GnRH Antagonist Cetrorelix Administration Before hCG for Protection of Ovarian Hyperstimulation Syndrome.

OBJECTIVE: Studying the effect of GnRH antagonist administration on the day of hCG to cases of IVF/ICSI with estradiol level above 5000 ng/dl for protection of ovarian hyperstimulation syndrome. DESIGN: Prospective study. MATERIALS AND METHODS: Sixty patients undergoing controlled hyperstimulation COH, for IVF/ICSI using long agonist and E2 level on the day of hCG, are above 5000 ng/dl, 52 patients received single dose of cetrorelix 0.25 mg on the day of hCG, and 8 patients received two doses of 0.25 mg/day cetrorelix started one day before the day of hCG. RESULTS: There was no significant difference regarding patients BMI, number of stimulation days, recombinant FSH dose, and number of retrieved oocytes. Clinical pregnancy rate was 76.6% (46/60), in patients received single dose of antagonist PR were significantly higher 80.7% (42/52) versus 50% (4/8) in patients received two doses p = 0.047. Live birth rate was 50% (30/60), abortion rate was 20% (12/60), and preterm delivery was 20% (12/60). Mean E2 was 6853.2 ng/dl. Six patients developed moderate ovarian hyperstimulation OHSS (6/60) 10% and no cases of severe OHSS. CONCLUSIONS: GnRH antagonist administration on the day of hCG in cases undergoing IVF/ICSI with long agonist protocol is effective in protection of OHSS and does not affect the clinical pregnancy rate nor live birth rate.

Non-invasive methods for embryo selection.

With the widespread use of assisted reproduction, a simple and practical method for embryo selection is needed to optimize the chances of pregnancy while diminishing the incidence of multiple pregnancy and its accompanying problems. Many non-invasive methods for embryo selection have been proposed and some are more promising than others. This review summarizes these methods and attempts to evaluate them in the light of the best currently available evidence and to find out whether any of them is ripe for replacing or supplementing the time-honored method of morphological assessment.

Religious aspects of assisted reproduction

Human response to new developments regarding birth, death, marriage and divorce is largely shaped by religious beliefs. When assisted reproduction was introduced into medical practice in the last quarter of the twentieth century, it was fiercely attacked by some religious groups and highly welcomed by others. Today, assisted reproduction is accepted in nearly all its forms by Judaism, Hinduism and Buddhism, although most Orthodox Jews refuse third party involvement. On the contrary assisted reproduction is totally unacceptable to Roman Catholicism, while Protestants, Anglicans, Coptic Christians and Sunni Muslims accept most of its forms, which do not involve gamete or embryo donation. Orthodox Christians are less strict than Catholic Christians but still refuse third party involvement. Interestingly, in contrast to Sunni Islam, Shi'a Islam accepts gamete donation and has made provisions to institutionalize it. Chinese culture is strongly influenced by Confucianism, which accepts all forms of assisted reproduction that do not involve third parties. Other communities follow the law of the land, which is usually dictated by the religious group(s) that make(s) the majority of that specific community. The debate will certainly continue as long as new developments arise in the ever-evolving field of assisted reproduction.

Does ovulation induction increase the risk of gynecological cancer?

The risk of developing gynaecological cancer following ovulation induction therapy in infertile patients is not easy to determine due to many confounding factors. These include the fact that infertility in itself is a known risk factor for some of these cancers, that these patients are subjected to increased surveillance compared to the general population and that the drugs used for ovulation induction are sometimes used in combination. Notwithstanding these limitations, most of the studies have not confirmed a link between these drugs and invasive ovarian cancers, although some studies have suggested that the risk of borderline ovarian tumors may be increased. Investigations regarding breast cancer risk have produced inconsistent results and more information on the subject is warranted. On the contrary, many studies suggest that drugs used for ovulation induction may increase the risk of uterine cancers. More large well-designed studies are still needed to further clarify the effects on cancer risk of these drugs and will allow more in-depth subgroup analysis based on both patient and disease characteristics.

Prevalence and risk factors for spousal violence among women attending health care centres in Alexandria, Egypt.

We conducted a cross-sectional survey to determine the prevalence of, and factors affecting, spousal violence among 3271 ever-married women attending 12 randomly selected family health centres in Alexandria Governorate. More than three-quarters of the participants (77%) reported experiencing spousal violence during their marital life. Emotional violence was the most common type reported (71.0%), followed by physical (50.3%), economic (40.8%) and sexual (37.1%) violence. The study confirms the high prevalence of spousal violence across all socioeconomic strata. Logistic regression analysis indicated large family size, divorce or separation, low educational attainment of husband, smoking habit and drug use in husband, husband's psychological status and history of exposure to physical violence during adolescence were associated with spousal violence. This high rate of spousal violence highlights the urgent need for government and civil society to address the issue, which hinders progress toward Egypt's development goals.

Long-term pituitary down-regulation before in vitro fertilization (IVF) for women with endometriosis.

BACKGROUND: Women with endometriosis who are treated with in vitro fertilization (IVF) or intracytoplasmic sperm injection (ICSI) have a lower pregnancy rate compared to women with tubal factor infertility. It has been suggested that the administration of gonadotrophin releasing hormone (GnRH) agonists for a few months prior to IVF or ICSI increases the pregnancy rate. OBJECTIVES: To determine the effectiveness of administering GnRH agonists for three to six months prior to IVF or ICSI in women with endometriosis. SEARCH STRATEGY: We used computer searches of the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, the National Research Register (NRR) and the MDSG Specialised Register of controlled trials. We handsearched proceedings of annual meetings of the American Society for Reproductive Medicine (ASRM) and the European Society for Human Reproduction and Embryology (ESHRE). We reviewed lists of references in original research and review articles. We contacted experts in various countries to identify unpublished trials. SELECTION CRITERIA: We included randomised controlled trials using any GnRH agonist prior to IVF or ICSI to treat women with any degree of endometriosis diagnosed by laparoscopy or laparotomy DATA COLLECTION AND ANALYSIS: Two independent review authors abstracted data (HNS and JGV). We sent e-mails to investigators to seek additional information. We assessed the validity of each study using the methods suggested in the Cochrane Handbook. The data were checked by the third review author (SD) and any disagreement was resolved by arbitration with the fourth review author (AA). We generated 2 x 2 tables for principal outcome measures. The Peto-modified Mantel-Haenszel technique was used to calculate odds ratios (OR) and assess statistical heterogeneity between studies. MAIN RESULTS: Three randomised controlled trials (with 165 women) were included. The live birth rate per woman was significantly higher in women receiving the GnRH agonist compared to the control group (OR 9.19, 95% CI 1.08 to 78.22). However, this was based on one trial reporting "viable pregnancy" only. The clinical pregnancy rate per woman was also significantly higher (three studies: OR 4.28, 95% CI 2.00 to 9.15). The information on miscarriage rates came from two trials with high heterogeneity and, therefore, results of the meta-analysis were doubtful. The included studies provided insufficient data to investigate the effects of administration of GnRH agonists on multiple or ectopic pregnancies, fetal abnormalities or other complications. AUTHORS' CONCLUSIONS: The administration of GnRH agonists for a period of three to six months prior to IVF or ICSI in women with endometriosis increases the odds of clinical pregnancy by fourfold. Data regarding adverse effects of this therapy on the mother or fetus are not available at present.

Assisted hatching.

Assisted hatching entails the opening or thinning of the zona pellucida before embryo transfer in order to improve the results of in vitro fertilization (IVF) and intracytoplasmic sperm injection (ICSI). The technique can be performed mechanically, chemically or with a laser beam. A piezoelectric method has also been described. Meta-analyses of randomised trials have shown that assisted hatching increases the clinical pregnancy, implantation and on-going pregnancy rates in patients with poor prognosis for IVF and ICSI, particularly those with repeated implantation failure. The technique is not without risks, and has been associated with an increased incidence of monozygotic twinning. Nevertheless, it remains an invaluable tool in assisted reproductive technology.

Ultrasound measurement of the uterocervical angle before embryo transfer: a prospective controlled study.

BACKGROUND: The study aim was to determine whether moulding the embryo transfer catheter according to the uterocervical angle measured by ultrasound could improve pregnancy and implantation rates. METHODS: Patients were alternately allocated to one of two groups. In the ultrasound-guided group (n = 320), the catheter was moulded according to the uterocervical angle measured by abdominal ultrasound. In controls (n = 320), embryo transfer was performed using the "clinical feel" method. RESULTS: Moulding the embryo transfer catheter according to the uterocervical angle significantly increased clinical pregnancy [(OR = 1.57, 95% CI (1.08-2.27)] and implantation rates [(OR = 1.47, 95% CI (1.10-1.96)] compared with the "clinical feel" method. It also significantly reduced difficult transfers [(OR = 0.25, 95% CI (0.16-0.40)] and blood during transfers [OR = 0.71, 95% CI (0.50-0.99)]. Patients with large angles (>60 degrees ) had significantly lower pregnancy rates compared with those with no angle [OR = 0.36, 95% CI (0.16-0.52)]. CONCLUSIONS: Moulding the embryo transfer catheter according to the uterocervical angle measured by ultrasound increases clinical pregnancy and implantation rates and diminishes the incidence of difficult and bloody transfers.

[The ancient Alexandria school of medicine]. / L'ancienne école de médecine d'Alexandrie.

A famous medical school was established in old Alexandria during the third century BC. Although mainly Greek in essence, and following the Hippocratic teachings, it was heavily tainted by the medical practices of ancient Egypt. Anatomy was particularly advanced due to the possibility of dissecting the human body. The most important Alexandrian physicians were Herophilus and Erasistratus. Many graduates of this medical school traveled and practiced throughout the Mediterranean basin. Galen, the famous Roman physician studied in Alexandria before practicing in Rome. His teachings and writings survived well into the sixteenth century and formed the basis of more modern medical practices during the renaissance. These writings were conserved partly by Christian monks and partly by Arab and Jewish scholars of the middle ages. The medical school of Alexandria was still active until late in the 3rd century AD. However, it slipped slowly into oblivion after the fire of 389 AD, which also devastated its famous library.

Minimal requirements for a successful outcome in anovulatory patients treated with human menopausal gonadotropins.

OBJECTIVE: To determine the minimal requirements for achieving a full-term singleton pregnancy in hMG-treated patients. METHODS: One hundred and ninety-two pregnancy cycles resulting from hMG therapy in infertile patients were retrospectively studied to determine the minimal requirements for the occurrence of a pregnancy in those women. The cycles were divided into five groups: pregnancies ending in miscarriage, ectopic pregnancies, pregnancies ending in preterm delivery, full-term singleton pregnancies, and full-term multiple pregnancies. The number of hMG ampules, the number of preovulatory follicles reaching 18 mm or more in diameter, the cervical mucus score (Insler), the number of living spermatozoa per high-power field (HPF) observed in the cervical mucus on the day of hCG administration, and the midluteal plasma progesterone concentration were determined and correlated with the outcome of the pregnancy in the five groups studied. The minimal requirements for the occurrence of a full-term singleton pregnancy were also determined. RESULTS: In this cohort of 192 women, the mean number of hMG ampules administered was 25.38 (1903.5 IU), the mean number of preovulatory follicles reaching 18 mm was 2.1, the mean cervical mucus score (Insler) was 9.48, and the mean number of motile spermatozoa per HPF in the cervical mucus on the day of hCG administration was 19.3. There were no statistically significant differences between the five groups studied regarding these four variables. The mean midluteal plasma progesterone concentration was 29.07 ng/mL and there was no statistically significant difference in midluteal plasma progesterone concentration between the cycles resulting in full-term deliveries and those ending in miscarriage. However, a statistically significant difference in midluteal plasma progesterone concentration was found between the cycles resulting in full-term singleton pregnancies and those resulting in full-term multiple pregnancies. CONCLUSIONS: The minimal requirements for achieving a full-term singleton pregnancy were 9 ampules of hMG (675 IU), one 18-mm follicle, a cervical mucus score (Insler) of 6 on the day of hCG administration, and a midluteal plasma progesterone concentration of 10.83 ng/mL. The presence of motile spermatozoa in the cervical mucus was a reassuring sign in 92.7% of instances but was not an absolute necessity for a successful outcome.

Mathematical relationships between uterine contractions, cervical dilatation, descent and rotation in spontaneous vertex deliveries.

OBJECTIVE: To determine the mathematical relationships between the strength and duration of the uterine contractions, the descent and rotation of the fetal head and the degree of cervical dilatation in 50 multiparous women with spontaneous vaginal deliveries using a simple device applied to the fetal vertex. METHOD: A simple device for monitoring the progress of labor was applied to the fetal vertex. The device allows the continuous monitoring of descent and rotation of the fetal head. The amount of descent and the degree of rotation were also determined by repeated vaginal examinations as well as the degree of cervical dilatation. The frequency of uterine contractions was also recorded on a partogram. RESULT: A good correlation was found between the amount of descent of the fetal vertex (r = 0.975) and between the degree of rotation of the fetal head (0.83) determined by both methods. Multiple regression analysis was then performed and the degree of cervical dilatation in cm at any given time during the first stage of labor was found to be equal to 2.859 + 0.583 fetal head station in (cm) + 0.1983 internal rotation in degrees -0.0493 (station x internal rotation) + 0.1599 station2 + 0.3622 uterine contractions per 10 min. A nomogram was constructed allowing the calculation of cervical dilatation for a given station of the head, degree of rotation and frequency of uterine contractions. CONCLUSION: There is a defined mathematical relationship between the degree of descent and rotation of the fetal head, the degree of cervical dilatation and the frequency of uterine contractions in multiparous women with vertex presentation. The first three variables can be continuously determined by using the described device. Incorporation of the device into a reusable fetal scalp electrode allows the dual mechanical and electronic monitoring during labor with minimal vaginal examinations.

Reference values for the midluteal plasma progesterone concentration: evidence from human menopausal gonadotropin-stimulated pregnancy cycles.

OBJECTIVE: To determine reference values for the midluteal plasma progesterone concentration. DESIGN: Retrospective analysis. SETTING: Infertility clinic at an academic medical center. PATIENT(S): One hundred ninety-two infertile women who became pregnant after induction of ovulation with hMG. INTERVENTION(S): The plasma progesterone level was measured during the midluteal phase of the hMG treatment cycle. MAIN OUTCOME MEASURE(S): The midluteal plasma progesterone concentration was correlated with the outcome of the pregnancy. RESULT(S): In this cohort of 192 women in whom ovulation was induced with hMG and 5,000 IU of hCG, the mean midluteal plasma progesterone concentrations were 29.07 ng/mL, 25.85 ng/mL, 31.49 ng/mL, 41.39 ng/mL, and 28.64 ng/mL in all cycles that resulted in pregnancy, cycles that resulted in full-term singleton pregnancy, cycles that resulted in full-term multiple pregnancy, cycles that resulted in preterm pregnancy, and cycles that ended in miscarriage, respectively. There was no statistically significant difference in the progesterone concentration between the cycles that resulted in full-term pregnancy and those that ended in miscarriage, but there was a statistically significant difference between the cycles that resulted in singleton pregnancy and those that resulted in multiple pregnancy. The minimum value that was compatible with a full-term pregnancy in this cohort of women was 10.83 ng/mL. CONCLUSION(S): In a cohort of 192 women, the minimum plasma progesterone concentration on day 7 in women who attained a full-term pregnancy after induction of ovulation with 5,000 IU of hCG was 10.83 ng/mL.

Construction of a local standard symphysis fundal height curves for monitoring intrauterine fetal growth.

The aim of the present study was to construct standard symphysis fundal height percentile curves to be used as a reference chart in monitoring fetal growth. The construction was based on 1185 observations (symphysis fundal height measured to the nearest 0.5 cm by a malleable elastic tape) obtained from follow up of 105 cases of healthy pregnant women who were: sure of date of their last menstrual period, confirmed by early dating scan "before 20th gestational week", experienced a very strict normal course of pregnancy, giving birth to normal term newborn with appropriate weight for gestational age and sex. The selection of the study sample went through several screening levels starting by 4088 cases and ending by 105 cases. The measurements were taken biweekly from the 18th week of gestation to delivery "37-42 weeks of gestation." Tenth, 25th, 50th, 75th, 90th and 95th percentiles were calculated and represented graphically. Mean, mean-1 SD, mean-2 SD, mean +1 SD, mean + 2 SD were also calculated and represented graphically. The curve of best fit was determined by polynominal regression. The resulted percentile curves and mean values were found to be comparable to those in both developed and developing countries. It was recommended to incorporate the reference charts of symphysis fundal height into the maternity services after using it in routine antenatal examination for large number of cases and establishing its sensitivity and specificity.

A comparison of 2 methods for monitoring gonadotrophin therapy.

One hundred and seventy nine (179) ovarian cycles from 52 patients treated with human menopausal gonadotrophins were retrospectively analysed. Eighty one (81) cycles were monitored by serial measurements of plasma oestradiol concentrations and 98 cycles were monitored by realtime ultrasound scanning of ovarian follicles. The results suggest that realtime ultrasonography, used alone, is a safe and effective method for monitoring gonadotrophin therapy.

Blood hormone levels in egyptian women on norethisterone oenanthate.

Ten Egyptian women who were using the injectable contraceptive norethisterone oenanthate (NET-OEN) for at least 6 months were monitored weekly for a period of 12 weeks by measuring 3 pituitary hormones (FSH, LH and prolactin) and 2 ovarian hormones (oestradiol 17-B and progesterone). It was concluded that NET-OEN is a strong ovulation inhibitor, at least after its use for 6 months. Prolactin levels were depressed and this is in contradiction with the findings in rats.

PIP: 10 Egyptian women who were using the injectable contraceptive norethisterone enanthate (NET-EN) for at least 6 months were monitored weekly for a period of 12 weeks by measuring 3 pituitary hormones (FSH, LH, prolactin) and 2 ovarian hormones (estradiol 17-B and progesterone). It was concluded that NET-EN is a strong ovulation inhibitor, at least after its use for 6 months. Prolactin levels were depressed and this is in contrast to the findings in rats.