Secondary infertility due to intrauterine fetal bone retention: A case report and review of the literature.

BACKGROUND: Intrauterine retention of fetal bone fragments is a rare condition that could happen after abortion (especially illegal abortion). It can cause secondary infertility as bone fragments can work as an intrauterine contraceptive device. CASE: A 25-year-old Iranian woman was referred to Shariati Hospital due to infertility. During infertility work up to normal semen analysis, adequate ovarian reserve with regular ovulatory cycles was documented. An ultrasound scan revealed focal echogenic shadowing lesions inside the uterine cavity. Hysteroscopy was conducted and many intrauterine bone fragments were revealed. Six months after hysteroscopic removal of fetal bones, the patient became pregnant and delivered a healthy and term baby. CONCLUSION: Intrauterine fetal bone retention is a scarce event that happens after pregnancy termination due to the incomplete evacuation of fetal tissues. It can cause dysfunctional uterine bleeding, menorrhagia, dysmenorrhea, pelvic pain, abnormal vaginal discharge, and secondary infertility. The detection of the problem and the removal of the remained bones by hysteroscopy have made possible to treat the patient safely and restore normal uterine function and female fertility.

Pre-curettage cerclage in a viable triplet cervical pregnancy: A case report and review of literature.

BACKGROUND: Cervical ectopic pregnancy (CEP) is a rare and dangerous form of ectopic pregnancy in which the blastocyst is installed within the endo-cervical canal. CEP diagnosis requires special awareness to evaluate patient precisely. Individualizing controversial medical and surgical management strategies is of importance in medical practice. CASE: A 35-year-old nulliparous woman on her 9th week of pregnancy was referred to our hospital with vaginal bleeding preliminary misdiagnosed as aborting intrauterine pregnancy. Transvaginal ultrasound revealed an empty uterus and a viable triplet pregnancy just below the level of internal os. Cervical curettage after cerclage suture placement procedure removed conception tissues completely. Consequently, in the next few hours vaginal bleeding decreased to minimal amount and vital signs remained within normal limits and there was no hematocrit change. On follow-up day 32, serum B-HCG became negative. CONCLUSION: CEP diagnosis requires special attention and awareness to evaluate patient precisely along with skillful assessment of possible risk factors. Lifesaving treatment beside fertility preservation was successful with pre-curettage cerclage.

Therapeutic and Analgesic Efficacy of Laser in Conjunction With Pharmaceutical Therapy for Trigeminal Neuralgia.

Introduction: Trigeminal neuralgia (TN) is the most common neuralgia in the head and neck region and a common cause of orofacial pain. It is routinely treated with carbamazepine. Laser, acupuncture and radiofrequency are among other treatment modalities for this condition. This study sought to assess the efficacy of laser therapy in conjunction with carbamazepine for treatment of TN. Methods: A total of 30 patients who met the inclusion criteria were divided into 2 groups of cases and controls (n=15) by double blind randomized controlled clinical trial. All patients received 100 mg carbamazepine at baseline and another 100 mg after 2 days for pain control. In the case group, low level laser therapy (LLLT) was also performed in addition to pharmaceutical therapy. Sham laser was used in the control group instead of LLLT. Treatment was continued for 9 sessions (3 days a week). The intensity of pain was measured and compared in the 2 groups using visual analog scale (VAS) in 3 period. The qualitative variables among the groups were compared using the repeated measures analysis of variance (ANOVA). Results: The severity of pain was lower at the end of treatment in the case compared to the control group so this difference was statistically significant (P=0.003). The severity of pain decreased in both groups over time. Significant difference was noted in this regard between the 2 groups either (P=0.003). At the end of treatment pain intensity dropped in the intervention group from 6/8 to 1/2 and control group from 6/6 to 2/7. Conclusion: Laser therapy did add to the value of pharmaceutical therapy for treatment of TN. Both groups experienced significant improvement over time. So it is better to used laser complementary therapy to reduce side effects and the medicine dosage.

In vitro fertilization outcome in frozen versus fresh embryo transfer in women with elevated progesterone level on the day of HCG injection: An RCT.

BACKGROUND: The effect of elevated progesterone level on human chorionic gonadotropin (HCG) day in in vitro fertilization cycles is controversial. Some suppose that rise in progesterone level seems to have a negative impact on implantation and pregnancy by desynchronizing the endometrium, while others disagree. OBJECTIVE: To evaluate the superiority of the frozen cycle over fresh cycle on live birth in patients with elevated progesterone level on HCG day. MATERIALS AND METHODS: In this double-blind, randomized clinical trial, 72 women undergoing assisted reproductive technology with elevated progesterone level (≥1.8 ng/dl) on HCG day were included. The participants were grouped by fresh versus frozen embryo transfer, randomly. Finally, the clinical pregnancy and live birth rate were compared. RESULTS: The implantation rate was 21.51%. The clinical pregnancy rate was 47.22% in fresh embryo transfer group (17/36) and 41.66% in frozen group (15/36) (p=0. 40). The live birth rate was not significantly difference between two groups (p=0.56). CONCLUSION: None of the fresh and frozen cycles are superior to the other and we recommend individualizing the decision for each patient. The frozen cycle may impose more emotional stress on patients.

Comparison of Morphine Suppository and Diclofenac Suppository for Pain Management After Elective Caesarean Section.

This study investigated efficacy and side effects of Morphine suppository for pain management after the first elective caesarean delivery in comparison to Diclofenac suppository. One hundred women aged 18-40 with term pregnancies undergoing elective caesarean section for the first time participated in this prospective project. Exclusion criteria included drug sensitivity, fetal malformations or defects, and complications during the cesarean operation. After same spinal anesthesia and same surgical techniques and in the recovery room patients consecutively received 100 mg diclofenac suppository or 10 mg morphine suppository. The pain severity was rated by "Numerical Rating Scale." There was not the difference between two groups in terms of basal information. Pain score was significantly different between two groups in the first 12 hours (5.66 ±1.36 in morphine group and 3.63±0.96 in diclofenac group) but not in the second 12 hour period. Considering pain scores every two hours in first 12 hours and every 4 hours in second 12 hours, morphine group had higher scores in comparison to diclofenac group. Also, the morphine group required pethidine injection sooner than the other group. The time giving first pethidine injection was 3.28±2.16 hours after operation in morphine group and 5.24±4.07 hours after operation (P<0.05). This study demonstrated that diclofenac suppository in comparison to morphine suppository decreased subjective pain scores in the first twenty-four hours after elective caesarean section which reached statistical significance in the first twelve hours. Although in diclofenac group, pethidine injection was prescribed significantly later.

Comparison of Efficacy of Granisetron and Promethazine in Control of Hyperemesis Gravidarum.

PURPOSE: Hyperemesis gravidarum is the third leading cause of hospitalization during pregnancy. 5-HT3-receptor antagonists are the most effective against chemotherapy-induced nausea and vomiting and radiation. This randomized study aimed to compare and evaluate the efficacies of granisetron and promethazine for controlling nausea and vomiting of pregnancy. METHODS: The included patients were administered (oral and intravenous) granisetron and promethazine randomly. The patients were evaluated for nausea and vomiting by a senior gynecology resident blinded to designated drugs. RESULTS: This study revealed that granisetron significantly decreased nausea and vomiting in pregnant women (p < 0.05). Greater patient satisfaction and lesser adverse drug reactions in women receiving granisetron observed in this study suggest that it can be introduced as a more effective and safer drug in comparison with promethazine. CONCLUSIONS: Considering the prevalence of nausea and vomiting of pregnancy and hyperemesis gravidarum, we can state that it is a health-related problem with economic, social and psychological dimensions. All efforts especially simple outpatient strategies to reduce its severity will help the pregnant woman continue her pregnancy with more satisfaction.

Embryo transfer in days 2 to 4 following intracytoplasmic sperm injection: a prospective cohort study.

BACKGROUND: Improvement of assisted reproductive technique (ART) results in higher pregnancy rates from positive Beta HCG to take home baby statistics. Despite developments in culture media allowing blastocyst stage transfer, some centers apply second, third and sometimes fourth day post injection for embryo transfer. This study aimed to compare their reproductive outcomes. METHODS: This prospective cohort study conducted on 218 infertile couples with at least 4 oocytes retrieved and 2 good quality embryos. They were divided consecutively into 2nd (ET2) or 3rd (ET3) day embryo transfer. Some patients experienced 4rd (ET4) day embryo transfer due to weekend reasons, so we included them in our comparison as well. There were 98, 97 and 23 patients in the aforementioned groups, respectively. Reproductive and pregnancy outcomes were evaluated by Chi square and t-test with the significance level set at α=0.05. RESULTS: Totally, 73 patients (33%) had positive beta HCG and 39.7 percent of them (n=29) experienced pregnancy loss. Positive Beta HCG was detected in 31(31.6%) of ET2 patients, 38 (39.2%) of ET3 patients and 4 (17.4%) of ET4 group. Abortion or pregnancy loss was reported in 9 (29%) of ET2 patients, 18 (47.4%) of ET3 patients and 2 (50%) of ET4 group. CONCLUSION: Our study demonstrated that there may be a higher pregnancy as well as higher abortion in day 3 embryo transfer.

Hysteroscopy in patients with repeated implantation failure improves the outcome of assisted reproductive technology in fresh and frozen cycles.

AIM: Repeated implantation failure (RIF) is still a problem for many patients and their physicians. Some interventions have been practiced to overcome the problem; one is uterine cavity assessment before assisted reproductive technology (ART) cycles. This study aimed to evaluate the effect of hysteroscopy in women experiencing recurrent implantation failure with apparently normal uterine cavity before assisted reproductive techniques. MATERIAL AND METHODS: This was a cohort study with historical controls conducted in a university hospital. A total of 353 women with RIF undergoing ART with normal hysterosalpingography and transvaginal ultrasound were evaluated. The intervention group underwent hysteroscopy with a rigid, 30°, 4-mm hysteroscope in the menstrual cycle just before ART; in the control group hysteroscopy was not performed. Basal characteristics, stimulation parameters and pregnancy rates were compared between the two groups. RESULTS: Chemical pregnancy occurred in 58.5% of women in the hysteroscopy group versus 34.1% of control women (odds ratio [OR]: 2.7; 95% confidence interval [CI]: 1.7-4.2; P < 0.001). Clinical pregnancy occurred in 50.7% and 30.3% of women in the hysteroscopy and control groups, respectively (OR: 2.4; 95%CI: 1.5-3.7; P < 0.001). Delivery rate was 35.5% in hysteroscopy women and 21.1% in control women (OR: 1.9; 95%CI: 1.2-3.1; P = 0.008). The results of hysteroscopy were normal in 103 women (72.5%), and they revealed inflammation in 22 (15.5%), polyp in 16 (11.3%) and Asherman syndrome in one patient (0.7%). CONCLUSIONS: Hysteroscopy in the menstrual cycle before ovarian stimulation in fresh cycles and before endometrial preparation in frozen thawed cycles in women experiencing recurrent implantation failure with apparently normal uterine cavity significantly increases the pregnancy rates in fresh and frozen cycles, respectively.

The prevalence of Chlamydia trachomatis in patients who remained symptomatic after completion of sexually transmitted infection treatment.

BACKGROUND: Sexually transmitted infections (STIs) are among the most common causes of illness in the world and have far-reaching health, economic and social consequences for many countries. Failure to diagnose and treat STIs at an early stage may result in serious complications and sequels. OBJECTIVE: This study aimed to determine the prevalence of Chlamydia trachomatis infection in patients who remain symptomatic after completion of their first episode of treatment for STI. MATERIALS AND METHODS: We conducted a cross-sectional study on 49 patients suffering from symptoms or signs of sexually transmitted infections despite their first complete anti STI treatment. Conducting physical exam and smear preparation from vaginal discharge, diagnosis was confirmed by Polymerase chain reaction (PCR) method on every patient's first-voided urine sample. RESULTS: Among the etiologic factors investigated in this study, Chlamydia was reported in 17 patients. Trichomoniasis, Candidiasis, Gonorrhea and nonspecific germs were next organisms with 11, 9, 6 and 6 patients, respectively. Sixteen specimens were PCR positive (32.65%), while 33 patients had negative PCR results (67.34%) for Chlamydia trachomatis. CONCLUSION: Gonorrheal infection was the most prevalent infection in patients with completed treatment (6/10), which must be remembered in patients follow ups, because this prevalence warrants empirical therapy for Gonorrheain similar clinical conditions. Chlamydia trachomatis was the responsible organism in approximately a quarter of patients (17/75) who despite their full compliance on anti-Chlamydial treatment still suffered from signs and symptoms of STI. This rate also recommends empirical therapy for Chlamydia trachomatis in the similar clinical signs and symptoms.

Treatment of ovarian hyperstimulation syndrome using gonadotropin releasing hormone antagonist: a pilot study.

OBJECTIVE: This novel study describes an effective outpatient treatment for ovarian hyperstimulation syndrome (OHSS) that results in rapid normalization of symptoms. STUDY DESIGN: A total of twenty-seven infertile women undergoing assisted reproductive technique with early-onset OHSS were enrolled in this non-randomized clinical trial in an academic infertility center. In all patients, after complete desensitization with long-term protocol ovarian stimulation with gonadotropins was commenced. Final oocyte maturation was triggered with human chorionic gonadotrophin. Oocytes were collected 36-38 h later using transvaginal-guided follicle aspiration under general anaesthesia. All embryos were frozen and study group patients received two consecutive doses of GnRH antagonist (Cetrotide) and the control group received daily dose of cabergoline for a week. RESULTS: The research revealed that moderate and severe OHSS, hospitalization or acute care for OHSS and ascites tap were significantly lower in the antagonist (Cetrotide) group. The Patients' satisfaction with Cetrotide was noticeable. No side effect was reported in either group. CONCLUSION: GnRH antagonists seem to be an effective outpatient treatment with rapid onset activity and minimal side effects for the management of early OHSS.

Prediction of assisted reproductive technique outcome in elevated early follicular phase follicle stimulating hormone with Mullerian inhibiting substance level.

BACKGROUND: Detection of best predictor of ovarian reserve in patients with temporarily or consistently elevated early follicular phase serum levels of FSH is one of the most important goals in assisted reproductive technique (ART). OBJECTIVE: To evaluate whether high level of anti-mullerian hormone level is related to success of ART in patients with temporarily or consistently elevated early follicular phase serum levels of FSH. MATERIALS AND METHODS: Sixty three women underwent intracytoplasmic sperm injection (ICSI) with GnRH-agonist long protocol or intrauterine insemination (IUI) in a prospective cohort study. FSH, inhibin B and anti-Mullerian hormone (AMH) levels were measured in these women whom were divided to three groups (persistently elevated FSH, variably elevated FSH and, normal FSH level). Basal characteristics, stimulation parameters, and pregnancy occurrence were evaluated. RESULTS: AMH was significantly higher in women with persistently elevated early follicular phase FSH achieving pregnancy. Women with normal FSH did not have significant difference in AMH level between conceived and non conceived cycles. Women with only one elevated early follicular phase FSH achieving pregnancy did not have significant difference in AMH level with non pregnant women. Response to gonadotropin stimulation, recommendation to oocyte donation significantly differed between the groups. CONCLUSION: This study has demonstrated that relatively young women with persistently or intermittently elevated day 3 FSH levels have diminished ovarian reserve and lower ART success. However, in women whose FSH levels were constantly elevated, AMH (not inhibin B) concentrations were significantly higher in ART cycles resulting in pregnancy. Therefore, AMH level is a good predictor of ART outcome in patients with elevated early follicular phase serum levels of FSH.

Predictive value of the level of vitamin D in follicular fluid on the outcome of assisted reproductive technology.

OBJECTIVE: To assess the correlation between the levels of vitamin D in follicular fluid and serum, and to determine whether the level of 25-hydroxyvitamin D (25OH-D) in follicular fluid of infertile women undergoing assisted reproductive technology (ART) is associated with the outcome. STUDY DESIGN: Eighty-two infertile women undergoing ART at an academic tertiary care centre were recruited for a prospective cohort study. Levels of 25OH-D in follicular fluid and serum were measured. Standardized regimens for pituitary downregulation and controlled ovarian hyperstimulation were employed. Patient and cycle parameters, and clinical pregnancy (defined as evidence of intra-uterine gestation sac plus heart rate on ultrasound) were determined. RESULTS: A significant correlation was found between the levels of vitamin D in follicular fluid and serum (r=0.767, p=0.001). The overall rates of chemical, clinical and ongoing pregnancy were 35.5% (n=29), 29.3% (n=24) and 23.2% (n=19), respectively. No significant difference was found in these pregnancy rates between the tertiles of 25OH-D level in follicular fluid (p=0.959, 0.995 and 0.604, respectively). The median serum level of vitamin D was 8.13 (range 5.37-13.62)ng/ml in the clinically pregnant group and 8.29 (range 5.93-21.23)ng/ml in the non-pregnant group (p=0.235). Interestingly, the median level of vitamin D in follicular fluid was 9.19 (range 5.25-19.51)ng/ml in the clinically pregnant group and 10.34 (range 5.89-29.69)ng/ml in the non-pregnant group (p=0.433). The fertilization rate decreased significantly and the implantation rate increased (not significantly) with increasing tertiles of 25OH-D level in follicular fluid. CONCLUSIONS: The level of 25OH-D in follicular fluid is reflective of body stores of vitamin D. Most subjects in this study were deficient in vitamin D, but this study found that vitamin D deficiency does not play a pivotal role in the outcome of ART.

Estradiol supplementation during the luteal phase in poor responder patients undergoing in vitro fertilization: a randomized clinical trial.

PURPOSE: This study was designed to evaluate the effects of adding Estradiol (E2) supplementation to progesterone (P) on improvement of pregnancy outcomes in poor responder patients who underwent in vitro fertilization (IVF). METHODS: In a prospective randomized clinical trial, 118 poor responder patients, older than 38 years without contraindications of estradiol consumption from Infertility clinic of a university hospital were randomly divided (by computerized software) into two groups. Control group (59 patients) received only P and intervention group (59 patients) received P and E2 (4 mg/d). Supplementation was done with 4 mg E2 in the luteal phase. Fertilization rate, implantation rate, biochemical and clinical pregnancy rates, abortion rate, ongoing pregnancy, multiple pregnancy and ectopic pregnancy rates were documented for those who completed the study protocol in each group (per protocol analysis) and compared between groups. RESULT: Fifty five patients in control group and 53 patients in intervention group successfully completed the study protocol. Treatment outcomes were not significantly different between two groups. CONCLUSION: For poor responder women who underwent IVF, addition of E2 to P supplementation could not significantly improve pregnancy outcomes.

The effectiveness of cabergoline for the prevention of ovarian hyperstimulation syndrome.

Type 2 receptors for vascular endothelial growth factor are believed to be involved in the pathophysiology of ovarian hyperstimulation syndrome (OHSS). The objective of this study was to examine the preventive effects of cabergoline on OHSS and its complications. The study is a non randomized clinical trial conducted in 2006-2008 on 75 patients, which were at risk of OHSS and underwent assisted reproductive techniques. The diagnosis and severity of OHSS were determined using standard criteria. The study included an intervention and a control group. The intervention group comprised of 50 women at risk of OHSS, who were treated with cabergoline (1 mg every other day for 8 days) commencing from the day of ovum pick up. The control group comprised of 25 historical cases, which were similar to the case group. The latter group did not receive cabergoline, and their OHSS, if occurred, were managed conservatively after hospital admission. The rates of OHSS, baseline characteristics, ovarian stimulation parameters, and pregnancy occurrence were compared. There was no significant difference between baseline characteristics or ovarian stimulation parameters form the two groups. The incidence of OHSS in the cabergoline-treated group, was significantly (P=0.01) lower than that in the control group (12% vs 36%). Embryo freezing was significantly (P=0.001) lower in the control group, but cycle cancellation was significantly (0.03) lower in the cabergoline group. The findings of the study indicate that cabergoline reduces the incidence of OHSS, and is not associated with adverse effects on pregnancy.

Comparison of gonadotropin-releasing hormone agonists and antagonists in assisted reproduction cycles of polycystic ovarian syndrome patients.

AIM: Gonadotropin-releasing hormone (GnRH) antagonists have reduced the incidence of severe ovarian hyper stimulation syndrome (OHSS) and rate of hospitalization due to severe OHSS, especially in polycystic ovarian syndrome (PCOS) patients. The present study aimed to compare the outcomes of patients with PCOS undergoing controlled ovarian hyperstimulation (COH) with GnRH agonist versus GnRH antagonist protocols for assisted reproduction cycles. METHODS: The present clinical trial compared GnRH antagonist (cetrorelix) and GnRH agonist (buserelin) protocols during COH of 112 infertile PCOS patients entering assisted reproduction cycles. The primary outcome measure was pregnancy occurrence. Basal characteristics of the participants, stimulation cycle responses, pregnancy outcomes, incidence of OHSS and types of OHSS were considered in both groups. RESULTS: Regarding chemical and clinical pregnancy rates, the number of retrieved oocytes was significantly higher and OHSS was significantly lower in the antagonist group. Follicle stimulating hormone (FSH), luteinizing hormone (LH) levels, number of follicles, number of follicles >18 mm, relative frequency of mature oocytes, number and days of gonadotropin injections, day of human chorionic gonadotropin (HCG) administration, estradiol level and abortion were similar between the two groups. CONCLUSION: GnRH antagonists are more effective, safe and a well tolerated alternative to agonists for assisted reproduction cycles in PCOS patients. GnRH antagonists are associated with a reduction in the incidence of OHSS in these patients.

Menstrual cycle length in relation to antimüllerian hormone and follicle-stimulating hormone.

OBJECTIVE: To find a relationship between serum antimüllerian hormone (AMH) and follicle-stimulating hormone (FSH) levels in women with regular menstruation. STUDY DESIGN: A cross-sectional study was conducted on 71 women with male factor infertility. Serum level of AMH and FSH and mean menstrual cycle length (MCL) were measured. The study aimed to find the correlation between serum AMH and FSH levels in normal menstrual cycles. RESULTS: Our study included 71 women. Of them, 53 had an MCL of 25-35 days (group A) and 18 women had an MCL > 35 days (group B). The mean AMH in group A and group B differed significantly (4.11 +/- 3.4 ng/L, 7.42 +/- 4.34 ng/L, respectively; p < 0.008). In group A, reverse correlation between FSH and AMH was found (r = -0.32, p < 0.03). CONCLUSION: AMH level had significant difference with FSH in patients of group A who had FSH > or = 12 IU/L or FSH < 12 IU/L (1.02 +/- 0.7, 4.8 +/- 3.5 ng/L, respectively; p < 0.02). Serum AMH level with threshold of 2.2 ng/L had sensitivity of 75% and specificity of 82% in predicting FSH > or = 12 IU/L on the third day of menstrual cycle.

Testosterone and dehydroepiandrosterone sulphate levels and IVF/ICSI results.

OBJECTIVE: To determine the effect of serum androgens [testosterone and dehydroepiandrosterone sulphate (DHEAS)] on in vitro fertilization/intracytoplasmic sperm injection (IVF/ICSI) outcomes. STUDY DESIGN: This observational (cross sectional) study was conducted on 53 consecutive infertile women undergoing IVF cycles in an academic infertility clinic between September 2006 and August 2007. Basal testosterone and DHEAS were measured and on third day of IVF cycle and on 14th day of embryo transfer these values were re-checked. Serum beta-hCG analysis was done 12 days after embryo transfer and ultrasound scan was scheduled 2 weeks later. RESULTS: Testosterone level was significantly elevated in pregnant women on 14th day of embryo transfer (p < 0.001). Testosterone and DHEAS concentrations on third day of IVF cycle and DHEAS concentration 2 weeks after embryo transfer had not significant correlation with IVF success, but mean androgens concentrations were higher in pregnant group. CONCLUSION: Serum testosterone concentration on 14th day of embryo transfer can predict successful IVF cycles, so with regulating androgen levels, improved pregnancy rates can be expected.