Clomiphene citrate plus N-acetyl cysteine versus letrozole for induction of ovulation in infertile patients with polycystic ovarian disease: a randomized clinical trial

Background: Polycystic ovarian disease (PCOD), a common endocrine disorder with multisystem affection, is the most common cause of anovulatory infertility. Our objective is to evaluate the effect of using clomiphene citrate (CC) plus N-acetyl cysteine (NAC) versus letrozole in ovulation induction in infertile patients with PCOD.Methods: Reproductive-aged infertile women either primary or secondary diagnosed as PCOD according to Rotterdam criteria, 2003 were considered for enrollment. Eligible women for were recruited and randomized (1:1) to receive either CC 100 mg plus NAC 600 mg (CC+NAC arm) or letrozole 5 mg (NCT03241472, clinicaltrials.gov). All medications were started from day 3 of the menstrual cycle for 5 days. The primary outcome was the ovulation rate in both groups. Secondary outcomes included the mid-cyclic endometrial thickness, ovarian hyperstimulation, and clinical pregnancy and miscarriage rates.Results: One hundred ten patients were enrolled and randomized to CC+NAC arm (n=55) or letrozole (n=55). The ovulation rate in patients in letrozole arm was significantly higher than CC+NAC arm (71.8% versus 53.2%, p=0.01). Additionally, endometrial thickness was higher in letrozole arm (mean±SD: 11.46±1.61 versus 9.0±1.13, p=0.031). However, no statistical significant difference with regarding the ovarian hyperstimulation rate (1.8% versus 3.6%, p=0.157), clinical pregnancy rate [3/19 patients (27.3%) versus 19/55 (34.5%), p=0.409] and miscarriage rate [4/15 patients (26.7%) versus 19/55 (15.8%), p=0.317] in CC+NAC versus letrozole groups respectively.Conclusions: Addition of NAC to CC in ovulation induction leads to comparable pregnancy rate as letrozole. However, letrozole produces high ovulation rate and the better mid-cyclic endometrial thickness.

Evaluation of the uterine cavity by office hysteroscopy in patients with infertility and recurrent pregnancy loss: a cross sectional study

Background: The aim of the present study is to determine role of hysteroscopy in women presented with primary or secondary infertility and in women presented with recurrent pregnancy loss.Methods: This cross-sectional study was conducted at Obstetrics and Genecology Department, Women Health Hospital Assiut University, Egypt from October 2016 to February 2018. Reproductive aged women who are suspected as having intrauterine pathology, such as submucosal myoma, endometrial polyps or other endometrial pathological findings based on the transvaginal ultrasound were enrolled. All patients were scheduled for office hysteroscopy as an outpatient. An informed consent was obtained prior to participation in the study.Results: Hysteroscopy was performed in 139 infertile women and 41 cases of repeated pregnancy loss. With regard to infertile patients; 67.6% of the patients had normal findings, 10.1% of the patients had intrauterine adhesion, 8.6% of the patients had intrauterine polyp. 5.8% of the patients had septate uterus and 3.6% of the patients had depressed fundus. With regard to patients with recurrent pregnancy loss; 51.2% of the patients had normal findings, 21.9% of the patients had partial septum, 9.8% of patients had intrauterine adhesions, 7.3% of patients had intrauterine polyp and 4.9% of the patients had submucous myoma.Conclusions: It was concluded that hysteroscopy should be considered as routine investigation in evaluation of women with primary and secondary infertility.

Early Risk Assessment In Right Ventricular Infarction By TIMI Risk Score.

Background: Inferior myocardial infarction complicated by right ventricular infarction is associated with a greater risk of in-hospital mortality and cardiovascular related complications. Early risk stratification of patients with right ventricular infarction is crucial for appropriate management and reduction of adverse cardiac events. The development of TIMI risk score has provided a useful tool to quickly and easily stratify patients with right ventricular infarction. We conducted this study to evaluate the prognostic value of TIMI Risk Score analysis in patients with right ventricular infarction. Methods: This observational study was conducted in the department of Cardiology in NICVD, Dhaka, from July 2006 to June 2008. Considering inclusion and exclusion criteria, a total of 60 patients with right ventricular infarction were evaluated. All the patients were evaluated clinically and ECG was done after admission. Patients were categorized into two groups by TIMI risk scoring. Patients with low TIMI risk score(0-3) were in Group-I and patients with high TIMI risk score(4- 14) were in Group-II. Results: The study revealed no statistically significant difference among the patients of two groups (p>0.05) in relation to sex, weight, risk factors and presenting complaints. Analysis revealed statistically significant difference among the patients of two groups (p<0.05) in relation to age, duration of chest pain, clinical parameters, Killip class of heart failure and LVEF. Regarding inhospital outcome, 51.7% patients developed complications during the study period and all the complications were more in group II patients with high TIMI risk score(4-14). Death (18.3%) was the most common complication followed by cardiogenic shock (15.0%), complete heart block(6.6%),cardiac arrest(6.6%),VT(3.3%)and 2nd degree heart block(1.6%). Conclusion: This study indicates that on admission - TIMI risk score analysis can identify patients with right ventricular infarction at higher risk for in-hospital mortality and morbidity.

Pseudotumor cerebri and prolactin secreting pituitary adenoma. Association or coincidence?

The occurrence of pseudotumor cerebri [PTC] and hyperprolactinemia related to a prolactinoma are extremely rare, and the link between these pathologies has not been examined adequately in the post-MRI era. We report a patient with a small intrasellar prolactinoma who also developed PTC. Magnetic resonance venography did not show any evidence of compression of the cavernous or any other sinuses. She initially responded to treatment with acetazolamide and cabergoline. However 9 months later, her PTC symptoms recurred despite a normal serum prolactin level and a mild reduction of the pituitary tumor size on MRI. She improved after a lumboperitoneal shunt. We conclude that the findings in our patient do not support an association between PTC and hyperprolactinemia or prolactinoma. However, the case supports the need for clinicians to consider the diagnosis of PTC when patients with small pituitary lesions exhibit raised intracranial pressure features

Immunochromatographic (rK39) strip test in the diagnosis of visceral leishmaniasis in Bangladesh.

Immunochromatographic strip test (ICT strip test) for the diagnosis of visceral leishmaniasis was evaluated in this study in the context of a case-control study. A total sixty consecutive cases of kala-azar admitted in all four Medicine Units of Mymensingh Medical College Hospital during the period of May 2002 to February 2003 was included here. Parasitological confirmation was done by demonstration of leishmania donovani bodies in bone marrow or splenic aspiration in all cases. A total 120 controls was taken of which sixty were asymptomatic endemic controls with no previous history of kala-azar and sixty were admitted patients suffering from diseases other than kala-azar (malaria, tuberculosis, enteric fever and chronic liver disease). ICT strip test for kala-azar was done in all cases and controls. Only 2 of the confirmed kala-azar cases were negative and the remaining 58 cases were positive for ICT strip test which gives the sensitivity of this test 96.6%. Among the controls, 118 were negative for ICT strip test and two of the asymptomatic controls were positive for this test with no clinical evidence of kala-azar. So, the estimated specificity of ICT strip test is 98.3%. The predictive value for a negative result was 98.3% and for a positive result was 96.6%. The ICT strip test is easy, quick, requires no technical facilities with higher sensitivity and specificity entails it to be the ideal test for the diagnosis of kala-azar in field level.

Hairy cell leukaemia with advanced treatment - a case report.

A case of hairy cell leukaemia (HCL), a rare leukaemia, is reported here. The patient was presented with high grade continuous fever with left upper abdominal discomfort for 6 days. He was moderately anaemic, had no peripheral lymphadenopathy with mild hepatosplenomegaly. He was anaemic (Hb-7.8 gm/dl), total leukocyte count was 20 x 109/L. Peripheral blood film showed lymphocytosis (92%) with neutropenia (8%) and absolute neutophil count (ANC) was 1 x 109/L. On review, 88% of the peripheral cells had peripheral hairy projections resembling hairy cell (HC). Bone marrow examination was consistent with HCL (morrow hairy cell = 52%) including marker studies. Tartrate resistant acid phosphatase test (TRAP) was also positive. He had opportunistic mycobecterial infection giving a positive bronchial lavage for acid fast bacilli. After controlling the infection he was advised a single dose chemotherapy of 2-chlorodeoxyadenosine (2-CDA). After that he was in partial remission and after 25 months clinical and pathological relapses occurred and a second dose of 2-CDA was given and the patient went into complete remission.

Clinical profile of Kala-azar in adults: as seen in Mymensingh Medical College Hospital, Mymensingh, Bangladesh.

A total of eighty-one consecutive cases of Kala-azar admitted in all four medicine units of Mymensingh Medical College Hospital during the period from January 2002 to mid August 2002 were included in this study. The number of the patients clearly indicates that the burden of Kala-azar in this region is significant and expanding, which constituted 1.90% of total admission in all 4 medicine units during this period. Majority of the patients were of 20-29 years of age. Male to female ratio was 1.38:1. Maximum number of the patients were of poor socio-economic group with history of housing made up of mud and having close proximity with cattle house. Fever and splenomegaly (100%) were the predominant features. Hepatomegaly was found in 91.36% of the cases. Other clinical manifestations were weight loss (79.01%), normal or increased appetite (65.43%), generalized weakness (72.84%), pallor (69.13%), cough (25.92%), jaundice (17.28%), abdominal Pain (12.34%), hyperpigmentation (9.88%), ascites (4.94%) and bleeding manifestations (4.94%). Notable concomitant illnesses were urinary tract infection (7.40%), pulmonary tuberculosis (3.70%), malaria (1.23%), scabies (4.94%), heart failure (3.70%) and chronic liver disease (2.47%). Due to wide diversity of clinical presentations, clinical features of kala-azar should be evaluated in details which will pave the hidden cases into light.

IL-6 and IGFII in normal ovulatory; anovulatory pcos and controlled ovarian hyperstimulation cycles

Cytokine interleukin-6 [IL-6] and insulin like growth factor II [IGF-II] are polyfunctional regulatory peptides. They have a wide variety of biological activities including ovulation regulation of gonadal steroid secretion by the ovaries, corpus luteum function and embryo implantation. To investigate their role in normal ovulation, polycystic ovary syndrome [PCOS] and controlled ovarian hyperstimulation [COH] this study is conducted. Department of Obstetrics and Gynecology and Clinical Pathology, Assiut University Hospital, Assiut, Egypt. Sixty women were included in this study from 3 groups of patients; 20 women in each group. First group includes women with normal ovulatory cycle and a second group includes women with anovulatory PCOS cycle and a third group of women prepared for assisted reproduction by [ICSI]. Three blood samples from each women were obtained at day 3 of the cycle day 12 or day of ovum pick up and day 22 of the cycle. Follicular Fluid [FF]collected at the day of ovum pick up from women undergoing [ICSI]. Blood and FFsamples were assayed for IL-6 and IGF-II as well as E2, FSH, LH and P, using [ELISA] technique. The mean values of IL-6 level in the early follicular phase in normal ovulatory, PCOS and COH groups were 12.93 +/- 0.77, 101.99 +/- 32.04 and 12.86 +/- 0.88 [pg/ml], respectively. There is highly significant increase in PCOS group in comparison to normal ovulatory and COH groups. IL-6 significantly increased in patients with increased number of follicles than those of low number of follicles in COH group. The mean values of IL-6 in late follicular phase were 11.4 +/- 0.88, 99.7 +/- 4.0, 27.3 +/- 8.0 in the three groups, respectively. The level is only significanlly increased in those patients with COH than the level in early follicular phase inside each group. The mean values of IL-6 in the mid luteal phase were 176.6 +/- 29.7 and 68.7 +/- 52.3 [pg/ml] in normal ovulatory and PCOS groups. There was highly significant increase in the ovulatory than the anvulatory cycle. There was a significant increase of IL-6 in FF at the time of ovum pick up over the serum samples taken at the same time. The mean values of IGF-II level in late follicular phase were 589.97 +/- 22.58, 466.4 +/.- 41.74 and 770.7 +/- 79.38 [ng/ml] in normal ovulatory, PCOS and COH group, respectively. The increase of IGF-II in cases of COH than normal ovulatory cycle shows its significant role in steroidogenesis which is important for the elevated E2 level in this group. IL-6 may be an early predictor for the ovarian responce and the development of ovarian Hyper stimulation syndrome [OHSS] with the othor hormonal and US parameters. IL-6 may be taken in consideration as a maker for corpus luteum function in conjunction with progesterone in day 22. The elevation of IL-6 in day 3 in PCOS patients than in the normal ovulatory cycle may partially explain the increased liability to OHSS in these patients. The significant reduction in IGF-II in cases of PCOS may play a role in anovulation

Endothelial dysfunction an doxidative stress in gestational diabetes [a follow-up study]

Gestational diabetes is characterized by glucose intolerance first recognized during pregnancy. Women with gestational diabetes are more prone to develop type II diabetes later in life. The increased risk of premature endothelial dysfunction with hyperglycemia might be related in part to augmented expression of cell adhesion molecules. Diabetes is also characterized by oxidative stress which in turn determines endothelial dysfunction via nitric oxide synthase linked pathway. Aim: To evaluate the effect of gestational diabetes on the adhesive molecules and status of oxidative stress. Subjects and Five hundred and eighty seven pregnant women [24-28 weeks of gestation] with no risk factors and normal renal and liver functions were tested for serum glucose by screen test and-when necessary- glucose tolerance curve. Thirty three cases [5.6%] who have gestational diabetes constituted the patients group. Twenty healthy pregnant women with negative screen test and glucose tolerance curve were taken as a control group. Both patients and controls were investigated for serum E- selectin, VCAM-1, endothelin-1, nitric oxide, lipid peroxidation and superoxide dismutase [SOD], during gestation and after delivery. During gestation, sE-selectin was higher and sVCAM-1 was lower in diabetic cases than controls but with no significant differences, while significant elevations of lipid peroxidation [p < 0.01] and SOD [p < 0.001] in patients group compared to control group. Three months after delivery, significant elevations of sE-selectin [p < 0.001], sVCAM-1 [p < 0.001], and SOD [p < 0.001] were observed in women with gestational diabetes compared to the controls. There were significant reduction in lipid peroxidation and SOD [p < 0.001] in the patients after delivery as compared to that during pregnancy, while sE-selectin, sVCAM-1 and NO were higher after delivery than during pregnancy but the difference was statistically insignificant. The controls showed significant decrease in levels of endothelin-1, sE-selectin and sVCAM-l with longitudinal follow up. The follow up study revealed that six cases [patients group A] continued with impaired glucose toerance curve [31.6%] and thirteen cases [patients group B] returned with normal glucose curve. In group A, there were significant elevation of E-selectin [p < 0.05] and significant decrease of endothelin-l [p < 0.01] as compared to group B, while NO and SOD were reduced but the difference was statistically insignificant. Sustained elevations of sE-selectin and sVCAM-1 in cases with gestational diabetes even after delivery may reflect vascular injury or risk factor for endothelial dysfunction. Furthermore the elevations of lipid peroxidation and SOD in the patients group during pregnancy may be implicated this pathogenesis of gestational diabetes and may be considered as sensitive indicators of oxidative stress in gestational diabetes

Cesarean section in mild preeclamptic patients; spinal versus epidural anesthesia

This study was carried out in Assiut University Hospital in the Department of Obstetrics and Gynecology, in the period from January 2002 to January 2003. The study was approved by our local institutional ethics committee. All patients had been informed about the nature of the study and a written or verbal consent was obtained from each one. Forty parturients with mild pre-eclampsia [systolic blood pressure 140-160mm/Hg diastolic blood pressure 90-100mm/Hg] undergoing cesarean section, with no contraindication for regional anesthesia [sepsis,bleeding tendency, severe stenotic valvular heart disease and platelet count < 100000 mm3] were enrolled in the study. General and obstetric examination as well as obstetric ultrasonography were done for all women. Patients were allocated randomly into two groups; group 1 received spinal anesthesia, bupivacain 0.5% [[8-12 mg] [2-2.5ml]] and group II received epidural anesthesia, bupivacain 0.5% [[30 -40 mg] [6 -8ml]] and lidocaine 2% [[120-160 mg] [6- 8ml]]. Hemodynamic data [systolic, diastolic, mean blood pressure and heart rate] were recorded immediately before induction of anesthesia and every 5 minutes after induction till the end of the operation. Neonatal outcome was assessed by Apgar score at I minute and 5 minutes any infra-operative complication was recorded. Amount of blood loss was subjectively assessed by the obstetrician. The quality of anesthesia was assessed in the two groups by sensory level determination and Bromage scale for motor block assessment, subjective assessment of the quality of anesthesia was done using VRS scales. Amount of crystalloid fluid and ephedrine doses were estimated. Side effects such as hypotension, bradycardia, nausea, and vomiting were recorded. The study showed that: Blood pressure decreased significantly after induction of regional block at 5, 10 and 15 minutes than the baseline value in the two groups, where it was lower in group I than group II. Heart rate decreased significantly after induction of regional block than the baseline value in both groups but was within the physiologic range. Neonatal outcome was favorable in both groups, Apgar score at 1 minute and 5 minutes >8 points. No recorded intra-operative complications and blood loss was average. As regards the quality of anesthesia The motor and sensory block were more pronounced in spinal group than epidural group, the patients were more satisfactory and comfortable in spinal than epidural group. The amounts of crystalloid fluid and ephedrine used for prevention and treatment of hypotension were comparable with no significant difference between both groups. Side effects: There were insignificant difference between the two groups as regards nausea, vomiting, bradycardia hypotension and shivering. The regional anesthesia [Spinal-epidural] is a sound choice in mild pre-eclamptic parturient provided that all risk factors [including thrombocytopenia and platelet function defect] are assessed and the patient is stable. The amount of blood loss is within normal and the neonatal outcome is satisfactory. Spinal anesthesia is superior to epidural anesthesia, because both techniques have similar haemodynamic changes and neonatal outcome. However, the spinal anesthesia has many advantages over epidural anesthesia like easy technique, less time consuming, less cost, intense sensory and motor block and patients with spinal anesthesia are more satisfactory than with epidural anesthesia, the surgeon also feels more satisfied. This study was carried out in mild preeclamptic parturient and further studies are needed to evaluate maternal and neonatal safety of these techniques in severe pre-eclampsia

Acceptability for the use of postpartum intrauterine contraceptive devices: Assiut experience

To evaluate the acceptance of postpartum intrauterine contraceptive devices [PPIUCD] among the inhabitants of Assiut governorate, Egypt and to study the factors that influence this acceptance. Subjects and Contraceptive counseling was given to 3,541 clients: 1,880 and 1,661 during the antenatal visits and postpartum hospitalization, respectively. Acceptors during antenatal counseling were to receive IUCDs via postplacental insertion in the case of vaginal delivery or transcesarean insertion in case of abdominal delivery. The clients who refused PPIUCD and chose interval IUCD insertion were referred to the Family Planning Clinic after the end of puerperium. Among postpartum counselees, PPIUCD acceptors received predischarge insertion within 48 h of delivery and the interval IUCD were referred to have IUCD inserted after the end of puerperium. The acceptance rate of both PPIUCD and interval IUCD and the percentage of actual insertions were recorded. The causes of both acceptance and refusal were also recorded. Of the 3,541 clients, 1,024 [28.9%] accepted the use of IUCD after delivery. Acceptance was approximately the same during antenal and postpartum counseling: 26.4 and 31.8%, respectively. Verbal acceptance was higher among women with formal education than among illiterate women. Planning another pregnancy in the near future, preference for another contraceptive method, namely lactational infertility, and complications from previous use of IUCD were the most common reasons for refusing the use of IUCD. Of the 1,024 verbal acceptors, only 243 [23.7%] had the actual insertion of IUCD. Both the acceptance and actual insertion of IUCD were low probably because the use of IUCD is a new concept in the community. For these women, the only opportunity to receive information about contraceptives is during childbirth when they are in contact with medical personnel. Hence, it is suggested that family planning should be integrated with maternal and child-care services in order to effectively promote the use of contraceptive devices in these women who otherwise would not seek the use of such a device

Value of transrectal ultrasonography in the assessment of azoospermic patients before ICSI

The purpose of this article is to evaluate the role of ultrasonography of male reproductive system, especially scrotal and transrectal ultrasonography in the management of infertile males before ICSI as a predictive value for sperm recovery in testicular sperm extraction [TESE]. In this study selected group of 140 infertile men with azoospermia were examined with scrotal and transrectal US. According to clinical and transrectal examination, these patients were subdivided into two groups. Group I of 64 patients had evidence of major obstructive abnormalities of male genital tract system and group II of 76 patients had no or minor non obstructive transrectal US abnormalities. All the 140 patients in the last two semen analysis have azoospermia which persists in spite of medical or surgical treatment. In group I, five patients had congenital bilateral absence of the vas deferens, two have congenital unilateral absence of the vas deferens and congenital obstructive pathology of the contralateral duct system. Proximal or distal duct system obstruction was diagnosed in 57 cases. These patients have a normal FSH level and small volume of ejaculate, and significantly higher testicular volume. In 61 patients of them [95.3%] testicular sperm were found in testicular biopsy. The other 76 patients in Group II were subdivided into two categories according to the presence or absence of minor non-obstructive transrectal abnormalities. In the 30 patients who had additional abnormalities thought to be directly related to semen deficiency 17 cases [56.7%] showed sperms in testicular biopsy. These patients have FSH at the upper level of normal with testicular volume at lower level of normal and with low ejaculate volume. In the remaining 46 patients with high level FSH, low testicular volume in US with normal ejaculatory volume and within normal transrectal US, only 19 cases [41.3%] showed sperms in testicular biopsy

Schistosomiasis as a possible cause of female infertility

This study was conducted on 1625 infertile women selected for laparoscopy over a two-year period. All the patients were subjected to urinalysis, hysterosalpingography, endometrial biopsy in addition to semen analysis of their husbands. Laparoscopic guided biopsy of suspicious lesions of genital organs was taken. Histopathological evidence of schistosomiasis was proved in 27 cases. Twenty cases of them had only tubal affection, ten cases had hydrosalpinx and ten had granulomata on the outer surface of the tube. Three had peritubal small cysts formation. Two had tubo-ovarian masses and two cases showed peritoneal nodules. The histopathology of all lesions showed the characteristic of bilharzial ova

Modified vecchietti operation for creation of a neovagina

In the modified technique, a simple apparatus utilizing the principles of the original Vecchietti operation was used but without opening the bladder peritoneum. First opening the skin through a small Pfannenstiel incision, followed by the rectus sheath, then dissected the retropubic space without opening the peritoneum. After threading an unabsorbable thread in the olive, the Stamy needle was used to pass the threads on each side of the bladder neck and the upper ends of the threads were passed lateral to the two recti muscles and fixed on a traction apparatus on the abdomen. A total of 23 patients were operated upon. Before the operation, the mean length of the vaginal pouch was 1.7 +/- 0.45 cm and the mean length became 8.1 +/- 1.6 cm at the end of the traction after the operation. Except transient stress incontinence in one patient, no complications were recorded. The advantages of the operation were that the normal anatomy and innervation were maintained. It was an extraperitoneal approach with low incidence of complications and there was no perineal scar allowing sexual intercourse within two weeks after discharge from the hospital

An evaluation of a new gel system (ID-gel) for antibody screening and identification.

An evaluation of the new "ID-Gel System" (Diamed) for the detection of red cell antibody-antigen reactions was undertaken in the King Khalid University Hospital Blood Bank. Antibody screening was performed in 700 patient samples using both the conventional test tube (bovine albumin and LISS) techniques and the new ID-gel technique. The results obtained were as follows: a) 70 antibodies of various types were detected by the bovine albumin technique. b) 98 antibodies were spotted by LISS. c) The ID-gel system detected 122 antibodies (17.43%) which included all those detected by the other two techniques. It was concluded that the ID-gel system is a far more sensitive technique than the conventional Blood Bank immuno-haematological tests. In addition, the ID-system has the further advantage of standardization of the test, shorter incubation time, no washing procedure and reduces the technologist time, effort and perhaps number.