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Physiological oocyte activation requires a synergy between the oocyte and sperm to release calcium (Ca ) through oscillations. The absence of such synergy between the oocyte and sperm leads to a negative impact on oocyte activation. Artificial oocyte activation (AOA) can be performed by mechanical, chemical, or electrical approaches. Studies have shown that AOA is helpful in cases of fertilization failure or low fertilization rate, especially in couples with globozoospermia. However, mixed opinions are present on the effect of AOA on blastocyst rate. Thus, this study aimed to investigate the effect of AOA on blastocyst rate in patients with poor or no blastocyst development on their previous In Vitro Fertilization-Intracytoplasmic Sperm Injection (IVF-ICSI) attempt. This retrospective cohort single-center study compared intracytoplasmic sperm injection (ICSI) AOA cycles with previous conventional ICSI cycles, and conventional ICSI without AOA cycles with previous conventional ICSI cycles in couples with failed or low blastocyst rates (<30%) in the original ICSI cycle. In total, 54 couples with suboptimal blastocyst development between January 2018 and October 2023 were included in the study. Twenty-two couples underwent an ICSI-AOA cycle consisting of calcium ionophore (GM508-CultActive) exposure on their second cycle, and 32 couples underwent conventional ICSI without an AOA cycle on their second cycle. The primary outcome measured was blastocyst rate, and secondary outcomes were the percentage of patients without usable embryos, oocyte maturation, fertilization, and pregnancy rates. We compared 22 AOA cycles to previous conventional ICSI cycles in the same patients and 32 conventional ICSI cycles without AOA to previous conventional ICSI cycles in the same patients. After AOA, the blastocyst rate was not significantly higher than the control group (48% versus 29%, p=0.19). Conversely, the blastocyst rate was significantly higher in the conventional ICSI without AOA cycles than in the control group (48% versus 24%, p=0.04). The fertilization rate and the percentage of patients without usable embryos were not statistically significant between the first and second cycles in both groups. The literature still lacks strong evidence for AOA overcoming impaired embryonic development. Therefore, AOA remains reserved for couples with a failed or low fertilization history to improve fertilization results. Optimal laboratory conditions and ovarian stimulation modifications without AOA may improve blastocyst rates. Further research is needed to validate our findings due to the presence of confounding factors, small sample size, and retrospective design of the study.

Cervical ectopic pregnancy is a rare and potentially life-threatening condition, often presenting with irregular vaginal bleeding and a palpable cervical mass. The coexistence of cervical fibroids further complicates the diagnosis and management. A 29-year-old woman, P L , presented with a history of three months of irregular and heavy vaginal bleeding. She also reported recurrent urinary tract infections and difficulty in passing urine for the past two years. On per abdominal examination, the uterus was enlarged to 20 weeks of gestation. Transvaginal ultrasound showed a cervical ectopic pregnancy of nine weeks and six days of gestation in the presence of a large cervical fibroid. The patient underwent emergency laparotomy with a total hysterectomy. Intraoperative findings included a highly vascular, 20-week-sized uterus and a gestational sac located in the posterior lip of the cervix. Considering rarity and possible untoward events, the case was taken under general anesthesia. Severe bleeding complicated the management, requiring internal iliac artery ligation. The patient's postoperative course was uneventful, and she was discharged on day 5. This case report highlights the challenges in diagnosing and managing a cervical ectopic pregnancy complicated by a large cervical fibroid.

Background and objective Total abdominal hysterectomy represents one of the most frequently performed gynecological procedures globally, with intraoperative hemorrhage constituting a significant clinical concern impacting surgical outcomes and patient morbidity. Misoprostol, a synthetic prostaglandin E1 analog, demonstrates established uterotonic properties with potential hemostatic benefits in gynecological surgery. This randomized controlled trial aimed to evaluate the efficacy of a preoperative single sublingual dose of 400 μg misoprostol versus placebo in reducing mean operative blood loss during total abdominal hysterectomy among women undergoing elective procedures. Methodology This randomized controlled trial (Trial registration number: SPH0000567) was conducted at the Department of Obstetrics and Gynecology Unit-I, Sandeman Provincial Hospital, Quetta, from October 2015 to April 2016. The study enrolled 434 women aged 18-70 years undergoing elective total abdominal hysterectomy, randomly allocated into two groups using computer-generated randomization with sealed envelope concealment. Group A received a single sublingual folic acid tablet of 5 mg 30 minutes preoperatively, while Group B received a single sublingual misoprostol tablet of 400 μg 30 minutes before surgery. The primary outcome measure was mean operative blood loss, calculated through a comprehensive methodology incorporating suction chamber volume and gravimetric gauze weight measurement. Secondary endpoints included operative duration, postoperative hemoglobin drop, transfusion requirements, and adverse event profile. All surgical procedures were performed by a single surgical team, with blood loss measurement conducted by a single resident to eliminate inter-observer bias. Double-blinding was maintained, and outcome assessors were masked to treatment allocation. Results The study demonstrated a statistically significant reduction in mean operative blood loss in the misoprostol group compared to the placebo group, with values of 364.55±53.26 ml versus 422.65±56.77 ml, respectively, representing a mean difference of 58.1 ml (13.7%) reduction (p<0.001). Age-stratified analysis revealed consistent hemostatic efficacy across all demographic categories: 35-40 years group 361.97±56.25 ml versus 420.11±51.95 ml (p<0.001), 41-45 years group 367.43±43.05 ml versus 419.07±62.96 ml (p<0.001), and 46-50 years group 362.79±60.96 ml versus 426.67±53.26 ml (p<0.001). Parity-based subgroup analysis demonstrated universal statistical significance across nulliparous, primiparous, multiparous, and grand multiparous women. Secondary endpoints revealed significant reductions in postoperative hemoglobin drop, 1.85±0.42 g/dl versus 2.34±0.56 g/dl (p<0.001), and transfusion requirements, 8 patients (3.7%) versus 23 patients (10.6%) (p=0.003), representing a 65% relative risk reduction. Hospital length of stay was reduced to 2.8±0.6 days versus 3.1±0.7 days (p=0.012). Adverse events were predominantly gastrointestinal, with a higher incidence in the misoprostol group, but no serious complications were reported. Conclusion Preoperative sublingual misoprostol 400 μg administered 30 minutes before total abdominal hysterectomy significantly reduces intraoperative blood loss with an acceptable safety profile. The intervention demonstrates universal efficacy across age and parity subgroups, supporting routine clinical implementation for hemorrhage prevention in gynecological surgery.

Background and objective Intrauterine growth restriction (IUGR) represents a significant obstetric complication with substantial global prevalence, with idiopathic cases constituting a considerable proportion where conventional therapeutic interventions demonstrate limited efficacy. Progesterone analogues have emerged as potential therapeutic agents for managing pregnancy-related complications, though evidence regarding their specific application in idiopathic IUGR remains limited. This prospective observational study aimed to evaluate the efficacy of oral dydrogesterone supplementation in improving neonatal birth weight outcomes among pregnant women diagnosed with idiopathic IUGR compared to conventional treatment modalities. Methodology A prospective observational study was conducted at the Department of Obstetrics and Gynecology, Sandeman Provincial Hospital, Quetta, over a six-month period from October 16, 2015, to April 15, 2016. The study enrolled 46 pregnant women aged 18-35 years with singleton pregnancies presenting at 28-34 weeks of gestation and diagnosed with idiopathic IUGR. Participants were allocated into two groups using a lottery method: Group A received conventional treatment comprising iron, folic acid supplementation, complete bed rest, and a high-protein diet, while Group B received identical conventional treatment plus oral dydrogesterone 10 mg twice daily for a minimum of four weeks or until delivery. The primary outcome measure was neonatal birth weight assessed within the first hour of delivery by trained nursing staff using calibrated scales. Results The study demonstrated statistically significant improvement in mean neonatal birth weight in the dydrogesterone group compared to conventional treatment, with mean birth weights of 2.10±0.19 kg versus 1.60±0.22 kg, respectively, representing a clinically meaningful difference of 0.50 kg with p<0.001. The dydrogesterone intervention achieved a 31.3% relative increase in birth weight outcomes. Subgroup analysis revealed consistent therapeutic benefits across all demographic stratifications, including age groups 18-23 years (2.08±0.21 kg versus 1.60±0.29 kg, p=0.016), 24-29 years (2.06±0.16 kg versus 1.64±0.22 kg, p<0.001), and 30-35 years (2.18±0.23 kg versus 1.62±0.20 kg, p<0.001). Parity analysis demonstrated significant improvements in primiparous (2.06±0.18 kg versus 1.65±0.23 kg, p<0.001), multiparous (2.15±0.23 kg versus 1.61±0.20 kg, p<0.001), and grand multiparous participants (2.15±0.07 kg versus 1.60±0.14 kg, p=0.039). Treatment success rate, defined as achieving a birth weight greater than 2.0 kg, was 91.3% (n=21) in the dydrogesterone group compared to 13.0% (n=3) in conventional treatment (p<0.001). Safety analysis revealed excellent tolerability with minimal adverse events reported in 8.7% (n=2) of dydrogesterone recipients. Conclusion Oral dydrogesterone supplementation demonstrates significant therapeutic efficacy in improving neonatal birth weight outcomes in idiopathic IUGR with an excellent safety profile. The substantial birth weight improvement of 0.50 kg supports potential integration into evidence-based clinical protocols for this challenging obstetric condition, warranting further large-scale randomized controlled trials for definitive clinical validation.

Introduction The obstetrical team's efforts are consistently focused on minimizing the number of cesarean sections, particularly in nulliparous women. One of the most crucial steps is to understand the risk factors that predispose the woman to a cesarean section. This study aimed to identify the predictors of emergency cesarean sections in nulliparous women using a machine learning approach. Methods A retrospective cohort study was carried out at a maternal tertiary center in Iran among nulliparous women with a single cephalic pregnancy, ≥37 weeks of gestation, and induced or spontaneous labor, who gave birth between January 2020 and December 2022. The exclusion criteria were maternal request for cesarean section or those who delivered via cesarean section before the onset of labor. The rate of emergency cesarean section and the performance of machine learning in predicting emergency cesarean section were the outcome measures. Twenty-three factors potentially linked to the method of childbirth were initially identified, and included age, educational level, place of residence, medical insurance, nationality, attending prenatal education course, gestational age, the onset of labor, having a doula during the labor process, analgesia during labor, history of infertility, history of abortion, maternal anemia, cardiovascular disease, diabetes, maternal obesity, preeclampsia, prolonged rupture of membrane, placenta abruption, meconium amniotic fluid, intrauterine growth retardation, newborn weight, and newborn sex. The input data were fed into seven machine learning models: linear regression, logistic regression, decision tree classification, random forest classification, XGBoost classification, permutation classification (KNN), and deep learning. Results During the study period, 1916 (71.8%) of the 2668 births were vaginal, while 752 (28.2%) were by cesarean section. Cesarean sections were more common in mothers of advanced age and with a higher level of education. Attending a prenatal education course was also linked to the method of childbirth. Induced labor was more common in women who had a cesarean section. Those who had a doula were more likely to give birth vaginally. Maternal diabetes, obesity, preeclampsia, thyroid disease, placental abruption, meconium amniotic fluid, and fetal macrosomia were all linked to the method of childbirth. The area under the curve (AUC) for each model turned out to be: linear regression (0.86), XGBoost classification (0.83), logistic regression (0.79), deep learning (0.78), permutation classification (K-Nearest Neighbors or KNN) (0.77), decision tree classification (0.76), and random forest classification (0.72). Linear regression had a better diagnostic performance than other models with the area under the ROC curve (AUROC): 0.86, accuracy: 0.82, precision: 0.79, recall: 0.85, and F1-Score: 0.79). The linear regression model showed that advanced maternal age, advanced maternal education, diabetes, preeclampsia, placenta abruption, hypothyroidism, meconium amniotic fluid, late-term pregnancy, doula support, and attending prenatal courses were predictors of emergency cesarean section in nulliparous women. Conclusions Utilizing a clinical database and various machine learning algorithms showed potential in predicting emergency cesarean section. Additional prospective research, including intrapartum clinical characteristics, is essential for improving the accuracy of prediction accuracy.

Heterotopic pregnancy is defined as the simultaneous presence of gestation in two different sites, typically comprising an intrauterine pregnancy and an ectopic pregnancy. Due to the widespread use of assisted reproductive technologies (ARTs), the incidence of heterotopic pregnancies has increased significantly. A 36-year-old Caucasian woman, gravida 1, para 0, Rhesus positive, was referred to our hospital with a suspected ectopic pregnancy following her third in vitro fertilization with intracytoplasmic sperm injection cycle. The patient reported no vaginal bleeding or abdominal pain at the time of admission. Her medical history included dysmenorrhea, dyspareunia, and prior hysteroscopic removal of an endometrial polyp. She had no other significant medical, surgical, or family history. Transvaginal ultrasound confirmed the diagnosis of a heterotopic pregnancy. The patient underwent surgical management to address the ectopic component. The incidence of heterotopic pregnancy has risen in recent years due to the increased use of ARTs. In cases of tubal ectopic pregnancy, surgical intervention should be carefully considered, even when the risk to the coexisting intrauterine pregnancy cannot be entirely excluded.

Cesarean scar endometriosis is a rare form of endometriosis characterized by the presence of functional endometrial tissue within a surgical scar. Diagnosing this condition is challenging, as it is frequently misdiagnosed as granulomas, hernias, abscesses, hematomas, or neoplasms. The classic triad of symptoms includes a positive surgical history, cyclical pain, and a mass at the surgical scar. The presented case highlights the pivotal role of imaging modalities such as MRI, along with histopathological confirmation, in establishing a definitive diagnosis. Surgical excision with clear margins is the mainstay of treatment and remains superior to medical therapy in terms of long-term outcomes. Diagnosis relies on a high index of clinical suspicion. Clinical evaluation, along with ultrasound, computed tomography (CT), or magnetic resonance imaging (MRI), aids in diagnosis. Surgical intervention is the definitive treatment, providing specimens for histopathological confirmation. We report the case of a 27-year-old woman with a history of one cesarean delivery who presented with a progressively enlarging, painful mass over her lower abdominal scar. The pain was cyclical and associated with menstruation. MRI revealed a heterogeneous mass not reaching rectus sheath. Surgical excision of the lesion was performed, and histopathological examination confirmed the diagnosis of endometriosis. The patient recovered uneventfully, with complete resolution of symptoms and no recurrence at six-month follow-up. This case highlights the importance of considering scar endometriosis in women with a history of cesarean section who present with cyclical pain and a mass at the scar site. Early recognition and surgical excision are essential for symptom relief and to prevent recurrence. Increased clinical awareness is crucial to avoid misdiagnosis and unnecessary delays in treatment.

A 30-year-old woman presented with abdominal pain, amenorrhea, and a significantly enlarged abdomen. Initially, she believed she was pregnant due to the cessation of her menstrual cycles and gradual abdominal growth over several months. However, an ultrasound examination revealed a massive ovarian cyst, rather than a pregnancy. Due to the patient's extremely late presentation, which resulted in a giant ovarian cyst, a laparotomy was necessitated over laparoscopy, as the sheer size and complexity of the case demanded an open surgical approach to ensure safe and effective management. Despite the challenges posed by the case, the healthy ovary was successfully preserved, pertaining to the young age of the patient. This case underscores the importance of regular medical check-ups and timely ultrasounds for early detection and management of ovarian cysts. The absence of distinctive symptoms in this case made accurate preoperative diagnosis challenging, emphasizing the need for awareness and prompt evaluation to prevent complications. Early diagnosis and intervention are crucial in managing ovarian cysts and preventing potential complications, highlighting the significance of timely medical evaluation.

Intraoperative adhesions, particularly between the bladder and cesarean scar, as well as between the uterus and anterior abdominal wall, are commonly encountered in patients with a history of cesarean sections. These adhesions substantially elevate the risk of severe intraoperative complications, including bowel or bladder injuries, during hysterectomy. The incidence of bladder complications is significantly lower in patients with one or two prior cesarean sections compared to those with three or more. Moreover, the likelihood of inadvertent cystotomy is several times higher in patients with three or more cesarean sections than in those with no prior cesarean sections. Here, we report a simple, safe, and reproducible  approach for bladder dissection. This innovative technique, developed by us, is particularly effective when the lateral window cannot be identified. With the rising incidence of cesarean sections, surgeons are increasingly encountering dense bladder adhesions during hysterectomies. The Head-On technique was developed specifically for bladder dissection in such cases to minimize the risk of urogenital tract injuries.

Ovarian stimulation is used in assisted reproductive technology to help infertile couples achieve pregnancy. Luteal-phase stimulation with progestin-primed ovarian stimulation (PPOS) is a practical approach, as it involves oral medication with fewer daily injections compared to gonadotropin-releasing hormone (GnRH) agonist or GnRH antagonist protocols. Unintended pregnancy during ovarian stimulation or after oocyte pick-up (OPU) is rare but possible. We present the case of a 38-year-old patient with secondary infertility, known to have endometriosis, chronic inflammatory demyelinating polyneuropathy, and low ovarian reserve. She initially underwent ovarian stimulation with an antagonist protocol, which was later switched to luteal-phase PPOS to improve synchronization. For ovulation induction to initiate luteal-phase stimulation, the patient received human chorionic gonadotropin (hCG). A pregnancy test performed during ovarian stimulation yielded a result consistent with exogenous hCG administration. On the day of OPU, a corpus luteum was observed in the right ovary, and two follicles were present in the left ovary. OPU resulted in the retrieval of one oocyte, which developed into a blastocyst and was subsequently cryopreserved. A natural pregnancy was detected by hCG testing 10 days after OPU, prompted by a delayed menstrual cycle and the corpus luteum observed during OPU. Transvaginal ultrasound confirmed an intrauterine pregnancy with a positive fetal heartbeat. This case highlights the importance of considering the possibility of pregnancy even after luteal-phase PPOS and OPU, taking into account both the patient's clinical context and laboratory findings.