Letrozole or clomiphene citrate as first line for anovulatory infertility: a debate

Clomiphene citrate has been traditionally used as the drug of choice in treating women with anovulatory infertility. In the last decade letrozole, an aromatase inhibitor has emerged as alternative ovulation induction agent. Literature confirms that letrozole has a definitive role in anovulatory women who have not responded to the clomiphene therapy. However its role as an alternative to clomiphene as first line therapy continues to be debated. Although it is probable that the overall benefits of letrozole surpass clomiphene citrate, currently available data does not confirm this view. There is need for large well-designed trials

Epidural anesthesia and post-operative analgesia for bilateral inguinal mesh hernioplasty: Comparison of equipotent doses of ropivacaine and bupivacaine

Objectives: Ropivacaine is a long-acting amide local anesthetic, which is structurally very similar to bupivacaine but produces less motor block and less cardiac and central nervous system toxicity. It is also about 40% less potent than bupivacaine. Our double blind study was designed to compare the clinical efficacy of the equipotent doses of ropivacaine 0.75% and bupivacaine 0.5% for epidural anesthesia and ropivacaine 0.2% and bupivacaine 0.125% for post-operative analgesia in patients undergoing bilateral mesh hernioplasty. Methods: Sixty-one patients were randomized to receive 15 ml of 0.75% ropivacaine or 0.5% bupivacaine. Sensory and motor block characteristics were compared. Changes in heart rate, mean arterial blood pressure, and adverse effects were noted. For post-operative analgesia, 0.2% ropivacaine and 0.125% bupivacaine were given as continuous epidural infusion. Analgesia using VAS scores, motor block, volume of local anesthetic used and patient satisfaction was assessed. Results: There was no significant variation in the sensory block profile. A greater intensity of motor block was achieved with bupivacaine in the beginning but by 30 minutes the difference was not significant. Duration of motor block was similar in the two groups. Visual analog scale scores were similar in both groups during the post-operative period, with a similar motor block profile. No major side effects were noted in any group. Conclusion: The equipotent doses of ropivacaine and bupivacaine provided good quality epidural anesthesia and post-operative analgesia

Outcomes of renal transplantation in patients with immunoglobulin A nephropathy in India

<b>Background: </b> There is a paucity of data on the course of renal transplant in patients with immunoglobulin A (IgA) nephropathy (IgAN) from India. While the natural history of IgAN in the Indian context is rapidly progressive, the post-transplant course remains speculative. <b> Aim:</b> To study the graft survival in renal transplant recipients whose native kidney disease was IgAN and the incidence and correlates of recurrent disease. <b> Settings and Designs:</b> Retrospective case control study from a Nephrology unit of a large tertiary care center. <b> Materials and Methods:</b> The outcomes of 56 transplant patients (58 grafts) with biopsy-proven IgAN and of 116 patients without IgAN or diabetic nephropathy, transplanted during the same period were analyzed. Correlates of biopsy-confirmed recurrent disease were determined. <b> Statistical Analysis:</b> Means were analyzed by Student&#x2032;s <i> t</i> test and Mann-Whitney test; proportions were determined by Chi-square analysis and graft survival curves were generated using the Kaplan-Meier. <b> Results:</b> Five-year graft survival for IgA patients was not significantly different from that in the reference group (90&#x0025; and 79&#x0025;,<i> P</i> = 0.6). During a mean follow-up of 42 months (range, 1-144), 28 event graft biopsies were required in 20 grafts of IgAN. Histological recurrence was diagnosed in five of the 20 available biopsies (25&#x0025;) after a mean duration of 28 months. Recurrence did not correlate with donor status, HLA B35 and A2, recipient age, gender or immunosuppression. <b> Conclusions: </b> Renal transplantation is an appropriate treatment modality for IgA nephropathy patients with end-stage renal disease in India, despite the potential for recurrent disease. The posttransplant course is an indolent one when compared to the malignant pretransplant phase

Outcomes of renal transplantation in patients with immunoglobulin A nephropathy in India

Background: There is a paucity of data on the course of renal transplant in patients with immunoglobulin A (IgA) nephropathy (IgAN) from India. While the natural history of IgAN in the Indian context is rapidly progressive, the post-transplant course remains speculative. Aim: To study the graft survival in renal transplant recipients whose native kidney disease was IgAN and the incidence and correlates of recurrent disease. Settings and Designs: Retrospective case control study from a Nephrology unit of a large tertiary care center. Materials and Methods: The outcomes of 56 transplant patients (58 grafts) with biopsy-proven IgAN and of 116 patients without IgAN or diabetic nephropathy, transplanted during the same period were analyzed. Correlates of biopsy-confirmed recurrent disease were determined. Statistical Analysis: Means were analyzed by Student′s t test and Mann-Whitney test; proportions were determined by Chi-square analysis and graft survival curves were generated using the Kaplan-Meier. Results: Five-year graft survival for IgA patients was not significantly different from that in the reference group (90% and 79%, P = 0.6). During a mean follow-up of 42 months (range, 1-144), 28 event graft biopsies were required in 20 grafts of IgAN. Histological recurrence was diagnosed in five of the 20 available biopsies (25%) after a mean duration of 28 months. Recurrence did not correlate with donor status, HLA B35 and A2, recipient age, gender or immunosuppression. Conclusions: Renal transplantation is an appropriate treatment modality for IgA nephropathy patients with end-stage renal disease in India, despite the potential for recurrent disease. The posttransplant course is an indolent one when compared to the malignant pretransplant phase

Outcomes of renal transplantation in patients with immunoglobulin A nephropathy in India

Background: There is a paucity of data on the course of renal transplant in patients with immunoglobulin A (IgA) nephropathy (IgAN) from India. While the natural history of IgAN in the Indian context is rapidly progressive, the post-transplant course remains speculative. Aim: To study the graft survival in renal transplant recipients whose native kidney disease was IgAN and the incidence and correlates of recurrent disease. Settings and Designs: Retrospective case control study from a Nephrology unit of a large tertiary care center. Materials and Methods: The outcomes of 56 transplant patients (58 grafts) with biopsy-proven IgAN and of 116 patients without IgAN or diabetic nephropathy, transplanted during the same period were analyzed. Correlates of biopsy-confirmed recurrent disease were determined. Statistical Analysis: Means were analyzed by Student\u2032s t test and Mann-Whitney test; proportions were determined by Chi-square analysis and graft survival curves were generated using the Kaplan-Meier. Results: Five-year graft survival for IgA patients was not significantly different from that in the reference group (90% and 79%, P = 0.6). During a mean follow-up of 42 months (range, 1-144), 28 event graft biopsies were required in 20 grafts of IgAN. Histological recurrence was diagnosed in five of the 20 available biopsies (25%) after a mean duration of 28 months. Recurrence did not correlate with donor status, HLA B35 and A2, recipient age, gender or immunosuppression. Conclusions: Renal transplantation is an appropriate treatment modality for IgA nephropathy patients with end-stage renal disease in India, despite the potential for recurrent disease. The posttransplant course is an indolent one when compared to the malignant pretransplant phase

Blastocyst stage transfer vs cleavage stage embryo transfer

Objective: To evaluate the efficacy of blastocyst transfer in comparison with cleavage stage embryo in a similar cohort of women. Design: Retrospective analysis. Setting: University teaching hospital. Materials and Methods: Women aged 35 or less undergoing in vitro fertilization/intracytoplasmic sperm injection between January 2005 and December 2006 were included in the study. When four or more grade 1 embryos were observed on day 3, extended culture till day 5 was undertaken. This policy was compared with a cohort of women who had at least three grade 1 embryos on day 3 and who had undergone a cleavage stage embryo transfer during the time period of January 2002-December 2004. Primary outcome evaluated was implantation rate and clinical pregnancy rate. Results: Group 1 consisted of 50 women who underwent extended culture and blastocyst transfer. Group 2 comprised of 85 women who had cleavage transfer. The implantation rate for embryos transferred in group 1 was significantly higher than that for embryos transferred on day 3 (40.16% vs 11.43%). The clinical pregnancy rate was also significantly better with blastocyst transfer as compared with cleavage stage transfer (62% vs 29.76%). Significantly fewer embryos were required for transfer at the blastocyst stage compared with day 3 transfer (2.54 vs 3.45). Conclusion: In selected cases, blastocyst transfer with fewer embryos can be performed with high implantation and clinical pregnancy rates. This policy could lead to a reduction in the incidence of higher-order pregnancies

Prevalence of metabolic syndrome in women with polycystic ovary syndrome attending an infertility clinic in a tertiary care hospital in south India

Objective: The aim of the present study was to evaluate the prevalence of metabolic syndrome in women with polycystic ovary syndrome (PCOS). Setting: Infertility clinic in a tertiary care hospital. Study Design: A prospective cross-sectional study. Materials and Methods: All the women attending the infertility clinic categorized as polycystic ovary syndrome according to Rotterdam criteria (2003) during the study period were included in the study. The women with PCOS underwent screening for metabolic syndrome as defined by the modified American Heart Association/National Heart Lung Blood Institute (AHA/NHLBI) modified ATP 111 (2005) definition. A multivariate logistic regression analysis was applied and significant predictors identified for the prediction of metabolic syndrome. Results: The overall prevalence of metabolic syndrome according to the modified AHA/NHLBI ATP III (2005) criteria was 37.5%. A total of 5.8 % cases were detected to have diabetes mellitus, 8.3% had impaired fasting glucose, and 11.7 % had an impaired glucose test. Dyslipidemia was present in 93.3% cases of PCOS. Among all the risk factors, age and waist hip ratio ≥0.85 were strongly associated with the presence of metabolic syndrome. Conclusion: Infertile women with PCOS, particularly those with age ≥25 years or with central obesity (a waist hip ratio of ≥0.85), are at a higher risk of developing metabolic syndrome and should be offered screening tests

Effect of controlled hypercapnia on cerebrospinal fluid pressure and operating conditions during transsphenoidal operations for pituitary macroadenoma

Controlled hypercapnia was assessed for its effectiveness in raising cerebrospinal fluid pressure to enable descent of the suprasellar portion of pituitary macroadenomas during transsphenoidal surgery. The result was compared in a randomized, single blind trial with intermittent boluses of saline injected intrathecally. Intrathecal pressures were monitored in both groups. Twenty-seven of 29 patients in the study group and 25 of 28 patients in the control group reached the target pressure of 20 mm Hg. The mean ETCO2 at the time of maximum pressure was 42.34 +/- 4.75 mm Hg in the study group and 29.81 +/- 2.61 mm Hg in the control group, (P&#60; .001). Mean arterial carbon dioxide was 46.90 +/- 6.55 and 31.42 +/- 4.87 mm Hg, respectively. Surgeons blinded to the technique assessed the descent of the tumor. The operating conditions were judged by the surgeons to be satisfactory for 20 patients in the study group and 17 patients in the control group. Both techniques were equally effective in raising intracranial pressure and in providing descent of the suprasellar component of the tumor. No untoward side effects occurred while using either technique. The authors conclude that controlled hypercapnia is effective in producing descent of the suprasellar portion of a pituitary adenoma

Blastocyst cryopreservation using solid surface vitrification: A preliminary study

Objective: The objective was to evaluate the effectiveness of a blastocyst cryopreservation program using solid surface vitrification. Setting: This study took place in a university teaching hospital. Study Design: Retrospective observational study. Materials and Methods: Women undergoing frozen embryo transfer cycles over a 4-year period between 2006 and 2010 were studied. The cryopreservation policy followed was a vitrification protocol performed at the blastocyst stage, using a solid surface (nonimmersion) method. The post-thaw survival rate, implantation rate, clinical pregnancy rate, live birth rate, and neonatal outcome were recorded. Results: Eighty-one women underwent 86 frozen embryo transfer cycles. Of the 240 blastocysts warmed, 204 survived giving a cryosurvival rate of 85% (204/240). The clinical pregnancy, implantation, miscarriage, ongoing pregnancy, and live birth rates per transfer were 47%, 29%, 12%, 16%, and 23% respectively. Of the 20 live births, there were 16 singletons and 4 twins. Eleven boys and 13 girls were delivered with no major or minor abnormality detected. Conclusion(s): The blastocyst vitrification protocol using the solid surface method is effective with results comparable to fresh blastocyst transfers. While retaining the rapid cooling effect, the nonimmersion technique eliminates the risk of contamination and disease transmission. Larger studies with long-term follow-up data would further confirm the efficacy and safety of this method of vitrification