الفهرس 
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Abstract
SUMMARY
Over the last 20 years, the method of ovarian stimulation have markedly progressed. This became very obvious with the increasing success in Assisted Reproductive Technologies.
Folliculogenesis is the basic unit of ovarian activity, which has a dual purpose: oocyte maturation and steroid production. Although pituitary gonadotropins and ovarian steroids play a dominant role in follicular development, it has become apparent that a variety of peptide hormones secreted by the ovary play an important role especially in selection and maintenance of the single dominant follicle. One of these peptides in Insulin Growth Factor — I. The current challenges are to understand how specific growth factor system regulate folliculogenesis and how these interactions are integrated.
Follicle growth passes into stages of primordial follicle, primary follicle, preantral, antral follicle, the dominant follicle and the preovulatory follicle. Then ovulation takes place and corpus luteum is formed.
There are multiple cause of disorders of ovulation e.g.: Anovulation due to loss of FSH stimulation, persistent estrogen secretion, abnormal estrogen clearance and metabolism, extragrandular estrogen production, loss of LH stimulation, local ovarian condition or insulin resistant.
Polycystic ovary syndrome which is characterized by hypersecretion of LH with normal or subnormal FSH and increase androgen secreted from the stroma of the polycystic ovary while the clinical diagnosis of PCOS is obesity, . acne and hirsutism with irregular menstruation ”oligoamenorrhea”.
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Luteal phase inadequacy as the corpus luteum function can be responsible for abnormal pattern of endometrial development and appropriate hormonal output.
Luteinized unruptured follicle disease (LUF): there is no follicular rupture and
a cystic structure persists in the luteal phase of the cycle associated with an
elevated serum progesterone concentration.
We can be diagnosed the anovulatory infertility by the symptoms that suggest ovulation — basal body temperature (BBT), vaginal cytology, cervical mucous secretion and the post coital test, endometrial biopsy, hormonal assay, and ultrasonography.
By the ultrasonography we can detect the timing of ovulation and management the female infertility. Ultrasound allows repeated scanning of pelvic structures either by transvaginal and transabdominal route. Follicular ruptures with presumed release of the ovum has been observed sonographically as after evaluation the dominant follicle which reaches to 18 — 22mm followed by a sudden decrease in follicular size and escape of fluid into the preovulatory area of cul-de-sac as peak volumes detected in the early luteal phase.
We can also detect the endometrial changes of ovulation which is becoming further thickened reaching to 5 — 6mm. By ultrasound there is an associated increase in echogenicity reflecting distention of the glands in the function with mucin and glycogen, by transvaginally U.S. is more accurate for determination of ovulation and fluid in cul-de-sac than abdominal U.S.
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There are medical and surgical methods for ovulation induction.
Clomiphene citrate is the most commonly used drug, it can be given in a dose of 50 — 100 mg / day starting from the 5th or even 3rel day of the cycle and for 5 days.
HCG can be given for triggering ovulation IM in a dose of 5000 — 10.000 IU.
Extended clomiphene citrate therapy is tried but comparable to its few results, human menopausal gonadotropin therapy is superior.
Tamoxifen is another drug, which is similar to clomiphene citrate. It is used either alone (20 - 40 mg / day for 5 days starting from day 3 or 5 of the cycle), or combined with clomiphene citrate.
Patients who fail to achieve good follicular development and maturation on clomiphene citrate treatment are candidates for gonadotropin treatment.
The success with gonadotropin therapy depends on ovarian reserve. Numerous screening methods have been proposed to assess prospectively ovarian reserve and to individualize treatment regimes.
Human menopausal gonadotropin therapy (HMG) can be given from day 8 in a stepwise manner to 4 — 5 ampoules / day depending on the individual ovarian response, with close monitoring till the growing follicle is ready for triggering. Also close monitoring is important to avoid ovarian hyperstimulation syndrome.
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Triggering of ovulation could be by FICG, gonadotropin — releasing hormone or recombinant LH.
Controlled ovarian hyperstimulation is the protocol used for recruitment of a large number of follicles and retrieval of their oocytes.
Pulsatile administration of HMG is a method of administration the aim of which is to reproduce pattern of gonadotropin secretion similar to that produced during normal menstrual cycle. HMG can be given in combination with clomiphene citrate to reduce gonadotropin requirement and attendants surveillance intensity.
Follicle stimulating hormone either urinary or recombinant shows increasing success in induction of ovulation specially in PCOD patients when it is given in low dose regimen.
Gonadotropin — releasing hormone (LHRH) is used for ovulation induction either for triggering of ovulation in HMG stimulated cycles (flare up effect) or to induce desensitization of the pituitary (down regulation). Luteal phase support is needed if GnRH-a is involved in ovarian stimulation protocol.
Other adjuvant medical treatments in ovulation induction are:
•Dexamethazone for adrenal suppression.
•Bromocriptine specially in cases with hyperprolactinemia.
•Growth hormone, it was found to augment the ovarian response to HMG therapy.
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•Biguanides thought to play an important role in ovulation induction especially in cases of PCOD.
•Oral contraceptive pills have been used prior to ovarian stimulation, it is thought to decrease risk of ovarian hyperstimulation in high risk patients.
Different protocols of ovarian stimulation using combination of variable drugs
are available.
High order ovarian stimulation could be injurious to women’s health. Ovarian hyperstimulation syndrome is the most serious complication of ovarian induction.
Also recent reports relating ovarian cancer and ovarian stimulation.
Nowadays surgical methods of ovulation induction are rarely used. It is indicated only in women who fail to respond to medical therapy. The current used surgical procedures are laparoscopic ovarian cautery, laser laparoscopic vaporization.
Complications of ovarian stimulation are multiple and the most serious complication is the ovarian hyperstimulation syndrome (OHSS) which is characterized by sudden of vascular permeability which results in the development of a massive extra vascular exadate due to hyperestrogenemia as the exodate accumulates primarily in the peritoneal cavity causing a protein rich ascites and loss of fluid in the third space causes a hemo concentration by close monitoring can be detected if there is multiple pregnancy which increased the risk of OHSS. OHSS mainly accompanied by
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the ovulation induction by clomiphene citrate, and increased mainly with treatment by clomid with pergonal together.
Other complications of ovarian stimulation are ovarian cancer but it is relatively uncommon condition.
In this study by ultrasonic comparison between different ovulation induction
protocols included forty women divided into four groups:
Group I, including 10 women undertaking of clomiphene citrate alone 50 -150mg per day from cycle day 3 - 7.
Group II, includes 10 women who received clomiphene citrate (50 — 100 mg) with administration of tamoxifen (20 - 40 mg / day) beginning 3 or 5 of the cycle.
Group III, includes 10 women who received Human menopausal gonadotropin (HMG) (75 i.0 FSH + 75 i.0 LH). Starting on cycle day 3 for 5 - 8 days. The dose will increase when indicated from day 8 in a stepwise manner to 4 - 5 ampoules / day depending on the individual ovarian response as detected by transvaginal sonography, available preparation are (pergonal).
Group IV, includes 10 women who received clomiphene citrate (100 mg / day) from cycle day 3 to 7, combined with the administration of Human menopausal gonadotropin (HMG) (2 ampoules / day).