Improved Pregnancy Outcomes and Endometrial Receptivity by Thawed Frozen Embryo Transfer in Mildly Stimulated Cycles with Letrozole Combined with Estrogen in Women with Unresponsive Thin Endometrium Compared to Standard Endometrial Preparation with Estrogen Alone: A Retrospective Study.

Context: Infertile women undergoing frozen embryo transfer (FET) cycles may not show optimal endometrial growth with estrogens alone. Aim: To evaluate clinical effect of mild stimulation with letrozole and estrogens on endometrial growth in comparison to standard endometrial preparation with oral and topical estrogens in infertile women with unresponsive thin endometrium undergoing FET. Settings and design: Retrospective observational case-control study. Material and methods: Forty women unresponsive to first AC-FET cycle were given mild stimulation with letrozole and estrogens as second LE-FET cycle for endometrial preparation (LE-FET study group) and compared with 40 historical controls who had received two cycles of AC-FET (AC-FET control group). Responses were assessed by optimal endometrial thickness (≥ 7 mm) and clinical pregnancy. Statistical analysis: Descriptive statistics were elaborated by mean ± SD and percentages. Results were expressed by mean ± SD, unpaired t test for difference in endometrial thickness, chi square and Fisher exact test to compare the difference in pregnancy among both groups. Results: Mean endometrial thickness was significantly increased in LE-FET study group (6.68 ± 2.09 mm) versus AC-FET control group (5.35 ± 1.90 mm). Higher clinical pregnancy rate was noted in study group as compared to control group (35% versus 12.5%). Conclusion: This study suggests that letrozole with estradiol (LE-FET) compared to estradiol alone (AC-FET) for second cycle significantly increased endometrial thickness and improved clinical pregnancy rates in women with unresponsive thin endometrium after first AC-FET cycle with estradiol alone. Addition of letrozole to estrogen upfront for FET cycles may enhance endometrial receptivity and might improve pregnancy outcomes.

Prevalence of Polycystic Ovarian Syndrome, Phenotypes and their Ovulation Response to Sequential Letrozole Dose Escalation among Infertile Women at a Tertiary Care Centre in Southern India.

Background: Women with polycystic ovarian syndrome (PCOS) often have anovulatory infertility requiring ovulation induction with letrozole. Aims: This study aimed to determine the prevalence and phenotypic categorisation of infertile PCOS women and to assess ovulatory response and pregnancy rates of PCOS phenotypes with sequential letrozole dose escalation. Study Setting and Design: This was a prospective observational study. Materials and Methods: One hundred seventy-five infertile PCOS women were enrolled. One hundred fifty-six women received ovulation induction as per the protocol with sequential letrozole dose escalation in each subsequent cycle (2.5 mg, 5 mg and 7.5 mg). Responses were assessed by ovulation and/or pregnancy. Statistical Analysis Used: Descriptive statistics were elaborated by means, medians, frequencies and percentages. Group comparisons and linear correlation between two continuous variables were done using appropriate statistical tests. Results: Eighty-seven (49.7%) women were Phenotype A; 11 (6.3%) were Phenotype B; 20 (11.4%) were Phenotype C and 57 (32.6%) were Phenotype D in our study. After excluding the lost to follow up participants in each induction cycle, 33.3% (2.5 mg dose); 62.8% (5 mg dose) and 78.9% (7.5 mg dose) women responded to letrozole. A significant increase in ovulation to escalating letrozole doses was noted (Phenotype A: 35.1% to 2.5 mg, 53.7% to 5 mg and 72.7% to 7.5 mg; Phenotype B: 30% to 2.5 mg and 80% to 5 mg; Phenotype C: 35.3% to 2.5 mg and 87.5% to 5 mg and Phenotype D: 30.8% to 2.5 mg, 65.6% to 5 mg and 87.5% to 7.5 mg). Fifty-six of 156 (35.9%) infertile PCOS women achieved pregnancy; increase in pregnancy rates with escalated doses of letrozole was noted. Conclusion: All PCOS phenotypes show a similar response to escalating doses of letrozole. The role of phenotypic sub-categorisation for variable response to letrozole as an ovulation-inducing agent is uncertain.

Clinical Spectrum of Rheumatic Manifestations in HIV Infected Males at a Tertiary Care Hospital.

BACKGROUND: In the current era of effective Anti retroviral therapy (ART), and Human Immunodeficiency Virus (HIV) infection becoming a chronic illness, there has been a gradual rise in the prevalence of rheumatic manifestations associated with this disease. These are characterized by a modified clinical course and widened spectrum of a few emerging rheumatic manifestations seen with HIV infection. AIMS AND OBJECTIVES: To assess the type, frequency, prevalence and clinical spectrum of rheumatic manifestations among &male patients followed at an HIV clinic of a tertiary care defence hospital. MATERIALS AND METHODS: All male patients with confirmed HIV infection at the study centre were studied after obtaining informed consent. A detailed history was taken including the date of seropositivity, symptoms of rheumatic disease, family history of rheumatic illness, and treatment history with ART. A detailed general and systemic examination was performed and rheumatic symptoms guided appropriate investigations were carried out on as required basis. RESULTS: 879 confirmed HIV cases were evaluated for rheumatic manifestations during the study period. Of these 499 cases were newly detected HIV cases and the rest 380 were old cases on follow up. Rheumatic disorders were diagnosed in 16 cases (1.82%). Spondyloarthropathy was the commonest presentation i.e. 5 out of 16 cases (31.25 % of the rheumatic disorders). Mean age was 37 years (range 27-52 yrs). 2 patients of the study group had the rheumatic illness prior to detection of HIV. Psoriatic Arthritis (0.114 %) was seen in 1 patient who was HLA B-27 negative. Reactive arthritis (0.227 %) was noted in 2 patients. 1 patient had cutaneous small vessel vasculitis (0.114 %), whereas 1 of the patient developed DLE (0.114 %) over neck. HIV related non specific polyarthritis (0.114 %) of the large joints was noted in 1 patient who was RF negative, while polyarthralgia (0.340 %) was noted in 3 patients. 10 patients (60 %) had CD 4 count < 200 cells/ µL, whereas 6 patients had a CD 4 count between 200 and 500 cells/µL. 13 out of 16 patients detected to have rheumatic illnesses were on ART. CONCLUSION: With the advent of ART, the clinical spectrum of HIV infection is changing as a chronic treatable disease. Present study consisting mainly adult males, showed only 1.82 % prevalence of rheumatic disorders in HIV infection. Early diagnosis, availability of ART and prompt treatment of opportunistic infections have changed the clinical profile of HIV patients. Impact of ART in producing and affecting the clinical spectrum of rheumatic disease has to be kept in mind while treating HIV-infected patients.