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Dijkzigt Academic Hospital & Erasmus University Medical School, Rotterdam, The Netherlands
ABSTRACT
Urinary gonadotrophin preparations have been available for fertility
therapy for almost 35 years. Although these preparations have been improved
over the years, the introduction of human recombinant follicle-stimulating
hormone to the market represents the first major breakthrough in this area.
Clinical studies undertaken so far have shown this preparation to be safe,
pure and potent.
The major clinical advantage may turn out to be the possibility
for structural alterations, thereby altering the biopotency and half-life
of the compound. This fascinating development will certainly provide the
clinical investigator with a whole new set of tools to manipulate ovarian
function. Moreover, the clinician will have the unique and challenging
opportunity to tailor compounds and corresponding circulating half-lives
according to the treatment goal and the individual needs of the patient.
Key words: Recombinant, FSH, follicle-stimulating hormone, gonadotropins,
ovulation induction, in vitro fertilization
Outpatient endometrial biopsy.
Botros Rizk, M.D.*, Johan Smitz, M.D.||, Serag N. M. Youssif,
M.D., Afifa Halim Kirolos, M.D., Magdy Ragheb, M.D.§, Samy Saleeb,
M.D.#
Department of Obstetrics & Gynecology, Division of Reproductive Endocrinology, University of South Alabama Mobile, Alabama
ABSTRACT
Objective: Our first objective is to review and critically analyze the published data comparing the different modalities of endometrial biopsies. Our second objective is to integrate the sonographic findings in the clinical management to rationalize the use of endometrial biopsy.
Study design: The study was designed to review endometrial biopsy from the gynecologist, patient and pathologist perspectives. Major studies comparing the Novak, Vabra and Pipelle endometrial biopsies were analyzed. Studies addressing the use of transvaginal sonography in the evaluation of the pre- and postmenopausal patients were incorporated.
Conclusions: The results are reported in three different groups of patients. In patients undergoing endometrial biopsy for endometrial dating, large studies comparing the Novak curette with the Pipelle suction curette showed comparable efficacy in terms of tissue adequacy. However, the pain experienced was significantly less with the Pipelle. In patients with abnormal uterine bleeding, larger samples of patients were analyzed. In comparison to Vabra curettage, Pipelle had a higher rating according to the gynecologists, pathologists and patients satisfaction. In comparison of the percentage of endometrial surface evaluated, the Vabra aspirator had a significantly higher success than the Pipelle. The Pipelle was equally effective to the Novak curette and to the Tiss U-Trap. In patients diagnosed with or suspected to have gynecological cancer, transvaginal sonography should be performed before any procedure. The cut-off limit for endometrial abnormality is positively related to the positive predictive value of the ultrasound testing. Most authors would agree that a cut-off limit of 5 mm is satisfactory. In patients with known endometrial cancer, the Pipelle had 97.5% sensitivity. Hysteroscopy, dilatation and curettage should be performed if the endometrial cavity could not be negotiated.
Key words: Endometrial biopsy, sonography, transvaginal endometrial dating, abnormal uterine bleeding, endometrial cancer, Pipelle, Novak, Vabra.
The use of a high-dose combined oral
contraceptive preparation for suppression of endogenous gonadotrophins
in a bioequivalence study of two urinary gonadotrophin preparations.
Henk J. Out, M.D., Ph.D. , Bart C.J.M. Fauser, M.D. Ph.D.§,
Peter F.J. Donderwinkel, M.D.§ Herjan.J.T. Coelingh
Bennink, M.D. Ph.D.
Medical Research and Development Unit, NV Organon, Oss, the Netherlands; and Section of Reproductive Endocrinology and Fertility, Department of Obstetrics and Gynaecology, Dijkzigt Academic Hospital and Erasmus University, Rotterdam, the Netherlands.
ABSTRACT
Objectives: To investigate the level of pituitary suppression obtained with a high-dose oral contraceptive preparation, and to assess and compare the pharmacokinetics of Humegon® (FSH:LH ratio 1:1; hMG 1:1) and Normegon® (FSH:LH ratio 3:1; hMG 3:1) in healthy female volunteers.
Design: A randomised, open-label, group-comparative, single-dose, cross-over, single-centre study.
Patients: Twenty four healthy female volunteers.
Setting: Dijkzigt Academic Hospital.
Intervention: Serum levels of FSH, LHspecific, hCG and LHtotal were measured immediately before gonadotrophin injection. For FSH and LHspecific, peak serum concentration (Cmax), peak serum time (tmax), area under curve up to the last detectable point (AUD) were assessed. For FSH, also area under curve up to infinity (AUC0-¥) was assessed. Adequate pituitary suppression was established and maintained while using a high-dose oral contraceptive (Lyndiol), as expressed by mean FSH and LH serum levels <1 IU/L, continuously suppressed E2 and progesterone serum levels, and the absence of follicles >10 mm.
Main outcome measure: FSH AUC0-¥ and AUD, LH Lhspecific,, hCG, LHtotal.
Results: Extent of FSH absorption, expressed by the AUC0-¥ and AUD was 425 ± 97 and 417 ± 94 IU·h/L for hMG 3:1 and 455 ± 75 and 447 ± 71 IU·h/L for hMG 1:1. Rate of absorption, expressed by Cmax and tmax, was 4.45 ± 1.0 IU/L and 26.4 ± 8.3 h for hMG 3:1, and the corresponding figures were 4.87 ± 0.8 IU/L and 29.0 ± 7.3 h for hMG 1:1. With respect to FSH, bioequivalence was proven for all parameters. For LHspecific, pharmacokinetic parameters were comparable for both preparations, but bioequivalence could not be proven.
Conclusion: A high-dose oral contraceptive provides adequate pituitary suppression of endogenous gonadotrophins and is therefore suitable for pharmacokinetic studies of gonadotrophins. HMG 3:1 is bioequivalent with hMG 1:1 with respect to FSH immunoreactivity. Bioequivalence for LHspecific parameters could not be proven due to a large inter-subject variability.
Key words: Pharmacokinetics/gonadotrophins/FSH/high-dose oral contraceptive
Can IVF be more natural? : First pregnancies
in human IVF using autologous follicular fluid with cumulus co-culture
as a sole culture condition system.
Essam Al-Dein M. Khalifa, M.D.*
Infertility/IVF Center - King Fahad Specialist Hospital, Buraidah, Al-Qassim, Kingdom of Saudi Arabia.
ABSTRACT
Objective: To evaluate the use of autologous follicular fluid (FF), per se, as insemination medium and the combined FF with autologous cumulus co-culture as growth IVF culture system.
Design: A prospective clinical study.
Setting: The Infertility/IVF center - King
Fahad Specialist Hospital (Governmental Hospital).
Patients: Thirty IVF cycles, in 30 couples
treated for tubal (non-endometriotic), male factor or unexplained infertility
were enrolled in this study.
Interventions: Each patient served as its own control, as half of the patients oocytes were inseminated in follicular fluid and the resulted zygotes were grown in FF with autologous cumulus co-culture as growth culture, (group I). The other half were inseminated and zygotes were grown in a conventional IVF culture, (group 2).
Main outcome measures: Fertilization, embryo development, fragmentation and IVF outcome.
Results: The normal fertilization rate (2PN) being higher in FF Group (87% versus 75%), while the incidence of polyspermia is less (4% versus 9%). The embryo development is better in FF-cumulus co-culture group compared to the conventional culture. Twenty seven patients proceeded to ET with 13 women achieved pregnancy, 1 triplet, 4 twin and 8 singleton pregnancies. In ten cycles the embryos grown in the FF-Cumulus co-culture were far better, and hence solely transferred resulting in 5 normal ongoing pregnancies 1 delivered triplet.
Conclusions: It seems that autologous follicular fluid can support fertilization in the IVF system. Moreover, the combination of growth factors present in FF with the benefits of autologous cumulus co-culture can support the development of human embryos. This may be a new avenue towards use of more natural methods in IVF.
Key words: FF, Cumulus co-culture, Human IVF, Implantation and pregnancy rate.
Surgical complications of operative
laparoscopy: The Egyptian experience.
Mohamed Zayed, M.D.*, Omima Idris, M.D., Mohamed Roshdy, M.D.,
Gamal Wafa. M.D.
Department of Obstetrics and Gynecology , Cairo and Ain Shams Universities
ABSTRACT
Objectives: To report on the incidence of different surgical complications observed in our first 832 cases of operative pelviscopy performed during a 3 years period (1993-1995).
Design: Retrospective Study.
Materials and Methods: Eight hundred and thirty two cases of operative pelviscopy cases were evaluated for the presence of surgical complications.
Results: The overall incidence of surgical complications major and minor was 4.08%. The incidence of major intraoperative complications was 0.96%. Large bowel injury was observed in 3 cases (0.36%) of enterolysis. All cases were diagnosed intraoperatively and one case was managed through the laparoscope and the other two cases by open laparotomy. Bladder injury occurred in one case of LAVH that was repaired vaginally. Major vascular complications including intraoperative bleeding occurred in 0.72% of the cases. The overall incidence of major postoperative complications was 0.72%, including a major hematoma of the anterior abdominal wall, intestinal obstruction, postoperative ileus and intraperitoneal hemorrhage. Minor postoperative complications were observed in 2.4% of the cases. This include ecchymosis, small hematomas of the anterior abdominal wall, minor wound infection, surgical emphysema and vulval edema. Cellulitis and wound abscess occurred in one case. Failure to complete the procedure by operative laparoscopy occurred in 7 cases (0.84%). No ureteric injury was observed in this series.
Conclusion: Although laparoscopic surgery is considered a minimally invasive surgery intended to reduce operative morbidity, hospital stay and cost, yet it is sometimes associated with major surgical complications. Like any other surgical procedures, many of the surgical complications can be prevented if proper surgical technique is adopted. Moreover, intraoperative diagnosis has a major impact on the prognosis of visceral complication.
Key words: Laparoscopy, surgical complications.
Outcome of the ovulation induction
cycles with low-dose follicle-stimulating hormone in clomiphene citrate
resistant women with polycystic ovary syndrome.
Ali Rüstü Ergür, M.D.*, Tansu Küçük,
M.D., Yusuf Ziya Yerg?k, M.D.*, Ercüment Müngen, M.D.*, Aktug
Ertekin, M.D.*, Levent Tütüncü, M.D.*
Gülhane Military Medical Academy, Departments of Obstetrics and Gynecology, Istanbul and Ankara, Turkey.
ABSTRACT
Objective To determine the efficiency of ovulation induction cycles with low dose follicle-stimulating hormone (FSH) in clomiphene citrate (CC) resistant polycystic ovary syndrome (PCOS) patients.
Design: Prospective study.
Setting: Two, large military academic centers.
Patients: Twenty-six infertile, clomiphene citrate resistant PCOS patients underwent ovulation induction with low dose FSH in a total of 59 cycles.
Interventions: Administration of 75 IU FSH
starting on the second day of cycle for a week and if no ovarian response
detected, increase in FSH dose with half of starting dose until an adequate
response per five days.
Main outcome measures : Ovulation, pregnancy, abortion, birth
rates and especially pattern of follicular development, amount of FSH required,
serum E2 concentrations, ovarian hyperstimulation syndrome (OHSS), multiple
pregnancy.
Results: Twenty patients ovulated at least once and 69.5% of the 59 cycles were ovulatory. The conception and cycle fecundity rates were 42.3% for 3 months and 18.64 %, respectively, with only one twin pregnancy while the abortion rate was 18.1%. The big proportion of the cycles were with the monofollicular development 45/59 (76%) and the rest of them were with two-three follicles 10/59 (16.9%) and multifollicular 4 /59 (6.7%). No OHSS was detected with this regimen in our study.
Conclusions: In anovulatory, infertile patients with PCOS, low-dose FSH administration avoids multifollicular development and consequently OHSS and multiple pregnancy while maintaining a high pregnancy and a low abortion rate.
Key Words: Low dose FSH therapy, Polycystic ovary syndrome, Ovulation induction
Methods for isolation and purification
of post-ejaculate human round spermatids for possible use in intracytoplasmic
round spermatid injection.
Panayiotis M. Zavos, Ed.S., Ph.D. §, Panayota N.
Zarmakoupis-Zavos, M.D. §, Frank L. Barnes, Ph.D. ||, Jan Tesarik,
M.D., Ph.D., Juan R. Correa, Ph.D.
Andrology Institute of Lexington and Kentucky Center for Reproductive
Medicine, Lexington, Kentucky; Pacific Fertility Medical Center, San Francisco,
California; and University of Granada, Spain.
ABSTRACT
Objective: To develop methods for the isolation and purification of round spermatids (RS) from ejaculated semen specimens recovered from patients suffering from nonobstructive azoospermia for the purpose of performing intracytoplasmic round spermatid injections (ROSI) into human oocytes.
Design: Prospective study.
Setting: Andrology Institute of Lexington, Lexington, Kentucky.
Patients: Six men with nonobstructive azoospermia.
Interventions: Semen specimens were washed via centrifugation prior to selection and purification of RS. The RS were isolated via a multi-layer Percoll (90, 80, 70, 60 and 40% Percoll) centrifugation procedure. The isolated RS were purified via a second multi-layer Percoll (70, 40, 30 and 20% Percoll) centrifugation procedure. Purified RS were washed twice, resuspended in polyvinylpyrrolidone (PVP) and identified via microscopy.
Main Outcome Measures: Isolation and purification
of RS from other round cells (RC) and seminal debris.
Results: High recovery of RS (66 to 76% of the original RS population)
with minimal background (round cells and debris) after Percoll isolation
and the various purification steps.
Conclusions: Large quantities of RS were detected in the original ejaculates and subsequently isolated and purified. Intracytoplasmic injection techniques with ejaculated and purified spermatids can be beneficial for patients with defective spermatogenesis such as nonobstructive azoospermia, without any required urologic intervention.
Key words: Round spermatids, nonobstructive azoospermia, spermatid isolation and purification
Embryo transfer - effect of catheter
type and technical difficulties on outcome: a review of 114 procedure.
Badreldin A. Mustafa, F.R.C.O.G.* , Suha T. Djamil, B.Sc.*,
Aurora B. Santiago, R.N.*
IVF Unit, New Jeddah Clinic Hospital, Jeddah, Saudi Arabia
ABSTRACT
Objectives: To analyze the factors involved in Embryo Transfer and their effect on the IVF outcome.
Design: Retrospective study.
Methods: The effect of the type of embryo transfer catheter on the pregnancy rate was evaluated in 114 procedures.
Results: The embryo transfer resulted in 34 pregnancies (29.8%) including three ectopic pregnancies (2.6%). Bourn Wallace catheter was used in easy transfer and yielded a 34.9% pregnancy rate. Frydman (set) was used in difficult transfers and yielded a pregnancy rate of 16.1%.
Conclusion: Easy Embryo Transfer was associated with higher pregnancy rate, while difficulty in transfer jeopardized the outcome. We recommend the use of Bourn Wallace Catheter for easy transfers.
Key Word: Embryo Transfer, embryo Transfer Catheter, mock ET
Sperm parameters and their effects
on fertilization rate in conventional IVF-ET
Ismail Cepni, M.D.*, Hulya Senol , Mehmet H. Idil, M.D. *,
Asli Duran , Pelin Ocal, M.D. , Fato? Yald?r ,
Erdal Budak, M.D. *, Tulay Irez Ph.D. *, Feyhan Elibol , M.
Feridun Aksu M.D.*
Cerrahpasa Medical Faculty and IVF-ET Research and Practice Center, Istanbul University- Turkey
ABSTRACT
Objective: To demonstrate the effects of standard sperm parameters and sperm motility on fertilization rate and embryo development.
Design: Prospective clinical study.
Setting: Istanbul University IVF-ET Research and Practice Center, Istanbul - Turkey
Patients: Two hundred - nine patients who underwent IVF-ET program in 1995.
Main Outcome Measures: Standard sperm parameters such as sperm concentration, morphology and motility were determined prior and after the swim-up procedure. Sperm motility 24 hours after oocyte insemination was also determined.
Results: Sperm concentration, motility and morphology in the fresh semen preparation, sperm concentration in the swim-up inseminate and sperm motility 24 hours after oocyte insemination were all found to be significant parameters effecting fertilization and embryo development (p<0.001). In order to determine independent prognostic parameters effecting fertilization and embryo development, a logistic regression analysis was employed, including the standard sperm parameters before and after swim-up, sperm motility 24 hours after oocyte insemination and number of oocytes picked up at IVF-ET program. Sperm motility 24 hours after oocyte insemination was found to be the significant parameter influencing fertilization and embryo development (p<0.001). The cut-off level for sperm motility at 24 hours post-insemination was calculated as 50% by student t test. Eighty percent of the patients having more than 50% sperm motility at 24 hours after the insemination had achieved fertilization, whereas only 4.2% of the patients having less than 30% motility had achieved fertilization.
Conclusion: The evaluation of sperm motility at 24 hours after oocyte insemination is a simple and readily performed test which can provide valuable information regarding outcome of conventional IVF-ET.
Key Words: In vitro fertilization, fertilization, sperm parameters, swim - up
Ovarian decompression for severe ovarian
hyperstimulation syndrome.
Pankaj Shrivastav, M.D, M.R.C.O.G.* , Prashant Nadkarni,
M.R.C.O.G.*, Meenakshi Bharath, M.D. *, Ian Craft, FRCS, F.R.C.O.G.*, Maya
Srivastava, F.R.C.O.G.
Dubai Gynecology & Fertility Center, Dubai, and Al Zahra Hospital,
Ajman, UAE
ABSTRACT
A rare case of severe ovarian hyperstimulation syndrome characterized by bilateral huge enlargement of both ovaries in the absence of ascites was treated by transvaginal aspiration of the cysts of one ovary. Marked improvement followed the treatment.
Key Words: ovarian hyperstimulation syndrome,
ovarian enlargement, ovulation induction, ovarian decompression.
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Persistent pelvic abscess after transvaginal ultrasound-guided oocyte retrieval.
Recai Pabuçcu, M.D., Tansu Küçü, M.D., NamI?k Kemal Duru, M.D., Vedat Atay, M.D., Esat Orhon, M.D., Müfit Cemal Yenen, M.D.
Department of Obstetrics and Gynecology, GATA School of Medicine, Ankara, Turkey
ABSTRACT
Objective: To present a case with persistent pelvic abscess as a hazardous complication related to transvaginal ultrasound-guided oocyte retrieval.
Design: A case report.
Setting: GATA School of Medicine, IVF-ET Unit.
Intervention: Two successive laparotomies after transvaginal ultrasound-guided oocyte retrieval.
Results: The patient underwent salpingo-oophorectomy for ruptured tubo-ovarian abscess. After fifteen days, fistula formation to abdominal incision was observed with a giant retrouterine mass. Drainage of pelvic abscess was performed at the second exploratory laparotomy.
Conclusion: Although rare, pelvic infection should be kept in mind as a serious complication after transvaginal oocyte retrieval.
Key words: Pelvic abscess, transvaginal oocyte retrieval.