Prevalence of gestational diabetes mellitus and pregnancy outcomes in Asian women with polycystic ovary syndrome.

The aim of this study was to determine the prevalence of gestational diabetes mellitus (GDM) and the pregnancy outcomes in Asian women with polycystic ovary syndrome (PCOS). The retrospective cohort study was performed to compare pregnancy outcomes of 47 pregnancies in 41 PCOS women with 264 pregnancies in 222 women with normal menstruation. Logistic regression was used to assess the risk of PCOS on GDM, hypertensive disorder in pregnancy (HDP) and premature delivery. The mean age of both groups was 31 years. The mean body mass index (BMI) and proportion of BMI of > 25 kg/m2 were significantly higher in the PCOS than in the control group. There was no difference in the prevalence of GDM between the PCOS women and the high-risk group of the controls. The prevalence of HDP and premature delivery was significantly greater in PCOS women (21.3 and 13.3%) than in the controls (6.4 and 5.4%), respectively. PCOS was demonstrated as a risk factor for GDM and HDP with borderline statistical significance, but not for premature birth. The Cesarean section rate was higher in the PCOS than in the control group. In conclusion, the prevalence of GDM in Asian women with PCOS is high and comparable to those of a high-risk group.

Prevalence of type 2 diabetes mellitus and impaired glucose tolerance in Asian women with polycystic ovary syndrome.

OBJECTIVES: To determine the prevalence of abnormalities of glucose metabolism in Asian women with polycystic ovary syndrome (PCOS) and to assess the different impacts of the 1985 and 1999 WHO consultations and the ADA criteria for the diagnosis of type 2 diabetes mellitus (DM). METHODS: Eighty-five women with PCOS were consecutively included in the study at the Reproductive Endocrinology Unit, Department of Ob-Gyn, Ramathibodi Hospital, Mahidol University. All women underwent a standard oral glucose tolerance test (OGTT). Fasting insulin and testosterone levels were also measured. RESULTS: Seventy-nine women consented to the OGTT. The prevalence of impaired glucose tolerance (IGT) and type 2 DM was 22.8 and 15.2% with the 1985 WHO criteria, and 20.3 and 17.7% according to the 1999 WHO consultation criteria, respectively. The recommendation of the ADA using the fasting glucose levels could only determine a prevalence of 6.3% for type 2 DM. The fasting insulin and testosterone levels were significantly higher in DM than IGT and normal glucose tolerance (NGT) subgroups. The PCOS women with abnormalities of glucose metabolism had a greater body mass index (BMI), higher fasting glucose and 2-h post-load glucose levels than those with NGT. The prevalence of glucose intolerance significantly increased with BMI. CONCLUSIONS: Similar to other ethnic populations, Asian women with PCOS are at risk of developing IGT and type 2 DM especially if obese. The recommendation of the ADA is not appropriate for the diagnosis of type 2 DM in PCOS women.

Laparoscopic hysterectomy using laparosonic coagulating shears: experience of 15 cases.

In conventional laparoscopic hysterectomy, adequate hemostasis is provided by bipolar coagulation, staple, and suture. The Laparosonic Coagulating Shears (LCS) have been proven to give both hemostasis and cutting. The objective of this study was to evaluate the efficacy of the LCS for laparoscopic hysterectomy. Fifteen patients indicated for hysterectomy were enrolled for laparoscopic hysterectomy using LCS. Each procedure was performed under general endotracheal anesthesia. The LCS were operated at power level 1 though 5. All pedicles, blood vessels, and tissues were coagulated and cut by LCS. The cardinal ligaments were cut and ligated transvaginally. The uterus was removed through the vagina. The operative finding, uterine volume and weight, operative time, CO2 volume, blood loss and hospital stay were recorded. Among the 15 cases, the indications were myoma uteri (7 cases), adenomyosis (6 cases) and adenomyosis with endometriomas (2 cases). The mean volume of the uterus was 226.8 cm3 (range 77-399 cm3) and mean weight was 188.8 g (range 85-320 g). Mean operative time was 171.6 min (range 114-210 min) and CO2 loss was 313.8 liters (range 120-650 liters). Blood loss was 366.7 ml (range 100-1,500 ml). LCS can be used for coagulation and cutting simultaneously. Minimal charring and smoke was observed during operation. In general, the hospital stay was 3 days (range 2-4 days), except for one case of recto-sigmoid injury and 2 cases of ureteric injury when the hospital stay was 7, 10, and 12 days, respectively. The injuries occurred in cases with anatomic distortion, profuse bleeding, and dense adhesion. LCS can be used as an alternative instrument for coagulation and dissection. According to our experience, it produces less charring and smoke compared to electrocoagulation. However, a high rate of complications were still encountered.

Cost-effectiveness of IVF in women 38 years and older.

OBJECTIVE: To compare the cost per delivery in women younger than 38 years with women equal to or older than 38 years of age attempting IVF. METHODS: All couples undergoing IVF treatment between October 1991 and September 1998 were enrolled in this study. A standard protocol of controlled ovarian hyperstimulation was employed throughout the study. Four hundred and seven cases were allocated to two groups - group I composed of patients younger than 38 years of age and group II of patient equal to or older than 38 years of age. The total cost of each successful outcome was the goal of our study. RESULTS: A total of 407 women underwent 722 stimulated cycles for IVF of which 122 cycles (16.89%) did not proceed to oocyte retrieval. We found statistically significant differences in the cancellation rate, the number of hMG ampoules, the number of oocytes retrieved, the number of oocytes fertilized, the number of embryos transferred, the clinical pregnancy rate, the rate of multiple pregnancy, the delivery per initiated cycle and the cost per delivery between the two groups (P<0.05, significant). The cost per delivery in group II was approximately 3.6 times that of group I. CONCLUSIONS: Women age 38 years or more have less chance of a successful outcome from IVF treatment. Couples contemplating IVF should be provided with accurate information about prognosis for the pregnancy and the financial costs.

Assessment of sperm cryodamage and strategies to improve outcome.

Sperm cryopreservation still represents a valuable clinical aid in the management of infertility. Its current principal indications include (1) donor sperm insemination; (2) freezing before cancer therapy to maintain reproductive capacity; (3) patient's convenience; and (4) because of the outstanding success with ICSI, even patients with different degrees of oligo-asthenoteratozoospermia can now be offered the use of frozen/thawed sperm for oocyte micromanipulation. Although sperm cryopreservation/thawing and results of insemination and IVF have been consistently good using donor semen, results of infertile men (with or without various degrees of oligoasthenoteratozoospermia) have yielded remarkably lower rates of survival and pregnancy. Freezing/thawing techniques have not been subjected to major changes in the last years, Furthermore, the exact nature of sperm cryodamage still remains to be elucidated. Various aspects of sperm freezing are revisited here (1) development of new technical approaches for cryopreservation; (2) analysis of the stimulatory effect of putative cryoprotectant additives; (3) the use of intrauterine insemination-ready processed samples; and (4) selection and optimization of end-points for analysis of cryodamage. It is expected that advances in such areas will improve significantly the cryopreservation/thawing outcome particularly as related to semen samples of subfertile men.

Efficacy of laparoscopic ovulation induction in polycystic ovary syndrome.

This prospective study was aimed to evaluate the efficacy of laparoscopic ovarian electrocoagulation in women with PCOS. Twenty-three PCOS women who had refractory to clomiphene citrate attending the Reproductive Endocrinology Unit, Ramathibodi Hospital between March 1995 and June 1998 were enrolled in the study. In all patients, electrocoagulation on the ovarian surface of both ovaries was performed through laparoscope under general anesthesia. Two patients were lost to follow-up for unknown reasons. The remaining 21 women had a mean age of 30.3 +/- 3.9 years (range 21-39) and mean duration of infertility of 4.1 +/- 2.8 years (range 1-11). There was no intra-operative and post-operative complication. After surgery, ovulation was documented in 16 out of 18 (88.9%) patients. Fifteen (71.4%) patients became pregnant. Fourteen pregnancies (93.3%) occurred within 9 months after surgery. Twelve women (80%) became pregnant in spontaneous cycles without any treatment. The outcomes of pregnancies were 10 live births, 3 ongoing pregnancies and 2 abortions. This study reveals the high efficacy of ovarian electrocoagulation in infertile women with PCOS. High pregnancy and low abortion rates are convincing. This surgical technique should be the treatment of choice for women with CC-resistant PCOS.

Modulation of sperm tail protein tyrosine phosphorylation by pentoxifylline and its correlation with hyperactivated motility.

OBJECTIVE: To assess the effect of pentoxifylline on human sperm functions that are crucial to fertilization. DESIGN: Prospective, controlled study. SETTING: Academic tertiary care institute. PATIENT(S): Healthy male sperm donors. INTERVENTION(S): The effects of pentoxifylline (3.6 mM) on hyperactivated motility, sperm binding to the zona pellucida, and sperm protein tyrosine phosphorylation were evaluated. MAIN OUTCOME MEASURE(S): Hyperactivated motility was assessed by computer-assisted motion analysis, and tight binding of sperm to homologous zonae pellucidae was examined using the hemizona assay. Sperm protein phosphorylation was evaluated using indirect immunofluorescence with an antibody to phosphotyrosine (PY20). RESULT(S): Pentoxifylline significantly stimulated hyperactivated motility at 1 hour and 4 hours; it also significantly increased sperm binding to the zona pellucida and enhanced sperm tail tyrosine phosphorylation at 4 hours under capacitating conditions. There was a statistically significant correlation between hyperactivated motility and sperm tail protein phosphorylation. CONCLUSION(S): Pentoxifylline stimulates sperm functions that are essential to achieving fertilization under in vitro conditions in sperm obtained from fertile men. The enhancement of hyperactivated motility is associated with the stimulation of sperm tail tyrosine phosphorylation, suggesting a causal relation and the involvement of a modulatory effect after cyclic adenosine monophosphate-dependent phosphorylation of intermediate proteins.

Pentoxifylline stimulates various sperm motion parameters and cervical mucus penetrability in patients with asthenozoospermia.

Pentoxifylline (PTX) was incubated in vitro with human spermatozoa to examine its effects on sperm motility characteristics and bovine cervical mucus penetrability (BCMP). Sperm motion parameters were assessed by computer-assisted motion analysis (CASA) using HTM-IVOS and BCMP was evaluated using the Penetrak kit. In vitro incubation with PTX (1 mg ml-1; 3.6 mM, 30 min) did not significantly change percentage motility, average path velocity (VAP), straight-line velocity (VSL) or beat cross frequency (BCF) of spermatozoa from normozoospermic or asthenozoospermic samples. However, it significantly increased curvilinear velocity (VCL), amplitude of lateral head displacement (ALH) and hyperactivated motility (HA), and significantly decreased linearity (LIN) of spermatozoa from both samples. Pentoxifylline was found to increase BCMP scores for spermatozoa from asthenozoospermic samples, but did not affect scores for spermatozoa from normozoospermic samples. Bovine cervical mucus penetrability (BCMP) was found to be positively and significantly correlated with the percentage motility of both non-PTX-treated and PTX-treated spermatozoa for asthenozoospermic samples. These results demonstrated that PTX enhanced several motion sperm parameters as well as BCMP in asthenozoospermic samples and suggest a potential use of the methylxanthine in infertile patients with motility defects undergoing artificial insemination.

Plasma membrane integrity of cryopreserved human sperm: an investigation of the results of the hypoosmotic swelling test, the water test, and eosin-Y staining.

OBJECTIVE: [1] To examine the relationship between sperm membrane integrity and motion parameters before and after cryopreservation; [2] to determine the capacity of the membrane integrity tests to predict the outcome of cryopreservation in fertile and infertile men; and [3] to examine the degree of agreement between tail and head membrane integrity of testicular and ejaculated immotile sperm cryopreserved for intracytoplasmic sperm injection. DESIGN: Prospective study. SETTING: Academic tertiary care institution. PATIENT(S): Fertile donors and normozoospermic oligozoospermic, and asthenozoospermic subfertile men. INTERVENTION(S): Semen samples were cryopreserved and thawed for analysis. MAIN OUTCOME MEASURE(S): Sperm membrane integrity and computer-assisted motion parameters. RESULT(S): The hypoosmotic swelling test and water test had a significant and positive correlation in the fresh and cryopreserved ejaculates of all groups. The results of the hypoosmotic swelling test correlated positively with the percent motility in the fresh ejaculates of fertile and subfertile men. None of the membrane integrity tests correlated with the cryosurvival rate in any group. In the ejaculated and testicular samples with no postcryopreservation motility, the simultaneous assessment of hypoosmotic swelling test and eosin showed that of 33% sperm exhibiting coiling with the hypoosmotic swelling test, only 9% were eosin negative, whereas 24% were eosin positive. CONCLUSION(S): [1] The water test may be a simpler replacement for the hypoosmotic swelling test; [2] none of the membrane integrity tests predicted sperm motility after cryopreservation; and [3] there was a high degree of disagreement between the hypoosmotic swelling test and eosin in the samples with no postcryopreservation motility.

Comparison of various methods of processing human cryopreserved-thawed semen samples.

We compared the efficacy of various methods of processing cryopreserved-thawed samples for the recovery of functionally adequate spermatozoa as assessed by the response to the sperm stress test (SST), an index of temperature activated sperm membrane lipid peroxidation, and immediate and delayed changes in sperm viability and motion parameters. Donor semen samples (n = 28) were cryopreserved-thawed and divided into six equal parts, one part was used as control and the remaining parts were used to compare five methods of sperm processing as follows: direct Percoll gradient processing, washing by one-step or stepwise addition of the washing medium followed by Percoll processing, and washing by one-step or stepwise addition of the washing medium. Additional samples (n = 10) were evaluated for the immediate and delayed (6 h at 37 degrees C) impact of one-step and stepwise washing (without Percoll separation). Compared with wash-only methods, samples processed using Percoll had a significantly higher SST score (P = 0.001), motility, rapid spermatozoa (>50 microm/s), curvilinear velocity and motility index (P < 0.001). Comparing various Percoll methods, direct Percoll processing resulted in the highest number of motile spermatozoa recovered (P < 0.00001) and a higher SST score based on curvilinear velocity (P = 0.001). Stepwise washing gave a significantly higher number of motile spermatozoa (P < 0.001) but with a significantly lower SST score based on the concentration of motile spermatozoa (P = 0.001), motility (P = 0.001) and motility index (P = 0.01). Sperm viability and motion parameters after 6 h of incubation showed no difference between one-step and stepwise washing. In conclusion, compared with wash-only methods, Percoll processed samples resulted in the recovery of spermatozoa with superior quality as assessed by SST and motion analysis. One-step washing of the samples gave an overall comparable recovery compared to the samples prepared stepwise. Having significantly higher SST scores, similar viability and the maintenance of motility, one-step washing may be a better method of processing thawed samples than the stepwise washing.

Propofol anesthesia for transvaginal ultrasound guided oocyte retrieval.

The purposes of this study were to determine the efficacy of propofol anesthesia for oocyte retrieval and its effect on IVF outcomes. The anesthetic records of 339 oocyte retrieval cycles were analysed. The mean of total amount of propofol, duration of anesthesia and oocyte pick up were 197.7 +/- 84.2 mg, 25.2 +/- 8.5 and 19.5 +/- 7.4 minutes, respectively. In all cases propofol induced anesthesia within seconds. Mean recovery time was 32.2 +/- 5.4 minutes. Significant nausea and vomiting occurred in one patient. Mild hypotension was observed in 55 out of 339 cycles (16.2%) which did not correlate to the amount and duration of propofol used. A total of 3,417 oocytes were obtained. Fertilization occurred in 2,431 oocytes (71.1%). Mean cleavage rate was 84.5 per cent of fertilized eggs. Mean number of transferred embryo was 4.4 +/- 2.0. Embryos were transferred in 321 cycles, resulted in 73 pregnancies (21.5% per oocyte pick up and 22.7% per transfer). Neither the dose of propofol or the duration of anesthesia has significant effect on pregnancy rate. Propofol anesthesia was found to be efficacious for oocyte retrieval with a rapid induction and recovery, and minimal side effects. The fertilization and pregnancy rates are comparable to other reports using different anesthetic or analgesic agents. However, to reliably determine if propofol affects the IVF outcome a prospective and randomized trial should be performed.

Outcome of pregnancy in IVF-ET cycle at Ramathibodi Hospital.

As assisted reproductive technology is being developed, in vitro fertilization and embryo transfer (IVF-ET) are the treatments of choice for many infertility problems. The outcome of pregnancies achieved by IVF-ET is different from that of spontaneous pregnancies. In this retrospective study, the outcome of pregnancies from 400 IVF treatment cycles performed from October 1991 to October 1994 were reported. There were 80 pregnancies (20% per oocyte retrieval, 21.9% per embryo transfer) with an increased rate of abortion (30%), multiple pregnancy (20%), ectopic pregnancy (6.25%), heterotopic pregnancy (1.25%), preterm delivery (11.8%), low birth weight (35.8%) and cesarean section (62.7%). This study shows that the complication rate of pregnancies from IVF-ET cycles was higher than that found in spontaneous pregnancies. Some complications such as multiple pregnancies may be prevented by limiting the number of transferred embryos. From this study, all IVF-ET pregnancy should be considered as high risk pregnancies.

Determinants of multiple pregnancies in in vitro fertilization other than number of transferred embryos.

The aim of this study is to assess the many different parameters involved in the incidence of multiple pregnancies, such as maternal age, stimulation, endometrium, receptivity and the quality of the transferred embryos. During a 3.5 year period, 86 pregnancies were recorded in our IVF unit. A single gestational sac was identified by early ultrasonography in 67 patients, while in 19 others, multiple sacs were noted. Patient characteristics, treatment cycles and embryology results were similar in the two groups. When the number of transferred embryos was kept similar in both groups, EIR was found to be a valuable prognostic determinant for multiple pregnancies in IVF.

"Simplified IVF": program for developing countries.

The aim of this study is to assess the results of the "Simplified IVF" program at Ramathibodi Hospital. Ramathibodi IVF program has been in operation since October, 1991. Some steps of the conventional IVF procedures have been modified due to the limitation of resources. The embryo laboratory is a simple, clean room situated in a different building from the oocyte recovery room. Short protocol of GnRHa/HMG is used for ovarian stimulation. Monitoring of the follicular development is performed by ultrasound alone with limited number of scans (2-3 times/cycle). Oocyte retrieval is carried out under transvaginal ultrasound guidance and the aspirate transported to the embryo laboratory in a simple insulated box. Luteal phase is supported by giving micronized progesterone. Eighty five couples have undergone 105 ovarian stimulation cycles. OR was done in 100 cycles from 80 couples. Total oocytes collected is 1091. The fertilization rate is 75 per cent. Embryos were transferred in 97 cycles. Clinical pregnancy occurred in 25 cycles. Pregnancy rate per OR and ET is 25 and 25.8 per cent respectively. Nineteen patients have delivered (6 twins, 13 singletons). Simplification of procedures has enabled the IVF service to be available in a center with limited resources without compromising the results. Other advantages are improvement of the patient's convenience, cost savings and less time consumed as well as being less stressful.