1,800 research outputs found
Dealing with equipment failure during oocyte retrieval
No full textThis chapter includes clinical cases, background, evidence-based practical management options, preventive measures, key-point summaries of equipment failure during oocyte retrieval and answers to questions patients ask. It is important any equipment failure is clearly documented, reported on the institution's reporting system and reviewed for learning and actions to mitigate future risk. If the issues cannot be adequately resolved, no oocytes may be retrieved in the window of time available after ovulation trigger. In such cases, the patient will require a full explanation and discussion as per the duty of candor. The question about any equipment failure is not if but rather when it will happen. A good preventive strategy will reduce the chance of failure, allow its prompt recognition and have a plan B for what to do when it occurs.</p
Surgical treatment of fibroids for subfertility
No full textBACKGROUND: Fibroids are the most common benign tumours of the female genital tract and are associated with numerous clinical problems including a possible negative impact on fertility. In women requesting preservation of fertility, fibroids can be surgically removed (myomectomy) by laparotomy, laparoscopically or hysteroscopically depending on the size, site and type of fibroid. Myomectomy is however a procedure that is not without risk and can result in serious complications. It is therefore essential to determine whether such a procedure can result in an improvement in fertility and, if so, to then determine the ideal surgical approach.OBJECTIVES: To examine the effect of myomectomy on fertility outcomes and to compare different surgical approaches.SEARCH METHODS: We searched the Cochrane Gynaecology and Fertility Group (CGFG) Specialised Register, CENTRAL, MEDLINE, Embase, PsycINFO, CINAHL, Epistemonikos database, World Health Organization (WHO) International Clinical Trials Registry Platform search portal, Database of Abstracts of Reviews of Effects (DARE), LILACS, conference abstracts on the ISI Web of Knowledge, OpenSigle for grey literature from Europe, and reference list of relevant papers. The final search was in February 2019.SELECTION CRITERIA: Randomised controlled trials (RCTs) examining the effect of myomectomy compared to no intervention or where different surgical approaches are compared regarding the effect on fertility outcomes in a group of infertile women suffering from uterine fibroids.DATA COLLECTION AND ANALYSIS: Data collection and analysis were conducted in accordance with the procedure suggested in the Cochrane Handbook for Systematic Reviews of Interventions.MAIN RESULTS: This review included four RCTs with 442 participants. The evidence was very low-quality with the main limitations being due to serious imprecision, inconsistency and indirectness. Myomectomy versus no intervention One study examined the effect of myomectomy compared to no intervention on reproductive outcomes. We are uncertain whether myomectomy improves clinical pregnancy rate for intramural (odds ratio (OR) 1.88, 95% confidence interval (CI) 0.57 to 6.14; 45 participants; one study; very low-quality evidence), submucous (OR 2.04, 95% CI 0.62 to 6.66; 52 participants; one study; very low-quality evidence), intramural/subserous (OR 2.00, 95% CI 0.40 to 10.09; 31 participants; one study; very low-quality evidence) or intramural/submucous fibroids (OR 3.24, 95% CI 0.72 to 14.57; 42 participants; one study; very low-quality evidence). Similarly, we are uncertain whether myomectomy reduces miscarriage rate for intramural fibroids (OR 1.33, 95% CI 0.26 to 6.78; 45 participants; one study; very low-quality evidence), submucous fibroids (OR 1.27, 95% CI 0.27 to 5.97; 52 participants; one study; very low-quality evidence), intramural/subserous fibroids (OR 0.80, 95% CI 0.10 to 6.54; 31 participants; one study; very low-quality evidence) or intramural/submucous fibroids (OR 2.00, 95% CI 0.32 to 12.33; 42 participants; one study; very low-quality evidence). This study did not report on live birth, preterm delivery, ongoing pregnancy or caesarean section rate. Laparoscopic myomectomy versus myomectomy by laparotomy or mini-laparotomy Two studies compared laparoscopic myomectomy to myomectomy at laparotomy or mini-laparotomy. We are uncertain whether laparoscopic myomectomy compared to laparotomy or mini-laparotomy improves live birth rate (OR 0.80, 95% CI 0.42 to 1.50; 177 participants; two studies; I2 = 0%; very low-quality evidence), preterm delivery rate (OR 0.70, 95% CI 0.11 to 4.29; participants = 177; two studies; I2 = 0%, very low-quality evidence), clinical pregnancy rate (OR 0.96, 95% CI 0.52 to 1.78; 177 participants; two studies; I2 = 0%, very low-quality evidence), ongoing pregnancy rate (OR 1.61, 95% CI 0.26 to 10.04; 115 participants; one study; very low-quality evidence), miscarriage rate (OR 1.25, 95% CI 0.40 to 3.89; participants = 177; two studies; I2 = 0%, very low-quality evidence), or caesarean section rate (OR 0.69, 95% CI 0.34 to 1.39; participants = 177; two studies; I2 = 21%, very low-quality evidence). Monopolar resectoscope versus bipolar resectoscope One study evaluated the use of two electrosurgical systems during hysteroscopic myomectomy. We are uncertain whether bipolar resectoscope use compared to monopolar resectoscope use improves live birth/ongoing pregnancy rate (OR 0.86, 95% CI 0.30 to 2.50; 68 participants; one study, very low-quality evidence), clinical pregnancy rate (OR 0.88, 95% CI 0.33 to 2.36; 68 participants; one study; very low-quality evidence), or miscarriage rate (OR 1.00, 95% CI 0.19 to 5.34; participants = 68; one study; very low-quality evidence). This study did not report on preterm delivery or caesarean section rate. AUTHORS' CONCLUSIONS: There is limited evidence to determine the role of myomectomy for infertility in women with fibroids as only one trial compared myomectomy with no myomectomy. If the decision is made to have a myomectomy, the current evidence does not indicate a superior method (laparoscopy, laparotomy or different electrosurgical systems) to improve rates of live birth, preterm delivery, clinical pregnancy, ongoing pregnancy, miscarriage, or caesarean section. Furthermore, the existing evidence needs to be viewed with caution due to the small number of events, minimal number of studies and very low-quality evidence.</p
The patient with thrombophilia
No full textThis chapter includes clinical cases, background, evidence-based practical management options, preventive measures, key-point summaries of thrombophilia and answers to questions patients ask. Thromboembolism is a rare complication of ovarian stimulation for IVF. Venous thrombosis is a potentially serious disorder which may often lead to post-thrombotic syndrome causing chronic morbidity. Because women undergoing IVF are generally young and active, this may afflict their lives for many years. screening for thrombophilia should be considered in women with a history of recurrent miscarriage, or personal or family history of venous thromboembolism (VTE). The management of the woman with a single previous VTE has been controversial, but data from studies of pregnancy may guide therapy in the context of IVF. Clinical reports of deep venous thrombosis occurring following IVF treatment indicate that it most frequently presents in early pregnancy between 5 and 10 weeks after human chorionic gonadotropin administration.</p
Discrete choice experiment exploring women's preferences in a novel device designed to monitor the womb environment and improve our understanding of reproductive disorders
No full textObjectives The study aims to determine the relative importance of key attributes of a novel intrauterine device. The device monitors uterine oxygen, pH and temperature in real time with the aim of improving our understanding and treatment of reproductive disorders. Design A discrete choice experiment was used to elicit preferences in this novel investigative tool. The attributes and levels used in the choice scenarios were length of time using the device (7, 14 or 28 days), information obtained to guide treatment (limited, majority or all cases), risk of complications (1% or 10%) and discreteness (completely discrete, moderately discrete or indiscrete). Setting Secondary care hospital in Hampshire, UK. Participants 361 women of reproductive age. Primary and secondary outcome measures Conditional logit and latent class logit regression models to determine the preference for each attribute. Results Conditional logit coefficients allow comparison between attributes; women placed most importance on obtaining information to guide treatment in all cases (2.771), followed by having a completely discrete device (1.104), reducing risk of complications by 1% (0.184) and decreased length of time by 1 day (0.0150). All coefficients p<0.01. Latent class conditional logit assigns participants to two classes with 27.4% in class 1 who are less likely to have higher education or qualify for National Health Service-funded in vitro fertilisation compared with class 2. Those in class 2 placed 1.7 times more importance on a device whose information guided treatment in all cases and a 1% decrease in complications risk was nearly 15 times more attractive. Conclusions Women placed most importance on having a device that obtains information to guide treatment and are willing to use the device for a longer, have a device with higher risk of complications and an indiscrete device if it is able to provide answers and direction for treatment of their reproductive disorder.</p
Acupuncture and assisted conception. (Protocol)
No full textBACKGROUND: Acupuncture has recently been studied in assisted reproductive treatment (ART) although its role in reproductive medicine is still debated. OBJECTIVES: To determine the effectiveness of acupuncture in the outcomes of ART. SEARCH STRATEGY: All reports which describe randomised controlled trials of acupuncture in assisted conception were obtained through searches of the Menstrual Disorders and Subfertility Group Specialised Register, CENTRAL, Ovid MEDLINE (1996 to August 2007), EMBASE (1980 to August 2007), CINAHL (Cumulative Index to Nursing & Allied Health Literature) (1982 to August 2007), AMED, National Research Register, Clinical Trials register (www.clinicaltrials.gov), and the Chinese database of clinical trials. SELECTION CRITERIA: Randomised controlled trials of acupuncture for couples who were undergoing ART comparing acupuncture treatment alone or acupuncture with concurrent ART versus no treatment, placebo or sham acupuncture plus ART for the treatment of primary and secondary infertility. Women with medical illness deemed contraindications for ART or acupuncture were excluded. DATA COLLECTION AND ANALYSIS: Sixteen randomised controlled trials were identified that involved acupuncture and assisted conception. Thirteen trials were included in the review and three were excluded. Quality assessment and data extraction were performed independently by two review authors. Meta-analysis was performed using odds ratio (OR) for dichotomous outcomes. The outcome measures were live birth rate, clinical ongoing pregnancy rate, miscarriage rate, and any reported side effects of treatment. MAIN RESULTS: There is evidence of benefit when acupuncture is performed on the day of embryo transfer (ET) on the live birth rate (OR 1.89, 95% CI 1.29 to 2.77) but not when it is performed two to three days after ET (OR 1.79, 95% CI 0.93 to 3.44). There is no evidence of benefit on pregnancy outcomes when acupuncture is performed around the time of oocyte retrieval. AUTHORS' CONCLUSIONS: Acupuncture performed on the day of ET shows a beneficial effect on the live birth rate; however, with the present evidence this could be attributed to placebo effect and the small number of women included in the trials. Acupuncture should not be offered during the luteal phase in routine clinical practice until further evidence is available from sufficiently powered RCTs.<br/
Pre and post operative medical therapy for endometriosis surgery
No full textBackground: Endometriosis is a common gynaecological condition affecting approximately 10% of women of reproductive age (Ozkan 2008). Common symptoms are dysmenorrhoea, pelvic pain, infertility or a pelvic mass. Diagnosis by laparoscopy or laparotomy enables identification of the location, extent and severity of the disease. Surgery may include removal (excision) or destruction (ablation) of endometriotic tissue, division of adhesions and removal of endometriotic cysts. Laparoscopic excision or ablation of endometriosis has been shown to be effective in the management of pain in mild to moderate endometriosis. Adjunctive medical treatment pre or post-operatively may prolong the symptom-free interval.Objectives: To determine the effectiveness of medical therapies for hormonal suppression before or after surgery for endometriosis for improving painful symptoms, reducing disease recurrence and increasing pregnancy rates.Search strategy: We searched the Cochrane Menstrual Disorders and Subfertility Group Trials Register (searched Sept 2010), the Cochrane Central Register of Controlled Trials (CENTRAL) in The Cochrane Library (Sept 2010), MEDLINE (January 1966 to September 2010), EMBASE (January 1985 to September 2010) and reference lists of articles.Selection criteria: Trials were included if they were randomised controlled trials comparing medical therapies for hormonal suppression before or after or before and after, surgery for endometriosis.Data collection and analysis: Data extraction and assessment of risk of bias were performed independently by two authors. Where possible, data were combined using relative risk (RR), standardised mean difference or mean difference and 95% confidence intervals (CI).Main results: Sixteen trials were included. Two trials of pre-surgical medical therapy showed no evidence of benefit compared to surgery alone. There was no evidence of benefit for post-surgical hormonal suppression of endometriosis compared to surgery alone for the outcomes of pain, disease recurrence or pregnancy rates (RR 0.84, 95% CI 0.59 to 1.18). There were no trials identified in the search that compared hormonal suppression of endometriosis before and after surgery with surgery alone. One trial found no evidence that pre-surgical hormonal suppression was different from post-surgical hormonal suppression for the outcome of pain. Another single trial comparing post-surgical medical therapy with both pre and post-surgery found no difference in the outcomes of American Fertility Society (AFS) scores and pregnancy rate.Authors' conclusions: There is no evidence of benefit associated with post surgical medical therapy and insufficient evidence to determine whether there is a benefit from pre-surgical medical therapy with regard to the outcomes evaluated.<br/
Are skin scar characteristics associated with the degree of pelvic adhesions at laparoscopy?
No full textObjectiveTo investigate whether individual or a combination of abdominal surgical scar characteristics can predict the severity and extent of intra-abdominal adhesions.DesignA prospective cohort study.SettingA tertiary referral center in the United Kingdom.Patient(s)One hundred women who had previously undergone abdominopelvic surgery and were undergoing an elective laparoscopic gynecologic operations.Intervention(s)Abdominal scars were evaluated preoperatively using the modified Manchester Scar Questionnaire Adhesions were assessed intraoperatively and compared with the cutaneous findings.Main Outcome Measure(s)Presence and severity of intra-abdominal adhesions.Result(s)Of 100 women recruited into this study, 71 (71%) women were found to have intra-abdominal Aadhesions, and 29 (29%) had no adhesions. Women who had more than one abdominal scar, a palpable scar, and/or a longer scar were most likely to have pelvic adhesions during the current surgery. Women with the highest mean scar scores also had a greater total adhesion score.Conclusion(s)Adhesions are a common postoperative consequence of open or laparoscopic surgery. Skin scar characteristics are associated with the presence and degree of pelvic adhesions. Future studies should examine whether these characteristics can be used as a preoperative predictive tool to facilitate surgical decision-making and elective operating room organization
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