Emmanuel Kalu

To determine whether a live birth or miscarriage in a previous IVF cycle is predictive of success in a subsequent cycle. Retrospective study Private IVF unit 1141 couples having a second IVF cycle. 3 groups; Group I: women who had a live birth in the first cycle, Group II those who had a miscarriage, Group III, women who had a negative pregnancy test in their first cycle. Pregnancy (PR), Live birth (LBR) & miscarriage rates in the second cycle. For women < than 40: PR was 46.4% (368/793), miscarriage rate was 29.9% and the LBR was 32.5% (258/793). Women in groups I & II had a statistically higher PR than those in group III 63.3% v 55.2% v 41.9% respectively. LBR was higher 45% v 37.8 v 29.6% respectively. Miscarriage rate was similar. For women 40 years and older: The PR was 21.0% (73/348), miscarriage rate was 52.1% (38/73) and the LBR was 10.1% (35/348).There was no significant difference in PR among women in groups I, II & III. The LBR and miscarriage rates were similar in all groups. Young women who had a live birth and those who experienced an early miscarriage after IVF have a greater likelihood of achieving a live birth in a second cycle. Outcome of first IVF cycle however does not predict subsequent IVF success in older women.

Bartholin's glands are prone to obstruction at their opening into the vestibule, forming cysts which could be infected to become gland abscess. In our unit, treatment of Bartholin's abscess is usually surgical. In addition to surgical treatment, antimicrobial agents are often administered before microbial culture results are known. In this study, we aimed to determine the most common pathogens in Bartholin's glands abscess in our local population so that empiric antimicrobial therapy, if required, could be correctly directed. Among the 78 cases reviewed, there was positive microbial culture in 73.9%. Bartholin's abscess was commonly caused by opportunistic organisms, either as single agents or polymicrobial infections. Aerobic organisms were the commonest with coliforms being the most common bacteria. No cases of N. gonorrhoea or C. trachomatis were encountered. Flucloxacillin as a single agent was the most frequently prescribed antibiotic. Poly-pharmacy was common practice. It was concluded that whether adjuvant antibiotic therapy is necessary following surgical treatment of Bartholin's abscess is still controversial. Where antibiotics are required, the optimal initial therapy is not known. As poly-microbial infections are common, a broad spectrum agent like co-amoxiclav may be suitable for empirical treatment until culture results are known.

Couples infected with HIV, hepatitis B virus (HBV) and hepatitis C virus (HCV) are increasingly seeking assisted conception. These couples avoid unprotected intercourse and use condoms at all times in order to minimize the risk of infecting their partner. As this practice inhibits pregnancy, assisted procreation is generally required for safe conception. For many couples, access to such services is restricted on ethical, geographical and financial grounds. The aim of the study was to assess the fertility needs, geographical origin and state funding of patients with blood-borne viral infection. A retrospective review of the medical records of couples referred for fertility treatment between January 1999 and December 2006, where one or both partners were infected with HIV, HBV and/or HCV, was carried out. Of the 205 couples included in the study, 44% lived in London, 51% came from elsewhere in the United Kingdom and 5% travelled from outside the United Kingdom to seek treatment. Genitourinary medicine clinics were the main source of referral. 85.8% of couples had HIV infection, 15.1% were infected with HBV and 13.6% had HCV infection. Fertility screening identified a high incidence of male factor infertility (33.3%) in HIV-infected men and tubal disease (40.8%) in HIV-infected women. Only 23.6% of HIV-infected couples, 20% of HBV-infected couples and 12.5% of HCV-infected couples obtained state funding for assisted conception. Fertility screening identified a high incidence of male and tubal factor subfertility among couples living with HIV, HBV and HCV. Limited access to specialist clinics equipped to cater for these couples and restricted funding may impact negatively on couples obtaining risk-reducing assisted reproduction treatment. This may have long-term public health implications as individuals attempt to conceive through unprotected intercourse.

Background The relationship between elevated basal FSH and embryo quality remains a topic of heated discussion among practitioners of ART. Some authors suggest a negative effect of raised FSH on the quality of embryos and therefore on IVF treatment outcome. We postulate that women with elevated FSH who respond well to ovarian stimulation and have embryos to transfer, have the same chance of conceiving like women of a similar age with normal FSH. To test this hypothesis, we studied women with elevated basal FSH who made enough embryos to qualify for blastocyst culture and day 5 embryo transfer. Methods Analysis of data collected prospectively, on women age 25–43 years, who underwent IVF between January 2005 and December 2006. The women were divided into: those with high FSH (≥10 IU/L) and women with normal FSH ( 10 IU/L. In this group, there was no significant difference in the pregnancy and live birth rates between women with elevated and those with normal FSH, (67.2% vs 65.6%) and (51.9% vs 43.8%) respectively. In this selected group of women where quantity is not an issue, the quality of embryos was same irrespective of whether the basal FSH was low or high. Conclusion Women with elevated basal FSH who respond well to stimulation and generate a good number of oocytes / embryos have a chance of becoming pregnant and having a live birth similar to that of women of their age. Women should therefore not be denied the benefits of IVF based solely on the basal FSH level as a subset may respond well and therefore have a good chance of taking home a baby.

Intrauterine retention of foetal bones is an uncommon but recognised complication of late termination of pregnancy. Secondary subfertility, abnormal uterine bleeding and vaginal discharge are the usual presenting complaints. We report a case of prolonged retention of foetal bones for 14 years in a woman who presented with chronic pelvic pain. Hysteroscopic examination was diagnostic and therapeutic. Retained foetal bones are an uncommon intrauterine cause of chronic pelvic pain that should be considered particularly when a woman with a history of late termination presents with pelvic pain. Hysteroscopic evacuation is curative.

To investigate changes in the ratio of T-cell subpopulations expressing intracellular T helper1 (Th1) and T helper 2 (Th2) cytokines in women with a history of recurrent failed implantation under going in-vitro fertilization (IVF)-embryo transfer. Twenty-eight peripheral blood samples were obtained at two time points, from 14 women undergoing IVF treatment; eight women with a history of recurrent failed implantation, who did not get pregnant in the index IVF cycle and six who had one or more previous successful IVF pregnancy and who became pregnant in the index IVF cycle. The proportion of lymphocytes expressing interferon-gamma (IFN-gamma), tumour necrosis factor-alpha (TNF-alpha), and interleukin 4 (IL-4) and the Th1:Th2 ratios of IFN-gamma:IL-4, and TNF-alpha:IL-4 in T helper cells was measured by flow cytometry, in samples obtained before commencing IVF treatment and in samples obtained after ovarian stimulation (on the day of oocyte retrieval). In samples collected during oocyte retrieval, women with a history of recurrent failed implantation had a higher IFN-gamma:IL-4 and TNF-alpha:IL-4 ratio than the control group, (18.6+/-9.3 versus 6.47+/-1.68, P=0.009) and (39.1+/-15.7 versus 11.53+/-3.76, P=0.001) respectively. In women with a history of recurrent failed implantation the ratio of IFN-gamma:IL-4 and TNF-alpha:IL-4 at oocyte retrieval was higher than pre-treatment ratios (18.6+/-9.3 versus 12.01+/-9.8, P=0.018) and 39.10+/-15.7 versus 18.66+/-11.42, P=0.010) respectively, showing a Th1 bias. In women with a successful IVF the converse was true; the ratio at oocyte retrieval was significantly lower than pre-treatment ratios (6.47+/-1.68 versus 9.37+/-6.8, P=0.035) and 11.53+/-3.76 versus 18.60+/-12.9, P=0.027) respectively, representing a Th2 bias. Women with a history of unexplained recurrent failed IVF treatment have a Th1 bias and this polarization is more enhanced following hormonal manipulations during IVF treatment. Comparing pre-treatment ratios of IFN-gamma:IL-4 and TNF-alpha:IL-4 to ratios obtained at oocyte retrieval may be clinically useful. Women with recurrent failed IVF have increasing ratios.

Premature ovarian failure (POF) generally describes a syndrome consisting of amenorrhea, sex steroid deficiency, and elevated/menopausal levels of ganadotropins in a woman aged more than two standard deviations below the mean age at menopause estimated for the reference population. Numerous questions relating to this condition remain unanswered, and several important management issues are yet to be addressed. The challenges posed by this important condition range from difficulties with nomenclature to the absence of standardized diagnostic criteria and management guidelines. In the present paper we discuss the management of spontaneous premature ovarian failure, highlight the challenging issues, review the current literature and propose a practical management outline based on our local practice. Women with POF have unique needs that require special attention. There is an urgent need for a more suitable terminology and evidence-based guidelines on which to establish the diagnosis and manage this difficult condition.

Objective To evaluate the effectiveness of pre-clinic request of investigations to facilitate diagnosis in couples referred to the infertility clinic and to assess patient satisfaction of the concept. Study design Prospective cohort study with analysis of patient satisfaction questionnaire. Investigation packs were sent to patients in advance of their clinic appointment. These contained written explanation about various fertility tests to enable patients to have investigations before their first clinic appointment. The results should then be available at the time of consultation enabling a diagnosis to be made at their first clinic visit. Results Eighty percent (43/54) of couples had completed all the investigations requested by the time of their clinic appointment. The full investigation results of 41 couples were available at the time of consultation. From the available results, a diagnosis could be reached in 76% of couples at the first clinic visit. Twenty-three percent of couples were not happy with the concept of pre-clinic investigation and would prefer to come to clinic first to discuss these tests, even if that meant a delay in diagnosis. There appears to be a trend in age, with those who were satisfied with the concept of pre-clinic investigation being older. Older women seem to have an increasing sense of urgency with advancing age. Conclusion While the concept of pre-clinic request of investigations may not be suitable for every couple it does allow for early initiation of treatment in selected patients.