Successful Pregnancy Outcome in a Lady with Polyglandular Autoimmune Syndrome Type II.

We report a case of a lady who had polyglandular autoimmune syndrome type II (hypothyroidism, Addison's disease, vitiligo), who completed a successful pregnancy. Addison's disease (AD) was confirmed by the presence of anti-adrenal antibodies and hyponatremia. The patient had pre-pregnancy counselling about the need of antepartum, intrapartum and postpartum steroids. The pregnancy was managed with endocrinologist and obstetrician inputs, and appropriate follow-ups. Her pregnancy was completed with no complications. Labour was complicated by hyponatremia, secondary to nausea and vomiting that needed anaesthesia consultation. The patient delivered by vaginal delivery with no perinatal or early neonatal complications. The fetal growth was at 90th centile. Management in pregnancy, labour and postnatal period requires multidisciplinary care by the endocrinologist, obstetrician, midwife, anaesthetist and neonatologist. Key Words: Addison's disease, Hypothyroidism, Hyponatremia, Labour, Pregnancy.

Economic perspective of evaluating fertility treatment in obese and overweight infertile women.

OBJECTIVES: To evaluate direct cost of in-vitro fertilization/intracytoplasmic sperm injection (IVF/ICSI) cycle and reproductive outcomes among infertile women with different body mass index (BMI). METHODS: A retrospective study of 826 subfertility patients who had IVF or IVF-ICSI in 2017 to 2018 were reviewed. The patients were divided into 4 groups bestowing to BMI to normal weight (18.5-24.9 kg/m2), underweight (<18.5 kg/m2), overweight(25-29.9 kg/m2), and obese(≥30 kg/m2). Data on treatment costs of IVF/ICSI and reproductive outcomes were collected and analyzed. A total of 338 patients (40.9%) were overweight, and 300 (36.3%) patients were obese. A bottom-up methodology was used to measure the resource utilization. The capital inputs needed for individual procedures were defined and calculated by consulting with appropriate clinicians and priced using market prices for 2017-2018. RESULTS: There was no statistical significant difference for live birth rate (LBR) among the BMI groups, with the occurrence of LBR in 23 women with normal BMI (13.1%), in 48 (14.2%) women who were overweight, in 48 (16%) in women who were obese (p=0.7). The median cost for IVF/ICSI treatment cycle did not differ across BMI groups; the cost was 10,380 SAR for women of normal weight, 10,440 SAR for women who are overweight and obese (p=0.6). CONCLUSION: Our results suggest that costs of IVF/IVF-ICSI is not significantly affected in women who are overweight or obese.

Association of vitamin D deficiency to the risk of preeclampsia in Saudi Arabia.

OBJECTIVE: Vitamin D levels have shown significant geographical distribution, therefore, this study was conducted to evaluate its relationship to a specific geographic area with a high prevalence of vitamin D deficiency to the important maternal manifestation of preeclampsia. This study established the association of vitamin D deficiency to preeclampsia among women of reproductive age. METHODS: It is a retrospective case-control study done to measure serum vitamin D levels in pregnant women receiving care at the King Fahad Medical City Riyadh with preeclampsia (n=100) and normal pregnancy (controls, n=200) from 2012 to 2014. Odds of developing preeclampsia with vitamin D deficiency were calculated using logistic regression analysis. RESULTS: The mean serum vitamin D level was 25.35?ng/ml in controls and 15.95?ng/ml in pre-eclampsia women. Comparing to those who had a serum vitamin D level of <50ng/ml, the odds ratio of developing preeclampsia in women with vitamin D deficiency was 4.2 (95% CI=1.23-14.35) while adjusting for age, BMI and duration of pregnancy. CONCLUSIONS: The risk of developing preeclampsia might increase by up to 4-fold in women with vitamin D deficiency. Since preeclampsia could lead to maternal and neonatal complications, vitamin D could be added during pregnancy to decrease these adverse consequences.

Risk of Infertility Index in Women with Polycystic Ovarian Syndrome.

OBJECTIVE: To construct the risk of infertility index for women with polycystic ovarian syndrome, that can be used to assess the prognostic factors for conception; and categorise them in mild, moderate and high-risk groups. STUDY DESIGN: Descriptive study. PLACE AND DURATION OF STUDY: King Fahad Medical City, Riyadh, Saudi Arabia from March 2017 to  February 2018.   Methodology: Fifty women who were diagnosed as polycystic ovarian syndrome were selected by simple randomisation. After initial scrutiny, 39 women with all clinical, biochemical and sonographic features of Rotterdam criteria were included. Patients with congenital adrenal hyperplasia (CAH) and premature ovarian insufficiency (POI) were excluded. Risk of infertility (RII) scale was used to assess the score in women with polycystic ovarian syndrome (PCOS) and classify them into different risk categories like mild (score ≤7), moderate  (score 8-10) and severe  (score >10). RESULTS: There were 5.1% cases with a mild score, 61.5% with a moderate score, and 33.3% with a severe score. For cases in the high-risk group, 89.8% of women had no pregnancy. RII with the cut-off point of 12.5 had a sensitivity of 100%, and specificity of 88.2%, for the defined outcome. Area under the curve was 0.553 and 95% CI was 48.3% (lower bound) and 62.3% (upper bound). CONCLUSION: PCOS patients can be categorised in mild, moderate and high-risk depending on the score on RII scale. The patients with higher score of RII had fewer chances of pregnancy with assisted reproductive technologies (ART). Once the intensity of the risk of PCOS is identified, focused management can be implied thereby reducing the duration of infertility and cost of the treatment. Key Words: Risk, Female infertility, Index, Polycystic ovarian syndrome, Assisted reproductive technology.

Outcomes of Robot-assisted Laparoscopic Gynecological Surgery.

OBJECTIVE: To compare the outcomes of robot-assisted (RA) and standard laparoscopic gynecological surgery (S-LGS) in a tertiary care hospital, and evaluate the factors affecting the outcomes of RA-LGS to identify areas of improvement. STUDY DESIGN: A descriptive study. PLACE AND DURATION OF STUDY: King Fahad Medical City, Riyadh, Saudi Arabia, from 2013 to 2018. METHODOLOGY: In this 5-year retrospective study, 65 LGS cases, including 37 RA-LGS and 28 S-LGS, in a single tertiary care hospital, were included. Demographic data, clinical pathological details, and complications of the cases were recorded. Surgeons performing RA-LGS were also interviewed regarding their training/experience, competency of surgical assistance, and suggestions for improving training. RESULTS: Operative times (3.70 ±0.96 vs. 2.07 ±0.78 h, p <0.001) and hospital stays (3.53 ±3.29 vs. 1.96 ±1.34 days, p=0.022) were significantly longer in the RA-LGS group than in the S-LGS group. Intraoperative complications, which were primarily adjacent organ damage (21.6% vs. 0.0%, p=0.029), were significantly more common in the RA-LGS group. There were no significant differences between the groups in terms of the need to convert to laparotomy, immediate/late postoperative complications, estimated blood loss, or the need for blood transfusion. The interview survey results suggested the lack of a trained team assisting in RA-LGS, as the reason for the poor outcomes. CONCLUSION: There were no advantages of RA-LGS over S-LGS. Longer training periods for RA-LGS, with minimum 20-50 cases as part of a structured training programme, may improve outcomes.

47, XXX syndrome with infertility, premature ovarian insufficiency, and streak ovaries.

We report a patient with primary infertility and clinical manifestation of premature ovarian insufficiency (POI) who upon investigation was found to have streak ovaries, and genetic testing revealed Trisomy X (47, XXX). Therefore, we suggest for genetic testing in women with POI to detect common aneuploidies for better counseling and treatment.