Persistent Idiopathic Prolactin Elevation Merits Macroprolactin Estimation: A Case Report and Review of Literature.

The prevalence of hyperprolactinemia ranges from about 0.4% in an unselected adult population to as high as 9%-17% in women with reproductive disorders. It may cause infertility in about 11% of the oligospermic males. Rarely, the cause of persistently elevated prolactin remains obscure even after thorough work up. Macroprolactinemia is biologically inactive, high-molecular-weight form of prolactin resulting from its binding to immunoglobulin G, causing a decrease in its clearance. We report the case of a 35-year-old female, detected to have hyperprolactinemia on multiple tests, during routine work up for primary infertility. Secondary causes for the same were ruled out. A magnetic resonance imaging (MRI) of the brain excluded a prolactinoma. This prompted an estimation of prolactin levels after polyethylene glycol precipitation which showed a decrease to 5.58 ng/mL, with <40% recovery, confirming the presence of macroprolactin. Thus, persistently elevated prolactin levels in the background of negative neurological imaging necessitate the estimation of macroprolactin.

Role of Hysterosalpingography in Diagnosing Tubal Blockage - A Prospective Diagnostic Study.

BACKGROUND: Women with abnormal hysterosalpingography (HSG) are anxious regarding the presence of tubal pathology. It is important to know the predictive value of HSG and the need for subsequent laparoscopy following an abnormal report. In the era of assisted reproductive technology, the role of invasive testing such as diagnostic laparoscopy is being increasingly questioned due to its invasiveness and associated risks. There is a need to explore the positive predictive value (PPV) of HSG in detecting bilateral tubal block in our population as PPV changes with the prevalence of disease. AIM: The aim of this study was to evaluate the diagnostic accuracy of HSG in identifying tubal blockage in subfertile women. SETTING AND DESIGN: This was a prospective diagnostic study conducted in the department of reproductive medicine and surgery in a university-level hospital. MATERIALS AND METHODS: The study included 199 subfertile women who had undergone HSG earlier and were planned for laparoscopy from April 2017 to January 2021. Findings of HSG and laparoscopy were compared with HSG as index test and laparoscopy as reference test, and the outcomes analysed were PPV of HSG for a bilateral tubal block, bilateral hydrosalpinx, abnormal HSG (unilateral or bilateral tubal block) and agreement between HSG and diagnostic laparoscopy in detecting normal and abnormal findings. STATISTICAL ANALYSIS: Kappa statistics, Stuart-Maxwell tests of marginal homogeneity and prevalence-adjusted bias-adjusted kappa (PABAK) statistics were used. RESULTS: The PPV for a bilateral block with HSG was 20.9% (95% CI: 13.7-29.7). The PPV of HSG for bilateral hydrosalpinx was 50.0% (95% CI: 6.8-93.2). PABAK was estimated to be 0.42 (95% CI: 0.30-0.55), suggestive of moderate agreement between the tests. Findings of laparoscopy in women with at least one patent tube in HSG showed that in 12.3% of cases, the management was likely to change due to the operative findings. CONCLUSION: The current study showed low PPV for bilateral tubal block diagnosed with HSG which translates into a need for further confirmation by laparoscopy. In one out of every eight women with at least one patent tube on HSG, performing laparoscopy changed the management.

Effectiveness of spontaneous ovulation as monitored by urinary luteinising hormone versus induced ovulation by administration of human chorionic gonadotrophin in couples undergoing gonadotrophin-stimulated intrauterine insemination: a randomised controlled trial.

OBJECTIVE: To compare effectiveness of spontaneous ovulation monitored by urinary luteinising hormone (LH) versus induced ovulation by administration of human chorionic gonadotrophin (hCG) in couples undergoing gonadotrophin-stimulated intrauterine insemination (IUI). DESIGN: Randomised controlled trial. SETTING: University-level infertility unit. POPULATION: Couples with unexplained infertility, mild endometriosis, mild male factor infertility and polycystic ovarian syndrome. METHODS: Couples were randomised to an LH group (Group A), in which urinary LH was measured daily to detect spontaneous ovulation, or an hCG group (Group B), in which urinary hCG was administered as a trigger. MAIN OUTCOME MEASURES: Clinical pregnancy rate. Secondary outcomes - ongoing pregnancy, live birth, multiple pregnancy and miscarriage rates. RESULTS: A total of 392 couples were randomised with 196 in each arm. The clinical pregnancy rate per woman randomised was 14/196 (7.1%) in the LH arm versus 15/196 (7.6%) in the hCG arm (P = 0.847, which was not statistically significant). Similarly, the ongoing pregnancy rates [13/196 (6.6%) versus 14/196 (7.1%); P = 0.84] and the live birth rates [13/196 (6.6%) versus 14/196 (7.1%); P = 0.84] between the two groups did not show any significant difference. The duration of stimulation and gonadotrophin dosage also did not differ significantly between the two methods. CONCLUSION: There was no significant difference in clinical pregnancy rates when urinary LH and hCG trigger were compared as methods to time insemination in women undergoing gonadotropin-stimulated IUI. TWEETABLE ABSTRACT: A randomised controlled study showing similar effectiveness between two different methods of timing IUI.

Effectiveness of Anti-Mullerian Hormone-tailored Protocol Compared to Conventional Protocol in Women Undergoing In vitro Fertilization: A Randomized Controlled Trial.

BACKGROUND: Assessment of ovarian reserve before an in vitro fertilization cycle (IVF) is one among the many factors that predicts a successful cycle. Individualized protocol based on ovarian reserve is designed to optimize the pregnancy outcome without compromising the patient safety. Although authors have shown that anti-Mullerian hormone-tailored (AMH) protocols have reduced the treatment burden and improved pregnancy rates, a few others have questioned its efficacy. AIMS: The aim of this study was to decide whether the AMH-tailored protocol or the conventional protocol better decides IVF outcomes. SETTING AND DESIGN: Prospective randomized controlled trial conducted at a tertiary level university hospital. MATERIALS AND METHODS: Patients undergoing theirfirst IVF cycle who fulfilled the inclusion criteria were recruited and randomized to each group. Serum follicle-stimulating hormone was done for the patients on day 2 or 3 of a prior menstrual cycle, and serum AMH was done in the preceding cycle. STATISTICAL ANALYSIS: Analysis was performed using SPSS software version 16. RESULTS AND CONCLUSION: There were 100 patients in each group. A total of 83 patients underwent embryo transfer in the conventional group and 78 patients in the AMH group. The clinical pregnancy rates per initiated cycle (36.4% vs. 33.3%) and per embryo transfer (45.1% vs. 41.3%) were similar in both the groups. There was no statistical difference in the number of cycles cancelled due to poor response or the risk of ovarian hyperstimulation syndrome in both the groups. Hence, this study showed the similar effectiveness of AMH-tailored protocol and conventional protocol in women undergoing IVF.

Affordable ART: a different perspective.

BACKGROUND: Although ≈ 10% of the population is affected by infertility, the treatment option of in-vitro fertilisation (IVF) remains unaffordable for the majority of infertile couples. We have initiated a lowcost programme incorporating an uncommonly used, but recognized, ovarian stimulation protocol, together with certain costlimiting initiatives in an established assisted reproductive technology (ART) set up. METHODS: The medical records of women who underwent the lowcost programme were analysed. Clomiphene citrate 50 mg daily was administered from Day 2 of the cycle and continued till the day of hCG trigger, thus preventing the LH surge. Intermittent doses of human menopausal gonadotrophin 150 IU were administered on alternate days from the 5th day onwards. Oocyte retrieval was carried out once at least two follicles of >18 mm were identified. The cycle was monitored by ultrasound only, with embryo transfer being carried out on Day 3. Clinical outcomes were recorded together with an estimation of the direct costs per cycle. Direct cost calculations did not include professional charges or facility costs. RESULTS: Of 143 women evaluated, 104 women underwent embryo transfer. The live birth rate and clinical pregnancy rate per embryo transfer were 19 and 22%. The live birth rate per initiated cycle was 14% (20/143). The multiple pregnancy rate was 26% with no case of ovarian hyperstimulation syndrome being recorded. The average direct cost per cycle was US$ 675 for IVF and US$ 725 for an ICSI treatment cycle. CONCLUSIONS: Using this protocol, together with several costcutting measures, we achieved an acceptable live birth rate per transfer of 19% at a reasonable cost. This approach could be used by established ART centres to provide treatment to couples who cannot afford conventional ART.

Aromatase inhibitors in women with clomiphene citrate resistance: a randomized, double-blind, placebo-controlled trial.

In 36 women with polycystic ovary syndrome and clomiphene citrate resistance, letrozole, an aromatase inhibitor, statistically significantly increased the ovulation rate by 33.3% in the treatment group, indicating that letrozole can be used as an effective and simple alternate ovulation-inducing agent in these women.

A rare case report: ovarian heterotopic pregnancy after in vitro fertilization.

OBJECTIVE: To report a case of ovarian heterotopic pregnancy after an IVF cycle. DESIGN: Case report. SETTING: Reproductive medicine unit, Christian Medical College Hospital, Vellore, India. PATIENT(S): A woman with an ovarian heterotopic pregnancy. INTERVENTION(S): Laparoscopic removal of ovarian ectopic pregnancy. MAIN OUTCOME MEASURE(S): Early detection and successful treatment of heterotopic pregnancy. RESULT(S): Successful laparoscopic management of ovarian pregnancy resulting in a single viable ongoing intrauterine pregnancy. CONCLUSION(S): Clinicians need to be aware of such rare and potentially fatal presentations after IVF, because early diagnosis and management in these cases can yield a favorable outcome.

HIV and obstetric complications and fetal outcomes in Vellore, India.

Antenatal prevalence is more than 1% in parts of India, yet little is known about the complications and fetal outcomes in this region. We reviewed the records of 23,386 women who delivered at the Christian Medical College Hospital in Vellore, India from 2000 through 2002. HIV-infected women were more likely than HIV-uninfected women to have pregnancy-induced hypertension, anaemia, breech presentations, stillborn babies and fetal deaths. HIV-infected women who did not receive mother-to-child transmission prophylaxis or had breech fetal presentation were more likely to have fetal deaths (P = 0.001). HIV prophylaxis and optimal prenatal care should be a priority for HIV-infected pregnant women in resource-limited countries.