Middle East Fertility Society Journal

Hereditary female cancers: Breast, ovarian, and endometrial

J. Morgan Tucker, Botros Rizk — 2011-12-01

Abstract: Hereditary cancers breast, ovarian, and endometrial cancers comprise a significant portion of cancers affecting women. This paper strives to review the genetics and current screening, prophylaxis, and treatment of these malignancies.

Progestin potency – Assessment and relevance to choice of oral contraceptives

Norman Goldstuck — 2011-12-01

Abstract: Objectives: To evaluate current information on the potency of older and newer progestins and the relevance to oral contraceptive (OC) use.Methods: A medline search back to the last review (1985) was conducted.Results: A thorough review of the pharmacology of the older and newer progestins and their classification is presented. This is followed by a review of the methods of assessment of progestin potency in women. Histological as well as newer biochemical methods (nuclear receptors and placental protein 14) are examined. Progestin potency values for the older and newer progestins are presented and the reasons for the discrepancies discussed. The delay of menses assay and its problems with newer formulations is examined including data on current 30–35μg ethinylestradiol containing OCs. The role of progestin potency in disease causation and prevention, especially in relation to breast cancer and the protective effects in ovarian and endometrial cancer is reviewed. The term ‘effective progestin activity’ (EPA) which is dose X potency is defined. The EPA enables comparisons of differing progestin containing preparations. The terms ‘low dose’ and ‘low potency’ and their historical introduction and implications are discussed. Newer epidemiological studies still use the old histological data and delay of menses data despite their limited relevance to OCs in present use.Conclusions: Newer progestins are more receptor selective and potency is less relevant than it was with older progestins. Epidemiological studies of progestin potency and its role in disease generally use out of date information. There is still confusion about the relationship of dose and potency in some studies. The use of the EPA can help eliminate this.

GnRH antagonist for pituitary desensitization in IVF: Is it a time for a change of practice?

Mohamed A.F.M. Youssef, H. Elashmawi — 2011-12-01

Although long GnRH agonist has been the standard and most widely used protocol for pituitary down regulation all over the world in IVF/ICSI treatment cycles for three decades , there are many debates about the optimal long GnRH agonist regimen to be used. First, there is no consensus as regards the type of preparation to be used, whether as a daily fixed dose injection, daily injection with decrease to half dose when starting ovarian stimulation or one injection per treatment cycle or use of nasal spray. Second, there is no agreement on the day of initiation of GnRH agonist in the standard long protocol either day 21 mid-luteal or early follicular phases . Third, there is no consensus on the proper dealing with ovarian cysts developing under the flare up effect of GnRH agonist in the mid luteal day 21 protocols . Fourth, Long GnRH agonist is associated with increased risk of complications such as hypoestrogenic symptoms and the ovarian hyperstimulation syndrome (OHSS) . In summary, long GnRH agonist due to its associated side effects, long duration of treatment (up to 8weeks), repeated injections which might increase IVF patients discomfort and drop-out, would not be considered as a patient friendly protocol.

GnRH antagonist for pituitary supression in IVF: Is it time for a change of practice?

Amr Wahba, Hesham Al-Inany — 2011-12-01

The first IVF baby was born as a result of an oocyte picked up in a natural cycle. However, the success rate of this protocol was very low. Clomiphene citrate and human menopausal gonadotrophins (hMG) were later introduced for ovarian stimulation and were found to improve pregnancy rates. Since then, ovarian stimulation became an essential step in in vitro fertilization/Embryo transfer (IVF/ET).

Persistent endometrial polyps may affect the pregnancy rate in patients undergoing intrauterine insemination

Amal Shohayeb, Amany Shaltout — 2011-12-01

Abstract: Objective: To determine whether polypectomy before intrauterine insemination achieved better pregnancy outcomes than no intervention.Study design and setting: A prospective comparative study conducted in a private assisted reproduction centre.Subjects and methods: A total of 120 women having asymptomatic endometrial polyp (EP) that was diagnosed by 3D ultrasound and color Doppler and undergoing IUI were randomly allocated to one of two pre-treatment groups. Hysteroscopic polypectomy was performed in the study group while in the control group no intervention was done. All patients were scheduled to receive four cycles of IUI in both groups within 12months duration. The first IUI cycle was planned after three menstrual cycles in both groups.Results: No complications after hysteroscopic polypectomy were recorded. A total of 37 pregnancies occurred, 25 cases in the study group which included 57 cases and 12 cases in the control group which included 53 cases. Two cases in the study group and one case in the control group got pregnant during the 3months waiting period, before performing IUI. Cumulative pregnancy rate in both groups after four IUI cycles was 23 (38.3%) in the study group and 11 (18.3%) in the control group. This difference was statistically significant (p=0.015).Conclusion: Persistent endometrial polyps are likely to impair reproductive performance in this selected patient group and hysteroscopic polypectomy before IUI can be considered an effective measure especially as it is a safe procedure with a low complication rate.

Pregnancy outcome after hystero-salpingo-contrast-sonography (HyCoSy) versus hysterosalpingography (HSG) using different contrast media

Emad M. Siam — 2011-12-01

Abstract: Objective: The main conventional imaging modalities used to assess female tubal patency are hysterosalpingography (HSG) and Hystero-salpingo-contrast-sonography (HyCoSy), which could also be used to guide tubal recanalization.Study design: It is a comparative study, which aims to test whether the use of a homogenously mixed saline and air contrast sonography could enhance the chance of spontaneous clinical pregnancy in women undergoing subfertility investigation, this is compared with other contrast media used for Hysterosalpigography (HSG). Couples with at least 1year of infertility who were scheduled for a consultation including a hysterosalpingo-contrast-sonography (HyCoSy) were invited to participate in the study. We compared flushing with a homogenously mixed saline and air as a water-soluble contrast medium, compared with another group who used either Oil Soluble (OSCM) or Water Soluble (WSCO) as contrast media for HSG. Randomization sequence was computer generated, stratified for age and group allocation was concealed. Primary outcome was clinical pregnancy, defined as a sonographically visible fetal sac, detected within 6, and 12months from randomization, after confirmation of tubal patency. Secondary outcomes were spontaneous miscarriage and birth. Exclusion criteria were female age>40years, severe male infertility, previously known severe tubal infertility and suspected anovulation.Results: The mean age of the study population (n=334) was 31.9years. Duration of infertility was 2.1years. The clinical pregnancy rate was .31% in the HyCoSy group and 22% in the non-flushing group, compared with 33% after HSG, using oil soluble medium, and 32% after using soluble medium in HSG. Differences in reproductive outcome among contrast material groups were not statistically significant (x28 5 6.08, p. 5.64). Whatever the cause of infertility, the use of different contrast materials led to no significant differences in the rates of live births.Conclusion: The pregnancy rates after performing HyCoSy using the proposed homogenously mixed saline and water are nearly the same as those following HSG using different contrast media with inherent advantage of avoiding exposure to radiation.

Micro-dose flare-up gonadotrophin-releasing hormone (GnRH) agonist vs. flexible gonadotrophin-releasing hormone (GnRH) antagonist protocol in patient with poor ovarian reserve

2011-12-01

Abstract: Objective: To compare the efficacy of two methods of ovarian stimulation, namely micro-dose flare-up gonadotrophin-releasing hormone (GnRH) agonist protocol and flexible gonadotrophin-releasing hormone (GnRH) antagonist protocol in patients with poor ovarian reserve.Design: A prospective, randomized, double blind clinical trial.Setting: Department of Obstetrics and Gynecology, Faculty of Medicine, Suez Canal University, Infertility Clinic, Ismailia, Egypt, Private Center, Cairo, Egypt, December 2006–May 2008.Patient(s): Fifty-nine patients with poor ovarian responses based on the following criteria ovarian volume <3ml . Low antral follicular count (AFC) <6 . Cycle (day 3) FSH >8IU/l undergoing IVF/ICSI treatment. Exclusion criteria: (1) any other cause of infertility other than poor ovarian reserve; (2) refusal of the patient to be enrolled to the study.Intervention(s): All women were prospectively randomized into two groups by computer-assisted randomization. The patients in group 1 were stimulated according to the micro-dose flare-up protocol (n=30), while the patients in group 2 were stimulated according to flexible antagonist protocol (n=29).Main outcome measure(s): The mean number of oocytes retrieved was the primary outcome measure, number of mature oocytes retrieved, number of fertilized oocytes, number of embryos transferred, stimulation duration (days), total dose of gonadotrophin IU, estradiol concentration on the day of hCG administration, fertilization rate, implantation rate, ongoing pregnancy rate were secondary outcome measures, cancellation rate.Result(s): The use of flexible GnRH antagonist protocol ended with significantly less gonadotrophin requirements (2831.9±623.02 vs. 3187.5±704.04; p=0.04) and a shorter duration of stimulation (9.6±2.02 vs. 10.8±2.4days; p=0.04). The fertilization rate (77.3% vs. 68.5), implantation rate (12.2% vs. 8.9%), and ongoing pregnancy rate (20.8% vs. 12.5%) were higher in the antagonist group but did not achieve statistical significance. The cancellation rate was higher in the agonist group (20% vs. 17.2%) but the difference was not statistically significant. The numbers of oocytes retrieved, mature oocytes, fertilized oocytes, embryo transfer, and the estradiol concentration on the day of hCG were not significantly different between the two groups compared.Conclusion(s): The role of flexile GnRH antagonist in women with poor ovarian reserves appear to be promising and further randomized clinical trials are needed.

Comparison of simple uterine manipulator-injector (SUMI) with the Cohen cannula in gynecologic laparoscopy

2011-12-01

Abstract: Objective: To assess the effectiveness and safety of using simple uterine manipulator injector (SUMI) compared to Cohen cannula in laparoscopy.Design: A Pilot randomized trial, incorporating 40 patients randomized into Group I or SUMI (n=22) and Group II or Cohen cannula (n=18).Setting: Ain Shams Maternity Hospital, Cairo, Egypt.Material and methods: Forty patients with infertility planned to undergo laparoscopy. The assigned uterine cannula was applied according to defined rules, followed by laparoscopy. Main outcome measures were application and removal time, uterine maneuverability in sagittal and coronal planes, easiness of insertion and manipulation, dye injection and its leakage, abandonment of the use of cannula, and adverse effect or complication.Results: Application time was longer with SUMI (3.8±1.3 vs. 1.3±1.1min, P<0.001). The range of uterine maneuverability had wider angles with SUMI, both in sagittal (77.7±12.7 vs. 47.2±21.9, P<0.001) and coronal (139.6±30.4 vs. 89.4±22.4, P<0.001) plains. The easiness of insertion, manipulation, dye injection and removal were comparable. The incidence of dye leakage was higher with SUMI (27.3% vs. 5.9%, P<0.05), yet minimal and not affecting dye test. Cohen cannula use was abandoned due to marked limitation of uterine maneuverability in one case and due to considerable dye leakage in another. No incidents of uterine perforation or cervical laceration requiring suturing were recorded.Conclusion: Although SUMI takes longer to insert, the ease of its use is comparable with the Cohen cannula. A major advantage of its use is increased range of uterine maneuverability with better surgical field exposure.

The predictive value of uterine blood flow in detecting the risk of adverse pregnancy outcome in patients with polycystic ovary syndrome

Amal A. Nouh, Sally M. Shalaby — 2011-12-01

Abstract: Objectives: To assess the value of uterine artery Doppler screening during pregnancy in predicting adverse pregnancy outcomes in women with polycystic ovary syndrome (PCOS).Design: A prospective case control study.Setting: Obstetrics and Gynecology and Medical Biochemistry departments, Zagazig University Hospital, Egypt.Method: Forty pregnant women with ovulatory PCOS (PCOS group) and 40 age- and body mass index-matched healthy pregnant controls (control group) underwent serial Doppler velocimetry measurements of the uterine artery, measurements of free androgen index and fasting glucose/insulin ratio during first and late second trimesters.Main outcome measures: Blood flow impedance indices, free androgen index, fasting glucose/insulin ratio and pregnancy outcomes. Student’s t-test, χ2-test, and specificity and sensitivity tests were used for statistical analysis of the data.Results: Patients with PCOS had a significantly higher level of testosterone, androstenedione, dehydroepiandrosterone sulfate, free androgen index, fasting glucose/fasting insulin level in the first and late second trimesters (P⩽0.05).A significantly (P<0.05) higher PI value was observed in the PCOS group than in the control group in the first and late second trimesters. At 26weeks of gestation 27.2% of pregnant patients with PCOS had a notch on either side, comparing with 12.8% of the control group. The rate of adverse pregnancy outcomes was significantly higher in pregnant patients with PCOS 45% versus 10% in the control group.Conclusions: Uterine artery Doppler indices have a higher predictive value for abnormal pregnancy outcomes in pregnant patients with PCOS.

Uterus didelphys with imperforate hemivagina and ipsilateral renal agenesis complicated by hematocolpos, hematometra and hematosalpinex. The challenge of intact hymen

Kamal M. Zahran, Diaa Eldeen M. Abd El Aal, Moustafa H.M. Othman, Eman R. Ahmed — 2011-12-01

Abstract: Background: Uterine didelphys with obstructed hemivagina is an extremely rare condition. This diagnosis should be considered whenever an adolescent is presented with severe dysmenorrhea and progressive pelvic mass.Case: A 15-year-old girl presented with uterus didelphys with obstructed left hemivagina and ipsilateral renal agenesis. Excision of the septum was done using monopolar diathermy in the cutting mode under laparoscopic and hysteroscopic guidance, taking into consideration the integrity of the hymen. Complete recovery was achieved within one week.Conclusion: The prompt and accurate diagnosis of this condition is essential to prevent complications from acute illness and to preserve future fertility. Ultrasonography, CT scan and MRI are the initial steps for its diagnosis; however, laparoscopy is a crucial tool for confirmation of the diagnosis. In order to avoid the associated morbidity of delayed management, surgical intervention should be considered as the first line therapy, taking into consideration the social and traditional backgrounds of the parents and patients.

Effective sample size calculation: How many patients will I need to include in my study?

Mohamed A.F.M. Youssef — 2011-12-01

Properly designed clinical trials are the heart of evidence based medicine (EBM). A well defined research question and adequate sample size with an appropriate statistical power, relative to the aim of the study, are the main pillars for properly designed clinical trials to retrieve accurate results. Although it is unethical to expose your patients to the risk of the intervention, waste your resources and time to conduct a study with lower power or inadequate sample size, there are many published clinical trials that ignored these pillars because it is always difficult to be planned prospectively.

Mona Aboulghar — 2011-12-01

“Ovarian Stimulation is a text that is comprehensive, insightful, contains a great deal of new information, and is well organized, making it easy to read”. Those were the words by which Professor Alan De Cherney started his Foreword to this book. The book has been edited by Mohamed Aboulghar and Botros Rizk, who are well known experts in the field of human reproduction. The editors wrote a very touching dedication to their dear friend and Nobel Prize laurite Professor Robert Edwards in which they expressed their gratitude for his friendship and mentorship.