Outcomes of assisted reproductive technologies at the Nairobi In Vitro Fertilisation Centre.

BACKGROUND: Infertility is a common problem affecting up to ten per cent of married couples. A systematic evaluation of aetiologic factors forms the basis for choice of treatment and future fertility. On the global perspective, Assisted Reproductive Technologies (ART) has become internationally recognised treatment option for some infertile couples. A report on the current outcomes of ART practice at The Nairobi IVF Centre is presented. OBJECTIVE: To describe the practice of assisted reproduction and present a report on the current outcomes. DESIGN: A retrospective survey of data on assisted reproduction practice from August 2005 to July 2008. SETTING: The Nairobi IVF Centre a private medical practice in Nairobi, Kenya. INTERVENTIONS: Treatment of infertile couples by various assisted reproductive technologies including in vitro fertilisation (IVF), intra-cytoplasmic sperm injection (ICSI), uterine fresh embryo transfer (ET), and frozen/thawed uterine ET (FTET). MAIN OUTCOME MEASURES: Fertilisation, embryo cleavage, ET, embryo freeze/thaw survival, preclinical pregnancy and clinical pregnancy rates, live births and other obstetric outcomes. RESULTS: A total of 362 IVF cycles were performed. Following controlled ovarian hyperstimulation, an average of 12 oocytes were retrieved per patient while the fertilisation and subsequent embryo cleavage rates were 67 and 91.2% respectively. An average of three embryos were transferred and the embryo transfer rate was 93.3% per cycle started and 96.6% per oocyte retrieval. Surplus embryos were available for cryopreservation in 106 (50.1%) cycles. On thawing frozen embryos, the survival rate was 65.5%. Following ET, the overall pre-clinical pregnancies were 124 (36.2%) of which 99 (28.9%) developed into clinical pregnancies per cycle. Of the clinical pregnancies, 72 (73%) were singletons, 23 (23%) twin gestations and four triplets (4%). A total of 52 mothers have been delivered either by Caesarian section 45 (86.5%) or spontaneous vertex delivery seven (13.5%) to 61 live babies of whom 36 were females and 25 males. A further 28 IVF clinical pregnancies are ongoing, 26 following fresh embryo transfer and two from frozen/thawed embryos. CONCLUSION: Our results on ART practice reflects a pregnancy outcome comparable to that reported by other fertility centres globally. Couples with infertility in East and Central Africa for whom ART treatment is indicated may now access the service locally.

Environmental and occupational exposure to lead.

OBJECTIVE: To determine the status of environmental and occupational lead exposure in selected areas in Nairobi, Kenya. DESIGN: Cross sectional study. SETTING: Kariobangi North, Babadogo, Waithaka and Pumwani for assessment of environmental exposure to lead (Pb) and Ziwani Jua Kali works for assessment of occupational lead exposure. Olkalou in Nyandarua District was the covariate study area. SUBJECTS: Three hundred and eight children and adults participated. RESULTS: Blood lead levels (BLLs) obtained for the entire sample (n = 308) ranged from 0.4 to 65 microg/dl of blood. One hundred and sixty nine (55%) of the total sample had levels equal to or below 4.9 microg/dl, while 62 (20%) of the sample had levels ranging from 5.0 to 9.9 microg/dl. Blood lead levels above 10 microg/dl were recorded in 77 (25%) of the total sample. Within Nairobi, 32 (15.3%) of the study subjects in areas meant for assessment of environmental lead exposure had levels above the WHO/CDC action levels of 10 microg/dl of blood. The mean BLL for the occupationally exposed (Ziwani Jua kali) was 22.6 +/- 13.4 microg/dl. Among the workers, 89% had BLLs above 10 microg/dl. In general, 15% of the entire sample (for both environmental and occupational groups) in Nairobi had BLLs above 15 microg/dl. The covariate group at Olkalou had a mean BLL of 1.3 +/- 0.9 microg/dl. CONCLUSION: The prevalence of environmental lead exposure to the general public is high in Nairobi compared to Olkalou where non exposure was reported. Occupational lead exposure has been identified to be at alarming levels and urgent intervention measures are recommended.

Experience with IUCD insertion outside of menses in Kenya.

OBJECTIVE: To determine if women receiving intrauterine devices (IUCDs) outside of menses have an acceptable rate of insertion problems and subsequent IUCD-related complications. DESIGN: Cross-sectional and prospective cohort study of insertions at times other than during menses. SETTING: The study was carried out in two government family planning (FP) clinics in Nairobi, Kenya. SUBJECTS: After appropriate pre-test and post-test HIV counselling, 1686 women requesting IUCDs at two FP clinics between 1994 and 1995 in Nairobi were enrolled at baseline into a study examining the effect of human immuno-deficiency virus (HIV) infection on IUCD-related complications. Six hundred and forty nine women (156 HIV-infected and 493 HIV-uninfected) were selected for the four month follow up study. They were classified according to their menstrual cycle status at time of IUCD insertion. MAIN OUTCOME MEASURES: Problems at the time of insertion (pain, bleeding, immediate expulsion) and IUCD-related complications through four months. RESULTS: Rates of immediate insertion problems were low in the women who had insertions during menses (7.0%), outside of menses (4.0%) or had oligomenorrhea/amenorrhea (2.6%). The adjusted odds ratios for IUCD insertion problems outside of menses and in oligomenorrhea/amenorrhea (versus women with insertion during menses) were 0.54 (95 % CI 0.18-1.59) and 0.39 (95% CI 0.12-1.29) respectively. IUCD-related complications were higher in the oligomenorrhea/amenorrhea (11.5%) or insertion outside of menses (6.9%), than the within menses (4.3%) groups. However, the differences were not statistically significant. Adjusted odds ratios for IUCD outside of menses and oligomenorrhoea/amenorrhea groups were 1.65 (95% CI 0.21-12.91) and 2.72 (95% CI 0.34-21.71) respectively. CONCLUSION: The results confirm that the IUCD can be safely inserted outside of menses with minimal insertion difficulties and subsequent complications. Availability of IUCDs outside of menses may enhance IUCD acceptance in Kenya and create better opportunity for visual screening of the cervix for sexually transmitted infections.

Pharmacodynamic effects of depot-medroxyprogesterone acetate (DMPA) administered to lactating women on their male infants.

Normal postpartum women, who had a spontaneous vaginal delivery of one full-term male infant, free of congenital abnormalities and other diseases, were recruited for this study. Thirteen women received 150 mg depot-medroxy-progesterone acetate (DMPA), intramuscularly on days 42 + 1 and 126 + 1 postpartum. Infants of nine mothers, who did not receive DMPA, served as controls. Blood samples were collected from treated mothers on days 44, 47, 74, 124, 128, and 130 postpartum for medroxyprogesterone acetate (MPA) measurements. Four-hour urine collections were obtained from all 22 infants in the morning on days 38, 40, 42, 44, 46, 53, 60, 67, 74, 88, 102, 116, 122, 124, 126, 128, 130, and 137. Urinary follicle stimulating hormone (FSH), luteinizing hormone (LH), unconjugated testosterone, and unconjugated cortisol were measured by radioimmunoassay, and serum MPA and urinary MPA metabolites were measured by gas chromatography-mass spectrometry (GC-MS). No MPA metabolites could be detected in the urine of the infants from the DMPA-receiving mothers. Hormonal profiles in the urine samples were not suppressed in comparison with those of the control infants. The present study demonstrates that DMPA, administered to the mother, does not influence the hormonal regulation of the breast-fed normal male infant.

Effects of the triphasic oral contraceptive on lipid and lipoprotein metabolism.

PIP: The effects of the triphasic oral contraceptive (OC) ethinyl estradiol (EE) and levonorgestrel (LNG) on lipid and lipoprotein metabolism were evaluated in 97 black Kenyan women. Subjects were recruited from the Family Planning Clinic and were followed for 12 months. There was an increase in fasting levels of total cholesterol. These changes were not statistically significant. However, the triglyceride increase was statistically significant at 9 months and 12 months (p0.05). The high density cholesterol remained unchanged. Thus, this triphasic OC was found to have minimal effect on lipid and lipoprotein metabolism.^ieng

A survey to determine the knowledge, attitudes and practice of family planning amongst the nursing staff at Kenyatta National Hospital.

PIP: This survey was conducted at the Kenyatta National Hospital between March-June 1988 to assess the attitudes, basic knowledge and personal use of contraceptives among the nursing staff and to determine how these would influence family planning utilization in the country. In 1987, a similar survey was conducted among the physicians at this same hospital. A total of 432 nurses were interviewed; 64.4% of the nurses were currently using contraceptives and 7.7% had used them continuously. The IUD was used by 47.1% of the nurses. 62.3% of the nurses indicated that they would be able to discuss contraceptive use with their teenage daughters but only 29.6% would provide contraceptives. 66.7% of the nurses had extensive knowledge of contraceptives (over 60% knowledge) but knowledge concerning male contraceptives and newer methods such as Norplant was poor.^ieng

Changes in plasma HDL-cholesterol in women using oral contraceptives in Kenya.

PIP: 125 black Kenyan women attending the Kenyatta National Family Welfare Clinic were randomly allocated to combined and fixed dose oral contraceptives (Eugynon: 500 mcg dl-norgestrel + 50 mcg ethinyl estradiol or Microgynon: 150 mcg levonorgestel + 30 mcg ethinyl estradiol). They were between 18-33 years of age with a mean of 25 +or- 7 years. The mean parity of this group was 3 and they had a mean education standard of 8 years. Fasting blood sampled were taken on recruitment (control cycle) and thereafter once for cycles 1, 3, 6, 9, and 12 during OC use. HDL-cholesterol was estimated in the sear. The 2 OCs elicited a significant decrease in levels of HDL-cholesterol (p0.01).^ieng

Menstrual blood loss (MBL) in nulliparous Kenyan women.

PIP: Menstrual blood loss (MBL) was evaluated in 74 nulliporous Kenyan women aged between 20 and 27 years. The hemoglobin levels were all in normal range with the mean of 13.65 +or- 0.8, 13.84 +or- 1.2 and 13.04 +or- 1.2 g/100 ml respectively in 3 populations. The MBL was comparable in the 3 populations with the mean of 35.1 +or- 12.6, 30.6 +or- 8.7 and 32.2 +or- 9.4 ml respectively. There was no difference of statistical significance between the 2 periods studied per each individual. This study objectively assesses the menstrual blood loss in 3 population groups--2 urban and 1 rural. The data can be used to evaluate menstrual blood loss before and after initiation of various contraceptives used in Kenya. Subjects were volunteers who were not on any contraception except barrier or natural rhythm methods, not under psychological stress and who exhibited normal physical female characteristics on examination. Those who wished to drop out, became pregnant or desired contraception, were excluded. The study confirms the individual constancy of the menstrual blood loss in this population. This has important practical implications since a single determination of the menstrual blood loss may be a fairly good expression for the average blood loss in a woman. The immediate effect of various treatments such as IUD insertion or oral contraceptives on the MBL may easily be evaluated quantitatively by measurements in consecutive periods using only 1 period as a control. The quick method can be easily used in evaluating pathological conditions e.g. iron-deficiency due to heavy bleeding, IUD-associated hemorrhage, menorrhagia and uterine fibroid.^ieng

Hormonal patterns during the menstrual cycles in healthy black Kenyan women.

PIP: 17 regularly mentruating young black Kenyan women were studied during a mentrual cylcle for their reproductive hormonal patterns. The serum concentrations of Follicle Stimulating Hormone (FSH), Luteinizing Hormone (LH) and Prolactin (PRL) were determined by World Health Organization Matched Reagent Programme Radioimmunoassay (WHO-MR-RIA). A biphasic basal body temperature (BBT) record was also noted. The hormonal patterns showed a mid-cycle LH surge and rise in plasma progesterone beginning with the LH peak and lasting a maximum of 6-8 days after the LH peak. Cycle lengths ranged from 25-32 days with a mean of 28 plus or minus 2 days. The follicular phase ranged from 10-17 days, and the luteal phase lasted from 13-15 days. When the mean LH and FSH concentrations and the mean BBT curve were synchronized on the day of the mid-cycle LH peak, the temperature elevation occured about 48 days after the LH peak. Along with the LH, the FSH showed a mid-cycle peak. The results of this study are consistent with those already documented for Caucasian, Asian and African females^ieng

The pituitary reserve for gonadotrophins and prolactin in women under long-term use of depo-medroxyprogesterone acetate (DMPA) as a contraceptive.

PIP: Pituitary reserve was assessed in women who had used depo-medroxyprogesterone acetate (DMPA) for 1, 5 and 10 years, and their responses were compared to 2 control groups--IUD users and noncontraceptive users. 100 ug GnRH and 200ug TRH were injected as a bolus and the Follicle Stimulating Hormone (FSH), Luteinizing Hormone (LH) and Prolaction (PRL) responses noted. The basal PRL levels were similar in all groups. The PRL response to stimulation was significantly greater among 5 and 10 year DMPA users and also IUD users. The mean basal levels of LH were within the normal follicular phase range in all groups. However, the response to stimulation was significantly higher among 1 and 5 year DMPA users when compared with noncontraceptive users. The basal serum FSH levels in both the study and control groups were comparable to those of normally cycling women in the follicular phase. The response to stimulation was greater in the 10 year DMPA users when compared to both the noncontraceptive users and IUD users. The study shows that basal levels of FSH, LH and PRL were similar in the study and control groups. The observed amplified response to stimulation among longterm DMPA users could be the result of failure of gonadotropin cyclic release, possibly resulting in increased pituitary reserves.^ieng

Baseline studies on semen and hormonal parameters in fertile Black males in Kenya.

PIP: Masturbatory semen specimen from 49 fertile Black African males in Kenya whose wives were pregnant was obtained after at least 3 days of abstinence for the analysis of parameters which included volume motility, vitality, sperm concentration, pH, fructose and acid phosphatase levels. About 1/2 the spermatozoa was actively progressive in motility, while 40% was nonmotile. Vitality in the 1st hour revealed that 81.4% of the sperm was alive. About 90% of the semen specimens had more than 40% idea forms of spermatozoa. Spermatozoal abnormalities were a frequent feature. There was no correlation between age and the testicular volume, but seminal fluid volume and sperm density tended to decrease with age. Serum levels of Follicle Stimulating Hormone, Luteinizing Hormone, Prolactin and Testosterone were determined in the subjects' sera, enabling the establishment of reference values for these parameters in African Kenyan males.^ieng