Fertility NEWS LETTER

Ideal fertility : ICSI / IVF & Genetic Center India

Dear Colleges
Hello

Premature rupture of membrane is one of the very important issue in obstetrics, esp. when it is remote from term (PPROM). Rupture of membrane takes away the shield for the fetus and exposes it or vaginal flora and infection.

Infection is the most clearly recognized and more widely studied cause of preterm birth. Infection is responsible for between 20-40% of all cases of preterm birth, and this variation depends on the criteria used for the diagnosis of infection. The most rigorous criteria are positive cultures or demonstration of bacterial fingerprints by polymerase chain reaction in the amniotic fluid. The less stringent criterion is the presence of leukocytic infiltration in the placenta. The evidence demonstrating that intrauterine infection is a cause of preterm birth is overwhelming and involves positive cultures indicating bacterial colonization and invasion of the chorioamnion, the amniotic fluid , and the fetus; histological demonstration of infection in the placenta, membranes and umbilical cord; and hematological and biochemical findings consistent with infection..

Color Doppler is one the finest tool in the assessment of growth retarded fetus. Evaluation of systolic and diastolic blood flow and their ratio in umbilical artery and the middle cerebral artery gives us a great idea about the fetal compromise and the risks.

There is a topic on CA-125 by one of our colleague Dr.Sarika Sharma .I welcome it .

With warm regards
Sincerely Yours
Dr. D’Pankar Banerji

1. Identifying  Chorioamnionitis

There are mainly three criteria, which tell that there is infection and there are chances of premature labor, or should we do conservative treatment in cases of PROM.

1. WBC count
2. C-reactive protein estimation
3. Fetal biophysical profile, esp. fetal breathing movements

Laboratory and biophysical tests are widely used to predict the development of infection in women with PPROM. A commonly used test is the maternal leukocyte count (WBC) at the time of admission to the hospital.WBC greater than 12,000/cmm had a 67% sensitive the and 82 % positive predictive value for the disgonsi of amniotic infections. But is confusing as more than 12,000 WBC with neutophila may be normal, and injection of steroids for fetal pulmonary maturity causes an immediate increrase in WBC count.

A useful blood test is the determination of C-Reactive Protein (CRP), a substance that increases markedly in patients with infection and inflammation. The upper limit of normal CRP concentration during pregnancy is 0.9 mg/dl with no variation due to gestational age. Women with acure chorioamnionitis usually have CRP values above 3.0 or 4.0 mg/dl and women with subclinical infection or inflammation exhibit values between 0.9 and 3.0 mg/dl. But the CRP has some limitations too. CRP is highly specific for the diagnosis of intrauterine infection, with CRP elevation usually occurring  1-3 days before the development of clinical signs. CRP concentration is not altered by administration of steroids. CRP is much better predictor of infection than the WBC. However it is prudent not to make the diagnosis of chorioamnionitis infection on the basis of CRP concentration alone by rather the diagnosis of acute infection requires the presence of fever and diagnosis of subclinical infection requires amniocentesis.

Fetal biophysical activities help a lot to identify the presence of intrauterine infection. The absence of fetal breathing and gross body movements during a 30 minutes period of observation was associated with chorioamnionitis in almost 100 % of the cases. When fetal breathing movements were present for at least one episode lasting 30 or more seconds during a 30 minutes periods the possibility of infection was less than 5 %. First manifestations of the impending fetal infection may be nonreactive NST and the absence of fetal breathing movements. Even the efficacy of amniotic fluid gram staining may be inferior to daily BPP in predicting the development of amnionitis.

2. Relation ship between Systolic /Diastolic(s/d) ratio of Umbilical artery and middle cerebral artery in late      pregnancy

• UA Doppler indicates presence or absence of placental resistance to the blood flow from the fetus to the placenta and has a strong correlation with the acid/base balance of the fetus.
• Measurement of interest is UA s/d ratio.
• Simple rule to remember is that the UA s/d ratio should be under 3.0 after 30 weeks of gestation.
• Evidence supporting a role for UA Doppler in surveillance of high risk pregnancy is robust.
• Middle cerebral artery Doppler shows minimal or absent diastolic flow showing high resistance to flow.
• During the initial stage of placental insufficiency UA diastolic flow decreases and s/d  ratio increases while the compensatory increase of the brain circulation causes increase in diastolic flow with resulting decrease in the MCA S/D ratio.
• When MCA s/d ratio decreases than the UA s/d ratio then it is called brain sparing effect or centralization of flow.
• Centralization of the flow is not an indicator of fetal hypoxemia or acidosis, but a compensatory state of appreciable placental blood flow resistance.
• Fetal anemia can be measured by Peak systolic blood flow in middle cerebral artery in Rh negative sensitized pregnancy

3. Capsule on CA-125 Dr.Sarika Sharma MS ( ObGy )

• CA 125 is a high molecular weight surface glycoprotein
• It is an antigenic determinant derived from coelomic epithelium and mullerian duct
• Its normal level is < 35 U / ml
• Mainly used to differentiate between a benign ovarian mass and a malignant epithelial ovarian mass
• It is elevated in 80% of patients with epithelial ovarian cancers particularly non mucinous tumours
• But unfortunately, this antigen is also detectable in a variety of benign conditions like fibroid, endometriosis, pregnancy, pelvic inflammatory disease, ectopic pregnancy, adenomyosis, ovarian cyst adenomas, liver disease, pancreatitis, peritonitis, renal failure, luteal phase of menstrual cycle and even in 1% of normal individuals!
• Serum CA 125 levels can be used during chemotherapy to follow these patients whose level were positive at the initiation of therapy. The change in level correlates with response
• the levels frequently become undetectable after the initial surgical resection and one or two cycles of chemotherapy
• Positive levels are useful in predicting the presence of disease, but negative levels are an insensitive determinant of the absence of disease
• The predictive value of the positive test was 100% during follow up
• But if the level was less than 35 U/ml during follow up, 44% of patients had disease at 2nd look surgery
• If levels are  persistently elevated after 3 cycles of chemotherapy, they most likely have resistant clones and if level rise after treatment, the disease has comeback and the treatment has failed

4. Fellowship course in Reproductive endocrinology and Infertility

Program :

Day 1 :

Theory :
Basic reproductive endocrinology of female, Understanding of Hypothalamo-pituitary-gonadal axis

Practical :
Microscopy, stereozoom, trinocular, micro-photography and documentation ,inverted microscope and micromanipulator introduction.

Day 2 :

Theory :
Introduction to cell biology and cell division and cell culture, Meiosis and Gametogenesis,  Culture media preparation

Practical :
Tissue culture media preparation for IUI

Day 3 :

Theory :
Basic endocrinology of Male, Hormonal control of Spermatogenesis

Practical :
Routine semen analysis, sperm preparation methods for IUI, hands on

Day 4 :

Theory :
Anovulation and Polycystic ovaries ,Hirsutism

Practical :
Preparation of culture dishes and droplet making under oil.

Day 5 :

Theory :
Amenorrhoea ,How to deal with it.

Practical :
Hands-on retrieval of mammalian eggs and their in vitro maturation.

Day 6 :

Theory :
Induction of Ovulation for IUI and IVF

Practical :
Observation and demonstration of Cryo preservation techniques

• Theory classes will be from  9.30am to 11.00am.
• Candidates can repeat their practical, if they wish
• Candidates will be involved in daily OPD infertility counseling and treatment approach from 11-4 . They will see and do transvaginal sonography (as patients allow).
• They will be allowed to observe IVF and ICSI procedures done during their stay. They will have access in embryology laboratory to see the lab set up and equipments and exposure to embryology ( observation), fertilization to blastocyst stage and embryo transfer.
• Fees : Rs .25,000 per candidate. Students** : Rs.15,000
• One or Two  candidates are allowed in one batch
• Course will be from Monday to Saturday of a week.
• Certificate of attendance will be given at the end of the course
• Prior registration is must with full payment( demand draft in the name of Dr.D'Pankar Banerji,payable at Jabalpur)
• Stay and food is extra. Stay @ Rs. 500-1500/day can be arranged in nearby hotels within one kilometer of the venue

Faculty :
Dr.D'Pankar Banerji, Consulting Gynecologist and Infertility specialist
Dr. Mrs. Rinku Banerji ,Consulting Pathologist and Embryologist

Venue : Ideal Fertility, ICSI,IVF and Genetic center, Jabalpur
Depending on the availability of cases.
Student, applies to undergraduate medical students and residents. A letter from the Head of the Department proving the participant’s student status must accompany each student registration

Sale :
CO2 Incubator Minicellmate, GenX USA , 6yrs old Rs. 1,00,000 ( working condition)
Logiq XP ,Color Doppler,2005 with three probes ( TV/TR, Abdominal Sector,and Linear) in excellent condition at Rs. 7,00,000( owner going for 4-D machine).