Letrozole+ GnRH antagonist stimulation protocol in poor ovarian responders undergoing intracytoplasmic sperm injection cycles: an RCT

Background: Gonadotropin-releasing hormone [GnRH] antagonist protocol has been proposed as a potentially proper option for the patients with limited ovarian reserve. Nevertheless, there is no significant difference in terms of clinical pregnancy between the GnRH antagonist and agonist cycles. The use of aromatase inhibitors such as letrozole was suggested by some studies

Objective: The object of this study was to evaluate the efficacy of letrozole cotreatment with GnRH-antagonist protocol in ovarian stimulation of poor responder patients undergoing intracytoplasmic sperm injection

Materials and Methods: A double-blinded randomized control trial was conducted on 70 infertile women with poor ovarian response based on Bologna criteria in two groups: letrozole+GnRH-antagonist [LA] group and placebo+GnRH-antagonist [PA] group [n=35/each]. The LA group involved at letrozole 2.5 mg daily over 5 days and recombinant human follicle stimulating hormone 225 IU/daily. The PA group received placebo over 5 days and recombinant human follicle stimulating hormone at the same starting day and dose, similar to LA group. GnRH-antagonist was introduced once one or more follicle reached >/= 14 mm. The main outcome measures were the number of oocytes retrieved, fertilization rate, implantation rate, cycle cancellation rate, and clinical pregnancy rate

Results: There were no significant differences in demographic characteristics between groups. There were no significant differences between groups regarding the number of oocytes retrieved [p=0.81], number of embryos transferred [p=0.82], fertilization rate [p=0.225], implantation rate [p=0.72], total cycle cancelation rate [p=0.08], and clinical pregnancy rate [p=0.12]

Conclusion: The use of letrozole in GnRH-antagonist cycles does not improve clinical outcomes in poor responder patients undergoing intracytoplasmic sperm injection

role of autoimmunity in premature ovarian failure

Premature ovarian failure [POF] is a heterogeneous syndrome with several causative factors. Autoimmune mechanisms are involved in pathogenesis of 4-30% of POF cases. The present review focuses on the role of autoimmunity in the pathophysiology of POF. The evidences for an autoimmune etiology are: demonstration of ovarian autoantibodies, the presence of lymphocytic oophoritis, and association with other autoimmune disorders. Several ovarian antigenic targets have been identified in POF patients. The oocyte seems to be the most often targeted cell. Lymphocytic oophoritis is widely present in POF associated adrenal insufficiency. Addisons disease is one of the most common autoimmune disorders associated with POF. Early detection of this potentially life threatening disease was recommended in several studies. The gold standard for detecting autoimmune POF is ovarian biopsy. This procedure is not recommended due to unknown clinical value, expense, and risks. Several immunoassays have been proposed as substitute diagnostic tools. Nevertheless, there is no clinically proven sensitive and specific serum test to confirm the diagnosis of autoimmune POF or to anticipate the patient's chance of developing POF or associated diseases. Some authors suggested the possible effects of immuno-modulating therapy on the resumption of ovarian function and fertility in a selected group of autoimmune POF patients. However, in most instances, this treatment fails to reverse the course of the disease. Numerous studies illustrated that standard treatment outcome for infertility is less effective in the presence of ovarian autoimmunity. The antibody-induced damage could be a pathogenic factor. Nevertheless, the precise cause remains obscure

Simultaneous serous cyst adenoma and ovarian pregnancy in an infertile woman

Ovarian pregnancy is a rare form of extra uterine pregnancy. Serous cyst adenoma is a benign variant of epithelial cell tumors of ovary. The coexistence of a cyst adenoma with an ovarian pregnancy in the same ovary is extremely rare. Some studies suggested that infertility or ovulation-inducing drugs can be involved in increased risk of ovarian tumors and ovarian pregnancies. A 28-year-old infertile woman presented with a ruptured ovarian pregnancy following ovulation induction with metformin. She had a concurrent benign serous cyst adenoma in the same ovary. Resection of both ovarian pregnancy and tumoral mass were performed. The ovary was preserved. Removal of gestational tissue and preservation of the involved ovary are the best options for management of ovarian pregnancy in young patient. Although there is an association between infertility/ovulation inducting medications and ovarian gestation, their connections with serous cyst adenoma are undetermined

Pathogenesis and causes of premature ovarian failure: an update

Premature ovarian failure [POF] affects 1% of young women. This condition has significant psychological sequelae and major health implications. POF seriously interferes with fertility and family planning. Diverse etiologies are associated with POF. Literature review related to the causes and pathogenesis of POF, cited between the year 1900 and May 2010.POF may be either spontaneous or induced. The known causes include:-Genetic disorders, which could involve the X chromosome or autosomes. However, the growing body of literature demonstrates a list of newly discovered mutations that may be responsible for causing POF. Most of these mutations are extremely rare, and most cases of POF are still considered to be idiopathic. -Autoimmune causes; there is some evidence of an association of POF with lymphocytic oophoritis and other autoimmune disorders. Antiovarian antibodies are reported in POF, but their specificity and pathogenic role are obscure. -Iatrogenic causes; chemotherapy, radiotherapy and pelvic surgery can lead to POF. -Infectious Causes; some viral and microbial infections can be followed by POF. -Environmental toxins, such as cigarette smoking are reported as risk factors of spontaneous POF. -Idiopathic; in most cases, no identifiable etiology can be recognized after complete evaluation

Controlled ovarian hyperstimulation and intrauterine insemination cycles in patients with unilateral tubal blockage diagnosed by hysterosalpingography

Controlled ovarian hyperstimulation and intrauterine insemination [IUI] cycle is an ideal protocol for some subfertile patients. So, we decided to try this therapeutic protocol for the patients with unilateral tubal blockage diagnosed by hysterosalpingography [HSG]. To evaluate the effect of unilateral tubal blockage diagnosed by HSG on cumulative pregnancy rate [CPR] of the stimulated IUI cycles. A cross-sectional analysis was performed between October 2006 and October 2009 in an academic reproductive endocrinology and infertility center. Two groups of patients undergoing stimulated IUI cycles were compared. Sixtyfour infertile couples with unilateral tubal blockage diagnosed by HSG as the sole cause of infertility in the group [I], and two hundred couples with unexplained infertility in the group [II]. The patients underwent 3 consecutive ovarian hyperstimulation [Clomiphen citrate and human menopausal gonadotropin] and IUI cycles. The main outcome measurements were the CPRs per patients for 3 consecutive stimulated IUI cycles. Cycle characteristics were found to be homogenous between the both groups. CPRs were similar in group I [26.6%] and group II [28%] [p=0.87; OR=1.075; 95% CI: 0.57 -2.28]. Unilateral tubal blockage [diagnosed on HSG] has no effect on success rate of stimulated IUI cycles, so COH and IUI could be recommended as the initial therapeutic protocol in these patients

case report of spontaneous pregnancy during hormonal replacement therapy for premature ovarian failure

Premature ovarian failure [POF] is a common condition; its incidence is estimated to be as great as 1 in 100 by the age of 40 years. Physiologic replacement of ovarian steroid hormones seems rational until the age of normal menopause. Temporary return of ovarian function and pregnancy may occur rarely in women with POF. We report a case of POF who conceived during hormone replacement therapy. A 30 years-old woman with confirmed POF after pelvic surgery and sever emotional stress conceived spontaneously. Return of ovarian function and achievement of pregnancy is possible in women with POF