Background: Polycystic ovarian syndrome (PCOS) is the most common cause of anovulatory infertility worldwide. In addition to a poor conception rate, pregnancy loss rates are significantly higher (30-50%) during the first trimester in women with PCOS. Insulin resistance (IR) in this syndrome is not only implicated toward early pregnancy loss (EPL) but also pathognomic for various obstetrical complications during pregnancy. We evaluated the role of Metformin in the reduction of EPL in women with PCOS who conceived spontaneously or after induction ovulation with or without Metformin. Objective: The primary objective was to evaluate the effectiveness of Metformin in the reduction of EPL in women with PCOS. Secondary outcomes like gestational diabetes, pregnancy-induced hypertension and intrauterine growth restriction were also analyzed at the end of the study. Material and Methods: This case-control study was conducted from March 2005 to March 2008 in the infertility and antenatal clinics of the Department of Obstetrics and Gynecology of Aga Khan University Hospital, Karachi, Pakistan. A total of 197 infertile women with PCOS were included. 'Cases' were women with PCOS who conceived while taking Metformin and it whom it was continued throughout pregnancy. 'Controls' were women in whom Metformin was either stopped in first trimester after confirmation of pregnancy (by serum beta HCG or by ultrasound) or they conceived spontaneously without the use of Metformin. Results: All 197 women in this study had a confirmed diagnosis of PCOS (Rotterdam criteria). These women were followed till the final outcome of pregnancy was achieved. Both groups were compared for risk of EPL. It was found that continuation of Metformin during pregnancy reduces EPL, i.e. 8.8 vs. 29.4% in cases and controls, respectively (p < 0.001). In the subset of women with a prior history of miscarriage, the pregnancy loss rate was 12.5% in the Metformin versus 49.4% in control group (p = 0.002). Conclusion: Metformin continuation during pregnancy significantly reduces EPL in women with PCOS. IR may play a significant role in EPL. Copyright (C) 2009 S. Karger AG, Basel

Acute bleeding after delivery can be a life-threatening complication. Emergency hysterectomy is usually undertaken as a last resort. This study was conducted in order to estimate the incidence, indications, risk factors and complications associated with peripartum hysterectomy performed at a tertiary care hospital. We retrospectively analysed 39 of 45 cases of emergency peripartum hysterectomy performed at the Aga Khan University Hospital from 1997–2006. Peripartum hysterectomy was defined as one performed for a haemorrhage after delivery which is unresponsive to other treatments. The most frequent indications for peripartum hysterectomy were morbidly adherent placenta (46%) and uterine atony (23%). The duration of surgery was shorter ( P = 0.045) but the complications were higher ( P = 0.029) in total compared with subtotal hysterectomies. Our results suggest that caesarean deliveries are associated with an increased risk for peripartum hysterectomy, which is of concern given the increasing rate of caesarean deliveries. Subtotal hysterectomy is a reasonable alternative in emergency obstetric hysterectomy.

No guidelines exist for the continuous use of metformin during pregnancy by women with polycystic ovarian syndrome (PCOS), thus the ideal duration of treatment is unknown. This case-control study compared pregnancy outcomes in 105 infertile women with PCOS who conceived while taking metformin to those of 32 women with PCOS who conceived spontaneously without metformin; all study patients received care at antenatal clinics in Pakistan from 2005 to 2006. Cases were categorized into 1 of 3 groups based on duration of treatment: group A, 40 women with PCOS who stopped metformin between 4 and 16 weeks of gestation; group B, 20 women who used the drug until 32 weeks of gestation; and group C, 45 women who continued metformin until delivery. The mean dose of metformin in all 3 case groups was 1.5 gm/d, and the 3 groups were matched for age, height, and weight. The incidence of pregnancy complications, including intrauterine growth restriction, and the live birth rates in the 3 study groups and the control group were compared. There were no miscarriages in group C compared with 20% and 10% in groups A and B and 18.7% in controls. The rate of pregnancy-induced hypertension/preeclampsia was 38.4% in the controls and 43.7% in group A, 33% in group B, and 13.9% in group C (P < 0.02). The rate of gestational diabetes requiring insulin was 19.2% in the controls and 18.7%, 33.3%, and 2.5% in groups A, B, and C (P < 0.004), respectively. The incidence of intrauterine growth restriction rate was significantly lower in group C (2.2%; P < 0.05) compared with groups A (21.8%) and B (16.6%) and the controls (19.2%). Preterm delivery occurred less frequently and the live birth rate was higher in group C compared with groups A and B and the controls. There were no major birth defects, stillbirths, or perinatal deaths among the study groups. This is one of the few studies evaluating the safety and effectiveness of metformin in women with PCOS according to its duration of use during pregnancy. The investigators believe that these results demonstrate the safety of this agent in pregnancy.

Kahraman, S. 212 Kamei, T. 24 Kanayama, S. 133 Karger, T. IV Karlikaya, G. 212 Karša, M. 222 Kavanagh, J.J. 35 Kawaguchi, R. 133 Kaya, M. 217 Kikuchi, A. 73, 116 Kim, D.Y. 62 Kim, H.S. 62 Kim, J.C. 62 Kim, J.W. 41 Kim, S.K. 41 Kim, S.W. 123 Kim, Y.-H. 62 Kitanaka, T. 133 Kliucinskas, M. 32 Kobayashi, H. 133 Kollender, Y. 89 Kostirova, M. 47 Kozuma, S. 116 Kriplani, A. 84 Ku, J.H. 62, 123 Kulaš, T. 222 Kumbak, B. 212

Introduction: We aimed to determine pregnancy and miscarriage rates following intracytoplasmic sperm injection (ICSI) cycles using retrieved epididymal and testicular sperm in azoospermic men and ejaculated sperm in oligospermic and normospermic men. Materials and Methods: This retrospective study was carried out on 517 couples who underwent ICSI. They included 96 couples with azoospermia and 421 with oligospermia or normal sperm count in the male partner. Of the men with azoospermia, 69 underwent percutaneous epididymal aspiration (PESA) and 47 underwent testicular sperm extraction (TESE). In the 421 men with oligospermia or normal sperm count, ejaculated sperm was used for ICSI. The differences in the outcomes of ICSI using PESA or TESE and ejaculated sperm were evaluated. The main outcome measures were pregnancy and miscarriage rates. Results: No significant differences were seen in pregnancy and miscarriage rates with surgically retrieved and ejaculated sperm. The pregnancy rates (including frozen embryo transfer) were 43.5%, 36.2%, and 41.4% in couples with PESA, TESE, and ejaculated sperm, respectively (P = .93). The miscarriage rates were 16.7%, 23.5%, and 12.1%, respectively (P = .37). Conclusion: Intracytoplasmic sperm injection in combination with PESA and TESE is an effective method and can successfully be performed to treat men with azoospermia. The outcomes with these procedures are comparable to ICSI using ejaculated sperm.

Background: Polycystic ovarian syndrome (PCOS) is a common endocrine disorder which causes anovulatory infertility. Obesity is one of the factors which directly modifies the clinical, biochemical and metabolic expression of this syndrome. Recently a genetic association of PCOS with intrafamily marriages has been postulated. This study investigates the association of environmental factors such as BMI and intrafamily marriages with the clinical, biochemical and hormonal features of this syndrome. Objective: To determine the relationship of different clinical, biochemical parameters and hormonal assay with the BMI of women who are known to have PCOS, and to compare these demographic features with intrafamily marriages. Material and Methods: From January 2005 until December 2006, patients attending the infertility clinic at Aga Khan University Hospital, Karachi, were evaluated for their clinical features. Couples were divided into 2 groups: group A had a history of first-degree intrafamily marriages, and group B had none. Complete biochemical evaluation was performed by day-2 serum FSH, LH, prolactin, testosterone and fasting serum insulin levels. The results were recorded on a data collection form. Ultrasonic evaluation was performed with transvaginal ultrasound to check the morphological appearance of the ovaries. A modified glucose tolerance test with 75 g glucose was performed and the results were recorded as normal, impaired and abnormal. Insulin resistance was calculated using the HOMA index method. Results: During this period 203 patients were evaluated for demographic and biochemical features of PCOS. The prevalence of obesity was 70% with 59.3% women found to have hyperinsulinemia while 52.3% of patients had insulin resistance according to the HOMA index method. Univariate and multivariate analyses were used to compare the 2 groups. A linear relationship between oligomenorrhea, family history of diabetes, tonic LH, high fasting serum insulin levels, insulin resistance and an abnormal glucose tolerance test was revealed, keeping intrafamily marriage and BMI as dependent variables. In this population 48% of couples were in first-degree intrafamily marriages, suggesting the possibility of a high genetic predisposition for abnormal metabolic features beside ethnic predisposition. Conclusion: A linear relationship of high BMI and family marriages has been seen with insulin resistance, oligomenorrhea and impaired glycemic control. The number of obese women and the high rate of intrafamily marriages make our population genetically susceptible to metabolic complications.

Aim: Polycystic ovarian syndrome (PCOS) is one of the most common endocrinopathies in women of reproductive age. It is associated with hyperinsulinemia and insulin resistance which is further aggravated during pregnancy. This mechanism has a pivotal role in the development of various complications during pregnancy. In the past few years, metformin, an insulin sensitizer, has been extensively evaluated for induction of ovulation. Its therapeutic use during pregnancy is, however, a recent strategy and is a debatable issue. At present, evidence is inadequate to support the long-term use of insulin-sensitizing agents during pregnancy. It is a challenge for both clinicians and researchers to provide good evidence of the safety of metformin for long-term use and during pregnancy. This study aimed to evaluate pregnancy outcomes in women with PCOS who conceived while on metformin treatment, and continued the medication for a variable length of time during pregnancy.Methods: This case-control study was conducted from January 2005 to December 2006 at the antenatal clinics of the Department of Obstetrics and Gynecology, Aga Khan University, Karachi, Pakistan. The sample included 137 infertile women with PCOS; of these, 105 conceived while taking metformin (cases), while 32 conceived spontaneously without metformin (controls). Outcomes were measured in three groups of cases which were formed according to the duration of use of metformin during pregnancy. Comparison was made between these groups and women with PCOS who conceived spontaneously.Results: All 137 women in this study had a confirmed diagnosis of PCOS (Rotterdam criteria). These women were followed up during their course of pregnancy; data forms were completed once they had delivered. Cases were divided into three groups: group A, 40 women who stopped metformin between 4-16 weeks of pregnancy; group B, 20 women who received metformin up until 32 weeks of gestation; and group C; 45 women who continued metformin throughout pregnancy. All the groups were matched by age, height and weight. Comparison was in terms of early and late pregnancy complications, intrauterine growth restriction and live birth rates. In groups A, B and C the rate of pregnancy-induced hypertension/pre-eclampsia was 43.7%, 33% and 13.9% respectively (P < 0.020). Rates of gestational diabetes requiring insulin treatment in groups A and B were 18.7% and 33.3% compared to 2.5% in group C (P < 0.004). The rate of intrauterine growth restriction was significantly low in group C: 2.5% compared to 19.2% and 16.6% in groups A and B respectively (P < 0.046). Frequency of preterm labor and live birth rate was significantly better in group C compared to groups A and B. Overall rate of miscarriages was 7.8%. Controls were comparable to group A in terms of early and late pregnancy complications.Conclusion: In women with PCOS, continuous use of metformin during pregnancy significantly reduced the rate of miscarriage, gestational diabetes requiring insulin treatment and fetal growth restriction. No congenital anomaly, intrauterine death or stillbirth was reported in this study.

A teen aged girl with rapidly developing pelvic mass, associated with weight loss and left leg weakness, was evaluated and found to have Ewing's sarcoma of non-osseous origin from pelvis, which is a rare situation. She was treated by a multidisciplinary approach by surgery, chemotherapy and rehabilitation by physiotherapy to effective response.

Objective: To determine the prevalence of urinary tract injuries, identification of risk factors and methods employed for repair and their outcomes. Study Design: Cross-sectional study of patients who had urinary tract injuries during major obstetric and gynaecological surgeries at the Aga Khan University Hospital (AKUH) from 1985 to 2004. Material and Methods: Computer-generated discharge summaries of patients who underwent major obstetric and gynaecological procedures during the 20 years of study period were retrieved. Information was collected on data collection form, and entered in SPSS version 13 and analysed. Results: During the study period 12,567 obstetrics and 5,966 gynaecological procedures were performed. There were 3,910 abdominal hysterectomies, 984 myomectomies, 591 ovarian/ adenexal surgeries and 481 vaginal hysterectomies. Out of these 110 urinary tract injuries were identified, 71 (64.5%) were of the urinary bladder and 39 (35.5%) were ureteric in origin, 31 (43.6%) bladder injuries were sustained during caesarean sections while 40 (56.3%) were during gynaecological procedures. In obstetric cases there were two ureteric injuries, the other ureteric injuries were sustained during surgeries for benign gynaecological conditions. The prevalence of bladder and ureteric injuries in obstetric surgeries was 0.25 and 0.02%, respectively, whereas in gynaecological surgeries the prevalence was 0.7 and 0.6% for urinary bladder and ureteric injuries. These figures compare well with other published series. Conclusion: Urinary tract injuries are an uncommon occurrence but when they occur they have serious implications in terms of morbidity and litigation. The prevalence of urinary bladder and ureteric injuries observed in our review is comparable to previous reported international series. Of concern is the fact that most of the ureteric injuries were diagnosed post operatively which means that further vigilance and preventive strategies need to be designed.

Objective: To evaluate and compare the clinical, biochemical and ultrasonic features of infertile women with PCOS from the two infertility centers of Karachi, The Aga Khan University Hospital and Concept Fertility Centre.Study Design: Cross-sectional, analytical study.Place and Duration of Study: The Aga Khan University Hospital, and Concept Fertility Centre, Karachi, Pakistan, from January 2003 till December 2004.Patients and Methods: Patients attending the Infertility Clinics of Aga Khan University Hospital, Karachi and Concept Fertility Centre, Karachi, were evaluated for their clinical features. Complete biochemical evaluation was performed by day 2 FSH, LH, serum prolactin, serum testosterone and fasting serum insulin determination. These results were recorded on the data collection form. Ultrasonic evaluation was performed with transvaginal ultrasound to check the morphological appearance of ovaries.Results: A total of 508 patients were evaluated for epidemiological features of PCOS. Frequency of PCOS in the infertility clinic was 17.6% with high rate of obesity (68.5%) and hyperinsulinemia (59%). The highest rate of abnormal clinical, biochemical features were seen above BMI of 30.Conclusion: High rates of obesity, hyperinsulinemia and impaired glycemic control were seen in this series. It was demonstrated that high BMI had an association and correlation with abnormal clinical and biochemical features. Obese women with PCOS need more attention for their appropriate management.

OBJECTIVE:To identify factors influencing medical student participation in an obstetrics and gynaecology (OBGYN) setting.METHODS:This was a cross sectional study carried out on patients admitted in OBGYN wards of Aga Khan University Hospital, Karachi, Pakistan. A total of 250 patients consented to participate in this study.RESULTS:Eighty three percent of the people responded 'yes' to the question of being initially seen by a medical student. People who consented were 3.5 times more likely to know that their primary consultant was a teacher at a medical school i.e. they were initially aware that they were in a teaching hospital (p-value < 0.01). Additionally, people who did consent were 3.5 times more likely to have been admitted because of labour/delivery (p-value < 0.001) and 2.7 times more likely to have a monthly income of more than Rs. 20,000 (p-value < 0.05).CONCLUSIONS:A number of factors have been identified in our study along with proposed solutions. Identification of these potentially modifiable factors in the medical student-patient interaction is important to improve the involvement of medical students in the care of the patients.

The proximity of the urinary tract to the reproductive organs puts it at risk of injury and incontinence as a consequence of gynaecological surgery. Incontinence to urine after gynaecological surgery is distressing to both the patient and the surgeon; in particular, formation of a urinary fistula after surgery is seen as a disaster by both. It also has long-term medicolegal implications. In this review. the main emphasis is on the prevention, evaluation, diagnosis and management of urinary tract injury. Other causes of postoperative incontinence are addressed briefly.

While millennium development goals (MDGs) which are to be achieved by 2015 are admirable they ignore many treatable conditions causing disability and distress in womens lives. World Health Organization (WHO) in an attempt to move away from mortality-based indicators has advocated estimation of disease burden via disability adusted life years (DALYs). DALY calculations so far have excluded important gynaecological condition such as subfertility and have concentrated more on obstetrical conditions. To accurately assess health status in its wider context a measure of social or mental distress would be required as part of the measure of disability. (excerpt)

OBJECTIVE:To review practice of massive primary postpartum haemorrhage management and develop a protocol.METHODS:Cross-sectional study conducted at the Department of Obstetrics and Gynaecology at Aga Khan University Hospital, Karachi between January 1, 2003 and July 31, 2004. Women with primary postpartum haemorrhage and had blood loss > or = 1000ml were included in the study. Medical record files of these women were reviewed for maternal mortality and morbidities which included mode of delivery, possible cause of postpartum haemorrhage, supportive, medical and surgical interventions.RESULTS:Approximately 3% (140/4881) of women had primary postpartum haemorrhage. 'Near miss' cases with blood loss > or = 1500ml was encountered in 14.37% (20/140) of these cases. Fifty-six percent (18/32) of the women who had massive postpartum haemorrhage delivered vaginally. Uterine-atony was found to be the most common cause, while care in High Dependency Unit (HDU) was required in 87.5% (28/32) of women. In very few cases balloon tamponade (2-cases) and compression sutures (2-cases) were used. Hysterectomy was performed in 4-cases and all of them encountered complications. Blood transfusions were required in 56% of women who had massive postpartum haemorrhage.CONCLUSION:This study highlights the existence variable practices for the management of postpartum haemorrhage. Interventions to evaluate and control bleeding were relatively aggressive; newer and less invasive options were underutilized. Introduction of an evidence-based management model can potentially reduce the practice variability and improve the quality of care.

There is a large body of literature investigating the mechanism, risk factors, and pathophysiology of postpartum urinary retention; it is usually a temporary condition where early diagnosis and appropriate management can avoid long term complication. This article reviews the etiology, prevention, management and long-term implications of retention for bladder functions.

Pelvic inflammatory disease and pelvic abscesses have been reported as a major complication following a wide variety of obstetrical, gynaecological and surgical procedures. The aim of this review article is to emphasize the need for a more aggressive approach to detect and to treat what can be a debilitating condition that if inadequately treated may result in mortality. The large numbers of options available are discussed under the headings of: conservative management, interventional radiological management and surgical treatment. Lastly, preventive strategies are discussed, as pelvic inflammatory disease may result in tubal factor infertility, ectopic pregnancies, chronic pelvic pain and tubo-ovarian/pelvic abscesses.