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Objective: To evaluate the role of the placenta accreta index (PAI) score in predicting placenta accreta spectrum (PAS).Methods: In this prospective study, the PAI was applied to 100 third-trimester pregnant women with at least one previous cesarean delivery (CS) and anterior low-lying placenta or placenta previa. PAI score was calculated based on placental location, number of CS, abnormal placental lacunae, sagittal smallest myometrial thickness (SSMT), and bridging vessels. Histopathologic confirmation was obtained if hysterectomy was performed. Outcome measures were area under the receiver-operating characteristics curve (AUC-ROC) and the best cut-off point of PAI. Regression analysis of the PAI parameters was performed.Results: The PAI had an AUC of 0.84 (95% confidence interval [CI] 0.75-0.91). The best cut-off point of PAI was 5.37, with a sensitivity of 83.9%, a specificity of 76.3%, a positive predictive value of 85.2%, a negative predictive value of 74.3%, and an accuracy of 81%. PAI parameters showed a significant association with histopathologically proven PAS (n = 23). The highest odds ratio (OR) was achieved with lacunae grades 2 and 3 (OR 9.22, 95% CI 2.02-42) and the lowest OR with SSMT <1.5 mm (OR 3.78, 95% CI 1.3-10.6).Conclusion: The PAI appears to be a promising predictor of PAS in high-risk women who required hysterectomy. [ABSTRACT FROM AUTHOR]

Aim: To compare the efficacy of minimal stimulation and clomiphene citrate (CC) as a first-line treatment for anovulatory infertility associated with polycystic ovary syndrome (PCOS). Methods: One hundred and thirteen women with PCOS were selected in this randomized controlled trial. Patients received minimal stimulation protocol consisted of 5 days CC (100 mg/day) then 150 IU of highly purified uFSH on cycle day 9 ( n = 58, 159 cycles) or CC only ( n = 55, 153 cycles) for up to three cycles. Outcome measures were: clinical pregnancy rate per cycle, number of growing and mature follicles, serum E2, endometrial thickness at the hCG day, serum P, ovulation and miscarriage rates. Results: There were no differences between both groups regarding the clinical pregnancy rate per cycle and per woman (8.8% vs. 7.8 % and 24.1% vs. 21.8%; p = 0.23, p = 0.36, respectively). One twin pregnancy occurred in each group. Miscarriage rate was comparable (14.3% vs. 16.7%; p = 0.38). No differences were found regarding the number of follicles, serum P, ovulation rate, E2 and endometrial thickness at the hCG day (7.8 ± 0.5 vs. 7.6 ± 0.6 mm; p = 0.52). Conclusions: Ovulation induction with minimal stimulation is not more effective than CC alone for achieving pregnancy when used as initial treatment in PCOS patients. [ABSTRACT FROM AUTHOR]

Aim. To compare the effect of combined metformin--clomiphene citrate (CC) with highly purified urinary FSH (HP-uFSH) for ovulation induction in CC-resistant women with polycystic ovary syndrome (PCOS). Methods. One-hundred fifty-three anovulatory women with CC-resistant PCOS were selected in this randomised controlled trial. Patients received combined metformin--CC ( n == 75, 205 cycles) or HP-uFSH ( n == 78, 186 cycles) for three cycles. Outcome measures were; Ovulation rate, number of growing and mature follicles, serum E2, serum P, endometrial thickness, pregnancy and miscarriage rates. Results. The ovulation rate per cycle was significantly higher in the HP-uFSH group (83.8%% vs. 62%%, p == 0.01). The number of follicles ≥≥12 mm ≥≥14 mm and ≥≥18 mm on the hCG day was significantly greater in the HP-uFSH group ( p == 0.01, p == 0.02 and p == 0.03, respectively). Pregnancy occurred in 23/205 cycles (11.2%%) in combined metformin--CC group and 40/186 cycles (21.5%%) in the HP-uFSH group; the difference was statistically significant ( p == 0.02). Two patients in the HP-uFSH group suffered mild OHSS. Conclusions. Combined metformin--CC resulted in modest ovulation and pregnancy rates without side effects. It is logical to offer this first for CC-resistant PCOS women before resorting to more expensive alternatives especially in developing communities where economic aspects of therapy are important. [ABSTRACT FROM AUTHOR]

Objective: To compare the effect of letrozole with combined metformin and clomiphene citrate (CC) for ovulation induction in CC-resistant women with polycystic ovary syndrome (PCOS). Design: A randomized controlled trial. Setting: University teaching hospital and a private practice setting. Patient(s): Two hundred fifty anovulatory women (582 cycles) with CC-resistant PCOS. Intervention(s): Patients received 2.5 mg of letrozole daily (123 patients, 285 cycles) or combined metformin–CC (127 patients, 297 cycles) for three treatment cycles. Main Outcome Measure(s): Ovulation rate, number of follicles, serum E2, serum P, endometrial thickness, pregnancy, and miscarriage rates. Result(s): Ovulation occurred in 185/285 cycles (64.9%) in the letrozole group versus 207/297 cycles (69.6%) in the combined metformin–CC group, without statistically significant difference. The total number of follicles was significantly more in the combined metformin–CC group (4.4 ± 0.4 vs. 6.8 ± 0.3). A nonsignificant increase in endometrial thickness on the day of hCG administration was observed in the letrozole group (9.5 ± 0.2 mm vs. 9.1 ± 0.1 mm). No statistically significant difference regarding the pregnancy rate (PR) was observed between both groups (14.7% vs. 14.4%). Conclusion(s): Letrozole and combined metformin–CC are equally effective for inducing ovulation and achieving pregnancy in patients with CC-resistant PCOS. [Copyright &y& Elsevier]

Orally active aromatase inhibitors (AIs) have gained attention for treatment of infertile women with endometriosis in whom aromatase p450 is aberrantly expressed. This review aimed to critically appraise and summarize the available evidence concerning the use of AIs for management of endometriosis-associated infertility. PubMed was searched to May 2015 with the following key words: endometriosis, infertility and aromatase. Priority was given for randomized controlled trials (RCTs) followed by other study designs. Main outcome measures were as follows: rates of clinical pregnancy, miscarriage and live birth as well as endocrine outcomes. Eighty-two abstracts were screened and six original articles were included. A RCT demonstrated that post-operative letrozole treatment did not improve spontaneous pregnancy rate. Another RCT reported no superiority of letrozole superovulation over clomiphene citrate (each combined with intrauterine insemination) in minimalmild endometriosis and previous laparoscopic treatment. Anastrozole significantly inhibited the growth of endometriotic cells and their estrogen production in culture. In assisted reproductive technology (ART) cycles, dual suppression (Agonist/anastrozole) was tested in a pilot study with a pregnancy rate of 45% however, high pregnancy loss (30%) occurred. A retrospective study showed that letrozole may improve endometrial receptivity in endometriotic patients undergoing in vitro fertilization (IVF). An opposite view from an in vitro study showed lower estradiol production and aromatase expression in cultured granulosa cells from endometriotic women undergoing IVF and marked reduction under letrozole. In conclusion, current evidence is limited. More trials are warranted to enhance our knowledge and provide a clear and unequivocal evidence to guide our clinical management of infertile women with endometriosis using AIs.

Objective: Abdominal wall adhesions at laparoscopy may predispose infertile patients to access-related injuries and increase the complexity of the procedure. We have observed concern from referring physicians regarding the safety of surgical laparoscopy in infertile patients who previously underwent surgery because of the risk of abdominal adhesions. To assess the risk of intraabdominal adhesions at laparoscopy, a retrospective cohort study was performed., Methods: All infertile patients who underwent a reproductive laparoscopic procedure in a 6-year period at our institution were included in this study. A chart review was performed to obtain demographic/surgical data and identify preoperative risk factors for intraabdominal adhesions. Operative videotapes were reviewed to determine the presence and location of adhesions. Standard statistical analyses were performed., Results: During the study period, 254 infertile patients underwent reproductive surgical laparoscopy, and videotapes on 164 (65%) were available for review. A total of 88 patients (54%) were identified with preoperative risk factors for intraabdominal adhesions (group 1), while 76 (46%) had no risk factors (group 2). The relative risk of adhesions was 1.34 (95% CI, range 0.89 to 2.01, P=0.18) when risk factors were identified. There were no differences in the groups regarding patient age, operative time, access technique, conversion to open surgery, or complications. Estimated blood loss was significantly higher in group 2, likely due to the predominance of laparoscopic surgery for ovarian endometriomata and complexity of the cases rather than the presence or absence of intraabdominal adhesion risk factors., Conclusions: No difference existed in the risk of intraabdominal adhesions in infertile patients with and without identifiable preoperative risk factors. Preoperative risk factors for intraabdominal adhesions should not contraindicate the surgical laparoscopic approach for reproductive procedures.