Intrauterine insemination in Jamaica as a low-cost subfertility treatment in a low-resource region.

OBJECTIVE: To determine the impact of intrauterine insemination on the management of subfertility in Jamaica. METHODS: The present study was a retrospective analysis of all intrauterine insemination cycles completed from May 1, 2002, to August 31, 2005, at the University of the West Indies, Mona, Jamaica. The cycle pregnancy rate (CPR), live-birth rate (LBR), and cumulative pregnancy rate were obtained and prognostic factors were reviewed. RESULTS: The CPR, LBR, and cumulative pregnancy rate were 10.1%, 8.8%, and 13.9%, respectively. Improved success was significantly associated with a shorter period of infertility (3.10 ± 1.43 years vs 5.22 ± 2.89 years; P = 0.01). Women younger than 40 years of age, men with increased post-preparation sperm counts, and couples undergoing 2-3 cycles had improved outcomes. CONCLUSION: Intrauterine insemination represents a safe and cost-effective option for mild male factor infertility or unexplained infertility, especially in resource-poor regions such as the Caribbean. Repeated failed cycles identify those who would probably benefit from early intervention with in vitro fertilization.

A case of severe ovarian hyperstimulation syndrome

Ovarian hyperstimulation syndrome (OHSS) is the serious physiological complication in patients undergoing controlled ovarian hyperstimulation. In a recently concluded treatment cycle of 28 women at the fertility management unit at the University Hospital of the West Indies, one patient developed symptoms and signs of severe ovarian hyperstimulation syndrome. Administration of human chorionic gonadotrophin (HCG) had a direct influence on the development of the syndrome. High risk cases, such as young patients, particularly those with polycystic ovaries or those with serum oestradiol levels >10,000 pmol/l and a large number of follicles, must be identified. Preventative measures include cylce cancellation, reduction of HCG dosage, egg retrieval and cryopreservation of embryos rather than embryo transfer.(Au)

The inaugural in vitro fertilisation cycle in Jamaica: an overview

INTRODUCTION: At the Fertility Management Unit, an assisted reproduction technology service was established in June 2000. Twenty-eight couples were enrolled for treatment, which was carried out in collaboration with staff of the Midland Fertility Service, United Kingdom, and a local team of doctors, nurses and embryologist. The main Pre-treatment diagnoses were tubal factors in eight (28.5 percent) women and oligospermia in eight males (28.5 percent). The mean age of the women was 34.1 years (range 27 to 41 years). METHODS: All patients under the "long protacol" with down regulations of the hypothalamo-pituitary-ovarian axis, using subcutaneous injections of the gonadotrophin releasing hormone agonist (Buserelin), followed by stimulation with the human menopausal gonadotrophin (Pergonal), for ovulation induction. Monitoring of the response was by use of transvaginal ultrasound at the end of down regulation, day 5 of stimulation and from day 9 until the follicles were determined to be ready for retrieval. Oestradiol levels were measured and human chorionic gonadotrophin (Profasi) was given to mature the oocytes. Oocyte recovery was by transvaginal ultrasound-guided needle aspiration of the follicles 35 hours later. Two days after egg recovery and fertilisation, embryos were transferred back to the patient. There were 24 transfers of 1, 2 or 3 embryos. Fertilised embryos not transferred were cryopreserved at -70 degree celcius. Ten women received human chorionic gonadotrophin (HCG) on the day of transfer and 2, 4 and 6 days later, for luteal phase support, and 24 women received progesterone pessaries. RESULTS: All women responded and came to oocyte recovery. There were 3 cases of ovarian hyperstimulation syndrome (OHSS), one severe and 2 mild. Ten couples had intracytoplasmic sperm injection (ICSI) as planned. Two percutaneous epididymal sperm aspirations were necessary due to aspermia, so these had ICSI as well. Standard in vitro firtilzation procedures were used in 16 cases. Twenty-five patients (89.3 percent) had fertilised oocytes. Three couples had no fertilisations. The patient with severe OHSS had numerous fertilisations but no embryos were transferred to the patient. Five patients (20.8 percent) had "chemical" pregnancies. Three pregnancies have continued, 2 twins and one singleton. The pregnancy rate for viable pregnancies is therefore 12.5 percent. CONCLUSION: In vitro fertilization had been successfully achieved (Au)

Correlation between transvaginal ultrasound measured endometrial thickness and histopathological findings in black women with postmenopausal bleeding

OBJECTIVES: To determine whether a postmenopausal endometrial thickness of 5 mm excludes endometrial pathology in the black woman with postmenopausal bleeding. METHODS: Seventy-five black women with postmenopausal bleeding participated in this prospective study between August 1, 1998 and July 31, 1999. The patients had a questionnaire administered, which sought to obtain general information about their age, gynaecological, obstetric and social history. The patients then had a transvaginal ultrasound with double layer measurement of their endometrium; this was followed by hysteroscopy and suction curettage. The curettings were sent for histopathological analysis. The local hospital ethics comittee approved the study. RESULTS: Correlation between the endometrial thickness and endometrial pathology was not very reliable. Fifty per cent of the patients with endometrial cancer had an endometrial thickness of 3-4 mm. Seventy per cent of the women with endometrial thickness of greater than 5 mm had benign pathology. Additionally, the following characteristics were found to be more strongly associated with endometrial cancer: age over 65 years (p = 0.015; relative risk (rr) 1.406), 5 or more years since menopause (p = 0.0176; rr = 1.295) and primary infertility (p = 0.0124; rr = 0.438). CONCLUSION: A double layer endometrial thickness of less than 5 mm, as measured by transvaginal ultrasound, does not exclude endometrial cancer as a cause of postemnopausal bleeding in the black female. A black, postmenopausal female with transvaginal ultrasound measured double layer endometrial thickness of 3 mm or greater and postmenopausal bleeding needs further investigation. Age, time since menopause, endometrial thickness and infertility are strongly associated with endometrial cancer in postmenopausal black women.(Au)

Diabetes in the peri-menopausal period - position statement

Menopause and oestrogen deficiency result in adverse changes in various lipoproteins and calcium metabolism, which may lead to increased risk of coronary artery disease, osteoporosis and Alzheimer's disease. Diabetic women are also at increased risk for cardiovascular disease, hypertension, stroke, endometrial cancer and Alzheimer's disease. Hormone replacement therapy has been shown to reduce the risk of cardiovascular disease, osteoporosis, endometrial cancer, and may even reduce the risk of Alzheimer's disease. The purpose of this review is to demonstrate that sufficient evidence now exists to confirm that hormone replacement therapy is both safe and beneficial for the perimenopausal and post-menopausal diabetic woman.(AU)

Large loop excision of the transformation zone (LLETZ) an alternative treatment for cervical intraepithelial neoplasia

The technique of large loop excision of the transformation zone (LLETZ) as an alternative to destructive/ablative method of treatment of cervical intraepithelial neoplasia (CIN) such as cryotherapy, laser vaporization and cone biopsy of uterine cerix is assessed. Forty-five patients underwent this procedure for either diagnostic or therapeutic reasons. It was well-tolerated, and minor bleeding occurred in 4.4 per cent of patients. The quality of the histological specimen was excellent in all cases, only two showing evidence of charring artefacts. In 11 patients (24.4 per cent ), a more serious lesion was detected than that found at punch biopsy of the cervix. This method offers a cheaper and more effective alternative to laser vaporization and combines the benefits of the gold standard cone biopsy of the cervix with that of local ablative techniques.

Large loop excision of the transformation zone (LLETZ) an alternative treatment for cervical intraepithelial neoplasia

The technique of large loop excision of the transformation zone (LLETZ) as an alternative to destructive/ablative method of treatment of cervical intraepithelial neoplasia (CIN) such as cryotherapy, laser vaporization and cone biopsy of uterine cerix is assessed. Forty-five patients underwent this procedure for either diagnostic or therapeutic reasons. It was well-tolerated, and minor bleeding occurred in 4.4 per cent of patients. The quality of the histological specimen was excellent in all cases, only two showing evidence of charring artefacts. In 11 patients (24.4 per cent), a more serious lesion was detected than that found at punch biopsy of the cervix. This method offers a cheaper and more effective alternative to laser vaporization and combines the benefits of the gold standard cone biopsy of the cervix with that of local ablative techniques. (AU)

In vitro Fertilization: the Jamacian experience

In June 2000, twenty-eight infertile couples were treated by vitro fertilization and embryo transfer at our initial assisted reproduction programme carried out in conjunction with Midland Fertility Services, Aldridge, Birmingham, England. A pre-requisite for treatment was that on day 3 of the menstrual cycle the levels of follicle stimulating hormone (FSH) and oestradiol (E2) should be <10iu/l and <100pg/ml respectively in the female partner. The ages of the women ranged from 26 to 42 years with a mean age of 35.5 years. Down regulation was carried out by using buserelin acetate 0.5 ug subcutaneously from day 21 of the cycle for 21 days. This process was completed when the ovaries and pituitary gland were quiescent and the endometrial thickness <4 mm in diameter. On completion of down regulation the gonadotrophin hormone, pergonal (dosage of 150-450 units) was used for ovarian hyperstimulation. A total of 294 oocytes (mean of 10.5, range 2-45) were retrieved of which 138 were fertilized (mean of 4.9, range of 0-28). Twenty-four patients each received a mean of two embryos. Five patients (20.8 percent) had positive pregnancy tests. Three patients (0.1 percent) developed ovarian hyperstimulation syndrome (OHSS), one had the severe, and two, the mild form of the syndrome. All three cases were treated successfully. The success at the initial IFV controlled ovarian hyperstimulation augers well for the future of infertile couples seeking treatment at the Fertility Management Unit, The University of the West Indies, Jamaica (AU)