GG Hospital

Mrs.S.R,26 years old woman, who was married for 7.5 years, came to GG Hospital in Aug’2004 anxious to conceive. Her menstrual cycles were regular. USG revealed a normal uterus with polycystic ovaries, diagnostic laparoscopy confirmed the same. Semen analysis of the Husband revealed oligoasthenoteratozoospermia with an FSH level of 29. 04 miu/ml and a normal physical examination. She underwent one cycle of ART (ICSI) which failed. Subsequently the next attempt was a dual procedure of GIFT and ICSI-ET. We retrieved 11 oocytes of which 2 oocytes with husband’s sperms were transferred into the left tube and 3 ICSI embryos (remaining oocytes failed to fertilize) were transferred into the uterine cavity on day 2. "Her? BHCG levels on the 27th and 29th day were 71.5 and 171.9 mIU/ml respectively." On the 38th day an intrauterine gestational sac was visualized and both ovaries appeared moderately enlarged (left more than right) by TVS. At 7-8 weeks of pregnancy she was admitted for acute pain in the lower abdomen and giddiness. She was hypotensive and pale. She was immediately resuscitated and her vitals settled. An USG was performed which revealed a viable intrauterine pregnancy along with free fluid in the cul-de-sac with probe tenderness in the left fornix. The initial diagnosis was made as a twisted left ovary. An emergency laparotomy was decided, owing to her general condition. Per operatively there was haemoperitoneum which on evacuation revealed a left heterotropic pregnancy with a single twist of the left ovarian pedicle.

Mrs.K.V, 28 years old woman, married for 8 years, a known case of polycystic ovarian disease, was seen by us for primary infertility on November 2003. Semen analysis of the husband was normal. She had undergone ovarian wedge resection by laparotomy in 2000 at another centre. Subsequently a diagnostic hysterolaparoscopy done at our centre revealed plastered pelvis and Arcuate but otherwise normal uterine cavity.

She underwent her first cycle of IVF with stimulation protocol using GnRh analogue and recombinant FSH and HMG. She developed moderate OHSS with retrieval of 30 oocytes and hence the cycle was cancelled. Since the husband’s count and motility were normal on the day of aspiration, the oocytes were inseminated. However the next day none of the oocytes had fertilized and rescue ICSI was performed. It was noted that only 18 oocytes were of metaphase –II and hence were injected. 4 oocytes fertilized and were frozen. The hospital stay was uneventful and the patient returned for a frozen - thawed embryo replacement after 2 months.

She was started on hormone replacement therapy and embryo transfer was done after thawing on day 18 of her cycle. All the four thawed embryos survived and were of good quality. After 12 days, the first BHCG was 232 mIU/mL and her second BHCG value was 676 mIU/mL. Her first ultrasound revealed a twin gestation on the 38th day and subsequently there was a spontaneous reduction to singleton at 9 weeks of gestation. Her antenatal period was uneventful and she was delivered of male baby. Weighing 2.7 KG by elective LSCS on 28th January 2005

The pedicle was untwisted and left salpingectomy was performed. Postoperative period was uneventful. USG on the day of discharge showed viable intrauterine pregnancy corresponding to 8 weeks. The patient subsequently developed gestational diabetes mellitus which was controlled with insulin. She delivered a live female baby weighing 2.6 KG by elective LSCS on 30th June 2005.

In a case of mild OHSS with dual procedure an anticipation of heterotropic pregnancy should also be taken into consideration, although the adnexa may be obscured due to an enlarged ovary.

Although oocytes recovered from cases of PCOD are plentiful, they are not always mature. It would have been worthwhile to have done ICSI on 50% of the retrieved oocytes, even though the sperm count and motility were normal. Normally rescue ICSI is not advocated by most infertologists, but in this case it proved to be worthwhile. Needless to say we have had only a handful of successful pregnancies following rescue ICSI.



	' Prof. Peter Brinsden '


	Dr.Partick Quinn & Dianna Paynne	Dr. Rohini Edirinsinghe	Our Hon'ble Chief Minister Dr.J.Jaylalithaa
			Our Hon'ble Chief Minister Dr.J.Jaylalithaa

	We also had Dr. Rohini Edirinsinghe, in Feb 2004 who gave a talk on PGD and latest trends in ART Prof. Marco Filicori, Bologna, Italy, visited our IVF lab in Aug 2004
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