Abstract

For women of advanced age with abnormally increased FSH levels, standardized hormonal stimulation often represents a cost-intensive procedure with a low success rate. It is well established now that with mild ovarian stimulation, there is a greater percentage of goodquality eggs (although a smaller number) than with higherdose conventional stimulation. Mild stimulation protocols reduce the mean number of days of stimulation, the total amount of gonadotropins used and the mean number of oocytes retrieved. The proportion of high-quality and euploid embryos seems to be higher compared with conventional stimulation protocols, and the pregnancy rate per embryo transfer is comparable. Moreover, the reduced costs, the better tolerability for patients and the less time needed to complete an IVF cycle make mild approaches clinically and cost-effective over a given period of time. The low number of embryos available for transfer poses a great challenge in the management of older women going in for IVF. A potential management of these older women is to create a sufficient pool of embryos by accumulating vitrified good-grade embryos over several minimal stimulation and natural cycles. At the end of the accumulation process, these embryos can be subjected to a preimplantation genetic screening using next-generation sequencing and then the pool would have only chromosomal normal embryos with maximal chances of implantation. This would potentially make the chances of success for older women similar to normal responders. This management, however, is unthinkable without an outstanding vitrification program. The option of accumulating embryos has become a promising reality with the advent of vitrification technologies.

Abstract

Objective: This study was carried out to determine the maternal (including thromboembolic and hemorrhagic complications) and fetal outcomes (including miscarriage, stillbirth, baby death, and live birth) in women with mechanical heart valves managed with therapeutic doses of unfractionated heparin (UFH) versus enoxaparin during pregnancy.

Methods: This is a prospective comparative, nonrandomized study. Pregnant women with mechanical heart valves presenting to high-risk pregnancy unit of Benha University Hospital, Egypt were treated with UFH 15,000 U/12 h versus enoxaparin (Clexane) 1 mg/kg SC/12 h during pregnancy and the results were analyzed.

Results: 40 pregnant women were included in the study. In 20 pregnant women, anticoagulation was with UFH, and 20 pregnant women received enoxaparin. One (3 %) thrombotic complication occurred with enoxaparin treatment. Noncompliance or subtherapeutic levels contributed to this outcome in this case. Antenatal hemorrhage occurred in 4 (10 %) and postpartum hemorrhagic complications in 5 (12.5 %) pregnancies. Of the 32 pregnant women who continued after 20 weeks’ gestation, 100 % (17/17) of the women taking predominantly UFH had a surviving infant compared with 93 % (14/15) of the women taking primarily enoxaparin (p = 0.25). One intrauterine fetal death occurred in the enoxaparin group. There was no significant difference in the live birth rates between the two groups (p = 0.31).

Conclusions: Compliance with therapeutic dose of UFH during pregnancy in women with mechanical heart valves is associated with a low risk of valve thrombosis and good fetal outcomes, but meticulous monitoring is essential.

Abstract

Background: The data on the prevalence of recurrent spontaneous miscarriage (RSM) in India are scarce. This study aimed to determine the prevalence of RSM in Indian females.

Methods: Female patients aged between 18 and 45 years with history of at least one spontaneous miscarriage were enrolled in the study. The probability of a subsequent miscarriage after the first, second, and third miscarriage was determined. The prevalence of RSM (defined as loss of >=3 pregnancies of <= 20 weeks gestation each) between different age groups was compared using x² test. Binary logistic regression analysis was applied to determine any association between RSM and the presence of risk factors.

Results: Of the 2398 patients screened for eligibility, 767 (32 %) had a history of at least one spontaneous miscarriage. The prevalence of RSM among the 753 enrolled patients who satisfied the eligibility criteria in the study was 7.46 %. RSM was mostly recorded in the age group of >= 33 years (14.68 %, n = 32). In patients with RSM, the second and third miscarriages were more prevalent during 7th week to end of 11th week of gestation. The probability of having a subsequent miscarriage after the first, second, and third miscarriage was 0.25, 0.34, and 0.22, respectively. There was a significant association (p < 0.05) between RSM and clotting disorders, immunological factors, infections, and genetic disorders.

Conclusion: The study revealed a higher prevalence of RSM among the Indian women as compared to western data. Age, clotting disorders, immunological factors, infections, and genetic disorders were the significant risk factors associated with RSM.

Abstract

Background: Congenital anomalies of the kidney and urinary tract in the developing countries have a poor prognosis due to limited experience in antenatal and postnatal management.

Patients and methods: A 3-year retrospective study was carried out from January 2011 to December 2013. The following data were collected and analyzed: maternal age, gravidity, parity, gestational age at diagnosis, and ultrasonography findings. Final diagnosis after birth, the performed surgeries, follow-up data, as well as survival at one year were also analyzed.

Results: The mean age of the included patients was 28 years (range 20–35 years). The mean parity was 1.7 (range 0–4). The mean gestational age at diagnosis was 26 weeks (range 15–36 weeks). Consanguinity was reported in 10 cases (24.4 %). There were 25 males and 16 females. Bilateral renal agenesis was the commonest type (19.5 %). The anomalies of kidneys and urinary tract in our cases were associated with other anomalies in 8 cases (19.5 %). Oligohydramnios was detected in bilateral renal agenesis and posterior urethral valve. Surgical interference during the first 6 months was performed in 6 cases; pyeloplasty for unilateral or bilateral hydronephrosis was performed in 5 cases; and excision of solitary renal cyst performed in one case. By the end of the first year, two of the three cases with chronic renal disease, who were under peritoneal dialysis, died, and three cases who had undergone pyeloplasty were lost to follow-up.

Conclusion: Among the 41 cases with antenatally diagnosed renal and urinary malformations; bilateral renal agenesis was the commonest anomaly (19.5 %). There were high rates of induction of abortion, IUFD, and neonatal deaths. The poor outcome may be due to lack of experience in performing invasive therapeutic fetal procedures.

Abstract

Aim: Aim of this study is to find out clinical relevance of estimating PON1 arylesterase activity, total oxidative stress (TOS), nitric oxide (NO), and vitamin C levels in maternal serum for prediction of birth weight of newborn.

Methods: We have investigated the PON1 arylesterase activity, TOS, NO, vitamin C, total protein, and albumin levels in 56 postnatal clinic patients having newborn weighing < 2500 gm (low birth weight) and compared with 56 postnatal clinic patients having newborn weighing > 2500 gm. Samples were collected immediately after delivery.

Results: PON1 arylesterase activity levels show significant decrease in cases as compared to controls (93.27 ± 13.76 kU/l vs. 112.77 ± 9.42 kU/l). Nitric oxide (nitrate ? nitrite) levels are also found to be significantly decreased in cases with respect to controls (22.89 ± 2.65 umol/l vs. 24.73 ± 3.80 umol/l). Total oxidative stress is significantly increased in cases than in control subjects (23.34 ± 2.64 lmol H2O2 equiv./l vs. ± 21.43 ± 2.47 lmol H2O2 equiv/l). Vitamin C levels are also significantly decreased in cases as compared to controls (1.23 ± 0.25 mg/dl vs. 1.34 ± 0.28 mg/dl). Positive correlation between neonatal birth weight and maternal serum PON1 arylesterase activity (r = 0.682, p\0.05) while negative correlation is obtained between neonatal birth weight and maternal serum oxidative stress (r = -0.478, p< 0.05). Logistic regression analysis is applied for assessing predictive utility which demonstrated a significant association of birth weight with PON1 arylesterase activity (AUC = 0.960, Naglekerke’s R2 = 0.793, p< 0.05)

Conclusion: Decreased arylesterase activity and antioxidant vitamin C levels with increased total oxidative stress in maternal serum may be considered as the additional risk factors for the development of low birth weight newborn.

Abstract

Objective: This study compares the efficacy of sequential clomiphene citrate (CC) ? Gonadotropin to that of Gonadotropin alone with ultrasound monitoring.

Methods: It is a retrospective analytic study done on a total of 100 couples to compare two groups receiving CC ? Gonadotropin and Gonadotropin alone for ovarian stimulation followed by intrauterine Insemination (IUI). We studied the cycle performance parameters. Cumulative pregnancy rates and ovulation rates were the primary outcomes. Results were analyzed following the intention-totreat principle.

Results: There were no significant differences with respect to indications and the numbers of dominant follicles recruited. The endometrial thickness was significantly better in Gonadotropin-alone group (P < 0.05). Ovulation rate was better for CC ? Gonadotropin at 95.91 %. Nine pregnancies were in the CC ? Gonadotropin group (18.36 %) and 17 in Gonadotropin-alone group (33.3 %).

Conclusions: Significant differences in pregnancy rates and endometrial thickness were seen. Gonadotropin alone thus appears to give better results, but CC ? Gonadotropin seems to be a cost-effective drug.

Abstract

The purpose of this study: This study was undertaken to evaluate the role of positron emission tomography–CT (PET–CT) in diagnosis and management of gynecological malignancies in primary and recurrent settings and also to investigate its role in inappropriately treated patients, for pretreatment evaluation (staging) to help in proper therapeutic management.

Method: This is a retrospective study of 56 patients of gynecological malignancy registered in Gujarat Cancer Research Institute from June 2011 to December 2013.

Results: Out of 56 cases where PET was done, the results were as follows: carcinoma cervix—23, carcinoma ovary—20, carcinoma endometrium—9, carcinoma vulva— 1, carcinoma vagina—2, and GTN—1. PET scan was negative in 37 % of patients where CT scan was suspicious, which changed the therapeutic modality and prevented further unnecessary interventions. In cases where clinical suspicion of recurrence was high based on rising tumor marker and CT scan was negative, subsequent PET– CT was able to pick up malignancy in 75 % cases. Eleven patients (25 %) with suspected recurrence with inconclusive CT scan and negative PET–CT scan were kept on follow-up, thus reducing further morbidity and cost.

Conclusion: Addition of PET-CT, a noninvasive method to the oncologist’s imaging armamentarium may ultimately improve both outcomes and costs by altering management strategies in primary and recurrent settings. The potential use of PET–CT appears promising in several decisionmaking steps in the management of patients with gynecological malignancy. It defines the extent of metastatic disease which enables the clinician to decide regarding salvageable surgical intervention or palliative measures.

Abstract

Introduction: Advanced fertilization techniques like frozen embryo transfer (FET) and assisted reproductive technology have become popular and commonly used methods to treat patients suffering from infertility. Incidences of infertility are on a rise due to increased representation of females in the work place, delay in marriages, stress, and ignorance.

Methods: We performed this prospective therapeutic study to compare FET and fresh embryo transfer in the treatment of infertility in terms of conception rate, patient acceptance, complications, and patient’s compliance. A prospective screening therapeutic study on 108 patients, from September 2013 to September 2014 in Karnataka, India, randomized the patients into 2 groups (n = 54), Group-I treated with day-3 FET while Group-II was treated with fresh embryo transfer, after performing ICSI.

Results: In 108 patients, 45 % patients were within 35 years of age, 35 % were in the age group 35–39. Significantly, 22 (40.75 %) patients treated with FET conceived (P = 0.022), whereas 16 (29.63 %) patients treated with fresh embryo transfer conceived (P = 0.59).

Discussion: There is limited published literature from the subcontinent, comparing techniques like FET and embryo transfers in the treatment of infertility. Awareness and economic reforms must be formulated in India to facilitate individuals facing infertility problems to conceive.

Conclusion: FET has better and significant conception rates compared to fresh embryo transfers. FET shares an advantage of providing good quality embryos for future and subsequent implantations in cases of failure. Patient counseling and motivation play a pivotal role in the success of therapeutic procedure.

Abstract

Study Objectives: This meta-analysis was performed to compare the outcomes between NACT-S andRT for locally advanced cancer cervix. The primary end points were survival benefits.

Searching Method: The data sources for the search included medline, national library of medicine, and the embase search engines. Inclusion criteria included studies published between 2000 and 2012, and FIGO stages IB2 to IVA. Studies had to be properly randomized, prospective, or retrospective and only phase III. Further, the studies had to be with two arms, including one arm for neoadjuvant chemotherapy then-surgery (NACT-S), and the other arm for radiotherapy (RT).

Results: Data were collected from 1171 patients enrolled in seven phase III trials. The 5-year PFS (progression-free survival) for NACT-S and RT were 62 and 45.5 %, respectively. The 5-year OS for NACT-S and RT were 66 and 49 %, respectively. NACT-S was associated with better late toxicities compared to RT.

Conclusion: NACT-S is a reasonable treatment option for locally advanced cancer cervix. It achieved better results than RT, especially for stages from IB2 to IIB.

Abstract

Introduction: Although the incidence of cancer cervix has reduced in India during the last two decades, still most of the patients presenting in tertiary care centers are in advanced stages.

Material and Methods: At this center, we see 6% of cancer cervix cases every year, and most of these cases are in stage III and IVa. All these patients have squamous cell carcinoma and were treated with a combination of external and intracavitary radiotherapy along with concurrent cisplatin given once weekly. Eightynine point nine % patients had achieved a complete response.

Results: Local recurrence was seen in 17.9% at a median duration of 10.5 months, and 8.17% developed distant metastasis involving lung, liver, bone, and supraclavicular lymph nodes. Three patients developed metastasis at unusual sites involving breast, paraspinal muscles, and duodenum which are very rarely involved. These patients were treated with chemotherapy using carboplatin and Paclitaxel combination but succumbed within 8–10 months of development of metastasis.

Conclusion: The cause of involvement of these unusual sites is not clear, but it may be hematological spread, and we want to share these reports such that these sites are seen during follow-up of patients of cancer cervix.

Abstract

Background Primary vaginal carcinoma is rare, accounting for 1–2 % of all gynecological malignancies. Being rare, most observations are based on retrospective and comparative analyses. This study was aimed to retrospectively analyze the prognostic factors and its relevance in the outcomes of primary vaginal cancers.

Materials Medical records of all cases of primary vaginal cancers, presented to Department of Oncology, from 2004 to 2012, at a tertiary care center in southern India, were retrieved from electronic medical records, and were analyzed.

Results The total number of cases was 32. Median age at presentation was 64.28 years. Squamous histology accounted for 84.4 %, with the rest being adenocarcinoma. Surgery was offered for five (15.6 %), and concurrent chemotherapy for 14 (43.8 %) patients. Three patients had only surgery. All others received radiotherapy. Twenty received external beam radiation (EBRT) and vaginal brachytherapy (VBT); seven only EBRT and two, adjuvant radiation. Five patients had residual disease; two, stage III, and three stage IV. Median follow-up was 55.83 months. Twelve patients were alive at last follow-up (37.5 %), while 14 were dead (43.8 %—8 of disease and 6 of other causes). Six patients were lost to follow-up (18.8 %). Twenty patients were disease free. Seven had recurrence, three loco-regional and four distant. Median overall survival (OS) was 86.1 months, disease-free survival (DFS) 90.17 months, and disease-specific survival (DSS) 97.13 months. When well and moderately differentiated tumors were taken together, the 5-year OS, DFS, and DSS rates were, 56.6, 64.3, and 82.3 %. For poorly differentiated tumors, median OS, DFS, and DSS were, 20.9, 14.6, and 20.9 months, with statistically significant advantage for better grade tumors, for DSS (p 0.050). Better 5-year OS, DFS, and DSS rates were observed for stage I ? II group, with 54.9, 79.8, and 78.9 %, compared with advanced stage where the same were 54.8, 38.2, and 68.6 % (DFS—p 0.003, DSS—p 0.009). Grade and stage of tumor had statistically significant predictive value over the outcomes, while tumor size showed a significant trend. Patients treated with combination of EBRT and VBT fared well.

Conclusion Our study could conclude that grade of differentiation was a significant predictor of poor survival as was stage of disease. Combination of VBT and external beam radiotherapy provides good DFS.

Abstract

Aim The data of survival for Indian cervical cancer patients treated by indigenous modifications of the protocol are scarce. The objective of this retrospective study was to analyze the efficacy and tolerability in patients of cervical carcinoma treated by neoadjuvant chemotherapy followed by concurrent chemoradiation.

Materials and Methods Three hundred and thirty two cases of squamous cell carcinoma of cervix who received 3 cycles of neoadjuvant chemotherapy followed concurrent chemoradiation were retrospectively analyzed for overall survival (OS), disease-free survival (DFS), and local pelvic control rate.

Results The 3-year OS and DFS were 93.7 % for stage I-B, 88.0 and 84.0 % for stage II-A, 82.8 and 79.7 % for stage II-B, 70.0 and 64.9 % for stage III-A, 59.3 and 52.4 % for stage III-B, and 53.6 and 32.1 % for stage IV-A disease. The 5-year OS and DFS rates were 93.7 and 87.5 % for stage I-B, 84.0 % for Stage II-A, 79.7 and 76.6 % for stage II-B, 67.6 and 59.5 % for stage III-A, 48.4 and 41.9 % for stage III-B, and 28.6 and 14.3 % for stage IV-A disease.

Conclusion Neoadjuvant chemotherapy followed by concurrent chemoradiation is feasible and produces impressive disease-free and overall survival. This protocol is especially helpful for busy cancer centers with long waiting lists on radiotherapy machines.

Abstract

Study objective: The objective of this study was to prospectively analyze the risks and benefits of total laparoscopic hysterectomy (TLH) compared with total abdominal hysterectomy (TAH) and the effects of learning curve on them over 4 years (March 2010–April 2014).

Design: It was a prospective randomized study.

Setting: The study was conducted in Delhi government hospital which had no staff with previous experience of advanced laparoscopic surgeries.

Patients: Two hundred fifty patients were operated on for benign gynecological conditions (35–65 years). The numbers of cases operated laparoscopically were as follows— 22 in 2010, 25 in 2011, 32 in 2012, and 46 in 2013. Equal number. of patients operated by open surgery were taken in the study during the same time period.

Results: Two hundred fifty cases were operated since March 2010, by either laparoscopic or open surgery. Incidence of major complications was—1.6 % for TLH compared to 4 % in TAH. After the first year of surgery, this incidence has fallen to 0 % in subsequent years in TLH group. The incidence of minor complications declined from 14 to 4.5 % in the third year of study. Total rate of conversion to laparotomy was 9.7 %, which again had a significant decline after the first year. TLH also clearly showed superior benefits of less intraoperative blood loss, early postoperative ambulance, and shorter period of hospital stay in comparison with TAH.

Conclusion: The study has led us to conclude that TLH is a safe, effective, and reproducible technique after the completion of a period of training necessary to standardize the procedure. This approach must be established in our real, day-to-day clinical practice.

Abstract

Background: The present study summarizes the results of treatment in the form of disease-free survival and overall survival in bulky stage IB2 and locally advanced (stages II–IVA) squamous cell carcinoma of the uterine cervix. The treatment has been given in the form of NACT followed by CCRT in one arm and CCRT in the other arm.

Materials and Methods: This retrospective study analyzed 713 cervical cancer patients who were treated at our center during 2007 and 2008; out of 713 patients, data of 612 patients have been compared. The patients’ data were analyzed retrospectively. Patients had undergone PF 28.6 %, TPF 21.5 %, and only CCRT 49.9 %. Majority of patients were in the age group 41–50 years, while stage wise, mainly stage IIIb and IIb. Disease-free survival was observed on the basis of stage and NACT. The survival analyses were performed using the Kaplan–Meier method. All statistical calculations were done with SPSS Statistics version 20.0.

Results: For cancer cervix NACT versus CCRT, the DFS rate was at 5 years (58.3 vs. 41.8 % p = 0.001). NACT followed by CCRT demonstrated significantly superior DFS as compared to definitive CCRT, respectively, TPF (hazard ratio (HR) = 0.248, 95 % confidence interval (CI) 0.123–0.500; p < 0.001), PF (HR = 0.445, 95 % CI 0.266–0.722; p = 0.002). The results of univariate stage, age, and multivariate study show that stage hemoglobin level, interval between external-intracavitary radiation, and type of neoadjuvant chemotherapy were the factors affected survival cervical patients treated with radiation. The grade 3/4 hematologic toxicities were more in the NACT group than CCRT (p < 0.001) while the non-hematological toxicity was not significant; the TPF group experienced more toxicity than PF (p = 0.029). This treatment regimen is feasible as evidenced by the acceptable toxicity of NACT and by the high compliance to radiotherapy. The grade 3/4 hematologic toxicities were more inNACT groups than CCRT (p < 0.001); the TPF group experienced more toxicity than PF (p = 0.029).

Conclusion: TPF/PF as NACT is feasible and produces impressive responses in cancer cervix.