Combination of zygote andembryo morphology scoring couldaccurately aid to predict the outcomeof intra-cytoplasmic sperm injectionprocedures

This study was designed to examine the relationship between zygoteand embryo morphology as judged by Z-scoring and Embryo scoring systems, and to test whether these scores could be used to predict accurate-ly the outcome of cycles of intracytoplasmic sperm injection[ICSI] judged by detection of chemical pregnancy. The study comprised 78 infertile couples that had undergone ICSI. After ICSI procedure, oocytes were cultured and assessed for the presence of pronuclei after 16-18 h of incubation. Zygotes were scored for the position of pronuclei, position and type of nucleoli and cytoplasmic morphology, each parameter was awarded a scoreof 5 points. Embryos were scored for the blastomere volume and synchrony of cleavage, the level of multinucleation and the extent of fragmentation, each of parameter was awarded a score of 5 points. Zygotes and embryos awarded score of 15 were categorized as Z1 or E1, those scored10-14 were categorized as Z2 or E2 and those scored <10 were Z3 or E3.The establishment of a chemical pregnancy was considered as a positive beta-hCG test >20 IU/L at 12 days after embryo transfer and was consid-ered for evaluation of the predictability of the outcome of ICSI procedure. The mean number of oocytes retrieved was 7.1+/-2.6_patient and succeeded fertilization was reported in 422 of a total of 536 oocytes [80.6%].There were 113 zygotes [26.16%] of Z1 score, 186 zygotes [43.06%] of Z2 score and 133 zygotes [30.78%] of Z3 score; whereas, 101 embryos [23.38%] were of E1 score, 187 embryos [43.29%] were of E2 score and144 embryos [33.33%] were of E3 score. There was a positive significant correlation between the determined zygote and embryo scores, [p<0.001].Pregnancy was diagnosed in 19 patients [24.35%], 10 females [52.63%] had embryos morphologically graded Z1E1, 4 females [21.05%] had embryos' graded Z2E2, 2 females [10.52%] had embryos graded Z1E3 and the other 3[15.79%] had their embryos graded Z1E2, Z2E1 and Z3E1, respectively. Morphological scoring depending on both zygote and embryo scoring could predict the outcome of ICSI with specificity 91.77% and ac-curacy rate of 90.05%, while depending on zygote score alone the specificity and accuracy rates were 75.79% and 73.15%, respectively and depending on embryo score only specificity and accuracy rates were 78.4%and 77.77% with a significant difference in the predictability depending on combined scores compared to that depending on either zygote score[p<0.001] or embryo score [p<0.01]. It could be concluded that morphological scoring using combination of zygote and embryo scores aid to predict accurately the outcome of ICSI procedures

Prediction of the outcome of laparoscopic ovarian drilling for polycystic ovarian syndrome in women with anovulatory infertility

Background: Laparoscopic ovarian drilling [LOD] has been commonly used for the treatment of clomiphene citrate [CC]-resistant women with polycystic ovarian syndrome [PCOS]. However, about 20-30% of anovulatory women with PCOS fail to respond to LOD. So, identifying factors that can predict the outcome of this modality of treatment may help the clinician for proper selection and counseling of those women about their chances for the success of WD

Objective: The aim of this study is to determine the clinical, endocrinologic, biochemical and ultrasonographic factors that can predict the success of treatment following LOD in CC-resistant women with PCOS. Design: A prospective designed study. Setting: Departments of Obstetrics and Gynecology, Mansoura and Benha University Hospitals

Patients and Methods: Sixty-seven CC-resistant PCOS patients were included in the study. Preoperative evaluation of the known clinical, endocrinologic, biochemical and ultrasongraphic factors associated with PCOS were done initially. Then, all patients included in the study underwent LOD using the triple-puncture technique. Post-operatively, all women were followed-up for the occurrence of either ovulation or pregnancy. Those with persistent anovulation after LOD were offered CC. The effect of the different pre-operative characteristics on the ovulation and pregnancy rates after LOD was assessed. Moreover, women were divided into two or three categories according to the severity of each of the known factors associated with PCOS. The success rates were compared between the categories of each factor. Multiple logistic regression analysis was used to identify independent predictors of success of LOD. Main outcome measure: Ovulation and pregnancy rates

Results: Of the 67 women, 36 [53.7%] ovulated spontaneously and a further 14 women ovulated after the addition of CC, giving an overall ovulation rate of 74.6% [50 out of 67]. From those ovulated spontaneously [36], 26 [38.8%] conceived spontaneously, and the overall pregnancy rate after the help of CC was 49.2% [33 out of 67]. Women with duration of infertility > 6 years, marked obesity [BMI 35 Kg / m[2]], marked hyperandrogenism [serum testosterone >/= 1.8 ng /dL], and insulin resistance [serum fasting insulin >/= 20 uU/ mL, and/or a fasting glucose insulin ratio 10 IU/L] did not reach statistical significance to affect the outcome, but once ovulation was achieved, it appeared to be associated with higher pregnancy rate

Conclusion: Longer duration of infertility, marked obesity, marked hyperandrogenism and marked insulin resistance seemed to be associated with high probability of LOD failure. On the other hand, a high pretreatment LH level appeared to be associated with a high probability of pregnancy once ovulation is achieved

role of serum vascular endothelial growth factor in the prediction of ovarian hyperstimulation syndrome in women with polycysic ovarian syndrome

Background: Ovarian hyperstimulation syndrome [OHSS] is an iatrogenic and potentially life-threatening complication of treatment with fertility drugs. Women with polycystic ovaries [PCO] and polycystic ovarian syndrome [PCOS] are at a particularly higher risk of developing OHSS. The traditional determinants viz, serum estradiol [E2] concentrations and the number of follicles on the day of human chorionic gonadotrophin [hCG] administration are not only increasingly recognized that they do not adequately define the risks for this syndrome but also do not accurately predict its occurrence. On the other hand, numerous reports now emphasized the role of vascular endothelial growth factor [VEGF] as an important mediator of the syndrome and that it provides a nonsteroidal index of the ovarian response to gonadotrophin simulation

Objective: The aim of this study was to examine the possible role of the circulating serum VEGF concentration pattern during ovarian stimulation as a method of predicting OHSS in women with PCOS and hence its possible real prevention. Design: A prospective designed study. Setting: Outpatient women's clinics, Departments of Obstetrics and Gynecology, Benha and Mansoura University Hospitals

Patients and Methods: A total of ninety-six women with anovulatory infertility due to PCOS were included in the study. All women underwent controlled ovarian stimulation and were followed-up for the development of OHSS. Cases who developed mild OHSS [n=6] were excluded from the study, while those who developed either moderate [n=6] or severe OHSS [n=2] were only included. Consequently, the remaining studied women [n=90] were divided into two groups: an "OHSS group" [moderate, n = 8] and a "non OHSS group" [n = 82]. Serum was collected from all patients in the early follicular phase before the initiation of the treatment, on the days of hCG injection and 48 hours after hCG injection and was assayed for VEGF concentration

Results: The serum VEGF concentration increased significantly in all the studied women during ovarian stimulation irrespective of whether OHSS developed or not. The rise was significantly higher on the day of hCG administration than in the early follicular phase at the beginning of ovarian stimulation in both groups [it increased from 156.3 +/- 45.2 to 257.4 +/- 108.6 pg/mL in women in whom OHSS developed and from 145.4 +/- 39.8 to 168.2 +/- 36.5 pg/mL in women in whom it did not] [P < 0.01].There was a further increment in the VEGF concentration 48 hours after hCG administration in both groups [up to 398.5 +/- 112.9 and 186.2 +/- 42.8 pg/mL respectively]. The levels of serum VEGF on both the day of hCG administration and 48 hours after hCG administration were significantly higher in women with OHSS than those without OHSS. A cut-off value of 240 pg/mL for serum VEGF concentration on the day of hCG administration offered a sensitivity of 76.8%, negative predictive value [NPV] of 82.2% and positive predictive value [PPV] of 73.4%. The rise in the serum VEGF concentration that occurred between the day of the beginning of cycle stimulation and the day of hCG administration [referred to as the "VEGF rise before hCG administration"] and that occurred between the day of hCG administration and 48 hours after hCG administration [referred to as the "VEGF rise after hCG administration"] were significantly higher in women in whom OHSS developed than in those without OHSS [P < 0.05]. Both were found to be good markers for the development of OHSS. The sensitivity, NPV and PPV for "VEGF rise after hCG administration" at a cut-off value of 100 pg/mL were 96.6%, 93.8% and 65.4% respectively in the prediction of OHSS. Similar values, although slightly lower were obtained for the "VEGF rise before hCG administration" at a cutoff value of 70pg/ mL [90.2%, 91.4% and 62.3% respectively]

Conclusion: The "VEGF rise after hCG administration" might offer a good single marker for prediction but not real prevention of the development of OHSS in PCOS women during ovarian simulation. Worthily "VEGF rise before hCG administration" might offer a similar good single marker for its prediction and also a real chance for its prevention at the same time both in in vitro fertilization [TVF] and non-IVF stimulated cycles. Prevention can be achieved by withholding hCG administration, canceling the cycle, lowering the dose of hCG or withholding hCG for a couple of days [coasting] and thus ultimately avoiding a life- threatening complication in such at risk group of women

Foley's catheter thermal endometrial ablation versus hysteroscopic rollerball endometrial ablation in treatment of dysfunctional menorrhagia

To compare the efficacy and safety of thermal endometrial ablation with the use of Foley's catheter with hysteroscopic rollerball endometrial ablation in the treatment of dysfunctional menorrhagia. A randomized clinical prospective comparative study. Benha University Hospital. The study included eighty patients with persistent dysfunctional menorrhagia not responding to medical treatment for whom follow up data were available for 12 months and fulfilled the inclusion criteria that were enrolled in the study. The patients were randomized into two equal groups of 40 patients each. Patients in the first group were treated by thermal ablation with the use of Foley's catheter, while those of the second group were treated by hysteroscopic rollerball ablation. Preliminary pelvic sonography, hysteroscopy and endometrial biopsy were performed to exclude intrauterine pathology. The procedure was done in the early follicular phase of menstrual cycle under general anesthesia. The main outcome measures included a 12 months follow up of menstrual blood loss and any adverse events. The twelve months follow up indicated that both techniques significantly reduced menstrual blood flow. Success rates, as reflected by percent of patients who returned to normal menstrual bleeing pattern or less were comparable being 80% for thermal balloon group and 85% for the rollerball group. The procedural time was reduced significantly in the uterine thermal balloon group [p < 0.05]. Intraoperative complications occurred in three [7.5%] of the hysteroscopic rollerball group, while no intraoperative complications occurred in the thermal balloon group. Thermal endometrial ablation with the use of Foley's catheter is a safe, simple, easy, cheap and mininally invasive procedure. It is effective as hysteroscopic rollerball ablation in treatment of dysfunctional menorrhagia, however long term follow up on large number of patients is requird for further assessment

Pronuclear scoring system of zygotes is a specific predictor of embryo morphological grade on day 3 after IVF/ICSI

This study was designed to evaluate the applicability of the pronuclear scoring system [2-score] alone, or in combination with maternal variables to predict embryo grade determined on day 3 from a large number of embryos derived from patients undergoing treatment with IVF and/or ICSI. The study included 92 couples assigned to undergo NF or ICSI for primary [66.3%] or secondary [33.7%] infertility due to male factor in 30.4%. female factor in 55.5% or unexplained infertility in 14.1 %. A total of 500 zygotes of a total of 611 oocytes were evaluated for 2-scoring at 16-1 8 hours after fertilization and followed for embryo grading on day 3 for evaluation of statistical relation between both and to determine the specificity and sensitivity of Z-score and certain maternal variables in such relation. There were 265, 172, 43 and 20 zygotes of 2-1, 2-2, 2-3 and 2-4 scores. Using regression analysis, 2-scoring showed highly significant [P=0.000] difference in comparison to other variables in prediction of the embryo grade on day 3 and showed high specificity as determined using the receiver operating characteristic [ROC] curve analysis. It could be concluded that the pronuclear scoring sys tern of zygotes is a specific predictor of the embryo grade on day 3 after n/F and/or ICSI and significantly aid for selection of top quality embryo

Does oocyte granularity affect ICSI prognosis?

This study was designed' to evaluate the relationship between oocyte granularity and fertilization rate, further embryonic development and the outcome of ICSI. The study included 986 oocytes retrieved from 92 patients undergoing ICSI treatment that was assessed for oocyte cytoplasm morphology as either normal oocytes with clear cytoplasm and homogeneous fine granularity, granular oocytes that showed dark cytoplasm with granularity either homogeneous affecting the whole cytoplasm [Generalized] or concentrated as a dark mass in the central portion of the oocyte with a clear peripheral ring [Localized] or having cytoplasmic inclusions: then, the embryo quality was graded after 16-18, 48 and 60 hours; into grade I [embryos without fragmentation], grade II [embryos with <20% of the volume of the embryo fragmented] and grade III [embryos with enucleate fragments present in 20-50% of the volume of the embryo]. There were 348 [35.3%] oocytes with normal cytoplasm [Group A], 308 [31.2%] oocyte had generalized granularity [Group B], 21 4 [21.7%] with localized dense central granularity, [Group C] and 116 [11.8%] with cytoplasmic inclusions [Group D]. Fertilization rate, determined after 16-1 8 hours, was 69% [n=240] in group A, 64% [n=197] in group B, 60% [n=128] in group C and 65 [56%] in group D. Cleavage rate determined at 48 hours after ICSI was 60%, 52%, 43% and 32% in the four groups, respectively. Cytoplasmic fragmentation, evaluated 60 hours after ICSI, was reported in 0-10% of group -4, 10-20% of group B, 15-25% in-group C and >25% in group D. Good quality embryo was detected in 40% in-group A oocytes, 25% in group 8, 10% in group C and <10% in group D oocytes. There was a significant difference in cleavage rate of fertilized oocytes categorized according to cytoplasmic granularity, [F=4.34, p=0.0375] with a significant increase of percentage of cytoplasmic fragmentation in oocytes with dense granularity, compared to oocytes with $ne granularity, [F=100.96, p=0.0000] and a significant difference in percentage of good quality embryos between fertilized oocytes categorized according to cytoplasmic granularity, [F=7.469, p=0.0275]. It could be concluded that although oocyte granularity does not significantly affect fertilize ability in ICSI procedure; it affects embryo cleavage rate and embryo fragmentation significantly and hence the predictability of the outcome of ICSI procedure reflected as the percentage of good quality embryo