Influence of endometrial thickness on pregnancy rates in modified natural cycle frozen-thawed embryo transfer.

INTRODUCTION: Pregnancy after frozen-thawed embryo transfer (FET) is a multifactorial process. Although embryo quality is a key factor in determining pregnancy, other factors, including maternal determinants, are also considered to be predictive. Even though an association between endometrial thickness measured by transvaginal ultrasound and pregnancy rates has been reported in patients undergoing various assisted reproductive technology treatments, whether endometrial thickness predicts achieving pregnancy after natural cycle FET (NC-FET) remains unclear. MATERIAL AND METHODS: In this cohort study, 463 patients allocated to the modified NC-FET (mNC-FET) arm of a previously published randomized controlled trial were included. Monitoring in mNC-FET cycles consisted of regular ultrasound scans, measuring both dominant follicle and endometrial thickness. When the dominant follicle reached a size of 16-20 mm, an injection of human chorionic gonadotrophin was administered and embryo thawing and transfer planned. No minimal endometrial thickness was defined below which transfer was to be deferred. The primary endpoint was ongoing pregnancy rate. RESULTS: Overall, the ongoing pregnancy rate per started FET cycle was 12.5%. Multivariate regression analyses showed that embryo quality was the only significant predictor for ongoing pregnancy. Mean endometrial thickness did not differ between patients achieving ongoing pregnancy and those who did not (9.0 vs. 8.8 mm, p = 0.4). Comparable results were obtained with regard to clinical pregnancy, live birth and miscarriage rates. The area under the receiver operator curve was 0.5, indicating little discriminatory value of endometrial thickness. CONCLUSIONS: Given that endometrial thickness was not found to be predictive of pregnancy after mNC-FET, cancellation based on endometrial thickness alone may not be justified.

The effectiveness of intrauterine insemination: A matched cohort study.

OBJECTIVE: To study the effectiveness of an intrauterine insemination (IUI) program compared to no treatment in subfertile couples with unexplained subfertility and a poor prognosis on natural conception. STUDY DESIGN: A retrospective matched cohort study in which ongoing pregnancy rates in 72 couples who voluntarily dropped out of treatment with IUI were compared to ongoing pregnancy rates in 144 couples who continued treatment with IUI. Couples with unexplained subfertility, mild male subfertility or cervical factor subfertility who started treatment with IUI between January 2000 and December 2008 were included. Couples were matched on hospital, age, duration of subfertility, primary or secondary subfertility and diagnosis. Primary outcome was cumulative ongoing pregnancy rate after three years. Time to pregnancy was censored at the moment couples were lost to follow up or when their child wish ended and, for the no-treatment group, when couples re-started treatment. RESULTS: After three years, there were 18 pregnancies in the stopped treatment group (25%) versus 41 pregnancies in the IUI group (28%) (RR 1.1 (0.59-2.2)(p=0.4)). The cumulative pregnancy rate after three years was 40% in both groups, showing no difference in time to ongoing pregnancy (shared frailty model p=0.86). CONCLUSIONS: In couples with unexplained subfertility and a poor prognosis for natural conception, treatment with IUI does not to add to expectant management. There is need for a randomized clinical trial comparing IUI with expectant management in these couples.

Attitude of maternity staff regarding episiotomies in an African rural hospital with high HIV prevalence: a descriptive qualitative study.

In a typical sub-Saharan African rural hospital, maternity staff seems to avoid episiotomies. The aim of this research is to develop a deeper understanding in the attitude of maternity staff regarding episiotomies. We used a descriptive qualitative approach: interviews, written questionnaires, and a group discussion. All methods showed strong reservations toward episiotomies among staff members. Most staff members have been trained to be very restrictive concerning episiotomies to prevent the transmission of human immunodeficiency virus (HIV). As a result of training and hence changing attitudes, the use of episiotomies is limited in all patients; even when strong indications are present and sometimes regardless of HIV status. This might increase the number of neonatal deaths.

Barriers and facilitators for the implementation of an online clinical health community in addition to usual fertility care: a cross-sectional study.

BACKGROUND: Online health communities are becoming more popular in health care. Patients and professionals can communicate with one another online, patients can find peer support, and professionals can use it as an additional information channel to their patients. However, the implementation of online health communities into daily practice is challenging. These challenges relate to the fact that patients need to be activated to (1) become a member (ie, subscription) and (2) participate actively within the community before any effect can be expected. Therefore, we aimed at answering 2 research questions: (1) what factors are associated with subscription to an online health community, and (2) which are associated with becoming an active participant within an online health community. OBJECTIVE: To identify barriers and facilitators as perceived by patients for the implementation of an online health community. METHODS: We performed a cross-sectional study. Three Dutch fertility clinics (2 IVF-licensed) offered their patients a secure online clinical health community through which clinicians can provide online information and patients can ask questions to the medical team or share experiences and find support from peers. We randomly selected and invited 278 men and women suffering from infertility and attending 1 of the participating clinics. Participants filled out a questionnaire about their background characteristics and current use of the online community. Possible barriers and facilitators were divided into 2 parts: (1) those for subscription to the community, and (2) those for active participation in the community. We performed 2 multivariate logistic regression analyses to calculate determinants for both subscription and active participation. RESULTS: Subscription appeared to be associated with patients' background characteristics (eg, gender, treatment phase), intervention-related facilitators (odds ratio [OR] 2.45, 95% CI 1.14-5.27), and patient-related barriers (OR 0.20, 95% CI 0.08-0.54), such as not feeling the need for such an online health community. After subscription, determinants for participation consisted of aspects related to participant's age (OR 0.86, 95% CI 0.76-0.97), length of infertility (OR 1.48, 05% CI 1.09-2.02), and to intervention-related facilitators (OR 5.79, 95% CI 2.40-13.98), such as its reliable character and possibility to interact with the medical team and peers. CONCLUSIONS: Implementing an online health community in addition to usual fertility care should be performed stepwise. At least 2 strategies are needed to increase the proportion of patient subscribers and consequently make them active participants. First, the marketing strategy should contain information tailored to different subgroups of the patient population. Second, for a living online health community, incorporation of interactive elements, as well as frequent news and updates are needed. These results imply that involving patients and their needs into the promotion strategy, community's design, and implementation are crucial.

Tissue composition of the vaginal wall in women with pelvic organ prolapse.

BACKGROUND/AIMS: To determine the composition of the vaginal wall and to explore the connective tissue layer, muscularis and basement membrane in relation to the pathogenesis of pelvic organ prolapse (POP). METHODS: We performed a histopathological study with respect to the composition of the vaginal wall of 33 patients and 9 controls. Tissue samples from the vaginal wall were analysed for collagens II and IV, desmin, elastin, fibronectin, smooth muscle actin (SMA) and transforming growth factor (TGF)-ß1 using (immuno)histochemistry. Morphometric analyses were also performed. RESULTS: Morphometric characteristics and expression of SMA, TGF-ß1, elastin and collagen II were significantly altered in women with POP. CONCLUSION: Our results suggest that there could be an altered tissue composition of the vaginal wall in women with POP. SMA expression could play a role in the pathogenesis of POP. The alterations in elastin and TGF-ß1 expression are likely a result of POP.

A comparison of suprapubic and transurethral catheterization on postoperative urinary retention after vaginal prolapse repair: a randomized controlled trial.

AIM: To compare the effect of suprapubic and transurethral catheterization on postvoid residual volumes (PRVs) after cystocele repair. METHODS: 126 women who underwent pelvic organ prolapse surgery including cystocele repair were randomized to suprapubic or transurethral catheterization. At the third postoperative day, PRVs were measured. The number of women with PRV >150 ml, need for prolonged catheterization, recatheterization, length of hospital stay, frequency of urinary tract infections and complications were determined. RESULTS: PRVs exceeded 150 ml in 13 out of 64 (20%) and 14 out of 62 (23%) women in the suprapubic and transurethral group, respectively (p = 0.76). In the suprapubic group a higher rate of urine leakage was noted (27 vs. 7%, p = 0.003). 10 women (16%) allocated to the suprapubic group switched to transurethral catheterization, because of problems with the suprapubic catheter. No protocol deviations were reported in the transurethral group. Of the women in both groups, 9% developed urinary tract infections (p = 0.93). CONCLUSIONS: Suprapubic catheterization was comparable to transurethral catheterization in the prevention of postoperative voiding dysfunction after vaginal prolapse surgery, but it was associated with a higher rate of complications.

Patients' attitude towards residents' participation during gynaecological surgery.

OBJECTIVE: To evaluate patients' attitude towards participation of residents in training in gynaecological surgery and patients understanding of resident position. STUDY DESIGN: An observational survey study was performed between July and February 2007-2008 in an outpatient clinic of a department of obstetrics and gynaecology of a teaching hospital. Patients planned for gynaecological surgery were concerned eligible. 247 questionnaires were handed out of which 204 were returned (response rate 82.6%). Primary outcome measure was level of confidence in a resident performing hysterectomy in various operative settings. Secondary, patients' understanding of the medical education system was tested. RESULTS: There was no difference between confidence in a specialist performing a hysterectomy compared to an experienced resident considered competent and under supervision of a specialist. Respondents have significantly less confidence in less experienced residents operating under supervision and in all residents operating without supervision (P<0.001). From the respondents, 85.6% believes a resident in training has received less education than a resident not in training. 38.6% believes a resident received less training than a medical student. Statistical analysis was done in SPSS 16.0 (SSPS Inc., Chicago, IL, USA) using a Wilcoxon signed-rank test. CONCLUSIONS: Respondents have confidence in a resident in training performing an operation under supervision when it concerns an experienced resident that is considered competent. A majority of respondents does not understand the position of a resident in training. Patient education on resident participation should be improved and the certainty that an operating resident is competent should be emphasized.

Reliability of an automatic ultrasound system in the post partum period in measuring urinary retention.

BACKGROUND: Urinary retention in the post partum period may lead to short- and long-term complications. OBJECTIVE: To investigate the reliability of an automatic ultrasound system to measure the volume of the bladder post partum. METHODS: About 85 women, who delivered vaginally were observed 6 hr post partum. When the bladder volume measured by BladderScan BVI 3000 was more than 300 ml, it was compared with the bladder volume measured by catheterization. RESULTS: Ten additional catheterizations were performed by using BladderScan BVI 3000, when compared with the number of estimated cathetharizations based on clinical indications. Eight women had a residual volume of more than 300 ml, of whom two got an indwelling catheter. Using Bland-Altman methods, there was no significant difference in volumes measured by BladderScan BVI 3000 or by catheterization. Also, there was no significant difference between two observers. CONCLUSION: The BladderScan BVI 3000 is a reliable and non-invasive method to recognize urinary retention in the post partum period.

Obesity and Clomiphene Challenge Test as predictors of outcome of in vitro fertilization and intracytoplasmic sperm injection.

One hundred and sixty-two consecutive patients undergoing in vitro fertilization (IVF) or IVF/intracytoplasmic sperm injection (ICSI) were studied to determine the effect of obesity on the outcome of this treatment and to evaluate the prognostic value of the Clomiphene Challenge Test (CCT) in controlled ovarian hyperstimulation. In this prospective clinical study, we assessed the mean number of stimulation days, the mean gonadotropin level/day, cancellation rate, the mean thickness of the endometrium, the mean number of oocytes retrieved, the fertilization rate, the clinical pregnancy rate/embryo transfer and the abortion rate. Obese women had a doubled risk of cancellation due to poor response, although this was not statistically significant. Furthermore, they showed up to 45% lower fertilization rates compared to women of normal weight. The CCT was a good predictor of IVF and IVF/ICSI outcome. Women with an abnormal CCT needed more days of stimulation and higher doses of gonadotropins to reach an adequate stimulation, but still overall results were less than in women with a normal CCT. We conclude that obesity negatively affects IVF and IVF/ICSI outcome, and that CCT is a useful prognosticator of response to ovarian stimulation. Obese patients show a tendency to experience more cancellation due to poor response and lower fertilization rates. Obese women should be counseled on their possible poor performance in IVF and IVF/ICSI programs.

Cytokeratin 17 and p63 are markers of the HPV target cell, the cervical stem cell.

BACKGROUND: Basic research on HPV has focused on identifying the genetic changes that lead to cervical carcinoma. However, while focusing on the molecular biology of the cancer, understanding of its cellular biology has lagged: the target cell of the HPV infection is unknown. MATERIALS AND METHODS: In this study we identified the stem cell population of the cervical epithelium by monoclonal antibodies against p63, a homologue of the tumor suppressor gene p53 and cytokeratin 17 (CK17). RESULTS: We noted p63 expression consistently in the nuclei of reserve cells, hyperplasia of the reserve cells and the basal layer of the ectocervical epithelium, while CK17 only stained endocervical reserve cells and reserve cell hyperplasia. CONCLUSION: We conclude that both p63 and CK17 are suitable markers for cervical stem cell identification. Both markers, therefore, qualify for the identification of the HPV target cell.