Clomiphene citrate co-treatment with low dose urinary FSH versus urinary FSH for clomiphene resistant PCOS: randomized controlled trial.

PURPOSE: The aim of this study was to examine the effect of clomiphene citrate [CC] co-administration during the use of exogenous low-dose urinary FSH [uFSH] for induction of ovulation in CC-resistant infertile PCOS women. METHODS: In a randomised controlled setting, 174 CC-resistant infertile PCOS women were randomized into two parallel groups; Group I received CC 100 mg/day for 5 days plus uFSH 37.5 IU/day while group II received only uFSH 37.5 IU /day. Subsequent increments of uFSH by 37.5 IU/day were made according to response. Primary outcome was ovulation rate. Secondary outcomes were clinical pregnancy rates, number of follicles, endometrial thickness, and gonadotropins consumption. RESULTS: Our results have demonstrated that group I compared to group II had significantly higher ovulation rate per intention to treat [ITT] [72.4 % vs. 34.2 %, p < 0.001]. Clinical pregnancy and live birth rates were comparable between the two groups. Group I consumed significantly lower total FSH dose and needed significantly shorter stimulation duration compared to group II. CONCLUSION: CC co-administered during low dose HP uFSH versus uFSH for CC-resistant PCOS yields significantly higher ovulation rate and less consumption of FSH.

The effects of timing of intrauterine insemination in relation to ovulation and the number of inseminations on cycle pregnancy rate in common infertility etiologies.

BACKGROUND: Controlled ovarian hyperstimulation with intrauterine insemination (COH/IUI) is an established tool in medically assisted conception for many infertility factors. However, the proper timing of IUI after hCG trigger and the frequency of IUI are still debated. We aimed to examine the association between the cycle pregnancy rate (CPR) and: (i) single IUI timed at 36 ± 2 h post-hCG (pre- or post-ovulation) (ii) the number of IUI (single or double) for pre-ovulatory cases both aims in male, anovulatory and unexplained infertility. METHODS: The study included a total 1146 first-stimulated cycles in infertile couples due to male factor, anovulation or unexplained infertility. Cycles were stimulated by clomiphine citrate (CC) or sequential CC-hMG or hMG and monitored by transvaginal ultrasound. When the leading follicle reached ≥ 18 mm mean diameter, 10000 IU hCG was given to trigger ovulation and IUI was timed for 36 ± 2 h later. Semen was processed and ovulation was checked at the time of IUI. Post-ovulatory cases received single IUI, while pre-ovulatory cases were sequentially randomized to receive either single or double IUI. The end-point of the cycle was CPR. RESULTS: Overall CPR in the whole cohort was 10.1%. When ovulation was present before IUI, CPR was 11.7% compared with 6.7% when ovulation was absent [OR (95% CI): 1.85 (1.12-3.06), P = 0.015]. When this OR was computed according to infertility etiology, it was 1.26 (0.52-2.95) (P = 0.82) for male factor infertility and 2.24 (1.23-4.08) (P = 0.007) for non-male factor infertility. Comparing the CPR for double versus single IUI in pre-ovulatory cases, the OR for all cycles was 1.9 (0.76-4.7) (P = 0.22), but according to etiology, it was 4.667 (0.9-24.13) (P = 0.06) in male factor and 1.2 (0.43-3.33) (P = 0.779) for non-male factors. CONCLUSIONS: Single IUI timed post-ovulation gives a better CPR when compared with single pre-ovulation IUI for non-male infertility, whereas for male factors, pre-ovulation, double IUI gives a better CPR when compared with single IUI.

Modified thermal balloon endometrial ablation in low resource settings: a cost-effective method using Foley's catheter.

OBJECTIVE: To assess the efficacy of a modified Foley's catheter endometrial ablation in the treatment of abnormal uterine bleeding in low resource settings. METHODS: Four hundred and thirty premenopausal women with abnormal uterine bleeding were subjected to thermal balloon endometrial ablation using modified Foley's catheter. The primary outcome measure was patient satisfaction regarding menstrual blood loss. Secondary measures included improvement in quality of life scores and failure rates. RESULTS: Three hundred and three patients were available for evaluation at 3-year follow up. 270/303 (89.1%) reported their satisfaction as indicated by reduction in days of menstrual flow per cycle (4.2 vs. 8.8 days, p < 0.0001). There was a significant improvement in quality of life scores (p < 0.0001). The rate of failure varies according to the interval of follow up from 15.6% at 6 months to 10.9% at 3 years. CONCLUSION: Modified Foley's catheter endometrial ablation is a cost effective alternative to other thermal endometrial ablation techniques in the treatment of abnormal uterine bleeding in low resource settings.

Effect of childhood kidney transplantation on puberty.

OBJECTIVE: To evaluate sexual and linear growth in kidney transplant (KTX) children receiving cyclosporine A, low-dose prednisolone and azathioprine. STUDY DESIGN: Prospective case-control study. SETTING: University-affiliated urology and nephrology center, obstetric and gynecology departments. PATIENT(S): Eighteen girls and 21 boys with successful KTX before the age of 16 years. Controls were healthy and age matched (200 girls and 171 boys). INTERVENTION(S): Assessment of sexual maturation by Tanner staging and linear growth by height standard deviation score (HSDS) and height increment (HI). MAIN OUTCOME MEASURE(S): Pubertal age in KTX vs. control, ratios of KTX with normal and retarded sexual maturation and linear growth. RESULT(S): Puberty in KTX children was significantly delayed compared with controls. Delayed sexual maturation was found in 22.2% of girls and 19.1% of boys, and poor HSDS was found in 38.9% of girls and 33.3% of boys. Improvement in HSDS was significantly lower in girls compared with boys. Improvement in HSDS did not significantly differ in prepubertal vs. pubertal children. Prepubertal HI was significantly higher than pubertal HI in boys, but not in girls. Significant negative correlation was found between HI, duration of immunosuppression, and serum creatinine level. CONCLUSION(S): KTX children receiving cyclosporine A, low-dose prednisolone, and azathioprine showed acceptable sexual and physical maturation in a majority of cases. Impaired sexual and linear growth after receiving KTX is related to poor graft function, post-KTX interval, and gender.

Uterine artery occlusion for treatment of symptomatic uterine myomas.

OBJECTIVE: To compare the effectiveness and safety of uterine artery occlusion by laparoscopy versus embolization as a treatment modality for symptomatic uterine fibroids. METHODS: Ninety-six premenopausal women with symptomatic uterine leiomyomata were studied. None of them desired further pregnancy. They were randomized to treatment either by laparoscopic occlusion (group 1) or by radiologic embolization of uterine arteries (group 2). The primary outcome measure was patient satisfaction as regards menstrual blood loss compared with pretreatment loss. Secondary outcome measures included postoperative pain, complications, secondary interventions, and failures. RESULTS: Ninety women were followed for 1, 3, 6, and 12 months after both procedures. The primary outcome was comparable between the 2 groups (86.7% after laparoscopic occlusion versus 88.8% after embolization, with no statistically significant difference). After 12 months of follow-up, more patients resumed heavy periods in the uterine artery occlusion group [4/45 patients, 8.8% in occlusion group compared with 3/45 (6.6%) in embolization group, P=0.044]. CONCLUSION: Both laparoscopic occlusion and superselective embolization of uterine arteries improved clinical symptoms in the majority of patients. At 12-month follow-up, embolization might be more effective.

Preliminary uterine artery ligation versus pericervical mechanical tourniquet in reducing hemorrhage during abdominal myomectomy.

OBJECTIVE: To compare the effectiveness of preliminary uterine artery ligation versus pericervical mechanical tourniquet in reducing hemorrhage during myomectomy. METHODS: A total of 103 patients undergoing myomectomy were randomly allocated to undergo preliminary uterine artery ligation (52 patients) or pericervical tourniquet (51 patients). The primary outcome measure was estimated blood loss. Secondary outcomes included duration of the operation, duration of hospital stay, postoperative hemoglobin, and the need for postoperative analgesia. RESULTS: Operative blood loss was significantly less with uterine artery ligation compared with tourniquet (433.80+/-285.21 vs 823.23+/-237.33mL, P<0.001). The mean duration of the operation was lower in the uterine artery ligation group compared with the tourniquet group (50.5+/-8.7 vs 76.3+/-9.4 minutes, P<0.001). Postoperative hospital stay was significantly shorter in the uterine artery ligation group compared with the tourniquet group (4.1+/-0.1 vs 5.1+/-0.2 days; P<0.001). Postoperative hemoglobin concentrations and the need for postoperative analgesia were higher in the uterine artery ligation group (P=0.012 and P<0.001, respectively). CONCLUSION: Uterine artery ligation was more effective than pericervical tourniquet as a preliminary step in reducing blood loss during abdominal myomectomy.

Is expectant management of early-onset severe preeclampsia worthwhile in low-resource settings?

OBJECTIVE: To evaluate the maternal and perinatal outcome following expectant management of early-onset severe preeclampsia (PE) at a tertiary hospital in Mansoura, Egypt. METHODS: This prospective, observational study included 211 patients with severe PE, occurring between 24 and 34 weeks of gestation. They were classified according to gestational age on admission into three groups. Group 1 included 61 patients with gestational ages between 24 and 28 weeks. Group 2 (28 to <32 weeks) included 66 patients and group 3 (32-34 weeks) included 84 patients. Outcome measures included prolongation of gestation, and maternal and perinatal complications. RESULTS: The median overall prolongation of gestation was 12 +/- 6 days. The rate of neonatal survival significantly increased (P < 0.001) from 12/61 (19.7%) in group 1 to 30/66 (45.5%) in group 2 and 67/84 (79.8%) in group 3. There were no maternal mortalities; however, 43 (20.4%) women developed significant morbidities. HELLP syndrome, renal impairment and placental abruption were the main complications. CONCLUSION: In low-resource settings, expectant management of early-onset severe PE is associated with relatively higher rates of perinatal mortality and maternal morbidity and should be limited to gestational ages between 28 and 34 weeks of gestation.

The effect of luteal phase support protocol on cycle outcome and luteal phase hormone profile in long agonist protocol intracytoplasmic sperm injection cycles: a randomized clinical trial.

OBJECTIVE: To study the effect of luteal phase support protocol on cycle outcome and luteal phase hormone profile, in long agonist protocol intracytoplasmic sperm injection (ICSI) cycles. DESIGN: Prospective randomized trial. SETTING: Private infertility center. PATIENT(S): Two hundred seventy-four women undergoing first ICSI cycles were randomized after ovum pickup into three groups of luteal support. INTERVENTION(S): Group I received IM P (P(4)) only, group II received P(4) + oral E(2) valerate, group III received P(4) + hCG. MAIN OUTCOME MEASURE(S): Pregnancy rate (PR), implantation rate, rates of multiple pregnancy and miscarriage, and midluteal serum E(2) and P(4), and midluteal E(2):P(4) ratio. RESULT(S): The PR and implantation rates were significantly higher in group II compared to group I and the miscarriage rate was significantly lower in group II compared with group I. Midluteal E(2) was significantly higher in group II compared with group I. The decline in E(2) after ovum pickup was lowest in group II, highest in group I. The midluteal E(2):P(4) ratio was significantly higher in group II compared with groups I and III. CONCLUSION(S): The E(2) luteal phase supplementation in long GnRH-agonist (GnRH-a) protocol ICSI cycles resulted in better cycle outcome and better luteal phase hormone profile.

Paraumbilical hernia repair during cesarean delivery.

BACKGROUND AND OBJECTIVES: Pregnant women with paraumbilical hernia usually postpone hernia repair until after delivery, but some patients request that it be done during cesarean delivery. Therefore, we evaluated the outcome of combined cesarean delivery and paraumbilical hernia repair in a prospective study at a tertiary referral university hospital. PATIENTS AND METHODS: In a prospective study, we compared the outcome of 48 patients undergoing cesarean delivery combined with paraumbilical hernia repair versus 100 low-risk patients undergoing cesarean delivery alone. The main outcome measures were operation time, blood loss, severity of pain, peripartum complications, hospital stay, hernia recurrence, and patient satisfaction. RESULTS: The combined procedure took significantly longer than cesarean delivery alone (75.2 minutes versus 60.5 minutes, P<.001)). There were no major complications. Wound infection occurred in 6 patients (4.1%). Hospital stay did not differ significantly from those of controls. Pain at the hernia site repair occurred in two patients, and one hernia recurred in the hernia repair group during a mean follow-up period of 22 months (range, 6-36 months). All hernia patients reported that they preferred the combined operation. CONCLUSIONS: Combined cesarean delivery and paraumbilical hernia repair had the advantage of a single incision, single anesthesia, and a single hospital stay while avoiding re-hospitalization for a separate hernia repair. Our results indicate that the combination approach is safe, effective, and well accepted.