The establishment of the first IVF registry in Egypt
Ragaa T. Mansour

ABSTRACT

Objective: To summarize the procedures of ART cycles initiated in Egypt in 1999 and 2000.

Design: The Forms prepared by the International Working Group for Registers on Assisted Reproduction (IWGROAR), which is now the IFFS Task Force for Registers on Assisted Reproduction, were distributed to all IVF centers in Egypt. IVF/ICSI data for the years 1999, 2000 were collected anonymously.

Participants: Data were collected from 17 centers in 1999, and 18 centers in 2000.

Main outcome measures: The total number of IVF/ICSI cycles, incidence of clinical pregnancy, abortion, delivery, stillbirth and complications.

Results: For the year 1999, data were collected from 17 centers, however 3 were excluded. In 2000, data were collected from 18 centers, and none were excluded. The total number of cycles performed was 5, 515 and 6, 508 respectively for the years 1999 and 2000. ICSI constituted 90% of ART cycles in 1999 and 91.5% in 2000. The clinical pregnancy rate per pick-up was 29.6% in ICSI and 28% in IVF for the year 1999, and 28.9% in ICSI and 33.6% in IVF for the year 2000. Twin deliveries represented 17% in IVF and 30% in ICSI in 1999, and 43% in IVF and 32.2% in ICSI in 2000. Triplet deliveries represented 4% in IVF and ICSI in 1999, and 8% in IVF and 4% in ICSI in 2000. The reported frozen-thawed embryo replacement cycles represented only 5% and 7.4% of the total number of ART cycles in 1999, and 2000 respectively. Ovarian hyperstimulation syndrome complicated 1.6% and 2% for 1999 and 2000 respectively. As a result of IVF/ICSI procedures, 1, 757 neonates were born in 1999 and 2, 127 were born in 2000.

Conclusions: This is the first report of IVF registries in Egypt. It is a voluntary one that included data for 1999, 2000. In 2000, more ART cycles were reported compared to 1999, an increase of 18%. The clinical pregnancy rates are comparable for both years. The practice of cryopreservation of embryos is very limited to only a few centers. The multiple pregnancy rate was high due to the transfer of > 3 embryos. OHSS was also high and preventative measures had to be more strict. More efforts should be done to complete data on deliveries and perinatal mortalities. More IVF centers are expected to participate in the next registry.

Key words: Egypt, IVF, ICSI, Register Data

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Subtle endometriosis
Aboubakr M. Elnashar

Department of Obstetrics and Gynecology, Benha University Hospital, Egypt

 ABSTRACT

In the last decade, increasing attention has been drawn to subtle forms of endometriosis (SE), i.e. endometriotic lesions that lack the typical black-blue, powder-burn appearance. Subtle lesions are more common than the classic dark blue-black lesions in adolescents. The most common type of SE is white opacification and the next most common is glandular-like excrescence. SE progresses to pigmented E over time. Red lesions are probably the first stage of early implantation of endometrial glands and stroma and white lesions could be latent stages of E. In the new ASRM classification, peritoneal and ovarian implants of E are categorized into red (red, red-pink and clear lesions), white (white, yellow-brown and peritoneal defects) and black (black and blue lesions). SE has the same symptoms that characterize classic E. Negative laparoscopy results do not mean that the patient has no E. Laparoscopic diagnosis of SE can be facilitated by peritoneal blood painting, use of liquid introduced into the pelvis, near contact laparoscopy, bubble test or transvaginal hydrolaparoscopy. E, whether its lesions are pigmented or not, does not itself demand treatment unless it is causing, or it is likely to cause symptoms. SE should receive the same therapeutic attention that classic lesions do.

Key words: endometriosis, laparoscopy, infertility

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Outcome of inadvertent administration of a gonadotropin-releasing hormone agonist in early pregnancy
Mohamed A. Sasy, Azza Abdel-Fattah, Botros Rizk and Mostafa I. Abuzeid

Center for Reproductive Medicine, Hurley Medical Center, Flint, Michigan, USA

 ABSTRACT

Objective: To evaluate the outcome of early pregnancies that occurred during inadvertent administration of GnRH-a.

Design:  Retrospective study

Materials and Methods:  Nine patients who spontaneously conceived during the same month of GnRH-a initiation were studied.  The patients were given Lupron 1.0 mg daily starting on day 21 of the preceding cycle.  With the onset of menses, the dosage was reduced to 0.5 mg daily.  If menstruation did not occur, a serum quantitative beta hCG was performed.  Lupron was stopped immediately if the pregnancy test was positive.  The patients were counseled and started on progesterone suppositories 50 mg twice daily for three  months, and an ultrasound scan was performed at six to seven weeks gestation.

Results:  Six patients delivered and all babies were normal.  One patient who had a twin gestation showed one blighted ovum at nine weeks gestation, and the second twin was delivered by Cesarean section at 26 weeks for severe placental abruption.  The outcome of the remaining pregnancies were as follows: two patients had blighted ova at 6.5 weeks gestation and one had a missed abortion at 12.5 weeks.  In two of these three patients, the duration of GnRH-a exposure was longer than the remaining seven patients. 

Conclusion:  Brief exposure to GnRH-a in very early pregnancy appears to be harmless.  However, the effect of longer exposure of the fetus to GnRH-a remains to be determined.

Key words: Inadvertent exposure, GnRH-a

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The use of metformin in overweight and lean infertile patients with polycystic ovarian syndrome: a randomized controlled trial
Abdel-Maguid Ramzy, Hesham Al-Inany, Zakaria Aboulmaaty; Sara El-Kateb and Mona Abdel Badie

Departments of Obstetrics and Gynecology and Department of chemical pathology, Cairo University, Cairo, Egypt

 ABSTRACT

Objective: to investigate the potential value of metformin prior to and concomitant with the use of clomiphene citrate and its impact on improving ovulation rate and regularity of the cycle in Polycystic ovarian syndrome women both overweight and lean types.

Setting: Kasr El-Aini Hospital.

Design: open labeled randomized controlled trial. Randomization was done on alternate number.

Materials and methods: sixty infertile women were divided into two groups: Group I: (n=30) had BMI> 28 and Group II :(n=30) had BMI< 28. Each group was further subdivided into 2 subgroups A& B. Group A: no = 15 patients given metformin 500 mg t.d.s. for 6 weeks prior to clomiphene citrate. induction for three cycles and continued throughout induction. The other subgroup B: no =15 patients were given placebo instead of metformin. Both subgroups were compared regarding BMI, biochemical criteria, regularity of the cycles and success of ovulation induction before and after taking metformin or placebo respectively.

Results: A statistically significant difference both in the individual cycles and in the cumulative response regarding ovulation induction was observed between the two subgroups of each group. However, no conception has occurred in both groups.

Conclusion: A significantly higher successful ovulation induction rates can be achieved with the use of metformin  (prior to and as an adjuvant to clomid), both in overweight and lean women with polycystic ovarian syndrome.

Key words:  infertility, obesity, PCO, metformin, RCT, BMI

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Relation of polycystic ovary syndrome and pelvic endometriosis: coincidence or causal relation
Selcuk Arslan, Oya Gokmen and Gorkem Tuncay

Zekai Tahir Burak Romen's Hospital, department of Endoscopic Surgery, Turkey

 ABSTRACT

Objective: To determine relation of polycystic ovary syndrome (PCO) and pelvic endometriosis.

Materials and Methods: 3954 gynecologic patients underwent laparoscopic surgery from 1995 - 1999 were examined for coexistence of PCO and endometriosis.

Setting: Zekai Tahir Burak Romen's Hospital, department of Endoscopic Surgery.

Results: The frequency of the polycystic ovary syndrome and endometriosis occurring together compared with the incidence of polycystic ovaries alone, and that of endometriosis alone was significantly higher when compared to the whole series laparoscoped (x2: 120.4, p< 0.001), and to the infertile subgroup (x2: 56.03, p< 0.001). There were no significant clinical differences among the patients who have polycystic ovary (PCO) or endometriosis or both of them. The serum concentrations of LH, FSH, LH/FSH, prolactin, testosterone, and dehydroepiandrosterone sulfate were also similar in each group.

Conclusion: At the end of our study, we postulate that it is irregular, progesterone deficient cycles leading to relative hypoestrogenism caused by polycystic ovaries may lead to the increase in the incidence of endometriosis in later years.

Key Words: Endometriosis, Polycystic ovary syndrome.

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Does embryo transfer catheter type affect pregnancy rate?
Ismail Aboul Foutouh, Mahmoud Tolba, Ahmed Nakieb, Mohamed Youssef, Mohamed Rushdi, and Wael Abdel Meguid

Galaa Assisted Reproductive Unit (GARU), Cairo, Egypt

 ABSTRACT

Objective: To compare two different types of embryo transfer catheters (a soft catheter with a rigid one ) used in our unit.

Design: Prospective controlled trial

Participants: Patients were randomly allocated into 2 groups according to which embryo transfer catheter was used. Group 1 used Wallace catheter for embryo transfer (no=114) and Group 2 used Rocket catheter (no=91). Transfer was done under ultrasound guidance.

Results: The pregnancy rate for group I using the Wallace catheter was 32 pregnancies (28.1%), while the pregnancy rate for the Group II patients was 13 pregnancies (14.3%). (P <0.05)

Conclusion: it seems that the softer the catheter, the better is the pregnancy rate. The tendency towards a better pregnancy rate with the softer catheter owing to their softer inner sheath follow the contour of the cervical and uterine access while minimizing endometrium trauma and this may be the cause of the better results using the soft catheter

Key words: IVF, ICSI, embryo transfer, catheter, pregnancy

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Administration of mannitol to prevent severe ovarian hyperstimulation syndrome; a randomized controlled trial
Aboutaleb Saremi, Mohammad Alam, and Mina Motaghi

Infertility Department, Sarem Community hospital & research center, Tehran, Iran.

 ABSTRACT

Objective: To evaluate the effect of intravenous mannitol on the prevention of severe ovarian hyperstimulation syndrome (OHSS) in high - risk cases with polycystic ovarian syndrome (PCOS).

Materials and Methods: 226 cases with PCOS were allocated to study group (A) and Control group (B) in a simple random method. 3 gr/Kg (Body Weight) mannitol was administered to patients in Group A the day after starting hCG administration that continued daily till the third day after embryo transfer. Control group (B) received no drugs. Physicians, who were blinded to patients trial group, observed them for occurrence of OHSS.

Results: The patients were statistically similar according to age and body weight. The cumulative incidence of severe OHSS was 6.4 percent in group A and 15.5 percent in group B. The relative risk of severe OHSS (group A to group B) was 0.41(95% CI: 0.18-0.94). Pregnancy rates were not statistically different between the two groups.

Conclusion: To our knowledge, there is no previous study done about the administration of mannitol to prevent OHSS. According to strong association and biologic plausibility, it appears that this preventive method is effective in super-ovulated high-risk PCOS cases. Complementary studies with more detailed assessment of gestational outcome are recommended.

Key words: OHSS, Prevention, ART, Mannitol.

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Detection of fetal DNA and fetal cells in maternal blood by polymerase chain reaction technique
Mirvat El-Ansary, Hesham Al-Inany, Sahar  Hussein and Mariam Farag

Departments of Clinical Pathology and Obstetrics and Gynecology, Faculty of Medicine, Cairo University, Cairo, Egypt

  ABSTRACT

Objective: To attempt at the detection of fetal DNA in maternal plasma and the identification of fetal cells in maternal circulation during pregnancy. Both cell free fetal DNA and fetal cells in maternal peripheral blood would offer noninvasive means of fetal diagnosis.

Design: prospective single center study

Setting: Kasr El-Aini Hospital

Participants: Twenty one pregnant healthy female with known fetal sex by ultrasound.

Interventions: maternal blood samples at gestational ages ranging from 10 to 26 weeks of gestation were analyzed. Cell free fetal DNA was detected in maternal plasma by Sex Determining Region Y sequence specific nested polymerase chain reaction. The Y DNA sequence from a male fetus has been used as a model system to detect fetal DNA in maternal plasma because of the obvious lack of this sequence in the mother. Fetal origin of the separated cells was confirmed by correlating the presence or absence of Y chromosome Sex Determining Region Y sequence specific PCR with the true sex of the fetus.

Results: Accurate fetal gender diagnosis was achieved in 81.0% of pregnant women with a false negative rate of 19.0%. The sensitivity of the Y-DNA specific nested PCR for detecting male bearing pregnancies from maternal plasma was 73.3% and the specificity was 100%. Significantly higher sensitivity of male detection in late gestational ages of 18 to 26 weeks compared to earlier ages of 10 to 17 weeks was observed. One hundred percent accuracy of fetal sex determination was achieved. Sensitivity and specificity as regards male detection were 100%.

Conclusion: It is feasible to analyze fetal loci using fetal DNA from maternal plasma by nested polymerase chain reaction. Cell free fetal DNA and fetal cells in maternal peripheral blood do exist and can be used for the analysis of Mendelian genetic disorders and fetal aneuploidies.

Key words:  fetal DNA, fetal cells, PCR.

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Effectiveness and cost-effectiveness of urinary FSH versus recombinant FSH in clomiphene citrate-resistant anovulatory infertile patients: opposing the policy of abandoning the use of urinary FSH
Abdelhamid M. Attia, Ehab M. Soliman, Mostafa M. El-Sadek, Hesham S. Hamza, Mahmoud E. Salem, and Ashraf S. Younis

Department of Obstetrics and Gynecology, Faculty of Medicine, Cairo University, Cairo, Egypt

ABSTRACT

Objective: To compare the effectiveness and cost-effectiveness of recombinant FSH (r-FSH) and urinary FSH (u-FSH) in the induction of ovulation in WHO group II anovulatory infertile women.

Design: A prospective comparative study.

Materials and methods: Sixty clomiphene citrate-resistant anovulatory infertile women, allocated into 2 groups, underwent ovarian induction and timed intercourse with a starting daily dose of either 50IU r-FSH or 75IU u-FSH in a low dose step-up protocol. A total of 107 stimulation cycles were monitored by ultrasound for ovarian response and pregnancy.

Results: There were no significant differences between the 2 groups either in the duration of stimulation, follicular response, cycle cancellation rate, cumulative ovulation and pregnancy rates, incidence of abortion, or ovarian hyperstimulation rate. The only significant differences were in the cost/cycle and the cost/pregnancy with u-FSH being more cost effective.

Conclusion: r-FSH (starting with 50IU/day) and u-FSH (starting with 75IU/day) are equally both effective and safe for the induction of ovulation in WHO group II anovulation women. However, u-FSH is more cost effective than r-FSH. For that purpose; abandoning its production and marketing would raise a great concern for health care providers and would add more financial burdens, without real benefit, on patients in developing countries. Such policy should be strongly opposed.

Keywords: anovulation/induction of ovulation/low dose/r-FSH/u-FSH

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Significance of endometrial polyps detected hysteroscopically in eumenorrheic infertile women
Tarek A. Shokeir

Department of Obstetrics & Gynecology, Fertility Care Unit, Mansoura Faculty of Medicine, Mansoura University Hospital, Mansoura, Egypt

 ABSTRACT

Objective: This study was designed to determine if the incidence of small endometrial polyps detected hysteroscopically in an infertile eumenorrheic population differed from that in an apparently fertile eumenorrheic population. Evidence was sought to determine whether removal of such lesions would enhance reproductive performance.

Materials and methods: In a prospective study, 266 consecutive infertile women had undergone complete fertility evaluation at a tertiary university infertility clinic. All women had not experienced any change in their menstrual cycles. They were divided into two groups; 235 infertile patients (group 1) and 31 requesting a reversal of a previous tubal sterilization (group 2). All patients were examined by simultaneous combined laparoscopy and hysteroscopy as part of their routine infertility evaluation. When endometrial polyps were noted they were removed by hysteroscopic resection and subjected to histopathologic examination. Those patients in whom the only apparent finding was endometrial polyps were followed up to determine their reproductive outcomes subsequent to removal of the polyps.

Results: Hysteroscopy was successful in 224 of 235 infertile women and in all 31 of those who previously had been sterilized. Of a total of 224 uterine cavities visualized in the infertile group, 134 were judged to be normal (60%) and 90 were abnormal (40%). The most frequent intrauterine changes found were adhesions and endometrial polyps. Endometrial polyps were noted in 35 patients of group 1 and in 1 patient of group 2, a difference of statistical significance (P<0.01). Most polyps were located in the region of utero-tubal junction and proved to be functional. A 50% pregnancy rate was achieved by hysteroscopic removal of such polypi.

Conclusions: Diagnostic hysteroscopy should be used routinely in the work-up of infertile woman, even in the presence of eumenorrhea. Persistent functional endometrial polyps, even if small, are likely to impair fertility in this select patient group. Removal of such lesions may improve subsequent reproductive performance.

Key Words: infertility, female, hysteroscopy, endometrial polyps

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