Ultrasonographic guided ovarian stroma hydrocoagulation for ovarian stimulation in polycystic ovary syndrome.

OBJECTIVE: To evaluate the safety and effectiveness of transvaginal ultrasound guided injection of hot saline into the ovarian stroma in polycystic ovary syndrome (PCOS) cases in an office based gynecology practice under local anesthesia. SETTING: Outpatient gynecologic clinic. STUDY DESIGN: Pilot study. PARTICIPANTS: Fifty-two anovulatory infertile females diagnosed as PCOS by clinical, chemical and ultrasound criteria were recruited for the study. All cases were resistant to clomiphene citrate for more than 6 months. INTERVENTION: Injection of warm sterile saline (75C) into the ovarian stroma under transvaginal monitoring using ovum pickup needle. OUTCOME MEASURES: Cycle regularity, ovulation rate and safety were primary outcomes. Pregnancy rate and patient convenience were our secondary outcomes. RESULTS: Ovulation has been achieved in 73.1% of clomiphene citrate resistant PCOS cases and resulted in pregnancy in 26.9% of these cases. No adverse effects were recorded and the procedure was tolerable in most cases. CONCLUSION: Transvaginal ultrasound guided ovarian stroma hydrocoagulation (TOSH) in an office setting seems to be a safe, economic and practical procedure that is acceptable by the patients. If larger studies confirm its effectiveness it may be an attractive alternative to conventional ovarian drilling.

Management of long-standing unexplained infertility: A prospective study.

OBJECTIVE: Our purpose was to evaluate a protocol for the management of long-standing unexplained infertility. STUDY DESIGN: A prospective study was conducted at an in vitro fertilization-embryo transfer center with 485 patients with the diagnosis of long-standing unexplained infertility. Patients were treated by means of controlled ovarian hyperstimulation and intrauterine insemination for a maximum of 3 cycles. Those who did not become pregnant underwent in vitro fertilization and intracytoplasmic sperm injection on sibling oocytes. RESULTS: Among 485 patients, 921 cycles of controlled ovarian hyperstimulation and intrauterine insemination were performed. The pregnancy rate was 15.7% per cycle and 29.8% per patient. Among those who did not become pregnant, 131 patients underwent in vitro fertilization and intracytoplasmic sperm injection into sibling oocytes; 48 women became pregnant (36.7%). There was total failure of the in vitro fertilization oocytes in 23 cycles (17.6%). CONCLUSION: Management of long-standing unexplained infertility with controlled ovarian hyperstimulation and intrauterine insemination resulted in a reasonable pregnancy rate. Treatment by means of in vitro fertilization and intracytoplasmic sperm injection into sibling oocytes among patients who did not become pregnant resulted in a good pregnancy rate. The overall results showed that the proposed protocol for management of unexplained infertility is satisfactory.

Uterine myomata and outcome of assisted reproduction.

The aim of this work was to study the effect of uterine myomata on the implantation rate and outcome in in-vitro fertilization (IVF) and intracytoplasmic sperm injection (ICSI). Among 406 patients, 51 (12.6%) were found to have uterine corporeal myomata. Twelve patients were excluded from the study as they had large myomata, submucous myomata or intramural myomata encroaching on the cavity. These patients were advised to have myomectomy before being enrolled in the IVF/ICSI programme. The remaining patients (n = 39) were sorted according to the number, site and size of the myomata as assessed by transvaginal sonography. Three patients had more than one myoma. Most of the myomata were subserous (72.7%) and the mean diameter of the myomata was 3.5 +/- 0.9 cm. A control group (n = 367) was chosen with normal uteri and no history of uterine reconstruction surgery. The mean age of myoma patients was 34.7 +/- 3.6 years as compared to 34.0 +/- 4.4 years in the control group. The age, period of infertility, body mass index, duration and number of human menopausal gonadotrophin ampoules needed for stimulation, oestradiol levels, number of oocytes retrieved and the fertilization rate were not significantly different in the myoma patients compared to the control group. Fifteen myoma patients (38.5%) subsequently showed one or more pregnancy sacs on ultrasonography of which three (20%) spontaneously aborted during the first trimester and two (13.3%) had preterm labour, as compared to 123 (33.5%), 19 (15.5%) and nine (7.3%) respectively, among the control group (P = 0.27, 0.33 and 0.21). In conclusion, uterine corporeal myomata, not encroaching on the cavity and <7 cm in mean diameter, do not affect the implantation or miscarriage rates in IVF or ICSI.

Intracytoplasmic sperm injection using surgically retrieved epididymal and testicular spermatozoa in cases of obstructive and non-obstructive azoospermia.

This was a retrospective study of 115 patients who underwent 124 cycles of ICSI using surgically retrieved spermatozoa. The objective was to compare the results of ICSI in patients with obstructive azoospermia using epididymal spermatozoa (36 cycles) or testicular spermatozoa (58 cycles) with ICSI in patients with non-obstructive azoospermia using testicular spermatozoa (30 cycles). When epididymal spermatozoa were used for ICSI, the fertilization rate per injected metaphase-II oocyte and the clinical pregnancy rate per ICSI cycle were 60.4 and 25%, respectively. When testicular spermatozoa were used in obstructive cases, the fertilization rate and pregnancy rate were 57.9 and 34.5%. In non-obstructive cases the fertilization and pregnancy rates were 41.2 and 16.6%. When patients with obstructive azoospermia were regrouped according to the cause of obstruction, the fertilization and pregnancy rates were 59.1 and 35.1% in acquired obstruction and 58.7 and 24.3% in congenital obstruction. The fertilization and pregnancy rates were not statistically different (p > 0.05) when testicular or epididymal spermatozoa were used in obstructive cases; neither was statistically different (p > 0.05) when compared in patients with congenital and acquired obstruction. On the other hand, the fertilization and pregnancy rates in cases with non-obstructive azoospermia were significantly lower (p < 0.05) than in obstructive cases.

Oocyte quality in patients with severe ovarian hyperstimulation syndrome.

OBJECTIVE: To study the oocyte quality in patients with ovarian hyperstimulation syndrome (OHSS). DESIGN: Retrospective study. SETTING: The Egyptian IVF-ET Center. PATIENT(S): Forty-two patients who developed severe OHSS (group A) were studied for the mean number of oocytes retrieved, percentage of high-quality oocytes, embryo quality, and fertilization, implantation, and pregnancy rates; these patients were compared with an age-matched control group who did not develop OHSS (group B; n = 183) after superstimulation for IVF or intracytoplasmic sperm injection. INTERVENTION(S): In vitro fertilization and ICSI. MAIN OUTCOME MEASURE(S): Fertilization and pregnancy rates. RESULT(S): In group A, the mean number of oocytes retrieved was significantly higher, whereas the percentage of high-quality oocytes and the fertilization rate were significantly lower than that in group B. There were no statistically significant differences in the quality of embryos transferred or the implantation or pregnancy rate between the groups. The percentage of high-quality oocytes and the fertilization rate were significantly lower in patients with polycystic ovaries (PCO) in both groups. CONCLUSION(S): The inferior quality and maturity of oocytes in OHSS reduced the fertilization rate but did not affect the quality or the number of embryos transferred or the pregnancy rate. The effect on oocyte quality could be due to the prevalence of PCO in this group of patients.

Intracytoplasmic sperm injection using microsurgically retrieved epididymal and testicular sperm.

OBJECTIVE: To evaluate treatment of couples who are infertile due to unreconstructable obstructive azoospermia with microsurgical epididymal sperm aspiration or testicular sperm and intracytoplasmic sperm injection (ICSI). DESIGN: Prospective. SETTING: The Egyptian IVF-ET Center in association with Cairo University. PATIENTS: Twenty-three couples who are infertile due to obstructive azoospermia in which reconstructive microsurgery failed or was not possible. INTERVENTIONS: Microsurgical epididymal or testicular sperm retrieval and ICSI in 24 cycles. MAIN OUTCOME MEASURES: Fertilization and pregnancies. RESULTS: All 24 cycles had successful fertilization and reached the ET stage. In microsurgical epididymal sperm aspiration cases, fertilization rate per metaphase II oocyte was 63% (109/ 172). Six patients became pregnant, including one set of twins and one set of triplets. One pregnancy resulted from the use of cryothawed epididymal sperm. In testicular sperm aspiration cases, the fertilization rate was 59% (32/54) and four clinical pregnancies resulted. CONCLUSION: The use of microepididymal sperm aspiration or testicular sperm aspiration in conjunction with ICSI provide a highly precise and efficient procedure for achieving pregnancy in cases of unreconstuctable obstructive azoospermia.

In vitro fertilization in a spontaneous cycle: a successful simple protocol.

OBJECTIVE: To study the efficacy of a simple protocol of in vitro fertilization in the spontaneous natural cycle. METHOD: A prospective study using in vitro fertilization in a natural cycle for the treatment of infertility due to tubal factor. RESULTS: Fifty-eight patients were monitored by vaginal ultrasound and LH in urine for 229 cycles. In 49.8% of the cycles the pick-up was canceled because of the early LH rise or failure to visualize a dominant follicle. Ovum pick-up was performed in 112 cycles and oocyte retrieval rate was 87.5%. Embryo transfer was performed in 86 cycles, pregnancy rate per pick-up was 10.2%, and there was no pregnancy wastage. CONCLUSION: IVF in a spontaneous cycle is a simple, low cost and safe treatment, which yields reasonable PR, for young regularly menstruating women with tubal factors of infertility.

Successful treatment of infertile women with hypothalamic primary and secondary protracted amenorrhoea using gonadotrophin releasing hormone analogue and human menopausal gonadotrophin.

Thirty-one women with hypothalamic primary or protracted secondary amenorrhoea were treated with human menopausal gonadotrophin (HMG) in 89 cycles, but adequate follicular growth failed to occur. They were then treated with a gonadotrophin releasing hormone analogue (GnRHa) and HMG in 91 cycles. An adequate ovarian response occurred in 68 cycles (74.7%) and pregnancy occurred in 26 cycles (28.6%). GnRHa and HMG produced an adequate ovarian response in hypothalamic amenorrhoeic patients who failed to respond to HMG alone. The strong initial agonistic effect of GnRHa produced sudden high levels of FSH that might possibly have initiated folliculogenesis which was continued by HMG.