Usama M. Fouda

Enoxaparin versus unfractionated heparin in the management of recurrent abortion secondary to antiphospholipid syndrome.

To determine whether low molecular weight heparin (LMWH) plus low‐dose aspirin (LDA) is comparable in efficacy and safety to unfractionated heparin (UFH) plus LDA in the management of pregnant women with a history of recurrent spontaneous abortion secondary to antiphospholipid syndrome (APS).

Extended letrozole regimen versus clomiphene citrate for superovulation in patients with unexplained infertility undergoing intrauterine insemination: A randomized controlled trial

BackgroundThe aim of this randomized controlled trial was to compare the efficacy of extended letrozole regimen with clomiphene citrate in women with unexplained infertility undergoing superovulation and intrauterine insemination (IUI).MethodsTwo hundred and fourteen patients with unexplained infertility were randomized into two equal groups using computer generated list and were treated by either letrozole 2.5 mg/day from cycle day 1 to 9 (extended letrozole group, 211 cycles) or clomiphene citrate 100 mg/day from cycle day 3 to 7 (clomiphene citrate group,210 cycles). Intrauterine insemination was performed 36 to 40 hours after HCG administration.ResultsBoth groups were comparable with regard to number of mature follicles (2.24 +/- 0.80 Vs 2.13 +/- 0.76) and the day of HCG administration. Serum estradiol was significantly greater in clomiphene citrate group (356 +/- 151 Vs 822 +/- 302 pg/ml, P = < 0.001) and the endometrial thickness was significantly greater in extended letrozole group (9.10 +/- 1.84 Vs 8.18 +/- 1.93 mm, P = < 0.001).The pregnancy rate per cycle and cumulative pregnancy rate were significantly greater in extended letrozole group (18.96% Vs 11.43% and 37.73% Vs 22.86%, respectively).ConclusionThe extended letrozole regimen had a superior efficacy as compared with clomiphene citrate in patients of unexplained infertility undergoing superovulation and IUI.Trial registrationClinicalTrials.gov, NCT01232075

Diclofenac plus lidocaine gel for pain relief during intrauterine device insertion. A randomized, double-blinded, placebo-controlled study

OBJECTIVE To determine the effectiveness of diclofenac potassium combined with 2% lidocaine gel in reducing the pain of intrauterine device (IUD) insertion. STUDY DESIGN We randomized 90 parous women requesting copper T380A IUD insertion in a 1:1 ratio to active or placebo treatment. Active treatment included administration of two 50-mg diclofenac potassium tablets 1h before IUD insertion, application of 3mL of 2% lidocaine gel on the anterior cervical lip 3min before IUD insertion and placement of a cotton swab soaked in 2% lidocaine gel in the cervical canal 3min before IUD insertion. Women in the placebo group received placebo tablets and gel. Participants assessed pain intensity using a 10-cm visual analog scale (VAS). We considered a 2-cm difference in VAS pain score between both groups during IUD insertion to be a clinically significant difference. RESULTS Subjects receiving active treatment, as compared to placebo, experienced less pain during tenaculum placement (1.66±0.85 vs. 2.33±1.19, p=.003) and IUD insertion (3.14±0.92 vs. 3.94±1.3, p=.001). Women who delivered only by cesarean section had higher pain scores with IUD insertion compared with women with previous vaginal deliveries (4.41±1.24 vs. 3.29±1.05, p=.001). CONCLUSION Diclofenac potassium combined with 2% lidocaine gel slightly reduced pain scores during tenaculum application and copper IUD insertion in parous women; however, the reduction in pain scores lacked clinical significance. IMPLICATIONS Although we found a statistically significant lowering of pain scores with pretreatment with diclofenac potassium and lidocaine gel in parous women having copper IUD placement, the reduction is not clinically relevant. These findings may be more relevant for nulliparous women who experience more pain than parous women with IUD insertion and support studies of diclofenac potassium and lidocaine gel in this population.

Ultrasound guided aspiration of hydrosalpinx fluid versus salpingectomy in the management of patients with ultrasound visible hydrosalpinx undergoing IVF-ET: a randomized controlled trial

BackgroundThe aim of this study was to compare the efficacy of ultrasound guided aspiration of hydrosalpinx fluid at the time of oocyte retrieval with salpingectomy in the management of patients with ultrasound visible hydrosalpinx undergoing IVF-ET.MethodsOne hundred and sixty patients with ultrasound visible hydrosalpinx were randomized into salpingectomy group and aspiration group using computer generated randomization list and sequentially numbered sealed envelopes containing allocation information written on a card.ResultsThe clinical pregnancy rate per started cycle and the implantation rate were non- significantly higher in the salpingectomy group compared with the aspiration group [40% vs. 27.5% (p value = 0.132) and 18.95% vs. 12.82% (p value =0.124), respectively]. In the aspiration group, 34.21% of patients had rapid re-accumulation of the hydrosalpinx fluid (i.e. within first two weeks after embryo transfer). Whereas, the clinical pregnancy rate per transfer cycle and the implantation rate were significantly higher in salpingectomy group compared with the subgroup of patients with rapid re-accumulation of hydrosalpinx fluid [42.67% vs. 19.23% (p value = 0.036) and 18.95% vs. 7.58% (p value = 0.032), respectively], no significant differences were detected between the salpingectomy group and the subgroup of patients with no re-accumulation of hydrosalpinx fluid (42.67% vs. 34% (p value = 0.356) and 18.95% vs. 15.5% (p value = 0.457), respectively).ConclusionThe small sample size could be the cause of failure of detecting significant increase in implantation and pregnancy rates in salpingectomy group compared with aspiration group. Further larger randomized controlled trials are needed to determine whether salpingectomy is more effective than aspiration of hydrosalpinx fluid or not. Moreover, the data presented in this study suggested that rapid re-accumulation of hydrosalpinx fluid is an obstacle against successful implantation and the cause of lower success rate with ultrasound guided aspiration of hydrosalpinx fluid compared with salpingectomy.Trial registrationClinical trials.gov (NCT02008240), registered 8 December 2013.

Effect of ultrasound-guided aspiration of hydrosalpingeal fluid during oocyte retrieval on the outcomes of in vitro fertilisation-embryo transfer: a randomised controlled trial (NCT01040351)

Objective. To determine whether the ultrasound-guided aspiration of hydrosalpingeal fluid at the time of oocyte retrieval can improve the outcomes of in vitro fertilisation-embryo transfer (IVF-ET). Patients. One hundred and ten women with ultrasound-visible hydrosalpinges were randomised to two groups based on computer generated randomisation list. Fifty-four women underwent ultrasound-guided aspiration of hydrosalpingeal fluid prior to IVF-ET and 53 women underwent IVF-ET without any prior intervention. Results. Patients who underwent aspiration of hydrosalpinges demonstrated a significantly increased implantation, clinical pregnancy rates. Among the patients in the aspiration group, the implantation rate and pregnancy rates were higher in the subgroup of patients with no reaccumulation of hydrosalpingeal fluid within the first 2 weeks after aspiration compared to patients with reaccumulation of hydrosalpingeal fluid within the first 2 weeks after aspiration, but this difference failed to reach statistical significance. Furthermore, no pregnancies occurred in the four patients with uterine fluid collection detected during IVF-ET cycles. Conclusion. The aspiration of hydrosalpingeal fluid at the time of oocyte retrieval is simple, safe and effective procedure for treatment of patients with ultrasound-visible hydrosalpinges particularly those without rapid reaccumulation of hydrosalpingeal fluid after aspiration or uterine fluid collection during the IVF-ET cycles.

Hysteroscopic Myomectomy of Large Submucous Myomas in a 1-Step Procedure Using Multiple Slicing Sessions Technique.

OBJECTIVE To evaluate the feasibility and efficacy of our technique for resectoscopic removal of large symptomatic submucous myomas. DESIGN Prospective study (Canadian Task Force classification II-3). SETTING A university teaching hospital and a private hospital. PATIENTS Forty-nine patients with submucous myomas ≥ 4 cm in diameter complaining of abnormal uterine bleeding. Seventeen patients were also complaining of infertility. INTERVENTIONS The intrauterine portion of submucous myomas was resected using the slicing technique. Slicing started at the site of the maximum bulge of the myoma and was continued down to the level of the endometrial surface. Each slicing session lasted for 5 to 10 minutes. After each slicing session, saline infusion was discontinued and restarted alternatively several times to induce rapid changes in the intrauterine pressure (hydromassage) to stimulate uterine contractions. The resectoscope was removed, and ovum forceps was used to extract the myoma fragments. Bimanual massage of the uterus was performed to induce extrusion of the intramural portion of the myoma into the uterine cavity. The same steps (slicing session lasting for 5-10 minutes to excise the portion of the myoma extruded into the uterine cavity, hydromassage, and uterine massage) were repeated several times until complete removal of the myoma. MEASUREMENTS AND MAIN RESULTS The mean diameter of the principle myomas was 51.94 ± 5.58 mm. The rate of 1-step complete resection of myomas was 91.84% (45/49). Improvement of bleeding symptoms was observed in all patients with complete resection of myomas. Nine of the 17 infertile women conceived after hysteroscopic myomectomy. One-step complete resection of myomas was more frequent in patients with myomas < 6 cm (43/44 [97.73%] vs 2/5 [40%], risk ratio [RR] = 2.44, p = .002), single myomas (39/40 [97.5%] vs 6/9 [66.67%], RR = 1.46, p = .016), principle myomas with a Lasmar score < 7 (32/32 [100%] vs 13/17 [76.47%], RR = 1.31, p = .011), and myomas with less than 50% extension into the myometrium (26/26 [100%] vs 19/23 [82.61%], RR = 1.21, p = .042). The rate of 1-step complete removal of myomas was 95% (19/20) for type II myomas < 6 cm and 0% (0/3) for type II myomas ≥ 6 cm. CONCLUSION Our technique of hysteroscopic myomectomy is a safe and effective management for submucous myomas up to 6 cm in diameter.

Role of fetal echocardiography in the evaluation of structure and function of fetal heart in diabetic pregnancies.

Objective: To detect the structural and functional changes of fetal hearts in diabetic pregnancies by using Doppler echocardiography. Methods: This prospective study included 119 pregnant women divided into three groups. Group 1 included 47 pregnant patients with pre-existing diabetes mellitus (DM), group 2 included 40 patients with gestational diabetes and group 3 included 32 non-diabetic pregnant women. M-mode echocardiography was used to measure the thickness of the fetal ventricular walls and interventricular septum. The mitral and tricuspid early (E) and late (A) diastolic velocities and the ventricular shortening fraction were measured. Results: HbA1c % was significantly lower in gestational diabetes group compared with the pre-existing diabetes group. The interventricular septum was significantly thicker in the pre-existing diabetes group compared with other groups. Tricuspid and mitral E/A ratios were significantly lower in the pre-existing diabetes group compared with gestational diabetes and control groups. Moreover, there were no significant differences in the tricuspid and mitral E/A ratios between gestational diabetes group and the control group. The right and left ventricular shortening fractions were similar in the three groups. Conclusion: Fetuses of women with well-controlled gestational diabetes lack the diastolic dysfunction that is present in fetuses of women with pre-existing diabetes

Impetigo herpetiformis during the puerperium triggered by secondary hypoparathyroidism: a case report

A 38-year-old multiparous woman with post thyroidectomy hypoparathyroidism developed pruritic erythematous patches with multiple pustules on its margins on her thighs and groin accompanied by fever few days after delivery by caesarean section. Impetigo herpetiformis was diagnosed based on the typical clinicopathological findings. The patient was treated with intravenous fluids, calcium, Calcitrol and corticosteroids. The correction of hypocalcaemia was accompanied with rapid improvement of her skin disease and general condition. Our case is the fourth case of impetigo herpetiformis initially presented during puerperium and the first case of puerperal impetigo herpetiformis that is precipitated by secondary hypoparathyroidism. The awareness of the possible occurrence of impetigo herpetiformis during the puerperium allows early diagnosis, treatment and prevention of maternal complications.

Extended high dose letrozole regimen versus short low dose letrozole regimen as an adjuvant to gonadotropin releasing hormone antagonist protocol in poor responders undergoing IVF-ET*

Objective. To compare the efficacy and cost-effectiveness of extended high dose letrozole regimen/HPuFSH-gonadotropin releasing hormone antagonist (GnRHant) protocol with short low dose letrozole regimen/HPuFSH-GnRHant protocol in poor responders undergoing IVF-ET. Methods. In this randomized controlled trial, 136 women who responded poorly to GnRH agonist long protocol in their first IVF cycle were randomized into two equal groups using computer generated list and were treated in the second IVF cycle by either extended letrozole regimen (5 mg/day during the first 5 days of cycle and 2.5 mg/day during the subsequent 3 days) combined with HPuFSH-GnRHant protocol or short letrozole regimen (2.5 mg/day from cycle day 3–7) combined with HPuFSH-GnRHant protocol. Results. There were no significant differences between both groups with regard to number of oocytes retrieved and clinical pregnancy rate (5.39 ± 2.08 vs. 5.20 ± 1.88 and 22.06% vs. 16.18%, respectively).The total gonadotropins dose and medications cost per cycle were significantly lower in extended letrozole group (44.87 ± 9.16 vs. 59.97 ± 14.91 ampoules and 616.52 ± 94.97 vs. 746.84 ± 149.21 US Dollars (

Low dosing of gonadotropins in in vitro fertilization cycles for women with poor ovarian reserve: systematic review and meta-analysis

), respectively).The cost-effectiveness ratio was 2794