Effect of endometrial scratching on unassisted conception for unexplained infertility: a randomized controlled trial.

OBJECTIVE: To investigate whether endometrial scratching increases the chance of live birth in women with unexplained infertility attempting to conceive without assisted reproductive technology. DESIGN: Randomized, placebo-controlled, participant-blind, multicenter international trial. SETTING: Fertility clinics. PATIENT(S): Women with a diagnosis of unexplained infertility trying to conceive without assistance. INTERVENTION(S): Participants were randomly assigned to receive an endometrial biopsy or a placebo procedure (placement of a biopsy catheter in the posterior fornix, without inserting it into the external cervical os). Both groups performed regular unprotected intercourse with the intention of conceiving over three consecutive study cycles. MAIN OUTCOME MEASURE(S): The primary outcome was live birth. RESULT(S): A total of 220 women underwent randomization. The live birth rate was 9% (10 of 113 women) in the endometrial-scratch group and 7% (7 of 107 women) in the control group (adjusted OR, 1.39; 95% CI, 0.50-4.03). There were no differences between the groups in the secondary outcomes of clinical pregnancy, viable pregnancy, ongoing pregnancy, and miscarriage. Endometrial scratching was associated with a higher pain score on a 10-point scale (adjusted mean difference, 3.07; 95% CI, 2.53-3.60). CONCLUSION(S): This trial did not find evidence that endometrial scratching improves the live birth rate in women with unexplained infertility trying to conceive without assistance. CLINICAL TRIAL REGISTRATION NUMBER: Australian New Zealand Clinical Trials Registry ACTRN12614000656639.

A randomized trial of endometrial scratching in women with PCOS undergoing ovulation induction cycles.

RESEARCH QUESTION: Does endometrial scratching improve the chance of a live birth in women with polycystic ovary syndrome (PCOS) undergoing ovulation induction and trying to conceive? DESIGN: An international, multicentre, randomized, sham-controlled trial across six fertility clinics in three countries (New Zealand, UK and Brazil). Women with a diagnosis of PCOS who were planning to commence ovulation induction cycles (at least three cycles) in order to conceive were randomly assigned to receive the pipelle (scratch) procedure or a sham (placebo) procedure in the first cycle of ovulation induction. Women kept a diary of ovulation induction and sexual intercourse timing over three consecutive cycles and pregnancies were followed up to live birth. Primary outcome was live birth and secondary outcomes were clinical pregnancy, ongoing pregnancy, multiple pregnancy, adverse pregnancy outcomes, neonatal outcomes, bleeding following procedure and pain score following procedure. RESULTS: A total of 117 women were randomized; 58 to the scratch group and 59 to the sham group. Live birth occurred in 11 (19%) women in the scratch group and 14 (24%) in the sham group (odds ratio 0.76, 95% confidence interval [CI] 0.30-1.92). Secondary outcomes were similar in each group. Significantly higher pain scores were reported in the scratch group (adjusted mean difference 3.2, 95% CI 2.5-3.9) when measured on a visual analogue scale. CONCLUSION: No difference was detected in live birth rate for women with PCOS who received an endometrial scratch when trying to conceive using ovulation induction; however, uncertainty remains due to the small sample size in this study.

Single embryo transfer for all?

Historically to maintain live birth rates for women undergoing in vitro fertilisation (IVF), multiple embryos were transferred. Improvements in technology have meant a move to selective single embryo transfer (SET). Do we now have enough confidence in SET to make it mandatory?

Emergency peripartum hysterectomy: a 10-year review in a tertiary obstetric hospital.

AIM: To evaluate the incidence, indications and complications associated with emergency peripartum hysterectomy (EPH) performed at Christchurch Women's Hospital, New Zealand. METHODS: A retrospective case series analysis of EPH from 2000-2009. Cases were identified using the hospital's computerised database. Those medical records were reviewed. EPH was defined as one performed for major postpartum haemorrhage unresponsive to other treatment within 24 hours of delivery. RESULTS: Nineteen EPH cases were identified among 47,520 deliveries, giving an incidence of 0.4 per 1000 deliveries. The indications were invasive placental adhesion--accreta, increta, percreta (63%), uterine atony (16%), placenta praevia (10.5%) and uterine tear with atony (10.5%). All cases of abnormal placentation in this study had previous caesareans or curettages. A significant association between previous uterine surgery and abnormal placentation was shown (p=0.02), especially those with previous caesarean (p=0.003). No maternal or perinatal mortality was recorded. Maternal morbidity was prevalent, including eight disseminated intravascular coagulopathies, seven intensive care, three bladder injuries, two re-explorations, one respiratory failure and one pulmonary embolism. CONCLUSION: Invasive placental adhesion is the major indication for EPH. This study demonstrates an association between the presence of scarred uteri as a result of previous uterine surgery, and abnormal placentation.