T.S. Palihawadana

Simple educational intervention will improve the efficacy of routine antenatal iron supplementation

Aim:  Sri Lanka has a policy of free provision of iron supplements to pregnant women. However, iron deficiency anemia remains common in pregnancy.

Aetiology of infertility among females seeking treatment at a tertiary care hospital in Sri Lanka.

OBJECTIVES Aim of this study was to describe the proportion of contributory factors of female infertility in a population that sought fertility treatment. Furthermore, the clinical findings and underlying pathologies associated with ovulatory dysfunction were also sought. METHODS A cross-sectional study was carried out at the infertility clinic of the North Colombo Teaching Hospital. New clinic attendees were recruited and both partners had a detailed clinical interview. The women underwent a baseline pelvic ultrasound scan, assessment of ovulation and a hormone profile. Tests for tubal patency were carried out when clinically indicated. RESULTS Ovulatory dysfunction was noted in 53% (n=218). Clinical and investigatory findings associated with ovulatory dysfunction included irregular menstrual cycles, acanthosis nigricans, hirsutism, polycystic ovary syndrome, a LH:FSH ratio of >1, and increased TSH or testosterone levels. Unilateral tubal occlusion was seen in 9.1 % (n=18) while it was bilateral in 1% (n=2). Abnormalities in sexual function were noted in 10.8% (n=56). CONCLUSIONS Abnormalities in ovulation were common. Clinical findings that could be used to recognise women at risk of ovulatory dysfunction were identified. Abnormalities in sexual function, which are often overlooked in the clinical management of infertility, were seen in over 10% of patients. Tubal factor infertility is rare.

A comparison of endometrial thickness following augmentation of ovulation with clomifene citrate or letrozole in women with ovulatory infertility

OBJECTIVES To compare endometrial thickness following augmentation of ovulation with clomifene (CC) and letrozole and to assess the rate of multi-follicle development and the FSH fluctuations during the stimulated cycles. METHODS A comparative study was carried out at the infertility clinic of Faculty of Medicine, University of Kelaniya, Sri Lanka. Each arm included 25 participants. They received either 100 mg of CC or 2.5 mg of letrozole per day for 5 days starting from 2nd day of the cycle. The fluctuation of FSH in the follicular phase of the cycle, the endometrial thickness and the number of pre-ovulatory follicles on the day of detecting a mature follicle, were measured. RESULTS Treatment with letrozole resulted in a smaller rise in the follicular phase FSH, which was shorter in duration than with CC. Also it resulted in a higher mean endometrial thickness at the time of detecting a mature follicle [9.89 (SD=2.02) mm vs. 8.58 (SD=1.32) mm; p=0.021]. Augmentation of ovulation with CC showed a trend towards multi-follicle development compared to letrozole. CONCLUSIONS This study suggests that letrozole is superior to CC in augmentation of ovulation in terms of endometrial growth and mono-follicle development. However more studies are needed to assess how these differences affect the treatment outcome before it is recommended for clinical use.

EP29.06: Metabolic syndrome and risk of endometrial carcinoma among asymptomatic, postmenopausal, urban Sri Lankan females: a community cohort follow‐up study

Oral Presentation Abstract (OP 023), 130th Anniversary International Medical Congress, Sri Lanka Medical Association, 13th-16th July 2017 Colombo, Sri Lanka

OP03.04: A randomised control trial on the retention of intrauterine copper contraceptive device following postplacental and interval insertion

Objectives: Intrauterine device (IUD) is a widely used reversible contraceptive method worldwide. Routinely, it is inserted at 6 weeks after delivery. Post-placental insertion (within 48 hours of child birth) has been described recently to improve its uptake. This study aimed to compare the retention rate of intra uterine copper (Copper T) device between post-placental and interval insertion (6 weeks after childbirth). Methods: A randomised control study was carried out in two hospitals in Sri Lanka. All consented women were randomly allocated for post-placental or interval period insertion of the IUD. An ultrasound evaluations was done after insertion to measure distance between IUD and the internal os. Six weeks after insertion a clinical evaluation was done to elicit a history of fever, abnormal vaginal discharge or expulsion of the device. A further ultrasound evaluation was also done to confirm presence and location of the IUD. Results: The study included 77 and 63 participants in the post placental and interval groups respectively. Expulsion within 6 weeks was seen in 7 of 77 (9.0%; 95% CI, 4.4 to 17.6) in post-placental and 7 of 63 (11.1%; 95% CI 5.5–21.2) in interval group respectively (P=0.78). Mean distance from lower end of the device to the internal os at insertion was significantly low among subjects who had IUD expulsion (mean length difference between successful and fallen 12.4 mm 95% CI -4.3 to 29.1, P=0.14; mean length in interval group 9.04 mm 95% CI -4.23 to 22.31, P=0.18). Conclusions: Expulsion rate of IUD was not significantly higher with post-placental compared with interval placement. Ultrasound can be used effectively to guide the retention of an IUD after both post-placental and interval insertions.

Factors associated with nonresponse to ovulation induction using letrozole among women with World Health Organization group II anovulation

Context: Letrozole, a third generation aromatase inhibitor is gaining importance in ovulation induction. Some prefer to use it as a second line agent in women who fail to respond to clomifene citrate. However, our knowledge about the predictors of response to letrozole is limited. Aims: The study was aimed at identifying the factors associated with letrozole resistance among women with World Health Organization (WHO) group II anovulation. Subjects and Methods: Study was conducted at the infertility clinic at a tertiary care hospital in Sri Lanka. A case-control study design was used and included 50 subjects with WHO group II anovulation (25 clomifene responsive and 25 clomifene resistant). After a treatment cycle of letrozole, the factors were compared between the subjects who responded and those who failed to respond to treatment. Results: Ovulation was achieved in 76% (n = 19) of subjects who had responded to clomifene previously and in 24% (n = 6) with clomifene resistance. The factors associated with letrozole resistance included the presence of hirsutism (odds ratio [OR]: 3.89; 95% confidence interval [CI]: 1.2-12.3) and clomifene resistance (OR: 10.03; 95% CI: 2.81-35.7). The early follicular phase mean (standard deviation) luteinizing hormone level was significantly higher among the nonresponders (9.75 [4.78] - 7.28 [2.3]; P = 0.02). Nonresponders showed significantly lower levels of oestradiol on the 5 th and 9 th days (28.50 [3.39] pg/mL vs. 7.49 [3.62] pg/mL; P = 0.0007 and 142.04 [76.22] pg/mL vs. 28.10 [12.8] pg/mL; P = 0.0001) of the menstrual cycle, respectively. Conclusions: The features associated with resistance to Letrozole at a dose of 2.5 mg show some overlap with those associated with clomifene resistance. However, some features do not show similar association. The effectiveness of letrozole at a dose of 2.5 mg in induction of ovulation among women with clomifene resistance is low and it does not seem to be a suitable treatment at a dose of 2.5 mg for this indication.

Caring for women in their post reproductive life: current recommendations on hormone replacement therapy

Introduction The post reproductive life denotes the period in a woman’s life after she reaches menopause and is a period that brings about many physical as well as psychological changes. Menopause is a diagnosis usually made in retrospect by the absence of menstruation for more than one year. However, ovarian function is known to diminish by late 30s, resulting in complete failure by the early 50s in most women [1]. This period of change in ovarian function is called the menopausal transition. A woman may experience many symptoms during this transition and in the postmenopausal age that ensues. The main symptoms of menopause include vasomotor symptoms, problems related to changes in urogenital epithelium and those due to impaired cognitive functions. The sexual function of women is also affected due to these effects as well as other changes. As the average life expectancy of a woman in Sri Lanka is 79 years and the mean age of menopause is around 51 years nearly one third of a woman’s life will be post menapausal [2].