Hassan N. Sallam

Ultrasound-guided embryo transfer: a meta-analysis of randomized controlled trials

OBJECTIVE To conduct a meta-analysis of randomized controlled studies to evaluate abdominal ultrasound-guided embryo transfer compared to the clinical touch method. DESIGN Meta-analysis. SETTING Four studies performed in academic research centers in Barcelona, Vizcaya, Hong Kong, and Madrid. PATIENT(S) A total of 2,051 patients: 1,024 received ultrasound-guided embryo transfers and 1,027 received clinical touch method transfers. INTERVENTION(S) Fourteen studies were retrieved from the literature, but only four of them fitted our selection criteria. The meta-analysis was conducted using the RevMan software with the Peto-modified Mantel-Haenszel method and the fixed effect model. MAIN OUTCOME MEASURE(S) The primary outcome measures were the clinical pregnancy and ongoing pregnancy rates. The secondary outcome measures were the incidences of ectopic pregnancies, miscarriage rate, multiple pregnancies, and difficult transfers. RESULT(S) Compared to the clinical touch method, abdominal ultrasound-guided transfer significantly increased the clinical pregnancy rate and the ongoing pregnancy rate. There was no effect on the incidence of ectopic pregnancy, multiple pregnancy, or miscarriage rate. CONCLSUION(S): Ultrasound-guided embryo transfer increases the clinical pregnancy and ongoing pregnancy rates significantly compared to the clinical touch method.

Gonadatrophin suppression to prevent chemotherapy-induced ovarian damage: a randomized controlled trial.

OBJECTIVE: To estimate the effectiveness of gonadotropin-releasing hormone (GnRH) analogues cotreatment in preventing chemotherapy-induced amenorrhea in young breast cancer patients undergoing cyclophosphamide-based chemotherapy. METHODS: One hundred hormone-insensitive breast cancer participants (aged 18-40 years) were recruited from two university-affiliated oncology centers in Egypt. Opting for type of cotreatment was based on available timeframe until start of chemotherapy. Fifty women ready for early chemotherapy were randomized to receive either chemotherapy alone (arm I) or chemotherapy after downregulation (estradiol less than 50 pg/mL) by GnRH antagonist and agonist (arm II). Then, GnRH antagonist was discontinued and agonist was continued until the end of chemotherapy. When chemotherapy was to start later than 10 days after study inclusion, 50 women were randomized to receive either chemotherapy alone (arm III) or chemotherapy after downregulation with GnRH agonist (arm IV). Resumption of menstruation at 12 months after end of chemotherapy was the primary outcome. Postchemotherapy hormonal and ultrasound changes were secondary outcomes. RESULTS: Twelve months after termination of chemotherapy, there were no differences in menstruation resumption rates between GnRH-treated patients and control group individuals in either early (80% in arms I and II, risk ratio 1, 95% confidence interval 0.7-.32; P=1.00) or delayed chemotherapy groups (80% and 84% in arms III and IV, risk ratio 0.95, 95% confidence interval 0.73-1.235; P=.71). There were no differences in hormonal and ultrasound markers between GnRH analogue users and control group individuals. The use of GnRH analogue cotreatment did not predict independently the odds of menstruating at 12 months. CONCLUSION: GnRH analogue cotreatment does not offer a significant protective effect on ovarian function in patients treated by cyclophosphamide-based chemotherapy. CLINICAL TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry. www.anzctr.org.au, ACTRN12609001059257. LEVEL OF EVIDENCE: I

Assisted hatching--a meta-analysis of randomized controlled trials.

AbstractPurpose: To conduct a meta-analysis of randomized controlled trials (RCTs) on assisted hatching. Methods: One hundred sixty-five studies were retrieved from the literature, but only 13 of them fitted our selection criteria. The meta-analysis was conducted using the RevMan software with the Peto-modified Mantel–Haenszel method. Results: Assisted hatching increases the pregnancy [OR (±95% CI) = 2.51 (1.91–3.29)], implantation [OR (±95% CI) = 2.38 (1.87–3.03)], and ongoing pregnancy rates [OR (±95% CI) = 2.65 (1.85–3.79)] significantly in poor prognosis patients undergoing IVF or ICSI. For patients with repeated IVF failures, the OR (±95% CI) were 2.84 (1.99–4.06) for pregnancy, 2.53 (1.85–3.47) for implantation, and 3.51 (2.12–5.82) for ongoing pregnancy rates, in favor of assisted hatching. Conclusions: Assisted hatching increases the pregnancy, implantation, and ongoing pregnancy rates significantly in patients with a poor prognosis undergoing IVF or ICSI, particularly those with repeated failures.

Impact of Technical Difficulties, Choice of Catheter, and the Presence of Blood on the Success of Embryo Transfer—Experience from a Single Provider

AbstractPurpose: To investigate the impact of technical difficulties, choice of catheter, and the presence of blood during embryo transfer on the results of in vitro fertilization and ICSI. Methods: A cohort of 784 consecutive cycles in 655 in vitro fertilization and ICSI patients were studied. Results: Negotiating the cervix, using the volsellum, presence of blood on the catheter wall or on the cervix did not affect the results. Changing the catheter and blood on the catheter tip reduced the pregnancy (P < 0.05 and P < 0.05) and implantation rates (P < 0.001 and P < 0.01). The Ultrasoft catheter produced higher pregnancy (P < 0.0005) and implantation rates (P < 0.01) compared to the more rigid Frydman catheter. Conclusions: Negotiation of the cervix, the use of a volsellum, and the presence of blood on the catheter wall or on the cervix do not affect the results. Changing the catheter and blood on the catheter tip significantly diminish the pregnancy and implantation rates. Soft catheters perform better.

Progesterone supplementation to prevent recurrent miscarriage and to reduce implantation failure in assisted reproduction cycles

Implantation failure has been questioned for many cases of recurrent miscarriage and unsuccessful assisted reproduction. The exact cause of implantation failure is not known, but luteal phase defect is encountered in many of these cases. Consequently, women with recurrent miscarriages have been treated with progesterone supplementation with various degrees of success, and a recent meta-analysis has shown trends for improved live birth rates in those women. Progesterone probably acts as an immunological suppressant blocking T-helper (Th)1 activity and inducing release of Th2 cytokines. Numerous studies have confirmed that ovarian stimulation used in assisted reproduction is associated with luteal phase insufficiency, even when gonadotrophin-releasing hormone antagonists are used. In those patients, advanced endometrial histological maturity and a decrease in the concentration of cytoplasmic progesterone receptors are observed. Progesterone supplementation results in a trend towards improved ongoing and clinical pregnancy rates, except in patients treated with human menopausal gonadotrophin-only regimens, in whom ongoing pregnancy rates increase significantly. More randomized controlled trials are needed to increase the power of the currently available meta-analyses to further evaluate progesterone supplementation in both conditions.

Reference values for the midluteal plasma progesterone concentration: evidence from human menopausal gonadotropin-stimulated pregnancy cycles.

OBJECTIVE To determine reference values for the midluteal plasma progesterone concentration. DESIGN Retrospective analysis. SETTING Infertility clinic at an academic medical center. PATIENT(S) One hundred ninety-two infertile women who became pregnant after induction of ovulation with hMG. INTERVENTION(S) The plasma progesterone level was measured during the midluteal phase of the hMG treatment cycle. MAIN OUTCOME MEASURE(S) The midluteal plasma progesterone concentration was correlated with the outcome of the pregnancy. RESULT(S) In this cohort of 192 women in whom ovulation was induced with hMG and 5,000 IU of hCG, the mean midluteal plasma progesterone concentrations were 29.07 ng/mL, 25.85 ng/mL, 31.49 ng/mL, 41.39 ng/mL, and 28.64 ng/mL in all cycles that resulted in pregnancy, cycles that resulted in full-term singleton pregnancy, cycles that resulted in full-term multiple pregnancy, cycles that resulted in preterm pregnancy, and cycles that ended in miscarriage, respectively. There was no statistically significant difference in the progesterone concentration between the cycles that resulted in full-term pregnancy and those that ended in miscarriage, but there was a statistically significant difference between the cycles that resulted in singleton pregnancy and those that resulted in multiple pregnancy. The minimum value that was compatible with a full-term pregnancy in this cohort of women was 10.83 ng/mL. CONCLUSION(S) In a cohort of 192 women, the minimum plasma progesterone concentration on day 7 in women who attained a full-term pregnancy after induction of ovulation with 5,000 IU of hCG was 10.83 ng/mL.

Prevalence and type distribution of human papillomavirus among women older than 18 years in Egypt: a multicenter, observational study.

OBJECTIVES Persistent infection with high-risk (HR) human papillomavirus (HPV) is associated with premalignant lesions and cervical cancer, the third most common cancer amongst women globally and the second most frequent in Egypt. We studied the prevalence and type distribution of HPV and documented HPV infection awareness and health-related behaviours for HPV infection. METHODS This was a multicenter, hospital-based observational study of women ≥18 years of age who attended for a gynaecological examination during October 2010-August 2011. Cervical samples were tested using Linear Array HPV genotyping. Two questionnaires on awareness and health-related behaviour were completed. RESULTS Four hundred and forty-three women with a mean age of 39.3±14.0 years were included in the analysis. HPV DNA was detected in 10.4% of women; a single HPV-type infection was found in 6.5% and multiple infections in 3.8%. The most prevalent HR types among HPV-positive women were HPV-16 (19.6%) and HPV-31 and HPV-51 (15.2% each); low-risk types included HPV-62 (17.4%) and HPV-84 (10.9%). The prevalence of HPV-18 was low (6.5%). The prevalence of any HR HPV-type was highest in women aged 45-54 years (9.2%). CONCLUSIONS The overall prevalence of HPV in Egypt was 10.4% and was highest (9.2%) amongst women aged 45-54 years. These data provide important reference information for public health authorities considering HPV prevention in Egypt.

Vaginal administration of a combined oral contraceptive containing norethisterone acetate

The effects of vaginal administration of an oral contraceptive pill containing 1 mg of norethisterone acetate and 0.05 mg of ethinyl oestradiol were studied in 20 subjects for a total of 57 cycles. The results show effective ovulation suppression in the two dose regimens used. The lower dose regimen was associated with fewer side effects and no breakthrough bleeding. No significant change was observed in the serum concentration of glucose, total proteins, albumin, cholesterol and HDL after several cycles of treatment in both dose regimens used. It is concluded that vaginal administration of this preparation of oral contraceptives is an effective alternative method of hormonal contraception.

Improving placental blood flow in pre-eclampsia with prostaglandin A1

Prostaglandin A1 is a potent hypotensive, peripheral vasodilator, a weak oxytocic, antiplatelet aggregator. It improves the renal hemodynamics. Its effect on placental circulation was evaluated (expressed as systolic/diastolic ratio and umbilical artery resistance index) in 20 women with severe pre‐eclampsia and 10 normotensive pregnant women, by using the Doppler technique. Moreover, another 10 women with severe pre‐eclampsia received dextrose 5% as a placebo for comparative purposes. Significant improvements in both parameters studied were observed in the women with severe pre‐eclampsia. The beneficial changes differed significantly from the recorded values when using dextrose in pre‐eclampsia or prostaglandin A, in normotensive subjects. Such promising data add another important perspective to prostaglandin A, in severe pre‐eclampsia and may open up new avenues for its use in other situations with compromised placental flow.

Power Doppler flow mapping and four-dimensional ultrasound for evaluating tubal patency compared with laparoscopy

OBJECTIVES To study the accuracy of four-dimensional (4D) ultrasound and power Doppler flow mapping in detecting tubal patency in women with sub-/infertility, and compare it with laparoscopy and chromopertubation. STUDY DESIGN A prospective study. The study was performed in the outpatient clinic and infertility unit of a university hospital. The sonographic team and laparoscopic team were blinded to the results of each other. Women aged younger than 43 years seeking medical advice due to primary or secondary infertility and who planned to have a diagnostic laparoscopy performed, were recruited to the study after signing an informed consent. All of the recruited patients had power Doppler flow mapping and 4D hysterosalpingo-sonography by injecting sterile saline into the fallopian tubes 1 day before surgery. Registering Doppler signals, while using power Doppler, both at the tubal ostia and fimbrial end and the ability to demonstrate the course of the tube especially the isthmus and fimbrial end, while using 4D mode, was considered a patent tube. RESULTS Out of 50 recruited patients, 33 women had bilateral patent tubes and five had unilateral patent tubes as shown by chromopertubation during diagnostic laparoscopy. Sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and accuracy for two-dimensional power Doppler hysterosalpingography were 94.4%, 100%, 100%, 89.2%, and 96.2%, respectively and for 4D ultrasound were 70.4%, 100%, 100%, 70.4%, and 82.6%, respectively. CONCLUSIONS Four-dimensional saline hysterosalpingography has acceptable accuracy in detecting tubal patency, but is surpassed by power Doppler saline hysterosalpingography. Power Doppler saline hysterosalpingography could be incorporated into the routine sub-/infertility workup.