Spontaneous ovulation and pregnancy in women with polycystic ovarian disease; a cross sectional study

Background: Polycystic ovary disease (PCOD) is the most common endocrine disorder in women of reproductive age, with a prevalence of approximately 5-10%. This study aims to assess the rate of spontaneous ovulation and pregnancy in patients. The present study was a cross sectional study conducted at Woman's Health Hospital, Assiut University, Assiut, Egypt.Methods: The current study was a cross sectional study carried out in Assiut Women's Health Hospital between the 1st October 2016 and 31st July 2017. The patients were selected as infertile patients with PCOD. The patient ages range between 20 and 35 years. The BMI is between 18 and 30 Kg/m2. The main outcome measure was the rate of spontaneous ovulation and spontaneous pregnancy in the 3 cycles.Results: The mean age of the study participants was 26.64±4.59 years and the mean BMI was 24.46±2.62Kg/m2. The sonographic ovarian volume was 12.47±0.69 mm3 for the right ovary and 12.74±0.73 mm3 for the left ovary. No difference in the serum FSH, LH, FSH/LH ratio and prolactin over the 3 consecutive cycles. The rate of spontaneous ovulation in the 3 cycles was 6 women (8.6%) and 2 cases (2.8%) became pregnant spontaneously during the study period. There is no statistical significant difference between ovulating and non-ovulating women according to the BMI and ovarian volume.Conclusions: The present study concluded that the rate of spontaneous ovulation was 8.6% in women with PCOD within 3 cycles with no adverse effects of drugs or surgical interference

Laparoscopic ovarian drilling-plus: a one-stop management approach for PCO-associated infertility

Background: The current study aims to estimate additional values of laparoscopic intervention for diagnosis and treatment of concomitant pelvic pathologies among infertile women with clomiphene-resistant polycystic ovarian syndrome (PCOS) subjected to laparoscopic ovarian drilling (LOD) in comparison to non-PCOS infertile women subjected to diagnostic/therapeutic laparoscopy.Methods: A prospective cross sectional observational study was carried out in the Endoscopic unit of a tertiary care university hospital.  The study included 232 infertile women planned for laparoscopy were divided into a study group A (116 cases) with clomiphene-resistant PCOS and a control group B (116 cases) without PCOS. Each group was further subdivided into two subgroups according to the presence and absence of risk factors (RF) for adhesion formation. Diagnostic/operative laparoscopy was done. The main study outcome was the prevalence of any pelvic abnormalities seen during laparoscopy.Results: Both groups showed insignificant difference regarding socio-demographic history and basic data. Laparoscopy detected pelvic pathologies in 44 cases (37.9%) and 86 cases (74.1%) in both groups respectively. In group A, we diagnosed pelvic pathologies in 29 (32.6%) and 15 (55.6%) cases with and without RF respectively while in group B they were diagnosed in 76 (84.4%) and 10 (38.5%) cases with and without RF respectively. If compared to women with unexplained infertility, PCO patients without risk factors have an insignificant but higher prevalence of pelvic abnormalities. All concomitant pelvic pathologies in both groups were treated on a one-stop (see and treat) basis.Conclusions: Detection and proper management of associated pelvic pathologies at laparoscopy is a valuable additional advantage of LOD particularly in women with positive risk factors. LOD plus see and treat associated pathologies is a time saving and prompt management approach for women with PCO–associated infertility

Evaluation of the uterine cavity by office hysteroscopy in patients with infertility and recurrent pregnancy loss: a cross sectional study

Background: The aim of the present study is to determine role of hysteroscopy in women presented with primary or secondary infertility and in women presented with recurrent pregnancy loss.Methods: This cross-sectional study was conducted at Obstetrics and Genecology Department, Women Health Hospital Assiut University, Egypt from October 2016 to February 2018. Reproductive aged women who are suspected as having intrauterine pathology, such as submucosal myoma, endometrial polyps or other endometrial pathological findings based on the transvaginal ultrasound were enrolled. All patients were scheduled for office hysteroscopy as an outpatient. An informed consent was obtained prior to participation in the study.Results: Hysteroscopy was performed in 139 infertile women and 41 cases of repeated pregnancy loss. With regard to infertile patients; 67.6% of the patients had normal findings, 10.1% of the patients had intrauterine adhesion, 8.6% of the patients had intrauterine polyp. 5.8% of the patients had septate uterus and 3.6% of the patients had depressed fundus. With regard to patients with recurrent pregnancy loss; 51.2% of the patients had normal findings, 21.9% of the patients had partial septum, 9.8% of patients had intrauterine adhesions, 7.3% of patients had intrauterine polyp and 4.9% of the patients had submucous myoma.Conclusions: It was concluded that hysteroscopy should be considered as routine investigation in evaluation of women with primary and secondary infertility

The Effect of use of Vaginal Lactobacillus Rhamnosus for Prevention of Recurrence of Vulvovaginal Candidiasis: A randomized controlled trial

Objectives:The study aims to investigate the role of vaginal administration of Lactobacillus Rhamnosus after vaginal miconazole for prevention of recurrence among women with vulvovaginal candidiasis (VVC).Materials and Methods:A randomized clinical study was done in Women Health Hospital–Assiut University–Egypt. All women presented with symptoms suggestive of VVC to the clinic had been examined and approached for participation. Eligible participants were randomly assigned to one of three groups: Group (A) received lactobacillus containing vaginal capsules daily for one week postmenstrual. Group (B) received vaginal miconazole 400 mg once daily for 3days at bedtime postmenstrual. Group (C) received vaginal miconazole 400 mg once daily for 3 days at bedtime postmenstrual followed by lactobacillus containing vaginal capsules twice daily for one week. The primary outcome was to study the rate of recurrence of symptoms after 1, 3, 6 months of treatment. Results:During the study period, 202 participants with recurrent VVC were approached to participate in this study. No significant differences were found between the three study groups with regards patients’ age, residence, parity. After 1 month, symptoms of VVC recurred in 68.4%, 24.6% and 17.2% of women in group A, B, C consecutively. The recurrence rate increases after 3 months to become 87.5%, 60% and 33.3% consecutively in the three groups. Finally after 6 months, 94.4%, 88.7%, and 44.6% of women in group A, B, C consecutively suffered from RVVC. The recurrence rate is lower in group C (combination group) with statistically significant difference (p=0.0001).Conclusions:Vaginal administration of Lactobacillus Rhamnosus twice daily for 1 week after vaginal miconazole leads to vaginal colonization and associated at 6 months follow up with decrease the recurrence rate of VVC

Undiagnosed endometrial abnormalities in women with normal hysterosalpingography scheduled for IVF: prospective evaluation of three-dimensional transvaginal ultrasound versus office hysteroscopy

Objectives: To compare the diagnostic accuracy of three-dimensional transvaginal ultrasound (3D-US) to office hysteroscopy (OH) in the screening of uterine cavity with normal hysterosalpingography (HSG) findings for subtle endometrial abnormalities before in vitro-fertilization (IVF). Methods: A prospective cohort cost-modeling study was carried out in a University hospital. We included 120 infertile women with a normal uterine cavity on HSG scheduled for IVF. All cases were evaluated by 3D-US, and the results were compared with OH findings. Results: OH revealed cavitary endometrial lesions (CLs) in thirty-four women (28.3%). Endometrial polyps were the most common detected lesions (16, 47.1%). 3D-US had 88.2% sensitivity, 96.5% specificity, 90.9% positive predictive value, 95.4% negative predictive value, and 94.2% overall accuracy for CLs. The overall agreement between 3D-US and OH was near-perfect (κ=0.86, 95% CI=0.75-0.96). Irregular menstrual bleeds and prior endometrial procedures were significant predictors for CLs (aOR=24.96, 95% CI=2.71–230.04, P=0.005, aOR=9.16, 95% CI=2.13–39.3, P=0.002, respectively). A selective screening strategy discerning OH to women with these predictors and/or women with abnormal 2D-US would have an NPV of 92.8 % with substantial cost benefits. Conclusions: In the pre-IVF work up, 3D-US, a non-invasive imaging modality, seems to be nearly comparable to OH. Office hysteroscopy screening prioritizing women with abnormal 2D-US, irregular menstrual periods and/or prior endometrial traumatization could yield a satisfactory cost-effective approach for identifying endometrial lesions

Burnout among surgeons before and during the SARS-CoV-2 pandemic: an international survey

Background: SARS-CoV-2 pandemic has had many significant impacts within the surgical realm, and surgeons have been obligated to reconsider almost every aspect of daily clinical practice. Methods: This is a cross-sectional study reported in compliance with the CHERRIES guidelines and conducted through an online platform from June 14th to July 15th, 2020. The primary outcome was the burden of burnout during the pandemic indicated by the validated Shirom-Melamed Burnout Measure. Results: Nine hundred fifty-four surgeons completed the survey. The median length of practice was 10 years; 78.2% included were male with a median age of 37 years old, 39.5% were consultants, 68.9% were general surgeons, and 55.7% were affiliated with an academic institution. Overall, there was a significant increase in the mean burnout score during the pandemic; longer years of practice and older age were significantly associated with less burnout. There were significant reductions in the median number of outpatient visits, operated cases, on-call hours, emergency visits, and research work, so, 48.2% of respondents felt that the training resources were insufficient. The majority (81.3%) of respondents reported that their hospitals were included in the management of COVID-19, 66.5% felt their roles had been minimized; 41% were asked to assist in non-surgical medical practices, and 37.6% of respondents were included in COVID-19 management. Conclusions: There was a significant burnout among trainees. Almost all aspects of clinical and research activities were affected with a significant reduction in the volume of research, outpatient clinic visits, surgical procedures, on-call hours, and emergency cases hindering the training. Trial registration: The study was registered on clicaltrials.gov "NCT04433286" on 16/06/2020

Impact of opioid-free analgesia on pain severity and patient satisfaction after discharge from surgery: multispecialty, prospective cohort study in 25 countries

Background: Balancing opioid stewardship and the need for adequate analgesia following discharge after surgery is challenging. This study aimed to compare the outcomes for patients discharged with opioid versus opioid-free analgesia after common surgical procedures.Methods: This international, multicentre, prospective cohort study collected data from patients undergoing common acute and elective general surgical, urological, gynaecological, and orthopaedic procedures. The primary outcomes were patient-reported time in severe pain measured on a numerical analogue scale from 0 to 100% and patient-reported satisfaction with pain relief during the first week following discharge. Data were collected by in-hospital chart review and patient telephone interview 1 week after discharge.Results: The study recruited 4273 patients from 144 centres in 25 countries; 1311 patients (30.7%) were prescribed opioid analgesia at discharge. Patients reported being in severe pain for 10 (i.q.r. 1-30)% of the first week after discharge and rated satisfaction with analgesia as 90 (i.q.r. 80-100) of 100. After adjustment for confounders, opioid analgesia on discharge was independently associated with increased pain severity (risk ratio 1.52, 95% c.i. 1.31 to 1.76; P < 0.001) and re-presentation to healthcare providers owing to side-effects of medication (OR 2.38, 95% c.i. 1.36 to 4.17; P = 0.004), but not with satisfaction with analgesia (beta coefficient 0.92, 95% c.i. -1.52 to 3.36; P = 0.468) compared with opioid-free analgesia. Although opioid prescribing varied greatly between high-income and low- and middle-income countries, patient-reported outcomes did not.Conclusion: Opioid analgesia prescription on surgical discharge is associated with a higher risk of re-presentation owing to side-effects of medication and increased patient-reported pain, but not with changes in patient-reported satisfaction. Opioid-free discharge analgesia should be adopted routinely

Clomiphene citrate plus N-acetyl cysteine versus letrozole for induction of ovulation in infertile patients with polycystic ovarian disease: a randomized clinical trial

Background: Polycystic ovarian disease (PCOD), a common endocrine disorder with multisystem affection, is the most common cause of anovulatory infertility. Our objective is to evaluate the effect of using clomiphene citrate (CC) plus N-acetyl cysteine (NAC) versus letrozole in ovulation induction in infertile patients with PCOD.Methods: Reproductive-aged infertile women either primary or secondary diagnosed as PCOD according to Rotterdam criteria, 2003 were considered for enrollment. Eligible women for were recruited and randomized (1:1) to receive either CC 100 mg plus NAC 600 mg (CC+NAC arm) or letrozole 5 mg (NCT03241472, clinicaltrials.gov). All medications were started from day 3 of the menstrual cycle for 5 days. The primary outcome was the ovulation rate in both groups. Secondary outcomes included the mid-cyclic endometrial thickness, ovarian hyperstimulation, and clinical pregnancy and miscarriage rates.Results: One hundred ten patients were enrolled and randomized to CC+NAC arm (n=55) or letrozole (n=55). The ovulation rate in patients in letrozole arm was significantly higher than CC+NAC arm (71.8% versus 53.2%, p=0.01). Additionally, endometrial thickness was higher in letrozole arm (mean±SD: 11.46±1.61 versus 9.0±1.13, p=0.031). However, no statistical significant difference with regarding the ovarian hyperstimulation rate (1.8% versus 3.6%, p=0.157), clinical pregnancy rate [3/19 patients (27.3%) versus 19/55 (34.5%), p=0.409] and miscarriage rate [4/15 patients (26.7%) versus 19/55 (15.8%), p=0.317] in CC+NAC versus letrozole groups respectively.Conclusions: Addition of NAC to CC in ovulation induction leads to comparable pregnancy rate as letrozole. However, letrozole produces high ovulation rate and the better mid-cyclic endometrial thickness

Laparoscopic ovarian re-electro cautery versus ovulation induction with FSH for persistant anovulation after laparoscopic PCOS treatment

Objectives: To determine the effectiveness and safety of either another laparoscopic ovarian drilling or purified urinary FSH for induction of ovulation in PCOS patients who were treated previously by laparoscopic electrocautary but still anovulatory. Design: Comparative prospective clinical study between two groups of anovulatory infertile women after laparoscopic electrocutary. Setting: Infertility treatment unit in Assiut University Hospital, Assiut, Egypt. Patients:Fifty five patients treated previously by laparoscopic ovarian drilling for anovulatory PCOS infertility and still anovulatory and infertile after six months at least from the procedure were included in this study. Intervention: Thirty patients exposed to another laparoscopic ovarian drilling (group A) and 25 patients were stimulated by purified FSH for 3 cycles (group B). Main Outcome measures: Pelvic adhesions, Hormonal profile, Ovulation rate and Pregnancy rate were estimated. Results: Pelvic adhesions were found in 27.2% of patients, hormonal profile showed considerable change toward normal values in the group of patients who were exposed to another laparoscopic drilling, while there were slight changes in patients who were subsequently subjected to FSH stimulation. Within three stimulated cycles ovulation occurred in 16 patients (53.3%) in drilling group after clomiphene citrate compared to 18 patients (72%) in FSH stimulated group. The pregnancy rate per cycle was very low (3.8% per cycle in all included patients and 6.6% per patient). The pregnancy rate per cycle was 2.2% in group A and 5.7% in group B and the cumulative pregnancy rate per patient was higher in FSH group (16%) versus 6.6% in the redrilling group. All pregnancies occurred in stimulated cycles. Conclusion: Ovarian stimulation with purified FSH gave better ovulation and pregnancy rate than ovarian laparoscopic redrilling followed by clomiphene citrate stimulation. Although the ovulation rate of both procedures was to some extent high; yet the pregnancy rate was low and this should be discussed with the patients during counseling. Another laparoscopic redrilling is followed by low pregnancy rate and possible hazards of adhesion formation