 |
|
|
|
Reproductive Medicine Unit, Liverpool Women’s Hospital, Liverpool, United Kingdom
ABSTRACT
One of the most important developments in the treatment of infertility in recent years has been the widespread use of gonadotrophin releasing hormone analogues (GnRH-as). Following their introduction to gynaecological practice in the 1980s, the indications and uses have expanded enormously, none more so than in the treatment of aspects of infertility and in particular in their use in assisted reproduction programmes.
This article will review the pharmacology of GnRH-as and their use in assisted reproduction, ovarian hyperstimulation syndrome, endometriosis, and miscarriage.
The amino acid sequencing of gonadotrophin releasing hormone (GnRH)
was first determined in 1971
(1). Because of its short biological activity, analogues were
synthesized by substituting other amino acid bases or complex molecules
(2).These were initially used to treat sex-hormone
Conjuring today - a philosophy about
endometriosis, pain and fertility.
Johannes L.H. Evers, M.D.*
Academisch Ziekenhuis Maastricht, and The University of Maastricht.
ABSTRACT
Endometrium can grow inside and outside the uterus. Inside the uterus it is a prerequisite for implantation to occur, and thus for fertility. Outside the uterus it is believed by some to decrease fertility. In this contribution to the Middle East Fertility Society Journal it is argued that, since no morphological characteristics differentiate intra- from extra-uterine endometrium, also functional characteristics will have to be reconsidered. Why would drug treatment eradicate ectopic endometrium and not eutopic? Why would medical suppression, which is of proven benefit in the treatment of endometriosis-related pain, extend its effect beyond the period of treatment? We have been drawing the wrong conclusions from the wrong studies, and we have mistakenly prescribed the wrong treatment to the wrong category of patients, depriving subfertile women of the chance of a pregnancy for an unnecessarily long period of time. This is not to say that all we have been doing was in vain. Principles of Evidence-Based Reproductive Medicine however oblige us to re-evaluate all studies from the past and develop new ones which will give the final answer to the complex problem of endometriosis, pain and subfertility.
Variations in pregnancy rates following
intrauterine insemination among infertility centers: can the inseminators
make a difference?
Panayiotis M. Zavos, Ed.S., Ph.D.†‡§ Michel
Abouabdalla, M.D.||, Panayota N. Zarmakoupis-Zavos, M.D. §, Pavlos
Aslanis, M.D., Juan R. Correa, Ph.D. †
Andrology Institute of Lexington and Kentucky Center for Reproductive Medicine, Lexington, Kentucky, USA; Clinique Dr. Rizk, Beirut, Lebanon; and Greek-American Andrology Institute of Athens, Greece.
ABSTRACT
Objective: To evaluate possible differences in pregnancy rates (PRs) that might exist among various infertility clinics and their physicians performing intrauterine inseminations (IUIs).
Design: A prospective study including two hundred eighty-three couples participated in this study at six different infertility clinics in the USA. The couples underwent IUI at each location under standardized conditions.
Setting: Six different infertility clinics in the USA.
Patients: Two hundred eighty-three couples undergoing infertility treatment were selected for this study.
Main Outcome Measures: Pregnancy rates and pregnancies per cycle at each location.
Results: The clinical PRs by location and clinical PRs per cycle were statistically different among the various physicians that performed the IUIs.
Conclusions: The results obtained suggest that there is a human factor involved when IUIs are performed by different physicians specializing in the treatment of infertility.
Key Words: Intrauterine insemination, infertility clinics, inseminator, pregnancy rates.
Pregnancy after intracytoplasmic injection
using cryo-thawed epididymal and testicular spermatozoa.
Ahmed Kamal, M.D.*, Ibrahim Fahmy, M.D., Ragaa Mansour, M.D.,
Gamal Serour, M.D., Mohamed Aboulghar, M.D., Nevine A.Tawab, B.Sc.
The Egyptian IVF-ET Center. Maadi, Cairo.
ABSTRACT
Objective: To report our experience in using cryo-thawed testicular and epididymal spermatozoa in intracytoplasmic sperm injection (ICSI).
Design: Retrospective study comparing the results of using fresh and cryo-thawed samples from the same couples.
Setting: The Egyptian IVF-ET Center.
Patients: Twelve patients who underwent surgical retrieval of sperm. The excess spermatozoa were cryopreserved and used in other cycles.
Interventions: Surgical retrieval of spermatozoa for ICSI and cryopreservation of excess spermatozoa.
Main outcome measures: Fertilization rate, embryo quality and pregnancy rate.
Results: All 12 couples had successful fertilization and reached the embryo transfer stage. The fertilization rate was 56.1% when cryo-thawed testicular sperm were used, and 56.8% when cryo-thawed epididymal sperm were used. Four pregnancies were achieved and six babies were delivered.
Conclusion: The use of cryo-thawed testicular, or epididymal spermatozoa for ICSI gives comparable results to fresh samples and offers a valuable therapeutic option in azoospermic patients, sparing them repeated testicular biopsies for future ICSI cycles.
Key Words: ICSI, cryopreservation, epididymal sperm, testicular sperm.
Royan institute, Jehad Daneshgahi, Medical University of Iran, Tehran, Iran
ABSTRACT
Objective: To investigate the effect of Vero cell coculture on development of one and two cell murine embryos.
Design: Prospective experimental study.
Materials and Methods: Two separate sets of experiments were carried out; In the first experiment 307 one cell embryos were cocultured with (174) and without (133) Vero cells. In the second experiment 436 two cell embryos were also cocultured with (249) and without (187) Vero cells. The development of different groups of embryos were evaluated. Results were compared using chi-square test.
Setting: Research laboratory associated with clinical IVF program.
Results: In experiment 1, cocultured one cell embryos showed significantly higher development beyond two cell stage (53% compare to 38%). Although, the rate of development to blastocyst in two groups was nearly identical (6% compare to 5%). In experiment 2, Vero cell monolayer improved the rate of blastocyst transformation of two cell mouse embryos (80% compare to 75%). The rate of hatching significantly increased in coculture group(48% compare to 27%).
Conclusion: Vero cell monolayer is unable to support one cell mouse embryos through developmental stages towards blastocyst transformation. However, when the embryo passes the early stages in vivo, Vero cell can improve development.
Key words: coculture, Vero cell, mouse embryo, developmental block.
Assessment of the nine month lactational
amenorrhea method (extended LAM) for family planning in Egypt.
Ahmed M. Makhlouf, M.D.*† Hossam T. Salem, M.D.*, Moemen
A. Kamel, M.D.*, Mamdouh M. Shaaban, M.D.*,
Mamdouh M. Anwar, M.D.‡
Department of Obstetrics and Gynecology* and Physiology Department ‡, School of Medicine, Assiut University, Assiut.
ABSTRACT
Objective: To explore the possibility of extending the use of Lactational Amenorrhea Method (LAM) for family planning from the end of sixth to the end of the ninth month postpartum with respect to assess the efficacy and acceptability of this method (extended LAM or LAM-9).
Design: Clinical prospective non comparative study.
Setting: Normal breastfeeding women in Assiut, Egypt.
Patients: One hundred and fifty women were using LAM for six months and opted to continue to rely on lactational amenorrhea to prevent pregnancy while actively breastfeeding for up to 9 months postpartum were followed up monthly from the end of the sixth to the end of the ninth postpartum month. Active breastfeeding meant no intervals between breastfeeds longer than 6 hours and giving the breast to the infant before any supplement. The study was a continuation of a clinical study of LAM done in the same center.
Interventions: Mothers who successfully completed six months of LAM were taught to use the extended LAM. One hundred and fifty of whom were interviewed clinically each month. A subset of 62 women were closely monitored by frequent vaginal ultrasonographic examinations to follow up ovarian follicular development and blood samples were taken from these volunteers for measurement of prolactin and progesterone in the serum at each visit.
Results: Life table pregnancy rate was 0.45% among women who opted to continue actively breastfeed their infants and continue to rely on lactational amenorrhea as a contraceptive method between the end of the sixth to the end of the ninth postpartum month. More than 60% of these women could continue to have the criteria for LAM-9 (LAM extended past the sixth postpartum month to the end of the ninth month postpartum). Normal ovulation with adequate luteal phase was likely to occur prior to menstruation in only two of the sixty two women relying on LAM-9.
Conclusion: This study demonstrated the effectiveness and acceptability of extended LAM or LAM-9 as a family planning method among actively breastfeeding women who remained amenorrheic up to the end of the ninth postpartum month.
Key words: Lactational amenorrhea, extended LAM, contraceptive effectiveness, ovulation monitoring.
Hysteroscopic metroplasty for the management
of septate uterus under ultrasound guidance.
Osama A. Shawki, M.D.*, Mehany A. Sattar, M.D.†
Al Ebtessama Hospital, Heliopolis, Cairo, Egypt
ABSTRACT
Objective: To assess the value and safety of hysteroscopic resection of the septate uterus under ultrasonographic guide.
Design: Prospective study.
Setting: Al Ebtessama Hospital, Heliopolis, Cairo.
Patients: Eleven patients had septate uterus as proved by hysterosalpingography and hysteroscopy. Eight patients presented with infertility and 3 with recurrent miscarriage.
Intervention: Hysteroscopic metroplasty under sonographic guidance was performed between June 1992 and June 1995 for resection of septate uterus. Patients were followed up until December 1995.
Main outcome measures: Safety of the combined technique using ultrasound with hysteroscopic methroplasty regarding post-operative restoration of normal uterine cavity, uterine perforation and hemorrhage.
Results: Hysteroscopic resection of septate uterus was performed in 11 patients under trans-abdominal ultrasound guidance achieving a perfect restoration of a normal uterine cavity in 9 cases (82%). Subtle arcuate configuration, not more than 1 cm in depth, was detected in 2 cases. No perforation occurred and bleeding was encountered in 3 cases but did not require any intervention.
Conclusion: Hysteroscopic metroplasty for management of septate uterus using ultrasound guidance is an efficient and safe technique.
Key words: Hysteroscopic metroplasty, septate uterus, ultrasonographic guidance.
Ultrasound prediction of follicular
volume during ovarian stimulation.
Khaldoun Sharif, M.R.C.O.G., M.F.F.P., F.I.C.S.*, Dimitrios Bilalis,
M.R.C.O.G., Masoud Afnan, M.R.C.O.G., Hany Lasheen, M.R.C.O.G., Yacoub
Khalaf, M.R.C.O.G., M.Sc., M.D.
Assisted Conception Unit, University of Birmingham, Birmingham, UK
ABSTRACT
Objective: To evaluate the correlation between the ultrasound measurement of different diameters of ovarian follicles and their actual volume, during ovarian stimulation for assisted reproduction.
Design: A prospective clinical study.
Setting: A University-based assisted conception unit.
Patients: Twenty patients undergoing transvaginal ultrasound-directed oocyte retrieval during their in-vitro fertilization and embryo transfer treatment.
Methods: One hundred ovarian follicles were sonographically categorized by shape (round, polygonal, or irregular) and measured in 3 diameters; cranio-caudal and transverse in one plane and antero-posterior in a second perpendicular plane. The follicular fluid was aspirated under ultrasound guidance and the volume recorded.
Main outcome measures: The mean of the first two diameters, and the mean of the 3 diameters were calculated and each was analyzed for correlation with follicular volume in different shape follicles.
Results: All follicles, regardless of their shape, showed a statistically significant correlation between their 3-diameter mean and volume. Round and polygonal follicles had highly significant correlation between both 2 and 3-diameter means and measured volumes. In irregular follicles, only the 3-diameter mean significantly correlated with volume.
Conclusions: The mean of 2 follicular diameters accurately predicts the volume of round and polygonal follicles and should be used in monitoring ovarian stimulation for assisted reproduction, as in current practice. However, when the follicles are irregular in shape, only the mean of 3 diameters accurately reflects their volume.
Key words: Follicular volume, ovarian stimulation, ultrasound.
Comparison between different methods
of semen processing and different stimuli for inducing the acrosome reaction.
Ahmed A. Sattar, M.D.*†, Marc Van den Bergh, M.T.§, Greta
Verheyen, M.Sc.‡, André Van Steirteghem, Ph.D.‡
Department of Andrology, Cairo University Hospital, Cairo, Egypt*, Center for Reproductive Medicine, Academic Hospital, Dutch-Speaking Free University of Bussels‡, and Fertility Clinic, Erasmus Hospital, French-Speaking Free University of Brussels§, Brussels, Belgium
ABSTRACT
Objective: To compare the efficiency of different methods for selecting human spermatozoa in low-quality semen samples and evaluation of different methods for inducing the acrosome reaction in normal human sperm.
Setting: Andrology laboratory, Center for reproductive medicine, at Dutch-speaking Brussels Free University, Belgium.
Intervention: Fifteen semen samples were prepared by 4 different methods: swim-Up, migration-gravity sedimentation, a 2-layer Percoll and 3-layer Percoll density gradient. In other semen samples, acrosome reaction was induced by incubation in glucose -containing medium, by calcium ionophore A23187 treatment, by incubation with lysophosphatidyl-choline(LPC), by electroporation or by incubation with Ca2+-containing medium (5mM CaCl2). Acrosomal loss was assessed by conjunction of Hoechst 33258 supravital stain and concanavalin A- lectin binding to the inner acrosomal membrane.
Main outcome measures: Concentration, motility, and morphology were examined before and after semen preparation for each technique. The mean percentage of live acrosome-reacted spermatozoa was determined for each method of induction.
Results: The 2 or 3 layer Percoll density gradient centrifugation appeared to be more effective for the recovery of motile spermatozoa than the two other methods. No differences in sperm morphology were observed after preparation by the 4 different methods. The 2 or 3 layer Percoll density gradients separations were equally effective.The percentage of acrosome-reacted spermatozoa increased from 2.2% to 12.4% in presence of glucose and to 10.6% without glucose after a 48h period of incubation. Electroporation resulted in 16.05% acrosome-reacted spermatozoa versus 23% ( P<0.05 ) after exposure to A23187. Incubation with lysophosphatidyl-choline followed by incubation with 5mM Ca2+ results in 54% acrosome-reacted spermatozoa and was more effective than a combination of electroporation and incubation with 5mM CaCl2 (50 %).
Conclusions: Percoll density gradient centrifugation resulted in a significantly higher recovery of motile sperm cells. In terms of acrosome reaction of human spermatozoa, LPC resulted in the highest percentage of acrosomal loss compared to the other stimuli.
Key Words: , Percoll, Migration-gravity sedimentation, Glucose, Calcium-ionophore, Electroporation, Lysophosphatidyl -choline, acrosome
The clinical value of multiple endocrine
stimulation test (MEST) in cases of secondary amenorrhea.
Mohamed Shaarawy, Ph.D., F.R.C.Path.*, Sherif Abdel Rahman
El-Sharkawy, M.D., Ashraf Samir Younis, M.D., Hesham Salah El-Din Hamza,
M.D.
Department of Obstetrics and Gynecology, Faculty of Medicine, Cairo University, Cairo, Egypt
ABSTRACT
Objective: To assess hypothalamic-pituitary-ovarian-thyroid adrenal-cortical function by a multiple endocrine stimulation test in selected cases of secondary amenorrhea.
Patients: Twenty patients with secondary amenorrhea were selected to have normal basal values of serum FSH, LH, PRL, TSH and free testosterone as well as positive progesterone withdrawal test. They were free from Local uterine defects as well as adnexal or ovarian masses. In addition, ten volunteers of healthy fertile women were chosen as controls.
Design: Non-randomized prospective study.
Setting: Obstetrics and Gynecology department, Cairo University hospitals.
Intervention: All cases were subjected to multiple endocrine stimulation test (MEST) using a single intravenous bolus of GnRH (100 (g), TRH (200 (g) and insulin (0.1 U/Kg) and blood samples were withdrawn before and 30, 60, 90 and 120 minutes after stimulation.
Main Outcome Measures: Serum level of FSH, LH, PRL, GH, TSH, and Cortisol by the corresponding I125 radioimmunoassay.
Results: Negative Responses of FSH (78%),
LH (66%), GH (70%), PRL (66%), TSH (50%) and cortisol (30%) were demonstrated
in cases of secondary amenorrhea indicating that normal basal values of
these hormones might be misleading for the assessment of endocrine abnormalities.
Pituitary failure sequence may be related to the anatomical location of
the respective secretory cells failure, gonadotropes (85%) somatotropes
(75%), lactotropes (60%), thyrotropes (50%) and adrenocorticotropes (40%).
The pattern of various endocrinopathies among cases of secondary amenorrhea
was, panhypopituitrism (30%) hypothalamic disorder (10%), isolated gonadotrophin
deficiency (10%) isolated GH deficiency (5%), combined gonadotrophin and
GH deficiency (10%). Within normal responders to MEST, 5% of reactive hyperprolactinemia
and 30% of subclinical hypothyroidism were diagnosed.
Conclusion: The value of MEST is superior to basal hormone assays
in the diagnosis and choice of treatment of various endocrine abnormalities
in cases of secondary amenohrrea.
Key Words: Secondary amenorrhea, MEST, gonadotrophins and GH deficiencies, reactive hyperprolactinemia, subclinical hypothyroidism.
The evaluation of hysteroscopic endometrial
resection in the management of dysfunctional uterine bleeding.
Mahmoud T.M. Talaat, M.D.*, Hany M. El-Didy, M.D. *†, Maher M.
Ahmed, M.D. *, Omaima A. Edris, M.D. *, Hesham A. El-Ghazaly, M.D.*, Abdallah,
M. Khalil, M.D. ‡
The Departments of Obstetrics and Gynecology and Pathology, Faculty of Medicine, Cairo University
ABSTRACT
Objective : To evaluate hysteroscopic endometrial resection in the management of dysfunctional uterine bleeding.
Design : Retrospective analysis.
Material and Methods : Short and long term results of endometrial resection in 32 patients with dysfunctional uterine bleeding who were treated by endometrial resection using diathermy resectoscope were evaluated.
Results : The mean operative time of hysteroscopic
endometrial resection was 31.6 ( 4.8 minutes. The reported operative complications
were : Anesthetic problems (9.7%), uterine perforation (3.1%), fluid overload
> 1000 mL (12.5%) and bleeding during the procedure (3.1%). During a two
year follow-up period, the rate of amenorrhea declined from 47% after 6
months to reach 34.4%, with a similar decrease in satisfaction rate from
81.5% to 68.8%, uterine cramps persisted in 12.5% of patients and became
more severe in 15.6% of patients. With regard to premenstrual syndrome
(PMS), eight patients did not feel improvement of such symptoms postoperatively
out of 18 patients who had it before the operation. No single case of pregnancy,
serious postoperative infection or malignancy was reported. Hysterectomy
was carried out in six patients for benign causes and fractional curettage
was done in three patients who developed some suspicion of malignancy one
year or more later. Proper selection of patients seems to be an important
factor to success. The greatest success was achieved in premenopausal women
presenting with bleeding not associated with adnexal masses, extensive
endometriosis or adenomyosis.
Conclusion : Hysteroscopic endometrial resection is effective
in treatment of dysfunctional uterine bleeding in selected patients. Short
term outcomes are encouraging. The real place for endometrial resection
can be established by long term follow-up analysis of patients satisfaction
and symptomatology.
Key words : Hysteroscopic endometrial resection, dysfunctional uterine bleeding, short-term, long-term outcome, success rate, failure rate.
Sperm chromosomal abnormalities in
a familial Mediterranean fever patient treated with colchicine.
Renée H. Martin, Ph.D.*
Department of Medical Genetics, Faculty of Medicine, University of Calgary, and department of genetics, Alberta Children’s Hospital, Calgary, Alberta, Canada
ABSTRACT
Sperm chromosomal abnormalities were studied in a patient with Familial Mediterranean Fever who had been treated with colchicine. Multicolor fluorescence in situ hybridization (FISH) analysis of 20,000 sperm demonstrated no significant increase in the frequency of aneuploidy for chromosomes 1, 12, X or Y. There was also no significant change in the sex ratio of sperm or in the frequency of diploid sperm.
Mid trimester abortion of three live
fetuses after reduction of twelve live fetuses following treatment with
human menopausal gonadotrophins.
Falah A. Khalifa, M.D.*, Suleiman T. Dabit, M.D.
Assisted Reproduction Unit, Al-Amal Hospital, Amman, Jordan
ABSTRACT
A patient with polycystic ovaries received human menopausal gonadotropin (hMG) for ovulation induction and she got pregnant in twelve fetuses. Fetal reduction was done at two stages, the first was through the transvaginal route, and the second was through the transabdominal route. Cervical cerclage was performed later but the patient aborted in the second trimester.