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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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Current uses of aromatase inhibitors in gynecology
Aboubakr M. Elnashar
Department of Gynecology and Obstetrics, Benha University Hospital, Egypt
ABSTRACT
Third generation aromatase inhibitors (AI) offer increased potency, specificity and better tolerability than the former compounds. Letrozole (LE) and Anastrozole (AN) were approved for marketing in 1997 for treatment of advanced breast cancer to suppress estrogen production. Letrozole was shown to be more effective than tamoxifen and has displaced progestins as preferred therapy. Blockade of estrogen synthesis by an AI in the early part of the menstrual cycle results in release of the estrogen negative feedback centrally and an increase in gonadotrophin secretion resulting in stimulation of ovarian follicle development. Moreover, by blocking conversion of androgens to estrogens in the ovary, the accumulating androgens increase follicular sensitivity through amplification of FSH receptor gene expression. Letrozole is more effective than clomiphene citrate (CC) in induction of ovulation in anovulatory infertility. Because of its much shorter half-life (2 days) and absence of estrogen receptor depletion, LE has no effect on endometrial thickness or cervical mucus. Letrozole is effective for ovulation induction in CC resistant PCOS.
Letrozole is effective for increased follicle recruitment in ovulatory (unexplained) infertility. LE can replace CC in patients with unexplained infertility undergoing ovulation induction and IUI. When Letrozole was used with FSH, a significant reduction occurred in the FSH dose needed for controlled ovarian hyperstimulation, and improvement was seen in ovarian response to FSH in poor responders. Letrozole can be given as 2.5 mg /day on day 3 to 7 of the menstrual cycle or a single dose of 20 mg on day 3. This group of drugs appears to be safe, convenient and inexpensive and has the potential to replace CC as first line treatment for ovulation induction. Anastrozole (1 mg/day for 6 months) is very effective and safe in management of class IV endometriosis.
Key words: Aromatase inhibitor, endometriosis, breast cancer, ovulation induction
The response of transforming growth
factor- (TGF- ) to glucose ingestion in anovulatory women with polycystic
ovarian syndrome
Afaf Felemban, David Morris, Mizan Chowdhury, Anie Philip and Togas
Tulandi
Department of Obstetrics and Gynecology and Department of Surgery, McGill University, Montreal, Quebec, Canada
ABSTRACT
Objectives: To evaluate the response of transforming growth factor-b (TGF-b) to glucose ingestion in anovulatory women with polycystic ovary syndrome (PCOS).
Design: Prospective study.
Patients: 10 anovulatory women with PCOS and 6 women without PCOS.
Intervention: Blood sampling before and 120 minutes after glucose ingestion.
Main outcome measures: Serum TGF-b responses to glucose ingestion.
Results: Serum insulin levels after glucose ingestion in PCOS women were higher than in women without PCOS (1619.0 ± 260.9 and 552.7 ± 105.1 pmol/L). There was a significant decline in total TGF-b levels before and after glucose ingestion in women with and without PCOS. The bioactive TGF-b levels after glucose ingestion were significantly lower in women with PCOS, but not in those without PCOS. The baseline serum insulin levels were not correlated with active TGF-b (r: 0.29) or total TGF-b levels (r: 0.28), but basal glucose and total TGF-b levels were significantly correlated (r: 0.74, P <0.001).
Conclusions: Glucose ingestion decreases serum TGF-b levels. The decline in bioactive TGF-b levels suggests that not only TGF-b secretion is decreased, but the activation of TGF-b is also weakened by glucose ingestion. To the best of our knowledge, this is the first report of a change in TGF-b induced by glucose in human.
Key words: Glucose, serum TGF-b, PCOS
Cytogenetic studies in couples with
recurrent fetal wastage
Hanan I. Elbastawisy, Shahira R. Nowier and Magdi ElSheikh
Department of Ophthalmic Genetics, Research Institute of Ophthalmology, Cairo and Heliopolis fertility and genetics center, Cairo, Egypt
ABSTRACT
Objective: To lay stress on chromosomal anomalies as a cause for early abortions and RFL, and the importance of cytogenetic studies in giving an appropriate genetic counseling regarding future pregnancies.
Design: Prospective study
Materials and Methods: Cytogenetic analysis was performed on 250 couples (125 males & 125 females) with recurrent fetal loss (RFL). Chromosome preparations were obtained from peripheral blood and stained using trypsin-Giemsa banding technique.
Results: A chromosomal anomaly was detected in 21 partners (8.4%). There was no relation with the number of abortions. The major chromosomal abnormalities were mosaicism (2.8%), Robertsonian translocation (1.2%), reciprocal translocation (0.8%), and marker chromosome (0.4%). While minor chromosomal abnormalities were pericentric inversion of chromosome 9 and chromosomal breaks (1.6%) each. Maternal carriers of major chromosomal abnormalities were 6 cases (2.4%), while paternal carriers were 7 cases (2.8%). The most frequently affected chromosomes were number 7,14, & 21.
Conclusion: This analysis can aid in management and counseling in cases of RFL. Cytogenetic studies for parents with two or more pregnancy losses must be performed because of the high incidence of chromosomal abnormalities in spontaneous abortions. When a translocation or other abnormality predisposing to an abnormal zygote is found, prenatal diagnosis should be considered in subsequent pregnancies.
Key words: Recurrent fetal loss- chromosomal abnormality- repeated abortions.
A comparison of a step-up protocol with
high fixed dose gonadotropin administration for controlled ovarian stimulation
in obese patients without polycystic ovarian syndrome: a prospective randomized
trial
Patrick Ehimen Egbase, Mona Al Sharhan and J G Grudzinskas
IVF Center, Maternity Hospital, Kuwait
ABSTRACT
Objective: To examine the follicular growth, embryology and clinical outcome in a randomized study of two protocols, step-up and high fixed dose gonadotropin administration in obese patients without polycystic ovarian syndrome.
Design: Prospective randomized trial
Setting: Ministry of Health affiliated IVF Center.
Subjects: Eighty four obese patients (body mass index [BMI] >30), aged <35 years without ultrasound evidence of polycystic ovaries, normal basal follicle stimulating hormone (FSH) and luteinizing hormone (LH) levels and regular normal menstruation undergoing their first conventional IVF or ICSI treatment cycle.
Intervention(s): Step-up or high fixed dose gonadotropin administration protocol for controlled ovarian stimulation after luteal phase long protocol pituitary down regulation.
Main outcome Measure(s): Ovarian follicular response, embryology and clinical outcome.
Result(s): The mean number of ampoules of highly purified (hp) FSH (75iu/ampoule) was statistically significantly higher in the high fixed dose protocol while the duration (days) of administration was statistically significantly longer in the step-up protocol. The percentage of follicular synchrony and the number of good quality embryos were statistically significantly higher in the high fixed dose protocol. The implantation and clinical pregnancy rates in fresh embryo transfer cycles were similar in both groups. There were no cases of severe OHSS.
Conclusion: In comparison to step-up, the high fixed dose gonadotropin administration protocol resulted in a statistically significantly higher percentage of ovarian follicular synchrony and number of good quality of embryos. The shorter duration of administration reduces the discomfort of daily injections.
Key Words: Step-up, high fixed dose, gonadotropin administration, obesity without PCOS.
Study of the
endometrium by transvaginal sonography and color flow Doppler in postmenopausal
breast cancer patients treated with Tamoxifen
Amr Hussein, Alaa Ebrashi, Ahmad Abdel Meguid, Gamal Youssef and Ayman
Abdel Haleem
Department of Obstetrics and Gynecology, Faculty of medicine, Cairo University, Cairo, Egypt
ABSTRACT
Objective: To evaluate the effect of tamoxifen on the endometrium by transvaginal color Doppler ultrasound and endometrial biopsy.
Design: Prospective controlled trial.
Settings: Department of Obstetrics and Gynecology, Kasr El Aini Hospital, Faculty of Medicine, Cairo University.
Participants: Fifty six asymptomatic postmenopausal women treated with tamoxifen were recruited (Group I) while fifty asymptomatic postmenopausal women were taken as a control group (Group II). All patients in group I were treated with tamoxifen (20-mg day) for breast cancer for at least 1 year.
Interventions: All women underwent transvaginal color Doppler sonography and endometrial biopsy. The endometrium was scanned by transvaginal ultrasound to evaluate the endometrial thickness. Transvaginal sonohysterography was done for patients in the tamoxifen group in which thickened endometrium > 5 mm was detected by transvaginal sonography. Color Doppler sonography was used to evaluate the resistance index (RI) of the uterine and endometrial arteries when possible.
Results: Patients receiving tamoxifen had a significantly thicker endometrium compared to the control group (P <0.05). Endometrial pathology was observed in 34% (19/56) of cases. There were no cases of endometrial cancers, however, twelve benign endometrial polyps were found, most of them having atypical sonographic endometrial pattern with regular borders and small hypoechoic cystic areas. Seven endometrial hyperplasia and in one of these cases, atypia was observed. In the control group endometrial pathology was observed in 6% (3/50) of cases. Using a 5 mm cutoff point of endometrial thickness, vaginal sonography showed a sensitivity of 86.6% in detecting endometrial abnormalities in tamoxifen-treated patients. Resistance index values were significantly higher in the control group (mean 0.88 ± 0.1; range 0.84-0.9) than in those of the study group (mean 0.78 ± 0.06; range 0.6-0.89; P < 0.005).
Conclusion: postmenopausal patients receiving tamoxifen more than one year are liable to endometrial pathological and blood flow changes. These patients should be screened by transvaginal sonography and may need sonohysterography for better visualization of endometrial polyps and endometrial hyperplasia.
Key wards: Breast cancer, Tamoxifen, Endometrium, Transvaginal sonography, Transvaginal color Doppler.
Evaluation of etiological factors among
702 Jordanian infertile couples
Lubna H. Tahtamouni, Hameed A. Al- Hajj and Majed S. Bata
Department of Biological Sciences, University of Jordan, Amman, Jordan, and the Hashemite University, Zarqa, Jordan; and Department of Obstetrics and Gynecology, Jordan University Hospital, Amman, Jordan
ABSTRACT
Objective: To evaluate etiological factors causing infertility in 702 Jordanian couples
Design and setting: Interview of patients and reference to their medical records.
Results: Among the infertile couples, 71.4% had primary infertility, and 28.6% had secondary infertility. In these couples, the mean duration (±SD) of primary infertility was 6.76 ± 5.05 years, and that of secondary infertility was 4.49±3.48 years. Two major causes of primary infertility were identified: male factor (51.2%) and anovulation (25.6%). As for secondary infertility, three causes were attributed: male factor (29.1%), anovulation (25.6%) and tubal factor (23.1%).
Conclusions: This study demonstrates that infertility in Jordanian couples is caused by either male or female factors. The first includes testicular diseases or obstruction of extratesticular ducts. The second involves anovulation and tubal occlusion or peritubal adhesion. Identification of the causes of infertility should help patients suffering from this problem to be referred to assisted reproduction centers for treatment. A more comprehensive, population- based, study remains to be done.
Keywords: Primary infertility, secondary infertility, male factor, anovulation, tubal factor.
Danazol loaded intrauterine device
(D-IUD): a novel conservative management for uterine adenomyosis
Osama A.Shawki
Department of Obstetrics and Gynecology, Cairo University, and Al Ebtesama Center For Infertility And Advanced Endoscopic Surgery, Cairo, Egypt
ABSTRACT
Objective: To evaluate the efficacy and tolerability of treatment with a Danazol loaded IUD designed specifically to be a drug delivery system (DDS) for intrauterine application in patients suffering from adenomyosis - related symptoms like increased menstrual blood loss, dysmenorrhea and pelvic pain.
Setting: Tertiary care center for infertility and advanced Endoscopic surgery.
Design: Prospective, non-comparative pilot study.
Patient(s): The study included twenty-one women aged 22 - 42 years (mean age 34 -+ 2.4 years) complaining of persistent increase in menstrual blood loss (MBL) and menstrual related pains associated with uterine adenomyosis diagnosed at transvaginal ultrasound.
Intervention(s): All cases were subjected to careful transvaginal sonography and hysteroscopic guided endomyometrial biopsy to confirm diagnosis of uterine adenomyosis and also exclude other possible lesion could be responsible for the symptoms. Insertion of 400 mg loaded danazol IUD was done under light general anesthesia within the first week postmenstrual. Duration of application was 6 months and then removed to observe response. All cases were followed by transvaginal sonography and assessment of menstrual blood loss and pain through pictorial blood assessment and pain visual analogue scale on monthly basis.
Main outcome Measure(s): Menstrual pattern, MBL, pain, serum hemoglobin.
Result(s): Application of IUD was successful in all cases and no significant complications encountered. Menstrual related pains and dysmenorrhea was completely resolved in 17 women (80.9%). Sixteen cases (76%) reported improvement of bleeding and regular menstrual blood flow by the end of follow up period of six months. Spontaneous expulsion occurred in one case. Significant increase in hemoglobin observed during treatment. Among 9 infertile women, two achieved spontaneous pregnancy within six months after removal of the IUD. Serum level of danazol after local IUD application was undetectable. No systemic side effects known with danazol ever occurred during the study.
Conclusion: Our provisional findings confirm that a danazol releasing device applied inside uterine cavity in cases with adenomyosis has a marked and safe relief of menstrual related pains and menorrhagia. Additionally, it avoids all systemic side effect generated during oral danazol treatment.
Key words: Adenomyosis, danazol, intrauterine device, drug delivery system, dysmenorrhea, menorrhagia
The effect of tibolone on serum lipid and
lipoprotein levels in oophorectomized patients
Yilmaz Atay, Ibrahim F. Urünsak and S. Cansun Demir
Department of Obstetrics and Gynecology, Faculty of Medicine, University of Cukurova, Balcali, Adana, Turkey
ABSTRACT
Objective: The aim of this study is to evaluate the effect of Tibolone after 3 and 6 months of therapy, on serum lipid and lipoprotein levels in oophorectomized patients.
Design: Prospective open label uncontrolled study.
Setting: University of Cukurova, Department of Obstetrics and Gynecology
Materials and methods: Thirty patients who were admitted to University of Cukurova, Department of Obstetrics and Gynecology between January 1999 and January 2000 and had Total Abdominal Hysterectomy and Bilateral Salpingo-oophorectomy for indications other than malignancy were studied. We wanted to determine the changes in lipid and lipoprotein levels in patients 30 days after operation and we studies the effect of Tibolone on these patients at 3 and 6 months postoperatively. After we obtained the blood sample on 30th postoperative day, tibolone was begun as a one tablet daily regimen.
Main outcome measures: Changes in lipid and lipoprotein levels
Results: The levels of total cholesterol decreased 26%, LDL 11%, Triglyceride 31% and levels of HDL increased 31% between the postoperative 30th day and 6th month.
Conclusion: Tibolone improves the lipid profile in women after surgical menopause.
Key words: Tibolone, serum lipid and lipoprotein levels, oophorectomy.
Routine office microhysteroscopy using the
vaginoscopic approach in patients prepared for in vitro fertilization or
intrauterine insemination
Mohamed Zayed, Omaima Idris, Ahmed N. Hosni, Ayman Abdel Halim, Ashraf
Ramadan and Adel Farouk
Infertility and IVF center -Women's Medical center, Cairo, Egypt
ABSTRACT
Objective: To evaluate the usefulness in diagnosis, outcome, patient acceptability, side effects and complications of office microhysteroscopy in patients enrolled for IVF or IUI protocols.
Design: Prospective observational study
Setting: Infertility outpatient clinic.
Materials and methods: One hundred and twenty four patients attending infertility outpatient gynecology clinic in preparation for IVF or IUI were examined using the 2.5 mm semi-rigid 0 angle office microhysteroscopy by the vaginoscopic approach without the use of speculum, tenaculum, or analgesia and using saline as distension medium.
Results: The procedure was successful in all the patients except four due to obliteration of the cervical canal. Only mild cramping pain was experienced in most of the patients but was well tolerated in all. In approximately 15.8% (19 cases) intrauterine pathological lesions (polyps, adhesions, endometritis and submucous fibroids) were detected that necessitated treatment before starting medical preparation for IVF or IUI. In 4 out of the 7 cases of endometrial polyps diagnosed by hysteroscopy were missed by ultrasound examination. Ultrasonography was unable to diagnose conditions as adhesions, endometritis, cervical stenosis and marked cervicitis that were found in 17.5% of the cases. The duration of the office hysteroscopy was less than 10 minutes. No complications occurred in this study from the use of office hysteroscopy.
Conclusion: The initial results have shown that the use of office microhysteroscopy in the evaluation of the infertile patients is a very useful and precise method for the diagnosis of uterine factors of infertility an important step for the success of ART.
Role of embryo morphology and cumulative
embryo score in pregnancy outcome from in vitro fertilization and
intracytoplasmic sperm injection cycles
Mohammad Ali Khalili & Fatima Moinia
Research and Clinical Center for Infertility, Yazd University of Medical Sciences, Yazd, Iran
ABSTRACT
Objective: The main objective was to study the role of both embryo morphology and cumulative embryo score (CES) on the outcome of pregnancy in conventional in vitro fertilization (IVF) and intracytoplasmic sperm injection (ICSI) cycles.
Design: Prospective study.
Setting: University Infertility Center
Materials and Methods: Sixty patients were divided into 2 groups, 30 after IVF and 30 after ICSI. The first 15 pregnant women were compared to the 1st 15 non-pregnant women in both IVF and ICSI programs prospectively. The clinical parameters along with embryo grading and CES were recorded for each group. The embryo morphological feature was graded according to Hill 1989; while, CES was assessed using Steer 1992 criteria.
Results: A total of 395 MII oocytes were aspirated resulting in 272 embryos (IVF=126, ICSI=146). The mean of female age in the IVF and ICSI groups were 29.45± 4.9 and 31.26±5.2, respectively. There was no significant difference in the mean number of transferred embryos in the IVF and ICSI cycles, which were 3.26±1.03 and 3.46±1.12, respectively. There was a significantly higher mean of CES in IVF pregnant as compared to non-pregnant patients, 41.26±15.9 and 26.38±13.3, respectively (p<0.05). There was no significant difference in the CES in ICSI cycles (50.86±16.6 versus 41.6±24.3). In addition, only one embryo (grade A or B) was transferred in 8 pregnant patients. No grade A embryos were transferred in over 50% of patients who failed to become pregnant. Also, only one embryo “ D” was transferred in the pregnant cases.
Conclusion: Evaluation of embryo morphology in combination with CES is a quick methodology that may help to select the number of embryos to be transferred, and may increase the pregnancy rates. However, CES alone may not predict the possibilities of pregnancy.
Key words: Cumulative embryo score, embryo morphology, ICSI, IVF
Normal pregnancy outcome after inadvertent long-term exposure
to gonadotropin releasing hormone agonist
H. Abdel-Hamid, Y. Rezk, M.G. Nawar, E. Formentini, H. Chehata, M.
Abuzeid, and B. Rizk
Division of Reproductive Endocrinology, Hurley Medical Center, Flint, Michigan, and Division of Reproductive Endocrinology, University of South Alabama, Mobile, Alabama
ABSTRACT
Objective: To report a case of normal pregnancy outcome following inadvertent long term exposure to gonadotropin releasing hormone agonist (GnRHa) during the first and most of the second trimester of pregnancy.
Design: Case report
Setting: A university-based in vitro fertilization laboratory
Patient: Woman with prolonged exposure to GnRHa during pregnancy
Intervention: Pituitary down regulation with mid-luteal phase GnRHa preparation
Result: Normal pregnancy outcome
Conclusion: There does not appear to be an increased risk of birth defects or pregnancy wastage in human pregnancies following prolonged exposure to GnRHa
Key Words: Pregnancy outcome, GnRHa, teratogenicity
Successful IVF outcome through a natural cycle in a poor
responder after repeated failure with stimulated IVF cycles
Raja Z.Karaki, Falah A. Khalifa, Noreen KH. Shah and Tarek M.Lahloub
Fertility and Assisted Reproduction Unit.Al-Amal Maternity Hospital, Amman, Jordan.
ABSTRACT
Objective: To present a successful in-vitro fertilization (IVF) pregnancy and delivery in a natural cycle after previous repeated failure of stimulated IVF trials.
Design: Case report
Setting: Private assisted reproduction unit.
Patient(s): A 32- years old patient with six previous IVF cycles failure, through which she showed poor ovarian response to regular protocols of ovulation induction.
Intervention(s): ICSI technique was applied after oocyte retrieval in a natural cycle for two attempts.
Main Outcome Measure(s): Oocyte retrieval, fertilization, embryo cleavage and clinical pregnancy outcome.
Result(s): In each trial of the two natural cycles of IVF, one metaphase II oocyte was obtained, injected and fertilized. A good quality embryo was formed and transferred into the uterus. The first attempt did not succeed. In the second, the patient conceived and had a full term gestation and delivery of a healthy female baby.
Conclusion(s): IVF in a natural cycle is a suitable alternative to stimulated cycles in poor responders. This approach should be considered after failure of the classical IVF treatment in such a group of patients.
Key word(s): Natural cycle / poor responder /stimulated cycle / IVF.
Pregnancies and births from embryos generated from oocytes
fertilized by stump tail spermatozoa
J. Ali, S. Rahbar, H. Burjaq, M. AlFlamerzi and MAM. Shahata
Assisted Conception Unit, Women's Hospital, Hamad Medical Corporation, Doha, Qatar and JA Global Pty Ltd, Australia
ABSTRACT
Objective: To document fertilizations and pregnancies in a case of stump-tailed spermatozoa.
Setting: Government funded Assisted Conception Unit
Design: Case-report
Patients and methods: A case of male infertility and childlessness of 16 years due to totally immotile stump tail spermatozoa is presented. The male partner was 43 years old when he approached us in 1996. His wife was 37 years old and had normal unremarkable gynecological history. There was no spermatozoa in testicular specimen. The male produced a semen specimen on the day of oocyte retrieval containing about 100,000 totally immotile stump tail spermatozoa.
Result: A viability stain showed 44.6 % to be viable. The couple underwent a total of four ICSI treatment cycles using ejaculatory stump tail spermatozoa between 1996 and 2001. The couple achieved three pregnancies of which two resulted in normal term deliveries while the third pregnancy is currently ongoing. The fertilization rate ranged between 33 to 44% with a mean of 37.9 %. A total of 33 oocytes were collected from which 10 embryos were generated by ICSI. All 10 embryos were transferred on four separate treatment cycles, of which 3 implanted, one per treatment cycle, with the exception of the second cycle, giving an implantation rate of 30%. The fertilization rate was low at 38% following ICSI with stump tail spermatozoa, which could be related to an inability of the operator to select viable spermatozoa for ICSI.
Conclusion: We believe this report to be the first to document three viable pregnancies (with two normal deliveries and an on-going pregnancy) in a case of male infertility attributed to stump tail spermatozoa.
Keywords: stump tailed spermatozoa, infertility, fertilization, pregnancy