Adel Saad Helal

The effects of timing of intrauterine insemination in relation to ovulation and the number of inseminations on cycle pregnancy rate in common infertility etiologies

BACKGROUND Controlled ovarian hyperstimulation with intrauterine insemination (COH/IUI) is an established tool in medically assisted conception for many infertility factors. However, the proper timing of IUI after hCG trigger and the frequency of IUI are still debated. We aimed to examine the association between the cycle pregnancy rate (CPR) and: (i) single IUI timed at 36 ± 2 h post-hCG (pre- or post-ovulation) (ii) the number of IUI (single or double) for pre-ovulatory cases both aims in male, anovulatory and unexplained infertility. METHODS The study included a total 1146 first-stimulated cycles in infertile couples due to male factor, anovulation or unexplained infertility. Cycles were stimulated by clomiphine citrate (CC) or sequential CC-hMG or hMG and monitored by transvaginal ultrasound. When the leading follicle reached ≥ 18 mm mean diameter, 10000 IU hCG was given to trigger ovulation and IUI was timed for 36 ± 2 h later. Semen was processed and ovulation was checked at the time of IUI. Post-ovulatory cases received single IUI, while pre-ovulatory cases were sequentially randomized to receive either single or double IUI. The end-point of the cycle was CPR. RESULTS Overall CPR in the whole cohort was 10.1%. When ovulation was present before IUI, CPR was 11.7% compared with 6.7% when ovulation was absent [OR (95% CI): 1.85 (1.12-3.06), P = 0.015]. When this OR was computed according to infertility etiology, it was 1.26 (0.52-2.95) (P = 0.82) for male factor infertility and 2.24 (1.23-4.08) (P = 0.007) for non-male factor infertility. Comparing the CPR for double versus single IUI in pre-ovulatory cases, the OR for all cycles was 1.9 (0.76-4.7) (P = 0.22), but according to etiology, it was 4.667 (0.9-24.13) (P = 0.06) in male factor and 1.2 (0.43-3.33) (P = 0.779) for non-male factors. CONCLUSIONS Single IUI timed post-ovulation gives a better CPR when compared with single pre-ovulation IUI for non-male infertility, whereas for male factors, pre-ovulation, double IUI gives a better CPR when compared with single IUI.

The effect of luteal phase support protocol on cycle outcome and luteal phase hormone profile in long agonist protocol intracytoplasmic sperm injection cycles: a randomized clinical trial

OBJECTIVE To study the effect of luteal phase support protocol on cycle outcome and luteal phase hormone profile, in long agonist protocol intracytoplasmic sperm injection (ICSI) cycles. DESIGN Prospective randomized trial. SETTING Private infertility center. PATIENT(S) Two hundred seventy-four women undergoing first ICSI cycles were randomized after ovum pickup into three groups of luteal support. INTERVENTION(S) Group I received IM P (P(4)) only, group II received P(4) + oral E(2) valerate, group III received P(4) + hCG. MAIN OUTCOME MEASURE(S) Pregnancy rate (PR), implantation rate, rates of multiple pregnancy and miscarriage, and midluteal serum E(2) and P(4), and midluteal E(2):P(4) ratio. RESULT(S) The PR and implantation rates were significantly higher in group II compared to group I and the miscarriage rate was significantly lower in group II compared with group I. Midluteal E(2) was significantly higher in group II compared with group I. The decline in E(2) after ovum pickup was lowest in group II, highest in group I. The midluteal E(2):P(4) ratio was significantly higher in group II compared with groups I and III. CONCLUSION(S) The E(2) luteal phase supplementation in long GnRH-agonist (GnRH-a) protocol ICSI cycles resulted in better cycle outcome and better luteal phase hormone profile.

Preliminary uterine artery ligation versus pericervical mechanical tourniquet in reducing hemorrhage during abdominal myomectomy.

To compare the effectiveness of preliminary uterine artery ligation versus pericervical mechanical tourniquet in reducing hemorrhage during myomectomy.

Effect of childhood kidney transplantation on puberty

OBJECTIVE To evaluate sexual and linear growth in kidney transplant (KTX) children receiving cyclosporine A, low-dose prednisolone and azathioprine. STUDY DESIGN Prospective case-control study. SETTING University-affiliated urology and nephrology center, obstetric and gynecology departments. PATIENT(S) Eighteen girls and 21 boys with successful KTX before the age of 16 years. Controls were healthy and age matched (200 girls and 171 boys). INTERVENTION(S) Assessment of sexual maturation by Tanner staging and linear growth by height standard deviation score (HSDS) and height increment (HI). MAIN OUTCOME MEASURE(S) Pubertal age in KTX vs. control, ratios of KTX with normal and retarded sexual maturation and linear growth. RESULT(S) Puberty in KTX children was significantly delayed compared with controls. Delayed sexual maturation was found in 22.2% of girls and 19.1% of boys, and poor HSDS was found in 38.9% of girls and 33.3% of boys. Improvement in HSDS was significantly lower in girls compared with boys. Improvement in HSDS did not significantly differ in prepubertal vs. pubertal children. Prepubertal HI was significantly higher than pubertal HI in boys, but not in girls. Significant negative correlation was found between HI, duration of immunosuppression, and serum creatinine level. CONCLUSION(S) KTX children receiving cyclosporine A, low-dose prednisolone, and azathioprine showed acceptable sexual and physical maturation in a majority of cases. Impaired sexual and linear growth after receiving KTX is related to poor graft function, post-KTX interval, and gender.

Rising Rates of Caesarean Delivery at Mansoura University Hospital: A Reason for Concern

Objectives: To study the rates and indications of Caesarean delivery at Mansoura University Hospital in Egypt. Patients and methods: This retrospective study collected data on caesarean delivery rates and indications from the medical records of 34598 women admitted to both emergency and high risk obstetric units over a 5-year period (January 2006-December 2010). Results: The overall rate of caesarean delivery was 47.25%. Rates at the high risk and the emergency units were 79.33% and 29.15% respectively. The annual rate of caesarean delivery increased significantly (p<0.01) from 42.65% in 2006 to 55.33 % in 2010, mainly due to an increase in the rate of caesarean at the emergency unit. The most common causes were repeat caesarean (35.78%), medical disorders complicating pregnancy (14.25%), failure to progress in labor (10.37%) and malpresentations (9.9%). Vaginal birth after caesarean (VBAC) was attempted in 2078 women and was successful in 22.23%. Conclusion: The overall rate of caesarean delivery at Mansoura University hospital was 47.25%. This high rate was mainly attributed to previous caesarean delivery, low rate of successful VBAC and the very low rate of attempted instrumental delivery.

Transvaginal Bilateral Uterine Artery Occlusion for Treatment of Symptomatic Uterine Myomas: An Effective Modality in Low Resource Settings

Objective: To study the effectiveness and safety of bilateral uterine artery occlusion through the vaginal approach as an alternative treatment modality for symptomatic uterine myomas. Methods: Sixty-nine premenopausal women with symptomatic uterine leiomyomata were studied. None of them desired further pregnancy underwent bilateral vaginal uterine arteries occlusion. The primary outcome measures were patient satisfaction as regards menstrual blood loss compared with pre treatment loss and operative duration. Secondary outcome measures included postoperative pain, complications, secondary interventions, and failures. Results: Sixty-three women were completed follow up till 24 months after the procedure. The primary outcomes were encouraging as regards patient satisfaction for post treatment blood loss (90.7 %) and mean operative duration ( 35 ±9.5 minutes). After 6 months of follow-up, 6 patients resumed heavy periods and interventions needs secondary. Conclusion: Trans-vaginal occlusion of uterine arteries improved clinical symptoms in the majority of patients.