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Problem: Recurrent implantation failure (RIF) after multiple embryo transfers remains a vexing problem and immunomodulators have been used with conflicting results. This study aims to assess the effect of immunomodulation therapy on live birth rate (LBR) in women with RIF undergoing assisted reproduction treatment (ART). Method of study design: This is a retrospective cohort study in multicentre network of private assisted conception units in the UK. The study included women who had at least two failed attempts of embryo transfers at CARE fertility network in the period from 1997 to 2018. Women in the treatment group had immunomodulator drugs in the form of corticosteroids, low molecular weight heparin (LMWH), and intravenous intralipid (IVIL) infusions, either separately or in combination, after immunological testing, in addition to standard ART whilst women in the control group had only ART without immunomodulators. The primary outcome was LBR per cycle. Secondary outcomes included the rates of clinical pregnancy (CPR), cumulative live birth (CLBR), and miscarriage. Results: A total of 27 163 ART cycles fulfilled the inclusion criteria, of which 5083 had immunomodulation treatment in addition to standard ART treatment, and 22 080 had standard ART treatment alone. Women in the treatment group were significantly older (mean age 38.5 vs. 37.1 years, p <.001), and had a higher number of previous failed ART cycles (mean 4.3 vs. 3.8, p <.01). There was a higher LBR in women who received immunomodulation therapy when compared with the control group (20.9% vs. 15.8%, odds ratio [OR] 1.4, 95% confidence interval [CI] 1.29–1.53, p <.001). Multivariate regression analysis showed that immunomodulation treatment was a significant independent predictor of live birth after adjusting for other confounders (adjusted OR [aOR] 1.33, 95% CI 1.15–1.54, p <.001). Survival analysis showed a higher CLBR in the treatment group (adjusted hazard ratio [aHR] 1.78, 95% CI 1.62–1.94, p <.001). Conclusion(s): This study provides evidence of a potential beneficial effect of immunomodulation therapy in women with RIF after immunological testing. There remains a need for high quality, adequately powered multicentre RCTs to robustly address the role of immunomodulation in women with RIF. There is also an urgent need for standardised screening tests for immune disorders that could preclude implantation. [ABSTRACT FROM AUTHOR]

Objective: To assess the efficacy of first‐trimester three‐dimensional (3D) placental volume as well as 3D power Doppler of placental vascular indices for early prediction of pre‐eclampsia. Methods: The prospective cohort study included over 2019 women with a singleton pregnancy in their first trimester at 11–13+ weeks of pregnancy. All women were examined by 3D abdominal ultrasound, including Doppler techniques for the placental volume and placental vascular indices. Uterine artery Doppler indices were also assessed. All participants were cared for until delivery for assessment of pregnancy outcomes. Results: In all, 163 women developed pre‐eclampsia while 1856 women remained normotensive. The women with pre‐eclampsia had significantly lower placental volume (77.09 ml vs. 99.8 ml, p < 0.001), and placental vascular indices (vascularization index, flow index, and vascularization flow index were 7.41 vs. 9.89, 39.03 vs. 46.63, and 2.77 vs. 4.4, respectively, p < 0.001). In contrast, women with pre‐eclampsia had significantly high mean uterine pulsatility index and resistance index (2.02 vs. 1.11, 0.83 vs. 0.64, respectively, p < 0.001) compared with the normotensive women. The placental vascular indices were highly sensitive, whereas the placental volume and the mean uterine pulsatility index and resistance index had higher specificity for the prediction of pre‐eclampsia. Conclusion: First‐trimester assessment through 3D placental volume and power Doppler of placental vascular indices, especially in combination with uterine artery Doppler assessment, revealed an increase in the accuracy of early detection of women at risk for developing pre‐eclampsia. Synopsis: First‐trimester assessment of three‐dimensional placental volume and power Doppler of placental vascular indices, when combined with assessment of uterine artery Doppler, could increase the accuracy of early prediction of pre‐eclampsia. [ABSTRACT FROM AUTHOR]

Background: The clinical implication of the increased serum progesterone level on the day of HCG administration in assisted reproduction treatment (ART) is still controversial. The current study aimed to compare the predictive value of serum progesterone on day of HCG administration / metaphase II oocyte (P/MII) ratio on IVF/ ICSI outcome to serum progesterone (P) level alone and the ratio of serum progesterone/estradiol level (P/E2) ratio in prediction of pregnancy rates after ART. Material & methods: Two hundred patients admitted to the IVF/ICSI program at Minia IVF center in Egypt in the period from October 2016 to May 2018 were included in this study. Serum Progesterone (P) and Estradiol (E2) levels were estimated on the day of HCG administration. The ratio between serum P and the number of MII oocytes (P/MII ratio) was calculated and the predictive values of the three parameters (P, P/E2 ratio and P/MII ratio) in prediction of cycle outcomes were measured. Results: P/ MII oocyte ratio was significantly lower in patients who attained clinical pregnancy (n = 97) as compared with those who couldn't whilst there was no significant difference in P and P/E2 ratio between the two groups. Using a cut off value of 0.125, the sensitivity and specificity of progesterone/ MII ratio in prediction of no pregnancy in IVF/ICSI were 75.7 and 77.1% respectively with the area under The Receiver operating curve (ROC-AUC) = 0.808. The respective values of the ROC-AUC for the P and P/E2 ratio were 0.651 and 0.712 with sensitivity and specificity of 71.2 and 73.5%for P level and of 72.5 and 75.3% for P/E2 ratio. Implantation or clinical pregnancy rates were significantly different between patients with high and low P/MII ratio irrespective of day of embryo transfer (day 3 or 5). Conclusions: In patients with normal ovarian response, serum progesterone on day of HCG / MII oocyte ratio can be a useful predictor of pregnancy outcomes and in deciding on freezing of all embryos for later transfer instead of high progesterone level alone. [ABSTRACT FROM AUTHOR]

Passive sampling has emerged as a promising tool to assess the presence of hydrophobic organic contaminants (HOC) in water, sediment, and biota, such as polychlorinated dibenzo‐p‐dioxins/furans (PCDD/Fs) or polychlorinated biphenyls (PCBs). Previous work evaluated the ability of passive samplers to predict the bioavailability of sedimentary HOCs mostly in the laboratory, often for marine organisms. The present study assessed the use of low‐density polyethylene (LDPE) to derive freely dissolved concentrations of PCDD/Fs and PCBs in porewater in situ versus ex situ and in river water. An LDPE‐based multisampler system was deployed at 4 locations along the lower Passaic River (NJ, USA) in sediment and the water column, where sediment and benthic species samples were also collected. Good agreement was generally observed for PCDD/F and PCB concentrations comparing in situ and ex situ approaches (within 0.30–39%). Significant linear relationships were derived between log LDPE–based and log lipid–based concentrations of PCDD/Fs and PCBs. The in situ multisampler system showed promise to derive HOC concentrations in porewater and river water and to predict the bioaccumulation potential of HOCs in benthic biota. Environ Toxicol Chem 2020;39:1174–1185. © 2020 SETAC [ABSTRACT FROM AUTHOR]

Abstract Little is known about the presence of organophosphate flame retardants (OPFRs) as a substitute for polybrominated diphenyl ethers in developing countries. This study investigated - for the first time - concentrations, sources and exposure levels of OPFRs in the indoor and outdoor environments of Alexandria, Egypt, in dust and gas-phase samples. Passive samplers were deployed (n = 78) to determine gaseous concentrations, and various dust samples were collected from apartments (n = 25), working places (n = 14), cars (n = 18), and outdoors (OD, n = 30). Indoor concentrations (air: 7.0–64 pg/m3; dust: 150–1850 ng/g) were significantly higher than outdoor (2.0–16 pg/m3 and 83–475 ng/g) concentrations. Tris-1,3-dichloropropyl phosphate (TDCIPP), tris(1-chloro-2-propyl) phosphate (TCIPP), tri (2-butoxyethyl) phosphate (TBOEP) and triphenyl phosphate (TPHP) dominated in all samples with more indoor variabilities. Profiles of OPFRs in OD and floor dust (collected from carpets and floors) were similar but differed from elevated fine dust (collected 1 m above the floor from all available surfaces), possibly due to the influence of carryover of OD by shoes. Despite the high uncertainty in dust – air partitioning coefficients, log transformed values showed significant linear relationships with log octanol – air-partitioning coefficients in all microenvironments, indicating an equilibrium partitioning between dust and vapor. Exposure assessment indicated the importance of the dermal exposure route for adults and ingestion route for children. Graphical abstract Image 1 Highlights • Indoor levels of OPFRs were significantly higher than outdoors. • PBDEs > OPFRs > NFRs and OPFRs > PBDEs > NFRS In the gaseous and dust samples respectively. • TDCIPP, TCIPP, TBOEP and TPHP dominated OPFRs in all samples with more indoor variability. • Significant log-linear K dust-air -K OA relationships indicated equilibrium partitioning. • Dermal and ingestion pathways are important exposure routes. [ABSTRACT FROM AUTHOR]

The bioavailability and bioaccumulation of sedimentary hydrophobic organic compounds (HOCs) is of concern at contaminated sites. Passive samplers have emerged as a promising tool to measure the bioavailability of sedimentary HOCs and possibly to estimate their bioaccumulation. We thus analyzed HOCs including organochlorine pesticides (OCPs), polybrominated diphenyl ethers (PBDEs), polychlorinated biphenyls (PCBs), and polychlorinated dibenzo‐p‐dioxins/furans (PCDD/Fs) in sediment, porewater, and river water using low‐density polyethylene passive samplers and in 11 different finfish species and blue crab from the lower Passaic River. In addition, perfluorinated alkyl acids (PFAAs) were measured in grab water samples, sediment, and fish. Best predictors of bioaccumulation in biota were either porewater concentrations (for PCBs and OCPs) or sediment organic carbon (PBDEs and PFAAs), including black carbon (OCPs, PCBs, and some PCDD/F congeners)–normalized concentrations. Measured lipid‐based concentrations of the majority of HOCs exceeded the chemicals' activities in porewater by at least 2‐fold, suggesting dietary uptake. Trophic magnification factors were >1 for moderately hydrophobic analytes (log octanol–water partitioning coefficient [KOW] = 6.5–8.2) with low metabolic transformation rates (<0.01 d−1), including longer alkyl chain PFAAs. For analytes with lower (4.5–6.5) and higher (>8.2) KOWs, metabolic transformation was more important in reducing trophic magnification. Environ Toxicol Chem 2019;38:872–882. © 2019 SETAC [ABSTRACT FROM AUTHOR]

Abstract Research question What is the association of endometrial thickness with pregnancy losses and live births in IVF treatment and the optimal threshold that optimizes the IVF outcome? Design Data were analysed from 25,767 IVF cycles from centres of the CARE Fertility Group in the UK between 2007 and 2016. Transvaginal ultrasound was conducted to measure the maximum endometrial thickness during gonadotrophin stimulation. Live birth rates were per embryo transfer. Pregnancy loss rates included the combination of biochemical and clinical pregnancy losses. Results The live birth rate was 15.6% with 5 mm or less endometrial thickness and gradually increased to 33.1% with an endometrial thickness of 10 mm. On the other hand, the pregnancy loss rate was 41.7% with 5 mm or less endometrial thickness and gradually decreased to 26.5% with an endometrial thickness of 10 mm. Statistical modelling for optimal endometrial thickness threshold found 10 mm or more maximized live births and minimized pregnancy losses. This association was independent after adjusting for confounders such as age, oocyte number, number of transferred embryos, ovarian stimulation protocol and embryo quality for live births (crude RR 1.27; 95% CI 1.21 to 1.33; Adjusted RR 1.18; 95% CI 1.12 to 1.23) and pregnancy losses (crude RR 0.83; 95% CI 0.77 to 0.89; adjusted RR 0.86; 95% CI 0.8 to 0.92). Conclusions Endometrial thickness is strongly associated with pregnancy losses and live births in IVF, and the optimal endometrial thickness threshold of 10 mm or more maximized live births and minimized pregnancy losses. [ABSTRACT FROM AUTHOR]

There is scant information on the presence of the polybrominated diphenyl ethers (PBDEs) and other alternative flame-retardants (NFRs) in Africa. Hence, to investigate their levels, sources, and human exposure scenarios, elevated fine dust (EFD) samples from apartments (n = 12), working places (n = 9) and cars (n = 12), floor dust (FD) samples (n = 5) and outdoor dust samples (n = 21) were collected from Alexandria, Egypt, during 2014. Gaseous concentrations were estimated using low density polyethylene sheets (n = 33 and 21 for indoor and outdoor sites, respectively). Indoor gaseous and dust PBDE (7.0–300 pg/m 3 ; 4.0–770 ng/g), and NFR (0.40–48 pg/m 3 ; 0.50–8.5 ng/g) concentrations were significantly higher (p = 0.004–0.02) than outdoor concentrations (PBDEs: 3.0–41 pg/m 3 , 1.5–195 ng/g; NFRs: 0.20–13 pg/m 3 , 0.50–4.0 ng/g). Median PBDE concentration in cars (210 ng/g) was higher than in apartments and working places (130  ng/g respectively). PBDE concentrations in FD were 7.0–14-folds lower than EFD concentrations. Outdoor PBDE concentrations were significantly higher (p < 0.01) at residential–industrial places with older buildings. All samples were dominated by BDE-47 and 99. HBB, BTBPE and DDC-CO were the most abundant NFRs in EFD samples. Profiles of PBDE and NFR in FD closely matched those of outdoor dust, indicating a possible carryover from the outdoor environment. Although factors such as number of electronics, construction year and floor type significantly correlated with the majority of PBDE congeners and some NFRs in apartments and working places, sources were not clearly identified for NFRs. Significant log-linear relationships were obtained between theoretical and calculated dust-air partitioning coefficients for all samples indicating an equilibrium state between dust and vapor. Low possibility of occurrence of adverse health effects was concluded, with the inhalation pathway (for adults) and dust ingestion (for children) acting as the most important exposure routes. [ABSTRACT FROM AUTHOR]

In the aquatic environment, the behavior of hydrophobic organic contaminants (HOCs), such as polybrominated diphenyl ethers (PBDEs), depends on the congeners' physicochemical properties, environmental conditions and the presence of competing natural sorbents, including particulate and dissolved organic carbon (DOC) and black carbon (BC). Although BC is known as an important sedimentary sorbent for HOCs, its affinity for PBDEs has been poorly constrained. To better understand the biogeochemical controls on PBDEs, 12 PBDE congeners were measured in air, water, sediment and porewater of the lower Passaic River. BDE-47 and BDE-99 dominated in all media. In sediments and water, the dual OC + BC approach better predicted PBDE partitioning compared to the simple OC isotherm. Field-derived KBC values for PBDEs were inversely correlated with aqueous solubility [log KBC sediments(water) = -log Cwsat * 0.95 (1.2) + 0.36 (-0.69)]; they reflected near background to highly contaminated regions across the Passaic River. In the water column, PBDEs appeared at equilibrium partitioning between particles and colloids: OC + BC were responsible for the sorption of 65% of PBDEs, followed by colloids (30%); only 5% of PDBEs were truly dissolved. Calculated sediment-water diffusive fluxes greatly overwhelmed the atmospheric depositional flux to the river. [ABSTRACT FROM AUTHOR]

Objectives: To evaluate the two-week referral system by analysing the 2-week wait (2WW) referrals to the rapid access gynaecology clinic over one year. We have also sought to identify the risk factors for endometrial cancer to help setting criteria that can be used to prioritise urgent appointments, refine subsequent management strategies.Study Design: Retrospective review of the data of all women referred for suspected gynaecological cancers over one year via the 2 WW office at Queen's Hospital, Romford, UK. Data of all other women in whom a diagnosis of a gynaecological malignancy was made during the same period following non-urgent (non-2WW) referrals were also collected.Results: Over one year, a total of 1105 women were referred under the 2WW for suspected gynaecological malignancy. A total of 765 patients (69.23%) were referred with suspected endometrial cancer and the main indication for referral was postmenopausal bleeding. Hundred-seventy nine women (16.20%) were referred with suspected ovarian cancer. A pelvic mass found in 62 of these women and this was the main indication of referral. The number of women referred with suspected cervical cancer was 117 (10.59%) and the main indication for referral was postcoital bleeding. Forty-four women (3.98%) referred with suspected vulvo-vaginal cancer and the main presentation was vulval lesion. The positive predictive value of referrals for diagnosing endometrial, ovarian, cervical and vulvo-vaginal malignancy was 8.1%, 9.5%, 5.98% and 13.64% and the overall predictive value for diagnosing gynaecological malignancy was 8.33%. The predictive values of the 2WW referrals for diagnosing different types of gynaecological cancers in premenopausal women are low compared to postmenopausal women (1.86% and 9.89% respectively, p<0.001). The number of cancers diagnosed through non-urgent system was higher than the number diagnosed through urgent system (95 vs. 92). Presence of diabetes mellitus, increased endometrial thickness, prolonged bleeding and advancing age represent the best model for predicting endometrial cancer.Conclusion: The overall predictive value of the 2WW system for suspected gynaecological malignancies is low particularly in premenopausal women. The current referral criteria need to be modified with a view to incorporating risk factors to prioritise urgent appointments and refine subsequent management plans. [ABSTRACT FROM AUTHOR]

The purpose of this study was to determine the levels, distribution and toxicological potential of organochlorine pesticides (OCPs) and polychlorinated biphenyls (PCBs) in sewage sludge samples from several WWTPs in the Alexandria area, Egypt. The POPs of interest were 26 PCBs and 16 OCPs. Analyses were performed by gas chromatography with electron impact mass spectrometric detection in the selected ion monitoring mode (GC-MS-SIM) using deuterated organochlorines as internal standards. Total concentrations of OCPs and Σ7 PCBs (ICES) in sludge ranged from 44.2 to 489 μg/kg dw. and 5,600 to 11,000 μg/kg dw., respectively. The highest concentration levels were found for PCBs, HCHs, DDTs, and HCB, in this order. The PCB homologue profiles in sludge samples were dominated by penta- and hexa-chlorinated biphenyls. Seasonal variations were observed for OCPs with higher levels in summer, which reflects more usage in warmer climates. Composite profiles of OCP metabolites indicated new inputs of lindane and technical endosulfan and earlier usage of DDT and technical chlordane. Contamination levels of OCPs and PCBs for Egyptian sludge can be categorized as moderate to high compared to other countries worldwide. The OCP content in none of the samples exceeded limits set by the European Commission for use of sludge in agriculture; while all the concentrations of PCBs in sludge samples were higher by one order of magnitude than the upper limit for land application. [ABSTRACT FROM PUBLISHER]

Key content: Obesity is associated with infertility and poor obstetric outcomes.The current trends of advanced maternal age and rising obesity rates contribute indirectly to the growing demand for fertility treatment and assisted reproduction treatment (ART), posing clinical and ethical dilemmas for fertility service providers.The live‐birth rate, after ART, is significantly lower in obese women than non‐obese women, possibly due to impaired oocyte quality and/or defective endometrial receptivity. Poor ART outcomes correlate positively with the severity of obesity.Management of obesity‐related infertility should include diet, exercise, cognitive behavioural interventions and possibly adjunctive pharmacotherapy. Bariatric surgery may benefit morbidly obese women who struggle to lose weight otherwise.Randomised controlled trials are required to clarify the effects of various therapeutic interventions for obesity on ART outcomes. Learning objectives: To understand the association of obesity and infertility with ART outcomes.To learn the principles of obesity‐related infertility management. Ethical issues: To understand the ethical challenges in the provision of ART for obese women and to inform the stance of professional bodies, such as the British Fertility Society and the European Society of Human Reproduction and Embryology. [ABSTRACT FROM AUTHOR]

The purpose of this study was to determine concentrations of organochlorine pesticides (OCPs) and polychlorinated biphenyls (PCBs) in Nile tilapia (Oreochromis niloticus) and Bouri fish (Mugilcephalus) from Lake Qarun, a protected area of Egypt, and evaluate the relative ecological risk of these compounds. Different tissues of the fish species were analyzed for 26 chlorinated pesticides and 29 PCB congeners. Total concentrations (µg/kg wet weight, ww) of OCPs ranged between 1487 and 6217 (mean: 3260) and of PCBs between 9.0 and 61 (mean: 34). The trend of detected organochlorine pollutants was: endrin aldehyde > dieldrin > hexachlorobenzene > PCBs > endrin > 1,1,1-trichloro-2,2-bis(p-chlorophenyl)ethanes (DDTs). Heptachlor epoxide;oxy-,cis-, andtrans-chlordane;trans-nonachlor; β-hexachlorocyclohexane; δ-hexachlorocyclohexane; and endosulfan I and endosulfan sulfate levels were below the detection limit. The ratios of (1,1-dichloro-2,2-bis(p-chlorophenyl)ethylenes [DDEs] + 1,1-dichloro-2,2-bis(p-chlorophenyl)ethanes [DDDs])/ΣDDTs in fish tissues indicated no recent DDT exposure. Concentrations of DDTs and PCBs were generally comparable or higher than those found in studies of similar species worldwide. The concentrations of hexachlorobenzene, dieldrin, and endrin aldehyde in fish muscles exceeded the maximum residue level recommended by various organizations. [ABSTRACT FROM AUTHOR]

A difficult and traumatic embryo transfer can negatively impact on embryo implantation. This study retrospectively compared the outcomes of “very difficult transcervical embryo transfer” (vdTCET) versus transmyometrial embryo transfer (TMET) in a single centre over 10 years, reporting on 128 patients with vdTCET and 46 patients with TMET. The definition of vdTCET was a procedure rated by an experienced practitioner (with more than 100 transfers per year for >2 years) as very difficult and required two or more of the following: use of tenaculum, change of embryo transfer catheter and use of a stylet, reloading of the embryos or cancelling the procedure and freezing the embryo to transfer after cervical dilatation. The clinical pregnancy rates for TMET and vdTCET were 32.6% and 25%, respectively and the live birth rates were 26.1% and 16.4%, respectively. There was only one case of minor bleeding in the TMET group (2.2%). This study showed that TMET is a good alternative option in cases of vdTCET where it is impossible to achieve transcervical embryo transfer and may benefit cases with repeated failed cycles after vdTCET. Its superiority over vdTCET however could not be demonstrated. [ABSTRACT FROM AUTHOR]

Sub-endometrial junctional zone peristalsis is increased by ovarian stimulation and traumatic embryo transfer, and is linked with decreased implantation and pregnancy rates in assisted reproduction treatments. Various agents have been used to inhibit uterine hyper-peristalsis at the time of embryo transfer with conflicting results. This systematic review aimed to identify if uterine relaxants administered in the peri-implantation period during assisted reproduction treatments could improve pregnancy outcomes through literature search with no language restrictions. The review reports on 3546 patients in 17 randomized controlled trials published between 1993 and 2014. Women undergoing assisted reproduction techniques who either received a uterine relaxant agent in the peri-implantation period versus placebo or no treatment were included. Primary outcome was live birth rate. The meta-analyses did not show statistically significant benefit of any uterine relaxing agents on live birth rate. Other meta-analyses did not show a significant effect on the clinical pregnancy, spontaneous abortion, ectopic pregnancy and multiple pregnancy rate. Most of the included studies were of low quality and lacked significant power to detect minimally important effect. Evidence is insufficient to recommend using these agents in routine practice. Further methodologically robust randomized controlled trials with more refined selection criteria might reveal a beneficial effect. [ABSTRACT FROM AUTHOR]

Polychlorinated dibenzo- p-dioxins and dibenzofurans (PCDD/Fs) were measured in sediments (surface and deeper sediments) and porewater of the lower Passaic River and Newark Bay (New Jersey, USA) to apportion their sources and conduct an ecological risk assessment. Positive matrix factorization was applied to identify sources of PCDD/Fs. Five source profiles were extracted from the positive matrix factorization model applied to the sediment samples including chloranil, combustion, polychlorinated biphenyl impurities, mixed urban sources, and the historical contamination from the former Diamond Alkali plant. The ecological risk assessment was estimated using several lines of evidence depending on site-specific data (blue crab and fish samples representing different feeding habits and positions in the trophic wood web of the river). Porewater concentrations gave the best estimates of lipid concentrations especially in the blue crab samples (with an average factor difference of 3.8). Calculated hazard quotients (HQs) for the fish samples and blue crab were >1 based on the no-effect concentration and tissue screening concentration approaches. At the same time, calculated porewater toxic units were >1. Sediment concentrations exceeded the published sediment quality guidelines for the protection of fish and benthic species, indicating the existence of significant risk to the aquatic life in the Passaic River. Accordingly, further actions and control measures are needed to reduce the emission of PCDD/Fs from ongoing sources. Environ Toxicol Chem 2016;35:550-562. © 2015 SETAC [ABSTRACT FROM AUTHOR]

Low-density polyethylene (LDPE) passive samplers were deployed in upland surface waters and the overlying atmosphere during May and June 2012, to determine the transport and trends of freely dissolved and gaseous organochlorine pesticides (OCPs) along altitudinal gradients in mountain regions in south and southeast Brazil. Gaseous OCP concentrations were dominated by hexachlorobenzene (3.0–29 pg m −3 ) and endosulfans (Ʃ = α -endosulfan + β -endosulfan + endosulfan sulphate, 170–260 pg m −3 ), whereas freely dissolved endosulfans were significantly higher than all other OCPs (p < 0.001). The presence of some target pesticides at the highest elevation sites indicated their efficient high-altitude transport from regional sources. Air–water exchange gradients indicated net deposition of most volatile and recently banned OCPs (e.g., HCB, endosulfan) over Brazilian mountains. Moreover, the exposure of these sites to large-scale continental airflows with varying source contributions may partly explain the atmospheric deposition of selected OCPs over upland freshwaters at tropical and subtropical mountains sites in Brazil. These findings, coupled with LDPE passive air and water sampling measurements, point out the potential inputs from distant sources of semi-volatile chemicals to the two high-altitude sites. [ABSTRACT FROM AUTHOR]

Polychlorinated biphenyls (PCBs) continue to be contaminants of concern across the Great Lakes. It is unclear whether current concentrations are driven by ongoing primary emissions from their original uses, or whether ambient PCBs are dominated by their environmental cycling. Freely dissolved PCBs in air and water were measured using polyethylene passive samplers across Lakes Erie and Ontario during summer and fall, 2011, to investigate their spatial distribution, determine and apportion their sources and to asses their air-water exchange gradients. Average gaseous and freely dissolved Σ29 PCB concentrations ranged from 5.0 to 160 pg/m³ and 2.0 to 55 pg/L respectively. Gaseous concentrations were significantly correlated (R² = 0.80) with the urban area within a 3-20 km radius. Fugacity ratios indicated that the majority of PCBs are volatilizing from the water thus acting as a secondary source for the atmosphere. Dissolved PCBs were probably linked to PCB emissions from contaminated sites and areas of concern. Positive matrix factorization indicated that although volatilized Aroclors (gaseous PCBs) and unaltered Aroclors (dissolved PCBs) dominate in some samples, ongoing non-Aroclor sources such as paints/pigments (PCB 11) and coal/wood combustion showed significant contributions across the lower Great Lakes. Accordingly, control strategies should give further attention to PCBs emitted from current use sources. [ABSTRACT FROM AUTHOR]

The bioaccumulation and biomagnification of sediment-bound hydrophobic organic contaminants (HOCs) are of major concern for environmental and human health. In dynamic estuaries, HOCs can be taken up from sediments, porewater, or the overlying water column concentrations directly or via the diet. The transfer of HOCs including polycyclic aromatic hydrocarbons (PAHs), polychlorinated biphenyls (PCBs), and polychlorinated dibenzo-p-dioxins/furans (PCDD/Fs) to resident/migratory biota was investigated in 11 finfish species and blue crabs (Callinectes sapidus) in the Passaic River estuary. Concurrently, passive samplers were deployed to assess porewater and overlying water column concentrations. Biota were assigned to three trophic levels based on their tissue 15N isotope values and published life history strategies. There were no significant differences in trophic magnification factors (TMFs) calculated based on life-history scenarios, implying that the migratory species, mostly juveniles, had equilibrated with in situ sources of pollutants at the time they were sampled. Bioaccumulation factors and TMFs were >1 for most PCBs and tetra- and penta- CDD/DFs, indicating that they underwent biomagnification in the food web. All PAHs, PCB 11, and other lower chlorinated PCBs and PCDD/Fs did not magnify. Results from the analysis of HOC profiles implied that biota accumulated HOCs from sediments, porewater, and diet but not from overlying water. [ABSTRACT FROM AUTHOR]

Polyethylene passive samplers were deployed during summer and fall of 2011 in the lower Great Lakes to assess the spatial distribution and sources of gaseous and freely dissolved organochlorine pesticides (OCPs) and their air-water exchange. Average gaseous OCP concentrations ranged from nondetect to 133 pg/m3. Gaseous concentrations of hexachlorobenzene, dieldrin, and chlordanes were significantly greater (Mann-Whitney test, p < 0.05) at Lake Erie than Lake Ontario. A multiple linear regression implied that both cropland and urban areas within 50 and 10 km buffer zones, respectively, were critical parameters to explain the total variability in atmospheric concentrations. Freely dissolved OCP concentrations (nondetect to 114 pg/L) were lower than previously reported. Aqueous half-lives generally ranged from 1.7 to 6.7 years. Nonetheless, concentrations of p,p'-DDE and chlordanes were higher than New York State Ambient Water Quality Standards for the protection of human health from the consumption of fish. Spatial distributions of freely dissolved OCPs in both lakes were influenced by loadings from areas of concern and the water circulation patterns. Flux calculations indicated net deposition of γ-hexachlorocyclohexane, heptachlor-epoxide, and α-and /β-endosulfan (-0.02 to -33 ng/m2/day) and net volatilization of heptachlor, aldrin, trcms-chlordane, and frans-nonachlor (0.0 to 9.0 ng /m 2/day) in most samples. [ABSTRACT FROM AUTHOR]

Polyethylene passive samplers (PEs) were used to measure concentrations of gaseous and dissolved polycyclic aromatic hydrocarbons (PAHs) in the air and water throughout the lower Great Lakes during summer and fall of 2011. Atmospheric ∑15PAH concentrations ranged from 2.1 ng/m3 in Cape Vincent (NY) to 76.4 ng/m3 in downtown Cleveland (OH). Aqueous ∑18PAH concentrations ranged from 2.4 ng/L at an offshore Lake Erie site to 30.4 ng/L in Sheffield Lake (OH). Gaseous PAH concentrations correlated strongly with population within 3-40 km of the sampling site depending on the compound considered, suggesting that urban centers are a primary source of gaseous PAHs (except retene) in the lower Great Lakes region. The significance of distant population (within 20 km) versus local population (within 3 km) increased with subcooled liquid vapor pressure. Most dissolved aqueous PAHs did not correlate significantly with population, nor were they consistently related to river discharge, wastewater effluents, or precipitation. Air-water exchange calculations implied that diffusive exchange was a source of phenanthrene to surface waters, while acenaphthylene volatilized out of the lakes. Comparison of air-water fluxes with temperature suggested that the significance of urban centers as sources of dissolved PAHs via diffusive exchange may decrease in warmer months. [ABSTRACT FROM AUTHOR]

Abstract: In this study, three receptor models [factor analysis/multiple linear regression (FA/MLR), positive matrix factorization (PMF) and UNMIX] were applied seasonally to investigate the source apportionment of PAHs in the atmospheric environment of Alexandria, and a lifetime cancer risk was assessed. ∑44 (gas+particle) PAH concentrations varied from 330 to 1770ngm−3 and 170–1290ngm−3 in the summer and winter seasons respectively. PAH concentrations at the industrial sites were significantly higher than at the traffic and residential sites during the winter season (p <0.001). Summer PAH concentrations were significantly higher than the winter season at the traffic sites (p =0.027). Results obtained from the three receptor models were comparable. Vehicle emissions, both diesel and gasoline contributed on average 36.0–49.0% and 19.0–34.0% respectively, natural gas combustion 11.0–27.0% and, during the summer only, also evaporative/uncombusted petroleum sources 8.00–18.0%. Seasonal trends were found for the gasoline emission source. Overall, PMF and UNMIX models afforded better source identification than did FA/MLR. The lifetime cancer risk assessment showed that incremental lifetime cancer risks (ILTCRs) were greater than the acceptable level of 10−6 through dermal and ingestion routes at all the investigated sites and through the inhalation route at the industrial and traffic sites only. Total ILTCRs (6.64×10−3–4.42×10−2) indicated high potential risks to the local residents. [Copyright &y& Elsevier]

Abstract: Organochlorine pesticides (OCPs) and polychlorinated biphenyls (PCBs) were determined in sediment samples collected from 34 locations in Lake Qarun, Egypt to elucidate their concentrations, distribution, possible sources and potential ecological risk. A total of 25 OCPs and 29 PCBs were identified and quantified. OCPs and PCBs were found to be ubiquitous pollutants in the aquatic environment of Lake Qarun, particular near urban areas reflecting the local usage and input of these pollutants. Total concentrations of OCPs and PCBs in sediments ranged from 1.01 to 164.8ngg−1 and 1.48 to 137.2ngg−1, respectively. Among OCPs, γ-HCH, heptachlor, aldrin, endrin, p,p′-DDE, oxy-chlordane and endosulfan I and II were the most abundant compounds. The composition of PCB congeners was dominated by the tri-, tetra-, penta- and hexa-chlorinated biphenyls. The ratios of certain metabolites (isomers) to their parent compounds (mixtures) indicated there are still new inputs of lindane, endrin, heptachlor and technical endosulfan to Qarun Lake, while the ratios of (p,p′-DDE+p,p′-DDD)/∑p,p′-DDTs indicate earlier usage of DDT. Contamination levels of PCBs and HCHs can be categorized as moderate to high compared to other urbanized regions worldwide. According to established sediment quality guidelines, γ-HCH, endrin and chlordanes would be more concerned OCP species for the ecotoxicological risk in Lake Qarun. [Copyright &y& Elsevier]

Polyethylene samplers (PEs) were deployed at 11 locations in Alexandria, Egypt during summer and winter to test and characterize them as passive samplers for concentrations, sources, and seasonal variations of atmospheric concentrations of polycyclic aromatic hydrocarbons (PAHs). PE-air equilibrium was attained faster for a wider range of PAHs during the winter season possibly due to increased wind speeds. Calculated PE-air partitioning constants, KPE-A, in our study [Log KPE-A = 0.9426 × Log KOA - 0.022 (n = 12, R² = 0.99, Std error = 0.053)] agreed with literature values within <46%. For parent (except naphthalene), mono- and dialkylated PAHs, active sampling based concentrations of PAHs were within an average factor of 1.4 (1.0-5.6) compared to the PE based values. For C3-4 alkylated PAHs, KPE-A values were lower than predicted, on average by ~0.8 log units per carbon in the alkylation. Enthalpies of vaporization (ΔHvap) accurately corrected KPE-As for temperature differences between winter and summer sampling. PAH profiles were dominated by naphthalene, phenanthrene, and alkylated phenanthrenes. Calculated diagnostic ratios indicated that PAHs originated mainly from vehicle emissions. [ABSTRACT FROM AUTHOR]

Abstract: Concentrations of Al, As, Ba, Be, Cd, Cr, Cu, Fe, Mn, Ni, Pb, Se, Sn, V and Zn in road dust particles at seven sites in the Delta region have been investigated using atomic absorption spectroscopy (AAS). Results showed that samples were highly contaminated with Cd, Pb, Sn and Zn and moderately contaminated with As, Se, Ba and Cu when compared to the average crustal background concentrations of metals. The output of the principle component analysis revealed that Al, Fe, Be and Mn were predominantly driven from natural sources and that all the other metals were anthropogenically driven from industrial activities (As, Ba, Cd, Cr, Cu, Se, and Sn) and traffic emissions (Pb, Ni and V). Results of the applied risk assessment indicated that the higher risk of occurrence of adverse non-carcinogenic health effects is associated with the exposure of children to Al, Fe, As, Cr, Pb and Zn via the ingestion pathway and that carcinogenic health effects are not expected to occur from the exposure to metals in the road dust of the Delta region. However, given the large uncertainties associated with the estimates of toxicity values and exposure factors, and the absence of site-specific biometric factors, these results should be regarded as a screening data. Further research should be undertaken before any definite conclusions regarding potential health effects are drawn. [ABSTRACT FROM AUTHOR]

BACKGROUND: The influence of fibroids on fertility is poorly understood. Submucosal and intramural fibroids that distort the endometrial cavity have been associated with decreased pregnancy rates (PRs) following IVF treatment. However, there is uncertainty about the effect of intramural fibroids that do not distort the endometrial cavity on IVF outcomes. [ABSTRACT FROM PUBLISHER]

Abstract: The contamination of sediments and mussels sampled from Abu Qir Bay by polycyclic aromatic hydrocarbons (PAHs) was investigated. Concentrations of PAHs recorded in the bay sediments ranged from

The aim of this study was to assess the accuracy of antral follicle count (AFC) performed after pituitary down-regulation (dAFC) in predicting poor ovarian response and the influence of using different thresholds of follicle size and count on its accuracy. Using three definitions of follicle size, three dAFC were determined for every patient in a consecutive cohort of 148 IVF cycles. The performance of the dAFC in predicting poor ovarian response (as expressed by area under the curve; AUC) for follicle size definitions of 2-5.2-8.2-10 ram, was not significantly different (AUC 0.80, 0.80, 0.79, respectively). Multilevel likelihood ratio for dAFC thresholds of ≤10, 11-15,16-20 and >20 were 5.43 (95% confidence interval 0.81-36.6), 3.06 (1.54-6.06), 1.63 (0.74-3.62) and 0.37 (0.19-4).75) with post-test probabilities of poor ovarian response of 50%, 36%, 23% and 6%, respectively, for a pretest probability of 15.5% for poor ovarian response. The single most important predictor of ovarian response was dAFC. The highest predictive performance was obtained in a model combining age and body mass index and dAFC (AUC = 0.82) showing only marginal improvement over dAFC alone. In conclusion, the performance of dAFC is the same regardless of the definition used for the size of antral follicles. [ABSTRACT FROM AUTHOR]

This article proposes a new measurement reporting method applied for HSUPA systems. The presented mechanism offers an efficient uplink quality of service, especially in soft hand-over mobility conditions. 3GPP specifications restrict mobility procedures (such as serving cell change) to downlink quality measurement reporting. However, with the high data rate introduced on the uplink in HSUPA systems, downlink-only measurements can introduce reporting delays or mobility decision inaccuracies, and thus throughput degradation. The proposed algorithm provides event-based uplink measurements for the block error rate quality on each radio link in the HSUPA active set. Networks can then use the proposed mechanism along with the downlink event-based measurements to trigger a mobility procedure. The results show enhancements to the uplink throughput and overall system performance. [ABSTRACT FROM AUTHOR]

New nanophenolic oxime complexes of the type [M(κ2‐Saly)2] {where HSaly = salicyl‐aldoxime; M = Co(1), Ni(2), Cu(3), Pd(4), Pt(5), Zn(6), Cd(7), and Hg(8)} were prepared and characterized by different spectroscopic methods. The surface morphology and the micrographs of the investigated complexes were checked by the scanning electron microscopy (SEM) and X‐ray diffraction (XRD) analysis. The results indicate the successful preparation of nanocomplexes with nanoparticles size. In addition, the antibacterial activity was studied against three different pathogenic bacteria, and the Pt(II) complex displayed the highest activity compared with free salicylaldoxime ligand and other complexes. Magnetic susceptibility and ultraviolet (UV)–visible spectroscopic measurements were used to deduce the geometry of the complexes, which was then validated by density functional theory (DFT) calculations. The in vitro antitumor activity was investigated by MTT assays against HepG‐2 cell lines. The Zn(II) and Pt(II) complexes displayed good activity with IC50 values at 17.31 ± 0.95 and 11.78 ± 0.54 μM, respectively. In contrast, the [Cu(Saly)2] and [Ni(Saly)2] complexes showed the lowest activity against tested cells. [ABSTRACT FROM AUTHOR]

Many randomized trials have evaluated the use of various pituitary suppression regimens to improve outcome of poor responders undergoing IVF treatment. A systematic review was conducted of the trials of gonadotrophin-releasing hormone (GnRH) agonist long regimen, GnRH agonist short regimen, GnRH antagonist regimen, as well as other pituitary suppression regimens in poor responders undergoing IVF/intracytoplasmic sperm injection (ICSI) treatment. The search included MEDLINE, EMBASE, Cochrane Library, National Research Register and ISI proceedings, and all randomized controlled trials comparing the various pituitary suppression regimens in poor responders were included. Study selection, quality appraisal and data extraction were performed independently and in duplicate. The main outcome measures were number of oocytes retrieved, cycles cancelled before oocyte retrieval and pregnancy rates. A total of 680 women considered as poor responders undergoing IVF/ICSI treatment were included in nine randomized controlled trials. The quality of these studies was variable: for example, only three of the studies had clear evidence of allocation concealment. Meta-analyses of the results of the studies did not show a consistent benefit for any one pituitary suppression regimen over the other regimens in improving outcome measures. Currently available evidence does not favour any one pituitary suppression regimen for women with poor ovarian response undergoing IVF/ICSI treatment. [ABSTRACT FROM AUTHOR]

Objective: To investigate the association between luteal serum progesterone levels and frozen embryo transfer (FET) outcomes.Design: Systematic review and meta-analysis.Setting: Not applicable.Patient(s): Women undergoing FET.Intervention(s): We conducted electronic searches of MEDLINE, PubMed, CINAHL, EMBASE, the Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials, Web of Science, ClinicalTrials.gov, and grey literature (not widely available) from inception to March 2021 to identify cohort studies in which the serum luteal progesterone level was measured around the time of FET.Main Outcome Measure(s): Ongoing pregnancy or live birth rate, clinical pregnancy rate, and miscarriage rate.Result(s): Among the studies analyzing serum progesterone level thresholds <10 ng/mL, a higher serum progesterone level was associated with increased rates of ongoing pregnancy or live birth (relative risk [RR] 1.47, 95% confidence interval [CI] 1.28 to 1.70), higher chance of clinical pregnancy (RR 1.31, 95% CI 1.16 to 1.49), and lower risk of miscarriage (RR 0.62, 95% CI 0.50 to 0.77) in cycles using exclusively vaginal progesterone and blastocyst embryos. There was uncertainty about whether progesterone thresholds ≥10 ng/mL were associated with FET outcomes in sensitivity analyses including all studies, owing to high interstudy heterogeneity and wide CIs.Conclusion(s): Our findings indicate that there may be a minimum clinically important luteal serum concentration of progesterone required to ensure an optimal endocrine milieu during embryo implantation and early pregnancy after FET treatment. Future clinical trials are required to assess whether administering higher-dose luteal phase support improves outcomes in women with a low serum progesterone level at the time of FET.Prospero Number: CRD42019157071. [ABSTRACT FROM AUTHOR]

Background: Endometriosis affects the responsiveness to ovarian stimulation. This study aimed to assess the role of Dienogest pretreatment for endometriosis suppression as compared to Gonadotropin-releasing hormone agonist (GnRHa) in patients with endometriosis pursuing IVF treatment.Methods: In this randomized controlled trial, 134 women with endometriosis-related infertility were randomly allocated to group A (n = 67) who had monthly depot GnRHa for 3 months before ovarian stimulation in IVF treatment (Ultra-long protocol), and Group B (n = 67) who had daily oral Dienogest 2 mg/d for 3 months before starting standard long protocol for IVF. The primary outcome measure was the number of oocytes retrieved. The secondary outcome measures included the number of mature oocytes, fertilization rate, quality of life assessed by FertiQoL scores, cost of treatment, and pregnancy outcomes.Results: Although there was no statistically significant difference between both groups regarding ovarian stimulation, response parameters, and pregnancy outcomes, the Dienogest group had a lower cost of treatment (2773 vs. 3664 EGP, P < 0.001), lower side effects (29.9% vs. 59.7%, P < 0.001), higher FertiQoL treatment scores (33.2 vs. 25.1, P < 0.001) and higher tolerability scores (14.1 vs. 9.4, P < 0.001 < 0.001).Conclusion: Our study indicates that Dienogest is a suitable and safe substitute for GnRHa pretreatment in endometriosis patients.Trial Registration: NCT04500743 "Retrospectively registered on August 5, 2020". [ABSTRACT FROM AUTHOR]

Compared with dry and wet deposition fluxes, air-water exchange flux cannot be directly measured experimentally. Its model-based calculation contains considerable uncertainty because of the uncertainties in input parameters. To capture the inherent variability of air-water exchange flux of PCBs across the lower Great Lakes and to calculate their annual gross volatilization loss, 57 pairs of air and water samples from 19 sites across Lakes Erie and Ontario were collected using passive sampling technology during 2011-2012. Error propagation analysis and Monte Carlo simulation were applied to estimate uncertainty in the air-water exchange fluxes. Results from both methods were similar, but error propagation analysis estimated a smaller uncertainty than Monte Carlo simulation in cases of net deposition. Maximum likelihood estimations (MLE) of wind speed and air temperature were recommended to quantify the site-specific air-water exchange flux. An assumed 30-40% of relative uncertainty in overall air-water mass transfer velocity was confirmed. MLEs of volatilization fluxes of total PCBs across Lakes Erie and Ontario were 0.78 and 0.53 ng m-2 day-1, respectively, and gross volatilization losses of total PCBs over the whole lakes were 74 kg year-1 for Lake Erie and 63 kg year-1 for Lake Ontario. Mass balance analysis across Lake Ontario indicated that volatilization was the uppermost loss process of aqueous PCBs. [ABSTRACT FROM AUTHOR]

Polyethylene passive sampling was performed to quantify gaseous and freely dissolved polychlorinated biphenyls (PCBs) in the air and water of Lakes Erie and Ontario during 2011-2012. In view of differing physical characteristics and the impacts of historical contamination by PCBs within these lakes, spatial variation of PCB concentrations and air-water exchange across these lakes may be expected. Both lakes displayed statistically similar aqueous and atmospheric PCB concentrations. Total aqueous concentrations of 29 PCBs ranged from 1.5 pg L-1 in the open lake of Lake Erie (site E02) in 2011 spring to 105 pg L-1 in Niagara (site On05) in 2012 summer, while total atmospheric concentrations were 7.7-634 pg m-3 across both lakes. A west-to-east gradient was observed for aqueous PCBs in Lake Erie. River discharge and localized influences (e.g., sediment resuspension and regional alongshore transport) likely dominated spatial trends of aqueous PCBs in both lakes. Air-water exchange fluxes of Σ7PCBs ranged from -2.4 (±1.9) ng m-2 day-1 (deposition) in Sheffield (site E03) to 9.0 (±3.1) ng m-2 day-1 (volatilization) in Niagara (site On05). Net volatilization of PCBs was the primary trend across most sites and periods. Almost half of variation in air-water exchange fluxes was attributed to the difference in aqueous concentrations of PCBs. Uncertainty analysis in fugacity ratios and mass fluxes in air-water exchange of PCBs indicated that PCBs have reached or approached equilibrium only at the eastern Lake Erie and along the Canadian shore of Lake Ontario sites, where air-water exchange fluxes dominated atmospheric concentrations. [ABSTRACT FROM AUTHOR]

Objective: To assess the effect of fasting in Ramadan on amniotic fluid index (AFI). Design: A cross sectional observational study. Methods: This study was conducted between July 21, 2012 and August 17, 2012, which corresponded to the 3rd and 27th days of the month of Ramadan 1433 and from July 12, 2013 and August 6, 2013, which corresponded to the 3rd and 27th days of the month of Ramadan 1434. Pregnant women attending the antenatal care clinic at Assiut and Qena University Hospitals were included in this study. The study groups included fasting and non fasting women beyond 36 weeks of gestation. The study took place at the same time of day (i.e., between 9 and 12 AM). Results: A total of 221 pregnant women were studied, 97 fasting and 124 non fasting. As regards age, parity and the gestational age no significant differences were reported. The AFI was less affected by fasting, also there was a significant difference in the AFI between fasting and non fasting pregnant women with oligohydramnios (4.00 ± 0.82 and 2.64 ± 1.12 respectively). A positive relationship with gravidity was observed as AFI increased with the increase of gravidity in pregnant fasting women, on the other hand there was variable non significant relation between AFI and gravidity in pregnant non fasting women. Conclusion: We conclude that the fasting in Ramadan has no effect on or may improve the AFI in the last month, while gravidity plays a role in the AFI in fasting group. [ABSTRACT FROM AUTHOR]

Background: Controlling massive haemorrhage from morbidly adherent placenta (MAP) at caesarean section is a major surgical challenge to obstetricians. This study compares different intra-operative interventions to control haemorrhage from morbidly adherent placenta and its impact on maternal morbidity.Methods: Retrospective analysis was done for baseline characteristics, intra-operative and postoperative complications of 125 patients with morbidly adherent placenta who had elective CS at 35-38 weeks gestation in the period from 01/2012 to 01/2017. The included patients were categorized into three groups according to intra-operative interventions they had for controlling bleeding; Group A (n = 42) had only balloon tamponade, Group B (n = 40) had balloon tamponade and bilateral uterine artery ligation, in Group C (n = 43) all cases were managed by bilateral uterine artery ligation and inverting the cervix into the uterine cavity and suturing the anterior and/or the posterior cervical lips into the anterior and/or posterior walls of the lower uterine segment using the cervix as a natural tamponade.Results: There were no differences of baseline characteristics of patients in all groups. Group C had significantly better outcomes as compared with groups A and B; less total blood loss (Group C 2869.5 ml vs Group B 4580 ml, Group A 4812 ml, P <  0.001), less requirement of blood transfusion more than 4 units (Group C 4/43, Group B 10/40,Group A 12/42, P <  0.02), significant reduction in prolonged hospital stay over 10 days (Group C 2/43, Group B 9/40,Group A 14/42, P < 0.001) and lower risk of coagulopathy (Group C 4/43, B 8/40, A 9/42), visceral injuries (Group C 4/43 vs B 8/40, A 10/42,P < 0.01) and need for hysterectomy (Group C 4/43 vs B 11/40, A 13/42,P < 0.001).Conclusion: A combination bilateral uterine artery ligation and using the cervix as a natural tamponade are very effective and simple methods in controlling bleeding resulting from separated placenta accreta.Trial Registration: The findings are part of the research project registered in ClinicalTrials.gov NCT02590484 . Registered 28 October 2015. [ABSTRACT FROM AUTHOR]