Perioperative low-dose ketamine improves postoperative analgesia following Cesarean delivery with general anesthesia.

OBJECTIVE: In this study, the effect of perioperative uses of low dose ketamine on post-operative wound pain and analgesic consumption in patients undergoing elective Cesarean section was evaluated. METHODS: In randomized, double blind clinical trial, 52 women with American Society of Anesthesiologists (ASA) class I-II identification undergoing elective Cesarean section in general anesthesia were enrolled. In the ketamine group (group K), a ketamine bolus of 0.5 mg kg(-1) IV was administered at the time of induction of general anesthesia. After induction, a ketamine infusion of 0.25 mg kg(-1) h(-1) was started and discontinued at the end of surgery. Patients allocated to the control group (group C) were given identical volumes of saline. The cumulative dose of morphine consumption after surgery was measured as the primary outcome of this study. Secondary outcomes were pain control assessed by numeric rating scale (NRS) and need for rescue analgesia and incidence of side effects. RESULTS: The mean 24-h morphine consumption was lower in group K (p = 0,001). At 15 min postoperatively, NRS values were lower in group K than group C (p = 0,001). There was no difference among groups regarding the need for supplemental analgesia (rescue diclofenac doses) (p > 0.05). CONCLUSIONS: Perioperative uses of low dose ketamine decreased post-operative opioid requirements, which was observed long after the normal expected duration of ketamine.

Practice of embryo transfer: recommendations during and after.

Many patient and embryo factors influence the outcome of assisted reproductive technology (ART) treatment. The predictors for a successful ART cycle include female age, ovarian reserve, embryo quality, endometrial receptivity, and embryo transfer (ET) technique. ET, the final step of ART, has recently been noted as a crucial step affecting ART success. Variables affecting pregnancy rates following ET include ultrasound guidance, ease of ET transfer, catheter type, transfer and catheter-loading technique, blood or mucus effects, retained embryos, trial transfer, the physician's experience, and catheter tip placement. Despite the lack of consensus regarding the optimal ET technique, it is generally recommended that during ET, the disruption of the endometrium and the induction of uterine contractions should be avoided. The exposure of embryos to the ambient conditions should be minimized, and the embryo(s) should be placed at an optimal position within the fundal region of the uterine cavity.

Which cut-off value of serum anti-Müllerian hormone level can predict poor ovarian reserve, poor ovarian response to stimulation and in vitro fertilization success? A prospective data analysis.

The aim of our study is to demonstrate which cut-off value of serum anti-Müllerian hormone (AMH) level can predict poor ovarian reserve, poor ovarian response to stimulation and IVF outcomes. About 311 of 520 women enrolled IVF treatment cycle that meets inclusion criteria were recruited for this prospective data analysis. Data were collected for: age, duration of infertility, basal FSH and AMH level, total dosage of gonadotropins, maximum estradiol levels, duration of stimulations, total number of oocytes retrieved and clinical PR. Mean AMH was 1.76 ± 1.4 ng/ml and mean age was 33.25 ± 5.5 years. Clinical PR was 39.8% (n = 124). AMH was inversely correlated to total dosage of gonadotropins and age, AMH positively had a significant correlation with maximum estradiol levels, duration of stimulations and total number of oocytes retrieved. The patients in both categories of AMH levels, ≤0.5 and ≤1 ng/ml responded poorly to ovarian stimulation, had significantly higher total dosage of gonadotropins used and FSH levels on cycle day 3, lower maximum E2 levels and clinical PR. AMH could be an acceptable screening test in prediction of ovarian reserve, response to ovarian stimulation and PRs. AMH cut-off value ≤1 ng/ml may predict poor ovarian reserve, poor ovarian response to stimulation and IVF outcomes.

A potential novel strategy, inhibition of vasopressin-induced VEGF secretion by relcovaptan, for decreasing the incidence of ovarian hyperstimulation syndrome in the hyperstimulated rat model.

OBJECTIVE: To investigate the effects of V1A receptor antagonist through inhibition of vasopressin-induced VEGF secretion in an experimental model. STUDY DESIGN: Thirty rats were randomly divided into five groups. Four groups were given 10IU pregnant mare serum gonadotropin/day (sc) at 8:00-8:30am on days 22-25 of life. They were administered 30IU hCG at 8:00-8:30am on day 26 of life. On days 26 and 27 of life at 8:00am and 4:00pm, (ip) per animal, 50µg/kg/day GnRH antagonist in the GnRH antagonist group, 0.3mg relcovaptan in the high dose relcovaptan group, and 0.15mg relcovaptan in the low dose relcovaptan group were administered. The control group was given the same dosage of 0.9% saline solution (ip) on days 22-26 day of life. The main outcomes were weight gain, ovarian weights, peritoneal fluid VEGF values, corpus luteum count, and atretic follicle count. RESULTS: Weight gain was highest in the OHSS group; it was almost twice as much in the OHSS group than it was in the control group. Ovarian weights were significantly lower in all treatment groups (p=0.03). There was no statistically significant difference in ovarian weights between the GnRH antagonist and relcovaptan groups (p=0.176). The evaluation of peritoneal fluid VEGF-A levels revealed statistically significant differences between levels in the treatment groups and in the OHSS group (p=0.005). Atretic follicle count in the OHSS group was significantly lower (p=0.048). In all treatment groups, CL counts were prominently lower than they were in the OHSS group (p=0.002). CONCLUSION: Relcovaptan may be a novel strategy for decreasing risk of OHSS by inhibition of vasopressin-induced VEGF secretion through V1A receptor antagonist.

The importance of the length of uterine cavity, the position of the tip of the inner catheter and the distance between the fundal endometrial surface and the air bubbles as determinants of the pregnancy rate in IVF cycles.

OBJECTIVE: To evaluate the relationship between the pregnancy rate (PR) and the positioning of the intrauterine catheter at embryo transfer (ET) under transabdominal ultrasound (US) guidance in in vitro fertilization (IVF) cycles. STUDY DESIGN: Prospective data analysis of 281 consecutive US-guided fresh ETs performed by a single physician at Yeditepe University Hospital IVF Center, Istanbul, Turkey, after controlled ovarian hyperstimulation between April 2012 and March 2013. The length of the uterine cavity (A), the distance between the fundal endometrial surface and the tip of inner catheter (B), the distance between the fundal endometrial surface and the air bubbles (C), and the pregnancy rates (PRs) were recorded. RESULTS: The mean age of the patients was 33.25±5.5 years. Of all transfers, 115 (40.9%) resulted in a clinical pregnancy. With regard to distance (C), the clinical intrauterine pregnancy rates were 65.2%, 32.2% and 2.6% in the <10mm, 10-20mm, and 20mm distance groups, respectively. The PR was dramatically reduced in cases with >10mm between the fundal endometrial surface and the air bubbles, although this did not reach statistical significance. Between those patients who conceived and those who did not, there was no significant difference in terms of the distance between the fundal endometrial surface and the tip of inner catheter, the ratio of A/B or the ratio of B/C. CONCLUSIONS: The final position of the air bubble used as an identifier of the position of the embryo at ET can be determinative for PR, although it cannot be predicted. Clinical pregnancy rates appeared higher in cases with air bubbles closer to the fundus and the optimal position of the air bubble seems to be a distance of <10mm from the fundal endometrial surface. It could be advisable to monitor the final position of air bubble at ET for identifying PR. In addition, the depth of uterine cavity may be considered to indirectly be important factor as it affects ET depth. The optimal distance between the fundal endometrial surface and the tip of inner catheter is 1.5-2cm. Further well-designed randomized controlled trials are required to optimize ET technique in the future.

The Diagnosis and Management of Asherman's Syndrome Developed after Cesarean Section and Reproductive Outcome.

Intrauterine adhesions (IUAs) frequently occur as a result of trauma to the basal layer of endometrium following pregnancy-related curettage such as incomplete abortion (33,3%), postpartum hemorrhage (37,5%), and elective abortion (8,3%). Hysterotomy, myomectomy, Cesarean section, hysteroscopic procedures, such as resection of submucosal leiomyomata or uterine septae, and endometrial ablation are less common etiologic factors resulting in IUA formation. Patients with Asherman's syndrome usually present with menstrual disturbances, infertility, or recurrent pregnancy loss. A successful treatment of infertility could be achieved by restoration of the uterine cavity, prevention of IUA reformation, and promotion of healing process. We presented the diagnosis and management of a case that suffers from menstrual disturbances and secondary infertility resulted from IUA formation developed after Cesarean section.