[Diagnostic hysteroscopy before the first in vitro fertilization. For whom?]

For some teams, hysteroscopy, should be performed before each IVF attempt to maximize the chances of implantation because of the high cost, the investment in time and the psychological impact of each IVF cycle, but answer to the question of the systematic practice of hysteroscopy prior to IVF is far from settled. Assess the benefits of conducting a routine hysteroscopy before the first IVF / ICSI and to identify subgroups in whom this examination provides a real benefit. This is a comparative retrospective study about 334 patients, included in an IVF program with micro-injection, in the center of ART of Aziza Othmana hospital of Tunis, for a period of one year. The results of ICSI in patients with a first attempt at IVF / ICSI were compared according to the realization [HSC +] or not [HSC-] of a diagnostic hysteroscopy prior to the first IVF attempt. The implantation rate in our series was 21.62%. We got a pregnancy in 128 cases, that is a pregnancy rate per transfer of 38.32%. The rate of live births was 29.34%, including 94.89% deliveries to terms with living fetus. We found no significant difference between groups "HSC +" and "HSC -" in terms of pregnancy rates of biological or clinical pregnancy rate or in terms of live births. But, in patients aged 40 and over, we found improved results of IVF in a meaningful way in the group "+ HSC". Our study finds no benefit in terms of outcomes of IVF/ ICSI to the completion of hysteroscopy in a systematic way, despite a high incidence of abnormalities detected by intra-cavity examination. The benefit of routine hysteroscopy is significant only in women 40 and older

[Cost of medical treatment with methotrexate for ectopic pregnancy. Comparative study medical versus conservative laparoscopy. Experience of Aziza Othmana's hospital]

The ectopic pregnancy can be treated surgically [conservative or radical] or medically. Currently, the choice between medical and surgical treatment is a critical issue. One of the parameters of this choice is the total cost of management. To compare the cost of the management of ectopic pregnancy by medical treatment [methotrexate, MTX] and coeliochirurgicaux. This is a prospective, comparative, nonrandomized,unicentric study, on 39 patients who have ectopic pregnancies treated with MTX versus 16 patients treated by laparoscopic surgery with conservative treatment. This study was collected at the service of Obstetrics and Gynecology Reproductive Medicine Aziza Othmana Hospital [Tunis] for a period of two years. The average cost of hospital stay per patient was 549.38 dt for the MTX group against 268.39 dt for laparoscopic surgery group [p <0.001]. There was no statistically significant difference between the two groups. In terms of overall absenteeism, there is no statistically significant difference [16.43 vs 17.5 days]. The initial treatment with MTX costs more cost than the conservative laparoscopic treatment and this is mainly due to the long period of hospitalization

[Delivery in twin pregnancies. The experience of the obstetrics department of Aziza Othmana's hospital, about 117 cases]

The conduct and delivery of twin pregnancies are interspersed with as well as maternal fetal and neonatal complications. The obstetrician is faced with the birth of 2 children often fragile and a uterus often exposed to dynamic dystocia. To study the maternal and newborn morbidity and mortality in twins, in order to clear the optimal route of delivery in such circumstances. A retrospective study over a period of 3 years [1 January 2005 to December 31, 2007], about 117 twin pregnancies. Inclusion criteria were a term exceeding 28 weeks and fetuses alive. We analyzed maternal complications during and after delivery and neonatal complications. Maternal complications were significantly more frequent in case of caesarean section. The frequency of perinatal complications [Apgar score, respiratory distress, immediate neonatal resuscitation and neonatal intensive care unit transfer] in the first twin was not influenced by the route of delivery as opposed to the second twin which Apgar score's alters when vaginally. The newborns of low birth weight [<1,500 Kg] and those whose term was less than 32 weeks were more at risk of an Apgar score <7 [at 1 and 5 minutes], respiratory complications, need for immediate resuscitation and transfer to intensive care and that statistically significant both for the 1st and the 2nd twins. The twins pregnancies' morbidity appears to be more related to prematurity and intra uterine growth retardation] more than to the mode of delivery and hence the interest to detect and prevent its anomalies. It seems that vaginal delivery has a deleterious effect at least for the second twin but cesarean section doesn't seem to be the solution. Better learning techniques and obstetric maneuvers would reduce morbidity

[Basal fsh level is only predictive of the quantitative aspect of the ovarian response]

Determination FSH and LH at day 3 of the menstrual cycle predicts the response to stimulation. To evaluate the value of FSH and LH measurements compared with women's age in predicting qualitative and quantitative ovarian response to gonadotrophin stimulation. 305 patients underwent at least one intra cytoplasmic sperm injection [ICSI] cycle. The levels of FSH and LH at day 3 were determined in an earlier cycle. A good quantitative ovarian response was defined as [3]3 oocytes retrieved and 3 embryos obtained. A good qualitative ovarian response was defined as a percentage of mature oocytes [3] 75% and immature ones²15% of the total number of oocytes retrieved with at least one top quality embryo obtained. Receiver operating characteristic [ROC] curves were generated for FSH, LH and female age. FSH is better than female age in predicting the number of oocytes retrieved [respectively ROCAUC=0.77, p=10-3 versus ROCAUC=0.73, p=10-3] and the number of embryos obtained [ROCAUC=0.69, p=10-3 versus ROCAUC=0.66, p=10-3]. LH is non predictive. None of the three tested parameters was predictive of the fertilization and pregnancy rates. An FSH cutoff was calculated and a value of 7.8mUI/ml is associated with a sensitivity of 73% and a specificity of 70% for the prediction of ovarian response to controlled stimulation. Basal FSH level predicts good quantitative rather than qualitative response. LH is non predictive. FSH and LH do not predict pregnancy rate. Patients having high FSH levels should not be excluded from IVF/ICSI treatment

[Particularities of pregnancy and labor in 40 - year-old women about 300 cases]

Pregnancy beyond age 40 is considered as a high risk pregnancy associated with high rates of maternal and fetal complications. To analyze particularities of pregnancy and labor and to examine obstetrical and neonatal outcomes among women age 40 years and older. There was a retrospective study including two groups of 300 patients, the first including the 40-year-old and over women [case group], and the second including 20-to 39 -year-old mothers [control group]. The mean age for the case group was 41 years. Ten [10.6%] of the women in the case group were primiparous as compared with twenty-seven [27.5%] in the control one [p=0.001]. The antenatal surveillance was better in the control group. The morphologic sonography was performed in 73% of cases of 40-year-old-women versus 90% in the control group [p<0.001]. Maternal age 40 and over was associated with an increased risk for gestational diabetes [6.4% versus 1.7%, p<0.001]. The premature rupture of membranes was frequent in the case group [25.7% versus 11.7% p<0.001], and the amniotic fluid meconuim [16.3% versus 6.7%, p<0.001]. The risk for cesarean section was higher in older women [25.7% versus 14% avec p<0.001]. Neonatal outcomes [Apgar score, birth weight, perinatal mortality] were similar to those in the younger age group. The analysis of our results and the review of the literature have proven that advanced-maternal-age pregnancy is associated with increased complications. So more recommendations' are necessary to ameliorate the management of this pregnancy

[ retrospective study of 339 ICSI cycles: assessment of the two first years of activity of the assisted reproductive technology's center of Aziza Othmana's hospital]

Intracytoplasmic sperm injection [ICSI] is a micro-manipulation-assisted fertilization, whereby one spermatozoon is injected into the oocyte cytoplasm. Initially, ICSI was the treatment of choice for male factor infertility. However, because of the high fertilization and pregnancy rates achieved with this technique, the scope of the procedure has been widened to include couples with other causes of infertility. The aim of this study was to study the progression of the activity of the assisted reproductive technology's center of Aziza Othmana's Hospital and the ICSI results during the first two years. Our study included 269 infertile couples who underwent 339 ICSI cycles between 1st May 2001 and 30 April 2003. Cycles with no oocytes obtained at the follicular aspiration and women aged over 40 years were excluded from this study. The number of ICSI cycles progressed in our center: 150 ICSI cycles in the 1st year, 189 ICSI cycles in the 2nd year. The mean number of picked-up oocytes was 8,8 +/- 5,6. The fertilization rate was 62. The mean number of transferred embryos was 3,1 +/- 1,5. The pregnancy rate per transfer was 32,4%. The miscarriage rate was 28,4%. The take home baby rate was 67,9%. The number of couples undergoing ICSI cycles in our center is increasing. The fertilization rates and pregnancy rates in our center are similar to those published in the literature

[Are there any predictive factors for successful intracytoplasmic sperm injection. Statical analysis of 339 cycles]

Intracytoplasmic sperm injection [ICSI] outcome is tightly depinding of male and female factors. The assessment of several clinical and laboratory parameters may predict results of ICSI. This study aimed at investigation which parameter[s] may predict successful intracytoplamic sperm injection for infertility. We restrospectively analysed patients who had intracytoplasmic sperm injection for male or female factor infertility. The clinical and laboratory factors that influenced the fertilization, pregnancy and implantation rates were also analysed. Three hundred and thirty nine cycles in 269 couples were analysed. Women's age, etiology of infertility, duration of infertility, number of retrived oocyts, sperm parametres and number of transferred embryos were evaluated. Optimal pregnancy rates were observed in women aged 25-35 years, with gradual decline with advanced age [p=0.049]. The pregnancy/transfert rate was statistically depending of, the number of retrieved oocytes [p<0.001] and the number of transferred embryos [p<0.001]. However, transferring more than three embryos was no significatively superior to two or three. Etiology of infertility had no influence in fertilization and pregnancy, but may predict the implantation rate [p=0.042]. The duration of infertility was of no value in predicting the fertilization, implantation or pregnancy rates, and neither seems to be the sperm parameters. The only statitically significant variables of ICSI outcome were women partner's age, number of retrived oocytes and number of transferred embryos

[Intrauterine insemination with conjoint semen. How to increase the success rate?]

Intrauterine insemination is usually proposed as the first line therapy for infertility related to cervical hostility, male factor, unexplained infertility or mild endometriosis. The overall success rate of IUI is about 10-20%clinial pregnncy per cycle. The Aim of this study is to evaluate factors that increase the succes rate of IUl. We restrospectively analysed 206 cycles of JUl with partner's semen in 138 infertile couples. The clinical and laboratory factors that may influence the pregnancy rates were analysed women's age, etiology of infertility, duration of infertility, ovarian stimulation, day of hGC and sperm parametres. The per-cycle clinical pregnancy rate was of 14.56%. Optimal pregnancy rates were observed in less than 38 years old women [18.29%vs 9.52%. p<0.05]. The succes rate was statistically depending of the number of IUI cycles until three [p<0.05], the day of hGC [p<0.05] and the sperm count after conventionally prepared semen [p<0.05]. Sperm parameters was of no value in predecting the pregnancy rates, and neither seam's to be the total dose of administrated Gonadotrophin or the etiology of infertility, but it seams that, when a cervical factor or PCO were involved, the succes rate is higher. Besides, getting three or more than three follicles may increase the succes rate but expose to a warrying risk of multiple pregnancy. According to this study, the only statitically significant factors that are associated with successful IUI were, women partner's age [<38 ans], number of IUl cycles [during the first three JUl cycles], day of hGC [>J13] and sperm count after conventional semen preparation [>1.10[6]/mL]

About 102 post term pregnancy

It was a retrospective and continous prospective study about 102 post-term pregnancy recensed on a 14 monthds period. The aim of this study is to evaluate our management of post term pregnancy and the peto-maternal mobidity and mortality. Frequency of post-term pregnancy in our stydy is 5.92 percent, in rate of cession sector is not higher it is of 18.62. there is no maternal mortality. Neonatal mortality is a about 19 percent, the rate of neonatal morbidity is 2.9 percent