Background: Third-and fourth-degree perineal tears are associated with significant discomfort and impact on women's quality of life after labor. We reviewed the literature on risk factors for obstetric anal sphincter injuries (OASIS), focusing on modifiable risk factors for OASIS to help obstetricians prevent them. Methods: We searched MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, and Scopus using key search terms. We selected clinical studies, systematic reviews, and meta-analyses in English investigating antepartum and intrapartum factors associated with OASIS. Three researchers independently selected studies and documented outcomes. Results: We identified forty-two relevant articles for inclusion. Among antepartum factors, primiparity, neonatal birth weight, and ethnicity were associated with a higher risk of OASIS. Instrumental delivery, midline episiotomy, duration of the second stage of labor, persistent occiput posterior position, and labor augmentation were those intrapartum factors reported associated with OASIS. Conclusions: Multiple anteand intrapartum factors are associated with a higher risk of OASIS. The actual modifiable factor is episiotomy during the second stage of labor. However, literature reporting episiotomy associated with a reduction in OASIS prevalence during instrumental delivery is limited. These results may help obstetricians recognize women at higher risk of developing severe perineal tears and recommend further investigation on the role of episiotomy in an operative delivery.
Study question What is the intra-day variation of serum progesterone related to vaginal progesterone administration on the day of frozen embryo transfer (FET) in an artificial cycle? Summary answer We observed a statistically significant intra-day variation of serum progesterone (P) levels on the day of FET in artificially prepared cycles (AC). What is known already The use of FET cycles has increased enormously. In an attempt to further optimize pregnancy outcomes after FET, recent studies have focused on the importance of correct serum luteal P levels in both natural and AC-FET cycles. Despite the different cut-off values proposed to define low serum P, it is generally accepted that lower serum P values(<8.8 ng/ml) around the day of FET are associated with lower live birth rates and higher miscarriage rates. However, a single luteal serum P measurement can be misleading given the diurnal variation and the impact of patient characteristics such as age, BMI, parity, ethnicity. Study design, size, duration A prospective cohort study was conducted at a tertiary university-based hospital encompassing twenty-two patients undergoing a single blastocyst transfer in an AC from August to December 2022. Sample size calculation was performed using a paired t-test resulting in twenty-two patients required to detect a difference of 15% between the first and the last daily progesterone value with a false-positive rate of 5%(two-sided),a power of 80%,assuming a standard deviation of change in the outcome of 0.250. Participants/materials, setting, methods Patients with a normal BMI,aged between 18 and 40 years old, were included. Endometrial preparation was achieved by administering estradiol valerate(6 mg/day) until an adequate endometrial thickness was reached. Consecutively, micronized vaginal progesterone(MVP, 800 mg/die) was started five days prior to blastocyst transfer. P levels were evaluated on the day of FET at 08:00h, 12:00h, 16:00h, and 20:00h. The first and last blood samples were collected just before the intake of MVP,at 8:00h and 20:00h. Main results and the role of chance Mean age of the study population was 33.95 ± 3.98 years and BMI 23.10 ± 1.95 kg/m2. Basal FSH was 7.84 ± 2.31 IU/L and estradiol concentration at 8:00h on the day of FET was 206.04 ± 93.32 ng/L. Mean P values at 08:00h, 12:00h, 16:00h and 20:00h were 11.72 ± 4.99 µg/L, 13.59 ± 6.33 µg/L, 10.23 ± 3.81 µg/L and 9.28 ± 3.09 µg/L,respectively. Statistically significant differences in P values were observed between measurements performed at 08:00h and 20:00h (p = 0,007), 8:00h and 12:00h(p < 0,001), 12:00h and 16:00h (p < 0,001), and 16:00h and 20:00h (p = 0,004). The proportion of patients encountering low P values, defined as P < 8.8 ng/ml, was 27,3% at 8:00h, 13,6% at 12:00h, 40,9% at 16:00h, and 36,4% at 20:00h. Moreover, the difference in patients with normal P values (> 8.8 ng/ml) was statistically significant between samples performed at 8:00h and 12:00h and 12:00h and 16:00h (p = 0.009 and p = 0.01 respectively). No difference was observed in normal P values between 16:00h and 20:00h(p = 0.3) and 8:00h and 20:00h(p = 0,07). Additionally, no association was found either between age and BMI and the first progesterone evaluation of the day, neither between these parameters and the difference in P levels between 8:00h and 20:00h. Limitations, reasons for caution The strict inclusion criteria applied in this study could potentially imply a bias when extrapolating the results to a wider infertile population undergoing AC-FET cycles. A confirmation of the findings in larger prospective studies including a more heterogeneous patient population is recommended. Wider implications of the findings The results of this study highlight the importance of a standardized procedure for the timing of progesterone measurements, partly taken into account the last MVP intake. This is especially important when clinical actions, such as additional P supplementation, are considered when low or high P values are encountered. Trial registration number not applicable
Study question What are the reproductive treatment outcomes in women who underwent elective oocyte cryopreservation (EOC) returning to our clinic with a desire for a child? Summary answer Whether to warm oocytes or to first use fresh oocytes for ART depends on age upon returning, but both strategies resulted in favourable reproductive outcomes. What is known already Most affluent countries have observed a trend towards postponement of childbearing, and EOC is increasingly used in an attempt to extend the reproductive lifespan and mitigate age-related fertility decline. Although most follow-up studies after EOC have focused on women who requested oocyte warming, a substantial proportion of women who do not conceive naturally eventually embark for a fertility treatment without using their cryopreserved oocytes. Reports on reproductive outcomes in past EOC users are scarce, and the lack of reproductive treatment algorithms in this group of women hampers efficiency of clinical practice. Study design, size, duration This retrospective observational single-center study includes 843 women who had elective oocyte vitrification for non-medical reasons between 2009 and 2019, and describes the outcomes of the diverse reproductive treatment strategies that were performed in these women when they returned to the same clinic because of a desire for pregnancy until May 2022. Participants/materials, setting, methods Patient characteristics and data of ovarian stimulation of EOC cycles were analyzed, as well as data related to ovarian stimulation and laboratory data of ART in women who pursued fertility treatment with and/or without using their cryopreserved oocytes. The primary outcome was the live birth rate (LBR) per patient after oocyte warming and after ART using fresh oocytes. Secondary outcomes were laboratory outcomes and LBR per embryo transfer. Main results and the role of chance A total of 1353 EOC cycles (1.6 ± 0.9 per patient) were performed. Mean age was 36.5 ± 2.8 years. At the time of EOC 174 (20,6%) women had a partner. On average, 13.7 ± 9.2 mature oocytes were cryopreserved. After 39.9 ± 23.4 months, 231 (27.4%) women returned to the clinic. Upon returning, mean age was 40.4 ± 3.1 years, mean AMH 2.3 ± 2.0 ng/mL, and 150/231 (64,9%) patients had a partner. As a primary approach, 110/231 (47.6 %) past EOC women embarked on oocyte warming, 50/231 (21.6%) had intrauterine insemination, and 71/231 (30.7%) had ART using fresh oocytes. Cumulative LBR (CLBR) was 45.9 % (106/231) and miscarriage rate (MR) was 30.7% (51/166) in the entire cohort. A subset of 90/231 (39.0%) patients exclusively had oocyte warming, at 41.6 ± 3.0 years, with 10.0 ± 5.2 oocytes warmed per patient. 52/231 (22.5%) patients exclusively had ART using fresh oocytes, at a mean age of 39.0 ± 2.8 years, with 9.9 ± 7.4 mature oocytes retrieved per patient. CLBR was 37/90 (41.1%) in the oocyte warming-only group and 25/52 (48.1%) in the OS-only group. MR/transfer was 25.0% and 29.3% in the oocyte warming-only group and the OS-only group, respectively. Limitations, reasons for caution Both the small sample size and the retrospective design are limitations of this study. The decision to embark on a specific reproductive treatment strategy was based on patient preference, after counseling of treatment options. This precludes direct comparison of the efficacy of reproductive treatment options in past EOC users. Wider implications of the findings Reporting of clinical outcomes of women who underwent EOC and returned to the clinic to embark on divergent reproductive treatment strategies is mandatory to establish guidelines for best clinical practice in this growing patient population. Trial registration number Not applicable
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