Amr Wahba

Abnormal uterine bleeding in midlife: The role of levonorgestrel intrauterine system

Abnormal uterine bleeding is a common gynecological complaint affecting 10-30% of women in midlife and constitute about one-third of all outpatient gynecological visits. It adversely affects the quality of womans life and can lead to psychological, social, medical, and sexual problems and thus necessitating appropriate and adequate management. Different treatment modalities for such problems are available, yet the levonorgestrel intrauterine system (LNG-IUS) has recently provided a good treatment option effective in treating such complaints and at the same time, having a reliable contraceptive effect which is desired by such age group. For women in their reproductive years, the LNG-IUS has become one of the most acceptable medical treatments for menorrhagia, reducing referrals to specialists, and decreasing the recourse to operative treatments. It is easy to insert, has a sustained effect, cost-effective, and well tolerated besides providing reliable contraception.

Gonadotropin-releasing hormone antagonists versus standard androgen suppression therapy for advanced prostate cancer A systematic review with meta-analysis.

Objectives To evaluate efficacy and safety of gonadotropin-releasing hormone (GnRH) antagonists compared to standard androgen suppression therapy for advanced prostate cancer. Setting The international review team included methodologists of the German Cochrane Centre and clinical experts. Participants We searched CENTRAL, MEDLINE, Web of Science, EMBASE, trial registries and conference books for randomised controlled trials (RCT) for effectiveness data analysis, and randomised or non-randomised controlled studies (non-RCT) for safety data analysis (March 2015). Two authors independently screened identified articles, extracted data, evaluated risk of bias and rated quality of evidence according to GRADE. Results 13 studies (10 RCTs, 3 non-RCTs) were included. No study reported cancer-specific survival or clinical progression. There were no differences in overall mortality (RR 1.35, 95% CI 0.63 to 2.93), treatment failure (RR 0.91, 95% CI 0.70 to 1.17) or prostate-specific antigen progression (RR 0.83, 95% CI 0.64 to 1.06). While there was no difference in quality of life related to urinary symptoms, improved quality of life regarding prostate symptoms, measured with the International Prostate Symptom Score (IPSS), with the use of GnRH antagonists compared with the use of standard androgen suppression therapy (mean score difference −0.40, 95% CI −0.94 to 0.14, and −1.84, 95% CI −3.00 to −0.69, respectively) was found. Quality of evidence for all assessed outcomes was rated low according to GRADE. The risk for injection-site events was increased, but cardiovascular events may occur less often by using GnRH antagonist. Available evidence is hampered by risk of bias, selective reporting and limited follow-up. Conclusions There is currently insufficient evidence to make firm conclusive statements on the efficacy of GnRH antagonist compared to standard androgen suppression therapy for advanced prostate cancer. There is need for further high-quality research on GnRH antagonists with long-term follow-up. Trial registration number CRD42012002751.

Cost effectiveness of letrozole and purified urinary FSH in treating women with clomiphene citrate-resistant polycystic ovarian syndrome: a randomized controlled trial

Abstract We aimed to compare the cost effectiveness of letrozole versus purified urinary follicle stimulating hormone (FSH) in treating patients with clomiphene citrate (CC)-resistant polycystic ovary syndrome (PCOS). This was a randomized trial conducted in Cairo University and Beni-Suef University Hospitals, Egypt. A cohort of 140 eligible women was randomized to receive either letrozole 2.5 mg twice daily for five days, or FSH using a graduated regimen starting with a dose of 75 IU. Treatment was repeated for three months if pregnancy did not occur. There were no significant differences between the two treatments in the cumulative clinical pregnancy rate (30% vs. 34%; p = 0.578), cumulative ovulation rate (47% vs. 57%; p = 0.236), miscarriage rate (9% vs. 4%, p > 0.999) or multiple pregnancy rate (0% and 8%, p = 0.491) but the FSH cycles were 4.8 times more expensive. Letrozole and FSH were both effective in treating women with CC-resistant PCOS but letrozole was more cost effective.Study registration number: NCT02304107.

Follicular output rate can predict clinical pregnancy in women with unexplained infertility undergoing IVF/ICSI: a prospective cohort study

This study aimed to determine whether follicular output rate (FORT) can predict the clinical pregnancy rate in women with unexplained infertility undergoing IVF/ICSI. This was a prospective study conducted at Dar El Teb subfertility centre in Cairo between June 2014 and July 2016. A total of 303 women with unexplained infertility, who were undergoing IVF/ICSI, were divided into three groups according to FORT tertile values. FORT was calculated as pre-ovulatory follicle count/antral follicle count × 100. There was a progressive and significant increase from the low to the high FORT groups in the clinical pregnancy rate (29.9%, 43.3% and 57.8%; P < 0.001), number of retrieved oocytes (5.4 ± 1.5, versus 6.8 ± 2.8, and 7.4 ± 2.1; P < 0.001), and fertilization rate (48.4 ± 21.8 versus 55.3 ± 20.3 and 57.4 ± 19.2; P = 0.006). Multivariate logistic regression analysis revealed that the correlation between FORT and pregnancy was independent of potential confounding factors (P = 0.008). We concluded that FORT is an independent variable affecting the clinical pregnancy rate in IVF/ICSI cycles. Higher FORT values had better oocyte yield and clinical pregnancy rates in women with unexplained infertility undergoing IVF/ICSI with potentially normal ovarian response.

A randomized double-blind controlled trial of different filling pressures in operative outpatient hysteroscopy

To identify the optimal filling pressure during operative outpatient hysteroscopy that allows completion of the procedure while minimizing pain.

3D ultrasound assessment of endometrial junctional zone anatomy as a predictor of the outcome of ICSI cycles

OBJECTIVE To study the relation between junctional zone thickness (JZ) and success of implantation in IVF/ICSI cycles. STUDY DESIGN A prospective study included 100 infertility patients undergoing ICSI. The long protocol was used in all patients. JZ was measured using 3D ultrasound, in the coronal section, at three places, on two occasions. First measurement was done before HMG was started (i.e. when down regulation was achieved). Second measurement was done on the day of ovum pick up (OPU). Follow up after treatment was done to determine the rate of implantation. RESULTS There was a highly significant difference between pregnant and non pregnant treated women regarding the measurement of JZ at the day of OPU at all sites named fundal (0.27±0.1 vs. 0.38±0.14), anterior (0.28±0.07 vs. 0.36±0.09), posterior (0.32±0.1 vs. 0.37±0.09) and average (0.29±0.08 vs. 0.37±0.09) respectively. The cut off value, sensitivity and specificity of measurement of JZ at fundus were (≤0.31,90% and 66.7%), at anterior wall were (≤0.35,90% and 60%), at posterior wall (≤0.25, 50% and 93.3%) and average were (≤0.32,70% and 70%) respectively. CONCLUSION The thinner the junctional zone at day of OPU, the higher the implantation rate and the difference between JZ measured at the day of down regulation and the day of OPU is a predictor of the outcome of ICSI cycles.

The use of human epididymis protein 4 for differentiation between benign and malignant ovarian neoplasm

Objective To assess and compare the sensitivity, specificity, and predictive values of human epididymis factor 4 (HE4) and CA125 (cancer antigen 125 or carbohydrate antigen 125) in the evaluation of ovarian masses (whether benign, endometriomas, or malignant). Patients and methods This was a prospective study carried out in Kasr Al Aini University Hospitals that included 30 patients who presented with adnexal masses and were treated surgically. Patients were divided into three groups: patients with benign ovarian masses, those with ovarian endometriomas, and those with malignant ovarian masses. Assessment of history, examination, and laboratory workup including HE4 and CA125 were carried out for all patients, in addition to abdominal and vaginal ultrasounds, surgical treatment, or staging. Results An receiver-operator characteristic curve with area under the curve in benign versus malignant ovarian lesions showed a 100% sensitivity and a 96% specificity for CA125 at a cut-off value of 40, whereas it showed a 100% sensitivity and a 67% specificity for HE4 at a cut-off value of 42.7. Conclusion In our study population, measurement of HE4 did not provide further benefit over measurement of CA125 in patients with ovarian masses (whether benign ovarian cysts, endometriomas, or malignant ovarian diseases). As the sample size of our study is small, further studies are needed to confirm or confute this result.

Changing Attitudes in Obstetrics and Gynecology - How Evidence Based Medicine is Changing Our Practice?

Evidence-based medicine (EBM) is the process of systematically reviewing, appraising and using clinical research findings to aid the delivery of optimum clinical care to patients (Rosenberg and Donald, 1995). It is considered a new trend in both teaching medicine and supporting the clinical decisive process, answering the clinical questions. The basis of the evidence-based medicine comprises of analysing and interpreting current and reliable medical publications concerning certain subject (Laudanski and Pierzynski., 2000).

Does the addition of LH activity to FSH make gonadotrophins more superior? A systematic review and meta-analysis

Background The contribution of luteinizing hormone (LH) activity to follicle-stimulating hormone (FSH) in ovarian stimulation in improving the outcome of IVF/intracytoplasmic sperm injection (ICSI) has been an area of major debate. Objective To systematically locate, review, and analyze the best available evidence on the value of additional LH activity in ovarian stimulation in IVF and/or ICSI irrespective of the source of LH. Design Systematic review of properly randomized trials comparing FSH only [as recombinant FSH (recFSH)] vs. LH-containing protocols (derived either from a urinary source or developed by recombinant technology) in women undergoing IVF and/or ICSI with desensitization achieved either by long GnRH agonist or GnRH antagonist protocols. A meticulous search was carried out using electronic databases and hand searches of the literature. Results Thirty-one trials were identified. Only nine trials reported on live birth rate and ovarian hyperstimulation (OHSS) rates. Pooling of the trials showed that the live birth rate did not show a statistically significant difference [recFSH (304/1120; 27.14%) vs. FSH/LH (324/1110; 29.19%) (P=0.29; odds ratio (OR)=0.90, 95% confidence interval (CI)=0.75–1.09)]. OHSS rates also did not show a significant difference [recFSH (34/1888; 1.80%) vs. FSH/LH (29/1843; 1.57%) (P=0.79; OR=1.08, 95% CI=0.63–1.83)]. The clinical pregnancy rate significantly favored additional LH activity [(recFSH (748/2758; 27.1%) vs. FSH/LH (838/2772; 30.2%), P=0.008; OR=0.85 95% CI=0.76–0.96)], whereas FSH-only protocols (recFSH) yielded a higher number of retrieved oocytes compared with LH-containing protocols (FSH/LH) (P=0.002; mean difference=1.25, 95% CI=0.48–2.02). Conclusion LH activity is not paramount in ovarian stimulation.