Inter-cycle and inter-observer variability of the antral follicle count in routine clinical practice.

Antral follicle count (AFC) is a reliable predictor of ovarian response to stimulation and its inter-cycle and inter-observer variability has been extensively studied on in vitro fertilization (IVF), mostly in highly selected populations within studies not originally designed for this purpose. In this retrospective cohort study, we assess the inter-cycle variation of AFC in a setting similar to that of the daily practice. We included only patients undergoing mild stimulation for intrauterine insemination (IUI). One hundred and forty-eight patients had two (62 patients, group A), three (49 patients, group B) or four (37 patients, group C) IUI cycles and AFC was measured on early follicular phase of each cycle by one of the members of the medical team within daily practice. Intra-class correlation coefficients were used to estimate variability. Inter-cycle variability rendered ICCs above 0.70 in all groups improving along with the number of cycles [Group A ICC 0.78 (95%CI 0.66-0.86), Group B ICC 0.87 (95%CI 0.80-0.92) and Group C ICC 0.91 (95%CI 0.85-0.95)]. Inter-observer variability showed a high degree of concordance with ICCs above 0.95. We provide the closest approximation to real inter-cycle and inter-observer AFC variability expected in routine clinical practice.

Antral Follicle Priming Before Intracytoplasmic Sperm Injection in Previously Diagnosed Low Responders: A Randomized Controlled Trial (FOLLPRIM).

CONTEXT: A low response to controlled ovarian hyperstimulation implies a reduced number of embryos and impaired pregnancy rate. Follicular priming with steroids before controlled ovarian hyperstimulation has been suggested to improve the subsequent ovarian response. OBJECTIVE: The purpose of this study was to determine the best follicular priming protocol in low responders and to investigate the intrafollicular mechanisms triggered by steroid hormone priming. DESIGN: This was a single-center, randomized, parallel, open-label, controlled trial, in two phases. SETTING: The setting was a university-based in vitro fertilization unit. PATIENTS: Potential low responders (n = 99) underwent a first intracytoplasmic sperm injection cycle. Confirmed low responders (n = 66) were randomized to different priming protocols before a new intracytoplasmic sperm injection. INTERVENTIONS: Randomized patients underwent one of the following priming strategies: transdermal testosterone (20 µg/kg/d), transdermal estradiol (200 µg/d), or combined estrogens and oral contraceptive pills (30 µg of ethinyl estradiol plus 150 µg of desogestrel administered during the luteal phase of two consecutive cycles) and 4 mg/d of estradiol valerate during the follicular phase between them. MAIN OUTCOMES MEASURES: Metaphase II (MII) oocytes were retrieved. Gene expression levels in the granulosa cells of steroidogenesis enzymes and FSH, LH, and androgen receptors were measured. RESULTS: The number of retrieved MII oocytes did not differ between the interventional groups (testosterone, 2.2 ± 2.0; estrogen, 2.7 ± 1.7; and combined estrogens and oral contraceptive pills, 2.0 ± 1.3; not significant). Compared with those in nonprimed cycles, estradiol pretreatment yielded more MII oocytes (primed, 2.7 ± 1.7; nonprimed, 1.6 ± 1.2; P = .029) although the clinical pregnancy rate was higher in patients treated with testosterone (P = .003). Testosterone pretreatment increased androgen receptor expression (P = .028) compared with that for the previous cycle without priming. CONCLUSIONS: The results of the present trial do not support the superiority of one priming strategy over the others.

Scar abscess six years after cesarean section: Laparoscopic and hysteroscopic management.

Long-term infection of pelvic organs after cesarean section is a rare event still associated with maternal morbidity. Undrained collection of pus is associated with persistent fever. Hysterectomy has been classically suggested as a safe option to treat this kind of lesion. We present the case of a patient who presented an abscess in the cesarean section scar tissue 6 years after the surgery. The myometrium covering the abscess was almost absent. This lesion was first managed with antibiotic therapy and ultrasound-guided aspiration. After failure of the initial therapy, this situation was managed by hysteroscopic fulguration of the capsule under laparoscopic control. For patients with abscesses spreading into the uterine cavity, endoscopic management is a feasible and safe intervention that may be offered to the patient after a correct evaluation.