Ajog 2016

Volume 2, Number 1, 2016

ISSN 0971-8788

Asian Journal of

Obstetrics &

Gynecology Practice In this Issue Evaluation and Treatment of Infertility Women’s and Providers’ Experiences with Injectable Contraceptives (Depo-Provera): A View from Vadodara, India Three Different Presentations of Ectopic Pregnancy in the Same Patient Enlarged Ovaries Following IVF/ICSI as an Etiology of Obstructive Uropathy Resulting in Acute Renal Failure A Laparoscopic Surprise 59th All India Congress of Obstetrics & Gynaecology (AICOG 2016) Journal Scan

With Best Compliments from

Asian Journal of

Online Submission

Volume 2, Number 1, 2016

An IJCP Group Publication Corporate Panel Dr Sanjiv Chopra Prof. of Medicine and Faculty Dean Harvard Medical School Group Consultant Editor Dr Deepak Chopra Chief Editorial Advisor Dr KK Aggarwal Group Editor-in-Chief IJCP Group, eMedinewS and eMediNexus Dr Veena Aggarwal MD, Group Executive Editor AJOG Specialty Panel

Dr Alka Kriplani Editor Consultant Editor Dr Urmil Sharma Assistant Editors Dr Nutan Agarwal (Delhi) Dr Neera Aggarwal (Delhi) Dr A Biswas (Singapore) Dr CS Dawn (Kolkata) Dr Gauri (Delhi) Dr Suneeta Mittal (Delhi) Dr S Mehra (Delhi) Dr Prashant Mangeshikar (Mumbai) Dr Prakash Trivedi (Mumbai) Dr Gita Ganguly Mukherjee (Kolkata)

Dr (Mrs) Prabha Arora (Delhi) Dr Hema Divakar (Bangalore) Dr Kamini A Rao (Bangalore) Dr Deepti Goswami (Delhi) Dr Neerja Bhatla (Delhi) Dr Bhawna Malhotra (Delhi) Dr Biswas Nicholas (Australia) Dr Sudhaa Sharma (Jammu) Dr Jaibhagwan Sharma (Delhi) Dr Veena Mathur (Agra) Dr Garima Kachhawa

Editorial Board Obstetrics and Gynaecology Dr Alka Kriplani Dr Thankam Verma Dr Kamala Selvaraj

ENT Dr Jasveer Singh

Cardiology Dr Praveen Chandra Dr SK Parashar

Gastroenterology Dr Ajay Kumar

Paediatrics Dr Swati Y Bhave Diabetology Dr CR Anand Moses Dr Sidhartha Das Dr A Ramachandran Dr Samith A Shetty

Dentistry Dr KMK Masthan Dr Rajesh Chandna

Dermatology Dr Hasmukh J Shroff Neurology Dr V Nagarajan Journal of Applied Medicine and Surgery Dr SM Rajendran Dr Jayakar Thomas

Anand Gopal Bhatnagar Editorial Anchor Advisory Body Heart Care Foundation of India Non-Resident Indians Chamber of Commerce and Industry World Fellowship of Religions

Contents from the issue editor

Recurrent Pregnancy Loss: Evidence-based Management 5 Alka Kriplani

FROM THE DESK OF the GROUP EDITOR-IN-CHIEF

Air Pollution and the Heart

6

KK Aggarwal

Review article

Evaluation and Treatment of Infertility

7

Tammy J. Lindsay, Kirsten R. Vitrikas

Clinical Study

Women’s and Providers’ Experiences with Injectable Contraceptives (Depo-Provera): A View from Vadodara, India 15 Prakash V Kotecha, Sangita V Patel, Rajendra K Baxi, Shagufa Kapadia, Kedar Mehta

Case report

Three Different Presentations of Ectopic Pregnancy in the Same Patient

20

Madhupriya, Kundavi Shankar, Lakshmi Shanmugasundaram, Thangam R Varma

Enlarged Ovaries Following IVF/ICSI as an Etiology of Obstructive Uropathy Resulting in Acute Renal Failure Pratibha Vishwakarma, Priya Mohan, Kundavi Shankar, Thangam R Varma

24

Asian Journal of Volume 2, Number 1, 2016

Contents

Published, Printed and Edited by Dr KK Aggarwal, on behalf of IJCP Publications Ltd. and Published at E-219, Greater Kailash, Part-1 New Delhi-110 048 E-mail: editorial@ijcp.com

case report

A Laparoscopic Surprise

27

Shweta Suryaraj, MG Dhanalakshmi

Printed at Crystal Offset, Chennai Copyright 2016 IJCP Publications Ltd. All rights reserved.

The copyright for all the editorial material contained in journal, in the form of layout, content including images and design, is held by IJCP Publications Ltd. No part of this publication may be published in any form whatsoever without the prior written permission of the publisher.

Conference Update

59th All India Congress of Obstetrics and Gynaecology (AICOG 2016)

30

Editorial Policies

Research Review

The purpose of IJCP Academy of CME is to serve the medical profession and provide print continuing medical education as a part of their social commitment. The information and opinions presented in IJCP group publications reflect the views of the authors, not those of the journal, unless so stated. Advertising is accepted only if judged to be in harmony with the purpose of the journal; however, IJCP group reserves the right to reject any advertising at its sole discretion. Neither acceptance nor rejection constitutes an endorsement by IJCP group of a particular policy, product or procedure. We believe that readers need to be aware of any affiliation or financial relationship (employment, consultancies, stock ownership, honoraria, etc.) between an author and any organization or entity that has a direct financial interest in the subject matter or materials the author is writing about. We inform the reader of any pertinent relationships disclosed. A disclosure statement, where appropriate, is published at the end of the relevant article.

Journal Scan

Note: Asian Journal of Obs and Gynae Practice does not guarantee, directly or indirectly, the quality or efficacy of any product or service described in the advertisements or other material which is commercial in nature in this issue.

33

Resveratrol and Obesity: Can Resveratrol Relieve Metabolic Disturbances?

Effects of Resveratrol Supplements on Vascular Health in Postmenopausal Women

Resveratrol, Obesity and Diabetes

Resveratrol and Antiaging Activity

Resveratrol Prevents Age-related Memory

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from the issue editor

Recurrent Pregnancy Loss: Evidence-based Management

Dr Alka Kriplani

Professor and Head of Unit II Dept. of Obstetrics and Gynecology AIIMS, New Delhi

Recurrent pregnancy loss (RPL) is a very frustrating problem.

Start investigating RPL after two consecutive miscarriages.

Etiology - anatomic, genetic, immunologic and thrombotic, endocrine, infectious, unexplained.

Preimplantation genetic diagnosis (PGD) has advantages of fewer miscarriages, less emotional distress and less time to successful pregnancy.

Disadvantages of PGD - Emotional cost of failed cycles, financial cost of in vitro fertilization.

Unexplained RPL has an incidence rate of 50%.

Empirical therapies: common.

Many therapies fail to show benefit in randomized controlled trials.

Offer evidence-based approach including counseling + psychological support.

■■■■

Asian Journal of Obstetrics and Gynecology Practice, Vol. 2, No. 1, 2016

5

FROM THE DESK OF the GROUP EDITOR-IN-CHIEF

Air Pollution and the Heart

Prof. Dr KK Aggarwal

Group Editor-in-Chief IJCP Group, eMedinewS and eMediNexus

6

Air pollution, and specifically fine particulate matter, is associated with increased cardiovascular disease (CVD) mortality.

Air pollution has emerged as a potentially modifiable risk factor for the development of CVD.

Multiple observational studies have demonstrated an association between fine particulate air pollution (primarily from the use of fossil fuels in automobiles, power plants and for heating purposes) and cardiovascular and cardiopulmonary mortality as well as an increased risk for the development of acute coronary syndromes.

The Women's Health Initiative observational study database of more than 65,000 postmenopausal women without prior CVD was used to evaluate the relation between a woman's long-term exposure to air pollutants and the risk for a first cardiovascular event. For each 10 µg/m 3 increase in pollution concentration, there were significant increases in the risk of any cardiovascular event (hazard ratio [HR] 1.24), death from CVD (HR 1.76), and of cerebrovascular events (HR 1.35) (N Engl J Med. 2007;356:447).

Mortality data from nearly 4,50,000 patients in the American Cancer Society Cancer Prevention Study II data base were correlated to air pollution data, including average concentrations of ozone and fine particulate matter (≤2.5 µm in diameter [PM 2.5]).

In multivariate analysis PM 2.5, but not ozone, concentration was significantly associated with the risk of death from cardiovascular causes (relative risk 1.2).

(N Engl J Med. 2009;360:1085).

Both the American Heart Association (2010) and the European Society of Cardiology (2015) have issued official statements discussing the association between long-term exposure to fine particulate air pollution and increased risk of developing CVD (Circulation. 2010; 121:2331. Eur Heart J. 2015;36:83).

In addition to long-term risk, short-term exposure to air pollutants (both ozone and fine particulate matter) has been associated with acute coronary ischemic events.

Possible mechanisms by which fine particulate air pollution may increase the risk of CVD include (Eur Heart J. 2015;36:83); an increase in mean resting arterial blood pressure through an increase in sympathetic tone and/or the modulation of basal systemic vascular tone (Circulation. 2002;105:1534); an increase in the likelihood of intravascular thrombosis through transient increases in plasma viscosity and impaired endothelial dysfunction (Circulation. 2002;106:933) and the initiation and promotion of atherosclerosis (Circulation. 2010;121:2755).

Multiple observational studies have demonstrated an association between fine particulate air pollution and distance from a major urban road or freeway and cardiovascular and cardiopulmonary mortality.

However, there is conflicting evidence concerning whether air pollution is (J Thromb Haemost. 2010; 8:669); or is not (J Thromb Haemost. 2011;9:672); causally related to VTE development.

(Source: Uptodate) Asian Journal of Obstetrics and Gynecology Practice, Vol. 2, No. 1, 2016

Review article

Evaluation and Treatment of Infertility Tammy J. Lindsay, Kirsten R. Vitrikas

Abstract Infertility is defined as the inability to achieve pregnancy after one year of regular, unprotected intercourse. Evaluation may be initiated sooner in patients who have risk factors for infertility or if the female partner is older than 35 years. Causes of infertility include male factors, ovulatory dysfunction, uterine abnormalities, tubal obstruction, peritoneal factors, or cervical factors. A history and physical examination can help direct the evaluation. Men should undergo evaluation with a semen analysis. Abnormalities of sperm may be treated with gonadotropin therapy, intrauterine insemination, or in vitro fertilization.

Ovulation should be documented by serum progesterone level measurement at cycle day 21. Evaluation of the uterus and fallopian tubes can be performed by hysterosalpingography in women with no risk of obstruction. For patients with a history of endometriosis, pelvic infections, or ectopic pregnancy, evaluation with hysteroscopy or laparoscopy is recommended.

Women with anovulation may be treated in the primary care setting with clomiphene to induce ovulation. Treatment of tubal obstruction generally requires referral for subspecialty care. Unexplained infertility in women or men may be managed with another year of unprotected intercourse, or may proceed to assisted reproductive technologies, such as intrauterine insemination or in vitro fertilization.

Keywords: Infertility, hysterosalpingography, hysteroscopy, laparoscopy, tubal obstruction, unprotected intercourse, assisted reproductive technologies

I

nfertility is defined as the inability to become pregnant after 12 months of regular, unprotected intercourse. In a survey from 2006 to 2010, more than 1.5 million U.S. women, or 6% of the married population 15 to 44 years of age, reported infertility, and 6.7 million women reported impaired ability to get pregnant or carry a baby to term.1 Among couples 15 to 44 years of age, nearly 7 million have used infertility services at some point.2 This encompasses couples with infertility and impaired ability to get pregnant, but it does not capture those who are not married, so actual numbers may be underestimated. These numbers are comparable to those of other industrialized nations.3,4 Infertility may arise from male factors, female factors, or a combination of these (Table 15-8).

Because 85% of couples conceive spontaneously within 12 months if having intercourse regularly,5 it

TAMMY J. LINDSAY, MD, FAAFP, is the chief of medical staff at Scott Air Force Base, Ill., and a clinical associate professor at Saint Louis University Family Medicine Residency in Belleville, Ill. KIRSTEN R. VITRIKAS, MD, FAAFP, is the program director at David Grant Medical Center Family Medicine Residency at Travis Air Force Base, Calif. She is also an assistant professor at the Uniformed Services University of the Health Sciences Department of Community and Family Medicine in Bethesda, Md. Source: Adapted form Am Fam Physician. 2015;91(5):308-314.

Asian Journal of Obstetrics and Gynecology Practice, Vol. 2, No. 1, 2016

Table 1. Etiology of Infertility Factors Combined factors

Percentage 40

Male factors

26 to 30

Ovulatory dysfunction

21 to 25

Tubal factors

14 to 20

Other (e.g., cervical factors, peritoneal factors, uterine abnormalities)

10 to 13

Unexplained

25 to 28

Information from references 5 through 8.

is important to identify those who will benefit from infertility evaluation. Generally, evaluation should be offered to couples who have not conceived after one year of unprotected vaginal intercourse. Counseling about options should be offered to couples who are not physically able to conceive (i.e., same-sex couples or persons lacking reproductive organs). Women older than 35 years or couples with known risk factors for infertility may warrant evaluation at six months.6,8 It is important for primary care physicians to be familiar with the workup and prognosis for infertile couples.

A British study found that patients valued primary care 7

review article physicians who were well informed about infertility and the treatment process.9 Because anxiety over infertility may cause increased stress and decreased libido, further compounding the problem, formal counseling is encouraged for couples experiencing infertility.8 Evaluation of Men Causes of male infertility include infection, injury, toxin exposures, anatomic variances, chromosomal abnormalities, systemic diseases, and sperm antibodies.

Additional risk factors may include smoking, alcohol use, obesity, and older age; however, the data are hampered by a lack of pregnancy-related outcomes.8-16 One retrospective case-control study of 650 men with infertility and 698 control participants questioned the role of environmental risk; no association could be determined after assessing for multiple factors including shift work, stress, and pesticides.17 Evaluation of male infertility starts with a history and physical examination focusing on previous fertility, pelvic or inguinal surgeries, systemic diseases, and exposures. The laboratory evaluation begins with a semen analysis. Instructions for collecting the sample should include abstinence from ejaculation for 48 to 72 hours. Because sperm generation time is just over two months, it is recommended to wait three months before repeat sampling.8 A normal sample according to the 2010 World Health Organization (WHO) guidelines is described in Table 2.18 If the semen analysis result is abnormal, further evaluation is indicated (Table 36-8,10,19,20). If oligospermia or azoospermia is noted, hypogonadism should be suspected. Obtaining morning levels of total testosterone (normal range = 240 to 950 ng per dL [8.3 to 33.0 nmol per L]) and follicle-stimulating hormone (FSH; normal range = 1.5 to 12.4 mIU per mL [1.5 to 12.4 IU per L]) can help differentiate between primary and secondary disorders. A decreased testosterone level with an increased FSH level points to primary hypogonadism. A low testosterone level with a low FSH level signals a secondary cause. Some causes, such as hyperprolactinemia, are reversible with proper treatment. Other testing may be needed based on circumstances, including testicular biopsy, genetic testing, and imaging (Table 36-8,10,19,20). Postcoital testing and antisperm antibody testing are no longer considered useful in this evaluation.21,22 8

Table 2. World Health Organization 2010 Semen Analysis Reference Guidelines Characteristic

Normal reference

Morphologically normal

4%

Motility (progressive)

32%

Motility (total)

40%

Sperm count

39 million per ejaculate; 15 million per mL

Vitality

58%

Volume

At least 1.5 mL

NOTE: Oligospermia = sperm count < 15 million per mL; asthenozoospermia = < 40% of the sperm are motile; teratozoospermia = normal morphology < 4%.

If an individual has all three low sperm conditions, it is known as OAT syndrome, which is typically associated with an increased likelihood of genetic etiology of the infertility. Total motility differs from progressive motility only in the notation of forward movement.

Information from reference 18.

Evaluation of Women The etiology of female infertility can be broken down into ovulation disorders, uterine abnormalities, tubal obstruction, and peritoneal factors. Cervical factors are also thought to play a minor role, although they are rarely the sole cause. Evaluation of cervical mucus is unreliable; therefore, investigation is not helpful with the management of infertility.6 The initial history should cover menstrual history, timing and frequency of intercourse, previous use of contraception, previous pregnancies and outcomes, pelvic infections, medication use, occupational exposures, substance abuse, alcohol intake, tobacco use, and previous surgery on reproductive organs. A review of systems and physical examination of the endocrine and gynecologic systems should be performed. Other considerations include preconception screening and vaccination for preventable diseases such as rubella and varicella, sexually transmitted infections, and cervical cancer, based on appropriate guidelines and risk.

WHO categorizes ovulatory disorders into three groups: group I is caused by hypothalamic pituitary failure (10%), group II results from dysfunction of hypothalamic-pituitary-ovarian axis (85%), and group III is caused by ovarian failure (5%).8 Women in group I typically present with amenorrhea and low gonadotropin levels, most commonly from low Asian Journal of Obstetrics and Gynecology Practice, Vol. 2, No. 1, 2016

Review article Table 3. Etiology and Evaluation of Infertility Condition

History and physical examination

Laboratory and radiologic testing

Comments

Endometriosis or pelvic History of abdominal or pelvic adhesions surgery; history consistent with endometriosis

Rarely helpful

Generally diagnosed on laparoscopy; consider in women with otherwise unexplained infertility

Hypothalamic amenorrhea

Amenorrhea or oligomenorrhea; low body mass index

Low to normal FSH level; low estradiol level

Encourage weight gain

Ovarian failure/ insufficiency

Amenorrhea or oligomenorrhea; menopausal symptoms; family history of early menopause; single ovary; chemotherapy or radiation therapy; previous ovarian surgery; history of autoimmune disease

Elevated FSH level; low estradiol level

Consider additional tests of ovarian reserve (antral follicle count, antimüllerian hormone level, clomiphene challenge test)

Ovulatory disorder

Irregular menses; hirsutism; obesity (polycystic ovary syndrome); galactorrhea (hyperprolactinemia); fatigue; hair loss (hypothyroidism)

Progesterone level < 5 ng per mL Check TSH and prolactin levels (15.9 nmol per L); elevated prolactin based on clinical symptoms level; low TSH level

Tubal blockage

History of pelvic infections or endometriosis

Abnormal hysterosalpingography result

Usually necessitates subspecialist referral for treatment

Uterine abnormalities

Dyspareunia; dysmenorrhea; history of anatomic developmental abnormalities; family history of uterine fibroids; abnormal palpation and inspection

Abnormal hysterosalpingography or ultrasonography result

May necessitate subspecialist referral for treatment

Genetic etiology:

Y deletions: small testes

Y deletions XXY (Klinefelter syndrome)

Klinefelter phenotype: small testes, tall, gynecomastia, learning disabilities

Both syndromes result in normal semen volume but low sperm count

Y deletions can be passed to offspring if intracytoplasmic sperm injection is used with in vitro fertilization; genetic counseling is indicated

Female

Male

Y deletions may present as normal hormone levels or have an elevated FSH level Klinefelter syndrome typically results in low testosterone level and an elevated FSH level

Other genetics: CFTR gene (cystic fibrosis) 5T allele (cystic fibrosis)

Absence of the vas deferens

Low volume semen analysis

Because of the inheritance pattern, genetic testing of the partner is warranted, and counseling is indicated if she is a carrier

Obstruction of the vas deferens or epididymis Ejaculatory dysfunction

History of infection, trauma, or vasectomy; normal testicular examination

Low volume semen analysis; transrectal ultrasonography can identify obstruction

Rare cause of infertility; evaluation reserved for fertility specialist

Systemic disease (not all-inclusive): Hemochromatosis Kallmann syndrome Pituitary tumor Sarcoidosis

—

Low FSH level; low testosterone level; check prolactin level and, if elevated, perform imaging for pituitary tumor

Infiltrative processes that cause a small number of infertility cases; however, effective treatment is available

Unclear etiology

Normal testicular examination

Normal FSH level; normal semen volume; low sperm count

Subspecialist may consider testicular biopsy to determine obstructive vs. nonobstructive azoospermia

FSH = Follicle-stimulating hormone; TSH = Thyroid-stimulating hormone.

Information from references 6 through 8, 10, 19, and 20.

Asian Journal of Obstetrics and Gynecology Practice, Vol. 2, No. 1, 2016

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review article body weight or excessive exercise. Women in group II include those with polycystic ovary syndrome and hyperprolactinemia. Women in group III can conceive only with oocyte donation and in vitro fertilization.

Women with regular menstrual cycles are likely to be ovulating and should be offered serum progesterone testing at day 21 to confirm ovulation.8 If a woman has irregular cycles, the testing should be conducted later in the cycle, starting seven days before presumed onset of menses, and repeated weekly until menses.6,8 A progesterone level of 5 ng per mL (15.9 nmol per L) or greater implies ovulation.6,23 Anovulatory women should have further investigation to determine treatable causes such as thyroid disorders or hyperprolactinemia based on symptoms.8 A high serum FSH level (greater than 30 to 40 mIU per mL [30 to 40 IU per L]) with a low estradiol level can distinguish ovarian failure from hypothalamic pituitary failure, which typically reveals a low or normal FSH level (less than 10 mIU per mL [10 IU per L]) and a low estradiol level. Basal body temperatures are no longer considered a reliable indicator of ovulation, and are not recommended for evaluating ovulation.6,8,23 A high FSH level (10 to 20 mIU per mL [10 to 20 IU per L]) drawn on day 3 of the menstrual cycle is associated with infertility. A high serum estradiol level (greater than 60 to 80 pg per mL [220 to 294 pmol per L]) in conjunction with a normal FSH level has also been associated with lower pregnancy rates. This combination of laboratory test results may indicate ovarian insufficiency or diminished ovarian reserve.24 Other tests of ovarian reserve, such as the clomiphene challenge test, antral follicle count, and antim端llerian hormone level, are also generally performed to predict response to ovarian stimulation with exogenous gonadotropins and assisted reproductive technology. However, these tests have only poor to moderate predictive value despite widespread use.25 Women with no clear risk of tubal obstruction should be offered hysterosalpingography to screen for tubal occlusion and structural uterine abnormalities.8,26,27 As opposed to laparoscopy or hysteroscopy, hysterosalpingography is a minimally invasive procedure with potentially therapeutic effects and should be considered before more invasive methods of assessing tubal patency.6 Women with risk factors for tubal obstruction, such as endometriosis, previous pelvic infections, or ectopic pregnancy, should instead be offered 10

hysteroscopy or laparoscopy with dye to assess for other pelvic pathology.8 These studies are more sensitive and may delineate an abnormally formed uterus or structural problems, such as fibroids. This allows for the diagnosis and treatment of conditions such as endometriosis with one procedure. Treatment of tubal obstruction generally requires referral for subspecialty care.

Endometrial biopsy should be performed only in women with suspected pathology (chronic endometritis or neoplasia). Histologic endometrial dating is not considered reliable nor is it predictive of fertility.6,28 Additionally, postcoital testing of cervical mucus is no longer recommended because it does not affect clinical management or predict the inability to conceive.22 Treatment of Male Infertility Underlying etiology determines the therapeutic course, although male infertility is unexplained in 40% to 50% of cases.29 When the semen analysis is abnormal, referral to a male fertility specialist or reproductive endocrinologist is warranted. When anatomic variance or obstruction is suspected, referral for surgical evaluation and treatment is appropriate.

If an endocrinopathy, such as hyperprolactinemia, is diagnosed, the underlying cause should be treated.

In patients with varicocele, there is insufficient evidence to suggest corrective surgery will increase live birth rates, despite improvement in semen analysis results.30-32 Other treatment options include antiestrogens and gonadotropin therapy, which showed a trend toward increased live birth rates in a Cochrane review.33 Use of antioxidants such as zinc, vitamin E, or L-carnitine showed increased live birth rates in three small randomized controlled trials in couples undergoing assisted reproductive technology.34 Although intrauterine insemination has been shown to be equally effective as timed intercourse in unstimulated cycles, there is a modest increase in live birth rates when combined with ovarian stimulation.8,33,35,36 Lastly, in vitro fertilization, with or without intracytoplasmic sperm injection, is the mainstay of assisted reproductive technology for male factor infertility.

Treatment of Anovulatory Conditions Women with WHO group I ovulatory disorders should be counseled to achieve a normal body weight.

They may benefit from referral to a physician comfortable with prescribing pulsatile administration Asian Journal of Obstetrics and Gynecology Practice, Vol. 2, No. 1, 2016

Review article of gonadotropin-releasing hormone or gonadotropins with luteinizing hormone activity to induce ovulation.8,37 Women in WHO group II, including those who are overweight and who have polycystic ovary syndrome, can benefit from weight loss, exercise, and lifestyle modifications to restore ovulatory cycles and achieve pregnancy.37 Clomiphene has also proven effective for

ovulation induction in women with polycystic ovary syndrome.37,38 The addition of 1,500 to 1,700 mg of metformin daily may increase ovulation and pregnancy rates, but it does not significantly improve live birth rates over clomiphene alone.38,39 Family physicians may choose to attempt ovulation induction in anovulatory women (WHO group II) with clomiphene. Ovulation induction agents

Infertility Evaluation Couple with 12 months of infertility

Male evaluation

Female evaluation

Semen analysis

Ovulation evaluation (day 21 progesterone level)

If normal, pursue other etiologies

If abnormal, refer to male fertility specialist

Progesterone level < 5 ng per mL (15.9 nmol per L), evaluate for cause

Progesterone level â&#x2030;Ľ 5 ng per mL, indicates ovulation

Thyroid-stimulating hormone, prolactin, follicle-stimulating hormone, and estradiol levels

Assess for tubal patency/ uterine abnormalities (hysterosalpingography vs. laparoscopy)

Treat underlying causes

Consider ovulation induction for World Health Organization group II disorders with clomiphene

Surgical correction of tubal obstruction or uterine adhesions

Assess need for ART referral

Assess need for ART referral Figure 1. Algorithm for infertility evaluation.

(ART = Assisted reproductive technology.)

Asian Journal of Obstetrics and Gynecology Practice, Vol. 2, No. 1, 2016

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review article increase the risk of multiple pregnancy, ovarian hyperstimulation syndrome, and thrombosis, and they may increase the risk of ovarian cancer in women who remain nulliparous.40 Patients using these agents should be counseled about these risks. The initial dosage of clomiphene is 50 mg daily for five days starting on day 3 to 5 of the menstrual cycle. This should be followed by documentation of ovulation via serum progesterone. If this is unsuccessful, the dosage may be increased to 100 mg daily. Patients who do not achieve ovulation after three to six cycles should be referred to an infertility specialist for further treatment. Couples who do not conceive after treatment for six cycles with documented ovulation should also consider referral to an infertility specialist.41 Treatment of Unexplained Infertility Couples who have no identified cause of infertility should be counseled on timing of intercourse for the most fertile period (i.e., the six days preceding ovulation).42 Urinary luteinizing hormone kits indicate the midcycle luteinizing hormone surge that precedes ovulation by one to two days. These may be purchased over the counter and allow couples to predict the most fertile days in the cycle.6 Accuracy may be improved by use on midday or evening urine specimens, which correlate better with the peak in serum luteinizing hormone levels.43 Other low-cost methods of monitoring for ovulation, although less effective, include basal body temperature measurements and cervical mucus changes.42 However, none of these methods has been proven to increase pregnancy rates when used to predict timing of intercourse.

Additionally, there is concern that the stress of a strict schedule for intercourse may lead to reduced frequency of intercourse.44 Therefore, a simple recommendation is for vaginal intercourse every two to three days to optimize the chance of pregnancy.8 Patients should be counseled that 50% of couples who have not conceived in the first year of trying will conceive in the second year.8 Couples with unexplained infertility may want to consider another year of intercourse before moving to more costly and invasive therapies, such as assisted reproductive technology.8 Intrauterine insemination and ovulation induction do not result in increased pregnancy rates in women with unexplained infertility.8,45 12

Figure 1 provides an algorithmic approach to the evaluation of infertility.

Lifestyle Factors All couples should be counseled to abstain from tobacco use, limit alcohol consumption, and aim for a body mass index less than 30 kg per m2 to improve their chances of natural conception or using assisted reproductive technology.8,46 Obesity impairs fertility and the response to fertility treatments, including in vitro fertilization; therefore, it is advisable to counsel patients who are obese to lose weight before conception or infertility treatments.8 Involvement in group counseling and exercise is more effective than weight loss advice alone.8 Counseling on lifestyle modifications is reasonable because exposures to tobacco and alcohol are associated with lower rates of fertility.47 Motivational interviewing techniques for modifiable risk factors, such as obesity, tobacco, illicit drugs, and alcohol, can decrease the targeted risk factor.48 However, there is no firm evidence that preconception counseling leads to increased live birth rates, in part because no studies on this topic have been performed.10 References 1. Chandra A, Copen CE, Stephen EH. Infertility and impaired fecundity in the United States, 1982-2010: data from the National Survey of Family Growth. Natl Health Stat Rep. 2013;(67):1-18.

2. Chandra A, Copen CE, Stephen EH. Infertility service use in the United States: data from the National Survey of Family Growth, 1982-2010. Natl Health Stat Report.

2014;(73):1-21.

3. Bushnik T, Cook JL, Yuzpe AA, Tough S, Collins J. Estimating the prevalence of infertility in Canada [published correction appears in Hum Reprod. 2013;28(4):1151].

Hum Reprod. 2012;27(3):738-746.

4. Oakley L, Doyle P, Maconochie N. Lifetime prevalence of infertility and infertility treatment in the UK: results from a population-based survey of reproduction. Hum Reprod.

2008;23(2):447-450.

5. Gutmacher AF. Factors effecting normal expectancy of conception. J Am Med Assoc. 1956;161(9):855-860.

6. Practice Committee of American Society for Reproductive Medicine. Diagnostic evaluation of the infertile female: a committee opinion. Fertil Steril. 2012;98(2): 302-307.

Asian Journal of Obstetrics and Gynecology Practice, Vol. 2, No. 1, 2016

Review article 7. Thonneau P, Marchand S, Tallec A, et al. Incidence and main causes of infertility in a resident population (1,850,000) of three French regions (1988-1989). Hum Reprod. 1991;6(6):811-816.

8. National Collaborating Centre for Women’s and Children’s Health. Fertility: assessment and treatment for people with fertility problems. London, United Kingdom: National Institute for Health and Clinical Excellence (NICE); February 2013:1-63. (Clinical guideline no. 156).

9. Hinton L, Kurinczuk JJ, Ziebland S. Reassured or fobbed off? Perspectives on infertility consultations in primary care: a qualitative study. Br J Gen Pract. 2012;62(599):e438-e445.

10. Anderson K, Norman RJ, Middleton P. Preconception lifestyle advice for people with subfertility. Cochrane Database Syst Rev. 2010;(4):CD008189.

11. Hull MG, North K, Taylor H, Farrow A, Ford WC. Delayed conception and active and passive smoking. The Avon Longitudinal Study of Pregnancy and Childhood Study Team. Fertil Steril. 2000;74(4):725-733.

12. Hjollund NH, Storgaard L, Ernst E, Bonde JP, Olsen J. The relation between daily activities and scrotal temperature.

Reprod Toxicol. 2002;16(3):209-214.

13. de La Rochebrochard E, Thonneau P. Paternal age > or = 40 years: an important risk factor for infertility. Am J Obstet Gynecol. 2003;189(4):901-905.

14. Hassan MA, Killick SR. Effect of male age on fertility: evidence for the decline in male fertility with increasing age.

Fertil Steril. 2003;79(suppl 3):1520-1527.

15. Sermondade N, Faure C, Fezeu L, Lévy R, Czernichow S; Obesity-Fertility Collaborative Group. Obesity and increased risk for oligozoospermia and azoospermia. Arch Intern Med. 2012;172(5):440-442.

16. Povey AC, Clyma JA, McNamee R, et al.; Participating Centres of Chaps-UK. Modifiable and non-modifiable risk factors for poor semen quality: a case-referent study. Hum Reprod. 2012;27(9):2799-2806.

17. Gracia CR, Sammel MD, Coutifaris C, Guzick DS, Barnhart KT. Occupational exposures and male infertility.

Am J Epidemiol. 2005;162(8):729-733.

18. Cooper TG, Noonan E, von Eckardstein S, et al. World Health Organization reference values for human semen characteristics. Hum Reprod Update. 2010;16(3):231-245.

19. American Urological Association Education and Research, Inc. The evaluation of the azoospermic male: AUA best practice statement. Linthicum, Md.: American Urological Association, Inc.; 2010.

Asian Journal of Obstetrics and Gynecology Practice, Vol. 2, No. 1, 2016

20. Hofherr SE, Wiktor AE, Kipp BR, Dawson DB, Van Dyke DL. Clinical diagnostic testing for the cytogenetic and molecular causes of male infertility: the Mayo Clinic experience. J Assist Reprod Genet. 2011;28(11): 1091-1098.

21. Kamel RM. Management of the infertile couple: an evidencebased protocol. Reprod Biol Endocrinol. 2010;8:21.

22. Oei SG, Helmerhorst FM, Bloemenkamp KW, Hollants FA, Meerpoel DE, Keirse MJ. Effectiveness of the postcoital test: randomised controlled trial. BMJ. 1998;317(7157): 502-505.

23. Rowe PJ, Comhaire FH, Hargreave TB, Mellows HJ. WHO Manual for the Standardized Investigation and Diagnosis of the Infertile Couple. New York, NY: Cambridge University Press; 1993.

24. Nelson LM. Clinical practice. Primary ovarian insufficiency.

N Engl J Med. 2009;360(6):606-614.

25. Broekmans FJ, Kwee J, Hendriks DJ, Mol BW, Lambalk CB. A systematic review of tests predicting ovarian reserve and IVF outcome. Hum Reprod Update. 2006;12(6): 685-718.

26. Opsahl MS, Miller B, Klein TA. The predictive value of hysterosalpingography for tubal and peritoneal infertility factors. Fertil Steril. 1993;60(3):444-448.

27. Luttjeboer F, Harada T, Hughes E, Johnson N, Lilford R, Mol BW. Tubal flushing for subfertility. Cochrane Database Syst Rev. 2007;(3):CD003718.

28. Coutifaris C, Myers ER, Guzick DS, et al.; NICHD National Cooperative Reproductive Medicine Network.

Histological dating of timed endometrial biopsy tissue is not related to fertility status. Fertil Steril. 2004;82(5): 1264-1272.

29. Jungwirth A, Giwercman A, Tournaye H, et al. European Association of Urology guidelines on male infertility: the 2012 update. Eur Urol. 2012;62(2):324-332.

30. Baazeem A, Belzile E, Ciampi A, et al. Varicocele and male factor infertility treatment: a new meta-analysis and review of the role of varicocele repair. Eur Urol. 2011;60(4): 796-808.

31. Kroese AC, de Lange NM, Collins J, Evers JL. Surgery or embolization for varicoceles in subfertile men. Cochrane Database Syst Rev. 2012;(10):CD000479.

32. Evers JL, Collins JA. Assessment of efficacy of varicocele repair for male subfertility: a systematic review. Lancet.

2003;361(9372):1849-1852.

33. Attia AM, Abou-Setta AM, Al-Inany HG. Gonadotrophins for idiopathic male factor subfertility. Cochrane Database Syst Rev. 2013;(8):CD005071.

34. Showell MG, Brown J, Yazdani A, Stankiewicz MT, Hart RJ. Antioxidants for male subfertility. Cochrane Database Syst Rev. 2011;(1):CD007411.

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review article 35. Bensdorp AJ, Cohlen BJ, Heineman MJ, Vandekerckhove P. Intrauterine insemination for male subfertility. Cochrane Database Syst Rev. 2007;(4):CD000360.

36. Veltman-Verhulst SM, Cohlen BJ, Hughes E, Heineman MJ. Intra-uterine insemination for unexplained subfertility.

Cochrane Database Syst Rev. 2012;(9):CD001838.

37. Vause TD, Cheung AP, Sierra S, et al.; Society of Obstetricians and Gynecologists of Canada. Ovulation induction in polycystic ovary syndrome [published corrections appear in J Obstet Gynaecol Can. 2010;32(11):1027, and J Obstet Gynaecol Can. 2011;33(1):12]. J Obstet Gynaecol Can. 2010;32(5):495-502.

38. Sun X, Zhang D, Zhang W. Effect of metformin on ovulation and reproductive outcomes in women with polycystic ovary syndrome: a meta-analysis of randomized controlled trials. Arch Gynecol Obstet. 2013;288(2): 423-430.

39. Tang T, Lord JM, Norman RJ, Yasmin E, Balen AH. Insulinsensitising drugs (metformin, rosiglitazone, pioglitazone, D-chiro-inositol) for women with polycystic ovary syndrome, oligo amenorrhoea and subfertility. Cochrane Database Syst Rev. 2012;(5):CD003053.

40. Trabert B, Lamb EJ, Scoccia B, et al. Ovulation-inducing drugs and ovarian cancer risk: results from an extended follow-up of a large United States infertility cohort. Fertil Steril. 2013;100(6):1660-1666.

41. Practice Committee of the American Society for Reproductive Medicine. Use of clomiphene citrate in

infertile women: a committee opinion. Fertil Steril.

2013;100(2):341-348.

42. Practice Committee of American Society for Reproductive Medicine in collaboration with Society for Reproductive Endocrinology and Infertility. Optimizing natural fertility: a committee opinion. Fertil Steril. 2013;100(3): 631-637.

43. Luciano AA, Peluso J, Koch EI, Maier D, Kuslis S, Davison E. Temporal relationship and reliability of the clinical, hormonal, and ultrasonographic indices of ovulation in infertile women. Obstet Gynecol. 1990;75(3 pt 1): 412-416.

44. Andrews FM, Abbey A, Halman LJ. Is fertility-problem stress different? The dynamics of stress in fertile and infertile couples. Fertil Steril. 1992;57(6):1247-1253.

45. Hughes E, Brown J, Collins JJ, Vanderkerchove P. Clomiphene citrate for unexplained subfertility in women.

Cochrane Database Syst Rev. 2010;(1):CD000057.

46. Clark AM, Thornley B, Tomlinson L, Galletley C, Norman RJ. Weight loss in obese infertile women results in improvement in reproductive outcome for all forms of fertility treatment. Hum Reprod. 1998;13(6):1502-1505.

47. Weinberg CR, Wilcox AJ, Baird DD. Reduced fecundability in women with prenatal exposure to cigarette smoking. Am J Epidemiol. 1989;129(5):1072-1078.

48. Homan G, Litt J, Norman RJ. The FAST study: fertility assessment and advice targeting lifestyle choices and behaviours: a pilot study. Hum Reprod. 2012;27(8): 2396-2404.

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Nutritional Approaches to Improving Sex Hormone Balance

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Increase phytoestrogens consumption (soy, flax, 1-2 cups of cruciferous vegetables daily).

Eat organic foods to minimize intake of xenoestrogens, hormone and antibiotics.

Use filtered water (reverse osmosis) to eliminate xenoestrogens.

Use garlic for sulfur and to help with detoxification.

Consume a high-fiber diet (25-50 g a day, including legumes, whole grains, vegetables, nuts and seeds, fruit).

Increase intake of omega-3 fatty acids (small, nonpredatory cold-water fish: wild salmon, sardines, herring) and flax seeds.

Balance glucose metabolism through a low glycemic load, high phytonutrient index.

Asian Journal of Obstetrics and Gynecology Practice, Vol. 2, No. 1, 2016

Clinical Study

Women’s and Providers’ Experiences with Injectable Contraceptives (Depo-Provera): A View from Vadodara, India Prakash V Kotecha*, Sangita V Patel†, Rajendra K Baxi‡, Shagufa Kapadia#, Kedar Mehta$

Abstract Objective: To compare users’ and providers’ perspectives on injectable contraceptives (IC). Material and methods: This qualitative study employed semi-structured in-depth interview technique. Sixty women with experience of using IC and 10 doctors involved in providing IC were selected. Telephonic interviews of doctors were also conducted. Results: Over 50% of the women had side effects and had discontinued use within 1 year. The most common “likes’’ according to women included ease of use, being tension free for 3 months and being effective and those of the providers were that it reduced anemia, privacy could be maintained, noncontraceptive benefits, good substitute, not to be taken daily like pills, safe and effective. The most common “dislikes’’ reported by providers and clients were excessive bleeding, amenorrhea, irregular periods, spotting, weight gain and frequent pregnancy tests. Conclusion: Although certain distinct advantages of IC have been expressed, the associated problems are equally significant and therefore IC should not be an over-the-counter contraceptive.

Keywords: Clients’ and providers’ perspectives, depo-provera, injectable contraceptives, India, qualitative study

C

hoice of contraceptive methods is a key element of family planning that benefits both women and providers. Offering client’s choices can help increase contraceptive prevalence rates. Data from 36 developing countries indicate that making one additional modern method widely available could increase contraceptive prevalence by about 12%.1 Hence, there is a need to expand contraceptive choices.

Progestin-only injectable contraceptives (POIC), i.e., Depo-medroxyprogesterone acetate (DMPA) and norethisterone enanthate (NETEN) are newer contraceptives. Awareness about POIC is low in India *Technical Advisor Academy for Educational Development, New Delhi † Associate Professor ‡ Professor Dept. of Preventive and Social Medicine Medical College-Baroda, Vadodara, Gujarat # Professor and Head Dept. of Human Development and Family Studies Faculty of Home Science, MS University, Vadodara, Gujarat $ Assistant Professor Dept. of Preventive and Social Medicine GMERS Medical College, Gotri, Vadodara, Gujarat Address for correspondence Dr Sangita V Patel Associate Professor Dept. of Preventive and Social Medicine Medical College-Baroda, Vadodara - 390 001, Gujarat E-mail: sangita_psm@yahoo.co.in

Asian Journal of Obstetrics and Gynecology Practice, Vol. 2, No. 1, 2016

(19%) with near zero usage for contraception.2 Early attempts for clinical trials of DMPA by the Indian Council of Medical Research (ICMR) in the 1970s were abandoned due to unacceptable high rates of bleeding disorders in DMPA users. After the US Food and Drug Administration (FDA) approval of DMPA for contraceptive use in 1992, the Drug Controller of India licensed NETEN (1986) and DMPA (1993) for restricted use in the private sector with a condition that the manufacturers carry out post-marketing surveillance amongst Indian women.3 The present study, thus was undertaken to compare women’s and providers’ perspectives on injectable contraceptive (IC) and to identify whether to include IC in our National Family Welfare Program or not as policy making decisions.

Material and Methods Sample Selection

Women, who had experience of using IC either at the time of study or in the past, were selected for the study from the list provided by IC providers. The providers comprised of doctors involved in providing IC, many of them were involved with IC projects. Telephonic interviews were also conducted and information was elicited from different gynecologists of the city, irrespective of whether they prescribe IC to their clients at present or not.

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clinical study Enrollment

Obstetrics and Gynecology specialists who prescribed IC were asked to give their voluntary consent for participation after taking consent from their clients.

A total of 10 doctors who prescribed IC to their clients and 60 women were studied. To ensure that, we get total picture of users’ perspective we enrolled both types of users - current and past and to assure positive recall adequately we decided to take them in the ratio of 3:1 as far as possible and obtained them from government and private practitioners. While interviewing the doctors who prescribed IC, it was realized that to know the exact number of doctors who prefer use of IC as contraceptive method, would not be possible from interviewing only those doctors who prescribed IC. Thus in an effort to have a quick data on these aspects, a telephonic interview was attempted by picking up telephone numbers of all obstetricians from doctor’s directory. For the telephonic interviews, 85 doctors irrespective of whether they prescribed the injection or not, were interviewed. Five doctors refused to give consent for telephonic interview.

Reasons for Using IC

The influence of the doctor was evident in the responses of 23% of the women who reported “no other option left” as one of the reasons for using IC. It was interesting to see that 78% of the women had negative perceptions about one or more contraceptive methods without ever using them! About three-fourths of the women did not want to use Copper T. There were many women who admitted that it would be difficult for them to remember taking pills daily and hence had found IC as a suitable alternative.

A 29-year-old woman with one child reasoned, “Taking pills everyday is a problem, and on top of it I feel uneasy, have nausea and headache”.

Another woman explained, “We both are not comfortable using condoms, there was white discharge due to Copper T and by using pills I used to get excessive bleeding. So, I had to take injections”.

Study Tools

Women’s Likes

Women who consented were assured of confidentiality and interviewed by co-investigators using semi-structured in-depth interview technique. Similarly, semi-structured interviews of 10 providers who prescribed IC to their clients were conducted by the senior investigator. The research staff noted down the interviews and later translated them into English after reviewing for accuracy.

Transcripts were content analyzed using the technique of open coding to discover conceptual patterns or themes, in the text. Themes found to be both salient and repeated in the text were defined and used as codes to organize the text into categories. The quantitative study was done by telephonic interview.

“Likes” about IC were reported by 97% of the women, understandably from more current than past users.

Results Demographic Profile of IC Users

Of the 60 women interviewed, 16 were those who had taken IC in the past and were no longer continuing it, whereas 44 were those who were currently taking IC. Most of the women belonged to the age group of 25-29 years. Four out of the 60 women were illiterate.

Most of the women (45%) had at least secondary education. More than three-fourths of the women 16

were housewives. Majority (53%) of women using IC belonged to relatively better socioeconomic class.

Voices of IC Users “There is no tension for 3 months and only some people suffer from side effects while others may not”.

“It is better than taking pills daily. IC is simple and convenient”.

“It is good that after taking the injection I don’t get periods, so I get more time to worship God”.

What Doctors Like About IC

Majority of the doctors viewed IC as a better option as compared to pills or Copper T. More than half reported “not having to take the pains of remembering it daily like in case of oral contraceptive (OC) pills” as the major point in favor of IC. Almost half of the doctors pointed out that irregular menstruation perceived as a problem by the IC users, was in a way advantageous to them.

A senior lady gynecologist observed, “Since menorrhagic patients lose so much blood, amenorrhea due to IC could be beneficial to them”.

Asian Journal of Obstetrics and Gynecology Practice, Vol. 2, No. 1, 2016

clinical study Some doctors believed that the use of IC is gradually increasing.

One of the prominent lady gynecologists practicing since more than two decades stated, “IC gives 100% safety and assurance. I advise my clients to try IC first before going to OC pills or Copper T”.

Majority of them preferred giving IC to post-delivery cases.

As mentioned by one of the lady gynecologists, “During the lactation period, clients do not mind amenorrhea due to IC, as they are mentally prepared for amenorrhea. They are happy about it, as their main concern is that they should not get pregnant”.

Dislikes and Problems

When asked regarding their dislikes, 57% of the women reported having dislikes about IC, which were more in past users than current users.

A school teacher troubled with the problem of spotting said, “I am scared, what if something happens when I am at the school”?

A 23-year-old woman, who did not get periods for a year, explained: “If we do not get our periods then the uterus may get infected, tumor or cancer of uterus may also occur”.

A woman fed-up of excessive bleeding said, “Husband wife’s relation gets disturbed due to continuous bleeding”.

Frequent visits to doctor due to continuous bleeding were also a matter of concern. The prevalence of problems was almost the same in both current and past users. The problems reported were the side effects of IC experienced by the women.

A woman with three children, who had continuous excessive bleeding for 16-17 days retorted, “It would be alright even if I would have conceived again, but at least I would have not faced such problems”.

A woman, who discontinued taking IC, reasoned, “I felt there is no guarantee of the injection. I did not get periods for 2-3 months. So, I felt as if I have conceived”.

The side effects of IC were the major cause of concern for the doctors as well. Menstrual irregularity was reported as the most common complaint by their Asian Journal of Obstetrics and Gynecology Practice, Vol. 2, No. 1, 2016

clients. According to some of the doctors, amenorrhea due to IC is quite stressful for their clients as they are always in confusion whether amenorrhea is just a side effect of IC or is it because they have conceived.

A senior lady doctor said, “If I just examine and say that they have not conceived, they do not believe it. I have to do a pregnancy test. So, there is an additional expense”.

Apart from this, the doctors also highlighted the sociocultural impact and psychological stress of menstrual irregularity and amenorrhea in particular.

“In our society, it is strongly believed that menstrual cycle should be regular”.

Return of fertility was also a concern mentioned.

One doctor emphasized this saying, “Return of fertility is the most important research aspect of IC and it should be done”.

Perceptions of Providers Obtained by Quantitative Survey

Out of the 83 doctors who were interviewed on phone, about 16% never prescribed IC, while 84% had prescribed IC at some time during their practice and 41% were currently prescribing IC. Only about onefifth of the doctors reported positive qualities regarding IC (20.4%). Positive qualities were reportedly higher in case of doctors who currently prescribe the injection (35.3%) as compared to those who used to prescribe IC in the past (14%) and those who have never prescribed IC to their clients till now (7.7%). However, negative qualities were reported by a majority of the doctors (94%) and among them the percentage of doctors who used to prescribe IC in the past was the highest (36/36) as compared to those who presently prescribe IC (31/34). Among the 13 doctors who had never prescribed IC in the past, 11 of them had negative perceptions regarding IC. This might be one of the reasons for not prescribing IC to their clients.

A doctor who had never prescribed IC said, “I know that due to injection side effects are obvious then why should it be given and why should one try”.

Some doctors were in favor of IC even though they were aware of the side effects that it caused. As can be expected, most of the doctors who currently prescribed IC reported these qualities as compared to those who had stopped prescribing IC. 17

clinical study According to a senior lady gynecologist, “IC is good as there is no fear of getting pregnant for 3 months. Although I am willing to give, my clients hesitate because of side effects”.

Even though some doctors mentioned the favorable points, most of them expressed their dissatisfaction regarding IC due to its side effects, which is similar to our findings from the in-depth interviews. Out of the 83 doctors interviewed, 78 of them had negative perceptions about IC-based on the problems faced by their clients after using it. Amenorrhea and irregular bleeding were the two major complaints of the clients, as reported by most doctors.

This was followed by substantial dissatisfaction of the clients due to various side effects of IC for which they blamed the doctors.

As one lady doctor who prescribed IC in the past puts it, “Clients with amenorrhea who did not get cured even by medicines, used to come and complain about it and blame me for it. It was such a headache. This was the main reason for me to stop prescribing IC”.

Psychosocial stress associated with menstrual irregularity was another important concern with the clients.

Referring to this, one of the doctors endorsed this view, “Every woman wants 1 monthly cycle. If they do not get periods, they are always in a dilemma whether they are pregnant or not”.

Women’s likes zz zz zz zz

Good for those who cannot swallow pills No monthly tension of periods No botheration in doing routine work Simple and comfortable

Women’s dislikes zz zz zz zz

Severe backache and headache Possibility of damage to uterus Problem in going to religious places Mental tension due to problems in menstrual cycle

Discussion The ‘likes’ reported by clients for using IC were being tension free after having taken it, simple, comfortable and no botheration in doing routine work. The most common likes by providers and clients were that of the convenience of having to take the injection only once in 3 months, effective in preventing pregnancy and good substitute when other contraceptives give problem. However, the side effects or problems due to IC were the major cause of concern for all the doctors, even though they acknowledged the benefits of IC. One study showed likes of DMPA are independent of intercourse and also independent of the user’s memory (and thus of continuing motivation).4 Higher percentage of past users had “dislikes” than current users implying that for the past users these dislikes were perhaps the reasons for having discontinued IC. Over 50% of the women reported some or the other complaints. The problems presented were mainly the side effects of IC experienced by the women. The most common dislikes reported both by women and providers were excessive bleeding, amenorrhea, irregular periods, scanty bleeding, spotting, weight gain and frequent pregnancy tests as shown in Figure 1. Psychological stress due to problems in menstrual cycle, religious restrictions, severe backache and possibility of damage to uterus were mentioned

Common likes zz zz zz

Effective in preventing pregnancy Not to be taken daily like pills but just once in 3 months Good substitute when other contraceptives give problem

Doctor’s likes zz zz zz zz

Reduces anemia Good for menorrhagic patients Privacy can be maintained Noncontraceptive benefits

Common dislikes zz zz zz zz zz zz zz

Excessive bleeding Amenorrhea Irregular periods Scanty bleeding Spotting Weight gain Frequent pregnancy tests

Doctors’ dislikes zz zz

Break through bleeding Delayed fertility and lack of data related to that

Figure 1. Likes and dislikes of IC according to women and doctors.

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Asian Journal of Obstetrics and Gynecology Practice, Vol. 2, No. 1, 2016

clinical study as dislikes particularly by women. While for the doctors, delayed fertility and lack of data related to it was a major concern. Over half of the doctors from quantitative survey had stopped prescribing IC as their clients had adverse problems out of proportion to the possible advantages that they could perceive.

Three different studies reported irregular bleeding, spotting and amenorrhea as the common side effects.5-7 However, rising popularity of injectable contraceptives in Sub-Saharan Africa has also been documented.8 The most commonly reported reasons for method discontinuation are side effects, primarily menstrual irregularities and weight gain.6,9 DPMA carries a higher risk of amenorrhea than NETEN and may be recommended to women who prefer minimal menstrual bleeding.10 Dr C Sathyamala in her monograph articulates that it is not suitable for nulliparous women, adolescents and breastfeeding women.11 Studies thus far have not shown any serious long-term effects of DMPA or NETEN. However, both have been used for a relatively short time and the potential longterm effects (over >15 years) are not yet known.12 Hence, counseling provided by the doctors plays an important role in the acceptance of IC as a reliable and convenient method.

Inadequate counseling leading to lack of knowledge regarding possible side effects of IC brings about substantial dissatisfaction among IC users and hence is likely to affect its continuation rate. Doctors were not in favor of making IC “over-the-counter” available to women and believed that it was suitable only for a particular group of clients and IC should be given to the clients only under their supervision.

A large number of providers also believe that IC is very unsafe and is a banned contraceptive and should not be used. Based on the complaints of side effects by the clients, quite a few of those who started prescribing with enthusiasm have now backed out from their routine prescription. This study was only carried out in one region of India and is thus not necessarily representative of all of India.

Acknowledgments

We express sincere thanks to: zz

UNFPA, New Delhi office in general and Dr Dinesh Agrawal in particular for financial and technical assistance for this study.

zz

Practicing gynecologists, doctors and their clients whose support and co-operation made this study a reality.

References 1. Ross JA. Management strategies for family planning programs. Centre for Population and Family Health, School of Public health. New York: Columbia University; 1989.

2. NFHS. National Family Health Survey. International Institute for Population Science, Mumbai, India; 1993.

3. SAMA. Unveiled reality: a study on women's experiences with Depo-Provera: an injectable contraceptive. Delhi: SAMA; 2000.

4. Bigrigg A, Evans M, Gbolade B, Newton J, Pollard L, Szarewski A, et al. Depo Provera. Position paper on clinical use, effectiveness and side effects. Br J Fam Plann.

1999;25(2):69-76.

5. Siddhivinayak Hirve. Injectables as a choice - evidencebased lessons. Indian J Med Ethics. 2005;2(1).

6. Polaneczky M, Guarnaccia M, Alon J, Wiley J. Early experience with the contraceptive use of depot medroxyprogesterone acetate in an inner-city clinic population. Fam Plann Perspect. 1996;28(4):174-8.

7. Sarojini NB, Murthy L. Why women's groups oppose injectable contraceptives. Indian J Med Ethics. 2005;2(1):9.

8. Adetunji J. Rising popularity of injectable contraceptives in Sub-Saharan Africa. Population Association of America, Los Angeles, Office of Population and Reproductive Health, Bureau for Global Health, US Agency for International Development (USAID); 2006.

9. Sangi-Haghpeykar H, Poindexter AN 3rd, Bateman L, Ditmore JR. Experiences of injectable contraceptive users in an urban setting. Obstet Gynecol. 1996;88(2):227-33.

10. Draper BH, Morroni C, Hoffman MN, Smit JA, Beksinska ME, Hapgood JP, et al. Depot medroxyprogesterone versus norethisterone oenanthate for long-acting progestogenic contraception. Cochrane Database Syst Rev. 2006;(3):CD005214.

11. Sathyamala C. An epidemiological review of the injectable contraceptive Depo-Provera. Medico Friend Circle and Forum for Women's Health. Mumbai; 2000 and 2001.

12. World Health Organization. Facts about injectable contraceptives: Memorandum from a WHO meeting.

Bulletin of the World Health Organization. 1982;60(2): 199-210.

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Asian Journal of Obstetrics and Gynecology Practice, Vol. 2, No. 1, 2016

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case report

Three Different Presentations of Ectopic Pregnancy in the Same Patient Madhupriya*, Kundavi Shankar*, Lakshmi Shanmugasundaram*, Thangam R Varma*

Abstract We present a case report of ectopic pregnancy in a patient on the residual stump of the salpingectomized tube. In the case scenario presented below, there were three different kinds of presentation of ectopic pregnancy in the same patient - left tubal, ectopic pregnancy implanted in scar site and repeat ectopic in the tubal stump of previously salpingectomized tube.

Keywords: Ectopic pregnancy, scar implantation pregnancy, tubal pregnancy, tubal stump pregnancy, salpingectomy, methotrexate

I

psilateral ectopic pregnancy following salpingectomy (total or partial) is rare with <12 cases reported in the literature in the last 10 years.1 Takeda et al2 reported that the incidence of tubal stump pregnancy was 1.16% of all ectopic pregnancies. Ko et al3 reported an incidence of six tubal stump pregnancies among 1,466 ectopic pregnancies amounting to 0.4%.

The ectopic pregnancy on the residual tubal stump after salpingectomy has been sporadically reported.2,4-10 The true incidence of pregnancy in scar has not been determined because so few cases have been reported in the literature; there are only 18 published cases in the English medical literature between 1978 and 2001.11 Case Report A 27-year-old lady came to us in 2008 for secondary subfertility evaluation. She was married for about 5 years with regular cycles. She had two previous spontaneous conceptions. First pregnancy ended in missed miscarriage at 8 weeks; cytogenetic analysis of the evacuated products of conception showed karyotype of 69 XXY (triploidy). Karyotyping of both partners were done and were found to be normal.

Second pregnancy was a left ampullary ruptured ectopic pregnancy. Laparoscopic left salpingectomy was done.

*Institute of Reproductive Medicine, Madras Medical Mission Mogappair, Chennai, Tamil Nadu Address for correspondence Dr Madhupriya C/o: Institute of Reproductive Medicine Madras Medical Mission Mogappair, Chennai, Tamil Nadu E-mail: kalakanda_amp@yahoo.co.in

20

In the interval period, antiphospholipid antibodies were assessed and found to be normal; semen analysis done was normal.

She conceived for the third time with clomipheneinduced cycle with timed intercourse. It was a viable singleton pregnancy evidenced by fetal cardiac activity on ultrasound at 6 weeks gestation. But, the pregnancy ended in missed miscarriage at 8+ weeks. Fetal karyotyping of the evacuated products of conception was reported to be normal.

She then conceived spontaneously in 2009; was under cover of low-dose aspirin and low-molecular-weight heparin throughout the pregnancy. She had gestational diabetes mellitus (GDM) and was taking insulin; she developed fetal intrauterine growth restriction (IUGR) in the third trimester. She delivered at term by lowersegment cesarean section (LSCS).

Her 5th pregnancy was a spontaneous conception. Scan done at 6 weeks and 6 days showed a sac located in the lower endometrial cavity. She was counseled about the finding and followed up conservatively. Scan done at 8 weeks gestation (transabdominal sonography [TAS] + transvaginal sonography [TVS]) showed a gestational sac with large yolk sac in endometrial cavity only about 5 mm from the uterine serosa.

Recheck TAS done revealed the sac in the lower, anterior uterine serosa suggestive of scar implantation ectopic pregnancy (Fig. 1). Sac was located 13 mm above the cervix with no abnormal vasculature in the lower anterior abdominal wall.

The diagnosis of ectopic pregnancy implanted in the previously done LSCS scar site was made. She was Asian Journal of Obstetrics and Gynecology Practice, Vol. 2, No. 1, 2016

Case Report

Figure 1. Scar implantation pregnancy - in previous LSCS scar.

managed medically with injection methotrexate 75 mg and followed up with β-human chorionic gonadotropin (β-hCG) titers, until it decreased to baseline. The uterine cavity rechecked after her first periods showed no sac at the scar implantation site. Her 6th pregnancy in 2014 was a spontaneous conception. She had slowly doubling β-hCG levels. Scan (TAS + TVS) was suggestive of left adnexal pregnancy at 5+ weeks gestation. In view of previously salpingectomized status of the patient, re-evaluation of the finding by a repeat ultrasound was done. The ultrasound findings confirmed the ectopic tubal pregnancy in the stump of previously salpingectomized left tube (Figs. 2 and 3). She was initially managed medically with methotrexate injection. An emergency, laparoscopic excision of the left tubal stump was done in view of suspected ectopic pregnancy rupture with signs of hemoperitoneum. Histopathological report confirmed the ruptured left tubal stump with ectopic pregnancy within.

Discussion

Figure 2. Left tubal stump - ectopic pregnancy.

Figure 3. Tubal stump with pregnancy in situ.

Asian Journal of Obstetrics and Gynecology Practice, Vol. 2, No. 1, 2016

Reviewing the literature, the incidence of ectopic pregnancies in tubal stump and ectopic pregnancies in the scar implantation sites have been quoted to be very low. Implantation of a pregnancy within a cesarean fibrous tissue scar is considered to be the rarest form of ectopic pregnancy and a life‐threatening condition.11 This is because of the very high-risk for uterine rupture and all the maternal complications related to it.12-14 Of the many theories for explaining its occurrence, the most reasonable one seems to be that the blastocyst enters into the myometrium through a microscopic dehiscent tract. This may be created throughout a trauma of a previous cesarean section or any other uterine surgery15 or even following manual removal of the placenta.11 Another mechanism for intramural implantation is in vitro fertilization (IVF) and embryo transfer, even in the absence of any previous uterine surgery.16 The true incidence of pregnancy in scar has not been determined because so few cases have been reported in the literature; there are only 18 published cases in the English medical literature between 1978 and 2001.11 Between 2002 and mid-2003; however, 25 additional cases were reported 18 of which took place in a single center.14 This may reflect both the increasing number of cesarean sections being performed 21

Case Report and the more widespread use of the TVS that allows earlier detection of such pregnancies. This apparent increase is likely multifactorial, related to increasing numbers of cesarean deliveries, increased use of TVS and a heightened awareness of this diagnosis.14,17,18 The diagnosis of cesarean scar pregnancy is made primarily using TVS with a reported sensitivity of 84.6%.18 The major differential diagnoses to consider are spontaneous abortion in progress or cervical ectopic pregnancy.14,18 Several imaging criteria have been proposed to improve diagnostic accuracy. These include an empty uterine cavity and endocervical canal, location of the gestational sac peripherally within the anterior portion of the lower uterine segment, deficient or absent myometrium between the gestational sac and the bladder12,19 and complete encasement of the gestational sac by myometrium and/or fibrous scar tissue.17 Peritrophoblastic flow should be detected at the site of implantation at the scar.14,17 The rarity of this entity results in a lack of consensus on optimal management. Reported strategies include expectant management, systemic methotrexate therapy, local injection of methotrexate or other embryocides, gestational sac aspiration, dilatation and curettage, surgical laparotomy/hysterotomy, hysteroscopy, laparoscopy and uterine artery embolization.18,20 The most difficult question in clinical practice is whether termination of a desired live first trimester scar pregnancy is justified based on current clinical experience. To answer this question, we need to be reasonably confident that there are significant risks to a mother’s health, if pregnancy is allowed to continue.

We need to provide evidence showing that treatment in early pregnancy is safe and effective, that this treatment will preserve woman’s fertility and that the risk of recurrence of scar implantation is low.

Recommendations of the recent enquiry into maternal deaths in the UK have strengthened the arguments in favor of early intervention. The enquiry has identified abnormally adherent placenta following previous cesarean section as one of the leading causes of maternal morbidity and mortality and has advised clinicians to make every effort to identify an abnormally adherent placenta as soon as possible in order to minimize maternal risks.21 Recent studies have shown that surgical treatment of scar ectopics in the first trimester can be accomplished 22

safely and effectively with a relatively little blood loss.22 There is also emerging evidence that women’s fertility is not compromised by the treatment of scar pregnancy, that the subsequent pregnancy outcomes are not adversely affected by the scar implantation and the risk of recurrence is very low.23 The available evidence suggests that the first trimester surgical evacuation of nonviable scar pregnancy is relatively simple and safe. In view of the low-risk of recurrence, it is difficult at present to justify the use of any surgical procedures, either minimally invasive or open, to repair defective cesarean section scars.

Research has speculated that the mechanism for tubal stump pregnancy involves normal fertilization of an oocyte after ovulation from one ovary. The fertilized oocyte in the ipsilateral tube later is carried to the contralateral remnant tube by the intrauterine fluids.

This speculation is supported by the ectopic pregnancy cases involving contralateral to unilateral intrafallopian gamete transfer.24 Ectopic pregnancy in the stump of the ligated tube can be explained either by the trapped fertilized ovum or by the tuboperitoneal fistula formation theory.25-27 In both the instances, fertilized ovum would have been entrapped in the stump because of the narrow isthmic portion of the tube.

When the diagnosis of repeat ectopic pregnancy in the stump of the previously salpingectomized patient is considered, the differential diagnosis of cornual pregnancy is ruled out when preoperatively: zz zz zz zz zz

There was no evidence of an abnormal uterine horn Presence of round ligament on the medial aspect of the gravid swelling Presence of a narrow part separating the mass from the uterus It was sufficient to just apply an artery forceps between the gravid swelling and the uterus There was no need to cut into the uterine cornu to remove the stump.6

References 1. Fischer S, Keirse MJ. When salpingectomy is not salpingectomy−ipsilateral recurrence of tubal pregnancy.

Obstet Gynecol Int. 2009;2009:524864.

2. Takeda A, Manabe S, Mitsui T, Nakamura H. Spontaneous ectopic pregnancy occurring in the isthmic portion of the remnant tube after ipsilateral adnexectomy: report of two cases. J Obstet Gynaecol Res. 2006;32(2):190-4.

Asian Journal of Obstetrics and Gynecology Practice, Vol. 2, No. 1, 2016

Case Report 3. Ko PC, Liang CC, Lo TS, Huang HY. Six cases of tubal stump pregnancy: complication of assisted reproductive technology? Fertil Steril. 2011;95(7):2432.e1-4.

16. Hamilton CJ, Legarth J, Jaroudi KA. Intramural pregnancy after in vitro fertilization and embryo transfer. Fertil Steril.

1992;57(1):215-7.

4. Corti A, Rolandi L. Ectopic pregnancy in the site of prior adnexectomy. Osp Maggiore. 1964;59:413-22.

17. Seow KM, Huang LW, Lin YH, Lin MY, Tsai YL, Hwang JL. Cesarean scar pregnancy: issues in management.

Ultrasound Obstet Gynecol. 2004;23(3):247-53.

5. Benzi G, Mazza L. Recurrence of ectopic pregnancy in a residual tubal stump after prior adnexectomy for extrauterine pregnancy. Minerva Ginecol. 1967;19(4):171-8.

6. Krzaniak S. Ectopic gestation in a tubal stump. Postgrad Med J. 1968;44(508):191-2.

7. Bernardini L, Valenzano M, Foglia G. Spontaneous interstitial pregnancy on a tubal stump after unilateral adenectomy followed by transvaginal colour Doppler Ultrasound. Hum Reprod. 1998;13(6):1723-6.

8. Milingos DS, Black M, Bain C. Three surgically managed ipsilateral spontaneous ectopic pregnancies. Obstet Gynecol. 2008;112(2 Pt 2):458-9.

9. Faleyimu BL, Igberase GO, Momoh MO. Ipsilateral ectopic pregnancy occurring in the stump of a previous ectopic site: a case report. Cases J. 2008;1(1):343.

10. Sturlese E, Retto G, Palmara V, De Dominici R, Lo Re C, Santoro G. Ectopic pregnancy in tubal remnant stump after ipsilateral adnexectomy for cystic teratoma. Arch Gynecol Obstet. 2009;280(6):1015-7.

11. Fylstra DL, Pound-Chang T, Miller MG, Cooper A, Miller KM. Ectopic pregnancy within a cesarean delivery scar: a case report. Am J Obstet Gynecol. 2002;187(2):302-4.

12. Fylstra DL. Ectopic pregnancy within a cesarean scar: a review. Obstet Gynecol Surv. 2002;57(8):537-43.

13. Herman A, Weinraub Z, Avrech O, Maymon R, Ron-El R, Bukovsky Y. Follow up and outcome of isthmic pregnancy located in a previous caesarean section scar. Br J Obstet Gynaecol. 1995;102(10):839-41.

14. Jurkovic D, Hillaby K, Woelfer B, Lawrence A, Salim R, Elson CJ. First-trimester diagnosis and management of pregnancies implanted into the lower uterine segment cesarean section scar. Ultrasound Obstet Gynecol. 2003;21 (3):220-7.

15. Cheng PJ, Chueh HY, Soong YK. Sonographic diagnosis of a uterine defect in a pregnancy at 6 weeks’ gestation with a history of curettage. Ultrasound Obstet Gynecol.

2003;21(5):501-3.

18. Rotas MA, Haberman S, Levgur M. Cesarean scar ectopic pregnancies: etiology, diagnosis, and management. Obstet Gynecol. 2006;107(6):1373-81.

19. Vial Y, Petignat P, Hohlfeld P. Pregnancy in a cesarean scar.

Ultrasound Obstet Gynecol. 2000;16(6):592-3.

20. Maymon R, Halperin R, Mendlovic S, Schneider D, Herman A. Ectopic pregnancies in a caesarean scar: review of the medical approach to an iatrogenic complication.

Hum Reprod Update. 2004;10(6):515-23.

21. Confidential Enquiry into Maternal and Child Health.

Saving Mothers’ Lives: Reviewing Maternal Deaths to Make Motherhood Safer 2003-2005. The Seventh Report of the Confidential Enquiries into Maternal Deaths in the United Kingdom. London: CEMACH; 2007. p. 78.

22. Jurkovic D, Ben-Nagi J, Ofilli-Yebovi D, Sawyer E, Helmy S, Yazbek J. Efficacy of Shirodkar cervical suture in securing hemostasis following surgical evacuation of cesarean scar ectopic pregnancy. Ultrasound Obstet Gynecol.

2007;30(1):95-100.

23. Ben Nagi J, Helmy S, Ofili-Yebovi D, Yazbek J, Sawyer E, Jurkovic D. Reproductive outcomes of women with a previous history of caesarean scar ectopic pregnancies. Hum Reprod. 2007;22(7):2012-5.

24. Keeping D, Harrison K, Sherrin D. Ectopic pregnancy contralateral to unilateral GIFT. Aust N Z J Obstet Gynaecol. 1993;33(1):95-6.

25. Tindal VR (Ed.). Jeffcoate’s Principles of Gynecology. 5th Edition, London: Butterworths; 1987. p. 214.

26. McCausland A. High rate of ectopic pregnancy following laparoscopic tubal coagulation failures. Incidence and etiology. Am J Obstet Gynecol. 1980;136(1):97-101.

27. McCausland AM. Recanalization and fistulization of the fallopian tubes are thought to be the causes of pregnancies following female sterilization. Am J Obstet Gynecol.

1981;139(1):114-5.

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Case report

Enlarged Ovaries Following IVF/ICSI as an Etiology of Obstructive Uropathy Resulting in Acute Renal Failure Pratibha Vishwakarma*, Priya Mohan†, Kundavi Shankar‡, Thangam R Varma#

Abstract In vitro fertilization (IVF) is one of the most comprehensively registered interventions in clinical medicine. IVF is regarded as safe with very few complications. We report a woman who developed acute renal failure due to compression of both ureters from enlarged stimulated ovaries. The condition was diagnosed using magnetic resonance imaging. It was treated with insertion of double-J stents in both ureters and dialysis. Compression of the ureters due to enlarged ovaries should be considered if a patient especially with pre-existing endometriosis develops acute renal failure following IVF. Keywords: Acute renal failure, in vitro fertilization, ovarian hyperstimulation syndrome, ultrasound

D

uring the last 35 years, in vitro fertilization, (IVF) has become an important treatment option in patients with infertility. Following hormone stimulation, the oocytes are collected from the ovaries transvaginally using ultrasound guidance.

The procedure is regarded as safe. The most common complications are hemorrhages, pelvic abscesses and pain. There are also some reports of ureteric damage after puncture by the collecting needle.1,2 We report a case, where a woman with pre-existing endometriosis developed acute renal failure due to compression of both ureters from enlarged stimulated ovaries.

Case Report A 28-year-old woman married for 8 years, with two previous first trimester miscarriages presented to us for treatment of secondary subfertility. She had history of 2 laparoscopies elsewhere suggestive of bilateral tubal block and extensive adhesions between tubes, ovaries and uterus suggestive of stage IV endometriosis. She had regular cycles with a body mass index (BMI) of 20. *Post Doctor Fellow † Private Practitioner ‡ Senior Consultant # Medical Director Institute of Reproductive Medicine and Women’s Health Madras Medical Mission Hospital, Chennai, Tamil Nadu Address for correspondence Dr Pratibha Vishwakarma H. No. 1/2641, Street No-3, Loni Road, Ram Nagar Shahdara, New Delhi -110 032 E-mail: pratibha_vish@yahoo.co.in

24

She had a past history of surgically corrected atrial septal defect at 5 years of age, asymptomatic; since then with good left ventricular ejection fraction. She had ureteric calculi diagnosed on both sides on ultrasound done outside with no renal changes 3 years back, for which she underwent conservative management.

Her follicle-stimulating hormone (FSH) was 12.3 mIU/L and luteinizing hormone (LH) was 14.2 mIU/L, antimullerian hormone (AMH)-1.2 pmol/L with reduced antral follicle count with 2 cm endometriotic cyst on both ovaries. Kidneys were normal. Husband’s semen analysis was normal.

Hysteroscopy and trial transfer was done as preIVF evaluation. She was counseled for therapeutic trial and a flexible antagonist protocol was followed.

Recombinant FSH was used for stimulation. Five oocytes were retrieved under ultrasound guidance after 35 hours of human chorionic gonadotropin (hCG) trigger. Three embryos were fertilized and three 8-cell Grade A embryos were transferred without any difficulty.

Six days following embryo transfer, she reported with loin pain and high-grade fever and reduced urinary output. There was no tenderness on abdominal examination. Investigations revealed normal leukocyte count with more than hundred pus cells on routine urine analysis. Renal function test revealed a picture of pre-renal failure with a serum urea of 100 mg/dL and creatinine of 7.9 mg/dL. Serum electrolytes showed hyperkalemia. Investigations to rule out other causes of pyrexia were normal. Ultrasound showed bilateral enlarged ovaries measuring right 5 × 6 cm and left Asian Journal of Obstetrics and Gynecology Practice, Vol. 2, No. 1, 2016

Case Report 6 × 7 cm and bilateral hydronephrosis (Fig. 1).

Magnetic resonance imaging (MRI) scan showed bilateral hydronephrosis and enlarged ovaries, which led to compression of ureters. She was catheterized and her urine output was only 300 mL/24 hours.

Nephrologist’s and urologist’s opinion were taken.

Injection carbapenem following sensitivity to Klebsiella and extended-spectrum beta-lactamase (ESBL) growth on culture was started. Patient was transferred to nephrology department and dialysis was done as her creatinine showed increasing trend and persistent oliguria. Serum creatinine started to decline following dialysis. Double-J (DJ) stent was inserted. The postoperative course was uneventful and her creatinine level showed declining trends. Oral progesterone was continued as luteal support and on Day 16 of embryo transfer, β-hCG was positive. Her β-hCG showed an increasing trend. Renal sonogram was repeated and it was normal. The patient was asymptomatic and urine culture was negative.

At 6 weeks from last menstrual period (LMP), ultrasound showed evidence of echogenic ring and presence of yolk sac with no cardiac activity and fluid collection was seen in the right adnexa suggestive of right ectopic pregnancy. She was posted for an emergency laparoscopy as she was hemodynamically stable, which needed conversion to laparotomy in view of frozen pelvis.

Approximately, 1 liter of blood and clots were removed along with necrotic and hemorrhagic tissue scattered in the abdominal cavity. Right tube was the seat of rupture and salpingectomy was done. Right ovary was stuck to the back of uterus, and left ovary stuck to

Figure 1. Ultrasound showing bilateral stimulated enlarged ovaries compressing both ureters resulting in bilateral hydronephrosis.

Asian Journal of Obstetrics and Gynecology Practice, Vol. 2, No. 1, 2016

lateral pelvic wall. Abdomen was washed with saline and a drain was placed. Two units of packed cells were transfused postoperatively. Histopathology confirmed ruptured ectopic gestation in the right tube. She was discharged in a stable condition. DJ stent was removed 6 weeks later.

Discussion Transvaginally, ultrasound-guided oocyte retrieval has become the gold standard for IVF therapy. It is considered as a well-tolerated, cost-effective and safe procedure.3,4 A few cases of ureteral damage due to puncture of the ureter by the collecting needle have been described. In one case, the ureter was compressed by a stimulated ovary in a patient with a transplanted pelvic kidney.5 The diagnosis of ureteral compression was confirmed by MRI scan, a procedure without ionizing radiation and which should not cause any harm to fertilized embryos.6 Severe pelvic adhesions may have worsened the situation by limiting the normal movement of the ovaries. Ovarian hyperstimulation syndrome (OHSS) is a common complication in assisted reproductive technologies. In spite of frequent occurrence of abdominal compartment syndrome and oliguria in OHSS, acute renal failure secondary to obstructive uropathy is uncommon in OHSS.7 Acute renal failure due to a hypovolemic state following production of protein-rich ascites in patients with OHSS has been reported,8 but in this case, no ascites and only slight hemoconcentration was noted. The most pronounced finding was the huge enlargement of the ovaries and bilateral hydronephrosis.

To date, there have been just two case reports of obstructive uropathy associated with OHSS.9 The patient was diagnosed earlier as having stage 4 endometriosis and frozen pelvis. Even though the complication risk related to IVF is low, one should be aware of a possible compression or damage to the ureters with subsequent development of acute renal failure. Injury, either by direct puncture or extrinsic compression, compromised ureteral function, but did not completely halt urination—a testimony to the resilient nature of this structure and an intimation of more frequent, unrecognized injury. We, therefore, suggest that obstructive uropathy should also be considered as a possible etiology in patients with enlarged ovaries who develop oliguria or acute renal failure.

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Case Report References 1. Coroleu B, Lopez Mourelle F, Hereter L, Veiga A, Calderon G, Martinez F, et al. Ureteral lesion secondary to vaginal ultrasound follicular puncture for oocyte recovery in in-vitro fertilization. Hum Reprod. 1997;12(5):948-50.

2. Miller PB, Price T, Nichols JE Jr, Hill L. Acute ureteral obstruction following transvaginal oocyte retrieval for IVF. Hum Reprod. 2002;17(1):137-8.

3. L enz S, Lauritsen JG, Kjellow M. Collection of human oocytes for in vitro fertilisation by ultrasonically guided follicular puncture. Lancet. 1981;1(8230):1163-4.

4. Tanbo T, Henriksen T, Magnus Ø, Abyholm T. Oocyte retrieval in an IVF program. A comparison of laparoscopic and transvaginal ultrasound-guided follicular puncture.

Acta Obstet Gynecol Scand. 1988;67(3):243-6.

5. Khalaf Y, Elkington N, Anderson H, Taylor A, Braude P. Ovarian hyperstimulation syndrome and its effect on renal

function in a renal transplant patient undergoing IVF treatment: case report. Hum Reprod. 2000;15(6):1275-7.

6. Vilos AG, Feyles V, Vilos GA, Oraif A, Abdul-Jabbar H, Power N. Ureteric injury during transvaginal ultrasound guided oocyte retrieval. J Obstet Gynaecol Can. 2015;37(1):52-5.

7. Malbrain ML, Cheatham ML, Kirkpatrick A, Sugrue M, Parr M, De Waele J, et al. Results from the International Conference of Experts on Intra-abdominal Hypertension and Abdominal Compartment Syndrome. I. Definitions.

Intensive Care Med. 2006;32(11):1722-32.

8. Winkler J, Pinkas H, Tadir Y, Boner G, Ovadia J. Acute decline in renal function as a consequence of ovarian hyperstimulation syndrome. Nephron. 1992;60(1):104-7.

9. Merrilees DA, Kennedy-Smith A, Robinson RG. Obstructive uropathy as the etiology of renal failure in ovarian hyperstimulation syndrome. Fertil Steril.

2008;89(4):992.e1-2.

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Prevalence of Endometriosis Diagnosed by Laparoscopy in Adolescents with Dysmenorrhea or Chronic Pelvic Pain: A Systematic Review Background: Endometriosis associated with pain symptoms in adolescents has been extensively reported, but the exact prevalence is unclear because pain symptoms may be atypical and endometriosis can only be diagnosed by laparoscopy. The aim of this paper is to provide a systematic review of the prevalence of endometriosis diagnosed by laparoscopy in adolescents.

Methods: A systematic literature search was carried out for relevant articles published between 1980 and 2011 in the databases PUBMED and EMBASE, based on the keywords ‘endometriosis’, ‘laparoscopy’, ‘adolescents’ and ‘chronic pelvic pain (CPP)’. In addition, the reference lists of the selected articles were examined.

Results: Based on 15 selected studies, the overall prevalence of visually confirmed endometriosis was 62% (543/880; range 25-100%) in all adolescent girls undergoing laparoscopic investigation, 75% (237/314) in girls with CPP resistant to treatment, 70% (102/146) in girls with dysmenorrhea and 49% (204/420) in girls with CPP that is not necessarily resistant to treatment. Among the adolescent girls with endometriosis, the overall prevalence of American Society of Reproductive Medicine classified moderate-severe endometriosis was 32% (82/259) in all girls, 16% (17/108) in girls with CPP resistant to treatment, 29% (21/74) in girls with dysmenorrhea and 57% (44/77) in girls with CPP that is not necessarily resistant to treatment, 29% (21/74) in girls with dysmenorrhea and 57% (44/77) in girls with CPP that is not necessarily resistant to treatment.

Due to the quality of the included papers an overestimation of the prevalence and/or severity of endometriosis is possible.

Conclusions: About two-thirds of adolescent girls with CPP or dysmenorrhea have laparoscopic evidence of endometriosis. About one-third of these adolescents with endometriosis have moderate-severe disease. The value of early detection of endometriosis in symptomatic adolescents and the indications for laparoscopic investigation in adolescents require more research.

Source: Hum Reprod Update. 2013;19(5):570-82.

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Asian Journal of Obstetrics and Gynecology Practice, Vol. 2, No. 1, 2016

Case Report

A Laparoscopic Surprise Shweta Suryaraj*, MG Dhanalakshmi†

Abstract A 30-year-old female, gravida 2, para 1, live 1 at 6 weeks of gestational age was admitted through the outpatient department of our institution with complaints of spotting per vaginum for 1 day. Per speculum examination revealed minimal bleeding through the os. A bimanual examination revealed a normal-sized uterus with minimal posterior forniceal tenderness. With clinical suspicion of either a spontaneous abortion or an ectopic pregnancy, serum β-human chorionic gonadotropin (β-hCG) was done, which was 22,217 IU/L and a confirmatory ultrasound done showed left-sided unruptured ectopic gestation.

A laparoscopic procedure was planned. Intraoperatively, a left-sided unruptured ovarian ectopic pregnancy was noted. Further in the article, we shall discuss the incidence, etiology, clinical features, diagnostic methods and criteria, management options and outcome for an ovarian ectopic pregnancy.

Keywords: Ovarian pregnancy, Spiegelberg criteria, laparoscopy

Case Report A 30-year-old female, gravida 2, para 1, live 1 at 6 weeks of gestational age was admitted through the outpatient department of our institution with complaints of spotting per vaginum for 1 day. On examination, no pallor and vitals were stable. Per speculum examination revealed minimal bleeding through the external os and a per vaginal examination revealed a normal-sized uterus and minimal posterior forniceal tenderness. There was no cervical motion tenderness. On investigation, hemoglobin was 12.7 g/dL, total count 10,300 cells/mm3, platelets 2.12 lacs/mm3 and blood group was B positive. With clinical suspicion of either a spontaneous abortion or an ectopic pregnancy, serum β-human chorionic gonadotropin (β-hCG) was done, which was 22,217 IU/L and an ultrasound done showed an empty uterine cavity with a left-sided unruptured ectopic gestation of size 3.2 × 2.8 cm close to the left ovary with a fetal pole (4.15 mm) and minimal free-fluid in the pouch of Douglas (Figs. 1 and 2). *Postgraduate Professor Dept. of Obstetrics and Gynecology Sri Ramachandra Medical University, Chennai, Tamil Nadu Address for correspondence Dr Shweta Suryaraj No. 257, Z-Block, 4A, Silver Springs Apartments 6th Street, Anna Nagar, Chennai - 600 040, Tamil Nadu Email: shwetasuryaraj@gmail.com

Figure 1. Empty uterine cavity with a thickened endometrium (7.55 mm).

†

Asian Journal of Obstetrics and Gynecology Practice, Vol. 2, No. 1, 2016

Figure 2. Ectopic sac with fetal pole.

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Case Report

a Figure 4. Histopathology slide showing trophoblastic villi; stained with hematoxylin and eosin.

Discussion Ovarian pregnancy is a rare event. They make-up 0.3-3%1 of all ectopic pregnancies. Incidence varies from 1 in 2,500 to 1 in 40,000 pregnancies.2 It occurs when the ovum has not been released and fertilization occurs in the ovary. It clinically and radiologically mimics a tubal pregnancy and can be life-threatening in case of rupture, causing intra-abdominal hemorrhage and hence it is a surgical emergency. b Figure 3 a and b. Gestational sac seen in the left ovary.

In view of an elevated serum b-hCG value and ultrasound diagnosis of an ectopic pregnancy, the patient was planned for a laparoscopic procedure.

Intraoperatively, the following findings were noted: An unruptured ovarian pregnancy 3 Ă&#x2014; 3 cm in size on the left side (Fig. 3 a and b), 50 mL of free-fluid, normal left fallopian tube, normal right ovary and fallopian tube and a normal uterus with no hemoperitoneum.

A resection of the ectopic sac was done leaving the left ovary intact.

Histopathology of the specimen showed trophoblastic villi, but not ovarian tissue as we removed only the sac (Fig. 4).

Postoperatively, patient was stable and discharged on postoperative Day 1. On her review, a week later, serum β-hCG was 440.50 IU/L and it further dropped to 22 IU/L 3 weeks later.

28

A few risk factors have been found to have a relationship with ovarian pregnancy. They are pelvic inflammatory disease, intrauterine contraceptive devices,3 endometriosis and assisted reproductive techniques.4 Incidence of ovarian ectopic in intrauterine contraceptive device users is 19.3% and those conceived by assisted reproductive techniques is 18.1%,5 being the two most important risk factors.

An ovarian pregnancy can present with symptoms and signs of a normal intrauterine pregnancy or present with life-threatening symptoms of shock.

Nausea, vomiting, abdominal pain, vaginal bleeding, tachycardia, hypotension and shock are the signs and symptoms a patient can present with. Rupture in the first trimester is the usual rule in an ovarian ectopy, but the pregnancy can advance to term.6 Spiegelberg Criteria

The following criteria should be met in order to confirm an ovarian pregnancy:7 zz

The gestational sac is located in the region of the ovary Asian Journal of Obstetrics and Gynecology Practice, Vol. 2, No. 1, 2016

Case Report zz

The gestational sac is attached to the uterus by the ovarian ligament

zz

Ovarian tissue is histologically proven in the wall of the gestational sac

zz

The fallopian tube on the involved side is intact.

Diagnosis of an ovarian ectopic pregnancy can be done with a good history and clinical examination, serum b-hCG value, ultrasound and histopathology.

A history of nausea, vomiting, severe abdominal pain, bleeding per vaginum with a positive urine pregnancy test will usually give us a suspicion of an ectopic pregnancy. A per vaginal examination may reveal an adnexal mass, forniceal tenderness or cervical motion tenderness. A serum b-hCG value elevated much beyond that expected for the gestational age may be present. A transvaginal ultrasound usually confirms the diagnosis with an empty uterine cavity and an ovarian mass/adnexal mass.8 Histopathology proving the presence of ovarian tissue in the specimen confirms the diagnosis of an ovarian ectopic pregnancy.

Though medical management options are available, surgery is the treatment of choice. Methotrexate can be used for the treatment of tubal ectopic pregnancy with a success rate of >82%, with a b-hCG value between 10,000 and 14,999 IU/L.9 However, failure rates are high with an ovarian ectopic pregnancy. It can be used when there may be remnant tissue left behind after surgery. Surgical options are laparoscopic oophorectomy and partial wedge resection.10 In our case, we removed the sac in toto without removing any ovarian tissue. Fertility after ovarian pregnancy usually remains unmodified.11

References 1. Salas Valien JS, Reyero Alvarez MP, González Morán MA, García Merayo M, Nieves Díez C. Ectopic ovarian pregnancy. An Med Intern. 1995;12(4):192-4.

2. Gerin-Lojoie L. Ovarian pregnancy. Am J Obstet Gynecol.

1951;62(4):920-9.

3. Mehmood SA, Thomas JA. Primary ectopic ovarian pregnancy (report of three cases). J Postgrad Med. 1985;31(4):219-22.

4. Qublan H, Tahat Y, Al-Masri A. Primary ovarian pregnancy after the empty follicle syndrome: a case report. J Obstet Gynaecol Res. 2008;34:422-4.

5. Joseph RJ, Irvine LM. Ovarian ectopic pregnancy: aetiology, diagnosis and challenges in surgical management. J Obstet Gynaecol. 2012;32(5):472-4.

6. Darbar RD, Reddy CC, Despande NR, Nagalotimath SJ. Primary ovarian pregnancy (a case report). J Obstet Gynecol India. 1976;28:310.

7. Spigelberg O. Casusistik der ovarialschwangerschaft. Arch Gynecol. 1878;13:73.

8. Russel JB, Cutler LR. Transvaginal ultrasonographic detection of primary ovarian pregnancy with laparoscopic removal: a case report. Fertil Steril. 1989;51(6):1055-6.

9. Lipscomb GH, McCord ML, Stovall TG, Huff G, Portera SG, Ling FW. Predictors of success of methotrexate treatment in women with tubal ectopic pregnancies. N Engl J Med. 1999;341(26):1974-8.

10. Chahtane A, Dehayni M, Rhrab B, Kharbach A, El Amrani S, Chaoui A. Ovarian pregnancy: four cases with review of literature. Rev Fr Gynecol Obstet. 1993;88(1):35-8.

11. Portundo JA, Ochoa C, Gomez BJ, Uribaron A. Fertility and contraception of 8 patients with ovarian pregnancy. Int J Fertil. 1984;29(4):254-6.

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Endometriosis Diagnosis: Still an Enigma Pradip Kumar

Endometriosis may be divided into superficial, deep and ovarian.

Laparoscopy is gold standard for diagnosis of endometriosis.

Laparoscopy provides the luxury of diagnosis and management in the same sitting.

Revised American Fertility Society Classification is the most widely used staging system for endometriosis.

Asian Journal of Obstetrics and Gynecology Practice, Vol. 2, No. 1, 2016

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Conference Update

59th All India Congress of Obstetrics & Gynaecology (AICOG 2016) Saving Lives with Safer Abortion Technology and Practice

In Asia, there were 26 million induced abortions in 2003; estimated 10.5 million unsafe abortions.

Why do women risk unsafe abortion zz

Denial or limitations to accessing services: Restrictive laws; facilities too few and often unevenly distributed; lack of access to qualified providers

Lack of awareness zz Poor quality of services zz Cost of services zz Gender roles and norms: Stigma, opposition, lack of autonomy.

The ground reality is that there are low tech settings with nonavailability of equipment and erratic electricity supply. zz

Technical developments: MVA syringe - MVA Pilot Project: Pioneering project to introduce MVA at district level in healthcare - down to PHC level. zz According to the MTP Act, the following facilities should be provided: First trimester terminations: Gynecology/ labor table, backup for treating shock and facilities for transportation Second trimester terminations: OT table and instruments for abdominal and gynecological surgery, anesthetic equipment zz

All terminations: Resuscitation and sterilization equipment, drugs and parenteral fluids.

MOHFW GOI Comprehensive Abortion Care Guidelines: First trimester termination.

Up to 49 days: Day 1 mifepristone 200 mg; Day 3 misoprostol 400 µg - oral/vaginal zz From 49 to 63 days: Day 1 mifepristone 200 mg; Day 3 misoprostol 800 μg - oral/vaginal. zz Adjunct medications: Antibiotics, analgesics and antiemetics.

FOGSI Safe Abortion Consensus 2004 FOGSI ICOG GCPR 2010 - Suggested protocol for mifepristone misoprostol for second trimester termination Mifepristone 200 mg followed after 36-48 hours by misoprostol 400 mg of oral, sublingual or vaginal every 3-6 hours up to 5 doses. zz

The impediments in implementing the present policy for safe abortion care services to women should be addressed and measures taken to facilitate the provision of existing providers.

FOGSI has established itself as an institution towards improving the overall health of women and address their unmet needs.

FOGSI recommends strategies to train and strengthen the role of existing providers in comprehensive abortion care.

Antibiotics in Obstetrics High Dependency Unit

Dr Sushila Kharkwal, Jhansi

Start the empiric antimicrobials on the basis of clinical evaluation.

Continue the intravenous drugs for at least 48-72 hours.

Revise treatment every 24 hours.

With the availability of the sensitivity, switch the drug to a more precise pathogen.

Select the most appropriate narrow spectrum antibiotics after c/s.

30

Dr Nozer Sheriar, Mumbai

Use the most effective, least toxic, less expensive drugs.

Give the complete course of the drug and treat septic focus.

Watch for clinical response to the treatment.

With the failure of response, switch over to higher groups of antimicrobials.

Biomarkers of infection, C-reactive protein and calcitonin are potentially useful in the diagnosis of infection as well as in the assessment of its response to antibiotics.

Asian Journal of Obstetrics and Gynecology Practice, Vol. 2, No. 1, 2016

Conference Update Best Route of Hysterectomy: What is the Evidence?

Routes of hysterectomy zz

Vaginal hysterectomy laparoscopic assistance

with

or

zz

Abdominal hysterectomy

zz

Laparoscopic hysterectomy - LAVH or TLH

zz

Robotic-assisted lap hysterectomy.

zz

Symptomatic uterine leiomyomas

zz

Endometriosis

zz

Prolapse

zz

Abnormal uterine bleeding

zz

Genital malignancies.

Vaginal hysterectomy is the approach of choice whenever feasible, based on its well-documented advantages and lower complication rates.

The choice of whether to perform prophylactic oophorectomy at the time of hysterectomy is based on the patient’s age, risk factors and informed wishes, but not on the route of hysterectomy.

Laparoscopic hysterectomy is an alternative to abdominal hysterectomy for those patients in whom a vaginal hysterectomy is not indicated or feasible.

When all else fails, abdominal hysterectomy saves the day.

Robot-assisted hysterectomy: More data are needed to determine its role in the performance of hysterectomy.

without

Indications for hysterectomy

Dr Ayona Barthakur, Guwahati

Consumptive Coagulopathy: How to Manage?

Dr Abhay Bhave

Recognize disseminated intravascular coagulation (DIC) clinically- awareness.

Component therapy: Transfusional; massive transfusion protocol 1:1:1; nontransfusional care.

Appropriate tests: CBC, PT, PTT, plasma fibrinogen, smear.

Nontransfusional supportive care:

Treat the underlying cause-sepsis or infection.

Deliver where appropriate.

zz

Recombinant factor VIIa zz Uterine artery embolization/cesarean hysterectomy in severe PPH. zz

Imaging Modalities in Infertility

Uterine cavity and tubal assessment - Integral part of subfertility investigations.

Laparoscopy with chromopertubation + hysteroscopy ‘‘gold standard’’.

Current imaging modalities: Hysterosalpingography (HSG); transvaginal ultrasound scan (TVS); saline hysterosonography (SHG/SIS); 3D ultrasound scan and MRI.

Dr Jyotsna Pundir, London

secondary role in assessment of uterine cavity Intrauterine filling defects.

3D ultrasound scan: Accurate, noninvasive diagnosis of congenital uterine anomalies; compared to hysteroscopysensitivity of 92% and specificity of 99%.

MRI only in clinically indicated cases.

Hysterosalpingo constrast sonography can be easily incorporated and considered as the most cost-effective test.

HSG has primary role in tubal assessment and

Sorting the Dilemmas of Cervical Pregnancy

Dr Saswati Sanyal Choudhury

Early diagnosis and treatment with conservative methods is ideal but is a challenge.

Cervical pregnancy should be kept in mind while treating every case of abortion.

Anticipation and preparedness:

Asian Journal of Obstetrics and Gynecology Practice, Vol. 2, No. 1, 2016

Tranexamic acid/EACA

zz

Prevents morbidity and mortality

zz

Preserves uterus and fertility.

Optimal approach is largely unknown.

Conservative treatment in combination of modalities appear to be safe and effective.

31

Conference Update Youth: Catch Them Young!!

Dr Kamini A Rao

An obese woman is thrice as likely to be infertile as a normal woman.

Chances of pregnancy are reduced by 5% for every BMI unit that exceeds 29 kg/m2.

Obesity does not affect IVF outcomes in women using donor oocytes.

Oocyte quality rather than endometrial receptivity may be the overriding factor influencing IVF outcomes in obese women using autologous oocytes.

Management protocols:

zz

Counseling for weight reduction and lifestyle modification (diet, exercise, smoking cessation, behavioral techniques)

zz

Carbohydrate and fat restricted diet

zz

Diet restriction and exercise

zz

Low glycemic index diet up to 85% will improve menstrual cycle regularity and ovulation in about 6 months.

Can be offered to females without partners

zz

Mature eggs are retrieved and frozen and stored

zz

Vitrified oocytes also have a post thaw survival rate of >65%.

Radiation

zz

Chemotherapy

zz

Infection

zz

Surgery.

zz

Endometriosis in adolescents: Progressive dysmenorrhea; acyclic pain; dyspareunia; gastrointestinal complaints

Women attempting natural conception or ART should be advised to discontinue smoking.

Modifying lifestyle at early age is a form of primordial prevention and is cheap and effective.

Dr Sonia Malik, New Delhi

Ovarian insult is defined as injury to the ovary due to: zz

Affects women during the prime years of their lives

Empiric therapy: Younger than 18 years → Combination hormone therapy and NSAIDs Older than 18 years → Empiric trial of GnRH agonist therapy For patients younger than 18 years with persistent pelvic pain - Combination hormone therapy and laparoscopic procedure; only procedures that preserve fertility options should be applied; after surgery adolescents should be treated with medical therapy until childbearing.

In unmarried women treat to delay progression and for symptomatic relief Encourage early childbearing after proper counseling.

Surgical Ovarian Insult

zz

zz

Oocyte cryopreservation: zz

Endometriosis:

A successful operation means not only removal of ovarian pathology but also maintenance of ovarian function and subsequent pregnancy with live birth.

Physicians should be aware that laparoscopic conservative surgery for endometriosis is a challenging task. The skill and experience of laparoscopists play an important role in determining the final IVF-ICSI outcome for infertile patients operated on for ovarian endometriomas.

Surgery on the ovary, however minimal, must be carefully planned and executed so that it does not produce adverse results and poor fertility outcome.

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Asian Journal of Obstetrics and Gynecology Practice, Vol. 2, No. 1, 2016

Research Review

Journal Scan

Resveratrol and Obesity: Can Resveratrol Relieve Metabolic Disturbances?

There is an increasing need for novel preventive and therapeutic strategies to combat obesity and related metabolic disorders. In this respect, the natural polyphenol resveratrol has attracted significant interest.

Animal studies indicate that resveratrol mimics the effects of calorie restriction via activation of sirtuin 1 (SIRT1). SIRT1 is an important player in the regulation of cellular energy homeostasis and mitochondrial biogenesis. Rodent studies have shown beneficial effects of resveratrol supplementation on mitochondrial function, glucose metabolism, body composition and liver fat accumulation. However, confirmation of these beneficial effects in humans by placebo-controlled clinical trials remains relatively limited. This review will give an overview of preclinical and clinical studies examining the effects of resveratrol on obesity-induced negative health outcomes. This article is part of a special issue entitled: resveratrol: challenges in translating preclinical findings to improved patient outcomes.

Source: Biochim Biophys Acta. 2015;1852(6):1137-44.

Effects of Resveratrol Supplements on Vascular Health in Postmenopausal Women Data from in vitro and animal models suggest the potential for resveratrol to reduce the risk of the development and progression of certain chronic diseases, including cardiovascular disease. However, the amount of resveratrol used in these studies typically exceeds what is found in the diet. This has led to considerable interest in resveratrol as a supplement, but data in humans with regard to the bioavailability and biological effects of supplemental resveratrol are limited. The current study compared the effects of trans-resveratrol and a resveratrolarginine conjugate on measures of vascular function in a group of at-risk women. Twenty-seven postmenopausal women were randomly assigned to consume either 90 mg of resveratrol as the resveratrol-arginine conjugate (ResArg) or as trans-resveratrol (t-Res), a minimum of 1 week apart. Microvascular function was measured Asian Journal of Obstetrics and Gynecology Practice, Vol. 2, No. 1, 2016

by peripheral arterial tonometry before and 2 hours after the intake of each supplement. Two indices were calculated: the reactive hyperemia index (RHI) and the Framingham reactive hyperemia index (FRHI). Neither trans-resveratrol nor resveratrol-arginine conjugate supplementation resulted in significant changes in RHI 2 hours after intake (t-Res: 0 h: 2.51 ± 0.13; 2 h: 2.40 ± 0.12; p = 0.45; ResArg: 0 h: 2.08 ± 0.13; 2 h: 2.38 ± 0.12; p = 0.09), however, both trans-resveratrol and resveratrol-arginine conjugate supplementation resulted in significant changes in FRHI 2 hours after intake (t-Res: 0 h, 0.85 ± 0.07; 2 h, 0.96 ± 0.05; p = 0.01; ResArg: 0 h, 0.67 ± 0.08; 2 h, 0.88 ± 0.05; p = 0.02).

No significant differences were observed between the trans-resveratrol and resveratrol-arginine conjugate supplement groups for changes from baseline values for either the RHI (t-Res: -0.11 ± 0.16; ResArg: 0.31 ± 0.17; p = 0.22) or the FRHI (t-Res: 0.11 ± 0.04; ResArg: 0.22 ± 0.08; p = 0.25). Both trans-resveratrol and resveratrolarginine conjugate supplementation may improve vascular function 2 hours after intake, however the changes in vascular function between two supplementations were not significantly different. Based on a previous 1 hour study, our results suggest a relatively short-time period of action of the resveratrol-arginine conjugate on vascular function. Improvements in vascular function tended to be more pronounced with the resveratrol-arginine conjugate compared to trans-resveratrol.

Source: http://search.proquest.com/docview/1722264108 Resveratrol, Obesity and Diabetes Recent studies suggest that resveratol may have antidiabetic potential in addition to its other numerous health benefits.

At this point, almost all research pertinent to resveratrol’s antihyperglycemic effects has been conducted on animals but the results are very promising. The mechanism of resveratrol’s action is complex and is demonstrated to involve both insulin-dependent and insulin-independent effects. The broad-spectrum of resveratrol effects is enlarged by new data demonstrating its great potency in relation to obesity. It is well-established that resveratrol exerts beneficial effects in rodents fed a high-calorie diet.

33

Research Review In some studies, resveratrol was reported to reduce body weight and adiposity in obese animals. The action of this compound involves favorable changes in gene expressions and in enzyme activities. In a recent publication it has been proposed that the mechanism by which resveratrol exerts favorable effects on obesity is associated with the induction of genes for oxidative phosphorylation and mitochondrial biogenesis. However, the precise molecular mechanism up to this point is not totally clear and since these effects are established mainly on animal models, it would be of interest to investigate the antidiabetic and obesity potential of resveratrol on humans.

Suggested Reading 1. Das M, Das DK. Resveratrol and cardiovascular health.

Mol Aspects Med. 2010;31(6):503-12.

2. Szkudelska K, Szkudelski T. Resveratrol, obesity and diabetes. Eur J Pharmacol. 2010;635(1-3):1-8.

3. Xu Q, Si LY. Resveratrol role in cardiovascular and metabolic health and potential mechanisms of action. Nut Res. 2012;32(9):648-58.

Resveratrol and Antiaging Activity Caloric restriction has been proven to extend the lifespan of a number of species, including mammals. In recent studies it has been reported that resveratrol shifts the physiology of middle-aged mice on high-calorie diet

towards that of mice on standard diet and significantly increases their survival. It has been shown that obese animals whose diet was supplemented with resveratrol not only lived longer, but were more active and produced fewer cases of the negative effects of a high-calorie diet.

In addition, reduced insulin-like growth factor-1 levels, increased number of mitochondria and improved motor function have also been observed.

Source: Food Chemistry. 2012;130:797-813.

Resveratrol Prevents Age-related Memory Administration of resveratrol (RESV), a naturally occurring polyphenol found in high concentrations in the skin of red grapes, appears suitable for counteracting agerelated detrimental changes in the hippocampus because of its proangiogenic and anti-inflammatory properties with no adverse side effects. Indeed, RESV has been shown to mediate a wide range of biological activities including extension of the lifespan and delayed onset of age related diseases.1-6 References 1.

2.

3.

4.

5.

6.

Nat Rev Drug Discov. 2006;5(6):493-506.

Pharmacol Ther. 2011;131(3):269-86.

J Cereb Blood Flow Metab. 2012;32(5):884-95.

Nature. 2006;444(7117):337-42.

Curr Med Chem. 2008;15(19):1887-98.

Neurochem Int. 2009;54(2):111-8.

■■■■

Gestational Diabetes Mellitus: Still More to Explore Shuseela, Priti, AK Gupta, Sunil, MU Rabbani 75 g single step glucose challenge test is the recommended screening and diagnostic test for gestational diabetes mellitus (GDM).

It should be conducted as soon as possible.

HbA1C has no role in GDM; it only differentiates it from pre-existing diabetes milletus- indicates pregnancy having predilection for congenital malformations.

In pregnancy, blood sugar levels are much lower than nonpregnant women.

First step for management of GDM should be medical nutrition therapy.

For self-monitoring of blood glucose levels, the glucometers must be calibrated with lab values.

Close fetomaternal surveillance required for management of GDM. If in serial USG scans AC >75th centile, it trends towards macrosomia.

If GDM is well-controlled, wait for spontaneous labor till 39-40 weeks. If any obstetric or diabetic complication is there, opt for elective delivery by 38 weeks.

In active labor, measure blood sugar 2 hourly.

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Asian Journal of Obstetrics and Gynecology Practice, Vol. 2, No. 1, 2016

Asian

Journal of

OBSTETRICS & GYNECOLOGY Practice

Information for Authors

Manuscripts should be prepared in accordance with the ‘Uniform requirements for manuscripts submitted to biomedical journals’ compiled by the International Committee of Medical Journal Editors (Ann. Intern. Med. 1992;96: 766-767).

Asian Journal of Obstetrics and Gynaecology Practice strongly disapproves of the submission of the same articles simultaneously to different journals for consideration as well as duplicate publication and will decline to accept fresh manuscripts submitted by authors who have done so.

The boxed checklist will help authors in preparing their manuscript according to our requirements. Improperly prepared manuscripts may be returned to the author without review. The checklist should accompany each manuscript.

Authors may provide on the checklist, the names and addresses of experts from Asia and from other parts of the World who, in the authors’ opinion, are best qualified to review the paper.

Covering letter -

- -

The covering letter should explain if there is any deviation from the standard IMRAD format (Introduction, Methods, Results and Discussion) and should outline the importance of the paper.

Principal/Senior author must sign the covering letter indicating full responsibility for the paper submitted, preferably with signatures of all the authors.

Articles must be accompanied by a declaration by all authors stating that the article has not been published in any other Journal/Book. Authors should mentioned complete designation and departments, etc. on the manuscript.

Manuscript - Three complete sets of the manuscript should be submitted and preferably with a CD; typed double spaced throughout (including references, tables and legends to figures).

- The manuscript should be arranged as follow: Covering letter, Checklist, Title page, Abstract, Keywords (for indexing, if required), Introduction, Methods, Results, Discussion, References, Tables, Legends to Figures and Figures.

- All pages should be numbered consecutively beginning with the title page.

Note: Please keep a copy of your manuscript as we are not responsible for its loss in the mail. Manuscripts will not be returned to authors.

Title page Should contain the title, short title, names of all the authors (without degrees or diplomas), names and full location of the departments and institutions where the work was performed, name of the corresponding authors, acknowledgment of financial support and abbreviations used.

Asian Journal of Obstetrics and Gynecology Practice, Vol. 2, No. 1, 2016

-

The title should be of no more than 80 characters and should represent the major theme of the manuscript.

A subtitle can be added if necessary.

-

A short title of not more than 50 characters (including inter-word spaces) for use as a running head should be included.

- The name, telephone and fax numbers, e-mail and postal addresses of the author to whom communications are to be sent should be typed in the lower right corner of the title page.

-

A list of abbreviations used in the paper should be included. In general, the use of abbreviations is discouraged unless they are essential for improving the readability of the text.

Summary - The summary of not more than 200 words. It must convey the essential features of the paper.

- It should not contain abbreviations, footnotes or references.

Introduction - The introduction should state why the study was carried out and what were its specific aims/objectives.

Methods - These should be described in sufficient detail to permit evaluation and duplication of the work by others.

- Ethical guidelines followed by the investigations should be described.

Statistics The following information should be given: - The statistical universe i.e., the population from which the sample for the study is selected.

-

Method of selecting the sample (cases, subjects, etc. from the statistical universe).

-

Method of allocating the subjects into different groups.

-

Statistical methods used for presentation and analysis of data i.e., in terms of mean and standard deviation values or percentages and statistical tests such as Student’s ‘t’ test, Chi-square test and analysis of variance or non-parametric tests and multivariate techniques.

-

Confidence intervals for the measurements should be provided wherever appropriate.

Results -

These should be concise and include only the tables and figures necessary to enhance the understanding of the text.

35

Discussion -

This should consist of a review of the literature and relate the major findings of the article to other publications on the subject. The particular relevance of the results to healthcare in India should be stressed, e.g. practicality and cost.

References These should conform to the Vancouver style. References should be numbered in the order in which they appear in the texts and these numbers should be inserted above the lines on each occasion the author is cited (Sinha12 confirmed other reports13,14...). References cited only in tables or in legends to figures should be numbered in the text of the particular table or illustration. Include among the references papers accepted but not yet published; designate the journal and add ‘in press’ (in parentheses). Information from manuscripts submitted but not yet accepted should be cited in the text as ‘unpublished observations’ (in parentheses).

At the end of the article the full list of references should include the names of all authors if there are fewer than seven or if there are more, the first six followed by et al., the full title of the journal article or book chapters; the title of journals abbreviated according to the style of the Index Medicus and the first and final page numbers of the article or chapter. The authors should check that the references are accurate. If they are not this may result in the rejection of an otherwise adequate contribution.

Examples of common forms of references are: Articles Paintal AS. Impulses in vagal afferent fibres from specific pulmonary deflation receptors. The response of those receptors to phenylguanide, potato S-hydroxytryptamine and their role in respiratory and cardiovascular reflexes.

Q. J. Expt. Physiol. 1955;40:89-111.

-

Do not use clips/staples on photographs and artwork.

-

Illustrations must be drawn neatly by an artist and photographs must be sent on glossy paper. No captions should be written directly on the photographs or illustration. Legends to all photographs and illustrations should be typed on a separate sheet of paper. All illustrations and figures must be referred to in the text and abbreviated as ‘Fig.’.

Please complete the following checklist and attach to the manuscript: 1. Classification (e.g. original article, review, selected summary, etc.)_______________________________ 2. Total number of pages ________________________ 3. Number of tables ____________________________ 4. Number of figures ___________________________ 5. Special requests _____________________________ 6. Suggestions for reviewers (name and postal address)

Books

Indian 1.____________Foreign 1.________________

Stansfield AG. Lymph Node Biopsy Interpretation Churchill Livingstone, New York 1985.

2.____________ 2.________________

3.____________ 3.________________

Articles in Books

4.____________ 4.________________

Strong MS. Recurrent respiratory papillomatosis. In: Scott Brown’s Otolaryngology. Paediatric Otolaryngology Evans JNG (Ed.), Butterworths, London 1987;6:466-470.

7. All authors’ signatures________________________ 8.

Corresponding author’s name, current postal and e-mail address and telephone and fax numbers __________________________________________

Tables -

These should be typed double spaced on separate sheets with the table number (in Roman Arabic numerals) and title above the table and explanatory notes below the table.

Legends - These should be typed double spaces on a separate sheet and figure numbers (in Arabic numerals) corresponding with the order in which the figures are presented in the text.

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Figures - Two complete sets of glossy prints of high quality should be submitted. The labelling must be clear and neat.

- All photomicrographs should indicate the magnification of the print.

- Special features should be indicated by arrows or letters which contrast with the background.

- The back of each illustration should bear the first author’s last name, figure number and an arrow indicating the top. This should be written lightly in pencil only. Please do not use a hard pencil, ball point or felt pen.

- Color illustrations will be accepted if they make a contribution to the understanding of the article.

The legend must include enough information to permit interpretation of the figure without reference to the text.

Online Submission Also e-issue @ www.ijcpgroup.com For Editorial Correspondence

Dr KK Aggarwal

Group Editor-in-Chief Asian Journal of Clinical Cardiology E - 219, Greater Kailash, Part - 1, New Delhi - 110 048. Phone: 011-40587513 E-mail: editorial@ijcp.com, Website: www.ijcpgroup.com

Asian Journal of Obstetrics and Gynecology Practice, Vol. 2, No. 1, 2016