Minerva obstetrics and gynecology最新文献

Introduction: Artificial intelligence (AI) is revolutionizing healthcare by enhancing diagnostics, optimizing treatment plans, and improving patient outcomes through data analysis and predictive modeling. Within the field of reproductive endocrinology and infertility, machine learning algorithms trained on large datasets can analyze images, laboratory results, and genetic information to optimize in vitro fertilization outcomes.

Evidence acquisition: A comprehensive search of the electronic databases PubMeD and MEDLINE was conducted, and search results were narrowed to publications after the year 2020 yielding 54 publications included in this review; select seminal publications from before the year 2020 were also included.

Evidence synthesis: This review summarizes the most recent evidence demonstrating the design, implementation, and validation of AI in assisted reproductive technologies. The summarized findings are categorized by application of AI to the embryology laboratory and to clinical workflows as well as highlighting ethical concerns regarding the use of such tools.

Conclusions: AI-powered tools have been deployed in fertility clinics and embryology laboratories to enhance gamete selection and as drivers of quality improvement. Despite the promise of AI, challenges such as data bias, ethical concerns, and regulatory hurdles persist. As AI continues to evolve, its integration into reproductive medicine holds the potential to improve success rates and expand the accessibility of infertility treatments.

Background: Given associations between abnormal maternal serum analytes and small for gestational age, 3^rd trimester fetal growth ultrasounds are commonly obtained despite lack of evidence. We evaluated associations between isolated abnormal analytes, 3^rd trimester fetal growth restriction, and neonatal complications.

Methods: This retrospective, single institution cohort study included women with analytes from 2010-2019. Multiple gestation, delivery <28 weeks gestation, and those with another indication for a 3^rd trimester US were excluded. Fetal growth restriction prevalence at the first 3^rd trimester US with abnormal analytes was calculated, as well as its association with small for gestational age. Associations between abnormal analytes and neonatal outcomes (small for gestational age, intensive care, umbilical artery pH <7.0, 5-minute APGAR <7, preterm delivery, neonatal death) were also evaluated.

Results: Among 11,092 pregnancies, 1136 had isolated abnormal analytes, of which 613 had 3^rd trimester ultrasounds. Of these, 10 (1.6%) had growth restriction at the first 3^rd trimester ultrasound, and 99 (16.1%) were small for gestation. Abnormal analytes were associated with increased small for gestational age, intensive care admit, and preterm delivery. Only 9.1% of small for gestational age neonates had growth restriction at the first 3^rd trimester ultrasound.

Conclusions: Third trimester fetal growth restriction is uncommon with isolated abnormal analytes, and early 3^rd trimester ultrasound for this indication may commonly miss small for gestational age. These findings contribute to 1) evidence-based fetal surveillance in this setting, and 2) knowledge regarding potential implications on growth restriction detection by replacing serum analyte screening with cell free fetal DNA.

Introduction: Assisted reproductive technologies (ART) aim to address the underlying causes of infertility, resulting in a healthy live birth. One aspect that appears receiving less attention yet is equally crucial as any other steps in the ART process, is embryo transfer (ET). Even with optimal embryos, a successful live birth cannot be achieved without a precise and atraumatic transfer to the correct location within the uterine cavity. Compared to other advancements in laboratory and clinic, relatively few innovations have occurred in ET.

Evidence acquisition: This literature review aimed to summarize the latest evidence in four main sections: requirements and preparations for ET, the ET procedure, complications, training and competence.

Evidence synthesis: The review emphasizes the need for appropriate equipment, including soft-tip catheters and high-resolution ultrasound machines, to minimize trauma and enhance ET precision. Additionally, rigorous quality control in the laboratory is essential for achieving optimal clinical outcomes. Despite the technical simplicity of ET, complications such as cervical trauma, retained embryos, and rare expulsion from the cervix highlight the need for further research and improvement in this critical step of the process. Finally, the necessity for well-trained practitioners and embryologists, with competence regularly evaluated through performance indicators, is crucial.

Conclusions: Further research is needed to standardize ET techniques and improve ART outcomes, suggesting that each step of ET may significantly influence the procedure's success. Attention to detail and adherence to key factors are critical to optimizing the transfer of an embryo to the uterus, leading to higher pregnancy rates and better patient outcomes.

Background: The association of cervical ripening balloons (CRB) and misoprostol for induction of labor (IoL) is frequently used, although there is poor evidence about the optimal timing and protocol for their combination. The aim of this study was to compare a concurrent and a sequential scheme for administration of oral misoprostol in association with CRB, in terms of mode and timing of delivery and rate of adverse events.

Methods: This was an observational study comparing two consecutive cohorts of women with unfavorable cervix undergoing IoL by means of double-balloon CRB combined with oral misoprostol, with either a sequential scheme (retrospective cohort, N.=36) or a concurrent administration (prospective cohort, N.=30). The primary outcome was the rate of vaginal delivery (VD); secondary outcomes included the interval of time to labor and delivery and the incidence of maternal or perinatal complications.

Results: The concurrent administration of misoprostol combined with CRB resulted in a similar rate of VD compared to the sequential scheme (63.9% vs. 76.7%, P=0.29). Both time to active labor (32.7±10.9 vs. 21.8±9.6 hours, P=0.001) and to vaginal delivery (34.0±12.6 vs. 25.3±10.2 hours, P=0.016) were shorter for concurrent misoprostol administration, resulting in a higher rate of VD within 24 hours (13.9% vs. 43.3%, P=0.01). The rate of maternal and perinatal adverse outcomes did not differ significantly between the two groups.

Conclusions: Concurrent use of CRB and oral misoprostol might be preferable due to similar results in terms of mode of delivery, achieved in a shorter time with no increase in complications; further studies on larger populations will be needed to verify potential differences in CS rates and rare adverse events.

Background: Controlled ovarian stimulation during in-vitro fertilization (IVF) is personalized based on anticipated hyper, normal, poor response. With respect to poor responders, who are often treated using higher gonadotropin dosing and combination of urinary and recombinant gonadotropins (rFSH) with marginal benefit, we report our experience with a newer, more potent rFSH (Follitropin-δ) undergoing IVF.

Methods: Retrospective analysis of all IVF cycles in which follitropin-δ was used alone or combined with urinary gonadotropins over a 3-year period. Patients were grouped according to the POSEIDON Classification as expected low responders (POSEIDON 3-4; AMH<1.2; N.=45), unexpected low responders (POSEIDON 1-2; retrieval of ≤9 oocytes; N.=67) and those with a normal response (N.=93). Demographic, stimulation (including target number of retrieved oocytes [8 to14]), embryology and clinical outcome parameters (clinical pregnancy rate [CPR], live birth rate [LBR], cumulative live birth rate [cLBR]) were compared.

Results: Those categorized as POSEIDON patients were older, had lower ovarian reserve, were more likely to use a mixed protocol, less likely to reach the target oocytes retrieved (35.7% vs. 51.6%, P<0.001), and had a lower cLBR per patient (29.5% vs. 38.7%, P=0.006) when compared to non-POSEIDON patients. Expected low responders (POSEIDON 3-4) were older and had lower AMH when compared to unexpected low responders (POSEIDON 1-2), but no differences in the target of oocytes retrieved (33.3% vs. 37.3%, P=0.66) and cLBR (28.9% vs. 37.3%, P=0.06) were noted.

Conclusions: In expected low responders, follitropin-δ can be used to optimize oocyte collection and clinical outcome though one may need to deviate from the algorithm-suggested dose. Future studies should explore stimulation modifications in unexpected low responders.

Background: Histological evaluation of ovarian tissue harvested as part of the attempt to preserve fertility might clarify the mechanism by which ovarian failure is caused. The purpose of this study was to compare the histologic appearance of ovarian tissue harvested for ovarian tissue cryopreservation (OTC) in chemotherapy naïve and chemotherapy exposed patients regarding the presence of follicles in different stages of development and to explore ovarian tissue histology in patients exposed to low- and high-cytotoxicity risk chemotherapy.

Methods: A cohort of post-pubertal cancer survivors who underwent OTC between 1997 and 2018 was evaluated. An expert pathologist reviewed the pathology slides taken during OTC. The assessment included counting number of primordial, primary, secondary, and antral follicles. A comparison was made between chemotherapy naïve and chemotherapy exposed women and further between women who previously received low- versus high-risk gonadotoxic regimens.

Results: Seventy post-pubertal patients were included in the study. Seventeen (24.3%) received chemotherapy prior to OTC, and 53 (75.7%) were chemotherapy naïve at the time of OTC. A significant difference was found only in the number of secondary follicles, which was increased in chemotherapy naïve patients (2.81±4.26 vs. 0.88±1.18, respectively; P=0.005). Similar results were observed in a subgroup analysis of hematologic malignancies separately. Comparison of patients with previous exposure to chemotherapy revealed similar follicular appearance, except for the number of secondary follicles, which was higher in patients receiving low-risk compared to high-risk chemotherapy (1.40±1.28 vs. 0.14±0.35, respectively; P=0.006).

Conclusions: The ovarian follicular pool at OTC appears comparable between chemotherapy naïve individuals and those post-exposure, as well as among patients receiving low versus high-risk gonadotoxic regimens, with the exception of secondary follicles, which are presented in increased numbers in chemotherapy naïve and those exposed to low-risk gonadotoxic chemotherapy.

Uterus transplantation (UTx) emerged as a groundbreaking solution for women facing absolute uterine factor infertility (AUFI), offering hope for childbearing since the first proof-of-concept of UTx in 2014 by the first live birth from a woman with uterine graft. This review provides a comprehensive overview of the evolution of UTx from foundational animal research to current clinical trials and cases. Recent advancements in surgical techniques, including a shift towards robotic approaches, have improved graft removal and transplantation, though challenges persist in optimizing immunosuppressive strategies and rejection monitoring. Given the absence of Fallopian tube transplantation in UTx, in vitro fertilization (IVF) is an integral part of the process. This review delves into the intricacies of combining UTx with IVF, addressing crucial questions about the timing of oocyte retrieval, cryopreservation of oocytes or embryos, and the optimal timing for the first embryo transfer post-UTx. The significance of the International Society Uterus Transplantation (ISUTx) registry is highlighted for evaluating overall success rates, complications, and live births. Examining the long-term health outcomes for donors, recipients, partners, and children born from transplanted grafts, the review acknowledges the life-giving nature of UTx. Cost considerations are explored, anticipating a potential decrease in costs with enhanced efficiency. The discussion emphasizes the evolving landscape of UTx, proposing a scheme for program setup and outlining future directions. This comprehensive analysis marks a significant milestone in the field, transitioning UTx from experimental to mainstream clinical practice. As criteria widen and outcomes improve, UTx is poised to become a realistic and accessible alternative for treating AUFI, representing a significant advancement in reproductive medicine worldwide.

Background: The primary purpose of this study was to verify if trabecular bone score (TBS) might fit with the changes of bone mineral density (BMD) confirming as a reliable marker of bone fragility.

Methods: A retrospective observational study on 898 Italian women (aged 40-90 years) was conducted between January 2021 and February 2023. All recruited women were divided into two main groups according to TBS (Group A: TBS ≥1.31; Group B: TBS<1.31) and, further, in five subgroups according to age.

Results: According to univariate ANOVA, there was not significant difference of BMI between group A and group B but Bonferroni Test found that BMI significantly differed for age subgroups and TBS value (P<0.05). ANOVA analysis reported that mean L1-L4 BMD and/or T-score were significantly different for age and TBS (P=0.000); Bonferroni Test found that L1-L4 BMD significantly differed in the comparison of age subgroups for Group A and Group B (P<0.05). Besides, Bonferroni analysis found significant differences regarding total and neck femoral BMD and/or T-score in the comparison between age subgroups for group A and group B (P<0.05). As for neck femoral BMD and T-score, all significances were observed for group B in the comparison between subgroups aged over 60 years and others (P<0.05). Multivariate logistic regression analysis showed that age and femoral neck BMD significantly contribute to TBS (P<0.05).

Conclusions: Our results seem to suggest that low level of TBS may detect patients that could be more prone to bone frailty consistently with age and BMD at both vertebral and cortical level. However, its role in clinical practice should be refined.