Mohan S. Kamath

PREDICTIVE FACTORS FOR PREGNANCY AFTER INTRAUTERINE INSEMINATION: A PROSPECTIVE STUDY OF FACTORS AFFECTING OUTCOME

OBJECTIVE: To determine the predictive factors for pregnancy after controlled ovarian hyperstimulation (COH)/intrauterine insemination (IUI). DESIGN: Prospective observational study. SETTING: University-level tertiary care center. PATIENTS AND METHODS: 366 patients undergoing 480 stimulated IUI cycles between November 2007 and December 2008. INTERVENTIONS: Ovarian stimulation with gonadotrophins was initiated and a single IUI was performed 36 h after triggering ovulation. MAIN OUTCOME MEASURES: The primary outcome measures were clinical pregnancy and live birth rates. Predictive factors evaluated were female age, duration of infertility, indication for IUI, number of preovulatory follicles, luteinizing hormone level on day of trigger and postwash total motile fraction (TMF). RESULTS: The overall clinical pregnancy rate and live birth rate were 8.75% and 5.83%, respectively. Among the predictive factors evaluated, the duration of infertility (5.36 vs. 6.71 years, P = 0.032) and the TMF (between 10 and 20 million, P = 0.002) significantly influenced the clinical pregnancy rate. CONCLUSION: Our results indicate that COH/IUI is not an effective option in couples with infertility due to a male factor. Prolonged duration of infertility is also associated with decreased success, and should be considered when planning treatment.

Use of GnRH analogues pre-operatively for hysteroscopic resection of submucous fibroids: a systematic review and meta-analysis

GnRH analogues are commonly used before hysteroscopic myomectomy to make surgery easier and safer, but they are expensive, have potential side effects and lack a robust evidence base to support this practice. We undertook a systematic review of the literature to determine whether, in women with submucous fibroids, pre-operative GnRH analogues were more effective than placebo/no treatment in terms of symptom relief, complications and ease of surgery. The outcomes were patient-reported relief of symptoms, complete resection of the fibroids, operative time and complications. Meta-analysis was performed where appropriate. Two trials including 86 women were identified. The assessment of symptom relief differed in the two trials: hence it was not possible to combine these data. The relative risk for completion of surgery and mean differences (95% confidence intervals) for operating time and fluid deficit were [0.94 (0.68-1.31); -5.34 min, (-7.55 min to -3.12 min) and -176.2 ml, (-281.05 ml to -71.5 ml)] respectively. Our results suggest that GnRHa may improve some outcomes but there is insufficient evidence to support their routine use prior to hysteroscopic resection of submucous fibroids. More randomised trials are needed to inform definitive conclusions.

Affordable ART: a different perspective

BACKGROUND Although ≈ 10% of the population is affected by infertility, the treatment option of in-vitro fertilisation (IVF) remains unaffordable for the majority of infertile couples. We have initiated a lowcost programme incorporating an uncommonly used, but recognized, ovarian stimulation protocol, together with certain costlimiting initiatives in an established assisted reproductive technology (ART) set up. METHODS The medical records of women who underwent the lowcost programme were analysed. Clomiphene citrate 50 mg daily was administered from Day 2 of the cycle and continued till the day of hCG trigger, thus preventing the LH surge. Intermittent doses of human menopausal gonadotrophin 150 IU were administered on alternate days from the 5th day onwards. Oocyte retrieval was carried out once at least two follicles of >18 mm were identified. The cycle was monitored by ultrasound only, with embryo transfer being carried out on Day 3. Clinical outcomes were recorded together with an estimation of the direct costs per cycle. Direct cost calculations did not include professional charges or facility costs. RESULTS Of 143 women evaluated, 104 women underwent embryo transfer. The live birth rate and clinical pregnancy rate per embryo transfer were 19 and 22%. The live birth rate per initiated cycle was 14% (20/143). The multiple pregnancy rate was 26% with no case of ovarian hyperstimulation syndrome being recorded. The average direct cost per cycle was US

Blastocyst stage transfer vs cleavage stage embryo transfer

675 for IVF and US

Aromatase inhibitors in women with clomiphene citrate resistance: a randomized, double-blind, placebo-controlled trial

725 for an ICSI treatment cycle. CONCLUSIONS Using this protocol, together with several costcutting measures, we achieved an acceptable live birth rate per transfer of 19% at a reasonable cost. This approach could be used by established ART centres to provide treatment to couples who cannot afford conventional ART.

Letrozole or clomiphene citrate as first line for anovulatory infertility: a debate

OBJECTIVE: To evaluate the efficacy of blastocyst transfer in comparison with cleavage stage embryo in a similar cohort of women. DESIGN: Retrospective analysis. SETTING: University teaching hospital. MATERIALS AND METHODS: Women aged 35 or less undergoing in vitro fertilization/intracytoplasmic sperm injection between January 2005 and December 2006 were included in the study. When four or more grade 1 embryos were observed on day 3, extended culture till day 5 was undertaken. This policy was compared with a cohort of women who had at least three grade 1 embryos on day 3 and who had undergone a cleavage stage embryo transfer during the time period of January 2002–December 2004. Primary outcome evaluated was implantation rate and clinical pregnancy rate. RESULTS: Group 1 consisted of 50 women who underwent extended culture and blastocyst transfer. Group 2 comprised of 85 women who had cleavage transfer. The implantation rate for embryos transferred in group 1 was significantly higher than that for embryos transferred on day 3 (40.16% vs 11.43%). The clinical pregnancy rate was also significantly better with blastocyst transfer as compared with cleavage stage transfer (62% vs 29.76%). Significantly fewer embryos were required for transfer at the blastocyst stage compared with day 3 transfer (2.54 vs 3.45). CONCLUSION: In selected cases, blastocyst transfer with fewer embryos can be performed with high implantation and clinical pregnancy rates. This policy could lead to a reduction in the incidence of higher-order pregnancies.

A rare case report: ovarian heterotopic pregnancy after in vitro fertilization

In 36 women with polycystic ovary syndrome and clomiphene citrate resistance, letrozole, an aromatase inhibitor, statistically significantly increased the ovulation rate by 33.3% in the treatment group, indicating that letrozole can be used as an effective and simple alternate ovulation-inducing agent in these women.

Prevalence of metabolic syndrome in women with polycystic ovary syndrome attending an infertility clinic in a tertiary care hospital in south India

Clomiphene citrate has been traditionally used as the drug of choice in treating women with anovulatory infertility. In the last decade letrozole, an aromatase inhibitor has emerged as alternative ovulation induction agent. Literature confirms that letrozole has a definitive role in anovulatory women who have not responded to the clomiphene therapy. However its role as an alternative to clomiphene as first line therapy continues to be debated. Although it is probable that the overall benefits of letrozole surpass clomiphene citrate, currently available data does not confirm this view. There is need for large well-designed trials.

Fertility and age.

OBJECTIVE To report a case of ovarian heterotopic pregnancy after an IVF cycle. DESIGN Case report. SETTING Reproductive medicine unit, Christian Medical College Hospital, Vellore, India. PATIENT(S) A woman with an ovarian heterotopic pregnancy. INTERVENTION(S) Laparoscopic removal of ovarian ectopic pregnancy. MAIN OUTCOME MEASURE(S) Early detection and successful treatment of heterotopic pregnancy. RESULT(S) Successful laparoscopic management of ovarian pregnancy resulting in a single viable ongoing intrauterine pregnancy. CONCLUSION(S) Clinicians need to be aware of such rare and potentially fatal presentations after IVF, because early diagnosis and management in these cases can yield a favorable outcome.

Ulipristal acetate for uterine fibroids: a systematic review and meta-analysis

OBJECTIVE: The aim of the present study was to evaluate the prevalence of metabolic syndrome in women with polycystic ovary syndrome (PCOS). SETTING: Infertility clinic in a tertiary care hospital. STUDY DESIGN: A prospective cross-sectional study. MATERIALS AND METHODS: All the women attending the infertility clinic categorized as polycystic ovary syndrome according to Rotterdam criteria (2003) during the study period were included in the study. The women with PCOS underwent screening for metabolic syndrome as defined by the modified American Heart Association/National Heart Lung Blood Institute (AHA/NHLBI) modified ATP 111 (2005) definition. A multivariate logistic regression analysis was applied and significant predictors identified for the prediction of metabolic syndrome. RESULTS: The overall prevalence of metabolic syndrome according to the modified AHA/NHLBI ATP III (2005) criteria was 37.5%. A total of 5.8 % cases were detected to have diabetes mellitus, 8.3% had impaired fasting glucose, and 11.7 % had an impaired glucose test. Dyslipidemia was present in 93.3% cases of PCOS. Among all the risk factors, age and waist hip ratio ≥0.85 were strongly associated with the presence of metabolic syndrome. CONCLUSION: Infertile women with PCOS, particularly those with age ≥25 years or with central obesity (a waist hip ratio of ≥0.85), are at a higher risk of developing metabolic syndrome and should be offered screening tests.