Adding the phytoestrogen Cimicifugae Racemosae to clomiphene induction cycles with timed intercourse in polycystic ovary syndrome improves cycle outcomes and pregnancy rates - a randomized trial.

BACKGROUND: Owing to their potential to act as estrogen receptor modulators and interfere with aromatase enzyme in animal studies, phytoestrogens (PE) may be useful as part of ovulation induction for polycystic ovary syndrome (PCOS). PATIENTS AND METHODS: Patients <35 years, presenting with infertility and PCOS, were included and randomly allocated to either group I (clomiphene citrate; CC) or group II (CC plus Cimicifugae racemosae; CR). Primary outcome was pregnancy rate. Secondary outcomes included ovulation, midcycle serum estradiol and luteinizing hormone (LH) as well as mid-luteal serum progesterone. RESULTS: Analysis included 98 patients in group I versus 96 patients in group II. Both groups were matched regarding demographics and basic data. Significant differences were elicited when comparing days until HCG injection (15.0 ± 1.7 versus 12.0 ± 1.9, p=0.91), endometrial thickness (mm) (8.5 ± 1.9 versus 12.5 ± 1.9, p<0.001), serum levels of mid-luteal and midcycle estradiol (p<0.001; Figure 2), LH (IU/ml) (p<0.001) as well as mid-luteal progesterone (p<0.001). PE plus CC group had significantly higher clinical pregnancies per cycle (33/192 (17.2%) versus 71/204 (34.8%), p<0.01), compared to the CC only group. CONCLUSIONS: Adding CR to clomiphene-induction cycles with timed intercourse in polycystic ovarian syndrome improves cycle outcomes and pregnancy rates.

Hybrid septate uterus, coexistence of bicornuate and septate varieties: a genuine report.

AIM: To highlight the coexistence of a uterine septum in cases diagnosed as bicornuate uterus on the basis of the external shape of the uterine fundus and to present the outcomes of its hysteroscopic management. METHODS: Descriptive clinical report. Cases with two-chambered uterine cavities were recruited with exclusion of cases with pure bicornuate uteri. The differentiation between hybrid and pure septate uterine varieties was based on clinical evaluation, transvaginal ultrasonic evaluation, hysterosalpingography and in addition to bimanual examination under anesthesia. The final diagnosis was confirmed by combined hysteroscopy-laparoscopy examinations. Cases with pure and hybrid septate uteri were managed by hysteroscopic metroplasty and the outcomes were compared. RESULTS: Out of 357 cases of double chambered uteri, 18 cases (5%) were found to be a pure bicornuate variety (PBV), 322 (90.2%) cases were found to have pure septate variety (PSV) and 17 cases (4.8%) were found to have hybrid septate variety (HSV). In HSV, there was external fundal depression dividing only the upper part of the corpus giving an imprecise impression of a bicornuate uterus with a laparoscopic view, but there was a long extension of the dividing interface. Nine cases with HSV were associated with a complete utero-cervico-vaginal septum, and five cases had a complete uterine septum. The diagnosis of asymmetric horns, hemi-obstruction or bicervical uterus was made in three cases with HSV. All cases with a septate uterus were offered hysteroscopic metroplasty, and cases with fundal depression were operated under laparoscopic monitoring. In cases with HSV, the procedure was performed safely and successfully in 16/17 cases (94%). One uterine perforation was encountered, giving a six-fold increase in the perforation risk, and passed uneventfully. Successful reproductive outcomes were reported in 178/189 cases (94.1%) with PSV and in 12/15 (80%) with HSV. CONCLUSIONS: External fundal depressions of variable depths are associating with a septate uterus, indicating coexistence of the two anomalies. These cases are candidates for hysteroscopic metroplasty under appropriate sonographic and/or laparoscopic monitoring.

Management of eclampsia at Assiut University Hospital, Egypt.

OBJECTIVE: To evaluate the protocol used for management of eclampsia at Assiut University Hospital, Assiut, Egypt. METHODS: In a prospective cross-sectional study, data were collected from 1998 women treated for eclampsia at Assiut University Hospital between January 1990 and January 2010, including 1594 cases of prepartum eclampsia, 75 of intrapartum eclampsia, 16 of intercurrent eclampsia, and 313 of postpartum eclampsia. The treatment regimen included use of nifedipine as an antihypertensive, magnesium sulfate as an anticonvulsant, rapid interruption of pregnancy, and admission to the ICU. Data were evaluated for control of blood pressure, prevention and control of convulsions, and maternal and perinatal outcomes. RESULTS: Magnesium sulfate was effective in controlling convulsions in 98.1% of women. Nifedipine initiated a smooth decline in blood pressure (P>0.0001). There were 79 maternal deaths (3.95%). Maternal morbidity occurred in 439 (22%) women. Twenty-seven percent of women delivered vaginally (most of these women were admitted postpartum). Perinatal mortality occurred in 7.9% of cases. CONCLUSION: A combination of nifedipine as an antihypertensive drug, magnesium sulfate as an anticonvulsant, rapid interruption of pregnancy, and managing the patients in the ICU resulted in a marked improvement in the outcome for both mother and fetus at Assiut University Hospital.

Emergency contraception in the context of marriage in Upper Egypt.

OBJECTIVE: To explore the degree of knowledge, perception, and practice of emergency contraception (EC) within marital relations in Egypt. METHODS: The present study was a pilot cross-sectional survey. Eligible participants were randomly selected from 4 governorates in Upper Egypt. A questionnaire was designed by the investigators and administered to an unselected sample of healthcare providers and potential users of EC. The questionnaire collected information in 4 domains: demographics; knowledge about EC; attitudes toward EC; and practice of EC in Egypt. RESULTS: In total, 240 healthcare providers and 60 potential users of EC completed the questionnaire. Approximately 85% of healthcare providers and 30% of potential users had heard about EC. A similar proportion of study participants said that EC methods are needed. Only 32.7% of healthcare providers and very few potential users had actually used EC. CONCLUSION: There is a need for EC in Egypt. However, a big gap in knowledge leads to nonuse or incorrect use of EC and negative attitude toward it. If health service planners and policy makers could fill this gap, a considerable decline in the prevalence of unwanted pregnancy may be achieved by using EC.

Primary infertility and health-related quality of life in Upper Egypt.

OBJECTIVE: To assess the effect of infertility on the health-related quality of life and sexual function of infertile women in Upper Egypt. METHOD: The Quality-of-Life Questionnaire (QLQ) C30, version 2, and a visual analog scale were used to assess the quality of life and sexual satisfaction of 116 women with primary infertility and 116 fertile women with similar sociodemographic characteristics. We also looked for associations between the results and infertility duration. RESULTS: Compared with the fertile women, the women with primary infertility had significantly lower scores for both health-related quality of life and sexual function, and their sexual function was the most disturbed during the fourth, fifth, and sixth years of their marriage. CONCLUSION: Women with primary infertility need to be treated medically and psychologically to improve their quality of life and sexual function.

Does visceral peritoneal closure affect post-cesarean urinary symptoms? A randomized clinical trial.

INTRODUCTION AND HYPOTHESIS: We hypothesized that upward bladder traction by visceral peritoneal closure during cesarean sections may have an impact on postpartum urinary complaints. METHODS: Based on a 90% power of the study and a 95% confidence interval, a sample size of 114 patients in each arm was needed to detect a 15% difference between both groups regarding postpartum urinary incontinence. To account for follow-up losses, we prospectively randomized 620 term primigravidas undergoing non-emergency cesareans into two groups (310 each): group 1, visceral peritoneal closure; group 2, non-closure. We compared perineal ultrasound findings 30 min before and 48 h after surgery. The UDI-6 questionnaire was used to assess urinary complaints. RESULTS: Group 1 showed significant widening of the posterior urethrovesical angle and alpha angle, more urethral descent 48 h postpartum and higher incidence of frequency, urge and stress incontinence 8 weeks postpartum. Symptoms disappeared almost completely after 6 months. CONCLUSIONS: Compared to visceral peritoneal non-closure, cesarean with visceral closure is associated with significant postpartum frequency of urination and/or incontinence that disappear without treatment almost completely within 6 months.

Prevalence and characteristics of female sexual dysfunction in a sample of women from Upper Egypt.

OBJECTIVE: To study the prevalence and associated risk factors for female sexual dysfunction (FSD) in Upper Egypt. METHODS: Married women attending the outpatient clinic of Sohag University Hospital between February 2008 and March 2009 were recruited. Through direct interviews, each woman completed a questionnaire that included questions on sexual dysfunction. RESULTS: From 648 recruited patients, 47 declined to participate in the study. Of the 601 remaining participants, 462 women (76.9%) reported 1 or more sexual problems. Low sexual desire was the most common sexual problem (66.4%). Patients with FSD were significantly more likely to be older than 40 years, have sexual intercourse fewer than 3 times a week, have been married for 10 years or more, have 5 children or more, be circumcised, have a husband aged 40 years or more, and be postmenopausal. Age of the women maintained a statistically significant positive relationship with FSD in the regression model (odds ratio 1.39; 95% CI, 1.26-1.53). CONCLUSIONS: There was a high prevalence of FSD in this sample of women from Upper Egypt. The prevalence of sexual problems increased with increasing age of the women.

Bilateral uterine artery ligation plus B-Lynch procedure for atonic postpartum hemorrhage with placenta accreta.

OBJECTIVE: To assess the effectiveness of bilateral uterine artery ligation followed by B-Lynch compression suturing in women with atonic postpartum hemorrhage and placental site bleeding due to adherent placenta accreta. METHOD: This protocol was followed in 26 women undergoing cesarean delivery for placenta accreta. RESULTS: Two women died from disseminated intravascular coagulopathy. In the remaining 24 women, placental remnants completely disappeared within 8 months and ovulation resumed after a mean+/-SD of 51.6+/-3.2 days. Moreover, 18 women (75%) became pregnant within 12 months. CONCLUSION: Atonic postpartum hemorrhage and placental site bleeding due to adherent placenta accreta can be safely controlled by bilateral uterine artery ligation followed by B-Lynch compression suturing in women who desire to remain fertile.

Clomiphene citrate plus tamoxifen versus laparoscopic ovarian drilling in women with clomiphene-resistant polycystic ovary syndrome.

OBJECTIVE: To compare the efficacy of clomiphene citrate (CC) plus tamoxifen with that of laparoscopic ovarian drilling in clomiphene-resistant women with polycystic ovary syndrome (PCOS). METHOD: We randomly allocated 150 women with CC-resistant PCOS to a combined medication group (group 1) or a laparoscopic surgery group (group 2). The primary outcome was the live birth rate in each group; secondary outcomes were the rates of ovulation, clinical pregnancy and miscarriage. RESULTS: There were no significant differences between the groups regarding rates of ovulation (81.3% vs 85.3%), pregnancy (53.3% vs 50.7%), or live births (49.3% vs 44.0%), but the mean endometrium thickness was significantly greater on the day of human chorionic gonadotropin administration in group 1 (P<0.001). CONCLUSION: Clomiphene citrate plus tamoxifen was as effective as laparoscopic ovarian drilling in promoting ovulation and pregnancy.

Supplementation of clomiphene citrate cycles with Cimicifuga racemosa or ethinyl oestradiol--a randomized trial.

The anti-oestrogenic activity of clomiphene citrate (CC) on the cervical mucous and endometrium may be the reason for the relatively low pregnancy rates in CC induction cycles. Various follicular-phase supplements have been tried to improve cycle outcome in these patients. This study compared follicular-phase supplementation with either phytoestrogen (PE) or ethinyl oestradiol (EE) in CC induction cycles for the treatment of unexplained infertility. A total of 134 patients were randomly allocated to each treatment group (67 each). The PE group needed significantly fewer days for adequate follicular maturation, had a thicker endometrium and higher oestradiol concentration at the time of human chorionic gonadotrophin injection (all P < 0.001). The PE group had higher luteal-phase serum progesterone compared with the EE group. No significant difference was found regarding clinical pregnancy rates (14.0% versus 21.1%, respectively). In conclusion, the cycle characteristics in unexplained infertility women treated with clomiphene citrate induction and timed intercourse improved after follicular-phase supplementation with PE compared with EE supplementation. Further studies are needed to confirm the mechanism beyond these effects.

Oral misoprostol reduces vaginal bleeding following surgical evacuation for first trimester spontaneous abortion.

OBJECTIVE: To assess the effectiveness and tolerability of misoprostol to reduce the amount and duration of vaginal bleeding following surgical evacuation for first trimester spontaneous abortion. METHODS: A total of 160 patients who underwent surgical evacuation for first trimester spontaneous abortion between 8 and 12 weeks of pregnancy were randomized into 2 groups to receive either 200 microg of oral misoprostol immediately after evacuation followed every 6 hours for 48 hours or no misoprostol. Pain scores, duration and amount of bleeding, and endometrial thickness were assessed over 10 days. RESULTS: Women who received misoprostol had significantly fewer bleeding days after evacuation (4.11+/-2.69 vs 5.89+/-3.06; P<0.001), fewer patients reported vaginal bleeding lasting 10 days or more (3.8% vs 15.0%; P=0.014), and endometrial thickness 10 days after evacuation was less (6.25+/-2.38 vs 7.23+/-1.94; P=0.05). Pain scores were comparable in both groups (1.54+/-0.65 vs 1.63+/-0.83; P=0.40) after 10 days. CONCLUSION: Oral misoprostol is effective in reducing the prevalence and amount of vaginal bleeding after surgical evacuation for first trimester spontaneous abortion.

Effect of short-term maternal fasting in the third trimester on uterine, umbilical, and fetal middle cerebral artery Doppler indices.

OBJECTIVE: To assess the effect of short-term maternal fasting on uterine, umbilical, and middle cerebral artery Doppler indices, and on maternal serum glucose levels and fetal behavior. METHODS: Maternal serum glucose levels, fetal biophysical profiles, and uterine, umbilical, and middle cerebral artery Doppler indices were assessed in 110 healthy women in the third trimester of pregnancy after fasting for 10-12 hours and 2 hours after a balanced meal. RESULTS: Maternal serum glucose levels, nonstress test results, fetal breathing movements, and biophysical profile improved after a meal compared with after fasting for 10-12 hours. Uterine, umbilical, and middle cerebral artery Doppler indices were not significantly different after fasting and after a meal. CONCLUSION: Short-term maternal fasting during the third trimester of pregnancy has no effect on uterine, umbilical, or fetal cerebral artery Doppler indices, and has a transient but significant effect on maternal serum glucose levels and fetal behavior.

Hysterosalpingo-contrast sonography versus radiographic hysterosalpingography in the evaluation of tubal patency.

OBJECTIVE: To compare the efficacy of hysterosalpingo-contrast sonography (HyCoSy) using a saline solution with that of radiographic hysterosalpingography (HSG) in the assessment of tubal patency. METHOD: We compared the findings obtained by the 2 methods with those obtained by standard diagnostic laparoscopy with the chromopertubation test in a study with 88 infertile women younger than 40 years. RESULTS: The sensitivity, specificity, and diagnostic accuracy of HyCoSy and HSG were similar, and 65 (74%) of the women reported the pain associated with HyCoSy as mild to moderate. CONCLUSION: The HyCoSy procedure is well tolerated and can be used as a primary tool for the evaluation of tubal patency in infertile women.

Rectal misoprostol versus intravenous oxytocin for prevention of postpartum hemorrhage.

OBJECTIVE: To assess the effectiveness of 800 microg of rectal misoprostol compared with an intravenous infusion of 5 IU of oxytocin as prophylaxis against postpartum hemorrhage (PPH). METHODS: A total of 514 women in labor were randomized into two groups (257 women in each). Within 1 minute of delivery of the anterior shoulder participants in group 1 received 800 microg of rectal misoprostol and 1 ampoule of normal saline in 5 mL lactated Ringer solution intravenously; group 2 received a rectal placebo tablet and 5 IU of oxytocin in 5 mL lactated Ringer solution intravenously. RESULTS: Both groups were comparable regarding the need for uterotonics, blood transfusion, and hematocrit drop of 10% or greater, 24 hours post partum (P=0.54, P=0.25, and P=0.85, respectively). Fever was significantly higher among misoprostol patients (18.7% vs 0.8%, P<0.001). CONCLUSIONS: Routine use of 800 microg of rectal misoprostol was effective in reducing blood loss after delivery. We recommend the regimen for low-resource, busy obstetric settings.

Parietal peritoneal closure and persistent postcesarean pain.

OBJECTIVE: To assess the incidence of persistent pain after cesarean delivery. METHODS: A total of 340 pregnant women with no history of abdominal surgery were randomized to undergo or not undergo parietal peritoneal closure following elective cesarean delivery. Pain scores were recorded on the 1st and 15th postoperative day and the women were followed up every 2 weeks up to 8 months after surgery. RESULTS: Overall and epigastric abdominal pain were more frequent in the closure than in the nonclosure group. Pain scores on the 1st and 15th days and after 8 months were higher in the closure group, in which the incidence of persistent postcesarean pain was 17.8% after 8 months. CONCLUSION: Parietal peritoneal closure after cesarean delivery is associated with a higher incidence of early and persistent postoperative pain. A high pain score on the 1st day is a predictor of persistent pain.

Effect of oral N-acetyl cysteine on recurrent preterm labor following treatment for bacterial vaginosis.

OBJECTIVE: To evaluate the effect of N-acetyl cysteine (NAC) on gestational age at delivery in women with previous preterm labor and bacterial vaginosis. METHODS: A randomized, double-blind, placebo-controlled trial with 280 women between 16 and 18 weeks of pregnancy who had 1 previous preterm birth and had just been successfully treated for bacterial vaginosis with metronidazole for 1 week. The women were randomized to receive 0.6 g of NAC per day plus 17-hydroxyprogesterone caproate (17-OHPC) or placebo plus 17-OHPC until 36 completed weeks of pregnancy or active labor. A vaginal swab was taken during labor. RESULTS: Reaching 36 weeks of pregnancy was more frequent (P<0.05) and gestational age at delivery was significantly higher in the NAC than in the placebo group (37.4 weeks+/-0.4 weeks vs 34.1 weeks+/-1.2 weeks, P<0.05). The discontinuation rate was 11.4% in the NAC group. CONCLUSIONS: Oral NAC was found to reduce the recurrence of preterm birth in patients with bacterial vaginosis.

Sublingual versus vaginal misoprostol for induction of labor at term: a randomized prospective placebo-controlled study.

AIMS: To assess the effectiveness and safety of sublingual misoprostol (50 microg), compared with the same dose administered vaginally every 6 h for cervical ripening and labor induction in women with a viable fetus in the third trimester of pregnancy. METHODS: This double-blind randomized prospective placebo-controlled trial included 480 women with medical or obstetric indications for labor induction and undilated, uneffaced cervices. The patients were assigned randomly to receive 50 microg of sublingual or 50 microg of vaginal misoprostol every 6 h for 24 h. Maternal and neonatal outcome were analyzed. RESULTS: A total of 169 (70.4%) patients delivered vaginally in the sublingual group compared to 160 (66.7%) in the vaginal group. The main indications for cesarean section in both groups were fetal distress (33/71 [46.4%] vs 38/80 [47.5%]), followed by failure of labor progress. Thirty three (13.8%) patients in the sublingual group had meconium staining of the amniotic fluid compared to 39 (16.3%) in the vaginal group. There was no difference between the groups regarding the induction-to-delivery interval, duration of labor, neonatal outcome or maternal side-effects. CONCLUSION: Sublingual misoprostol is as effective as vaginal misoprostol for induction of labor at term. Moreover, the sublingual route is associated with a significantly higher patient satisfaction rate than vaginal misoprostol.

Endometrial sonographic characters predicting pregnancy following recurrent clomiphene induction in unexplained infertility.

Patients with unexplained infertility managed repeatedly with clomiphene citrate need parameters to predict pregnancy to save them further unsuccessful trials and shorten their treatment to pregnancy interval. Ovulation was induced in 226 unexplained infertility patients, who had three previous failed cycles, with 100 mg clomiphene citrate (CC) from days 3 to 7 of the cycle. Human chorionic gonadotrophin (HCG) injection (10,000 IU i.m.) was given and timed intercourse was recommended when a leading follicle reached >17 mm and serum oestradiol exceeded 200 pg/ml. A receiver operating characteristic (ROC) curve showed that endometrial thickness >11.60 mm was associated with the lowest, while values >5.50 mm were associated with the highest chance of pregnancy. An endometrial thickness of 7.05 mm showed the best sensitivity and specificity. Patients with endometrial thickness <7.05 mm (n = 98) had significantly more clinical pregnancies (28.6 versus 8.9%), fewer days until HCG injection, thicker endometrium, higher serum progesterone measured on days 20-22 and more triple layer endometria than patients with endometrial thickness > or =7.05 mm (n = 56). It is concluded that endometrial thickness range of 5.50-8.25 mm and triple layer endometrium are highly predictive for pregnancy in patients with unexplained infertility induced with CC after repeated failures. Endometrial thickness of 11.60 mm was associated with a low chance of pregnancy.