Gynecologic and Obstetric Investigation最新文献

Objective: This study aimed to evaluate whether having only one blastocyst-stage embryo on Day 5/6 rectify the live birth rate (LBR) when various number of oocytes had been collected.

Design: A retrospective cohort study from two in vitro fertilization (IVF) centers has been conducted. Participants/Materials: The study included women undergoing IVF treatment whose cycles resulted in only one blastocyst-stage embryo available for frozen transfer on Day 5/6. Cases with no oocyte retrieval, no blastocyst development, or missing clinical data were excluded. There were no restrictions based on female age or BMI to reflect real-world clinical conditions.

Setting: A multi-center study was conducted.

Methods: This retrospective cohort study included 2,125 single blastocyst frozen embryo transfer cycles performed between November 2018 and February 2023. All patients had only one blastocyst-stage embryo available for transfer on Day 5/6, regardless of the number of oocytes retrieved during controlled ovarian stimulation. Patients were stratified into quartiles based on their blastocyst-to-oocyte ratio. Baseline demographic, ovarian stimulation, and embryological parameters were compared across quartiles. The primary outcome was the LBR. Binary logistic regression was used to identify independent predictors of the LBR, including female age, embryo quality, BMI, and blastocyst-to-oocyte ratio.

Results: The mean blastocyst-to-oocyte ratio was 18.6%. Patients in the lowest quartile had significantly younger mean age and higher AMH levels compared to the highest quartile. Although blastocyst development rates increased across quartiles, the LBR was lower in the highest quartile from all other groups (24.5% vs. 31.9 to 29.9%). When the LBR was analyzed as dependent variable, binary logistic regression identified female age (β = 0.93, 95% CI: 0.92-0.95, p < 0.001) and embryo quality (β = 2.35, 95% CI: 1.62-3.39, p < 0.001, compared with moderate-quality embryos; β = 4.22, 95% CI: 2.91-6.11, p < 0.001, compared with poor-quality embryos) as independent predictors. However, the blastocyst-to-oocyte ratio did not demonstrate a significant association with the LBR.

Limitations: The retrospective design and absence of genetic testing for embryo ploidy might limit the ability to establish causality. Variability in laboratory conditions and stimulation protocols may also have introduced confounding factors.

Conclusions: The blastocyst-to-oocyte ratio does not significantly impact the LBR when only one blastocyst is available for transfer. Instead, female age and embryo quality remain the most critical factors in determining the LBR. These findings emphasize the importance of embryo selection over numerical ovarian response parameters in clinical decision-making to obtain live birth.

Aim: This study aimed to investigate the impact of various endometrial preparation protocols on pregnancy outcomes in women with polycystic ovarian syndrome (PCOS) undergoing frozen embryo transfer (FET).

Method: We conducted a comprehensive search of electronic databases, including PubMed, Embase, and the Cochrane Library, from their inception until February 2024 to identify relevant studies. The network meta-analysis (NMA) was performed using STATA 14.0 software.

Results: Seventeen studies met the inclusion criteria, encompassing 16,082 FET cycles (four randomized controlled trials and thirteen observational studies). Women with PCOS undergoing FET using the gonadotropin-releasing hormone agonist (GnRH-a) + hormone replacement therapy (HRT) protocol demonstrated a higher clinical pregnancy rate (CPR) compared to those using HRT alone (OR 1.50, 95% CI: 1.13-1.99). No significant differences were observed in the ongoing pregnancy rate (OPR) and ectopic pregnancy rate among the four examined endometrial preparation protocols (human menopausal gonadotropin [HMG]/follicle-stimulating hormone [FSH], letrozole [LE], HRT, and GnRH-a + HRT). Regarding the miscarriage rate (MR), the LE ovulation induction protocol exhibited a lower MR than the HRT protocol (OR 0.59, 95% CI: 0.46-0.74). The surface under the cumulative ranking curve indicated that the GnRH-a + HRT protocol was the most effective for the CPR. In contrast, the LE ovulation induction protocol was the most effective for minimizing the MR.

Conclusion: Our NMA suggests that the GnRH-a + HRT protocol results in a higher CPR compared to the HRT protocol in PCOS women undergoing FET, albeit with a higher risk of miscarriage. While offering comparable CPRs and OPRs to the GnRH-a + HRT protocol, the LE ovulation induction protocol presents a lower MR than the other endometrial preparation protocols.

Objective: The objective of this study was to evaluate the frequency of severe stages of placenta accreta spectrum (PAS) in relation to the number of previous cesarean deliveries (PCDs).

Design: We conducted a retrospective cohort study.

Setting: The study was carried out at the University of Texas Health Science Center at Houston (UTHealth), Houston, TX, USA.

Participants: A total of 176 patients with histopathologically confirmed PAS were included in the study. The frequency of each stage of PAS severity was analyzed in relation to the number of PCDs Methods: Differences in the frequency of different stages of PAS severity among patients with varying numbers of PCDs were estimated. Adjusted logistic regression models were used to evaluate the association between the number of PCDs and PAS severity.

Results: In our referral center, the frequency of placenta accreta was 18.1% (n = 32/176), placenta increta 55.6% (n = 98/176), and placenta percreta 26.1% (n = 46/176). There were 8 patients with no PCDs, 48 with 1 PCD, 62 with 2 PCDs, and 58 with ≥3 PCDs. The frequency of placenta increta was similar among all PCDs groups; however, the frequency of placenta percreta was significantly higher among women with ≥3 PCDs (25/58 [43.1%]) as compared to those with ≤2 PCDs (21/118 [17.7%], aOR, 3.49 [95% confidence interval, 1.73-7.05]; p = 0.005). Patients with no PCDs had a higher frequency of placenta accreta and a similar frequency of placenta increta to those with a history of PCDs.

Limitations: The study was conducted at a single center with a high referral rate for severe forms of PAS, which may restrict the generalizability of the findings. Additionally, the classification of PAS relies heavily on histopathologic interpretation, which can introduce potential biases depending on provider experience and the criteria used.

Conclusion: The frequency placenta increta was similar among women with the suspicion of PAS regardless of the number of PCDs. Women with ≥3 PCDs had a significantly higher frequency of placenta percreta.

Objective: Epidemiological and in vitro studies of epithelial ovarian cancer (OC) strongly suggest a link between hormone receptor (HR) expression, tumorigenesis, and survival. Antihormonal therapies have shown antitumor activity in OC, both alone and combined with other treatments. The primary objective of this study was to examine the expression patterns of estrogen- and progesterone receptors (ER and PR) in OC across different histological subtypes and assess their prognostic value in disease progression.

Design: Retrospective analysis of data from 164 patients who received primary treatment at University Hospital Frankfurt between January 1999 and December 2019.

Materials, setting, methods: The expression of both HRs was determined through immunostaining of tissue samples and evaluated using the immunoreactive score (IRS) according to Remmele and Stegner. Correlation and survival analyses evaluated the prognostic and predictive significance of HR expression.

Results: The correlation between ER and PR expression with histological subtypes was significant (p = 0.002 and p = 0.013, respectively). Strong ER and PR expression was more common in HGSC, low-grade serous carcinoma, and EC, while low PR expression was linked to higher tumor grading (p = 0.032). Notably, clear cell carcinoma patients with weak PR expression had better survival rates than those with strong PR expression (p = 0.025). The difference in overall survival (OS) between ER-positive and ER-negative patients was minimal (55 vs. 51 months; p = 0.906). Median progression-free survival (PFS) and OS were slightly better in cases with weak PR expression (24 and 58 months) compared to strong PR expression (19 and 53 months; p = 0.797 and p = 0.45, respectively). In cases with strong ER expression and suboptimal debulking (TR >1 cm), disease recurrence was delayed (median PFS: 8 vs. 14 months; p = 0.038), a difference not seen after optimal debulking or in overall OS.

Limitations: This single-center, retrospective study limits generalizability. We could not distinguish PR isoforms or assess ER/PR ratios or interactions, limiting molecular insight.

Conclusion: ER and PR expression did not demonstrate a significant overall impact on survival in the entire cohort. However, the expression patterns and associated prognosis of ER and PR differed significantly depending on histological subtypes and clinical factors.

Introduction: Due to its anti-inflammatory properties, low-dose aspirin (LDA) has been theorized to mitigate spontaneous preterm birth (PTB). This systematic review and meta-analysis aims to report the available evidence to determine whether LDA administration prevents any spontaneous PTB.

Methods: Embase, PubMed, Scopus, Cochrane Central Register, and Web of Science databases were searched, and the protocol was registered within the PROSPERO database (CRD42021288021). Data were examined using Review Manager 5.4 Software.

Results: The search yielded 261 relevant articles, from which 11 pertinent studies were included in this meta-analysis. While LDA showed a reduction of spontaneous PTB rates (odds ratio [OR] 0.93; 95% confidence interval [CI] 0.84-1.04), the results lacked statistical significance. Nevertheless, LDA significantly reduced the rate of spontaneous PTB <34 weeks (6 studies; OR 0.85; 95% CI 0.78-0.93). Also, subgroup analysis of high-risk women (OR 0.96; 95% CI 0.78-1.17) and healthy women (OR 0.91; 95% CI 0.79-1.04) showed that LDA had a non-significant trend to reduce spontaneous PTB rates. Moreover, there was a statistically significant reduction in spontaneous PTB when LDA administration was initiated before 16 weeks (5 studies; OR 0.91; 95% CI 0.83-0.98), although not for LDA dosages below 100 mg (9 studies; OR 0.97; 95% CI 0.91-1.03).

Conclusion: This meta-analysis indicates a statistically significant reduction in spontaneous PTB rates associated with LDA administration only in spontaneous PTB pregnancies before 34 weeks (not any spontaneous PTB) and for LDA administration starting before 16 weeks. Although LDA can potentially prevent any spontaneous PTB, further well-conducted trials focussing specifically on this subgroup are warranted to provide robust evidence of its efficacy.

Objectives: The aim of the study was to evaluate whether the use of a 12-week liraglutide treatment changes the endometrial gene expression during the implantation window in infertile obese women with polycystic ovarian syndrome (PCOS) undergoing in vitro fertilization (IVF).

Design: A cross-sectional study involving treated and non-treated subjects was conducted.

Participants: Infertile women with PCOS and BMI ≥30 kg/m2 participated in the study.

Setting: The study was conducted at a tertiary-care university hospital.

Methods: Endometrial biopsies were collected from 20 infertile women during the implantation window, 1 month prior to entering the IVF procedure. Endometrium transcriptome of 10 participants, who had been pretreated with low-dose liraglutide 1.2 mg QD for 12 weeks and achieved at least a 5% reduction in body weight, was compared to endometrium transcriptome of 10 treatment-naive participants, who had a stable body weight over the last 12 weeks. Next-generation sequencing was conducted to analyze RNA from the samples. The resulting data were processed to discern key canonical pathways and predict activations or inhibitions. Gene networks were constructed based on established published associations.

Results: Gene Set Analysis (GSA) identified a total of 17 canonical pathways that were significantly differentially expressed between the two groups. The most important canonical pathways included GLP-1 receptor activation, modulation of inflammation and oxidative stress response, alterations in glucose homeostasis, and energy consumption, with YWHAG being a notable central gene in the associated network. The results indicate a possible involvement of the AKT pathway in the liraglutide mode of action.

Limitations: The main limitations include its cross-sectional design and considerable number of upregulated and downregulated genes.

Conclusions: Short-term low-dose liraglutide treatment prior to IVF was associated with changes in the endometrial transcriptome that could potentially be important for improving endometrial receptivity and fertility in women with obesity and PCOS.

Objectives: The primary aim of this study was to assess the association between endometrial compaction and pregnancy outcomes in Hormone Replacement Therapy-Frozen Embryo Transfer (HRT-FET) protocols. The secondary objective was to investigate the correlation between serum progesterone levels and pregnancy success in FET cycles.

Design: Prospective cohort study was conducted during January-April 2024.

Setting: The study was conducted at a university-affiliated hospital in Tehran, Iran.

Participants: Infertile women under 40 years undergoing HRT-FET participated in the study. Patients with uterine and genetic factors were excluded.

Materials and method: Data on endometrial thickness and serum progesterone levels were gathered, and patients were divided into groups based on the presence or absence of endometrial compaction using transvaginal sonography. Univariate and multivariate statistical analyses, including logistic regression models, were employed to assess factors associated with pregnancy outcomes.

Results: Ninety participants with similar demographic profiles were enrolled in the study. The biochemical and clinical pregnancy rates were higher in the group with endometrial compaction, at 37.3% and 33.3%, respectively, compared to 15.4% in both categories for the group without compaction, with a statistically significant difference in biochemical pregnancy rates (p = 0.022). The live birth rate was also higher in the compaction group (21.6%) compared to the non-compaction group (7.7%), showing a borderline statistical difference in the chi-square analysis (p = 0.072). No significant difference in serum progesterone levels was observed between patients with and without endometrial compaction.

Limitations: While simultaneous evaluation of endometrial compaction and serum progesterone with adjustment for confounders enhanced internal validity, the study's single-center design and limited sample size restricted subgroup analyses and statistical power. Further research with larger cohorts and consideration of progesterone administration routes is needed to confirm and extend these findings.

Conclusions: Endometrial compaction on the day of embryo transfer is linked to increased rates of biochemical and clinical pregnancies. This association remains consistent regardless of serum progesterone levels, highlighting the independent influence of endometrial compaction on pregnancy success.

Objectives: The primary objective of this study was to determine whether the volume of cervical varices, quantified by magnetic resonance imaging (MRI), predicts massive intraoperative blood loss in placenta previa. The secondary objective was to examine the relationship between cervical varices volume and placental location, sponge-like findings on transvaginal ultrasound (TVUS), and active lower uterine segment bleeding.

Design: A retrospective cohort study was conducted.

Participants/materials, setting, methods: This study included 98 individuals with singleton pregnancies and placenta previa who underwent prenatal MRI and cesarean section at a tertiary care center in Japan between April 2012 and March 2021. MRI was performed around 34 weeks of gestation as part of routine placenta accreta spectrum (PAS) screening. Cervical varices were defined as high-signal vascular structures located within the cervix and lower uterine segment on sagittal T2-weighted MRI. Their volume was manually calculated as an approximate cervical varices volume (aVCV). Receiver operating characteristic (ROC) analysis was used to determine the optimal aVCV cutoff for predicting massive blood loss (defined as ≥1,500 mL). Logistic regression was used to assess independent predictors of bleeding. A subgroup analysis was conducted among patients with posterior placenta previa without PAS.

Results: Cervical varices were detected by MRI in 94.9% of cases. ROC analysis identified 36.0 cm3 as the optimal aVCV cutoff (AUC: 0.63), with a specificity of 86.2% and positive predictive value of 75.9%. Large cervical varices (aVCV >36.0 cm3) were significantly associated with massive bleeding (adjusted odds ratio: 9.44; 95% CI: 3.11-28.7). They also correlated with sponge-like findings on TVUS and posterior placental location but were smaller in cases with anterior placenta or PAS despite high bleeding volumes. Active bleeding from the lower uterine segment was more common in the large aVCV group and was associated with massive hemorrhage in non-PAS cases. In a subgroup of patients with posterior placenta previa without PAS (n = 43), predictive performance improved (AUC: 0.72; specificity: 95.8%; odds ratio: 9.53; 95% CI: 2.19-41.4).

Conclusion: Large cervical varices are an independent predictor of massive blood loss in placenta previa, particularly in posterior previa without PAS. Recognition of cervical venous enlargement as a core hemorrhagic risk factor may improve preoperative preparedness and promote broader efforts to refine diagnostic approaches.

Objectives: The aim of this study was to evaluate the diagnostic accuracy of pelvic magnetic resonance imaging (MRI) interpreted using the #Enzian classification system by comparing MRI findings with laparoscopic outcomes in women suspected of having endometriosis.

Design: Retrospective observational study.

Participants and setting: Twenty-four women aged 19 to 49 who underwent laparoscopic surgery for endometriosis at Galilee Medical Center from 2016 to 2023 had preoperative pelvic MRI available.

Methods: MRI and laparoscopic findings were classified using the #Enzian classification across 64 anatomical compartments. Diagnostic accuracy was evaluated for lesion location and size. Associations between MRI accuracy and patient characteristics were analyzed using appropriate statistical tests.

Results: MRI accurately identified the lesion location in 31.3% of compartments and lesion size in 20.3%. The highest accuracy was found in the tubo-ovarian region (60%), rectovaginal septum (42.9%), and ovaries (41.7%), while the lowest accuracy was observed in the parametrium (7.1%), rectum, extragenital sites, bladder and ureter (0%). Higher age, parity, and gastrointestinal symptoms were significantly associated with improved MRI accuracy (p < 0.05).

Limitations: The small sample size, retrospective design, and MRI scans from various centers with differing imaging quality and radiologist expertise may restrict generalizability.

Conclusions: MRI utilizing the #Enzian classification provides a structured method for evaluating deep infiltrating endometriosis; however, it demonstrates limited accuracy for superficial or parametrial disease. While it is useful for surgical planning, MRI cannot substitute for laparoscopy, which remains crucial for a thorough evaluation and treatment of endometriosis.