Pregnancy failure after spontaneous conception or ovulation induction: endocrine causes and treatment
Adolf E. Schindler

Institute of Medical Research and Education, Essen, Germany

ABSTRACT

The spontaneous abortion rate in the general population is about 10%. In some women treated with drug regimens for ovulation induction with or without modern assisted reproductive technology (IVF/ICSI etc.) the rate of pregnancy failure is high. Special attention should be directed towards women with recurrent abortion after spontaneous or stimulated cycles without or combined with methods of ART. Besides the known organic defects of the reproductive system the endocrine abnormalities need to be considered (i.e. corpus luteum insufficiency, disturbances of the luteo-placental shift, trophoblast disturbance). In case of abnormal progesterone and estradiol at the beginning of pregnancy, at the time of the luteo-placental shift or delayed placental endocrine function later in time treatment with progesterone or progestins or estrogen/progestin combinations should be done and the therapeutic effect controlled by repeated progesterone and estradiol measurements.

Keywords: Pregnancy, pregnancy failure, habitual abortion, progesterone, estradiol, hCG

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Endometrial receptivity
Aboubakr M. Elnashar and Gamal I. Aboul-Enein

Benha and Zagazig University Hospitals, Egypt

ABSTRACT

Embryo implantation depends on the quality of the ovum and endometrial receptivity. Endometrial receptivity is a temporally unique sequence of factors that make the endometrium receptive to embryonic implantation. Implantation window is a period during which the endometrium is optimally receptive to implanting blastocyst (D6-10 postovulation). No conclusive evidence of age related histological changes in the endometrium.  The biochemical markers of endometrial receptivity include endometrial adhesion molecules (e.g. integrins), endometrial anti-adhesion molecules (e.g. mucin 1), endometrial cytokines, endometrial growth factors, endometrial immune markers and other endometrial markers. Integrins are the best markers of endometrial receptivity. Most interest has been focused on the av b 3 integrin since it appears in endometrial glands and luminal surface on D20-21.   Endometrial function test may be the most efficient way to directly assess endometrial receptivity prior to undergoing expensive ART procedures as it can identify unreceptive endometrium. Pinopodes, are morphological markers of endometrial receptivity, which persist for 24 to 48 hours between days 19 and 21 of the cycle. Non invasive assessment of endometrial receptivity includes, high resolution transvaginal ultrasonography (US), three-dimensional US, Doppler US, three-dimensional power Doppler US, magnetic resonance imaging and endometrial tissue blood flow. Four strategies for improving endometrial receptivity: to develop ovarian stimulation protocols that cause a minimum reduction in endometrial receptivity or may even increase it; to avoid the endometrium during stimulated cycles, to improve uterine vascularization and to treat the pathology.

Key words: Endometrial receptivity, implantation, infertility

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Assessment of the value of ultrasound monitoring and doubling of insemination in clomiphene citrate stimulated IUI cycles
Hamdy Azab and Nahed Afify

Saudi German Hospital, Aseer, Saudi Arabia

ABSTRACT

Objective: To compare the results of controlled ovarian stimulation and intra-uterine insemination using 4 protocols.

Design: Prospective non randomized study.

Setting: An assisted reproduction unit in a private hospital.

Materials and methods: 91 couples with unexplained infertility and 79 couples with male subfertility. All women received clomiphene citrate 50 mg twice daily starting from the 3rd day of cycle for 5 days. Patients were classified into 4 groups. The 1st group (45 patients, 125 cycles) was monitored by transvaginal sonography. HCG was given when at least one follicle reaches a diameter of 17 mm or more. IUI was scheduled 36 hours after the HCG shot. The 2nd group (43 patients, 118 cycles) was also monitored by ultrasound and HCG was given as before, double insemination was done 20 hours and 40 hours after the HCG shot. In the 3rd group (42 patients, 112 cycles), monitoring of ovulation was done using commercial urinary LH detection kit, IUI was scheduled 24 hours after detection of LH. In the 4th group (40 patients, 108 cycles), monitoring of ovulation was done by urinary LH detection kit, double insemination was done 12 and 24 hours after detection of LH.

Main Outcome measure: Clinical pregnancy rate (PR).

Results: A total of 170 patients underwent 463 cycles with an average of 2.72 cycles per patient. The total number of pregnancies was 31 with an overall PR of 18% per patient and 7% per cycle. The overall pregnancies for groups I, II, III, and IV were 8 (18% per patient, 6% per cycle), 9 (21% per patient, 8% per cycle), 7 (17% per patient, 6% per cycle), and 7 (18% per patient, 6% per cycle), respectively. There was no statistically significant difference between any two groups. Patients with unexplained infertility and patients with infertility duration of less than 4 years had significantly higher PR than patients with male subfertility and patients of infertility duration more than 4 years respectively.

Conclusion: Clomiphene citrate (CC) stimulated IUI cycles, self monitored by urinary LH kits and employing single insemination, appear to be a simple, relatively effective and inexpensive initial management for couples with unexplained infertility or mild male factor subfertility of less than 4 years duration.

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Plasma transfusion on the day of oocyte aspiration may reduce ovarian hyperstimulation syndrome in patients with polycystic ovary
Yousef M. Alhelou, Tharwat Y. Alhelou, Ghada S. Alkerenawi, and Sandra N. Akela

The ART center, Alhelou International Hospital, 177-50 Nasser Street, Gaza city, Palestine.

ABSTRACT

Objective: To determine the efficiency of plasma transfusion on the day of oocyte aspiration in preventing ovarian hyperstimulation syndrome (OHSS) in polycystic ovary (PCO) patients undergoing ART cycles.

Design: Prospective randomized study.

Setting: The ART center at Alhelou International Hospital, Gaza city, Palestine.

Subjects: 93 PCO patients who are at risk of OHSS.

Intervention: 1-3 units of plasma were administrated on the day of oocyte aspiration.

Main Outcome Measures: The incidence and degrees of OHSS.

Results: 93 cases were randomized in total, 46 cases received plasma, 47 cases did not receive plasma (control).

There was a noticeable difference in the two groups related to the occurrence of OHSS, the plasma group had 4 mild 8.7% and 1 moderate 2.2%, total % 10.9, where as 7 mild 14.9% and 3 moderate 6.4%, total % 21.3 in the control group, all were early onset of OHSS.

Conclusion: Our study proposes that plasma administration may reduce the percent and degree of OHSS in PCO patients undergoing ART. Plasma administration has no effect on the pregnancy rate.

Key Words: OHSS, PCOS, Plasma, ART, ICSI

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Outcome of repeated testicular sperm extraction and ICSI in patients with non-obstructive azoospermia
Ahmed Kamal, Ibrahim Fahmy, Ragaa Mansour, Ahmed Abou-Setta, Gamal Serour and Mohamed Aboulghar

The Egyptian IVF-ET Center; Maadi, Cairo, Egypt

ABSTRACT

Objective: To evaluate the outcome of repeated TESE/ICSI, in patients with non-obstructive azoospermia, to collect sufficient information for adequate counseling of the patients.

Design: Retrospective study

Setting: The Egyptian IVF-ET center

Materials and Methods: 41 patients suffering from non-obstructive azoospermia underwent 59 repeated TESE/ICSI cycles. All of the patients had repeated TESE/ICSI because of failure to achieve pregnancy (n=30), previous abortion (n=3), or because they wanted another child (n=8). Eleven patients repeated the procedure more than once. At each procedure multiple small biopsies were taken from each testicle. The interval between the repetitions of TESE was at least six months.

Main Outcome Measures: Sperm retrieval rate in each repeated trial, and the clinical pregnancy rate per ICSI cycle

Results: During repeated TESE, the mean sperm retrieval rate was 91.5%. Patients were divided into two groups according to previous pregnancy in the first trial. In group 1, (n = 11) pregnancy occurred in the first trial. They underwent 16 TESE/ICSI repeated cycles. Of these, 9 of them became pregnant a second time (PR 56.3 %). On the other hand the 30 patients who had failed to achieve pregnancy in the first trial (Group 2), underwent 43 repeated cycles. Of these only 7 became pregnant in the following trials (16.3 %). This difference is statistically significant (X2 9.59, P< 0.05).

Conclusion: In patients with non-obstructive azoospermia, when spermatozoa were retrieved in the first TESE/ICSI cycle, the sperm recovery rate during repeated TESE trials is quite high in our study (91.5%). Previous pregnancy is a good prediction for a second pregnancy in the subsequent trials.

Keywords: Repeated TESE, Intracytoplasmic sperm injection, sperm retrieval rate,

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Ovulation prediction in spontaneous and induced cycles: the role of ovarian reserve markers
Amgad O. Gohar, A.R. El-Edwi and Hossam ELDin S.H. Abdallah

Department of Obstetrics and Gynaecology, Faculty of Medicine, El Minia University, El Minia, Egypt.

ABSTRACT

Objective (s): To evaluate the role of day 3 serum; FSH, inhibin-B and estradiol, (biochemical markers), ultrasound measured antral follicle count AFC and ovarian volume OV (biophysical markers) in ovulation prediction in induced cycles in infertile patients with different induction protocols. Also, the secondary aim was to analyze the correlations between these markers and prediction of ovulation success in induced cycles with different induction protocols.

Design: Prospective comparative controlled study

Settings: Infertility Clinic, University Hospital, El Minia & IVF center, Egypt.

Patients: Eighty infertile patients (study group) classified into four subgroups, twenty patients each according to the method of ovulation induction and twenty matched fertile subjects (control group).

Interventions: Day 3 serum; inhibin-B, FSH and estradiol were measured together with transvaginal ultrasound measurements of the antral follicle count and ovarian volume in the study and the control groups. The study group was subdivided into four subgroups according the method of ovulation induction; whether clomiphene citrate (group I), or urinary follicle stimulating hormone (group II), or low dose recombinant follicle stimulating hormone (group III) or long protocol (group IV).

Main outcome measures: The predictive values of different screening markers in relation to ovulation. Other outcome measures were the analysis of the correlations between various biochemical and biophysical markers and prediction of ovulation success in induced cycles with different induction protocols.

Results: The predictive values of FSH (<10 IU/L), inhibin-B (> 45 pg/ml), estradiol (<75 pg/ml), AFC (> 6), and OV (>3 cmｳ) in relation to ovulation prediction were statistically comparable (P>0.05). Multivariate analysis of the variables that predict ovulation in induced cycles demonstrated that of the biochemical variables FSH was the most significant contributor to ovulation (R2 = 0.93, P £ 0.01), while of the biophysical variables AFC is the most significant one (R 2= 0.46, P £ 0.01).

Conclusions: Day 3 serum; FSH, inhibin-B and estradiol, ultrasound measured AFC and ovarian volume are comparable screening markers of the ovarian reserve in the general infertility patients. Of the biochemical factors the main predictor for ovulation in induced cycles is FSH while AFC is the main biophysical one.

Key words: Ovulation prediction, FSH, Inhibin-B, estradiol, transvaginal ultrasound, antral follicle count AFC, ovarian volume OV, Infertility

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Laparoscopic management of ovarian dermoid cysts
Osama Shawki, Ihab Soliman, Alaa Ebrashy, Mustafa El Sadek and Abeer Bahnassy

Department of Gynecology, Cairo University and department of pathology, national cancer institute, Egypt

ABSTRACT

Objective: To evaluate the safety and potential advantages of laparoscopic approach for management of ovarian dermoid cysts.

Design: Retrospective study.

Methods: >From May 1999 to February 2002, 28 patients underwent laparoscopic removal of dermoid cysts.

Intervention: Exposure of Douglass pouch and avoidance of Trenedelenberg's position offered guarantee that any spilled material will be collected and confined to Cul de sac only with no further spread. After removal of cyst, we perform forceful jet wash lavage and aspiration simultaneously using wide bored 2 canulae from both lateral ports using copious amount of fluid (8-12 liters)

Results: Thirty-one dermoid cysts with mean diameter of 7.5 centimeter were removed successfully in 28 patients. The operative techniques employed were ovarian cystectomy for 28 cysts, salpingo-oophrectomy for 3 cysts and one case had salpingo-oophrectomy together with LAVH. In one case we performed concomitant hysteroscopic excision of complete uterine septum. Fourteen cysts were removed through enucleation and removal through trocar sleeve. Ten cases were treated via enucleation and removal within impermeable endobag. Seven cases were managed by removal of cysts via posterior colpotomy; one of them was associated during step of LAVH. We encountered total of fourteen spillages during the procedures. Spillage occured in 10 cases (71%) in instance of trocar removal without the use of endo bag, one case (10%) for removal within impermeable endo bag, and 3 cases (42%) in cases of colpotomy removal. No spillage occurred in the case of LAVH. Mean hospital stay after surgery was 0.9 day, and there were no significant intraoperative complications apart from inferior epigastric injury at site of secondary puncture.

Conclusion: After we did review of 14 studies in the literature added to our study, we revealed only 0.2% incidence of chemical peritonitis following laparoscopic removal of dermoid cysts. Laparoscopic approach allows proper exposure of Cul de sac and allows forceful jet lavage aspiration ensuring pelvic clean out from any microscopic material of the dermoid cyst. A situation may not be available during open laparotomy.

Keywords: Laparoscopy, dermoid cyst, ovarian cystectomy, spillage.

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Trends of sex ratios in an urban Saudi Arabian population
Zainab A. Babay

Department of Obstetrics & Gynecology, College of Medicine King Saud University, King Khalid University Hospital, Riyadh, Saudi Arabia

ABSTRACT

Objectives: This study analyzes the distribution of sex ratio at birth in a Saudi population using data collected from the birth database of an urban teaching hospital and to assess the potential effect of the gulf war on it.

Design: Database on all hospital births was used to calculate the sex ratios for all live births.

Setting: Births at King Khalid University Hospital (KKUH), Riyadh, Saudi Arabia totaling 67,643.

Subjects: All live births from 1983 -2000.

Outcome Measure: Sex ratio male/female (expressed as the proportion of the total live births that were males).

Results: The average sex ratio from 67,643 births, was 1.033 (95% CI, 1.029-1.037), significantly different from the world average of 1.055. The male proportion at King Khalid University Hospital, Riyadh, decreased significantly after 1990 (Gulf war). This represented a cumulative loss of 15.7 male births per 1000 live births from 1983-2000.

Conclusion: The decreased sex ratio observed in our study as well as in other parts of the world add to the importance of the effect of environmental factors on the reproductive health of populations, in addition to the sensitivity of the sex ratio as an unambiguous marker for that.

Key Words: Sex ratio; Trends; Saudi Arabia; Male proportion.

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Laparoscopic ovarian re-electro cautery versus ovulation induction with FSH for persistant anovulation after laparoscopic PCOS treatment
Momen A. Kamel, Alaa El-Din Abdel Hamid, Mahmoud Abdel-Rahim and Sayed  Mostafa

Department of Obstetrics and Gynaecology, Assiut University Hospital, Assiut, Egypt.

ABSTRACT

Objectives: To determine the effectiveness and safety of either another laparoscopic ovarian drilling or purified urinary FSH for induction of ovulation in PCOS patients who were treated previously by laparoscopic electrocautary but still anovulatory.

Design: Comparative prospective clinical study between two groups of anovulatory infertile women after laparoscopic electrocutary.

Setting: Infertility treatment unit in Assiut University Hospital, Assiut, Egypt.

Patients: Fifty five patients treated previously by laparoscopic ovarian drilling for anovulatory PCOS infertility and still anovulatory and infertile after six months at least from the procedure were included in this study.

Intervention: Thirty patients exposed to another laparoscopic ovarian drilling (group A) and 25 patients were stimulated by purified FSH for 3 cycles (group B).

Main Outcome measures: Pelvic adhesions, Hormonal profile, Ovulation rate and Pregnancy rate were estimated.

Results: Pelvic adhesions were found in 27.2% of patients, hormonal profile showed considerable change toward normal values in the group of patients who were exposed to another laparoscopic drilling, while there were slight changes in patients who were subsequently subjected to FSH stimulation.

      Within three stimulated cycles ovulation occurred in 16 patients (53.3%) in drilling group after clomiphene citrate compared to 18 patients (72%) in FSH stimulated group. The pregnancy rate per cycle was very low (3.8% per cycle in all included patients and 6.6% per patient). The pregnancy rate per cycle was 2.2% in group A and 5.7% in group B and the cumulative pregnancy rate per patient was higher in FSH group (16%) versus 6.6% in the redrilling group. All pregnancies occurred in stimulated cycles.

Conclusion: Ovarian stimulation with purified FSH gave better ovulation and pregnancy rate than ovarian laparoscopic redrilling followed by clomiphene citrate stimulation. Although the ovulation rate of both procedures was to some extent high; yet the pregnancy rate was low and this should be discussed with the patients during counseling. Another laparoscopic redrilling is followed by low pregnancy rate and possible hazards of adhesion formation.

Key words: polycystic ovary, infertility, induction of ovulation, second look laparoscopy, clomiphene citrate failure, laparoscopic re-electrocautary.

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Three Dimentional Transvaginal ultrasound in the assessment of uterine lesions: when do we really need it?
Alaa N. Ebrashy, Mohamed Momtaz, Osama A. Shawky, Ehab M. Soliman and Zakareya Aboul Maaty

Department of Obstetrics and gynecology, Kasr El Aini Hospital, Cairo University, Cairo, Egypt

ABSTRACT

Objective: To evaluate the use of Transvaginal 3D U/S in the assessment of uterine pathology and uterine cavity abnormalities.

Materials and methods: We included 65 patients in our study, age range between 21-47. The main complaint of these patients was either vaginal bleeding, reproductive failure, recurrent abortion or infertility. Procedures Done were: -2D TVS -3D TVS for all cases -HSG -Sonohysterography using saline - Hysteroscopy -Laparoscopy done only in uterine cavity abnormalities.

Results: 65 cases were examined by both Transvaginal 2Dand 3D U/S. 9 cases showed normal uterine cavity and no uterine pathology. Twenty nine cases had myomas either single or multiple. From the 29 cases, 8 cases had submucus myomas. There were 7 cases had endometrial polyps, 12 cases had thickened endometrium. 6 cases had uterine cavity anomalies (septate or bicornuate). Two cases had intrauterine adhesions. There were 4 cases (2 cases with Mullerian anomalies both were septate uterus and 2 cases with intrauterine adhesions) all were diagnosed by Transvaginal 3D U/S, while being missed by 2D U/S (4 false negative cases). 2 cases of endometrial polyps were missed by HSG and diagnosed by Transvaginal 3D U/S (-2 false negative cases). Transvaginal 3D U/S correlated well with HSG and hysteroscopy in the diagnosis of Mullerian anomalies however with an additional information concerning the visualization of the surrounding myometrium and the accurate differentiation between septate and Bicornuate uterus.

Conclusion: TVS is an excellent tool that provides valuable information in investigating the uterine cavity abnormalities. 3D TVS allows surface and volume rendering that can produce photographic images. It is much advantageous than HSG and Hysteroscopy in the differentiation between different types of uterine anomalies. It is of great value in delineating with certain the exact position of the submucous myomas or endometrial polypi in relation to the cavity. It is believed that, in the near future, 3D U/S equipment will be less expensive, which will allow its wide spread application.

Key words: 3D transvaginal U/S -Uterine cavity - Hysteroscopy-uterine cavity anomalies

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