[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

laparoscopic vecchietti technique for vaginal agenesis

To evaluate feasibility and surgical long term, anatomic and functional results of the laparoscopic Vecchietti procedure to treat women with vaginal agenesis. We reported six cases of patients with a Mayer-Rokitansky-Kster-Hauser syndrome. The surgical procedure was the same for all patients. The results have been evaluated on the operative time, the intra and postoperative complications, the antalgic drugs consumption, the transit recovery, the hospital stay, the neovagina length, and the post operative sexual satisfaction. The mean operative time was 77.5 minutes. The mean paracetamol consumption was: 9.8 g. The mean transit recovery, and hospital stay were: 2 days, 9.8 days, respectively. No intra or postoperative complication occurred. The mean neovagina length evaluated at one year follow-up visit was 7.5 cm. Five patients have regular sexual activity. Three of them reported sexual satisfaction and showed having orgasm [clitoral: 3 cases, clitoral and vaginal: 2 cases]. The 2 remaining patients reported dyspareunia. The global satisfaction index was of 71.6%. This surgical technique appeared to be safe, effective and reproducible. It allowed to obtain a neovagina with enough length and have encouraging results on sexual functioning Laparoscopy reduces the psychological and aesthetic consequences of surgery, especially for these young patients already distressed by their malformation

[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

[ usefulness of elastase measurement in the sperm for the diagnosis of urogenital male inflammation and infection]

Genital tract inflammation is a frequent cause of infertility among men, usually clinically silent with only leukocytospermia defined as the presence of white blood cells [WBC]>1.10[6]/ml in semen. During the inflammation process, granulocytes discharge large amounts of proteases such as elastase. The elastase linked to its inhibitor in the form of a complex the elastase alpha1-protease inhibitor in semen is suggested as a potential marker of genital tract inflammation. To assess the measurement of elastase as a biomarker of genital tract inflammation by comparing this technique with the detection of leukocytospermia according to the WHO guidelines. methods: This study interested 83 infertile men attending the andrology center for semen analysis. Leukocytospermia was assessed by a peroxydase test and elastase concentration by immunoassay in the seminal plasma. An elevated elastase was found in 38% of men. A similarity was found between leukocytospermia and elastase in 79% of cases, kappa coefficient concordance with leukocytospermia is good [0.78]. The sensitivity of the elastase is 100%, the specificity= 75%. The positive predictive value is 47%, the negative predictive value is 100% with a Youden index=0.75. All patients with leukocytospermia>1.106/ml had an elastase>250ng/ml, 73% of them a concentration>1000 ng/ml. In the group of patients with no leucocytospermia, 75% had elastase<250ng/ml, 21% had concentration between 250 and 1000ng/ml and 4% [3 patients] a concentration>1000ng/ml. Seminal elastase is a more sensitive marker than leucocytospermia in the diagnosis of male urogenital inflammation and infection

[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

[Quality of life during menstruation in women with an inherited bleeding disorder: a 31 cases study]

Menstruations, by their abundance and their duration, can be a source of impaired quality of life. Women with inherited bleeding disorders appear to be, specially at risk. Assess the impact of menstrual blood loss on the quality of life for women with inherited bleeding disorders. 31 women with various inherited bleeding disorders were interviewed. They completed a quality of life questionnaire. Von Willebrand disease was the most frequent inherited bleeding disorder in our population [38.7%]. 54.8% of patients had a menstrual period more than 6 days 61.3% of them consider their menstrual flow to be normal. The general condition apart of the menstrual period was considered medium to poor in 35.5% of patients. The average score assessing the impact of menstruation on daily life was of 5.00 +/- 3.47. Only 19.35% of patients felt that dysmenorrhea significantly affect their quality of life. Impaired quality of life was seen in 64.5% of patients according to score A and in 41.9% of them according to score B. During menstruation 22.6% of the patients didn't do to work or to school because of the menstrual flow. On the other hand, 48.4% of patients were hospitalized at least once for a heavy menstrual flow. The quality of life during menstruation, in women with an inherited bleeding disorder, according to the different scores appear altered. Although because of the small size of our study population, we could not prove correlation between the importance of menstrual blood loss and the impairment of quality of life

Clinicals and biologicals aspects of ICSI cycles on polycystic ovary syndrome patients

To analyse clinical and biological pecularities of Polycystics Ovarian Syndrome[PCOS] patients enrolled on ICSI cycles and compare them to normo-ovulatory women. 100 controlled ovarian stimulation cycles for ICSI in women with PCOS and 200 cycles in normo-ovulatory women. There was no significant difference in term of cancellation rate [5,5% in PCOS group vs 5%;NS]. The mean number of follicles was higher in patients with PCOS [18,1 +/- 8,5 vs 9,4 +/- 5,5;p<0,05], Oocyte mature rate and fertilization rate were higher in PCOS group [67% vs 52%; p<0,05] [75% vs 63,7%; p<0,05] respectively. Grade 1 Embryo rate was significantly higher in PCOS group [69% vs 53%; p<0,05]. Implantation rate [16,6% vs 12,1%; NS] and clinical pregnancy rate per transfer [3 1,5% vs 22,2%; NS] did not differ statistically in the two groups. Miscarriage rate was higher in PCOS group but this did not reach the statistical significance [20% vs 7,1%; NS]. 11 cases of Ovarian hyperstimulation syndrome occurred in PCOS group versus 4 on normo-ovulatory group. Use of ICSI as fertilization technique was correlated with good biologic parameters on PCOS patients with better fertilization rate and embryo quality and similar pregnancy rate comparing to normo-ovulatory women. However, it still be great concern about high risk of miscarriages and Hyperstimulation ovarian syndrome

[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

[Increased risk of early pregnancy loss and lower live birth rate with GNRH antagonist vs long GNRH agonist protocol in PCOS women undergoing controlled ovarian hyperstimulation]

To compare standard long GnRH agonist protocol [Tripnorelin] anti GnRH antagonist regimens [Cetrorelix] in polycystic ovary syndrome [PCOS] patients undergoing controlled ovarian stimulation [COS] for ICSI cycles. Retrospective case-control study. 106 POS patients undergoing COS for ICSI with long GnRH agonist protocol [Tripnorelin] were matched with age and BMI to 106 PCOS patients undergoing COS for ICSI with GnRH antagonist [Cetrorelix] during the same period. Ovarian stimulation with recombinant follicle stimulating hormone [rFSH] was used in the two groups. Oral contraceptive pill pretreatment was used in all patients undergoing ovarian stimulation using GnRH antagonists. ICSI was performed for male infertility in all casts. The main outcome measures evaluated were: cancellation of the cycles, number of aspirated follicles, oocyte maturity, fertilization rate, Embryo quality, pregnancy and implantation rates, clinical abortion rate, multiple pregnancy rate and the live birth rate rate. Kchi2 teat and t Student test were used for differences between normo-ovulatory and PCOS patients and the limit of significantly was net at p<0.0S. There. was no significant difference in term of cancellation rant [2.8%vs 1.8%; NS], Duration of gonadotrophin stimulation [9,7 +/- 0,7 vs 11,2 +/- 1,9 days; p<0,001] and gonadotrophin consumption [2209.0 +/- S4S Vs 1411,1 +/- 217,9 1.11: p<0,001] were significantly decreased with GnRH antagonist. The mean oestradiol level on the triggering day was significantly higher in the agonist group [3347,85 +/- 99 vs 2354,45 +/- 839; p<0,001]. A fall in LH level of a 50%from sitmulation days [S8] to S1was observed in GnRH antagonist group. Risk of ovarian] hyperstimulation syndrome [OHSS] was significantly decreased with GnRH antagonist [1.8%vs 10.7%; p=0.01]. The mean number of retrival oncytes [15.9 +/- 5,9 vs 17.3 +/- 8.3; ns] and the mean number of mature oncytes [11.43 +/- 4.2 vs 11.9 +/- 6.4; ns3 were similar in the two groups. fertilization rate [73.3%va 75.8%; NS], mean number of grade I and 2 embryos [6.3 +/- 2.7 vs 6.9 +/- 3.9; NS], mean number of transferred embryos [1.9 +/- 0.7 vs 1.8 +/- 0,7; NS],implantation rate[13.3%vs 18.45%; ns] and clinical pregnancy rate per transfer [28.6%vs 31.1%;ns] did not differ statistically is she two groups. Twin and triplet pregnancies rates were also similar in the two groups [7.1%vs 9.3%; NS] and [3S%vs 3.1%; NS] respectively. Live birth rate [12,2%vs 20.7%; p<0.001] was significantly lower in GnRH antagonist group and miscarrage rate was significantly higher in this same group [42.8%vs 18.7%;p<0.001]. GnRH antagonist protocol is a short and simple protocol with a significant reduction in incidence of OHSS and amount of gonadotrophins. However. GnRH antagonist protocol provides a lower live birth rate and an increased risk of early pregnancy loss compared no the GnRH agonist long protocol. Further studies are necessary for more solid conclusions

[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]

prise en charge des thrombopenies severes au cours de la grossesse et de l'accouchement. A propos de 14 cas et une revue de la litterature

Thrombocytopenia occured in 14 of 5557 pregnant women [0,25%] in our hospital over 4-year interval. The patients with thrombocytopenia could be devided into two groups' healthy women 2 patients [14,28%] hypertensive patients and patients with immune thrombocytopenia 12 patients [85.72%]. Cesarian section rate for delivery was 35,7%. Six foetal loss were observed. Foetal morbidity is represented by prematurity and low weigh at delivery [3 cases] and in one case cerebral bleeding was observed.

Fibromes uterins: fertilite apres myomectomie. A propos de 41 cas

Fibromyomas are among the most frequent pathologies of women in their reqroductive years; that's why clinicians studied their impact on fertility especially when no other cause is found. In this retrospective study of 41 infertile patints between January 1996 and December 1999, the authors tried to define the asses of myomectomy in these cases and the relevant factors that influence the post-operative results in terms of fertility. 24 patients were operated by laparotomy, 7 by laparoscopy and 10 by hysteroscopy. Once surgery was performed, 19 women conceived [46,34%] with delays ranging between 3 and 36 months [mean delay: 15.5 months]. An age of less than 40, a sterility of less than 5 years duration and the absence of associated factors seems to enhance the chances of these patients to conceive after mytomectomy. No significant difference was noted in terms of subsequent fertility between the group of primary infertility and that of secondary sterility; neither concerning the myomas' number, size or place. Pregnancy rates after sugery were equivalent wether the myomectomy was performed by laparotomy or laparoscopy. It is, then, reasonable to propose to infertile patients with uterine myomas, a conservative surgery especially if they are young and if their sterility is unexplained for less than five years

Epilepsie et grossesse: Necessite d'une prise en charge combinee.

Pregnant women with epilepsy are at risk for a variety of complications, that require an interdisciplinary cooperation between neurologists, pediatricians and obstericians. We report a retrospective study of 50 pregnant women with epilepsy over a 5 year period. Phenobarbital is largely the most used [74%]. During pregnancy, an increase in seizure frequency was noticed in 27 cases [54%]. Baribituric were essentially maintained in 74% of cases. We have reported a relatively high intervention rate during the delivery. Forty eight babies [96%] were born at term. There were no cases of neonatal haemorrhage or perinatal death. Symptoms of drug impregnation were found in 7 cases [14%]. Four children born to epileptic mothers treated during pregnancy had congenital malformations. Pregnancy doesn't have a catastrophic effect on the course of epilepsiy apart from the risk of an increase in the frequency of the fits. This risk must be reduced thanks to an optimal use of an anti-convulsive therapy before and during pregnancy. The major risk being foetal, mainly foetal malformations and hemorrhages