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Purpose: The incidence of birth defects is increased in children born after assisted reproductive technologies (ART). However, changes in ART over time could influence this incidence. To investigate this issue, we present the frequency and trends of birth defects in ART and natural pregnancies in Lombardy, Northern Italy, during the period 2014–2020. Methods: This is a population-based study using automated system of healthcare utilization (HCU) databases. ART pregnancies included only those obtained with conventional IVF or ICSI. After identifying the total number of deliveries, the rate of newborns with birth defects was compared between natural and ART pregnancies. A logistic regression model was used to calculate the adjusted odd ratio (OR). Analyses were repeated for every calendar year. Results: Overall, 508,421 deliveries were identified, of which 14,067 (2.8%) were achieved after IVF-ICSI. A decreasing trend in birth defects over time was highlighted. The adjusted OR dropped from 1.40 (95%CI: 1.03–1.91) in 2014 to 0.92 (95%CI: 0.69–1.22) in 2020. During the study period, a significant reduction in multiple pregnancy and in the ratio of ICSI to conventional IVF was also observed, explaining at least in part the positive trend observed for birth defects. Conclusion: The increased risk of birth defects in children born after IVF-ICSI is not steady over time. A decline of this risk emerged in our region. Policy changes in ART may explain this beneficial effect.

Purpose To assess the outcome of excess follicle aspiration before intrauterine insemination (EFABI) in intrauterine insemination (IUI) cycles with 4-6 follicles >= 14 mm. Methods A retrospective case-control study with 1559 patients undergoing IUI (donor and husband's sperm), of whom 86 underwent EFABI. We studied also an historical series of 2213 patients before EFABI implementation. For 3.5 years, all women undergoing IUI developing 4-6 follicles >= 14 mm were offered EFABI on the day of hCG administration. Pregnancy rates (PRs), multiple PRs, and adverse effects were measured. Results EFABI was associated with a similar multiple PR (17.8% vs 17.5% in non-EFABI cases), with no triplets in EFABI patients. Live birth rates were significantly higher in EFABI cycles in IUI overall (25.5% vs 15.2%). When considered separately, the performance of EFABI resulted in significantly increased live birth rates in IUI-donor cycles (32.5% vs 18.5%), whereas the differences in IUI-husband cycles (19.5% vs 12.9%) did not reach statistical significance. The PR was 21.2% during the EFABI implementation period and 19.4% in the pre-EFABI period. Conclusions EFABI in cycles in which 4-6 follicles reach >= 14 mm is a simple option that reduces cycle cancellation rates, results in higher PRs than cycles with 1-3 follicles, and lowers the risk of multiple pregnancy.

Multiple gestations have become an increasing phenomenon that has impacted public health globally, largely due to the application of assisted reproductive technologies. The objective of this work was to find out the discourse that the health professionals involved in its follow-up have in our context. For this, a qualitative methodology was chosen, with semi-structured interviews recorded in audio, prior authorisation, and transcribed verbatim. It was based on a script designed for this purpose, with the following analysis categories: the current trend of multiple gestations, impact, and follow-up. The content analysis was based on the experiences, knowledge, and perceptions of the professionals interviewed. Professionals stated that the current socioeconomic and legal context hinders a single embryo transfer policy that decreases multiple gestation rates. They emphasised the importance of the psychic impact of such gestations on the couple, on the mother in particular, as well as the economic effect on families, health, and society in general. They expressed the need to create specific protocols to assist these gestations. Midwives, in particular, demanded that the health administration recognise and support the differentiated care they perform with this type of gestation. Work on specific models is needed to adequately size the impact of multiple gestations, as well as to generate social health policies that lead to co-responsible reconciliation measures that favour women having one pregnancy at a time.

Unexplained infertility is a common diagnosis among couples with infertility. Pragmatic treatment options in these couples are directed at trying to improve chances to conceive, and consequently intrauterine insemination (IUI) with ovarian stimulation and in vitro fertilization (IVF) are standard clinical practice, while expectant management remains an important alternative. While evidence on IVF or IUI with ovarian stimulation versus expectant management was inconclusive, these interventions seem more effective in couples with a poor prognosis of natural conception. Strategies such as strict cancellation criteria and single-embryo transfer aim to reduce multiple pregnancies without compromising cumulative live birth. We propose a prognosis-based approach to manage couples with unexplained infertility so as to expose less couples to unnecessary interventions and less mothers and children to the potential adverse effects of ovarian stimulation or laboratory procedures.Copyright © 2020 Thieme Medical Publishers, Inc.. All rights reserved.

Objective: It has been suggested that lockdown during the COVID-19 pandemic decreased prematurity rates. We investigated the impact of lockdown on obstetric outcomes. Study Design: We performed a cohort study on women who gave birth at three maternity hospitals in metropolitan Melbourne, Australia, between Jan 1st, 2019 and Sept 16th, 2020. Data were extracted from the common birth registry of the three maternities. The second lockdown started July 8th, 2020 and required people to stay at home, with limited exemptions. We performed interrupted time-series analysis to compare the monthly rates of preterm birth before 34 weeks prior to and after July 2020. We also compared the group of women who delivered between July and September 2020 to the group of women who delivered during the same period in 2019. Result(s): A total 15,394 women gave birth. Interrupted time-series analysis demonstrated a significantly lower monthly rate of deliveries before 34 weeks of gestational age after July 2020 (Figure 1; p = 0.001). There were 2,207 deliveries between July to Sept. 2019 and 1,870 deliveries between July to Sept. 2020. Baseline characteristics were comparable, except for a significantly difference in twins (1.5% in 2020 versus 2.6% in 2019, p = 0.012). After excluding women with pregnancies complicated by major fetal abnormalities or stillbirth, the risk of preterm delivery before 34 weeks was much lower in patients who delivered between July and September 2020 (2.1% versus 3.3%, RR 0.64, 95% CI 0.44 to 0.94, p = 0.022) (Table 1). Similar patterns were observed for iatrogenic and spontaneous preterm birth at different gestational ages. The effect persisted after logistic regression adjustment for multiple pregnancies (adjusted OR 0.65, 95% CI 0.46 to 0.96, p = 0.028). The decrease in prematurity was not at the cost of an increase in stillbirth or undetected small for gestational age neonates. Conclusion(s): Strict lockdown has a strong impact on iatrogenic and spontaneous

Multiple gestations have become an increasing phenomenon that has impacted public health globally, largely due to the application of assisted reproductive technologies. The objective of this work was to find out the discourse that the health professionals involved in its follow-up have in our context. For this, a qualitative methodology was chosen, with semi-structured interviews recorded in audio, prior authorisation, and transcribed verbatim. It was based on a script designed for this purpose, with the following analysis categories: the current trend of multiple gestations, impact, and follow-up. The content analysis was based on the experiences, knowledge, and perceptions of the professionals interviewed. Professionals stated that the current socioeconomic and legal context hinders a single embryo transfer policy that decreases multiple gestation rates. They emphasised the importance of the psychic impact of such gestations on the couple, on the mother in particular, as well as the economic effect on families, health, and society in general. They expressed the need to create specific protocols to assist these gestations. Midwives, in particular, demanded that the health administration recognise and support the differentiated care they perform with this type of gestation. Work on specific models is needed to adequately size the impact of multiple gestations, as well as to generate social health policies that lead to co-responsible reconciliation measures that favour women having one pregnancy at a time.

Purpose: The risk of monozygotic (MZT) twinning is increased in pregnancies after assisted reproductive technologies (ART). However, determinants remain poorly understood. To shed more light on this issue, we analyzed the estimated frequency of MZT twins from ART in Lombardy, Northern Italy, during the period 2007–2017. Methods: This is a population-based study using regional healthcare databases of Lombardy Region. After having detected the total number of deliveries of sex-concordant and sex-discordant twins from ART, we calculated MZT rate using Weinberg’s method. Standardized ratios (SRs) and corresponding 95% confidence intervals (CI) of MZT deliveries, adjusted for maternal age, were computed according to calendar period, parity, and type of ART. Results: On the whole, 19,130 deliveries from ART were identified, of which 3,446 were twins. The estimated rate of MZT births among ART pregnancies was higher but decreased over time (p-value = 0.03); the SRs being 1.33 (95% CI: 1.18–1.51), 0.96 (95% CI: 0.83–1.11), and 0.92 (95% CI: 0.79–1.07) for the periods 2007–2010, 2011–2014, and 2015–2017, respectively. The SRs of MZT among women undergoing first-level techniques, conventional in vitro fertilization (IVF), and intracytoplasmic sperm injection (ICSI) were 0.47 (95% CI: 0.38–0.57), 1.02 (95% CI: 0.88–1.17), and 1.43 (95% CI: 1.27–1.61) (p-value < 0.0001). The ratio of MZT births was significantly higher in women younger than 35 years (p-value < 0.0001) and slightly higher among nulliparae (p-value < 0.0001). Conclusion: Despite a reduction of MZT rate from ART over the time, the risk remains higher among ART pregnancies rather than natural ones. Younger women and women undergoing ICSI showed the highest risk of all.

To assess the role of the placental growth factor in the development of gestational complications during multiple pregnancy, there was conducted a study of this indicator in serum of 320 pregnant women with multiple pregnancy in the first trimester and 40 pregnant women with singleton pregnancy (the control group).          The objective of the research was to study the effect of placental growth factors on the gestational process in multiple pregnancy.          Materials and Methods. There was conducted a prospective study of pregnancy and childbirth in 320 females with multiple pregnancy (the main group) and 40 healthy women with singleton pregnancy. The level of serum placental growth factor was determined by enzyme-linked immunosorbent assay using monoclonal antibodies in the first trimester of pregnancy. The indicators of the hemostasis system (vascular, platelet and coagulation components) were evaluated according to generally accepted methods. Doppler ultrasound of the placental and fetal blood flow was performed in the uterine arteries, the umbilical artery and vein, the fetal middle cerebral artery.          Results. Women with multiple pregnancy were at high risk of developing gestational complications such as preterm deliveries (67.8%, p<0.01), placental dysfunction, pre-eclampsia (17.5%, p<0.05). The disorders of the vascular platelet and coagulation hemostasis in the first trimester of pregnancy were the main risk factors for early termination of pregnancy. Low level of serum placental growth factor in pregnant women with multiple pregnancy in case of preterm delivery, placental dysfunction and pre-eclampsia (111.23 ± 8.4, 203.24 ± 6.4 and 305.86 ± 7.4 pg/ml), in comparison with the corresponding indicators in singleton pregnancy (418.2 ± 10.4 pg/ml), was proven to be a prognostic marker for the development of gestational complic

STUDY QUESTION: Over a time period of 3 years, which order of expectant management (EM), IUI with ovarian stimulation (IUI-OS) and IVF is the most cost-effective for couples with unexplained subfertility with the female age below 38 years? SUMMARY ANSWER: If a live birth is considered worth e32 000 or less, 2 years of EM followed by IVF was the most cost-effective, whereas above e32 000 this was 1 year of EM, 1 year of IUI-OS and then 1 year of IVF. WHAT IS KNOWN ALREADY: IUI-OS and IVF are commonly used fertility treatments for unexplained subfertility although many couples can conceive naturally, as no identifiable barrier to conception could be found by definition. Few countries have guidelines on when to proceed with medically assisted reproduction (MAR), mostly based on the expected probability of live birth after treatment, but there is a lack of evidence to support the strategies proposed by these guidelines. The increased uptake of IUI-OS and IVF over the past decades and costs related to reimbursement of these treatments are pressing concerns to health service providers. For MAR to remain affordable, sustainable and a responsible use of public funds, guidance is needed on the cost-effectiveness of treatment strategies for unexplained subfertility, including EM. STUDY DESIGN, SIZE, DURATION: We developed a decision analytic Markov model that follows couples with unexplained subfertility of which the woman is under 38 years of age for a time period of 3 years from completion of the fertility workup onwards. We divided the time axis of 3 years into three separate periods, each comprising 1 year. The model was based on contemporary evidence, most notably the dynamic prediction model for natural conception, which was combined with MAR treatment effects from a network meta-analysis on randomized controlled trials. We changed the order of options for managing unexplained subfertility for the 1 year periods to yield five different treatment policies in total: IVF-E

Introduction The ProTWIN trial previously showed no beneficial effect of treatment with a cervical pessary vs usual care to prevent preterm birth in women with a multiple pregnancy. However, in women with a midtrimester short cervix (<38 mm), pessary did reduce the composite outcome of neonatal morbidity and mortality. This follow‐up study evaluates the long‐term outcomes of all children born to mothers who participated in the ProTWIN trial at 4 years of age. Material and methods Parents received the Ages and Stages Questionnaire, Strength and Difficulties Questionnaire and a health questionnaire. All questionnaires were reported separately and as a combined outcome (abnormal child outcome). A linear mixed effects model was used to adjust for correlated data in twins and correction for confounders was performed. In exploratory analysis, a composite outcome of death or survival with abnormal child outcome was used by combining extrapolated data on child outcome with survival data. All data were analyzed for the total group and the subgroup of women with midtrimester short cervix. Results Of the original 813 women of the ProTWIN trial, we approached 579, of whom 258 participated (45%) in follow up. We received questionnaires of 514 children (281 pessary vs 233 control), with 119 children in the subgroup of women with midtrimester short cervix. An abnormal child outcome was found in 23% in the pessary group vs 16% in the control group (odds ratio 1.58; 95% confidence interval .94‐2.65). In exploratory analysis with extrapolated data on child outcome (n = 815), no difference in abnormal child outcome was seen between the pessary and control group. In the subgroup of women with a short cervix (n = 268), this composite outcome indicated a favorable outcome for children born to mothers with pessary. Conclusions In women with a multiple pregnancy, the use of a cervical pessary did not improve development, behavior or physical outcomes of the surviving children at age 4.

Research question: Elective single-embryo transfer (eSET) at blastocyst stage is widely used to reduce the frequency of multiple pregnancies after IVF. There are, however, concerns about increased risks for the offspring with prolonged embryo culture. Is it possible to select embryos for transfer at the early cleavage stage and still achieve low twin rates at preserved high live birth rates? Design: A prediction model (PM) was developed to optimize eSET based on variables known 2 days after oocyte retrieval (fresh day 2 embryo transfers; double-embryo transfers 1999-2002 (n=2846) and SET 1999-2003 (n=945); n total=3791). Seventy-five variables were analysed for association with pregnancy chance and twin risk and combined for PM construction. This PM was validated in 2004-2016 including frozen-thawed transfers (FET), to compare cumulative live birth rate (CLBR) and twin rate before (1999-2002 fresh embryo transfers plus FET from the same oocyte retrievals until the end of 2007, n=3495) and after (2004-2011 fresh embryo transfers plus FET from the same oocyte retrievals until the end of 2016, n=11195) implementing the model. Results: The PM was constructed from four independent variables: female age, embryo score, ovarian sensitivity and treatment history. The calibration, i.e. the fit of observed versus predicted results, was excellent both at construction and at validation. Without compromising CLBR, twin rate was reduced from 25.2% to 3.8%, accompanied by profound improvements in perinatal outcome. Conclusion: The results provide the first successful construction, validation and impact analysis of a day 2 transfer PM to reduce multiple pregnancies.

The current approach to screening for pre-eclampsia is based on guidelines that rely on medical and obstetric history in early pregnancy to select a high-risk group that might benefit from low-dose aspirin. However, combined screening tests with the addition of biophysical and biochemical measurements have shown significantly better detection rates for preterm pre-eclampsia. Furthermore, the administration of aspirin for the 10% screen-positive group can lead to a significant reduction in severe and preterm forms of pre-eclampsia. This review aims to answer frequently asked questions related to the clinical implementation of screening and the management of screening results.Copyright © 2019 The Authors. Australian and New Zealand Journal of Obstetrics and Gynaecology published by John Wiley & Sons Australia, Ltd on behalf of Royal Australian and New Zealand College of Obstetricians and Gynaecologists.

Polycystic ovary syndrome (PCOS) is associated with worsened pregnancy and infant outcomes, higher body mass index (BMI), and longitudinal weight gain. Despite most of the clinical features of PCOS being risk factors for worsened infant outcomes in the general population, their impact on infant outcomes in PCOS is unknown. We aimed to investigate the association of PCOS with infant outcomes considering maternal adiposity, other known risk factors, and potential confounders. The meta-analyses included 42 studies in 7041 women with PCOS and 63 722 women without PCOS. PCOS was associated with higher gestational weight gain (GWG) and with higher preterm birth and large for gestational age and with lower birth weight with this association varying by geographic continent, PCOS phenotypes, and study quality. However, PCOS was associated with none of these outcomes on BMI-matched studies. Gestational diabetes was significantly associated with an increased preterm birth on meta-regression. We report for the first time that GWG is higher in PCOS. Infant outcomes vary by geographic continent and study quality but are similar in BMI-matched women with and without PCOS. This suggests that infant outcomes in PCOS may be related to maternal obesity. These novel findings warrant future studies in PCOS investigating screening and management of infant outcomes with consideration of maternal obesity.Copyright © 2019 World Obesity Federation

INTRODUCTION: We have developed the first international evidence-based guideline for the diagnosis and management of polycystic ovary syndrome (PCOS), with an integrated translation program incorporating resources for health professionals and consumers. The development process involved an extensive Australian-led international and multidisciplinary collaboration of health professionals and consumers over 2 years. The guideline is approved by the National Health and Medical Research Council and aims to support both health professionals and women with PCOS in improving care, health outcomes and quality of life. A robust evaluation process will enable practice benchmarking and feedback to further inform evidence-based practice. We propose that this methodology could be used in developing and implementing guidelines for other women's health conditions and beyond. Main recommendations: The recommendations cover the following broad areas: diagnosis, screening and risk assessment depending on life stage; emotional wellbeing; healthy lifestyle; pharmacological treatment for non-fertility indications; and assessment and treatment of infertility. Changes in management as a result of this guideline: *Diagnosis:when the combination of hyperandrogenism and ovulatory dysfunction is present, ultrasound examination of the ovaries is not necessary for diagnosis of PCOS in adult women;requires the combination of hyperandrogenism and ovulatory dysfunction in young women within 8 years of menarche, with ultrasound examination of the ovaries not recommended, owing to the overlap with normal ovarian physiology; andadolescents with some clinical features of PCOS, but without a clear diagnosis, should be regarded as "at risk" and receive follow-up assessment.*Screening for metabolic complications has been refined and incorporates both PCOS status and additional metabolic risk factors.*Treatment of infertility: letrozole is now first line treatment for infertility as it improves live birth

Objective: Traditionally, tubal patency testing during fertility work-up is performed by hysterosalpingography (HSG). Hysterosalpingo-foam-sonography (HyFoSy) is an alternative technique without radiation exposure and is less expensive than HSG. Globally, there is a shift towards the use of office-based diagnostic methods, such as HyFoSy. Here, we assess whether HyFoSy is as accurate as HSG in evaluating tubal patency and if it leads to comparable pregnancy outcomes. Design(s): Multicenter prospective comparative study with a randomized non-inferiority design. Material(s) and Method(s): Participating women underwent both HyFoSy and HSG, in randomized order, by a physician unaware of the result of the first test (NTR 4746). In case of discordant results for HyFoSy/HSG, women were randomly allocated to either a management strategy based on HyFoSy or one based on HSG. Assuming 7% discordant results, we needed to recruit 1,163 participants (van Rijswijk et al., 2018). Primary outcome is ongoing pregnancy within 12-months after inclusion. Secondary outcomes are concordance between HSG and HyFoSy, pain scores, live birth, time to pregnancy, clinical pregnancy, miscarriage, multiple pregnancy, preterm birth. Result(s): Between June 2015 and January 2019, a total of 1164 women were scheduled to undergo HSG and HyFoSy. At moment of writing, data on 97% was available. 2.3% of the women did not undergo any tests, 5.0% had HSG only and 0.6% had HyFoSy only. From the women who had both tests, 2.9% had an inconclusive HSG and 8.5% had an inconclusive HyFoSy (RR 2.3, 95%CI 1.6-3.2). In 0.8%, both tests were inconclusive. Among the women with two tests completed, 85% had concordant results (94.7% patent tubes, 3% with unilateral occlusion, 0.9% with bilateral occlusion, 1.4% with other findings). The mean pain score on the 1-10 VAS-scale was 5.4 (95%CI 5.2-5.6) for HSG compared to 3.0 (95%CI 2.9-3.2) for HyFoSy (p-value<0.001). Pain score of HyFoSy was not affected by the order of

Polycystic ovary syndrome (PCOS) is a common, complex condition that affects up to 18% of reproductive-aged women, causing reproductive, metabolic and psychological dysfunctions. We performed an overview and appraisal of methodological quality of systematic reviews that assessed medical and surgical treatments for reproductive outcomes in women with PCOS. Databases (MEDLINE, EMBASE, CINAHL PLUS and PROSPERO) were searched on the 15th of September 2017. We included any systematic review that assessed the effect of medical or surgical management of PCOS on reproductive, pregnancy and neonatal outcomes. Eligibility assessment, data extraction and quality assessment by the Assessing the Methodological Quality of Systematic Reviews (AMSTAR) tool were performed in duplicate. We identified 53 reviews comprising 44 reviews included in this overview; the majority were moderate to high quality. In unselected women with PCOS, letrozole was associated with a higher live birth rate than clomiphene citrate (CC), while CC was better than metformin or placebo. In women with CC-resistant PCOS, gonadotrophins were associated with a higher live birth rate than CC plus metformin, which was better than laparoscopic ovarian drilling (LOD). LOD was associated with lower multiple pregnancy rates than other medical treatments. In women with PCOS undergoing in vitro fertilization/intracytoplasmic sperm injection (IVF/ICSI), the addition of metformin to gonadotrophins resulted in less ovarian hyperstimulation syndrome (OHSS), and higher pregnancy and live birth rates than gonadotrophins alone. Gonadotrophin releasing hormone (GnRH) antagonist was associated with less OHSS, gonadotrophin units and shorter stimulation length than GnRH agonist. Letrozole appears to be a good first line treatment and gonadotrophins, as a second line treatment, for anovulatory women with PCOS. LOD results in lower multiple pregnancy rates. However, due to the heterogeneous nature of the included populations of wom

In the past, more than one embryo was often replaced with IVF to increase the chance of a pregnancy. The flip side is that this also increases the chance of a multiple pregnancy. More and more often only one embryo is replaced because multiple pregnancies are associated with complications for mother and child. In this thesis, the long-term costs and outcomes of singles and multiple births born after IVF have been mapped and used to calculate the long-term cost-effectiveness of various embryo transfer strategies. The replacement of two embryos has the highest chance of success, but is also the most expensive. In terms of cost effectiveness, the preferred strategy depends on the analysis period. From an economic perspective, it is preferable to replace two embryos if the long-term costs and outcomes of the children are included

Background: Pregnancy in older women is of great relevance. This study was undertaken to examine whether older women have higher rates of poorer perinatal outcome and whether any increased risk may be attributable to factors associated with advancing maternal age. Method: It was a retrospective study done in a multi-speciality hospital. 57 elderly pregnant women more than 33 years of age coming for the delivery were taken. Results: According to our data, 47% of patients were in 33-35 yrs age group and 42% were in group 36-40yrs. Maximum age of the patient was 46yrs. In our data Majority of the patients were housewives (61.40 %) and 38.59 % were employed. In our data 35% were conceived after assisted reproductive technology, Cerclage was done in 8.67%, 1.75% patients had previous history of anomalous fetus. 21.05% of patients had twin pregnancy. Majority of the patients (80.7%) were delivered by caesarian section. Preterm delivery rate was 49.1%. Normal Vaginal delivery rate was only 14%. Conclusion: The study of complications with advanced maternal age is important. There are greater chances of developing adverse perinatal outcome. The neonate carries the risk of low apgar scores, low birth weight and neonatal death.

Objective: Optimal management of twin deliveries is controversial. We aimed to assess potential risk factors correlated to the development of hypoxia in the second twin after vaginal delivery of the first twin. Study design: This is a retrospective observational study including diamniotic twin pregnancies delivering at our Institution at 35 weeks of gestational age or more, weighing ≥1800 g. Hypoxia was defined as at least one of the following: Apgar score <5 at 10 minute, neonatal resuscitation for >10 minutes, neonatal acidosis (pH ≤7 and/or BE ≥12 mmol/L). Results: A number of 275 diamniotic twin pregnancies met the inclusion criteria and were divided within the following groups: (1) second twin not developing neonatal hypoxia (n = 265); and (2) second twin developing neonatal hypoxia (n = 10). The rate of second twins with neonatal hypoxia during the study period was 3.6% (10/275). Abnormal cardiotocography during the intertwin delivery interval, defined as ACOG category III, was significantly correlated to second twin hypoxia. Of interest, there was no significant difference in the intertwin delivery interval between the study groups. In addition, breech presentation of the second twin did not show to be a risk factor for neonatal hypoxia. None of the second twins developing neonatal hypoxia was reported to have encephalopathy (follow up of at least 24 months). At multivariate analysis, only abnormal cardiotocography was an independent risk factor for second twin hypoxia (OR 17.8, 95% CI 4.1–77.2). Conclusions: In our study, neonatal hypoxia was significantly correlated to abnormal cardiotocography, while intertwin delivery interval was not correlated to the development of this adverse neonatal outcome, Objective: Optimal management of twin deliveries is controversial. We aimed to assess potential risk factors correlated to the development of hypoxia in the second twin after vaginal delivery of the first twin. Study design: This is a retrospective observational study including diamniotic twin pregnancies delivering at our Institution at 35 weeks of gestational age or more, weighing ≥1800 g. Hypoxia was defined as at least one of the following: Apgar score <5 at 10 minute, neonatal resuscitation for >10 minutes, neonatal acidosis (pH ≤7 and/or BE ≥12 mmol/L). Results: A number of 275 diamniotic twin pregnancies met the inclusion criteria and were divided within the following groups: (1) second twin not developing neonatal hypoxia (n = 265); and (2) second twin developing neonatal hypoxia (n = 10). The rate of second twins with neonatal hypoxia during the study period was 3.6% (10/275). Abnormal cardiotocography during the intertwin delivery interval, defined as ACOG category III, was significantly correlated to second twin hypoxia. Of interest, there was no significant difference in the intertwin delivery interval between the study groups. In addition, breech presentation of the second twin did not show to be a risk factor for neonatal hypoxia. None of the second twins developing neonatal hypoxia was reported to have encephalopathy (follow up of at least 24 months). At multivariate analysis, only abnormal cardiotocography was an independent risk factor for second twin hypoxia (OR 17.8, 95% CI 4.1–77.2). Conclusions: In our study, neonatal hypoxia was significantly correlated to abnormal cardiotocography, while intertwin delivery interval was not correlated to the development of this adverse neonatal outcome.

Objective: Optimal management of twin deliveries is controversial. We aimed to assess if intertwin delivery interval, after vaginal delivery of the first twin, may have an influence on adverse neonatal outcomes of the second twin Study design: This is a retrospective observational study including diamniotic twin pregnancies with vaginal delivery of the first twin, between January 2000 and July 2017. Inclusion criteria were diamniotic pregnancies and vaginal delivery of the first twin. We excluded higher twin order, monoamniotic pregnancies, cesarean delivery of the first twin and patients with missing data. Results: A number of 400 diamniotic twin pregnancies met the inclusion criteria and were divided, considering intertwin delivery interval into (1) ≤30 minutes (n = 365); and (2) >30 minutes (n = 35). Considering the two study groups, maternal and first twin characteristics and outcomes were similar. Second twin reported higher incidence of cesarean section and vacuum delivery, but similar incidence of neonatal adverse outcomes, in case of intertwin interval >30 minutes. At multivariate analysis, a difference between second and first twin weight ≥25% was correlated to neonatal adverse outcome, while we did not found this correlation with a cut-off of 30 minutes. Conclusions: In our study, growth discrepancy between twins was significantly correlated to adverse neonatal outcomes, while intertwin delivery time was not an influencing factor. So, in line with this result, in our clinical practice, we do not use a fixed time in which both twins should be delivered, neither in monochorionic nor in dichorionic pregnancies, when fetal wellbeing was demonstrated during labor

Although there is a growing body of literature reporting that pregnancies in women with polycystic ovary syndrome (PCOS) are associated with greater complications than those without PCOS, methodological differences across studies make these results difficult to consolidate. This narrative review outlines potential mechanisms involved in adverse pregnancy outcomes in PCOS and the nature of the complications. It covers limitations of current evidence and future research directions. Future research should include prospective studies with phenotypic stratification of PCOS and matching or consideration of specific PCOS manifestations and risk factors specific to each pregnancy complication. This review also emphasizes the importance of following a healthy lifestyle for women with PCOS and of individualized care according to overall risk factors for pregnancy complications.Copyright © 2018 John Wiley & Sons Ltd

Study question: Which is the most effective and safe intervention in couples with unexplained infertility, expectant management, ovarian stimulation (OS), intrauterine insemination (IUI), OS-IUI or IVF? Summary answer: IVF and OS-IUI were the most effective but least safe interventions, while expectant management and IUI were the least effective but safest interventions. What is known already: Existing systematic reviews have conducted head to head comparison of interventions using pairwise meta-analyses to evaluate the effectiveness of interventions in couples with unexplained infertility. As this approach only allows the comparison of two interventions at a time and is dependent on the availability of appropriate primary evaluative studies, it is difficult to identify the best intervention in terms of effectiveness and safety. Network meta-analysis compares multiple treatments in a single statistical model by using both direct and indirect evidence and provides a hierarchy of these treatments which can better inform clinical decision making. Study design, size, duration: We performed a systematic review and network meta-analysis of relevant randomised controlled trials (RCTs). We searched electronic databases including MEDLINE, Embase, PsycINFO, CINAHL, the Cochrane Gynaecology and Fertility Group specialised register of controlled trials, the Cochrane Central Register of Studies Online, as well as ref-erence lists to identify eligible studies. We also searched trial registers for ongoing trials. Participants/materials, setting, methods: We included RCTs comparing at least two of following interventions in couples with unexplained infertility: 1) expectant management (including timed intercourse); 2) ovarian stimulation using gonadotropins, aromatase inhibitors or anti-estrogens; 3) IUI alone; 4) OS-IUI; and 5) in vitro fertilisation (IVF) or combined with intracytoplasmic injection (ICSI). The primary effectiveness outcome is a composite of cumulative live birth

Objective: To study the effectiveness of different ovulation induction protocols in infertile women with polycystic ovary syndrome (PCOS) undergoing intrauterine insemination (IUI). Design(s): Retrospective cohort study. Patient(s): Infertile women with PCOS undergoing IUI had ovulation induced with clomiphene citrate (CC), letrozole, or gonadotropins. Main Outcome Measure(s): Live birth and multiple pregnancy rates. Result(s): We performed 1068 IUI cycles in 765 couples. Live birth rates were comparable in CC-stimulated cycles (13.9%), letrozole-stimulated cycles (13.5%, OR 0.96 [95% CI, 0.63, 1.47]), and gonadotropins-stimulated cycles (13.2%, OR 0.94[95% CI, 0.62, 1.43]). Multiple pregnancy rates were 8.3%, 4.1% (OR 0.47 [95% CI, 0.09, 2.42]), and 3.3% (OR 0.34 [95% CI, 0.07, 1.95]) in CC, letrozole and gonadotropins stimulated cycles, respectively. Compared to CC, letrozole generated more often mono-follicular growth (75.9% versus 67.0%; OR 1.55 [95% CI, 1.11, 2.15]) but not more often after gonadotropins (72.9%, OR 1.17 [95% CI, 0.82, 1.66]. Cycles with multi-follicular growth did not result in statistically higher live birth rates than cycles with mono-follicular growth (15.8% vs. 12.7%, OR 1.29 [95% CI 0.89, 1.89]), but more often in multiple pregnancies (15.5% versus 0.8%, OR 22.4 [95% CI, 2.8, 181.6]). Conclusion(s): In women with PCOS undergoing stimulated IUI, CC, letrozole and gonadotropins were equally effective and safe. Since multi-follicular growth increased the multiple pregnancy rates without increasing the overall live birth rate, ovulation induction would strictly aim for mono-follicular growth. Since letrozole had the highest mono-follicular growth rate, we recommend this drug as the treatment of first choice in infertile women undergoing ovulation induction and IUI.Copyright © 2018

STUDY QUESTION: Is FSH or clomiphene citrate (CC) the most effective stimulation regimen in terms of ongoing pregnancies in couples with unexplained subfertility undergoing IUI with adherence to strict cancellation criteria as a measure to reduce the number of multiple pregnancies? SUMMARY ANSWER: In IUI with adherence to strict cancellation criteria, ovarian stimulation with FSH is not superior to CC in terms of the cumulative ongoing pregnancy rate, and yields a similar, low multiple pregnancy rate. WHAT IS ALREADY KNOWN: FSH has been shown to result in higher pregnancy rates compared to CC, but at the cost of high multiple pregnancy rates. To reduce the risk of multiple pregnancy, new ovarian stimulation regimens have been suggested, these include strict cancellation criteria to limit the number of dominant follicles per cycle i.e. withholding insemination when more than three dominant follicles develop. With such a strategy, it is unclear whether the ovarian stimulation should be done with FSH or with CC. STUDY DESIGN, SIZE, DURATION: We performed an open-label multicenter randomized superiority controlled trial in the Netherlands (NTR 4057). PARTICIPANTS/MATERIALS, SETTING, METHODS: We randomized couples diagnosed with unexplained subfertility and scheduled for a maximum of four cycles of IUI with ovarian stimulation with 75 IU FSH or 100 mg CC. Cycles were cancelled when more then three dominant follicles developed. The primary outcome was cumulative ongoing pregnancy rate. Multiple pregnancy was a secondary outcome. We analysed the data on intention to treat basis. We calculated relative risks and absolute risk difference with 95% CI. MAIN RESULTS AND THE ROLE OF CHANCE: Between July 2013 and March 2016, we allocated 369 women to ovarian stimulation with FSH and 369 women to ovarian stimulation with CC. A total of 113 women (31%) had an ongoing pregnancy following ovarian stimulation with FSH and 97 women (26%) had an ongoing pregnancy following ovarian stimu

Резюме. Проведений ретельний аналіз перебігу пологів та перинатальних наслідків у вагітних двійнею. Доведено, що багатоплідна вагітність є чинником високого ризику перинатальних ускладнень. Вивчено особливості процесу неонатальної адаптації у близнюків залежно від тактики розродження. Мета дослідження – поліпшення перинатальних наслідків у жінок з багатоплідною вагітністю шляхом оптимізації тактики ведення вагітних.Матеріал і методи. Обстеженено 68 вагітних з двійнею після екстракорпорального запліднення (ЕКЗ), що склали І групу, 62 вагітних зі спонтанною двійнею – ІІ група, та 38 жінок з самостійною одноплідною вагітністю, котрі увійшли в контрольну групу. Вагітних І та ІІ груп залежно від призначеного лікування розділено на дві підгрупи: ІА (36 вагітних) та ІІА (32 вагітних) отримували стандартний обсяг лікувально-профілактичних заходів. Підгрупи ІВ (32 вагітних) та ІІВ (30 вагітних), крім стандартних лікувально-профілактичних заходів, отримували натуральний мікронізований прогестерон (200 мг 3 рази на добу). Усім вагітним проведено повне клініко-лабораторне обстеження з використанням ультразвукового дослідження (УЗД), доплерометрії, кардіо­токографії (КТГ), визначення біофізичного профілю плода. Проведений аналіз перебігу вагітності, пологів, післяпологового періоду та стан неонатальної адаптації в обстежуваних групах. У неонатальному періоді здійснювали нейросонографію, у частини новонароджених відслідковували психомоторний розвиток у перші шість місяців життя. Отримані результати статистично обробляли з використанням стандартних пакетів прикладного статистичного аналізу (Statistic 6.0 for Windows, Statgraphics v. 7.0). Результати. Результати аналізу перебігу вагітності у пацієнток з ЕКЗ виявили кількість серйозних ускладнень під час вагітності та пологів: загроза передчасних пологів (66,2 %), плацентарна дисфункція (48,5 %), залізодефіцитна анемія (51,5 %), прееклампсія (52,9 %), передчасний розрив плодових оболонок (17,6 %), слабкість пологової діяльності, Резюме. Проведен тщательный анализ течения родов и перинатальных исходов у беременных двойней. Доказано, что многоплодная беременность является фактором высокого риска перинатальных осложнений. Изучены особенности процесса неонатальной адаптации у близнецов в зависимости от тактики родоразрешения.Цель исследования – улучшение перинатальных исходов у женщин с многоплодной беременностью путем оптимизации тактики ведения беременных.Материал и методы. Обследовано 68 беременных с двойней после экстракорпорального оплодотворения (ЭКО), составивших І группу обследуемых, 62 беременных со спонтанной двойней - II группа, и 38 женщин с самостоятельной одноплодной беременностью, которые вошли в контрольную группу. Беременных I и II групп в зависимости от назначенного лечения были разделены на две подгруппы: IА (36 беременных) и IIА (32 беременных) получали стандартный объем лечебно-профилактических мероприятий. Подгруппы IB (32 беременные) и IIB (30 беременных) помимо стандартных лечебно-профилактических мероприятий получали натуральный микронизированный прогестерон (200 мг 3 раза в сутки). Всем беременным было проведено полное клинико-лабораторное обследование с использованием ультразвукового исследования (УЗИ), допплерометрии, кардиотокографии (КТГ), определение биофизического профиля плода. Проведен анализ течения беременности, родов, послеродового периода и состояние неонатальной адаптации у обследуемых группах. В неонатальном периоде осуществлялась нейросонография, у части новорожденных отслеживалось психомоторное развитие в первые шесть месяцев жизни. Полученные результаты статистически обрабатывали с использованием стандартных пакетов прикладного статистического анализа (Statistic 6.0 for Windows, Statgraphics v. 7.0). Результаты. Результаты анализа течения беременности у пациенток с ЭКО обнаружили количество серьезных осложнений во время беременности и родов: угроза преждевременных родов (66,2%), плацентарная дисфункция (48,5%), железодефицитная анемия (51,5%), преэклам, A thorough analysis of the course of labor and perinatal outcomes was conducted in pregnant twins. It is proved that multiple pregnancy is a factor of high risk of perinatal complications. The features of the process of neonatal adaptation in twins are studied depending on the tactics of delivery. Goal: to improve perinatal outcomes in women with multiple pregnancies by optimizing the management of pregnancy.Material and methods. Examined 68 pregnant women with twins after IVF, who made up the I group of subjects, 62 pregnant women with spontaneous twins - group II, and 38 women with self-singleton pregnancy who entered the control group. Pregnant Groups I and II, depending on the treatment prescribed, were divided into two subgroups: IА (36 pregnant women) and IIA (32 pregnant women) received a standard amount of treatment and prophylactic measures. Subgroups IB (32 pregnant women) and IIB (30 pregnant women) received natural micronized progesterone (200 mg 3 times a day) in addition to standard treatment and prophylactic measures. All pregnant women underwent a complete clinical and laboratory examination using ultrasound, Doppler, and cardiotocography (CTG), and a biophysical profile of the fetus. The analysis of the course of pregnancy, childbirth, the postpartum period and the state of neonatal adaptation in the surveyed groups were carried out. In the neonatal period, neurosonography was performed, a part of the newborns were followed by psychomotor development in the first six months of life. The obtained results were statistically processed using standard packages of applied statistical analysis (Statistic 6.0 for Windows, Statgraphics v. 7.0).Results. The results of pregnancy analysis in patients with IVF revealed a number of serious complications during pregnancy and childbirth: the threat of premature birth (66.2%), placental dysfunction (48.5%), iron deficiency anemia (51.5%), preeclampsia (52, 9%), premature rupture of amniotic membranes (17.

Multiple pregnancies are classified as high risk because of the complications that can affect the mother and fetuses. Multiple pregnancies are associated with hypertensive disorders, gestational diabetes mellitus, anemia, premature birth, prepartum and postpartum hemorrhages and maternal death. It is important to establish the diagnosis in the first trimester, ultrasound allows to diagnose the number of multiples, chorionicity and amnionicity, The most common complication of multiple pregnancy is preterm birth., Los embarazos múltiples se clasifican como de alto riesgo debido a las complicaciones que pueden afectar a la madre y los fetos. Los embarazos múltiples se asocian con trastornos hipertensivos, diabetes mellitus gestacional, anemia, nacimiento prematuro, hemorragias preparto y posparto y muerte materna. Es importante establecer el diagnóstico en el primer trimestre,el ultrasonido permite diagnosticar el número de múltiplos, corionicidad y amniosicidad. La complicación más común del embarazo múltiple es el nacimiento prematuro.

We represent the results of the combined method of treatment and prevention of miscarriage in women with a multiple pregnancy and a high risk of the threat of termination the pregnancy because of using the obstetric unloading pessaries, combined with micronized progesterone. The efficiency of this method of treatment is evidenced by the rapid elimination of clinical symptoms of threatened abortion, accelerating the regression of ultrasound markers, reducing the number of complications in of pregnant women and reducing the time of their stay in hospital.Goal: To evaluate the effectiveness of the handling the obstetric pessary in combination with micronized progesterone at women with multifetal pregnancy and a high risk of miscarriage.Materials and methods. We analyzed 120 cases of multifetal pregnancies with signs of miscarriage within the terms from 16 to 28 weeks. The first group of the examined women was: 40 pregnant women with twins and signs of miscarriage, who in the scheme of treatment and prophylactic measures were offered to use the unloading obstetric pessaries in combination with continuous therapy by natural micronized progesterone until 36 weeks of pregnancy. The second group included 40 pregnant women with twins, who were laid seam on the cervix because of istmicocervical insufficiency and were applied short-term courses of therapy by gestagens. The control group comprised 40 pregnant women with twins at the age of 16-28 weeks of pregnancy who were conducted the therapy about the threat of miscarriage according to the current clinical protocols (Order of the Ministry of Health of Ukraine No. 624). It was carried out the analysis of the course of pregnancy, childbirth, the postpartum period and the state of neonatal adaptation in the surveyed groups.Results of the research and their discussion. In the first group, urgent childbirth occurred in 34 (85%) cases, in group II in 29 (72.5%) cases, in control group – in 25 (62.5%) cases. Cesarean delivery was p

Objective: To construct a prediction model for live birth after in vitro fertilization/intracytoplasmic sperm injection (IVF/ICSI) treatment and single-embryo transfer (SET) after 2 days of embryo culture. Design: Prospective observational cohort study. Setting: University-affiliated private infertility center. Patient(s): SET in 8,451 IVF/ICSI treatments in 5,699 unselected consecutive couples during 1999-2014. Intervention(s): A total of 100 basal patient characteristics and treatment data were analyzed for associations with live birth after IVF/ICSI (adjusted for repeated treatments) and subsequently combined for prediction model construction. Main Outcome Measure(s): Live birth rate (LBR) and performance of live birth prediction model. Result(s): Embryo score, treatment history, ovarian sensitivity index (OSI; number of oocytes/total dose of FSH administered), female age, infertility cause, endometrial thickness, and female height were all independent predictors of live birth. A prediction model (training data set; n = 5,722) based on these variables showed moderate discrimination, but predicted LBR with high accuracy in subgroups of patients, with LBR estimates ranging from <10% to >40%. Outcomes were similar in an internal validation data set (n = 2,460). Conclusion(s): Based on 100 variables prospectively recorded during a 15-year period, a model for live birth prediction after strict SET was constructed and showed excellent calibration in internal validation. For the first time, female height qualified as a predictor of live birth after IVF/ICSI.

Background: Severe fetal growth restriction (FGR) (< third centile) in a singleton pregnancy undelivered by 40 weeks is one of a number of Victorian Perinatal Services Performance Indicators, which aim to provide a measure of the quality and safety of maternity care. Women of refugee background have been found to have poorer perinatal outcomes compared to others and these outcomes can in part be explained by previous history. However, less access to and engagement with pregnancy care may also be contributing factors. This study examined the impact of likely refugee background on severe FGR in a singleton pregnancy undelivered by 40 weeks. Method(s): A retrospective study was undertaken utilising data on women who gave birth to a severely growth-restricted infant at Monash Health during January 2013-July 2015. Unadjusted and adjusted analyses were undertaken to examine the association between the mother being of likely refugee background and severe FGR in singletons delivered after 40 weeks. Result(s): There was an association between the mother being of likely refugee background and giving birth to a severely growth-restricted baby after 40 weeks with these mothers at two and half times the odds compared to mothers of non-refugee background (adjusted odds ratio 2.52; 95% confidence interval: 1.44-4.42). Conclusion(s): While detecting FGR is clinically challenging, our findings suggest that maternity services need to be supported to offer care tailored to the specific needs of vulnerable and disadvantaged populations. Providing quality, culturally responsive and accessible care is fundamental to addressing refugee maternal and perinatal health inequalities.Copyright © 2017 The Royal Australian and New Zealand College of Obstetricians and Gynaecologists

Study question: How do pregnancy and birth outcomes differ between single (SET)- and double-embryo transfers (DET) when considering blastocyst quality? Summary answer: A high-quality embryo in a single transfer has better outcomes than in a double-embryo transfer with another embryo of any quality. What is known already: The transfer of multiple embryos in in-vitro fertilisation (IVF) was originally utilized to maximise rates of implantation and pregnancy; however, its use has subsequently led to a high risk of multiple pregnancy and its associated complications. It is also accepted that SET results in healthier babies. Although SET is typically preferred, a variety of factors may influence the decision to concurrently transfer a second embryo. The quality of embryos is one such factor, and it remains unclear how this may affect pregnancy outcomes. Study design, size, duration: This was a retrospective cohort study of 4275 single-embryo transfers and 881 double-embryo transfers in the blastocyst stage that occurred between 2005 and 2015. All SETs and DETs during this period were eligible for inclusion in the study (n = 72,867). Exclusion criteria included cases with missing data points (n = 10,564), duplicate transfers (n = 41,721), and transfers not utilising day-5 embryos (n = 8,715). Cases were also excluded where the quality of embryos was not adequate for our analysis (n = 6711) Participants/materials, setting, methods: Data was extracted from private IVF clinic database. To keep data independent, embryo transfers included in the study were limited to one per woman. An internal embryo quality grading system was used - Grade A (very good) to D (poor). Grade A SETs were compared with DETs with at least one Grade A embryo. Chi-square test used and crude odds ratios quoted. Logistic regression was performed with adjusted odds ratios, controlling for number of factors. Main results and the role of chance: We found that implantation, clinical pregnancy and live birth

Проведений ретельний аналіз перебігу пологів та перинатальних наслідків у 92 вагітних із двійнею та 40 жінок з одноплідною вагітністю. Доведено, що багатоплідна вагітність є чинником високого ризику перинатальних ускладнень. Вивчено особливості процесу неонатальної адаптації у близнюків залежно від тактики при розродженні. Деференційований підхід до підготовки та ведення пологів, ретельне спостереження за пацієнтками та динамічний моніторинг стану плодів дозволяють знизити частоту постнатальних ускладнень, сприяючи зниженню перинатальної захворюваності і смертності., Проведен тщательный анализ течения родов и перинатальных исходов у 92 беременных с двойней и 40 женщин с одноплодной беременностью. Доказано, что многоплодная беременность является фактором высокого риска перинатальных осложнений. Изучены особенности процесса неонатальной адаптации у близнецов в зависимости от тактики при родоразрешении. Дифференцированый подход к подготовке и ведению родов, тщательное наблюдение за пациентками и динамический мониторинг состояния плодов позволяют снизить частоту постнатальных осложнений, способствуя снижению перинатальной заболеваемости и смертности., We have carried out a thorough analysis of the delivery and perinatal outcomes in 92 pregnant women with twins and 40 women with singleton pregnancy. It is proved that multiple pregnancy is a high risk factor of perinatal complications. We studied some peculiarities of the process of neonatal adaptation in twins depending on tactics during delivery. Differentiated approach to the preparation and management of labour, careful monitoring of patients and dynamic monitoring of the condition of the fetus reduce the incidence of postnatal complications, contributing to reducing perinatal morbidity and mortality.

Цель исследования — изучение дифференциальных особенностей эхографических мониторингов и перинатальных результатов при различных специфических осложнениях монохориального (МХ) многоплодия.Дизайн — проспективное когортное обсервационное одноцентровое исследование.Пациенты и методы. Эхографически были обследованы 246 женщин с многоплодной беременностью, из них 134 — с мультихориальным и 112 — с МХ типом многоплодия. Из 112 МХ беременностей встречались следующие варианты: 101 беременность — МХ двойни; 10 троен с монохориальностью; 1 трихориальная четверня. Изученные постнатальные результаты классифицировались следующим образом: неблагоприятный общий постнатальный результат (ОПР) — перинатальная или младенческая смерть; неблагоприятный клинический постнатальный результат (КПР) — тяжелая либо персистирующая постнатальная заболеваемость.Результаты. У 73/112 пациенток (65%) с МХ многоплодием имелись эхографические особенности и последовательности эхографических изменений: фето-фетальный трансфузионный синдром (ФФТС) имели 15 женщин, из них у 9 наблюдался хронический некорригированный ФФТС, 6 находились под наблюдением до и после фетоскопической коррекции; острая межблизнецовая трансфузия (ОМТ) — 3 случая; последовательность анемии-полицитемии близнецов (TAPS) — 1 случай; селективная задержка роста (сЗРП) одного их МХ плодов — 28 случаев; после гибели одного из МХ близнецов мониторировано 7 беременностей, после гибели одного из дихориальных близнецов — 8 беременностей. Наиболее неблагоприятными ОПР сопровождался некорригированный ФФТС, наиболее неблагоприятные КПР имели МХ плоды при сЗРП. ОМТ не имела каких-либо специфических антенатальных предикторов. Допплеровские изменения по типу интермиттирующего нулевого кровотока артерии пуповины при МХ многоплодии являлись трудно интерпретируемыми и сопровождались умеренно повышенным риском неблагоприятных ОПР и КПР (OR 1,88; 1,64–2,09 при СI 95%), в связи с чем оценивать степень перинатального риска при подобном эхографическом вари, Мета дослідження — вивчення диференціальних особливостей ехографічних моніторингів та перинатальних результатів при різних специфічних ускладненнях монохоріальної (МХ) багатоплідної вагітності. Дизайн - проспективне когортне обсерваційне одноцентрове дослідження. Пацієнти і методи. Ехографічно були обстежені 246 жінок із багатоплідною вагітністю, з них 134 з мультихоріальним і 112 з МХ типом багатоплідної вагітності. З 112 МХ вагітностей зустрічалися наступні варіанти: 101 вагітність — МХ двійні; 10 трійнят з монохоріальністю; 1 трихоріальна чотирьохплідна вагітність. Вивчені постнатальні результати були класифіковані наступним чином: несприятливий загальний постнатальний результат (ЗПР) — перинатальна або малюкова смерть; несприятливий клінічний постнатальний результат (КПР) — важка або персистуюча постнатальная захворюваність. Результати. У 73/112 пацієнток (65%) з МХ вагітністю спостерігалися ехографічні особливості та послідовності ехографічних змін: фето-фетальний трансфузійний синдром (ФФТС) мали 15 жінок, з них у 9 спостерігався хронічний некоригований ФФТС, 6 перебували під наглядом до та після фетоскопічної корекції; 3 випадки гострої міжблизнюкової трансфузії (ГМТ); 1 випадок послідовності анемії-поліцитемії близнюків (TAPS); 28 випадків селективної затримки росту (сЗРП) одного з МХ плодів; після загибелі одного з МХ близнюків моніторували 7 вагітностей, після загибелі одного з дихоріальних близнюків — 8 вагітностей. Найбільш несприятливими ЗПР супроводжувався некорегований ФФТС, найбільш несприятливі КПР мали МХ плоди при сЗРП. ГМТ не мала специфічних антенатальних предикторів. Допплерівські зміни за типом інтермітуючого нульового кровотоку артерії пуповини при МХ вагітності було важко інтерпретувати, оскільки вони супроводжувалися помірно підвищеним ризиком несприятливих ЗПР та КПР (OR 1,88; 1,64–2,09 при СI 95%), тобто оцінювати ступінь перинатального ризику при подібному ехографічному варіанті моніторингу МХ вагітності вкрай складно. Висновки. Такі спе, The purpose was to study the differential features of ultrasonographic (US) monitoring and perinatal results with various specific complications of monochorionic (MC) multiple pregnancy. Design — single-center prospective cohort observational study. Material and methods. US studies were conducted in 246 women with multiple pregnancies, including 134 with multichorionic type and 112 with MC type of multiple pregnancy. MC pregnancies had the following options: 101 MC twins; 10 MC triplets; 1 MC quadruplets. Postnatal results were classified as follows: adverse general postnatal outcome (GPO) meant perinatal or infant death; adverse clinical postnatal outcome (CPO) meant severe neonatal morbidity. Results. In 73/112 patients (65%) with MC multiple pregnancy some US features and sequences of changes were observed. 15 women had twin-to-twin transfusion syndrome (TTTS), 9 of them had the chronic uncorrected TTTS and 6 were under observation before and after in8utero treatment; 3 women had acute inter-twin transfusion (AITT); in 1 case there was anemia-polycythemia sequence (TAPS); selective fetal growth retardation (sFGR) was detected in 28 cases and after single intrauterine death 7 MC and 8 multichorionic pregnancies were monitored. The most unfavorable GPO were in unimproved TTTS, and the most unfavorable CPO were in sFGR. AITT did not have any specific antenatal predictors. Abnormal Doppler by type of intermittent absent umbilical artery flow in MC pregnancy were difficult to interpret and were accompanied by a moderately increased risk of adverse GPO and CPO (OR 1.88; 1.64–2.09 while 95% CI). So it is extremely difficult to evaluate the degree of perinatal risk in such a form of US monitoring of МС multiple pregnancy. Conclusions. Such specific anomalies of MC multiple pregnancy as TTTS, TAPS and sFGR have some similar US manifestations but different perinatal prognosis and require different tactics. Antenatal monitoring, including fetometry, amniometry and Doppler a

Tato bakalářská práce se zabývá vlivem věku rodičky na průběh celého těhotenství a porodu. Práce je členěna na část teoretickou a část výzkumnou. Teoretická část se zaměřuje na rizikový faktor věku a jeho význam v otázce plodnosti, a na stanovení dalších rizikových faktorů souvisejících s věkem rodičky. Dále se teoretická část věnuje možným dopadům nízkého či vyššího věku těhotných žen na další vývoj gravidity a na proces porodu. Ve výzkumné části prezentujeme data získaná retrospektivní studií z ošetřovatelské dokumentace. Cílem tohoto šetření bylo zjistit rozdíly v prožívání a průběhu gravidity a porodu žen do 20 let a žen starších 35 let., This Bachelor's thesis examines the influence of age of a woman in childbed on pregnancy and parturition. The thesis consists of a theoretical part and a research part. The theoretical part focuses on the risk factor of age and its influence on fertility. It also investigates other risk factors connected to the age of a woman in childbed, as well as the impacts young age or advanced age of a pregnant woman may have on gravidity and parturition. The research part presents data obtained by a retrospective study of nursing documentation. The aim of this study was to determine the differences in the experience women under 20 years and over 35 years of age have with their gravidity and parturition., Katedra porodní asistence a zdravotně sociální práce, Hodnocení vedoucího: dobře Hodnocení oponenta: dobře Doplňující otázky k obhajobě: 1. Ve své praxi jste se setkala s tím, zda věk ženy ovlivňuje průběh porodu? A jak? Obhajoba bakalářské práce s prezentací dobrá., Dokončená práce s úspěšnou obhajobou

Background: Improvements in vitrification now make frozen embryo transfers (FETs) a viable alternative to fresh embryo transfer, with reports fromobservational studies and randomized controlled trials suggesting that: (i) the endometrium in stimulated cycles is not optimally prepared for implantation; (ii) pregnancy rates are increased following FET and (iii) perinatal outcomes are less affected after FET. methods: This review integrates and discusses the available clinical and scientific evidence supporting embryo transfer in a natural cycle. Result(s): Laboratory-based studies demonstrate morphological and molecular changes to the endometrium and reduced responsiveness of the endometriumtohCG, resulting fromcontrolledovarian stimulation.Theliteraturedemonstrates reducedendometrial receptivity incontrolledovarian stimulation cycles and supports the clinical observations that FET reduces the risk of ovarian hyperstimulation syndrome and improves outcomes for both the mother and baby. Conclusion(s): This review provides the basis for an evidence-based approach towards changes in routine IVF, which may ultimately result in higher delivery rates of healthier term babies.Copyright © The Author 2014. Published by Oxford University Press on behalf of the European Society of Human Reproduction and Embryology. All rights reserved.

Aim: The aim of this study was to describe the distribution of magnetic resonance imaging (MRI) patterns in a large population sample of children with cerebral palsy (CP) and to examine associations between MRI patterns, and antenatal and perinatal variables. Method(s): Data were retrieved from the Victorian CP Register for 884 children (527 males, 357 females) born between 1999 and 2006. Postneonatal MRI was classified for 594 children. For 563 children (329 males, 234 females) for whom classification was to a single MRI pattern, the frequency of each variable was compared between patterns and with the population frequency. Result(s): White matter injury was the most common MRI pattern (45%), followed by grey matter injury (14%), normal imaging (13%), malformations (10%), focal vascular insults (9%), and miscellaneous patterns (7%). Parity, birth gestation, level of neonatal care, Apgar score, and time to established respiration varied between MRI patterns (p<0.01). Nulliparity was most strongly associated with focal vascular insults, whereas multiparity was associated only with malformations. Grey matter injury was not associated with birth in a tertiary unit, but was strongly associated with severe perinatal compromise. The frequency of neonatal seizures and of nursery admissions was lowest among children with malformations. Interpretation(s): As known risk factors for CP are differentially associated with specific MRI patterns, future exploration of causal pathways might be facilitated when performed in pathogenically defined groups. © 2013 Mac Keith Press.

Background: Higher order multiple pregnancies present significant challenges to the health services providing care. Here we describe care processes for and outcomes of a spontaneous quintuplet pregnancy in a 47 year old woman with 12 existing children. We highlight the counselling, resource, and planning challenges and describe how a multidisciplinary approach ensured woman centered care and optimal outcomes. Method(s): From referral at 12 weeks of pregnancy, care was provided through a maternal-fetal medicine service by a consultant obstetrician and a lead senior midwife. From the 20th week of the pregnancy regular multidisciplinary meetings involving Maternal Fetal Medicine medical and midwifery staff, neonatologists, neonatal nurses, anaesthetists, theatre nurses and social workers were held to plan for an elective caesarean section at around 32 weeks gestation and to ensure that the needs of both mother and babies were met. Result(s): Serial fetal surveillance identified severe growth restriction in one fetus at 26 weeks gestation. With the outcomes of the other four fetuses in mind, the mother chose to continue the pregnancy in the knowledge of the likely loss of the growth restricted fetus. The mother was admitted to hospital from 24 weeks due to an inability to function at home. At 30 weeks gestation the demise of the growth restricted fetus was confirmed. At 31 weeks and 2 days a team of 32 health professionals were involved in an elective lower segment caesarean section delivering 4 live infants in good condition and one stillborn baby. The mother and surviving infants made uncomplicated recoveries. Conclusion(s): While very resource intensive, a multidisciplinary approach to care of women with higher order multiple pregnancy can achieve excellent outcomes.

Aims To evaluate the performance of a collaborative fetal therapy service for treatment for twin-twin transfusion syndrome (TTTS). Methods The Victorian Fetal Therapy Service (VFTS) was developed in 2006. It is a state-based three-centre collaborative service comprising a surgical team and clinical leadership group, designed to optimise access to, and performance of, fetoscopic procedures in Victoria. This is a prospective cohort study of VFTS patients referred for fetoscopic laser photocoagulation (FLP) for TTTS since 2006. Results Forty-nine consecutive women with advanced (stage 2-4) TTTS between 2006 and 2011 were included in this study. Overall survival was 67 of 98 (68%), and survival of >=1 twin was seen in 42 of 49 pregnancies (86%). There was no difference in survival by disease stage at diagnosis (>=1 survivor: 66% (stage 2 or 3 TTTS) vs 77% (stage 4 TTTS), P = 0.44), nor by surgical era (>=1 survivor: 60% (2006-2008) vs 74% of cases (2009-2011), P = 0.21). The median gestation gained post-FLP was 10.5 weeks. Conclusion These results are consistent with published series and confirm the success of a novel service delivery model for fetal therapy in Victoria. We suggest that collaborative models such as ours should be considered for fetal conditions where treatment is complex and the total number of cases is small to ensure a consistent approach to assessment, management and follow-up of patients and to optimise training and research opportunities. © 2013 The Authors ANZJOG © 2013 The Royal Australian and New Zealand College of Obstetricians and Gynaecologists.

Background: Higher order deliveries present organizational and clinical challenges to a nursery. Quintuplets were delivered at Monash Medical Centre in 2012. Method(s): In preparation for the delivery, additional medical and nursery staff were rostered on call, from 25 weeks gestation. The newborn transport service was alerted in case all five babies could not be accommodated in a single nursery. An increased number of resuscitaires were also provided to the hospital. To minimize the risk of errors, colour-coded hats and linen were prepared for each infant, with matching labels for staff involved in the delivery. Elective caesarean section was performed at 34 weeks gestation following demise of one fetus. Prior to attending the birth, staff teams were allocated to individual babies. Cot allocations, in theatre and the nursery, were pre-allocated. The surviving four babies were admitted in pairs to separate rooms in the NICU to manage staff workloads on admission, and limit identification errors. Result(s): Co-ordination from delivery to admission was a smooth process. Staff reported a high level of satisfaction with this outcome. All babies had an uneventful clinical course and were discharged home before the expected date of confinement. Conclusion(s): Extensive planning can facilitate efficiency and safety during the delivery and admission of higher order multiples.

Background: To provide current data on maternal and neonatal outcomes in triplet pregnancies in an Australian population. Method(s): Retrospective case note review of all triplet pregnancies managed within a single Australian tertiary centre. Result(s): Fifty-four sets of triplets were managed from January 1996 to October 2002. A total of 59% resulted from the use of assisted reproductive technologies. The median gestation at delivery was 32.5 weeks (range: 21-36 weeks); 14% delivered prior to 28 weeks and 43% delivered before 32 weeks. Preterm labour and preterm rupture of membranes were the most common antenatal complications occurring in 57 and 22% of pregnancies, respectively. A total of 93% of pregnancies were delivered by Caesarean section and 37% of mothers experienced at least one post-partum complication. A total of 96% of neonates were liveborn, with a median birthweight of 1644 g (range: 165-2888 g). The two most common neonatal complications were jaundice and hypoglycaemia in 52 and 43% of liveborn neonates, respectively. A total of 28% of neonates were below the 10th centile for gestational age and sex. A total of 8% of neonates demonstrated congenital anomalies. The perinatal mortality at a gestational age of 20-24 weeks was 100%, 22% at 25-28 weeks and zero for those babies born at 29 weeks or beyond. Conclusion(s): Assisted reproductive technologies contribute significantly to the incidence of triplet pregnancies. Gestational age at delivery and perinatal mortality is comparable to published international data. Triplets born in a tertiary centre beyond 28 weeks gestation have a very favourable prognosis in the newborn period.

Objective. To determine the growth and physical outcome at 2 years of age for children born after assisted reproductive techniques in the state of Victoria. Design. Using a case-matched control study between January 1991 and July 1993, 314 children (196 singletons, 47 sets of twins, 8 sets of triplets) conceived after in vitro fertilization (IVF) and related techniques at the Monash IVF and Royal Women's Hospital Reproductive Biology Unit and 150 control children (113 singletons, 17 sets of twins, 1 set of triplets) randomly selected from the general population using the Victorian Perinatal Data Collection Unit records were enrolled to be examined for minor dysmorphic and major organ abnormalities. Singleton and twin cases were matched for plurality and gestation and date of birth. Triplets were not matched. Results. IVF status was not a significant independent factor for physical outcomes, including malformation rates, nor for days of hospitalization postdischarge and operations. There was no significant interaction between IVF status and mean percentiles for weight and head circumference. The IVF group had a greater mean length percentile. Twins in both groups had significantly poorer physical outcomes than singletons on some measures. Conclusion. This study did not demonstrate an independent IVF effect on the growth and physical outcome of children at 2 years of age when matched for plurality and gestation. The poor outcomes where noted were related to the effects of multiple births. These findings must be viewed in context of the response rates and therefore representativeness of the data. The need for longitudinal studies is demonstrated.

Background: Recent studies suggest that metformin may be more effective in women with polycystic ovary syndrome (PCOS) who are non-obese. The objective here is to determine and compare the effectiveness of metformin and clomiphene citrate for improving fertility outcomes in women with PCOS and a BMI < 32 kg/m 2 (BMI 32 kg/m 2 was used to allow for international differences in BMI values which determine access to infertility therapy through the public health system). Method(s): Databases were searched for English language articles until July 2011. Inclusion criteria: women of any age, ethnicity and weight with PCOS diagnosed by all current criteria, who are infertile; at least 1000 mg of any type of metformin at any frequency, including slow release and standard release, compared with any type, dose and frequency of clomiphene citrate. Outcome(s): rates of ovulation, live birth, pregnancy, multiple pregnancies, miscarriage, adverse events, quality of life and cost effectiveness. Data were extracted and risk of bias assessed. A random effects model was used for meta-analyses of data, using risk ratios (relative risk). Result(s): The search returned 4981 articles, 580 articles addressed metformin or clomiphene citrate and four randomized controlled trials (RCTs) comparing metformin with clomiphene citrate were included. Upon meta-analysis of the four RCTs, we were unable to detect a statistically significant difference between the two interventions for any outcome in women with PCOS and a BMI < 32 kg/m. 2, owing to significant heterogeneity across the RCTs. Conclusion(s): Owing to conflicting findings and heterogeneity across the included RCTs, there is insufficient evidence to establish a difference between metformin and clomiphene citrate in terms of ovulation, pregnancy, live birth, miscarriage and multiple pregnancy rates in women with PCOS and a BMI < 32 kg/m. 2. However, a lack of superiority of one treatment is not evidence for equivalence, and further methodolo

Objectives: It has been previously shown that glucocorticoids alter umbilical artery flow velocity waveforms in singleton pregnancies complicated by umbilical artery absent end diastolic flow. Whether similar effects are evident in multiple pregnancies where one fetus has umbilical artery absent end diastolic flow is not known. Method(s): Women with a twin or triplet pregnancy complicated by umbilical artery absent end diastolic flow in one fetus were admitted to hospital for intensive fetal surveillance including daily umbilical artery flow velocity waveform studies, as per hospital protocol. All women received prophylactic betamethasone (11.4 mg x 2, 24 h apart in anticipation of preterm delivery. Result(s): Between October 1996 and February 2002, 24 women with a multiple pregnancy complicated by umbilical artery absent end diastolic flow were cared for. Of these, six had a pregnancy with feto-fetal transfusion and excluded from further analysis. Of the remaining 18 women, eight had monochorionic diamniotic twins, eight had dichorionic twins, and two had trichorionic, triamniotic triplets. The median (range) gestation at diagnosis of umbilical artery absent end diastolic flow was 210.5 days (173-241). In nine (50%) of the 18 pregnancies the administration of betamethasone was associated with return of umbilical artery end diastolic flow for a median of 5 days. There was no association between this effect and chorionicity. The median (range) interval from diagnosis of umbilical artery absent end diastolic flow to delivery was 11 days (1-46). Conclusion(s): As previously reported in singleton pregnancies, the maternal administration of betamethasone in multiple pregnancies with umbilical artery absent end diastolic flow is associated with a transient return of end diastolic flow.

OBJECTIVE: To determine the effectiveness of human menopausal gonadotropin (hMG) with intrauterine insemination (IUI) for the treatment of various causes of infertility and to identify prognostic factors for the success of this treatment. STUDY DESIGN: Retrospective chart analysis. RESULT(S): Of the 271 cycles initiated, 247 were completed in 104 couples, and analysis of these cycles showed that the overall cycle fecundity rate was 10% and the pregnancy rate 22%. The miscarriage rate was 8% and tire ectopic pregnancy rate 4%. The multiple pregnancy rate was 29%. For the various causes of in fertility, we found that the cycle fecundity rate was 7% for male factor, 11% for oligoovulation, 8% for tubal/pelvic factor, 13% for minimal endometriosis, 18% for mild endometriosis, 17% for moderate endometriosis, 3% for women aged <=40 years, 75% for myoma, and 7% for idiopathic infertility. We also found that one IUI timed at 36-48 hours was as effective as two IUIs timed at 18-24 and 36-48 hours after human chorionic gonadotropin (hCG) administration. Poor prognostic factors that were elicited from this study were: (1) failure of pregnancy in three cycles of treatment, (2) female age <=40 years, (3) requirement of >300 IU of hMG daily, and (4) presence of more than eight mature follicles at the time of hCG administration. CONCLUSION(S): HMC and IUI are effective treatment of some causes of infertility.

In early pregnancy, serum levels of the luteal-derived hormone pro-alphaC inhibin peak by the second week after conception. Whether this early rise is biologically important and a consistent feature of only successful pregnancy is unknown. We undertook a prospective cross-sectional study to determine whether serum pro-alphaC inhibin levels at d 15-17 are predictive of a successful clinical in vitro fertilization pregnancy and compared levels between fresh embryo transfer (ET) and frozen-thawed ET. Median (95% confidence interval) pro-alphaC inhibin levels were 68 (57-76) pg/ml in 204 women who did not become clinically pregnant after ET, significantly lower than in either 90 women who became clinically pregnant after fresh ET and who had 3139 (1684-4220) pg/ml or in 39 women with a successful frozen ET who had 877 (678-1111) pg/ml. Pro-alphaC was highly sensitive and specific in predicting clinical pregnancy success but did not improve on the performance of human chorionic gonadotropin. Pro-alphaC inhibin levels were not correlated with progesterone or human chorionic gonadotropin. Levels were no higher in singleton compared with multiple pregnancies and did not increase across gestation, suggestive of a luteal source. The increase in circulating pro-alphaC inhibin in very early pregnancy is highly specific to clinical pregnancy, suggesting a possible biological role in early gestation.

The increased incidence of multiple deliveries in Spain, in addition to changes in age at maternity and parity, is attributed to assisted reproductive treatments, but the relative contribution of the latter to this rise remains uncertain, due to the scarce information provided by clinics practicing those treatments. Population based data (1984-2004), including information on mother's age, nationality, marital status, date of delivery, and the characteristics of each (parity, single or multiple), and sex of newborns were provided by the Spanish Institute of Statistics. Twinning and triplet deliveries relate to maternal age, parity, and nationality. For younger ages (≤ 19, 20-24, 25-29) rates remained constant over time, but for older women (30-34, 35-39, ≥ 40) rates increased after 1994. From 1984 to 2004 the percentage of twins of opposite sex increased from 24.31 to 36.58 per cent. Since 1997, Spanish and non-Spanish mothers differentiate with respect to multiple maternity at ages over 30. In addition to unmarried Spanish women, immigrants constitute a reliable reference group that determines the convenience of segregating information on multiple deliveries respecting origin. The proportion of twins and triplets of opposite sex, maternal age, and parity patterns observed are concordant with a differential access to reproductive treatments depending on the woman's age. The present norm regulating the maximum number of fertilizations per cycle and the demand for these treatments explain the high incidence of multiple deliveries in Spain. A modified logistic curve predicts a stabilization of multiple deliveries, which will probably continue to be high in Spain., Depto. de Biodiversidad, Ecología y Evolución, Depto. de Estadística e Investigación Operativa, Fac. de Ciencias Biológicas, Fac. de Ciencias Matemáticas, TRUE, pub