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We present the case of a 30-year-old female with primary infertility who had multiple large myomas up to 22 weeks uterine size. She had a body mass index of 42 kg/m2 and also concurrent endometriosis, for which she was on medical management. After meticulous preoperative planning, total robotic myomectomy and endometriosis clearance was done. Four large myomas weighing a total of 750 g were removed after morcellation. Console time was 160 min, and she made an uneventful recovery with only 0.1 g/dL drop in hemoglobin. Robotic myomectomy is considered as an improvement over laparotomy for patients with up to three myomas and when the surgical time does not exceed 4 hours. We were successful in our attempt at total robotic myomectomy to extend these limits and had a positive surgical outcome.

Associations between anaesthetic techniques and pregnancy outcomes were assessed among 129,742 pregnancies delivered by caesarean section (CS) in low- and middle-income countries (LMICs) using two WHO databases. Anaesthesia was categorized as general anaesthesia (GA) and neuraxial anaesthesia (NA). Outcomes included maternal death (MD), maternal near miss (MNM), severe maternal outcome (SMO), intensive care unit (ICU) admission, early neonatal death (END), neonatal near miss (NNM), severe neonatal outcome (SNO), Apgar score

Anaemia during pregnancy is most commonly observed and highly prevalent in South-East Asia. Various effective programmes have been laid down for its management, mainly daily supplementation of iron folic acid (IFA) tablets. Following the same, standard obstetrical practice has included the IFA supplementation without requiring the determination of iron deficiency. In this study, a total of 120 primigravida (N = 60; non-anaemic (Hb > 11 g/dl) and N = 60 anaemic (Hb = 8–11 g/dl)) were selected among those attending the Antenatal Clinic in Department of Obstetrics and Gynaecology, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, India. They were supplemented with daily and weekly IFA tablets till 6 weeks postpartum. Corresponding changes in haemoglobin level on advance of pregnancy, side effects and compliance associated with daily and weekly IFA supplementation and its associations with iron status markers were studied. The inflammatory markers were also estimated. The statistical significance level (p

Background Pregnancy is associated with biochemical changes leading to increased nutritional demands for the developing fetus that result in altered micronutrient status. The Indian dietary pattern is highly diversified and the data about dietary intake patterns, blood micronutrient profiles and their relation to low birthweight (LBW) is scarce. Methods Healthy pregnant women (HPW) were enrolled and followed-up to their assess dietary intake of nutrients, micronutrient profiles and birthweight using a dietary recall method, serum analysis and infant weight measurements, respectively. Results At enrolment, more than 90% of HPW had a dietary intake below the recommended dietary allowance (RDA). A significant change in the dietary intake pattern of energy, protein, fat, vitamin A and vitamin C (P 2) = 3.16, P = 0.177]. Zinc (Zn) deficiency, magnesium deficiency (MgDef) and anemia ranged between 54–67%, 18–43% and 33–93% which was aggravated at each follow-up visit (P ≤ 0.05). MgDef was significantly associated with LBW [odds ratio (OR): 4.21; P = 0.01] and the risk exacerbate with the persistence of deficiency along with gestation (OR: 7.34; P = 0.04). Pre-delivery (OR: 0.57; P = 0.04) and postpartum (OR: 0.37; P = 0.05) anemia, and a vitamin A-deficient diet (OR: 3.78; P = 0.04) were significantly associated with LBW. LBW risk was much higher in women consuming a vitamin A-deficient diet throughout gestation compared to vitamin A-sufficient dietary intake (OR: 10.00; P = 0.05). Conclusion The studied population had a dietary intake well below the RDA. MgDef, anemia and a vitamin A-deficient diet were found to be associated with an increased likelihood of LBW. Nutrient enrichment strategies should be used to combat prevalent micronutrient deficiencies and LBW.

We present here a report, based on data obtained from six selected North Indian hospitals, on variations in the number of human deliveries over the period from 1 October 2010 to 30 September 2011. We tried to identify whether there are any cycles exhibited by the data. We discover cyclicity over different months of the year and days of the week whereas cyclicity over different phases of the lunar cycle is not clearly established.

The molecular mechanism of iron transfer across placenta in response to maternal anemic status/ iron supplementation is not clear. We hypothesized that maternal iron/ anemia status during early trimesters can be utilized as a biomarker tool to get estimates of placental iron status. Early interventions can be envisaged to maintain optimum placental/ foetal iron levels for healthy pregnancy outcomes. One hundred twenty primigravida were recruited and divided into non-anemic and anemic group on the basis of hemoglobin levels. The groups were randomly allocated to receive daily and weekly iron folic acid (IFA) tablets till six weeks postpartum. Hematological and iron status markers in blood and placenta were studied along with the delivery notes. Weekly IFA supplementation in anemic primigravidas resulted in significantly reduced levels of hematological markers (p

Background: To prevent post-partum hemorrhage the concept of active management of third stage of labour has been proposed which decreases the blood loss by 40-68%. The best preventive strategy is active management of the third stage of labour. The objective of the study was to study risk factors of postpartum hemorrhage and indications for caesarean section. Methods: A hospital based cross sectional study was carried out among 100 women at term for a period of one year. Pregnant women who are at term i.e. at 38-39 weeks of gestation were included in the study. Detailed history, clinical examination and investigations were carried out. Results: The mean pre pregnancy BMI in study group was 22.4±3.96. The majority of patients recruited were primiparous. Socio-demographic data shows that there was no statistical difference in place of residence, occupation and level of literacy between two groups. The prevalence of anemia among women at term was found to be 43%. The most common obstetric high risk factor was gestational diabetes mellitus in 10% followed by gestational hypertension in (6%). 71% of women underwent the emergency LSCS. The most common indication for LSCS was fetal distress in 29% of cases followed by mal-presentation in 12% of cases. Conclusions: The prevalence of anemia among women at term was found to be 43%. The different medical high risk factors were human immunodeficiency virus positive (asymptomatic diagnosed during pregnancy), Hepatitis B antigen positive, cardiovascular risk, hypothyroidism, epilepsy observed in the groups. Other high risk factors included asthma, Crohns disease, and systemic sclerosis.

Background: In India, caesarean section rate is rising, so the impact of prophylactic injection of tranexamic acid in decreasing blood loss during caesarean section would be more beneficial in terms of having minimal blood loss intra operatively and post operatively and thereby decreasing maternal morbidity. The objective of the study was to evaluate the efficacy of prophylactic tranexamic acid in reducing blood loss during and after caesarean section. Methods: A randomized controlled trial among 200 term women with singleton pregnancy for a period of 2 years was carried out. They were randomized by computer generated numbers into two groups: study group-100 women receiving prophylactic tranexamic acid women and control group-100 women receiving placebo. Results: The blood loss during caesarean section was less in the tranexamic acid group compared to the placebo group. Similarly blood loss measured 6hrs after caesarean section was less in the tranexamic acid group compared to placebo group. 20-40min before the time of incision was the ideal time gap for administering the injection tranexamic acid for its optimum efficacy. Tranexamic acid group had lesser requirement of uterotonic when compared to placebo, but need for blood transfusion was similar in both the groups. Greater fall in the hemoglobin and haematocrit occurred in placebo group compared to tranexamic acid group. No changes in the post-operative vitals or side effects were seen in the tranexamic acid group. Even no change in birth weight and Apgar scores was seen in neonates of tranexamic acid group. Conclusions: Injection tranexamic acid is the, antifibrinolytic agent that can be used for prophylactic administration before caesarean section for decreasing blood loss during surgery.

Summary Background Anaemia affects as many as half of all pregnant women in low-income and middle-income countries, but the burden of disease and associated maternal mortality are not robustly quantified. We aimed to assess the association between severe anaemia and maternal death with data from the WHO Multicountry Survey on maternal and newborn health. Methods We used multilevel and propensity score regression analyses to establish the relation between severe anaemia and maternal death in 359 health facilities in 29 countries across Latin America, Africa, the Western Pacific, eastern Mediterranean, and southeast Asia. Severe anaemia was defined as antenatal or postnatal haemoglobin concentrations of less than 70 g/L in a blood sample obtained before death. Maternal death was defined as death any time after admission until the seventh day post partum or discharge. In regression analyses, we adjusted for post-partum haemorrhage, general anaesthesia, admission to intensive care, sepsis, pre-eclampsia or eclampsia, thrombocytopenia, shock, massive transfusion, severe oliguria, failure to form clots, and severe acidosis as confounding variables. These variables were used to develop the propensity score. Findings 312 281 women admitted in labour or with ectopic pregnancies were included in the adjusted multilevel logistic analysis, and 12 470 were included in the propensity score regression analysis. The adjusted odds ratio for maternal death in women with severe anaemia compared with those without severe anaemia was 2·36 (95% CI 1·60–3·48). In the propensity score analysis, severe anaemia was also associated with maternal death (adjusted odds ratio 1·86 [95% CI 1·39–2·49]). Interpretation Prevention and treatment of anaemia during pregnancy and post partum should remain a global public health and research priority. Funding Barts and the London Charity.

Introduction In high-income countries, a reduced clinical threshold for obstetric interventions such as labour induction (LI) and prelabour caesarean delivery (PLCD) has played a substantial role in increasing rates of late preterm births. However, the association between provider-initiated delivery and perinatal outcomes have not been studied in a multicountry setting including low-income and middle-income countries. Methods 286 hospitals in 29 countries participated in the WHO Multi-Country Survey on Maternal and Newborn Health and yielded 2 52 198 singleton births of at least 34 weeks in 2010–2011. We used an ecological analysis based on generalised estimating equations under multilevel logistic regression to estimate associations between hospital rates of PLCD and LI with rates of late preterm birth (34–36 weeks), stillbirth and intrahospital early neonatal death, in relation to country development based on the Human Development Index (HDI). Results Rates of LI were higher in hospitals from very high-HDI (median 10.9%) and high-HDI (11.2%) countries compared with medium-HDI (4.0%) or low-HDI (3.8%) countries. Rates of PLCD were by far the lowest in low-HDI countries compared with countries in the other three categories (5.1% vs 12.0%–17.9%). Higher rates of PLCD were associated with lower perinatal death rates (OR 0.87 (0.79, 0.95) per 5% increase in PLCD) and non-significantly with late preterm birth (1.04 (0.98, 1.10)) regardless of country development. LI rates were positively associated with late preterm birth (1.04 (1.01, 1.06)) regardless of country development and with perinatal death (1.06 (0.98, 1.15)) only in middle-HDI and low- HDI countries. Conclusion PLCD was associated with reduced perinatal mortality and non-significantly with increased late preterm birth. LI was associated with increases in both late preterm birth and, in less-developed countries, perinatal mortality. Efforts to provide sufficient, but avoid excessive, access to provider-initiated delivery should be tailored to the local context.

Emergency contraception (EC) is a safe and effective method which is used to prevent unwanted pregnancy after unprotected sexual intercourse. Many of the unwanted pregnancies end in unsafe abortions. The search for an ideal contraceptive, which does not interfere with spontaneity or pleasure of the sexual act, yet effectively controls the fertility, is still continuing. Numerous contraceptive techniques are available, yet contraceptive coverage continues to be poor in India. Thus, even when not planning for a pregnancy, exposure to unprotected sex takes place often, necessitating the use of emergency contraception. This need may also arise due to failure of contraceptive method being used (condom rupture, diaphragm slippage, forgotten oral pills) or following sexual assault. Emergency contraception is an intervention that can prevent a large number of unwanted pregnancies resulting from failure of regular contraception or unplanned sexual activity, which in turn helps in reducing the maternal mortality and morbidity due to unsafe abortions. However, a concern has been expressed regarding repeated and indiscriminate usage of e-pill, currently the rational use of emergency contraception is being promoted as it is expected to make a significant dent in reducing the number of unwanted pregnancies and unsafe abortions. In fact, since the introduction of emergency contraception, the contribution of unsafe abortion towards maternal mortality has declined from 13 to 8 per cent.

The aim of this study was to assess the role of total serum estradiol on the day of injection HCG, estradiol per mature follicle, and estradiol per oocytes retrieved (OR) on clinical pregnancy rate (CPR) and oocyte/embryo quality in assisted reproduction.A retrospective review of 342 in vitro fertilization cycles with normal ovarian reserve in women who underwent long GnRH agonist protocol was included. The outcomes assessed are number of OR, number of mature oocytes (MO), number of oocytes fertilized (FO), fertilization rate, number of embryos cleaved (EC), cleavage rate (CR), number of Grade I embryos (E), number of cryopreserved embryos (CPE), and CPR. The Estradiol/follicle ratio (E2/fol) was defined as estradiol level per mature follicle 14 mm in diameter. Estradiol/oocyte (E2/O) ratio was defined as estradiol level per OR. These two ratios were categorized by the 25th percentile into four groups.A positive correlation was seen between E2/fol and OR (r = .334, p value = .0001), MO (r = .335, p value = .0001), FO (r = .222, p value = .002), and CPE (r = .289, p value = .0001). Increased CPR was seen in Group C (E2/fol = 200-299.99) compared to Group A, B, and D (p value = .033). With E2/O ratio, negative correlation was seen between E2/O and OR (r = -.281, p value = .002), MO (r = -.296, p value = .008), FO (r = -.220, p value = .003), EC (r = -.211, p value = .004), Grade 1 embryo (r = -.216, p value = .001), and CPE (r = -.206, p value = .005). No difference in FR, CR, or CPR was seen. No difference was seen in CPR with total serum estradiol.In conclusion, serum estradiol is an important determinant of IVF success. While total serum estradiol does not exert any positive or negative influence on IVF outcome, estradiol per mature follicle and retrieved oocytes do have an impact. Pregnancy rate is better when E2/fol is between 200 and 299.99 pg/ml. Also, increasing serum E2/fol positively correlates with better oocytes and embryo quality. In contrast, E2/O negatively correlates with oocytes and embryo quality parameters.

Diagnostic hysteroscopy is a vital tool and a gold standard to evaluate the uterine cavity. The aim of this study was to estimate the prevalence of unsuspected intrauterine abnormalities. This cross-sectional study was done involving 870 asymptomatic, infertile women enrolled for IVF, who underwent a transvaginal ultrasound followed by office hysteroscopy. The presence of uterine cavity abnormalities was recorded. Transvaginal sonography revealed abnormal findings in 113 patients (12.9 %). Hysteroscopy confirmed the ultrasound findings in 76 (67.3 %) women with no obvious findings seen on hysteroscopy in 37 (32.7 %). Among the 757 women, who had a normal pelvic scan, abnormal findings were observed in 108 (14.2 %) on hysteroscopy, while the remaining 649 (85.7 %) patients had normal findings on hysteroscopy. Thus, a total of 184 (21.1 %) patients had confirmed abnormalities that required to be treated before performing IVF/ICSI. The present study highlights the relatively higher prevalence of intrauterine abnormalities in our patient population. Diagnosing and treating these abnormalities are imperative to improve the success of IVF treatment. Therefore, a routine diagnostic hysteroscopy in these patients becomes mandatory before proceeding with expensive procedures such as assisted reproduction.

The objective of this study was to determine whether ovarian reserve markers can predict ovarian response in women undergoing their first cycle of assisted reproduction. This prospective observational study included 292 infertile patients undergoing their first IVF trial in the Assisted Reproductive Unit in a tertiary care hospital. Day 2 follicle stimulating hormone (FSH), Inhibin B, anti-Mullerian hormone (AMH), antral follicle count (AFC) and ovarian volume was measured before commencement of controlled ovarian hyperstimulation. The main outcome measures were oocytes retrieved and this was correlated with ovarian reserve markers. The mean age was 31.8 (±4.4) years and mean duration of infertility 8.2 (±3.9) years. The correlation between oocytes retrieved and age, day 2 FSH, Inhibin B, AMH, AFC and volume of the ovary was calculated. A negative correlation was found with age (r = −0.22, p

Mitochondrial DNA (mtDNA) of oocyte is critical for its function, embryo quality and development. Analysis of complete mtDNA of 49 oocytes and 18 blastocysts from 67 females opting for IVF revealed 437 nucleotide variations. 40.29% samples had either disease associated or non-synonymous novel or pathogenic mutation in evolutionarily conserved regions. Samples with disease associated mtDNA mutations had low fertilization rate and poor embryo quality, however no difference in implantation or clinical pregnancy rate was observed. Screening mtDNA from oocyte/blastocyst is a simple, clinically reliable method for diagnostic evaluation of female infertility and may reduce risk of mtDNA disease transmission.

Objective To evaluate the extent to which stillbirths affect international comparisons of preterm birth rates in low- and middle-income countries. Design Secondary analysis of a multi-country cross-sectional study. Setting 29 countries participating in the World Health Organization Multicountry Survey on Maternal and Newborn Health. Population 258 215 singleton deliveries in 286 hospitals. Methods We describe how inclusion or exclusion of stillbirth affect rates of preterm births in 29 countries. Main outcome measures Preterm delivery. Results In all countries, preterm birth rates were substantially lower when based on live births only, than when based on total births. However, the increase in preterm birth rates with inclusion of stillbirths was substantially higher in low Human Development Index (HDI) countries [median 18.2%, interquartile range (17.2–34.6%)] compared with medium (4.3%, 3.0–6.7%), and high-HDI countries (4.8%, 4.4–5.5%). Conclusion Inclusion of stillbirths leads to higher estimates of preterm birth rate in all countries, with a disproportionately large effect in low-HDI countries. Preterm birth rates based on live births alone do not accurately reflect international disparities in perinatal health; thus improved registration and reporting of stillbirths are necessary. Tweetable abstract Inclusion of stillbirths increases preterm birth rates estimates, especially in low-HDI countries.

To evaluate the role of umbilical cord serum (UCS) and autologous serum (AS) therapy in reepithelialization of corneal graft after keratoplasty in a randomized controlled trial. A total of 105 eyes with epithelial defect (ED) after keratoplasty (penetrating keratoplasty—67 and anterior lamellar keratoplasty—38) on the first postoperative day were included in the study. The eyes were randomized into three groups: UCS (n=35), AS (n=35), and artificial tears (AT) (n=35). All patients received standard postoperative medical therapy. The primary outcome measure was time to epithelialization, and secondary outcome measures were best-corrected visual acuity and graft clarity. The ED healed completely in 103 eyes. The mean time for complete reepithelialization was 2.5±2.1, 3.1±2.2, and 4.5±1.4 days in UCS, AS, and AT groups, respectively. The mean percentage decrease in the size of the ED was significantly better in the UCS and AS groups as compared with the AT group (P=0.001). The rate of reepithelialization was comparable between the AS and UCS groups (P=0.3). On bivariate analysis, significant correlation was found between the mean size of postoperative ED, grade of the donor cornea (P=0.001), and the presence of preoperative ED (P=0.001). No complications were associated with the use of serum therapy. Most of the cases of postkeratoplasty corneal ED can be managed with AT only. The serum therapy (AS/UCS) helps in the faster reepithelialization of postkeratoplasty ED as compared with AT and may be considered as a treatment option for early epithelial healing.

Emergency contraception is a safe and effective method to prevent an unwanted pregnancy after an unprotected or inadequately protected sexual intercourse. Several methods for emergency contraception (EC) are currently registered in many countries for use in an emergency to prevent a pregnancy following an unprotected, possibly fertile intercourse or after a contraceptive accident like condom rupture. Different methods have varying modes of action, time frame of efficacy, dosage schedule and unwanted effects. Since several methods are available it is important to decide the best method.In this article the available literature on emergency contraception has been reviewed and an attempt has been made to discuss the need for emergency contraception and compare different options for emergency contraception in terms of their efficacy in pregnancy prevention, their safety profile and unwanted side effects. EC repeated use and initiating a regular method after EC use are also discussed.Emergency contraceptive methods include copper Intra-uterine devices (IUD) and different types of pills like estrogen progestin combination pill (Yuzpe Regimen), Progestin only pill (LNG), antiprogestin pill (Mifepristone), and progesterone modulator Uripristal Acetate (UPA). There is a marginal difference in the mechanism of action, efficacy including time frame and ability to protect from pregnancy with regular doses in obese women, drug interactions and side effects. These are discussed in detail.Copper IUD is the most effective emergency contraceptive with advantage of providing continued contraception. However, it cannot be used universally due to lack of infrastructure and a trained provider as well as not being suitable option for women at risk of sexually transmitted infections. Amongst different pills LNG is more effective with fewer side effects than Yuzpe regimen. LNG and UPA are comparable with similar efficacy and side effect profile. UPA has a wider window of efficacy, in LNG efficacy declines after 72 hours. UPA is more suitable for obese women. Mifepristone is effective but is registered as EC pill only in few countries and use is limited as it is also used as an abortion pill. Yuzpe regimen is the least effective of all contraceptive pills as EC, and works only till 72 hours of unprotected sex, but is useful in places where dedicated methods are not available, as it is easily accessible. Any combined pill can be used in this regimen except triphasic pill.

Male infertility is a multi-factorial disorder, and identification of its etiology in an individual is critical for treatment. Systematically elucidating the underlying genetic causes (chromosomal and Yq microdeletion) and factors, such as reactive oxygen species (ROS) levels and total antioxidant capacity (TAC), which contribute to sperm DNA damage, may help to reduce the number of men with idiopathic infertility and provide them with the most suitable therapeutics and counseling. This study was done to comprehensively investigate genetic and oxidative stress factors that might be the etiology of a large percentage of men with idiopathic infertility. One hundred twelve infertile men and 76 fertile controls were screened for chromosomal aberrations and Yq microdeletions. ROS, TAC, and sperm DNA damage were assessed in cytogenetically normal, non-azoospermic men with intact Y chromosome (n = 93). ROS was assessed in neat and washed semen by chemiluminescence; seminal TAC with a commercially available kit; and sperm DNA damage by the comet assay. Two men had cytogenetic abnormalities and seven men harbored Yq microdeletions. ROS levels in neat and washed semen of infertile men were significantly higher (P

Malondialdehyde (MDA) is widely used as oxidative stress biomarker in biomedical research. Plasma is stored in deep freezers generally till analysis. Effect of such storage on MDA values, which may be variable and prolong, was incidentally observed in the ongoing study which is to estimate oxidative stress with oral iron. Plasma from blood samples of pregnant women (20-30 years age) in third trimester of singleton pregnancy (n = 139), consuming oral iron tablets was stored at -20 °C with intention of MDA estimation, as soon as possible. However logistic problems led this storage for prolonged and variable period (1-708 days). When values of MDA estimated using "Ohkawa" 79 method and readings were plotted against time to check the temporal effect, it showed a hyperbolic curve. Standard deviation (SD) was lowest when samples were tested within 3 weeks time. The samples analyzed within 3 weeks had mean ± SD value of 31.59 ± 26.11 μmol/L, while 123.7 ± 93.97 and 366.5 ± 189.8 μmol/L for samples stored for 1-3 and 4 months to 1 year respectively. Mean ± SD were 539.9 ± 196.8 in the samples store for more than a year. Rate of change in values was also lowest (0.0433 μmol/L/day) in the samples tested within first 3 weeks, which rose to 1.2 μmol/L/day during 3 month's storage. This rate peaked at storage of 120 days (1.87 μmol/L/day) and fell to 0.502 μmol/L/day in the second year of storage. It is concluded that at -20 °C, only 3 weeks of storage time should be considered valid for fairly acceptable stability in MDA values.

To determine whether there is any improvement in the endometrial receptivity in infertile women with Asherman’s syndrome undergoing hysteroscopic adhesiolysis. This was a prospective observational clinical analysis of 40 infertile patients who underwent hysteroscopic adhesiolysis for Asherman’s syndrome in a tertiary level hospital. Endometrial thickness and blood flow impedance of the uterine spiral artery by transvaginal color pulsed Doppler ultrasound was measured post-menstrual on day 2/3 and post-menstrual on day 21 pre- and post-hysteroscopic adhesiolysis or at a randomly chosen time in patients with amenorrhea. The age of the patients was 18–36 years (mean 29.2 years). The mean duration of infertility was 6.9 years. There were 27 (67.5 %) women with primary infertility and 13 (32.5 %) had secondary infertility. 22 (55 %) women had had genital tuberculosis in the past. A significant improvement in the endometrial thickness was observed on day 2 (p

Objective: To study patient perception of pain and anxiety before and after amniocentesis (AC) and transabdominal chorionic villus sampling (CVS) and the clinical correlates of pain and anxiety. Methods: 92 women underwent AC and 78 CVS. Visual analog scale was used to quantify pain and anxiety, immediately before and after the procedure. Factors which could affect pain and anxiety were noted. Results: The pain and anxiety anticipated before the procedures were significantly less than actually perceived. The pre-procedure anxiety did not correlate with post-procedure pain. There was no correlation between anticipated pain or anxiety and age, parity, education, socioeconomic status, and history of procedure in previous pregnancy in both the AC and CVS groups. Post-procedure pain did not correlate with age, parity, education, socioeconomic status, abdominal scar, placental location, number of needle insertion, repeat procedure or abdominal wall thickness in either group. However, on multiple linear regression the overall post-procedure pain was associated with the number of needle insertions. Conclusion: Though pre-procedure pain and anxiety levels are high, most patient experience less pain and anxiety after the procedure.

To correlate ovarian response to stimulation and IVF outcome according to the women's body mass index (BMI).Records of all patients who underwent IVF cycle in our institution from January 2008 to October 2010 were reviewed retrospectively. Three hundred and twenty-eight patients underwent 342 in vitro fertilization (IVF) cycles or intra-cytoplasmic sperm injection (ICSI) and were divided into four subgroups according to BMI; underweight, BMI 18.5; normal weight, 18.5-24.9; overweight, 25.0-29.9; and obese,30.0.In our study, with increasing BMI negative co-relation was seen with clinical pregnancy rate (CPR) (P value = 0.040). Increased doses of gonadotropins were required with increase in patients BMI (P value = 0.045). In the present study, no difference was seen in the number of oocyte retrieved but a decreased fertilization and cleavage rate was seen with decreased number of cryo-preserved embryos with increasing BMI. This study shows that poorer oocyte quality is seen with increasing BMI which results in reduced CPR. In our study no deleterious effect of low BMI was seen on IVF outcome and CPR.Female obesity impairs IVF outcome potentially by impairing oocyte quality but does not affect ovarian response to stimulation.

Aims and Objectives : To evaluate the role of endometrial thickness, pattern and sub-endometrial blood flows measured by 2D power Doppler ultrasound to predict pregnancy during in-vitro fertilization (IVF) treatment. Study Design : Prospective, non-randomized clinical study. Materials and Methods : This was a prospective observational study. A total of 101 infertile women were recruited from our IVF-ET program from January to December, 2009. Women with tubal factor, male factor and unexplained infertility were included in the study. Results : The mean age was 35 years and mean duration of infertility was 8 years. Seventy five (74.25%) patients had primary infertility and 26 (25.74%) had secondary infertility. The mean endometrial thickness was 8.1 mm and endometrial blood flow was in Zone I in 18 patients, 28 patients had blood flow in Zone II and 54 had in Zone III. Overall, 27 (26.73%) patients conceived and in these women the endometrial thickness was between 6 and 12 mm. Conclusions : With a thin endometrium (≤7 mm) and no-triple-line endometrial pattern coexisting in an in-vitro fertilization/intracytoplasmic sperm injection (IVF/ICSI) candidate, cryopreservation should be recommended. With a thin endometrium and a good texture (triple-line), other prognostic factors, such as embryo quality, should be taken into account. The endometrial vascularity has a useful predictive value on the implantation rate in IVF cycles irrespective of the morphological appearance of the endometrium. However, further study is needed to make a definitive conclusion.

Study Objective To compare the analgesic efficacy of lignocaine gel–soaked Silastic bands compared with rectal diclofenac suppositories in patients undergoing interval laparoscopic sterilization under conscious sedation. Design Prospective, randomized, controlled, single-blinded, clinical trial. Setting Day-case center in a tertiary care hospital in India. Patients Ninety-six women undergoing interval laparoscopic sterilization using Silastic bands (Yoon rings) randomly allocated by computer-generated random numbers into 3 groups. Interventions All women received intravenous sedation with injection diazepam and pentazocine along with local infiltration lignocaine injected at the site of the incision meant for insertion of the single site laparocator. In group 1 (n = 32), the Silastic bands (Falope rings) were presoaked in 2% sterile lignocaine gel; in group 2 (n = 32), women received a 100-mg rectal diclofenac suppository while on the operating table; and women in group 3 received only conventional analgesic. Pain perception was assessed using an 11-point visual analog score just after the procedure while still on the table (zero minutes), at 30 minutes and 1 hour after the procedure, and at discharge. Measurements and Main Results The women in all 3 groups were comparable insofar as age and parity. At zero minutes (while on the operating table), the pain score in all 3 groups was similar. However, the pain scores at 30 and 60 minutes, and at discharge were significantly lower in groups 1 and group 2 compared with group 3. However, 2 women (6.25%) in group 2 and 6 (18.75%) in group 3 required supplemental analgesia within 1 hour, and were administered a 500-mg oral dose of mefenamic acid. The need for further analgesia was significantly lower in groups 1 and 2 compared with group 3 (p = .02). Comparison of groups 1 and 3 revealed that in group 1, the pain scores were significantly lower at 30 minutes (p = .02), 1 hour (p = .005), and at discharge (p = .004). No patients in group 1 requested analgesia, whereas 6 women in group 3 asked for further analgesia within an hour postoperatively (p = .01). Similarly in groups 2 and 3, women who received diclofenac suppositories had significantly lower pain scores at the specified intervals (p = 0.02, 0.002, and 0.02, respectively). Conclusion Application of lignocaine gel to Falope rings and preoperative insertion of a rectal diclofenac suppository are simple and effective measures for pain control in the early postoperative period in patients undergoing day-case laparoscopic sterilization under conscious sedation. Either method could be incorporated into routine practice, depending on patient and physician choice.

Purpose To explore differential gene expression between autologous eutopic and ectopic endometrium and the effect of phases, infertility, and severity of disease on this. Methods cDNA arrays followed by post hoc analysis for 1190 selected human genes were performed to analyze transcript expression in autologous eutopic and ectopic endometrial samples obtained from 6 proven fertile and 4 subfertile volunteers with endometriosis (stage 3: n=5; stage 4: n=5) during either the proliferative (n=7) or secretory (n=3) phase. Results cDNA-based expression array analysis appeared sensitive, precise, and reliable in unsupervised analysis and quantitative RT-PCR. Sample clustering analysis revealed maximal cluster coefficient (C=0.8) between eutopic and ectopic clusters for all pairs, followed by that yielded by phases of cycle (C=0.6); fertility history (C=0.3), and stages of severity (C=0.3) had marginal effects. Of 42 genes showing differential regulation in pooled analysis, 3 genes (CAGA, MT2A, and VIM) were up-regulated and 39 genes including EPHA2, FOXM1, HPSE, ITGA5, ITGAE, ITGB3, PAEP, and TGFBR1 were down-regulated in ectopic endometrium. The high transcript number of AFP, ALOX15, F2RL1, and PRKCG in proliferative phase eutopic endometrium appears to be a potential biomarker for endometriosis. Conclusions Differential expression of specific genes appeared as distinguishing features for ectopic endometrium compared with eutopic endometrium; many of them might be associated with poor cellular integrity of endometriotic cells. However, ectopic endometrium did not show overt molecular indication of tumorigenic potential.

Objective To compare the efficacy of manual vacuum aspiration (MVA) with electric vacuum aspiration (EVA) and to evaluate whether cervical priming with misoprostol facilitates cervical dilation and reduces complications associated with first-trimester medical abortion performed up to 10 weeks of pregnancy. Methods A total of 600 women who requested termination of pregnancy were randomized into 4 groups (150 women in each group). Group I and II received a vaginal placebo 3 hours before MVA or EVA, respectively. Group III and IV received 400 μg of vaginal misoprostol 3 hours before MVA or EVA, respectively. Results Complete abortion rates after MVA and EVA were both 97.9%; after cervical priming with misoprostol complete abortion rates were 98.6% versus 97.3% after cervical priming with placebo ( P > 0.05). Administration of misoprostol into the vagina before MVA resulted in 99.3% complete abortions ( P = 0.40), and the least operative blood loss, operating time, and need for cervical dilation ( P P > 0.05). Conclusion For surgical evacuation, EVA and MVA did not differ in efficacy. Cervical priming 3 hours before MVA for termination of pregnancy significantly reduced the need for cervical dilation and the operative time, and improved the efficacy of the procedure. Pretreatment with vaginal misoprostol before MVA is a safe and effective method for terminating pregnancies of up to 10 weeks of gestation. Clinical Trials Registry: CTRI/2009/091/000008

Objective: The study objective was to evaluate use of oxidized regenerated cellulose (Surgicel®) for epithelialization of neovagina in vaginal agenesis. Design: A prospective, longitudinal study (Canadian Task Force classification II-2) was conducted at a tertiary care center. Method: Ten (10) women (ages: 17–25 years) with vaginal agenesis, undergoing surgical construction of vagina over a period of 2 years, were included in the study. The surgical technique involved creation of a neovagina by modified Sheares technique, followed by use of a foam mold covered with a condom and further wrapped in oxidized cellulose to aid epithelialization. The main outcome measures evaluated were effectiveness and complications (if any) with the use of oxidized cellulose for epithelialization of neovagina. Results: There were no intraoperative complications. Adequate vaginal length (7–10 cm) was achieved in all cases on foam mold removal. On follow-up at 6 months, all vaginas were well epithelialized. One (1) pa...