Stimulation of the high responders and strategies to prevent ovarian hyperstimulation syndrome
Ziad Rafic Hubayter and Suheil Jamil Muasher

Division of Reproductive Endocrinology and Infertility, Department of Gynecology and Obstetrics, Johns Hopkins University School of Medicine, Baltimore MD, U.S.A.

ABSTRACT

Identification of high responder patients is essential prior to ovarian stimulation for in vitro fertilization. These patients usually yield a high number of oocytes (> 15) with high peak estradiol levels (> 3000 pg/ml). Pregnancy and implantation rates are excellent in these patients, but at the expense of a higher risk of ovarian hyperstimulation syndrome (OHSS). Different strategies are reported and discussed with advantages and disadvantages for each. The goal should be an approach that will maintain the good outcome while minimizing the risk of OHSS.

Key words: high responder, ovarian hyperstimulation syndrome, OHSS, in vitro fertilization.

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Is there a place for slow freezing and thawing of embryos for IVF?
Batuhan Ozmen, Vassili Palapelas, and Safaa Al-Hasani

University of Ankara, Department of Gynaecology and Obstetrics, Center of Artificial Reproductive Techniques, Campus of Mamak, Ankara, Turkey; Third Department of Obstetrics and Gynecologic Clinic Aristolte University of Thessaloniki, Greece; and University of Schleswig-Holstein, Department of Gynaecology and Obstetrics, Reproductive Medicine Unit, Campus of Luebeck, Luebeck-Germany

ABSTRACT

Since the significance of embryo and gamete freezing was understood in artificial reproduction, there has been a great competition between conventional slow freezing and rapid freezing methods. More recently, as the success and simplicity of rapid techniques were pointed out, the balance between these methods has been changed in advantage of vitrification, and slow freezing techniques has become controversial due to difficulties, expenses and respective low success rates. Even the early performers of slow freezing methods began to select rapid techniques at their laboratory. On the contrary, some disadvantages of rapid techniques have also been indicated in previous publications

Nevertheless, none of these practical and hypothetical disadvantages decreased the popularity of rapid techniques. Therefore vitrification still seems to win the battle and will be the cryopreservation method of future.

Keywords: Vitrification, embryo freezing, gamete freezing, IVF 

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Assessment of endometrial receptivity in unexplained infertility by Doppler ultrasound and interleukin-1
Mohamed A. Metawe, Zakia Abol Leil, Hamdy Azab, Manal Hamdy, Yasser M.Shaban, and Walid Elsherbiny

Department of Obstetrics and Gynecology, Suez Canal University; Department of Obstetrics and Gynecology, Cairo University; and Department of Chemical Pathology, Cairo University, Egypt

ABSTRACT

Objective: to estimate endometrial receptivity in women with unexplained infertility.

Design: prospective clinical trial

Setting: Suez canal and Cairo University hospitals

Materials and Methods: The study included 63 women with unexplained infertility and a control group = 31 normal fertile women. All women had transvaginal Doppler imaging of the uterine and spiral arteries on the same day of interleukin assay. 39 patients of the study group were monitored during natural cycles, while the remaining 24 patients were monitored through stimulated cycles using clomiphene citrate, gonadotropins, and a combination of both.

Outcome measures: The resistance index (RI) and the pulsatility index (PI) were evaluated in uterine and spiral arteries. All women had a serum assay of IL-1b using the ELISA technique on cycle day 21 -24.

Results: The PI and the RI of the uterine arteries were significantly higher in the study group (3.8 ± 0.61, 0.96 ± 0.04) compared to the control group (2.82 ± 0.10, 0.83 ± 0.07). The endometrial thickness was significantly higher in stimulated cycles compare to natural cycles. The PI and the RI of spiral arteries were significantly higher in the study group (1.4 ± 0.39, 0.67 ± 0.06) compared to the control group (0.96 ± 0.10, 0.58 ± 0.05). When a cut of value of 15 pg/ml was considered, there was no significant difference between the 2 groups regarding serum IL-1b. 

Conclusion: Doppler study of endometrial blood flow can be an important tool in evaluation of uterine receptivity in women with unexplained infertility. Serum IL-1b appears of less value in this respect.

Key words: Endometrial receptivity, Doppler study, unexplained infertility, interleukin-1b.

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Circulating soluble transferrin receptor and ferritin in obese polycystic ovary syndrome
Mohamed Abd El-Hafez, Amal El-Shehaby, and Mary N. Rizk

Departments of Medical Biochemistry, Internal Medicine, and Obstetrics and Gynecology, Faculty of Medicine,Cairo University, Cairo, Egypt

ABSTRACT

Objective: To determine serum ferritin and soluble transferrin receptor (sTfR) concentrations in PCOS women and to clarify their relationship to insulin resistance and metabolic features of PCOS.

Materials and methods: This cross-sectional study consisted of 20 obese patients with PCOS, 15 healthy obese, normally menstruating, age and BMI matched women, and 10 healthy, age matched, lean women as control groups. Serum ferritin and soluble transferrin receptor levels were measured using an enzyme-linked immunosorbent assay. Additionally, participants were subjected to hormonal assays, lipid profile, fasting glucose, iron, total iron binding capacity and insulin serum levels as well as transvaginal ultrasonography. The homeostasis model assessment of insulin resistance (HOMA-IR), Free Androgen Index (FAI, Body mass index (BMI) and Waist to hip ratio (WHR) were also calculated for each participant.

Results: The mean serum ferritin level was significantly higher in obese PCOS patients compared to both obese and lean control subjects. Also, the mean serum ferritin level was significantly higher in obese compared to lean control subjects. On the other hand, mean serum sTfR level was significantly lower in both obese PCOS compared to both obese and lean subjects. While, no significant difference was observed between obese and lean subjects as regard sTfR. The mean fasting insulin level, and mean HOMA-IR value were significantly higher in obese PCOS patients compared to both obese and lean control subjects. In addition, obese subjects had significantly higher mean fasting insulin level and mean HOMA-IR value compared to lean control subjects. In both PCOS patients and obese control subjects, serum ferritin levels showed a significant inverse correlation with soluble transferrin receptor in all of the studied groups.

Conclusion: Obese PCOS women have lower soluble transferrin receptor levels compared to obese and normal controls. sTfR is highly correlated with ferritin. Furthermore, sTfR could serve as a sensitive marker for iron overload in obese, PCOS patients, or metabolic syndrome.

Key Words: ferritin, soluble transferrin receptor, polycystic ovary syndrome, obesity.

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Color Doppler study of the uteroplacental circulation in early pregnancy complicated by threatened miscarriage
Dina Gamal El-Deen El-Kholi, and Mohamed Abd El-Geleel Hefaida

Department of Obstetrics and Gynecology and Department of Diagnostic Radiology Faculty of Medicine, Tanta University

ABSTRACT

Objective: to predict of the outcome of threatened miscarriage in early pregnancy using color Doppler study of the intervillous space (IVS) and resistance index (RI) of the decidual spiral arteries (DSA) supplying the IVS.

Material and methods: a prospective-observational study performed on 46 pregnant patients (7-11weeks) suffering of threatened miscarriage. Ultrasound and color Doppler examinations of the uteroplacental circulation was performed using endovaginal probe of 6.5 MHz. The presence or absence of blood in the IVS as well as RI of the DSA were assessed.

Results: The patients were divided into three groups based the findings of the color Doppler study. Group (A): blood flow was present in the IVS and RI of the DSA was >0.55 (22 cases), 11 cases (50%) miscarried and pregnancy continued normally up to 28 weeks ( period of follow up). Group (B) 19 cases (41.30%) blood flow in the IVS was absent but RI of DSA was >0.55, two cases (10.50 %) aborted while in17 cases (89.47 %) pregnancy continued up to the end of the period of follow up. Group (C)- 5 cases (10.86 %) blood flow was absent in the IVS and RI of DSA was <0.55, pregnancy continued to the end of follow up period.

Conclusion: combined assessment of the blood flow in the IVS and RI of the DSA offer better prediction of the outcome of threatened miscarriage in early pregnancy. The highest rate of fetal loss (50%) was encountered when blood was present in the IVS and RI of the DSA was >0.55. The pregnancy loss was nil when no blood flow was detected in the IVS and RI of DSA was <0.55.

Keywords: threatened miscarriage, blood flow in the intervillous space, RI of decidual spiral arteries, outcome of pregnancy.

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Down-regulation in women with polycystic ovarian syndrome: a prospective case controlled trial
Mohamed Khaled Moustafa, Ahmed Abdelwahed, Ibrahium Abosekena, Shokry Abdelazim, and Mahmoud Ibrahim Abdelsta

Dr Erfan And Bagedo General Hospital, Jeddah, Saudi Arabia Obstetrics and Gynecology Department, AL-Azher University, Egypt

ABSTRACT

Objective: To compare the use of gonadotrophin-releasing hormone agonists (GnRHa) with antagonists (GnRH-ant) in subfertile women undergoing assisted reproduction with polycystic ovarian syndrome (PCOS)

Materials and Methods: we performed a prospective trial with 80 women with PCOS undergoing in vitro fertilization for anovulatory infertility. The women were pragmatically divided into two groups according to patient/physician preference and previous cycle history. Women in the agonist group were administered the standard long protocol of down-regulation, while women in the antagonist group were administered a fixed day-6 antagonist protocol.

Results: There were no significant differences in patient demographics between the two groups. In the antagonist group, fewer days of stimulation and amount of gonadotrophins were required to reach the criteria for human chorionic gonadotropin administration. Even so, there were no significant differences in the clinical and ongoing pregnancy rates, miscarriage rate, and occurrence of ovarian hyperstimulation.

Conclusions: Women with PCOS should be counseled regarding the use of GnRH antagonist for down-regulation during assisted reproduction. In addition, more randomized controlled trials should be performed to determine the optimum protocol in this subgroup of infertile population.

Key words: polycystic ovary, down regulation, GnRH analogues

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Letrozole - metformin versus clomiphene citrate - metformin in induction of ovulation in clomiphene citrate resistant patients with polycystic ovary syndrome (PCOS)
Usama M. F. Fouda, Adel F. El Bigawy, Hesham S. Elshaer, Ashraf A. Eldaly, and Abdalla Y. Elkateb

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

ABSTRACT

Objective: The aim of this study was to compare the effect of combined clomiphene citrate (150 mg) - metformin (1700mg) and combined letrozole (2.5mg) - metformin (1700 mg) on ovulation in clomiphene citrate resistant patients with PCOS.

Design: Prospective quasi-randomized trial.

Setting: University teaching hospital.

Materials and methods: Infertile PCOS patients resistant to clomiphene citrate were randomized into letrozole -metformin group (30 patients) and clomiphene citrate –metformin group (30 patients). After two months of metformin administration, clomiphene citrate or letrozole was added to metformin on days 3-7 of menses.

Main outcome measures: Number of follicles, endometrial thickness. Ovulation and pregnancy rates per cycle.

Results: Ovulation occurred in 71.4% of the cycles (40/56) in clomiphene citrate - metformin group and 77.8% of the cycles (42/54) in letrozole - metformin group. The endometrial thickness was significantly higher in letrozole - metformin group; the number of mature follicles was significantly lower in the letrozole - metformin group. Pregnancy rate per cycle was 10.7% in clomiphene citrate-metformin group and 18.5% in letrozole - metformin group.

Conclusion: Combined letrozole –metformin is as effective as or even superior to combined clomiphene citrate –metformin in ovulation induction in clomiphene citrate resistant patients with PCOS. Unlike clomiphene citrate, letrozole has no adverse effect on the endometrium, causes monoovulation in the majority of stimulation cycles. These advantages make combined letrozole –metformin a better alternative than combined clomiphene citrate –metformin in ovulation induction in clomiphene citrate resistant patients with PCOS.

Key words: letrozole, clomiphene citrate, metformin, polycystic ovary syndrome, clomiphene citrate resistance, ovulation, conception

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Live birth in a subsequent successful in vitro fertilization following previous complicated oocyte retrieval
Ebtisam Al-Mizyen, R Bevan, N Pulsford, and J. G. Grudzinskas

Queen Mary's Hospital, Roehampton, and The London Bridge Fertility, Gynaecology and Genetics Centre, London, UK.

ABSTRACT

Transvaginal ultrasound-guided oocyte retrieval (TVOR) is a procedure for assisted reproductive technology (ART). This case resulting in a live birth after successful in vitro fertilization following previous complicated oocyte retrieval.

Key words: pregnancy, transvaginal oocyte retrieval complication, in vitro fertilization

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