It is well established in the literature that anti-Mullerian hormone (AMH) is one of the most reliable tests to predict response to controlled ovarian hyperstimulation. Low AMH levels (< 6 pmol/l) ...

To evaluate if AMH levels can be used as a predictor for response to ovulation induction with clomiphene citrate. To assess if there is any correlation between the AMH levels in anovulatory women and the dosage of clomiphene citrate needed to achieve ovulation. Prospective cohort study. 100 consecutive women undergoing ovulation induction with Clomiphene citrate in St Helier hospital were studied. All the womenwould had their AMH levels checked before commencing clomiphene citrate. All of them undergo follicular tracking in their first cycle by serial Trans vaginal ultrsonogram (response is defined as the confirmation of ovulation either by collapsed leading follicle or day 21 progesterone in women who missed their last scan appointment). If there was no response to 50 mg of clomiphene then the dose is increased to 100mg in the next cycle with follicular tracking. If no response is observed despite of 100mg of clomiphene citrate (non responders) further management is then individualised depending on the clinical situation. Data was collected regarding their age, ethnicity, BMI, type and duration of infertility, presence of PCOS, use of metformin, hormone profile and AMH value. Data was then analysed with appropriate statistical tests. The difference in mean AMH level was statistically significant between the two groups(29.8 vs 70, P value <0.003) Various AMH cut off levels as a predictor for resistance to ovulation induction with clomiphene were plotted on the ROC (receiver operating characteristic) curve. The AMH level of 40 and above is found to be a good predictor with a sensitivity of 85% and a specificity of 80%. Despite a small sample a significant trend was seen between the AMH levels and response to ovulation induction.A specific cut off value to predict response may influence future management plan in this subgroup of women.

PROBLEM: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.METHOD OF STUDY: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).RESULTS: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.CONCLUSION: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.

OBJECTIVE:To study the serum and peritoneal fluid cytokine profiles in infertile women with minimal/mild active endometriosis.METHODS:Fifty-seven consecutive infertile women undergoing laparoscopy for unexplained infertility had peritoneal fluid and serum samples obtained at the time of laparoscopy. The levels of interleukin-6 (IL-6), interleukin-8 (IL-8), interleukin-1 beta (IL-1 beta), vascular endothelial growth factor (VEGF), tumor necrosis factor-alpha (TNF-alpha), monocyte chemotatic protein-1 (MCP-1), RANTES, platelet derived growth factor (PDGF), soluble Fas (sFas), and soluble Fas Ligand (sFasL) in peritoneal fluid and serum were measured to compare the concentration in both biological fluids, in women who have minimal/mild red endometriosis using women with no endometriosis as controls.RESULTS:Peritoneal fluid levels of MCP-1, IL-8 and IL-6 were significantly higher in the endometriosis group (P < 0.012, P = 0.003, and P = 0.015, respectively). There was no significant difference in the peritoneal fluid levels of IL-1 beta, TNF-alpha, RANTES, VEGF, PDGF, sFas and sFasL in the two groups. Although serum levels of IL-8 were higher in women with endometriosis, the difference was not significant (P = 0.07). Serum levels of PDGF, IL-6, RANTES, IL-1 beta, TNF-alpha, and sFas, were not significantly different in the two groups.CONCLUSION:The elevated levels of MCP-1, IL-6, and IL-8 in peritoneal fluid but not serum may indicate the importance of local macrophage activating factors in the pathogenesis of endometriosis.

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.

Intestinal obstruction in pregnancy is rare and difficult to diagnose. Common causes of gestational intestinal obstruction include adhesions, volvulus, intussuscetion, carcinoma, hernia and appendicitis [3]. Abdomial pain is a comman feature, but the displacement of abdominal organs as pregnancy progresses results in atypical location of the pain and hence delay in diagnosis. We report a case of intestinal obstruction at 33 weeks gestation in a woman with previous appendicectomy. Clinical suspicion of the presence of obstruction is required for prompt diagnosis and aggressive intervention, to minimise the morbidity and mortality of this rare complication of pregnancy.

Complete loss of vision on the delivery suit is a worrying and unusual experience for patients and clinicians. Sudden total blindness, associated with confusion and hemiparesis is even more so, and this is what obtains in Posterior Reversible Leucoencephalopathy Syndrome (PRES).PRES is a recently recognized syndrome characterized clinically by headache, altered mental status, seizures, cortical blindness and other focal neurological signs, with imaging findings of bilateral cortical and subcortical changes on CT and MRI.This syndrome has been reported in a number of clinical conditions characterized by either an acute elevation of blood pressure or treatment with certain drugs. We report a case of cortical blindness, altered mental status and hemiparesis in a 34 year old woman with severe pre-eclampsia complicated by PRES in the puerperium. Abnormalities were demonstrated on CT and MRI with persistent unusual ischemic hyperintensity on T1 weighted MRI imaging thought to correspond with a specific reactive astrocytosis unlike that seen in typical infarction or hemorrhage.It is important for clinicians to be aware of this rare complication of pre-eclampsia, as early recognition will facilitate treatment and prevent permanent neuronal damage.

This fourth best practice review examines four series of common primary care questions in laboratory medicine are examined in this review: (1) safety monitoring for three common drugs; (2) use of prostate-specific antigen; (3) investigation of vaginal discharge; and (4) investigation of subfertility. The review is presented in question - answer format, referenced for each question series. The recommendations represent a precis of the guidance found using a standardised literature search of national and international guidance notes, consensus statements, health policy documents and evidence-based medicine reviews, supplemented by Medline Embase searches to identify relevant primary research documents. They are not standards but form a guide to be set in the clinical context. Most of them are consensus based rather than evidence based. They will be updated periodically to take account of new information.

This review will discuss the investigation of infertility, with emphasis on laboratory testing and reference to the value of other investigations, including clinical and radiological. The role of laboratory investigations is viewed within an appropriate clinically directed pathway that includes medical, surgical, and social history together with environmental factors. Because embryology and assisted reproduction techniques are developing rapidly and produce continuous changes in everyday practice, this article gives a critical review of the plethora of tests that are currently used.