In case you missed it: Here are the top 5 posts this month

September was a very busy month with lots of good research papers and systematic reviews published on various topics. We also saw many guidelines and recommendations updates from ACOG, ASRM and USPSTF. Here are the top 5 most read posts for the month of September.

USPSTF simplifies cervical cancer screening recommendations: Dual testing no longer advised

The US Preventive Services Task Force (USPSTF) has issued new draft recommendations for cervical cancer screening with a major change that it recommends either cervical cytology (CC) or high-risk HPV (hrHPV) test as a screening procedure every 3 years for women aged 30-65 years, and not both ( Grade A)  

https://obgynupdated.blogspot.com/2017/09/uspstf-simplifies-cervical-cancer.html

ACOG issues clinical practice guidelines for Gestational Diabetes Mellitus

The American College of Obstetricians and Gynecologists (ACOG) has issued clinical practice guidelines for the diagnosis and treatment of gestational diabetes mellitus (GDM).

Although prevalence of GDM is directly proportional to prevalence of type 2 DM in a given population, it is estimated that GDM accounts for 90% of cases diabetes in pregnancy. The prevalence of DM in pregnancy is around 6-9%.

https://obgynupdated.blogspot.com/2017/09/acog-issues-clinical-practice.html

ASRM guidelines update: Metformin alone is not the first line of treatment for ovulation induction in women with PCOS

Practice Committee of the American Society for Reproductive Medicine does not recommend Metformin alone for ovulation induction as a first line therapy in women with PCOS. The guidelines were published in Journal Fertility and Sterility Epub ahead of print.

Metformin is a biguanide used as an oral insulin lowering agent in type2 diabetes, but also used enthusiastically in women with PCOS because of shared pathophysiology of insulin resistance in both.

https://obgynupdated.blogspot.com/2017/09/asrm-guidelines-update-metformin-alone.html

Oral Nifedipine parallels IV hydralazine in lowering down BP in acute hypertensive emergency in pregnancy

Intravenous hydralazine and oral nifedipine both exhibit the same efficacy in lowering the blood pressure in acute hypertensive emergency of pregnancy reports the results of small randomized trial published online in journal American Journal of Obstetrics and Gynecology.

https://obgynupdated.blogspot.com/2017/09/oral-nifedipine-parallels-iv.html

Oral diclofenac potassium plus cervical lidocaine cream eases the pain during hysterosalpingography

Oral diclofenac potassium tab 30 minutes before hysterosalpingography (HSG) and cervical lidocaine cream 5% significantly relieves pain and eases patient anxiety during the procedure and for half an hour after reports the results of a randomized trial published in September issue of journal Fertility and Sterility.

https://obgynupdated.blogspot.com/2017/09/oral-diclofenac-potassium-plus-cervical.html 

Oral diclofenac potassium plus cervical lidocaine cream eases the pain during hysterosalpingography

Oral diclofenac potassium tab 30 minutes before hysterosalpingography (HSG) and cervical lidocaine cream 5% significantly relieves pain and eases patient anxiety during the procedure and for half an hour after reports the results of a randomized trial published in September issue of journal Fertility and Sterility.

According to American Society for Reproductive Medicine (ASRM) tubal factor infertility accounts for 25%-30% of causes of female infertility, and HSG is simple and cost-effective method for evaluation of tubal patency.

Often patients are very apprehensive of the procedure because of pain felt during the procedure. This small randomized trial investigated the effect of 50 mg of oral diclofenac potassium half an hour before the procedure with lidocaine gel 5% applied to the anterior cervical lip, followed by 3 ml placed in the cervical canal using a sterile needless syringe vs placebo in alleviating the pain felt with the procedure.

The trial recruited 140 infertile women, comparable in demographic, parity and prior mode of delivery and randomized to receive either diclofenac plus gel vs placebo.

The patients self-evaluated the pain they felt during various steps of procedure like placing the speculum, holding the anterior lip, injection of the dye and 5 minutes and 30 minutes after the procedure and rated it on a 10 cm Visual Analog Scale(VAS).

A 2 cm difference between pain rating between both the study arms was considered clinically significant. The researchers also looked at any need of additional analgesic and side effects of the test itself.

It was seen that women in the diclofenac arm reported considerable less pain during pushing of the dye, 5 minutes and 30 minutes post procedure (median: 4 vs. 7, p=0.0001; 2 vs. 4, p=0.0001; 1 vs. 2.5, p= 0.0001, respectively)

Nearly 50% more women in the placebo group asked for additional analgesic (p=0.245).

The researchers concluded that diclofenac potassium and cervical lidocaine is considerably effective in reducing the pain during and after HSG test.

Full text

Hysterosalpingography with oil-based contrast boosts pregnancy rates: A landmark study

Infertile women undergoing Hysterosalpingography (HSG) with an oil based contrast have a 10% higher chances of getting pregnant and continue the pregnancy as compared to women who have HSG with a water based medium reports results of a multicentric, randomized trial from Netherlands.

The study was published online May 18 in the New England Journal of Medicine and presented at the 13th World Congress on Endometriosis in Vancouver, Canada.

Looking back, the debate about superiority of one medium over other has been going on for 50 years. It is known that flushing of the fallopian tube enhances fertility, but controversy about the type of medium continues.

First HSG was carried out by Carey in 1914 and he used collergol. Lipiodol was introduced by Sicard and Forestier in 1924 and remained a popular contrast medium for many decades. Later, water-soluble contrast material was generally preferred as it avoided the possible complication of oil embolism.

A 2007 update of Cochrane review concluded that “Flushing of the tubes with oil-soluble media increases subsequent pregnancy rates in infertility patients. Clinicians should consider flushing the tubes with OSCM before contemplating more invasive therapies.”

While other smaller studies have reported that contrast does not affect the cumulative pregnancy rate.

The current study called the The H2Oil study was conducted by Professor Ben W.J. Mol along with Dr. Kim Dreyer & Dr. Velja Mijatovic from the Department of Reproductive Medicine, VU University Medical Centre, Amsterdam, and their multi-center research team from 27 hospitals in the Netherlands.

The study recruited 1,119 women who were undergoing fertility treatment and were advised hysterosalpingography (HSG). The women were randomized to a standard HSG with water-soluble contrast medium (WSCM)(Hystero) or another group which used an oil-based contrast with Lipiodol Ultra-Fluide. (LIPIODOL Ultra-Fluid 480 Injection 10 mL, GUERBET). (Ethiodol in the United States). Then couples received expectant management or the women underwent intrauterine insemination.

All women were between 18 and 39 years of age, with regular menstrual cycles, and were undergoing treatment for infertility for at least 1 year.

The primary outcome measure was positive fetal heart rate by USG at 12 weeks of pregnancy within 6 months of the HSG test. Multiple secondary outcomes were tested like positive pregnancy test by USG, live birth, ectopic pregnancy, miscarriage and pain scores by the Visual-Analogue Scale for Pain.

After statistical analysis at 6 months, it was seen that 220(39.7%) in oil-based group had an ongoing pregnancy versus 161(29.1%) in water based group (P <.001). The oil based group also had considerable more live birth rates, 38.8% versus 28.1% (P <.001).   

Professor Mol said “This means that for every ten women undergoing an HSG to test their fallopian tubes, if Lipiodol® is used for that test, there will be one more pregnancy six months later and, consequently, one more baby nine months after that.”

The groups were comparable to each other in terms of bilateral tubal patency, pain score, miscarriage rates, ectopic pregnancy, twins, stillbirth rates and median duration of pregnancy.  

“If we move to the use of Lipiodol® Ultra-Fluid for routine diagnostic tubal patency testing, more women will have a successful fertility outcome and will avoid the need for other expensive fertility treatments such as IVF. I believe that is justifiable at this point,” he further added.

Professor Mol has a personal connection with the study which came to light only when he started researching about HSG. He himself was born, after his mother underwent HSG using Lipiodol after being infertile for 9 years.  

Professor Neil Johnson, President of the World Endometriosis Society concluded “This new study from our Dutch colleagues confirms beyond doubt the fertility value of Lipiodol® Ultra-Fluid.”