Omar Shebl

Anti muellerian hormone serum levels in women with endometriosis: A case–control study

Objective. To compare the anti muellerian hormone (AMH) serum levels in women with and without endometriosis. Design. A case–control study Setting. Womens General Hospital, Linz, Austria. Patient(s). Our study included a total of 909 patients undergoing in vitro fertilisation/intracytoplasmic sperm injection (IVF/ICSI) treatment or consulting our specific endometriosis unit. After proofing the exclusion criteria, 153 of these patients with endometriosis (study group) were matched with 306 patients undergoing IVF/ICSI treatment because of a male factor (control group). Interventions. None. Main outcome measures. AMH serum level. Results. Mean AMH serum level was significantly lower in the study than in the control group (2.75 ± 2.0 ng/ml vs. 3.46 ± 2.30 ng/ml, p < 0.001). In women with mild endometriosis (rAFS I-II), the mean AMH level was almost equal to the control group (3.28 ± 1.93 ng/ml vs. 3.44 ± 2.06 ng/ml; p = 0.61). A significant difference in mean AMH serum level was found between women with severe endometriosis (rAFS III-IV) and the control group (2.38 ± 1.83 ng/ml vs. 3.58 ± 2.46 ng/ml; p < 0.0001). Conclusion. Lower AMH serum levels and an association with the severity were found in women with endometriosis. Physicians have to be aware of this fact. Because of the expected lower response on a controlled ovarian hyperstimulation (COH), AMH serum level should be measured to optimise the dose of gonadotropin treatment previous to a COH, especially in women with severe endometriosis.

Prognosis of oocytes showing aggregation of smooth endoplasmic reticulum

Few cytoplasmic dysmorphisms of oocytes have been reported to negatively influence the further fate of the ova. One such anomaly, namely the central aggregation of the smooth endoplasmic reticulum (SER), has recently been associated with suboptimal outcome in a limited number of patients. In order to increase prognostic value, it was decided to prospectively screen all intracytoplasmic sperm injection patients within 1 year for eggs showing aggregations of SER. In addition, all deliveries (obstetric and neonatal data) were analysed. Occurrence of SER cluster was related to duration (P < 0.001) and dosage (P < 0.01) of the stimulation. Fertilization (58.9%) and blastulation rate (44.0%) were lower (P < 0.01) in affected ova compared with unaffected counterparts (77.4 and 87.8%, respectively). Pregnancies in women with affected gametes were accompanied by a higher incidence of obstetric problems (P < 0.01) leading to a non-significant trend towards earlier delivery and significantly reduced birthweight (P < 0.05). It is strongly recommended to avoid transfer of embryos/blastocysts derived from SER cluster-positive gametes. Patients have to be informed that even transfer of sibling oocytes without this anomaly involves a higher risk of detrimental outcome.

Age-related distribution of basal serum AMH level in women of reproductive age and a presumably healthy cohort

In this study, day 1 to 4 serum anti-Müllerian hormone (AMH) level was analyzed in 2,741 patients attending our department for reproductive medicine or reproductive surgery, including a subgroup of 1,105 women who attended an assisted reproductive technology program because of a male factor as a presumably healthy subgroup. Day 1 to 4 serum AMH levels showed an age-dependent distribution and there is a wide range of AMH in each year of age analyzed, showing that even young women are at a risk of reduced ovarian reserve.

The rASRM score and the Enzian classification for endometriosis: their strengths and weaknesses

The revised American Society for Reproductive Medicine (rASRM) score is currently the best‐known classification of endometriosis and is the one most widely used throughout the world. It is relatively easy to use, but it does not take into account the involvement of retroperitoneal structures with deeply infiltrating endometriosis. For this reason, the Enzian classification was developed as a supplement to the rASRM score, in order to provide a morphologically descriptive classification of deeply infiltrating endometriosis. The Enzian classification currently has a poor level of international acceptance and is mainly used in the German‐speaking countries. It was revised in 2011 and is now also easier to use. This article describes the strengths and weaknesses of the rASRM score and the Enzian classification and their common potential for classifying endometriosis.

Pharmacological stimulation of sperm motility in frozen and thawed testicular sperm using the dimethylxanthine theophylline

OBJECTIVE To evaluate whether the use of theophylline improves sperm motility and treatment outcome in frozen-thawed testicular sperm extraction (TESE). DESIGN Artificial sperm activation was offered to azoospermic patients between January and October 2010 in two different centers (identical lab conditions). SETTING IVF units of public hospitals. PATIENT(S) Sixty-five patients participated and gave informed consent. INTERVENTION(S) Sibling oocytes were split into a study (intracytoplasmic sperm injection [ICSI] with thawed testicular sperm treated with theophylline) and a control group (ICSI with thawed untreated sperm). MAIN OUTCOME MEASURE(S) Sperm motility, time for sperm selection, rates of fertilization, implantation, clinical pregnancy, and live birth. RESULT(S) All patients but one (98.5%) showed a significant improvement in testicular sperm motility when theophylline was used. In addition, sperm selection took significantly less time in the study as compared with in the untreated control group. Corresponding rates of fertilization (79.9% vs. 63.3%) and blastulation (63.9% vs. 46.8%) were significantly increased. Significantly more patients achieved clinical pregnancy if embryos/blastocysts derived from oocytes that had been injected with pharmacologically stimulated testicular spermatozoa were transferred (53.9% vs. 23.8%). This also holds true for the implantation rate. CONCLUSION(S) Theophylline turned out to be a reliable tool in stimulating testicular spermatozoa after thawing. Its immediate effect allows for faster and more accurate selection of viable sperm, which in turn improved fertilization and pregnancy outcome in this prospective study.

Hypocalcemic tetany in the newborn as a manifestation of unrecognized maternal primary hyperparathyroidism

ZusammenfassungEin primärer Hyperparathyreoidismus in der Schwangerschaft tritt sehr selten auf und ist mit einer erhöhten mütterlichen und kindlichen Morbidität und Mortalität verbunden. Wir präsentieren einen Fall, bei dem eine hypokalzämische Tetanie des Neugeborenen – bedingt durch einen passageren Hypoparathyreoidismus im Kind – letztendlich zur Entdeckung eines nicht diagnostizierten primären Hyperparathyreoidismus der Mutter führte. Eine offensichtlich gesunde 30-jährige Frau hatte eine unauffällige Schwangerschaft und Geburt. Am fünfzehnten postpartalen Tag entwickelte das Neugeborene eine hypokalzämische Tetanie. Nach Gabe von Vitamin D und Kalzium sistierten die Krämpfe und die weitere Entwicklung des Kindes war völlig normal. Die weitere Evaluierung der Mutter führte zur Diagnose eines maternalen primären Hyperparathyreoidismus. In der Folge wurde ein Adenom an der rechten unteren Nebenschilddrüse entfernt. Die Suche nach den Ursachen einer Hypokalziämie bei Neugeborenen soll sich nicht nur auf den betroffenen Patienten beziehen. Die Untersuchung der offensichtlich gesunden Mutter und der multidisziplinäre Zugang können sowohl dem kleinen Patienten als auch der Mutter Genesung erbringen.SummaryPrimary hyperparathyroidism (PHP) during pregnancy is a very rare event that increases maternal and perinatal morbidity and mortality. We present a case in which hypocalcemic tetany of the neonatal infant – caused by transient hypoparathyroidism in the child – finally revealed asymptomatic maternal PHP. An apparently healthy 30-year-old woman had an uneventful pregnancy and delivery. On the 15th postpartal day, the newborn developed hypocalcemic tetany. After receiving supplementation of calcium and vitamin D, the child developed without further pathological findings. Laboratory and radiological studies in the mother led to a diagnosis of maternal PHP. An adenoma of the right lower parathyroid gland was subsequently removed. The search for the cause of hypocalcemia in a newborn should not focus on the patient alone. Examining the apparently healthy mother and approaching the case in a multidisciplinary fashion may benefit both the child and the mother.

Enzian classification: does it correlate with clinical symptoms and the rASRM score?

To assess the extent to which the Enzian classification correlates with the revised American Society for Reproductive Medicine (rASRM) score and clinical symptoms in women with deeply infiltrating endometriosis.

Quantitative and qualitative trophectoderm grading allows for prediction of live birth and gender

PurposeProlonged in vitro culture is thought to affect pre- and postnatal development of the embryo. This prospective study was set up to determine whether quality/size of inner cell mass (ICM) (from which the fetus ultimately develops) and trophectoderm (TE) (from which the placenta ultimately develops) is reflected in birth and placental weight, healthy live-birth rate, and gender after fresh and frozen single blastocyst transfer.MethodsIn 225 patients, qualitative scoring of blastocysts was done according to the criteria expansion, ICM, and TE appearance. In parallel, all three parameters were quantified semi-automatically.ResultsTE quality and cell number were the only parameters that predicted treatment outcome. In detail, pregnancies that continued on to a live birth could be distinguished from those pregnancies that aborted on the basis of TE grade and cell number. Male blastocysts had a 2.53 higher chance of showing TE of quality A compared to female ones. There was no correlation between the appearance of both cell lineages and birth or placental weight, respectively.ConclusionsThe presented correlation of TE with outcome indicates that TE scoring could replace ICM scoring in terms of priority. This would automatically require a rethinking process in terms of blastocyst selection and cryopreservation strategy.

Healthy live birth using theophylline in a case of retrograde ejaculation and absolute asthenozoospermia

OBJECTIVE To analyze whether the use of ready-to-use theophylline is a feasible option in a case of retrograde ejaculation and absolute asthenozoospermia. DESIGN Case report. SETTING In vitro fertilization unit of a public hospital. PATIENT(S) Thirty-one-year-old nulliparous woman, and 39-year-old male with retrograde ejaculation and absolute asthenozoospermia. INTERVENTION(S) Retrieval of postejaculatory urine, restoration of motility using a methylxanthine, intracytoplasmic sperm injection, single-embryo transfer. MAIN OUTCOME MEASURE(S) Sperm motility, fertilization, embryo quality, live birth. RESULT(S) Successful fertilization and a single-embryo transfer resulted in a healthy live birth. CONCLUSION(S) Theophylline turned out to be a safe, efficient agent for stimulating immotile spermatozoa in patients with retrograde ejaculation.

Ectopic pregnancies with unusual location and an angular pregnancy: Report of eight cases.

ZusammenfassungZWECK DER STUDIE: Durch die vermehrte Anwendung von assistierter Reproduktionstechnologie kommt es auch zu einer Zunahme von ektopen Schwangerschaften mit untypischen Lokalisationen und der damit vergesellschafteten erhöhten mütterlichen Morbidität und Mortalität. Sieben Fallberichte von ektopen Schwangerschaften mit seltenen Lokalisationen und eine anguläre Schwangerschaft werden vorgestellt, die diagnostischen und therapeutischen Optionen diskutiert sowie eine kurze Literaturübersicht inklusive genauer Nomenklatur wird präsentiert. UNTERSUCHUNGEN UND METHODEN: Fallberichtserie von sieben ektopen Schwangerschaften in untypischer Lokalisation, nach künstlicher Befruchtung oder spontan entstanden (Sectionarbenschwangerschaft, Bauchhöhlenschwangerschaft im Mesoappendix) sowie eine anguläre Schwangerschaft. Alle Patienten wurden in den letzen acht Jahren an unserer Klinik behandelt. Eine retrospektive Analyse. ERGEBNISSE: Interstitielle Schwangerschaft, cornuale Schwangerschaft, Sectionarbenschwangerschaft, Bauchhöhlenschwangerschaft im Omentum majus, heterotope-zervikale Schwangerschaft, Bauchhöhlenschwangerschaft im Mesoappendix, anguläre Schwangerschaft. Alle Patienten wurden operativ therapiert. SCHLUSSFOLGERUNG: Die Diagnose von ektopen Schwangerschaften, besonders derer in unüblichen Lokalisationen, ist schwierig und wird verkompliziert durch die embryonale Einnistung in unmittelbarer Nähe des Ostium uterinum tubae. Hier besonders hinsichtlich der genauen Beurteilung einer intra- oder extrauterinen Lokalisation. Hohe Komplikationsraten und verschiedene Behandlungsmöglichkeiten erschweren die Situation.SummaryOBJECTIVE: The increased use of assisted reproduction techniques has been accompanied by an increase in ectopic pregnancies with unusual location being associated with significant maternal morbidity and mortality. This article reports on seven cases of ectopic pregnancies with unusual location and an angular pregnancy. Diagnostic and therapeutic strategies are discussed and a brief review of literature is presented. STUDY DESIGN: Case series of seven cases with ectopic pregnancy in unusual location, following assisted reproductive technique or conceived spontaneously (cesarean scar pregnancy and early abdominal pregnancy in mesoappendix) and an angular pregnancy, having presented at our hospital during the last eight years. Retrospective analyses. RESULTS: Interstitial pregnancy, cornual pregnancy, cesarean scar pregnancy, early abdominal pregnancy in omentum majus, heterotopic (cervical) pregnancy, early abdominal pregnancy in mesoappendix, angular pregnancy. All patients were surgically treated. CONCLUSION: Diagnosis of ectopic pregnancy with unusual location may be difficult, and differentiation of intact intrauterine or extrauterine pregnancy with adequate consideration of the area of uterine ostium of the fallopian tube may be delicate. Moreover, varying treatment strategies and high rates of complications aggravate the situation.