Role of dydrogesterone in the treatment of idiopathic IUGR

Background: a) To evaluate the therapeutic efficacy of dydrogesterone in the treatment of pregnant women with idiopathic fetal growth restriction. b) To compare the outcome with the control group receiving conventional treatment in the form of rest and high protein diet.Methods: Pregnant women with idiopathic IUGR between 28-34 weeks gestation were randomized to eitherGroup 1: Control group receiving conventional treatment in the form of rest and high protein diet (n=41).Group 2: Study group receiving dydrogesterone (n=43)Primary outcome were compared in terms of fetal birth weight, apgar at birth, perinatal morbidity and mortality. Secondary outcomes in terms of changes in Doppler indices, gestational age at delivery, requirement for inductions, need for cesarean sections for IUGR, fetal distress in labour were compared.Results: Average fetal birth weight in kg were (1.71± 0.37 vs 2.03 ± 0.4, p=S), poor apgar scores (29.3% vs 20.9%, p=NS), nursery admissions (46% vs 18.6%, p=S), perinatal mortality (7.3% vs 4.7%, p=NS) in the control and study group respectively. Average gestational age at delivery was 36.4± 2.34 vs 36.9 ± 1.93 weeks (p=NS) in the control and study group respectively. Labour inductions were similar and cesarean section rates were significantly more in the control group as compared to the study group  receiving dydrogesterone (39% vs 23.3%, p=S).Conclusion: Dydrogesterone for the treatment of IUGR looks promising as it favourably affects the fetal birth weight and nursery stay

Fibroid originated from rudimentary horn in mullerian agenesis

Mullerian agenesis or Mayer Rokitansky- Kuster- Hauser syndrome is defined by congenital absence of both the uterus and vagina. It affects 1 in 4000-5000 females. Leiomyoma arising from the uterine remanent in case of MRKH is very rare. Very few cases have been reported in literature. The exact etiopathogenesis of leiomyoma from the rudimentary uterus in MRKH syndrome is not known. We are reporting a rare case of 35-year-old married, nulliparous female who presented with primary amenorrhea and lump in lower abdomen since, 1 year. On physical examination, a mass of 18-week size of uterus, firm in consistency, irregular, nontender, mobile from side to side, occupying right iliac and hypogastric region was detected. Provisional diagnosis of multiple leiomyoma with mullerian anomaly was made on USG and MRI for which laparotomy was performed. Per-operatively, there was a mass of approx. 15 x 8 x 8 cm consisting of multiple fibroids present, uterus not visualized separately. Right ovary and tube absent. Left fallopian tube and ovary were normal arising from left rudimentary horn with no endometrial tissue. Blind end with no cervix. Partial agenesis of vagina. No communication possible between rudimentary horn and vagina. Patient underwent hysterectomy in view of non-functioning uterus. Histopathology report confirmed the diagnosis. Finally, it was diagnosed as a case of multiple leiomyoma originating from uterine remanent. Post-operative period was uneventful

Association of occupational exposure on semen density in male industrial workers undergoing infertility treatment at tertiary care hospital

Background: Working with particular substances or under certain working situations may cause some workers to experience abnormalities in their sexual or reproductive health. Occupational exposures can lead to infertility, but the workers may not be aware of such problems. The purpose of the study was to determine the association between male infertility and occupation of industrial workers in organized sector.Methods: Prospective case-controlled study that included 136 industrial workers working in organized sector and attending infertility clinic for treatment. This study included male partners aged between 21-46 years with primary or secondary infertility and undertaking same occupation for at least last three months. Complete infertility workup of all male partners attending infertility clinic was done that included detailed history and information related to occupation. Routine semen parameters were evaluated according to the 2010 World Health Organization (WHO) criteria.Results: In the present study, significant semen abnormalities were observed in male partners with age more than 31 years and undertaking arduous jobs for more than 5 years (p <0.05) in study group (n=136) as compared to control group (n=62). The abnormal semen count were observed in 114 (83.2%) workers in the study group that included 43 (31.6%) with total sperm concentration (TSC) less than 10 million/ml and azoospermia in 44 (32.3%). Reduced motility (asthenozoo-spermia) was observed in majority 125 (91.9%) of male partners. The findings were significant (p <0.05) as compared to control group.Conclusions: Preventive measures in the workplace need to be established to reduce the effect of occupational hazards and its influence in the semen parameters ultimately leading to infertility

Colorectal cancer in pregnancy mimicking tuberculosis

Colorectal cancer in pregnancy is extremely rare and presentation may mimic symptoms of pregnancy or abdominal tuberculosis delaying diagnosis. We hereby report a case presenting to us in late pregnancy misdiagnosed as a case of abdominal tuberculosis

Case Report A Rare Case of Flare-Up of PID in Infertility Treatment

Case Presentation. Mrs. X, 35 years old, case of primary infertility, was diagnosed to have genital tuberculosis on the basis of PCR positive and hysterolaparoscopy findings and received category I ATT for 6 months. Following ATT completion, her USG revealed no evidence of tuboovarian mass or hydrosalpinx. Since her tubes were patent, she underwent 3 cycles of ovulation induction and 2 cycles of IUI. The women presented with acute PID, five days after IUI, and was conservatively managed. She again presented 24 days after IUI with persistent low grade fever and abdominal pain. Suspecting relapse of genital tuberculosis, she was started on category II ATT. She had acute episodes of high grade fever with chills 2 weeks after starting ATT and MRI revealed bilateral TO masses suggestive of pyosalpinx. Emergency laparotomy was done, pus was drained, and cyst wall was removed and HPE was suggestive of chronic inflammation with few granulation tissues. ATT was continued for one year and the woman improved. Conclusion. The possibility of flare-up of PID (pelvic inflammatory disease) in treated case of tuberculosis undergoing infertility management should be kept in mind and aggressive management should be done

An intrauterine insemination audit at tertiary care hospital: A 4½ years' retrospective analysis of 800 intrauterine insemination cycles

Background: There are many variables that may influence the success rates of intrauterine insemination (IUI) treatment. Therefore, a regular audit program is needed for planning effective infertility treatment and improving pregnancy outcomes. Aims and Objectives: The main objective of this study was to identify the crucial predicting factors that can influence the IUI success. Materials and Methods: A retrospective analysis of 800 IUI cycles done from January, 2013 to August, 2017 in 651 couples with various etiologies of infertility. The common etiologies included female factor of ovulatory dysfunction, tubal, endocrinal, male factor, male and female factors combined, and unexplained factors. Ovulation induction was done either by clomiphene citrate (CC) alone or in combination of CC with gonadotropins or pure gonadotropins only. Human chorionic gonadotropin trigger was given when at least one dominant follicle measuring ≥18 mm with an endometrial thickness of >7 mm was obtained. IUI was done post 36 h of trigger. The double-density gradient method was the preferred method of sperm preparation. Results: In 800 cycles in corresponding 651 couples, the total outcome was 113 pregnancies (14.1%) per cycle with overall pregnancy rate (PR) per couple of 17.3%. The highest PR was observed in the patient with ovulatory dysfunction (21.2%), followed by patients with combined factor (15.1%) and male factor (14.7%). In the study, a higher PR was achieved in the female ≤25 years (18.9%) P < 0.04 with significant findings with duration of infertility ≤5 years (15.1%) having primary infertility (14.5%) with low body mass index <25 (14.1%). IUI success rate was highest in the first cycle (14.6%) followed by second cycle (14.0%) and third cycle (3.5%). Conclusion: IUI audit enables the characterization of prognostic factors to achieve improved PR. This study identifies the factors that can predict improved pregnancy outcome in women age ≤25 years and endometrium thickness between 9 and 11 mm. We also recommend IUI as a first line of infertility treatment for couples in low-income setting provided the women age and duration of infertility are acceptably low

A Rare Case of Flare-Up of PID in Infertility Treatment

Case Presentation. Mrs. X, 35 years old, case of primary infertility, was diagnosed to have genital tuberculosis on the basis of PCR positive and hysterolaparoscopy findings and received category I ATT for 6 months. Following ATT completion, her USG revealed no evidence of tuboovarian mass or hydrosalpinx. Since her tubes were patent, she underwent 3 cycles of ovulation induction and 2 cycles of IUI. The women presented with acute PID, five days after IUI, and was conservatively managed. She again presented 24 days after IUI with persistent low grade fever and abdominal pain. Suspecting relapse of genital tuberculosis, she was started on category II ATT. She had acute episodes of high grade fever with chills 2 weeks after starting ATT and MRI revealed bilateral TO masses suggestive of pyosalpinx. Emergency laparotomy was done, pus was drained, and cyst wall was removed and HPE was suggestive of chronic inflammation with few granulation tissues. ATT was continued for one year and the woman improved. Conclusion. The possibility of flare-up of PID (pelvic inflammatory disease) in treated case of tuberculosis undergoing infertility management should be kept in mind and aggressive management should be done

Prediction of mortality and morbidity by simplified acute physiology score II in obstetric intensive care unit admissions

Background: Critical care in obstetrics has received much attention in recent times. Despite progress in medical field and improvement in health facilities provided, maternal mortality is still very high in most of the developing countries. Aim: To study and analyze records of patients requiring intensive care in obstetrics and to assess utility of simplified acute physiology score (SAPS II) for predicting maternal mortality. Setting: A multidisciplinary intensive care unit (ICU) at a tertiary care center. Design:Retrospective review. Materials and Methods: Fifty-seven consecutive obstetric patients′ records requiring ICU admissions were studied for clinical picture, diagnosis, complications, morbidity and mortality over a period of 2½ years - from 1st May 2002 to 31st Oct. 2004. SAPS II score was calculated according to the different variables for predicting mortality. Statistical analysis: SAPS II scores were regressed on mortality status using logistic regression analysis. The predictability was assessed by goodness-of-fit test and receiver operated characteristic curve. Results: Maternal mortality in obstetric ICU admissions was 1.15/1,000 deliveries, amounting to 40.35% of obstetric ICU admissions. The mean SAP II score was significantly higher (40.04 ± 12.97 vs. 22.6 ± 7.31) in those patients who died compared to survivors (P < 0.001%). Conclusions: The SAPS II accurately predicted mortality in obstetric patients admitted to ICU. Computation of the score as a routine in ICU may help in identifying those at high risk of mortality and then to reduce this risk

Therapeutic efficacy of endometrial scratching in repeated Controlled Ovarian Stimulation (COS) failure cycles

Objective: The objective of the study was (1) “to evaluate the therapeutic efficacy of endometrial scratching in repeated controlled ovarian stimulation (COS) failure cycles.” And (2) “to compare differences in pregnancy outcome by endometrial scratching in early (D2–D4) and late follicular phases (D7–D9) of the same stimulation cycle.” Materials and Methods: Women attending infertility clinic in a tertiary care center and who have two or more repeated COS failure cycles and planned for COS with intrauterine insemination (IUI) were included in the study which is a prospective parallel, interventional, single-blinded, randomized control study, in 1:1 allocation ratio. A total of 165 patients were recruited and randomly allocated into three groups: Group A (n = 55) underwent endometrial scratching on D2–D4 of the same COS cycle, Group B (n = 55) on D7–D9, and Group C (n = 55) no intervention done. All the patients underwent COS according to standard protocol followed by IUI. Results: Clinical pregnancy rate was 12.73% (odds ratio [OR] =0.87 95% confidence interval [CI] =0.288–2.55, P = 1), 16.36% (OR = 1.15; 95% CI = 0.40–3.23, P = 1), and 14.54%, respectively, in Group A, B, and C, respectively (P = 0.86), as per intention to treat analysis. Using Chi-square test, P value between Group A and B was 0.787, between Group A and C was 1.000, and between Group B and C was 1.000. As per protocol analysis, clinical pregnancy rate was 13.46% (OR = 0.83; 95% CI = 0.27–2.5, P = 0.74), 19.57% (OR = 1.3 95%; CI = 0.45–3.73, P = 0.41), and 15.69%. Using Chi-square test, P value between Group A and B was 0.588, between Group A and C was 0.967, and between Group B and C was 0.815. No abortions and multiple pregnancies occurred in either of the groups. Conclusion: The effect found was of good quantum in Group B as per protocol analysis which could be of clinical relevance if larger sample size would have been taken. Endometrial scratching is a cost-effective and easy technique which may improve clinical pregnancy rates in previous COS failure cycles, but more trials are needed to be conducted using larger sample size to achieve the improved and significant outcome

Comparative prospective study of Hysterosalpingography and hysteroscopy in infertile women

Aim: To compare the findings and diagnostic accuracy of Hysterosalpingography (HSG) and hysteroscopy in infertile women. Setting and Design: Prospective comparative study in a tertiary care Centre. Material and Methods: 108 women with primary or secondary infertility were recruited. In all women after basic infertility workup, both HSG and hysteroscopy were performed. Results: Out of 108 women, in 3 women HSG couldn’t be done and in one woman there was uterine perforation on hysteroscopy. HSG showed normal uterine cavity in 77.8% (81/105) women and abnormal in 22.85% (24/105). Hysteroscopy findings were normal in 70.09% (75/107) and abnormal in 29.91% (32/107). Hysteroscopy detected incidental findings in 15.38% (16/104) cases. HSG showed irregular uterine cavity in 14.15% (15/105) women but on hysteroscopy; normal cavity was present in 6 (40%) women and abnormality was detected in 9 (60%) women. The sensitivity, specificity, positive predictive and negative predictive value of HSG in evaluating uterine cavity abnormalities were 44.83% (95% confidence interval (CI); 0.26–0.64), 86.67% (95% CI; 0.76–0.93), 56.52% (95% CI; 0.34–0.76) and 80.25% (95%CI; 0.69–0.88). Positive likelihood ratio and negative likelihood ratio of HSG in detecting uterine cavity abnormality was 3.36 and 0.64 respectively. The agreement between HSG and hysteroscopy was 75%. This was statistically significant (P value = 0.001) with fair strength of agreement between HSG and hysteroscopy. (k value= 0.336). Conclusion: Hysteroscopy should be performed in all infertile patients as it can detect significant number of incidental findings missed by HSG