Delphi consensus on add-ons and social midia in Assisted Reproductive Technology.

This article reports the annals of a national consensus meeting on add-ons and social networks in Assisted Reproduction Techniques (ART). The panel of experts has developed a set of consensus points and this document is intended to be referenced as a national consensus to allow social networks and add-ons to be used in ART, following the standards of the Code of Medical Ethics and the Federal Council of Medicine, in a safe ethical and responsible way.

Oocyte Morphology and Reproductive Outcomes - Case Report and Literature Review.

Oocyte quality could be negatively affected by many factors including smoking, alcohol consumption, obesity, woman's age, endometriosis and controlled ovarian stimulation (COS), during assisted reproductive technology (ART), in addition to genetic factors, such as hormone receptor polymorphisms, for example. We know that the increase in the reactive oxygen species (ROS) due to systemic disorders causes biochemical and morphological changes to the oocytes, interfering with their quality. The oocyte dysmorphism can be expressed through intra and/or extra cytoplasmic changes. In general, the size and number of oocytes' morphological abnormalities are directly related to preimplantation development failure. This case report is based on four in vitro fertilization (IVF) cycles performed by a patient with oocyte dysmorphism in all oocytes captured. The literature review on this topic aims to relate the characteristics of the oocytes, presented in the case report, with research results about the quality and morphology of the oocytes.

Embryo placement in IVF and reproductive outcomes: a cohort analysis and review.

OBJECTIVE: The objective of the present study was to determine the influence of the embryo placement depth on the endometrial cavity in relation to the reproductive outcomes, after frozen-thawed embryo transfer performed under transabdominal ultrasound guidance. METHODS: Retrospective cohort study that evaluated the influence of the embryo placement depth in the endometrial cavity in relation to the reproductive outcomes of patients submitted to cryotransfer cycles at a private assisted reproduction clinic, from 2012 to 2017. The patients were classified according to three variables: <10mm, 10 to 15mm and >15mm. The primary outcome was clinical pregnancy, and the secondary outcomes were miscarriage, ongoing pregnancy and live birth. The data was summarized as relative risk, with a 95%CI. RESULTS: Clinical and ongoing pregnancy rates were higher in the 10-15mm and >15mm Groups, when compared to the <10mm Group; there was no statistical difference between the groups in terms of miscarriage and live birth rates. We performed a subsequent analysis, using the same sample of patients, comparing only the <10mm and ≥10mm variables. The ≥10mm Group had better reproductive outcomes, with higher clinical and ongoing pregnancy rates. CONCLUSION: Pregnancy rates are influenced by embryo transfer site, and better results can be achieved when the tip of the catheter is placed in the central area of the endometrial cavity, especially when the distance from the endometrial fundus is >10mm.

Oral dydrogesterone vs. vaginal progesterone capsules for luteal-phase support in women undergoing embryo transfer: a systematic review and meta-analysis.

OBJECTIVE: To identify, appraise, and summarize the evidence from randomized controlled trials (RCTs) comparing oral dydrogesterone to vaginal progesterone capsules for luteal-phase support (LPS) in women offered fresh or frozen embryo transfers following in vitro fertilization. METHODS: Two independent authors screened the literature for papers based on titles and abstracts, then selected the studies, extracted data, and assessed the risk of bias. Dydrogesterone and progesterone were compared based on risk ratios (RR) and the precision of the estimates was assessed through the 95% confidence interval (CI). RESULTS: An electronic search performed on June 7, 2017 retrieved 376 records, nine of which were papers deemed eligible and included in this systematic review and quantitative analysis. Good quality evidence indicates that oral dydrogesterone provided at least similar results than vaginal progesterone capsules on live birth/ongoing pregnancy (RR=1.08, 95%CI=0.92-1.26, I2=29%, 8 RCTs, 3,386 women) and clinical pregnancy rates (RR 1.10, 95% CI 0.95 to 1.27; I2=43%; 9 RCTs; 4,061 women). Additionally, moderate quality evidence suggests there is no relevant difference on miscarriage rates (RR=0.92, 95%CI=0.68-1.26, I2=6%, 8 RCTs, 988 clinical pregnancies; the quality of the evidence was downgraded because of imprecision). CONCLUSIONS: Good quality evidence from RCTs suggest that oral dydrogesterone provides at least similar reproductive outcomes than vaginal progesterone capsules when used for LPS in women undergoing embryo transfers. Dydrogesterone is a reasonable option and the choice of either of the medications should be based on cost and side effects.

Corifollitropin alfa compared to daily rFSH or HP-HMG in GnRH antagonist controlled ovarian stimulation protocol for patients undergoing assisted reproduction.

OBJECTIVE: This study aimed to compare the outcomes of controlled ovarian stimulation (COS) with corifollitropin alfa versus daily recombinant follicle-stimulating hormone (rRFSH) or highly purified human menopausal gonadotropin (HP-HMG) in patients undergoing in vitro fertilization (IVF) cycles based on gonadotropin-releasing hormone (GnRH) antagonist protocols. The primary endpoints were total number of oocytes and mature oocytes. METHODS: This retrospective study looked into 132 controlled ovarian stimulation cycles from IVF or oocyte cryopreservation performed in a private human reproduction center between January 1 and December 31, 2014. Enrollment criteria: women aged < 40 years submitted to COS with corifollitropin alfa 100µg or 150µg (n = 26) and rFSH or HP-HMG in the first seven days of treatment with daily doses of 150-225 IU (n = 106); all subjects were on GnRH antagonist protocols. RESULTS: The groups had similar mean ages and duration of stimulation. The mean number ± standard deviation of total aspirated oocytes and MII oocytes was 11.9±10 and 10.3±7.9 in the corifollitropin alfa group, and 10.9±7.2 and 8.6±5.7 in the group on rFSH or HMG (p>0.05). There were no significant differences in fertilization (76.9% vs. 76.8%, p=1.0), biochemical pregnancy (66.7% vs. 47.2%, p=0.1561) or embryo implantation rates (68.7% vs. 50%, p=0.2588) between the groups using corifollitropin alfa and rFSH or HMG, respectively. CONCLUSIONS: Corifollitropin alfa seems to be as effective as rFSH or HP-HMG when used in the first seven days of ovulation induction for patients undergoing assisted reproduction in GnRH antagonist protocols.

Novel technique for adhesion barrier insertion by using cut-off surgical glove fingers in laparoscopic surgery.

AIM: Laparoscopic surgery causes fewer postoperative adhesions than laparotomy and adhesion barriers are used to lessen the chance of adhesion. Sodium hyaluronate and carboxymethylcellulose (SH-CMC), a bioresorbable membrane, is effective in preventing adhesions. However, its properties make it difficult to insert the film into the abdominal cavity and to place it into the target area during laparoscopic surgeries. Here we report a novel technique for applying SH-CMC during laparoscopic surgeries by using cut-off surgical glove fingers. METHODS: In our dry-box experiment, we found that SH-CMC became more flexible after moisturizing for 30 s. Therefore, for this procedure, we moisturizing both sides of the SH-CMC sheet (7.35 × 6.35 cm) on wet gauze (for 30 s). The film was rolled into cut-off surgical glove fingers and inserted into the abdominal cavity through a 12-mm trocar. The film was then removed from the glove finger and unrolled onto the target area (glove-finger method). RESULTS: The dry-box experiment revealed that moisturizing both sides of SH-CMC for 30 s/side, 15 min after package removal, made the film more flexible. Ninety of 96 attempts with SH-CMC were successful among the 24 patients who underwent total laparoscopic hysterectomy with our glove-finger method. CONCLUSION: Our glove-finger method can realize the smooth application of SH-CMC to the target area during laparoscopic surgeries.

Embryo stage of development is not decisive for reproductive outcomes in frozen-thawed embryo transfer cycles.

OBJECTIVE: To evaluate if the outcomes of IVF/ICSI in frozen-thawed embryo transfer and fresh embryo transfer cycles differ in relation to cleavage and blastocyst stages. METHODS: Retrospective cohort study to compare IVF/ICSI outcomes between fresh embryo transfer and frozen-thawed embryo transfer cycles, according to the stage of embryo development. Analysis was carried out on 443 consecutive embryo transfer cycles performed between January 1st and December 31st, 2014. Women aged up to 38 and submitted to embryo transfer cycles with fresh (n = 309) or frozen-thawed (n = 134) embryos at a private center for assistance in human reproduction were considered for analysis. Results in each group were stratified according to the stage of embryo development: cleavage stage and blastocyst stage. Main outcome measures were implantation rate, clinical pregnancy rate, ongoing pregnancy rate and live birth rate per cycle. RESULTS: In the fresh embryo transfer group, for cleavage stage versus blastocyst stage, respectively, implantation rates were 22% and 47% (p = 0.0005); clinical pregnancy rates were 34% and 64% (p = 0.0057); the ongoing pregnancy rates were 30% and 61% (p = 0.0046) and live birth rates were 28% and 55% (p = 0.0148). There were no significant differences in the rates between cleavage and blastocyst stages in the frozen-thawed group, neither between fresh and frozen-thawed cleavage embryo transfers nor between fresh and frozen-thawed blastocyst transfers. CONCLUSION: Our results confirm that blastocyst transfer is better than cleavage stage in fresh embryo transfer cycles. In frozen-thawed cycles, cleavage or blastocyst stages seem to offer similar reproductive outcomes.

Indução de ovulação em pacientes com tumor estrogênio­dependente: diretrizes clínicas da Sociedade Brasileira de Reprodução Humana / Ovulation induction in patients with estrogen­dependent tumors: a Brazilian Society of Human Reproduction clinical practice guideline

A oncofertilidade é um campo de interesse interdisciplinar de desenvolvimento recente que busca mesclar os conhecimentos em oncologia e medicina reprodutiva, com a contribuição das técnicas de reprodução assistida, para o desenvolvimento de estratégias de preservação da função gonadal e oferecer a possibilidade da procriação biológica aos sobreviventes de câncer. As estratégias de preservação da fertilidade feminina em pacientes oncológicas atualmente aceitas para a prática rotineira são a criopreservação de embriões e a criopreservação de oócitos maduros. Ocorre que, para execução de ambos, a indução de ovulação é obrigatória e, com ela, vêm os riscos teóricos de estimulação do crescimento de tumores estrogênio­dependentes e a postergação do início do tratamento antineoplásico. Os protocolos de estimulação ovariana de início aleatório contemplam a intenção de se minimizar o atraso no início da quimioterapia ou radioterapia e o bloqueio ao crescimento tumoral e oferecem resultados satisfatórios, semelhantes aos obtidos em protocolos de início habitual. Apresentamos neste artigo as diretrizes clínicas da Sociedade Brasileira de Reprodução Humana para indução de ovulação em pacientes com tumor estrogênio­dependente.(AU)

Oncofertility is an interdisciplinary interest field of recent development, which aims to merge the knowledge in oncology and reproductive medicine, with the help of assisted reproductive technologies, to develop strategies for gonadal function preservation and to offer the possibility of biological procreation to cancer survivors. Preservation strategies of female fertility in oncological patients currently accepted for routine practice are the cryopreservation of embryos and cryopreservation of mature oocytes. It happens that ovulation induction is mandatory for executing both strategies, and with it the theoretical risk of stimulation of estrogen­dependent tumors growth and the postponement of anti­neoplastic treatment. Random­start ovarian stimulation protocols include the intention of minimizing the delay in onset of chemo­radiotherapy and to block tumor growth, providing satisfactory results, similar to those obtained in the usual beginning protocols. This article presents the clinical guidelines of the Brazilian Society of Human Reproduction for ovulation induction in patients with estrogen­dependent tumors.(AU)

Reproductive planning in times of Zika: getting pregnant or delaying plans? The opinion of the Brazilian Society of Assisted Reproduction Committee - a basis for a bioethical discussion.

Although the causality between Zika virus, microcephaly, and other central nervous system disorders has been taken for granted by the scientific community, many uncertainties remain. The gap of knowledge at the moment is large enough to remove part of the confidence physicians have on the advice given to patients - and infertile women in particular - on their reproductive plans. Pretreatment serologic screening is a possible strategy to offer more confidence for individuals choosing to bear children regardless of the Zika virus, but the tests currently available do not seem to be sufficiently adequate. Until now, there is no formal recommendation to avoid pregnancy solely because of the Zika virus outbreak, and the choice of becoming pregnant has been regarded as a personal decision to be made by each woman and her family.

Pregnancy after hysteroscopic metroplasty under laparoscopy in a woman with complete septate uterus: a case report.

A 31-year-old nulligravid woman with a 3 year history of infertility visited our hospital. After consultation and a transvaginal ultrasound and MR imaging, her uterine anomaly was identified as complete septate uterus: class V (a) by the American Fertility Society (AFS). She had a doubled uterine cervix and a vaginal septum. Hysteroscopic metroplasty was performed with the aid of a laparoscopy. Both tubal patencies were confirmed with indigocarmine in a laparoscopic image. Laparoscopic electronic cautery was also done on the left ovarian endometrioma (stage 1 endometriosis; the revised American Society for Reproductive Medicine (rASRM) classification 4 point minimal). We distrained an intrauterine device in the uterine cavity and removed it after two cycles of menstruation. The patient subsequently became pregnant during her third menstrual cycle and the current progress of her pregnancy is favorable.

The association between follicular size at the time of spontaneous rupture and pregnancy rates in clomiphene citrate treated PCOS patients in coit cycles.

OBJECTIVE: To investigate the follicular size at spontaneous rupture on pregnancy rate in patients with polycystic ovary syndrome (PCOS) undergoing clomiphene citrate (CC) ovulation. DESIGN: Cross-sectional study. PATIENTS AND METHODS: One hundred and four women with ovulatory cycles after use of CC followed by ultrasound to determine the follicle size at the time of rupture, which was subsequently correlated with the occurrence of pregnancy or not in coit cycles. RESULTS: In the group of follicular rupture at a mean diameter ≤25 mm (n = 54), pregnancy rate was 35.1% and when follicular rupture occurred at a mean diameter >25 mm (n = 50), it was 34% (p > 0.05). When different diameters at follicular rupture were randomly correlated with the pregnancy rate, there was no significant difference. CONCLUSION: Our data suggest that the occurrence of pregnancy after ovulation induction with CC in women with PCOS is not associated with follicle size at the time of rupture.

Ovarian mucinous epithelial neoplasm showing immunohistochemical pattern of lower gastrointestinal origin with stromal minor sex-cord elements: A case report.

•We report a case of an ovarian mucinous cystadenoma that exhibited extensive sex-cord differentiation.•The ovarian tumor coincided with a uterine endometrial carcinoma.•The immunohistochemical pattern of mucinous epithelium of the ovarian tumor was suggestive of lower gastrointestinal origin.

Attenuated increases in blood pressure by dynamic resistance exercise in middle-aged men.

The present study was performed to test the hypothesis that the blood pressure (BP) response to resistance exercise in middle-aged men with stiffening arteries is greater than that in young men with compliant arteries. The BP responses to acute dynamic resistance exercise (leg press) at individual relative (low, moderate and high) and absolute intensities were investigated in both young and middle-aged men. A total of 21 sedentary healthy normotensive men, 21-25 years of age (young) and 41-59 years of age (middle-aged), were included in the study. At rest, the arterial compliance (simultaneous ultrasound and applanation tonometry) and muscle strength (leg press) were lower, and indices of arterial stiffness and BP were higher in the middle-aged men than in the young men (p < 0.05). There were no significant differences in height, body mass, or heart rate between the two groups. During exercise, the systolic BP of the middle-aged men at 80% one-repetition maximum (1RM) was significantly lower than that of the young men for the last half of the exercise period (p < 0.05). The amounts of change in systolic and diastolic BP from baseline to the end of resistance exercise were lower in the middle-aged men than in the young men at individual relative intensities (p < 0.05) and at individual absolute intensity. In contrast to our hypothesis, these findings indicated that the BP response during dynamic resistance exercise using large muscle groups may be attenuated in middle-aged men relative to young men.

Avaliação do injetável combinado mensal Cyclofem© em estudo introdutório multicêntrico / Evaluation of once a month combined injectable contracptive Cyclofem© in introductory study multicentred

O objetivo do estudo foi avaliar o contraceptivo hormonal combinado injetável mensal, que contém 5mg de cipionato de estradiol e 25mg de acetato de medroxiprogesterona (Cyclofem) até um e dois anos de uso. As injeções foram administradas a cada 30+_3 dias nas clínicas. Para a análise dos dados foi utilizado o método de tabela de vida. O número total de mulheres no estudo foi de 369. As taxas brutas de descontinuação do Cyclofem até um e dois anos de uso mostraram que não houve nenhuma gravidez nos dois anos de seguimento; a descontinuação por amenorréia e disturbios menstruais foi de 12,6 por 100 mulheres, taxa acumulada ao fim de um ano e de 18,1 por 100 mulheres após dois anos de uso. A maioria das descontinuações ocorreram por razões pessoais. A taxa de continuação foi de 50,8 e de19,4 no final do primeiro e segundo ano respectivamente. Os nossos resultados mostraram que o Cyclofem é mais uma opção de método contraceptivo, segura e com baixas taxas de descontinuação por razões médicas. Uma orientação adequada e um bom aconselhamento durante a escolha do contraceptivo por parte das usuárias, assim como durante o seguimento do uso, podem esclarecer dúvidas e derrubar crenças, diminuindo as descontinuações por alterações menstruais e amenorréia. A necessidade de novos métodos contraceptivos eficazes e reversíveis é premente, principalmente no Brasil e o Cyclofem constitui-se em uma nova opção segura e eficaz