Subsequent Fertility Outcomes Research Articles

Prevalence and Risk Factors of Sonographically Detected Cesarean Scar Defects: A Review

Abstract Cesarean section is the most commonly performed uterine surgical procedure globally, with rising rates observed in India, increasing from 8.5% in 2005 to 17.2% in 2015. Cesarean section scars are associated with future obstetric complications such as placenta praevia, morbidly adherent placenta, and cesarean scar pregnancies. Scar defects are found in 42%–70% of women with previous cesarean sections. The objective of this study is to review the prevalence and risk factors of cesarean scar defects (CSDs) detected sonographically and to understand their clinical implications. A literature search was conducted using the keywords related to cesarean scar defects, transvaginal ultrasound, and abnormal uterine bleeding from PubMed Central, Medline, and Google Scholar. Articles analyzing prevalence, etiology, and risk factors were included, whereas treatment-related articles were excluded. Thirty-seven articles were analyzed. Studies indicate a prevalence of CSD between 24% and 70% with transvaginal ultrasound, and higher (56%–84%) with saline infusion sonography. CSD is defined as a hypoechoic area within the myometrium of the lower uterine segment, varying in definitions based on indentation measurements of 1 mm or 2 mm. Hypotheses on CSD formation include impaired wound healing from lower segment cesarean incisions, incomplete uterine wall closure, adhesion-related counteracting forces, and patient-related factors such as body mass index and hypertension. Identifying CSD is vital for evaluating women with previous cesarean sections and relevant gynecological symptoms. More long-term cohort studies are necessary to ascertain the incidence of CSD, its risk factors, and subsequent fertility outcomes. Special attention should be given to the quality of life for women affected by CSDs. Further research is warranted given the increasing cesarean section rates in India and the associated scope for study.

Effect of military service on fertility: evidence from the 2001 draft suspension in Spain

PurposeMany European countries suspended mandatory conscription after the Cold War, and especially between 2000 and 2010. However, with the changing security situation in Europe, more and more countries are considering the re-introduction of the draft. That is why, it is important to evaluate the impact of conscription on draftees, including its effect on fertility outcomes. Additionally, fertility is of particular interest because birth rates have been below replacement levels in most European countries at least in the last two decades. This, combined with the increase in life expectancy, has contributed to aging population and raises concerns about the future economic prospects and sustainability of the continent. Military service could be related to fertility in several ways. Compulsory service for men would affect the marriage market and subsequently child-bearing outcomes. For example, men who serve in the military would have to delay higher education at least by a year, given that they plan to continue their education after high school. One possibility is that this leads to older men meeting younger women if partners meet at college. Alternatively, in case the partners know each other prior to the draft, service could delay marriage by up to a year due to the conscription, postponing planning and having children, and potentially having fewer children as women might be less able or less willing to have a child after a certain age. Finally, some men who plan and would otherwise continue their education might choose to not do so or to further postpone it once they disattach from studying during their service. For some men, this might influence their marital and subsequent fertility outcomes. In either of these scenarios, a draft or its suspension is likely to be connected to fertility.Design/methodology/approachThis study examines the effect of the suspension of the draft in Spain in December 2001 on three fertility outcomes of men that would have been drafted in the absence of the suspension. The author performs the analysis in a difference-in-differences framework. Potential concerns and policy implications are also discussed.FindingsThe findings suggest that after the suspension of the draft, individuals started to have their first child earlier given that they decide to have children. Consistent with the overall time trend, they became less likely to have a child and started to have fewer children. However, the age at birth of the first child decreased while the number of children and the likelihood of having a child increased for men relative to women, after compared to before the suspension of the mandatory draft.Originality/valueThe author extends prior literature by investigating the effect of the abolition of compulsory military service in Spain in December 2001 on fertility. This is novel is several ways. First, to the best of the author’s knowledge, previous literature has examined the effect of this Spanish reform only on labor market outcomes prior to men's conscription. Second, even for other countries that terminated the compulsory draft, fertility has been under-studied, providing an opportunity for further exploration. Third, this analysis is based on rich Census data, representative of the population in Spain. Finally, given the inconclusive findings of previous studies for other countries and the proposed re-introduction of the draft in some parts of Europe, additional evidence of the effect of the conscription has important policy implications necessary for the evaluation of future military service policy decisions.

The impact of systemic methotrexate and surgical management on fertility preservation in tubal ectopic pregnancy among Saudi women

Background The impact of various management plans on subsequent fertility after tubal ectopic pregnancy (EP) is not well known. The objective of the present study was an evaluation of the subsequent fertility outcome among women with EP managed either surgical or medical with systemic methotrexate or medical management followed by surgical one. Patients and methods A retrospective cohort study was done by reviewing of medical records of all women diagnosed with EP at King Faisal Military Hospital, Southern Region, Saudi Arabia throughout the period from January 2015 to December 2016 provided that they were hemodynamic stable, with starting βhCG level less than 10000 IU/L, and adnexal mass less than 5 cm. These cases were followed for four years from January 2017 to December 2020. Results The study included 85 women with EP. Their mean age was 31.3 ± 6.7 years. Medical management (systemic Methotrexate) was followed in 48.2% of cases whereas surgical management was applied for 43.5% of them while medical management followed by surgical one was seen in 8.2% of cases. Complete follow-up throughout 2017–2020 was available for 52 women. A history of recurrent EP was observed among 3 women (5.8%). Most of them (75%) had a viable pregnancy. There was no statistically significant association between the method of management of EP and subsequent fertility, although the rate of normal pregnancy (intrauterine viable pregnancy ≥ 24 weeks which is the age of viability at our hospital) was higher among those managed surgically or by medical followed by surgical management than those managed medical only (84.6% and 100% vs. 62.5%). Conclusion Although the normal pregnancy rate was higher among those managed surgically or by medical followed by surgical management than those managed medically only, this was not statistically significant.

Subsequent fertility, pregnancy, and gynaecological and psychological outcomes after maternal-fetal surgery for open spina bifida: A prospective cohort study.

To determine the medium-term maternal impact of open fetal spina bifida repair. Prospective cohort study. University Hospitals Leuven, Belgium. Mothers who had open maternal-fetal spina bifida repair between March 2012 and December 2021. A patient-reported survey on subsequent fertility, pregnancy, and gynaecological and psychological outcomes. Complications during subsequent pregnancies, and gynaecological and psychological problems. Seventy-two out of 100 invited women completed the questionnaire (72%). Despite being advised not to, seven of 13 women attempting to conceive became pregnant within 2 years after fetal surgery and one woman delivered vaginally. Two of the 16 subsequent pregnancies were complicated by an open neural tube defect. One pregnancy was complicated by a placenta accreta and one pregnancy was complicated by a uterine rupture, both with good neonatal outcomes. Nearly half of respondents who did not attempt to conceive reported that this was because of their experience of the index pregnancy and caring for the index child. Three out of four respondents reported medium-term psychological problems, mostly anxiety for the health of the index child, fear for recurrence in subsequent pregnancies and feelings of guilt. Open maternal-fetal surgery for spina bifida did not appear to affect fertility in our cohort. Half of the attempts to conceive took place within 2 years. One uterine rupture and one placenta accreta occurred in 16 subsequent pregnancies. Most respondents reported psychological problems linked to the index pregnancy, which reinforces the need for long-term psychological support.

Subsequent fertility after cesarean scar pregnancy: a retrospective analysis

BackgroundCesarean scar pregnancy (CSP) refers to the implantation and growth of the gestational sac at a uterine scarring site due to a previous cesarean section. The effects of CSP on subsequent fertility have emerged as a clinical issue of importance in gynecology and obstetrics in China owing to the increasing rate of cesarean section over the past 30 years in combination with the abolition of the national family planning policy, allowing for subsequent pregnancies. Therefore, we aimed to investigate the effects of CSP treatment on subsequent fertility and pregnancy outcomes.MethodsThe study consecutively enrolled 499 women treated for CSP at Taizhou Hospital between January 2009 and December 2018. The study outcomes were the rate of secondary infertility and pregnancy outcomes. Clinical information was collected at the time of admission for CSP treatment. Information on subsequent fertility and pregnancy outcomes was collected via telephonic follow-up.ResultsAmong the 499 women who met the inclusion criteria for CSP, 48 were lost to follow-up. Most women (74.9%, 338/451) did not express the desire for a subsequent pregnancy after CSP treatment. Among the 113 women who initially desired a subsequent pregnancy, 62 finally abandoned fertility plans. Among the 51 women who pursued pregnancy, 48 pregnancies were recorded in 43 women, infertility secondary to CSP treatment was identified in 15.7% (8/51) of women, and 60.8% (31/51) of women achieved full-term pregnancy, with placenta accreta spectrum identified in two women, one requiring a hysterectomy during cesarean section due to massive bleeding. Among the 16 women treated with uterine artery embolization combined with uterine aspiration and 18 women treated by ultrasound-guided local lauromacrogol injection combined with uterine aspiration, a successful full-term pregnancy rate of 68.8% (11/16) and 88.9% (16/18), respectively, was achieved. There were five cases of recurrent CSP among all 76 pregnancies (6.6%).ConclusionOver a long-term follow-up of women after CSP treatment, a high successful fertility rate was identified, with also an increased CSP recurrence rate. Uterine artery embolization combined with uterine aspiration and ultrasound-guided local lauromacrogol injection combined with uterine aspiration showed high rates of successful post-treatment fertility and pregnancy.

Menstrual, fertility and psychological impacts after uterine compression sutures for postpartum hemorrhage: a prospective cohort study

BackgroundUterine compression suture is an important conservative surgical technique in managing atonic postpartum hemorrhage. In this study, we aim to evaluate the subsequent menstrual, fertility and psychological outcomes after uterine compression sutures.MethodsThis was a prospective cohort study between 2009 and 2022 conducted in a tertiary obstetric unit (6000 deliveries per year) in Hong Kong SAR. Women with primary postpartum hemorrhage successfully treated with uterine compression sutures were followed-up in postnatal clinic for two years after delivery. Data on menstrual pattern were collected during each visit. Psychological impact after uterine compression suture was assessed using a standardized questionnaire. Subsequent pregnancies were identified by territory-wide computer registry and telephone interviews. Women with postpartum hemorrhage treated with uterotonic agents only were chosen as controls.ResultsIn our cohort (n = 80), 87.9% of women had return of menses within six months after delivery. Regular monthly cycle was observed in 95.6% of women. Majority of women reported similar menstrual flow (75%), menstrual days (85.3%) and no change in dysmenorrhea status (88.2%) as compared before. Among eight (11.8%) women who reported hypomenorrhea after uterine compression sutures, two cases of Asherman’s syndrome were diagnosed. Among 23 subsequent pregnancies (16 livebirths), no significant differences in outcome were observed except more omental or bowel adhesions (37.5% vs. 8.8%, p = 0.007), recurrence of hemorrhage (68.8% vs. 7.5%, p < 0.001) and repeated compression sutures (12.5% vs. 0%, p = 0.024) were seen in women with previous compression sutures. Over half of the couple declined future fertility after uterine compression sutures with 38.2% of women recalled unpleasant memories and 22.1% reported life-long adverse impact especially tokophobia.ConclusionMajority of women with history of uterine compression sutures had similar menstruation and pregnancy outcomes as compared to those who did not have sutures. However, they had higher intrapartum risk of visceral adhesions, recurrence of hemorrhage and repeated compression sutures next pregnancy. Furthermore, couple could be more susceptible to negative emotional impact.

Outcome in women undergoing uterine artery embolization for arterio-venous malformation diagnosed post-pregnancy-A retrospective study.

Objective:To analyse the outcome of patients with symptomatic arterio-venous malformation (AVM), formed following pregnancy and managed by uterine artery embolization (UAE).Materials and Methods:This retrospective study was conducted after ethical approval and included 15 patients presenting with abnormal uterine bleeding following pregnancy, who were suspected to have an AVM which later was confirmed by angiography and managed with UAE. Presenting symptoms, post- UAE complications and subsequent fertility outcomes were noted. Follow-up period ranged from 6 months to 2.5 years.Results:The mean age was 28.4±3.82 years and mean parity was 1.3. Out of 15 cases, 9 (60%) presented after abortion, 4 (26.6%) after normal vaginal delivery and 2 (13.3%) after cesarean delivery; of these 10/15 (66.7%) patients had a history of curettage. The most common presenting symptom was continuous bleeding per-vaginum since the antecedent pregnancy in 9/15 (60%) patients and 6/15 (40%) patients had irregular bleeding. The mean duration of symptoms was 91±85.7 (30-360) days. For UAE, embolic agents used were polyvinyl alcohol (PVA) particles (300-500 μm) in 2 (13.3%), 30% glue injection in 3 (20%), the combination of PVA with glue injection in 4 (26.6%) and PVA with gelfoam in 6 (40%) patients. After UAE, bleeding responded within 3.6±0.97 (3-6) days in all but one patient who required repeat UAE one month later. All women resumed their normal menstrual cycle in 31.3±5.2 (24-42) days. Ten patients desired conception, of whom 5 (50%) conceived within 13.2±5.1 (6-19) months after UAE. Two women carried pregnancy to term, one underwent preterm cesarean for growth restriction with oligohydramnios. One patient had postpartum hemorrhage, which was managed medically. One had spontaneous abortion at 6 weeks gestation and the other is 13 weeks pregnant at present.Conclusion:UAE is an effective treatment modality for the management of symptomatic post-pregnancy AVMs.

Obstetrical and Fertility Outcomes Following Transcatheter Pelvic Arterial Embolization for Postpartum Hemorrhage: A Cohort Follow-Up Study.

Objectives: Management of severe postpartum hemorrhage (PPH) includes transcatheter pelvic arterial embolization (TAE). Data regarding subsequent fertility and obstetrical outcomes is limited, as most fertility outcomes derive from TAE in uterine fibroma. The purpose of our study was to evaluate the long-term outcomes of patients undergoing TAE, particularly concerning subsequent fertility and following pregnancies. Material and methods: We included 28 patients who underwent TAE for PPH at our institution between 2009 and 2018 in a retrospective cohort study. Data were assessed by reviewing patients’ charts and by contacting the patients. Results: Ten patients had prophylactic balloon occlusion before cesarean section because of anticipated PPH, with planned hysterectomy by placenta increta/percreta. All these patients were excluded from the analysis regarding fertility. 16 (73%) patients reported having regular menstruation after TAE. In total, 11 women had no desire for subsequent pregnancy. Seven of the remaining 11 patients (63.6%) had a total of 13 spontaneous pregnancies, nine of these resulted in miscarriages. Four patients delivered a live baby (36.4%). Two of these (50%) had recurrent PPH and treatment was conservative. Of the patients with infertility (n = 4, 36.4%), two (18.1%) underwent assisted infertility treatment without success. Conclusion: Our study suggests that the fertility of patients undergoing TAE due to PPH is limited. In women who conceive, the risk for first trimester miscarriage as well as recurrent PPH seems to be increased. If this is a consequence of the underlying cause of PPH or the TAE remains unknown. Larger follow-up cohorts are needed. In the meantime, patients who desire pregnancy after TAE should be counseled accordingly.

Fertility outcomes subsequent to medical and surgical treatment for ectopic pregnancy: A retrospective cohort study in Iran.

BackgroundEctopic pregnancy (EP) and its treatment methods may affect subsequent fertility outcomes.ObjectiveTo compare methotrexate (MTX), laparoscopic salpingostomy, and salpingectomy methods of EP treatment and their effects on fertility outcomes.Materials and MethodsThis retrospective cohort study was performed on women receiving a definitive diagnosis of tubular EP from 2014 to 2017 at Arash Medical Center, Tehran, Iran. In total, 194 women were studied, of which 64 were treated with MTX, 52 underwent salpingostomy, and 78 underwent salpingectomy, depending on their clinical status. Basic information, obstetrics history, and major outcomes of the treatment after an 18-month follow-up, including recurrence of EP, miscarriage, and successful intrauterine pregnancy (IUP), were recorded and variables were compared among the three groups.ResultsThere was no significant difference in fertility outcomes among the three groups. Among the studied variables, predictors of successful IUP after EP treatment were multiparity (Hazard Ratio (HR): 1.37; 95%CI: 1.06-1.77), no history of miscarriage (HR: 2.37; 95%CI: 1.01-5.56), and a higher number of live births (HR: 1.54; 95%CI: 1.01-2.37). On the other hand, predictors of EP recurrence included nulliparity (HR: 1.61; 95%CI: 1.02-2.53) and a lower number of live births (HR: 3.84; 95%CI: 1.43-10.98). The effect of other factors, including the utilized therapeutic modalities, was not statistically significant.ConclusionThe current study results demonstrated that after an 18-month follow-up, fertility outcomes, including recurrence of EP and successful IUP, were not significantly different among the subjects with EP treated with MTX, salpingostomy, or salpingectomy. Further studies with long-term follow-ups are recommended.

Laparoscopic Intracapsular Myomectomy in Women 40 Years Old and Over with Symptomatic Uterine Fibroids. A Pilot Study.

Authors evaluated the impact of laparoscopic intracapsular myomectomy (LIM) in women 40 years of age and over with desire of future fertility compared with medical management of symptomatic fibroids, by a prospective cohort study in University affiliated Hospitals. This study includes a cohort of women 40 years of age and older with symptomatic intramural fibroids with desire of future fertility. Women with symptomatic fibroid uterus were offered to undergo LIM or medical management. They were encouraged to attempt conception either spontaneously or by assisted reproductive technology (ART) according to their individual preference. All women were followed for 2 years. Fibroid characteristics, pre- and post-surgical variables, including surgical complications, days of hospitalization, pregnancy rate, and obstetrical outcomes were collected. A total of 100 patient were included in the analysis. Fifty patients were assigned to the LIM group and 50 to the medical treatment group (MT). Groups were similar regarding age (43.5 ± 2.4 and 43.5 ± 2.4, p = 0.99), body mass index (23.8 ± 3.1 and 24.2 ± 3.1, p = 0.54), parity (0.46 ± 0.09 and 0.58 ± 0.09, p = 0.37), fibroid number (1.38 ± 0.6 and 1.46 ± 0.6, p = 0.53), and fibroid size (5.92 ± 1.62 cm vs. 5.94 ± 1.49 cm, p = 0.949). Of the patients who underwent LIM, 62% conceived within the study period compared with 56% in the control group ( p = 0.54). Pregnancy was achieved by ART in 44% of the patients of the LIM group and 30% in control group. There was no significant difference in pregnancy rates among the two groups regarding spontaneous pregnancy rate ( p = 0.332), nor in pregnancies obtained by ART with own eggs ( p = 0.146) and oocyte or embryo donation ( p = 0.821). The take home baby rate was 65% (20/31) in the LIM group and 61% (17/28) in the control group ( p = 0.7851). Both groups had similar rate of miscarriage ( p = 0.748). Patients 40 years old and over with symptomatic fibroid uterus who undergo LIM have similar subsequent fertility and obstetrical outcomes than women treated with medical management. LIM has no detrimental impact on future fertility in women 40 years old and over.

Tubal flushing for subfertility.

Tubal flushing for subfertility.

Tubal factor infertility with prior ectopic pregnancy: a double whammy? A retrospective cohort study of 2,892 women

To investigate the impact of a history of previous naturally conceived tubal ectopic pregnancy (TEP) on subsequent IVF/intracytoplasmic sperm injection (ICSI) pregnancy and perinatal outcomes. Retrospective cohort study. Reproductive medicine center in a tertiary hospital. A total of 2,892 women with tubal infertility undergoing the first fresh IVF/ICSI cycle. Women were stratified into three groups according to the type of previous naturally conceived pregnancy: TEP, intrauterine pregnancy (IUP), and no pregnancy. Pregnancy and neonatal outcomes were analyzed for each cohort and stratified into the following categories based on female age: <30 years, 30-35 years, and ≥35 years. Of the 2,892 patients with tubal factor infertility, 511 (17.7%) women had a history of TEP, 1,044 (36.1%) had prior IUP, and 1,337 (46.2%) had never been pregnant. Couples with an initial TEP tended to be younger and had experienced a shorter duration of infertility. Across the whole cohort, the optimal live birth rate decreased in older age groups. Live birth rates stratified by maternal age (<30, 30-35, ≥35 years) did not differ between the TEP group (59.9%, 53.7%, 45.5%) and the IUP (62.0%, 53.8%, 40.6%) and no pregnancy group (56.7%, 54.4%, 45.6%). This did not change after adjusting for confounders such as age and years of infertility. Previous treatment of TEP with salpingectomy, salpingostomy, or medical treatment did not significantly affect subsequent fertility outcomes. The rates of preterm and low birth weight after TEP were also not significantly higher than in women with a previous IUP. Fertility history, including previous TEP, does not influence the probability of live birth after IVF/ICSI in women with tubal factor infertility.

Uterine artery embolization for postpartum and postabortion hemorrhage: a retrospective analysis of complications, subsequent fertility and pregnancy outcomes.

To evaluate the impact of UAE for postpartum and postabortion hemorrhage on future infertility, especially in patients undergoing infertility treatment, along with angiographic endpoints. Sixty-two sessions performed emergent or prophylactic UAE for postpartum or postabortion hemorrhage between 2008 and 2017 were selected. Subsequent pregnancy outcomes and complications were investigated as primary outcomes. The cases were divided into two groups based on the presence of massive hemorrhage. The relationships between angiographic endpoints and complications were also evaluated as secondary outcomes. The mean patient age was 34.1 ± 6.5years. Fourteen of the 23 patients (60.9%) with desired fertility achieved pregnancy and 10 patients achieved live births (43.5%). In the patients during infertility treatment, three of the four patients had complications of severe adhesion after caesarean section or placenta accreta. In the group of patients with massive hemorrhage, the occurrence of uterine infection was significantly high (p = 0.014), but the angiographic endpoints were not significant, regardless of the occurrence of uterine infection. It was unnecessary to modify embolic endpoint according to seriousness of the hemorrhage. The pregnancy and live birth rates were acceptable, although patients undergoing infertility treatment had a higher rate of delivery complications.

Does Mothers’ Parental Leave Uptake Stimulate Continued Employment and Family Formation? Evidence for Belgium

Parental leave schemes undoubtedly facilitate the combination of work and family life during leave-taking. In addition to this instantaneous effect of parental leave uptake, a growing yet limited body of research addresses the question of subsequent effects of parental leave uptake. As work-family policies, such as parental leave, are geared towards stimulating family formation and (female) employment, this study assessed whether the individual uptake of parental leave by employed mothers after the birth of a child yielded differential parity progression and employment patterns compared to eligible employed mothers that did not take leave. Using data from the Belgian Administrative Socio-Demographic panel, we applied dynamic propensity score matching and hazard models. Our results indicate that previous leave uptake is a differentiating factor in subsequent fertility and employment outcomes, but also that (self-)selection strongly affects this relation. Descriptive analyses indicate that mothers who use leave shortly after childbearing exhibit a similar progression to second births, more third births and less fourth births, while displaying substantially lower hazards of exiting the labour force regardless of parity. However, when controlling for the fact that mothers who use parental leave exhibit a stronger pre-birth attachment to the labour force, work for larger employers in specific employment sectors, and also differ from non-users in terms of household characteristics (e.g., higher household income, more likely to be married and less likely to have a non-Belgian background), many associations between leave uptake and subsequent fertility and employment outcomes turn neutral or even negative. No indication for higher parity progression among leave users was found and the hazard of exiting the labour force was moderately higher for leave users. These empirical results are discussed in the Belgian context of low parental leave benefits, short leave entitlements and low uptake of parental leave, features which are also displayed by other Western European countries and contrast with the Nordic European countries studied in previous research.

Invited Review: Unique reproductive challenges for certified organic dairy herds

ABSTRACT Purpose Because dairy production under organic regulations is unique in multiple aspects, reproductive management in these systems is performed under specific conditions. The purpose of this review was to highlight some particular reproductive challenges associated with organic certified dairy production in the United States. Sources Refereed scientific journals and books available in online databases were consulted in this review. Only peer-reviewed articles published in English were selected. Synthesis Over the past decade, the demand for organically produced food has increased in the United States, with the emergence of organic milk production as one of the fastest growing segments of organic agriculture in the country. Among many specific requirements, regulations for organic dairies in the United States mandate minimum grazing times, together with sufficient levels of DMI coming from pasture. In addition, the use of antibiotics and hormones (excluding oxytocin for postpartum disorders) is prohibited. This scenario results in particular reproductive challenges with specific implications. Although this review centers on reproduction, it also attempts to discuss other areas that indirectly affect the approach to reproductive management and the subsequent fertility outcomes. Conclusions and Applications Multiple interrelated factors are unique to organic dairy production, and they influence fertility. Lower levels of milk production, use of heterosis, smaller herd sizes, unavailability of reproductive hormones to manage estrous and ovulation and antimicrobials to treat reproductive disease are elements that should be considered when analyzing fertility in organic certified dairies.

Does medical treatment of ectopic pregnancy with methotrexate have better subsequent fertility outcomes than surgical treatment?

Does medical treatment of ectopic pregnancy with methotrexate have better subsequent fertility outcomes than surgical treatment?

Consultation and treatment behaviour of infertile couples in China: a population-based study.

The prevalence of infertility in couples actively trying to conceive is 25%. What is the consultation-seeking behaviour, diagnosis and related treatment in infertile couples across China? Large cross-sectional population-based study in 2010-2011, in which 25,270 couples from eight provinces/municipalities in China were approached by a multistage stratified cluster sampling strategy. Among the 2680 couples reporting infertility, 1246 infertile couples consulted a fertility doctor. Age of the couple, man's body mass index and women's educational level were found to be associated with consultation behaviour. After the fertility work-up, diagnoses were tubal infertility (n=353, 28.3%), unexplained infertility (n=311, 25.0%), male infertility (n=234, 18.8%), ovulatory disorder (n=194, 15.6%) and endometriosis (n=34, 2.7%), while 8.6% (n=107) were not classified. Most couples received non-assisted reproductive technology (ART) fertility treatment (n=906, 89.3%), with a proportion using traditional Chinese medicine (TCM) (n=298, 29.4%). Intrauterine insemination (n=62, 6.1%) and IVF/intracytoplasmic sperm injection (n=57, 5.6%) were less frequent. Medical treatment and outcomes among five subtypes of infertility were also reported: about 30% of couples with unexplained infertility (n=94, 30.3%) or male infertility (n=67, 29.0%) used TCM to treat infertility. Apart from patients with endometriosis, of whom 20.6% (n=7) received ART, patients with other infertility subtypes rarely received ART. For subsequent fertility outcome, 94% of them did not achieve a pregnancy. The prevalence of infertility in China is high, but the uptake of treatment is relatively low.

Analysis on clinical effects of dilation and curettage guided by ultrasonography versus hysteroscopy after uterine artery embolization in the treatment of cesarean scar pregnancy.

PurposeThe purpose of this study was to investigate the efficiency, complications, and subsequent fertility outcomes of two methods in treating patients with cesarean scar pregnancy (CSP) after receiving uterine artery embolization (UAE) treatment.Patients and methodsA total of 62 CSP patients who visited our hospital and underwent UAE from January 2013 to January 2018 were retrospectively analyzed. Patients were either treated by dilation and curettage (D&C) guided by ultrasonography or hysteroscopy. The differences of related clinical indicators, clinical efficacy, complications, and subsequent fertility outcomes between the two groups were analyzed.ResultsThe rates of therapeutic success of the ultrasonography group and hysteroscopy group were 84.6% and 95.7%, respectively, the difference was not statistically significant (P=0.243). However, the intraoperative blood loss, duration of hospitalization, and overall complications were significantly lower in hysteroscopy group compared with D&C guided by ultrasonography group (P<0.05 for all). Meanwhile, hysteroscopy had the advantage of discovering potential diverticulum in the lower segment of anterior wall of uterus (P<0.001).ConclusionD&C guided by ultrasonography or hysteroscopy for the treatment of CSP after UAE resulted in similarly good clinical outcomes. Compared with treatment of D&C guided by ultrasonography, hysteroscopy had less complications and had the advantages of discovering diverticulum. It can be used as an effective way for the treatment of CSP.

Allostatic load, a measure of chronic physiological stress, is associated with pregnancy outcomes, but not fertility, among women with unexplained infertility.

Among infertile women undergoing ovarian stimulation, is allostatic load (AL), a measure of chronic physiological stress, associated with subsequent fertility and pregnancy outcomes? AL at baseline was not associated with conception, spontaneous abortion or live birth, however, it was significantly associated with increased odds of pre-eclampsia and preterm birth among women who had a live birth in the study. Several studies have linked AL during pregnancy to adverse outcomes including preterm birth and pre-eclampsia, hypothesizing that it may contribute to well-documented disparities in pregnancy and birth outcomes. However, AL biomarkers change over the course of pregnancy, raising questions as to whether gestational AL assessment is a valid measure of cumulative physiologic stress starting long before pregnancy. To better understand how AL may impact reproductive outcomes, AL measurement in the non-pregnant state (i.e. prior to conception) is needed. A secondary data analysis based on data from 836 women who participated in Assessment of Multiple Intrauterine Gestations from Ovarian Stimulation (AMIGOS), a multi-center, randomized clinical trial of ovarian stimulation conducted from 2011 to 2014. Ovulatory women with unexplained infertility (ages 18-40) were enrolled and at baseline, biological and anthropometric measures were collected. AL scores were calculated as a composite of the following baseline variables determined a priori: BMI, waist-to-hip ratio, systolic blood pressure, diastolic blood pressure, dehydroepiandrosterone sulfate, high-density lipoprotein cholesterol, low-density lipoprotein cholesterol, triglycerides, C-reactive protein and HOMA score. Participants received ovarian stimulation for up to four cycles and if they conceived, were followed throughout pregnancy. We fit multi-variable logistic regression models examining AL (one-tailed and two-tailed) in relation to the following reproductive outcomes: conception, spontaneous abortion, live birth, pre-eclampsia, preterm birth and low birthweight. Adjusting for covariates, a unit increase in two-tailed AL score was associated with 62% increased odds of pre-eclampsia (OR: 1.62, 95% CI: 1.14, 2.38) 44% increased odds of preterm birth (OR: 1.44, 95% CI: 1.02, 2.08), and 39% increased odds of low birthweight (OR: 1.39, 95% CI: 0.99, 1.97). The relationship between AL and preterm birth was mediated by pre-eclampsia (P = 0.0003). In one-tailed AL analyses, associations were similar, but slightly attenuated. AL was not associated with fertility outcomes (conception, spontaneous abortion, live birth). Results may not be generalizable to fertile women who conceive naturally or women with other types of infertility. Comparisons to previous, related work are difficult because variables included in AL composite measures vary across studies. AL may be indicative of overall poor health, rather than being specific to chronic physiological stress. Our results suggest that chronic physiological stress may not impact success of ovarian stimulation, however, they confirm and extend previous work suggesting that AL is associated with adverse pregnancy outcomes. Physiological dysregulation due to chronic stress has been proposed as a possible mechanism underlying disparities in birth outcomes, which are currently poorly understood. Assessing biomarkers of physiological dysregulation pre-conception or in early pregnancy, may help to identify women at risk of adverse pregnancy outcomes, particularly pre-eclampsia. Support for AMIGOS was provided by: U10 HD39005, U10 HD38992, U10 HD27049, U10 HD38998, U10 HD055942, HD055944, U10 HD055936 and U10HD055925. Support for the current analysis was provided by T32ES007271, R25HD075737, P30ES001247 and P30ES005022. This research was made possible by funding by American Recovery and Reinvestment Act. The content is solely the responsibility of the authors and does not necessarily represent the official views of NICHD, NIEHS or NIH. E.B., W.V., O.M., R.A., M.R., V.B., G.W.B., C.C., E.E., S.K., R.U., P.C, H.Z., N.S. and S.T. have nothing to disclose. R.L. reported serving as a consultant to Abbvie, Bayer, Kindex, Odega, Millendo and Fractyl and serving as a site investigator and receiving grants from Ferring. K.H. reported receiving grants from Roche Diagnostics and Ferring. R.R. reported a grant from AbbVie. M.D. reported being on the Board of Directors of and a stockholder in Advanced Reproductive Care. Clinical Trials.gov number: NCT01044862.

Subsequent fertility, pregnancy, and gynecologic outcomes after fetoscopic laser therapy for twin-twin transfusion syndrome compared with normal monochorionic twin gestations

An improved survival and quality of life for neonatal survivors after fetoscopic laser therapy for twin-twin transfusion syndrome has been reported. However, little is known about the medium-term maternal effects after fetoscopic laser therapy with respect to reproductive and gynecologic outcomes. The objective of this study was to document reproductive, obstetric, gynecological, and psychological outcomes in women who underwent fetoscopic laser therapy for twin-twin transfusion syndrome. This was a monocentric controlled study on consecutive women who underwent fetoscopic laser therapy for twin-twin transfusion syndrome between 2007 and 2013 at the University Hospitals Leuven (cases; n= 198). Controls were women followed up during the same time period for an uncomplicated monochorionic diamniotic twin pregnancy and with an uneventful course (controls; n= 211). All patients received a questionnaire inquiring on their fertility, later pregnancies, and gynecological outcomes. The response rate was 50.4% (cases: n= 95; controls: n=109). Most baseline characteristics were similar across both groups. Women in the fetoscopic laser therapy group attempted a new pregnancy more frequently (34% [31 of 92] vs 21% [22 of 107] in controls; P < .05) and became pregnant more often (100% [31 of 31] vs 82% [18 of 22]; P<.05).We observed a shorter interpregnancy interval in cases than controls (median interval, 12 [interquartile range, 5-27] vs 24 [interquartile range, 15-30] months) (P < .05). This was also observed in cases who lost one or both fetuses or babies in the index pregnancy (median interval, 9 [interquartile range, 3.5-25.5] months; P < .05). The complication rate during subsequent pregnancies (26% [8 of 31] vs 11% [2 of 19]; P=.194) and at delivery (17% [5 of 30] vs 11% [2 of 19]; P= .554) were comparable. More women who underwent fetoscopic laser coagulation reported relevant psychological symptoms (44% [40 of 92] vs 21% [23 of 107]; P < .05). When only women in whom there was a double-surviving twin pair were considered, there were no differences in psychological symptoms compared with controls (16% [15 of 55] vs 21% [23 of 107]; P= .411). Gynecological problems were equally frequent in both groups (20% [18 of 92] vs 31% [33 of 107]; P= .069). No adverse medium-term maternal effects with respect to fertility, obstetric, and gynecological outcomes were observed after fetoscopic laser therapy. However, these women reported more psychological or emotional problems than women with monochorionic diamniotic who did not have laser therapy, in particular when this was complicated by a fetal loss.