SlideShare ist ein Scribd-Unternehmen logo
1 von 55
Downloaden Sie, um offline zu lesen
Identifying the signs for
Implantation Failure and Miscarriage
By
Roy Farquharson
Liverpool Women's Hospital
UK
Contact: rgfarquharson@yahoo.com
1
Declaration of Interests
• Executive Committee member, European Society of
Human Reproduction and Embryology (2011 - 2015)

• NICE Guideline Development Group for ectopic
pregnancy and miscarriage (CG 154; 2010-2013)
• Chair, Association of Early Pregnancy Units
(2006-2011)
• Co-ordinator, ESHRE Special Interest Group for Early
Pregnancy (2007-2010)
• Associate Editor, Human Reproduction Update (20102014)
2
Educational Objectives
• Learning Objectives
•
• At the conclusion of this presentation, participants
should be able to:
• Describe the assessment for the diagnosis of
implantation failure, ectopic pregnancy and
miscarriage
• Acknowledge the limitations of available diagnostic
methods
• Develop a practical approach to using relevant tests
and management protocols.
3
4
Predictive Modelling for Early
Pregnancy
Best
Area of Interest Diagnostic
Utility

Parameter(s)

Ovulation

Biomarker

D21 Progesterone

Pregnancy of
Unknown
Location (PUL)

Transvaginal
(TVU) Scan
and Biomarker

TVU Scan
+ HCG doubling
time/ratio
+/- Progesterone
Pregnancy of
Scan
Fetal heart action
Uncertain Viability Scan
plus Crown-rump
(PUV)
ExclusivelyScan length

5
Practical Advice - PULs
3. Predicting outcome

 Hormones
 Human chorionic gonadotrophin (hCG)
 Progesterone
 Other:





Creatine kinase
CA 125
Activin A
Inhibin A

 Mathematical Models

6
HCG changes in normal
pregnancy

•

Mean (SE) serum concentrations of human chorionic gonadotrophin (adapted
from Braunstein et al 1976)

7
Haemodynamically stable
Pain free
Expectant management

PUL
Haemodynamically stable

Haemodynamically unstable

Pain

Pain

? Serum hCG
Serum hCG levels
at 0 and 48 hrs +/progesterone
? Intra-uterine Pregnancy

Consider
laparoscopy/laparotomy

Consider laparoscopy

? Ectopic Pregnancy

? Failing PUL

8
Practical Advice - PULs
3. Predicting outcome

 Hormones
 Human chorionic gonadotrophin (hCG)
 Progesterone
 Other:





Creatine kinase
CA 125
Activin A
Inhibin A

 Mathematical Models

9
Serum hCG Levels
Single Levels

Serial Levels

Discriminatory Zone

10
Serum hCG Levels
Single Levels

Serial Levels

Discriminatory Zone
 Developed with respect to transabdominal USS
 Lower levels of hCG used with TVS
 Using a single value of hCG in a PUL population
is of limited value:
 Many ectopic pregnancies have a low hCG
 Clinicians may be falsely reassured
11
Serum hCG Levels
Single Levels

Serial Levels
Change over 48hrs
(hCG ratio)

Intrauterine Pregnancies (IUPs)
 Kadar et al. (1981) first to describe the minimal
rate of rise for an IUP to be 66% over 48hrs
 More recently minimal rise reported to be 53%
(Barnhart et al. 2004)

 In clinical practice a more conservative cut-off of
35% has been suggested
12
Serum hCG Levels
Single Levels

Serial Levels
Change over 48hrs
(hCG ratio)

Failing PULs
 A decline of 21-35% at 48 hours depending on initial
hCG level ( levels at presentation – rate of
decrease) (Barnhart et al. 2004)
 An hCG decrease of >13% (hCG ratio < 0.87) has
been shown to have a sensitivity of 92.7% and a
specificity of 96.7% for the prediction of a failing PUL
(Condous et al., 2006)

13
Serum hCG Levels
Single Levels

Serial Levels
Change over 48hrs
(hCG ratio)

Ectopic Pregnancies (EPs)
 ‘No single way to characterize the pattern of serum
hCG behaviour’ (Silva et al., 2006)
 hCG profile mimicked IUP in 21% and a spontaneous
miscarriage in 8% (Silva et al., 2006)
 Sensitivity of 83% for EP when IUP excluded by hCG
rise < 35% and failing PUL excluded by hCG decrease >
14
21-35% (Seeber et al., 2006)
Evidence based management of PULs

Predicting outcome
 Hormones
 Human chorionic gonadotrophin (hCG)
 Progesterone
 Other:





Creatine kinase
CA 125
Activin A
Inhibin A

 Mathematical Models

15
Serum Progesterone Levels
Serum
Progesterone
< 20 nmol/L
PPV > 95% to predict
pregnancy failure
(Banerjee et al., 2001)

Viable IUPs reported with
levels < 16nmol/L

> 60 nmol/L
‘Strongly’ associated
with viable
pregnancies
Discriminative capacity
insufficient to diagnose
ectopic pregnancy with
certainty (Mol et al., 1998)

Good at predicting viability but not location

16
Pregnancies of Unknown
Location (PULs)
• The majority of PULs fail and resolve
spontaneously (44% – 69%) RCOG green top guideline on
Tubal Pregnancy 2004 sourcing five observational studies

• Of the remainder, ectopic pregnancy was
subsequently diagnosed in 14 to 28%
• Intervention (medical or surgical) was
required in approx 25% cases

17
HCG in practice (NICE 2012)
• Clinical symptoms more important than HCG results
• HCG levels do not ‘locate’ the pregnancy nor assess
viability
• 2 levels 48 hours apart are useful for ‘risk
stratification’ and act as best evidence for
subsequent management
• Limitations of prediction should be shared and
acknowledged to patients (eg ectopic pregnancy HCG levels
mimic viable IUP in 21% and EPL in 8%)
• Ectopic pregnancy and miscarriage: diagnosis and initial management in
early pregnancy of ectopic pregnancy and miscarriage. (NICE Clinical
guideline 154; 2012; www.nice.org.uk)
18
Sites of ectopic pregnancies

Illustration: John Yanson.Seeber. Suspected Ectopic Pregnancy. Obstet Gynecol 2006.
From: Seeber: Obstet Gynecol, Volume 107(2, Part 1).February 2006.399-413

19
Ectopic Pregnancy
• Variable mode of presentation
• ‘Mask of invisibility’
• High index of suspicion and vigilance
eg against diagnosis of complete early
pregnancy loss
• All areas of emergency care provision will
receive cases of undiagnosed ectopic
pregnancy
20
Ectopic Pregnancy
presentation
• ACUTE (typical)
• Collapse with lower
abdominal pain, tachycardia
and hypotension
• Pain, amenorrhoea and sign
of pelvic tenderness
• EPU presentation with
positive pregnancy test,
scan showing empty uterus
and adenexal
inhomogeneous mass

• CHRONIC (atypical)
• Symptoms mimicking
gastroenteritis
• Light irregular bleeding
• >1/3rd of all patients have
no risk factors

21
HCG studies
•
•
•
•
•
•
•

Review question
What is the diagnostic accuracy of two or more hCG measurements for
determining an ectopic pregnancy in women with pain and bleeding and
pregnancy of unknown location?
Description of included studies
Nine studies were included in this review (Barnhart et al., 2010; Condous et al.,
2004; Condous et al., 2007; Dart et al., 1999; Daus et al., 1989; Hahlin et al., 1991;
Mol et al., 1998; Stewart et al., 1995; Thorburn et al., 1992).
Five prospective cohort studies (Condous et al., 2004; Condous et al., 2007; Hahlin
et al., 1991; Mol et al., 1998; Thorburn et al., 1992)
Four retrospective cohort studies (Barnhart et al., 2010; Dart et al., 1999; Daus et
al., 1989; Stewart et al., 1995).
Conducted in the UK (Condous et al., 2004; Condous et al., 2007), the USA (Dart et
al., 1999; Daus et al., 1989; Stewart et al., 1995), the Netherlands (Mol et al.,
1998) and Sweden (Hahlin et al., 1991; Thorburn et al., 1992). One study (Barnhart
et al., 2010) was conducted in both the UK and USA.

22
GRADE system
•

•

GRADE (Grading of Recommendations
Assessment,Development and Evaluation) assesses
evidence on an outcome-by-outcome basis
Quality can vary within a study and is based on 5
factors:
–

Study design

–

Limitations
Inconsistency
Indirectness
Imprecision

–
–
–

23
23

23
Summary of findings

Quality assessment

No. of
studies

Design

Limitati
ons

Incon
siste
ncy

Indirect
ness

Imprec
ision

Other
consider
ations

Nu
m
be
r
of
w
o
m
en

Measure of diagnostic accuracy
Sensiti
vity %
(95%
CI)

Specifi
city %
(95%
CI)

Positi
ve
predic
tive
value
%
(95%
CI)

Negative
predictiv
e value
% (95%
CI)

Positiv
e
likelih
ood
ratio
%
(95%
CI)

Negati
ve
likelih
ood
ratio
%
(95%
CI)

Qualit
y%
(95%
CI)

GRADE findings for the diagnosis of ectopic pregnancy using two or more hCG measurements
Model M4
1 study
Condous
et al.,
2007

prospec
tive
study

1 study
Barnhart
et
al.,
2010

retrospe
ctive
study
(2
included
cohorts:
UK and
adjuste
d USA)

serious1,
6

serious4,
6

serious4,
6

no
seriou
s
incons
istenc
y

serious2,

no
seriou
s
incons
istenc
y

serious2,

no
seriou
s
incons
istenc
y

serious1

12

12

no
serious
impreci
sion

none

no
serious
impreci
sion

none

173

431

80.0
(59.8,
100)

80.8
(65.6,
95.9)

88.6
(83.7,
93.6)

88.9
(85.8,
92.0)

40.0
(22.5,
57.5)

31.8
(20.6,
43.1)

97.9
(95.6,
100)

98.6
(97.4,
99.8)

7.02
(4.25,
11.61)

7.27
(5.21,
10.14)

0.23
(0.08
,
0.62)

0.22
(0.10
,
0.48)

LOW

V.
LOW

3

no
serious
impreci
sion

none

544

54.8
(45.2,
64.4)

87.7
(84.7,
90.8)

51.4
(42.1,
60.7)

89.2
(86.2,
92.1)

4.47
(3.29,
6.06)

0.52
(0.46
,
0.64)

V.
LOW

24
Treatment Options for EcP and PUL
•

Laparoscopic surgery ESEP RCT 2013 (NL)
– Salpingectomy versus Salpingostomy

•

Systemic Methotrexate (MTX)
- DEMETER RCT 2013 (Fr)

•

–

Expectant management
- METEX RCT 2013 (NL)

25
When can expectant management be
employed?
•
•
•
•
•
•
•

Clinically stable
Minimal symptoms
Discriminatory HCG zone: 1000-2000iu/l
Weekly USS
Twice weekly HCG until <20 iu/l
Compliance with follow up
Immediate access to hospital

26
Take home messages
• Laparoscopic surgery is cornerstone of
treatment intervention with ectopic
pregnancy
• Results of RCT’s (DEMETER) improve evidence
level and inform practice eg less MTX use
• Advantages of centralisation of care in EPU
• CMACH report on awareness of failed medical
management
27
It’s all about Quality of Care

28
The signs of Miscarriage
• Exclusively ultrasound based
• Updated CRL measurements
• Revised crown rump length criteria for
confirmed diagnosis of early pregnancy loss
(>7mm; NICE GDG & RCOG 2012)
• Acknowledgement of inherent, wide biological
variation of embryo growth velocities
• Specificity of viability assessment is 99.9%
29
Comparison of the CRL curve (solid line) with the Robinson
curve (dashdotted) and the Hadlock curve (dotted)
90
80
70

CRL (in mm)

60
50
40
30
20
10
0
40

50

60

70
GA (in days)

80

90

100

30
Updated Gestational Age
Measurement in early pregnancy
• Total number of pregnancies: 6666 (2002-2008)
• No. Excluded = 2956 (uncertain dates, redated, infertility treatment,
miscarriage, stillbirth, genetic or congenital abnormalities)
• No. Included = 3710 normal singleton pregnancies dated according to
known and recorded last menstrual period (LMP) with confirmed viability
at the time of the nuchal scan
• Predominantly transvaginal ultrasound below 10 weeks by contrast with
Robinson transabdominal derived CRL curve (BMJ, 1972)
• The gestational age (GA) ranged between 35 and 98 days
• Linear mixed-effects model in order to account for possible codependency of multiple CRL measurements in the same patient

Reference: Bottomley C ,Bourne T. Dating and
growth in the first trimester. Best Practice and
research Clin Obstet Gynaecol 2009 ; ESHRE
precongress course, Roma, 2010

31
TV Ultrasound
Fetal loss with CRL =7mm

32
Embryoscopy – the
close-up
H=head/heart prominence, Y=yolk sac, B=bubble

33
TVU – small embryonic structure
in disproportionately large sac

34
Embryoscopy
– short body stalk with 6mm CRL
- cytogenetics = 47XY+7

35
Fetal loss at 7 weeks
CRL = 19mm

36
Cytogenetics = 47XY+15
Small head compared to CRL, dysplastic face, partial encephalocele

37
Is Treatment Failure in RM a valid
concept?
- Cytogenetic Analysis of Pregnancy Loss in RM

38
Opportunityisnowhere

39
microarrays
• technique
high resolution WHOLE genome scan

cytogenetics

FISH

arrays

40
• Microarray
Advantages
- SINGLE test vs Karyotype + 5 FISH tests
- DNA extraction directly vs cell culture
- detect low level fetal cells vs maternal cell contamination
- higher resolution vs lower resolution

Disadvantages
- CANNOT detect ‘balanced’ rearrangements

- confirmatory follow up studies

41
• Trisomy 10 - TR
Karyotype = Normal Female
Array = Abnormal MALE result +10
FISH = confirmed +10 (70% MCC)

42
• 14q deletion - JS
Karyotype = Normal
Female
Array = Abnormal Female –
deletion 14q

FISH = confirm deletion in 11%
of cells (89% MCC)

43
RM – Evaluation of Array CGH v Conventional Cytogenetics
(McNamee et al, British Journal of Hospital Medicine, 2013, 74, 36-40 )

Array CGH and
conventional
cytogenetics

N=50

Triploidy on
FISH
N=4

Normal result
N=23(46%)

Abnormal result
N=27 (54%)

Diagnosed with
conventional
cytogenetics

Missed with

N=14

N=9

NUMERICAL

+16 x3
+15 x2
+21 x2
+13 x2
+22

+10
+14
-X x2

conventional
cytogenetics

NUMERICAL
+22
+10
+15
+8
+16
STRUCTURAL
>dup(22)(q11.2q11.2) ,
>del(14q)(q31.1) ,t(1:q1
6)mat
>del(13q)12.3-q34
44
Pregnancy Success Prediction Matrix

Following idiopathic RM, the predicted probability (%) of successful pregnancy is determined by age
and previous miscarriage history ( 95% confidence interval <20% in bold).

_____________________________________________________________________________
Age

Number of Previous Miscarriages

(yrs)
2
3
4
5
_____________________________________________________________________________
20

92

90

88

85

25

89

86

82

79

30

84

80

76

71

35

77

73

68

62

40

69

64

58

52

45

60

54

48

42

_______________________________________________________________________
Brigham et al, Hum Rep, 1999, 14, 2868-2871; PROMISE Trial 2010 MRC/HTA funded
45
Previous single miscarriage
Risk of preterm delivery <37 weeks
OR 1.1-1.4

ONE MISCARRIAGE
Basso '98
1.333/ 21.166
Buchmayer '04 1.293/ 21.631
Martius '98
1.069/ 13.461
Pickering '91
?/ 8.589
Smith '06
673/ 9.215
Hammoud '07
369/ 5.973
Pickering '85
?/ 3.927
Thom '92
174/ 2.146
Lang '96
?/?
Bhattacharya '08 128/ 1.404
Lekea '90
117/ 1.291
El-Bastawissi '03
69/ 143
Schoenbaum '80
17/189
Nguyen '04
16/164
0.1

1

10

46
Previous two or more miscarriages
Risk of preterm delivery <37 weeks
I

OR 1.1-1.4

II

OR 1.6-2.1

III

OR 1.5-3.0

TWO MISCARRIAGES
Basso '98
432/ 5.268
Martius '98
309/ 2.788
Smith '06
178/ 1.792
Buchmayer '04
146/ 1.742
Pickering '91
?/ 1.524
Hammoud '07
88/ 908
Lang '96
?/ ?
Pickering '85
?/ 689
Lekea '90
73/ 439
El-Bastawissi '03
31/ 57
Nguyen '04
8/ 33
RECURRENT MISCARRIAGE
Martius '98
151/ 639
Thom '92
63/ 638
Lang '96
?/ ?
Hammoud '07
36/ 225
Lekea '90
?/ ?
Hughes '91
11/88
Jivraj '01
7 /61
0.1

1

10

47
Previous miscarriage(s)
Risk of very preterm delivery <34 weeks
I
II

OR 2.2-3.4

III

ONE MISCARRIAGE
Basso '98
466/ 21.166
Buchmayer '04 219/ 21.631
Martius '98
195/ 13.461
Smith '06
138/ 9.215
Hammoud '07
92/ 5.973
Bhattacharya '08 39/ 1.404
Thom '92
26/ 2.146
El-Bastawissi '03
16/ 90

OR 1.5-1.7

NS 2.4-6.7

TWO MISCARRIAGES
Basso '98
158/ 5.268
Martius '98
71/ 2.788
Smith '06
56/1.792
Buchmayer '04
44/ 1.742
Hammoud '07
6/ 908
El-Bastawissi '03
6/ 32
RECURRENT MISCARRIAGE
Martius '98
52/ 639
Thom '92
27/ 638
Hammoud '07
5/ 225
0.1

1

10
48
Previous miscarriage(s)
Risk of small for gestational age
I

NS

II

OR 1.4

III

NS (?)

ONE MISCARRIAGE
Basso '98
1.291/ 21.166
Pickering '85
?/ 3.927
Lang '96
?/ ?
Thom '92
94/ 2.146
Parazzini '07
96/ 439
TWO MISCARRIAGES
Basso '98
395/ 5.268
Pickering '85
?/ 689
Lang '96
?/ ?
RECURRENT MISCARRIAGE
Thom '92
41/ 638
Lang '96
?/ ?
Jivraj '01
5/ 61
Hughes '91
3/ 88
0.1

1

10

49
Risk of adverse outcome in subsequent
pregnancy
OR/

*RR

Termination of
pregnancy

Miscarriage
1

≥2

≥3

1

≥2

1.0-3.31.2

1.0-1.54

-

ns

ns

Placental abruption

ns

1.54

-

ns

ns

Placenta previa

ns

1.74

*6.04

ns

ns

Preterm <37

1.1-1.43,5

1.6-2.13.5

*1.5-3.01,6

1.1-1.36,8

1.6-2.36,8

Preterm <34

1.5-1.73,5

2.2-3.43,5

*2.4-6.71,6

1.3-1.57,8

1.8-2.97,8

SGA p<10

ns

1.45

?1

ns

ns

LBW <2500

ns

?4,5

*2.04

ns

ns

LBW <1500

ns

ns

-

?9,10

?9

Cong. Malformation

ns

ns

*1.84

ns

ns

Low AS

ns

ns

ns

ns

ns

1.92

ns

ns

ns

ns

Number
Preeclampsia

Intrauterine Fetal death

1 Thom et al. 1992; 2 Bhattacharya et al., 2008; 3 Buchmayer et al., 2004; 4 Sheiner et al., 2005; 5 Basso et al.,
50
1998; 6 Martius et al., 1998; 7 Moreau et al 2005; 8 Ancel et al., 2004; 9 Lumley 1985; 10 Reime et al 2008
Vanishing Twin phenomenon
• Spontaneous reduction of a multiple pregnancy
• IVF-population (~5%)
• Incidence 10-30%1-3
• Studies: IVF population
• Vanishing twin IVF pregnancies, which were
spontaneous reduced from twin to single
pregnancies, were compared to single IVF
pregnancies

1 Dickey et al., 2002; 2 Landy and Keith 1998; 3 Pinborg et al., 2005

51
Vanishing Twin: Risk of
Preeclampsia and SGA
PREECLAMPSIA
*Pinborg 2007
Chasen 2006
X
SGA
Shebl 2007
*Pinborg 2007
La Sala 2004
Dickey 2002
Chasen 2006
0

1

2

3

4

5

6

Preeclampsia and SGA

52
Vanishing Twin;
SGA-LBW
Low birht weight <2500g

Cas
e

Control

O
R

95%CI

%Case

2004

Retrospective

62

437

Pinborg et al

2007

Retrospective

642

5.237

1,7

1,1-2,7

S

187

424

2,8

1,1-7,1

S

2,0

1,5-2,6

2005

Retrospective

642

5.237

Shebl et al

2007

Retrospective

46

8,9%

Signi

La Sala et al

Pinborg et al

9,7%

%Control

NS

vanishing twin > 8 wks vs <8 wks

11,7%

6,3%

0,001

92

26,1%

12,0%

0,036

3,2%

2,7%

4,1%

1,5%

Very low birth weight <1500g
La Sala et al

2004

Retrospective

62

437

Pinborg et al

2005

Retrospective

642

5.237

3,0

1,9-4,7

NS
0,001

Small for gestational age p<10
Chasen et al

2006

Retrospective

55

168

14,5%

9,6%

NS

Dickey et al

2002

Retrospective

140

4.683

15,7%

4,5%

NS

La Sala et al

2004

Retrospective

62

437

9,7%

15,6%

NS

Pinborg et al

2007

Retrospective

642

5.237

1,6

1,1-2,3

S

187

424

2,1

0,99-4,4

NS

46

92

Shebl et al

2007

Retrospective

32,6%

16,3%

Vanishing twin > 8 wks vs. <8 wks

0,029

53
The Sound of Life - Greetings
From Liverpool!!

54
Sites of ectopic pregnancies

Illustration: John Yanson.Seeber. Suspected Ectopic Pregnancy. Obstet Gynecol 2006.
From: Seeber: Obstet Gynecol, Volume 107(2, Part 1).February 2006.399-413

55

Weitere ähnliche Inhalte

Was ist angesagt?

Approach to a case of female infertility dr monikha
Approach to a case of female infertility dr monikhaApproach to a case of female infertility dr monikha
Approach to a case of female infertility dr monikhaMonikha Ess Ess
 
Management of the Infertile Couple in a Primary Care Setting. Part I
Management of the Infertile Couple in a Primary Care Setting. Part IManagement of the Infertile Couple in a Primary Care Setting. Part I
Management of the Infertile Couple in a Primary Care Setting. Part IMilie Nwoye
 
Pregnancy of unknown location
Pregnancy of unknown locationPregnancy of unknown location
Pregnancy of unknown locationAhmad Saber
 
Infertility 2014 : evidence that matters
Infertility 2014  : evidence that mattersInfertility 2014  : evidence that matters
Infertility 2014 : evidence that mattersHesham Al-Inany
 
UNEXPLAINED INFERTILITY & INTRAUTERINE INSEMINATION Dr. Sharda jain Lifecare...
UNEXPLAINED  INFERTILITY &INTRAUTERINE INSEMINATION Dr. Sharda jain Lifecare...UNEXPLAINED  INFERTILITY &INTRAUTERINE INSEMINATION Dr. Sharda jain Lifecare...
UNEXPLAINED INFERTILITY & INTRAUTERINE INSEMINATION Dr. Sharda jain Lifecare...Lifecare Centre
 
INFERTILITY Update 2017 MANAGEMENT OF INFERTILE COUPLE
INFERTILITY Update  2017 MANAGEMENT OF INFERTILE COUPLE INFERTILITY Update  2017 MANAGEMENT OF INFERTILE COUPLE
INFERTILITY Update 2017 MANAGEMENT OF INFERTILE COUPLE Lifecare Centre
 
Evidence based infertility management
Evidence based infertility managementEvidence based infertility management
Evidence based infertility managementHesham Al-Inany
 
1 iui a z, including techniques of iui & lps Dr. Sharda jain & Team
1 iui a z, including techniques of iui & lps Dr. Sharda jain & Team1 iui a z, including techniques of iui & lps Dr. Sharda jain & Team
1 iui a z, including techniques of iui & lps Dr. Sharda jain & TeamLifecare Centre
 
Intrauterine Insemination Treatment
Intrauterine Insemination TreatmentIntrauterine Insemination Treatment
Intrauterine Insemination Treatmentwaqar888
 
Role of IUI in the era of IVF
Role of IUI in the era of IVFRole of IUI in the era of IVF
Role of IUI in the era of IVFSujoy Dasgupta
 
Recurrent Implantation Failure
Recurrent Implantation FailureRecurrent Implantation Failure
Recurrent Implantation FailureShivani Sachdev
 
Intrauterine insemination (iui)
Intrauterine insemination  (iui)Intrauterine insemination  (iui)
Intrauterine insemination (iui)Hesham Al-Inany
 
Post Coital Test (PCT): A Panel Discussion
Post Coital Test (PCT): A Panel DiscussionPost Coital Test (PCT): A Panel Discussion
Post Coital Test (PCT): A Panel DiscussionMohamed Walaa El Deeb
 
Intrauterine Insemination UPDATE 2018
Intrauterine Insemination UPDATE 2018 Intrauterine Insemination UPDATE 2018
Intrauterine Insemination UPDATE 2018 Lifecare Centre
 
WHEN TO REFER A PATIENT FOR ASSISTED REPRODUCTION ( ART ) / IVF BY DR SHASHW...
WHEN TO REFER A PATIENT FOR ASSISTED REPRODUCTION ( ART )  / IVF BY DR SHASHW...WHEN TO REFER A PATIENT FOR ASSISTED REPRODUCTION ( ART )  / IVF BY DR SHASHW...
WHEN TO REFER A PATIENT FOR ASSISTED REPRODUCTION ( ART ) / IVF BY DR SHASHW...DR SHASHWAT JANI
 

Was ist angesagt? (20)

Approach to a case of female infertility dr monikha
Approach to a case of female infertility dr monikhaApproach to a case of female infertility dr monikha
Approach to a case of female infertility dr monikha
 
Intra uterine insemination for unexplained infertility
Intra uterine insemination for unexplained infertilityIntra uterine insemination for unexplained infertility
Intra uterine insemination for unexplained infertility
 
Management of the Infertile Couple in a Primary Care Setting. Part I
Management of the Infertile Couple in a Primary Care Setting. Part IManagement of the Infertile Couple in a Primary Care Setting. Part I
Management of the Infertile Couple in a Primary Care Setting. Part I
 
Pregnancy of unknown location
Pregnancy of unknown locationPregnancy of unknown location
Pregnancy of unknown location
 
Implantation Failure in IVF
Implantation Failure in IVFImplantation Failure in IVF
Implantation Failure in IVF
 
Infertility 2014 : evidence that matters
Infertility 2014  : evidence that mattersInfertility 2014  : evidence that matters
Infertility 2014 : evidence that matters
 
UNEXPLAINED INFERTILITY & INTRAUTERINE INSEMINATION Dr. Sharda jain Lifecare...
UNEXPLAINED  INFERTILITY &INTRAUTERINE INSEMINATION Dr. Sharda jain Lifecare...UNEXPLAINED  INFERTILITY &INTRAUTERINE INSEMINATION Dr. Sharda jain Lifecare...
UNEXPLAINED INFERTILITY & INTRAUTERINE INSEMINATION Dr. Sharda jain Lifecare...
 
INFERTILITY Update 2017 MANAGEMENT OF INFERTILE COUPLE
INFERTILITY Update  2017 MANAGEMENT OF INFERTILE COUPLE INFERTILITY Update  2017 MANAGEMENT OF INFERTILE COUPLE
INFERTILITY Update 2017 MANAGEMENT OF INFERTILE COUPLE
 
Evidence based infertility management
Evidence based infertility managementEvidence based infertility management
Evidence based infertility management
 
Endometriosis
EndometriosisEndometriosis
Endometriosis
 
1 iui a z, including techniques of iui & lps Dr. Sharda jain & Team
1 iui a z, including techniques of iui & lps Dr. Sharda jain & Team1 iui a z, including techniques of iui & lps Dr. Sharda jain & Team
1 iui a z, including techniques of iui & lps Dr. Sharda jain & Team
 
Intrauterine Insemination Treatment
Intrauterine Insemination TreatmentIntrauterine Insemination Treatment
Intrauterine Insemination Treatment
 
Role of IUI in the era of IVF
Role of IUI in the era of IVFRole of IUI in the era of IVF
Role of IUI in the era of IVF
 
Recurrent Implantation Failure
Recurrent Implantation FailureRecurrent Implantation Failure
Recurrent Implantation Failure
 
Intrauterine insemination (iui)
Intrauterine insemination  (iui)Intrauterine insemination  (iui)
Intrauterine insemination (iui)
 
Post Coital Test (PCT): A Panel Discussion
Post Coital Test (PCT): A Panel DiscussionPost Coital Test (PCT): A Panel Discussion
Post Coital Test (PCT): A Panel Discussion
 
Research & infertility
Research & infertilityResearch & infertility
Research & infertility
 
Endometriosis in IVF
Endometriosis in IVFEndometriosis in IVF
Endometriosis in IVF
 
Intrauterine Insemination UPDATE 2018
Intrauterine Insemination UPDATE 2018 Intrauterine Insemination UPDATE 2018
Intrauterine Insemination UPDATE 2018
 
WHEN TO REFER A PATIENT FOR ASSISTED REPRODUCTION ( ART ) / IVF BY DR SHASHW...
WHEN TO REFER A PATIENT FOR ASSISTED REPRODUCTION ( ART )  / IVF BY DR SHASHW...WHEN TO REFER A PATIENT FOR ASSISTED REPRODUCTION ( ART )  / IVF BY DR SHASHW...
WHEN TO REFER A PATIENT FOR ASSISTED REPRODUCTION ( ART ) / IVF BY DR SHASHW...
 

Andere mochten auch

Early trimester miscarriages
Early trimester miscarriages Early trimester miscarriages
Early trimester miscarriages hinaaamir
 
NewLife India - Steps to Reduce the Chance of Recurrent Miscarriages
NewLife India - Steps to Reduce the Chance of Recurrent MiscarriagesNewLife India - Steps to Reduce the Chance of Recurrent Miscarriages
NewLife India - Steps to Reduce the Chance of Recurrent MiscarriagesNEW LIFE- IVF CLINIC INDIA
 
The Enigma of implantation
The Enigma of implantationThe Enigma of implantation
The Enigma of implantationPriya Bhave.
 
Recurrent implantation failure
Recurrent implantation failureRecurrent implantation failure
Recurrent implantation failureAboubakr Elnashar
 
Role of progesterone in Pregnancy
Role of progesterone in Pregnancy Role of progesterone in Pregnancy
Role of progesterone in Pregnancy Lifecare Centre
 
Bài chia sẻ ngày họp mặt truyền thống lần thứ 16
Bài chia sẻ ngày họp mặt truyền thống lần thứ 16Bài chia sẻ ngày họp mặt truyền thống lần thứ 16
Bài chia sẻ ngày họp mặt truyền thống lần thứ 16Triz VietNam
 
final fantasy 10 completo
final fantasy 10 completofinal fantasy 10 completo
final fantasy 10 completocapell18
 
Q2. how does your media product represent
Q2. how does your media product representQ2. how does your media product represent
Q2. how does your media product representJessicaChong96
 
Nazi pop twins analysis
Nazi pop twins analysisNazi pop twins analysis
Nazi pop twins analysisJessicaChong96
 
Barber trucking 4th quarter 2013 on line safety meeting
Barber trucking 4th quarter 2013 on line safety meetingBarber trucking 4th quarter 2013 on line safety meeting
Barber trucking 4th quarter 2013 on line safety meetingBarber15825
 
Music questionnaires graphs
Music questionnaires graphsMusic questionnaires graphs
Music questionnaires graphsDanDuncalf1
 

Andere mochten auch (20)

Early trimester miscarriages
Early trimester miscarriages Early trimester miscarriages
Early trimester miscarriages
 
NewLife India - Steps to Reduce the Chance of Recurrent Miscarriages
NewLife India - Steps to Reduce the Chance of Recurrent MiscarriagesNewLife India - Steps to Reduce the Chance of Recurrent Miscarriages
NewLife India - Steps to Reduce the Chance of Recurrent Miscarriages
 
Recurrent implantation failure
Recurrent implantation failureRecurrent implantation failure
Recurrent implantation failure
 
The Enigma of implantation
The Enigma of implantationThe Enigma of implantation
The Enigma of implantation
 
Recurrent implantation failure
Recurrent implantation failureRecurrent implantation failure
Recurrent implantation failure
 
Role of progesterone in Pregnancy
Role of progesterone in Pregnancy Role of progesterone in Pregnancy
Role of progesterone in Pregnancy
 
Bài chia sẻ ngày họp mặt truyền thống lần thứ 16
Bài chia sẻ ngày họp mặt truyền thống lần thứ 16Bài chia sẻ ngày họp mặt truyền thống lần thứ 16
Bài chia sẻ ngày họp mặt truyền thống lần thứ 16
 
Livre blanc-innovation-vf
Livre blanc-innovation-vfLivre blanc-innovation-vf
Livre blanc-innovation-vf
 
final fantasy 10 completo
final fantasy 10 completofinal fantasy 10 completo
final fantasy 10 completo
 
Q2. how does your media product represent
Q2. how does your media product representQ2. how does your media product represent
Q2. how does your media product represent
 
Dag Boutsen
Dag BoutsenDag Boutsen
Dag Boutsen
 
Questionnaire Results
Questionnaire ResultsQuestionnaire Results
Questionnaire Results
 
Nazi pop twins analysis
Nazi pop twins analysisNazi pop twins analysis
Nazi pop twins analysis
 
Barber trucking 4th quarter 2013 on line safety meeting
Barber trucking 4th quarter 2013 on line safety meetingBarber trucking 4th quarter 2013 on line safety meeting
Barber trucking 4th quarter 2013 on line safety meeting
 
Acx - How it Works
Acx - How it WorksAcx - How it Works
Acx - How it Works
 
Genre theories
Genre theoriesGenre theories
Genre theories
 
Management ii
Management iiManagement ii
Management ii
 
Music questionnaires graphs
Music questionnaires graphsMusic questionnaires graphs
Music questionnaires graphs
 
Doc2
Doc2Doc2
Doc2
 
IVF Treatment - New Life Clinic India
IVF Treatment - New Life Clinic IndiaIVF Treatment - New Life Clinic India
IVF Treatment - New Life Clinic India
 

Ähnlich wie Identifying the Signs for Implantation Failure and Miscarriage

Investigation infertility
Investigation infertilityInvestigation infertility
Investigation infertilityRuth Nwokoma
 
Recombinant vs urinary gonadotrophins
Recombinant vs urinary gonadotrophinsRecombinant vs urinary gonadotrophins
Recombinant vs urinary gonadotrophinsHesham Al-Inany
 
Insight AUB Management Guidelines on AUB in Reproductive Period
Insight AUB Management Guidelines  on AUB  in Reproductive PeriodInsight AUB Management Guidelines  on AUB  in Reproductive Period
Insight AUB Management Guidelines on AUB in Reproductive PeriodLifecare Centre
 
Insight AUB Management Guidelines on AUB in Reproductive Period
Insight AUB Management Guidelines  on AUB  in Reproductive PeriodInsight AUB Management Guidelines  on AUB  in Reproductive Period
Insight AUB Management Guidelines on AUB in Reproductive PeriodDGFPublicAwareness
 
Recombinantvsurinarygonadotrophins2 140608112530-phpapp01
Recombinantvsurinarygonadotrophins2 140608112530-phpapp01Recombinantvsurinarygonadotrophins2 140608112530-phpapp01
Recombinantvsurinarygonadotrophins2 140608112530-phpapp01鋒博 蔡
 
Progestogens in miscarriages | Progestogens in Early Pregnancy | Seeds of In...
Progestogens in miscarriages  | Progestogens in Early Pregnancy | Seeds of In...Progestogens in miscarriages  | Progestogens in Early Pregnancy | Seeds of In...
Progestogens in miscarriages | Progestogens in Early Pregnancy | Seeds of In...SOI Delhi
 
Investigation of infertility modified
Investigation of infertility modifiedInvestigation of infertility modified
Investigation of infertility modifiedHesham Al-Inany
 
3 tubal pregnancy medical management 1998
3 tubal pregnancy medical management 19983 tubal pregnancy medical management 1998
3 tubal pregnancy medical management 1998alx34
 
To pill or not to pill in GnRa-antagonist protocols Candido Tomás, Ovumia 030...
To pill or not to pill in GnRa-antagonist protocols Candido Tomás, Ovumia 030...To pill or not to pill in GnRa-antagonist protocols Candido Tomás, Ovumia 030...
To pill or not to pill in GnRa-antagonist protocols Candido Tomás, Ovumia 030...Candido Tomás
 
Unexplained Infertility by Dr. Nidhi Sharma | Jindal IVF Chandigarh
Unexplained Infertility by Dr. Nidhi Sharma | Jindal IVF ChandigarhUnexplained Infertility by Dr. Nidhi Sharma | Jindal IVF Chandigarh
Unexplained Infertility by Dr. Nidhi Sharma | Jindal IVF ChandigarhJindal IVF Chandigarh
 
Embryo Transfer Technologies and Luteal Phase Support to Maximize Pregnancy R...
Embryo Transfer Technologies and Luteal Phase Support to Maximize Pregnancy R...Embryo Transfer Technologies and Luteal Phase Support to Maximize Pregnancy R...
Embryo Transfer Technologies and Luteal Phase Support to Maximize Pregnancy R...Sandro Esteves
 
Fertility Preserving Hysteroscopic Surgery
Fertility Preserving Hysteroscopic SurgeryFertility Preserving Hysteroscopic Surgery
Fertility Preserving Hysteroscopic SurgerySujoy Dasgupta
 
ESHRE Guideline on Recurrent Pregnancy Loss (RPL)
ESHRE Guideline on Recurrent Pregnancy Loss (RPL)ESHRE Guideline on Recurrent Pregnancy Loss (RPL)
ESHRE Guideline on Recurrent Pregnancy Loss (RPL)Sujoy Dasgupta
 
PANEL DISCUSSION ON ENDOMETRIOSIS RELATED INFERTILITY (EVIDENCE BASED)
PANEL DISCUSSION ON ENDOMETRIOSIS RELATED INFERTILITY (EVIDENCE BASED)PANEL DISCUSSION ON ENDOMETRIOSIS RELATED INFERTILITY (EVIDENCE BASED)
PANEL DISCUSSION ON ENDOMETRIOSIS RELATED INFERTILITY (EVIDENCE BASED)Lifecare Centre
 

Ähnlich wie Identifying the Signs for Implantation Failure and Miscarriage (20)

Investigation infertility
Investigation infertilityInvestigation infertility
Investigation infertility
 
Recombinant vs urinary gonadotrophins
Recombinant vs urinary gonadotrophinsRecombinant vs urinary gonadotrophins
Recombinant vs urinary gonadotrophins
 
Insight AUB Management Guidelines on AUB in Reproductive Period
Insight AUB Management Guidelines  on AUB  in Reproductive PeriodInsight AUB Management Guidelines  on AUB  in Reproductive Period
Insight AUB Management Guidelines on AUB in Reproductive Period
 
Insight AUB Management Guidelines on AUB in Reproductive Period
Insight AUB Management Guidelines  on AUB  in Reproductive PeriodInsight AUB Management Guidelines  on AUB  in Reproductive Period
Insight AUB Management Guidelines on AUB in Reproductive Period
 
Recombinantvsurinarygonadotrophins2 140608112530-phpapp01
Recombinantvsurinarygonadotrophins2 140608112530-phpapp01Recombinantvsurinarygonadotrophins2 140608112530-phpapp01
Recombinantvsurinarygonadotrophins2 140608112530-phpapp01
 
Progestogens in miscarriages | Progestogens in Early Pregnancy | Seeds of In...
Progestogens in miscarriages  | Progestogens in Early Pregnancy | Seeds of In...Progestogens in miscarriages  | Progestogens in Early Pregnancy | Seeds of In...
Progestogens in miscarriages | Progestogens in Early Pregnancy | Seeds of In...
 
Investigation of infertility modified
Investigation of infertility modifiedInvestigation of infertility modified
Investigation of infertility modified
 
3 tubal pregnancy medical management 1998
3 tubal pregnancy medical management 19983 tubal pregnancy medical management 1998
3 tubal pregnancy medical management 1998
 
To pill or not to pill in GnRa-antagonist protocols Candido Tomás, Ovumia 030...
To pill or not to pill in GnRa-antagonist protocols Candido Tomás, Ovumia 030...To pill or not to pill in GnRa-antagonist protocols Candido Tomás, Ovumia 030...
To pill or not to pill in GnRa-antagonist protocols Candido Tomás, Ovumia 030...
 
Unexplained Infertility by Dr. Nidhi Sharma | Jindal IVF Chandigarh
Unexplained Infertility by Dr. Nidhi Sharma | Jindal IVF ChandigarhUnexplained Infertility by Dr. Nidhi Sharma | Jindal IVF Chandigarh
Unexplained Infertility by Dr. Nidhi Sharma | Jindal IVF Chandigarh
 
UOG Journal Club: Cervical length screening for prevention of preterm birth i...
UOG Journal Club: Cervical length screening for prevention of preterm birth i...UOG Journal Club: Cervical length screening for prevention of preterm birth i...
UOG Journal Club: Cervical length screening for prevention of preterm birth i...
 
International Journal of Reproductive Medicine & Gynecology
International Journal of Reproductive Medicine & GynecologyInternational Journal of Reproductive Medicine & Gynecology
International Journal of Reproductive Medicine & Gynecology
 
Embryo Transfer Technologies and Luteal Phase Support to Maximize Pregnancy R...
Embryo Transfer Technologies and Luteal Phase Support to Maximize Pregnancy R...Embryo Transfer Technologies and Luteal Phase Support to Maximize Pregnancy R...
Embryo Transfer Technologies and Luteal Phase Support to Maximize Pregnancy R...
 
UOG Journal Club: September 2016
UOG Journal Club: September 2016UOG Journal Club: September 2016
UOG Journal Club: September 2016
 
Pregnancy test
Pregnancy testPregnancy test
Pregnancy test
 
Fertility Preserving Hysteroscopic Surgery
Fertility Preserving Hysteroscopic SurgeryFertility Preserving Hysteroscopic Surgery
Fertility Preserving Hysteroscopic Surgery
 
論文
論文論文
論文
 
ESHRE Guideline on Recurrent Pregnancy Loss (RPL)
ESHRE Guideline on Recurrent Pregnancy Loss (RPL)ESHRE Guideline on Recurrent Pregnancy Loss (RPL)
ESHRE Guideline on Recurrent Pregnancy Loss (RPL)
 
Ls,infertility 2007
Ls,infertility 2007Ls,infertility 2007
Ls,infertility 2007
 
PANEL DISCUSSION ON ENDOMETRIOSIS RELATED INFERTILITY (EVIDENCE BASED)
PANEL DISCUSSION ON ENDOMETRIOSIS RELATED INFERTILITY (EVIDENCE BASED)PANEL DISCUSSION ON ENDOMETRIOSIS RELATED INFERTILITY (EVIDENCE BASED)
PANEL DISCUSSION ON ENDOMETRIOSIS RELATED INFERTILITY (EVIDENCE BASED)
 

Kürzlich hochgeladen

How to cure cirrhosis and chronic hepatitis naturally
How to cure cirrhosis and chronic hepatitis naturallyHow to cure cirrhosis and chronic hepatitis naturally
How to cure cirrhosis and chronic hepatitis naturallyZurück zum Ursprung
 
CPR.nursingoutlook.pdf , Bsc nursing student
CPR.nursingoutlook.pdf , Bsc nursing studentCPR.nursingoutlook.pdf , Bsc nursing student
CPR.nursingoutlook.pdf , Bsc nursing studentsaileshpanda05
 
Using Data Visualization in Public Health Communications
Using Data Visualization in Public Health CommunicationsUsing Data Visualization in Public Health Communications
Using Data Visualization in Public Health Communicationskatiequigley33
 
Male Infertility Panel Discussion by Dr Sujoy Dasgupta
Male Infertility Panel Discussion by Dr Sujoy DasguptaMale Infertility Panel Discussion by Dr Sujoy Dasgupta
Male Infertility Panel Discussion by Dr Sujoy DasguptaSujoy Dasgupta
 
Microbiology lecture presentation-1.pptx
Microbiology lecture presentation-1.pptxMicrobiology lecture presentation-1.pptx
Microbiology lecture presentation-1.pptxkitati1
 
Physiotherapy Management of Rheumatoid Arthritis
Physiotherapy Management of Rheumatoid ArthritisPhysiotherapy Management of Rheumatoid Arthritis
Physiotherapy Management of Rheumatoid ArthritisNilofarRasheed1
 
Different drug regularity bodies in different countries.
Different drug regularity bodies in different countries.Different drug regularity bodies in different countries.
Different drug regularity bodies in different countries.kishan singh tomar
 
High-Performance Thin-Layer Chromatography (HPTLC)
High-Performance Thin-Layer Chromatography (HPTLC)High-Performance Thin-Layer Chromatography (HPTLC)
High-Performance Thin-Layer Chromatography (HPTLC)kishan singh tomar
 
Female Reproductive Physiology Before Pregnancy
Female Reproductive Physiology Before PregnancyFemale Reproductive Physiology Before Pregnancy
Female Reproductive Physiology Before PregnancyMedicoseAcademics
 
ANATOMICAL FAETURES OF BONES FOR NURSING STUDENTS .pptx
ANATOMICAL FAETURES OF BONES  FOR NURSING STUDENTS .pptxANATOMICAL FAETURES OF BONES  FOR NURSING STUDENTS .pptx
ANATOMICAL FAETURES OF BONES FOR NURSING STUDENTS .pptxWINCY THIRUMURUGAN
 
historyofpsychiatryinindia. Senthil Thirusangu
historyofpsychiatryinindia. Senthil Thirusanguhistoryofpsychiatryinindia. Senthil Thirusangu
historyofpsychiatryinindia. Senthil Thirusangu Medical University
 
introduction to neurology (nervous system, areas, motor and sensory systems)
introduction to neurology (nervous system, areas, motor and sensory systems)introduction to neurology (nervous system, areas, motor and sensory systems)
introduction to neurology (nervous system, areas, motor and sensory systems)Mohamed Rizk Khodair
 
Pregnacny, Parturition, and Lactation.pdf
Pregnacny, Parturition, and Lactation.pdfPregnacny, Parturition, and Lactation.pdf
Pregnacny, Parturition, and Lactation.pdfMedicoseAcademics
 
SGK RỐI LOẠN TOAN KIỀM ĐHYHN RẤT HAY VÀ ĐẶC SẮC.pdf
SGK RỐI LOẠN TOAN KIỀM ĐHYHN RẤT HAY VÀ ĐẶC SẮC.pdfSGK RỐI LOẠN TOAN KIỀM ĐHYHN RẤT HAY VÀ ĐẶC SẮC.pdf
SGK RỐI LOẠN TOAN KIỀM ĐHYHN RẤT HAY VÀ ĐẶC SẮC.pdfHongBiThi1
 
Physiology of Smooth Muscles -Mechanics of contraction and relaxation
Physiology of Smooth Muscles -Mechanics of contraction and relaxationPhysiology of Smooth Muscles -Mechanics of contraction and relaxation
Physiology of Smooth Muscles -Mechanics of contraction and relaxationMedicoseAcademics
 
Red Blood Cells_anemia & polycythemia.pdf
Red Blood Cells_anemia & polycythemia.pdfRed Blood Cells_anemia & polycythemia.pdf
Red Blood Cells_anemia & polycythemia.pdfMedicoseAcademics
 
FDMA FLAP - The first dorsal metacarpal artery (FDMA) flap is used mainly for...
FDMA FLAP - The first dorsal metacarpal artery (FDMA) flap is used mainly for...FDMA FLAP - The first dorsal metacarpal artery (FDMA) flap is used mainly for...
FDMA FLAP - The first dorsal metacarpal artery (FDMA) flap is used mainly for...Shubhanshu Gaurav
 
Bulimia nervosa ( Eating Disorders) Mental Health Nursing.
Bulimia nervosa ( Eating Disorders) Mental Health Nursing.Bulimia nervosa ( Eating Disorders) Mental Health Nursing.
Bulimia nervosa ( Eating Disorders) Mental Health Nursing.aarjukhadka22
 
EXERCISE PERFORMANCE.pptx, Lung function
EXERCISE PERFORMANCE.pptx, Lung functionEXERCISE PERFORMANCE.pptx, Lung function
EXERCISE PERFORMANCE.pptx, Lung functionkrishnareddy157915
 

Kürzlich hochgeladen (20)

How to cure cirrhosis and chronic hepatitis naturally
How to cure cirrhosis and chronic hepatitis naturallyHow to cure cirrhosis and chronic hepatitis naturally
How to cure cirrhosis and chronic hepatitis naturally
 
CPR.nursingoutlook.pdf , Bsc nursing student
CPR.nursingoutlook.pdf , Bsc nursing studentCPR.nursingoutlook.pdf , Bsc nursing student
CPR.nursingoutlook.pdf , Bsc nursing student
 
Using Data Visualization in Public Health Communications
Using Data Visualization in Public Health CommunicationsUsing Data Visualization in Public Health Communications
Using Data Visualization in Public Health Communications
 
Male Infertility Panel Discussion by Dr Sujoy Dasgupta
Male Infertility Panel Discussion by Dr Sujoy DasguptaMale Infertility Panel Discussion by Dr Sujoy Dasgupta
Male Infertility Panel Discussion by Dr Sujoy Dasgupta
 
Microbiology lecture presentation-1.pptx
Microbiology lecture presentation-1.pptxMicrobiology lecture presentation-1.pptx
Microbiology lecture presentation-1.pptx
 
Physiotherapy Management of Rheumatoid Arthritis
Physiotherapy Management of Rheumatoid ArthritisPhysiotherapy Management of Rheumatoid Arthritis
Physiotherapy Management of Rheumatoid Arthritis
 
Different drug regularity bodies in different countries.
Different drug regularity bodies in different countries.Different drug regularity bodies in different countries.
Different drug regularity bodies in different countries.
 
High-Performance Thin-Layer Chromatography (HPTLC)
High-Performance Thin-Layer Chromatography (HPTLC)High-Performance Thin-Layer Chromatography (HPTLC)
High-Performance Thin-Layer Chromatography (HPTLC)
 
Female Reproductive Physiology Before Pregnancy
Female Reproductive Physiology Before PregnancyFemale Reproductive Physiology Before Pregnancy
Female Reproductive Physiology Before Pregnancy
 
ANATOMICAL FAETURES OF BONES FOR NURSING STUDENTS .pptx
ANATOMICAL FAETURES OF BONES  FOR NURSING STUDENTS .pptxANATOMICAL FAETURES OF BONES  FOR NURSING STUDENTS .pptx
ANATOMICAL FAETURES OF BONES FOR NURSING STUDENTS .pptx
 
Cone beam CT: concepts and applications.pptx
Cone beam CT: concepts and applications.pptxCone beam CT: concepts and applications.pptx
Cone beam CT: concepts and applications.pptx
 
historyofpsychiatryinindia. Senthil Thirusangu
historyofpsychiatryinindia. Senthil Thirusanguhistoryofpsychiatryinindia. Senthil Thirusangu
historyofpsychiatryinindia. Senthil Thirusangu
 
introduction to neurology (nervous system, areas, motor and sensory systems)
introduction to neurology (nervous system, areas, motor and sensory systems)introduction to neurology (nervous system, areas, motor and sensory systems)
introduction to neurology (nervous system, areas, motor and sensory systems)
 
Pregnacny, Parturition, and Lactation.pdf
Pregnacny, Parturition, and Lactation.pdfPregnacny, Parturition, and Lactation.pdf
Pregnacny, Parturition, and Lactation.pdf
 
SGK RỐI LOẠN TOAN KIỀM ĐHYHN RẤT HAY VÀ ĐẶC SẮC.pdf
SGK RỐI LOẠN TOAN KIỀM ĐHYHN RẤT HAY VÀ ĐẶC SẮC.pdfSGK RỐI LOẠN TOAN KIỀM ĐHYHN RẤT HAY VÀ ĐẶC SẮC.pdf
SGK RỐI LOẠN TOAN KIỀM ĐHYHN RẤT HAY VÀ ĐẶC SẮC.pdf
 
Physiology of Smooth Muscles -Mechanics of contraction and relaxation
Physiology of Smooth Muscles -Mechanics of contraction and relaxationPhysiology of Smooth Muscles -Mechanics of contraction and relaxation
Physiology of Smooth Muscles -Mechanics of contraction and relaxation
 
Red Blood Cells_anemia & polycythemia.pdf
Red Blood Cells_anemia & polycythemia.pdfRed Blood Cells_anemia & polycythemia.pdf
Red Blood Cells_anemia & polycythemia.pdf
 
FDMA FLAP - The first dorsal metacarpal artery (FDMA) flap is used mainly for...
FDMA FLAP - The first dorsal metacarpal artery (FDMA) flap is used mainly for...FDMA FLAP - The first dorsal metacarpal artery (FDMA) flap is used mainly for...
FDMA FLAP - The first dorsal metacarpal artery (FDMA) flap is used mainly for...
 
Bulimia nervosa ( Eating Disorders) Mental Health Nursing.
Bulimia nervosa ( Eating Disorders) Mental Health Nursing.Bulimia nervosa ( Eating Disorders) Mental Health Nursing.
Bulimia nervosa ( Eating Disorders) Mental Health Nursing.
 
EXERCISE PERFORMANCE.pptx, Lung function
EXERCISE PERFORMANCE.pptx, Lung functionEXERCISE PERFORMANCE.pptx, Lung function
EXERCISE PERFORMANCE.pptx, Lung function
 

Identifying the Signs for Implantation Failure and Miscarriage

  • 1. Identifying the signs for Implantation Failure and Miscarriage By Roy Farquharson Liverpool Women's Hospital UK Contact: rgfarquharson@yahoo.com 1
  • 2. Declaration of Interests • Executive Committee member, European Society of Human Reproduction and Embryology (2011 - 2015) • NICE Guideline Development Group for ectopic pregnancy and miscarriage (CG 154; 2010-2013) • Chair, Association of Early Pregnancy Units (2006-2011) • Co-ordinator, ESHRE Special Interest Group for Early Pregnancy (2007-2010) • Associate Editor, Human Reproduction Update (20102014) 2
  • 3. Educational Objectives • Learning Objectives • • At the conclusion of this presentation, participants should be able to: • Describe the assessment for the diagnosis of implantation failure, ectopic pregnancy and miscarriage • Acknowledge the limitations of available diagnostic methods • Develop a practical approach to using relevant tests and management protocols. 3
  • 4. 4
  • 5. Predictive Modelling for Early Pregnancy Best Area of Interest Diagnostic Utility Parameter(s) Ovulation Biomarker D21 Progesterone Pregnancy of Unknown Location (PUL) Transvaginal (TVU) Scan and Biomarker TVU Scan + HCG doubling time/ratio +/- Progesterone Pregnancy of Scan Fetal heart action Uncertain Viability Scan plus Crown-rump (PUV) ExclusivelyScan length 5
  • 6. Practical Advice - PULs 3. Predicting outcome  Hormones  Human chorionic gonadotrophin (hCG)  Progesterone  Other:     Creatine kinase CA 125 Activin A Inhibin A  Mathematical Models 6
  • 7. HCG changes in normal pregnancy • Mean (SE) serum concentrations of human chorionic gonadotrophin (adapted from Braunstein et al 1976) 7
  • 8. Haemodynamically stable Pain free Expectant management PUL Haemodynamically stable Haemodynamically unstable Pain Pain ? Serum hCG Serum hCG levels at 0 and 48 hrs +/progesterone ? Intra-uterine Pregnancy Consider laparoscopy/laparotomy Consider laparoscopy ? Ectopic Pregnancy ? Failing PUL 8
  • 9. Practical Advice - PULs 3. Predicting outcome  Hormones  Human chorionic gonadotrophin (hCG)  Progesterone  Other:     Creatine kinase CA 125 Activin A Inhibin A  Mathematical Models 9
  • 10. Serum hCG Levels Single Levels Serial Levels Discriminatory Zone 10
  • 11. Serum hCG Levels Single Levels Serial Levels Discriminatory Zone  Developed with respect to transabdominal USS  Lower levels of hCG used with TVS  Using a single value of hCG in a PUL population is of limited value:  Many ectopic pregnancies have a low hCG  Clinicians may be falsely reassured 11
  • 12. Serum hCG Levels Single Levels Serial Levels Change over 48hrs (hCG ratio) Intrauterine Pregnancies (IUPs)  Kadar et al. (1981) first to describe the minimal rate of rise for an IUP to be 66% over 48hrs  More recently minimal rise reported to be 53% (Barnhart et al. 2004)  In clinical practice a more conservative cut-off of 35% has been suggested 12
  • 13. Serum hCG Levels Single Levels Serial Levels Change over 48hrs (hCG ratio) Failing PULs  A decline of 21-35% at 48 hours depending on initial hCG level ( levels at presentation – rate of decrease) (Barnhart et al. 2004)  An hCG decrease of >13% (hCG ratio < 0.87) has been shown to have a sensitivity of 92.7% and a specificity of 96.7% for the prediction of a failing PUL (Condous et al., 2006) 13
  • 14. Serum hCG Levels Single Levels Serial Levels Change over 48hrs (hCG ratio) Ectopic Pregnancies (EPs)  ‘No single way to characterize the pattern of serum hCG behaviour’ (Silva et al., 2006)  hCG profile mimicked IUP in 21% and a spontaneous miscarriage in 8% (Silva et al., 2006)  Sensitivity of 83% for EP when IUP excluded by hCG rise < 35% and failing PUL excluded by hCG decrease > 14 21-35% (Seeber et al., 2006)
  • 15. Evidence based management of PULs Predicting outcome  Hormones  Human chorionic gonadotrophin (hCG)  Progesterone  Other:     Creatine kinase CA 125 Activin A Inhibin A  Mathematical Models 15
  • 16. Serum Progesterone Levels Serum Progesterone < 20 nmol/L PPV > 95% to predict pregnancy failure (Banerjee et al., 2001) Viable IUPs reported with levels < 16nmol/L > 60 nmol/L ‘Strongly’ associated with viable pregnancies Discriminative capacity insufficient to diagnose ectopic pregnancy with certainty (Mol et al., 1998) Good at predicting viability but not location 16
  • 17. Pregnancies of Unknown Location (PULs) • The majority of PULs fail and resolve spontaneously (44% – 69%) RCOG green top guideline on Tubal Pregnancy 2004 sourcing five observational studies • Of the remainder, ectopic pregnancy was subsequently diagnosed in 14 to 28% • Intervention (medical or surgical) was required in approx 25% cases 17
  • 18. HCG in practice (NICE 2012) • Clinical symptoms more important than HCG results • HCG levels do not ‘locate’ the pregnancy nor assess viability • 2 levels 48 hours apart are useful for ‘risk stratification’ and act as best evidence for subsequent management • Limitations of prediction should be shared and acknowledged to patients (eg ectopic pregnancy HCG levels mimic viable IUP in 21% and EPL in 8%) • Ectopic pregnancy and miscarriage: diagnosis and initial management in early pregnancy of ectopic pregnancy and miscarriage. (NICE Clinical guideline 154; 2012; www.nice.org.uk) 18
  • 19. Sites of ectopic pregnancies Illustration: John Yanson.Seeber. Suspected Ectopic Pregnancy. Obstet Gynecol 2006. From: Seeber: Obstet Gynecol, Volume 107(2, Part 1).February 2006.399-413 19
  • 20. Ectopic Pregnancy • Variable mode of presentation • ‘Mask of invisibility’ • High index of suspicion and vigilance eg against diagnosis of complete early pregnancy loss • All areas of emergency care provision will receive cases of undiagnosed ectopic pregnancy 20
  • 21. Ectopic Pregnancy presentation • ACUTE (typical) • Collapse with lower abdominal pain, tachycardia and hypotension • Pain, amenorrhoea and sign of pelvic tenderness • EPU presentation with positive pregnancy test, scan showing empty uterus and adenexal inhomogeneous mass • CHRONIC (atypical) • Symptoms mimicking gastroenteritis • Light irregular bleeding • >1/3rd of all patients have no risk factors 21
  • 22. HCG studies • • • • • • • Review question What is the diagnostic accuracy of two or more hCG measurements for determining an ectopic pregnancy in women with pain and bleeding and pregnancy of unknown location? Description of included studies Nine studies were included in this review (Barnhart et al., 2010; Condous et al., 2004; Condous et al., 2007; Dart et al., 1999; Daus et al., 1989; Hahlin et al., 1991; Mol et al., 1998; Stewart et al., 1995; Thorburn et al., 1992). Five prospective cohort studies (Condous et al., 2004; Condous et al., 2007; Hahlin et al., 1991; Mol et al., 1998; Thorburn et al., 1992) Four retrospective cohort studies (Barnhart et al., 2010; Dart et al., 1999; Daus et al., 1989; Stewart et al., 1995). Conducted in the UK (Condous et al., 2004; Condous et al., 2007), the USA (Dart et al., 1999; Daus et al., 1989; Stewart et al., 1995), the Netherlands (Mol et al., 1998) and Sweden (Hahlin et al., 1991; Thorburn et al., 1992). One study (Barnhart et al., 2010) was conducted in both the UK and USA. 22
  • 23. GRADE system • • GRADE (Grading of Recommendations Assessment,Development and Evaluation) assesses evidence on an outcome-by-outcome basis Quality can vary within a study and is based on 5 factors: – Study design – Limitations Inconsistency Indirectness Imprecision – – – 23 23 23
  • 24. Summary of findings Quality assessment No. of studies Design Limitati ons Incon siste ncy Indirect ness Imprec ision Other consider ations Nu m be r of w o m en Measure of diagnostic accuracy Sensiti vity % (95% CI) Specifi city % (95% CI) Positi ve predic tive value % (95% CI) Negative predictiv e value % (95% CI) Positiv e likelih ood ratio % (95% CI) Negati ve likelih ood ratio % (95% CI) Qualit y% (95% CI) GRADE findings for the diagnosis of ectopic pregnancy using two or more hCG measurements Model M4 1 study Condous et al., 2007 prospec tive study 1 study Barnhart et al., 2010 retrospe ctive study (2 included cohorts: UK and adjuste d USA) serious1, 6 serious4, 6 serious4, 6 no seriou s incons istenc y serious2, no seriou s incons istenc y serious2, no seriou s incons istenc y serious1 12 12 no serious impreci sion none no serious impreci sion none 173 431 80.0 (59.8, 100) 80.8 (65.6, 95.9) 88.6 (83.7, 93.6) 88.9 (85.8, 92.0) 40.0 (22.5, 57.5) 31.8 (20.6, 43.1) 97.9 (95.6, 100) 98.6 (97.4, 99.8) 7.02 (4.25, 11.61) 7.27 (5.21, 10.14) 0.23 (0.08 , 0.62) 0.22 (0.10 , 0.48) LOW V. LOW 3 no serious impreci sion none 544 54.8 (45.2, 64.4) 87.7 (84.7, 90.8) 51.4 (42.1, 60.7) 89.2 (86.2, 92.1) 4.47 (3.29, 6.06) 0.52 (0.46 , 0.64) V. LOW 24
  • 25. Treatment Options for EcP and PUL • Laparoscopic surgery ESEP RCT 2013 (NL) – Salpingectomy versus Salpingostomy • Systemic Methotrexate (MTX) - DEMETER RCT 2013 (Fr) • – Expectant management - METEX RCT 2013 (NL) 25
  • 26. When can expectant management be employed? • • • • • • • Clinically stable Minimal symptoms Discriminatory HCG zone: 1000-2000iu/l Weekly USS Twice weekly HCG until <20 iu/l Compliance with follow up Immediate access to hospital 26
  • 27. Take home messages • Laparoscopic surgery is cornerstone of treatment intervention with ectopic pregnancy • Results of RCT’s (DEMETER) improve evidence level and inform practice eg less MTX use • Advantages of centralisation of care in EPU • CMACH report on awareness of failed medical management 27
  • 28. It’s all about Quality of Care 28
  • 29. The signs of Miscarriage • Exclusively ultrasound based • Updated CRL measurements • Revised crown rump length criteria for confirmed diagnosis of early pregnancy loss (>7mm; NICE GDG & RCOG 2012) • Acknowledgement of inherent, wide biological variation of embryo growth velocities • Specificity of viability assessment is 99.9% 29
  • 30. Comparison of the CRL curve (solid line) with the Robinson curve (dashdotted) and the Hadlock curve (dotted) 90 80 70 CRL (in mm) 60 50 40 30 20 10 0 40 50 60 70 GA (in days) 80 90 100 30
  • 31. Updated Gestational Age Measurement in early pregnancy • Total number of pregnancies: 6666 (2002-2008) • No. Excluded = 2956 (uncertain dates, redated, infertility treatment, miscarriage, stillbirth, genetic or congenital abnormalities) • No. Included = 3710 normal singleton pregnancies dated according to known and recorded last menstrual period (LMP) with confirmed viability at the time of the nuchal scan • Predominantly transvaginal ultrasound below 10 weeks by contrast with Robinson transabdominal derived CRL curve (BMJ, 1972) • The gestational age (GA) ranged between 35 and 98 days • Linear mixed-effects model in order to account for possible codependency of multiple CRL measurements in the same patient Reference: Bottomley C ,Bourne T. Dating and growth in the first trimester. Best Practice and research Clin Obstet Gynaecol 2009 ; ESHRE precongress course, Roma, 2010 31
  • 32. TV Ultrasound Fetal loss with CRL =7mm 32
  • 33. Embryoscopy – the close-up H=head/heart prominence, Y=yolk sac, B=bubble 33
  • 34. TVU – small embryonic structure in disproportionately large sac 34
  • 35. Embryoscopy – short body stalk with 6mm CRL - cytogenetics = 47XY+7 35
  • 36. Fetal loss at 7 weeks CRL = 19mm 36
  • 37. Cytogenetics = 47XY+15 Small head compared to CRL, dysplastic face, partial encephalocele 37
  • 38. Is Treatment Failure in RM a valid concept? - Cytogenetic Analysis of Pregnancy Loss in RM 38
  • 40. microarrays • technique high resolution WHOLE genome scan cytogenetics FISH arrays 40
  • 41. • Microarray Advantages - SINGLE test vs Karyotype + 5 FISH tests - DNA extraction directly vs cell culture - detect low level fetal cells vs maternal cell contamination - higher resolution vs lower resolution Disadvantages - CANNOT detect ‘balanced’ rearrangements - confirmatory follow up studies 41
  • 42. • Trisomy 10 - TR Karyotype = Normal Female Array = Abnormal MALE result +10 FISH = confirmed +10 (70% MCC) 42
  • 43. • 14q deletion - JS Karyotype = Normal Female Array = Abnormal Female – deletion 14q FISH = confirm deletion in 11% of cells (89% MCC) 43
  • 44. RM – Evaluation of Array CGH v Conventional Cytogenetics (McNamee et al, British Journal of Hospital Medicine, 2013, 74, 36-40 ) Array CGH and conventional cytogenetics N=50 Triploidy on FISH N=4 Normal result N=23(46%) Abnormal result N=27 (54%) Diagnosed with conventional cytogenetics Missed with N=14 N=9 NUMERICAL +16 x3 +15 x2 +21 x2 +13 x2 +22 +10 +14 -X x2 conventional cytogenetics NUMERICAL +22 +10 +15 +8 +16 STRUCTURAL >dup(22)(q11.2q11.2) , >del(14q)(q31.1) ,t(1:q1 6)mat >del(13q)12.3-q34 44
  • 45. Pregnancy Success Prediction Matrix Following idiopathic RM, the predicted probability (%) of successful pregnancy is determined by age and previous miscarriage history ( 95% confidence interval <20% in bold). _____________________________________________________________________________ Age Number of Previous Miscarriages (yrs) 2 3 4 5 _____________________________________________________________________________ 20 92 90 88 85 25 89 86 82 79 30 84 80 76 71 35 77 73 68 62 40 69 64 58 52 45 60 54 48 42 _______________________________________________________________________ Brigham et al, Hum Rep, 1999, 14, 2868-2871; PROMISE Trial 2010 MRC/HTA funded 45
  • 46. Previous single miscarriage Risk of preterm delivery <37 weeks OR 1.1-1.4 ONE MISCARRIAGE Basso '98 1.333/ 21.166 Buchmayer '04 1.293/ 21.631 Martius '98 1.069/ 13.461 Pickering '91 ?/ 8.589 Smith '06 673/ 9.215 Hammoud '07 369/ 5.973 Pickering '85 ?/ 3.927 Thom '92 174/ 2.146 Lang '96 ?/? Bhattacharya '08 128/ 1.404 Lekea '90 117/ 1.291 El-Bastawissi '03 69/ 143 Schoenbaum '80 17/189 Nguyen '04 16/164 0.1 1 10 46
  • 47. Previous two or more miscarriages Risk of preterm delivery <37 weeks I OR 1.1-1.4 II OR 1.6-2.1 III OR 1.5-3.0 TWO MISCARRIAGES Basso '98 432/ 5.268 Martius '98 309/ 2.788 Smith '06 178/ 1.792 Buchmayer '04 146/ 1.742 Pickering '91 ?/ 1.524 Hammoud '07 88/ 908 Lang '96 ?/ ? Pickering '85 ?/ 689 Lekea '90 73/ 439 El-Bastawissi '03 31/ 57 Nguyen '04 8/ 33 RECURRENT MISCARRIAGE Martius '98 151/ 639 Thom '92 63/ 638 Lang '96 ?/ ? Hammoud '07 36/ 225 Lekea '90 ?/ ? Hughes '91 11/88 Jivraj '01 7 /61 0.1 1 10 47
  • 48. Previous miscarriage(s) Risk of very preterm delivery <34 weeks I II OR 2.2-3.4 III ONE MISCARRIAGE Basso '98 466/ 21.166 Buchmayer '04 219/ 21.631 Martius '98 195/ 13.461 Smith '06 138/ 9.215 Hammoud '07 92/ 5.973 Bhattacharya '08 39/ 1.404 Thom '92 26/ 2.146 El-Bastawissi '03 16/ 90 OR 1.5-1.7 NS 2.4-6.7 TWO MISCARRIAGES Basso '98 158/ 5.268 Martius '98 71/ 2.788 Smith '06 56/1.792 Buchmayer '04 44/ 1.742 Hammoud '07 6/ 908 El-Bastawissi '03 6/ 32 RECURRENT MISCARRIAGE Martius '98 52/ 639 Thom '92 27/ 638 Hammoud '07 5/ 225 0.1 1 10 48
  • 49. Previous miscarriage(s) Risk of small for gestational age I NS II OR 1.4 III NS (?) ONE MISCARRIAGE Basso '98 1.291/ 21.166 Pickering '85 ?/ 3.927 Lang '96 ?/ ? Thom '92 94/ 2.146 Parazzini '07 96/ 439 TWO MISCARRIAGES Basso '98 395/ 5.268 Pickering '85 ?/ 689 Lang '96 ?/ ? RECURRENT MISCARRIAGE Thom '92 41/ 638 Lang '96 ?/ ? Jivraj '01 5/ 61 Hughes '91 3/ 88 0.1 1 10 49
  • 50. Risk of adverse outcome in subsequent pregnancy OR/ *RR Termination of pregnancy Miscarriage 1 ≥2 ≥3 1 ≥2 1.0-3.31.2 1.0-1.54 - ns ns Placental abruption ns 1.54 - ns ns Placenta previa ns 1.74 *6.04 ns ns Preterm <37 1.1-1.43,5 1.6-2.13.5 *1.5-3.01,6 1.1-1.36,8 1.6-2.36,8 Preterm <34 1.5-1.73,5 2.2-3.43,5 *2.4-6.71,6 1.3-1.57,8 1.8-2.97,8 SGA p<10 ns 1.45 ?1 ns ns LBW <2500 ns ?4,5 *2.04 ns ns LBW <1500 ns ns - ?9,10 ?9 Cong. Malformation ns ns *1.84 ns ns Low AS ns ns ns ns ns 1.92 ns ns ns ns Number Preeclampsia Intrauterine Fetal death 1 Thom et al. 1992; 2 Bhattacharya et al., 2008; 3 Buchmayer et al., 2004; 4 Sheiner et al., 2005; 5 Basso et al., 50 1998; 6 Martius et al., 1998; 7 Moreau et al 2005; 8 Ancel et al., 2004; 9 Lumley 1985; 10 Reime et al 2008
  • 51. Vanishing Twin phenomenon • Spontaneous reduction of a multiple pregnancy • IVF-population (~5%) • Incidence 10-30%1-3 • Studies: IVF population • Vanishing twin IVF pregnancies, which were spontaneous reduced from twin to single pregnancies, were compared to single IVF pregnancies 1 Dickey et al., 2002; 2 Landy and Keith 1998; 3 Pinborg et al., 2005 51
  • 52. Vanishing Twin: Risk of Preeclampsia and SGA PREECLAMPSIA *Pinborg 2007 Chasen 2006 X SGA Shebl 2007 *Pinborg 2007 La Sala 2004 Dickey 2002 Chasen 2006 0 1 2 3 4 5 6 Preeclampsia and SGA 52
  • 53. Vanishing Twin; SGA-LBW Low birht weight <2500g Cas e Control O R 95%CI %Case 2004 Retrospective 62 437 Pinborg et al 2007 Retrospective 642 5.237 1,7 1,1-2,7 S 187 424 2,8 1,1-7,1 S 2,0 1,5-2,6 2005 Retrospective 642 5.237 Shebl et al 2007 Retrospective 46 8,9% Signi La Sala et al Pinborg et al 9,7% %Control NS vanishing twin > 8 wks vs <8 wks 11,7% 6,3% 0,001 92 26,1% 12,0% 0,036 3,2% 2,7% 4,1% 1,5% Very low birth weight <1500g La Sala et al 2004 Retrospective 62 437 Pinborg et al 2005 Retrospective 642 5.237 3,0 1,9-4,7 NS 0,001 Small for gestational age p<10 Chasen et al 2006 Retrospective 55 168 14,5% 9,6% NS Dickey et al 2002 Retrospective 140 4.683 15,7% 4,5% NS La Sala et al 2004 Retrospective 62 437 9,7% 15,6% NS Pinborg et al 2007 Retrospective 642 5.237 1,6 1,1-2,3 S 187 424 2,1 0,99-4,4 NS 46 92 Shebl et al 2007 Retrospective 32,6% 16,3% Vanishing twin > 8 wks vs. <8 wks 0,029 53
  • 54. The Sound of Life - Greetings From Liverpool!! 54
  • 55. Sites of ectopic pregnancies Illustration: John Yanson.Seeber. Suspected Ectopic Pregnancy. Obstet Gynecol 2006. From: Seeber: Obstet Gynecol, Volume 107(2, Part 1).February 2006.399-413 55