Sohani Verma

ADVANCED MATERNAL AGE AND OBSTETRIC PERFORMANCE

Background Women older than 35 years have traditionally been termed as of “advanced maternal age”, and considered to have higher incidence of obstetric complications and adverse pregnancy outcomes than younger pregnant women. The available scientific data suggests that risks begin to accelerate after the age of 35 years and increase more rapidly after the age of 40 years. Majority of these studies are from western countries and literature on obstetric performance of Indian women of 35 years age and above is sparse. Objective The study was aimed to assess if there was an age related incremental rise in obstetric complications and adverse outcome in women aged 35 years and above, as compared to their younger counterparts. Material and Methods This is a retrospective study based on the maternity records of 2560 deliveries under a single obstetrician at a private tertiary referral hospital - Indraprastha Apollo Hospitals, New Delhi. A total of 173 deliveries in mothers aged 35 year or above were identified. An equal number of women in the age group 34 years or less were randomly selected as the control group. The total numbers of patients (346) were subdivided into following four groups - group A- Women 40 years age and above (35), group B - women between 37 and 39 years age (58), group C- women of 35 and 36 years age (80) and group D Control group- women less than 34 years age (173). The antenatal complications, gestation age at delivery, mode of delivery, pregnancy outcome, birth weight of baby and Apgar Score were studies. A comparative analysis was made among above groups. Results The incidence of deliveries in women of 35 years or above age was noted to be 7% of all deliveries (2560) during the study period. The women 40 years and above age group constituted 1.4% of total number of deliveries. The mean age of women in control group (173patients) was 29.2 years. As the maternity unit where study was undertaken, is the part of multispeciality tertiary referral hospital, even the control group had a high number of women with fetal growth restriction (38.7%), preterm premature rupture of membranes (11%), hypertension (13.3%), diabetes mellitus (8.7%) and other medical disorders leading to a high incidence of operative deliveries (60.7%) and births of preterm Conclusion The women aged 35 years and above have obstetric complications, similar to the high risk pregnancy group in younger women and increased rates of operative deliveries. However with careful monitoring, timely intervention and tertiary level maternal and neonatal care, these women can expect a favourable obstetric outcome.

Clomiphene citrate usage pattern in India: A knowledge, attitude, and practice survey among gynecologists

Introduction: Clomiphene citrate (CC) has an important place in therapy for management of ovulatory dysfunction. The objective of the present survey was to understand the knowledge, attitude, and practice (KAP) of Indian gynecologists toward the use of CC. Materials and Methods: A prospective, cross-sectional, observational, questionnaire-based KAP survey conducted among Indian gynecologists. Out of 22 multiple-choice questions (MCQs), 9 questions were related to efficacy, 5 to safety, and 8 to perception about CC usage in routine clinical practice. Data were summarized by percentages in frequency tables and graphs. Results: Seven hundred seventy-one gynecologists in total across India participated in this survey. The majority of the participants preferred CC in treatment of ovulatory dysfunction associated with polycystic ovary syndrome (PCOS). The ovulation rate was reported to vary 21-60% and the pregnancy rate was noticed to be 11-30% by the majority of the participants. CC was reported to have very good to excellent efficacy and tolerability. Resistance to CC was encountered sometimes. Commonly encountered adverse effects included abdominal/pelvic discomfort or pain, ovarian enlargement, and nausea and vomiting. Frequent complications included multiple gestation, ovarian hyperstimulation syndrome (OHSS), and spontaneous abortion. Quite a few doctors reported congenital malformations with CC therapy. A majority of participants preferred CC in a dose of 50-100 mg/day for 5 days starting on the second or third day of the cycle. Most participants advised natural conception to patients receiving CC therapy. Metformin and gonadotropins were the preferred drugs coadministered with CC treatment. Conclusion: The present KAP survey highlighted CC as a commonly used agent for ovulatory dysfunction, with very good to excellent efficacy and tolerability.

Predictive Value of Transvaginal Colour and Power Dopplerultrasound During in-vitro-Fertilization Treatment

Background Transvaginal ultrasound is an essential adjunct in the modern management of couples undergoing in-vitro-fertilization (IVF) treatment. Newer technologies such as colour and power Doppler ultrasound are superior in the assessment of dynamic changes taking place during the follicular and endometrial development. Objective The study was aimed to assess if transvaginal colour and power Doppler ultrasound can help in the better timing of oocyte retrieval and to evaluate the predictive value of this technology for the ovarian response and pregnancy results. Material and Methods A total of 78 womenundergoing IVF and Intracytoplasmic Sperm Injection (ICSI) were examined by transvaginal ultrasonographywith colour and Doppler ultrasound. We assessed the perifollicular vascularity, ovarian arteries blood flow, endometrial thickness and morphology, myometrial contractivity and echogenicity, subendometrialvascularization, uterine artery pulsatility index and blood flow. The uterine parameters were combined as perthe Uterine Scoring System of Reproduction (USSR). All parameters were correlated with the pregnancy rate. Results The overall pregnancy rate was 34.6%. both follicular and uterine scores were significantly higher in the pregnant women as compared to non-pregnant women. Conclusion The transvaginal colour and power Doppler ultrasonography is a valuable adjunct to determine the optimal time for mature oocytes retrieval and uterine receptivity. The uterine score calculated prior to IVF cycles appears to be a useful predictor of implantation.

Ovarian Stimulation in Cancer Patient

Ovarian stimulation in cancer patients is a relatively new and challenging concept. A large number of cancer patients in the reproductive-age group are now expected to survive and lead a normal life. However, various therapies responsible for this markedly improved prognosis can also cause a significant detrimental effect on the reproductive ability. It is important that all young patients diagnosed with cancer are fully informed and offered the option of various fertility preservation strategies. Ovarian stimulation followed by either embryo or mature oocyte cryopreservation is currently the most successful option. Special considerations are required while performing ovarian stimulation in cancer patients. A detailed pretreatment assessment, counseling, and proper selection of ovarian stimulation protocol within the available short time period with minimum side effects are crucial to maximize the success of fertility preservation.

Good clinical practice recommendations on management of infertility in patients from India with polycystic ovary syndrome

Sonia Malik, Sohani Verma, Kuldeep Jain, Pankaj Talwar, Bharati Dhorepatil, Gouri Devi, Umesh Jindal, Sudha Prasad, Kanad Dev Nayar, Neena Malhotra, Neeta Singh, Geeta Radhakrishnan, Rashmi Sharma, Leena Wadhwa, Nomita Chandhiok, Gita Khanna, Sushma Sinha, Pondicherry Marudachalam Gopinath Past president, Indian Fertility Society, FS Secretariat, Department of Obstetrics & Gynecology, MAMC, Lok Nayak Hospital, Jawahar Lal Nehru Marg, New Delhi-110002 PCOS Working GroupIndian Fertility Society, Jawahar Lal Nehru Marg, New Delhi-110002, India

Robertsonian Trans Locations—in a Young Couple with Recurrent Miscarriage

Recurrent miscarriage is a cause of concern for not only the pregnant couple but also the treating doctor. Once a couple is faced with this problem, they travel from one physician to the other looking for the cause and a potential remedy. Cytogenetic analysis of the couple forms an import investigation and is not available in many centers. We herewith report a case of Robetsonian translocation in a young couple who has a potential to have a normal child now.

Lissencephaly child showing FISH negative and mutation in DCX gene with normal parental genetic makeup

Lissencephaly is a clinically and genetically heterogeneous malformation of the brain, leading to a severe disabling condition and seizures. The recent discovery of molecular techniques and identification of lissencephaly genes (LIS 1 and DCX) has allowed etiologic diagnosis of this disorder. We describe a patient with lissencephaly in whom fluorescence in situ hybridization and DCX mutation analysis determined etiologic diagnosis, allowing precise genetic counseling and providing prenatal diagnosis for the family.

Fertility Preservation before Therapy for Cancer New Perspectives

As the number of young and adult nulliparous cancer survivors is constantly increasing due to progress in the field of oncology, the adverse effect of the life saving cancer therapy on reproductive function is assuming greater importance. Appropriate strategies to spare fertility in all young cancer patients must be considered. Recent advances in assisted reproduction technology such as in-vitro fertilization (IVF), intra-cytoplasmic sperm injection (ICSI) and cryopreservation have revolutionized the options available to these patients for their fertility preservation. While sperm and embryo cryopreservation are now established procedures, oocyte (mature or immature) cryopreservation has limited application till date. Ovarian tissue cryopreservation although at present an experimental technique, is fast emerging out as the most promising future option for fertility preservation. There is need for the professionals dealing with young cancer patients to familiarize themselves with these developments and with the importance of describing and providing access to these options. All possible fertility preservation options should be offered and discussed before starting the therapy for cancer. A multidisciplinary approach involving a close liaison between oncology and assisted conception units is crucial for providing the proper guidance and support to the young vulnerable patients diagnosed with cancer and their families in deciding what is likely to be the most appropriate course of action for them.

SUCCESSFUL OUTCOME AFTER INTRACYTOPLASMIC SPERM INJECTION AND EMBRYO TRANSFER (ICSI AND ET) WITH INTRAVENOUS IMMUNOGLOBULIN (IVIG) TREATMENT IN A COUPLE WITH PREVIOUS REPEATED FAILED ICSI / ET CYCLES AND SICKLE CELL TRAIT

Infertile couples with repeated in vitro fertilization (IVF) failures pose a difficult problem. Unsuccessful implantation following transfer of good quality embroyes is usually contributed to the poor receptivityof the endometrium involving both hormonal and immunological factors. Although exact role is still disputed, elements of the immune system are probably involved in at least some of the cases. Intravenous immunoglobulin (IVIG) is well known to have strong immunomodulating effects in several well -established disorders, and has been tried in unexplained reproductive failures. It is also imperative to screen the infertile couples thoroughly to minimize the risk of transmitting any abnormality to the offspring. In the case presented, IVIG was administered following ICSI and ET. Sickle cell trait in both partners was detected only after the ET. Successful implantation was achieved and chorionic villus sampling to exclude sickle cell disease was performed during the first trimester of pregnancy. A healthy female child with a birth weight of 3000 grams was born by caesarian section at full term. However, large well-structured studies examining the benefits of immunological evaluation and treatment are necessary before definite recommendation for the routine use of IVIG in repeated unexplained IVF failure can be made.