Tarek Shokeir

Significance of endometrial polyps detected hysteroscopically in eumenorrheic infertile women

Aim:  To determine if the incidence of small endometrial polyps detected hysteroscopically in an infertile eumenorrheic population differed from that in an apparently fertile eumenorrheic population. Evidence was sought to determine whether removal of such lesions would enhance reproductive performance.

Pregnancy outcome after ovulation induction with aromatase inhibitors or clomiphene citrate in unexplained infertility

Objective. To evaluate the pregnancy outcome after ovulation induction with aromatase inhibitors or clomiphene citrate (CC). Design. A prospective, randomized, controlled trial. Setting. A university hospital center and a private practice setting. Population. The study comprised a total of 796 infertile women (1,100 cycles) and 200 spontaneously pregnant women (298 cycles) as a control group. Methods. Patients were allocated treatment either with 100 mg of CC daily (420 patients, 634 cycles), 5 mg of letrozole daily (269 patients, 323 cycles) or 1 mg of anastrozole daily (107 patients, 143 cycles) for 5 days starting on day 3 of menses. Main outcome measures. The occurrence of pregnancy, miscarriage and neonatal condition. Results. Pregnancy occurred in 167/1,398 cycles (11.9%) in total without significant differences between groups. The total miscarriage rate was 16.1% (varied between 14.2% in CC group and 19.9% in anastrozole group) without difference between spontaneous and stimulated pregnancies. There were 129 deliveries in all groups. There were no significant differences between the stimulated and spontaneous pregnancies as regards mean gestational age, premature deliveries, birth weight, SGA<10th percentile or five minutes Apgar score. There was one case of complete cleft palate and one case of major congenital heart problem in the letrozole group. There were two cases of talipus equinovarus in the CC and spontaneous pregnancy group. Conclusion. Aromatase inhibitors and CC resulted in favorable pregnancy outcomes and average miscarriage rates. Safety of the drugs for both the mother and fetuses was documented.

Submucous myomas and their implications in the pregnancy rates of patients with otherwise unexplained primary infertility undergoing hysteroscopic myomectomy: a randomized matched control study

OBJECTIVE To determine whether hysteroscopic myomectomy for submucous fibroids in women with unexplained primary infertility achieved better pregnancy rates than no intervention. DESIGN Prospective randomized matched control trial. SETTING Tertiary university fertility care unit. PATIENT(S) From January 1999 to February 2006, a total of 215 women with unexplained primary infertility and with ultrasonographically diagnosed submucous myomas as the sole cause for fertility failure were recruited. INTERVENTION(S) Women were randomly allocated to one of two pretreatment groups matched by age. Hysteroscopic myomectomy was performed in the study group (n = 101). Diagnostic hysteroscopy and myoma biopsy was performed in the control group (n = 103). No fertility therapy was given for either group. MAIN OUTCOME MEASURE(S) Clinical pregnancy rates according to patient and myoma characteristics. RESULT(S) The baseline characteristics of both patients and submucous myomas were comparable. Among patients with complete follow-up, a total of 93 (45.6%) pregnancies occured-64 (63.4%) in the study group and 29 (28.2%) in the control group. Women in the study group had a better possibility of becoming pregnant after hysteroscopic myomectomy with a relative risk of 2.1 (95% confidence interval, 1.5-2.9). No difference in pregnancy rates was observed according to size, number, and location of myomas in both groups. However, fertility rates appeared to increase after hysteroscopic myomectomy of type 0 and type I myomas (P < 0.05). In contrast, for the subgroup of patients with type II myomas, no difference in fertility rates were noted. CONCLUSION(S) Hysteroscopic myomectomy for submucous fibroids in women with unexplained primary infertility is effective in achieving a better pregnancy rate. We think that a multicenter study should be conducted before evaluating the impact of submucous myoma characteristics on fertility outcome.

Letrozole versus combined metformin and clomiphene citrate for ovulation induction in clomiphene-resistant women with polycystic ovary syndrome: a randomized controlled trial

OBJECTIVE To compare the effect of letrozole with combined metformin and clomiphene citrate (CC) for ovulation induction in CC-resistant women with polycystic ovary syndrome (PCOS). DESIGN A randomized controlled trial. SETTING University teaching hospital and a private practice setting. PATIENT(S) Two hundred fifty anovulatory women (582 cycles) with CC-resistant PCOS. INTERVENTION(S) Patients received 2.5 mg of letrozole daily (123 patients, 285 cycles) or combined metformin-CC (127 patients, 297 cycles) for three treatment cycles. MAIN OUTCOME MEASURE(S) Ovulation rate, number of follicles, serum E(2), serum P, endometrial thickness, pregnancy, and miscarriage rates. RESULT(S) Ovulation occurred in 185/285 cycles (64.9%) in the letrozole group versus 207/297 cycles (69.6%) in the combined metformin-CC group, without statistically significant difference. The total number of follicles was significantly more in the combined metformin-CC group (4.4+/-0.4 vs. 6.8+/-0.3). A nonsignificant increase in endometrial thickness on the day of hCG administration was observed in the letrozole group (9.5+/-0.2 mm vs. 9.1+/-0.1 mm). No statistically significant difference regarding the pregnancy rate (PR) was observed between both groups (14.7% vs. 14.4%). CONCLUSION(S) Letrozole and combined metformin-CC are equally effective for inducing ovulation and achieving pregnancy in patients with CC-resistant PCOS.

Determinants of fertility and reproductive success after hysteroscopic septoplasty for women with unexplained primary infertility: a prospective analysis of 88 cases

OBJECTIVE To evaluate prospectively the effect of hysteroscopic septoplasty as therapy for unexplained primary infertility in women with uterine septum as a sole cause for reproductive failure and to define the factors influencing reproductive success. STUDY DESIGN In a prospective comparative study, we enrolled 103 infertile women with uterine septum as a sole cause for reproductive failure. They had had unexplained primary infertility >2 years and a follow-up >12 months. Uterine anomalies were diagnosed by means of hysterosalpingography (HSG) and 2D-transvaginal sonography (TVS) with intrauterine saline infusion. Hysteroscopic septoplasty was performed in the early follicular phase. Pregnancy rates (PR) according to patient and septum characteristics (septum size) were the main outcome measures. RESULTS Follow-up was complete for 88 patients. The mean (±SD) age of the patients was 36.1±2.1 years. Forty-two patients became pregnant (40.7%). The mean (±SD) delay in conception was 7.5±2.6 months. Nearly 80% of the pregnant women conceived spontaneously. Of 44 pregnancies in 42 women, 36 live newborns were delivered. The PR was significantly higher in women <35 years of age or with <3 years of unexplained primary infertility. Moreover, in women with a septum size larger than one-half of their uterine length the PR was significantly higher than those with septum size <1/2 of their uterus (P=.12). CONCLUSION Fertility and pregnancy after hysteroscopic septoplasty in women with unexplained primary infertility and uterine septum as a sole cause for reproductive failure seems to depend on patient age, duration of infertility before septoplasty, and septum size. Women with a septum size larger than one-half of their uterine length have a higher chance of successful pregnancy after hysteroscopic septoplasty.

Combined diagnostic approach of laparoscopy and hysteroscopy in the evaluation of female infertility: Results of 612 patients

Aim:  To clarify the role of a combined diagnostic approach using laparoscopy and hysteroscopy in the evaluation of female infertility in developing countries.

Reducing blood loss at abdominal myomectomy with preoperative use of dinoprostone intravaginal suppository: a randomized placebo-controlled pilot study

OBJECTIVE To determine the effect of a single preoperative intravaginal prostaglandin E(2) (PGE(2); dinoprostone) suppository on reducing intraoperative blood loss and the need for subsequent blood transfusion at abdominal myomectomy for symptomatic leiomyomas. STUDY DESIGN In a prospective randomized double-blind placebo-controlled pilot study, 108 women who had abdominal myomectomy for symptomatic leiomyomas were enrolled. Patients were randomly assigned to receive a single dose of intravaginal 20mg dinoprostone (n=54) or placebo (n=54) 60 min before the operation. The primary outcome was the operative blood loss. The secondary outcomes were the need for blood transfusion, change in hemoglobin (Hb) level 24h after operation, and the prevalence of side effects. RESULTS Blood loss and transfusion rate were significantly greater in the group without PGE(2) suppository (group B) than in the group with PGE(2) (group A): they were respectively 485.7 ± 361.3 mL vs 364.1 ± 279.4 mL (P=.02; relative risk [RR] 0.95; 95% confidence interval [CI], 0.63-1.45) and 18.5% vs 3.7% (P=.04; RR 1.32; 95% CI, 3.7-18.5). Group B had a significant decrease in Hb level 24h after operation compared with group A (P<.05). There was no difference in the patient demographics, intraoperative characteristics, postoperative stay, complications, and the side effects between the two groups. CONCLUSION A single pre-operative dose of dinoprostone administered intravaginally could be a safe and reliable method to help decrease blood loss during abdominal myomectomy. Further larger prospective studies are required to support this conclusion.

An RCT: Use of Oxytocin Drip during Hysteroscopic Endometrial Resection and Its Effect on Operative Blood Loss and Glycine Deficit

OBJECTIVE To estimate the influence of oxytocin infusion on operative blood loss and glycine deficit during hysteroscopic transcervical endometrial resection (TCRE) for abnormal uterine bleeding (AUB). DESIGN Prospective, randomized, placebo-controlled study (Canadian Task Force classification I). SETTING Tertiary Care University Hospital. PATIENTS Forty-eight women with abnormal uterine bleeding that was unresponsive to conservative medical management were randomly assigned to undergo hysteroscopic TCRE with either oxytocin infusion (group A) or saline (group B). Intravenous Ringers lactate solution was used during surgery. INTERVENTIONS TCRE was carried out with glycine 1.5% mixed with 2% ethanol as a distension medium. For group A: one ampoule of oxytocin (10 U/mL/amp) was added to 500 mL Ringers lactate solution running at a rate of 400 mU/min during surgery. In group B, one ampoule of saline solution was added to the Ringers solution and run at a similar rate. The amount of distension medium used, fluid deficit, blood levels of albumin and ethanol, hematocrit, hemoglobin, changes in serum sodium levels (Na+), and central venous pressure were compared between the groups. MEASUREMENTS AND MAIN RESULTS The mean volume of distension fluid used and operating time were not significantly different in both groups (4.18 ± 0.2 vs 4.5 ± 0.5 L, and 28.3 ± 4.2 vs 27.5 ± 5.4 min, respectively). Although operating time, volume of distension fluid used, decrease in albumin level and hematocrit were less in the oxytocin than in the saline group, the differences were not statistically significant. The ethanol levels in blood, decrease in serum Na+, and glycine deficit were significantly lower in the oxytocin than in the saline group (17.4 ± 3.8 vs 25.3 ± 4.2 mg/ml, 6.7 ± 1.2 vs 9.1 ± 0.9 mEq/L, and 0.49 ± 0.08 vs 0.66 ± 0.05 L, respectively; p <.05). There was no significant difference in mean total uterine size, endometrial thickness, weight of resected tissue, and other demographic data between the study groups. CONCLUSIONS Oxytocin infusion combined with skillful surgical techniques may prevent fluid overload and glycine deficit during hysteroscopic TCRE for abnormal uterine bleeding. Although there is a trend toward a decrease in operative blood loss, further randomized trials are required to confirm this finding.

Sonohysterography as a first-line evaluation for uterine abnormalities in women with recurrent failed in vitro fertilization-embryo transfer.

We evaluated the uterine cavity by sonohysterography (SHG) in patients with recurrent failed IVF-embryo transfer despite transfer of good quality embryos, compared with other diagnostic methods. We found that SHG is highly valuable and should be applied routinely as a first-line, office-based diagnostic tool in such cases.

Endothelial function in young women with polycystic ovary syndrome (PCOS): Implications of body mass index (BMI) and insulin resistance

SUMMARY BACKGROUND Evidence regarding endothelial function in both obese and nonobese women with PCOS is contradictory. It is unknown whether obese women with PCOS carry an increased risk related to body mass index (BMI). AIM To identify endothelial function and investigate its relationship to body mass index and insulin resistance in young women with PCOS. SUBJECTS AND METHODS Twenty-two obese women with PCOS (BMI 35.2 ± 3.2) as well as fourteen lean women (BMI 22.8 ± 2.1)with PCOS were included in the study. Fasting serum insulin, blood glucose were estimated and HOMA and Quicki index were calculated. All patients were subjected to ultrasound recording of brachial artery diameter at rest and after reactive hyperemia (FMD) for assessment of endothelial function. Ten age matched healthy females with normal BMI were chosen as a control group. RESULTS There were higher basal insulin levels with lower Quicki index and higher HOMA index in women with PCOS than normal group, but the differences were significant only between obese PCOS subgroup and control. On the other hand, FMD was significantly and equally decreased in both groups of women with PCOS, compared with control subjects (3.7 ± 3.2% in the nonobese subgroup and 3.5 ± 2.8% in the obese one vs. 10.6 ± 4.1% in control subjects, P, 0.001). FMD was not correlated with BMI nor insulin resistance indices. CONCLUSIONS Endothelial dysfunction is already present in young women with PCOS. In this patient group, it cannot be attributed to insulin resistance or obesity.