Vitamin D levels in couples undergoing In vitro Fertilization: Lack of Association with Embryo Quality or Pregnancy Rates.

OBJECTIVE: To investigate the potential impact of vitamin D serum levels of couples going through in vitro fertilization in terms of embryo quality and pregnancy rates. DESIGN: Retrospective cohort study SETTING: Fertipraxis, private human reproduction center on Rio de Janeiro, Brazil. SUBJECTS: 267 couples who underwent intracytoplasmic sperm injection between January 2017 and March 2019. EXPOSURE: The couples were categorized into four groups based on 25OH vitamin D levels measured at the beginning of the stimulation protocol: Group 1 with levels ≥ 30 ng/mL for both women and men; Group 2 with levels < 30 ng/mL for both; Group 3 with women < 30 ng/mL and men ≥ 30 ng/mL; and Group 4 with women ≥ 30 ng/mL and men < 30 ng/mL. MAIN OUTCOME MEASURES: We consider quantity and quality of embryos during the cleavage and blastocyst stages as primary outcomes. Correspondingly, clinical pregnancy rate was regarded as a secondary outcome. RESULTS: Our findings revealed no significant correlations between the studied VD groups and the evaluated outcomes. This includes quantity and quality of embryos during the cleavage and blastocyst stages, as well as clinical pregnancy rate. Primary analysis revealed a small but statistically significant difference in the duration of controlled ovarian stimulation between group 1 and group 2 (p=0.035; CI=0.07 - 3.04) and between group 1 and group 3 (p=0.040; CI=0.05 - 3.23). CONCLUSION: The present study found no correlation between the studied VD levels and quantity and quality of cleavage or blastocyst stage embryos, nor did it show any impact on clinical pregnancy rates. Further well designed, prospective studies are warranted to determine whether and how vitamin D affects reproductive outcomes.

Vaginal micronized progesterone on preventing luteinizing hormone untimely surge in ART cycles: A prospective proof-of-concept study.

OBJECTIVE: A new approach to evaluate whether Progestin-Primed Ovarian Stimulation with micronized vaginal progesterone was as effective as using dydrogesterone in suppress LH pulse surge in young women under stimulation in an oocyte donor programme. METHODS: This prospective study included 21 patients aged 19 to 32 years-old stimulated with Elonva® 150, associated or not with Menopur® or Merional® (75 or 150IU) since the beginning of the cycle, plus HMG 150-225IU after the 8th day or just HMG 150-300IU per day. Patients were placed in a PPOS protocol with micronized vaginal progesterone (MVP) 200 mg (Gynpro® Exeltis or Junno Farmoquimica) every 12 hours or dydrogesterone (Duphaston® Abbott) 10 mg every 8 hours from the start of stimulation until the day after the GnRH trigger with Triptorelin 0.2 mg (Gonapeptyl daily®). The primary endpoint was the prevention of untimely LH surge, and secondarily the number of 16 mm follicles, retrieved oocytes and metafase II. RESULTS: Fourteen oocyte donor patients were prescribed MVP while seven others received dydrogesterone (DYG).The gonadotropin protocols included 04 with Corifollitropin alfa 150 plus HMG since the beginning and complemented after the 7th day, and 17 times of just HMG. There was no diferences in the number of follicles >10≤15mm, ≥16mm or number of metafase II oocytes. There was no untimely LH surge on both groups and no OHSS was developed after the agonist trigger. CONCLUSIONS: Progestin-Primed Ovarian Stimulation with micronized vaginal progesterone seems to be a compelling choice for preventing premature ovulation without compromising oocyte quality in women undergoing ovarian stimulation.

Metabolomic analysis of follicular fluid from women with Hashimoto thyroiditis.

Hashimoto thyroiditis is an autoimmune disease characterized by hypothyroidism and a high level of anti-thyroid autoantibodies. It has shown to negatively impact female fertility; however, the mechanisms are unclear. Ovarian follicular fluid appears to be the key to understanding how Hashimoto thyroiditis affecst fertility. Thus, we aimed to evaluated the metabolic profile of follicular fluid and antithyroid autoantibody levels in the context of Hashimoto thyroiditis. We collected follicular fluid from 61 patients, namely 38 women with thyroid autoantibody positivity and 23 women as negative controls, undergoing in vitro fertilization treatment. Follicular fluid samples were analyzed using metabolomics, and thyroid autoantibodies were measured. Fifteen metabolites with higher concentrations in the follicular fluid samples from Hashimoto thyroiditis were identified, comprising five possible affected pathways: the glycerophospholipid, arachidonic acid, linoleic acid, alpha-linolenic acid, and sphingolipid metabolism pathways. These pathways are known to regulate ovarian functions. In addition, antithyroglobulin antibody concentrations in both serum and follicular fluid were more than tenfold higher in women with Hashimoto thyroiditis than in controls. Our data showed that the metabolic profile of follicular fluid is altered in women with Hashimoto thyroiditis, suggesting a potential mechanistic explanation for the association of this disease with female infertility.

The management of infertility for primary care physicians.

To conduct this review of primary care, we looked for related papers in PubMed from the last 15 years. WHO's initial concept of Health defined a condition of physical, mental, and social well-being, nowadays extended to quality of life. Infertility or not being able to form a family fits perfectly into the definition. Primary care is responsible for mandatory discussions about fertility as part of a broader aspect regarding reproductive health issues. Having children is a decision taken by heterosexual couples, same sex couples, or single individuals. Understanding factors associated with infertility help guiding propedeutic. Although woman's age is one of the main factors to influence treatment success rates, multifactorial male factor may contribute to 50 percent. Infertility consultations should include partners, alleviating the accompanying stress and anxiety. Anamnesis must focus on duration of infertility, primary or secondary, sexual activity, and lifestyle habits such as smoking, alcohol consumption, diet, physical activity, use of licit and/or illicit drugs, and occupational risks. Previous treatments should be accessed. Management of infertility by primary care is mandatory, and patients requiring specialized treatments must not have their journey protracted. Strategies and couple-based interventions are essential to continuity of care and close follow-up should follow these patients.

Evaluation of follicular flushing with double lumen needle in patients undergoing assisted reproductive technology treatments.

OBJECTIVE: The purpose of this study was to investigate the possible impact of follicular flushing on the number of oocytes retrieved and oocytes in metaphase II in patients with poor ovarian response (POR) compared to direct aspiration. METHODS: This prospective, comparative, randomized single center study included 208 punctures of patients with POR, submitted to assisted reproduction technology (ART) treatments. Two groups were compared; one in which double lumen needles were used (Wallace DNS1733) for follicular flushing (n=105), and one in which single lumen needles were used (Wallace ONS1733) for direct aspiration (n=103), upon the observation of ≤ 5 follicles between 15-17 mm, ≤ 4 follicles with sizes greater than 18 mm on hCG day, and ≤ 7 recovered oocytes. RESULTS: There were no differences in age (39.07±3.88 vs. 38.11±3.43); weight (61.73±17.53 vs. 65.96±15.44); AMH (0.63±0.59 vs. 0.94±0.97); stimulation days (9.57±1.87 vs. 10.29±2.82); estradiol levels (788.94±670.82 vs. 940.16±694.69); progesterone (617.29±319.76 vs. 561.18±486.78); or number of follicles with sizes ≥18 mm (1.84±0.95 vs. 2.07±1.09). Although gonadotropin totals (1678.28±798.52 vs. 2080.45±852.36; p=0.0008), number of aspirated oocytes (3.00±2.11 vs. 3.69±2.20; p=0.02), and number of metaphase II oocytes (2.20±1.64 vs. 2.99±1.88; p=0.02) were significantly different, oocyte / follicle ratio ≥15 mm (0.93 vs. 0.98) and metaphase II oocytes / follicles ≥15 mm (0.68 vs. 0.79) were similar in both groups. The failure to capture was 16% vs. 9.8%. CONCLUSIONS: Considering that there was no difference in the oocyte per follicle ratio, follicular flushing did not increase the number of oocytes recovered from poor responders.

Psychological Intervention in the Oocyte Pick-up Room and Recovery Room in Assisted Reproduction: new listening accounts.

OBJECTIVE: This study seeks to identify the role and possible participation of a psychologist/psychoanalyst inside an Oocyte Pick-up Room and Recovery Room (OPR-RR) in an Assisted Reproduction clinic and its implications on patients and team. METHODS: Prospective study of psychological support during the procedures from September 2014 to December 2018. Most visits took place during oocyte retrievals, for either IVF/ICSI or gamete freezing. RESULTS: Of the 2,343 cases, the psychologist was present in 965 of them (41%), during oocyte retrievals, with available professionals in 59% of the times (722 cases). The embryo transfers (1,011) had psychological assistance in 20% of the time (218 cases). The intrauterine insemination cases were excluded for not happening in a surgical environment. The recovery room was identified as one of the spaces for welcoming and listening to anxieties, desires, projects, worries, fears, frustrations, joys and expectations for those who come to the clinic seeking the desire to gestate. The patients' talks, collected in observations transcribed from what was heard, with dates and types of procedures, were discussed with either the team or the assistant physician. The team stands positively in the presence of a psychologist/psychoanalyst, who brings new perceptions and the development of the whole art of listening, for all involved. CONCLUSION: The presence of a psychologist/psychoanalyst in the Oocyte Pick-up Room and the Recovery Room in an Assisted Reproduction clinic means an opportunity to listen to patients' emotions, providing well-being to patients and echoing in the teamwork relationships.

Bladder hematoma: a complication from an oocyte retrieval procedure.

INTRODUCTION: More than one million fertilization cycles are performed every year. The incidence of serious complications associated with transvaginal oocyte pick-up is low, but the procedure is not risk-free. Risks are inherent to procedures in which thin needles and sharp instruments are introduced into the vaginal wall and ovarian capsule to access the ovaries. CASE DESCRIPTION: A 45-year-old patient reported urinary discomfort and difficulty urinating after her second cycle, 12 hours after oocyte pick-up. She had visible hematuria with small blood clots. Transvaginal ultrasound examination performed 24 hours after pick-up showed a heterogeneous intravesical image suggestive of a clot; her bladder measured 23x19mm. She was afebrile and in good condition. The patient was managed conservatively and offered fluids. The clot was expelled within a matter of hours. This case of a bladder hematoma was the first in the 21 years of a clinic where all procedures are guided by ultrasonography with clear visualization of the tip of the needle throughout the 15-20 minutes of the procedure. Patients submitted to ultrasound-guided transvaginal oocyte pick-up procedures in IVF protocols must be informed of this rare potential complication.

Live Births after Fertility-saving Surgery in Ovarian Borderline Tumor and Oocyte Donation: Case Report.

A left borderline serous ovarian tumor stage I (FIGO) was discovered and treated in a 26-year-old black nulliparous woman, by conservative approach (laparotomy, salpingo- oophorectomy). In a six months interval she had a 7.5 x 7.1 x 5.7cm multilocular contralateral tumor with septa and vegetative areas and in a year interval a CT showed a 8.4 x 7.4 x 7.0 lesion that precluded a follicular aspiration. The authors discuss the multidisciplinary strategy and the approach with the couple: the best option considered would be the resection of the tumor remaining attached to a new study pelvic. If possible uterine conservation should be held for further procedure of oocyte donation. Two years from the first surgery she had the second laparotomy and six months later she had an ICSI with oocyte donation. She became pregnant and delivered two 34 week-pregnancy boys through C-section due to hypertension plus preeclampsia. There happened a post- operative intestinal obstruction that required a new surgical approach to adhesions lysis. There was no report of tumor lesions then. Seven months later, mother and children are doing well. Comments are made about borderline ovarian tumors and fertility-sparing approaches.

Utilização da contagem de folículos antrais para predição do padrão de resposta em ciclos de hiperestimulação controlada com antagonista de GnRH / Use of antral follicle count to predict the response pattern in controlled ovarian hyperstimulation cycles with GnRH antagonist

OBJETIVO: verificar se existe relação preditiva entre a contagem de folículos antrais (CFA) no segundo dia do ciclo com o padrão de resposta em ciclos de hiperestimulação ovariana controlada para injeção intracitoplasmática de espermatozóide (ICSI). MÉTODOS: estudo prospectivo, desenvolvido de maio de 2004 a maio de 2005, no qual 51 pacientes com idade <37 anos foram submetidas a reprodução assistida/ICSI, em protocolo de hiperestimulação ovariana com gonadotrofina recombinante e antagonista de hormônio liberador de gonadotrofinas (GnRH). Foi realizada ultra-sonografia transvaginal (USTV) no segundo dia do ciclo, para contagem do número de folículos de 2 a 10 mm, quando do início do estímulo, dados comparados com o número de folículos >15 mm no dia do desencadeamento da ovulação, número total e em metáfase II de oócitos captados, número de embriões de boa qualidade transferidos e taxa de gestação. A análise estatística foi realizada pelos testes t de Student e de Mann-Whitney, com significância estatística de 5 por cento (p<0,05). RESULTADOS: o grupo de estudo teve média de idade de 32,4 anos. A CFA média foi de 7,1, com mínimo de 1 e máximo de 16. Considerando a CFA como variável principal, foi observada correlação direta significativa com o número de folículos acima de 15 mm no dia do desencadeamento da ovulação (p=0,0001), o número total (p=0,0001) e em metáfase II (p=0,0001) de oócitos captados. Tal correlação entre a CFA e gravidez não foi observada (p=0,43). Não foi demonstrada uma correlação significativa entre a CFA e o número de embriões de boa qualidade transferidos (p=0,081). CONCLUSÕES: a CFA no segundo dia do ciclo estimulado pode ser utilizada na predição da qualidade da estimulação ovariana, do número de oócitos captados e do número de oócitos maduros em ciclos de fertilização in vitro utilizando antagonista de GnRH.

PURPOSE: to establish whether there is a predictive relationship between the antral follicle count (AFC) on the second day of the cycle and the response pattern in controlled ovarian hyperstimulation cycles for intracytoplasmic sperm injection (ICSI). METHODS: a prospective study developed from May 2004 to May 2005, in which 51 patients aged <37 years old were submitted to assisted reproduction/ICSI in ovarian hyperstimulation protocol with gonadotropin recombinant and gonadotropin-releasing hormone (GnRH) antagonist. A transvaginal ultrasonography was performed on the second day of the cycle, to count the number of follicles measuring 2 to 10 mm, at the beginning of stimulus, data compared with the number of follicles with >15 mm on the day of ovulation triggering, the total number of oocytes retrieved and in metaphases II, the number of good quality embryos transferred and pregnancy rate. The statistical analysis was performed by the t-Student test and the Mann-Whitney test, with statistical significance of 5 percent (p<0.05). RESULTS: the mean age in the study group was 32.4 years. The AFC average was 7.1, minimum of 1 and maximum of 16. Considering AFC as a main variable, a significant direct correlation was observed with the number of follicles >15 mm on the day of ovulation triggering (p=0.0001), the total number of oocytes retrieved (p=0.0001) and those in metaphases II (p=0.0001). Such correlation between AFC and pregnancy was not observed (p=0.43). There was no significant correlation between AFC and the number of good quality embryos transferred (p=0.081). CONCLUSIONS: AFC on the second day of the stimulated cycle can be used to predict the quality of ovarian stimulation, the number of oocytes retrieved and the number of mature oocytes in in vitro fertilization cycles using GnRH antagonist.

[Use of antral follicle count to predict the response pattern in controlled ovarian hyperstimulation cycles with GnRH antagonist]. / Utilização da contagem de folículos antrais para predição do padrão de resposta em ciclos de hiperestimulação controlada com antagonista de GnRH.

PURPOSE: to establish whether there is a predictive relationship between the antral follicle count (AFC) on the second day of the cycle and the response pattern in controlled ovarian hyperstimulation cycles for intracytoplasmic sperm injection (ICSI). METHODS: a prospective study developed from May 2004 to May 2005, in which 51 patients aged <37 years old were submitted to assisted reproduction/ICSI in ovarian hyperstimulation protocol with gonadotropin recombinant and gonadotropin-releasing hormone (GnRH) antagonist. A transvaginal ultrasonography was performed on the second day of the cycle, to count the number of follicles measuring 2 to 10 mm, at the beginning of stimulus, data compared with the number of follicles with >15 mm on the day of ovulation triggering, the total number of oocytes retrieved and in metaphases II, the number of good quality embryos transferred and pregnancy rate. The statistical analysis was performed by the t-Student test and the Mann-Whitney test, with statistical significance of 5% (p<0.05). RESULTS: the mean age in the study group was 32.4 years. The AFC average was 7.1, minimum of 1 and maximum of 16. Considering AFC as a main variable, a significant direct correlation was observed with the number of follicles >15 mm on the day of ovulation triggering (p=0.0001), the total number of oocytes retrieved (p=0.0001) and those in metaphases II (p=0.0001). Such correlation between AFC and pregnancy was not observed (p=0.43). There was no significant correlation between AFC and the number of good quality embryos transferred (p=0.081). CONCLUSIONS: AFC on the second day of the stimulated cycle can be used to predict the quality of ovarian stimulation, the number of oocytes retrieved and the number of mature oocytes in in vitro fertilization cycles using GnRH antagonist.