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The Official Journal of the Middle East Fertility Society Abstracts of
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The Official Journal of the Middle East Fertility Society Abstracts of
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Insulin resistance in polycystic ovary
syndrome and the role of oral hypoglycemic agents
Mohamed F. Mitwally and Robert F. Casper
Division of Reproductive Sciences, Department of Obstetrics & Gynecology, University of Toronto, Toronto, Canada.
ABSTRACT
Polycystic ovary syndrome is one of the most common endocrine disorders in women in the reproductive age group. Its prevalence cannot be determined with precision because it depends on the definition. Approximately 60% to 70% of women with PCOS are obese, and it is well known that obesity is associated with insulin resistance. However, women with PCOS have evidence of insulin resistance beyond that of obesity. The exact mechanism(s) for insulin resistance is uncertain, but a post-receptor defect in adipose tissue has been suggested. Insulin is an atherogenic hormone and insulin resistance with hyperinsulinemia is a major risk factor for the development of noninsulin-dependent diabetes mellitus at a young age. Historically, management of PCOS has been based upon symptom control, especially correction of oligomenorrhea and hirsutism. However, we believe that newer therapies aimed at correcting the problem of insulin resistance and hyperinsulinemia have the potential to treat the basic disorder of PCOS with long-term health benefits. Sufficient studies have been conducted to suggest that insulin-sensitizing agents decrease serum androgen levels and improve ovulation in women with PCOS. It also seems likely (although yet unproven) that these agents will prevent long-term hyperinsulinemia-related complications such as cardiovascular disease risk in patients with PCOS.
Key Words: Polycystic ovary syndrome, hyperinsulinemia, insulin resistance, hyperandrogenism, metformin, troglitazone.
Quality control in the IVF laboratory
using human sperm motility assay and correlation of the results with embryo
formation rates in IVF cycles
Tansu Küçük, N. Kemal Duru, Esat Orhon and Recai
Pabuçcu.
Gülhane School of Medicine, Department of Obstetrics and Gynecology, IVF Unit, Ankara, Turkey
ABSTRACT
Objective: The aim of the current prospective, clinical study is to perform quality control tests of new batches of mediums using human sperm motility assay, and detect their correlation with the embryo formation rate in IVF cycles.
Setting: Gülhane School of Medicine, Dept Ob. & Gyn, IVF Unit, Ankara, Turkey.
Materials and Methods: Human sperm motility assay is used to classify medium batches according to 24th hr motility percentage as good (more than 50%) and poor (less than 50%). Those media that were used in IVF cycles and embryo formation rates were compared.
Results: A total of 54 batches of medium were assessed with human sperm motility assay. Fourteen batches were associated with poor motility (< 50%). In twelve of those, the embryo formation rate was less than 25%, while in one it was between 25%-75% and in another higher than 75%. Forty batches were associated with good motility according to the assay (>50%). The embryo formation rate was less than 25% in six of the good motility mediums while it was between 25%-75% in eight and higher than 75% in twenty-six.
Conclusion: We concluded that human sperm motility assay (HSMA) is a simple, rapid, sensitive and low-cost assay for quality control in IVF laboratories.
Key words: Human sperm motility assay, quality control.
Peritoneal fluid embryotoxicity and
tumor necrosis factor alpha level in endometriosis associated infertility
Diaa M. El-Mowafi, Wafaa A. El-Mosallamy, Emad Basiony, Sayed
Abdel Ghany,Roshdan M. Arafa and Umnia A. El-Hendy.
Obstetrics & Gynecology* and Microbiology & Immunology Departments, Benha Faculty of Medicine, Egypt
ABSTRACT
Objective: To detect the effect of peritoneal fluid (PF) from patients with endometriosis on the development of 2-cell mouse embryos in vitro, and the possible role of tumor necrosis factor alpha (TNF-a) in this toxicity is evaluated.
Design and setting: Prospective controlled study.
Subjects and interventions: Peritoneal fluid (PF) samples were collected through laparoscopy from 30 infertile females with endometriosis (IF-E) (test group) and another 30 fertile females without endometriosis (F-NE) (control group). PF samples were subjected to study their effect on 2-cell mouse embryos development, estimation of total protein concentration, detection of different protein bands by sodium dodycyl sulfate polyacrylamide gel electrophoresis (SDS-PAGE) and estimation of tumor necrosing factor (TNF-a) by western blotting and ELISA.
Results: The embryotoxicity of PF in the IF-E group was significantly higher than in the F-NE group (P<0.001). Fifty seven out of 306 2-cell mouse embryos reached the blastocyst stage in the IF-E group compared to 280/300 embryos in F-NE group. The total protein concentration was significantly higher in the IF-E group (P< 0.001). Analysis of PF by SDS-PAGE showed similar protein bands but the total number was 10-22 bands (mean 11 bands) in the IF-E group compared to 5-8 bands (mean 7 bands) in the F-NE group. A peritoneal fluid protein band corresponding to 32 Kd appeared in all PF samples of the IF-E group and was not detected in PF of F-NE samples. A band of TNF-a was detected by western blotting in all samples of IF-E and in only 7/30 samples of F-NE. The level of TNF-a was significantly higher in IF-E group (P<0.0001).
Conclusion: The PF from patients with mild endometriosis were embryotoxic to the 2-cell mouse embryos and had a high level of protein concentration and TNF-a as well as a foreign protein band at 32Kd. These results suggest the presence of one or more PF factors that are toxic to early embryonic development and thus may play a role in the infertility associated with endometriosis, without pelvic adhesions or other anatomical distortions.
Key words: Infertility, endometriosis, peritoneal fluid, 2-cell mouse embryo, embryotoxicity.
Endometrial preparation before hysteroscopic
surgery for uterine bleeding: a prospective randomized multicenter evaluation
Osama Shawki, Albert J. Peters and Abraham S. Hebert.
Department of Gynecology, Cairo University, Egypt, and department of Ob/Gyn, Pennsylvania Hospital, Philadelphia PA, USA.
ABSTRACT
Objective: To compare the outcome and cost-effectiveness of various forms of preoperative endometrial preparation prior to hysteroscopic endometrial destruction for abnormal uterine bleeding.
Design: Multicenter, prospective, comparative, randomized study.
Setting: A tertiary care hospital in Cairo, Egypt and two academic tertiary care teaching hospitals in The United States.
Patients: One hundred thirty-one premenopausal women, who had completed childbearing, with a mean age of 45.7 years, with abnormal uterine bleeding refractory to medical management without histologic evidence of endometrial neoplasia were studied.
Interventions: The 131 patients were randomized for preoperative preparation to hysteroscopic endometrial destruction to 1 of 5 groups as follows: Group I, dilation and curettage (D&C) (39); Group II, gonadotropin releasing hormone analogue (GnRHa) for 1 month (23); Group III, GnRHa for 3 months (26); Group IV, danazol for 3 months (26); and Group V medroxyprogesterone acetate 15mg for 3 months (27). The choice of endometrial ablation or endometrial resection was selected by the surgeon.
Main outcome measures: Improvement of bleeding patterns, amenorrhea, operative times, complications, and relative cost were the measured outcomes.
Results: The mean follow-up time was one year from the time of the procedure. Overall, the D&C pretreatment group experienced 39/39 (100%) improvement and 7/39 (18.0%) amenorrhea; the GnRHa for 1 month pretreatment group experienced 21/23(91.3%) improvement and 9/23(39.1%) amenorrhea; the GnRHa for 3 months pretreatment group experienced 24/26(92.3%) improvement and 10/26 (38.5%) amenorrhea; the danacrine for 3 months pretreatment group experienced 24/26(92.3%) improvement and 9/26(34.6%) amenorrhea; and the medroxyprogesterone acetate (MPA) for 3 months group experienced 23/27(85.1%) improvement and 7/27(25.9%) amenorrhea.
Conclusion: Endometrial destruction whether by the ablation or resection technique, regardless of the type of surgical pretreatment, is a safe and effective surgical approach to the treatment of abnormal uterine bleeding. D&C or MPA appear to be the most cost-effective pretreatment regimens. MPA pretreatment may confer the added advantage of decreasing blood flow and allowing better hysteroscopic visualization than D&C pretreatment.
Key words: Endometrial ablation, hysteroscopy, GnRH-a, MPA, uterine bleeding.
Improvements in sperm quantitative
and qualitative measurements via the use of a gravity-free centrifugation
(GFC) technique during swim-up
Panayiotis M. Zavos, Michel Abou-Abdallah, R. S. Jeyendran and
P. N. Zarmakoupis-Zavos
Andrology Institute of America ; Kentucky Center for Reproductive Medicine and IVF, Lexington, Kentucky, USA; Greek-American Andrology Institute of Athens, Greece; Clinique Dr. Rizk, Beirut, Lebanon; and Andrology Lab Services, Chicago, Illinois, USA ;
ABSTRACT
Objectiv: To evaluate and compare the number of motile spermatozoa recovered following the use of a gravity free centrifugation (GFC) swim up technique (SpermPrepTM GFC) with the number of motile spermatozoa recovered following the use of the standard "swim-up" technique.
Design: Prospectively controlled in vitro study.
Setting: Private IVF and Andrology Centers.
Materials and Methods: To assess the efficacy of the SpermPrepTM GFC technique, a total of ten ejaculates were used. Each properly liquefied ejaculate was divided into two 0.5 ml aliquots, diluted, centrifuged (500XG) for 7 minutes, the supernatant was decanted, and the sperm pellet was gently overlayered with 1.0 ml of medium. One aliquot was subjected to the SpermPrepTM GFC technique and the other to the standard "swim-up" technique. After centrifugation (10 min) only the top 0.5 ml of medium was aspirated and the number of motile sperm was determined and compared between the two treatments.
Results: The SpermPrepTM GFC technique, as applied in this study, using a 10 minute centrifugation time, yielded higher (P<0.05) total concentration of sperm, as compared to the standard "swim-up" technique: 21.4+3.4 vs. 13.0+3.2, respectively. The motile concentration of sperm was, 19.3 vs. 11.1 (p<0.05), using the SpermPrepTM GFC vs. the standard "swim-up" technique. However, no significant differences were noted for the HOS, morphology, percentage of motility and grade of motility.
Conclusions: The SpermPrepTM GFC technique, as applied in this study, yielded a higher number of sperm, as well as, a higher number of motile sperm within ten minutes, when compared to the standard "swim-up" technique.
Keywords: Gravity-free centrifugation, swim-up, sperm measurements
Endoscopic management of chronic pelvic
pain
Ahmed F. Amin, Atef M. Darwish, Ahmed M. Makhlouf, Hosam T. Salem
and Zin E. Zareh.
Departments of Obstetrics & Gynecology and Anesthesiology, Assiut University School of Medicine, Assiut, Egypt
ABSTRACT
Objective: To evaluate the value of a combined laparoscopy and hysteroscopy in the management of patients with chronic pelvic pain (CPP).
Design: Prospective non-comparative study.
Setting: One hundred patients suffering from CPP, defined as non-menstrual pain of 3 or more months duration that localizes in the anatomic pelvis and is severe enough to cause functional disability and require medical or surgical treatment.
Interventions: All patients underwent a combined laparoscopy and hysteroscopy. Twenty-eight cases had no diagnosable lesions for whom laparoscopic uterosacral nerve ablation (LUNA) was carried out. Suitable endoscopic management was performed for each diagnosable case. Pre- and postoperative (6 months) pain assessment was measured using the visual analogue scale (VAS) scoring system.
Results: Thirty two of the studied patients had previous laparotomies. Pelvic adhesions (44%), chronic pelvic inflammatory disease (12%), pelvic endometriosis (6%), ovarian cysts (6%) and uterine fibroids (4%) were diagnosed by laparoscopy. Concomitant hysteroscopic evaluation showed intrauterine adhesions (8%), uterine polyps (4%) and uterine septa (3%). Fifty percent of all the women were reported to be pain free at the end of a 6 month follow-up period. Thirty eight percent showed a marked improvement and 12 percent showed no change in their complaints. LUNA was done for endoscopically free patients with 100% improvement in their pains.
Conclusions: The combined use of laparoscopy
and hysteroscopy is a valuable diagnostic and therapeutic procedure in
patients with chronic pelvic pain. The long-term results of LUNA need further
evaluation.
Keywords: Chronic pelvic pain, laparoscopy, hysteroscopy, LUNA
Diffuse spermatogenic arrest, a special
histology picture associated with failure of sperm retrieval in TESE procedures:
a retrospective and prospective study
Sherif A. Ghazi, Tarek Al - Dessouki, Amani Rakha, Emmad Soliman
and Samir A. Abbas
The Saudi Center for Reproductive Technology, United Doctors Hospital, Jeddah, Saudi Arabia.
ABSTRACT
Objective: To try to find a correlation between the findings during the testicular sperm extraction procedures (TESE) and the testicular histology.
Design: Retrospective and prospective study.
Setting: Private family health care and assisted reproduction center.
Patients: In the retrospective study 154 patients with functional azoospermia who underwent the TESE procedure were included, while in the prospective study 25 patients coming for the TESE procedure and having previous testicular biopsy showing a pof diffuse spermatogenic arrest were recruited.
Intervention: Histology picture was examined independently from any previous classification and correlated with the sperm recovery in the TESE.
Results: A special histology picture (diffuse spermatogenic arrest) was always associated with a negative TESE outcome (no sperm) both in the retrospective and prospective studies.
Conclusion: The identification of this histology picture in patients with functional azoospermia coming for the TESE procedure would save a substantial number of patients the unnecessary risks of multiple biopsies.
Keywords: Azoospermia, Spermatogenesis, Testis, TESE, ICSI.
Changes in the Doppler indices of blood
flow in the dominant human graffian follicle before ovulation in natural
and induced cycles
Amr Mohammed Aboul Ela and Essam Moustafa Aboul Fetooh.
Deparement of Obestetric and Gynecology, Cairo University.
ABSTRACT
Objective: To assess regional changes in blood flow in the dominant graffian follicle before ovulation.
Setting: Obstetric and gynecology department, Kaser El Aini hospital
Patients: Sixty three women attending an outpatient clinic at , Kaser El Aini hospital for infertility work during natural and induced cycles. Two groups of patients were studied. First Group:34 patients (aged 20-28 years ) were studied during their natural cycle, 18 of them completed the follow up. Second Group: 29 patients (aged 20-28 years ) were studied during their induced cycle by 100 mg clomiphene citerate from the third day of the cycle for 5days, 16 of them completed the follow up.
Interventions: Doppler indices of blood flow was obtained from vessels in different regions of the dominant Graffian follicle (base, lateral part and apex ) using transvaginal ultrasonography with Doppler imaging on day 8-12 and after LH surge but before follicular rupture. Immuno assay were used to measure the blood concentration of LH daily from day 10 of the cycle.
Main outcome measures: Resistance index in the uterine arteries and 3 regions of the dominant follicle (Apical, lateral and basal parts), the day and time of onset of LH surge (defined as serum concentration of LH> 22 IU/L).
Results: The resistance index (RI) was similar in the vessels at the base, lateral parts and apex of the cycle; day 10-12 then gradually increased at the apex. Twelve hours after the LH surge, there was a decrease in the blood flow observed at the apical parts of the follicle, but there was a sustained low RI at the base and the lateral parts.
Research and clinical center for infertility, department of Obstetrics and Gynecology, Shahid Sadoughi Medical Sciences of Yazd, Iran; and department of Reproductive Biology and Biotechnology (Jahad Danshgahi), Shahid Beheshti Medical Sciences University, Iran
ABSTRACT
Objective: To determine the role of follicular fluid aspiration of 50% of the follicles prior to hCG or GnRH-agonist administration to trigger ovulation, in the prevention of severe ovarian hyperstimulation syndrome (OHSS) in our ART program.
Design: Prospective clinical study.
Subjects: Twenty seven patients with a history of OHSS in a previous treatment cycle.
Intervention: Women were stimulated by administration of hMG alone, or after down regulation with GnRH-a. When the leading follicle reached 17 mm in diameter, half of the follicles were aspirated under ultrasound guidance. After 12-24 hours 10,000 IU of hCG were given in down regulated cycles and 0.5 ml GnRH-a was injected in cycles stimulated by hMG only. Timed intercourse, intrauterine insemination (IUI) and in vitro fertilization (IVF) were performed according to the indication of treatment. All patients were followed up for the occurrence of OHSS and the outcome of the procedure.
Main outcome measures: Occurrence of OHSS and pregnancy rate.
Results: Out of 27 patients, 8 couples underwent IVF. In total, 50 oocytes were collected and 30 embryos were transferred. One woman became pregnant. In the other 19 patients IUI (n=4) and timed intercourse (n=15) were performed. Three patients became pregnant. Reduction of half of follicular fluid caused a decrease in E2 level <4000 pg/ml. One woman was hospitalized for severe OHSS and 4 women developed moderate OHSS.
Conclusion: Our result suggests that HFFA prior to triggering of ovulation may reduce the occurrence of severe OHSS in patients at risk.
Key words: Follicular aspiration, OHSS, in vitro fertilization.
A case of ovarian rupture following
transvaginal ultrasonographically guided oocytes retrieval
Mona Al-Yousef, Kamal Jaroudi and Johannes Hollanders
Department of Obstetrics and Gynecology (MBC 52), King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
ABSTRACT
A case of hemoperitoneum due to ovarian rupture following oocyte aspiration is reported. A patient undergoing in-vitro fertilization (IVF) and embryo transfer (ET), had a sudden hypotensive episode after transvaginal ultrasound guided oocyte retrieval. Ultrasound scan examination identified the presence of free fluid in the pelvis. The patient underwent a laparotomy, which confirmed an ovarian rupture as a cause of massive hemoperitoneum. Hemostatic sutures and closure of the ruptured ovary resulted in hemostasis and preservation of the ovary.
Keywords: Acute hemoperitoneum, ovarian rupture, in-vitro fertilization, transvaginal oocyte retrieval complications.