields satisfactory results, and complies with current public expectations of animal welfare standards. This article reviews critical morphophysiological aspects of transcervical embryo flushing and transfer, and the prospect of both techniques to replace surgical methods for multiple ovulation and embryo transfer (MOET) programs in sheep. We have also discussed some potential pharmacological and technical developments in the field of non-invasive embryo recovery and deposition.

Effects of different doses of estradiol benzoate used in a cervical relaxation protocol on the success of non-surgical embryo recovery and luteal function in superovulated ewes.

This study investigated the effectiveness of different doses of estradiol benzoate (EB) to promote cervical relaxation and their effects on luteal function and outcomes of non-surgical embryo recovery (NSER) in sheep. Multiparous (MULT) and nulliparous (NULL) crossbred Lacaune X Santa Inês ewes were superovulated and naturally bred. Seven days after progesterone withdrawal, females were randomly assigned to one of three distinct cervical relaxation protocols, consisting of i.m. treatment with 37.5 µg d-cloprostenol and different doses of EB: 0.0 mg (0.0EB group; n = 3 NULL and 14 MULT); 0.5 mg (0.5EB group; n = 4 NULL and 12 MULT) or 1.0 mg (1.0EB group, n = 6 NULL and 11 MULT) 16 h before NSER. All ewes received 50 IU of oxytocin 20 min before NSER (D17). Blood samples were collected and ultrasound exams (B-mode and color Doppler) were performed at two timepoints: immediately before d-cloprostenol and EB treatments and prior to NSER. Estrous behavior, corpora lutea count and NSER success outcomes were not affected by EB treatments nor parity (P > 0.05). Embryo recovery rate was greater for ewes in the 0.5EB group and in the NULL ewes (P < 0.05). Ovarian biometrics differed between the two evaluation timepoints in all groups (P < 0.05). Plasma estradiol increased over time, reaching a significant greater level in 1.0EB ewes compared to controls on D17 (P < 0.05), whereas progesterone concentrations decreased over time in all groups (P > 0.05). In conclusion, treatments did not affect NSER success but they did affect luteal function by altering P4 and E2 concentrations. Therefore, the NSER technique can be successfully performed in ewes with or without prior treatment with EB.

Lower and extended dosage of misoprostol for cervical ripening in 1st trimester miscarriage (MISO200): A randomized clinical trial.

OBJECTIVE: To compare the efficacy of priming the uterine cervix before Manual Vaccum Aspiration (MVA) using 200 µg or 400 µg of vaginal misoprostol, inserted a mean time of 6 h before MVA in first trimester miscarriage. STUDY DESIGN: Randomized, triple-blind, non-inferiority clinical trial. Patients between 18 and 50 years old, with a diagnosis of miscarriage, were eligible for the study. Patients were allocated to receive either 200 µg or 400 µg of misoprostol before the MVA. The primary outcome was the need to dilate the uterine cervix with mechanical dilators (Hegar dilators). As a secondary outcome, cervical dilatation ≥8 mm before the procedure was considered successful. A difference of <25% was considered as non-inferior. RESULTS: Between December 21, 2016 and October 6, 2019, 269 women were screened. After screening, 105 and 106 women received 200 µg and 400 µg of misoprostol, respectively. Mechanical cervical dilatation was not necessary in 84.8% (95%CI 77% to 90%) and 96.2% (95%CI 91% to 99%), in the 200 µg and 400 µg groups, respectively [difference = 11.5% (95%CI 3.7% to 19.2%). Cervical dilatation of ≥8 mm was 52.4% (95%CI 42.9% to 61.7%) in the 200 µg misoprostol group, while in the 400 µg group was 71.7% (95%CI 62.5% to 79.4%) [difference = 19.3% (95%CI 6.5 to 32.2). CONCLUSION: After a mean time of 6 h, 200 µg of vaginal misoprostol is not inferior to 400 µg of misoprostol for cervical priming before MVA, in first trimester miscarriage. This non-inferiority was not observed when the ≥8 mm criterion was considered.

Successful transcervical uterine flushing can be performed without or reduced dose of oestradiol benzoate in cervical relaxation protocol in Dorper ewes.

This study assessed the efficiency of cervical relaxation protocol using none, half or full dose (1.0 mg) of oestradiol benzoate in Dorper ewes subjected to non-surgical embryo recovery (NSER). Thirty-six pluriparous ewes received progestogen sponge (60 mg) for 9 days plus eCG administration (300 IU i.m.) 24 hr before sponge removal. Ewes were not mated and were randomly assigned to receive at 16 hr before NSER 37.5 µg d-cloprostenol i.m. and different doses of oestradiol benzoate: 0.0 mg (0EB group; n = 12); 0.5 mg (0.5EB group; n = 12) or 1.0 mg of oestradiol (1.0EB group, n = 12). All ewes received oxytocin (50 IU) i.v. 20 min before NSER, which was performed 8 days after sponge removal. Corpora lutea were counted by transrectal ultrasonography 24 hr before NSER. After procedure, the ewes were kept in natural breeding period to check their post-NSER fertility. NSER was performed in 91.7% (33/36) of the animals with overall fluid recovery efficiency over 97% (p > .05). The cervical transposing with Hegar dilator was longer (p < .05) in 0EB (4.2 ± 0.3 min) compared to 0.5EB (1.7 ± 0.3 min) and 1.0EB group (1.5 ± 0.3 min). The cervical transposing with mandrel/catheter was longer (p < .05) in 0EB (2.4 ± 0.5 min) than 1.0EB group (1.3 ± 0.5 min). Overall duration of uterine flushing was 25.4 min with structure recovery rate of 43.5%, with no difference among groups (p > .05). The post-NSER fertility was higher (p < .05) in 0.0EB (90%) than 0.5EB group (36.4%). In conclusion, NSER can be successfully performed in Dorper ewes by using a cervical relaxation protocol without oestradiol benzoate.

Preovulatory follicular dynamics, ovulatory response and embryo yield in Lacaune ewes subjected to synchronous estrus induction protocols and non-surgical embryo recovery.

The objective of this study was to assess the effect of the duration of progesterone-based estrus induction protocols on preovulatory follicular dynamics, ovulatory response, and embryo yield after non-surgical embryo recovery (NSER) in Lacaune ewes. Females received acetate medroxyprogesterone intravaginal sponges for six (G-6; n = 14) or nine (G-9; n = 14) days plus d-cloprostenol and eCG 24 h before sponge removal (Day 0). Preovulatory follicular dynamics and the luteal characteristics are evaluated by B-mode and Color-Doppler ultrasonography. NSER was performed five to six days after ovulation. The estrous behavior rate was 85.7% for both groups, and the percentage of ewes that ovulated was 92.9% in G-6 and 100% in G-9. The day of wave emergence (relative to Day 0) did not differ (P > 0.05) between G-6 (-3.0 ±â€¯0.5) and G-9 (-4.2 ±â€¯0.5). The number of follicles of size 4.1-5.0 mm was higher (P < 0.05) in G-9 (1.4 ±â€¯0.2) compared to G-6 (0.8 ±â€¯0.2) during the Days -4 to 0. At NSER, the transcervical penetration rate was 95.2% (20/21) and its duration time was lower (P < 0.05) in G-9 (3.4 ±â€¯0.6 min) than in G-6 (7.2 ±â€¯1.3 min). The number of ovulations and viable embryos was higher (P < 0.05) in G-9 (2.9 ±â€¯0.3 and 1.3 ±â€¯0.4, respectively) than in G-6 (1.9 ±â€¯0.3 and 0.4 ±â€¯0.2, respectively). In conclusion, the 9-day protocol promoted higher ovulation rate and embryo yield; moreover, the cervical dilation treatment allowed NSER in a high percentage of Lacaune ewes.

Combined treatment with oestradiol benzoate, d-cloprostenol and oxytocin permits cervical dilation and nonsurgical embryo recovery in ewes.

This study examined the feasibility of transcervical embryo recovery after the hormonal treatment to induce cervical dilation, following the 7-day oestrous synchronization protocol in multiparous Santa Inês ewes. A total of 23 cyclic ewes received two doses of 37.5 µg of d-cloprostenol by latero-vulvar route 7 days apart. After the second injection of d-cloprostenol, the ewes were checked for oestrus (every 12 hr) and then mated by fertile rams throughout the oestrous period. All ewes received 37.5 µg of d-cloprostenol (latero-vulvar) and 1 mg of oestradiol benzoate by either intramuscular (EBim group; n = 12) or intravaginal (EBivg group; n = 11) route 16 hr before embryo flushing. Twenty minutes before the flushing, 50 IU of oxytocin were administered intravenously. The oestrous response (i.e., the percentage of ewes that showed signs of oestrous behaviour after the second d-cloprostenol injection) was 91.3% (21/23). The proportion of successfully penetrated ewes (81.8% compared with 80.0%), the mean duration of embryo flushing (24.7 ± 2.0 min compared 26.2 ± 1.9 min), the flushing fluid recovery rate (94.8 ± 1.3% compared with 91.0 ± 2.9%) and the average number of structures recovered per ewe (0.5 ± 0.4 compared with 0.8 ± 0.4) did not vary (p > 0.05) between the EBim and EBivg groups. Viable embryos were recovered from 41.2% (7/17) of successfully penetrated ewes. It can be concluded that nonsurgical (i.e., transcervical) embryo collection can be performed in oestrous-synchronized Santa Inês ewes pretreated with d-cloprostenol, oxytocin and oestradiol benzoate, with the latter hormone administered by either the intramuscular or intravaginal route.

Colheita transcervical de embriões em ovelhas e cabras / Transcervical embryo collection in ewes and does

A biotécnica de múltipla ovulação e transferência de embriões (MOTE) em pequenos ruminantes tem aplicações que se estendem da pesquisa básica à aplicada. Porém, ainda existem etapas no processo da biotécnica que reduzem sua eficiência e restringem sua utilização, a exemplo da necessidade de procedimentos cirúrgicos. Em caprinos, já é possível realizar a MOTE sem nenhuma intervenção cirúrgica e com resultados satisfatórios. Todavia, em ovinos, as particularidades anatômicas da cérvix dificultam sua transposição, fazendo com que etapas cirúrgicas ainda sejam necessárias. Com foco nessa limitação, tem-se estudado e descrito técnicas para a dilatação cervical e métodos para triagem de doadoras de embrião com maior facilidade para transposição cervical. Assim, a colheita não cirúrgica, principalmente na espécie ovina, vem se tornando uma realidade exequível em condições de campo e pesquisa.

In small ruminants, the multiple ovulation and embryo transfer (MOET) has applications in basic and applied research. However, there are still drawbacks in this biotechnology hampering its applicability and efficiency, as the need of surgical intervention. In goats, it is possible to perform MOET without any surgical procedure and with satisfactory results. Although, in sheep, the anatomical features of the cervix make transcervical transposition challenging, leading to a wider use of surgical steps in this specie. In the attempt to overcome these limitations, techniques for cervical dilation and methods for screening donors with cervices that can be easily transposed have been studied and described. Therefore, the nonsurgical embryo collection, mainly in the ovine species, has become feasible under field and research conditions.

Colheita transcervical de embriões em ovelhas e cabras / Transcervical embryo collection in ewes and does

A biotécnica de múltipla ovulação e transferência de embriões (MOTE) em pequenos ruminantes tem aplicações que se estendem da pesquisa básica à aplicada. Porém, ainda existem etapas no processo da biotécnica que reduzem sua eficiência e restringem sua utilização, a exemplo da necessidade de procedimentos cirúrgicos. Em caprinos, já é possível realizar a MOTE sem nenhuma intervenção cirúrgica e com resultados satisfatórios. Todavia, em ovinos, as particularidades anatômicas da cérvix dificultam sua transposição, fazendo com que etapas cirúrgicas ainda sejam necessárias. Com foco nessa limitação, tem-se estudado e descrito técnicas para a dilatação cervical e métodos para triagem de doadoras de embrião com maior facilidade para transposição cervical. Assim, a colheita não cirúrgica, principalmente na espécie ovina, vem se tornando uma realidade exequível em condições de campo e pesquisa.(AU)

In small ruminants, the multiple ovulation and embryo transfer (MOET) has applications in basic and applied research. However, there are still drawbacks in this biotechnology hampering its applicability and efficiency, as the need of surgical intervention. In goats, it is possible to perform MOET without any surgical procedure and with satisfactory results. Although, in sheep, the anatomical features of the cervix make transcervical transposition challenging, leading to a wider use of surgical steps in this specie. In the attempt to overcome these limitations, techniques for cervical dilation and methods for screening donors with cervices that can be easily transposed have been studied and described. Therefore, the nonsurgical embryo collection, mainly in the ovine species, has become feasible under field and research conditions.(AU)

Descripción de la curva de trabajo de parto en un hospital de tercer nivel de atención / Description of the labor curve in a third-level care hospital

Resumen OBJETIVO Describir la curva de trabajo de parto en una muestra de pacientes atendidas en el Hospital de Ginecoobstetricia Luis Castelazo Ayala y sentar las bases para redefinir el trabajo de parto normal en la paciente primigesta y, por ende, sus alteraciones. MATERIALES Y MÉTODOS Estudio retrospectivo y descriptivo efectuado en pacientes primigestas sanas con embarazo entre 37 y 41 semanas atendidas para parto eutócico en el Hospital de Ginecoobstetricia Luis Castelazo Ayala del Instituto Mexicano del Seguro Social. Descripción del patrón de progresión del primer estadio de trabajo de parto y de la relación entre el tiempo y la dilatación cervical. RESULTADOS Se incluyeron 370 pacientes primigestas sanas. El trabajo de parto duró, en promedio, 862 minutos (14 horas y 12 minutos). La curva de trabajo de parto graficada fue una pendiente con curva ascendente, con una fase de aceleración desde el inicio de los 4 centímetros de dilatación; a partir de ese momento la duración promedio del trabajo de parto fue de 234 minutos (3 horas y 54 minutos), con un patrón de dilatación de 0.4-0.7 cm por h. CONCLUSIÓN La curva del primer estadio del trabajo de parto de las pacientes estudiadas tuvo un patrón de pendiente ascendente, con una aceleración mayor a partir de los 4 cm de dilatación. Nuestra curva difiere en su morfología de la clásica curva sigmoide de atención de parto de Friedman; a pesar de ello ambas curvas coinciden en que el trabajo de parto entra en su fase activa a los 4 centímetros de dilatación.

Abstract OBJECTIVE To describe the labor curve and the dilation-time ratio of the first stage of labor in a group of patients of the Hospital de Ginecoobstetricia Luis Castelazo Ayala. MATERIALS AND METHODS A retrospective and descriptive study with 370 healthy pregnancy primiparous patients between 37 and 41 gestation weeks admitted in the Obstetrics & Gynecology Hospital "Luis Castelazo Ayala" of the Mexican Social Security Institute. All patients were attended of eutocic delivery without any complication. We reviewed the partogram and the progression of cervical dilation on the first stage of labor. By observing the relationship between time and cervical dilation we described we elaborate a labor curve. RESULTS Labor in its entirety lasted on average 862 minutes (14 hours and 12 minutes). The delivery labor curve graphed was a slope upward curve, with an acceleration phase from 4 centimeters dilated, from that moment the duration of labor average was 234 minutes (3 hours and 54 minutes), with a dilating pattern of 0.4-0.7 cm / h. CONCLUSION The curve of the first stage of labor we studied has an upslope pattern, with an increased acceleration from 4 centimeters of dilation. Our curve differs from the classical sigmoid curve care delivery Dr. Friedman in their basic morphology, however both curves agree that labor enters its active phase in the 4 centimeters of dilation.

Experiencia con un dispositivo para dilatación cervical controlada / Experience with a device for controlled cervical dilation

Resumen OBJETIVO: Observar y valorar la eficacia y seguridad en humanos de este nuevo dispositivo para dilatación cervical. MATERIALES Y MÉTODOS: Estudio prospectivo, experimental y de intervención, efectuado en pacientes atendidas entre los meses de enero a diciembre de 2015 en el Hospital General Santa María del Puerto (España) a quienes se realizaron procedimientos diagnósticos y terapéuticos ginecológicos que requirieron dilatación cervical; se utilizó el dispositivo Aqueduct-100®. RESULTADOS: se estudiaron 50 pacientes con edad media de 50 años. Hubo dos grupos de tratamiento: 1) 38 pacientes con dilatación de 5 minutos y 2) 12 con 3 minutos. La indicación más frecuente del procedimiento fue la histeroscopia diagnóstica (44%). El diámetro cervical medio, inicial y posterior al procedimiento, fue de 2.8 y 7.7 mm, respectivamente. La valoración del dispositivo por los especialistas fue de buena a excelente. No se registraron complicaciones relacionadas con el proceso de dilatación cervical. CONCLUSIONES: El dispositivo estudiado es una alternativa sencilla y efectiva para la realización de maniobras de dilatación cervical, previas a diversos procedimientos intrauterinos y endometriales.

Abstract OBJECTIVE: To observe and assess the efficacy and safety of this new cervical dilator device, for the first time in humans. Thus, if the study is successful, raise a second phase through a randomized clinical trial, which purpose shall be to show if there is a superiority of this device with respect to common mechanics dilators. MATERIALS AND METHODS: Prospective, experimental intervention study, in patients undergoing gynecological diagnostic and therapeutic procedures, requiring cervical dilatation, using the Aqueduct - 100®, the Hospital General Santa María del Puerto (Spain). The study included 50 patients who met the criteria for inclusion, in the period January-December 2015. RESULTS: The mean age of the patients was 52.6 years. They were divided into two treatment groups: 38 patients were subjected to a process of expansion of 5 minutes and 12 3-minute processes. The description of the most frequent procedure was the realization of a diagnostic Hysteroscopy (44%). The cervical diameter medium, both initial and subsequent procedure was 2.8 and 7.7 mm, respectively. The valuation of the device by the specialists who used it, ranged between good and excellent rating for all items. There was no complication associated with the process of cervical dilatation with the device. CONCLUSIONS: The Aqueduct - 100® device can be a simple and effective alternative to perform cervical dilatation maneuvers necessary for performing gynecological procedures, intrauterine and endometrial level.