Laparoscopic ovarian drilling before IVF/ICSI in polycystic ovarian syndrome patients with high antimullarian hormone.

OBJECTIVE: To evaluate the effect of performing laparoscopic ovarian drilling [LOD] before proceeding to in vitro fertilization [IVF] or intracytoplasmic sperm injection [ICSI] on the cycle outcomes in polycystic ovarian syndrome [PCOS] patients with high antimullerian hormone [AMH] levels. STUDY DESIGN: A retrospective case-control study. PATIENTS AND METHODS: The study was conducted in the Fertility Care Unit in our University Hospital. The participants of the study were PCOS women with high serum AMH levels [≥ 7 ng/ml] who were subjected to IVF/ICSI. Women who underwent LOD in the preceding 3 months before IVF/ICSI [study group; n = 76] were compared with a control group of women who did not undergo LOD [control group; n = 71]. RESULTS: Total gonadotropin consumption and the number of stimulation days were significantly lower with LOD [P = 0.026 and 0.010, respectively]. Oocyte maturity rate was significantly higher with LOD [P = 0.028]. The incidence of severe OHSS was significantly lower with LOD [P = 0.026]. No significant difference between both groups in the pregnancy and implantation rates. CONCLUSION: The LOD before IVF/ICSI in PCOS patients with high AMH [≥ 7 ng/ml] has the benefits of reduction in gonadotropins consumption and stimulation days with an increase in the percentage of collected mature oocytes and decrease in the incidence of severe OHSS; however, it seems not to improve the pregnancy and implantation rates.

Myomectomy during cesarean section: A retrospective cohort study.

OBJECTIVE: To evaluate the value of myomectomy during delivery by cesarean section (CS) in pregnant women with uterine fibroids. METHODS: Retrospective cohort study of pregnant women diagnosed to have uterine fibroids during index pregnancy. Women who underwent myomectomy during CS (study group; n = 91) were compared with women in whom myomectomy was not performed during CS (control group; n = 87). RESULTS: No significant difference between both groups in the amount of blood transfusion and postoperative hemoglobin level. The operative time was significantly higher in the myomectomy group than in the control group (80.22 ± 13.06 vs 56.67 ± 8.85 min; P < 0.001). Also, the postoperative hospital stay period was significantly higher in the myomectomy group (P < 0.001). CONCLUSION: Myomectomy during CS can be performed safely without increase in the peripartum maternal morbidities. It only may prolong the operative time and postoperative hospital stay period but it may have many benefits including avoiding another operation to remove fibroids.

Timing of initiation of low-molecular-weight heparin administration in pregnant women with antiphospholipid syndrome: a randomized clinical trial of efficacy and safety.

OBJECTIVE: We aimed to evaluate the effect of different timing of initiation of low-molecular-weight heparin (LMWH) administration on the pregnancy outcomes in women with antiphospholipid syndrome (APS). MATERIALS AND METHODS: A randomized controlled study was conducted on women with obstetrical APS. All participants were randomly divided at documentation of positive pregnancy test into two groups; early initiation group in which LMWH therapy was started once positive pregnancy test was established (in the fifth week of gestation), and later initiation group in which LMWH therapy was started after sonographic confirmation of fetal cardiac pulsation (in the seventh week of gestation). In both groups, LMWH (enoxaparin) was given at a dose of 40 mg/day subcutaneously and the therapy continued until end of pregnancy. The primary outcome measure was ongoing pregnancy rate and the secondary outcome measures were fetal loss, live birth rate, preterm labor before 34 weeks of gestation, intrauterine growth restriction (IUGR), and congenital fetal malformations. RESULTS: Ninety-four women (48 in the early initiation group and 46 in the later initiation group) were subjected to final analysis. The ongoing pregnancy rate was significantly higher in the early initiation group than in the later initiation group (81.2% vs 60.9%; P=0.040). However, both groups were similar in the incidences of fetal loss, preterm labor before 34 weeks of gestation, and IUGR, and live birth rate. No recorded congenital fetal malformations in both groups. CONCLUSION: Early administration of LMWH for pregnant women with obstetrical APS reduces early pregnancy loss, but does not affect the incidence of late obstetrical complications.

Analgesic effect of adding magnesium sulfate to epidural levobupivacaine in patients with pre-eclampsia undergoing elective cesarean section.

BACKGROUND AND AIMS: Magnesium is a physiological antagonist of NMDA receptor and a calcium channel blocker. This study was designed to test the analgesic effect of magnesium sulfate (MgSO4) when added to epidural anesthesia in mild pre-eclampsia. MATERIAL AND METHODS: Sixty parturients with mild pre-eclampsia were allocated randomly to two equal groups. The Placebo group received 20 ml levobupivacaine hydrochloride 0.5% plus 5 ml isotonic saline 0.9% using two separate syringes. The Magnesium group received the same amount of local anesthetic plus 5 ml of 10% MgSO4(500 mg) using two separate syringes. The primary outcome was pain free period. While, the secondary outcomes were the onset of motor block and the time needed to achieve complete motor block. The analgesic profile was evaluated by visual analog scale (VAS) during rest or motion, the time to first request for analgesia, and the total analgesic consumption. RESULTS: The pain-free period was significantly longer in the Magnesium group (311.3 ± 21.4) compared to placebo group (153.1 ± 22.18). The total postoperative consumption of fentanyl was significantly lower in the Magnesium group (42.4 ± 5.3) than that in the placebo group (94.4 ± 9.9), with a P value 0. 01. Both the onset time of motor block and the time needed to achieve complete motor block were significantly shorter among the Magnesium group (4.4 ± 1.4 and 8.2 ± 0.4, respectively), with a P value of 0. 01. CONCLUSION: The addition of 500 mg MgSO4 to epidural anesthesia fastens both sensory and motor blockade and improves postoperative analgesic profile.

Intrauterine Inflated Foley's Catheter Balloon in the Management of Abnormally Invasive Placenta Previa: A Case-Control Study.

OBJECTIVE: To describe the use of intrauterine inflated Foley's catheter balloon for control of postpartum hemorrhage (PPH) during cesarean section (CS) in cases of abnormally invasive placenta previa aiming to preserve the uterus. METHODS: Retrospective case-control study of the data of women who underwent elective CS on abnormally adherent placenta previa was carried out. Women in whom inflated Foley's catheter balloon was used for control of PPH during CS (n = 40) were compared with a control group of women who underwent elective CS by the same technique but without use of intrauterine catheter balloon (n = 38). RESULTS: Use of intrauterine inflated Foley's catheter balloon significantly reduced the estimated amount of blood loss (P = 0.008), amounts of crystalloids, colloids and packed red blood cells transfusion (P = 0.025, 0.017 and 0.022, respectively), and the need for bilateral internal iliac artery (IIA) ligation (P = 0.016). No significant difference was observed between both groups regarding the use of massive transfusion protocol, performing cesarean hysterectomy, relaparotomy, and admission to the intensive care unit. CONCLUSION: Application of an intrauterine inflated Foley's catheter balloon during CS in cases of morbidly adherent placenta previa helps to control PPH with preservation of the uterus and decreases the need for the invasive IIA ligation.

Early fetal reduction to twin versus prophylactic cervical cerclage for triplet pregnancies conceived with assisted reproductive techniques.

OBJECTIVE: To compare the obstetric outcomes of triplet gestations managed by early fetal reduction to twins with those managed by prophylactic cervical cerclage in women conceived with assisted reproductive techniques (ART). MATERIALS AND METHODS: Retrospective study of the pregnancy and neonatal outcomes of trichorionic triplet gestations achieved by ART and managed either by early transvaginal fetal reduction to twins (n = 53) or by prophylactic placement of cervical cerclage (n = 65). RESULTS: The pregnancy duration was significantly longer with fetal reduction and the incidences of delivery before 34 and 32 weeks gestational age were significantly lower with fetal reduction. Both miscarriage and live birth rates were comparable in the two groups. The incidences of very low birth weight (VLBW), neonatal respiratory distress syndrome (RDS), admission to neonatal intensive care unit (NICU) and early neonatal death (END) were significantly lower with fetal reduction. CONCLUSION: Early transvaginal reduction of triplets to twins leads to improved obstetric outcomes as it decreases prematurity and its related neonatal morbidities and mortality without increase in the miscarriage rate. Early fetal reduction seems to be better than continuation of triplet pregnancies with prophylactic placement of cervical cerclage.

Accelerated Coasting Does Not Affect Oocyte Maturation.

AIMS: The study aimed to assess the efficacy of accelerating the process of coasting through adding gonadotropin releasing hormone (GnRH) antagonist (GnRH-ant) on the day of triggering of oocyte maturation without withholding the GnRH agonist (GnRHa) in women at risk for developing ovarian hyperstimulation syndrome (OHSS). METHODS: Retrospective case-control study of the outcomes of GnRHa cycles in which women were at risk to develop OHSS. Women who underwent acceleration of coasting (n = 50) were compared with a control group of women who underwent usual coasting (n = 57). RESULTS: The oocyte maturation and fertilization rates were significantly higher in the accelerated coasting group than in the usual coasting group (83.05 vs. 67.62%; p < 0.001 and 79.85 vs. 65.84%; p < 0.001, respectively). The pregnancy rates were higher in the accelerated coasting group than in the usual coasting group but without statistically significant difference. The incidences of mild, moderate, and severe OHSS were not significantly different between both groups. CONCLUSION: Acceleration of coasting in cases of OHSS through treatment with GnRH-ant after pituitary suppression with GnRHa offered a novel approach to reduce estradiol level, avoid cycle cancellation, and maintain excellent oocyte maturation rate and thus high pregnancy rate with prevention of OHSS.

Bone marrow mesenchymal stem cell repair of cyclophosphamide-induced ovarian insufficiency in a mouse model.

OBJECTIVE: Attempting in vivo healing of cyclophosphamide-induced ovarian insufficiency in a mouse model using bone marrow mesenchymal stem cells (BMMSCs). METHODS: Female BALB/c white mice were used to prepare a model for premature ovarian failure by single intraperitoneal injection of cyclophosphamide (80 mg/kg). Ten mice were injected with BMMSCs and then sacrificed after 21 days for morphometric evaluation of the ovaries. Hormonal profile was evaluated while mice were being sacrificed. Another 10 mice were left for natural breeding with male mice, and 5 of these were injected with BMMSCs. Oocyte-like structures were obtained from 3 mice and were subjected to in vitro fertilization/intracytoplasmic sperm injection. RESULTS: Morphometric analysis of the ovaries demonstrated the presence of newly formed primordial follicles. Contribution of MSCs to the formation of these follicles was proven by a labeling technique. There was a drop in estradiol and rise in follicle-stimulating hormone levels, followed by resumption of the hormonal levels to near normal 21 days after MSCs therapy. The 5 mice that were injected with MSCs became pregnant after natural breeding. Fertilization and further division was reported in 5 oocytes subjected to intracytoplasmic sperm injection, but division did not continue. CONCLUSION: From this proof-of-concept trial, we can say that healing of damaged ovaries after chemotherapy in mice is possible using in vivo therapy with BMMSCs. This should open the gate for a series of animal studies that test the possibility of in vitro maturation of germinal epithelium of the ovary into mature oocytes.