Hormonal treatment for idiopathic male infertility in the light of evidence-based andrology
 Ibrahim M. Fahmy

Professor of Andrology, Faculty of Medicine, Cairo University; Andrology consultant, The Egyptian IVF-ET center, Cairo, Egypt

ABSTRACT

Hormonal regulation of testicular function by gonadotrophins and testosterone plays a fundamental role in spermatogenesis. Hormonal replacement therapy by gonadotrophins can improve semen parameters and restore fertility in patients with hypogonadotrophic hypogonadism. Therefore gonadotrophin therapy is a logical approach to improve seminal parameters and treat idiopathic male infertility. Other forms of hormonal therapy such as, GnRH analogues, androgens, anti-estrogens, aromatase inhibitors, growth hormone and prolactin-suppressing drugs can also be offered as an empirical treatment to males with idiopathic infertility. In this review we present the current state of knowledge and uncertainties about the hormonal treatment of idiopathic male factor infertility, based on the best available evidence from systematic reviews, and randomized-controlled trials. Available data suggest a beneficial effect of gonadotrophin therapy for idiopathic male factor subfertility but requests more studies for better evaluation. Androgen alone should not be offered to patients with idiopathic oligozoospermia, but a combination with antiestrogen might be useful. The anti-estrogens and the aromatse inhibitors might proof useful in a subgroup of patients with elevated estrogen / testosterone ratio, but more studies are needed. Randomized controlled trials assessing other forms of therapy and combination treatments are rare. Since, the available studies are still at its preliminary stages, no solid recommendations can be offered for the time being. More controlled studies are needed to assess properly the therapeutic benefits for various hormonal therapies currently used to treat idiopathic oligo-astheno-teratozoospermia.

Keywords: Treatment, idiopathic male infertility, evidence based.

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Uterine septum resection: does it impact fertility?
 Stefano Bettocchi, Marialuigia Spinelli, Anna Lina Camporiale, Luigi Selvaggi, Attilio Di Spiezio Sardo, and Carmine Nappi

Department of General and Specialistic Surgical Sciences, Section of Obstetrics and Gynecology - University of Bari, Italy, and Department of Obstetrics and Gynaecology and Pathophisiology of Human Reproduction – University of Naples “Federico II”, Italy

ABSTRACT

The septate uterus is the commonest congenital anomaly of the uterus and it represents a considerable clinical issue, since it is usually associated with recurrent pregnancy loss and may also impair fertility. Recurrent pregnancy loss associated with the septate uterus can be due to numerous conditions, including the diminished size of the uterus, the cervical incompetence, the poor response to estrogen of the endometrial mucosa covering the septum, the poor endometrial decidualization, as well as the higher or uncoordinated contractility of the uterine wall. It has been suggested that primary infertility associated with the septate uterus may be the result of an abnormal blood supply to the septal tissue, leading to a pathological implantation dynamics, even though some recent publications suggest that probably pathogenesis of primary infertility is multi-factorial and not only caused by the presence and the type of the uterine septum. Currently, the combined use of laparoscopy and hysteroscopy is the gold standard for diagnosing the septate uterus, although recent reports of three-dimensional ultrasound appear promising.

Hysteroscopic metroplasty by means of resectoscope is the current standard of care for the uterine septum. However, such approach requires cervical dilatation, local or general anaesthesia and an operating room. With the introduction of smaller diameter scopes with continuous flow systems and working channels through which mechanical instruments and bipolar electrodes can be inserted, the metroplasty can now be performed easily and safely also on an outpatient basis. Effectiveness of metroplasty for reproductive outcome has been exhaustively evaluated. A meta-analysis of published retrospective data has shown that metroplasty in women with recurrent miscarriage (≥ 3) significantly improves subsequent reproductive outcome. On the other hand, the role of metroplasty in infertile women with a septate uterus for whom all other causes have been excluded still needs to be completely clarified. However, in accordance with the available data and considering the feasibility, minimal morbidity, and cost-effectiveness of hysteroscopic metroplasty (mostly if performed in outpatient setting with 5Fr bipolar electrodes or mechanical instruments), this procedure should be done in all cases of uterine septum, even in asymptomatic cases. Indeed in these latter patients, the prophylactic metroplasty could prevent miscarriage, preterm labour, or presentation anomalies.

Keywords:  hysteroscopy, infertility, metroplasty, recurrent pregnancy loss, uterine septa.

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Randomized controlled study comparing a modified antagonist protocol to the conventional long agonist protocol for infertile patients with PCOS undergoing ICSI
 Mohamed Eid, Amal Shohayeb, Amany Shaltout, Samir Abbas, and Hesham Al-Inany

Department of Obstetrics and Gynecology, Cairo University, and Samir Abbas Fertility center, Jedda, Saudi Arabia

ABSTRACT

Objective: to compare the value of a modified Gn-RH antagonist protocol against the conventional long Gn-RH agonist protocol for women with polycystic ovarian syndrome (PCOS) undergoing ICSI.

Design: randomized controlled trial

Setting: tertiary care center

Materials and Methods: Women undergoing ICSI were randomized to two groups :  Group A  (n= 79) received GnRH antagonist 0.25 mg on day 1,2 then day 8 till day of hCG. Group B (n= 79) received GnRH agonist long protocol 0.5 mg daily as standard. In all women, recombinant FSH was used as low fixed dose (150 i.u.) till day of hCG.

Results: There was no statistically significant difference between both groups regarding clinical pregnancy rate, ongoing pregnancy rate, serum LH day 3, cancellation rate and number of embryo transferred. However, there was significant reduction in rate of severe OHSS, reduction of number of ampoules and lower number of oocytes retrieved in Group A .

Conclusion: the modified antagonist protocol is a safer option to PCOS women undergoing ICSI with comparable pregnancy rate to the standard GnRH agonist long protocol.

Keywords: GnRH agonist, GnRH antagonist, ICSI, PCOS

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Accuracy of 3-D ultrasound for first trimester fetal gender identification in women with advanced maternal reproductive age
 Sherif El Mekkawi, Ghada Mahmoud, Nadine Alaa, Mohamed Eid, Taha Mohamed, and Rushdi Ammar

Departments of Obstetrics and Gynecology, Ain Shams University and Cairo University, Cairo, Egypt

ABSTRACT

Objective: To evaluate the role of three-dimensional ultrasound in the determination of the fetal gender in the first trimester of pregnant women aged 35 years or older.

Design: Prospective test of diagnostic accuracy.

Materials & Methods: One-hundred pregnant women in their first trimester were subjected to three-dimensional ultrasound examination by two sonographers using a Voluson 730 ultrasound machine. Sex identification was confirmed after delivery to estimate accuracy.

Results: The study showed an 82% accuracy rate in the prediction of the fetal gender. There was a statistically significant difference in the false prediction of male fetuses as compared with female fetuses. Gestational age did not seem to be a significant co-factor with regards the accuracy of fetal gender identification.

Conclusion: Identification of fetal sex in the first trimester is feasible and of reasonable accuracy.

Key words: early pregnancy, fetal gender, 3-D ultrasound

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Operative laparoscopy for the treatment of large ovarian dermoid cyst
 Nora N. Sahly, Amal Shobkshi, Sharifa A. Alsibiani, and Abdulrahim A. Rouzi

Departments of Obstetrics and Gynecology, King Abdulaziz University, Jeddah, Saudi Arabia

ABSTRACT

Objective: To assess the effectiveness of operative laparoscopy for treatment of large ovarian dermoid cyst.

Materials and Methods: From January 1997 through January 2007, all operative laparoscopy notes at King Abdulaziz University Hospital, Jeddah, Saudi Arabia were reviewed. Inclusion criteria included women with ovarian dermoid cyst (less than 10 cm), were reviewed. Ten women with ovarian dermoid cysts 8 cm ± 2 (mean ± SD) underwent ovarian laparoscopic cystectomy by the same surgeon. The age was 27 ± 7 years (mean ± SD). They all had normal tumor markers (CA 125, CEA, alpha fetoprotein, and beta human chorionic gonadotropin). Eight women were multiparous and two women were nulliparous. The presenting symptoms were pelvi-abdominal pain in six women, secondary infertility in two women, and abnormal vaginal bleeding in two women. Eight women had unilateral dermoid cyst and two women had bilateral dermoid cysts.

Results: Laparoscopic ovarian cystectomy was successfully done in all women. There was no conversion to laparatomy in this series. The mean operative time was 90 ± 15 minutes. Estimated blood loss was 300 ±50 ml. There were no intraoperative complications. Histology showed benign cystic teratoma. Long term follow up (7 ± 3 years) showed no recurrence of the cyst and five women got pregnant after the procedure (two infertility women, two previous nulliparous women and one multiparous woman).

Conclusion: Laparoscopic ovarian cystectomy is effective for large ovarian dermoid cysts.

Keywords:  Laparoscopy, big dermoid cyst.

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Endocrine and metabolic dysfunction in normal weight Egyptian women with typical polycystic ovary syndrome
 Dina Gamal Eldeen Elkholi, and Halah Mohamed Nagy

Department of Obstetrics and Gynecology, and Department of Clinical Pathology, Tanta University, Tanta, Egypt

ABSTRACT

Objective: to study the endocrine and metabolic dysfunction: insulin sensitivity, somatotropic and LH axes in normo-weight Egyptian women with classic polycystic ovary syndrome.

Design: a cross sectional study.

Materials and Methods: sixty eight normo-weight women with polycystic ovary syndrome (PCOS) and 30 normal cycling women (NW) as control. Women with PCOS were divided into two groups: PCOS with normal insulin sensitivity (NIS), 52 cases 76.5% and PCOS with insulin resistance and hyperinsulinism (IR/ HI) 16 cases 23.52%. Clinical and biochemical studies of all groups.

Main outcome measure: insulin resistance.

Results: PCOS with IR/HI showed significantly higher values than NW and PCOS with NIS in the following criteria: waist hip ratio (WHR), Ferriman Gallwey score, fasting insulin, fasting glucose, free insulin-like growth factor-1 (fIGF-!), growth hormone -binding protein (GHBP), cholesterol, LDL-c, LH/FSH ratio, LH, total testosterone But significantly lower growth hormone (GH), insulin- like growth factor binding protein-1 (IGFBP-1), sex hormone-binding globulin (SHBG) than the other two groups. The same was also found but to a less extent between PCOS with NIS and NW.

Conclusion: in normo-weight Egyptian women with PCOS IR/HI was detected in 23.52%. Clinical and biochemical criteria denote that IR/HI is found in one subtype of PCOS that is associated high cholesterol and LDL-c. Recommendation: Insulin resistance test should be performed to all cases of PCOS to detect this subtype.

Key words: Polycystic ovary syndrome. insulin resistance and hyperinsulinism, GH, LH, IGF-1, GH, IGFBP-1, GH binding protein.

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Ultrasound-guided embryo transfer; procedure recording
 Mohamed Eid, Amal Shohayeb, Amany Shaltout, and Samir Abbas

Dr. Samir Abbas Medical Center (IVF unit), Jeddah, Saudi Arabia; and Department of Obstetrics and Gynecology, Cairo University, Egypt.

ABSTRACT

Objective: The introduction of ultrasound (US) monitoring has revolutionized all aspects of IVF, including the embryo transfer (ET) technique. Even so, the relationship observation of the air brackets around the embryo containing media and the outcomes of US-guided ET is not yet clear. This prospective, observational study was designed to record ET technique under trans-abdominal ultrasound guidance aiming to detect new confirmatory objective signs.   

Materials and Methods: One hundred-twenty infertile couples undergoing US-guided ET were recruited from our fertility clinic. Embryo transfer was performed using two air bubbles to surround the embryo containing media. In addition to air bubble, another two observational signs were recorded to confirm proper embryo location in the uterine cavity during deposition, namely echogenic dot and stream jet. All transfers were recorded prospectively and analyzed with the individual patient data.

Results: By order of frequency: echogenic dot, stream jet, and air bubble were visualized in 65% (78/120), 25% (30/120) and 10% (12/120) of transfers, respectively. In comparison, echogenic dot was considered more reliable as it is more visible, easily detected, more persistent, and could even be seen after catheter withdrawal. The clinical pregnancy rate was in the study group was 34% which is slightly higher than our concurrent pregnancy rate when clinical touch ET was performed (27%).

Conclusion: The search for the definitive signs that will improve the reliability of ultrasound-guided ET technique is still lacking. Our results proved that, we can rely on echogenic signs (echogenic dots and stream jet) more than echoluscent sign (air bubble), but this observation needs further extended studies.

Key words: ultrasound-guided ET/clinical-touch ET/IVF medium/IVF/ICSI.

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GnRH agonist short versus GnRH antagonist protocols in poor responder: a case- controlled study
 Mohamed Khaled Moustafa

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

ABSTRACT

Objective: There is much debate on whether or not GnRH antagonist is preferential in women who responded poorly in a previous trial with GnRH agonist protocol. The aim of our study is to determine from our center’s experience whether there was any benefit from changing strategies to an antagonist protocol in women who have experienced a poor response to the agonist protocol in a previous stimulation cycle. 

Materials and Methods: In this study, 70 patients who underwent ovarian hyperstimulation with highly purified or recombinant FSH were divided into two groups depending on the type of GnRH analogue used to prevent premature LH surge: GnRH agonist short protocol group (n = 35) and GnRH antagonist protocol group (n = 35).

Results: There was no significant difference between the two groups for mean-age, duration of infertility or baseline FSH. There were a significantly higher number of ampoules of gonadotrophin and duration of analogue use in the agonist group. In contrast, there was a significantly higher number of mature oocyte retrieved, 2 PN embryos in the antagonist group. The numbers of embryos transferred were similar, as were the clinical pregnancy rate in both groups.

Conclusion: The addition of GnRH antagonist to ovarian stimulation protocol may be used for poor responder, but does not seem to affect the primary outcome, the clinical pregnancy rate. Randomized clinical studies with adequate sample sizes are required to clarify this issue further.

Keywords: GnRH antagonist,  poor responders, GnRH agonist.

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