Multiple transvaginal ascitic fluid aspirations improves the clinical and reproductive outcome in patients undergoing in vitro fertilisation treatment complicated by severe early ovarian hyperstimulation syndrome.

The objective of this study is to examine the effect of repeated transvaginal ascitic fluid aspiration on the reproductive outcome in patients undergoing in vitro fertilisation treatment complicated with severe ovarian hyperstimulation syndrome. A total of 65 women with severe early OHSS were hospitalised and managed with transvaginal ascitic fluid aspiration either in < 3 occasions (control group; n = 29) or ≥ 3 occasions (multiple aspirations) (study group; n = 36). All patients in both groups received intravenous fluid, human albumin and thromboprophylaxis. Patients in the study group received significantly lower amounts of parenteral fluid (p < 0.05), human albumin (p < 0.01), and LMWH (p < 0.001). In addition, they had significantly lower days of hospitalisation (p < 0.01) as compared with the control group. There was no significant difference in the cancellation rate between the two groups, but patients who underwent multiple aspiration had a significantly higher pregnancy rate (82.8% vs 41.7%, p < 001) and significantly lower abortion rate (10.3% vs 40%, p < 0.05) compared with the control group. Repeated transvaginal asitic fluid aspiration even with large amounts is safe and effective in the treatment of symptomatic patients with severe OHSS. The pregnancy rate increased significantly along with a significant decrease in the abortion rate was observed after multiple aspirations compared with < 3 aspirations.

Miscarriage and clinical correlates of leukocyte count in patients with ovarian hyperstimulation syndrome.

SUMMARY: This study was conducted to determine the pregnancy outcome in women with ovarian hyperstimulation syndrome and leukocytosis. From a total of 944 women who underwent IVF-ET, 89 (9.4%) developed OHSS, of whom 67 underwent embryo transfer. The criteria of the study were met by 53 women and underwent WBC count and haematological, hormonal and biochemical tests were performed on the day of HCG administration. Statistical comparison was made between women with a WBC count of >15,000 and those with a WBC count of <15,000. Patients with WBC count of >15,000 at the time of HCG administration (n = 24) had significantly increased rate of early pregnancy loss than women who had WBC count of <15,000 (n = 29). No other blood, chemical and hormonal parameters were different between the two groups. It is concluded that women with ovarian hyperstimulation syndrome in an IVF-ET cycle are more likely to miscarry if they have a WBC count of >15,000 on the day of HCG administration.

Metformin in the treatment of clomiphene citrate-resistant women with polycystic ovary syndrome undergoing in vitro fertilisation treatment: a randomised controlled trial.

This study was conducted to determine the efficacy of metformin vs placebo in women with polycystic ovary syndrome (PCOS) undergoing IVF treatment. A total of 66 CC-resistant patients were studied prospectively. The women were randomly assigned to receive 850 mg of metformin (n = 34) or placebo (n = 32) twice daily that started 1 month before commencing the IVF treatment and continued to the day of the pregnancy test. Compared with the metformin-treated group, women who received a placebo had a significant increase in terms of days of stimulation with HMG, number of HMG ampoules, number of follicles >14 mm, number of oocytes retrieved, number of mature eggs, fertilisation rate and oestradiol level on the day of hCG administration. Similarly, women in the placebo group showed a significant increase in poor quality embryos, cancellation rate and the rate of ovarian hyperstimulation syndrome, as compared with the metformin-treated group. On the other hand, women who received metformin showed a significantly higher number of good quality embryos and implantation rate when compared with the placebo controls. Despite the transfer of a similar number of embryos, an insignificant increased in the pregnancy rate along with significant reduction in the abortion rate was observed in the metformin-treated group as compared with the placebo controls. No fetal abnormalities were encountered in the babies born in the metformin-treated group. It is concluded that metformin affects positively the quality of both oocytes and embryos without a significant increase in the pregnancy rate. It decreases significantly the rates of abortion and ovarian hyperstimulation syndrome.

Blood transfusion in obstetrics: the pregnant women's point of view.

The objective of this study was to determine the views and compliance of a group of pregnant women regarding obstetric-related blood transfusion. In this prospective questionnaire-based analysis, a total of 300 pregnant women who attended the antenatal care clinic were included. The mean age and gestational age of patients were 31.6 years and 27.4 weeks, respectively. All demographic and questionnaire data were recorded and analysed. A total of 41% of participants were aware of the possible need for blood transfusion in pregnancy and 88% of all women would accept blood transfusion when necessary. The remaining 12% would refuse blood transfusion, even if it was life-saving, because of the fear of blood transfusion complications. It is concluded that counselling and a management plan should be scheduled for pregnancy, and management protocols should be developed for women who refuse blood transfusion. Transfusion alternatives should be discussed with women who will not accept the allogenic blood transfusion.

Low-molecular-weight heparin in the treatment of recurrent IVF-ET failure and thrombophilia: a prospective randomized placebo-controlled trial.

INTRODUCTION: Recently, thrombophilia (acquired and inherited) has been implicated in recurrent IVF-ET failure. The objective of this study was to determine the effect and safety of thromboprophylaxis using low-molecular-weight heparin (LMWH) in women with recurrent in vitro fertilization (IVF)-embryo transfer (ET) failure and thrombophilia. METHODS: Eighty-three women with history of three or more previous IVF failures and who had at least one thrombophilic defect were eligible for this study. Patients were randomly allocated into two groups: Group A (n = 42) received enoxaparin 40 mg/day, and group B (n = 41) received placebo (NaCl 0.9%). Both treatments started on the day of ET and continued until delivery or foetal demise was diagnosed. The primary outcomes were the implantation, pregnancy and live birth rates. RESULTS: Patients who received LMWH for thromboprophylaxis had a significant increase in the implantation and pregnancy rates compared with the placebo group (20.9% vs. 6.1% and 31% vs. 9.6%, respectively; p < 0.001 and p < 0.05, respectively). A significant increase in the live birth rate was observed in the heparin-treated group compared with placebo (23.8% vs. 2.8%, respectively; p < 0.05). The abortion rate was significantly higher in the placebo-treated group compared to the heparin-treated group (p < 0.05). The frequency of treatment complications did not differ between the two study groups. CONCLUSIONS: LMWH is a safe and effective thromboprophylactic treatment for women with thrombophilia and recurrent IVF-ET failures. The implantation rate, pregnancy and live birth rates are significantly increased with such treatment.

Luteal phase support with GnRH-a improves implantation and pregnancy rates in IVF cycles with endometrium of

OBJECTIVE: The objective of this study was to examine the use of gonadotrophin-releasing hormone agonist (GnRH-a) for luteal phase in a group of patients with thin endometrium (

Luteinized unruptured follicle syndrome: incidence and recurrence rate in infertile women with unexplained infertility undergoing intrauterine insemination.

BACKGROUND: The objective of this study was to determine the incidence and recurrence rate of luteinized unruptured follicle (LUF) syndrome in women with unexplained infertility undergoing intrauterine insemination (IUI). METHODS: A total of 167 women with unexplained infertility who underwent 292 cycles of IUI were enrolled in the study. All patients were treated with clomiphene citrate, 50-150 mg/daily from day 5 to 9 of their menstrual cycle. Ultrasound examination to confirm ovulation was performed on the day of IUI (day 0) and every day thereafter for another 3 days (days 1, 2 and 3). A total of 69 women who failed to conceive in the first cycle and 56 women who failed to conceive in the second cycle underwent second and third cycles, respectively. RESULTS: Of the total 167 patients who underwent first cycle, 42 (25%) had LUF. The incidence of LUF was 56.5% in 69 patients who underwent a second cycle of IUI treatment, of whom 33 patients had LUF in the first cycle with recurrence rate of 78.6%. In 56 patients who underwent 3 consecutive cycles, the incidence of LUF was 58.9% and recurrence rate of 90%. No pregnancies were recorded in patients with LUF during the study period. CONCLUSION: The incidence and recurrence rate of LUF are significantly increased in subsequent cycles of IUI. In these patients, other options of infertility treatment might be justified.

Ovarian cyst formation following GnRH agonist administration in IVF cycles: incidence and impact.

BACKGROUND: The formation of functional ovarian cysts has been recognized as one of the side effects of GnRH agonist administration. The formation of cysts during IVF treatment may be of no clinical significance or may negatively influence its outcome. The objective of this study was to determine the incidence of ovarian cyst formation following GnRH agonist administration and to examine their effect on IVF outcome. METHODS: A prospective study of 1317 IVF patients who developed one or more functional ovarian cysts of >or=15 mm following GnRH agonist treatment was performed. Transvaginal ultrasonographic-guided cyst aspiration was carried out in 76 randomly allocated patients out of 122 patients who were found to have functional ovarian cysts before starting ovarian stimulation with gonadotropins. RESULTS: The incidence of follicular cyst formation was 9.3%. Cyst cycles in comparison with non-cyst cycles had significantly elevated day 3 basal FSH (mean+/-SD of 8.3+/-3.2 versus 5.3+/-2.6 mIU/ml, P<0.05) and required more ampoules of gonadotropins (46.3+/-16.5 versus 35+/-14.6, P<0.01). Furthermore, they showed a statistically significant decrease in the quality and number of oocytes retrieved, fertilization rate, number and quality of embryos, implantation and pregnancy rates, with a significant increase in cancellation and abortion rates. Patients with bilateral cysts had a significantly lower number of oocytes and embryos retrieved, with a lower proportion of metaphase II oocytes. They also had a higher proportion of poor quality embryos. Cyst aspiration was not associated with a significant difference in the above parameters. CONCLUSIONS: The incidence of cyst formation during GnRH agonist treatment is lower than previously reported. In such cases, the quality of oocytes and embryos were significantly compromised, with a significant increase in the cycle cancellation rate and a decrease in the implantation and pregnancy rates. Neither conservative management nor cyst aspiration improved the IVF outcome.

In-vitro fertilisation treatment: factors affecting its results and outcome.

The objective of this study was to determine factors affecting results and outcome of in-vitro fertilisation (IVF). In this retrospective study, a total of 891 infertile women underwent IVF/ICSI cycles at the King Hussein Medical Center (KHMC) between January 2001 and December 2002. Conventional IVF treatment was performed in 64.6% of women and intracytoplasmic sperm injection (ICSI) in 35.4%, using a standardised long luteal protocol. Pregnancy rate was analysed according to age, type of infertility, cause of infertility, duration of infertility, number of eggs collected and follicle stimulating hormone (FSH) levels. A total of 126 cycles (14.1%) were cancelled. Among 765 cycles continued, fertilisation rate was 73.9%, implantation rate was 15.1% and pregnancy rate was 29.8%. Pregnant women had a multiple pregnancy rate of 28.9%, abortion rate of 13.6% and ectopic pregnancy rate of 1.3%. Duration and type of infertility had no significant effect on the pregnancy rate. Factors which appear to affect significantly the outcome of treatment include the woman's age, cause of infertility, basal concentrations of FSH, adequate ovarian responsiveness and the number of eggs collected. In some cases with poor outcome, the understanding of these factors may predict the results and lead to the development of new strategies to improve the outcome of IVF treatment.

Metformin in the treatment of clomiphene citrate-resistant women with high BMI and primary infertility: clinical results and reproductive outcome.

The objective of this study was to evaluate the clinical and reproductive outcome in clomiphene-citrate (CC)-resistant women with high body mass index (BMI) and primary infertility. This was a case series based at the King Hussein Medical center, Amman, Jordan. Nineteen CC-resistant women with polycystic ovary syndrome (PCOS) who had high BMI and primary infertility were studied. All women received metformin monotherapy; 850 mg twice daily for a period of 6 months. If pregnancy occurred, metformin was continued for the first 12 weeks of pregnancy. The main outcome measures were a reduction in the BMI, resumption of regular menses, ovulation and pregnancy rates. Resumption of regular cycles was observed in 13 of 19 (68.4%) women. Ovulation and pregnancy were achieved in 9 (47.4%) and 6 (31.6%) of the 19 women, respectively. A significant reduction in the body weight after treatment reflected by a significant reduction in the BMI was noted. Metformin monotherapy is effective in CC-resistant women with morbid obesity and primary infertility and should be considered as first-line treatment in these patients.

Severe pre-eclampsia and maternal thyroid function.

This study was conducted to determine the thyroid function in severe pre-eclamptic patients compared with healthy controls. Twenty-seven women with severe pre-eclampsia and 26 healthy normotensive controls were studied prospectively. Both groups were matched according to three gestational age subgroups; 30-33,34-37 and 38-41 weeks. Serum concentrations of free thyroxine(Fr4), free triiodothyronine (FT3) and thyroid-stimulating hormone (TSH) were measured by immunochemoluminiscence using an automated analyser (Immulite 2000). Pre-eclamptic women obviously showed a statistically significant increase in terms of systolic BP, diastolic BP, levels of urinary albumin and uric acid compared with the healthy controls. There were no significant differences in the levels of FT4, FT3 and TSH between the two study groups in the various gestational age subgroups. We conclude that the thyroid function is not altered in severe pre-clampsia, therefore it does not reflect the severity of pre-eclampsia.

Medical vs. surgical treatment for clomiphene citrate-resistant women with polycystic ovary syndrome.

This study was conducted to evaluate the efficacy of metformin compared with ovarian drilling in the treatment of clomiphene citrate (CC) resistant women with polycystic ovary syndrome. A total of 161 infertile, CC-resistant women with PCOS aged 22-34 years (mean 25.5 +/- 4.4) were evaluated prospectively during the period between January 2000 and December 2001. Patients were allocated into two groups; group 1 includes 64 women who received metformin, 850 mg twice daily throughout the cycle, and group 2 which includes 97 women who underwent laparoscopic ovarian drilling. If spontaneous ovulation or pregnancy was not achieved within 3 months after treatment, CC was added with increments of 50 mg (up to 150 mg/day) for both groups. Clinical and menstrual characteristics in addition to the hormonal profile were evaluated before and after the treatment. There were no significant differences between the two groups in terms of age, body weight, BMI, duration of infertility and serum hormone levels (androgens, gonadotrophins, insulin) before starting the treatment. A significant improvement in the regularity of menstrual cycles (P < 0.05) and a significant reduction in the serum levels of testosterone(P<0.01), androstenedione (P<0.01), DHEAS (P <0.05), LH (P<0.01) and LH:FSH ratio (P<0.05) were noted after the treatment. There were no significant differences between the metformin group compared with the drilling group in the rates of ovulation (79.7% vs. 83.5%) and pregnancy (64.1% vs. 59.8%). It is concluded that CC-resistant patients with polycystic ovary syndrome can be treated effectively either by metformin or by laparoscopic ovarian drilling. Menstrual cycle pattern and the rates of ovulation and pregnancy are improved significantly, due most probably to the significant decrease in the levels of androgens and luteinising hormone.

Fine needle aspiration cytology compared with open biopsy histology for the diagnosis of azoospermia.

This was a comparative study to determine the diagnostic value of fine needle aspiration of the testis compared with open testicular biopsy in azoospermic men. A total of 34 infertile, azoospermic patients aged from 26-54 years underwent concurrent testicular fine needle aspiration (FNA) and biopsy. The testis was aspirated at three separated sites (upper, middle and lower pole) using a 20 ml syringe and 21-G butterfly needle. A testicular biopsy was taken from the same sites. Samples obtained from FNA were air-dried and stained with Romanowsky-May-Grunwald-Giemsa method. Sections obtained from testicular biopsy were stained with haematoxylin and eosin (H&E). The patient's history, semen analyses, hormonal profile and testicular volume were analysed, and in addition to the histological results azoospermia was classified into obstructive and non-obstructive. A good correlation between cytological smears and histological sections was found in 65 of 68 testes (95.6%). Normal spermatogenesis was diagnosed in seven patients (20.6%), hypospermatogenesis in nine (26.5%), late maturation arrest in five (14.7%), early maturation arrest in three (8.8%) and Sertoli only-cell in 10 (29.4%) patients. Discordance between cytology and histology was observed in three of 68 testes (4.4%) and was related to inadequacy of FNA. Testicular fine needle aspiration is a simple, minimally-invasive procedure that can diagnose accurately testicular function. In addition to the testicular volume and hormonal status, it can differentiate the obstructive from non-obstructive azoospermia. In cases of non-obstructive azoospermia, multiple passes with a fine needle can be performed instead of open testicular biopsy for sperm extraction if present.

Toxoplasmosis and habitual abortion.

We set out to determine the role of toxoplasmosis, detected by serological tests, in habitual abortion. A total of 280 pregnant women aged 15-46 years with parity ranged from 0-9 were studied prospectively between January 2000 and May 2001 at King Hussein Medical Center. Analyses for IgG and IgM anti-toxoplasma were carried out using indirect fluorescent antibody assay (IFAT) and enzyme-linked immunosorbent assay (ELISA). Titres of the order of 1:16-1:2048 were considered positive. According to the results, women were divided into two groups; seropositive (n=132) and seronegative (n=148). One hundred and thirty-two (47.1%) pregnant women showed seropositivity to IgG anti-toxoplasma; of them, two (1.5%) developed IgM anti-toxoplasma during the second trimester. A statistically significant increase in the rate of seropositivity to toxoplasma with increasing age and parity was found (P<0.05). There was no significant difference in the rate of habitual abortion between seropositive and seronegative women. The seropositivity was higher among women living in rural areas (P<0.02), who are using rainwater to drink (P<0.02), ingesting undercooked meat (P<0.001) and who have contact with soil (P<0.02). Toxoplasma antibodies detected by positive serological tests tend to be higher with increased age and parity. It seems that they have no role in habitual abortion.

The effect of antenatal corticosteroid therapy on pregnancies complicated by premature rupture of membranes.

UNLABELLED: This study was carried out to examine the effect of antenatal corticosteroid therapy on pregnancies complicated by premature rupture of membranes (PROMs). For this purpose, 139 patients with a singleton pregnancy (27-34 weeks of gestation) complicated by PROMs were evaluated prospectively during the period January 1997 to February 1999 at two Jordanian military hospitals (Prince Rhashed and Prince Zaid). Patients were allocated into two groups; Group 1 included 72 patients treated with dexamethsone (24 mg divided into 4 doses 12 hours apart), and Group 2 which included 67 patients whoreceived no treatment (control group). All women were examined clinically and the diagnosis of PROMs was demonstrated using vaginal speculum, nitrazine paper examination and ultrasonography. All neonates were evaluated clinically, radiologically, and by laboratory investigations. Pearson's Chi-square and Fisher's exact tests were used to assess the significance of differences between the two study groups. Respiratory distress syndrome (RDS), necrotizing enterocolitis (NEC), intraventricular haemorrhage (IVH), and days of hospital stay were significantly reduced in premature infants of the corticosteroid treated women compared with the controls (p<0.04, p<0.04, p<0.04, and p<0.05, respectively). The perinatal mortality was significantly decreased among the corticosteroid treated group in the gestational subgroups 31-32 and 33-34 weeks (p<0.04), and in all birth weight subgroups (p<0.03). RDS was statistically a significant factor which resulted in increased perinatal mortality in the control group (p=0.02). Regarding the occurrence of postpartum endometritis there was a statistically significant increase among the corticosteroid treated group compared with the controls (p<0.04). CONCLUSION: Antenatal corticosteroid therapy in pregnancies complicated by PROMs has a positive influencing effect on premature infants between 31 and 34 weeks of gestation, decreasing significantly the perinatal morbidity and mortality. It should be used with particular relevance to the developing world where surfactant is not available or where neonatal intensive care units are lacking.

Spinal versus general anesthesia for elective cesarean delivery: a prospective comparative study.

OBJECTIVE: To study the efficacy and safety of spinal anesthesia for elective cesarean section as compared with general anesthesia. PATIENTS AND METHODS: 175 women undergoing elective cesarean section were studied prospectively. They were allocated into two groups; the first group (n=60) received spinal anesthesia, and the second one (n=115) received general anesthesia for elective cesarean section. Preoperative and intraoperative BP and IV fluids were recorded. Chi-Square and Fisher's exact tests were used to compare differences between the two groups; p < 0.05 was considered significant. RESULTS: There were no differences between the two groups in terms of demographics, indication for elective cesarean section, operative time, gestational age, 1 and 5-min Apgar scores, and the means of preoperative and postoperative systolic and diastolic BP. A statistically significant increase was observed in terms of hypotension, postoperative analgesia, pre-induction and intraoperative IV fluids in the spinal group as compared to the general anesthesia group (p < 0.001, p < 0.01, and p < 0.01, respectively). CONCLUSION: Spinal anesthesia is as effective as a general anesthesia. Maternal and fetal outcome are favorable. Maternal hypotension can be managed successfully with modest doses of ephedrine and IV fluid infusions. It provides sufficient postoperative analgesia allowing the mother to have more vitality and comfort than those who receive general anesthesia.

Intrapartum common peroneal nerve compression resulted in foot drop: a case report.

This case report is to illustrate a case of a 24-year-old Jordanian woman, gravida 1, para 0 who developed intrapartum foot drop due to compression injury of the common peroneal nerve behind the head of fibula. Diagnosis was based on history, clinical examination and electrophysiological studies. Treatment included daily sessions of physiotherapy. Complete recovery of the condition took place within 2 months.