In-vitro fertilisation in women aged 40 years and above.

INTRODUCTION: To compare the results of in-vitro fertilisation (IVF) in women aged less than 40 years with those aged 40 years and above with baseline follicle-stimulating hormone (FSH) levels less than 15iu and using their own oocytes. METHODS: A total of 2179 fresh IVF cycles were started in KK Women's and Children's Hospital IVF Centre from 1997 to 2002, of which 247 cycles were done in women 40 to 45 years with FSH levels less than 15iu. The remaining 1932 cycles were performed in another group of women aged less than 40 years old. All couples were treated using our hospital's IVF protocol, and the same clinical and embryological team was involved in all treatments. The medical records of patient outcomes were retrospectively reviewed. The main outcomes measured were clinical pregnancy, miscarriage and delivery rates. RESULTS: The total number of fresh cycles performed in women over 40 years was 247 cycles. Of these, 186 (75.3 percent) cycles reached oocyte collection, and 179 (72.5 percent) cycles reached embryo transfer. The total number of pregnancies was 22 (12.3 percent). The number of cancelled cycles was 61 (24.7 percent). Women less than 40 years of age demonstrated higher rates in cycles reaching oocyte collection (89.2 percent), embryo transfer (84.6 percent), pregnancy rates (32.9 percent) and live-birth rates (24.0 percent). They also reported a lower miscarriage (36.1 percent) and cancellation rate (10.9 percent) as compared to the group of older women. CONCLUSION: As older women seek IVF treatment, it is necessary for them to understand that chances of pregnancy decrease with increasing age. Our results show that as women exceed 40 years old, pregnancy and live-birth rates fall with concurrent rising miscarriage and cycle cancellation rates.

A prospective controlled study of the effect of intramural uterine fibroids on the outcome of assisted conception.

BACKGROUND: Although uterine fibroids occur in 30% of women and are associated with a degree of subfertility, the effect of intramural fibroids on the outcome of IVF or ICSI treatment has not been prospectively studied. METHODS: Data were prospectively collected on 434 women undergoing IVF/ICSI in the assisted conception unit of an inner London teaching hospital. Patients were assessed for the presence of fibroids by transvaginal ultrasound and hysterosonography or hysteroscopy where appropriate. RESULTS: During the study period, 112 women with (study), and 322 women without (controls), intramural fibroids were treated. Patients were similar regarding the cause and duration of their infertility, number of previous treatments, and basal serum FSH concentration. Women in the study group were on average 2 years older (36.4 versus 34.6 years; P < 0.01). There was no significant difference in the duration of ovarian stimulation or gonadotrophin requirement, number of follicles developed, oocytes collected, embryos available for transfer or replaced. When analysing only women with intramural fibroids of < or =5 cm in size (n = 106) pregnancy, implantation and ongoing pregnancy rates were significantly reduced: 23.3, 11.9 and 15.1 respectively compared with 34.1, 20.2 and 28.3% in the control group (P = 0.016, P = 0.018 and P = 0.003). The mean size of the largest fibroids was 2.3 cm (90% range 2.1-2.5 cm). Logistic regression analysis demonstrated that the presence of intramural fibroids was one of the significant variables affecting the chance of an ongoing pregnancy, even after controlling for the number of embryos available for replacement and increasing age, particularly age > or =40 years, odds ratio 0.46 (CI 0.24-0.88; P = 0.019). CONCLUSION: This study demonstrated that an intramural fibroid halves the chances of an ongoing pregnancy following assisted conception.

Clinical application of preimplantation genetic diagnosis.

Preimplantation genetic diagnosis (PGD) is an early alternative to prenatal diagnosis that is suitable for a small group of patients who are at substantial risk of conceiving a pregnancy affected by a known genetic defect. Four centres are licensed to perform PGD in the UK. This article reviews the clinical experience of PGD at the Guy's and St Thomas' Centre for Preimplantation Genetic Diagnosis, now the busiest unit for PGD in the UK, and compares it with information from other centres in Europe. The results from the first 40 cycles of treatment and the 12 pregnancies arising from those cycles are detailed. It is our belief that PGD should be seen as an extension of a clinical genetic service, rather than an arm of assisted conception. Making the distinction between treatment for infertility and prevention of genetic defect as part of genetic service provision may improve access to health service funding for patients deserving of PGD.

Routine screening for Chlamydia trachomatis in subfertile women--is it time to start?

UNLABELLED: Genital Chlamydia trachomatis infection has long been recognised as the major cause of pelvic disease and subsequently infertility. The diagnosis of this infection has traditionally relied on tissue culture. The availability of DNA amplification methods like ligase chain reaction promises faster and more sensitive results. This study was conducted to evaluate the prevalence of chlamydial infection in a subfertile population subgroup. AIM: A case control longitudinal study of 100 subfertile women in a tertiary teaching hospital were analyzed for the prevalence of genital Chlamydia trachomatis infection using ligase chain reaction test kit. RESULTS: A prevalence rate of 8% was detected, the majority being 25 years old or less (33.3%), p = 0.007. All patients gave no prior history of abnormal PAP smears, hospitalisation for pelvic inflammatory disease or abnormal vaginal discharge at the time of investigation. CONCLUSION: Our infertile group of patients has a relatively high incidence of silent genital Chlamydia trachomatis infection. This being highest in the below 25 years old age group. This finding indicates that screening for chlamydia may be necessary for the subfertile couple presenting to clinic. This is especially so if the patient is of the younger age group.

Clinical pregnancy following blastomere biopsy and PGD for a reciprocal translocation carrier: analysis of meiotic outcomes and embryo quality in two IVF cycles.

A couple were referred for preimplantation genetic diagnosis (PGD) following diagnosis of a reciprocal translocation in the female partner: 46,XX,t(14;22)(q11.2;q13.3). PGD was carried out using fluorescence in situ hybridization (FISH) with probes specific for the translocated and centric segments of chromosome 22. An initial cycle was unsuccessful, producing 11 embryos for biopsy, only one of which, when followed up on day 4, yielded more than 10 nuclei (median 7.5, n=10). In addition, five of the embryos showed mosaic or chaotic chromosome constitutions; some of these embryos had fragmented or multilobed abnormal nuclei, hindering interpretation of the FISH signals. The single embryo transferred did not result in a pregnancy. A second cycle, using a revised protocol, produced 10 embryos, three of which were transferred, resulting in an ongoing singleton pregnancy. All the remaining embryos yielded 12 to 23 nuclei by day 4 (median 17, n=7). Apart from some tetraploid nuclei, only one embryo showed mosaicism. The significance of the changes in protocol leading to the successful outcome is discussed, and the pattern of meiotic segregation products is analysed and compared with other previous reports of reciprocal translocations.

Profile of patients seen at a psychosexual clinic in a gynaecological teaching hospital--the Singapore experience.

Ignorance is not bliss when it comes to sexuality. Psychosexual problems lead to shame, fumbling, needless fears, low-self esteem and even subfertility. The demands for help appears to be increasing; as the general population become more aware of its presence and the treatment options available through the mass media and better health education. Sex therapy has traditionally been the realm of the psychiatrist but with the gynaecologist as the first contact for most women, the number of women seeking advice directly from their doctors will only increase with time. A total of 243 new cases of sexual dysfunction were treated at the sexual problem clinic in Kandang Kerbau Hospital between January 1994 and November 1996; majority of which were self-referrals (48.5%). The patient pool consisted of more males than females although the clinical setting is in an obstetrics and gynaecology teaching institute. Vaginismus and erectile problems constituted the main complaints. Erectile problems are more common in the patients above 40 years old (p < 0.001). We report here our experience of such a sexual problem clinic and hope to provide insight into this area of medicine from the perspective of a practising gynaecologist.

Ureteral injuries in an obstetric and gynaecology teaching hospital.

Between November 1994 to May 1996, there was a total of eight ureteric injuries out of 2495 major gynaecologic operations and one ureteric injury out of 4146 caesarean sections at the Kandang Kerbau Hospital, giving the incidence to be 0.3% and 0.02% respectively. Antecedent operations were four abdominal hysterectomies, two Werthiem's hysterectomies, one laparoscopic-assisted vaginal hysterectomy and one caesarean section. All operations were performed by qualified specialists. Three patients had previous abdominal operations and five patients had procedures complicated by dense adhesions. Only one injury was detected intraoperatively and the rest presented with uretero-vaginal fistula. One presented with immediate postoperative anuria. The average time interval for diagnosis ranged between one day and twenty-three days (average 10.7 days). The commonest damage was transection of the ureter. Double J stents were used in all repairs with two cases requiring reimplantation with psoas hitch, and two cases of ureteroneocystostomies and one case of primary reanastomosis. There were no mortality in our series.

Optimising management of stillbirths in modern Singapore.

OBJECTIVE: To conduct a critical analysis of stillbirths in Kandang Kerbau Hospital with emphasis on epidemiological factors, related causes and investigation strategies. DESIGN: A prospective study. SETTING: Kandang Kerbau Hospital. PATIENTS: Case records containing antenatal and post-partum details of all 136 stillbirths were obtained from the medical records office and reviewed by 3 obstetricians. Epidemiological data, antenatal history, intrapartum progress, post-partum investigation, post-mortem findings (where applicable) were reviewed and recorded. RESULTS: The incidence of stillbirths was 4.48/ 1,000 in 1994. 73.1% of the stillbirths were macerated. Significantly higher stillbirth rates were noted in the Malays and unbooked or late booking cases. The causes of stillbirths were unexplained in 29.4%. Fetal anomalies constituted 18.4%, followed by asphyxia, abruptio, and cord accidents. Maternal obstetrical problems contributed to the rest. CONCLUSION: A comprehensive management strategy to reduce stillbirths include community and patient education, early or shared antenatal care, careful prenatal surveillance, optimum investigations as well as a careful audit with adequate bereavement and counselling.

Three cases of fatal pulmonary embolism in obstetrics.

We conducted a retrospective analysis of maternal deaths in our hospital from January 1992 to December 1995. Cases of fatal pulmonary embolism were identified and analysed with respect to their past history, antenatal and peripartum progress, clinical presentation and investigation. There were 7 maternal deaths during this period and autopsies were performed in all cases. Pulmonary embolism was the leading cause of maternal mortality, responsible for 3 deaths. The incidence of fatal pulmonary embolism was 4.9 per 100,000 maternities. One case occurred antepartum and 2 occurred postpartum. The antepartum case occurred after a period of immobilisation, and both postpartum cases occurred after emergency Caesarean sections. Dyspnoea and sudden cardiovascular collapse were the commonest presentations. Electrocardiograph and arterial blood gases were abnormal in both patients in whom the tests were performed. Death occurred within 11 hours of presentation of symptoms in all 3 cases. Pulmonary embolism was more common among our population than previously reported, and was the leading cause of maternal mortality in our institution over the last 4 years. Immobilisation and Caesarean section were the major risk factors. Identification of high risk situation, antithrombotic prophylaxis and a high degree of suspicion were the key to reducing the incidence of fatal pulmonary embolism in obstetric patients.

A case report: cephalic replacement and emergency caesarean section for the resolution of shoulder dystocia.

Shoulder dystocia is a serious complication of delivery. Various manoeuvres had been described, all aim at achieving shoulder descent and vaginal delivery. We report a case whereby shoulder dystocia was managed by a rather unique technique--the foetal head was replaced in the vagina and baby delivered by emergency Caesarean Section.

An analysis of risk factors for the prediction of shoulder dystocia in 16,471 consecutive births.

This paper is a univariate analysis of the demographic, antepartum and intrapartum risk factors in a series of 16,471 consecutive deliveries in a tertiary obstetric and gynaecological unit in Singapore. In total, 12,229 term vaginal cephalic deliveries with 77 cases of shoulder dystocia were entered into the study for analysis. The incidence of shoulder dystocia was found to be 0.63% of all term vaginal cephalic deliveries. There is a direct relationship between increasing infant birthweight and incidence of shoulder dystocia. The critical birthweight for the prediction of shoulder dystocia is 3600 g. In order of decreasing relative risks, the factors which appear to be predictive of shoulder dystocia are a birthweight in excess of 3600 g, diabetes in pregnancy, lower social class, of Indian origin, maternal weight in excess of 70 kg, parity more than 4, and the use of oxytocics during labour. The local birthweight distribution is very different from the West. A policy for elective caesarean section for birthweights in excess of 4000 g (97% tile) would prevent 44% of shoulder dystocias, increase the caesarean section rate by 2% and half the perinatal mortality among births with shoulder dystocia.