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Article
Role of Low-Dose Human Chorionic Gonadotropin Following Clomiphene Citrate in Folliculogenesis and Ovulation in Infertile Women

Authors: Omaima I. Khalaf --- Manal T. Al-Obaidi --- Lubna A. Al-Anbari
Journal: Iraqi Journal of Embryos and Infertility Researches المجلة العراقية لبحوث الأجنة والعقم ISSN: eISSN: 26166984 / pISSN: 22180265 Year: 2018 Volume: 8 Issue: 1 Pages: 29-37
Publisher: Al-Nahrain University جامعة النهرين

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Abstract

Background:Ovulation disorders, usually presents as menstrual disturbance, arethe cause of infertility in around 25% of couples who have difficulty to conceive.The drug most commonly prescribed for the induction of ovulation is clomiphenecitrate (CC). If the patient does not ovulate after the use of CC, the choice wasto add gonadotropins. Gonadotropin therapy is very expensive with significantrisks of high order multiple gestations and ovarian hyperstimulation syndrome.Human chorionic gonadotropin hCG can function as a surrogate for LH and occupiesLH receptors for more than 24 hours allowing prolonged stimulation alsoit has longer half-life and greater affinity for the LH receptor.Objective: The purpose of this study was to compare the effectiveness of lowdosehuman chorionic gonadotropin (hCG) in the late follicular phase to induceovulation in clomifene citrate resistant patients who had previously failed toovulate on clomiphene citrate (CC) alone.Subjects,Materials and Methods: A total of 71 patients who attend infertilityclinic in the High Institute of Infertility Diagnosis and Assisted ReproductiveTechnologies, Al-Nahrain University, where prospectively randomly assignedinto two groups. hCG Group received 100 mg dose of CC from day 5 of menstrualcycle for 5 days, then each patient received 200 IU hCG (DICLAIR®)subcutaneous injection daily when the largest follicle mean diameter was 12 mmor larger starting on day twelve of menstrual cycle. Non-hCG group received 150mg dose of CC from day 5 of menstrual cycle for 5 days, and both groups weremonitored with transvaginal ultrasound. Ultrasound measurements of folliclenumber and growth, ovulation, endometrial thickness and pattern were recordedand compared between the two groups. Student t test and fisher exact test wereused for statistical comparison between the two groups.Results: The low-dose hCG group had significantly higher percentage of ovulatorycycles (80% vs 44.4% P value 0.006). There was no significant difference inthe endometrial thickness between the groups but it appears higher in hCG group(10.55±1.82 vs. 9.62 ± 1.87 in non-hCG group, p value 0.056). Non significantbut higher incidence of echogenic (luteinized) endometrium 48 hour post ovulationin hCG group (36/40 (90%) vs. 20/25 (80%) for non-hCG group p-value =0.288).Conclusions: The use of low-dose hCG after CC in the late follicular phase resultsin continued follicle growth, higher ovulation rate. This treatment offers anefficient and cost-effective alternative before gonadotropin therapy for this typeof patients.


Article
Role of Endometrial Scratch in Enhancing Pregnancy Rate of ICSI Cycle Through Its Effect on TNF-α

Authors: Wasan A. Abdulhameed --- Manal T. AL-Obaidi --- Fadya K. AL-Jorani
Journal: Iraqi Journal of Embryos and Infertility Researches المجلة العراقية لبحوث الأجنة والعقم ISSN: eISSN: 26166984 / pISSN: 22180265 Year: 2018 Volume: 8 Issue: 2 Pages: 1-6
Publisher: Al-Nahrain University جامعة النهرين

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Abstract

AbstractBackground:The overall success rate of assisted reproductive techniques is onlyabout 30% due to certain limiting factors. Endometrial scratching could induceinflammatory response which manifested by the up-regulation of different cytokinesand chemokines with subsequent accumulation of immune cells in the injuredsite. One of the most important cytokine in this regard is TNF-α which wasfound to induce tissue remodeling by stimulating the production of many otherpro-inflammatory cytokines.Objectives:To investigate the role of endometrial injury during the luteal phasebefore ICSI cycles in the enhancement of pregnancy outcomes.Materials and Methods:This prospective study was undertaken in the High Instituteof Infertility diagnosis and Assisted Reproductive Techniques / Al-NahrainUniversity. All women were undergone ICSI cycles. Women in the intervensiongroup underwent endometrial scratching with a Pipelle catheter in luteal phasepreceding cycle. Blood sample was taken before scratch. All patients undergocontrolled ovarian hyperstimulation, oocyte retrieval and embryo transfer, anotherblood sample was taken at day of embryo transfer to measure level of TNF-α.Clinical pregnancy rate then evaluation after luteal support of two weeks.Results:The patients in scratch group has higher pregnancy rate (14/23) 60.9%than non intervention group (11/33) 33.3% although not significant (p value0.057).The results showed that the TNF-α after scratch (54.53±10.2) was significantlyhigher than before scratch (39.26±14.74) in the same group, as p value was( <0.001). In addition the TNF-α was significantly higher in scratch group(54.53±10.2) than control (25.91±9.08) as p value was (< 0.001) .Conclusion:Induced endometrial local injury is an easy, simple and cost-effectivetechnique that can be used to improve the uterine receptivity and enhanceembryo transplantation.


Article
Evaluation of Serum TNF-α in Insulin Resistant Non PCOS Pa - tients Undergoing ICSI: A Randomized Clinical Trial

Authors: Manal T. Al-Obaidi --- Mohammad O. Selman --- Manar Alhoda Z. Al-Faqheri
Journal: Iraqi Journal of Embryos and Infertility Researches المجلة العراقية لبحوث الأجنة والعقم ISSN: eISSN: 26166984 / pISSN: 22180265 Year: 2018 Volume: 8 Issue: 2 Pages: 27-35
Publisher: Al-Nahrain University جامعة النهرين

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Abstract

Background:With the rapid evolution of assisted reproductive technologies,more and more studies are concerned about the possible influential factors onthe success rates of these procedures, with the efforts are now mainly directedtoward defining these factors in a trial to increase these rates. Of these factors,inflammation is considered among the most remarkable and is in the focus ofthe updated studies. However, most of these studies are evaluating the role ofinflammation in patients with polycystic ovarian syndrome(PCOS) , while theimpact of this inflammation in insulin resistant non PCOS patients is underestimatedand not well evaluated .Objectives:This study is a trial to elucidate the importance of one of the inflammatorymediators , Tumor Necrosis Factor-alpha (TNF – α) , in insulin resistantpatients undergoing IVF ( ICSI ) cycles .Patients and Methods:A group of 27non-PCOS infertile patients were selectedfor this clinical randomized prospective study from patients attending thehigh institute for infertility diagnosis and assisted reproductive technologies /Al-Nahrain University and subjected to intra-cytoplasmic sperm injection (ICSI)procedure. BMI was measured for all patients and they were classified accordingto WHO classification into 3 groups : Acceptable , overweight and obese . Fastingplasma level of glucose and insulin was investigated and insulin resistanceindex (HOMA) was calculated. Serum TNF-α has been measured using ELISAand the relation with insulin resistance was investigated. Finally, the pregnancyrate, as a primary reproductive endpoint was compared according to TNF -a andinsulin resistance levels between different study subjects.Results: Of the 27 infertile patients , 17(63 %) were non obese and 10 (37%)were obese , 15(55.5%) were having HOMA index < 1.6 and 12 (44.5 %) werehaving HOMA index ≥ 1.6 . BMI was found to be positively correlated with higherHOMA index ( P = 0.01 and R= 0.4 in spearman correlation). Investigating therelation between TNF-α with BMI revealed that TNF-α levels are increasing withthe increment in BMI, However , the difference in the mean TNF-α between thethree BMI groups failed to achieve statistical significance (P=0.1). In contrastto that, when stratifying for HOMA index , TNF-α was significantly correlatedwith it ( spearman correlation R= 0.4 , P=0.01 ) , and patients with HOMA index≥1.6 were found to have higher levels of TNF-α (The effect of insulin resistance was also implicated on pregnancy rates , as those with highinsulin resistance were shown to have significantly lower pregnancy rates when compared tothose with low indices of resistance (P = 0.03) . However, the impact TNF-α on pregnancyrates was apparently less significant (P= 0.5).Conclusion: Rate of asymptomatic bacterial vaginosis was 32.6 % in pregnant women comparedto 73.3% in non- pregnant group, being highly significant higher in those women whofailed to get pregnant.

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